1

perinataluri asfiqsia /

hipoqsiur-iSemiuri

encefalopaTia

klinikuri praqtikis erovnuli rekomendacia

(gaidlaini)

2

klinikuri praqtikis erovnuli rekomendacia (gaidlaini)

`perinataluri asfiqsia / hipoqsiur-iSemiuri encefalopaTia~

miRebulia klinikuri praqtikis erovnuli rekomendaciebis

(gaidlainebi) da daavadebaTa marTvis saxelmwifo standartebis

(protokolebi) SemuSavebis, Sefasebis da danergvis erovnuli

sabWos 2008 wlis 5 noembris #1 sxdomaze da damtkicebulia

saqarTvelos Sromis, janmrTelobisa da socialuri dacvis

ministris 2009 wlis 14 aprilis # 142/o brZanebiT.

3

perinataluri asfiqsia / hipoqsiur-iSemiuri encefalopaTia

1. definicia, sinonimebi, terminologia1-9:

definicia

perinataluri asfiqsia mdgomareobaa, romelic viTardeba ante, intra an

postnatalur periodSi Jangbadis miwodebis darRvevis gamo da xasiaTdeba

bradikardiiT, airTa cvlis darRveviT da organoebis araadekvaturi

perfuziiT.

hipoqsiur–iSemiuri encefalopaTia (hie) Jangbadis araadekvaturi miwodebis

gamo cns (Tavis da zurgis tvini) ujredebis dazianebaa, romelic vlindeba

sunTqvis problemebiT, tonusisa da refleqsebis daqveiTebiT, cnobierebis

darRveviT, gulyriT. hie-m SeiZleba gamoiwvios sikvdili neonatalur

periodSi, mogvianebiT ki – ganviTarebis globaluri Seferxeba, mentaluri

retardacia, cerebruli dambla10,11. hie-s diagnostikisaTvis saWiroa sami

komponentis arseboba: darRvevebi orsulobis da mSobiarobis periodSi,

adreul postnatalur periodSi klinikurad gamovlenili nevrologiuri

darRvevebi da sicocxlis pirvelive dReebSi arsebuli sistemuri

cvlilebebi.

neonataluri depresia mdgomareobaa, romelic vlindeba mxolod sicocxlis

pirveli saaTis ganmavlobaSi axalSobilis daTrgunviT da ar aris

dakavSirebuli prenatalur paTologiasTan. igi ar moiTxovs laboratoriul

da instrumentul kvlevebs.

sinonimebi - perinataluri hipoqsia, iSemia, asfiqsia, axalSobilTa asfiqsia,

dabadebis asfiqsia.

gamoyenebuli Semoklebebi

hie – hipoqsiur iSemiuri encefalopaTia

gaidlaini gankuTvnilia

⇒ samedicino personalisaTvis, romelic muSaobs axalSobilTan, rogorc

samSobiaro saxlSi, ise stacionarSi – neonatologi, mean-ginekologi,

ojaxis eqimi, pediatri.

gaidlainis samizne jgufi:

⇒ axalSobilebi, romlebsac aReniSnebaT perinataluri asfiqsia an misi

ganviTarebis riski.

4

2. epidemiologia

perinataluri asfiqsia/hipoqsiur-iSemiuri encefalopaTia (hie) axalSobilTa

sikvdilobisa da avadobis erT-erT seriozul mizezad rCeba.

perinataluri asfiqsiis sixSire gestaciis 28 kviraze daaxloebiT 30%,

droul axalSobilebSi 20% Seadgens13. aSS-s janmrTelobis statistikis

nacionaluri centris monacemebiT axalSobilTa asfiqsiiT gamowveuli

sikvdiloba 14,4-ia yovel 100 000 cocxladSobilze. janmos monacemebiT

msoflioSi asfiqsiiT 1 mln bavSvi iRupeba14.

sxvadasxva qveynis monacemebiT mZime hipoqsiur iSemiuri encefalopaTiis

sixSire Seadgens 2-9 SemTxvevas yovel 1000 cocxladSobilze15,16.

mZime hie-s dros sikvdiloba 50-75%-ia, maT Soris yvelaze maRalia

neonataluri sikvdiloba, romelic gamowveulia multiorganuli dazianebiT.

hie-s iwvevs mentaluri retardaciis, epilefsiis, sxvadasxva xarisxis

cerebruli damblis ganviTarebas. mZime hie-s dros zemoT aRniSnuli

paTologia gvxvdeba SemTxvevaTa 90-100%, saSualo simZimis hie-s dros ki - 30-

50%17, msubuqi hie-s dros seriozuli nevrologiuri garTulebebi SeiZleba

ar ganviTardes. im SemTxvevebSic ki Tu ar aRiniSneba Tavis tvinis aSkara

dazianeba 15-20%-Si SeiZleba aRiniSnos saskolo asakis bavSvebSi swavlis

siZneleebi.

3. etiopaTogenezi1-9,18,19

asfiqsiis/hie-s risk-faqtorebia:

antenataluri:

• saSvilosnosSiga zrdis Seferxeba;

• mZime preeklamfsia;

• vadagadacileba;

• placentis paTologia;

• dedis virusuli da baqteriuli infeqciebi;

• sisxldena orsulobisas;

• dedis farisebri jirkvlis da gul-sisxlZarRvTa paTologia.

risk-faqtorebs miekuTvneba aseve: socialur_ekonomikuri statusi, gulyris

an nevrologiuri daavadebis ojaxuri anamnezi, dafexmZimeba uSvilobis gamo

mkurnalobis Semdeg.

intranataluri:

• persistuli oqcipitoposteriuli pozicia;

• maRali temperatura mSobiarobis dros;

• saswrafo sakeisro kveTa;

• placentis gagleja;

• swrafi vaginaluri mSobiaroba;

• mwvave intranataluri mdgomareobebi: Wiplaris kompresia, prolapsi

da a.S.

5

neonataluri

• araadekvaturi reanimacia;

• pirveladi adaptaciis darRveva.

paTfiziologia:

hipoqsiur-iSemiuri encefalopaTia ganpirobebulia Tavis tvinis hipoqsiiTa da

iSemiiT, rasac mosdevs neironebis dazianeba. hipoqsiis/asfiqsiis dasawyisSi

viTardeba kompensatoruli reaqcia _ adrenalinis hiperproduqcia, sisxlis

wnevis da cerebruli sisxlis nakadis gazrda (sisxlis mimoqcevis

centralizacia), rac ganapirobebs Tavis tvinis perfuziis SenarCunebas.

adreuli kompensaciuri meqanizmebis amowurvis Semdeg, qveiTdeba sisxlis

wneva, mcirdeba cerebruli sisxlis nakadi, viTardeba hipoqsemia, rac iwvevs

ujredSiga energetikul ukmarisobas. dazianebis adreul etapze Tavis tvinis

temperatura qveiTdeba, gamoTavisufldeba neirogadamtani γ-aminoerbos mJava, rac amcirebs cerebruli oqsigenaciis moTxovnilebas da Sesabamisad

tranzitorulad amcirebs asfiqsiis damzianebel efeqts.

asfiqsiis sawyisi fazis Semdeg cerebruli metabolizmi SeiZleba aRdges,

Tumca gauareseba viTardeba reperfuziis dros anu meorad fazaSi, romelic

iwyeba sawyisi dazianebidan 6-24 sT-Si, xasiaTdeba tvinis SeSupebiT da

apoptoziT (ujredebis programirebuli sikvdili). am fazas ewodeba –

neironebis dazianebis mogvianebiTi faza. misi xangrZlivoba ar aris zustad

cnobili, magram miCneulia rom is grZeldeba 24-48 sT, Semdeg ki iwyeba

aRdgena.

4. klinikuri simptomatika1-9,19:

amerikis pediatriis akademiis (AAP) da amerikis meanobisa da ginekologiis

kolejis (ACOG) gaidlainis Tanaxmad perinataluri asfiqsiis ZiriTadi

kriteriumebia13:

• Rrma metaboluri an Sereuli acidozi, Wiplaris arteriaSi pH < 7,00

fuZeTaQdeficiti > 12 mmol/l • apgaris dabali qulebis (0-3) persistireba 5 wuTze met xans

• klinikurad nevrologiuri darRvevebi (gulyra, hipotonia, koma)

• adreul neonatalur periodSi poliorganuli sistemuri disfunqcia

(Tirkmlis, RviZlis, sasunTqi, gul-sisxlZarRvTa da kuW-nawlvis

traqtis dazianeba)

Tu aRniSnuli maxasiaTeblebi ar aris gamoxatuli, SeuZlebelia asfiqsiis

arsebobaze saubari. maRali apgaris qula > 6 gamoricxavs intranataluri

asfiqsiis arsebobas12.

asfiqsiis diagnostika mxolod apgaris qulebis mixedviT ar aris

gamarTlebuli. sicocxlis me-5 wT-ze apgaris qula 3 an naklebi SeiZleba

6

miuTiTebdes asfiqsiis arsebobaze mxolod sxva diagnostikur

kriteriumebTan erTad.

apgaris dabali qulebi hipoqsiis garda SesaZlebelia mTeli rigi

faqtorebiT iyos ganpirobebuli. mocemuli faqtorebia13:

• dRenakluloba da gestaciur asakTan SedarebiT mcire wona - am

axalSobilebs axasiaTebT hipotonia, akrocianozi, nevrologiuri

reaqciisa da refleqsebis daTrgunva. aqedan gamomdinare apgaris

maqsimaluri qula SeiZleba iyos 6-7. gestaciis 30 kviramde dabadebul

dRenaklulebSi apgaris qula SeiZleba 2-3 iyos asfiqsiis gareSec;

• dedasTan gamoyenebuli medikamentebi - dedis anesTeziisa da analgeziis

gamo ganviTarebuli depresia;

• infeqcia;

• nerv-kunTovani darRvevebi;

• gul-sisxlZarRvTa Tandayolili mankebi.

Tu apgaris qula 0-3-ia sicocxlis me-15 wuTze bavSvTa cerebruli damblis

ganviTarebis sixSire 10%-s, xolo Tu me-20 wuTze - 60%_s Seadgens.

klasifikacia:

msubuqi Hhie:

- sicocxlis pirvel dReebSi mcired momatebuli kunTTa tonusi da

cocxali Rrma myesTa refleqsebi;

- axalSobili agznebulia, moros da tacebis refleqsi gaZlierebulia.

cnobierebis daTrgunva iSviaTia, SeiZleba gamovlindes Zilianoba.

aRiniSneba gardamavali qceviTi anomaliebi, rogoricaa kvebasTan

dakavSirebuli problemebi;

- dabadebidan 3-4 dRisaTvis cns-is statusi SeiZleba iyos normaluri.

sicocxlis pirvel saaTebSi simptomebis ararsebobas an msubuqi hies

SeiZleba mohyves uecari gauareseba, romelic miuTiTebs Tavis tvinis

ujredebis mimdinare disfunqciaze, dazianebasa da sikvdilze.

saSualo simZimis hie:

- vlindeba leTargia, mniSvnelovani hipotonia, daqveiTebuli Rrma

myesTa refleqsebi;

- tacebis, moros, wovis refleqsebi daTrgunulia an ar iwveva;

- sicocxlis pirvel 24 sT-Si SeiZleba gamovlindes gulyra;

- 1-2 kviraSi SesaZlebelia sruli gamojanmrTeleba, rac

asocirebulia ukeTes gamosavalTan momavalSi.

mZime hie:

- vlindeba koma an stupori;

- sunTqva SiZleba iyos araregularuli, axalSobils xSirad

esaWiroeba damxmare ventilacia;

7

- damaxasiaTebelia generalizebuli hipotonia da daTrgunuli Rrma

myesTa refleqsebi;

- wovis, ylapvis, tacebis, moros refleqsebi ar iwveva;

- Tavis tvinis nervebis gamokvlevis dros SeiZleba gamovlindes

Tvalebis asimetriuli deviacia, nistagmi, “Tojinis Tvalebi”;

- Tvalis gugebi SeiZleba iyos gafarToebuli, Suqze reaqcia

daqveiTebuli;

- gulyra vlindeba adreul etapze da dasawyisSi SeiZleba

rezistentuli iyos tradiciul mkurnalobaze. igi ZiriTadad

generalizebuli xasiaTisaa. dazianebis progresirebasTan erTad

gulyra praqtikulad ar vlindeba da eeg xdeba izoeleqtruli an

gviCvenebs mkveTri supresiis niSnebs. am periodisaTvis progresirebs

tvinis SeSupeba da gamoixateba yiflibandis daWimva;

- damaxasiaTebelia araregularuli guliscemis sixSire da arteriuli

wnevis maCveneblebis cvalebadoba.

mZime hie-s dros maRalia adreuli neonataluri sikvdilobis maCvenebeli.

axalSobilebSi, romlebic gadarCebian:

- cnobierebis done umjobesdeba me-4-5 dRisaTvis;

- hipotonia da kvebiTi problemebi persistirebs, zondiT kveba SeiZleba

gaxangrZlivdes ramdenime Tve.

hies Tan axlavs Semdegi multiorganuli dazianebebi

⇒ sasunTqi sistema: pulmonuri hipertenzia, surfaqtantis meoradi deficiti,

mekoniumis aspiracia, filtvidan sisxldena, filtvis SeSupeba.

⇒ saSarde sistema: mwvave tubuluri da kortikaluri nekrozi, oliguria,

renuli ukmarisoba.

⇒ kardiovaskuluri sistema: Ria arteriuli sadinari, miokardiumis

dazianeba, hipotenzia, Soki, gulis SegubebiTi ukmarisoba, samkariani

sarqvlis ukmarisoba.

⇒ metaboluri: acidozi, hipoglikemia, hipokalciemia, hiponatriemia,

hiperamonemia, hiperkalemia.

⇒ gastrointestinuri sistema: nekrozuli enterokoliti, stresuli wyluli.

ZiriTadad damaxasiaTebelia peristaltikis daqveiTeba da kuWis evakuaciis

Seferxeba.

⇒ RviZlis disfunqcia: iSemia azianebs RviZlis sinTezur, eqskretorul da

detoqsikaciur funqciebs. vlindeba transaminazebis donis mateba, sisxlis

Semadedebeli faqtorebis sinTezis Semcireba, proTrombinis da

aqtivirebuli parcialuri Tromboplastinis drois gaxangrZliveba, rac

klinikurad asocirebulia sisxldenebTan.

⇒ hematologiuri: Trombocitopenia, hemolizi, Zvlis tvinis depresia,

sisxlZarRvTaSida Sededebis sindromi.

8

5. daavadebis diagnozi

hie-s diagozi damyarebulia anamnezze, obieqtur da nevrologiur

gamokvlevebze. ar arsebobs specifiuri testi romelic yovelTvis

daadasturebs an uaryofs hie-s.

perinataluri asfiqsiis damadasturebeli maxasiaTeblebia9,13:

• Rrma metaboluri an Sereuli acidozi;

• Wiplaris arteriaSi pH < 7,00 fuZeTaQdeficiti > 12 mmol/l; • apgaris dabali qulebis (0-3) persistireba 5 wuTze met xans;

• klinikurad arakeTilsaimedo nevrologiuri darRvevebi, rogoricaa

gulyra, hipotonia, koma an hie;

• adreul neonatalur periodSi poliorganuli sistemuri

disfunqcia.

Tu aRniSnuli maxasiaTeblebi ar aris gamoxatuli, SeuZlebelia asfiqsiis

arsebobaze saubari.

h. sarnatisa da m. sarnatis mier 1976 wels mowodebulia hie-s

xarisxobrivi klasifikacia. es sqema saukeTesoa hie-is gamosavlis

prognozirebisaTvis (mtkicebulebis done I)20.

neonataluri hipoqsiur-iSemiuri encefalopaTiis klasifikacia

niSnebi msubuqi (I x.) saSualo (II x.) mZime (III x.)

cnobierebis

done

agznebadoba leTargia stupori, koma

nerv-kunTovani

kontroli

• kunTTa

tonusi

norma msubuqi

hipotonia

daqveiTeba

• poza norma fleqsia aramyari

decerebracia

• Rrma

refleqsebi

gacxovelebuli

gacxovelebuli

ar iwveva

• miokloniebi aris aris ar aris

rTuli

refleqsebi

• wova susti susti an ar

aris

ar aris

• moro cocxali

susti

ar aris

• okulo-

vestibuluri

norma

gacxovelebuli

susti an ar aris

• kisris

tonur

susti cocxali ar aris

• autonomiuri

funqciebi

simpatikotonia

parasimpatikoto

nia

orive

daTrgunulia

I

9

• gugebi midriazi

miozi

araTanabari,

susti reaqciiT

sinaTleze

• guliscema taqikardia bradikardia cvalebadi

• bronquli

sekreti

mwiri Warbi

cvalebadi

• nawlavTa

peristaltika

norma an

daqveiTebuli

momatebuli,

diarea

cvalebadi

• gulyrebi ar aris xSiria decerebracia

• eeg

normaluri dabali voltaJi,

romelsac

erTveba

iqtaluri

aqtivoba

Caqroba-

aRmocenebis

paterni

izoxazamde

vardniT

xangrZlivoba <24 sT 24 sT-dan 14

dRemde

dReebi, kvirebi

gamosavali kargi sxvadasxva letaloba an mZime

deficiti

janmrTelobis msoflio organizaciis mier mowodebulia hie-s Sefasebis da

klasifikaciis martivi sqema31

niSani I stadia

(msubuqi)

II stadia

(saS. simZimis)

III stadia

(mZime)

cnobiereba momatebuli agznebadoba

daTrgunva koma

kunTTa tonusi umniSvnelod darRveuli

zomierad daRveuli

mkveTrad darRveuli

wovis refleqsi norma an umniSvnelod daTrgunuli

daTrgunuli ar iwveva

fiziologiuri

refleqsebi

gacxovelebuli daTrgunuli ar iwveva

gulyra ar aris gamoxatuli gamoxatuli

Rerovani

refleqsebi

norma norma darRveuli

sunTqva taqipnoe perioduli apnoe mZime apnoe

* Sesabamisi stadiis encefalopaTiis diagnostikisaTvis aucilebelia

gamoxatuli iyos didi asoebiT da muqad gamoyofili niSnebidan 1 mainc.

diferenciuli diagnozi

diferenciuli diagnozi unda gatardes iseT daavadebebTan,

rogoricaa:

• meningoencefaliti;

• cns malformaciebi;

10

• metabolizmis Tnadayolili darRvevebi;

• samSobiaro travmebi;

• nerv-kunTovani daavadebebi;

• dedis mier medikamentebis gamoyeneba;

• neonataluri depresia.

6. gamokvlevis sqema5,6,8,9,19

neirogamosaxviTi kvlevebi

rutinuli neorogamosaxviTi kvlevebi yovelTvis ar miuTiTebs dazianebaze,

kvlevis normaluri Sedegi ar gamoricxavs hie-s arsebobas.

• kraniuli ultrasonografiuli gamokvleva: SeiZleba gamovlindes

intracerebruli da intraventrikuluri hemoragia. tvinis SeSupebis

dros aRiniSneba parkuWebis zomis Semcireba. hie-s dros mxolod

ultrasonografiuli kvleva arainformatiulia. diagnostikurad

mniSvnelovania dopleruli ultrasonografia, kerZod – arteriebis

rezistentobis indeqsis gansazRvra. gamosavali arakeTilsaimedoa, Tu

maCvenebeli < 0,5-0,6_ze.

gestaciis 30 kviramde dabadebul axalSobilebs yvela SemTxvevaSi

unda CautardeT ultrasonografiuli kvleva (rekomendacia B)31. kvlevis Catarebis saukeTeso periods miekuTvneba sicocxlis me-7-

14 dRe.

• kompiuteruli tomografia gansakuTrebiT mniSvnelovania tvinis

SeSupebis da hemoragiis diagnostirebisaTvis. SeiZleba iyos gverdiTi

parkuWebis daviwroeba, Rarebis da xveulebis gasadaveba. Semcirebuli

simkvrivis areebi miuTiTebs infarqtis zonebis arsebobaze.

intraventrikuluri hemoragia iSviaTia droul axalSobilebSi.

kompiuteruli tomografiiT SesaZlebelia ukana fosos hemoragiis

gamovlena, rac ar vlindeba sonografiiT.

• magnitur rezonansuli gamokvleva - mniSvnelovania saSualo da mZime

hie-s diagnostikaSi. GgansakuTrebiT mielinizaciis statusis, ruxi-

TeTri nivTierebis dazianebis xarisxis, Tavis tvinis ganviTarebis

defeqtebis da Semdgomi nevrologiuri gamosavlis dasadgenad.

misi Catareba mizanSewonilia sicocxlis me-2-8 dRes droul

axalSobilebSi (rekomendacia A). kvleva mniSvnelovania

dinamikaSi monitoringisaTvis.

sxva testebi:

• amplitude_integrirebadi eleqtroencefalograma (aEEG) –kvlevebiT

dadginda, rom dabadebidan ramdenime saaTSi warmoebuli erT arxiani

aEEG Tavis tvinis dazianebis da hie-s Sefasebis efeqturi saSualebaa.

normaluri aEEG ar gamoricxavs Tavis tvinis dazianebis arsebobis SesaZleblobas, maSin roca aEEG-ze mZime an saSualo dazianebis

maCvenebeli miuTiTebs Tavis tvinis dazianebasaE da arakeTilsaimedo

gamosavalze. paTologiad miCneulia amplitudis farTo meryeoba

B

A

11

bazisuri voltaJiT nulis axlos da pikuri amplitudiT 5-is qvemoT.

aEEG -Ti SeiZleba aseveKkrunCxvebis diagnostikac.

• standartuli eeg: gamoiyeneba rekomendebulia axalSobilis zogadi

mdgomareobis stabilizaciis Semdeg. mravalarxiani eeg kvleva

utardeba yvela axlSobils saeWvo krunCxvebiT da hie-iT. is

mniSvnelovania krunCxvis dros dazianebis lokalizaciisa da

simZimis Sesafaseblad. ase rom, aSkara klinikuri krunCxvebis ar

arsebobis drosac ki tradiciuli eeg unda Catardes daavadebis

adreul stadiaze gansakuTrebiT saSualo da mZime SemTxvevebSi.

subklinikuri krunCxva, romlebic vlindeba mxolod eeg-ze, iwvevs

Tavis tvinis dazianebas. axalSobilebSi, romlebic imyofebian

damxmare ventilaciaze, miorelaqsantebis da sedatiuri saSualebebis

gamoyenebam SeiZleba SeniRbos adreuli krunCxvebis simptomebi.

antikonvulsiuri Terapiis didi dozebic cvlis eeg-s monacemebs.

ganmeorebiTi eeg aucilebelia cvlilebebis dinamikis Sesafaseblad.

misi Catareba mizanSewonilia gaweris win. pirvel kviraSi klinikur

mdgomareobasTan erTad eeg-ze gaumjobeseba, dadebiTi prognozuli

maCvenebelia.

• specialuri sensoruli gamokvleva: smenis skriningi.

• retinuli da ofTalmologiuri gamokvleva.

laboratoriuli gamokvlevebi:

Tavis tvinis dazianebis simZimis Sesafaseblad da organoTa funqciuri

statusis monitorirebisaTvis mravali testia mowodebuli.

• mJava tutovani wonasworobis gansazRvra;

• Sratis eleqtrolitebi: mZime hie-s dros mniSvnelovania Sratis

eleqtrolitebis yoveldRiuri Sefaseba mdgomareobis gaumjobesebamde.

mniSvnelovnad daqveiTebulia natriumis, kaliumis, qloridebis done.

diurezis Semcireba da wonis Warbi namati SeiZleba miuTiTebdes mwvave

tubulur dazianebasa an antidiurezuli hormonis araadekvatur

sekreciaze;

• renuli funqciis Seswavla: Sratis kreatinini, kreatininis klirensi da

Sardovana;

• kardiuli da RviZlis enzimebis done Seesabameba hie-s simZimis xarisxs.

sxva mniSvnelovani gamokvlevebi:

• sisxlis airebi

• sisxlis saerTo analizi TrombocitebiT

• proTrombinis dro, parcialuri Tromboplastinis dro

• sisxlis bioqimiuri kveleva (glukoza, kalciumi, magniumi,

osmolaroba)

• Sardis osmolaroba, saerTo analizi

• RviZlis funqciebi, pirdapiri da saerTo bilirubini

• liqvoris gamokvleva

• ekg, eqokardioskopia

12

7. mkurnalobis sqema5,6,8,9,19

dabadebisTanave aucilebelia adekvaturi reanimaciis Catareba (ix. gaidlaini

- axalSobilTa reanimacia samSobiaro blokSi).

krunCxvis SemTxvevaSi SesaZlebelia mniSvnelovnad daziandes organizmis

sxvadasxva funqcia, ris gamoc xSir SemTxvevaSi axalSobili saWiroebs

ventilacias, oqsigenacias, sisxlis wnevis stabilizacias. gulyra SeiZleba

moixsnas fenobarbitaliT an lorazepamiT. mocemuli preparatebi warmodgens

I rigis antikonvulsantebs. fenitoini gamoiyeneba, Tu aRniSnuli

medikamentebi uefeqtoa.

medikamenturi Terapia

• fenobarbitali

Cveneba _ klinikuri an subklinikuri gulyra, romelic vlindeba eeg-ze;

mkurnalobis kursis xangrZlivoba damokidebulia klinikur statusze

da eeg-s monacemebze,Uumetes SemTxvevaSi SeiZleba Sewydes sicocxlis

pirvel Tveze. Tu nevrologiuri darRvevebi an eeg-ze cvlilebebi

persistirebs, mkurnaloba grZeldeba ramdenime Tvidan erT wlamde. eeg

da klinikuri statusi aris mkurnalobis kursis da xangrZlivobis

ganmsazRvreli.

doza _ sawyisi doza 20 mg/kg, preparati SeyavT venaSi 10-15 wT-is

ganmavlobaSi (infuzomatiT), refraqterul SemTxevebSi SeiZleba

damatebiTi dozis Seyvana - 5-10 mg/kg-ze. SemanarCunebeli dozaa 3-5

mg/kg/dReSi, SemanarCunebeli dozis Seyvana xdeba sawyisi dozis

Seyvanidan 12-24 sT-is Semdeg, dReSi 2-jer 12 saaTis intervaliT, Seyvanis

gzaa peroraluri, intravenuri, intramuskuluri an reqtaluri.

sifrTxilis zomebi:

- saWiroa wnevisa da respiraciis kontroli, SeiZleba ganviTardes

respiraciuli distresi da saWiro gaxdes damxmare ventilacia.

- axlSobilSi pirveli 1-2 kviris ganmavlobaSi gaxangrZlivebulia prepartis

naxevrad daSlis periodi, rasac SeiZleba moyves wamlis akumulacia,

amitom mizanSewonilia SratSi preparatis koncentraciis (N-15-30 mkg/ml)

monitoringi da SemanarCunebeli dozis Sesworeba.

• lorazepami

Cveneba - gamoiyeneba fenobarbitalze refraqteruli krunCxvis dros.

doza _ erTjeradi dozaa 0.05-0.1 mg/kg venaSi neli nakadiT, doza meordeba

klinikuri mdgomareobis mixedviT.

sifrTxilis zomebi: dRenakl axalSoblebSi, romlebic iReben lorazepams

sedaciisaTvis, SeiZleba gamoiwvios respiratoruli depresia da

riTmuli miokloniebi.

13

• fenitoini

Cveneba- gamoyeneba fenobarbitalze da lorazepamze refraqteruli krunCxvis

SemTxevaSi. sococxlis pirveli Tveebis ganmavlobaSi Ppreparatis

oraluri gamoyenebisas Sewova umniSvneloa.

doza _ sawyisi doza 15-20 mg/kg. Seyvana xdeba infuzomatiT minimum 30 wT-is

ganmavlobaSi, SemanarCunebeli dozaa 4-8 mg/kg 24 sT_Si erTxel venaSi

neli nakadiT, infuzis siCqare ar unda aRematebodes 0.5 mg/kg/wT;

preparatis ganzaveba xdeba fiziologiur xsnarSi. fenitoinis

intravenuri Seyvanis win da Semdeg mizanSewonilia kaTeteris Carecxva

0.9% NaCL-iT.

sifrTxilis zomebi: sasurvelia SratSi fenitoinis koncentraciis (N- 6-15 mcg/ml) monitoringi, aucilebelia aseve bradikardiis, ariTmiis da

hipotenziis monitoringi infuziis ganmavlobaSi; medikamenti aramdgradia

IV xnarebSi, ar aris mizanSewonili misi Seyvana centraluri venaSi,

daleqvis riskis gamo. SeuTavsebelia glukozis, deqstrozis da

aminomJavebis, lipidebis xsnarebTan, bevr antibiotikTan, heparinTan,

insulinTan. medikamentis sisxlZarRvidan gaJonvam SeiZleba gamoiwvios

mZime lokaluri nekrozi.

L

• diazepami

Cveneba – gamoiyeneba mxolod im SemTxvevaSi, Tu fenobarbitali da fenitoini

ar aris xelmisawvdomi.

doza – erTjeradi dozaa 0,1-0,3 mg/kg venaSi nela, efeqtis ar arsebobisas

ganmeorebiTi Seyvana xdeba 15-30 wuTSi an iwyeba mudmivi infuzia 0,3

mg/kg/sT.

sifrTxilis zomebi: ar aris rekomendebuli diazepamis fenobarbitalTan

gamoyeneba erTad, radgan maRalia cirkulaciuri kolafsisa da sunTqvis

gaCerebis ganviTarebis riski.

damxmare Terapiis sxva aspeqtebi

saWiroa:

• adekvaturi ventilaciis, perfuziis da metaboluri statusis

SenarCuneba;

• hipoqsiis, hiperkapniis, hipokapniis prevencia;

• sisxlis gazebis da mJava–tutovani wonasworobis SenarCuneba

fiziologiur sazRvrebSi;

• sisxlis wnevis monitoringi da stabilizacia. vazopresorebis da

inotropuli agentebis, mocirkulire sisxlis moculobis

Semavseblebis gamoyenebiT;

• centraluri Ht – 40-45% maCveneblis SenarCuneba;

• siTxis da glukozis homeostazis SenarCuneba;

14

• pirveli ori dRis ganmavlobaSi intravenuri siTxis infuziis

SezRudva gestaciuri asakis mixedviT sadReRamiso siTxis

moTxovnilebis 2/3-mde;

• siTxiT da eleqtrolitebiT Terapia individualurad klinikuri

statusis, wonis cvlilebis, Sardis gamoyofis, Sratis

eleqtrolitebis da renaluri funqciis gaTvaliswinebiT.

axalSobilis mdgomareobis gaumjobesebisas (Sardis gamoyofa

izrdeba) saWiroa siTxis miwodebis koreqcia.

• hipoTermia mkurnalobis axali meTodia. is gamoiyeneba msubuqi da

saSualo simZimis hie-s SemTxvevebSi. cxovelis modelze Catarebul

ramdenime eqspetrimentsa da erTeul limitirebul klinikur cdebSi,

miRebulia dadebiTi efeqti, magram gamosavali Sefasebulia mxolod

18-22 Tvis asakamde. sxeulis temperaturis daqveiTeba 2-30C (zomieri hipoTermia) tvinis hipoqsia-iSemiis Semdeg amcirebs tvinis dazianebas

da aumjobesebs gamosavals eqsperimentul kvlevaSi

(mtkicebulebis done IV)21-23. axalSobilebze Catarebuli

kvlevebi mwiria da urTierTgamomricxavi Sedegebi aqvs

(mtkicebulebis done II)24-27. mZime hipoTermiam SeiZleba

gamoiwvios ariTmia, sisxldena, Trombozi da sefsisi, Tumca

es garTulebebi ar gamovlenila zomieri hipoTermiis dros

(mtkicebulebis done II)25,26,28.

ar arsebobs sakmarisi mtkicebuleba imisTvis, rom rutinulad

gamoyenebuli iyos sistemuri an cerebruli hipoTermia im

axalSobilebSi, romlebsac aReniSnebaT asfiqsia da hie. saWiroa

kvlevebis gagrZeleba am mimarTulebiT.

cxovelebze Catarebuli kvlevebi gviCvenebs, rom iSemiis

dros da mis mere ganviTarebuli hiperTermia, iwvevs tvinis

dazianebas (mtkicebulebis done IV)29.

gamomdinare zemoaRniSnulidan, im axalSobilebs, romlebsac

CautardaT reanimacia esaWiroebaT temperaturis mkacri

kontroli, raTa ar ganviTardes iatrogenuli hiperTermia.

radgan hiperTermiam SeiZleba gamoiwvios tvinis dazianeba

(rekomendacia B)14.

kveba:

umetes SemTxvevebSi (saSualo da mZime hie-s dros) pirveli sami dRis

ganmavlobaSi an sanam cnobierebis done ar gaumjobesdeba mizanSewonilia

parenteruli kveba. Semdeg iwyeba minimaluri kveba dedis gamowvelili rZiT

an formuliT daaxloebiT 5 ml yovel 3-4 sT-Si. paralelurad unda

warmoebdes muclis garSemowerilobis, nawlavTa xmianobis, nawlavTa

moqmedebis da kuWSi narCeni masebis monitoringi. nebismieri aRniSnul

simptomTagani SeiZleba miuTiTebdes nekrozul enterokolitis arsebobaze.

axalSobilebi perinataluri asfiqsiiT miekuTvnebian nekrozuli

enterokolitis ganviTarebis riskis jgufs.

B

IV

IV

II

II

15

konsultaciebi:

- krunCxvebis marTvis, eeg-s interpretaciisaTvis aucilebelia bavSvTa

nevrologis konsultacia.

referali9

hie-s saSualo simZimis da mZime formebis SemTxvevaSi saWiroa axalSobilis

transportireba maRali donis klinikaSi saTanado nevrologiuri kvlevisa

da nevrologis konsultaciis Casatareblad.

8. meTvalyureoba9:

saSualo da mZime xarisxis hies SemTxvevaSi pacients esaWiroeba sxvadasxva

specialistis meTvalyureoba (pediatri, nevropaTologi, ganviTarebis

pediatri da sxv.).

mkurnaloba gaweris Semdeg

krunCxvis sawinaaRmdego mkurnalobis xangrZlivoba damokidebulia cns-s

dazianebis xarisxsa da eeg-s monacemebze:

- axalSobilTa umravlesobasTan, romlebic viTardebian normalurad

da hospitalidan gaweramde aqvT normaluri eeg, fenobarbitaliT

mkurnaloba wydeba dabadebidan 3-4 kviris Semdeg.

- cns-is mniSvnelovani paTologiis mqone CvilebSi fenobarbitalis

mkurnalobis xangrZlivobis Sesaxeb gadawyvetilebas iRebs nevrologi

bavSvis mdgomareobis mixedviT.

prognozi:

gulyrebi cudi prognozis maCvenebelia: gulyrebis arseboba 2-5-jer zrdis

nevrologiuri garTulebis risks; antikonvulsantebisadmi rezistentul

gulyrebs calsaxad axlavs letaloba an myari nevrologiuri darRvevebi;

arakeTilsaimedo gamosavalis riski miT ufro maRalia, rac ufro adre

(gansakuTrebiT dabadebidan pirvel 4 saaTSi) iwyeba gulyrebi.

nevrologiuri statusis darRveva, romelic xangrZlivdeba pirveli 7-10 dRis

Semdeg, Cveulebriv, cudi prognozis maCvenebelia. M

persistirebadi kvebiTi problemebi miuTiTebs cns-is mniSvnelovan

dazianebaze.

hie-s mqone pacientebSi Tavis garSemowerilobis arasakmarisi zrda

sicocxlis pirvel wlis ganmavlobaSi momavalSi nevrologiuri problemebis

ganviTarebis erT-erTi markeria.

9. gaidlainis gadasinjvisa da ganaxlebis vada – 4 weli

16

10. gaidlainis miRebis xerxi/wyaro

gaidlainis SemuSavebis meTodologia

• axalSobilTa asfiqsiis/hipoqsiur iSemiuri encefalopaTiis

prevenciis da marTvis principebis Sesaxeb arsebobs samecniero

mtkicebulebis safuZvelze Seqmnil rekomendaciaTa mcire

raodenoba. mocemuli gaidlainis Seqmnis 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.

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

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

17

(SEEK)

National electronic Library for Health (NeLH)

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

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

Scottish Intercollegiate Guidelines Network (SIGN)

http://www.sign.ac.uk

German Guideline Information Service (GERGIS)

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

avstralia Australian National Health and Medical Research Council (NHMRC)

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

axali zelandia

New Zealand Guidelines Group (NZGG)

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

mtkicebiTi medicinis

specialistTa

regionTaSorisi

sazogadoeba

http://www.osdm.org

klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi

da meTodebi

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

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

biblioTeka.

publikaciebis CarTvis/gamoricxvis kriteriumebi

• arCeul iqna kvlevebi Semdegi dizainiT: randomizebuli

kontrolirebadi kvlevebi, sistemuri mimoxilvebi da meta-analizi,

erTmomentiani, kohortuli kvlevebi;

• rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12

wliani SezRudva. Tumca zogjer gamoyenebuli iyo ufro adreuli

publikaciebi, romlebic dResac aqtualuria da safuZvlad udevs

sxva Tanamedrove mtkicebulebebs;

• dadgenili iyo enobrivi SezRudvebi, radganac samuSao jgufs

SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod

inglisur da rusul enebze.

18

moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi

• samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi.

Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri

meToduri rekomendacia axalSobilTa asfiqsiis/hie-s marTvis

sakiTxebze, romlebic Seicavda jgufis miznis Sesaferis saWiro

informacias. am rekomendaciebis Sefasebisas gamoyenebuli iyo

rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (94,96-98). samuSao jgufi xelmZRvanelobda saqarTvelos Sromis, janmrTelobisa

da socialuri dacvis saministros mier SemuSavebuli nacionaluri

gaidlainebis gzamkvleviT. Sefasebis Sedegad amorCeuli iyo qvemoT

CamoTvlili organizaciebis gaidlainebi:

⇒ amerikis pediatriis akademia

⇒ axalSobilTa movla, manuali – j. kloherti

⇒ pediatria – nelsoni

⇒ janmrTelobis msoflio organizacia

• rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli

iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis

saministros 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

19

Vb klinikuri gamocdileba,

aRwerilobiTi kvlevebi an

eqspertTa angariSi

11. alternatiuli gaidlaini ar arsebobs

12. gamoyenebuli literatura:

1. Levene, M. Neonatal Neurology. Chp 8, pp 157-200;2000 2. Volpe, J. Neurology of the Newborn, Chapter 6. Pp. 211-369. W. B. Sauders, 1995 3. NGC STATUS: The information was veryfied by the guideline developer on April 10. 2003 4. Shah, P, Riphagen, S, Beyene, J et al. Multiorgan dysfunction in infants with post-asphyxial

hypoxic-ischemic encephalopathy. Arch Dis Child Fetal Neonatal Ed 2004; 89:F152. 5. Manual of Neonatal care; J. Cloherty, E. Eichenwald, A. Strark fifth edition, 2004 6. Clinical features, diagnosis, and treatment of neonatal encephalopathy;

Yvonne Wu, MD, MPH UpToDate performs a continuous review of over 350 journals and other resources. Updates are added as important new information is published. The literature review for version 14.2 is current through April 2006; this topic was last changed on March 31, 2006. www.uptodate.com

7. Etiology and pathogenesis of neonatal encephalopathy; Yvonne Wu, MD, MPH; www.uptodate.com UpToDate performs a continuous review of over 350 journals and other resources. Updates are added as important new information is published. The literature review for version 14.2 is current through April 2006; this topic was last changed on April 19, 2005

8. Systemic effects of perinatal asphyxia; Lisa M Adcock, MD; Ann R Stark, MD UpToDate performs a continuous review of over 350 journals and other resources. Updates are added as important new information is published. The literature review for version 14.2 is current through April 2006; this topic was last changed on April 28, 2006 www.uptodate.com

9. Hypoxic-Ischemic Encephalopathy; American Academy of Pediatrics, American Association for the History of Medicine, American Osler Society, American Pediatric Society, College of Physicians of Philadelphia, Society for Pediatric Research; www.emedicine.com; Last Updated: June 30, 2006

10. Hankins G.D.V, - et al - Neonatal Organ System Injury in Acute Birth Asphyxia Sufficient to Result in Neonatal Encephalopathy - VOL. 99, NO. 5, PART 1, 2002 The American College of Obstetricians and Gynecologists.

11. Badawi N, Kurinczuk JJ, Keogh JM, Alessandri LM, O’Sullivan F, Burton PF, et al. Antepartum risk factors for newborn encephalopathy: The Western Australian casecontrol study. BMJ 1998;317:1549 –53.

12. Casey BM, McIntire DD, Leveno KJ. The continuing value of the Apgar score for the assessment of newborn infants. N Engl J Med 2001; 344; 467-71

13. Програма Реанимации новорожденных руководство по подготовке преподователей – AIHA - 2000

14. American Heart Association in collaboration with International Liaison Committee on Resuscitation. Guidelines 2005 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Concensus on Science, Part 11, 7: Neonatal Resuscitation. Circulation 2005;112:91-9

15. Futrakul S et al - Risk Factors for Hypoxic-Ischemic Encephalopathy in Asphyxiated Newborn Infants J Med Assoc Thai Vol. 89 No. 3 2006 322-328;

20

16. Badawi N. - Antepartum risk factors for newborn encephalopathy: the Western Australian case-control study BMJ 1998;317:1549-1553

17. Volpe JJ. Hypoxic-ischemic encephalopathy: clinical aspects. In: Volpe JJ, editor. Neurology of the newborn. 3rd ed. Philadelphia: WB Saunders; 1995: 314-69.

18. Badawi N. - Antepartum risk factors for newborn encephalopathy: the Western Australian case-control study BMJ 1998;317:1549-1553

19. Nelson textbook of Pediatricas 2005 20. Perlman JM, Risser R. Can asphyxiated infants at risk for neonatal seizures be rapidly

identified by current high-risk markers? Pediatrics. 1996 Apr; 97(4): 456-62 21. Gunn A, Gunn T, de Haan H, Williams C, Gluckman P. Dramatic neuronal rescue with

prolonged selective head cooling after ischemia in fetal lambs. J Clin Invest 1997;99:248-56. 22. Laptook A, Corbett R, Sterett R, Burns DK, Tollefsbol G. Modest hypothermia provides partial

neuroprotection when used for immediate resuscitation after brain ischemia. Pediatr Res 1997;42:17-23.

23. Thoresen M, Bagenholm R, Loberg E, Apricena F. Posthypoxic cooling of neonatal rats provides protection against brain injury. Arch Dis Child Fetal Neonatal Ed 1996;74:F3-F9.

24. Bernard S, Gray T, Buist M, Jones B. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002;346:557-63.

25. Eicher D, Wagner C, Katikaneni L, Hulsey T. Moderate hypothermia in neonatal encephalopathy: efficacy outcomes. Pediatr Neurol. 2005;32:11-7.

26. Gluckman P, Wyatt J, Azzopardi D, Ballard R. Selective head cooling with mild systemic hypothermia after neonatal encephalopathy: multicentre randomised trial. Lancet 2005;365:663-70.

27. Thoresen M,.Whitelaw A. Cardiovascular changes during mild therapeutic hypothermia and rewarming in infants with hypoxic-ischemic encephalopathy. Pediatrics 2000;106:92-9.

28. Shankaran S, Laptook A, Wright L, Ehrenkranz R. Whole-body hypothermia for neonatal encephalopathy: animal observations as a basis for a randomized, controlled pilot study in term infants. Pediatrics 2002;110:377-85.

29. Coimbra C, Boris-Moller F, Drake M, Wieloch T. Diminished neuronal damage in the rat brain by late treatment with the antipyretic drug dipyrone or cooling following cerebral ischemia. Acta Neuropathol. 1996;92:447-53.

30. Основы ухода за новорожденнымми и грудное вскармливание - ВОЗб 2002 31. WHO - Managing Newborn Problems – A Guide for doctors, nurses and midwives – 2003

21

13. avtorTa jgufi

pediatrTa da neontologTa kavSiri `alternativa~

samuSao jgufi:

⇒ dimitri abelaSvili - medicinis doqtori; Tbilisis saxelmwifo

samedicino universitetis diplomis Semdgomi da uwyveti samedicino

ganaTlebis instituti, m. iaSvilis saxelobis bavSvTa centraluri

klinikuri saavadmyofos reanimaciisa da gadaudebeli daxmarebis

samsaxuris ufrosi, axalSobilTa reanimaciis ganyofilebis gamge.

pediatrTa da neontologTa kavSiri `alternativa~-s wevri;

⇒ merab maWaraSvili _ neonatologi, m.SaraSiZis samedicino centri

generaluri direqtoris moadgile neonatologiasa da pediatriaSi.

pediatrTa da neontologTa kavSiri `alternativa~-s wevri;

⇒ gela mecxvariSvili - medicinis doqtori, q. Tbilisis ss akademikos

o. RuduSauris saxelobis erovnuli samedicno centris

neonatologiis samsaxuris ufrosi;

⇒ maka mSvildaZe _ neonatologi, CaCavas sax. mean ginekologiisa da

perinatologiis instituti, saqarTvelos Sromis, janmrTelobisa da

socialuri dacvis saministros eqsperti. pediatrTa da neontologTa

kavSiri `alternativa~-s wevri;

⇒ maia xerxeuliZe – medicinis doqtori, Tbilisis saxelmwifo

samedicino universitetis pediatriis departamentis asistent-

profesori. pediatrTa da neontologTa kavSiri `alternativa~-s

wevri;

⇒ nani yavlaSvili – medicinis doqtori, Tbilisis saxelmwifo

samedicino universitetis pediatriis departamentis asistent-

profesori. pediatrTa da neontologTa kavSiri `alternativa~-s

wevri.

eqspertebi:

⇒ irakli favleniSvili – profesori, Tbilisis saxelmwifo

samedicino universitetis diplomis Semdgomi da uwyveti samedicino

ganaTlebis institutis direqtori;

⇒ nana tatiSvili - medicinis doqtori; m. iaSvilis saxelobis bavSvTa

centraluri klinikuri saavadmyofos nevrologiuri departamentis

ufrosi;

⇒ lela woworia _ saqarTvelos Sromis, janmrTelobisa da

socialuri dacvis saministros jandacvis departamenti;

⇒ Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da

socialuri dacvis saministros jandacvis departamenti.