病人使用萬古黴素（Vancomycin）治療 MRSA 感染。下列何種發現需護理師立即暫停輸注？（選所有適合的）
A client is prescribed intravenous vancomycin for a severe MRSA infection. Which clinical assessment findings require the nurse to pause the infusion immediately? (Select all that apply.)
- ABlood pressure 88/50 mmHg血壓 88/50 mmHg正確答案
- BFlushing of the face and neck臉部與頸部潮紅
- CGeneralized pruritus全身性搔癢
- DWheezing and dyspnea喘鳴與呼吸困難正確答案
- EHeart rate 105 bpm心跳 105 bpm
- A血壓 88/50 mmHg
- D喘鳴與呼吸困難
Vancomycin 輸注時的反應分兩類：(1) vancomycin 輸注反應（vancomycin infusion reaction，舊稱紅人症候群） (RMS) — 由於 histamine 釋放引起的非過敏反應，典型症狀為臉頸部潮紅、上半身搔癢，處理方式是「減慢輸注速率」並可給予 antihistamine，通常不需暫停。(2) 過敏反應 / anaphylaxis — 出現低血壓（A）、喘鳴或呼吸困難（D）為過敏性休克的關鍵指標，必須立即暫停輸注並啟動急救。本題詢問「需立即暫停」，故 A 與 D 為正解；B（潮紅）與 C（搔癢）若單獨出現屬於 RMS 範疇，可透過減速處理；E（輕度心搏過速）通常不需暫停。如果 B/C 伴隨血壓下降或呼吸窘迫則升級為過敏反應、應立即停止。
- A · 正確答案血壓 88/50 mmHg
低血壓 88/50 mmHg 為過敏性反應警訊，必須立刻暫停輸注。
- B臉部與頸部潮紅
單純臉頸潮紅多為 Red Man Syndrome，應「減慢輸注速率」而非立即暫停；若伴隨血壓下降或呼吸窘迫才升級為暫停。
- C全身性搔癢
單純全身搔癢通常為 Red Man Syndrome，應減速並給予抗組織胺；若伴隨過敏性休克徵象才需暫停。
- D · 正確答案喘鳴與呼吸困難
喘鳴與呼吸困難為過敏性休克的關鍵指標，必須立刻暫停輸注並呼叫支援。
- E心跳 105 bpm
輕度心搏過速 105 bpm 單獨出現不需暫停輸注，只需持續觀察。
美國醫院針對 Vancomycin 給藥常有明確的「紅人症」處理協定，護理師權限較大；台灣臨床多偏向先暫停並通知醫師開立抗組織胺。
English explanation
Reactions during vancomycin infusion fall into two categories: (1) Red Man Syndrome (RMS)—a non-allergic reaction caused by histamine release, typically presenting with flushing of the face and neck and upper-body pruritus. It is managed by slowing the infusion rate and may be treated with antihistamines; pausing the infusion is usually not required. (2) Allergic reaction / anaphylaxis—the appearance of hypotension (A) or wheezing/dyspnea (D) are key indicators of anaphylactic shock and require immediate cessation of the infusion and initiation of emergency care. Because the question asks which findings require immediately pausing, A and D are correct; B (flushing) and C (pruritus) alone fall within the spectrum of RMS and can be managed by slowing the rate; E (mild tachycardia) usually does not require pausing. If B or C is accompanied by hypotension or respiratory distress, the situation is escalated to anaphylaxis and the infusion should be stopped immediately.
最近修訂：2026-05-17