经验分享-方洁-临床药师对H7N9患者的药学监护探讨.ppt

1、临床药师对临床药师对H7N9患者的患者的药学监护探讨药学监护探讨上海交通大学医学院附属瑞金医院上海交通大学医学院附属瑞金医院药剂科药剂科方洁方洁现现病史病史p患者男性，患者男性，54岁岁p主诉：全身酸痛伴发热咳嗽主诉：全身酸痛伴发热咳嗽7天，加重伴呼吸困难天，加重伴呼吸困难4天天p病情经过病情经过平素于公园晨练（可接触鸟类），平素于公园晨练（可接触鸟类），3.30号接触禽类号接触禽类4.3号出现全身酸痛乏力号出现全身酸痛乏力4.5号发热，号发热，Tmax39.3C，伴咳嗽，痰较少，伴咳嗽，痰较少4.7就诊于南翔医院，查就诊于南翔医院，查WBC5.64109LNE70.6%利巴韦利巴韦林应用两天

2、无缓解林应用两天无缓解4.9于瑞金北院门诊查胸片：右肺门旁团块影，左中肺团片影，于瑞金北院门诊查胸片：右肺门旁团块影，左中肺团片影，伏乐新、氨溴索应用伏乐新、氨溴索应用1天后无缓解天后无缓解现现病史病史p病情经过（续上页）病情经过（续上页）4.10出现呼吸困难，查血常规出现呼吸困难，查血常规WBC4.77109L，N82.5%，LY15%；血气分析；血气分析PH7.53，PaO25.13kpa，PaCO24.33kpa，SpO275%；胸片见病变范围明显增大，专家组会诊后列为监；胸片见病变范围明显增大，专家组会诊后列为监测病例，收住北院测病例，收住北院ICU负压病房，查咽拭子负压病房，查咽拭子

3、H7N9阳性，予阳性，予奥司奥司他韦他韦+美罗培南美罗培南+莫西沙星抗感染、莫西沙星抗感染、IVIG增强免疫，激素缓解炎症增强免疫，激素缓解炎症等等4.10先后予鼻导管吸氧、鼻导管加面罩双通道给氧、先后予鼻导管吸氧、鼻导管加面罩双通道给氧、BiPAP，4.12予予气管插管气管插管PC模式机械通气，模式机械通气，PC19cmH2O，PEEP18cmH2O，SpO2最高可升至最高可升至98%4.14为进一步治疗收住我院为进一步治疗收住我院RICU负压病房负压病房4.14入院情况及处理入院情况及处理p入院时情况：入院时情况：T37.8C，HR100次次/分，分，BP149/88mmHg，RR23次次

4、/分，分，SpO297%p入院后处理：入院后处理：呼吸支持：气管插管呼吸支持：气管插管+NIV，PCV，PEEP18-19cmH2O，吸氧，吸氧85-90%镇静肌松：咪达唑仑、艾贝宁、万可松镇静肌松：咪达唑仑、艾贝宁、万可松抗感染：抗感染：美罗培南美罗培南+帕拉米韦（特批）帕拉米韦（特批）抗炎：甲强龙、乌司他丁抗炎：甲强龙、乌司他丁其它：抗凝、降温、化痰、保肝护胃、改善肠道功能、全身支持其它：抗凝、降温、化痰、保肝护胃、改善肠道功能、全身支持等等出入量情况出入量情况入量（入量（ml）尿量（尿量（ml）排便（排便（g）4.1419601680800/E4.1523221495300/E4.162

5、4962160700/E4.17210936806204.181895412004.1919903455650/E4.204382376504.2146505590200/E4.222908361050/E4.2324541635700/E4.24288016356004.2534402461100/E出入量入量（入量（ml）尿量（尿量（ml）排便（排便（g）4.2623114491250/E4.2722903550300/E4.2820503005450/E4.2921203680400/E4.30302033403505.134062980500/E5.2313729354005.3377

6、02370250/E5.434752640350/E5.524802230500/E5.6238015753505.729401915750/E5.832001500350/E5.924502170500/E出入量入量（入量（ml）尿量（尿量（ml）排便（排便（g）5.1024762546350/E5.1123362460500/E5.1225402430300/E5.1325301970600/E5.1425352441350/E5.1524311650250/E5.1626152100400/E5.1725602245300/E5.1824752726700/E5.192490214410

7、0/E5.2018451088500/E5.2122801352300/E5.2223901865450/E5.2327101855700/E呼吸机参数调整呼吸机参数调整PEEPPCFiO2RRVitSpO24.1422-1815-11100-7020430-50096-984.151816-1470-452250098-1004.16181445-602250098-1004.17181645-402345097-1004.1817-16154023470-49098-1004.1915154023420-48093-984.2012154523430-50093-984.211115502

8、3450954.2211155523430-50093-954.2310156023430-50093-95无创机械通气无创机械通气IPAPEPAPRR吸氧浓度吸氧浓度4.23201022604.2415102250-704.25151122604.2617112260-704.2718121870-804.2818121870-804.2918121870-805.118111680-905.217101675-80无创机械通气无创机械通气IPAPEPAPRR吸氧浓度吸氧浓度5.317101675-80%5.61491680-85%5.81191480-90%5.10129480%5.121

9、291080-85%5.131591085-90%5.151491080-90%5.171171085-100%5.2015101090-100%5.221291090-100%生命体征生命体征BP(mmHg)HR(次次/分分)RR(次次/分分)T(摄氏度摄氏度)SpO2(%)4.23113/67108233794-974.24135/781172538.590-964.25121/901021937.9974.26133/721062338.3944.27135/741052537.8945.1123/7698243795-995.2125/80912237.492-955.3131/849

10、52037.493-965.6123/821052437.294-985.8125/80952037.294-98 生命体征BP(mmHg)HR(次次/分分)RR(次次/分分)T(摄氏度摄氏度)SpO2(%)5.10122/84982337.394%5.13125/901102537.295%5.15140/951032337.195%5.17139/9899243794%5.20113/761062236.893%5.22120/8498203796%5.27120/921032236.894%血气分析血气分析PHPaO2(kpa)PaCO2(kpa)SpO2SBE(mmol/L)4.147

11、.3712.227.4196.54.74.157.4111.126.7196.15.84.15（17:00）7.4517.135.8498.85.14.167.439.106.5892.96.94.177.4025.07.5899.48.44.187.4113.047.3797.28.44.197.3915.757.7398.38.54.207.3413.159.0596.88.54.217.3812.277.6896.86.44.227.4113.376.4897.54.84.237.4512.875.1397.51.94.247.4110.685.9695.12.54.257.3912.5

12、76.0198.81.6血气分析血气分析PHPaO2(kpa)PaCO2(kpa)SpO2SBE(mmol/L)4.267.38116.47963.54.277.389.766.6393.33.44.287.3314.408.0097.74.24.297.409.897.0794.26.04.307.3812.677.5097.16.15.17.4212.166.79976.45.27.408.756.8690.55.35.37.4010.346.8194.95.15.67.369.346.4692.10.95.87.3710.496.6394.92.45.107.3417.616.5798.

13、3-0.15.127.3610.237.394.53.55.137.3612.017.496.64.05.157.389.586.5693.12.7血气分析PHPaO2(kpa)PaCO2(kpa)SpO2SBE(mmol/L)5.177.3810.596.7594.92.85.207.349.067.7089.93.25.227.367.227.3981.44.05.247.3710.977.2895.44.55.277.368.517.2488.63.6氧合指数变化氧合指数变化FiO2PaO2(kpa)氧合指数氧合指数4.14100%12.2292.74.1565%11.12130.94.

14、15（17:00）60%17.13216.94.1660%9.10115.24.1755%25345.54.1840%13.04248.94.1940%12.3233.74.2045%13.152224.2150%12.27184.14.2255%13.37182.34.2360%12.871604.2560%16.20202.5氧合指数变化氧合指数变化FiO2PaO2(kpa)氧合指数氧合指数4.2675%11.01104.2770%9.761044.2875%14.401444.2975%9.8998.94.3075%12.67126.75.180%12.161145.275%8.7587

15、.55.375%10.341035.680%9.3487.55.880%10.4998.35.1085%17.61155.45.1280%10.2395.95.1390%12.01100氧合指数FiO2PaO2(kpa)氧合指数氧合指数5.1580%9.5889.85.1790%10.688.35.20100%9.0668.45.2290%7.2260.25.2490%10.9791.45.27100%8.5163.8血常规血常规WBCNELYHbHctPLT4.144.1687.98.01330.4021484.154.3586.79.01340.3991414.165.0284.010.6

16、1220.3781694.174.647714.41160.3681744.184.2975.817.21170.3602104.197.9167.626.81270.3831814.209.6177.517.31290.3942824.2110.9876.517.71450.3672614.2213.4485.97.71160.3562644.2311.9785.97.11180.3512514.249.9685.27.31060.3212224.255.1083.110.41010.304192血常规血常规WBCNELYHbHctPLT4.267.2282.79.81010.3061974.276.9575.216.41000.2942324.286.1678.516.71070.3212524.298.0776.616.51140.3331804.309.2275.616.41090.3173045.18.7475.215.61100.3283355.28.0869.321.71100.3233615.37.8569.420.31130.3313775.67.4862.922.9