# 情境 35歲個案因重度憂鬱使用sertraline、戒菸用bupropion、有遠期癲癇病史，現因術後疼痛開立tramadol 100 mg PO q6h。優先護理為何?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375215&lang=zh-tw  
> language: zh-TW  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## 題目

情境 35歲個案因重度憂鬱使用sertraline、戒菸用bupropion、有遠期癲癇病史，現因術後疼痛開立tramadol 100 mg PO q6h。優先護理為何?

## 選項

1. 暫停tramadol並聯絡處方者；tramadol會降低抽搐閾值，個案有抽搐史並合用bupropion(亦降低閾值)；具血清素作用，與sertraline合用會增加血清素症候群風險；屬Schedule IV鴉片類前驅藥需CYP2D6代謝、反應變異大；建議改用其他鎮痛劑並密切監測。 **✔ 正確答案**
2. tramadol為非管制鎮痛劑比其他鴉片安全，依醫囑投藥。
3. 加用diphenhydramine以增強止痛效果。
4. 為克服與sertraline的交互作用，tramadol增量為200 mg q4h。

**正確答案: 1**

## 解析

Tramadol為中樞作用鎮痛劑，具弱μ受體作用與血清素及正腎上腺素再吸收抑制。本案危險原因：(1) tramadol降低抽搐閾值，於有抽搐病史或合用降閾值藥物(bupropion、抗精神病藥、MAOI)時禁用或極度謹慎；(2) 血清素作用與SSRI、SNRI、MAOI、triptan、linezolid、methylene blue、ondansetron合用會引發血清素症候群 — sertraline為SSRI；(3) 為Schedule IV管制藥，止痛與活性代謝物需CYP2D6代謝，存在ultra-rapid metabolizer(類似morphine毒性濃度)與poor metabolizer(無鎮痛效果)變異；(4) FDA於12歲以下兒童、扁桃/腺樣切除術後18歲以下與哺乳期禁用；(5) 便秘、暈眩、噁心、低血糖；雖呼吸抑制比full μ受體促效劑低但仍存在風險；(6) 停藥需漸減避免戒斷。標準護理回應：暫停劑量、向處方者表達擔憂、必要時於再評估sertraline及討論bupropion後改用定時acetaminophen加非tramadol鴉片，輔以多模式非藥物策略。加量、加diphenhydramine、認為非管制就安全皆錯誤。

## 深入解析

tramadol加上抽搐史加上bupropion加上SSRI等於抽搐與血清素風險疊加。暫停並倡議改用其他選擇 — tramadol不是大家以為的安全鴉片。

## 重要概念

- **tramadol** — 弱μ加SNRI作用、Schedule IV、CYP2D6、降低抽搐閾值、血清素症候群風險
- **seizure threshold drugs** — tramadol、bupropion、抗精神病藥、MAOI、quinolone、meperidine，過量時更明顯
- **tramadol pediatric warning** — 12歲以下/T&A後18歲以下/哺乳期boxed warning，與codeine相同

## 相同主題題目

- [A nurse is reviewing the morning lab results for an adult client receiving warfarin for at…](https://mymerci.kr/pages/nclex_q.php?qn_id=360515&lang=zh-tw)
- [A client is admitted to the emergency department after ingesting an unknown amount of acet…](https://mymerci.kr/pages/nclex_q.php?qn_id=362720&lang=zh-tw)
- [A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. Bef…](https://mymerci.kr/pages/nclex_q.php?qn_id=362756&lang=zh-tw)
- [A 28-year-old client with type 1 diabetes receives regular insulin 6 units and NPH insulin…](https://mymerci.kr/pages/nclex_q.php?qn_id=362792&lang=zh-tw)
- [A client receives IV vancomycin 1 g every 12 hours for MRSA bacteremia. Before the next do…](https://mymerci.kr/pages/nclex_q.php?qn_id=362833&lang=zh-tw)
- [A client with bipolar disorder has been taking lithium carbonate 600 mg orally three times…](https://mymerci.kr/pages/nclex_q.php?qn_id=362894&lang=zh-tw)
- [An 80-year-old male with heart failure is prescribed digoxin 0.125 mg daily. During mornin…](https://mymerci.kr/pages/nclex_q.php?qn_id=372686&lang=zh-tw)
- [A 38-year-old female with rheumatoid arthritis is being discharged with a new prescription…](https://mymerci.kr/pages/nclex_q.php?qn_id=372687&lang=zh-tw)

## 以其他語言閱讀

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=375215&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=375215&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=375215&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=375215&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=375215&lang=vi)

---

More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw)

_僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_