病人正在靜脈輸注萬古黴素（Vancomycin），出現潮紅、搔癢及低血壓。護理師首要處置為何？
A client is receiving intravenous vancomycin. The nurse notes flushing, pruritus, and hypotension. What is the priority intervention?
- AIncrease the IV infusion rate增加靜脈輸注速率
- BObtain a serum trough level取得血清谷值濃度
- CStop the vancomycin infusion✓ 正解停止萬古黴素輸注
- DAdminister an antihistamine immediately立即給予抗組織胺
萬古黴素（Vancomycin）輸注過快會導致非免疫介導的組織胺釋放，引發「紅人症候群（Red Man Syndrome）」。臨床表現包括上半身潮紅、搔癢、低血壓及心跳過快。護理師首要處置應為停止輸注，以阻止藥物進一步進入體循環，隨後依醫囑給予抗組織胺或降低輸注速度。安全優先級別中，移除致病因子（藥物）是第一步。
Infusing vancomycin too rapidly causes non-immune-mediated histamine release, triggering 'Red Man Syndrome.' Clinical manifestations include flushing of the upper body, itching, hypotension, and tachycardia. The nurse's first action is to stop the infusion to prevent further drug from entering the systemic circulation, followed by administration of antihistamines or reduction of the infusion rate as ordered. In the safety priority order, removing the causative agent (the medication) is the first step.
美國臨床對於萬古黴素輸注有嚴格標準，通常要求至少 60-90 分鐘給藥，並依據劑量調整。若發生紅人症候群，護理師需依醫院 policy 暫停後由醫師評估是否減慢速度重啟，且需監測腎功能及 trough level 以預防腎毒性。