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心脏生物瓣膜置换术后并发血小板减少症的药学监护实践
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| 篇名： | 心脏生物瓣膜置换术后并发血小板减少症的药学监护实践 |
| TITLE： | Pharmaceutical care in thrombocytopenia after bioprosthetic heart valve replacement |
| 摘要： | 目的 为心脏生物瓣膜置换术后并发血小板减少症等复杂病例的抗凝治疗、药物不良反应监测及个体化用药调整提供参考。方法临床药师参与1例心脏生物瓣膜置换术后并发血小板减少症的药学监护。针对心功能不全，临床药师建议维持口服富马酸比索洛尔、沙库巴曲缬沙坦钠、螺内酯、呋塞米和氯化钾，加用左西孟旦增强心肌收缩力，监测血压、心率及血钾浓度；针对血小板减少症，基于文献评估风险，建议应用重组人白细胞介素11（rhIL-11）、输注血小板，并采用那曲肝素钙桥接华法林进行抗凝治疗，根据国际标准化比值（INR）调整华法林剂量；针对快室率心房颤动，建议予胺碘酮及地高辛治疗；针对急性肝损伤，临床药师怀疑为胺碘酮及rhIL-11所致，建议停用相关药物，予丁二磺酸腺苷蛋氨酸联合多烯磷脂酰胆碱行保肝治疗；对患者进行抗凝用药教育，强调需严密监测INR，密切观察出血及血栓事件。结果临床医师采纳上述建议。经干预后，患者肝功能显著改善，丙氨酸氨基转移酶降至70U/L，天冬氨酸氨基转移酶降至42U/L，心率稳定为70～100次/min，心功能平稳，INR控制在1.80～2.50，病情好转出院。结论临床药师通过权衡抗凝与出血风险，协助临床制定个体化抗凝方案，开展药物不良反应监测与评估，优化用药策略，有效保障了患者的用药安全与疗效。 |
| ABSTRACT： | OBJECTIVE To provide a reference for anticoagulation therapy， adverse drug reaction monitoring， and individualized medication adjustment in complex cases， such as those with thrombocytopenia following bioprosthetic heart valve replacement. METHODS Clinical pharmacists participated in the pharmaceutical care of a patient with thrombocytopenia following bioprosthetic heart valve replacement. For cardiac insufficiency， the pharmacists recommended maintaining oral bisoprolol， sacubitril/valsartan， spironolactone， furosemide， and potassium chloride， with levosimendan added to enhance myocardial contractility， while monitoring blood pressure， heart rate and serum potassium levels. For thrombocytopenia， based on literature- based risk assessment， the pharmacists advised administering recombinant human interleukin-11 （rhIL-11）， platelet transfusion， and employing anticoagulation therapy with nadroparin calcium bridging to warfarin， with warfarin dosage adjusted according to the international normalized ratio （INR）. For rapid ventricular rate atrial fibrillation， amiodarone and digoxin were recommended. For acute liver injury， suspected to be induced by amiodarone and rhIL-11， the pharmacists suggested discontinuing the relevant drugs and treating with ademetionine 1，4-butanedisulfonate combined with polyene phosphatidylcholine for liver protection treatment. The patient received anticoagulation medication education emphasizing strict INR monitoring and close observation for bleeding or thrombotic events. RESULTS The clinicians adopted these recommendations. Following the intervention， the patient’s liver function showed significant improvement， with alanine aminotransferase decreasing to 70 U/L and aspartate aminotransferase to 42 U/L. The ventricular rate stabilized at 70-100 beats per minute， cardiac function remained stable， the INR was maintained within the target range of 1.80-2.50， and the patient was ultimately discharged with improved condition. CONCLUSIONS Through balancing anticoagulation and bleeding risks， the clinical pharmacists applied pharmaceutical expertise to assist in developing personalized anticoagulation regimens， conducted adverse drug reaction monitoring and evaluation， and optimized medication strategies， thereby effectively ensuring patient safety and therapeutic efficacy. |
| 期刊： | 2026年第37卷第01期 |
| 作者： | 殷欢莉；黄跃洲；罗敏 |
| AUTHORS： | YIN Huanli，HUANG Yuezhou，LUO Min |
| 关键字： | 心脏生物瓣膜置换术；血小板减少症；抗凝治疗；药物性肝损伤；药学监护 |
| KEYWORDS： | bioprosthetic heart valve replacement； thrombocytopenia； anticoagulation therapy； drug-induced liver injury； |
| 阅读数： | 85 次 |
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