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Can you guess the trick behind this much-debated prescription?
Recently, fever patients in many places across the country have "drummed" again, especially children with low resistance, some children have not been in class for a month or two due to infection with influenza A, just almost, and they have been infected with influenza B, fever and cough are intermittent, parents and children suffer together, and they don't know when it will be a head......
With the surge in the number of children's cough clinics, a grassroots prescription exploded in the medical industry, which immediately sparked a strong discussion among nearly 200,000 doctors and caused a wave of waves!
It can be seen from this grassroots prescription that the child goes to the doctor with a cold and fever, and the doctor comes up and does a lot of operations. It is still understandable to prescribe clindamycin, followed by traditional Chinese medicine injection Qingkailing, hormone drug dexamethasone, and antiviral drug ribavirin.
As soon as I saw this prescription, my scalp was numb, this is just a grassroots medicine, and I threw a nuclear bomb when I came up, and a total of 5 hormones and ribavirin were used, and they were actually injected and administered, and it was not a local nebulization that could reduce side effects. Dazhang can't help but ask, is there really a doctor who is so bold? Without rigorous and careful consideration, he prescribes such a comprehensive attack on children as soon as he comes up, without considering the consequences at all?
In this prescription, a variety of anti-allergic drugs are also used while using traditional Chinese medicine preparations, even if allergies or side effects occur due to traditional Chinese medicine injection preparations, the symptoms may be masked, who will bear the risks in the later stage?
This much-debated prescription
Can you guess what's going on behind it?
There are many doctors who follow the post, and some of them said: Dimi can not only reduce fever, anti-inflammatory and cough, anti-inflammatory and relieve sore throat, wonderful! This kind of prescription is a common way in various clinics. This kind of prescription is in the clinic, no one supervises, it is all consciously or conscientiously, as for the hormone messes up menstruation, ribavirin reproductive toxicity side effects......
After seeing this prescription, a doctor in northern Anhui Province said: "Clinics basically use this prescription! You know, the effect is not bad, and the common people like this kind of prescription, why don't they use penicillin or cephalosporin, but replace it with clindamycin? Because penicillin is easy to be allergic, cephalosporin needs skin test, and left oxygen has gastrointestinal reactions, so they chose an effective and compromise prescription, using clindamycin or lincomycin, and some clinics can even prescribe extremely broad-spectrum imipenem! Don't care about cultivating any super drug-resistant bacteria, the people say that if it's good, that's good, if you can't cure the disease in three days, you're a quacker!"
"Qing Kailing, Yan Hu Ning, Banlan Root, Bupleurum and Andrographis are all necessary, as long as it is a traditional Chinese medicine preparation, then you can make a lot of money, and the clinic will be opened, don't care if the Chinese medicine injection is not safe, and it is not allergic! If you don't use Qing Kailing, these drugs can only rot in the medicine storehouse. Hormones must also be used 2-3 days ago, patients pursue symptomatic effects, and clinic doctors must use them if they want to mix it up, otherwise they may be labeled as unskilled doctors, which is one of the reasons why regular internal medicine doctors can't do clinics. ”
"As for ribavirin, even if the guidelines say that there are many contraindications, children should use it with caution, what anaphylactic shock, reproductive toxicity, but there are so many patients with influenza A and B, there is always an antiviral drug, and there is always one that can cure the disease. These drugs are cheap, effective, and highly profitable, as for the follow-up impact of patients, there is no time to take care of them, this is the treatment logic of the clinic doctors, what do the big three use, what do they use, until the big three are useless......"
In addition, there is also a doctor who is familiar with the key to explain the reason: if the grassroots do not prescribe like this, it is basically a quarrel every day, and the fever does not go away after injections, and if you quarrel too much, you will get used to using hormones.
A doctor in Sichuan agrees with this view and empathizes, saying that three months ago he would have rejected the prescription, but then he met a child with an upper respiratory tract infection who came to see the doctor and completely changed his mind. Because the child was taken to the clinic for hormones as soon as he caught a cold, the doctor told the child's grandfather not to use hormones first, so as not to affect the child's development, and there is a process of cold and cough, and it will not be cured in a day with any medicine. The child's symptoms did not improve significantly after the doctor prescribed medicine and treatment according to the principle, and the child's grandmother came to the office to scold the next morning, "The young doctor only deserves to sit in the office and wait for death, and he can't even cure a cold and cough, and he can't catch up with the village doctor of a clinic." All kinds of foul language are unbearable, the doctor said that after experiencing this matter, he felt mixed feelings in the face of this prescription, and perhaps he didn't want to think about the long-term harm of the vegetarian anymore.
200,000 doctors were stunned!
Tertiary doctors: non-standardized, high risk
Can you stop opening like that?
A respiratory physician from a tertiary hospital in Chongqing disagrees with this prescription very much, but more helplessly, she said that the effect of this prescription must be very good, you know, hormones, antivirals, broad-spectrum antibiotics are used, can it be bad? But seeing a doctor is not the same principle as fighting a war, for children, it is absolutely impossible to engage in full coverage of firepower, the scope of the strike, otherwise the consequences are really dangerous! The amount of hormones and ribavirin in this prescription is very large, and the concentration of the solution is not right, and in previous medical accidents, sudden death and anaphylactic shock caused by too high concentration and too fast drip rate abound, which are all lessons. A professional doctor will never allow hormones, antibiotics, and antivirals to be mixed together, and this prescription is messing around. If you want to use antibiotics on children, you will generally choose narrow-spectrum antibiotics to strike accurately, but some clinic doctors even prescribe imipenem, which is no different from death. ”
Dazhang believes that no doctor knows about the side effects of hormones, but there is a risk that patients do not understand the mixed use of hormones, antibiotics, and antivirals, and just want to get better quickly. To be honest, with only two bottles of vitamins, patients can be relieved, and clinics can make money, not that they really need such heavy and miscellaneous drugs, hormones can not be prescribed, and the stakes are clearly explained to patients, no patient will not understand, not to mention that in the face of a young child, parents will put their children in danger?
Perhaps, the status quo of some grassroots is like this, no blood test, no CT, no even a variety of antigen detection reagents, fever and cough can not be accurately diagnosed, in order to save trouble and seek comprehensiveness, but also in order to pursue the effect, three vegetarian and one soup (antibiotics, hormones, antivirals, and sugar and salt) has become the standard, as for the rest, the people don't care, the people will only look at the effect, as long as he does not hit him with serious problems.
But once there is a serious problem, the patient and the clinic can not bear the heavy price, in the final analysis, this is a matter of probability, both the doctor and the patient are lucky, are gambling, betting that the patient is okay, gambling that they are the favored person of fate, but everyone may forget that no matter what, there will always be one side to fail! This is really helpless, and there is still a very long way to go in the work of patient education.
Attention should be paid to the safe use of drugs
Avoid the combination of ceftriaxone + dexamethasone!
Avoid the use of Chinese herbal injections in children!
Under the current situation of patients blindly seeking results and immediate results, it is conceivable that it is difficult to change some non-standard drugs at the grassroots level, after all, there are no patients if there is no effect. However, Dazhang still advises grassroots doctors to pay more attention to the safety of drug compatibility, and avoid prescribing at ordinary times!
A few days ago, a case of sudden death of a patient caused by dexamethasone combined with ceftriaxone was reported clinically.
By consulting the instructions of ceftriaxone, it can be seen that erythromycin, tetracycline, amphotericin B, vasoactive drugs (m-hydroxylamine, norepinephrine, etc.), phenytoin, chlorpromazine, promethazine, vitamin B, vitamin C, etc. will be turbid when cephalomycin intravenous infusion is added. Because there are many contraindications to the compatibility of this product, it should be administered separately.
Secondly, disulfiram-like reactions can occur in individual patients when drinking alcohol or taking alcoholic drugs during the application of ceftriaxone, so alcohol and alcohol-containing drugs should be avoided during the application of this product and in the following days.
Dexamethasone is a highly effective and low-toxicity glucocorticoid, which can produce turbidity, precipitation and other chemical and physical reactions when mixed with a variety of drugs (such as levofloxacin, calcium gluconate, etc.).
Dexamethasone contains two alkene bonds and has a certain reducing property, while ceftriaxone sodium contains a carboxyl group and has a certain oxidizing property. The compatibility of the two may undergo redox reaction or polymerization reaction, which will bring about changes in physical and chemical properties.
Ceftriaxone sodium for injection is a raw powder sterile filling preparation, and the pH should be controlled in a weakly acidic environment of 6.0~8.0 after adding water to make a solution, and the β-lactam ring has good stability in a near-neutral solution environment. The most used dosage form of dexamethasone is dexamethasone sodium phosphate injection, and the pH of its aqueous solution is relatively stable and weakly alkaline when it is 7.5~10.5. The two are mixed in the same aqueous solution, and there is a possibility that an acid-base neutralization reaction will occur.
During the period from January 1, 2007 to December 31, 2016, the adverse drug reactions of ceftriaxone sodium and dexamethasone in the same bottle were statistically analyzed, and a total of 2111 cases were searched, and 1289 cases were finally included, of which 166 cases (12.88%) were seriously reported, and the route of administration was intravenous infusion (1275 cases, accounting for 98.91%).
Therefore, the combination of cephalosporins and dexamethasone in the same bottle has the risk of changing physical and chemical properties, which will reduce the efficacy and cause more adverse drug reactions. Dexamethasone in the same bottle is not enough to completely prevent allergic reactions to ceftriaxone sodium. Clinically, cephalosporins and dexamethasone should be avoided in combination with the same bottle to prevent the occurrence of adverse drug reactions.
Dating back even further, a township doctor gave a prescription to the grandson of a 4-year-old boy in the village, which also sparked a lot of controversy:
Ceftriaxone sodium for injection 1g + dexamethasone sodium phosphate for injection 2mg + 0.9% sodium chloride injection 100, intravenous infusion
Amikacin sulfate injection 1ml + 5% glucosrose injection 100ml, intravenous infusion
Qingkailing injection 8ml + 5% glucose injection 100ml, intravenous infusion
100ml of ceftriaxone sodium for injection + 5% glucose injection, intravenous infusion
Total: 17.2 yuan
Seeing this prescription, the layman felt that it was a big praise, and the disease was cured for 17.2 yuan, which is much more conscientious than spending hundreds of dollars at every turn in a big hospital. But insiders gasped, for a 4-year-old child, such medication is too terrible. Dazhang consulted with a clinical pharmacist with many years of experience, and he asked the following problems with the prescription drug:
1. Amikacin is prohibited in children. Amikacin is a commonly used and inexpensive aminoglycoside, but the side effects are obvious, and there have been quite a lot of painful lessons in clinical practice. In the past, it was common to see children who became deaf due to the use of aminoglycosides, causing lifelong regrets. The Guidelines for the Clinical Use of Antimicrobial Drugs also clearly state that aminoglycosides should be avoided in pediatric patients and should only be used if the condition requires no other better options, which is obviously not a special case in this case.
2. The dose of ceftriaxone is obviously large. The conventional dose of ceftriaxone for adults is 1~2g, once a day, and the same dose used by 4-year-old children in this case is obviously large.
3. Qingkailing injection is risky. In 2015, the national adverse drug reaction monitoring network received a total of 127,000 reports of traditional Chinese medicine injection preparations, and 9,798 serious reports (7.7%) Since 2018, the Food and Drug Administration has issued several announcements, successively requiring a variety of traditional Chinese medicine preparations such as Bupleurum Injection, Shuanghuanglian Injection and Houttuynia cordata injection to revise the instructions, and emphasizing that children, newborns and infants should be used with caution or prohibited. Therefore, for pediatric patients, doctors should be cautious when prescribing this type of traditional Chinese medicine injection.
4. Fever cannot be reduced with dexamethasone. For hormone antipyretic, it is clearly mentioned in the "Guidelines for the Clinical Application of Glucocorticoids (Draft for Comments)", but it is generally not recommended.
For the diagnosis of upper respiratory tract infection, assuming that there are manifestations such as pharyngeal edema that may require the use of corticosteroids, then the nebulization of budesonide should also be considered first for the patient in this case, rather than the long-acting dexamethasone, which has relatively more adverse effects.
What is even more infuriating is that the doctor in question explained that "there are many loopholes", he said that the use of dexamethasone injection is to prevent possible allergic reactions to ceftriaxone and Qingkailing, and that the rescue conditions of township hospitals are poor, and it is better to use hormones to prevent allergic reactions, okay?
In fact, it is true that this doctor does not even understand the most basic medical knowledge, and it is helpless to say that it sounds good, and quack medicine if it is difficult to hear, and the problem of this prescription lies in the dosage and compatibility, as well as the problem of hypoallergenic thinking. Upper respiratory tract infection: dexamethasone in order to reduce fever as soon as possible, ceftriaxone to be used as a bacterial infection, anti-infection, prescribing aminoglycosides and traditional Chinese medicine injections to 4-year-old children, is not for money but also for life! Whether it is a grassroots or a tertiary hospital, what is the justification for such a prescription?
One of the big problems today is not the lack of drugs, but the abuse of drugs. It is true that some primary care conditions are poor, but it cannot be a reason for doctors to blindly use drugs.
The profession of a doctor needs to be persistent. I believe that every doctor has the right to follow, but for patients, the assessment of risks and benefits should be tilted in which way the invisible balance should be tilted. Think differently, if such a patient is your own child, how will this prescription be prescribed?