Upload
others
View
13
Download
0
Embed Size (px)
Citation preview
1
hiperbilirubinemiis marTva
axalSobil bavSvebSi,
romelTa gestaciuri asaki 35 da
meti kviraa
klinikuri praqtikis erovnuli rekomendacia
(gaidlaini)
2
klinikuri praqtikis erovnuli rekomendacia (gaidlaini)
`hiperbilirubinemiis marTva axalSobil bavSvebSi, romelTa
gestaciuri asaki 35 da meti kviraa~ miRebulia klinikuri
praqtikis erovnuli rekomendaciebis (gaidlainebi) da
daavadebaTa marTvis saxelmwifo standartebis (protokolebi)
SemuSavebis, Sefasebis da danergvis erovnuli sabWos 2007 wlis
21 martis #1 sxdomaze da damtkicebulia saqarTvelos Sromis,
janmrTelobisa da socialuri dacvis ministris 2007 wlis 27
agvistos # 258/o brZanebiT.
3
hiperbilirubinemiis marTva axalSobil bavSvebSi,
romelTa gestaciuri asaki 35 da meti kviraa
1. daavadebis definicia, sinonimebi, klasifikacia da terminologia
axalSobilTa siyviTle axalSobilis kanis da sklerebis yviTeli
Seferilobaa, rac ganpirobebulia qsovilebSi bilirubinis CalagebiT.
hiperbilirubinemiad miCneulia sisxlis SratSi bilirubinis
Semcvelobis mateba 85 µmol/L (5 mg/dl-ze) metad1.
tranzitoruli (fiziologiuri) siyviTle msubuqi arakoniugirebuli
(arapirdapiri) bilirubinemiaa, romelic vlindeba sicocxlis 48-120 sT-Si.
mwvave bilirubinuli encefalopaTia – arapirdapiri bilirubinis
toqsiuri zemoqmedebiT ganpirobebuli cns-is darRveva, romelic vlindeba
mwvaved adreul neonatalur periodSi.
kerniqterusi _ bilirubinis toqsiurobiT ganpirobebuli qronikuli
da permanentuli xasiaTis cns-is dazianeba.
butanis nomograma saSualebas iZleva ganisazRvros ramdenad maRalia
mZime hiperbilirubinemiis ganviTarebis riski axalSobilis asakis
(saaTebSi) da Sratis bilirubinis koncentraciis gaTvaliswinebiT.
gaidlaini gankuTvnilia
⇒ samedicino personalisaTvis, romelic muSaobs axalSobilTan,
rogorc samSobiaro saxlSi, ise stacionarSi – neonatologi,
pediatri.
gaidlainis samizne jgufi:
⇒ 35 kviris da meti gestaciuri asakis axalSobilebi, romelTac
ganuviTardaT hiperbilirubinemia.
⇒ gaidlainSi ar aris ganxiluli 35 kviraze naklebi gestaciuri
asakis dRenaklul axalSobilTa hiperbilirubinemiis marTva
gaidlainis gacnobis Semdeg samedicino personals ecodineba, rom
aucilebelia
1. ZuZuTi kvebis propaganda da mxardaWera.
2. saeqTno protokolebis Sedgena hiperbilirubinemiis identifikaciisa
da SefasebisaTvis.
3. Ssb da tkb gansazRvra axalSobilebSi, romelTac siyviTle
gamouvlindaT dabadebidan pirvel 24 sT-Si.
4. siyviTlis xarisxis gansazRvrisTvis siyviTlis intensivobis
vizualuri SefasebasTan erTad laboratoriuli kvlevis Catareba
(mxolod vizualuri Sefasebisas xSiria daignostikuri Secdoma,
gansakuTrebiT muqkanian axalSobilebSi).
4
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.
gamoyenebuli Semoklebebi:
Sbs – Sratis saerTo bilirubini
tkb – transkutanuri bilirubini
b/a - bilirubinis da albuminis Sefardeba
rds – respiraciul distres sindromi
1 µmol/L = 17,1 mg/dl
2. epidemiologia1-3
tranzitoruli (fiziologiuri) siyviTle viTardeba dRenaklul
axalSobilTa umravlesobasa da droul axalSobilTa 25-50%-Si. 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
hiperbiliribinemiis 5 SemTxveva63.
3. etiopaTogenezi1,2,4
hiperbilirubinemia SesaZlebelia mimdinareobdes arapirdapiri an
pirdapiri bilirubinis donis momatebiT. gaZlierebuli hemolizi,
bilirubinis koniugaciis unaris Semcireba iwvevs arapirdapir
bilirubinemias, xolo naRvlis eqskreciis darRveva – pirdapir
bilirubinemias.
1. tranzitoruli siyviTlis mizezebi:
• erTrocitebis da hemoglobinis maRali Semcveloba
• eriTrocitebis sicocxlis xangrZlivobis daqveiTeba
• fetaluri hemoglobinis Semcveli eriTrocitebis hemolizi
• RviZlSi bilirubinis koniugaciis unaris umwifroba
• bilirubinis gazrdili enterohepatuli cirkulacia
• RviZlis mier plazmidan bilirubinis moxmarebis Semcireba
5
2. paTologiuri siyviTlis mizezebi:
eriTrocitebis hemolizis gaZliereba:
• sisxlis jgufuri da rezus SeuTavsebloba
• Tandayolili membrano (sferocitozi da sxv.), fermentopaTia
(glukoza 6 fosfatdehidrogenazas - g6fd – ukmarisoba da sxv.) da hemoglobinopaTia (Talasemia da sxv.)
• policitemia
• kefalohematoma, sisxlCaqcevebi
• infeqcia
bilirubinis koniugaciis Semcireba
• dRenakluloba
• iSviaTi Tanadayolili daavadebebi (Jilberis, krigler-naiaris
sindromi da sxva)
• bilirubinis metabolizmis da eqskreciis darRveva (rotoris da
dubin-jonsonis sindromi)
bilirubinis reabsorbciis gazrda gastrointestinuri traqtidan
• asfiqsia
• kvebis gvian dawyeba, iSviaTi kveba
• nawlavTa obstruqcia
• mekoniumis pasaJis Seferexeba
naRvlis eqskreciis darRveva
• biliaruli atrezia
• qolestazuri sindromi
• sefsisi
• saSvilosnosSida infeqcia
• hepatiti
• cisturi fibrozi (mukoviscidozi)
siyviTle ZuZuTi kvebis dros5
• 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).
• ZuZuTi kvebis araswori reJimiT ganpirobebuli, iSviaTi ZuZuTi
kvebis SemTxevaSi arasakmarisi raodenobiT rZis miReba iwvevs
enterohepaturi cirkulaciis gazrdas.
siyviTle agreTve SeiZleba ganpirobebuli iyos: endokrinuli
paTologiiT (hipoTireozi da sxv.) dedasTan an bavSvTan zogierTi
medikamentis gamoyeneba (sulfanilamidebi, oqsitocini, nitrofuranebi da
sxv).
6
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) da/an nekroziT. yvelaze metad ziandeba bazaluri ganglia da
Tavis tvinis Reros okulomotoruli da auditoruli funqciebis
makontrolebeli birTvebi.
Tu droul axalSobilebSi bilirubini gadaWarbebs 428 - 513 µmol/L (25-30 mg/dl), maRalia bilirubinis toqsiuri moqmedebis ganviTarebis riski.
Ssb toqsiuroba variabeluria da damokidebulia axalSobilis
janmrTelobis mdgomareobasa da gestaciur asakze6.
mZime hiperbilirubinemiis ganviTarebis risk-faqtorebi
mZime hiperbilirubinemiis ganviTrebis riski miT ufro maRalia, rac
ufro meti riskis faqtoria gamoxatuli axalSobilTan:
maRali riski1,2
− dabadebidan pirvel 24sT-Si gamovlenili siyviTle7.
− gaweris win Ssb an tkb done butanis nomogramaze maRali riskis
zonaSi8,9
− sisxlis jgufuri SeuTavsebloba dadebiTi pirdapiri
antiglobulinuri testiT, sxva cnobili hemolizuri daavadeba
(mag.: g6fd deficiti), − gestaciuri asaki 35-36 kvira 10,11
− da-Zmas Catarebuli aqvs fotoTerapia11,12
− kefalohematoma an mniSvnelovani sisxlCaqcevebi10
− araxSiri ZuZuTi kveba, rodesac aReniSneba wonaSi mkveTri kleba
(>12%-ze meti)2,10,11
dabali riski
_ gaweris win Ssb an tkb-is done butanis nomogramaze maRali
gardamavali riskis zonaSi8,9
_ gestaciuri asaki 37-38 kvira10,11
_ da-Zmis anamnezSi siyviTle11,12
_ diabetiT daavadebuli dedis makrosomuli axalSobili
_ dedis asaki ≥ 25 welze10
_ mamrobiTi sqesi10,11
mdgomareobebi, romlis drosac mZime hiperbilirubinemiis ganviTarebis
riski Zalian dabalia:
− gestaciuri asaki ≥ 41 kviraze10, − srulyofili enteraluri kveba10,11
− gawera stacionaridan 72 sT-is Semdeg8,9,13
− Ssb butanis nomogramaze dabali riskis zonaSi8,9
7
4. klinikuri simptomatika rekomendacia - siyviTlis monitoringi unda moxdes yvela
axalSobilTan rutinulad vitaluri funqciebis Sefasebisas, ara
nakleb 8-12 sT-Si erTxel (rekomendacia D)1. siyviTlis arsebobis Sefaseba unda moxdes kargad ganaTebul oTaxSi,
umjobesia dRis Suqze fanjarasTan. siyviTle Cveulebriv pirvelad
vlindeba saxeze da Semdeg progresirebs kaudalurad sxeulsa da
kidurebze14. siyviTlis ukeT gansazRvrisaTvis tardeba kanze TiTis
zewolis testi. zewola lokalurad amcirebs kanis perfuzias da xels
uwyobs siyviTlis diagnostikas. rodesac bilirubini 68-137 µmol/L (4-8
mg/dl), Cveulebriv iqterulia saxe da sklera, Tu bilirubini >257 µmol/L (15 mg/d) siyviTle vlindeba mTel sxeulze xelis da fexisgulebis
CaTvliT. Ssb an tkb mizanSewonilia gaizomos, Tu siyviTle vlindeba
Wipis qvemoT. krameris modificirebuli sqema saSualebas iZleva siyviTlis
gavrcelebis mixedviT vivaraudoT, Tu ramdenia Sratis saerTo
bilirubinis done.
krameris modificirebuli sqema3,14 cxrili 1
zona
1 2 3 4 5
Ssb µmol/L
100
150
200
250
>250
siyviTlis xarisxis gansazRvra
siyviTlis intensivobis mxolod
vizualuri SefasebiT xSirad iwvevs
diagnostikur Secdomas, gansakuTrebiT
muqkanian axalSobilebSi. (rekomendacia
C)1,16,17.
cxrili 2 siyviTlis simZimis Sefaseba lokalizaciis mixedviT (janmo)3
asaki (dRe) siyviTlis lokalizacia daskvna
1 nebismieri*
«saSiSi» siyviTle 2 kidurebi*
≥ 3 terfebi, mtevnebi
* sicocxlis I dRes nebismier adgilas an II dRes kidurebze gamovlenili
siyviTle saWiroebs dauyovnebliv fotoTerapiis dawyebas analizis
pasuxis miRebamde.
C
D
8
axalSobilTa siyviTlisGgarTulebebi
axalSobilTa siyviTlisGgarTulebebia mwvave da qronikuli
(kerniqterusi) bilirubinuli encefalopaTia, romlebic uxSiresad
hemolizuri daavadebis dros viTardeba62.
mwvave bilirubinuli encefalopaTia1
mwvave bilirubinuli encefalopaTias axasiaTebs ganviTarebis 3 faza:
1. adreuli faza vlindeba ramdenime dReSi da axasiaTebs leTargia,
hipotonia, susti wova da sustad gamoxatuli “cerebruli kivili”.
2. gardamavali stadia viTardeba kviris bolos da axasiTebs
zomieri stupori, agznebadoba da hipertonia. axalSobils
SeiZleba aReniSnos cxeleba mkveTrad gamoxatuli “cerebruli
kivili”. 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 “cerebruli
kivili”, apnoe, cxeleba, sakvebis autanloba, Rrma stupori
komamde, zogjer krunCxvebi da sikvdili. 18;19
kerniqterusi1,47
Bmwvave bilirubinuli encefalopaTiis Semdeg gadarCenil
axalSobils sicocxlis pirveli wlis manZilze uviTardeba
bilirubinuli encefalopaTiis mZime qronikuli forma, romelic 3
ZiriTadi gamovlinebiT xasiaTdeba 18-20 motoruli darRvevebi - aTetoiduri cerebluri dambla, tremori,
qorea
mxedvelobis darRvevebi
smeniTi disfunqcia
inteleqtualuri darRvevebi SedarebiT iSviaTia.
kerniqterusis dros 70%-Si aRiniSneba nevrologiuri darRvevebi da
10%-Si sikvdiloba.
9
diferenciuli diagnozi:
axalSobilTa siyviTlis dros unda ganisazRvros siyviTle
fiziologiuria Tu paTologiuri3.
fiziologiuri siyviTle
paTologiuri siyviTle
vlindeba ara uadres 2 dRisa da
qreba me-10-14 dRisTvis
vlindeba pirvel 24 saaTSi an
7 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
axalSobilTa fiziologiuri siyviTlis dros bilirubinis
Semcvelobis pikuri done sicocxlis III dRisTvis uxSiresad 85,5-136,8 µmol/L (5-8 mg/dl-ia), Semdeg xdeba misi donis daqveiTeba. 205,2µmol/L-mde (12 mg/dl) mateba fiziologiurad iTvleba. 35-37 kviris gestaciuri asakis
axalSobilebSi Bbilirubinis donem SeiZleba maqsimums miaRwios
dabadebidan me-7 dRes.
arakoniugirebuli hiperbilirubinemiis ufro maRali done sxvadasxva
paTologiuri mdgomareobebis dros vlindeba2.
dedis rZiT ganpirobebuli siyviTlis sadiagnostikod (samkurnalod)
SeiZleba Semdegi maCveneblebis gamoyeneba5:
• dedis rZiT ganpirobebuli siyviTle vlindeba me-4-14 dRes
• 24-48sT-is ganmavlobaSi ZuZuTi kvebis Sewyveta da alternatiul
sakvebis miwodeba iwvevs bilirubinis donis daqveiTdebas.
axalSobilTa hiperbilirubinemiis difdiagnozi ix. algormiTi 1.
10
klinikurad gamoxatuli siyviTle
hiperbilirubinemia
bilirubini ≥ 205 µmol/L da
axalSobilis asaki < 24sT
bilirubini < 205 µmol/L da
axalSobilis asaki > 24sT
kumbsis testi bilirubinis
kontroli
dadebiTi uaryofiTi
antisxeulebis
gansazRvra
Rh ABO Kell da sxva.
pirdapiri bilirubini
> 34,2 µmol/L
hematokriti
< 34,2 µmol/L
norma an dabali maRali
• policitemia
• materno-fetaluri
transfuzia
• Wiplaris gviani
gadakvanZva
hepatiti
saSvilosnosSiga
infeqcia
sanaRvle gzebis
obstruqcia
sefsisi
galaqtozemia
α-1-antitrifsinis
deficiti
mukoviscidozi
Tirozinozi
qolestazi
aTaSangi
hemoqromatozi
eriTrocitebis
morfologia
retikulocitebis
raodenoba
paTologia norma
sferocitozi
elifsocitozi
stomatocitozi
piknocitozi
ABO SeuTavsebloba
eriTrocitebis
fermentTa deficiti
α Talasemia
medikamentebi (mag.
penicilni)
sisxlZarRvTaSida
Sededebis sindromi
sisxldena
gazrdili enterohepatuli
cirkulacia
dedis rZiT ganpirobebuli
siyviTle
hipoTireozi
krigler-naiaris sindromi
diabetiani dedis axalSob.
rds
asfiqsia
infeqcia
Jilberis sindromi
medikamentebi (novobiocini)
galaqtozemia
axalSobilTa hiperbilirubinemiis diferenciuli diagnozis algoriTmi
11
5. daavadebis diagnozi:
diagnozi efuZneba klinikur gamovlinebas – kanisa da xiluli
lorwovani garsebis siyviTles, bilirubinemiuli encefalopaTiis niSnebs
da hiperbilirubinemias.
6. gamokvlevis sqema1,15
rekomendacia1:
tkb da/an Ssb unda ganesazRvros yvela axalSobils,
romelsac siyviTle gamouvlinda sicocxlis pirvel 24sT-Si
(rekomendacia C)7. tkb da/an Ssb unda ganesazRvros yvela axalSobils,
romelsac gamouvlinda asakTan Seusabamo mkveTri siyviTle
(rekomendacia D). bilirubinis donis Sefaseba unda moxdes axalSobilis
asakis (saaTebSi) gaTvaliswinebiT (sqema 1) (rekomendacia C).
Tu axalSobils utardeba fotoTerapia an aReniSneba
bilirubinis swrafi mateba (sqema 1 – 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.21 damatebiTi
laboratoriuli gamokvlevebi unda Catardes Tu anamneziT
da obieqturi gamokvlevebiT saeWvoa sefsisi (rekomendacia C).
Tu pirdapiri an koniugirebuli bilirubinis done
momatebulia, rekomendirebulia damatebiTi gamokvlevebi
qolestazis sadiagnostikod (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) glukoza-6-fosfat dehidrogenazas donis gansazRvra
saWiroa im axalSobilebTan, romelTa ojaxuri anamnezi an
eTnikuri an geografiuli warmoSoba miuTiTebs g6fd-s
deficitze da utardebaT fotoTerapia da/an
axalSobilebTan, Tu fotoTerapia uefeqtoa. (sqema 3)
(rekomendacia C).
C
D
C
D
C
C
D
D
C
12
cxrili 3: 35 da meti gestaciuri asakis axalSobilSi gamovlenili
siyviTlis laboratoriuli Sefaseba1,22
Cveneba laboratoriuli kvleva pirvel 24 sT-Si gamovlenili
siyviTle • tkb da/an Ssb gansazRvra
asakisaTvis Seusabamo mkveTri
siyviTle kanze G • tkb da/an Ssb gansazRvra
axalSobils utardeba fotoTerapia
an aReniSneba bilirubinis swrafi
mateba (namati >8.5 µmol/L/sT an 0.5 mg/dl/sT) (butanis nomogramaze
maCvenebeli kveTs percentilebs),
rac ar aixsneba obieqturi
gamokvleviT da anamnezuri
monacemebiT
• sisxlis jgufi da rezusi kumbsis testi, Tu ar aris gakeTebuli
Wiplaris sisxlSi
• sisxlis saerTo analizi, da nacxi
formiani elementebis
morfologiis Sesaswavlad
• pirdapiri (koniugirebuli)
bilirubinis gansazRvra
• Tu SesaZlebelia, isazRvreba
retikulocitebis ricxvi, g6fd
• Ssb ganmeorebiT isazRvreba 4-24
sT-Si, axalSobilis asakisa da
Ssb donis Sesabamisad
fotoTerapia uSedegoa an Ssb aRwevs
dones, romelzec naCvenebia
SenacvlebiTi transfuzia
• Tu SesaZlebelia, isazRvreba
retikulocitebis ricxvi, g6fd
• SesaZlebelia saWiro gaxdes
hematokritis da albuminis
gansazRvra
momatebulia pirdapiri
(koniugirebuli) bilirubinis done • Sardis anlizi
• Sardis kultura
• gamokvleva sefsisze, Tu misi
arseboba saeWvoa anamneziT an
obieqturi gamokvleviT
siyviTle sami kviris asakis an
avadmyof axalSobilSi
• saerTo da pirdapiri
(koniugirebuli) bilirubini
• pirdapiri bilirubinis
momatebisas tardeba kvleva
qolestazis sadiagnostikod • skriningi hipoTireozsa da
galaqtozemiaze
• axalSobilis Sefaseba
hipoTireozis simptomebis
gamosavlenad
13
sqema 1. butanis nomograma
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 34-54µmol/L (2-3 mg/dl) variabelobiT. bevr SemTxvevaSi xdeba Sratis bilirubinis gansazRvris
Canacvleba transkutanuri gansazRvriT, gansakuTrebiT maSin, roca Ssb < 257 µmol/L (15 mg/dl)23-28.
Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes
saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT
transfuziaze gadawyvetilebis miRebis dros.
14
7. mkurnalobis sqema pirveladi profilaqtika
rekomendacia1 • eqimma unda urCios dedas ganaxorcielos moTxovnilebiTi
ZuZuTi kveba dReSi 8-12-jer (rekomendacia C)30. - arasrulyofili kaloriebis miRebam da/an dehidrataciam,
SeiZleba gamoiwvios Hhiperbilirubinemiis ganviTareba31,32. • ZuZuTi kvebis SemTxevaSi, Tu axalSobils ar aReniSneba
dehidratacia, ar aris rekomedirebuli wylisa da
deqstrozis rutinulad damateba (rekomendacia: B da C). - wylis da deqstrozis damateba ar axdens
hiperbilirubinemiis ganviTarebis profilaqtikasa da Ssb-s
Semcirebas33.
• yvela Rh (D) negatiur orsuls an melogines mizanSewonilia
Cautardes anti D imonoglobuliniT profilaqtika
(rekomendacia A)33: − orsulobis 28 kviraze (garda im SemTxvevebisa, rodesac bavSvis
mamac Rh (D) negatiuria) − mSobiarobidan 72 sT-is gamnavlobaSi, Tu axalSobili Rh (D)
pozitiuria
− orsulobis pirvel trimestrSi ganviTarebuli abortis da
invaziuri procedurebis dros rogorica: amniocentezi, nayofis
invaziuri procedurebi.
meoradi profilaqtika
rekomendacia: klinicistma unda moaxdinos axalSobilTa
hiperbilirubinemiis ganviTarebis riskebis sistemuri Sefaseba
neonatalur periodSi (rekomendacia B)1. sisxlis jgufobrioba
rekomendacia1
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 igi 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).
C
B
A
C
B
B
B
C
15
mkurnalobis ZiriTadi principebia:
fotoTerapia
SenacvlebiTi transfuzia
mkurnaloba iwyeba fotoTerapiiT.
fotoTerapia
fotoTerapiis dros kanis zeda SreebSi Calagebuli arapirdapiri
bilirubini iSleba fotoqimiuri gziT wyalSi xsnad koniugatebad,
romlebic gamoiyofa SardiT da naRveliT. rekomendacia: yvela samSobiaro saxli unda iyos aRWurvili
mowyobilobiT, romelic saWiroa intensiuri fotoTerapiisaTvis
(rekomendacia D)1.
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
hiperbiliruminemias (hemolizuri daavadeba, g6fd deficiti, asfiqsia,
mkveTrad gamoxatuli leTargia, temperaturis arastabiluroba, sefsisi,
acidozi an hipoalbuminemia <3,0 g/dl).
amerikis pediatriuli akademiis rekomendaciiT gamoiyeneba sqema (sqema
2), romelic axalSobilis asaksa da bilirubinis donesTan erTad
iTvaliswinebs risk-faqtorebsa da gestaciur asaks. mocemuli sqemis
mixedviT “intensiuri” fotoTerapia iwyeba, Semdegi principebiT:
dabali riskis axalSobili* (janmrTeli, risk-faqtorebis gareSe,
gestacia > 38 kvira) – Ssb >12 mg/dl (205 µmol/L) 24 sT-Si, Ssb >15
mg/dl (257 µmol/L) 48 sT-Si, Ssb >18 mg/dl (308 µmol/L) >72 sT.
saSualo riskis axalSobili (gestacia > 38 kvira da risk-faqtorebi,
an gestacia 35-37 kvira risk-faqtorebis gareSe gareSe) – Ssb > 10
mg/dl (171 µmol/L) 24 sT-Si, Ssb >13 mg/dl (222 µmol/L) 48 sT-Si, Ssb
>15 mg/dl (257 µmol/L) >72 sT. gestaciis 35 kviris axalSobilebSi
fotoTerapia SeiZleba daiwyos ufro dabal maCveneblebze.
maRali riskis axalSobili (gestacia 35-37 kvira da risk-faqtorebi) -
Ssb > 8 mg/dl (137 µmol/L) 24 sT-Si, Ssb >11 mg/dl (188 µmol/L) 48 sT-
Si, Ssb >13.5 mg/dl (231 µmol/L) >72 sT.
* Tu dabali riskis axalSobilebSi Ssb done 2-3 mg/dl-iT dabalia
moyvanil monacemebze, SesaZlebelia mkurnalobis dawyeba “Cveulebrivi”
fotoTerapiiT
• stacionarSi gamoxatuli siyviTliT Semosul axalSobils utardeba
“intensiuri” fotoTerapia bilirubinis maCveneblis gansazRvramde
• “intensiuri” fotoTerapia aseve rekomendebulia hemolizuri
daavadebis dros35
D
16
sqema 2. fotoTerapiis gaidlini 35 kviris da meti gestaciuri asakis
hospitalizebul axalSobilebSi1
rekomendacia: Tu Sratis albuminis maCvenebeli naklebia 3.0
g/dl-ze, fotoTerapiis dawyeba rekomendebulis ufro dabali
maCveneblebis dros (rekomendacia D)1.
janmos rekomendacia fotoTerapiis dawyebis Cvenebebis Sesaxeb
mocemulia cxrilSi 4.
cxrili 4. fotoTerapiis Cveneba Ssb mixedviT (janmo)3
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris
mqone axalSobili*
mg/dl µmol/L mg/dl µmol/LI gamoxatuli siyviTle
II 15 260 13 220
III 18 310 16 270
IV da meti 20 340 17 290
Tu ar aris bilirubinis gansazRvris saSualeba Ssb savaraudo donis
dasadgenaT SeiZleba krameris modificirebuli sqemis gamoyeneba. janmos
rekomendaciiT fotoTerapia iwyeba, Tu siyviTlis lokalizaciis mixedviT
siyviTlis simZimis Sefasebisas (cxrili 1) dadginda “saSiSi siyviTle”.
fotoTerapiis ukuCveneba:
pirdapiri (koniugirebuli) hiperbilirubinemia (pirdapiri
bilirubini Ssb-s 50%-ze metia)1,36 Tandayolili porfiria an porfiriis ojaxuri anamnezi1,37.
D
D
17
fotoTerapiis teqnika1
fotoTerapiis efeqturoba damokidebulia dozaze. fotoTerapiis
doza anu speqtruli iradiacia damokidebulia naTuris simZlavreze,
sinaTlis wyarosa da bavSvs Soris manZilsa da dasxivebis farTobze.
sinaTlis wyaro
fotoTerapiis sinaTlis speqtri damokidebulia sinaTlis wyaroze da
filtrze. yvelaze farTod gavrcelebuli fotoTerapiis mowyobiloba
Seicavs dRis Suqis, gril TeTr, cisfer, an “specialur cisfer”
fluorescentul naTurebs.
manZils sinaTlis wyarodan axalSobilamde didi mniSvneloba eniWeba,
sasurvelia axalSobili moTavsdes sinaTlis wyarodan im minimalur
manZilze, romelic miTiTebulia fotoTerapiis mowyobilobis
instruqciaSi38. halogenis fotoTerapiis naTurebi ar SeiZleba moTavsdes
axalSobilTan axlos, radgan SeiZleba gamoiwvios damwvroba.
sxeulis zedapiris farTobi
bilirubinis maRali Semcvelobisas, mniSvnelovania fotoTerapiis
dros dasxivdes sxeulis zedapiris rac SeiZleba meti farTobi.
“Cveulebrivi fotoTerapia” - sinaTlis speqtris iradiacia dabalia (6-
12 µW/cm2/nm) (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 monacemebs.
“intensiuri fotoTerapia” - lurj-mwvane speqtris iradiacia (talRis
sigrZe daaxloebiT 430-490 nm) sul cota 30 µW/cm2/nm-ia (isazRvreba
axalSobilis kanze fotoTerapiis aparatis centris qveS). gazomva xdeba im
warmoebis radiometriT romelic mowodebulia fotoTerapiiis sistemis
aparatis mwarmoeblis mier39. sinaTlis talRis asareklad TeTreuli unda
iyos TeTri, inkubatori da sawolis gverdebi daifaros TeTri qsoviliT
an aluminis folgiT40.
fotoTerapiis procedura da monitoringi3
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 > 37,50C saWiroa oTaxis temperaturis daqveiTeba an
fotoTerapiis droebiT Sewyveta, sanam bavSvis temperatura ar iqneba
normis farglebSi (36,5-37,50C). fotoTerapia mimdinareobas mudmivad, igi wydeba mxolod im
procedurebis dros, romelTa warmoeba ar SeiZleba sinaTlis
wyaros qveS.
centraluri cianozis arsebobis Sesafaseblad fotoTerapia unda
Sewydes mcire droiT
fotoTerapiis dros unda gagrZeldes bavSvis kveba:
18
⇒ axalSobilTan 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.
⇒ Tu bavSvi ikvebeba gamowvelili rZiT, formuliT an
parenteralurad, misawodebeli sakvebis an siTxis raodenoba
izrdeba dRiuri normis 10 %-iT.
⇒ Tu bavSvi ikvebeba zondiT an parenteralurad, fotoTerapia
mimdinareobs uwyvetad.
⇒ fotoTerapiis dros axalSobils ar esaWiroeba rutinulad
damatebiT siTxis an sakvebis miwodeba. damateba naCvenebia
mxolod araefeqturi ZuZuTi kvebis, sxeulis masis
paTologiuri danakargis (>10%-ze mesame dRisTvis) da
dehidrataciis SemTxvevaSi.
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.
⇒ adeqvatur kvebaze miuTiTebs 4-6 sveli safeni 24 sT-Si da
nawlavTa moqmedeba 3-4 jer/dReSi sicocxlis meoTxe dRisaTvis.
janmrTeli drouli axalSobilis nawlavTa moqmedeba da diurezi
(minimaluri maCveneblebi) 41 cxrili 5
dRe nawlavTa minimaluri
moqmedeba/24sT
sveli safeni/24sT
1 1 1
2 1 2
3 1 3
4 2 yviTeli fafisebri 4
5 2YyviTeli fafisebri 5-6
⇒ dehidrataciaze miuTiTebs Semdegi niSnebis arseboba5
- masis paTologiuri kleba (>10%-ze mesame dRisTvis)
- anuria 4-6 sT
- Cacvenili Tvalebi
- Cavardnili yoflibandi
- daqveiTebuli kanis elastiuroba (kanis naoWi swordeba
nela)
- daqveiTebuli kanis kapilaruli avseba (>3 wm)
- taqikardia
- Sratis Na >145, HCO3 <17
C
19
bilirubinis monitoringi fotoTerapiis dros1
fotoTerapiis efeqturobaze miuTiTebs sawyisi bilirubinis
maCveneblis Semcireba 6-20%-iT standartuli42 da 30-40%-iT intensiuri8,43
fotoTerapiis dawyebidan 24sT-Si. fotoTerapiis dros kanis vizualuri SefasebasTan erTad
aucilebelia Sratis bilirubinis gansazRvra, radgan fotoTerapia
“aTeTrebs” kans1.
• Tu Ssb 342–428 µmol/L L (20–25 mg/d), ganmeorebiTi gansazRvra _ 3-4 sT-
Si,
• Tu Ssb <342 µmol/L L (20 mg/d), ganmeorebiTi gansazRvra xdeba 4–6 sT-Si,
Tu Ssb agrZelebs daqveiTebas ganmeorebiTi gansazRvra 8-12 sT-Si.
• 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
• intensiur fotoTerapiis miuxedavad Ssb-is ucvleli done an mateba,
miuTiTebs hemolizze.
⇒ anemia/hemolizis Sefaseba5 SesaZlebelia sisxlis saerTo
analizis mixedviT - Hgb< 130 g/l,LHct < 40%,
retikulocitebi - > 6%
• Ssb < 13–14 mg/dL (239 µmol/L), fotoTerapia wydeba
• fotoTerapiis Sewyvetidan 24 sT-Si kontroldeba Ssb, Tu Ssb
moimata im donemde, romelzec daiwyo fotoTerapia, fotoTerapia
ganmeorebiT iwyeba8.
fotoTerapiis garTulebebi
fotoTerapiis garTulebebi1.,2: ⇒ mwvane feris ganavali/diarea (mkurnalobas ar saWiroebs)
⇒ dehidratacia ⇒ muclis Seberva (mkurnalobas ar saWiroebs)
⇒ Tvalis SesaZlo dazianeba
yvelaze seriozuli, magram iSviaTi klinikuri garTulebaa brinjaos
axalSobilis sindromi44, romelic vlindeba qolestazuri siyviTlis
mqone axalSobilSi kanis, Sratis da Sardis muqi, nacrisfer-yavisferi
SeferilobiT45. brinjaos axalSobilis sindromi ar vlindeba qolestazis
mqone yvela axalSobilTan. 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:
⇒ purpura ⇒ bulozuri gamonayari
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.
20
mzis ultraiisferi sxivebiT Terapia
marTalia, mzis sxivebs gaaCniaT mniSvnelovani iradiacia 425-475 nm,
magram radganac maRalia axalSobilis damwvrobis ganviTarebis riski
(SiSveli axalSobilis mzeze yofnis gamo) es meTodi rekomendebuli ar
aris1,2,46.
intravenuri imunoglobulinis gamoyeneba
rekomendacia: izoimunuri hemolizuri daavadebis dros
rekomendebulia intravenuri imunoglobulinis gamoyeneba (0,5-1
g/kg 2 sT-s ganmavlobaSi), Tu Ssb imatebs intensiuri
fotoTerapiis miuxedavad an Ssb aris 2-3 mg/dl-iT (34-51mkmol/l) naklebi SenacvlebiTi transfuziis Cvenebis doneze (sqema 3).
aucilebelobis SemTxvevaSi intravenuri imunoglobulinis doza
SeiZleba ganmeordes 12 sT-Si. (rekomendacia B)1,48. kvlevebiT dadgenilia, rom intravenuri imunoglobulini amcirebs
SenacvlebiTi transfuziis saWiroebas Rh da ABO hemolizuri daavadebis
dros49,50. SenacvlebiTi transfuzia
rekomendacia: SenacvlebiTi transfuzia unda Caataros mxolod
gamocdilma samedicino personalma intensiuri Terapiis
ganyofilebaSi monitoringisa da srulyofili reanimaciis
SesaZleblobis pirobebSi (rekomendacia D)1.
SenacvlebiTi transfuziis Cvenebebi (rekomendacia D)1:
mwvave bilirubinuli encefalopaTia51-53 - SenacvlebiTi
transfuzia iwyeba dauyovnebliv.
intensiuri fotoTerapiis miuxedavad:
* Ssb mateba - Ssb aRemateba SenacvlebiTi transfuziis
dawyebis maCvenebls.
* ucvleli Ssb.
samSobiarodan gawerili axalSobilebis hospitalizaciis
SemTxvevaSi Ssb-s maRali maCvenebeli - aRemateba SenacvlebiTi
transfuziis dawyebis maCvenebls (sqema 3). (transfuziamde iwyeba
“intensiuri” fotoTerapia da saWiroebis SemTxvevaSi
rehidratacia, Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu
adekvaturi rehidrataciisa da “intensiuri” fotoTerapiis
miuxedavad Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali
4-6 sT-is Semdeg, iwyeba SenacvlebiTi transfuzia)62.
b/a Sefardeba Ssb maCvenebelTan (cxrili 6) erTad gamoiyeneba,
rogorc damatebiTi faqtori SenacvlebiTi transfuziis dawyebis
gansazRvrisTvis53.
B
D
D
21
sqema 3. SenacvlebiTi transfuziis gaidlini 35 kviris da meti gestaciuri
asakis hospitalizebul axalSobilebSi1
cxrili 6. bilirubinisa da albuminis Sefardeba, rodesac saWiroa
SenacvlebiTi transfuzia1
riskis kategoria
b/a Sefardeba, rodesac
saWiroa SenacvlebiTi
transfuzia
Ssb (mg/dl)/
alb (g/dl)
Ssb (µmol/L)/ alb (µmol/L)
axalSobilebi gestaciuri asaki - ≥38 kvira 8.0 0.94
janmrTeli axalSobilebi gestaciuri asakiT an
riskis jgufis axalSobilebi gestaciuri
asakiT ≥38 kvira an izoimunuri hemolizuri
daavadeba an g6fd deficiti
7.2 0.84
riskis jgufis axalSobilebi gestaciuri
asakiT 35–36 kvira an izoimunuri hemolizuri
daavadeba an g6fd deficiti
6.8 0.80
janmos rekomendacia sisxlis SenacvlebiTi gadasxmis Cvenebebis
Sesaxeb mocemulia cxrilSi 7.
22
cxrili 7. SenacvlebiTi transfuziis Cveneba Ssb mixedviT (janmo)3
asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris
mqone axalSobili*
mg/dl µmol/L mg/dl µmol/LI 15 260 13 220
II 25 425 15 260
III 30 510 20 340
IV 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.
teqnika1,4,54
• SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-), xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli. Tu saxezea orive
saxis SeuTavsebloba gamoiyeneba O(I) Rh(-) sisxli.
• sisxli gamokvleuli unda iyos Sidssa da sxva infeqciebze.
• gadasasxmeli sisxlis raodenoba Seadgens axalSobilis mocirkulire sisxlis ormag raodenobas, saSualod 170-180 ml/kg. an
gadasasxmeli sisxlis gamosaTvleli formula gamoiTvleba 85 x axalSobilis wona kg x 2
• 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 36,7-37,00C-mde. • dRenaklulebsa da mZime mdgomareobaSi myof axalSobilebSi
Senacvleba xdeba 5-10 ml-iT
axalSobilis momzadeba 49
• kuWis SigTavsis aspiracia zondiT 8F da Ria zondis datoveba kuWSi • SeiZleba saWiro gaxdes bavSvis dabma
• SeiZleba sawovaras gamoyeneba
• Sardis Semkrebis gamoyeneba diurezis kontrolisTvis
SelacvlebiTi transfuziis Catarebamde fasdeba axlSobilis 49
• temperatura • guliscema
• sunTqva
• wneva • glukoza SratSi
• Sardis analizi
• ganavlis analizi sisxlis Semcvelobaze
• kanis feri • tonusi • qceva
23
uSualod transfuziis dros fasdeba vitaluri niSnebi (yovel 15 wT-Si) 49
• temperatura • guliscema (mwvervalze) (umjobesia kardiomonitoriT)
• sunTqva
• kanis feri • qceva
monitoringi transfuziis Semdeg 49
• grZeldeba fotoTerapia
• kardiomonitoringi kontroldeba
• sisxlis wneva proceduris damTavrebis Semdeg
• saaTobrivad 6 sT-is ganmavlobaSi: temperatura, guliscema
(mwvervalze), sunTqva
• glukoza SratSi yovel 3 sT-Si 24 sT-is ganmavlobaSi
• muclis garSemoweriloba 3-4 sT-Si 24 sT-is ganmavlobaSi,
nawlavebis peristaltikis auskultacia
• Sardis analizi
• ganavali sisxlis Semcvelobaze
• sakvebis autanlobis niSnebi: Rebineba, muclis Seberva
• Ssb 6 sT-Si erTxel
SenacvlebiTi transfuziis riski:
sikvdiloba - 3 SemTxveva 1000 transfuziaze56,57
SenacvlebiTi transfuziis dros garTulebis saxiT 5%-Si vlindeba57
- apnoe, bradikardia, cianozi, vazospazmi, Trombozi, nekrozuli
enterokoliti. aseve SeiZleba ganviTardes hipoqsiur-iSemiuri
encefalopaTia58.
sxva mkurnaloba1:
fenobarbitali – xels uwyobs bilirubinis koniugacias da amcirebs
Ssb dones. ar arsebobs sakmarisi mtkicebulebebi fenobarbitalis
gamosayeneblad, rodesac arsebobs siyviTlis mkurnalobis ufro efeqturi
meTodebi (mag. fotoTerapia).
referali1,3
referali maRali donis klinikaSi xorcieldeba, Tu:
ar aris fotoTerapiis Catarebis SesaZlebloba.
axalSobils sWirdeba fotoTerapia da ar aris Ssb gansazRvris
saSualeba
fotoTerapiis miuxedavad:
⇒ Ssb ar mcirdeba ⇒ Ssb izrdeba an aRemateba 342 µmol/L
siyviTlis lokalizaciis mixedviT siyviTlis simZimis Sefasebisas
dadgenili “saSiSi siyviTle”. mwvave bilirubinuli encefalopaTia bilirubinis maRali saaTobrivi namati 8.5 µmol/L/sT (>0.5 mg/dl/sT).
24
ojaxur anamnezSi mZime siyviTlis an kerniqterusis arseboba siyviTlesTan erTad vlindeba sxva daavadebis niSnebi (mag. sefsisi)
pirdapiri (koniugirebuli) hiperbilirubinemia (pirdapiri
bilirubini Ssb-s 50%-ze metia)
riskis Sefaseba samSobiarodan gaweramde1
rekomendacia: • yvela axalSobilis gaweramde unda Sefasdes
hiperbilirubinemiis ganviTarebis riski, yvela ganyofilebas
unda hqondes protokoli siyviTlis SefasebisTvis, aseTi
Sefaseba gansakuTrebiT mniSvnelovania im
axalSobilebisaTvis romlebic ewerebian dabadebidan 72 sT-ze
adre (rekomendacia C). • riskis SefasebisaTvis gamoyenebuli unda iqnas 2 midgoma
(calcalke an kombinaciaSi): gaweris win bilirubinis
gansazRvra (Ssb an tkb) da/an klinikuri risk-faqtorebis
Sefaseba8,9,22,59-61 risk-faqtorebis arseboba an Ssb maRali
maCveneblebi gaweris Semdeg Sesabamisi meTvalyureobis
aucilebelobis Cvenebaa (rekomendacia C). • yvela samSobiarom unda miawodos mSobels zepiri da/an
werilobiTi informacia binaze siyviTlis Sefasebis da
saSiSroebis niSnebis Sesaxeb (rekomendacia D).
8. meTvalyureoba rekomendacia1
• yvela axalSobili samSobiarodan gaweris Semdeg ramdenime
dReSi unda Sefasdes kvalificiuri samedicino
profesionalis mier (rekomendacia C). • fasdeba - siyviTlis arseboba, axalSobilis wona, kvebis
efeqturoba, Rebinebis arseboba (rekomendacia C). • meTvalyureobis grafiki: Tu axalSobili samSobiarodan
ewereba 48-72 sT-Si, samedicino Sefaseba tardeba 120 sT-is (5
dRe) asakSi (rekomendacia C). • 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 – 3 weli
C
C
C
C
D
C
D
25
12. gaidlainis miRebis xerxi/wyaro
gaidlainis SemuSavebis meTodologia
• 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
rekomendaciebis adaptirebuli variantis SemuSaveba, romelic
erTis mxriv pasuxebs saerTaSoriso moTxovnebs, xolo meore
mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa
rogorc adamianur, ise teqnikur resursebs.
• rekomendaciaTa moZieba xorcieldeboda eleqtronuli
monacemTa bazis gamoyenebiT.
cxrili 2
qveyana da resursis
dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
http://www.guideline.gov
Centers for Disease Control and Prevention (CDC)
http://www.phppo.cdc.gov/CDCRecommends/AdvSearchV.asp
Agency for Healthcare Research and Quality (AHRQ)
http://www.ahrq.gov/clinic/cpgsix.htm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
http://hstat.nlm.nih.gov
Institute of Clinical Systems Improvement (ICSI)
http://www.icsi.org
American Medical Association http://www.ama-assn.org
Canadian Medical Association (CMA)
http://mdm.ca/cpgsnew/cpgs/index.asp
Health Canada – Population and Public Health Branch (PPHB)
http://www.hc-sc.gc.ca/pphb-dgspsp/dpg_e.html
didi britaneTi National Institute for Clinical Excellence (NICE)
http://www.nice.org.uk
Sheffield Evidence for Effectiveness and Knowledge (SEEK)
http://www.shef.ac.uk/seek/guidelines.htm
26
National electronic Library for Health (NeLH)
http://www.nelh.nhs.uk/guidelinesfinder
PRODIGY Clinical Guidance http://www.prodigy.nhs.uk/ClinicalGuidance
Scottish Intercollegiate Guidelines Network (SIGN)
http://www.sign.ac.uk
German Guideline Information Service (GERGIS)
http://www.leitlinien.de/english/english/view;
avstralia Australian National Health and Medical Research Council (NHMRC)
http://www.health.gov.au/hfs/nhmrc/publicat/cp-home.htm
axali zelandia
New Zealand Guidelines Group (NZGG)
http://www.nzgg.org.nz/library.cfm
mtkicebiTi medicinis
specialistTa
regionTaSorisi
sazogadoeba
http://www.osdm.org
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi
wyaroebi da meTodebi
• koxreinis biblioTeka - The Cochrane Library 2006, Issue 2, • amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini – MEDLINE • jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvis/gamoricxvis kriteriumebi
• arCeul iqna kvlevebi Semdegi dizainiT: randomizebuli,
kontrolirebadi, sistemuri mimoxilvebi da meta-analizi,
erTmomentiani, kohortuli kvlevebi
• rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12
wliani SezRudva. Tumca zogjer gamoyenebuli iyo ufro
adreuli publikaciebi, romlebic dResac aqtualuria da
safuZvlad udevs sxva Tanamedrove mtkicebulebebs.
• dadgenili iyo enobrivi SezRudvebi, radganac samuSao jgufs
SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod
inglisur da rusul enebze.
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
• 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
27
rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (94,96-98). 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:
⇒ amerikis pediatrTa akademia
⇒ msoflo jandacvis organizacia
⇒ kanadis pediatrTa sazogadoeba – nayofi da axalSobilis
komiteti
⇒ britaneTis reproduqciuli janmrTelobis programa
• 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
28
13. alternatiuli gaidlaini ar arsebobs 14. gamoyenebuli literatura
1. American Academy of Pediatrics - Subcommittee on Hyperbilirubinemia Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation CLINICAL PRACTICE GUIDELINE, PEDIATRICS (ISSN 0031 4005). Copyright © 2004
2. Ronald J Wong, David K Stevenson, MD - Clinical features and management of unconjugated hyperbilirubinemia in term and near term infants - ©2005 UpToDate www.uptodate.com
3. World Health Organization - Managing Newborn Problems – A Guide for doctors, nurses and midwives – 2003
4. Nelson - Textbook of pediatrics 2005 5. Cloherty - Manual of neonatal care, 2004 6. Jaundice in the healthy term newborn – Newborn guideline 4. British Columbia
Reproductive Care Program, Original – April 1993, Revised April 2002 7. Newman TB, Liljestrand P, Escobar GJ. Jaundice noted in the first 24 hours after birth in a
managed care organization. Arch Pediatr Adolesc Med. 2002;156:1244–1250 8. Bhutani V, Gourley GR, Adler S, Kreamer B, Dalman C, Johnson LH. Noninvasive
measurement of total serum bilirubin in a multiracial predischarge newborn population to assess the risk of severe hyperbilirubinemia. Pediatrics. 2000;106(2). Available at: www.pediatrics.org/cgi/content/full/106/2/e17
9. Bhutani VK, Johnson L, Sivieri EM. Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns. Pediatrics. 1999;103: 6–14
10. Newman TB, Xiong B, Gonzales VM, Escobar GJ. Prediction and prevention, of extreme neonatal hyperbilirubinemia in a mature health maintenance organization. Arch Pediatr Adolesc Med. 2000;154:1140–1147
11. Maisels MJ, Kring EA. Length of stay, jaundice, and hospital readmission. Pediatrics. 1998;101:995–998
12. Gale R, Seidman DS, Dollberg S, Stevenson DK. Epidemiology of neonatal jaundice in the Jerusalem population. J Pediatr Gastroenterol Nutr. 1990;10:82–86
13. Soskolne El, Schumacher R, Fyock C, Young ML, Schork A. The effect of early discharge and other factors on readmission rates of newborns. Arch Pediatr Adolesc Med. 1996;150:373–379
14. Kramer LI. Advancement of dermal icterus in the jaundiced newborn. Am J Dis Child. 1969;118:454–458
15. M Kaplan, C Hammerman - American Academy of Pediatrics guidelines for detecting neonatal hyperbilirubinaemia and preventing kernicterus Arch. Dis. Child. Fetal Neonatal Ed 2005;90;450-451
16. Moyer VA, Ahn C, Sneed S. Accuracy of clinical judgment in neonatal jaundice. Arch Pediatr Adolesc Med. 2000;154:391–394
17. Tayaba R, Gribetz D, Gribetz I, Holzman IR. Noninvasive estimation of serum bilirubin. Pediatrics. 1998;102(3). Available at: www.pediatrics. org/cgi/content/full/102/3/e28
18. Johnson LH, Bhutani VK, Brown AK. System-based approach to management of neonatal jaundice and prevention of kernicterus. J Pediatr. 2002;140:396–403
19. Volpe JJ. Neurology of the Newborn. 4th ed. Philadelphia, PA: W. B. Saunders; 2001 20. Kim MH, Yoon JJ, Sher J, Brown AK. Lack of predictive indices in kernicterus. A
comparison of clinical and pathologic factors in infants with or without kernicterus. Pediatrics. 1980;66:852–858
21. Garcia FJ, Nager AL. Jaundice as an early diagnostic sign of urinary tract infection in infancy. Pediatrics. 2002;109:846–851
29
22. Kaplan M, Hammerman C, Feldman R, Brisk R. Predischarge bilirubin screening in glucose-6-phosphate dehydrogenase-deficient neonates. Pediatrics. 2000;105:533–537
23. Maisels MJ, Kring E. Transcutaneous bilirubinometry decreases the need for serum bilirubin measurements and saves money. Pediatrics. 1997;99:599–601
24. Ip S, Glicken S, Kulig J, Obrien R, Sege R, Lau J. Management of Neonatal Hyperbilirubinemia. Rockville, MD: US Department of Health and Human Services, Agency for Healthcare Research and Quality; 2003. AHRQ Publication 03-E011
25. Bhutani V, Gourley GR, Adler S, Kreamer B, Dalman C, Johnson LH. Noninvasive measurement of total serum bilirubin in a multiracial predischarge newborn population to assess the risk of severe hyperbilirubinemia. Pediatrics. 2000;106(2). Available at: www.pediatrics.org/cgi/content/full/106/2/e17
26. Yasuda S, Itoh S, Isobe K, et al. New transcutaneous jaundice device with two optical paths. J Perinat Med. 2003;31:81–88
27. Maisels MJ, Ostrea EJ Jr, Touch S, et al. Evaluation of a new transcutaneous bilirubinometer. Pediatrics. 2004;113:1638–1645
28. Ebbesen F, Rasmussen LM, Wimberley PD. A new transcutaneous bilirubinometer, bilicheck, used in the neonatal intensive care unit and the maternity ward. Acta Paediatr. 2002;91:203–211
29. Rubaltelli FF, Gourley GR, Loskamp N, et al. Transcutaneous bilirubin measurement: a multicenter evaluation of a new device. Pediatrics. 2001;107:1264–1271
30. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2002:220–224
31. Bertini G, Dani C, Trochin M, Rubaltelli F. Is breastfeeding really favoring early neonatal jaundice? Pediatrics. 2001;107(3). Available at: www.pediatrics.org/cgi/content/full/107/3/e41
32. Yamauchi Y, Yamanouchi I. Breast-feeding frequency during the first 24 hours after birth in full-term neonates. Pediatrics. 1990;86:171–175
33. De Carvalho M, Holl M, Harvey D. Effects of water supplementation on physiological jaundice in breast-fed babies. Arch Dis Child. 1981;56: 568–569
34. American College of Obstetricians and Gynecologists - Prevention of Rh D alloimmunization. 1999 May (reviewed 2004) http://www.guidelines.gov
35. Sameer Wagle - Hemolytic Disease of Newborn Last Updated: June 22, 2006 http://www.emedicine.com/PED/topic959.htm
36. American Family Practice Notebook, LLC – Phototherapy - 2002, 37. Kearns GL, Williams BJ, Timmons OD. Fluorescein phototoxicity in a premature infant. J
Pediatr. 1985;107:796–798 38. Maisels MJ. Phototherapy—traditional and nontraditional. J Perinatol.2001;21(suppl
1):S93–S97 39. Fiberoptic phototherapy systems. Health Devices. 1995;24:132–153 40. Thor WR Hansen, MD, PhD, MHA, Jaundice, Neonatal - eMedicine Neonatology Last
Updated: June 8, 2006 41. Fetus and Newborn Committee, Canadian Paediatric Society (CPS) - Approach to the
management of hyperbilirubinemia in term newborn infants Paediatrics & Child Health 1999;4(2):161-164 Reference No. FN98-02 Revision March 2002
42. Yasuda S, Itoh S, Isobe K. New transcutaneous jaundice device with two optical paths. J Perinat Med 2003;31:81-8.
43. Maisels MJ, Kring E. Bilirubin rebound following intensive phototherapy. Arch Pediatr Adolesc Med. 2002;156:669–672
44. Rubaltelli FF, Jori G, Reddi E. Bronze baby syndrome: a new porphyrinrelated disorder. Pediatr Res. 1983;17:327–330
45. Meisel P, Jahrig D, Theel L, Ordt A, Jahrig K. The bronze baby syndrome: consequence of impaired excretion of photobilirubin? Photobiochem Photobiophys. 1982;3:345–352
30
46. Cremer RJ, Perryman PW, Richards DH. Influence of light on the hyperbilirubinemia of infants. Lancet. 1958;1(7030):1094–1097
47. Johnson LH, Bhutani VK, Brown AK. System-based approach to management of neonatal jaundice and prevention of kernicterus. J Pediatr. 2002;140:396–403
48. Gottstein R, Cooke R. Systematic review of intravenous immunoglobulin in haemolytic disease of the newborn. Arch Dis Child Fetal Neonatal Ed. 2003;88:F6–F10
49. Rubo J, Albrecht K, Lasch P, et al. High-dose intravenous immune globulin therapy for hyperbilirubinemia caused by Rh hemolytic disease. J Pediatr. 1992;121:93–97
50. Hammerman C, Kaplan M, Vreman HJ, Stevenson DK. Intravenous immune globulin in neonatal ABO isoimmunization: factors associated with clinical efficacy. Biol Neonate. 1996;70:69–74
51. Volpe JJ. Neurology of the Newborn. 4th ed. Philadelphia, PA: W. B. Saunders; 2001 52. Harris M, Bernbaum J, Polin J, Zimmerman R, Polin RA. Developmental follow-up of
breastfed term and near-term infants with marked hyperbilirubinemia. Pediatrics. 2001;107:1075–1080
53. Ahlfors CE. Criteria for exchange transfusion in jaundiced newborns. Pediatrics. 1994;93:488–494
54. Intensive Care Nursery House Staff Manual - Hemolytic Disease of the Newborn - The Regents of the University of California Copyright © 2004
55. Philip Beeby - Department of Neonatal Medicine Nursing Protocols Royal Prince Alfred HospitalJaundice Exchange Transfusion Revised May, 2006
56. Keenan WJ, Novak KK, Sutherland JM, Bryla DA, Fetterly KL. Morbidity and mortality associated with exchange transfusion. Pediatrics. 1985; 75:417–421
57. Hovi L, Siimes MA. Exchange transfusion with fresh heparinized blood is a safe procedure: Experiences from 1069 newborns. Acta Paediatr Scand. 1985;74:360–365
58. Jackson JC. Adverse events associated with exchange transfusion in healthy and ill newborns. Pediatrics. 1997;99(5):e7. Available at: www.pediatrics.org/cgi/content/full/99/5/e7
59. Alpay F, Sarici S, Tosuncuk HD, Serdar MA, Inanc¸ N, Go¨kc¸ay E. The value of first-day bilirubin measurement in predicting the development of significant hyperbilirubinemia in healthy term newborns. Pediatrics. 2000;106(2). Available at: www.pediatrics.org/cgi/content/full/106/2/e16
60. Carbonell X, Botet F, Figueras J, Riu-Godo A. Prediction of hyperbilirubinaemia in the healthy term newborn. Acta Paediatr. 2001;90:166–170
61. Stevenson DK, Fanaroff AA, Maisels MJ, et al. Prediction of hyperbilirubinemia in near-term and term infants. Pediatrics. 2001;108:31–39
62. Fetus and Newborn Committee, Canadian Paediatric Society (CPS) - Approach to the management of hyperbilirubinemia in term newborn infants - Paediatrics & Child Health 1999;4(2):161-164 Reference No. FN98-02
63. a. kvezereli-kopaZe, m. kvezereli-kopaZe, z. mTvareliZe – anemiebi
bavSvTa asakSi - 2003w.
31
15. avtorTa jgufi:
⇒ maia xerxeuliZe – medicinis doqtori, Tbilisis saxelmwifo
samedicino universitetis pediatriis departamentis asistent-
profesori. pediatrTa da neonatologTa kavSiri “alternativa”
⇒ dimitri abelaSvili - medicinis doqtori, Tbilisis saxelmwifo
samedicino universitetis diplomis Semdgomi da uwyveti
samedicino ganaTlebis instituti, m. iaSvilis saxelobis bavSvTa
centraluri klinikuri saavadmyofos reanimaciisa da
gadaudebeli daxmarebis samsaxuris ufrosi, axalSobilTa
reanimaciis ganyofilebis gamge. pediatrTa da neonatologTa
kavSiri “alternativa”
⇒ maka mSvildaZe _ neonatologi, CaCavas sax. mean-ginekologiisa da
perinatologiis instituti, saqarTvelos Sromis, janmrTelobisa
da socialuri dacvis saministros eqsperti
⇒ nani yavlaSvili – medicinis doqtori, Tbilisis saxelmwifo
samedicino universitetis pediatriis departamentis asistent-
profesori. pediatrTa da neonatologTa kavSiri “alternativa”
eqspertebi:
⇒ avTandil kvezereli-kopaZe – profesori, pediatriis s/k
institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli,
pediatrTa sazogadoebis Tavmjdomare
⇒ Tamaz korZaxia – neonatologi, samSobiaro saxli “hera”,
generaluri direqtori
⇒ qeTevan nemsaZe – medicinis mecnierebaTa doqtori, Tbilisis
saxelmwifo samedicino universitetis pediatriis departamentis
profesori;
⇒ lela woworia _ saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis saministros janmrTelobis dacvis
departamenti;
⇒ Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis saministros janmrTelobis dacvis
departamenti.