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発熱と解熱剤

むかしいんないb

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発熱と解熱剤

  1. 1. 発熱と解熱剤 救急部 木村 圭一
  2. 2. はじめに 発熱時のメチロン、 ボルタレンをやめま せんか?
  3. 3. マッシー池田先生の主張 強力なNSAIDsを単なる解熱目的で使うことは 不利益の方が大きい。 メチロンは、1965年に死亡事故が多発した風 邪薬の成分。 もし事故が起こったら誰も助けてくれません 。
  4. 4. 以下を提案 メチロン、ボルタレン、 インダシンの単なる解熱 目的の投与は辞めましょ う。
  5. 5. 発熱の利点 免疫能を向上させるという説がある。 白血球の殺菌能力を高めるという報告がある。 病原体が増殖しにくい。 熱が出ていると言うことで医療従事者の目にと まりやすい。
  6. 6. 発熱の欠点 発熱恐怖症 体温が3度上昇すると、酸素消費量が 13%増える。 患者が苦痛である。 医療従事者も不安である。
  7. 7. 解熱剤の利点 熱が下がることで、発熱の不利 益を解消出来る。 インフルエンザの抗体価を上昇 させたとする報告がある。
  8. 8. Early antipyretic exposure does not increase mortality in patients with gram-negative severe sepsis: a retrospective cohort study. Abstract Existing data suggest that antipyretic medications may have deleterious effects on immune function and may increase mortality in human infection. This study was designed to evaluate the impact of antipyretic therapy on 28-day in-hospital mortality when administered early in the course of gram-negative severe sepsis or septic shock. This study was a single-center retrospective cohort study at a 1,111-bed academic medical center of all febrile patients with gram-negative bacteremia hospitalized with severe sepsis or septic shock (n = 278) between Jan 2002 and Feb 2008. Although the raw mortality was lower in the group that received an early antipyretic medication (22 vs. 35 %, p = 0.01), patients in the early antipyretic group had higher mean arterial pressure (58.0 vs. 52.7, p = 0.01) and higher 24-h T (max) (39.3 vs. 39.0, p < 0.01). Early antipyretic therapy was not significantly associated with 28-day in-hospital mortality (adjusted OR 0.55, 0.29-1.03) in a multivariable logistic regression model controlling for APACHE-II score, hypotension, pneumonia, surgery during hospitalization, persistent fever, and in-hospital dialysis. In conclusion, early antipyretic therapy is not associated with increased mortality. Intern Emerg Med. 2012 Oct;7(5):463-70. Epub 2012 Aug 28.
  9. 9. 解熱剤の欠点 二度と発熱しない訳ではないので、再度発熱する時に エネルギーを使う。上下することが患者に悪さをする 。 解熱することで血圧低下することがある。 発熱の利点をなくしてしまう。 熱が下がったと安心して患者の観察がおろそかになる 。
  10. 10. Prophylactic use of antipyretic agents with childhood immunizations and antibody response: reason for concern? Abstract INTRODUCTION: In the pediatric primary care setting, well-child visits constitute over 50% of all encounters, treating over 24 million children annually. Anticipatory guidance topics vary based on different ages, but immunizations are a focal point of all well-child visits. This article addresses the prophylactic use of antipyretic agents with the administration of immunizations as a potential reason of concern. METHODS: A literature review of the use of antipyretic agents in conjunction with immunizations and the effectiveness of treatment was performed. RESULTS: Based on several studies, the standard recommendation of administering antipyretic agents with immunization administration was a routine. Twenty years later, the scientific evidence was questioned. A pivotal study questioned these standards, noting no benefit and potential decreased immune response. DISCUSSION: Although the prophylactic use of antipyretics has been a standard in pediatrics, the lack of scientific support in the reduction of adverse effects of the vaccinations and the possibility of decreased immune response warrants further research. J Pediatr Health Care. 2012 May-Jun;26(3):200-3. Epub 2011 Feb 26.
  11. 11. Association of body temperature and antipyretic treatments with mortality of critically ill patients with and without sepsis: multi-centered prospective observational study. INTRODUCTION: Fever is frequently observed in critically ill patients. An independent association of fever with increased mortality has been observed in non- neurological critically ill patients with mixed febrile etiology. The association of fever and antipyretics with mortality, however, may be different between infective and non-infective illness. METHODS: We designed a prospective observational study to investigate the independent association of fever and the use of antipyretic treatments with mortality in critically ill patients with and without sepsis. We included 1,425 consecutive adult critically ill patients (without neurological injury) requiring >48 hours intensive care admitted in 25 ICUs. We recorded four-hourly body temperature and all antipyretic treatments until ICU discharge or 28 days after ICU admission, whichever occurred first. For septic and non-septic patients, we separately assessed the association of maximum body temperature during ICU stay (MAXICU) and the use of antipyretic treatments with 28-day mortality. RESULTS: We recorded body temperature 63,441 times. Antipyretic treatment was given 4,863 times to 737 patients (51.7%). We found that treatment with non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen independently increased 28-day mortality for septic patients (adjusted odds ratio: NSAIDs: 2.61, P=0.028, acetaminophen: 2.05, P=0.01), but not for non-septic patients (adjusted odds ratio: NSAIDs: 0.22, P=0.15, acetaminophen: 0.58, P=0.63). Application of physical cooling did not associate with mortality in either group. Relative to the reference range (MAXICU 36.5°C to 37.4°C), MAXICU≥39.5°C increased risk of 28-day mortality in septic patients (adjusted odds ratio 8.14, P=0.01), but not in non-septic patients (adjusted odds ratio 0.47, P=0.11). CONCLUSIONS: In non-septic patients, high fever (≥39.5°C) independently associated with mortality, without association of administration of NSAIDs or acetaminophen with mortality. In contrast, in septic patients, administration of NSAIDs or acetaminophen independently associated with 28-day mortality, without association of fever with mortality. These findings suggest that fever and antipyretics may have different biological or clinical or both implications for patients with and without sepsis. Crit Care. 2012 Feb 28;16(1):R33.
  12. 12. Systematic review and meta-analysis of the effects of antipyretic medications on mortality in Streptococcus pneumoniae infections. AIM: To determine whether the use of antipyretic medications in the treatment of Streptococcus pneumoniae infection affects mortality in humans or animal models. DESIGN: A systematic search of Medline, Embase, and The Cochrane Register of Controlled Trials was undertaken to identify in vivo animal experiments or randomised, controlled trials in humans of antipyretic medication in S pneumoniae infection which reported mortality data. Meta-analysis was by inverse variance weighted method for odds ratios. SETTING: Antipyretics are recommended for the symptomatic treatment of various diseases caused by S pneumoniae. However, there is evidence that fever is a protective physiological response to infection, that treating fever secondary to infection may be harmful, and that some strains of S pneumoniae are temperature sensitive. MAIN OUTCOME MEASURES: Mortality associated with antipyretic use in S pneumoniae infection. RESULTS: Four studies from two publications met the inclusion criteria and investigated the use of aspirin in animal models. The pooled estimate of mortality was an OR with aspirin treatment of 1.97 (95% CI 1.22 to 3.19). There were no suitable human studies identified. CONCLUSIONS: A twofold increased risk of mortality was found with aspirin treatment in animal models of S pneumoniae infection. No relevant human studies were identified. It is difficult to generalise from animal models to clinical medicine, but based on these findings and the prevalence and severity of S pneumoniae infections worldwide, future study of the effects of antipyretic therapy in S pneumoniae infection in humans is recommended. Postgrad Med J. 2012 Jan;88(1035):21-7. doi: 10.1136/postgradmedj-2011-130217. Epub 2011 Nov 25.
  13. 13. 熱が出ると脱水に? 体温が上昇すると不感蒸泄が増える 。 むしろ解熱する時に大量発汗するの で、解熱剤を使う方が脱水になるか も知れない。
  14. 14. けいれんの予防になる? なりません。
  15. 15. 診断の妨げになる? 注意すれば問題ないが、忙し い毎日の中でそれが出来るか どうか、、、、、、、
  16. 16. まとめ 発熱が悪さをするかどうか、解熱が悪さ をするかどうか、よく分かっていない。 どの薬剤を使っても熱は下がる(程度の 差こそあれ)。 危険と言われている薬を使うのは避ける べきでは?

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