# 一位 78 歲、體重 70 公斤、肌酸酐廓清率 (CrCl) 22 mL/min 的個案，因急性肺栓塞入院治療。醫囑開立依諾肝素 1 mg/kg 皮下注射，每 12 小時一次。護理師最適當的措施為何？

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=374968&lang=zh-tw  
> language: zh-TW  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## 題目

一位 78 歲、體重 70 公斤、肌酸酐廓清率 (CrCl) 22 mL/min 的個案，因急性肺栓塞入院治療。醫囑開立依諾肝素 1 mg/kg 皮下注射，每 12 小時一次。護理師最適當的措施為何？

## 選項

1. 依照醫囑每12小時皮下注射enoxaparin 1 mg/kg；計劃在第三次給藥後4小時檢測抗Xa水平，因為即使皮下給藥，個案的腎功能不全仍可能改變藥物動力學。
2. 依照醫囑每12小時皮下注射enoxaparin 1 mg/kg；低分子量肝素依賴肝臟清除，並非經腎臟排除，因此即使肌酸酐清除率為22 mL/min，此方案仍屬適當。
3. 對於急性肺栓塞且肌酸酐清除率為22 mL/min的個案，每12小時皮下注射enoxaparin 0.5 mg/kg；此劑量減少考量了腎功能不全時延長的排除半衰期，以維持治療性抗凝血作用。
4. 暫停劑量並聯絡醫師 — 嚴重腎不全(CrCl **✔ 正確答案**

**正確答案: 4**

## 解析

依諾肝素與腎功能不全
依諾肝素（低分子量肝素）經腎臟清除。在重度腎功能不全 (CrCl

## 深入解析

為何選2
Enoxaparin(LMWH)經腎排泄 — 嚴重腎不全(CrCl

## 重要概念

- **CrCl·enoxaparin** — Creatinine clearance — 腎功能估算。Cockcroft-Gault·CKD-EPI。CrCl
- **Anti-Xa level** — LMWH·fondaparinux效果指標。SC後4小時peak。治療目標:0.5~1.0 IU/mL(q12h)或1.0~2.0 IU/mL(q24h)。預防0.2~0.5。腎不全·肥胖·懷孕·年齡極端者監測。UFH亦可用anti-Xa 0.3~0.7替代aPTT。
- **腎不全抗凝選擇** — CrCl

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