1

axalSobilTa hipoglikemia

klinikuri praqtikis erovnuli rekomendacia

(gaidlaini)

2

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.

3

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.

II

II

II

IV

4

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

III

III

III

5

• 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.

6

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

7

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

C

III

A

II

A

II

IV

8

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

9

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

10

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.