S???t v?? vi???c s??? d???ng thu???c h??? s???t ??? tr??? em

S???t ??? tr??? em l?? m???t trong nh???ng tri???u ch???ng l??m s??ng th?????ng g???p nh???t v?? c??ng l?? m???i quan t??m l???n c???a b??? m??? khi???n h??? t??m ?????n c??c b??c s?? nhi khoa. Nhi???u ph??? huynh cho s??? d???ng thu???c h??? s???t khi tr??? s???t nh??? hay th???m ch?? l?? kh??ng s???t, b???i v?? h??? ngh?? r???ng ?????a tr??? c???n ph???i duy tr?? nhi???t ????? ??? m???c ???b??nh th?????ng???. Tuy nhi??n, s???t kh??ng ph???i l?? m???t b???nh m?? ???? l?? m???t c?? ch??? sinh l?? c?? l???i c?? t??c d???ng trong vi???c ch???ng l???i s??? vi??m nhi???m. Kh??ng c?? b???ng ch???ng n??o cho th???y b???n th??n c??n s???t tr??? n??n n???ng h??n sau khi b??? b???nh hay g??y ra c??c bi???n ch???ng th???n kinh l??u d??i. V?? v???y m???c ti??u ch??nh c???a ??i???u tr??? s???t ??? tr??? l?? n??n c???i thi???n s??? tho???i m??i h??n l?? t???p trung v??o vi???c l??m nhi???t ????? c?? th??? v??? m???c b??nh th?????ng. Khi t?? v???n cho cha m??? ho???c nh???ng ng?????i ch??m s??c cho tr??? s???t c???n ????? cao vi???c quan s??t t??nh tr???ng acetaminophen v?? ibuprofen trong h??? s???t ??? tr???. C?? b???ng ch???ng cho th???y vi???c k???t h???p 2 lo???i n??y t??ng hi???u qu??? h??n vi???c ch??? d??ng 1 lo???i ????n l???; tuy nhi??n, c??ng c?? nh???ng b???ng ch???ng v??? vi???c ??i???u tr??? k???t h???p ph???c t???p v?? s??? d???ng kh??ng ????ng c?? th??? g??y m???t an to??n cao h??n. C??c b??c s?? nhi khoa c??ng c?? th??? g??p ph???n gi??? an to??n cho b???nh nh??n b???ng vi???c tham gia v??o c??? v???n li???u l?????ng v?? c??c c??ng th???c thu???c.

1. T???ng quan

S???t l?? m???t trong nh???ng tri???u ch???ng l??m s??ng th?????ng g???p nh???t v?? c??ng l?? m???i quan t??m l???n c???a b??? m??? khi???n h??? t??m ?????n c??c b??c s?? nhi khoa, theo ?????c t??nh s???t chi???m 1/3 c??c tri???u ch???ng c???a b???nh ??? tr??? em. S???t ??? tr??? em th?????ng l?? nguy??n nh??n ch??nh d???n ?????n th??m kh??m b??c s?? ?????t xu???t, c??c cu???c g???i cho b??c s?? gia ????nh ????? ???????c t?? v???n v??? c??ch ki???m so??t c??n s???t v?? s??? d???ng r???ng r??i thu???c h??? s???t kh??ng k?? ????n.

B??? m??? th?????ng quan t??m ?????n vi???c ph???i duy tr?? nhi???t ????? c???a tr??? ??? m???c ???b??nh th?????ng???. Nhi???u ph??? huynh cho tr??? d??ng thu???c h??? s???t c??? khi tr??? s???t nh??? ho???c ngay c??? khi kh??ng s???t. Kho???ng m???t n???a s??? b??? m??? coi nhi???t ????? d?????i 38 ??(100.4) l?? b??? s???t v?? 25% ng?????i ch??m s??c s??? cho tr??? d??ng thu???c h??? s???t khi nhi???t ????? d?????i 37.8??(100). H??n n???a, 85% b??? m??? (n = 340) ???????c b??o c??o l?? s??? ????nh th???c ?????a tr??? d???y ????? cho d??ng thu???c h??? s???t. Th???t kh??ng may, c?? ?????n m???t n???a s??? b??? m??? d??ng sai li???u l?????ng c???a thu???c; kho???ng 15% b??? m??? cho tr??? d??ng acetaminophen ho???c ibuprofen v???i li???u t???i ??a. Ng?????i ch??m s??c n??n hi???u r???ng li???u d??ng ph???i d???a v??o c??n n???ng ho???c chi???u cao c???a tr??? h??n l?? tu???i c?? kh??? n??ng ????a ra li???u l?????ng ch??nh x??c h??n.

B??c s?? v?? y t?? l?? nh???ng ngu???n th??ng tin ch??nh v??? ki???m so??t c??n s???t ??? tr??? nh??? cho b??? m??? v?? ng?????i ch??m s??c, m???c d?? c?? m???t s??? s??? kh??c bi???t trong quan ??i???m v??? ??i???u tr??? c???a h???. C??c ch??? ?????nh c???a b??c s?? nhi khoa b???t ?????u ??i???u tr??? b???ng thu???c h??? s???t l?? nhi???t ????? cao h??n 38.3??(101) v?? l??m t??ng s??? tho???i m??i c???a tr???. M???c d?? ch??? 13% b??c s?? nhi khoa tr??ch d???n c??? th??? r???ng kh?? ch???u l?? d???u hi???u ch??nh cho vi???c s??? d???ng thu???c h??? s???t, ??i???u n??y th?????ng ???????c ????? c???p trong c??c khuy???n ngh??? c???a h???. H???u h???t c??c b??c s?? nhi khoa (80%) tin r???ng m???t ?????a tr??? ??ang ng??? say kh??ng n??n b??? ????nh th???c ch??? ????? d??ng thu???c h??? s???t. S??? d???ng thu???c h??? s???t v???n l?? m???t ph????ng ph??p ph??? bi???n ???????c c??c b???c ph??? huynh v?? ???????c c??c b??c s?? nhi khoa khuy???n ngh???. Do ????, c??c b??c s?? c???n h?????ng d???n b??? m???, ng?????i ch??m s??c hi???u r?? khi n??o c???n s??? d???ng thu???c h??? s???t v?? li???u l?????ng ph?? h???p v???i tr???.

2. Sinh l?? c???a s???t

C???n nh???n m???nh r???ng s???t kh??ng ph???i l?? m???t b???nh m?? l?? m???t c?? ch??? sinh l?? v???i t??c d???ng c?? l???i cho c?? th??? trong vi???c ch???ng l???i s??? vi??m nhi???m. S???t l??m ch???m s??? ph??t tri???n v?? sinh s???n c???a vi khu???n v?? virus do c?? kh??? n??ng gi??p c?? th??? t??ng c?????ng s???n xu???t b???ch c???u trung t??nh v?? t??? b??o lympho T h??? tr??? ?????c bi???t trong giai ??o???n nhi???m tr??ng c???p t??nh. M???c ????? s???t kh??ng ph???i l??c n??o c??ng t????ng ???ng v???i ????? n???ng c???a b???nh. H???u h???t c??c c??n s???t di???n ra trong th???i gian ng???n, l??nh t??nh v?? t???o l???p kh??ng th??? gi??p b???o v??? c?? th??? ch???ng vi??m nhi???m, m???t s??? nghi??n c???u c??n ch??? ra r???ng s???t gi??p c?? th??? ph???c h???i nhanh h??n v?? h??? th???ng mi???n d???ch c??ng ???????c c???ng c??? ????? ph??ng c??c b???nh kh??c, m???c d?? c??ng c?? m???t v??i tr?????ng h???p g??y bi???n ch???ng nguy hi???m. C??c b???ng ch???ng kh??ng k???t lu???n ???????c vi???c ??i???u tr??? b???ng thu???c h??? s???t ?????c bi???t l?? ch??? d??ng ibuprofen ho???c k???t h???p v???i acetaminophen l??m t??ng nguy c?? bi???n ch???ng ??? m???t s??? lo???i nhi???m tr??ng. Nh???ng l???i ??ch ti???m ???n c???a vi???c h??? s???t l?? l??m gi???m b???t s??? kh?? ch???u c???a b???nh nh??n, gi???m t??nh tr???ng v?? c???m, gi???m s??? m???t n?????c. Vi???c h??? s???t c??ng c?? th??? g??y m???t s??? r???i ro cho ng?????i b???nh nh?? l??m m??? tri???u ch???ng khi???n vi???c ch???n ??o??n g???p kh?? kh??n khi???n ??i???u tr??? c??ng b??? ch???m tr???, ngo??i ra t??c d???ng ph??? c???a thu???c c??ng c?? th??? ???nh h?????ng x???u ?????n tr???.

Kh??ng c?? b???ng ch???ng cho th???y tr??? em c?? s???t, ?????i m???t v???i s??? t??ng th??n nhi???t c?? nguy c?? gia t??ng c??c bi???n ch???ng nh?? t???n th????ng n??o. S???t l?? m???t ph???n ???ng b??nh th?????ng d???n ?????n t??ng ?????i???m chu???n??? c???a v??ng d?????i ?????i ????? ????p ???ng v???i c??c pyrogen n???i sinh v?? ngo???i sinh. Tr??i l???i, ch???ng t??ng th??n nhi???t l?? m???t ph???n ???ng sinh l?? b???nh hi???m g???p v???i s??? r???i lo???n c??n b???ng n???i m??i (kh??ng thay ?????i ??i???m chu???n v??ng d?????i ?????i) d???n ?????n sinh nhi???t v?????t qu?? kh??? n??ng t???n nhi???t. ?????c ??i???m c???a ch???ng t??ng th??n nhi???t l?? da kh??, n??ng v?? r???i lo???n ch???c n??ng th???n kinh trung ????ng d???n ?????n co gi???t, m?? s???ng ho???c h??n m??. T??ng th??n nhi???t c???n ???????c x??? tr?? k???p th???i, v?? ??? nhi???t ????? tr??n 41??- 42, c??c r???i lo???n ch???c n??ng sinh l?? b???t ?????u x???y ra. C??c nghi??n c???u t??? c??c nh??n vi??n y t??? ???????c ti???t l??? r???ng h???u h???t h??? tin r???ng c?? th??? s??? g???p c??c v???n ????? x???u khi nhi???t ????? t??ng tr??n 40??(104), m???c d?? ni???m tin n??y kh??ng ???????c ch???ng minh. M???t ?????a tr??? ??? nhi???t ????? 40??trong ch???ng t??ng th??n nhi???t kh?? kh??c do v???i ?????a tr??? 40??trong s???t th??ng th?????ng (c?? th??? c???t nhi???t). Do ????, vi???c suy lu???n c??c tri???u ch???ng t????ng t??? nh??ng ??? nh???ng b???nh kh??c nhau l?? v???n ????? kh??.

3. M???c ti??u ??i???u tr???

????? th???o lu???n v??? vi???c d??ng thu???c h??? s???t ??? tr??? em ph???i b???t ?????u b???ng vi???c xem x??t m???c ????? hi???u qu??? khi vi???c ??i???u tr??? k???t th??c. Khi t?? v???n cho gia ????nh, c??c b??c s?? chuy??n khoa n??n nh???n m???nh v??? c???i thi???n s??? tho???i m??i v?? c??c d???u hi???u b???nh ??? tr??? ch??? kh??ng n??n qu?? ch?? tr???ng ?????n nh???ng v???n ????? c???a b?? m???. M???c ti??u ch??nh c???a vi???c ??i???u tr??? khi tr??? b??? s???t l?? l??m t??ng s??? tho???i m??i ??? tr???. H???u h???t c??c b??c s?? nhi khoa quan s??t ???????c, c??ng m???t s??? d??? li???u nghi??n c???u cho th???y s???t l??m tr??? em thay ?????i v??? ho???t ?????ng sinh ho???t, gi???c ng??? v?? h??nh vi. Th???t kh??ng may, c?? m???t s??? ??t nghi??n c???u l??m s??ng ????? c???p ?????n m???c ????? c???i thi???n c???a thu???c?? h??? s???t li??n quan ?????n s??? kh?? ch???u c???a c?? th???. V?? v???y kh??ng th??? kh???ng ?????nh r???ng li???u s??? tho???i m??i c?? ???????c c???i thi???n khi nhi???t ????? v??? b??nh th?????ng hay kh??ng do khi ch?????m ???m c?? th??? gi???m nhi???t ????? nh??ng l???i kh??ng l??m t??ng s??? tho???i m??i. Vi???c s??? d???ng r?????u ????? l??m m??t c?? th??? kh??ng ph???i l?? ph????ng ph??p th??ch h???p v?? ???? c?? nh???ng t??c d???ng kh??ng mong mu???n li??n quan ?????n s??? h???p thu r?????u ??? to??n th??n. H??n n???a thu???c h??? s???t c?? hi???u qu??? l??m s??ng v??? vi???c gi???m ??au, c?? th??? n??ng cao hi???u qu??? t???ng th???. B???t k??? c?? ch??? ch??nh x??c l?? g??, nhi???u b??c s?? v???n ti???p t???c khuy???n kh??ch s??? d???ng thu???c h??? s???t v?? h??? tin r???ng h???u h???t k???t qu??? t???t c???a ch??ng l?? c???i thi???n ???????c s??? tho???i m??i c???a tr???, nh???ng d???n ch???ng k??m theo nh?? t??ng kh??? n??ng ??n u???ng, ??t c??u k???nh h??n v?? t??ng kh??? n??ng ho???t ?????ng. V?? ???? l?? nh???ng l???i ??ch quan tr???ng nh???t c???a vi???c s??? d???ng thu???c h??? s???t, ??i???u quan tr???ng nh???t l?? t?? v???n b??? m??? theo d??i ho???t ?????ng, quan s??t c??c b???t th?????ng (n???u c??), ?????c bi???t l?? c???n ch?? tr???ng ?????n l?????ng n?????c u???ng c???a tr???.

C?? nhi???u t??i li???u cho th???y ph??? huynh, y t?? v?? b??c s?? c?? nh???ng lo ng???i ????ng k??? v??? t??c d???ng kh??ng mong mu???n c???a s???t ???????c m?? t??? trong ???ch???ng s??? s???t???, h??? cho r???ng s???t cao kh??ng ???????c ??i???u tr??? c?? li??n quan ?????n c??c tri???u ch???ng nh?? co gi???t, t???n th????ng n??o v?? t??? vong. C?? ?? ki???n cho r???ng m???i lo s??? qu?? m???c v??? nh???ng nguy c?? s???t, m?? ???nh h?????ng ?????n s??? h??nh th??nh h??ng r??o t??? b???o v??? c???a c?? th???, c??c b??c s?? ??ang th??c ?????y mong mu???n qu?? m???c ??? ph??? huynh v??? vi???c c???n ??i???u tr??? s???t m???t c??ch t??ch c???c ??? tr???.

Kh??ng c?? b???ng ch???ng cho th???y h??? s???t s??? l??m gi???m t??? l??? m???c b???nh ho???c t??? vong do s???t. C??c tr?????ng h???p ngo???i l??? c?? th??? x???y ra do tr??? m???c c??c b???nh m???n t??nh ch??a ???????c ph??t hi???n d???n ?????n v???c trao ?????i ch???t kh??ng b??nh th?????ng, ho???c tr??? b??? b???nh n???ng d???n ?????n c?? th??? kh??ng ch???u ???????c nhu c???u trao ?????i ch???t t??ng l??n do s???t; c??ng kh??ng c?? b???ng ch???ng h??? s???t l??m gi???m s??? t??i ph??t c???a c??c c??n co gi???t.

M???c d?? kh??ng c?? ????? b???ng ch???ng, nh??ng nhi???u b??c s?? nhi khoa v???n khuy???n c??o th???c h??nh m???t c??ch th?????ng quy ti???n x??? l?? v???i acetaminophen ho???c ibuprofen tr?????c khi b???nh nh??n ???????c ti??m ph??ng ????? gi???m b???t s??? kh?? ch???u t???i v??? tr?? ti??m v?? gi???m ph???n ???ng s???t. K???t qu??? c???a 1 nghi??n c???u g???n ????y cho th???y gi???m ????p ???ng mi???n d???ch v???i vaccine ??? nh???ng b???nh nh??n ???????c ??i???u tr??? b???ng thu???c h??? s???t.

D?? c??c t??i li???u hi???n c??n h???n ch??? v??? c??c nguy c?? th???c t??? c???a s???t v?? l???i ??ch c???a ph????ng ph??p h??? s???t, nh??ng t??c d???ng c???a n?? gi??p c???i thi???n s??? tho???i m??i ??? b???nh nh??n ph?? h???p v???i m???c ti??u ??i???u tr???.

3.1 Acetaminophen

Sau khi c?? ?????y ????? c??c b???ng ch???ng v??? m???i li??n quan gi???a salicylate v???i h???i ch???ng Reye, acetaminophen c?? b???n ???? thay th??? aspirin trong ??i???u tr??? s???t. Li???u u???ng acetaminophen t??? 10 ??? 15 mg/kg, kho???ng c??ch gi???a c??c li???u l?? 4 ??? 6 gi??? ???????c coi l?? an to??n v?? hi???u qu???. Th??ng th?????ng, t??c d???ng h??? s???t s??? b???t ?????u trong 30 ??? 60 ph??t ??? kho???ng 80% tr??? em (B???ng 1).

M???c d?? c?? c??c ph??c ????? thay ?????i li???u l?????ng kh??c nhau ???? ???????c ????? xu???t, kh??ng c?? b???ng ch???ng n??o ch??? ra r???ng d??ng li???u t???n c??ng ???????ng u???ng (30 mg/kg/li???u) ho???c ???????ng tr???c tr??ng (40mg/kg/li???u) c?? hi???u qu??? h??? s???t t???t h??n. Li???u ?????t tr???c tr??ng cao h??n th?????ng d??ng trong ph???u thu???t, kh??ng ???????c khuy???n c??o s??? d???ng trong ch??m s??c th??ng th?????ng. Vi???c s??? d???ng li???u cao h??n trong th???c h??nh l??m s??ng c?? th??? g??y c??c r???i ro ti???m ???n, vi???c nh???m l???n v??? li???u s??? d???ng qu?? li???u c?? th??? g??y t???n h???i ?????n gan, v?? th??? li???u l?????ng nh?? v???y kh??ng ???????c khuy???n kh??ch.

M???c d?? ?????c t??nh tr??n gan c???a acetaminophen ??? li???u khuy???n c??o hi???m khi ???????c b??o c??o, nh??ng ?????c t??nh th?????ng th???y nh???t trong tr?????ng h???p qu?? li???u c???p t??nh. Ngo??i ra, c??n c?? m???i li??n quan ????ng k??? v??? kh??? n??ng b??? vi??m gan ??? c??c b???nh nh??n c?? li??n quan ?????n vi???c d??ng acetaminophen qu?? li???u m???n t??nh. C??c tr?????ng h???p ???????c b??o c??o th?????ng g???p nh???t l?? nh???ng tr??? ???????c ch??? ?????nh d??ng li???u t???n c??ng (kho???ng 15 mg/kg/ li???u) ho???c d??ng ??? li???u ??i???u tr??? nh??ng kho???ng c??ch m???i li???u l???i ??t h??n 4 gi???, d???n ?????n li???u h??n 90 mg/kg/ng??y trong v??i ng??y. Cho tr??? em d??ng acetaminophen ???????c b??o ch??? cho ng?????i l???n c??ng c?? th??? d???n ?????n vi???c d??ng qu?? li???u. Trong m???t lo???t c??c tr?????ng h???p ???????c b??o c??o, c?? ?????n m???t n???a s??? tr??? em b??? nhi???m ?????c gan l?? do s??? d???ng acetaminophen ch??? ph???m d??nh cho ng?????i l???n. M???t m???i quan t??m kh??c v??? s??? an to??n c???a thu???c l?? c??c tri???u ch???ng v??? hen suy???n, m???c d?? nh???n th???y vi???c s??? d???ng acetaminophen c?? li??n quan ?????n hen suy???n, nh??ng v???n ch??a ???????c ch???ng minh.

3.2 Ibuprofen

Vi???c s??? d???ng Ibuprofen ????? ki???m so??t c??n s???t ng??y c??ng t??ng do n?? cho th???y c?? kh??? n??ng h??? s???t k??o d??i h??n tr??n l??m s??ng (B???ng 1). C??c nghi??n c???u so s??nh hi???u qu??? c???a ibuprofen v?? acetaminophen ???? c?? nhi???u k???t qu??? kh??c nhau; ??i???m chung l?? c??? 2 lo???i thu???c ?????u c?? hi???u qu??? h??n gi??? d?????c trong vi???c h??? s???t; v?? ibuprofen (10mg/kg/li???u) ??t nh???t c??ng c?? hi???u qu??? h??? nhi???t ????? c?? th??? h??n acetaminophen (15 mg/kg/li???u) khi ???????c d??ng m???t l???n duy nh???t ho???c khi d??ng theo khuy???n c??o ??i???u tr???. C??c s??? li???u c??ng cho th???y m???c ????? s???t v?? tu???i c???a tr??? (ch??? kh??ng ph???i lo???i thu???c ???????c s??? d???ng) c?? th??? l?? nh???ng y???u t??? ch??nh quy???t ?????nh hi???u qu??? ??i???u tr??? c???a vi???c h??? s???t. C??c nghi??n c???u so s??nh t??c d???ng c???a ibuprofen v?? acetaminophen v??? t??ng kh??? n??ng linh ho???t v?? s??? tho???i m??i ??? tr??? c??n ch??a r??.

Ch??a c?? b???ng ch???ng ????? ch??? ra c?? s??? kh??c bi???t ????ng k??? v??? s??? an to??n c???a li???u ti??u chu???n c???a ibuprofen v?? acetaminophen n??i chung ??? tr??? t??? 6 th??ng tu???i ?????n 12 tu???i. T????ng t??? c??c lo???i thu???c ch???ng vi??m kh??ng steroid kh??c (NSAID), ibuprofen c?? th??? g??y vi??m d??? d??y m???c d?? kh??ng c?? nhi???u s??? li???u cho th???y ???? l?? hi???n t?????ng ph??? bi???n khi s??? d???ng c???p t??nh khi s???t. Tuy nhi??n, ???? c?? c??c b??o c??o v??? c??c tr?????ng h???p ch???y m??u, vi??m lo??t d??? d??y ??? t?? tr??ng, th???c qu???n li??n quan ?????n nhi???u thu???c NSAID, k??? c??? ibuprofen, ngay c??? khi ch??? d??ng v???i li???u h??? s???t gi???m ??au th??ng th?????ng. Ibuprofen kh??ng l??m tr???m tr???ng th??m c??c tri???u ch???ng hen suy???n.

M???i quan t??m ???? ???????c t??ng l??n khi c?? c??c nghi??n c???u v??? ?????c t??nh c???a ibuprofen l??n th???n. Trong nhi???u tr?????ng h???p, tr??? em c?? s???t ph??t tri???n suy th???n khi ???????c ??i???u tr??? b???ng ibuprofen ho???c c??c NSAID kh??c. V?? v???y, c???n th???n tr???ng khi s??? d???ng ibuprofen ??? tr??? b??? m???t n?????c ho???c m???c c??c b???nh n???i khoa ph???c t???p. ??? tr??? em b??? m???t n?????c, t???ng h???p prostaglandin tr??? th??nh m???t c?? ch??? quan tr???ng ????? duy tr?? l??u l?????ng m??u ?????n th???n th??ch h???p. Vi???c s??? d???ng ibuprofen ho???c b???t k??? NSAID n??o l??m c???n tr??? t??c d???ng tr??n th???n c???a prostaglandin, l??m gi???m l??u l?????ng m??u ?????n th???n v?? c?? kh??? n??ng l???ng ?????ng ho???c l??m tr???m tr???ng th??m t??nh tr???ng r???i lo???n ch???c n??ng th???n. Tuy nhi??n, kh??ng th??? x??c ?????nh t??? l??? th???c t??? c???a suy th???n li??n quan ?????n ibuprofen sau khi s??? d???ng th???i gian ng???n, v?? n?? ch??a ???????c ??i???u tra ho???c b??o c??o m???t c??ch c?? h??? th???ng. Tr??? em c?? nguy c?? cao b??? ng??? ?????c th???n li??n quan ?????n ibuprofen l?? tr??? b??? m???t n?????c, m???c c??c b???nh tim m???ch, b???nh th???n t??? tr?????c ho???c ??ang s??? d???ng ?????ng th???i c??c thu???c g??y t??c d???ng ph??? l??n th???n kh??c. M???t nh??m kh??c c?? nguy c?? m???c b???nh l?? tr??? s?? sinh d?????i 6 th??ng v?? kh??? n??ng c?? s??? kh??c bi???t v??? d?????c ?????ng h???c c???a ibuprofen v?? s??? kh??c bi???t v??? s??? ph??t tri???n trong ch???c n??ng c???a th???n. C??c s??? li???u kh??ng ????? ????? ????a ra khuy???n ngh??? c??? th??? v??? vi???c s??? d???ng ibuprofen ????? h??? s???t ho???c gi???m ??au ??? tr??? em d?????i 6 th??ng (c?? m???t s??? th??ng tin v??? li???u l?????ng cho vi???c ????ng ???ng ?????ng m???ch ??? tr??? s?? sinh), m???c d?? t??? h?????ng d???n s??? d???ng ghi l?? ???h???i b??c s????? ????? ???????c h?????ng d???n v??? vi???c s??? d???ng n??. M???t nguy c?? ti???m ???n kh??c li??n quan ?????n vi???c s??? d???ng ibuprofen l?? m???i li??n quan c?? th??? c?? gi???a thu???c v?? nhi???m khu???n li??n c???u nh??m A ho???c s??? x??m nhi???m c???a b???nh th???y ?????u. Tuy nhi??n, th???i ??i???m b??o c??o ch??a ????? s??? li???u ????? k???t lu???n m???i quan h??? gi???a ibuprofen v?? li??n c???u khu???n nh??m A x??m nhi???m.

B???ng 1: Th??ng tin thu???c h??? s???t

S??? li???u ?????i di???n cho m???c trung b??nh t??? c??c ngu???n ???????c tham chi???u

– Nh??n l?? 75 mg/kg; 90 mg/kg m???i ng??y ???????c gi???i h???n ??t h??n 3 ng??y li??n t???c

– Tr??? khi ???????c khuy???n ngh??? ?????c bi???t b???i nh?? s???n xu???t, v?? ch??? sau khi tr??? s?? sinh ???????c ki???m tra b???i chuy??n gia ch??m s??c s???c kh???e.

3.3 Xen k??? ho???c k???t h???p tr??? li???u

Ph????ng ph??p th?????ng ???????c ??p d???ng ????? ki???m so??t c??n s???t l?? s??? d???ng xen k??? ho???c k???t h???p acetaminophen v?? ibuprofen. Trong m???t cu???c kh???o s??t v???i 256 ph??? huynh, 67% cho bi???t h??? d??ng acetaminophen v?? ibuprofen xen k??? ????? ki???m so??t c??n s???t, 81% trong s??? ???? n??i r???ng h??? ???? nghe theo l???i khuy??n c???a c??c chuy??n gia y t???. M???c d?? 4 gi??? l?? kho???ng th???i gian th?????ng xuy??n nh???t, c??c b??? m??? cho bi???t tr??? li???u xen k??? c??? sau 2, 3, 4 v?? 6 gi???, ??i???u n??y cho th???y r???ng kh??ng c?? s??? th???ng nh???t v??? h?????ng d???n d??ng thu???c.

T???i th???i ??i???m n??y ???? c?? 5 nghi??n c???u v??? so s??nh t??c d???ng ri??ng r??? ho???c k???t h???p c???a ibuprofen v?? acetaminophen. Ban ?????u, nh???ng thay ?????i v??? nhi???t ????? l?? t????ng t??? nhau v???i c??c ?????i t?????ng trong nh??m nghi??n c???u n??y, b???t k??? ph????ng ph??p tr??? li???u n??o. Tuy nhi??n, sau 4 gi??? sau khi b???t ?????u d??ng thu???c, t??c d???ng h??? nhi???t ????? ti???p t???c ???????c k??o d??i ??? nh??m ??i???u tr??? k???t h???p. V?? d???, 6 v?? 8 gi??? sau khi b???t ?????u nghi??n c???u, t??? l??? tr??? ??? nh??m k???t h???p nhi???u h??n (t????ng ???ng 83% v?? 81%) so v???i nh???ng tr??? trong nh??m ch??? d??ng ibuprofen (t????ng ???ng 58% v?? 35%). Ch??? c?? 1 nghi??n c???u ????nh gi?? c??c v???n ????? li??n quan ?????n s??? c??ng th???ng v?? tho???i m??i th???y ??i???m s??? c??ng th???ng th???p h??n v?? th???i gian c???n ch??m s??c ??t h??n trong nh??m ??i???u tr??? k???t h???p. M???t nghi??n c???u kh??c cho th???y c?? xu h?????ng b??nh th?????ng h??a c??c tri???u ch???ng v??o 24 ??? 48 gi??? sau khi b???t ?????u ??i???u tr???, nh??ng nh???ng xu h?????ng n??y bi???n m???t v??o ng??y th??? 5.

M???c d?? c??c nghi??n c???u n??i tr??n cung c???p m???t s??? b???ng ch???ng cho th???y vi???c k???t h???p c?? hi???u qu??? h??n trong vi???c h??? nhi???t ?????, nh??ng v???n c??n nh???ng c??u h???i li??n quan ?????n t??nh an to??n c???a ph????ng ph??p n??y c??ng nh?? hi???u qu??? trong vi???c c???i thi???n s??? kh?? ch???u, ????y l?? m???c ti??u ??i???u tr??? ch??nh. Kh??? n??ng b??? m??? kh??ng nh???n ???????c ho???c kh??ng hi???u h?????ng d???n s??? d???ng, k???t h???p v???i m???t lo???t c??c lo???i thu???c c?? ch???a c??c th??nh ph???n n??y, l??m t??ng kh??? n??ng d??ng thu???c kh??ng ch??nh x??c ho???c d??ng thu???c qu?? li???u. Cu???i c??ng, nh???ng th??i quen n??y c??ng l??m t??ng n???i s??? s???t ???? t???n t???i.

M???c d?? c?? m???t s??? b???ng ch???ng cho th???y ph????ng ph??p k???t h???p tr??? li???u c?? th??? h??? nhi???t ????? c?? th??? trong th???i gian d??i h??n, nh??ng kh??ng c?? b???ng ch???ng n??o cho th???y ph????ng ph??p n??y c???i thi???n t???ng th??? ???????c c??c k???t qu??? l??m s??ng kh??c. Ngo??i ra nh???ng nghi??n c???u n??y ch??a ????? s??? l?????ng ?????i t?????ng ????? ????nh gi?? ?????y ????? t??nh an to??n c???a ph????ng ph??p n??y. Do ????, kh??ng c?? ????? b???ng ch???ng ????? ???ng h??? ho???c b??c b??? vi???c s??? d???ng ??i???u tr??? k???t h???p th?????ng quy v???i acetaminophen v?? ibuprofen. C??c chuy??n gia ch???n l??m theo ph????ng ph??p n??y n??n t?? v???n k??? cho ph??? huynh v??? c??ng th???c, li???u l?????ng v?? kho???ng th???i gian th??ch h???p v?? nh???n m???nh s??? tho???i m??i c???a tr??? thay v?? h??? s???t.

4. H?????ng d???n cho ng?????i ch??m s??c

??i???u quan tr???ng nh???t ?????i v???i b??c s?? nhi khoa l?? ph???i m?? t??? r?? c??ch s??? d???ng ????ng (v?? d???: c??ng th???c, li???u l?????ng, v?? kho???ng c??ch d??ng thu???c) c???a acetaminophen v?? ibuprofen cho ng?????i ch??m s??c (B???ng 1). C???i thi???n s??? an to??n cho tr??? em b???ng c??ch ghi nh??n r?? r??ng v?? ????a ra c??c ph????ng ph??p d??ng thu???c ????n gi???n, n???ng ????? thu???c ???????c ti??u chu???n h??a. C??c s???n ph???m tr??? ho, c???m c?? ch???a acetaminophen v?? ibuprofen kh??ng n??n cho tr??? d??ng v?? b??? m??? c?? th??? v?? ?? cho con u???ng ?????ng th???i c??? li???u h??? s???t v?? ho, c???m l???nh c?? ch???a c??ng th??nh ph???n. Ngo??i ra, c??n thi???u hi???u qu??? ???????c ki???m ch???ng c???a nh??m s???n ph???m k???t h???p n??y. ?????i v???i nh???ng tr??? c???n d??ng ch??? ph???m d???ng l???ng, b??c s?? n??n khuy???n kh??ch gia ????nh ch??? s??? d???ng 1 lo???i. Acetaminophen l?? th??nh ph???n ????n ph??? bi???n nh???t khi???n tr??? em ph???i kh??m t???i khoa c???p c???u do d??ng thu???c qu?? li???u, v?? h??n 80% c??c l???n kh??m n??y l?? do vi???c u???ng thu???c kh??ng ???????c gi??m s??t; do ????, vi???c x??? l?? v?? b???o qu???n thu???c h??? s???t ????ng c??ch c???n ???????c khuy???n kh??ch.

5. K???t Lu???n

T?? v???n ph?? h???p v??? c??ch qu???n l?? c??n s???t b???t ?????u b???ng c??ch gi??p b??? m??? hi???u r???ng s???t v??? b???n ch???t kh??ng g??y nguy hi???m cho m???t ?????a tr??? kh???e m???nh m?? c??n c?? l???i. M???c ti??u th???c s??? c???a h??? s???t kh??ng ch??? l?? b??nh th?????ng h??a nhi???t ????? c?? th??? m?? l?? c???i thi???n s??? tho???i m??i t???ng th???. Acetaminophen v?? ibuprofen, khi ???????c s??? d???ng v???i li???u l?????ng th??ch h???p, ???????c coi l?? an to??n v?? hi???u qu??? trong h???u h???t c??c t??nh hu???ng l??m s??ng. Tuy nhi??n, nh?? v???i t???t c??? c??c lo???i thu???c, ch??ng n??n ???????c s??? d???ng m???t c??ch th???n tr???ng ????? gi???m t??c d???ng ph??? v?? ?????c t??nh c???a n??. ??i???u tr??? k???t h???p acetaminophen v?? ibuprofen c?? th??? khi???n tr??? s?? sinh v?? tr??? em c?? sai s??? l???n khi d??ng thu???c v?? c??c k???t qu??? b???t l???i, v?? nh???ng nguy c?? ti???m ???n n??y ph???i ???????c xem x??t c???n th???n. Khi t?? v???n cho m???t gia ????nh v??? qu???n l?? c??n s???t ??? tr??? em, b??c s?? nhi khoa c???n l??m gi???m thi???u ch???ng s??? s???t v?? nh???n m???nh r???ng vi???c s??? d???ng thu???c h??? s???t kh??ng ng??n ch???n ???????c c??n co gi???t do s???t; c??c b??c s?? c???n t???p trung v??o vi???c theo d??i c??c d???u hi???u/ tri???u ch???ng c???a b???nh nghi??m tr???ng, c???i thi???n s??? tho???i m??i c???a tr??? b???ng c??ch duy tr?? n?????c v?? ??i???n gi???i, gi??o d???c b??? m??? v??? c??ch s??? d???ng, li???u l?????ng th??ch h???p v?? b???o qu???n an to??n thu???c h??? s???t. ????? t??ng c?????ng s??? an to??n cho tr???, b??c s?? n??n ???ng h??? m???t s??? c??ng th???c h???n ch??? acetaminophen v?? ibuprofen, ?????ng th???i ghi nh??n r?? r??ng v??? h?????ng d???n s??? d???ng thu???c v?? d???ng c??? ?????nh l?????ng ??i k??m cho c??c s???n ph???m h??? s???t.

Ngu???n: Section on Clinical Pharmacology and Therapeutics; Committee on Drugs, Sullivan JE, Farrar HC. Fever and antipyretic use in children. Pediatrics. 2011 Mar;127(3):580-7. doi: 10.1542/peds.2010-3852. Epub 2011 Feb 28. PMID: 21357332.

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