Semcveloba - geosf.files. · PDF fileSemdeg. aRniSnuli faqtebis analizi aCvenebs Semdeg ZiriTad statistikas, romgulis ... Øpacientebi, romlebic saWiroeben masiur sisxlis trasfuzias

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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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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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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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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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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


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


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


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 àmbus~ (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


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


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 pulsoqsimetri 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


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 àmbus~ (bag-valve-mask system) parkiT ventilacia,

rom gaZlierdes oqsigenacia da ventilacia, manam sanam mouxmobdeT intensivists

movlis asistents.

19


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


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


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


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


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


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


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


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


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


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


· 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


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.

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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


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


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


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


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.

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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.

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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.

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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.

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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.

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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

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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.

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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.

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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


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


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


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


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;

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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


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


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.

53


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


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


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


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


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 àutoregulaciis~ 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


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


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


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


2.6 kunTSida

es aris narkotikuli analgetikebis Seyvanis tradiciuli gza, yvelaze xSirad

gamoiyeneba gautkivarebis òTx 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


suraTi 17: opiatebiT kunTSida gautkivarebis optimizebuli `4 saaTiani prn ~ reJimi (modifiedfrom Gould et al., BMJ 1992; 305: 1187)

68


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


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


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


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


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


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


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 àra~-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.: ès 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.

76


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.

77


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

78


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.

79


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


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


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.

82


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


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


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


SHO - Senior House Officer

SpR – specialisti registratori

SVR - sistemuri sisxlZarRvovani rezistentoba

TPR - temperatura, pulsi, sunTqva

U&Es - Sardovana da eleqtrolitebi

91

ALERT -is Sefasebis gegma.

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