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英国药学监护实践模式与方法(PharmaceuticalCarePracticeinUK)杨赴云fyy0326sina关于“PharmaceuticalCare”的翻译“Pharmaceuticalservice”药学服务“Clinica

lPharmacy”临床药学“ClinicalPharmacyservice”临床药学服务“Pharmaceuticalcare”药学监护“Care”和“Service”◼Care《LONGMANDICTION

ARYOFTEMPERARYENGLISH》–Worry;anxiety;sorrow;grief;–Charge;keeping;protection;responsibility;–Seriousattention;–Carefuln

essinavoidingharm,damage◼Service《LONGMANDICTIONARYOFTEMPERARYENGLISH》–Workordutydoneforsomeone–Anactorjobdoneinfavorofsomeone◼CARE

《大英汉词典》–烦恼，忧虑，操心–注意，当心，小心，谨慎–关切，关心，关怀，爱护–看护，照管，照顾，管理，监护–负责照管的事，负责，责任◼SERVICE《大英汉词典》–帮佣，业务，事务：尤指公共事务–业务机构，行政部门–劳役，服务性工作–礼拜，宗教仪式◼ICU“IntensiveCare

Unit”“重症监护病房”◼CCU“CardiacCareUnit”“心脏病监护病房”药学服务PharmaceuticalService◼范围广泛，所有与药学有关的服务。如，卫生行政药事管理部门，企业的制药技术服务，医院的药学

服务等。◼医院药学部门所提供的系统的服务，包括药品的配制和分发，提供与药物和疾病有关的信息，所有病人用药剂量的监测，审查医生处方并录入数据库等。（TheDepartmentofPharmacyprovidessystems-basedservicesincludingdrug

anddiseasestateinformation,drugpreparationanddistribution,anddosagemonitoringservicesforallpatients.）临床药学ClinicalPharmacy◼临床药学是由药

学专业人员实施的，帮助临床最大效益的使用药物，并且将药物的毒性降到最小的学科。（Clinicalpharmacyisadisciplineconcernedwiththeapplicationofpharmaceuticalexpertisetohelpmaximisedrugef

ficacyandminimisedrugtoxicityinindividualpatients.）临床药学服务Clinicalpharmacyservice◼选择用药◼药代动力学评价给药剂量和方法◼对病人用药的咨询和教育◼其他优化药

物治疗的方法。药学监护Pharmaceuticalcare◼1990年RobertCipolle，LindaStrand将药学监护定义为“以病人为中心的实践，实践者负责病人与用药有关的需求并为之负责”（Pharmaceutica

lcareisapatient-centredpracticeinwhichthepractitionerassumesresponsibilityforapatient’sdrug-relatedneedsandisheldacc

ountableforthiscommitment.）◼药学监护实践是一次实践针对一个病人。由三部分组成：评估病人的需求，制定监护计划，跟踪评价。（Itisbuiltuponepatientatatime.Ithasthreecomponents:assessm

entofthepatient‘sneeds;developmentofacareplan;andfollowupevaluation.）PharmaceuticalservicesClinicalphar

macyservicesPharmaceuticalcareATypicalDayofaClinicalPharmacistinUK英国临床药师的一天Morning8:30–12:00(Coffeebreak10:00–10:30)◼Se

etheblackboard–Thoseadmission–Thosedischarge◼Forthosewhodischargetoday–Prescribingtheirdischargedrugs–Contactwiththeirlocalpharma

cist–Approachtothepatient◼Forthosewhowereadmitted–Medicalhistory–Drughistory–Theknowledgeofthepatient–Potentialdrugrelated

problems–Careplan◼Wardround–Doctors,nurseandpharmacist–Discussingaboutthedrugrelatedneeds◼Reviewtheo

therpatientswhohaspotentialproblems–Signsandsymptomsofthepatients–Laboratorytests–DocumentedAfternoon13:00–16:30◼Wardmeetings◼Nursemeeti

ngs◼Pharmacistsmeetings◼Dispensing◼LibraryFortheindividualpatienttheMinnesotaModeltheBritishModeltheCanadianModeltheAustraliaModelTheMinnesota

ModelHolisticApproach药学监护计划（PharmaceuticalCarePlan)病人情况合并症疾病史及用药史协同治疗药物曾有过的不良反应疾病及用药•病人条件•选择合适的药药学服务病人的旅程59岁女病人DA,因前胸剧烈疼痛,疼痛放射性的传播到左臂,急救中心到家中急

救并送到SGH医院急诊.病人主诉:胸部剧烈疼痛,呈放射性传到左臂,恶心.急救医生给diamorphin后疼痛缓解.aspirin300mgCase入院检查:•BP137/81mmHg•pulse62bpm•resp

iratoryrates16•temperature36℃•SaO297%onair•HerJVP,HSwerenormal•herchestwasclear.病史.MrsDA过去没有疾病记载用药史MrsDA住院前没有

用过药物ECG显示ST段升高,诊断急性下壁心肌梗塞诊断病人社会关系与丈夫一起住吸烟每天25支喝酒每周20units.◼Unit–8gor10mlofpurealcohol–Halfapintofordinarystrengthlager/beer/cider(3.5-4

%A.B.V.)=1unit–A25mlpubmeasureofaspirit(40%A.B.V)=1unit–Asmallglassofwine(8-9%)=1unit◼1pint=568ml1unit=284mlbeer◼Day1(09/01/04)➢streptokinas

e1.5muiv链激酶metoclopramide10mgiv甲氧氯普胺metoprolol25mg美托洛尔Enoxaparin40mg,依诺肝素aspirin75mg,阿司匹林simvastatin40mg辛伐

他丁ramipril2.5mg雷米普利Paracetamol1g扑热息痛◼稍后复查,ECG显示病人恢复良好,病人生命体征很好◼BP113/81mmHg◼pulse73bpm◼RR17◼Day2(10/01/04)–MrsDA今

天没有胸痛–心律为正常窦律–感觉非常疲劳,起床时头晕–血压BP73-97/34-69mmHg–Metoprolol25mgbdchangetoatenolol25mgbd–BP↑123/69mmHg◼

Day4(12/01/04)–无胸痛症状,生命体征稳定–活动良好,可以在病房内走动–停用enoxaparin◼Day5(13/01/04)–BP83-113/47-65–Nicotine帖剂–空腹血糖10.7mmol/l.–建议营养学家重新调整饮食–Ramipril剂量由

2.5mg增加到5mgBD–今天可以出院Date09/0110/0112/0113/01Na(135-145)mmol/l138135140141K(3.5-5.0)mmol/l4.24.04.1Urea(3.3-6.0)mm

ol/l4.36.34.64.5Gluc(3.9-5.0)mmol/l11.210.7Creat(70-110)mol/l56716258TnT(<0.04)g/l6.83ALT(5-59)IU/l33Bili(3-16)mol/l7AlkPhos(30-1

40)IU/l154Alb(35-50)g/l41AST(9-52)IU/l31Haem(12-18)g/gl15.113.9Plat(150-400)109/l207149WCC(4-11)109/l9.17.6病人实验室数据◼出院带药:Aspiri

n75mgodAtenolol25mgbdRamipril5mgbdSimvastatin40mgodGTNspray2puffsprnNicotinePatch15mgfor2hours急性心肌梗塞AcuteMyoc

ardialInfarction◼Epidemiology–TheWHOestimatedthatin2019,12.6percentofdeathsworldwidewerefromischemicheartdisease.–Ischemicheartdiseaseistheleadingcau

seofdeathindevelopedcountries,butthirdtoAIDSandlowerrespiratoryinfectionsindevelopingcountries.◼RiskfactorsRiskfactorsforatherosclerosisaregene

rallyriskfactorsformyocardialinfarction:–Olderage–Malegender–Cigarettesmoking–Hypercholesterolemia–Diabetes–Hypertensi

on–Obesity◼Diagnosticcriteria–WHOcriteriahaveclassicallybeenusedtodiagnoseMI;apatientisdiagnosedwithmyocardialinfarctioniftwo(probable)orthree(d

efinite)ofthefollowingcriteriaaresatisfied:1.Clinicalhistoryofischaemictypechestpainlastingformorethan20minutes2.C

hangesinserialECGtracings3.Riseandfallofserumcardiacbiomarkerssuchascreatinekinase,troponinI,andlactatedehydrogenaseisozymesspecificforthehea

rt.◼TreatmentofMyocardialinfarction–Treatmentofinfarctionmaybedividedintothreecategories:◼immediatecarethatisdesignedtoremovepain,preventde

teriorationandimprovecardiacfunction;◼managementofcomplications,notablyheartfailureandarrhythmias;◼secondaryprophylaxis,preven

tionofafurtherinfarctionordeath.◼ImmediateCare–Thetimingoftreatmentisvital,sincemyocardialdamageafteronsetofanacuteischemicepisodeis

progressiveandtherearepathologicaldatatosuggestthatitisirreversibleat6hours急性心梗的治疗路径◼SuspectedMIwithinthelast24hours◼Givesolubleaspirin300mgimm

ediately(unlesscontraindicatedoralreadygiven).Then75mgdaily(contraindications:recentGIbleedingoractivepepticulcer,knownaspirin

intolerance).◼TreatmentofinfarctpainIVDiamorphine2.5mg+/-IVmetoclopramide10mg.◼ObtainECGandfollowthethrombolysisprotoc

olforAcuteMI.◼Ifnocontra-indications,initiate:–Beta-blocker–ACEinhibitor,especiallyifevidenceofanteriorMIorleftventric

ulardysfunction急性心梗溶栓治疗路径AMI症状?请主治医生复查nono60分钟后重复ECG两个或多个肢体导联ST升高1mm,两个或多个胸部导联ST升高2mm,或左束支传导阻滞.符合ECG标准yesyes有否溶栓禁忌症?绝对禁忌:脑出血,

最近大的创伤/手术/头部受伤,一个月内有胃肠出血,其他出血性疾病.相对禁忌:6个月前TIA,口服抗凝血治疗,孕妇后产后一周内,顽固性高血压(收缩压>180mmHg),感染性心内膜炎yesStreptokinase1.5MU50ml0.9%NaClor5%glucoseover1hourAlt

eplasewithin6-12hours,10mgiv,then50mgintravenousinfusionover60minutesSincethepresenceofantistreptokinaseantib

odiesfromday5to12monthspostadministrationmayrenderfurthertreatmentduringthistimeineffective,itisimportanttodocumentthepatienthadbeengivenstreptokinas

eandtoissuethepatientwitha“streptokinasecard”whichincludesthedateofadministration.Lifestyle◼Improvingdiet–Advisepatientsnottotakesupplementsc

ontainingbeta-carotene.–Donotadvisepatientstotakeantioxidantsupplements(vitaminEand/orC)orfolicacidtoreducecardiovascularris

k.–Advisepatientstoconsumeatleast7gofomega3fattyacidsperweekfromtwotofourportionsofoilyfish.–Considerprovidingatleast1gdaily

ofomega-3-acidethylesterstreatmentlicensedforsecondarypreventionpostMIforupto4yearsforpatientswhohavehadanMIwithin3monthsandarenotach

ieving7gofomega3fattyacidsperweek.–Donotroutinelyinitiateomega-3-acidethylesterssupplementsforpatientswhohavehadanMImorethan3monthsearl

ier.–EncouragepatientstoeataMediterranean-stylediet.◼Deliveringdietary–Giveconsistenthealthyeatingadvicethatistailoredtothepatient’sneedsa

ndthatcanbeextendedadvicetothewholefamily.–Offerpatientsanindividualconsultationtodiscussdiet,includingt

heircurrenteatinghabits,andadviceonimprovingtheirdiet.◼Controllingalcohol–Advisepatientstokeepweeklyalcoholco

nsumptionwithinsafelimits(nomorethan21unitsofconsumptionalcoholperweekformenor14unitsperweekforwomen)andt

oavoidbingedrinking.◼Smokingcessation–Advisesmokerstoquitandofferassistancefromasmokingcessationservice.–Offersmokerswhohaveexpressedad

esiretoquitsupport,adviceandreferraltoanintensivesupportservice.–Ifapatientisunableorunwillingtoacceptareferral,offerp

harmacotherapy.◼Controllingweight–Offeroverweightandobesepatientsadviceandsupporttoachieveandmaintainahealthyweight.◼Improvingphysicalac

tivitylevels–Encouragepatientstoundertakesufficientregularphysicalactivitytoincreaseexercisecapacity.–The

yshouldaimtobephysicallyactivefor20–30minutesadaytothepointofslightbreathlessness.Forpatientsnotachievingthis,advisethemtoincreasethei

ractivityinastep-by-stepway,aimingtoincreasetheirexercisecapacity.Theyshouldstartatalevelthatiscomfortable,andincrease

thedurationandintensityofactivityastheygainfitness.–Discusscurrentandpastactivitylevelsandpreferenceswithpatients.–Thebenefitofexe

rcisemaybeenhancedbytailoredadvicefromasuitablyqualifiedprofessional.CardiacrehabilitationafteranacuteMI◼Cardiacrehabilitationprogrammeshaveb

eenconsistentlyshowntoreducemortalityratesinCHDpatients.◼Cardiacrehabilitationisthecoordinatedsumofinterventionsrequiredtoensurethebestpos

siblephysical,psychologicalandsocialconditionstoenabletheCHDpatienttopreserveorresumeoptimalfunctioninginsociety.◼Italsoaimstosloworreverseprogre

ssionofthedisease.Cardiacrehabilitationcannotberegardedasanisolatedformorstageoftherapy,butmustbeintegr

atedwithinsecondarypreventionservices,ofwhichitformsonlyonefacet(WHOdefinition,1993).◼Cardiacrehabilitatio

ninpatientsafterMIreducesall-causeandcardiovascularmortalityratesprovideditincludesanexercisecomponent◼OfferallpatientswhohavehadanacuteMItr

eatmentwithacombinationofthefollowingdrugs:•ACEinhibitor•aspirin•beta-blocker•statin.Drugtherapy◼ACEinhibitors–OfferACEinhibitorsea

rlyafterpresentationandtitrateupwardstothemaximumtoleratedortargetdose.–DonotroutinelyprescribeARBsunlessthepatientisintolerantorallergict

oanACEinhibitor.–ContinueACEinhibitorsindefinitelyinpatientswithpreservedLVfunctionorLVSD,whetherornottheyhaveheartfailuresym

ptoms.–EarlyafteranacuteMI,donotroutinelyusethecombinationofACEinhibitor/ARBforpatientswithheartfailureand/orLVSD.◼Assessment/monitori

ng–AssessLVfunctioninallpatientswhohavehadanMI.–Measurerenalfunction,serumelectrolytesandBPbeforestartinganACEinhibitororARBandaga

inwithin1or2weeks.–Monitorpatientsasthedoseistitratedandmorefrequentlyforpatientsatincreasedriskofdeteriorationinr

enalfunction.–Monitorpatientswithchronicheartfailure◼Antiplatelettherapy–Offeraspirinandcontinueindefinitely.–Donotofferclopidogrelaloneasfir

st-linetherapybutconsideritforpatientswithaspirinhypersensitivity.–Ifthepatienthasnotbeentreatedwith

acombinationofaspirinandclopidogrelduringtheacutephaseofanMI,donotroutinelyinitiatethiscombination.-Clopidogrelincombinationwit

hlow-doseaspirinisrecommendedinthemanagementofnon-ST-segment-elevationacutecoronarysyndromeinpeoplew

hoareatmoderatetohighriskofMIordeath.Itisrecommendedthatthiscombinationiscontinuedfor12monthsafterthemostrecentacuteepisode.Thereafterstandardcare,in

cludinglow-doseaspirinalone,isrecommended.–ForpatientsafteraSTEMItreatedwiththecombinationofaspirinandclopidogrelduringthefirst24

hours,thiscombinationshouldbecontinuedforatleast4weeks.Thereafterstandardtreatmentincludinglow-doseaspirin

shouldbegivenunlessthereareotherindicationstocontinuedualantiplatelettherapy.–Forpatientswithahistoryofdyspepsia,consideraPPIandlow-doseaspir

in.–Forpatientswithahistoryofaspirin-inducedulcerbleedingwhoseulcershavehealedandwhoareH.pylorinegative

,considerafull-dosePPIandlow-doseaspirin.◼Beta-blockers–Offerabeta-blockerassoonasthepatientisclinicallystab

leandtitrateupwardstothemaximumtolerateddose.–Continuetreatmentindefinitely.–ForpatientswithLVSDbeingofferedtreatme

nt,abeta-blockerlicensedforuseinheartfailuremaybepreferred.Carvedilolbisoprolol◼Potassiumchannelactivato

rs–Nicorandilisnotrecommendedtoreducecardiovascularrisk.◼VitaminKantagonists–High-intensitywarfarin(INR>3)shouldnotbeconsider

edasanalternativetoaspirininfirst-linetreatment.–Forpatientsunabletotakeaspirinorclopidogrel,considermoderate-intensitywarfarin(INR2–3)forupto4

yearsandpossiblylonger.–Thecombinationofwarfarinandclopidogrelisnotroutinelyrecommended.◼Calciumchannelblockers–Donotroutinelyusecalciumcha

nnelblockersforsecondaryprevention.–Ifbeta-blockersarecontraindicatedorneedtobediscontinued,considerdiltiazemorverapamilforseco

ndarypreventioninpatientswithoutpulmonarycongestionorLVSD.–Forpatientswhoarestable,calciumchannelblockersm

aybeusedtotreathypertensionand/orangina.–Forpatientswithheartfailure,useamlodipineandavoidverapamil,diltiazemandshort-actingdihydropyridineagent

sinlinewithNICEclinicalguideline◼Aldosteroneantagonists–Forpatientswithsymptomsand/orsignsofheartfailureandLVSD,initiatetre

atmentwithanaldosteroneantagonistlicensedforpost-MItreatmentwithin3–14daysoftheMI,preferablyafterACEinhibitortherap

y.–ForpatientswithclinicalheartfailureandLVSDalreadybeingtreatedwithanaldosteroneantagonistforaconcomitantcondition,continuewit

hthealdosteroneantagonistoranalternative,licensedforearlypost-MItreatment.◼Assessment/monitoring–Monitorrenalfunctionandserumpotassiumbeforeandduring

treatment.Ifhyperkalaemiaisaproblem,halvethedoseorstopthetreatment.◼Statinsandotherlipidloweringagents–Statintreatmentisrec

ommendedforadultswithclinicalevidenceofCVDandshouldbeofferedassoonaspossible.–Discusstherisksandbenefitsoftreatmentwiththepat

ient,takingintoaccountcomorbiditiesandlifeexpectancy.–Starttherapywithadrugwithalowacquisitioncost(ta

kingintoaccountrequireddailydoseandproductpriceperdose).–Forpatientsintolerantofstatins,otherlipidlowerin

gagentsshouldbeconsidered.–Reduceorstopthedoseofstatinsifthereareissuessurroundingthemetabolicpathway,foodand/ordruginterac

tionsand/orconcomitantillness.–Discontinuethestatinandseekspecialistadviceifpatientsdevelopperipheralneuropathythatmaybeattributabletoth

estatintreatment.◼Assessment/monitoring–Measurebaselineliverenzymesbeforeinitiation.–Donotroutinelyexcludepatientswhohaveraisedliverenzymesf

romtreatment.–Routinemonitoringofcreatinekinaseinasymptomaticpatientsisnotrecommended,butshouldbemeasuredinpatientswhodevelop

musclesymptoms.PatientEducationEducationandstressmanagementprogrammesreducecardiacmortalityandMIrecurrenceinpostMIpatients◼Questionsyoum

ightliketoaskaboutmedicines–HowlongwillIhavetotakethemedicinesfor?–Whatisthebesttimeofdaytotakethemedicines?–Arethereanyserioussid

eeffectsassociatedwiththemedicines?–WhatshouldIdoifIgetanysideeffects?–ArethereanyfoodsordrinksthatIshouldavoid?–Whatsortofi

mprovementsmightIexpecttonotice?–Howlongwillittaketonoticeanyeffect?药学监护计划（PHARMACEUTICALCAREPLAN）日期Date监护点/期望结果CareIssues/Desiredoutput措施Acti

on结果OutputDay1(09/01)Drughistory-ensurethedrughistoryaccuratelyandcorrectlyCheckDH-discusswithpatient-medicalnotes-GP/communitypharmacistPatientdidn

’ttakeanydrugsonadmissionAcutetreatmentonacutemyocardialinfarction-ensureappropriateacutetreatmentChecktoensure-aspirin-streptokinase-metoc

lopramide-bblockerNocontraindicationalldrugprescribedandgivenappropriatelyDateCareIssues/DesiredoutputActionOutputSecondaryp

reventiononMI-ensureappropriatesecondarypreventionChecktoensure-aspirin-ACEinhibitor-B-blocker-statinAspirin75mg,ramipri

l2.5mg,metoprolol25mg,simvastatin40mgwereprescribedPreventionofDVT-ensureappropriatetreatmentChecktoensure-lowmoleculeweighthepari

nEnoxaparin40mgwasprescribedstopAwaresideeffectofACEinhibitor-ensurenohypotension-awaretherenalfunctionCheckBPC

heckU&EsBP108-145/55-91mmHgU&EsstableDateCareIssues/DesiredoutputActionOutputday2Metoprololdueto↓BPDizziness,can’ttolerate-e

nsurepatienttolerate-patientdizziness-alternativedrugsMonitorBPMonitorU&EsObservepatientBP↓73-97mmHgsystoliconmetopr

ololChangetoatenolol,BP↑123/69mmHgAwareSEofb-blocker-ensurenohypotension-awaretherenalfunctionMonitorBPMonit

orU&EsBP123/69mmHgU&EsstableAwareSEofSimvastatin-ensurenohepatotoxicity-ensurenomyopathyMonitorLFTsD/WpatientLFTsnorm

alNomusclepain,notenderness,noweaknessDateCareIssues/DesiredoutputActionOutputday5GTNspray-ensurecorrectuseofsprays-e

nsurethecorrectdosageD/Wpatient-howtouseit-notmorethanthreetimesin15minutes-takespraywhensittingdownifpossibleGoodcomprehensionSmokecessation-

ensurecorrectuseofpatch-ensurecorrectfrequencyD/Wpatient-maximumfrequency1patch/24hoursPatientgoodcomprehensionDateCareIssues/DesiredoutputAct

ionOutputpatientdischarge-ensurecorrectuseofdrugsathomeAspirinAtenololRamiprilSimvastatinGTNsprayNicotinePa

tchD/WpatientaboutthedrugsatdischargepatientgoodcomprehensionThanks