# シナリオ 68歳敗血症ICU患者がIV tobramycin・IV vancomycin・IV furosemide持続点滴・最近のCT IV造影剤を受けている。4日目にクレアチニン1.1→2.0 mg/dL上昇、尿量0.3 mL/kg/hに低下、薬局がtobramycinトラフ3.8 mg/Lを報告。最も適切な統合看護/ケア調整行為はどれか。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375228&lang=ja  
> language: ja  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## 問題

シナリオ 68歳敗血症ICU患者がIV tobramycin・IV vancomycin・IV furosemide持続点滴・最近のCT IV造影剤を受けている。4日目にクレアチニン1.1→2.0 mg/dL上昇、尿量0.3 mL/kg/hに低下、薬局がtobramycinトラフ3.8 mg/Lを報告。最も適切な統合看護/ケア調整行為はどれか。

## 選択肢

1. トラフ毒性克服のためtobramycin増量。
2. 敗血症で抗菌薬必須のため全薬を継続。
3. 次回tobramycinを保留し処方医と薬剤師に連絡・同時腎毒性を見直し最小化(furosemide持続中止検討・追加造影剤延期・vancomycin用量再評価)・培養に応じた非アミノグリコシド剤への保留/中止予期・厳密I/O・毎日体重・電解質・耳毒性監視・体液過剰なく適切な容量確保。 **✔ 正解**
4. 腎の炎症軽減のためNSAID追加。

**正解: 3**

## 解説

アミノグリコシド腎毒性は同時の腎毒性薬剤で著明に増幅 — ループ利尿薬(K・Mg喪失で耳毒性も増強)・IVヨード造影剤(血管収縮と尿細管障害)・vancomycin(近位尿細管毒性の加算)・NSAID・ACEi・ARB。治療域超のトラフ(3.8 mg/L、目標

## 詳細解説

敗血症患者の多剤腎毒性。tobramycin保留・腎毒性削減を協調・非アミノグリコシドへ変更・厳密I/Oと耳毒性監視。NSAIDと増量は罠。

## 重要概念

- **tobramycin** — アミノグリコシド・グラム陰性・緑膿菌・CFで吸入製剤・腎/耳毒性監視
- **polypharmacy nephrotoxicity** — アミノグリコシド+vancomycin+造影剤+利尿薬の累積リスク・薬剤協調レビュー
- **septic AKI** — 低灌流+直接腎毒性・多剤・精緻な容量管理・腎毒性薬剤保留

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