使用Glutamine治療於毒性表皮壞死溶解症患者之實證照護

毒性表皮壞死溶解症是由史帝芬強生症候群惡化演變而成，會造成皮膚黏膜大面積破損，並影響多個器官，主要原因為藥物過敏。本文描述一位62歲女性因急性腎盂腎炎服用藥物，造成藥物過敏，引發毒性表皮壞死溶解症，而產生皮膚完整性受損及急性疼痛等問題甚或到生命危象。筆者身為內科加護病房專科護理師，臨床任務是與醫師提供ICU重症病人連續性及整合的護理與醫療照護，透過實證方式找尋相關文獻，發現Glutamine有助於病人皮膚修復，在與醫療團隊、病人及家屬討論後，給予病人Glutamine補充營養及Aquacel Ag敷料換藥，病人疼痛指數大幅降低、皮膚受損範圍也由體表面積近30%降至10%以下，並無感染徵象。筆者於此個案照護過程，運用專業知識提供直接照護及藉由主動關懷、與聽，適時給予心理支持並與個案建立良好的護病關係，隨時注意個案生理變化與舒適狀況，終改善個案症狀。期望此重症臨床護理經驗，可供相關案例之臨床照護參考。

關鍵字

毒性表皮壞死溶解症；口服麩醯胺

並列摘要

Toxic epidermal necrolysis is the deterioration of Stevens-Johnson Syndrome, resulting in extensive skin, mucous membranes damage and influences of many organs. It is majorly caused by the drug allergies. This article described a 62-year-old woman who took medicine for flu but subsequently developed a toxic epidermal necrolysis due to drug allergy, resulting in life crisis, impaired skin integrity, and acute pain. The author is a nurse practitioner in the medical intensive care unit clinically working with the physicians to provide ICU patients with continuous and integrated medical care. Glutamine could help the repairment of skin has been fund in the evidence-based literature. After discussing with the medical teams, patients, and families, Glutamine Therapy and Aquacel Ag dressings for wound care were applied to this patient. Then, the pain scores and range of skin damage were greatly reduced, from 30% to less than 10%, and without any sign of infection. During the care process, the author paid intensive attention to the physiological changes of patients and used professional knowledge to provide direct care for improving the patient’s symptoms. The author also actively cared, listened, and provided sufficient psychological support to the patient, and noticed any psychological changes of patient. The author also established a good relationship with the patient. The author expects that this ICU nursing care experience can provide a reference to relevant clinical care.

並列關鍵字

Toxic epidermal necrolysis ； Glutamine

參考文獻

童恒新、蔡秀鸞、王采芷（2010）．台灣專科護理師執業現況調查．台灣醫學，14（3），264－271。https://doi.org/10.6320/FJM.2010.14(3).03

黃立言、劉秉一、鄭幼文、張俊梁、諶立中、許文欣⋯柯富彰（2010）．不只是皮膚疾病：以內科醫師觀點談毒性表皮溶解症．內科學誌，21（1），12－25。https://doi.org/10.6314/JIMT.2010.21(1).03

Bollhalder, L., Pfeil, A. M., Tomonaga, Y., & Schwenkglenks, M. (2013). A systematic literature review and meta-analysis of randomized clinical trials of parenteral glutamine supplementation. Clinical Nutrition, 32(2), 213-223. https://doi.org/10.1016/j.clnu.2012.11.003

Creamer, D., Walsh, S. A., Dziewulski, P., Exton, L. S., Lee, H. Y., Dart, J. K. G., ... Smith, C. H. (2016). UK guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults 2016. Journal of Plastic, Reconstructive & Aesthetic Surgery, 69(6), e119-e153. https://doi.org/10.1016/j.bjps.2016.01.034

de Luis, D. A., Culebras, J. M., Aller, R., & Eiros-Bouza, J. M. (2014). Surgical infection and malnutrition. Nutricion Hospitalaria, 30(3), 509-513. https://doi.org/10.3305/nh.2014.30.3.7702

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使用Glutamine治療於毒性表皮壞死溶解症患者之實證照護

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