# 一位護理師正在監測一名接受持續性靜脈輸注肝素治療肺栓塞的個案。護理師應將哪些發現視為出血徵象，需要立即通知醫師？（請選擇所有適用選項）

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=363988&lang=zh-tw  
> language: zh-TW  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## 題目

一位護理師正在監測一名接受持續性靜脈輸注肝素治療肺栓塞的個案。護理師應將哪些發現視為出血徵象，需要立即通知醫師？（請選擇所有適用選項）

1

室內空氣SpO2 96%

2

刷牙後牙齦出血

3

血尿

4

黑色柏油樣便

5

aPTT為對照值的1.5-2.5倍

## 解析

血尿、黑便（黑色柏油樣糞便）及輕柔刷牙後牙齦出血為肝素所致全身性出血的徵象，需要立即通知醫師。脈搏血氧飽和度96%為正常。部分凝血活酶時間（aPTT）為控制值的1.5至2.5倍是肝素的治療範圍，屬於預期目標。

## 深入解析

臨床判斷
heparin出血徵象: 血尿、黑便、牙齦出血、吐血、瘀斑、顱內出血致劇烈頭痛。治療aPTT: 對照值的1.5-2.5倍(或anti-Xa 0.3-0.7 IU/mL)。逆轉: protamine sulfate每100單位heparin 1 mg(最多50 mg)。

記憶口訣
HEPARIN出血: Hematuria、Ecchymosis、Petechiae、Anemia、Reduced HCT、INR/aPTT上升、Nosebleed

韓 vs 美
治療aPTT與逆轉方案全球一致。臺灣醫學中心ICU亦採anti-Xa監測未分餾heparin;區域醫院仍以aPTT為主。

## 臨床情境

臨床指引
heparin監測(CHEST 2021抗栓指引):
- aPTT目標 對照值的1.5-2.5倍或機構特定範圍
- Anti-Xa目標 0.3-0.7 IU/mL(更精確、干擾少)
- 基礎檢驗: aPTT、PT/INR、CBC、血小板
- aPTT複查: 開始6小時後與每次調速後
- 每日CBC以篩HIT

HIT(heparin引起血小板減少症):
- 5-10天內血小板較基準下降>50%
- 反常性血栓
- 立即停heparin、改用替代抗凝藥(argatroban、bivalirudin)

注意
逆轉: protamine sulfate 每100單位 heparin 1 mg(每次最多50 mg)。慢速IV push以避免低血壓與過敏。應備epinephrine。

## 重要概念

- **Heparin** — 間接thrombin抑制劑,透過增強antithrombin III使IIa(thrombin)與Xa因子失活。急性血栓(DVT、PE、MI、中風)以持續靜脈注射。以aPTT或anti-Xa監測。解毒劑: protamine sulfate。
- **aPTT治療範圍** — 活化部分凝血酶原時間。未分餾heparin治療期間之監測。治療目標為對照值1.5-2.5倍(多數實驗室約60-100秒)。低於: 次治療,加速度。高於: 出血風險,暫停或減速。
- **HIT(heparin引起血小板減少症)** — heparin暴露5-10天後出現之免疫介導血小板減少(若曾暴露可於數小時內)。血小板較基準下降>50%。具反常血栓風險。需立即停heparin並改用直接thrombin抑制劑(argatroban)或Xa因子抑制劑。

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