# 70歲男性因泌尿道敗血症致敗血性休克入內科加護;18:00啟動Surviving Sepsis Hour-1組合。追蹤乳酸、平均動脈壓(MAP)、norepinephrine劑量。請審視趨勢並選出正確判讀。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=393481&lang=zh-tw  
> language: zh-TW  
> subject: Medical Emergencies  
> category: PA

## 題目

70歲男性因泌尿道敗血症致敗血性休克入內科加護;18:00啟動Surviving Sepsis Hour-1組合。追蹤乳酸、平均動脈壓(MAP)、norepinephrine劑量。請審視趨勢並選出正確判讀。

| Time | Data |
| --- | --- |
| 18:00 (bundle start) | MAP 58、乳酸 4.2 mmol/L、體溫 39.0 C，正在給予 30 mL/kg 晶體液 bolus，尚未使用血管升壓劑 |
| 19:00 | MAP 62、乳酸 3.8 mmol/L，使用 norepinephrine 0.05 mcg/kg/min |
| 21:00 | MAP 70、乳酸 2.8 mmol/L，使用 norepinephrine 0.10 mcg/kg/min |
| 23:00 | MAP 75、乳酸 1.8 mmol/L，norepinephrine 降至 0.05 mcg/kg/min |

Q1. 這四個時間點的趨勢最適合描述為下列何者？

改善中
穩定
惡化中

Q2. 23:00 時的優先處置為何？

持續敗血症 bundle，並於下一個間隔重新評估
立即停止 norepinephrine 並移除所有 IV 輸液
因生命徵象已穩定而停止抗生素
為了進一步升壓而升級使用第二種血管升壓劑

## 解析

趨勢判讀
乳酸由4.2降至1.8 mmol/L、MAP由58升至75 mmHg、norepinephrine調降中,呈現改善 — 敗血症組合奏效;繼續組合並再評估。

## 深入解析

步驟1 — 目標定錨
Surviving Sepsis目標:MAP ≥ 65 mmHg、乳酸下降、升壓劑遞減;本例三項皆向正確方向移動。

步驟2 — 軌跡判讀
乳酸 4.2 → 3.8 → 2.8 → 1.8 mmol/L:5小時一致下降。
MAP 58 → 62 → 70 → 75 mmHg:21:00跨過65且維持。
Norepinephrine 0.05 → 0.10 → 0.05:23:00之遞減反映病人反應。

步驟3 — 應對
組合奏效中,應繼續敗血症組合並於下一間隔再評估;達標時不需追加升壓、不可驟停升壓、不可提前停抗生素(療程依感染源)。

關鍵觀念
趨勢題評估能否識別正向軌跡並避免不必要升級;NCLEX獎勵向對的方向保持臨床慣性(組合奏效時維持)。

## 臨床情境

情境
70歲男性,內科加護,泌尿道敗血症之敗血性休克。18:00啟動Surviving Sepsis Hour-1組合(廣效抗生素、30 mL/kg晶質液、血液培養、乳酸、感染源辨識)。

追蹤
護理師每小時記錄MAP、乳酸與norepinephrine劑量,審視趨勢決定下一步。

背景
Surviving Sepsis Campaign目標:MAP ≥ 65 mmHg、乳酸下降(再灌流指標)、隨時間調降升壓劑。

## 重要概念

- **Surviving Sepsis Hour-1組合** — 乳酸測定、血液培養、廣效抗生素、低血壓或乳酸>4則30 mL/kg晶質液、輸液後MAP<65則norepinephrine。
- **平均動脈壓(MAP)** — 心動週期之平均動脈壓,約等於舒張壓+1/3(收縮-舒張)。敗血症目標≥65 mmHg以維持器官灌流。
- **乳酸** — 休克時組織低灌流之標記。6-8小時內未清除乳酸預示死亡率上升;趨勢比單值更具意義。

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