護理師準備給予病人 Vancomycin 1g 靜脈輸注，隨後觀察到病人皮膚潮紅且血壓降至 90/50 mmHg。護理師應優先採取的行動為何？
A nurse is preparing to administer Vancomycin 1g IVPB to a client. The nurse observes the client's skin flushing and notes a blood pressure of 90/50 mmHg. What is the priority nursing action?
- ASlow the infusion rate減慢輸注速率
- BAdminister a bolus of normal saline給予生理食鹽水推注
- CStop the infusion immediately✓ 正解立即停止輸注
- DAdminister an antihistamine給予抗組織胺
此個案呈現的是『紅人症候群』（Red Man Syndrome），通常是因靜脈輸注 Vancomycin 速度過快導致組織胺大量釋放。雖然輕微的潮紅可能透過減慢速度解決，但本題病人已經出現血壓下降（90/50 mmHg），這代表發生了嚴重的過敏反應或低血壓休克狀態，必須立刻停止藥物輸注，以中斷過敏原的進入。先停止輸注是移除誘發因子的基本安全步驟，接著才需要評估生命徵象、通報醫師及給予必要的急救藥物（如抗組織胺或升壓劑）。若僅僅是減慢速度，無法立即阻止已經進入血液的藥物持續影響全身血管擴張，因此『停止輸注』是此時保護病人安全的第一優先級動作。
This case represents Red Man Syndrome, usually caused by infusing vancomycin too rapidly, which triggers massive histamine release. Although mild flushing may resolve with slowing the infusion, this patient already shows a drop in blood pressure (90/50 mmHg), indicating a severe anaphylactic reaction or hypotensive shock state; the medication must be stopped immediately to interrupt entry of the offending agent. Stopping the infusion first is the basic safety step of removing the trigger; only then does the nurse reassess vital signs, notify the physician, and administer necessary emergency medications (such as antihistamines or vasopressors). Merely slowing the rate cannot immediately halt the systemic vasodilation caused by drug already in the bloodstream, so stopping the infusion is the first-priority action to protect patient safety at this moment.
美國護理師依據醫院協定（Standing Order）處理紅人症候群的權限較大，通常會先行停止並評估；台灣臨床作業中，護理師遇到此狀況會立即暫停並直接呼叫醫師，因為評估過敏反應嚴重度需醫師判斷是否需給予類固醇或腎上腺素。