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hiperbilirubinemiis marTva axalSobil bavSvebSi romelTa
gestaciuri asaki 35 da meti kviraa
klinikuri rekomendaciis mizania
rArr samedicino personalisTvis mtkicebulebebze dafuZnebuli uaxlesi samecniero informaciis miwodebis gziT axalSobilTa hiperbilirubinemiis prevenciis diagnostikisa marTvis Tanamedrove principebis danergva da drouli referalis ganxorcieleba
rArr Seamciros mZime hiperbilirubinemiis da misi garTulebebis ganviTarebis riski
gaidlaini gankuTvnilia
rArr samedicino personalisaTvis romelic muSaobs axalSobilTan rogorc samSobiaro saxlSi ise stacionarsa Tu pirveladi jandacvis rgolSi ndash neonatologi pediatri ojaxis eqimi
rArr gaidlaini aseve SeiZleba gamoyenebuli iyos umaRlesi da saSualo samedicino dawesebulebis pedagogebis mier uwyveti samedicino ganaTlebisaTvis
gaidlainis samizne jgufirArr 35 kviris da meti gestaciuri asakis axalSobilebi romelTac
ganuviTardaT hiperbilirubinemia
gaidlainis gacnobis Semdeg samedicino personals ecodineba rom aucilebelia
1 ZuZuTi kvebis propaganda da mxardaWera2 saeqTno protokolebis Sedgena hiperbilirubinemiis identifikaciisa
da SefasebisaTvis 3 Ssb da tkb gansazRvra axalSobilebSi romelTac siyviTle
gamouvlindaT dabadebidan pirvel 24 sT-Si4 siyviTlis xarisxis gansazRvrisTvis siyviTlis intensivobis
vizualuri SefasebasTan erTad laboratoriuli kvlevis Catareba (mxolod vizualuri Sefasebisas xSiria daignostikuri Secdoma gansakuTrebiT muqkanian axalSobilebSi)
5 bilirubinis maCveneblis interpretacia axalSobilis asakTan (saaTebSi) mimarTebaSi
6 hiperbilirubinemiis ganviTarebis maRali riskis gamovlena da maTi monitoringi
7 mZime hiperbilirubinemiis ganviTarebis riskis sistemuri Sefaseba yvela axalSobilTan
8 mSoblebisadmi werilobiTi da zepiri informaciis miwodeba axalSobilTa siyviTlis Seasaxeb
9 axalSobilis mkurnaloba Cvenebis mixedviT fotoTerapiiTa da SenacvlebiTi transfuziiT
10 Sesabamisi ambulatoriuli meTvalyureobis uzrunvelyofa rac axalSobilis gaweris drosa da riskis Sefasebas efuZneba
1
1 daavadebis definicia sinonimebi klasifikacia da terminologia
axalSobilTa siyviTle axalSobilis kanis da sklerebis yviTeli Seferilobaa rac ganpirobebulia qsovilebSi bilirubinis CalagebiT
axalSobilebSi siyviTle vlindeba roca bilirubinis Semcveloba sisxlis SratSi gadaaWarbebs 5 mgdl (85 micromolL) (AMERICAN ACADEMY OF PEDIATRICS 2004)
fiziologiuri siyviTle msubuqi arakoniugirebuli (arapirdapiri) bilirubinemiaa romelic vlindeba sicocxlis 48-120 sT-Si bilirubinis Semcvelobis pikuri done sicocxlis III dRisTvis uxSiresad 5-8 mgdl-ia (86-136 micromolL) Semdeg xdeba misi donis daqveiTeba 12 mgdl-mde mateba fiziologiurad iTvleba 35-37 kv gestaciuri asakis axalSobilebSi Bbilirubinis donem SeiZleba maqimums miaRwios dabadebidan me-7 dRes
arakoniugirebuli hiperbilirubinemiis ufro maRali done sxvadasxva paTologiuri mdgomareobebis dros vlindeba (Ronald J Wong 2005)
hiperbilirubinemia paTologiuria roca Sratis saerTo bilirubinis done (TSB) gadaaWarbebs 95 percentils butanis nomogramaSi (Ronald J Wong 2005)
butanis nomograma saSualebas iZleva ganisazRvros ramdenad maRalia mZime hiperbilirubinemiis ganviTarebis riski axalSobilis asakis (saaTebSi) da Sratis bilirubinis koncentraciis gaTvaliswinebiT
mwvave bilirubinuli encefalopaTia - axalSobilobis pirvel kviraSi manifestirebuli bilirubinuli toqsiurobis mwvave periodi
kerniqterusi _ gamoiyeneba bilirubinis toqsiurobis qronikuli da permanentuli klinikuri gamosavlis asaRwerad
gamoyenebuli Semoklebebi
Sbs ndash Sratis saerTo bilirubinitkb ndash transkutanuri bilirubiniba - bilirubinis da albuminis Sefardebards ndash respiraciul distres sindromi
epidemiologiafiziologiuri siyviTle viTardeba dRenaklul axalSobilTa
umravlesobasa da droul axalSobilTa 25-50-Si janmrTel droul axalSobilTa 61-Si Sratis bilirubinis maqsimaluri done aRemateba 129mgdl 3 -Si ki _ 15mgdl
multinacionaluri kvlevebis monacemebiT 30 saaTis asakisaTvis axalSobilTa 5 ndash 40 -Si Sratis saerTo bilirubinis done aWarbebs 95 percentils butanis nomogramaSi daniis monacemebiT mZime hiperbilirubinemiis sixSire 35 kviraze meti gestaciis axalSobilebSi Seadgens 25-s 100 000 cocxladSobilze janmos monacemebiT axalSobilTa hemolizuri daavadebis sixSire Seadgens 1-s yovel 2000-3000 axalSobilze
saqarTveloSi zusti statistikuri monacemebi ar arsebobs Tumca 2000 wlis maCveneblebiT yovel 1000 cocxladSobilze gamovlinda 5 SemTxveva
2
etiopaTogenezi
mizezebi (Ronald J Wong 2005)(AMERICAN ACADEMY OF PEDIATRICS 2004)
hiperbilirubinemia SesaZlebelia mimdinareobdes arapirdapiri an pirdapiri bilirubinis donis momatebiT gaZlierebuli hemolizi bilirubinis koniugaciis unaris Semcireba iwvevs arapirdapir bilirubinemias xolo naRvlis eqskreciis darRveva ndash pirdapir bilirubinemias
1 fiziologiuri siyviTle
bull erTrocitebis da hemoglobinis maRali Semcveloba
bull fetaluri hemoglobinis Semcveli eriTrocitebis hemolizi
bull RviZlSi bilirubinis koniugaciis unaris umwifroba
bull bilirubinis gazrdili enterohepatuli cirkulacia
bull RviZlis mier plazmidan bilirubinis moxmarebis Semcireba
2 paTologiuri siyviTle eriTrocitebis hemolizis gaZliereba
bull sisxlis jgufuri da rezus SeuTavsebloba
bull Tandayolili membrano (sferocitozi da sxv) fermento (glukoza 6 fosfatdehidrogenazas - g6fd ndash ukmarisoba da sxv) da hemoglobinopaTia (Talasemia da sxv)
bull policitemia
bull kefalohematoma sisxlCaqcevebi
bull infeqciabilirubinis koniugaciis Semcireba
bull dRenakluloba
bull iSviaTi Tanadayolili daavadebebi (Jilberis krigler-naiaris sindromi da sxva)
bull bilirubinis metabolizmis da eqskreciis darRveva (rotoris da dubin-jonsonis sindromi)
bilirubinis reabsorbciis gazrda gastrointestinuri traqtidanbull asfiqsia
bull kvebis gvian dawyeba iSviaTi kveba
bull nawlavTa obstruqcia
bull mekoniumis pasaJis Seferexeba
3 naRvlis eqskreciis darRveva
bull sefsisi
bull saSvilosnosSida infeqcia
bull hepatiti
bull qolestazuri sindromi
bull biliaruli atrezia
bull cisturi fibrozi (mukoviscidozi)
4 siyviTle ZuZuTi kvebis dros
bull dedis rZiT ganpirobebuli (ariasis sindromi) savaraudoa dedis rZeSi arsebuli nivTierebis (araesterificirebuli cximovani mJavebis da hormon pregnanis) gavlena bilirubinis metabolizmze (iTrguneba ferment glukuroniltransferazas aqtivoba da bilirubinis koniugacia)
3
bull ZuZuTi kvebis araswori reJimiT ganpirobebuli iSviaTi ZuZuTi kvebis SemTxevaSi arasakmarisi raodenobiT rZis miReba iwvevs enterohepaturi cirkulaciis gazrdas
bilirubinis toqsiuroba - bilirubini potenciuri neirotoqsinia arakoniugirebulma bilirubinma romelic ar aris dakavSirebuli albuminTan SeiZleba gaiaros hematoencefaluri barieri da Tavis tvinSi gamoiwvios ujredebis sikvdili apoptoziT (ujredebis programirebuli sikvdili) daan nekroziT yvelaze metad ziandeba bazaluri ganglia da Tavis tvinis Reros okulomotoruli da auditoruli funqciebis makontrolebeli birTvebi
Tu droul axalSobilebSi bilirubini gadaWarbebs 25-30 mgdl (428 - 513 micromolL) maRalia bilirubinis toqsiuri moqmedebis ganviTarebis riski Ssb toqsiuroba variabeluria da damokidebulia axalSobilis janmrTelobis mdgomareobaze da gestaciur asakze
mZime hiperbilirubinemiis ganviTarebis risk-faqtorebi mZime hiperbilirubinemiis ganviTrebis riski miT ufro maRalia rac
ufro meti riskis faqtoria gamoxatuli axalSobilTanmaRali riski (AMERICAN ACADEMY OF PEDIATRICS 2004) (Ronald J Wong 2005)
minus dabadebidan pirvel 24sT-Si gamovlenili siyviTle minus gaweris win Ssb an tkb done butanis nomogramaze maRali riskis
zonaSi
minus sisxlis jgufuri SeuTavsebloba dadebiTi pirdapiri antiglobulinuri testiT sxva cnobili hemolizuri daavadeba (mag g6fd deficiti)
minus gestaciuri asaki 35-36 kvira minus da-Zmas Catarebuli aqvs fotoTerapia
minus kefalohematoma an mniSvnelovani sisxlCaqcevebi (Newman TB 2000)minus araxSiri ZuZuTi kveba rodesac aReniSneba wonaSi mkveTri kleba
(gt12-ze meti) (Newman TB 2000 dabali riski
gaweris win Ssb an tkb-is done butanis nomogramaze maRali gardamavali riskis zonaSi
gestaciuri asaki 37-38 kvira (Newman TB 2000 da-Zmis anamnezSi siyviTle diabetiT daavadebuli dedis makrosomuli axalSobili
dedis asaki ge 25 welze (Newman TB 2000) mamrobiTi sqesi (Newman TB 2000 )
mdgomareobebi romlis drosac mZime hiperbilirubinemiis ganviTarebis riski Zalian dabalia
minus gestaciuri asaki ge 41 kviraze (Newman TB 2000)minus srulyofili enteraluri kveba (Newman TB 2000)minus gawera stacionaridan 72 sT-is Semdeg
minus Ssb dabali riskis zonaSi
4
klinikuri simptomatika
rekomendacia - siyviTlis monitoringi unda moxdes yvela axalSobilTan rutinulad vitaluri funqciebis Sefasebisas ara nakleb 8-12 sT-Si erTxel (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)siyviTlis arsebobis Sefaseba unda moxdes kargad ganaTebul oTaxSi umjobesia dRis Suqze fanjarasTan siyviTle Cveulebriv pirvelad vlindeba saxeze da Semdeg progresirebs kaudalurad sxeulsa da kidurebze siyviTlis ukeT gansazRvrisaTvis tardeba kanze TiTis zewolis testi zewola lokalurad amcirebs kanis perfuzias da xels uwyobs siyviTlis diagnostikas rodesac bilirubini 4-8 mgdl (68-137 micromolL) Cveulebriv iqterulia saxe da sklera Tu bilirubini gt15 mgdL (257 micromolL) siyviTle vlindeba mTel sxeulze xelis da fexisgulebis CaTvliT Ssb an tkb mizanSewonilia gaizomos Tu siyviTle vlindeba Wipis qvemoT
siyviTlis simZimis Sefaseba lokalizaciis mixedviT (WHO 2003) cxrili 1
asaki (dRe) siyviTlis lokalizacia daskvna
1 nebismieri
2 kidurebi
ge 3 terfebi mtevnebi
laquosaSiSiraquo siyviTle
sicocxlis I dRes nebismier adgilas an II dRes kidurebze gamovlenili siyviTle saWiroebs dauyovnebliv fotoTerapiis dawyebas analizis pasuxis miRebamde
krameris modificirebuli sqema cxrili 2
zona1 2 3 4 5
Ssb micromolL 100 150 200 250 gt250
krameris modificirebuli sqema saSualebas iZleva siyviTlis gavrcelebis mixedviT vivaraudoT Tu ramdenia Sratis saerTo bilirubinis done
siyviTlis xarisxis gansazRvra siyviTlis intensivobis mxolod vizualuri SefasebiT xSirad iwvevs daignostikur Secdomas gansakuTrebiT muqkanian axalSobilebSi
(rekomendacia C) (AMERICAN ACADEMY OF PEDIATRICS 2004)
axalSobilTa siyviTlisGgarTulebebimwvave da qronikuli (kerniqterusi) bilirubinuli encefalopaTiamwvave bilirubinuli encefalopaTia (AMERICAN ACADEMY OF PEDIATRICS 2004) mwvave bilirubinuli encefalopaTias axasiaTebs ganviTarebis 3 faza
5
C
1 adreuli faza vlindeba ramdenime dReSi da axasiaTebs leTargia hipotonia susti wova da sustad gamoxatuli ldquotvinismieri kivilirdquo
2 gardamavali stadia viTardeba kviris bolos da axasiTebs zomieri stupori agznebadoba da hipertonia axalSobils SeiZleba aReniSnos cxeleba mkveTrad gamoxatuli ldquotvinismieri kivilirdquo hipertonia vlindeba kisris (retrokolisi) da sxeulis (opistotonusi) ukan rkaliseburad gadaxriT
3 bolo stadia vlindeba 1 kviris Semdeg am dros centraluri nervuli sistemis dazianeba Seuqcevadia mas axasiaTebs mkveTri retrokolisi da opistotonusi mkveTrad gamoxatuli ldquotvinismieri kivilirdquo apnoe cxeleba sakvebis autanloba Rrma stupori komamde zogjer krunCxvebi da sikvdili
kerniqterusi (AMERICAN ACADEMY OF PEDIATRICS 2004)Bmwvave bilirubinuli encefalopaTiis Semdeg gadarCenil
axalSobils sicocxlis pirveli wlis manZilze uviTardeba bilirubinuli encefalopaTiis mZime qronikuli forma romelic 3 ZiriTadi gamovlinebiT xasiaTdeba
motoruli darRvevebi - aTetoiduri cerebluri dambla tremori qorea
mxedvelobis darRvevebi smeniTi disfunqcia inteleqtualuri darRvevebi SedarebiT iSviaTia damatebiT SeiZleba
ganviTardes kbilis emalis hipoplazia kerniqterusis dros 70-Si aRiniSneba nevrologiuri darRvevebi da
10-Si sikvdiloba
diferenciuli diagnoziaxalSobilTa siyviTlis dros unda ganisazRvros siyviTle
fiziologiuria Tu paTologiuri
fiziologiuri siyviTle paTologiuri siyviTle
vlindeba ara uadres 2 dRisa da qreba me-10-14 dRisTvis
vlindeba pirvel 24 saaTSi an7 dRis Semdeg
gavrceleba ar aRemateba krameris 1-3 zonebs
gavrceleba krameris nebismieri zona sicocxlis I dRes 4 zona sicocxlis II dRes da 5 zona nebismier asakSi
bavSvi aqtiuria temperatura normaluria wovis refleqsi kargia
zogadi mdgomareoba damakmayofilebeli an darRveuli
Sardis da ganavlis feri ar icvleba
SeiZleba iyos Sardis da ganavlis feris cvlileba
RviZli da elenTa ar aris gadidebuli
SeiZleba iyos hepatosplenomegalia
dedis rZiT ganpirobebuli siyviTlis sadiagnostikod (samkurnalod) SeiZleba Semdegi maCveneblebis gamoyeneba
bull dedis rZiT ganpirobebuli siyviTle vlindeba me-4-14 dRes
bull 24-48sT-is ganmavlobaSi ZuZuTi kvebis Sewyveta da alternatiul sakvebis miwodeba iwvevs bilirubinis donis daqveiTdebas
6
axalSobilTa hiperbilirubinemiis difdiagnozi ix algormiTi 1
gamokvlevis sqema
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004) tkb daan Ssb unda ganesazRvros yvela axalSobils
romelsac siyviTle gamouvlinda sicocxlis pirvel 24sT-Si (ix algoriTmi I da cxrili 3 ) (rekomendacia C)
tkb daan Ssb ganmeorebiTi gansazRvris dro da saWiroeba damokidebulia bilirubinis doneze (sqema 2) axalSobilis asakze hiperbilirubinemiis dinamikaze rekomendaciebi Ssb gansazRvrisaTvis dabadebidan 24 sT-is Semdeg mowodebulia I algoriTmsa da cxrilSi 3
tkb daan Ssb unda ganesazRvros yvela axalSobils romelsac gamouvlinda asakTan Seusabamo mkveTri siyviTle (rekomendacia D)
bilirubinis donis Sefaseba unda moxdes axalSobilis asakis (saaTebSi) gaTvaliswinebiT (sqema 2) (rekomendacia
C) Tu axalSobils utardeba fotoTerapia an aReniSneba
bilirubinis swrafi mateba (sqema 2 ndash butanis sqemaze monacemi kveTs percentilebs) rac ar aixsneba obieqturi gamokvleviT da anamnezuri monacemebiT saWiroa siyviTlis SesaZlo mizezebis dadgena (rekomendacia D)
axalSobilebs romelTac aReniSnebaT pirdapiri (koniugirebuli) bilirubinis mateba unda CautardeT Sardis saerTo da baqteriologiuri gamokvleva damatebiTi laboratoriuli gamokvlevebi unda Catardes Tu anamneziT da obieqturi gamokvelevebiT saeWvoa sefsisi (rekomendacia
C) avadmyof axalSobilebsa da Cvilebs romelTac aReniSnebaT
siyviTle 3 kviris an ufro mogvianebiT asakSi unda ganesazRvroT saerTo da pirdapiri (koniugirebuli) bilirubini qolestazis sadiagnostikod (cxrili 3) (rekomendacia D) aseT axalSobilebTan mizanSewonilia skriningi hipoTireozsa da galaqtozemiaze (rekomendacia D)
Tu pirdapiri an koniugirebuli bilirubinis done momatebulia rekomendirebulia damatebiTi gamokvlevebi qolestazis sadiagnostikod (rekomendacia C)
glukoza-6-fosfat dehidrogenazas donis gansazRvra saWiroa im axalSobilebTan romelTa ojaxuri anamnezi an eTnikuri an geografiuli warmoSoba miuTiTebs g6fd-s deficitze da utardebaT fotoTerapia daan axalSobilebTan Tu fotoTerapia uefeqtoa (sqema 3) (rekomendacia C)
7
C
D
C
D
C
C
C
D
D
cxrili 3 35 da meti gestaciuri asakis axalSobilSi gamovlenili siyviTlis laboratoriuli Sefaseba (AMERICAN ACADEMY OF PEDIATRICS 2004)
Cveneba laboratoriuli kvlevapirvel 24 sT-Si gamovlenili siyviTle
bull tkb daan Ssb gansazRvra
asakisaTvis Seusabamo mkveTri siyviTle kanze G
bull tkb daan Ssb gansazRvra
axalSobils utardeba fotoTerapia an aReniSneba bilirubinis swrafi mateba (sqema 2 ndash butanis sqemaze maCvenebeli kveTs percentilebs) rac ar aixsneba obieqturi gamokvleviT da anamnezuri monacemebiT
bull sisxlis jgufi da rezusi kumbsis testi Tu ar aris gakeTebuli Wiplaris sisxlSi
bull sisxlis saerTo analizi da nacxi formiani elementebis morfologiis Sesaswavlad
bull pirdapiri (koniugirebuli) bilirubinis gansazRvra
bull Tu SesaZlebelia isazRvreba retikulocitebis ricxvi g6fd
bull Ssb ganmeorebiT isazRvreba 4-24 sT-Si axalSobilis asakisa da Ssb donis Sesabamisad
fotoTerapia uSedegoa an Ssb aRwevs dones romelzec naCvenebia SenacvlebiTi transfuzia
bull Tu SesaZlebelia isazRvreba retikulocitebis ricxvi g6fd
momatebulia pirdapiri (koniugirebuli) bilirubinis done
bull Sardis anlizi
bull Sardis kultura
bull gamokvleva sefsisze Tu misi arseboba saeWvoa anamneziT an obieqturi gamokvleviT
siyviTle sami kviris asakis an avadmyof axalSobilSi
bull saerTo da pirdapiri (koniugirebuli) bilirubini
bull pirdapiri bilirubinis momatebisas tardeba kvleva qolestazis sadiagnostikod
bull skriningi hipoTireozsa da galaqtozemiaze
bull axalSobilis Sefaseba hipoTireozis simptomebis gamosavlenad
sqema 1 butanis nomograma
8
butanis nomograma saSualebas iZleva ganisazRvros ramdenad maRalia mZime hiperbilirubinemiis ganviTarebis riski axalSobilis asakis (saaTebSi) da Sratis bilirubinis koncentraciis gaTvaliswinebiT bilirubinis gansazRvra
bilirubini isazRvreba transkutanurad da sisxlis SratSi transkutanuri gansazRvra gamarTlebulia rogorc skriningis
meTodi is isazRvreba specialuri aparatiT aRniSnuli xelsawyos gamoyenebiT bilirubinis gansazRvra SesaZloa 2-3 mgdl (34-54micromolL) variabelobiT bevr SemTxvevaSi xdeba Sratis bilirubinis gansazRvris Canacvleba transkutanuri gansazRvriT gansakuTrebiT maSin roca Ssb lt 15 mgdl (257 micromolL)
fotoTerapiis dros kanis vizualuri SefasebasTan erTad aucilebelia Sratis bilirubinis gansazRvra radgan fotoTerapia ldquoaTeTrebsrdquo kans (American Academy of Pediatrics 2004)
pirveladi profilaqtika
rekomendacia (American Academy of Pediatrics 2004) bull eqimma unda urCios dedas ganaxorcielos moTxovnilebiTi ZuZuTi kveba dReSi 8-12-jer (rekomendacia C) - arasrulyofili kaloriebis miRebam daan dehidrataciam SeiZleba gamoiwvios Hhiperbilirubinemiis ganviTareba
bull ZuZuTi kvebis SemTxevaSi Tu axalSobils ar aReniSneba dehidratacia ar aris rekomedirebuli wylisa da deqstrozis rutinulad damateba (rekomendacia B da C) -
9
C
B
C
wylis da deqstrozis damateba ar axdens hiperbilirubinemiis ganviTarebis profilaqtikasa da Ssb-s Semcirebas
bull yvela Rh (D) negatiur orsuls an melogines mizanSewonilia Cautardes anti D imonoglobuliniT profilaqtika (rekomendacia A)
minus orsulobis 28 kviraze (garda im SemTxvevebisa rodesac bavSvis mamac Rh (D) negatiuria)
minus mSobiarobidan 72 sT-is gamnavlobaSi Tu axalSobili Rh (D) pozituiria
minus orsulobis pirvel trimestrSi ganviTarebuli abortis da invaziuri procedurebis dros rogorica amniocentezi nayofis invaziuri procedurebi
meoradi profilaqtikarekomendacia klinicistma unda moaxdinos axalSobilTa hiperbilirubinemiis ganviTarebis riskebis sistemuri Sefaseba neonatalur periodSi (rekomendacia B)(AMERICAN ACADEMY OF PEDIATRICS 2004)
sisxlis jgufobriobarekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
yvela orsuli qali unda iyos gamokvleuli ABO da Rh(D) sisxlis jgufebze da hqondes Catarebuli skriningi SratSi izoimunur antisxeulebze (rekomendacia B)
Tu dedas ar Cautarebia prenatalurad sisxlis jgufis da rezusis gamokvleva an igis Rh negatiuria mkacrad aris rekomendirebuli pirdapiri antisxeulebis testis (an kumbsis testi) sisxlis jgufis da Rh (D) tipis gansazRvra axalSobilis (Wiplaris) sisxlSi (rekomendacia B)
Tu dedas sixlis jgufi aris O Rh(D) pozitiuri axalSobilis sisxlis jgufis da pirdapiri antisxeulis testis gansazRvris aucilebloba damokidebulia meTvalyureobis xarisxze gaweris win riskis Sefasebasa da gaweris Semdeg meTvalyureobaze (rekomendacia C)
mkurnalobis sqemamkurnalobis ZiriTadi principebia
fotoTerapia SenacvlebiTi transfuzia
mkurnaloba iwyeba fotoTerapiiTfotoTerapiis dros kanis zeda SreebSi Calagebuli arapirdapiri bilirubini iSleba fotoqimiuri gziT wyalSi xsnad koniugatebad romlebic gamoiyofa SardiT da naRveliTrekomendacia yvela samSobiaro saxli unda iyos aRWurvili mowyobilobiT romelic saWiroa intensiuri fotoTerapiisaTvis (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)fotoTerapiis Cvenebebi
fotoTerapia iwyeba Tu bulirubinis done aRemateba 95 percentils butanis nomogramaze (sqema 1) amave dros metad mniSvnelovania risk-faqtorebis gaTvaliswineba romlebic xels uwyobs mZime
10
A
B
B
B
C
D
hiperbiliruminemias (hemolizuri daavadeba g6fd deficiti asfiqsia mkveTrad gamoxatuli leTargia temperaturis arastabiluroba sefsisi acidozi an hipoalbuminemia lt30 gdl)
amerikis pediatriuli akademiis rekomendaciiT gamoiyeneba sqema (sqema 2) romelic axalSobilis asaksa da bilirubinis donesTan erTad iTvaliswinebs risk-faqtorebsa da gestaciur asaks mocemuli sqemis mixedviT ldquointensiurirdquo fotoTerapia iwyeba Semdegi principebiT
dabali riskis axalSobili (janmrTeli risk-faqtorebis gareSe gestacia gt 38 kvira) ndash Ssb gt12 mgdl (205 micromolL) 24 sT-Si Ssb gt15 mgdl (257 micromolL) 48 sT-Si Ssb gt18 mgdl (308 micromolL) gt72 sT
saSualo riskis axalSobili (gestacia gt 38 kvira da risk-faqtorebi an gestacia 35-37 kvira risk-faqtorebis gareSe gareSe) ndash Ssb gt 10 mgdl (171 micromolL) 24 sT-Si Ssb gt13 mgdl (222 micromolL) 48 sT-Si Ssb gt15 mgdl (257 micromolL) gt72 sT gestaciis 35 kviris axalSobilebSi fotoTerapia SeiZleba daiwyos ufro dabal maCveneblebze
maRali riskis axalSobili (gestacia 35-37 kvira da risk-faqtorebi) - Ssb gt 8 mgdl (137 micromolL) 24 sT-Si Ssb gt11 mgdl (188 micromolL) 48 sT-Si Ssb gt135 mgdl (231 micromolL) gt72 sT
Tu dabali riskis axalSobilebSi Ssb done 2-3 mgdl-iT dabalia moyvanil monacemebze SesaZlebelia mkurnalobis dawyeba ldquoCveulebrivirdquo fotoTerapiiT
bull stacionarSi gamoxatuli siyviTliT Semosul axalSobils utardeba ldquointensiurirdquo fotoTerapia bilirubinis maCveneblis gansazRvramde
bull ldquointensiurirdquo fotoTerapia aseve rekomendebulia hemolizuri daavadebis dros
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
janmos rekomendacia fotoTerapiis dawyebis Cvenebebis Sesaxeb mocemulia cxrilSi 4
cxrili 4 fotoTerapiis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI gamoxatuli siyviTleII 15 260 13 220III 18 310 16 270
IV da meti 20 340 17 290janmos rekomendaciiT fotoTerapia iwyeba Tu siyviTlis
lokalizaciis mixedviT siyviTlis simZimis Sefasebisas (cxrili 1) dadginda ldquosaSiSi siyviTlerdquo
Tu ar aris bilirubinis gansazRvris saSualeba Ssb savaraudo donis dasadgenaT SeiZleba krameris modificirebuli sqemis gamoyeneba
11
sqema 2 fotoTerapiis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (AMERICAN ACADEMY OF PEDIATRICS 2004)
rekomendacia Tu Sratis albuminis maCvenebeli naklebia 30 gdl-ze fotoTerapiis dawyeba rekomendebulis ufro dabali maCveneblebis dros (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis ukuCveneba pirdapiri (koniugirebuli) hiperbilirubinemia (pirdapiri
bilirubini Ssb-s 50-ze metia) (American Family Practice Notebook 2002 ) (AMERICAN ACADEMY OF PEDIATRICS 2004)
Tandayolili porfiria an porfiriis ojaxuri anamnezi (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis teqnikafotoTerapiis efeqturoba damokidebulia dozaze fotoTerapiis doza anu speqtruli iradiacia damokidebulia naTuris simZlavreze sinaTlis wyarosa da bavSvs Soris manZilsa da dasxivebis farTobze sinaTlis wyarofotoTerapiis sinaTlis speqtri damokidebulia sinaTlis wyaroze da filtrze yvelaze farTod gavrcelebuli fotoTerapiis mowyobiloba Seicavs dRis Suqis gril TeTr cisfer an ldquospecialur cisferrdquo fluorescentul naTurebs manZils sinaTlis wyarodan axalSobilamde didi mniSvneloba eniWeba sasurvelia axalSobili moTavsdes sinaTlis wyarodan im minimalur manZilze romelic miTiTebulia fotoTerapiis mowyobilobis instruqciaSi halogenis fotoTerapiis naTurebi ar SeiZleba moTavsdes axalSobilTan axlos radgan SeiZleba gamoiwvios damwvroba
12
DD
sxeulis zedapiris farTobibilirubinis maRali Semcvelobisas mniSvnelovania fotoTerapiis dros dasxivdes sxeulis zedapiris rac SeiZleba meti farTobi
ldquoCveulebrivi fotoTerapiardquo - sinaTlis speqtris iradiacia dabalia (6-12 microWcm2nm) (talRis sigrZe daaxloebiT 425-475 nm) da damokidebulia sxvadasxva mwarmoeblis mier mowodebul fotoTerapiiis sistemis aparatis monacemebze saWiroa aparatis Semowmeba Seesabameba Tu ara sinaTlis speqtris iradiacia mwarmoeblis mier mowodebul monacemebsldquointensiuri fotoTerapiardquo - lurj-mwvane speqtris iradiacia (talRis
sigrZe daaxloebiT 430-490 nm) sul cota 30 microWcm2nm-ia (isazRvreba axalSobilis kanze fototerapiis aparatis centris qveS) gazomva xdeba im warmoebis radiometriT romelic mowodebulia fotoTerapiiis sistemis aparatis mwarmoeblis mier sinaTlis talRis asareklad TeTreuli unda iyos TeTri kuvezi da sawolis gverdebi daifaros TeTri qsoviliT an aluminis folgiT
fotoTerapiis procedura da monitoringi
temperatura sinaTlis wyaros qveS unda iyos 28-300C
fotoTerapiis dros bavSvi unda iyos SiSveli ecvas erTjeradi higienuri safeni Tvalebze unda hqondes damcavi saTvale
yovel 3 saaTSi erTxel bavSvs unda Seucvalon pozicia
yovel 3 saaTSi erTxel unda Sefasdes sinaTlis wyaros qveS arsebuli temperatura da axalSobilis sxeulis temperatura Tu bavSvis t metia metia 3750C saWiroa oTaxis temperaturis daqveiTeba an fotoTerapiis droebiT Sewyveta sanam bavSvis temperatura ar iqneba normis farglebSi (365-3750C)
fotoTerapia mimdinareobas mudmivad igi wydeba mxolod im procedurebis dros romelTa warmoeba ra SeiZleba sinaTlis wyaros qveS
centraluri cianozis arsebobis Sesafaseblad fotoTerapia unda Sewydes mcire droiT
fotoTerapiis dros unda gagrZeldes bavSvis kveba
rArraxalSobilTan unda gagrZeldes ZuZuTi kveba moTxovnilebis mixedviT (intervali kvebaTa Soris araumetes 3 sT-isa) (rekomendacia C) ZuZuTi kvebis dros wydeba fotoTerapia da Sesabamisad bavSvs unda moexsnas damcavi saTvale
rArrTu bavSvi ikvebeba gamowvelili rZiT formuliT an parenteralurad misawodebeli sakvebis an siTxis raodenoba izrdeba dRiuri normis 10 -iT
rArr Tu bavSvi ikvebeba zondiT an parenteralurad fotoTerapia mimdinareobs uwyvetad
rArrCveulebriv fotoTerapiis dros axalSobils ar esaWiroeba damatebiT siTxis an sakvebis miwodeba damateba naCvenebia mxolod araefeqturi ZuZuTi kvebis sxeulis masis paTologiuri danakargis (gt10-ze mesame dRisTvis) da dehidrataciis SemTxvevaSi
13
C
fotoTerapiis dros bilirubinis daSlis produqtebi gamoiyofa SardiT da naRveliT adeqvaturi hidrataciis SenarCuneba da Sesabamisad adekvaturi diurzis SenarCuneba zrdis fotoTerapiis efeqturobas
zogierT axalSobils hiperbilirubinemiiT aReniSneba dehidratacia da saWiroa damatebiTi siTxis miwodeba (per-os an intravenurad) dehidrataciis koreqciisaTvis
araefeqturi ZuZuTi kvebis SemTxvevaSi fotoTerapiis dros axalSobils damatebiT miewodeba gamowvelili dedis rZe donoris rZe an xelovnuri sakvebi
rArr adeqvatur kvebaze miuTiTebs 4-6 sveli safeni 24 sT-Si da nawlavTa moqmedeba 3-4 jerdReSi meoTxe dRisaTvis
janmrTeli drouli axalSobilis nawlavTa moqmedeba da diurezi (minimaluri maCveneblebi) cxrili 5 (Fetus and Newborn Committee 1999)
dRe nawlavTa minimaluri moqmedeba24sT
sveli safeni24sT
1 1 12 1 23 1 gardamavali 34 2 yviTeli fafisebri 45 2YyviTeli fafisebri 5-6
rArrdehidrataciaze miuTiTebs Semdegi niSnebis arseboba - masis paTologiuri kleba (gt10-ze mesame dRisTvis)- anuria 4-6 sT- Cacvenili Tvalebi- Cavardnili yoflibandi - - daqveiTebuli kanis elastiuroba (kanis naoWi swordeba
nela)- daqveiTebuli kanis kapilaruli avseba (gt3 wm)- taqikardia- Sratis Na gt145 HCO3 lt17
bilirubinis monitoringi fotoTerapiis dros (American Aacademy of Pediatrics 2004)
sawyisi bilirubinis maCveneblis Semcireba 6-20-iT standartuli da 30-40-iT intensiuri fotoTerapiis dawyebidan 24sT-Si mis efeqturobaze miuTiTebs
bull Tu Ssb ge 25 mgdL (428 micromolL) ganmeorebiTi gansazRvra 2ndash3 sT-Si
bull Tu Ssb 20ndash25 mgdL (342ndash428 micromolL) ganmeorebiTi gansazRvra 3-4 sT-Si
bull Tu Ssb lt20 mgdL (342 micromolL) ganmeorebiTi gansazRvra 4ndash6 sT-Si Tu Ssb agrZelebs daqveiTebas ganmeorebiTi gansazRvra 8-12 sT-Si
bull Tu Ssb ar mcirdeba an uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones an Ssb albuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6) iwyeba SenacvlebiTi transfuzia Tu amis saSualeba aris an xorcieldeba referali
bull intensiur fotoTerapiis miuxedavad Ssb-is ucvleli done an mateba miuTiTebs hemolizze
14
rArr anemiahemolizis Sefaseba SesaZlebelia sisxlis saerTo analizis mixedviT - Hgblt 130 glLHct lt 40 retikulocitebi - gt 6
bull Ssb lt 13ndash14 mgdL (239 micromolL) fotoTerapia wydeba
bull fotoTerapiis Sewyvetidan 24 sT-Si kontroldeba Ssb Tu Ssb moimata im donemde romelzec daiwyo fotoTerapia fotoTerapia ganmeorebiT iwyeba
fotoTerapiis garTulebebi
fotoTerapiis garTulebebi (Ronald J Wong 2005 American Aacademy of Pediatrics 2004)
rArrmwvane feris ganavalidiarea (mkurnalobas ar saWiroebs)
rArr dehidratacia
rArr muclis Seberva (mkurnalobas ar saWiroebs)
rArr Tvalis SesaZlo dazianeba yvelaze seriozuli magram iSviaTi klinikuri garTulebaa brinjaos
axalSobilis sindromi romelic vlindeba qolestazuri siyviTlis mqone axalSobilSi kanis Sratis da Sardis muqi nacrisfer-yavisferi SeferilobiT brinjaos axalSobilis sindromi ar vlindeba qolestazis mqone yvela axalSobilTan Tu arsebobs fotoTerapiis Cveneba pirdapiri hiperbilirubinemia ar warmoadgens fotoTerapiis winaaRmdeg Cvenebas axalSobilebSi romelTac uviTardebaT brinjaos sindromi naCvenebia SenacvlebiTi transfuzia monacemebis arasrulyofilebis gamo mkacri rekomendaciis gakeTeba ar SeiZleba
mZime qolestazuri siyviTlis mqone axalSobilebSi fotoTerapiis dros aseve SeiZleba ganviTardes
rArr purpura
rArr bulozuri gamonayari
mzis ultraiisferi sxivebiT TerapiamarTalia mzis sxivebs gaaCniaT mniSvnelovani iradiacia 425-475 nm magram radganac maRalia axalSobilis damwvrobis ganviTarebis riski (SiSveli axalSobilis mzeze yofnis gamo) es meTodi rekomendebuli ar aris
(Ronald J Wong 2005 (American Aacademy of Pediatrics 2004)
intravenuri imunoglobulinis gamoyenebarekomendacia izoimunuri hemolizuri daavadebis dros rekomendebulia intravenuri imunoglobulinis gamoyeneba (05-1 gkg 2 sT-s ganmavlobaSi) Tu Ssb imatebs intensiuri fotoTerapiis miuxedavad an Ssb aris 2-3 mgdl-iT (34-51mkmoll) naklebi SenacvlebiTi transfuziis Cvenebis doneze (fighellip4) aucilebelobis SemTxvevaSi intravenuri imunoglobulinis es doza SeiZleba ganmeordes 12 sT-Si (rekomendacia B) American Aacademy of Pediatrics 2004)
15
fotoTerapiis dros kanSi Calagebuli bilirubini swrafad iSleba amitom ar aris rekomendebuli kanis ferze dayrdnobiT SratSi
bilirubinis donis Sesafaseba rogorc fotoTerapiis dros ise misi Sewyvetidan 24 sT-is ganmavlobaSi
B
kvlevebiT dadgenilia rom intravenuri imunoglobulini amcirebs SenacvlebiTi transfuziis saWiroebas Rh da ABO hemolizuri daavadebis dros
SenacvlebiTi transfuzia
SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleluli unda iyos Semowmebuli da dasxivebuli gadasasxmeli sisxlis raodenoba Seadgens 170-180 mlkg
rekomendacia SenacvlebiTi transfuzia unda Caataros mxolod gamocdilma samedicino personalma intensiuri Terapiis ganyofilebaSi monitoringisa da srulyofili reanimaciis SesaZleblobis pirobebSi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
SenacvlebiTi transfuziis Cvenebebi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
mwvave bilirubinuli encefalopaTia intensiuri fotoTerapiis miuxedavad Ssb mateba an ucvleli
monacemi samSobiarodan gawerili axalSobilebis hospitalizaciis
SemTxvevaSi Ssb-s maRali maCvenebeli - aRemateba SenacvlebiTi transfuziis dawyebis maCvenebls (sqema 3) (transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia) (ix cxrili 6)
ba Sefardeba Ssb maCvenebelTan (cxrili 6) erTad gamoiyeneba rogorc damatebiTi faqtori SenacvlebiTi transfuziis dawyebis gansasazRvravad
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
sqema 3 SenacvlebiTi transfuziis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (American Academy of Pediatrics 2004)
16
D
D
cxrili 6 bilirubinisa da albuminis Sefardeba rodesac saWiroa SenacvlebiTi transfuzia (AMERICAN ACADEMY OF PEDIATRICS 2004)
riskis kategoria
ba Sefardeba rodesac saWiroa SenacvlebiTi
transfuziaSsb mgdl alb gdl
Ssb micromolL alb micromolL
axalSobilebi gestaciuri asaki - ge38 kvira 80 094
janmrTeli axalSobilebi gestaciuri asakiT an riskis jgufis axalSobilebi
gestaciuri asakiT ge38 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
72 084
riskis jgufis axalSobilebi gestaciuri asakiT 35ndash36 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
68 080
janmos rekomendacia sisxlis SenacvlebiTi gadasxmis Cvenebebis Sesaxeb mocemulia cxrilSi 7
cxrili 7 SenacvlebiTi transfuziis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI 15 260 13 220II 25 425 15 260
17
III 30 510 20 340IV da meti 30 510 20 340
Tu Ssb uaxlovdeba im dones rodesac naCvenebia SenacvlebiTi transfuzia
sisxli dauyovnebliv igzavneba raTa dadgindes jgufi da rezusi da SeTavseba Tu klinikaSi aris transfuziis saSualeba
an xorcieldeba referali
teqnika (AMERICAN ACADEMY OF PEDIATRICS 2004
bull mwvave bilirubinuli encefalopaTiis dros SenacvlebiTi transfuzia iwyeba dauyovnebliv
bull sxva SemTxvevaSi transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia
bull SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleuli unda iyos Semowmebuli da dasxivebuli
bull gadasasxmeli sisxlis raodenoba Seadgens axalSobilis mocirkulire sisxlis ormag raodenobas saSualod 170-180 mlkg an gadasasxmeli sisxlis gamosaTvleli formula gamoiTvleba 85 x axalSobilis wona kg x 2
bull SenacvlebisaTvis xdeba 2 venis an arteria da venis kaTeterizacia iReben bavSvis 20 ml sisxls da SeyavT 20 ml donoris sisxli (3-4 wT-is ganmavlobaSi) SemTbaris 367-3700C-mde
bull dRenaklulebsa da mZime mdgomareobaSi myof axalSobilebSi Senacvleba xdeba 5-10 ml-iT
axalSobilis momzadeba
bull kuWis SigTavsis aspiracia zondiT 8F da Ria zondis datoveba kuWSibull SeiZleba saWiro gaxdes bavSvis dabma
bull SeiZleba sawovaras gamoyeneba
bull Sardis Semkrebis gamoyeneba diurezis kontrolisTvisaxlSobilis winaswar Sefaseba
bull temperatura
bull guliscema
bull sunTqva
bull wneva
bull glukoza SratSi
bull Sardis analizi
bull ganavlis analizi sisxlis Semcvelobaze
bull kanis feri
bull tonusi
bull qcevauSualod transfuziis dros fasdeba vitaluri niSnebi (yovel 15 wT-Si)
18
bull temperatura
bull guliscema (mwvervalze) (umjobesia kardiomonitoriT)
bull sunTqva
bull kanis feri
bull qceva
monitoringi transfuziis Semdeg bull grZeldeba fotoTerapia
bull kardio monitoringi
bull sisxlis wneva proceduris damTavrebis Semdeg
bull saaTobrivad 6 sT-is ganmavlobaSi temperatura guliscema (mwvervalze) sunTqva
bull glukoza SratSi yovel 3 sT-Si 24 sT-is ganmavlobaSi
bull muclis garSemoweriloba 3-4 sT-Si 24 sT-is ganmavlobaSi nawlavebis peristaltikis auskultacia
bull Sardis analizi
bull ganavali sisxlis Semcvelobaze
bull sakvebis autanlobis niSnebi Rebineba muclis Seberva
bull Ssb 6 sT-Si erTxel
SenacvlebiTi transfuziis riskisikvdiloba - 3 SemTxveva 1000 transfuziaze SenacvlebiTi transfuziis dros garTulebis saxiT 5-Si vlindeba
- apnoe bradikardia cianozi vazospazmi Trombozi nekrozuli enterokoliti aseve SeiZleba ganviTardes hipoqsiur-iSemiuri encefalopaTia da SeZenili imunodeficitis sindromi
sxva mkurnalobafenobarbitali ndash xels uwyobs bilirubinis koniugacias da amcirebs
Ssb dones ar arsebobs sakmarisi mtkicebulebebi fenobarbitalis gamosayeneblad rodesac arsebobs siyviTlis mkurnalobis ufro efeqturi meTodebi (mag fotoTerapia)
referali AMERICAN ACADEMY OF PEDIATRICS 2004)referali maRali donis klinikaSi xorcieldeba Tu
ar aris fotoTerapiis Catarebis SesaZlebloba fotoTerapiis miuxedavad
rArr Ssb ar mcirdeba
rArr Ssb uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones da ar aris transfuziis saSualeba
rArr Ssbalbuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6)
Tu siyviTle gamovlinda I dRes siyviTlis lokalizaciis mixedviT siyviTlis simZimis Sefasebisas
(cxrili 1) dadgenili ldquosaSiSi siyviTlerdquo
bilirubinis maRali namati 85 micromolLsT (gt05 mgdlsT)
gaxangrZlivebuli siyviTle (14 dRe da meti) ojaxur anamnezSi mZime siyviTlis an kerniqterusis arseboba siyviTlis dros sxva daavadebis niSnebis arseboba (mg sefsisi)
19
riskis Sefaseba gaweramde
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
bull yvela axalSobilis gaweramde unda Sefasdes hiperbilirubinemiis ganviTarebis riski yvela ganyofilebas unda hqondes protokoli siyviTlis SefasebisTvis aseTi Sefaseba gansakuTrebiT mniSvnelovania im axalSobilebisaTvis romlebis ewerebian dabadebidan 72 sT-ze adre (rekomendacia C)
bull amerikis pediatrTa akademiis rekomendaciiT riskis SefasebisaTvis gamoyenebuli unda iqnas 2 midgoma (calcalke an kombinaciaSi) gaweris win bilirubinis gansazRvra (Ssb an tkb) daan klinikuri risk-faqtorebis Sefaseba risk-faqtorebis arseboba an Ssb maRali maCveneblebi gaweris Semdeg Sesabamisi meTvalyureobis aucilebelobis Cvenebaa (rekomendacia C)
bull yvela samSobiarom unda miawodos mSobels zepiri daan werilobiTi informacia binaze siyviTlis Sefasebis da saSiSroebis niSnebis Sesaxeb (rekomendacia D)
meTvalyureoba
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)bull yvela axalSobili samSobiarodan gaweriis Semdeg ramdenime dReSi unda Sefasdes kvalificuri samedicino profesionalis mier (rekomendacia C)
bull fasdeba - siyviTlis arseboba axalSobilis wona kvebis efeqturoba Rebinebis arseboba (rekomendacia C)
bull meTvalyureobis grafiki Tu axalSobili samSobiarodan ewereba 48-72 sT-Si samedicino Sefaseba tardeba 120 sT-is (5 dRe) asakSi (rekomendacia C)
bull Tu samSobiarodan gaweris Semdeg meTvalyureoba SeuZlebelia da arsebobs hiperbilirubinemiis ganviTarebis risk-faqtorebi axalSobilis gawera unda gadaidos sanam ar iqneba uzrunvelyofili Sesabamisi meTvalyureoba an sanam gaivlis maRali riskis periodi (72-96sT) (rekomendacia D)
11 gaidlainis gadasinjvisa da ganaxlebis vada ndash 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlainis SemuSavebis meTodologia
bull axalSobilTa hiperbilirubinemiis prevenciis diagnostikisa da marTvis principebis Sesaxeb arsebobs samecniero mtkicebulebis safuZvelze Seqmnil rekomendaciaTa sakmarisi raodenoba mocemuli gaidlainis Semqmnis procesSi samuSao jgufis gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve arsebuli praqtikuli rekomendaciebi moxda arsebuli
20
C
C
C
C
D
C
D
rekomendaciebis adaptirebuli variantis SemuSaveba romelic erTis mxriv pasuxebs saerTaSoriso moTxovnebs xolo meore mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa rogorc adamianur ise teqnikur resursebs
bull rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa bazis gamoyenebiT
cxrili 2
qveyana da resursis dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
httpwwwguidelinegov
Centers for Disease Control and Prevention (CDC)
httpwwwphppocdcgovCDCRecommendsAdvSearchVasp
Agency for Healthcare Research and Quality (AHRQ)
httpwwwahrqgovcliniccpgsixhtm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
httphstatnlmnihgov
Institute of Clinical Systems Improvement (ICSI)
httpwwwicsiorg
American Medical Association httpwwwama-assnorg
Canadian Medical Association (CMA)
httpmdmcacpgsnewcpgsindexasp
Health Canada ndash Population and Public Health Branch (PPHB)
httpwwwhc-scgccapphb-dgspspdpg_ehtml
didi britaneTi
National Institute for Clinical Excellence (NICE)
httpwwwniceorguk
Sheffield Evidence for Effectiveness and Knowledge (SEEK)
httpwwwshefacukseekguidelineshtm
National electronic Library for Health (NeLH)
httpwwwnelhnhsukguidelinesfinder
PRODIGY Clinical Guidance httpwwwprodigynhsukClinicalGuidance
Scottish Intercollegiate Guidelines Network (SIGN)
httpwwwsignacuk
German Guideline Information Service (GERGIS)
httpwwwleitliniendeenglishenglishview
avstralia
Australian National Health and httpwwwhealthgovauhfsnhmrcpublicatcp-
21
Medical Research Council (NHMRC) homehtmaxali zelandia
New Zealand Guidelines Group (NZGG)
httpwwwnzggorgnzlibrarycfm
mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba
httpwwwosdmorg
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi
bull koxreinis biblioTeka - The Cochrane Library 2006 Issue 2 bull amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini ndash MEDLINEbull jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvisgamoricxvis kriteriumebi
bull arCeul iqna kvlevebi Semdegi dizainiT randomizebuli kontrolirebadi sistemuri mimoxilvebi da meta-analizi erTmomentiani kohortuli kvlevebi
bull rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12 wliani SezRudva Tumca zogjer gamoyenebuli iyo ufro adreuli publikaciebi romlebic dResac aqtualuria da safuZvlad udevs sxva Tanamedrove mtkicebulebebs
bull dadgenili iyo enobrivi SezRudvebi radganac samuSao jgufs SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod inglisur da rusul enebze
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
bull samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri meToduri rekomendacia axalSobilTa hiperbilirubinemiis marTvis sakiTxebze romlebic Seicavda jgufis miznis Sesaferis saWiro informacias am rekomendaciebis Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (9496-98) samuSao jgufi xelmZRvanelobda saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mier SemuSavebuli nacionaluri gaidlainebis gzamkvleviT Sefasebis Sedegad amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi
rArr amerikis pediatrTa akademia
rArr msoflo jandacvis organizacia
rArr kanadis pediatrTa sazogadoeba ndash nayofi da axalSobilis komiteti
rArr britaneTis reproduqciuli janmrTelobis programa
22
bull rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da rekomendaciebis xarisxis sqema
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris
done (Muir Gray)xarisxi rekomendaciis xarisxi
(Cook et al)I Zlieri mtkicebuleba
eyrdnoba minimum erT sistemur mimoxilvas
romelic efuZneba swori dizainis mqone randomizebul
kontrolirebad kvleva
A eyrdnoba I donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erTi swori dizainis mqone
randomizebul kontrolirebad kvleva
B eyrdnoba II donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
III klinikuri kvleva randomizaciis gareSe
kohortuli da SemTxveva-kontrolis kvlevebi
C eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi
D eyrdnoba IV da V donis mtkicebulebas saWiroebs
konsesuss
Va avtoritetul profesionalTa mosazreba
Vb klinikuri gamocdileba aRwerilobiTi kvlevebi an
eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
15 avtorTa jgufi
bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis
bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi
rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
23
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24
1 daavadebis definicia sinonimebi klasifikacia da terminologia
axalSobilTa siyviTle axalSobilis kanis da sklerebis yviTeli Seferilobaa rac ganpirobebulia qsovilebSi bilirubinis CalagebiT
axalSobilebSi siyviTle vlindeba roca bilirubinis Semcveloba sisxlis SratSi gadaaWarbebs 5 mgdl (85 micromolL) (AMERICAN ACADEMY OF PEDIATRICS 2004)
fiziologiuri siyviTle msubuqi arakoniugirebuli (arapirdapiri) bilirubinemiaa romelic vlindeba sicocxlis 48-120 sT-Si bilirubinis Semcvelobis pikuri done sicocxlis III dRisTvis uxSiresad 5-8 mgdl-ia (86-136 micromolL) Semdeg xdeba misi donis daqveiTeba 12 mgdl-mde mateba fiziologiurad iTvleba 35-37 kv gestaciuri asakis axalSobilebSi Bbilirubinis donem SeiZleba maqimums miaRwios dabadebidan me-7 dRes
arakoniugirebuli hiperbilirubinemiis ufro maRali done sxvadasxva paTologiuri mdgomareobebis dros vlindeba (Ronald J Wong 2005)
hiperbilirubinemia paTologiuria roca Sratis saerTo bilirubinis done (TSB) gadaaWarbebs 95 percentils butanis nomogramaSi (Ronald J Wong 2005)
butanis nomograma saSualebas iZleva ganisazRvros ramdenad maRalia mZime hiperbilirubinemiis ganviTarebis riski axalSobilis asakis (saaTebSi) da Sratis bilirubinis koncentraciis gaTvaliswinebiT
mwvave bilirubinuli encefalopaTia - axalSobilobis pirvel kviraSi manifestirebuli bilirubinuli toqsiurobis mwvave periodi
kerniqterusi _ gamoiyeneba bilirubinis toqsiurobis qronikuli da permanentuli klinikuri gamosavlis asaRwerad
gamoyenebuli Semoklebebi
Sbs ndash Sratis saerTo bilirubinitkb ndash transkutanuri bilirubiniba - bilirubinis da albuminis Sefardebards ndash respiraciul distres sindromi
epidemiologiafiziologiuri siyviTle viTardeba dRenaklul axalSobilTa
umravlesobasa da droul axalSobilTa 25-50-Si janmrTel droul axalSobilTa 61-Si Sratis bilirubinis maqsimaluri done aRemateba 129mgdl 3 -Si ki _ 15mgdl
multinacionaluri kvlevebis monacemebiT 30 saaTis asakisaTvis axalSobilTa 5 ndash 40 -Si Sratis saerTo bilirubinis done aWarbebs 95 percentils butanis nomogramaSi daniis monacemebiT mZime hiperbilirubinemiis sixSire 35 kviraze meti gestaciis axalSobilebSi Seadgens 25-s 100 000 cocxladSobilze janmos monacemebiT axalSobilTa hemolizuri daavadebis sixSire Seadgens 1-s yovel 2000-3000 axalSobilze
saqarTveloSi zusti statistikuri monacemebi ar arsebobs Tumca 2000 wlis maCveneblebiT yovel 1000 cocxladSobilze gamovlinda 5 SemTxveva
2
etiopaTogenezi
mizezebi (Ronald J Wong 2005)(AMERICAN ACADEMY OF PEDIATRICS 2004)
hiperbilirubinemia SesaZlebelia mimdinareobdes arapirdapiri an pirdapiri bilirubinis donis momatebiT gaZlierebuli hemolizi bilirubinis koniugaciis unaris Semcireba iwvevs arapirdapir bilirubinemias xolo naRvlis eqskreciis darRveva ndash pirdapir bilirubinemias
1 fiziologiuri siyviTle
bull erTrocitebis da hemoglobinis maRali Semcveloba
bull fetaluri hemoglobinis Semcveli eriTrocitebis hemolizi
bull RviZlSi bilirubinis koniugaciis unaris umwifroba
bull bilirubinis gazrdili enterohepatuli cirkulacia
bull RviZlis mier plazmidan bilirubinis moxmarebis Semcireba
2 paTologiuri siyviTle eriTrocitebis hemolizis gaZliereba
bull sisxlis jgufuri da rezus SeuTavsebloba
bull Tandayolili membrano (sferocitozi da sxv) fermento (glukoza 6 fosfatdehidrogenazas - g6fd ndash ukmarisoba da sxv) da hemoglobinopaTia (Talasemia da sxv)
bull policitemia
bull kefalohematoma sisxlCaqcevebi
bull infeqciabilirubinis koniugaciis Semcireba
bull dRenakluloba
bull iSviaTi Tanadayolili daavadebebi (Jilberis krigler-naiaris sindromi da sxva)
bull bilirubinis metabolizmis da eqskreciis darRveva (rotoris da dubin-jonsonis sindromi)
bilirubinis reabsorbciis gazrda gastrointestinuri traqtidanbull asfiqsia
bull kvebis gvian dawyeba iSviaTi kveba
bull nawlavTa obstruqcia
bull mekoniumis pasaJis Seferexeba
3 naRvlis eqskreciis darRveva
bull sefsisi
bull saSvilosnosSida infeqcia
bull hepatiti
bull qolestazuri sindromi
bull biliaruli atrezia
bull cisturi fibrozi (mukoviscidozi)
4 siyviTle ZuZuTi kvebis dros
bull dedis rZiT ganpirobebuli (ariasis sindromi) savaraudoa dedis rZeSi arsebuli nivTierebis (araesterificirebuli cximovani mJavebis da hormon pregnanis) gavlena bilirubinis metabolizmze (iTrguneba ferment glukuroniltransferazas aqtivoba da bilirubinis koniugacia)
3
bull ZuZuTi kvebis araswori reJimiT ganpirobebuli iSviaTi ZuZuTi kvebis SemTxevaSi arasakmarisi raodenobiT rZis miReba iwvevs enterohepaturi cirkulaciis gazrdas
bilirubinis toqsiuroba - bilirubini potenciuri neirotoqsinia arakoniugirebulma bilirubinma romelic ar aris dakavSirebuli albuminTan SeiZleba gaiaros hematoencefaluri barieri da Tavis tvinSi gamoiwvios ujredebis sikvdili apoptoziT (ujredebis programirebuli sikvdili) daan nekroziT yvelaze metad ziandeba bazaluri ganglia da Tavis tvinis Reros okulomotoruli da auditoruli funqciebis makontrolebeli birTvebi
Tu droul axalSobilebSi bilirubini gadaWarbebs 25-30 mgdl (428 - 513 micromolL) maRalia bilirubinis toqsiuri moqmedebis ganviTarebis riski Ssb toqsiuroba variabeluria da damokidebulia axalSobilis janmrTelobis mdgomareobaze da gestaciur asakze
mZime hiperbilirubinemiis ganviTarebis risk-faqtorebi mZime hiperbilirubinemiis ganviTrebis riski miT ufro maRalia rac
ufro meti riskis faqtoria gamoxatuli axalSobilTanmaRali riski (AMERICAN ACADEMY OF PEDIATRICS 2004) (Ronald J Wong 2005)
minus dabadebidan pirvel 24sT-Si gamovlenili siyviTle minus gaweris win Ssb an tkb done butanis nomogramaze maRali riskis
zonaSi
minus sisxlis jgufuri SeuTavsebloba dadebiTi pirdapiri antiglobulinuri testiT sxva cnobili hemolizuri daavadeba (mag g6fd deficiti)
minus gestaciuri asaki 35-36 kvira minus da-Zmas Catarebuli aqvs fotoTerapia
minus kefalohematoma an mniSvnelovani sisxlCaqcevebi (Newman TB 2000)minus araxSiri ZuZuTi kveba rodesac aReniSneba wonaSi mkveTri kleba
(gt12-ze meti) (Newman TB 2000 dabali riski
gaweris win Ssb an tkb-is done butanis nomogramaze maRali gardamavali riskis zonaSi
gestaciuri asaki 37-38 kvira (Newman TB 2000 da-Zmis anamnezSi siyviTle diabetiT daavadebuli dedis makrosomuli axalSobili
dedis asaki ge 25 welze (Newman TB 2000) mamrobiTi sqesi (Newman TB 2000 )
mdgomareobebi romlis drosac mZime hiperbilirubinemiis ganviTarebis riski Zalian dabalia
minus gestaciuri asaki ge 41 kviraze (Newman TB 2000)minus srulyofili enteraluri kveba (Newman TB 2000)minus gawera stacionaridan 72 sT-is Semdeg
minus Ssb dabali riskis zonaSi
4
klinikuri simptomatika
rekomendacia - siyviTlis monitoringi unda moxdes yvela axalSobilTan rutinulad vitaluri funqciebis Sefasebisas ara nakleb 8-12 sT-Si erTxel (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)siyviTlis arsebobis Sefaseba unda moxdes kargad ganaTebul oTaxSi umjobesia dRis Suqze fanjarasTan siyviTle Cveulebriv pirvelad vlindeba saxeze da Semdeg progresirebs kaudalurad sxeulsa da kidurebze siyviTlis ukeT gansazRvrisaTvis tardeba kanze TiTis zewolis testi zewola lokalurad amcirebs kanis perfuzias da xels uwyobs siyviTlis diagnostikas rodesac bilirubini 4-8 mgdl (68-137 micromolL) Cveulebriv iqterulia saxe da sklera Tu bilirubini gt15 mgdL (257 micromolL) siyviTle vlindeba mTel sxeulze xelis da fexisgulebis CaTvliT Ssb an tkb mizanSewonilia gaizomos Tu siyviTle vlindeba Wipis qvemoT
siyviTlis simZimis Sefaseba lokalizaciis mixedviT (WHO 2003) cxrili 1
asaki (dRe) siyviTlis lokalizacia daskvna
1 nebismieri
2 kidurebi
ge 3 terfebi mtevnebi
laquosaSiSiraquo siyviTle
sicocxlis I dRes nebismier adgilas an II dRes kidurebze gamovlenili siyviTle saWiroebs dauyovnebliv fotoTerapiis dawyebas analizis pasuxis miRebamde
krameris modificirebuli sqema cxrili 2
zona1 2 3 4 5
Ssb micromolL 100 150 200 250 gt250
krameris modificirebuli sqema saSualebas iZleva siyviTlis gavrcelebis mixedviT vivaraudoT Tu ramdenia Sratis saerTo bilirubinis done
siyviTlis xarisxis gansazRvra siyviTlis intensivobis mxolod vizualuri SefasebiT xSirad iwvevs daignostikur Secdomas gansakuTrebiT muqkanian axalSobilebSi
(rekomendacia C) (AMERICAN ACADEMY OF PEDIATRICS 2004)
axalSobilTa siyviTlisGgarTulebebimwvave da qronikuli (kerniqterusi) bilirubinuli encefalopaTiamwvave bilirubinuli encefalopaTia (AMERICAN ACADEMY OF PEDIATRICS 2004) mwvave bilirubinuli encefalopaTias axasiaTebs ganviTarebis 3 faza
5
C
1 adreuli faza vlindeba ramdenime dReSi da axasiaTebs leTargia hipotonia susti wova da sustad gamoxatuli ldquotvinismieri kivilirdquo
2 gardamavali stadia viTardeba kviris bolos da axasiTebs zomieri stupori agznebadoba da hipertonia axalSobils SeiZleba aReniSnos cxeleba mkveTrad gamoxatuli ldquotvinismieri kivilirdquo hipertonia vlindeba kisris (retrokolisi) da sxeulis (opistotonusi) ukan rkaliseburad gadaxriT
3 bolo stadia vlindeba 1 kviris Semdeg am dros centraluri nervuli sistemis dazianeba Seuqcevadia mas axasiaTebs mkveTri retrokolisi da opistotonusi mkveTrad gamoxatuli ldquotvinismieri kivilirdquo apnoe cxeleba sakvebis autanloba Rrma stupori komamde zogjer krunCxvebi da sikvdili
kerniqterusi (AMERICAN ACADEMY OF PEDIATRICS 2004)Bmwvave bilirubinuli encefalopaTiis Semdeg gadarCenil
axalSobils sicocxlis pirveli wlis manZilze uviTardeba bilirubinuli encefalopaTiis mZime qronikuli forma romelic 3 ZiriTadi gamovlinebiT xasiaTdeba
motoruli darRvevebi - aTetoiduri cerebluri dambla tremori qorea
mxedvelobis darRvevebi smeniTi disfunqcia inteleqtualuri darRvevebi SedarebiT iSviaTia damatebiT SeiZleba
ganviTardes kbilis emalis hipoplazia kerniqterusis dros 70-Si aRiniSneba nevrologiuri darRvevebi da
10-Si sikvdiloba
diferenciuli diagnoziaxalSobilTa siyviTlis dros unda ganisazRvros siyviTle
fiziologiuria Tu paTologiuri
fiziologiuri siyviTle paTologiuri siyviTle
vlindeba ara uadres 2 dRisa da qreba me-10-14 dRisTvis
vlindeba pirvel 24 saaTSi an7 dRis Semdeg
gavrceleba ar aRemateba krameris 1-3 zonebs
gavrceleba krameris nebismieri zona sicocxlis I dRes 4 zona sicocxlis II dRes da 5 zona nebismier asakSi
bavSvi aqtiuria temperatura normaluria wovis refleqsi kargia
zogadi mdgomareoba damakmayofilebeli an darRveuli
Sardis da ganavlis feri ar icvleba
SeiZleba iyos Sardis da ganavlis feris cvlileba
RviZli da elenTa ar aris gadidebuli
SeiZleba iyos hepatosplenomegalia
dedis rZiT ganpirobebuli siyviTlis sadiagnostikod (samkurnalod) SeiZleba Semdegi maCveneblebis gamoyeneba
bull dedis rZiT ganpirobebuli siyviTle vlindeba me-4-14 dRes
bull 24-48sT-is ganmavlobaSi ZuZuTi kvebis Sewyveta da alternatiul sakvebis miwodeba iwvevs bilirubinis donis daqveiTdebas
6
axalSobilTa hiperbilirubinemiis difdiagnozi ix algormiTi 1
gamokvlevis sqema
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004) tkb daan Ssb unda ganesazRvros yvela axalSobils
romelsac siyviTle gamouvlinda sicocxlis pirvel 24sT-Si (ix algoriTmi I da cxrili 3 ) (rekomendacia C)
tkb daan Ssb ganmeorebiTi gansazRvris dro da saWiroeba damokidebulia bilirubinis doneze (sqema 2) axalSobilis asakze hiperbilirubinemiis dinamikaze rekomendaciebi Ssb gansazRvrisaTvis dabadebidan 24 sT-is Semdeg mowodebulia I algoriTmsa da cxrilSi 3
tkb daan Ssb unda ganesazRvros yvela axalSobils romelsac gamouvlinda asakTan Seusabamo mkveTri siyviTle (rekomendacia D)
bilirubinis donis Sefaseba unda moxdes axalSobilis asakis (saaTebSi) gaTvaliswinebiT (sqema 2) (rekomendacia
C) Tu axalSobils utardeba fotoTerapia an aReniSneba
bilirubinis swrafi mateba (sqema 2 ndash butanis sqemaze monacemi kveTs percentilebs) rac ar aixsneba obieqturi gamokvleviT da anamnezuri monacemebiT saWiroa siyviTlis SesaZlo mizezebis dadgena (rekomendacia D)
axalSobilebs romelTac aReniSnebaT pirdapiri (koniugirebuli) bilirubinis mateba unda CautardeT Sardis saerTo da baqteriologiuri gamokvleva damatebiTi laboratoriuli gamokvlevebi unda Catardes Tu anamneziT da obieqturi gamokvelevebiT saeWvoa sefsisi (rekomendacia
C) avadmyof axalSobilebsa da Cvilebs romelTac aReniSnebaT
siyviTle 3 kviris an ufro mogvianebiT asakSi unda ganesazRvroT saerTo da pirdapiri (koniugirebuli) bilirubini qolestazis sadiagnostikod (cxrili 3) (rekomendacia D) aseT axalSobilebTan mizanSewonilia skriningi hipoTireozsa da galaqtozemiaze (rekomendacia D)
Tu pirdapiri an koniugirebuli bilirubinis done momatebulia rekomendirebulia damatebiTi gamokvlevebi qolestazis sadiagnostikod (rekomendacia C)
glukoza-6-fosfat dehidrogenazas donis gansazRvra saWiroa im axalSobilebTan romelTa ojaxuri anamnezi an eTnikuri an geografiuli warmoSoba miuTiTebs g6fd-s deficitze da utardebaT fotoTerapia daan axalSobilebTan Tu fotoTerapia uefeqtoa (sqema 3) (rekomendacia C)
7
C
D
C
D
C
C
C
D
D
cxrili 3 35 da meti gestaciuri asakis axalSobilSi gamovlenili siyviTlis laboratoriuli Sefaseba (AMERICAN ACADEMY OF PEDIATRICS 2004)
Cveneba laboratoriuli kvlevapirvel 24 sT-Si gamovlenili siyviTle
bull tkb daan Ssb gansazRvra
asakisaTvis Seusabamo mkveTri siyviTle kanze G
bull tkb daan Ssb gansazRvra
axalSobils utardeba fotoTerapia an aReniSneba bilirubinis swrafi mateba (sqema 2 ndash butanis sqemaze maCvenebeli kveTs percentilebs) rac ar aixsneba obieqturi gamokvleviT da anamnezuri monacemebiT
bull sisxlis jgufi da rezusi kumbsis testi Tu ar aris gakeTebuli Wiplaris sisxlSi
bull sisxlis saerTo analizi da nacxi formiani elementebis morfologiis Sesaswavlad
bull pirdapiri (koniugirebuli) bilirubinis gansazRvra
bull Tu SesaZlebelia isazRvreba retikulocitebis ricxvi g6fd
bull Ssb ganmeorebiT isazRvreba 4-24 sT-Si axalSobilis asakisa da Ssb donis Sesabamisad
fotoTerapia uSedegoa an Ssb aRwevs dones romelzec naCvenebia SenacvlebiTi transfuzia
bull Tu SesaZlebelia isazRvreba retikulocitebis ricxvi g6fd
momatebulia pirdapiri (koniugirebuli) bilirubinis done
bull Sardis anlizi
bull Sardis kultura
bull gamokvleva sefsisze Tu misi arseboba saeWvoa anamneziT an obieqturi gamokvleviT
siyviTle sami kviris asakis an avadmyof axalSobilSi
bull saerTo da pirdapiri (koniugirebuli) bilirubini
bull pirdapiri bilirubinis momatebisas tardeba kvleva qolestazis sadiagnostikod
bull skriningi hipoTireozsa da galaqtozemiaze
bull axalSobilis Sefaseba hipoTireozis simptomebis gamosavlenad
sqema 1 butanis nomograma
8
butanis nomograma saSualebas iZleva ganisazRvros ramdenad maRalia mZime hiperbilirubinemiis ganviTarebis riski axalSobilis asakis (saaTebSi) da Sratis bilirubinis koncentraciis gaTvaliswinebiT bilirubinis gansazRvra
bilirubini isazRvreba transkutanurad da sisxlis SratSi transkutanuri gansazRvra gamarTlebulia rogorc skriningis
meTodi is isazRvreba specialuri aparatiT aRniSnuli xelsawyos gamoyenebiT bilirubinis gansazRvra SesaZloa 2-3 mgdl (34-54micromolL) variabelobiT bevr SemTxvevaSi xdeba Sratis bilirubinis gansazRvris Canacvleba transkutanuri gansazRvriT gansakuTrebiT maSin roca Ssb lt 15 mgdl (257 micromolL)
fotoTerapiis dros kanis vizualuri SefasebasTan erTad aucilebelia Sratis bilirubinis gansazRvra radgan fotoTerapia ldquoaTeTrebsrdquo kans (American Academy of Pediatrics 2004)
pirveladi profilaqtika
rekomendacia (American Academy of Pediatrics 2004) bull eqimma unda urCios dedas ganaxorcielos moTxovnilebiTi ZuZuTi kveba dReSi 8-12-jer (rekomendacia C) - arasrulyofili kaloriebis miRebam daan dehidrataciam SeiZleba gamoiwvios Hhiperbilirubinemiis ganviTareba
bull ZuZuTi kvebis SemTxevaSi Tu axalSobils ar aReniSneba dehidratacia ar aris rekomedirebuli wylisa da deqstrozis rutinulad damateba (rekomendacia B da C) -
9
C
B
C
wylis da deqstrozis damateba ar axdens hiperbilirubinemiis ganviTarebis profilaqtikasa da Ssb-s Semcirebas
bull yvela Rh (D) negatiur orsuls an melogines mizanSewonilia Cautardes anti D imonoglobuliniT profilaqtika (rekomendacia A)
minus orsulobis 28 kviraze (garda im SemTxvevebisa rodesac bavSvis mamac Rh (D) negatiuria)
minus mSobiarobidan 72 sT-is gamnavlobaSi Tu axalSobili Rh (D) pozituiria
minus orsulobis pirvel trimestrSi ganviTarebuli abortis da invaziuri procedurebis dros rogorica amniocentezi nayofis invaziuri procedurebi
meoradi profilaqtikarekomendacia klinicistma unda moaxdinos axalSobilTa hiperbilirubinemiis ganviTarebis riskebis sistemuri Sefaseba neonatalur periodSi (rekomendacia B)(AMERICAN ACADEMY OF PEDIATRICS 2004)
sisxlis jgufobriobarekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
yvela orsuli qali unda iyos gamokvleuli ABO da Rh(D) sisxlis jgufebze da hqondes Catarebuli skriningi SratSi izoimunur antisxeulebze (rekomendacia B)
Tu dedas ar Cautarebia prenatalurad sisxlis jgufis da rezusis gamokvleva an igis Rh negatiuria mkacrad aris rekomendirebuli pirdapiri antisxeulebis testis (an kumbsis testi) sisxlis jgufis da Rh (D) tipis gansazRvra axalSobilis (Wiplaris) sisxlSi (rekomendacia B)
Tu dedas sixlis jgufi aris O Rh(D) pozitiuri axalSobilis sisxlis jgufis da pirdapiri antisxeulis testis gansazRvris aucilebloba damokidebulia meTvalyureobis xarisxze gaweris win riskis Sefasebasa da gaweris Semdeg meTvalyureobaze (rekomendacia C)
mkurnalobis sqemamkurnalobis ZiriTadi principebia
fotoTerapia SenacvlebiTi transfuzia
mkurnaloba iwyeba fotoTerapiiTfotoTerapiis dros kanis zeda SreebSi Calagebuli arapirdapiri bilirubini iSleba fotoqimiuri gziT wyalSi xsnad koniugatebad romlebic gamoiyofa SardiT da naRveliTrekomendacia yvela samSobiaro saxli unda iyos aRWurvili mowyobilobiT romelic saWiroa intensiuri fotoTerapiisaTvis (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)fotoTerapiis Cvenebebi
fotoTerapia iwyeba Tu bulirubinis done aRemateba 95 percentils butanis nomogramaze (sqema 1) amave dros metad mniSvnelovania risk-faqtorebis gaTvaliswineba romlebic xels uwyobs mZime
10
A
B
B
B
C
D
hiperbiliruminemias (hemolizuri daavadeba g6fd deficiti asfiqsia mkveTrad gamoxatuli leTargia temperaturis arastabiluroba sefsisi acidozi an hipoalbuminemia lt30 gdl)
amerikis pediatriuli akademiis rekomendaciiT gamoiyeneba sqema (sqema 2) romelic axalSobilis asaksa da bilirubinis donesTan erTad iTvaliswinebs risk-faqtorebsa da gestaciur asaks mocemuli sqemis mixedviT ldquointensiurirdquo fotoTerapia iwyeba Semdegi principebiT
dabali riskis axalSobili (janmrTeli risk-faqtorebis gareSe gestacia gt 38 kvira) ndash Ssb gt12 mgdl (205 micromolL) 24 sT-Si Ssb gt15 mgdl (257 micromolL) 48 sT-Si Ssb gt18 mgdl (308 micromolL) gt72 sT
saSualo riskis axalSobili (gestacia gt 38 kvira da risk-faqtorebi an gestacia 35-37 kvira risk-faqtorebis gareSe gareSe) ndash Ssb gt 10 mgdl (171 micromolL) 24 sT-Si Ssb gt13 mgdl (222 micromolL) 48 sT-Si Ssb gt15 mgdl (257 micromolL) gt72 sT gestaciis 35 kviris axalSobilebSi fotoTerapia SeiZleba daiwyos ufro dabal maCveneblebze
maRali riskis axalSobili (gestacia 35-37 kvira da risk-faqtorebi) - Ssb gt 8 mgdl (137 micromolL) 24 sT-Si Ssb gt11 mgdl (188 micromolL) 48 sT-Si Ssb gt135 mgdl (231 micromolL) gt72 sT
Tu dabali riskis axalSobilebSi Ssb done 2-3 mgdl-iT dabalia moyvanil monacemebze SesaZlebelia mkurnalobis dawyeba ldquoCveulebrivirdquo fotoTerapiiT
bull stacionarSi gamoxatuli siyviTliT Semosul axalSobils utardeba ldquointensiurirdquo fotoTerapia bilirubinis maCveneblis gansazRvramde
bull ldquointensiurirdquo fotoTerapia aseve rekomendebulia hemolizuri daavadebis dros
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
janmos rekomendacia fotoTerapiis dawyebis Cvenebebis Sesaxeb mocemulia cxrilSi 4
cxrili 4 fotoTerapiis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI gamoxatuli siyviTleII 15 260 13 220III 18 310 16 270
IV da meti 20 340 17 290janmos rekomendaciiT fotoTerapia iwyeba Tu siyviTlis
lokalizaciis mixedviT siyviTlis simZimis Sefasebisas (cxrili 1) dadginda ldquosaSiSi siyviTlerdquo
Tu ar aris bilirubinis gansazRvris saSualeba Ssb savaraudo donis dasadgenaT SeiZleba krameris modificirebuli sqemis gamoyeneba
11
sqema 2 fotoTerapiis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (AMERICAN ACADEMY OF PEDIATRICS 2004)
rekomendacia Tu Sratis albuminis maCvenebeli naklebia 30 gdl-ze fotoTerapiis dawyeba rekomendebulis ufro dabali maCveneblebis dros (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis ukuCveneba pirdapiri (koniugirebuli) hiperbilirubinemia (pirdapiri
bilirubini Ssb-s 50-ze metia) (American Family Practice Notebook 2002 ) (AMERICAN ACADEMY OF PEDIATRICS 2004)
Tandayolili porfiria an porfiriis ojaxuri anamnezi (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis teqnikafotoTerapiis efeqturoba damokidebulia dozaze fotoTerapiis doza anu speqtruli iradiacia damokidebulia naTuris simZlavreze sinaTlis wyarosa da bavSvs Soris manZilsa da dasxivebis farTobze sinaTlis wyarofotoTerapiis sinaTlis speqtri damokidebulia sinaTlis wyaroze da filtrze yvelaze farTod gavrcelebuli fotoTerapiis mowyobiloba Seicavs dRis Suqis gril TeTr cisfer an ldquospecialur cisferrdquo fluorescentul naTurebs manZils sinaTlis wyarodan axalSobilamde didi mniSvneloba eniWeba sasurvelia axalSobili moTavsdes sinaTlis wyarodan im minimalur manZilze romelic miTiTebulia fotoTerapiis mowyobilobis instruqciaSi halogenis fotoTerapiis naTurebi ar SeiZleba moTavsdes axalSobilTan axlos radgan SeiZleba gamoiwvios damwvroba
12
DD
sxeulis zedapiris farTobibilirubinis maRali Semcvelobisas mniSvnelovania fotoTerapiis dros dasxivdes sxeulis zedapiris rac SeiZleba meti farTobi
ldquoCveulebrivi fotoTerapiardquo - sinaTlis speqtris iradiacia dabalia (6-12 microWcm2nm) (talRis sigrZe daaxloebiT 425-475 nm) da damokidebulia sxvadasxva mwarmoeblis mier mowodebul fotoTerapiiis sistemis aparatis monacemebze saWiroa aparatis Semowmeba Seesabameba Tu ara sinaTlis speqtris iradiacia mwarmoeblis mier mowodebul monacemebsldquointensiuri fotoTerapiardquo - lurj-mwvane speqtris iradiacia (talRis
sigrZe daaxloebiT 430-490 nm) sul cota 30 microWcm2nm-ia (isazRvreba axalSobilis kanze fototerapiis aparatis centris qveS) gazomva xdeba im warmoebis radiometriT romelic mowodebulia fotoTerapiiis sistemis aparatis mwarmoeblis mier sinaTlis talRis asareklad TeTreuli unda iyos TeTri kuvezi da sawolis gverdebi daifaros TeTri qsoviliT an aluminis folgiT
fotoTerapiis procedura da monitoringi
temperatura sinaTlis wyaros qveS unda iyos 28-300C
fotoTerapiis dros bavSvi unda iyos SiSveli ecvas erTjeradi higienuri safeni Tvalebze unda hqondes damcavi saTvale
yovel 3 saaTSi erTxel bavSvs unda Seucvalon pozicia
yovel 3 saaTSi erTxel unda Sefasdes sinaTlis wyaros qveS arsebuli temperatura da axalSobilis sxeulis temperatura Tu bavSvis t metia metia 3750C saWiroa oTaxis temperaturis daqveiTeba an fotoTerapiis droebiT Sewyveta sanam bavSvis temperatura ar iqneba normis farglebSi (365-3750C)
fotoTerapia mimdinareobas mudmivad igi wydeba mxolod im procedurebis dros romelTa warmoeba ra SeiZleba sinaTlis wyaros qveS
centraluri cianozis arsebobis Sesafaseblad fotoTerapia unda Sewydes mcire droiT
fotoTerapiis dros unda gagrZeldes bavSvis kveba
rArraxalSobilTan unda gagrZeldes ZuZuTi kveba moTxovnilebis mixedviT (intervali kvebaTa Soris araumetes 3 sT-isa) (rekomendacia C) ZuZuTi kvebis dros wydeba fotoTerapia da Sesabamisad bavSvs unda moexsnas damcavi saTvale
rArrTu bavSvi ikvebeba gamowvelili rZiT formuliT an parenteralurad misawodebeli sakvebis an siTxis raodenoba izrdeba dRiuri normis 10 -iT
rArr Tu bavSvi ikvebeba zondiT an parenteralurad fotoTerapia mimdinareobs uwyvetad
rArrCveulebriv fotoTerapiis dros axalSobils ar esaWiroeba damatebiT siTxis an sakvebis miwodeba damateba naCvenebia mxolod araefeqturi ZuZuTi kvebis sxeulis masis paTologiuri danakargis (gt10-ze mesame dRisTvis) da dehidrataciis SemTxvevaSi
13
C
fotoTerapiis dros bilirubinis daSlis produqtebi gamoiyofa SardiT da naRveliT adeqvaturi hidrataciis SenarCuneba da Sesabamisad adekvaturi diurzis SenarCuneba zrdis fotoTerapiis efeqturobas
zogierT axalSobils hiperbilirubinemiiT aReniSneba dehidratacia da saWiroa damatebiTi siTxis miwodeba (per-os an intravenurad) dehidrataciis koreqciisaTvis
araefeqturi ZuZuTi kvebis SemTxvevaSi fotoTerapiis dros axalSobils damatebiT miewodeba gamowvelili dedis rZe donoris rZe an xelovnuri sakvebi
rArr adeqvatur kvebaze miuTiTebs 4-6 sveli safeni 24 sT-Si da nawlavTa moqmedeba 3-4 jerdReSi meoTxe dRisaTvis
janmrTeli drouli axalSobilis nawlavTa moqmedeba da diurezi (minimaluri maCveneblebi) cxrili 5 (Fetus and Newborn Committee 1999)
dRe nawlavTa minimaluri moqmedeba24sT
sveli safeni24sT
1 1 12 1 23 1 gardamavali 34 2 yviTeli fafisebri 45 2YyviTeli fafisebri 5-6
rArrdehidrataciaze miuTiTebs Semdegi niSnebis arseboba - masis paTologiuri kleba (gt10-ze mesame dRisTvis)- anuria 4-6 sT- Cacvenili Tvalebi- Cavardnili yoflibandi - - daqveiTebuli kanis elastiuroba (kanis naoWi swordeba
nela)- daqveiTebuli kanis kapilaruli avseba (gt3 wm)- taqikardia- Sratis Na gt145 HCO3 lt17
bilirubinis monitoringi fotoTerapiis dros (American Aacademy of Pediatrics 2004)
sawyisi bilirubinis maCveneblis Semcireba 6-20-iT standartuli da 30-40-iT intensiuri fotoTerapiis dawyebidan 24sT-Si mis efeqturobaze miuTiTebs
bull Tu Ssb ge 25 mgdL (428 micromolL) ganmeorebiTi gansazRvra 2ndash3 sT-Si
bull Tu Ssb 20ndash25 mgdL (342ndash428 micromolL) ganmeorebiTi gansazRvra 3-4 sT-Si
bull Tu Ssb lt20 mgdL (342 micromolL) ganmeorebiTi gansazRvra 4ndash6 sT-Si Tu Ssb agrZelebs daqveiTebas ganmeorebiTi gansazRvra 8-12 sT-Si
bull Tu Ssb ar mcirdeba an uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones an Ssb albuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6) iwyeba SenacvlebiTi transfuzia Tu amis saSualeba aris an xorcieldeba referali
bull intensiur fotoTerapiis miuxedavad Ssb-is ucvleli done an mateba miuTiTebs hemolizze
14
rArr anemiahemolizis Sefaseba SesaZlebelia sisxlis saerTo analizis mixedviT - Hgblt 130 glLHct lt 40 retikulocitebi - gt 6
bull Ssb lt 13ndash14 mgdL (239 micromolL) fotoTerapia wydeba
bull fotoTerapiis Sewyvetidan 24 sT-Si kontroldeba Ssb Tu Ssb moimata im donemde romelzec daiwyo fotoTerapia fotoTerapia ganmeorebiT iwyeba
fotoTerapiis garTulebebi
fotoTerapiis garTulebebi (Ronald J Wong 2005 American Aacademy of Pediatrics 2004)
rArrmwvane feris ganavalidiarea (mkurnalobas ar saWiroebs)
rArr dehidratacia
rArr muclis Seberva (mkurnalobas ar saWiroebs)
rArr Tvalis SesaZlo dazianeba yvelaze seriozuli magram iSviaTi klinikuri garTulebaa brinjaos
axalSobilis sindromi romelic vlindeba qolestazuri siyviTlis mqone axalSobilSi kanis Sratis da Sardis muqi nacrisfer-yavisferi SeferilobiT brinjaos axalSobilis sindromi ar vlindeba qolestazis mqone yvela axalSobilTan Tu arsebobs fotoTerapiis Cveneba pirdapiri hiperbilirubinemia ar warmoadgens fotoTerapiis winaaRmdeg Cvenebas axalSobilebSi romelTac uviTardebaT brinjaos sindromi naCvenebia SenacvlebiTi transfuzia monacemebis arasrulyofilebis gamo mkacri rekomendaciis gakeTeba ar SeiZleba
mZime qolestazuri siyviTlis mqone axalSobilebSi fotoTerapiis dros aseve SeiZleba ganviTardes
rArr purpura
rArr bulozuri gamonayari
mzis ultraiisferi sxivebiT TerapiamarTalia mzis sxivebs gaaCniaT mniSvnelovani iradiacia 425-475 nm magram radganac maRalia axalSobilis damwvrobis ganviTarebis riski (SiSveli axalSobilis mzeze yofnis gamo) es meTodi rekomendebuli ar aris
(Ronald J Wong 2005 (American Aacademy of Pediatrics 2004)
intravenuri imunoglobulinis gamoyenebarekomendacia izoimunuri hemolizuri daavadebis dros rekomendebulia intravenuri imunoglobulinis gamoyeneba (05-1 gkg 2 sT-s ganmavlobaSi) Tu Ssb imatebs intensiuri fotoTerapiis miuxedavad an Ssb aris 2-3 mgdl-iT (34-51mkmoll) naklebi SenacvlebiTi transfuziis Cvenebis doneze (fighellip4) aucilebelobis SemTxvevaSi intravenuri imunoglobulinis es doza SeiZleba ganmeordes 12 sT-Si (rekomendacia B) American Aacademy of Pediatrics 2004)
15
fotoTerapiis dros kanSi Calagebuli bilirubini swrafad iSleba amitom ar aris rekomendebuli kanis ferze dayrdnobiT SratSi
bilirubinis donis Sesafaseba rogorc fotoTerapiis dros ise misi Sewyvetidan 24 sT-is ganmavlobaSi
B
kvlevebiT dadgenilia rom intravenuri imunoglobulini amcirebs SenacvlebiTi transfuziis saWiroebas Rh da ABO hemolizuri daavadebis dros
SenacvlebiTi transfuzia
SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleluli unda iyos Semowmebuli da dasxivebuli gadasasxmeli sisxlis raodenoba Seadgens 170-180 mlkg
rekomendacia SenacvlebiTi transfuzia unda Caataros mxolod gamocdilma samedicino personalma intensiuri Terapiis ganyofilebaSi monitoringisa da srulyofili reanimaciis SesaZleblobis pirobebSi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
SenacvlebiTi transfuziis Cvenebebi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
mwvave bilirubinuli encefalopaTia intensiuri fotoTerapiis miuxedavad Ssb mateba an ucvleli
monacemi samSobiarodan gawerili axalSobilebis hospitalizaciis
SemTxvevaSi Ssb-s maRali maCvenebeli - aRemateba SenacvlebiTi transfuziis dawyebis maCvenebls (sqema 3) (transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia) (ix cxrili 6)
ba Sefardeba Ssb maCvenebelTan (cxrili 6) erTad gamoiyeneba rogorc damatebiTi faqtori SenacvlebiTi transfuziis dawyebis gansasazRvravad
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
sqema 3 SenacvlebiTi transfuziis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (American Academy of Pediatrics 2004)
16
D
D
cxrili 6 bilirubinisa da albuminis Sefardeba rodesac saWiroa SenacvlebiTi transfuzia (AMERICAN ACADEMY OF PEDIATRICS 2004)
riskis kategoria
ba Sefardeba rodesac saWiroa SenacvlebiTi
transfuziaSsb mgdl alb gdl
Ssb micromolL alb micromolL
axalSobilebi gestaciuri asaki - ge38 kvira 80 094
janmrTeli axalSobilebi gestaciuri asakiT an riskis jgufis axalSobilebi
gestaciuri asakiT ge38 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
72 084
riskis jgufis axalSobilebi gestaciuri asakiT 35ndash36 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
68 080
janmos rekomendacia sisxlis SenacvlebiTi gadasxmis Cvenebebis Sesaxeb mocemulia cxrilSi 7
cxrili 7 SenacvlebiTi transfuziis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI 15 260 13 220II 25 425 15 260
17
III 30 510 20 340IV da meti 30 510 20 340
Tu Ssb uaxlovdeba im dones rodesac naCvenebia SenacvlebiTi transfuzia
sisxli dauyovnebliv igzavneba raTa dadgindes jgufi da rezusi da SeTavseba Tu klinikaSi aris transfuziis saSualeba
an xorcieldeba referali
teqnika (AMERICAN ACADEMY OF PEDIATRICS 2004
bull mwvave bilirubinuli encefalopaTiis dros SenacvlebiTi transfuzia iwyeba dauyovnebliv
bull sxva SemTxvevaSi transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia
bull SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleuli unda iyos Semowmebuli da dasxivebuli
bull gadasasxmeli sisxlis raodenoba Seadgens axalSobilis mocirkulire sisxlis ormag raodenobas saSualod 170-180 mlkg an gadasasxmeli sisxlis gamosaTvleli formula gamoiTvleba 85 x axalSobilis wona kg x 2
bull SenacvlebisaTvis xdeba 2 venis an arteria da venis kaTeterizacia iReben bavSvis 20 ml sisxls da SeyavT 20 ml donoris sisxli (3-4 wT-is ganmavlobaSi) SemTbaris 367-3700C-mde
bull dRenaklulebsa da mZime mdgomareobaSi myof axalSobilebSi Senacvleba xdeba 5-10 ml-iT
axalSobilis momzadeba
bull kuWis SigTavsis aspiracia zondiT 8F da Ria zondis datoveba kuWSibull SeiZleba saWiro gaxdes bavSvis dabma
bull SeiZleba sawovaras gamoyeneba
bull Sardis Semkrebis gamoyeneba diurezis kontrolisTvisaxlSobilis winaswar Sefaseba
bull temperatura
bull guliscema
bull sunTqva
bull wneva
bull glukoza SratSi
bull Sardis analizi
bull ganavlis analizi sisxlis Semcvelobaze
bull kanis feri
bull tonusi
bull qcevauSualod transfuziis dros fasdeba vitaluri niSnebi (yovel 15 wT-Si)
18
bull temperatura
bull guliscema (mwvervalze) (umjobesia kardiomonitoriT)
bull sunTqva
bull kanis feri
bull qceva
monitoringi transfuziis Semdeg bull grZeldeba fotoTerapia
bull kardio monitoringi
bull sisxlis wneva proceduris damTavrebis Semdeg
bull saaTobrivad 6 sT-is ganmavlobaSi temperatura guliscema (mwvervalze) sunTqva
bull glukoza SratSi yovel 3 sT-Si 24 sT-is ganmavlobaSi
bull muclis garSemoweriloba 3-4 sT-Si 24 sT-is ganmavlobaSi nawlavebis peristaltikis auskultacia
bull Sardis analizi
bull ganavali sisxlis Semcvelobaze
bull sakvebis autanlobis niSnebi Rebineba muclis Seberva
bull Ssb 6 sT-Si erTxel
SenacvlebiTi transfuziis riskisikvdiloba - 3 SemTxveva 1000 transfuziaze SenacvlebiTi transfuziis dros garTulebis saxiT 5-Si vlindeba
- apnoe bradikardia cianozi vazospazmi Trombozi nekrozuli enterokoliti aseve SeiZleba ganviTardes hipoqsiur-iSemiuri encefalopaTia da SeZenili imunodeficitis sindromi
sxva mkurnalobafenobarbitali ndash xels uwyobs bilirubinis koniugacias da amcirebs
Ssb dones ar arsebobs sakmarisi mtkicebulebebi fenobarbitalis gamosayeneblad rodesac arsebobs siyviTlis mkurnalobis ufro efeqturi meTodebi (mag fotoTerapia)
referali AMERICAN ACADEMY OF PEDIATRICS 2004)referali maRali donis klinikaSi xorcieldeba Tu
ar aris fotoTerapiis Catarebis SesaZlebloba fotoTerapiis miuxedavad
rArr Ssb ar mcirdeba
rArr Ssb uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones da ar aris transfuziis saSualeba
rArr Ssbalbuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6)
Tu siyviTle gamovlinda I dRes siyviTlis lokalizaciis mixedviT siyviTlis simZimis Sefasebisas
(cxrili 1) dadgenili ldquosaSiSi siyviTlerdquo
bilirubinis maRali namati 85 micromolLsT (gt05 mgdlsT)
gaxangrZlivebuli siyviTle (14 dRe da meti) ojaxur anamnezSi mZime siyviTlis an kerniqterusis arseboba siyviTlis dros sxva daavadebis niSnebis arseboba (mg sefsisi)
19
riskis Sefaseba gaweramde
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
bull yvela axalSobilis gaweramde unda Sefasdes hiperbilirubinemiis ganviTarebis riski yvela ganyofilebas unda hqondes protokoli siyviTlis SefasebisTvis aseTi Sefaseba gansakuTrebiT mniSvnelovania im axalSobilebisaTvis romlebis ewerebian dabadebidan 72 sT-ze adre (rekomendacia C)
bull amerikis pediatrTa akademiis rekomendaciiT riskis SefasebisaTvis gamoyenebuli unda iqnas 2 midgoma (calcalke an kombinaciaSi) gaweris win bilirubinis gansazRvra (Ssb an tkb) daan klinikuri risk-faqtorebis Sefaseba risk-faqtorebis arseboba an Ssb maRali maCveneblebi gaweris Semdeg Sesabamisi meTvalyureobis aucilebelobis Cvenebaa (rekomendacia C)
bull yvela samSobiarom unda miawodos mSobels zepiri daan werilobiTi informacia binaze siyviTlis Sefasebis da saSiSroebis niSnebis Sesaxeb (rekomendacia D)
meTvalyureoba
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)bull yvela axalSobili samSobiarodan gaweriis Semdeg ramdenime dReSi unda Sefasdes kvalificuri samedicino profesionalis mier (rekomendacia C)
bull fasdeba - siyviTlis arseboba axalSobilis wona kvebis efeqturoba Rebinebis arseboba (rekomendacia C)
bull meTvalyureobis grafiki Tu axalSobili samSobiarodan ewereba 48-72 sT-Si samedicino Sefaseba tardeba 120 sT-is (5 dRe) asakSi (rekomendacia C)
bull Tu samSobiarodan gaweris Semdeg meTvalyureoba SeuZlebelia da arsebobs hiperbilirubinemiis ganviTarebis risk-faqtorebi axalSobilis gawera unda gadaidos sanam ar iqneba uzrunvelyofili Sesabamisi meTvalyureoba an sanam gaivlis maRali riskis periodi (72-96sT) (rekomendacia D)
11 gaidlainis gadasinjvisa da ganaxlebis vada ndash 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlainis SemuSavebis meTodologia
bull axalSobilTa hiperbilirubinemiis prevenciis diagnostikisa da marTvis principebis Sesaxeb arsebobs samecniero mtkicebulebis safuZvelze Seqmnil rekomendaciaTa sakmarisi raodenoba mocemuli gaidlainis Semqmnis procesSi samuSao jgufis gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve arsebuli praqtikuli rekomendaciebi moxda arsebuli
20
C
C
C
C
D
C
D
rekomendaciebis adaptirebuli variantis SemuSaveba romelic erTis mxriv pasuxebs saerTaSoriso moTxovnebs xolo meore mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa rogorc adamianur ise teqnikur resursebs
bull rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa bazis gamoyenebiT
cxrili 2
qveyana da resursis dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
httpwwwguidelinegov
Centers for Disease Control and Prevention (CDC)
httpwwwphppocdcgovCDCRecommendsAdvSearchVasp
Agency for Healthcare Research and Quality (AHRQ)
httpwwwahrqgovcliniccpgsixhtm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
httphstatnlmnihgov
Institute of Clinical Systems Improvement (ICSI)
httpwwwicsiorg
American Medical Association httpwwwama-assnorg
Canadian Medical Association (CMA)
httpmdmcacpgsnewcpgsindexasp
Health Canada ndash Population and Public Health Branch (PPHB)
httpwwwhc-scgccapphb-dgspspdpg_ehtml
didi britaneTi
National Institute for Clinical Excellence (NICE)
httpwwwniceorguk
Sheffield Evidence for Effectiveness and Knowledge (SEEK)
httpwwwshefacukseekguidelineshtm
National electronic Library for Health (NeLH)
httpwwwnelhnhsukguidelinesfinder
PRODIGY Clinical Guidance httpwwwprodigynhsukClinicalGuidance
Scottish Intercollegiate Guidelines Network (SIGN)
httpwwwsignacuk
German Guideline Information Service (GERGIS)
httpwwwleitliniendeenglishenglishview
avstralia
Australian National Health and httpwwwhealthgovauhfsnhmrcpublicatcp-
21
Medical Research Council (NHMRC) homehtmaxali zelandia
New Zealand Guidelines Group (NZGG)
httpwwwnzggorgnzlibrarycfm
mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba
httpwwwosdmorg
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi
bull koxreinis biblioTeka - The Cochrane Library 2006 Issue 2 bull amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini ndash MEDLINEbull jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvisgamoricxvis kriteriumebi
bull arCeul iqna kvlevebi Semdegi dizainiT randomizebuli kontrolirebadi sistemuri mimoxilvebi da meta-analizi erTmomentiani kohortuli kvlevebi
bull rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12 wliani SezRudva Tumca zogjer gamoyenebuli iyo ufro adreuli publikaciebi romlebic dResac aqtualuria da safuZvlad udevs sxva Tanamedrove mtkicebulebebs
bull dadgenili iyo enobrivi SezRudvebi radganac samuSao jgufs SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod inglisur da rusul enebze
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
bull samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri meToduri rekomendacia axalSobilTa hiperbilirubinemiis marTvis sakiTxebze romlebic Seicavda jgufis miznis Sesaferis saWiro informacias am rekomendaciebis Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (9496-98) samuSao jgufi xelmZRvanelobda saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mier SemuSavebuli nacionaluri gaidlainebis gzamkvleviT Sefasebis Sedegad amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi
rArr amerikis pediatrTa akademia
rArr msoflo jandacvis organizacia
rArr kanadis pediatrTa sazogadoeba ndash nayofi da axalSobilis komiteti
rArr britaneTis reproduqciuli janmrTelobis programa
22
bull rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da rekomendaciebis xarisxis sqema
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris
done (Muir Gray)xarisxi rekomendaciis xarisxi
(Cook et al)I Zlieri mtkicebuleba
eyrdnoba minimum erT sistemur mimoxilvas
romelic efuZneba swori dizainis mqone randomizebul
kontrolirebad kvleva
A eyrdnoba I donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erTi swori dizainis mqone
randomizebul kontrolirebad kvleva
B eyrdnoba II donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
III klinikuri kvleva randomizaciis gareSe
kohortuli da SemTxveva-kontrolis kvlevebi
C eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi
D eyrdnoba IV da V donis mtkicebulebas saWiroebs
konsesuss
Va avtoritetul profesionalTa mosazreba
Vb klinikuri gamocdileba aRwerilobiTi kvlevebi an
eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
15 avtorTa jgufi
bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis
bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi
rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
23
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24
etiopaTogenezi
mizezebi (Ronald J Wong 2005)(AMERICAN ACADEMY OF PEDIATRICS 2004)
hiperbilirubinemia SesaZlebelia mimdinareobdes arapirdapiri an pirdapiri bilirubinis donis momatebiT gaZlierebuli hemolizi bilirubinis koniugaciis unaris Semcireba iwvevs arapirdapir bilirubinemias xolo naRvlis eqskreciis darRveva ndash pirdapir bilirubinemias
1 fiziologiuri siyviTle
bull erTrocitebis da hemoglobinis maRali Semcveloba
bull fetaluri hemoglobinis Semcveli eriTrocitebis hemolizi
bull RviZlSi bilirubinis koniugaciis unaris umwifroba
bull bilirubinis gazrdili enterohepatuli cirkulacia
bull RviZlis mier plazmidan bilirubinis moxmarebis Semcireba
2 paTologiuri siyviTle eriTrocitebis hemolizis gaZliereba
bull sisxlis jgufuri da rezus SeuTavsebloba
bull Tandayolili membrano (sferocitozi da sxv) fermento (glukoza 6 fosfatdehidrogenazas - g6fd ndash ukmarisoba da sxv) da hemoglobinopaTia (Talasemia da sxv)
bull policitemia
bull kefalohematoma sisxlCaqcevebi
bull infeqciabilirubinis koniugaciis Semcireba
bull dRenakluloba
bull iSviaTi Tanadayolili daavadebebi (Jilberis krigler-naiaris sindromi da sxva)
bull bilirubinis metabolizmis da eqskreciis darRveva (rotoris da dubin-jonsonis sindromi)
bilirubinis reabsorbciis gazrda gastrointestinuri traqtidanbull asfiqsia
bull kvebis gvian dawyeba iSviaTi kveba
bull nawlavTa obstruqcia
bull mekoniumis pasaJis Seferexeba
3 naRvlis eqskreciis darRveva
bull sefsisi
bull saSvilosnosSida infeqcia
bull hepatiti
bull qolestazuri sindromi
bull biliaruli atrezia
bull cisturi fibrozi (mukoviscidozi)
4 siyviTle ZuZuTi kvebis dros
bull dedis rZiT ganpirobebuli (ariasis sindromi) savaraudoa dedis rZeSi arsebuli nivTierebis (araesterificirebuli cximovani mJavebis da hormon pregnanis) gavlena bilirubinis metabolizmze (iTrguneba ferment glukuroniltransferazas aqtivoba da bilirubinis koniugacia)
3
bull ZuZuTi kvebis araswori reJimiT ganpirobebuli iSviaTi ZuZuTi kvebis SemTxevaSi arasakmarisi raodenobiT rZis miReba iwvevs enterohepaturi cirkulaciis gazrdas
bilirubinis toqsiuroba - bilirubini potenciuri neirotoqsinia arakoniugirebulma bilirubinma romelic ar aris dakavSirebuli albuminTan SeiZleba gaiaros hematoencefaluri barieri da Tavis tvinSi gamoiwvios ujredebis sikvdili apoptoziT (ujredebis programirebuli sikvdili) daan nekroziT yvelaze metad ziandeba bazaluri ganglia da Tavis tvinis Reros okulomotoruli da auditoruli funqciebis makontrolebeli birTvebi
Tu droul axalSobilebSi bilirubini gadaWarbebs 25-30 mgdl (428 - 513 micromolL) maRalia bilirubinis toqsiuri moqmedebis ganviTarebis riski Ssb toqsiuroba variabeluria da damokidebulia axalSobilis janmrTelobis mdgomareobaze da gestaciur asakze
mZime hiperbilirubinemiis ganviTarebis risk-faqtorebi mZime hiperbilirubinemiis ganviTrebis riski miT ufro maRalia rac
ufro meti riskis faqtoria gamoxatuli axalSobilTanmaRali riski (AMERICAN ACADEMY OF PEDIATRICS 2004) (Ronald J Wong 2005)
minus dabadebidan pirvel 24sT-Si gamovlenili siyviTle minus gaweris win Ssb an tkb done butanis nomogramaze maRali riskis
zonaSi
minus sisxlis jgufuri SeuTavsebloba dadebiTi pirdapiri antiglobulinuri testiT sxva cnobili hemolizuri daavadeba (mag g6fd deficiti)
minus gestaciuri asaki 35-36 kvira minus da-Zmas Catarebuli aqvs fotoTerapia
minus kefalohematoma an mniSvnelovani sisxlCaqcevebi (Newman TB 2000)minus araxSiri ZuZuTi kveba rodesac aReniSneba wonaSi mkveTri kleba
(gt12-ze meti) (Newman TB 2000 dabali riski
gaweris win Ssb an tkb-is done butanis nomogramaze maRali gardamavali riskis zonaSi
gestaciuri asaki 37-38 kvira (Newman TB 2000 da-Zmis anamnezSi siyviTle diabetiT daavadebuli dedis makrosomuli axalSobili
dedis asaki ge 25 welze (Newman TB 2000) mamrobiTi sqesi (Newman TB 2000 )
mdgomareobebi romlis drosac mZime hiperbilirubinemiis ganviTarebis riski Zalian dabalia
minus gestaciuri asaki ge 41 kviraze (Newman TB 2000)minus srulyofili enteraluri kveba (Newman TB 2000)minus gawera stacionaridan 72 sT-is Semdeg
minus Ssb dabali riskis zonaSi
4
klinikuri simptomatika
rekomendacia - siyviTlis monitoringi unda moxdes yvela axalSobilTan rutinulad vitaluri funqciebis Sefasebisas ara nakleb 8-12 sT-Si erTxel (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)siyviTlis arsebobis Sefaseba unda moxdes kargad ganaTebul oTaxSi umjobesia dRis Suqze fanjarasTan siyviTle Cveulebriv pirvelad vlindeba saxeze da Semdeg progresirebs kaudalurad sxeulsa da kidurebze siyviTlis ukeT gansazRvrisaTvis tardeba kanze TiTis zewolis testi zewola lokalurad amcirebs kanis perfuzias da xels uwyobs siyviTlis diagnostikas rodesac bilirubini 4-8 mgdl (68-137 micromolL) Cveulebriv iqterulia saxe da sklera Tu bilirubini gt15 mgdL (257 micromolL) siyviTle vlindeba mTel sxeulze xelis da fexisgulebis CaTvliT Ssb an tkb mizanSewonilia gaizomos Tu siyviTle vlindeba Wipis qvemoT
siyviTlis simZimis Sefaseba lokalizaciis mixedviT (WHO 2003) cxrili 1
asaki (dRe) siyviTlis lokalizacia daskvna
1 nebismieri
2 kidurebi
ge 3 terfebi mtevnebi
laquosaSiSiraquo siyviTle
sicocxlis I dRes nebismier adgilas an II dRes kidurebze gamovlenili siyviTle saWiroebs dauyovnebliv fotoTerapiis dawyebas analizis pasuxis miRebamde
krameris modificirebuli sqema cxrili 2
zona1 2 3 4 5
Ssb micromolL 100 150 200 250 gt250
krameris modificirebuli sqema saSualebas iZleva siyviTlis gavrcelebis mixedviT vivaraudoT Tu ramdenia Sratis saerTo bilirubinis done
siyviTlis xarisxis gansazRvra siyviTlis intensivobis mxolod vizualuri SefasebiT xSirad iwvevs daignostikur Secdomas gansakuTrebiT muqkanian axalSobilebSi
(rekomendacia C) (AMERICAN ACADEMY OF PEDIATRICS 2004)
axalSobilTa siyviTlisGgarTulebebimwvave da qronikuli (kerniqterusi) bilirubinuli encefalopaTiamwvave bilirubinuli encefalopaTia (AMERICAN ACADEMY OF PEDIATRICS 2004) mwvave bilirubinuli encefalopaTias axasiaTebs ganviTarebis 3 faza
5
C
1 adreuli faza vlindeba ramdenime dReSi da axasiaTebs leTargia hipotonia susti wova da sustad gamoxatuli ldquotvinismieri kivilirdquo
2 gardamavali stadia viTardeba kviris bolos da axasiTebs zomieri stupori agznebadoba da hipertonia axalSobils SeiZleba aReniSnos cxeleba mkveTrad gamoxatuli ldquotvinismieri kivilirdquo hipertonia vlindeba kisris (retrokolisi) da sxeulis (opistotonusi) ukan rkaliseburad gadaxriT
3 bolo stadia vlindeba 1 kviris Semdeg am dros centraluri nervuli sistemis dazianeba Seuqcevadia mas axasiaTebs mkveTri retrokolisi da opistotonusi mkveTrad gamoxatuli ldquotvinismieri kivilirdquo apnoe cxeleba sakvebis autanloba Rrma stupori komamde zogjer krunCxvebi da sikvdili
kerniqterusi (AMERICAN ACADEMY OF PEDIATRICS 2004)Bmwvave bilirubinuli encefalopaTiis Semdeg gadarCenil
axalSobils sicocxlis pirveli wlis manZilze uviTardeba bilirubinuli encefalopaTiis mZime qronikuli forma romelic 3 ZiriTadi gamovlinebiT xasiaTdeba
motoruli darRvevebi - aTetoiduri cerebluri dambla tremori qorea
mxedvelobis darRvevebi smeniTi disfunqcia inteleqtualuri darRvevebi SedarebiT iSviaTia damatebiT SeiZleba
ganviTardes kbilis emalis hipoplazia kerniqterusis dros 70-Si aRiniSneba nevrologiuri darRvevebi da
10-Si sikvdiloba
diferenciuli diagnoziaxalSobilTa siyviTlis dros unda ganisazRvros siyviTle
fiziologiuria Tu paTologiuri
fiziologiuri siyviTle paTologiuri siyviTle
vlindeba ara uadres 2 dRisa da qreba me-10-14 dRisTvis
vlindeba pirvel 24 saaTSi an7 dRis Semdeg
gavrceleba ar aRemateba krameris 1-3 zonebs
gavrceleba krameris nebismieri zona sicocxlis I dRes 4 zona sicocxlis II dRes da 5 zona nebismier asakSi
bavSvi aqtiuria temperatura normaluria wovis refleqsi kargia
zogadi mdgomareoba damakmayofilebeli an darRveuli
Sardis da ganavlis feri ar icvleba
SeiZleba iyos Sardis da ganavlis feris cvlileba
RviZli da elenTa ar aris gadidebuli
SeiZleba iyos hepatosplenomegalia
dedis rZiT ganpirobebuli siyviTlis sadiagnostikod (samkurnalod) SeiZleba Semdegi maCveneblebis gamoyeneba
bull dedis rZiT ganpirobebuli siyviTle vlindeba me-4-14 dRes
bull 24-48sT-is ganmavlobaSi ZuZuTi kvebis Sewyveta da alternatiul sakvebis miwodeba iwvevs bilirubinis donis daqveiTdebas
6
axalSobilTa hiperbilirubinemiis difdiagnozi ix algormiTi 1
gamokvlevis sqema
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004) tkb daan Ssb unda ganesazRvros yvela axalSobils
romelsac siyviTle gamouvlinda sicocxlis pirvel 24sT-Si (ix algoriTmi I da cxrili 3 ) (rekomendacia C)
tkb daan Ssb ganmeorebiTi gansazRvris dro da saWiroeba damokidebulia bilirubinis doneze (sqema 2) axalSobilis asakze hiperbilirubinemiis dinamikaze rekomendaciebi Ssb gansazRvrisaTvis dabadebidan 24 sT-is Semdeg mowodebulia I algoriTmsa da cxrilSi 3
tkb daan Ssb unda ganesazRvros yvela axalSobils romelsac gamouvlinda asakTan Seusabamo mkveTri siyviTle (rekomendacia D)
bilirubinis donis Sefaseba unda moxdes axalSobilis asakis (saaTebSi) gaTvaliswinebiT (sqema 2) (rekomendacia
C) Tu axalSobils utardeba fotoTerapia an aReniSneba
bilirubinis swrafi mateba (sqema 2 ndash butanis sqemaze monacemi kveTs percentilebs) rac ar aixsneba obieqturi gamokvleviT da anamnezuri monacemebiT saWiroa siyviTlis SesaZlo mizezebis dadgena (rekomendacia D)
axalSobilebs romelTac aReniSnebaT pirdapiri (koniugirebuli) bilirubinis mateba unda CautardeT Sardis saerTo da baqteriologiuri gamokvleva damatebiTi laboratoriuli gamokvlevebi unda Catardes Tu anamneziT da obieqturi gamokvelevebiT saeWvoa sefsisi (rekomendacia
C) avadmyof axalSobilebsa da Cvilebs romelTac aReniSnebaT
siyviTle 3 kviris an ufro mogvianebiT asakSi unda ganesazRvroT saerTo da pirdapiri (koniugirebuli) bilirubini qolestazis sadiagnostikod (cxrili 3) (rekomendacia D) aseT axalSobilebTan mizanSewonilia skriningi hipoTireozsa da galaqtozemiaze (rekomendacia D)
Tu pirdapiri an koniugirebuli bilirubinis done momatebulia rekomendirebulia damatebiTi gamokvlevebi qolestazis sadiagnostikod (rekomendacia C)
glukoza-6-fosfat dehidrogenazas donis gansazRvra saWiroa im axalSobilebTan romelTa ojaxuri anamnezi an eTnikuri an geografiuli warmoSoba miuTiTebs g6fd-s deficitze da utardebaT fotoTerapia daan axalSobilebTan Tu fotoTerapia uefeqtoa (sqema 3) (rekomendacia C)
7
C
D
C
D
C
C
C
D
D
cxrili 3 35 da meti gestaciuri asakis axalSobilSi gamovlenili siyviTlis laboratoriuli Sefaseba (AMERICAN ACADEMY OF PEDIATRICS 2004)
Cveneba laboratoriuli kvlevapirvel 24 sT-Si gamovlenili siyviTle
bull tkb daan Ssb gansazRvra
asakisaTvis Seusabamo mkveTri siyviTle kanze G
bull tkb daan Ssb gansazRvra
axalSobils utardeba fotoTerapia an aReniSneba bilirubinis swrafi mateba (sqema 2 ndash butanis sqemaze maCvenebeli kveTs percentilebs) rac ar aixsneba obieqturi gamokvleviT da anamnezuri monacemebiT
bull sisxlis jgufi da rezusi kumbsis testi Tu ar aris gakeTebuli Wiplaris sisxlSi
bull sisxlis saerTo analizi da nacxi formiani elementebis morfologiis Sesaswavlad
bull pirdapiri (koniugirebuli) bilirubinis gansazRvra
bull Tu SesaZlebelia isazRvreba retikulocitebis ricxvi g6fd
bull Ssb ganmeorebiT isazRvreba 4-24 sT-Si axalSobilis asakisa da Ssb donis Sesabamisad
fotoTerapia uSedegoa an Ssb aRwevs dones romelzec naCvenebia SenacvlebiTi transfuzia
bull Tu SesaZlebelia isazRvreba retikulocitebis ricxvi g6fd
momatebulia pirdapiri (koniugirebuli) bilirubinis done
bull Sardis anlizi
bull Sardis kultura
bull gamokvleva sefsisze Tu misi arseboba saeWvoa anamneziT an obieqturi gamokvleviT
siyviTle sami kviris asakis an avadmyof axalSobilSi
bull saerTo da pirdapiri (koniugirebuli) bilirubini
bull pirdapiri bilirubinis momatebisas tardeba kvleva qolestazis sadiagnostikod
bull skriningi hipoTireozsa da galaqtozemiaze
bull axalSobilis Sefaseba hipoTireozis simptomebis gamosavlenad
sqema 1 butanis nomograma
8
butanis nomograma saSualebas iZleva ganisazRvros ramdenad maRalia mZime hiperbilirubinemiis ganviTarebis riski axalSobilis asakis (saaTebSi) da Sratis bilirubinis koncentraciis gaTvaliswinebiT bilirubinis gansazRvra
bilirubini isazRvreba transkutanurad da sisxlis SratSi transkutanuri gansazRvra gamarTlebulia rogorc skriningis
meTodi is isazRvreba specialuri aparatiT aRniSnuli xelsawyos gamoyenebiT bilirubinis gansazRvra SesaZloa 2-3 mgdl (34-54micromolL) variabelobiT bevr SemTxvevaSi xdeba Sratis bilirubinis gansazRvris Canacvleba transkutanuri gansazRvriT gansakuTrebiT maSin roca Ssb lt 15 mgdl (257 micromolL)
fotoTerapiis dros kanis vizualuri SefasebasTan erTad aucilebelia Sratis bilirubinis gansazRvra radgan fotoTerapia ldquoaTeTrebsrdquo kans (American Academy of Pediatrics 2004)
pirveladi profilaqtika
rekomendacia (American Academy of Pediatrics 2004) bull eqimma unda urCios dedas ganaxorcielos moTxovnilebiTi ZuZuTi kveba dReSi 8-12-jer (rekomendacia C) - arasrulyofili kaloriebis miRebam daan dehidrataciam SeiZleba gamoiwvios Hhiperbilirubinemiis ganviTareba
bull ZuZuTi kvebis SemTxevaSi Tu axalSobils ar aReniSneba dehidratacia ar aris rekomedirebuli wylisa da deqstrozis rutinulad damateba (rekomendacia B da C) -
9
C
B
C
wylis da deqstrozis damateba ar axdens hiperbilirubinemiis ganviTarebis profilaqtikasa da Ssb-s Semcirebas
bull yvela Rh (D) negatiur orsuls an melogines mizanSewonilia Cautardes anti D imonoglobuliniT profilaqtika (rekomendacia A)
minus orsulobis 28 kviraze (garda im SemTxvevebisa rodesac bavSvis mamac Rh (D) negatiuria)
minus mSobiarobidan 72 sT-is gamnavlobaSi Tu axalSobili Rh (D) pozituiria
minus orsulobis pirvel trimestrSi ganviTarebuli abortis da invaziuri procedurebis dros rogorica amniocentezi nayofis invaziuri procedurebi
meoradi profilaqtikarekomendacia klinicistma unda moaxdinos axalSobilTa hiperbilirubinemiis ganviTarebis riskebis sistemuri Sefaseba neonatalur periodSi (rekomendacia B)(AMERICAN ACADEMY OF PEDIATRICS 2004)
sisxlis jgufobriobarekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
yvela orsuli qali unda iyos gamokvleuli ABO da Rh(D) sisxlis jgufebze da hqondes Catarebuli skriningi SratSi izoimunur antisxeulebze (rekomendacia B)
Tu dedas ar Cautarebia prenatalurad sisxlis jgufis da rezusis gamokvleva an igis Rh negatiuria mkacrad aris rekomendirebuli pirdapiri antisxeulebis testis (an kumbsis testi) sisxlis jgufis da Rh (D) tipis gansazRvra axalSobilis (Wiplaris) sisxlSi (rekomendacia B)
Tu dedas sixlis jgufi aris O Rh(D) pozitiuri axalSobilis sisxlis jgufis da pirdapiri antisxeulis testis gansazRvris aucilebloba damokidebulia meTvalyureobis xarisxze gaweris win riskis Sefasebasa da gaweris Semdeg meTvalyureobaze (rekomendacia C)
mkurnalobis sqemamkurnalobis ZiriTadi principebia
fotoTerapia SenacvlebiTi transfuzia
mkurnaloba iwyeba fotoTerapiiTfotoTerapiis dros kanis zeda SreebSi Calagebuli arapirdapiri bilirubini iSleba fotoqimiuri gziT wyalSi xsnad koniugatebad romlebic gamoiyofa SardiT da naRveliTrekomendacia yvela samSobiaro saxli unda iyos aRWurvili mowyobilobiT romelic saWiroa intensiuri fotoTerapiisaTvis (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)fotoTerapiis Cvenebebi
fotoTerapia iwyeba Tu bulirubinis done aRemateba 95 percentils butanis nomogramaze (sqema 1) amave dros metad mniSvnelovania risk-faqtorebis gaTvaliswineba romlebic xels uwyobs mZime
10
A
B
B
B
C
D
hiperbiliruminemias (hemolizuri daavadeba g6fd deficiti asfiqsia mkveTrad gamoxatuli leTargia temperaturis arastabiluroba sefsisi acidozi an hipoalbuminemia lt30 gdl)
amerikis pediatriuli akademiis rekomendaciiT gamoiyeneba sqema (sqema 2) romelic axalSobilis asaksa da bilirubinis donesTan erTad iTvaliswinebs risk-faqtorebsa da gestaciur asaks mocemuli sqemis mixedviT ldquointensiurirdquo fotoTerapia iwyeba Semdegi principebiT
dabali riskis axalSobili (janmrTeli risk-faqtorebis gareSe gestacia gt 38 kvira) ndash Ssb gt12 mgdl (205 micromolL) 24 sT-Si Ssb gt15 mgdl (257 micromolL) 48 sT-Si Ssb gt18 mgdl (308 micromolL) gt72 sT
saSualo riskis axalSobili (gestacia gt 38 kvira da risk-faqtorebi an gestacia 35-37 kvira risk-faqtorebis gareSe gareSe) ndash Ssb gt 10 mgdl (171 micromolL) 24 sT-Si Ssb gt13 mgdl (222 micromolL) 48 sT-Si Ssb gt15 mgdl (257 micromolL) gt72 sT gestaciis 35 kviris axalSobilebSi fotoTerapia SeiZleba daiwyos ufro dabal maCveneblebze
maRali riskis axalSobili (gestacia 35-37 kvira da risk-faqtorebi) - Ssb gt 8 mgdl (137 micromolL) 24 sT-Si Ssb gt11 mgdl (188 micromolL) 48 sT-Si Ssb gt135 mgdl (231 micromolL) gt72 sT
Tu dabali riskis axalSobilebSi Ssb done 2-3 mgdl-iT dabalia moyvanil monacemebze SesaZlebelia mkurnalobis dawyeba ldquoCveulebrivirdquo fotoTerapiiT
bull stacionarSi gamoxatuli siyviTliT Semosul axalSobils utardeba ldquointensiurirdquo fotoTerapia bilirubinis maCveneblis gansazRvramde
bull ldquointensiurirdquo fotoTerapia aseve rekomendebulia hemolizuri daavadebis dros
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
janmos rekomendacia fotoTerapiis dawyebis Cvenebebis Sesaxeb mocemulia cxrilSi 4
cxrili 4 fotoTerapiis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI gamoxatuli siyviTleII 15 260 13 220III 18 310 16 270
IV da meti 20 340 17 290janmos rekomendaciiT fotoTerapia iwyeba Tu siyviTlis
lokalizaciis mixedviT siyviTlis simZimis Sefasebisas (cxrili 1) dadginda ldquosaSiSi siyviTlerdquo
Tu ar aris bilirubinis gansazRvris saSualeba Ssb savaraudo donis dasadgenaT SeiZleba krameris modificirebuli sqemis gamoyeneba
11
sqema 2 fotoTerapiis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (AMERICAN ACADEMY OF PEDIATRICS 2004)
rekomendacia Tu Sratis albuminis maCvenebeli naklebia 30 gdl-ze fotoTerapiis dawyeba rekomendebulis ufro dabali maCveneblebis dros (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis ukuCveneba pirdapiri (koniugirebuli) hiperbilirubinemia (pirdapiri
bilirubini Ssb-s 50-ze metia) (American Family Practice Notebook 2002 ) (AMERICAN ACADEMY OF PEDIATRICS 2004)
Tandayolili porfiria an porfiriis ojaxuri anamnezi (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis teqnikafotoTerapiis efeqturoba damokidebulia dozaze fotoTerapiis doza anu speqtruli iradiacia damokidebulia naTuris simZlavreze sinaTlis wyarosa da bavSvs Soris manZilsa da dasxivebis farTobze sinaTlis wyarofotoTerapiis sinaTlis speqtri damokidebulia sinaTlis wyaroze da filtrze yvelaze farTod gavrcelebuli fotoTerapiis mowyobiloba Seicavs dRis Suqis gril TeTr cisfer an ldquospecialur cisferrdquo fluorescentul naTurebs manZils sinaTlis wyarodan axalSobilamde didi mniSvneloba eniWeba sasurvelia axalSobili moTavsdes sinaTlis wyarodan im minimalur manZilze romelic miTiTebulia fotoTerapiis mowyobilobis instruqciaSi halogenis fotoTerapiis naTurebi ar SeiZleba moTavsdes axalSobilTan axlos radgan SeiZleba gamoiwvios damwvroba
12
DD
sxeulis zedapiris farTobibilirubinis maRali Semcvelobisas mniSvnelovania fotoTerapiis dros dasxivdes sxeulis zedapiris rac SeiZleba meti farTobi
ldquoCveulebrivi fotoTerapiardquo - sinaTlis speqtris iradiacia dabalia (6-12 microWcm2nm) (talRis sigrZe daaxloebiT 425-475 nm) da damokidebulia sxvadasxva mwarmoeblis mier mowodebul fotoTerapiiis sistemis aparatis monacemebze saWiroa aparatis Semowmeba Seesabameba Tu ara sinaTlis speqtris iradiacia mwarmoeblis mier mowodebul monacemebsldquointensiuri fotoTerapiardquo - lurj-mwvane speqtris iradiacia (talRis
sigrZe daaxloebiT 430-490 nm) sul cota 30 microWcm2nm-ia (isazRvreba axalSobilis kanze fototerapiis aparatis centris qveS) gazomva xdeba im warmoebis radiometriT romelic mowodebulia fotoTerapiiis sistemis aparatis mwarmoeblis mier sinaTlis talRis asareklad TeTreuli unda iyos TeTri kuvezi da sawolis gverdebi daifaros TeTri qsoviliT an aluminis folgiT
fotoTerapiis procedura da monitoringi
temperatura sinaTlis wyaros qveS unda iyos 28-300C
fotoTerapiis dros bavSvi unda iyos SiSveli ecvas erTjeradi higienuri safeni Tvalebze unda hqondes damcavi saTvale
yovel 3 saaTSi erTxel bavSvs unda Seucvalon pozicia
yovel 3 saaTSi erTxel unda Sefasdes sinaTlis wyaros qveS arsebuli temperatura da axalSobilis sxeulis temperatura Tu bavSvis t metia metia 3750C saWiroa oTaxis temperaturis daqveiTeba an fotoTerapiis droebiT Sewyveta sanam bavSvis temperatura ar iqneba normis farglebSi (365-3750C)
fotoTerapia mimdinareobas mudmivad igi wydeba mxolod im procedurebis dros romelTa warmoeba ra SeiZleba sinaTlis wyaros qveS
centraluri cianozis arsebobis Sesafaseblad fotoTerapia unda Sewydes mcire droiT
fotoTerapiis dros unda gagrZeldes bavSvis kveba
rArraxalSobilTan unda gagrZeldes ZuZuTi kveba moTxovnilebis mixedviT (intervali kvebaTa Soris araumetes 3 sT-isa) (rekomendacia C) ZuZuTi kvebis dros wydeba fotoTerapia da Sesabamisad bavSvs unda moexsnas damcavi saTvale
rArrTu bavSvi ikvebeba gamowvelili rZiT formuliT an parenteralurad misawodebeli sakvebis an siTxis raodenoba izrdeba dRiuri normis 10 -iT
rArr Tu bavSvi ikvebeba zondiT an parenteralurad fotoTerapia mimdinareobs uwyvetad
rArrCveulebriv fotoTerapiis dros axalSobils ar esaWiroeba damatebiT siTxis an sakvebis miwodeba damateba naCvenebia mxolod araefeqturi ZuZuTi kvebis sxeulis masis paTologiuri danakargis (gt10-ze mesame dRisTvis) da dehidrataciis SemTxvevaSi
13
C
fotoTerapiis dros bilirubinis daSlis produqtebi gamoiyofa SardiT da naRveliT adeqvaturi hidrataciis SenarCuneba da Sesabamisad adekvaturi diurzis SenarCuneba zrdis fotoTerapiis efeqturobas
zogierT axalSobils hiperbilirubinemiiT aReniSneba dehidratacia da saWiroa damatebiTi siTxis miwodeba (per-os an intravenurad) dehidrataciis koreqciisaTvis
araefeqturi ZuZuTi kvebis SemTxvevaSi fotoTerapiis dros axalSobils damatebiT miewodeba gamowvelili dedis rZe donoris rZe an xelovnuri sakvebi
rArr adeqvatur kvebaze miuTiTebs 4-6 sveli safeni 24 sT-Si da nawlavTa moqmedeba 3-4 jerdReSi meoTxe dRisaTvis
janmrTeli drouli axalSobilis nawlavTa moqmedeba da diurezi (minimaluri maCveneblebi) cxrili 5 (Fetus and Newborn Committee 1999)
dRe nawlavTa minimaluri moqmedeba24sT
sveli safeni24sT
1 1 12 1 23 1 gardamavali 34 2 yviTeli fafisebri 45 2YyviTeli fafisebri 5-6
rArrdehidrataciaze miuTiTebs Semdegi niSnebis arseboba - masis paTologiuri kleba (gt10-ze mesame dRisTvis)- anuria 4-6 sT- Cacvenili Tvalebi- Cavardnili yoflibandi - - daqveiTebuli kanis elastiuroba (kanis naoWi swordeba
nela)- daqveiTebuli kanis kapilaruli avseba (gt3 wm)- taqikardia- Sratis Na gt145 HCO3 lt17
bilirubinis monitoringi fotoTerapiis dros (American Aacademy of Pediatrics 2004)
sawyisi bilirubinis maCveneblis Semcireba 6-20-iT standartuli da 30-40-iT intensiuri fotoTerapiis dawyebidan 24sT-Si mis efeqturobaze miuTiTebs
bull Tu Ssb ge 25 mgdL (428 micromolL) ganmeorebiTi gansazRvra 2ndash3 sT-Si
bull Tu Ssb 20ndash25 mgdL (342ndash428 micromolL) ganmeorebiTi gansazRvra 3-4 sT-Si
bull Tu Ssb lt20 mgdL (342 micromolL) ganmeorebiTi gansazRvra 4ndash6 sT-Si Tu Ssb agrZelebs daqveiTebas ganmeorebiTi gansazRvra 8-12 sT-Si
bull Tu Ssb ar mcirdeba an uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones an Ssb albuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6) iwyeba SenacvlebiTi transfuzia Tu amis saSualeba aris an xorcieldeba referali
bull intensiur fotoTerapiis miuxedavad Ssb-is ucvleli done an mateba miuTiTebs hemolizze
14
rArr anemiahemolizis Sefaseba SesaZlebelia sisxlis saerTo analizis mixedviT - Hgblt 130 glLHct lt 40 retikulocitebi - gt 6
bull Ssb lt 13ndash14 mgdL (239 micromolL) fotoTerapia wydeba
bull fotoTerapiis Sewyvetidan 24 sT-Si kontroldeba Ssb Tu Ssb moimata im donemde romelzec daiwyo fotoTerapia fotoTerapia ganmeorebiT iwyeba
fotoTerapiis garTulebebi
fotoTerapiis garTulebebi (Ronald J Wong 2005 American Aacademy of Pediatrics 2004)
rArrmwvane feris ganavalidiarea (mkurnalobas ar saWiroebs)
rArr dehidratacia
rArr muclis Seberva (mkurnalobas ar saWiroebs)
rArr Tvalis SesaZlo dazianeba yvelaze seriozuli magram iSviaTi klinikuri garTulebaa brinjaos
axalSobilis sindromi romelic vlindeba qolestazuri siyviTlis mqone axalSobilSi kanis Sratis da Sardis muqi nacrisfer-yavisferi SeferilobiT brinjaos axalSobilis sindromi ar vlindeba qolestazis mqone yvela axalSobilTan Tu arsebobs fotoTerapiis Cveneba pirdapiri hiperbilirubinemia ar warmoadgens fotoTerapiis winaaRmdeg Cvenebas axalSobilebSi romelTac uviTardebaT brinjaos sindromi naCvenebia SenacvlebiTi transfuzia monacemebis arasrulyofilebis gamo mkacri rekomendaciis gakeTeba ar SeiZleba
mZime qolestazuri siyviTlis mqone axalSobilebSi fotoTerapiis dros aseve SeiZleba ganviTardes
rArr purpura
rArr bulozuri gamonayari
mzis ultraiisferi sxivebiT TerapiamarTalia mzis sxivebs gaaCniaT mniSvnelovani iradiacia 425-475 nm magram radganac maRalia axalSobilis damwvrobis ganviTarebis riski (SiSveli axalSobilis mzeze yofnis gamo) es meTodi rekomendebuli ar aris
(Ronald J Wong 2005 (American Aacademy of Pediatrics 2004)
intravenuri imunoglobulinis gamoyenebarekomendacia izoimunuri hemolizuri daavadebis dros rekomendebulia intravenuri imunoglobulinis gamoyeneba (05-1 gkg 2 sT-s ganmavlobaSi) Tu Ssb imatebs intensiuri fotoTerapiis miuxedavad an Ssb aris 2-3 mgdl-iT (34-51mkmoll) naklebi SenacvlebiTi transfuziis Cvenebis doneze (fighellip4) aucilebelobis SemTxvevaSi intravenuri imunoglobulinis es doza SeiZleba ganmeordes 12 sT-Si (rekomendacia B) American Aacademy of Pediatrics 2004)
15
fotoTerapiis dros kanSi Calagebuli bilirubini swrafad iSleba amitom ar aris rekomendebuli kanis ferze dayrdnobiT SratSi
bilirubinis donis Sesafaseba rogorc fotoTerapiis dros ise misi Sewyvetidan 24 sT-is ganmavlobaSi
B
kvlevebiT dadgenilia rom intravenuri imunoglobulini amcirebs SenacvlebiTi transfuziis saWiroebas Rh da ABO hemolizuri daavadebis dros
SenacvlebiTi transfuzia
SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleluli unda iyos Semowmebuli da dasxivebuli gadasasxmeli sisxlis raodenoba Seadgens 170-180 mlkg
rekomendacia SenacvlebiTi transfuzia unda Caataros mxolod gamocdilma samedicino personalma intensiuri Terapiis ganyofilebaSi monitoringisa da srulyofili reanimaciis SesaZleblobis pirobebSi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
SenacvlebiTi transfuziis Cvenebebi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
mwvave bilirubinuli encefalopaTia intensiuri fotoTerapiis miuxedavad Ssb mateba an ucvleli
monacemi samSobiarodan gawerili axalSobilebis hospitalizaciis
SemTxvevaSi Ssb-s maRali maCvenebeli - aRemateba SenacvlebiTi transfuziis dawyebis maCvenebls (sqema 3) (transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia) (ix cxrili 6)
ba Sefardeba Ssb maCvenebelTan (cxrili 6) erTad gamoiyeneba rogorc damatebiTi faqtori SenacvlebiTi transfuziis dawyebis gansasazRvravad
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
sqema 3 SenacvlebiTi transfuziis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (American Academy of Pediatrics 2004)
16
D
D
cxrili 6 bilirubinisa da albuminis Sefardeba rodesac saWiroa SenacvlebiTi transfuzia (AMERICAN ACADEMY OF PEDIATRICS 2004)
riskis kategoria
ba Sefardeba rodesac saWiroa SenacvlebiTi
transfuziaSsb mgdl alb gdl
Ssb micromolL alb micromolL
axalSobilebi gestaciuri asaki - ge38 kvira 80 094
janmrTeli axalSobilebi gestaciuri asakiT an riskis jgufis axalSobilebi
gestaciuri asakiT ge38 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
72 084
riskis jgufis axalSobilebi gestaciuri asakiT 35ndash36 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
68 080
janmos rekomendacia sisxlis SenacvlebiTi gadasxmis Cvenebebis Sesaxeb mocemulia cxrilSi 7
cxrili 7 SenacvlebiTi transfuziis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI 15 260 13 220II 25 425 15 260
17
III 30 510 20 340IV da meti 30 510 20 340
Tu Ssb uaxlovdeba im dones rodesac naCvenebia SenacvlebiTi transfuzia
sisxli dauyovnebliv igzavneba raTa dadgindes jgufi da rezusi da SeTavseba Tu klinikaSi aris transfuziis saSualeba
an xorcieldeba referali
teqnika (AMERICAN ACADEMY OF PEDIATRICS 2004
bull mwvave bilirubinuli encefalopaTiis dros SenacvlebiTi transfuzia iwyeba dauyovnebliv
bull sxva SemTxvevaSi transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia
bull SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleuli unda iyos Semowmebuli da dasxivebuli
bull gadasasxmeli sisxlis raodenoba Seadgens axalSobilis mocirkulire sisxlis ormag raodenobas saSualod 170-180 mlkg an gadasasxmeli sisxlis gamosaTvleli formula gamoiTvleba 85 x axalSobilis wona kg x 2
bull SenacvlebisaTvis xdeba 2 venis an arteria da venis kaTeterizacia iReben bavSvis 20 ml sisxls da SeyavT 20 ml donoris sisxli (3-4 wT-is ganmavlobaSi) SemTbaris 367-3700C-mde
bull dRenaklulebsa da mZime mdgomareobaSi myof axalSobilebSi Senacvleba xdeba 5-10 ml-iT
axalSobilis momzadeba
bull kuWis SigTavsis aspiracia zondiT 8F da Ria zondis datoveba kuWSibull SeiZleba saWiro gaxdes bavSvis dabma
bull SeiZleba sawovaras gamoyeneba
bull Sardis Semkrebis gamoyeneba diurezis kontrolisTvisaxlSobilis winaswar Sefaseba
bull temperatura
bull guliscema
bull sunTqva
bull wneva
bull glukoza SratSi
bull Sardis analizi
bull ganavlis analizi sisxlis Semcvelobaze
bull kanis feri
bull tonusi
bull qcevauSualod transfuziis dros fasdeba vitaluri niSnebi (yovel 15 wT-Si)
18
bull temperatura
bull guliscema (mwvervalze) (umjobesia kardiomonitoriT)
bull sunTqva
bull kanis feri
bull qceva
monitoringi transfuziis Semdeg bull grZeldeba fotoTerapia
bull kardio monitoringi
bull sisxlis wneva proceduris damTavrebis Semdeg
bull saaTobrivad 6 sT-is ganmavlobaSi temperatura guliscema (mwvervalze) sunTqva
bull glukoza SratSi yovel 3 sT-Si 24 sT-is ganmavlobaSi
bull muclis garSemoweriloba 3-4 sT-Si 24 sT-is ganmavlobaSi nawlavebis peristaltikis auskultacia
bull Sardis analizi
bull ganavali sisxlis Semcvelobaze
bull sakvebis autanlobis niSnebi Rebineba muclis Seberva
bull Ssb 6 sT-Si erTxel
SenacvlebiTi transfuziis riskisikvdiloba - 3 SemTxveva 1000 transfuziaze SenacvlebiTi transfuziis dros garTulebis saxiT 5-Si vlindeba
- apnoe bradikardia cianozi vazospazmi Trombozi nekrozuli enterokoliti aseve SeiZleba ganviTardes hipoqsiur-iSemiuri encefalopaTia da SeZenili imunodeficitis sindromi
sxva mkurnalobafenobarbitali ndash xels uwyobs bilirubinis koniugacias da amcirebs
Ssb dones ar arsebobs sakmarisi mtkicebulebebi fenobarbitalis gamosayeneblad rodesac arsebobs siyviTlis mkurnalobis ufro efeqturi meTodebi (mag fotoTerapia)
referali AMERICAN ACADEMY OF PEDIATRICS 2004)referali maRali donis klinikaSi xorcieldeba Tu
ar aris fotoTerapiis Catarebis SesaZlebloba fotoTerapiis miuxedavad
rArr Ssb ar mcirdeba
rArr Ssb uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones da ar aris transfuziis saSualeba
rArr Ssbalbuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6)
Tu siyviTle gamovlinda I dRes siyviTlis lokalizaciis mixedviT siyviTlis simZimis Sefasebisas
(cxrili 1) dadgenili ldquosaSiSi siyviTlerdquo
bilirubinis maRali namati 85 micromolLsT (gt05 mgdlsT)
gaxangrZlivebuli siyviTle (14 dRe da meti) ojaxur anamnezSi mZime siyviTlis an kerniqterusis arseboba siyviTlis dros sxva daavadebis niSnebis arseboba (mg sefsisi)
19
riskis Sefaseba gaweramde
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
bull yvela axalSobilis gaweramde unda Sefasdes hiperbilirubinemiis ganviTarebis riski yvela ganyofilebas unda hqondes protokoli siyviTlis SefasebisTvis aseTi Sefaseba gansakuTrebiT mniSvnelovania im axalSobilebisaTvis romlebis ewerebian dabadebidan 72 sT-ze adre (rekomendacia C)
bull amerikis pediatrTa akademiis rekomendaciiT riskis SefasebisaTvis gamoyenebuli unda iqnas 2 midgoma (calcalke an kombinaciaSi) gaweris win bilirubinis gansazRvra (Ssb an tkb) daan klinikuri risk-faqtorebis Sefaseba risk-faqtorebis arseboba an Ssb maRali maCveneblebi gaweris Semdeg Sesabamisi meTvalyureobis aucilebelobis Cvenebaa (rekomendacia C)
bull yvela samSobiarom unda miawodos mSobels zepiri daan werilobiTi informacia binaze siyviTlis Sefasebis da saSiSroebis niSnebis Sesaxeb (rekomendacia D)
meTvalyureoba
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)bull yvela axalSobili samSobiarodan gaweriis Semdeg ramdenime dReSi unda Sefasdes kvalificuri samedicino profesionalis mier (rekomendacia C)
bull fasdeba - siyviTlis arseboba axalSobilis wona kvebis efeqturoba Rebinebis arseboba (rekomendacia C)
bull meTvalyureobis grafiki Tu axalSobili samSobiarodan ewereba 48-72 sT-Si samedicino Sefaseba tardeba 120 sT-is (5 dRe) asakSi (rekomendacia C)
bull Tu samSobiarodan gaweris Semdeg meTvalyureoba SeuZlebelia da arsebobs hiperbilirubinemiis ganviTarebis risk-faqtorebi axalSobilis gawera unda gadaidos sanam ar iqneba uzrunvelyofili Sesabamisi meTvalyureoba an sanam gaivlis maRali riskis periodi (72-96sT) (rekomendacia D)
11 gaidlainis gadasinjvisa da ganaxlebis vada ndash 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlainis SemuSavebis meTodologia
bull axalSobilTa hiperbilirubinemiis prevenciis diagnostikisa da marTvis principebis Sesaxeb arsebobs samecniero mtkicebulebis safuZvelze Seqmnil rekomendaciaTa sakmarisi raodenoba mocemuli gaidlainis Semqmnis procesSi samuSao jgufis gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve arsebuli praqtikuli rekomendaciebi moxda arsebuli
20
C
C
C
C
D
C
D
rekomendaciebis adaptirebuli variantis SemuSaveba romelic erTis mxriv pasuxebs saerTaSoriso moTxovnebs xolo meore mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa rogorc adamianur ise teqnikur resursebs
bull rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa bazis gamoyenebiT
cxrili 2
qveyana da resursis dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
httpwwwguidelinegov
Centers for Disease Control and Prevention (CDC)
httpwwwphppocdcgovCDCRecommendsAdvSearchVasp
Agency for Healthcare Research and Quality (AHRQ)
httpwwwahrqgovcliniccpgsixhtm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
httphstatnlmnihgov
Institute of Clinical Systems Improvement (ICSI)
httpwwwicsiorg
American Medical Association httpwwwama-assnorg
Canadian Medical Association (CMA)
httpmdmcacpgsnewcpgsindexasp
Health Canada ndash Population and Public Health Branch (PPHB)
httpwwwhc-scgccapphb-dgspspdpg_ehtml
didi britaneTi
National Institute for Clinical Excellence (NICE)
httpwwwniceorguk
Sheffield Evidence for Effectiveness and Knowledge (SEEK)
httpwwwshefacukseekguidelineshtm
National electronic Library for Health (NeLH)
httpwwwnelhnhsukguidelinesfinder
PRODIGY Clinical Guidance httpwwwprodigynhsukClinicalGuidance
Scottish Intercollegiate Guidelines Network (SIGN)
httpwwwsignacuk
German Guideline Information Service (GERGIS)
httpwwwleitliniendeenglishenglishview
avstralia
Australian National Health and httpwwwhealthgovauhfsnhmrcpublicatcp-
21
Medical Research Council (NHMRC) homehtmaxali zelandia
New Zealand Guidelines Group (NZGG)
httpwwwnzggorgnzlibrarycfm
mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba
httpwwwosdmorg
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi
bull koxreinis biblioTeka - The Cochrane Library 2006 Issue 2 bull amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini ndash MEDLINEbull jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvisgamoricxvis kriteriumebi
bull arCeul iqna kvlevebi Semdegi dizainiT randomizebuli kontrolirebadi sistemuri mimoxilvebi da meta-analizi erTmomentiani kohortuli kvlevebi
bull rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12 wliani SezRudva Tumca zogjer gamoyenebuli iyo ufro adreuli publikaciebi romlebic dResac aqtualuria da safuZvlad udevs sxva Tanamedrove mtkicebulebebs
bull dadgenili iyo enobrivi SezRudvebi radganac samuSao jgufs SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod inglisur da rusul enebze
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
bull samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri meToduri rekomendacia axalSobilTa hiperbilirubinemiis marTvis sakiTxebze romlebic Seicavda jgufis miznis Sesaferis saWiro informacias am rekomendaciebis Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (9496-98) samuSao jgufi xelmZRvanelobda saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mier SemuSavebuli nacionaluri gaidlainebis gzamkvleviT Sefasebis Sedegad amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi
rArr amerikis pediatrTa akademia
rArr msoflo jandacvis organizacia
rArr kanadis pediatrTa sazogadoeba ndash nayofi da axalSobilis komiteti
rArr britaneTis reproduqciuli janmrTelobis programa
22
bull rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da rekomendaciebis xarisxis sqema
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris
done (Muir Gray)xarisxi rekomendaciis xarisxi
(Cook et al)I Zlieri mtkicebuleba
eyrdnoba minimum erT sistemur mimoxilvas
romelic efuZneba swori dizainis mqone randomizebul
kontrolirebad kvleva
A eyrdnoba I donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erTi swori dizainis mqone
randomizebul kontrolirebad kvleva
B eyrdnoba II donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
III klinikuri kvleva randomizaciis gareSe
kohortuli da SemTxveva-kontrolis kvlevebi
C eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi
D eyrdnoba IV da V donis mtkicebulebas saWiroebs
konsesuss
Va avtoritetul profesionalTa mosazreba
Vb klinikuri gamocdileba aRwerilobiTi kvlevebi an
eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
15 avtorTa jgufi
bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis
bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi
rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
23
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24
bull ZuZuTi kvebis araswori reJimiT ganpirobebuli iSviaTi ZuZuTi kvebis SemTxevaSi arasakmarisi raodenobiT rZis miReba iwvevs enterohepaturi cirkulaciis gazrdas
bilirubinis toqsiuroba - bilirubini potenciuri neirotoqsinia arakoniugirebulma bilirubinma romelic ar aris dakavSirebuli albuminTan SeiZleba gaiaros hematoencefaluri barieri da Tavis tvinSi gamoiwvios ujredebis sikvdili apoptoziT (ujredebis programirebuli sikvdili) daan nekroziT yvelaze metad ziandeba bazaluri ganglia da Tavis tvinis Reros okulomotoruli da auditoruli funqciebis makontrolebeli birTvebi
Tu droul axalSobilebSi bilirubini gadaWarbebs 25-30 mgdl (428 - 513 micromolL) maRalia bilirubinis toqsiuri moqmedebis ganviTarebis riski Ssb toqsiuroba variabeluria da damokidebulia axalSobilis janmrTelobis mdgomareobaze da gestaciur asakze
mZime hiperbilirubinemiis ganviTarebis risk-faqtorebi mZime hiperbilirubinemiis ganviTrebis riski miT ufro maRalia rac
ufro meti riskis faqtoria gamoxatuli axalSobilTanmaRali riski (AMERICAN ACADEMY OF PEDIATRICS 2004) (Ronald J Wong 2005)
minus dabadebidan pirvel 24sT-Si gamovlenili siyviTle minus gaweris win Ssb an tkb done butanis nomogramaze maRali riskis
zonaSi
minus sisxlis jgufuri SeuTavsebloba dadebiTi pirdapiri antiglobulinuri testiT sxva cnobili hemolizuri daavadeba (mag g6fd deficiti)
minus gestaciuri asaki 35-36 kvira minus da-Zmas Catarebuli aqvs fotoTerapia
minus kefalohematoma an mniSvnelovani sisxlCaqcevebi (Newman TB 2000)minus araxSiri ZuZuTi kveba rodesac aReniSneba wonaSi mkveTri kleba
(gt12-ze meti) (Newman TB 2000 dabali riski
gaweris win Ssb an tkb-is done butanis nomogramaze maRali gardamavali riskis zonaSi
gestaciuri asaki 37-38 kvira (Newman TB 2000 da-Zmis anamnezSi siyviTle diabetiT daavadebuli dedis makrosomuli axalSobili
dedis asaki ge 25 welze (Newman TB 2000) mamrobiTi sqesi (Newman TB 2000 )
mdgomareobebi romlis drosac mZime hiperbilirubinemiis ganviTarebis riski Zalian dabalia
minus gestaciuri asaki ge 41 kviraze (Newman TB 2000)minus srulyofili enteraluri kveba (Newman TB 2000)minus gawera stacionaridan 72 sT-is Semdeg
minus Ssb dabali riskis zonaSi
4
klinikuri simptomatika
rekomendacia - siyviTlis monitoringi unda moxdes yvela axalSobilTan rutinulad vitaluri funqciebis Sefasebisas ara nakleb 8-12 sT-Si erTxel (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)siyviTlis arsebobis Sefaseba unda moxdes kargad ganaTebul oTaxSi umjobesia dRis Suqze fanjarasTan siyviTle Cveulebriv pirvelad vlindeba saxeze da Semdeg progresirebs kaudalurad sxeulsa da kidurebze siyviTlis ukeT gansazRvrisaTvis tardeba kanze TiTis zewolis testi zewola lokalurad amcirebs kanis perfuzias da xels uwyobs siyviTlis diagnostikas rodesac bilirubini 4-8 mgdl (68-137 micromolL) Cveulebriv iqterulia saxe da sklera Tu bilirubini gt15 mgdL (257 micromolL) siyviTle vlindeba mTel sxeulze xelis da fexisgulebis CaTvliT Ssb an tkb mizanSewonilia gaizomos Tu siyviTle vlindeba Wipis qvemoT
siyviTlis simZimis Sefaseba lokalizaciis mixedviT (WHO 2003) cxrili 1
asaki (dRe) siyviTlis lokalizacia daskvna
1 nebismieri
2 kidurebi
ge 3 terfebi mtevnebi
laquosaSiSiraquo siyviTle
sicocxlis I dRes nebismier adgilas an II dRes kidurebze gamovlenili siyviTle saWiroebs dauyovnebliv fotoTerapiis dawyebas analizis pasuxis miRebamde
krameris modificirebuli sqema cxrili 2
zona1 2 3 4 5
Ssb micromolL 100 150 200 250 gt250
krameris modificirebuli sqema saSualebas iZleva siyviTlis gavrcelebis mixedviT vivaraudoT Tu ramdenia Sratis saerTo bilirubinis done
siyviTlis xarisxis gansazRvra siyviTlis intensivobis mxolod vizualuri SefasebiT xSirad iwvevs daignostikur Secdomas gansakuTrebiT muqkanian axalSobilebSi
(rekomendacia C) (AMERICAN ACADEMY OF PEDIATRICS 2004)
axalSobilTa siyviTlisGgarTulebebimwvave da qronikuli (kerniqterusi) bilirubinuli encefalopaTiamwvave bilirubinuli encefalopaTia (AMERICAN ACADEMY OF PEDIATRICS 2004) mwvave bilirubinuli encefalopaTias axasiaTebs ganviTarebis 3 faza
5
C
1 adreuli faza vlindeba ramdenime dReSi da axasiaTebs leTargia hipotonia susti wova da sustad gamoxatuli ldquotvinismieri kivilirdquo
2 gardamavali stadia viTardeba kviris bolos da axasiTebs zomieri stupori agznebadoba da hipertonia axalSobils SeiZleba aReniSnos cxeleba mkveTrad gamoxatuli ldquotvinismieri kivilirdquo hipertonia vlindeba kisris (retrokolisi) da sxeulis (opistotonusi) ukan rkaliseburad gadaxriT
3 bolo stadia vlindeba 1 kviris Semdeg am dros centraluri nervuli sistemis dazianeba Seuqcevadia mas axasiaTebs mkveTri retrokolisi da opistotonusi mkveTrad gamoxatuli ldquotvinismieri kivilirdquo apnoe cxeleba sakvebis autanloba Rrma stupori komamde zogjer krunCxvebi da sikvdili
kerniqterusi (AMERICAN ACADEMY OF PEDIATRICS 2004)Bmwvave bilirubinuli encefalopaTiis Semdeg gadarCenil
axalSobils sicocxlis pirveli wlis manZilze uviTardeba bilirubinuli encefalopaTiis mZime qronikuli forma romelic 3 ZiriTadi gamovlinebiT xasiaTdeba
motoruli darRvevebi - aTetoiduri cerebluri dambla tremori qorea
mxedvelobis darRvevebi smeniTi disfunqcia inteleqtualuri darRvevebi SedarebiT iSviaTia damatebiT SeiZleba
ganviTardes kbilis emalis hipoplazia kerniqterusis dros 70-Si aRiniSneba nevrologiuri darRvevebi da
10-Si sikvdiloba
diferenciuli diagnoziaxalSobilTa siyviTlis dros unda ganisazRvros siyviTle
fiziologiuria Tu paTologiuri
fiziologiuri siyviTle paTologiuri siyviTle
vlindeba ara uadres 2 dRisa da qreba me-10-14 dRisTvis
vlindeba pirvel 24 saaTSi an7 dRis Semdeg
gavrceleba ar aRemateba krameris 1-3 zonebs
gavrceleba krameris nebismieri zona sicocxlis I dRes 4 zona sicocxlis II dRes da 5 zona nebismier asakSi
bavSvi aqtiuria temperatura normaluria wovis refleqsi kargia
zogadi mdgomareoba damakmayofilebeli an darRveuli
Sardis da ganavlis feri ar icvleba
SeiZleba iyos Sardis da ganavlis feris cvlileba
RviZli da elenTa ar aris gadidebuli
SeiZleba iyos hepatosplenomegalia
dedis rZiT ganpirobebuli siyviTlis sadiagnostikod (samkurnalod) SeiZleba Semdegi maCveneblebis gamoyeneba
bull dedis rZiT ganpirobebuli siyviTle vlindeba me-4-14 dRes
bull 24-48sT-is ganmavlobaSi ZuZuTi kvebis Sewyveta da alternatiul sakvebis miwodeba iwvevs bilirubinis donis daqveiTdebas
6
axalSobilTa hiperbilirubinemiis difdiagnozi ix algormiTi 1
gamokvlevis sqema
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004) tkb daan Ssb unda ganesazRvros yvela axalSobils
romelsac siyviTle gamouvlinda sicocxlis pirvel 24sT-Si (ix algoriTmi I da cxrili 3 ) (rekomendacia C)
tkb daan Ssb ganmeorebiTi gansazRvris dro da saWiroeba damokidebulia bilirubinis doneze (sqema 2) axalSobilis asakze hiperbilirubinemiis dinamikaze rekomendaciebi Ssb gansazRvrisaTvis dabadebidan 24 sT-is Semdeg mowodebulia I algoriTmsa da cxrilSi 3
tkb daan Ssb unda ganesazRvros yvela axalSobils romelsac gamouvlinda asakTan Seusabamo mkveTri siyviTle (rekomendacia D)
bilirubinis donis Sefaseba unda moxdes axalSobilis asakis (saaTebSi) gaTvaliswinebiT (sqema 2) (rekomendacia
C) Tu axalSobils utardeba fotoTerapia an aReniSneba
bilirubinis swrafi mateba (sqema 2 ndash butanis sqemaze monacemi kveTs percentilebs) rac ar aixsneba obieqturi gamokvleviT da anamnezuri monacemebiT saWiroa siyviTlis SesaZlo mizezebis dadgena (rekomendacia D)
axalSobilebs romelTac aReniSnebaT pirdapiri (koniugirebuli) bilirubinis mateba unda CautardeT Sardis saerTo da baqteriologiuri gamokvleva damatebiTi laboratoriuli gamokvlevebi unda Catardes Tu anamneziT da obieqturi gamokvelevebiT saeWvoa sefsisi (rekomendacia
C) avadmyof axalSobilebsa da Cvilebs romelTac aReniSnebaT
siyviTle 3 kviris an ufro mogvianebiT asakSi unda ganesazRvroT saerTo da pirdapiri (koniugirebuli) bilirubini qolestazis sadiagnostikod (cxrili 3) (rekomendacia D) aseT axalSobilebTan mizanSewonilia skriningi hipoTireozsa da galaqtozemiaze (rekomendacia D)
Tu pirdapiri an koniugirebuli bilirubinis done momatebulia rekomendirebulia damatebiTi gamokvlevebi qolestazis sadiagnostikod (rekomendacia C)
glukoza-6-fosfat dehidrogenazas donis gansazRvra saWiroa im axalSobilebTan romelTa ojaxuri anamnezi an eTnikuri an geografiuli warmoSoba miuTiTebs g6fd-s deficitze da utardebaT fotoTerapia daan axalSobilebTan Tu fotoTerapia uefeqtoa (sqema 3) (rekomendacia C)
7
C
D
C
D
C
C
C
D
D
cxrili 3 35 da meti gestaciuri asakis axalSobilSi gamovlenili siyviTlis laboratoriuli Sefaseba (AMERICAN ACADEMY OF PEDIATRICS 2004)
Cveneba laboratoriuli kvlevapirvel 24 sT-Si gamovlenili siyviTle
bull tkb daan Ssb gansazRvra
asakisaTvis Seusabamo mkveTri siyviTle kanze G
bull tkb daan Ssb gansazRvra
axalSobils utardeba fotoTerapia an aReniSneba bilirubinis swrafi mateba (sqema 2 ndash butanis sqemaze maCvenebeli kveTs percentilebs) rac ar aixsneba obieqturi gamokvleviT da anamnezuri monacemebiT
bull sisxlis jgufi da rezusi kumbsis testi Tu ar aris gakeTebuli Wiplaris sisxlSi
bull sisxlis saerTo analizi da nacxi formiani elementebis morfologiis Sesaswavlad
bull pirdapiri (koniugirebuli) bilirubinis gansazRvra
bull Tu SesaZlebelia isazRvreba retikulocitebis ricxvi g6fd
bull Ssb ganmeorebiT isazRvreba 4-24 sT-Si axalSobilis asakisa da Ssb donis Sesabamisad
fotoTerapia uSedegoa an Ssb aRwevs dones romelzec naCvenebia SenacvlebiTi transfuzia
bull Tu SesaZlebelia isazRvreba retikulocitebis ricxvi g6fd
momatebulia pirdapiri (koniugirebuli) bilirubinis done
bull Sardis anlizi
bull Sardis kultura
bull gamokvleva sefsisze Tu misi arseboba saeWvoa anamneziT an obieqturi gamokvleviT
siyviTle sami kviris asakis an avadmyof axalSobilSi
bull saerTo da pirdapiri (koniugirebuli) bilirubini
bull pirdapiri bilirubinis momatebisas tardeba kvleva qolestazis sadiagnostikod
bull skriningi hipoTireozsa da galaqtozemiaze
bull axalSobilis Sefaseba hipoTireozis simptomebis gamosavlenad
sqema 1 butanis nomograma
8
butanis nomograma saSualebas iZleva ganisazRvros ramdenad maRalia mZime hiperbilirubinemiis ganviTarebis riski axalSobilis asakis (saaTebSi) da Sratis bilirubinis koncentraciis gaTvaliswinebiT bilirubinis gansazRvra
bilirubini isazRvreba transkutanurad da sisxlis SratSi transkutanuri gansazRvra gamarTlebulia rogorc skriningis
meTodi is isazRvreba specialuri aparatiT aRniSnuli xelsawyos gamoyenebiT bilirubinis gansazRvra SesaZloa 2-3 mgdl (34-54micromolL) variabelobiT bevr SemTxvevaSi xdeba Sratis bilirubinis gansazRvris Canacvleba transkutanuri gansazRvriT gansakuTrebiT maSin roca Ssb lt 15 mgdl (257 micromolL)
fotoTerapiis dros kanis vizualuri SefasebasTan erTad aucilebelia Sratis bilirubinis gansazRvra radgan fotoTerapia ldquoaTeTrebsrdquo kans (American Academy of Pediatrics 2004)
pirveladi profilaqtika
rekomendacia (American Academy of Pediatrics 2004) bull eqimma unda urCios dedas ganaxorcielos moTxovnilebiTi ZuZuTi kveba dReSi 8-12-jer (rekomendacia C) - arasrulyofili kaloriebis miRebam daan dehidrataciam SeiZleba gamoiwvios Hhiperbilirubinemiis ganviTareba
bull ZuZuTi kvebis SemTxevaSi Tu axalSobils ar aReniSneba dehidratacia ar aris rekomedirebuli wylisa da deqstrozis rutinulad damateba (rekomendacia B da C) -
9
C
B
C
wylis da deqstrozis damateba ar axdens hiperbilirubinemiis ganviTarebis profilaqtikasa da Ssb-s Semcirebas
bull yvela Rh (D) negatiur orsuls an melogines mizanSewonilia Cautardes anti D imonoglobuliniT profilaqtika (rekomendacia A)
minus orsulobis 28 kviraze (garda im SemTxvevebisa rodesac bavSvis mamac Rh (D) negatiuria)
minus mSobiarobidan 72 sT-is gamnavlobaSi Tu axalSobili Rh (D) pozituiria
minus orsulobis pirvel trimestrSi ganviTarebuli abortis da invaziuri procedurebis dros rogorica amniocentezi nayofis invaziuri procedurebi
meoradi profilaqtikarekomendacia klinicistma unda moaxdinos axalSobilTa hiperbilirubinemiis ganviTarebis riskebis sistemuri Sefaseba neonatalur periodSi (rekomendacia B)(AMERICAN ACADEMY OF PEDIATRICS 2004)
sisxlis jgufobriobarekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
yvela orsuli qali unda iyos gamokvleuli ABO da Rh(D) sisxlis jgufebze da hqondes Catarebuli skriningi SratSi izoimunur antisxeulebze (rekomendacia B)
Tu dedas ar Cautarebia prenatalurad sisxlis jgufis da rezusis gamokvleva an igis Rh negatiuria mkacrad aris rekomendirebuli pirdapiri antisxeulebis testis (an kumbsis testi) sisxlis jgufis da Rh (D) tipis gansazRvra axalSobilis (Wiplaris) sisxlSi (rekomendacia B)
Tu dedas sixlis jgufi aris O Rh(D) pozitiuri axalSobilis sisxlis jgufis da pirdapiri antisxeulis testis gansazRvris aucilebloba damokidebulia meTvalyureobis xarisxze gaweris win riskis Sefasebasa da gaweris Semdeg meTvalyureobaze (rekomendacia C)
mkurnalobis sqemamkurnalobis ZiriTadi principebia
fotoTerapia SenacvlebiTi transfuzia
mkurnaloba iwyeba fotoTerapiiTfotoTerapiis dros kanis zeda SreebSi Calagebuli arapirdapiri bilirubini iSleba fotoqimiuri gziT wyalSi xsnad koniugatebad romlebic gamoiyofa SardiT da naRveliTrekomendacia yvela samSobiaro saxli unda iyos aRWurvili mowyobilobiT romelic saWiroa intensiuri fotoTerapiisaTvis (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)fotoTerapiis Cvenebebi
fotoTerapia iwyeba Tu bulirubinis done aRemateba 95 percentils butanis nomogramaze (sqema 1) amave dros metad mniSvnelovania risk-faqtorebis gaTvaliswineba romlebic xels uwyobs mZime
10
A
B
B
B
C
D
hiperbiliruminemias (hemolizuri daavadeba g6fd deficiti asfiqsia mkveTrad gamoxatuli leTargia temperaturis arastabiluroba sefsisi acidozi an hipoalbuminemia lt30 gdl)
amerikis pediatriuli akademiis rekomendaciiT gamoiyeneba sqema (sqema 2) romelic axalSobilis asaksa da bilirubinis donesTan erTad iTvaliswinebs risk-faqtorebsa da gestaciur asaks mocemuli sqemis mixedviT ldquointensiurirdquo fotoTerapia iwyeba Semdegi principebiT
dabali riskis axalSobili (janmrTeli risk-faqtorebis gareSe gestacia gt 38 kvira) ndash Ssb gt12 mgdl (205 micromolL) 24 sT-Si Ssb gt15 mgdl (257 micromolL) 48 sT-Si Ssb gt18 mgdl (308 micromolL) gt72 sT
saSualo riskis axalSobili (gestacia gt 38 kvira da risk-faqtorebi an gestacia 35-37 kvira risk-faqtorebis gareSe gareSe) ndash Ssb gt 10 mgdl (171 micromolL) 24 sT-Si Ssb gt13 mgdl (222 micromolL) 48 sT-Si Ssb gt15 mgdl (257 micromolL) gt72 sT gestaciis 35 kviris axalSobilebSi fotoTerapia SeiZleba daiwyos ufro dabal maCveneblebze
maRali riskis axalSobili (gestacia 35-37 kvira da risk-faqtorebi) - Ssb gt 8 mgdl (137 micromolL) 24 sT-Si Ssb gt11 mgdl (188 micromolL) 48 sT-Si Ssb gt135 mgdl (231 micromolL) gt72 sT
Tu dabali riskis axalSobilebSi Ssb done 2-3 mgdl-iT dabalia moyvanil monacemebze SesaZlebelia mkurnalobis dawyeba ldquoCveulebrivirdquo fotoTerapiiT
bull stacionarSi gamoxatuli siyviTliT Semosul axalSobils utardeba ldquointensiurirdquo fotoTerapia bilirubinis maCveneblis gansazRvramde
bull ldquointensiurirdquo fotoTerapia aseve rekomendebulia hemolizuri daavadebis dros
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
janmos rekomendacia fotoTerapiis dawyebis Cvenebebis Sesaxeb mocemulia cxrilSi 4
cxrili 4 fotoTerapiis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI gamoxatuli siyviTleII 15 260 13 220III 18 310 16 270
IV da meti 20 340 17 290janmos rekomendaciiT fotoTerapia iwyeba Tu siyviTlis
lokalizaciis mixedviT siyviTlis simZimis Sefasebisas (cxrili 1) dadginda ldquosaSiSi siyviTlerdquo
Tu ar aris bilirubinis gansazRvris saSualeba Ssb savaraudo donis dasadgenaT SeiZleba krameris modificirebuli sqemis gamoyeneba
11
sqema 2 fotoTerapiis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (AMERICAN ACADEMY OF PEDIATRICS 2004)
rekomendacia Tu Sratis albuminis maCvenebeli naklebia 30 gdl-ze fotoTerapiis dawyeba rekomendebulis ufro dabali maCveneblebis dros (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis ukuCveneba pirdapiri (koniugirebuli) hiperbilirubinemia (pirdapiri
bilirubini Ssb-s 50-ze metia) (American Family Practice Notebook 2002 ) (AMERICAN ACADEMY OF PEDIATRICS 2004)
Tandayolili porfiria an porfiriis ojaxuri anamnezi (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis teqnikafotoTerapiis efeqturoba damokidebulia dozaze fotoTerapiis doza anu speqtruli iradiacia damokidebulia naTuris simZlavreze sinaTlis wyarosa da bavSvs Soris manZilsa da dasxivebis farTobze sinaTlis wyarofotoTerapiis sinaTlis speqtri damokidebulia sinaTlis wyaroze da filtrze yvelaze farTod gavrcelebuli fotoTerapiis mowyobiloba Seicavs dRis Suqis gril TeTr cisfer an ldquospecialur cisferrdquo fluorescentul naTurebs manZils sinaTlis wyarodan axalSobilamde didi mniSvneloba eniWeba sasurvelia axalSobili moTavsdes sinaTlis wyarodan im minimalur manZilze romelic miTiTebulia fotoTerapiis mowyobilobis instruqciaSi halogenis fotoTerapiis naTurebi ar SeiZleba moTavsdes axalSobilTan axlos radgan SeiZleba gamoiwvios damwvroba
12
DD
sxeulis zedapiris farTobibilirubinis maRali Semcvelobisas mniSvnelovania fotoTerapiis dros dasxivdes sxeulis zedapiris rac SeiZleba meti farTobi
ldquoCveulebrivi fotoTerapiardquo - sinaTlis speqtris iradiacia dabalia (6-12 microWcm2nm) (talRis sigrZe daaxloebiT 425-475 nm) da damokidebulia sxvadasxva mwarmoeblis mier mowodebul fotoTerapiiis sistemis aparatis monacemebze saWiroa aparatis Semowmeba Seesabameba Tu ara sinaTlis speqtris iradiacia mwarmoeblis mier mowodebul monacemebsldquointensiuri fotoTerapiardquo - lurj-mwvane speqtris iradiacia (talRis
sigrZe daaxloebiT 430-490 nm) sul cota 30 microWcm2nm-ia (isazRvreba axalSobilis kanze fototerapiis aparatis centris qveS) gazomva xdeba im warmoebis radiometriT romelic mowodebulia fotoTerapiiis sistemis aparatis mwarmoeblis mier sinaTlis talRis asareklad TeTreuli unda iyos TeTri kuvezi da sawolis gverdebi daifaros TeTri qsoviliT an aluminis folgiT
fotoTerapiis procedura da monitoringi
temperatura sinaTlis wyaros qveS unda iyos 28-300C
fotoTerapiis dros bavSvi unda iyos SiSveli ecvas erTjeradi higienuri safeni Tvalebze unda hqondes damcavi saTvale
yovel 3 saaTSi erTxel bavSvs unda Seucvalon pozicia
yovel 3 saaTSi erTxel unda Sefasdes sinaTlis wyaros qveS arsebuli temperatura da axalSobilis sxeulis temperatura Tu bavSvis t metia metia 3750C saWiroa oTaxis temperaturis daqveiTeba an fotoTerapiis droebiT Sewyveta sanam bavSvis temperatura ar iqneba normis farglebSi (365-3750C)
fotoTerapia mimdinareobas mudmivad igi wydeba mxolod im procedurebis dros romelTa warmoeba ra SeiZleba sinaTlis wyaros qveS
centraluri cianozis arsebobis Sesafaseblad fotoTerapia unda Sewydes mcire droiT
fotoTerapiis dros unda gagrZeldes bavSvis kveba
rArraxalSobilTan unda gagrZeldes ZuZuTi kveba moTxovnilebis mixedviT (intervali kvebaTa Soris araumetes 3 sT-isa) (rekomendacia C) ZuZuTi kvebis dros wydeba fotoTerapia da Sesabamisad bavSvs unda moexsnas damcavi saTvale
rArrTu bavSvi ikvebeba gamowvelili rZiT formuliT an parenteralurad misawodebeli sakvebis an siTxis raodenoba izrdeba dRiuri normis 10 -iT
rArr Tu bavSvi ikvebeba zondiT an parenteralurad fotoTerapia mimdinareobs uwyvetad
rArrCveulebriv fotoTerapiis dros axalSobils ar esaWiroeba damatebiT siTxis an sakvebis miwodeba damateba naCvenebia mxolod araefeqturi ZuZuTi kvebis sxeulis masis paTologiuri danakargis (gt10-ze mesame dRisTvis) da dehidrataciis SemTxvevaSi
13
C
fotoTerapiis dros bilirubinis daSlis produqtebi gamoiyofa SardiT da naRveliT adeqvaturi hidrataciis SenarCuneba da Sesabamisad adekvaturi diurzis SenarCuneba zrdis fotoTerapiis efeqturobas
zogierT axalSobils hiperbilirubinemiiT aReniSneba dehidratacia da saWiroa damatebiTi siTxis miwodeba (per-os an intravenurad) dehidrataciis koreqciisaTvis
araefeqturi ZuZuTi kvebis SemTxvevaSi fotoTerapiis dros axalSobils damatebiT miewodeba gamowvelili dedis rZe donoris rZe an xelovnuri sakvebi
rArr adeqvatur kvebaze miuTiTebs 4-6 sveli safeni 24 sT-Si da nawlavTa moqmedeba 3-4 jerdReSi meoTxe dRisaTvis
janmrTeli drouli axalSobilis nawlavTa moqmedeba da diurezi (minimaluri maCveneblebi) cxrili 5 (Fetus and Newborn Committee 1999)
dRe nawlavTa minimaluri moqmedeba24sT
sveli safeni24sT
1 1 12 1 23 1 gardamavali 34 2 yviTeli fafisebri 45 2YyviTeli fafisebri 5-6
rArrdehidrataciaze miuTiTebs Semdegi niSnebis arseboba - masis paTologiuri kleba (gt10-ze mesame dRisTvis)- anuria 4-6 sT- Cacvenili Tvalebi- Cavardnili yoflibandi - - daqveiTebuli kanis elastiuroba (kanis naoWi swordeba
nela)- daqveiTebuli kanis kapilaruli avseba (gt3 wm)- taqikardia- Sratis Na gt145 HCO3 lt17
bilirubinis monitoringi fotoTerapiis dros (American Aacademy of Pediatrics 2004)
sawyisi bilirubinis maCveneblis Semcireba 6-20-iT standartuli da 30-40-iT intensiuri fotoTerapiis dawyebidan 24sT-Si mis efeqturobaze miuTiTebs
bull Tu Ssb ge 25 mgdL (428 micromolL) ganmeorebiTi gansazRvra 2ndash3 sT-Si
bull Tu Ssb 20ndash25 mgdL (342ndash428 micromolL) ganmeorebiTi gansazRvra 3-4 sT-Si
bull Tu Ssb lt20 mgdL (342 micromolL) ganmeorebiTi gansazRvra 4ndash6 sT-Si Tu Ssb agrZelebs daqveiTebas ganmeorebiTi gansazRvra 8-12 sT-Si
bull Tu Ssb ar mcirdeba an uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones an Ssb albuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6) iwyeba SenacvlebiTi transfuzia Tu amis saSualeba aris an xorcieldeba referali
bull intensiur fotoTerapiis miuxedavad Ssb-is ucvleli done an mateba miuTiTebs hemolizze
14
rArr anemiahemolizis Sefaseba SesaZlebelia sisxlis saerTo analizis mixedviT - Hgblt 130 glLHct lt 40 retikulocitebi - gt 6
bull Ssb lt 13ndash14 mgdL (239 micromolL) fotoTerapia wydeba
bull fotoTerapiis Sewyvetidan 24 sT-Si kontroldeba Ssb Tu Ssb moimata im donemde romelzec daiwyo fotoTerapia fotoTerapia ganmeorebiT iwyeba
fotoTerapiis garTulebebi
fotoTerapiis garTulebebi (Ronald J Wong 2005 American Aacademy of Pediatrics 2004)
rArrmwvane feris ganavalidiarea (mkurnalobas ar saWiroebs)
rArr dehidratacia
rArr muclis Seberva (mkurnalobas ar saWiroebs)
rArr Tvalis SesaZlo dazianeba yvelaze seriozuli magram iSviaTi klinikuri garTulebaa brinjaos
axalSobilis sindromi romelic vlindeba qolestazuri siyviTlis mqone axalSobilSi kanis Sratis da Sardis muqi nacrisfer-yavisferi SeferilobiT brinjaos axalSobilis sindromi ar vlindeba qolestazis mqone yvela axalSobilTan Tu arsebobs fotoTerapiis Cveneba pirdapiri hiperbilirubinemia ar warmoadgens fotoTerapiis winaaRmdeg Cvenebas axalSobilebSi romelTac uviTardebaT brinjaos sindromi naCvenebia SenacvlebiTi transfuzia monacemebis arasrulyofilebis gamo mkacri rekomendaciis gakeTeba ar SeiZleba
mZime qolestazuri siyviTlis mqone axalSobilebSi fotoTerapiis dros aseve SeiZleba ganviTardes
rArr purpura
rArr bulozuri gamonayari
mzis ultraiisferi sxivebiT TerapiamarTalia mzis sxivebs gaaCniaT mniSvnelovani iradiacia 425-475 nm magram radganac maRalia axalSobilis damwvrobis ganviTarebis riski (SiSveli axalSobilis mzeze yofnis gamo) es meTodi rekomendebuli ar aris
(Ronald J Wong 2005 (American Aacademy of Pediatrics 2004)
intravenuri imunoglobulinis gamoyenebarekomendacia izoimunuri hemolizuri daavadebis dros rekomendebulia intravenuri imunoglobulinis gamoyeneba (05-1 gkg 2 sT-s ganmavlobaSi) Tu Ssb imatebs intensiuri fotoTerapiis miuxedavad an Ssb aris 2-3 mgdl-iT (34-51mkmoll) naklebi SenacvlebiTi transfuziis Cvenebis doneze (fighellip4) aucilebelobis SemTxvevaSi intravenuri imunoglobulinis es doza SeiZleba ganmeordes 12 sT-Si (rekomendacia B) American Aacademy of Pediatrics 2004)
15
fotoTerapiis dros kanSi Calagebuli bilirubini swrafad iSleba amitom ar aris rekomendebuli kanis ferze dayrdnobiT SratSi
bilirubinis donis Sesafaseba rogorc fotoTerapiis dros ise misi Sewyvetidan 24 sT-is ganmavlobaSi
B
kvlevebiT dadgenilia rom intravenuri imunoglobulini amcirebs SenacvlebiTi transfuziis saWiroebas Rh da ABO hemolizuri daavadebis dros
SenacvlebiTi transfuzia
SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleluli unda iyos Semowmebuli da dasxivebuli gadasasxmeli sisxlis raodenoba Seadgens 170-180 mlkg
rekomendacia SenacvlebiTi transfuzia unda Caataros mxolod gamocdilma samedicino personalma intensiuri Terapiis ganyofilebaSi monitoringisa da srulyofili reanimaciis SesaZleblobis pirobebSi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
SenacvlebiTi transfuziis Cvenebebi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
mwvave bilirubinuli encefalopaTia intensiuri fotoTerapiis miuxedavad Ssb mateba an ucvleli
monacemi samSobiarodan gawerili axalSobilebis hospitalizaciis
SemTxvevaSi Ssb-s maRali maCvenebeli - aRemateba SenacvlebiTi transfuziis dawyebis maCvenebls (sqema 3) (transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia) (ix cxrili 6)
ba Sefardeba Ssb maCvenebelTan (cxrili 6) erTad gamoiyeneba rogorc damatebiTi faqtori SenacvlebiTi transfuziis dawyebis gansasazRvravad
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
sqema 3 SenacvlebiTi transfuziis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (American Academy of Pediatrics 2004)
16
D
D
cxrili 6 bilirubinisa da albuminis Sefardeba rodesac saWiroa SenacvlebiTi transfuzia (AMERICAN ACADEMY OF PEDIATRICS 2004)
riskis kategoria
ba Sefardeba rodesac saWiroa SenacvlebiTi
transfuziaSsb mgdl alb gdl
Ssb micromolL alb micromolL
axalSobilebi gestaciuri asaki - ge38 kvira 80 094
janmrTeli axalSobilebi gestaciuri asakiT an riskis jgufis axalSobilebi
gestaciuri asakiT ge38 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
72 084
riskis jgufis axalSobilebi gestaciuri asakiT 35ndash36 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
68 080
janmos rekomendacia sisxlis SenacvlebiTi gadasxmis Cvenebebis Sesaxeb mocemulia cxrilSi 7
cxrili 7 SenacvlebiTi transfuziis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI 15 260 13 220II 25 425 15 260
17
III 30 510 20 340IV da meti 30 510 20 340
Tu Ssb uaxlovdeba im dones rodesac naCvenebia SenacvlebiTi transfuzia
sisxli dauyovnebliv igzavneba raTa dadgindes jgufi da rezusi da SeTavseba Tu klinikaSi aris transfuziis saSualeba
an xorcieldeba referali
teqnika (AMERICAN ACADEMY OF PEDIATRICS 2004
bull mwvave bilirubinuli encefalopaTiis dros SenacvlebiTi transfuzia iwyeba dauyovnebliv
bull sxva SemTxvevaSi transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia
bull SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleuli unda iyos Semowmebuli da dasxivebuli
bull gadasasxmeli sisxlis raodenoba Seadgens axalSobilis mocirkulire sisxlis ormag raodenobas saSualod 170-180 mlkg an gadasasxmeli sisxlis gamosaTvleli formula gamoiTvleba 85 x axalSobilis wona kg x 2
bull SenacvlebisaTvis xdeba 2 venis an arteria da venis kaTeterizacia iReben bavSvis 20 ml sisxls da SeyavT 20 ml donoris sisxli (3-4 wT-is ganmavlobaSi) SemTbaris 367-3700C-mde
bull dRenaklulebsa da mZime mdgomareobaSi myof axalSobilebSi Senacvleba xdeba 5-10 ml-iT
axalSobilis momzadeba
bull kuWis SigTavsis aspiracia zondiT 8F da Ria zondis datoveba kuWSibull SeiZleba saWiro gaxdes bavSvis dabma
bull SeiZleba sawovaras gamoyeneba
bull Sardis Semkrebis gamoyeneba diurezis kontrolisTvisaxlSobilis winaswar Sefaseba
bull temperatura
bull guliscema
bull sunTqva
bull wneva
bull glukoza SratSi
bull Sardis analizi
bull ganavlis analizi sisxlis Semcvelobaze
bull kanis feri
bull tonusi
bull qcevauSualod transfuziis dros fasdeba vitaluri niSnebi (yovel 15 wT-Si)
18
bull temperatura
bull guliscema (mwvervalze) (umjobesia kardiomonitoriT)
bull sunTqva
bull kanis feri
bull qceva
monitoringi transfuziis Semdeg bull grZeldeba fotoTerapia
bull kardio monitoringi
bull sisxlis wneva proceduris damTavrebis Semdeg
bull saaTobrivad 6 sT-is ganmavlobaSi temperatura guliscema (mwvervalze) sunTqva
bull glukoza SratSi yovel 3 sT-Si 24 sT-is ganmavlobaSi
bull muclis garSemoweriloba 3-4 sT-Si 24 sT-is ganmavlobaSi nawlavebis peristaltikis auskultacia
bull Sardis analizi
bull ganavali sisxlis Semcvelobaze
bull sakvebis autanlobis niSnebi Rebineba muclis Seberva
bull Ssb 6 sT-Si erTxel
SenacvlebiTi transfuziis riskisikvdiloba - 3 SemTxveva 1000 transfuziaze SenacvlebiTi transfuziis dros garTulebis saxiT 5-Si vlindeba
- apnoe bradikardia cianozi vazospazmi Trombozi nekrozuli enterokoliti aseve SeiZleba ganviTardes hipoqsiur-iSemiuri encefalopaTia da SeZenili imunodeficitis sindromi
sxva mkurnalobafenobarbitali ndash xels uwyobs bilirubinis koniugacias da amcirebs
Ssb dones ar arsebobs sakmarisi mtkicebulebebi fenobarbitalis gamosayeneblad rodesac arsebobs siyviTlis mkurnalobis ufro efeqturi meTodebi (mag fotoTerapia)
referali AMERICAN ACADEMY OF PEDIATRICS 2004)referali maRali donis klinikaSi xorcieldeba Tu
ar aris fotoTerapiis Catarebis SesaZlebloba fotoTerapiis miuxedavad
rArr Ssb ar mcirdeba
rArr Ssb uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones da ar aris transfuziis saSualeba
rArr Ssbalbuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6)
Tu siyviTle gamovlinda I dRes siyviTlis lokalizaciis mixedviT siyviTlis simZimis Sefasebisas
(cxrili 1) dadgenili ldquosaSiSi siyviTlerdquo
bilirubinis maRali namati 85 micromolLsT (gt05 mgdlsT)
gaxangrZlivebuli siyviTle (14 dRe da meti) ojaxur anamnezSi mZime siyviTlis an kerniqterusis arseboba siyviTlis dros sxva daavadebis niSnebis arseboba (mg sefsisi)
19
riskis Sefaseba gaweramde
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
bull yvela axalSobilis gaweramde unda Sefasdes hiperbilirubinemiis ganviTarebis riski yvela ganyofilebas unda hqondes protokoli siyviTlis SefasebisTvis aseTi Sefaseba gansakuTrebiT mniSvnelovania im axalSobilebisaTvis romlebis ewerebian dabadebidan 72 sT-ze adre (rekomendacia C)
bull amerikis pediatrTa akademiis rekomendaciiT riskis SefasebisaTvis gamoyenebuli unda iqnas 2 midgoma (calcalke an kombinaciaSi) gaweris win bilirubinis gansazRvra (Ssb an tkb) daan klinikuri risk-faqtorebis Sefaseba risk-faqtorebis arseboba an Ssb maRali maCveneblebi gaweris Semdeg Sesabamisi meTvalyureobis aucilebelobis Cvenebaa (rekomendacia C)
bull yvela samSobiarom unda miawodos mSobels zepiri daan werilobiTi informacia binaze siyviTlis Sefasebis da saSiSroebis niSnebis Sesaxeb (rekomendacia D)
meTvalyureoba
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)bull yvela axalSobili samSobiarodan gaweriis Semdeg ramdenime dReSi unda Sefasdes kvalificuri samedicino profesionalis mier (rekomendacia C)
bull fasdeba - siyviTlis arseboba axalSobilis wona kvebis efeqturoba Rebinebis arseboba (rekomendacia C)
bull meTvalyureobis grafiki Tu axalSobili samSobiarodan ewereba 48-72 sT-Si samedicino Sefaseba tardeba 120 sT-is (5 dRe) asakSi (rekomendacia C)
bull Tu samSobiarodan gaweris Semdeg meTvalyureoba SeuZlebelia da arsebobs hiperbilirubinemiis ganviTarebis risk-faqtorebi axalSobilis gawera unda gadaidos sanam ar iqneba uzrunvelyofili Sesabamisi meTvalyureoba an sanam gaivlis maRali riskis periodi (72-96sT) (rekomendacia D)
11 gaidlainis gadasinjvisa da ganaxlebis vada ndash 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlainis SemuSavebis meTodologia
bull axalSobilTa hiperbilirubinemiis prevenciis diagnostikisa da marTvis principebis Sesaxeb arsebobs samecniero mtkicebulebis safuZvelze Seqmnil rekomendaciaTa sakmarisi raodenoba mocemuli gaidlainis Semqmnis procesSi samuSao jgufis gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve arsebuli praqtikuli rekomendaciebi moxda arsebuli
20
C
C
C
C
D
C
D
rekomendaciebis adaptirebuli variantis SemuSaveba romelic erTis mxriv pasuxebs saerTaSoriso moTxovnebs xolo meore mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa rogorc adamianur ise teqnikur resursebs
bull rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa bazis gamoyenebiT
cxrili 2
qveyana da resursis dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
httpwwwguidelinegov
Centers for Disease Control and Prevention (CDC)
httpwwwphppocdcgovCDCRecommendsAdvSearchVasp
Agency for Healthcare Research and Quality (AHRQ)
httpwwwahrqgovcliniccpgsixhtm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
httphstatnlmnihgov
Institute of Clinical Systems Improvement (ICSI)
httpwwwicsiorg
American Medical Association httpwwwama-assnorg
Canadian Medical Association (CMA)
httpmdmcacpgsnewcpgsindexasp
Health Canada ndash Population and Public Health Branch (PPHB)
httpwwwhc-scgccapphb-dgspspdpg_ehtml
didi britaneTi
National Institute for Clinical Excellence (NICE)
httpwwwniceorguk
Sheffield Evidence for Effectiveness and Knowledge (SEEK)
httpwwwshefacukseekguidelineshtm
National electronic Library for Health (NeLH)
httpwwwnelhnhsukguidelinesfinder
PRODIGY Clinical Guidance httpwwwprodigynhsukClinicalGuidance
Scottish Intercollegiate Guidelines Network (SIGN)
httpwwwsignacuk
German Guideline Information Service (GERGIS)
httpwwwleitliniendeenglishenglishview
avstralia
Australian National Health and httpwwwhealthgovauhfsnhmrcpublicatcp-
21
Medical Research Council (NHMRC) homehtmaxali zelandia
New Zealand Guidelines Group (NZGG)
httpwwwnzggorgnzlibrarycfm
mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba
httpwwwosdmorg
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi
bull koxreinis biblioTeka - The Cochrane Library 2006 Issue 2 bull amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini ndash MEDLINEbull jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvisgamoricxvis kriteriumebi
bull arCeul iqna kvlevebi Semdegi dizainiT randomizebuli kontrolirebadi sistemuri mimoxilvebi da meta-analizi erTmomentiani kohortuli kvlevebi
bull rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12 wliani SezRudva Tumca zogjer gamoyenebuli iyo ufro adreuli publikaciebi romlebic dResac aqtualuria da safuZvlad udevs sxva Tanamedrove mtkicebulebebs
bull dadgenili iyo enobrivi SezRudvebi radganac samuSao jgufs SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod inglisur da rusul enebze
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
bull samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri meToduri rekomendacia axalSobilTa hiperbilirubinemiis marTvis sakiTxebze romlebic Seicavda jgufis miznis Sesaferis saWiro informacias am rekomendaciebis Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (9496-98) samuSao jgufi xelmZRvanelobda saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mier SemuSavebuli nacionaluri gaidlainebis gzamkvleviT Sefasebis Sedegad amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi
rArr amerikis pediatrTa akademia
rArr msoflo jandacvis organizacia
rArr kanadis pediatrTa sazogadoeba ndash nayofi da axalSobilis komiteti
rArr britaneTis reproduqciuli janmrTelobis programa
22
bull rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da rekomendaciebis xarisxis sqema
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris
done (Muir Gray)xarisxi rekomendaciis xarisxi
(Cook et al)I Zlieri mtkicebuleba
eyrdnoba minimum erT sistemur mimoxilvas
romelic efuZneba swori dizainis mqone randomizebul
kontrolirebad kvleva
A eyrdnoba I donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erTi swori dizainis mqone
randomizebul kontrolirebad kvleva
B eyrdnoba II donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
III klinikuri kvleva randomizaciis gareSe
kohortuli da SemTxveva-kontrolis kvlevebi
C eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi
D eyrdnoba IV da V donis mtkicebulebas saWiroebs
konsesuss
Va avtoritetul profesionalTa mosazreba
Vb klinikuri gamocdileba aRwerilobiTi kvlevebi an
eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
15 avtorTa jgufi
bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis
bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi
rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
23
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24
klinikuri simptomatika
rekomendacia - siyviTlis monitoringi unda moxdes yvela axalSobilTan rutinulad vitaluri funqciebis Sefasebisas ara nakleb 8-12 sT-Si erTxel (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)siyviTlis arsebobis Sefaseba unda moxdes kargad ganaTebul oTaxSi umjobesia dRis Suqze fanjarasTan siyviTle Cveulebriv pirvelad vlindeba saxeze da Semdeg progresirebs kaudalurad sxeulsa da kidurebze siyviTlis ukeT gansazRvrisaTvis tardeba kanze TiTis zewolis testi zewola lokalurad amcirebs kanis perfuzias da xels uwyobs siyviTlis diagnostikas rodesac bilirubini 4-8 mgdl (68-137 micromolL) Cveulebriv iqterulia saxe da sklera Tu bilirubini gt15 mgdL (257 micromolL) siyviTle vlindeba mTel sxeulze xelis da fexisgulebis CaTvliT Ssb an tkb mizanSewonilia gaizomos Tu siyviTle vlindeba Wipis qvemoT
siyviTlis simZimis Sefaseba lokalizaciis mixedviT (WHO 2003) cxrili 1
asaki (dRe) siyviTlis lokalizacia daskvna
1 nebismieri
2 kidurebi
ge 3 terfebi mtevnebi
laquosaSiSiraquo siyviTle
sicocxlis I dRes nebismier adgilas an II dRes kidurebze gamovlenili siyviTle saWiroebs dauyovnebliv fotoTerapiis dawyebas analizis pasuxis miRebamde
krameris modificirebuli sqema cxrili 2
zona1 2 3 4 5
Ssb micromolL 100 150 200 250 gt250
krameris modificirebuli sqema saSualebas iZleva siyviTlis gavrcelebis mixedviT vivaraudoT Tu ramdenia Sratis saerTo bilirubinis done
siyviTlis xarisxis gansazRvra siyviTlis intensivobis mxolod vizualuri SefasebiT xSirad iwvevs daignostikur Secdomas gansakuTrebiT muqkanian axalSobilebSi
(rekomendacia C) (AMERICAN ACADEMY OF PEDIATRICS 2004)
axalSobilTa siyviTlisGgarTulebebimwvave da qronikuli (kerniqterusi) bilirubinuli encefalopaTiamwvave bilirubinuli encefalopaTia (AMERICAN ACADEMY OF PEDIATRICS 2004) mwvave bilirubinuli encefalopaTias axasiaTebs ganviTarebis 3 faza
5
C
1 adreuli faza vlindeba ramdenime dReSi da axasiaTebs leTargia hipotonia susti wova da sustad gamoxatuli ldquotvinismieri kivilirdquo
2 gardamavali stadia viTardeba kviris bolos da axasiTebs zomieri stupori agznebadoba da hipertonia axalSobils SeiZleba aReniSnos cxeleba mkveTrad gamoxatuli ldquotvinismieri kivilirdquo hipertonia vlindeba kisris (retrokolisi) da sxeulis (opistotonusi) ukan rkaliseburad gadaxriT
3 bolo stadia vlindeba 1 kviris Semdeg am dros centraluri nervuli sistemis dazianeba Seuqcevadia mas axasiaTebs mkveTri retrokolisi da opistotonusi mkveTrad gamoxatuli ldquotvinismieri kivilirdquo apnoe cxeleba sakvebis autanloba Rrma stupori komamde zogjer krunCxvebi da sikvdili
kerniqterusi (AMERICAN ACADEMY OF PEDIATRICS 2004)Bmwvave bilirubinuli encefalopaTiis Semdeg gadarCenil
axalSobils sicocxlis pirveli wlis manZilze uviTardeba bilirubinuli encefalopaTiis mZime qronikuli forma romelic 3 ZiriTadi gamovlinebiT xasiaTdeba
motoruli darRvevebi - aTetoiduri cerebluri dambla tremori qorea
mxedvelobis darRvevebi smeniTi disfunqcia inteleqtualuri darRvevebi SedarebiT iSviaTia damatebiT SeiZleba
ganviTardes kbilis emalis hipoplazia kerniqterusis dros 70-Si aRiniSneba nevrologiuri darRvevebi da
10-Si sikvdiloba
diferenciuli diagnoziaxalSobilTa siyviTlis dros unda ganisazRvros siyviTle
fiziologiuria Tu paTologiuri
fiziologiuri siyviTle paTologiuri siyviTle
vlindeba ara uadres 2 dRisa da qreba me-10-14 dRisTvis
vlindeba pirvel 24 saaTSi an7 dRis Semdeg
gavrceleba ar aRemateba krameris 1-3 zonebs
gavrceleba krameris nebismieri zona sicocxlis I dRes 4 zona sicocxlis II dRes da 5 zona nebismier asakSi
bavSvi aqtiuria temperatura normaluria wovis refleqsi kargia
zogadi mdgomareoba damakmayofilebeli an darRveuli
Sardis da ganavlis feri ar icvleba
SeiZleba iyos Sardis da ganavlis feris cvlileba
RviZli da elenTa ar aris gadidebuli
SeiZleba iyos hepatosplenomegalia
dedis rZiT ganpirobebuli siyviTlis sadiagnostikod (samkurnalod) SeiZleba Semdegi maCveneblebis gamoyeneba
bull dedis rZiT ganpirobebuli siyviTle vlindeba me-4-14 dRes
bull 24-48sT-is ganmavlobaSi ZuZuTi kvebis Sewyveta da alternatiul sakvebis miwodeba iwvevs bilirubinis donis daqveiTdebas
6
axalSobilTa hiperbilirubinemiis difdiagnozi ix algormiTi 1
gamokvlevis sqema
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004) tkb daan Ssb unda ganesazRvros yvela axalSobils
romelsac siyviTle gamouvlinda sicocxlis pirvel 24sT-Si (ix algoriTmi I da cxrili 3 ) (rekomendacia C)
tkb daan Ssb ganmeorebiTi gansazRvris dro da saWiroeba damokidebulia bilirubinis doneze (sqema 2) axalSobilis asakze hiperbilirubinemiis dinamikaze rekomendaciebi Ssb gansazRvrisaTvis dabadebidan 24 sT-is Semdeg mowodebulia I algoriTmsa da cxrilSi 3
tkb daan Ssb unda ganesazRvros yvela axalSobils romelsac gamouvlinda asakTan Seusabamo mkveTri siyviTle (rekomendacia D)
bilirubinis donis Sefaseba unda moxdes axalSobilis asakis (saaTebSi) gaTvaliswinebiT (sqema 2) (rekomendacia
C) Tu axalSobils utardeba fotoTerapia an aReniSneba
bilirubinis swrafi mateba (sqema 2 ndash butanis sqemaze monacemi kveTs percentilebs) rac ar aixsneba obieqturi gamokvleviT da anamnezuri monacemebiT saWiroa siyviTlis SesaZlo mizezebis dadgena (rekomendacia D)
axalSobilebs romelTac aReniSnebaT pirdapiri (koniugirebuli) bilirubinis mateba unda CautardeT Sardis saerTo da baqteriologiuri gamokvleva damatebiTi laboratoriuli gamokvlevebi unda Catardes Tu anamneziT da obieqturi gamokvelevebiT saeWvoa sefsisi (rekomendacia
C) avadmyof axalSobilebsa da Cvilebs romelTac aReniSnebaT
siyviTle 3 kviris an ufro mogvianebiT asakSi unda ganesazRvroT saerTo da pirdapiri (koniugirebuli) bilirubini qolestazis sadiagnostikod (cxrili 3) (rekomendacia D) aseT axalSobilebTan mizanSewonilia skriningi hipoTireozsa da galaqtozemiaze (rekomendacia D)
Tu pirdapiri an koniugirebuli bilirubinis done momatebulia rekomendirebulia damatebiTi gamokvlevebi qolestazis sadiagnostikod (rekomendacia C)
glukoza-6-fosfat dehidrogenazas donis gansazRvra saWiroa im axalSobilebTan romelTa ojaxuri anamnezi an eTnikuri an geografiuli warmoSoba miuTiTebs g6fd-s deficitze da utardebaT fotoTerapia daan axalSobilebTan Tu fotoTerapia uefeqtoa (sqema 3) (rekomendacia C)
7
C
D
C
D
C
C
C
D
D
cxrili 3 35 da meti gestaciuri asakis axalSobilSi gamovlenili siyviTlis laboratoriuli Sefaseba (AMERICAN ACADEMY OF PEDIATRICS 2004)
Cveneba laboratoriuli kvlevapirvel 24 sT-Si gamovlenili siyviTle
bull tkb daan Ssb gansazRvra
asakisaTvis Seusabamo mkveTri siyviTle kanze G
bull tkb daan Ssb gansazRvra
axalSobils utardeba fotoTerapia an aReniSneba bilirubinis swrafi mateba (sqema 2 ndash butanis sqemaze maCvenebeli kveTs percentilebs) rac ar aixsneba obieqturi gamokvleviT da anamnezuri monacemebiT
bull sisxlis jgufi da rezusi kumbsis testi Tu ar aris gakeTebuli Wiplaris sisxlSi
bull sisxlis saerTo analizi da nacxi formiani elementebis morfologiis Sesaswavlad
bull pirdapiri (koniugirebuli) bilirubinis gansazRvra
bull Tu SesaZlebelia isazRvreba retikulocitebis ricxvi g6fd
bull Ssb ganmeorebiT isazRvreba 4-24 sT-Si axalSobilis asakisa da Ssb donis Sesabamisad
fotoTerapia uSedegoa an Ssb aRwevs dones romelzec naCvenebia SenacvlebiTi transfuzia
bull Tu SesaZlebelia isazRvreba retikulocitebis ricxvi g6fd
momatebulia pirdapiri (koniugirebuli) bilirubinis done
bull Sardis anlizi
bull Sardis kultura
bull gamokvleva sefsisze Tu misi arseboba saeWvoa anamneziT an obieqturi gamokvleviT
siyviTle sami kviris asakis an avadmyof axalSobilSi
bull saerTo da pirdapiri (koniugirebuli) bilirubini
bull pirdapiri bilirubinis momatebisas tardeba kvleva qolestazis sadiagnostikod
bull skriningi hipoTireozsa da galaqtozemiaze
bull axalSobilis Sefaseba hipoTireozis simptomebis gamosavlenad
sqema 1 butanis nomograma
8
butanis nomograma saSualebas iZleva ganisazRvros ramdenad maRalia mZime hiperbilirubinemiis ganviTarebis riski axalSobilis asakis (saaTebSi) da Sratis bilirubinis koncentraciis gaTvaliswinebiT bilirubinis gansazRvra
bilirubini isazRvreba transkutanurad da sisxlis SratSi transkutanuri gansazRvra gamarTlebulia rogorc skriningis
meTodi is isazRvreba specialuri aparatiT aRniSnuli xelsawyos gamoyenebiT bilirubinis gansazRvra SesaZloa 2-3 mgdl (34-54micromolL) variabelobiT bevr SemTxvevaSi xdeba Sratis bilirubinis gansazRvris Canacvleba transkutanuri gansazRvriT gansakuTrebiT maSin roca Ssb lt 15 mgdl (257 micromolL)
fotoTerapiis dros kanis vizualuri SefasebasTan erTad aucilebelia Sratis bilirubinis gansazRvra radgan fotoTerapia ldquoaTeTrebsrdquo kans (American Academy of Pediatrics 2004)
pirveladi profilaqtika
rekomendacia (American Academy of Pediatrics 2004) bull eqimma unda urCios dedas ganaxorcielos moTxovnilebiTi ZuZuTi kveba dReSi 8-12-jer (rekomendacia C) - arasrulyofili kaloriebis miRebam daan dehidrataciam SeiZleba gamoiwvios Hhiperbilirubinemiis ganviTareba
bull ZuZuTi kvebis SemTxevaSi Tu axalSobils ar aReniSneba dehidratacia ar aris rekomedirebuli wylisa da deqstrozis rutinulad damateba (rekomendacia B da C) -
9
C
B
C
wylis da deqstrozis damateba ar axdens hiperbilirubinemiis ganviTarebis profilaqtikasa da Ssb-s Semcirebas
bull yvela Rh (D) negatiur orsuls an melogines mizanSewonilia Cautardes anti D imonoglobuliniT profilaqtika (rekomendacia A)
minus orsulobis 28 kviraze (garda im SemTxvevebisa rodesac bavSvis mamac Rh (D) negatiuria)
minus mSobiarobidan 72 sT-is gamnavlobaSi Tu axalSobili Rh (D) pozituiria
minus orsulobis pirvel trimestrSi ganviTarebuli abortis da invaziuri procedurebis dros rogorica amniocentezi nayofis invaziuri procedurebi
meoradi profilaqtikarekomendacia klinicistma unda moaxdinos axalSobilTa hiperbilirubinemiis ganviTarebis riskebis sistemuri Sefaseba neonatalur periodSi (rekomendacia B)(AMERICAN ACADEMY OF PEDIATRICS 2004)
sisxlis jgufobriobarekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
yvela orsuli qali unda iyos gamokvleuli ABO da Rh(D) sisxlis jgufebze da hqondes Catarebuli skriningi SratSi izoimunur antisxeulebze (rekomendacia B)
Tu dedas ar Cautarebia prenatalurad sisxlis jgufis da rezusis gamokvleva an igis Rh negatiuria mkacrad aris rekomendirebuli pirdapiri antisxeulebis testis (an kumbsis testi) sisxlis jgufis da Rh (D) tipis gansazRvra axalSobilis (Wiplaris) sisxlSi (rekomendacia B)
Tu dedas sixlis jgufi aris O Rh(D) pozitiuri axalSobilis sisxlis jgufis da pirdapiri antisxeulis testis gansazRvris aucilebloba damokidebulia meTvalyureobis xarisxze gaweris win riskis Sefasebasa da gaweris Semdeg meTvalyureobaze (rekomendacia C)
mkurnalobis sqemamkurnalobis ZiriTadi principebia
fotoTerapia SenacvlebiTi transfuzia
mkurnaloba iwyeba fotoTerapiiTfotoTerapiis dros kanis zeda SreebSi Calagebuli arapirdapiri bilirubini iSleba fotoqimiuri gziT wyalSi xsnad koniugatebad romlebic gamoiyofa SardiT da naRveliTrekomendacia yvela samSobiaro saxli unda iyos aRWurvili mowyobilobiT romelic saWiroa intensiuri fotoTerapiisaTvis (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)fotoTerapiis Cvenebebi
fotoTerapia iwyeba Tu bulirubinis done aRemateba 95 percentils butanis nomogramaze (sqema 1) amave dros metad mniSvnelovania risk-faqtorebis gaTvaliswineba romlebic xels uwyobs mZime
10
A
B
B
B
C
D
hiperbiliruminemias (hemolizuri daavadeba g6fd deficiti asfiqsia mkveTrad gamoxatuli leTargia temperaturis arastabiluroba sefsisi acidozi an hipoalbuminemia lt30 gdl)
amerikis pediatriuli akademiis rekomendaciiT gamoiyeneba sqema (sqema 2) romelic axalSobilis asaksa da bilirubinis donesTan erTad iTvaliswinebs risk-faqtorebsa da gestaciur asaks mocemuli sqemis mixedviT ldquointensiurirdquo fotoTerapia iwyeba Semdegi principebiT
dabali riskis axalSobili (janmrTeli risk-faqtorebis gareSe gestacia gt 38 kvira) ndash Ssb gt12 mgdl (205 micromolL) 24 sT-Si Ssb gt15 mgdl (257 micromolL) 48 sT-Si Ssb gt18 mgdl (308 micromolL) gt72 sT
saSualo riskis axalSobili (gestacia gt 38 kvira da risk-faqtorebi an gestacia 35-37 kvira risk-faqtorebis gareSe gareSe) ndash Ssb gt 10 mgdl (171 micromolL) 24 sT-Si Ssb gt13 mgdl (222 micromolL) 48 sT-Si Ssb gt15 mgdl (257 micromolL) gt72 sT gestaciis 35 kviris axalSobilebSi fotoTerapia SeiZleba daiwyos ufro dabal maCveneblebze
maRali riskis axalSobili (gestacia 35-37 kvira da risk-faqtorebi) - Ssb gt 8 mgdl (137 micromolL) 24 sT-Si Ssb gt11 mgdl (188 micromolL) 48 sT-Si Ssb gt135 mgdl (231 micromolL) gt72 sT
Tu dabali riskis axalSobilebSi Ssb done 2-3 mgdl-iT dabalia moyvanil monacemebze SesaZlebelia mkurnalobis dawyeba ldquoCveulebrivirdquo fotoTerapiiT
bull stacionarSi gamoxatuli siyviTliT Semosul axalSobils utardeba ldquointensiurirdquo fotoTerapia bilirubinis maCveneblis gansazRvramde
bull ldquointensiurirdquo fotoTerapia aseve rekomendebulia hemolizuri daavadebis dros
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
janmos rekomendacia fotoTerapiis dawyebis Cvenebebis Sesaxeb mocemulia cxrilSi 4
cxrili 4 fotoTerapiis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI gamoxatuli siyviTleII 15 260 13 220III 18 310 16 270
IV da meti 20 340 17 290janmos rekomendaciiT fotoTerapia iwyeba Tu siyviTlis
lokalizaciis mixedviT siyviTlis simZimis Sefasebisas (cxrili 1) dadginda ldquosaSiSi siyviTlerdquo
Tu ar aris bilirubinis gansazRvris saSualeba Ssb savaraudo donis dasadgenaT SeiZleba krameris modificirebuli sqemis gamoyeneba
11
sqema 2 fotoTerapiis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (AMERICAN ACADEMY OF PEDIATRICS 2004)
rekomendacia Tu Sratis albuminis maCvenebeli naklebia 30 gdl-ze fotoTerapiis dawyeba rekomendebulis ufro dabali maCveneblebis dros (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis ukuCveneba pirdapiri (koniugirebuli) hiperbilirubinemia (pirdapiri
bilirubini Ssb-s 50-ze metia) (American Family Practice Notebook 2002 ) (AMERICAN ACADEMY OF PEDIATRICS 2004)
Tandayolili porfiria an porfiriis ojaxuri anamnezi (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis teqnikafotoTerapiis efeqturoba damokidebulia dozaze fotoTerapiis doza anu speqtruli iradiacia damokidebulia naTuris simZlavreze sinaTlis wyarosa da bavSvs Soris manZilsa da dasxivebis farTobze sinaTlis wyarofotoTerapiis sinaTlis speqtri damokidebulia sinaTlis wyaroze da filtrze yvelaze farTod gavrcelebuli fotoTerapiis mowyobiloba Seicavs dRis Suqis gril TeTr cisfer an ldquospecialur cisferrdquo fluorescentul naTurebs manZils sinaTlis wyarodan axalSobilamde didi mniSvneloba eniWeba sasurvelia axalSobili moTavsdes sinaTlis wyarodan im minimalur manZilze romelic miTiTebulia fotoTerapiis mowyobilobis instruqciaSi halogenis fotoTerapiis naTurebi ar SeiZleba moTavsdes axalSobilTan axlos radgan SeiZleba gamoiwvios damwvroba
12
DD
sxeulis zedapiris farTobibilirubinis maRali Semcvelobisas mniSvnelovania fotoTerapiis dros dasxivdes sxeulis zedapiris rac SeiZleba meti farTobi
ldquoCveulebrivi fotoTerapiardquo - sinaTlis speqtris iradiacia dabalia (6-12 microWcm2nm) (talRis sigrZe daaxloebiT 425-475 nm) da damokidebulia sxvadasxva mwarmoeblis mier mowodebul fotoTerapiiis sistemis aparatis monacemebze saWiroa aparatis Semowmeba Seesabameba Tu ara sinaTlis speqtris iradiacia mwarmoeblis mier mowodebul monacemebsldquointensiuri fotoTerapiardquo - lurj-mwvane speqtris iradiacia (talRis
sigrZe daaxloebiT 430-490 nm) sul cota 30 microWcm2nm-ia (isazRvreba axalSobilis kanze fototerapiis aparatis centris qveS) gazomva xdeba im warmoebis radiometriT romelic mowodebulia fotoTerapiiis sistemis aparatis mwarmoeblis mier sinaTlis talRis asareklad TeTreuli unda iyos TeTri kuvezi da sawolis gverdebi daifaros TeTri qsoviliT an aluminis folgiT
fotoTerapiis procedura da monitoringi
temperatura sinaTlis wyaros qveS unda iyos 28-300C
fotoTerapiis dros bavSvi unda iyos SiSveli ecvas erTjeradi higienuri safeni Tvalebze unda hqondes damcavi saTvale
yovel 3 saaTSi erTxel bavSvs unda Seucvalon pozicia
yovel 3 saaTSi erTxel unda Sefasdes sinaTlis wyaros qveS arsebuli temperatura da axalSobilis sxeulis temperatura Tu bavSvis t metia metia 3750C saWiroa oTaxis temperaturis daqveiTeba an fotoTerapiis droebiT Sewyveta sanam bavSvis temperatura ar iqneba normis farglebSi (365-3750C)
fotoTerapia mimdinareobas mudmivad igi wydeba mxolod im procedurebis dros romelTa warmoeba ra SeiZleba sinaTlis wyaros qveS
centraluri cianozis arsebobis Sesafaseblad fotoTerapia unda Sewydes mcire droiT
fotoTerapiis dros unda gagrZeldes bavSvis kveba
rArraxalSobilTan unda gagrZeldes ZuZuTi kveba moTxovnilebis mixedviT (intervali kvebaTa Soris araumetes 3 sT-isa) (rekomendacia C) ZuZuTi kvebis dros wydeba fotoTerapia da Sesabamisad bavSvs unda moexsnas damcavi saTvale
rArrTu bavSvi ikvebeba gamowvelili rZiT formuliT an parenteralurad misawodebeli sakvebis an siTxis raodenoba izrdeba dRiuri normis 10 -iT
rArr Tu bavSvi ikvebeba zondiT an parenteralurad fotoTerapia mimdinareobs uwyvetad
rArrCveulebriv fotoTerapiis dros axalSobils ar esaWiroeba damatebiT siTxis an sakvebis miwodeba damateba naCvenebia mxolod araefeqturi ZuZuTi kvebis sxeulis masis paTologiuri danakargis (gt10-ze mesame dRisTvis) da dehidrataciis SemTxvevaSi
13
C
fotoTerapiis dros bilirubinis daSlis produqtebi gamoiyofa SardiT da naRveliT adeqvaturi hidrataciis SenarCuneba da Sesabamisad adekvaturi diurzis SenarCuneba zrdis fotoTerapiis efeqturobas
zogierT axalSobils hiperbilirubinemiiT aReniSneba dehidratacia da saWiroa damatebiTi siTxis miwodeba (per-os an intravenurad) dehidrataciis koreqciisaTvis
araefeqturi ZuZuTi kvebis SemTxvevaSi fotoTerapiis dros axalSobils damatebiT miewodeba gamowvelili dedis rZe donoris rZe an xelovnuri sakvebi
rArr adeqvatur kvebaze miuTiTebs 4-6 sveli safeni 24 sT-Si da nawlavTa moqmedeba 3-4 jerdReSi meoTxe dRisaTvis
janmrTeli drouli axalSobilis nawlavTa moqmedeba da diurezi (minimaluri maCveneblebi) cxrili 5 (Fetus and Newborn Committee 1999)
dRe nawlavTa minimaluri moqmedeba24sT
sveli safeni24sT
1 1 12 1 23 1 gardamavali 34 2 yviTeli fafisebri 45 2YyviTeli fafisebri 5-6
rArrdehidrataciaze miuTiTebs Semdegi niSnebis arseboba - masis paTologiuri kleba (gt10-ze mesame dRisTvis)- anuria 4-6 sT- Cacvenili Tvalebi- Cavardnili yoflibandi - - daqveiTebuli kanis elastiuroba (kanis naoWi swordeba
nela)- daqveiTebuli kanis kapilaruli avseba (gt3 wm)- taqikardia- Sratis Na gt145 HCO3 lt17
bilirubinis monitoringi fotoTerapiis dros (American Aacademy of Pediatrics 2004)
sawyisi bilirubinis maCveneblis Semcireba 6-20-iT standartuli da 30-40-iT intensiuri fotoTerapiis dawyebidan 24sT-Si mis efeqturobaze miuTiTebs
bull Tu Ssb ge 25 mgdL (428 micromolL) ganmeorebiTi gansazRvra 2ndash3 sT-Si
bull Tu Ssb 20ndash25 mgdL (342ndash428 micromolL) ganmeorebiTi gansazRvra 3-4 sT-Si
bull Tu Ssb lt20 mgdL (342 micromolL) ganmeorebiTi gansazRvra 4ndash6 sT-Si Tu Ssb agrZelebs daqveiTebas ganmeorebiTi gansazRvra 8-12 sT-Si
bull Tu Ssb ar mcirdeba an uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones an Ssb albuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6) iwyeba SenacvlebiTi transfuzia Tu amis saSualeba aris an xorcieldeba referali
bull intensiur fotoTerapiis miuxedavad Ssb-is ucvleli done an mateba miuTiTebs hemolizze
14
rArr anemiahemolizis Sefaseba SesaZlebelia sisxlis saerTo analizis mixedviT - Hgblt 130 glLHct lt 40 retikulocitebi - gt 6
bull Ssb lt 13ndash14 mgdL (239 micromolL) fotoTerapia wydeba
bull fotoTerapiis Sewyvetidan 24 sT-Si kontroldeba Ssb Tu Ssb moimata im donemde romelzec daiwyo fotoTerapia fotoTerapia ganmeorebiT iwyeba
fotoTerapiis garTulebebi
fotoTerapiis garTulebebi (Ronald J Wong 2005 American Aacademy of Pediatrics 2004)
rArrmwvane feris ganavalidiarea (mkurnalobas ar saWiroebs)
rArr dehidratacia
rArr muclis Seberva (mkurnalobas ar saWiroebs)
rArr Tvalis SesaZlo dazianeba yvelaze seriozuli magram iSviaTi klinikuri garTulebaa brinjaos
axalSobilis sindromi romelic vlindeba qolestazuri siyviTlis mqone axalSobilSi kanis Sratis da Sardis muqi nacrisfer-yavisferi SeferilobiT brinjaos axalSobilis sindromi ar vlindeba qolestazis mqone yvela axalSobilTan Tu arsebobs fotoTerapiis Cveneba pirdapiri hiperbilirubinemia ar warmoadgens fotoTerapiis winaaRmdeg Cvenebas axalSobilebSi romelTac uviTardebaT brinjaos sindromi naCvenebia SenacvlebiTi transfuzia monacemebis arasrulyofilebis gamo mkacri rekomendaciis gakeTeba ar SeiZleba
mZime qolestazuri siyviTlis mqone axalSobilebSi fotoTerapiis dros aseve SeiZleba ganviTardes
rArr purpura
rArr bulozuri gamonayari
mzis ultraiisferi sxivebiT TerapiamarTalia mzis sxivebs gaaCniaT mniSvnelovani iradiacia 425-475 nm magram radganac maRalia axalSobilis damwvrobis ganviTarebis riski (SiSveli axalSobilis mzeze yofnis gamo) es meTodi rekomendebuli ar aris
(Ronald J Wong 2005 (American Aacademy of Pediatrics 2004)
intravenuri imunoglobulinis gamoyenebarekomendacia izoimunuri hemolizuri daavadebis dros rekomendebulia intravenuri imunoglobulinis gamoyeneba (05-1 gkg 2 sT-s ganmavlobaSi) Tu Ssb imatebs intensiuri fotoTerapiis miuxedavad an Ssb aris 2-3 mgdl-iT (34-51mkmoll) naklebi SenacvlebiTi transfuziis Cvenebis doneze (fighellip4) aucilebelobis SemTxvevaSi intravenuri imunoglobulinis es doza SeiZleba ganmeordes 12 sT-Si (rekomendacia B) American Aacademy of Pediatrics 2004)
15
fotoTerapiis dros kanSi Calagebuli bilirubini swrafad iSleba amitom ar aris rekomendebuli kanis ferze dayrdnobiT SratSi
bilirubinis donis Sesafaseba rogorc fotoTerapiis dros ise misi Sewyvetidan 24 sT-is ganmavlobaSi
B
kvlevebiT dadgenilia rom intravenuri imunoglobulini amcirebs SenacvlebiTi transfuziis saWiroebas Rh da ABO hemolizuri daavadebis dros
SenacvlebiTi transfuzia
SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleluli unda iyos Semowmebuli da dasxivebuli gadasasxmeli sisxlis raodenoba Seadgens 170-180 mlkg
rekomendacia SenacvlebiTi transfuzia unda Caataros mxolod gamocdilma samedicino personalma intensiuri Terapiis ganyofilebaSi monitoringisa da srulyofili reanimaciis SesaZleblobis pirobebSi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
SenacvlebiTi transfuziis Cvenebebi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
mwvave bilirubinuli encefalopaTia intensiuri fotoTerapiis miuxedavad Ssb mateba an ucvleli
monacemi samSobiarodan gawerili axalSobilebis hospitalizaciis
SemTxvevaSi Ssb-s maRali maCvenebeli - aRemateba SenacvlebiTi transfuziis dawyebis maCvenebls (sqema 3) (transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia) (ix cxrili 6)
ba Sefardeba Ssb maCvenebelTan (cxrili 6) erTad gamoiyeneba rogorc damatebiTi faqtori SenacvlebiTi transfuziis dawyebis gansasazRvravad
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
sqema 3 SenacvlebiTi transfuziis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (American Academy of Pediatrics 2004)
16
D
D
cxrili 6 bilirubinisa da albuminis Sefardeba rodesac saWiroa SenacvlebiTi transfuzia (AMERICAN ACADEMY OF PEDIATRICS 2004)
riskis kategoria
ba Sefardeba rodesac saWiroa SenacvlebiTi
transfuziaSsb mgdl alb gdl
Ssb micromolL alb micromolL
axalSobilebi gestaciuri asaki - ge38 kvira 80 094
janmrTeli axalSobilebi gestaciuri asakiT an riskis jgufis axalSobilebi
gestaciuri asakiT ge38 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
72 084
riskis jgufis axalSobilebi gestaciuri asakiT 35ndash36 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
68 080
janmos rekomendacia sisxlis SenacvlebiTi gadasxmis Cvenebebis Sesaxeb mocemulia cxrilSi 7
cxrili 7 SenacvlebiTi transfuziis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI 15 260 13 220II 25 425 15 260
17
III 30 510 20 340IV da meti 30 510 20 340
Tu Ssb uaxlovdeba im dones rodesac naCvenebia SenacvlebiTi transfuzia
sisxli dauyovnebliv igzavneba raTa dadgindes jgufi da rezusi da SeTavseba Tu klinikaSi aris transfuziis saSualeba
an xorcieldeba referali
teqnika (AMERICAN ACADEMY OF PEDIATRICS 2004
bull mwvave bilirubinuli encefalopaTiis dros SenacvlebiTi transfuzia iwyeba dauyovnebliv
bull sxva SemTxvevaSi transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia
bull SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleuli unda iyos Semowmebuli da dasxivebuli
bull gadasasxmeli sisxlis raodenoba Seadgens axalSobilis mocirkulire sisxlis ormag raodenobas saSualod 170-180 mlkg an gadasasxmeli sisxlis gamosaTvleli formula gamoiTvleba 85 x axalSobilis wona kg x 2
bull SenacvlebisaTvis xdeba 2 venis an arteria da venis kaTeterizacia iReben bavSvis 20 ml sisxls da SeyavT 20 ml donoris sisxli (3-4 wT-is ganmavlobaSi) SemTbaris 367-3700C-mde
bull dRenaklulebsa da mZime mdgomareobaSi myof axalSobilebSi Senacvleba xdeba 5-10 ml-iT
axalSobilis momzadeba
bull kuWis SigTavsis aspiracia zondiT 8F da Ria zondis datoveba kuWSibull SeiZleba saWiro gaxdes bavSvis dabma
bull SeiZleba sawovaras gamoyeneba
bull Sardis Semkrebis gamoyeneba diurezis kontrolisTvisaxlSobilis winaswar Sefaseba
bull temperatura
bull guliscema
bull sunTqva
bull wneva
bull glukoza SratSi
bull Sardis analizi
bull ganavlis analizi sisxlis Semcvelobaze
bull kanis feri
bull tonusi
bull qcevauSualod transfuziis dros fasdeba vitaluri niSnebi (yovel 15 wT-Si)
18
bull temperatura
bull guliscema (mwvervalze) (umjobesia kardiomonitoriT)
bull sunTqva
bull kanis feri
bull qceva
monitoringi transfuziis Semdeg bull grZeldeba fotoTerapia
bull kardio monitoringi
bull sisxlis wneva proceduris damTavrebis Semdeg
bull saaTobrivad 6 sT-is ganmavlobaSi temperatura guliscema (mwvervalze) sunTqva
bull glukoza SratSi yovel 3 sT-Si 24 sT-is ganmavlobaSi
bull muclis garSemoweriloba 3-4 sT-Si 24 sT-is ganmavlobaSi nawlavebis peristaltikis auskultacia
bull Sardis analizi
bull ganavali sisxlis Semcvelobaze
bull sakvebis autanlobis niSnebi Rebineba muclis Seberva
bull Ssb 6 sT-Si erTxel
SenacvlebiTi transfuziis riskisikvdiloba - 3 SemTxveva 1000 transfuziaze SenacvlebiTi transfuziis dros garTulebis saxiT 5-Si vlindeba
- apnoe bradikardia cianozi vazospazmi Trombozi nekrozuli enterokoliti aseve SeiZleba ganviTardes hipoqsiur-iSemiuri encefalopaTia da SeZenili imunodeficitis sindromi
sxva mkurnalobafenobarbitali ndash xels uwyobs bilirubinis koniugacias da amcirebs
Ssb dones ar arsebobs sakmarisi mtkicebulebebi fenobarbitalis gamosayeneblad rodesac arsebobs siyviTlis mkurnalobis ufro efeqturi meTodebi (mag fotoTerapia)
referali AMERICAN ACADEMY OF PEDIATRICS 2004)referali maRali donis klinikaSi xorcieldeba Tu
ar aris fotoTerapiis Catarebis SesaZlebloba fotoTerapiis miuxedavad
rArr Ssb ar mcirdeba
rArr Ssb uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones da ar aris transfuziis saSualeba
rArr Ssbalbuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6)
Tu siyviTle gamovlinda I dRes siyviTlis lokalizaciis mixedviT siyviTlis simZimis Sefasebisas
(cxrili 1) dadgenili ldquosaSiSi siyviTlerdquo
bilirubinis maRali namati 85 micromolLsT (gt05 mgdlsT)
gaxangrZlivebuli siyviTle (14 dRe da meti) ojaxur anamnezSi mZime siyviTlis an kerniqterusis arseboba siyviTlis dros sxva daavadebis niSnebis arseboba (mg sefsisi)
19
riskis Sefaseba gaweramde
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
bull yvela axalSobilis gaweramde unda Sefasdes hiperbilirubinemiis ganviTarebis riski yvela ganyofilebas unda hqondes protokoli siyviTlis SefasebisTvis aseTi Sefaseba gansakuTrebiT mniSvnelovania im axalSobilebisaTvis romlebis ewerebian dabadebidan 72 sT-ze adre (rekomendacia C)
bull amerikis pediatrTa akademiis rekomendaciiT riskis SefasebisaTvis gamoyenebuli unda iqnas 2 midgoma (calcalke an kombinaciaSi) gaweris win bilirubinis gansazRvra (Ssb an tkb) daan klinikuri risk-faqtorebis Sefaseba risk-faqtorebis arseboba an Ssb maRali maCveneblebi gaweris Semdeg Sesabamisi meTvalyureobis aucilebelobis Cvenebaa (rekomendacia C)
bull yvela samSobiarom unda miawodos mSobels zepiri daan werilobiTi informacia binaze siyviTlis Sefasebis da saSiSroebis niSnebis Sesaxeb (rekomendacia D)
meTvalyureoba
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)bull yvela axalSobili samSobiarodan gaweriis Semdeg ramdenime dReSi unda Sefasdes kvalificuri samedicino profesionalis mier (rekomendacia C)
bull fasdeba - siyviTlis arseboba axalSobilis wona kvebis efeqturoba Rebinebis arseboba (rekomendacia C)
bull meTvalyureobis grafiki Tu axalSobili samSobiarodan ewereba 48-72 sT-Si samedicino Sefaseba tardeba 120 sT-is (5 dRe) asakSi (rekomendacia C)
bull Tu samSobiarodan gaweris Semdeg meTvalyureoba SeuZlebelia da arsebobs hiperbilirubinemiis ganviTarebis risk-faqtorebi axalSobilis gawera unda gadaidos sanam ar iqneba uzrunvelyofili Sesabamisi meTvalyureoba an sanam gaivlis maRali riskis periodi (72-96sT) (rekomendacia D)
11 gaidlainis gadasinjvisa da ganaxlebis vada ndash 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlainis SemuSavebis meTodologia
bull axalSobilTa hiperbilirubinemiis prevenciis diagnostikisa da marTvis principebis Sesaxeb arsebobs samecniero mtkicebulebis safuZvelze Seqmnil rekomendaciaTa sakmarisi raodenoba mocemuli gaidlainis Semqmnis procesSi samuSao jgufis gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve arsebuli praqtikuli rekomendaciebi moxda arsebuli
20
C
C
C
C
D
C
D
rekomendaciebis adaptirebuli variantis SemuSaveba romelic erTis mxriv pasuxebs saerTaSoriso moTxovnebs xolo meore mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa rogorc adamianur ise teqnikur resursebs
bull rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa bazis gamoyenebiT
cxrili 2
qveyana da resursis dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
httpwwwguidelinegov
Centers for Disease Control and Prevention (CDC)
httpwwwphppocdcgovCDCRecommendsAdvSearchVasp
Agency for Healthcare Research and Quality (AHRQ)
httpwwwahrqgovcliniccpgsixhtm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
httphstatnlmnihgov
Institute of Clinical Systems Improvement (ICSI)
httpwwwicsiorg
American Medical Association httpwwwama-assnorg
Canadian Medical Association (CMA)
httpmdmcacpgsnewcpgsindexasp
Health Canada ndash Population and Public Health Branch (PPHB)
httpwwwhc-scgccapphb-dgspspdpg_ehtml
didi britaneTi
National Institute for Clinical Excellence (NICE)
httpwwwniceorguk
Sheffield Evidence for Effectiveness and Knowledge (SEEK)
httpwwwshefacukseekguidelineshtm
National electronic Library for Health (NeLH)
httpwwwnelhnhsukguidelinesfinder
PRODIGY Clinical Guidance httpwwwprodigynhsukClinicalGuidance
Scottish Intercollegiate Guidelines Network (SIGN)
httpwwwsignacuk
German Guideline Information Service (GERGIS)
httpwwwleitliniendeenglishenglishview
avstralia
Australian National Health and httpwwwhealthgovauhfsnhmrcpublicatcp-
21
Medical Research Council (NHMRC) homehtmaxali zelandia
New Zealand Guidelines Group (NZGG)
httpwwwnzggorgnzlibrarycfm
mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba
httpwwwosdmorg
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi
bull koxreinis biblioTeka - The Cochrane Library 2006 Issue 2 bull amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini ndash MEDLINEbull jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvisgamoricxvis kriteriumebi
bull arCeul iqna kvlevebi Semdegi dizainiT randomizebuli kontrolirebadi sistemuri mimoxilvebi da meta-analizi erTmomentiani kohortuli kvlevebi
bull rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12 wliani SezRudva Tumca zogjer gamoyenebuli iyo ufro adreuli publikaciebi romlebic dResac aqtualuria da safuZvlad udevs sxva Tanamedrove mtkicebulebebs
bull dadgenili iyo enobrivi SezRudvebi radganac samuSao jgufs SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod inglisur da rusul enebze
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
bull samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri meToduri rekomendacia axalSobilTa hiperbilirubinemiis marTvis sakiTxebze romlebic Seicavda jgufis miznis Sesaferis saWiro informacias am rekomendaciebis Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (9496-98) samuSao jgufi xelmZRvanelobda saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mier SemuSavebuli nacionaluri gaidlainebis gzamkvleviT Sefasebis Sedegad amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi
rArr amerikis pediatrTa akademia
rArr msoflo jandacvis organizacia
rArr kanadis pediatrTa sazogadoeba ndash nayofi da axalSobilis komiteti
rArr britaneTis reproduqciuli janmrTelobis programa
22
bull rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da rekomendaciebis xarisxis sqema
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris
done (Muir Gray)xarisxi rekomendaciis xarisxi
(Cook et al)I Zlieri mtkicebuleba
eyrdnoba minimum erT sistemur mimoxilvas
romelic efuZneba swori dizainis mqone randomizebul
kontrolirebad kvleva
A eyrdnoba I donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erTi swori dizainis mqone
randomizebul kontrolirebad kvleva
B eyrdnoba II donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
III klinikuri kvleva randomizaciis gareSe
kohortuli da SemTxveva-kontrolis kvlevebi
C eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi
D eyrdnoba IV da V donis mtkicebulebas saWiroebs
konsesuss
Va avtoritetul profesionalTa mosazreba
Vb klinikuri gamocdileba aRwerilobiTi kvlevebi an
eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
15 avtorTa jgufi
bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis
bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi
rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
23
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24
1 adreuli faza vlindeba ramdenime dReSi da axasiaTebs leTargia hipotonia susti wova da sustad gamoxatuli ldquotvinismieri kivilirdquo
2 gardamavali stadia viTardeba kviris bolos da axasiTebs zomieri stupori agznebadoba da hipertonia axalSobils SeiZleba aReniSnos cxeleba mkveTrad gamoxatuli ldquotvinismieri kivilirdquo hipertonia vlindeba kisris (retrokolisi) da sxeulis (opistotonusi) ukan rkaliseburad gadaxriT
3 bolo stadia vlindeba 1 kviris Semdeg am dros centraluri nervuli sistemis dazianeba Seuqcevadia mas axasiaTebs mkveTri retrokolisi da opistotonusi mkveTrad gamoxatuli ldquotvinismieri kivilirdquo apnoe cxeleba sakvebis autanloba Rrma stupori komamde zogjer krunCxvebi da sikvdili
kerniqterusi (AMERICAN ACADEMY OF PEDIATRICS 2004)Bmwvave bilirubinuli encefalopaTiis Semdeg gadarCenil
axalSobils sicocxlis pirveli wlis manZilze uviTardeba bilirubinuli encefalopaTiis mZime qronikuli forma romelic 3 ZiriTadi gamovlinebiT xasiaTdeba
motoruli darRvevebi - aTetoiduri cerebluri dambla tremori qorea
mxedvelobis darRvevebi smeniTi disfunqcia inteleqtualuri darRvevebi SedarebiT iSviaTia damatebiT SeiZleba
ganviTardes kbilis emalis hipoplazia kerniqterusis dros 70-Si aRiniSneba nevrologiuri darRvevebi da
10-Si sikvdiloba
diferenciuli diagnoziaxalSobilTa siyviTlis dros unda ganisazRvros siyviTle
fiziologiuria Tu paTologiuri
fiziologiuri siyviTle paTologiuri siyviTle
vlindeba ara uadres 2 dRisa da qreba me-10-14 dRisTvis
vlindeba pirvel 24 saaTSi an7 dRis Semdeg
gavrceleba ar aRemateba krameris 1-3 zonebs
gavrceleba krameris nebismieri zona sicocxlis I dRes 4 zona sicocxlis II dRes da 5 zona nebismier asakSi
bavSvi aqtiuria temperatura normaluria wovis refleqsi kargia
zogadi mdgomareoba damakmayofilebeli an darRveuli
Sardis da ganavlis feri ar icvleba
SeiZleba iyos Sardis da ganavlis feris cvlileba
RviZli da elenTa ar aris gadidebuli
SeiZleba iyos hepatosplenomegalia
dedis rZiT ganpirobebuli siyviTlis sadiagnostikod (samkurnalod) SeiZleba Semdegi maCveneblebis gamoyeneba
bull dedis rZiT ganpirobebuli siyviTle vlindeba me-4-14 dRes
bull 24-48sT-is ganmavlobaSi ZuZuTi kvebis Sewyveta da alternatiul sakvebis miwodeba iwvevs bilirubinis donis daqveiTdebas
6
axalSobilTa hiperbilirubinemiis difdiagnozi ix algormiTi 1
gamokvlevis sqema
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004) tkb daan Ssb unda ganesazRvros yvela axalSobils
romelsac siyviTle gamouvlinda sicocxlis pirvel 24sT-Si (ix algoriTmi I da cxrili 3 ) (rekomendacia C)
tkb daan Ssb ganmeorebiTi gansazRvris dro da saWiroeba damokidebulia bilirubinis doneze (sqema 2) axalSobilis asakze hiperbilirubinemiis dinamikaze rekomendaciebi Ssb gansazRvrisaTvis dabadebidan 24 sT-is Semdeg mowodebulia I algoriTmsa da cxrilSi 3
tkb daan Ssb unda ganesazRvros yvela axalSobils romelsac gamouvlinda asakTan Seusabamo mkveTri siyviTle (rekomendacia D)
bilirubinis donis Sefaseba unda moxdes axalSobilis asakis (saaTebSi) gaTvaliswinebiT (sqema 2) (rekomendacia
C) Tu axalSobils utardeba fotoTerapia an aReniSneba
bilirubinis swrafi mateba (sqema 2 ndash butanis sqemaze monacemi kveTs percentilebs) rac ar aixsneba obieqturi gamokvleviT da anamnezuri monacemebiT saWiroa siyviTlis SesaZlo mizezebis dadgena (rekomendacia D)
axalSobilebs romelTac aReniSnebaT pirdapiri (koniugirebuli) bilirubinis mateba unda CautardeT Sardis saerTo da baqteriologiuri gamokvleva damatebiTi laboratoriuli gamokvlevebi unda Catardes Tu anamneziT da obieqturi gamokvelevebiT saeWvoa sefsisi (rekomendacia
C) avadmyof axalSobilebsa da Cvilebs romelTac aReniSnebaT
siyviTle 3 kviris an ufro mogvianebiT asakSi unda ganesazRvroT saerTo da pirdapiri (koniugirebuli) bilirubini qolestazis sadiagnostikod (cxrili 3) (rekomendacia D) aseT axalSobilebTan mizanSewonilia skriningi hipoTireozsa da galaqtozemiaze (rekomendacia D)
Tu pirdapiri an koniugirebuli bilirubinis done momatebulia rekomendirebulia damatebiTi gamokvlevebi qolestazis sadiagnostikod (rekomendacia C)
glukoza-6-fosfat dehidrogenazas donis gansazRvra saWiroa im axalSobilebTan romelTa ojaxuri anamnezi an eTnikuri an geografiuli warmoSoba miuTiTebs g6fd-s deficitze da utardebaT fotoTerapia daan axalSobilebTan Tu fotoTerapia uefeqtoa (sqema 3) (rekomendacia C)
7
C
D
C
D
C
C
C
D
D
cxrili 3 35 da meti gestaciuri asakis axalSobilSi gamovlenili siyviTlis laboratoriuli Sefaseba (AMERICAN ACADEMY OF PEDIATRICS 2004)
Cveneba laboratoriuli kvlevapirvel 24 sT-Si gamovlenili siyviTle
bull tkb daan Ssb gansazRvra
asakisaTvis Seusabamo mkveTri siyviTle kanze G
bull tkb daan Ssb gansazRvra
axalSobils utardeba fotoTerapia an aReniSneba bilirubinis swrafi mateba (sqema 2 ndash butanis sqemaze maCvenebeli kveTs percentilebs) rac ar aixsneba obieqturi gamokvleviT da anamnezuri monacemebiT
bull sisxlis jgufi da rezusi kumbsis testi Tu ar aris gakeTebuli Wiplaris sisxlSi
bull sisxlis saerTo analizi da nacxi formiani elementebis morfologiis Sesaswavlad
bull pirdapiri (koniugirebuli) bilirubinis gansazRvra
bull Tu SesaZlebelia isazRvreba retikulocitebis ricxvi g6fd
bull Ssb ganmeorebiT isazRvreba 4-24 sT-Si axalSobilis asakisa da Ssb donis Sesabamisad
fotoTerapia uSedegoa an Ssb aRwevs dones romelzec naCvenebia SenacvlebiTi transfuzia
bull Tu SesaZlebelia isazRvreba retikulocitebis ricxvi g6fd
momatebulia pirdapiri (koniugirebuli) bilirubinis done
bull Sardis anlizi
bull Sardis kultura
bull gamokvleva sefsisze Tu misi arseboba saeWvoa anamneziT an obieqturi gamokvleviT
siyviTle sami kviris asakis an avadmyof axalSobilSi
bull saerTo da pirdapiri (koniugirebuli) bilirubini
bull pirdapiri bilirubinis momatebisas tardeba kvleva qolestazis sadiagnostikod
bull skriningi hipoTireozsa da galaqtozemiaze
bull axalSobilis Sefaseba hipoTireozis simptomebis gamosavlenad
sqema 1 butanis nomograma
8
butanis nomograma saSualebas iZleva ganisazRvros ramdenad maRalia mZime hiperbilirubinemiis ganviTarebis riski axalSobilis asakis (saaTebSi) da Sratis bilirubinis koncentraciis gaTvaliswinebiT bilirubinis gansazRvra
bilirubini isazRvreba transkutanurad da sisxlis SratSi transkutanuri gansazRvra gamarTlebulia rogorc skriningis
meTodi is isazRvreba specialuri aparatiT aRniSnuli xelsawyos gamoyenebiT bilirubinis gansazRvra SesaZloa 2-3 mgdl (34-54micromolL) variabelobiT bevr SemTxvevaSi xdeba Sratis bilirubinis gansazRvris Canacvleba transkutanuri gansazRvriT gansakuTrebiT maSin roca Ssb lt 15 mgdl (257 micromolL)
fotoTerapiis dros kanis vizualuri SefasebasTan erTad aucilebelia Sratis bilirubinis gansazRvra radgan fotoTerapia ldquoaTeTrebsrdquo kans (American Academy of Pediatrics 2004)
pirveladi profilaqtika
rekomendacia (American Academy of Pediatrics 2004) bull eqimma unda urCios dedas ganaxorcielos moTxovnilebiTi ZuZuTi kveba dReSi 8-12-jer (rekomendacia C) - arasrulyofili kaloriebis miRebam daan dehidrataciam SeiZleba gamoiwvios Hhiperbilirubinemiis ganviTareba
bull ZuZuTi kvebis SemTxevaSi Tu axalSobils ar aReniSneba dehidratacia ar aris rekomedirebuli wylisa da deqstrozis rutinulad damateba (rekomendacia B da C) -
9
C
B
C
wylis da deqstrozis damateba ar axdens hiperbilirubinemiis ganviTarebis profilaqtikasa da Ssb-s Semcirebas
bull yvela Rh (D) negatiur orsuls an melogines mizanSewonilia Cautardes anti D imonoglobuliniT profilaqtika (rekomendacia A)
minus orsulobis 28 kviraze (garda im SemTxvevebisa rodesac bavSvis mamac Rh (D) negatiuria)
minus mSobiarobidan 72 sT-is gamnavlobaSi Tu axalSobili Rh (D) pozituiria
minus orsulobis pirvel trimestrSi ganviTarebuli abortis da invaziuri procedurebis dros rogorica amniocentezi nayofis invaziuri procedurebi
meoradi profilaqtikarekomendacia klinicistma unda moaxdinos axalSobilTa hiperbilirubinemiis ganviTarebis riskebis sistemuri Sefaseba neonatalur periodSi (rekomendacia B)(AMERICAN ACADEMY OF PEDIATRICS 2004)
sisxlis jgufobriobarekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
yvela orsuli qali unda iyos gamokvleuli ABO da Rh(D) sisxlis jgufebze da hqondes Catarebuli skriningi SratSi izoimunur antisxeulebze (rekomendacia B)
Tu dedas ar Cautarebia prenatalurad sisxlis jgufis da rezusis gamokvleva an igis Rh negatiuria mkacrad aris rekomendirebuli pirdapiri antisxeulebis testis (an kumbsis testi) sisxlis jgufis da Rh (D) tipis gansazRvra axalSobilis (Wiplaris) sisxlSi (rekomendacia B)
Tu dedas sixlis jgufi aris O Rh(D) pozitiuri axalSobilis sisxlis jgufis da pirdapiri antisxeulis testis gansazRvris aucilebloba damokidebulia meTvalyureobis xarisxze gaweris win riskis Sefasebasa da gaweris Semdeg meTvalyureobaze (rekomendacia C)
mkurnalobis sqemamkurnalobis ZiriTadi principebia
fotoTerapia SenacvlebiTi transfuzia
mkurnaloba iwyeba fotoTerapiiTfotoTerapiis dros kanis zeda SreebSi Calagebuli arapirdapiri bilirubini iSleba fotoqimiuri gziT wyalSi xsnad koniugatebad romlebic gamoiyofa SardiT da naRveliTrekomendacia yvela samSobiaro saxli unda iyos aRWurvili mowyobilobiT romelic saWiroa intensiuri fotoTerapiisaTvis (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)fotoTerapiis Cvenebebi
fotoTerapia iwyeba Tu bulirubinis done aRemateba 95 percentils butanis nomogramaze (sqema 1) amave dros metad mniSvnelovania risk-faqtorebis gaTvaliswineba romlebic xels uwyobs mZime
10
A
B
B
B
C
D
hiperbiliruminemias (hemolizuri daavadeba g6fd deficiti asfiqsia mkveTrad gamoxatuli leTargia temperaturis arastabiluroba sefsisi acidozi an hipoalbuminemia lt30 gdl)
amerikis pediatriuli akademiis rekomendaciiT gamoiyeneba sqema (sqema 2) romelic axalSobilis asaksa da bilirubinis donesTan erTad iTvaliswinebs risk-faqtorebsa da gestaciur asaks mocemuli sqemis mixedviT ldquointensiurirdquo fotoTerapia iwyeba Semdegi principebiT
dabali riskis axalSobili (janmrTeli risk-faqtorebis gareSe gestacia gt 38 kvira) ndash Ssb gt12 mgdl (205 micromolL) 24 sT-Si Ssb gt15 mgdl (257 micromolL) 48 sT-Si Ssb gt18 mgdl (308 micromolL) gt72 sT
saSualo riskis axalSobili (gestacia gt 38 kvira da risk-faqtorebi an gestacia 35-37 kvira risk-faqtorebis gareSe gareSe) ndash Ssb gt 10 mgdl (171 micromolL) 24 sT-Si Ssb gt13 mgdl (222 micromolL) 48 sT-Si Ssb gt15 mgdl (257 micromolL) gt72 sT gestaciis 35 kviris axalSobilebSi fotoTerapia SeiZleba daiwyos ufro dabal maCveneblebze
maRali riskis axalSobili (gestacia 35-37 kvira da risk-faqtorebi) - Ssb gt 8 mgdl (137 micromolL) 24 sT-Si Ssb gt11 mgdl (188 micromolL) 48 sT-Si Ssb gt135 mgdl (231 micromolL) gt72 sT
Tu dabali riskis axalSobilebSi Ssb done 2-3 mgdl-iT dabalia moyvanil monacemebze SesaZlebelia mkurnalobis dawyeba ldquoCveulebrivirdquo fotoTerapiiT
bull stacionarSi gamoxatuli siyviTliT Semosul axalSobils utardeba ldquointensiurirdquo fotoTerapia bilirubinis maCveneblis gansazRvramde
bull ldquointensiurirdquo fotoTerapia aseve rekomendebulia hemolizuri daavadebis dros
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
janmos rekomendacia fotoTerapiis dawyebis Cvenebebis Sesaxeb mocemulia cxrilSi 4
cxrili 4 fotoTerapiis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI gamoxatuli siyviTleII 15 260 13 220III 18 310 16 270
IV da meti 20 340 17 290janmos rekomendaciiT fotoTerapia iwyeba Tu siyviTlis
lokalizaciis mixedviT siyviTlis simZimis Sefasebisas (cxrili 1) dadginda ldquosaSiSi siyviTlerdquo
Tu ar aris bilirubinis gansazRvris saSualeba Ssb savaraudo donis dasadgenaT SeiZleba krameris modificirebuli sqemis gamoyeneba
11
sqema 2 fotoTerapiis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (AMERICAN ACADEMY OF PEDIATRICS 2004)
rekomendacia Tu Sratis albuminis maCvenebeli naklebia 30 gdl-ze fotoTerapiis dawyeba rekomendebulis ufro dabali maCveneblebis dros (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis ukuCveneba pirdapiri (koniugirebuli) hiperbilirubinemia (pirdapiri
bilirubini Ssb-s 50-ze metia) (American Family Practice Notebook 2002 ) (AMERICAN ACADEMY OF PEDIATRICS 2004)
Tandayolili porfiria an porfiriis ojaxuri anamnezi (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis teqnikafotoTerapiis efeqturoba damokidebulia dozaze fotoTerapiis doza anu speqtruli iradiacia damokidebulia naTuris simZlavreze sinaTlis wyarosa da bavSvs Soris manZilsa da dasxivebis farTobze sinaTlis wyarofotoTerapiis sinaTlis speqtri damokidebulia sinaTlis wyaroze da filtrze yvelaze farTod gavrcelebuli fotoTerapiis mowyobiloba Seicavs dRis Suqis gril TeTr cisfer an ldquospecialur cisferrdquo fluorescentul naTurebs manZils sinaTlis wyarodan axalSobilamde didi mniSvneloba eniWeba sasurvelia axalSobili moTavsdes sinaTlis wyarodan im minimalur manZilze romelic miTiTebulia fotoTerapiis mowyobilobis instruqciaSi halogenis fotoTerapiis naTurebi ar SeiZleba moTavsdes axalSobilTan axlos radgan SeiZleba gamoiwvios damwvroba
12
DD
sxeulis zedapiris farTobibilirubinis maRali Semcvelobisas mniSvnelovania fotoTerapiis dros dasxivdes sxeulis zedapiris rac SeiZleba meti farTobi
ldquoCveulebrivi fotoTerapiardquo - sinaTlis speqtris iradiacia dabalia (6-12 microWcm2nm) (talRis sigrZe daaxloebiT 425-475 nm) da damokidebulia sxvadasxva mwarmoeblis mier mowodebul fotoTerapiiis sistemis aparatis monacemebze saWiroa aparatis Semowmeba Seesabameba Tu ara sinaTlis speqtris iradiacia mwarmoeblis mier mowodebul monacemebsldquointensiuri fotoTerapiardquo - lurj-mwvane speqtris iradiacia (talRis
sigrZe daaxloebiT 430-490 nm) sul cota 30 microWcm2nm-ia (isazRvreba axalSobilis kanze fototerapiis aparatis centris qveS) gazomva xdeba im warmoebis radiometriT romelic mowodebulia fotoTerapiiis sistemis aparatis mwarmoeblis mier sinaTlis talRis asareklad TeTreuli unda iyos TeTri kuvezi da sawolis gverdebi daifaros TeTri qsoviliT an aluminis folgiT
fotoTerapiis procedura da monitoringi
temperatura sinaTlis wyaros qveS unda iyos 28-300C
fotoTerapiis dros bavSvi unda iyos SiSveli ecvas erTjeradi higienuri safeni Tvalebze unda hqondes damcavi saTvale
yovel 3 saaTSi erTxel bavSvs unda Seucvalon pozicia
yovel 3 saaTSi erTxel unda Sefasdes sinaTlis wyaros qveS arsebuli temperatura da axalSobilis sxeulis temperatura Tu bavSvis t metia metia 3750C saWiroa oTaxis temperaturis daqveiTeba an fotoTerapiis droebiT Sewyveta sanam bavSvis temperatura ar iqneba normis farglebSi (365-3750C)
fotoTerapia mimdinareobas mudmivad igi wydeba mxolod im procedurebis dros romelTa warmoeba ra SeiZleba sinaTlis wyaros qveS
centraluri cianozis arsebobis Sesafaseblad fotoTerapia unda Sewydes mcire droiT
fotoTerapiis dros unda gagrZeldes bavSvis kveba
rArraxalSobilTan unda gagrZeldes ZuZuTi kveba moTxovnilebis mixedviT (intervali kvebaTa Soris araumetes 3 sT-isa) (rekomendacia C) ZuZuTi kvebis dros wydeba fotoTerapia da Sesabamisad bavSvs unda moexsnas damcavi saTvale
rArrTu bavSvi ikvebeba gamowvelili rZiT formuliT an parenteralurad misawodebeli sakvebis an siTxis raodenoba izrdeba dRiuri normis 10 -iT
rArr Tu bavSvi ikvebeba zondiT an parenteralurad fotoTerapia mimdinareobs uwyvetad
rArrCveulebriv fotoTerapiis dros axalSobils ar esaWiroeba damatebiT siTxis an sakvebis miwodeba damateba naCvenebia mxolod araefeqturi ZuZuTi kvebis sxeulis masis paTologiuri danakargis (gt10-ze mesame dRisTvis) da dehidrataciis SemTxvevaSi
13
C
fotoTerapiis dros bilirubinis daSlis produqtebi gamoiyofa SardiT da naRveliT adeqvaturi hidrataciis SenarCuneba da Sesabamisad adekvaturi diurzis SenarCuneba zrdis fotoTerapiis efeqturobas
zogierT axalSobils hiperbilirubinemiiT aReniSneba dehidratacia da saWiroa damatebiTi siTxis miwodeba (per-os an intravenurad) dehidrataciis koreqciisaTvis
araefeqturi ZuZuTi kvebis SemTxvevaSi fotoTerapiis dros axalSobils damatebiT miewodeba gamowvelili dedis rZe donoris rZe an xelovnuri sakvebi
rArr adeqvatur kvebaze miuTiTebs 4-6 sveli safeni 24 sT-Si da nawlavTa moqmedeba 3-4 jerdReSi meoTxe dRisaTvis
janmrTeli drouli axalSobilis nawlavTa moqmedeba da diurezi (minimaluri maCveneblebi) cxrili 5 (Fetus and Newborn Committee 1999)
dRe nawlavTa minimaluri moqmedeba24sT
sveli safeni24sT
1 1 12 1 23 1 gardamavali 34 2 yviTeli fafisebri 45 2YyviTeli fafisebri 5-6
rArrdehidrataciaze miuTiTebs Semdegi niSnebis arseboba - masis paTologiuri kleba (gt10-ze mesame dRisTvis)- anuria 4-6 sT- Cacvenili Tvalebi- Cavardnili yoflibandi - - daqveiTebuli kanis elastiuroba (kanis naoWi swordeba
nela)- daqveiTebuli kanis kapilaruli avseba (gt3 wm)- taqikardia- Sratis Na gt145 HCO3 lt17
bilirubinis monitoringi fotoTerapiis dros (American Aacademy of Pediatrics 2004)
sawyisi bilirubinis maCveneblis Semcireba 6-20-iT standartuli da 30-40-iT intensiuri fotoTerapiis dawyebidan 24sT-Si mis efeqturobaze miuTiTebs
bull Tu Ssb ge 25 mgdL (428 micromolL) ganmeorebiTi gansazRvra 2ndash3 sT-Si
bull Tu Ssb 20ndash25 mgdL (342ndash428 micromolL) ganmeorebiTi gansazRvra 3-4 sT-Si
bull Tu Ssb lt20 mgdL (342 micromolL) ganmeorebiTi gansazRvra 4ndash6 sT-Si Tu Ssb agrZelebs daqveiTebas ganmeorebiTi gansazRvra 8-12 sT-Si
bull Tu Ssb ar mcirdeba an uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones an Ssb albuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6) iwyeba SenacvlebiTi transfuzia Tu amis saSualeba aris an xorcieldeba referali
bull intensiur fotoTerapiis miuxedavad Ssb-is ucvleli done an mateba miuTiTebs hemolizze
14
rArr anemiahemolizis Sefaseba SesaZlebelia sisxlis saerTo analizis mixedviT - Hgblt 130 glLHct lt 40 retikulocitebi - gt 6
bull Ssb lt 13ndash14 mgdL (239 micromolL) fotoTerapia wydeba
bull fotoTerapiis Sewyvetidan 24 sT-Si kontroldeba Ssb Tu Ssb moimata im donemde romelzec daiwyo fotoTerapia fotoTerapia ganmeorebiT iwyeba
fotoTerapiis garTulebebi
fotoTerapiis garTulebebi (Ronald J Wong 2005 American Aacademy of Pediatrics 2004)
rArrmwvane feris ganavalidiarea (mkurnalobas ar saWiroebs)
rArr dehidratacia
rArr muclis Seberva (mkurnalobas ar saWiroebs)
rArr Tvalis SesaZlo dazianeba yvelaze seriozuli magram iSviaTi klinikuri garTulebaa brinjaos
axalSobilis sindromi romelic vlindeba qolestazuri siyviTlis mqone axalSobilSi kanis Sratis da Sardis muqi nacrisfer-yavisferi SeferilobiT brinjaos axalSobilis sindromi ar vlindeba qolestazis mqone yvela axalSobilTan Tu arsebobs fotoTerapiis Cveneba pirdapiri hiperbilirubinemia ar warmoadgens fotoTerapiis winaaRmdeg Cvenebas axalSobilebSi romelTac uviTardebaT brinjaos sindromi naCvenebia SenacvlebiTi transfuzia monacemebis arasrulyofilebis gamo mkacri rekomendaciis gakeTeba ar SeiZleba
mZime qolestazuri siyviTlis mqone axalSobilebSi fotoTerapiis dros aseve SeiZleba ganviTardes
rArr purpura
rArr bulozuri gamonayari
mzis ultraiisferi sxivebiT TerapiamarTalia mzis sxivebs gaaCniaT mniSvnelovani iradiacia 425-475 nm magram radganac maRalia axalSobilis damwvrobis ganviTarebis riski (SiSveli axalSobilis mzeze yofnis gamo) es meTodi rekomendebuli ar aris
(Ronald J Wong 2005 (American Aacademy of Pediatrics 2004)
intravenuri imunoglobulinis gamoyenebarekomendacia izoimunuri hemolizuri daavadebis dros rekomendebulia intravenuri imunoglobulinis gamoyeneba (05-1 gkg 2 sT-s ganmavlobaSi) Tu Ssb imatebs intensiuri fotoTerapiis miuxedavad an Ssb aris 2-3 mgdl-iT (34-51mkmoll) naklebi SenacvlebiTi transfuziis Cvenebis doneze (fighellip4) aucilebelobis SemTxvevaSi intravenuri imunoglobulinis es doza SeiZleba ganmeordes 12 sT-Si (rekomendacia B) American Aacademy of Pediatrics 2004)
15
fotoTerapiis dros kanSi Calagebuli bilirubini swrafad iSleba amitom ar aris rekomendebuli kanis ferze dayrdnobiT SratSi
bilirubinis donis Sesafaseba rogorc fotoTerapiis dros ise misi Sewyvetidan 24 sT-is ganmavlobaSi
B
kvlevebiT dadgenilia rom intravenuri imunoglobulini amcirebs SenacvlebiTi transfuziis saWiroebas Rh da ABO hemolizuri daavadebis dros
SenacvlebiTi transfuzia
SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleluli unda iyos Semowmebuli da dasxivebuli gadasasxmeli sisxlis raodenoba Seadgens 170-180 mlkg
rekomendacia SenacvlebiTi transfuzia unda Caataros mxolod gamocdilma samedicino personalma intensiuri Terapiis ganyofilebaSi monitoringisa da srulyofili reanimaciis SesaZleblobis pirobebSi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
SenacvlebiTi transfuziis Cvenebebi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
mwvave bilirubinuli encefalopaTia intensiuri fotoTerapiis miuxedavad Ssb mateba an ucvleli
monacemi samSobiarodan gawerili axalSobilebis hospitalizaciis
SemTxvevaSi Ssb-s maRali maCvenebeli - aRemateba SenacvlebiTi transfuziis dawyebis maCvenebls (sqema 3) (transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia) (ix cxrili 6)
ba Sefardeba Ssb maCvenebelTan (cxrili 6) erTad gamoiyeneba rogorc damatebiTi faqtori SenacvlebiTi transfuziis dawyebis gansasazRvravad
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
sqema 3 SenacvlebiTi transfuziis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (American Academy of Pediatrics 2004)
16
D
D
cxrili 6 bilirubinisa da albuminis Sefardeba rodesac saWiroa SenacvlebiTi transfuzia (AMERICAN ACADEMY OF PEDIATRICS 2004)
riskis kategoria
ba Sefardeba rodesac saWiroa SenacvlebiTi
transfuziaSsb mgdl alb gdl
Ssb micromolL alb micromolL
axalSobilebi gestaciuri asaki - ge38 kvira 80 094
janmrTeli axalSobilebi gestaciuri asakiT an riskis jgufis axalSobilebi
gestaciuri asakiT ge38 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
72 084
riskis jgufis axalSobilebi gestaciuri asakiT 35ndash36 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
68 080
janmos rekomendacia sisxlis SenacvlebiTi gadasxmis Cvenebebis Sesaxeb mocemulia cxrilSi 7
cxrili 7 SenacvlebiTi transfuziis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI 15 260 13 220II 25 425 15 260
17
III 30 510 20 340IV da meti 30 510 20 340
Tu Ssb uaxlovdeba im dones rodesac naCvenebia SenacvlebiTi transfuzia
sisxli dauyovnebliv igzavneba raTa dadgindes jgufi da rezusi da SeTavseba Tu klinikaSi aris transfuziis saSualeba
an xorcieldeba referali
teqnika (AMERICAN ACADEMY OF PEDIATRICS 2004
bull mwvave bilirubinuli encefalopaTiis dros SenacvlebiTi transfuzia iwyeba dauyovnebliv
bull sxva SemTxvevaSi transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia
bull SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleuli unda iyos Semowmebuli da dasxivebuli
bull gadasasxmeli sisxlis raodenoba Seadgens axalSobilis mocirkulire sisxlis ormag raodenobas saSualod 170-180 mlkg an gadasasxmeli sisxlis gamosaTvleli formula gamoiTvleba 85 x axalSobilis wona kg x 2
bull SenacvlebisaTvis xdeba 2 venis an arteria da venis kaTeterizacia iReben bavSvis 20 ml sisxls da SeyavT 20 ml donoris sisxli (3-4 wT-is ganmavlobaSi) SemTbaris 367-3700C-mde
bull dRenaklulebsa da mZime mdgomareobaSi myof axalSobilebSi Senacvleba xdeba 5-10 ml-iT
axalSobilis momzadeba
bull kuWis SigTavsis aspiracia zondiT 8F da Ria zondis datoveba kuWSibull SeiZleba saWiro gaxdes bavSvis dabma
bull SeiZleba sawovaras gamoyeneba
bull Sardis Semkrebis gamoyeneba diurezis kontrolisTvisaxlSobilis winaswar Sefaseba
bull temperatura
bull guliscema
bull sunTqva
bull wneva
bull glukoza SratSi
bull Sardis analizi
bull ganavlis analizi sisxlis Semcvelobaze
bull kanis feri
bull tonusi
bull qcevauSualod transfuziis dros fasdeba vitaluri niSnebi (yovel 15 wT-Si)
18
bull temperatura
bull guliscema (mwvervalze) (umjobesia kardiomonitoriT)
bull sunTqva
bull kanis feri
bull qceva
monitoringi transfuziis Semdeg bull grZeldeba fotoTerapia
bull kardio monitoringi
bull sisxlis wneva proceduris damTavrebis Semdeg
bull saaTobrivad 6 sT-is ganmavlobaSi temperatura guliscema (mwvervalze) sunTqva
bull glukoza SratSi yovel 3 sT-Si 24 sT-is ganmavlobaSi
bull muclis garSemoweriloba 3-4 sT-Si 24 sT-is ganmavlobaSi nawlavebis peristaltikis auskultacia
bull Sardis analizi
bull ganavali sisxlis Semcvelobaze
bull sakvebis autanlobis niSnebi Rebineba muclis Seberva
bull Ssb 6 sT-Si erTxel
SenacvlebiTi transfuziis riskisikvdiloba - 3 SemTxveva 1000 transfuziaze SenacvlebiTi transfuziis dros garTulebis saxiT 5-Si vlindeba
- apnoe bradikardia cianozi vazospazmi Trombozi nekrozuli enterokoliti aseve SeiZleba ganviTardes hipoqsiur-iSemiuri encefalopaTia da SeZenili imunodeficitis sindromi
sxva mkurnalobafenobarbitali ndash xels uwyobs bilirubinis koniugacias da amcirebs
Ssb dones ar arsebobs sakmarisi mtkicebulebebi fenobarbitalis gamosayeneblad rodesac arsebobs siyviTlis mkurnalobis ufro efeqturi meTodebi (mag fotoTerapia)
referali AMERICAN ACADEMY OF PEDIATRICS 2004)referali maRali donis klinikaSi xorcieldeba Tu
ar aris fotoTerapiis Catarebis SesaZlebloba fotoTerapiis miuxedavad
rArr Ssb ar mcirdeba
rArr Ssb uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones da ar aris transfuziis saSualeba
rArr Ssbalbuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6)
Tu siyviTle gamovlinda I dRes siyviTlis lokalizaciis mixedviT siyviTlis simZimis Sefasebisas
(cxrili 1) dadgenili ldquosaSiSi siyviTlerdquo
bilirubinis maRali namati 85 micromolLsT (gt05 mgdlsT)
gaxangrZlivebuli siyviTle (14 dRe da meti) ojaxur anamnezSi mZime siyviTlis an kerniqterusis arseboba siyviTlis dros sxva daavadebis niSnebis arseboba (mg sefsisi)
19
riskis Sefaseba gaweramde
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
bull yvela axalSobilis gaweramde unda Sefasdes hiperbilirubinemiis ganviTarebis riski yvela ganyofilebas unda hqondes protokoli siyviTlis SefasebisTvis aseTi Sefaseba gansakuTrebiT mniSvnelovania im axalSobilebisaTvis romlebis ewerebian dabadebidan 72 sT-ze adre (rekomendacia C)
bull amerikis pediatrTa akademiis rekomendaciiT riskis SefasebisaTvis gamoyenebuli unda iqnas 2 midgoma (calcalke an kombinaciaSi) gaweris win bilirubinis gansazRvra (Ssb an tkb) daan klinikuri risk-faqtorebis Sefaseba risk-faqtorebis arseboba an Ssb maRali maCveneblebi gaweris Semdeg Sesabamisi meTvalyureobis aucilebelobis Cvenebaa (rekomendacia C)
bull yvela samSobiarom unda miawodos mSobels zepiri daan werilobiTi informacia binaze siyviTlis Sefasebis da saSiSroebis niSnebis Sesaxeb (rekomendacia D)
meTvalyureoba
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)bull yvela axalSobili samSobiarodan gaweriis Semdeg ramdenime dReSi unda Sefasdes kvalificuri samedicino profesionalis mier (rekomendacia C)
bull fasdeba - siyviTlis arseboba axalSobilis wona kvebis efeqturoba Rebinebis arseboba (rekomendacia C)
bull meTvalyureobis grafiki Tu axalSobili samSobiarodan ewereba 48-72 sT-Si samedicino Sefaseba tardeba 120 sT-is (5 dRe) asakSi (rekomendacia C)
bull Tu samSobiarodan gaweris Semdeg meTvalyureoba SeuZlebelia da arsebobs hiperbilirubinemiis ganviTarebis risk-faqtorebi axalSobilis gawera unda gadaidos sanam ar iqneba uzrunvelyofili Sesabamisi meTvalyureoba an sanam gaivlis maRali riskis periodi (72-96sT) (rekomendacia D)
11 gaidlainis gadasinjvisa da ganaxlebis vada ndash 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlainis SemuSavebis meTodologia
bull axalSobilTa hiperbilirubinemiis prevenciis diagnostikisa da marTvis principebis Sesaxeb arsebobs samecniero mtkicebulebis safuZvelze Seqmnil rekomendaciaTa sakmarisi raodenoba mocemuli gaidlainis Semqmnis procesSi samuSao jgufis gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve arsebuli praqtikuli rekomendaciebi moxda arsebuli
20
C
C
C
C
D
C
D
rekomendaciebis adaptirebuli variantis SemuSaveba romelic erTis mxriv pasuxebs saerTaSoriso moTxovnebs xolo meore mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa rogorc adamianur ise teqnikur resursebs
bull rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa bazis gamoyenebiT
cxrili 2
qveyana da resursis dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
httpwwwguidelinegov
Centers for Disease Control and Prevention (CDC)
httpwwwphppocdcgovCDCRecommendsAdvSearchVasp
Agency for Healthcare Research and Quality (AHRQ)
httpwwwahrqgovcliniccpgsixhtm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
httphstatnlmnihgov
Institute of Clinical Systems Improvement (ICSI)
httpwwwicsiorg
American Medical Association httpwwwama-assnorg
Canadian Medical Association (CMA)
httpmdmcacpgsnewcpgsindexasp
Health Canada ndash Population and Public Health Branch (PPHB)
httpwwwhc-scgccapphb-dgspspdpg_ehtml
didi britaneTi
National Institute for Clinical Excellence (NICE)
httpwwwniceorguk
Sheffield Evidence for Effectiveness and Knowledge (SEEK)
httpwwwshefacukseekguidelineshtm
National electronic Library for Health (NeLH)
httpwwwnelhnhsukguidelinesfinder
PRODIGY Clinical Guidance httpwwwprodigynhsukClinicalGuidance
Scottish Intercollegiate Guidelines Network (SIGN)
httpwwwsignacuk
German Guideline Information Service (GERGIS)
httpwwwleitliniendeenglishenglishview
avstralia
Australian National Health and httpwwwhealthgovauhfsnhmrcpublicatcp-
21
Medical Research Council (NHMRC) homehtmaxali zelandia
New Zealand Guidelines Group (NZGG)
httpwwwnzggorgnzlibrarycfm
mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba
httpwwwosdmorg
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi
bull koxreinis biblioTeka - The Cochrane Library 2006 Issue 2 bull amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini ndash MEDLINEbull jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvisgamoricxvis kriteriumebi
bull arCeul iqna kvlevebi Semdegi dizainiT randomizebuli kontrolirebadi sistemuri mimoxilvebi da meta-analizi erTmomentiani kohortuli kvlevebi
bull rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12 wliani SezRudva Tumca zogjer gamoyenebuli iyo ufro adreuli publikaciebi romlebic dResac aqtualuria da safuZvlad udevs sxva Tanamedrove mtkicebulebebs
bull dadgenili iyo enobrivi SezRudvebi radganac samuSao jgufs SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod inglisur da rusul enebze
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
bull samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri meToduri rekomendacia axalSobilTa hiperbilirubinemiis marTvis sakiTxebze romlebic Seicavda jgufis miznis Sesaferis saWiro informacias am rekomendaciebis Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (9496-98) samuSao jgufi xelmZRvanelobda saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mier SemuSavebuli nacionaluri gaidlainebis gzamkvleviT Sefasebis Sedegad amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi
rArr amerikis pediatrTa akademia
rArr msoflo jandacvis organizacia
rArr kanadis pediatrTa sazogadoeba ndash nayofi da axalSobilis komiteti
rArr britaneTis reproduqciuli janmrTelobis programa
22
bull rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da rekomendaciebis xarisxis sqema
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris
done (Muir Gray)xarisxi rekomendaciis xarisxi
(Cook et al)I Zlieri mtkicebuleba
eyrdnoba minimum erT sistemur mimoxilvas
romelic efuZneba swori dizainis mqone randomizebul
kontrolirebad kvleva
A eyrdnoba I donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erTi swori dizainis mqone
randomizebul kontrolirebad kvleva
B eyrdnoba II donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
III klinikuri kvleva randomizaciis gareSe
kohortuli da SemTxveva-kontrolis kvlevebi
C eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi
D eyrdnoba IV da V donis mtkicebulebas saWiroebs
konsesuss
Va avtoritetul profesionalTa mosazreba
Vb klinikuri gamocdileba aRwerilobiTi kvlevebi an
eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
15 avtorTa jgufi
bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis
bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi
rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
23
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24
axalSobilTa hiperbilirubinemiis difdiagnozi ix algormiTi 1
gamokvlevis sqema
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004) tkb daan Ssb unda ganesazRvros yvela axalSobils
romelsac siyviTle gamouvlinda sicocxlis pirvel 24sT-Si (ix algoriTmi I da cxrili 3 ) (rekomendacia C)
tkb daan Ssb ganmeorebiTi gansazRvris dro da saWiroeba damokidebulia bilirubinis doneze (sqema 2) axalSobilis asakze hiperbilirubinemiis dinamikaze rekomendaciebi Ssb gansazRvrisaTvis dabadebidan 24 sT-is Semdeg mowodebulia I algoriTmsa da cxrilSi 3
tkb daan Ssb unda ganesazRvros yvela axalSobils romelsac gamouvlinda asakTan Seusabamo mkveTri siyviTle (rekomendacia D)
bilirubinis donis Sefaseba unda moxdes axalSobilis asakis (saaTebSi) gaTvaliswinebiT (sqema 2) (rekomendacia
C) Tu axalSobils utardeba fotoTerapia an aReniSneba
bilirubinis swrafi mateba (sqema 2 ndash butanis sqemaze monacemi kveTs percentilebs) rac ar aixsneba obieqturi gamokvleviT da anamnezuri monacemebiT saWiroa siyviTlis SesaZlo mizezebis dadgena (rekomendacia D)
axalSobilebs romelTac aReniSnebaT pirdapiri (koniugirebuli) bilirubinis mateba unda CautardeT Sardis saerTo da baqteriologiuri gamokvleva damatebiTi laboratoriuli gamokvlevebi unda Catardes Tu anamneziT da obieqturi gamokvelevebiT saeWvoa sefsisi (rekomendacia
C) avadmyof axalSobilebsa da Cvilebs romelTac aReniSnebaT
siyviTle 3 kviris an ufro mogvianebiT asakSi unda ganesazRvroT saerTo da pirdapiri (koniugirebuli) bilirubini qolestazis sadiagnostikod (cxrili 3) (rekomendacia D) aseT axalSobilebTan mizanSewonilia skriningi hipoTireozsa da galaqtozemiaze (rekomendacia D)
Tu pirdapiri an koniugirebuli bilirubinis done momatebulia rekomendirebulia damatebiTi gamokvlevebi qolestazis sadiagnostikod (rekomendacia C)
glukoza-6-fosfat dehidrogenazas donis gansazRvra saWiroa im axalSobilebTan romelTa ojaxuri anamnezi an eTnikuri an geografiuli warmoSoba miuTiTebs g6fd-s deficitze da utardebaT fotoTerapia daan axalSobilebTan Tu fotoTerapia uefeqtoa (sqema 3) (rekomendacia C)
7
C
D
C
D
C
C
C
D
D
cxrili 3 35 da meti gestaciuri asakis axalSobilSi gamovlenili siyviTlis laboratoriuli Sefaseba (AMERICAN ACADEMY OF PEDIATRICS 2004)
Cveneba laboratoriuli kvlevapirvel 24 sT-Si gamovlenili siyviTle
bull tkb daan Ssb gansazRvra
asakisaTvis Seusabamo mkveTri siyviTle kanze G
bull tkb daan Ssb gansazRvra
axalSobils utardeba fotoTerapia an aReniSneba bilirubinis swrafi mateba (sqema 2 ndash butanis sqemaze maCvenebeli kveTs percentilebs) rac ar aixsneba obieqturi gamokvleviT da anamnezuri monacemebiT
bull sisxlis jgufi da rezusi kumbsis testi Tu ar aris gakeTebuli Wiplaris sisxlSi
bull sisxlis saerTo analizi da nacxi formiani elementebis morfologiis Sesaswavlad
bull pirdapiri (koniugirebuli) bilirubinis gansazRvra
bull Tu SesaZlebelia isazRvreba retikulocitebis ricxvi g6fd
bull Ssb ganmeorebiT isazRvreba 4-24 sT-Si axalSobilis asakisa da Ssb donis Sesabamisad
fotoTerapia uSedegoa an Ssb aRwevs dones romelzec naCvenebia SenacvlebiTi transfuzia
bull Tu SesaZlebelia isazRvreba retikulocitebis ricxvi g6fd
momatebulia pirdapiri (koniugirebuli) bilirubinis done
bull Sardis anlizi
bull Sardis kultura
bull gamokvleva sefsisze Tu misi arseboba saeWvoa anamneziT an obieqturi gamokvleviT
siyviTle sami kviris asakis an avadmyof axalSobilSi
bull saerTo da pirdapiri (koniugirebuli) bilirubini
bull pirdapiri bilirubinis momatebisas tardeba kvleva qolestazis sadiagnostikod
bull skriningi hipoTireozsa da galaqtozemiaze
bull axalSobilis Sefaseba hipoTireozis simptomebis gamosavlenad
sqema 1 butanis nomograma
8
butanis nomograma saSualebas iZleva ganisazRvros ramdenad maRalia mZime hiperbilirubinemiis ganviTarebis riski axalSobilis asakis (saaTebSi) da Sratis bilirubinis koncentraciis gaTvaliswinebiT bilirubinis gansazRvra
bilirubini isazRvreba transkutanurad da sisxlis SratSi transkutanuri gansazRvra gamarTlebulia rogorc skriningis
meTodi is isazRvreba specialuri aparatiT aRniSnuli xelsawyos gamoyenebiT bilirubinis gansazRvra SesaZloa 2-3 mgdl (34-54micromolL) variabelobiT bevr SemTxvevaSi xdeba Sratis bilirubinis gansazRvris Canacvleba transkutanuri gansazRvriT gansakuTrebiT maSin roca Ssb lt 15 mgdl (257 micromolL)
fotoTerapiis dros kanis vizualuri SefasebasTan erTad aucilebelia Sratis bilirubinis gansazRvra radgan fotoTerapia ldquoaTeTrebsrdquo kans (American Academy of Pediatrics 2004)
pirveladi profilaqtika
rekomendacia (American Academy of Pediatrics 2004) bull eqimma unda urCios dedas ganaxorcielos moTxovnilebiTi ZuZuTi kveba dReSi 8-12-jer (rekomendacia C) - arasrulyofili kaloriebis miRebam daan dehidrataciam SeiZleba gamoiwvios Hhiperbilirubinemiis ganviTareba
bull ZuZuTi kvebis SemTxevaSi Tu axalSobils ar aReniSneba dehidratacia ar aris rekomedirebuli wylisa da deqstrozis rutinulad damateba (rekomendacia B da C) -
9
C
B
C
wylis da deqstrozis damateba ar axdens hiperbilirubinemiis ganviTarebis profilaqtikasa da Ssb-s Semcirebas
bull yvela Rh (D) negatiur orsuls an melogines mizanSewonilia Cautardes anti D imonoglobuliniT profilaqtika (rekomendacia A)
minus orsulobis 28 kviraze (garda im SemTxvevebisa rodesac bavSvis mamac Rh (D) negatiuria)
minus mSobiarobidan 72 sT-is gamnavlobaSi Tu axalSobili Rh (D) pozituiria
minus orsulobis pirvel trimestrSi ganviTarebuli abortis da invaziuri procedurebis dros rogorica amniocentezi nayofis invaziuri procedurebi
meoradi profilaqtikarekomendacia klinicistma unda moaxdinos axalSobilTa hiperbilirubinemiis ganviTarebis riskebis sistemuri Sefaseba neonatalur periodSi (rekomendacia B)(AMERICAN ACADEMY OF PEDIATRICS 2004)
sisxlis jgufobriobarekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
yvela orsuli qali unda iyos gamokvleuli ABO da Rh(D) sisxlis jgufebze da hqondes Catarebuli skriningi SratSi izoimunur antisxeulebze (rekomendacia B)
Tu dedas ar Cautarebia prenatalurad sisxlis jgufis da rezusis gamokvleva an igis Rh negatiuria mkacrad aris rekomendirebuli pirdapiri antisxeulebis testis (an kumbsis testi) sisxlis jgufis da Rh (D) tipis gansazRvra axalSobilis (Wiplaris) sisxlSi (rekomendacia B)
Tu dedas sixlis jgufi aris O Rh(D) pozitiuri axalSobilis sisxlis jgufis da pirdapiri antisxeulis testis gansazRvris aucilebloba damokidebulia meTvalyureobis xarisxze gaweris win riskis Sefasebasa da gaweris Semdeg meTvalyureobaze (rekomendacia C)
mkurnalobis sqemamkurnalobis ZiriTadi principebia
fotoTerapia SenacvlebiTi transfuzia
mkurnaloba iwyeba fotoTerapiiTfotoTerapiis dros kanis zeda SreebSi Calagebuli arapirdapiri bilirubini iSleba fotoqimiuri gziT wyalSi xsnad koniugatebad romlebic gamoiyofa SardiT da naRveliTrekomendacia yvela samSobiaro saxli unda iyos aRWurvili mowyobilobiT romelic saWiroa intensiuri fotoTerapiisaTvis (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)fotoTerapiis Cvenebebi
fotoTerapia iwyeba Tu bulirubinis done aRemateba 95 percentils butanis nomogramaze (sqema 1) amave dros metad mniSvnelovania risk-faqtorebis gaTvaliswineba romlebic xels uwyobs mZime
10
A
B
B
B
C
D
hiperbiliruminemias (hemolizuri daavadeba g6fd deficiti asfiqsia mkveTrad gamoxatuli leTargia temperaturis arastabiluroba sefsisi acidozi an hipoalbuminemia lt30 gdl)
amerikis pediatriuli akademiis rekomendaciiT gamoiyeneba sqema (sqema 2) romelic axalSobilis asaksa da bilirubinis donesTan erTad iTvaliswinebs risk-faqtorebsa da gestaciur asaks mocemuli sqemis mixedviT ldquointensiurirdquo fotoTerapia iwyeba Semdegi principebiT
dabali riskis axalSobili (janmrTeli risk-faqtorebis gareSe gestacia gt 38 kvira) ndash Ssb gt12 mgdl (205 micromolL) 24 sT-Si Ssb gt15 mgdl (257 micromolL) 48 sT-Si Ssb gt18 mgdl (308 micromolL) gt72 sT
saSualo riskis axalSobili (gestacia gt 38 kvira da risk-faqtorebi an gestacia 35-37 kvira risk-faqtorebis gareSe gareSe) ndash Ssb gt 10 mgdl (171 micromolL) 24 sT-Si Ssb gt13 mgdl (222 micromolL) 48 sT-Si Ssb gt15 mgdl (257 micromolL) gt72 sT gestaciis 35 kviris axalSobilebSi fotoTerapia SeiZleba daiwyos ufro dabal maCveneblebze
maRali riskis axalSobili (gestacia 35-37 kvira da risk-faqtorebi) - Ssb gt 8 mgdl (137 micromolL) 24 sT-Si Ssb gt11 mgdl (188 micromolL) 48 sT-Si Ssb gt135 mgdl (231 micromolL) gt72 sT
Tu dabali riskis axalSobilebSi Ssb done 2-3 mgdl-iT dabalia moyvanil monacemebze SesaZlebelia mkurnalobis dawyeba ldquoCveulebrivirdquo fotoTerapiiT
bull stacionarSi gamoxatuli siyviTliT Semosul axalSobils utardeba ldquointensiurirdquo fotoTerapia bilirubinis maCveneblis gansazRvramde
bull ldquointensiurirdquo fotoTerapia aseve rekomendebulia hemolizuri daavadebis dros
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
janmos rekomendacia fotoTerapiis dawyebis Cvenebebis Sesaxeb mocemulia cxrilSi 4
cxrili 4 fotoTerapiis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI gamoxatuli siyviTleII 15 260 13 220III 18 310 16 270
IV da meti 20 340 17 290janmos rekomendaciiT fotoTerapia iwyeba Tu siyviTlis
lokalizaciis mixedviT siyviTlis simZimis Sefasebisas (cxrili 1) dadginda ldquosaSiSi siyviTlerdquo
Tu ar aris bilirubinis gansazRvris saSualeba Ssb savaraudo donis dasadgenaT SeiZleba krameris modificirebuli sqemis gamoyeneba
11
sqema 2 fotoTerapiis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (AMERICAN ACADEMY OF PEDIATRICS 2004)
rekomendacia Tu Sratis albuminis maCvenebeli naklebia 30 gdl-ze fotoTerapiis dawyeba rekomendebulis ufro dabali maCveneblebis dros (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis ukuCveneba pirdapiri (koniugirebuli) hiperbilirubinemia (pirdapiri
bilirubini Ssb-s 50-ze metia) (American Family Practice Notebook 2002 ) (AMERICAN ACADEMY OF PEDIATRICS 2004)
Tandayolili porfiria an porfiriis ojaxuri anamnezi (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis teqnikafotoTerapiis efeqturoba damokidebulia dozaze fotoTerapiis doza anu speqtruli iradiacia damokidebulia naTuris simZlavreze sinaTlis wyarosa da bavSvs Soris manZilsa da dasxivebis farTobze sinaTlis wyarofotoTerapiis sinaTlis speqtri damokidebulia sinaTlis wyaroze da filtrze yvelaze farTod gavrcelebuli fotoTerapiis mowyobiloba Seicavs dRis Suqis gril TeTr cisfer an ldquospecialur cisferrdquo fluorescentul naTurebs manZils sinaTlis wyarodan axalSobilamde didi mniSvneloba eniWeba sasurvelia axalSobili moTavsdes sinaTlis wyarodan im minimalur manZilze romelic miTiTebulia fotoTerapiis mowyobilobis instruqciaSi halogenis fotoTerapiis naTurebi ar SeiZleba moTavsdes axalSobilTan axlos radgan SeiZleba gamoiwvios damwvroba
12
DD
sxeulis zedapiris farTobibilirubinis maRali Semcvelobisas mniSvnelovania fotoTerapiis dros dasxivdes sxeulis zedapiris rac SeiZleba meti farTobi
ldquoCveulebrivi fotoTerapiardquo - sinaTlis speqtris iradiacia dabalia (6-12 microWcm2nm) (talRis sigrZe daaxloebiT 425-475 nm) da damokidebulia sxvadasxva mwarmoeblis mier mowodebul fotoTerapiiis sistemis aparatis monacemebze saWiroa aparatis Semowmeba Seesabameba Tu ara sinaTlis speqtris iradiacia mwarmoeblis mier mowodebul monacemebsldquointensiuri fotoTerapiardquo - lurj-mwvane speqtris iradiacia (talRis
sigrZe daaxloebiT 430-490 nm) sul cota 30 microWcm2nm-ia (isazRvreba axalSobilis kanze fototerapiis aparatis centris qveS) gazomva xdeba im warmoebis radiometriT romelic mowodebulia fotoTerapiiis sistemis aparatis mwarmoeblis mier sinaTlis talRis asareklad TeTreuli unda iyos TeTri kuvezi da sawolis gverdebi daifaros TeTri qsoviliT an aluminis folgiT
fotoTerapiis procedura da monitoringi
temperatura sinaTlis wyaros qveS unda iyos 28-300C
fotoTerapiis dros bavSvi unda iyos SiSveli ecvas erTjeradi higienuri safeni Tvalebze unda hqondes damcavi saTvale
yovel 3 saaTSi erTxel bavSvs unda Seucvalon pozicia
yovel 3 saaTSi erTxel unda Sefasdes sinaTlis wyaros qveS arsebuli temperatura da axalSobilis sxeulis temperatura Tu bavSvis t metia metia 3750C saWiroa oTaxis temperaturis daqveiTeba an fotoTerapiis droebiT Sewyveta sanam bavSvis temperatura ar iqneba normis farglebSi (365-3750C)
fotoTerapia mimdinareobas mudmivad igi wydeba mxolod im procedurebis dros romelTa warmoeba ra SeiZleba sinaTlis wyaros qveS
centraluri cianozis arsebobis Sesafaseblad fotoTerapia unda Sewydes mcire droiT
fotoTerapiis dros unda gagrZeldes bavSvis kveba
rArraxalSobilTan unda gagrZeldes ZuZuTi kveba moTxovnilebis mixedviT (intervali kvebaTa Soris araumetes 3 sT-isa) (rekomendacia C) ZuZuTi kvebis dros wydeba fotoTerapia da Sesabamisad bavSvs unda moexsnas damcavi saTvale
rArrTu bavSvi ikvebeba gamowvelili rZiT formuliT an parenteralurad misawodebeli sakvebis an siTxis raodenoba izrdeba dRiuri normis 10 -iT
rArr Tu bavSvi ikvebeba zondiT an parenteralurad fotoTerapia mimdinareobs uwyvetad
rArrCveulebriv fotoTerapiis dros axalSobils ar esaWiroeba damatebiT siTxis an sakvebis miwodeba damateba naCvenebia mxolod araefeqturi ZuZuTi kvebis sxeulis masis paTologiuri danakargis (gt10-ze mesame dRisTvis) da dehidrataciis SemTxvevaSi
13
C
fotoTerapiis dros bilirubinis daSlis produqtebi gamoiyofa SardiT da naRveliT adeqvaturi hidrataciis SenarCuneba da Sesabamisad adekvaturi diurzis SenarCuneba zrdis fotoTerapiis efeqturobas
zogierT axalSobils hiperbilirubinemiiT aReniSneba dehidratacia da saWiroa damatebiTi siTxis miwodeba (per-os an intravenurad) dehidrataciis koreqciisaTvis
araefeqturi ZuZuTi kvebis SemTxvevaSi fotoTerapiis dros axalSobils damatebiT miewodeba gamowvelili dedis rZe donoris rZe an xelovnuri sakvebi
rArr adeqvatur kvebaze miuTiTebs 4-6 sveli safeni 24 sT-Si da nawlavTa moqmedeba 3-4 jerdReSi meoTxe dRisaTvis
janmrTeli drouli axalSobilis nawlavTa moqmedeba da diurezi (minimaluri maCveneblebi) cxrili 5 (Fetus and Newborn Committee 1999)
dRe nawlavTa minimaluri moqmedeba24sT
sveli safeni24sT
1 1 12 1 23 1 gardamavali 34 2 yviTeli fafisebri 45 2YyviTeli fafisebri 5-6
rArrdehidrataciaze miuTiTebs Semdegi niSnebis arseboba - masis paTologiuri kleba (gt10-ze mesame dRisTvis)- anuria 4-6 sT- Cacvenili Tvalebi- Cavardnili yoflibandi - - daqveiTebuli kanis elastiuroba (kanis naoWi swordeba
nela)- daqveiTebuli kanis kapilaruli avseba (gt3 wm)- taqikardia- Sratis Na gt145 HCO3 lt17
bilirubinis monitoringi fotoTerapiis dros (American Aacademy of Pediatrics 2004)
sawyisi bilirubinis maCveneblis Semcireba 6-20-iT standartuli da 30-40-iT intensiuri fotoTerapiis dawyebidan 24sT-Si mis efeqturobaze miuTiTebs
bull Tu Ssb ge 25 mgdL (428 micromolL) ganmeorebiTi gansazRvra 2ndash3 sT-Si
bull Tu Ssb 20ndash25 mgdL (342ndash428 micromolL) ganmeorebiTi gansazRvra 3-4 sT-Si
bull Tu Ssb lt20 mgdL (342 micromolL) ganmeorebiTi gansazRvra 4ndash6 sT-Si Tu Ssb agrZelebs daqveiTebas ganmeorebiTi gansazRvra 8-12 sT-Si
bull Tu Ssb ar mcirdeba an uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones an Ssb albuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6) iwyeba SenacvlebiTi transfuzia Tu amis saSualeba aris an xorcieldeba referali
bull intensiur fotoTerapiis miuxedavad Ssb-is ucvleli done an mateba miuTiTebs hemolizze
14
rArr anemiahemolizis Sefaseba SesaZlebelia sisxlis saerTo analizis mixedviT - Hgblt 130 glLHct lt 40 retikulocitebi - gt 6
bull Ssb lt 13ndash14 mgdL (239 micromolL) fotoTerapia wydeba
bull fotoTerapiis Sewyvetidan 24 sT-Si kontroldeba Ssb Tu Ssb moimata im donemde romelzec daiwyo fotoTerapia fotoTerapia ganmeorebiT iwyeba
fotoTerapiis garTulebebi
fotoTerapiis garTulebebi (Ronald J Wong 2005 American Aacademy of Pediatrics 2004)
rArrmwvane feris ganavalidiarea (mkurnalobas ar saWiroebs)
rArr dehidratacia
rArr muclis Seberva (mkurnalobas ar saWiroebs)
rArr Tvalis SesaZlo dazianeba yvelaze seriozuli magram iSviaTi klinikuri garTulebaa brinjaos
axalSobilis sindromi romelic vlindeba qolestazuri siyviTlis mqone axalSobilSi kanis Sratis da Sardis muqi nacrisfer-yavisferi SeferilobiT brinjaos axalSobilis sindromi ar vlindeba qolestazis mqone yvela axalSobilTan Tu arsebobs fotoTerapiis Cveneba pirdapiri hiperbilirubinemia ar warmoadgens fotoTerapiis winaaRmdeg Cvenebas axalSobilebSi romelTac uviTardebaT brinjaos sindromi naCvenebia SenacvlebiTi transfuzia monacemebis arasrulyofilebis gamo mkacri rekomendaciis gakeTeba ar SeiZleba
mZime qolestazuri siyviTlis mqone axalSobilebSi fotoTerapiis dros aseve SeiZleba ganviTardes
rArr purpura
rArr bulozuri gamonayari
mzis ultraiisferi sxivebiT TerapiamarTalia mzis sxivebs gaaCniaT mniSvnelovani iradiacia 425-475 nm magram radganac maRalia axalSobilis damwvrobis ganviTarebis riski (SiSveli axalSobilis mzeze yofnis gamo) es meTodi rekomendebuli ar aris
(Ronald J Wong 2005 (American Aacademy of Pediatrics 2004)
intravenuri imunoglobulinis gamoyenebarekomendacia izoimunuri hemolizuri daavadebis dros rekomendebulia intravenuri imunoglobulinis gamoyeneba (05-1 gkg 2 sT-s ganmavlobaSi) Tu Ssb imatebs intensiuri fotoTerapiis miuxedavad an Ssb aris 2-3 mgdl-iT (34-51mkmoll) naklebi SenacvlebiTi transfuziis Cvenebis doneze (fighellip4) aucilebelobis SemTxvevaSi intravenuri imunoglobulinis es doza SeiZleba ganmeordes 12 sT-Si (rekomendacia B) American Aacademy of Pediatrics 2004)
15
fotoTerapiis dros kanSi Calagebuli bilirubini swrafad iSleba amitom ar aris rekomendebuli kanis ferze dayrdnobiT SratSi
bilirubinis donis Sesafaseba rogorc fotoTerapiis dros ise misi Sewyvetidan 24 sT-is ganmavlobaSi
B
kvlevebiT dadgenilia rom intravenuri imunoglobulini amcirebs SenacvlebiTi transfuziis saWiroebas Rh da ABO hemolizuri daavadebis dros
SenacvlebiTi transfuzia
SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleluli unda iyos Semowmebuli da dasxivebuli gadasasxmeli sisxlis raodenoba Seadgens 170-180 mlkg
rekomendacia SenacvlebiTi transfuzia unda Caataros mxolod gamocdilma samedicino personalma intensiuri Terapiis ganyofilebaSi monitoringisa da srulyofili reanimaciis SesaZleblobis pirobebSi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
SenacvlebiTi transfuziis Cvenebebi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
mwvave bilirubinuli encefalopaTia intensiuri fotoTerapiis miuxedavad Ssb mateba an ucvleli
monacemi samSobiarodan gawerili axalSobilebis hospitalizaciis
SemTxvevaSi Ssb-s maRali maCvenebeli - aRemateba SenacvlebiTi transfuziis dawyebis maCvenebls (sqema 3) (transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia) (ix cxrili 6)
ba Sefardeba Ssb maCvenebelTan (cxrili 6) erTad gamoiyeneba rogorc damatebiTi faqtori SenacvlebiTi transfuziis dawyebis gansasazRvravad
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
sqema 3 SenacvlebiTi transfuziis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (American Academy of Pediatrics 2004)
16
D
D
cxrili 6 bilirubinisa da albuminis Sefardeba rodesac saWiroa SenacvlebiTi transfuzia (AMERICAN ACADEMY OF PEDIATRICS 2004)
riskis kategoria
ba Sefardeba rodesac saWiroa SenacvlebiTi
transfuziaSsb mgdl alb gdl
Ssb micromolL alb micromolL
axalSobilebi gestaciuri asaki - ge38 kvira 80 094
janmrTeli axalSobilebi gestaciuri asakiT an riskis jgufis axalSobilebi
gestaciuri asakiT ge38 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
72 084
riskis jgufis axalSobilebi gestaciuri asakiT 35ndash36 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
68 080
janmos rekomendacia sisxlis SenacvlebiTi gadasxmis Cvenebebis Sesaxeb mocemulia cxrilSi 7
cxrili 7 SenacvlebiTi transfuziis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI 15 260 13 220II 25 425 15 260
17
III 30 510 20 340IV da meti 30 510 20 340
Tu Ssb uaxlovdeba im dones rodesac naCvenebia SenacvlebiTi transfuzia
sisxli dauyovnebliv igzavneba raTa dadgindes jgufi da rezusi da SeTavseba Tu klinikaSi aris transfuziis saSualeba
an xorcieldeba referali
teqnika (AMERICAN ACADEMY OF PEDIATRICS 2004
bull mwvave bilirubinuli encefalopaTiis dros SenacvlebiTi transfuzia iwyeba dauyovnebliv
bull sxva SemTxvevaSi transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia
bull SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleuli unda iyos Semowmebuli da dasxivebuli
bull gadasasxmeli sisxlis raodenoba Seadgens axalSobilis mocirkulire sisxlis ormag raodenobas saSualod 170-180 mlkg an gadasasxmeli sisxlis gamosaTvleli formula gamoiTvleba 85 x axalSobilis wona kg x 2
bull SenacvlebisaTvis xdeba 2 venis an arteria da venis kaTeterizacia iReben bavSvis 20 ml sisxls da SeyavT 20 ml donoris sisxli (3-4 wT-is ganmavlobaSi) SemTbaris 367-3700C-mde
bull dRenaklulebsa da mZime mdgomareobaSi myof axalSobilebSi Senacvleba xdeba 5-10 ml-iT
axalSobilis momzadeba
bull kuWis SigTavsis aspiracia zondiT 8F da Ria zondis datoveba kuWSibull SeiZleba saWiro gaxdes bavSvis dabma
bull SeiZleba sawovaras gamoyeneba
bull Sardis Semkrebis gamoyeneba diurezis kontrolisTvisaxlSobilis winaswar Sefaseba
bull temperatura
bull guliscema
bull sunTqva
bull wneva
bull glukoza SratSi
bull Sardis analizi
bull ganavlis analizi sisxlis Semcvelobaze
bull kanis feri
bull tonusi
bull qcevauSualod transfuziis dros fasdeba vitaluri niSnebi (yovel 15 wT-Si)
18
bull temperatura
bull guliscema (mwvervalze) (umjobesia kardiomonitoriT)
bull sunTqva
bull kanis feri
bull qceva
monitoringi transfuziis Semdeg bull grZeldeba fotoTerapia
bull kardio monitoringi
bull sisxlis wneva proceduris damTavrebis Semdeg
bull saaTobrivad 6 sT-is ganmavlobaSi temperatura guliscema (mwvervalze) sunTqva
bull glukoza SratSi yovel 3 sT-Si 24 sT-is ganmavlobaSi
bull muclis garSemoweriloba 3-4 sT-Si 24 sT-is ganmavlobaSi nawlavebis peristaltikis auskultacia
bull Sardis analizi
bull ganavali sisxlis Semcvelobaze
bull sakvebis autanlobis niSnebi Rebineba muclis Seberva
bull Ssb 6 sT-Si erTxel
SenacvlebiTi transfuziis riskisikvdiloba - 3 SemTxveva 1000 transfuziaze SenacvlebiTi transfuziis dros garTulebis saxiT 5-Si vlindeba
- apnoe bradikardia cianozi vazospazmi Trombozi nekrozuli enterokoliti aseve SeiZleba ganviTardes hipoqsiur-iSemiuri encefalopaTia da SeZenili imunodeficitis sindromi
sxva mkurnalobafenobarbitali ndash xels uwyobs bilirubinis koniugacias da amcirebs
Ssb dones ar arsebobs sakmarisi mtkicebulebebi fenobarbitalis gamosayeneblad rodesac arsebobs siyviTlis mkurnalobis ufro efeqturi meTodebi (mag fotoTerapia)
referali AMERICAN ACADEMY OF PEDIATRICS 2004)referali maRali donis klinikaSi xorcieldeba Tu
ar aris fotoTerapiis Catarebis SesaZlebloba fotoTerapiis miuxedavad
rArr Ssb ar mcirdeba
rArr Ssb uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones da ar aris transfuziis saSualeba
rArr Ssbalbuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6)
Tu siyviTle gamovlinda I dRes siyviTlis lokalizaciis mixedviT siyviTlis simZimis Sefasebisas
(cxrili 1) dadgenili ldquosaSiSi siyviTlerdquo
bilirubinis maRali namati 85 micromolLsT (gt05 mgdlsT)
gaxangrZlivebuli siyviTle (14 dRe da meti) ojaxur anamnezSi mZime siyviTlis an kerniqterusis arseboba siyviTlis dros sxva daavadebis niSnebis arseboba (mg sefsisi)
19
riskis Sefaseba gaweramde
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
bull yvela axalSobilis gaweramde unda Sefasdes hiperbilirubinemiis ganviTarebis riski yvela ganyofilebas unda hqondes protokoli siyviTlis SefasebisTvis aseTi Sefaseba gansakuTrebiT mniSvnelovania im axalSobilebisaTvis romlebis ewerebian dabadebidan 72 sT-ze adre (rekomendacia C)
bull amerikis pediatrTa akademiis rekomendaciiT riskis SefasebisaTvis gamoyenebuli unda iqnas 2 midgoma (calcalke an kombinaciaSi) gaweris win bilirubinis gansazRvra (Ssb an tkb) daan klinikuri risk-faqtorebis Sefaseba risk-faqtorebis arseboba an Ssb maRali maCveneblebi gaweris Semdeg Sesabamisi meTvalyureobis aucilebelobis Cvenebaa (rekomendacia C)
bull yvela samSobiarom unda miawodos mSobels zepiri daan werilobiTi informacia binaze siyviTlis Sefasebis da saSiSroebis niSnebis Sesaxeb (rekomendacia D)
meTvalyureoba
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)bull yvela axalSobili samSobiarodan gaweriis Semdeg ramdenime dReSi unda Sefasdes kvalificuri samedicino profesionalis mier (rekomendacia C)
bull fasdeba - siyviTlis arseboba axalSobilis wona kvebis efeqturoba Rebinebis arseboba (rekomendacia C)
bull meTvalyureobis grafiki Tu axalSobili samSobiarodan ewereba 48-72 sT-Si samedicino Sefaseba tardeba 120 sT-is (5 dRe) asakSi (rekomendacia C)
bull Tu samSobiarodan gaweris Semdeg meTvalyureoba SeuZlebelia da arsebobs hiperbilirubinemiis ganviTarebis risk-faqtorebi axalSobilis gawera unda gadaidos sanam ar iqneba uzrunvelyofili Sesabamisi meTvalyureoba an sanam gaivlis maRali riskis periodi (72-96sT) (rekomendacia D)
11 gaidlainis gadasinjvisa da ganaxlebis vada ndash 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlainis SemuSavebis meTodologia
bull axalSobilTa hiperbilirubinemiis prevenciis diagnostikisa da marTvis principebis Sesaxeb arsebobs samecniero mtkicebulebis safuZvelze Seqmnil rekomendaciaTa sakmarisi raodenoba mocemuli gaidlainis Semqmnis procesSi samuSao jgufis gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve arsebuli praqtikuli rekomendaciebi moxda arsebuli
20
C
C
C
C
D
C
D
rekomendaciebis adaptirebuli variantis SemuSaveba romelic erTis mxriv pasuxebs saerTaSoriso moTxovnebs xolo meore mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa rogorc adamianur ise teqnikur resursebs
bull rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa bazis gamoyenebiT
cxrili 2
qveyana da resursis dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
httpwwwguidelinegov
Centers for Disease Control and Prevention (CDC)
httpwwwphppocdcgovCDCRecommendsAdvSearchVasp
Agency for Healthcare Research and Quality (AHRQ)
httpwwwahrqgovcliniccpgsixhtm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
httphstatnlmnihgov
Institute of Clinical Systems Improvement (ICSI)
httpwwwicsiorg
American Medical Association httpwwwama-assnorg
Canadian Medical Association (CMA)
httpmdmcacpgsnewcpgsindexasp
Health Canada ndash Population and Public Health Branch (PPHB)
httpwwwhc-scgccapphb-dgspspdpg_ehtml
didi britaneTi
National Institute for Clinical Excellence (NICE)
httpwwwniceorguk
Sheffield Evidence for Effectiveness and Knowledge (SEEK)
httpwwwshefacukseekguidelineshtm
National electronic Library for Health (NeLH)
httpwwwnelhnhsukguidelinesfinder
PRODIGY Clinical Guidance httpwwwprodigynhsukClinicalGuidance
Scottish Intercollegiate Guidelines Network (SIGN)
httpwwwsignacuk
German Guideline Information Service (GERGIS)
httpwwwleitliniendeenglishenglishview
avstralia
Australian National Health and httpwwwhealthgovauhfsnhmrcpublicatcp-
21
Medical Research Council (NHMRC) homehtmaxali zelandia
New Zealand Guidelines Group (NZGG)
httpwwwnzggorgnzlibrarycfm
mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba
httpwwwosdmorg
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi
bull koxreinis biblioTeka - The Cochrane Library 2006 Issue 2 bull amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini ndash MEDLINEbull jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvisgamoricxvis kriteriumebi
bull arCeul iqna kvlevebi Semdegi dizainiT randomizebuli kontrolirebadi sistemuri mimoxilvebi da meta-analizi erTmomentiani kohortuli kvlevebi
bull rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12 wliani SezRudva Tumca zogjer gamoyenebuli iyo ufro adreuli publikaciebi romlebic dResac aqtualuria da safuZvlad udevs sxva Tanamedrove mtkicebulebebs
bull dadgenili iyo enobrivi SezRudvebi radganac samuSao jgufs SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod inglisur da rusul enebze
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
bull samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri meToduri rekomendacia axalSobilTa hiperbilirubinemiis marTvis sakiTxebze romlebic Seicavda jgufis miznis Sesaferis saWiro informacias am rekomendaciebis Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (9496-98) samuSao jgufi xelmZRvanelobda saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mier SemuSavebuli nacionaluri gaidlainebis gzamkvleviT Sefasebis Sedegad amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi
rArr amerikis pediatrTa akademia
rArr msoflo jandacvis organizacia
rArr kanadis pediatrTa sazogadoeba ndash nayofi da axalSobilis komiteti
rArr britaneTis reproduqciuli janmrTelobis programa
22
bull rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da rekomendaciebis xarisxis sqema
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris
done (Muir Gray)xarisxi rekomendaciis xarisxi
(Cook et al)I Zlieri mtkicebuleba
eyrdnoba minimum erT sistemur mimoxilvas
romelic efuZneba swori dizainis mqone randomizebul
kontrolirebad kvleva
A eyrdnoba I donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erTi swori dizainis mqone
randomizebul kontrolirebad kvleva
B eyrdnoba II donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
III klinikuri kvleva randomizaciis gareSe
kohortuli da SemTxveva-kontrolis kvlevebi
C eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi
D eyrdnoba IV da V donis mtkicebulebas saWiroebs
konsesuss
Va avtoritetul profesionalTa mosazreba
Vb klinikuri gamocdileba aRwerilobiTi kvlevebi an
eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
15 avtorTa jgufi
bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis
bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi
rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
23
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24
cxrili 3 35 da meti gestaciuri asakis axalSobilSi gamovlenili siyviTlis laboratoriuli Sefaseba (AMERICAN ACADEMY OF PEDIATRICS 2004)
Cveneba laboratoriuli kvlevapirvel 24 sT-Si gamovlenili siyviTle
bull tkb daan Ssb gansazRvra
asakisaTvis Seusabamo mkveTri siyviTle kanze G
bull tkb daan Ssb gansazRvra
axalSobils utardeba fotoTerapia an aReniSneba bilirubinis swrafi mateba (sqema 2 ndash butanis sqemaze maCvenebeli kveTs percentilebs) rac ar aixsneba obieqturi gamokvleviT da anamnezuri monacemebiT
bull sisxlis jgufi da rezusi kumbsis testi Tu ar aris gakeTebuli Wiplaris sisxlSi
bull sisxlis saerTo analizi da nacxi formiani elementebis morfologiis Sesaswavlad
bull pirdapiri (koniugirebuli) bilirubinis gansazRvra
bull Tu SesaZlebelia isazRvreba retikulocitebis ricxvi g6fd
bull Ssb ganmeorebiT isazRvreba 4-24 sT-Si axalSobilis asakisa da Ssb donis Sesabamisad
fotoTerapia uSedegoa an Ssb aRwevs dones romelzec naCvenebia SenacvlebiTi transfuzia
bull Tu SesaZlebelia isazRvreba retikulocitebis ricxvi g6fd
momatebulia pirdapiri (koniugirebuli) bilirubinis done
bull Sardis anlizi
bull Sardis kultura
bull gamokvleva sefsisze Tu misi arseboba saeWvoa anamneziT an obieqturi gamokvleviT
siyviTle sami kviris asakis an avadmyof axalSobilSi
bull saerTo da pirdapiri (koniugirebuli) bilirubini
bull pirdapiri bilirubinis momatebisas tardeba kvleva qolestazis sadiagnostikod
bull skriningi hipoTireozsa da galaqtozemiaze
bull axalSobilis Sefaseba hipoTireozis simptomebis gamosavlenad
sqema 1 butanis nomograma
8
butanis nomograma saSualebas iZleva ganisazRvros ramdenad maRalia mZime hiperbilirubinemiis ganviTarebis riski axalSobilis asakis (saaTebSi) da Sratis bilirubinis koncentraciis gaTvaliswinebiT bilirubinis gansazRvra
bilirubini isazRvreba transkutanurad da sisxlis SratSi transkutanuri gansazRvra gamarTlebulia rogorc skriningis
meTodi is isazRvreba specialuri aparatiT aRniSnuli xelsawyos gamoyenebiT bilirubinis gansazRvra SesaZloa 2-3 mgdl (34-54micromolL) variabelobiT bevr SemTxvevaSi xdeba Sratis bilirubinis gansazRvris Canacvleba transkutanuri gansazRvriT gansakuTrebiT maSin roca Ssb lt 15 mgdl (257 micromolL)
fotoTerapiis dros kanis vizualuri SefasebasTan erTad aucilebelia Sratis bilirubinis gansazRvra radgan fotoTerapia ldquoaTeTrebsrdquo kans (American Academy of Pediatrics 2004)
pirveladi profilaqtika
rekomendacia (American Academy of Pediatrics 2004) bull eqimma unda urCios dedas ganaxorcielos moTxovnilebiTi ZuZuTi kveba dReSi 8-12-jer (rekomendacia C) - arasrulyofili kaloriebis miRebam daan dehidrataciam SeiZleba gamoiwvios Hhiperbilirubinemiis ganviTareba
bull ZuZuTi kvebis SemTxevaSi Tu axalSobils ar aReniSneba dehidratacia ar aris rekomedirebuli wylisa da deqstrozis rutinulad damateba (rekomendacia B da C) -
9
C
B
C
wylis da deqstrozis damateba ar axdens hiperbilirubinemiis ganviTarebis profilaqtikasa da Ssb-s Semcirebas
bull yvela Rh (D) negatiur orsuls an melogines mizanSewonilia Cautardes anti D imonoglobuliniT profilaqtika (rekomendacia A)
minus orsulobis 28 kviraze (garda im SemTxvevebisa rodesac bavSvis mamac Rh (D) negatiuria)
minus mSobiarobidan 72 sT-is gamnavlobaSi Tu axalSobili Rh (D) pozituiria
minus orsulobis pirvel trimestrSi ganviTarebuli abortis da invaziuri procedurebis dros rogorica amniocentezi nayofis invaziuri procedurebi
meoradi profilaqtikarekomendacia klinicistma unda moaxdinos axalSobilTa hiperbilirubinemiis ganviTarebis riskebis sistemuri Sefaseba neonatalur periodSi (rekomendacia B)(AMERICAN ACADEMY OF PEDIATRICS 2004)
sisxlis jgufobriobarekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
yvela orsuli qali unda iyos gamokvleuli ABO da Rh(D) sisxlis jgufebze da hqondes Catarebuli skriningi SratSi izoimunur antisxeulebze (rekomendacia B)
Tu dedas ar Cautarebia prenatalurad sisxlis jgufis da rezusis gamokvleva an igis Rh negatiuria mkacrad aris rekomendirebuli pirdapiri antisxeulebis testis (an kumbsis testi) sisxlis jgufis da Rh (D) tipis gansazRvra axalSobilis (Wiplaris) sisxlSi (rekomendacia B)
Tu dedas sixlis jgufi aris O Rh(D) pozitiuri axalSobilis sisxlis jgufis da pirdapiri antisxeulis testis gansazRvris aucilebloba damokidebulia meTvalyureobis xarisxze gaweris win riskis Sefasebasa da gaweris Semdeg meTvalyureobaze (rekomendacia C)
mkurnalobis sqemamkurnalobis ZiriTadi principebia
fotoTerapia SenacvlebiTi transfuzia
mkurnaloba iwyeba fotoTerapiiTfotoTerapiis dros kanis zeda SreebSi Calagebuli arapirdapiri bilirubini iSleba fotoqimiuri gziT wyalSi xsnad koniugatebad romlebic gamoiyofa SardiT da naRveliTrekomendacia yvela samSobiaro saxli unda iyos aRWurvili mowyobilobiT romelic saWiroa intensiuri fotoTerapiisaTvis (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)fotoTerapiis Cvenebebi
fotoTerapia iwyeba Tu bulirubinis done aRemateba 95 percentils butanis nomogramaze (sqema 1) amave dros metad mniSvnelovania risk-faqtorebis gaTvaliswineba romlebic xels uwyobs mZime
10
A
B
B
B
C
D
hiperbiliruminemias (hemolizuri daavadeba g6fd deficiti asfiqsia mkveTrad gamoxatuli leTargia temperaturis arastabiluroba sefsisi acidozi an hipoalbuminemia lt30 gdl)
amerikis pediatriuli akademiis rekomendaciiT gamoiyeneba sqema (sqema 2) romelic axalSobilis asaksa da bilirubinis donesTan erTad iTvaliswinebs risk-faqtorebsa da gestaciur asaks mocemuli sqemis mixedviT ldquointensiurirdquo fotoTerapia iwyeba Semdegi principebiT
dabali riskis axalSobili (janmrTeli risk-faqtorebis gareSe gestacia gt 38 kvira) ndash Ssb gt12 mgdl (205 micromolL) 24 sT-Si Ssb gt15 mgdl (257 micromolL) 48 sT-Si Ssb gt18 mgdl (308 micromolL) gt72 sT
saSualo riskis axalSobili (gestacia gt 38 kvira da risk-faqtorebi an gestacia 35-37 kvira risk-faqtorebis gareSe gareSe) ndash Ssb gt 10 mgdl (171 micromolL) 24 sT-Si Ssb gt13 mgdl (222 micromolL) 48 sT-Si Ssb gt15 mgdl (257 micromolL) gt72 sT gestaciis 35 kviris axalSobilebSi fotoTerapia SeiZleba daiwyos ufro dabal maCveneblebze
maRali riskis axalSobili (gestacia 35-37 kvira da risk-faqtorebi) - Ssb gt 8 mgdl (137 micromolL) 24 sT-Si Ssb gt11 mgdl (188 micromolL) 48 sT-Si Ssb gt135 mgdl (231 micromolL) gt72 sT
Tu dabali riskis axalSobilebSi Ssb done 2-3 mgdl-iT dabalia moyvanil monacemebze SesaZlebelia mkurnalobis dawyeba ldquoCveulebrivirdquo fotoTerapiiT
bull stacionarSi gamoxatuli siyviTliT Semosul axalSobils utardeba ldquointensiurirdquo fotoTerapia bilirubinis maCveneblis gansazRvramde
bull ldquointensiurirdquo fotoTerapia aseve rekomendebulia hemolizuri daavadebis dros
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
janmos rekomendacia fotoTerapiis dawyebis Cvenebebis Sesaxeb mocemulia cxrilSi 4
cxrili 4 fotoTerapiis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI gamoxatuli siyviTleII 15 260 13 220III 18 310 16 270
IV da meti 20 340 17 290janmos rekomendaciiT fotoTerapia iwyeba Tu siyviTlis
lokalizaciis mixedviT siyviTlis simZimis Sefasebisas (cxrili 1) dadginda ldquosaSiSi siyviTlerdquo
Tu ar aris bilirubinis gansazRvris saSualeba Ssb savaraudo donis dasadgenaT SeiZleba krameris modificirebuli sqemis gamoyeneba
11
sqema 2 fotoTerapiis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (AMERICAN ACADEMY OF PEDIATRICS 2004)
rekomendacia Tu Sratis albuminis maCvenebeli naklebia 30 gdl-ze fotoTerapiis dawyeba rekomendebulis ufro dabali maCveneblebis dros (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis ukuCveneba pirdapiri (koniugirebuli) hiperbilirubinemia (pirdapiri
bilirubini Ssb-s 50-ze metia) (American Family Practice Notebook 2002 ) (AMERICAN ACADEMY OF PEDIATRICS 2004)
Tandayolili porfiria an porfiriis ojaxuri anamnezi (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis teqnikafotoTerapiis efeqturoba damokidebulia dozaze fotoTerapiis doza anu speqtruli iradiacia damokidebulia naTuris simZlavreze sinaTlis wyarosa da bavSvs Soris manZilsa da dasxivebis farTobze sinaTlis wyarofotoTerapiis sinaTlis speqtri damokidebulia sinaTlis wyaroze da filtrze yvelaze farTod gavrcelebuli fotoTerapiis mowyobiloba Seicavs dRis Suqis gril TeTr cisfer an ldquospecialur cisferrdquo fluorescentul naTurebs manZils sinaTlis wyarodan axalSobilamde didi mniSvneloba eniWeba sasurvelia axalSobili moTavsdes sinaTlis wyarodan im minimalur manZilze romelic miTiTebulia fotoTerapiis mowyobilobis instruqciaSi halogenis fotoTerapiis naTurebi ar SeiZleba moTavsdes axalSobilTan axlos radgan SeiZleba gamoiwvios damwvroba
12
DD
sxeulis zedapiris farTobibilirubinis maRali Semcvelobisas mniSvnelovania fotoTerapiis dros dasxivdes sxeulis zedapiris rac SeiZleba meti farTobi
ldquoCveulebrivi fotoTerapiardquo - sinaTlis speqtris iradiacia dabalia (6-12 microWcm2nm) (talRis sigrZe daaxloebiT 425-475 nm) da damokidebulia sxvadasxva mwarmoeblis mier mowodebul fotoTerapiiis sistemis aparatis monacemebze saWiroa aparatis Semowmeba Seesabameba Tu ara sinaTlis speqtris iradiacia mwarmoeblis mier mowodebul monacemebsldquointensiuri fotoTerapiardquo - lurj-mwvane speqtris iradiacia (talRis
sigrZe daaxloebiT 430-490 nm) sul cota 30 microWcm2nm-ia (isazRvreba axalSobilis kanze fototerapiis aparatis centris qveS) gazomva xdeba im warmoebis radiometriT romelic mowodebulia fotoTerapiiis sistemis aparatis mwarmoeblis mier sinaTlis talRis asareklad TeTreuli unda iyos TeTri kuvezi da sawolis gverdebi daifaros TeTri qsoviliT an aluminis folgiT
fotoTerapiis procedura da monitoringi
temperatura sinaTlis wyaros qveS unda iyos 28-300C
fotoTerapiis dros bavSvi unda iyos SiSveli ecvas erTjeradi higienuri safeni Tvalebze unda hqondes damcavi saTvale
yovel 3 saaTSi erTxel bavSvs unda Seucvalon pozicia
yovel 3 saaTSi erTxel unda Sefasdes sinaTlis wyaros qveS arsebuli temperatura da axalSobilis sxeulis temperatura Tu bavSvis t metia metia 3750C saWiroa oTaxis temperaturis daqveiTeba an fotoTerapiis droebiT Sewyveta sanam bavSvis temperatura ar iqneba normis farglebSi (365-3750C)
fotoTerapia mimdinareobas mudmivad igi wydeba mxolod im procedurebis dros romelTa warmoeba ra SeiZleba sinaTlis wyaros qveS
centraluri cianozis arsebobis Sesafaseblad fotoTerapia unda Sewydes mcire droiT
fotoTerapiis dros unda gagrZeldes bavSvis kveba
rArraxalSobilTan unda gagrZeldes ZuZuTi kveba moTxovnilebis mixedviT (intervali kvebaTa Soris araumetes 3 sT-isa) (rekomendacia C) ZuZuTi kvebis dros wydeba fotoTerapia da Sesabamisad bavSvs unda moexsnas damcavi saTvale
rArrTu bavSvi ikvebeba gamowvelili rZiT formuliT an parenteralurad misawodebeli sakvebis an siTxis raodenoba izrdeba dRiuri normis 10 -iT
rArr Tu bavSvi ikvebeba zondiT an parenteralurad fotoTerapia mimdinareobs uwyvetad
rArrCveulebriv fotoTerapiis dros axalSobils ar esaWiroeba damatebiT siTxis an sakvebis miwodeba damateba naCvenebia mxolod araefeqturi ZuZuTi kvebis sxeulis masis paTologiuri danakargis (gt10-ze mesame dRisTvis) da dehidrataciis SemTxvevaSi
13
C
fotoTerapiis dros bilirubinis daSlis produqtebi gamoiyofa SardiT da naRveliT adeqvaturi hidrataciis SenarCuneba da Sesabamisad adekvaturi diurzis SenarCuneba zrdis fotoTerapiis efeqturobas
zogierT axalSobils hiperbilirubinemiiT aReniSneba dehidratacia da saWiroa damatebiTi siTxis miwodeba (per-os an intravenurad) dehidrataciis koreqciisaTvis
araefeqturi ZuZuTi kvebis SemTxvevaSi fotoTerapiis dros axalSobils damatebiT miewodeba gamowvelili dedis rZe donoris rZe an xelovnuri sakvebi
rArr adeqvatur kvebaze miuTiTebs 4-6 sveli safeni 24 sT-Si da nawlavTa moqmedeba 3-4 jerdReSi meoTxe dRisaTvis
janmrTeli drouli axalSobilis nawlavTa moqmedeba da diurezi (minimaluri maCveneblebi) cxrili 5 (Fetus and Newborn Committee 1999)
dRe nawlavTa minimaluri moqmedeba24sT
sveli safeni24sT
1 1 12 1 23 1 gardamavali 34 2 yviTeli fafisebri 45 2YyviTeli fafisebri 5-6
rArrdehidrataciaze miuTiTebs Semdegi niSnebis arseboba - masis paTologiuri kleba (gt10-ze mesame dRisTvis)- anuria 4-6 sT- Cacvenili Tvalebi- Cavardnili yoflibandi - - daqveiTebuli kanis elastiuroba (kanis naoWi swordeba
nela)- daqveiTebuli kanis kapilaruli avseba (gt3 wm)- taqikardia- Sratis Na gt145 HCO3 lt17
bilirubinis monitoringi fotoTerapiis dros (American Aacademy of Pediatrics 2004)
sawyisi bilirubinis maCveneblis Semcireba 6-20-iT standartuli da 30-40-iT intensiuri fotoTerapiis dawyebidan 24sT-Si mis efeqturobaze miuTiTebs
bull Tu Ssb ge 25 mgdL (428 micromolL) ganmeorebiTi gansazRvra 2ndash3 sT-Si
bull Tu Ssb 20ndash25 mgdL (342ndash428 micromolL) ganmeorebiTi gansazRvra 3-4 sT-Si
bull Tu Ssb lt20 mgdL (342 micromolL) ganmeorebiTi gansazRvra 4ndash6 sT-Si Tu Ssb agrZelebs daqveiTebas ganmeorebiTi gansazRvra 8-12 sT-Si
bull Tu Ssb ar mcirdeba an uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones an Ssb albuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6) iwyeba SenacvlebiTi transfuzia Tu amis saSualeba aris an xorcieldeba referali
bull intensiur fotoTerapiis miuxedavad Ssb-is ucvleli done an mateba miuTiTebs hemolizze
14
rArr anemiahemolizis Sefaseba SesaZlebelia sisxlis saerTo analizis mixedviT - Hgblt 130 glLHct lt 40 retikulocitebi - gt 6
bull Ssb lt 13ndash14 mgdL (239 micromolL) fotoTerapia wydeba
bull fotoTerapiis Sewyvetidan 24 sT-Si kontroldeba Ssb Tu Ssb moimata im donemde romelzec daiwyo fotoTerapia fotoTerapia ganmeorebiT iwyeba
fotoTerapiis garTulebebi
fotoTerapiis garTulebebi (Ronald J Wong 2005 American Aacademy of Pediatrics 2004)
rArrmwvane feris ganavalidiarea (mkurnalobas ar saWiroebs)
rArr dehidratacia
rArr muclis Seberva (mkurnalobas ar saWiroebs)
rArr Tvalis SesaZlo dazianeba yvelaze seriozuli magram iSviaTi klinikuri garTulebaa brinjaos
axalSobilis sindromi romelic vlindeba qolestazuri siyviTlis mqone axalSobilSi kanis Sratis da Sardis muqi nacrisfer-yavisferi SeferilobiT brinjaos axalSobilis sindromi ar vlindeba qolestazis mqone yvela axalSobilTan Tu arsebobs fotoTerapiis Cveneba pirdapiri hiperbilirubinemia ar warmoadgens fotoTerapiis winaaRmdeg Cvenebas axalSobilebSi romelTac uviTardebaT brinjaos sindromi naCvenebia SenacvlebiTi transfuzia monacemebis arasrulyofilebis gamo mkacri rekomendaciis gakeTeba ar SeiZleba
mZime qolestazuri siyviTlis mqone axalSobilebSi fotoTerapiis dros aseve SeiZleba ganviTardes
rArr purpura
rArr bulozuri gamonayari
mzis ultraiisferi sxivebiT TerapiamarTalia mzis sxivebs gaaCniaT mniSvnelovani iradiacia 425-475 nm magram radganac maRalia axalSobilis damwvrobis ganviTarebis riski (SiSveli axalSobilis mzeze yofnis gamo) es meTodi rekomendebuli ar aris
(Ronald J Wong 2005 (American Aacademy of Pediatrics 2004)
intravenuri imunoglobulinis gamoyenebarekomendacia izoimunuri hemolizuri daavadebis dros rekomendebulia intravenuri imunoglobulinis gamoyeneba (05-1 gkg 2 sT-s ganmavlobaSi) Tu Ssb imatebs intensiuri fotoTerapiis miuxedavad an Ssb aris 2-3 mgdl-iT (34-51mkmoll) naklebi SenacvlebiTi transfuziis Cvenebis doneze (fighellip4) aucilebelobis SemTxvevaSi intravenuri imunoglobulinis es doza SeiZleba ganmeordes 12 sT-Si (rekomendacia B) American Aacademy of Pediatrics 2004)
15
fotoTerapiis dros kanSi Calagebuli bilirubini swrafad iSleba amitom ar aris rekomendebuli kanis ferze dayrdnobiT SratSi
bilirubinis donis Sesafaseba rogorc fotoTerapiis dros ise misi Sewyvetidan 24 sT-is ganmavlobaSi
B
kvlevebiT dadgenilia rom intravenuri imunoglobulini amcirebs SenacvlebiTi transfuziis saWiroebas Rh da ABO hemolizuri daavadebis dros
SenacvlebiTi transfuzia
SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleluli unda iyos Semowmebuli da dasxivebuli gadasasxmeli sisxlis raodenoba Seadgens 170-180 mlkg
rekomendacia SenacvlebiTi transfuzia unda Caataros mxolod gamocdilma samedicino personalma intensiuri Terapiis ganyofilebaSi monitoringisa da srulyofili reanimaciis SesaZleblobis pirobebSi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
SenacvlebiTi transfuziis Cvenebebi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
mwvave bilirubinuli encefalopaTia intensiuri fotoTerapiis miuxedavad Ssb mateba an ucvleli
monacemi samSobiarodan gawerili axalSobilebis hospitalizaciis
SemTxvevaSi Ssb-s maRali maCvenebeli - aRemateba SenacvlebiTi transfuziis dawyebis maCvenebls (sqema 3) (transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia) (ix cxrili 6)
ba Sefardeba Ssb maCvenebelTan (cxrili 6) erTad gamoiyeneba rogorc damatebiTi faqtori SenacvlebiTi transfuziis dawyebis gansasazRvravad
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
sqema 3 SenacvlebiTi transfuziis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (American Academy of Pediatrics 2004)
16
D
D
cxrili 6 bilirubinisa da albuminis Sefardeba rodesac saWiroa SenacvlebiTi transfuzia (AMERICAN ACADEMY OF PEDIATRICS 2004)
riskis kategoria
ba Sefardeba rodesac saWiroa SenacvlebiTi
transfuziaSsb mgdl alb gdl
Ssb micromolL alb micromolL
axalSobilebi gestaciuri asaki - ge38 kvira 80 094
janmrTeli axalSobilebi gestaciuri asakiT an riskis jgufis axalSobilebi
gestaciuri asakiT ge38 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
72 084
riskis jgufis axalSobilebi gestaciuri asakiT 35ndash36 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
68 080
janmos rekomendacia sisxlis SenacvlebiTi gadasxmis Cvenebebis Sesaxeb mocemulia cxrilSi 7
cxrili 7 SenacvlebiTi transfuziis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI 15 260 13 220II 25 425 15 260
17
III 30 510 20 340IV da meti 30 510 20 340
Tu Ssb uaxlovdeba im dones rodesac naCvenebia SenacvlebiTi transfuzia
sisxli dauyovnebliv igzavneba raTa dadgindes jgufi da rezusi da SeTavseba Tu klinikaSi aris transfuziis saSualeba
an xorcieldeba referali
teqnika (AMERICAN ACADEMY OF PEDIATRICS 2004
bull mwvave bilirubinuli encefalopaTiis dros SenacvlebiTi transfuzia iwyeba dauyovnebliv
bull sxva SemTxvevaSi transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia
bull SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleuli unda iyos Semowmebuli da dasxivebuli
bull gadasasxmeli sisxlis raodenoba Seadgens axalSobilis mocirkulire sisxlis ormag raodenobas saSualod 170-180 mlkg an gadasasxmeli sisxlis gamosaTvleli formula gamoiTvleba 85 x axalSobilis wona kg x 2
bull SenacvlebisaTvis xdeba 2 venis an arteria da venis kaTeterizacia iReben bavSvis 20 ml sisxls da SeyavT 20 ml donoris sisxli (3-4 wT-is ganmavlobaSi) SemTbaris 367-3700C-mde
bull dRenaklulebsa da mZime mdgomareobaSi myof axalSobilebSi Senacvleba xdeba 5-10 ml-iT
axalSobilis momzadeba
bull kuWis SigTavsis aspiracia zondiT 8F da Ria zondis datoveba kuWSibull SeiZleba saWiro gaxdes bavSvis dabma
bull SeiZleba sawovaras gamoyeneba
bull Sardis Semkrebis gamoyeneba diurezis kontrolisTvisaxlSobilis winaswar Sefaseba
bull temperatura
bull guliscema
bull sunTqva
bull wneva
bull glukoza SratSi
bull Sardis analizi
bull ganavlis analizi sisxlis Semcvelobaze
bull kanis feri
bull tonusi
bull qcevauSualod transfuziis dros fasdeba vitaluri niSnebi (yovel 15 wT-Si)
18
bull temperatura
bull guliscema (mwvervalze) (umjobesia kardiomonitoriT)
bull sunTqva
bull kanis feri
bull qceva
monitoringi transfuziis Semdeg bull grZeldeba fotoTerapia
bull kardio monitoringi
bull sisxlis wneva proceduris damTavrebis Semdeg
bull saaTobrivad 6 sT-is ganmavlobaSi temperatura guliscema (mwvervalze) sunTqva
bull glukoza SratSi yovel 3 sT-Si 24 sT-is ganmavlobaSi
bull muclis garSemoweriloba 3-4 sT-Si 24 sT-is ganmavlobaSi nawlavebis peristaltikis auskultacia
bull Sardis analizi
bull ganavali sisxlis Semcvelobaze
bull sakvebis autanlobis niSnebi Rebineba muclis Seberva
bull Ssb 6 sT-Si erTxel
SenacvlebiTi transfuziis riskisikvdiloba - 3 SemTxveva 1000 transfuziaze SenacvlebiTi transfuziis dros garTulebis saxiT 5-Si vlindeba
- apnoe bradikardia cianozi vazospazmi Trombozi nekrozuli enterokoliti aseve SeiZleba ganviTardes hipoqsiur-iSemiuri encefalopaTia da SeZenili imunodeficitis sindromi
sxva mkurnalobafenobarbitali ndash xels uwyobs bilirubinis koniugacias da amcirebs
Ssb dones ar arsebobs sakmarisi mtkicebulebebi fenobarbitalis gamosayeneblad rodesac arsebobs siyviTlis mkurnalobis ufro efeqturi meTodebi (mag fotoTerapia)
referali AMERICAN ACADEMY OF PEDIATRICS 2004)referali maRali donis klinikaSi xorcieldeba Tu
ar aris fotoTerapiis Catarebis SesaZlebloba fotoTerapiis miuxedavad
rArr Ssb ar mcirdeba
rArr Ssb uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones da ar aris transfuziis saSualeba
rArr Ssbalbuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6)
Tu siyviTle gamovlinda I dRes siyviTlis lokalizaciis mixedviT siyviTlis simZimis Sefasebisas
(cxrili 1) dadgenili ldquosaSiSi siyviTlerdquo
bilirubinis maRali namati 85 micromolLsT (gt05 mgdlsT)
gaxangrZlivebuli siyviTle (14 dRe da meti) ojaxur anamnezSi mZime siyviTlis an kerniqterusis arseboba siyviTlis dros sxva daavadebis niSnebis arseboba (mg sefsisi)
19
riskis Sefaseba gaweramde
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
bull yvela axalSobilis gaweramde unda Sefasdes hiperbilirubinemiis ganviTarebis riski yvela ganyofilebas unda hqondes protokoli siyviTlis SefasebisTvis aseTi Sefaseba gansakuTrebiT mniSvnelovania im axalSobilebisaTvis romlebis ewerebian dabadebidan 72 sT-ze adre (rekomendacia C)
bull amerikis pediatrTa akademiis rekomendaciiT riskis SefasebisaTvis gamoyenebuli unda iqnas 2 midgoma (calcalke an kombinaciaSi) gaweris win bilirubinis gansazRvra (Ssb an tkb) daan klinikuri risk-faqtorebis Sefaseba risk-faqtorebis arseboba an Ssb maRali maCveneblebi gaweris Semdeg Sesabamisi meTvalyureobis aucilebelobis Cvenebaa (rekomendacia C)
bull yvela samSobiarom unda miawodos mSobels zepiri daan werilobiTi informacia binaze siyviTlis Sefasebis da saSiSroebis niSnebis Sesaxeb (rekomendacia D)
meTvalyureoba
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)bull yvela axalSobili samSobiarodan gaweriis Semdeg ramdenime dReSi unda Sefasdes kvalificuri samedicino profesionalis mier (rekomendacia C)
bull fasdeba - siyviTlis arseboba axalSobilis wona kvebis efeqturoba Rebinebis arseboba (rekomendacia C)
bull meTvalyureobis grafiki Tu axalSobili samSobiarodan ewereba 48-72 sT-Si samedicino Sefaseba tardeba 120 sT-is (5 dRe) asakSi (rekomendacia C)
bull Tu samSobiarodan gaweris Semdeg meTvalyureoba SeuZlebelia da arsebobs hiperbilirubinemiis ganviTarebis risk-faqtorebi axalSobilis gawera unda gadaidos sanam ar iqneba uzrunvelyofili Sesabamisi meTvalyureoba an sanam gaivlis maRali riskis periodi (72-96sT) (rekomendacia D)
11 gaidlainis gadasinjvisa da ganaxlebis vada ndash 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlainis SemuSavebis meTodologia
bull axalSobilTa hiperbilirubinemiis prevenciis diagnostikisa da marTvis principebis Sesaxeb arsebobs samecniero mtkicebulebis safuZvelze Seqmnil rekomendaciaTa sakmarisi raodenoba mocemuli gaidlainis Semqmnis procesSi samuSao jgufis gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve arsebuli praqtikuli rekomendaciebi moxda arsebuli
20
C
C
C
C
D
C
D
rekomendaciebis adaptirebuli variantis SemuSaveba romelic erTis mxriv pasuxebs saerTaSoriso moTxovnebs xolo meore mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa rogorc adamianur ise teqnikur resursebs
bull rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa bazis gamoyenebiT
cxrili 2
qveyana da resursis dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
httpwwwguidelinegov
Centers for Disease Control and Prevention (CDC)
httpwwwphppocdcgovCDCRecommendsAdvSearchVasp
Agency for Healthcare Research and Quality (AHRQ)
httpwwwahrqgovcliniccpgsixhtm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
httphstatnlmnihgov
Institute of Clinical Systems Improvement (ICSI)
httpwwwicsiorg
American Medical Association httpwwwama-assnorg
Canadian Medical Association (CMA)
httpmdmcacpgsnewcpgsindexasp
Health Canada ndash Population and Public Health Branch (PPHB)
httpwwwhc-scgccapphb-dgspspdpg_ehtml
didi britaneTi
National Institute for Clinical Excellence (NICE)
httpwwwniceorguk
Sheffield Evidence for Effectiveness and Knowledge (SEEK)
httpwwwshefacukseekguidelineshtm
National electronic Library for Health (NeLH)
httpwwwnelhnhsukguidelinesfinder
PRODIGY Clinical Guidance httpwwwprodigynhsukClinicalGuidance
Scottish Intercollegiate Guidelines Network (SIGN)
httpwwwsignacuk
German Guideline Information Service (GERGIS)
httpwwwleitliniendeenglishenglishview
avstralia
Australian National Health and httpwwwhealthgovauhfsnhmrcpublicatcp-
21
Medical Research Council (NHMRC) homehtmaxali zelandia
New Zealand Guidelines Group (NZGG)
httpwwwnzggorgnzlibrarycfm
mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba
httpwwwosdmorg
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi
bull koxreinis biblioTeka - The Cochrane Library 2006 Issue 2 bull amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini ndash MEDLINEbull jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvisgamoricxvis kriteriumebi
bull arCeul iqna kvlevebi Semdegi dizainiT randomizebuli kontrolirebadi sistemuri mimoxilvebi da meta-analizi erTmomentiani kohortuli kvlevebi
bull rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12 wliani SezRudva Tumca zogjer gamoyenebuli iyo ufro adreuli publikaciebi romlebic dResac aqtualuria da safuZvlad udevs sxva Tanamedrove mtkicebulebebs
bull dadgenili iyo enobrivi SezRudvebi radganac samuSao jgufs SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod inglisur da rusul enebze
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
bull samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri meToduri rekomendacia axalSobilTa hiperbilirubinemiis marTvis sakiTxebze romlebic Seicavda jgufis miznis Sesaferis saWiro informacias am rekomendaciebis Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (9496-98) samuSao jgufi xelmZRvanelobda saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mier SemuSavebuli nacionaluri gaidlainebis gzamkvleviT Sefasebis Sedegad amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi
rArr amerikis pediatrTa akademia
rArr msoflo jandacvis organizacia
rArr kanadis pediatrTa sazogadoeba ndash nayofi da axalSobilis komiteti
rArr britaneTis reproduqciuli janmrTelobis programa
22
bull rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da rekomendaciebis xarisxis sqema
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris
done (Muir Gray)xarisxi rekomendaciis xarisxi
(Cook et al)I Zlieri mtkicebuleba
eyrdnoba minimum erT sistemur mimoxilvas
romelic efuZneba swori dizainis mqone randomizebul
kontrolirebad kvleva
A eyrdnoba I donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erTi swori dizainis mqone
randomizebul kontrolirebad kvleva
B eyrdnoba II donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
III klinikuri kvleva randomizaciis gareSe
kohortuli da SemTxveva-kontrolis kvlevebi
C eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi
D eyrdnoba IV da V donis mtkicebulebas saWiroebs
konsesuss
Va avtoritetul profesionalTa mosazreba
Vb klinikuri gamocdileba aRwerilobiTi kvlevebi an
eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
15 avtorTa jgufi
bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis
bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi
rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
23
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24
butanis nomograma saSualebas iZleva ganisazRvros ramdenad maRalia mZime hiperbilirubinemiis ganviTarebis riski axalSobilis asakis (saaTebSi) da Sratis bilirubinis koncentraciis gaTvaliswinebiT bilirubinis gansazRvra
bilirubini isazRvreba transkutanurad da sisxlis SratSi transkutanuri gansazRvra gamarTlebulia rogorc skriningis
meTodi is isazRvreba specialuri aparatiT aRniSnuli xelsawyos gamoyenebiT bilirubinis gansazRvra SesaZloa 2-3 mgdl (34-54micromolL) variabelobiT bevr SemTxvevaSi xdeba Sratis bilirubinis gansazRvris Canacvleba transkutanuri gansazRvriT gansakuTrebiT maSin roca Ssb lt 15 mgdl (257 micromolL)
fotoTerapiis dros kanis vizualuri SefasebasTan erTad aucilebelia Sratis bilirubinis gansazRvra radgan fotoTerapia ldquoaTeTrebsrdquo kans (American Academy of Pediatrics 2004)
pirveladi profilaqtika
rekomendacia (American Academy of Pediatrics 2004) bull eqimma unda urCios dedas ganaxorcielos moTxovnilebiTi ZuZuTi kveba dReSi 8-12-jer (rekomendacia C) - arasrulyofili kaloriebis miRebam daan dehidrataciam SeiZleba gamoiwvios Hhiperbilirubinemiis ganviTareba
bull ZuZuTi kvebis SemTxevaSi Tu axalSobils ar aReniSneba dehidratacia ar aris rekomedirebuli wylisa da deqstrozis rutinulad damateba (rekomendacia B da C) -
9
C
B
C
wylis da deqstrozis damateba ar axdens hiperbilirubinemiis ganviTarebis profilaqtikasa da Ssb-s Semcirebas
bull yvela Rh (D) negatiur orsuls an melogines mizanSewonilia Cautardes anti D imonoglobuliniT profilaqtika (rekomendacia A)
minus orsulobis 28 kviraze (garda im SemTxvevebisa rodesac bavSvis mamac Rh (D) negatiuria)
minus mSobiarobidan 72 sT-is gamnavlobaSi Tu axalSobili Rh (D) pozituiria
minus orsulobis pirvel trimestrSi ganviTarebuli abortis da invaziuri procedurebis dros rogorica amniocentezi nayofis invaziuri procedurebi
meoradi profilaqtikarekomendacia klinicistma unda moaxdinos axalSobilTa hiperbilirubinemiis ganviTarebis riskebis sistemuri Sefaseba neonatalur periodSi (rekomendacia B)(AMERICAN ACADEMY OF PEDIATRICS 2004)
sisxlis jgufobriobarekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
yvela orsuli qali unda iyos gamokvleuli ABO da Rh(D) sisxlis jgufebze da hqondes Catarebuli skriningi SratSi izoimunur antisxeulebze (rekomendacia B)
Tu dedas ar Cautarebia prenatalurad sisxlis jgufis da rezusis gamokvleva an igis Rh negatiuria mkacrad aris rekomendirebuli pirdapiri antisxeulebis testis (an kumbsis testi) sisxlis jgufis da Rh (D) tipis gansazRvra axalSobilis (Wiplaris) sisxlSi (rekomendacia B)
Tu dedas sixlis jgufi aris O Rh(D) pozitiuri axalSobilis sisxlis jgufis da pirdapiri antisxeulis testis gansazRvris aucilebloba damokidebulia meTvalyureobis xarisxze gaweris win riskis Sefasebasa da gaweris Semdeg meTvalyureobaze (rekomendacia C)
mkurnalobis sqemamkurnalobis ZiriTadi principebia
fotoTerapia SenacvlebiTi transfuzia
mkurnaloba iwyeba fotoTerapiiTfotoTerapiis dros kanis zeda SreebSi Calagebuli arapirdapiri bilirubini iSleba fotoqimiuri gziT wyalSi xsnad koniugatebad romlebic gamoiyofa SardiT da naRveliTrekomendacia yvela samSobiaro saxli unda iyos aRWurvili mowyobilobiT romelic saWiroa intensiuri fotoTerapiisaTvis (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)fotoTerapiis Cvenebebi
fotoTerapia iwyeba Tu bulirubinis done aRemateba 95 percentils butanis nomogramaze (sqema 1) amave dros metad mniSvnelovania risk-faqtorebis gaTvaliswineba romlebic xels uwyobs mZime
10
A
B
B
B
C
D
hiperbiliruminemias (hemolizuri daavadeba g6fd deficiti asfiqsia mkveTrad gamoxatuli leTargia temperaturis arastabiluroba sefsisi acidozi an hipoalbuminemia lt30 gdl)
amerikis pediatriuli akademiis rekomendaciiT gamoiyeneba sqema (sqema 2) romelic axalSobilis asaksa da bilirubinis donesTan erTad iTvaliswinebs risk-faqtorebsa da gestaciur asaks mocemuli sqemis mixedviT ldquointensiurirdquo fotoTerapia iwyeba Semdegi principebiT
dabali riskis axalSobili (janmrTeli risk-faqtorebis gareSe gestacia gt 38 kvira) ndash Ssb gt12 mgdl (205 micromolL) 24 sT-Si Ssb gt15 mgdl (257 micromolL) 48 sT-Si Ssb gt18 mgdl (308 micromolL) gt72 sT
saSualo riskis axalSobili (gestacia gt 38 kvira da risk-faqtorebi an gestacia 35-37 kvira risk-faqtorebis gareSe gareSe) ndash Ssb gt 10 mgdl (171 micromolL) 24 sT-Si Ssb gt13 mgdl (222 micromolL) 48 sT-Si Ssb gt15 mgdl (257 micromolL) gt72 sT gestaciis 35 kviris axalSobilebSi fotoTerapia SeiZleba daiwyos ufro dabal maCveneblebze
maRali riskis axalSobili (gestacia 35-37 kvira da risk-faqtorebi) - Ssb gt 8 mgdl (137 micromolL) 24 sT-Si Ssb gt11 mgdl (188 micromolL) 48 sT-Si Ssb gt135 mgdl (231 micromolL) gt72 sT
Tu dabali riskis axalSobilebSi Ssb done 2-3 mgdl-iT dabalia moyvanil monacemebze SesaZlebelia mkurnalobis dawyeba ldquoCveulebrivirdquo fotoTerapiiT
bull stacionarSi gamoxatuli siyviTliT Semosul axalSobils utardeba ldquointensiurirdquo fotoTerapia bilirubinis maCveneblis gansazRvramde
bull ldquointensiurirdquo fotoTerapia aseve rekomendebulia hemolizuri daavadebis dros
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
janmos rekomendacia fotoTerapiis dawyebis Cvenebebis Sesaxeb mocemulia cxrilSi 4
cxrili 4 fotoTerapiis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI gamoxatuli siyviTleII 15 260 13 220III 18 310 16 270
IV da meti 20 340 17 290janmos rekomendaciiT fotoTerapia iwyeba Tu siyviTlis
lokalizaciis mixedviT siyviTlis simZimis Sefasebisas (cxrili 1) dadginda ldquosaSiSi siyviTlerdquo
Tu ar aris bilirubinis gansazRvris saSualeba Ssb savaraudo donis dasadgenaT SeiZleba krameris modificirebuli sqemis gamoyeneba
11
sqema 2 fotoTerapiis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (AMERICAN ACADEMY OF PEDIATRICS 2004)
rekomendacia Tu Sratis albuminis maCvenebeli naklebia 30 gdl-ze fotoTerapiis dawyeba rekomendebulis ufro dabali maCveneblebis dros (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis ukuCveneba pirdapiri (koniugirebuli) hiperbilirubinemia (pirdapiri
bilirubini Ssb-s 50-ze metia) (American Family Practice Notebook 2002 ) (AMERICAN ACADEMY OF PEDIATRICS 2004)
Tandayolili porfiria an porfiriis ojaxuri anamnezi (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis teqnikafotoTerapiis efeqturoba damokidebulia dozaze fotoTerapiis doza anu speqtruli iradiacia damokidebulia naTuris simZlavreze sinaTlis wyarosa da bavSvs Soris manZilsa da dasxivebis farTobze sinaTlis wyarofotoTerapiis sinaTlis speqtri damokidebulia sinaTlis wyaroze da filtrze yvelaze farTod gavrcelebuli fotoTerapiis mowyobiloba Seicavs dRis Suqis gril TeTr cisfer an ldquospecialur cisferrdquo fluorescentul naTurebs manZils sinaTlis wyarodan axalSobilamde didi mniSvneloba eniWeba sasurvelia axalSobili moTavsdes sinaTlis wyarodan im minimalur manZilze romelic miTiTebulia fotoTerapiis mowyobilobis instruqciaSi halogenis fotoTerapiis naTurebi ar SeiZleba moTavsdes axalSobilTan axlos radgan SeiZleba gamoiwvios damwvroba
12
DD
sxeulis zedapiris farTobibilirubinis maRali Semcvelobisas mniSvnelovania fotoTerapiis dros dasxivdes sxeulis zedapiris rac SeiZleba meti farTobi
ldquoCveulebrivi fotoTerapiardquo - sinaTlis speqtris iradiacia dabalia (6-12 microWcm2nm) (talRis sigrZe daaxloebiT 425-475 nm) da damokidebulia sxvadasxva mwarmoeblis mier mowodebul fotoTerapiiis sistemis aparatis monacemebze saWiroa aparatis Semowmeba Seesabameba Tu ara sinaTlis speqtris iradiacia mwarmoeblis mier mowodebul monacemebsldquointensiuri fotoTerapiardquo - lurj-mwvane speqtris iradiacia (talRis
sigrZe daaxloebiT 430-490 nm) sul cota 30 microWcm2nm-ia (isazRvreba axalSobilis kanze fototerapiis aparatis centris qveS) gazomva xdeba im warmoebis radiometriT romelic mowodebulia fotoTerapiiis sistemis aparatis mwarmoeblis mier sinaTlis talRis asareklad TeTreuli unda iyos TeTri kuvezi da sawolis gverdebi daifaros TeTri qsoviliT an aluminis folgiT
fotoTerapiis procedura da monitoringi
temperatura sinaTlis wyaros qveS unda iyos 28-300C
fotoTerapiis dros bavSvi unda iyos SiSveli ecvas erTjeradi higienuri safeni Tvalebze unda hqondes damcavi saTvale
yovel 3 saaTSi erTxel bavSvs unda Seucvalon pozicia
yovel 3 saaTSi erTxel unda Sefasdes sinaTlis wyaros qveS arsebuli temperatura da axalSobilis sxeulis temperatura Tu bavSvis t metia metia 3750C saWiroa oTaxis temperaturis daqveiTeba an fotoTerapiis droebiT Sewyveta sanam bavSvis temperatura ar iqneba normis farglebSi (365-3750C)
fotoTerapia mimdinareobas mudmivad igi wydeba mxolod im procedurebis dros romelTa warmoeba ra SeiZleba sinaTlis wyaros qveS
centraluri cianozis arsebobis Sesafaseblad fotoTerapia unda Sewydes mcire droiT
fotoTerapiis dros unda gagrZeldes bavSvis kveba
rArraxalSobilTan unda gagrZeldes ZuZuTi kveba moTxovnilebis mixedviT (intervali kvebaTa Soris araumetes 3 sT-isa) (rekomendacia C) ZuZuTi kvebis dros wydeba fotoTerapia da Sesabamisad bavSvs unda moexsnas damcavi saTvale
rArrTu bavSvi ikvebeba gamowvelili rZiT formuliT an parenteralurad misawodebeli sakvebis an siTxis raodenoba izrdeba dRiuri normis 10 -iT
rArr Tu bavSvi ikvebeba zondiT an parenteralurad fotoTerapia mimdinareobs uwyvetad
rArrCveulebriv fotoTerapiis dros axalSobils ar esaWiroeba damatebiT siTxis an sakvebis miwodeba damateba naCvenebia mxolod araefeqturi ZuZuTi kvebis sxeulis masis paTologiuri danakargis (gt10-ze mesame dRisTvis) da dehidrataciis SemTxvevaSi
13
C
fotoTerapiis dros bilirubinis daSlis produqtebi gamoiyofa SardiT da naRveliT adeqvaturi hidrataciis SenarCuneba da Sesabamisad adekvaturi diurzis SenarCuneba zrdis fotoTerapiis efeqturobas
zogierT axalSobils hiperbilirubinemiiT aReniSneba dehidratacia da saWiroa damatebiTi siTxis miwodeba (per-os an intravenurad) dehidrataciis koreqciisaTvis
araefeqturi ZuZuTi kvebis SemTxvevaSi fotoTerapiis dros axalSobils damatebiT miewodeba gamowvelili dedis rZe donoris rZe an xelovnuri sakvebi
rArr adeqvatur kvebaze miuTiTebs 4-6 sveli safeni 24 sT-Si da nawlavTa moqmedeba 3-4 jerdReSi meoTxe dRisaTvis
janmrTeli drouli axalSobilis nawlavTa moqmedeba da diurezi (minimaluri maCveneblebi) cxrili 5 (Fetus and Newborn Committee 1999)
dRe nawlavTa minimaluri moqmedeba24sT
sveli safeni24sT
1 1 12 1 23 1 gardamavali 34 2 yviTeli fafisebri 45 2YyviTeli fafisebri 5-6
rArrdehidrataciaze miuTiTebs Semdegi niSnebis arseboba - masis paTologiuri kleba (gt10-ze mesame dRisTvis)- anuria 4-6 sT- Cacvenili Tvalebi- Cavardnili yoflibandi - - daqveiTebuli kanis elastiuroba (kanis naoWi swordeba
nela)- daqveiTebuli kanis kapilaruli avseba (gt3 wm)- taqikardia- Sratis Na gt145 HCO3 lt17
bilirubinis monitoringi fotoTerapiis dros (American Aacademy of Pediatrics 2004)
sawyisi bilirubinis maCveneblis Semcireba 6-20-iT standartuli da 30-40-iT intensiuri fotoTerapiis dawyebidan 24sT-Si mis efeqturobaze miuTiTebs
bull Tu Ssb ge 25 mgdL (428 micromolL) ganmeorebiTi gansazRvra 2ndash3 sT-Si
bull Tu Ssb 20ndash25 mgdL (342ndash428 micromolL) ganmeorebiTi gansazRvra 3-4 sT-Si
bull Tu Ssb lt20 mgdL (342 micromolL) ganmeorebiTi gansazRvra 4ndash6 sT-Si Tu Ssb agrZelebs daqveiTebas ganmeorebiTi gansazRvra 8-12 sT-Si
bull Tu Ssb ar mcirdeba an uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones an Ssb albuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6) iwyeba SenacvlebiTi transfuzia Tu amis saSualeba aris an xorcieldeba referali
bull intensiur fotoTerapiis miuxedavad Ssb-is ucvleli done an mateba miuTiTebs hemolizze
14
rArr anemiahemolizis Sefaseba SesaZlebelia sisxlis saerTo analizis mixedviT - Hgblt 130 glLHct lt 40 retikulocitebi - gt 6
bull Ssb lt 13ndash14 mgdL (239 micromolL) fotoTerapia wydeba
bull fotoTerapiis Sewyvetidan 24 sT-Si kontroldeba Ssb Tu Ssb moimata im donemde romelzec daiwyo fotoTerapia fotoTerapia ganmeorebiT iwyeba
fotoTerapiis garTulebebi
fotoTerapiis garTulebebi (Ronald J Wong 2005 American Aacademy of Pediatrics 2004)
rArrmwvane feris ganavalidiarea (mkurnalobas ar saWiroebs)
rArr dehidratacia
rArr muclis Seberva (mkurnalobas ar saWiroebs)
rArr Tvalis SesaZlo dazianeba yvelaze seriozuli magram iSviaTi klinikuri garTulebaa brinjaos
axalSobilis sindromi romelic vlindeba qolestazuri siyviTlis mqone axalSobilSi kanis Sratis da Sardis muqi nacrisfer-yavisferi SeferilobiT brinjaos axalSobilis sindromi ar vlindeba qolestazis mqone yvela axalSobilTan Tu arsebobs fotoTerapiis Cveneba pirdapiri hiperbilirubinemia ar warmoadgens fotoTerapiis winaaRmdeg Cvenebas axalSobilebSi romelTac uviTardebaT brinjaos sindromi naCvenebia SenacvlebiTi transfuzia monacemebis arasrulyofilebis gamo mkacri rekomendaciis gakeTeba ar SeiZleba
mZime qolestazuri siyviTlis mqone axalSobilebSi fotoTerapiis dros aseve SeiZleba ganviTardes
rArr purpura
rArr bulozuri gamonayari
mzis ultraiisferi sxivebiT TerapiamarTalia mzis sxivebs gaaCniaT mniSvnelovani iradiacia 425-475 nm magram radganac maRalia axalSobilis damwvrobis ganviTarebis riski (SiSveli axalSobilis mzeze yofnis gamo) es meTodi rekomendebuli ar aris
(Ronald J Wong 2005 (American Aacademy of Pediatrics 2004)
intravenuri imunoglobulinis gamoyenebarekomendacia izoimunuri hemolizuri daavadebis dros rekomendebulia intravenuri imunoglobulinis gamoyeneba (05-1 gkg 2 sT-s ganmavlobaSi) Tu Ssb imatebs intensiuri fotoTerapiis miuxedavad an Ssb aris 2-3 mgdl-iT (34-51mkmoll) naklebi SenacvlebiTi transfuziis Cvenebis doneze (fighellip4) aucilebelobis SemTxvevaSi intravenuri imunoglobulinis es doza SeiZleba ganmeordes 12 sT-Si (rekomendacia B) American Aacademy of Pediatrics 2004)
15
fotoTerapiis dros kanSi Calagebuli bilirubini swrafad iSleba amitom ar aris rekomendebuli kanis ferze dayrdnobiT SratSi
bilirubinis donis Sesafaseba rogorc fotoTerapiis dros ise misi Sewyvetidan 24 sT-is ganmavlobaSi
B
kvlevebiT dadgenilia rom intravenuri imunoglobulini amcirebs SenacvlebiTi transfuziis saWiroebas Rh da ABO hemolizuri daavadebis dros
SenacvlebiTi transfuzia
SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleluli unda iyos Semowmebuli da dasxivebuli gadasasxmeli sisxlis raodenoba Seadgens 170-180 mlkg
rekomendacia SenacvlebiTi transfuzia unda Caataros mxolod gamocdilma samedicino personalma intensiuri Terapiis ganyofilebaSi monitoringisa da srulyofili reanimaciis SesaZleblobis pirobebSi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
SenacvlebiTi transfuziis Cvenebebi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
mwvave bilirubinuli encefalopaTia intensiuri fotoTerapiis miuxedavad Ssb mateba an ucvleli
monacemi samSobiarodan gawerili axalSobilebis hospitalizaciis
SemTxvevaSi Ssb-s maRali maCvenebeli - aRemateba SenacvlebiTi transfuziis dawyebis maCvenebls (sqema 3) (transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia) (ix cxrili 6)
ba Sefardeba Ssb maCvenebelTan (cxrili 6) erTad gamoiyeneba rogorc damatebiTi faqtori SenacvlebiTi transfuziis dawyebis gansasazRvravad
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
sqema 3 SenacvlebiTi transfuziis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (American Academy of Pediatrics 2004)
16
D
D
cxrili 6 bilirubinisa da albuminis Sefardeba rodesac saWiroa SenacvlebiTi transfuzia (AMERICAN ACADEMY OF PEDIATRICS 2004)
riskis kategoria
ba Sefardeba rodesac saWiroa SenacvlebiTi
transfuziaSsb mgdl alb gdl
Ssb micromolL alb micromolL
axalSobilebi gestaciuri asaki - ge38 kvira 80 094
janmrTeli axalSobilebi gestaciuri asakiT an riskis jgufis axalSobilebi
gestaciuri asakiT ge38 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
72 084
riskis jgufis axalSobilebi gestaciuri asakiT 35ndash36 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
68 080
janmos rekomendacia sisxlis SenacvlebiTi gadasxmis Cvenebebis Sesaxeb mocemulia cxrilSi 7
cxrili 7 SenacvlebiTi transfuziis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI 15 260 13 220II 25 425 15 260
17
III 30 510 20 340IV da meti 30 510 20 340
Tu Ssb uaxlovdeba im dones rodesac naCvenebia SenacvlebiTi transfuzia
sisxli dauyovnebliv igzavneba raTa dadgindes jgufi da rezusi da SeTavseba Tu klinikaSi aris transfuziis saSualeba
an xorcieldeba referali
teqnika (AMERICAN ACADEMY OF PEDIATRICS 2004
bull mwvave bilirubinuli encefalopaTiis dros SenacvlebiTi transfuzia iwyeba dauyovnebliv
bull sxva SemTxvevaSi transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia
bull SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleuli unda iyos Semowmebuli da dasxivebuli
bull gadasasxmeli sisxlis raodenoba Seadgens axalSobilis mocirkulire sisxlis ormag raodenobas saSualod 170-180 mlkg an gadasasxmeli sisxlis gamosaTvleli formula gamoiTvleba 85 x axalSobilis wona kg x 2
bull SenacvlebisaTvis xdeba 2 venis an arteria da venis kaTeterizacia iReben bavSvis 20 ml sisxls da SeyavT 20 ml donoris sisxli (3-4 wT-is ganmavlobaSi) SemTbaris 367-3700C-mde
bull dRenaklulebsa da mZime mdgomareobaSi myof axalSobilebSi Senacvleba xdeba 5-10 ml-iT
axalSobilis momzadeba
bull kuWis SigTavsis aspiracia zondiT 8F da Ria zondis datoveba kuWSibull SeiZleba saWiro gaxdes bavSvis dabma
bull SeiZleba sawovaras gamoyeneba
bull Sardis Semkrebis gamoyeneba diurezis kontrolisTvisaxlSobilis winaswar Sefaseba
bull temperatura
bull guliscema
bull sunTqva
bull wneva
bull glukoza SratSi
bull Sardis analizi
bull ganavlis analizi sisxlis Semcvelobaze
bull kanis feri
bull tonusi
bull qcevauSualod transfuziis dros fasdeba vitaluri niSnebi (yovel 15 wT-Si)
18
bull temperatura
bull guliscema (mwvervalze) (umjobesia kardiomonitoriT)
bull sunTqva
bull kanis feri
bull qceva
monitoringi transfuziis Semdeg bull grZeldeba fotoTerapia
bull kardio monitoringi
bull sisxlis wneva proceduris damTavrebis Semdeg
bull saaTobrivad 6 sT-is ganmavlobaSi temperatura guliscema (mwvervalze) sunTqva
bull glukoza SratSi yovel 3 sT-Si 24 sT-is ganmavlobaSi
bull muclis garSemoweriloba 3-4 sT-Si 24 sT-is ganmavlobaSi nawlavebis peristaltikis auskultacia
bull Sardis analizi
bull ganavali sisxlis Semcvelobaze
bull sakvebis autanlobis niSnebi Rebineba muclis Seberva
bull Ssb 6 sT-Si erTxel
SenacvlebiTi transfuziis riskisikvdiloba - 3 SemTxveva 1000 transfuziaze SenacvlebiTi transfuziis dros garTulebis saxiT 5-Si vlindeba
- apnoe bradikardia cianozi vazospazmi Trombozi nekrozuli enterokoliti aseve SeiZleba ganviTardes hipoqsiur-iSemiuri encefalopaTia da SeZenili imunodeficitis sindromi
sxva mkurnalobafenobarbitali ndash xels uwyobs bilirubinis koniugacias da amcirebs
Ssb dones ar arsebobs sakmarisi mtkicebulebebi fenobarbitalis gamosayeneblad rodesac arsebobs siyviTlis mkurnalobis ufro efeqturi meTodebi (mag fotoTerapia)
referali AMERICAN ACADEMY OF PEDIATRICS 2004)referali maRali donis klinikaSi xorcieldeba Tu
ar aris fotoTerapiis Catarebis SesaZlebloba fotoTerapiis miuxedavad
rArr Ssb ar mcirdeba
rArr Ssb uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones da ar aris transfuziis saSualeba
rArr Ssbalbuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6)
Tu siyviTle gamovlinda I dRes siyviTlis lokalizaciis mixedviT siyviTlis simZimis Sefasebisas
(cxrili 1) dadgenili ldquosaSiSi siyviTlerdquo
bilirubinis maRali namati 85 micromolLsT (gt05 mgdlsT)
gaxangrZlivebuli siyviTle (14 dRe da meti) ojaxur anamnezSi mZime siyviTlis an kerniqterusis arseboba siyviTlis dros sxva daavadebis niSnebis arseboba (mg sefsisi)
19
riskis Sefaseba gaweramde
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
bull yvela axalSobilis gaweramde unda Sefasdes hiperbilirubinemiis ganviTarebis riski yvela ganyofilebas unda hqondes protokoli siyviTlis SefasebisTvis aseTi Sefaseba gansakuTrebiT mniSvnelovania im axalSobilebisaTvis romlebis ewerebian dabadebidan 72 sT-ze adre (rekomendacia C)
bull amerikis pediatrTa akademiis rekomendaciiT riskis SefasebisaTvis gamoyenebuli unda iqnas 2 midgoma (calcalke an kombinaciaSi) gaweris win bilirubinis gansazRvra (Ssb an tkb) daan klinikuri risk-faqtorebis Sefaseba risk-faqtorebis arseboba an Ssb maRali maCveneblebi gaweris Semdeg Sesabamisi meTvalyureobis aucilebelobis Cvenebaa (rekomendacia C)
bull yvela samSobiarom unda miawodos mSobels zepiri daan werilobiTi informacia binaze siyviTlis Sefasebis da saSiSroebis niSnebis Sesaxeb (rekomendacia D)
meTvalyureoba
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)bull yvela axalSobili samSobiarodan gaweriis Semdeg ramdenime dReSi unda Sefasdes kvalificuri samedicino profesionalis mier (rekomendacia C)
bull fasdeba - siyviTlis arseboba axalSobilis wona kvebis efeqturoba Rebinebis arseboba (rekomendacia C)
bull meTvalyureobis grafiki Tu axalSobili samSobiarodan ewereba 48-72 sT-Si samedicino Sefaseba tardeba 120 sT-is (5 dRe) asakSi (rekomendacia C)
bull Tu samSobiarodan gaweris Semdeg meTvalyureoba SeuZlebelia da arsebobs hiperbilirubinemiis ganviTarebis risk-faqtorebi axalSobilis gawera unda gadaidos sanam ar iqneba uzrunvelyofili Sesabamisi meTvalyureoba an sanam gaivlis maRali riskis periodi (72-96sT) (rekomendacia D)
11 gaidlainis gadasinjvisa da ganaxlebis vada ndash 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlainis SemuSavebis meTodologia
bull axalSobilTa hiperbilirubinemiis prevenciis diagnostikisa da marTvis principebis Sesaxeb arsebobs samecniero mtkicebulebis safuZvelze Seqmnil rekomendaciaTa sakmarisi raodenoba mocemuli gaidlainis Semqmnis procesSi samuSao jgufis gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve arsebuli praqtikuli rekomendaciebi moxda arsebuli
20
C
C
C
C
D
C
D
rekomendaciebis adaptirebuli variantis SemuSaveba romelic erTis mxriv pasuxebs saerTaSoriso moTxovnebs xolo meore mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa rogorc adamianur ise teqnikur resursebs
bull rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa bazis gamoyenebiT
cxrili 2
qveyana da resursis dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
httpwwwguidelinegov
Centers for Disease Control and Prevention (CDC)
httpwwwphppocdcgovCDCRecommendsAdvSearchVasp
Agency for Healthcare Research and Quality (AHRQ)
httpwwwahrqgovcliniccpgsixhtm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
httphstatnlmnihgov
Institute of Clinical Systems Improvement (ICSI)
httpwwwicsiorg
American Medical Association httpwwwama-assnorg
Canadian Medical Association (CMA)
httpmdmcacpgsnewcpgsindexasp
Health Canada ndash Population and Public Health Branch (PPHB)
httpwwwhc-scgccapphb-dgspspdpg_ehtml
didi britaneTi
National Institute for Clinical Excellence (NICE)
httpwwwniceorguk
Sheffield Evidence for Effectiveness and Knowledge (SEEK)
httpwwwshefacukseekguidelineshtm
National electronic Library for Health (NeLH)
httpwwwnelhnhsukguidelinesfinder
PRODIGY Clinical Guidance httpwwwprodigynhsukClinicalGuidance
Scottish Intercollegiate Guidelines Network (SIGN)
httpwwwsignacuk
German Guideline Information Service (GERGIS)
httpwwwleitliniendeenglishenglishview
avstralia
Australian National Health and httpwwwhealthgovauhfsnhmrcpublicatcp-
21
Medical Research Council (NHMRC) homehtmaxali zelandia
New Zealand Guidelines Group (NZGG)
httpwwwnzggorgnzlibrarycfm
mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba
httpwwwosdmorg
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi
bull koxreinis biblioTeka - The Cochrane Library 2006 Issue 2 bull amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini ndash MEDLINEbull jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvisgamoricxvis kriteriumebi
bull arCeul iqna kvlevebi Semdegi dizainiT randomizebuli kontrolirebadi sistemuri mimoxilvebi da meta-analizi erTmomentiani kohortuli kvlevebi
bull rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12 wliani SezRudva Tumca zogjer gamoyenebuli iyo ufro adreuli publikaciebi romlebic dResac aqtualuria da safuZvlad udevs sxva Tanamedrove mtkicebulebebs
bull dadgenili iyo enobrivi SezRudvebi radganac samuSao jgufs SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod inglisur da rusul enebze
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
bull samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri meToduri rekomendacia axalSobilTa hiperbilirubinemiis marTvis sakiTxebze romlebic Seicavda jgufis miznis Sesaferis saWiro informacias am rekomendaciebis Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (9496-98) samuSao jgufi xelmZRvanelobda saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mier SemuSavebuli nacionaluri gaidlainebis gzamkvleviT Sefasebis Sedegad amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi
rArr amerikis pediatrTa akademia
rArr msoflo jandacvis organizacia
rArr kanadis pediatrTa sazogadoeba ndash nayofi da axalSobilis komiteti
rArr britaneTis reproduqciuli janmrTelobis programa
22
bull rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da rekomendaciebis xarisxis sqema
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris
done (Muir Gray)xarisxi rekomendaciis xarisxi
(Cook et al)I Zlieri mtkicebuleba
eyrdnoba minimum erT sistemur mimoxilvas
romelic efuZneba swori dizainis mqone randomizebul
kontrolirebad kvleva
A eyrdnoba I donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erTi swori dizainis mqone
randomizebul kontrolirebad kvleva
B eyrdnoba II donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
III klinikuri kvleva randomizaciis gareSe
kohortuli da SemTxveva-kontrolis kvlevebi
C eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi
D eyrdnoba IV da V donis mtkicebulebas saWiroebs
konsesuss
Va avtoritetul profesionalTa mosazreba
Vb klinikuri gamocdileba aRwerilobiTi kvlevebi an
eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
15 avtorTa jgufi
bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis
bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi
rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
23
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24
wylis da deqstrozis damateba ar axdens hiperbilirubinemiis ganviTarebis profilaqtikasa da Ssb-s Semcirebas
bull yvela Rh (D) negatiur orsuls an melogines mizanSewonilia Cautardes anti D imonoglobuliniT profilaqtika (rekomendacia A)
minus orsulobis 28 kviraze (garda im SemTxvevebisa rodesac bavSvis mamac Rh (D) negatiuria)
minus mSobiarobidan 72 sT-is gamnavlobaSi Tu axalSobili Rh (D) pozituiria
minus orsulobis pirvel trimestrSi ganviTarebuli abortis da invaziuri procedurebis dros rogorica amniocentezi nayofis invaziuri procedurebi
meoradi profilaqtikarekomendacia klinicistma unda moaxdinos axalSobilTa hiperbilirubinemiis ganviTarebis riskebis sistemuri Sefaseba neonatalur periodSi (rekomendacia B)(AMERICAN ACADEMY OF PEDIATRICS 2004)
sisxlis jgufobriobarekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
yvela orsuli qali unda iyos gamokvleuli ABO da Rh(D) sisxlis jgufebze da hqondes Catarebuli skriningi SratSi izoimunur antisxeulebze (rekomendacia B)
Tu dedas ar Cautarebia prenatalurad sisxlis jgufis da rezusis gamokvleva an igis Rh negatiuria mkacrad aris rekomendirebuli pirdapiri antisxeulebis testis (an kumbsis testi) sisxlis jgufis da Rh (D) tipis gansazRvra axalSobilis (Wiplaris) sisxlSi (rekomendacia B)
Tu dedas sixlis jgufi aris O Rh(D) pozitiuri axalSobilis sisxlis jgufis da pirdapiri antisxeulis testis gansazRvris aucilebloba damokidebulia meTvalyureobis xarisxze gaweris win riskis Sefasebasa da gaweris Semdeg meTvalyureobaze (rekomendacia C)
mkurnalobis sqemamkurnalobis ZiriTadi principebia
fotoTerapia SenacvlebiTi transfuzia
mkurnaloba iwyeba fotoTerapiiTfotoTerapiis dros kanis zeda SreebSi Calagebuli arapirdapiri bilirubini iSleba fotoqimiuri gziT wyalSi xsnad koniugatebad romlebic gamoiyofa SardiT da naRveliTrekomendacia yvela samSobiaro saxli unda iyos aRWurvili mowyobilobiT romelic saWiroa intensiuri fotoTerapiisaTvis (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)fotoTerapiis Cvenebebi
fotoTerapia iwyeba Tu bulirubinis done aRemateba 95 percentils butanis nomogramaze (sqema 1) amave dros metad mniSvnelovania risk-faqtorebis gaTvaliswineba romlebic xels uwyobs mZime
10
A
B
B
B
C
D
hiperbiliruminemias (hemolizuri daavadeba g6fd deficiti asfiqsia mkveTrad gamoxatuli leTargia temperaturis arastabiluroba sefsisi acidozi an hipoalbuminemia lt30 gdl)
amerikis pediatriuli akademiis rekomendaciiT gamoiyeneba sqema (sqema 2) romelic axalSobilis asaksa da bilirubinis donesTan erTad iTvaliswinebs risk-faqtorebsa da gestaciur asaks mocemuli sqemis mixedviT ldquointensiurirdquo fotoTerapia iwyeba Semdegi principebiT
dabali riskis axalSobili (janmrTeli risk-faqtorebis gareSe gestacia gt 38 kvira) ndash Ssb gt12 mgdl (205 micromolL) 24 sT-Si Ssb gt15 mgdl (257 micromolL) 48 sT-Si Ssb gt18 mgdl (308 micromolL) gt72 sT
saSualo riskis axalSobili (gestacia gt 38 kvira da risk-faqtorebi an gestacia 35-37 kvira risk-faqtorebis gareSe gareSe) ndash Ssb gt 10 mgdl (171 micromolL) 24 sT-Si Ssb gt13 mgdl (222 micromolL) 48 sT-Si Ssb gt15 mgdl (257 micromolL) gt72 sT gestaciis 35 kviris axalSobilebSi fotoTerapia SeiZleba daiwyos ufro dabal maCveneblebze
maRali riskis axalSobili (gestacia 35-37 kvira da risk-faqtorebi) - Ssb gt 8 mgdl (137 micromolL) 24 sT-Si Ssb gt11 mgdl (188 micromolL) 48 sT-Si Ssb gt135 mgdl (231 micromolL) gt72 sT
Tu dabali riskis axalSobilebSi Ssb done 2-3 mgdl-iT dabalia moyvanil monacemebze SesaZlebelia mkurnalobis dawyeba ldquoCveulebrivirdquo fotoTerapiiT
bull stacionarSi gamoxatuli siyviTliT Semosul axalSobils utardeba ldquointensiurirdquo fotoTerapia bilirubinis maCveneblis gansazRvramde
bull ldquointensiurirdquo fotoTerapia aseve rekomendebulia hemolizuri daavadebis dros
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
janmos rekomendacia fotoTerapiis dawyebis Cvenebebis Sesaxeb mocemulia cxrilSi 4
cxrili 4 fotoTerapiis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI gamoxatuli siyviTleII 15 260 13 220III 18 310 16 270
IV da meti 20 340 17 290janmos rekomendaciiT fotoTerapia iwyeba Tu siyviTlis
lokalizaciis mixedviT siyviTlis simZimis Sefasebisas (cxrili 1) dadginda ldquosaSiSi siyviTlerdquo
Tu ar aris bilirubinis gansazRvris saSualeba Ssb savaraudo donis dasadgenaT SeiZleba krameris modificirebuli sqemis gamoyeneba
11
sqema 2 fotoTerapiis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (AMERICAN ACADEMY OF PEDIATRICS 2004)
rekomendacia Tu Sratis albuminis maCvenebeli naklebia 30 gdl-ze fotoTerapiis dawyeba rekomendebulis ufro dabali maCveneblebis dros (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis ukuCveneba pirdapiri (koniugirebuli) hiperbilirubinemia (pirdapiri
bilirubini Ssb-s 50-ze metia) (American Family Practice Notebook 2002 ) (AMERICAN ACADEMY OF PEDIATRICS 2004)
Tandayolili porfiria an porfiriis ojaxuri anamnezi (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis teqnikafotoTerapiis efeqturoba damokidebulia dozaze fotoTerapiis doza anu speqtruli iradiacia damokidebulia naTuris simZlavreze sinaTlis wyarosa da bavSvs Soris manZilsa da dasxivebis farTobze sinaTlis wyarofotoTerapiis sinaTlis speqtri damokidebulia sinaTlis wyaroze da filtrze yvelaze farTod gavrcelebuli fotoTerapiis mowyobiloba Seicavs dRis Suqis gril TeTr cisfer an ldquospecialur cisferrdquo fluorescentul naTurebs manZils sinaTlis wyarodan axalSobilamde didi mniSvneloba eniWeba sasurvelia axalSobili moTavsdes sinaTlis wyarodan im minimalur manZilze romelic miTiTebulia fotoTerapiis mowyobilobis instruqciaSi halogenis fotoTerapiis naTurebi ar SeiZleba moTavsdes axalSobilTan axlos radgan SeiZleba gamoiwvios damwvroba
12
DD
sxeulis zedapiris farTobibilirubinis maRali Semcvelobisas mniSvnelovania fotoTerapiis dros dasxivdes sxeulis zedapiris rac SeiZleba meti farTobi
ldquoCveulebrivi fotoTerapiardquo - sinaTlis speqtris iradiacia dabalia (6-12 microWcm2nm) (talRis sigrZe daaxloebiT 425-475 nm) da damokidebulia sxvadasxva mwarmoeblis mier mowodebul fotoTerapiiis sistemis aparatis monacemebze saWiroa aparatis Semowmeba Seesabameba Tu ara sinaTlis speqtris iradiacia mwarmoeblis mier mowodebul monacemebsldquointensiuri fotoTerapiardquo - lurj-mwvane speqtris iradiacia (talRis
sigrZe daaxloebiT 430-490 nm) sul cota 30 microWcm2nm-ia (isazRvreba axalSobilis kanze fototerapiis aparatis centris qveS) gazomva xdeba im warmoebis radiometriT romelic mowodebulia fotoTerapiiis sistemis aparatis mwarmoeblis mier sinaTlis talRis asareklad TeTreuli unda iyos TeTri kuvezi da sawolis gverdebi daifaros TeTri qsoviliT an aluminis folgiT
fotoTerapiis procedura da monitoringi
temperatura sinaTlis wyaros qveS unda iyos 28-300C
fotoTerapiis dros bavSvi unda iyos SiSveli ecvas erTjeradi higienuri safeni Tvalebze unda hqondes damcavi saTvale
yovel 3 saaTSi erTxel bavSvs unda Seucvalon pozicia
yovel 3 saaTSi erTxel unda Sefasdes sinaTlis wyaros qveS arsebuli temperatura da axalSobilis sxeulis temperatura Tu bavSvis t metia metia 3750C saWiroa oTaxis temperaturis daqveiTeba an fotoTerapiis droebiT Sewyveta sanam bavSvis temperatura ar iqneba normis farglebSi (365-3750C)
fotoTerapia mimdinareobas mudmivad igi wydeba mxolod im procedurebis dros romelTa warmoeba ra SeiZleba sinaTlis wyaros qveS
centraluri cianozis arsebobis Sesafaseblad fotoTerapia unda Sewydes mcire droiT
fotoTerapiis dros unda gagrZeldes bavSvis kveba
rArraxalSobilTan unda gagrZeldes ZuZuTi kveba moTxovnilebis mixedviT (intervali kvebaTa Soris araumetes 3 sT-isa) (rekomendacia C) ZuZuTi kvebis dros wydeba fotoTerapia da Sesabamisad bavSvs unda moexsnas damcavi saTvale
rArrTu bavSvi ikvebeba gamowvelili rZiT formuliT an parenteralurad misawodebeli sakvebis an siTxis raodenoba izrdeba dRiuri normis 10 -iT
rArr Tu bavSvi ikvebeba zondiT an parenteralurad fotoTerapia mimdinareobs uwyvetad
rArrCveulebriv fotoTerapiis dros axalSobils ar esaWiroeba damatebiT siTxis an sakvebis miwodeba damateba naCvenebia mxolod araefeqturi ZuZuTi kvebis sxeulis masis paTologiuri danakargis (gt10-ze mesame dRisTvis) da dehidrataciis SemTxvevaSi
13
C
fotoTerapiis dros bilirubinis daSlis produqtebi gamoiyofa SardiT da naRveliT adeqvaturi hidrataciis SenarCuneba da Sesabamisad adekvaturi diurzis SenarCuneba zrdis fotoTerapiis efeqturobas
zogierT axalSobils hiperbilirubinemiiT aReniSneba dehidratacia da saWiroa damatebiTi siTxis miwodeba (per-os an intravenurad) dehidrataciis koreqciisaTvis
araefeqturi ZuZuTi kvebis SemTxvevaSi fotoTerapiis dros axalSobils damatebiT miewodeba gamowvelili dedis rZe donoris rZe an xelovnuri sakvebi
rArr adeqvatur kvebaze miuTiTebs 4-6 sveli safeni 24 sT-Si da nawlavTa moqmedeba 3-4 jerdReSi meoTxe dRisaTvis
janmrTeli drouli axalSobilis nawlavTa moqmedeba da diurezi (minimaluri maCveneblebi) cxrili 5 (Fetus and Newborn Committee 1999)
dRe nawlavTa minimaluri moqmedeba24sT
sveli safeni24sT
1 1 12 1 23 1 gardamavali 34 2 yviTeli fafisebri 45 2YyviTeli fafisebri 5-6
rArrdehidrataciaze miuTiTebs Semdegi niSnebis arseboba - masis paTologiuri kleba (gt10-ze mesame dRisTvis)- anuria 4-6 sT- Cacvenili Tvalebi- Cavardnili yoflibandi - - daqveiTebuli kanis elastiuroba (kanis naoWi swordeba
nela)- daqveiTebuli kanis kapilaruli avseba (gt3 wm)- taqikardia- Sratis Na gt145 HCO3 lt17
bilirubinis monitoringi fotoTerapiis dros (American Aacademy of Pediatrics 2004)
sawyisi bilirubinis maCveneblis Semcireba 6-20-iT standartuli da 30-40-iT intensiuri fotoTerapiis dawyebidan 24sT-Si mis efeqturobaze miuTiTebs
bull Tu Ssb ge 25 mgdL (428 micromolL) ganmeorebiTi gansazRvra 2ndash3 sT-Si
bull Tu Ssb 20ndash25 mgdL (342ndash428 micromolL) ganmeorebiTi gansazRvra 3-4 sT-Si
bull Tu Ssb lt20 mgdL (342 micromolL) ganmeorebiTi gansazRvra 4ndash6 sT-Si Tu Ssb agrZelebs daqveiTebas ganmeorebiTi gansazRvra 8-12 sT-Si
bull Tu Ssb ar mcirdeba an uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones an Ssb albuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6) iwyeba SenacvlebiTi transfuzia Tu amis saSualeba aris an xorcieldeba referali
bull intensiur fotoTerapiis miuxedavad Ssb-is ucvleli done an mateba miuTiTebs hemolizze
14
rArr anemiahemolizis Sefaseba SesaZlebelia sisxlis saerTo analizis mixedviT - Hgblt 130 glLHct lt 40 retikulocitebi - gt 6
bull Ssb lt 13ndash14 mgdL (239 micromolL) fotoTerapia wydeba
bull fotoTerapiis Sewyvetidan 24 sT-Si kontroldeba Ssb Tu Ssb moimata im donemde romelzec daiwyo fotoTerapia fotoTerapia ganmeorebiT iwyeba
fotoTerapiis garTulebebi
fotoTerapiis garTulebebi (Ronald J Wong 2005 American Aacademy of Pediatrics 2004)
rArrmwvane feris ganavalidiarea (mkurnalobas ar saWiroebs)
rArr dehidratacia
rArr muclis Seberva (mkurnalobas ar saWiroebs)
rArr Tvalis SesaZlo dazianeba yvelaze seriozuli magram iSviaTi klinikuri garTulebaa brinjaos
axalSobilis sindromi romelic vlindeba qolestazuri siyviTlis mqone axalSobilSi kanis Sratis da Sardis muqi nacrisfer-yavisferi SeferilobiT brinjaos axalSobilis sindromi ar vlindeba qolestazis mqone yvela axalSobilTan Tu arsebobs fotoTerapiis Cveneba pirdapiri hiperbilirubinemia ar warmoadgens fotoTerapiis winaaRmdeg Cvenebas axalSobilebSi romelTac uviTardebaT brinjaos sindromi naCvenebia SenacvlebiTi transfuzia monacemebis arasrulyofilebis gamo mkacri rekomendaciis gakeTeba ar SeiZleba
mZime qolestazuri siyviTlis mqone axalSobilebSi fotoTerapiis dros aseve SeiZleba ganviTardes
rArr purpura
rArr bulozuri gamonayari
mzis ultraiisferi sxivebiT TerapiamarTalia mzis sxivebs gaaCniaT mniSvnelovani iradiacia 425-475 nm magram radganac maRalia axalSobilis damwvrobis ganviTarebis riski (SiSveli axalSobilis mzeze yofnis gamo) es meTodi rekomendebuli ar aris
(Ronald J Wong 2005 (American Aacademy of Pediatrics 2004)
intravenuri imunoglobulinis gamoyenebarekomendacia izoimunuri hemolizuri daavadebis dros rekomendebulia intravenuri imunoglobulinis gamoyeneba (05-1 gkg 2 sT-s ganmavlobaSi) Tu Ssb imatebs intensiuri fotoTerapiis miuxedavad an Ssb aris 2-3 mgdl-iT (34-51mkmoll) naklebi SenacvlebiTi transfuziis Cvenebis doneze (fighellip4) aucilebelobis SemTxvevaSi intravenuri imunoglobulinis es doza SeiZleba ganmeordes 12 sT-Si (rekomendacia B) American Aacademy of Pediatrics 2004)
15
fotoTerapiis dros kanSi Calagebuli bilirubini swrafad iSleba amitom ar aris rekomendebuli kanis ferze dayrdnobiT SratSi
bilirubinis donis Sesafaseba rogorc fotoTerapiis dros ise misi Sewyvetidan 24 sT-is ganmavlobaSi
B
kvlevebiT dadgenilia rom intravenuri imunoglobulini amcirebs SenacvlebiTi transfuziis saWiroebas Rh da ABO hemolizuri daavadebis dros
SenacvlebiTi transfuzia
SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleluli unda iyos Semowmebuli da dasxivebuli gadasasxmeli sisxlis raodenoba Seadgens 170-180 mlkg
rekomendacia SenacvlebiTi transfuzia unda Caataros mxolod gamocdilma samedicino personalma intensiuri Terapiis ganyofilebaSi monitoringisa da srulyofili reanimaciis SesaZleblobis pirobebSi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
SenacvlebiTi transfuziis Cvenebebi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
mwvave bilirubinuli encefalopaTia intensiuri fotoTerapiis miuxedavad Ssb mateba an ucvleli
monacemi samSobiarodan gawerili axalSobilebis hospitalizaciis
SemTxvevaSi Ssb-s maRali maCvenebeli - aRemateba SenacvlebiTi transfuziis dawyebis maCvenebls (sqema 3) (transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia) (ix cxrili 6)
ba Sefardeba Ssb maCvenebelTan (cxrili 6) erTad gamoiyeneba rogorc damatebiTi faqtori SenacvlebiTi transfuziis dawyebis gansasazRvravad
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
sqema 3 SenacvlebiTi transfuziis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (American Academy of Pediatrics 2004)
16
D
D
cxrili 6 bilirubinisa da albuminis Sefardeba rodesac saWiroa SenacvlebiTi transfuzia (AMERICAN ACADEMY OF PEDIATRICS 2004)
riskis kategoria
ba Sefardeba rodesac saWiroa SenacvlebiTi
transfuziaSsb mgdl alb gdl
Ssb micromolL alb micromolL
axalSobilebi gestaciuri asaki - ge38 kvira 80 094
janmrTeli axalSobilebi gestaciuri asakiT an riskis jgufis axalSobilebi
gestaciuri asakiT ge38 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
72 084
riskis jgufis axalSobilebi gestaciuri asakiT 35ndash36 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
68 080
janmos rekomendacia sisxlis SenacvlebiTi gadasxmis Cvenebebis Sesaxeb mocemulia cxrilSi 7
cxrili 7 SenacvlebiTi transfuziis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI 15 260 13 220II 25 425 15 260
17
III 30 510 20 340IV da meti 30 510 20 340
Tu Ssb uaxlovdeba im dones rodesac naCvenebia SenacvlebiTi transfuzia
sisxli dauyovnebliv igzavneba raTa dadgindes jgufi da rezusi da SeTavseba Tu klinikaSi aris transfuziis saSualeba
an xorcieldeba referali
teqnika (AMERICAN ACADEMY OF PEDIATRICS 2004
bull mwvave bilirubinuli encefalopaTiis dros SenacvlebiTi transfuzia iwyeba dauyovnebliv
bull sxva SemTxvevaSi transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia
bull SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleuli unda iyos Semowmebuli da dasxivebuli
bull gadasasxmeli sisxlis raodenoba Seadgens axalSobilis mocirkulire sisxlis ormag raodenobas saSualod 170-180 mlkg an gadasasxmeli sisxlis gamosaTvleli formula gamoiTvleba 85 x axalSobilis wona kg x 2
bull SenacvlebisaTvis xdeba 2 venis an arteria da venis kaTeterizacia iReben bavSvis 20 ml sisxls da SeyavT 20 ml donoris sisxli (3-4 wT-is ganmavlobaSi) SemTbaris 367-3700C-mde
bull dRenaklulebsa da mZime mdgomareobaSi myof axalSobilebSi Senacvleba xdeba 5-10 ml-iT
axalSobilis momzadeba
bull kuWis SigTavsis aspiracia zondiT 8F da Ria zondis datoveba kuWSibull SeiZleba saWiro gaxdes bavSvis dabma
bull SeiZleba sawovaras gamoyeneba
bull Sardis Semkrebis gamoyeneba diurezis kontrolisTvisaxlSobilis winaswar Sefaseba
bull temperatura
bull guliscema
bull sunTqva
bull wneva
bull glukoza SratSi
bull Sardis analizi
bull ganavlis analizi sisxlis Semcvelobaze
bull kanis feri
bull tonusi
bull qcevauSualod transfuziis dros fasdeba vitaluri niSnebi (yovel 15 wT-Si)
18
bull temperatura
bull guliscema (mwvervalze) (umjobesia kardiomonitoriT)
bull sunTqva
bull kanis feri
bull qceva
monitoringi transfuziis Semdeg bull grZeldeba fotoTerapia
bull kardio monitoringi
bull sisxlis wneva proceduris damTavrebis Semdeg
bull saaTobrivad 6 sT-is ganmavlobaSi temperatura guliscema (mwvervalze) sunTqva
bull glukoza SratSi yovel 3 sT-Si 24 sT-is ganmavlobaSi
bull muclis garSemoweriloba 3-4 sT-Si 24 sT-is ganmavlobaSi nawlavebis peristaltikis auskultacia
bull Sardis analizi
bull ganavali sisxlis Semcvelobaze
bull sakvebis autanlobis niSnebi Rebineba muclis Seberva
bull Ssb 6 sT-Si erTxel
SenacvlebiTi transfuziis riskisikvdiloba - 3 SemTxveva 1000 transfuziaze SenacvlebiTi transfuziis dros garTulebis saxiT 5-Si vlindeba
- apnoe bradikardia cianozi vazospazmi Trombozi nekrozuli enterokoliti aseve SeiZleba ganviTardes hipoqsiur-iSemiuri encefalopaTia da SeZenili imunodeficitis sindromi
sxva mkurnalobafenobarbitali ndash xels uwyobs bilirubinis koniugacias da amcirebs
Ssb dones ar arsebobs sakmarisi mtkicebulebebi fenobarbitalis gamosayeneblad rodesac arsebobs siyviTlis mkurnalobis ufro efeqturi meTodebi (mag fotoTerapia)
referali AMERICAN ACADEMY OF PEDIATRICS 2004)referali maRali donis klinikaSi xorcieldeba Tu
ar aris fotoTerapiis Catarebis SesaZlebloba fotoTerapiis miuxedavad
rArr Ssb ar mcirdeba
rArr Ssb uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones da ar aris transfuziis saSualeba
rArr Ssbalbuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6)
Tu siyviTle gamovlinda I dRes siyviTlis lokalizaciis mixedviT siyviTlis simZimis Sefasebisas
(cxrili 1) dadgenili ldquosaSiSi siyviTlerdquo
bilirubinis maRali namati 85 micromolLsT (gt05 mgdlsT)
gaxangrZlivebuli siyviTle (14 dRe da meti) ojaxur anamnezSi mZime siyviTlis an kerniqterusis arseboba siyviTlis dros sxva daavadebis niSnebis arseboba (mg sefsisi)
19
riskis Sefaseba gaweramde
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
bull yvela axalSobilis gaweramde unda Sefasdes hiperbilirubinemiis ganviTarebis riski yvela ganyofilebas unda hqondes protokoli siyviTlis SefasebisTvis aseTi Sefaseba gansakuTrebiT mniSvnelovania im axalSobilebisaTvis romlebis ewerebian dabadebidan 72 sT-ze adre (rekomendacia C)
bull amerikis pediatrTa akademiis rekomendaciiT riskis SefasebisaTvis gamoyenebuli unda iqnas 2 midgoma (calcalke an kombinaciaSi) gaweris win bilirubinis gansazRvra (Ssb an tkb) daan klinikuri risk-faqtorebis Sefaseba risk-faqtorebis arseboba an Ssb maRali maCveneblebi gaweris Semdeg Sesabamisi meTvalyureobis aucilebelobis Cvenebaa (rekomendacia C)
bull yvela samSobiarom unda miawodos mSobels zepiri daan werilobiTi informacia binaze siyviTlis Sefasebis da saSiSroebis niSnebis Sesaxeb (rekomendacia D)
meTvalyureoba
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)bull yvela axalSobili samSobiarodan gaweriis Semdeg ramdenime dReSi unda Sefasdes kvalificuri samedicino profesionalis mier (rekomendacia C)
bull fasdeba - siyviTlis arseboba axalSobilis wona kvebis efeqturoba Rebinebis arseboba (rekomendacia C)
bull meTvalyureobis grafiki Tu axalSobili samSobiarodan ewereba 48-72 sT-Si samedicino Sefaseba tardeba 120 sT-is (5 dRe) asakSi (rekomendacia C)
bull Tu samSobiarodan gaweris Semdeg meTvalyureoba SeuZlebelia da arsebobs hiperbilirubinemiis ganviTarebis risk-faqtorebi axalSobilis gawera unda gadaidos sanam ar iqneba uzrunvelyofili Sesabamisi meTvalyureoba an sanam gaivlis maRali riskis periodi (72-96sT) (rekomendacia D)
11 gaidlainis gadasinjvisa da ganaxlebis vada ndash 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlainis SemuSavebis meTodologia
bull axalSobilTa hiperbilirubinemiis prevenciis diagnostikisa da marTvis principebis Sesaxeb arsebobs samecniero mtkicebulebis safuZvelze Seqmnil rekomendaciaTa sakmarisi raodenoba mocemuli gaidlainis Semqmnis procesSi samuSao jgufis gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve arsebuli praqtikuli rekomendaciebi moxda arsebuli
20
C
C
C
C
D
C
D
rekomendaciebis adaptirebuli variantis SemuSaveba romelic erTis mxriv pasuxebs saerTaSoriso moTxovnebs xolo meore mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa rogorc adamianur ise teqnikur resursebs
bull rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa bazis gamoyenebiT
cxrili 2
qveyana da resursis dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
httpwwwguidelinegov
Centers for Disease Control and Prevention (CDC)
httpwwwphppocdcgovCDCRecommendsAdvSearchVasp
Agency for Healthcare Research and Quality (AHRQ)
httpwwwahrqgovcliniccpgsixhtm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
httphstatnlmnihgov
Institute of Clinical Systems Improvement (ICSI)
httpwwwicsiorg
American Medical Association httpwwwama-assnorg
Canadian Medical Association (CMA)
httpmdmcacpgsnewcpgsindexasp
Health Canada ndash Population and Public Health Branch (PPHB)
httpwwwhc-scgccapphb-dgspspdpg_ehtml
didi britaneTi
National Institute for Clinical Excellence (NICE)
httpwwwniceorguk
Sheffield Evidence for Effectiveness and Knowledge (SEEK)
httpwwwshefacukseekguidelineshtm
National electronic Library for Health (NeLH)
httpwwwnelhnhsukguidelinesfinder
PRODIGY Clinical Guidance httpwwwprodigynhsukClinicalGuidance
Scottish Intercollegiate Guidelines Network (SIGN)
httpwwwsignacuk
German Guideline Information Service (GERGIS)
httpwwwleitliniendeenglishenglishview
avstralia
Australian National Health and httpwwwhealthgovauhfsnhmrcpublicatcp-
21
Medical Research Council (NHMRC) homehtmaxali zelandia
New Zealand Guidelines Group (NZGG)
httpwwwnzggorgnzlibrarycfm
mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba
httpwwwosdmorg
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi
bull koxreinis biblioTeka - The Cochrane Library 2006 Issue 2 bull amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini ndash MEDLINEbull jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvisgamoricxvis kriteriumebi
bull arCeul iqna kvlevebi Semdegi dizainiT randomizebuli kontrolirebadi sistemuri mimoxilvebi da meta-analizi erTmomentiani kohortuli kvlevebi
bull rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12 wliani SezRudva Tumca zogjer gamoyenebuli iyo ufro adreuli publikaciebi romlebic dResac aqtualuria da safuZvlad udevs sxva Tanamedrove mtkicebulebebs
bull dadgenili iyo enobrivi SezRudvebi radganac samuSao jgufs SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod inglisur da rusul enebze
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
bull samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri meToduri rekomendacia axalSobilTa hiperbilirubinemiis marTvis sakiTxebze romlebic Seicavda jgufis miznis Sesaferis saWiro informacias am rekomendaciebis Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (9496-98) samuSao jgufi xelmZRvanelobda saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mier SemuSavebuli nacionaluri gaidlainebis gzamkvleviT Sefasebis Sedegad amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi
rArr amerikis pediatrTa akademia
rArr msoflo jandacvis organizacia
rArr kanadis pediatrTa sazogadoeba ndash nayofi da axalSobilis komiteti
rArr britaneTis reproduqciuli janmrTelobis programa
22
bull rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da rekomendaciebis xarisxis sqema
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris
done (Muir Gray)xarisxi rekomendaciis xarisxi
(Cook et al)I Zlieri mtkicebuleba
eyrdnoba minimum erT sistemur mimoxilvas
romelic efuZneba swori dizainis mqone randomizebul
kontrolirebad kvleva
A eyrdnoba I donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erTi swori dizainis mqone
randomizebul kontrolirebad kvleva
B eyrdnoba II donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
III klinikuri kvleva randomizaciis gareSe
kohortuli da SemTxveva-kontrolis kvlevebi
C eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi
D eyrdnoba IV da V donis mtkicebulebas saWiroebs
konsesuss
Va avtoritetul profesionalTa mosazreba
Vb klinikuri gamocdileba aRwerilobiTi kvlevebi an
eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
15 avtorTa jgufi
bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis
bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi
rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
23
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24
hiperbiliruminemias (hemolizuri daavadeba g6fd deficiti asfiqsia mkveTrad gamoxatuli leTargia temperaturis arastabiluroba sefsisi acidozi an hipoalbuminemia lt30 gdl)
amerikis pediatriuli akademiis rekomendaciiT gamoiyeneba sqema (sqema 2) romelic axalSobilis asaksa da bilirubinis donesTan erTad iTvaliswinebs risk-faqtorebsa da gestaciur asaks mocemuli sqemis mixedviT ldquointensiurirdquo fotoTerapia iwyeba Semdegi principebiT
dabali riskis axalSobili (janmrTeli risk-faqtorebis gareSe gestacia gt 38 kvira) ndash Ssb gt12 mgdl (205 micromolL) 24 sT-Si Ssb gt15 mgdl (257 micromolL) 48 sT-Si Ssb gt18 mgdl (308 micromolL) gt72 sT
saSualo riskis axalSobili (gestacia gt 38 kvira da risk-faqtorebi an gestacia 35-37 kvira risk-faqtorebis gareSe gareSe) ndash Ssb gt 10 mgdl (171 micromolL) 24 sT-Si Ssb gt13 mgdl (222 micromolL) 48 sT-Si Ssb gt15 mgdl (257 micromolL) gt72 sT gestaciis 35 kviris axalSobilebSi fotoTerapia SeiZleba daiwyos ufro dabal maCveneblebze
maRali riskis axalSobili (gestacia 35-37 kvira da risk-faqtorebi) - Ssb gt 8 mgdl (137 micromolL) 24 sT-Si Ssb gt11 mgdl (188 micromolL) 48 sT-Si Ssb gt135 mgdl (231 micromolL) gt72 sT
Tu dabali riskis axalSobilebSi Ssb done 2-3 mgdl-iT dabalia moyvanil monacemebze SesaZlebelia mkurnalobis dawyeba ldquoCveulebrivirdquo fotoTerapiiT
bull stacionarSi gamoxatuli siyviTliT Semosul axalSobils utardeba ldquointensiurirdquo fotoTerapia bilirubinis maCveneblis gansazRvramde
bull ldquointensiurirdquo fotoTerapia aseve rekomendebulia hemolizuri daavadebis dros
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
janmos rekomendacia fotoTerapiis dawyebis Cvenebebis Sesaxeb mocemulia cxrilSi 4
cxrili 4 fotoTerapiis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI gamoxatuli siyviTleII 15 260 13 220III 18 310 16 270
IV da meti 20 340 17 290janmos rekomendaciiT fotoTerapia iwyeba Tu siyviTlis
lokalizaciis mixedviT siyviTlis simZimis Sefasebisas (cxrili 1) dadginda ldquosaSiSi siyviTlerdquo
Tu ar aris bilirubinis gansazRvris saSualeba Ssb savaraudo donis dasadgenaT SeiZleba krameris modificirebuli sqemis gamoyeneba
11
sqema 2 fotoTerapiis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (AMERICAN ACADEMY OF PEDIATRICS 2004)
rekomendacia Tu Sratis albuminis maCvenebeli naklebia 30 gdl-ze fotoTerapiis dawyeba rekomendebulis ufro dabali maCveneblebis dros (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis ukuCveneba pirdapiri (koniugirebuli) hiperbilirubinemia (pirdapiri
bilirubini Ssb-s 50-ze metia) (American Family Practice Notebook 2002 ) (AMERICAN ACADEMY OF PEDIATRICS 2004)
Tandayolili porfiria an porfiriis ojaxuri anamnezi (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis teqnikafotoTerapiis efeqturoba damokidebulia dozaze fotoTerapiis doza anu speqtruli iradiacia damokidebulia naTuris simZlavreze sinaTlis wyarosa da bavSvs Soris manZilsa da dasxivebis farTobze sinaTlis wyarofotoTerapiis sinaTlis speqtri damokidebulia sinaTlis wyaroze da filtrze yvelaze farTod gavrcelebuli fotoTerapiis mowyobiloba Seicavs dRis Suqis gril TeTr cisfer an ldquospecialur cisferrdquo fluorescentul naTurebs manZils sinaTlis wyarodan axalSobilamde didi mniSvneloba eniWeba sasurvelia axalSobili moTavsdes sinaTlis wyarodan im minimalur manZilze romelic miTiTebulia fotoTerapiis mowyobilobis instruqciaSi halogenis fotoTerapiis naTurebi ar SeiZleba moTavsdes axalSobilTan axlos radgan SeiZleba gamoiwvios damwvroba
12
DD
sxeulis zedapiris farTobibilirubinis maRali Semcvelobisas mniSvnelovania fotoTerapiis dros dasxivdes sxeulis zedapiris rac SeiZleba meti farTobi
ldquoCveulebrivi fotoTerapiardquo - sinaTlis speqtris iradiacia dabalia (6-12 microWcm2nm) (talRis sigrZe daaxloebiT 425-475 nm) da damokidebulia sxvadasxva mwarmoeblis mier mowodebul fotoTerapiiis sistemis aparatis monacemebze saWiroa aparatis Semowmeba Seesabameba Tu ara sinaTlis speqtris iradiacia mwarmoeblis mier mowodebul monacemebsldquointensiuri fotoTerapiardquo - lurj-mwvane speqtris iradiacia (talRis
sigrZe daaxloebiT 430-490 nm) sul cota 30 microWcm2nm-ia (isazRvreba axalSobilis kanze fototerapiis aparatis centris qveS) gazomva xdeba im warmoebis radiometriT romelic mowodebulia fotoTerapiiis sistemis aparatis mwarmoeblis mier sinaTlis talRis asareklad TeTreuli unda iyos TeTri kuvezi da sawolis gverdebi daifaros TeTri qsoviliT an aluminis folgiT
fotoTerapiis procedura da monitoringi
temperatura sinaTlis wyaros qveS unda iyos 28-300C
fotoTerapiis dros bavSvi unda iyos SiSveli ecvas erTjeradi higienuri safeni Tvalebze unda hqondes damcavi saTvale
yovel 3 saaTSi erTxel bavSvs unda Seucvalon pozicia
yovel 3 saaTSi erTxel unda Sefasdes sinaTlis wyaros qveS arsebuli temperatura da axalSobilis sxeulis temperatura Tu bavSvis t metia metia 3750C saWiroa oTaxis temperaturis daqveiTeba an fotoTerapiis droebiT Sewyveta sanam bavSvis temperatura ar iqneba normis farglebSi (365-3750C)
fotoTerapia mimdinareobas mudmivad igi wydeba mxolod im procedurebis dros romelTa warmoeba ra SeiZleba sinaTlis wyaros qveS
centraluri cianozis arsebobis Sesafaseblad fotoTerapia unda Sewydes mcire droiT
fotoTerapiis dros unda gagrZeldes bavSvis kveba
rArraxalSobilTan unda gagrZeldes ZuZuTi kveba moTxovnilebis mixedviT (intervali kvebaTa Soris araumetes 3 sT-isa) (rekomendacia C) ZuZuTi kvebis dros wydeba fotoTerapia da Sesabamisad bavSvs unda moexsnas damcavi saTvale
rArrTu bavSvi ikvebeba gamowvelili rZiT formuliT an parenteralurad misawodebeli sakvebis an siTxis raodenoba izrdeba dRiuri normis 10 -iT
rArr Tu bavSvi ikvebeba zondiT an parenteralurad fotoTerapia mimdinareobs uwyvetad
rArrCveulebriv fotoTerapiis dros axalSobils ar esaWiroeba damatebiT siTxis an sakvebis miwodeba damateba naCvenebia mxolod araefeqturi ZuZuTi kvebis sxeulis masis paTologiuri danakargis (gt10-ze mesame dRisTvis) da dehidrataciis SemTxvevaSi
13
C
fotoTerapiis dros bilirubinis daSlis produqtebi gamoiyofa SardiT da naRveliT adeqvaturi hidrataciis SenarCuneba da Sesabamisad adekvaturi diurzis SenarCuneba zrdis fotoTerapiis efeqturobas
zogierT axalSobils hiperbilirubinemiiT aReniSneba dehidratacia da saWiroa damatebiTi siTxis miwodeba (per-os an intravenurad) dehidrataciis koreqciisaTvis
araefeqturi ZuZuTi kvebis SemTxvevaSi fotoTerapiis dros axalSobils damatebiT miewodeba gamowvelili dedis rZe donoris rZe an xelovnuri sakvebi
rArr adeqvatur kvebaze miuTiTebs 4-6 sveli safeni 24 sT-Si da nawlavTa moqmedeba 3-4 jerdReSi meoTxe dRisaTvis
janmrTeli drouli axalSobilis nawlavTa moqmedeba da diurezi (minimaluri maCveneblebi) cxrili 5 (Fetus and Newborn Committee 1999)
dRe nawlavTa minimaluri moqmedeba24sT
sveli safeni24sT
1 1 12 1 23 1 gardamavali 34 2 yviTeli fafisebri 45 2YyviTeli fafisebri 5-6
rArrdehidrataciaze miuTiTebs Semdegi niSnebis arseboba - masis paTologiuri kleba (gt10-ze mesame dRisTvis)- anuria 4-6 sT- Cacvenili Tvalebi- Cavardnili yoflibandi - - daqveiTebuli kanis elastiuroba (kanis naoWi swordeba
nela)- daqveiTebuli kanis kapilaruli avseba (gt3 wm)- taqikardia- Sratis Na gt145 HCO3 lt17
bilirubinis monitoringi fotoTerapiis dros (American Aacademy of Pediatrics 2004)
sawyisi bilirubinis maCveneblis Semcireba 6-20-iT standartuli da 30-40-iT intensiuri fotoTerapiis dawyebidan 24sT-Si mis efeqturobaze miuTiTebs
bull Tu Ssb ge 25 mgdL (428 micromolL) ganmeorebiTi gansazRvra 2ndash3 sT-Si
bull Tu Ssb 20ndash25 mgdL (342ndash428 micromolL) ganmeorebiTi gansazRvra 3-4 sT-Si
bull Tu Ssb lt20 mgdL (342 micromolL) ganmeorebiTi gansazRvra 4ndash6 sT-Si Tu Ssb agrZelebs daqveiTebas ganmeorebiTi gansazRvra 8-12 sT-Si
bull Tu Ssb ar mcirdeba an uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones an Ssb albuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6) iwyeba SenacvlebiTi transfuzia Tu amis saSualeba aris an xorcieldeba referali
bull intensiur fotoTerapiis miuxedavad Ssb-is ucvleli done an mateba miuTiTebs hemolizze
14
rArr anemiahemolizis Sefaseba SesaZlebelia sisxlis saerTo analizis mixedviT - Hgblt 130 glLHct lt 40 retikulocitebi - gt 6
bull Ssb lt 13ndash14 mgdL (239 micromolL) fotoTerapia wydeba
bull fotoTerapiis Sewyvetidan 24 sT-Si kontroldeba Ssb Tu Ssb moimata im donemde romelzec daiwyo fotoTerapia fotoTerapia ganmeorebiT iwyeba
fotoTerapiis garTulebebi
fotoTerapiis garTulebebi (Ronald J Wong 2005 American Aacademy of Pediatrics 2004)
rArrmwvane feris ganavalidiarea (mkurnalobas ar saWiroebs)
rArr dehidratacia
rArr muclis Seberva (mkurnalobas ar saWiroebs)
rArr Tvalis SesaZlo dazianeba yvelaze seriozuli magram iSviaTi klinikuri garTulebaa brinjaos
axalSobilis sindromi romelic vlindeba qolestazuri siyviTlis mqone axalSobilSi kanis Sratis da Sardis muqi nacrisfer-yavisferi SeferilobiT brinjaos axalSobilis sindromi ar vlindeba qolestazis mqone yvela axalSobilTan Tu arsebobs fotoTerapiis Cveneba pirdapiri hiperbilirubinemia ar warmoadgens fotoTerapiis winaaRmdeg Cvenebas axalSobilebSi romelTac uviTardebaT brinjaos sindromi naCvenebia SenacvlebiTi transfuzia monacemebis arasrulyofilebis gamo mkacri rekomendaciis gakeTeba ar SeiZleba
mZime qolestazuri siyviTlis mqone axalSobilebSi fotoTerapiis dros aseve SeiZleba ganviTardes
rArr purpura
rArr bulozuri gamonayari
mzis ultraiisferi sxivebiT TerapiamarTalia mzis sxivebs gaaCniaT mniSvnelovani iradiacia 425-475 nm magram radganac maRalia axalSobilis damwvrobis ganviTarebis riski (SiSveli axalSobilis mzeze yofnis gamo) es meTodi rekomendebuli ar aris
(Ronald J Wong 2005 (American Aacademy of Pediatrics 2004)
intravenuri imunoglobulinis gamoyenebarekomendacia izoimunuri hemolizuri daavadebis dros rekomendebulia intravenuri imunoglobulinis gamoyeneba (05-1 gkg 2 sT-s ganmavlobaSi) Tu Ssb imatebs intensiuri fotoTerapiis miuxedavad an Ssb aris 2-3 mgdl-iT (34-51mkmoll) naklebi SenacvlebiTi transfuziis Cvenebis doneze (fighellip4) aucilebelobis SemTxvevaSi intravenuri imunoglobulinis es doza SeiZleba ganmeordes 12 sT-Si (rekomendacia B) American Aacademy of Pediatrics 2004)
15
fotoTerapiis dros kanSi Calagebuli bilirubini swrafad iSleba amitom ar aris rekomendebuli kanis ferze dayrdnobiT SratSi
bilirubinis donis Sesafaseba rogorc fotoTerapiis dros ise misi Sewyvetidan 24 sT-is ganmavlobaSi
B
kvlevebiT dadgenilia rom intravenuri imunoglobulini amcirebs SenacvlebiTi transfuziis saWiroebas Rh da ABO hemolizuri daavadebis dros
SenacvlebiTi transfuzia
SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleluli unda iyos Semowmebuli da dasxivebuli gadasasxmeli sisxlis raodenoba Seadgens 170-180 mlkg
rekomendacia SenacvlebiTi transfuzia unda Caataros mxolod gamocdilma samedicino personalma intensiuri Terapiis ganyofilebaSi monitoringisa da srulyofili reanimaciis SesaZleblobis pirobebSi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
SenacvlebiTi transfuziis Cvenebebi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
mwvave bilirubinuli encefalopaTia intensiuri fotoTerapiis miuxedavad Ssb mateba an ucvleli
monacemi samSobiarodan gawerili axalSobilebis hospitalizaciis
SemTxvevaSi Ssb-s maRali maCvenebeli - aRemateba SenacvlebiTi transfuziis dawyebis maCvenebls (sqema 3) (transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia) (ix cxrili 6)
ba Sefardeba Ssb maCvenebelTan (cxrili 6) erTad gamoiyeneba rogorc damatebiTi faqtori SenacvlebiTi transfuziis dawyebis gansasazRvravad
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
sqema 3 SenacvlebiTi transfuziis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (American Academy of Pediatrics 2004)
16
D
D
cxrili 6 bilirubinisa da albuminis Sefardeba rodesac saWiroa SenacvlebiTi transfuzia (AMERICAN ACADEMY OF PEDIATRICS 2004)
riskis kategoria
ba Sefardeba rodesac saWiroa SenacvlebiTi
transfuziaSsb mgdl alb gdl
Ssb micromolL alb micromolL
axalSobilebi gestaciuri asaki - ge38 kvira 80 094
janmrTeli axalSobilebi gestaciuri asakiT an riskis jgufis axalSobilebi
gestaciuri asakiT ge38 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
72 084
riskis jgufis axalSobilebi gestaciuri asakiT 35ndash36 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
68 080
janmos rekomendacia sisxlis SenacvlebiTi gadasxmis Cvenebebis Sesaxeb mocemulia cxrilSi 7
cxrili 7 SenacvlebiTi transfuziis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI 15 260 13 220II 25 425 15 260
17
III 30 510 20 340IV da meti 30 510 20 340
Tu Ssb uaxlovdeba im dones rodesac naCvenebia SenacvlebiTi transfuzia
sisxli dauyovnebliv igzavneba raTa dadgindes jgufi da rezusi da SeTavseba Tu klinikaSi aris transfuziis saSualeba
an xorcieldeba referali
teqnika (AMERICAN ACADEMY OF PEDIATRICS 2004
bull mwvave bilirubinuli encefalopaTiis dros SenacvlebiTi transfuzia iwyeba dauyovnebliv
bull sxva SemTxvevaSi transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia
bull SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleuli unda iyos Semowmebuli da dasxivebuli
bull gadasasxmeli sisxlis raodenoba Seadgens axalSobilis mocirkulire sisxlis ormag raodenobas saSualod 170-180 mlkg an gadasasxmeli sisxlis gamosaTvleli formula gamoiTvleba 85 x axalSobilis wona kg x 2
bull SenacvlebisaTvis xdeba 2 venis an arteria da venis kaTeterizacia iReben bavSvis 20 ml sisxls da SeyavT 20 ml donoris sisxli (3-4 wT-is ganmavlobaSi) SemTbaris 367-3700C-mde
bull dRenaklulebsa da mZime mdgomareobaSi myof axalSobilebSi Senacvleba xdeba 5-10 ml-iT
axalSobilis momzadeba
bull kuWis SigTavsis aspiracia zondiT 8F da Ria zondis datoveba kuWSibull SeiZleba saWiro gaxdes bavSvis dabma
bull SeiZleba sawovaras gamoyeneba
bull Sardis Semkrebis gamoyeneba diurezis kontrolisTvisaxlSobilis winaswar Sefaseba
bull temperatura
bull guliscema
bull sunTqva
bull wneva
bull glukoza SratSi
bull Sardis analizi
bull ganavlis analizi sisxlis Semcvelobaze
bull kanis feri
bull tonusi
bull qcevauSualod transfuziis dros fasdeba vitaluri niSnebi (yovel 15 wT-Si)
18
bull temperatura
bull guliscema (mwvervalze) (umjobesia kardiomonitoriT)
bull sunTqva
bull kanis feri
bull qceva
monitoringi transfuziis Semdeg bull grZeldeba fotoTerapia
bull kardio monitoringi
bull sisxlis wneva proceduris damTavrebis Semdeg
bull saaTobrivad 6 sT-is ganmavlobaSi temperatura guliscema (mwvervalze) sunTqva
bull glukoza SratSi yovel 3 sT-Si 24 sT-is ganmavlobaSi
bull muclis garSemoweriloba 3-4 sT-Si 24 sT-is ganmavlobaSi nawlavebis peristaltikis auskultacia
bull Sardis analizi
bull ganavali sisxlis Semcvelobaze
bull sakvebis autanlobis niSnebi Rebineba muclis Seberva
bull Ssb 6 sT-Si erTxel
SenacvlebiTi transfuziis riskisikvdiloba - 3 SemTxveva 1000 transfuziaze SenacvlebiTi transfuziis dros garTulebis saxiT 5-Si vlindeba
- apnoe bradikardia cianozi vazospazmi Trombozi nekrozuli enterokoliti aseve SeiZleba ganviTardes hipoqsiur-iSemiuri encefalopaTia da SeZenili imunodeficitis sindromi
sxva mkurnalobafenobarbitali ndash xels uwyobs bilirubinis koniugacias da amcirebs
Ssb dones ar arsebobs sakmarisi mtkicebulebebi fenobarbitalis gamosayeneblad rodesac arsebobs siyviTlis mkurnalobis ufro efeqturi meTodebi (mag fotoTerapia)
referali AMERICAN ACADEMY OF PEDIATRICS 2004)referali maRali donis klinikaSi xorcieldeba Tu
ar aris fotoTerapiis Catarebis SesaZlebloba fotoTerapiis miuxedavad
rArr Ssb ar mcirdeba
rArr Ssb uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones da ar aris transfuziis saSualeba
rArr Ssbalbuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6)
Tu siyviTle gamovlinda I dRes siyviTlis lokalizaciis mixedviT siyviTlis simZimis Sefasebisas
(cxrili 1) dadgenili ldquosaSiSi siyviTlerdquo
bilirubinis maRali namati 85 micromolLsT (gt05 mgdlsT)
gaxangrZlivebuli siyviTle (14 dRe da meti) ojaxur anamnezSi mZime siyviTlis an kerniqterusis arseboba siyviTlis dros sxva daavadebis niSnebis arseboba (mg sefsisi)
19
riskis Sefaseba gaweramde
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
bull yvela axalSobilis gaweramde unda Sefasdes hiperbilirubinemiis ganviTarebis riski yvela ganyofilebas unda hqondes protokoli siyviTlis SefasebisTvis aseTi Sefaseba gansakuTrebiT mniSvnelovania im axalSobilebisaTvis romlebis ewerebian dabadebidan 72 sT-ze adre (rekomendacia C)
bull amerikis pediatrTa akademiis rekomendaciiT riskis SefasebisaTvis gamoyenebuli unda iqnas 2 midgoma (calcalke an kombinaciaSi) gaweris win bilirubinis gansazRvra (Ssb an tkb) daan klinikuri risk-faqtorebis Sefaseba risk-faqtorebis arseboba an Ssb maRali maCveneblebi gaweris Semdeg Sesabamisi meTvalyureobis aucilebelobis Cvenebaa (rekomendacia C)
bull yvela samSobiarom unda miawodos mSobels zepiri daan werilobiTi informacia binaze siyviTlis Sefasebis da saSiSroebis niSnebis Sesaxeb (rekomendacia D)
meTvalyureoba
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)bull yvela axalSobili samSobiarodan gaweriis Semdeg ramdenime dReSi unda Sefasdes kvalificuri samedicino profesionalis mier (rekomendacia C)
bull fasdeba - siyviTlis arseboba axalSobilis wona kvebis efeqturoba Rebinebis arseboba (rekomendacia C)
bull meTvalyureobis grafiki Tu axalSobili samSobiarodan ewereba 48-72 sT-Si samedicino Sefaseba tardeba 120 sT-is (5 dRe) asakSi (rekomendacia C)
bull Tu samSobiarodan gaweris Semdeg meTvalyureoba SeuZlebelia da arsebobs hiperbilirubinemiis ganviTarebis risk-faqtorebi axalSobilis gawera unda gadaidos sanam ar iqneba uzrunvelyofili Sesabamisi meTvalyureoba an sanam gaivlis maRali riskis periodi (72-96sT) (rekomendacia D)
11 gaidlainis gadasinjvisa da ganaxlebis vada ndash 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlainis SemuSavebis meTodologia
bull axalSobilTa hiperbilirubinemiis prevenciis diagnostikisa da marTvis principebis Sesaxeb arsebobs samecniero mtkicebulebis safuZvelze Seqmnil rekomendaciaTa sakmarisi raodenoba mocemuli gaidlainis Semqmnis procesSi samuSao jgufis gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve arsebuli praqtikuli rekomendaciebi moxda arsebuli
20
C
C
C
C
D
C
D
rekomendaciebis adaptirebuli variantis SemuSaveba romelic erTis mxriv pasuxebs saerTaSoriso moTxovnebs xolo meore mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa rogorc adamianur ise teqnikur resursebs
bull rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa bazis gamoyenebiT
cxrili 2
qveyana da resursis dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
httpwwwguidelinegov
Centers for Disease Control and Prevention (CDC)
httpwwwphppocdcgovCDCRecommendsAdvSearchVasp
Agency for Healthcare Research and Quality (AHRQ)
httpwwwahrqgovcliniccpgsixhtm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
httphstatnlmnihgov
Institute of Clinical Systems Improvement (ICSI)
httpwwwicsiorg
American Medical Association httpwwwama-assnorg
Canadian Medical Association (CMA)
httpmdmcacpgsnewcpgsindexasp
Health Canada ndash Population and Public Health Branch (PPHB)
httpwwwhc-scgccapphb-dgspspdpg_ehtml
didi britaneTi
National Institute for Clinical Excellence (NICE)
httpwwwniceorguk
Sheffield Evidence for Effectiveness and Knowledge (SEEK)
httpwwwshefacukseekguidelineshtm
National electronic Library for Health (NeLH)
httpwwwnelhnhsukguidelinesfinder
PRODIGY Clinical Guidance httpwwwprodigynhsukClinicalGuidance
Scottish Intercollegiate Guidelines Network (SIGN)
httpwwwsignacuk
German Guideline Information Service (GERGIS)
httpwwwleitliniendeenglishenglishview
avstralia
Australian National Health and httpwwwhealthgovauhfsnhmrcpublicatcp-
21
Medical Research Council (NHMRC) homehtmaxali zelandia
New Zealand Guidelines Group (NZGG)
httpwwwnzggorgnzlibrarycfm
mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba
httpwwwosdmorg
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi
bull koxreinis biblioTeka - The Cochrane Library 2006 Issue 2 bull amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini ndash MEDLINEbull jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvisgamoricxvis kriteriumebi
bull arCeul iqna kvlevebi Semdegi dizainiT randomizebuli kontrolirebadi sistemuri mimoxilvebi da meta-analizi erTmomentiani kohortuli kvlevebi
bull rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12 wliani SezRudva Tumca zogjer gamoyenebuli iyo ufro adreuli publikaciebi romlebic dResac aqtualuria da safuZvlad udevs sxva Tanamedrove mtkicebulebebs
bull dadgenili iyo enobrivi SezRudvebi radganac samuSao jgufs SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod inglisur da rusul enebze
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
bull samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri meToduri rekomendacia axalSobilTa hiperbilirubinemiis marTvis sakiTxebze romlebic Seicavda jgufis miznis Sesaferis saWiro informacias am rekomendaciebis Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (9496-98) samuSao jgufi xelmZRvanelobda saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mier SemuSavebuli nacionaluri gaidlainebis gzamkvleviT Sefasebis Sedegad amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi
rArr amerikis pediatrTa akademia
rArr msoflo jandacvis organizacia
rArr kanadis pediatrTa sazogadoeba ndash nayofi da axalSobilis komiteti
rArr britaneTis reproduqciuli janmrTelobis programa
22
bull rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da rekomendaciebis xarisxis sqema
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris
done (Muir Gray)xarisxi rekomendaciis xarisxi
(Cook et al)I Zlieri mtkicebuleba
eyrdnoba minimum erT sistemur mimoxilvas
romelic efuZneba swori dizainis mqone randomizebul
kontrolirebad kvleva
A eyrdnoba I donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erTi swori dizainis mqone
randomizebul kontrolirebad kvleva
B eyrdnoba II donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
III klinikuri kvleva randomizaciis gareSe
kohortuli da SemTxveva-kontrolis kvlevebi
C eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi
D eyrdnoba IV da V donis mtkicebulebas saWiroebs
konsesuss
Va avtoritetul profesionalTa mosazreba
Vb klinikuri gamocdileba aRwerilobiTi kvlevebi an
eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
15 avtorTa jgufi
bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis
bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi
rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
23
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24
sqema 2 fotoTerapiis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (AMERICAN ACADEMY OF PEDIATRICS 2004)
rekomendacia Tu Sratis albuminis maCvenebeli naklebia 30 gdl-ze fotoTerapiis dawyeba rekomendebulis ufro dabali maCveneblebis dros (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis ukuCveneba pirdapiri (koniugirebuli) hiperbilirubinemia (pirdapiri
bilirubini Ssb-s 50-ze metia) (American Family Practice Notebook 2002 ) (AMERICAN ACADEMY OF PEDIATRICS 2004)
Tandayolili porfiria an porfiriis ojaxuri anamnezi (AMERICAN ACADEMY OF PEDIATRICS 2004)
fotoTerapiis teqnikafotoTerapiis efeqturoba damokidebulia dozaze fotoTerapiis doza anu speqtruli iradiacia damokidebulia naTuris simZlavreze sinaTlis wyarosa da bavSvs Soris manZilsa da dasxivebis farTobze sinaTlis wyarofotoTerapiis sinaTlis speqtri damokidebulia sinaTlis wyaroze da filtrze yvelaze farTod gavrcelebuli fotoTerapiis mowyobiloba Seicavs dRis Suqis gril TeTr cisfer an ldquospecialur cisferrdquo fluorescentul naTurebs manZils sinaTlis wyarodan axalSobilamde didi mniSvneloba eniWeba sasurvelia axalSobili moTavsdes sinaTlis wyarodan im minimalur manZilze romelic miTiTebulia fotoTerapiis mowyobilobis instruqciaSi halogenis fotoTerapiis naTurebi ar SeiZleba moTavsdes axalSobilTan axlos radgan SeiZleba gamoiwvios damwvroba
12
DD
sxeulis zedapiris farTobibilirubinis maRali Semcvelobisas mniSvnelovania fotoTerapiis dros dasxivdes sxeulis zedapiris rac SeiZleba meti farTobi
ldquoCveulebrivi fotoTerapiardquo - sinaTlis speqtris iradiacia dabalia (6-12 microWcm2nm) (talRis sigrZe daaxloebiT 425-475 nm) da damokidebulia sxvadasxva mwarmoeblis mier mowodebul fotoTerapiiis sistemis aparatis monacemebze saWiroa aparatis Semowmeba Seesabameba Tu ara sinaTlis speqtris iradiacia mwarmoeblis mier mowodebul monacemebsldquointensiuri fotoTerapiardquo - lurj-mwvane speqtris iradiacia (talRis
sigrZe daaxloebiT 430-490 nm) sul cota 30 microWcm2nm-ia (isazRvreba axalSobilis kanze fototerapiis aparatis centris qveS) gazomva xdeba im warmoebis radiometriT romelic mowodebulia fotoTerapiiis sistemis aparatis mwarmoeblis mier sinaTlis talRis asareklad TeTreuli unda iyos TeTri kuvezi da sawolis gverdebi daifaros TeTri qsoviliT an aluminis folgiT
fotoTerapiis procedura da monitoringi
temperatura sinaTlis wyaros qveS unda iyos 28-300C
fotoTerapiis dros bavSvi unda iyos SiSveli ecvas erTjeradi higienuri safeni Tvalebze unda hqondes damcavi saTvale
yovel 3 saaTSi erTxel bavSvs unda Seucvalon pozicia
yovel 3 saaTSi erTxel unda Sefasdes sinaTlis wyaros qveS arsebuli temperatura da axalSobilis sxeulis temperatura Tu bavSvis t metia metia 3750C saWiroa oTaxis temperaturis daqveiTeba an fotoTerapiis droebiT Sewyveta sanam bavSvis temperatura ar iqneba normis farglebSi (365-3750C)
fotoTerapia mimdinareobas mudmivad igi wydeba mxolod im procedurebis dros romelTa warmoeba ra SeiZleba sinaTlis wyaros qveS
centraluri cianozis arsebobis Sesafaseblad fotoTerapia unda Sewydes mcire droiT
fotoTerapiis dros unda gagrZeldes bavSvis kveba
rArraxalSobilTan unda gagrZeldes ZuZuTi kveba moTxovnilebis mixedviT (intervali kvebaTa Soris araumetes 3 sT-isa) (rekomendacia C) ZuZuTi kvebis dros wydeba fotoTerapia da Sesabamisad bavSvs unda moexsnas damcavi saTvale
rArrTu bavSvi ikvebeba gamowvelili rZiT formuliT an parenteralurad misawodebeli sakvebis an siTxis raodenoba izrdeba dRiuri normis 10 -iT
rArr Tu bavSvi ikvebeba zondiT an parenteralurad fotoTerapia mimdinareobs uwyvetad
rArrCveulebriv fotoTerapiis dros axalSobils ar esaWiroeba damatebiT siTxis an sakvebis miwodeba damateba naCvenebia mxolod araefeqturi ZuZuTi kvebis sxeulis masis paTologiuri danakargis (gt10-ze mesame dRisTvis) da dehidrataciis SemTxvevaSi
13
C
fotoTerapiis dros bilirubinis daSlis produqtebi gamoiyofa SardiT da naRveliT adeqvaturi hidrataciis SenarCuneba da Sesabamisad adekvaturi diurzis SenarCuneba zrdis fotoTerapiis efeqturobas
zogierT axalSobils hiperbilirubinemiiT aReniSneba dehidratacia da saWiroa damatebiTi siTxis miwodeba (per-os an intravenurad) dehidrataciis koreqciisaTvis
araefeqturi ZuZuTi kvebis SemTxvevaSi fotoTerapiis dros axalSobils damatebiT miewodeba gamowvelili dedis rZe donoris rZe an xelovnuri sakvebi
rArr adeqvatur kvebaze miuTiTebs 4-6 sveli safeni 24 sT-Si da nawlavTa moqmedeba 3-4 jerdReSi meoTxe dRisaTvis
janmrTeli drouli axalSobilis nawlavTa moqmedeba da diurezi (minimaluri maCveneblebi) cxrili 5 (Fetus and Newborn Committee 1999)
dRe nawlavTa minimaluri moqmedeba24sT
sveli safeni24sT
1 1 12 1 23 1 gardamavali 34 2 yviTeli fafisebri 45 2YyviTeli fafisebri 5-6
rArrdehidrataciaze miuTiTebs Semdegi niSnebis arseboba - masis paTologiuri kleba (gt10-ze mesame dRisTvis)- anuria 4-6 sT- Cacvenili Tvalebi- Cavardnili yoflibandi - - daqveiTebuli kanis elastiuroba (kanis naoWi swordeba
nela)- daqveiTebuli kanis kapilaruli avseba (gt3 wm)- taqikardia- Sratis Na gt145 HCO3 lt17
bilirubinis monitoringi fotoTerapiis dros (American Aacademy of Pediatrics 2004)
sawyisi bilirubinis maCveneblis Semcireba 6-20-iT standartuli da 30-40-iT intensiuri fotoTerapiis dawyebidan 24sT-Si mis efeqturobaze miuTiTebs
bull Tu Ssb ge 25 mgdL (428 micromolL) ganmeorebiTi gansazRvra 2ndash3 sT-Si
bull Tu Ssb 20ndash25 mgdL (342ndash428 micromolL) ganmeorebiTi gansazRvra 3-4 sT-Si
bull Tu Ssb lt20 mgdL (342 micromolL) ganmeorebiTi gansazRvra 4ndash6 sT-Si Tu Ssb agrZelebs daqveiTebas ganmeorebiTi gansazRvra 8-12 sT-Si
bull Tu Ssb ar mcirdeba an uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones an Ssb albuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6) iwyeba SenacvlebiTi transfuzia Tu amis saSualeba aris an xorcieldeba referali
bull intensiur fotoTerapiis miuxedavad Ssb-is ucvleli done an mateba miuTiTebs hemolizze
14
rArr anemiahemolizis Sefaseba SesaZlebelia sisxlis saerTo analizis mixedviT - Hgblt 130 glLHct lt 40 retikulocitebi - gt 6
bull Ssb lt 13ndash14 mgdL (239 micromolL) fotoTerapia wydeba
bull fotoTerapiis Sewyvetidan 24 sT-Si kontroldeba Ssb Tu Ssb moimata im donemde romelzec daiwyo fotoTerapia fotoTerapia ganmeorebiT iwyeba
fotoTerapiis garTulebebi
fotoTerapiis garTulebebi (Ronald J Wong 2005 American Aacademy of Pediatrics 2004)
rArrmwvane feris ganavalidiarea (mkurnalobas ar saWiroebs)
rArr dehidratacia
rArr muclis Seberva (mkurnalobas ar saWiroebs)
rArr Tvalis SesaZlo dazianeba yvelaze seriozuli magram iSviaTi klinikuri garTulebaa brinjaos
axalSobilis sindromi romelic vlindeba qolestazuri siyviTlis mqone axalSobilSi kanis Sratis da Sardis muqi nacrisfer-yavisferi SeferilobiT brinjaos axalSobilis sindromi ar vlindeba qolestazis mqone yvela axalSobilTan Tu arsebobs fotoTerapiis Cveneba pirdapiri hiperbilirubinemia ar warmoadgens fotoTerapiis winaaRmdeg Cvenebas axalSobilebSi romelTac uviTardebaT brinjaos sindromi naCvenebia SenacvlebiTi transfuzia monacemebis arasrulyofilebis gamo mkacri rekomendaciis gakeTeba ar SeiZleba
mZime qolestazuri siyviTlis mqone axalSobilebSi fotoTerapiis dros aseve SeiZleba ganviTardes
rArr purpura
rArr bulozuri gamonayari
mzis ultraiisferi sxivebiT TerapiamarTalia mzis sxivebs gaaCniaT mniSvnelovani iradiacia 425-475 nm magram radganac maRalia axalSobilis damwvrobis ganviTarebis riski (SiSveli axalSobilis mzeze yofnis gamo) es meTodi rekomendebuli ar aris
(Ronald J Wong 2005 (American Aacademy of Pediatrics 2004)
intravenuri imunoglobulinis gamoyenebarekomendacia izoimunuri hemolizuri daavadebis dros rekomendebulia intravenuri imunoglobulinis gamoyeneba (05-1 gkg 2 sT-s ganmavlobaSi) Tu Ssb imatebs intensiuri fotoTerapiis miuxedavad an Ssb aris 2-3 mgdl-iT (34-51mkmoll) naklebi SenacvlebiTi transfuziis Cvenebis doneze (fighellip4) aucilebelobis SemTxvevaSi intravenuri imunoglobulinis es doza SeiZleba ganmeordes 12 sT-Si (rekomendacia B) American Aacademy of Pediatrics 2004)
15
fotoTerapiis dros kanSi Calagebuli bilirubini swrafad iSleba amitom ar aris rekomendebuli kanis ferze dayrdnobiT SratSi
bilirubinis donis Sesafaseba rogorc fotoTerapiis dros ise misi Sewyvetidan 24 sT-is ganmavlobaSi
B
kvlevebiT dadgenilia rom intravenuri imunoglobulini amcirebs SenacvlebiTi transfuziis saWiroebas Rh da ABO hemolizuri daavadebis dros
SenacvlebiTi transfuzia
SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleluli unda iyos Semowmebuli da dasxivebuli gadasasxmeli sisxlis raodenoba Seadgens 170-180 mlkg
rekomendacia SenacvlebiTi transfuzia unda Caataros mxolod gamocdilma samedicino personalma intensiuri Terapiis ganyofilebaSi monitoringisa da srulyofili reanimaciis SesaZleblobis pirobebSi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
SenacvlebiTi transfuziis Cvenebebi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
mwvave bilirubinuli encefalopaTia intensiuri fotoTerapiis miuxedavad Ssb mateba an ucvleli
monacemi samSobiarodan gawerili axalSobilebis hospitalizaciis
SemTxvevaSi Ssb-s maRali maCvenebeli - aRemateba SenacvlebiTi transfuziis dawyebis maCvenebls (sqema 3) (transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia) (ix cxrili 6)
ba Sefardeba Ssb maCvenebelTan (cxrili 6) erTad gamoiyeneba rogorc damatebiTi faqtori SenacvlebiTi transfuziis dawyebis gansasazRvravad
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
sqema 3 SenacvlebiTi transfuziis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (American Academy of Pediatrics 2004)
16
D
D
cxrili 6 bilirubinisa da albuminis Sefardeba rodesac saWiroa SenacvlebiTi transfuzia (AMERICAN ACADEMY OF PEDIATRICS 2004)
riskis kategoria
ba Sefardeba rodesac saWiroa SenacvlebiTi
transfuziaSsb mgdl alb gdl
Ssb micromolL alb micromolL
axalSobilebi gestaciuri asaki - ge38 kvira 80 094
janmrTeli axalSobilebi gestaciuri asakiT an riskis jgufis axalSobilebi
gestaciuri asakiT ge38 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
72 084
riskis jgufis axalSobilebi gestaciuri asakiT 35ndash36 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
68 080
janmos rekomendacia sisxlis SenacvlebiTi gadasxmis Cvenebebis Sesaxeb mocemulia cxrilSi 7
cxrili 7 SenacvlebiTi transfuziis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI 15 260 13 220II 25 425 15 260
17
III 30 510 20 340IV da meti 30 510 20 340
Tu Ssb uaxlovdeba im dones rodesac naCvenebia SenacvlebiTi transfuzia
sisxli dauyovnebliv igzavneba raTa dadgindes jgufi da rezusi da SeTavseba Tu klinikaSi aris transfuziis saSualeba
an xorcieldeba referali
teqnika (AMERICAN ACADEMY OF PEDIATRICS 2004
bull mwvave bilirubinuli encefalopaTiis dros SenacvlebiTi transfuzia iwyeba dauyovnebliv
bull sxva SemTxvevaSi transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia
bull SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleuli unda iyos Semowmebuli da dasxivebuli
bull gadasasxmeli sisxlis raodenoba Seadgens axalSobilis mocirkulire sisxlis ormag raodenobas saSualod 170-180 mlkg an gadasasxmeli sisxlis gamosaTvleli formula gamoiTvleba 85 x axalSobilis wona kg x 2
bull SenacvlebisaTvis xdeba 2 venis an arteria da venis kaTeterizacia iReben bavSvis 20 ml sisxls da SeyavT 20 ml donoris sisxli (3-4 wT-is ganmavlobaSi) SemTbaris 367-3700C-mde
bull dRenaklulebsa da mZime mdgomareobaSi myof axalSobilebSi Senacvleba xdeba 5-10 ml-iT
axalSobilis momzadeba
bull kuWis SigTavsis aspiracia zondiT 8F da Ria zondis datoveba kuWSibull SeiZleba saWiro gaxdes bavSvis dabma
bull SeiZleba sawovaras gamoyeneba
bull Sardis Semkrebis gamoyeneba diurezis kontrolisTvisaxlSobilis winaswar Sefaseba
bull temperatura
bull guliscema
bull sunTqva
bull wneva
bull glukoza SratSi
bull Sardis analizi
bull ganavlis analizi sisxlis Semcvelobaze
bull kanis feri
bull tonusi
bull qcevauSualod transfuziis dros fasdeba vitaluri niSnebi (yovel 15 wT-Si)
18
bull temperatura
bull guliscema (mwvervalze) (umjobesia kardiomonitoriT)
bull sunTqva
bull kanis feri
bull qceva
monitoringi transfuziis Semdeg bull grZeldeba fotoTerapia
bull kardio monitoringi
bull sisxlis wneva proceduris damTavrebis Semdeg
bull saaTobrivad 6 sT-is ganmavlobaSi temperatura guliscema (mwvervalze) sunTqva
bull glukoza SratSi yovel 3 sT-Si 24 sT-is ganmavlobaSi
bull muclis garSemoweriloba 3-4 sT-Si 24 sT-is ganmavlobaSi nawlavebis peristaltikis auskultacia
bull Sardis analizi
bull ganavali sisxlis Semcvelobaze
bull sakvebis autanlobis niSnebi Rebineba muclis Seberva
bull Ssb 6 sT-Si erTxel
SenacvlebiTi transfuziis riskisikvdiloba - 3 SemTxveva 1000 transfuziaze SenacvlebiTi transfuziis dros garTulebis saxiT 5-Si vlindeba
- apnoe bradikardia cianozi vazospazmi Trombozi nekrozuli enterokoliti aseve SeiZleba ganviTardes hipoqsiur-iSemiuri encefalopaTia da SeZenili imunodeficitis sindromi
sxva mkurnalobafenobarbitali ndash xels uwyobs bilirubinis koniugacias da amcirebs
Ssb dones ar arsebobs sakmarisi mtkicebulebebi fenobarbitalis gamosayeneblad rodesac arsebobs siyviTlis mkurnalobis ufro efeqturi meTodebi (mag fotoTerapia)
referali AMERICAN ACADEMY OF PEDIATRICS 2004)referali maRali donis klinikaSi xorcieldeba Tu
ar aris fotoTerapiis Catarebis SesaZlebloba fotoTerapiis miuxedavad
rArr Ssb ar mcirdeba
rArr Ssb uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones da ar aris transfuziis saSualeba
rArr Ssbalbuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6)
Tu siyviTle gamovlinda I dRes siyviTlis lokalizaciis mixedviT siyviTlis simZimis Sefasebisas
(cxrili 1) dadgenili ldquosaSiSi siyviTlerdquo
bilirubinis maRali namati 85 micromolLsT (gt05 mgdlsT)
gaxangrZlivebuli siyviTle (14 dRe da meti) ojaxur anamnezSi mZime siyviTlis an kerniqterusis arseboba siyviTlis dros sxva daavadebis niSnebis arseboba (mg sefsisi)
19
riskis Sefaseba gaweramde
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
bull yvela axalSobilis gaweramde unda Sefasdes hiperbilirubinemiis ganviTarebis riski yvela ganyofilebas unda hqondes protokoli siyviTlis SefasebisTvis aseTi Sefaseba gansakuTrebiT mniSvnelovania im axalSobilebisaTvis romlebis ewerebian dabadebidan 72 sT-ze adre (rekomendacia C)
bull amerikis pediatrTa akademiis rekomendaciiT riskis SefasebisaTvis gamoyenebuli unda iqnas 2 midgoma (calcalke an kombinaciaSi) gaweris win bilirubinis gansazRvra (Ssb an tkb) daan klinikuri risk-faqtorebis Sefaseba risk-faqtorebis arseboba an Ssb maRali maCveneblebi gaweris Semdeg Sesabamisi meTvalyureobis aucilebelobis Cvenebaa (rekomendacia C)
bull yvela samSobiarom unda miawodos mSobels zepiri daan werilobiTi informacia binaze siyviTlis Sefasebis da saSiSroebis niSnebis Sesaxeb (rekomendacia D)
meTvalyureoba
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)bull yvela axalSobili samSobiarodan gaweriis Semdeg ramdenime dReSi unda Sefasdes kvalificuri samedicino profesionalis mier (rekomendacia C)
bull fasdeba - siyviTlis arseboba axalSobilis wona kvebis efeqturoba Rebinebis arseboba (rekomendacia C)
bull meTvalyureobis grafiki Tu axalSobili samSobiarodan ewereba 48-72 sT-Si samedicino Sefaseba tardeba 120 sT-is (5 dRe) asakSi (rekomendacia C)
bull Tu samSobiarodan gaweris Semdeg meTvalyureoba SeuZlebelia da arsebobs hiperbilirubinemiis ganviTarebis risk-faqtorebi axalSobilis gawera unda gadaidos sanam ar iqneba uzrunvelyofili Sesabamisi meTvalyureoba an sanam gaivlis maRali riskis periodi (72-96sT) (rekomendacia D)
11 gaidlainis gadasinjvisa da ganaxlebis vada ndash 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlainis SemuSavebis meTodologia
bull axalSobilTa hiperbilirubinemiis prevenciis diagnostikisa da marTvis principebis Sesaxeb arsebobs samecniero mtkicebulebis safuZvelze Seqmnil rekomendaciaTa sakmarisi raodenoba mocemuli gaidlainis Semqmnis procesSi samuSao jgufis gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve arsebuli praqtikuli rekomendaciebi moxda arsebuli
20
C
C
C
C
D
C
D
rekomendaciebis adaptirebuli variantis SemuSaveba romelic erTis mxriv pasuxebs saerTaSoriso moTxovnebs xolo meore mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa rogorc adamianur ise teqnikur resursebs
bull rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa bazis gamoyenebiT
cxrili 2
qveyana da resursis dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
httpwwwguidelinegov
Centers for Disease Control and Prevention (CDC)
httpwwwphppocdcgovCDCRecommendsAdvSearchVasp
Agency for Healthcare Research and Quality (AHRQ)
httpwwwahrqgovcliniccpgsixhtm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
httphstatnlmnihgov
Institute of Clinical Systems Improvement (ICSI)
httpwwwicsiorg
American Medical Association httpwwwama-assnorg
Canadian Medical Association (CMA)
httpmdmcacpgsnewcpgsindexasp
Health Canada ndash Population and Public Health Branch (PPHB)
httpwwwhc-scgccapphb-dgspspdpg_ehtml
didi britaneTi
National Institute for Clinical Excellence (NICE)
httpwwwniceorguk
Sheffield Evidence for Effectiveness and Knowledge (SEEK)
httpwwwshefacukseekguidelineshtm
National electronic Library for Health (NeLH)
httpwwwnelhnhsukguidelinesfinder
PRODIGY Clinical Guidance httpwwwprodigynhsukClinicalGuidance
Scottish Intercollegiate Guidelines Network (SIGN)
httpwwwsignacuk
German Guideline Information Service (GERGIS)
httpwwwleitliniendeenglishenglishview
avstralia
Australian National Health and httpwwwhealthgovauhfsnhmrcpublicatcp-
21
Medical Research Council (NHMRC) homehtmaxali zelandia
New Zealand Guidelines Group (NZGG)
httpwwwnzggorgnzlibrarycfm
mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba
httpwwwosdmorg
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi
bull koxreinis biblioTeka - The Cochrane Library 2006 Issue 2 bull amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini ndash MEDLINEbull jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvisgamoricxvis kriteriumebi
bull arCeul iqna kvlevebi Semdegi dizainiT randomizebuli kontrolirebadi sistemuri mimoxilvebi da meta-analizi erTmomentiani kohortuli kvlevebi
bull rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12 wliani SezRudva Tumca zogjer gamoyenebuli iyo ufro adreuli publikaciebi romlebic dResac aqtualuria da safuZvlad udevs sxva Tanamedrove mtkicebulebebs
bull dadgenili iyo enobrivi SezRudvebi radganac samuSao jgufs SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod inglisur da rusul enebze
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
bull samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri meToduri rekomendacia axalSobilTa hiperbilirubinemiis marTvis sakiTxebze romlebic Seicavda jgufis miznis Sesaferis saWiro informacias am rekomendaciebis Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (9496-98) samuSao jgufi xelmZRvanelobda saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mier SemuSavebuli nacionaluri gaidlainebis gzamkvleviT Sefasebis Sedegad amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi
rArr amerikis pediatrTa akademia
rArr msoflo jandacvis organizacia
rArr kanadis pediatrTa sazogadoeba ndash nayofi da axalSobilis komiteti
rArr britaneTis reproduqciuli janmrTelobis programa
22
bull rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da rekomendaciebis xarisxis sqema
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris
done (Muir Gray)xarisxi rekomendaciis xarisxi
(Cook et al)I Zlieri mtkicebuleba
eyrdnoba minimum erT sistemur mimoxilvas
romelic efuZneba swori dizainis mqone randomizebul
kontrolirebad kvleva
A eyrdnoba I donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erTi swori dizainis mqone
randomizebul kontrolirebad kvleva
B eyrdnoba II donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
III klinikuri kvleva randomizaciis gareSe
kohortuli da SemTxveva-kontrolis kvlevebi
C eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi
D eyrdnoba IV da V donis mtkicebulebas saWiroebs
konsesuss
Va avtoritetul profesionalTa mosazreba
Vb klinikuri gamocdileba aRwerilobiTi kvlevebi an
eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
15 avtorTa jgufi
bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis
bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi
rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
23
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24
sxeulis zedapiris farTobibilirubinis maRali Semcvelobisas mniSvnelovania fotoTerapiis dros dasxivdes sxeulis zedapiris rac SeiZleba meti farTobi
ldquoCveulebrivi fotoTerapiardquo - sinaTlis speqtris iradiacia dabalia (6-12 microWcm2nm) (talRis sigrZe daaxloebiT 425-475 nm) da damokidebulia sxvadasxva mwarmoeblis mier mowodebul fotoTerapiiis sistemis aparatis monacemebze saWiroa aparatis Semowmeba Seesabameba Tu ara sinaTlis speqtris iradiacia mwarmoeblis mier mowodebul monacemebsldquointensiuri fotoTerapiardquo - lurj-mwvane speqtris iradiacia (talRis
sigrZe daaxloebiT 430-490 nm) sul cota 30 microWcm2nm-ia (isazRvreba axalSobilis kanze fototerapiis aparatis centris qveS) gazomva xdeba im warmoebis radiometriT romelic mowodebulia fotoTerapiiis sistemis aparatis mwarmoeblis mier sinaTlis talRis asareklad TeTreuli unda iyos TeTri kuvezi da sawolis gverdebi daifaros TeTri qsoviliT an aluminis folgiT
fotoTerapiis procedura da monitoringi
temperatura sinaTlis wyaros qveS unda iyos 28-300C
fotoTerapiis dros bavSvi unda iyos SiSveli ecvas erTjeradi higienuri safeni Tvalebze unda hqondes damcavi saTvale
yovel 3 saaTSi erTxel bavSvs unda Seucvalon pozicia
yovel 3 saaTSi erTxel unda Sefasdes sinaTlis wyaros qveS arsebuli temperatura da axalSobilis sxeulis temperatura Tu bavSvis t metia metia 3750C saWiroa oTaxis temperaturis daqveiTeba an fotoTerapiis droebiT Sewyveta sanam bavSvis temperatura ar iqneba normis farglebSi (365-3750C)
fotoTerapia mimdinareobas mudmivad igi wydeba mxolod im procedurebis dros romelTa warmoeba ra SeiZleba sinaTlis wyaros qveS
centraluri cianozis arsebobis Sesafaseblad fotoTerapia unda Sewydes mcire droiT
fotoTerapiis dros unda gagrZeldes bavSvis kveba
rArraxalSobilTan unda gagrZeldes ZuZuTi kveba moTxovnilebis mixedviT (intervali kvebaTa Soris araumetes 3 sT-isa) (rekomendacia C) ZuZuTi kvebis dros wydeba fotoTerapia da Sesabamisad bavSvs unda moexsnas damcavi saTvale
rArrTu bavSvi ikvebeba gamowvelili rZiT formuliT an parenteralurad misawodebeli sakvebis an siTxis raodenoba izrdeba dRiuri normis 10 -iT
rArr Tu bavSvi ikvebeba zondiT an parenteralurad fotoTerapia mimdinareobs uwyvetad
rArrCveulebriv fotoTerapiis dros axalSobils ar esaWiroeba damatebiT siTxis an sakvebis miwodeba damateba naCvenebia mxolod araefeqturi ZuZuTi kvebis sxeulis masis paTologiuri danakargis (gt10-ze mesame dRisTvis) da dehidrataciis SemTxvevaSi
13
C
fotoTerapiis dros bilirubinis daSlis produqtebi gamoiyofa SardiT da naRveliT adeqvaturi hidrataciis SenarCuneba da Sesabamisad adekvaturi diurzis SenarCuneba zrdis fotoTerapiis efeqturobas
zogierT axalSobils hiperbilirubinemiiT aReniSneba dehidratacia da saWiroa damatebiTi siTxis miwodeba (per-os an intravenurad) dehidrataciis koreqciisaTvis
araefeqturi ZuZuTi kvebis SemTxvevaSi fotoTerapiis dros axalSobils damatebiT miewodeba gamowvelili dedis rZe donoris rZe an xelovnuri sakvebi
rArr adeqvatur kvebaze miuTiTebs 4-6 sveli safeni 24 sT-Si da nawlavTa moqmedeba 3-4 jerdReSi meoTxe dRisaTvis
janmrTeli drouli axalSobilis nawlavTa moqmedeba da diurezi (minimaluri maCveneblebi) cxrili 5 (Fetus and Newborn Committee 1999)
dRe nawlavTa minimaluri moqmedeba24sT
sveli safeni24sT
1 1 12 1 23 1 gardamavali 34 2 yviTeli fafisebri 45 2YyviTeli fafisebri 5-6
rArrdehidrataciaze miuTiTebs Semdegi niSnebis arseboba - masis paTologiuri kleba (gt10-ze mesame dRisTvis)- anuria 4-6 sT- Cacvenili Tvalebi- Cavardnili yoflibandi - - daqveiTebuli kanis elastiuroba (kanis naoWi swordeba
nela)- daqveiTebuli kanis kapilaruli avseba (gt3 wm)- taqikardia- Sratis Na gt145 HCO3 lt17
bilirubinis monitoringi fotoTerapiis dros (American Aacademy of Pediatrics 2004)
sawyisi bilirubinis maCveneblis Semcireba 6-20-iT standartuli da 30-40-iT intensiuri fotoTerapiis dawyebidan 24sT-Si mis efeqturobaze miuTiTebs
bull Tu Ssb ge 25 mgdL (428 micromolL) ganmeorebiTi gansazRvra 2ndash3 sT-Si
bull Tu Ssb 20ndash25 mgdL (342ndash428 micromolL) ganmeorebiTi gansazRvra 3-4 sT-Si
bull Tu Ssb lt20 mgdL (342 micromolL) ganmeorebiTi gansazRvra 4ndash6 sT-Si Tu Ssb agrZelebs daqveiTebas ganmeorebiTi gansazRvra 8-12 sT-Si
bull Tu Ssb ar mcirdeba an uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones an Ssb albuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6) iwyeba SenacvlebiTi transfuzia Tu amis saSualeba aris an xorcieldeba referali
bull intensiur fotoTerapiis miuxedavad Ssb-is ucvleli done an mateba miuTiTebs hemolizze
14
rArr anemiahemolizis Sefaseba SesaZlebelia sisxlis saerTo analizis mixedviT - Hgblt 130 glLHct lt 40 retikulocitebi - gt 6
bull Ssb lt 13ndash14 mgdL (239 micromolL) fotoTerapia wydeba
bull fotoTerapiis Sewyvetidan 24 sT-Si kontroldeba Ssb Tu Ssb moimata im donemde romelzec daiwyo fotoTerapia fotoTerapia ganmeorebiT iwyeba
fotoTerapiis garTulebebi
fotoTerapiis garTulebebi (Ronald J Wong 2005 American Aacademy of Pediatrics 2004)
rArrmwvane feris ganavalidiarea (mkurnalobas ar saWiroebs)
rArr dehidratacia
rArr muclis Seberva (mkurnalobas ar saWiroebs)
rArr Tvalis SesaZlo dazianeba yvelaze seriozuli magram iSviaTi klinikuri garTulebaa brinjaos
axalSobilis sindromi romelic vlindeba qolestazuri siyviTlis mqone axalSobilSi kanis Sratis da Sardis muqi nacrisfer-yavisferi SeferilobiT brinjaos axalSobilis sindromi ar vlindeba qolestazis mqone yvela axalSobilTan Tu arsebobs fotoTerapiis Cveneba pirdapiri hiperbilirubinemia ar warmoadgens fotoTerapiis winaaRmdeg Cvenebas axalSobilebSi romelTac uviTardebaT brinjaos sindromi naCvenebia SenacvlebiTi transfuzia monacemebis arasrulyofilebis gamo mkacri rekomendaciis gakeTeba ar SeiZleba
mZime qolestazuri siyviTlis mqone axalSobilebSi fotoTerapiis dros aseve SeiZleba ganviTardes
rArr purpura
rArr bulozuri gamonayari
mzis ultraiisferi sxivebiT TerapiamarTalia mzis sxivebs gaaCniaT mniSvnelovani iradiacia 425-475 nm magram radganac maRalia axalSobilis damwvrobis ganviTarebis riski (SiSveli axalSobilis mzeze yofnis gamo) es meTodi rekomendebuli ar aris
(Ronald J Wong 2005 (American Aacademy of Pediatrics 2004)
intravenuri imunoglobulinis gamoyenebarekomendacia izoimunuri hemolizuri daavadebis dros rekomendebulia intravenuri imunoglobulinis gamoyeneba (05-1 gkg 2 sT-s ganmavlobaSi) Tu Ssb imatebs intensiuri fotoTerapiis miuxedavad an Ssb aris 2-3 mgdl-iT (34-51mkmoll) naklebi SenacvlebiTi transfuziis Cvenebis doneze (fighellip4) aucilebelobis SemTxvevaSi intravenuri imunoglobulinis es doza SeiZleba ganmeordes 12 sT-Si (rekomendacia B) American Aacademy of Pediatrics 2004)
15
fotoTerapiis dros kanSi Calagebuli bilirubini swrafad iSleba amitom ar aris rekomendebuli kanis ferze dayrdnobiT SratSi
bilirubinis donis Sesafaseba rogorc fotoTerapiis dros ise misi Sewyvetidan 24 sT-is ganmavlobaSi
B
kvlevebiT dadgenilia rom intravenuri imunoglobulini amcirebs SenacvlebiTi transfuziis saWiroebas Rh da ABO hemolizuri daavadebis dros
SenacvlebiTi transfuzia
SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleluli unda iyos Semowmebuli da dasxivebuli gadasasxmeli sisxlis raodenoba Seadgens 170-180 mlkg
rekomendacia SenacvlebiTi transfuzia unda Caataros mxolod gamocdilma samedicino personalma intensiuri Terapiis ganyofilebaSi monitoringisa da srulyofili reanimaciis SesaZleblobis pirobebSi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
SenacvlebiTi transfuziis Cvenebebi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
mwvave bilirubinuli encefalopaTia intensiuri fotoTerapiis miuxedavad Ssb mateba an ucvleli
monacemi samSobiarodan gawerili axalSobilebis hospitalizaciis
SemTxvevaSi Ssb-s maRali maCvenebeli - aRemateba SenacvlebiTi transfuziis dawyebis maCvenebls (sqema 3) (transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia) (ix cxrili 6)
ba Sefardeba Ssb maCvenebelTan (cxrili 6) erTad gamoiyeneba rogorc damatebiTi faqtori SenacvlebiTi transfuziis dawyebis gansasazRvravad
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
sqema 3 SenacvlebiTi transfuziis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (American Academy of Pediatrics 2004)
16
D
D
cxrili 6 bilirubinisa da albuminis Sefardeba rodesac saWiroa SenacvlebiTi transfuzia (AMERICAN ACADEMY OF PEDIATRICS 2004)
riskis kategoria
ba Sefardeba rodesac saWiroa SenacvlebiTi
transfuziaSsb mgdl alb gdl
Ssb micromolL alb micromolL
axalSobilebi gestaciuri asaki - ge38 kvira 80 094
janmrTeli axalSobilebi gestaciuri asakiT an riskis jgufis axalSobilebi
gestaciuri asakiT ge38 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
72 084
riskis jgufis axalSobilebi gestaciuri asakiT 35ndash36 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
68 080
janmos rekomendacia sisxlis SenacvlebiTi gadasxmis Cvenebebis Sesaxeb mocemulia cxrilSi 7
cxrili 7 SenacvlebiTi transfuziis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI 15 260 13 220II 25 425 15 260
17
III 30 510 20 340IV da meti 30 510 20 340
Tu Ssb uaxlovdeba im dones rodesac naCvenebia SenacvlebiTi transfuzia
sisxli dauyovnebliv igzavneba raTa dadgindes jgufi da rezusi da SeTavseba Tu klinikaSi aris transfuziis saSualeba
an xorcieldeba referali
teqnika (AMERICAN ACADEMY OF PEDIATRICS 2004
bull mwvave bilirubinuli encefalopaTiis dros SenacvlebiTi transfuzia iwyeba dauyovnebliv
bull sxva SemTxvevaSi transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia
bull SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleuli unda iyos Semowmebuli da dasxivebuli
bull gadasasxmeli sisxlis raodenoba Seadgens axalSobilis mocirkulire sisxlis ormag raodenobas saSualod 170-180 mlkg an gadasasxmeli sisxlis gamosaTvleli formula gamoiTvleba 85 x axalSobilis wona kg x 2
bull SenacvlebisaTvis xdeba 2 venis an arteria da venis kaTeterizacia iReben bavSvis 20 ml sisxls da SeyavT 20 ml donoris sisxli (3-4 wT-is ganmavlobaSi) SemTbaris 367-3700C-mde
bull dRenaklulebsa da mZime mdgomareobaSi myof axalSobilebSi Senacvleba xdeba 5-10 ml-iT
axalSobilis momzadeba
bull kuWis SigTavsis aspiracia zondiT 8F da Ria zondis datoveba kuWSibull SeiZleba saWiro gaxdes bavSvis dabma
bull SeiZleba sawovaras gamoyeneba
bull Sardis Semkrebis gamoyeneba diurezis kontrolisTvisaxlSobilis winaswar Sefaseba
bull temperatura
bull guliscema
bull sunTqva
bull wneva
bull glukoza SratSi
bull Sardis analizi
bull ganavlis analizi sisxlis Semcvelobaze
bull kanis feri
bull tonusi
bull qcevauSualod transfuziis dros fasdeba vitaluri niSnebi (yovel 15 wT-Si)
18
bull temperatura
bull guliscema (mwvervalze) (umjobesia kardiomonitoriT)
bull sunTqva
bull kanis feri
bull qceva
monitoringi transfuziis Semdeg bull grZeldeba fotoTerapia
bull kardio monitoringi
bull sisxlis wneva proceduris damTavrebis Semdeg
bull saaTobrivad 6 sT-is ganmavlobaSi temperatura guliscema (mwvervalze) sunTqva
bull glukoza SratSi yovel 3 sT-Si 24 sT-is ganmavlobaSi
bull muclis garSemoweriloba 3-4 sT-Si 24 sT-is ganmavlobaSi nawlavebis peristaltikis auskultacia
bull Sardis analizi
bull ganavali sisxlis Semcvelobaze
bull sakvebis autanlobis niSnebi Rebineba muclis Seberva
bull Ssb 6 sT-Si erTxel
SenacvlebiTi transfuziis riskisikvdiloba - 3 SemTxveva 1000 transfuziaze SenacvlebiTi transfuziis dros garTulebis saxiT 5-Si vlindeba
- apnoe bradikardia cianozi vazospazmi Trombozi nekrozuli enterokoliti aseve SeiZleba ganviTardes hipoqsiur-iSemiuri encefalopaTia da SeZenili imunodeficitis sindromi
sxva mkurnalobafenobarbitali ndash xels uwyobs bilirubinis koniugacias da amcirebs
Ssb dones ar arsebobs sakmarisi mtkicebulebebi fenobarbitalis gamosayeneblad rodesac arsebobs siyviTlis mkurnalobis ufro efeqturi meTodebi (mag fotoTerapia)
referali AMERICAN ACADEMY OF PEDIATRICS 2004)referali maRali donis klinikaSi xorcieldeba Tu
ar aris fotoTerapiis Catarebis SesaZlebloba fotoTerapiis miuxedavad
rArr Ssb ar mcirdeba
rArr Ssb uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones da ar aris transfuziis saSualeba
rArr Ssbalbuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6)
Tu siyviTle gamovlinda I dRes siyviTlis lokalizaciis mixedviT siyviTlis simZimis Sefasebisas
(cxrili 1) dadgenili ldquosaSiSi siyviTlerdquo
bilirubinis maRali namati 85 micromolLsT (gt05 mgdlsT)
gaxangrZlivebuli siyviTle (14 dRe da meti) ojaxur anamnezSi mZime siyviTlis an kerniqterusis arseboba siyviTlis dros sxva daavadebis niSnebis arseboba (mg sefsisi)
19
riskis Sefaseba gaweramde
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
bull yvela axalSobilis gaweramde unda Sefasdes hiperbilirubinemiis ganviTarebis riski yvela ganyofilebas unda hqondes protokoli siyviTlis SefasebisTvis aseTi Sefaseba gansakuTrebiT mniSvnelovania im axalSobilebisaTvis romlebis ewerebian dabadebidan 72 sT-ze adre (rekomendacia C)
bull amerikis pediatrTa akademiis rekomendaciiT riskis SefasebisaTvis gamoyenebuli unda iqnas 2 midgoma (calcalke an kombinaciaSi) gaweris win bilirubinis gansazRvra (Ssb an tkb) daan klinikuri risk-faqtorebis Sefaseba risk-faqtorebis arseboba an Ssb maRali maCveneblebi gaweris Semdeg Sesabamisi meTvalyureobis aucilebelobis Cvenebaa (rekomendacia C)
bull yvela samSobiarom unda miawodos mSobels zepiri daan werilobiTi informacia binaze siyviTlis Sefasebis da saSiSroebis niSnebis Sesaxeb (rekomendacia D)
meTvalyureoba
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)bull yvela axalSobili samSobiarodan gaweriis Semdeg ramdenime dReSi unda Sefasdes kvalificuri samedicino profesionalis mier (rekomendacia C)
bull fasdeba - siyviTlis arseboba axalSobilis wona kvebis efeqturoba Rebinebis arseboba (rekomendacia C)
bull meTvalyureobis grafiki Tu axalSobili samSobiarodan ewereba 48-72 sT-Si samedicino Sefaseba tardeba 120 sT-is (5 dRe) asakSi (rekomendacia C)
bull Tu samSobiarodan gaweris Semdeg meTvalyureoba SeuZlebelia da arsebobs hiperbilirubinemiis ganviTarebis risk-faqtorebi axalSobilis gawera unda gadaidos sanam ar iqneba uzrunvelyofili Sesabamisi meTvalyureoba an sanam gaivlis maRali riskis periodi (72-96sT) (rekomendacia D)
11 gaidlainis gadasinjvisa da ganaxlebis vada ndash 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlainis SemuSavebis meTodologia
bull axalSobilTa hiperbilirubinemiis prevenciis diagnostikisa da marTvis principebis Sesaxeb arsebobs samecniero mtkicebulebis safuZvelze Seqmnil rekomendaciaTa sakmarisi raodenoba mocemuli gaidlainis Semqmnis procesSi samuSao jgufis gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve arsebuli praqtikuli rekomendaciebi moxda arsebuli
20
C
C
C
C
D
C
D
rekomendaciebis adaptirebuli variantis SemuSaveba romelic erTis mxriv pasuxebs saerTaSoriso moTxovnebs xolo meore mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa rogorc adamianur ise teqnikur resursebs
bull rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa bazis gamoyenebiT
cxrili 2
qveyana da resursis dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
httpwwwguidelinegov
Centers for Disease Control and Prevention (CDC)
httpwwwphppocdcgovCDCRecommendsAdvSearchVasp
Agency for Healthcare Research and Quality (AHRQ)
httpwwwahrqgovcliniccpgsixhtm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
httphstatnlmnihgov
Institute of Clinical Systems Improvement (ICSI)
httpwwwicsiorg
American Medical Association httpwwwama-assnorg
Canadian Medical Association (CMA)
httpmdmcacpgsnewcpgsindexasp
Health Canada ndash Population and Public Health Branch (PPHB)
httpwwwhc-scgccapphb-dgspspdpg_ehtml
didi britaneTi
National Institute for Clinical Excellence (NICE)
httpwwwniceorguk
Sheffield Evidence for Effectiveness and Knowledge (SEEK)
httpwwwshefacukseekguidelineshtm
National electronic Library for Health (NeLH)
httpwwwnelhnhsukguidelinesfinder
PRODIGY Clinical Guidance httpwwwprodigynhsukClinicalGuidance
Scottish Intercollegiate Guidelines Network (SIGN)
httpwwwsignacuk
German Guideline Information Service (GERGIS)
httpwwwleitliniendeenglishenglishview
avstralia
Australian National Health and httpwwwhealthgovauhfsnhmrcpublicatcp-
21
Medical Research Council (NHMRC) homehtmaxali zelandia
New Zealand Guidelines Group (NZGG)
httpwwwnzggorgnzlibrarycfm
mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba
httpwwwosdmorg
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi
bull koxreinis biblioTeka - The Cochrane Library 2006 Issue 2 bull amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini ndash MEDLINEbull jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvisgamoricxvis kriteriumebi
bull arCeul iqna kvlevebi Semdegi dizainiT randomizebuli kontrolirebadi sistemuri mimoxilvebi da meta-analizi erTmomentiani kohortuli kvlevebi
bull rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12 wliani SezRudva Tumca zogjer gamoyenebuli iyo ufro adreuli publikaciebi romlebic dResac aqtualuria da safuZvlad udevs sxva Tanamedrove mtkicebulebebs
bull dadgenili iyo enobrivi SezRudvebi radganac samuSao jgufs SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod inglisur da rusul enebze
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
bull samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri meToduri rekomendacia axalSobilTa hiperbilirubinemiis marTvis sakiTxebze romlebic Seicavda jgufis miznis Sesaferis saWiro informacias am rekomendaciebis Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (9496-98) samuSao jgufi xelmZRvanelobda saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mier SemuSavebuli nacionaluri gaidlainebis gzamkvleviT Sefasebis Sedegad amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi
rArr amerikis pediatrTa akademia
rArr msoflo jandacvis organizacia
rArr kanadis pediatrTa sazogadoeba ndash nayofi da axalSobilis komiteti
rArr britaneTis reproduqciuli janmrTelobis programa
22
bull rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da rekomendaciebis xarisxis sqema
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris
done (Muir Gray)xarisxi rekomendaciis xarisxi
(Cook et al)I Zlieri mtkicebuleba
eyrdnoba minimum erT sistemur mimoxilvas
romelic efuZneba swori dizainis mqone randomizebul
kontrolirebad kvleva
A eyrdnoba I donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erTi swori dizainis mqone
randomizebul kontrolirebad kvleva
B eyrdnoba II donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
III klinikuri kvleva randomizaciis gareSe
kohortuli da SemTxveva-kontrolis kvlevebi
C eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi
D eyrdnoba IV da V donis mtkicebulebas saWiroebs
konsesuss
Va avtoritetul profesionalTa mosazreba
Vb klinikuri gamocdileba aRwerilobiTi kvlevebi an
eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
15 avtorTa jgufi
bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis
bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi
rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
23
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24
fotoTerapiis dros bilirubinis daSlis produqtebi gamoiyofa SardiT da naRveliT adeqvaturi hidrataciis SenarCuneba da Sesabamisad adekvaturi diurzis SenarCuneba zrdis fotoTerapiis efeqturobas
zogierT axalSobils hiperbilirubinemiiT aReniSneba dehidratacia da saWiroa damatebiTi siTxis miwodeba (per-os an intravenurad) dehidrataciis koreqciisaTvis
araefeqturi ZuZuTi kvebis SemTxvevaSi fotoTerapiis dros axalSobils damatebiT miewodeba gamowvelili dedis rZe donoris rZe an xelovnuri sakvebi
rArr adeqvatur kvebaze miuTiTebs 4-6 sveli safeni 24 sT-Si da nawlavTa moqmedeba 3-4 jerdReSi meoTxe dRisaTvis
janmrTeli drouli axalSobilis nawlavTa moqmedeba da diurezi (minimaluri maCveneblebi) cxrili 5 (Fetus and Newborn Committee 1999)
dRe nawlavTa minimaluri moqmedeba24sT
sveli safeni24sT
1 1 12 1 23 1 gardamavali 34 2 yviTeli fafisebri 45 2YyviTeli fafisebri 5-6
rArrdehidrataciaze miuTiTebs Semdegi niSnebis arseboba - masis paTologiuri kleba (gt10-ze mesame dRisTvis)- anuria 4-6 sT- Cacvenili Tvalebi- Cavardnili yoflibandi - - daqveiTebuli kanis elastiuroba (kanis naoWi swordeba
nela)- daqveiTebuli kanis kapilaruli avseba (gt3 wm)- taqikardia- Sratis Na gt145 HCO3 lt17
bilirubinis monitoringi fotoTerapiis dros (American Aacademy of Pediatrics 2004)
sawyisi bilirubinis maCveneblis Semcireba 6-20-iT standartuli da 30-40-iT intensiuri fotoTerapiis dawyebidan 24sT-Si mis efeqturobaze miuTiTebs
bull Tu Ssb ge 25 mgdL (428 micromolL) ganmeorebiTi gansazRvra 2ndash3 sT-Si
bull Tu Ssb 20ndash25 mgdL (342ndash428 micromolL) ganmeorebiTi gansazRvra 3-4 sT-Si
bull Tu Ssb lt20 mgdL (342 micromolL) ganmeorebiTi gansazRvra 4ndash6 sT-Si Tu Ssb agrZelebs daqveiTebas ganmeorebiTi gansazRvra 8-12 sT-Si
bull Tu Ssb ar mcirdeba an uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones an Ssb albuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6) iwyeba SenacvlebiTi transfuzia Tu amis saSualeba aris an xorcieldeba referali
bull intensiur fotoTerapiis miuxedavad Ssb-is ucvleli done an mateba miuTiTebs hemolizze
14
rArr anemiahemolizis Sefaseba SesaZlebelia sisxlis saerTo analizis mixedviT - Hgblt 130 glLHct lt 40 retikulocitebi - gt 6
bull Ssb lt 13ndash14 mgdL (239 micromolL) fotoTerapia wydeba
bull fotoTerapiis Sewyvetidan 24 sT-Si kontroldeba Ssb Tu Ssb moimata im donemde romelzec daiwyo fotoTerapia fotoTerapia ganmeorebiT iwyeba
fotoTerapiis garTulebebi
fotoTerapiis garTulebebi (Ronald J Wong 2005 American Aacademy of Pediatrics 2004)
rArrmwvane feris ganavalidiarea (mkurnalobas ar saWiroebs)
rArr dehidratacia
rArr muclis Seberva (mkurnalobas ar saWiroebs)
rArr Tvalis SesaZlo dazianeba yvelaze seriozuli magram iSviaTi klinikuri garTulebaa brinjaos
axalSobilis sindromi romelic vlindeba qolestazuri siyviTlis mqone axalSobilSi kanis Sratis da Sardis muqi nacrisfer-yavisferi SeferilobiT brinjaos axalSobilis sindromi ar vlindeba qolestazis mqone yvela axalSobilTan Tu arsebobs fotoTerapiis Cveneba pirdapiri hiperbilirubinemia ar warmoadgens fotoTerapiis winaaRmdeg Cvenebas axalSobilebSi romelTac uviTardebaT brinjaos sindromi naCvenebia SenacvlebiTi transfuzia monacemebis arasrulyofilebis gamo mkacri rekomendaciis gakeTeba ar SeiZleba
mZime qolestazuri siyviTlis mqone axalSobilebSi fotoTerapiis dros aseve SeiZleba ganviTardes
rArr purpura
rArr bulozuri gamonayari
mzis ultraiisferi sxivebiT TerapiamarTalia mzis sxivebs gaaCniaT mniSvnelovani iradiacia 425-475 nm magram radganac maRalia axalSobilis damwvrobis ganviTarebis riski (SiSveli axalSobilis mzeze yofnis gamo) es meTodi rekomendebuli ar aris
(Ronald J Wong 2005 (American Aacademy of Pediatrics 2004)
intravenuri imunoglobulinis gamoyenebarekomendacia izoimunuri hemolizuri daavadebis dros rekomendebulia intravenuri imunoglobulinis gamoyeneba (05-1 gkg 2 sT-s ganmavlobaSi) Tu Ssb imatebs intensiuri fotoTerapiis miuxedavad an Ssb aris 2-3 mgdl-iT (34-51mkmoll) naklebi SenacvlebiTi transfuziis Cvenebis doneze (fighellip4) aucilebelobis SemTxvevaSi intravenuri imunoglobulinis es doza SeiZleba ganmeordes 12 sT-Si (rekomendacia B) American Aacademy of Pediatrics 2004)
15
fotoTerapiis dros kanSi Calagebuli bilirubini swrafad iSleba amitom ar aris rekomendebuli kanis ferze dayrdnobiT SratSi
bilirubinis donis Sesafaseba rogorc fotoTerapiis dros ise misi Sewyvetidan 24 sT-is ganmavlobaSi
B
kvlevebiT dadgenilia rom intravenuri imunoglobulini amcirebs SenacvlebiTi transfuziis saWiroebas Rh da ABO hemolizuri daavadebis dros
SenacvlebiTi transfuzia
SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleluli unda iyos Semowmebuli da dasxivebuli gadasasxmeli sisxlis raodenoba Seadgens 170-180 mlkg
rekomendacia SenacvlebiTi transfuzia unda Caataros mxolod gamocdilma samedicino personalma intensiuri Terapiis ganyofilebaSi monitoringisa da srulyofili reanimaciis SesaZleblobis pirobebSi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
SenacvlebiTi transfuziis Cvenebebi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
mwvave bilirubinuli encefalopaTia intensiuri fotoTerapiis miuxedavad Ssb mateba an ucvleli
monacemi samSobiarodan gawerili axalSobilebis hospitalizaciis
SemTxvevaSi Ssb-s maRali maCvenebeli - aRemateba SenacvlebiTi transfuziis dawyebis maCvenebls (sqema 3) (transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia) (ix cxrili 6)
ba Sefardeba Ssb maCvenebelTan (cxrili 6) erTad gamoiyeneba rogorc damatebiTi faqtori SenacvlebiTi transfuziis dawyebis gansasazRvravad
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
sqema 3 SenacvlebiTi transfuziis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (American Academy of Pediatrics 2004)
16
D
D
cxrili 6 bilirubinisa da albuminis Sefardeba rodesac saWiroa SenacvlebiTi transfuzia (AMERICAN ACADEMY OF PEDIATRICS 2004)
riskis kategoria
ba Sefardeba rodesac saWiroa SenacvlebiTi
transfuziaSsb mgdl alb gdl
Ssb micromolL alb micromolL
axalSobilebi gestaciuri asaki - ge38 kvira 80 094
janmrTeli axalSobilebi gestaciuri asakiT an riskis jgufis axalSobilebi
gestaciuri asakiT ge38 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
72 084
riskis jgufis axalSobilebi gestaciuri asakiT 35ndash36 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
68 080
janmos rekomendacia sisxlis SenacvlebiTi gadasxmis Cvenebebis Sesaxeb mocemulia cxrilSi 7
cxrili 7 SenacvlebiTi transfuziis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI 15 260 13 220II 25 425 15 260
17
III 30 510 20 340IV da meti 30 510 20 340
Tu Ssb uaxlovdeba im dones rodesac naCvenebia SenacvlebiTi transfuzia
sisxli dauyovnebliv igzavneba raTa dadgindes jgufi da rezusi da SeTavseba Tu klinikaSi aris transfuziis saSualeba
an xorcieldeba referali
teqnika (AMERICAN ACADEMY OF PEDIATRICS 2004
bull mwvave bilirubinuli encefalopaTiis dros SenacvlebiTi transfuzia iwyeba dauyovnebliv
bull sxva SemTxvevaSi transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia
bull SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleuli unda iyos Semowmebuli da dasxivebuli
bull gadasasxmeli sisxlis raodenoba Seadgens axalSobilis mocirkulire sisxlis ormag raodenobas saSualod 170-180 mlkg an gadasasxmeli sisxlis gamosaTvleli formula gamoiTvleba 85 x axalSobilis wona kg x 2
bull SenacvlebisaTvis xdeba 2 venis an arteria da venis kaTeterizacia iReben bavSvis 20 ml sisxls da SeyavT 20 ml donoris sisxli (3-4 wT-is ganmavlobaSi) SemTbaris 367-3700C-mde
bull dRenaklulebsa da mZime mdgomareobaSi myof axalSobilebSi Senacvleba xdeba 5-10 ml-iT
axalSobilis momzadeba
bull kuWis SigTavsis aspiracia zondiT 8F da Ria zondis datoveba kuWSibull SeiZleba saWiro gaxdes bavSvis dabma
bull SeiZleba sawovaras gamoyeneba
bull Sardis Semkrebis gamoyeneba diurezis kontrolisTvisaxlSobilis winaswar Sefaseba
bull temperatura
bull guliscema
bull sunTqva
bull wneva
bull glukoza SratSi
bull Sardis analizi
bull ganavlis analizi sisxlis Semcvelobaze
bull kanis feri
bull tonusi
bull qcevauSualod transfuziis dros fasdeba vitaluri niSnebi (yovel 15 wT-Si)
18
bull temperatura
bull guliscema (mwvervalze) (umjobesia kardiomonitoriT)
bull sunTqva
bull kanis feri
bull qceva
monitoringi transfuziis Semdeg bull grZeldeba fotoTerapia
bull kardio monitoringi
bull sisxlis wneva proceduris damTavrebis Semdeg
bull saaTobrivad 6 sT-is ganmavlobaSi temperatura guliscema (mwvervalze) sunTqva
bull glukoza SratSi yovel 3 sT-Si 24 sT-is ganmavlobaSi
bull muclis garSemoweriloba 3-4 sT-Si 24 sT-is ganmavlobaSi nawlavebis peristaltikis auskultacia
bull Sardis analizi
bull ganavali sisxlis Semcvelobaze
bull sakvebis autanlobis niSnebi Rebineba muclis Seberva
bull Ssb 6 sT-Si erTxel
SenacvlebiTi transfuziis riskisikvdiloba - 3 SemTxveva 1000 transfuziaze SenacvlebiTi transfuziis dros garTulebis saxiT 5-Si vlindeba
- apnoe bradikardia cianozi vazospazmi Trombozi nekrozuli enterokoliti aseve SeiZleba ganviTardes hipoqsiur-iSemiuri encefalopaTia da SeZenili imunodeficitis sindromi
sxva mkurnalobafenobarbitali ndash xels uwyobs bilirubinis koniugacias da amcirebs
Ssb dones ar arsebobs sakmarisi mtkicebulebebi fenobarbitalis gamosayeneblad rodesac arsebobs siyviTlis mkurnalobis ufro efeqturi meTodebi (mag fotoTerapia)
referali AMERICAN ACADEMY OF PEDIATRICS 2004)referali maRali donis klinikaSi xorcieldeba Tu
ar aris fotoTerapiis Catarebis SesaZlebloba fotoTerapiis miuxedavad
rArr Ssb ar mcirdeba
rArr Ssb uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones da ar aris transfuziis saSualeba
rArr Ssbalbuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6)
Tu siyviTle gamovlinda I dRes siyviTlis lokalizaciis mixedviT siyviTlis simZimis Sefasebisas
(cxrili 1) dadgenili ldquosaSiSi siyviTlerdquo
bilirubinis maRali namati 85 micromolLsT (gt05 mgdlsT)
gaxangrZlivebuli siyviTle (14 dRe da meti) ojaxur anamnezSi mZime siyviTlis an kerniqterusis arseboba siyviTlis dros sxva daavadebis niSnebis arseboba (mg sefsisi)
19
riskis Sefaseba gaweramde
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
bull yvela axalSobilis gaweramde unda Sefasdes hiperbilirubinemiis ganviTarebis riski yvela ganyofilebas unda hqondes protokoli siyviTlis SefasebisTvis aseTi Sefaseba gansakuTrebiT mniSvnelovania im axalSobilebisaTvis romlebis ewerebian dabadebidan 72 sT-ze adre (rekomendacia C)
bull amerikis pediatrTa akademiis rekomendaciiT riskis SefasebisaTvis gamoyenebuli unda iqnas 2 midgoma (calcalke an kombinaciaSi) gaweris win bilirubinis gansazRvra (Ssb an tkb) daan klinikuri risk-faqtorebis Sefaseba risk-faqtorebis arseboba an Ssb maRali maCveneblebi gaweris Semdeg Sesabamisi meTvalyureobis aucilebelobis Cvenebaa (rekomendacia C)
bull yvela samSobiarom unda miawodos mSobels zepiri daan werilobiTi informacia binaze siyviTlis Sefasebis da saSiSroebis niSnebis Sesaxeb (rekomendacia D)
meTvalyureoba
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)bull yvela axalSobili samSobiarodan gaweriis Semdeg ramdenime dReSi unda Sefasdes kvalificuri samedicino profesionalis mier (rekomendacia C)
bull fasdeba - siyviTlis arseboba axalSobilis wona kvebis efeqturoba Rebinebis arseboba (rekomendacia C)
bull meTvalyureobis grafiki Tu axalSobili samSobiarodan ewereba 48-72 sT-Si samedicino Sefaseba tardeba 120 sT-is (5 dRe) asakSi (rekomendacia C)
bull Tu samSobiarodan gaweris Semdeg meTvalyureoba SeuZlebelia da arsebobs hiperbilirubinemiis ganviTarebis risk-faqtorebi axalSobilis gawera unda gadaidos sanam ar iqneba uzrunvelyofili Sesabamisi meTvalyureoba an sanam gaivlis maRali riskis periodi (72-96sT) (rekomendacia D)
11 gaidlainis gadasinjvisa da ganaxlebis vada ndash 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlainis SemuSavebis meTodologia
bull axalSobilTa hiperbilirubinemiis prevenciis diagnostikisa da marTvis principebis Sesaxeb arsebobs samecniero mtkicebulebis safuZvelze Seqmnil rekomendaciaTa sakmarisi raodenoba mocemuli gaidlainis Semqmnis procesSi samuSao jgufis gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve arsebuli praqtikuli rekomendaciebi moxda arsebuli
20
C
C
C
C
D
C
D
rekomendaciebis adaptirebuli variantis SemuSaveba romelic erTis mxriv pasuxebs saerTaSoriso moTxovnebs xolo meore mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa rogorc adamianur ise teqnikur resursebs
bull rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa bazis gamoyenebiT
cxrili 2
qveyana da resursis dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
httpwwwguidelinegov
Centers for Disease Control and Prevention (CDC)
httpwwwphppocdcgovCDCRecommendsAdvSearchVasp
Agency for Healthcare Research and Quality (AHRQ)
httpwwwahrqgovcliniccpgsixhtm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
httphstatnlmnihgov
Institute of Clinical Systems Improvement (ICSI)
httpwwwicsiorg
American Medical Association httpwwwama-assnorg
Canadian Medical Association (CMA)
httpmdmcacpgsnewcpgsindexasp
Health Canada ndash Population and Public Health Branch (PPHB)
httpwwwhc-scgccapphb-dgspspdpg_ehtml
didi britaneTi
National Institute for Clinical Excellence (NICE)
httpwwwniceorguk
Sheffield Evidence for Effectiveness and Knowledge (SEEK)
httpwwwshefacukseekguidelineshtm
National electronic Library for Health (NeLH)
httpwwwnelhnhsukguidelinesfinder
PRODIGY Clinical Guidance httpwwwprodigynhsukClinicalGuidance
Scottish Intercollegiate Guidelines Network (SIGN)
httpwwwsignacuk
German Guideline Information Service (GERGIS)
httpwwwleitliniendeenglishenglishview
avstralia
Australian National Health and httpwwwhealthgovauhfsnhmrcpublicatcp-
21
Medical Research Council (NHMRC) homehtmaxali zelandia
New Zealand Guidelines Group (NZGG)
httpwwwnzggorgnzlibrarycfm
mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba
httpwwwosdmorg
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi
bull koxreinis biblioTeka - The Cochrane Library 2006 Issue 2 bull amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini ndash MEDLINEbull jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvisgamoricxvis kriteriumebi
bull arCeul iqna kvlevebi Semdegi dizainiT randomizebuli kontrolirebadi sistemuri mimoxilvebi da meta-analizi erTmomentiani kohortuli kvlevebi
bull rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12 wliani SezRudva Tumca zogjer gamoyenebuli iyo ufro adreuli publikaciebi romlebic dResac aqtualuria da safuZvlad udevs sxva Tanamedrove mtkicebulebebs
bull dadgenili iyo enobrivi SezRudvebi radganac samuSao jgufs SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod inglisur da rusul enebze
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
bull samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri meToduri rekomendacia axalSobilTa hiperbilirubinemiis marTvis sakiTxebze romlebic Seicavda jgufis miznis Sesaferis saWiro informacias am rekomendaciebis Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (9496-98) samuSao jgufi xelmZRvanelobda saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mier SemuSavebuli nacionaluri gaidlainebis gzamkvleviT Sefasebis Sedegad amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi
rArr amerikis pediatrTa akademia
rArr msoflo jandacvis organizacia
rArr kanadis pediatrTa sazogadoeba ndash nayofi da axalSobilis komiteti
rArr britaneTis reproduqciuli janmrTelobis programa
22
bull rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da rekomendaciebis xarisxis sqema
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris
done (Muir Gray)xarisxi rekomendaciis xarisxi
(Cook et al)I Zlieri mtkicebuleba
eyrdnoba minimum erT sistemur mimoxilvas
romelic efuZneba swori dizainis mqone randomizebul
kontrolirebad kvleva
A eyrdnoba I donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erTi swori dizainis mqone
randomizebul kontrolirebad kvleva
B eyrdnoba II donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
III klinikuri kvleva randomizaciis gareSe
kohortuli da SemTxveva-kontrolis kvlevebi
C eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi
D eyrdnoba IV da V donis mtkicebulebas saWiroebs
konsesuss
Va avtoritetul profesionalTa mosazreba
Vb klinikuri gamocdileba aRwerilobiTi kvlevebi an
eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
15 avtorTa jgufi
bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis
bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi
rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
23
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24
rArr anemiahemolizis Sefaseba SesaZlebelia sisxlis saerTo analizis mixedviT - Hgblt 130 glLHct lt 40 retikulocitebi - gt 6
bull Ssb lt 13ndash14 mgdL (239 micromolL) fotoTerapia wydeba
bull fotoTerapiis Sewyvetidan 24 sT-Si kontroldeba Ssb Tu Ssb moimata im donemde romelzec daiwyo fotoTerapia fotoTerapia ganmeorebiT iwyeba
fotoTerapiis garTulebebi
fotoTerapiis garTulebebi (Ronald J Wong 2005 American Aacademy of Pediatrics 2004)
rArrmwvane feris ganavalidiarea (mkurnalobas ar saWiroebs)
rArr dehidratacia
rArr muclis Seberva (mkurnalobas ar saWiroebs)
rArr Tvalis SesaZlo dazianeba yvelaze seriozuli magram iSviaTi klinikuri garTulebaa brinjaos
axalSobilis sindromi romelic vlindeba qolestazuri siyviTlis mqone axalSobilSi kanis Sratis da Sardis muqi nacrisfer-yavisferi SeferilobiT brinjaos axalSobilis sindromi ar vlindeba qolestazis mqone yvela axalSobilTan Tu arsebobs fotoTerapiis Cveneba pirdapiri hiperbilirubinemia ar warmoadgens fotoTerapiis winaaRmdeg Cvenebas axalSobilebSi romelTac uviTardebaT brinjaos sindromi naCvenebia SenacvlebiTi transfuzia monacemebis arasrulyofilebis gamo mkacri rekomendaciis gakeTeba ar SeiZleba
mZime qolestazuri siyviTlis mqone axalSobilebSi fotoTerapiis dros aseve SeiZleba ganviTardes
rArr purpura
rArr bulozuri gamonayari
mzis ultraiisferi sxivebiT TerapiamarTalia mzis sxivebs gaaCniaT mniSvnelovani iradiacia 425-475 nm magram radganac maRalia axalSobilis damwvrobis ganviTarebis riski (SiSveli axalSobilis mzeze yofnis gamo) es meTodi rekomendebuli ar aris
(Ronald J Wong 2005 (American Aacademy of Pediatrics 2004)
intravenuri imunoglobulinis gamoyenebarekomendacia izoimunuri hemolizuri daavadebis dros rekomendebulia intravenuri imunoglobulinis gamoyeneba (05-1 gkg 2 sT-s ganmavlobaSi) Tu Ssb imatebs intensiuri fotoTerapiis miuxedavad an Ssb aris 2-3 mgdl-iT (34-51mkmoll) naklebi SenacvlebiTi transfuziis Cvenebis doneze (fighellip4) aucilebelobis SemTxvevaSi intravenuri imunoglobulinis es doza SeiZleba ganmeordes 12 sT-Si (rekomendacia B) American Aacademy of Pediatrics 2004)
15
fotoTerapiis dros kanSi Calagebuli bilirubini swrafad iSleba amitom ar aris rekomendebuli kanis ferze dayrdnobiT SratSi
bilirubinis donis Sesafaseba rogorc fotoTerapiis dros ise misi Sewyvetidan 24 sT-is ganmavlobaSi
B
kvlevebiT dadgenilia rom intravenuri imunoglobulini amcirebs SenacvlebiTi transfuziis saWiroebas Rh da ABO hemolizuri daavadebis dros
SenacvlebiTi transfuzia
SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleluli unda iyos Semowmebuli da dasxivebuli gadasasxmeli sisxlis raodenoba Seadgens 170-180 mlkg
rekomendacia SenacvlebiTi transfuzia unda Caataros mxolod gamocdilma samedicino personalma intensiuri Terapiis ganyofilebaSi monitoringisa da srulyofili reanimaciis SesaZleblobis pirobebSi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
SenacvlebiTi transfuziis Cvenebebi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
mwvave bilirubinuli encefalopaTia intensiuri fotoTerapiis miuxedavad Ssb mateba an ucvleli
monacemi samSobiarodan gawerili axalSobilebis hospitalizaciis
SemTxvevaSi Ssb-s maRali maCvenebeli - aRemateba SenacvlebiTi transfuziis dawyebis maCvenebls (sqema 3) (transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia) (ix cxrili 6)
ba Sefardeba Ssb maCvenebelTan (cxrili 6) erTad gamoiyeneba rogorc damatebiTi faqtori SenacvlebiTi transfuziis dawyebis gansasazRvravad
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
sqema 3 SenacvlebiTi transfuziis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (American Academy of Pediatrics 2004)
16
D
D
cxrili 6 bilirubinisa da albuminis Sefardeba rodesac saWiroa SenacvlebiTi transfuzia (AMERICAN ACADEMY OF PEDIATRICS 2004)
riskis kategoria
ba Sefardeba rodesac saWiroa SenacvlebiTi
transfuziaSsb mgdl alb gdl
Ssb micromolL alb micromolL
axalSobilebi gestaciuri asaki - ge38 kvira 80 094
janmrTeli axalSobilebi gestaciuri asakiT an riskis jgufis axalSobilebi
gestaciuri asakiT ge38 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
72 084
riskis jgufis axalSobilebi gestaciuri asakiT 35ndash36 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
68 080
janmos rekomendacia sisxlis SenacvlebiTi gadasxmis Cvenebebis Sesaxeb mocemulia cxrilSi 7
cxrili 7 SenacvlebiTi transfuziis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI 15 260 13 220II 25 425 15 260
17
III 30 510 20 340IV da meti 30 510 20 340
Tu Ssb uaxlovdeba im dones rodesac naCvenebia SenacvlebiTi transfuzia
sisxli dauyovnebliv igzavneba raTa dadgindes jgufi da rezusi da SeTavseba Tu klinikaSi aris transfuziis saSualeba
an xorcieldeba referali
teqnika (AMERICAN ACADEMY OF PEDIATRICS 2004
bull mwvave bilirubinuli encefalopaTiis dros SenacvlebiTi transfuzia iwyeba dauyovnebliv
bull sxva SemTxvevaSi transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia
bull SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleuli unda iyos Semowmebuli da dasxivebuli
bull gadasasxmeli sisxlis raodenoba Seadgens axalSobilis mocirkulire sisxlis ormag raodenobas saSualod 170-180 mlkg an gadasasxmeli sisxlis gamosaTvleli formula gamoiTvleba 85 x axalSobilis wona kg x 2
bull SenacvlebisaTvis xdeba 2 venis an arteria da venis kaTeterizacia iReben bavSvis 20 ml sisxls da SeyavT 20 ml donoris sisxli (3-4 wT-is ganmavlobaSi) SemTbaris 367-3700C-mde
bull dRenaklulebsa da mZime mdgomareobaSi myof axalSobilebSi Senacvleba xdeba 5-10 ml-iT
axalSobilis momzadeba
bull kuWis SigTavsis aspiracia zondiT 8F da Ria zondis datoveba kuWSibull SeiZleba saWiro gaxdes bavSvis dabma
bull SeiZleba sawovaras gamoyeneba
bull Sardis Semkrebis gamoyeneba diurezis kontrolisTvisaxlSobilis winaswar Sefaseba
bull temperatura
bull guliscema
bull sunTqva
bull wneva
bull glukoza SratSi
bull Sardis analizi
bull ganavlis analizi sisxlis Semcvelobaze
bull kanis feri
bull tonusi
bull qcevauSualod transfuziis dros fasdeba vitaluri niSnebi (yovel 15 wT-Si)
18
bull temperatura
bull guliscema (mwvervalze) (umjobesia kardiomonitoriT)
bull sunTqva
bull kanis feri
bull qceva
monitoringi transfuziis Semdeg bull grZeldeba fotoTerapia
bull kardio monitoringi
bull sisxlis wneva proceduris damTavrebis Semdeg
bull saaTobrivad 6 sT-is ganmavlobaSi temperatura guliscema (mwvervalze) sunTqva
bull glukoza SratSi yovel 3 sT-Si 24 sT-is ganmavlobaSi
bull muclis garSemoweriloba 3-4 sT-Si 24 sT-is ganmavlobaSi nawlavebis peristaltikis auskultacia
bull Sardis analizi
bull ganavali sisxlis Semcvelobaze
bull sakvebis autanlobis niSnebi Rebineba muclis Seberva
bull Ssb 6 sT-Si erTxel
SenacvlebiTi transfuziis riskisikvdiloba - 3 SemTxveva 1000 transfuziaze SenacvlebiTi transfuziis dros garTulebis saxiT 5-Si vlindeba
- apnoe bradikardia cianozi vazospazmi Trombozi nekrozuli enterokoliti aseve SeiZleba ganviTardes hipoqsiur-iSemiuri encefalopaTia da SeZenili imunodeficitis sindromi
sxva mkurnalobafenobarbitali ndash xels uwyobs bilirubinis koniugacias da amcirebs
Ssb dones ar arsebobs sakmarisi mtkicebulebebi fenobarbitalis gamosayeneblad rodesac arsebobs siyviTlis mkurnalobis ufro efeqturi meTodebi (mag fotoTerapia)
referali AMERICAN ACADEMY OF PEDIATRICS 2004)referali maRali donis klinikaSi xorcieldeba Tu
ar aris fotoTerapiis Catarebis SesaZlebloba fotoTerapiis miuxedavad
rArr Ssb ar mcirdeba
rArr Ssb uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones da ar aris transfuziis saSualeba
rArr Ssbalbuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6)
Tu siyviTle gamovlinda I dRes siyviTlis lokalizaciis mixedviT siyviTlis simZimis Sefasebisas
(cxrili 1) dadgenili ldquosaSiSi siyviTlerdquo
bilirubinis maRali namati 85 micromolLsT (gt05 mgdlsT)
gaxangrZlivebuli siyviTle (14 dRe da meti) ojaxur anamnezSi mZime siyviTlis an kerniqterusis arseboba siyviTlis dros sxva daavadebis niSnebis arseboba (mg sefsisi)
19
riskis Sefaseba gaweramde
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
bull yvela axalSobilis gaweramde unda Sefasdes hiperbilirubinemiis ganviTarebis riski yvela ganyofilebas unda hqondes protokoli siyviTlis SefasebisTvis aseTi Sefaseba gansakuTrebiT mniSvnelovania im axalSobilebisaTvis romlebis ewerebian dabadebidan 72 sT-ze adre (rekomendacia C)
bull amerikis pediatrTa akademiis rekomendaciiT riskis SefasebisaTvis gamoyenebuli unda iqnas 2 midgoma (calcalke an kombinaciaSi) gaweris win bilirubinis gansazRvra (Ssb an tkb) daan klinikuri risk-faqtorebis Sefaseba risk-faqtorebis arseboba an Ssb maRali maCveneblebi gaweris Semdeg Sesabamisi meTvalyureobis aucilebelobis Cvenebaa (rekomendacia C)
bull yvela samSobiarom unda miawodos mSobels zepiri daan werilobiTi informacia binaze siyviTlis Sefasebis da saSiSroebis niSnebis Sesaxeb (rekomendacia D)
meTvalyureoba
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)bull yvela axalSobili samSobiarodan gaweriis Semdeg ramdenime dReSi unda Sefasdes kvalificuri samedicino profesionalis mier (rekomendacia C)
bull fasdeba - siyviTlis arseboba axalSobilis wona kvebis efeqturoba Rebinebis arseboba (rekomendacia C)
bull meTvalyureobis grafiki Tu axalSobili samSobiarodan ewereba 48-72 sT-Si samedicino Sefaseba tardeba 120 sT-is (5 dRe) asakSi (rekomendacia C)
bull Tu samSobiarodan gaweris Semdeg meTvalyureoba SeuZlebelia da arsebobs hiperbilirubinemiis ganviTarebis risk-faqtorebi axalSobilis gawera unda gadaidos sanam ar iqneba uzrunvelyofili Sesabamisi meTvalyureoba an sanam gaivlis maRali riskis periodi (72-96sT) (rekomendacia D)
11 gaidlainis gadasinjvisa da ganaxlebis vada ndash 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlainis SemuSavebis meTodologia
bull axalSobilTa hiperbilirubinemiis prevenciis diagnostikisa da marTvis principebis Sesaxeb arsebobs samecniero mtkicebulebis safuZvelze Seqmnil rekomendaciaTa sakmarisi raodenoba mocemuli gaidlainis Semqmnis procesSi samuSao jgufis gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve arsebuli praqtikuli rekomendaciebi moxda arsebuli
20
C
C
C
C
D
C
D
rekomendaciebis adaptirebuli variantis SemuSaveba romelic erTis mxriv pasuxebs saerTaSoriso moTxovnebs xolo meore mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa rogorc adamianur ise teqnikur resursebs
bull rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa bazis gamoyenebiT
cxrili 2
qveyana da resursis dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
httpwwwguidelinegov
Centers for Disease Control and Prevention (CDC)
httpwwwphppocdcgovCDCRecommendsAdvSearchVasp
Agency for Healthcare Research and Quality (AHRQ)
httpwwwahrqgovcliniccpgsixhtm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
httphstatnlmnihgov
Institute of Clinical Systems Improvement (ICSI)
httpwwwicsiorg
American Medical Association httpwwwama-assnorg
Canadian Medical Association (CMA)
httpmdmcacpgsnewcpgsindexasp
Health Canada ndash Population and Public Health Branch (PPHB)
httpwwwhc-scgccapphb-dgspspdpg_ehtml
didi britaneTi
National Institute for Clinical Excellence (NICE)
httpwwwniceorguk
Sheffield Evidence for Effectiveness and Knowledge (SEEK)
httpwwwshefacukseekguidelineshtm
National electronic Library for Health (NeLH)
httpwwwnelhnhsukguidelinesfinder
PRODIGY Clinical Guidance httpwwwprodigynhsukClinicalGuidance
Scottish Intercollegiate Guidelines Network (SIGN)
httpwwwsignacuk
German Guideline Information Service (GERGIS)
httpwwwleitliniendeenglishenglishview
avstralia
Australian National Health and httpwwwhealthgovauhfsnhmrcpublicatcp-
21
Medical Research Council (NHMRC) homehtmaxali zelandia
New Zealand Guidelines Group (NZGG)
httpwwwnzggorgnzlibrarycfm
mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba
httpwwwosdmorg
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi
bull koxreinis biblioTeka - The Cochrane Library 2006 Issue 2 bull amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini ndash MEDLINEbull jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvisgamoricxvis kriteriumebi
bull arCeul iqna kvlevebi Semdegi dizainiT randomizebuli kontrolirebadi sistemuri mimoxilvebi da meta-analizi erTmomentiani kohortuli kvlevebi
bull rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12 wliani SezRudva Tumca zogjer gamoyenebuli iyo ufro adreuli publikaciebi romlebic dResac aqtualuria da safuZvlad udevs sxva Tanamedrove mtkicebulebebs
bull dadgenili iyo enobrivi SezRudvebi radganac samuSao jgufs SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod inglisur da rusul enebze
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
bull samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri meToduri rekomendacia axalSobilTa hiperbilirubinemiis marTvis sakiTxebze romlebic Seicavda jgufis miznis Sesaferis saWiro informacias am rekomendaciebis Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (9496-98) samuSao jgufi xelmZRvanelobda saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mier SemuSavebuli nacionaluri gaidlainebis gzamkvleviT Sefasebis Sedegad amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi
rArr amerikis pediatrTa akademia
rArr msoflo jandacvis organizacia
rArr kanadis pediatrTa sazogadoeba ndash nayofi da axalSobilis komiteti
rArr britaneTis reproduqciuli janmrTelobis programa
22
bull rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da rekomendaciebis xarisxis sqema
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris
done (Muir Gray)xarisxi rekomendaciis xarisxi
(Cook et al)I Zlieri mtkicebuleba
eyrdnoba minimum erT sistemur mimoxilvas
romelic efuZneba swori dizainis mqone randomizebul
kontrolirebad kvleva
A eyrdnoba I donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erTi swori dizainis mqone
randomizebul kontrolirebad kvleva
B eyrdnoba II donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
III klinikuri kvleva randomizaciis gareSe
kohortuli da SemTxveva-kontrolis kvlevebi
C eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi
D eyrdnoba IV da V donis mtkicebulebas saWiroebs
konsesuss
Va avtoritetul profesionalTa mosazreba
Vb klinikuri gamocdileba aRwerilobiTi kvlevebi an
eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
15 avtorTa jgufi
bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis
bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi
rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
23
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24
kvlevebiT dadgenilia rom intravenuri imunoglobulini amcirebs SenacvlebiTi transfuziis saWiroebas Rh da ABO hemolizuri daavadebis dros
SenacvlebiTi transfuzia
SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleluli unda iyos Semowmebuli da dasxivebuli gadasasxmeli sisxlis raodenoba Seadgens 170-180 mlkg
rekomendacia SenacvlebiTi transfuzia unda Caataros mxolod gamocdilma samedicino personalma intensiuri Terapiis ganyofilebaSi monitoringisa da srulyofili reanimaciis SesaZleblobis pirobebSi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
SenacvlebiTi transfuziis Cvenebebi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)
mwvave bilirubinuli encefalopaTia intensiuri fotoTerapiis miuxedavad Ssb mateba an ucvleli
monacemi samSobiarodan gawerili axalSobilebis hospitalizaciis
SemTxvevaSi Ssb-s maRali maCvenebeli - aRemateba SenacvlebiTi transfuziis dawyebis maCvenebls (sqema 3) (transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia) (ix cxrili 6)
ba Sefardeba Ssb maCvenebelTan (cxrili 6) erTad gamoiyeneba rogorc damatebiTi faqtori SenacvlebiTi transfuziis dawyebis gansasazRvravad
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros
sqema 3 SenacvlebiTi transfuziis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (American Academy of Pediatrics 2004)
16
D
D
cxrili 6 bilirubinisa da albuminis Sefardeba rodesac saWiroa SenacvlebiTi transfuzia (AMERICAN ACADEMY OF PEDIATRICS 2004)
riskis kategoria
ba Sefardeba rodesac saWiroa SenacvlebiTi
transfuziaSsb mgdl alb gdl
Ssb micromolL alb micromolL
axalSobilebi gestaciuri asaki - ge38 kvira 80 094
janmrTeli axalSobilebi gestaciuri asakiT an riskis jgufis axalSobilebi
gestaciuri asakiT ge38 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
72 084
riskis jgufis axalSobilebi gestaciuri asakiT 35ndash36 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
68 080
janmos rekomendacia sisxlis SenacvlebiTi gadasxmis Cvenebebis Sesaxeb mocemulia cxrilSi 7
cxrili 7 SenacvlebiTi transfuziis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI 15 260 13 220II 25 425 15 260
17
III 30 510 20 340IV da meti 30 510 20 340
Tu Ssb uaxlovdeba im dones rodesac naCvenebia SenacvlebiTi transfuzia
sisxli dauyovnebliv igzavneba raTa dadgindes jgufi da rezusi da SeTavseba Tu klinikaSi aris transfuziis saSualeba
an xorcieldeba referali
teqnika (AMERICAN ACADEMY OF PEDIATRICS 2004
bull mwvave bilirubinuli encefalopaTiis dros SenacvlebiTi transfuzia iwyeba dauyovnebliv
bull sxva SemTxvevaSi transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia
bull SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleuli unda iyos Semowmebuli da dasxivebuli
bull gadasasxmeli sisxlis raodenoba Seadgens axalSobilis mocirkulire sisxlis ormag raodenobas saSualod 170-180 mlkg an gadasasxmeli sisxlis gamosaTvleli formula gamoiTvleba 85 x axalSobilis wona kg x 2
bull SenacvlebisaTvis xdeba 2 venis an arteria da venis kaTeterizacia iReben bavSvis 20 ml sisxls da SeyavT 20 ml donoris sisxli (3-4 wT-is ganmavlobaSi) SemTbaris 367-3700C-mde
bull dRenaklulebsa da mZime mdgomareobaSi myof axalSobilebSi Senacvleba xdeba 5-10 ml-iT
axalSobilis momzadeba
bull kuWis SigTavsis aspiracia zondiT 8F da Ria zondis datoveba kuWSibull SeiZleba saWiro gaxdes bavSvis dabma
bull SeiZleba sawovaras gamoyeneba
bull Sardis Semkrebis gamoyeneba diurezis kontrolisTvisaxlSobilis winaswar Sefaseba
bull temperatura
bull guliscema
bull sunTqva
bull wneva
bull glukoza SratSi
bull Sardis analizi
bull ganavlis analizi sisxlis Semcvelobaze
bull kanis feri
bull tonusi
bull qcevauSualod transfuziis dros fasdeba vitaluri niSnebi (yovel 15 wT-Si)
18
bull temperatura
bull guliscema (mwvervalze) (umjobesia kardiomonitoriT)
bull sunTqva
bull kanis feri
bull qceva
monitoringi transfuziis Semdeg bull grZeldeba fotoTerapia
bull kardio monitoringi
bull sisxlis wneva proceduris damTavrebis Semdeg
bull saaTobrivad 6 sT-is ganmavlobaSi temperatura guliscema (mwvervalze) sunTqva
bull glukoza SratSi yovel 3 sT-Si 24 sT-is ganmavlobaSi
bull muclis garSemoweriloba 3-4 sT-Si 24 sT-is ganmavlobaSi nawlavebis peristaltikis auskultacia
bull Sardis analizi
bull ganavali sisxlis Semcvelobaze
bull sakvebis autanlobis niSnebi Rebineba muclis Seberva
bull Ssb 6 sT-Si erTxel
SenacvlebiTi transfuziis riskisikvdiloba - 3 SemTxveva 1000 transfuziaze SenacvlebiTi transfuziis dros garTulebis saxiT 5-Si vlindeba
- apnoe bradikardia cianozi vazospazmi Trombozi nekrozuli enterokoliti aseve SeiZleba ganviTardes hipoqsiur-iSemiuri encefalopaTia da SeZenili imunodeficitis sindromi
sxva mkurnalobafenobarbitali ndash xels uwyobs bilirubinis koniugacias da amcirebs
Ssb dones ar arsebobs sakmarisi mtkicebulebebi fenobarbitalis gamosayeneblad rodesac arsebobs siyviTlis mkurnalobis ufro efeqturi meTodebi (mag fotoTerapia)
referali AMERICAN ACADEMY OF PEDIATRICS 2004)referali maRali donis klinikaSi xorcieldeba Tu
ar aris fotoTerapiis Catarebis SesaZlebloba fotoTerapiis miuxedavad
rArr Ssb ar mcirdeba
rArr Ssb uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones da ar aris transfuziis saSualeba
rArr Ssbalbuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6)
Tu siyviTle gamovlinda I dRes siyviTlis lokalizaciis mixedviT siyviTlis simZimis Sefasebisas
(cxrili 1) dadgenili ldquosaSiSi siyviTlerdquo
bilirubinis maRali namati 85 micromolLsT (gt05 mgdlsT)
gaxangrZlivebuli siyviTle (14 dRe da meti) ojaxur anamnezSi mZime siyviTlis an kerniqterusis arseboba siyviTlis dros sxva daavadebis niSnebis arseboba (mg sefsisi)
19
riskis Sefaseba gaweramde
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
bull yvela axalSobilis gaweramde unda Sefasdes hiperbilirubinemiis ganviTarebis riski yvela ganyofilebas unda hqondes protokoli siyviTlis SefasebisTvis aseTi Sefaseba gansakuTrebiT mniSvnelovania im axalSobilebisaTvis romlebis ewerebian dabadebidan 72 sT-ze adre (rekomendacia C)
bull amerikis pediatrTa akademiis rekomendaciiT riskis SefasebisaTvis gamoyenebuli unda iqnas 2 midgoma (calcalke an kombinaciaSi) gaweris win bilirubinis gansazRvra (Ssb an tkb) daan klinikuri risk-faqtorebis Sefaseba risk-faqtorebis arseboba an Ssb maRali maCveneblebi gaweris Semdeg Sesabamisi meTvalyureobis aucilebelobis Cvenebaa (rekomendacia C)
bull yvela samSobiarom unda miawodos mSobels zepiri daan werilobiTi informacia binaze siyviTlis Sefasebis da saSiSroebis niSnebis Sesaxeb (rekomendacia D)
meTvalyureoba
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)bull yvela axalSobili samSobiarodan gaweriis Semdeg ramdenime dReSi unda Sefasdes kvalificuri samedicino profesionalis mier (rekomendacia C)
bull fasdeba - siyviTlis arseboba axalSobilis wona kvebis efeqturoba Rebinebis arseboba (rekomendacia C)
bull meTvalyureobis grafiki Tu axalSobili samSobiarodan ewereba 48-72 sT-Si samedicino Sefaseba tardeba 120 sT-is (5 dRe) asakSi (rekomendacia C)
bull Tu samSobiarodan gaweris Semdeg meTvalyureoba SeuZlebelia da arsebobs hiperbilirubinemiis ganviTarebis risk-faqtorebi axalSobilis gawera unda gadaidos sanam ar iqneba uzrunvelyofili Sesabamisi meTvalyureoba an sanam gaivlis maRali riskis periodi (72-96sT) (rekomendacia D)
11 gaidlainis gadasinjvisa da ganaxlebis vada ndash 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlainis SemuSavebis meTodologia
bull axalSobilTa hiperbilirubinemiis prevenciis diagnostikisa da marTvis principebis Sesaxeb arsebobs samecniero mtkicebulebis safuZvelze Seqmnil rekomendaciaTa sakmarisi raodenoba mocemuli gaidlainis Semqmnis procesSi samuSao jgufis gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve arsebuli praqtikuli rekomendaciebi moxda arsebuli
20
C
C
C
C
D
C
D
rekomendaciebis adaptirebuli variantis SemuSaveba romelic erTis mxriv pasuxebs saerTaSoriso moTxovnebs xolo meore mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa rogorc adamianur ise teqnikur resursebs
bull rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa bazis gamoyenebiT
cxrili 2
qveyana da resursis dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
httpwwwguidelinegov
Centers for Disease Control and Prevention (CDC)
httpwwwphppocdcgovCDCRecommendsAdvSearchVasp
Agency for Healthcare Research and Quality (AHRQ)
httpwwwahrqgovcliniccpgsixhtm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
httphstatnlmnihgov
Institute of Clinical Systems Improvement (ICSI)
httpwwwicsiorg
American Medical Association httpwwwama-assnorg
Canadian Medical Association (CMA)
httpmdmcacpgsnewcpgsindexasp
Health Canada ndash Population and Public Health Branch (PPHB)
httpwwwhc-scgccapphb-dgspspdpg_ehtml
didi britaneTi
National Institute for Clinical Excellence (NICE)
httpwwwniceorguk
Sheffield Evidence for Effectiveness and Knowledge (SEEK)
httpwwwshefacukseekguidelineshtm
National electronic Library for Health (NeLH)
httpwwwnelhnhsukguidelinesfinder
PRODIGY Clinical Guidance httpwwwprodigynhsukClinicalGuidance
Scottish Intercollegiate Guidelines Network (SIGN)
httpwwwsignacuk
German Guideline Information Service (GERGIS)
httpwwwleitliniendeenglishenglishview
avstralia
Australian National Health and httpwwwhealthgovauhfsnhmrcpublicatcp-
21
Medical Research Council (NHMRC) homehtmaxali zelandia
New Zealand Guidelines Group (NZGG)
httpwwwnzggorgnzlibrarycfm
mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba
httpwwwosdmorg
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi
bull koxreinis biblioTeka - The Cochrane Library 2006 Issue 2 bull amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini ndash MEDLINEbull jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvisgamoricxvis kriteriumebi
bull arCeul iqna kvlevebi Semdegi dizainiT randomizebuli kontrolirebadi sistemuri mimoxilvebi da meta-analizi erTmomentiani kohortuli kvlevebi
bull rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12 wliani SezRudva Tumca zogjer gamoyenebuli iyo ufro adreuli publikaciebi romlebic dResac aqtualuria da safuZvlad udevs sxva Tanamedrove mtkicebulebebs
bull dadgenili iyo enobrivi SezRudvebi radganac samuSao jgufs SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod inglisur da rusul enebze
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
bull samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri meToduri rekomendacia axalSobilTa hiperbilirubinemiis marTvis sakiTxebze romlebic Seicavda jgufis miznis Sesaferis saWiro informacias am rekomendaciebis Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (9496-98) samuSao jgufi xelmZRvanelobda saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mier SemuSavebuli nacionaluri gaidlainebis gzamkvleviT Sefasebis Sedegad amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi
rArr amerikis pediatrTa akademia
rArr msoflo jandacvis organizacia
rArr kanadis pediatrTa sazogadoeba ndash nayofi da axalSobilis komiteti
rArr britaneTis reproduqciuli janmrTelobis programa
22
bull rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da rekomendaciebis xarisxis sqema
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris
done (Muir Gray)xarisxi rekomendaciis xarisxi
(Cook et al)I Zlieri mtkicebuleba
eyrdnoba minimum erT sistemur mimoxilvas
romelic efuZneba swori dizainis mqone randomizebul
kontrolirebad kvleva
A eyrdnoba I donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erTi swori dizainis mqone
randomizebul kontrolirebad kvleva
B eyrdnoba II donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
III klinikuri kvleva randomizaciis gareSe
kohortuli da SemTxveva-kontrolis kvlevebi
C eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi
D eyrdnoba IV da V donis mtkicebulebas saWiroebs
konsesuss
Va avtoritetul profesionalTa mosazreba
Vb klinikuri gamocdileba aRwerilobiTi kvlevebi an
eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
15 avtorTa jgufi
bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis
bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi
rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
23
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24
cxrili 6 bilirubinisa da albuminis Sefardeba rodesac saWiroa SenacvlebiTi transfuzia (AMERICAN ACADEMY OF PEDIATRICS 2004)
riskis kategoria
ba Sefardeba rodesac saWiroa SenacvlebiTi
transfuziaSsb mgdl alb gdl
Ssb micromolL alb micromolL
axalSobilebi gestaciuri asaki - ge38 kvira 80 094
janmrTeli axalSobilebi gestaciuri asakiT an riskis jgufis axalSobilebi
gestaciuri asakiT ge38 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
72 084
riskis jgufis axalSobilebi gestaciuri asakiT 35ndash36 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti
68 080
janmos rekomendacia sisxlis SenacvlebiTi gadasxmis Cvenebebis Sesaxeb mocemulia cxrilSi 7
cxrili 7 SenacvlebiTi transfuziis Cveneba Ssb mixedviT (janmo)
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili
mgdl micromolL mgdl micromolLI 15 260 13 220II 25 425 15 260
17
III 30 510 20 340IV da meti 30 510 20 340
Tu Ssb uaxlovdeba im dones rodesac naCvenebia SenacvlebiTi transfuzia
sisxli dauyovnebliv igzavneba raTa dadgindes jgufi da rezusi da SeTavseba Tu klinikaSi aris transfuziis saSualeba
an xorcieldeba referali
teqnika (AMERICAN ACADEMY OF PEDIATRICS 2004
bull mwvave bilirubinuli encefalopaTiis dros SenacvlebiTi transfuzia iwyeba dauyovnebliv
bull sxva SemTxvevaSi transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia
bull SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleuli unda iyos Semowmebuli da dasxivebuli
bull gadasasxmeli sisxlis raodenoba Seadgens axalSobilis mocirkulire sisxlis ormag raodenobas saSualod 170-180 mlkg an gadasasxmeli sisxlis gamosaTvleli formula gamoiTvleba 85 x axalSobilis wona kg x 2
bull SenacvlebisaTvis xdeba 2 venis an arteria da venis kaTeterizacia iReben bavSvis 20 ml sisxls da SeyavT 20 ml donoris sisxli (3-4 wT-is ganmavlobaSi) SemTbaris 367-3700C-mde
bull dRenaklulebsa da mZime mdgomareobaSi myof axalSobilebSi Senacvleba xdeba 5-10 ml-iT
axalSobilis momzadeba
bull kuWis SigTavsis aspiracia zondiT 8F da Ria zondis datoveba kuWSibull SeiZleba saWiro gaxdes bavSvis dabma
bull SeiZleba sawovaras gamoyeneba
bull Sardis Semkrebis gamoyeneba diurezis kontrolisTvisaxlSobilis winaswar Sefaseba
bull temperatura
bull guliscema
bull sunTqva
bull wneva
bull glukoza SratSi
bull Sardis analizi
bull ganavlis analizi sisxlis Semcvelobaze
bull kanis feri
bull tonusi
bull qcevauSualod transfuziis dros fasdeba vitaluri niSnebi (yovel 15 wT-Si)
18
bull temperatura
bull guliscema (mwvervalze) (umjobesia kardiomonitoriT)
bull sunTqva
bull kanis feri
bull qceva
monitoringi transfuziis Semdeg bull grZeldeba fotoTerapia
bull kardio monitoringi
bull sisxlis wneva proceduris damTavrebis Semdeg
bull saaTobrivad 6 sT-is ganmavlobaSi temperatura guliscema (mwvervalze) sunTqva
bull glukoza SratSi yovel 3 sT-Si 24 sT-is ganmavlobaSi
bull muclis garSemoweriloba 3-4 sT-Si 24 sT-is ganmavlobaSi nawlavebis peristaltikis auskultacia
bull Sardis analizi
bull ganavali sisxlis Semcvelobaze
bull sakvebis autanlobis niSnebi Rebineba muclis Seberva
bull Ssb 6 sT-Si erTxel
SenacvlebiTi transfuziis riskisikvdiloba - 3 SemTxveva 1000 transfuziaze SenacvlebiTi transfuziis dros garTulebis saxiT 5-Si vlindeba
- apnoe bradikardia cianozi vazospazmi Trombozi nekrozuli enterokoliti aseve SeiZleba ganviTardes hipoqsiur-iSemiuri encefalopaTia da SeZenili imunodeficitis sindromi
sxva mkurnalobafenobarbitali ndash xels uwyobs bilirubinis koniugacias da amcirebs
Ssb dones ar arsebobs sakmarisi mtkicebulebebi fenobarbitalis gamosayeneblad rodesac arsebobs siyviTlis mkurnalobis ufro efeqturi meTodebi (mag fotoTerapia)
referali AMERICAN ACADEMY OF PEDIATRICS 2004)referali maRali donis klinikaSi xorcieldeba Tu
ar aris fotoTerapiis Catarebis SesaZlebloba fotoTerapiis miuxedavad
rArr Ssb ar mcirdeba
rArr Ssb uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones da ar aris transfuziis saSualeba
rArr Ssbalbuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6)
Tu siyviTle gamovlinda I dRes siyviTlis lokalizaciis mixedviT siyviTlis simZimis Sefasebisas
(cxrili 1) dadgenili ldquosaSiSi siyviTlerdquo
bilirubinis maRali namati 85 micromolLsT (gt05 mgdlsT)
gaxangrZlivebuli siyviTle (14 dRe da meti) ojaxur anamnezSi mZime siyviTlis an kerniqterusis arseboba siyviTlis dros sxva daavadebis niSnebis arseboba (mg sefsisi)
19
riskis Sefaseba gaweramde
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
bull yvela axalSobilis gaweramde unda Sefasdes hiperbilirubinemiis ganviTarebis riski yvela ganyofilebas unda hqondes protokoli siyviTlis SefasebisTvis aseTi Sefaseba gansakuTrebiT mniSvnelovania im axalSobilebisaTvis romlebis ewerebian dabadebidan 72 sT-ze adre (rekomendacia C)
bull amerikis pediatrTa akademiis rekomendaciiT riskis SefasebisaTvis gamoyenebuli unda iqnas 2 midgoma (calcalke an kombinaciaSi) gaweris win bilirubinis gansazRvra (Ssb an tkb) daan klinikuri risk-faqtorebis Sefaseba risk-faqtorebis arseboba an Ssb maRali maCveneblebi gaweris Semdeg Sesabamisi meTvalyureobis aucilebelobis Cvenebaa (rekomendacia C)
bull yvela samSobiarom unda miawodos mSobels zepiri daan werilobiTi informacia binaze siyviTlis Sefasebis da saSiSroebis niSnebis Sesaxeb (rekomendacia D)
meTvalyureoba
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)bull yvela axalSobili samSobiarodan gaweriis Semdeg ramdenime dReSi unda Sefasdes kvalificuri samedicino profesionalis mier (rekomendacia C)
bull fasdeba - siyviTlis arseboba axalSobilis wona kvebis efeqturoba Rebinebis arseboba (rekomendacia C)
bull meTvalyureobis grafiki Tu axalSobili samSobiarodan ewereba 48-72 sT-Si samedicino Sefaseba tardeba 120 sT-is (5 dRe) asakSi (rekomendacia C)
bull Tu samSobiarodan gaweris Semdeg meTvalyureoba SeuZlebelia da arsebobs hiperbilirubinemiis ganviTarebis risk-faqtorebi axalSobilis gawera unda gadaidos sanam ar iqneba uzrunvelyofili Sesabamisi meTvalyureoba an sanam gaivlis maRali riskis periodi (72-96sT) (rekomendacia D)
11 gaidlainis gadasinjvisa da ganaxlebis vada ndash 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlainis SemuSavebis meTodologia
bull axalSobilTa hiperbilirubinemiis prevenciis diagnostikisa da marTvis principebis Sesaxeb arsebobs samecniero mtkicebulebis safuZvelze Seqmnil rekomendaciaTa sakmarisi raodenoba mocemuli gaidlainis Semqmnis procesSi samuSao jgufis gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve arsebuli praqtikuli rekomendaciebi moxda arsebuli
20
C
C
C
C
D
C
D
rekomendaciebis adaptirebuli variantis SemuSaveba romelic erTis mxriv pasuxebs saerTaSoriso moTxovnebs xolo meore mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa rogorc adamianur ise teqnikur resursebs
bull rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa bazis gamoyenebiT
cxrili 2
qveyana da resursis dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
httpwwwguidelinegov
Centers for Disease Control and Prevention (CDC)
httpwwwphppocdcgovCDCRecommendsAdvSearchVasp
Agency for Healthcare Research and Quality (AHRQ)
httpwwwahrqgovcliniccpgsixhtm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
httphstatnlmnihgov
Institute of Clinical Systems Improvement (ICSI)
httpwwwicsiorg
American Medical Association httpwwwama-assnorg
Canadian Medical Association (CMA)
httpmdmcacpgsnewcpgsindexasp
Health Canada ndash Population and Public Health Branch (PPHB)
httpwwwhc-scgccapphb-dgspspdpg_ehtml
didi britaneTi
National Institute for Clinical Excellence (NICE)
httpwwwniceorguk
Sheffield Evidence for Effectiveness and Knowledge (SEEK)
httpwwwshefacukseekguidelineshtm
National electronic Library for Health (NeLH)
httpwwwnelhnhsukguidelinesfinder
PRODIGY Clinical Guidance httpwwwprodigynhsukClinicalGuidance
Scottish Intercollegiate Guidelines Network (SIGN)
httpwwwsignacuk
German Guideline Information Service (GERGIS)
httpwwwleitliniendeenglishenglishview
avstralia
Australian National Health and httpwwwhealthgovauhfsnhmrcpublicatcp-
21
Medical Research Council (NHMRC) homehtmaxali zelandia
New Zealand Guidelines Group (NZGG)
httpwwwnzggorgnzlibrarycfm
mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba
httpwwwosdmorg
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi
bull koxreinis biblioTeka - The Cochrane Library 2006 Issue 2 bull amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini ndash MEDLINEbull jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvisgamoricxvis kriteriumebi
bull arCeul iqna kvlevebi Semdegi dizainiT randomizebuli kontrolirebadi sistemuri mimoxilvebi da meta-analizi erTmomentiani kohortuli kvlevebi
bull rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12 wliani SezRudva Tumca zogjer gamoyenebuli iyo ufro adreuli publikaciebi romlebic dResac aqtualuria da safuZvlad udevs sxva Tanamedrove mtkicebulebebs
bull dadgenili iyo enobrivi SezRudvebi radganac samuSao jgufs SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod inglisur da rusul enebze
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
bull samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri meToduri rekomendacia axalSobilTa hiperbilirubinemiis marTvis sakiTxebze romlebic Seicavda jgufis miznis Sesaferis saWiro informacias am rekomendaciebis Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (9496-98) samuSao jgufi xelmZRvanelobda saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mier SemuSavebuli nacionaluri gaidlainebis gzamkvleviT Sefasebis Sedegad amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi
rArr amerikis pediatrTa akademia
rArr msoflo jandacvis organizacia
rArr kanadis pediatrTa sazogadoeba ndash nayofi da axalSobilis komiteti
rArr britaneTis reproduqciuli janmrTelobis programa
22
bull rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da rekomendaciebis xarisxis sqema
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris
done (Muir Gray)xarisxi rekomendaciis xarisxi
(Cook et al)I Zlieri mtkicebuleba
eyrdnoba minimum erT sistemur mimoxilvas
romelic efuZneba swori dizainis mqone randomizebul
kontrolirebad kvleva
A eyrdnoba I donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erTi swori dizainis mqone
randomizebul kontrolirebad kvleva
B eyrdnoba II donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
III klinikuri kvleva randomizaciis gareSe
kohortuli da SemTxveva-kontrolis kvlevebi
C eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi
D eyrdnoba IV da V donis mtkicebulebas saWiroebs
konsesuss
Va avtoritetul profesionalTa mosazreba
Vb klinikuri gamocdileba aRwerilobiTi kvlevebi an
eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
15 avtorTa jgufi
bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis
bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi
rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
23
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24
III 30 510 20 340IV da meti 30 510 20 340
Tu Ssb uaxlovdeba im dones rodesac naCvenebia SenacvlebiTi transfuzia
sisxli dauyovnebliv igzavneba raTa dadgindes jgufi da rezusi da SeTavseba Tu klinikaSi aris transfuziis saSualeba
an xorcieldeba referali
teqnika (AMERICAN ACADEMY OF PEDIATRICS 2004
bull mwvave bilirubinuli encefalopaTiis dros SenacvlebiTi transfuzia iwyeba dauyovnebliv
bull sxva SemTxvevaSi transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia
bull SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleuli unda iyos Semowmebuli da dasxivebuli
bull gadasasxmeli sisxlis raodenoba Seadgens axalSobilis mocirkulire sisxlis ormag raodenobas saSualod 170-180 mlkg an gadasasxmeli sisxlis gamosaTvleli formula gamoiTvleba 85 x axalSobilis wona kg x 2
bull SenacvlebisaTvis xdeba 2 venis an arteria da venis kaTeterizacia iReben bavSvis 20 ml sisxls da SeyavT 20 ml donoris sisxli (3-4 wT-is ganmavlobaSi) SemTbaris 367-3700C-mde
bull dRenaklulebsa da mZime mdgomareobaSi myof axalSobilebSi Senacvleba xdeba 5-10 ml-iT
axalSobilis momzadeba
bull kuWis SigTavsis aspiracia zondiT 8F da Ria zondis datoveba kuWSibull SeiZleba saWiro gaxdes bavSvis dabma
bull SeiZleba sawovaras gamoyeneba
bull Sardis Semkrebis gamoyeneba diurezis kontrolisTvisaxlSobilis winaswar Sefaseba
bull temperatura
bull guliscema
bull sunTqva
bull wneva
bull glukoza SratSi
bull Sardis analizi
bull ganavlis analizi sisxlis Semcvelobaze
bull kanis feri
bull tonusi
bull qcevauSualod transfuziis dros fasdeba vitaluri niSnebi (yovel 15 wT-Si)
18
bull temperatura
bull guliscema (mwvervalze) (umjobesia kardiomonitoriT)
bull sunTqva
bull kanis feri
bull qceva
monitoringi transfuziis Semdeg bull grZeldeba fotoTerapia
bull kardio monitoringi
bull sisxlis wneva proceduris damTavrebis Semdeg
bull saaTobrivad 6 sT-is ganmavlobaSi temperatura guliscema (mwvervalze) sunTqva
bull glukoza SratSi yovel 3 sT-Si 24 sT-is ganmavlobaSi
bull muclis garSemoweriloba 3-4 sT-Si 24 sT-is ganmavlobaSi nawlavebis peristaltikis auskultacia
bull Sardis analizi
bull ganavali sisxlis Semcvelobaze
bull sakvebis autanlobis niSnebi Rebineba muclis Seberva
bull Ssb 6 sT-Si erTxel
SenacvlebiTi transfuziis riskisikvdiloba - 3 SemTxveva 1000 transfuziaze SenacvlebiTi transfuziis dros garTulebis saxiT 5-Si vlindeba
- apnoe bradikardia cianozi vazospazmi Trombozi nekrozuli enterokoliti aseve SeiZleba ganviTardes hipoqsiur-iSemiuri encefalopaTia da SeZenili imunodeficitis sindromi
sxva mkurnalobafenobarbitali ndash xels uwyobs bilirubinis koniugacias da amcirebs
Ssb dones ar arsebobs sakmarisi mtkicebulebebi fenobarbitalis gamosayeneblad rodesac arsebobs siyviTlis mkurnalobis ufro efeqturi meTodebi (mag fotoTerapia)
referali AMERICAN ACADEMY OF PEDIATRICS 2004)referali maRali donis klinikaSi xorcieldeba Tu
ar aris fotoTerapiis Catarebis SesaZlebloba fotoTerapiis miuxedavad
rArr Ssb ar mcirdeba
rArr Ssb uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones da ar aris transfuziis saSualeba
rArr Ssbalbuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6)
Tu siyviTle gamovlinda I dRes siyviTlis lokalizaciis mixedviT siyviTlis simZimis Sefasebisas
(cxrili 1) dadgenili ldquosaSiSi siyviTlerdquo
bilirubinis maRali namati 85 micromolLsT (gt05 mgdlsT)
gaxangrZlivebuli siyviTle (14 dRe da meti) ojaxur anamnezSi mZime siyviTlis an kerniqterusis arseboba siyviTlis dros sxva daavadebis niSnebis arseboba (mg sefsisi)
19
riskis Sefaseba gaweramde
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
bull yvela axalSobilis gaweramde unda Sefasdes hiperbilirubinemiis ganviTarebis riski yvela ganyofilebas unda hqondes protokoli siyviTlis SefasebisTvis aseTi Sefaseba gansakuTrebiT mniSvnelovania im axalSobilebisaTvis romlebis ewerebian dabadebidan 72 sT-ze adre (rekomendacia C)
bull amerikis pediatrTa akademiis rekomendaciiT riskis SefasebisaTvis gamoyenebuli unda iqnas 2 midgoma (calcalke an kombinaciaSi) gaweris win bilirubinis gansazRvra (Ssb an tkb) daan klinikuri risk-faqtorebis Sefaseba risk-faqtorebis arseboba an Ssb maRali maCveneblebi gaweris Semdeg Sesabamisi meTvalyureobis aucilebelobis Cvenebaa (rekomendacia C)
bull yvela samSobiarom unda miawodos mSobels zepiri daan werilobiTi informacia binaze siyviTlis Sefasebis da saSiSroebis niSnebis Sesaxeb (rekomendacia D)
meTvalyureoba
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)bull yvela axalSobili samSobiarodan gaweriis Semdeg ramdenime dReSi unda Sefasdes kvalificuri samedicino profesionalis mier (rekomendacia C)
bull fasdeba - siyviTlis arseboba axalSobilis wona kvebis efeqturoba Rebinebis arseboba (rekomendacia C)
bull meTvalyureobis grafiki Tu axalSobili samSobiarodan ewereba 48-72 sT-Si samedicino Sefaseba tardeba 120 sT-is (5 dRe) asakSi (rekomendacia C)
bull Tu samSobiarodan gaweris Semdeg meTvalyureoba SeuZlebelia da arsebobs hiperbilirubinemiis ganviTarebis risk-faqtorebi axalSobilis gawera unda gadaidos sanam ar iqneba uzrunvelyofili Sesabamisi meTvalyureoba an sanam gaivlis maRali riskis periodi (72-96sT) (rekomendacia D)
11 gaidlainis gadasinjvisa da ganaxlebis vada ndash 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlainis SemuSavebis meTodologia
bull axalSobilTa hiperbilirubinemiis prevenciis diagnostikisa da marTvis principebis Sesaxeb arsebobs samecniero mtkicebulebis safuZvelze Seqmnil rekomendaciaTa sakmarisi raodenoba mocemuli gaidlainis Semqmnis procesSi samuSao jgufis gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve arsebuli praqtikuli rekomendaciebi moxda arsebuli
20
C
C
C
C
D
C
D
rekomendaciebis adaptirebuli variantis SemuSaveba romelic erTis mxriv pasuxebs saerTaSoriso moTxovnebs xolo meore mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa rogorc adamianur ise teqnikur resursebs
bull rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa bazis gamoyenebiT
cxrili 2
qveyana da resursis dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
httpwwwguidelinegov
Centers for Disease Control and Prevention (CDC)
httpwwwphppocdcgovCDCRecommendsAdvSearchVasp
Agency for Healthcare Research and Quality (AHRQ)
httpwwwahrqgovcliniccpgsixhtm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
httphstatnlmnihgov
Institute of Clinical Systems Improvement (ICSI)
httpwwwicsiorg
American Medical Association httpwwwama-assnorg
Canadian Medical Association (CMA)
httpmdmcacpgsnewcpgsindexasp
Health Canada ndash Population and Public Health Branch (PPHB)
httpwwwhc-scgccapphb-dgspspdpg_ehtml
didi britaneTi
National Institute for Clinical Excellence (NICE)
httpwwwniceorguk
Sheffield Evidence for Effectiveness and Knowledge (SEEK)
httpwwwshefacukseekguidelineshtm
National electronic Library for Health (NeLH)
httpwwwnelhnhsukguidelinesfinder
PRODIGY Clinical Guidance httpwwwprodigynhsukClinicalGuidance
Scottish Intercollegiate Guidelines Network (SIGN)
httpwwwsignacuk
German Guideline Information Service (GERGIS)
httpwwwleitliniendeenglishenglishview
avstralia
Australian National Health and httpwwwhealthgovauhfsnhmrcpublicatcp-
21
Medical Research Council (NHMRC) homehtmaxali zelandia
New Zealand Guidelines Group (NZGG)
httpwwwnzggorgnzlibrarycfm
mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba
httpwwwosdmorg
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi
bull koxreinis biblioTeka - The Cochrane Library 2006 Issue 2 bull amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini ndash MEDLINEbull jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvisgamoricxvis kriteriumebi
bull arCeul iqna kvlevebi Semdegi dizainiT randomizebuli kontrolirebadi sistemuri mimoxilvebi da meta-analizi erTmomentiani kohortuli kvlevebi
bull rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12 wliani SezRudva Tumca zogjer gamoyenebuli iyo ufro adreuli publikaciebi romlebic dResac aqtualuria da safuZvlad udevs sxva Tanamedrove mtkicebulebebs
bull dadgenili iyo enobrivi SezRudvebi radganac samuSao jgufs SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod inglisur da rusul enebze
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
bull samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri meToduri rekomendacia axalSobilTa hiperbilirubinemiis marTvis sakiTxebze romlebic Seicavda jgufis miznis Sesaferis saWiro informacias am rekomendaciebis Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (9496-98) samuSao jgufi xelmZRvanelobda saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mier SemuSavebuli nacionaluri gaidlainebis gzamkvleviT Sefasebis Sedegad amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi
rArr amerikis pediatrTa akademia
rArr msoflo jandacvis organizacia
rArr kanadis pediatrTa sazogadoeba ndash nayofi da axalSobilis komiteti
rArr britaneTis reproduqciuli janmrTelobis programa
22
bull rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da rekomendaciebis xarisxis sqema
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris
done (Muir Gray)xarisxi rekomendaciis xarisxi
(Cook et al)I Zlieri mtkicebuleba
eyrdnoba minimum erT sistemur mimoxilvas
romelic efuZneba swori dizainis mqone randomizebul
kontrolirebad kvleva
A eyrdnoba I donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erTi swori dizainis mqone
randomizebul kontrolirebad kvleva
B eyrdnoba II donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
III klinikuri kvleva randomizaciis gareSe
kohortuli da SemTxveva-kontrolis kvlevebi
C eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi
D eyrdnoba IV da V donis mtkicebulebas saWiroebs
konsesuss
Va avtoritetul profesionalTa mosazreba
Vb klinikuri gamocdileba aRwerilobiTi kvlevebi an
eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
15 avtorTa jgufi
bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis
bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi
rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
23
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24
bull temperatura
bull guliscema (mwvervalze) (umjobesia kardiomonitoriT)
bull sunTqva
bull kanis feri
bull qceva
monitoringi transfuziis Semdeg bull grZeldeba fotoTerapia
bull kardio monitoringi
bull sisxlis wneva proceduris damTavrebis Semdeg
bull saaTobrivad 6 sT-is ganmavlobaSi temperatura guliscema (mwvervalze) sunTqva
bull glukoza SratSi yovel 3 sT-Si 24 sT-is ganmavlobaSi
bull muclis garSemoweriloba 3-4 sT-Si 24 sT-is ganmavlobaSi nawlavebis peristaltikis auskultacia
bull Sardis analizi
bull ganavali sisxlis Semcvelobaze
bull sakvebis autanlobis niSnebi Rebineba muclis Seberva
bull Ssb 6 sT-Si erTxel
SenacvlebiTi transfuziis riskisikvdiloba - 3 SemTxveva 1000 transfuziaze SenacvlebiTi transfuziis dros garTulebis saxiT 5-Si vlindeba
- apnoe bradikardia cianozi vazospazmi Trombozi nekrozuli enterokoliti aseve SeiZleba ganviTardes hipoqsiur-iSemiuri encefalopaTia da SeZenili imunodeficitis sindromi
sxva mkurnalobafenobarbitali ndash xels uwyobs bilirubinis koniugacias da amcirebs
Ssb dones ar arsebobs sakmarisi mtkicebulebebi fenobarbitalis gamosayeneblad rodesac arsebobs siyviTlis mkurnalobis ufro efeqturi meTodebi (mag fotoTerapia)
referali AMERICAN ACADEMY OF PEDIATRICS 2004)referali maRali donis klinikaSi xorcieldeba Tu
ar aris fotoTerapiis Catarebis SesaZlebloba fotoTerapiis miuxedavad
rArr Ssb ar mcirdeba
rArr Ssb uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones da ar aris transfuziis saSualeba
rArr Ssbalbuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6)
Tu siyviTle gamovlinda I dRes siyviTlis lokalizaciis mixedviT siyviTlis simZimis Sefasebisas
(cxrili 1) dadgenili ldquosaSiSi siyviTlerdquo
bilirubinis maRali namati 85 micromolLsT (gt05 mgdlsT)
gaxangrZlivebuli siyviTle (14 dRe da meti) ojaxur anamnezSi mZime siyviTlis an kerniqterusis arseboba siyviTlis dros sxva daavadebis niSnebis arseboba (mg sefsisi)
19
riskis Sefaseba gaweramde
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
bull yvela axalSobilis gaweramde unda Sefasdes hiperbilirubinemiis ganviTarebis riski yvela ganyofilebas unda hqondes protokoli siyviTlis SefasebisTvis aseTi Sefaseba gansakuTrebiT mniSvnelovania im axalSobilebisaTvis romlebis ewerebian dabadebidan 72 sT-ze adre (rekomendacia C)
bull amerikis pediatrTa akademiis rekomendaciiT riskis SefasebisaTvis gamoyenebuli unda iqnas 2 midgoma (calcalke an kombinaciaSi) gaweris win bilirubinis gansazRvra (Ssb an tkb) daan klinikuri risk-faqtorebis Sefaseba risk-faqtorebis arseboba an Ssb maRali maCveneblebi gaweris Semdeg Sesabamisi meTvalyureobis aucilebelobis Cvenebaa (rekomendacia C)
bull yvela samSobiarom unda miawodos mSobels zepiri daan werilobiTi informacia binaze siyviTlis Sefasebis da saSiSroebis niSnebis Sesaxeb (rekomendacia D)
meTvalyureoba
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)bull yvela axalSobili samSobiarodan gaweriis Semdeg ramdenime dReSi unda Sefasdes kvalificuri samedicino profesionalis mier (rekomendacia C)
bull fasdeba - siyviTlis arseboba axalSobilis wona kvebis efeqturoba Rebinebis arseboba (rekomendacia C)
bull meTvalyureobis grafiki Tu axalSobili samSobiarodan ewereba 48-72 sT-Si samedicino Sefaseba tardeba 120 sT-is (5 dRe) asakSi (rekomendacia C)
bull Tu samSobiarodan gaweris Semdeg meTvalyureoba SeuZlebelia da arsebobs hiperbilirubinemiis ganviTarebis risk-faqtorebi axalSobilis gawera unda gadaidos sanam ar iqneba uzrunvelyofili Sesabamisi meTvalyureoba an sanam gaivlis maRali riskis periodi (72-96sT) (rekomendacia D)
11 gaidlainis gadasinjvisa da ganaxlebis vada ndash 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlainis SemuSavebis meTodologia
bull axalSobilTa hiperbilirubinemiis prevenciis diagnostikisa da marTvis principebis Sesaxeb arsebobs samecniero mtkicebulebis safuZvelze Seqmnil rekomendaciaTa sakmarisi raodenoba mocemuli gaidlainis Semqmnis procesSi samuSao jgufis gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve arsebuli praqtikuli rekomendaciebi moxda arsebuli
20
C
C
C
C
D
C
D
rekomendaciebis adaptirebuli variantis SemuSaveba romelic erTis mxriv pasuxebs saerTaSoriso moTxovnebs xolo meore mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa rogorc adamianur ise teqnikur resursebs
bull rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa bazis gamoyenebiT
cxrili 2
qveyana da resursis dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
httpwwwguidelinegov
Centers for Disease Control and Prevention (CDC)
httpwwwphppocdcgovCDCRecommendsAdvSearchVasp
Agency for Healthcare Research and Quality (AHRQ)
httpwwwahrqgovcliniccpgsixhtm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
httphstatnlmnihgov
Institute of Clinical Systems Improvement (ICSI)
httpwwwicsiorg
American Medical Association httpwwwama-assnorg
Canadian Medical Association (CMA)
httpmdmcacpgsnewcpgsindexasp
Health Canada ndash Population and Public Health Branch (PPHB)
httpwwwhc-scgccapphb-dgspspdpg_ehtml
didi britaneTi
National Institute for Clinical Excellence (NICE)
httpwwwniceorguk
Sheffield Evidence for Effectiveness and Knowledge (SEEK)
httpwwwshefacukseekguidelineshtm
National electronic Library for Health (NeLH)
httpwwwnelhnhsukguidelinesfinder
PRODIGY Clinical Guidance httpwwwprodigynhsukClinicalGuidance
Scottish Intercollegiate Guidelines Network (SIGN)
httpwwwsignacuk
German Guideline Information Service (GERGIS)
httpwwwleitliniendeenglishenglishview
avstralia
Australian National Health and httpwwwhealthgovauhfsnhmrcpublicatcp-
21
Medical Research Council (NHMRC) homehtmaxali zelandia
New Zealand Guidelines Group (NZGG)
httpwwwnzggorgnzlibrarycfm
mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba
httpwwwosdmorg
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi
bull koxreinis biblioTeka - The Cochrane Library 2006 Issue 2 bull amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini ndash MEDLINEbull jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvisgamoricxvis kriteriumebi
bull arCeul iqna kvlevebi Semdegi dizainiT randomizebuli kontrolirebadi sistemuri mimoxilvebi da meta-analizi erTmomentiani kohortuli kvlevebi
bull rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12 wliani SezRudva Tumca zogjer gamoyenebuli iyo ufro adreuli publikaciebi romlebic dResac aqtualuria da safuZvlad udevs sxva Tanamedrove mtkicebulebebs
bull dadgenili iyo enobrivi SezRudvebi radganac samuSao jgufs SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod inglisur da rusul enebze
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
bull samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri meToduri rekomendacia axalSobilTa hiperbilirubinemiis marTvis sakiTxebze romlebic Seicavda jgufis miznis Sesaferis saWiro informacias am rekomendaciebis Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (9496-98) samuSao jgufi xelmZRvanelobda saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mier SemuSavebuli nacionaluri gaidlainebis gzamkvleviT Sefasebis Sedegad amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi
rArr amerikis pediatrTa akademia
rArr msoflo jandacvis organizacia
rArr kanadis pediatrTa sazogadoeba ndash nayofi da axalSobilis komiteti
rArr britaneTis reproduqciuli janmrTelobis programa
22
bull rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da rekomendaciebis xarisxis sqema
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris
done (Muir Gray)xarisxi rekomendaciis xarisxi
(Cook et al)I Zlieri mtkicebuleba
eyrdnoba minimum erT sistemur mimoxilvas
romelic efuZneba swori dizainis mqone randomizebul
kontrolirebad kvleva
A eyrdnoba I donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erTi swori dizainis mqone
randomizebul kontrolirebad kvleva
B eyrdnoba II donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
III klinikuri kvleva randomizaciis gareSe
kohortuli da SemTxveva-kontrolis kvlevebi
C eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi
D eyrdnoba IV da V donis mtkicebulebas saWiroebs
konsesuss
Va avtoritetul profesionalTa mosazreba
Vb klinikuri gamocdileba aRwerilobiTi kvlevebi an
eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
15 avtorTa jgufi
bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis
bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi
rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
23
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24
riskis Sefaseba gaweramde
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)
bull yvela axalSobilis gaweramde unda Sefasdes hiperbilirubinemiis ganviTarebis riski yvela ganyofilebas unda hqondes protokoli siyviTlis SefasebisTvis aseTi Sefaseba gansakuTrebiT mniSvnelovania im axalSobilebisaTvis romlebis ewerebian dabadebidan 72 sT-ze adre (rekomendacia C)
bull amerikis pediatrTa akademiis rekomendaciiT riskis SefasebisaTvis gamoyenebuli unda iqnas 2 midgoma (calcalke an kombinaciaSi) gaweris win bilirubinis gansazRvra (Ssb an tkb) daan klinikuri risk-faqtorebis Sefaseba risk-faqtorebis arseboba an Ssb maRali maCveneblebi gaweris Semdeg Sesabamisi meTvalyureobis aucilebelobis Cvenebaa (rekomendacia C)
bull yvela samSobiarom unda miawodos mSobels zepiri daan werilobiTi informacia binaze siyviTlis Sefasebis da saSiSroebis niSnebis Sesaxeb (rekomendacia D)
meTvalyureoba
rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)bull yvela axalSobili samSobiarodan gaweriis Semdeg ramdenime dReSi unda Sefasdes kvalificuri samedicino profesionalis mier (rekomendacia C)
bull fasdeba - siyviTlis arseboba axalSobilis wona kvebis efeqturoba Rebinebis arseboba (rekomendacia C)
bull meTvalyureobis grafiki Tu axalSobili samSobiarodan ewereba 48-72 sT-Si samedicino Sefaseba tardeba 120 sT-is (5 dRe) asakSi (rekomendacia C)
bull Tu samSobiarodan gaweris Semdeg meTvalyureoba SeuZlebelia da arsebobs hiperbilirubinemiis ganviTarebis risk-faqtorebi axalSobilis gawera unda gadaidos sanam ar iqneba uzrunvelyofili Sesabamisi meTvalyureoba an sanam gaivlis maRali riskis periodi (72-96sT) (rekomendacia D)
11 gaidlainis gadasinjvisa da ganaxlebis vada ndash 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlainis SemuSavebis meTodologia
bull axalSobilTa hiperbilirubinemiis prevenciis diagnostikisa da marTvis principebis Sesaxeb arsebobs samecniero mtkicebulebis safuZvelze Seqmnil rekomendaciaTa sakmarisi raodenoba mocemuli gaidlainis Semqmnis procesSi samuSao jgufis gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve arsebuli praqtikuli rekomendaciebi moxda arsebuli
20
C
C
C
C
D
C
D
rekomendaciebis adaptirebuli variantis SemuSaveba romelic erTis mxriv pasuxebs saerTaSoriso moTxovnebs xolo meore mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa rogorc adamianur ise teqnikur resursebs
bull rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa bazis gamoyenebiT
cxrili 2
qveyana da resursis dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
httpwwwguidelinegov
Centers for Disease Control and Prevention (CDC)
httpwwwphppocdcgovCDCRecommendsAdvSearchVasp
Agency for Healthcare Research and Quality (AHRQ)
httpwwwahrqgovcliniccpgsixhtm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
httphstatnlmnihgov
Institute of Clinical Systems Improvement (ICSI)
httpwwwicsiorg
American Medical Association httpwwwama-assnorg
Canadian Medical Association (CMA)
httpmdmcacpgsnewcpgsindexasp
Health Canada ndash Population and Public Health Branch (PPHB)
httpwwwhc-scgccapphb-dgspspdpg_ehtml
didi britaneTi
National Institute for Clinical Excellence (NICE)
httpwwwniceorguk
Sheffield Evidence for Effectiveness and Knowledge (SEEK)
httpwwwshefacukseekguidelineshtm
National electronic Library for Health (NeLH)
httpwwwnelhnhsukguidelinesfinder
PRODIGY Clinical Guidance httpwwwprodigynhsukClinicalGuidance
Scottish Intercollegiate Guidelines Network (SIGN)
httpwwwsignacuk
German Guideline Information Service (GERGIS)
httpwwwleitliniendeenglishenglishview
avstralia
Australian National Health and httpwwwhealthgovauhfsnhmrcpublicatcp-
21
Medical Research Council (NHMRC) homehtmaxali zelandia
New Zealand Guidelines Group (NZGG)
httpwwwnzggorgnzlibrarycfm
mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba
httpwwwosdmorg
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi
bull koxreinis biblioTeka - The Cochrane Library 2006 Issue 2 bull amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini ndash MEDLINEbull jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvisgamoricxvis kriteriumebi
bull arCeul iqna kvlevebi Semdegi dizainiT randomizebuli kontrolirebadi sistemuri mimoxilvebi da meta-analizi erTmomentiani kohortuli kvlevebi
bull rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12 wliani SezRudva Tumca zogjer gamoyenebuli iyo ufro adreuli publikaciebi romlebic dResac aqtualuria da safuZvlad udevs sxva Tanamedrove mtkicebulebebs
bull dadgenili iyo enobrivi SezRudvebi radganac samuSao jgufs SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod inglisur da rusul enebze
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
bull samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri meToduri rekomendacia axalSobilTa hiperbilirubinemiis marTvis sakiTxebze romlebic Seicavda jgufis miznis Sesaferis saWiro informacias am rekomendaciebis Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (9496-98) samuSao jgufi xelmZRvanelobda saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mier SemuSavebuli nacionaluri gaidlainebis gzamkvleviT Sefasebis Sedegad amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi
rArr amerikis pediatrTa akademia
rArr msoflo jandacvis organizacia
rArr kanadis pediatrTa sazogadoeba ndash nayofi da axalSobilis komiteti
rArr britaneTis reproduqciuli janmrTelobis programa
22
bull rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da rekomendaciebis xarisxis sqema
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris
done (Muir Gray)xarisxi rekomendaciis xarisxi
(Cook et al)I Zlieri mtkicebuleba
eyrdnoba minimum erT sistemur mimoxilvas
romelic efuZneba swori dizainis mqone randomizebul
kontrolirebad kvleva
A eyrdnoba I donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erTi swori dizainis mqone
randomizebul kontrolirebad kvleva
B eyrdnoba II donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
III klinikuri kvleva randomizaciis gareSe
kohortuli da SemTxveva-kontrolis kvlevebi
C eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi
D eyrdnoba IV da V donis mtkicebulebas saWiroebs
konsesuss
Va avtoritetul profesionalTa mosazreba
Vb klinikuri gamocdileba aRwerilobiTi kvlevebi an
eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
15 avtorTa jgufi
bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis
bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi
rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
23
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24
rekomendaciebis adaptirebuli variantis SemuSaveba romelic erTis mxriv pasuxebs saerTaSoriso moTxovnebs xolo meore mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa rogorc adamianur ise teqnikur resursebs
bull rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa bazis gamoyenebiT
cxrili 2
qveyana da resursis dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
httpwwwguidelinegov
Centers for Disease Control and Prevention (CDC)
httpwwwphppocdcgovCDCRecommendsAdvSearchVasp
Agency for Healthcare Research and Quality (AHRQ)
httpwwwahrqgovcliniccpgsixhtm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
httphstatnlmnihgov
Institute of Clinical Systems Improvement (ICSI)
httpwwwicsiorg
American Medical Association httpwwwama-assnorg
Canadian Medical Association (CMA)
httpmdmcacpgsnewcpgsindexasp
Health Canada ndash Population and Public Health Branch (PPHB)
httpwwwhc-scgccapphb-dgspspdpg_ehtml
didi britaneTi
National Institute for Clinical Excellence (NICE)
httpwwwniceorguk
Sheffield Evidence for Effectiveness and Knowledge (SEEK)
httpwwwshefacukseekguidelineshtm
National electronic Library for Health (NeLH)
httpwwwnelhnhsukguidelinesfinder
PRODIGY Clinical Guidance httpwwwprodigynhsukClinicalGuidance
Scottish Intercollegiate Guidelines Network (SIGN)
httpwwwsignacuk
German Guideline Information Service (GERGIS)
httpwwwleitliniendeenglishenglishview
avstralia
Australian National Health and httpwwwhealthgovauhfsnhmrcpublicatcp-
21
Medical Research Council (NHMRC) homehtmaxali zelandia
New Zealand Guidelines Group (NZGG)
httpwwwnzggorgnzlibrarycfm
mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba
httpwwwosdmorg
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi
bull koxreinis biblioTeka - The Cochrane Library 2006 Issue 2 bull amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini ndash MEDLINEbull jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvisgamoricxvis kriteriumebi
bull arCeul iqna kvlevebi Semdegi dizainiT randomizebuli kontrolirebadi sistemuri mimoxilvebi da meta-analizi erTmomentiani kohortuli kvlevebi
bull rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12 wliani SezRudva Tumca zogjer gamoyenebuli iyo ufro adreuli publikaciebi romlebic dResac aqtualuria da safuZvlad udevs sxva Tanamedrove mtkicebulebebs
bull dadgenili iyo enobrivi SezRudvebi radganac samuSao jgufs SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod inglisur da rusul enebze
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
bull samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri meToduri rekomendacia axalSobilTa hiperbilirubinemiis marTvis sakiTxebze romlebic Seicavda jgufis miznis Sesaferis saWiro informacias am rekomendaciebis Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (9496-98) samuSao jgufi xelmZRvanelobda saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mier SemuSavebuli nacionaluri gaidlainebis gzamkvleviT Sefasebis Sedegad amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi
rArr amerikis pediatrTa akademia
rArr msoflo jandacvis organizacia
rArr kanadis pediatrTa sazogadoeba ndash nayofi da axalSobilis komiteti
rArr britaneTis reproduqciuli janmrTelobis programa
22
bull rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da rekomendaciebis xarisxis sqema
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris
done (Muir Gray)xarisxi rekomendaciis xarisxi
(Cook et al)I Zlieri mtkicebuleba
eyrdnoba minimum erT sistemur mimoxilvas
romelic efuZneba swori dizainis mqone randomizebul
kontrolirebad kvleva
A eyrdnoba I donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erTi swori dizainis mqone
randomizebul kontrolirebad kvleva
B eyrdnoba II donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
III klinikuri kvleva randomizaciis gareSe
kohortuli da SemTxveva-kontrolis kvlevebi
C eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi
D eyrdnoba IV da V donis mtkicebulebas saWiroebs
konsesuss
Va avtoritetul profesionalTa mosazreba
Vb klinikuri gamocdileba aRwerilobiTi kvlevebi an
eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
15 avtorTa jgufi
bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis
bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi
rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
23
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24
Medical Research Council (NHMRC) homehtmaxali zelandia
New Zealand Guidelines Group (NZGG)
httpwwwnzggorgnzlibrarycfm
mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba
httpwwwosdmorg
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi
bull koxreinis biblioTeka - The Cochrane Library 2006 Issue 2 bull amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini ndash MEDLINEbull jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvisgamoricxvis kriteriumebi
bull arCeul iqna kvlevebi Semdegi dizainiT randomizebuli kontrolirebadi sistemuri mimoxilvebi da meta-analizi erTmomentiani kohortuli kvlevebi
bull rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12 wliani SezRudva Tumca zogjer gamoyenebuli iyo ufro adreuli publikaciebi romlebic dResac aqtualuria da safuZvlad udevs sxva Tanamedrove mtkicebulebebs
bull dadgenili iyo enobrivi SezRudvebi radganac samuSao jgufs SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod inglisur da rusul enebze
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
bull samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri meToduri rekomendacia axalSobilTa hiperbilirubinemiis marTvis sakiTxebze romlebic Seicavda jgufis miznis Sesaferis saWiro informacias am rekomendaciebis Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (9496-98) samuSao jgufi xelmZRvanelobda saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mier SemuSavebuli nacionaluri gaidlainebis gzamkvleviT Sefasebis Sedegad amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi
rArr amerikis pediatrTa akademia
rArr msoflo jandacvis organizacia
rArr kanadis pediatrTa sazogadoeba ndash nayofi da axalSobilis komiteti
rArr britaneTis reproduqciuli janmrTelobis programa
22
bull rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da rekomendaciebis xarisxis sqema
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris
done (Muir Gray)xarisxi rekomendaciis xarisxi
(Cook et al)I Zlieri mtkicebuleba
eyrdnoba minimum erT sistemur mimoxilvas
romelic efuZneba swori dizainis mqone randomizebul
kontrolirebad kvleva
A eyrdnoba I donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erTi swori dizainis mqone
randomizebul kontrolirebad kvleva
B eyrdnoba II donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
III klinikuri kvleva randomizaciis gareSe
kohortuli da SemTxveva-kontrolis kvlevebi
C eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi
D eyrdnoba IV da V donis mtkicebulebas saWiroebs
konsesuss
Va avtoritetul profesionalTa mosazreba
Vb klinikuri gamocdileba aRwerilobiTi kvlevebi an
eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
15 avtorTa jgufi
bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis
bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi
rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
23
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24
bull rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da rekomendaciebis xarisxis sqema
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris
done (Muir Gray)xarisxi rekomendaciis xarisxi
(Cook et al)I Zlieri mtkicebuleba
eyrdnoba minimum erT sistemur mimoxilvas
romelic efuZneba swori dizainis mqone randomizebul
kontrolirebad kvleva
A eyrdnoba I donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erTi swori dizainis mqone
randomizebul kontrolirebad kvleva
B eyrdnoba II donis mtkicebulebas da
Sesabamisad mtkiced rekomendebulia
III klinikuri kvleva randomizaciis gareSe
kohortuli da SemTxveva-kontrolis kvlevebi
C eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi
D eyrdnoba IV da V donis mtkicebulebas saWiroebs
konsesuss
Va avtoritetul profesionalTa mosazreba
Vb klinikuri gamocdileba aRwerilobiTi kvlevebi an
eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
15 avtorTa jgufi
bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis
bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi
rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
23
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24
rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti
rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori
eqspertebi
rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli
rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori
24