摘要
1例1月龄男婴因患先天性高胰岛素血症从国外自购二氮嗪胶囊治疗。为纠正患儿的低血糖状态,计划在静脉补充高浓度葡萄糖的同时,给予口服二氮嗪胶囊,初始剂量为8.72 mg、3次/d[5 mg/(kg·d)],并在密切监测血糖的情况下逐渐减少静脉葡萄糖的补充,增加二氮嗪的剂量,最终停用静脉输注葡萄糖保持血糖稳定(≥3.9 mmol/L)。开始治疗后1~7 d,按计划调整静脉葡萄糖和二氮嗪剂量,患儿血糖3.1~5.3 mmol/L,无低血糖发生。第8天,药师查房发现患儿呼之不醒,急查血糖2.2 mmol/L。追问其家属,发现患儿家属自行将二氮嗪剂量减至入院时的初始剂量,导致患儿低血糖发作,属于自备药管理缺失导致的用药错误。药师立即对患儿家属进行用药安全相关科普知识教育,重新调整二氮嗪剂量,患儿血糖恢复正常。随着二氮嗪治疗剂量的增加,患儿出现水钠潴留不良反应,药师查阅以往文献后建议加用氢氯噻嗪,患儿不良反应消失。藉由此次事件,在临床药师的努力下,医院建立了特殊疾病自备药临床管理规范和安全用药数据库,组织了医师和药师联合服务的多学科团队,加强了对患儿住院和出院后治疗的用药安全管理,收到良好效果。
An one⁃month⁃old boy was treated with diazoxide capsules purchased by his parents from abroad for congenital hyperinsulinemia.In order to correct his hypoglycemia,the treatment plan was designed as follows:diazoxide capsules with an initial dose of 8.72 mg orally thrice daily[5 mg/(kg·d)]and intravenously high concentration glucose were given at the same time,then the supplement of intravenous glucose was gradually reduced and the dose of diazoxide was gradually increased under close monitoring of blood glucose levels,and finally the intravenous glucose was stopped with the stable blood glucose level(≥3.9 mmol/L).During the first 7 days of treatment,the dose of intravenous glucose and diazoxide were adjusted as planned,the child′s blood glucose was 3.1-5.3 mmol/L,and no hypoglycemia occurred.On the 8th day,the pharmacist found that the child was not awake and the blood glucose was 2.2 mmol/L during patient rounds.After questioning his parents,it was found that the dose of diazoxide was reduced to the initial dose by the parents themselves,leading to an episode of hypoglycemia,which was a medication error caused by the lack of self⁃supplied drugs management.The pharmacist immediately intervened on his parents′treatment adherence.The dose of diazoxide was re⁃adjusted and the child′s blood glucose returned to normal.With the increase of the diazoxide dose,the child developed an adverse reaction of water and sodium retention.The addition of hydrochlorothiazide was recommended by the pharmacists after reviewing previous literatures and the adverse reaction of the child disappeared.Through this case,the clinical management standard of self⁃supplied drugs for special diseases and the database of safe drug use were established and a multi-disciplinary team for joint services consisting physicians and pharmacists was formed in the hospital under the efforts of clinical pharmacists.The safety management of medication in treatment of hospitalized and discharged children was strengthened and good results have been achieved.
作者
杨佳
江永贤
陈文文
陶婉君
李根
Yang Jia;Jiang Yongxian;Chen Wenwen;Tao Wanjun;Li Gen(Department of Pharmacy,Chengdu Women′s and Children′s Central Hospital,School of Medicine,University of Electronic Science and Technology of China,Chengdu 611731,China)
出处
《药物不良反应杂志》
CSCD
2021年第4期202-204,共3页
Adverse Drug Reactions Journal
关键词
先天性高胰岛素血症
二氮嗪
用药错误
药剂师
安全管理
Congenital hyperinsulinism
Diazoxide
Medication errors
Pharmacists
Safety management
