英国临床药学模式和方法 (成都)杨赴云

null英国药学监护实践模式与 ( Pharmaceutical Care Practice in UK) 杨赴云 fyy0326@sina.com英国药学监护实践模式与方法 ( Pharmaceutical Care Practice in UK) 杨赴云 fyy0326@sina.com 关于“Pharmaceutical Care” 的翻译 “Pharmaceutical service” 药学服务 “Clinical Pharmacy ”临床药学 “Clinical Pharmacy service”临床药学服务 “Pharmaceutical care” 药学监护关于“Pharmaceutical Care” 的翻译 “Pharmaceutical service” 药学服务 “Clinical Pharmacy ”临床药学 “Clinical Pharmacy service”临床药学服务 “Pharmaceutical care” 药学监护“Care” 和 “Service” “Care” 和 “Service” Care 《 LONGMAN DICTIONARY OF TEMPERARY ENGLISH 》 Worry; anxiety; sorrow; grief; Charge; keeping; protection; responsibility; Serious attention; Carefulness in avoiding harm, damage Service 《 LONGMAN DICTIONARY OF TEMPERARY ENGLISH 》 Work or duty done for someone An act or job done in favor of someonenullCARE 《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nullICU “Intensive Care Unit” “重症监护病房” CCU “Cardiac Care Unit” “心脏病监护病房” 药学服务 Pharmaceutical Service药学服务 Pharmaceutical Service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。（The Department of Pharmacy provides systems-based services including drug and disease state information, drug preparation and distribution, and dosage monitoring services for all patients. ） nullnullnull临床药学 Clinical Pharmacy临床药学 Clinical Pharmacy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。（Clinical pharmacy is a discipline concerned with the application of pharmaceutical expertise to help maximise drug efficacy and minimise drug toxicity in individual patients.）临床药学服务 Clinical pharmacy service临床药学服务 Clinical pharmacy service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 Pharmaceutical care药学监护 Pharmaceutical care1990年Robert Cipolle，Linda Strand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” （Pharmaceutical care is a patient-centred practice in which the practitioner assumes responsibility for a patient’s drug-related needs and is held accountable for this commitment.） null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。 （It is built up one patient at a time. It has three components: assessment of the patient‘s needs; development of a care plan; and follow up evaluation.） nullPharmaceutical services Clinical pharmacy servicesPharmaceutical careA Typical Day of a Clinical Pharmacist in UK A Typical Day of a Clinical Pharmacist in UK 英国临床药师的一天 Morning 8:30 – 12:00 (Coffee break 10:00 – 10:30) Morning 8:30 – 12:00 (Coffee break 10:00 – 10:30)See the blackboard Those admission Those dischargenullFor those who discharge today Prescribing their discharge drugs Contact with their local pharmacist Approach to the patient nullFor those who were admitted Medical history Drug history The knowledge of the patient Potential drug related problems Care plannullWard round Doctors, nurse and pharmacist Discussing about the drug related needs Afternoon 13:00 – 16:30Afternoon 13:00 – 16:30Review the other patients who has potential problems Signs and symptoms of the patients Laboratory tests Documented nullWard meetings Nurse meetings Pharmacists meetings Dispensing Library For the individual patient the Minnesota Model the British Model the Canadian Model the Australia ModelFor the individual patient the Minnesota Model the British Model the Canadian Model the Australia ModelThe Minnesota Model Holistic ApproachThe Minnesota Model Holistic Approachnull药学监护计划 （Pharmaceutical Care Plan)　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 null 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.aspirin 300mgCase         入院检查: BP 137/81 mmHg pulse 62 bpm respiratory rates 16 temperature 36℃ SaO2 97% on air Her JVP, HS were normal her chest was clear.     ECG 显示 ST 段升高, 诊断 急性下壁心肌梗塞 病史. Mrs DA 过去没有疾病记载 用药史 Mrs DA 住院前没有用过药物 诊断  null病人社会关系与丈夫一起住 吸烟 每天25 支 喝酒 每周20 units. nullUnit 8g or 10 ml of pure alcohol Half a pint of ordinary strength lager/beer/cider(3.5-4% A.B.V.) = 1 unit A 25ml pub measure of a spirit (40%A.B.V) =1 unit A small glass of wine(8-9%) =1 unit 1pint = 568ml 1unit=284ml beernullDay 1(09/01/04) streptokinase 1.5 mu iv 链激酶 metoclopramide 10mg iv 甲氧氯普胺 metoprolol 25mg 美托洛尔 Enoxaparin 40mg, 依诺肝素 aspirin 75mg, 阿司匹林 simvastatin 40mg 辛伐他丁 ramipril 2.5mg 雷米普利 Paracetamol 1g 扑热息痛null稍后复查, ECG 显示病人恢复良好 ,病人生命体征很好 BP 113/81 mmHg pulse 73bpm RR 17         Day 2(10/01/04) Mrs DA 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BP 73-97/34-69mmHg Metoprolol 25mg bd change to atenolol 25mg bd BP↑123/69mmHg         Day 4(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     Day 5(13/01/04) BP 83-113/47-65 Nicotine 帖剂 空腹血糖 10.7 mmol/l. 建议营养学家重新调整饮食 Ramipril 剂量由2.5mg增加到 5mg BD 今天可以出院 病人实验室数据病人实验室数据null出院带药:   Aspirin 75mg od Atenolol 25mg bd Ramipril 5mg bd Simvastatin 40mg od GTN spray 2puffs prn Nicotine Patch 15mg for 2 hours 急性心肌梗塞 Acute Myocardial Infarction 急性心肌梗塞 Acute Myocardial InfarctionEpidemiology The WHO estimated that in 2002, 12.6 percent of deaths worldwide were from ischemic heart disease. Ischemic heart disease is the leading cause of death in developed countries, but third to AIDS and lower respiratory infections in developing countries. nullRisk factors Risk factors for atherosclerosis are generally risk factors for myocardial infarction: Older age Male gender Cigarette smoking Hypercholesterolemia Diabetes Hypertension Obesity nullDiagnostic criteria WHO criteria have classically been used to diagnose MI; a patient is diagnosed with myocardial infarction if two (probable) or three (definite) of the following criteria are satisfied: Clinical history of ischaemic type chest pain lasting for more than 20 minutes Changes in serial ECG tracings Rise and fall of serum cardiac biomarkers such as creatine kinase, troponin I, and lactate dehydrogenase isozymes specific for the heart. nullTreatment of Myocardial infarction Treatment of infarction may be divided into three categories: immediate care that is designed to remove pain, prevent deterioration and improve cardiac function; management of complications, notably heart failure and arrhythmias; secondary prophylaxis , prevention of a further infarction or death. nullImmediate Care The timing of treatment is vital, since myocardial damage after onset of an acute ischemic episode is progressive and there are pathological data to suggest that it is irreversible at 6 hours null 急性心梗的治疗路径 Suspected MI within the last 24 hours Give soluble aspirin 300mg immediately(unless contraindicated or already given). Then 75mg daily (contraindications: recent GI bleeding or active peptic ulcer, known aspirin intolerance). Treatment of infarct pain IV Diamorphine2.5mg +/- IV metoclopramide 10mg. Obtain ECG and follow the thrombolysis protocol for Acute MI. If no contra-indications, initiate: Beta-blocker ACE inhibitor,especially if evidence of anterior MI or left ventricular dysfunction null 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 yesnullStreptokinase 1.5MU 50ml 0.9% NaCl or 5% glucose over 1 hour Alteplase within 6-12 hours, 10mg iv, then 50mg intravenous infusion over 60 minutesSince the presence of antistreptokinase antibodies from day 5 to 12 months post administration may render further treatment during this time ineffective, it is important to document the patient had been given streptokinase and to issue the patient with a “streptokinase card” which includes the date of administration. nullLifestyleLifestyleImproving diet Advise patients not to take supplements containing beta-carotene. Do not advise patients to take antioxidant supplements (vitamin E and/or C) or folic acid to reduce cardiovascular risk. Advise patients to consume at least 7 g of omega 3 fatty acids per week from two to four portions of oily fish. Consider providing at least 1 g daily of omega-3-acid ethyl esters treatment licensed for secondary prevention post MI for up to 4 years for patients who have had an MI within 3 months and are not achieving 7 g of omega 3 fatty acids per week. Do not routinely initiate omega-3-acid ethyl esters supplements for patients who have had an MI more than 3 months earlier. Encourage patients to eat a Mediterranean-style diet.nullDelivering dietary Give consistent healthy eating advice that is tailored to the patient’s needs and that can be extended advice to the whole family. Offer patients an individual consultation to discuss diet, including their current eating habits, and advice on improving their diet. nullControlling alcohol Advise patients to keep weekly alcohol consumption within safe limits (no more than 21 units of consumption alcohol per week for men or 14 units per week for women) and to avoid binge drinking. Smoking cessation Advise smokers to quit and offer assistance from a smoking cessation service. Offer smokers who have expressed a desire to quit support, advice and referral to an intensive support service. If a patient is unable or unwilling to accept a referral, offer pharmacotherapy. Controlling weight Offer overweight and obese patients advice and support to achieve and maintain a healthy weight. nullImproving physical activity levels Encourage patients to undertake sufficient regular physical activity to increase exercise capacity. They should aim to be physically active for 20–30 minutes a day to the point of slight breathlessness. For patients not achieving this, advise them to increase their activity in a step-by-step way, aiming to increase their exercise capacity. They should start at a level that is comfortable, and increase the duration and intensity of activity as they gain fitness. Discuss current and past activity levels and preferences with patients. The benefit of exercise may be enhanced by tailored advice from a suitably qualified professional.Cardiac rehabilitation after an acute MICardiac rehabilitation after an acute MICardiac rehabilitation programmes have been consistently shown to reduce mortality rates in CHD patients. Cardiac rehabilitation is the coordinated sum of interventions required to ensure the best possible physical, psychological and social conditions to enable the CHD patient to preserve or resume optimal functioning in society. It also aims to slow or reverse progression of the disease. Cardiac rehabilitation cannot be regarded as an isolated form or stage of therapy, but must be integrated within secondary prevention services, of which it forms only one facet (WHO definition, 1993). Cardiac rehabilitation in patients after MI reduces all-cause and cardiovascular mortality rates provided it includes an exercise component Drug therapy Drug therapy Offer all patients who have had an acute MI treatment with a combination of the following drugs: • ACE inhibitor • aspirin • beta-blocker • statin. nullACE inhibitors Offer ACE inhibitors early after presentation and titrate upwards to the maximum tolerated or target dose. Do not routinely prescribe ARBs unless the patient is intolerant or allergic to an ACE inhibitor. Continue ACE inhibitors indefinitely in patients with preserved LV function or LVSD, whether or not they have heart failure symptoms. Early after an acute MI, do not routinely use the combination of ACE inhibitor/ARB for patients with heart failure and/or LVSD. nullAssessment/monitoring Assess LV function in all patients who have had an MI. Measure renal function, serum electrolytes and BP before starting an ACE inhibitor or ARB and again within 1 or 2 weeks. Monitor patients as the dose is titrated and more frequently for patients at increased risk of deterioration in renal function. Monitor patients with chronic heart failure nullAntiplatelet therapy Offer aspirin and continue indefinitely. Do not offer clopidogrel alone as first-line therapy but consider it for patients with aspirin hypersensitivity. If the patient has not been treated with a combination of aspirin and clopidogrel during the acute phase of an MI, do not routinely initiate this combination. - Clopidogrel in combination with low-dose aspirin is recommended in the management of non-ST-segment-elevation acute coronary syndrome in people who are at moderate to high risk of MI or death. It is recommended that this combination is continued for 12 months after the most recent acute episode. Thereafter standard care, including low-dose aspirin alone, is recommended.null For patients after a STEMI treated with the combination of aspirin and clopidogrel during the first 24 hours, this combination should be continued for at least 4 weeks. Thereafter standard treatment including low-dose aspirin should be given unless there are other indications to continue dual antiplatelet therapy. For patients with a history of dyspepsia, consider a PPI and low-dose aspirin. For patients with a history of aspirin-induced ulcer bleeding whose ulcers have healed and who are H. pylori negative,consider a full-dose PPI and low-dose aspirin. nullBeta-blockers Offer a beta-blocker as soon as the patient is clinically stable and titrate upwards to the maximum tolerated dose. Continue treatment indefinitely. For patients with LVSD being offered treatment, a beta-blocker licensed for use in heart failure may be preferred. Carvedilol bisoprolol nullPotassium channel activators Nicorandil is not recommended to reduce cardiovascular risk. nullVitamin K antagonists High-intensity warfarin (INR >3) should not be considered as an alternative to aspirin in first-line treatment. For patients unable to take aspirin or clopidogrel, consider moderate-intensity warfarin (INR 2–3) for up to 4 years and possibly longer. The combination of warfarin and clopidogrel is not routinely recommended. nullCalcium channel blockers Do not routinely use calcium channel blockers for secondary prevention. If beta-blockers are contraindicated or need to be discontinued, consider diltiazem or verapamil for secondary prevention in patients without pulmonary congestion or LVSD. For patients who are stable, calcium channel blockers may be used to treat hypertension and/or angina. For patients with heart failure, use amlodipine and avoid verapamil, diltiazem and short-acting dihydropyridine agents in line with NICE clinical guideline nullAldosterone antagonists For patients with symptoms and/or signs of heart failure and LVSD, initiate treatment with an aldosterone antagonist licensed for post-MI treatment within 3–14 days of the MI, preferably after ACE inhibitor therapy. For patients with clinical heart failure and LVSD already being treated with an aldosterone antagonist for a concomitant condition, continue with the aldosterone antagonist or an alternative, licensed for early post-MI treatment. nullAssessment/monitoring Monitor renal function and serum potassium before and during treatment. If hyperkalaemia is a problem, halve the dose or stop the treatment. nullStatins and other lipid lowering agents Statin treatment is recommended for adults with clinical evidence of CVD and should be offered as soon as possible. Discuss the risks and benefits of treatment with the patient, taking into account comorbidities and life expectancy. Start therapy with a drug with a low acquisition cost (taking into account required daily dose and product price per dose). nullFor patients intolerant of statins, other lipid lowering agents should be considered. Reduce or stop the dose of statins if there are issues surrounding the metabolic pathway, food and/or drug interactions and/or concomitant illness. Discontinue the statin and seek specialist advice if patients develop peripheral neuropathy that may be attributable to the statin treatment. nullAssessment/monitoring Measure baseline liver enzymes before initiation. Do not routinely exclude patients who have raised liver enzymes from treatment. Routine monitoring of creatine kinase in asymptomatic patients is not recommended, but should be measured in patients who develop muscle symptoms. Patient Education Patient Education Education and stress management programmes reduce cardiac mortality and MI recurrence in post MI patients Questions you might like to ask about medicines How long will I have to take the medicines for? What is the best time of day to take the medicines? Are there any serious side effects associated with the medicines? What should I do if I get any side effects? Are there any foods or drinks that I should avoid? What sort of improvements might I expect to notice? How long will it take to notice any effect? 药学监护计划（PHARMACEUTICAL CARE PLAN） 药学监护计划（PHARMACEUTICAL CARE PLAN） nullnullnullnullThanksThanks