# 情境 75歲MRSA肺炎個案接受vancomycin，第5天檢驗：creatinine自1.0升至1.7 mg/dL、尿量降至0.4 mL/kg/h、vancomycin trough 25 mg/L、合併使用gentamicin且昨日有IV顯影劑。優先護理為何?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375223&lang=zh-tw  
> language: zh-TW  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## 題目

情境 75歲MRSA肺炎個案接受vancomycin，第5天檢驗：creatinine自1.0升至1.7 mg/dL、尿量降至0.4 mL/kg/h、vancomycin trough 25 mg/L、合併使用gentamicin且昨日有IV顯影劑。優先護理為何?

## 選項

1. 繼續使用vancomycin，並通知處方醫師考慮加入furosemide以促進排尿；肌酸酐上升可能是顯影劑引起的腎病變，而非vancomycin毒性；預期暫停gentamicin、增加靜脈輸液以促進腎臟清除、24小時後重複檢查肌酸酐及波谷濃度、維持嚴格輸出入量記錄，並繼續vancomycin療程。
2. 繼續使用vancomycin，並依方案給予acetylcysteine和sodium bicarbonate治療顯影劑引起的腎病變；肌酸酐上升是靜脈注射顯影劑的已知影響，並非vancomycin毒性；預期暫停gentamicin、增加靜脈輸液以提升腎臟清除率、12小時後重複檢查肌酸酐及波谷濃度、維持嚴格輸出入量與每日體重監測，並注意聽力變化。
3. 繼續以目前劑量和時程給予vancomycin，因為1.7 mg/dL的肌酸酐在75歲個案中並未顯著升高，可能僅反映年齡相關的衰退；若肌酸酐上升超過2.0 mg/dL或尿量降至0.3 mL/kg/h以下，應通知處方醫師；持續嚴格輸出入量、每日體重，48小時後重複檢驗，並維持gentamicin及計劃下一次顯影檢查。
4. 暫停下一劑vancomycin並通知處方者；表現為vancomycin相關AKI且因gentamicin與顯影劑加成；預期暫停或減量、再驗creatinine與trough、嚴格I/O與每日體重、檢視並減少其他腎毒性藥物、評估聽力與平衡之耳毒性。 **✔ 正確答案**

**正確答案: 4**

## 解析

Vancomycin於trough超過15~20 mg/L、療程超過7天、原有腎損、高齡、低血容、合併腎毒性藥物(aminoglycoside、IV顯影劑、NSAID、ACEi、ARB、loop diuretic、部分研究中的piperacillin-tazobactam)時更易造成AKI。本案 — 高齡、creatinine上升、少尿、超過治療範圍的trough 25 mg/L、合用gentamicin、最近顯影劑 — 強烈提示vancomycin相關AKI。標準護理：(1) 暫停下一劑並聯絡處方者；(2) 預期暫停或減量、再驗creatinine與trough、可能改AUC或替代藥(linezolid、daptomycin)；(3) 嚴格I/O、每日體重、監測液體過量與電解質；(4) 檢視並減少其他腎毒性(可行時暫停NSAID與ACEi/ARB、評估顯影劑必要性、依感染科建議暫停或減量gentamicin)；(5) 耳毒性評估 — 聽力改變、耳鳴、暈眩、平衡 — vancomycin於高trough可造成聽覺/前庭毒性；(6) 無禁忌時確保足夠水分。維持同劑量、增量、加用NSAID皆不安全並使腎損惡化。

## 深入解析

暫停加上通知、調整劑量、減少腎毒性、監測耳毒性。Vancomycin AKI為NCLEX高頻安全主題。

## 重要概念

- **vancomycin nephrotoxicity** — trough>20、>7天、高齡、合併腎毒性、AKI、暫停/減量、AUC再給藥
- **concurrent nephrotoxins** — aminoglycoside、顯影劑、NSAID、ACEi/ARB、loop、pip-tazo，累積風險
- **vancomycin ototoxicity** — 高trough、聽力改變、耳鳴、暈眩、平衡，需評估聽覺與前庭

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