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HDsarCevi
dasabuTebuli [faqtebze dafuZnebuli] medicina samedicino mtkicebulebaTa done da rekomendaciebis xarisxi 4 n. raWvelliSvili, i. xabazi klinikuri mtkicebulebani generalizebuli SfoTviTi aSliloba 5 qristofer geili da mark ouqli-brauni, momazada e. faRavam posttravmuli stresuli aSliloba 9 jonaTan bisoni, momazada e. faRavam klinikuri praqtikis rekomendaciebi klinikuri praqtikis rekomendacia – “gaidlaini”: 12 klinikuri praqtikis nacionaluri gaidlainis struqtura da mniSvneloba saqarTvelos samedicino seqtorisaTvis z. kirtava, k. papoSvili, n. raWveliSvili d. korZaia, x. zaldastaniSvili, i. sasania, i. xabazi, o. asaTiani gulis ukmarisobis mkurnaloba – klinikuri 19 praqtikis rekomendacia k. papoSvili, k. surgulaZe, q. mdinaraZe, n. raWveliSvili, n. farcxalaZe, n. ilksoi mwvave diareis mkurnaloba (2 Tvidan 30 5 wlamde asakis bavSvebSi) – klinikuri praqtikis rekomendacia i. xabazi, j. yifiani, n. raWveliSvili, z. kirtava, s. lenski febriluri gulyra bavSvTa asakSi – 42 klinikuri praqtikis rekomendacia n. tatiSvili, T. samxaraZe, T. yifiani, v. bokeria, i. sasania, i. xabazi, n. raWveliSvili, z. kirtava, m. grinvaldi septiuri Sokis mkurnaloba – 50 klinikuri praqtikis rekomendacia o. asaTiani, z. metreveli, m. kapanaZe, n. raWveliSvili, e.l. barnhemi preeklampsia - klinikuri praqtikis rekomendacia 64 z. sinauriZe, r. suluxia, n. zaldastaniSvili, m. nemsaZe, o. asaTiani, z. kirtava, n. raWveliSvili, k. papoSvili, m. Cekli asTmuri statusis marTva – 73 klinikuri praqtikis rekomendacia o. asaTiani, z. metreveli, m. kapanaZe, z. kirtava, n. raWveliSvili, k. papoSvili, a. siore
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iumori samedicino Temaze 84 informacia saqarTvelos Sromis, janmrTelobisa da 86 socialuri dacvis saministro internetSi saqarTvelos jandacvis saministros da 89 jandacvis sistemis veb-gverdis saaplikacio forma
CONTENT
Evidence Based Medicine LEVEL OF EVIDENCE STRENGTH AND GRADE 4 OF RECOMMENDATIONS N. Rachvelishvili, I.Khabazi GENERALIZED ANXIETY DISORDER Christopher Gale and Mark Oakley-Brown POSTTRAUMATIC STRESS DISORDER Jonathan Bisson (based on Clinical Evidence, issue 9) – H. Phagava Clinical Practice Guidlines CLINICAL PRACTICE GIDELINES: A STRUCTURE 18 AND IMPORTANCE OF NATIONAL CLINICAL PRACTICE GUIDELINES FOR GEORGIAN MEDICINE Z. Kirtava, K. Paposhvili,, N. Rachvelishvili, D. Kordzaia, Kh. Zaldastanishvili, I. Sasania, I. Khabazi, O. Asatiani HEART FAILURE TREATMENT – CLINICAL 29 PRACTICE GUIDELINE K. paposhvili, K. Surguladze, K. Mdinaradze, N. Rachvelishvili, N. Partskhaladze, N. Ilksoi TREATMENT OF ACUTE DIARRHEA (IN CHILDREN 42 FROM 2 MONTHS TO 5 YEARS) - CLINICAL PRACTICE GUIDELINE
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I. Khabazi, J. Kipiani, N. Rachvelishvili, Z. Kirtava, S. Lanski FEBRILE SEIZURES IN CHILDREN – 50 CLINICAL PRACTICE GUIDELINE N. Tatishvili, T. Samkharadze, T. Kipiani, I. Bokeria, I. Sasania, I. Khabazi, N. Rachvelishvili, Z. Kirtava, M. Greenwald TREATMENT OF SEPTIC SHOCK – 64 CLINICAL PRACTICE GUIDELINE O. Asatiani, Z. Metreveli, M. Kapanadze, N. Rachvelishvili, E.L. Burnham PREECLAMPSIA - CLINICAL PRACTICE GUIDELINE 73 Z. Sinauridze, R.. Sulukhia, N. Zaldastanishvili, M. Nemsadze, O. Asatiani, Z. Kirtava, N. Rachvelishvili, K. Paposhvili ASTHMATIC STATUS MANAGEMENT – 83 CLINICAL PRACTICE GUIDELINE O. Asatiani, Z. Metreveli, M. Kapanadze, N. Rachvelishvili, K. Paposhvili, A. Siore MEDICAL HUMOR 84 Information MINISTRY OF LABOUR, HEALTH AND SOCIAL AFFAIRS ON THE WEB APPLICATION FOR THE GEORGIAN HEALTH MINISTRY AND GEORGIAN HEALTH SYSTEM WEB-PAGES
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mtkicebulebaTa done da rekomendaciebis xarisxi n. raWveliSvili, i. xabazi
dasabuTebuli medicinis mtkicebulebebis donis da rekomendaciebis xarisxis
diferencirebisaTvis SemoRebulia gradaciaTa cxrili, romelsac gamoiyeneben
samedicino literaturis damowmebis dros. gansakuTrebiT mizanSewonilia
msgavsi gradaciis gaTvaliswineba da sabolood - miTiTeba klinikuri praqtikis
rekomendaciebis momzadebis procesSi.
mtkicebulebaTa done da rekomendaciebis xarisxi
done (
mtkicebulebis siZlieris done
Muir Gray)
xarisxi
rekomendaciis xarisxi (Cook et al)
I Zlieri mtkicebuleba, eyrdnoba
minimum erT sistemur mimoxilvas,
romelic efuZneba swori dizainis
mqone randomizebul
kontrolirebad kvlevas
A eyrdnoba I donis
mtkicebulebas da
Sesabamisad mtkiced
rekomendebulia
I I Zlieri mtkicebuleba, eyrdnoba
minimum 1 swori dizainis mqone
randomizebul kontrolirebad
kvlevas
B eyrdnoba I donis
mtkicebulebas da
Sesabamisad
rekomendebulia
I I I klinikuri kvleva randomizaciis
gareSe, kohortuli da SemTxveva-
kontrolis kvlevebi
C eyrdnoba III donis
mtkicebulebas; SeiZleba
CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli
kvlevebi
D eyrdnoba IV da V donis
mtkicebulebas; saWiroebs
konsensuss
Va avtoritetul profesionalTa
mosazreba
Vb klinikuri gamocdileba,
aRwerilobiTi kvlevebi an
eqspertTa angariSi.
Level of Evidence Strength and Grade of Recommendations N. Rachvelishvili, I. Khabazi Partners for Health, NGO; M. Iashvili Children’s’ Central Hospital, Tbilisi The chart represents an adaptation of delineations of Evidence strength levels (I-V) and Grade of Recommendations (A-D) based on those evidences. It is recommended to use the chart whilst developing/adapting Clinical Practice Guidelines.
5
generalizebuli SfoTviTi aSliloba qristofer geili da mark ouqli-brauni
Generalized Anxiety Disorder Christopher Gale and Mark Oakley-Browne Clinical Evidence, BMJ Publishing Group klinikuri mtkicebulebani
2003 w. (IX gamoSveba) moamzada e. faRavam
ganmartebebi
generalizebuli SfoTviTi aSliloba ganimarteba, rogorc yoveldRiuri
movlenebsa da problemebTan dakavSirebiT gadaWarbebuli aRelvebuloba da
daZabuloba, romelsac adgili aqvs 6 Tvis ganmavlobaSi, dReebis
umravlesobisas iseT zRvramde, rom adamians aqvs distresi, an uZneldeba
yoveldRiuri saqmeebis gakeTeba. mas SeiZleba Semdegi simptomebi da niSnebi
axasiaTebdes: momatebuli motoruli daZabuloba (daRliloba, kankali,
mousvenroba, kunTebis daZabuloba); avtonomuri hiperaqtiuloba (qoSini,
aCqarebuli gulis cema, piris simSrale, civi xelebi, Tavbru); momatebuli
sifxizle da irgvliv yuradRebiT SeTvaliereba (devnis SegrZneba, momatebuli
SekrTobis SegrZneba, koncentraciis darRveva), magram ara panikis Setevebi.
epidemiologiuri da klinikuri kvlevebis erTma arasistematurma mimoxilvam
SfoTviTi aSlilobebiT daavadebulebSi (generalizebuli SfoTviTi aSlilobis
CaTvliT) daadgina cxovrebis xarisxisa da fsiqosocialuri funqcionirebis
gamoxatuli daqveiTeba. agreTve am mimoxilviT Cans, rom generalizebuli
SfoTviTi aSlilobis mqone adamianebi zogadad sakuTari cxovrebiT nakleb
kmayofilebi arian da garkveulad uWirT sxvadasxva rolis Sesruleba,
socialuri davalebebis ganxorcieleba, an orive.
avadoba / daavadebianoba
erTma mimoxilvam daadgina, rom generalizebuli SfoTviTi aSlilobis
daavadebianoba zrdasrulebSi 1,5-3,0%-s Seadgens. mis Tanaxmad mozrdilebis 3-5%-
s hqondaT generalizebuli SfoTviTi aSliloba Seswavlis wina wels da 4-7%-s
ki – rodesme cxovrebis ganmavlobaSi. erTma arasistematurma mimoxilvam
mimoixila aSS nacionaluri Tanmxlebi daavadebebis gamokiTxva, romelmac
daadgina, rom generalizebuli SfoTviTi aSlilobis diagnozis mqone adamianTa
90%-ze mets hqondaT Tanmxlebi diagnozi – disTimia (22%), depresia (39-69%),
somatizacia, sxva SfoTviTi aSlilobebi, bipolaruli aSliloba, narkomania.
epidemiologiur kvlevebSi generalizebuli SfoTviTi aSlilobis diagnozis
dasasmelad gamoyenebuli saSualebebis sandooba aradamakmayofilebelia. erTma
aSS kvlevam, zusti diagnostikuri kriteriumebiT (DSM-III-R), gamoTvala, rom
adamianTa 5%-s cxovrebis raRac periodSi generalizebuli SfoTviTi aSliloba
ganuviTardebaT. depresiuli da SfoTviTi aSlilobebis mqone adamianTa axlaxan
Catarebulma kohortulma kvlevam daadgina, rom 49%-s im adamianebisa, visac
Tavdapirvelad generalizebuli SfoTviTi aSlilobis diagnozi dausves, es
diagnozi kidev ori wlis ganmavlobaSi SeiZleboda klinikurad hqonodaT.
erTi arasistematuri mimoxilvis Tanaxmad mamakacebSi generalizebuli
SfoTviTi aSlilobis avadoba qalebSi am ricxvis naxevaria. Svidi
epidemiologiuri kvlevis erTma arasistematurma mimoxilvam daadgina
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moxucebulebSi SfoTviTi aSlilobebis dabali sixSire. axalgazrda da ufrosi
mozrdilebis 20 dakvirvebiTi kvlevis sxva arasistematurma mimoxilvam
daadgina, rom stresuli davalebebis mimarT avtonomuri agznebuloba naklebia
moxucebulebSi da moxucebulebi stresul davalebebs ufro swrafad eCvevian,
vidre axalgazrdebi.
etiologia / risk faqtorebi
mosaxleobis erTma kvlevam da klinikurma kvlevam daadgina, rom
generalizebuli SfoTviTi aSliloba kavSirSia wvrili stresoruli faqtorebis
ricxvTan da ar aris damokidebuli demografiul faqtorebze. magram es monacemi
aRiniSneboda klinikur populaciaSi sxva diagnozebis mqone adamianebSi.
samoqalaqo travmis fsiqologiuri Sedegebis erTma arasistematurma mimoxilvam
(5 SemTxvevis kontrolirebuli kvleva) aRmoaCina, rom oTx Tu xuT kvlevaSi
moxsenebuli generalizebuli SfoTviTi aSlilobis sixSire mniSvnelovnad
gaizarda sakontrolo mosaxleobasTan SedarebiT (cvlilebis siCqare 3,3, 95% CI 2.0-dan 5,5-mde). krosseqciuri kvlevebis erTma sistematurma mimoxilvam daadgina,
rom daSineba (Tanatolebis viqtimizacia) dakavSirebulia generalizebuli
SfoTviTi aSlilobis sixSiris mniSvnelovnad momatebasTan (efeqtis zoma 0,21).
SfoTviTi aSlilobebis (generalizebuli SfoTviTi aSlilobis CaTvliT)
genetikuri epidemiologiuri kvlevebis erTma sistematurma mimoxilvam ipova
ori saojaxo kvleva da sami tyupebze kvleva. saojaxo kvlevebma (45 indeqsuri
SemTxveva, 225 pirveli rigis naTesavi) generalizebul SfoTviT aSlilobebs
Soris mniSvnelovani kavSiri daadgina indeqsur SemTxvevebSi da maTi pirveli
rigis naTesavebSi (OR 6,1, 95% CI 2,5-dan 14,9-mde). tyupebze kvlevebma (13 305
adamiani) daadgina, rom generalizebuli SfoTviTi aSlilobis mimarT
midrekilebis Secvlis 32% (95% CI 24%-dan 39%-mde) genetikuri faqtorebiT iyo
axsnili.
prognozi
erTma sistematurma mimoxilvam daadgina, rom generalizebuli SfoTviTi
aSlilobis mqone mozrdilebis 25% srul remisiaSi iqneba 2 weliwadSi, xolo
38%-s remisia 5 weliwadSi eqnebaT.
raSi mdgomareobs mkurnalobis efeqturoba?
savaraudod dadebiTi efeqti
buSpironi
randomizebuli kontrolirebuli kvlevebis Tanaxmad buSpironi
placebosTan SedarebiT 4-9 kviris Tavze simptomebs mniSvnelovnad aumjobesebs.
randomizebulma kontrolirebulma kvlevebma ver aRmoaCina buSpironis
upiratesoba klinikuri simptomebis sixSiris cvlilebis mixedviT mkurnalobis
6-8 kviris Tavze antidepresantebTan, diazepamTan, hidroqsizinTan Sedarebisas,
magram SesaZlebelia kvlevebs ar gaaCnda klinikurad mniSvnelovani gansxvavebis
dadgenis Zala.
7
garkveuli antidepresantebi (imipramini, opipramoli, paroqsetini,
trazodoni, venlafaqsini)
erTma sistematurma mimoxilvam da oTxma randomizebulma
kontrolirebulma kvlevam daadgina, rom placebosTan SedarebiT
antidepresantebi (imipramini, opipramoli, paroqsetini, trazodoni,
venlafaqsini) 4-8 kviris Tavze simptomebs sagrZnoblad aumjobesebs.
amave dros randomizebulma kontrolirebulma kvlevebma ver daadgina
mniSvnelovani gansxvaveba am antidepresantebisa an - antidepresantebisa da
benzodiazepines kombinaciis, an - buSpironis gamoyenebas Soris. randomizebuli
kontrolirebuli kvlevebisa da dakvirvebiTi kvlevebis Tanaxmad
antidepresantebi kavSirSia sedaciasTan, TavbrusTan, gulisrevasTan, dacemebTan
da seqsualur disfunqciasTan.
kognitiuri Terapia
orma randomizebulma kontrolirebulma kvlevam mcire sabuTi ipova imis
dasamtkiceblad, rom kognitiuri qceviTi Terapia iseTi meTodebis
kombinirebisas, rogoricaa mxileba-gamomJRavneba (exposure), relaqsacia da
kognitiuri restruqturizacia, amcirebs SfoTvisa da depresiis gamovlinebas 4-12
kviris Tavze mxolod molodinis siis kontrolsa da SfoTvis marTvis
swavlebasTan SedarebiT, mxolod relaqsaciis swavlebasa Tu aradireqtiul
fsiqoTerapiasTan SedarebiT. orma momdevno randomizebulma
kontrolirebulma kvlevam ver daadgina simptomebs Soris 13 kvirasa da 24
TveSi mniSvnelovani sxvaoba kognitiuri Terapiisa Tu gamoyenebiTi relaqsaciis
dros.
sargebeli da ziani daaxloebiT Tanabaria
benzodiazepinebi
erTma sistematurma mimoxilvam da erTma momdevno randomizebulma
kontrolirebulma kvlevam mcire sabuTi ipova imis dasamtkiceblad, rom
placebosTan SedarebiT benzodiazepinebi 2-9 kviraSi simptomebs amcirebs. Tumca
randomizebulma kontrolirebulma kvlevebma da dakvirvebiTma kvlevebma
daadgina, rom benzodiazepinebi zrdis wamalze damokidebulebis, sedaciis,
industrialuri ubeduri SemTxvevebisa da sagzao-satransporto ubeduri
SemTxvevebis risks.
erTi arasistematuri mimoxilvis Tanaxmad benzodiazepinebs, orsulobis
bolo periodSi Tu laqtaciis periodSi gamoyenebisas, SeuZliaT axalSobilebSi
gverdiTi efeqtebis gamowveva.
erTma randomizebulma kontrolirebulma kvlevam ver daadgina SfoTvis
simptomebSi mniSvnelovani sxvaoba xangrZlivi gamoyofis alprazolamis Tu
bromazepamis gamoyenebis dros, xolo sxva randomizebuli kontrolirebuli
kvlevis Tanaxmad ar iqna naxuli mniSvnelovani sxvaoba saerTo simptomebSi
mezaqsolamisa Tu alprazolamis gamoyenebisas. randomizebuli
kontrolirebuli kvlevebidan miRebuli mcire sabuTis Tanaxmad 6-8 kviraSi
generalizebuli SfoTvis simptomebSi ar aRiniSneboda mniSvnelovani sxvaoba
benzodiazepinebis Tu buSpironis, abekarnilis, Tu antidepresantebis
gamoyenebisas. cudi xarisxis randomizebuli kontrolirebuli kvlevebis erTma
sistematurma mimoxilvam benzodiazepinebiT xangrZlivi mkurnalobis
efeqturobis Sesaxeb arasakmarisi sabuTi ipova.
8
kava (kava) SfoTviT, generalizebuli SfoTviTi aSlilobiT daavadebulebs Soris
Catarebuli sistematuri mimoxilvis Tanaxmad placebosTan SedarebiT kava (kava) mniSvnelovnad amcirebs SfoTvis simptomebs 4 kviris Tavze. amave dros
dakvirvebebi gviCvenebs, rom kava SeiZleba asocirebuli iyos
hepatotoqsiurobasTan.
efeqturoba ucnobia
abekarnili
randomizebulma kontrolirebulma kvlevebma urTierTsawinaaRmdego
Cveneba naxa simptomebis SemcirebasTan dakavSirebiT abekarnilis efeqturobis
Sesaxeb placebosTan SedarebiT.
antifsiqoturi wamlebi
erTi mcire randomizebuli kontrolirebuli kvlevidan mcire
damamtkicebeli sabuTi vipoveT imis Sesaxeb, rom 4 kviraSi trifluoperazini
placebosTan SedarebiT SfoTvas mniSvnelovnad amcirebdes, samagierod is metad
iwvevda Zilianobas, eqstrapiramidul reaqciebsa da moZraobis sxva darRvevebs.
β-blokatorebi
β-blokatorebis efeqturobis Sesaxeb randomizebuli kontrolirebuli
kvlevebi ver vnaxeT.
hidroqsizini
orma randomizebulma kontrolirebulma kvlevam hidroqsizini placebos Seadara da
sxvadasxva Sedegi miiRo. erTma randomizebulma kontrolirebulma kvlevam daadgina,
rom daaxloebiT 1 Tvis Semdeg hidroqsizinma SfoTvis simptomebi placebosTan
SedarebiT sagrZnoblad gaaumjobesa, meorem ki mkurnalobebs Soris mniSvnelovani
gansxvaveba ver naxa. erTma momdevno randomizebulma kontrolirebulma kvlevam
mniSvnelovani gansxvaveba ver daadgina 28 dReSi hidroqsizinis buSpironTan
SedarebiT efeqturobaSi. Cven ver vipoveT randomizebuli kontrolirebuli
kvlevebi xangrZlivi Terapiis Sesaxeb.
9
posttravmuli stresuli aSliloba jonaTan bisoni
Posttraumatic Stress Disorder Jonathan Bisson Clinical Evidence, BMJ Publishing Group klinikuri mtkicebulebani
2003 w. (IX gamoSveba) moamzada e. faRavam
ganmartebebi
posttravmul stresul aSlilobas SeiZleba adgili hqondes mniSvnelovani
travmuli movlenis Semdeg. simptomebs miekuTvneba: Semawuxebeli fiqrebi da
koSmaruli sizmrebi travmuli movlenis Sesaxeb, gancalkevebiTi qceva, zogadi
ureaqtiuloba, momatebuli gaRizianebadoba, Warbi sifxizle sul cota 1 Tvis
ganmavlobaSi. mwvave stresuli aSliloba Cndeba mniSvnelovani travmuli
movlenis Semdeg pirveli Tvis ganmavlobaSi da gulisxmobs simptomebis
arsebobas minimum 2 dRis ganmavlobaSi. is hgavs posttravmul stresul
aSlilobas, magram diagnozis dasmisTvis saWiroa ufro disocirebuli
simptomebis arseboba.
avadoba / daavadebianoba
aSS-Si Catarebulma didma jvaredinma kvlevam daadgina, rom qalebis 10% da
mamakacebis 5% aqvT posttravmuli stresuli aSliloba maTi cxovrebis
romeliRac periodSi.
etiologia / risk faqtorebi
risk faqtorebs miekuTvneba: iseTi mniSvnelovani travmuli movlena,
rogoricaa gaupatiureba, fsiqiatriuli aSlilobebis anamnezi, travmis Semdeg
mwvave distresi da depresia, socialuri mxardaWeris nakleboba, pirovnuli
faqtorebi (rogoricaa nevrotizmi).
prognozi
aSS-Si Catarebulma didma krosseqciurma kvlevam daadgina, rom pacientTa 1/3-
ze meti kvlav Seesatyviseba posttravmuli stresuli aSlilobis kriteriumebs
diagnozidan 6 wlis Semdegac. amasTanave, krosseqciuri kvlevebi prognozis
Sesaxeb nakleb sabuTs gvawvdis.
raSi mdgomareobs profilaqtikuri fsiqologiuri Carevis
efeqturoba?
savaraudod dadebiTi efeqti
mwvave stresuli aSlilobis mqone pacientebis kognitiuri qceviTi
mravalepizodiani Terapia
10
travmuli movlenis (ubeduri SemTxveva an araseqsualuri Tavdasxma) Semdeg
ganviTarebuli mwvave stresuli aSlilobis mqone pacientebs Soris Catarebuli
ori mcire randomizebuli kontrolirebuli kvlevis Tanaxmad kognitiuri
qceviTi Terapiis xuTi seansi mniSvnelovnad amcirebs - - mxardamWer
fsiqoTerapiasTan SedarebiT posttravmuli stresuli aSlilobis mqone
pacientebis ricxvs 6 Tvis Semdeg,.
efeqturoba ucnobia
kognitiuri qceviTi mravalepizodiani Terapia yvela im pacientis mimarT,
visac raime travma gadaxda Tavs
erTi randomizebuli kontrolirebuli kvlevis Tanaxmad, romelic
Catarebuli iyo im avtobusis mZRolebs Soris, visac gasuli 5 Tvis ganmavlobaSi
daesxnen Tavs, Catarebuli kognitiuri qceviTi Terapia mniSvnelovnad amcirebs
SfoTvisa da Tavsmoxveuli (akviatebuli) simptomebis gamovlenas 6 Tvis Semdeg
Cveulebriv mkurnalobasTan SedarebiT, magram mniSvnelovani sxvaoba ar iqna
naxuli depresiisa da gancalkevebis simptomebSi. sxva randomizebulma
kontrolirebulma kvlevam Seadara kognitiuri qceviTi Terapiisa da
Cveulebrivi mkurnalobis Sedegebi im adamianebSi, vinc travma wina 5-12 Tvis
ganmavlobaSi gadaitana, da ver daadgina mniSvnelovani gansxvaveba
posttravmuli stresuli aSlilobis zogadi simptomebis gamovlenaSi 6 Tvis
Tavze.
mexsierebis mravalepizodiani restruqturizacia
erTma randomizebulma kontrolirebulma kvlevam arasakmarisi sabuTi
mogvawoda mxardamWer TerapiasTan SedarebiT mexsierebis restruqturizaciis
Sesafaseblad im adamianebSi, vinc travma bolo 24 saaTSi gadaitana.
travmuli movlenis mravalepizodiani mxardaWera
orma randomizebulma kontrolirebulma kvlevam mogvawoda arasakmarisi
sabuTi im adamianebSi, vinc travma 1 dRidan 1 kviramde drois periodSi
gadaitana, kolaboraciuli mkurnalobis, romelic moicavs emociur, socialur
da praqtikur mxardaWeras, Sesafaseblad.
efeqturoba naklebad savaraudoa
erTepizodiani fsiqologiuri Careva (“debrifingi”) yvelaSi, vinc travma
gadaitana
wina TveSi gadatanili travmis mqone adamianebs Soris Catarebuli
randomizebuli kontrolirebuli kvlevebis Tanaxmad ar iqna naxuli
mniSvnelovani gansxvaveba fsiqologiuri debrifingis erT seanssa da saerTod
debrifingis arCatarebas Soris 3 TveSi an 1 weliwadSi posttravmuli stresuli
aSlilobis ganviTarebis sixSireze.
raSi mdgomareobs mkurnalobis efeqturoba?
dadebiTi efeqti
11
kognitiuri qceviTi Terapia
randomizebulma kontrolirebulma kvlevebma daadgina, rom kognitiuri
qceviTi Terapia sagrZnoblad amcirebs posttravmuli stresuli aSlilobis
simptomebs, SfoTvasa da depresias, mkurnalobis arCatarebasa Tu mxardamWer
fsiqoTerapiasTan SedarebiT.
Tvalis moZraobebis desensitizacia da reprocesireba
randomizebulma kontrolirebulma kvlevebma daadgina, rom Tvalis
moZraobebis desensitizacia da reprocesireba simptomebs amcirebs, molodinis,
siis kontrolsa da relaqsaciuri Terapiis debrifingTan SedarebiT. ori
randomizebuli kontrolirebuli kvlevis Tanaxmad simptomebSi mniSvnelovani
sxvaoba ar iqna naxuli Tvalebis moZraobis desensitizaciasa da reprocesings
Soris gamomJRavnebis (exposure) TerapiasTan SedarebiT.
paroqsetini
erTma sistematurma mimoxilvam da momdevno randomizebulma
kontrolirebulma kvlevebma daadgina, rom paroqsetini, placebosTan
SedarebiT, 3 TveSi simptomebs amcirebs.
sertralini
erTma sistematurma mimoxilvam da momdevno randomizebulma
kontrolirebulma kvlevebma daadgina, rom sertralini simptomebs amcirebs 3-7
TveSi placebosTan SedarebiT.
savaraudod dadebiTi efeqti
fluoqsetini
orma randomizebulma kontrolirebulma kvlevam daadgina, rom
fluoqsetins SeuZlia simptomebis Semcireba 3 TveSi placebosTan SedarebiT.
efeqturoba ucnobia
afeqtis marTva, dramatuli Terapia, hipnoTerapia, stacionaruli
programebi, sxva medikamentozuri mkurnaloba (brofaromini, amitriptilini,
lamotrigini, imipramini, fenelzini, nefazodoni, karbamazepini, antifsiqozuri
wamlebi, benzodiazepinebi), fsiqodinamiuri fsiqoTerapia, mxardamWeri
fsiqoTerapia
simptomebis gaumjobesebis mxriv am Carevebis efeqturobaze arasakmarisi
mtkicebulebebia moZiebuli.
12
klinikuri praqtikis rekomendacia – `gaidlaini~: klinikuri praqtikis nacionaluri gaidlainis struqtura da mniSvneloba saqarTvelos samedicino seqtorisaTvis
z. kirtava, k. papoSvili, n. raWveliSvili, d. korZaia, x. zaldastaniSvili, i.
sasania, i. xabazi, o. asaTiani
termini “Guideline” sxvadasxva leqsikoniT ganimarteba, rogorc `zogadi
mimarTuleba~, `saxelmZRvanelo miTiTeba~, `generaluri mimarTuleba~,
`direqtiva~, `rekomendacia~. samedicino literaturaSi (praqtikaSi)
gansakuTrebiT xSirad gamoiyeneba termini “Clinical Practice Guidelines” da/an
sxvadasxva enaSi Sesuli misi Sesabamisi neologizmebi. saqarTvelos enis
palatis da samedicino kanonmdeblobis jgufis mier rekomendebul iqna am
etapze Tavi Segvekavebina axali qarTuli terminis SemoRebisagan , ris gamoc
SevCerdiT terminze `klinikuri praqtikis rekomendaciebi~. amave dros aSkaraa,
rom Tavad qarTvel specialistTa umravlesoba sul ufro amjobinebs
gamoiyenos termini `klinikuri praqtikis gaidlaini~, anu mokled - `gaidlaini~,
romelic Tavisi formatiT da SinaarsiT ufro miesadageba am samedicino
dokumentis konkretul arss – iyos ufro metad savaldebulo, vidre `miTiTeba~
an `rekomendacia~, magram amavdroulad - nakleb dogmaturi da arc ise
aucilebeli – rogorc `direqtiva~.
samedicino informatikis ganviTarebisa da Tanamedrove msoflio sainformacio
resursebiT saqarTvelos biosamedicino seqtoris uzrunvelyofis amocanis
gadaWraSi mniSvnelovani nabiji iyo 1996 wels atlanta-Tbilisis janmrTelobis
TanamSromlobis programis farglebSi erovnuli sainformacio saswavlo
centris daarseba. 1997 wels am centrSi amerikeli partniorebis – emoris
universitetis janmrTelobis samecniero centris biblioTekis TanamSromlebis
karl vudvortisa da stiv futis - mier Catarda pirveli seminari
dasabuTebuli medicinis (Evidence Based Medicine) da klinikuri praqtikis
gaidlainebis Sesaxeb. gaidlainebis formatsa da mniSvnelobas Seexo 2000-2001
ww. evrosabWos egidiT TbilisSi organizebuli ori samuSao seminari
janmrTelobis teqnologiebis Sefasebis meTodologiis Sesaxeb. es seminarebi
Catarda organizacia `partniorebi janmrTelobisaTvis~ (yofili – atlanta-
Tbilisis janmrTelobis TanamSromlobis programa, Tav-re a. kobalaZe)
mier saqarTvelos Sromis, janmrTelobis da socialuri dacvis saministrosa
da evropis sabWos jandacvis komitetis (CDSP) mxardaWeriT. aqve warmodgenil
iqna evrosabWos saeqsperto jgufis mier momzadebuli rekomendaciebi
`saukeTeso samedicino praqtikis gaidlainebis Seqmnis meTodologia~1. amave
periodSi amerikis janmrTelobis saerTaSoriso kavSiris (AIHA) mier
mxardaWerili iqna ramdenime praqtikuli gaidlainis SemuSaveba pirveladi
jandacvis sferoSi, raSic qarTvelma specialistebmac miiRes monawileoba. 2001
wlidan `Ria sazogadoeba saqarTvelos fondisa~ da zogierTi sxva
saerTaSoriso da arasamTavrobo organizaciis iniciativiT SemuSavebul iqna
gaidlainebi sxvadasxva samedicino specialobaSi. am friad sasargeblo
iniciativas Tan axlda is kazusi, rom momzadda erTi da imave nozologiis
marTvis ramdenime gaidlaini, amasTanave maTi formati da samecniero dasabuTeba
sakmaod gansxvavebuli iyo. arada, aRiarebulia, rom klinikuri praqtikis
1 - - evropis sabWos aRniSnuli rekomendacia amJamad n. raWveliSvilis da z. kirtavas mier
qarTulad iTargmna da uaxloes xanSi gamoqveyndeba.
13
gaidlainis sayovelTao danergvis aucilebeli pirobaa maTi standartizacia
(garkveul donemde mainc).
amis gaTvaliswinebiT 2002-2003 ww. fond `Ria sazogadoeba - saqarTvelos~
mxardaWeriT saqarTvelos Sromis, janmrTelobisa da socialuri dacvis
saministrosa da jandacvis marTvis nacionaluri centris specialistebis mier
gaxorcielda proeqti “mtkicebulebebze dafuZnebuli samedicino momsaxurebis
xarisxis amaRlebisa da kontrolis mudmivganaxlebadi institucionaluri
sistemis modeli” (proeqtis direqtori - x. zaldastaniSvili), ris Sedegadac
momzadda dokumenti “klinikuri praqtikis nacionaluri gaidlainis” Sesaxeb,
romelic ganxilul iqna proeqtis bolos Catarebul seminarze, rac seriozul
nabijad unda CaiTvalos. samwuxarod, am seminaris Semdeg ver moxerxda
momavali samuSaoebis gegmis miReba, da implementaciis gagrZeleba. winamdebare
statia swored am sakiTxis xelaxla wamowevas da procesis daCqarebas isaxavs
miznad.
“klinikuri praqtikis nacionaluri gaidlainis” ganmartebisaTvis Sejerda
janmo-s, amerikis jandacvis saerTaSoriso kavSiris, evropis sabWos jandacvis
komitetis da aSS medicinis institutis mier mowodebuli ganmartebebi.
“klinikuri praqtikis nacionaluri gaidlaini” warmoadgens konkretuli
klinikuri mdgomareobis mimarT saxelmwifos politikis amsaxveli dokuments,
romelSic asaxulia mocemulia samedicino daxmarebis sxvadasxva etapze
daavadebis diagnostikisa da mkurnalobis praqtikuli klinikuri
rekomendaciebis sruli cikli, romelic mecnierul mtkicebulebebs efuZneba.
gaidlaini gamiznulia praqtikosi eqimebisaTvis, jandacvis politikis
ganmsazRvrelebisa da pacientebisaTvis. igi moicavs klinikuri kvlevebiT
sarwmunod dadasturebul, subieqtivizmisagan Tavisufal, martivi struqturis
da praqtikuli mimarTulebis mqone monacemebs. gaidlaini Seicavs
mtkicebulebaTa Sesaxeb monacemebs. gadawyvetilebebis miRebis Canawers
(`protokols~) SeiZleba hqondes algoriTmis saxe. Tumca klinikuri praqtikis
nacionaluri gaidlaini saxelmZRvanelo unda iyos samedicino
personalisaTvis, magram konkretuli avadmyofisa Tu mdgomareobis
gaTvaliswinebiT samedicino praqtikis ganmaxorcielebeli personalisaTvis
gaidlainis zusti Sesruleba ar iqneba savaldebulo.
“klinikuri praqtikis nacionaluri gaidlainis” Sinaarsi:
veyrdnobiT ra evrosabWos rekomendacias “gaidlainebis” SemuSavebisa da
gavrcelebis Sesaxeb da amave dros viTvaliswinebT saqarTvelos jandacvis
qselis maxasiaTeblebs (struqtura, materialur-teqnikuri, finansuri da
adamianuri resursebi), mizanSewonilad migvaCnia erTdroulad erTi daavadebis
gaidlainis sami versiis warmoeba (SemuSaveba): versia profesionalebisaTvis,
mokle versia araprofesionalebisaTvis/pacientebisaTvis da reziume jandacvis
politikis ganmsazRvrelTaTvis. evrosabWo aseve iZleva profesionalTaTvis
Semoklebuli – e.w. “jibis” variantis warmoebis rekomendacias. winamdebare
statiaSi Cven gadavwyvoteT im variantis struqturis warmodgena, romelic
swored praqtikosi eqimebisaTvisaa gansazRvruli da romelze muSaobiTac,
albaT, unda daiwyos gaidlainebis momzadeba (pacientTa versia da reziume
savaraudod ZiriTadi versiis momzadebis da miRebis Semdeg Camoyalibdeba).
K
14
klinikuri praqtikis nacionaluri gaidlainis sqema
(versia praqtikosi eqimebisaTvis)
I. daavadebis definicia, sinonimebi, klasifikacia da terminologia (saWiroebis SemTxvevaSi SeiZleba Sevides am daavadebis sxvadasxva formebis
da garTulebebis definiciebic)
II. epidemiologia (mokle Sejameba. amave TavSi, an VII-Si dasaSvebia
prognozic)
epidemiologia saqarTvelosaTvis - sasurvelia
III. etiopaTogenezi (mokle reziume): daavadebis substrati/paTogenezi/gamomwvevebis CamonaTvali/risk-faqtorebi
IV. klinikuri simptomatika:
a) simptomebis CamonaTvali; b) daavadebis tipebi, (Tu es mniSvnelovania mkurnalobis TvalsazrisiT);
g) daavadebis garTulebebi – sasurvelia, roca es iwvevs mkurnalobis
modificirebas
V. daavadebis diagnozi:
a) diagnostikuri kriteriumi – mTavari klinikuri simptomebis da
instrumentul-laboratoriuli monacemebis erToblioba, sadac es
SesaZlebelia;
b) diferencialuri diagnozi - [CamonaTvali]
g) simZimis xarisxi – [mokled]
VI. gamokvlevebis sqema (sasurvelia – specifiuri gamokvlevebis
Tanmimdevrobis an Catarebis drois CvenebiT, SeiZleba – algoriTmis saxiT)
VII. mkurnalobis sqema (preparatis jgufis doneze, Tumca sasurvelia
specifiuri Cvenebebis – formebis/garTulebebis, ZiriTadi preparatebis
dozirebis da xangrZlivobis mixedviT; aqve mizanSewonilia iqnas miTiTebuli
ZiriTadi gverdiTi movlenebi da mkurnalobis SezRudvebi. mkurnalobis sqema
SeiZleba Sejamebul iqnas algoriTmis saxiT)
VIII. reabilitacia/meTvalyureoba [sadac es mniSvnelovania]
IX. eTikur-samarTlebrivi rekomendaciebi*
X. praqtikaSi adaptaciis da protokolebis SemuSavebis rekomendaciebi**
XI. gaidlainis gadasinjvis da ganaxlebis vada (sasurvelia – 2 weli)
XII. gaidlainis miRebis xerxi/wyaro (pirdapiri Targmani, adaptacia, Tu
sxvadasxva gaidlainebis Sejereba)
XIII. alternatiuli gaidlainis miTiTeba (Tu arsebobs da ar iqna CarTuli
Sejerebul gaidlainTa ricxvSi)
XIV. gamoyenebuli literatura (mtkicebulebis xarisxis miTiTebiT, Tu es
SesaZloa)
avtorTa jgufi (redaqtori, koleqtivi, recenzentebi/eqspertebi)
15
** - aRniSnuli sakiTxebi dasaSvebia ar Sevides gaidlainis Tavdapirvel versiaSi, da
daematos gaidlainis miRebis Semdeg saministrosa, dazRvevis organizaciebsa da
saavadmyofos administraciasTan ganxilvis safuZvelze
amJamad amerikis saerTaSoriso janmrTelobis kavSiris (AIHA) da USAID-is
mxardaWeriT q. Tbilisis or wamyvan saavadmyofoSi – akad. RuduSauris sax.
erovnul samedicino centrsa da m. iaSvilis sax. bavSvTa centralur
saavadmyofoSi mimdinareobs samedicino praqtikis gaidlainebis momzadeba da
danergva, risi saboloo mizanicaa samedicino momsaxurebis dafuZneba
dasabuTebuli medicinis (Evidence Based Medicine) uaxles miRwevebze, samkurnalo
procesis standartizireba da am momsaxurebis xarisxis amaRleba, amavdroulad
- kontrolis gaumjobesebis meqanizmis Camoyalibeba da amoqmedeba. proeqtis
ganxorcielebaSi monawileobs amerikuli organizacia `partniorebi
saerTaSoriso TanamSromlobisaTvis~ (PfID, xel-i - saqarTvelos sapatio
moqalaqe, prof. k. uokeri) da qarTuli organizacia `partniorebi
janmrTelobisaTvis~ - orive es organizacia 1992 wlidan cnobilia atlanta-
Tbilisi janmrTelobis TanamSromlobis saxeliT. am saqmianobas win uZRoda
2003-2004 wlebSi Sesabamisi Teoriuli bazis da adamianuri resursis Seqmna
erovnuli sainformacio saswavlo centrisa da zemoTdasaxelebuli ori
partniori saavadmyofos bazaze. Catarda specialistTa 2 gundis viziti aSS-Si
vaSingtonisa da atlantis dawesebulebebSi - aSS erovnuli samedicino
biblioTeka (NLM), janmrTelobis erovnuli institutebi (NIH), janmrTelobis
kvlevisa da xarisxis saagento (AHRQ), samxedro samedicino universiteti
(USUHS), emorisa da jorjiis Statis universitetebi, greidis, krauford
longis, iglstonis, forsaitis, atlantis veteranTa administraciis, skotiS
raitis da sxva saavadmyofoebsa da maTi xarisxis kontrolisa da gaidlainebis
SemuSavebis samsaxurebSi, aseve seminarebi – TbilisSi, da saavadmyofoebis
gaidlainebis SemmuSavebel samuSao jgufebTan Catarebuli 30-mde samuSao
Sexvedra. Jurnalis winamdebare nomerSi SemogTavazebT dasaxelebuli qarTul-
amerikuli proeqtis farglebSi momzadebul gaidlainebs, romelic
zemoTmoyvanil sqemas efuZneba.
samedicino daxmarebis xarisxis kontroli da gaidlainebis koordinacia
saqarTveloSi arsebuli situacia, kerZod ki - erTsadaimave sakiTxze sxvadasxva
gaidlaini arseboba, - sakmaod seriozul sirTuleebs warmoSobs. maTi
validurobis TvalsazrisiTac da zogjer - urTierTgamomricxavi informaciis
Semcvelobis gamo. albaT gamarTlebuli iqneba, Tu zogadi praqtikis
eqimebisaTvis mowodebul iqneba erTi nacionaluri gaidlaini. am SemTxvevaSi
ori alternativa arsebobs: - an winaswar arCeva im dawesebulebisa, sadac
gaidlainebi momzaddeba, an kidev raime makoordinirebeli organos Seqmna,
romelic sxvadasxva dawesebulebebisa da eqimTa koleqtivebis mier
momzadebuli gaidlainebis recenzirebiT da maTTvis `nacionaluri~ standartis
miniWebiT iqneba dakavebuli. vfiqrobT, es ukanaskneli midgoma ufro
gamarTlebulia. saWiroa gaviTvaliswinoT sxvadasxva dadebiTi gamocdileba,
romelic dagrovilia ganviTarebul qveynebSi: kerZod zemoTnaxsenebi aSS-is
Agency for Health Research an Quality (AHRQ) – janmrTelobis kvlevisa da xarisxis
saagentosa da didi britaneTis - National Institute of Clinical Excellence (NICE) - klinikuri srulyofilebis erovnuli institutis struqtura da muSaobis
meTodologiebi. unda moxdes gaidlainebis SemuSavebisa da praqtikaSi danergvis
erTiani sistemis makoordinirebeli struqturis debulebis momzadeba da
SemdgomSi misi Camoyalibeba, romlis mizani aseve zogadad samedicino
16
daxmarebis xarisxis Sefasebisa da amaRlebis mudmivganaxlebadi procesis
xelSewyoba iqneba. misi funqciebi SeiZleba Semdegi saxiT ganisazRvros2:
• samecniero siaxleebis mopovebisa da maTi samedicino personalisaTvis
xelmisawvdomobis procesis uzrunvelyofa;
• saerTaSoriso standartebTan harmonizirebuli nacionaluri “gaidlainebis”
SemuSavebisa da praqtikaSi danergvis uwyveti procesis organizeba;
• samedicino momsaxurebis xarisxis amaRlebis mizniT prioritetebis
gansazRvra, “gaidlainebis” danergvis procesis koordinirebuli
etapobriobisa da gegmiurobis xelis Sewyobis uzrunvelyofa;
• samedicino momsaxurebis xarisxis Sefaseba (“gaidlainebis” danergvis Sedegi)
_ mosaxleobaSi avadobis maCveneblis dadebiTi dinamikis an konkretuli
klinikuri SemTxvevebis gamosavalis gaumjobesebis monitoringis meSveobiT.
Sida da gare auditis meqanizmebis SemuSaveba;
• “gaidlainebis” praqtikaSi danergvasTan dakavSirebuli
iniciativebis/sakiTxebis ganxilva, mosalodneli siZneleebis prognozireba
da maTi daZlevis gzebis dasaxva;
• saxelmwifo da arasamTavrobo struqturebTan, msgavsi miznebis
saerTaSoriso organizaciebTan da kerZo pirebTan TanamSromloba.
sakoordinacio sabWos SemadgenlobaSi iqnebian jandacvis organizatorebi,
ekonomistebi, gamocdili klinicistebi da jandacvis profesionalebi,
samedicino da akademiuri dawesebulebebisa da profesiuli asociaciebis
warmomadgenlebi. P
SemuSavebuli “gaidlainebi” danergvamde gaivlis eqspertizas. eqspertizis
Catareba SeiZleba daevalos sakoordinacio sabWosTan arsebul specialur
dargobrivi komisiebs an profesiul asociaciebs, risTvisac winaswar
gansazRvruli iqneba “gaidlainebis” Sefasebis kriteriumebi;
eqspertizis Semdgom “gaidlainebs” mieniWeba nacionaluri “gaidlainis”
statusi.
samedicino praqtikaSi nacionaluri “gaidlainebis” danergva:
• samedicino momsaxurebis xarisxis amaRlebis mizniT nacionaluri
“gaidlainebis” SemuSavebisa da praqtikaSi danergvis makoordinirebeli
organos, arasamTavrobo organizaciebis da wamyvani klinikebis mier unda
ganxorcieldes qveynis masStabiT am sferoSi arsebuli gamocdilebis da
inteleqtualuri SesaZleblobebis mobilizeba;
• makoordinirebeli organo saWiroebis SemTxvevaSi qveyanaSi arsebuli
resursebis moZiebis gziT xels Seuwyobs samedicino dawesebulebebSi
nacionaluri “gaidlainebis” danergvisas warmoqmnili SesaZlo problemebis
daZlevas. SeimuSavebs
ganaxorcielebs RonisZiebebs, rogoricaa dawesebulebebis materialur-
teqnikuri bazis, kadrebis, SesaZleblobebis Seswavla, konkretul pirobebSi
nacionaluri “gaidlainis” adaptaciis SesaZleblobebis Sefaseba,
2 - statiis avtorebis mosazreba mxolod garkveul potenciur CamonaTvals moicavs. rogorc am,
iseve sxva sakiTxebTan mimarTebaSi, nebismieri alternatiuli azri, Sesworeba anda komentari
madlobiT iqneba miRebuli. saboloo sityva ki Sesabamis saministroebsa da profesiul
asociaciebze iqneba.
17
dawesebulebis saWiro cvlilebebis gansaxorcieleblad rekomendaciebis
SemuSaveba da saWiroebis SemTxvevaSi misi gardaqmnisaTvis saWiro gzebis
moZieba;
• nacionaluri “gaidlainebis” danergvis mizniT Seiqmnas procesis yvela
konkretul samedicino obieqtis doneze Casatarebeli RonisZiebebis Semcveli
programa;
• nacionaluri “gaidlainebis” danergvisas makoordinirebeli organos mier
procesis permanentuli da gegmiuri ganviTarebisaTvis gamoyenebuli unda
iqnas saxelmwifos xelT arsebuli berketebi da motivaciebi.
gaidlainebis danergvis procesis Sefaseba:
sasurvelia am amocanis ganxorcieleba dawesebulebis da qveynis doneze:
• unda SemuSavdes dawesebulebebSi nacionaluri “gaidlainebis” danergvis
Sedegebis Sefasebis erovnuli indikatorebi da Seiqmnas rekomendaciebi
Sida da gare auditis warmoebisaTvis;
• saWiroebis SemTxvevaSi makoordinirebelma organom (rodesac dawesebuleba
daxmarebisaTvis mimarTavs), mis xelT arsebuli resursebis safuZvelze unda
iTanamSromlos Sesabamisad uflebamosil da gamocdil organizaciebTan an -
kerZo eqspertebTan aRniSnuli samuSaoebis gansaxorcieleblad
nacionaluri “gaidlainebis” ganaxleba:
• miTiTebul vadaSi unda moxdes nacionaluri “gaidlainebis” gadaxedva.
evrosabWos rekomendacia uxSiresad mizanSewonilad miiCnevs 2-wlian
periods. ra Tqma unda gaidlainis gadaxedva ar niSnavs, rom igi aucileblad
unda Seicvalos. Tu ganvlil periodSi raime mniSvnelovani siaxle ar iqneba
aRmoCenili, gaidlaini SeiZleba isev ucvleli saxiT damtkicdes, risTvisac
Sesabamisad dadgenili wesi unda arsebobdes.
• nacionaluri “gaidlainebi” unda ganaxldes janmrTelobis teqnologiebis
ganviTarebis da samkurnalo saSualebebis Sesaxeb axali mtkicebebulebis
gamoCenis kvaldakval.
• eqspertizis Sedegebze dayrdnobiT moxdeba “gaidlainis” legalizeba;
• ganaxlebuli “gaidlaini” ganTavsdeba sainformacio bankSi (repozitoriumSi);
aseTi repozitoriumi SeiZleba ganTavsdes erovnuli sainformacio saswavlo
centris serverze.
• nacionaluri “gaidlainebis” praqtikaSi danergvis dadgenili wesis
gaTvaliswinebiT Catardeba ukve danergil `gaidlainSi~ siaxleebis
Canacvleba;
daskvna:
qveynis jandacvis seqtorisaTvis mniSvnelovania jandacvis sistemis finansuri
organizaciis da xarisxis kontrolis amocanebis umokles droSi gadawyveta,
rasac ukavSirdeba mosaxleobis usafrTxoebis da avadmyofis uflebebis dacvis
umniSvnelovanesi moTxovna. am amocanebis gadaWra ki mxolod Tanamedrove
dasabuTebul medicines faqtebze dafuZnebuli samedicino praqtikis meToduri
rekomendaciebis – gaidlainebis – SemuSavebis pirobiT SeiZleba ganxorcieldes.
gaidlaini, Tundac erovnuli kvalifikaciis mqone – dogmas ar warmoadgens.
konkretuli eqimis, Tu samedicino dawesebulebebis mier daSvebuli unda iyos
sxva gaidlainis an samkurnalo midgomis gamoyeneba, oRond im pirobiT, rom maT
gamoyenebas aseve safuZvlad eqneba dasabuTebuli medicinis wyaroebi da/an
18
saTanado auditis SemTxvevaSi gamomyenebel pirebs SeeZlebaT daamtkicon misi
validuroba.
sarekomendacio sabWos ZiriTadi roli unda iyos procesis organizacia,
Sefaseba, rekomendaciebis gaweva da erovnuli gaidlainebis
eqspertiza/damtkiceba.
Clinical Practice Guidelines: a Structure and Importance of National Clinical Practice Guidelines for Georgian Medicine Z. Kirtava, K. Paposhvili, N. Rachvelishvili, D. Kordzaia, Kh. Zaldastanishvili, I. Sasania, I. Khabazi, O. Asatiani The article represents discussion paper about establishment of standard of “National Clinical Practice Guideline” and system of its expertise/auditing, approval, revision and monitoring as a State Council on Clinical Practice Guidelines, considering western experience of Agency for Health Research an Quality (AHRQ) of USA and National Institute of Clinical Excellence (NICE) of UK. The following is presented as template for National CPG (Doctor’s Version): I. Definition, synonyms, classification and terminology of a disease. (Definitions of the different forms and complications of the disease may also be included in form of Glossary at the end of CPG if it is necessary). II. Epidemiology (briefly, Prognosis is also acceptable here) / Epidemiology for Georgia*. III. Etiology/pathogenesis (briefly): substrate of the disease/pathogenesis/the list of causes. IV. Clinical symptoms: a)the list of symptoms; b)types of the disease (if it is necessary for treatment); c)complications. V. Diagnosis of the disease: a)diagnostic/classification criteria – aggregation of main clinical symptoms and lab data); d)differential diagnosis; c)degree of severity. Investigation scheme (presented in specific investigation orders or as time of performance is desirable – or as an algorithm). VI. Treatment scheme (on the level of medication groups, although indication of specific signs – forms/complications, doses and duration of the main medications is desirable; Main side effects and limitations should also be noted. Treatment scheme may also be summarized as an algorithm. VII. Rehabilitation/Monitoring. VIII. Review and renewal period for the guideline (2 years is desirable if not otherwise proven). IX. Guideline formation techniques/sources (direct translation, adaptation or combination of the different guidelines). X. Alternative Guideline(s) (if available). XI. Credits/sources (indicating the quality of the evidence if possible). XII. Group of authors (editors, experts, etc.).
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gulis ukmarisobis mkurnalobis klinikuri praqtikis rekomendacia
(gaidlaini)
k. papoSvili, k. surgulaZe, q. mdinaraZe, z. kirtava, n. raWveliSvili, n.
farcxalaZe, n. ilksoi
q. Tbilisis me-2 saavadmyofos kardiologiuri ganyofileba
kavSiri “partniorebi janmrTelobisaTvis”,
emoris universitetis samedicino skola (atlanta, jorjia).
I. definicia, klasifikacia, terminologia
gulis ukmarisoba warmoadgens kompleqsur klinikur sindroms, romelic
perikardiumis, miokardiumis, endokardiumis an msxvili sisxlZarRvebis
daavadebiT SeiZleba iyos gamowveuli, magram ZiriTadad marcxena parkuWis
funqciis darRvevas ukavSirdeba. es ukanaskneli farTo speqtrs moicavs da
meryeobs upiratesad diastoluri disfunqciidan (normaluri zomis marcxena
parkuWi normaluri dacliT, magram darRveuli avsebiTurT) upiratesad
sistolur disfunqciamde (mkveTrad dilatirebuli marcxena parkuWi
daqveiTebuli kumSvadobiTurT).
qvemdebare rekomendaciebi marcxena parkuWis sistoluri disfunqciiT
gamowveuli gulis qronikuli ukmarisobis farmakologiur mkurnalobas
moicavs. aRniSnuli disfunqciis ZiriTad niSans marcxena parkuWis gandevnis
fraqciis daqveiTeba (Cveulebriv < 40%) warmoadgens. erTiani azri diastoluri
disfunqciis mkurnalobis Taobaze jerjerobiT ar arsebobs.
II. epidemiologia
evropaSi gulis ukmarisoba mosaxleobis 0.4-2%-s aReniSneba. misi sixSire
asakTan erTad mkveTrad matulobs. gulis ukmarisobis mqone pacientTa saSualo
asaki 74 welia. msubuqi simptomebis mqone pacientTa sikvdilis riski wliurad
5-10% Seadgens, daavadebis mZimed mimdinareobisas ki – 30-40% aRwevs. es
monacemebi simsivnis calkeuli formebis sikvdilianobas aRemateba.
III. paTofiziologia
marcxena parkuWis sistoluri disfunqcia ufro xSirad gulis iSemiuri
daavadebiT aris gamowveuli, Tumca SeiZleba ganpirobebuli iyos araiSemiuri
mizeziTac, romlis dadgena an xerxdeba (mag. hipertenzia, Tiroiduli daavadeba,
alkoholizmi, miokarditi), an - ara (mag. idiopaTiuri dilataciuri
kardiomiopaTia).
gulis ukmarisoba SeiZleba ganikurnos spontanurad (mag. miokarditi) an
gamomwvevi mizezis sruli mocilebis Sedegad (mag. sarqvlovani dazianebis
20
qirurgiuli koreqcia), Tumca Cveulebriv igi progresirebad daavadebas
warmoadgens.
progresirebis umniSvnelovanesi faqtoria endogenuri neirohormonuli
sistemebis _ renin-angiotenzin-aldosteronis sistemisa da simpaTikuri nervuli
sistemis qronikuli aqtivacia. angiotenzin II, aldosteroni da noradrenalini
ara marto zrdian parkuWis hemodinamikur datvirTvas natriumis Sekavebisa da
periferiuli vazokonstriqciis meSveobiT, aramed gulze uSualo toqsiur
zemoqmedebasac axdenen. am neirohormonuli faqtorebis zemoqmedebiT gulis
struqtura da funqcia ganuxrelad uaresdeba. marcxena parkuWi mzard
dilatacias ganicdis da sul ufro sferul formas iRebs. aRniSnuli procesi
remodelirebis saxeliT aris cnobili.
gulis es struqturuli cvlilebebi da funqciis daqveiTeba miokardiumis
axali xiluli dazianebis gareSec Rrmavdeba da sabolood pacientis daRupvas
iwvevs. uecarma sikvdilma gulis ukmarisobis evolucia nebismier dros
SeiZleba Sewyvitos.
IV. klinikuri simptomebi
gulis ukmarisobis klinikur simptomebs warmoadgenen qoSini da daRla, rac
zRudavs datvirTvis unars. siTxis Sekaveba pulmonuri da/an periferiuli
SeSupebis saxiT vlindeba. daavadebis progresirebasTan erTad klinikuri
suraTi TandaTan mZimdeba da simptomebi mosvenebis an umniSvnelo datvirTvis
drosac SeiZleba gamovlindes.
V. diagnozi
gulis ukmarisobis mqone pacientTa Sefasebisas yvelaze mniSvnelovani
eqokardioskopiiT marcxena parkuWis gandevnis fraqciis gansazRvraa. igi
warmoadgens ZiriTad saSualebas, romlis meSveobiTac sistoluri disfunqcia
da sxva saxis gulis ukmarisoba erTmaneTisagan ganirCeva. amave dros am
meTodiT klinicists aqvs SesaZlebloba Seafasos parkuWis Rrus zoma,
sarqvelebis dazianebis xarisxi, agreTve gamoavlinos regionaluri
kumSvadobis cvlilebebi, rac koronaruli arteriebis daavadebaze msjelobis
saSualebas iZleva.
VI. Ppirveladi gamokvlevis sqema
yoveli pacienti, romelsac aReniSneba gulis ukmarisobis niSnebi an
simptomebi, unda gamokvleul iqnas, raTa:
1) dadgindes gulis paTologiis gamomwvevi wamyvani etiologuri faqtori;
2) gamovlenil iqnas gulis ukmarisobis progresirebis xelSemwyobi
faqtorebi
TiToeuli pacienti saWiroebs Semdeg ZiriTad gamokvlevebs:
1. anamnezi da fizikuri gasinjva;
2. eleqtrokardiograma (ekg);
21
3. gulmkerdis rentgenograma;
4. sisxlisa da Sardis saerTo analizi;
5. sisxlSi eleqtrolitebis, Sardovanas, azotis, kreatininis, glukozis
gansazRvra;
6. RviZlis funqciuri sinjebi;
7. eqokardiograma, rac aucilebelia gulis SegubebiTi ukmarisobis zusti
diagnozis dasadgenad.
eqokardiograma naCvenebia:
- axladgamovlenili gulis ukmarisobis SemTxvevaSi;
- auxsneli dekompensaciis arsebobisas;
- sarqvlovani paTologiis arsebobis fonze zogadi statusis uecari
cvlilebisas (gauaresebisas).
8. kvlevis damatebiTi informatiuli testebia: - samkurnalo saSualebebis skriningi; - gulis enzimebis donis gansazRvra (Tu gulmkerdis areSi tkivilis an
mgomareobis gauaresebis, progresirebis mizezi ucnobia);
- digoqsinis donis gansazRvra;
- Tiroid-mastimulirebeli hormonis (TSH) donis gansazRvra (am testis Cvenebebi Semdegia: mocimcime ariTmia, monacemebi farisebri jirkvlis
daavadebis Sesaxeb, asaki > 65 w.);
- natriurezuli peptidis (BNP) b tipis donis gansazRvra. - BNP warmoadgens cilas, romelic Tavisufldeba parkuWebidan moculobis an
wnevis matebis sapasuxod. im pacientebSi, romelTac qoSini aReniSnebaT, BNP donis gansazRvra SeiZleba dagvexmaros davadasturoT an gamovricxoT gulis
ukmarisoba, rogorc zemoTaaRniSnuli gamovlinebebis mizezi. BNP-s normaluri
maCvenebeli (<50) gulis qronikuli ukmarisobis gamoricxvis, xolo misi
Zalian maRali done (>600) gulis qronikuli ukmarisobis dadasturebis
efeqturi markeria. meore mxriv, saSualo maCveneblebi (100-500) diagnostikaSi
did daxmarebas ver gagviwevs (diagnostikuri Rirebuleba dabalia). pacientebs
marcxena parkuWis disfunqciiT, romelTa BNP-s done 100-500 farglebSia,
SeiZleba aReniSnebodeT qoSini, romelic ar aris gamowveuli gulis
qronikuli ukmarisobiT.
periodulad aucilebelia ganisazRvros :
− pacientis funqciuri SesaZleblobebi,
− moculobiTi statusi
− sisxlis eleqtrolitebi
− Tirkmelebis funqcia
VII. mkurnaloba
mkurnalobis ZiriTadi principebi
gulis ukmarisobis mkurnaloba unda daiwyos nebismieri iseTi Semdegom
CamoTvlili mizezebis mocilebiT, rac daavadebis progresirebas uwyobs xels,
rogoricaa: iSemia, aritmia, arakontrolirebadi hipertenzia, sarqvlebis
dazianebis progresireba, infeqciebi, narkomania, alkoholizmi, dietisa da
samkurnalo saSualebebis miRebis reJimis ugulebelyofa. Tu gulis
22
ukmarisobis damamZimebeli faqtorebi ver iqna gamovlenili, unda moxdes
farmakoTerapiis optimizacia.
gulis ukmarisobis mkurnaloba (farmakoTerapia) ori gziT SeiZleba
warimarTos. erTi mxriv, SesaZlebelia gulis kumSvadobis stimulacia dadebiTi
inotropuli saSualebebis daxmarebiT, an - gulis gantvirTva periferiuli
vazodilatorebis meSveobiT. aRniSnuli midgomiT SeiZleba hemodinamikuri
sargeblisa da klinikuri gaumjobesebis swrafi miRweva, magram am wamlebis
xangrZliv gamoyenebas sargebeli garantirebulad ar mosdevs da, piriqiT,
SesaZloa avadobisa da sikvdilobis gazrda gamoiwvios.
meore mxriv, neirohormonuli antagonistebi (age inhibitorebi, spironolaqtoni
da beta-blokerebi) dauyovnebliv simptomur sargebels ar iZlevian da SeiZleba
droebiT misi (mdgomareobis) gauaresebac ki gamoiwvion, magram xangrZlivi
mkurnalobisas aumjobeseben klinikur statuss da amcireben kardiovaskulur
garTulebebs. Sesabamisad, gulis ukmarisobis mqone pacientTa Soris avadobisa
da sikvdilobis riskis Semcirebis yvelaze efeqtur saSualebas warmoadgens
daavadebis ganmapirobebel faqtorebze zemoqmedeba da ara hemodinamikuri
Careva.
mkurnalobis zogadi zomebi (principebi)
gulis axali dazianebis riskis Semcireba:
(1) Tambaqos mowevis Sewyveta.
(2) msuqani pacientebis mier wonis dakleba.
(3) hipertenziis, hiperlipidemiisa da Saqriani diabetis kontroli.
(4) alkoholis miRebis Sewyveta.
siTxis balansis SenarCuneba:
− marilis miRebis zomieri SezRudva (< 3 g/dR) da
− yoveldRiuri awonva (wonis yoveldRiuri kontroli) siTxis
Sekavebis adreuli dadgenis mizniT.
fizikuri kondiciis (mdgomareobis) gaumjobeseba:
gulis ukmarisobis mqone pacientebma ar unda SezRudon TavianTi fizikuri
aqtivoba da monawileoba unda miiRon zomieri xarisxis varjiSebSi, raTa
Tavidan aicilon an ukuaqcion fizikuri ganviTarebis maCveneblebis daqveiTeba.
antikoagulaciuri Terpia gulis SegubebiTi ukmarisobis dros:
miuxedavad imisa, rom mxardamWeri mtkicebulebebi arasakmarisia, zogierTi
eqimi yvela im pacients utarebs antikoagulacias, romelTac marcxena parkuWis
gandevnis fraqciis gamoxatuli daqveiTeba da/an dilataciuri kardiomiopaTia
aReniSnebaT.
antikoagulacia varfariniT yvelze ufro gamarTlebulia pacientebSi,
romelTac anamnezSi aReniSnebodaT:
1. paroqsizmuli an qronikuli mocimcime ariTmia (winagulTa fibrilacia);
2. Tromboemboliuri garTuleba;
3. identificirebuli gulSida Trombi.
23
calkeuli pacientebisaTvis rekomendebulia:
(1) parkuWovani riTmis kontroli - winagulovani fibrilaciis an sxva
supraventrikuluri taqikardiis mqone pacientebisaTvis.
(2) antikoagulacia - winagulovani fibrilaciis (mocimcime aritmiis) an
anamnezSi emboliuri epizodis mqone pacientebisaTvis.
(3) koronaruli revaskularizacia - stenokardiis mqone pacientebisaTvis.
calkeuli farmakologiuri jgufebi:
Sardmdenebi
Sardmdenebi unda daeniSnos gulis ukmarisobis mqone yvela pacients, visac
siTxis Sekaveba aReniSneba. Tanmxlebi arteriuli hipertenziis dros,
xangrZlivi moqmedebis gamo, umjobesia Tiaziduri Sardmdenis
(hidroqloroTiazidi) daniSvna. danarCeni pacientebisaTvis, gansakuTrebiT
Tirkmlis ukmarisobisa da siTxis gamoxatuli Sekavebis dros, upiratesoba
maryuJovan Sardmdenebs eniWebaT. mkurnaloba Cveulebriv dabali doziT iwyeba
(mag. furosemidi 20-40 mg/dR). doza TandaTan izrdeba, sanam Sardis gamoyofa ar
moimatebs an sxeulis wona ar daiklebs (saSualod 0.5-1.0 kg/dR). mkurnalobis
mizans warmoadgens siTxis Sekavebis simptomebisa da niSnebis moxsna, rac
sauRle venaTa wnevis normalizaciiTa da periferiuli SeSupebis gaqrobiT
fasdeba. Sardmdenis SemanarCunebeli doza ise unda SevarCioT, rom siTxis
xelaxali Sekaveba Tavidan agvacilos. amis yvelaze efeqtur saSualebas
sxeulis wonis yoveldRiuri gansazRvra warmoadgens. wonis momatebis an
daklebisas Sardmdenis dozis saTanado koreqcia unda moxdes.
gulis ukmarisobis progresirebasTan erTad saWiro xdeba Sardmdenis dozis
gazrda. Tu furosemidis dRiuri doza 80 mg-s aRemateba, umjobesi iqneba misi
dayofa da 2-3 jerze micema. SardmdenTa rezistentobis gadasalaxavad agreTve
gamoiyeneba:
1. SardmdenTa intravenuri Seyvana (mag. furosemidi 40-80 mg 2-3_jer
dRiurad).
2. Tu aRiniSneba adeqvaturi pasuxi furosemidze, magram kvlav saxezea
moculobiTi gadatvirTva, unda gaizardos Seyvanis sixSire; 3. Tu furosemidze pasuxi araadeqvaturia, gamoviyenoT maryuJovani da
Tiaziduri Sardmdenebis kombinacia (mag. hidroqloroTiazidis 25 mg-is
micema furosemidis miRebamde 30 wuTiT adre).
4. Tu moculobiTi gadatvirTva kvlavac saxezea, magram pacients hipotenzia
aReniSneba, Tirkmlis perfuziis gaumjobesebis mizniT naCvenebia dadebiTi
inotropuli saSualebebis xanmokle intravenuli Seyvana (dopamini 2-4
mkg/kg/wT an dobutamini 2-5 mkg/kg/wT).
did yuradRebas saWiroebs eleqtrolituri balansis SenarCuneba,
gansakuTrebiT SardmdenTa maRali dozisa da/an maTi kombinirebuli gamoyenebis
dros. angiotenzin-gardamqmneli enzimis (age) inhibitorisa da/an kaliumis
damzogvel saSualebasTan (mag. spironolaqtoni) erTad furosemidis
kombinirebuli gamoyeneba pacientTa umravlesobas eleqtrolitur disbalanss
24
Tavidan aacilebs. SardmdenTa gadaWarbebul gamoyenebas SeiZleba hipotenzia da
azotemia mohyves. Tu pacients siTxis Sekaveba ar aReniSneba, es garTulebebi
hipovolemiiT unda iyos gamowveuli da Sardmdenis doza Semcirebas saWiroebs.
siTxis Sekavebis fonze ganviTarebuli hipotenzia da azotemia gulis
ukmarisobis gauaresebasa da efeqturi periferiuli perfuziis daqveiTebas
asaxavs. aseT dros unda vecadoT SevinarCunoT Sardmdenis doza da
gavaumjobesoT organoTa perfuzia dadebiTi inotropuli saSualebebis an
vazodilatorebis xanmokle gamoyenebis meSveobiT.
age inhibitorebi
age inhibitorebi aumjobeseben simptomebsa da klinikur statuss da amcireben
sikvdilisa da hospitalizaciis risks gulis msubuqi, zomieri da mZime
ukmarisobis dros. es sargebeli gulis iSemiuri daavadebis arsebobasa an
ararsebobaze damokidebuli ar aris. Sesabamisad, age inhibitori unda
daeniSnos gulis ukmarisobis mqone yvela pacients, visac ar aReniSneba misi
gamoyenebis ukuCveneba (mag. angioedema, orsuloba, Tirkmlis arteriis
bilateraluri stenozi an Tirkmelebis mZime ukmarisoba - anuria) an -
mkurnalobis autanloba. age inhibitori frTxilad unda gamoviyenoT, Tu
aRiniSneba:
(1) gamoxatuli hipotenzia (sisxlis sistoluri wneva < 80 mm vwy).
(2) Sratis kreatininis mkveTri momateba (> 3 mg/l);
(3) kreatininis klirensi < 30 ml/wT
(4) gamoxatuli hiperkalemia (kaliumis done SratSi > 5.5 meqv/l).
age inhibitorebis efeqturobas amcirebs siTxis Sekaveba, uaryofiT moqmedebas
ki aZlierebs siTxis dakargva, amitom age inhibitoris daniSvnamde SardmdenTa
optimaluri doza unda iqnas SerCeuli. mkurnaloba dabali doziT iwyeba (mag.
kaptoprili 6.25 mg samjer dRiurad an enalaprili 2.5 mg orjer dRiurad). Tu
pacienti dozas kargad itans, xdeba misi gaormageba 3-7 dRiani intervaliT.
Tuki uaryofiTi moqmedeba xels ar SegviSlis, doza samizne dozis miRwevamde
unda gaizardos (kaptoprili 150 mg/dR da enalaprili 20 mg/dR).
age inhibitorebis uaryofiTi moqmedeba mkurnalobis dawyebisTanave SeiZleba
gamovlindes, magram maT xangrZliv gamoyenebas Cveulebriv xels ar uSlis. es
uaryofiTi moqmedeba SeiZleba ukavSirdebodes bradikininis dagrovebas (xvela
da angioedema) an angiotenzinis daTrgunvas (hipotenzia, Tirkmlis funqciis
gauareseba da hiperkalemia). aucilebelia xvelis sxva mizezebis (gansakuTrebiT
filtvebis Segubebis) gamoricxva. Tu pacienti age inhibitors ver iRebs xvelis
an angioedemis gamo, umjobesia angiotenzinis receptorTa blokeri gamoviyenoT.
hipotenzia da azotemia SeiZleba SevamsubuqoT SardmdenTa dozis SemcirebiTa
da marilis liberalizaciiT, Tuki pacients siTxis gamoxatuli Sekaveba ar
aReniSneba. roca hipotenzia, azotemia da hiperkalemia xels uSlis age
inhibitoris xmarebas, SesaZlebelia izosorbid-dinitratisa da hidralazinis
kombinaciis daniSvna.
age inhibitoris klinikuri efeqti SeiZleba ramdenime Tvis Semdeg gamovlindes.
Tu pacientis mdgomareoba ar umjobesdeba, age inhibitoris miReba mainc
25
ganusazRvreli vadiT unda gagrZeldes sikvdilisa da ganmeorebiTi
hospitalizaciis riskis Semcirebis mizniT.
age inhibitorisa da aldosteronis antagonistis (spironolaqtoni) kombinacia
renin-angiotenzin-aldosteronis sistemis ufro srulyofil daTrgunvas iwvevs.
gulis mZime ukmarisobis mqone pacientebisaTvis spironolaqtonis 25 mg/dR
damateba avadobisa da sikvdilobis Semcirebas axdens.
angiotenzinis receptorebis blokerebi (arb)
sadReisod ar moipoveba damajerebeli mtkicebulebebi gulis ukmarisobis
mkurnalobaSi angiotenzinis receptorebis blokerebis upiratesobis Sesaxeb
ageAinhibitorebTan SedarebiT. amitom age inhibitorebi kvlavac rCeba arCevis
preparatebad im pacientebSi, romlebic maT kargad itanen. arb ki mxolod im
SemTxvevaSi iniSneba, Tu pacients age inhibitorebis mimarT autanloba
aReniSneba (Seupovari xvela). arb miRebam SeiZleba gamoiwvios Tirkmelebis
disfunqcia (funqciis gauareseba), hiperkaliemia da angioedema (kvinkes SeSupeba).
hidralazini/nitratebi
hidralazin/nitratiT kombinirebuli Terapiis Sedegad gamovlinda, rom isini
amcireben sikvdilobas, ganapirobeben gulis ukmarisobis funqciuri klasis
gaumjobesebas digoqsinTan da diuretikebTan SedarebiT. Tumca sikvdilobis
Semcirebis mxriv es mkurnaloba age inhibitorebTan SedarebiT ufro mcire
sargebelTanaa asocirebuli.
hidralazin/nitratiT kombinirebuli mkurnaloba naCvenebia, Tu:
1. age inhibitorebiT an arb–iT mkurnaloba ukunaCvenebia
(hiperkaliemia, angioedema an kreatininis klirensi < 30 ml/wT)
2. saWiroa arteriuli wnevis damatebiTi daqveiTeba age inhibitorebisa da/an
angiotenzinis receptorebis blokerebis maqsimaluri dozirebis fonze.
beta-blokerebi
iseve rogorc age inhibitorebi, beta-blokerebi aumjobeseben simptomebsa da
klinikur statuss da amcireben sikvdilisa da hospitalizaciis risks gulis
msubuqi, zomieri da mZime ukmarisobis dros. am gaumjobesebas Tan axlavs
marcxena parkuWis gandevnis fraqciis mniSvnelovani momateba. es sargebeli
gulis iSemiuri daavadebis arsebobasa an ararsebobaze damokidebuli ar aris.
beta-blokerebis efeqturoba dadasturebuli iqna im pacientebisaTvis, vinc ukve
iRebda age inhibitors, rac adasturebs mosazrebas ori neirohormonuli
sistemis kombinirebuli daTrgunvis aditiuri moqmedebis Sesaxeb. Sesabamisad,
beta-blokeri unda daeniSnos gulis ukmarisobis mqone yvela pacients, visac ar
aReniSneba misi gamoyenebis ukuCveneba (mag. bronqospazmi, simptomuri
bradikardia an gulis maRali xarisxis blokada) an mkurnalobis autanloba.
amave dros, beta-blokeri ar SeiZleba mivceT gulis dekompensirebuli
SegubebiTi ukmarisobis mqone pacientebs, visac siTxis gamoxatuli Sekaveba
aReniSnebaT da intensiur diurezs moiTxoven an intravenuli inotropuli
mkurnaloba esaWiroebaT. aseT dros jer klinikuri stabiluroba unda iqnas
miRweuli da beta-blokeri mere unda davniSnoT.
26
mkurnaloba dabali doziT iwyeba (karvediloli 3.125 mg orjer dRiurad,
metoprololi 6.25 mg orjer dRiurad an bisoprololi 1.25 mg dRiurad). Tu
pacienti dozas kargad itans, xdeba misi gaormageba orkviriani intervaliT.
Tuki uaryofiTi moqmedeba xels ar SegviSlis, doza samizne dozis miRwevamde
unda gaizardos (karvediloli 50-100 mg/dR, metoprololi 200 mg/dR da
bisoprololi 10 mg/dR).
beta-blokerebis gamoyenebasM sami saxis uaryofiTi efeqti SeiZleba mohyves:
(1) hipotenzia, romelic vazodilataciiT SeiZleba iyos gamowveuli, Tumca
ufro xSirad droebiT xasiaTs atarebs. misi ganviTarebis riski
naklebi iqneba, Tuki beta-blokers, age inhibitorsa da vazodilators
(Tu ixmareba) drois garkveuli intervaliT davuniSnavT. age
inhibitorisa da vazodilatoris doza droebiT SeiZleba SevamciroT
kidec.
(2) beta-blokeriT mkurnalobis dawyebas siTxis Sekaveba da gulis
ukmarisobis gauareseba SeiZleba mohyves. am garTulebas pacientis
yoveldRiuri awonva agvacilebs. wonis momatebis sapasuxod Sardmdenis
doza unda gaizardos, sanam pacientis wona sawyis maCvenebels ar
daubrundeba.
(3) beta-blokeris dozis gazrdas bradikardiisa da gulis blokadis
riski axlavs. Tu guliscemis sixSire wuTSi 50-ze qvemoT Camova anda
meore an mesame xarisxis bloki ganviTardeba, beta-blokeris doza unda
SevamciroT, an igi unda moixsnas.
beta-blokeris klinikuri efeqti SeiZleba ramdenime Tvis Semdeg gamovlindes.
Tu pacientis mdgomareoba ar umjobesdeba, beta-blokeris miReba mainc
ganusazRvreli vadiT unda gagrZeldes sikvdilisa da hospitalizaciis riskis
Semcirebis mizniT.
digoqsini
digoqsini aumjobesebs simptomebsa da klinikur statuss, da Sesabamisad
amcirebs hospitalizaciis risks gulis ukmarisobis dros, magram ar moqmedebs
sikvdilobaze. amis gamo, aucilebeli ar aris digoqsini gulis ukmarisobis
mqone yvela pacients daeniSnos. gamarTlebuli iqneba misi micema im
pacientebisaTvis, romlebic iReben sikvdilisa da hospitalizaciis riskis
Semamcirebel saSualebebs (age inhibitori da beta-blokeri) da mainc
aReniSnebaT gulis ukmarisobis simptomebi. digoqsinis dRiuri dozaa 0.25 mg. 70
welze ufro xnier an Tirkmlis disfunqciis mqone pacientebs SeiZleba 0.125
mg/dR mivceT. maRali doza (0.375-0.5 mg/dR) SeiZleba winagulovani fibrilaciis
dros gamoviyenoT, magram sinusuri riTmis dros misi xmareba gamarTlebuli ar
aris. spironolaqtoni
27
spironolaqtoni, - age inhibitorebTan, beta-blokerebTan, markuJovan
diuretikebTan kombinaciis SemTxvevaSi, - amcirebs sikvdilobasa da avadobas
pacientebSi gulis mZime ukmarisobiT (NYHA-s III-IV klasi). rekomendirebuli
dRiuri doza 25 mg-ia. Tirkmelebis funqcia da kaliumis donis monitoringi
unda ganxorcieldes mkurnalobis dawyebidan pirveli 2-3 kviris ganmavlobaSi
da periodulad SemdgomSic. spironolaqtoni ar iniSneba, Tu kaliumis
Semcveloba SratSi >5.0 meq/lLan Sratis kreatinini > 2.5 mg/l.
kalciumis arxis blokerebi
kalciumis arxis blokerebis umravlesoba ar unda dainiSnos sistoluri
disfunqciis dros maTi uaryofiTi inotropuli efeqtis gamo. gamonakliss
amlodipini warmoadgens. miuxedavad imisa, rom amlodipiniT mkurnaloba ar
axdens gavlenas sikvdilobisa da kardiovaskularuli paTologiis gamo
hospitalizaciis kombinirebul riskze, igi SeiZleba davniSnoT age
inhibitorebiT, beta-blokerebiTa da diuretikebiT kombinirebuli
mkurnalobisas, im SemTxvevaSi, Tu arteriuli wnevis damatebiTi kontroli
aucilebelia.
VIII. rebilitacia/meTvalyureoba: Sejerebuli monacemebis moZieba ver moxerxda, Tumca specialistebi gvirCeven:
1. xeli SevuwyoT (wavaxalisoT) fizikuri aqtivoba, datvirTvaze
individualuri tolerantobis (amtanobis) gaTvaliswinebiT;
2. gansakuTrebuli yuradReba gavamaxviloT dietisa da farmakologiuri
mkurnalobis Sesabamisobaze;
3. CautaroT pacientebs konsultaciebi narkotikuli damokidebulebisa da
Tambaqos mowevis mavneobis Sesaxeb;
4. SeviswavloT pacientebis saganmanaTleblo literatura da SevafasoT
daavadebis arsis Secnoba;
5. CavataroT zogadi Terapevtis, dietologisa da klinikuri
farmakologis konsultacia;
6. CavutaroT pacientebs pnevmoniisa da gripis sawinaaRmdego imunizacia;
7. uzrunvelyoT yovel 5-10 dReSi pacientis meTvalyureoba ubnis
Terapevtis mier
IX. gaidlainis gadasinjvisa da ganaxlebis vada:
gaidlainis gadasinjvis vada 2 wels Seadgens.
X. gaidlainis miRebis xerxi/wyaro:
gaidlaini yvela saerToevropuli da amerikuli gaidlainis Sejerebis gziT
aris miRebuli.
28
gamoyenebuli literatura:
1. Consensus recommendations for the management of chronic heart failure. Am J Cardiol 83: 1A-38A, 1999.
2. Heart Failure Society of America guidelines for management of patients with heart failure caused by left ventricular systolic dysfunction: pharmacological approaches. J Card Fail 5: 357-82, 1999.
3. Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J 22: 1527-60, 2001. 4. ACC/AHA practice guidelines for evaluation and management of chronic heart failure in the adult. J
Am Coll Cardiol 38: 2101-13, 2001. 5. McMurray J, Cohen-Solal A, Dietz R, et al. Practical recommendations for heart failure treatment.
Eur J Heart Failure 3: 495-502, 2001. 6. Nohria A, Lewis E, Stevenson LW. Medical management of advanced heart failure. JAMA
2002;287:628-40. 7. Maisel AS, Krishaswamy P, Nowak RM, et al. Rapid measurement of B-type natriuretic peptide in
the emergency diagnosis of heart failure. N Engl J Med 2002;347:161-7. 8. Cohn JN, Johnson G, Ziesche S, et al. A comparison of enalapril with hydralazine-isosorbide dinitrate
in the treatment of chronic congestive heart failure. N Engl J Med 1991;325:303-10. 9. Tsuyuki RT, McKelvie RS, Arnold JM, et al. Acute precipitants of congestive heart failure
exacerbations. Arch Intern Med 2001;161:2337-42. 10. Brater DC. Diuretic therapy. N Eng J Med 1998;339:387-95. 11. Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on morbidity and mortality in
patients with severe heart failure. RALES Investigators. New Engl J Med 1999;341:709-17. 12. Packer M, O’Connor CM, Ghali JK, et al. Effect of amlodipine on morbidity and mortality in severe
chronic heart failure. Prospective Randomized Amlodipine Survival Evaluation (PRAISE) Study Group. N Engl J Med 1996; 335:1107-14.
13. Baker DW, Wright RF. Management of heart failure IV. Anticoagulation for patients with heart failure due to left ventricular systolic dysfunction. JAMA 1994;272:1614-8.
14. McKelvie RS, Yusuf S, Pericak D, et al. Comparison of candesartan, enalapril, and their combination in congestive heart failure: randomized evaluation of strategies for left ventricular dysfunction (RESOLVD) pilot study. Circulation 1999;100:1056-64.
15. Pitt B, Poole-Wilson PA, Segal R, et al. Effect of losartan compared with captopril on mortality in patients with symptomatic heart failure: randomised trial. ELITE II. Lancet 2000;355:1582-7.
avtorTa jgufi: 1. k. papoSvili, janmrTelobis da socialuri dacvis erovnuli
institutis direqtori
2. k. surgulaZe – qalaqis me-2 saavadmyofos kardiologi
3. q. mdinaraZe – erovnuli sainformacio saswavlo centris asistenti
recenzentebi:
• m.m.k. z. kirtava – erovnuli sainformacio saswavlo centris
direqtori, kavSiri `partniorebi janmrTelobisaTvis~
Tavmjdomare, Tbilisis sax. samedicino universitetis Sinagan
sneulebaTa #1 kaTedris asistenti
• m.m.k. n. raWveliSvili, Tbilisis sax. samedicino universitetis
Sinagan sneulebaTa #1 kaTedris asistenti, kavSiri `partniorebi
janmrTelobisaTvis~ gamgeobis wevri
• n. farcxalaZe, kavSiri `partniorebi janmrTelobisaTvis~
Tavmjdomaris moadgile
• n. ilksoi, emoris universitetis samedicino skola, Sinagan
sneulebaTa kaTedra
29
Clinical Practice Guideline – Management of Heart Failure The group of authors: K. Paposhvili – deputy director of National Information Learning Centre, Head of Cardiology Research, City Hospital #7, K. Surguladze – cardiologist, City Hospital #7 K. Mdinaradze – cardiologist, City Hospital #7 Reviewers/editors
1. Z. Kirtava, MD, PhD – director of National Information Learning Centre, the chairman of “Partners for Health” NGO, member of editorial board of BMJ 2. N. Rachvelishvili, MD, PhD – assistant of Department of Internal Diseases #1 of Tbilisi State Medical University, Board member of “Partners for Health”, 3. N. Phartskhaladze, MD, MPH, “Partners for Health” NGO 4. N. Ilksoy, MD. Dept. of Medicine, Emory University. Atlanta GA
Heart Failure Treatment - Clinical Practice Guideline K. Paposhvili, K. Surguladze, K. Mdinaradze, N. Rachvelishvili, N. Partskhaladze, N. Ilksoi City Hospital #2 Cardiology Dept, Partners for Health NGO, Emory University School of Medicine / Partners for International Development, Atlanta, GA, USA an article provides a CPG on Heart Failure treatment, based on Consensus recommendations for the management of chronic heart failure and on different most recent European and American guidelines of this most important pathology among cardiovascular disorders.
30
,
mwvave diareis mkurnaloba
2 Tvidan 5 wlamde asakis bavSvebSi
i. xabazi, j. yifiani, n. raWveliSvili, z. kirtava s. lenski
m. iaSvilis sax. bavSvTa centraluri saavadmyofo, kavSiri “partniorebi
janmrTelobisaTvis”, Tbilisi, saqarTvelo; emoris universitetis samedicino
skola/`partniorebi saerTaSoriso ganviTarebisaTvis~ (atlanta, jorjia, aSS)
I. definicia: diarea aris nawlavTa moqmedebis cvlileba, romlis drosac saxezea defekacia
Cveulze ufro gaxSirebuli da/an Txeli konsistenciis ganavliT;
mwvaved iTvleba diarea, romlis xangrZlivoba ≤7 dReze.
diarea (RebinebiT an Rebinebis gareSe) xSiri problemaa da Seadgens
gadaudebeli daxmarebis ganyofilebaSi pediatriul avadmyofTa mimarTvis 16%-s.
pacienti saWiroebs klinikur Sefasebas, gamokvlevebs hospitalizaciasa da
mkurnalobas. Semosvlisas erTnairi simZimis daavadebis mqone bavSvTa marTva
xSirad gansxvavebulad mimdinareobs. axalgazrda eqimebs, romlebic naxuloben
sawyis etapze aseT avadmyofTa udides nawils, uxdebaT mniSvnelovani
gadawyvetilebebis miReba. rekomendaciis mTavari mizania gauadvilos eqimebs
gadaudebeli daxmarebis saWiroebis SemTxvevaSi swrafi da adeqvaturi
gadawyvetilebebis miRebis procesi da moxdes analogiuri klinikuri
problemebis mqone avadmyofTa msgavsi sqemiT marTvis uzrunvelyofa.
samizne populacia:
rekomendaciebi mowodebulia 2 Tvidan 5 wlamde asakis bavSvebSi mwvave diareis
(romelsac SesaZlebelia Tan axldes Rebineba, cxeleba da muclis tkivili)
samarTavad.
mocemuli rekomendaciebi ar aris sakmarisi pacientis marTvisaTvis Semdgomi
mdgomareobis dros:
• gamoxatulia toqsikozi da/an saWiroebs reanimaciaSi mkurnalobas.
• diarea 7 dReze meti xangrZlivobiT.
• dadasturebuli daavadeba, romelsac axlavs imunodeficiti an ZiriTad
organoTa sistemebis dazianeba
• Rebineba diareis gareSe.
• diarea, romelsac axlavs zrda-ganviTarebaSi CamorCena.
• diarea da/an Rebineba metaboluri daavadebis dros.
• dadasturebuli hiper- an hiponatremiuli dehidratacia.
31
II. epidemiologia mwvave gastroenteriti axalSobilebsa da bavSvebSi warmoadgens erT-erT
yvelaze farTod gavrcelebul daavadebas mTel msoflioSi. aSS-Si
yovelwliurad mw. diareis mizeziT saavadmyofos mimarTavs daaxloebiT 1,5 mln.
avadmyofi, aqedan 200 000 Tavsdeba stacionarSi, da wliurad saSualod 300-mde
letaluri SemTxveva aRiniSneba.
did britaneTSi yovelwliurad 6-dan 1 bavSvi diareis epizodis gamo mimarTavs
zogadi praqtikis eqims. diarea RebinebiT an Rebinebis gareSe Seadgens
gadaudebeli daxmarebis ganyofilebaSi pediatriul avadmyofTa mimarTvis 16%-s.
gastroenteritis sixSire mniSvnelovnad maRalia socialurad daucveli
fenebSi (Burkhart DM 1999 [A]).
III. etiopaTogenezi etiologia evropisa da amerikis ganviTarebul qveynebSi diareaTa 70-80%
virusuli (umeteswilad rotavirusuli) etiologiisaa. sxvadasxva baqteriuli
genezis diarea SemTxvevaTa 10-20% gvxvdeba, parazituli - 10%-Si. (ix. cxrili 1)
cxrili 1
infeqciuri enteritis gamomwvevi etiologiuri agentebi
virusebi baqteriebi parazitebi
Rotavirus* Enteric Adenovirus Norwalk Virus Calicivirus Astrovirus Parvovirus
Salmonella* Shigella** Campylobacter jejuni Yersinia Enterocolitica (ufro xSiria evropasa da
kanadaSi) Enterohemorrhagic E. coli Clostridium difficile (iatrogenuli)
Giardia Lamblia* Entamoeba histolytica Cryptosporidium
*yvelaze xSiri kategoriaSi
paTogenezi
diarea SesaZlebelia ganisazRvros, rogorc fekaluri siTxis Warbi (normaze
meti moculobiT) eqskrecia, Sesabamisad diareis mizezi SeiZleba gaxdes kuW-
nawlavis traqtSi wylis sekreciis gaZliereba, absorbciis Semcireba an orive
maTganis kombinacia. radgan wylis gadaadgileba xdeba osmosuri gradientis
mixedviT da damokidebulia xsnadi nivTierebebis koncentraciaze nawlavis
sanaTurSi, paTogenezis safuZvlad SeiZleba miviCnioT xsnadi nivTierebebis
absorbciisa da sekreciis darRveva.
sekreciis gaZliereba
diareis xSiri mizezs warmoadgens eleqtrolitebis gaZlierebuli sekrecia, am
dros SeiZleba sakvebi elementebis (rogorc eleqtrolitebis, ise -
araeleqtrolitebis) Sewovis funqcia intaqturi iyos. iseTi nivTierebebi,
rogoricaa baqteriuli endotoqsinebi, gastrointestinuri hormonebi, iwveven
qloridebis aqtiuri sekreciis stimulacias.
32
aqedan gamomdinare, endotoqsiniT gamowveuli diareis dros rehidrataciis
mizniT glukozo-eleqtrolituri xsnarebis gamoyeneba SesaZlebeli da
efeqturia.
absorbciis daqveiTeba
xsnadi nivTierebebis absorbciis daqveiTeba zrdis nawlavis sanaTurSi osmosur
wnevas da Sesabamisad wylis sekrecias. osmosur diareas adgili aqvs iseTi
xsnarebis per os miRebisas, romlebic cudad Seiwovebian nawlavis sanaTurSi
(laqtuloza, sorbitoli). naxSirwylebis malabsorbciasTan asocirebuli
osmosuri diareis simZimis prognozireba per os miRebuli naxSirwylebis
raodenobis mixedviT naklebad prognozirebadia, ramdenadac naxirwylebis
baqteriuli fermentaciis Sedegad kolinjSi warmoiqmneba moklejaWviani
cximovani mJavebi, romlebic aZliereben natriumisa da wylis Sewovas da
akompensireben wvril nawlavSi ganxorcielebul siTxeebisa da
eleqtrolitebis danakargs.
wvrili nawlavis lorwovanis difuzuri dazianeba iwvevs yvela nivTierebis
araspecifiur malabsorbcias. wvrili nawlavis generalizebuli dazianebis
magaliTia virusuli gastroenteriti. marTalia aseT SemTxvevebSi bavSvebis
umravlesobas umcirdeba wvrili nawlavis Semwovi funqcia msxvil nawlavSi
yovelTvis rCeba sakmarisi absorbciuli rezervi standartuli sarehidratacio
programis efeqturad ganxorcielebisaTvis
Sesabamisad diareis paTogenezidan gamomdinare baqteriuli da virusuli
gastroenteritebis dros glukoza-eleqtrolituri xsnarebi warmoadgens
efeqtur sarehidratacio saSualebas.
IV. klinikuri simptomatika dehidratacia diareasTan asocirebuli yvelaze mniSvnelovani simptomia,
romlis marTvazec aris ZiriTadad fokusirebuli mocemuli rekomendacia.
Tanmxleb simptomebs ganekuTvneba gulisreva, Rebineba, sicxe da muclis
tkivili. dehidrataciis xarisxis Sefaseba; ix. cxrili 2
• dehidrataciis xarisxi yvelaze ukeT fasdeba sxeulis saerTo wonasTan
wonis kargvis procentuli mimarTebiT (dehidrataciis epizodamde
arsebuli parametris gaTvaliswinebiT);
• klinikurad Zneli dasafiqsirebelia sxeulis wonis 3-5% kargva;
• rehidrataciis Sedegad wonis mateba xSirad aris arsebuli dehidrataciis
xarisxis Sefasebis erTaderTi gza;
• dehidrataciis arapirdapir niSnebad miCneuli parametrebis specifiuroba
da mgrZnobeloba (sensitiuroba) naklebia; aRniSnul parametrTagan
saukeTesod iTvleba lorwovani garsebis simSrale, kapilaruli avsebis
dro, cremlis gamoyofis intensivoba da mentaluri statusi;
• am cxrilis ZiriTadi nawilis nebismieri 3 parametri gansazRvravs 5%-ze
met dehidratacias 87% mgrZnobelobiTa (sensitiurobiT) da 82%
specifiurobiT (Duggan 1992[C], Gorelick 1997[C]);
cxrili 2 dehidrataciis xarisxis Sefseba fizikaluri monacemebis mixedviT
33
parametri msubuqi <6% saSualo 6-9% mZime >9%
lorwovani
garsebi odnav mSrali mSrali mSrali
kidurebi
Tbili,
kapilaruli
avseba kargi
dagvianebuli
kapilaruli avseba
> 3wm
aWrelebuli,
kapilaruli avseba >5
wm
cremldena norma Semcirebuli ar aris
ZiriTadi
mentaluri
statusi norma
normaluridan
apaTiurobamde
(ganurCeveli)
normaluridan komamde
sisxlis
wneva norma norma norma/Semcirebuli
pulsis
`xarisxi” norma norma/Semcirebuli Semcirebuli
guliscemis
sixSire norma momatebuli
momatebuli an
Semcirebuli
turgori norma Semcirebuli Semcirebuli
yiflibandi
(CvilebSi) norma Cavardnili Cavardnili
Tvalebi norma Cacvenili Rrmad Cacvenili
Sardis
gamoyofa
mcired
Semcirebuli <1 mg/kg/sT <<1 mg/kg/sT
wyurvili mcired
momatebuli momatebuli
SeiZleba verc
pasuxobdes
mwvave diarea (RebinebiT an Rebinebis gareSe) 2Tve -- 5w. bavSvebSi
diagnostikisa da marTvis algoriTmi
dasawyisi
triaJi
(satelefono)
mkurnaloba
binaze?
• oraluri rehidrataciuli xsnari
(ORS), xSiri kveba mcire ulufebiT
• Rebinebis SemTxvevaSi - damatebiT
10 ml/kg ORS (an sxva siTxe) yvela
Rebinebaze da defekaciaze.
• Tu dakarguli siTxis moculoba
aRemateba miRebuli siTxis raodenobas
_ ganmeorebiTi konsultacia.
ER an pediatris konsultacia
gaumjobeseba
mdgradi
gaumjobesebaLD
gad
d
gany
ORS,kveba
ulu
Rebi
SemT
dama
ml/k
sxva
yvel
Rebi
defe
mkurna
bina
in
momzadeba
gasawerad,
darigeba, Semdgomi
dakvirvebis
organizeba
ara
ara ara
dasasruli
ara
awonva, Sedareba normasTan
da sawyis wonasTan (Tu
SesaZlebelia)
dehidrataciis Sefaseba
34
audebeli
axmarebis
ofilebaSi ER
xSiri
mcire
febiT,
nebis
xvevaSi
tebiT 10
g ORS (an siTxe)
a
nebaze da
kaciaze
dehidratacia
>5%
dehidratacia
>9%
loba
ze?
arCunebs
sakvebs
30-60 ml ORS yovel 15 wT-Si - 4sT (mizani 50 ml/kg);
damatebiT 10 ml ORS (an sxva siTxe) yvela Rebinebaze da
kuWis moqmedebaze
i/v rehidratacia Tu siTxis Svvseba ar xerxdeba da
grZeldeba peroraluri kargva.
vTavazobT sakvebs, maSinve, rogorc ki bavSvi
adeqvaturad hidratirebulia da inarCunebs sakvebs
mZime rehidrataciis mkurnalobas
viwyebT gadaudebeli daxmarebis
ganyofilebaSi
hipovolemiuri Sokis
mkurnalobis sqemiT (protokoliT)
wonaSi namati
aris?
Semdegi
parametrebis
Sefaseba:
cremldena,
kapilaruli
avseba,
lorwovani
garsebis
sisvele,
cnobiereba
ara
ara
ara
ara
awonva
35
V. diferenciuli diagnozi:
sarwmuno monacemebi imis Sesaxeb, Tu saavadmyofoebSi diareis mizeziT
hospitalizebul bavSvebs SemdegSi ra sixSiriT uviTardebaT sxvadasxva
daavadeba, ar aris gamoqveynebuli. warmodgenili cxrili diferenciuli
diagnozisaTvis (cxrili 3), romelic efuZneba gamoqveynebul monacemebsa
(Vb, D) da konsensuss, marTalia, ar aris srulyofili, magram warmoadgens
garkveul “samaxsovros” (aide memoir) klinicistebisaTvis (eyrdnoba Vb siZlieris mtkicebulebasa da delfis konsensuss, rekomendaciis xarisxi D). aucilebelia klinicistma droulad moaxdinos diareiT mimdinare iseTi
sicocxlisaTvis saSiSi mdgomareobebis amocnoba, rogoricaa: mwvave muceli
(Vb, D, Tiaqris CaWedva (Vb, D), hemolizur uremiuli sindromi (III, C). am
SemTxvevebisaTvis damaxasiaTebeli simptomebi gvxvdeba mwvave
gastroenteritis drosac, amitom diferenciuli diagnozis gatareba
gansakuTrebul sifrTxiles saWiroebs.
cxrili 3 - mwvave diareis diferenciuli diagnozis mTavari obieqtebi
kategoria magaliTi
infeqcia enteruli: virusuli (yvelaze xSiri), baqteriuli,
parazituli
parenteruli: saSarde gzebis infeqcia, Sua yuris
anTeba, pnevmonia (prevalirebs Rebineba)
qirurgiuli apendiciti, invaginacia, obstruqcia, mokle nawlavis
sindromi.
sistemuri
daavadebebi
endokrinopaTiebi (diabeti, hiperTireoidizmi,
Tandayolili adreno-hiperplazia, adisonis
daavadeba, hiperparaTireoidizmi), imunodeficiti
antibiotik-
asocirebuli
antibiotikebis miRebis periodSi da iSviaTad
fsevdomembranuli koliti
sxvadasxva Sekruloba hipersekreciiT, toqsinebi, hemolizur-
uremiuli sindromi, axalfexadgmuli bavSvis diarea,
Zaladoba
dietis darRveva sakvebis autanloba (laqtoza, Zroxis rZis proteini)/
alergia, SimSiloba
malabsorbcia mukoviscidozi, celiakia
anTeba wylulovani koliti / kronis daavadeba, hirSprungis
daavadeba
idiopaTiuri/
fsiqogenuri
gaRizianebuli nawlavis sindromi
rekomendacia diferenciuli diagnozisaTvis
mwvave virusuli gastroenteritis garda sxva mizezis arsebobaze unda
gvafiqrebinos Semdegi klinikuri niSnebis arsebobam (rekomendebulia
specialistis konsultacia da/an damatebiTi kvleva):
• muclis tkivili, daWimuloba, defansiT an mis gareSe (Vb, D). • kanis siWrele, oligo/anuria, sisxliani diarea (III, C). • zogadi simZime, romelic ar Seesabameba dehidrataciis xarisxis (Vb, D). • Soki (Vb, D).
36
VI. gamokvlevis gegma specifiuri kvleva paTogenis aRmoCenis mizniT ar aris rekomendebuli
(eqspertTa konsensusi), garda im SemTxvevebisa, roca saqme exeba Semdegs:
• asaki <3 Tveze eqspertis komentari –
1. specifiuri kvleva paTogenis aRmoCenis mizniT ar aris aucilebeli, Tu pacients ar
aReniSneba zomieri dehidratacia mainc;
2. sisxlis saerTo analizis gakeTeba mizanSewonilia mxolod im SemTxvevaSi, Tu aris eWvi
baqteriemiaze (mag. maRali temperatura);
• imunosupresia
• septiuri/toqsiuri pacienti, toqsikozi*
• maRali temperatura
• sisxliani ganavali
am SemTxvevebSi damatebiT keTdeba sisxlis saerTo analizi, ganavlis
baqteriologiuri da mikroskopuli kvleva (cxrili 7). * toqsikozi sefsis-sindromis analogiuri simptomokompleqsia: leTargia, qsovilTa
perfuziis darRveva, mniSvnelovani hipo- an hiperventilacia, cianozi. leTargia aris
cnobierebis mdgomareoba, romelic xasiaTdeba mxedvelobiTi (vizualuri) kontaqtis
daqveiTebiT an ararsebobiT, bavSvis mier mSoblebis Secnobis darRveviT. 24 Tvemde naklebi asakis bavSvebSi, romelTac aReniSnebaT temperatura** da
diarea, mizanSewonilia aseve Sardis saerTo analizisa da baqteriologiuri
kvlevis Catareba, saSarde gzebis infeqciis gamoricxvis mizniT.
** temperaturis maCvenebeli barafis gaidlainis mixedviT
0-90 dRe _ 38º C 3-24 Tve _ 39º C
rekomendacia sisxlis analizisaTvis
plazmis eleqtrolitebis, Sardovana/kreatininis donis gansazRvra naCvenebia
Tu aRiniSneba:
• mZime dehidratacia cirkulatoruli darRvevebiT.
• saSualo simZimis dehidratacia comiseburi konsistenciis
kaniT, roca eWvia hipernatremiaze.
• saSualo simZimis dehidratacia, roca anamnezuri fizikaluri
monacemebi ar Seesabameba diareis epizodebis simwvaves.
VII. mkurnaloba A. rehidratacia – mizanSewonilia oraluri da intravenuri (i/v) Terapia,
ix. qvemoT;
B. antidiareuli da antiemeturi preparatebiT mkurnaloba ar aris
mizanSewoli (I, A).
C. antibiotikebi rekomendebuli mxolod zog SemTxvevaSi (cxrili 7).
D. probiotikebi (Laqtobacillus GG) amcireben diareis xangrZlivobas da
rotavirusmtareblobas (Guandalini 2000 [B], Guarino 1997 [B]).
A. rehidrataciis taqtika ix. algoriTmSi;
evropaSi, amerikasa da ganviTarebad qveynebSi Catarebuli rigi randomizebuli
kontrolirebadi kvlevebis safuZvelze mopovebulia mtkicebulebebi, romelTa
37
mixedviT oraluri rehidratacia (oraluri rehidrataciis siTxis – ORS - micema) warmoadgens ufro usafrTxo da swraf saSualebas dehidrataciisa da
acidozis koreqciisaTvis, vidre intravenuri Terapia (I, A). oraluri
rehidrataciis warumatebelobis SemTxvevebis sixSire (warumatebeloba
ganisazRvreba, rogorc dehidrataciis simptomebis persistireba an Sebruneba,
rac warmoadgens intravenuri rehidrataciis Cvenebas) Seadgens 3.6%. da
amasTanave oraluri rehidratacia amcirebs gulyris risks hipernatremiuli
dehidrataciis koreqciis procesSi ( II, B). saSualo-zomieri dehidrataciis marTvis rekomendaciebi
• bavSvs, visac mwvave gastroenteritis gamo aqvs saSualo-zomieri
dehidratacia, unda ganesazRvros deficiti da igi unda Seivsos ORS-is gamoyenebiT (30-80 ml/kg). ORS-s vaZlevT cotas da xSirad 3-4 saaTis
ganmavlobaSi, Tu aris amis praqtikuli saSualeba (mtkicebulebis
done I, delfis konsensusi, rekomendaciebis xarisxi A). rekomendirebulia 5 ml siTxis micema yovel 1-2 wuTSi, Tu ar
aRiniSneba Rebineba, mizanSewonilia siTxis moculobis gazrda
miRebis sixSiris SemcirebasTan erTad.
• Tu bavSvis momvlels ar SeuZlia (an ar surs) amis keTeba, an
rehidratacia unda warmoebdes mTeli Ramis ganmavlobaSi,
mizanSewonilia rehidrataciis warmoeba nazogastraluri zondis an
IV infuziis meSveobiT (mtkicebulebis done Va, delfis konsensusi
rekomendaciebis xarisxi D). • regularulad SeafaseT rehidrataciis Sedegi. Tu ar moxda
dehidrataciis klinikuri niSnebis gaumjobeseba, an saxezea
mdgomareobis gauareseba, mizanSewonilia rehidratacia
nazogastraluri zondis an i/v infuziis gamoyenebiT (mtkicebulebaTa
done Va, delfis konsensusi, rekomendaciebis xarisxi D.)
hidrataciis SenarCuneba/dehidrataciis prevencia
bavSvma, visac ar aReniSneba dehidratacis niSnebi da mas, visac ar aReniSneba
dehidrataciis niSnebi rehidrataciis Semdeg, SeiZleba miiRos Tavisufali
siTxeebi, Cveulebrivze ufro meti raodenobiT (cxrili 4 da 5).
am mizniT rekomendebulia bavSvisaTvis sasurveli da asakis Sesaferisi
racionis SerCeva (Alarcon 1992 [B], Brown 1994[B], Fayad 1993[B], Cohen 1995 [B]). Cveulebrivi kvebis reJimi - SezRudul an piriqiT gafarToebul kvebis
racionTan SedarebiT - ufro efeqturad moqmedebs diareis xangrZlivobis
Semcirebaze. (Margolis 1990 [B], Alarcon 1991 [B], Placzek 1984 [B], Santoshan 1985 [B], Molina 1995 [B]).
cxrili 4
ORS-is moTxovnilebis gamoTvla
saSualo-zomieri dehidratacia (6-9%) : 30-80 ml/kg 4 sT-is ganmavlobaSi
mZime dehidratacia (≥9%) : 100 ml/kg 4sT-is ganmavlobaSi
praqtikuli Cvevebi:
dehidratirebul bavSvebs swyuriaT da isini Cveulebriv ar amboben uars ORS-is miRebaze
mieciT siTxeebi mcire ulufebiT, magram xSirad. Rebinebis SemTxvevaSi SeamcireT
moculoba da gazardeT sixSire (yovel 5-10 wuTSi)
Tu mSoblebs saTanado meTvalyureobis qveS ar SeuZliaT/ar surT ORS-is micema,
rehidratacia unda Catardes nazo-gastraluri zondis gamoyenebiT
38
cxrili 5
ORS-is SemanarCunebeli dozis gamoTvla
sxeulis pirvel 10 kg-ze 100ml 24 sT-Si
amas emateba: 50 ml/kg/dRe sxeulis masis momdevno 10 kg-ze
amas emateba: 20 ml/kg/dRe sxeulis masis darCenil wonaze
mag.: av-fis wona aris 22kg SemanarCunebeli ORS-is doza iTvleba: (10X100) + (10X50) +
(2X20) = 1540 ml/24sT-Si
yovel Rebineba/faRaraTze aRniSnul dozas emateba 10 ml/kg
SeniSvna: sufTa siTxeebi an Cveulebrivi kvebis racioni ar cvlis ORS-s dehidrataciis prevenciis an mkurnalobis procesSi (AAP 1996 [A,D).
cxrili N 6
oraluri rehidrataciis siTxeebis SedarebiTi daxasiaTeba
xsnarebi CHO
mmol/l Na
mmol/l K
mmol/
fuZe
mmol/l osmolaroba
siTxeebi, romlebic gamoiyeneba rehidrataciisaTvis
naturaliti
140
45 20 48 265 pediatriuli eleqtrolit 140 45 20 30 250 pedialiti
140 45 20 30 250
infaliti
70 50 25 30 200
rehidraliti 140 75 20 30 310 WHO/UNICEF –is
ORS 111 90 20 30 310
siTxeebi, romlebic ar gamoiyeneba rehidrataciisaTvis
kola 700 2 0 13 750 vaSlis wveni 690 5 32 0 730 qaTmis bulioni
0 250 8 0 500
sportuli
sasmeli 255 20 3 3 330
hospitalizaciis (maT Soris gadaudebeli daxmarebis ganyofilebaSi (ER) dayovnebis) Cvenebebi:
(eyrdnoba delfis konsensuss, radgan ar arsebobs gamoqveynebuli kvlevebi,
romlebic adareben ambulatoriuli an hospitaluri mkurnalobis
upiratesobas):
• mZime dehidratacia
• saSualo simZimis dehidrataciis dros pacienti yovndeba hospitalSi
daaxloebiT 2-4 saaTis ganmavlobaSi.
• pacientebi unda dayovndnen minimum 4-6 sT, Tu isini miekuTvnebian
maRali riskis jgufs:
o asaki <6 Tve (III, C).
o wyliani ganavali >8-jer dReSi (III, C).
o Rebineba > 4-6 dReSi (III, C).
• Sefasdes mSoblebis adeqvaturoba mkurnalobis aucileblobis
gaazrebis mxriv (da survili), Tu isini ver SeZleben pacientis binaze
movlas, maSin - sasurvelia hospitalizacia.
VIII. reabilitacia – meTvalyureoba binaze gaweris Cvenebebi:
• miRweulia adekvaturi rehidratacia (fasdeba wona, diurezi, pulsi,
cnobiereba)
• intravenuri infuzia aRar aris saWiro.
• siTxeebis miReba per os Warbobs an utoldeba danakargs.
• mSoblebi informirebuli arian adeqvaturad.
• samedicino monitoringi xelmisawvdomia telefoniT an ubnis
pediatrTan vizitiT.
sakvanZo rekomendaciebi
• maT, visac ar aReniSnebaT dehidratacia (<3%), unda gaagrZelon
normaluri siTxeebis miReba, yvelaze mcire, SemanarCunebeli doziT
(Va, D). • maT, visac aReniSnebaT saSualo-zomieri dehidratacia (6-9%), unda
ganesazRvros deficiti da moxdes misi Sevseba ORS-iT 4 sT-is
ganmavlobaSi (I, A) • ORS unda mivceT mcire ulufebiT, magram xSirad. Tu Rebineba
grZeldeba, siTxeebi unda mivceT nazo-gastraluri zondis
gamoyenebiT an i/v infuziis meSveobiT (I, A) • ar aris mizanSewonili Sardovana/eleqtrolitebis rutinuli kvleva,
Tu ar xdeba dehidrataciis IV infuziiT koreqcia, an ar aris
hipernatremiis klinikuri niSnebi (Va, D) • bavSvebi zomieri da mZime dehidrataciiT, rehidrataciis mizniT unda
moTavsdnen saavadmyofoSi (delfis konsensusi, D) • rehidrataciis Semdeg (4sT) rekomendirebulia normaluri sakvebis
miReba (I, A) • antidiareuli medikamentebi ar gamoiyeneba (I, A).
IX. rekomendaciis gadasinjvis da ganaxlebis vada – xuTi weli
X. rekomendaciebis miRebis meTodi. samecniero mtkicebulebebsa da
konsensusze damyarebuli rekomendaciebis sinTezi da adaptacia (ZiriTad
safuZvlad gamoyenebulia CamoTvlili literaturis 1 da 2 wyaro).
miRebuli rekomendaciebi efuZneba gamoqveynebuli literaturis sistemur
mimoxilvas da dazustebulia sam raundian delfis konsensusze.
XI. alternatiuli gaidlaini
39
40
Subcommittee on Acute Gastroenteritis, Provisional Committee on Quality Improvement; Clinical Practice Guideline: The Management of acute Gastroenteritis in Young Children; American Academy of Pediatrics, Pediatric Clinical Practice Guideline & Policies. 2002: 209-231.
XII. gamoyenebuli literatura 1. Armon K, Stephenson T, MacFaul R, Eccleston P, Werneke U. An evidence and consensus based
guideline for acute diarrhoea management. Arch Dis Child. 2001 Aug;85(2):132-42. Review. 2. Evidence based clinical practice guideline for children with acute gastroenteritis (AGE). Cincinnati
Children's Hospital Medical Center - Hospital/Medical Center. 1999 Nov (revised 2001 Apr). 13 pages. NGC:002343
3. Perlstein PH, Lichtenstein P, Cohen MB, Ruddy R, Schoettker PJ, Atherton HD, Kotagal U. Implementing an evidence-based acute gastroenteritis guideline at a children's hospital. Jt Comm J Qual Improv. 2002 Jan;28(1):20-30.
4. King CK, Glass R, Bresee JS, Duggan C; Centers for Disease Control and Prevention.Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16.
5. Subcommittee on Acute Gastroenteritis, Provisional Committee on Quality Improvement; Clinical Practice Guideline: The Management of acute Gastroenteritis in Young Children; American Academy of Pediatrics, Pediatric Clinical Practice Guideline & Policies. 2002: 209-231.
6. HH.B.Casteel MD and S.C.Fiedorek MD Oral Rehydration Theraphy The Pediatric Clinics of North America _ vol.37.295-300
7. Guideline for management of fever without source L.J. Baraff et alPediatrics AAP 1993 v. 92 #1
avtorebi:
1. m.m.k. i. xabazi _ m. iaSvilis sax. bavSvTa centrluri saavadmyofos uwyveti
ganaTlebis ganyofilebis gamge;
2. j. yifiani _ m. iaSvilis sax. bavSvTa centrluri saavadmyofos
gadaudebeli daxmarebis ganyofilebis eqimi
recenzentebi:
4. m.m.k. z. kirtava – erovnuli sainformacio saswavlo centris
direqtori, kavSiri `partniorebi janmrTelobisaTvis~ Tavmjdomare,
Tbilisis sax. samedicino universitetis Sinagan sneulebaTa #1
kaTedris asistenti
5. m.m.k. n. raWveliSvili, Tbilisis sax. samedicino universitetis Sinagan
sneulebaTa #1 kaTedris asistenti, kavSiri `partniorebi
janmrTelobisaTvis~ gamgeobis wevri
6. k. papoSvili, janmrTelobis da socialuri dacvis erovnuli
institutis direqtori
7. s. lenski, emoris universitetis samedicino skolis bavSvTa
gadaudebeli daxmarebis (hiu spoldingis saavadmyofo) profesori
cxrili 7 ganavlis baqteriologiuri analizis warmoebisa da
antibiotikoTerapiis dawyebis Cvenebebi
maRali riskis jgufi: asaki < 3 Tveze,
imunokomprometirebulebi,
septiuri/ toqsiuri mdgomareoba
ganavlis
baqteriologia,
koprologia da
empiriuli
antibiotikoTerapia
(cefalosporini)
ki ara sisxliani ganavali,
hiperTermia
konkretuli
specifiuri paTogenis
afeTqeba
ganavlis
baqteriologia,
CBC koprologia +
atibiotiki Cvenebis
mixedviT
ki ara damxmare movla
ix. algoriTmi
umkurnale specifiur paTogens Cvenebis mixedviT
gamomwvevi
antibiotikis
efeqturoba
upiratesi
arCevani
alternatiuli
arCevani
komentari
Shigella maRalefeqturi Trimethoprimsulfamethozazole (TMP-SMZ)
III Taobis cefalosporini, Ampicillin Ciprofloxacin
aRiniSneba rezistentobis zrda Ampicillin, TMP-SMZ mimarT; Cipro-s gamoyeneba bavSvebSi naCvenebi
ar aris Salmonella ara
efeqturi
III Taobis cefalospo
rini
Ampicillin TMP-SMZ Ciprofloxacin Chloramphenicol
ant. iniSneba mxolod invaziuri
daavadebis SemTxvevaSi, bavSvis
asaki <3 Tveze, funqciuri an
anatomiuri asplenia,
neoplazia, Sidsi, kuW-nawlavis
traqtis qronikuli daavadeba,
imunosupresiuli Terapiaze
myofi pacienti
Campylobacter
efeqturia, naCvenebia zog
SemTxvevaSi
Erythromycin Ciprofloxacin
Tetracycline 8 wlamde bavSvebSi ZiriTadad
ar mkurnaloben
Yersinia
ucnobi
Cholera
maRalefeqturi Tetracycline
TMP-SMZ 8 wlamde ZiriTadad ar
ixmareba (mxolod
rehidratacia!)
Aeromonas
ucnobi
Enterotoxigenic E. coli
efeqturia,
magram naCvenebia
iSviaTad
TMP-SMZ antibiotikebi, zrdian
hemolizur-uremiuli sindromis
albaTobas da
winaaRmdegnaCvenebia
Enterohemorrhagic E. coli
ucnobi
Clostridium difficile
efeqturia,
magram naCvenebia
iSviaTad
Metronidazole
Vancomycin (oral)
upiratesia metronidazoli,
vankomicin-rezistentuli
enterokokebis problemis gamo
41
42
Treatment of Acute Diarrhea (in children from 2 months to 5 years) I. Khabazi, J. Kiphiani, N. Rachvelishvili, Z. Kirtava, S. Lanski M. Iashvili Children’s Central Hospital, Partners for Health NGO, Tbilisi, Georgia School of Medicine, Emory University/Partners for International Development, Atlanta, GA, USA The guideline represents an adaptation and compilation of several guidelines devoted to one of the most important children’s pathology - accute diarrhea. The algothythms of diagnostic procedures and treatment options are presented.
febriluri gulyra bavSvTa asakSi
n. tatiSvili, T. samxaraZe, T. yifiani, v. bokeria, i. sasania,
i. xabazi, n. raWveliSvili, z. kirtava, m. grinvaldi
m. iaSvilis sax. bavSvTa centraluri saavadmyofo,
kavSiri `partniorebi janmrTelobisaTvis~,
emoris universitetis samedicino skola / `partniorebi saerTaSoriso
ganviTarebisaTvis~ (atlanta, jorjia, aSS)
I. definicia febriluri gulyra ganisazRvreba, rogorc patara bavSvebSi xSiri, magram mainc
moulodneli paTologia, romelsac Cveulebriv kargi prognozi da momavalSi
gulyrebis ganmeorebiTi ganviTarebis dabali riski axasiaTebs. aSS
janmrTelobis erovnuli institutis definicia Semdgom kriteriumebs aRwers
febrilur gulyrasTan dakavSirebiT:
• gulyra, romelic Tan axlavs febrilur daavadebas erT Tveze meti asakis
bavSvebSi, uxSiresad - 6 Tvidan 6 wlis asakamde;
• gamoricxulia cns infeqcia;
• pacientis anamnezSi ar aris afebriluri gulyris epizodi.
febriluri gulyrebi iyofa martiv da rTul gulyrebad. dayofa mniSvnelovania
maTi Semdgomi marTvis TvalsazrisiT.
martivi febriluri gulyra ganisazRvreba, rogorc:
• xanmokle (xangrZlivoba < 15 wT);
• ara-fokaluri generalizebuli epizodi;
43
• izolirebuli (gulyris erTi epizodi 24 sT-Si, an - febriluri
daavadebis erTi periodis ganmavlobaSi);
rTuli febriluri gulyra ganisazRvreba, rogorc:
• fokaluri;
• prolongirebuli, - grZeldeba 15 wT-ze didxans;
• ganmeorebadi (erT gulyraze meti 24 sT-is an - febriluri daavadebis erTi
periodis ganmavlobaSi);
• viTardeba 38,5°C-ze dabal temperaturaze;
• aRiniSneba gulyris Semdgomi nevrologiuri deficiti;
febrilur gulyraTa daaxloebiT 30% rTulia.
morecidive febriluri gulyrebi. febriluri gulyrebis mqone bavSvTa
daaxloebiT erT mesamedSi febriluri gulyrebi morecidivea.
II. epidemiologia. sixSire (insidensi) _ 2-4%, cota ufro maRalia aziis regionSi
uxSiresad ganviTarebis saSualo asaki – 1-2 weli;
febriluri gulyrebi yvelaze xSiria bavSvTa gulyrebs Soris. evropuli
monacemebiT febriluri gulyrais riski populaciaSi 2.7-3.3%-s Seadgens.
febriluri gulyris pirveli epizodis Semdeg misi gameorebis riski ki 29-35%-ia
(orive mtkicebuleba B xarisxisaa). febriluri gulyra ZiriTadad viTardeba 6
Tvidan 5 wlamde asakSi. sixSiris piki modis 12-dan 24-Tvemde asakze (maqsimumi -
daaxloebiT 18 Tvis asakze).
martivi febriluri gulyris Semdeg epilefsiis ganviTarebis riski 1.0-2.4%-ia
(mtkicebuleba C xarisxisaa), xolo rTuli febriluri gulyris Semdeg – 4.1-6%
(B xarisxis mtkicebuleba). rTuli febriluri gulyra aseve ukavSirdeba
meningitis arsebobis SedarebiT maRal risks, vidre martivi febriluri gulyra
(C xarisxis mtkicebuleba), Tumca, iTvleba, rom meningitis riski zogadad
febriluri gulyrebis dros araa maRali (0.6-6.7%, C xarisxis mtkicebuleba).
III. etiologia / risk-faqtorebi skolamdeli asaki mniSvnelovan risks warmoadgens febriluri gulyrebis
ganviTarebisTvis, vinaidan am asakobriv jgufSi gansakuTrebiT maRalia
infeqciaTa da febrilur daavadebaTa sixSire, xolo krunCxviTi zRurbli
SedarebiT dabalia.
ramdenime kvlevam aRmoaCina xSiri serologiuri gamovlena antisxeulebisa
adamianis herpesvirus-6-isadmi, romelic rozeolas gamomwvevi agentia.
imunizaciis Semdgomi febriluri gulyrebi arsiT ar gansxvavdebian sxva
febriluri gulyrebisagan. febrilur gulyraTa provocirebas yvelaze xSirad
iwvevs yivanaxvelis vaqcina. imunizacia ar ganixileba, rogorc febriluri
gulyris gamomwvevi TavisTavadi mizezi.
febriluri gulyris pirveli epizodis ganviTarebis risk-faqtorebi:
• maRali temperatura;
• pirveli an meore xarisxis naTesavi anamnezSi febriluri gulyriT;
44
• ganviTarebaSi CamorCena;
risk-faqtorebi ganmeorebiTi febriluri gulyrebisaTvis: 16%-Si febriluri gulyris ganmeoreba xdeba pirvel 24 saaTSi; zogadad ganmeorebis riski - 33%-ia; pacientTa 9%-s
sami da meti febriluri gulyra uviTardeba; 75%-Si ganmeoreba xdeba erTi wlis ganmavlobaSi;
martivi da rTuli febriluri gulyrebis ganmeorebis riski erTnairia.
risk-faqtorebi epilefsiis ganviTarebisaTvis:
• ganviTarebis Seferxeba gulyris pirvel epizodamde;
• epilefsiis ojaxuri istoria;
• rTuli febriluri gulyra pirvel epizodad;
martivi febriluri gulyris SemTxvevaSi epilefsiis ganviTarebis riski < 5%.
risk-faqtorebi tyupebSi Seadgens 10-20%-s. riski ufro maRalia, Tu mSoblebs
anamnezSi aReniSnebaT febriluri gulyris epizodi.
IV. klinikuri simptomatika febriluri gulyris simptomokompleqsi uxSiresad Semdegia:
• cxeleba (37.8°C an meti), • gulyra febrilur periodSi (obieqturad verificirebuli an anamnezSi),
• saerTo sisuste (gansakuTrebiT gulyris Semdeg),
• kunTebis tkivili,
• Tavis tkivili, an Tabrusxveva (aucilebeli ar aris)
febriluri gulyra Cveulebriv viTardeba febriluri daavadebis mimdinareobis
adreul etapze, xSirad - rogorc daavadebis pirveli simptomi. Ggulyra
SesaZloa ganviTardes nebismieri tipis da xarisxis cxelebis fonze. gulyraTa
yvelaze metad gavrcelebuli tipia tonur-klonuri, Tumca SesaZloa adgili
hqondes mxolod tonuri komponentis, an mxolod klonuri komponetis
ganviTarebas tonuri daWimvis gareSe. gulyris xangrZlivoba uxSiresad ar
aRemateba 6 wT-s. gulyraTa mxolod 8% grZeldeba 15 wT-ze didxans.
V. daavadebis diagnozi
diagnostikuri kriteriumebi - ix. I.
pacientTa umravlesoba samedicino dawesebulebaSi xvdeba gulyris CaTavebis
Semdeg. gulyris Semdgomi mdgomareoba SesaZloa gagrZeldes wuTebi da saaTebi.
anamnezis Sekrebisas yuradReba unda mieqces TviT gulyris aRweras, sasurvelia
gamokiTxul iqnas uSualo mowme. aucilebelia cxelebis mizezis Zieba. saWiroa
gamoiricxos iseT paTologiaTa arseboba, rogoricaa meningiti, encefaliti,
seriozuli eleqtrolituri disbalansi, Tavis travma, intoqsikacia an raime
sxva mwvave nevrologiuri daavadeba. YyuradRebas imsaxurebs ojaxur anamnezSi
gulyrebis arseboba.
aucilebelia, detaluri fizikuri da nevrologiuri gasinjva. Ggasinjvis dros
gansakuTrebuli yuradReba unda mieqces neiroinfeqciis arsebobisTvis
damaxasiaTebeli niSnebis arsebobas. amasTan, mxedvelobaSi unda viqonioT is
45
garemoeba, rom erT wlamde asakis bavSvebSi meningealuri niSnebi (meningizmi,
kernigis an bruZinskis niSnebi) SesaZloa arc iyos gamoxatuli. unda gaisinjos
wina yiflibandi momatebuli wnevis gamovlenis mizniT. gamoricxul unda iyos
Zaladobis da travmuli dazianebis arseboba.
febriluri gulyris dros diferencireba pirvel rigSi saWiroa Semdeg
daavadebebTan:
• meningiti/encefaliti;
• gastroenteriti (gansakuTrebiT – Sigelozi);
• intoqsikacia: difenhidramini, tricikluri antidepresantebi, amfetamini,
kokaini da a.S.
• dehidratacia an eleqtrolituri disbalansis sxva mizezebi.
febriluri cxelebiT avadmyofis diagnostikuri algoriTmi moyvanilia cxril
#1-Si.
VI. gamokvlevis gegma martivi febriluri gulyris gamo momarTul pacientTa umravlesobas ar esaWiroeba laboratoriuli gamokvlevebi da
cns-is radiologiuri gamokvlevebi (kt, mrt). rutinuli eeg kvleva aseve naklebinformatiulia. Tu xanmokle
postiqturi (gulyris Semdgomi) mdgomareobis Semdeg swrafad moxda cnobierebis aRdgena, ramdenime saaTiani
dakvirvebis Semdgom SesaZlebelia pacientis saxlSi gaSveba.
gamonakliss warmoadgenen 18 Tveze naklebi asakis Cvilebi. mravali eqspertis
azriT am asakobriv jgufSi aucilebelia Tav-zurg-tvinis siTxis kvleva.
lumbaluri punqcia.Ffebrilur gulyraTa mqone bavSvebs Soris meningitis
arsebobis sixSire meryeobs 2%-dan 5%-mde. Aamerikis pediatriuli akademiis
mier rekomendirebulia lumbaluri punqciis gakeTeba Semdeg SemTxvevebSi:
• febriluri gulyris mqone 12 Tveze naklebi asakis bavSvebSi;
• pirveli rTuli febriluri gulyris dros;
• myari leTargiis dros;
• klinikaSi Semosvlamde ukve dawyebuli antibiotikoTerapiis SemTxvevaSi;
12-dan 18 Tvemde asakis bavSvebSi aucilebelia dawvrilebiTi nevrologiuri
gasinjva, vinaidan meningealuri simptomatika SesaZloa Zlier sustad iyos
gamoxatuli.
Tu bavSvis asaki aRemateba 18 Tves da saxeze ar aris saeWvo nevrologiuri
niSnebi, lumbaluri punqciis gakeTeba ar aris aucilebeli. L
lumbaluri punqciis ukuCvenebebia (Armon et al.): cnobierebis dabindva (glazgos
SkaliT <13), septicemiuri Sokis niSnebi, meningokokuri infeqciis klinikuri
niSnebi, momatebuli qalasSida wnevis niSnebi, fokaluri nevrologiuri niSnebi.
• sisxlis saerTo analizi
• Sratis eleqtrolitebi, kalciumi, fosfori, magniumi
• glukozis done sisxlSi
6 Tveze meti asakis bavSvisTvis am kvlevebs limitirebuli Rirebuleba gaaCnia;
yuradReba mimarTuli unda iyos ZiriTadi daavadebisa da infeqciis wyaros
identifikaciaze.
46
kt, mrt Llimitirebuli Rirebulebisaa. Mmrt ar aris naCvenebi martivi
febriluri gulyris dros. prolongirebuli an fokaluri febriluri gulyris
dros mrt kvlevis Rirebuleba sadavoa
E eeg. eeg monacemebi SesaZloa iyos abnormaluri: - rTuli febriluri
gulyrebis, febriluri gulyrebis Sesaxeb ojaxuri istoriis, winmswrebi
neiroganviTarebiTi paTologiis dros. ar arsebobs sarwmuno informacia eeg
monacemebis safuZvelze epilefsiis ganviTarebis SesaZleblobis prognozirebis
Sesaxeb.
1 wlamde asakis bavSvebSi rogorc kompleqsuri, aseve – martivi febriluri
gulyris ganviTareba gacilebiT ufro saeWvoa neiro- da/an metaboluri
paTologiis arsebobis mxriv. amdenad, CvilebSi mizanSewonilia, rom
klinicistma gaiTvaliswinos Semdegi gamokvlevebi: Sratis eleqtrolitebi,
lumbaruli punqcia, kt an mrt da saavadmyofoSi 24 saaTiT dayovneba. es
gadawyvetileba SeiZleba individualurad modificirebuli iyos klinikuri
SemTxvevisa da mkurnali eqimis eqspertizis Sesabamisad.
VII. mkurnalobis sqema
mkurnaloba uSualod gulyris dros mkurnaloba binaze. febrilur gulyraTa umravlesoba xanmoklea, maTi
xangrZlivoba ar aRemateba 6 wuTs. aseT SemTxvevebSi mkurnaloba ar aris
saWiro. 6 wuTze meti xangrZlivobis gulyris SemTxvevaSi gamoiyeneba
reqtaluri diazepami. amisaTvis saWiroa mSoblebis trenireba. reqtaluri
diazepami aseve gamoiyeneba morecidive febriluri gulyrebis mqone bavSvebSi
maRali cxelebis dros, rodesac febriluri gulyris ganviTarebis Sansi
maRalia, an bavSvi imyofeba samedicino centridan moSorebiT.
hospitaluri mkurnaloba. mimarTulia gulyris kupirebisaken. miuxedavad
imisa, rom febrilur gulyrebs garTulebebi iSviaTad axasiaTebT, ar unda
dagvaviwydes aspiraciis riski. hospitalSi ZiriTadad gamoiyeneba intravenuri
an reqtaluri diazepami, lorazepami, midazolami. Tu gulyra iRebs statusur
mimdinareobas, gamoiyeneba krunCxviTi statusis mkurnalobis protokoli.
mkurnaloba cxelebis dros antipiretuli saSualebebi Ggamoiyeneba cxelebis sawinaaRmdegod, Tumc
morecidive febriluri gulyris prevenciisaTvis isini ar arian efeqturni.
qronikuli prevenciuli Terapia. qronikuli prevenciuli Terapiis sakiTxi SesaZloa ganxilul iqnes xSiri
morecidive febriluri gulyrebis (rTuli an martivi) arsebobis SemTxvevaSi.
qronikuli prevenciuli Terapia febrilur gulyraTa ganviTarebis sixSires
amcirebs, magram ar arsebobs mtkicebulebebi imis sasargeblod, rom febrilur
gulyraTa prevencia epilefsiis SesaZlo ganviTarebis risks amcirebs.
qronikuli prevenciuli Terapiis mizniT gamoyeneba Semdegi preparatebi:
47
fenobarbitali _ kontrolirebadi ormagi brma meTodiT Sesrulebuli
kvlevebis monacemebis mixedviT fenobarbitali mniSvnelovnad amcirebs
morecidive febriluri gulyrebis ganviTarebis Sanss _ 25%-dan 5%-mde.
valproatis mJava _ randomizebuli kontrolirebadi kvlevebiT valproatis
mJaviT mkurnalobis fonze morecidive febriluri gulyrebis mqone bavSvTagan
gulyra ganumeorda mxolod 4%-s, nacvlad 35%-sa sakontrolo jgufidan
karbamazepini _ zogjer ukeT aitaneba, magram naklebad efeqturad iTvleba
morecidive febriluri gulyrebis prevenciis TvalsazrisiT.
prognozi. ukanaskneli ocdaxuTwliani dakvirvebis safuZvelze febrilur
gulyrebi fasdeba rogorc keTilTvisebiani paTologia. is ar aris
asocirebuli tvinis raime arsebiT dazianebasTan da febriluri gulyrebis
mqone bavSvTa mxolod mcire procents uviTardeba SemdgomSi epilefsia.
dadgenilia, rom antiepilefsiuri medikamentebiT SesaZlebelia febrilur
gulyraTa prevencia, Tumca antiepilefsiuri Terapia ver cvlis SemdgomSi
epilefsiis ganviTarebis risks.
VIII. reabilitacia / meTvalyureoba – specialuri miTiTebebi
gaidlainebis doneze ar aris SeTanxmebuli.
IX. gaidlainis gadasinjvis da ganaxlebis vada _ ori weli
X. gaidlainis miRebis gza da wyaroebi _ literaturis Targmani,
ramdenime gaidlainebis Sejereba da adaptacia.
XI. alternatiuli gaidlaini – ar aris moyvanili
XII. gamoyenebuli literatura:
1. “Practice parameter: The Neurodiagnostic Evaluation of the Child with a First Simple Febrile Seizure” Pediatrics, 1996; 97(#5 May) 769-772.
2. Warden, et al “Evaluation and Management of Febrile Seizures in the Out-of-Hospital and Emergency Department Settings” Annals of Emergency Medicine 2003 41(#2 Feb) pp215-222.
3. Baumer JH “Evidence based guideline for post-seizure management in children presenting acutely to secondary care” Arch Dis Child 2004;89:278-280.
4. Hirtz DG “Febrile Seizures” Pediatrics in Review 1997; 18:1 January 5-9. 5. Carroll W, Brookfield D. “Lumbar Puncture following febrile convulsion: a painful pointless
procedure? Arch Dis Child 2002;87:238-240. 6. Waruiru C, Appleton R. “Febrile Seizures: an update” Arch Dis Child 2004;89:751-756. 7. Bernard L. Maria, “Current Management in Child Neurology”, B. C. Decker Inc., 1999, pp.
296-302. 8. Joseph J. Volpe, “Neurology of the Newborn”, W. B. Saunders Comp., 2000, pp. 717-813. 9. Kenneth F. Swaiman, Stephen Ashwal, “Pediatric Neurology, Principles and Practice”, Mosby, 1999,
pp. 981-1025. 10. Martin A. Samuels, “Manual of Neurologic Therapeutics”, Lippincott Williams and Wilkins, 1999, pp.
149-217. 11. Kenneth W. Lindsay, Ian Bone, “Neurology and Neurosurgery Illustrated”, Churchill Livingstone,
2001, pp. 470-498. 12. Bruce O. Berg, “Principles of Child Neurology”, McGraw-Hill, 1996, pp. 749-839.
48
13. Gerald M. Fenichel, Clinical Pediatric Neurology,Saunders Company, 2001, 47-77. 14. Jean Aicardi, Deseases of the Nervous System in Childhood, Mac Keith Press, 1998, 373-438. 15. S. E. Behrman, Pediatric Decision Making, Mosby, 2003, 640-646. 16. S.E. Behrman, Nelson Textbook of Pediatrics, 2003, 725-745. 17. David A. Bergman, AMERICAN ACADEMY OF PEDIATRICS 18. Practice Parameter: Long-term Treatment of the Child With Simple Febrile Seizures Pediatrics,
1999; 103(#6, June) 19. Martin Offringa, Virginia A. Moyer. Evidence Based Management of Seizures Associated with Fever.
BMJ, 2001; 323:1111-4; 20. J.H. Baumer. Evidence based Guideline for Post-seizure Management in Children Presenting
Acutely to Secondary Care. Arch Dis Child 2004; 89:278–280; 21. D. Hirtz, Berg, D. Bettis, C. Camfield, P. Camfield. Practice parameter: Treatment of the child with a
first unprovoked seizure. Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society, 2002;
22. Kate Armon, Maria Atkinson, Miss Philippa Eccleston, Monica Lakhanpaul, Roderick MacFaul, Stephanie Smith, Ursula Werneke, William Whitehouse, Lynne Williams, Terence Stephenson. Evidence Based Guideline for the Management of Children Presenting Post Seizure. Developed 1999 January, updated 2002 July. 119 p. Paediatric Accident and Emergency Research Group: www.pier.org.uk
mix. iaSvilis sax. bavSvTa respublikuri saavadmyofos avtorTa jgufi:
n. tatiSvili
T. samxaraZe
T. yifiani
v. bokeria
i. sasania
i. xabazi
recenzentebi:
8. m.m.k. z. kirtava – erovnuli sainformacio saswavlo centris
direqtori, kavSiri `partniorebi janmrTelobisaTvis~ Tavmjdomare,
Tbilisis sax. samedicino universitetis Sinagan sneulebaTa #1
kaTedris asistenti
9. m.m.k. n. raWveliSvili, Tbilisis sax. samedicino universitetis Sinagan
sneulebaTa #1 kaTedris asistenti, kavSiri `partniorebi
janmrTelobisaTvis~ gamgeobis wevri
10. maikl grinvaldi, emoris universitetis samedicino skolis
pediatriuli gadaudebeli daxmarebis specialisti
(Michael Greenwald, Pediatric Emergency Medicine, Emory University, Atlanta, GA, USA)
cxrili #1
49
ar aris [axali]
nevrologiuri niSnebi*
da asaki > 6Tve
martivi febriluri
gulyra:
generalizebuli, < 15
wT da 1 epiz./24 sT rTuli febriluri
gulyra: fokaluri,
> 15 wT da/an >1
epizodze - 24 sT-Si
axali nevrol.
niSnebi da
asaki < 6 Tve
aucilebelia kt, lp,
eleqtrolitebi + cxelebasTan
dakavS. RonisZiebebi
(neiroinfeqciis gamoricxva!)
18 Tve – 6 weli < 18 Tveze
lp; kt; eleqtro
litebi;
hospitali-
zacia#; cxelebasTanN dakavS.
RonisZiebebi
dakvirvevba
2 sT;
cxelebasTan
dakavS.
RonisZiebebi
gamomjo-
bineba
gawera binaze
Sesabamisi
instruqciiT
rCeba
post-
iqtaluri
* - moicavs meningitis niSnebs, gamoricxavs
postiqtalur
gamovlinebebs
# - empiriuli lp miT
ufro rekomendebulia,
rac ufro dabalia
pacientis asaki
> 6 weli
mwvave febriluri gulyra
anamnezSi ar aris afebriluri gulyra
gulyrasa da
cxelebasTan
dakavSirebuli
standartuli
RonisZiebebi
50
Febrile Seizure in Children N. Tatishvili, T. Samkharadze, T. Kipiani, I. Bokeria, I. Sasania, I. Khabazi, N. Rachvelishvili, Z. Kirtava, M. Greenwald The diagnosis of febrile seizures describes a commonly occurring yet unpredictable event in young children which has an excellent prognosis and low risk of future seizures. The US National Institutes of Health definition includes the following features: 1) Occurs in early childhood, usually between 6 months and 6 years; 2) Excludes conditions suggestive of intracranial infection; 3) Excludes patients with previous non-febrile seizures. The article provides a new National type guideline for Febirle Seizure, which represents compilation and adaptation of different CPGs, reviewed by US expert.
septiuri Sokis mkurnaloba
o. asaTiani, z. metreveli, m. kapanaZe, n. raWveliSvili, e. l. barnhemi
akad. o. RuduSauris sax. erovnuli samedicino centri,
kavSiri `partniorebi janmrTelobisaTvis~, (Tbilisi, saqarTvelo)
emoris universitetis samedicino skola / `partniorebi saerTaSoriso
ganviTarebisaTvis~ (atlanta, jorjia, aSS)
I. daavadebis definicia: istoriulad sefsis mravali sxvadasxva ganmartebaa mowodebuli, Tumca arc
erTi fiziologiuri Tu laboratoriuli parametri universalurad ver
asaxavs sefsisis arss.
yvelaze ufro Tanamedrove, farTod gavrcelebuli ganmartebebi Semdegia:
sefsisi: warmoadgens sistemur anTebiT pasuxs infeqciaze.
mZime sefsisi: infeqciiT inducirebuli organuli disfunqcia an
hipoperfuziuli darRvevebi.
septiuri Soki: sefsisis fonze ganviTarebuli hipotenzia, romelic ar
swordeba infuziuri TerapiiT da dakavSirebulia organul disfunqciasTan an
hipoperfuziul darRvevebTan.
1991 w. amerikis gulmkerdis qirurgTa kolejisa da kritikul
mdgomareobaTa medicinis sazogadoebis SemaTanxmebel konferenciaze
miRebuli nomenklaturiT septiuri Soki xasiaTdeba sefsisiT, hipotenziiT,
hipovolemiiT da qsovilTa damtkicebuli araadeqvaturi perfuziiT.
sefsisi xasiaTdeba anTebis sistemuri sapasuxo reaqciiTa da
damtkicebuli baqteriemiiT.
mZime sefsisis diagnozi ismeba poliorganuli ukmarisobis arsebobisas.
51
II. epidemiologia:
amerikis SeerTebul StatebSi yovel 100 hospitalizaciaze sefsisis 2±0,16 SemTxveva fiqsirdeba. saerTaSoriso maCvenebeli – 1.36 SemTxveva 100
hospitalizaciaze.
anTebis sistemuri sapasuxo reaqciis dros sikvdilianoba Seadgens 7%,
sefsisis SemTxvevaSi – 16-20%, septiuri Sokisas – 45%.
SemTxvevaTa 18%-Si septiuri Soki rTuldeba mozrdilTa respiratoruli
distres sindromiT, 50%-Si - Tirkmlis mwvave ukmarisobiT, 38%-Si -
diseminirebuli sisxlZarRvSida Sededebis sindromiT.
III. etiologia/risk-faqtorebi/paTologia: etiologiuri faqtorebi: nebismierma infeqciurma procesma SeiZleba gamoiwvios sefsisis
ganviTareba, gansakuTrebiT - mkurnalobis Cautareblobis, dagvianebis an
araadeqvaturobis/araefeqturobis SemTxvevaSi. xolo sefsisi xSir SemTxvevaSi
SesaZloa garTuldes septiuri SokiT.
paTogenezi: infeqciis SemTxvevaSi gamomwvevi mikroorganizmis produqtebis
urTierTqmedeba maspinZeli organizmis ujredebTan da plazmis cilebTan iwvevs
reaqciaTa kaskadis CarTvas, rasac sabolood mivyavarT ujredTa dazianebasa da
sikvdilamde, aseve mediatorebis - araqidonis mJavis daSlis produqtebis
(leikotrienebi, prostaglandinebi, Tromboqsani); kateqolaminebis,
glukokortikoidebis; prekalikreinis; bradikininis; histaminis; endorfinis;
enkefalinis; adrenokortikotropuli hormonis; miokardiumis depresantuli
faqtoris; kaxeqtinis; interleikini-1; komplementis sistemis da fibrinolizuri
sistemis produqtebis - gamonTavisuflebamde.
yovelive zemoTaRniSnuli iwvevs gul-sisxlZarRvTa sistemis daTrgunvas,
mikrocirkulaciis moSlas, qsovilTa perfuziis daqveiTebas, metaboluri
procesebis darRvevas da sabolood - Sokuri mdgomareobis ganviTarebas.
IV. klinikuri simptomatika:
septiuri Sokis specifiuri da paTognomuri simptomebi ar arsebobs.
sistemuri anTebiTi pasuxis sindromis (SIRS) diagnozi ismeba, Tu aRiniSneba
ori an meti Semdegi simptomebidan:
1. temperatura - 38oC-ze meti an 36 oC-ze naklebi;
2. gulis SekumSvaTa sixSire > 90/wT;
3. sunTqvis sixSire meti >20/wT;
4. leikocitebi > 12000/l, an < 4000/l, an umwifari
formebis raodenoba > 10%-s (marcxniv gadaxra).
- klinikuri niSnebi zogjer pirveladi keris identifikaciis
saSualebas iZleva:
• Tavisa da kisris infeqcia – yuris tkivili, Tavis tkivili, yelis tkivili,
sinusitis movlenebi, kisris limfuri jirkvlebis gadideba;
52
• gulmkerdisa da filtvismieri infeqcia – xvela (gansakuTrebiT -
produqtiuli), tkivili mkerdis areSi, dispnoe;
• saWmlis momnelebeli traqtis infeqcia – tkivili muclis areSi,
gulisreva, Rebineba, faRaraTi;
• Sard-sasqeso organoebis infeqcia – tkivili muclis qveda nawilSi,
dizuria, menstrualuri ciklis darRveva;
- araspecifiuri niSnebidan aRsaniSnavia:
zogadi sisuste;
Tavbrusxveva;
cxeleba, Semcivneba, hiperTermia (moxucebsa da alkoholizmiT
daavadebulebSi SeiZleba aRiniSnebodes hipoTermia);
gulisreva, Rebineba;
taqikardia;
taqipnoe, xSirad - kusmaulis tipis sunTqviT;
peteqiuri gamonayari kanze an retikularuli livedo;
arteriuli hipotenzia;
oflianoba;
splenomegalia;
cnobierebis areva da/an daTrgunva, zogjer komamde;
V. daavadebis diagnozi: diagnostikuri kriteriumebi:
septiuri Sokis specifiuri da paTognomuri diagnostikuri kriteriumebi
ar arsebobs. Ddiagnozi efuZneba anTebaze sistemuri xasiaTis pasuxisa da
zogadad Sokis niSnebis gamovlenas.
diferencialuri diagnozi unda gatardes Semdeg mdgomareobebTan:
Tirkmlis mwvave ukmarisoba;
adrenaluri krizi;
anafilaqsia;
kardiogenuli Soki;
diabeturi ketoacidozi;
diseminirebuli sisxlZarRvSida Sededebis sindromi (DIC-sindromi); stenokardiuli Seteva;
hiperTireoidizmi;
miokardiumis mwvave infarqti;
miokardiumis ruptura;
paraneoplastiuri sindromi;
filtvis arteriis Tromboembolia;
mozrdilTa respiratoruli distres sindromi;
hipovolemiuri Soki;
sistemuri anTebiTi pasuxis sindromi;
salicilatebiT intoqsikacia;
stiven-jonsonis sindromi;
zurgis tvinis travma.
VI. gamokvlevis sqema:
53
septiur Sokze eWvis mitanisTanave pacients stacionarSi unda Cautardes
Semdegi gamokvlevebi:
sisxlis baqteriologiuri analizi
1. analizi aRebuli unda iqnes antibiotikoTerapiis dawyebamde.
2. saeWvo SemTxvevaSi (rodesac laboratoriuli kvlevis pasuxi
uaryofiTia, xolo klinikurad aSkarad saqme gvaqvs sefsissa da
septiur SokTan) analizebis seriis Sesruleba 2 dRis ganmavlobaSi
zedized, dReSi 3-5-jer.
3. sisxli unda iyos venidan axlad aRebuli, sisxlis raodenoba ar
unda iyos 15-20 ml-ze naklebi, sisxlisa da niadagis raodenobis
Sefardeba unda iyos 1:10-1:20;
sisxlis saerTo analizi (hemoglobinis dones mniSvneloba aqvs
adeqvaturi oqsigenaciis misaRwevad, leikocitozi da formulis marcxniv
gadaxra infeqciis simZimis Sefasebis saSualebas gvaZlevs);
mJava-tutovani wonasworoba (laqtat-acidozi qsovilTa perfuziis
daqveiTebis da Sokis simZimis Sefasebis saSualebas iZleva);
Sardis saerTo analizi;
Sardis baqteriologiuri analizi;
sxvadasxva biologiuri siTxeebis da/an qsovilebis baqteriologiuri
analizi;
C-reaqtiuli cila (mniSvnelovani diagnostikuri markeria, dinamikaSi am
maCveneblis cvlileba informaciis gvaZlevs sefsisisa da septiuri Sokis
progresirebaze an regresze);
sxvadasxva garTulebebisa da infeqciis pirveladi wyaros gamovlenis mizniT
saWiroa Semdegi damatebiTi gamokvlevebis Catareba:
koagulograma (sefsisisa da septiuri Sokis erTerTi yvelaze mZime
garTulebis - diseminirebuli sisxlZarRvSida Sededebis sindromis
verifikacia);
kreatinini sisxlSi;
bilirubini sisxlSi;
alaninaminotransferaza (alt);
aspartataminotransferaza (ast);
tute fosfataza (RviZlisa da Tirkmlis funqciebis Seswavla
mniSvnelovania mZime sefsisis dros poliorganuli ukmarisobis
Sesafaseblad);
albumini sisxlSi;
glikemia;
sisxlis eleqtrolitebi;
gulmkerdis rentgenografia;
muclis Rrus organoTa ultrabgeriTi gamokvleva;
kompiuteruli tomografia (instrumentuli kvlevis meTodebi infeqciis
kerebis gamovlinebis saSualebas gvaZleven);
lumbaluri punqcia (arsebiTi mniSvneloba aqvs neiroinfeqciis
diagnostikaSi);
sefsisis dros ar unda dagvaviwydes zogierTi gavrcelebuli etiologiuri
faqtori, romelTa gamosavlenadac xandaxan damatebiTi gamokvlevebis Catarebaa
saWiro:
centraluri venuri kaTeteriT (cvk) gamowveuli infeqcia:
54
• cvk gamowveul infeqciaze eWvis dros saWiroa kaTeteris amoReba da
baqteriologiuri gamokvleva.
• Tu eWvia kaTeteris punqciis adgilze infeqciis arsebobaze, saWiroa
nacxis aReba da baqteriologiuri gamokvleva.
• Tu kaTeteris punqciis adgilze Cirqovani gamonadenia, kaTeteri unda
Caidgas sxva, infeqciis keridan daSorebul adgilze, miuxedavad
baqteriologiuri kvlevis monacemebisa.
ventilator-asocirebuli pnevmonia (vap):
• vap-ze eWvis dros saWiroa sisxlis orjeradi baqteriologiuri
gamokvlevisa da gulmkerdis rentgenografiis Catareba.
• plevraSi siTxis arsebobis SemTxvevaSi, saWiroa punqcia da siTxis
baqteriologiuri Seswavla.
• zogierTi monacemebiT, bronqoskopia (bronqoalveoluri lavaJiT an
nacxis aRebiT) garkveuli diagnostikuri Rirebulebisaa, magram es
monacemebi jer kidev sakamaToa.
• endotraqeuli milidan sekretis gramis wesiT gamokvleva aseve
SeiZleba dagvexmaros mkurnalobis sworad warmarTvaSi.
intraabdominuri infeqcia:
• aucilebelia sisxlis baqteriologiuri gamokvleva zemoT aRniSnuli
principebiT.
• Cirqis an gamonadenis arsebobis SemTxvevaSi saWiroa nacxis aReba da
gamokvleva. gaTvaliswinebul unda iqnas anaerobuli koinfeqciis
arsebobac. sokovan infeqcias didi yuradReba unda mieqces da unda
Catardes antimikozuri preparatebiT mkurnaloba, sanam es diagnozi ar
gamoiricxeba.
• naCvenebia instrumentuli kvleva. eqoskopia xSir SemTxvevaSi
sakmarisia, magram kompiuteruli tomografia (sasurvelia – kontrastuli
CT) ufro informatiulia. nebismieri siTxis arsebobisas unda moxdes misi
drenaJi da mikroskopuli Seswavla.
mwvave akalkulozuri qolecistiti:
• eWvi unda iqnas mitanili yvela septiur pacientSi (gansakuTrebiT
postoperaciul), visac aReniSneba tkivili muclis zeda marjvena
kvadrantSi da sanaRvle gzebis obstruqciisaTvis damaxasiaTebeli
RviZlis funqciuri sinjebis cvlilebebi.
• mizanSewonilia gadaudebeli ultrabgeriTi gamokvleviT
diagnostireba da zog SemTxvevaSi - perkutaneulad drenireba.
sinusiti:
• mosalodnelia yvela pacientSi nazotraqeuli miliT an nazogastruli
zondiT, gansakuTrebiT Tavis tvinis dazianebis dros.
• saWiroa rentgenografiuli an CT-gamokvleva.
• ganxilul unda iqnas sinusis antraluri punqciis (antral puncture) sakiTxi, Tu masSi siTxis done fiqsirdeba.
VII. mkurnalobis sqema:
− infuziur Terapia: -
55
− infuziuri Terapia dauyovnebliv unda iqnas dawyebuli ori msxvili periferiuli
kaTeteriT. kaTeteris diametri ufro mniSvnelovani parametria, vidre misi
sigrZe.
− septiuri Sokis SemTxvevaSi infuziuri Terapiis mizania perfuziis
gaumjobeseba da ujreduli metabolizmis normalizeba.
− Sratis laqtatis donis momateba miuTiTebs qsovilebis hipoperfuziaze
riskis jgufis pacientebSi, romelTac hipotenzia ar aReniSnebaT.
− centraluri venis kaTeterizacia saWiroa rogorc xangrZlivi da masiuri
infuziuri Terapiis Casatareblad, ise - centraluri venuri wnevis
monitoringisaTvis;
− aucilebelia Sardis buStis kaTeterizacia saaTobrivi diurezis
SefasebisaTvis;
− arteriis kanulacia rogorc laboratoriuli gamokvlevebisaTvis, ise
invaziurad arteriuli wnevis monitoringisaTvis;
− filtvis arteriis kaTeterizacia (svan-gancis kaTeteriT) gulis
wuTmoculobis, saerTo periferiuli winaaRmdegobis gansazRvris, mcire
wris hemodinamikuri SefasebisaTvis. Aam manipulaciis Sesaxeb azrTa
sxvadasxvaobaa. igi ar axdens dadebiT efeqts sefsisis gamosavalze,
Tumca saSualebas gvaZlevs miviRoT informacia, rac adeqvaturi
Terapiis SerCevaSi dagvexmareba
− pirvel 6 saaTSi mkurnalobis mizania yvela Semdegi
parametris stabilizacia:
1. centraluri venuri wneva – 12-18 mmHg, 2. saSualo arteriuli wneva - >65 mmHg, 3. saaTobrivi diurezi - ≥0.5 ml/kg*sT
4. centraluri an Sereuli venuri sisxlis Jangbadis saturacia ≥ 70%. kristaloidebi: natriumis qloridis 0,9%-iani xsnari, i/v;
ringer-laqtatis xsnari i/v.
infuziis moculoba damokidebulia hipovolemiis xarisxze da SeiZleba
ramdenime litriTac ganisazRvros dRe-RameSi. ukuCvenebebi: filtvebis an Tavis
tvinis SeSupeba, rac SeiZleba fataluri gamosavliT dasruldes. amdenad didi
mniSvneloba aqvs infuziis moculobisa da tempis kontrols.
koloidebi: deqstrani - 70 – 800 ml-mde;
hidroqsieTilsaxamebeli 6% an 10% - 1000-1500 ml-mde;
albuminis 5% xsnari – 250-500 ml-mde.
maTi ≈50% rCeba sisxlZarRvovan kalapotSi da amdenad ufro swrafad SeiZleba
hipovolemiis gamosworeba.
ukuCvenebebia: prepartisadmi hipermgrZnobeloba, filtvebis SeSupeba.
sisxlis preparatebi: septiuri Sokis dros eqspertTa umravlesobis mier
rekomendebulia hemoglobinis donis SenarCuneba 90-100 g/l doneze.
hemoglobinis es done kargad aitaneba pacientTa umravlesobis mier,
kardiologiuri darRvevebis arsebobis SemTxvevaSic. xolo Tu saxeze ar gvaqvs
Tanmxlebi kardiuli daavadeba, hemoglobinis done 70-80 g/l-ic misaRebia.
vazopresorebi: vazopresorebiT mkurnaloba dawyebul unda iqnes maSin, roca
mxolod siTxeebiT ver xerxdeba adeqvaturi arteriuli wnevisa da organoTa
perfuziis aRdgena. vazopresorebi xSirad aucilebelia sicocxlis
gadasarCenad da perfuziis SesanarCuneblad kritikuli hipotenziis dros.
titrirebul unda iqnas minimaluri saWiro dozebi.
56
septiuri Sokisas hipotenziis koreqciisaTvis pirveli rigis preparatebia
norepinefrini (noradrenalini) an dopamini. dopamini zrdis saSualo arteriul
wnevas upirvelesad gulis indeqsis gazrdis gziT da minimalur zemoqmedebas
axdens sistemur sisxlZarRvovan rezistentobaze. sasurvelia, dopaminis dozam
ar gadaaWarbos 20 mkg/kg/*wT. mZime sefsisis SemTxvevaSi dopaminis dabali
dozebis gamoyeneba Tirkmlis funqciis SenarCuneba/gaumjobesebisaTvis ar aris
rekomendirebuli. dopaminis dabali dozebi Tirkmelebis dacvis mizniT ar unda
iyos gamoyenebuli, rogorc mZime sefsisis mkurnalobis sqemis Semadgeneli
nawili.
norepinefrini TvalnaTliv aumjobesebs saSualo arteriul wnevas da
glomerulur filtracias, gansakuTrebiT maRali gulis gadmosrolis / dabali
sisxlZarRvovani rezistentobis mqone pacientebSi.
dopamini – 1-5 mkg/kg/wT, maqsimaluri doza 20 mkg/kg/wT;
epinefrini/adrenalini da norepinefrini/noradrenalini – 2 mkg/kg/wT.
ukuCvenebebia: koronaruli daavadeba, arakontrolirebadi hipertenzia, mZime
parkuWovani taqikardia. aseT SemTxvevebSi gamoiyeneba mxolod sasicocxlo
CvenebebiT.
gverdiTi efeqtebi: miokardiumis iSemia, ariTmia, tremori, hipertenzia.
oqsigenoTerapia: saWiroa qsovilebamde Jangbadis maqsimaluri miwodebisaTvis.
mZime SemTxvevebSi (sefsisisa da septiuri Sokis dros mozrdilTa
respiratoruli distres sindromis ganviTarebis didi albaTobaa) SeiZleba
saWiro gaxdes traqeis intubacia da filtvebis xelovnuri ventilacia (fxv),
romlis reJimi da parametrebi unda SeirCes sasunTqi sistemis mdgomareobis
Sesabamisad).
filtvebis mwvave dazianebis/mozrdilTa respiratoruli distres sindromis
dros fxv dawyebul unda iqnas CasunTqvis mcire moculobiT (daaxloebiT 6
ml/kg). CasunTqvis platos wneva ar unda aRematebodes 30 wylis sv. hiperkapnia
dasaSvebia CasunTqvis moculobisa da CasunTqvis platos wnevis minimizaciis
SesanarCuneblad (egreT wodebuli “dasaSvebi hiperkapnia”).
gasaTvaliswinebelia, rom fxv-m SeiZleba kidev ufro arastabiluri gaxados
hemodinamika gulisaken venuri ukudinebis Semcirebis gamo. am mavne zegavlenis
Semcireba SeiZleba CasunTqvis wnevis (Pinsp), CasunTqvis drois (Tinsp), amosunTqvis
bolos dadebiTi wnevis (PEEP) minimalizaciiT.
zogjer mimarTaven hiperbarul oqsigenoTerapias, gansakuTrebiT - rbili
qsovilebis nekrozis dros.
antibiotikebi: empiriuli antibiotikoTerapia dawyebul unda iqnes
rac SeiZleba swrafad da farTo speqtris preparatis meSveobiT unda
gadafaros yvela SesaZlo flora – rogorc gram-dadebiTi, aseve gram-
uaryofiTi da anaerobuli flora.
retrospeqtiuli kvlevebiT dadgenilia, rom gram-uaryofiTi baqteriebiT
gamowveuli hematogenuri infeqciebisas Sesabamisi antibiotikebis daniSvna
amcirebs sikvdilianobas.
igive efeqti unda gvqondes gramdadebiTi sefsisis drosac, miuxedavad
imisa, rom amis mtkicebulebebi jer ar moipoveba.
antibiotikoTerapiis aucilebeli pirobaa maTi intravenuri Seyvana.
(antibiotikebis dozireba, Cvenebebi da ukuCvenebebi ixileT danarTSi, cxrili
#1).
57
empiriuli mkurnalobisas monoTerapia nebismieri mesame an meoTxe generaciis
cefalosporinebiT an karbapenemebiT iseve efeqturia, rogorc beta-laqtamebisa
da aminoglikozidebis kombinacia mZimed mimdinare sefsisiT im pacientebSi,
romelTac neitropenia ar aReniSnebaT.
ftorqinolonebi monoTerapiis saxiT ar aris rekomendebuli gramdadebiT
floraze maTi suboptimaluri zemoqmedebis gamo.
glikopeptidebi (mag. vankomicini) mizanSewonilia umZimes pacientebSi
kaTeterasocirebuli infeqciiT an im centrebSi, sadac meTicilin-
rezistentuli stafilokoki dominirebs.
antifungaluri agentebi ar unda iqnas gamoyenebuli rutinulad empiriul
TerapiaSi.
aucilebelia kulturebis Seswavla mkurnalobis optimizaciis mizniT,
rogorc araefeqturi antibiotikebis drouli moxsnisaTvis, aseve - arsebuli
antibiotikoTerapiis Sevsebisa da koreqciisaTvis.
kortikosteroidebi:
i/v kortikosteroidebis gamoyeneba naCvenebia pacientebSi, romlebic, miuxedavad
siTxeebiT Sevsebisa, saWiroeben vazopresorebs, raTa SenarCunebuli iqnas
adeqvaturi arteriuli wneva.
hidrokortizoni - 200-300mg/dR, gayofili 3-4 dozad an mudmivi infuziis saxiT 7
dRis ganmavlobaSi. dRiurad 300 mg meti hidrokortizoni sSeyvana araa
rekomendebuli. SesaZloa gamoviyenoT sxva steroiduli preparatebic
ekvivalentur dozebSi.
zogi eqspertis mosazrebiT saWiroa adrenokortikotropuli hormonis (akth) 250
mkg-iT mastimulirebeli testis Catareba. Tu pacients akth-s Seyvanidan 30-60 wT-
is Semdeg aReniSneba kortizolis koncentraciis momateba > 9 mkg/dl-ze,
kortikosteroidebiT mkurnaloba ar unda Catardes. magram klinicistebma ar
unda daelodon akth-s mastimulirebeli testis Sedegebs kortikosteroidebiT
mkurnalobis dasawyebad da unda axsovdeT, rom hidrokortizoni moqmedebs
kortizolis koncentraciaze, maSin rodesac deqsametazoni eqvivalentur
dozaSi amas ar iwvevs.
rekombinanturi aqtivirebuli
proteini C (rhAPC) rekomendebulia sikvdilianobis maRali riskis mqone
pacientebSi (APACHE II >25, poliorganuli ukmarisobis, septiuri Sokis, mozrdilTa
respiratoruli distres sindromis dros. misi winaaRmdegCvenebebi mocemulia
cxril 2-Si. aRsaniSnavia, rom saqarTveloSi es preparati jerjerobiT ar
gamoiyeneba.
glikemiis kontroli: glikemia SenarCunebuli unda iyos <8,3 mmol/l
donemde yvela SesaZlo SemTxvevaSi. es SesaZlebelia
insulinisa da glukozis mudmivi infuziiT. mkurnalobis
dasawyisSi glikemiis kontroli unda xdebodes ufro
xSirad (yovel 30-60 wT), xolo stabilizaciis Semdeg
regularulad (yovel 4 sT).
bikarbonati: qsovilTa hipoperfuziiT gamowveuli laqtat-acidemiis
mkurnalobaSi bikarbonatis efeqturobis mtkicebulebebi
ar arsebobs.
Rrma venebis Trombozis
profilaqtika yvela pacients unda utardebodes profilaqtika
dabalmolekuluri hepariniT an Cveulebrivi heparinis dabali dozebiT.
58
pacientebs, romelTaTvisac heparini ukunaCvenebia, utardebaT fizikuri
meTodebiT profilaqtika (damwoli naxvevis dadeba).
maRali riskis pacientebSi (mZime sefsisi, anamnezSi Rrma venebis
Trombozis arseboba) profilaqtika xorcieldeba kombinirebulad, rogorc
medikamentozuri Terapiis, ise - fizikuri meTodebis gamoyenebiT.
stresuli wylulis profilaqtika:
utardeba mZime sefsisiT yvela avadmyofs. H2-blokerebi
yvelaze ukeTaa Seswavlili da yvelaze xSiradac
gamoiyeneba.
amas gansakuTrebuli mniSvneloba eniWeba im SemTxvevebSi,
Tu adgili aqvs koagulopaTias, meqanikur ventilacias
da hipotenzias, radgan am
dros stresuli wylulis ganviTarebis riski
gansakuTrebiT maRalia.
operaciuli mkurnaloba: aucilebelia infeqciis kerebis (gulmkerdisa
da muclis Rruebi, centraluri nervuli
sistema, rbili qsovilebi) gamovlena, adeqvaturi
drenireba da drouli likvidacia.
IX. gaidlainis gadasinjvisa da ganaxlebis vada: Cvens mier warmodgenili gaidlainis gadasinjvis vadaa 2 weli.
X. gaidlainis miRebis xerxi: aRniSnuli gaidlaini miRebulia literaturis Ziebis Sedegad SerCeuli
sxvadasxva gaidlainebis Sejerebisa da adaptaciis gziT. amdenad
alternatiuli gaidlaini ar aris warmodgenili
XI. gamoyenebuli literatura:
1. New gudelines for the management of sepsis/septic shock. April 2004. http://www.pulmonaryreviews.com
2. Dellinger RP, Carlet JM, Masur H, Gerlach H, calandra T, Cohen J, Gea-Banacloche J, Keh D,
marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM; Surviving Sepsis Campaign Management Guidelines Committee. 2004 Mar. http://www.ncbi.nlm.nih.gov
3. J Stephan Stapczynski, MD, Shock, Septic. July 25, 2002. http://www.emedicine.com
4. Abraham E, Wunderink R, Silverman H, et al: Efficacy and safety of monoclonal antibody to
human tumor necrosis factor alpha in patients with sepsis syndrome. A randomized, controlled, double-blind, multicenter clinical trial. TNF-alpha MAb Sepsis Study Group. JAMA 1995 Mar 22-29; 273(12): 934-41http://www.ncbi.nlm.nih.gov
5. Beal AL, Cerra FB: Multiple organ failure syndrome in the 1990s. Systemic inflammatory
response and organ dysfunction. JAMA 1994 Jan 19; 271(3): 226-33 http://www.ncbi.nlm.nih.gov
6. Brun-Buisson C, Doyon F, Carlet J, et al: Incidence, risk factors, and outcome of severe sepsis and septic shock in adults. A multicenter prospective study in intensive care units. French ICU Group for Severe Sepsis. JAMA 1995 Sep 27; 274(12): 968-74 http://www.ncbi.nlm.nih.gov
59
7. Cronin L, Cook DJ, Carlet J, et al: Corticosteroid treatment for sepsis: a critical appraisal and meta- analysis of the literature. Crit Care Med 1995 Aug; 23(8): 1430-9 http://www.ncbi.nlm.nih.gov
8. Eidelman LA, Putterman D, Putterman C, Sprung CL: The spectrum of septic encephalopathy.
Definitions, etiologies, and mortalities. JAMA 1996 Feb 14; 275(6): 470-3 http://www.ncbi.nlm.nih.gov
9. Gattinoni L, Brazzi L, Pelosi P, et al: A trial of goal-oriented hemodynamic therapy in critically ill
patients. SvO2 Collaborative Group. N Engl J Med 1995 Oct 19; 333(16): 1025-32 http://www.ncbi.nlm.nih.gov
10. Guest TM, Ramanathan AV, Tuteur PG, et al: Myocardial injury in critically ill patients. A
frequently unrecognized complication. JAMA 1995 Jun 28; 273(24): 1945-9 http://www.ncbi.nlm.nih.gov
11. Le Gall JR, Lemeshow S, Leleu G, et al: Customized probability models for early severe sepsis in
adult intensive care patients. Intensive Care Unit Scoring Group. JAMA 1995 Feb 22; 273(8): 644-50http://www.ncbi.nlm.nih.gov
12. Lefering R, Neugebauer EA: Steroid controversy in sepsis and septic shock: a meta-analysis. Crit
Care Med 1995 Jul; 23(7): 1294-303http://www.ncbi.nlm.nih.gov
13. Lundberg JS, Perl TM, Wiblin T, et al: Septic shock: an analysis of outcomes for patients with onset on hospital wards versus intensive care units. Crit Care Med 1998 Jun; 26(6): 1020-4http://www.ncbi.nlm.nih.gov
14. Lynn WA, Cohen J: Adjunctive therapy for septic shock: a review of experimental approaches.
Clin Infect Dis 1995 Jan; 20(1): 143-58http://www.ncbi.nlm.nih.gov
15. Quartin AA, Schein RM, Kett DH, Peduzzi PN: Magnitude and duration of the effect of sepsis l on survival. Department of Veterans Affairs Systemic Sepsis Cooperative Studies Group. JAMA 1997 Apr 2; 277(13): 1058-63http://www.ncbi.nlm.nih.gov
16. Rady MY, Rivers EP, Nowak RM: Resuscitation of the critically ill in the ED: responses of blood
pressure, heart rate, shock index, central venous oxygen saturation, and lactate. Am J Emerg Med 1996 Mar; 14(2): 218-25http://www.ncbi.nlm.nih.gov
17. Rangel-Frausto MS, Pittet D, Costigan M, et al: The natural history of the systemic inflammatory
response syndrome (SIRS). A prospective study. JAMA 1995 Jan 11; 273(2): 117-23http://www.ncbi.nlm.nih.gov
18. Sands KE, Bates DW, Lanken PN, et al: Epidemiology of sepsis syndrome in 8 academic medical
centers. Academic Medical Center Consortium Sepsis Project Working Group. JAMA 1997 Jul 16; 278(3): 234-40http://www.ncbi.nlm.nih.gov
19. Schierhout G, Roberts I: Fluid resuscitation with colloid or crystalloid solutions in critically ill
patients: a systematic review of randomized trials. ALYSIS 1998 Mar 28; 316(7136): 961-4http://www.ncbi.nlm.nih.gov
20. Wenzel RP, Pinsky MR, Ulevitch RJ, Young L: Current understanding of sepsis. Clin Infect Dis
1996 Mar; 22(3): 407-12http://www.ncbi.nlm.nih.gov
60
21. Wheeler AP, Bernard GR: Treating patients with severe sepsis. N Engl J Med 1999 Jan 21; 340(3): 207-14http://www.ncbi.nlm.nih.gov
avtorTa jgufi: olRa asaTiani – akad. o. RuduSauris sax. erovnuli samedici-
no centris informaciis marTvisa da uwyveti
samedicino ganaTlebis samsaxuris ufrosi, zaza metreveli – akad. o. RuduSauris sax. erovnuli samedi-
cino centris katastrofisa da gadaudebeli
medicinis samsaxuris ufrosi,
mamuka kapanaZe - akad. o. RuduSauris sax. erovnuli samedicino
centris gadaudebeli daxmarebis (mimRebi) gan-
yofilebis eqimi-reanimatologi.
recenzentebi:
11. m.m.k. z. kirtava – erovnuli sainformacio saswavlo centris
direqtori, kavSiri `partniorebi janmrTelobisaTvis~ Tavmjdomare,
Tbilisis sax. samedicino universitetis Sinagan sneulebaTa #1
kaTedris asistenti
12. m.m.k. n. raWveliSvili, Tbilisis sax. samedicino universitetis Sinagan
sneulebaTa #1 kaTedris asistenti, kavSiri `partniorebi
janmrTelobisaTvis~ gamgeobis wevri
13. k. papoSvili, socialuri da jandacvis erovnuli institutis
direqtori
14. e. l. barnhemi – Terapiis, pulmonologiis, alergologiis da
kritikuli medicinis profesori, emoris universitetis samedicino
skola, atlanta, jorjiis Stati, aSS
(E. L. Burnham, MD—Assistant Professor of Medicine, Pulmonary, Allergy, and Critical Care Medicine, Emory University School of Medicine, Atlanta, Georgia, USA)
61
danarTi:
cxrili #1
antibiotikoTerapia septiuri Sokis dros
dasaxeleba moqmedebis speqtri dozireba SeniSvna
cefuroqsimi
meore Taobis ce-
falosporini,
moqmedebs gramda-
debiT floraze da
E. coli, Klebsiella pneumoniae, Haemophilus influenzae.
1,5 g yovel 8
sT-Si, i/v.
ukunaCvenebia hiper-
mgrZnobelobisas,
aminoglikozidebTan
erTad aZlierebs maT
nefrotoqsiur
efeqts. Tirkmlis
ukmarisobisas
saWiroa dozis ko-
regireba. aZlierebs
antikoagulantebis
moqmedebas.
cefotaqsimi mesame Taobis ce-
falosporini,
moqmedebs gram-
uaryofiT flora-
ze, gansakuTrebiT
Escherichia coli, Proteus, Klebsiella.
1-2 g yovel 4
sT-Si, i/v.
ukunaCvenebia hiper-
mgrZnobelobisas,
aminoglikozidebTan
erTad aZlierebs maT
nefrotoqsiur
efeqts. Tirkmlis
ukmarisobisas
saWiroa dozis
koregireba.
ceftriaqsoni moqmedebs penici-
linaza maprodu-
cirebel mikro-
organizmebze.
1 g yovel
6-12 sT-Si, i/v.
ukunaCvenebia hiper-
mgrZnobelobisas,
aminoglikozidebTan
erTad aZlierebs maT
nefrotoqsiur
efeqts. Tirkmlis
ukmarisobisas saWi-
roa dozis koregi-
reba. sifrTxiliT
unda iqnas gamoyene-
buli penicilinze
alergiis SemTxve-
vaSi.
Tikarcilin/
klavulanati
beta-laqtamaza
daculi antibio-
tiki, moqmedebs
umravles gramda-
debiT(garda MRSA Stamebisa), gram-
uaryofiT da anae-
robul floraze.
3,1 g yovel 4-6
sT-Si, i/v.
ukunaCvenebia hiper-
mgZnobelobisas,
saWiroa RviZlisa da
Tirkmlis funqciebis
monitoringi (ALT, AST, kreatininis klirensis
gansazRvra).
piperacilin/
tazobaqtami
beta-laqtamaza
daculi antibio-
tiki, moqmedebs
umravles gramda-
3,375 g yovel
6 sT-Si, i/v
ukunaCvenebia hiper-
mgZnobelobisas,
saWiroa RviZlisa da
Tirkmlis funqciebis
62
debiT(garda MRSA Stamebisa), gram-
uaryofiT da anae-
robul floraze.
monitorringi (ALT, AST, kreatininis klirensis
gansazRvra).
imipenemi karbapenemebis
jgufis preparati,
yvelaze farTo
moqmedebis speqtriT.
500 mg yovel
6 sT-Si, i/v.
ukunaCvenebia prepa-
ratisadmi hiper-
mgrZnobelobisa da 12
wlamde asakis
bavSvebSi. Tirkmlis
ukmarisobisas saWi-
roa dozis koreq-cia.
meropenemi karbapenemebis jgu-
fis kidev erTi
warmomadgeneli.
imipenemTan Seda-
rebiT, xasiaTdeba
ufro maRali aqti-
vobiT gramuaryo-
fiT baqteriebis
mimarT, da
daqveiTebuli
aqtivobiT - stafi-
lokokze da strep-
tokokze; aseve mo-
matebuli SeRweva-
dobiT hematoence-
falur barierSi.
1 g yovel 8
sT-Si, i/v.
igive,
an ix. imipenemi
klindamicini moqmedebs ZiriTa-
dad anaerobul
floraze da ram-
denadme - strepto-
kokebze.
600-900 mg
yovel 8sT-Si,
i/v
ukunaCvenebia hiper-
mgZnobelobisas,
wylulovani koli-
tis, RviZlis ukma-
risobisas da anti-
biotikasocirebuli
kolitisas.
Tirkmelebis
disfunqciisas dozis
koreqcia saWiro ar
aris.
metronida-
zoli
moqmedebs anaero-
bul baqteriebze da
protozoaze.
rogorc wesi ga-
moiyeneba sxva
antibiotikebTan
kombinaciaSi, ga-
monaklisia
Clostridium difficile-Ti
gamowveuli
enterokoliti,
rodesac monoTe-
rapiac sakmarisia.
500 mg yovel
8sT-Si
wveTovnad, i/v.
ukunaCvenebia hiper-
mgrZnobelobisas.
zrdis antikoagu-
lantebis toqsiur
efeqts, RviZlis
daavadebebisas
saWiroa dozis ko-
regireba.
ciproflo- ftorqinolonebis 400 mg yovel ukunaCvenebia hiper-
63
qsacini jgufis preparati,
moqmedebs umrav-les
gramuaryo-fiT da
anaero-bul
floraze,
metnaklebad moq-
medebs strepto-
kokebze.
12 sT-Si, i/v. mgrZnobelobisas,
zrdis Teofilinis,
kofeinis, ciklo-
sporinis da
digoqsinis
toqsiurobas,
SeiZleba gaaZlieros
antikoagulantebis
efeqti (saWiroa
proTrombinis drois
monitoringi).
Tirkmlis
ukmarisobisas dozis
koreqcia.
cxrili #2
rekombinantuli aqtivirebuli protein C (rhAPC) ukuCvenebebi rhAPC zrdis sisxldenis risks. rhAPC ukunaCvenebia Semdeg klinikur
situaciebSi, rodesac sisxldena SeiZleba dakavSirebuli iyos maRal
sikvdilianobasTan • aqtiuri Sinagani sisxldena • hemoragiuli insulti bolo 3 Tvis manZilze
• intrakraniuli an intraspinaluri operacia an Tavis tvinis mZime travma
bolo 2 Tvis manZilze
• travma, romelic dakavSirebulia sicocxlisaTvis saxifaTo sisxldenis
maRal riskTan
• epiduruli kaTeteris arseboba
• intrakraniuli simsivne, an Tavis tvinis masiuri dazianeba, an cerebruli
Tiaqari
64
Treatment of Septic Shock O. Asatiani, Z. Metreveli, M. Kapanadze, N. Rachvelishvili, E. L. Burnham National Medical Center after Prof. O. Gudushauri, Partners for Health NGO, Tbilisi, Georgia; Emory University School of Medicine, Partners for International Development, Atlanta, GA, USA The artcile presents a draft for new national guideline – result of compilation and adaptation of Guidelines for Septic Shock diagnosis and management, developed by Georgian doctors from National Medical Center in Tbilisi. The guideline is based on recent Evidence Based Medicine materials, latest US and European guidelines on sepsis/septic schock management. Final version has been reviewed by US expert from Emory University in Atlanta, GA.
preeklampsia
z. sinauriZe, r. suluxia, n. zaldastaniSvili, m. nemsaZe, o. asaTiani
z. kirtava, n. raWveliSvili, k. papoSvili, m. Cekli
akad. o. RuduSauris sax. erovnuli samedicino centri,
kavSiri `partniorebi janmrTelobisaTvis~,
emoris universitetis samedicino skola /`partniorebi saerTaSoriso
ganviTarebisaTvis~ (atlanta, jorjia, aSS).
I. definicia da klasifikacia
daavadebaTa saerTaSoriso klasifikaciis me-X gadaxedvis mixedviT orsulobaSi
hipertenziuli mdgomareobebis cnebis qveS gaerTianebulia Semdegi
paTologiuri mdgomareobebi: qronikuli hipertenzia da orsulobiT gamowveuli
hipertenzia. es bolo Tavis mxriv iyofa orsulTa tranzitorul hipertenziad
da preeklempsia/eklampsiad.
qronikuli hipertenzia - mudmivi hipertenzia, romelic xasiaTdeba arteriuli
wnevis momatebiT 140/100 vwy.sv, magram ara umetes 160/110 vwy.sv da Cndeba
orsulobamde an orsulobis 20 kviramde.
65
orsulobiT gamowveuli hipertenzia - hipertenzia, romelic viTardeba
orsulobis dros da qreba orsulobis Semdeg. am jgufSi gaerTianebulia
orsulTa tranzitoruli hipertenzia da preeklempsia/eklampsia.
• orsulTa tranzitoruli hipertenziis dros arteriuli wneva ar
aRemateba 150/100 vwy.sv-s da mas ar axasiaTebs proteinuria da SeSupeba.
• preeklempsia/eklampsia es aris hipertenzia, proteinuriasTan da
SeSupebasTan erTad, romelic viTardeba orsulobis 20 kviris Semdeg.
preeklampsiis dros arteriuli wneva aRemateba
a) 140/90 vwy.sv-s,
an –
b) sawyis sistoluri wnevas - 30 vwy.sv-iT, xolo sawyis diastoluri wnevas -
15 vwy.sv-iT.
ganasxvaveben msubuq da mZime formis preeklampsias. mZime formis
preeklampsias axasiaTebs Semdegi parametrebi:
1. sistoluri wneva 160 vwy.sv an diastoluri wneva - 110 vwy.sv, rac
daregistrirebul iqna 2-jeradad 6 saaTian intervalSi.
2. proteinuria 5g/24 sT-Si3 da meti;
3. oliguria (<400 ml/24 sT-Si);
4. Zlieri Tavis tkivili da mxedvelobis dabindva;
5. filtvis SeSupebis niSnebi;
6. cianozi.
am fonze krunCxvebis Camoyalibebis SemTxvevaSi saubroben eklampsiaze.
saqarTvelo 1993 wlidan aris janmrTelobis dacvis msoflio organizaciis
(WHO) wevri, am droidan moyolebuli Cvens qveyanaSi gamoiyeneba es klasifikacia
da ara Zveli rusuli (orsulTa nefropaTia) an raime sxva (OPH- gestozi) klasifikacia.
II. epidemiologia
msoflio janmrTelobis dacvis organizaciis monacemebiT preeklampsiisgan
marto evropaSi weliwadSi iRupeba 14,000 orsuli. ra Tqma unda,
gardacvlilebis ZiriTadi procenti modis ganviTarebad qveynebze. saerTod,
msoflioSi preeklampsiis gavrceleba Seadgens 4-9%; kerZod, amerikis
SeerTebul StatebSi preeklampsiis sixSire - 5-5.5%. yofili sabWoTa kavSiris
qveynebidan preeklampsiis yvelaze maRali maCveneblebi aRiniSneboda yirgizeTSi
(9-11%).
preeklampsiis gavrceleba saqarTveloSi Seadgens orsulobis 6-7%. preeklampsia
gvxdeba qalis yvela reproduqciul asakSi, magram misi ganviTarebis riski
ufro maRalia 20 wlamde orsulebSi da 35 wlis zemoT. preeklempsiis dros
maRalia perinataluri sikvdilianoba (5.4%) da avadoba (3 - 30%).
III. etiopaTogenezi da risk-faqtorebi
3 Zveli (sabWoTa) klasifikaciis mixedviT proteinuriis diagnozi ismeboda 24 sT-Si 3 g da meti cilis
gamoyofisas.
66
daavadebis paTogenezi bolomde ar aris garkveuli. Tumca dRevandeli
warmodgeniT, genetikuri midrekilebis Sedegad irRveva
decidualur/trofoblasturi urTierTkavSirebi, rac iwvevs placentaruli
perfuziis Semcirebas. placentaruli iSemiis Sedegad xdeba biologiurad
aqtiuri faqtorebis gamonTavisufleba da endoTeliaruli ujredebis naadrevi
apoptozi. es ukanaskneli aris generalizirebuli vazokonstriqciis, iSemiis da
Trombozis mizezi. yovelive zemoTTqmulis Sedegad viTardeba sasicocxlo
organoebis da placentis funqciis moSla.
aRweren preeklampsiis ganviTarebis Semdeg risk-faqtorebs:
1. eqstragenitaluri paTologiebi xelsayrel fons qmnian gestozis
CamoyalibebisaTvis. Tirkmlebisa da gul-sisxlZarRvTa sistemis daavadebebi,
agreTve endokrinuli paTologiebi (cximovani cvlis moSliT mimdinare
endokrinopaTiebi, farisebri jirkvlisa da Tirkmelzeda jirkvlis
kortikaluri Sris paTologiebi) ZiriTad fons qmnian mZime formis
preeklempsiis ganviTarebisaTvis. magram, damtkicebul risk-faqtors
warmoadgens mxolod diabeti.
2. preeklempsiis prognozirebisas gaTvaliswinebuli unda iqnas genetikuri
foni. qalTa 14-40%-s, romelTa dedebsac preeklampsia aqvT gadatanili,
orsulobis dros agreTve uviTardebaT es paTologia.
3. preeklempsiis sixSire da mimdinareobis simZime mWidrod ukavSirdeba
socialur faqtorebs. maRalia misi sixSire `mjdomare~ profesiis mqone
qalebsa da studentebSi. araxelsayreli sawarmoo (qimiuri, fizikuri da
sxva), klimaturi da ekologiuri faqtorebi, mavne Cvevebi (Tambaqos weva,
alkoholis Warbi moxmareba), araswori kveba, Sromisa da dasvenebis reJimis
darRveva da orsulobisadmi uaryofiTi damokidebuleba xels uwyobs
preeklempsis ganviTarebas.
4. preeklempsiis ganviTarebaSi garkveuli roli eniWebaT ginekologiur
paTologiebs. misi sixSire maRalia qalebSi, romelTac anamnezSi aReniSnebaT
menstrualuri ciklis darRvevebi, sasqeso organoebis anTebiTi daavadebebi,
saSvilosnos mioma, sasqeso organoebis ganviTarebis anomaliebi da abortebi.
5. maRali riskis jgufs unda mivakuTvnoT orsulebi, romelTac aReniSnebaT
mravalwylianoba, mravalnayofiani orsuloba, didi nayofi, anemia, Cveuli
abortebi, rezus-SeuTavsebloba da adreuli toqsikozi.
6. qalis asaki erT-erTi faqtoria, romelsac zemoqmedeba gaaCnia preeklampsiis
ganviTarebaze, mimdinareobasa da gamosavalze. igi ufro xSirad Zalzed
axalgazrda (19 wlamde asakis) da xandazmul (35 welze meti asakis)
orsulebSi viTardeba. 40 wlis zemoT preeklempsiis Camoyalibebis riski
erTi aTad izrdeba. varaudoben, rom amis mizezi mocemul kontingentSi
sasicocxlo mniSvnelobis mqone sistemaTa adaptaciuri SesaZleblobebis
daqveiTebaa.
7. erT-erTi risk-faqtoria pirveli orsuloba.
Tumca aRsaniSnavia, rom zemoT CamoTvlili risk-faqtorebis fonze
preeklampsiis ganviTareba ar aris dafuZnebuli myar mtkicebulebebze.
IV. klinikuri simptomatika
preeklempsia/eklampsiis klinikuri niSnebia:
67
1. arteriuli wnevis mateba 140/90 vwy.sv-ze zeviT, an sawyisi sistoluri
wnevis 30 vwy.sv – iT, xolo diastoluri wnevis - 15 vwy.sv-iT mateba;
2. proteinuria;
3. generalizirebuli SeSupeba.
garda zemoTaRniSnulisa, preeklampsiis mZime formas xSirad Tan sdevs
Semdegi klinikuri niSnebi:
− Tavis tkivili;
− mxedvelobis gauareseba; − tkivili epigastriumSi an marjvena ferdqveSa midamoSi;
− cnobierebis cvlileba;
− hipertenziuli encefalopaTia;
− taqikardia;
− taqipnoe;
− cxviris lorwovanis SeSupeba, rac aZnelebs cxviriT sunTqvas da xSirad
araswored interpretirdeba, rogorc mwvave respiratoruli infeqciis
simptomi;
− kanis qavili; − gulisreva, Rebineba;
− nayofis saSvilosnosSida ganviTarebis Seferxeba.
garTulebebi
preeklampsia SeiZleba garTuldes Semdgegi paTologiuri mdgomareobebiT:
1. normalurad mimagrebuli placentis naadrevi acliT, romelsac moyveba
disenimirebuli koagulopaTia;
2. TromboemboliiT, romelic gamoixateba adgilobrivi an
generalizirebuli TromboziT;
3. Tirkmlis pirveladi mwvave ukmarisobiT;
4. mikroangiopaTiuri hemolizuri anemiiT, romelic xasiaTdeba hematuriiT
da anemiiT; 5. hepatocelularuli darRveviT – RviZlis fermentebis momatebiT; 6. HEELP (Hepatic Enzymes Elevated Low Platelet) sindromiT - Trombocitebis
raodenobis SemcirebiT da RviZlis fermentebis momatebiT; 7. centralur nervul sistemaSi sisxlCaqceviT;
8. eklampsiiT, romelic gamoixateba krunCxvebiT da/an komiT.
V. diagnozi
preeklampsiis diagnozi efuZneba cangenmeisteris triadas:
1. arteriuli hipertenzia;
2. proteinuria;
3. SeSupeba.
dasabuTebuli medicinis Tanamedrove monacemebze dayrdnobiT SeiZleba iTqvas,
rom preeklampsiis diagnozis dasasmelad aRniSnuli diagnostikuri
kriteriumebidan aucilebelia proteinuriis arseboba.
VI. gamokvlevebis sqema
68
I. laboratoriuli diagnostika.
preeklampsiis diagnostikisaTvis pacientis SemosavlisTanave Casatarebelia
Semdegi diagnostikuri gamokvlevebi:
1. sisxlis saerTo analizi;
2. hematokriti;
3. sisxlis bioqimiuri analizi:
a) bilirubini;
b) Sardovana;
g) SardmJava;
d) saerTo cila;
e) cilovani fraqciebi;
h) AST; i) ALT; k) tute fosfatazis aqtivobis gansazRvra;
l) eleqtrolitebi;
4. koagulograma;
5. Sardis saerTo analizi;
garda zemoTaRniSnuli laboratoriuli testebisa, mkurnalobis swori
taqtikis SerCevisaTvis aseve sasurveli Semdegi gamokvlevebis Catareba:
1. venuri wnevis gansazRvra;
2. koloido-osmosuri wnevis gansazRvra;
3. Sardis analizi mikroalbuminuriaze;
4. Sardis baqteriologiuri analizi;
5. Sardis analizi zimnickis mixedviT.
II. sxivuri diagnostika:
1. Tavis tvinis kompiuteruli tomografia;
2. ultrasonografiuli kvleva
III. konsultaciebi:
• Terapevtis
• nefrologis
• nevropaTologis
• oftalmologis
• anesTeziologis
VII. mkurnalobis sqema
preeklampsiis marTvis ZiriTadi mizania maqsimalurad Semcirdes dedis da
nayofis dazianeba orsulobis Sewyvetamde, romelic aris sruli gankurnebis
erTaderTi gza. preeklampsiis msubuqi formis (arteriuli wneva ar aRemateba
140/90 vwy.sv, SeSupeba aReniSneba mxolod qveda kidurebze, proteinuria ar aris
an aReniSneba cilis mxolod niSnebi) mkurnalobas atarebs mxolod
specializirebuli ambulatoriuli dawesebuleba - qalTa konsultacia - 3
dRis ganvalobaSi, Tu am periodSi ar/ver moxerxda mdgomareobis gaumjobeseba,
mkurnalobas agrZeleben me-III an/da me-IV donis stacionaris pirobebSi.
specifiuri mkurnalobis Catareba aucilebelia mSobiarobis Semdegac 48 saaTis
ganvalobaSi.
prehospitaluri etapi:
69
samedicino personalma (eqTanma, bebia-qalma) unda uzrunvelyos orsulis
transportireba me–III an/da me–IV donis satacionarSi. transportirebis dros
unda Catardes periferiuli venis kaTeterizacia msxvili kaTeteriT (G 16 – 18), kaTeterizirebuli iqnas Sardis buSti, daiwyos Jangbadis miwodeba, dawesdes kontroli arteriul wnevaze, pulsze, nayofis guliscemaze. orsuli
transportirebuli unda iqnas marcxena gverdze mwoliare mdgomareobaSi.
stacionaruli daxmareba:
mZime preeklampsiis yvela SemTxveva unda warmarTuli iqnas, rogorc eklampsiis
SemTxveva
marTvis ZiriTadi principebi:
magniumis sulfatis gamoyeneba;
hipotenzia;
simptomaturi mkurnaloba;
nayofis distresis koreqcia;
orsulobis Sewyveta 34 kviris zemoT.
magniumis sulfatis gamoyeneba
magniumis sulfatis datvirTviTi Terapiuli doza Seadgens 4g (16 ml 25%-iani
xsnari) – 6g (24 ml 25%-iani xsnari) mSral nivTierebas. es doza Seyvanili unda
iqnas 20-30 wuTis ganvalobaSi intravenurad ganzavebul 100-200 ml
kristaloidur xsnarSi, sasurvelia Seyvana moxdes perfuzomatis meSveobiT.
SemdgomSi intravenuri infuzia unda gagrZeldes Semdegi doziT: 1-3 grami
mSrali nivTiereba/saaTSi (4-12 ml 25%-iani xsnari). infuzia unda
mimdinareobdes 24 saaTis ganvalobaSi, sasurvelia infuzomatis meSveobiT.
magniumis sulfatis dRiuri doza (mSral nivTierebaze gadaangariSebiT) 12
gramze naklebi ar unda iyos. unda gvaxsovdes, rom magniumas sulfati
gamoiyeneba krunCxvis profilaqtikisaTvis, da ara - rogorc hipotenziuri
saSualeba.
hipotenziuri mkurnaloba
hipotenziuri mkurnalobis ZiriTadi mizania davaqveiToT diastoluri wneva 90 vwy. sv-mde, amave dros unda gvaxsovdes, rom wnevis swafma vardnam SeiZleba
gamoiwvios placentaruli perfuziis moSla da uaryofoTad imoqmedos nayofze.
arteriuli wnevis maRali maCveneblebis dros (160/110 vwy.sv da meti)
hipotenziuri efeqtis misaRebad rekomendirebulia Semdegi preparatebi:
vazodilatatorebi (hidralazini, apresolini);
adrenoblokatorebi da centraluri adrenomimeturi saSualebebi
(klofelini, atenololi, labetololi);
ganglioblokerebi (benzoheqsoniumi, pentamini, arfonadi);
am preparatebis dozireba da gamoyenebis wesi mocemulia cxrilSi #1.
cxrili #1
saswrafo hipotenziuri Terapiis saSualebebi orsulobisas.
preparati dozireba moqmedeba
70
1. hidralazini
(Hidralazine)
10-50 mg kunTebSi 3-6
saaTSi;
5-25 mg venaSi 3-6 saaTSi;
(5-10 mg venaSi yovel 15-
20 wuTSi sasurveli
Sedegis miRebamde)
moqmedebis dawyeba:
10-20 wT;
maqsimaluri efeqti:
20-40 wT;
xangrZlivoba: 3-8 saaTi
2. labetaloli
(Labetalol)
20-50 mg venaSi 3-6
saaTSi;
20 mg venaSi nakadiT, 10
wT-is Semdeg
uefeqtobis SemTxvevaSi
40 mg; Semdeg 80 mg
yovel 10 wuTSi
maqsimalur dozamde
(220 mg)
moqmedebis dawyeba: 1-2 wT;
maqsimaluri efeqti: 10 wT;
xangrZlivoba: 6-16 saaTi
3. nifedipini4
(Nifedipine)
10 mg peroralurad 4-8
saaTSi
moqmedebis dawyeba: 5-10 wT;
maqsimaluri efeqti: 10-20
wT;
xangrZlivoba: 4-8 saaTi
4. arfonadi
(Arfonad)
2 g/l wveTovani i/v;
1-5 mg/wT siCqariT
moqmedebis dawyeba: 1-2 wT;
maqsimaluri efeqti: 2-5 wT;
xangrZlivoba: 10 wT
simptomuri mkurnaloba
preeklempsiis mkurnalobaSi didi mniSneloba aqvs infuziur Terapias. am
mizniT gamoiyeneba Semdegi infuziuri xsnarebi:
− koloiduri xsnarebi – axladgayinuli plazma, albumini, aminomJavebis
nakrebi;
− kristaloiduri xsnarebi - marilovani narevebi da glukozis xsnarebi.
kristaloiduri da koloiduri xsnarebis Tanafardoba damokidebulia
laboratoriul suraTze (saerTo cila, cilis fraqciebi). infuziuri Terapiis
pirobebSi nebadarTulia diurezuli saSualebebis (laziqsi, osmodiurezuli
preparatebi) gamoyeneba hematokritis kontroliT. hematokritis done ar unda
iyos 35-ze meti da 27-ze naklebi. infuziuri xsnaris Seyvanis siswrafe
daavadebis simZimezea damokidebuli da saSualod 100-200 ml/sT-s Seadgens.
saerTo gadasxmuli siTxis raodenoba ar unda aRematebodes 1500 ml/24 sT-Si.
sasurvelia, rom infuzia kontrolirebadi iyos da warmoebdes infuzomatis
saSualebiT.
nayofis distresis koreqcia
preeklampsiis dros perinataluri danakargebis Semcirebis mizniT didi
mniSneloba aqvs nayofis arsebuli distresis koreqcias. preeklampsiis
SemTxvevis marTvisas upirobo moTxovnaa nayofis mudmivi
eleqtrokardiografiuli monitoringi da aseve - ultrasonografiuli
doplerografiuli gamokvleva. nayofis mdgomareobis gasaumjobeseblad
aucilebelia Jangbadis miwodeba, vazoaqtiuri preparatebis da cilovani
fraqciebis gamoyeneba.
4 - nifedipinis gamoyeneba magniumis sulfatTan erTad ar aris mizanSewonili
orsulobis Sewyveta
saswrafo momSobiarebis Cvenebebi naCvenebia cxrili #2:
cxrili # 2
71
VIII. profilaqtika
/ reabili
tacia
saswrafo momSobiarebis Cvenebebia
dedis mxridan nayofis mxridan
1. orsulobis vada ≥38 kvira; 2. Trombocitebis raodenoba
<100 000;
3. RviZlis funqciebis
progresirebadi moSla;
4. eWvi placentas aclaze;
5. mdgradi Tavis tkivili da
mxedvelobis moSla;
6. mdgradi epigastraluri
tkivili, gulisreva da
Rebineba;
7. mZime preeklempsiis dros
uSedego mkurnaloba
ramdenime saaTidan erT
dRemde drois ganmavlobaSi -
eklampsiuri statusi;
8. gulis ukmarisoba,
filtvebis SeSupeba;
9. garTulebebi Tavis tvinis
mxridan - sisxlCaqcevebi
(masiuri an diseminirebuli),
Trombozebi, cerbraluri
hipoqsia, SeSupeba, koma;
10. Tvalis baduris SeSupeba da
aSreveba.
1. nayofis ganviTarebis
Seferxebis mZime forma;
2. oligohidroamnioni;
3. doplerografiuli
monacemebis mkveTri
gauareseba
4. placentis naadrevi aSreveba;
5. nayofis saSvilosnosSida
hipoqsiis niSnebis
gaZliereba.
dRevandel dRes arsebuli randomizebuli kvlevebis monacemebis safuZvelze
preeklampsiis profilaqtikis saSualebad miCneulia aspirinis dabali dozebis
(60 – 80 mg dRe-RameSi) gamoyeneba risk-faqtoris mqone orsulebSi. aqve unda
aRiniSnos, rom randomizebuli kvlevebis raodenoba ar gvaZlevs saSualebas
meta-analizis Catarebisa da es monacemebi ar eyrdnoba myar mtkicebulebas.
radgan mZime preeklampsiis Sedegad maRalia centraluri nervuli da gul-
sisxlZarRvTa sistemebis, Tirkmelebis dazianebis riski, mSobiarobis Semdeg
aucilebelia deda imyofebodes nevropaTologis, kardiologisa da
nefrologis meTvalyureobis qveS minimum erTi weliwadis ganmavlobaSi. es
aucilebelia agreTve Semdgomi orsulobebis normaluri mimdinareobisaTvis.
IX. gaidlainis gadasinjvis da ganaxlebis vada - 2 weli;
X. gaidlainis miRebis xerxi/wyaro – kohreinis eleqtronuli
biblioTekis, sxva faqtebze dafuZnebuli medicinis wyaroebis gamoyenebiT
72
miRebuli literaturis Sejereba da adaptacia.
XI. alternatiuli gaidlaini – ar aris moyvanili
XII. gamoyenebuli literatura:
1. sinauriZe z: preeklampsia/eklampsia. krebulSi: dedaTa da bavSvTa samedicino
daxmarebis meToduri rekomendaciebi. USAID; MSH; CIF. Tbilisi, 2002:204-215.
2. Brady WJ, DeBehnke DJ, Carter CT: Postpartum toxemia: hypertension, edema, proteinuria and
unresponsiveness in an unknown female. J Emerg Med 2001 Sep-Oct; 13(5): 643-8
3. Hals G, Crump T: The pregnant patient: guidelines for management of common life-threatening medical
disorders in the emergency department. Emerg Med Rep 2000 Mar 13; 57-9.
4. Rivers EP: Preeclampsia, eclampsia, and other hypertensive disorders of pregnancy. In: The Clinical Practice
of Emergency Medicine. 2nd ed. 1998: 315-21.
5. National High Blood Pressure Education Program: Working Group report on high blood pressure in
pregnancy. National Heart Lung and Blood Institute. Working Group Report on High Blood Pressure in
Pregnancy. Bethesda (MD): National Heart, Lung and Blood Institute (NHLBI); 2002 July.
avtorTa jgufi (akad. o. RuduSauris erovnuli samedicino centri):
1. m.m.k. z. sinauriZe – perinataluri centris mTavari meani, medicinis
mecnierebaTa kandidati;
2. prof. r. suluxia - perinataluri centris xelmZRvaneli;
3. m.m.k. n. zaldastaniSvili - perinataluri centris meani;
4. m. nemsaZe - perinataluri centris meani.
5. o. asaTiani – informaciis marTvisa da uwyveti ganaTlebis samsaxuris
ufrosi
recenzentebi:
15. m.m.k. z. kirtava – erovnuli sainformacio saswavlo centris
direqtori, kavSiri `partniorebi janmrTelobisaTvis~ Tavmjdomare,
Tbilisis sax. samedicino universitetis Sinagan sneulebaTa #1
kaTedris asistenti
16. m.m.k. n. raWveliSvili, Tbilisis sax. samedicino universitetis Sinagan
sneulebaTa #1 kaTedris asistenti, kavSiri `partniorebi
janmrTelobisaTvis~ gamgeobis wevri
17. k. papoSvili, janmrTelobis da socialuri dacvis erovnuli
institutis direqtori
18. m. Cekli, emoris universitetis samedicino skolis gadaudebeli
daxmarebis ganyofilebis specialisti
73
Preeclampsia Z. Sinauridze, R. Sulukhia, N. Zaldastanishvili, M. Nemsadze, O. Asatiani Z. Kirtava, N. Rachvelishvili, K. Paposhvili, M. Checkley National Medical Center after Prof. O. Gudushauri, Partners for Health NGO, Tbilisi, Georgia; Emory University School of Medicine, Partners for International Development, Atlanta, GA, USA
Preeclampsia is known as hypertensive disorder of pregnancy, revealed by arterial hypertension (usually exceeding 140/90 mm hg, or exceeding initial systolic pressure on 30 mm Hg and/or diastolic pressure on 15 mm Hg), proteinuria and generalized edema. The guideline has been developed mainly based on two recent emergenyc guidelines adaptation.
asTmuri statusis marTva
o. asaTiani, z. metreveli, m. kapanaZe, z. kirtava, n. raWveliSvili, k. papoSvili,
a. siore
akad. o. RuduSauris sax. erovnuli samedicino centri,
kavSiri `partniorebi janmrTelobisaTvis~,
emoris universitetis samedicino skola / `partniorebi saerTaSoriso
ganviTarebisaTvis~ (atlanta, jorjia, aSS).
I. daavadebis definicia:
bronquli asTma warmoadgens filtvebis qronikul daavadebas, romelic
xasiaTdeba sasunTqi gzebis anTebiT, obstruqciiTa da hiperreaqtiulobiT.
asTmuri statusi warmoadgens bronquli asTmis Setevas, romelic
xasiaTdeba ufro mZime da xangrZlivi mimdinareobiT, standartuli
mkurnalobisadmi rezistentobiT da sunTqvis mwvave ukmarisobiT. asTmuri
statusis xangrZlivoba SeiZleba iyos ramdenime saaTidan
4-6 dRemde da meti.
daavadebaTa saerTaSoriso klasifikaciiT asTmur statuss miniWebuli aqvs
kodi (ICD-10): J46
II. epidemiologia:
74
saerTaSoriso monacemebiT bronquli asTma sxvadasxva eTnikur jgufebSi
vlindeba mosaxleobis 1-30%-Si. amerikis SeerTebuli Statebis mosaxleobaSi
bronquli asTma aRiniSneba 4-8%-Si, aqedan daaxloebiT naxevari modis
bavSvebze. bronquli asTmis gamwvaveba (bronquli asTmis Seteva da/an asTmuri
statusi) gvxvdeba SemTxvevaTa 0,2-0,4%-Si.
qalebi asTmis gamwvavebiT (bronquli asTmis Seteva, asTmuri statusi)
orjer ufro xSirad mimarTaven gadaudebeli daxmarebis ganyofilebebs, vidre
mamakacebi.
aRsaniSnavia bronquli asTmis gamwvavebiT (bronquli asTmis SeteviT an
asTmuri statusiT) gamowveuli sikvdilianobis mateba 13:1000000-dan (1982 w.)
19:1000000-mde (1991 w.). amavdroulad izrdeba ara marto asTmiT gamowveuli
sikvdilianoba, aramed - daavadebis gavrcelebac.
Uuaxlesi monacemebiT bronquli asTmiT gamowveuli sikvdilianoba aRwevs
20-30:1000000-ze. amaTgan mxolod 10%-ia 40 wels gadacilebuli.
III. etiologia/risk-faqtorebi/paTologia: etiologiuri faqtorebi:
bronquli asTmiT daavadebulebSi asTmis gamwvaveba da asTmuri statusis
Camoyalibeba SeiZleba gamoiwvion Semdegma faqtorebma:
- respiratoruli infeqcia;
- alergenebTan kontaqti;
- civi, mSrali amindi, amindis cvalebadoba;
- fizikuri da emociuri datvirTva;
- Tambaqos moxmareba an Tambaqos kvamlTan Sexeba.
- asTmis sawinaaRmdego preparatebis miRebis Sewyveta
paTogenezi: asTmuri statusis mTavari paTofiziologiuri elementebia bronqebis
obstruqcia, ganpirobebuli bronqebis kedlis SeSupebiT, bronqospazmiT,
bronquli drenirebis darRveviT, bronquli sekretis gasqelebiT da lorwovani
sacobebiT bronqebis obturaciiiT, rac iwvevs CasunTqvis gaZnelebas,
amosunTqvis gaZlierebas da gaxangrZlivebas, filtvebis sasicocxlo
moculobis, filtvebis forsirebuli sasicocxlo moculobis, forsirebuli
amosunTqvis moculobis da amosunTqvis pikuri siCqaris daqveiTebas.
75
mwvave asTmis ganviTarebis mniSvnelovani meqanizmia antigen-antisxeulis
urTierTqmedeba, rac aaqtivebs membranul fosfolipazas da iwvevs araqidonis
mJavas warmoqmnas. es ukanaskneli ciklooqsigenazas mier metabolizirdeba
vazoaqtiur prostaglandinebad (mag. Tromboqsani, prostaciklini) an
leikotrienebad da maT winamorbedebad. yvela maTgani moqmedebs gluv
muskulaturaze da SeuZlia gamoiwvios sasunTqi gzebis hipermgrZnobeloba da
anTeba. leikotrienebis sinTezis da/an aqtivobis farmakologiur inhibitorebs
aqvT SesaniSnavi efeqti asTmis dros, rac TvalnaTliv aCvenebs ramdenad
mniSvnelovan mediatorebs warmoadgenen leikotrienebi asTmisa da filtvebis
obstruqciuli daavadebebis dros.
aseve mniSvnelovani momentia filtvebis “gadaberva” – avadmyofi
CaisunTqavs met haers, vidre amoisunTqavs. amas xels uwyobs bronqospazmis
fonze amosunTqvis aqtivaciac, rac iwvevs intraplevruli wnevis matebas,
bronqiolebis eqspiraciul kolafss da haeris Sekavebas filtvebSi. bronqebis
obturacia ki ganapirobebs ventilaciur-perfuziul disbalanss.
Yyvela zemoaRniSnuli faqtori iwvevs respiratoruli muskulaturis
gadaZabvas da gamofitvas, sunTqvis Jangbadovani fasis (efeqturobis)
Semcirebas, viTardeba progresirebadi hipoqsemia, hiperkapnia, respiratoruli
acidozi.
asTmuri statusi iwvevs hemodinamikur darRvevebsac – gulmkerdSida
wnevis mateba iwvevs marjvena winagulis diastoluri avsebis Semcirebas; aseve
viTardeba mcire wris hipertenzia. am or faqtors sabolood mivyavarT
marjvenagulovan ukmarisobamde. parkuWTaSua Zgidis gadanacvleba marcxniv da
marcxena parkuWis diastoluri avsebis daqveiTeba iwvevs marcxenaparkuWovan
ukmarisobas. garda amisa, hiperventilacias da gaZlierebul oflianobas xSirad
mivyavarT hipovolemiamde da hemokoncentraciamde.
IV. klinikuri simptomatika: - sunTqvis gaZneleba (gaZnelebulia amosunTqva), eqspiraciuli qoSini);
- xvela (mwvave an qronikuli), romelic dasawyisSi produqtiulia,
SemdgomSi - SeteviT xasiaTs iRebs, Tanac - ufro mSrali xdeba ; - sunTqvaSi damxmare kunTebis monawileoba;
- horizontalurad wolis SeuZlebloba:
mZime Setevisas pacients urCevnia jdoma;
Tu mdgomareoba kidev ufro mZimdeba, pacienti iRebs e. w. samkuTxa
pozicias - xelebiT dayrdnobilia sxeulze an raime saganze;
76
simptomebis progresirebas Tan axlavs mzardi hiperkapnia da
hiperventilacia, bolo stadiaSi _ profuzuli oflianoba, haeris
ukmarisobis SegrZneba, pacients urCevnia dawola;
- danawevrebuli metyvelebis uunaroba;
- centraluri cianozi;
- taqikardia, Zafisebri pulsi, paradoqsuli pulsi;
- arteriuli hipertenzia;
- fsiqo-motoruli aRgzneba;
- cnobierebis donis daqveiTeba, hipoqsiur hiperkapniur komamde;
- periferiuli SeSupebebi;
- stridori;
- kanqveSa emfizema;
- auskultaciiT - mSrali (mstvinav-mogugune) xixini, gaxangrZlivebuli
amosunTqva; bolo stadiaSi filtvebSi sunTqviTi xmianoba aRar moismineba;
- hipoventilacia, bradikardia da Seupovari hipoqsemia warmoadgenen
daavadebis prognozulad arakeTilsaimedo niSnebs.
V. diagnozi:
diagnozi eyrdnoba Semdeg monacemebs:
♦ anamnezuri monacemebi da fizikaluri gamokvleva;
♦ bronqodilatatorebis uefeqtoba (bronquli asTmis mwvave Setevisas
bronqodilatatorebi dadebiT efeqts iZlevian, xolo asTmuri statusis
diagnozis verificirebis erT-erTi kriteriumi swored maTi uefeqtobaa);
♦ pulsoqsimetriis monacemebi;
♦ spirometria (yvelaze ufro informatiuli da specifiuri testia).
diferencialuri diagnozi unda gatardes Semdeg paTologiebTan:
• aspiraciuli sindromi;
• bronqoeqtazia;
• bronqioliti;
• filtvis arteriis Tromboembolia;
• mukoviscidozi;
• zeda sasunTqi gzebis obstruqcia – ucxo sxeuli, traqeis
77
• stenozi, simsivniT zewola, traqeomalacia;
• pnevmoToraqsi;
• filtvebis SeSupeba;
• anafilaqsiuri/anafilaqtoiduri reaqcia.
VI. gamokvlevis sqema:
sawyisi gamokvleva iTvaliswinebs Semdeg testebs:
♦ sisxlis saerTo analizi (leikocitozi, eozinofilia);
♦ hematokriti (dehidrataciisa da hemokoncentraciis SefasebisaTvis);
♦ mJava-tutovani wonasworoba (hipoqsiisa da hiperkapniis Sefasebisa da
filtvebis xelovnuri ventilaciis saWiroebis gansazRvrisaTvis);
♦ pulsoqsimetria;
♦ spirometria (bronqospazmis obieqturi Sefasebis saSualebaa, PEF<saukeTeso
maCveneblis 40% an <200 l/wT; garda amisa, seriuli gazomvebi SesaZleblobas
gvaZlevs vimsjeloT mkurnalobis efeqturobaze).
♦ ekg (aucilebelia ekg-monitoringi, radgan SeiZleba ganviTardes sinusuri
taqikardia, deqstrograma, xolo supraventrikuluri taqikardia TeofiliniT
intoqsikaciis niSania).
mogvianebiT garTulebebisa da prognozis gansazRvrisaTvis saWiroa damatebiTi
gamokvlevebis Catareba:
♦ SratSi eleqtrolitebis gansazRvra (β2-agonistebi iwveven hipokalemias);
♦ glikemia;
♦ sisxlSi Teofilinis koncentraciis gansazRvra (saWiroa intoqsikaciis
Tavidan acilebis mizniT);
♦ gulmkerdis rentgenografia (gansakuTrebiT mniSvnelovania garTulebebis –
pnevmoToraqsis, pnevmomediastinumis, sinusitis, filtvebis SeSupebis -
gamosaricxad).
VII. mkurnalobis sqema: 1. oqsigenoTerapia – dauyovnebliv unda iqnas dawyebuli, Tu SpO2<91% da SeiZleba Sewydes - Tu SpO2>94%. sunTqvis ukmarisobis progresirebis
SemTxvevaSi SesaZloa saWiro gaxdes traqeis intubacia da filtvebis
xelovnuri ventilacia (fxv).
78
traqeis intubacia – traqeis intubaciis da fxv-s Cvenebebia: mzardi hipoqsemia
(PO2 <60 mmHg, SpO2 <85%), respiratoruli acidozi (pH<7,2), sasunTqi
muskulaturis gamofitva, cnobierebis donis daqveiTeba.
. am manipulaciam TviTon SeiZleba gamoiwvios bronqospazmi meqanikuri
gaRizianebis Sedegad, amitom igi umjobesia Catardes Rrma narkozis da ara -
zedapiruli sedaciis pirobebSi. am mizniT optimaluria ketamini – iwvevs
bronqodilatacias da aqvs minimaluri kardiodepresiuli moqmedeba.
intubirebul avadmyofebSi sedaciisaTvis propofoli ufro misaRebia, vidre
Tiopentali. benzodiazepinebis gamoyeneba aseve usafrTxoa. maqsimalurad unda
moveridoT relaqsantebis gamoyenebas. traqeis meqanikuri gaRizianebis Sedegad
gamowveuli bronqospazmis prevenciisaTvis kargi saSualebaa lidokaini 1-2 mg/kg
i/v.
premedikacia da fxv SeiZleba hemodinamikis depresiis mizezi gaxdes, amdenad
saWiroa, mzad viyoT intensiuri infuziuri TerapiisaTvis (msxvili i/v kaTeteri)
da vazopresorebis gamoyenebisaTvis. saintubacio mili maqsimaluri zomis unda
iyos, radgan SesaZloa saWiro gaxdes sanaciuri bronqoskopiis Catareba.
filtvebis xelovnuri ventilacia (fxv)
- fxv-s Cvenebebia: mzardi hipoqsemia (PO2<60mmHg, SpO2<85%), respiratoruli
acidozi (pH<7,2), sasunTqi muskulaturis gamofitva, cnobierebis donis
daqveiTeba. asTmis dros mkveTradaa gamoxatuli eqspiratoruli
obstruqcia da hiperinflacia (filtvebis gadaberva).
- marTviTi sunTqvis reJimi unda SeirCes ise, rom mivaRwioT amosunTqvis
bolos filtvebSi narCeni moculobis (end-expiratory lung volume(VEE), Sinagani pikuri amosunTqvis bolos wnevis PEEP-is (auto-PEEP) da hemodinamikis arastabilurobis Semcirebas. maRali VEE iwvevs CasunTqvis bolos filtvebis
narCeni moculobis (end- inspiratory lung volume (VEI) zrdas, rac baro- da moculobiTi travmis winapirobaa. SesunTqviTi nakadis maRali siCqare (inspiratory flow rate) axangrZlivebs amosunTqvis dros da amcirebs VEE-s da auto-PEEP-s, magram am dros sasunTq gzebSi maRali pikuri SesunTqviTi wneva peak inspiratory pressure (PIP) iqmneba. ventilaciis romelime reJimis upiratesoba klinikurad ar aris
dadasturebuli. SesunTqvisas airis nakadis siCqare (peak inspiratory flow) unda SeirCes pacientis moTxovnilebidan gamomdinare. gakontroldes auto-PEEP. unda gamoyenebul iqnas umciresi dasaSvebi wuTmoculoba da amosunTqvis
maqsimalurad gaxangrZlivebuli dro. Amis gansaxorcieleblad unda Semcirdes
VE, gaizardos amosunTqvis dro, gamoyenebul iqnas kontrolirebadi hiperkapnia.
rig situaciaSi sasargebloa PEEP. unda vecadeT platoze wneva SevinarCunoT <35 cmH2O-ze dabla. fxv-s sawyisi parametrebi SeiZleba aseTi iyos:
- FiO2 = 1.0 - CasunTqvis moculoba (VT)= 6-8 ml/kg; - sixSire (f) = 6-8/wT; - CasunTqvaze nakadis siCqare = 60-100 l/wT; - PEEP < 5 cm H2O; - PIP < 50 cm H2O; - inspiraciuli nakadis mrudi – sworxazovani.
79
2. adrenomimitiuri preparatebi β2-agonistebi – asTmis mkurnalobaSi warmoadgenen pirveli rigis preparatebs,
Tumca asTmuri statusis ganviTarebisas mosalodnelia maTze rezistentobis
ganviTareba da maT miRebas ex juvandibus diagnostikis azri hqondes. inhalacia
ufro efeqturia, vidre i/v Seyvana. parenteraluri gza misaRebia im SemTxvevaSi,
Tu inhalacia SeuZlebelia (Zlieri xvela). speiseris gamoyeneba ufro
efeqturia, vidre - nebulaizeris. ukunaCvenebia taqiaritmiebis,
hipermgrZnobelobis dros. Tu statusis dros inhalaciam Tavidanve efeqti ar
mogvca, ganmeorebiT miRebebs azri ara aqvs da unda gadavideT adrenalinis
jgufze.
salbutamoli – speiseriT 4-8 inhalacia, 15 wT-Si 3-4 inhalacia,
Semdgom - yovel 4-6 sT-Si. nebulaizeriT - 5-10 mg
20 wT-is ganmavlobaSi, Semdgom - yovel 4sT-Si.
parenteralurad - datvirTviTi doza: 4 mkg/kg da SemanarCunebeli: 0,2 mkg/kg/wT.
terbutalini – speiseriT 2 inhalacia yovel 4-6sT-Si, nebulaizeriT 5mg. kanqveS
0,25mg, uefeqtobisas SeiZleba igive doza ganmeordes 15-30 wT-Si, Semdgom yovel
4sT.
α,β-agonistebi: epinefrini (adrenalini) – β-agonisturi aqtivoba iwvevs
bronqodilatacias, alfa-agonisturi aqtivoba iwvevs periferiuli
sisxlZarRvovani rezistentobis gazrdas da dadebiT
efeqts iZleva sistemuri hipotenziisas.
- kanqveS: 0,3-0,5 mg, mikrodozatoriT: 4-8 mkg/wT, intubirebul pacientebSi
SesaZlebelia saintubacio milidan 5 ml 1:10000 xsnari. ukuCvenebebia:
koronaruli daavadeba, arakontrolirebadi hipertenzia, mZime parkuWovani
taqikardia. aseT SemTxvevebSi gamoiyeneba mxolod sasicocxlo CvenebiT.
gverdiTi efeqtebi: miokardiumis iSemia, aritmia, tremori, hipertenzia.
3. glukokortikoidebi –i/v da peroralur formebs erTidaigive efeqti aqvT.
Tavdapirvelad xvelis, qoSinis, fsiqo-motoruli agznebis gamo xSirad
80
SeuZlebelia preparatebis per os miReba, ris gamoc iwyeben maT intravenur
infuzias, xolo per os miReba dawyebuli unda iyos maSinve, roca ki es
SesaZlebelia. ukunaCvenebia peptiuri wylulis, hipermgrZnobelobis, virusuli
da sokovani infeqciebis, RviZlis daavadebebis dros. diuretikebTan kombinaciis
SemTxvevaSi, hipokalemiis Tavidan acilebis mizniT, saWiroa kaliumis donis
kontroli. digoqsinTan kombinaciaSi zrdis intoqsikaciis risks. gverdiTi
efeqtebidan aRsaniSnavia hiperglikemia, SeSupeba, osteoporozi, fsiqozi,
hipokalemia, miopaTia.
meTilprednizoloni – datvirTviTi doza: 2 mg/kg, SemanarCunebeli: 0,5-1 mg/kg
yovel 6sT-Si.
prednizoloni – 40-60 mg yovel 8sT-Si per os. beklametazoni – 2-4 inh. dReSi orjer, maqsimaluri doza: 20 inh.
4. qolinolitikebi – β2-agonistebTan erTad efeturia mZime xarisxis
garTulebebisas. ukunaCvenebia hipermgrZnobelobis dros. sifrTxiliT unda
iqnas gamoyenebuli RiakuTxovani glaukomis, winamdebare jirkvlis
hipertrofiis dros.
ipratropiumi – speiseriT 2-2 inhalacia, maqsimaluri doza: 12 inhalacia.
nebulaizeriT – 500 mkg 30-60 wT-is ganmavlobaSi.
5. Teofilini – meore rigis preparatia, rasac ganapirobebs maRali
toqsiuroba - mcire Terapiuli intervali. amis gamo ar unda iqnas gamoyenebuli
rutinulad da araa naCvenebi pirveli 4 sT-is ganmavlobaSi. gamoiyeneba mxolod
sxva preparatebis uefeqtobis SemTxvevaSi.
ukuCvenebebia: hipermgrZnobeloba, arakontrolirebadi aritmia,
hiperTireoidizmi, peptiuri wyluli. sifrTxiliT unda iqnas gamoyenebuli
hipertenziis, taqiaritmiis, filtvebis SeSupebisa da RviZlis daavadebebis
dros. preparatis i/v Seyvanis siCqare ar unda aWarbebdes 25 mg/wT-s.
aminofilini - datvirTviTi doza: 5 mg/kg 20 wT-is ganmavlobaSi,
SemanarCunebeli doza: 0,5-0,7 mg/kg/sT. dozebi naxevrdeba, Tu ukanaskneli 24sT-
is ganmavlobaSi pacients ukve aqvs miRebuli Teofilini. maqsimaluri doza: 1 g.
6. magniumis sulfati – datvirTvis doza: 2-4gr 20wT-is ganmavlobaSi,
SemanarCunebeli doza: 1 g/sT.
7. inhalaciuri anesTetikebi – β2-agonistebisadmi refraqterobis SemTxvevaSi
karg efeqts iZlevian. izoflurans minimaluri kardiodepresiuli da
aritmogenuli aqtivoba aqvs. halotani xasiaTdeba, izofluranTan SedarebiT,
ufro metad gamoxatuli bronqodilataciuri efeqtiT, ukunaCvenebia
hipermgrZnobelobisas, sifrTxiliT unda iqnas gamoyenebuli epinefrinTan
(adrenalinTan) da norepinefrinTan (noradrenalinTan) erTad, gverdiTi
efeqtebidan aRsaniSnavia RviZlis dazianeba .
halotani – 24 wlamde: 0,84 MAC; 42 wlamde: 0,76MAC; 81wlamde: 0,84 MAC.
8. rehidratacia
– ZiriTadad saWiroa siTxis danakargis Sevseba, amdenad mizanSewonilia
glukozis infuzia – 2-3 l/dR, mZime SemTxvevaSi 5 l-mde, centraluri venuri
wnevis, hematokritisa da saaTobrivi diurezis kontroliT, ukuCvenebebis
gaTvaliswinebiT (mag. gulis ukmarisoba).
- hipovolemiis koreqciisaTvis SesaZloa saWiro gaxdes koloidebis infuzia,
rekomendirebulia reologiuri Tvisebebis koloidebi.
81
9. antobiotikoTerapia – iniSneba mxolod infeqciis arsebobisas (si
nusiti, pnevmonia).
asTmuri statusis kupirebisa da intensiuri Terapiis Sewyvetis
kriteriumebia bronqospazmisa da obstruqciis, sunTqvis mwvave ukmarisobis
Semcireba. Ppulsoqsimetriis,, spirometriisa da, mJava-tutovani wonasworobis
parametrebis gaumjobeseba damatebiT kriteriumebad ganixileba.
Semdgomi mkurnaloba da monitornigi xorcieldeba Terapiul ganyofilebaSi.
VIII. reabilitacia / meTvalyureoba – specialuri miTiTebebi
gaidlainebis doneze ar aris SeTanxmebuli.
IX. gaidlainis gadasinjvisa da ganaxlebis vada: Cvens mier warmodgenili gaidlainis gadasinjvis vadaa 2 weli.
X. gaidlainis miRebis xerxi: aRniSnuli gaidlaini miRebulia literaturis Ziebis Sedegad SerCeuli
sxvadasxva gaidlainebis Sejerebisa da adaptaciis gziT.
XI. gamoyenebuli literatura: 1. British Guideline on the Management of Asthma. British Thoracic Society Scottish Intercollegiate Guidelines Network. Revised edition April 2004
2. Global strategy for asthma management and prevention. 2003. 180 p. [662 references] http://www.guidelines.gov
3. Status Asthmaticus - in the ER and the OR. Jon Hooper, MD, FRCPC, Department of Anaesthesia, Ottawa Civic Hospital, University of Ottawa, Ottawa- 1995. http://www.anesthesia.org/winterlude/wl95/wl95_8.html 4. Доказательная медицина и ее применение в пульмонологии (диагностика и лечение бронхиальной астмы), А.Н. Цой, В.В. Архипов, А.Г. Чучалин, ММА им. И.М. Сеченова, г. Москва, НИИ Пульмонологии МЗ РФ, г. Москва. 5. New Zealand Guidelines Group (NZGG). The diagnosis and treatment of adult asthma. Wellington (NZ): New Zealand Guidelines Group (NZGG); 2002 Sep. http://www.nzgg.org.nz 6. Singapore Ministry of Health. Management of asthma. Singapore: Singapore Ministry of Health; 2002
Jan. http://www.gov.sg
7. University of Michigan Health System. UMHS asthma guideline. Ann Arbor (MI): University of
Michigan Health System; 2000 Jan. http://cme.med.umich.edu
82
8. Asthma, Barry Brenner, MD, PhD, Chairman, Department of Emergency of Medicine, Professor, Departments of Emergency Medicine and Internal Medicine. http://www.emedicine.com 9. National Asthma Education and Prevention Program: Guidelines for the diagnosis and management of asthma. Bethesda: NIH Publication No. 97-4051 1997. http://www.nhlbi.nih.gov/nhlbi/othcomp/opec/naepp/naeppage.htm. 10. Cincinnati Children's Hospital Medical Center. Managing an acute exacerbation of asthma. Cincinnati
(OH): Cincinnati Children's Hospital Medical Center; 2002 Sep.
avtorTa jgufi: olRa asaTiani – akad. o. RuduSauris sax. erovnuli samedici-
no centris informaciis marTvisa da uwyveti
samedicino ganaTlebis samsaxuris ufrosi.
zaza metreveli – akad. o. RuduSauris sax. erovnuli samedi-
cino centris katastrofisa da gadaudebeli
medicinis samsaxuris ufrosi.
mamuka kapanaZe - akad. o. RuduSauris sax. erovnuli samedicino
centris gadaudebeli daxmarebis (mimRebi) gan-
yofilebis eqimi-reanimatologi.
recenzentebi:
19. m.m.k. z. kirtava – erovnuli sainformacio saswavlo centris
direqtori, kavSiri `partniorebi janmrTelobisaTvis~ Tavmjdomare,
Tbilisis sax. samedicino universitetis Sinagan sneulebaTa #1
kaTedris asistenti
20. m.m.k. n. raWveliSvili, Tbilisis sax. samedicino universitetis Sinagan
sneulebaTa #1 kaTedris asistenti, kavSiri `partniorebi
janmrTelobisaTvis~ gamgeobis wevri
21. k. papoSvili, janmrTelobis da socialuri dacvis erovnuli
institutis direqtori
22. a. siore – ufrosi rezidenti, filtvis, alergiis da kritikuli
medicinis ganyofileba, emoris universitetis samedicio skola,
atlanta, aSS
(Amsel M. Siore - MD, Senior Fellow, Pulmonary, Allergy and Critical Medicine, School of Medicine, Emory University, Atlanta, GA, USA)
83
Asthmatic Status Management O. Asatiani, Z. Metreveli, M. Kapanadze, N. Rachvelishvili, K. Paposhvili, A. Siore National Medical Center after Prof. O. Gudushauri, Partners for Health NGO, Tbilisi, Georgia; Emory University School of Medicine, Partners for International Development, Atlanta, GA, USA Asthmatic status (Status Asthmaticus) represents severe and long-term asthma exacerbation, resistant to standard treatment, and severe respiratory failure. The term of Status Asthmaticus could vary between several hours till 4-6 days. The condition is given code (ICD-10): J46. The guideline represents compilation and adaptation of British, Canadian, Singapure and some other recent guidelines on severe asthma.
84
iumori samedicino Temaze
patara bavSvi kbilis eqimTan miiyvanes. aRmoCnda, rom kbilSi Rru aqvs dasabJeni. “aba,
axalgazrdav, - mimarTa eqimma, - riT ginda, eg Seni kbili amovavsoT?”
`SokoladiT!~ – daufiqreblad miugo bavSvma.
sami eqimi saubrobs konferenciaze Sesvenebis dros.
erTi ambobs: `miyvars mxatvrebisTvis operaciis gakeTeba, iseTi xasxasa feradi
organoebi aqvT - guli naRdi wiTelia, kuWi – vardisferi, elenTa - mwvane.~
meorem aitaca Tema: `me ki buRaltrebi mirCevnia – gaxsni mucels da yvelaferi ise
danomrilia da Cawikwikebuli – Zalian advilia, araferi SegeSleba.~
`aba me advokatebis operirebas araferi mirCevnia – arc guli aqvT, arc jigari, Tanac
Tavi da ukana tani erTmaneTs cvlis.” – wertili dasva mesamem.
saswrafo daxmarebis telefonis - 911 (amerikelebi `cxra-TerTmets~ uZaxian)
SemoRebidan cota xanSi moxucma qalma mimarTa roCesteris saavadmyofos gadaudebeli
daxmarebis ganyofilebas, Zlivs daayena Tavisi manqana avtosadgomze da gaWirvebiT
gadmovida manqanidan. amis Semxedvare eqTanma gancvifrebulma hkiTxa: `ki magram, ar
gerCivnaT `cxra-TerTmetiT~ saswrafo gamogeZaxaT? aseT mdgomareobaSi manqanis tareba
ratom gadawyviteT?~
`Cems oxer telefons `11~ ara aqvs!~ - amoioxra moxucma.
eqimi: `TqvenTvis maqvs erTi cudi ambavi da… meore - Zalian cudi!~
pacienti (SiSiT): `jer cudi miTxariT!~
eqimi: `laboratoriidan damirekes da miTxres, rom Tqveni analizis Sedegia iseTia, rom
24 saaTis sicocxle TuRa dagrCeniaT!”
pacienti: `vai, Cems Tavs! ra meSveleba?! ki magram, amaze uaresi raRa unda iyos? ra aris
`Zalian cudi ambavi”??~
eqimi: `es informacia guSin diliT momawodes da mas aqeTaa geZebT!..~
Medical Humor
A little boy was taken to the dentist. It was discovered that he had a cavity that would have to be filled. "Now, young man," asked the dentist, "what kind of filling would you like for that tooth?"
"Chocolate, please," replied the youngster
3 Doctors are at a Convention talking Shop. The first Doctor says: "I love doing surgery on Artists, they are so colorful: red Hearts, pink Stomachs, green Spleens." The next Doctor says: "Me, I love doing surgery on Accountants, open them up and all their Parts are numbered, makes it very easy.” The third Doctor says: "I love doing surgery on Lawyers, they have no Heart, they have no Guts and the Head and the Ass are interchangeable!"
85
Shortly after the 911 emergency number became available, an elderly and quite ill lady appeared in a Rochester hospital emergency room, having driven herself to the hospital and barely managing to stagger in from the parking lot. The horrified nurse said, 'Why didn't you call the 911 number and get an ambulance?'
The lady said, 'My phone doesn't have an eleven.'
Doctor: I have some bad news and some very bad news. Patient: Well, might as well give me the bad news first. Doctor: The lab called with your test results. They said you have 24 hours to live. Patient: 24 hours! That's terrible! What could be worse? What's the very bad news? Doctor: I've been trying to reach you since yesterday.
86
saqarTvelos Sromis, janmrTelobis da socialuri dacvis
saministro internetSi
www.healthministry.ge an www.MoLHSA.ge
internetSi ganTavsebul resursebs sul ufro mzardi auditoria hyavs
saqarTveloSic. satelekomunikacio saSualebebisa da kompiuteruli
teqnologiebis SedarebiTi simwiris da enobrivi barieris gamo qveyanaSi
internetiT regularulad mosargebleTa raodenoba jer kidev dabalia da
eqspertTa umravlesobis azriT mosaxleobis 5%-10%-s ar aRemateba (Tanac maTi
absoluturi umravlesoba Tbilisis macxovrebelia). da mainc optimisturad
gangvawyobs am ricxvis mniSvnelovani zrdis dinamika bolo 3-4 wlis
ganmavlobaSi (2000 wels es maCvenebeli 1-2% iyo). amaze naTlad migvaniSnebs
drois swored am monakveTSi internet-klubebis da internet-kafeebis sakmaod
TvalSisacemi mozRvaveba, ADSL teqnologiis uswrafesi popularizacia,
ukabelo (Wi-Fi) internetiT aRWurvili sazogadoebrivi adgilebis gamoCena,
internetiT sargeblobis mravaljeradi baraTebis gavrceleba da is
mniSvnelovani dro da saxsrebi, romelic internetis momwodeblebis
(“provaiderebis”) mier televiziaSi da bilbordebze ganTavsebul reklamaSi
ixarjeba.
internetSi oficialuri da sajaro informaciis ganTavseba amerikis da evropis
mraval qveyanaSi sakanonmdeblo moTxovnaa. sazogadoebrivi samsaxuris
informacia – momsaxurebis saxeebi, sakanonmdeblo maregulirebeli
dokumentebi, tarifebi, satendero gancxadebebi, informacia katastrofebis Tu
epidemiologiuri safrTxis Sesaxeb, - Ria da xelmisawvdomi unda iyos
internetiTac. saqarTveloSi es jer araa aucilebeli moTxovna, Tumca evropul
struqturebSi integrirebisa da Ria sazogadoebis aSenebis kvalobaze, albaT es
axlo momavlis perspeqtivaa.
unda aRiniSnos, rom jandacvis da medicinis sakiTxebi mzardi popularobiT
sargeblobs mTel msoflioSi – sazogadoebas ainteresebs cxovrebis jansaRi
wesis, uaxlesi samedicino preparatebis, axali samedicino nou-haus,
samkurnalo-diagnostikuri centrebis da wamyvani klinikebis sakontaqto
monacemebi, da sxva sakiTxebi, amas emateba jandacvis profesionalTa da
pacientTa qseluri kavSirebi.
jandacvis saministro pirveli samTavrobo struqtura iyo saqarTveloSi,
romelsac ukve 1998 wels oficialuri veb-gverdi gaaCnda erovnuli
sainformacio saswavlo centris (essc) serverze – www.nilc.org.ge. 2001 wels Ria
sazogadoebis (sorosis) fondma Caatara konkursi, romliTac ganmovlinda
centraluri da aRmosavleT evropis da dsT rva qveynis jandacvis sistemis veb-
gverdi, romelTa ganaxlebisaTvis granti gamoiyo. essc-is mier momzadebulma
saqarTvelos jandacvis sistemis veb-portalma www.health.net.ge, - romelzec
ganTavsda jandacvis rogorc saxelmwifo, aseve arasamTavrobo da kerZo
seqtoris informaciebi da jandacvis statistikis srulyofili saxelmwifo da
regionaluri monacemebis baza – saboloo jamSi fondis sabWos mier am rva
proeqtis Sefasebisas xorvatiis Semdeg II adgili daikava. 2002 wels jandacvis
saministros tenderiT erovnul sainformacio saswavlo centrs daevala
saministros veb-gverdis ganaxleba, romelic aseve ganTavsda zemoTdasaxelebul
portalze.
87
2004 wels saministros struqturis cvlilebebis Semdeg dRis wesrigSi dadga
saministros axali veb-gverdis Seqmna. wlis bolos Catarebul tenderSi isev
erovnulma sainformacio saswavlo centrma gaimarjva da praqtikulad 6 kviris
ganmavlobaSi moamzada saintereso samenovani veb-gverdi, romelic
daregistrirda or paralelur misamarTze www.MoLHSA.ge (saministros inglisuri dasaxelebis - Ministry of Labour Health and Social Affairs – MoLHSA - abreviaturis mixedviT) da www.healthministry.ge (sxvadasxva qveynebis jandacvis
saministroebis veb-gverdebis yvelaze gavrcelebuli msgavsi domenuri
saxelebis analogiurad).
axali samenovani (qarTuli, inglisuri, rusuli) veb-gverdi cxra monacemTa
bazas moicavs da aRWurvilia srulyofili saZiebo sistemiT.
veb-gverdze warmodgenilia sruli informacia jandacvis sferoSi qveynis
erovnuli politikis da saministros struqturis Sesaxeb. aq nebismier adamians
SeuZlia gaecnos saministros biujets, samedicino standartebs da jandacvis,
socialuri da dasaqmebis sferoebis normatiul aqtebs. sakanonmdeblo
monacemTa bazis rva sxvadasxva kategoriaSi klasificirebulia saministros
brZanebebi, aseve moyvanilia Sesabamisi amonaridebi konstituciidan,
saqarTvelos kanonebi jandacvis da socialuri dacvis Sesaxeb, saerTaSoriso
konvenciebi da aqtebi.
veb-gverdze samedicino organizaciaTa Zieba SeiZleba saqarTvelos regionebis
rukis mixedviT ganxorcieldes da dawesebulebaTa saqmianobis licenzirebis
monacemebsac Seicavs, rac momxmarebels xels Seuwyobs samedicino daxmarebis
profilis sasurveli informaciis miRebaSi.
veb-gverdze aris specialuri baneri “tenderi/vakansia”
(http://www.healthministry.ge/vacancy.php), rac socialur da jandacvis sferoSi
gamocxadebuli satendero winadadebebis da vakanturi samuSao adgilebis
koleqtors warmoadgens da albaT bevri organizaciis da adamianis
dainteresebas gamoiwvevs. garda amisa, veb-gverds gaaCnia jandacvis da socialuri sferos saerTaSoriso
grantebis saZiebeli sistema inglisur enaze, romelic male 600-mde
saerTaSoriso organizaciis mier SemoTavazebuli grantebis Ziebis saSualebas
miscems eqimebs da jandacvis profesionalebs. veb-gverdze warmoadgenilia
samedicino mecnierebis da ganaTlebis sferoSi mniSvnelovani monacemebi –
saSualo da umaRlesi samedicino sawavleblebis CamonaTvali, diplomamdeli,
diplomisSemdgomis da uwyveti samedicino ganaTlebis normatiuli aqtebi,
programebi, sertificirebis formebi, informacia akreditaciis meTodebis da
kredit-saaTebis Sesaxeb da a.S.
jandacvis statistikis monacemTa baza – sruli versia (http://statistics.nilc.org.ge/stat/) 150-ze met abolutur da fardobiT statistikur parametrs warmogvidgens
regionebis mixedviT, xolo ZiriTad indikatorebze gadasvla calke bmuliT
mTavari gverdidan xdeba misamarTze -
http://www.healthministry.ge/healthcare_indicators.php#one – monacemebi mowodebulia
daavadebaTa kontrolis da samedicino statistikis erovnuli centris mier.
analogiurad aris warmodgenili socialuri dacvis
(http://www.healthministry.ge/socialcare_indicators.php) da dasaqmebis (http://www.healthministry.ge/employment_indicators.php#one ) indikatorebic, romlebic
88
statistikis saxelmwifo komitetis mier mowodebul mniSvnelovan indikatorebs
aerTianebs.
ganaxlebul veb-gverdze gaCnda axali ambebis da presis daijestis ganyofileba,
sadac Suqdeba saqarTveloSi Sromis, janmrTelobisa da socialuri dacvis
sferoSi momxdari nebismieri siaxle. aRniSnuli ganyofileba sistematurad
axldeba saministros aparatis presasa da sazogadoebasTan urTierTobis
sammarTvelos TanamSromlebis mier.
veb-gverdis mniSvnelovani miRwevaa mosaxleobasTan ukukavSiris SesaZlebloba.
am mizniT saitze Seqmnilia momxmareblis gverdi, romlis meSveobiTac
mosaxleobas SesaZlebloba aqvs SekiTxvebiT mimarTos saministros
warmomadgenlebs da umokles droSi pasuxi el-fostis meSveobiT miiRos.
dabolos, gverdze warmodgenilia qveynis jandacvis sistemis zogadi
struqtura, am sferoSi moRvawe arsamTavrobo da saerTaSoriso organizaciebi,
ganTavsebulia bmulebi saqarTvelos parlamentis janmrTelobis da socialuri
dacvis komitetTan, jandacvis msoflio organizaciasTan, evrosabWosTan,
sxvadasxva saerTaSoriso organizaciebTan.
vimedovnebT, es axali internet-resursi sargeblobas moutons momxmareblebs
maTTvis saWiro informaciis advilad moZiebaSi.
89
s a m e d i c i n o v e b – g v e r d e b i:
www.healthministry.ge www.MoLHSA.ge www.health.net.ge
erovnuli sainformacio
saswavlo centri (essc)
iv. javaxiSvilis q. #51
tel 94 13 88
faqsi 94 13 91
el-fosta: dmeskhi@nilc.org.ge interneti: www.nilc.org.ge
internetis veb-gverdis monacemebis forma organizaciebisaTvis
SeiZleba mowodebul iqnas rogorc qarTul, aseve - inglisur enebze, * - aRniSnulia aucilebeli punqtebi
sruli dasaxeleba da abreviatura
(rogorc qarTul, aseve - inglisur 1. * organizaciis dasaxeleba:
2. * organizaciis misamarTi:
qalaqi, kodi, quCa, nomeri, oTaxebis nomeri (rogorc qarTul, aseve -
+995-32-xx xx xx3. * telefoni #1:
+995-32-xx xx xx4. telefoni #2:
5. faqsi:
+995-32-xx xx xx
6. el-fosta:
7. veg-gverdi:
8. organizaciis struqtura:
arsebuli URL anda sasurveli abreviatura inglisurad
1. ganyofilebebis CamonaTvali
2. TanamSromelTa raodenoba
3 SeiZleba iyos organizaciuli gegma
9. * organizaciis xel-li piri:
* gvari, saxeli
10. organizaciis miznebi:
mokle aRweriloba (maqs 100 sityva)
11. organizaciis proeqtebi:
mimdinare: CamonaTvali da TiToeul proeqtze:
1. dasaxeleba
2. mokle aRweriloba (daaxlebiT 100 sityva
TiToeul proeqtze)
3. dafinansebis wyaro
4. ganxorcielebis periodi
5. regioni, sadac mimdinareobda
6. beneficiarTa raodenoba
7. proeqtSi monawileTa raodenoba
8. biujeti
Sesrulebuli:
CamonaTvali da TiToeul proeqtze igive
tipis informacia
12. organizaciis gegmebi: mokle informacia, anda Tu proeqtis zusti
monaxazi arsebobs, maSin imave formiT, rac
mimdinare proeqtebzea miTiTebuli:
13. organizaciis mier sxva iuridiul Tu fizikur pirebTan TanamSromlobis
sfero: gasaRebi sityvebi: Keywords
organizacia sTavazobs: (eqspertiza /servisi)
organizacias sWirdeba: (eqspertiza /servisi) 14. organizaciis partniorebi: miuTiTeT is organizaciebi, romelTanac
gindaT, rom Tqveni gverdidan iyos bmuli, mag.
jandacvis saministros romelime departamenti,
romelime saerTaSoriso organizacia (mag. damfinansebeli) da a.S.
.jpg, .gif anda romelime sxva grafikuli
faili, sasurvelia mcire zomis (ara
Corel)
15. organizaciis simbolo (logo):
16. * sakontaqto piris monacemebi (araa aucilebeli direqtoris, umjobesia –
sainformacio/teqnikuri personalis monacemebi)
* telefoni
* faqsi
* el-fosta
mobiluri telefoni
90
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