klinikuri praqtikis erovnuli rekomendacia (gaidlaini) · pdf file3 axalsobilta hipoglikemia 1....
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klinikuri praqtikis erovnuli rekomendacia (gaidlaini)
`axalSobilTa hipoglikemia~ 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 # 256/o
brZanebiT.
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axalSobilTa hipoglikemia
1. definicia:
neonatalur periodSi metaboluri cvlis yvelaze xSir problemas
hipoglikemia warmoadgens 1. 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 2;3. 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, klinikur
mdgomareobaze da sxv. glukozis Semcvelobis “normaluri zRvaris”
ganmarteba efuZneba 3 ZiriTad midgomas 1;4-5:
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 6
.
drouli, gestaciuri asakis Sesabamisi masis mqone
axalSobilTa 12-14%-Si sisxlSi Saqris Semcveloba naklebia
2,6 mmol/l-ze sicocxlis pirveli 72 sT-i 5. 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.)3;7
. dedis diabetis
SemTxvevaSi Catarebulma kvlevebma gviCvena, rom
gaxangrZlivebuli nevrologiuri dazianebebi vlindeba Tu
axalSobilis sisxlSi glukozis Semcveloba 1,6 mmol/l-ze
naklebia.
3. klinikuri suraTi da Carevis principebi. am mimarTebiT ar arsebobs
mtkicebulebebi, kvlevis arasakmarisi raodenobis gamo.
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II
II
IV
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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 hipoqsiis saxiT. diabetiT daavadebuli dedebis axalSobilebSi,
romelTa masac metia gestaciur asakze hipoglikemiis sixSire 38 %-s
aRwevs.
3. etiopaTogenezi:
risk-faqtorebi:
axalSobilTa hipoglikemiis risk faqtorebia 8;4;9;10;11
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) 4;4;4;12;13;13 . • gestaciur asakTan SedarebiT mcire masis axalSobili (< 10
centilze); mtkicebulebis done III)4;12;13.
• gestaciur asakTan SedarebiT didi masis axalSobili (> 90
centilze); mtkicebulebis done III)4;12;13.
• vadagadacilebuli axalSobili;
• perinataluri paTologia: asfiqsia, apgaris qula <5-ze me-5 wuTze.
travma, sisxlCaqceva, sefsisi, hipoTermia, policitemia, respiraciuli
distresi.
• endokrinuli paTologia an metaboluri darRvevebi
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III
III
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• hiperinsulinizmi
• bekvit-videmanis sindromi (damaxasiTebeli triada: Wipis Tiaqari,
makroglosia, visceromegalia)
neonataluri periodSi hipoglikemiis ganviTarebis ZiriTadi mizezebia 4;9;14:
• 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 adekvaturobaze, gliko da
glukogenezis gzebis simwifesa da aqtivobaze, endokrinuli 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 matulobs12;14-17. axalSobilis sisxlSi glukozis Semcevloba
damokidebulia kvebis droul dawyebaze14. xangrZlivi da mZime hipoglikemia
iwvevs tvinis dazianebas ujredul doneze.
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4. klinikuri simptomatika: arCeven simptomur da asimptomur hipoglikemias. hipoglikemiis
asimptomuri forma xasiaTdeba mxolod laboratoriuli cvlilebebiT.
hipoglikemiis simptomatika araspecifikuria, ris gamoc xSir
SemTxvevaSi Znelia misi diagnostika4;8;10;14;18.
hipoglikemiis ZiriTadi simptomebia:
• 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 8;19 • 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), 13;20;21 ar aris mizanSewonili prelaqtaciuri
glukozis xsnaris gamoyeneba, radgan igi dabalkaloriuli xsnaria da
Tavad SeiZleba gaxdes hipoglikemiis mizezi32.
• temperaturuli reJimis dacva ZuZuTi kvebasTan erTad
pipoglikemiis prevenciis saukeTeso gzaa (rekomendacia A)22
14
,31,32. • riskis jgufis axalSobilTa identifikacia da skriningi32.
Tu ver xorcieldeba ZuZuTi kveba saWiroa qalis gamowvelili rZis, an
xelovnuri formulis miwodeba. Tu SeuZlebelia peroraluri kveba
sicocxlis pirvelive saaTSi mizanSewonilia intravenuri infuzia.
A
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5. hipoglikemiis diagnozi
diagnostikuri kriteriumebi
hipoglikemiis simptomTa araspecifiurobis gamo, hipoglikemiis
diagnostikis dros iTavliswineben Whipple triadas2 • damaxasiaTebeli klinikuri suraTi;
• sisxlSi glukozis dabali Semcveloba;
• simptomebis gaqroba, rodesac glukozis Seyvanis Semdeg sisxlSi Saqris
Semcveloba miaRwevs normas.
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)23
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) 2;4;8;14;24,32;. 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) 4;14;24;2;8 .
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) 14
Tumca ukanasknel wlebSi Catarebuli kvlevis Sedegad miaCniaT,
rom riskis jufis axalSobilebma unda miiRon sakvebi sicocxlis I sT-
C
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is ganmavlobaSi da sisxlSi Saqris Semcveloba unda ganisazRvros
kvebidan 1 sT-Si (anu dabadebidan 2 sT-Si), araugvianes 4 sT-isa
(mtkicebulebis done IV) 4;10
Tu axalSobils aReniSneba hipoglikemia, risk-faqtorebis gareSe,
aucilebelia sefsisi gamoricxva.
7. mkurnaloba da monitoringi samkurnalo Careva saWiroa, Tu sisxlSi Saqris Semcveloba naklebia
2,0 mmol/l-ze (40 mg%).
mkurnalobis mizania SenarCundes sisxlSi Saqris donis 2,6 mmol/l da
meti (47mg%).24
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 erTxel4;14;24
. testireba SeiZleba
Sewydes Tu ganmeorebiTi II testirebis dros analiziT
miiRebuli monacemi metia 2,6-mmol/l-ze. (rekomenacia C)4;14;24.
• 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 erTxel1;4;14 testireba SeiZleba
Sewydes Tu analiziT miiRebuli monacemi metia 2,6-mmol/l-ze
ganmeorebiT II 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)4.
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.
C
C
IV
III
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Tu ver xorcieldeba ZuZuTi kveba saWiroa qalis gamowvelili rZis, 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:
_ hipoglikemiis klinikuri niSnebis arsebobisas, Tu
sisxlSi Saqris Semcveloba < 2,6 mmol/l-ze
(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)4;10;14;24 glukozis
bolusuri doza gulisxmobs glukozis 10 %-iani xsnars.
glukoza SehyavT nakaduri wesiT mcire moculobiT - 2 ml/kg-ze
3-5 wT ganmavlobaSi14;24.
• 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
mtkicebuleba25;26
_ 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-Si14;24.
_ 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
C
IV
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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.
• 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 27.
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).
axalSobilebSi maRali koncentraciis (25-50 %) xsnaris bolusuri
Seyvana ar aris mizanSewonili, radgan izrdeba Tavis tvinSi
sisxlCaqcevis ganviTarebis riski
11
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 28-30.
• 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 28-30
• 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
12
damatebiTi mkurnaloba persistiuli hipoglikemiis dros 28-30
• 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)
• 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)3;7.. dedis diabetis
SemTxvevaSi Catarebulma kvlevebma gviCvena, rom gaxangrZlivebuli
nevrologiuri dazianebebi vlindeba Tu axalSobilis sisxlSi
glukozis Semcveloba 1,6 mmol/l-ze naklebia.
II
II
IV
13
danarTi 1
skriningi
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
14
danarTi 2 riskis–jgufis axalSobilis marTva
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)
15
danarTi 3 riskis–jgufis axalSobili (glukoza <1,1mmol/l)
simptomuri axalSobili (glukoza <2,6 mmol/l-ze)
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)
16
8. gaidlainis gadasinjvisa da ganaxlebis vada – 4 weli
9. 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 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
17
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.
• 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
18
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
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
10. alternatiuli gaidlaini ar arsebobs
19
11. gamoyenebuli literatura
Reference List
1. Cornblath M. Neonatal Hypoglicemia 30 yares later:does it injure the brain? Historical suumory and present challenges. JPN.Acta Paediatr 1997;39:S7-S11.
2. Cornblath M,.Hawdon J. Contraversies regarding definition of neonatal hypoglycemia: suggested operational thresholds. Paediatrics 2000;105.
3. Plides R, Comblath M, Warren L. A prospective control study of neonatal hypoglycemia. Paediatrics 1975;54.
4. Fetus and newborn Comitttee, Canadian Paediatric Society, Paediatrics & child health. Screening guidelines for newborns at risk for low blood glucose. 2004;9:723-9.
5. Nicholl R. What is the normal range of blood glucose concentrations in healthy term newborns? Arc.Dis.Child 2003;88:238-9.
6. Srinivasam G, Pildes R, and a. Plasma glucose values in normal neonates; A new look. J.Paediatr 1986;109:114-7.
7. Koivistro M, BlancoЦSequeiros M, at a. Neonatal Symptomic and asymptomic hypoglicaemia. A follow up study of 151 children. Dev.Med.Child.Neurol. 1972;14:6003-14.
8. British Columbia reproductive healthcare program. Newborn guideline 5, Newborn hypoglycemia. 2003.
9. Cornblath M, Hawdon J, Williams A. Controversies regarding definition of neonatal hypoglycemia: Suggested operational thresholds. Pediatrics 2000;105:1141-5.
10. Larry E. Newbornm Hypoglicemia work group - Management of Neonatal hypoglycemia. Inermoutain.Health care 2004.
11. Kalhan S,.Parimi P.Gluconeogenesis in the fetus and neonate.Semin.Perinatol2000;24:94-106.
12. Hawdon J,.WardPlatt M. Petterns of metabolic adaptation for premature and term infants in the first neonatal week. Arch.Dis Child 1993;68:262-8.
13. Diwakar K,.Sasidhar M. Plasma glucose levels in term infants who are appropriate size for gestation and exclusively breast fed. Arch Dis Child Fetal Neonatal Ed 2002;87:F46-F48.
14. World Health Organization. Hypoglycaemia of the Newborn. Review of the Literature. 1997. 15. Anday E, Stanley C, Baker L, Delivori va-Papadopoulos M. Plasma ketones in newborn
infants: absence of suckling ketosis. Journal of Pediatrics98:628-30. 16. De Rooy L,.Hawdon J. Nutritional factors that affect the postnatal metabolic adaptation of
full-term small- and large-for-gestational-age infants. Pediatrics 2002;109:E42. 17. Swenne I, Edward U, Guastafsson J. Interrelationship between serum concentrations of
glucosae, glucagons and insulin during the first 2 days of life in healthy newborns. Acta Peadiatr. 1994;83:915-9.
18. British Columbia Reproductive Care Programme. Jaundice in the healthy term newborn, Newborn guideline 4. 1993.
19. Agrawal R, Lui K, Gupta J. Neonatal hypoglycaemia in infants of diabetic mothers. J Paediatr Child Health 2000;36:354-6.
20. Adejuyigbe E, Fasubaa O, Ajose O, Onayade A. Plasma glucose levels in exclusive breastfed newborns in the first 48 hours of life in Ile-Ife, Nigeria. Nitr.Health 2001;15:121-6.
21. Eidelman A.Hypoglycemia and the breastfed neonate.Acta paediatr 1997;39Suppl 1:S44-S47.
20
22. JBI. Management of asymptomatic hypoglycaemia in healthy term neonates for nurses and midwives. Best.Practice 2006;10.
23. Hussain K,.Sharief N. The inaccuracy of venous and capillary blood glucose measurement using reagent strips in the newborn period and the effect of haematocrit. Early Hum.Dev. 2000;57:111-21.
24. World Health Organization. A Guide for doctors, nurses and midwives. Managing.Newborn Problems. 2003.
25. Charsha D, McKinley P, Whitfield J. Glucagon infusion for treatment of hypoglycemia: Efficacy and safety in sick, preterm infants. Pediatrics 2003;111:220-1.
26. Miralles RE LAPMMAM. Experience with intravenous glucagon infusions as a treatment for resistant neonatal hypoglycemia. Arch Pediatr Adolesc Med 2002;156:999-1004.
27. Hemachandra A,.Cowett RM. Neonatal Hyperglycemia. Pediatrics in Review 1999;20:16-24. 28. Kahler S. Metabolic disorders associated with neonatal hypoglycemia. Journal
NeoReviews 2004;5:337. 29. Lonlay P. Persistent Hyperinsulinemic hypoglycemia.
Orphanet.encyclopedia.http://www.orpha.net./data/patho./GB/uk-PHHI.pdf. 2003. 30. McGowan J. Neonatal Hypoglycemia. Journal NeoReviews 1999;6-15. 31. JBI Management of asymptomatic hypoglycaemia in healthy term neonates for nurses and
midwives - - Best Practice - 2006, VL - 10 (1) 32. Newborn Care Manual - Newborn Care Unit, 23. 1/2005
12. avtorTa jgufi:
⇒ merab maWaraSvili _ neonatologi, m.SaraSiZis samedicino
centri generaluri direqtoris moadgile neonatologiasa da
pediatriaSi; pediatrTa da neonatologTa kavSiri
`alternativa~.
⇒ maia xerxeuliZe – medicinis doqtori, Tbilisis saxelmwifo
samedicino universitetis zogadi pediatriis departamentis
asistent-profesori; pediatrTa da neonatologTa kavSiri
`alternativa~.
⇒ nani yavlaSvili – medicinis doqtori, Tbilisis saxelmwifo
samedicino universitetis zogadi pediatriis departamentis
asistent-profesori; pediatrTa da neonatologTa kavSiri
`alternativa~.
eqsperti:
⇒ irakli favleniSvili – profesori, Tbilisis saxelmwifo
samedicino universitetis diplomis Semdgomi da uwyveti
samedicino ganaTlebis institutis direqtori
⇒ dimitri abelaSvili _ medicinis doqtori, Tssu
diplomisSemdgomi da uwyveti samedicino ganaTlebis
instituti; m.iaSvilis saxelobis bavSvTa centraluri
klinikuri saavadmyofos reanimaciisa da gadaudebeli
daxmarebis samsaxuris ufrosi, axalSobilTa reanimaciis
21
ganyofilebis gamge; pediatrTa da neonatologTa kavSiri
`alternativa~;
⇒ lela woworia _ saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis saministros janmrTelobis dacvis
departamenti;
⇒ Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis saministros janmrTelobis dacvis
departamenti.