— 藥理與非經腸給藥 · MEDIUM · MCQ —
病人正在接受靜脈輸注萬古黴素，護理師發現病人出現臉部潮紅、低血壓和心搏過速。護理師的首要行動為何？
A client is receiving an IV infusion of vancomycin. The nurse notes the client develops flushing, hypotension, and tachycardia. What is the nurse's priority action?
- AAdminister an antihistamine給予抗組織胺
- BDiscontinue the infusion停止輸注
- CSlow the infusion rate✓ 正解減緩輸注速率
- DAdminister an epinephrine injection給予腎上腺素注射
— Explanation · 中文詳解 —
此臨床表現為萬古黴素輸注症候群（Red Man Syndrome），通常是因為輸注速度過快導致組織胺釋放。處置首要為減慢輸注速度，若症狀未緩解才考慮停藥。抗組織胺適用於輕微過敏，腎上腺素僅用於過敏性休克，此個案並非單純過敏。
This clinical presentation is vancomycin infusion syndrome (Red Man Syndrome), usually caused by histamine release from too-rapid infusion. The first action is to slow the infusion rate; only if symptoms do not improve should discontinuation be considered. Antihistamines are appropriate for mild allergic reactions, and epinephrine is reserved for anaphylactic shock; this case is not a true allergic reaction.
✦ 台美臨床差異
美國護理師依據臨床指引調整輸注速度，台灣臨床護理師亦可針對藥物反應先暫停或減慢並通知醫師。