识别ICU肝移植受者的药物相关问题(DRPs)，确定药师干预的潜在影响。

回顾性研究2020年1月至2021年12月复旦大学附属中山医院肝脏外科ICU药师在药学监护和咨询中确定的DRPs、干预措施和接受情况。两名药师使用欧洲医药保健网分类系统V9.1对DRPs进行分类，根据解决DRPs对肝移植受者治疗的潜在影响，以六分制标准独立评审药师的干预措施。使用Gephi 0.9.2软件分析DRPs与原因的网络关系。

药师在药学监护期间共检测到97个DRPs，最常见类型为"(可能)发生药物不良事件"(51.5%)，DRPs的原因类型中"药物选择"占比最高(61.9%)。药师对药学监护中确定的DRPs共提出220项干预措施，医师层面122项，"提供干预措施给医师"占比最高；药物层面98项，"停用药物"占比最高。绝大多数干预措施被评估为"非常重要"(10.3%)、"重要"(64.0%)和"有些重要"(24.7%)。经过药师干预，88.7%(86/97)的DRPs得到解决。根据药学咨询的内容，药师共确定114个DRPs，64.0%与抗感染药物有关，最常见类型为"治疗有效性和安全性"(39.5%)，DRPs的原因类型中"药物选择"占比最高(40.4%)。针对药学咨询中确定的DRPs，药师提出的干预措施除医师层面(n＝202)和药物层面(n＝83)外，还有其他介入或行为(n＝10)。除17个DRPs的干预措施因无目标患者无法直接评估外，其余97个DRPs的干预措施中，具有"非常重要"、"重要"和"有些重要"潜在影响的比例分别为19.6%、52.6%和26.8%。经过药师干预，97.4%(111/114)的DRPs得到全部或部分解决。比较在药学监护和药学咨询中确定的DRPs原因，发现医师和药师均较为关注包括药物相互作用在内的药物组合问题，医师遇到"肾或肝功能不全时药物剂量调整"、需要"额外的药物信息"或"无法获得药物"时，更倾向于寻求药师帮助。DRPs与原因的网络关系分析显示，药学监护中原因最多样化的DRPs为"(可能)发生药物不良事件"和"治疗效果不佳"，分别有10个和8个原因；药学咨询中原因最多样化的DRPs为"治疗有效性和安全性"，有7个原因。

药师能够识别并解决ICU肝移植受者的DRPs，针对性药学干预对肝移植受者的治疗具有积极影响。在肝移植团队中，医师和药师知识体系的互补，有利于保证用药的安全性和有效性。

To identify drug-related problems (DRPs) in liver transplant recipients in the intensive care unit (ICU) and determine the potential impact of pharmacist interventions.

A retrospective study was conducted to review the DRPs, interventions, and acceptance identified by pharmacists during pharmaceutical care and consultations in the liver surgery ICU at Zhongshan Hospital, Fudan University, from January 2020 to December 2021. Two pharmacists classified DRPs using the Pharmaceutical Care Network Europe V9.1. Pharmacist interventions were independently assessed using a six-point scale based on the potential impact on the treatment of liver transplant recipients in resolving DRPs. Gephi 0.9.2 network analysis software was used to analyze the relationships between DRPs and causes.

During pharmaceutical care, pharmacists identified 97 DRPs, with the most common "adverse drug event (possibly) occurring" (51.5%). Among the types of causes for DRPs, "drug selection" accounted for the highest proportion (61.9%). Pharmacists proposed 220 interventions for the identified DRPs, with 122 interventions at the prescriber level, predominantly involving "intervention proposed to prescriber" . There were 98 interventions at drug level, with "drug paused or stopped" being the most common. The vast majority of interventions were rated as "very significant" (10.3%), "significant" (64.0%), and "somewhat significant" (24.7%). Following pharmacist interventions, 88.7% (86/97) of the DRPs were resolved. In terms of consultations, pharmacists identified 114 DRPs, with 64.0% related to anti-infective drugs. Physicians were more concerned about "treatment effectiveness and safety, " and among the causes for DRPs, "drug selection" had the highest proportion (40.4%). In addition to prescriber-level (n=202) and drug-level (n=83) interventions, pharmacists proposed other interventions or behaviors (n=10) for the DRPs identified during consultations. Except for 17 DRPs where interventions could not be directly evaluated due to the lack of target patients, among the remaining 97 DRPs, the proportions of interventions by pharmacists with "very significant" , "significant" , and "somewhat significant" potential impact were 19.6%, 52.6%, and 26.8%, respectively. Comparing the causes of DRPs identified during pharmaceutical care and consultations, both physicians and pharmacists were concerned about drug combination issues, including drug interactions. Physicians were more prone to seek pharmacist assistance when encountering "dose adjustment of renal or liver insufficiency" , "needing supplementary drug information" , or facing "unavailable prescribed drugs" . Network analysis of the relationships between DRPs and causes revealed that the most diverse causes in pharmaceutical care were "adverse drug event" and "effect of drug treatment not optimal" , with 10 and 8 causes, respectively. In consultations, the most diverse causes were related to "treatment effectiveness and safety" , with 7 causes.

Pharmacists can identify and resolve DRPs in liver transplant recipients in the ICU, and targeted pharmaceutical interventions positively impact their treatment. The complementary knowledge systems of physicians and pharmacists within the liver transplant team are conducive to ensuring the safety and reliability of medication.