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axalSobilTa persistentuli

pulmonaruli hipertenzia

Nnino solomoniaNnino solomoniaNnino solomoniaNnino solomonianeonatologineonatologineonatologineonatologi

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axalSobilTa persistentuli pulmonaruli hipertenzia (PPHN)

ZiriTadi aqcentebi

� fetaluri da neonataluri cirkulaciis fiziologiuri Taviseburebebi

� persistentuli pulmonaruli hipertenziis gamomwvevi mizezebi

� persistentuli pulmonaruli hipertenziis marTvis Tanamedrove meTodebi

gaseirneba warsulSi

� aRweril iqna pirvelad 1969 wels

samedicino literaturul cnobarSi gvxvdeboda samedicino literaturul cnobarSi gvxvdeboda samedicino literaturul cnobarSi gvxvdeboda samedicino literaturul cnobarSi gvxvdeboda sxvadasxva saxelwodebiT:sxvadasxva saxelwodebiT:sxvadasxva saxelwodebiT:sxvadasxva saxelwodebiT:

� “persistentuli fetaluri cirkulacia”

� sistemuri sisxlis mimoqceva fetaluri Suntebis gavliT (arteriuli sadinari, ovaluri xvreli)

� sistemuri hipoqsia

epidemiologia

� 1 – 2 / 1000 cocxladSobilze

� gansakuTrebiT xSiria droul da vada-gadacilebul axalSoblebSi

� sikvdiloba ~ 10% (11 - 34% 80-ian wlebSi)� sikvdiloba ~ 10% (11 - 34% 80-ian wlebSi)

� droulidroulidroulidrouli diagnozi da saTanado mkurnaloba ganapirobebs dadebiT gamosavals

� mizanSewonilia, aseTi axalSobilis droulidroulidroulidroulitransportireba mesame donis neonataluri intensiuri Terapiis ganyofilebaSi

fetaluri cirkulaciafetaluri cirkulaciafetaluri cirkulaciafetaluri cirkulaciaChronolab A.G. Switzerland © Copyright 1994 - 2009

1.1.1.1. RviZliRviZliRviZliRviZli

2.2.2.2. karis venakaris venakaris venakaris vena

3.3.3.3. Wiplaris venaWiplaris venaWiplaris venaWiplaris vena

4.4.4.4. venuri sadinari (venuri sadinari (venuri sadinari (venuri sadinari (Ductus venosus)

5.5.5.5. marjvena winagulimarjvena winagulimarjvena winagulimarjvena winaguli

6.6.6.6. marjvena parkuWimarjvena parkuWimarjvena parkuWimarjvena parkuWi

7.7.7.7. zeda Rru venazeda Rru venazeda Rru venazeda Rru vena

8.8.8.8. ovaluri xvreli (ovaluri xvreli (ovaluri xvreli (ovaluri xvreli (Foramen Ovale))))

9.9.9.9. qveda Rru venaqveda Rru venaqveda Rru venaqveda Rru vena

10.10.10.10. marcxena winagulimarcxena winagulimarcxena winagulimarcxena winaguli

11.11.11.11. marcxena parkuWimarcxena parkuWimarcxena parkuWimarcxena parkuWi

12.12.12.12. arteriuli sadiari arteriuli sadiari arteriuli sadiari arteriuli sadiari (Ductus arteriosus)

13.13.13.13. filtvebifiltvebifiltvebifiltvebi

14.14.14.14. filtvis venafiltvis venafiltvis venafiltvis vena

15.15.15.15. filtvis arteriafiltvis arteriafiltvis arteriafiltvis arteria

16.16.16.16. daRmavali aortadaRmavali aortadaRmavali aortadaRmavali aorta

17.17.17.17. Wiplaris arteriebiWiplaris arteriebiWiplaris arteriebiWiplaris arteriebi

18.18.18.18. aRmavali aortaaRmavali aortaaRmavali aortaaRmavali aorta

19.19.19.19. parkuWTaSua ZgideparkuWTaSua ZgideparkuWTaSua ZgideparkuWTaSua Zgide

20.20.20.20. parkuWis kedeliparkuWis kedeliparkuWis kedeliparkuWis kedeli

dabadebis Semdgomi periodis cirkulaciadabadebis Semdgomi periodis cirkulaciadabadebis Semdgomi periodis cirkulaciadabadebis Semdgomi periodis cirkulaciaChronolab A.G. Switzerland © Copyright 1994 - 2009

1.1.1.1. qveda Rru venaqveda Rru venaqveda Rru venaqveda Rru vena

2.2.2.2. RiZliRiZliRiZliRiZli

3.3.3.3. karis venakaris venakaris venakaris vena

4.4.4.4. RviZlis mrgvali ligamenti RviZlis mrgvali ligamenti RviZlis mrgvali ligamenti RviZlis mrgvali ligamenti (Ligamentum teres)

5.5.5.5. filtvebifiltvebifiltvebifiltvebi

6.6.6.6. filtvis venafiltvis venafiltvis venafiltvis vena

7.7.7.7. filtvis arteriafiltvis arteriafiltvis arteriafiltvis arteria

8.8.8.8. zeda Rru venazeda Rru venazeda Rru venazeda Rru vena8.8.8.8. zeda Rru venazeda Rru venazeda Rru venazeda Rru vena

9.9.9.9. arteriuli ligamenti arteriuli ligamenti arteriuli ligamenti arteriuli ligamenti (Ligamentum

arteriosus)

10.10.10.10. daxuruli ovaluri xvrelidaxuruli ovaluri xvrelidaxuruli ovaluri xvrelidaxuruli ovaluri xvreli

11.11.11.11. daRmavali aortadaRmavali aortadaRmavali aortadaRmavali aorta

12.12.12.12. Wiplaris medialuri ligamenti Wiplaris medialuri ligamenti Wiplaris medialuri ligamenti Wiplaris medialuri ligamenti (Medial umbilical ligament)

13.13.13.13. vezikularuli arteriebivezikularuli arteriebivezikularuli arteriebivezikularuli arteriebi

14.14.14.14. aRmavali aortaaRmavali aortaaRmavali aortaaRmavali aorta

15.15.15.15. parkuWTaSua ZgideparkuWTaSua ZgideparkuWTaSua ZgideparkuWTaSua Zgide

16.16.16.16. parkuWis kedeliparkuWis kedeliparkuWis kedeliparkuWis kedeli

fetaluri da postnataluri saturacia

faqtorebi, romlebic uzrunvelyofs nayofis arsebobas dabali oqsigenaciis pirobebSi

� ar saWiroebs siTbos generacias

� minimaluri respiratoruli aqtivoba

� daqveiTebuli motoruli aqtivoba

� ar saWiroebs sakvebis monelebas

nayofis sisxlismimoqceva dabadebis Semdeg sisxlismimoqcevanayofis sisxlismimoqceva dabadebis Semdeg sisxlismimoqcevanayofis sisxlismimoqceva dabadebis Semdeg sisxlismimoqcevanayofis sisxlismimoqceva dabadebis Semdeg sisxlismimoqceva

dabadebis Semdgomi periodis cvlilebebi

hemodinamikuri cvlilebebihemodinamikuri cvlilebebihemodinamikuri cvlilebebihemodinamikuri cvlilebebi� dabali rezistentobis placentaruli cikulaciis Sewyveta

� filtvis sisxlZarRvebis maRali rezistentobis Semcireba (filtvis arteriis wneva mcirdeba 50%-iT)

� filtvis sisxlZarRvebSi sisxlis nakadis mateba (10 jer)jer)

� sistemuri wnevis mateba

� fetaluri Suntebis (venuri sadinari, arteriuli sadinari, ovaluri xvreli) daxurva

sxva fiziologiuri cvlilebebisxva fiziologiuri cvlilebebisxva fiziologiuri cvlilebebisxva fiziologiuri cvlilebebi� glukozis homeostazi / Termogenezi / hormonaluri da metaboluri cvlilebebi

� mSobiaroba, stimulacia NO, PGI₂ gamoyofisTvis. � NO, PGI₂ zrdis cGMP da cAMP Ddones gluv kunTovan qsovilSi� V tipis da III tipis PDE axdens nukleotidebis degradacias

� ujredSi kalciumis donis Semcireba iwvevs kunTis relaqsacias

persistentuli pulmonaruli hipertenziis meqanizmi

1. paTologiurad Seviwrovebuli filtvis 1. paTologiurad Seviwrovebuli filtvis 1. paTologiurad Seviwrovebuli filtvis 1. paTologiurad Seviwrovebuli filtvis sisxlZarRvebisisxlZarRvebisisxlZarRvebisisxlZarRvebi

� mekoniumis aspiraciis sindromi� pnevmonia� respiratoruli distres sindromi

2. struqturulad aranormaluri filtvis 2. struqturulad aranormaluri filtvis 2. struqturulad aranormaluri filtvis 2. struqturulad aranormaluri filtvis 2. struqturulad aranormaluri filtvis 2. struqturulad aranormaluri filtvis 2. struqturulad aranormaluri filtvis 2. struqturulad aranormaluri filtvis sisxlZarRvebisisxlZarRvebisisxlZarRvebisisxlZarRvebi

� pirveladi persistentuli pulmonaruli hipertenzia

3. filtvis hipoplaziuri sisxlZarRvebi3. filtvis hipoplaziuri sisxlZarRvebi3. filtvis hipoplaziuri sisxlZarRvebi3. filtvis hipoplaziuri sisxlZarRvebi� diafragmis Tandayolili Tiaqari

� pulmonaluri hipoplazia (oligohidramnioni, PPROM)� alveolaru kapilaruli displazia

persistentuli pulmonaruli hipertenziis gamomwvevi mizezebi

� filtvis hipoplazia - 1%1%1%1%

� pnevmonia / sefsisi - 13%13%13%13%

� respiratoruli distres sindromi (RDS) - 17%17%17%17%sindromi (RDS) - 17%17%17%17%

� pirveladi persistentuli pulmonaruli hipertenzia

(PPHN) - 27%

� mekoniumis aspiraciis sindromi (MAS) - 42%

pirveladi persistentuli pulmonaluri hipertenzia

� sixSiriT meore adgilzea

� sagulisxmoa Ria arteriuli sadinris adreuli daxurva

� orsulobis periodSi miRebuli medikamentebi

arasteroiduli anTebiTis sawinaaRmdego saSualebebi (NSAID)

seleqtiuri serotoninis inhibitorebi SSRI

riskis jgufi

� drouli, vadagadacilebuli an gviani periodis dRenakluli axalSobili

� respiratoruli distresi - dabadebisTanave an dabadebidan xanmokle periodSi

� labiluri oqsigenacialabiluri oqsigenacia

� hipoqsiis xarisxi ar Seesabameba filtvis daavadebis xarisxs (rentgenografiulad)

� gasinjviT: taqipnea, retraqciebi, cianozi, sistoluri Suili

riskis jgufis pacientTaTvis mizanSewonilia

� monitoringi (saturacia, arteriuli wneva, guliscemisa da sunTqvis sixSire)

� gulmkerdis rentgenografia

� gulis eqoskopia� gulis eqoskopia

� arteriuli sisxlis gazebis analizi

� sisxlis saerTo analizi

� sisxlis bioqimiuri analizi

� sisxlis baqteriologiuri analizi

Hhiperoqsiis testi

arteriul sisxlSi PaO₂ gansazRvra rogorc 21% O₂ aseve 100%O₂ miwodebidan 10 wuTis Semdeg.

Tuki 100% O₂ is Semdeg::::

� PaO₂ < 50 mmHg - cianozuri gulis manki an pulmonaruli hipertenziapulmonaruli hipertenzia

� PaO₂ < 150 mmHg – pulmonaruli hipertenzia

� PaO₂ > 150 mmHg – filtvis parenqimuli daavadeba

� PaO₂ > 300 mmHg – normaluri filtvi

gulis eqoskopia

� anatomiuri defeqtis gamovlenis mizniT

� marjvnidan marcxena mxrivi Sunti

� ormxrivi Sunti

� btryeli parkuWTaSua Zgide

� marjvena parkuWis dilatacia

� trikuspidaluri regurgitacia - filtvis arteriis wnevi Sefaseba

Ppre da post - duqtaluri saturacia

persistentuli pulmonaruli hipertenzia

� normaluri rentgenografiuli rentgenografiuli maCvenebli


� pirveladi persistentuli pulmonaruli hipertenzia filtvis hipertenzia filtvis parenqimuli daavadebis ar arsebobis fonze


� mekoniumis aspiraciis sindromisindromi


� marcxena diafragmaluri TiaqariTiaqari


� persistentuli pulmonaruli hipertenzia respiratoruli distres sindromi; surfaqtantis miRebis miuxedavad mdgomareoba ucvlelia.

� gulis eqoskopiiT dadginda filtvis venebis totaluri anomaluri drenireba qvemo Rru venaSi

filtvis venebis anomaluri drenireba

mkurnalobis principebi

� alveolaruli oqsigenaciis gaumjobeseba

� pulmonaruli vazokonstriqciis Semcireba

� sistemuri wnevisa da perfuziis optimizacia� sistemuri wnevisa da perfuziis optimizacia

� alkalozuri statusi

� pulmonaruli vazodilatacia

� eqstra korporaluri membranuli oqsigenacia - ECMO

mkurnaloba

mniSvnelovani faqtorebimniSvnelovani faqtorebimniSvnelovani faqtorebimniSvnelovani faqtorebi

� neitraluri Termuli garemos (NTE) SenarCuneba

� eleqtrolituri disbalansis koreqcia

� glukozis homeostazi

� parenteraluri da enteraluri kveba

� anemiis mkurnaloba (Hct < 40)

� acidozis koreqcia (THAM; NaHCO₃)

aerobuli metabolizmi anaerobuli metabolizmiaerobuli metabolizmi anaerobuli metabolizmiaerobuli metabolizmi anaerobuli metabolizmiaerobuli metabolizmi anaerobuli metabolizmi

mkurnaloba

pacientis minimaluri stimulaciapacientis minimaluri stimulaciapacientis minimaluri stimulaciapacientis minimaluri stimulacia

� siCume

� tirili da agzneba zrdis O₂ - is moxmarebas

� sedaciuri da/an miorelaqsaciuri saSualebebi

morfini 0.05 – 0.1 mg/kg/sT

fentalini 1 - 4 mkg/kg/sT

midazolami 0.1 mg/kg yovel 4 sT, an saWiroebisamebr

pankuroniumi 0.1 mg/kg yovel 6sT, an saWiroebisamebr

mkurnalobabaqteriuli infeqciis profilaqtika / mkurnaloba

� ampicilini

� gentamicini

� sisxlis baqteriologiuri analizi� sisxlis baqteriologiuri analizi

� acikloviri !!! saeWvo anamnezis dros

� mkurnalobis reJimsa da xangZlivobas gansazRvravs klinikuri statusi da laboratoriuli kvlevis Sedegebi

mkurnaloba

msubuqi formis respiratoruli distresimsubuqi formis respiratoruli distresimsubuqi formis respiratoruli distresimsubuqi formis respiratoruli distresi

� nazaluri kanula an CPAP

� arteriuli gazebis monitoringi

� Wiplaris venisa da arteriis kaTeterizacia

� meqanikuri ventilacia� meqanikuri ventilacia

saSualo an mZime xarisxis respiratoruli saSualo an mZime xarisxis respiratoruli saSualo an mZime xarisxis respiratoruli saSualo an mZime xarisxis respiratoruli daavadeba saWiroebs SedarebiT agresiul daavadeba saWiroebs SedarebiT agresiul daavadeba saWiroebs SedarebiT agresiul daavadeba saWiroebs SedarebiT agresiul mkurnalobasmkurnalobasmkurnalobasmkurnalobas

mkurnaloba

saSualo an mZime xarisxis respiratoruli saSualo an mZime xarisxis respiratoruli saSualo an mZime xarisxis respiratoruli saSualo an mZime xarisxis respiratoruli daavadebadaavadebadaavadebadaavadeba

� oqsigenacia FiO₂ 0.1 (O₂Sa > 90% da < 98%) !??!??!??!??

� xelovnuri ventilaciaxelovnuri ventilacia

� surfaqtanti ????????

� pulmonaluri rezistentobis Semcireba

� sistemuri arteriuli wnevisa da perfuziis SenarCuneba

� marjvnidan – marcxena mxrivi Suntis mimarTulebis Secvla

mkurnaloba

filtvis xelovnuri ventilaciafiltvis xelovnuri ventilaciafiltvis xelovnuri ventilaciafiltvis xelovnuri ventilacia

� SIMV (PCPS)

� VG

� HFOV

mkurnalobamkurnalobamkurnalobamkurnaloba

maRali PaO₂ (> 100mmHg) da dabali PaCO₂

kvlevebma aCvena, rom

� sazianoa filtvisa da Tavis tvinis � sazianoa filtvisa da Tavis tvinis perfuziisTvis

� hiperoqsemia ar iwvevs filtvis rezistentobis metad Semcirebas

� Tumca, labiluri oqsigenaciis gamo, maRali PaO₂ > 100mmHg SenarCuneba praqtikaSi miRebulia

mkurnaloba

arteriuli wnevisa da perfuziis SenarCuneba

� kristaloidis an koloidis xsnari

(10 – 15 ml/kg)

� dopamini 2.5 – 20mkg/kg/wT � dopamini 2.5 – 20mkg/kg/wT

� dobutamini 2.5 – 20mkg/kg/wT

� epinefrini 0.03 – 0.10 mkg/kg/wT

� norepinefrini

� saWiroebis SemTxvevaSi hidrokortizoni (kortizolis donis gansazRvris Semdeg)


respiratoruli statusis simZimis Sefaseba

O

� oqsigenaciis indeqsi – OI = (MAP x FiO₂/PaO₂)x 100

MAP – mean airway pressure, (saSualo wneva)MAP – saSualo wneva

MAP = PEEP + ((PIP – PEEP) x [Ti / (Ti + Te)])

FiO₂ - miwodebuli Jangbadis koncentraciaPaO₂ - arteriul sisxlSi Jangbadis parcialuri wneva

� AaDO₂ = PAO₂ - PaO₂


pulmonaluri vazodilatacia

� inhalaciuri azotis oqsidi (iNO)

� milrinoni – PDE 3 – is inhibitori� milrinoni – PDE 3 – is inhibitori

0.5 – 0.75 mkg/kg/wT

� sildenafili (viagra) - PDE 5 inhibitori

2.5 – 2 mg/kg per os yovel 6 an 12 sT

inhalaciuri azotis oqsidi (NO)

� seleqtiuri pulmonaruli vazodilatatori

� efeqturoba damtkicebulia multi-centruli kvlevebis Sedegad

� doza 20 ppm

� metHg –is monitoringi (mkurnalobidan 24sT)

� azotis oqsidis (NO) swrafi moxsna xSirad mwvave hipoqsemiis mizezia

Ainhalaciuri azotis oqsidi (iNO)

eqstrakorporealuri membranuli oqsigenacia - ECMO

eqstrakorporealuri membranuli oqsigenacia - ECMO

ukuCveneba

� gestaciuri asaki < 34kv

� wona < 1500gr

� Tavis tvinis parkuWovani an parenqimuli � Tavis tvinis parkuWovani an parenqimuli sisxlCaqceva

� koagulopaTia

� letaluri Tandayolili anomalia

� filtvis Seuqcevadi daavadeba

� oqsigenaciis indeqsiT (OI) gamoxatuli sunTqvis ukmarisobis xarisxi inhalaciuri azotis oqsidiT mkrnalobis dawyebisas da ECMO mkurnalobis aucileloba Sebamis pacientebSi.


gamosavali

sikvdiloba

� iNO da ECMO danergvis Semdeg

Semcirda 25 - 50%-dan 10 - 15%- mdeSemcirda 25 - 50%-dan 10 - 15%- mde

avadoba

� smenis daqveiTeba da kognituri problemebi

20 – 40 %

gamoyenebuli literatura

� Gleason CA. Devaskar SU. Persistant pulmonary hypertension of the newborn. Avery’s Disease of the

Newborn, 9th ed. 2012

� Stainhorn RH. Neonatal Pulmonary Hypertension. Pediatr. Crit. Care Med. 2010: 11(Suppl 2)

s79-s84

� Konduri GG. Kim UO. Advances in the diagnosis and management of persistent pulmonary � Konduri GG. Kim UO. Advances in the diagnosis and management of persistent pulmonary

hypertension of the newborn. Pediatr. Clin. North Am. 2009 56 (3): 579 -600

� Abman SH. Recent advances in the pathgenesis and treatment of persistant pulmonary

hypertension of the newborn. Neonatology 2007;91(4):183-290

� Stainhorn RH. Farrow KN. Pulmonary hypertension in the neonate. Neoreviews 2007, 8 e14

SekiTxvebi????

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