一位因大範圍克隆氏症腸道切除的 45 歲男性，完全依賴經由中心靜脈導管以 80 mL/hr 輸注的全靜脈營養 (TPN)。在 14:00 的交班期間，護理師發現當前的 TPN 營養袋已經『完全空了』。藥局緊急表示新的一袋 TPN 還需要等 1.5 個小時才會準備好。個案開始展現出強烈的冒汗與極端顫抖。為了預防災難性的代謝危機，護理師必須立刻執行哪些積極的介入處置？（多選題）
A 45-year-old male with extensive Crohn's disease bowel resection relies entirely on Total Parenteral Nutrition (TPN) running via a central venous catheter at 80 mL/hr. During a shift change at 14:00, the nurse discovers that the current TPN bag is completely empty. The pharmacy urgently states the replacement TPN bag will not be ready for another 1.5 hours. The client begins to exhibit intense diaphoresis (sweating) and tremors. To prevent a catastrophic metabolic crisis, which immediate, aggressive interventions must the nurse execute? (Select all that apply.)
- AImmediately hang a bag of 10% Dextrose in Water (D10W) and infuse it at the exact same rate of 80 mL/hr.✓ 正解立即掛上 10% 葡萄糖注射液 (D10W)，並以相同速率 80 mL/hr 輸注。
- BFlush the central line with plain normal saline and safely lock the catheter until the newly formulated TPN arrives.以一般生理食鹽水沖洗中心靜脈導管，並安全地封管，直到新配製的 TPN 送達。
- CPerform a stat 'fingerstick' capillary blood glucose check to urgently document and monitor for severe hypoglycemia.✓ 正解立即執行指尖毛細血管血糖檢測，以緊急記錄並監測嚴重低血糖。
- DPrepare an immediate intravenous bolus of regular insulin to violently counteract the high-sugar concentration of the empty TPN.準備立即靜脈注射普通胰島素，以強烈對抗空 TPN 袋內的高糖濃度。
- EInform the client that since he is sweating, he must have a rapid systemic blood infection (sepsis) from the central line and activate a code.告知個案由於他正在冒汗，這一定是來自中心導管的全身性血液感染（敗血症），並啟動緊急代碼。
本題測試靜脈輸液最高階的治療：TPN 斷點的代謝急救理學。全靜脈營養 (TPN) 是一顆極端高濃度的葡萄糖炸彈。因為持續高濃度的糖分打入靜脈，病患的胰臟處於高度活化狀態，會超量分泌胰島素以維持平衡。一旦 TPN 『意外空袋或突然停止（Abrupt cessation）』，進入血液的糖分來源瞬間消失，但血中滿載著旺盛的胰島素大軍。這會導致剩餘的血糖被瞬間掃空，引爆極度致命的「反彈性低血糖休克（Rebound Hypoglycemia）」（出現冒冷汗、手抖、癲癇昏迷等嚴重症狀）。為了填補這個葡萄糖缺口，護理界有一項必須背誦的黃金指引：『當 TPN 用完且下一袋還沒到時，護理師必須立刻掛上 D10W (10% 葡萄糖水，部分外國醫院用 D20W)，並以原先 TPN 完全一模一樣的速率輸注』直到新 TPN 抵達為止（選項A正確）。同時，因為病患已出現冒汗手抖等低血糖症狀，必須立刻測量指尖血糖（選項C正確）。選項B暫停管路會放任病患陷入絕殺低血糖昏迷。選項D打胰島素是火上加油的絕對謀殺。選項E雖然中心靜脈導管易敗血症，但以臨床藥效動力學判斷，這當下更直觀且急迫的原因絕對是空袋所引發的低血糖發抖，而非敗血症。
This item tests the highest level of intravenous therapy management: the metabolic-emergency physiology of TPN interruption. Total parenteral nutrition (TPN) is an extremely concentrated glucose load. Because high-concentration sugar is continuously infused, the client's pancreas is highly activated and secretes large amounts of insulin to maintain balance. When TPN is abruptly stopped due to an empty bag or sudden cessation, the source of glucose entering the blood disappears instantaneously, but the blood still contains an exuberant army of insulin. The remaining blood glucose is rapidly swept away, triggering profoundly lethal rebound hypoglycemia (manifested as cold sweat, tremor, seizures, and coma). To bridge this glucose gap, the golden rule that nurses must memorize is: when the TPN bag runs out and the next bag has not yet arrived, the nurse must immediately hang D10W (10 percent dextrose in water, or D20W in some facilities) and infuse it at exactly the same rate as the previous TPN until the new TPN arrives (Option A is correct). At the same time, because the client already shows hypoglycemic signs such as sweating and tremor, a fingerstick blood glucose must be obtained immediately (Option C is correct). Option B (locking the line) would deny the hyper-insulinemic client any glucose, pushing him into a fatal hypoglycemic crisis. Option D (giving insulin) would be adding fuel to the fire and is absolutely a fatal medication error. Option E -- although central venous catheters do carry a risk of sepsis, by clinical pharmacokinetic and pharmacodynamic reasoning, the more direct and urgent cause at this moment is hypoglycemia and tremor resulting from the empty TPN bag, not sepsis.
世界通用藥理鐵律。只要看見 TPN 沒了下一袋還沒來，護理師的無差別反射動作就是抓起旁邊那瓶「D10W (10% Dextrose)」掛上去。台美醫院皆如此。