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 II 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) II Catarebuli kvelevebis safuZvelze dadginda, rom sisxlSi glukozis Semcveloba 2,6 mmol/l-ze naklebi korelirebs adreul (mtkicebulebis done II), da mogvianebiT nevrologiur II dazianebebTan (mtkicebulebis done II), an neiroimijingis cvlilebebTan (mtkicebulebis done IV.). dedis diabetis IV 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.
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gaidlaini gankuTvnilia samedicino personalisaTvis, rogorc samSobiaro saxlSi, pediatri.

romelic muSaobs axalSobilTan, ise stacionarSi neonatologi,

gaidlainis samizne jgufi: axalSobilebi, romlebsac aReniSnebaT hipoglikemiis ganviTarebis riski. 2. epidemiol ogia

hipoglikemia

an

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 III done III) . gestaciur asakTan SedarebiT mcire masis axalSobili (< 10 centilze); mtkicebulebis done III). III gestaciur asakTan SedarebiT didi masis axalSobili (> 90 centilze); mtkicebulebis done III). 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

 bekvit-videmanis sindromi (damaxasiTebeli makroglosia, visceromegalia)

triada:

Wipis

Tiaqari,

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, glikogenezi s 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 :

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) 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 diagnozi diagnostikuri kriteriumebi hipoglikemiis 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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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 ,32; (rekomendacia A) . 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) .

III

A II II A C

ar arsebobs kvlevebi, romelic mtkicebulbebze dayrdnobiT daadasturebs riskis jgufis axalSobilebSi pirveli skriningis IV 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 IV 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 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%). riskis jgufi, hipoglikemiis simptomebis gareSe (1,1 mmol/l < glukoz a < 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 C 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 C 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 III 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 C
6

(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 IV 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/lze gadasxma grZeldeba sanam Saqris done ar iqneba 2,6 mmol/lze. 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/dReSiiT. yoveli Semcirebis win isazRvreba Saqris Semcveloba. glukozis infuziis Sewyvetis Semdeg Saqris donis gansazRvra meordeba 12 sT-Si erTxel 24 sTis 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. axalSobilebSi maRali koncentraciis (25-50 %) xsnaris bolusuri Seyvana ar aris mizanSewonili, radgan izrdeba Tavis tvinSi sisxlCaqcevis ganviTarebis riski

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 koncentr aciis 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 .

Tandayolili hiperinsulinizmi (autosomur 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

dominanturi

an

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)

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.

II II IV

10

danarTi 1 skriningi janmrTeli drouli axalSobli riskis jgufis axalSobli axalSobli, hipoglikemiis klinikuri niSnebiT

ar saWiroebs skrinings

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

Saqris done unda ganisazRvros dauyovnebliv

11

danarTi 2 riskisjgufis 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 _ 1,1-1,8 mmol/l

glukoza < 1,1 mmol/l

xSiri ZuZuTi kveba ganmeorebiTi skriningi 3-6 sT-Si erTxel skriningi wydeba, Tu 2 testirebisas monacemi > 2,6 mmol/l-ze

kveba
ganmeorebiTi skriningi kvebidan 1 sT-Si

kveba
infuzuri Terapia glukozis 10%, 4-8 mg/kg/wT) skriningi 30 wT-Si

ix. hipoglikemiis klinikuri niSnebis mqone axalSobilis marTva

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)

12

danarTi 3 riskisjgufis 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 > 2,6 mmol/l

glukoza 1,1 - 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/dReSiiT yoveli Semcirebis win isazRvreba Saqris Semcveloba

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

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

skriningi 30 wT-Si glukoza < 1,1 mmol/l

infuziis Sewyvetis Semdeg skriningi meordeba 12 sT-Si erTxel 24 sT-is ganmavlobaSi

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) _

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

13

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 monacemTa bazis gamoyenebiT. xorcieldeboda eleqtronuli

cxrili 2 qveyana da dasaxeleba aSS US National Clearinghouse (NGC) Guideline http://www.guideline.gov http://www.phppo.cdc.gov/CDCRecommends/Adv SearchV.asp http://www.ahrq.gov/clinic/cpgsix.htm http://hstat.nlm.nih.gov resursis internet-misamarTi

Centers for Disease Control and Prevention (CDC) Agency for Healthcare Research and Quality (AHRQ) Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM) Institute of Clinical Improvement (ICSI) Systems

http://www.icsi.org http://www.ama-assn.org http://mdm.ca/cpgsnew/cpgs/index.asp http://www.hc-sc.gc.ca/pphb-dgspsp/dpg_e.html

American Medical Association Canadian (CMA) Medical Association

Health Canada Population and Public Health Branch (PPHB) didi britaneTi

14

National Institute for Clinical Excellence (NICE) Sheffield Effectiveness (SEEK) Evidence for and Knowledge

http://www.nice.org.uk http://www.shef.ac.uk/seek/guidelines.htm

National electronic Library for Health (NeLH) PRODIGY Clinical Guidance Scottish Intercollegiate Guidelines Network (SIGN) German Guideline Service (GERGIS) avstralia Australian National Health and Medical Research Council (NHMRC) axali zelandia New Zealand Guidelines Group (NZGG) mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba klinikuri rekomendaciebis wyaroebi da meTodebi Information

http://www.nelh.nhs.uk/guidelinesfinder http://www.prodigy.nhs.uk/ClinicalGuidance http://www.sign.ac.uk http://www.leitlinien.de/english/english/view;

http://www.health.gov.au/hfs/nhmrc/publicat/cphome.htm http://www.nzgg.org.nz/library.cfm http://www.osdm.org

da

mtkicebulebebis

moZiebis

damatebiTi

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 metaanalizi, 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 (94,9698). 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) Zlieri mtkicebuleba, eyrdnoba minimum erT sistemur mimoxilvas, romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvleva Zlieri mtkicebuleba, eyrdnoba minimum erTi swori dizainis mqone randomizebul kontrolirebad kvleva klinikuri kvleva xarisx i A rekomendaciis xarisxi (Cook et al) eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia

II

eyrdnoba II donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia eyrdnoba III donis

16

III

IV Va Vb

randomizaciis gareSe, kohortuli da SemTxvevakontrolis kvlevebi araeqsperimentuli multicentruli kvlevebi avtoritetul profesionalTa mosazreba klinikuri gamocdileba, aRwerilobiTi kvlevebi an eqspertTa angariSi

mtkicebulebas SeiZleba CaiTvalos Sesabamisad D eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss

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 socialuri dacvis saministro. Sromis, janmrTelobisa da

17