semcveloba - geosf.files. · pdf filesemdeg. arnisnuli faqtebis analizi acvenebs semdeg...
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Semcveloba
Sesavali _____________________________________________________________________51 winaTqma ____________________________________________________________________52 ALERT kursis miznebi_______________________________________________________63 riskis qveS myofi pacienti__________________________________________________7
kritikuli pacientis Sefaseba_______________________________________________111 Sesavali ___________________________________________________________________112 dauyovnebeli Sefaseba, monitoringi da mkurnaloba A-B-C-D-E____________113 pacientis sruli Sefaseba _________________________________________________244 gadawyvetilebebi da dagegmva _____________________________________________ 25
galurjebuli pacienti da sunTqvis gaZneleba__________________________291 cianozi ____________________________________________________________________292 sunTqcis gaCereba (dispnoe)________________________________________________353 oqsigenoTerapia ___________________________________________________________ 35
hipotenziuri pacienti_______________________________________________________441 sisxlis wnevis gazomva____________________________________________________442 hipotenziuri pacientis fiziologia______________________________________463 ratom aris hipotenzia saxifaTo?__________________________________________474 hipotenziis gamomwvevi mizezis mkurnaloba________________________________50
pacienti areuli cnobierebis doniT _______________________________________521 etiologia_________________________________________________________________522 Semcirebuli cnobierebis donis Sedegebi_________________________________523 pacientis cnobierebis donis Sefaseba____________________________________534 gugis reaqcia gaRizianebaze______________________________________________545 sasargeblo gamokvlevebi_________________________________________________546 daqveiTebuli cnobierebis donis gadaudebeli marTva____________________ 55
pacienti oliguriiT_________________________________________________________571 Sardis normaluri gamoyofa_______________________________________________572 renuli sisxlis nakadi____________________________________________________583 glomeruluri da tubularuli daavadebebi______________________________60
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sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
4 saSarde gzebis obstruqcia________________________________________________625 sxva moqmedebebi oliguriul pacientebSi__________________________________63
gautkivareba kritikuli mdgomareobis dros_______________________________641 Sesavali __________________________________________________________________642 gautkivarebis gzebi ______________________________________________________643 tkivilis da sedaciis monitoringi ______________________________________704 gautkivarebis damatebiTi meTodebi ________________________________________71
organizaciuli da komunikaciuri Cvevebi __________________________________ 721 organizaciuli Cvevebi_____________________________________________________722 komunikaciuri Cvevebi______________________________________________________743 cudi ambebis gadmocema____________________________________________________764 sakuTari Canawerebis gakeTeba________________________________________________83
damatebiTi literatura______________________________________________________85
terminebis ganmarteba________________________________________________________89
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sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
saxelmZRvanelos Targmanze imuSava Tbilisis saxelmwifo samedicino
universitetis studentTa samaSvelo mobilurma jgufma(Rescue team):
levani adeiSvili
natalia gziriSvili
Tamar kvarancxelia
qeTevan kankava
salome CixlaZe
irakli xabeiSvili
giorgi kapanaZe
wigns redaqtireba gaukeTa aleqsandre qoqraSvilma - MD, BSc kardifis
sauniversiteto klinika, uelsi, didi britaneti.
wignis gamocemaSi daxmarebisTvis gansakuTrebul madlobas vuxdiT Tssu-s
sagangebo situaciebze samedicino reagirebis marTvis saswavlo centris
xelmZRvanels ioseb maisuraZes.
Tbilisi 2012
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Sesavali
1 winaTqma
ukanaskneli ramdenime wlis ganmavobaSi hospitalizebuli pacientebis marTva
ufro kompleqsuri gaxda, rac gacilebiT ufro did datvirTvas da gulisxmyofas
moiTxovs jandacvis muSakebisgan. zogadad, wina aTwleulebisagan gansxvavebiT
pacientTa populacia ufro moxucebulia, mravlobiTi paTologiebiT, rac
kopmleqsur marTvas moiTxovs. saeqTno, samedicino, qirurgiuli da saanesTezio
dargebis ganviTareba niSnavs, rom kompleqsuri mkurnaloba da gamokvleva, romelic
winaT SeuZlebeli iyo an miiCneoda maRal riskianad, exla SesaZlebelia. amave
dros, hospitaluri samedicino kadrebis momzadebaSi mimdinare cvlilebebma da
palatis eqTnebis raodenobis Semcirebam gamoiwvia individulur pacientebze
uwyveti meTvalyureobis Semcireba. damatebiT, e.w. tradiciuli `firmis~ struqturis
dakargvam, sadac staJiorebi muSaobdenen erTi konsultantisTvis da mimagrebuli
iyvnen mxolod erT an or palataze, Seamcira eqimebsa da eqTnebs Soris mWidri
samuSao urTierTobis ganviTarebis SesaZlebloba.
ukve myaradaa dadgenili principi, rom `prevencia ukeTesia vide mkurnaloba~ da
yvelaze metad es principi swored mwvave daavadebis mqone pacientebis
mkurnalobasTan mimarTebaSia marTebuli. mZime daavadebis dros pacients erTxel
mainc uviTardeba romelime organos ukmarisoba, romelic intensiur mkurnalobas
saWiroebs, Semdgomi garTulebebi da hospitalSi sikvdilianoba aseve mniSvnelovnad
izrdeba. britaneTis yvelaze karg intensiur Terapiis ganyofilebebSic (ICU) ki
sikvdilianoba 20%-mdea, da damatebiTi 10% palataSi iwereba da iRupeba gaweramde.
faqtia, rom maRali sikvdilianobis maCvenebelze gavlenas axdens buneba da ZiriTadi
daavadebis simZime, Tumca marto eseni ar arian ZiriTadi ganmapirobebeli faqtorebi.
ukanasknelma gamokvlevebma aCvenes, rom 50%-ze meti pacienti romelTac intensiuri
Terapia dasWirdaT suboptimaluri Terapia hqondaT Catarebuli and dagvianebiT
iybnen mimarTulni intensiur TerapiaSi. sxva gamokvlevebi aCveneben, rom gulis
uecari gaCerebis xSiri mizezi misi paTo-fiziologiuri mdgomareobaa, romelic
potenciurad gankurnebadia. garda amisa, hospitalis datovebis molodinSi myofi
zogi pacientebi iRupebian intensiuri Terapiis ganyofilebidan palataSi gaweris
Semdeg. aRniSnuli faqtebis analizi aCvenebs Semdeg ZiriTad statistikas, rom gulis
uecari gaCerebis bevri SemTxvevebi, sikvdilianobis SemTxvevebi da intensiuri
mkurnalobisadmi daugegmavi mimarTvebi dakavSirebulia martivi, adreuli da
saTanado prevenciuli mkurnalobis danergvis ararsebobasTan.
gulis uecari gaCerebis bevri SemTxvevebi, sikvdilianobis SemTxvevebi da
intensiuri mkurnalobisadmi daugegmavi mimarTvebi dakavSirebulia adreuli da
saTanado prevenciuli mkurnalobis danergvis ararsebobasTan.
maSasadame, yvela mwvave daavadebis mqone pacientebis an mwvave daavadebebis
ganviTarebis riskqveS myofi pacientebis marTvis mizania, adreul etapze ama Tu im
paTo-fiziologiuri mdgomarebis aRmoCena da mativi prevenciuli Terapiuli
mkurnalobis Catareba, manam, sanam organos ukmarisoba Camoyalibdeba. garda amisa,
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sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
is pacientebi, romlebic swrafad ar pasuxoben martiv reanimaciul RonisZiebebs,
unda iyvnen ganxilulni Semdgomi maTi intensiuri Terapiis ganayofilebaSi adreul
gadagzavnasTan dakavSirebiT.
paTo-fiziologiuri mdgomareobis adreuli gamovlena da sawrafi, martivi
moqmedebebis Catareba amcirebs Semdgomi garTulebebis albaTobas da
inarCunebs bevri adamianis sicocxles.
2 ALERT kursis mizani
ALERT-is (damZimebuli pacientis amocnoba da mkurnaloba) kursi Seiqmna palatis
eqTnebis, eqimebis da sxva samedicino personalis (fizioTerapevtebis da
paramedikosebis) dasaxmareblad, raTa amoicnon riskis qveS myofi pacientebi,
adreul etapze gamoavlonon organos dazianeba an ukmarisoba, rom Catarebl iqnas
martivi mkurnaloba Semdgomi poliorganuli ukmarisobis jaWvuri kaskadis Tavidan
asacileblad. aseve am kursis mizania komunikaciuri SesaZleblobebis gaumjobeseba,
Semdgomi mkurnalobis gamartivebis mizniT. es kursi saSualebas gaZlevT
gamoicnoT, Tavidan aiciloT da umkurnaloT, amave dros gqondeT efeqturi
komunikacia pacientTan, mis axloblebTan da kolegebTan. kursis ZiriTadi
prioritetebia:
Ø gamocnoba
Ø Tavidan acileba
Ø mkurnaloba
Ø komunikacia
mosalodnelia, rom aRniSnuli kursis danergva pacientebs, maT naTesavebs da
samedicino personals konkretul sargebels moutans, rogoricaa:
ü zogadi palatebis pacientebis zedamxedvelobis gaumjobeseba.
ü zogad palatebSi gamoZaxebis raodenobis Semcireba, gulis ukmarisobis gamo.
ü saswrafo samedicino daxmarebisTvis adreuli da saTanado mimarTva.
ü intensiuri Terapis gamyofilebaSi ganmeorebiTi moxvedris Semcireba
ü saavadmyofoSi sikvdilianobis Semcireba
ü pacientis reanimaciul statusze gadawyvetilebis miRebis gaumjobeseba
ü multiprofesiuli gunduri muSaobis gaumjobeseba
ü komunikaciis gaumjobeseba da
ü naklebi saCivari pacientebisa da maTi naTesavebisgan.
ALERT-is kursi Seiqmna palatis eqimebis, eqTnebis da mokavSire profesionali
medikosebis dasaxmareblad, rom uvneblad da warmatebulad marTon mwvave
daavadebis mqone pacienti. am kursis formati efuZneba sicocxlis SenarCunebis
ramodenime programas (mg: ALS, ATLS, APLS da CCrISP), romelic iyenebs struqturul da
prioritetul marTvis sistemas, raTa daexmaron eqimebsa da eqTnebs maRali
standartis SesrulebaSi maSinac ki, roca isini maTvis uCveulo klinikuri
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Sesavali
situaciebis winaSe aRmoCndebian. Sedegad, ALERT-is kursidan miRebuli codna,
unarebi da damokidebuleba mogvianebiT Tqven karieraSi iqneba integrirebuli sxva
sicocxlis SenarCunebis meTodebisa da teqnikis kursis SeswavlasTan.
mwvave daavadebebis umravlesobis ganviTreba mihyveba ZiriTad paTofiziologiur
gzas, romelic aerTianebs sasunTqi gzebis dazianebas, sunTqvis da stabiluri
cirkulaciis ukmarisobas. ZiriTadi paTologiuri mdgomareobebis mcire raodenobis
swrafi gamovleniT da koreqciiT (mg. martivi Terapiis gamoyenebiT: oqsigenoTerapia
da siTxiT Terapia) SesaZlebelia bevri klinikuri krizis damakmayofileblad
marTva. ALERT-is kursi amuSavebs martiv sistemas, romelic SesaZlebelia
gamoyenebul iqnas mravali saxis ZiriTadi daavadebis mqone mwvave pacientis
(qirurgiuli an Terapiuli) marTvisTvis
kursis silabusis mixedviT riskis qveS myofi pacientis saTanado mkurnaloba
moiTxovs multiprofesionalur midgomas da gundur muSaobas. eqimebma mWidrod unda
iTanamSromlon eqTnebTan da fizioTerapevtebTan da unda aawyon kargi urTierToba
kolegebTan monaTesave disciplinebidan, gansakuTrebiT maRal damokidebul da
intensiuri mkurnalobis disciplinebidan. maSasadame, ALERT-is kursi Seiqmna
imisTvis, rom erTad da saerTo midgomiT, romelic gamoyenebuli iqneba klinikuri
praqtikisTvis, moamzadon samedicino personali, eqTnebi da monaTesave samedicino
dargebSi momuSave profesionalebi. gundis wevrebs Soris maRali xarisxis weriT
da verbalur komunikacias arsebiTi mniSvneloba aqvs, rac aRniSnulia mocemuli
kursis silabusSi. es kursi muSavdeba erTi dRis ganmavlobaSi da aerTianebs
interaqtiul seminarebs, praqtikul demonstraciebs da gaTamaSebul scenebs,
romelic Tqven dagexmarebaT gansazRvroT Tqveni moqmedeba da upasuxoT kiTxvas `ra
unda gavakeTo Semdeg?~.
riskis qveS myofi pacientis adeqvaturi mkurnaloba moiTxovs
multiprofesionalur midgomas da karg gundur muSaobas.
3 riskis qveS myofi pacienti
mwvave daavadebis aRmoCena Zalian advilia, roca is mZime mdgomareobas miaRwevs.
jer kidev adre, 1592 wels nikolo makiavelma aRwera cxeleba da ganacxada, rom
`dasawyisSi, rodesac temperatura dabalia misi arc amocnoba xdeba da Sesabamisad
arc mkurnaloba tardeba, Semdeg ki advilia amocnoba, magram mkurnaloba ki Zneli~.
amgvari gancxadeba SeiZleba moergos yvela daavadebas da amitomac saavadmyofos
samedicino personalis gamowvevas warmoadgens winsawar gansazRvros riskis qveS
myofi individebi da winaswar ganWvritos, Tu romel pacients ganuviTardeba
garTulebebi an momavalSi daWirdeba Sesabamisi mkurnaloba.
amis magaliTad SeiZleba moviyvanoT:
Ø pacientebi, romelic saWiroeben gadaudebel daxmarebas
Ø moxuci asakis pacientebi
Ø pacientebi sxvadasxva daavadebebis foniT (winaswar arsebuli daavadebebi.
mag.: diabeti, Tirkmlis ukmarisoba, asTma)
Ø umZimesi mwvave daavadebebiT daavadebuli pacientebi
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sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
Ø pacientebi romelTa janmrTlobis mdgomareoba progress ar ganicdis
miuxedavad mkurnalobis warmarTvisa
Ø SokSi myofi pacienti
Ø pacientebi, romlebic gamodian anesTeziidan
Ø pacientebi, romelTac aReniSnebaT hemoragiis recidivi qirurgiuli Carevis
Semdgom
Ø pacientebi, romlebic saWiroeben masiur sisxlis trasfuzias da
Ø pacientebi romlebic gadayavT reanimaciuli ganyofilebidan (ICU) zogad
palatebSi.
3.1 gamoZaxebis kriteriumi
yovelmxrivi (Rrma/amomwuravi) kritikuli zrunvis (Comprehensive Critical Care)janmrTelobis departamentis (Department of Health) mier gamoqveynebuli dokumentis
mixedviT, `gamoZaxebis kriteriumi~ palatis/morige samedicino personalis
dasaxmareblad, raTa moxdes kritikul mdgomareobaSi an riskis qveS myofi
pacientis identifikacia, xdeba metad mniSvnelovani. zogierTi hospitali iyenebs
sistemebs, romlebic iZaxebs pacientis sakuTar klinikur jgufs, rogoric aris
samedicino moulodneli SemTxvevis jgufi (Medical Emergency Team-MET) an hospitlis
gareT gamoZaxebis (outreach service) momsaxureba, specialur maCveneblebze (mag.:
sunTqvis sixSire (RR) >30wT-Si; sistoluri wneva (SBP) <90mmHg), calcalke an maT
kombinaciaze dayrdnobiT. sxva gamoyenebuli sistemebia mag.: modificirebuli
naadrevi gafrTxilebis qula (Modified Early Warning Score-MEWS) (sur.:1), romelsac
Wirdeba palatis/morige samedicino personali dakvirvebaTa aRsaniSnavad, rogoric
aris arteriuli wneva, gulis SekumSvaTa sixSire da a.S. es fiziologiuri
parametrebi Tavsdeba 0-dan 3 ciframde mniSvnelobebSi, romelic Seesabameba
normidan gadaxris xarisxis da miRebuli monacemebi jamdeba MEWS qulis
misaRebad. lokalurad miRebuli protokolebis mixedviT MEWS qula gamoiyeneba
SemdgomSi pacientis ufro specializebulad Sesafaseblad pirveladi jgufiT an
ufro zemdgomi samedicino personaliT.
gamoiyene `gamoZaxebis kriteriumi~ an naadrevi gafrTxilebis qulebi
sur.:1 modificirebuli naadrevi gafrTxilebis qula/MEWS
qula 3 2 1 0 1 2 3
HR <40 40-50 51-100 101-110 11-129 ≥130
BR <45%↓ ≤30↓ 15%↓ normaSia 15%↑ 30%↑ >45↑
RR ≤8 9-14 15-20 21-29 ≥30
TEMP
CNS
<35.0 35.0-38,4
A V
<38,4
P UUrine nuli <1ml/kg/2sT <1ml/kg/1sT >3ml/kg/2sT
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54 wlis Warbi wonis qali, romelsac aqvs susti asTma utardeba saswrafo
laparatomia nawlavTa gauvalobis gamo xuTSabaTs saRamoTi. pirveli
postoperaciuli Ramis ganmavlobaSi, analgezia warmoebuli iqna opiatiT
eqstraduralurad, magram mas ekargeba efeqti 05:30sT paraskevs. gamoZaxebaze myofms
eqimma (House officer) daniSna drogamoSvebiT intramuskularuli peTidini 4 saaTSi
erTxel, Tumca es ar aris sakmarisi pacientis tkivilisgan srulad
gansaTavisufleblad. pacients ewyeba Rrma sunTqvisa da xvelis gaZneleba,
miuxedavad imisa rom paraskev gulmkerdis rutinuli fizioTerapia Catarda, is
wesrigSi ver movida momdevno kviris bolos. pacientis sakuTarma samedicino
jgufma ver gadaca informacia gamoZaxebul jgufs pacientis mdgomareobis Sesaxeb,
sanam isini wavidodnen kviris bolos morigeobidan. SabaTs, pacients kvlav qonda
tkivili da ar SeeZlo Rrmad CasunTqva. mas qonda temperature, Cirqovani naxveli
da aSkara eqspiraciuli xixini. miuxedavad urgentuli moTxovnisa eqTanTa
personalis mxridan, rom PRHO viziti Catarebuliyo, sabolood pacienti naxa
23:45sT radgan is dakavebuli iyo 12 gadaudebeli miReba. qirurgiuli SpR iyo
darbazSi mTeli dRe. PRHO gaagzavna arteriuli sisxlis nimuSi sisxlSi gazebis
parcialuri wnevis analizis Casatareblad. ramac aCvena dabali PaO2 da maRali
PaCO2; es imiT aixsna, rom sunTqvis hipoqsiuri stimulaciiT da niRabiT miwodebuli
Jangbadis koncentracia Semcirda 60%-dan 28%-mde.
erTi saaTis Semdeg, swrafad gauaresda mdgomareoba da pacients gauCerda guli.
sabednierod, pacienti swrafad regirebs reanimaciul RonisZiebebze da gadayvanili
iqna intensiuri zrunvis erTeulSi. is 10 dRe darCa SeerTebuli xelovnuri
sunTqvis aparatze da Cautarda traqeostomia. is daaxloebiT 1 Tve darCa
hospitalSi.
ganixileT Semdegi:
Ø SegiZliaT daimaxsovroT amgvari SemTxvevebi?
Ø ratom iyo es konkretuli pacienti riskis qveS mqofi pacienti?
Ø ramdenad SeiZleboda am pacientis klinikuri kursis Tavidan acileba?
Ø rogor SeeZlo ALERT-is safuZvlebs rogirc aris winaswarganWvrite
(prognozi/predict), Tavidan aicile (prevent), umkurnale (treat) da daukavSirdi
(communicate). es principebi gamoiyeneba pacientis ukeTesad marTvisTvisa da
Sesabamisad kargi efeqtis miRwevisTvis.
Sesavali
3.2 kritikuli gamoZaxebis momsaxureobebi
Tavis rekomendaciebs Soris, yovelmxrivi (Rrma/amomwuravi) kritikuli zrunvis
(Comprehensive Critical Care) dokumenti xazs usvavs, rom pacientis zrunva zogad
palatebSi SeiZleba gaumjobesdes, Tu kritikuli zrunvis areebi (e.i. ICU da HDU)gauziareben TavianT Cvevebs zogadi palatis samedicino personals. bevr hospitals
axla yavs `gareT gamoZaxebis jgufebi~, romelic Sedgeba eqTenebisgan, eqimebisgan an
orivesgan erTad. Tavidan bolomde ALERT-is kursi da MEWS, gareT momsaxureba
warmoadgens `kritikuli zrunva kedlebis gareSe~-is magaliTebis komponentebs. es
saerTo warmodena cnobs imas, rom bevri mwvave daavadebiT Sepyrobili pacienti
xSirad moTavsebulia hospitlebis zogad palatebSi, da ara yovelTvis kritikuli
zrunvis erTeulebSi (CCU) da es kritikuli zrunva aris mkurnaloba da ara
adgili.
sanam ufro Sors wavalT cadeT es savarjiSo
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sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
Sejameba
Ø pacientebis marTvis sirTule gaizarda bolo wlebSi.
Ø kritikul mdgomareobaSi myofi pacientebis swrafi marTva moiTxovs
karg jgufur muSaobas da SesaniSnavi komunikaciis qonas.
Ø riskis qveS myofi pacientebis identifikacia gvexmareba
garTulebebis winaswar ganWvretasa da Tavidan acilebaSi.
Ø Sesabamisi adreuli moqmedebebis ganuxorcielebloba iwvevs
pacientis avadobisa da sikvdilobis zrdas.
Ø yuradRebis mipyroba detalebze sasicocxlod mniSvnelovania
kritikul mdgomareobaSi myofi pacientebis zrunvisas.
Ø prevencia ukeTesia vidre mkurnaloba.
Ø gamoZaxebis kriteriumi SeiZleba iyos gamosadegi riskis qveS mqofi
an gauaresebuli pacientebis identifikaciisas.
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kritikuli mdgomareobis mqone pacientis Sefaseba
am Tavis bolos Tqven SeZlebT:
ü gaigoT, Tu ratom aris Sefaseba da xelaxali Sefaseba mkurnalobis
aucilebeli sakiTxi mwvave daavadebis mqone pacientebisTvis.
ü Sefasebis racionaluri sistemis gamoyenebas, raTa usafrTxod marToT
kritikulad daavadebuli pacientebi.
ü gaigoT martivi Terapiuli RonisZiebebi, raTa MmZime pacientis mdgomareoba
daastabiluroT.
ü monitoringis martivi saSualebebis dadgenas, romelic sasargebloa
daavadebul pacientebSi.
ü gaigoT marTvis naTeli gegmis qonis saWiroeba yvela pacientisTvis da;
ü SeamCnioT mdgomareoba, romelSic damatebiTi daxmarebaa saWiro.
1 Sesavali
rodesac vmarTavT mZime daavadebul pacients an kritikuli daavadebis riskis
qveS myof pacientebs, sasicocxlod mniSvnelovania ganxorcieldes pacientis
sruli Tavdapirveli Sefaseba da Semdgomi mudmivi xelaxli Sefaseba. Aamis
gakeTeba advilia, Tu Sefasebis sqema aris gamartivebuli da jandacis gundis
yvela wevri iyenebs erTi da igive sistemur midgomas. Ees amcirebs Secdomis an
gaugebrobis albaTobas da uzrunvelyofs, rom mTelma gundma imuSaos erTi
saerTo miznisaTvis. qvemoT aRwerili sistema (suraTi 2) dafuZnebulia gamocdili
klinicistebis praqtikaze da umetesad mihyveba janmrTelobis SenarCunebis
daxvewili kursebis ZiriTad struqturas, did britaneTSi swored es struqtura
gamoiyeneba ZiriTadad. regularuli dakvireba mniSvnelovania, imisaTvis rom
SevafasoT Carevis efeqti da imitom, rom pacientebis mdgomareobis gauareseba
SeiZleba gagrZeldes mkurnalobis miuxedavad, an uSualod mkurnalobis gamo.
2 dauyovneblivi Sefaseba, monitoringi da mkurnaloba A-B-C-D-E sistemiT
dauyovneblivi Sefaseba, monitoringi da mkurnaloba
A-B-C-D-E
Sefasebis sistemis es nawili uSualod mimarTulia pacientis mdgomareobis
usafrTxoebisaken, vidre garkveuli diagnozis dasmisaken.
nebismieri pacientis Sefasebis dros iseTma martivma kiTxvam, rogoricaa -
`rogor xarT?~ SeiZleba mogvces mniSvnelovani informacia. magaliTad pacientis
normaluri verbaluri pasuxi gvaZlevs informacias, rom misi sasunTqi gza
gamavalia, sunTqavs da Tavis tvins perfuzia normaluria. Ppacientebi, romlebic
laparakoben mxolod mokle winadadebiT an erTi an ori sityviT, Cveulebriv arian
ukidures respiratorul distresSi(mg: mwvave asTma) da arian sunTvis uecari
gaCerebis riskis qveS.Ppacientis pasuxis ar arseboba aris Zalian mkafio niSini
seriozuli daavadebis arsebobisa.
12
suraTi 2 – ALERT -is Sefasebis gegma.
13
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
sicocxlis SenarCunebis sxva kursebze Sesabamiasd ALERT –is kursis Sefasebis
sistema iwyeba sicoxlisTvis potenciurad saSiSi movlenebis swrafi gamovleniT
da mkurnalobiT. Sesabamisad, is iyenebs ukve nacnob A-B-C-D-E sistemas, romelSic:
A sasunTqi gza (Airway);
B sunTqva (Breathing);
C cirkulacia (Circulation);
D uunaroba (cns-is funqcionireba), (Disability);
E pacientis sruli daTvaliereba (Exposure).
ALERT –is kursis Sefasebis sistema iwyeba sicoxlisTvis potenciurad saSiSi
movlenebis swrafi gamovleniT da mkurnalobiT.
Sefaseba da Semdgomi moqmedeba prioritetulia, radgan zogadad sasunTqi gzis
obstruqcia klavs ufro swrafad vidre araadeqvaturi sunTqva, xolo es
ukanaskneli Tavis mxriv ufro swrafad klavs, vidre sisxldena an kardialuri
disfunqcia.
kritikuli daavadebis mqone pacientis klinkuri SefasebisTvis yovelTvis
gamoiyeneT martivi monitorebi. gamoiyeneT pulsoqsimetri, ekg monitori da
uwyveti arainvaziuri sixlis wnevis monitori yvela mwvave daavadebis
mqone pacientebSi, ramdenadac SesaZlebelia swrafad da usafrTxod.
2.1 A - sasunTqi gza
zeda sasunTqi gzebis obstruqcia moiTxovs gadaudebeli samedicino Carevas.
obstruqcia SeiZleba iyos sruli an nawilobrivi da SeiZleba mdebareobdes
sasunTqi gzis nebismier doneze - piridan sasulemde. mZinare an ugono pacientSi
yvelaze xSiri mizezi aris xaxis obstruqcia eniT, romelic vardeba qvemoT,
rodesac kunTebis normaluri tonusi Semcirebulia (suraTi 3).
suraTi 3 – sasunTqi gzis obstruqcia, romilic gamowveulia enis da ybis kunTebis
tonusis daqveiTebiT.
zeda sasunTqi gzis obstruqcia SeiZleba ganapirobos Rebinebam, sekretebma,
sisxlma an kuWis wvenma; es aseve SeiZleba ganviTardes qsovilis SeSupebis gamo,
14
kritikuli mdgomareobis mqone pacientis Sefaseba
gamowveuli travmiT, alergiiT an infeqciiT. qveda sasunTqi gzebis obstruqcia
SeiZleba gamowveuli iyos xorxis SeSupebiT (damwvrobis dros, xorxis doneze
ganviTarebuli anTebis an alergiis dros), xorxis spazmiT (xorxSi ucxo sxeulis,
sekretebis/sisxlis moxvedris sapasuxod), an traqeobronquli obstruqciiT
(ganpirobebuli kuWis SigTavsis aspiraciiT, filtvebis SeSupebiT, siTxiT an
bronqospazmiT). mkurnalobis ar Catarebis SemTxvevaSi, sasunTqi gzis obstruqcias
mivyavarT arteriul sisxlSi Jangbadis parcialuri wnevis (Pa02) Semcirebisaken, eszrdis Tavis tvinis, Tirkmlebis, gulis hipoqsiuri dazianebis, aseve gulis
gaCerebis da sikvdilis risks.
mkurnalobis ar Catarebis SemTxvevaSi, sasunTqi gzis obstruqcias mivyavarT
arteriul sisxlSi Jangbadis parcialuri wnevis (Pa02) Semcirebisaken, es
zrdis Tavis tvinis, Tirkmlebis, gulis hipoqsiuri dazianebis, aseve gulis
gaCerebis da sikvdilis risks.
sasunTqi gzis obstruqciis arsebobis gamovlena dafuZnebulia martiv - `vuyureb,
vismen, vgrZnob~ midgomaze:
vuyureb
pacients, romelic sunTqavs ZaliT, sasunTqi gzis sruli obstruqciisas
aReniSneba muclis da gulmkerdis paradoqsuli moZraoba. nacvlad normaluri
sunTqviTi moZraobisa, romelis drosac gulmkerdis da muclis kedeli erTi
mimarTulebiT moZraobs, sasunTqi gzis obstruqciisas aRiniSneba sunTqvis -
`vxedav-davinaxe` modeli, romelSic CasunTqvas Tan sdevs muclis kedlis gareT da
gulmkerdis SigniTa moZraoba (amosunTqvisas piriqiT). sasunTqi gzis obstruqciis
sxva niSnebia damatebiTi sasunTqi kunTebis (kisris da mxarbeWis kunTebi)
monawileoba sunTqviT aqtSi da traqeis qvemoT CawevaSi. centraluri cianozi aris
sasunTqi gzis obstruqciis mogvianebiTi niSani. Zalzed mniSvnelovania
obstruqciis mizezis dadgena, amisaTvis sasunTqi gza unda Semowmdes sekretebis,
sisxlis, ucxo sxeulis da a.S. arsebobaze. Tumca, mniSvnelovania gvaxsovdes, rom
zeda sasunTqi gzis obstruqciis yvelaze savaraudo mizezi daqveiTebuli
cnobierebis donea (ixileT qvemoT).
vismen
sasunTqi gzis sruli obstruqciisas aranairi sunTqviTi xmebi ar ismis piridan
da cxviridan. nawilobrivi obstruqciisas haeris Sesvla Semcirebulia da xSirad
xmauriani. gansazRvruli xmebi miuTiTeben obstruqciis dones:
ü buybuyi miuTiTebs wylis arsebobaze piris RruSi an zeda sasunTq gzebSi;
ü xvrinva aRiniSneba maSin, rodesac xaxa nawilobriv aris daxuruli enis mier;
ü yivili ismis xorxis spazmis dros;
ü inspirciuli stridori ganpirobebulia xorxis zeda an mis doneze
ganviTarebuli obstruqciiT da;
ü eqspiraciuli xixini miuTiTebs sasunTqi gzebis kolafsze amosunTqvis dros
(mg: asTma).
15
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
vgrZnob
sasunTqi gzis obstruqciis arsebobis gansazRvris martivi gza aris pacientis
pirTan yuris dadebiT, an xelis uSulod piris win moTavsebiT haeris moZraobis
SegrZneba.
2.1.1 zeda sasunTqi gzis obstruqciis gadaudebeli marTva
xSir SemTxvevaSi martivi zomebi, romlebsac am dros unda mivmarToT aris
sasunTqi gzis gaxsna, rogorebicaa - amotumbva sekretebis mosacileblad, manevris
`nikapis aweva/ybaze xelis kvra` gamoyeneba an orofaringealuri milis Cadgma
(xSirad mas uwodeben Guedel airway - suraTi 4). im SemTvevaSi, rodesac
orofaringealuri milis Cadgma SeuZlebelia (mg: mWdrod daxuruli piri),
mizanSewonilia nazofaringealuri milis gamoyeneba.
suraTi 4 – sasunTqi gzis obstruqciis aRmofxvra Tavis ukan gadaweviT, nikapis
zemoT aweviT da orofaringealuri milis gamoyenebiT.
Tu es meTodebi uSedegoa, Cveulebriv aucilebelia endotarqeuli intubacia.
endotrqeuli mili SeiZleba Caidgas nazalurad an oralurad, magram intubacia
oraluri gziT, romelic xorxTan erTad vizualizdeba laringiskopis gamoyenebiT,
warmoadgens xelsayrel meTods. Tu pacients ganuviTarda kardiopulmonuri
ukmarisoba, an is eqstremalur mdgomareobaSia, intubacia SeiZleba gakeTdes
narkotikuli analgetikebis gamoyenebis gareSe. Tumca, Tu pacienti gonzea da
pasuxebs iZleva, saWiroa narkotikuli analgetikebis gamoyeneba, magram
intubaciisTvis unda davuZaxoT sasunTqi gzebis marTvaSi daxelovnebul
specialists. gamocdili specialistis daxmarebis molodinSi gamoiyeneT zemoT
aRwerili Tavis martivi mdebareoba da oro- an nazofaringealuri mili, rom
davicvaT sasunTqi gza da mivawodoT pacients 100%-iani Jangbadi `ambus~ (bag-valve-
mask system) parkiT. Tu pacientis sasunTqi gza ar gaixsna, SesaZloa saWiro gaxdes
sasunTqi gzis qirurgiuli meTodiT gaxsna(beWdisebri membranis gavliT), magram es
ar unda gakeTdes gamoucdeli personalis mier. Zalian iSviaTad pacients SeiZleba
hqondes zurgis tvinis kisris segmentis arsebuli paTologia. Tu es asea, manevrebi
sasunTq gzebTan unda ganxorcieldes zurgis tvinis kisris segmentis xeliT
stabilizaciis paralelurad.
16
kritikuli mdgomareobis mqone pacientis Sefaseba
martivi zomebi (nikapis aweva/ybaze xelis kvra, an orofaringealuri mili)
TiTqmis yovelTvis xsnis daxurul zeda sasunTq gzas.
2.2 B - sunTqva
martivi - `vuyureb, vismen, vgrZnob~ meTodiT aseve SesaZlebelia respiraciuli
distresis an araadeqvaturi ventilaciis arsebobis dadastureba.
vuyureb
sunTqvis (ventilacia) adeqvaturobis mniSvnelovan vizualur niSnebSi Sedis
Semdegi:
Ø oflis dena;
Ø centraluri cianozi;
Ø damatebiTi sasunTqi kunTebis (kisris da mxris sartylis kunTebi)
monawileoba sunTqvaSi;
Ø sunTqva mucliT;
Ø TiToeuli sunTqvis siRrme da;
Ø gulmkrdis Tanabari moZraoba orive mxares.
gulmkerdis calmxrivi moZraoba adasturebs qveSmdebare calmxriv paTologias
(mag. pnevmoToraqsi, pnevmonia, siTxis arseboba plevris RruSi). Tumca yvelaze
xSirad gamoyenebadi niSani pacientis sunTqvis Sesafaseblad aris sunTqvis
sixSire. sunTqvis sixSire gamoiTvleba sunTqviTi ciklebis daTvliT erT wuTSi.
erTi cikli ganixileba rogorc gulmkerdis eqskursiiT _ CasunTqviTi da
amosunTqviTi moZraobiT, romelic umjobesia daviTvaloT erTi sruli wuTis
ganmavlobaSi, vidre 15 wamis ganmavlobaSi da Semdgom gadavamravloT ciklebis
raodenobaze _ 4-ze.
sunTqvis sixSire iTvleba wuTSi sunTqviTi ciklebis daTvliT. erTi cikli
ganixileba, rogorc pacientis gulmkerdis erTi sruli CasunTqviTi da
amosunTqviTi moZraoba.
mosvenebis mdgomareobaSi sunTqviTi sixSire wuTSi 12-sa da 20-s Sorisaa. maRali
an mzardi sunTqvis sixSire avadmyofobis markeria da mianiSnebs, rom SesaZlebelia
pacientis mdgomareoba uceb gauaresdes. am stadiaze aseve aucilebelia gavarkvioT
aris Tu ara sunTqvis ritmi regularuli.
mosvenebis mdgomareobaSi sunTqviTi sixSire wuTSi 12-sa da 20-s Sorisaa.
maRali an mzardi sunTqvis sixSire avadmyofobis markeria da mianiSnebs, rom
SesaZlebelia pacientis mdgomareoba uceb gauaresdes.
17
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
sxva mniSvnelovani detalebs warmoadgens gulmkerdis deformacia (romelmac
SesaZlebelia gazardos normaluri sunTqvis gauaresebis riski), gazrdili wneva
sauRle venaSi (mag. mwvave asTmisa da dWimuli pnevmoToraqsis dros gulmkerdis
drenaJebis gamavloba, CasunTquli Jangbadis koncentracia (%) romelic imarTeba
pacientis mier da SaO2 –is wakiTxva puls-oqsimetrze. Tumca aucilebelia
davimaxsovroT, rom puls- oqsimetri ar aCvenebs gazrdil PaCO2-s da imas, rom Tu
pacienti aris oqsigenoTerapiaze, SaO2 SeiZleba iyos normaluri Zalian maRali
PaCO2-is fonze. muclis daWimva SesaZlebelia iqnas mxedvelobaSi miRebuli, radgan
aman SeiZleba gamoiwvios diafragmis moZraobis SezRudva da aqedan gamomdinare _
gauaresebisaken midrekili respiratoruli distresi.
vismen
stetoskopis gamoyenebamde, mousmine pacientis sunTqvas misi saxidan odnav
moSorebiT. xmauriani sunTqva mianiSnebs sasunTq gzebSi sekreciaze, ufro xSirad
iseT pacientebSi, romelTac ar SeuZliaT kargad amoxveleba an Rrmad CasunTqva.
stridoruli an xixiniT sunTqva mianiSnebs parcialur, Tumca mniSvnelovan
sasunTqi gzebis obstruqciaze (naxeT zemoT). auskultaciisas unda ganisazRvros
TviToeuli CasunTqvis siRrme da gulmkerdis Tanabari moZraoba. amavdroulad
unda Sefasdes sasunTqi xmianobebis xarisxi. bronquli sunTqva miuTiTebs
filtvebSi simkvrivis arsebobaze; filtvis xmianobis ararseboba an Sesusteba
mianiSnebs pnevmoToraqsze an siTxis arsebobaze plevraSi.
vgrZnob
es ZiriTadad tardeba auskultaciamde. pirvel rigSi unda Sefasdes traqeis
pozicia suprasternalur SemaRlebaze; erT mxareze deviacia miuTiTebs Suasayris
gadawevaze (magaliTad pnevmoToraqsis, filtvebis fibrozis an plevris RruSi
siTxis arsebobisas). unda gakeTdes gulmkerdis palpacia qirurgiuli emfizemis an
krepitaciis arsebobisas (pnevmoToraqsis dasadgenad) da gulmkerdis Tanabari
moZraobisa da siRrmis dasadgenad orive mxares. perkusiiTac aseve SesaZlebelia
gansxvavebuli bgerebis miReba, hiperrezonansi miuTiTebs pnevmoToraqsze, bgerebis
moyrueba ki qsovilis gamkvrivebasa da plevraSi siTxis arsebobaze.
18
kritikuli mdgomareobis mqone pacientis Sefaseba
gamkvriveba kolafsi pnevmoToraqsi siTxe
plevris
RruSi
moZraoba Semcirebulia
dazianebis
mxares
Semcirebulia
dazianebis
mxares
Semcirebulia
dazianebis
mxares
Semcirebulia
dazianebis
mxares
traqea centralurad gadaxrilia
dazianebis
mxares
centralurad an
gadaxrilia
dazianebis
sapirispiro
mxares
centralurad
an
gadaxrilia
dazianebis
sapirispiro
mxares
perkusia moyruebuli moyruebuli hiperezonansuli Zlier
myruebuli
sasunTqi
xmianobebi
bronquli bronquli an
Sesustebuli
Sesustebulia an
saerTod ar aris
Sesustebuli
cxrili 1: tipiuri fizikaluri niSnebi xSiri respiratoruli daavadebebis dros.
2.2.1 sasunTqi gzebis daavadebebis swrafi marTva
sasunTqi sistemis daavadebebis specifikuri mkurnaloba damokidebulia
gamomwvev mizezze da igi ganxiluli iqneba meoTxe TavSi, ‘lurji da
sunTqvaSekruli pacienti’. Tumca, swrafi Sefasebis dros sasicocxlo mniSvneloba
aqvs sicocxlisTvis saSiSi mdgomareobebis diagnostirebasa da mkurnalobas (mag.
mwvave asTma, filtvis SeSupeba, daWimuli pnevmoToraqsi, masiuri hemoToraqsi). am
yvelafers unda vumkurnaloT urgentulad, manam sanam gavagrZelebT pacientis
gamokvlevas. miuxedavad amisa yvela kritikuli avadmyofi unda iRebdes Jangbads
rom ar miviRoT sasicocxlo organoebis dazianeba an gulis gaCereba. sasunTqi
sistemis ukmarisobis ganviTarebis SemTxvevaSi, PaO2 unda iqnas SenarCunebuli rac
SeiZleba axlos 13kPa-Tan (100mmvw), sul cota 8kPa-ze (60mmvw) meti mainc an puls-
oqsimetrze saturacia unda iyos 90%. pacientebis umravlesobaSi es SesaZlebelia
miRweul iqnas usafrTxod maTi wamojdomiT da maRali wneviT Jangbadis miwodebiT
Jangbadis rezervuaris CanTidan niRbis meSveobiT. pacientTa im jgufSi, romlebic
itanjebian filtvebis qronikuli obstruqciuli daavadebiT (fqod), Jangbadis
maRal koncentracias SesaZlebelia gaaCndes uaryofiTi mxareebi da aseT
SemTxvevaSi limitirebuli mkurnaloba garantirebulia (ixileT Tavi
oqsigenoTerapiis Sesaxeb). aqedan gamomdinare am jgufis pacientebs emarTebaT
sasicocxlo organoebis dazianeba an gulis gaCereba Tu maT sisxlSi Jangbadis
done daeca. am jgufSi Cvens mizans warmoadgens PaO2 _ 8kPa (60mmHg) an saturaciapuls-oqsimetrze 90%. Tu romelime pacientis sunTqvis siRrme an sixSire
araadekvaturia unda gamoiyenoT `ambus~ (bag-valve-mask system) parkiT ventilacia,
rom gaZlierdes oqsigenacia da ventilacia, manam sanam mouxmobdeT intensivists
movlis asistents.
19
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
yvela kritikuli avadmyofi unda iRebdes Jangbads, raTa SenarCunebuli
iqnas PaO2 8kPa-is zemoT (60mmvw) an saturacia 90% puls oqsimetrze.
2.3 C _ cirkulacia
umravles samedicino da qirurgiul gadaudebel SemTxvevebSi hipovolemia
miCneulia Sokis pirvelad mizezad, roca damtkicebulia sapirispirod. manam sanam
aRmocendeba kardiogenuli Sokis naTeli niSnebi, yvela pacients romelsac aqvs
civi periferiuli nawilebi da taqikardia iTvleba, rom unda gadaesxas siTxeebi.
qirurgiuli pacientebSi swrafad unda iqnas gamoricxuli hemoragia (xiluli an
faruli).
manam sanam gamoCndeba kardiogenuli Sokis aSkara niSnebi, nebismieri
pacienti, romelsac aqvs civi periferiuli nawilebi da taqikardia,
saWiroebs intravenurad siTxeebis gadasxmas.
sasunTqi sistemis paTologias, mag. daWimuli pnevmoToraqss, SeuZlia moSalos
pacientis cirkulaciuri sistema, Tumca mas unda vumkurnaloT gamokvlevis
adreul etapze. manam sanam gamoiyenebT inspeqcias, auskultaciasa da palpacias
cirkulaciis Sesafaseblad.
vuyureb
gulsisxlZarRvTa sistemis moSlilobis dros aRiniSneba civi, fermkrTali
kidurebi an TiTebi. kapilarebis avsebis siCqare (normaSi 2 wamze naklebi)
SesaZlebelia swrafad Sefasdes TiTis wverebze 5 wamiani zewoliT, romelic unda
iyos gulis doneze (an odnav zemoT), imis mere rac SevwyvetT zewolas viTvliT
dros rac sWirdeba kapilarul avsebas. roca periferiuli cirkulacia
Sesustebulia, mag. gulidan gadmosrolili sisxlis raodenoba (postdatvirTva)Semcirebulia, am dros aseve SesaZlebelia aRiniSnebodes periferiuli cianozi.
periferiuli venebi iqneba gadavsebuli an kolafsirebuli. Semcirebuli
postdatvirTvis sxva naTeli maCvenebelia cnobierebis dabali done, Tu pacients
aqvs Sardsadenis kaTeteri, oliguria (Sardis moculoba <0.5 ml/kg/sT). inspeqcia
aseve unda moicavdes xiluli hemoragiis aRmoCenas Wrilobidan, Rrudan an
mtkicebulebebs aRmoCenili hemoragiisTvis (mag. gulmkerdis, intraperitonealuri
an gastrointenstinaluri), maSinac ki roca muclisa da gulmkerdis Rruebi
carielia.
carieli muclis Rruebi ar gamoricxavs aqtiur sisxldenas.
20
kritikuli mdgomareobis mqone pacientis Sefaseba
vismen
pacientis sisxlis wneva SesaZlebelia iyos sruliad normaluri, miuxedavad
Sokis arsebobisa, sakonpensacio meqanizmebis saSualebiT, romelic zrdis
periferiul rezistentobas Semcirebuli gulis wuTmoculobis fonze.
SeZlebisdagvarad unda aRiniSnos sistoluri da diastoluri values. dabali
diastoluri sisxlis wneva adasturebs arteriebis dilatacias (rogorc
sefsisisas), Semcirebuli pulsuri wneva (gansxvaveba sistolur da diastolur
wnevebis Soris, normaSi daaxloebiT 35-45 mmvw) adasturebs arteriul
vazodilatacias (kardiogenuli Soki an hipovolemia). gulis auskultaciiT
SesaZlebelia gamovlindes sarqvelebis dazianeba, magram es xSir SemTxvevaSi
gamousadegaria kritikuli pacientebis pirvelad gamokvlevaSi.
vrZnob
gulsisxlZarRvTa sistemis gamokvleva unda moicavdes centraluri da
periferiuli pulsis palpacias, romliTac unda dadgindes pulsis arseboba,
maCvenebeli, xarisxi, regularuloba da Tanabroba. susti pulsi amtkicebs
Semcirebul gulis wuTmoculobas, maSin roca Zafiseburi (bounding) pulsi
sefsisis indikatoria.
pacientis sisxlis wneva SesaZlebelia iyos sruliad normaluri, miuxedavad
Sokisa.
2.3.1 cirkulaciis moSlis swrafi marTva
konkretuli reanimaciis saSualebebi gamoyenebul unda iqnas cirkulaciis
moSlis mizezis mixedviT, Tumca mimarTuli unda iyos siTxis gadasxmaze,
hemoragiis kontrolze da qsovilebis perfuziis aRdgenisaken. swrafi (21 gv)
gamokvlevis dros Zalzed mniSvnelovania im mdgomareobebis aRmoCena, romlis
drosac saswrafo mkurnaloba sasicocxlo mniSvnelobisaa, mag. gulis tamponada,
masiuri an xangrZlivi hemoragiis dros, septicemiuri Soki. es aris urgentuli
mdgomareobebi, romelTac unda vumkurnalo saswrafod, manam sanam gavagrZelebT
pacientis gamokvlevas.
yvela kritikul mdgomareobaSi myof pacients unda hqondes adekvaturi siTxis
venuri miwodeba, minimum erTi, sasurvelia ori, 14 an 16g intravenuri kaTeteri.
gamoiyeneba mokle, farTo xvreliani kaTeteri, radgan maT aqvT yvelaze maRali
dinebis siCqare. 500ml SemTbari kristaloidebis Semcveli siTxis swrafi miwodeba
(5-10 wuTis ganmavlobaSi) xelsayrelia Tu pacienti normotenziulia, Tu pacienti
hipotenziuria sawyis etapze 1 litri misaRebia. im SemTxvevaSi Tu cnobilia, rom
pacients aqvs gulis mwvave ukmarisoba sawyis etapze man unda miiRos bolusurad
250ml siTxe da unda Catardes xSiri monitoringi (mag. gulmkerdis mosmena
krepitaciis aRmoCenis mizniT yoveli bolusis Semdeg, centraluri venuri wnevis
mxedvelobaSi miReba). regularulad pulsis sixSirisa da sisxlis wnevis
21
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
Semowmeba, romelic miznad isaxavs sistoluri sisxlis wnevis normalizebas, is
unda iyos >100 mmvw.
saWiroebis SemTxvevaSi, sisxli unda gaigzavnos sisxlis jgufis Sesamowmeblad
da jvaredin testze. sisxli sxva gamokvlevebisaTvis (SardmJava da
eleqtrolitebze, sisxlis saerTo analizze da sxva) aseve unda iqnas aRebuli
maSinve. zogierT pacientSi, imaT visac aReniSneba gastro-intestinuri an
intraabdominuri hemoragia esaWiroebaT saswrafo qirurgiuli Careva, romelic
erTaderTi efeqturi saSualebaa aseT SemTxvevaSi.
kristaloidebis Semcveli siTxis gadasxmis norma
normotenziuli 500
hipotenziuri 1000
savaraudod gulis daavadebiT 250
cxrili 2: siTxeebis daniSvna gulis ukmarisobis mqone pacientebisaTvis
sisxlis mimoqcevis ukmarisobis mqone pacientebis pirveladi gamokvlevis
mniSvnelovani nawilia xelaxali gadamowmeba. Tu ar aRiniSneba mdgomareobis
gaumjobeseba, unda gavimeoroT siTxis gadasxma qsovilebis perfuziis
gaumjobesebis mizniT. pacientebis mcire jgufSi siTxeebis gadasxmam SesaZlebelia
migviyvanos gulis ukmarisobis simptomebamde da niSnebamde (dispnoe, guliscemis
sixSiris momateba, gazrdili sauRle venis wneva, gulis mesame toni da filtvis
krepitacia auskultaciiT). Tu aRiniSna es simptomebi unda Semcirdes an saerTod
Sewydes siTxis miwodeba, aseT SemTxvevaSi unda gamoviyenoT qsovilebis perfuziis
gamaZlierebeli alternatiuli saSualebebi (mag. inotropebi, vazopresorebi).
pacientebi, romelTac esaWiroebaT didi raodenobiT siTxis infuzia, ar arian
stabilurebi, im SemTxvevaSic ki Tu aRiniSneba normaluri sasicocxlo
niSnebi.
2. 4 D _ cns
swrafad unda iqnas gamokvleuli pacientis nevrologiuri statusi, gugebis
gamokvleviTa (zoma, Tanabroba da sinaTleze reaqcia) da AVPU sistemis gamoyenebiT
(cxrili 3). damatebiT unda gamoiricxos hipoglikemia glukometris an dextrostixmeTodis gamoyenebiT.
22
kritikuli mdgomareobis mqone pacientis Sefaseba
cxrili 3: cnobierebis donis ganmsazRvreli Skala AVPU
cnobierebis dakargvis sxva mizezebSi Sedis hipoqsemia, hiperkapnia, Sokis Sedegad
tvinis hipoperfuzia an axlo warsulSi sedaciuri saSualebebis, gamayuCeblebis an
saanesTezio saSualebebis gamoyeneba. Tu yvla es mizezi gamoricxulia da
pacientis cnobiereba mainc daTrgunulia, saWiroa ABS-is gadaxedva, Tqven albaT
raime gamogrCaT.
Tu Zlieri hipoqsemia, hipoglikemia, hiperkapnia, Sokis Sedegad tvinis
hipoperfuzia an wamlebis moxmareba gamoricxulia, gadaxedeT ABC-is.
2.4.1 daTrgunuli cnobierebis swrafi marTva
gulaRma mwoliare, ugonod myofi pacientebi, romelTac aqvT adekvaturi
spontanuri ventilacia da sisxlis mimoqceva, imyofebian haergamtari gzebis
daxSobis saSiSroebis qveS. haergamtari gzebis dacviTi refleqsebi SesaZlebelia
arasakmarisni aRmoCndnen jirkvlebidan gamonayofi sekretis, nerwyvis an sisxlis
gadacdenisagan Tavis asarideblad. amrigad cnobiereba daTrgunuli pacientebis
movla umjobesia, maSin rodesac isini gverdulad wvanan. Tu aris xerxemlis
kisris nawilis paTologiis arsebobis saSiSroeba, pacienti unda iwves gulaRma da
mudmivi yuradReba unda mieqces haergamtar gzebs, raTa vuzrunvelyoT misi dacva
kuWis SigTavsis regurgitaciisagan. es moiTxovs eqimis an eqTnis yofnas pacientTan
mudmivad. Tu pacientis gadatrialeba aucilebelia, es unda ganaxorcielos
momuSave personalis ramodenime wevrma. zogadad pacientebs, romelTac
daTrgunuli aqvT cnobierebis done unda gadaviyvanoT intensiur ganyofilebaSi.
pacientebs, romelTac daTrgunuli aqvT cnobiereba unda gavuzomoT sisxlSi
glukozis Semcveloba. Tu is 3 mmol/l-ze qveviTaa, dauniSneT 25-50 mg glukozis
xsnari venaSi.
A normaluri cnobiereba (Alert)
V reagireba xmaze (Verbal)
P reagireba tkivilze(pain)
U reaqciis arqona(Unresponsive)
23
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
2.5 E - amocnoba
pacientis srulyofili gamokvlevisaTvis da imisaTvis, rom ar gamogvrCes
mniSvnelovani detalebi, SesaZlebelia saWiro gaxdes misi SiSveli sxeulis
daTvaliereba. es yvelaferi unda gakeTdes ise, rom pativi vceT pacientis Rirsebas
da ar davuSvaT sxeulis temperaturis vardna (siTbos dakargva). Sefasebis am
etapze gamokvleva koncentrirebuli unda iyos sxeulis im nawilze, romelic
yvelaze metad iwvevs pacientis cud mdgomareobas (mag. muclis Rruze operacia
gadatanil pacientze, romelsac aqvs hipovolemia).
am etapze CaatareT mizanmimarTuli kvelva.
2.6 sawyisi Sefasebisa da mkurnalobis periodis dasasruli
saswrafo Sefasebisa da mkurnalobis periodis Semdeg pacients unda etyobodes
ukeT yofnis niSnebi. agreTve unda Semcirdes kardiovaskularuli da sasunTqi
sistemebis kolafsis Sansebi. unda gaiTvaliswinoT gWirdebaT Tu ara daxmareba.
amis mizezi SeiZleba iyos is, rom situacia TqvenTvis ucnobia, saWiroa
specialistis SesaZleblobebi, an ubralod damxmare gesaWiroebaT. Tu es asea, ar
daayovnoT daxmarebis Txovna.
gWirdebaT daxmareba?
saWiroebis SemTxvevaSi pacientis haergamtari gzebi unda davicvaT martivi
haergamtari milebiT da pacienti unda imyofebodes gverdiT poziciaSi. puls-
oqsimetri ukve unda iyos damagrebuli da Jangbadis miwodebiT saturacia (Sa02)unda SevinarCunoT 100%-Tan maqsimalurad axlos, yvelaze cota 90%. saWiroebis
SemTxvevaSi unda daviwyoT ventilacia bag-valve-mask teqnikiT. pacients aseve unda
gadavusxaT siTxeebi. Cveni mizania pacients aRudges normaluri sisxlis wneva an
sistoluri aiwios 100 mmvw-ze metad. gulis cema unda daubrundes normas (60-100)
da unda gamoswordes hipoglikemia. gaxsovdeT, xSirad ramodenime wuTi sakmarisia,
rom reanimaciulma xerxebma imoqmedon. am stadiazec ki SesaZlebelia, rom
pacientis sasicocxlo niSnebi aradamakmayofilebeli iyos, magram isini unda
daubrundnen normalur mdgomareobas. am dros Tqven unda gadaxvideT pacientis
Sefasebis Semdeg etapze.
darwmundiT, rom yvela pacients utardeba monitoringi puls-oqsimetriT, xdeba
guliscemisa da sisxlis wnevis monitoringi arainvaziuri sisxlis wnevis
sazomi aparatiT. agreTve rutinulad unda aRiricxos sunTqvis sixSire.
24
kritikuli mdgomareobis mqone pacientis Sefaseba
3 pacientis sruli Sefaseba
pacientis sruli Sefaseba
gadaxedeT Canawerebs da cxrilebs
moipoveT pacientis avadmyofobis istoria
awarmoeT sistematiuri gamokvlevebi
SeamowmeT rutinuli gamokvlevebis Sedegebi
3.1 gadaxedeT pacientis Canawerebs da cxrilebs
pacientis Canawerebisa da cxrilebis Semowmeba (sisxlis wneva, nevrologiuri
gamokvlevis cxrili, siTxis balansi, daniSnuli wamlebis cxrili da sxva),
sasicocxlo niSnebis Canawerebis naxva da sxva eqimebTan erTad am yvelafris
ganxilva dagexmarebaT, rom daadginoT Tu ra mdgomareobaSi imyofeba pacienti
amJamad. erTi SexedviT SesaZlebelia mogeCvenoT, rom es Canawerebi zedmetad bevr
informacias Seicaven, magram maTi asimilacia SesaZlebelia sistemuri analiziT.
mniSvnelovania absoluturi maCveneblebisa da dinamikis codna. Mag tu sistoluri
wneva 150 iyo da 100 ze Camovarda, 100 rogorc maCvenebeli SeiZleba misaRebi iyos
rogorc izolirebuli maCvenebeli magram dinamikaSi 50 iT wnevis davardna
mniSvnelovania. (cxrili 4).
wamlebis receptebis gadaTvalierebisas daakvirdiT, aris Tu ara yvela
mniSvnelovani rutinuli medikamenti gamowerili da miwodebuli. dro da dro
wamlebis miwodeba saWiro iqneba sxvadasxva gzebiT (magaliTad oraluris magivrad
venidan).
sisxlis mimoqceva _ guliscema da ritmi/sisxlis wneva/ CVP
hidratacia _ intravenuri siTxeebi/ Sardis gamoyofa/ siTxis balansi
cnobiereba _ glazgos komis Skala
sunTqva _ sunTqvis sixSire/ CasunTquli Jangbadis koncentracia/ Sa02
temperatura _ temperatura
gansakuTrebuli maxsiaTeblebi _ drenireba/pacientebis avadmyofobis specifikuri
aspeqtebi
cxrili 4: pacientis cxrilebis (grafikebis) mimoxilva C.A.R.T. S sistemis mixedviT.
25
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
3.2 moipoveT pacientis avadmyofobis istoria da awarmoeT sistematiuri
gamokvlevebi
am etapze Canawerebi dagexmarebaT xazi gausvaT pacientis amJamindeli
samedicino da qirurgiul mdgomareobas da sxva adre arsebul daavadebebs. ko-
morbidulma mdgomareobebma (mag. hipertenzia, Saqriani diabeti) SeiZleba gavlena
iqonios im momentSi arsebul daavadebaze pacientis pasuxze, romelsac
aucileblad unda miaqcioT yuradReba. amis Semdeg aucilebelia pacientis
klinikuri gamokvleva tradiciuli formatiT. drodadro sasurvelia testebis
gameoreba, radgan eqimebsa da eqTnebs SesaZlebelia pirvel jerze gamorCeT
mniSvnelovani informacia.
mcire SualedebiT pacientis Sefaseba, an iseTi martivi Careva, rogoricaa
siTxis miwodeba xSirad gvexmareba diagnosis dazustebaSi.
3.3 rutinuli gamokvlevebisa da Sedegebis gadaxedva
axla ki droa gadaxedoT yvela gamokvlevis Sedegs, raTa darwmundeT, rom Tqven
SegwevT unari swrafad daexmaroT pacients. es unda moicavdes bioqomiur,
hematologiur da mikrobiologiur Sedegebs da radiologiur pasuxebs(cxrili 5)
bioqimia:
ü U&Eü sisxlis gazebi da mJavebis balansi
ü sisxlis glukoza
mikrobiologia:
ü sisxli
ü nerwyvi
ü Sardi
ü CFS
cxrili 5 – rutinuli gamokvlevebi da gegmebi
4 gadawyvetilebebi da dagegmva
gadawyvetilebebi da dagegmva
am etapze unda gadawyvitoT pacienti gamojanmrTelebis gzazea, ar aris
cvlilebebi Tu darwmunebuli ar xarT. agreTve unda gaiTvaliswinoT gaqvT Tu
ara sando diagnozi.
v umjobesdeba pacientis mdgomareoba?
v gaqvT saTanado diagnozi?
hematologia:
ü sisxlis saerTo analizi
ü sisxlis Sededeba
ü sisxlis jgufi
radiologia:
ü gulmkerdis radiograma
ekg
ü 12 ganxraSi.
26
kritikuli mdgomareobis mqone pacientis Sefaseba
4.1 pacientebi, romelTa mdgomareobac umjobesdeba da aqvT Sesabamisi
diagnozi, romelic srulad asaxavs maT amJamindel mdgomareobas
Tu Tqveni azriT pacientis mdgomareobis mizezebi naTelia, unda daigegmos
Sesabamisi mkurnaloba, Tumca aucilebelia Tqveni zemdgomi kolegis saqmis kursSi
Cayeneba. Tqven agreTve unda gadawyvitoT misaRebia Tu ara intensiurSi myofi
pacientebis gadayvana Cveulebriv palataSi, iq sadac maT SedarebiT naklebi movla
sWirdebaT. yvela stabilur pacients esaWiroeba marTvis gegma, romelic me-6
cxrilze gamosaxul faqtorebs asaxavs. es gegma agreTve unda Seicavdes sxva
momsaxure personalisaTvis gankuTvnil naTel instruqciebs. is gadawyvetilebebi,
omlebic am instruqciebs exeba, umjobesia ufros TanamSromlebTan SeTanxmebiT
Semdeg miiRoT. agreTve mniSvnelovania informaciis miwodebisa da gamxnevebis
mizniT pacientTan saubari.
sisxlis analizi siTxis balansi
radiografia siTxeebis miwodeba
specialistis azri wamlebi
drenaJi Tu milebi (? moSoreba) gautkivareba
oralurad misaRebi profilaqtika (mag. heparini)
kveba (parenteruli an enteraluri) fizioTerapia (gulmkerdi da kidurebi)
cxrili 6: stabilizebuli pacientis marTvis gegma
4.2 pacientebi romelTa mdgomareoba ar umjobesdeba an darwmunebuli ar
xarT maT gamojanmrTelebaSi
Tu ar aRiniSneba ukeTesoba, an Tqven ar xarT darwmunebuli misi janmrTelobis
mdgomareobis gaumjobesebaSi gadaxedeT ABC da iTxoveT daxmareba. SesaZlebelia,
rom Tqven mniSvnelovani miniSneba gamotoveT an is axlaxan gamoaSkaravda. amis
gaTvaliswineba dagexmarebaT swori diagnozis dasmaSi. sanam damxmare pirebi
movlen, ganagrZeT pacientis daxmareba.
4.3 pacientebi, romelTa mdgomareoba umjobesdeba, Tumca maT ar aqvT sando
diagnozi
Tu Tqven gyavT pacienti, romlis janmrTelobis mdgomareoba umjobesdeba,
magram Tqven ar gaqvT zusti diagnozi, saWiro iqneba misi Semdgomi gamokvleva da
mkurnaloba. am etapze mniSvnelovania daxmarebis moTxovna. sanam damxmare pirebi
movlen, ganagrZeT pacientis monitoringi, raTa darwmundeT, rom mdgomareoba
umjobesdeba an stabiluria. agreTve unda dafiqrdeT, saWiroa Tu ara ufro
maRali donis mzrunveloba (mag. HDU ICU).
27
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
4.4 specifikuri gamokvlevebi
sando diagnozis dasmas zogjer specifikuri gamokvlevebi esaWiroeba,
pacientebs ki daxmarebis aRmoCena gamokvlevebis Sedegebis gagebamde unda
CautardeT. magaliTad, SeiZleba saWiro gaxdes pacientis potenciurad saSiS
garemoSi, rogoricaa radiologiur departamentSi, gadayvana. aseT SemTxvevaSi
gamokvlevebi da daxmarebis aRmoCena paralelur reJimSi unda Catardes, xolo
personali mas Tan unda axldes procedurebis dros. arasamedicino personalma
aseT mdgomareobaSi pacienti ar unda gadaadgilon, pacientis gadaadgileba
ekrZaleba samedicino personalsac Tu maT Tan ar aqvT reanimaciuli mowyobiloba.
im SemTxvevaSic ki Tu saWiro procedurebi Zneli gasakeTebelia an droSi
mouxexebelia TqvenTvis da Tqveni gundisaTvis, ar unda danebdeT, radgan mZime
avadmyofebi spontanurad ar gamojanmrTeldebian, gansakuTrebiT dilis saaTebSi.
gamokvlevebis gadavadebam SeiZleba mdgomareobis gauareseba gamoiwvios da yvela
is winsvla, rac reanimaciuli saSualebebis daxmarebiT miiReT SeiZleba daikargos.
radiologiis departamenti saxifaTo adgilia avadmyofebisaTvis.
gesaWiroebaT daxmareba?
4.5 Canawerebis warmoeba
rodesac Tqven pacients sinjavT mniSvnelovania CanawerebSi amis aRniSvna
(ixileT me-9 Tavi organizaciuli da komunikaciuri unarebi). Canawerebis warmoeba
dagexmarebaT Tqveni azrebis dazustebaSi da saSualebas miscems sxva eqimebs
gaigon Tu ra moxda da rogori zemoqmedeba iqonia Tqvenma Carevam pacientis
janmrTelobaze. Tqven Canawerebs aseve samarTlebrivi mniSvneloba aqvs.
4.6 saboloo mzrunveloba
aqamde Tqveni mizani iyo pacientis sicocxlis SenarCuneba da gaumjobeseba,
raTa mas Cautardes saboloo mkurnalobis kursi. saboloo mkurnaloba SeiZleba
iyos konservatiuli, qirurgiuli an radiologiuri. xandaxan is samives moicavs da
swored amitom maTi koordinireba aucilebelia. am etapze mniSvnelovania, rom
Tqven saqmeSi gundis danarCeni wevrebi CarToT.
28
kritikuli mdgomareobis mqone pacientis Sefaseba
Sejameba:
ü Sefasebis marTviTi sistemis gamoyeneba amcirebs mniSvnelovani simptomebis
da niSnebis SeumCnevlobis risks.
ü Tu TvliT, rom situacias marto ver umklavdebiT moiTxoveT daxmareba.
ü sahaero gzebis dazianeba sicocxlisaTvis saxifaTo mdgomareobaa, igi
moiTxovs dauyovnebliv mkurnalobas. mkurnalobis xerxebi ki umeteswilad
martivia.
ü yvela kritikulma pacientma unda miiRos Jangbadi. sasurvelia Sa02 minimum
90% iyos.
ü yvela kritikul pacients unda gadaesxas siTxeebi venidan.
ü SeiswavleT yvela Canaweri da cxrili detalurad, detalebze yuradRebis
gamaxvileba Zalzed mniSvnelovania.
ü acnobeT Tqveni moqmedebis Sesaxeb verbalurad da werilobiT.
29
galurjebuli pacienti da sunTqvis gaZneleba
am Tavis bolos Tqven SegeZlebaT:
· ganasxvaoT centraluri da periferiuli cianozi da CamoTvaloT maTi
mizezebi;
· gaigoT sunTqvis gaCerebis mizezebi da
· aRweroT Jangbadis usafrTxo da racionaluri gamoyeneba.
1. cianozi
1.1 centraluri cianozi periferiuli cianozis pirispir
cianozi niSnavs kanis, frCxilis sawolebis, tuCebisa da enis galurjebas, rasac
iwvevs sisxli Jangbadis dabali wneviT (PaO2). is mimdinareobs ori formiT:
centraluri da periferiuli.
centraluri cianozi yalibdeba maSin, rodesac kapilarul sisxlSi 5gm/dl
aRdgenili hemoglobinia (deoqsihemoglobini) da Cveulebriv SesamCnevia, rodesac
arteriuli Jangbadis saturacia 85%-ze naklebia. centraluri cianozis gamomwvevi
xSiri mizezebi moicavs gulis an filtvebis daavadebebs da CamoTvlilia me-7
cxrilSi. cianozi TiTqmis yovelTvis aRiniSneba policitemiis dros da Zalian
iSviaTad anemiis dros. faqtiurad, anemiur pacientebs SeiZleba, hqondeT PaO2
normaluri mniSvneloba da normaluri saturacia, miuxedavad sisxlSi Jangbadis
Semcvelobis mkveTri daqveiTebisa.
mwvave pnevmonia qronikuli filtvebis qronikuli obstruqciuli
daavadeba
mwvave asTma filtvis fibrozi
filtvis edema gulis marjvena-marcxenamxrivi Sunti
filtvis embolia policitemia
pnevmoToraqsi
cxrili 7. centraluri cianozis xSiri mizezebi
periferiuli cianozi viTardeba maSin, rodesac mocirkulire sisxlis
oqsigenacia adeqvaturia, magram lokaluri cirkulaciis darRvevebis gamo kidurebi
lurj Seferilobas iRebs. periferiuli cianozi Sedegia dune periferiuli
cirkulaciisa, romelic viTardeba hipovolemiis, kardiogenuri Sokis, civi garemos
da arteriuli an venuri obstruqciis Sedegad. sisxlis moZraobis Seneleba iwvevs
qsovilebis mier sisxlidan meti Jangbadis aTvisebas, Sedegad izrdeba
deoqsigenirebuli mocirkulire sisxlis raodenoba. Tu periferia galurjebulia,
ena da tuCebi ki vardisferi, saqme gvaqvs periferiul cianozTan.
1.1.1 romeli darRvevebi iwvevs centralur cianozs?
centraluri cianozi SeiZleba iyos Semdegi procesebis Sedegi:
· hipoventilacia;
· darRvevebi, romelTa drosac ventilacia da perfuzia erTmaneTs ar
Seesabameba;
30
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
· darRvevebi, romlebic asocirebulia airebis gadatanis SeferxebasTan da
· marjvena-marcxenamxrivi intrakardiuli Sunti.
CamoTvlili mizezebidan hipoventilacia da paTologiebi, romlebic ventilacia-
perfuziis Sesabamisobis darRvevas iwvevs mwvave gadaudebel SemTxvevebSi cianozis
yvelaze xSiri mwvave mizezebia.
1.2 hipoventilacia
filtvebis umTavresi funqciaa Jangbadis aTviseba da naxSirorJangis gamoyofa.
naxSirorJangis moSoreba organizmidan damokidebulia filtvis adeqvatur mTlian
ventilaciaze (TiToeuli sunTqvis moculoba gamravlebuli sunTqvis sixSireze) da
misi koncentracia sisxlSi alveoluri ventilaciis ukuproporciulia. ufro
martivad, Tu pacientis sunTqva Semcirda (moculobis an sixSiris xarjze)
arteriul sisxlSi naxSirorJangis wneva (PaCO2) gaizrdeba. Tu alveoluri
ventilacia ganaxevrda, naxSirorJangis wneva gaormagdeba.
hipoventilacias axasiaTebs gazrdili PaCO2. hipoventilaciis (Semcirebuli
alveoluri ventilaciis) xSiri mizezebia sasunTqi gzebis obstruqcia, cns-is
damTrgunveli preparatebi (mag. sedaciurebi, opiatebi, saanesTezio saSualebebi,
Warbdozireba), cns-is paTologiebi (mag. meningiti), periferiuli neiromuskuluri
paTologiebi (mag. giien-bares sindromi, myasthenia gravis) da sunTqvis mwvave
ukmarisobis bolo stadia gamofitvis gamo (sasunTqi gzebis gazrdili winaRobis an
filtvis Semcirebuli damyolobis gamo).
hipoventilaciis xSiri mizezebi moicavs:
· sasunTqi gzebis obstruqcias;
· cns-damTrgunveli preparatebi;
· cns-daavadebebi;
· periferiuli neiromuskularuli daavadeba da
· gamofitva.
ratom iwvevs PaCO2–is gazrda PaO2–is Semcirebas?
PaCO2-sa da alveolur PO2 (PAO2)-s Soris damokidebuleba ganisazRvreba alveoluri
haeris tolobiT (ixileT modificirebuli formula qvemoT).
PAO2 = FiO2 (Pb-PAH2O) – , sadac PAO2 aris alveoluri PO2; FiO2 – Jangbadis fraqciuli
CasunTqvis koncentracia; Pb – barometruli wneva; PAH2O - wylis alveoluri
parcialuri wneva. roca FiO2, Pb, PAH2O mudmivia, PAO2 mcirdeba PaCO2 –is gazrdasTan
erTad. normalur filtvebSi PAO2 TiTqmis igive mniSvneloba aqvs, rac arteriul PO2
( PaO2)-s. Sesabamisad PaCO2–is gazrdasTan erTad PaO2 mcirdeba. hipoventilaciis dros
PaO2–is gazrda SesaZlebelia Jangbadis miwodebiT (zemoT mocemul tolobaSi FiO2-is
gazrdis gziT), magram es ar awesrigebs PaCO2–is dones.
31
galurjebuli pacienti da sunTqvis gaZneleba
mwvave hipoventilaciiT gamowveuli hipoqsemiis mkurnaloba:
· sveli wesiT Jangbadis miwodeba sakmarisad maRali koncentraciiT
(idealuria 100%), raTa PaO2 –ma moimatos 8kPa–zemetad (an SaO2 avides 90%-ze
maRal maCvenebelze);
· ambus parkiT damxmare ventilaciis uzrunvelyofa;
· cns-is wamliT inducirebuli depresiis Seqceva (magaliTad naloqsoni
opiatebis Warbdozirebis dros);
· saswrafod dakavSireba reanimaciis ganyofilebasTan asistirebisaTvis.
1.3 ventilacia-perfuziis Seusabamoba
Cveulebriv, filtvebis ventilacia da sisxlis nakadi Seesabameba erTmaneTs da amis
Sedegia gazTa normaluri cvla. Tu ventilacia Semcirda filtvebSi sisxlis
nakadTan SedarebiT (rogorc pnevmoniis dros) an Tu sisxlis nakadi Semcirda
ventilaciasTan SedarebiT (rogorc filtvis emboliis dros) aucileblad
viTardeba hipoqsemia. sunTqvis mwvave ukmarisobis mqone pacientebSi ventilacia-
perfuziis Sesabamisobis darRveva hipoqsemiis gamomwvevi yvelaze xSiri mizezia.
ventilacia-perfuziis Seusabamobis gamomwvevi yvelaze xSiri mizezebi moicavs:
· pnevmonia;
· filtvis edema;
· mwvave asTma;
· pnevmoToraqsi;
· filtvis embolia;
· filtvebis qronikuli obstruqciuli daavadeba da
· mwvave respiraciuli distres sindromi.
ventilacia-perfuziis darRvevis mqone pacientis specifikuri mkurnaloba
damokidebulia mis gamomwvev mizezze (cxrili 8), magram pirveli rigis Terapia
yovelTvis unda iyos mimarTuli ABC-s marTvaze.
1.3.1 pacientebi, romelTac ar awuxebT filtvebis qronikuli obstruqciuli
daavadeba.
32
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
mwvave respiratoruli daavadebis mqone pacientTa umralesobisaTvis ZiriTadi
riskia arasakmarisi Jangbadis micema, radgan hipoqsemiam SeiZleba gamoiwvios tvinis
dazianeba, kardiuli disriTmiebi, miokardiumis infarqti, gulis gaCereba.
Sesabamisad pacientebis umravlesobas SeiZleba mieces 100%-iani Jangbadi niRbiT da
Jangbadis rezervuariT (ixileT qveviT) moklevadiani uaryofiTi efeqtis riskis
gareSe. aseT pacientebSi gonivrulia, Jandbadis saturaciis (SaO2) samizne doned
arCeul iqnas 100% an sul mcire 90% (8kPa an 60mm.vwy.sv.). damatebiTi Jangbadis
efeqti yovelTvis unda Sefasdes pacientis sunTqvis sixSiris, siRrmis, sunTqvis
saxis, cnobierebis donis da puls-oqsimetriT gansazRvruli SaO2–is mixedviT.
pacientebisaTvis, romelTac ar awuxebT filtvebis
qronikuli obstruqciuli daavadeba SaO2–is samizne
mniSvnelobaa 100%.
suraTi 5: SaO2-is rekomendirebuli samizne done filtvebis qronikuli
obstruqciuli daavadebis armqone pacientebSi.
xSirad hipoqsemiaze pasuxi aris hiperventilacia – gazrdili alveoluri
ventilacia, radgan pacienti cdilobs, gazardos Jangbadis miwodeba filtvebidan.
aseT SemTxvevaSi sisxlSi airebis tipiuri Semcvelobaa daqveiTebuli PaCO2 da PaO2.
Tumca, rodesac pacienti iRleba gaxangrZlivebuli, gaZlierebuli sunTqviTi
ZalisxmeviT, PaCO2-is mniSvneloba iwyebs momatebas. es aris maCvenebeli
ventilaciuri daxmarebisaTvis (invaziuri an arainvaziuri ventilacia), da ara
Jangbadis koncentraciis daqveiTebisaTvis. daukavSirdiT reanimaciis ganyofilebas.
sunTqvis mwvave ukmarisobis mqone pacientebSi CasunTquli Jangbadis maRali
koncentracia ar iwvevs ventilaciis daTrgunvas.
1.3.2 filtvebis qronikuli obstruqciuli daavadebis mqone pacientebi
filtvebis qronikuli daavadebis mqone pacientebis umravlesoba pasuxobs iseve,
rogorc is pacientebi, romelTac qronikuli problemebi ar aqvT (e.i. maTi marTva
SeiZleba zemoT aRwerili sqemiT). Tumca filtvebis qronikuli obstruqciuli
33
galurjebuli pacienti da sunTqvis gaZneleba
daavadebis mqone pacientTa mcire nawili ukontrolod (maRali koncentraciiT)
Jangbadis miwodebis SemTxvevaSi sunTqvis daTrgunvis riskis qveS aris. am
pacientebs kargad yofnis drosac PaCO2–is done momatebuli aqvT da SesaZloa,
Seguebulebi iyvnen sisxlSi Jangbadis normalurTan SedarebiT daqveiTebul
koncentraciasTan. aseT pacientebs Jangbadis gamoyenebis dros gaZlierebuli
monitoringi sWirdebaT. Terapiis safuZvlad mainc rCeba Jangbadis miwodeba PaO2–is
normalizaciisTvis saWiro, an sul mcire, SaO2-is 90%-mde (8kPa an 60mm.vwy.sv.)
gazrdisaTvis saWiro koncentraciiT. aseTi pacientebisaTvis rekomendebulia
Terapiis dawyeba 35%-iani JangbadiT (venturis tipis Jangbadis miwodebis sistemis
gamoyenebiT) da Jangbadis koncentraciis TandaTan gazrda monitoringis pirobebSi.
es niSnavs, rom vinme mudmivad pacientTan unda iyos da akontrolos sunTqvis
sixSire, siRrme da saxe, cnobierebis done da puls-oqsimetriT gansazRvruli SaO2.
filtvebis qronikuli obstruqciuli daavadebis mqone pacientTa mcire
nawils uviTardeba sunTqvis depresia ukontrolod (maRali koncentraciiT)
Jangbadis miwodebis SemTxvevaSi.
pacientebisaTvis, romelTac awuxebT filtvebis
qronikuli obstruqciuli daavadeba SaO2–is samizne
mniSvnelobaa 90%.
suraTi 5: SaO2-is rekomendirebuli samizne done filtvebis qronikuli
obstruqciuli daavadebis mqone pacientebSi.
34
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
cxrili 8. ventilacia-perfuziis Seusabamobis gamomwvevi darRvevebis specifikuri
mkurnaloba.
ventilacia-perfuziis SeusabamobiT gamowveuli hipoqsemiis mkurnaloba:
· Jangbadis miwodeba sveli wesiT, raTa miRweul iqnas saturacia sul mcire
90% (8kPa an 60mm.vwy.sv.). pacientTa umravlesobisTvis 100%-iani Jangbadi
usafrTxoa.
· specifiuri mkurnaloba damokidebulia mizezze. is SeiZleba Seicavdes
antibiotikebs (pnevmonia), bronqodilatatorebs (mwvave asTma), gulmkerdis
drenirebas (pnevmoToraqsi), an antikoagulantebs (filtvis embolia).
· mwvave respiratoruli daavadebis dros Tu PaCO2 izrdeba an pacienti xdeba
Ziliani, miawodeT damxmare ventilacia ambus parkiT da daukavSirdi
reanimaciis ganyofilebas.
· Jangbadis miwodebis dros aucilebelia sunTqvis sixSiris, siRrmis, saxis,
cnobierebis donis da puls-oqsimetriT gansazRvruli SaO2-is mudmivi
kontroli.
1.4 airTa cvlis darRveva
alveolur-kapilarul membranaSi gasuli airis (Jangbadis) moculoba
ukuproporciulia misi sisqisa da proporciulia membranis gaswvriv parciuli
wnevis sxvaobisa. Sesabamisad, Jangbadis gadatana Senelebulia iseTi
mdgomareobebis dros, rogoricaa filtvis fibrozi, filtvis edema, rodesac
darRveva mkurnaloba/marTvapnevmonia Jangbadi sveli wesiT
fizioTerapiaantimikrobuli Terapia
filtvis edema diuretikebivenodilatatorebiopiatebi
mwvave asTma Jangbadi sveli wesiTbronqodilatatorebi (mag. salbutamoli)kortikosteroidebiantimikrobuli Terapia (Tu gamomwveviinfeqciuria)
filtvis embolia Tromboliziantikoagulantebi
filtvebis qronikuli obstruqciuli daavadeba Jangbadi sveli wesiTfizioTerapiaantimikrobuli Terapiabronqodilatatorebi (mag.salbutamoli)kortikosteroidebi
mwvave respiratoruli distress sindromi mizezis mkurnalobareanimaciisganyofilebisTvis mimarTva
35
galurjebuli pacienti da sunTqvis gaZneleba
membrana sqeldeba Sesabamisad fibrozuli qsovilis an intersticiuli, alveoluri
siTxis xarjze. hipoqsemiis nawilobriv Seqceva SesaZlebelia Jangbadis miwodebiT
da Sesabamisad parciuli wnevis gradientis gazrdiT. Jangbadis miwodeba unda
moxdes sveli wesiT, maRali koncentraciiT an sakmarisi koncentraciiT, raTa
miRweul iqnas saturacia sul mcire 90% (8kPa an 60mm.vwy.sv.). Tu airTa cvlis
darRvevis mizezi Seqcevadia (magaliTad filtvebis edema), mas sWirdeba saTanado
mkurnaloba.
1.5 marjvena-marcxenamxrivi intrakardiuli Sunti
es aris ventilacia-perfuziis Seusabamobis ukiduresi forma, rodesac sisxli
mTlianad gverds uvlis ventilaciis ubnebs. aseTi pacientebi or jgufad iyofian:
pacientebi, visTvisac cnobilia gulis Tandayolili defeqtis arseboba da
pacientebi SeZenili (mag. post-miokardiumis infarqtuli) darRveviT. JangbadiT
Terapia aseT pacientebSi ar aumjobesebs oqsigenacias, radgan is gavlenas ver
axdens Jangbadis Semcvelobaze im sisxlSi, romelic SuntSi miedineba.
2. sunTqvis gaZneleba (dispnoe)
dispnea xasiaTdeba sunTqvis sixSiris ukiduresad gazrdiT da gaZnelebiT. mas
iwvevs:
· gazrdili ventilaciuri moTxovnileba (mag. hipoqsemia, hiperkapnia, acidozi,
anemia, varjiSi);
· Semcirebuli ventilaciis moculoba (mag. gulmkerdis deformacia, daWimuli
filtvebi, haeris nakadis obstruqcia, sasunTqi kunTebis sisuste) da
· gazrdili subieqturi mgrZnobeloba (mag. isteria, SfoTva).
dispnoes marTva moicavs:
· pacientis ganTavsebas vertikalur poziciaSi;
· darwmuneba (aman, SesaZloa, Seamciros SfoTva);
· damatebiTi Jangbadis miReba (aman SesaZloa Seamciros zedmeti sunTqviTi
datvirTva);
· bronqodilatatorebis miReba (Tu aris bronqospazmi) da
· opiatebi (saWiroa sifrTxile maTi gamoyenebisas, radgan arian sunTqviTi
depresantebi).
3. oqsigenoTerapia
3.1 oqsigenoTerapiis daniSnuleba
Jangbadi aris wamali. iseve, rogorc yvela samkurnalo saSualebas, masac gaaCnia
upiratesobebi da gverdiTi efeqtebi. maSasadame, oqsigenoTerapia yovelTvis unda
iyos eqimis mier daniSnuli, gamonakliss warmoadgens gadaudebeli SemTxveveebi,
roca misi miReba xdeba verbaluri daniSnulebis safuZvelze, imisaTvis, rom
mkurnaloba dawyebul iqnas manam, sanam eqimi miaRwevdes pacientamde. receptSi
unda iyos miTiTebuli, Tu ra saxiT moxdeba Jangbadis miwodeba(mag. nazaluri
kanula, martivi sainhalacio niRabi), misaRebi Jangbadis procentuloba (Jangbadis
36
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
dinebis done misaRebia rogorc alternativa), Terapiis xangrZlivoba da
monitoringi (mag. oqsimetri, arteriuli sisxlis gazebi).
oqsigenoTerapiis daniSvnisas aucilebelia miTiTebul iqnas:
ü Jangbadis miwodebis gza
ü miwodebuli Jangbadis procentuloba (an nakadis done)
ü Terapiis xangrZlivoba
ü monitoringi
3.2 oqsigenoTerapiis monitoringi
yovelTvis akontroleT Tqvens mier daniSnuli oqsigenoTerpiisEefeqtebi. es
SeiZleba ganxorcieldes klinikurad (pacientis kanis feri, respiratoruli
distresis xarisxi, sunTqvis sixSire), pulsoqsimetris gamoyenebiTa da arteriul
sisxlSi gazebis maCveneblebis kontroliT. am ukanasknels aqvs upiratesoba, radgan
zomavs orives _ Jangbadisa da naxSirorJangis doneebs, aqedan gamomdinare,
gvaZlevs informacias, ris safuZvelzec SesaZlebelia gavakontroloT oqsigenacia
da ventilacia erTdroulad. Tu naxSirorJangis done iwyebs zrdas filtvebis
mwvave daavadebis mqone pacientSi, es misTvis xSir SemTxvevaSi damRlelia da
SesaZloa saWiro gaxdes ventilaciiT daxmareba. meores mxriv, Tu naxSirorJangis
done aiweva pacientSi filtvebis qronikuli daavadebiT, gonivruli
gadawyvetileba iqneba, Semcirdes miwodebuli Jangbadis koncentracia. ase rom,
gaxsovdeT, Tu davuSvebT, rom pacientis arteriul sisxlSi Jangbadis done Zalian
daeces, miviRebT gardauval Sedegebs: gulis riTmis darRveva, miokardiuli iSemia,
tvinis dazianeba da gulis gaCereba.
yovelTvis akontroleT oqsigenoTerapia:
klinikuri niSnebiT
pulsoqsimetris saSualebiT
arteriuli sisxlis gazebis maCveneblebiT.
3.2.1. sisxlis airebis gansazRvra
rodesac sazRvravT arteriul sisxlSi gazebs, ar moaSoroT pacients Jangbadis
sainhalacio niRabi. es klinikurad araswori da arasaWiro qmedebaa, romelic
Seicavs avadmyofis mdgomareobis moulodneli gauaresebis safrTxes, rac
SesaZlebelia arasasurveli SedegebiT damTavrdes. rogorcve CawerT, ra
koncentraciis Jangbadi miewodeba pacients, maSinve unda aRebul iqnas arteriuli
sisxlis gazebi, hipoqsemiis xarisxi unda Sefasdes alveoluri gazebis(alveolar-air)gantolebiT (ix.30gv.)
daimaxsovreT, rom aucileblobas ar warmoadgens da SesaZloa saSiSic iyos
pacientisTvis Jangbadis niRbis moxsna, nacvlad imisa, rom ganisazRvros
sisxlSi gazebis done.
37
galurjebuli pacienti da sunTqvis gaZneleba
3.2.2. puslsoqsimetria
pulsoqsimetriis danergvam SesaZlebeli gaxada kritikuli pacientis monitoringi
martivi gziT. arteriul sisxlSi Jangbadis saturacia(SaO2)
isazRvreba spacialuri deteqtoris moTavsebiT pacientis TiTis proqsimalur
falangze, yuris bibiloze an cxviris Zgideze.(?) oqsimetris deteqtoridan
gamosxivebuli sinaTle qsovilebis gavliT aRwevs sisxlamde da aRricxavs arekvlili
sinaTlis maCvenebels. oqsigenirebuli da araoqsigenirebuli hemoglobini
gansxvavebuli intensivobis sinaTles STanTqavs, xolo oqsimetri am informaciis
safuZvelze aRricxavs SaO2-s.
oqsimetris monacemebi garkveul SemTxvavaSi arasandoa, magaliTad, Tu qsovilebis
perfuzia sustia (mag.Sokis dros), Tu pacienti civ garemoSia, anda frCxili
dafarulia laqiT, aseve Tu pacienti kankalebs, an aqvs krunCxva. SaO2-is normaluri
done aris TiTqmis 100%.
Tu oqsimetri ver gawvdiT sinusoidur maCvenebels an SaO2-is dones, ar CaTveloT
rom is dazianebulia, SeiZleba pacienti iyos avad. :)
pulsoqsimetri gvawvdis SesaniSnav informacias sisxlis JangbadiT gajerebis
Sesaxeb, Tumca is ar uCvenebs ventilaciis adeqvaturobas. aqedan gamomdinare, roca
SaO2 normaa, es ar niSnavs imas, rom pacientis ventilacia sakmarisia naxSirorJangis
organizmidan gamosyofad. es mxolod arterul sisxlSi gazebis SemcvelobiT
ganisazRvreba. normaSi, hemoglobinis TiTqmis 100%-ia gajerebuli JangbadiT. 90%-is
qvemoT SaO2 swrafad ecema, rac gamosaxulis Jangbadis disociaciis mrudze (sur.7)
suraTi 7 - Jangbadis disociaciis mrudi. uCvenebs, Tu rogor swrafad ecema sisxlSi
Jangbadis parcialuri wneva, roca Jangbadis saturacia 90-is qvemoTaa.
38
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
oqsimetria gvawvdis SenasiSnav informacias sisxlis JangbadiT gajerebis Sesaxeb,
Tumca is ar uCvenebs ventilaciis adeqvaturobas.
3.3. Jangbadis mimRebi sistemebi
Jangbadis mimRebi sistemebis mravali saxe arsebobs, romelic iZleva saSualebas
pacients miewodos 21-dan 100%-mde koncentraciis Jangbadi. JangbadmimRebi sistemebis
ori ZiriTadi kategoria arsebobs: cvladi sistemebi, romelic Jangbads ventilaciis
moTxovnebis Sesabamisad awvdis da fiqsirebuli sistemebi, romlebic awvdis srul
ventilaciur resurss.(?)
3.3.1. cvladi JangbadmimRebi sistemebi
imisaTvis, rom pacientis ventilaciuri moTxovnebi dakmayofildes, es xelsawyoebi
ar awvdis Jangbads sruli ventilaciuri SesaZleblobebis farglebSi. isini pacientis
sasunTq sistemaSi rTaven rezervuarSi aresebul haers. rezervuars SesaZlebelia
warmoadgendes nazofaringsi, orofaringsi, niRabi da masTan dakavSirebuli haeris
parki. ra koncentraciiT miewodeba Jangbadi pacientis filtvebs ganisazRvreba Semdegi
maCveneblebiT: Jangbadis nakadis done, avadmyofis ventilaciuri maCveneblebi
(mag.CasunTquli haeris wuTmoculoba, sunTqvis sixSire) da CasunTquli haeris
odenoba. cvladi JangbadmimRebi sistemebi moicavs Semdeg xelsawyoebs: nazaluri
kanula, martivi niRabi, rezervuariani niRabi.
3.3.1(a). nazaluri kanula
M msubuqi nazaluri kanula Sedgeba ori gamoyofili kbilanisgan, amaTgan TiToeuli
maTgani Tavsdeba nestoSi, romelic uzrunvelyofs sasunTqi sistemis momaragebas 24%
dan 40%-mde Jangbadis Semcveli haeriT, rac damokidebulia miwodebili nakadis
siCqaris maCvenebelze. Nhaeris midinebis nabismieri reJimis SemTxvevaSi, Jangbadis
koncenracia icvleba CasunTqvebs Soris, ase rom, es damokidebulia pacientis
sunTqvis sixSireze , siRrmeze da CasunTquli haeris nakadze. Mmaqsimaluri Jangbadis
nakadis siCqare, rac SeiZleba gamoyenebul iqnas, daaxloebiT aris 6 litri/wuTSi,
radagac ufro maRalma siCqarem SesaZlebelia gamoiwvios cxviris lorwovanis
gamoSroba da gaxdes epistaqsisis mizezi.
39
galurjebuli pacienti da sunTqvis gaZneleba
sur. 8 nazaluri kanula. es sqema uCvenebs Jangbadis koncentraciis damokidebulebas
Jangbadis nakadis siCqareze, aseve pacientis sunTqvis sixSiresa da siRrmes.
3.3.1(a) martivi niRabi
pacientisTvis niRbis moTavsebis Semdeg, Jangbadis sarezervo moculoba izrdeba,
rac miRwevadia mxolod anatomiuri struqturebis saSualebiT (mag. nazofarinqsi).
Mminimaluri Jangbadis nakadis siCqare daaxloebiT aris 5 litri/wuTSi, imisaTvis,
rom Tavidan iqnas acilebuli niRabSi arsebul amosunTqul haerSi maRali
koncentraciis naxSirorJangis Semcveloba. CasunTqul haerSi Jangbadis koncentraciis
umniSvnelo aweva gulisxmobs Jangbadis nakadis siCqares 15 litri/wT-ze zeviT. am
tipis niRbebs SeuZlia miaRwios haerSi Jangbadis koncentracias maqsimum 50-60%-mde.
suraTi 9 - martivi niRabi. naCvenebia Jangbadis nakadis siCqaris cvlilebis pirobebSi
koncentraciis gansxvavebuli maCveneblebi.
40
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
3.3.1(g) non-rebreathing niRabi
am tipis niRbebi TiTqmis identuria martivi niRbebis, magram damatebulia masze
mimagrebuli rezervuaruli parki da erTi an ori sarqveli niRbis amosasunTq
nawilSi. sarqvelebi aCerebs amosunTqul gazebs, rom ar SeaRwios rezervuarul
parkSi (amiT azavebs Jangbads) da uzrunvelyofs oTaxSi arsebul haers
SeuRwevadobas. es kombinacia irTveba roca SasunTqul haerSi Jangbadis koncentracia
>60% (faqtobrivad, xSirad axlos 100%-Tan).
1. Tavdapirvelad darwmundiT, rom Jangbadi
gamosadegia, daamagreT Jangbadis mili
floumetrTan da momarTeT nakadis siCqare
15litri/wuTSi maCvenebelze.
2.daaxSeT sarqveli rezervuarsa da niRabs Soris, es
saSualebas miscems rezervuars , rom gaivsos.
3. rezervuarze xelis moWeriT vsazRvravT
niRabsa da rezervuars Soris arsebuli
sarqvlis vargisianobas. Tu razervuari ar
daicala, vcvliT niRabs axliT.
41
galurjebuli pacienti da sunTqvis gaZneleba
4. gaimeoreT me-2 moqmedeba.
5. moargeT pacients niRabis, rac ufro
mWidrod, miT ukeTesi.
suraTi 10 - Jangbadis niRabi rezervuarTan erTad.
moawesrigeT Jangbadis nakadis miwodebis siCqare ise, rom parki ifuSebodes erT
CasunTqvaze daaxloebiT mesamediT. CasunTqvis ganmavlobaSi xdeba oqsigenirebuli
haeris narevis gadaadgileba rezervuaruli parkis, niRbis da niRabze arsebuli
naxvretebis gavliT.
3.3.2 fiqsirebuli JangbadmimRebi sistemebi
es sistemebi awvdis sakmaris heris nakads, imisaTvis rom daakmayofilos nebismieri
pacietis wuTobrivi ventilaciuri moTxovna. CasunTqul haerSi Jangbadis
koncentracias gansazRvravs miwodebuli Jangbadis nakadis siCqare da ara pacientis
sunTqvis sixSire da siRrme. msgavsi tipis fiqsirebuli niRbebi, romlebic yvelaze
metad saavadmyofos palatebSi gamoiyeneba, venturi niRabia. isini haers atarebs venturiprincipis gaTvaliswinebiT. maRali nakadiT miewodeba ucvleli koncentraciis
Jangbadi mTeli sunTqvis ciklis ganmavlobaSi. niRabi im pirobiT gamoiyeneba, Tu
42
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
unda miewodos Jangbadi mxolod mudmivi koncentraciiT (mag. 24%, 35%) an Seicvalos
sxva maTganiT. xSirad feredadaa kodirebuli da gansxvavebuli TavebiTaa gamoyofili
sxvadasxva koncentraciis niRbebi erTmaneTisgan.
suraTi 11 - venturi Jangbadis niRabi. zedmiwevniT zustad gakontrolebulia
misawodebeli Jangbadis koncentracia. Cveulebriv ixmareba specifikuri adaptorebiT.
(originali sqemis modificirebuli varianti)
yovelTvis, rodesac marTavT oqsiganaciis process, darwmundiT, rom Jangbadis
floumetri CarTulia, xolo milebi dakavSirebulia niRabTan da StefselTan.
Tu Jangbadis wyaro aris cilindruli, SeamowmeT, rom cilindri Seicavs gazs.
43
galurjebuli pacienti da sunTqvis gaZneleba
Sejameba :
- yvela kritikuli pacientisTvis saWiroa Jangbadis miwodeba.osaCI
- centraluri cianozis ganviTareba SesaZloa gamowveuli iyos gulis an
filtvis daavadebiT.
- periferiuli cianozis mizezia periferiuli cirkulaciis Seneleba
(mag. hipovolemis, kardiogenuli Soki), civi garemo, arteriuli an
venuri obstruqcia.
- hipoventilacia da darRvevebi gavlenas axdens ventilacia-perfuziaze,
rac yvelaze xSirad cianoziT gamwvavebebis mizezi xdeba gadaudebel
siTuaciebSi.
- CasunTquli Jangbadis maRali koncentracia ar amcirebs ventilacias
mwvave respiratoruli darRvevebis mqone pacientSi.
- oqsigenoTerapia aucileblad unda iyos daniSnuli.
- aucilebelia oqsigenoTerapiis monitoringi.
- pacientebi ar ixocebian mxolod gazrdili naxSirorJangis doniT,
maTi sikvdilis mizezi hipoqsemiaa.
- oqsimetri zomavs oqsigenacias, da ara ventilacias.
44
hipotenziuri pacienti
mocemuli Tavis bolos Tqven SegeZlebaT:
Ø hipotenziis gadaudebeli mkurnalobis saWiroebis amocnoba
Ø fiziologiuri faqtorebis gageba, romelic pasuxismgebelia sisxlis
arteriul wnevaze
Ø organoebis sisxliT momaragebis Semcirebisas warmoSobili simptomebis
amocnoba; da
Ø hipotenziis marTvis aRwera
hipotenzias Cveulebriv moulodnelad vxvdebiT hospitalizirebul pacientebSi. is
unda ganixilebodes rogorc gadaudebeli SemTxveva, romelic moiTxovs swraf
mkurnalobasa da mizezis Zebnas. vidre arteriuli wneva daecema, bevri pacienti
warmoaCens adreul gamafrTxilebel simptomebs, rac migvaniSnebs imaze rom
gulsisxlZarRvTa sistema stresis qveS imyofeba mag.: mzardi an maRali pulsi.
hipotenzia xSirad aris stresuli cirkulaciis gviani siptomi. hipotenzias Sedegad
moyveba sasicocxlod mniSvnelovani organoTa sistemebis perfuziis darRveva (e.i.
Tirkmeli, tvini, guli).
1 arteriuli wnevis gazomva
vercxliswylis sfignomanometrebi rCeba yvelaze zust xelsawyoT arteriuli
wnevis gasazomad, Tumca zogierT qveynebSi amoRebuli iqna xmarebidan
vercxliswylis toqsiurobis gamo. Cveulebriv aneroiduli sfignomanometrebi ar
aris zusti, da ZiriTadad SedarebiT ufro dabal wnevas aCveneben, Tu regularulad
ar xdeba maTi kalibracia. hospitlebis umetesoba axla arteriul wnevas zomavs
avtomatizirebuli xelsawyoebiT, Tumca amgvar xelsawyoebsac axasiaTebT garkveuli
problemebi.
1.1 vercxliswylis sfignomanometri
gamoyenebamde xelsawyo unda Semowmdes zedmiwevniT:
Ø vercxliswylis menisko kargad unda Candes
Ø menisko unda iyos nulovan doneze
Ø Seamowme arteriuli wnevis manJeti, rom darwmunde rezinis kamera, milebi,
gayvanilobebi, gasaberi kamera da sarqvelebi wesrigSia da xma ismis.
Ø arteriuli wnevis gasazomi aparatis manJetis sigrZe unda iyos pacientis mxris
garSemowerilobis sul cota 80%. es niSnavs imas, rom TiToeuli pacienti
saWiroebs individualur Sefasebas sanam gansakuTrebul manjets gamoviyenebT.
normaluri mxrisTvis 35sm-iani manJeti normaluria; ufro didi mxrisTvis 42sm-
iani manJeti. xelmisawvdomia ufro patara manJetebi gamxdari
mozrdilebisTvisac.
Ø arteriuli wnevis gasazomi aparatis manJetis sigane unda iyos sul mcire
pacientis mxris garSemowerilobis 40%. ufro mozrdilebisTvis, es niSnavs
manJetis siganes meryeobas 12-15sm-is farglebSi.
Ø gamber-damCutavs xelsawyos unda SeeZlos wnevis SenarCuneba 40mm vr.wy.sv.-iT
zemoT vidre gazomili sistoluri arteriuli wneva (systolic BP) 3-5 wamSi swrafigabervis Semdeg. agreTve is unda iCutebodes Seuferxeblad; da
45
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
Ø milsadenis sigrZe manometrsa da manJets Soris unda iyos sul mcire 70sm.
wnevis gazomvisas, pacientis pozicia (mjdomare an mwoliare) unda iyos idealurad
standartuli. pacients mxari unda dauWiroT pacientis gulis doneze. Tu mxars ar
dauWerT, maSin miviRebT mcdar aweul arteriuli wnevas, rac ganpirobebuli iqneba
kunTebis izometruli SekumSviT da wneva romelic gazomilia damokidebul mxarze
agreTve iqneba maRali.
1.1.1 teqnika
Ø wnevis aparatis manJetis qveda kide unda mdebareobdes mxris arteriis
wertilidan 2-3sm-iT zemoT.
Ø mxris arteriis palpacia SeiZleba manJetis gabervisas sanam masSi wneva 30mm
v.w.s.-s miaRwevs, mis zemoT ki pulsis palpacia SeuZlebelia.
Ø stetoskopi ideba mxris arteriaze, umjobesia gamoviyenoT zaris bolo(bellend). is SeiZleba davikavoT mtkiced, magram ar unda davatanoT zedmeti
wneva(zewola).
Ø manJeti Semdeg ifuSeba nela 2-3mm-iT pulsis TiToeul dartymaze da
moismineba Cveulebriv korotkovis xmebi (cxrili 9).
faza xmebi wnevebi
I pirvelad susti, ganmeorebiTi, sufTa
gaxvretis xmebis gamoCena
sistoluri art. wneva
(Systolic BP)II mokle periodi, romlis ganmavlobaSic
xmebi SeiZleba Serbildes
auskultaciuri
fanjara
zogierT pacientSi xma SeiZleba mTlianad
gaqres
III maxvili xmebis dabruneba
IV xmebis uecari CaxSoba
V xmebis gaqroba diastoluri art. wneva
(Diastolic BP)
cxrili-9: korotkovis xmebi da maTi interpretacia.
1.2 arteriuli wnevis automaturi gasazomi xelsawyoebi rogorc vercxlis wylis sfignomanometrebi, aseve avtomaturi xelsawyoebi
gamoyenebamde unda Semowmdes. yuradReba unda mieqces manJetis kameras, milsadenebis,
SeerTebebis mdgomareobasa da manJetis zomebs. gaTviTcnobiereba individualuri
aparatebis gamoyenebaSi, maT kontrolSi da gangaSSi aris aucilebeli. gamoyenebis
dros Tu ver xerxdeba arteriuli wnevis gansazRvra, unda CavTvaloT rom es
pacientis mdgomareobis bralia, da ara aparatis cudi funqcionirebis.
Tu avtomaturi wnevis sazomi xelsawyo ver axdens arteriuli wnevis (BP) Sefasebas, ar dauSvaT rom is gafuWebulia. SeiZleba es pacientis
avadmyofobiT iyos gamowveuli!
46
hipotenziuri pacienti
2 hipotenziuri pacientis fiziologia
arteriuli wneva iqmneba pacientis gulis wuTmoculobiTa (Cardiac output - Q or CO) dasisxlZarRvovani winaaRmdegobis erTobliobiT. amitom, arteriuli wnevis dacema
SeiZleba gamowveuli iyos mxolod gulis wuTmoculobis davardniT, sisxlZarRvTa
rezistentobis dacemiT an orives erTdroulad dacemiT.
BP=guliswuTmoculoba X sisxlZarRvTa winaaRmdegoba
2.1 gulis wuTmoculoba
gulis wuTmoculoba ganisazRvreba ganisazRvreba 3 faqtoriT (sur.:12):
Ø predatvirTviT (gulis avseba anu CVP);Ø miokardiumis SekumSvis unariT (gulis SekumSvis Zala); da
Ø posdatvirTviT (aortaSi sisxlis gadadenis rezistentoba).
suraTi 12: faqtorebi, romlebic gavlenas axdenen gulis wuTmoculobaze: (a)predatvirTva, (b) postdatvirTva (sisxlZarRvTa winaaRmdegoba) (c)
2.1.1 predatvirTva
predatvirTva aris gulis avsebis wneva da damokidebulia sisxlis raodenobaze
romelic brundeba marjvena winasakanSi qsovilebidan. predatvirTva da gulis
wuTmoculoba aris dakavSirebuli gulis starlingis kanonTan. Tu guli
araadekvaturad ivseba sisxliT rac ganpirobebulia hipovolemiiT, maSin gulis
wuTmoculobac ecema. Cveulebriv absoluturi hipovolemiis mizezi aris hemoragia,
Rebineba da diarea, damwvrobebi da sefsisi (ukanaskneli ori imitom rom qsovilebSi
dakargvisaTvis). gadanawilebiTi hipovolemia (romlis drosac darRveulia sisxlis
miwodeba normaluri moculobis sisxlis cirkulaciis pirobebSi) gamowveulia
47
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
sedaciuri preparatebiT, alergiuli reaqciebiT da SeiZleba iyos epiduruli
anesTeziis Sedegi.
2.1.2 SekumSvis unari
gulis SekumSvis unarianoba gansazRvravs mis unars, sxeulSi gadatumbos sisxli.
Tu gulis SekumSvis unarianoba Semcirebulia, gulis wuTmoculoba daecema.
Cveulebriv gulis SekumSvis unarianobis Semcireba gamowveulia mikardiumis
ifarqtiT, ariTmiebiT, gulis sarqvlebis disfunqciiT, gulis tamponadiT da
filtvis emboliiT. agreTve unda gvaxsovdes, rom sefsisic iwvevs gulis SekumSvis
unarianobis Semcirebas.
2.1.3 postdatvirTva
postdatvirTva warmoadgens parkuWebidan gadmosrolil sisxlze gaweul
winaaRmdegobas. es SeiZleba ganvixiloT sisxlZarRvovani winaaRmdegobis analogad.
Tu aRiniSneba sisxlZarRvovani rezistentobis (winaaRmdegobis) gazrda, gulis
wuTmoculoba Semcirdeba, radgan es aris gulis gacarielebis didi winaaRmdegoba.
es aris hipotenziis gamomwvevi iSviaTi pirveladi mizezi. Tumca, sisxlZarRvovani
winaaRmdegoba xSirad izrdeba hipotenziis dros, rogorc kompensatoruli meqanizmi,
raTa SeinarCunos arteriuli wneva.
hipotenzia SeiZleba gamowveuli iyos sisxlZarRvovani winaaRmdegobis dacemiT.
ufro metad sisxlZarRvTa Semcirebuli winaaRmdegobis mizezs warmoadgens
simpatikuri nervuli sitemis aqtivobis Semcireba. ZiriTadi mizezebia: sefsisi,
wamlis dozirebis gadaWarbeba, zurgis tvinis maRal doneze dazianeba da epiduruli
gautkivareba lokaluri anesTeziuri agentebiT.
roca vxvdebiT hipotenziur pacients, SeecadeT daadginoT arteriuli
wnevis dacema gamowveuli predatvirTviT, SekumSvis unaris SemcirebiT
Tu postdatvirTviT.
3 ratom aris hipotenzia saxifaTo?
organoTa perfuzia damokidebulia sisxlis nakadis generaciaze, romelic eyrdnoba
adeqvatur arteriul wnevaze. organoebis umetesoba (gulis garda) saWiroebs
arteriul wnevas saSualod 70mmv.w.s.-ze zeviT, raTa normalurad ganxorcieldes
perfuzia da funqcia.
saSualo arteriuli wneva=diastoluri BP + (sistoluri BP - diastoluri BP)3
magaliTisTvis, normaluri renaluri sisxlis nakadi da glomeruluri filtraciis
siCqare TviTregulirdeba saSualo arteriuli wnevis 70mm.v.w.s.-sa da 170mmv.w.s.-s
Soris. Tu arteriuli wnevis Semcirebis gamo Semcirdeba renuli sisxlis nakadi,
glomeruluri filtraciis siCqare mcirdeba da Sardis produqcia ecema. amitom
48
hipotenziuri pacienti
Sardis produqcia warmoadgens Tikmlis adeqvaturi perfuziis niSans. Tu Sardis
produqcia daecema 1ml/kg/sT-ze dabla, maSin aman Tqven unda gagafrTxiloT, aris
SesaZleblo rom arteriuli wneva da renuli perfuzia aris araadeqvaturi.
ar dauSvaT, rom dabali raodenobis Sardis gamoyofas saaTobrivad (e.i.
0.5ml/kg/sT-Si) mkurnalobis gareSe datovoT an ar gamoikvlioT modevno 2
saaTis ganmavlobaSi an ufro met droSi.
cerebruli sisxlis nakadic msgavsad TviTregulirdeba saSualo arteriuli wnevis
60-140mm v.w.s. farglebSi. cerebruli perfuziis Semcirebas mivyavarT cnobierebis
donis SemcirebisaTan, aRiniSneba ZilianobiT, drosa da sivrceSi orientaciis
darRveva, aRgzneba da sabolood koma. amis gamo, rogorc AVPU (Alert, Voice, Pain,Unresponsive- sifzizle, xma, tkivili, pasuxis gacemis uunaro) aseve glazgos komis
Skala (Glasgow Coma Scales) orive perfuziis mgrZnobiare maCvenebelia. cnobierebis
donis ramenairi Semcireba (AVPU-qulis Semcireba an dacema GCS>2 quliT) moiTxovs
pacientis arteriuli wnevisa da perfuziis Sefasebas.
cnobierebis donis Semcireba (AVPU-qulis Semcireba an dacema GCS>2 quliT) savaraudod niSnavs cerebruli perfuziis Semcirebas da saWiroebs
dauyovnebliv Sefasebas, gamokvlevasa da mkurnalobas.
koronaruli sisxlis nakadi damokidebulia diastolur arteriul wnevaze.
arteriuli wnevis davardnam SeiZleba Zlier Seamciros koronaruli arteriebis
avseba, risi meoxebiTac viTardeba iSemia miokardiumSi.
sisxlis nakadi periferiebze (mag.: kani, TiTebi) mcirdeba hipotenziis umravles
SemTxvevebSi. es iwvevs gacivebas, periferiaze sifermkrTales da kapilarebis avsebis
drois prolongirebas. aseT SemTxvevaSi, puls oqsimetrma SeiZleba ver gansazRvros
pulsirebadi nakadi an awarmoos saturaciis gansazRvra. am movlenis gamo oqsimetri
gafuWebulad ar unda CavTvaloT – cadeT sakuTar TiTze Sesamowmeblad!
Hhipotenziis damazianebel faqtorebs moicavs:
Ø cnobierebis donis Semcireba, romelsac mivyavarT mkveTr cerebrul iSemiamde;
Ø oliguria, romelsac mivyavarT mwvave tubularul nekrozamde;
Ø nawlavis Semcirebuli perfuzia, iwvevs nawlavis iSemias;
Ø koronaruli sisxlis nakadis Semcireba, mivyavarT miokardiumis infaqtramde;
da
Ø kanis Semcirebuli perfuzia, mivyavarT kapilaruli avsebis drois Semcireba
da SesaZloa TiTebis iSemiamde;
49
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
suraTi 13: Semcirebuli arteriuli wneva Tavismxriv amcirebs sisxlis midinebas
sasicocxlod mniSvnelovan organoebSi.
organoTa cudi perfuziis simptomebi moicavs:
Ø cnobierebis donis Semcireba;
Ø fermkrTali, lurji, civi TiTebi; da
Ø oliguria
Tu pacients aqvs romelime niSani zemoT CamoTvlilidan, pirvelad ifiqre:
aris Tu ara pacientis perfuzia adeqvaturi?
50
hipotenziuri pacienti
4 hipotenziis gamomwvevi mizezis mkurnaloba
es damokidebulia imaze, rom gulis wuTmoculobaa Semcirebuli, sisxlZarRvovani
winaaRmdegoba, Tu orive erTad. xSirad gamomwvevi iqneba aSkara, mag.: aqtiuri
daufaravi hemoragia an dadasturebuli miokardiumis infarqti (ST elevacia e.k.g.-ze).
sisxldena SeiZleba iyos faruli- magaliTisTvis: yvela sisxldena
gastrointestinaluri traqtidan maSinve ar aaSkaravdeba. nebismier situaciaSi,
gadaxede pacientis grafikebsa da CaniSvnebs da gamoikvlie pacienti yuradRebiT.
pacientis istoriam SeiZleba mogceT naTeli gasaRebi. magaliTisTvis, naadrevi
postoperaciuli hipotenzia Cveulebriv gamowveulia sisxldeniT, Tumca is SeiZleba
agreTve ubralod gamowveuli iyos postoperaciulad siTxeebis arasakmarisi
intravenuri infuziiT. operaciidan ramodenime dRis Semdeg, hipotenzia, pireqsia da
cxeli periferiebi zrdis sefsisis SesaZleblobas. SesaZlo mizezebi moicavs martiv
gulmkerdis an Sardgamomyofi sistemis infeqcias, magram pacientebs, romelsac
gaukeTdaT nawlavis anastomozi, SeiZleba nakerebi gaixsna. radgan hipovolemia aris
hipotenziisa da Sokis yvelaze metad gavrcelebuli mizezi (da yvelaze advilad
Seqcevadi procesia), mieci siTxeebi. bolusiT 500-1000ml kristaloiduri xsnaris 5-
40wT-is ganmavlobaSi Seyvana warmoadgens Sesaferis inicialur safexurs. kargi
reagireba siTxeebis Seyvanaze moicavs gulis SekumSvaTa sixSiris Semcirebas,
kapilaruli avsebis drois Semcirebas, gaumjobesebul cnobierebis dones da Sardis
gamoyofis gazrdas. mizans warmoadgens pacientis sistoluri arteriuli wnevis
pacientisTvis damaxasiaTebel normalur donemde miRweva, xolo Tu ucnobia, 100mm
v.w.s.-ze maRla. Tu pacientis mdgomareoba ar umjobesdeba inicialuri (sawyisi)
bolusis Semdeg, SesaZloa procedura gavimeoroT. Tu arsebobs imis Sansi, rom
hiporenzia gamowveulia miokardiumiT, mieciT siTxis Semcirebuli moculoba (mag.:
250ml) da daakvirdiT efeqts yuradRebiT (mWidrod). daakvirdi gulis SekumSvaTa
sixSiris pasuxs (Tu siTxe aris saziano, SesaZloa man moimatos, vidre daeces) da
mousmine filtvebs (axali krepitacia/xixini gvavaraudebinebs siTxiT gadatvirTvas).
miuxedavad amisa, gaxsovdeT rom im pacientebSic ki sadac hipotenzia gamowveulia
miokardiumis mizezebiT, xadaxan mainc saWiroebs siTxeebs. Tu aucilebelia, CadgiT
centraluri venuri kaTeteri – magram im SemTxvevaSi Tu amis gamocdileba gagaCniaT.
sxva SemTxvevaSi dauZaxeT daxmarebas. siTxeebiT Canacvlebis miuxedavad, Tu
hipotenzia mainc persistirebs, SeiZleba gamoyeneuli iqnas medikamentebi (mag.:
dobutamini, noradrenalini).
swrafva pacientis normaluri sistoluri wnevisken
an sul mcire 100mm v.w.s. donisken
suraTi 14: mowodebuli miznis mniSvneloba arteriuli wnevisTvis
51
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
hipotenziis marTva
Ø darwmundi, rom pacientis haergamtari gzebi aris Ria da mieci maRal
koncentrirebuli Jangbadi.
Ø cade daadgino pacientis hipotenzia gamowveulia cirkulirebuli moculobis
SemcirebiT, gulis wuTmoculobis SemcirebiT, Tu Secvlili sistemuri
sisxZarRvovani winaaRmdegobiT.
Ø Tu puls oqsimetri ver gansazRvravs pulsirebad nakads an ver awarmoebs
saturaciis gansazRvras. am movlenis gamo oqsimetri gafuWebulad ar unda
CavTvaloT – cadeT sakuTar TiTze Sesamowmeblad!
Ø mieci siTxe bolusiT (500-1000ml); daakvirdi efeqts. gaimeore Tu aucilebelia.
Ø iswrafe sistoluri arteriuli wnevis maCveneblis >100mm v.w.s.-ken
Ø ganixileT centraluri venuri kaTeteris gamoyeneba siTxis Seyvanis
monitoringis warmoebisaTvis
Ø roca hipotenzia ar reagirebs mxolod siTxeebis Seyvanaze, SeiZleba saWiro
gaxdes vazoaqtiuri medikamentebis gamoyeneba
sabaziso ekg da sicocxlisTvis saSiSi riTmebi
sabaziso ekg-s wakiTxva nebiemier eqims unda SeeZlos. am TavSi Cven ar SevCerdebiT
ekg-s fiziologiur maxasiateblebze da Tu rogor iqmneba ekg, rac nebismier
kardiologiisa an fiziologiis wignSi SegiZliaT naxoT, aramed SemogTavazebT ekg-s
wakiTxvis formulas da sicocxlisTvis saSiSi riTmebis amocnobas.
nebismieri ekg-s wakiTxva daiwyeT martivi meTodiT:
Ø aris Tu ara eleqtruli aqtivoba
Ø sixSire QRS is komplqsis
Ø riTmi regularulia Tu ara
Ø qrs aris farTo Tu viwro
Ø RerZi yvelaze martivi meTodia Seamowmo 1el da mesame ganxrebSi. Tu QRSerTmaneTiskenaa mimarTuli marjvniv, xolo Tu sapirispirod, marcxniv
gadaxraa
Ø p aris Tu ara p yoveli QRS- is win Tu araregularulia
Ø st segmenti aris izoxazze, aweuli Tu Camoweuli
Ø eleqtruli aqtivobisas yovelTvis Seamowme pulsi vinaidan pulsis ar
qonisa da normaluri kompleqsebis arsebobisas monitorze unda
umkurnaloT rogorc asistolia gulis masaJiT.
52
pacienti areuli cnobierebis doniT
mocemuli Tavis bolos Tqven SeZlebT:
ü areuli cnobierebis donis mTavari mizezebis aRweras;
ü areuli cnobierebis donis Sedegebis ganxilvas;
ü imis aRweras, Tu rogor SevafasoT areuli cnobierebis donis mqone pacienti da;
ü areuli cnobierebis donis mqone pacientis gadaudebeli marTvis aRweras.
1 etiologia
daqveiTebuli cnobierebis done damaxasiaTebelia mwvave daavadebebisTvis. Ees
SeiZleba gamovlindes, rogorc uSulod intarkranialuri daavadebebis Sedegi (mg:
epilefsia, meningiti, cerebrovaskuluri dazianebebi) an meoradad sistemuri
mdgomarebis dros, gansakuTrebiT: hipotenziis, hipoglikemiis an sedaciuri wamlebis
gamoyenebisas (cxrili 10).
hipoqsemia intrakranialuri sisxldena
hipotenzia cerebraluri infarqti
hiperkapnia intrakranialuri infeqcia
hipoglikemia Tavis tvinis simsivne
hiponatriemia hipoTermia
wamlebi(mg: damamSvideblebi, opiatebi,
Warbdozirebebi) hiperTeremia
krunCxvebi hipoTireoidizmi
Tavis travma RviZlismieri encefalopaTia
cxrili 10 - daqveiTebuli cnobierebis donis mTavari mizezebi.
2 daqveiTebuli cnobierebis donis Sedegebi
cnobierebis donis daqveiTeba sicocxlisTvis potencirad saSiS zogierT
garTulebebTan aris dakavSirebuli. amaTgan yvelaze mniSvnelovania sasunTqi gzebis
obstruqcia, magram aseve mniSvnelovania faringealuri da xvelis refleqsis
daqveiTeba da pirnaRebi masebis aspiracia. Semcirebuli motoruli aqtivoba iwvevs
nawolebis ganviTarebas, aseve rqovanas refleqsis daqveiTeba da xamxamis unaris ar
arseboba xSirad xdeba mizezi rqovanas wylulis an Tvalis sxva dazianebasa.
daqveiTebulma cnobierebis donem SeiZleba ganoiwvios sasunTqi gzis
obstruqcia, sasunTqi gzebis damcvelobiTi refleqsebis dakargva, kanis
dazianeba da rqovanas wyluli.
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sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
3 pacientis cnobierebis donis Sefaseba
nebismieri pacientis cnobierebis donis swrafi SefasebisTvis sasargebloa AVPUSkalis gamoyeneba (ixileT me- gverdze). amav droulad Semowmebul unda iqnas
gugebis zoma, maTi Tanabroba da sinaTleze reaqcia. pacientis saswarfo Sefaseba
unda moxdes reanimaciuri RonosZiebebis paralelurad. mogvianebiT pacientis sruli
SefasebisTvis unda gamoviyenoT glazgos komis Skala (GCS), romelic iZleva
cnobierebis donis ufro konkretulad Sefasebis saSulebas.
glazgos komis Skala: pacientis yvelaze kargi reqcia stimulze fasdeba 15 quliT
da moicavs sam komponents – kargi motoruli pasuxi (maqsimum 6 qula), kargi
verbaluri pasuxi (maqsimum 5 qula) da Tvalebis gaReba (maqsimum 4 qula), (cxrili 11).
glazgos Skalis maqsimaluri qula aris 15, rac miuTiTebs, rom pacientis cnobierebis
done srul normaSia, xolo minimaluri qulaa 3. glazgos komis Skalis gamoyenebisas
stimulze pacientis pasuxebis raodenoba gansazRvreT upiratesad aRweriTi
terminebiT, vidre ricxviTi mniSvnelobiT. Tu cnobierebis done fasdeba Semdegi
xarisxiT - `gamoscems gaugebar xmebs, axdens tkivilis lokalizacias da tkivilis
sapasuxod axels Tvalebs~, umjobesia es Sefaseba CavweroT Semdegi saxiT V2, M5, E2,vidre ase - `glazgos komis Skala Seadgens 9 qulas~.
glazgos komis Skalaze mniSvnelovan gavlenas axdens hipoqsemia da hipotenzia,
amitom umjobesia pacienti reanimaciuli RonisZiebis Semdeg iqnas Sefasebuli am
meTodiT. calsaxad unda iTqvas, rom pacienti, romlis qula glazgos komis SkaliT
9-ze naklebia, unda iqnas intubirebuli, radgan am doneze sasunTqi gzebis refleqsebi
mniSvnelovnadaa daTrgunuli. es unda ganxorcieldes saanesTezio wamlebis
gamoyenebiT imisaTvis, rom ar moimatos qalasSida wnevam laringoskopiT intubaciisas
- Sesabamisad dauZaxeT intensiuri Terapiis muSakebs dasaxmareblad.
qula
Tvalebis gaxela spontanurad axels . 4
brZanebisas axels . .3
tkivilis sapasuxod axels . . 2
ar axels . 1
motoruli pasuxi asrulebs brZanebisas .. 6
axdens tkivilis lokalizacias . 5
axdens gamRizianeblis mocilebas . 4
paTologiuri moxra tkivilis sapasuxod . . 3
gamSlelebis reaqcia tkivilis sapasuxod . 2
ar iZleva motorul pasuxs . 1
verbaluri pasuxi pasuxobs orientirebulad 5
iZleva areul pasuxebs 4
iZleva Seuferebel pasuxebs . 3
gamoscems gaugebar xmebs .. 2
ar pasuxobs . 1
cxrili 11 - glazgos komis Skala.
54
pacienti areuli cnobierebis doniT
Tu glazgos komis Skala 9-ze naklebia, an Tu is ecema 2 quliT, aRniSnulis
Sesaxeb acnobeT intensiuri Tereapiis ganyofilebas.
4 gugebis reaqcia
Ppacientis gugebis zomis, Tanabrobis da reqciis cvlilebam SeiZleba mogvces
mniSvnelovani diagnostikuri informacia mwvave daavadebis dros. rodesac aRiniSneba
erT mxares mkveTrad, farTod dilatirebuli, arareaqtiuli gugebi vvaraudobT
unilateralurad ganviTarebul warmonaqmnze, romelic ikavebs qalasSida sivrces, es
SeiZleba gamoiwvios hematomam, simsivnem an abscesma. Tu pacienti paliatiuri ar aris,
es gadaudebel samedicino Carevas moiTxovs. Tu mkurnaloba dagvianda, gamosavali
cudi iqneba. mTavari sasunTqi gza, sunTqva da cirkulacia Semowmebul unda iqnas
saswrafod da dauyovnebliv unda davuZaxoT ufros medikoss daxmarebisTvis.
gugebi bilateralurad gafrToebulia ZiriTadad simpaTikuri hiperaqtiurobis dros
(SiSi, stresi, SfoTva da a.S.) an rodesac pacients miRebuli aqvs simpaTomimetikuri
preparatebi (mg. tricikluri antidepresantebis Warbdozireba) an rodesac aRniSnuli
preparatebi saWiroebisamebr aris Seyvanili (mg. adrenalini gulis gaCerebis dros).
gugebis Seviwroeba SeiZleba miuTiTebdes opiatebis gamoyenebaze an pacientis
cerebrivaskulur dazianebaze, romelic gavlenas axdes tvinis Reroze.
erT mxares mkveTrad, farTod dilatirebuli, arareaqtiuli gugebi miuTiTebs
unilateralurad ganviTarebul warmonaqmnze, romelic ikavebs qalasSida
sivrces – es aris gadaudebeli samedicino mdgomareoba.
5 sasargeblo gamokvlevebi
dasayisSi mniSvelovani testi daqveiTebuli cnobierebis mqone pacientis
gamokvlevis dros aris sisxlis glukozis gazomva (marTva ixileT qvemoT). rodesac
eWvi aris tvinis kompresiaze, intarkranialur sisxldenaze an momatebuli qalasSida
wnevaze, yvelaze sasargeblo da specifikuri gamokvleva am dros aris Tavis tvinis
kompiuteruli tomografia. imisaTvis rom es gamokvleva Catardes pacenti unda iwves
gulaRma daaxloebiT 15-30 wuTis ganmavlobaSi. yvela pacients, romelsac daucveli
aqvT sasunTqi gzebi unda CautardeTYintubacia da gautkivareba CT skanirebis dros.aseve warmoebul unda iqnas saTanado monitoringi (minimum=ekg, pulsoqsimetria da
sisxlis wneva) da gamocdili meTvalyure unda darCes pacientTan mudmivad. savaraudo
diagnozebze dayrdnobiT sxva sasargeblo gamokvlevebis sia mocemuli me-12 cxrilSi.
55
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
sisxlis glukoza Sardovana da eleqtrolitebi arteriuli sisxlis airebi
leikocitebis ricxvi Trombocitebis ricxvi Sededebis Seswavla
CSF analizi sisxlis kultura toqsikologiuri testebi
farisebri jirkvlis RviZlis funqciuri testebi Sardis amiaki
funqcia
cxrili 12 – sasargeblo gamokvlevebi daqveiTebuli cnobierebis mqone pacientebSi.
6 daqveiTebuli cnobierebis gadaudebeli marTva
daqveiTebuli cnobierebis mqone yvela pacientSi gazomeT sisxlSi glukozis done.
Tu glukozis done 3mmol/l-ze dabalia SeiyvaneT 25-20 ml 50 %-iani glukoza
intravenurad. garda imisa, rom hipoqsemia, hipotenzia da hiperkapnia iwveven
cnobierebis daqveiTebas, aseve maT SeuZliaT ufro daamZimon tvinis dazianeba
miuxedavad mizezisa. es ganpirobebulia imiT, rom isini xels uwyoben Tavis tvinis
SeSupebis ganviTarebas, romelic qalasSida wnevis momatebas iwvevs. umkurnaleT maT
saswrafoT.
hipoqsemia, hipotenzia da hiperkapnia amZimeben tvinis dazianebas miuxedavad
cnobierebis daqveiTebis pirveladi mizezisa.
viniaidan cerebraluri perfuziuli wneva dakavSirebulia saSualo arteriul
wnevasTan da intrakranialur wnevasTan, qalas Sida wnevis nebismieri saxiT momateba
zrdis Tavis tvinis iSemiis risks.
cerebraluri perfuziuli wneva = saSualo arteriul wneva – qalas Sida wneva
qalas Sida imatebs daxvelebisas, daZabvisas da araadeqvaturi ventilaciisas
(ganpirobebuli sisxlSi naxSirorJangis doniT), daqveiTebuli cnobierebis marTva
fokusirebulia obstruqciuli sasunTqi gzis gaTavisuflebaze da pacientis
adeqvaturi ventilaciisa da cirkulaciis uzrunvelyofaze. aseve yuradReba unda
gavamaxviloT imaze, rom davicvaT sasunTqi gza sekretebis, sisxlis da a.S.
moxvdrisagan pacientis horizontalurad lateraluli komis poziciaSi (sxeulis
3/4iT pronirebuli pozicia) dawveniT (ixileT usafrTxoebis zomebi zurgis tvini
kisris nawilis dazianebisas 2.4.1. seqciaSi). momatebuli qalas Sida wnevis mqone
pacientebi unda movaTavsoT ise, rom maTi Tavi 15º-iT iyos aweuli zemoT. Tumca,
vinaidan am poziciaSi maRalia sekretis aspiraciis riski, ufro pragmatuli midgoma
iqneba, Tu pacients davawvenT horizontalurad komis poziciaSi, Tu pacientis
56
pacienti areuli cnobierebis doniT
sasunTqi gza daculi ar aris traqeuli miliT. Tu ar aris absolituri
aucilebloba, moerideT pacientis pozicias qvemoT daweuli TaviT.
daawvineT pacienti horizontalurad lateraluli komis poziciaSi, Tu pacientis
sasunTqi gza daculi ar aris traqeuli miliT.
areuli cnobierebis marTva
Ø uzrunvelyaviT pacientis sasunTqi gza gamavloba.
Ø mieciT Jangbadi maRali koncentraciiT.
Ø Tu ventilacia araadeqvaturia, uzrunvelyaviT daxmarebiTi ventilacia xelis
sasunTqi mowyobilobis gamoyenebiT.
Ø gadausxiT intravenurad siTxeebi, raTa sistoluri arteriuli wneva avides
100mHg-ze maRla.
Ø wamlebiT inducirebuli cns-is depresiisas SeiyvaneT antidoti (mg: naloqsoni
opiatebis Warbdozirebisas).
Ø gazomeT sisxlSi glukozis done da Tu is 3mmol/l-ze dabalia SeiyvaneT
intravnurad.
Ø daawvineT pacienti horizontalurad lateraluli komis poziciaSi.
Sejameba
ü mwvave daavadebebisTvis damaxasiaTebelia daqveiTebuli cnobierebis done.
ü komis mTavari mizezebia hipoqsemia, hipoglikemia da hipotenzia.
ü cnobierebis donis daqveiTebam SeiZleba ganoiwvios sasunTqi gzis obstruqcia,
sasunTqi gzebis damcvelobiTi refleqsebis dakargva, kanis dazianeba da rqovanas
wyluli.
ü gamoiyeneT glazgos komis Skala, stimulze pacientis pasuxebis raodenoba
gansazRvreT aRweriTi terminebiT.
ü Tu glazgos komis Skala 9-ze naklebia, an Tu is ecema 2 quliT, aRniSnulis
Sesaxeb acnobeT intensiuri Tereapiis ganyofilebas.
ü areuli cnobierebis mkurnaloba fokusirebulia sasunTqi gzis gamavlobis
aRdgenaze, adeqvatur ventilaciaze da normaluri cirkulaciis uzrunvelyofaze.
57
oliguriuli pacienti
mocemuli Tavis Seswavlis Semdeg Tqven SeZlebT:
Ø Sardis normaluri produqciisa da gamoyofisaTvis aucilebeli faqtorebis
gagebas
Ø sisxlis miwodebis Semcirebis mizezebis ganxilvas
Ø oliguriis marTvis aRweras
staJior eqimebs xSirad Txoven gasinjon pacienti, romelsac Sardis gamoyofa
Semcirebuli aqvs. mcire raodenobis Sardi aris erT-erTi gamafrTxilebeli niSani
imisa, rom pacientis zogadi mdgomareoba uaresdeba. Sesabamisad, Sardis Semcirebis
mizezis dadgena aris mniSvnelovani, radgan araswori mkurnaloba xSirad Semdgomi
garTulebis mizezi xdeba. ufro metic, Tu oliguriis mizezi ar an ver iqneba
namkurnalebi, ganviTardeba Tirkmlis mwvave ukmarisoba, romelic maRali letalobiT
xasiaTdeba.
oliguria aris pacientis mdgomareobis gauaresebis adreuli niSani.
1 Sardis normaluri produqcia
normalur mdgomareobaSi gamoyofili Sardi moculoba DdReSi meryeobs 1,5-2
litrs Soris (i.e.>1ml/kg/sT). Sardis produqcia normaluria, rodesac Tirkmlebs
adeqvaturad miewodeba sisxli, Tirkmlebi normalurad funqcionireben da Sard-
gamomyof gzebSi ar aris dabrkoleba (obstruqcia).
1.1 Sardis gamoyofis winapirobebia
ü Tirkmlebis adeqvaturi sisxlmomoarageba
ü Tirkmlebis normaluri muSaoba
ü saSarde gzebSi dabrkolebis ar arseboba
1.2 ganmartebebi
oliguriis dros gamoyofili Sardis raodenoba dReSi Seadgens 100-400 ml-s.
anuriis dros Sardis raodenoba dReSi 100 ml-ze naklebia, xolo absolituri
anuriis dros Sardi saerTod ar gamoiyofa. absolituri anuria asaxavs saSarde
gzebis obstruqcias, sxva mizezis dadgenamde (cxrili 13).
58
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
cxrili 13: dizuriuli mdgomareoba da Sardis moculoba
2 renaluri sisxlis nakadi
renaluri sisxlis nakadi (RBF) wuTSi Seadgens daaxloebiT 1,2 litrs da
narCundeba mudmivad fenomenad wodebuli `autoregulaciis~ saSualebiT, roca
saSualo arteriuli wneva 70-sa da 170 mmHg Sorisaa (suraTi 15). hipertenziul
pacientebSi mrudma SeiZleba gadainacvlos marjvniv, radgan am SemTxvevaSi
autoregulacia mimdinareobs maRali saSualo arteriuli wnevis pirobebSi. sxva
sityvebiT rom vTqvaT, hipotenziuri pacientebi moiTxoven maRal saSualo arteriul
wnevas, rom renaluri sisxlis nakadi mudmivad iqnas normalur doneze SenarCunebuli.
suraTi 15 – renaluri sisxlis nakadis autoregulacia
Tu saSualo arteriuli wneva ecema autoregulaciis qveda zRvars qvemoT.
renaluri sisxlis nakadi mkveTrad ecema da msgavsad qveiTdeba Tirkmlis perfuzia.
am etapze kompensatorulad aqtiurdeba garkveuli autonomiuri da hormonuli
meqanizmebi, mg: adrenalini, noradrenalini, antidiurezuli hormoni (adh) da
aldosteroni gamoiyofa sistematurad. adh da aldosteroni zrdian marilebis da
wylis retencias, raTa SeinarCunon cirkulaciaSi myofi sisxlis moculoba da
Tirkmlebis perfuzia. Sesabamisad, Sardis moculoba da masSi natrumis Semcveloba
mcirdeba da misi xvedriTi wona (an osmolaroba) izrdeba. igive procesebi viTardeba
maSin, rodesac renaluri sisxlis nakadi mcirdeba gulis wuTmoculobis Semcirebis
gamo.
dizuriuli mdgomareoba ml dRe-RameSi
oliguria 100-400
anuria <100absolituri anuria Sardis ar arseboba
59
oliguriuli pacienti
Semcirebuli saSualo arteriul wnevis an renaluri sisxlis nakadis
sapasuxod gamoiyofa maRali koncentraciis da dabali moculobis Sardi,
natriumis dabali SemcvelobiT.
oliguria, romelic gamowveulia saSualo arteriul wnevis, renaluri sisxlis
nakadis an wuTmoculobis SemcirebiT, potenciurad Seqcevadia (cxrili 14), Tu swori
mkurnaloba droulad iqneba dawyebuli. sawyisi mkurnaloba moicavs intravenurad
siTxis gadasxmas bolusis saxiT (~500-1000 ml), sisxlis wnevis da Sardis moculobis
SefasebiT. kardiogenuri Sokis mqone pacientebmac unda miiRon intravenurad siTxe,
Tumca mcire moculobiT (~250 ml kristaloidi) da saWiroa Semdgom efeqtze
frTxili dakvirveba. TiTqmis yvela daavadebebis dros da filtvebis mwvave SeSupebis
drosac ki (sadac pacientma SesaZloa dakargos mniSvnelovani moculobis siTxe
filtvis intersticiuli sivrceebidan) rogorc wesi SeiniSneba hipovolemiis
elementebi. siTxis infuziis mizani aris cirkulaciuri moculobis da renaluri
perfuziis gazrda, romelic miiRweva swored gulis sisxliT avsebis da gulis
wuTmoculobis gazrdiT. sisxlis sistoluri wneva unda gaizardos 100mmHg –ze
metad. Tu SeiniSneba periferiuli vazokonstriqciis niSnebi (civ, lurji an
fermkrTali xelebi da fexebi), an centraluri da periferiuli venebis dabali
sisxlsavseoba, pacients eZleva meti siTxe intravenurad.
Tu pacients aqvs oliguria, pirvel rigSi vfiqrobT: aris Tu ara pacientis
perfuzia adeqvaturi?
M
Sardis gamoyofis samizne moculoba 0,5 ml/kg/sT
suraTi 16 – Sardis gamoyofisTvis gansazRvruli samizne moculoba
60
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
pacients, romelsac dabali Sardis saaTobrivi moculoba aqvs (mg: <0,5 ml/kg/sT),
ar datovoT mkurnalobis da gamokvlevis gareSe araumetes Semdgomi ori saaTis
ganmavlobaSi.
zogjer mxolod siTxis infuzia ar iZleva Sedegs pacientebSi da saWiro xdeba
inotropebis (mg. dobutamini) an vazopresorebis (noradrenalini) Seyvana. Tumca, sanam
vidre aRniSnuli medikamentebis Seyvanas daviwyebT aucilebelia davsvaT kiTxva: xom
ar esaWiroeba pacients meti siTxis infuzia?
cxrili 14: renaluri perfuziis daqveiTebis mizezebi
3 gorglovani da milakovani daavadebebi
maSin, rodesac renaluri perfuzia adeqvaturia, Tirkmlis gorglovani da
milakovani ujredebi ar funqcionireben sworad, romelime daavadebis an
nefrotoqsiuri wamlebis moqmedebis gamo. aseve Tirkmlis intersticiuli qsovili
SeiZleba daziandes, xSirad wamlebis zemoqmedebiT. zemoT xsenebul mizezebs
SeuZliaT Tirkmlis ukamarisobis gamowveva. gorglebi SeiZleba daziandes nebismieri
nefrituli (glomerulonefriti) daavadebis dros, maSin rodesac milakebis
normaluri funqcionireba SeiZleba daqveiTebul iqnas romelime daniSnuli
medikamentiT. aseve Tavisuflad SeiZleba wamlebi intersticiuli nefritis mizezi
gaxdes. cxrili 15 - ZiriTadi nefrotoqsiuri wamlebis sia.
Tirkmlebis parenqimulma daavadebam SeiZleba moiTxovos specialuri gamokvleva,
raTa dasmuli iqnas zusti diagnozi. Tumca, yvela formis daavadebis adreuli
marTvisTvis mniSvnelovani aris mkurnalobis gansazRvruli wertilebi. pirvel
rigSi, renaluri hipoperfuzia unda iqnas aRmofxvrili (ixileT zemoT). Semdeg,
dakvirvebiT unda iqnas Seswavlili wamalTa daniSnuleba nebismieri pacientis,
romelsac aqvs oliguria an momatebuli Sardovana/kreatininis done. Tu pacienti
iRebs nefrotoqsiur nivTierebas, aucileblad unda Sewydes misi miReba. darwmundiT,
rom aRniSnul viTarebas ganixilavT Tqveni gundis ufros wevrTan erTad.
hipovolemia hemoragia;
gaxangrZlivebuli diarea;
gastro-intestinaluri fistuliT an
nazogastraluri miliT siTxis dakargva;
diuretikebiT Terapia;
filtvebis SeSupeba;
sistemuri sisxlZarRvovani
rezistentobis daqveiTeba
sefsisi;
antihipertenziuli Terapia;
wamlebis Warbdozireba;
anesTetikebis da sedaciuri saSualebebis
gverdiTi efeqtebi;
gulis mtumbavi funqciis daqveiTeba miokardiumis mwvave infarqti;
ariTmiebi gulis wuTmoculobis daqveiTebiT;
kardiomiopaTia;
gulis tamponada;
61
oliguriuli pacienti
cxrili 15: ZiriTadi nefrotoqsiuri wamlebis sia.
SeamowmeT daniSnul wamalTa SesaZlo nefrotoqsiuroba nebismier pacientSi,
romelsac aqvs oliguria an momatebuli Sardovana/kreatininis done.
Cvelebriv, mwvave glomerulonefritis mqone pacientebSi milakebi normalurad
agrZeleben funqcionirebas, miuxedavad gorglovani filtraciis daqveiTebisa.
maSasadame, nebismier warmoqmnil Sards rogorc wesi aqvs natriumis dabali
koncentracia (<20 mmol/l) da maRali osmolaroba. oliguriis yvelaze xSiri mizezi
intensiuri Terapiis ganyofilebaSi an ukve stacionarSi myof pacientebSi aris mwvave
milakovani nekrozi. aRniSnulis mizezi SeiZleba gaxdes nefrotoqsiuri
medikamentebiT mkurnaloba an renaluri hipoperfuziis (ixileT zemoT) arasakmarisi
mkurnaloba an saerTod armkurnaloba. Tirkmlis ukmarisobis mqone oliguriuli
pacientis Sards mwvave milakovani nekrozis gamo aqvs damaxasiaTebeli Semadgenloba.
misi osmolaroba plazmis osmolarobis msgavsia (~300 mOsmol/l), radgan Tirkmlebs
aqvT dabali koncentraciis unari da ikargeba natriumi (Sardis natriumi >20 mmols/l).
cxrili 16: Sardis analizis tipiuri suraTi hipoperfuziis da Tirkmlis parenqimuli
dazianebis dros
aminoglikozidebi (mg: gentamicini
rentgenokontrastuli nivTierebebi
arasteroiduli anTebis sawinaaRmdego saSualebebi
ciklosforini
furosemidi (gansakuTrebiT gentamicinTan erTad)
cefalosporinebi
penicilinebi
osmolaroba (mOsmol/l) Sardis natriumi (mmol/l)
araadeqvaturi perfuzia >450 <10
Tirkmlis parenqimuli
dazianeba
~300 >20
62
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
kidev erTxel, aseTi pacientebis marTva moicavs pirvel rigSi renaluri
hipoperfuziis koreqcias da SesaZlo nefrotoqsiuri wamlebis miRebis Tavidan
acilebas. magram nebismieri mizezis SemTxvevaSi unda gvaxsovdes, rom oliguriis
miRma yovelTvis imaleba raime darRveva. oliguriis mqone pacientis marTvis dros
aucileblad unda veZioT oliguriis mizezi da swored es mizezi unda aRmovfxvraT.
oliguriis mizezi dadgenis gareSe wamlebis miReba(mg: furosemidi an dofamini),
romlebic ubralod zrdian Sardis raodenobas, aferxebs swori diagnozis dasmas da
mkurnalobas.
ar daniSnoT diuretikebi, rogorebicaa furosemidi an dofamini, Tu ar
aRiniSneba siTxiT gadatvirTvis niSnebi. es wamlebi ar unda iqnas
gamoyenebuli ubralod Sardis gamoyofis gasaZliereblad.
4 saSarde gzebis obstruqcia
pacientebs, romelTac saSarde gzebis obstruqcia aqvT, SesaZloa ganuviTardeT
oliguria, anuria an absolituri anuria. absolituri anuria pirvel rigSi asaxavs
saSarde gzebis obstruqcias (Sardis buStsa da Sardsadens Soris), sxva mizezis
dadgenamde. am dros pacientis muceli unda iqnas palaciiT Semowmebuli isinjeba Tu
ara Sardis buSti, Tu isinjeba, Sardis buStSi unda Caidgas kaTeteri. mamakacebSi
amis mizezi SeiZleba iyos prostatis hipertrofia, romelic digitalur-reqtaluri
gamokvleviT unda iqnas dazustebuli. Tu absolituri anuria ganuviTarda
kaTeterizebul pacients, amis mizezi SesaZloa iyos kaTeters Sida blokada. am
SemTxvevaSi, kaTeterSi unda SeviyvanoT steriluri wyali frTxilad da igive
moculoba gamoviRoT ukan. SesaZloa saWiro gaxdes arasworad Cadgmuli kaTeteris
xelaxla Cadgma an axali kaTeteris Cadgma. aucileblad SeamowmeT kaTeteris
sanaTuris gamavloba im SemTxvevaSi, Tu kaTeterizebul pacients aReniSneba
oliguria, anuria an absolituri anuria. Tumca, Sardis buStis kaTeteris
Semowmebamde, SegviZlia aviRoT Sardis mcire nimuSi analizisTvis (SardSi ntriumis
koncentracia da osmolaroba), romelic CvenTvis mniSvnelovan informacias mogvcems.
zogjer, aucilebelia muclis ultrabgeriTi gamokvleva Tirkmlebis da Sardis
buStis mdgomareobis SeswavlisTvis.
aucileblad SeamowmeT kaTeteris sanaTuris gamavloba im SemTxvevaSi, Tu
kaTeterizebul pacients aReniSneba oliguria, anuria an absolituri anuria.
63
oliguriuli pacienti
5 sxva moqmedebebi oliguriis mqone pacientebis mkurnalobaSi
ØSeamowmeT Sratis kaliumis done. Tirkmlis ukmarisobiT gamowveuli hiperkalemias
SegviZlia vumkurnaloT kalciumis rezoniumis oyniT, insulin-deqstrozebis
infuziiT, natriumis bikarbonatiT, kalciumis qloridiT, magram sabolood
SesaZlebelia saWiro gaxdes ufro efeqturi Terapiuli mkurnalobis meTodebis
(rogorc wesi invaziuri) CarTva.
ØSeamowmeT pacientis siTxis moculobiTi statusi. SeamowmeT pacientis siTxis
balansi da eZebeT SesaZlo SeSupeba, radgan Tirkmlis ukmarisobis mTavari niSania
hipervolemia da SeSupeba.
ØSeamowmeT pacientis sisxlis mJava-tutovani statusi. gakeTdes arteriuli sisxlis
analizi airebis Semcvelobaze.
oliguriis mqone pacientis marTva
ü gamokvlieT muclis Rru – isinjeba Tu ara gadavsebuli Sardis buSti?
ü Tu ar aris Cadgmuli kaTeteri unda Caidgas dauyovnebliv.
ü aiReT Sardis mcire nimuSi analizisTvis (masSi ntriumis koncentracia da
osmolaroba).
ü SeiyvaneT siTxe kaTeterSi, Tu es ukanaskneli Cadgmulia.
ü Tu ar aRiniSneba saSarde gzebis obstruqcia, daiwyeT siTxis infuzia.
ü Tu siTxeebis intravenurad infuzia ar zrdis sisxlis sistoluri wnevas
100mmHg –mde, SeiyvaneT inotropebi (upriania centralur venur kaTeterSi).
ü Tu inotropebis Seyvanis Semdegac ar izrdeba sisxlis sistoluri wneva
100mmHg –mde, dauZaxeT ufros eqims dasaxmareblad.
ü SeamowmeT daniSnuli wamlebi nefrotoqsiurobaze – SewyviteT dauyovnebliv!
ü ar daniSnoT furosemidi an dofamini, Tu ar aRiniSneba siTxiT gadatvirTvis
niSnebi.
ü eZieT oliguriis mizezebi.
Sejameba
· oliguria aris pacientis mdgomareobis gauaresebis adreuli niSani.
· absolituri anuria pirvel rigSi asaxavs saSarde gzebis obstruqcias,
sxva mizezis dadgenamde.
· Tu pacients aqvs oliguria, pirvel rigSi vfiqrobT: aris Tu
arapacientis perfuzia adeqvaturi?
· ar daniSnoT furosemidi an dofamini, Tu ar aRiniSneba siTxiT
gadatvirTvis niSnebi.
· eZieT oliguriis mizezebi.
· Sardis analizi SesaZloa dagvexmaros oliguriis mizezis dadgenaSi.
64
tkivilis Semsubuqeba mwvave daavadebebis dros
mocemuli Tavis Seswavlis Semdeg Tqven SeZlebT:
Ø tkivilis Semsubuqebis aucileblobis gagebas
Ø tkivilis Semsubuqebis ZiriTadi gzebis da maTi limitebis aRweras
Ø analgetikebis gverdiTi efeqtebis da maTi gamoyenebis teqnikis aRweras
Ø tkivilis Sefasebis aRweras
1 Sesavali
tkivilis Semsubuqeba pirvel rigSi aris humanuri saqcieli. Tumca, tkivilis
Semsubuqeba aseve mniSvnelovania, radgan tkivili asocirdeba arasasurvel fizikur
da fsiqikur efeqtebTan, rogorebicaa:
v momatebuli SfoTva da uZiloba;
v Wrilobis dagvianebuli an arasakmarisi mkurnaloba;
v ateleqtazi, hipoqsemia da hiperkapnia;
v Semcirebuli xvela, retencia da pnevmonia;
v gulis muSaobis da Jangbadis moxmarebis gazrda;
v kuWis dagvianebiT dacla;
v kortizolis momatebuli sekrecia, daqveiTebuli insulinis sekrecia da
hipereglikemia.
istoriulad saavadmyofoebSi tkivilis Semsubuqebis uzrunvelyofa sakmaod
dabali iyo, magram bolo dros is Zalian gaumjobesda, gansakuTrebiT mwvave
tkivilis gundebis Camoyalibebis Semdeg. Tumca, adeqvaturi gautkivarebis miRweva
jer kidev problemas warmoadgens. amis mizezi SeiZleba iyos: tkivilis araadeqvaturi
Sefaseba, daniSnulebis araswori gamowera, gautkivarebis meTodis da analgetikis
araswori SerCeva, saanesTezio saSualebebis arCevanis simwire da tkivilis
araadeqvaturi sixSiriT marTva. mniSvnelovania, rom yvela pacientis organizmi
gansxvavebulad pasuxobs gautkivarebas.
2 gautkivarebis gzebi
gautkivarebis saxvadasxva gzebi arsebobs. yvelaze gavrcelebuli gzebia:
inhalaciuri, transdermaluri, enisqveSa, peroraluri, kanqveSa, intravenuri
(bolusi/infuzia/PCA{pacientis mier TviTkontrolirebadi gautkivareba}),
eqstraduruli da reqtaluri.
gautkivarebis nebismieri meTodis arCevisas, pirvel rigSi darwmundiT, rom
Tqveni daniSnuleba zustia da mkafio.
65
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
2.1 inhalaciuri
sainhalacio entonoqsi (50% azotis oqsidi gajerebuli 50% JangbadiT) SeiZleba
daniSnul iqnas travmiT ganpirobebuli mwvave tkivilis mosaxsnelad, aseve
SesaZlebelia misi gamoyeneba fizioTerapiis dros qirurgiul da stacionarul
palatebSi, Tu pacients aqvs tkivili. am nivTierebis miReba xdeba specialuri
srqvliT kontrolirebadi aparatiT da aqvs usafrTxoebis damatebiTi meqanizmi,
romelic moTxovnis sistemis arsebobas gulisxmobs. maSasadame, Tu pacients CaeZineba
azotis oqsidis moqmedebis gamo, niRabi scildeba pacients saxidan da am gziT wydeba
entonoqsis miReba. azotis oqsidi Seiwoveba haeris Semcveli Rruebidan. amitom,
entonoqsis gamoyeneba ar SeiZleba pnevmoToraqsis mqone pacientSi, Tu ar aris
Cadgmuli gulmkerdis RruSi sadrenaJo mili da ar xdeba aqtiuri drenaJi.
2.2 transdermaluri
transdermaluri gautkivarebisTvis SesaZlebelia gamoyenebul iqnas mg: fentanili,
zeda kidurebisa da torsis kanis uTmo nawilebze SezeliT. pirveli Sezelvisas
plazmaSi misi donis momatebas sWirdeba dro.
2.3 enisqveSa
am dros wamlis moTavseba xdeba enis qveS. am gziT nivTierebis Seyvanisas wamali
RviZlis metabolizmis e.w. `pirveladi gavlis` gareSe xvdeba sistemur cirkulaciaSi.
am gziT SeiZleba SeviyvanoT opioiduri analgetiki buprenorfini. misi moqmedeba
iwyeba swrafad da grZeldeba 6-8 sT ganmavlobaSi. is xasiaTdeba opiatebis mimarT
rogorc agonisturi ise antagonisturi moqmedebiT, amitom is sxva opioid
damokidebul pacientebSi SeiZleba gamoyenebul iqnas narkotikze Tavis danebebis
mizniT. misi efeqti mxolod nawilobriv gansxvavdeba naloqsonisgan. gautkivarebis es
gza aseve SeiZleba gamoyenebul iqnas kardialuri tkivilis mosaxsnelad.
2.4 peroraluri
es aris yvelaze xSirad gamoyenebadi gautkivarebis gza, Tumca, mwvave tkivilis
dros naklebad. es meTodi aris umtkivneulo, martivi da saimedo, im SemTxvevaSi Tu
pacients ar aqvs kuW-nawlavis motorikis daqveiTeba (dagvianebuli pasaJi) da ileusi.
2.5 kanqveSa
bevri nivTiereba, romelic SeyavT kunTSi an intravenurad, aseve SeiZleba Seyvanil
iqnas kanqveS.
66
tkivilis Semsubuqeba mwvave daavadebebis dros
2.6 kunTSida
es aris narkotikuli analgetikebis Seyvanis tradiciuli gza, yvelaze xSirad
gamoiyeneba gautkivarebis `oTx saaTiani prn (pro re nata)~ reJimi. es aris
mosaxerxebeli da iafi gza, Tumca mas aqvs uaryofiTi mxare _ is mtkivneulia.
wyvetili kunTSida gautkivarebis gamoyenebam SeiZleba aseve gamoiwvios
aradeqvaturad kontrolirebuli tkivili, radgan plazmaSi nivTierebis done
mniSvnelovnad meryeobs, gansakuTrebiT SokSi myof pacientebSi. kunTSida
gautkivarebisas Znelia dozireba efeqtis mixedviT, radgan didia drois intervali
preparatis ineqciasa da miRebul efeqts Soris. aseve arsebobs mniSvnelovni
dayovneba pacientis pirvelad gamovlenil tkivilsa da Semdgom preparatebis miRebas
Soris.
standartuli oTx saaTiani prn kunTSida bolus gautkivareba xSirad
cvalebad gautkivarebas iwvevs.
2.6.1 optimizebuli kunTSida gautkivareba opiatebiT
es aris standartuli 4 saaTiani prn gautkivarebis modifikacia SemuSavebuli
Gould-s mier. es gulisxmobs analgetikis kunTSida saaTobriv ineqcias da tkivilis
regularul Sefasebas, am meTodis algoriTmi naCvenebia me-17 suraTze. pacientebi,
romlebic iReben am saxiT gautkivarebas, unda edgaT intravenurad kaTeteri.
kunTSida analgetikebis dozireba xdeba pacientis wonis mixedviT, xolo
gautkivarebisa da sedaciis donis monitoringi xorcieldeba skalebis gamoyeebiT,
romlebic am Tavis bolos aris ganxiluli.
saaTobrivi doza kunTSi (mg-Si)
petidini morfini
pacientis wona (kg)
40-65 50 7,5
66-100 7,5 100
Tu pacientis wona zemoT aRniSnuli normebis farglebs
gareTaa, gaiareT konsultacia anesTeziologTan
67
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
suraTi 17: opiatebiT kunTSida gautkivarebis optimizebuli `4 saaTiani prn ~ reJimi (modifiedfrom Gould et al., BMJ 1992; 305: 1187)
68
tkivilis Semsubuqeba mwvave daavadebebis dros
2.7 intravenuri (i.v.)
2.7.1 intravenuri bolusebi
es meTodi gamoiyeneba ZiriTadad opioidebiT gautkivarebis dros da moicavs
wamlis mcire bolusebis Seyvanas, sawinaaRmdego efeqtebis kontroliT. Tumca, es
ufro efeqturi gzaa gautkivarebis, vidre kunTSida. am meTodis drosac aRiniSneba
cvalebadi gautkivarebis problema (ixileT zemoT). am gzis gamoyenebiT miRebuli
warmatebuli gautkivareba moiTxovs pacientis mudmiv kontrols, raTa dabalansebul
iqnas wamlis sawinaaRmdebo efeqti (sunTqvis centris daTrgunva).
2.7.2 intravenuri infuzia
es aris gautkivarebis yvelaze xSirad gamoyenebadi meTodi intensiuri Terapiis
ganyofilebebSi da maRal damokidebul palatebSi, magram gamousadegari zogadi
saavadmyofoebis palatebisTvis. wamlis sainfuzio done dgindeba minimaluri
efeqturi doziT, Tumca amas sWirdeba raRac dro, plazmaSi nivTierebis garkveuli
donis misaRwevad. wyvetili i.v. bolus meTodis gamoyenebisas arsebobs Warbdozirebis
riski. dResdReobiT es teqnika iSviaTad gamoiyeneba zogadi saavadmyofoebis
palatebSi.
2.7.3 pacientis mier TviTkontrolirebadi gautkivareba (PCA)
gautkivarebis am meTodis dros pacienti tkivilis Sesabamisad TviTon axdens
analgetikis mcire dozebis ineqicas. es Ceulebriv moiTxovs daxvewil sistemas, es
sistema Seicavs daxvewil sainfuzio mowyobilobas, romelic moTxovnis Sesabamisad
axdens bolus ineqcias. paralelurad opioidebis Seyvana, rogorc uwyveti infuziuri
foni, dauSvebelia, radgan am dros srulyofili gautkivarebis miRebis gareSe
izrdeba Warbdozirebis riski. bolus ineqciisas nivTierebis raodenoba da Seyvanis
siCqare SesaZlebeblia Seicvalos uSualod gautkivarebis dros. uneblie
Warbdozirebis Tavidan acileba xdeba bolusis individualuri SerCeviT da saerTo
dozis marTviT. bolusebis Seyvanas Soris SesaZlebelia drois minimaluri
intervalis dayeneba (lock-out interval). sainfuzio porti sistemasTan dakavSirebuli unda
iyos calmxriv mimarTuli sarqvlis qvemoT, Tu masTan SeerTebulia meore sainfuzio
porti (Tavidan rom aviciloT retrograduli dineba meore sainfuzio portSi da
Semdgomi zedozireba, Tu es ukanaskneli gadavsebulia). PCA-m aCvena, rom standartul
kunTSida gautkivarebasTan SedarebiT, is ufro metad uzrunvelyofs plazmaSi wamlis
Tanabari donis SenarCunebas, minimaluri garTulebebs filtvismxriv, minimaluri
sedacias da zogadad moxmarebuli wamlis raodenobis Semcirebas. am dros gamoiyeneba
mcire naxevar daSlis periodis mqone wamlebi. gulisreva da Rebineba aris ZiriTadi
problema PCA-s ganmavlobaSi, Tu ar iqneba daniSnuli Rebinebis sawinaaRmdego
saSualebebi. es ganpirobebulia imiT, rom plazmaSi wamlis Tanabari donea da aseve
imiT rom, `saWiro` Rebinebis sawinaaRmdego saSualebebi, romlebic rutinulad
iqneboda miRebuli kunTSida opioidebis paralelurad aRar iniSneba, Tu `saWiro`
opioidebi xangrZlivad ar aris gamowerili.
69
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
yvela opiatebis gverdiTi efeqtebia sunTqvis centris daTrgunva da koma.
Ø sunTqvis daTrgunvis mkurnaloba: Tu sunTqvis sixSire 8-ze nalebia wuTSi,
Segvyavs 0,2 mg naloqsoni intarvenurad yovel 5 wuTSi da veZaxiT
anesTeziologs dasaxmareblad saswrafod.
Ø cnobierebis donis daqveTebis mkurnaloba: Tu pacientis modunebis xarisxi
fasdeba 3 quliT, vukeTebT intravenurad 0,2 mg naloqsons da viZaxebT
daxmarebas saswrafod.
2.8 eqstraduruli (epiduruli)
es teqnika gulisxmobs saanesTezio nivTierebis, ZiriTadad opioidebis,
lokalurad Seyvanas eqstradurul sivrceSi plastikuri kaTeteris saSualebiT. es
xorcieldeba epiduruli sivrceebis saanesTezio nivTierebiT avsebiT. xsnarebi,
romlebic am dros ZiriTadad gamoiyeneba aris 0,125%-iani bupivakaini an 0,125%-iani
bupivakainis da fentanilis (4 mikrogrami mililitrSi) kombinacia. aRniSnuli
saanesTezio nivTierebebi ablokireben impulsis gadacemas eqtradurul,
paravertebrul da subaraqnoidul fesvebSi, an uSualod moqmedeben zurgis tvinze.
maTi erTdrouli gamoyenebisas miiReba gautkivareba, romelis efeqti sxva zemoT
xsenebuli meTodebisas bevrad aRemateba. eqstraduruli gautkivarebis yvelaze
xSiri garTuleba stacionarul pacientebSi aris hipotenzia epiduruli sivrceebis
avsebis gamo (adgilobrivi saanesTezio saSualebiT) da sunTqvis daTrgunva
(opiatebiT).
eqstarduruli anesTeziis gverdiTi efeqtebia sicocxlisTvis saSiSi
hipotenzia, sunTqvis daTrgunva da cnobierebis daqveiTeba.
Ø hipotenziis mkurnaloba: Tu sisxlis sistoluri wneva 80 mmHg-ze dabalia
SeiyvaneT 6 mg efedrini bolusis saxiT (ganzaveba, 30 mg efedrini 9 ml
natriumis qloridis 0,9 % ian xsnarSi an saineqcio wyalSi, e.i. 6mg = 2 ml)
zogierT hospitalSi eqTnebs aqvT mxolod 6 mg-is ineqciis ufleba, xolo
eqimebs 6 mg-ze metis. aseve gaukeTeT 500 ml gelofuzini 15 wuTze metxans Tu
pacientis sistoluri wneva 80 mmHg-ze dabalia. dauZaxeT anesTeziologs
daxmarebisTvis.
Ø sunTqvis daTrgunvis mkurnaloba: Tu sunTqvis sixSire 8-ze nalebia wuTSi,
Segvyavs 0,2 mg naloqsoni intarvenurad yovel 5 wuTSi da veZaxiT
anesTeziologs dasaxmareblad saswrafod.
Ø cnobierebis donis daqveTebis mkurnaloba: Tu pacientis modunebis xarisxi
fasdeba 3 quliT, vukeTebT intravenurad 0,2 mg naloqsons da viZaxebT
daxmarebas saswrafod.
70
tkivilis Semsubuqeba mwvave daavadebebis dros
2.9 reqtaluri
am gziTGgautkivarebisas gamoiyeneba sxvadaxsva analgetikebi mg: diklofenaki.
diklofenaki (75-100 mg) aris arasteroiduli anTebis sawinaaRmdego saSualeba (aass),
romelic gamoiyeneba zogadi stacionaris palatebSi sanTlebis saxiT. aass-is
gamoyeneba ar SeiZleba (ara aqvs mniSvneloba reqtalurd Tu peroralurad) mwvave
pacientebSi (riskis qveS myof pacientebSi), radgan maT SeiZleba gamoiwvios
Tirkmlis mwvave ukmarisoba an/da gastro-intestinaluri sisxldena.
dikofenaki da sxva aass-s gamoyeneba ar SeiZleba mwvave pacientebSi (an riskis
qveS myof pacientebSi), radgan maT SeiZleba gamoiwvios Tirkmlis mwvave
ukmarisoba an/da gastro-intestinaluri sisxldena.
3 tkivilis da sedaciis monitoringi
imisaTvis, rom Semowmdes gautkivarebis efeqturoba, arsebobs ramdenime meTodi
tkivilis xarisxis Sesafaseblad (cxrili-17).
cxrili 17: tkivilis SefasebiTvis gamoyenebuli skalebis magaliTebi
gautkivarebis nebismieri meTodis gamoyenebisas aucilebelia pacientis vitaluri
niSnebis monitoringi. yvelaze mniSvnelovania sunTqvis sixSiris, sisxlis wnevis da
cnobierebis donis regularuli monitoringi. tkivilis da sedaciis Sefasebis iseTi
sistemebis gamoyenebiT, romlebic mocemulia me-18 cxrilSi, SesaZlebelia iseTi
gautkivarebis SerCeva, romlis drosac sedaciis niSnebis gareSe (0-2) miiReba kargi
gautkivareba (0-1). qvemoT mocemuli ori skala SeiZleba iqnas gamoyenebuli
pacientis progresis regularuli monitoringisTvis (saaTobrivi) da miRebuli
Sedegebi unda iqnas Sedarebuli normalur TPR (temperatura, pulsi, sunTqva)
maCvenebelTan. Tu aRiniSneba uecari an TandaTanobiTi cvlileba romelime
parametrSi, iTxoveT daxmareba pacientis mdgomareobis Sesabamisad.
skala magaliTebi
verbaluri ara, susti, moTmenadi,
Zlieri tkivili
ricxvobrivi 0,1,2,3
vizualuri
qceviTi gamoTqmebi, sxeulis ena,
fiziologia
71
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
cxrili 18 – tkivilis da sedaciis Sefasebis tipiuri qulebi
rodesac gamoZaxebul iqneba klinicisti tkivilis mqone pacientis sanaxavad,
dausviT Tqven Tavs Semdegi SekiTxvebi.
ü aris Tu ara gautkivarebis efeqturi meTodebi daniSnuli?
ü gautkivarebisTvis daniSnuli meTodi aris Tu ara efeqturi?
ü aris Tu ara mkurnaloba saTanado am pacientisTvis?
4 gautkivarebis damatebiTi meTodebi
daimaxsovreT, rom tkivilis SemsubuqebisTvis SesaZlebelia gamoviyenoT
sxvadasxva ara farmakologiuri meTodebi, magaliTad:
Ø motexilobis imobilizacia
Ø anTebadi saxsris imobilizacia
Ø anTebadi midamos gagrileba
Ø samkurnalo saTburis dadeba
Ø pacientis fsiqologiuri mxardaWera
Ø mosvenebiT Terapia
Ø nervis kanSida eleqtruli stimulacia (nkes)
Ø aromaTerapia
tkivilis Sefasebis qula sedaciis Sefasebis qula
ar aris tkivili 0 gonzea 0
susti tkivili 1 Tvlems periodulad 1
asatani tkivili 2 umTavresad Zinavs 2
Zlieri tkivili 3 Znelad iRviZebs 3
Sejameba
· tkivili iwvevs mniSvnelovan fsiqikur da fizikur darRvevebs.
· gautkivarebis sxvadasxva meTodebs gansxvavdebulad pasuxoben
pacientebi.
· darwmundiT, rom Tqvens mier daniSnuli gautkivareba zustia da mkafio.
· opiatebis gverdiTi efeqtebi moicavs sunTqvis da cnobierebis
daTrgunvas.
· opioiduri analgetikebis antidotia naloqsoni.
· lokalurma epidurulma saanesTzio nivTierebebma SeiZleba gamoiwvios
sicocxlisTvis saSiSi hipotenzia.
· diklofenakma da sxva arasteroiduli anTebis sawinaaaRmdego
saSulebebma SeiZleba gamoiwvios Tirkmlis ukmarisoba.
72
organizatoruli da komunikaciuri Cvevebi
am Tavis dasrulebis Semdeg Sen SegeZleba:L
· Tu ratom aris organizatoruli Cvevebi mniSvnelovani kritikuli pacientebis
marTvisaTvis
· Tu ratom aris kargi werilobiTi da verbaluri komunikaciis Cvevebi
mniSvnelovani gundis kargi muSaobisaTvisa da klinikuri mzrunvelobisaTvis
· sxvaobis aRwera mtkicebiTi (dadebiTi), agresiuli da pasiuri qceva
· zogierTi organizaciuli gamosavlis gageba da cudi ambebis gadacemis
kompeqsuraoba (sirTule); da
· kargi SeniSvnis-Senaxvis aucilebeli aspeqtebis aRwera
1 organizatoruli Cvevebi
mwvave zrunvis efeqturobis moTxovnebis mitana mravali moqmedebis orkestracia
(diriJoroba). gamokvlevebi da intervencia (Careva) SeiZleba iyos dagegmili da
specialistis mosazrebebis referalebi xSirad saWiroa. bevri am daSvebidan to thePRHO vinc, miuxedavad SedarebiTi gamoucdelobisa, iqneba molodinSi, rom
koordinacia gauwios maT da garantia nisces rom eseni moxdeba. warmatebis
misaRwevad, mniSvnelovania organizacia, xelmZRvaneloba, efeqturi komunikacia da
gadawyvetilebis miReba aris saWiro. am yvelafris gasaRebi aris informaciis
saWiroeba. Rogorc ar unda iyos amis Sesagroveba SeiZleba drois xarjva iyos da
yvelaze xSirad kargia rom sxvebs daavalo amgvari tipis moqmedebebis Sesruleba, im
dros roca ikaveb efeqtur organizacias Sekrebili monacemebis. sasargeblo aris rom
ganrigi (cxrili) Seni sakuTari saavadmyofos palatis Semovlebi Sesaferisad, rom
daazRvio mTavari mniSvnelovani informacia (mag.: laboratoriis Sedegebi, eqTnis
moxseneba) aris sasargeblo gadawyvetilebis misaRebad da dasagegmvaSi dasaxmareblad.
iSviaTad, Seni davaleba ar iqneba advili da iqneba dabrkolebebi pacientis marTvis
progresSi. magaliTisTvis, aman SeiZleba daadasturos siZnele rom miiRo Zveli
SeniSvnebi, moamzade wvrilmani gamokvleva (testi) an miiRe sxva eqimisgan azri.
xandaxan Sen dagWirdeba, rom iyo Seuvali (daamtkico) wamatebis misaRwevad (ixileT
qveviT).
kargi xelmZRvaneloba aris gadamwyveti, rom iyo jgufSi saukeTeso da es moiTxovs
ramdenime gansxvavebul Cvevas. es moicavs: codnas, unars (moxerxebulobas),
gadawyvetilebis miRebas, TavdaWeriloba, sxvebis xedvebis miReba da xandaxan
simtkicis gamovlineba (uryevoba). Cota adamiani flobs am yvelafers! Tu Sen imedi
gaqvs rom gaqon kargi praqtikisaTvis, gaxsovdes rom aqo sxvebic. agreTve ecade, rom
gaiTvaliswino da ganWvrito problema winaswar da daeTanxme rodesac xar mcdari, ar
ici, scdeba Tqveni kompetenciis (codnis) sazRvrebs an gWirdeba daxmareba. magaliTiT
xelmZRvaneloba aris mniSvnelovani. naklebad dasajerebelia rom sxvebi igrZnoben
gamosavali aris mniSvnelovani, Tu Sen rogor gaakeTeb. rogorc ar unda iyos, iyavi
TavdaWerili da miiRe gamocdili eqTnebis rCeva.
73
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
ixelmZRvanele magaliTiT!
roca TanamSromlob konsultantebTan, gaxsovdes rom umravlesobas esurveba, rom
swrafad (mardad) iyos informirebuli im pacientebze, romlebic Zlier SeuZlod
arian. es ar aris gasasamarTlebeli pacientis mokle gziT SefasebisaTvis,
gamokvlevisaTvis, mkurnalobisaTvis, gadawyvetilebis misaRebad an dasagegmad.
miuxedvad amisa, roca pacientebi arian eqtremalur mdgomareobaSi, an roca pacienti
saWiroebs Senis SesaZleblobis zRvars iqiT Carevas, consultants daWirdeba mokled
Txroba (Sejameba), Semoklebuli da naTeli aRwera pacientis problemis.
yvelaze gamomwvevi (rTuli/saeWvo) pacientebi, romlebic PRHO an palatis eqTanma
unda marTos arian albaT pacientebi miRebuli rogorc mwvave gauTvaliswinebeli
SemTxvevebi (Emergencies). es xSirad saWiroebs paralelur gamokvlevas, diagnozis
dasmas da urgentul mkurnalobas. aseTi pacientebis mravali saaTis ganmavlobaSi
datoveba, sanam ufrosi personali (Senior Staff) iqneba xelmisawvdomi iSviaTad
bolovdeba kargi gamosavliT. maSasadame, Sen unda uzrunvelyo, rom Sen gaqvs saRi
(saimedo) da srulyofili moqmedebis gegma yvela im pacientisaTvis romelic marcxs
ganicdis (Caagdebs), ar moaxdens reagirebas martiv reanimaciul RonisZiebaze, da Sen
dauZaxe adreulad dasaxmareblad. ar daelodo dilis Semovlas! codnis an Cvevis
nakleboba specialuri Carevis Casatareblad arasdros aris adeqvaturi mizezi
mkurnalobis dawyebis gadavadebisaTvis. daexmare!
miuxedavad saaTebisa da eqTnebis nimuSebiT muSaobisa da staJiori (Trainee) eqimebisSecvlisa, zrunvis ganuwyvetloba (uwyvetoba) rCeba aucilebeli elementi pacientis
kargi marTvisaTvis. es SeiZleba miRweul iqnes warmatebiT mxolod maSin, rodesac
pacientis pirveladi (dawyebiTi) gundi gadacems morige gamoZaxebiT (on-call) gunds,
sanam isini datoveben saavadmyofos RamiT. rogorc ar unda iyos (on-call) gunds
agreTve aqvs movaleoba, rom gadaxedos arsebul problemebs palatis pacientebs
Soris nebismieri gundidan da daaCqros saTanado gamokvlevebi da Terapia.
zrunvis ganuwyvetloba (uwyvetoba) aris aucilebeli elementi pacientis kargi
marTvisaTvis
PRHOs aris yvelaze xSirad naTxovni eqTnebis mier, rom iyos gadaxedili an
Sefasebuli pacientebSi, an dawvrilebiT aRiweros wamlis an siTxis recepti. kargad
momzadebul eqTans mogrovebuli eqneba yvela saWiro informacia SefardebiT pacients
daewyeba martivi Terapia (poziciis aRdgena, oqsigenacia, sisxlis glukozis gazomva,
pacientis saTanado pozaSi moTavseba da a.S.) sanam dasaxmareblad darekavs.
erTnairad, naklebad urgentuli problemebisTvis (rogoric aris out-of-hours fluid an
wamlis daniSnuleba), es exmareba eqims Tu eqTanma moagrova erTad pacientis
CaniSvnebi, axlaxan momxdari Sesabamisi Sedegebi da daniSnulebis sqemebi (cxrilebi).
74
organizatoruli da komunikaciuri Cvevebi
eqimebisTvis, darekva uecari saswrafo SemTxvevis dasaxmarebis gasawevad SeiZleba
gamoiwvios panika da mRelvareba. es bunebrivi damokidebulebebi SeiZleba Semcirdes
naTeli mosazrebebiTa da momzadebiT. roca telefonis zari Semodis, ifiqre winaswar.
`ra vici me pacientis da misi samedicino mdgomareobis Sesaxeb~? `ra unda gavakeTo
roca mival~? `rogor unda gavxado pacienti usafrTxo~? xSirad iqneba ramodenime
wuTi sanam Sen mixval pacientamde, yvelaze karg SemTxvevaSi. Amitomac, sanam
telefons dadeb, eqTans mieci naTeli instruqciebi, mag.: `mieci pacients 100%-iani
Jangbadi~, `daawvine pacienti komis poziciaSi (recovery or coma position),~ `me roca movaldamWirdeba i.v.i. (intravenuri inieqcia) dayeneba, gTxov dauyene intravenuri kanula da
gamimzade 500ml izotonuri marilis xsnari~. rogorc yovelTvis, miaqcie yuradReba
ABC-s sworad dawyebas pirvelad.
2 komunikaciuri Cvevebi
personalis urTierTobas SeiZleba qondes mniSvnelovani efeqti – rogorc
dadebiTi aseve uaryofiTi – mwvave daavadebebiT dasnebovnebuli pacientebis marTvaze.
jgufuri muSaoba aCqarebs pacientis marTvas, magram zewolebma stresis qveS SeiZleba
iSviaTad miiyvanos emociur agznebamde agresiis CarTviT da kolegebis pativiscemis
naklebobamde. aseTi sirTuleebi SeiZleba gauaresdes Tu inter-profesionaluri
(profesionalTa Soris) an inter-disciplinaruli (disciplinebs Soris) konkurenciebi
Caerios. xSirad, gaugebrobebi janmrTelobis dacvis TanamSromlebis jgufebs Soris
warmoiSoba gansakuTrebiT cudi komunikaciisas. yvelaze metad es exeba formalur an
maRal ara formalur jgufur Sexvedrebs sadac azrebi Rirseulad da Tavisuflad
gamoiTqmeba.
2.1 Seni gundis sxva wevrebTan komunikacia
2.1.1 vinmesTan dakontaqtebis ganzraxvis gansazRra
yvela savarjiSos dawyebis win mniSvnelovania komunikaciaSi, rom iniciatorma icis
telefonis zaris an kamaTis obieqti. magaliTisTvis, isurveb Tu ara Sen ubralod
rom acnobo vinmes rom pacienti (Sen favorit konsultants) movida stacionarSi, rom
gkiTxos rCeva menejmentisaTvis (marTvisaTvis), an rom gTxovos pirovneba (SesaZloa
Seni konsultanti) movides pacientis Sesafaseblad an proceduris Casatareblad
(Tavis Tavze asaRebad) (centraluri venis kaTeterizacia, operacia, ERCP, da a.S.)? Tu
Seni gzavnili ar aris naTeli, maSin SeiZleba ver miaRwio Sens mier dasaxuli miznis
miRwevaSi warmatebas, da Sen SegiZlia daasrulo warumateblobis SegrZneba. ufro
mniSvnelovnad, pacienti SeiZleba ar iRebdes im tipis mkurnalobasa da gamokvlevas
rac maT WirdebaT. sanam cdi vinmesTan darekvas, mcire droSi Seagrove monacemebi,
daalage Seni azrebi da daisaxe darekvis obieqtebi. daiwye saubari imaze, rom
daadgino naTlad raSi mdgomareobs problema. magaliTad:
`gamarjoba, eqimo vait, es aris jon brauni. me axlaxans vnaxe batoni grini, 40 wlis
mwvave abdominaluri tkiviliT. is Zalian cudad aris. me vfiqrob mas aqvs
septicemiuri Soki. me viqnebodi madlieri Tqven, rom mosuliyaviT da genaxaT CemTan
erTad, radgan me darwmunebuli ar var am diagnozSi da me Zalian vRelav imas, rom
misi mdgomareoba uaresdeba.
75
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
maSinve, es identificirebas ukeTebs Tu vin aris pacienti, rom Sen Relav mis
mdgomareobaze da Sen gsurs Seni zaris mimRebisgan miiRo daxmareba. Zalian advilia,
rom CamoTvalo grZeli rigi paTologiebisa, romelsac gaaCnia tendencia, rom
recipients goneba aurios da yuradReba gadaatanios realurad arsebuli
problemisagan. eqTnebi naxaven, rom amgvari midgoma ufro metad savaraudoa
dauyovnebeli daxmarebis aRmosaCenad samedicino personalis mxridan, vidre naCqarebi,
zogjer araTanmimdevruli, gzavnili romelic gadascems mcire Sesabamis droul
faqtebs pacientis Sesaxeb.
gadawyvite Seni telefonze darekvis da sakamaTo obieqti
2.1.2 iyavi mtkice, Seuvali
Seuvaloba niSnavs iyo pirdapiri, Cveuli da unda iyo pasuxismgebeli Sen
warmoTqmul sityvebze, azrebsa da moqmedebebze. amave dros mniSvnelovania, rom darCe
mSvidi da akontrolebde Sens Tavs, magram iyavi mzad rom mousmino. iyo Seuvali
yovelTvis ar niSnavs, rom Sen naxav Sens gzas. miuxedavad amisa es mogcems sarisko
Sanss, rom miaRwio Sens miznebs. es aris imis Sesaxeb rom gqondes sakuTari Tavis
pativiscema, rom ganacxado Tu ras iTxov sxva adamianebisagan, daicva sakuTari Tavi,
konfliqtis gadaWra da iswavlo `ara~-s Tqma. es agreTve moicavs pativiscemis qonas
sxvebis mimarT da TavianTi uflebebi ganacxadon TavianTi moTxovnebis Sesaxeb.
Seuvali gancxadeba Cveulebriv moicavs nacvalsaxels `me~, mag.: ` . . . me miudgebodi
amas sxvagvarad~; `SemiZlia SemogTavazoT gansxvavebuli gza amis gadasaWrelad?~.
Seuvali gancxadeba Cveulebriv moicavs nacvalsaxels `me~
es damikidebulebebi upirispirdeba agresiul yofaqcevas, samwuxarod Zalian xSirad
stacionarSi yoveldRiur cxovrebaSi. agresiuli adamianebi iyeneben sxvebs, iyeneben
muqaris, Zaladobis taqtikas, xSirad moqmedeben araprognozirebulad da an aqvT
mcire an ara aqvT pativiscema sxvebis moTxovnilebebze, grZnobebsa da azrebze.
naTlad, amgvari qmedebebi aris usargeblo, gansakuTrebiT stacionarSi jgufuri
samuSaos praqtikaSi, pativiscema sxvebis SesaZleblobis da TanamSromloba
warmoadgens aucileblobas. Tumca agresiuli qcevis Sedegebi moicavs mokle-vadian
jildos damnaSavesaTvis (damrRvevisaTvis), sabolood Camoyalibdeba konfliqtis
mdgomareoba. xalxs Seni SeeSindeba da Tavs agarideben. agresiuli komentarebi
xSirad Siecavs nacvalsaxels `Sen~, mag.: `es ar imuSavebs, Sen amgvarad unda
gagekeTebina~ an `Sen ar SegiZlia amis Tqma~. sabolood, zogi adamiani arc dadebiTad
moqmedebs da arc agresiulad, magram arian pasiurad. Tumca isini SeiZleba aRqmuli
iyvnen, rogorc sandomiani an sasargebloni, es jildo SieZleba iyos mokle
xangrZlivobis. pasiuri qceva xSirad win uZRvis sakuTari Tavis mimarT pativiscemis
dakargvas, rogorc pasiuri adamianebi SeiZleba gamoyenebuli iyvnen, imedgacruebuli
darCena, aRSfoTebuli, nawyeni, SeiZleba gairiyos da igrZnos Tavi rogorc
socialurad dabla mdgomma. rac yvelaze mTavaria, isini xSirad ver aRweven TavianT
miznebs.
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organizatoruli da komunikaciuri Cvevebi
3 cudi ambebis gadmocema
amgvari aris Tanamedrove stacionaris yoveldRiuri praqtika, rogoric aris bevri
saubari ojaxebTan, partniorebTan da axlo megobrebTan maTi ukiduresad mZimed
daavadebuli pacientebis Sesaxeb, romelic moicavs informacias Zlier damangreveli
seriozuli daavadebis Sesaxeb, gardauvali sikvdili, qmedunarianobis dakargva an
SezRudva an iseTi Sedegebi, romelic Secvlis maT sicocxles da momavlis
miswrafebebs. amitom, cudi ambis miwodebis procesi winaswar unda iyos dagegmili,
iseTi saxiT ganxorcieleba romelic warmoaCens humanurobas, mgrZnobiarobas,
TanagrZnobas, mzrunvelobasa da empaTias. informacia unda miewodos Sesabamis dros
celkeul dainteresebul pirebs. cudad gadacemul cud ambebs SeiZleba potenciurad
qondes damangreveli moqmedeba mis recipientebze. erTma daudevarma Sejaxebam
SeiZleba gamoiwvios mniSvnelovani gaugebrobebi, urTierTobebis gafuWeba
profesionalebsa da pacients/ojaxs Soris, momavlis urTierTobebis Seferxeba,
romelic sabolood saCivris aRZvramde migviyvans. es SeiZleba agreTve gaxdes mtkice
mogoneba da ulmobeli yuradReba TavianTi gabrazebis da simware da aferxebs
mwuxarebis process. Rodesac kargad aris Catarebuli, komunikaciam SeiZleba gaakeTos
bevri rom ndoba warmoSvas naTesavebsa ICU gunds Soris, rom Semcirdes eWvi
pacientSi/ojaxSi da amaRleba maTi realuri mdgomareobis Secnobis pacientis
janmrTelobis gamosavalSi.
miuxedavad amis didi mniSvnelobis qonisa, janmrTelobaze mzrunavi mcire
specialistebisa iRebs met formalur trenings efeqturi komunikaciis warmoebaSi.
umetesoba swavlobs samsaxurSi kolegebisgan, romlebic SeiZleba iyvnen
gamoucdelebi, arakvalificiurni da moumzadebelni. komunikacia samedicino
personalsa da pacientebs Soris xSirad ar myardeba, orive mxaris mxridan
sirTuleebis arsebobis gamo – janmrTelobaze mzrunavi specialistis mxridan
informaciis garkveviT gadacemis warumatebloba da pacientisa da naTesavebis mxridan
informaciis asimilaciis SeuZlebloba(cxrili 19).
ar arsebobs cudi ambebis gadacemis iseTi meTodi, romelic marTebulia yvela
SemTxvevisaTvis. marTla kulturuli, religiuri da erovnuli gansxvavebebi axdens
gavlenas sityvebze da Jestebze romlebic gamoiyeneba da manera romliTac informacia
miewodeba pirovnebas. agreTve, rodesac bavSvebi iReben cud ambebs, sagangebo
yuradReba unda daeTmos maTi inteleqtualuri da emociuri ganviTarebis dones.
miuxedavad amisa, garkveuli principebi exeba da am Tavis mizania gamoikvlios
sirTuleebi rac Tan sdevs cudi ambebis gadmocemas da uzrunvelyofs samedicino
personalis CarCos warmoqmnas, romelic gamoiyeneba amgvari Zneli amocanis
Sesrulebisas.
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sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
cxrili 19: faqtorebi romlebic pasuxismgebelia cudi komunikaciis CamoyalibebaSi
jandacvis TanamSromlebsa, pacientebsa da pacientebis ojaxebs SorisM KE
3.1 pacientebi da maTi ojaxebi
dResdReobiT sazogadoeba ufro gaTviTcnobierebuli da informirebulia, im
statiebisa da gamocemebis meSveobiT , romlebsac mudmivad adevnebs Tvalyurs. aqedan
gamomdinare moTxovna informaciaze ufro maRalia. pacinetebsa da maT ojaxis
warumatebloba komunikaciaSi ganpirobebuli
jandacvis specialistebiT
Økomunikaciuri Cvevebis nakleboba
Øsamedicino Jargonis gamoyeneba
Øpersonali ar miiCnevs mniSvnelovnad
informaciis micemas
Øarasakmarisi dro
Øcudi ambebis gadacema aris
arakomfortuli
Øsurvili rom daicva recipienti
mwuxarebaSi Cagdebisagan
Ø SiSi rom iyo dawyevlili da
dava warmoSva
ØSiSi recipientis emociuri reaqciis
ØsakuTari emociis gamoxatvis SiSi
Ømarcxi rom xazi gausvas (mag.: mauwyebeli
mxolod aZlevs faqtebs)
Øpacientebi sxvadasxva socialuri
donidan jandacvis specialistamde
ØaraTanmimdevruloba ambis miwodebisas
Ødokumentaciis nakleboba
Øpacientis codnis nakleboba jandacvis
jgufs Soris
warumatebloba komunikaciaSi
ganpirobebuli pacientiT/ojaxiT
ØnaTesavebis mRelvareba
Øambebi, romelic gadaicema araxesayrel
garemoSi, ojaxi ar SeuZlia
koncentrireba
Øpacientebi sxvadasxva inteleqtualuri
fonidan jandacvis TanamSromlamde
Øgulmaviwyoba
Øgajavreba da guliswyroma mimarTuli
eqimisaken/eqTnisaken/stacionarisaken
Øfizikuri danaklisi komunikaciaSi
mag.: siyrue
Øinteleqtualuri danaklisi komunikaciaSi
mag.: gonebrivi SezRuduloba
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organizatoruli da komunikaciuri Cvevebi
wevrebs sWirdebaT informaciis miwodeba maTTvis gasageb enaze, naklebi terminebis
gamoyenebiT. imedi umniSvnelovanesia, Tumca informacia aucileblad unda iyos
realuri. maT unda hqondeT xSiri kontaqti medicinis sferoSi momuSave personalTan
da amave dros unda grZnobdnen, rom arian srulad informirebulni. kritikul
avadmyofebsa da ojaxis wevrebs xSirad hgoniaT, rom medinicis muSakebi maTive dacvis
mizniT xSirad ganzrax ar awvdian raime informacias. swored amitom simarTlis Tqma
umniSvnelovanesia da samedicino personali valdebulia erTida igive informacia
gaumeoron mravalgzis Tu amas saCiroeba moiTxovs. maSinac ki, roca ojaxi ibrZvis
informaciis damalvisken, raTa ar moxdes pacientis emociur mxareze gavlena. Ees
TavisTavad moTxovs winsawar ganzraxul qmedebebs da informaciis Tanmimdevrul
miwodebas, radgan Secbuneba da mwuxareba zrdis ukmayofilebas pacientebSi jer kidev
winaswar. profesionalizmi axali ambebis miwodebis mxriv gansxvavebulia samedicino
personalSi. magram ar unda xdebodes mkurnalobis kursis dasrulebamde
konsultaciebs Soris miwodebuli informaciis gadakeTeba.
informacia daavadebis prognozze da avadmyofobis gamosavalze miwodebuli unda
iqnes srulad da realurad.
3.2 vin unda amcnos cudi ambebi
cudi ambebis Setyobineba erT-erTi umniSvnelovanesi movaleobaa, rac eqims akisria
pacientis winaSe. Mmas aqvs kanonieri ufleba pacientis movlisa da aucilebelia
hqondes Sesabamisi codna da gamocdileba, rom miiRos srulfasovani gadawyveta im
sadavo sakiTxebisa, romlebic SesaZlebelia warmoiSvas. Tumca es SemTxvevebi
SesaZloa gadaebaros SedarebiT dabal safexurze myof samedicino muSaks.
avadmyofebi sasaubrod yovelTvis eqimisken miiswrafian, gansakuTrebiT maSin roca
mdgomareoba ukiduresad mZimea. Tumca SesaZlebelia yvelaze Sesaferi pirovneba
maTTan saubrisa iyos naTesauri kavSiris mqone adamiani. Ees SeiZleba iyos eqimi,
eqTani an Tundac kapelani. rac xels uwyobs maT TanamSromlobas. samedicino gundis
TiToeul wevrs SeuZlia rame gansakuTrebuli SesTavazos pacients , amotomac
umeteswilad eqimi da eqTani (iSviaTi gamonaklisis dros kapelanic), eswrebian
pacientTan saubars. Zalian gvexmareba da uaRresad did rols TamaSobs, rodesac
avadmyofTan an misi ojaxis wevrebTan mosaubre pirs hqondes urTierToba am
adamianebTan da icnobdes maT. swored am mizeziT xSir SemTxvevaSi reaqcia SeiZleba
iyos winaswar gaTvaliswinebuli. Tumca es ar gulisxomobs imas, rom yvela
SemTxvevaSi SeiZleba winaswar reaqciis, Tundac daaxloebiT gamoTvlas, magaliTad
gamonaklisia kritikuli mdgomareoba. yvelaze kargi variantia rodesac eqimsa da
eqTans aqvT Zalian didi gamocdileba, roca isini liderebi arian sakuTar saqmeSi.
swored am gamocdilebiT miaqvT seriozuli mdgomareobis situacia pacientamde, da
rom isini mzad arian gascen pasuxi nebismier kiTxvas da saWiroebisamebr
gadaamisamarTon SekiTxvebi anonimurad. Aarsebobs kategoria samedicino personalisa
_ komunikaciis ostatebi. maT SeuZliaT informacia miawodon pacients maTTvis gasageb
enaze. Aam adamianebs usityvod esmiT avadmyofebis. xSirad saWiroeba iqmneba Tarjimnis
yolisa, aseT dros Tarjimani unda iyos navarjiSebi msgavs situaciaze, radgan bevri
niuansi SeiZleba iyos dakarguli Targmnisas.
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sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
3.3 sad unda vamcnoT cudi ambebi
Kkomunikaciis efeqturobis erT-erT umniSvnelovanes pirobas warmoadgens sworad
SerCeuli garemo. saavadmyofos meurveoba aris Ria sivrce, romelic xelSeuxeblobis
gancdas tovebs. cudi ambebis Setyobinebis adgils ar warmoadgens palatebi an
Tundac derefnebi. Uumjobesia Tuki iarsebebs mxolod am saqmisTvis specialurad
gamoyofili sivrce oTaxis an ofisis saxiT, romelic iqneba SesaZleblobisdagvarad
daSorebuli pacientebidan da palatebidan. es unda iyos sufTa, sasiamovno garemo,
romlis simSvidis atmosferos SeqmnaSi dekoraciebic ki miiReban monawileobas.
Ppraqtikuli informacia da sazogadoebriv telefonebze xelmisawvdomoba namdvilad
TamaSobs uaRresad did rols, rom Tavidan aviciloT sazogadoebis stresi da
Secbuneba. Mmsgavsi garemos momsaxureoba ukve mimaniSnebelia imisa, rom Sexvedris
mizezi cudi informaciaa. Mmxolod ukiduresad mZime kritikul mdgomareobasa da
Sori manZilis arsebobis dros nebadarTulia cudi ambebis satelefono zariT
Setyobineba.
3.4 rogor unda vacnoboT cudi informacia
Uumetesoba samedicino personalisa xSirad arian ukiduresad dakavebulni da droSi
SezRudulni. Mmiuxedavad amisa, drois udidesi nawili daTmobili unda iyos
pacientTan dialogisTvis. Aam ukanasknelis aucilebeli pirobaa, rom is
mimdinareobdes auCqareblad da medicinis muSakis TiToeul moZraobaSi igrZnobodes
TanagrZnoba. muSaobis dros saqmidan mowyveta peijerebiTa da telefonebiT
maqsimalurad unda iqnes Tavidan acilebuli. swored am SemTxvevaSi iqneba medicinis
personalis mTeli yuradReba mimarTuli pacientisa da misi ojaxis wevrebisken. Tuki
dro winaswar aris gaTvlili, Seferxebebis raodenoba minimumamde iqneba dasuli.
mniSvnelovnad matulobs mRelvareba dialogis molodinis, amasTan nebismieri
grZnobis, iqneba es brazi, gaRizianeba Tu patiosneba ufro mkveTrad gamoixateba.
prioritetulia dialogi, roca samedicino personali momzadebulia winaswar da ukve
Sexvedris dawyebamde aqvs gansazRvruli im informaciis dedaazri.
Ø pacientis saxeli da gvari (ra saxeliT aris cnobili)
Ø pacientis asaki
Ø pacientis saqmianoba
Ø Zveli samedicino istoriis Canawerebi
Ø dagnozi
Ø prognozi
Ø pacientis mdgomareobis mimdinareoba
Ø ukanaskneli mniSvnelovani movlenebi
Ø vis xedav Sen?
Ø ra aris Sexvedris mTavari mizani
Ø ojaxuri naTesaoba
Ø Tanmxlebi personalis mosazrebebi da gagebis unari
cxrili 20. Ggasaubrebamde saWiro informacia
80
organizatoruli da komunikaciuri Cvevebi
personalma unda icodes pacientis sruli saxeli da gvari TaviseburebebiTurT.
ageTve mniSvnelovania icnobdes pacientis samedicino istoriis Zvel Canawerebs, mis
socialur mdgomareobas, mudmivad unda akontrolebdes analizebis pasuxebs.
aranakleb mniSvnelovania isic, rom personalis jgufis wevrebma pacientsa da mis
ojaxis wevrebTan Sexvedramde erTmaneTs gauziaron sakuTari mosazrebebi da
Sexedulebebi.
M miuxedavad imisa rom pacienti da misi ojaxi iRebs Tavisufal, erTpirovnul
gadawyvetilebebs, romelTac Semdeg oficialur saxes aZleven, mniSvneloba aqvs
samedicino personalis gundis gadawyvetilebas. Ees ukanasknelni prioritets aniWeben
saxelis inicialebis pirveli asoTi gamosaxvas. momavalSi daSvebuli Secdomebis
Tavidan acilebis mizniT mniSvnelovania imis gaTvaliswineba Tu ras iTvaliswinebs
brZanebebi.
Ppirveli gadamwyveti nabijia imis gageba, Tu ramdenad aqvs pacients
gaTviTcnobierebuli sakuTari mdgomareoba. miuxedavad imisa, rom maT ar usaubriaT
garkveul sakiTxebze, SesaZlebelia gaakeTon sakuTari interpretacia. xSir
SemTxvevaSi ramdenime konsultaciis miuxedavad isini SesaZlebelia bolomde ver
Caswvdnen miwodebul infrmacias. Aamitomac saubari xSirad iwyeba Semdegi sityvebiT
“me Zalian damexmareba Tuki Tqven metyviT ramdenad sworad gaigeT da SeafaseT
arsebuli situacia”. maTi saubris mosmeniT unda iqnas gaTvaliswinebuli maTive
gaTviTcnobierebis done. Aaranakleb mniSvnelovania gvaxsovdes rom “cudi ambebi”-s
mravalgvari mniSvneloba arsebobs, yvela adamiani individualurad igebs. Ppacientis
ojaxis wevrebmac SesaZlebelia ar gaiTvaliswinon is SiSi rac samedicino personals
aqvs am situaciasTan dakavSirebiT.
pirveli gadamwyveti nabiji cudi ambis Setyobinebisas aris imis dadgena, Tu
rogor arian gaTviTcnobierebulni situaciaSi pacienti da misi ojaxis wevrebi.
informacia miwodebuli unda iqnes naTlad da lakonurad, Riad da patiosnad. Ees
ar unda iyos yalbi an Tundac SezRuduli pacientisa da misi ojaxis wevrebis dacvis
mizniT. Tavidan unda iqnes acilebuli efemizmi. iq sadac uimedo mdgomareobaa,
arakeTilgonieria avadmyofisa da misi garemocvis daimedeba. Tumca raime pozitiuri
informacia unda iqnes miwodebuli, rom imedi saWiro doziT iyos. aucilebelia cudi
ambebi Setyobinebuli iyos frTxilad da etapobrivad, raTa pacientsa da mis ojaxis
wevrebs hqondeT adaptirebis SesaZlebloba. Ggarkveul viTarebaSi gamarTlebulia
“gamafrTxilebeli gasrolis” gamoyeneba (mag: “vSiSob, TqvenTvis cudi informacia
maqvs” an “vSiSob, axali ambavi imaze gacilebiT uaresia, vidre Cven velodiT”) umetes
SemTxvevaSi Zalian gvexmareba.
A ar SeiZleba ugulebelyofil iqnas sxeulis enis Zala. samedicino personalis
komunikaciis daaxloebiT 60% swored usityvo urTierTobaze modis, Zalian mcire
procenti eTmoba sityvier kavSirs. Sesabamisad, eqimis qmedeba, rodesac is dgas karTan
da TanagrZnobiT ar ekideba pacientis umZimes mdgomareobas, Zalian did uaryofiT
gavlenas axdens urTierTobaze. Uumjobesia eqimi pacientTan dam is ojaxsi wevrebTan
axlos dajdes, am JestiT is iziarebs avadmyofis mdgomareobas da swored is
akontrolebs da warmarTavs am Sexvedras. TvaliT kontaqti da yuradReba miuTiTebs
imaze, rom is marTlac gulwrfelad ekideba Seqmnil situacias. gasaTvaliswinebelia,
rom xelebis an fexebis gadajvaredineba Tavdacvis niSania. Ddialogis dasawyisSive
81
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
garkveuli unda iqnas, vin aris ojaxis meTauri da misdami unda iyos drois umetesi
nawili mimarTuli, magram es ar niSnavs imas rom is adamiani gamoiyos mTeli
gundidan. Samedicino personals ar unda SeeSindes pacientTan da mis ojaxis
wevrebTan axlos dajdoma. mniSvnelovania, ar SevimCnioT dabneuloba Tu ojaxis
romelime wevri daiwyebs tirils an gamoxatavs Zlier emocias. Cveni mxardaWera
SesaZloa gamovxatoT maTi xelis daWeriT. Tuki davakvirdebiT avadmyofisa da misi
garemocvis sxeulis enas, Cven SegviZlia winaswar gavakeToT daskvna, Tu rogor
aRiqves Cvens mier miwodebuli informacia.
ukeTesia Tuki dialogis dros ugulebelyofili iqneba faqtebi, romlebic win
uZRoda daavadebas. sadac arsebobs msgavsi potenciali kritikisa, umjobesia Tu amis
gadalaxva moxdeba pacientis amJamindel problemebze fokusirebiT. Cveulebriv, Cven
gvaqvs informacia faqtebze, romlebmac gamoiwvies ukmayofileba. UukeTes SemTxvevaSi
SesaZlebelia misi ganmuxtva yovel etapze dasmuli nebismieri kiTxvis pasuxebiT.
garda amisa, Tu dialogi rTuldeba, mTavaria ar gavubrazdeT avadmyofsa da mis
garemocvas, SevecadoT sakuTar TavSi gavamarTlod isini da avuxsnaT yvela
problema.
xSirad med personali laparakobs gauTaveblad da ar aclis pacientsa da mis
ojaxis wevrebs TavianTi grZnobebis gamoxatvis saSualebas. efeqturia movusminoT
maT, es saSualebas iZleva swori da kargi urTierTobis CamoyalibebisTvis. aranakleb
mniSvnelovania gamoviyenoT winaswar dagegmili pauza dialogis msvlelobisas. es
exmareba pacientsa da mis ojaxis wevrebs nel-nela da nabij-nabij kargad gaiazron
personalis TiToeuli sityva da Caswvdnen maT mniSvnelobas. zogi iTxovs dros, rom
moaxdinos fiqrebis swori organizeba da Camoyalibeba, amas SeuZlia Seamsubuqos
empaTiuri siCume. xSirad wynari, MmSvidi wuTebi gadamwyvet rols TamaSoben,
windaxeduli da brZnuli gadawyvetileba miaRebinon ojaxis ufross. cudi
informaciis miwodebisas xSirad Cvenda sasikeTod moqmedebs empaTiuri cnobebis
gamoyeneba. Mmag: “aman SesaZlebelia daTrgunos Tqveni grZnobebi” an “es Zalian
usamarTloa”_ msgavsi frazebi exmarebaT grZnobebis gamoxatvaSi. Ddro aucileblad
unda davuTmoT im kiTxvebs, romlebic SesaZloa daibadon drois nebismier monakveTSi.
Tu med personals ar aqvs pasuxi konkretul kiTxvaze, dasaSvebia Tqvas rom am
kiTxvaze pasuxi jer ar arsebobs da Tu raime informacia iqneba moZiebuli,
aucileblad miawvdens mkurnalobis kursis msvlelobisas. cudi ambebis
Setyobinebisas pacientisa da misi ojaxis wevrebis reaqcia SeiZleba iyos mravalgvari
da med personali unda iyos mzad nebismieri qmedebisTvis. am dros Zalian did rols
TamaSobs moZRvris daxmareba.
Bbevri ojaxisTvis, gansakuTrebiT maSin, Tu sikvdili gardauvalia umniSvnelovanesia,
rom pacienti ar daitanjos, ar igrZnos tkivili. med personali valdebulia, rom
avadmyofi gaaTavisuflos tkivilisgan da SeZlebisdagvarad Seuqmnas komforti. maSin
roca pacienti kvdeba, fikusireba unda movaxdinoT “karg sikvdilze” da mivceT imis
garantia, rom sikvdili da kvdomis procesi gaioldeba.
Dda bolos umniSvnelovanesia, rom SevamowmoT ramdenad aqvs gacnobierebuli yoveli
axali informacia pacientsa da mis ojaxis wevrebs (am mizniT gamoiyeneba Semdegi
frazebi: “aris kidev raime, risi gagebasac Cemgan isurvebdiT” da a.S.). aucilebelia
vaiZuloT, pirvel rigSi sakuTari Tavi da SemdegSi irgvliv myofni, rom pacientTan
dam is garemocvasTan xSiri kontaqti warmatebis aucilebeli pirobaa.
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organizatoruli da komunikaciuri Cvevebi
SeamowmeT pacientisa da misi ojaxis wevrebis situaciaSi garkvevis done yoveli
axali informaciis miwodebisas.
3.5 eqTnebis specifiuri mniSvneloba
eqTani Cveulebisamebr pirveli xvdeba pacients da misi ojaxis wevrebs. isini
axdenen eqimisTvis saWiro informaciis Segrovebas da miwodebas. mopovebuli masala
individualurad modernizebulia yvela pacientisTvis. Tumca sazogadoeba yovelTvis
elodeba informaciis miRebas eqimisgan. eqTnebi rogorc wesi, martivad saurTierTobe
pirebs warmoadgenen pacientTaTvis. isini ufro didi xniT arian cvlaSi da daaxloeba
avadmyofebTan SesaZlebelia. maT SeuZliaT gadamwyveti roli iTamaSon pacientisa da
maTi ojaxis wevrebis adaptirebaSi mkurnalobaSi arsebul cvlilebebze. agreTve
eqTani amzadebs safuZvels cudi informaciis misawodeblad. Mmag: maT SeuZliaT
daexmaron ojaxis wevrebs gadawyvetilebis miRebaSi da am gadawyvetilebis
formulirebaSi, magram es unda moxdes Zalian frTxilad. amaSi exmareba sxeulis ena.
asset dros cudi informacia ojaxamde midis etapobrivad da eqimTan saubrisas Sokis
momenti naklebadaa gamoxatuli. piriqiT, gamocdili eqTani eqimTan dialogamde
axvedrebs mosalodneli informaciis prognozs.
xSir SemTxvevaSi eqTnebs uwevT TvalTmaqcoba im ojaxebisTvis, sadac
gamojanmrTelebis imedi ararealurad maRalia. Aamis gamo pacientis megobrebi
ugulebelyofen sasaubre oTaxSi maTTvis miwodebul informacias. eqTans ZaluZs am
procesis Semsubuqeba, magram saWiroa DZalian didi sifrTxile da Sedegad ojaxi
naTeli gonebi axdens situaciis gaanalizebas.
sasurvelia eqims dialogisas Tan axldes eqTani, raTa daexmaros pacientsa da mis
ojaxis wevrebs informaciis aRqmaSi. saubris msvlelobisas amxnevebs, TanaugrZnobs
da exmareba realobis sworad gaanalizebaSi. aseT dros xSirad ismeva iseTi rTuli
kiTxvebi rogoricaa “rogori iqneba sikvdilis procesi” an “ra SeiZleba iqnes
gakeTebuli”. Aam kiTxvebze pasuxi gacemuli unda iqnes frTxilad da patiosnad.
xSirad situacia saWiroebs informaciis xelmeored miwodebas.
3.6 sabuTebi dialogisTvis
saubris mimdinareobis aucilebel da mniSvnelovan pirobas warmoadgens TiToeuli
detalis zusti formulireba, raTa med personalis yvela wevrma SeZlos saqmeze
swori da zusti azris Camoyalibeba. dasaSvebia dialogSi marTivi frazebisa da
terminebis gamoyeneba. Aaucilebelia iyos sia im pirebisa, romlebmac uSualod miiRes
monawileoba eqimTan saubarSi da sasurvelia TiToeuli maTganis reaqcia dafiqsirdes.
Tuki sxva romelime eqimi iRebda monawileobas am saqmis msvlelobisas, unda
dafiqsirdes maTi mosazrebebic.
aucilebelia pacientTan da mis ojaxis wevrebTan dialogis detalebis zusti
aRwera eqTnis (samedicino) CanawerebSi
83
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
3.7 daskvna
cudi ambebis Setyobineba erT-erTi urTulesi davalebaa, romelic med personals
akisria. Tuki medicinis muSaki momzadebulia am saqmeSi, mas SeuZlia procesi
dadebiTad warmarTos, an kidev damangrevelad imoqmedos. orive SemTxvevaSi es faqti
mexsierebaSi did xans rCeba. miuxedavad didi gamocdilebisa unda vaRiaroT, rom am
saqmis idealurad warmarTva Zalian rTuli da isviaTia. warmatebulad CaiTvleba
komunikacia Tuki es procesi sasrveli SedegiT dasruldeba. AaseT SemTxvevaSi
mniSvnelovan rols ara marto sityvieri gamxneveba TamaSobs, aramed TanagrZnobiT
savse Jestikulaciac.
4. sakuTari Canawerebis gakeTeba
mas Semdeg rac Tqven ganmeorebiT SeiswavliT pacinetis mdgomareobas da
gaesaubrebiT mis ojaxis wevrebsa da megobrebs, aucilebelia darwmundeT, rom Tqveni
gundis romelime wevrma Canawerebi sruli sizustiT gaaforma. Ees exmareba sxvadasxva
kolegebs imis naxvaSi, rac Tqven moimoqmedeT avadmyofobis winaaRmdeg.
SesavalSi unda iyos Semdegi informacia:
v Tqveni saxeli da gvari da sxva mniSvnelovani detalebi (peijeris nomeri.)
v Semovlis TariRi da dro
v mimdinare klinikur kvlevis Sedegebi
v dif. Diagnozi
v ra RonisZiebebi iqna Catarebuli Tqvens mier (g.i.a., aRdgeniTi,
gamokvlevebi, mkurnaloba, mosazrebebi)
v Tqvens mier daniSnul mkurnalobaze pacientis organizmis pasuxi
v RonisZiebebi mimoxilvisTvis (Tqvens an sxvis mier Catarebuli)
v moqmedebisaTvis parametrebi(mag: damirekeT Tu saturaciis done 95%ze
qvemoT Camova)
xSirad samedicino (an Tundac eqTnis) Canawerebi moklebulia viTarebis detalur
aRweras, es ki aferxebs daavadebis Semdgomi etapebis marTvas. yovelTvis unda
gakeTdes Sesavali da dafiqsirdes eqimis mosazreba. eqTnebs unda mieceT zustad
gansazRvruli instruqciebi. Tu maT daavalebT pacientis sunTqvis monitoring
saWiroa monacemebis zusti miTiTeba.
84
organizatoruli da komunikaciuri Cvevebi
reziume
v efeqturi mkurnaloba moiTxovs organizebulobas, xelmZRvanelobas, Sedegian
komunikacias da gadawyvetilebebis miRebas.
v mieces naTeli, zusti instruqcia.
v saqme gaakeTebuli iqnas bolomde, agresiisa da pasiurobis gareSe
v Segrovebul iqnas yvela informacia, rac saWiroa pacientisa da misi ojaxis
wevrebis sruli informirebisTvis.
v pacientTan da mis naTesavebTan dialogis yvela detali iqnas detalurad
aRwerili da formulirebuli.
85
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terminebis ganmarteba
terminebis ganmarteba
ADH – antidiurezuli hormoni
ALERT - sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
ALS – sicocxlis SenarCunebis daxvewili algoriTmi
APLS - sicocxlis SenarCunebis daxvewili pediatriuli algoriTmi
ARDS – mwvave rtespiraciuli disters sindromi
ATLS - sicocxlis SenarCunebis daxvewili algoriTmi travmis dros
BP – sisxlis wneva
CPR – krdio-pulmonuri reanimacia
CVP – centraluri venuri wneva
CCrlSP - mwvaved daavadebuli qirurgiuli pacientis movla
DNAR - ar scadoT reanimaciis Catareba
ECG – eleqtrokardiografia
ERSCP – endoskopuri retrograduli qolangiopankreatografia
FBC – sisxlis formiani elementebis sruli daTvla
GCS – glazgos komis Skala
HDU - High Dependency Unit
ICU – intensiuri Terapiis ganyofileba
i.v. – intravenurad
i.m. - intramuskularulad
JVP – wneva sauRle venaSi
MEWS - modificirebuli naadrevi gafrTxilebis qula
PCA – pacientis mier TviTkontrolirebadi gautkivareba
PRHO - Pre-Registration House Officer
RCSE - Royal College of Surgeons of England
RBF - renaluri sisxlis nakadi
90
sicocxlisTvis saSiSi mwvave movlenebis amocnoba da mkurnaloba
SHO - Senior House Officer
SpR – specialisti registratori
SVR - sistemuri sisxlZarRvovani rezistentoba
TPR - temperatura, pulsi, sunTqva
U&Es - Sardovana da eleqtrolitebi
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ALERT -is Sefasebis gegma.