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1例中毒性表皮坏死松解症继发脓毒血症的药物治疗及监护

来源:用户上传      作者:陈昆 陈虹 方洁

  摘 要 目的:探讨临床师在中毒性表皮坏死松解症继发脓毒血症患者的治疗方案制定、治疗药物监测、皮肤护理、不良反应防治中的作用和价值。方法:临床药师通过ALEND评分识别可疑致敏药物为布洛芬,根据患者病原学检查结果,运用治疗药物监测协助临床医师优化抗感染治疗方案,同时对患者皮肤护理、药物不良反应等进行药学监护。结果:治疗后患者感染得到有效控制,临床症状好转,且未发生药物不良反应。结论:临床药师对患者实施全程药学监护,可优化治疗方案,及时发现和评估可能出现的严重药品不良反应,提高了药物治疗的安全性和有效性。
  关键词 中毒性表皮坏死松解症 脓毒血症 临床药师 药学监护
  中图分类号:R758.25 文献标志码:B 文章编号:1006-1533(2022)09-0058-05
  引用本文 陈昆, 陈虹, 方洁. 1例中毒性表皮坏死松解症继发脓毒血症的药物治疗及监护[J]. 上海医药, 2022, 43(9): 58-62.
  Pharmaceutical care of a case of toxic epidermal necrolysis secondary to sepsis
  CHEN Kun1,2, CHEN Hong3, FANG Jie2
  (1. Department of Pharmacy, the Hospital affiliated to Southwest Medical University, Luzhou 646000, China; 2. Department of Pharmacy, Ruijin Hospital affiliated to School of Medicine, Shanghai Jiao Tong University, Shanghai 200025, China; 3. Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200025, China)
  ABSTRACT Objective: To explore the role and value of clinical pharmacists in the formulation and adjustment of treatment plans, drug monitoring, skin care and prevention of adverse reactions for toxic epidermal necrolysis secondary to sepsis. Methods: Clinical pharmacists identified ibuprofen as the suspected sensitizer by ALEND score, used therapeutic drug monitoring to assist clinicians to optimize the anti-infective treatment plan based on the results of etiological examination and the characteristics of PK/PD of antibiotics in burn patients and also conducted pharmaceutical care for patients’ skin care, adverse drug reactions and so on. Results: Her infection was effectively controlled, clinical symptoms were improved, and no adverse drug reactions occurred after treatment. Conclusion: The whole-course pharmaceutical care provided by clinical pharmacists for patients with toxic epidermal necrolysis can optimize the treatment plan, timely detect and evaluate possible serious adverse drug reactions, and improve the safety and effectiveness of drug treatment.
  KEY WORDS toxic epidermal necrolysis; sepsis; clinical pharmacist; pharmaceutical care
  中毒性表皮坏死松解症(toxic epidermal necrolysis,TEN)和史提芬-强生症候群(Stevens-Johnson syndrome,SJS)是一种严重皮肤不良反应,以表皮剥脱和黏膜损害为特征,表皮剥脱面积≥30%时被诊断为TEN[1]。70%~90%的SJS/TEN由药物导致,最常见的致敏药物包括抗生素、别嘌醇、非甾体类抗炎药和抗癫痫药[2]。SJS/TEN急性期可累及多个脏器,出现肾衰竭、肠道病变、肺部病变和脓毒血症等一系并发症,如不及时救治可能危及患者生命[1]。本研究记录临床药师对1例TEN继发脓毒血症患者治疗全程的药学监护,探讨临床药师在TEN治疗中的作用与价值。
  1 病例资料
  患者,女性,25岁,体重50 kg。因“确诊亚急性皮肤红斑狼疮17年,发热皮疹3月余,加重5 d”入院。患者院外长期口服醋酸泼尼松片10 mg qd、沙利度胺50 mg qn,期间病情稳定。2020年5月5日,患者受凉后发热,伴寒战,Tmax 39.3 ℃,自行服用布洛芬后体温可降至正常,但随后再次发热。2020年5月8日自行加用奥司他韦、阿莫西林后,晚上出现躯干处红斑、瘙痒,次日加重蔓延至面部、颈部、四肢,伴颜面部浮肿,至当地医院住院治疗后皮疹好转。但2020年7月23日患者出现全身多发水疱,疱液澄清,予以甲泼尼龙60 mg qd ivgtt、丙种球蛋白20 g治疗后,水疱逐渐结痂干涸,但反复出现新发水疱。2020年8月14日起水疱明显增多,融合,表皮剥脱。2020年8月18日患者再次发热,Tmax 38.6 ℃,病情危重,于8月19日转入我院皮肤科。

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