# 情境 6個月嬰兒哺乳的母親來電。孩子剛接受門診扁桃腺切除術，外科醫師為孩子開立含acetaminophen的codeine液與為母親開立codeine。最適當的護理回應為何?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375165&lang=zh-tw  
> language: zh-TW  
> subject: Medical Emergencies  
> category: PA

## 題目

情境 6個月嬰兒哺乳的母親來電。孩子剛接受門診扁桃腺切除術，外科醫師為孩子開立含acetaminophen的codeine液與為母親開立codeine。最適當的護理回應為何?

## 選項

1. 兩個處方劑量減半再使用。
2. 只拒絕母親處方，孩子按處方服用。
3. 兩個處方都不安全；codeine在12歲以下兒童、扁桃/腺樣切除術後18歲以下、哺乳婦女有FDA boxed warning；部分人為CYP2D6 ultra-rapid metabolizer會把codeine快速轉成高劑量morphine，可造成嬰兒呼吸停止；請聯絡外科醫師改為acetaminophen加ibuprofen，或必要時hydrocodone或oxycodone。 **✔ 正確答案**
4. 安全；codeine是最溫和的鴉片類，適合兒童與哺乳母親。

**正確答案: 3**

## 解析

Codeine為前驅藥，由CYP2D6轉為morphine。產生量隨基因型差異甚大，poor metabolizer止痛效果不佳，ultra-rapid metabolizer則迅速轉成極高morphine濃度，可造成致命性呼吸抑制。FDA發出嚴格boxed warning：(1) 12歲以下兒童任何適應症禁用；(2) 扁桃或腺樣切除術後18歲以下禁用，常規劑量亦曾致死；(3) 哺乳婦女禁用，morphine可進入母乳引起嬰兒呼吸停止死亡；(4) 12~17歲合併肥胖、睡眠呼吸中止或嚴重肺病更需警覺；(5) tramadol有同樣的小兒/哺乳警告。較安全替代：acetaminophen、ibuprofen(6個月以上)；需鴉片時改用hydrocodone或oxycodone短期。半量、僅拒一張、按處方使用都不安全。護理師應聯絡處方醫師告知boxed warning並請更改。

## 深入解析

哺乳母與扁桃切除後兒童使用codeine等於boxed warning絕對禁忌。看到codeine出現於兒童或哺乳就要立刻聯想到CYP2D6 ultra-rapid metabolizer。

## 重要概念

- **codeine prodrug** — 由CYP2D6轉為morphine的前驅藥，效果/毒性隨基因型大幅變異
- **CYP2D6 ultra-rapid metabolizer** — 快速將codeine轉成morphine，高濃度，致命呼吸抑制風險
- **pediatric/lactation boxed warning** — 12歲以下/T&A後18歲以下/哺乳期，codeine與tramadol絕對禁用

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