1例67岁女性患者，因风湿性心脏病、二尖瓣置换术后心衰入院治疗，入院时合并肺部感染、呼吸衰竭等多种疾病。入院后给予无创呼吸机辅助呼吸，抗凝、强心、利尿、化痰、平喘、抗感染等药物治疗。患者心衰症状逐渐改善，但胸片提示肺部感染加重，结合患者症状体征及辅助检查考虑真菌感染。针对患者的肺部真菌感染，临床药师建议加用伏立康唑（负荷剂量：6 mg·kg-1，q 12 h，维持剂量4 mg·kg-1，q 12 h）进行抗真菌治疗；针对患者国际标准化比值（INR）的波动，临床药师分析了药物间的相互作用对华法林抗凝强度的影响；并对患者由于使用噻嗪类利尿剂导致的电解质紊乱，抗菌药物可能导致的QT间期延长、尖端扭转型室速等不良反应进行了药学监护。经过15 d治疗，患者病情稳定转入普通病房继续治疗。%One 67-year-old female patient with pulmonary infection, respiratory failure and other diseases was hospitalized primary for rheumatic heart disease and heart failure after mitral valve replacement surgery. The patient was treated by non-invasive mechanical ventilation, and anticoagulation, cardiotonic, diuretic, eliminating sputum, antiasthmatic as well as anti-infectious drugs. The heart failure symptom of the patient improved, however the lung infection aggravated. Fungal infection was considered according to the clinical signs and laboratory examinations of the patient. Pharmaceutical cares were given to the patient by clinical pharmacists in respect of the selection and dose adjustment of the antifungal agent, fluctuations analysis of the international normalized ratio (INR) due to the interactions between the warfarin and other drugs, the treatment of electrolyte imbalance after long-term use of thiazide diuretic and monitoring the side effect of the antibacterials such as QT interval prolonged, ventricle speed torsade de pointe, etc. After 15-day treatment, the patient's symptom improved, and the patient was transferred to the general ward for further treatments.
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