美國專科藥師認證經驗與臨床藥事照護案例分享 (bcccp急重症 ...

美國專科藥師認證經驗與臨床藥事照護案例分享(BCCCP急重症加護專科)

臺北榮總藥學部臨床藥學科陳佳慧藥師

20190905

Taipei Veterans General Hospital

Outline

bull Preparation for Critical care pharmacy specialist certification

bull Experiences of clinical pharmacy services in ICU


Critical Care Pharmacy Specialist Certification Content Outline

bull Domains

bull Clinical Knowledge and Application (65 percent of examination)

bull Practice Management Policy and Quality Improvement (15 percent of examination)

bull Evidence-Based Medicine Scholarship Education and Professional Development (20 percent of examination)


10 Sections (51 chapters)

bull Supportive care

bull Infectious disease

bull Neurocritical care

bull Hematology

bull Acute kidney injury

bull LiverGastrointestinal

bull Acute pulmonary disease

bull Cardiovascular critical care

bull Other Emergencies

bull Miscellaneous

ISBN 978-1-939862-20-4 2016 1072 pages

Price PrinteBook ($12995 member $10995)


The workbook includes

bull Chapters offering a comprehensive review of the full scope of Critical Care Pharmacy

bull Over 200 patient cases with explained answers to enhance your case based learning

bull Over 200 self-assessment questions with explained answers

bull Current and relevant references at the end of each chapter

Release date May 15 2019

Workbook Price

bull Print $275 member $175

bull Online (printable pdf) $265 member $165

Audio-synchronized slide presentations available online


ICU藥師參與臨床服務項目

bull Morning meeting

bull Ward round with doctors

bull 一位臨床藥師搭配一位主治醫師每日直接照顧約15床病人

bull 用藥合理性評估

bull Medication reconciliation

bull 建議用藥SOAP

bull Medication Error

bull Therapeutic Drug Monitoring

bull 藥物諮詢

bull ADR通報

bull 教學研究及文章發表

bull 跟診(每週1次)

bull 參與會議

bull 跨領域主任總查房臨床教學暨超其住院病人討論會議 (每週1次)

bull 期刊學術討論會議 (每週1-2次)

bull 死亡臨床病例討論會 (每月2-3例)

bull 重症Grand round (每2月1次)

Everyday 其他


Critical Thinking Skills

Adam M et al American Journal of Pharmaceutical Education 2019 83 Article 7033


Cases Discussion


bull Pneumonia related septic shock with respiratory failure sp ETT+MV

bull BAL yeast (+) under voriconazole empirical Abx with imipenem+teicoplanin

bull Anti-Glomerulus membrane disease with RPGN in ESRD sp renal transplant on 951021 in China under tacrolimus prednisolone and mycophenolic acid Complicated hematuria acute allograft kidney cellular rejection -sp MTP pulse therapy (500mg qd x3) x2 sp HD

WBC 13800 CRP 214 PCT 07 PLT 125000 Scr 315 Na 138 K 46

DDI voriconazole+tacrolimus

bull Voriconazole may increase the serum concentration of tacrolimus

Case 1Ms H 63 yo 148 cm 419 kg

S

O

A


DrugdoseroutefrequencyAugust September

11 14 17 20 23 26 29 1 3 5 7 9 11 13 15 17

Tacrolimus cap 1 mg 1 PO Q12H

Tacrolimus cap 05 mg 05 PO QD

Mycophenolic acid tab 180 mg 1 PO QD

Prednisolone tab 5 mg 1 PO QD

Methylprednisolone inj 3125 mg IVA Q12H

Tazocinreg inj 225 g IVA Q8HV

Sevatrimreg inj 5 ml 4 amp IVA QD

Bacidereg tab 400 mg 1 PO Q12H

Tienam 1000 mg IVA Q12H

Teicoplanin inj 600 mg IVA QO

Voriconazole tab 200 mg 1 PO Q12H

Anidulafungin inj 100 mg IVA QD

Midazolam tab 75 mg 1 PO QN

Propofol inj 500 mg50 ml 3 BOT IVD Q8H

TDM of Tacrolimus 31 35 60 76 46 72 17 379206 71 67

Q8H Q12Htab 4 mg BIDCC

1Q12H

1QD 1

QN

1Q12H

2 BIW14

1QD


Study design A retrospective pharmacokinetic study

Study population

bull Recipients of allogeneic HSCT who had already been on a steady dose of oral tacrolimus and were started on oral voriconazole for the treatment or prophylaxis of aspergillosis

bull 25 patients were evaluable and retrospectively evaluated

Methods Determination of the concentrationdose (CD) ratio of tacrolimus before and after receiving voriconazole

Taipei Veterans General Hospital12

Case 1

Dosage of Tacrolimus

bull Before Voricoanzole 1 mg 1 QD + 05 mg 1 QN = 15 mgday

bull After adding Voriconazole 1 mg 1 Q12H = 2 mgday

bull Recommendation 13 of original dosage = 05 mgdayfollowed with frequent monitoring of the tacrolimus blood levels

bull DC tacrolimus till TDM level return to target

bull Shift voriconazole to anidulafungin inj 100 mg qd


11 14 17 20 23 26 29 1 3 5 7 9 11 13 15 17





TDM of Tacrolimus 31 35 60 76 46 72 17 379 206 71 67

1 Q12H 1 QD

1 QN

1 Q12H

1 QD

P


Case 2

Mr T 68 yo 175 cm 688 kg

bull Liver cirrhosis suspect HCV and alcohol related Child Pugh classification C (score 11)

bull He was admitted for liver transplantation (schedule OP date 1130)

bull Transfer to ICU on 1129 due to respiratory failure sp ETT+MV suspect aspiration pneumonia related

bull Acute on chronic renal failure suspect hepatorenal syndrome under midodrine 25 mg bid

bull WBC 11300 CRP 197 PCT 066 PLT 25000 BUN 100 Scr 175(1118)-gt238(1128) TB 752 (1118)-gt1217(1128) ALT 45

bull Na 139 K 41

S

O


Drugs Dosage Route Frequency Duration

Tazocinreg inj 225 g 225 g IVA Q6H 1129-

Aminopoly-Hreg inj 500 ml (AA 7) 1 BOT IVD QD 1117-

Diltiazem (Herbesserreg ) tab 30 mg 1 TAB PO TID 1120-

Fentanylreg inj 01 mg2ml 1 AMP IVD Q2HPRN 1130-

Furosemide (Lasixreg ) inj 20 mg1ml 1 AMP IVA Q12H 1129-

Insulin aspart (Novorapidreg ) inj 100uml 666 IU SC TIDAC 1117-

Insulin detemir (Levemirreg ) inj 100uml 10 IU SC QN 1117-

Midodrine (Midorinereg ) tab 25 mg 1 TAB PO BID 1124-

Spironolactone (Spirotonereg ) tab 25 mg 2 TAB PO TID 1117-

Ursodeoxycholic (Ursolicreg ) tab 100 mg 1 TAB PO TID 1117-

Taipei Veterans General HospitalNassar Junior AP et al PLoS One 2014

Adverse eventsMortality rates at 30 days

AASLD guideline 2012 recommendationsAlbumin infusion plus administration of norepinephrine should also be considered in the treatment of type I hepatorenal syndrome when the patient is in the intensive care unit (Class IIa Level A)

Nassar Junior AP et al PLoS One 2014


Case 2bull Reassess the treatment of

type 1 hepatorenal syndrome

bull Insufficient dosage of midodrine for hepatorenalsyndrome

bull Please consider to DC midodrine and add norepinephrine 05-3 mghr+ albumin 1 gkg (70 g) on the first day then 20-40 gday

bull Please monitor vital signs renalhepatic function

A

P

Date


Case 3Mrs C 81 yo 150 cm 775 kg

bull Active problem

bull Left upper pole renal tumor in favor of renal cell carcinoma

bull Pyuria

bull Underlying disease

bull Type 2 DM HTN Af Heart failure COPD

bull Smoking(-) alcohol(-) drug allergy(-)

S O Urine routine 54 RBC 11-20 WBC 4+ squamous epi 3-5 pH 60 protein 10057 RBC 1+ WBC 4+ squamous epi21-35 pH 55 protein 100516 RBC 1+ WBC 4+ squamous epi6-10 pH 55 protein 100

Urine culture 503 GNB 20000ml GPC 30000ml507 Enterococcus faecium 2000ml yeast 5000ml516 Candida tropicalis

Sputum culture513 Acinetobacter baumanniicomplex


bull Lab dataBUN7-20

Scr05-12

Ccrgt60

ALT0-40

TB02-16

CRP0-05

ALB38-51

0506 35 141 346 lt5 096 355 38

0510 41 101 488 9 038 446 -

0516 45 090 538 18 031 419 35

0524 46 071 682 22 - 154 40

Na135-147

K34-47

WBC4500-11000

Hb14-18

PLT15k-35k

Glu65-115

0506 137 37 23900 152 128000 204

0510 139 33 15500 112 138000 257

0516 148 47 16600 112 367000 -

0524 147 35 21000 101 253000 -


Drug ProfileDrugs Dosage Route Frequency Duration

Cefazolin (Veterinreg ) inj 1000 mg 1000 mg IVA Q12H 20180503-0505

Piperacillintazobactam (Tazocinreg ) inj 225 g 45 g IVD Q6H 20180505-0514

Cefoperazonesulbactam (Brosymreg ) inj 1 g 2000 mg IVA Q12H 20180514-

Teicoplanin (Targocidreg ) inj 400 mg 600 mg IVA QD 20180510-0521

Anidulafungin (Erasixreg ) inj 100 mg 100 mg IVA QD 20180516-


Midazolam (Dormicumreg ) inj 5 mg5ml 1 AMP IVD Q2HPRN 20180506-

Pantoprazole (Pantolocreg ) inj 40 mg 40 mg IVA QD 20180506-

Esomeprazole (Nexiumreg ) tab 40 mg 1 TAB NGT QD 20180509-

Furosemide (Lasixreg ) inj 20 mg2ml 1 AMP IVA Q12H 20180507-0510

Insulin aspart 3070 (Novomix 30 FlexPenreg ) 1077 IU SC TIDAC 20180503-

Insulin glargine (Toujeoreg ) 15 IU SC HS 20180503-


Clinical Evaluation

CandiduriaRepeat culture of mid-stream urine sample

Candida (+)

Candida (-)

Asymptomatic

Symptomatic

Previous healthy pt

Predisposed outpatient

Predisposed inpatient

ObservationManage predisposing

conditions

Evidence for disseminated candidiasisUnstableneutropenic pt

Treatment

Treatment


Management for Candiduriabull Discontinuation of catheter

bull Medications

bull Fluconazole 200 mgday IV for 7-14 days (not Cglabrata or C krusei)

bull Amphotericin B deoxycholate 03-10 mgkgday IV for 1-7 days

bull Flucytocine 25 mgkg qid PO (alternative choice for Cglabrata)

bull Amphotericin B bladder irrigation highly effective in eradication of Candida cystitis but the effect is transient

bull Surgery Strongly recommended for urinary fungus balls

IDSA Infectious Diseases Association of America

Drug of Choice


Pharmacokinetic Parameters of Echinocandins

VariableCaspofunginCancidasreg

MicafunginMycaminereg

AnidulafunginErasixreg

T12 (hrs) 9-11 11-17 24-26

Vd (Lkg) 014 (967L) 0215-0242 05 (30-50 L)

AUC (mghL) 879-1148 1113 444-53

Protein binding () 96-97 998 84

Metabolism Via slow peptide hydrolysis and N-acetylation Also spontaneously degrades to inactive product

Via catechol-O-methyltransferase pathway

Not metabolised undergoes slow chemical degradation to inactive metabolites

Elimination 35 feces 41 urine (sim14 as unchanged drug)

40 feces lt15 urine(lt 1 as unchanged drug)

Primarily in feces (lt10 as intact drug) 1 urine

Dosage adjustment in renal insufficiency

No dose adjustment needed



Dosage adjustment in hepatic insufficiency

Child-Pugh class BC70 mg on day 1 followed by 35 mg once daily




Evidences of Echinocandins for CandiduriaResearch Caspofungin (Cancidasreg ) Micafungin (Mycaminereg )

Sobel JD et al Clin Infect Dis 2007(Case series)

bull 6 pts with significant candiduriabull 3 cases secondary to hematogenous

renal candidiasis were promptly eradicated

bull 3 cases of complicated ascending candida glabrata infection successfully treated

Schelenz SBMC Infect Dis 2006(Case report)

A case of obstructive pyonephrosis due to candida glabrata strain that failed to respond to intravenous treatment with caspofungin

Kane LE Muzevich KMMed Mycol Case Rep 2016(Case series)

5 cases with candiduria had resolution of baseline fungal with micafungin treated for a minimum of 6 days

Gabardi S et alInt Urol Nephrol 2016(Retrospective analysis)

bull 16 cases with candiduria (C albican39 C kruseiampglarata 33)

bull Short- and long-term urine sterilization

Grau S et alInt J Antimicrob Agents 2016 (Case series)

4 of 6 cases with fluconazole-resistant Candida spp UTI successfully treated


bull Suboptimal selection of anidulafungin concentration of urine lt1

bull Please switch anidulafungin to fluconazole 200 mg qdIVA

bull Please monitor fluconazole related side effects such as hepatotoxicity and prolonged Q-T interval on ECG etc

bull Please monitor vital signs infection signs and renalhepatic function

A

P


After Certification 重症Grand round

海外經驗分享教學~


Thank You


Outline

bull Preparation for Critical care pharmacy specialist certification

bull Experiences of clinical pharmacy services in ICU



bull Domains









bull Hematology






bull Miscellaneous

ISBN 978-1-939862-20-4 2016 1072 pages









Workbook Price














bull 藥物諮詢

bull ADR通報



bull 參與會議





Everyday 其他





Cases Discussion









S

O

A



11 14 17 20 23 26 29 1 3 5 7 9 11 13 15 17

















1Q12H

1QD 1

QN

1Q12H

2 BIW14

1QD



Study population





Case 1








11 14 17 20 23 26 29 1 3 5 7 9 11 13 15 17






1 Q12H 1 QD

1 QN

1 Q12H

1 QD

P


Case 2

Mr T 68 yo 175 cm 688 kg






bull Na 139 K 41

S

O























A

P

Date



bull Active problem


bull Pyuria









Scr05-12

Ccrgt60

ALT0-40

TB02-16

CRP0-05

ALB38-51

0506 35 141 346 lt5 096 355 38

0510 41 101 488 9 038 446 -

0516 45 090 538 18 031 419 35

0524 46 071 682 22 - 154 40

Na135-147

K34-47

WBC4500-11000

Hb14-18

PLT15k-35k

Glu65-115

0506 137 37 23900 152 128000 204

0510 139 33 15500 112 138000 257

0516 148 47 16600 112 367000 -

0524 147 35 21000 101 253000 -
















Clinical Evaluation


Candida (+)

Candida (-)

Asymptomatic

Symptomatic

Previous healthy pt




conditions


Treatment

Treatment



bull Medications







Drug of Choice






T12 (hrs) 9-11 11-17 24-26

Vd (Lkg) 014 (967L) 0215-0242 05 (30-50 L)

AUC (mghL) 879-1148 1113 444-53




































A

P





Thank You



bull Domains









bull Hematology






bull Miscellaneous

ISBN 978-1-939862-20-4 2016 1072 pages









Workbook Price














bull 藥物諮詢

bull ADR通報



bull 參與會議





Everyday 其他





Cases Discussion









S

O

A



11 14 17 20 23 26 29 1 3 5 7 9 11 13 15 17

















1Q12H

1QD 1

QN

1Q12H

2 BIW14

1QD



Study population





Case 1








11 14 17 20 23 26 29 1 3 5 7 9 11 13 15 17






1 Q12H 1 QD

1 QN

1 Q12H

1 QD

P


Case 2

Mr T 68 yo 175 cm 688 kg






bull Na 139 K 41

S

O























A

P

Date



bull Active problem


bull Pyuria









Scr05-12

Ccrgt60

ALT0-40

TB02-16

CRP0-05

ALB38-51

0506 35 141 346 lt5 096 355 38

0510 41 101 488 9 038 446 -

0516 45 090 538 18 031 419 35

0524 46 071 682 22 - 154 40

Na135-147

K34-47

WBC4500-11000

Hb14-18

PLT15k-35k

Glu65-115

0506 137 37 23900 152 128000 204

0510 139 33 15500 112 138000 257

0516 148 47 16600 112 367000 -

0524 147 35 21000 101 253000 -
















Clinical Evaluation


Candida (+)

Candida (-)

Asymptomatic

Symptomatic

Previous healthy pt




conditions


Treatment

Treatment



bull Medications







Drug of Choice






T12 (hrs) 9-11 11-17 24-26

Vd (Lkg) 014 (967L) 0215-0242 05 (30-50 L)

AUC (mghL) 879-1148 1113 444-53




































A

P





Thank You






bull Hematology






bull Miscellaneous

ISBN 978-1-939862-20-4 2016 1072 pages









Workbook Price














bull 藥物諮詢

bull ADR通報



bull 參與會議





Everyday 其他





Cases Discussion









S

O

A



11 14 17 20 23 26 29 1 3 5 7 9 11 13 15 17

















1Q12H

1QD 1

QN

1Q12H

2 BIW14

1QD



Study population





Case 1








11 14 17 20 23 26 29 1 3 5 7 9 11 13 15 17






1 Q12H 1 QD

1 QN

1 Q12H

1 QD

P


Case 2

Mr T 68 yo 175 cm 688 kg






bull Na 139 K 41

S

O























A

P

Date



bull Active problem


bull Pyuria









Scr05-12

Ccrgt60

ALT0-40

TB02-16

CRP0-05

ALB38-51

0506 35 141 346 lt5 096 355 38

0510 41 101 488 9 038 446 -

0516 45 090 538 18 031 419 35

0524 46 071 682 22 - 154 40

Na135-147

K34-47

WBC4500-11000

Hb14-18

PLT15k-35k

Glu65-115

0506 137 37 23900 152 128000 204

0510 139 33 15500 112 138000 257

0516 148 47 16600 112 367000 -

0524 147 35 21000 101 253000 -
















Clinical Evaluation


Candida (+)

Candida (-)

Asymptomatic

Symptomatic

Previous healthy pt




conditions


Treatment

Treatment



bull Medications







Drug of Choice






T12 (hrs) 9-11 11-17 24-26

Vd (Lkg) 014 (967L) 0215-0242 05 (30-50 L)

AUC (mghL) 879-1148 1113 444-53




































A

P





Thank You








Workbook Price














bull 藥物諮詢

bull ADR通報



bull 參與會議





Everyday 其他





Cases Discussion









S

O

A



11 14 17 20 23 26 29 1 3 5 7 9 11 13 15 17

















1Q12H

1QD 1

QN

1Q12H

2 BIW14

1QD



Study population





Case 1








11 14 17 20 23 26 29 1 3 5 7 9 11 13 15 17






1 Q12H 1 QD

1 QN

1 Q12H

1 QD

P


Case 2

Mr T 68 yo 175 cm 688 kg






bull Na 139 K 41

S

O























A

P

Date



bull Active problem


bull Pyuria









Scr05-12

Ccrgt60

ALT0-40

TB02-16

CRP0-05

ALB38-51

0506 35 141 346 lt5 096 355 38

0510 41 101 488 9 038 446 -

0516 45 090 538 18 031 419 35

0524 46 071 682 22 - 154 40

Na135-147

K34-47

WBC4500-11000

Hb14-18

PLT15k-35k

Glu65-115

0506 137 37 23900 152 128000 204

0510 139 33 15500 112 138000 257

0516 148 47 16600 112 367000 -

0524 147 35 21000 101 253000 -
















Clinical Evaluation


Candida (+)

Candida (-)

Asymptomatic

Symptomatic

Previous healthy pt




conditions


Treatment

Treatment



bull Medications







Drug of Choice






T12 (hrs) 9-11 11-17 24-26

Vd (Lkg) 014 (967L) 0215-0242 05 (30-50 L)

AUC (mghL) 879-1148 1113 444-53




































A

P





Thank You











bull 藥物諮詢

bull ADR通報



bull 參與會議





Everyday 其他





Cases Discussion









S

O

A



11 14 17 20 23 26 29 1 3 5 7 9 11 13 15 17

















1Q12H

1QD 1

QN

1Q12H

2 BIW14

1QD



Study population





Case 1








11 14 17 20 23 26 29 1 3 5 7 9 11 13 15 17






1 Q12H 1 QD

1 QN

1 Q12H

1 QD

P


Case 2

Mr T 68 yo 175 cm 688 kg






bull Na 139 K 41

S

O























A

P

Date



bull Active problem


bull Pyuria









Scr05-12

Ccrgt60

ALT0-40

TB02-16

CRP0-05

ALB38-51

0506 35 141 346 lt5 096 355 38

0510 41 101 488 9 038 446 -

0516 45 090 538 18 031 419 35

0524 46 071 682 22 - 154 40

Na135-147

K34-47

WBC4500-11000

Hb14-18

PLT15k-35k

Glu65-115

0506 137 37 23900 152 128000 204

0510 139 33 15500 112 138000 257

0516 148 47 16600 112 367000 -

0524 147 35 21000 101 253000 -
















Clinical Evaluation


Candida (+)

Candida (-)

Asymptomatic

Symptomatic

Previous healthy pt




conditions


Treatment

Treatment



bull Medications







Drug of Choice






T12 (hrs) 9-11 11-17 24-26

Vd (Lkg) 014 (967L) 0215-0242 05 (30-50 L)

AUC (mghL) 879-1148 1113 444-53




































A

P





Thank You





Cases Discussion









S

O

A



11 14 17 20 23 26 29 1 3 5 7 9 11 13 15 17

















1Q12H

1QD 1

QN

1Q12H

2 BIW14

1QD



Study population





Case 1








11 14 17 20 23 26 29 1 3 5 7 9 11 13 15 17






1 Q12H 1 QD

1 QN

1 Q12H

1 QD

P


Case 2

Mr T 68 yo 175 cm 688 kg






bull Na 139 K 41

S

O























A

P

Date



bull Active problem


bull Pyuria









Scr05-12

Ccrgt60

ALT0-40

TB02-16

CRP0-05

ALB38-51

0506 35 141 346 lt5 096 355 38

0510 41 101 488 9 038 446 -

0516 45 090 538 18 031 419 35

0524 46 071 682 22 - 154 40

Na135-147

K34-47

WBC4500-11000

Hb14-18

PLT15k-35k

Glu65-115

0506 137 37 23900 152 128000 204

0510 139 33 15500 112 138000 257

0516 148 47 16600 112 367000 -

0524 147 35 21000 101 253000 -
















Clinical Evaluation


Candida (+)

Candida (-)

Asymptomatic

Symptomatic

Previous healthy pt




conditions


Treatment

Treatment



bull Medications







Drug of Choice






T12 (hrs) 9-11 11-17 24-26

Vd (Lkg) 014 (967L) 0215-0242 05 (30-50 L)

AUC (mghL) 879-1148 1113 444-53




































A

P





Thank You









S

O

A



11 14 17 20 23 26 29 1 3 5 7 9 11 13 15 17

















1Q12H

1QD 1

QN

1Q12H

2 BIW14

1QD



Study population





Case 1








11 14 17 20 23 26 29 1 3 5 7 9 11 13 15 17






1 Q12H 1 QD

1 QN

1 Q12H

1 QD

P


Case 2

Mr T 68 yo 175 cm 688 kg






bull Na 139 K 41

S

O























A

P

Date



bull Active problem


bull Pyuria









Scr05-12

Ccrgt60

ALT0-40

TB02-16

CRP0-05

ALB38-51

0506 35 141 346 lt5 096 355 38

0510 41 101 488 9 038 446 -

0516 45 090 538 18 031 419 35

0524 46 071 682 22 - 154 40

Na135-147

K34-47

WBC4500-11000

Hb14-18

PLT15k-35k

Glu65-115

0506 137 37 23900 152 128000 204

0510 139 33 15500 112 138000 257

0516 148 47 16600 112 367000 -

0524 147 35 21000 101 253000 -
















Clinical Evaluation


Candida (+)

Candida (-)

Asymptomatic

Symptomatic

Previous healthy pt




conditions


Treatment

Treatment



bull Medications







Drug of Choice






T12 (hrs) 9-11 11-17 24-26

Vd (Lkg) 014 (967L) 0215-0242 05 (30-50 L)

AUC (mghL) 879-1148 1113 444-53




































A

P





Thank You



11 14 17 20 23 26 29 1 3 5 7 9 11 13 15 17

















1Q12H

1QD 1

QN

1Q12H

2 BIW14

1QD



Study population





Case 1








11 14 17 20 23 26 29 1 3 5 7 9 11 13 15 17






1 Q12H 1 QD

1 QN

1 Q12H

1 QD

P


Case 2

Mr T 68 yo 175 cm 688 kg






bull Na 139 K 41

S

O























A

P

Date



bull Active problem


bull Pyuria









Scr05-12

Ccrgt60

ALT0-40

TB02-16

CRP0-05

ALB38-51

0506 35 141 346 lt5 096 355 38

0510 41 101 488 9 038 446 -

0516 45 090 538 18 031 419 35

0524 46 071 682 22 - 154 40

Na135-147

K34-47

WBC4500-11000

Hb14-18

PLT15k-35k

Glu65-115

0506 137 37 23900 152 128000 204

0510 139 33 15500 112 138000 257

0516 148 47 16600 112 367000 -

0524 147 35 21000 101 253000 -
















Clinical Evaluation


Candida (+)

Candida (-)

Asymptomatic

Symptomatic

Previous healthy pt




conditions


Treatment

Treatment



bull Medications







Drug of Choice






T12 (hrs) 9-11 11-17 24-26

Vd (Lkg) 014 (967L) 0215-0242 05 (30-50 L)

AUC (mghL) 879-1148 1113 444-53




































A

P





Thank You



Study population





Case 1








11 14 17 20 23 26 29 1 3 5 7 9 11 13 15 17






1 Q12H 1 QD

1 QN

1 Q12H

1 QD

P


Case 2

Mr T 68 yo 175 cm 688 kg






bull Na 139 K 41

S

O























A

P

Date



bull Active problem


bull Pyuria









Scr05-12

Ccrgt60

ALT0-40

TB02-16

CRP0-05

ALB38-51

0506 35 141 346 lt5 096 355 38

0510 41 101 488 9 038 446 -

0516 45 090 538 18 031 419 35

0524 46 071 682 22 - 154 40

Na135-147

K34-47

WBC4500-11000

Hb14-18

PLT15k-35k

Glu65-115

0506 137 37 23900 152 128000 204

0510 139 33 15500 112 138000 257

0516 148 47 16600 112 367000 -

0524 147 35 21000 101 253000 -
















Clinical Evaluation


Candida (+)

Candida (-)

Asymptomatic

Symptomatic

Previous healthy pt




conditions


Treatment

Treatment



bull Medications







Drug of Choice






T12 (hrs) 9-11 11-17 24-26

Vd (Lkg) 014 (967L) 0215-0242 05 (30-50 L)

AUC (mghL) 879-1148 1113 444-53




































A

P





Thank You


Case 1








11 14 17 20 23 26 29 1 3 5 7 9 11 13 15 17






1 Q12H 1 QD

1 QN

1 Q12H

1 QD

P


Case 2

Mr T 68 yo 175 cm 688 kg






bull Na 139 K 41

S

O























A

P

Date



bull Active problem


bull Pyuria









Scr05-12

Ccrgt60

ALT0-40

TB02-16

CRP0-05

ALB38-51

0506 35 141 346 lt5 096 355 38

0510 41 101 488 9 038 446 -

0516 45 090 538 18 031 419 35

0524 46 071 682 22 - 154 40

Na135-147

K34-47

WBC4500-11000

Hb14-18

PLT15k-35k

Glu65-115

0506 137 37 23900 152 128000 204

0510 139 33 15500 112 138000 257

0516 148 47 16600 112 367000 -

0524 147 35 21000 101 253000 -
















Clinical Evaluation


Candida (+)

Candida (-)

Asymptomatic

Symptomatic

Previous healthy pt




conditions


Treatment

Treatment



bull Medications







Drug of Choice






T12 (hrs) 9-11 11-17 24-26

Vd (Lkg) 014 (967L) 0215-0242 05 (30-50 L)

AUC (mghL) 879-1148 1113 444-53




































A

P





Thank You


Case 2

Mr T 68 yo 175 cm 688 kg






bull Na 139 K 41

S

O























A

P

Date



bull Active problem


bull Pyuria









Scr05-12

Ccrgt60

ALT0-40

TB02-16

CRP0-05

ALB38-51

0506 35 141 346 lt5 096 355 38

0510 41 101 488 9 038 446 -

0516 45 090 538 18 031 419 35

0524 46 071 682 22 - 154 40

Na135-147

K34-47

WBC4500-11000

Hb14-18

PLT15k-35k

Glu65-115

0506 137 37 23900 152 128000 204

0510 139 33 15500 112 138000 257

0516 148 47 16600 112 367000 -

0524 147 35 21000 101 253000 -
















Clinical Evaluation


Candida (+)

Candida (-)

Asymptomatic

Symptomatic

Previous healthy pt




conditions


Treatment

Treatment



bull Medications







Drug of Choice






T12 (hrs) 9-11 11-17 24-26

Vd (Lkg) 014 (967L) 0215-0242 05 (30-50 L)

AUC (mghL) 879-1148 1113 444-53




































A

P





Thank You























A

P

Date



bull Active problem


bull Pyuria









Scr05-12

Ccrgt60

ALT0-40

TB02-16

CRP0-05

ALB38-51

0506 35 141 346 lt5 096 355 38

0510 41 101 488 9 038 446 -

0516 45 090 538 18 031 419 35

0524 46 071 682 22 - 154 40

Na135-147

K34-47

WBC4500-11000

Hb14-18

PLT15k-35k

Glu65-115

0506 137 37 23900 152 128000 204

0510 139 33 15500 112 138000 257

0516 148 47 16600 112 367000 -

0524 147 35 21000 101 253000 -
















Clinical Evaluation


Candida (+)

Candida (-)

Asymptomatic

Symptomatic

Previous healthy pt




conditions


Treatment

Treatment



bull Medications







Drug of Choice






T12 (hrs) 9-11 11-17 24-26

Vd (Lkg) 014 (967L) 0215-0242 05 (30-50 L)

AUC (mghL) 879-1148 1113 444-53




































A

P





Thank You



bull Active problem


bull Pyuria









Scr05-12

Ccrgt60

ALT0-40

TB02-16

CRP0-05

ALB38-51

0506 35 141 346 lt5 096 355 38

0510 41 101 488 9 038 446 -

0516 45 090 538 18 031 419 35

0524 46 071 682 22 - 154 40

Na135-147

K34-47

WBC4500-11000

Hb14-18

PLT15k-35k

Glu65-115

0506 137 37 23900 152 128000 204

0510 139 33 15500 112 138000 257

0516 148 47 16600 112 367000 -

0524 147 35 21000 101 253000 -
















Clinical Evaluation


Candida (+)

Candida (-)

Asymptomatic

Symptomatic

Previous healthy pt




conditions


Treatment

Treatment



bull Medications







Drug of Choice






T12 (hrs) 9-11 11-17 24-26

Vd (Lkg) 014 (967L) 0215-0242 05 (30-50 L)

AUC (mghL) 879-1148 1113 444-53




































A

P





Thank You



Scr05-12

Ccrgt60

ALT0-40

TB02-16

CRP0-05

ALB38-51

0506 35 141 346 lt5 096 355 38

0510 41 101 488 9 038 446 -

0516 45 090 538 18 031 419 35

0524 46 071 682 22 - 154 40

Na135-147

K34-47

WBC4500-11000

Hb14-18

PLT15k-35k

Glu65-115

0506 137 37 23900 152 128000 204

0510 139 33 15500 112 138000 257

0516 148 47 16600 112 367000 -

0524 147 35 21000 101 253000 -
















Clinical Evaluation


Candida (+)

Candida (-)

Asymptomatic

Symptomatic

Previous healthy pt




conditions


Treatment

Treatment



bull Medications







Drug of Choice






T12 (hrs) 9-11 11-17 24-26

Vd (Lkg) 014 (967L) 0215-0242 05 (30-50 L)

AUC (mghL) 879-1148 1113 444-53




































A

P





Thank You
















Clinical Evaluation


Candida (+)

Candida (-)

Asymptomatic

Symptomatic

Previous healthy pt




conditions


Treatment

Treatment



bull Medications







Drug of Choice






T12 (hrs) 9-11 11-17 24-26

Vd (Lkg) 014 (967L) 0215-0242 05 (30-50 L)

AUC (mghL) 879-1148 1113 444-53




































A

P





Thank You



bull Medications







Drug of Choice






T12 (hrs) 9-11 11-17 24-26

Vd (Lkg) 014 (967L) 0215-0242 05 (30-50 L)

AUC (mghL) 879-1148 1113 444-53




































A

P





Thank You






T12 (hrs) 9-11 11-17 24-26

Vd (Lkg) 014 (967L) 0215-0242 05 (30-50 L)

AUC (mghL) 879-1148 1113 444-53




































A

P





Thank You





















A

P





Thank You





Thank You

美國專科藥師認證經驗與臨床藥事照護案例分享 (bcccp急重症 ...

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Transcript of 美國專科藥師認證經驗與臨床藥事照護案例分享 (bcccp急重症 ...

美國專科藥師認證經驗 與臨床藥事照護案例分享 (bcccp急重症 ...

Documents

Transcript of 美國專科藥師認證經驗 與臨床藥事照護案例分享 (bcccp急重症 ...

美國專科藥師認證經驗與臨床藥事照護案例分享 (bcccp急重症 ...

Transcript of 美國專科藥師認證經驗與臨床藥事照護案例分享 (bcccp急重症 ...