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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.

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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.

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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.

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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

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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.).

19

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