axalsobilta persistentuli pulmonaruli hipertenzia _1.pdf · axalsobilta persistentuli pulmonaruli...
TRANSCRIPT
Nnino solomoniaNnino solomoniaNnino solomoniaNnino solomonia
axalSobilTa persistentuli
pulmonaruli hipertenzia
Nnino solomoniaNnino solomoniaNnino solomoniaNnino solomonianeonatologineonatologineonatologineonatologi
“NRP” – programis regionaluri instruqtoriprogramis regionaluri instruqtoriprogramis regionaluri instruqtoriprogramis regionaluri instruqtori
“S.T.A.B.L.E.” - programis mTavari instruqtoriprogramis mTavari instruqtoriprogramis mTavari instruqtoriprogramis mTavari instruqtori21/5/201321/5/201321/5/201321/5/2013
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
persistentuli pulmonaruli hipertenzia
� pirveladi persistentuli pulmonaruli hipertenzia filtvis hipertenzia filtvis parenqimuli daavadebis ar arsebobis fonze
persistentuli pulmonaruli hipertenzia
� mekoniumis aspiraciis sindromisindromi
persistentuli pulmonaruli hipertenzia
� marcxena diafragmaluri TiaqariTiaqari
persistentuli pulmonaruli hipertenzia
� 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)
mkurnalobamkurnalobamkurnalobamkurnaloba
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
mkurnalobamkurnalobamkurnalobamkurnaloba
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.
persistentuli pulmonaruli hipertenzia
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????