[faqtebze dafuZnebuli] medicina

mtkicebulebaTa done da rekomendaciebis xarisxin. raWveliSvili, i. xabazidasabuTebuli medicinis mtkicebulebebis donis da rekomendaciebis xarisxisdiferencirebisaTvis SemoRebulia gradaciaTa cxrili, romelsac gamoiyenebensamedicino literaturis damowmebis dros. gansakuTrebiT mizanSewoniliamsgavsi gradaciis gaTvaliswineba da sabolood - miTiTeba klinikuri praqtikisrekomendaciebis momzadebis procesSi.mtkicebulebaTa done da rekomendaciebis xarisximtkicebulebis siZlieris donedone Muir ( Gray)rekomendaciis xarisxi (Cookxarisxi et al)IZlieri mtkicebuleba, eyrdnobaminimum erT sistemur mimoxilvas,romelic efuZneba swori dizainismqone randomizebulkontrolirebad kvlevasAeyrdnoba I donismtkicebulebas daSesabamisad mtkicedrekomendebuliaI IZlieri mtkicebuleba, eyrdnobaminimum 1 swori dizainis mqonerandomizebul kontrolirebadkvlevasBeyrdnoba I donismtkicebulebas daSesabamisadrekomendebuliaI I Iklinikuri kvleva randomizaciisgareSe, kohortuli da SemTxvevakontroliskvlevebiCeyrdnoba III donismtkicebulebas; SeiZlebaCaiTvalos SesabamisadIVaraeqsperimentuli multicentrulikvlevebiDeyrdnoba IV da V donismtkicebulebas; saWiroebskonsensussVaavtoritetul profesionalTamosazrebaVbklinikuri gamocdileba,aRwerilobiTi kvlevebi aneqspertTa angariSi.Level of Evidence Strength and Grade of RecommendationsN. Rachvelishvili, I. KhabaziPartners for Health, NGO; M. Iashvili Children’s’ Central Hospital, TbilisiThe chart represents an adaptation of delineations of Evidence strength levels (I-V) and Grade ofRecommendations (A-D) based on those evidences. It is recommended to use the chart whilstdeveloping/adapting Clinical Practice Guidelines.4

generalizebuli SfoTviTi aSlilobaqristofer geili da mark ouqli-brauniGeneralized Anxiety DisorderChristopher Gale and Mark Oakley-BrowneClinical Evidence, BMJ Publishing Groupklinikuri mtkicebulebani2003 w. (IX gamoSveba)moamzada e. faRavamganmartebebigeneralizebuli SfoTviTi aSliloba ganimarteba, rogorc yoveldRiurimovlenebsa da problemebTan dakavSirebiT gadaWarbebuli aRelvebuloba dadaZabuloba, romelsac adgili aqvs 6 Tvis ganmavlobaSi, dReebisumravlesobisas iseT zRvramde, rom adamians aqvs distresi, an uZneldebayoveldRiuri saqmeebis gakeTeba. mas SeiZleba Semdegi simptomebi da niSnebiaxasiaTebdes: momatebuli motoruli daZabuloba (daRliloba, kankali,mousvenroba, kunTebis daZabuloba); avtonomuri hiperaqtiuloba (qoSini,aCqarebuli gulis cema, piris simSrale, civi xelebi, Tavbru); momatebulisifxizle da irgvliv yuradRebiT SeTvaliereba (devnis SegrZneba, momatebuliSekrTobis SegrZneba, koncentraciis darRveva), magram ara panikis Setevebi.epidemiologiuri da klinikuri kvlevebis erTma arasistematurma mimoxilvamSfoTviTi aSlilobebiT daavadebulebSi (generalizebuli SfoTviTi aSlilobisCaTvliT) daadgina cxovrebis xarisxisa da fsiqosocialuri funqcionirebisgamoxatuli daqveiTeba. agreTve am mimoxilviT Cans, rom generalizebuliSfoTviTi aSlilobis mqone adamianebi zogadad sakuTari cxovrebiT naklebkmayofilebi arian da garkveulad uWirT sxvadasxva rolis Sesruleba,socialuri davalebebis ganxorcieleba, an orive.avadoba / daavadebianobaerTma mimoxilvam daadgina, rom generalizebuli SfoTviTi aSlilobisdaavadebianoba zrdasrulebSi 1,5-3,0%-s Seadgens. mis Tanaxmad mozrdilebis 3-5%-s hqondaT generalizebuli SfoTviTi aSliloba Seswavlis wina wels da 4-7%-ski – rodesme cxovrebis ganmavlobaSi. erTma arasistematurma mimoxilvammimoixila aSS nacionaluri Tanmxlebi daavadebebis gamokiTxva, romelmacdaadgina, rom generalizebuli SfoTviTi aSlilobis diagnozis mqone adamianTa90%-ze mets hqondaT Tanmxlebi diagnozi – disTimia (22%), depresia (39-69%),somatizacia, sxva SfoTviTi aSlilobebi, bipolaruli aSliloba, narkomania.epidemiologiur kvlevebSi generalizebuli SfoTviTi aSlilobis diagnozisdasasmelad gamoyenebuli saSualebebis sandooba aradamakmayofilebelia. erTmaaSS kvlevam, zusti diagnostikuri kriteriumebiT (DSM-III-R), gamoTvala, romadamianTa 5%-s cxovrebis raRac periodSi generalizebuli SfoTviTi aSlilobaganuviTardebaT. depresiuli da SfoTviTi aSlilobebis mqone adamianTa axlaxanCatarebulma kohortulma kvlevam daadgina, rom 49%-s im adamianebisa, visacTavdapirvelad generalizebuli SfoTviTi aSlilobis diagnozi dausves, esdiagnozi kidev ori wlis ganmavlobaSi SeiZleboda klinikurad hqonodaT.erTi arasistematuri mimoxilvis Tanaxmad mamakacebSi generalizebuliSfoTviTi aSlilobis avadoba qalebSi am ricxvis naxevaria. Svidiepidemiologiuri kvlevis erTma arasistematurma mimoxilvam daadgina5

moxucebulebSi SfoTviTi aSlilobebis dabali sixSire. axalgazrda da ufrosimozrdilebis 20 dakvirvebiTi kvlevis sxva arasistematurma mimoxilvamdaadgina, rom stresuli davalebebis mimarT avtonomuri agznebuloba naklebiamoxucebulebSi da moxucebulebi stresul davalebebs ufro swrafad eCvevian,vidre axalgazrdebi.etiologia / risk faqtorebimosaxleobis erTma kvlevam da klinikurma kvlevam daadgina, romgeneralizebuli SfoTviTi aSliloba kavSirSia wvrili stresoruli faqtorebisricxvTan da ar aris damokidebuli demografiul faqtorebze. magram es monacemiaRiniSneboda klinikur populaciaSi sxva diagnozebis mqone adamianebSi.samoqalaqo travmis fsiqologiuri Sedegebis erTma arasistematurma mimoxilvam(5 SemTxvevis kontrolirebuli kvleva) aRmoaCina, rom oTx Tu xuT kvlevaSimoxsenebuli generalizebuli SfoTviTi aSlilobis sixSire mniSvnelovnadgaizarda sakontrolo mosaxleobasTan SedarebiT (cvlilebis siCqare 3,3, 95% CI2.0-dan 5,5-mde). krosseqciuri kvlevebis erTma sistematurma mimoxilvam daadgina,rom daSineba (Tanatolebis viqtimizacia) dakavSirebulia generalizebuliSfoTviTi aSlilobis sixSiris mniSvnelovnad momatebasTan (efeqtis zoma 0,21).SfoTviTi aSlilobebis (generalizebuli SfoTviTi aSlilobis CaTvliT)genetikuri epidemiologiuri kvlevebis erTma sistematurma mimoxilvam ipovaori saojaxo kvleva da sami tyupebze kvleva. saojaxo kvlevebma (45 indeqsuriSemTxveva, 225 pirveli rigis naTesavi) generalizebul SfoTviT aSlilobebsSoris mniSvnelovani kavSiri daadgina indeqsur SemTxvevebSi da maTi pirvelirigis naTesavebSi (OR 6,1, 95% CI 2,5-dan 14,9-mde). tyupebze kvlevebma (13 305adamiani) daadgina, rom generalizebuli SfoTviTi aSlilobis mimarTmidrekilebis Secvlis 32% (95% CI 24%-dan 39%-mde) genetikuri faqtorebiT iyoaxsnili.prognozierTma sistematurma mimoxilvam daadgina, rom generalizebuli SfoTviTiaSlilobis mqone mozrdilebis 25% srul remisiaSi iqneba 2 weliwadSi, xolo38%-s remisia 5 weliwadSi eqnebaT.raSi mdgomareobs mkurnalobis efeqturoba?savaraudod dadebiTi efeqtibuSpironirandomizebuli kontrolirebuli kvlevebis Tanaxmad buSpironiplacebosTan SedarebiT 4-9 kviris Tavze simptomebs mniSvnelovnad aumjobesebs.randomizebulma kontrolirebulma kvlevebma ver aRmoaCina buSpironisupiratesoba klinikuri simptomebis sixSiris cvlilebis mixedviT mkurnalobis6-8 kviris Tavze antidepresantebTan, diazepamTan, hidroqsizinTan Sedarebisas,magram SesaZlebelia kvlevebs ar gaaCnda klinikurad mniSvnelovani gansxvavebisdadgenis Zala.6

garkveuli antidepresantebi (imipramini, opipramoli, paroqsetini,trazodoni, venlafaqsini)erTma sistematurma mimoxilvam da oTxma randomizebulmakontrolirebulma kvlevam daadgina, rom placebosTan SedarebiTantidepresantebi (imipramini, opipramoli, paroqsetini, trazodoni,venlafaqsini) 4-8 kviris Tavze simptomebs sagrZnoblad aumjobesebs.amave dros randomizebulma kontrolirebulma kvlevebma ver daadginamniSvnelovani gansxvaveba am antidepresantebisa an - antidepresantebisa dabenzodiazepines kombinaciis, an - buSpironis gamoyenebas Soris. randomizebulikontrolirebuli kvlevebisa da dakvirvebiTi kvlevebis Tanaxmadantidepresantebi kavSirSia sedaciasTan, TavbrusTan, gulisrevasTan, dacemebTanda seqsualur disfunqciasTan.kognitiuri Terapiaorma randomizebulma kontrolirebulma kvlevam mcire sabuTi ipova imisdasamtkiceblad, rom kognitiuri qceviTi Terapia iseTi meTodebiskombinirebisas, rogoricaa mxileba-gamomJRavneba (exposure), relaqsacia dakognitiuri restruqturizacia, amcirebs SfoTvisa da depresiis gamovlinebas 4-12kviris Tavze mxolod molodinis siis kontrolsa da SfoTvis marTvisswavlebasTan SedarebiT, mxolod relaqsaciis swavlebasa Tu aradireqtiulfsiqoTerapiasTan SedarebiT. orma momdevno randomizebulmakontrolirebulma kvlevam ver daadgina simptomebs Soris 13 kvirasa da 24TveSi mniSvnelovani sxvaoba kognitiuri Terapiisa Tu gamoyenebiTi relaqsaciisdros.sargebeli da ziani daaxloebiT TanabariabenzodiazepinebierTma sistematurma mimoxilvam da erTma momdevno randomizebulmakontrolirebulma kvlevam mcire sabuTi ipova imis dasamtkiceblad, romplacebosTan SedarebiT benzodiazepinebi 2-9 kviraSi simptomebs amcirebs. Tumcarandomizebulma kontrolirebulma kvlevebma da dakvirvebiTma kvlevebmadaadgina, rom benzodiazepinebi zrdis wamalze damokidebulebis, sedaciis,industrialuri ubeduri SemTxvevebisa da sagzao-satransporto ubeduriSemTxvevebis risks.erTi arasistematuri mimoxilvis Tanaxmad benzodiazepinebs, orsulobisbolo periodSi Tu laqtaciis periodSi gamoyenebisas, SeuZliaT axalSobilebSigverdiTi efeqtebis gamowveva.erTma randomizebulma kontrolirebulma kvlevam ver daadgina SfoTvissimptomebSi mniSvnelovani sxvaoba xangrZlivi gamoyofis alprazolamis Tubromazepamis gamoyenebis dros, xolo sxva randomizebuli kontrolirebulikvlevis Tanaxmad ar iqna naxuli mniSvnelovani sxvaoba saerTo simptomebSimezaqsolamisa Tu alprazolamis gamoyenebisas. randomizebulikontrolirebuli kvlevebidan miRebuli mcire sabuTis Tanaxmad 6-8 kviraSigeneralizebuli SfoTvis simptomebSi ar aRiniSneboda mniSvnelovani sxvaobabenzodiazepinebis Tu buSpironis, abekarnilis, Tu antidepresantebisgamoyenebisas. cudi xarisxis randomizebuli kontrolirebuli kvlevebis erTmasistematurma mimoxilvam benzodiazepinebiT xangrZlivi mkurnalobisefeqturobis Sesaxeb arasakmarisi sabuTi ipova.7

kava (kava)SfoTviT, generalizebuli SfoTviTi aSlilobiT daavadebulebs SorisCatarebuli sistematuri mimoxilvis Tanaxmad placebosTan SedarebiT kava (kava)mniSvnelovnad amcirebs SfoTvis simptomebs 4 kviris Tavze. amave drosdakvirvebebi gviCvenebs, rom kava SeiZleba asocirebuli iyoshepatotoqsiurobasTan.efeqturoba ucnobiaabekarnilirandomizebulma kontrolirebulma kvlevebma urTierTsawinaaRmdegoCveneba naxa simptomebis SemcirebasTan dakavSirebiT abekarnilis efeqturobisSesaxeb placebosTan SedarebiT.antifsiqoturi wamlebierTi mcire randomizebuli kontrolirebuli kvlevidan mciredamamtkicebeli sabuTi vipoveT imis Sesaxeb, rom 4 kviraSi trifluoperaziniplacebosTan SedarebiT SfoTvas mniSvnelovnad amcirebdes, samagierod is metadiwvevda Zilianobas, eqstrapiramidul reaqciebsa da moZraobis sxva darRvevebs.β-blokatorebiβ-blokatorebis efeqturobis Sesaxeb randomizebuli kontrolirebulikvlevebi ver vnaxeT.hidroqsiziniorma randomizebulma kontrolirebulma kvlevam hidroqsizini placebos Seadara dasxvadasxva Sedegi miiRo. erTma randomizebulma kontrolirebulma kvlevam daadgina,rom daaxloebiT 1 Tvis Semdeg hidroqsizinma SfoTvis simptomebi placebosTanSedarebiT sagrZnoblad gaaumjobesa, meorem ki mkurnalobebs Soris mniSvnelovanigansxvaveba ver naxa. erTma momdevno randomizebulma kontrolirebulma kvlevammniSvnelovani gansxvaveba ver daadgina 28 dReSi hidroqsizinis buSpironTanSedarebiT efeqturobaSi. Cven ver vipoveT randomizebuli kontrolirebulikvlevebi xangrZlivi Terapiis Sesaxeb.8

posttravmuli stresuli aSlilobajonaTan bisoniPosttraumatic Stress DisorderJonathan BissonClinical Evidence, BMJ Publishing Groupklinikuri mtkicebulebani2003 w. (IX gamoSveba)moamzada e. faRavamganmartebebiposttravmul stresul aSlilobas SeiZleba adgili hqondes mniSvnelovanitravmuli movlenis Semdeg. simptomebs miekuTvneba: Semawuxebeli fiqrebi dakoSmaruli sizmrebi travmuli movlenis Sesaxeb, gancalkevebiTi qceva, zogadiureaqtiuloba, momatebuli gaRizianebadoba, Warbi sifxizle sul cota 1 TvisganmavlobaSi. mwvave stresuli aSliloba Cndeba mniSvnelovani travmulimovlenis Semdeg pirveli Tvis ganmavlobaSi da gulisxmobs simptomebisarsebobas minimum 2 dRis ganmavlobaSi. is hgavs posttravmul stresulaSlilobas, magram diagnozis dasmisTvis saWiroa ufro disocirebulisimptomebis arseboba.avadoba / daavadebianobaaSS-Si Catarebulma didma jvaredinma kvlevam daadgina, rom qalebis 10% damamakacebis 5% aqvT posttravmuli stresuli aSliloba maTi cxovrebisromeliRac periodSi.etiologia / risk faqtorebirisk faqtorebs miekuTvneba: iseTi mniSvnelovani travmuli movlena,rogoricaa gaupatiureba, fsiqiatriuli aSlilobebis anamnezi, travmis Semdegmwvave distresi da depresia, socialuri mxardaWeris nakleboba, pirovnulifaqtorebi (rogoricaa nevrotizmi).prognoziaSS-Si Catarebulma didma krosseqciurma kvlevam daadgina, rom pacientTa 1/3-ze meti kvlav Seesatyviseba posttravmuli stresuli aSlilobis kriteriumebsdiagnozidan 6 wlis Semdegac. amasTanave, krosseqciuri kvlevebi prognozisSesaxeb nakleb sabuTs gvawvdis.raSi mdgomareobs profilaqtikuri fsiqologiuri Carevisefeqturoba?savaraudod dadebiTi efeqtimwvave stresuli aSlilobis mqone pacientebis kognitiuri qceviTimravalepizodiani Terapia9

travmuli movlenis (ubeduri SemTxveva an araseqsualuri Tavdasxma) SemdegganviTarebuli mwvave stresuli aSlilobis mqone pacientebs Soris Catarebuliori mcire randomizebuli kontrolirebuli kvlevis Tanaxmad kognitiuriqceviTi Terapiis xuTi seansi mniSvnelovnad amcirebs - - mxardamWerfsiqoTerapiasTan SedarebiT posttravmuli stresuli aSlilobis mqonepacientebis ricxvs 6 Tvis Semdeg,.efeqturoba ucnobiakognitiuri qceviTi mravalepizodiani Terapia yvela im pacientis mimarT,visac raime travma gadaxda TavserTi randomizebuli kontrolirebuli kvlevis Tanaxmad, romelicCatarebuli iyo im avtobusis mZRolebs Soris, visac gasuli 5 Tvis ganmavlobaSidaesxnen Tavs, Catarebuli kognitiuri qceviTi Terapia mniSvnelovnad amcirebsSfoTvisa da Tavsmoxveuli (akviatebuli) simptomebis gamovlenas 6 Tvis SemdegCveulebriv mkurnalobasTan SedarebiT, magram mniSvnelovani sxvaoba ar iqnanaxuli depresiisa da gancalkevebis simptomebSi. sxva randomizebulmakontrolirebulma kvlevam Seadara kognitiuri qceviTi Terapiisa daCveulebrivi mkurnalobis Sedegebi im adamianebSi, vinc travma wina 5-12 TvisganmavlobaSi gadaitana, da ver daadgina mniSvnelovani gansxvavebaposttravmuli stresuli aSlilobis zogadi simptomebis gamovlenaSi 6 TvisTavze.mexsierebis mravalepizodiani restruqturizaciaerTma randomizebulma kontrolirebulma kvlevam arasakmarisi sabuTimogvawoda mxardamWer TerapiasTan SedarebiT mexsierebis restruqturizaciisSesafaseblad im adamianebSi, vinc travma bolo 24 saaTSi gadaitana.travmuli movlenis mravalepizodiani mxardaWeraorma randomizebulma kontrolirebulma kvlevam mogvawoda arasakmarisisabuTi im adamianebSi, vinc travma 1 dRidan 1 kviramde drois periodSigadaitana, kolaboraciuli mkurnalobis, romelic moicavs emociur, socialurda praqtikur mxardaWeras, Sesafaseblad.efeqturoba naklebad savaraudoaerTepizodiani fsiqologiuri Careva (“debrifingi”) yvelaSi, vinc travmagadaitanawina TveSi gadatanili travmis mqone adamianebs Soris Catarebulirandomizebuli kontrolirebuli kvlevebis Tanaxmad ar iqna naxulimniSvnelovani gansxvaveba fsiqologiuri debrifingis erT seanssa da saerToddebrifingis arCatarebas Soris 3 TveSi an 1 weliwadSi posttravmuli stresuliaSlilobis ganviTarebis sixSireze.raSi mdgomareobs mkurnalobis efeqturoba?dadebiTi efeqti10

kognitiuri qceviTi Terapiarandomizebulma kontrolirebulma kvlevebma daadgina, rom kognitiuriqceviTi Terapia sagrZnoblad amcirebs posttravmuli stresuli aSlilobissimptomebs, SfoTvasa da depresias, mkurnalobis arCatarebasa Tu mxardamWerfsiqoTerapiasTan SedarebiT.Tvalis moZraobebis desensitizacia da reprocesirebarandomizebulma kontrolirebulma kvlevebma daadgina, rom TvalismoZraobebis desensitizacia da reprocesireba simptomebs amcirebs, molodinis,siis kontrolsa da relaqsaciuri Terapiis debrifingTan SedarebiT. orirandomizebuli kontrolirebuli kvlevis Tanaxmad simptomebSi mniSvnelovanisxvaoba ar iqna naxuli Tvalebis moZraobis desensitizaciasa da reprocesingsSoris gamomJRavnebis (exposure) TerapiasTan SedarebiT.paroqsetinierTma sistematurma mimoxilvam da momdevno randomizebulmakontrolirebulma kvlevebma daadgina, rom paroqsetini, placebosTanSedarebiT, 3 TveSi simptomebs amcirebs.sertralinierTma sistematurma mimoxilvam da momdevno randomizebulmakontrolirebulma kvlevebma daadgina, rom sertralini simptomebs amcirebs 3-7TveSi placebosTan SedarebiT.savaraudod dadebiTi efeqtifluoqsetiniorma randomizebulma kontrolirebulma kvlevam daadgina, romfluoqsetins SeuZlia simptomebis Semcireba 3 TveSi placebosTan SedarebiT.efeqturoba ucnobiaafeqtis marTva, dramatuli Terapia, hipnoTerapia, stacionaruliprogramebi, sxva medikamentozuri mkurnaloba (brofaromini, amitriptilini,lamotrigini, imipramini, fenelzini, nefazodoni, karbamazepini, antifsiqozuriwamlebi, benzodiazepinebi), fsiqodinamiuri fsiqoTerapia, mxardamWerifsiqoTerapiasimptomebis gaumjobesebis mxriv am Carevebis efeqturobaze arasakmarisimtkicebulebebia moZiebuli.11

klinikuri praqtikis rekomendacia – `gaidlaini~:klinikuri praqtikis nacionaluri gaidlainis struqtura damniSvneloba saqarTvelos samedicino seqtorisaTvisz. kirtava, k. papoSvili, n. raWveliSvili, d. korZaia, x. zaldastaniSvili, i.sasania, i. xabazi, o. asaTianitermini “Guideline” sxvadasxva leqsikoniT ganimarteba, rogorc `zogadimimarTuleba~, `saxelmZRvanelo miTiTeba~, `generaluri mimarTuleba~,`direqtiva~, `rekomendacia~. samedicino literaturaSi (praqtikaSi)gansakuTrebiT xSirad gamoiyeneba termini “Clinical Practice Guidelines” da/ansxvadasxva enaSi Sesuli misi Sesabamisi neologizmebi. saqarTvelos enispalatis da samedicino kanonmdeblobis jgufis mier rekomendebul iqna ametapze Tavi Segvekavebina axali qarTuli terminis SemoRebisagan , ris gamocSevCerdiT terminze `klinikuri praqtikis rekomendaciebi~. amave dros aSkaraa,rom Tavad qarTvel specialistTa umravlesoba sul ufro amjobinebsgamoiyenos termini `klinikuri praqtikis gaidlaini~, anu mokled - `gaidlaini~,romelic Tavisi formatiT da SinaarsiT ufro miesadageba am samedicinodokumentis konkretul arss – iyos ufro metad savaldebulo, vidre `miTiTeba~an `rekomendacia~, magram amavdroulad - nakleb dogmaturi da arc iseaucilebeli – rogorc `direqtiva~.samedicino informatikis ganviTarebisa da Tanamedrove msoflio sainformacioresursebiT saqarTvelos biosamedicino seqtoris uzrunvelyofis amocanisgadaWraSi mniSvnelovani nabiji iyo 1996 wels atlanta-Tbilisis janmrTelobisTanamSromlobis programis farglebSi erovnuli sainformacio saswavlocentris daarseba. 1997 wels am centrSi amerikeli partniorebis – emorisuniversitetis janmrTelobis samecniero centris biblioTekis TanamSromlebiskarl vudvortisa da stiv futis - mier Catarda pirveli seminaridasabuTebuli medicinis (Evidence Based Medicine) da klinikuri praqtikisgaidlainebis Sesaxeb. gaidlainebis formatsa da mniSvnelobas Seexo 2000-2001ww. evrosabWos egidiT TbilisSi organizebuli ori samuSao seminarijanmrTelobis teqnologiebis Sefasebis meTodologiis Sesaxeb. es seminarebiCatarda organizacia `partniorebi janmrTelobisaTvis~ (yofili – atlanta-Tbilisis janmrTelobis TanamSromlobis programa, Tav-rea. kobalaZe)mier saqarTvelos Sromis, janmrTelobis da socialuri dacvis saministrosada evropis sabWos jandacvis komitetis (CDSP) mxardaWeriT. aqve warmodgeniliqna evrosabWos saeqsperto jgufis mier momzadebuli rekomendaciebi`saukeTeso samedicino praqtikis gaidlainebis Seqmnis meTodologia~ 1 . amaveperiodSi amerikis janmrTelobis saerTaSoriso kavSiris (AIHA) miermxardaWerili iqna ramdenime praqtikuli gaidlainis SemuSaveba pirveladijandacvis sferoSi, raSic qarTvelma specialistebmac miiRes monawileoba. 2001wlidan `Ria sazogadoeba saqarTvelos fondisa~ da zogierTi sxvasaerTaSoriso da arasamTavrobo organizaciis iniciativiT SemuSavebul iqnagaidlainebi sxvadasxva samedicino specialobaSi. am friad sasargebloiniciativas Tan axlda is kazusi, rom momzadda erTi da imave nozologiismarTvis ramdenime gaidlaini, amasTanave maTi formati da samecniero dasabuTebasakmaod gansxvavebuli iyo. arada, aRiarebulia, rom klinikuri praqtikis1 - - evropis sabWos aRniSnuli rekomendacia amJamad n. raWveliSvilis da z. kirtavas mierqarTulad iTargmna da uaxloes xanSi gamoqveyndeba.12

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 dacvissaministrosa da jandacvis marTvis nacionaluri centris specialistebis miergaxorcielda proeqti “mtkicebulebebze dafuZnebuli samedicino momsaxurebisxarisxis amaRlebisa da kontrolis mudmivganaxlebadi institucionalurisistemis modeli” (proeqtis direqtori - x. zaldastaniSvili), ris Sedegadacmomzadda dokumenti “klinikuri praqtikis nacionaluri gaidlainis” Sesaxeb,romelic ganxilul iqna proeqtis bolos Catarebul seminarze, rac seriozulnabijad unda CaiTvalos. samwuxarod, am seminaris Semdeg ver moxerxdamomavali samuSaoebis gegmis miReba, da implementaciis gagrZeleba. winamdebarestatia swored am sakiTxis xelaxla wamowevas da procesis daCqarebas isaxavsmiznad.“klinikuri praqtikis nacionaluri gaidlainis” ganmartebisaTvis Sejerdajanmo-s, amerikis jandacvis saerTaSoriso kavSiris, evropis sabWos jandacviskomitetis da aSS medicinis institutis mier mowodebuli ganmartebebi.“klinikuri praqtikis nacionaluri gaidlaini” warmoadgens konkretuliklinikuri mdgomareobis mimarT saxelmwifos politikis amsaxveli dokuments,romelSic asaxulia mocemulia samedicino daxmarebis sxvadasxva etapzedaavadebis diagnostikisa da mkurnalobis praqtikuli klinikurirekomendaciebis sruli cikli, romelic mecnierul mtkicebulebebs efuZneba.gaidlaini gamiznulia praqtikosi eqimebisaTvis, jandacvis politikisganmsazRvrelebisa da pacientebisaTvis. igi moicavs klinikuri kvlevebiTsarwmunod dadasturebul, subieqtivizmisagan Tavisufal, martivi struqturisda praqtikuli mimarTulebis mqone monacemebs. gaidlaini SeicavsmtkicebulebaTa Sesaxeb monacemebs. gadawyvetilebebis miRebis Canawers(`protokols~) SeiZleba hqondes algoriTmis saxe. Tumca klinikuri praqtikisnacionaluri gaidlaini saxelmZRvanelo unda iyos samedicinopersonalisaTvis, magram konkretuli avadmyofisa Tu mdgomareobisgaTvaliswinebiT samedicino praqtikis ganmaxorcielebeli personalisaTvisgaidlainis zusti Sesruleba ar iqneba savaldebulo.“klinikuri praqtikis nacionaluri gaidlainis” Sinaarsi:veyrdnobiT ra evrosabWos rekomendacias “gaidlainebis” SemuSavebisa dagavrcelebis Sesaxeb da amave dros viTvaliswinebT saqarTvelos jandacvisqselis maxasiaTeblebs (struqtura, materialur-teqnikuri, finansuri daadamianuri resursebi), mizanSewonilad migvaCnia erTdroulad erTi daavadebisgaidlainis sami versiis warmoeba (SemuSaveba): versia profesionalebisaTvis,mokle versia araprofesionalebisaTvis/pacientebisaTvis da reziume jandacvispolitikis ganmsazRvrelTaTvis. evrosabWo aseve iZleva profesionalTaTvisSemoklebuli – e.w. “jibis” variantis warmoebis rekomendacias. winamdebarestatiaSi Cven gadavwyvoteT im variantis struqturis warmodgena, romelicswored praqtikosi eqimebisaTvisaa gansazRvruli da romelze muSaobiTac,albaT, unda daiwyos gaidlainebis momzadeba (pacientTa versia da reziumesavaraudod ZiriTadi versiis momzadebis da miRebis Semdeg Camoyalibdeba).K13

klinikuri praqtikis nacionaluri gaidlainis sqema(versia praqtikosi eqimebisaTvis)I. daavadebis definicia, sinonimebi, klasifikacia da terminologia(saWiroebis SemTxvevaSi SeiZleba Sevides am daavadebis sxvadasxva formebisda garTulebebis definiciebic)II. epidemiologia (mokle Sejameba. amave TavSi, an VII-Si dasaSvebiaprognozic)epidemiologia saqarTvelosaTvis - sasurveliaIII. etiopaTogenezi (mokle reziume): daavadebissubstrati/paTogenezi/gamomwvevebis CamonaTvali/risk-faqtorebiIV.klinikuri simptomatika:a) simptomebis CamonaTvali;b) daavadebis tipebi, (Tu es mniSvnelovania mkurnalobis TvalsazrisiT);g) daavadebis garTulebebi – sasurvelia, roca es iwvevs mkurnalobismodificirebasV. daavadebis diagnozi:a) diagnostikuri kriteriumi – mTavari klinikuri simptomebis dainstrumentul-laboratoriuli monacemebis erToblioba, sadac esSesaZlebelia;b) diferencialuri diagnozi - [CamonaTvali]g) simZimis xarisxi – [mokled]VI. gamokvlevebis sqema (sasurvelia – specifiuri gamokvlevebisTanmimdevrobis an Catarebis drois CvenebiT, SeiZleba – algoriTmis saxiT)VII. mkurnalobis sqema (preparatis jgufis doneze, Tumca sasurveliaspecifiuri Cvenebebis – formebis/garTulebebis, ZiriTadi preparatebisdozirebis da xangrZlivobis mixedviT; aqve mizanSewonilia iqnas miTiTebuliZiriTadi gverdiTi movlenebi da mkurnalobis SezRudvebi. mkurnalobis sqemaSeiZleba 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, Tusxvadasxva gaidlainebis Sejereba)XIII. alternatiuli gaidlainis miTiTeba (Tu arsebobs da ar iqna CarTuliSejerebul gaidlainTa ricxvSi)XIV. gamoyenebuli literatura (mtkicebulebis xarisxis miTiTebiT, Tu esSesaZloa)avtorTa jgufi (redaqtori, koleqtivi, recenzentebi/eqspertebi)14

** - aRniSnuli sakiTxebi dasaSvebia ar Sevides gaidlainis Tavdapirvel versiaSi, dadaematos gaidlainis miRebis Semdeg saministrosa, dazRvevis organizaciebsa dasaavadmyofos administraciasTan ganxilvis safuZvelzeamJamad amerikis saerTaSoriso janmrTelobis kavSiris (AIHA) da USAID-ismxardaWeriT q. Tbilisis or wamyvan saavadmyofoSi – akad. RuduSauris sax.erovnul samedicino centrsa da m. iaSvilis sax. bavSvTa centralursaavadmyofoSi mimdinareobs samedicino praqtikis gaidlainebis momzadeba dadanergva, risi saboloo mizanicaa samedicino momsaxurebis dafuZnebadasabuTebuli medicinis (Evidence Based Medicine) uaxles miRwevebze, samkurnaloprocesis standartizireba da am momsaxurebis xarisxis amaRleba, amavdroulad- kontrolis gaumjobesebis meqanizmis Camoyalibeba da amoqmedeba. proeqtisganxorcielebaSi monawileobs amerikuli organizacia `partniorebisaerTaSoriso TanamSromlobisaTvis~ (PfID, xel-i - saqarTvelos sapatiomoqalaqe, prof. k. uokeri) da qarTuli organizacia `partniorebijanmrTelobisaTvis~ - orive es organizacia 1992 wlidan cnobilia atlanta-Tbilisi janmrTelobis TanamSromlobis saxeliT. am saqmianobas win uZRoda2003-2004 wlebSi Sesabamisi Teoriuli bazis da adamianuri resursis Seqmnaerovnuli sainformacio saswavlo centrisa da zemoTdasaxelebuli oripartniori saavadmyofos bazaze. Catarda specialistTa 2 gundis viziti aSS-SivaSingtonisa da atlantis dawesebulebebSi - aSS erovnuli samedicinobiblioTeka (NLM), janmrTelobis erovnuli institutebi (NIH), janmrTelobiskvlevisa da xarisxis saagento (AHRQ), samxedro samedicino universiteti(USUHS), emorisa da jorjiis Statis universitetebi, greidis, kraufordlongis, iglstonis, forsaitis, atlantis veteranTa administraciis, skotiSraitis da sxva saavadmyofoebsa da maTi xarisxis kontrolisa da gaidlainebisSemuSavebis samsaxurebSi, aseve seminarebi – TbilisSi, da saavadmyofoebisgaidlainebis SemmuSavebel samuSao jgufebTan Catarebuli 30-mde samuSaoSexvedra. Jurnalis winamdebare nomerSi SemogTavazebT dasaxelebuli qarTulamerikuliproeqtis farglebSi momzadebul gaidlainebs, romeliczemoTmoyvanil sqemas efuZneba.samedicino daxmarebis xarisxis kontroli da gaidlainebis koordinaciasaqarTveloSi arsebuli situacia, kerZod ki - erTsadaimave sakiTxze sxvadasxvagaidlaini arseboba, - sakmaod seriozul sirTuleebs warmoSobs. maTivalidurobis TvalsazrisiTac da zogjer - urTierTgamomricxavi informaciisSemcvelobis gamo. albaT gamarTlebuli iqneba, Tu zogadi praqtikiseqimebisaTvis mowodebul iqneba erTi nacionaluri gaidlaini. am SemTxvevaSiori alternativa arsebobs: - an winaswar arCeva im dawesebulebisa, sadacgaidlainebi momzaddeba, an kidev raime makoordinirebeli organos Seqmna,romelic sxvadasxva dawesebulebebisa da eqimTa koleqtivebis miermomzadebuli gaidlainebis recenzirebiT da maTTvis `nacionaluri~ standartisminiWebiT iqneba dakavebuli. vfiqrobT, es ukanaskneli midgoma ufrogamarTlebulia. saWiroa gaviTvaliswinoT sxvadasxva dadebiTi gamocdileba,romelic dagrovilia ganviTarebul qveynebSi: kerZod zemoTnaxsenebi aSS-isAgency for Health Research an Quality (AHRQ) – janmrTelobis kvlevisa da xarisxissaagentosa da didi britaneTis - National Institute of Clinical Excellence (NICE) -klinikuri srulyofilebis erovnuli institutis struqtura da muSaobismeTodologiebi. unda moxdes gaidlainebis SemuSavebisa da praqtikaSi danergviserTiani sistemis makoordinirebeli struqturis debulebis momzadeba daSemdgomSi misi Camoyalibeba, romlis mizani aseve zogadad samedicino15

daxmarebis xarisxis Sefasebisa da amaRlebis mudmivganaxlebadi procesisxelSewyoba iqneba. misi funqciebi SeiZleba Semdegi saxiT ganisazRvros 2 :• samecniero siaxleebis mopovebisa da maTi samedicino personalisaTvisxelmisawvdomobis procesis uzrunvelyofa;• saerTaSoriso standartebTan harmonizirebuli nacionaluri “gaidlainebis”SemuSavebisa da praqtikaSi danergvis uwyveti procesis organizeba;• samedicino momsaxurebis xarisxis amaRlebis mizniT prioritetebisgansazRvra, “gaidlainebis” danergvis procesis koordinirebulietapobriobisa da gegmiurobis xelis Sewyobis uzrunvelyofa;• samedicino momsaxurebis xarisxis Sefaseba (“gaidlainebis” danergvis Sedegi)_ mosaxleobaSi avadobis maCveneblis dadebiTi dinamikis an konkretuliklinikuri SemTxvevebis gamosavalis gaumjobesebis monitoringis meSveobiT.Sida da gare auditis meqanizmebis SemuSaveba;• “gaidlainebis” praqtikaSi danergvasTan dakavSirebuliiniciativebis/sakiTxebis ganxilva, mosalodneli siZneleebis prognozirebada maTi daZlevis gzebis dasaxva;• saxelmwifo da arasamTavrobo struqturebTan, msgavsi miznebissaerTaSoriso organizaciebTan da kerZo pirebTan TanamSromloba.sakoordinacio sabWos SemadgenlobaSi iqnebian jandacvis organizatorebi,ekonomistebi, gamocdili klinicistebi da jandacvis profesionalebi,samedicino da akademiuri dawesebulebebisa da profesiuli asociaciebiswarmomadgenlebi. PSemuSavebuli “gaidlainebi” danergvamde gaivlis eqspertizas. eqspertizisCatareba SeiZleba daevalos sakoordinacio sabWosTan arsebul specialurdargobrivi komisiebs an profesiul asociaciebs, risTvisac winaswargansazRvruli 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 makoordinirebeliorganos, arasamTavrobo organizaciebis da wamyvani klinikebis mier undaganxorcieldes qveynis masStabiT am sferoSi arsebuli gamocdilebis dainteleqtualuri SesaZleblobebis mobilizeba;• makoordinirebeli organo saWiroebis SemTxvevaSi qveyanaSi arsebuliresursebis moZiebis gziT xels Seuwyobs samedicino dawesebulebebSinacionaluri “gaidlainebis” danergvisas warmoqmnili SesaZlo problemebisdaZlevas. SeimuSavebsganaxorcielebs RonisZiebebs, rogoricaa dawesebulebebis materialurteqnikuribazis, kadrebis, SesaZleblobebis Seswavla, konkretul pirobebSinacionaluri “gaidlainis” adaptaciis SesaZleblobebis Sefaseba,2 - statiis avtorebis mosazreba mxolod garkveul potenciur CamonaTvals moicavs. rogorc am,iseve sxva sakiTxebTan mimarTebaSi, nebismieri alternatiuli azri, Sesworeba anda komentarimadlobiT iqneba miRebuli. saboloo sityva ki Sesabamis saministroebsa da profesiulasociaciebze iqneba.16

dawesebulebis saWiro cvlilebebis gansaxorcieleblad rekomendaciebisSemuSaveba da saWiroebis SemTxvevaSi misi gardaqmnisaTvis saWiro gzebismoZieba;• nacionaluri “gaidlainebis” danergvis mizniT Seiqmnas procesis yvelakonkretul samedicino obieqtis doneze Casatarebeli RonisZiebebis Semcveliprograma;• nacionaluri “gaidlainebis” danergvisas makoordinirebeli organos mierprocesis permanentuli da gegmiuri ganviTarebisaTvis gamoyenebuli undaiqnas saxelmwifos xelT arsebuli berketebi da motivaciebi.gaidlainebis danergvis procesis Sefaseba:sasurvelia am amocanis ganxorcieleba dawesebulebis da qveynis doneze:• unda SemuSavdes dawesebulebebSi nacionaluri “gaidlainebis” danergvisSedegebis Sefasebis erovnuli indikatorebi da Seiqmnas rekomendaciebiSida da gare auditis warmoebisaTvis;• saWiroebis SemTxvevaSi makoordinirebelma organom (rodesac dawesebulebadaxmarebisaTvis mimarTavs), mis xelT arsebuli resursebis safuZvelze undaiTanamSromlos Sesabamisad uflebamosil da gamocdil organizaciebTan an -kerZo eqspertebTan aRniSnuli samuSaoebis gansaxorcielebladnacionaluri “gaidlainebis” ganaxleba:• miTiTebul vadaSi unda moxdes nacionaluri “gaidlainebis” gadaxedva.evrosabWos rekomendacia uxSiresad mizanSewonilad miiCnevs 2-wlianperiods. ra Tqma unda gaidlainis gadaxedva ar niSnavs, rom igi aucilebladunda Seicvalos. Tu ganvlil periodSi raime mniSvnelovani siaxle ar iqnebaaRmoCenili, gaidlaini SeiZleba isev ucvleli saxiT damtkicdes, risTvisacSesabamisad dadgenili wesi unda arsebobdes.• nacionaluri “gaidlainebi” unda ganaxldes janmrTelobis teqnologiebisganviTarebis da samkurnalo saSualebebis Sesaxeb axali mtkicebebulebisgamoCenis kvaldakval.• eqspertizis Sedegebze dayrdnobiT moxdeba “gaidlainis” legalizeba;• ganaxlebuli “gaidlaini” ganTavsdeba sainformacio bankSi (repozitoriumSi);aseTi repozitoriumi SeiZleba ganTavsdes erovnuli sainformacio saswavlocentris serverze.• nacionaluri “gaidlainebis” praqtikaSi danergvis dadgenili wesisgaTvaliswinebiT Catardeba ukve danergil `gaidlainSi~ siaxleebisCanacvleba;daskvna:qveynis jandacvis seqtorisaTvis mniSvnelovania jandacvis sistemis finansuriorganizaciis da xarisxis kontrolis amocanebis umokles droSi gadawyveta,rasac ukavSirdeba mosaxleobis usafrTxoebis da avadmyofis uflebebis dacvisumniSvnelovanesi moTxovna. am amocanebis gadaWra ki mxolod TanamedrovedasabuTebul medicines faqtebze dafuZnebuli samedicino praqtikis meTodurirekomendaciebis – gaidlainebis – SemuSavebis pirobiT SeiZleba ganxorcieldes.gaidlaini, Tundac erovnuli kvalifikaciis mqone – dogmas ar warmoadgens.konkretuli eqimis, Tu samedicino dawesebulebebis mier daSvebuli unda iyossxva gaidlainis an samkurnalo midgomis gamoyeneba, oRond im pirobiT, rom maTgamoyenebas aseve safuZvlad eqneba dasabuTebuli medicinis wyaroebi da/an17

saTanado auditis SemTxvevaSi gamomyenebel pirebs SeeZlebaT daamtkicon misivaliduroba.sarekomendacio sabWos ZiriTadi roli unda iyos procesis organizacia,Sefaseba, rekomendaciebis gaweva da erovnuli gaidlainebiseqspertiza/damtkiceba.Clinical Practice Guidelines: a Structure and Importance of National ClinicalPractice Guidelines for Georgian MedicineZ. Kirtava, K. Paposhvili, N. Rachvelishvili, D. Kordzaia, Kh. Zaldastanishvili, I. Sasania, I. Khabazi, O. AsatianiThe 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 PracticeGuidelines, considering western experience of Agency for Health Research an Quality (AHRQ) of USA andNational 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 differentforms and complications of the disease may also be included in form of Glossary at the end of CPG if it isnecessary).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 clinicalsymptoms 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 andlimitations 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 thedifferent 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.).18

gulis ukmarisobis mkurnalobis klinikuri praqtikis rekomendacia(gaidlaini)k. papoSvili, k. surgulaZe, q. mdinaraZe, z. kirtava, n. raWveliSvili, n.farcxalaZe, n. ilksoiq. Tbilisis me-2 saavadmyofos kardiologiuri ganyofilebakavSiri “partniorebi janmrTelobisaTvis”,emoris universitetis samedicino skola (atlanta, jorjia).I. definicia, klasifikacia, terminologiagulis ukmarisoba warmoadgens kompleqsur klinikur sindroms, romelicperikardiumis, miokardiumis, endokardiumis an msxvili sisxlZarRvebisdaavadebiT SeiZleba iyos gamowveuli, magram ZiriTadad marcxena parkuWisfunqciis darRvevas ukavSirdeba. es ukanaskneli farTo speqtrs moicavs dameryeobs upiratesad diastoluri disfunqciidan (normaluri zomis marcxenaparkuWi normaluri dacliT, magram darRveuli avsebiTurT) upiratesadsistolur disfunqciamde (mkveTrad dilatirebuli marcxena parkuWidaqveiTebuli kumSvadobiTurT).qvemdebare rekomendaciebi marcxena parkuWis sistoluri disfunqciiTgamowveuli gulis qronikuli ukmarisobis farmakologiur mkurnalobasmoicavs. aRniSnuli disfunqciis ZiriTad niSans marcxena parkuWis gandevnisfraqciis daqveiTeba (Cveulebriv < 40%) warmoadgens. erTiani azri diastoluridisfunqciis mkurnalobis Taobaze jerjerobiT ar arsebobs.II. epidemiologiaevropaSi gulis ukmarisoba mosaxleobis 0.4-2%-s aReniSneba. misi sixSireasakTan erTad mkveTrad matulobs. gulis ukmarisobis mqone pacientTa saSualoasaki 74 welia. msubuqi simptomebis mqone pacientTa sikvdilis riski wliurad5-10% Seadgens, daavadebis mZimed mimdinareobisas ki – 30-40% aRwevs. esmonacemebi simsivnis calkeuli formebis sikvdilianobas aRemateba.III. paTofiziologiamarcxena parkuWis sistoluri disfunqcia ufro xSirad gulis iSemiuridaavadebiT aris gamowveuli, Tumca SeiZleba ganpirobebuli iyos araiSemiurimizeziTac, romlis dadgena an xerxdeba (mag. hipertenzia, Tiroiduli daavadeba,alkoholizmi, miokarditi), an - ara (mag. idiopaTiuri dilataciurikardiomiopaTia).gulis ukmarisoba SeiZleba ganikurnos spontanurad (mag. miokarditi) angamomwvevi mizezis sruli mocilebis Sedegad (mag. sarqvlovani dazianebis19

qirurgiuli koreqcia), Tumca Cveulebriv igi progresirebad daavadebaswarmoadgens.progresirebis umniSvnelovanesi faqtoria endogenuri neirohormonulisistemebis _ renin-angiotenzin-aldosteronis sistemisa da simpaTikuri nervulisistemis qronikuli aqtivacia. angiotenzin II, aldosteroni da noradrenaliniara marto zrdian parkuWis hemodinamikur datvirTvas natriumis Sekavebisa daperiferiuli vazokonstriqciis meSveobiT, aramed gulze uSualo toqsiurzemoqmedebasac axdenen. am neirohormonuli faqtorebis zemoqmedebiT gulisstruqtura da funqcia ganuxrelad uaresdeba. marcxena parkuWi mzarddilatacias ganicdis da sul ufro sferul formas iRebs. aRniSnuli procesiremodelirebis saxeliT aris cnobili.gulis es struqturuli cvlilebebi da funqciis daqveiTeba miokardiumisaxali xiluli dazianebis gareSec Rrmavdeba da sabolood pacientis daRupvasiwvevs. uecarma sikvdilma gulis ukmarisobis evolucia nebismier drosSeiZleba Sewyvitos.IV. klinikuri simptomebigulis ukmarisobis klinikur simptomebs warmoadgenen qoSini da daRla, raczRudavs datvirTvis unars. siTxis Sekaveba pulmonuri da/an periferiuliSeSupebis saxiT vlindeba. daavadebis progresirebasTan erTad klinikurisuraTi TandaTan mZimdeba da simptomebi mosvenebis an umniSvnelo datvirTvisdrosac SeiZleba gamovlindes.V. diagnozigulis ukmarisobis mqone pacientTa Sefasebisas yvelaze mniSvnelovanieqokardioskopiiT marcxena parkuWis gandevnis fraqciis gansazRvraa. igiwarmoadgens ZiriTad saSualebas, romlis meSveobiTac sistoluri disfunqciada sxva saxis gulis ukmarisoba erTmaneTisagan ganirCeva. amave dros ammeTodiT klinicists aqvs SesaZlebloba Seafasos parkuWis Rrus zoma,sarqvelebis dazianebis xarisxi, agreTve gamoavlinos regionalurikumSvadobis cvlilebebi, rac koronaruli arteriebis daavadebaze msjelobissaSualebas iZleva.VI. Ppirveladi gamokvlevis sqemayoveli pacienti, romelsac aReniSneba gulis ukmarisobis niSnebi ansimptomebi, unda gamokvleul iqnas, raTa:1) dadgindes gulis paTologiis gamomwvevi wamyvani etiologuri faqtori;2) gamovlenil iqnas gulis ukmarisobis progresirebis xelSemwyobifaqtorebiTiToeuli pacienti saWiroebs Semdeg ZiriTad gamokvlevebs:1. anamnezi da fizikuri gasinjva;2. eleqtrokardiograma (ekg);20

3. gulmkerdis rentgenograma;4. sisxlisa da Sardis saerTo analizi;5. sisxlSi eleqtrolitebis, Sardovanas, azotis, kreatininis, glukozisgansazRvra;6. RviZlis funqciuri sinjebi;7. eqokardiograma, rac aucilebelia gulis SegubebiTi ukmarisobis zustidiagnozis dasadgenad.eqokardiograma naCvenebia:- axladgamovlenili gulis ukmarisobis SemTxvevaSi;- auxsneli dekompensaciis arsebobisas;- sarqvlovani paTologiis arsebobis fonze zogadi statusis uecaricvlilebisas (gauaresebisas).8. kvlevis damatebiTi informatiuli testebia:- samkurnalo saSualebebis skriningi;- gulis enzimebis donis gansazRvra (Tu gulmkerdis areSi tkivilis anmgomareobis gauaresebis, progresirebis mizezi ucnobia);- digoqsinis donis gansazRvra;- Tiroid-mastimulirebeli hormonis (TSH) donis gansazRvra (am testisCvenebebi Semdegia: mocimcime ariTmia, monacemebi farisebri jirkvlisdaavadebis Sesaxeb, asaki > 65 w.);- natriurezuli peptidis (BNP) b tipis donis gansazRvra.- BNP warmoadgens cilas, romelic Tavisufldeba parkuWebidan moculobis anwnevis matebis sapasuxod. im pacientebSi, romelTac qoSini aReniSnebaT, BNPdonis gansazRvra SeiZleba dagvexmaros davadasturoT an gamovricxoT gulisukmarisoba, rogorc zemoTaaRniSnuli gamovlinebebis mizezi. BNP-s normalurimaCvenebeli (600) gulis qronikuli ukmarisobis dadasturebisefeqturi markeria. meore mxriv, saSualo maCveneblebi (100-500) diagnostikaSidid daxmarebas ver gagviwevs (diagnostikuri Rirebuleba dabalia). pacientebsmarcxena parkuWis disfunqciiT, romelTa BNP-s done 100-500 farglebSia,SeiZleba aReniSnebodeT qoSini, romelic ar aris gamowveuli gulisqronikuli ukmarisobiT.periodulad aucilebelia ganisazRvros :− pacientis funqciuri SesaZleblobebi,− moculobiTi statusi− sisxlis eleqtrolitebi− Tirkmelebis funqciaVII. mkurnalobamkurnalobis ZiriTadi principebigulis ukmarisobis mkurnaloba unda daiwyos nebismieri iseTi SemdegomCamoTvlili mizezebis mocilebiT, rac daavadebis progresirebas uwyobs xels,rogoricaa: iSemia, aritmia, arakontrolirebadi hipertenzia, sarqvlebisdazianebis progresireba, infeqciebi, narkomania, alkoholizmi, dietisa dasamkurnalo saSualebebis miRebis reJimis ugulebelyofa. Tu gulis21

ukmarisobis damamZimebeli faqtorebi ver iqna gamovlenili, unda moxdesfarmakoTerapiis optimizacia.gulis ukmarisobis mkurnaloba (farmakoTerapia) ori gziT SeiZlebawarimarTos. erTi mxriv, SesaZlebelia gulis kumSvadobis stimulacia dadebiTiinotropuli saSualebebis daxmarebiT, an - gulis gantvirTva periferiulivazodilatorebis meSveobiT. aRniSnuli midgomiT SeiZleba hemodinamikurisargeblisa da klinikuri gaumjobesebis swrafi miRweva, magram am wamlebisxangrZliv gamoyenebas sargebeli garantirebulad ar mosdevs da, piriqiT,SesaZloa avadobisa da sikvdilobis gazrda gamoiwvios.meore mxriv, neirohormonuli antagonistebi (age inhibitorebi, spironolaqtonida beta-blokerebi) dauyovnebliv simptomur sargebels ar iZlevian da SeiZlebadroebiT misi (mdgomareobis) gauaresebac ki gamoiwvion, magram xangrZlivimkurnalobisas aumjobeseben klinikur statuss da amcireben kardiovaskulurgarTulebebs. Sesabamisad, gulis ukmarisobis mqone pacientTa Soris avadobisada sikvdilobis riskis Semcirebis yvelaze efeqtur saSualebas warmoadgensdaavadebis ganmapirobebel faqtorebze zemoqmedeba da ara hemodinamikuriCareva.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) siTxisSekavebis adreuli dadgenis mizniT.fizikuri kondiciis (mdgomareobis) gaumjobeseba:gulis ukmarisobis mqone pacientebma ar unda SezRudon TavianTi fizikuriaqtivoba da monawileoba unda miiRon zomieri xarisxis varjiSebSi, raTaTavidan aicilon an ukuaqcion fizikuri ganviTarebis maCveneblebis daqveiTeba.antikoagulaciuri Terpia gulis SegubebiTi ukmarisobis dros:miuxedavad imisa, rom mxardamWeri mtkicebulebebi arasakmarisia, zogierTieqimi yvela im pacients utarebs antikoagulacias, romelTac marcxena parkuWisgandevnis fraqciis gamoxatuli daqveiTeba da/an dilataciuri kardiomiopaTiaaReniSnebaT.antikoagulacia varfariniT yvelze ufro gamarTlebulia pacientebSi,romelTac anamnezSi aReniSnebodaT:1. paroqsizmuli an qronikuli mocimcime ariTmia (winagulTa fibrilacia);2. Tromboemboliuri garTuleba;3. identificirebuli gulSida Trombi.22

calkeuli pacientebisaTvis rekomendebulia:(1) parkuWovani riTmis kontroli - winagulovani fibrilaciis an sxvasupraventrikuluri taqikardiis mqone pacientebisaTvis.(2) antikoagulacia - winagulovani fibrilaciis (mocimcime aritmiis) ananamnezSi emboliuri epizodis mqone pacientebisaTvis.(3) koronaruli revaskularizacia - stenokardiis mqone pacientebisaTvis.calkeuli farmakologiuri jgufebi:SardmdenebiSardmdenebi unda daeniSnos gulis ukmarisobis mqone yvela pacients, visacsiTxis Sekaveba aReniSneba. Tanmxlebi arteriuli hipertenziis dros,xangrZlivi moqmedebis gamo, umjobesia Tiaziduri Sardmdenis(hidroqloroTiazidi) daniSvna. danarCeni pacientebisaTvis, gansakuTrebiTTirkmlis ukmarisobisa da siTxis gamoxatuli Sekavebis dros, upiratesobamaryuJovan Sardmdenebs eniWebaT. mkurnaloba Cveulebriv dabali doziT iwyeba(mag. furosemidi 20-40 mg/dR). doza TandaTan izrdeba, sanam Sardis gamoyofa armoimatebs an sxeulis wona ar daiklebs (saSualod 0.5-1.0 kg/dR). mkurnalobismizans warmoadgens siTxis Sekavebis simptomebisa da niSnebis moxsna, racsauRle venaTa wnevis normalizaciiTa da periferiuli SeSupebis gaqrobiTfasdeba. Sardmdenis SemanarCunebeli doza ise unda SevarCioT, rom siTxisxelaxali Sekaveba Tavidan agvacilos. amis yvelaze efeqtur saSualebassxeulis wonis yoveldRiuri gansazRvra warmoadgens. wonis momatebis andaklebisas Sardmdenis dozis saTanado koreqcia unda moxdes.gulis ukmarisobis progresirebasTan erTad saWiro xdeba Sardmdenis dozisgazrda. Tu furosemidis dRiuri doza 80 mg-s aRemateba, umjobesi iqneba misidayofa da 2-3 jerze micema. SardmdenTa rezistentobis gadasalaxavad agreTvegamoiyeneba:1. SardmdenTa intravenuri Seyvana (mag. furosemidi 40-80 mg 2-3_jerdRiurad).2. Tu aRiniSneba adeqvaturi pasuxi furosemidze, magram kvlav saxezeamoculobiTi gadatvirTva, unda gaizardos Seyvanis sixSire;3. Tu furosemidze pasuxi araadeqvaturia, gamoviyenoT maryuJovani daTiaziduri Sardmdenebis kombinacia (mag. hidroqloroTiazidis 25 mg-ismicema furosemidis miRebamde 30 wuTiT adre).4. Tu moculobiTi gadatvirTva kvlavac saxezea, magram pacients hipotenziaaReniSneba, Tirkmlis perfuziis gaumjobesebis mizniT naCvenebia dadebiTiinotropuli saSualebebis xanmokle intravenuli Seyvana (dopamini 2-4mkg/kg/wT an dobutamini 2-5 mkg/kg/wT).did yuradRebas saWiroebs eleqtrolituri balansis SenarCuneba,gansakuTrebiT SardmdenTa maRali dozisa da/an maTi kombinirebuli gamoyenebisdros. angiotenzin-gardamqmneli enzimis (age) inhibitorisa da/an kaliumisdamzogvel saSualebasTan (mag. spironolaqtoni) erTad furosemidiskombinirebuli gamoyeneba pacientTa umravlesobas eleqtrolitur disbalanss23

Tavidan aacilebs. SardmdenTa gadaWarbebul gamoyenebas SeiZleba hipotenzia daazotemia mohyves. Tu pacients siTxis Sekaveba ar aReniSneba, es garTulebebihipovolemiiT unda iyos gamowveuli da Sardmdenis doza Semcirebas saWiroebs.siTxis Sekavebis fonze ganviTarebuli hipotenzia da azotemia gulisukmarisobis gauaresebasa da efeqturi periferiuli perfuziis daqveiTebasasaxavs. aseT dros unda vecadoT SevinarCunoT Sardmdenis doza dagavaumjobesoT organoTa perfuzia dadebiTi inotropuli saSualebebis anvazodilatorebis xanmokle gamoyenebis meSveobiT.age inhibitorebiage inhibitorebi aumjobeseben simptomebsa da klinikur statuss da amcirebensikvdilisa da hospitalizaciis risks gulis msubuqi, zomieri da mZimeukmarisobis dros. es sargebeli gulis iSemiuri daavadebis arsebobasa anararsebobaze damokidebuli ar aris. Sesabamisad, age inhibitori undadaeniSnos gulis ukmarisobis mqone yvela pacients, visac ar aReniSneba misigamoyenebis ukuCveneba (mag. angioedema, orsuloba, Tirkmlis arteriisbilateraluri stenozi an Tirkmelebis mZime ukmarisoba - anuria) an -mkurnalobis autanloba. age inhibitori frTxilad unda gamoviyenoT, TuaRiniSneba:(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 moqmedebaski aZlierebs siTxis dakargva, amitom age inhibitoris daniSvnamde SardmdenTaoptimaluri doza unda iqnas SerCeuli. mkurnaloba dabali doziT iwyeba (mag.kaptoprili 6.25 mg samjer dRiurad an enalaprili 2.5 mg orjer dRiurad). Tupacienti dozas kargad itans, xdeba misi gaormageba 3-7 dRiani intervaliT.Tuki uaryofiTi moqmedeba xels ar SegviSlis, doza samizne dozis miRwevamdeunda gaizardos (kaptoprili 150 mg/dR da enalaprili 20 mg/dR).age inhibitorebis uaryofiTi moqmedeba mkurnalobis dawyebisTanave SeiZlebagamovlindes, magram maT xangrZliv gamoyenebas Cveulebriv xels ar uSlis. esuaryofiTi moqmedeba SeiZleba ukavSirdebodes bradikininis dagrovebas (xvelada angioedema) an angiotenzinis daTrgunvas (hipotenzia, Tirkmlis funqciisgauareseba da hiperkalemia). aucilebelia xvelis sxva mizezebis (gansakuTrebiTfiltvebis Segubebis) gamoricxva. Tu pacienti age inhibitors ver iRebs xvelisan angioedemis gamo, umjobesia angiotenzinis receptorTa blokeri gamoviyenoT.hipotenzia da azotemia SeiZleba SevamsubuqoT SardmdenTa dozis SemcirebiTada marilis liberalizaciiT, Tuki pacients siTxis gamoxatuli Sekaveba araReniSneba. roca hipotenzia, azotemia da hiperkalemia xels uSlis ageinhibitoris xmarebas, SesaZlebelia izosorbid-dinitratisa da hidralaziniskombinaciis daniSvna.age inhibitoris klinikuri efeqti SeiZleba ramdenime Tvis Semdeg gamovlindes.Tu pacientis mdgomareoba ar umjobesdeba, age inhibitoris miReba mainc24

ganusazRvreli vadiT unda gagrZeldes sikvdilisa da ganmeorebiTihospitalizaciis riskis Semcirebis mizniT.age inhibitorisa da aldosteronis antagonistis (spironolaqtoni) kombinaciarenin-angiotenzin-aldosteronis sistemis ufro srulyofil daTrgunvas iwvevs.gulis mZime ukmarisobis mqone pacientebisaTvis spironolaqtonis 25 mg/dRdamateba avadobisa da sikvdilobis Semcirebas axdens.angiotenzinis receptorebis blokerebi (arb)sadReisod ar moipoveba damajerebeli mtkicebulebebi gulis ukmarisobismkurnalobaSi angiotenzinis receptorebis blokerebis upiratesobis SesaxebageAinhibitorebTan SedarebiT. amitom age inhibitorebi kvlavac rCeba arCevispreparatebad im pacientebSi, romlebic maT kargad itanen. arb ki mxolod imSemTxvevaSi iniSneba, Tu pacients age inhibitorebis mimarT autanlobaaReniSneba (Seupovari xvela). arb miRebam SeiZleba gamoiwvios Tirkmelebisdisfunqcia (funqciis gauareseba), hiperkaliemia da angioedema (kvinkes SeSupeba).hidralazini/nitratebihidralazin/nitratiT kombinirebuli Terapiis Sedegad gamovlinda, rom isiniamcireben sikvdilobas, ganapirobeben gulis ukmarisobis funqciuri klasisgaumjobesebas digoqsinTan da diuretikebTan SedarebiT. Tumca sikvdilobisSemcirebis mxriv es mkurnaloba age inhibitorebTan SedarebiT ufro mciresargebelTanaa 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/anangiotenzinis receptorebis blokerebis maqsimaluri dozirebis fonze.beta-blokerebiiseve rogorc age inhibitorebi, beta-blokerebi aumjobeseben simptomebsa daklinikur statuss da amcireben sikvdilisa da hospitalizaciis risks gulismsubuqi, zomieri da mZime ukmarisobis dros. am gaumjobesebas Tan axlavsmarcxena parkuWis gandevnis fraqciis mniSvnelovani momateba. es sargebeligulis iSemiuri daavadebis arsebobasa an ararsebobaze damokidebuli ar aris.beta-blokerebis efeqturoba dadasturebuli iqna im pacientebisaTvis, vinc ukveiRebda age inhibitors, rac adasturebs mosazrebas ori neirohormonulisistemis kombinirebuli daTrgunvis aditiuri moqmedebis Sesaxeb. Sesabamisad,beta-blokeri unda daeniSnos gulis ukmarisobis mqone yvela pacients, visac araReniSneba misi gamoyenebis ukuCveneba (mag. bronqospazmi, simptomuribradikardia an gulis maRali xarisxis blokada) an mkurnalobis autanloba.amave dros, beta-blokeri ar SeiZleba mivceT gulis dekompensirebuliSegubebiTi ukmarisobis mqone pacientebs, visac siTxis gamoxatuli SekavebaaReniSnebaT da intensiur diurezs moiTxoven an intravenuli inotropulimkurnaloba esaWiroebaT. aseT dros jer klinikuri stabiluroba unda iqnasmiRweuli da beta-blokeri mere unda davniSnoT.25

mkurnaloba dabali doziT iwyeba (karvediloli 3.125 mg orjer dRiurad,metoprololi 6.25 mg orjer dRiurad an bisoprololi 1.25 mg dRiurad). Tupacienti dozas kargad itans, xdeba misi gaormageba orkviriani intervaliT.Tuki uaryofiTi moqmedeba xels ar SegviSlis, doza samizne dozis miRwevamdeunda gaizardos (karvediloli 50-100 mg/dR, metoprololi 200 mg/dR dabisoprololi 10 mg/dR).beta-blokerebis gamoyenebasM sami saxis uaryofiTi efeqti SeiZleba mohyves:(1) hipotenzia, romelic vazodilataciiT SeiZleba iyos gamowveuli, Tumcaufro xSirad droebiT xasiaTs atarebs. misi ganviTarebis riskinaklebi iqneba, Tuki beta-blokers, age inhibitorsa da vazodilators(Tu ixmareba) drois garkveuli intervaliT davuniSnavT. ageinhibitorisa da vazodilatoris doza droebiT SeiZleba SevamciroTkidec.(2) beta-blokeriT mkurnalobis dawyebas siTxis Sekaveba da gulisukmarisobis gauareseba SeiZleba mohyves. am garTulebas pacientisyoveldRiuri awonva agvacilebs. wonis momatebis sapasuxod Sardmdenisdoza unda gaizardos, sanam pacientis wona sawyis maCvenebels ardaubrundeba.(3) beta-blokeris dozis gazrdas bradikardiisa da gulis blokadisriski axlavs. Tu guliscemis sixSire wuTSi 50-ze qvemoT Camova andameore an mesame xarisxis bloki ganviTardeba, beta-blokeris doza undaSevamciroT, an igi unda moixsnas.beta-blokeris klinikuri efeqti SeiZleba ramdenime Tvis Semdeg gamovlindes.Tu pacientis mdgomareoba ar umjobesdeba, beta-blokeris miReba maincganusazRvreli vadiT unda gagrZeldes sikvdilisa da hospitalizaciis riskisSemcirebis mizniT.digoqsinidigoqsini aumjobesebs simptomebsa da klinikur statuss, da Sesabamisadamcirebs hospitalizaciis risks gulis ukmarisobis dros, magram ar moqmedebssikvdilobaze. amis gamo, aucilebeli ar aris digoqsini gulis ukmarisobismqone yvela pacients daeniSnos. gamarTlebuli iqneba misi micema impacientebisaTvis, romlebic iReben sikvdilisa da hospitalizaciis riskisSemamcirebel saSualebebs (age inhibitori da beta-blokeri) da maincaReniSnebaT gulis ukmarisobis simptomebi. digoqsinis dRiuri dozaa 0.25 mg. 70welze ufro xnier an Tirkmlis disfunqciis mqone pacientebs SeiZleba 0.125mg/dR mivceT. maRali doza (0.375-0.5 mg/dR) SeiZleba winagulovani fibrilaciisdros gamoviyenoT, magram sinusuri riTmis dros misi xmareba gamarTlebuli araris.spironolaqtoni26

spironolaqtoni, - age inhibitorebTan, beta-blokerebTan, markuJovandiuretikebTan kombinaciis SemTxvevaSi, - amcirebs sikvdilobasa da avadobaspacientebSi gulis mZime ukmarisobiT (NYHA-s III-IV klasi). rekomendirebulidRiuri doza 25 mg-ia. Tirkmelebis funqcia da kaliumis donis monitoringiunda ganxorcieldes mkurnalobis dawyebidan pirveli 2-3 kviris ganmavlobaSida periodulad SemdgomSic. spironolaqtoni ar iniSneba, Tu kaliumisSemcveloba SratSi >5.0 meq/lLan Sratis kreatinini > 2.5 mg/l.kalciumis arxis blokerebikalciumis arxis blokerebis umravlesoba ar unda dainiSnos sistoluridisfunqciis dros maTi uaryofiTi inotropuli efeqtis gamo. gamonaklissamlodipini warmoadgens. miuxedavad imisa, rom amlodipiniT mkurnaloba araxdens gavlenas sikvdilobisa da kardiovaskularuli paTologiis gamohospitalizaciis kombinirebul riskze, igi SeiZleba davniSnoT ageinhibitorebiT, beta-blokerebiTa da diuretikebiT kombinirebulimkurnalobisas, im SemTxvevaSi, Tu arteriuli wnevis damatebiTi kontroliaucilebelia.VIII. rebilitacia/meTvalyureoba:Sejerebuli monacemebis moZieba ver moxerxda, Tumca specialistebi gvirCeven:1. xeli SevuwyoT (wavaxalisoT) fizikuri aqtivoba, datvirTvazeindividualuri tolerantobis (amtanobis) gaTvaliswinebiT;2. gansakuTrebuli yuradReba gavamaxviloT dietisa da farmakologiurimkurnalobis Sesabamisobaze;3. CautaroT pacientebs konsultaciebi narkotikuli damokidebulebisa daTambaqos mowevis mavneobis Sesaxeb;4. SeviswavloT pacientebis saganmanaTleblo literatura da SevafasoTdaavadebis arsis Secnoba;5. CavataroT zogadi Terapevtis, dietologisa da klinikurifarmakologis konsultacia;6. CavutaroT pacientebs pnevmoniisa da gripis sawinaaRmdego imunizacia;7. uzrunvelyoT yovel 5-10 dReSi pacientis meTvalyureoba ubnisTerapevtis mierIX. gaidlainis gadasinjvisa da ganaxlebis vada:gaidlainis gadasinjvis vada 2 wels Seadgens.X. gaidlainis miRebis xerxi/wyaro:gaidlaini yvela saerToevropuli da amerikuli gaidlainis Sejerebis gziTaris miRebuli.27

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 byleft 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. JAm 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. JAMA2002;287:628-40.7. Maisel AS, Krishaswamy P, Nowak RM, et al. Rapid measurement of B-type natriuretic peptide inthe 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 dinitratein 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 failureexacerbations. 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 inpatients 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 severechronic heart failure. Prospective Randomized Amlodipine Survival Evaluation (PRAISE) StudyGroup. N Engl J Med 1996; 335:1107-14.13. Baker DW, Wright RF. Management of heart failure IV. Anticoagulation for patients with heartfailure 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 combinationin 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 inpatients with symptomatic heart failure: randomised trial. ELITE II. Lancet 2000;355:1582-7.avtorTa jgufi:1. k. papoSvili, janmrTelobis da socialuri dacvis erovnuliinstitutis direqtori2. k. surgulaZe – qalaqis me-2 saavadmyofos kardiologi3. q. mdinaraZe – erovnuli sainformacio saswavlo centris asistentirecenzentebi:• m.m.k. z. kirtava – erovnuli sainformacio saswavlo centrisdireqtori, kavSiri `partniorebi janmrTelobisaTvis~Tavmjdomare, Tbilisis sax. samedicino universitetis SinagansneulebaTa #1 kaTedris asistenti• m.m.k. n. raWveliSvili, Tbilisis sax. samedicino universitetisSinagan sneulebaTa #1 kaTedris asistenti, kavSiri `partniorebijanmrTelobisaTvis~ gamgeobis wevri• n. farcxalaZe, kavSiri `partniorebi janmrTelobisaTvis~Tavmjdomaris moadgile• n. ilksoi, emoris universitetis samedicino skola, SinagansneulebaTa kaTedra28

Clinical Practice Guideline – Management of Heart FailureThe group of authors:K. Paposhvili – deputy director of National Information Learning Centre, Head of Cardiology Research,City Hospital #7,K. Surguladze – cardiologist, City Hospital #7K. Mdinaradze – cardiologist, City Hospital #7Reviewers/editors1. Z. Kirtava, MD, PhD – director of National Information Learning Centre, the chairman of“Partners for Health” NGO, member of editorial board of BMJ2. N. Rachvelishvili, MD, PhD – assistant of Department of Internal Diseases #1 of Tbilisi StateMedical University, Board member of “Partners for Health”,3. N. Phartskhaladze, MD, MPH, “Partners for Health” NGO4. N. Ilksoy, MD. Dept. of Medicine, Emory University. Atlanta GAHeart Failure Treatment - Clinical Practice GuidelineK. Paposhvili, K. Surguladze, K. Mdinaradze, N. Rachvelishvili, N. Partskhaladze, N. IlksoiCity Hospital #2 Cardiology Dept, Partners for Health NGO, Emory University School of Medicine/ Partners for International Development, Atlanta, GA, USAan article provides a CPG on Heart Failure treatment, based on Consensus recommendations for themanagement of chronic heart failure and on different most recent European and American guidelines ofthis most important pathology among cardiovascular disorders.29

mwvave diareis mkurnaloba2 Tvidan 5 wlamde asakis bavSvebSii. xabazi, j. yifiani, n. raWveliSvili, z. kirtava , s. lenskim. iaSvilis sax. bavSvTa centraluri saavadmyofo, kavSiri “partniorebijanmrTelobisaTvis”, Tbilisi, saqarTvelo; emoris universitetis samedicinoskola/`partniorebi saerTaSoriso ganviTarebisaTvis~ (atlanta, jorjia, aSS)I. definicia:diarea aris nawlavTa moqmedebis cvlileba, romlis drosac saxezea defekaciaCveulze ufro gaxSirebuli da/an Txeli konsistenciis ganavliT;mwvaved iTvleba diarea, romlis xangrZlivoba ≤7 dReze.diarea (RebinebiT an Rebinebis gareSe) xSiri problemaa da Seadgensgadaudebeli daxmarebis ganyofilebaSi pediatriul avadmyofTa mimarTvis 16%-s.pacienti saWiroebs klinikur Sefasebas, gamokvlevebs hospitalizaciasa damkurnalobas. Semosvlisas erTnairi simZimis daavadebis mqone bavSvTa marTvaxSirad gansxvavebulad mimdinareobs. axalgazrda eqimebs, romlebic naxulobensawyis etapze aseT avadmyofTa udides nawils, uxdebaT mniSvnelovanigadawyvetilebebis miReba. rekomendaciis mTavari mizania gauadvilos eqimebsgadaudebeli daxmarebis saWiroebis SemTxvevaSi swrafi da adeqvaturigadawyvetilebebis miRebis procesi da moxdes analogiuri klinikuriproblemebis 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 Semdgomimdgomareobis dros:• gamoxatulia toqsikozi da/an saWiroebs reanimaciaSi mkurnalobas.• diarea 7 dReze meti xangrZlivobiT.• dadasturebuli daavadeba, romelsac axlavs imunodeficiti an ZiriTadorganoTa sistemebis dazianeba• Rebineba diareis gareSe.• diarea, romelsac axlavs zrda-ganviTarebaSi CamorCena.• diarea da/an Rebineba metaboluri daavadebis dros.• dadasturebuli hiper- an hiponatremiuli dehidratacia.30

II. epidemiologiamwvave gastroenteriti axalSobilebsa da bavSvebSi warmoadgens erT-erTyvelaze farTod gavrcelebul daavadebas mTel msoflioSi. aSS-Siyovelwliurad mw. diareis mizeziT saavadmyofos mimarTavs daaxloebiT 1,5 mln.avadmyofi, aqedan 200 000 Tavsdeba stacionarSi, da wliurad saSualod 300-mdeletaluri SemTxveva aRiniSneba.did britaneTSi yovelwliurad 6-dan 1 bavSvi diareis epizodis gamo mimarTavszogadi praqtikis eqims. diarea RebinebiT an Rebinebis gareSe Seadgensgadaudebeli daxmarebis ganyofilebaSi pediatriul avadmyofTa mimarTvis 16%-s.gastroenteritis sixSire mniSvnelovnad maRalia socialurad daucvelifenebSi (Burkhart DM 1999 [A]).III. etiopaTogenezietiologia evropisa da amerikis ganviTarebul qveynebSi diareaTa 70-80%virusuli (umeteswilad rotavirusuli) etiologiisaa. sxvadasxva baqteriuligenezis diarea SemTxvevaTa 10-20% gvxvdeba, parazituli - 10%-Si. (ix. cxrili 1)infeqciuri enteritis gamomwvevi etiologiuri agentebicxrili 1virusebi baqteriebi parazitebiRotavirus*Enteric AdenovirusNorwalk VirusCalicivirusAstrovirusParvovirusSalmonella*Shigella**Campylobacter jejuniYersiniaEnterocolitica(ufro xSiriaevropasa dakanadaSi)Enterohemorrhagic E.coliClostridium difficile(iatrogenuli)Giardia Lamblia*Entamoeba histolyticaCryptosporidium*yvelaze xSiri kategoriaSipaTogenezidiarea SesaZlebelia ganisazRvros, rogorc fekaluri siTxis Warbi (normazemeti moculobiT) eqskrecia, Sesabamisad diareis mizezi SeiZleba gaxdes kuWnawlavistraqtSi wylis sekreciis gaZliereba, absorbciis Semcireba an orivemaTganis kombinacia. radgan wylis gadaadgileba xdeba osmosuri gradientismixedviT da damokidebulia xsnadi nivTierebebis koncentraciaze nawlavissanaTurSi, paTogenezis safuZvlad SeiZleba miviCnioT xsnadi nivTierebebisabsorbciisa da sekreciis darRveva.sekreciis gaZlierebadiareis xSiri mizezs warmoadgens eleqtrolitebis gaZlierebuli sekrecia, amdros SeiZleba sakvebi elementebis (rogorc eleqtrolitebis, ise -araeleqtrolitebis) Sewovis funqcia intaqturi iyos. iseTi nivTierebebi,rogoricaa baqteriuli endotoqsinebi, gastrointestinuri hormonebi, iwvevenqloridebis aqtiuri sekreciis stimulacias.31

aqedan gamomdinare, endotoqsiniT gamowveuli diareis dros rehidrataciismizniT glukozo-eleqtrolituri xsnarebis gamoyeneba SesaZlebeli daefeqturia.absorbciis daqveiTebaxsnadi nivTierebebis absorbciis daqveiTeba zrdis nawlavis sanaTurSi osmosurwnevas da Sesabamisad wylis sekrecias. osmosur diareas adgili aqvs iseTixsnarebis per os miRebisas, romlebic cudad Seiwovebian nawlavis sanaTurSi(laqtuloza, sorbitoli). naxSirwylebis malabsorbciasTan asocirebuliosmosuri diareis simZimis prognozireba per os miRebuli naxSirwylebisraodenobis mixedviT naklebad prognozirebadia, ramdenadac naxirwylebisbaqteriuli fermentaciis Sedegad kolinjSi warmoiqmneba moklejaWvianicximovani mJavebi, romlebic aZliereben natriumisa da wylis Sewovas daakompensireben wvril nawlavSi ganxorcielebul siTxeebisa daeleqtrolitebis danakargs.wvrili nawlavis lorwovanis difuzuri dazianeba iwvevs yvela nivTierebisaraspecifiur malabsorbcias. wvrili nawlavis generalizebuli dazianebismagaliTia virusuli gastroenteriti. marTalia aseT SemTxvevebSi bavSvebisumravlesobas umcirdeba wvrili nawlavis Semwovi funqcia msxvil nawlavSiyovelTvis rCeba sakmarisi absorbciuli rezervi standartuli sarehidratacioprogramis efeqturad ganxorcielebisaTvisSesabamisad diareis paTogenezidan gamomdinare baqteriuli da virusuligastroenteritebis dros glukoza-eleqtrolituri xsnarebi warmoadgensefeqtur sarehidratacio saSualebas.IV. klinikuri simptomatikadehidratacia diareasTan asocirebuli yvelaze mniSvnelovani simptomia,romlis marTvazec aris ZiriTadad fokusirebuli mocemuli rekomendacia.Tanmxleb simptomebs ganekuTvneba gulisreva, Rebineba, sicxe da muclistkivili.dehidrataciis xarisxis Sefaseba; ix. cxrili 2• dehidrataciis xarisxi yvelaze ukeT fasdeba sxeulis saerTo wonasTanwonis kargvis procentuli mimarTebiT (dehidrataciis epizodamdearsebuli parametris gaTvaliswinebiT);• klinikurad Zneli dasafiqsirebelia sxeulis wonis 3-5% kargva;• rehidrataciis Sedegad wonis mateba xSirad aris arsebuli dehidrataciisxarisxis Sefasebis erTaderTi gza;• dehidrataciis arapirdapir niSnebad miCneuli parametrebis specifiurobada mgrZnobeloba (sensitiuroba) naklebia; aRniSnul parametrTagansaukeTesod iTvleba lorwovani garsebis simSrale, kapilaruli avsebisdro, cremlis gamoyofis intensivoba da mentaluri statusi;• am cxrilis ZiriTadi nawilis nebismieri 3 parametri gansazRvravs 5%-zemet dehidratacias 87% mgrZnobelobiTa (sensitiurobiT) da 82%specifiurobiT (Duggan 1992[C], Gorelick 1997[C]);cxrili 2dehidrataciis xarisxis Sefseba fizikaluri monacemebis mixedviT32

ZiriTadiparametri msubuqi 9%lorwovanigarsebikidurebiodnav mSrali mSrali mSraliTbili,kapilaruliavseba kargidagvianebulikapilaruli avseba> 3wmcremldena norma Semcirebuli ar arisnormaluridanmentalurinormaapaTiurobamdestatusi(ganurCeveli)aWrelebuli,kapilaruli avseba >5wmnormaluridan komamdesisxliswnevanorma norma norma/Semcirebulipulsis`xarisxi”norma norma/Semcirebuli Semcirebuliguliscemismomatebuli annormamomatebulisixSireSemcirebuliturgori norma Semcirebuli Semcirebuliyiflibandi(CvilebSi)norma Cavardnili CavardniliTvalebi norma Cacvenili Rrmad CacveniliSardis mciredgamoyofa Semcirebuli

mwvave diarea (RebinebiT an Rebinebis gareSe) 2Tve -- 5w. bavSvebSidiagnostikisa da marTvis algoriTmidasasrulidasawyisitriaJi(satelefono)mkurnalobabinaze?araara• oraluri rehidrataciuli xsnari(ORS), xSiri kveba mcire ulufebiT• Rebinebis SemTxvevaSi - damatebiT10 ml/kg ORS (an sxva siTxe) yvelaRebinebaze da defekaciaze.• Tu dakarguli siTxis moculobaaRemateba miRebuli siTxis raodenobas_ ganmeorebiTi konsultacia.mdgradigaumjobesebaLDgaumjobesebaaramkurnalobabinaze?araER an pediatris konsultaciaawonva, Sedareba normasTanda sawyis wonasTan (TuSesaZlebelia)dehidrataciis Sefasebaaradehidratacia>5%dehidratacia>9%mZime rehidrataciis mkurnalobasviwyebT gadaudebeli daxmarebisganyofilebaSihipovolemiuri Sokismkurnalobis sqemiT (protokoliT)aramomzadebagasawerad,darigeba, SemdgomidakvirvebisorganizebawonaSi namatiaris?gadaudebelidaxmarebisganyofilebaSiERORS, xSirikveba mcireulufebiT,RebinebisSemTxvevaSidamatebiT 10ml/kg ORS (ansxva siTxe)yvelaRebinebaze dadefekaciazeinarCunebssakvebsaraara30-60 ml ORS yovel 15 wT-Si - 4sT (mizani 50 ml/kg);damatebiT 10 ml ORS (an sxva siTxe) yvela Rebinebaze dakuWis moqmedebazei/v rehidratacia Tu siTxis Svvseba ar xerxdeba dagrZeldeba peroraluri kargva.vTavazobT sakvebs, maSinve, rogorc ki bavSviadeqvaturad hidratirebulia da inarCunebs sakvebsSemdegiparametrebisSefaseba:cremldena,kapilaruliavseba,lorwovanigarsebissisvele,cnobierebaawonva34

V. diferenciuli diagnozi:sarwmuno monacemebi imis Sesaxeb, Tu saavadmyofoebSi diareis mizeziThospitalizebul bavSvebs SemdegSi ra sixSiriT uviTardebaT sxvadasxvadaavadeba, ar aris gamoqveynebuli. warmodgenili cxrili diferenciulidiagnozisaTvis (cxrili 3), romelic efuZneba gamoqveynebul monacemebsa(Vb, D) da konsensuss, marTalia, ar aris srulyofili, magram warmoadgensgarkveul “samaxsovros” (aide memoir) klinicistebisaTvis (eyrdnoba VbsiZlieris mtkicebulebasa da delfis konsensuss, rekomendaciis xarisxi D).aucilebelia klinicistma droulad moaxdinos diareiT mimdinare iseTisicocxlisaTvis saSiSi mdgomareobebis amocnoba, rogoricaa: mwvave muceli(Vb, D, Tiaqris CaWedva (Vb, D), hemolizur uremiuli sindromi (III, C). amSemTxvevebisaTvis damaxasiaTebeli simptomebi gvxvdeba mwvavegastroenteritis drosac, amitom diferenciuli diagnozis gatarebagansakuTrebul sifrTxiles saWiroebs.cxrili 3 - mwvave diareis diferenciuli diagnozis mTavari obieqtebikategoriamagaliTiinfeqcia enteruli: virusuli (yvelaze xSiri), baqteriuli,parazituliparenteruli: saSarde gzebis infeqcia, Sua yurisanTeba, pnevmonia (prevalirebs Rebineba)qirurgiuli apendiciti, invaginacia, obstruqcia, mokle nawlavissindromi.sistemuridaavadebebiendokrinopaTiebi (diabeti, hiperTireoidizmi,Tandayolili adreno-hiperplazia, adisonisdaavadeba, hiperparaTireoidizmi), imunodeficitiantibiotikebis miRebis periodSi da iSviaTadfsevdomembranuli kolitiantibiotikasocirebulisxvadasxva Sekruloba hipersekreciiT, toqsinebi, hemolizururemiulisindromi, axalfexadgmuli bavSvis diarea,Zaladobadietis darRvevamalabsorbciaanTebaidiopaTiuri/fsiqogenurisakvebis autanloba (laqtoza, Zroxis rZis proteini)/alergia, SimSilobamukoviscidozi, celiakiawylulovani koliti / kronis daavadeba, hirSprungisdaavadebagaRizianebuli nawlavis sindromirekomendacia diferenciuli diagnozisaTvismwvave virusuli gastroenteritis garda sxva mizezis arsebobaze undagvafiqrebinos Semdegi klinikuri niSnebis arsebobam (rekomendebuliaspecialistis 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).35

VI. gamokvlevis gegmaspecifiuri kvleva paTogenis aRmoCenis mizniT ar aris rekomendebuli(eqspertTa konsensusi), garda im SemTxvevebisa, roca saqme exeba Semdegs:• asaki

mixedviT oraluri rehidratacia (oraluri rehidrataciis siTxis – ORS - micema)warmoadgens ufro usafrTxo da swraf saSualebas dehidrataciisa daacidozis koreqciisaTvis, vidre intravenuri Terapia (I, A). oralurirehidrataciis warumatebelobis SemTxvevebis sixSire (warumatebelobaganisazRvreba, rogorc dehidrataciis simptomebis persistireba an Sebruneba,rac warmoadgens intravenuri rehidrataciis Cvenebas) Seadgens 3.6%. daamasTanave oraluri rehidratacia amcirebs gulyris risks hipernatremiulidehidrataciis koreqciis procesSi ( II, B).saSualo-zomieri dehidrataciis marTvis rekomendaciebi• bavSvs, visac mwvave gastroenteritis gamo aqvs saSualo-zomieridehidratacia, unda ganesazRvros deficiti da igi unda Seivsos ORSisgamoyenebiT (30-80 ml/kg). ORS-s vaZlevT cotas da xSirad 3-4 saaTisganmavlobaSi, Tu aris amis praqtikuli saSualeba (mtkicebulebisdone I, delfis konsensusi, rekomendaciebis xarisxi A).rekomendirebulia 5 ml siTxis micema yovel 1-2 wuTSi, Tu araRiniSneba Rebineba, mizanSewonilia siTxis moculobis gazrdamiRebis sixSiris SemcirebasTan erTad.• Tu bavSvis momvlels ar SeuZlia (an ar surs) amis keTeba, anrehidratacia unda warmoebdes mTeli Ramis ganmavlobaSi,mizanSewonilia rehidrataciis warmoeba nazogastraluri zondis anIV infuziis meSveobiT (mtkicebulebis done Va, delfis konsensusirekomendaciebis xarisxi D).• regularulad SeafaseT rehidrataciis Sedegi. Tu ar moxdadehidrataciis klinikuri niSnebis gaumjobeseba, an saxezeamdgomareobis gauareseba, mizanSewonilia rehidratacianazogastraluri zondis an i/v infuziis gamoyenebiT (mtkicebulebaTadone Va, delfis konsensusi, rekomendaciebis xarisxi D.)hidrataciis SenarCuneba/dehidrataciis prevenciabavSvma, visac ar aReniSneba dehidratacis niSnebi da mas, visac ar aReniSnebadehidrataciis niSnebi rehidrataciis Semdeg, SeiZleba miiRos TavisufalisiTxeebi, Cveulebrivze ufro meti raodenobiT (cxrili 4 da 5).am mizniT rekomendebulia bavSvisaTvis sasurveli da asakis Sesaferisiracionis SerCeva (Alarcon 1992 [B], Brown 1994[B], Fayad 1993[B], Cohen 1995 [B]).Cveulebrivi kvebis reJimi - SezRudul an piriqiT gafarToebul kvebisracionTan SedarebiT - ufro efeqturad moqmedebs diareis xangrZlivobisSemcirebaze. (Margolis 1990 [B], Alarcon 1991 [B], Placzek 1984 [B], Santoshan 1985 [B], Molina 1995[B]).ORS-is moTxovnilebis gamoTvlacxrili 4saSualo-zomieri dehidratacia (6-9%) :30-80 ml/kg 4 sT-is ganmavlobaSimZime dehidratacia (≥9%) :100 ml/kg 4sT-is ganmavlobaSipraqtikuli Cvevebi:dehidratirebul bavSvebs swyuriaT da isini Cveulebriv ar amboben uars ORS-ismiRebazemieciT siTxeebi mcire ulufebiT, magram xSirad. Rebinebis SemTxvevaSi SeamcireTmoculoba 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 gamoyenebiT37

ORS-is SemanarCunebeli dozis gamoTvlacxrili 5sxeulis pirvel 10 kg-ze 100ml 24 sT-Siamas emateba: 50 ml/kg/dRe sxeulis masis momdevno 10 kg-zeamas emateba: 20 ml/kg/dRe sxeulis masis darCenil wonazemag.: av-fis wona aris 22kg SemanarCunebeli ORS-is doza iTvleba: (10X100) + (10X50) +(2X20) = 1540 ml/24sT-Siyovel Rebineba/faRaraTze aRniSnul dozas emateba 10 ml/kgSeniSvna: sufTa siTxeebi an Cveulebrivi kvebis racioni ar cvlis ORS-sdehidrataciis prevenciis an mkurnalobis procesSi (AAP 1996 [A,D).oraluri rehidrataciis siTxeebis SedarebiTi daxasiaTebacxrili N 6CHONaKfuZexsnarebimmol/l mmol/l mmol/siTxeebi, romlebic gamoiyeneba rehidrataciisaTvismmol/losmolarobanaturaliti14045 20 48 265pediatriuli eleqtrolit 140 45 20 30 250pedialitiinfaliti140 45 20 30 25070 50 25 30 200rehidraliti 140 75 20 30 310WHO/UNICEF –isORS111 90 20 30 310siTxeebi, romlebic ar gamoiyeneba rehidrataciisaTviskola 700 2 0 13 750vaSlis wveni 690 5 32 0 730qaTmis bulioni0 250 8 0 500sportulisasmeli255 20 3 3 330hospitalizaciis (maT Soris gadaudebeli daxmarebis ganyofilebaSi (ER)dayovnebis) Cvenebebi:(eyrdnoba delfis konsensuss, radgan ar arsebobs gamoqveynebuli kvlevebi,romlebic adareben ambulatoriuli an hospitaluri mkurnalobisupiratesobas):• mZime dehidratacia38

• saSualo simZimis dehidrataciis dros pacienti yovndeba hospitalSidaaxloebiT 2-4 saaTis ganmavlobaSi.• pacientebi unda dayovndnen minimum 4-6 sT, Tu isini miekuTvnebianmaRali riskis jgufs:o asaki 8-jer dReSi (III, C).o Rebineba > 4-6 dReSi (III, C).• Sefasdes mSoblebis adeqvaturoba mkurnalobis aucileblobisgaazrebis mxriv (da survili), Tu isini ver SeZleben pacientis binazemovlas, maSin - sasurvelia hospitalizacia.VIII. reabilitacia – meTvalyureobabinaze 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 ubnispediatrTan vizitiT.sakvanZo rekomendaciebi• maT, visac ar aReniSnebaT dehidratacia (

Subcommittee on Acute Gastroenteritis, Provisional Committee on Quality Improvement; ClinicalPractice Guideline: The Management of acute Gastroenteritis in Young Children; American Academy ofPediatrics, Pediatric Clinical Practice Guideline & Policies. 2002: 209-231.XII. gamoyenebuli literatura1. Armon K, Stephenson T, MacFaul R, Eccleston P, Werneke U. An evidence and consensus basedguideline 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). CincinnatiChildren's Hospital Medical Center - Hospital/Medical Center. 1999 Nov (revised 2001 Apr). 13pages. NGC:0023433. 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 acutegastroenteritis 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; ClinicalPractice Guideline: The Management of acute Gastroenteritis in Young Children; American Academyof 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 NorthAmerica _ vol.37.295-3007. Guideline for management of fever without source L.J. Baraff et alPediatrics AAP 1993 v. 92 #1avtorebi:1. m.m.k. i. xabazi _ m. iaSvilis sax. bavSvTa centrluri saavadmyofos uwyvetiganaTlebis ganyofilebis gamge;2. j. yifiani _ m. iaSvilis sax. bavSvTa centrluri saavadmyofosgadaudebeli daxmarebis ganyofilebis eqimirecenzentebi:4. m.m.k. z. kirtava – erovnuli sainformacio saswavlo centrisdireqtori, kavSiri `partniorebi janmrTelobisaTvis~ Tavmjdomare,Tbilisis sax. samedicino universitetis Sinagan sneulebaTa #1kaTedris asistenti5. m.m.k. n. raWveliSvili, Tbilisis sax. samedicino universitetis SinagansneulebaTa #1 kaTedris asistenti, kavSiri `partniorebijanmrTelobisaTvis~ gamgeobis wevri6. k. papoSvili, janmrTelobis da socialuri dacvis erovnuliinstitutis direqtori7. s. lenski, emoris universitetis samedicino skolis bavSvTagadaudebeli daxmarebis (hiu spoldingis saavadmyofo) profesori40

cxrili 7 ganavlis baqteriologiuri analizis warmoebisa daantibiotikoTerapiis dawyebis CvenebebimaRali riskis jgufi:asaki < 3 Tveze,imunokomprometirebulebi,septiuri/ toqsiuri mdgomareobaganavlisbaqteriologia,koprologia daempiriuliantibiotikoTerapia(cefalosporini)ki ara sisxliani ganavali,ganavlisbaqteriologia,CBC koprologia +atibiotiki CvenebismixedviThiperTermiakonkretulispecifiuri paTogenisafeTqebaki ara damxmare movlaix. algoriTmiumkurnale specifiur paTogens Cvenebis mixedviTgamomwvevi antibiotikisefeqturobaupiratesiarCevaniShigella maRalefeqturi Trimethoprimsulfamethozazole(TMP-SMZ)SalmonellaCampylobacterYersiniaaraefeqturiefeqturia,naCvenebia zogSemTxvevaSiucnobiIII TaobiscefalosporiniErythromycinCiprofloxacinalternatiuli komentariarCevaniIII Taobiscefalosporini,AmpicillinCiprofloxacinAmpicillinTMP-SMZCiprofloxacinChloramphenicolTetracyclineaRiniSneba rezistentobis zrdaAmpicillin, TMP-SMZ mimarT; Cipro-sgamoyeneba bavSvebSi naCvenebiar arisant. iniSneba mxolod invaziuridaavadebis SemTxvevaSi, bavSvisasaki

Treatment of Acute Diarrhea (in children from 2 months to 5 years)I. Khabazi, J. Kiphiani, N. Rachvelishvili, Z. Kirtava, S. LanskiM. Iashvili Children’s Central Hospital, Partners for Health NGO, Tbilisi, GeorgiaSchool of Medicine, Emory University/Partners for International Development, Atlanta, GA, USAThe guideline represents an adaptation and compilation of several guidelines devoted to one of the mostimportant children’s pathology - accute diarrhea. The algothythms of diagnostic procedures and treatmentoptions are presented.febriluri gulyra bavSvTa asakSin. tatiSvili, T. samxaraZe, T. yifiani, v. bokeria, i. sasania,i. xabazi, n. raWveliSvili, z. kirtava, m. grinvaldim. iaSvilis sax. bavSvTa centraluri saavadmyofo,kavSiri `partniorebi janmrTelobisaTvis~,emoris universitetis samedicino skola / `partniorebi saerTaSorisoganviTarebisaTvis~ (atlanta, jorjia, aSS)I. definiciafebriluri gulyra ganisazRvreba, rogorc patara bavSvebSi xSiri, magram maincmoulodneli paTologia, romelsac Cveulebriv kargi prognozi da momavalSigulyrebis ganmeorebiTi ganviTarebis dabali riski axasiaTebs. aSSjanmrTelobis erovnuli institutis definicia Semdgom kriteriumebs aRwersfebrilur gulyrasTan dakavSirebiT:• gulyra, romelic Tan axlavs febrilur daavadebas erT Tveze meti asakisbavSvebSi, uxSiresad - 6 Tvidan 6 wlis asakamde;• gamoricxulia cns infeqcia;• pacientis anamnezSi ar aris afebriluri gulyris epizodi.febriluri gulyrebi iyofa martiv da rTul gulyrebad. dayofa mniSvnelovaniamaTi Semdgomi marTvis TvalsazrisiT.martivi febriluri gulyra ganisazRvreba, rogorc:• xanmokle (xangrZlivoba < 15 wT);• ara-fokaluri generalizebuli epizodi;42

• izolirebuli (gulyris erTi epizodi 24 sT-Si, an - febriluridaavadebis 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 erTiperiodis ganmavlobaSi);• viTardeba 38,5°C-ze dabal temperaturaze;• aRiniSneba gulyris Semdgomi nevrologiuri deficiti;febrilur gulyraTa daaxloebiT 30% rTulia.morecidive febriluri gulyrebi. febriluri gulyrebis mqone bavSvTadaaxloebiT erT mesamedSi febriluri gulyrebi morecidivea.II. epidemiologia.sixSire (insidensi) _ 2-4%, cota ufro maRalia aziis regionSiuxSiresad ganviTarebis saSualo asaki – 1-2 weli;febriluri gulyrebi yvelaze xSiria bavSvTa gulyrebs Soris. evropulimonacemebiT 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 6Tvidan 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 ukavSirdebameningitis arsebobis SedarebiT maRal risks, vidre martivi febriluri gulyra(C xarisxis mtkicebuleba), Tumca, iTvleba, rom meningitis riski zogadadfebriluri gulyrebis dros araa maRali (0.6-6.7%, C xarisxis mtkicebuleba).III. etiologia / risk-faqtorebiskolamdeli asaki mniSvnelovan risks warmoadgens febriluri gulyrebisganviTarebisTvis, vinaidan am asakobriv jgufSi gansakuTrebiT maRaliainfeqciaTa da febrilur daavadebaTa sixSire, xolo krunCxviTi zRurbliSedarebiT dabalia.ramdenime kvlevam aRmoaCina xSiri serologiuri gamovlena antisxeulebisaadamianis herpesvirus-6-isadmi, romelic rozeolas gamomwvevi agentia.imunizaciis Semdgomi febriluri gulyrebi arsiT ar gansxvavdebian sxvafebriluri gulyrebisagan. febrilur gulyraTa provocirebas yvelaze xSiradiwvevs yivanaxvelis vaqcina. imunizacia ar ganixileba, rogorc febrilurigulyris gamomwvevi TavisTavadi mizezi.febriluri gulyris pirveli epizodis ganviTarebis risk-faqtorebi:• maRali temperatura;• pirveli an meore xarisxis naTesavi anamnezSi febriluri gulyriT;43

• ganviTarebaSi CamorCena;risk-faqtorebi ganmeorebiTi febriluri gulyrebisaTvis:16%-Si febriluri gulyris ganmeoreba xdeba pirvel 24 saaTSi; zogadad ganmeorebis riski - 33%-ia; pacientTa 9%-ssami 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 mSoblebsanamnezSi aReniSnebaT febriluri gulyris epizodi.IV. klinikuri simptomatikafebriluri 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 mimdinareobisadreul etapze, xSirad - rogorc daavadebis pirveli simptomi. GgulyraSesaZloa ganviTardes nebismieri tipis da xarisxis cxelebis fonze. gulyraTayvelaze metad gavrcelebuli tipia tonur-klonuri, Tumca SesaZloa adgilihqondes mxolod tonuri komponentis, an mxolod klonuri komponetisganviTarebas tonuri daWimvis gareSe. gulyris xangrZlivoba uxSiresad araRemateba 6 wT-s. gulyraTa mxolod 8% grZeldeba 15 wT-ze didxans.V. daavadebis diagnozidiagnostikuri kriteriumebi - ix. I.pacientTa umravlesoba samedicino dawesebulebaSi xvdeba gulyris CaTavebisSemdeg. gulyris Semdgomi mdgomareoba SesaZloa gagrZeldes wuTebi da saaTebi.anamnezis Sekrebisas yuradReba unda mieqces TviT gulyris aRweras, sasurveliagamokiTxul iqnas uSualo mowme. aucilebelia cxelebis mizezis Zieba. saWiroagamoiricxos iseT paTologiaTa arseboba, rogoricaa meningiti, encefaliti,seriozuli eleqtrolituri disbalansi, Tavis travma, intoqsikacia an raimesxva mwvave nevrologiuri daavadeba. YyuradRebas imsaxurebs ojaxur anamnezSigulyrebis arseboba.aucilebelia, detaluri fizikuri da nevrologiuri gasinjva. Ggasinjvis drosgansakuTrebuli yuradReba unda mieqces neiroinfeqciis arsebobisTvisdamaxasiaTebeli niSnebis arsebobas. amasTan, mxedvelobaSi unda viqonioT is44

garemoeba, rom erT wlamde asakis bavSvebSi meningealuri niSnebi (meningizmi,kernigis an bruZinskis niSnebi) SesaZloa arc iyos gamoxatuli. unda gaisinjoswina yiflibandi momatebuli wnevis gamovlenis mizniT. gamoricxul unda iyosZaladobis da travmuli dazianebis arseboba.febriluri gulyris dros diferencireba pirvel rigSi saWiroa SemdegdaavadebebTan:• 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 gegmamartivi febriluri gulyris gamo momarTul pacientTa umravlesobas ar esaWiroeba laboratoriuli gamokvlevebi dacns-is radiologiuri gamokvlevebi (kt, mrt). rutinuli eeg kvleva aseve naklebinformatiulia. Tu xanmoklepostiqturi (gulyris Semdgomi) mdgomareobis Semdeg swrafad moxda cnobierebis aRdgena, ramdenime saaTianidakvirvebis Semdgom SesaZlebelia pacientis saxlSi gaSveba.gamonakliss warmoadgenen 18 Tveze naklebi asakis Cvilebi. mravali eqspertisazriT am asakobriv jgufSi aucilebelia Tav-zurg-tvinis siTxis kvleva.lumbaluri punqcia.Ffebrilur gulyraTa mqone bavSvebs Soris meningitisarsebobis sixSire meryeobs 2%-dan 5%-mde. Aamerikis pediatriuli akademiismier 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 nevrologiurigasinjva, vinaidan meningealuri simptomatika SesaZloa Zlier sustad iyosgamoxatuli.Tu bavSvis asaki aRemateba 18 Tves da saxeze ar aris saeWvo nevrologiuriniSnebi, lumbaluri punqciis gakeTeba ar aris aucilebeli. Llumbaluri punqciis ukuCvenebebia (Armon et al.): cnobierebis dabindva (glazgosSkaliT

kt, mrt Llimitirebuli Rirebulebisaa. Mmrt ar aris naCvenebi martivifebriluri gulyris dros. prolongirebuli an fokaluri febriluri gulyrisdros mrt kvlevis Rirebuleba sadavoaEeeg. eeg monacemebi SesaZloa iyos abnormaluri: - rTuli febrilurigulyrebis, febriluri gulyrebis Sesaxeb ojaxuri istoriis, winmswrebineiroganviTarebiTi paTologiis dros. ar arsebobs sarwmuno informacia eegmonacemebis safuZvelze epilefsiis ganviTarebis SesaZleblobis prognozirebisSesaxeb.1 wlamde asakis bavSvebSi rogorc kompleqsuri, aseve – martivi febrilurigulyris ganviTareba gacilebiT ufro saeWvoa neiro- da/an metaboluripaTologiis arsebobis mxriv. amdenad, CvilebSi mizanSewonilia, romklinicistma gaiTvaliswinos Semdegi gamokvlevebi: Sratis eleqtrolitebi,lumbaruli punqcia, kt an mrt da saavadmyofoSi 24 saaTiT dayovneba. esgadawyvetileba SeiZleba individualurad modificirebuli iyos klinikuriSemTxvevisa da mkurnali eqimis eqspertizis Sesabamisad.VII. mkurnalobis sqemamkurnaloba uSualod gulyris drosmkurnaloba binaze. febrilur gulyraTa umravlesoba xanmoklea, maTixangrZlivoba ar aRemateba 6 wuTs. aseT SemTxvevebSi mkurnaloba ar arissaWiro. 6 wuTze meti xangrZlivobis gulyris SemTxvevaSi gamoiyenebareqtaluri diazepami. amisaTvis saWiroa mSoblebis trenireba. reqtaluridiazepami aseve gamoiyeneba morecidive febriluri gulyrebis mqone bavSvebSimaRali cxelebis dros, rodesac febriluri gulyris ganviTarebis SansimaRalia, an bavSvi imyofeba samedicino centridan moSorebiT.hospitaluri mkurnaloba. mimarTulia gulyris kupirebisaken. miuxedavadimisa, rom febrilur gulyrebs garTulebebi iSviaTad axasiaTebT, ar undadagvaviwydes aspiraciis riski. hospitalSi ZiriTadad gamoiyeneba intravenurian reqtaluri diazepami, lorazepami, midazolami. Tu gulyra iRebs statusurmimdinareobas, gamoiyeneba krunCxviTi statusis mkurnalobis protokoli.mkurnaloba cxelebis drosantipiretuli saSualebebi Ggamoiyeneba cxelebis sawinaaRmdegod, Tumcmorecidive febriluri gulyris prevenciisaTvis isini ar arian efeqturni.qronikuli prevenciuli Terapia.qronikuli prevenciuli Terapiis sakiTxi SesaZloa ganxilul iqnes xSirimorecidive febriluri gulyrebis (rTuli an martivi) arsebobis SemTxvevaSi.qronikuli prevenciuli Terapia febrilur gulyraTa ganviTarebis sixSiresamcirebs, magram ar arsebobs mtkicebulebebi imis sasargeblod, rom febrilurgulyraTa prevencia epilefsiis SesaZlo ganviTarebis risks amcirebs.qronikuli prevenciuli Terapiis mizniT gamoyeneba Semdegi preparatebi:46

fenobarbitali _ kontrolirebadi ormagi brma meTodiT Sesrulebulikvlevebis monacemebis mixedviT fenobarbitali mniSvnelovnad amcirebsmorecidive febriluri gulyrebis ganviTarebis Sanss _ 25%-dan 5%-mde.valproatis mJava _ randomizebuli kontrolirebadi kvlevebiT valproatismJaviT mkurnalobis fonze morecidive febriluri gulyrebis mqone bavSvTagangulyra ganumeorda mxolod 4%-s, nacvlad 35%-sa sakontrolo jgufidankarbamazepini _ zogjer ukeT aitaneba, magram naklebad efeqturad iTvlebamorecidive febriluri gulyrebis prevenciis TvalsazrisiT.prognozi. ukanaskneli ocdaxuTwliani dakvirvebis safuZvelze febrilurgulyrebi fasdeba rogorc keTilTvisebiani paTologia. is ar arisasocirebuli tvinis raime arsebiT dazianebasTan da febriluri gulyrebismqone bavSvTa mxolod mcire procents uviTardeba SemdgomSi epilefsia.dadgenilia, rom antiepilefsiuri medikamentebiT SesaZlebelia febrilurgulyraTa prevencia, Tumca antiepilefsiuri Terapia ver cvlis SemdgomSiepilefsiis ganviTarebis risks.VIII. reabilitacia / meTvalyureoba – specialuri miTiTebebigaidlainebis doneze ar aris SeTanxmebuli.IX. gaidlainis gadasinjvis da ganaxlebis vada _ ori weliX. gaidlainis miRebis gza da wyaroebi _ literaturis Targmani,ramdenime gaidlainebis Sejereba da adaptacia.XI. alternatiuli gaidlaini – ar aris moyvaniliXII. gamoyenebuli literatura:1. “Practice parameter: The Neurodiagnostic Evaluation of the Child with a First Simple FebrileSeizure” Pediatrics, 1996; 97(#5 May) 769-772.2. Warden, et al “Evaluation and Management of Febrile Seizures in the Out-of-Hospital andEmergency Department Settings” Annals of Emergency Medicine 2003 41(#2 Feb) pp215-222.3. Baumer JH “Evidence based guideline for post-seizure management in children presentingacutely 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 pointlessprocedure? 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. 749-839.47

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 PEDIATRICS18. 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 PresentingAcutely 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 afirst unprovoked seizure. Report of the Quality Standards Subcommittee of the American Academyof 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. Developed1999 January, updated 2002 July. 119 p. Paediatric Accident and Emergency Research Group:www.pier.org.ukmix. iaSvilis sax. bavSvTa respublikuri saavadmyofos avtorTa jgufi:n. tatiSviliT. samxaraZeT. yifianiv. bokeriai. sasaniai. xabazirecenzentebi:8. m.m.k. z. kirtava – erovnuli sainformacio saswavlo centrisdireqtori, kavSiri `partniorebi janmrTelobisaTvis~ Tavmjdomare,Tbilisis sax. samedicino universitetis Sinagan sneulebaTa #1kaTedris asistenti9. m.m.k. n. raWveliSvili, Tbilisis sax. samedicino universitetis SinagansneulebaTa #1 kaTedris asistenti, kavSiri `partniorebijanmrTelobisaTvis~ gamgeobis wevri10. maikl grinvaldi, emoris universitetis samedicino skolispediatriuli gadaudebeli daxmarebis specialisti(Michael Greenwald, Pediatric Emergency Medicine, Emory University, Atlanta, GA, USA)48

cxrili #1mwvave febriluri gulyraanamnezSi ar aris afebriluri gulyraar aris [axali]nevrologiuri niSnebi*da asaki > 6Tveaxali nevrol.niSnebi daasaki < 6 Tve> 6 weligulyrasa dacxelebasTandakavSirebulistandartuliRonisZiebebimartivi febrilurigulyra:generalizebuli, < 15wT da 1 epiz./24 sTaucilebelia kt, lp,eleqtrolitebi + cxelebasTandakavS. RonisZiebebi(neiroinfeqciis gamoricxva!)rTuli febrilurigulyra: fokaluri,> 15 wT da/an >1epizodze - 24 sT-Si18 Tve – 6 weli < 18 Tvezedakvirvevba2 sT;cxelebasTandakavS.RonisZiebebigamomjobinebarCebapostiqtalurilp; kt; eleqtrolitebi;hospitalizacia#;cxelebasTanN dakavS.RonisZiebebigawera binazeSesabamisiinstruqciiT* - moicavs meningitisniSnebs, gamoricxavspostiqtalurgamovlinebebs# - empiriuli lp miTufro rekomendebulia,rac ufro dabaliapacientis asaki49

Febrile Seizure in ChildrenN. Tatishvili, T. Samkharadze, T. Kipiani, I. Bokeria, I. Sasania,I. Khabazi, N. Rachvelishvili, Z. Kirtava, M. GreenwaldThe diagnosis of febrile seizures describes a commonly occurring yet unpredictable event in young children whichhas an excellent prognosis and low risk of future seizures. The US National Institutes of Health definition includesthe following features: 1) Occurs in early childhood, usually between 6 months and 6 years; 2) Excludes conditionssuggestive of intracranial infection; 3) Excludes patients with previous non-febrile seizures. The article provides anew National type guideline for Febirle Seizure, which represents compilation and adaptation of different CPGs,reviewed by US expert.septiuri Sokis mkurnalobao. asaTiani, z. metreveli, m. kapanaZe, n. raWveliSvili, e. l. barnhemiakad. o. RuduSauris sax. erovnuli samedicino centri,kavSiri `partniorebi janmrTelobisaTvis~, (Tbilisi, saqarTvelo)emoris universitetis samedicino skola / `partniorebi saerTaSorisoganviTarebisaTvis~ (atlanta, jorjia, aSS)I. daavadebis definicia:istoriulad sefsis mravali sxvadasxva ganmartebaa mowodebuli, Tumca arcerTi fiziologiuri Tu laboratoriuli parametri universalurad verasaxavs sefsisis arss.yvelaze ufro Tanamedrove, farTod gavrcelebuli ganmartebebi Semdegia:sefsisi: warmoadgens sistemur anTebiT pasuxs infeqciaze.mZime sefsisi: infeqciiT inducirebuli organuli disfunqcia anhipoperfuziuli darRvevebi.septiuri Soki: sefsisis fonze ganviTarebuli hipotenzia, romelic arswordeba infuziuri TerapiiT da dakavSirebulia organul disfunqciasTan anhipoperfuziul darRvevebTan.1991 w. amerikis gulmkerdis qirurgTa kolejisa da kritikulmdgomareobaTa medicinis sazogadoebis SemaTanxmebel konferenciazemiRebuli nomenklaturiT septiuri Soki xasiaTdeba sefsisiT, hipotenziiT,hipovolemiiT da qsovilTa damtkicebuli araadeqvaturi perfuziiT.sefsisi xasiaTdeba anTebis sistemuri sapasuxo reaqciiTa dadamtkicebuli baqteriemiiT.mZime sefsisis diagnozi ismeba poliorganuli ukmarisobis arsebobisas.50

II. epidemiologia:amerikis SeerTebul StatebSi yovel 100 hospitalizaciaze sefsisis 2±0,16SemTxveva fiqsirdeba. saerTaSoriso maCvenebeli – 1.36 SemTxveva 100hospitalizaciaze.anTebis sistemuri sapasuxo reaqciis dros sikvdilianoba Seadgens 7%,sefsisis SemTxvevaSi – 16-20%, septiuri Sokisas – 45%.SemTxvevaTa 18%-Si septiuri Soki rTuldeba mozrdilTa respiratorulidistres sindromiT, 50%-Si - Tirkmlis mwvave ukmarisobiT, 38%-Si -diseminirebuli sisxlZarRvSida Sededebis sindromiT.III. etiologia/risk-faqtorebi/paTologia:etiologiuri faqtorebi:nebismierma infeqciurma procesma SeiZleba gamoiwvios sefsisisganviTareba, gansakuTrebiT - mkurnalobis Cautareblobis, dagvianebis anaraadeqvaturobis/araefeqturobis SemTxvevaSi. xolo sefsisi xSir SemTxvevaSiSesaZloa garTuldes septiuri SokiT.paTogenezi:infeqciis SemTxvevaSi gamomwvevi mikroorganizmis produqtebisurTierTqmedeba maspinZeli organizmis ujredebTan da plazmis cilebTan iwvevsreaqciaTa kaskadis CarTvas, rasac sabolood mivyavarT ujredTa dazianebasa dasikvdilamde, aseve mediatorebis - araqidonis mJavis daSlis produqtebis(leikotrienebi, prostaglandinebi, Tromboqsani); kateqolaminebis,glukokortikoidebis; prekalikreinis; bradikininis; histaminis; endorfinis;enkefalinis; adrenokortikotropuli hormonis; miokardiumis depresantulifaqtoris; kaxeqtinis; interleikini-1; komplementis sistemis da fibrinolizurisistemis produqtebis - gamonTavisuflebamde.yovelive zemoTaRniSnuli iwvevs gul-sisxlZarRvTa sistemis daTrgunvas,mikrocirkulaciis moSlas, qsovilTa perfuziis daqveiTebas, metaboluriprocesebis 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 aRiniSnebaori an meti Semdegi simptomebidan:1. temperatura - 38 o C-ze meti an 36 o C-ze naklebi;2. gulis SekumSvaTa sixSire > 90/wT;3. sunTqvis sixSire meti >20/wT;4. leikocitebi > 12000/l, an < 4000/l, an umwifariformebis raodenoba > 10%-s (marcxniv gadaxra).- klinikuri niSnebi zogjer pirveladi keris identifikaciissaSualebas iZleva:• Tavisa da kisris infeqcia – yuris tkivili, Tavis tkivili, yelis tkivili,sinusitis movlenebi, kisris limfuri jirkvlebis gadideba;51

• 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 alkoholizmiTdaavadebulebSi 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 kriteriumebiar arsebobs. Ddiagnozi efuZneba anTebaze sistemuri xasiaTis pasuxisa dazogadad 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:52

septiur Sokze eWvis mitanisTanave pacients stacionarSi unda CautardesSemdegi gamokvlevebi:‣ sisxlis baqteriologiuri analizi1. analizi aRebuli unda iqnes antibiotikoTerapiis dawyebamde.2. saeWvo SemTxvevaSi (rodesac laboratoriuli kvlevis pasuxiuaryofiTia, xolo klinikurad aSkarad saqme gvaqvs sefsissa daseptiur SokTan) analizebis seriis Sesruleba 2 dRis ganmavlobaSizedized, dReSi 3-5-jer.3. sisxli unda iyos venidan axlad aRebuli, sisxlis raodenoba arunda iyos 15-20 ml-ze naklebi, sisxlisa da niadagis raodenobisSefardeba unda iyos 1:10-1:20;‣ sisxlis saerTo analizi (hemoglobinis dones mniSvneloba aqvsadeqvaturi oqsigenaciis misaRwevad, leikocitozi da formulis marcxnivgadaxra infeqciis simZimis Sefasebis saSualebas gvaZlevs);‣ mJava-tutovani wonasworoba (laqtat-acidozi qsovilTa perfuziisdaqveiTebis da Sokis simZimis Sefasebis saSualebas iZleva);‣ Sardis saerTo analizi;‣ Sardis baqteriologiuri analizi;‣ sxvadasxva biologiuri siTxeebis da/an qsovilebis baqteriologiurianalizi;‣ C-reaqtiuli cila (mniSvnelovani diagnostikuri markeria, dinamikaSi ammaCveneblis cvlileba informaciis gvaZlevs sefsisisa da septiuri Sokisprogresirebaze an regresze);sxvadasxva garTulebebisa da infeqciis pirveladi wyaros gamovlenis mizniTsaWiroa Semdegi damatebiTi gamokvlevebis Catareba:‣ koagulograma (sefsisisa da septiuri Sokis erTerTi yvelaze mZimegarTulebis - diseminirebuli sisxlZarRvSida Sededebis sindromisverifikacia);‣ kreatinini sisxlSi;‣ bilirubini sisxlSi;‣ alaninaminotransferaza (alt);‣ aspartataminotransferaza (ast);‣ tute fosfataza (RviZlisa da Tirkmlis funqciebis SeswavlamniSvnelovania mZime sefsisis dros poliorganuli ukmarisobisSesafaseblad);‣ albumini sisxlSi;‣ glikemia;‣ sisxlis eleqtrolitebi;‣ gulmkerdis rentgenografia;‣ muclis Rrus organoTa ultrabgeriTi gamokvleva;‣ kompiuteruli tomografia (instrumentuli kvlevis meTodebi infeqciiskerebis gamovlinebis saSualebas gvaZleven);‣ lumbaluri punqcia (arsebiTi mniSvneloba aqvs neiroinfeqciisdiagnostikaSi);sefsisis dros ar unda dagvaviwydes zogierTi gavrcelebuli etiologiurifaqtori, romelTa gamosavlenadac xandaxan damatebiTi gamokvlevebis CatarebaasaWiro:‣ centraluri venuri kaTeteriT (cvk) gamowveuli infeqcia:53

• cvk gamowveul infeqciaze eWvis dros saWiroa kaTeteris amoReba dabaqteriologiuri gamokvleva.• Tu eWvia kaTeteris punqciis adgilze infeqciis arsebobaze, saWiroanacxis aReba da baqteriologiuri gamokvleva.• Tu kaTeteris punqciis adgilze Cirqovani gamonadenia, kaTeteri undaCaidgas sxva, infeqciis keridan daSorebul adgilze, miuxedavadbaqteriologiuri kvlevis monacemebisa.‣ ventilator-asocirebuli pnevmonia (vap):• vap-ze eWvis dros saWiroa sisxlis orjeradi baqteriologiurigamokvlevisa da gulmkerdis rentgenografiis Catareba.• plevraSi siTxis arsebobis SemTxvevaSi, saWiroa punqcia da siTxisbaqteriologiuri Seswavla.• zogierTi monacemebiT, bronqoskopia (bronqoalveoluri lavaJiT annacxis aRebiT) garkveuli diagnostikuri Rirebulebisaa, magram esmonacemebi jer kidev sakamaToa.• endotraqeuli milidan sekretis gramis wesiT gamokvleva aseveSeiZleba dagvexmaros mkurnalobis sworad warmarTvaSi.‣ intraabdominuri infeqcia:• aucilebelia sisxlis baqteriologiuri gamokvleva zemoT aRniSnuliprincipebiT.• Cirqis an gamonadenis arsebobis SemTxvevaSi saWiroa nacxis aReba dagamokvleva. gaTvaliswinebul unda iqnas anaerobuli koinfeqciisarsebobac. sokovan infeqcias didi yuradReba unda mieqces da undaCatardes antimikozuri preparatebiT mkurnaloba, sanam es diagnozi argamoiricxeba.• naCvenebia instrumentuli kvleva. eqoskopia xSir SemTxvevaSisakmarisia, magram kompiuteruli tomografia (sasurvelia – kontrastuliCT) ufro informatiulia. nebismieri siTxis arsebobisas unda moxdes misidrenaJi da mikroskopuli Seswavla.‣ mwvave akalkulozuri qolecistiti:• eWvi unda iqnas mitanili yvela septiur pacientSi (gansakuTrebiTpostoperaciul), visac aReniSneba tkivili muclis zeda marjvenakvadrantSi da sanaRvle gzebis obstruqciisaTvis damaxasiaTebeliRviZlis funqciuri sinjebis cvlilebebi.• mizanSewonilia gadaudebeli ultrabgeriTi gamokvleviTdiagnostireba da zog SemTxvevaSi - perkutaneulad drenireba.‣ sinusiti:• mosalodnelia yvela pacientSi nazotraqeuli miliT an nazogastrulizondiT, 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: -54

− infuziuri Terapia dauyovnebliv unda iqnas dawyebuli ori msxvili periferiulikaTeteriT. kaTeteris diametri ufro mniSvnelovani parametria, vidre misisigrZe.− septiuri Sokis SemTxvevaSi infuziuri Terapiis mizania perfuziisgaumjobeseba da ujreduli metabolizmis normalizeba.− Sratis laqtatis donis momateba miuTiTebs qsovilebis hipoperfuziazeriskis jgufis pacientebSi, romelTac hipotenzia ar aReniSnebaT.− centraluri venis kaTeterizacia saWiroa rogorc xangrZlivi da masiuriinfuziuri Terapiis Casatareblad, ise - centraluri venuri wnevismonitoringisaTvis;− aucilebelia Sardis buStis kaTeterizacia saaTobrivi diurezisSefasebisaTvis;− arteriis kanulacia rogorc laboratoriuli gamokvlevebisaTvis, iseinvaziurad arteriuli wnevis monitoringisaTvis;− filtvis arteriis kaTeterizacia (svan-gancis kaTeteriT) guliswuTmoculobis, saerTo periferiuli winaaRmdegobis gansazRvris, mcirewris hemodinamikuri SefasebisaTvis. Aam manipulaciis Sesaxeb azrTasxvadasxvaobaa. igi ar axdens dadebiT efeqts sefsisis gamosavalze,Tumca saSualebas gvaZlevs miviRoT informacia, rac adeqvaturiTerapiis SerCevaSi dagvexmareba− pirvel 6 saaTSi mkurnalobis mizania yvela Semdegiparametris stabilizacia:1. centraluri venuri wneva – 12-18 mmHg,2. saSualo arteriuli wneva - >65 mmHg,3. saaTobrivi diurezi - ≥0.5 ml/kg*sT4. 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 SeiZlebaramdenime litriTac ganisazRvros dRe-RameSi. ukuCvenebebi: filtvebis an Tavistvinis SeSupeba, rac SeiZleba fataluri gamosavliT dasruldes. amdenad didimniSvneloba 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 SeiZlebahipovolemiis gamosworeba.ukuCvenebebia: prepartisadmi hipermgrZnobeloba, filtvebis SeSupeba.sisxlis preparatebi: septiuri Sokis dros eqspertTa umravlesobis mierrekomendebulia hemoglobinis donis SenarCuneba 90-100 g/l doneze.hemoglobinis es done kargad aitaneba pacientTa umravlesobis mier,kardiologiuri darRvevebis arsebobis SemTxvevaSic. xolo Tu saxeze ar gvaqvsTanmxlebi kardiuli daavadeba, hemoglobinis done 70-80 g/l-ic misaRebia.vazopresorebi: vazopresorebiT mkurnaloba dawyebul unda iqnes maSin, rocamxolod siTxeebiT ver xerxdeba adeqvaturi arteriuli wnevisa da organoTaperfuziis aRdgena. vazopresorebi xSirad aucilebelia sicocxlisgadasarCenad da perfuziis SesanarCuneblad kritikuli hipotenziis dros.titrirebul unda iqnas minimaluri saWiro dozebi.55

septiuri Sokisas hipotenziis koreqciisaTvis pirveli rigis preparatebianorepinefrini (noradrenalini) an dopamini. dopamini zrdis saSualo arteriulwnevas upirvelesad gulis indeqsis gazrdis gziT da minimalur zemoqmedebasaxdens sistemur sisxlZarRvovan rezistentobaze. sasurvelia, dopaminis dozamar gadaaWarbos 20 mkg/kg/*wT. mZime sefsisis SemTxvevaSi dopaminis dabalidozebis gamoyeneba Tirkmlis funqciis SenarCuneba/gaumjobesebisaTvis ar arisrekomendirebuli. dopaminis dabali dozebi Tirkmelebis dacvis mizniT ar undaiyos gamoyenebuli, rogorc mZime sefsisis mkurnalobis sqemis Semadgenelinawili.norepinefrini TvalnaTliv aumjobesebs saSualo arteriul wnevas daglomerulur filtracias, gansakuTrebiT maRali gulis gadmosrolis / dabalisisxlZarRvovani 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, mZimeparkuWovani taqikardia. aseT SemTxvevebSi gamoiyeneba mxolod sasicocxloCvenebebiT.gverdiTi efeqtebi: miokardiumis iSemia, ariTmia, tremori, hipertenzia.oqsigenoTerapia: saWiroa qsovilebamde Jangbadis maqsimaluri miwodebisaTvis.mZime SemTxvevebSi (sefsisisa da septiuri Sokis dros mozrdilTarespiratoruli distres sindromis ganviTarebis didi albaTobaa) SeiZlebasaWiro gaxdes traqeis intubacia da filtvebis xelovnuri ventilacia (fxv),romlis reJimi da parametrebi unda SeirCes sasunTqi sistemis mdgomareobisSesabamisad).filtvebis mwvave dazianebis/mozrdilTa respiratoruli distres sindromisdros fxv dawyebul unda iqnas CasunTqvis mcire moculobiT (daaxloebiT 6ml/kg). CasunTqvis platos wneva ar unda aRematebodes 30 wylis sv. hiperkapniadasaSvebia CasunTqvis moculobisa da CasunTqvis platos wnevis minimizaciisSesanarCuneblad (egreT wodebuli “dasaSvebi hiperkapnia”).gasaTvaliswinebelia, rom fxv-m SeiZleba kidev ufro arastabiluri gaxadoshemodinamika gulisaken venuri ukudinebis Semcirebis gamo. am mavne zegavlenisSemcireba SeiZleba CasunTqvis wnevis (P insp ), CasunTqvis drois (T insp ), amosunTqvisbolos dadebiTi wnevis (PEEP) minimalizaciiT.zogjer mimarTaven hiperbarul oqsigenoTerapias, gansakuTrebiT - rbiliqsovilebis nekrozis dros.antibiotikebi: empiriuli antibiotikoTerapia dawyebul unda iqnesrac SeiZleba swrafad da farTo speqtris preparatis meSveobiT undagadafaros yvela SesaZlo flora – rogorc gram-dadebiTi, aseve gramuaryofiTida anaerobuli flora.retrospeqtiuli kvlevebiT dadgenilia, rom gram-uaryofiTi baqteriebiTgamowveuli hematogenuri infeqciebisas Sesabamisi antibiotikebis daniSvnaamcirebs sikvdilianobas.igive efeqti unda gvqondes gramdadebiTi sefsisis drosac, miuxedavadimisa, rom amis mtkicebulebebi jer ar moipoveba.antibiotikoTerapiis aucilebeli pirobaa maTi intravenuri Seyvana.(antibiotikebis dozireba, Cvenebebi da ukuCvenebebi ixileT danarTSi, cxrili#1).56

empiriuli mkurnalobisas monoTerapia nebismieri mesame an meoTxe generaciiscefalosporinebiT an karbapenemebiT iseve efeqturia, rogorc beta-laqtamebisada aminoglikozidebis kombinacia mZimed mimdinare sefsisiT im pacientebSi,romelTac neitropenia ar aReniSnebaT.ftorqinolonebi monoTerapiis saxiT ar aris rekomendebuli gramdadebiTfloraze maTi suboptimaluri zemoqmedebis gamo.glikopeptidebi (mag. vankomicini) mizanSewonilia umZimes pacientebSikaTeterasocirebuli infeqciiT an im centrebSi, sadac meTicilinrezistentulistafilokoki dominirebs.antifungaluri agentebi ar unda iqnas gamoyenebuli rutinulad empiriulTerapiaSi.aucilebelia kulturebis Seswavla mkurnalobis optimizaciis mizniT,rogorc araefeqturi antibiotikebis drouli moxsnisaTvis, aseve - arsebuliantibiotikoTerapiis Sevsebisa da koreqciisaTvis.kortikosteroidebi:i/v kortikosteroidebis gamoyeneba naCvenebia pacientebSi, romlebic, miuxedavadsiTxeebiT Sevsebisa, saWiroeben vazopresorebs, raTa SenarCunebuli iqnasadeqvaturi arteriuli wneva.hidrokortizoni - 200-300mg/dR, gayofili 3-4 dozad an mudmivi infuziis saxiT 7dRis ganmavlobaSi. dRiurad 300 mg meti hidrokortizoni sSeyvana araarekomendebuli. SesaZloa gamoviyenoT sxva steroiduli preparatebicekvivalentur dozebSi.zogi eqspertis mosazrebiT saWiroa adrenokortikotropuli hormonis (akth) 250mkg-iT mastimulirebeli testis Catareba. Tu pacients akth-s Seyvanidan 30-60 wTisSemdeg aReniSneba kortizolis koncentraciis momateba > 9 mkg/dl-ze,kortikosteroidebiT mkurnaloba ar unda Catardes. magram klinicistebma arunda daelodon akth-s mastimulirebeli testis Sedegebs kortikosteroidebiTmkurnalobis dasawyebad da unda axsovdeT, rom hidrokortizoni moqmedebskortizolis koncentraciaze, maSin rodesac deqsametazoni eqvivalenturdozaSi amas ar iwvevs.rekombinanturi aqtivirebuliproteini C (rhAPC) rekomendebulia sikvdilianobis maRali riskis mqonepacientebSi (APACHE II >25, poliorganuli ukmarisobis, septiuri Sokis, mozrdilTarespiratoruli distres sindromis dros. misi winaaRmdegCvenebebi mocemuliacxril 2-Si. aRsaniSnavia, rom saqarTveloSi es preparati jerjerobiT argamoiyeneba.glikemiis kontroli: glikemia SenarCunebuli unda iyos

pacientebs, romelTaTvisac heparini ukunaCvenebia, utardebaT fizikurimeTodebiT profilaqtika (damwoli naxvevis dadeba).maRali riskis pacientebSi (mZime sefsisi, anamnezSi Rrma venebisTrombozis arseboba) profilaqtika xorcieldeba kombinirebulad, rogorcmedikamentozuri Terapiis, ise - fizikuri meTodebis gamoyenebiT.stresuli wylulis profilaqtika:utardeba mZime sefsisiT yvela avadmyofs. H 2 -blokerebiyvelaze ukeTaa Seswavlili da yvelaze xSiradacgamoiyeneba.amas gansakuTrebuli mniSvneloba eniWeba im SemTxvevebSi,Tu adgili aqvs koagulopaTias, meqanikur ventilaciasda hipotenzias, radgan amdros stresuli wylulis ganviTarebis riskigansakuTrebiT maRalia.operaciuli mkurnaloba: aucilebelia infeqciis kerebis (gulmkerdisada muclis Rruebi, centraluri nervulisistema, rbili qsovilebi) gamovlena, adeqvaturidrenireba 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 SerCeulisxvadasxva gaidlainebis Sejerebisa da adaptaciis gziT. amdenadalternatiuli gaidlaini ar aris warmodgeniliXI. gamoyenebuli literatura:1. New gudelines for the management of sepsis/septic shock. April 2004.http://www.pulmonaryreviews.com2. 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 SepsisCampaign Management Guidelines Committee. 2004 Mar. http://www.ncbi.nlm.nih.gov3. J Stephan Stapczynski, MD, Shock, Septic. July 25, 2002. http://www.emedicine.com4. Abraham E, Wunderink R, Silverman H, et al: Efficacy and safety of monoclonal antibody tohuman 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 Mar22-29; 273(12): 934-41http://www.ncbi.nlm.nih.gov5. Beal AL, Cerra FB: Multiple organ failure syndrome in the 1990s. Systemic inflammatoryresponse and organ dysfunction. JAMA 1994 Jan 19; 271(3): 226-33 http://www.ncbi.nlm.nih.gov6. Brun-Buisson C, Doyon F, Carlet J, et al: Incidence, risk factors, and outcome of severe sepsisand septic shock in adults. A multicenter prospective study in intensive care units. French ICUGroup for Severe Sepsis. JAMA 1995 Sep 27; 274(12): 968-74 http://www.ncbi.nlm.nih.gov58

7. Cronin L, Cook DJ, Carlet J, et al: Corticosteroid treatment for sepsis: a critical appraisal andmeta- analysis of the literature. Crit Care Med 1995 Aug; 23(8): 1430-9http://www.ncbi.nlm.nih.gov8. Eidelman LA, Putterman D, Putterman C, Sprung CL: The spectrum of septic encephalopathy.Definitions, etiologies, and mortalities. JAMA 1996 Feb 14; 275(6): 470-3http://www.ncbi.nlm.nih.gov9. Gattinoni L, Brazzi L, Pelosi P, et al: A trial of goal-oriented hemodynamic therapy in critically illpatients. SvO2 Collaborative Group. N Engl J Med 1995 Oct 19; 333(16): 1025-32http://www.ncbi.nlm.nih.gov10. Guest TM, Ramanathan AV, Tuteur PG, et al: Myocardial injury in critically ill patients. Afrequently unrecognized complication. JAMA 1995 Jun 28; 273(24): 1945-9http://www.ncbi.nlm.nih.gov11. Le Gall JR, Lemeshow S, Leleu G, et al: Customized probability models for early severe sepsis inadult intensive care patients. Intensive Care Unit Scoring Group. JAMA 1995 Feb 22; 273(8):644-50http://www.ncbi.nlm.nih.gov12. Lefering R, Neugebauer EA: Steroid controversy in sepsis and septic shock: a meta-analysis. CritCare Med 1995 Jul; 23(7): 1294-303http://www.ncbi.nlm.nih.gov13. Lundberg JS, Perl TM, Wiblin T, et al: Septic shock: an analysis of outcomes for patients withonset on hospital wards versus intensive care units. Crit Care Med 1998 Jun; 26(6): 1020-4http://www.ncbi.nlm.nih.gov14. 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.gov15. Quartin AA, Schein RM, Kett DH, Peduzzi PN: Magnitude and duration of the effect of sepsis lon survival. Department of Veterans Affairs Systemic Sepsis Cooperative Studies Group. JAMA1997 Apr 2; 277(13): 1058-63http://www.ncbi.nlm.nih.gov16. Rady MY, Rivers EP, Nowak RM: Resuscitation of the critically ill in the ED: responses of bloodpressure, heart rate, shock index, central venous oxygen saturation, and lactate. Am J Emerg Med1996 Mar; 14(2): 218-25http://www.ncbi.nlm.nih.gov17. Rangel-Frausto MS, Pittet D, Costigan M, et al: The natural history of the systemic inflammatoryresponse syndrome (SIRS). A prospective study. JAMA 1995 Jan 11; 273(2): 117-23http://www.ncbi.nlm.nih.gov18. Sands KE, Bates DW, Lanken PN, et al: Epidemiology of sepsis syndrome in 8 academic medicalcenters. Academic Medical Center Consortium Sepsis Project Working Group. JAMA 1997 Jul16; 278(3): 234-40http://www.ncbi.nlm.nih.gov19. Schierhout G, Roberts I: Fluid resuscitation with colloid or crystalloid solutions in critically illpatients: a systematic review of randomized trials. ALYSIS 1998 Mar 28; 316(7136): 961-4http://www.ncbi.nlm.nih.gov20. Wenzel RP, Pinsky MR, Ulevitch RJ, Young L: Current understanding of sepsis. Clin Infect Dis1996 Mar; 22(3): 407-12http://www.ncbi.nlm.nih.gov59

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.govavtorTa jgufi:olRa asaTiani – akad. o. RuduSauris sax. erovnuli samedicinocentris informaciis marTvisa da uwyvetisamedicino ganaTlebis samsaxuris ufrosi,zaza metreveli – akad. o. RuduSauris sax. erovnuli samedicinocentris katastrofisa da gadaudebelimedicinis samsaxuris ufrosi,mamuka kapanaZe - akad. o. RuduSauris sax. erovnuli samedicinocentris gadaudebeli daxmarebis (mimRebi) ganyofilebiseqimi-reanimatologi.recenzentebi:11. m.m.k. z. kirtava – erovnuli sainformacio saswavlo centrisdireqtori, kavSiri `partniorebi janmrTelobisaTvis~ Tavmjdomare,Tbilisis sax. samedicino universitetis Sinagan sneulebaTa #1kaTedris asistenti12. m.m.k. n. raWveliSvili, Tbilisis sax. samedicino universitetis SinagansneulebaTa #1 kaTedris asistenti, kavSiri `partniorebijanmrTelobisaTvis~ gamgeobis wevri13. k. papoSvili, socialuri da jandacvis erovnuli institutisdireqtori14. e. l. barnhemi – Terapiis, pulmonologiis, alergologiis dakritikuli medicinis profesori, emoris universitetis samedicinoskola, atlanta, jorjiis Stati, aSS(E. L. Burnham, MD—Assistant Professor of Medicine, Pulmonary, Allergy, and Critical CareMedicine, Emory University School of Medicine, Atlanta, Georgia, USA)60

danarTi:cxrili #1antibiotikoTerapia septiuri Sokis drosdasaxeleba moqmedebis speqtri dozireba SeniSvnacefuroqsimi meore Taobis cefalosporini,moqmedebs gramdadebiTfloraze daE. coli, Klebsiellapneumoniae, Haemophilusinfluenzae.1,5 g yovel 8sT-Si, i/v.ukunaCvenebia hipermgrZnobelobisas,aminoglikozidebTanerTad aZlierebs maTnefrotoqsiurefeqts. TirkmlisukmarisobisassaWiroa dozis koregireba.aZlierebsantikoagulantebiscefotaqsimimesame Taobis cefalosporini,moqmedebs gramuaryofiTfloraze,gansakuTrebiTEscherichia coli, Proteus,Klebsiella.1-2 g yovel 4sT-Si, i/v.moqmedebas.ukunaCvenebia hipermgrZnobelobisas,aminoglikozidebTanerTad aZlierebs maTnefrotoqsiurefeqts. TirkmlisukmarisobisassaWiroa doziskoregireba.ceftriaqsoniTikarcilin/klavulanatipiperacilin/tazobaqtamimoqmedebs penicilinazamaproducirebelmikroorganizmebze.beta-laqtamazadaculi antibiotiki,moqmedebsumravles gramdadebiT(gardaMRSAStamebisa), gramuaryofiTda anaerobulfloraze.beta-laqtamazadaculi antibiotiki,moqmedebsumravles gramda-1 g yovel6-12 sT-Si, i/v.3,1 g yovel 4-6sT-Si, i/v.3,375 g yovel6 sT-Si, i/vukunaCvenebia hipermgrZnobelobisas,aminoglikozidebTanerTad aZlierebs maTnefrotoqsiurefeqts. Tirkmlisukmarisobisas saWiroadozis koregireba.sifrTxiliTunda iqnas gamoyenebulipenicilinzealergiis SemTxvevaSi.ukunaCvenebia hipermgZnobelobisas,saWiroa RviZlisa daTirkmlis funqciebismonitoringi (ALT,AST, kreatininisklirensisgansazRvra).ukunaCvenebia hipermgZnobelobisas,saWiroa RviZlisa daTirkmlis funqciebis61

imipenemimeropenemiklindamicinimetronidazolidebiT(garda MRSAStamebisa), gramuaryofiTda anaerobulfloraze.karbapenemebisjgufis preparati,yvelaze farTomoqmedebis speqtriT.karbapenemebis jgufiskidev erTiwarmomadgeneli.imipenemTan SedarebiT,xasiaTdebaufro maRali aqtivobiTgramuaryofiTbaqteriebismimarT, dadaqveiTebuliaqtivobiT - stafilokokzeda streptokokze;aseve momatebuliSeRwevadobiThematoencefalurbarierSi.moqmedebs ZiriTadadanaerobulfloraze da ramdenadme- streptokokebze.moqmedebs anaerobulbaqteriebze daprotozoaze.rogorc wesi gamoiyenebasxvaantibiotikebTankombinaciaSi, gamonaklisiaClostridium difficile-Tigamowveulienterokoliti,rodesac monoTerapiacsakmarisia.500 mg yovel6 sT-Si, i/v.1 g yovel 8sT-Si, i/v.600-900 mgyovel 8sT-Si,i/v500 mg yovel8sT-SiwveTovnad, i/v.monitorringi (ALT,AST, kreatininisklirensisgansazRvra).ukunaCvenebia preparatisadmihipermgrZnobelobisada 12wlamde asakisbavSvebSi. Tirkmlisukmarisobisas saWiroadozis koreq-cia.igive,an ix. imipenemiukunaCvenebia hipermgZnobelobisas,wylulovani kolitis,RviZlis ukmarisobisasda antibiotikasocirebulikolitisas.Tirkmelebisdisfunqciisas doziskoreqcia saWiro araris.ukunaCvenebia hipermgrZnobelobisas.zrdis antikoagulantebistoqsiurefeqts, RviZlisdaavadebebisassaWiroa dozis koregireba.ciproflo- ftorqinolonebis 400 mg yovel ukunaCvenebia hiper-62

qsacinijgufis preparati,moqmedebs umrav-lesgramuaryo-fiT daanaero-bulfloraze,metnaklebad moqmedebsstreptokokebze.12 sT-Si, i/v. mgrZnobelobisas,zrdis Teofilinis,kofeinis, ciklosporinisdadigoqsinistoqsiurobas,SeiZleba gaaZlierosantikoagulantebisefeqti (saWiroaproTrombinis droismonitoringi).Tirkmlisukmarisobisas doziskoreqcia.cxrili #2rekombinantuli aqtivirebuli protein C (rhAPC) ukuCvenebebirhAPC zrdis sisxldenis risks. rhAPC ukunaCvenebia Semdeg klinikursituaciebSi, rodesac sisxldena SeiZleba dakavSirebuli iyos maRalsikvdilianobasTan• aqtiuri Sinagani sisxldena• hemoragiuli insulti bolo 3 Tvis manZilze• intrakraniuli an intraspinaluri operacia an Tavis tvinis mZime travmabolo 2 Tvis manZilze• travma, romelic dakavSirebulia sicocxlisaTvis saxifaTo sisxldenismaRal riskTan• epiduruli kaTeteris arseboba• intrakraniuli simsivne, an Tavis tvinis masiuri dazianeba, an cerebruliTiaqari63

Treatment of Septic ShockO. Asatiani, Z. Metreveli, M. Kapanadze, N. Rachvelishvili, E. L. BurnhamNational Medical Center after Prof. O. Gudushauri, Partners for Health NGO, Tbilisi, Georgia;Emory University School of Medicine, Partners for International Development, Atlanta, GA, USAThe artcile presents a draft for new national guideline – result of compilation and adaptation ofGuidelines for Septic Shock diagnosis and management, developed by Georgian doctors from NationalMedical Center in Tbilisi. The guideline is based on recent Evidence Based Medicine materials, latest USand European guidelines on sepsis/septic schock management. Final version has been reviewed by USexpert from Emory University in Atlanta, GA.preeklampsiaz. sinauriZe, r. suluxia, n. zaldastaniSvili, m. nemsaZe, o. asaTianiz. kirtava, n. raWveliSvili, k. papoSvili, m. Cekliakad. o. RuduSauris sax. erovnuli samedicino centri,kavSiri `partniorebi janmrTelobisaTvis~,emoris universitetis samedicino skola /`partniorebi saerTaSorisoganviTarebisaTvis~ (atlanta, jorjia, aSS).I. definicia da klasifikaciadaavadebaTa saerTaSoriso klasifikaciis me-X gadaxedvis mixedviT orsulobaSihipertenziuli mdgomareobebis cnebis qveS gaerTianebulia SemdegipaTologiuri mdgomareobebi: qronikuli hipertenzia da orsulobiT gamowveulihipertenzia. es bolo Tavis mxriv iyofa orsulTa tranzitorul hipertenziadda preeklempsia/eklampsiad.qronikuli hipertenzia - mudmivi hipertenzia, romelic xasiaTdeba arteriuliwnevis momatebiT 140/100 vwy.sv, magram ara umetes 160/110 vwy.sv da Cndebaorsulobamde an orsulobis 20 kviramde.64

orsulobiT gamowveuli hipertenzia - hipertenzia, romelic viTardebaorsulobis dros da qreba orsulobis Semdeg. am jgufSi gaerTianebuliaorsulTa tranzitoruli hipertenzia da preeklempsia/eklampsia.• orsulTa tranzitoruli hipertenziis dros arteriuli wneva araRemateba 150/100 vwy.sv-s da mas ar axasiaTebs proteinuria da SeSupeba.• preeklempsia/eklampsia es aris hipertenzia, proteinuriasTan daSeSupebasTan erTad, romelic viTardeba orsulobis 20 kviris Semdeg.preeklampsiis dros arteriuli wneva aRematebaa) 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 formispreeklampsias axasiaTebs Semdegi parametrebi:1. sistoluri wneva 160 vwy.sv an diastoluri wneva - 110 vwy.sv, racdaregistrirebul iqna 2-jeradad 6 saaTian intervalSi.2. proteinuria 5g/24 sT-Si 3 da meti;3. oliguria (

daavadebis paTogenezi bolomde ar aris garkveuli. Tumca dRevandeliwarmodgeniT, genetikuri midrekilebis Sedegad irRvevadecidualur/trofoblasturi urTierTkavSirebi, rac iwvevs placentaruliperfuziis Semcirebas. placentaruli iSemiis Sedegad xdeba biologiuradaqtiuri faqtorebis gamonTavisufleba da endoTeliaruli ujredebis naadreviapoptozi. es ukanaskneli aris generalizirebuli vazokonstriqciis, iSemiis daTrombozis mizezi. yovelive zemoTTqmulis Sedegad viTardeba sasicocxloorganoebis da placentis funqciis moSla.aRweren preeklampsiis ganviTarebis Semdeg risk-faqtorebs:1. eqstragenitaluri paTologiebi xelsayrel fons qmnian gestozisCamoyalibebisaTvis. Tirkmlebisa da gul-sisxlZarRvTa sistemis daavadebebi,agreTve endokrinuli paTologiebi (cximovani cvlis moSliT mimdinareendokrinopaTiebi, farisebri jirkvlisa da Tirkmelzeda jirkvliskortikaluri Sris paTologiebi) ZiriTad fons qmnian mZime formispreeklempsiis ganviTarebisaTvis. magram, damtkicebul risk-faqtorswarmoadgens mxolod diabeti.2. preeklempsiis prognozirebisas gaTvaliswinebuli unda iqnas genetikurifoni. qalTa 14-40%-s, romelTa dedebsac preeklampsia aqvT gadatanili,orsulobis dros agreTve uviTardebaT es paTologia.3. preeklempsiis sixSire da mimdinareobis simZime mWidrod ukavSirdebasocialur faqtorebs. maRalia misi sixSire `mjdomare~ profesiis mqoneqalebsa da studentebSi. araxelsayreli sawarmoo (qimiuri, fizikuri dasxva), klimaturi da ekologiuri faqtorebi, mavne Cvevebi (Tambaqos weva,alkoholis Warbi moxmareba), araswori kveba, Sromisa da dasvenebis reJimisdarRveva da orsulobisadmi uaryofiTi damokidebuleba xels uwyobspreeklempsis ganviTarebas.4. preeklempsiis ganviTarebaSi garkveuli roli eniWebaT ginekologiurpaTologiebs. misi sixSire maRalia qalebSi, romelTac anamnezSi aReniSnebaTmenstrualuri ciklis darRvevebi, sasqeso organoebis anTebiTi daavadebebi,saSvilosnos mioma, sasqeso organoebis ganviTarebis anomaliebi da abortebi.5. maRali riskis jgufs unda mivakuTvnoT orsulebi, romelTac aReniSnebaTmravalwylianoba, mravalnayofiani orsuloba, didi nayofi, anemia, Cveuliabortebi, rezus-SeuTavsebloba da adreuli toqsikozi.6. qalis asaki erT-erTi faqtoria, romelsac zemoqmedeba gaaCnia preeklampsiisganviTarebaze, mimdinareobasa da gamosavalze. igi ufro xSirad Zalzedaxalgazrda (19 wlamde asakis) da xandazmul (35 welze meti asakis)orsulebSi viTardeba. 40 wlis zemoT preeklempsiis Camoyalibebis riskierTi aTad izrdeba. varaudoben, rom amis mizezi mocemul kontingentSisasicocxlo mniSvnelobis mqone sistemaTa adaptaciuri SesaZleblobebisdaqveiTebaa.7. erT-erTi risk-faqtoria pirveli orsuloba.Tumca aRsaniSnavia, rom zemoT CamoTvlili risk-faqtorebis fonzepreeklampsiis ganviTareba ar aris dafuZnebuli myar mtkicebulebebze.IV. klinikuri simptomatikapreeklempsia/eklampsiis klinikuri niSnebia:66

1. arteriuli wnevis mateba 140/90 vwy.sv-ze zeviT, an sawyisi sistoluriwnevis 30 vwy.sv – iT, xolo diastoluri wnevis - 15 vwy.sv-iT mateba;2. proteinuria;3. generalizirebuli SeSupeba.garda zemoTaRniSnulisa, preeklampsiis mZime formas xSirad Tan sdevsSemdegi 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 xSiradaraswored interpretirdeba, rogorc mwvave respiratoruli infeqciissimptomi;− kanis qavili;− gulisreva, Rebineba;− nayofis saSvilosnosSida ganviTarebis Seferxeba.garTulebebipreeklampsia SeiZleba garTuldes Semdgegi paTologiuri mdgomareobebiT:1. normalurad mimagrebuli placentis naadrevi acliT, romelsac moyvebadisenimirebuli koagulopaTia;2. TromboemboliiT, romelic gamoixateba adgilobrivi angeneralizirebuli TromboziT;3. Tirkmlis pirveladi mwvave ukmarisobiT;4. mikroangiopaTiuri hemolizuri anemiiT, romelic xasiaTdeba hematuriiTda anemiiT;5. hepatocelularuli darRveviT – RviZlis fermentebis momatebiT;6. HEELP (Hepatic Enzymes Elevated Low Platelet) sindromiT - Trombocitebisraodenobis SemcirebiT da RviZlis fermentebis momatebiT;7. centralur nervul sistemaSi sisxlCaqceviT;8. eklampsiiT, romelic gamoixateba krunCxvebiT da/an komiT.V. diagnozipreeklampsiis diagnozi efuZneba cangenmeisteris triadas:1. arteriuli hipertenzia;2. proteinuria;3. SeSupeba.dasabuTebuli medicinis Tanamedrove monacemebze dayrdnobiT SeiZleba iTqvas,rom preeklampsiis diagnozis dasasmelad aRniSnuli diagnostikurikriteriumebidan aucilebelia proteinuriis arseboba.VI. gamokvlevebis sqema67

I. laboratoriuli diagnostika.preeklampsiis diagnostikisaTvis pacientis SemosavlisTanave CasatarebeliaSemdegi 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 sworitaqtikis 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 kvlevaIII. konsultaciebi:• Terapevtis• nefrologis• nevropaTologis• oftalmologis• anesTeziologisVII. mkurnalobis sqemapreeklampsiis marTvis ZiriTadi mizania maqsimalurad Semcirdes dedis danayofis dazianeba orsulobis Sewyvetamde, romelic aris sruli gankurnebiserTaderTi gza. preeklampsiis msubuqi formis (arteriuli wneva ar aRemateba140/90 vwy.sv, SeSupeba aReniSneba mxolod qveda kidurebze, proteinuria ar arisan aReniSneba cilis mxolod niSnebi) mkurnalobas atarebs mxolodspecializirebuli ambulatoriuli dawesebuleba - qalTa konsultacia - 3dRis 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 saaTisganvalobaSi.prehospitaluri etapi:68

samedicino personalma (eqTanma, bebia-qalma) unda uzrunvelyos orsulistransportireba me–III an/da me–IV donis satacionarSi. transportirebis drosunda Catardes periferiuli venis kaTeterizacia msxvili kaTeteriT (G 16 – 18),kaTeterizirebuli iqnas Sardis buSti, daiwyos Jangbadis miwodeba, dawesdeskontroli arteriul wnevaze, pulsze, nayofis guliscemaze. orsulitransportirebuli unda iqnas marcxena gverdze mwoliare mdgomareobaSi.stacionaruli daxmareba:mZime preeklampsiis yvela SemTxveva unda warmarTuli iqnas, rogorc eklampsiisSemTxvevamarTvis ZiriTadi principebi:‣ magniumis sulfatis gamoyeneba;‣ hipotenzia;‣ simptomaturi mkurnaloba;‣ nayofis distresis koreqcia;‣ orsulobis Sewyveta 34 kviris zemoT.magniumis sulfatis gamoyenebamagniumis sulfatis datvirTviTi Terapiuli doza Seadgens 4g (16 ml 25%-ianixsnari) – 6g (24 ml 25%-iani xsnari) mSral nivTierebas. es doza Seyvanili undaiqnas 20-30 wuTis ganvalobaSi intravenurad ganzavebul 100-200 mlkristaloidur xsnarSi, sasurvelia Seyvana moxdes perfuzomatis meSveobiT.SemdgomSi intravenuri infuzia unda gagrZeldes Semdegi doziT: 1-3 gramimSrali nivTiereba/saaTSi (4-12 ml 25%-iani xsnari). infuzia undamimdinareobdes 24 saaTis ganvalobaSi, sasurvelia infuzomatis meSveobiT.magniumis sulfatis dRiuri doza (mSral nivTierebaze gadaangariSebiT) 12gramze naklebi ar unda iyos. unda gvaxsovdes, rom magniumas sulfatigamoiyeneba krunCxvis profilaqtikisaTvis, da ara - rogorc hipotenziurisaSualeba.hipotenziuri mkurnalobahipotenziuri mkurnalobis ZiriTadi mizania davaqveiToT diastoluri wneva 90vwy. sv-mde, amave dros unda gvaxsovdes, rom wnevis swafma vardnam SeiZlebagamoiwvios 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 #1saswrafo hipotenziuri Terapiis saSualebebi orsulobisas.preparati dozireba moqmedeba69

1. hidralazini(Hidralazine)2. labetaloli(Labetalol)10-50 mg kunTebSi 3-6saaTSi;5-25 mg venaSi 3-6 saaTSi;(5-10 mg venaSi yovel 15-20 wuTSi sasurveliSedegis miRebamde)20-50 mg venaSi 3-6saaTSi;20 mg venaSi nakadiT, 10wT-is Semdeguefeqtobis SemTxvevaSi40 mg; Semdeg 80 mgyovel 10 wuTSimaqsimalur dozamde(220 mg)3. nifedipini 4(Nifedipine) 10 mg peroralurad 4-8saaTSi4. arfonadi(Arfonad)2 g/l wveTovani i/v;1-5 mg/wT siCqariTmoqmedebis dawyeba:10-20 wT;maqsimaluri efeqti:20-40 wT;xangrZlivoba: 3-8 saaTimoqmedebis dawyeba: 1-2 wT;maqsimaluri efeqti: 10 wT;xangrZlivoba: 6-16 saaTimoqmedebis dawyeba: 5-10 wT;maqsimaluri efeqti: 10-20wT;xangrZlivoba: 4-8 saaTimoqmedebis dawyeba: 1-2 wT;maqsimaluri efeqti: 2-5 wT;xangrZlivoba: 10 wTsimptomuri mkurnalobapreeklempsiis mkurnalobaSi didi mniSneloba aqvs infuziur Terapias. ammizniT gamoiyeneba Semdegi infuziuri xsnarebi:− koloiduri xsnarebi – axladgayinuli plazma, albumini, aminomJavebisnakrebi;− kristaloiduri xsnarebi - marilovani narevebi da glukozis xsnarebi.kristaloiduri da koloiduri xsnarebis Tanafardoba damokidebulialaboratoriul suraTze (saerTo cila, cilis fraqciebi). infuziuri TerapiispirobebSi nebadarTulia diurezuli saSualebebis (laziqsi, osmodiurezulipreparatebi) gamoyeneba hematokritis kontroliT. hematokritis done ar undaiyos 35-ze meti da 27-ze naklebi. infuziuri xsnaris Seyvanis siswrafedaavadebis 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 infuzomatissaSualebiT.nayofis distresis koreqciapreeklampsiis dros perinataluri danakargebis Semcirebis mizniT didimniSneloba aqvs nayofis arsebuli distresis koreqcias. preeklampsiisSemTxvevis marTvisas upirobo moTxovnaa nayofis mudmivieleqtrokardiografiuli monitoringi da aseve - ultrasonografiulidoplerografiuli gamokvleva. nayofis mdgomareobis gasaumjobesebladaucilebelia Jangbadis miwodeba, vazoaqtiuri preparatebis da cilovanifraqciebis gamoyeneba.4 - nifedipinis gamoyeneba magniumis sulfatTan erTad ar aris mizanSewonili70

orsulobis Sewyvetasaswrafo momSobiarebis Cvenebebi naCvenebia cxrili #2:cxrili # 2taciasaswrafo momSobiarebis Cvenebebiadedis mxridannayofis mxridan1. orsulobis vada ≥38 kvira;2. Trombocitebis raodenoba

miRebuli literaturis Sejereba da adaptacia.XI. alternatiuli gaidlaini – ar aris moyvaniliXII. gamoyenebuli literatura:1. sinauriZe z: preeklampsia/eklampsia. krebulSi: dedaTa da bavSvTa samedicinodaxmarebis meToduri rekomendaciebi. USAID; MSH; CIF. Tbilisi, 2002:204-215.2. Brady WJ, DeBehnke DJ, Carter CT: Postpartum toxemia: hypertension, edema, proteinuria andunresponsiveness in an unknown female. J Emerg Med 2001 Sep-Oct; 13(5): 643-83. Hals G, Crump T: The pregnant patient: guidelines for management of common life-threatening medicaldisorders 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 Practiceof Emergency Medicine. 2nd ed. 1998: 315-21.5. National High Blood Pressure Education Program: Working Group report on high blood pressure inpregnancy. National Heart Lung and Blood Institute. Working Group Report on High Blood Pressure inPregnancy. 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, medicinismecnierebaTa 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 samsaxurisufrosirecenzentebi:15. m.m.k. z. kirtava – erovnuli sainformacio saswavlo centrisdireqtori, kavSiri `partniorebi janmrTelobisaTvis~ Tavmjdomare,Tbilisis sax. samedicino universitetis Sinagan sneulebaTa #1kaTedris asistenti16. m.m.k. n. raWveliSvili, Tbilisis sax. samedicino universitetis SinagansneulebaTa #1 kaTedris asistenti, kavSiri `partniorebijanmrTelobisaTvis~ gamgeobis wevri17. k. papoSvili, janmrTelobis da socialuri dacvis erovnuliinstitutis direqtori18. m. Cekli, emoris universitetis samedicino skolis gadaudebelidaxmarebis ganyofilebis specialisti72

PreeclampsiaZ. Sinauridze, R. Sulukhia, N. Zaldastanishvili, M. Nemsadze, O. AsatianiZ. Kirtava, N. Rachvelishvili, K. Paposhvili, M. CheckleyNational Medical Center after Prof. O. Gudushauri, Partners for Health NGO, Tbilisi, Georgia;Emory University School of Medicine, Partners for International Development, Atlanta, GA, USAPreeclampsia is known as hypertensive disorder of pregnancy, revealed by arterial hypertension (usuallyexceeding 140/90 mm hg, or exceeding initial systolic pressure on 30 mm Hg and/or diastolic pressure on15 mm Hg), proteinuria and generalized edema. The guideline has been developed mainly based on tworecent emergenyc guidelines adaptation.asTmuri statusis marTvao. asaTiani, z. metreveli, m. kapanaZe, z. kirtava, n. raWveliSvili, k. papoSvili,a. sioreakad. o. RuduSauris sax. erovnuli samedicino centri,kavSiri `partniorebi janmrTelobisaTvis~,emoris universitetis samedicino skola / `partniorebi saerTaSorisoganviTarebisaTvis~ (atlanta, jorjia, aSS).I. daavadebis definicia:bronquli asTma warmoadgens filtvebis qronikul daavadebas, romelicxasiaTdeba sasunTqi gzebis anTebiT, obstruqciiTa da hiperreaqtiulobiT.asTmuri statusi warmoadgens bronquli asTmis Setevas, romelicxasiaTdeba ufro mZime da xangrZlivi mimdinareobiT, standartulimkurnalobisadmi rezistentobiT da sunTqvis mwvave ukmarisobiT. asTmuristatusis xangrZlivoba SeiZleba iyos ramdenime saaTidan4-6 dRemde da meti.daavadebaTa saerTaSoriso klasifikaciiT asTmur statuss miniWebuli aqvskodi (ICD-10): J46II. epidemiologia:73

saerTaSoriso monacemebiT bronquli asTma sxvadasxva eTnikur jgufebSivlindeba mosaxleobis 1-30%-Si. amerikis SeerTebuli Statebis mosaxleobaSibronquli asTma aRiniSneba 4-8%-Si, aqedan daaxloebiT naxevari modisbavSvebze. bronquli asTmis gamwvaveba (bronquli asTmis Seteva da/an asTmuristatusi) gvxvdeba SemTxvevaTa 0,2-0,4%-Si.qalebi asTmis gamwvavebiT (bronquli asTmis Seteva, asTmuri statusi)orjer ufro xSirad mimarTaven gadaudebeli daxmarebis ganyofilebebs, vidremamakacebi.aRsaniSnavia bronquli asTmis gamwvavebiT (bronquli asTmis SeteviT anasTmuri statusiT) gamowveuli sikvdilianobis mateba 13:1000000-dan (1982 w.)19:1000000-mde (1991 w.). amavdroulad izrdeba ara marto asTmiT gamowveulisikvdilianoba, aramed - daavadebis gavrcelebac.Uuaxlesi monacemebiT bronquli asTmiT gamowveuli sikvdilianoba aRwevs20-30:1000000-ze. amaTgan mxolod 10%-ia 40 wels gadacilebuli.III. etiologia/risk-faqtorebi/paTologia:etiologiuri faqtorebi:bronquli asTmiT daavadebulebSi asTmis gamwvaveba da asTmuri statusisCamoyalibeba 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 SewyvetapaTogenezi:asTmuri statusis mTavari paTofiziologiuri elementebia bronqebisobstruqcia, ganpirobebuli bronqebis kedlis SeSupebiT, bronqospazmiT,bronquli drenirebis darRveviT, bronquli sekretis gasqelebiT da lorwovanisacobebiT bronqebis obturaciiiT, rac iwvevs CasunTqvis gaZnelebas,amosunTqvis gaZlierebas da gaxangrZlivebas, filtvebis sasicocxlomoculobis, filtvebis forsirebuli sasicocxlo moculobis, forsirebuliamosunTqvis moculobis da amosunTqvis pikuri siCqaris daqveiTebas.74

mwvave asTmis ganviTarebis mniSvnelovani meqanizmia antigen-antisxeulisurTierTqmedeba, rac aaqtivebs membranul fosfolipazas da iwvevs araqidonismJavas warmoqmnas. es ukanaskneli ciklooqsigenazas mier metabolizirdebavazoaqtiur prostaglandinebad (mag. Tromboqsani, prostaciklini) anleikotrienebad da maT winamorbedebad. yvela maTgani moqmedebs gluvmuskulaturaze da SeuZlia gamoiwvios sasunTqi gzebis hipermgrZnobeloba daanTeba. leikotrienebis sinTezis da/an aqtivobis farmakologiur inhibitorebsaqvT SesaniSnavi efeqti asTmis dros, rac TvalnaTliv aCvenebs ramdenadmniSvnelovan mediatorebs warmoadgenen leikotrienebi asTmisa da filtvebisobstruqciuli daavadebebis dros.aseve mniSvnelovani momentia filtvebis “gadaberva” – avadmyofiCaisunTqavs met haers, vidre amoisunTqavs. amas xels uwyobs bronqospazmisfonze amosunTqvis aqtivaciac, rac iwvevs intraplevruli wnevis matebas,bronqiolebis eqspiraciul kolafss da haeris Sekavebas filtvebSi. bronqebisobturacia ki ganapirobebs ventilaciur-perfuziul disbalanss.Yyvela zemoaRniSnuli faqtori iwvevs respiratoruli muskulaturisgadaZabvas da gamofitvas, sunTqvis Jangbadovani fasis (efeqturobis)Semcirebas, viTardeba progresirebadi hipoqsemia, hiperkapnia, respiratoruliacidozi.asTmuri statusi iwvevs hemodinamikur darRvevebsac – gulmkerdSidawnevis mateba iwvevs marjvena winagulis diastoluri avsebis Semcirebas; aseveviTardeba mcire wris hipertenzia. am or faqtors sabolood mivyavarTmarjvenagulovan ukmarisobamde. parkuWTaSua Zgidis gadanacvleba marcxniv damarcxena parkuWis diastoluri avsebis daqveiTeba iwvevs marcxenaparkuWovanukmarisobas. garda amisa, hiperventilacias da gaZlierebul oflianobas xSiradmivyavarT 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. samkuTxapozicias - xelebiT dayrdnobilia sxeulze an raime saganze;75

simptomebis progresirebas Tan axlavs mzardi hiperkapnia dahiperventilacia, bolo stadiaSi _ profuzuli oflianoba, haerisukmarisobis 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, gaxangrZlivebuliamosunTqva; bolo stadiaSi filtvebSi sunTqviTi xmianoba aRar moismineba;- hipoventilacia, bradikardia da Seupovari hipoqsemia warmoadgenendaavadebis prognozulad arakeTilsaimedo niSnebs.V. diagnozi:diagnozi eyrdnoba Semdeg monacemebs:♦ anamnezuri monacemebi da fizikaluri gamokvleva;♦ bronqodilatatorebis uefeqtoba (bronquli asTmis mwvave Setevisasbronqodilatatorebi dadebiT efeqts iZlevian, xolo asTmuri statusisdiagnozis 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, traqeis76

• 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 dafiltvebis xelovnuri ventilaciis saWiroebis gansazRvrisaTvis);♦ pulsoqsimetria;♦ spirometria (bronqospazmis obieqturi Sefasebis saSualebaa, PEF

traqeis intubacia – traqeis intubaciis da fxv-s Cvenebebia: mzardi hipoqsemia(PO2

2. adrenomimitiuri preparatebiβ2-agonistebi – asTmis mkurnalobaSi warmoadgenen pirveli rigis preparatebs,Tumca asTmuri statusis ganviTarebisas mosalodnelia maTze rezistentobisganviTareba da maT miRebas ex juvandibus diagnostikis azri hqondes. inhalaciaufro efeqturia, vidre i/v Seyvana. parenteraluri gza misaRebia im SemTxvevaSi,Tu inhalacia SeuZlebelia (Zlieri xvela). speiseris gamoyeneba ufroefeqturia, vidre - nebulaizeris. ukunaCvenebia taqiaritmiebis,hipermgrZnobelobis dros. Tu statusis dros inhalaciam Tavidanve efeqti armogvca, ganmeorebiT miRebebs azri ara aqvs da unda gadavideT adrenalinisjgufze.salbutamoli – speiseriT 4-8 inhalacia, 15 wT-Si 3-4 inhalacia,Semdgom - yovel 4-6 sT-Si. nebulaizeriT - 5-10 mg20 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. kanqveS0,25mg, uefeqtobisas SeiZleba igive doza ganmeordes 15-30 wT-Si, Semdgom yovel4sT.α,β-agonistebi: epinefrini (adrenalini) – β-agonisturi aqtivoba iwvevsbronqodilatacias, alfa-agonisturi aqtivoba iwvevs periferiulisisxlZarRvovani rezistentobis gazrdas da dadebiTefeqts iZleva sistemuri hipotenziisas.- kanqveS: 0,3-0,5 mg, mikrodozatoriT: 4-8 mkg/wT, intubirebul pacientebSiSesaZlebelia saintubacio milidan 5 ml 1:10000 xsnari. ukuCvenebebia:koronaruli daavadeba, arakontrolirebadi hipertenzia, mZime parkuWovanitaqikardia. 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 xSirad79

SeuZlebelia preparatebis per os miReba, ris gamoc iwyeben maT intravenurinfuzias, xolo per os miReba dawyebuli unda iyos maSinve, roca ki esSesaZlebelia. ukunaCvenebia peptiuri wylulis, hipermgrZnobelobis, virusulida sokovani infeqciebis, RviZlis daavadebebis dros. diuretikebTan kombinaciisSemTxvevaSi, hipokalemiis Tavidan acilebis mizniT, saWiroa kaliumis doniskontroli. digoqsinTan kombinaciaSi zrdis intoqsikaciis risks. gverdiTiefeqtebidan aRsaniSnavia hiperglikemia, SeSupeba, osteoporozi, fsiqozi,hipokalemia, miopaTia.meTilprednizoloni – datvirTviTi doza: 2 mg/kg, SemanarCunebeli: 0,5-1 mg/kgyovel 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 xarisxisgarTulebebisas. ukunaCvenebia hipermgrZnobelobis dros. sifrTxiliT undaiqnas gamoyenebuli RiakuTxovani glaukomis, winamdebare jirkvlishipertrofiis 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 maRalitoqsiuroba - mcire Terapiuli intervali. amis gamo ar unda iqnas gamoyenebulirutinulad da araa naCvenebi pirveli 4 sT-is ganmavlobaSi. gamoiyeneba mxolodsxva preparatebis uefeqtobis SemTxvevaSi.ukuCvenebebia: hipermgrZnobeloba, arakontrolirebadi aritmia,hiperTireoidizmi, peptiuri wyluli. sifrTxiliT unda iqnas gamoyenebulihipertenziis, taqiaritmiis, filtvebis SeSupebisa da RviZlis daavadebebisdros. 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 24sTisganmavlobaSi 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 SemTxvevaSikarg efeqts iZlevian. izoflurans minimaluri kardiodepresiuli daaritmogenuli aqtivoba aqvs. halotani xasiaTdeba, izofluranTan SedarebiT,ufro metad gamoxatuli bronqodilataciuri efeqtiT, ukunaCvenebiahipermgrZnobelobisas, sifrTxiliT unda iqnas gamoyenebuli epinefrinTan(adrenalinTan) da norepinefrinTan (noradrenalinTan) erTad, gverdiTiefeqtebidan 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 mizanSewoniliaglukozis infuzia – 2-3 l/dR, mZime SemTxvevaSi 5 l-mde, centraluri venuriwnevis, hematokritisa da saaTobrivi diurezis kontroliT, ukuCvenebebisgaTvaliswinebiT (mag. gulis ukmarisoba).- hipovolemiis koreqciisaTvis SesaZloa saWiro gaxdes koloidebis infuzia,rekomendirebulia reologiuri Tvisebebis koloidebi.80

9. antobiotikoTerapia – iniSneba mxolod infeqciis arsebobisas (sinusiti, pnevmonia).asTmuri statusis kupirebisa da intensiuri Terapiis Sewyvetiskriteriumebia bronqospazmisa da obstruqciis, sunTqvis mwvave ukmarisobisSemcireba. Ppulsoqsimetriis,, spirometriisa da, mJava-tutovani wonasworobisparametrebis gaumjobeseba damatebiT kriteriumebad ganixileba.Semdgomi mkurnaloba da monitornigi xorcieldeba Terapiul ganyofilebaSi.VIII. reabilitacia / meTvalyureoba – specialuri miTiTebebigaidlainebis 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 SerCeulisxvadasxva gaidlainebis Sejerebisa da adaptaciis gziT.XI. gamoyenebuli literatura:1. British Guideline on the Management of Asthma. British Thoracic Society Scottish IntercollegiateGuidelines Network. Revised edition April 20042. Global strategy for asthma management and prevention. 2003. 180 p. [662 references]http://www.guidelines.gov3. 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.html4. Доказательная медицина и ее применение в пульмонологии (диагностика и лечениебронхиальной 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.nz6. Singapore Ministry of Health. Management of asthma. Singapore: Singapore Ministry of Health; 2002Jan. http://www.gov.sg7. University of Michigan Health System. UMHS asthma guideline. Ann Arbor (MI): University ofMichigan Health System; 2000 Jan. http://cme.med.umich.edu81

8. Asthma, Barry Brenner, MD, PhD, Chairman, Department of Emergency of Medicine, Professor,Departments of Emergency Medicine and Internal Medicine. http://www.emedicine.com9. National Asthma Education and Prevention Program: Guidelines for the diagnosis and management ofasthma. 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 samedicinocentris informaciis marTvisa da uwyvetisamedicino ganaTlebis samsaxuris ufrosi.zaza metreveli – akad. o. RuduSauris sax. erovnuli samedicinocentris katastrofisa da gadaudebelimedicinis samsaxuris ufrosi.mamuka kapanaZe - akad. o. RuduSauris sax. erovnuli samedicinocentris gadaudebeli daxmarebis (mimRebi) ganyofilebiseqimi-reanimatologi.recenzentebi:19. m.m.k. z. kirtava – erovnuli sainformacio saswavlo centrisdireqtori, kavSiri `partniorebi janmrTelobisaTvis~ Tavmjdomare,Tbilisis sax. samedicino universitetis Sinagan sneulebaTa #1kaTedris asistenti20. m.m.k. n. raWveliSvili, Tbilisis sax. samedicino universitetis SinagansneulebaTa #1 kaTedris asistenti, kavSiri `partniorebijanmrTelobisaTvis~ gamgeobis wevri21. k. papoSvili, janmrTelobis da socialuri dacvis erovnuliinstitutis direqtori22. a. siore – ufrosi rezidenti, filtvis, alergiis da kritikulimedicinis ganyofileba, emoris universitetis samedicio skola,atlanta, aSS(Amsel M. Siore - MD, Senior Fellow, Pulmonary, Allergy and Critical Medicine, School ofMedicine, Emory University, Atlanta, GA, USA)82

Asthmatic Status ManagementO. Asatiani, Z. Metreveli, M. Kapanadze, N. Rachvelishvili, K. Paposhvili, A. SioreNational Medical Center after Prof. O. Gudushauri, Partners for Health NGO, Tbilisi, Georgia;Emory University School of Medicine, Partners for International Development, Atlanta, GA, USAAsthmatic status (Status Asthmaticus) represents severe and long-term asthma exacerbation, resistant tostandard treatment, and severe respiratory failure. The term of Status Asthmaticus could vary betweenseveral 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 otherrecent guidelines on severe asthma.83

iumori samedicino Temazepatara 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 feradiorganoebi aqvT - guli naRdi wiTelia, kuWi – vardisferi, elenTa - mwvane.~meorem aitaca Tema: `me ki buRaltrebi mirCevnia – gaxsni mucels da yvelaferi isedanomrilia da Cawikwikebuli – Zalian advilia, araferi SegeSleba.~`aba me advokatebis operirebas araferi mirCevnia – arc guli aqvT, arc jigari, TanacTavi da ukana tani erTmaneTs cvlis.” – wertili dasva mesamem.saswrafo daxmarebis telefonis - 911 (amerikelebi `cxra-TerTmets~ uZaxian)SemoRebidan cota xanSi moxucma qalma mimarTa roCesteris saavadmyofos gadaudebelidaxmarebis ganyofilebas, Zlivs daayena Tavisi manqana avtosadgomze da gaWirvebiTgadmovida manqanidan. amis Semxedvare eqTanma gancvifrebulma hkiTxa: `ki magram, argerCivnaT `cxra-TerTmetiT~ saswrafo gamogeZaxaT? aseT mdgomareobaSi manqanis tarebaratom 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, rom24 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 HumorA 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 youngster3 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 arenumbered, makes it very easy.”The third Doctor says: "I love doing surgery on Lawyers, they have no Heart, they have no Guts and theHead and the Ass are interchangeable!"84

Shortly after the 911 emergency number became available, an elderly and quite ill lady appeared in aRochester hospital emergency room, having driven herself to the hospital and barely managing tostagger in from the parking lot. The horrified nurse said, 'Why didn't you call the 911 number and get anambulance?'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.85

saqarTvelos Sromis, janmrTelobis da socialuri dacvissaministro internetSiwww.healthministry.ge an www.MoLHSA.geinternetSi ganTavsebul resursebs sul ufro mzardi auditoria hyavssaqarTveloSic. satelekomunikacio saSualebebisa da kompiuteruliteqnologiebis SedarebiTi simwiris da enobrivi barieris gamo qveyanaSiinternetiT regularulad mosargebleTa raodenoba jer kidev dabalia daeqspertTa umravlesobis azriT mosaxleobis 5%-10%-s ar aRemateba (Tanac maTiabsoluturi umravlesoba Tbilisis macxovrebelia). da mainc optimisturadgangvawyobs am ricxvis mniSvnelovani zrdis dinamika bolo 3-4 wlisganmavlobaSi (2000 wels es maCvenebeli 1-2% iyo). amaze naTlad migvaniSnebsdrois swored am monakveTSi internet-klubebis da internet-kafeebis sakmaodTvalSisacemi mozRvaveba, ADSL teqnologiis uswrafesi popularizacia,ukabelo (Wi-Fi) internetiT aRWurvili sazogadoebrivi adgilebis gamoCena,internetiT sargeblobis mravaljeradi baraTebis gavrceleba da ismniSvnelovani dro da saxsrebi, romelic internetis momwodeblebis(“provaiderebis”) mier televiziaSi da bilbordebze ganTavsebul reklamaSiixarjeba.internetSi oficialuri da sajaro informaciis ganTavseba amerikis da evropismraval qveyanaSi sakanonmdeblo moTxovnaa. sazogadoebrivi samsaxurisinformacia – momsaxurebis saxeebi, sakanonmdeblo maregulirebelidokumentebi, tarifebi, satendero gancxadebebi, informacia katastrofebis Tuepidemiologiuri safrTxis Sesaxeb, - Ria da xelmisawvdomi unda iyosinternetiTac. saqarTveloSi es jer araa aucilebeli moTxovna, Tumca evropulstruqturebSi integrirebisa da Ria sazogadoebis aSenebis kvalobaze, albaT esaxlo momavlis perspeqtivaa.unda aRiniSnos, rom jandacvis da medicinis sakiTxebi mzardi popularobiTsargeblobs mTel msoflioSi – sazogadoebas ainteresebs cxovrebis jansaRiwesis, uaxlesi samedicino preparatebis, axali samedicino nou-haus,samkurnalo-diagnostikuri centrebis da wamyvani klinikebis sakontaqtomonacemebi, da sxva sakiTxebi, amas emateba jandacvis profesionalTa dapacientTa qseluri kavSirebi.jandacvis saministro pirveli samTavrobo struqtura iyo saqarTveloSi,romelsac ukve 1998 wels oficialuri veb-gverdi gaaCnda erovnulisainformacio saswavlo centris (essc) serverze – www.nilc.org.ge. 2001 wels Riasazogadoebis (sorosis) fondma Caatara konkursi, romliTac ganmovlindacentraluri da aRmosavleT evropis da dsT rva qveynis jandacvis sistemis vebgverdi,romelTa ganaxlebisaTvis granti gamoiyo. essc-is mier momzadebulmasaqarTvelos jandacvis sistemis veb-portalma www.health.net.ge, - romelzecganTavsda jandacvis rogorc saxelmwifo, aseve arasamTavrobo da kerZoseqtoris informaciebi da jandacvis statistikis srulyofili saxelmwifo daregionaluri monacemebis baza – saboloo jamSi fondis sabWos mier am rvaproeqtis Sefasebisas xorvatiis Semdeg II adgili daikava. 2002 wels jandacvissaministros tenderiT erovnul sainformacio saswavlo centrs daevalasaministros veb-gverdis ganaxleba, romelic aseve ganTavsda zemoTdasaxelebulportalze.86

2004 wels saministros struqturis cvlilebebis Semdeg dRis wesrigSi dadgasaministros axali veb-gverdis Seqmna. wlis bolos Catarebul tenderSi iseverovnulma sainformacio saswavlo centrma gaimarjva da praqtikulad 6 kvirisganmavlobaSi moamzada saintereso samenovani veb-gverdi, romelicdaregistrirda or paralelur misamarTze www.MoLHSA.ge (saministrosinglisuri dasaxelebis - Ministry of Labour Health and Social Affairs – MoLHSA -abreviaturis mixedviT) da www.healthministry.ge (sxvadasxva qveynebis jandacvissaministroebis veb-gverdebis yvelaze gavrcelebuli msgavsi domenurisaxelebis analogiurad).axali samenovani (qarTuli, inglisuri, rusuli) veb-gverdi cxra monacemTabazas moicavs da aRWurvilia srulyofili saZiebo sistemiT.veb-gverdze warmodgenilia sruli informacia jandacvis sferoSi qveyniserovnuli politikis da saministros struqturis Sesaxeb. aq nebismier adamiansSeuZlia gaecnos saministros biujets, samedicino standartebs da jandacvis,socialuri da dasaqmebis sferoebis normatiul aqtebs. sakanonmdeblomonacemTa bazis rva sxvadasxva kategoriaSi klasificirebulia saministrosbrZanebebi, aseve moyvanilia Sesabamisi amonaridebi konstituciidan,saqarTvelos kanonebi jandacvis da socialuri dacvis Sesaxeb, saerTaSorisokonvenciebi da aqtebi.veb-gverdze samedicino organizaciaTa Zieba SeiZleba saqarTvelos regionebisrukis mixedviT ganxorcieldes da dawesebulebaTa saqmianobis licenzirebismonacemebsac Seicavs, rac momxmarebels xels Seuwyobs samedicino daxmarebisprofilis sasurveli informaciis miRebaSi.veb-gverdze aris specialuri baneri “tenderi/vakansia”(http://www.healthministry.ge/vacancy.php), rac socialur da jandacvis sferoSigamocxadebuli satendero winadadebebis da vakanturi samuSao adgilebiskoleqtors warmoadgens da albaT bevri organizaciis da adamianisdainteresebas gamoiwvevs.garda amisa, veb-gverds gaaCnia jandacvis da socialuri sferos saerTaSorisograntebis saZiebeli sistema inglisur enaze, romelic male 600-mdesaerTaSoriso organizaciis mier SemoTavazebuli grantebis Ziebis saSualebasmiscems eqimebs da jandacvis profesionalebs. veb-gverdze warmoadgeniliasamedicino 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 dakredit-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 warmogvidgensregionebis mixedviT, xolo ZiriTad indikatorebze gadasvla calke bmuliTmTavari gverdidan xdeba misamarTze -http://www.healthministry.ge/healthcare_indicators.php#one – monacemebi mowodebuliadaavadebaTa 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, romlebic87

statistikis saxelmwifo komitetis mier mowodebul mniSvnelovan indikatorebsaerTianebs.ganaxlebul veb-gverdze gaCnda axali ambebis da presis daijestis ganyofileba,sadac Suqdeba saqarTveloSi Sromis, janmrTelobisa da socialuri dacvissferoSi momxdari nebismieri siaxle. aRniSnuli ganyofileba sistematuradaxldeba saministros aparatis presasa da sazogadoebasTan urTierTobissammarTvelos TanamSromlebis mier.veb-gverdis mniSvnelovani miRwevaa mosaxleobasTan ukukavSiris SesaZlebloba.am mizniT saitze Seqmnilia momxmareblis gverdi, romlis meSveobiTacmosaxleobas SesaZlebloba aqvs SekiTxvebiT mimarTos saministroswarmomadgenlebs da umokles droSi pasuxi el-fostis meSveobiT miiRos.dabolos, gverdze warmodgenilia qveynis jandacvis sistemis zogadistruqtura, am sferoSi moRvawe arsamTavrobo da saerTaSoriso organizaciebi,ganTavsebulia bmulebi saqarTvelos parlamentis janmrTelobis da socialuridacvis komitetTan, jandacvis msoflio organizaciasTan, evrosabWosTan,sxvadasxva saerTaSoriso organizaciebTan.vimedovnebT, es axali internet-resursi sargeblobas moutons momxmareblebsmaTTvis saWiro informaciis advilad moZiebaSi.88

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.geerovnuli sainformaciosaswavlo centri (essc)iv. javaxiSvilis q. #51tel 94 13 88faqsi 94 13 91el-fosta: dmeskhi@nilc.org.geinterneti: www.nilc.org.geinternetis veb-gverdis monacemebis forma organizaciebisaTvisSeiZleba mowodebul iqnas rogorc qarTul, aseve - inglisur enebze,* - aRniSnulia aucilebeli punqtebi1. * organizaciis dasaxeleba:sruli dasaxeleba da abreviatura(rogorc qarTul, aseve - inglisur2. * organizaciis misamarTi:qalaqi, kodi, quCa, nomeri, oTaxebis nomeri (rogorc qarTul, aseve -3. * telefoni #1:4. telefoni #2:+995-32-xx xx xx+995-32-xx xx xx5. faqsi: +995-32-xx xx xx6. el-fosta:7. veg-gverdi:arsebuli URL anda sasurveli abreviatura inglisurad8. organizaciis struqtura:1. ganyofilebebis CamonaTvali2. TanamSromelTa raodenoba3 SeiZleba iyos organizaciuli gegma9. * organizaciis xel-li piri:* gvari, saxeli10. organizaciis miznebi:mokle aRweriloba (maqs 100 sityva)89

11. organizaciis proeqtebi:mimdinare:CamonaTvali da TiToeul proeqtze:1. dasaxeleba2. mokle aRweriloba (daaxlebiT 100 sityvaTiToeul proeqtze)3. dafinansebis wyaro4. ganxorcielebis periodi5. regioni, sadac mimdinareobda6. beneficiarTa raodenoba7. proeqtSi monawileTa raodenoba8. biujetiSesrulebuli:CamonaTvali da TiToeul proeqtze igivetipis informacia12. organizaciis gegmebi:mokle informacia, anda Tu proeqtis zustimonaxazi arsebobs, maSin imave formiT, racmimdinare proeqtebzea miTiTebuli:13. organizaciis mier sxva iuridiul Tu fizikur pirebTan TanamSromlobissfero:gasaRebi sityvebi: Keywordsorganizacia sTavazobs: (eqspertiza /servisi)organizacias sWirdeba: (eqspertiza /servisi)14. organizaciis partniorebi: miuTiTeT is organizaciebi, romelTanacgindaT, rom Tqveni gverdidan iyos bmuli, mag.jandacvis saministros romelime departamenti,romelime saerTaSoriso organizacia (mag.damfinansebeli) da a.S.15. organizaciis simbolo (logo):.jpg, .gif anda romelime sxva grafikulifaili, sasurvelia mcire zomis (araCorel)16. * sakontaqto piris monacemebi (araa aucilebeli direqtoris, umjobesia –sainformacio/teqnikuri personalis monacemebi)* telefoni* faqsi* el-fostamobiluri telefoni90