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1
perinataluri asfiqsia /
hipoqsiur-iSemiuri
encefalopaTia
klinikuri praqtikis erovnuli rekomendacia
(gaidlaini)
2
klinikuri praqtikis erovnuli rekomendacia (gaidlaini)
`perinataluri asfiqsia / hipoqsiur-iSemiuri encefalopaTia~
miRebulia klinikuri praqtikis erovnuli rekomendaciebis
(gaidlainebi) da daavadebaTa marTvis saxelmwifo standartebis
(protokolebi) SemuSavebis, Sefasebis da danergvis erovnuli
sabWos 2008 wlis 5 noembris #1 sxdomaze da damtkicebulia
saqarTvelos Sromis, janmrTelobisa da socialuri dacvis
ministris 2009 wlis 14 aprilis # 142/o brZanebiT.
3
perinataluri asfiqsia / hipoqsiur-iSemiuri encefalopaTia
1. definicia, sinonimebi, terminologia1-9:
definicia
perinataluri asfiqsia mdgomareobaa, romelic viTardeba ante, intra an
postnatalur periodSi Jangbadis miwodebis darRvevis gamo da xasiaTdeba
bradikardiiT, airTa cvlis darRveviT da organoebis araadekvaturi
perfuziiT.
hipoqsiur–iSemiuri encefalopaTia (hie) Jangbadis araadekvaturi miwodebis
gamo cns (Tavis da zurgis tvini) ujredebis dazianebaa, romelic vlindeba
sunTqvis problemebiT, tonusisa da refleqsebis daqveiTebiT, cnobierebis
darRveviT, gulyriT. hie-m SeiZleba gamoiwvios sikvdili neonatalur
periodSi, mogvianebiT ki – ganviTarebis globaluri Seferxeba, mentaluri
retardacia, cerebruli dambla10,11. hie-s diagnostikisaTvis saWiroa sami
komponentis arseboba: darRvevebi orsulobis da mSobiarobis periodSi,
adreul postnatalur periodSi klinikurad gamovlenili nevrologiuri
darRvevebi da sicocxlis pirvelive dReebSi arsebuli sistemuri
cvlilebebi.
neonataluri depresia mdgomareobaa, romelic vlindeba mxolod sicocxlis
pirveli saaTis ganmavlobaSi axalSobilis daTrgunviT da ar aris
dakavSirebuli prenatalur paTologiasTan. igi ar moiTxovs laboratoriul
da instrumentul kvlevebs.
sinonimebi - perinataluri hipoqsia, iSemia, asfiqsia, axalSobilTa asfiqsia,
dabadebis asfiqsia.
gamoyenebuli Semoklebebi
hie – hipoqsiur iSemiuri encefalopaTia
gaidlaini gankuTvnilia
⇒ samedicino personalisaTvis, romelic muSaobs axalSobilTan, rogorc
samSobiaro saxlSi, ise stacionarSi – neonatologi, mean-ginekologi,
ojaxis eqimi, pediatri.
gaidlainis samizne jgufi:
⇒ axalSobilebi, romlebsac aReniSnebaT perinataluri asfiqsia an misi
ganviTarebis riski.
4
2. epidemiologia
perinataluri asfiqsia/hipoqsiur-iSemiuri encefalopaTia (hie) axalSobilTa
sikvdilobisa da avadobis erT-erT seriozul mizezad rCeba.
perinataluri asfiqsiis sixSire gestaciis 28 kviraze daaxloebiT 30%,
droul axalSobilebSi 20% Seadgens13. aSS-s janmrTelobis statistikis
nacionaluri centris monacemebiT axalSobilTa asfiqsiiT gamowveuli
sikvdiloba 14,4-ia yovel 100 000 cocxladSobilze. janmos monacemebiT
msoflioSi asfiqsiiT 1 mln bavSvi iRupeba14.
sxvadasxva qveynis monacemebiT mZime hipoqsiur iSemiuri encefalopaTiis
sixSire Seadgens 2-9 SemTxvevas yovel 1000 cocxladSobilze15,16.
mZime hie-s dros sikvdiloba 50-75%-ia, maT Soris yvelaze maRalia
neonataluri sikvdiloba, romelic gamowveulia multiorganuli dazianebiT.
hie-s iwvevs mentaluri retardaciis, epilefsiis, sxvadasxva xarisxis
cerebruli damblis ganviTarebas. mZime hie-s dros zemoT aRniSnuli
paTologia gvxvdeba SemTxvevaTa 90-100%, saSualo simZimis hie-s dros ki - 30-
50%17, msubuqi hie-s dros seriozuli nevrologiuri garTulebebi SeiZleba
ar ganviTardes. im SemTxvevebSic ki Tu ar aRiniSneba Tavis tvinis aSkara
dazianeba 15-20%-Si SeiZleba aRiniSnos saskolo asakis bavSvebSi swavlis
siZneleebi.
3. etiopaTogenezi1-9,18,19
asfiqsiis/hie-s risk-faqtorebia:
antenataluri:
• saSvilosnosSiga zrdis Seferxeba;
• mZime preeklamfsia;
• vadagadacileba;
• placentis paTologia;
• dedis virusuli da baqteriuli infeqciebi;
• sisxldena orsulobisas;
• dedis farisebri jirkvlis da gul-sisxlZarRvTa paTologia.
risk-faqtorebs miekuTvneba aseve: socialur_ekonomikuri statusi, gulyris
an nevrologiuri daavadebis ojaxuri anamnezi, dafexmZimeba uSvilobis gamo
mkurnalobis Semdeg.
intranataluri:
• persistuli oqcipitoposteriuli pozicia;
• maRali temperatura mSobiarobis dros;
• saswrafo sakeisro kveTa;
• placentis gagleja;
• swrafi vaginaluri mSobiaroba;
• mwvave intranataluri mdgomareobebi: Wiplaris kompresia, prolapsi
da a.S.
5
neonataluri
• araadekvaturi reanimacia;
• pirveladi adaptaciis darRveva.
paTfiziologia:
hipoqsiur-iSemiuri encefalopaTia ganpirobebulia Tavis tvinis hipoqsiiTa da
iSemiiT, rasac mosdevs neironebis dazianeba. hipoqsiis/asfiqsiis dasawyisSi
viTardeba kompensatoruli reaqcia _ adrenalinis hiperproduqcia, sisxlis
wnevis da cerebruli sisxlis nakadis gazrda (sisxlis mimoqcevis
centralizacia), rac ganapirobebs Tavis tvinis perfuziis SenarCunebas.
adreuli kompensaciuri meqanizmebis amowurvis Semdeg, qveiTdeba sisxlis
wneva, mcirdeba cerebruli sisxlis nakadi, viTardeba hipoqsemia, rac iwvevs
ujredSiga energetikul ukmarisobas. dazianebis adreul etapze Tavis tvinis
temperatura qveiTdeba, gamoTavisufldeba neirogadamtani γ-aminoerbos mJava, rac amcirebs cerebruli oqsigenaciis moTxovnilebas da Sesabamisad
tranzitorulad amcirebs asfiqsiis damzianebel efeqts.
asfiqsiis sawyisi fazis Semdeg cerebruli metabolizmi SeiZleba aRdges,
Tumca gauareseba viTardeba reperfuziis dros anu meorad fazaSi, romelic
iwyeba sawyisi dazianebidan 6-24 sT-Si, xasiaTdeba tvinis SeSupebiT da
apoptoziT (ujredebis programirebuli sikvdili). am fazas ewodeba –
neironebis dazianebis mogvianebiTi faza. misi xangrZlivoba ar aris zustad
cnobili, magram miCneulia rom is grZeldeba 24-48 sT, Semdeg ki iwyeba
aRdgena.
4. klinikuri simptomatika1-9,19:
amerikis pediatriis akademiis (AAP) da amerikis meanobisa da ginekologiis
kolejis (ACOG) gaidlainis Tanaxmad perinataluri asfiqsiis ZiriTadi
kriteriumebia13:
• Rrma metaboluri an Sereuli acidozi, Wiplaris arteriaSi pH < 7,00
fuZeTaQdeficiti > 12 mmol/l • apgaris dabali qulebis (0-3) persistireba 5 wuTze met xans
• klinikurad nevrologiuri darRvevebi (gulyra, hipotonia, koma)
• adreul neonatalur periodSi poliorganuli sistemuri disfunqcia
(Tirkmlis, RviZlis, sasunTqi, gul-sisxlZarRvTa da kuW-nawlvis
traqtis dazianeba)
Tu aRniSnuli maxasiaTeblebi ar aris gamoxatuli, SeuZlebelia asfiqsiis
arsebobaze saubari. maRali apgaris qula > 6 gamoricxavs intranataluri
asfiqsiis arsebobas12.
asfiqsiis diagnostika mxolod apgaris qulebis mixedviT ar aris
gamarTlebuli. sicocxlis me-5 wT-ze apgaris qula 3 an naklebi SeiZleba
6
miuTiTebdes asfiqsiis arsebobaze mxolod sxva diagnostikur
kriteriumebTan erTad.
apgaris dabali qulebi hipoqsiis garda SesaZlebelia mTeli rigi
faqtorebiT iyos ganpirobebuli. mocemuli faqtorebia13:
• dRenakluloba da gestaciur asakTan SedarebiT mcire wona - am
axalSobilebs axasiaTebT hipotonia, akrocianozi, nevrologiuri
reaqciisa da refleqsebis daTrgunva. aqedan gamomdinare apgaris
maqsimaluri qula SeiZleba iyos 6-7. gestaciis 30 kviramde dabadebul
dRenaklulebSi apgaris qula SeiZleba 2-3 iyos asfiqsiis gareSec;
• dedasTan gamoyenebuli medikamentebi - dedis anesTeziisa da analgeziis
gamo ganviTarebuli depresia;
• infeqcia;
• nerv-kunTovani darRvevebi;
• gul-sisxlZarRvTa Tandayolili mankebi.
Tu apgaris qula 0-3-ia sicocxlis me-15 wuTze bavSvTa cerebruli damblis
ganviTarebis sixSire 10%-s, xolo Tu me-20 wuTze - 60%_s Seadgens.
klasifikacia:
msubuqi Hhie:
- sicocxlis pirvel dReebSi mcired momatebuli kunTTa tonusi da
cocxali Rrma myesTa refleqsebi;
- axalSobili agznebulia, moros da tacebis refleqsi gaZlierebulia.
cnobierebis daTrgunva iSviaTia, SeiZleba gamovlindes Zilianoba.
aRiniSneba gardamavali qceviTi anomaliebi, rogoricaa kvebasTan
dakavSirebuli problemebi;
- dabadebidan 3-4 dRisaTvis cns-is statusi SeiZleba iyos normaluri.
sicocxlis pirvel saaTebSi simptomebis ararsebobas an msubuqi hies
SeiZleba mohyves uecari gauareseba, romelic miuTiTebs Tavis tvinis
ujredebis mimdinare disfunqciaze, dazianebasa da sikvdilze.
saSualo simZimis hie:
- vlindeba leTargia, mniSvnelovani hipotonia, daqveiTebuli Rrma
myesTa refleqsebi;
- tacebis, moros, wovis refleqsebi daTrgunulia an ar iwveva;
- sicocxlis pirvel 24 sT-Si SeiZleba gamovlindes gulyra;
- 1-2 kviraSi SesaZlebelia sruli gamojanmrTeleba, rac
asocirebulia ukeTes gamosavalTan momavalSi.
mZime hie:
- vlindeba koma an stupori;
- sunTqva SiZleba iyos araregularuli, axalSobils xSirad
esaWiroeba damxmare ventilacia;
7
- damaxasiaTebelia generalizebuli hipotonia da daTrgunuli Rrma
myesTa refleqsebi;
- wovis, ylapvis, tacebis, moros refleqsebi ar iwveva;
- Tavis tvinis nervebis gamokvlevis dros SeiZleba gamovlindes
Tvalebis asimetriuli deviacia, nistagmi, “Tojinis Tvalebi”;
- Tvalis gugebi SeiZleba iyos gafarToebuli, Suqze reaqcia
daqveiTebuli;
- gulyra vlindeba adreul etapze da dasawyisSi SeiZleba
rezistentuli iyos tradiciul mkurnalobaze. igi ZiriTadad
generalizebuli xasiaTisaa. dazianebis progresirebasTan erTad
gulyra praqtikulad ar vlindeba da eeg xdeba izoeleqtruli an
gviCvenebs mkveTri supresiis niSnebs. am periodisaTvis progresirebs
tvinis SeSupeba da gamoixateba yiflibandis daWimva;
- damaxasiaTebelia araregularuli guliscemis sixSire da arteriuli
wnevis maCveneblebis cvalebadoba.
mZime hie-s dros maRalia adreuli neonataluri sikvdilobis maCvenebeli.
axalSobilebSi, romlebic gadarCebian:
- cnobierebis done umjobesdeba me-4-5 dRisaTvis;
- hipotonia da kvebiTi problemebi persistirebs, zondiT kveba SeiZleba
gaxangrZlivdes ramdenime Tve.
hies Tan axlavs Semdegi multiorganuli dazianebebi
⇒ sasunTqi sistema: pulmonuri hipertenzia, surfaqtantis meoradi deficiti,
mekoniumis aspiracia, filtvidan sisxldena, filtvis SeSupeba.
⇒ saSarde sistema: mwvave tubuluri da kortikaluri nekrozi, oliguria,
renuli ukmarisoba.
⇒ kardiovaskuluri sistema: Ria arteriuli sadinari, miokardiumis
dazianeba, hipotenzia, Soki, gulis SegubebiTi ukmarisoba, samkariani
sarqvlis ukmarisoba.
⇒ metaboluri: acidozi, hipoglikemia, hipokalciemia, hiponatriemia,
hiperamonemia, hiperkalemia.
⇒ gastrointestinuri sistema: nekrozuli enterokoliti, stresuli wyluli.
ZiriTadad damaxasiaTebelia peristaltikis daqveiTeba da kuWis evakuaciis
Seferxeba.
⇒ RviZlis disfunqcia: iSemia azianebs RviZlis sinTezur, eqskretorul da
detoqsikaciur funqciebs. vlindeba transaminazebis donis mateba, sisxlis
Semadedebeli faqtorebis sinTezis Semcireba, proTrombinis da
aqtivirebuli parcialuri Tromboplastinis drois gaxangrZliveba, rac
klinikurad asocirebulia sisxldenebTan.
⇒ hematologiuri: Trombocitopenia, hemolizi, Zvlis tvinis depresia,
sisxlZarRvTaSida Sededebis sindromi.
8
5. daavadebis diagnozi
hie-s diagozi damyarebulia anamnezze, obieqtur da nevrologiur
gamokvlevebze. ar arsebobs specifiuri testi romelic yovelTvis
daadasturebs an uaryofs hie-s.
perinataluri asfiqsiis damadasturebeli maxasiaTeblebia9,13:
• Rrma metaboluri an Sereuli acidozi;
• Wiplaris arteriaSi pH < 7,00 fuZeTaQdeficiti > 12 mmol/l; • apgaris dabali qulebis (0-3) persistireba 5 wuTze met xans;
• klinikurad arakeTilsaimedo nevrologiuri darRvevebi, rogoricaa
gulyra, hipotonia, koma an hie;
• adreul neonatalur periodSi poliorganuli sistemuri
disfunqcia.
Tu aRniSnuli maxasiaTeblebi ar aris gamoxatuli, SeuZlebelia asfiqsiis
arsebobaze saubari.
h. sarnatisa da m. sarnatis mier 1976 wels mowodebulia hie-s
xarisxobrivi klasifikacia. es sqema saukeTesoa hie-is gamosavlis
prognozirebisaTvis (mtkicebulebis done I)20.
neonataluri hipoqsiur-iSemiuri encefalopaTiis klasifikacia
niSnebi msubuqi (I x.) saSualo (II x.) mZime (III x.)
cnobierebis
done
agznebadoba leTargia stupori, koma
nerv-kunTovani
kontroli
• kunTTa
tonusi
norma msubuqi
hipotonia
daqveiTeba
• poza norma fleqsia aramyari
decerebracia
• Rrma
refleqsebi
gacxovelebuli
gacxovelebuli
ar iwveva
• miokloniebi aris aris ar aris
rTuli
refleqsebi
• wova susti susti an ar
aris
ar aris
• moro cocxali
susti
ar aris
• okulo-
vestibuluri
norma
gacxovelebuli
susti an ar aris
• kisris
tonur
susti cocxali ar aris
• autonomiuri
funqciebi
simpatikotonia
parasimpatikoto
nia
orive
daTrgunulia
I
9
• gugebi midriazi
miozi
araTanabari,
susti reaqciiT
sinaTleze
• guliscema taqikardia bradikardia cvalebadi
• bronquli
sekreti
mwiri Warbi
cvalebadi
• nawlavTa
peristaltika
norma an
daqveiTebuli
momatebuli,
diarea
cvalebadi
• gulyrebi ar aris xSiria decerebracia
• eeg
normaluri dabali voltaJi,
romelsac
erTveba
iqtaluri
aqtivoba
Caqroba-
aRmocenebis
paterni
izoxazamde
vardniT
xangrZlivoba <24 sT 24 sT-dan 14
dRemde
dReebi, kvirebi
gamosavali kargi sxvadasxva letaloba an mZime
deficiti
janmrTelobis msoflio organizaciis mier mowodebulia hie-s Sefasebis da
klasifikaciis martivi sqema31
niSani I stadia
(msubuqi)
II stadia
(saS. simZimis)
III stadia
(mZime)
cnobiereba momatebuli agznebadoba
daTrgunva koma
kunTTa tonusi umniSvnelod darRveuli
zomierad daRveuli
mkveTrad darRveuli
wovis refleqsi norma an umniSvnelod daTrgunuli
daTrgunuli ar iwveva
fiziologiuri
refleqsebi
gacxovelebuli daTrgunuli ar iwveva
gulyra ar aris gamoxatuli gamoxatuli
Rerovani
refleqsebi
norma norma darRveuli
sunTqva taqipnoe perioduli apnoe mZime apnoe
* Sesabamisi stadiis encefalopaTiis diagnostikisaTvis aucilebelia
gamoxatuli iyos didi asoebiT da muqad gamoyofili niSnebidan 1 mainc.
diferenciuli diagnozi
diferenciuli diagnozi unda gatardes iseT daavadebebTan,
rogoricaa:
• meningoencefaliti;
• cns malformaciebi;
10
• metabolizmis Tnadayolili darRvevebi;
• samSobiaro travmebi;
• nerv-kunTovani daavadebebi;
• dedis mier medikamentebis gamoyeneba;
• neonataluri depresia.
6. gamokvlevis sqema5,6,8,9,19
neirogamosaxviTi kvlevebi
rutinuli neorogamosaxviTi kvlevebi yovelTvis ar miuTiTebs dazianebaze,
kvlevis normaluri Sedegi ar gamoricxavs hie-s arsebobas.
• kraniuli ultrasonografiuli gamokvleva: SeiZleba gamovlindes
intracerebruli da intraventrikuluri hemoragia. tvinis SeSupebis
dros aRiniSneba parkuWebis zomis Semcireba. hie-s dros mxolod
ultrasonografiuli kvleva arainformatiulia. diagnostikurad
mniSvnelovania dopleruli ultrasonografia, kerZod – arteriebis
rezistentobis indeqsis gansazRvra. gamosavali arakeTilsaimedoa, Tu
maCvenebeli < 0,5-0,6_ze.
gestaciis 30 kviramde dabadebul axalSobilebs yvela SemTxvevaSi
unda CautardeT ultrasonografiuli kvleva (rekomendacia B)31. kvlevis Catarebis saukeTeso periods miekuTvneba sicocxlis me-7-
14 dRe.
• kompiuteruli tomografia gansakuTrebiT mniSvnelovania tvinis
SeSupebis da hemoragiis diagnostirebisaTvis. SeiZleba iyos gverdiTi
parkuWebis daviwroeba, Rarebis da xveulebis gasadaveba. Semcirebuli
simkvrivis areebi miuTiTebs infarqtis zonebis arsebobaze.
intraventrikuluri hemoragia iSviaTia droul axalSobilebSi.
kompiuteruli tomografiiT SesaZlebelia ukana fosos hemoragiis
gamovlena, rac ar vlindeba sonografiiT.
• magnitur rezonansuli gamokvleva - mniSvnelovania saSualo da mZime
hie-s diagnostikaSi. GgansakuTrebiT mielinizaciis statusis, ruxi-
TeTri nivTierebis dazianebis xarisxis, Tavis tvinis ganviTarebis
defeqtebis da Semdgomi nevrologiuri gamosavlis dasadgenad.
misi Catareba mizanSewonilia sicocxlis me-2-8 dRes droul
axalSobilebSi (rekomendacia A). kvleva mniSvnelovania
dinamikaSi monitoringisaTvis.
sxva testebi:
• amplitude_integrirebadi eleqtroencefalograma (aEEG) –kvlevebiT
dadginda, rom dabadebidan ramdenime saaTSi warmoebuli erT arxiani
aEEG Tavis tvinis dazianebis da hie-s Sefasebis efeqturi saSualebaa.
normaluri aEEG ar gamoricxavs Tavis tvinis dazianebis arsebobis SesaZleblobas, maSin roca aEEG-ze mZime an saSualo dazianebis
maCvenebeli miuTiTebs Tavis tvinis dazianebasaE da arakeTilsaimedo
gamosavalze. paTologiad miCneulia amplitudis farTo meryeoba
B
A
11
bazisuri voltaJiT nulis axlos da pikuri amplitudiT 5-is qvemoT.
aEEG -Ti SeiZleba aseveKkrunCxvebis diagnostikac.
• standartuli eeg: gamoiyeneba rekomendebulia axalSobilis zogadi
mdgomareobis stabilizaciis Semdeg. mravalarxiani eeg kvleva
utardeba yvela axlSobils saeWvo krunCxvebiT da hie-iT. is
mniSvnelovania krunCxvis dros dazianebis lokalizaciisa da
simZimis Sesafaseblad. ase rom, aSkara klinikuri krunCxvebis ar
arsebobis drosac ki tradiciuli eeg unda Catardes daavadebis
adreul stadiaze gansakuTrebiT saSualo da mZime SemTxvevebSi.
subklinikuri krunCxva, romlebic vlindeba mxolod eeg-ze, iwvevs
Tavis tvinis dazianebas. axalSobilebSi, romlebic imyofebian
damxmare ventilaciaze, miorelaqsantebis da sedatiuri saSualebebis
gamoyenebam SeiZleba SeniRbos adreuli krunCxvebis simptomebi.
antikonvulsiuri Terapiis didi dozebic cvlis eeg-s monacemebs.
ganmeorebiTi eeg aucilebelia cvlilebebis dinamikis Sesafaseblad.
misi Catareba mizanSewonilia gaweris win. pirvel kviraSi klinikur
mdgomareobasTan erTad eeg-ze gaumjobeseba, dadebiTi prognozuli
maCvenebelia.
• specialuri sensoruli gamokvleva: smenis skriningi.
• retinuli da ofTalmologiuri gamokvleva.
laboratoriuli gamokvlevebi:
Tavis tvinis dazianebis simZimis Sesafaseblad da organoTa funqciuri
statusis monitorirebisaTvis mravali testia mowodebuli.
• mJava tutovani wonasworobis gansazRvra;
• Sratis eleqtrolitebi: mZime hie-s dros mniSvnelovania Sratis
eleqtrolitebis yoveldRiuri Sefaseba mdgomareobis gaumjobesebamde.
mniSvnelovnad daqveiTebulia natriumis, kaliumis, qloridebis done.
diurezis Semcireba da wonis Warbi namati SeiZleba miuTiTebdes mwvave
tubulur dazianebasa an antidiurezuli hormonis araadekvatur
sekreciaze;
• renuli funqciis Seswavla: Sratis kreatinini, kreatininis klirensi da
Sardovana;
• kardiuli da RviZlis enzimebis done Seesabameba hie-s simZimis xarisxs.
sxva mniSvnelovani gamokvlevebi:
• sisxlis airebi
• sisxlis saerTo analizi TrombocitebiT
• proTrombinis dro, parcialuri Tromboplastinis dro
• sisxlis bioqimiuri kveleva (glukoza, kalciumi, magniumi,
osmolaroba)
• Sardis osmolaroba, saerTo analizi
• RviZlis funqciebi, pirdapiri da saerTo bilirubini
• liqvoris gamokvleva
• ekg, eqokardioskopia
12
7. mkurnalobis sqema5,6,8,9,19
dabadebisTanave aucilebelia adekvaturi reanimaciis Catareba (ix. gaidlaini
- axalSobilTa reanimacia samSobiaro blokSi).
krunCxvis SemTxvevaSi SesaZlebelia mniSvnelovnad daziandes organizmis
sxvadasxva funqcia, ris gamoc xSir SemTxvevaSi axalSobili saWiroebs
ventilacias, oqsigenacias, sisxlis wnevis stabilizacias. gulyra SeiZleba
moixsnas fenobarbitaliT an lorazepamiT. mocemuli preparatebi warmodgens
I rigis antikonvulsantebs. fenitoini gamoiyeneba, Tu aRniSnuli
medikamentebi uefeqtoa.
medikamenturi Terapia
• fenobarbitali
Cveneba _ klinikuri an subklinikuri gulyra, romelic vlindeba eeg-ze;
mkurnalobis kursis xangrZlivoba damokidebulia klinikur statusze
da eeg-s monacemebze,Uumetes SemTxvevaSi SeiZleba Sewydes sicocxlis
pirvel Tveze. Tu nevrologiuri darRvevebi an eeg-ze cvlilebebi
persistirebs, mkurnaloba grZeldeba ramdenime Tvidan erT wlamde. eeg
da klinikuri statusi aris mkurnalobis kursis da xangrZlivobis
ganmsazRvreli.
doza _ sawyisi doza 20 mg/kg, preparati SeyavT venaSi 10-15 wT-is
ganmavlobaSi (infuzomatiT), refraqterul SemTxevebSi SeiZleba
damatebiTi dozis Seyvana - 5-10 mg/kg-ze. SemanarCunebeli dozaa 3-5
mg/kg/dReSi, SemanarCunebeli dozis Seyvana xdeba sawyisi dozis
Seyvanidan 12-24 sT-is Semdeg, dReSi 2-jer 12 saaTis intervaliT, Seyvanis
gzaa peroraluri, intravenuri, intramuskuluri an reqtaluri.
sifrTxilis zomebi:
- saWiroa wnevisa da respiraciis kontroli, SeiZleba ganviTardes
respiraciuli distresi da saWiro gaxdes damxmare ventilacia.
- axlSobilSi pirveli 1-2 kviris ganmavlobaSi gaxangrZlivebulia prepartis
naxevrad daSlis periodi, rasac SeiZleba moyves wamlis akumulacia,
amitom mizanSewonilia SratSi preparatis koncentraciis (N-15-30 mkg/ml)
monitoringi da SemanarCunebeli dozis Sesworeba.
• lorazepami
Cveneba - gamoiyeneba fenobarbitalze refraqteruli krunCxvis dros.
doza _ erTjeradi dozaa 0.05-0.1 mg/kg venaSi neli nakadiT, doza meordeba
klinikuri mdgomareobis mixedviT.
sifrTxilis zomebi: dRenakl axalSoblebSi, romlebic iReben lorazepams
sedaciisaTvis, SeiZleba gamoiwvios respiratoruli depresia da
riTmuli miokloniebi.
13
• fenitoini
Cveneba- gamoyeneba fenobarbitalze da lorazepamze refraqteruli krunCxvis
SemTxevaSi. sococxlis pirveli Tveebis ganmavlobaSi Ppreparatis
oraluri gamoyenebisas Sewova umniSvneloa.
doza _ sawyisi doza 15-20 mg/kg. Seyvana xdeba infuzomatiT minimum 30 wT-is
ganmavlobaSi, SemanarCunebeli dozaa 4-8 mg/kg 24 sT_Si erTxel venaSi
neli nakadiT, infuzis siCqare ar unda aRematebodes 0.5 mg/kg/wT;
preparatis ganzaveba xdeba fiziologiur xsnarSi. fenitoinis
intravenuri Seyvanis win da Semdeg mizanSewonilia kaTeteris Carecxva
0.9% NaCL-iT.
sifrTxilis zomebi: sasurvelia SratSi fenitoinis koncentraciis (N- 6-15 mcg/ml) monitoringi, aucilebelia aseve bradikardiis, ariTmiis da
hipotenziis monitoringi infuziis ganmavlobaSi; medikamenti aramdgradia
IV xnarebSi, ar aris mizanSewonili misi Seyvana centraluri venaSi,
daleqvis riskis gamo. SeuTavsebelia glukozis, deqstrozis da
aminomJavebis, lipidebis xsnarebTan, bevr antibiotikTan, heparinTan,
insulinTan. medikamentis sisxlZarRvidan gaJonvam SeiZleba gamoiwvios
mZime lokaluri nekrozi.
L
• diazepami
Cveneba – gamoiyeneba mxolod im SemTxvevaSi, Tu fenobarbitali da fenitoini
ar aris xelmisawvdomi.
doza – erTjeradi dozaa 0,1-0,3 mg/kg venaSi nela, efeqtis ar arsebobisas
ganmeorebiTi Seyvana xdeba 15-30 wuTSi an iwyeba mudmivi infuzia 0,3
mg/kg/sT.
sifrTxilis zomebi: ar aris rekomendebuli diazepamis fenobarbitalTan
gamoyeneba erTad, radgan maRalia cirkulaciuri kolafsisa da sunTqvis
gaCerebis ganviTarebis riski.
damxmare Terapiis sxva aspeqtebi
saWiroa:
• adekvaturi ventilaciis, perfuziis da metaboluri statusis
SenarCuneba;
• hipoqsiis, hiperkapniis, hipokapniis prevencia;
• sisxlis gazebis da mJava–tutovani wonasworobis SenarCuneba
fiziologiur sazRvrebSi;
• sisxlis wnevis monitoringi da stabilizacia. vazopresorebis da
inotropuli agentebis, mocirkulire sisxlis moculobis
Semavseblebis gamoyenebiT;
• centraluri Ht – 40-45% maCveneblis SenarCuneba;
• siTxis da glukozis homeostazis SenarCuneba;
14
• pirveli ori dRis ganmavlobaSi intravenuri siTxis infuziis
SezRudva gestaciuri asakis mixedviT sadReRamiso siTxis
moTxovnilebis 2/3-mde;
• siTxiT da eleqtrolitebiT Terapia individualurad klinikuri
statusis, wonis cvlilebis, Sardis gamoyofis, Sratis
eleqtrolitebis da renaluri funqciis gaTvaliswinebiT.
axalSobilis mdgomareobis gaumjobesebisas (Sardis gamoyofa
izrdeba) saWiroa siTxis miwodebis koreqcia.
• hipoTermia mkurnalobis axali meTodia. is gamoiyeneba msubuqi da
saSualo simZimis hie-s SemTxvevebSi. cxovelis modelze Catarebul
ramdenime eqspetrimentsa da erTeul limitirebul klinikur cdebSi,
miRebulia dadebiTi efeqti, magram gamosavali Sefasebulia mxolod
18-22 Tvis asakamde. sxeulis temperaturis daqveiTeba 2-30C (zomieri hipoTermia) tvinis hipoqsia-iSemiis Semdeg amcirebs tvinis dazianebas
da aumjobesebs gamosavals eqsperimentul kvlevaSi
(mtkicebulebis done IV)21-23. axalSobilebze Catarebuli
kvlevebi mwiria da urTierTgamomricxavi Sedegebi aqvs
(mtkicebulebis done II)24-27. mZime hipoTermiam SeiZleba
gamoiwvios ariTmia, sisxldena, Trombozi da sefsisi, Tumca
es garTulebebi ar gamovlenila zomieri hipoTermiis dros
(mtkicebulebis done II)25,26,28.
ar arsebobs sakmarisi mtkicebuleba imisTvis, rom rutinulad
gamoyenebuli iyos sistemuri an cerebruli hipoTermia im
axalSobilebSi, romlebsac aReniSnebaT asfiqsia da hie. saWiroa
kvlevebis gagrZeleba am mimarTulebiT.
cxovelebze Catarebuli kvlevebi gviCvenebs, rom iSemiis
dros da mis mere ganviTarebuli hiperTermia, iwvevs tvinis
dazianebas (mtkicebulebis done IV)29.
gamomdinare zemoaRniSnulidan, im axalSobilebs, romlebsac
CautardaT reanimacia esaWiroebaT temperaturis mkacri
kontroli, raTa ar ganviTardes iatrogenuli hiperTermia.
radgan hiperTermiam SeiZleba gamoiwvios tvinis dazianeba
(rekomendacia B)14.
kveba:
umetes SemTxvevebSi (saSualo da mZime hie-s dros) pirveli sami dRis
ganmavlobaSi an sanam cnobierebis done ar gaumjobesdeba mizanSewonilia
parenteruli kveba. Semdeg iwyeba minimaluri kveba dedis gamowvelili rZiT
an formuliT daaxloebiT 5 ml yovel 3-4 sT-Si. paralelurad unda
warmoebdes muclis garSemowerilobis, nawlavTa xmianobis, nawlavTa
moqmedebis da kuWSi narCeni masebis monitoringi. nebismieri aRniSnul
simptomTagani SeiZleba miuTiTebdes nekrozul enterokolitis arsebobaze.
axalSobilebi perinataluri asfiqsiiT miekuTvnebian nekrozuli
enterokolitis ganviTarebis riskis jgufs.
B
IV
IV
II
II
15
konsultaciebi:
- krunCxvebis marTvis, eeg-s interpretaciisaTvis aucilebelia bavSvTa
nevrologis konsultacia.
referali9
hie-s saSualo simZimis da mZime formebis SemTxvevaSi saWiroa axalSobilis
transportireba maRali donis klinikaSi saTanado nevrologiuri kvlevisa
da nevrologis konsultaciis Casatareblad.
8. meTvalyureoba9:
saSualo da mZime xarisxis hies SemTxvevaSi pacients esaWiroeba sxvadasxva
specialistis meTvalyureoba (pediatri, nevropaTologi, ganviTarebis
pediatri da sxv.).
mkurnaloba gaweris Semdeg
krunCxvis sawinaaRmdego mkurnalobis xangrZlivoba damokidebulia cns-s
dazianebis xarisxsa da eeg-s monacemebze:
- axalSobilTa umravlesobasTan, romlebic viTardebian normalurad
da hospitalidan gaweramde aqvT normaluri eeg, fenobarbitaliT
mkurnaloba wydeba dabadebidan 3-4 kviris Semdeg.
- cns-is mniSvnelovani paTologiis mqone CvilebSi fenobarbitalis
mkurnalobis xangrZlivobis Sesaxeb gadawyvetilebas iRebs nevrologi
bavSvis mdgomareobis mixedviT.
prognozi:
gulyrebi cudi prognozis maCvenebelia: gulyrebis arseboba 2-5-jer zrdis
nevrologiuri garTulebis risks; antikonvulsantebisadmi rezistentul
gulyrebs calsaxad axlavs letaloba an myari nevrologiuri darRvevebi;
arakeTilsaimedo gamosavalis riski miT ufro maRalia, rac ufro adre
(gansakuTrebiT dabadebidan pirvel 4 saaTSi) iwyeba gulyrebi.
nevrologiuri statusis darRveva, romelic xangrZlivdeba pirveli 7-10 dRis
Semdeg, Cveulebriv, cudi prognozis maCvenebelia. M
persistirebadi kvebiTi problemebi miuTiTebs cns-is mniSvnelovan
dazianebaze.
hie-s mqone pacientebSi Tavis garSemowerilobis arasakmarisi zrda
sicocxlis pirvel wlis ganmavlobaSi momavalSi nevrologiuri problemebis
ganviTarebis erT-erTi markeria.
9. gaidlainis gadasinjvisa da ganaxlebis vada – 4 weli
16
10. gaidlainis miRebis xerxi/wyaro
gaidlainis SemuSavebis meTodologia
• axalSobilTa asfiqsiis/hipoqsiur iSemiuri encefalopaTiis
prevenciis da marTvis principebis Sesaxeb arsebobs samecniero
mtkicebulebis safuZvelze Seqmnil rekomendaciaTa mcire
raodenoba. mocemuli gaidlainis Seqmnis procesSi samuSao
jgufis gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve
arsebuli praqtikuli rekomendaciebi. moxda arsebuli
rekomendaciebis adaptirebuli variantis SemuSaveba, romelic
erTis mxriv pasuxebs saerTaSoriso moTxovnebs, xolo meore
mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa
rogorc adamianur, ise teqnikur resursebs.
• rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa
bazis gamoyenebiT.
qveyana da resursis
dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
http://www.guideline.gov
Centers for Disease Control and Prevention (CDC)
http://www.phppo.cdc.gov/CDCRecommends/AdvSearchV.asp
Agency for Healthcare Research and Quality (AHRQ)
http://www.ahrq.gov/clinic/cpgsix.htm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
http://hstat.nlm.nih.gov
Institute of Clinical Systems Improvement (ICSI)
http://www.icsi.org
American Medical Association http://www.ama-assn.org
Canadian Medical Association (CMA)
http://mdm.ca/cpgsnew/cpgs/index.asp
Health Canada – Population and Public Health Branch (PPHB)
http://www.hc-sc.gc.ca/pphb-dgspsp/dpg_e.html
didi britaneTi National Institute for Clinical Excellence (NICE)
http://www.nice.org.uk
Sheffield Evidence for Effectiveness and Knowledge
http://www.shef.ac.uk/seek/guidelines.htm
17
(SEEK)
National electronic Library for Health (NeLH)
http://www.nelh.nhs.uk/guidelinesfinder
PRODIGY Clinical Guidance http://www.prodigy.nhs.uk/ClinicalGuidance
Scottish Intercollegiate Guidelines Network (SIGN)
http://www.sign.ac.uk
German Guideline Information Service (GERGIS)
http://www.leitlinien.de/english/english/view;
avstralia Australian National Health and Medical Research Council (NHMRC)
http://www.health.gov.au/hfs/nhmrc/publicat/cp-home.htm
axali zelandia
New Zealand Guidelines Group (NZGG)
http://www.nzgg.org.nz/library.cfm
mtkicebiTi medicinis
specialistTa
regionTaSorisi
sazogadoeba
http://www.osdm.org
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi
da meTodebi
• koxreinis biblioTeka - The Cochrane Library 2006, Issue 2; • amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini – MEDLINE; • jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka.
publikaciebis CarTvis/gamoricxvis kriteriumebi
• arCeul iqna kvlevebi Semdegi dizainiT: randomizebuli
kontrolirebadi kvlevebi, sistemuri mimoxilvebi da meta-analizi,
erTmomentiani, kohortuli kvlevebi;
• rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12
wliani SezRudva. Tumca zogjer gamoyenebuli iyo ufro adreuli
publikaciebi, romlebic dResac aqtualuria da safuZvlad udevs
sxva Tanamedrove mtkicebulebebs;
• dadgenili iyo enobrivi SezRudvebi, radganac samuSao jgufs
SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod
inglisur da rusul enebze.
18
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
• samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi.
Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri
meToduri rekomendacia axalSobilTa asfiqsiis/hie-s marTvis
sakiTxebze, romlebic Seicavda jgufis miznis Sesaferis saWiro
informacias. am rekomendaciebis Sefasebisas gamoyenebuli iyo
rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (94,96-98). samuSao jgufi xelmZRvanelobda saqarTvelos Sromis, janmrTelobisa
da socialuri dacvis saministros mier SemuSavebuli nacionaluri
gaidlainebis gzamkvleviT. Sefasebis Sedegad amorCeuli iyo qvemoT
CamoTvlili organizaciebis gaidlainebi:
⇒ amerikis pediatriis akademia
⇒ axalSobilTa movla, manuali – j. kloherti
⇒ pediatria – nelsoni
⇒ janmrTelobis msoflio organizacia
• rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli
iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis
saministros mier mowodebuli mtkicebulebebis donisa da
rekomendaciebis xarisxis sqema.
mtkicebulebaTa doneebisa da rekomendaciebis gradaciebis sqema
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 kvleva
A eyrdnoba I donis
mtkicebulebas da
Sesabamisad mtkiced
rekomendebulia
II Zlieri mtkicebuleba,
eyrdnoba minimum erTi
swori dizainis mqone
randomizebul
kontrolirebad kvleva
B eyrdnoba II donis
mtkicebulebas da
Sesabamisad mtkiced
rekomendebulia
III 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
konsesuss
Va avtoritetul
profesionalTa mosazreba
19
Vb klinikuri gamocdileba,
aRwerilobiTi kvlevebi an
eqspertTa angariSi
11. alternatiuli gaidlaini ar arsebobs
12. gamoyenebuli literatura:
1. Levene, M. Neonatal Neurology. Chp 8, pp 157-200;2000 2. Volpe, J. Neurology of the Newborn, Chapter 6. Pp. 211-369. W. B. Sauders, 1995 3. NGC STATUS: The information was veryfied by the guideline developer on April 10. 2003 4. Shah, P, Riphagen, S, Beyene, J et al. Multiorgan dysfunction in infants with post-asphyxial
hypoxic-ischemic encephalopathy. Arch Dis Child Fetal Neonatal Ed 2004; 89:F152. 5. Manual of Neonatal care; J. Cloherty, E. Eichenwald, A. Strark fifth edition, 2004 6. Clinical features, diagnosis, and treatment of neonatal encephalopathy;
Yvonne Wu, MD, MPH UpToDate performs a continuous review of over 350 journals and other resources. Updates are added as important new information is published. The literature review for version 14.2 is current through April 2006; this topic was last changed on March 31, 2006. www.uptodate.com
7. Etiology and pathogenesis of neonatal encephalopathy; Yvonne Wu, MD, MPH; www.uptodate.com UpToDate performs a continuous review of over 350 journals and other resources. Updates are added as important new information is published. The literature review for version 14.2 is current through April 2006; this topic was last changed on April 19, 2005
8. Systemic effects of perinatal asphyxia; Lisa M Adcock, MD; Ann R Stark, MD UpToDate performs a continuous review of over 350 journals and other resources. Updates are added as important new information is published. The literature review for version 14.2 is current through April 2006; this topic was last changed on April 28, 2006 www.uptodate.com
9. Hypoxic-Ischemic Encephalopathy; American Academy of Pediatrics, American Association for the History of Medicine, American Osler Society, American Pediatric Society, College of Physicians of Philadelphia, Society for Pediatric Research; www.emedicine.com; Last Updated: June 30, 2006
10. Hankins G.D.V, - et al - Neonatal Organ System Injury in Acute Birth Asphyxia Sufficient to Result in Neonatal Encephalopathy - VOL. 99, NO. 5, PART 1, 2002 The American College of Obstetricians and Gynecologists.
11. Badawi N, Kurinczuk JJ, Keogh JM, Alessandri LM, O’Sullivan F, Burton PF, et al. Antepartum risk factors for newborn encephalopathy: The Western Australian casecontrol study. BMJ 1998;317:1549 –53.
12. Casey BM, McIntire DD, Leveno KJ. The continuing value of the Apgar score for the assessment of newborn infants. N Engl J Med 2001; 344; 467-71
13. Програма Реанимации новорожденных руководство по подготовке преподователей – AIHA - 2000
14. American Heart Association in collaboration with International Liaison Committee on Resuscitation. Guidelines 2005 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Concensus on Science, Part 11, 7: Neonatal Resuscitation. Circulation 2005;112:91-9
15. Futrakul S et al - Risk Factors for Hypoxic-Ischemic Encephalopathy in Asphyxiated Newborn Infants J Med Assoc Thai Vol. 89 No. 3 2006 322-328;
20
16. Badawi N. - Antepartum risk factors for newborn encephalopathy: the Western Australian case-control study BMJ 1998;317:1549-1553
17. Volpe JJ. Hypoxic-ischemic encephalopathy: clinical aspects. In: Volpe JJ, editor. Neurology of the newborn. 3rd ed. Philadelphia: WB Saunders; 1995: 314-69.
18. Badawi N. - Antepartum risk factors for newborn encephalopathy: the Western Australian case-control study BMJ 1998;317:1549-1553
19. Nelson textbook of Pediatricas 2005 20. Perlman JM, Risser R. Can asphyxiated infants at risk for neonatal seizures be rapidly
identified by current high-risk markers? Pediatrics. 1996 Apr; 97(4): 456-62 21. Gunn A, Gunn T, de Haan H, Williams C, Gluckman P. Dramatic neuronal rescue with
prolonged selective head cooling after ischemia in fetal lambs. J Clin Invest 1997;99:248-56. 22. Laptook A, Corbett R, Sterett R, Burns DK, Tollefsbol G. Modest hypothermia provides partial
neuroprotection when used for immediate resuscitation after brain ischemia. Pediatr Res 1997;42:17-23.
23. Thoresen M, Bagenholm R, Loberg E, Apricena F. Posthypoxic cooling of neonatal rats provides protection against brain injury. Arch Dis Child Fetal Neonatal Ed 1996;74:F3-F9.
24. Bernard S, Gray T, Buist M, Jones B. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002;346:557-63.
25. Eicher D, Wagner C, Katikaneni L, Hulsey T. Moderate hypothermia in neonatal encephalopathy: efficacy outcomes. Pediatr Neurol. 2005;32:11-7.
26. Gluckman P, Wyatt J, Azzopardi D, Ballard R. Selective head cooling with mild systemic hypothermia after neonatal encephalopathy: multicentre randomised trial. Lancet 2005;365:663-70.
27. Thoresen M,.Whitelaw A. Cardiovascular changes during mild therapeutic hypothermia and rewarming in infants with hypoxic-ischemic encephalopathy. Pediatrics 2000;106:92-9.
28. Shankaran S, Laptook A, Wright L, Ehrenkranz R. Whole-body hypothermia for neonatal encephalopathy: animal observations as a basis for a randomized, controlled pilot study in term infants. Pediatrics 2002;110:377-85.
29. Coimbra C, Boris-Moller F, Drake M, Wieloch T. Diminished neuronal damage in the rat brain by late treatment with the antipyretic drug dipyrone or cooling following cerebral ischemia. Acta Neuropathol. 1996;92:447-53.
30. Основы ухода за новорожденнымми и грудное вскармливание - ВОЗб 2002 31. WHO - Managing Newborn Problems – A Guide for doctors, nurses and midwives – 2003
21
13. avtorTa jgufi
pediatrTa da neontologTa kavSiri `alternativa~
samuSao jgufi:
⇒ dimitri abelaSvili - medicinis doqtori; Tbilisis saxelmwifo
samedicino universitetis diplomis Semdgomi da uwyveti samedicino
ganaTlebis instituti, m. iaSvilis saxelobis bavSvTa centraluri
klinikuri saavadmyofos reanimaciisa da gadaudebeli daxmarebis
samsaxuris ufrosi, axalSobilTa reanimaciis ganyofilebis gamge.
pediatrTa da neontologTa kavSiri `alternativa~-s wevri;
⇒ merab maWaraSvili _ neonatologi, m.SaraSiZis samedicino centri
generaluri direqtoris moadgile neonatologiasa da pediatriaSi.
pediatrTa da neontologTa kavSiri `alternativa~-s wevri;
⇒ gela mecxvariSvili - medicinis doqtori, q. Tbilisis ss akademikos
o. RuduSauris saxelobis erovnuli samedicno centris
neonatologiis samsaxuris ufrosi;
⇒ maka mSvildaZe _ neonatologi, CaCavas sax. mean ginekologiisa da
perinatologiis instituti, saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis saministros eqsperti. pediatrTa da neontologTa
kavSiri `alternativa~-s wevri;
⇒ maia xerxeuliZe – medicinis doqtori, Tbilisis saxelmwifo
samedicino universitetis pediatriis departamentis asistent-
profesori. pediatrTa da neontologTa kavSiri `alternativa~-s
wevri;
⇒ nani yavlaSvili – medicinis doqtori, Tbilisis saxelmwifo
samedicino universitetis pediatriis departamentis asistent-
profesori. pediatrTa da neontologTa kavSiri `alternativa~-s
wevri.
eqspertebi:
⇒ irakli favleniSvili – profesori, Tbilisis saxelmwifo
samedicino universitetis diplomis Semdgomi da uwyveti samedicino
ganaTlebis institutis direqtori;
⇒ nana tatiSvili - medicinis doqtori; m. iaSvilis saxelobis bavSvTa
centraluri klinikuri saavadmyofos nevrologiuri departamentis
ufrosi;
⇒ lela woworia _ saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis saministros jandacvis departamenti;
⇒ Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis saministros jandacvis departamenti.