目的：探讨临床药师参与心脏瓣膜置换术后并发急性肾衰竭患者的抗凝治疗、协助医师制订连续肾脏替代疗法（continuous renal replacement therapy ，CRRT）用药方案的实践。方法：临床药师参与3例典型心脏瓣膜置换术后并发急性肾衰竭患者的药物治疗过程，阐明心脏瓣膜置换术后并发急性肾衰竭的三大常见原因及其CRRT抗凝治疗方案，根据不同病因制订个体化的CRRT抗凝方案，并跟进治疗效果，提供药学服务，调整治疗方案。结果：医师接受了临床药师的治疗建议，患者治疗过程顺利，病情好转出院。结论：临床药师根据自身掌握的疾病病理生理特点和药学知识，可以有效地协助医师确立更适当的个体化治疗方案。%OBJECTIVE:To probe into the participation of clinical pharmacists in anticoagulant therapy for patients with acute renal failure after cardiac valve replacement , and the assist for clinicians in formulation of medication scheme of continuous renal replacement therapy (CRRT).METHODS: The clinical pharmacists participated into the whole therapeutic process of three patients with acute renal failure after typical cardiac valve replacement , explained three common causes of acute renal failure after typical cardiac valve replacement and the CRRT anticoagulant therapy scheme and formulated the individualized scheme according to different causes , so as to provide pharmaceutical care for patients and adjust the therapeutic scheme .RESULTS: The clinicians received the suggestions provided by the clinical pharmacists .The patients got better and discharged from hospital .CONCLUSIONS: The clinical pharmacists can effectively assist the clinicians to establish more appropriate individualized therapeutic scheme according to their own mastery of disease pathology physiology characteristics and the medicine knowledge .
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