meToduri rekomendacia

axalSobilTa hipoglikemia

1. definicia: neonatalur periodSi metaboluri cvlis yvelaze xSir problemas

hipoglikemia warmoadgens . glukoza, nayofisa da axalSobilis ZiriTadi energetikuli wyaroa. igi nebismieri qsovilis, maT Soris ki nervuli qsovilis metabolizmis aucilebeli komponentia. axalSobilTa hipoglikemiis, gansakuTrebiT ki mZime hipoglikemiis SemTxvevaSi, romelic xangrZlivad grZeldeba da ar aris sworad koregirebuli maRalia cns-is dazianebis da gonebrivi ganviTarebis Seferxebis riski . aqedan gamomdinare, sakmaod mniSvnelovania mocemuli problemis drouli identificireba da adekvaturi marTva.

jandacvis msoflio organizaciis monacemebiT axalSobilTa hipoglikemiad iTveleba sisxlSi glukozis 2,6 mmol/l-ze naklebi Semcveloba.

axalSobilTa hipoglikemiis Sesaxeb arsebuli maravlricxovani samecniero Sromebis miuxedavad, ar arsebobs srulyofili mtkicebulbebze dafuZnebuli rekomendaciebi hipoglikemiis definiciis, skriningisa da marTvis Sesaxeb. sisxlSi Saqris Semcvelobis “normaluri zRvari” damokidebulia axalSobilis dabadebis masaze, gestaciur asakze, klinikuri mdgomareobaze da sxv. glukozis Semcvelobis “normaluri zRvaris” ganmarteba efuZneba 3 ZiriTad midgomas :

1. sisxlSi glukozis Semcvelobas. drouli, ZuZuTi kvebaze myofi axalSobilebis gamokvlevisas dadginda, rom dabadebis Semdeg 1 sT-Si glukozis Semcveloba sisixlSi ecema 1,8 mmol/l-ze (mtkicebulebis done II), Semdeg imatebs da metia 2,0 mmol/l-ze sicocxlis pirveli 72 sT-is ganmavlobaSi . drouli, gestaciuri asakis Sesabamisi masis mqone axalSobilTa 12-14%-Si sisxlSi Saqris Semcveloba naklebia 2,6 mmol/l-ze sicocxlis pirveli 72 sT-i .

2. risk-faqtorebis arsebobas. hipoglikemiis riskis jgufis axalSobilebSi (droulebi dabadebis stresiT, dRenaklulebi, gestaciur asakTan SedarebiT mcire masis axalSobilebi) Catarebuli kvelevebis safuZvelze dadginda, rom sisxlSi glukozis Semcveloba 2,6 mmol/l-ze naklebi korelirebs adreul (mtkicebulebis done II), da mogvianebiT nevrologiur dazianebebTan (mtkicebulebis done II), an neiroimijingis cvlilebebTan (mtkicebulebis done IV.). dedis diabetis SemTxvevaSi Catarebulma kvlevebma gviCvena, rom gaxangrZlivebuli nevrologiuri dazianebebi vlindeba Tu axalSobilis sisxlSi glukozis Semcveloba 1,6 mmol/l-ze naklebia.

3. klinikuri suraTsa da Carevis principebs. am mimarTebiT ar arsebobs mtkicebulebebi, kvlevis arasakmarisi raodenobis gamo.

1

II

II

II

IV

gaidlaini gankuTvnilia

⇒ samedicino personalisaTvis, romelic muSaobs axalSobilTan, rogorc samSobiaro saxlSi, ise stacionarSi – neonatologi, pediatri.

gaidlainis samizne jgufi:

⇒ axalSobilebi, romlebsac aReniSnebaT hipoglikemia an hipoglikemiis ganviTarebis riski.

2. epidemiologia

axalSobilTa hipoglikemiis sixSire ar aris sakamarisad Seswavlili. misi gavrceleba damokidebulia gestaciur asaksa da dabadebis masaze. yvelaze maRali sixSire (67%) dafiqsirebulia dRenaklulebSi, romelTa masa naklebia gestaciur asakTan SedarebiT. gestaciur asakTan SedarebiT dabali masis mqone droul axalSobilebSi hipoglikemiis sixSire daaxloebiT 25 %-ia, gestaciuri asakis Sesabamisi maisis mqone droul axalSobilebSi _ 10 %. am ukanasknelTa umetesobas uvlindeboda dabadebis stresi hipqsiis saxiT. diabetiT daavadebuli dedebis axalSobilebSi, romelTa masac metia gestaciur asakze hipoglikemiis sixSire 38 %-s aRwevs.

3. etiopaTogenezi:

risk-faqtorebi:

axalSobilTa hipoglikemiis risk faqtorebia ;;;

dedismxrivi

• orsulTa diabeti

• glukozis gamoyeneba intranatalur periodSi

• dedisaTvis micemuli medikamentebi: beta-simpatikomimetikebi (mag. terbutalini), qlorpropamidi, propanoli, oraluri hipoglikemiuri medikamentebi

bavSvismxrivi • dRenakluli axalSobili gestaciis 37 kviramde (mtkicebulebis

done III) .• gestaciur asakTan SedarebiT mcire masis axalSobili (< 10 centilze); mtkicebulebis done III).

• gestaciur asakTan SedarebiT didi masis axalSobili (> 90 centilze); mtkicebulebis done III).

• vadagadacilebuli axalSobili;• perinataluri paTologia: asfiqsia, apgaris qula <5-ze me-5 wuTze. travma, sisxlCaqceva, sefsisi, hipoTermia, policitemia, respiraciuli distresi.

• endokrinuli paTologia an metaboluri darRvevebi

• hiperinsulinizmi

2

III

III

III

• bekvit-videmanis sindromi (damaxasiTebeli triada: Wipis Tiaqari, makroglosia, visceromegalia)

neonataluri periodSi hipoglikemiis ganviTarebis ZiriTadi mizezebia : • glukozis warmoqmnis daqveiTeba da glikogenis deficiti.

glukagonis utilizacia maRalia orsulobis bolo 6 kviris ganmavlobaSi. dRenaklulebs, gestaciur asakTan SedarebiT mcire masis axalSobilebs aqvT naklebi maragi, glukozis donesTan SefardebiT maRali insulinis Semcevloba, rac ganapirobebs sisxlSi glukozis dabal dones.

• anaerobuli glikolizis gaZliereba. perinataluri stresis, asfiqsiis, rds-is, hipoTermiis dros vlindeba kateqolaminebis gazrdili produqcia, hipoqsia, periferiuli sisxlismimoqcevis darRveva, rac iwvevs anaerobuli glikolizs, glukogenezis Seferxebas da hipoglikemiis ganviTarebas.

• hiperinsulinizmi. diabetiT daavadebuli dedis nayofi iRebs meti raodenobiT glukozas, rac ganapirobebs masis swraf namats da insulinis Warb produqcias. dabadebis Semdeg wydeba glukozis miwodeba, axalSobilis organizmi ki kvlav gamoimuSavebs meti raodenobis insulins.

• metabolizmis tempis gaZliereba, glikogenezis daqveiTeba, naxSirwylovani cvlis darRveva - sefsisis da infeqciebis SemTxvevaSi

• nivTierebaTa cvlis darRveva – endokrinuli paTologiebis da dagrovebis daavadebebis, bekvit-videmanis sindromis dros. aseT SemTxvevaSi Cveulebriv vlindeba persistiuli hipoglikemia. nayofis da axalSobilis ZiriTad energetikul substratebs glukoza,

aminomJavebi da laqtati warmoadgens. Tu antenatalur periodSi nayofi damokidebuli iyo dedis organizmidan miwodebul glukozis raodenobaze, dabadebis Semdeg igi unda gadaerTos glukozis da glikogenis warmoqmnis damukidebel gzaze. axalSobilis sisxlSi Saqris normuli Semcveloba damokidebulia glikogenis maragis adkvaturobaze, gliko da glukogenezis gzebis simwifesa da aqtivobaze, endorkrinuli sistemis pasuxze (glukozis sinTezi; cximebis metabolizmi; insulinis donis swrafi Semcireba).

dadgenilia, rom dabadebisTanave glukozis done ecema, xolo Tavisufali cxomovani mJevebis, ketonuri sxeulebis da glicerolis koncentracia matulobs. axalSobilis sisxlSi glukozis Semcevloba damokidebulia kvebis droul dawyebaze. xangrZlivi da mZime hipoglikemia iwvevs tvinis dazianebas ujredul doneze.

4. klinikuri simptomatika:

arCeven simptomur da asimptomur hipoglikemias. hipoglikemiis asimptomuri forma xasiaTdeba mxolod laboratoriuli cvlilebebiT.

hipoglikemiis simptomatika araspecifikuria, ris gamoc xSir SemTxvevaSi Znelia misi diagnostika. hipoglikemiis ZiriTadi simptomebia :

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• cnobierebis sxvadasxva donis darRveva _ agzneba, motoruli aqtivoba, romelic icleba daTrgunviT; leTargiiT, stuporiT da komiT

• susti xmiT tirili an piriqiT, xmamaRali e.w. “tvinovani” kivili;• wovis uunaroba; • temperaturis arastabiluroba da midrekileba hipoTermiisaken;• tremori, hiperkinezebi an hiporefleqsia

• kunTTa tonusis cvlileba (xSirad kunTTa hipotonia) • araregularuli sunTqva, taqipnoe, apnoe, • Tvalis simptomatika: mcuravi Tvalebi, nistagmi, Tvalis kaklis tonusis

daqveiTeba, • krunCxva.

riskis jgufis axalSobils hipoglikemia uxSiresad uvlindeba pirveli 24 sT ganmavlobaSi, adaptaciis periodSi.

diabetiT daavadebuli dedis axalSobils am niSnebTan erTad SeiZleba gamouvlindes

makrosomia

• samSobiaro travma

• Tandayolili anomaliebi

• rds

• policitemia

• hiperbilirubinemia

• miokardiumis disfunqcia

prevencia • ZuZuTi kvebis adreuli dawyeba. dabadebidan 1 sT-is ganmavlobaSi

bavSvma unda miiRos dedis rZe. dadgenilia, rom ZuZuTi kveba xels uwyobs sisxlSi Saqris donis stabilizacias (mtkicebulebis

siZlieris done II), ar aris mizanSewonili prelaqtaciuri glukozis xsnaris gamoyeneba, radgan igi dabalkaloriuli xsanria da Tavad SeiZleba gaxdes hipoglikemiis mizezi32.

• temperaturuli reJimis dacva ZuZuTi kvebasTan erTad pipoglikemiis prevenciis saukeTeso gzaa (rekomendacia A) ,31,32.

• riskis jgufis axalSobilTa identifikacia da skriningi32. Tu ver xorcieldeba ZuZuTi kveba saWiroa qalis gamowvelili riZis, an xelovnuri formulis miwodeba. Tu SeuZlebelia peroraluri kveba sicocxlis pirvelive saaTSi mizanSewonilia intravenuri infuzia.

5. hipoglikemiis diagnozidiagnostikuri kriteriumebihipoglikemiis simptomTa araspecifiurobis gamo, hipoglikemiis diagnostikis dros iTavliswineben Whipple triadas • damaxasiaTebeli klinikuri suraTi;• sisxlSi glukozis dabali Semcveloba;• simptomebis gaqroba, rodesac glukozis Seyvanis Semdeg sisxlSi Saqris

Semcveloba miaRwevs normas.

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A

sisxlSi Saqris donis gansazRvra tardeba skriningis meTodiT, Tu dadasturda hipoglikemia, mizanSewonilia laboratoriuli kvlevis Catareba. kapilarul da venur sisxlSi glukozis Semcveloba gansxvavdeba, agreTve gansxvavebulia plazmis Senaxvis Semdeg Catarebuli kvelevis monacemi (mtkicebulebis done III)

6. gamokvlevis sqema - skriningi (sqema ix. danarTi 1) 1. janmrTeli, drouli axalSobili, romelic miyvanilia ZuZusTan

dabadebidan 1 sT-Si da agrZelebs ZuZuTi kvebas moTxovnilebis mixedviT, ar saWiroebs rutinulad Saqris Semcvelobis gansazRvras da siTxis an xelovnuri sakvebis damatebas (rekomendacia A) ,32;. dadgenilia, rom janmrTel, droul axalSobls sicocxlis pirvel saaTSi SeiZleba aReniSnebodes glukozis dabali Semcveloba (mtkicebulebis done II). amave dros droul, janmrTel axalSobils aqvs unari gamoiyenos sxva energetikuli wyaro Saqris dabali Semcelobis pirobebSi (mtkicebulebis done II). janmrTel, droul axalSobils ar uvlindebaT “simptomuri” hipoglikemia mxolod arasakmarisi kvebis gamo, aseT SemTxvevaSi saWiroa sxva mizezis dadgena (rekomendacia A)31.

2. riskis jgufis axalSobilebs, kerZod ki gestaciuri asakis mixedviT mcire an didi masis axalSobils, dRenaklulsa da diabetiT daavadebuli dedis axalSobls rutinulad esaWiroeba Saqris donis gansazRvra (rekomendacia C)

3. axalSobilebs, hipoglikemiisaTvis damaxasiaTebeli klinikuri niSnebiT, sisixlSi Saqris Semcveloba unda ganesazrvoT dauyovnebliv (rekomendacia C) ; .

ar arsebobs kvlevebi, romelic mtkicebulbebze dayrdnobiT daadasturebs riskis jgufis axalSobilebSi pirveli skriningis Catarebis dros. jandacvis msoflio organizaciis 1997 wlis monacemebiT riskis jgufis axalSobilebs sisxlSi Saqris donis unda ganesazRvros dabadebidan 4-6 sT-Si (mtkicebulebis done IV)

Tumca ukanasknel wlebSi Catarebuli kvlevis Sedegad miaCniaT, rom riskis jufis axalSobilebma unda miiRon sakvebi sicocxlis I sT-is ganmavlobaSi da sisxlSi Saqris Semcveloba unda ganisazRvros kvebidan 1 sT-Si (anu dabadebidan 2 sT-Si), araugvianes 4 sT-isa (mtkicebulebis done IV)

Tu axalSobils aReniSneba hipoglikemia, risk-faqtorebis gareSe, aucilebelia sefsisi gamoricxva.

7. mkurnaloba da monitoringisamkurnalo Careva saWiroa, Tu sisxlSi Saqris Semcveloba naklebia

2,0 mmol/l-ze (40 mg%).

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C

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III

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mkurnalobis mizania SenarCundes sisxlSi Saqris donis 2,6 mmol/l da meti (47mg%).

riskis jgufi, hipoglikemiis simptomebis gareSe (1,1 mmol/l < glukoza < 2,6 mmol/l)

daculi unda iqnas Termuli reJimi pirvel rigSi unda daiwyos kveba da Catardes pirveli skriningi

sasurvelia dabadebidan 2 sT-Si (kvebidan 1 sT-is Semdeg).• Tu maCvenebeli aris 2,0-mmol/l-sa da 2,6 mmol/s Soris,

grZeldeba xSiri ZuZuTi kveba da ganmeorebiTi skriningi tardeba yovel 3-6 sT-Si erTxel. testireba SeiZleba Sewydes Tu analiziT miiRebuli monacemi metia 2,6-mmol/l-ze ganmeorebiT 2 testirebis dros. miuxedavad amisa gviani hipoglikemiis Tavidan asacildeblad: (rekomenacia C).

• Tu maCvenebeli aris 1,8-2,0-mmol/s Soris saWiroa ganmeorebiTi kveba da 1 sT-Si skriningis ganmeoreba. imis mixedviT Tu rogoria glukozis Semcveloba, marTvis taqtika gansxvavebulia:

_ Tu kvebis miuxedavad sisxlSi Saqris done naklebia 2,6 mmol/l-ze saWiroa intravenuri infuzia 10% glukozis xsnariT (Semdgomi skriningi da marTva mocemulia hipoglikemiis klinikuri niSnebis mqone axalSobilis marTvis nawilSi).

_ Tu kvebidan 1 sT-is Semdeg Saqris done metia 2,6 mmol/lze grZeldeba xSiri ZuZuTi kveba da ganmeorebiTi skriningi tardeba yovel 3-6 sT-Si erTxel testireba SeiZleba Sewydes Tu analiziT miiRebuli monacemi metia 2,6-mmol/l-ze ganmeorebiT 2 testirebis dros.

• Tu maCvenebeli naklebia 1,8-mmol/l-ze unda daiwyos infuzuri Terapia glukozis xsnariT (rekomenacia C), glukozis xsnaris infuzia iwyeba Tavdapirvelad 4-8 mg/kg/wT wveTovani infuzia (saSualod glukozis 10% xsnaris 80 ml/kg/dReSi) (mtkicebulebis done III). Semdgomi skriningi da marTva mocemulia hipoglikemiis klinikuri niSnebis mqone axalSobilis marTvis nawilSi.

• Tu maCvenebeli naklebia 1,1-mmol/l-ze axalSobilis marTva iseTivea, rogorc hipoglikemiis klinikuri niSnebis arsebobisas.

Tu ver xorcieldeba ZuZuTi kveba saWiroa qalis gamowvelili riZis, an xelovnuri formulis miwodeba (10 ml/kg-ze). Tu SeuZlebelia enteraluri kveba sicocxlis pirvelive saaTSi mizanSewonilia glukozis xsnaris infuzia.

hipoglikemiis simptomebis arseboba an riskis jgufi (glukoza < 1,1mmol/l)dauyovnebliv unda daiwyos glukozis bolusuri dozis intravenuri Seyvana , Tu

_ hipoglikemiis klinikuri niSnebis arsebobisas, Tu sisxlSi Saqris Semcveloba < 2,6 mmol/l-ze

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C

C

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III

(rekomendacia C). Tu sisxlSi glukozis Semcveloba > 2,6 mmol/l simptomatika ar aris ganpirobebuli hipoglikemiiT, saWiroa Semdgomi diagnostika.

_ riskis jgufis bavSvebSi sisxlSi Saqris koncentraciis daqveiTebisas <1,1 mmol/l-ze (25 mg%-ze metad) glukozis bolusuri doza gulisxmobs glukozis 10 %-iani xsnari. glukoza SehyavT nakaduri wesiT mcire moculobiT - 2 ml/kg-ze 3-5 wT ganmavlobaSi.

• bolusuri dozis Seyvanis Semdeg gadadian wveTovan infuziaze 4-8 mg/kg/wT (anu 10% glukozis xsnaris 2,4-4,8 ml/kg/sT. saSualod 80 ml/kg/dReSi). Saqris donis gansazRvra xdeba 30 wT-Si.

_ Tu glukozis done naklebia 1,1 mmol/l-ze, meordeba bolusuri dozis Seyvana da izrdeba infuziis siCqare 25 %-iT anu 10 % glukoza 100ml/kg/dReSi, an izrdeba xsnaris koncentracia 12,5%-mde da xsnaris Sesayvani raodenoba rCeba 80ml/kg/dReSi. glukozis gansazRvra xdeba 30 wT-Si. Tu ganmeorebiTi skriningis dros kvlav naklebia glukozis done 1,1-ze, meordeba bolusuri dozis Seyvana da grZledeba infuzia12,5 %iani xsnariT 100-120 ml/kg/dReSi. Tu 30 wT-Si mocemuli infuziis fonze glukozis Semcveloba naklebia 2,6-mmol/lze mizanSewonilia endokrinologis konsultacia, da pacientis referali (mtkicebulebis done IV). safiqrebelia endokrinuli paTologiis (hiperinsulinizmi) an metaboluri darRvevebis arseboba. Tu hipogilkemia persistirebs SeiZleba hidrokortizonis (5 mg/kg/24sT 4 Seyvanaze) parenteralurad gamoyeneba (ar arsebobs mtkicebuleba). Tu glukozis intravenuri infuzia ver xerxdeba an infuziis fonze ar imatebs Saqris Semcveloba alternativas warmoadgens glukagonis (01-03 mg/kg-ze) intravenuri Seyvana (ar arsebobs mtkicebuleba

_ Tu Saqris done metia 1,1 mmol/l-ze magram naklebia 2,6 mmol/l-

ze gadasxma grZeldeba sanam Saqris done ar iqneba ≥ 2,6 mmol/l-ze. glukozis gansazRvra xdeba yovel 3 sT-Si.

_ Tu Saqris done ≥ 2,6 mmol/l-ze 2 ganmeorebiTi skriningis dros infuzia TandaTan mcirdeba. dauSvebelia glukozis infuziis swrafi Sewyveta, nakadis siswrafe da xsnaris koncentracia TandaTan unda Semcirdes enteraluri kvebis gazrdasTan erTad. glukozis infuziis Sewyvetamde eqimi unda darwmundes, rom xorcieldeba xSiri ZuZuTi kveba an bavSvi iRebs xelovnur sakvebs minimum 10/ml/kg-ze 3 sT-Si erTxel. glukozis infuziis Semcireba xdeba 25 %-iT yovel 3-6 sT-Si erTxel, anu daaxloebiT 20-25 ml/kg/dReSi–iT. yoveli Semcirebis win isazRvreba Saqris Semcveloba. glukozis infuziis Sewyvetis Semdeg Saqris donis gansazRvra meordeba 12 sT-Si erTxel 24 sT-is ganmavlobaSi.

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IV

• periferiul venaSi dauSvebelia 12,5% maRali koncentraciis glukozis xsnaris infuzia. YTu saWiroa ufro maRali koncentraciis glukozis gamoyeneba, unda moxdes centraluri venis kaTeterizacia.

• Tu axalSobilis deda daavadebulia Saqriani diabetiT, akrZalulia swrafi nakadiT (bolusuri doza) Seyvana. aseT SemTxvevaSi hipoglikemiis koreqciisaTvis saWiroa maRali koncentraciis glukozis xsnaris (12.5%) gamoyeneba. Tu sisxlSi glukozis Semcveloba ar matulobs, dasaSvebia glukozis xsnaris koncentraciis gazrda 15%; 20%-mde.

glukozis infuziis SemTxvevaSi sisxlSi glukozis donis monitoringi saSualebas iZleva droulad gamovlindes infuziiT ganpirobebuli hiperglikemia. hiperglikemiad iTvleba sisxlSi glukozis done > 6.66 -6.94 mmol/l (> 120 - 125 mg/dl). hiperglikemia SeiZleba gamovlindes dehidrataciis niSnebiT, cxelebiT, glukozuriiT, metaboluri acidoziT. xSirad mimdinareobs asimptomurad.

Tu vlindeba sisxlSi glukozis Semcvelobis momateba, aucilebelia glukozis infuziis siCqaris TandaTanobiT Semcireba 1- 2 mg/kg wuTSi yovel 2-4 sT-Si, sanam ar miiRweva normoglikemiis done. aseve SesaZlebelia Semcirdes gadasasxmeli xsnaris koncentracia . 5 % -ze naklebi koncentraciis glukoza dabali osmolarobis xsnaria, romelmac SesaZlebelia ganapirobos hemolizi, amitom ar aris mizanSewonili mocemuli koncentraciis xsnaris gamoyeneba. Tu glukozis xsnaris infuziis siCqaris da koncentraciis Semcirebis miuxedavad grZeldeba hiperglikemia, aucilebelia endokrinologis konsultacia, insulinis gamoyenebaze gadawyvetilebis miReba da bavSvis gadayvana specializebul klinikaSi Semdgomi gamokvlevisaTvis (unda gamoiricxos diabetis arseboba).

referalis Cveneba: glukozis intravenuri infuzia ver xerxdeba hipoglikemiis simptomebis mqone (Saqris done < 2.6 mmol/l) an riskis

jgufis (glukoza < 1,1mmol/l) axalSobilebSi 3 bolusuri dozis Seyvanis da glukozis infuziis siCqaris orjer gazrdis Semdeg glukozis done sisxlSi < 2.6 mmol/l

gviani hipoglikemia Tu glukozis infuziis fonze ganviTarda hiperglikemia, romelic ar

regulirdeba glukozis xsnaris infuziis siCqaris da koncentraciis Semcirebis miuxedavad.

persistiuli an gvian ganviTarebuli hipoglikemiis dros specializebul stacionarSi saWiroa gamokvleva Semdegi daavadebebis gamosaricxad .

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axalSobilebSi maRali koncentraciis (25-50 %) xsnaris bolusuri Seyvana ar aris mizanSewonili, radgan izrdeba Tavis tvinSi sisxlCaqcevis

ganviTarebis riski

• Tandayolili hiperinsulinizmi (autosomur dominanturi an recesiuli)

• bekvit-videmanis sindromi

• pankreasis kunZulovani ujredebis adenoma

• metabolizmis Tandayolili darRvevebi; glikogenozebi galaqtozemia cximovani mJavebis daJangvis defeqtebi karnitinis deficiti aminoacidemia fruqtozis Tandayolili autanloba glukoneogenezis fermentebis deficiti

• endokrinuli darRvevebi hipopituitarizmi adrenaluri ukmarisoba

gamokvleva

• perinataluri anamnezis detaluri Segroveba, dedis glukozis

tolerantobis testi, axalSobilis fizikuri parametrebis Sefaseba, raTa gamoiricxos axalSobilTa hipoglikemiis uxSiresi mizezebi – sefsisi, gestaciur asakTan SedarebiT mcire da didi wonis axalSobilebi

• hiperinsulinemiis dadgena (insulinis donis gansazRvra)• insulinismsgavsi zrdis faqtor-1-is SemboWveli cilis (IGFBP-1)

gansazRvra (hiperinsulinemiis dros daqveiTebulia)

• sisxlSi da SardSi aminomJavebis gansazRvra

• SardSi ketosxeulebis gansazRvra• kortizolis, kateqolaminebis, zrdis hormonis, Tiroqsinis da

Tireomastimulirebeli hormonis gansazRvra

• Tavisufali cximovani mJavebis da alaninis raodenobis gansazRvra. persistiuli hipoglikemiis SemTxvevaSi aucilebelia endokrinologis konsultacia

damatebiTi mkurnaloba persistiuli hipoglikemiis dros

• sainfuzio glukozis xsnaris koncentraciis gazrda 12,5%-ze metad, am dros infuzia xdeba mxolod centarlur venaSi.

• kortikosteroidebi (amcirebs glukozis utilizacias) – hidrokortizoni 5-15 mg/kg/dReSi an prednizoloni 2 mg/kg/dReSi

• glukagoni (astimulirebs glikogenolizs) _ 30 mkg/kg Tu insulinis done normaluria, 300mkg/kg Tu insulinis done momatebulia. aqvs swrafi, tranzitoruli efeqti

• diazoqsidi (ainhibirebs insulinis sekrecias) – 15 mg/kg/dReSi (5 mg/kg 8 saaTSi erTxel)

9

• somatostatini (an misi gaxangrZlivebuli moqmedebis analogi oqtretid acetati) (ainhibirebs insulinis da zrdis hormonis sekrecias) - 5-10 mkg/kg yovel 6-8 saaTSi erTxel

• pankreateqtomia – amcirebs insulinis sekrecias (operirebulTa 33%-Si aRiniSneba hipoglikemiis recidivi, 40-60%-Si ki mogvianebiT viTardeba Saqriani diabeti.

prognozi hipoglikemiis riskis jgufis axalSobilebSi (droulebi samSobiaro stresiT, dRenaklulebi, gestaciur asakTan SedarebiT mcire masis axalSobilebi) Catarebuli kvelevebis safuZvelze dadginda, rom sisxlSi glukozis 2,6 mmol/l-ze naklebi Semcveloba korelirebs adreul (mtkicebulebis done II), da mogvianebiT nevrologiur dazianebebTan (mtkicebulebis done II), an neiroimijingis cvlilebebTan (mtkicebulebis done IV).. dedis diabetis SemTxvevaSi Catarebulma kvlevebma gviCvena, rom gaxangrZlivebuli nevrologiuri dazianebebi vlindeba Tu axalSobilis sisxlSi glukozis Semcveloba 1,6 mmol/l-ze naklebia.

10

II

II

IV

danarTi 1

skriningi

11

ar saWiroebs skrinings Saqris donis gansazRvra pirveli kvebidan 1 sT-Si, ara ugvianes 4 sT-isa

Saqris done unda ganisazRvros dauyovnebliv

riskis jgufis

axalSobli

janmrTeli drouli

axalSobli

axalSobli, hipoglikemiis klinikuri niSnebiT

danarTi 2 riskis–jgufis axalSobilis marTva

12

Saqris donis gansazRvra pirveli kvebidan 1 sT-Si,

glukoza _ 2,0-2,6 mmol/l

glukoza _ 1,8-2,0 mmol/l

glukoza < 1,1 mmol/l

• xSiri ZuZuTi kveba

• ganmeorebiTi skriningi 3-6 sT-Si erTxel

• skriningi wydeba, Tu 2 testirebisas mona-cemi > 2,6 mmol/l-ze

• kveba • ganmeorebiTi

skriningi kvebidan 1 sT-Si

ix. hipoglikemiis klinikuri niSnebis mqone axalSobilis marTva

glukoza _ 1,1-1,8 mmol/l

• kveba • infuzuri Terapia

glukozis 10%, 4-8 mg/kg/wT)

• skriningi 30 wT-Si

glukoza < 2,6 mmol/l

glukoza > 2,6 mmol/l

glukoza < 2,6 mmol/l

SeniSvna:_ diabetiT daavadebuli dedis da gestaciur asakiTan SedarebiT didi masis

axalSobilebTan saWiroa glukozis kontroli pirveli 12 sT-is ganmavlobaSi (daaxloebiT 6 sT-Si erTxel).

_ dRenakulebsa da gestaciur asakTan SedarebiT mcire masis axalSobilebTan saWiroa glukozis kontroli pirveli 36 sT-Si (12 sT-Si erTxel)

danarTi 3riskis–jgufis axalSobili (glukoza <1,1mmol/l) simptomuri axalSobili (glukoza <2,6 mmol/l-ze)

13

mkurnaloba iwyeba dauyovnebliv

• 10 % glukozis bousuri dozis (2ml/kg) intravenurad 3-5 wT-is ganmavlobaSi

• amis Semdeg 10 % glukozis infuzia 80 ml/kg/dReSi)

• ganmeorebiTi skriningi bolusuri dozidan 30 wT-Si

glukoza 1,1 - 2,6 mmol/l

glukoza > 2,6 mmol/l

glukoza < 1,1 mmol/l

• 3 sT-Si meordeba skriningi da Tu glukoza kvlav > 2,6 mmol/l-ze da xorcieldeba xSiri ZuZuTi kveba an bavSvi iRebs xelovnur sakvebs 10 ml/kg-ze

• gadasasxmeli xsnaris moculoba mcirdeba yovel 3-6 sT-Si 20-25 ml/kg/dReSi-iT

• yoveli Semcirebis win isazRvreba Saqris Semcveloba

infuziis Sewyvetis Semdeg skriningi meordeba 12 sT-Si

erTxel 24 sT-is ganmavlobaSi

• ganmeorebiTi bolusuri doza

• infuziis siCqaris gazrda 10 % glukozis 100 ml/kg/dReSi an 12,5 % glukoza 80/ml/kg/dReSi

• grZeldeba infuzia

• grZeldeba kveba

• 3 sT-Si meordeba skriningi isazRvreba Saqris Semcveloba

glukoza 1,1 - 2,6 mmol/l

glukoza > 2,6 mmol/l

glukoza < 1,1

mmol/l

skriningi 30 wT-Si

glukoza < 1,1 mmol/l

• meordeba bolusuri doza da infuzia 12,5 % glukoza 100-120 ml/kg/dReSi

• skriningi 30 wT-Si

• Tu glukoza <2,6 mmol/l. grZeldeba infuzia, saWiroa endokrinologis konsultacia da referali

SeniSvna:_ diabetiT daavadebuli dedis da

gestaciur asakiTan SedarebiT didi masis axalSobilebTan saWiroa glukozis kontroli pirveli 12 sT-is ganmavlobaSi (daaxloebiT 6 sT-Si erTxel).

_ dRenakulebsa da gestaciur asakTan SedarebiT mcire masis axalSobilebTan saWiroa glukozis kontroli pirveli 36 sT-Si (12 sT-Si erTxel)

11. gaidlainis gadasinjvisa da ganaxlebis vada – 4 weli

12. gaidlainis miRebis xerxi/wyaro

gaidlainis SemuSavebis meTodologia

• axalSobilTa hipoglikemiis prevenciis 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

14

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

National electronic Library for Health (NeLH)

http://www.nelh.nhs.uk/guidelinesfinder

PRODIGY Clinical Guidance http://www.prodigy.nhs.uk/ClinicalGuidance

Scottish Intercollegiate Guidelines Network (SIGN)

http://www.sign.ac.uk

German Guideline Information Service (GERGIS)

http://www.leitlinien.de/english/english/view;

avstralia

Australian National Health and Medical Research Council (NHMRC)

http://www.health.gov.au/hfs/nhmrc/publicat/cp-home.htm

axali zelandia

New Zealand Guidelines Group (NZGG)

http://www.nzgg.org.nz/library.cfm

mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba

http://www.osdm.org

klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi

• koxreinis biblioTeka - The Cochrane Library 2006, Issue 2, • amerikis samedicino biblioTekis mier Seqmnil eleqtronul

bibliografiul monacemTa baza - medlaini – MEDLINE• jandacvis msoflio organizaciis reproduqciuli janmrTelobis

biblioTeka

publikaciebis CarTvis/gamoricxvis kriteriumebi

• arCeul iqna kvlevebi Semdegi dizainiT: randomizebuli kontrolirebadi kvlevebi, sistemuri mimoxilvebi da meta-analizi, erTmomentiani, kohortuli kvlevebi

• rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12 wliani SezRudva. Tumca zogjer gamoyenebuli iyo ufro adreuli publikaciebi, romlebic dResac aqtualuria da safuZvlad udevs sxva Tanamedrove mtkicebulebebs.

15

• 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 hipoglikemiis marTvis sakiTxebze, romlebic Seicavda jgufis miznis Sesaferis saWiro informacias. am rekomendaciebis Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (94,96-98). samuSao jgufi xelmZRvanelobda saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministros samedicino standartebisa da normebis sammarTvelos mier SemuSavebuli nacionaluri gaidlainebis gzamkvleviT. Sefasebis Sedegad amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi:

⇒ 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 gradaciebis sqema

done mtkicebulebis

siZlieris done (Muir Gray)

xarisxi

rekomendaciis xarisxi

(Cook et al)

I Zlieri mtkicebuleba, eyrdnoba minimum erT sistemur mimoxilvas,

romelic efuZneba swori dizainis mqone randomizebul

kontrolirebad kvleva

A eyrdnoba I donis mtkicebulebas da

Sesabamisad mtkiced rekomendebulia

II Zlieri mtkicebuleba, eyrdnoba minimum erTi swori dizainis mqone

randomizebul kontrolirebad kvleva

B eyrdnoba II donis mtkicebulebas da

Sesabamisad mtkiced rekomendebulia

III klinikuri kvleva C eyrdnoba III donis

16

randomizaciis gareSe, kohortuli da SemTxveva-

kontrolis kvlevebi

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:

⇒ merab maWaraSvili _ neonatologi, m.SaraSiZis samedicino centri generaluri direqtoris moadgile neonatologiasa da pediatriaSi.

⇒ maia xerxeuliZe – medicinis doqtori, Tbilisis saxelmwifo samedicino universitetis zogadi pediatriis departamentis asistent-profesori.

⇒ nani yavlaSvili – medicinis doqtori, Tbilisis saxelmwifo samedicino universitetis zogadi pediatriis departamentis asistent-profesori.

eqsperti:

⇒ irakli favleniSvili – profesori, Tbilisis saxelmwifo samedicino universitetis diplomis Semdgomi da uwyveti samedicino ganaTlebis institutis direqtori

⇒ lela woworia – saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministro.

17