x Ɋɟɬɪɨɝɪɚɞɧɚɹ ɢɧɬɭɛɚɰɢɹ ɦɨɠɟɬ ɛɵɬɶ ɱɪɟɡɜɵɱɚɣɧɨ ɩɨɥɟɡɧɨɣ,ɤɨɝɞɚ ɩɪɨɱɢɟ ɦɟɬɨɞɵ ɧɟ ɞɚɥɢ ɪɟɡɭɥɶɬɚ-ɬɚ,ɧɨ ɦɨɠɟɬ ɜɵɩɨɥɧɹɬɶɫɹ ɢ ɜ ɩɥɚɧɨɜɨɦ ɩɨɪɹɞɤɟ.
Ɋɟɬɪɨɝɪɚɞɧɚɹ ɢɧɬɭɛɚɰɢɹ ɧɟ ɬɪɟɛɭɟɬ ɞɨɪɨɝɨɫɬɨɹ-ɳɟɝɨ ɨɛɨɪɭɞɨɜɚɧɢɹ ɢ ɥɟɝɤɨ ɨɫɭɳɟɫɬɜɢɦɚ ɩɪɢ ɧɚ-ɥɢɱɢɢ ɛɚɡɨɜɵɯ ɚɧɚɬɨɦɢɱɟɫɤɢɯ ɡɧɚɧɢɣ. ɉɪɨɬɢɜɨ-ɩɨɤɚɡɚɧɢɹ ɦɚɥɨɱɢɫɥɟɧɧɵ ɢ ɜɤɥɸɱɚɸɬ ɢɧɮɟɤɰɢɨɧ-ɧɵɣ ɢɥɢ ɨɩɭɯɨɥɟɜɵɣ ɩɪɨɰɟɫɫ ɜ ɨɛɥɚɫɬɢ ɩɭɧɤɰɢɢ ɢɥɢ ɧɚɪɭɲɟɧɢɹ ɫɜɟɪɬɵɜɚɧɢɹ. ȼ ɨɬɥɢɱɢɟ ɨɬ ɮɢɛ -ɪɨɛɪɨɧɯɨɫɤɨɩɢɢ ɧɚɥɢɱɢɟ ɤɪɨɜɢ ɜ ɞɵɯɚɬɟɥɶɧɵɯ ɩɭɬɹɯ ɧɟ ɡɚɬɪɭɞɧɹɟɬ ɦɚɧɢɩɭɥɹɰɢɢ.
ɋɜɟɬɹɳɢɟɫɹ ɫɬɢɥɟɬɵ ɢɥɢ ɡɨɧɞɵ
Ɇɟɬɨɞ ɨɫɧɨɜɚɧ ɧɚ ɢɫɩɨɥɶɡɨɜɚɧɢɢ ɝɢɛɤɨɝɨ ɫɬɢɥɟɬɚ ɫ ɢɫɬɨɱɧɢɤɨɦ ɫɜɟɬɚ ɧɚ ɤɨɧɰɟ.ɋɬɢɥɟɬ ɜɜɨɞɢɬɫɹ ɜ ɢɧɬɭ-ɛɚɰɢɨɧɧɭɸ ɬɪɭɛɤɭ ɢ ɫɝɢɛɚɟɬɫɹ ɞɨ L-ɨɛɪɚɡɧɨɣ ɮɨɪ-ɦɵ.Ƚɨɥɨɜɚ ɩɚɰɢɟɧɬɚ ɩɨɥɧɨɫɬɶɸ ɪɚɡɝɢɛɚɟɬɫɹ.Ɍɪɭɛɤɚ ɫɨ ɫɬɢɥɟɬɨɦ ɜɜɨɞɢɬɫɹ ɫɬɪɨɝɨ ɩɨ ɫɪɟɞɧɟɣ ɥɢɧɢɢ ɩɨ-ɥɨɫɬɢ ɪɬɚ; ɜɧɟɡɚɩɧɨɟ ɩɨɹɜɥɟɧɢɟ ɩɪɨɯɨɞɹɳɟɝɨ ɫɜɟɬɚ ɧɚ ɩɨɜɟɪɯɧɨɫɬɢ ɲɟɢ (ɬɪɚɧɫɥɸɦɢɧɚɰɢɹ) ɫɜɢɞɟɬɟɥɶɫɬ-ɜɭɟɬ ɨ ɜɯɨɠɞɟɧɢɢ ɤɨɧɱɢɤɚ ɜ ɝɨɪɬɚɧɶ.ɉɨɫɥɟ ɜɜɟɞɟɧɢɹ ɬɪɭɛɤɢ ɫɬɢɥɟɬ ɭɞɚɥɹɟɬɫɹ.
ɂɧɬɭɛɚɰɢɹ «ɜɫɥɟɩɭɸ»
ɂɧɬɭɛɚɰɢɹ ɦɨɠɟɬ ɛɵɬɶ ɜɵɩɨɥɧɟɧɚ ɩɪɢ ɨɬɫɭɬɫɬɜɢɢ ɩɪɹɦɨɣ ɢ ɧɟɩɪɹɦɨɣ ɜɢɡɭɚɥɢɡɚɰɢɢ ɝɨɥɨɫɨɜɨɣ ɳɟɥɢ.
Ⱦɥɹ ɷɬɨɝɨ ɦɨɝɭɬ ɛɵɬɶ ɢɫɩɨɥɶɡɨɜɚɧɵ ɧɚɡɨɬɪɚɯɟɚɥɶɧɚɹ ɢɧɬɭɛɚɰɢɹ «ɜɫɥɟɩɭɸ» ɢɥɢ ɬɚɤɬɢɥɶɧɚɹ ɨɪɨɬɪɚɯɟɚɥɶ-ɧɚɹ ɢɧɬɭɛɚɰɢɹ.
ɇɚɡɨɬɪɚɯɟɚɥɶɧɚɹ ɢɧɬɭɛɚɰɢɹ «ɜɫɥɟɩɭɸ»
ɉɪɨɰɟɞɭɪɚ ɦɨɠɟɬ ɛɵɬɶ ɜɵɩɨɥɧɟɧɚ ɭ ɧɚɯɨɞɹɳɟɝɨɫɹ ɜ ɫɨɡɧɚɧɢɢ ɩɚɰɢɟɧɬɚ.ɇɟɨɛɯɨɞɢɦɵɦɢ ɭɫɥɨɜɢɹɦɢ ɹɜɥɹ-ɸɬɫɹ ɪɚɡɭɦɧɚɹ ɫɟɞɚɰɢɹ,ɦɟɫɬɧɚɹ ɚɧɟɫɬɟɡɢɹ ɞɵɯɚɬɟɥɶ-ɧɵɯ ɩɭɬɟɣ ɢɥɢ ɫɨɯɪɚɧɟɧɢɟ ɚɞɟɤɜɚɬɧɨɝɨ ɞɵɯɚɧɢɹ ɭ ɚɧɟɫɬɟɡɢɪɨɜɚɧɧɨɝɨ ɩɚɰɢɟɧɬɚ. Ƚɨɥɨɜɚ ɭɤɥɚɞɵɜɚɟɬɫɹ ɤɚɤ ɞɥɹ ɩɪɹɦɨɣ ɥɚɪɢɧɝɨɫɤɨɩɢɢ,ɩɨɫɥɟ ɱɟɝɨ ɜ ɨɞɧɭ ɢɡ
ɧɨɡɞɪɟɣ ɚɤɤɭɪɚɬɧɨ ɜɜɨɞɢɬɫɹ ɫɦɹɝɱɟɧɧɚɹ, ɯɨɪɨɲɨ ɫɦɚɡɚɧɧɚɹ ɢɧɬɭɛɚɰɢɨɧɧɚɹ ɬɪɭɛɤɚ (ɨɛɵɱɧɨ 6-6,5 ɦɦ ɞɥɹ ɜɡɪɨɫɥɵɯ) ɞɨ ɬɟɯ ɩɨɪ, ɩɨɤɚ ɨɧɚ ɧɟ ɞɨɫɬɢɝɧɟɬ ɝɥɨɬɤɢ. Ɂɚɬɟɦ ɧɢɠɧɹɹ ɱɟɥɸɫɬɶ ɜɵɜɨɞɢɬɫɹ ɜɩɟɪɟɞ, ɚ ɫɜɨɛɨɞɧɚɹ ɧɨɡɞɪɹ ɡɚɤɪɵɜɚɟɬɫɹ.ȿɫɥɢ ɩɚɰɢɟɧɬ ɜ ɫɨɡɧɚ-ɧɢɢ,ɧɟɨɛɯɨɞɢɦɨ ɩɨɩɪɨɫɢɬɶ ɟɝɨ ɡɚɤɪɵɬɶ ɪɨɬ ɢ ɝɥɭɛɨ-ɤɨ ɞɵɲɚɬɶ. ȼ ɫɥɭɱɚɟ ɚɧɟɫɬɟɡɢɪɨɜɚɧɧɨɝɨ ɩɚɰɢɟɧɬɚ ɬɪɭɛɤɚ ɦɟɞɥɟɧɧɨ ɩɪɨɞɜɢɝɚɟɬɫɹ ɜɩɟɪɟɞ ɞɨ ɩɨɹɜɥɟɧɢɹ ɧɚ ɟɟ ɜɧɟɲɧɟɦ ɤɨɧɰɟ ɞɵɯɚɬɟɥɶɧɵɯ ɲɭɦɨɜ. ȼ ɷɬɨɣ ɫɢɬɭɚɰɢɢ ɤɪɚɣɧɟ ɩɨɥɟɡɧɚ ɤɚɩɧɨɝɪɚɮɢɹ.Ⱦɵɯɚɬɟɥɶɧɵɟ ɲɭɦɵ ɢ ɧɚɥɢɱɢɟ ɯɚɪɚɤɬɟɪɧɨɣ ɤɚɩɧɨɝɪɚɮɢɱɟɫɤɨɣ ɤɪɢɜɨɣ ɭɤɚɡɵɜɚɸɬ ɧɚ ɜɜɟɞɟɧɢɟ ɬɪɭɛɤɢ ɜ ɬɪɚɯɟɸ. ɇɚ-ɡɨɬɪɚɯɟɚɥɶɧɚɹ ɢɧɬɭɛɚɰɢɹ ɜɫɥɟɩɭɸ ɨɫɬɚɟɬɫɹ ɜɟɫɶɦɚ ɩɨɥɟɡɧɨɣ ɬɟɯɧɢɤɨɣ,ɬɚɤ ɤɚɤ ɧɟ ɬɪɟɛɭɟɬ ɞɨɩɨɥɧɢɬɟɥɶ-ɧɨɝɨ ɨɛɨɪɭɞɨɜɚɧɢɹ ɢ ɩɪɢɫɩɨɫɨɛɥɟɧɢɣ ɢ ɦɨɠɟɬ ɛɵɬɶ ɜɵɩɨɥɧɟɧɚ ɜ ɥɸɛɵɯ ɭɫɥɨɜɢɹɯ.
Ɍɚɤɬɢɥɶɧɚɹ ɨɪɨɬɪɚɯɟɚɥɶɧɚɹ ɢɧɬɭɛɚɰɢɹ («ɜɫɥɟɩɭɸ») Ɇɟɬɨɞ ɜɩɟɪɜɵɟ ɩɪɟɞɥɨɠɟɧ William MacEwen ɜ 1880 ɝ. ɂɧɬɭɛɚɰɢɹ ɜɵɩɨɥɧɹɟɬɫɹ ɫ ɩɨɦɨɳɶɸ ɧɟɩɨɫɪɟɞɫɬ-ɜɟɧɧɨɣ ɩɚɥɶɩɚɰɢɢ ɝɨɪɬɚɧɢ ɜɨ ɜɪɟɦɹ ɩɪɨɜɟɞɟɧɢɹ ɬɪɭɛɤɢ.
Ɂɚɤɥɸɱɟɧɢɟ
ȼ ɪɟɚɥɶɧɵɯ ɤɥɢɧɢɱɟɫɤɢɯ ɭɫɥɨɜɢɹɯ ɜɨɡɦɨɠɧɨ ɤɨɦɛɢ-ɧɢɪɨɜɚɧɧɨɟ ɩɪɢɦɟɧɟɧɢɟ ɩɪɟɞɫɬɚɜɥɟɧɧɵɯ ɦɟɬɨɞɢɤ:
ɜɫɟ ɡɚɜɢɫɢɬ ɨɬ ɨɫɨɛɟɧɧɨɫɬɟɣ ɤɥɢɧɢɱɟɫɤɨɝɨ ɫɥɭɱɚɹ, ɨɫɧɚɳɟɧɧɨɫɬɢ ɢ ɨɩɵɬɚ ɚɧɟɫɬɟɡɢɨɥɨɝɚ. ɋɬɨɹ ɩɟɪɟɞ ɜɵɛɨɪɨɦ ɧɚɢɥɭɱɲɟɣ ɞɥɹ ɷɬɨɝɨ ɫɥɭɱɚɹ ɢɧɬɭɛɚɰɢɢ ɦɟ-ɬɨɞɢɤɢ,ɧɟɨɛɯɨɞɢɦɨ ɜɡɜɟɫɢɬɶ ɜɫɟ ɷɬɢ ɮɚɤɬɨɪɵ.
Ⱦɥɹ ɞɚɥɶɧɟɣɲɟɝɨ ɱɬɟɧɢɹ
1. Fiberoptic Endoscopy and the Difficult Airway. A.
Ovassapian. Second Edition, 1996. Lippincott-Raven.
2. Airway Management. Hanowell and Waldron, 1996.
Lippincott-Raven.
Update In Anaesthesia
ɗɬɨ ɬɟɪɦɢɧ,ɢɫɩɨɥɶɡɨɜɚɧɧɵɣ ɜȾɨɤɥɚɞɚɯ ɨ ɡɚɤɪɵɬɵɯ ɪɚɫɫɥɟɞɨɜɚɧɢɹɯ ɫɥɭɱɚɟɜ ɦɚɬɟɪɢɧɫɤɨɣ ɫɦɟɪɬɧɨɫɬɢ ɜ ȼɟɥɢɤɨɛɪɢɬɚɧɢɢ [1], ɨɯɜɚɬɵɜɚɟɬ ɫɩɟɤɬɪ ɪɚɫɫɬɪɨɣɫɬɜ, ɜɤɥɸɱɚɸɳɢɯ ɩɪɟɷɤɥɚɦɩɫɢɸ, ɷɤɥɚɦɩɫɢɸ ɢ HELLP-ɫɢɧɞɪɨɦ (ɝɟɦɨɥɢɡ,ɩɨɜɵɲɟɧɧɵɣ ɭɪɨɜɟɧɶ ɩɟɱɟɧɨɱɧɵɯ ɮɟɪɦɟɧɬɨɜ ɢ ɬɪɨɦɛɨɰɢɬɨɩɟɧɢɹ). Ɉɫɬɪɵɣ ɠɢɪɨɜɨɣ ɝɟɩɚɬɨɡ ɢ ɞɪɭɝɢɟ ɦɢɤɪɨɚɧɝɢɨɩɚɬɢɢ ɭ ɛɟɪɟɦɟɧɧɵɯ ɛɥɢɡɤɢ ɫ ɝɢɩɟɪɬɟɧɡɢɜɧɵɦɢ ɪɚɫɫɬɪɨɣɫɬɜɚɦɢ ɢ ɦɨɝɭɬ ɜɨɡɧɢɤɚɬɶ ɨɞɧɨɜɪɟɦɟɧɧɨ.
ɉɪɟɷɤɥɚɦɩɫɢɹ ɹɜɥɹɟɬɫɹ ɦɭɥɶɬɢɫɢɫɬɟɦɧɵɦ ɪɚɫɫɬɪɨɣ-ɫɬɜɨɦ ɜɫɥɟɞɫɬɜɢɟ ɝɟɧɟɪɚɥɢɡɨɜɚɧɧɨɝɨ ɜɚɡɨɫɩɚɡɦɚ.
ɋɱɢɬɚɟɬɫɹ,ɱɬɨ ɩɥɚɰɟɧɬɚɪɧɚɹ ɢɲɟɦɢɹ ɦɨɠɟɬ ɜɵɡɜɚɬɶ ɬɪɨɮɨɛɥɚɫɬɢɱɟɫɤɭɸ ɮɪɚɝɦɟɧɬɚɰɢɸ. Ɋɚɫɩɪɨɫɬɪɚɧɟɧ-ɧɚɹ ɚɝɪɟɝɚɰɢɹ ɬɪɨɦɛɨɰɢɬɨɜ, ɜɵɡɜɚɧɧɚɹ ɷɬɢɦɢ ɮɪɚɝ-ɦɟɧɬɚɦɢ,ɫɩɨɫɨɛɫɬɜɭɟɬ ɜɵɫɜɨɛɨɠɞɟɧɢɸɫɟɪɨɬɨɧɢɧɚ.
ɗɬɨɬ ɦɟɞɢɚɬɨɪ ɨɬɜɟɬɫɬɜɟɧɟɧ ɡɚ ɪɚɡɜɢɬɢɟ ɝɟɧɟɪɚɥɢɡɨ-ɜɚɧɧɨɝɨ ɜɚɡɨɫɩɚɡɦɚ ɢ ɩɨɫɥɟɞɭɸɳɟɣ ɞɢɫɮɭɧɤɰɢɢ ɷɧ-ɞɨɬɟɥɢɚɥɶɧɵɯ ɤɥɟɬɨɤ. ɋɟɪɞɟɱɧɨ-ɫɨɫɭɞɢɫɬɚɹ, ɰɟɧ-ɬɪɚɥɶɧɚɹ ɧɟɪɜɧɚɹ,ɞɵɯɚɬɟɥɶɧɚɹ ɢ ɫɜɟɪɬɵɜɚɸɳɚɹ ɫɢɫ-ɬɟɦɵ,ɩɟɱɟɧɶ ɢ ɩɨɱɤɢ ɜ ɪɚɡɥɢɱɧɨɣ ɫɬɟɩɟɧɢ ɜɨɜɥɟɤɚ-ɸɬɫɹ ɜ ɩɚɬɨɥɨɝɢɱɟɫɤɢɣ ɩɪɨɰɟɫɫ [3].
Ɉɛɴɟɦ ɰɢɪɤɭɥɢɪɭɸɳɟɣ ɤɪɨɜɢ ɭɜɟɥɢɱɟɧ ɩɨ ɫɪɚɜɧɟ-ɧɢɸ ɫ ɫɨɫɬɨɹɧɢɟɦ ɞɨ ɛɟɪɟɦɟɧɧɨɫɬɢ,ɧɨ ɦɟɧɶɲɟ,ɱɟɦ ɩɪɢ ɧɨɪɦɚɥɶɧɨ ɩɪɨɬɟɤɚɸɳɟɣ ɛɟɪɟɦɟɧɧɨɫɬɢ. ɉɪɨɞɟ-ɦɨɧɫɬɪɢɪɨɜɚɧɧɵɟ ɫ ɩɨɦɨɳɶɸ ɤɚɬɟɬɟɪɚ ɜ ɥɟɝɨɱɧɨɣ ɚɪɬɟɪɢɢ (ɅȺ) ɞɚɧɧɵɟ ɨ ɩɨɬɨɤ-ɡɚɜɢɫɢɦɨɦ ɩɨɬɪɟɛɥɟ-ɧɢɢ ɤɢɫɥɨɪɨɞɚ ɩɨɤɚɡɚɥɢ, ɱɬɨ ɬɹɠɟɥɚɹ ɩɪɟɷɤɥɚɦɩɫɢɹ ɫɜɹɡɚɧɚ ɫ ɧɚɪɭɲɟɧɢɟɦ ɷɤɫɬɪɚɤɰɢɢ ɤɢɫɥɨɪɨɞɚ ɧɚ ɬɤɚ-ɧɟɜɨɦ ɭɪɨɜɧɟ. ɉɨɞɨɛɧɵɟ ɧɚɪɭɲɟɧɢɹ ɧɚɯɨɞɹɬ ɭ ɤɪɢ-ɬɢɱɟɫɤɢɯ ɩɚɰɢɟɧɬɨɜ ɫ ɩɨɥɢɨɪɝɚɧɧɨɣ ɧɟɞɨɫɬɚɬɨɱɧɨ-ɫɬɶɸ [4].
ɉɪɟɷɤɥɚɦɩɫɢɹ ɯɚɪɚɤɬɟɪɢɡɭɟɬɫɹ ɢɡɦɟɧɱɢɜɨɫɬɶɸ ɩɪɨ-ɹɜɥɟɧɢɣ ɢ ɫɤɨɪɨɫɬɢ ɩɪɨɝɪɟɫɫɢɪɨɜɚɧɢɹ. ȿɞɢɧɫɬɜɟɧ-ɧɵɦ ɛɟɡɭɫɥɨɜȿɞɢɧɫɬɜɟɧ-ɧɵɦ ɦɟɬɨɞɨɦ ɥɟɱɟɧɢɹ ɹɜɥɹɟɬɫɹ ɪɨɞɨ-ɪɚɡɪɟɲɟɧɢɟ. Ɉɞɧɚɤɨ ɩɟɪɟɞ ɧɚɱɚɥɨɦ ɜɵɡɞɨɪɨɜɥɟɧɢɹ ɤɥɢɧɢɱɟɫɤɢɟ ɢ ɥɚɛɨɪɚɬɨɪɧɵɟ ɩɨɤɚɡɚɬɟɥɢ ɜ ɫɥɟɞɭɸ-ɳɢɟ ɩɨɫɥɟ ɪɨɞɨɜ 24 ɱɚɫɚ ɡɚɱɚɫɬɭɸ ɩɪɨɞɨɥɠɚɸɬ ɭɯɭɞ-ɲɚɬɶɫɹ.
ɋɟɪɞɟɱɧɨ-ɫɨɫɭɞɢɫɬɚɹ ɫɢɫɬɟɦɚ
Ⱦɨ ɪɨɞɨɜ ɰɟɥɶɸ ɥɟɱɟɧɢɹ ɹɜɥɹɟɬɫɹ ɩɪɟɞɨɬɜɪɚɳɟɧɢɟ ɜɬɨɪɢɱɧɨɝɨ ɜɧɭɬɪɢɦɨɡɝɨɜɨɝɨ ɤɪɨɜɨɢɡɥɢɹɧɢɹ ɜɫɥɟɞɫɬ-ɜɢɟ ɧɟɭɩɪɚɜɥɹɟɦɨɣ ɚɪɬɟɪɢɚɥɶɧɨɣ ɝɢɩɟɪɬɟɧɡɢɢ, ɨɞɧɨ-ɜɪɟɦɟɧɧɨ ɫɨɯɪɚɧɹɹ ɦɚɬɨɱɧɨ-ɩɥɚɰɟɧɬɚɪɧɵɣ ɢ ɩɨɱɟɱ-ɧɵɣ ɤɪɨɜɨɬɨɤ. ɋɢɫɬɟɦɧɨɟ ɚɪɬɟɪɢɚɥɶɧɨɟ ɞɚɜɥɟɧɢɟ (ȺȾ) > 170/110 ɦɦ ɪɬ. ɫɬ. ɹɜɥɹɟɬɫɹ ɩɨɤɚɡɚɧɢɟɦ ɞɥɹ ɧɟɨɬɥɨɠɧɨɝɨ ɧɚɱɚɥɚ ɥɟɱɟɧɢɹ,ɩɪɢ ɷɬɨɦ ȺȾ ɧɟ ɞɨɥɠ-ɧɨ ɛɵɫɬɪɨ ɫɧɢɠɚɬɶɫɹ ɦɟɧɟɟ 130/90 ɦɦ ɪɬ.ɫɬ. [5]. Ⱦɥɹ ɧɟɨɬɥɨɠɧɨɣ ɬɟɪɚɩɢɢ ɩɨɞɯɨɞɹɬ ɫɥɟɞɭɸɳɢɟ ɩɪɟɩɚɪɚ-ɬɵ:
x ɋɨɫɭɞɨɪɚɫɲɢɪɹɸɳɢɣ ɩɪɟɩɚɪɚɬ ɝɢɞɪɚɥɚɡɢɧ ɷɮ-ɮɟɤɬɢɜɟɧ ɩɪɢ ɩɟɪɜɨɧɚɱɚɥɶɧɨɦ ɜɜɟɞɟɧɢɢ ɛɨɥɸɫɚ -ɦɢ ɩɨ 2,5-5 ɦɝ ɤɚɠɞɵɟ 20 ɦɢɧɭɬ,ɚ ɡɚɬɟɦ ɩɨɫɬɨɹɧ -ɧɨɣ ɢɧɮɭɡɢɟɣ. ɉɨɛɨɱɧɵɟ ɷɮɮɟɤɬɵ ɜ ɜɢɞɟ
ɝɨɥɨɜ-ɧɨɣ ɛɨɥɢ,ɞɪɨɠɢ ɢ ɪɜɨɬɵ ɦɨɝɭɬ ɢɦɢɬɢɪɨɜɚɬɶ ɩɪɢ-ɛɥɢɠɚɸɳɭɸɫɹ ɷɤɥɚɦɩɫɢɸ. Ɋɟɤɨɦɟɧɞɭɟɬɫɹ ɩɪɟɞ-ɜɚɪɢɬɟɥɶɧɨɟ ɛɨɥɸɫɧɨɟ ɜɜɟɞɟɧɢɟ ɤɨɥɥɨɢɞɨɜ (ɧɟ ɛɨɥɟɟ 500 ɦɥ) ɞɥɹ ɩɪɟɞɨɬɜɪɚɳɟɧɢɹ ɨɫɬɪɨɝɨ ɞɢɫɬ -ɪɟɫɫɚ ɩɥɨɞɚ ɜɫɥɟɞɫɬɜɢɟ ɜɚɡɨɞɢɥɚɬɚɰɢɢ.
x Ʌɚɛɟɬɚɥɨɥ ɨɛɥɚɞɚɟɬ ɫɨɫɭɞɨɪɚɫɲɢɪɹɸɳɢɦ Į-ɚɞɪɟɧɟɪɝɢɱɟɫɤɢɦ ɛɥɨɤɢɪɭɸɳɢɦ ɞɟɣɫɬɜɢɟɦ ɢ ȕ-ɛɥɨɤɢɪɭɸɳɟɣ ɚɤɬɢɜɧɨɫɬɶɸ, ɤɨɬɨɪɚɹ ɫɦɹɝɱɚɟɬ ɬɚɯɢɤɚɪɞɢɸ. ɉɪɟɩɚɪɚɬ ɨɛɵɱɧɨ ɷɮɮɟɤɬɢɜɟɧ ɩɪɢ ɜɜɟɞɟɧɢɢ ɜ ɞɨɡɟ 10-20 ɦɝ ɫ ɢɧɬɟɪɜɚɥɚɦɢ ɩɨ 5-10 ɦɢɧ (ɞɨ 100 ɦɝ).
x Ⱥɧɬɚɝɨɧɢɫɬ ɤɚɥɶɰɢɟɜɵɯ ɤɚɧɚɥɨɜ ɧɢɮɟɞɢɩɢɧ ɢɫ -ɩɨɥɶɡɭɟɬɫɹ ɜ ɤɚɱɟɫɬɜɟ ɚɧɬɢɝɢɩɟɪɬɟɧɡɢɜɧɨɝɨ ɩɪɟ-ɩɚɪɚɬɚ ɩɪɢ ɩɪɟɷɤɥɚɦɩɫɢɢ, ɯɨɬɹ ɫɭɳɟɫɬɜɭɟɬ ɜɟɪɨ-ɹɬɧɨɫɬɶ ɞɟɩɪɟɫɫɢɢ ɦɢɨɤɚɪɞɚ ɢ ɱɪɟɡɦɟɪɧɨɣ ɝɢɩɨ-ɬɟɧɡɢɢ,ɟɫɥɢ ɨɧ ɩɪɢɦɟɧɹɟɬɫɹ ɫɨɜɦɟɫɬɧɨ ɫ ɫɭɥɶɮɚ-ɬɨɦ ɦɚɝɧɢɹ (MgSO4), ɤɨɬɨɪɵɣ ɬɚɤɠɟ ɹɜɥɹɟɬɫɹ ɚɧ-ɬɚɝɨɧɢɫɬɨɦ ɤɚɥɶɰɢɹ.
x Ʉɟɬɚɧɫɟɪɢɧ, ɚɧɬɚɝɨɧɢɫɬ ɪɟɰɟɩɬɨɪɨɜ ɫɟɪɨɬɨɧɢɧɚ-2,ɨɛɥɚɞɚɟɬ ɚɧɬɢɝɢɩɟɪɬɟɧɡɢɜɧɵɦ ɷɮɮɟɤɬɨɦ, ɫɪɚɜ-ɧɢɦɵɦ ɫ ɝɢɞɪɚɥɚɡɢɧɨɦ, ɧɨ ɫ ɛɨɥɟɟ ɧɢɡɤɨɣ ɜɫɬɪɟ-ɱɚɟɦɨɫɬɶɸ ɝɨɥɨɜɧɨɣ ɛɨɥɢ, ɡɪɢɬɟɥɶɧɵɯ ɪɚɫ-ɫɬɪɨɣɫɬɜ ɢ ɬɨɲɧɨɬɵ/ɪɜɨɬɵ.ɂɡɜɟɫɬɧɨ,ɱɬɨ HELLP ɫɢɧɞɪɨɦ, ɨɥɢɝɭɪɢɹ, ɨɬɟɤ ɥɟɝɤɢɯ ɢ ɨɬɬɨɪɠɟɧɢɟ ɩɥɚɰɟɧɬɵ ɪɚɡɜɢɜɚɸɬɫɹ ɪɟɠɟ,ɟɫɥɢ ɠɟɧɳɢɧ ɥɟɱɢ-ɥɢ ɤɟɬɚɧɫɟɪɢɧɨɦ. ɗɬɨɬ ɫɟɥɟɤɬɢɜɧɵɣ ɛɥɨɤɚɬɨɪ ɪɟɰɟɩɬɨɪɨɜ ɫɟɪɨɬɨɧɢɧɚ-2 ɜ ɧɚɫɬɨɹɳɟɟ ɜɪɟɦɹ ɧɟɥɢɰɟɧɡɢɪɨɜɚɧ ɜ ȼɟɥɢɤɨɛɪɢɬɚɧɢɢ. ɋɤɨɪɟɟ ɜɫɟ-ɝɨ, ɩɪɟɩɚɪɚɬ ɞɟɣɫɬɜɭɟɬ ɧɚ ɭɪɨɜɧɟ ɬɪɨɦɛɨɰɢɬɚɪ-ɧɨ-ɷɧɞɨɬɟɥɢɚɥɶɧɨɝɨ ɜɡɚɢɦɨɞɟɣɫɬɜɢɹ, ɚ ɧɟ ɩɪɨ-ɫɬɨ ɤɚɤ ɜɚɡɨɞɢɥɚɬɚɬɨɪ [6].
ɉɪɟɷɤɥɚɦɩɫɢɹ ɪɟɞɤɨ ɜɵɡɵɜɚɟɬ ɧɚɪɭɲɟɧɢɟ ɮɭɧɤɰɢɢ ɫɟɪɞɰɚ ɭ ɦɨɥɨɞɵɯ, ɜ ɨɫɬɚɥɶɧɨɦ ɡɞɨɪɨɜɵɯ ɠɟɧɳɢɧ.
Ɍɨɥɶɤɨ ɧɟɛɨɥɶɲɚɹ ɱɚɫɬɶ ɩɚɰɢɟɧɬɨɜ ɫ ɩɪɟɷɤɥɚɦɩɫɢɟɣ ɢ ɪɚɡɜɢɜɲɢɦɫɹ ɨɬɟɤɨɦ ɥɟɝɤɢɯ ɢɦɟɟɬ ɫɧɢɠɟɧɧɭɸ ɫɢɫ -ɬɨɥɢɱɟɫɤɭɸ ɮɭɧɤɰɢɸ ɢ ɞɢɥɚɬɚɰɢɸ ɥɟɜɨɝɨ ɠɟɥɭɞɨɱ-ɤɚ [7]. Ɋɚɡɜɢɜɚɸɳɚɹɫɹ ɜ ɩɪɟɞɪɨɞɨɜɨɦ ɩɟɪɢɨɞɟ ɠɟɥɭɞɨɱ- ɤɚɪ-ɞɢɨɦɢɨɩɚɬɢɹ ɹɜɥɹɟɬɫɹ ɩɥɨɯɨ ɢɫɫɥɟɞɨɜɚɧɧɵɦ ɡɚɛɨɥɟɜɚ-ɧɢɟɦ ɫɟɪɞɰɚ,ɫɜɹɡɚɧɧɵɦ ɫ ɛɟɪɟɦɟɧɧɨɫɬɶɸ ɭ ɪɚɧɟɟ ɡɞɨ-ɪɨɜɵɯ ɢ ɧɟ ɢɦɟɸɳɢɯ ɨɪɝɚɧɢɱɟɫɤɨɣ ɤɚɪɞɢɚɥɶɧɨɣ ɩɚɬɨ-ɥɨɝɢɢ ɠɟɧɳɢɧ. ɋɭɳɧɨɫɬɶ ɜɡɚɢɦɨɫɜɹɡɢ ɤɚɪɞɢɨɦɢɨɩɚ-ɬɢɢ ɫ ɩɪɟɷɤɥɚɦɩɫɢɟɣ ɧɟɹɫɧɚ [8]. ɀɟɧɳɢɧɚɦ ɫ ɩɪɟɷɤ-ɥɚɦɩɫɢɟɣ ɢ ɨɬɟɤɨɦ ɥɟɝɤɢɯ ɞɨɥɠɧɚ ɛɵɬɶ ɜɵɩɨɥɧɟɧɚ ɷɯɨɤɚɪɞɢɨɝɪɚɮɢɹ ɞɥɹ ɜɵɹɜɥɟɧɢɹ ɩɪɢɡɧɚɤɨɜ ɤɚɪɞɢɨ-ɦɢɨɩɚɬɢɢ,ɤɨɬɨɪɚɹ ɥɭɱɲɟ ɩɨɞɞɚɟɬɫɹ ɥɟɱɟɧɢɸ ɩɪɢ ɪɚɧ-ɧɟɦ ɧɚɡɧɚɱɟɧɢɢ ɢɧɝɢɛɢɬɨɪɨɜ ȺɉɎ. Ɋɚɡɜɢɬɢɸ ɨɬɟɤɚ ɥɟɝɤɢɯ ɦɨɠɟɬ ɫɩɨɫɨɛɫɬɜɨɜɚɬɶ ɹɬɪɨɝɟɧɧɨɟ ɜɜɟɞɟɧɢɟ ɠɢɞɤɨɫɬɢ,ɧɚɡɧɚɱɟɧɢɟ ɫɬɟɪɨɢɞɨɜ ɞɥɹ ɫɬɢɦɭɥɹɰɢɢ ɫɨ-ɡɪɟɜɚɧɢɹ ɥɟɝɤɢɯ ɩɥɨɞɚ ɢ ȕ2-ɚɝɨɧɢɫɬɨɜ (ɧɚɩɪɢɦɟɪ, ɪɢ-ɬɨɞɪɢɧɚ)ɞɥɹ ɫɧɢɠɟɧɢɹ ɬɨɧɭɫɚ ɦɢɨɦɟɬɪɢɹ.
ɉɨɱɤɢ
ɉɨɪɚɠɟɧɢɟ ɩɨɱɟɱɧɵɯ ɤɥɭɛɨɱɤɨɜ ɜɵɡɵɜɚɟɬ
ɩɪɨɬɟɢɧɭ-ǫǰǷǭǸǺǭǵǯǰǪǵȃǭ ǸǨǹǹǺǸǶDZǹǺǪǨ ǻ ǩǭǸǭǴǭǵǵȃǽ
ǬȘ. Ǭ. Ǵ. dzȍȊȐ (ǵȖȚȚȐȕȋȍȔ, ǪȍȓȐȒȖȉȘȐȚȈȕȐȧ)
ɪɢɸ. Ɍɪɚɞɢɰɢɨɧɧɵɦ ɞɢɚɝɧɨɫɬɢɱɟɫɤɢɦ ɤɪɢɬɟɪɢɟɦ ɩɪɟɷɤɥɚɦɩɫɢɢ ɹɜɥɹɟɬɫɹ ɜɵɹɜɥɟɧɢɟ 300 ɦɝ ɛɟɥɤɚ ɜ ɦɨɱɟ ɡɚ 24 ɱɚɫɚ.Ɉɞɧɚɤɨ ɩɪɨɬɟɢɧɭɪɢɹ ɛɨɥɶɲɟ ɧɟ ɪɚɫ-ɫɦɚɬɪɢɜɚɟɬɫɹ ɤɚɤ ɧɟɢɡɛɟɠɧɵɣ ɩɪɢɡɧɚɤ ɡɚɛɨɥɟɜɚɧɢɹ [9]. ȼ ɨɬɥɢɱɢɟ ɨɬ ɤɨɧɰɟɧɬɪɚɰɢɢ ɦɨɱɟɜɨɣ ɤɢɫɥɨɬɵ ɜ ɫɵɜɨɪɨɬɤɟ ɤɪɨɜɢ ɫɬɟɩɟɧɶ ɢ ɫɤɨɪɨɫɬɶ ɭɜɟɥɢɱɟɧɢɹ ɩɪɨ-ɬɟɢɧɭɪɢɢ ɧɟ ɹɜɥɹɸɬɫɹ ɜɚɠɧɵɦɢ ɩɪɟɞɢɤɬɨɪɚɦɢ ɦɚɬɟ-ɪɢɧɫɤɨɝɨ ɢɥɢ ɩɟɪɢɧɚɬɚɥɶɧɨɝɨ ɢɫɯɨɞɚ. Ƚɢɩɟɪɭɪɢɤɟ-ɦɢɹ ɩɪɟɞɲɟɫɬɜɭɟɬ ɜɨɡɧɢɤɧɨɜɟɧɢɸ ɜɵɪɚɠɟɧɧɨɣ ɩɪɨ-ɬɟɢɧɭɪɢɢ ɩɪɢ ɩɪɟɷɤɥɚɦɩɫɢɢ.ɋɱɢɬɚɟɬɫɹ,ɱɬɨ ɝɢɩɟɪɭ-ɪɢɤɟɦɢɹ ɪɚɡɜɢɜɚɟɬɫɹ ɜ ɪɟɡɭɥɶɬɚɬɟ ɥɢɛɨ ɭɫɢɥɟɧɢɹ ɤɚ -ɧɚɥɶɰɟɜɨɣ ɪɟɚɛɫɨɪɛɰɢɢ ɦɨɱɟɜɨɣ ɤɢɫɥɨɬɵ,ɥɢɛɨ ɪɚɫ-ɩɚɞɚ ɛɨɝɚɬɨɝɨ ɹɞɪɚɦɢ (ɚ ɫɥɟɞɨɜɚɬɟɥɶɧɨ ɩɭɪɢɧɚɦɢ) ɫɢɧɰɢɬɢɨɬɪɨɮɨɛɥɚɫɬɚ.
Ɉɥɢɝɭɪɢɹ (ɞɢɭɪɟɡ < 30 ɦɥ/ɱ)ɜ ɬɟɱɟɧɢɟ 6 ɱɚɫɨɜ ɩɨɫɥɟ ɪɨɞɨɜ ɜɫɬɪɟɱɚɟɬɫɹ ɨɱɟɧɶ ɱɚɫɬɨ, ɨɞɧɚɤɨ ɩɪɢ ɷɬɨɦ ɧɟ ɫɥɟɞɭɟɬ ɩɨɞɪɚɡɭɦɟɜɚɬɶ ɝɢɩɨɜɨɥɟɦɢɸ. ȼ ɨɬɫɭɬɫɬɜɢɢ ɨɬɹɝɨɳɚɸɳɢɯ ɮɚɤɬɨɪɨɜ,ɬɚɤɢɯ ɤɚɤ ɛɨɥɶɲɚɹ ɤɪɨɜɨɩɨ-ɬɟɪɹ ɢɥɢ ɱɪɟɡɦɟɪɧɨɟ ɜɜɟɞɟɧɢɟ ɧɟɫɬɟɪɨɢɞɧɵɯ ɩɪɨɬɢ-ɜɨɜɨɫɩɚɥɢɬɟɥɶɧɵɯ ɩɪɟɩɚɪɚɬɨɜ, ɨɫɬɪɵɣ ɬɭɛɭɥɹɪɧɵɣ ɧɟɤɪɨɡ ɪɚɡɜɢɜɚɟɬɫɹ ɢɫɤɥɸɱɢɬɟɥɶɧɨ ɪɟɞɤɨ.
x ɋɭɳɟɫɬɜɭɟɬ ɦɚɥɨ ɞɨɤɚɡɚɧɧɵɯ ɮɚɤɬɨɜ, ɧɚ ɨɫɧɨɜɟ ɤɨɬɨɪɵɯ ɦɨɠɧɨ ɨɫɭɳɟɫɬɜɥɹɬɶ ɤɨɪɪɟɤɰɢɸ ɠɢɞɤɨ-ɫɬɧɨɝɨ ɛɚɥɚɧɫɚ ɩɪɢ ɩɪɟɷɤɥɚɦɩɫɢɢ – ɛɨɥɶɲɢɯ ɩɪɨ-ɫɩɟɤɬɢɜɧɵɯ ɢɫɫɥɟɞɨɜɚɧɢɣ, ɨɰɟɧɢɜɚɸɳɢɯ ɪɟɡɭɥɶ-ɬɚɬɵ ɥɟɱɟɧɢɹ, ɧɟ ɩɪɨɜɨɞɢɥɨɫɶ [10]. ɇɟɬ ɢɫɫɥɟɞɨ-ɜɚɧɢɣ, ɤɨɬɨɪɵɟ ɛɵ ɩɨɤɚɡɚɥɢ ɩɪɟɢɦɭɳɟɫɬɜɨ ɤɪɢ-ɫɬɚɥɥɨɢɞɨɜ ɢɥɢ ɤɨɥɥɨɢɞɨɜ. ɂɫɩɨɥɶɡɨɜɚɧɢɟ ɤɪɢ-ɫɬɚɥɥɨɢɞɨɜ ɦɨɠɟɬ ɭɦɟɧɶɲɢɬɶ ɤɨɥɥɨɢɞɧɨ-ɨɧɤɨɬɢɱɟɫɤɨɟ ɞɚɜɥɟɧɢɟ ɩɥɚɡɦɵ, ɚ ɛɨɥɟɟ ɞɥɢɬɟɥɶ-ɧɵɣ ɩɟɪɢɨɞ ɩɨɥɭɠɢɡɧɢ ɤɨɥɥɨɢɞɧɵɯ ɪɚɫɬɜɨɪɨɜ ɦɨɠɟɬ ɫɩɨɫɨɛɫɬɜɨɜɚɬɶ ɰɢɪɤɭɥɹɬɨɪɧɨɣ ɩɟɪɟɝɪɭɡɤɟ ɜ ɩɨɫɥɟɪɨɞɨɜɨɦ ɩɟɪɢɨɞɟ ɜɫɥɟɞɫɬɜɢɟ ɦɨɛɢɥɢɡɚɰɢɢ ɭɜɟɥɢɱɟɧɧɨɝɨ ɩɪɢ ɛɟɪɟɦɟɧɧɨɫɬɢ ɜɧɟɤɥɟɬɨɱɧɨɝɨ ɨɛɴɟɦɚ ɠɢɞɤɨɫɬɢ. Ʉɨɥɢɱɟɫɬɜɨ ɜɜɟɞɟɧɧɨɣ ɢ ɜɵ -ɜɟɞɟɧɧɨɣ ɠɢɞɤɨɫɬɢ ɧɟɨɛɯɨɞɢɦɨ ɬɳɚɬɟɥɶɧɨ ɮɢɤɫɢɪɨɜɚɬɶ. ȿɫɥɢ ɩɨɫɥɟ ɪɨɞɨɜ ɩɪɨɞɨɥɠɟɧɚ ɢɧɮɭɡɢɹ Syntocinon®, ɩɪɟɩɚɪɚɬ ɞɨɥɠɟɧ ɜɜɨɞɢɬɶɫɹ ɲɩɪɢɰɟɜɵɦ ɧɚɫɨɫɨɦ ɜ ɦɚɥɨɦ ɪɚɡɜɟɞɟɧɢɢ (ɧɚɩɪɢɦɟɪ, 40 ɟɞɢɧɢɰ ɜ 40 ɦɥ ɮɢɡɢɨɥɨɝɢɱɟɫɤɨɝɨ ɪɚɫɬɜɨɪɚ 10 ɦɥ/ɱ).
x ɉɨɤɚ ɪɨɞɵ ɧɟ ɨɫɥɨɠɧɟɧɵ ɤɪɨɜɨɩɨɬɟɪɟɣ (ɧɚɩɪɢɦɟɪ, ɨɬɫɥɨɣɤɚ ɩɥɚɰɟɧɬɵ),ɫɟɩɫɢɫɨɦ (ɧɚɩɪɢɦɟɪ, ɯɨɪɢɨɚɦ-ɧɢɨɧɢɬ)ɢ ɬ.ɩ.,ɩɨɤɚɡɚɧɢɹ ɞɥɹ ɢɧɜɚɡɢɜɧɨɝɨ ɦɨɧɢɬɨ -ɪɢɧɝɚ ɝɟɦɨɞɢɧɚɦɢɤɢ ɜɨɡɧɢɤɚɸɬ ɪɟɞɤɨ. ɂɡɦɟɪɟɧɢɟ ɐȼȾ ɩɨɡɜɨɥɹɟɬ ɩɨɞɬɜɟɪɞɢɬɶ ɝɢɩɨɜɨɥɟɦɢɸ ɢ ɩɨɦɨ-ɝɚɟɬ ɩɪɨɜɨɞɢɬɶ ɟɟ ɤɨɪɪɟɤɰɢɸ. Ʉɚɬɟɬɟɪɢɡɚɰɢɹ ɰɟɧ-ɬɪɚɥɶɧɨɣ ɜɟɧɵ ɱɟɪɟɡ ɩɨɞɤɨɠɧɭɸ ɜɟɧɭ ɜɟɪɯɧɟɣ ɤɨ-ɧɟɱɧɨɫɬɢ ɧɚɦɧɨɝɨ ɛɟɡɨɩɚɫɧɟɟ, ɱɟɦ ɞɪɭɝɢɟ ɜɢɞɵ ɫɨɫɭɞɢɫɬɨɝɨ ɞɨɫɬɭɩɚ, ɨɫɨɛɟɧɧɨ ɩɪɢ ɤɨɚɝɭɥɨɩɚɬɢɢ.
Ɉɛɫɬɪɭɤɰɢɹ ɞɵɯɚɬɟɥɶɧɵɯ ɩɭɬɟɣ ɜɫɥɟɞɫɬɜɢɟ ɧɟ-ɭɦɵɲɥɟɧɧɨɣ ɩɭɧɤɰɢɢ ɫɨɧɧɨɣ ɚɪɬɟɪɢɢ ɜ ɯɨɞɟ ɩɨ-ɩɵɬɤɢ ɤɚɬɟɬɟɪɢɡɚɰɢɢ ɹɪɟɦɧɨɣ ɜɟɧɵ ɢɝɪɚɟɬ ɜɚɠɧɭɸ ɪɨɥɶ ɜ ɜɨɡɧɢɤɧɨɜɟɧɢɢ ɤɪɢɬɢɱɟɫɤɢɯ ɫɨɫɬɨɹɧɢɣ ɢ ɦɚɬɟɪɢɧɫɤɨɣ ɥɟɬɚɥɶɧɨɫɬɢ.
x ɂɧɮɭɡɢɨɧɧɚɹ ɬɟɪɚɩɢɹ ɦɨɠɟɬ ɛɵɬɶ ɫ ɨɫɬɨɪɨɠɧɨ-ɫɬɶɸ ɩɪɟɞɩɪɢɧɹɬɚ,ɟɫɥɢ ɐȼȾ < 5 ɦɦ ɪɬ.ɫɬ. Ɉɞɧɚ-ɤɨ ɰɢɪɤɭɥɢɪɭɸɳɢɣ ɨɛɴɟɦ ɤɪɨɜɢ ɞɨɥɠɟɧ ɫɱɢɬɚɬɶ-ɫɹ ɜɨɫɩɨɥɧɟɧɧɵɦ, ɟɫɥɢ ɐȼȾ > 5 ɦɦ ɪɬ. ɫɬ. ɉɪɢ ɷɬɨɦ ɞɨɫɬɚɬɨɱɧɨ ɜɜɨɞɢɬɶ ɦɢɧɢɦɚɥɶɧɵɣ ɨɛɴɟɦ ɠɢɞɤɨɫɬɢ (ɧɚɩɪɢɦɟɪ, ɮɢɡɢɨɥɨɝɢɱɟɫɤɢɣ ɪɚɫɬɜɨɪ
ɢɥɢ ɪɚɫɬɜɨɪ Ƚɚɪɬɦɚɧɚ 20 ɦɥ/ɱ).
x Ⱦɨɩɚɦɢɧ ɜ ɞɨɡɟ 1-5 ɦɤɝ/ɤɝ/ɦɢɧ ɜɵɡɵɜɚɟɬ ɭɜɟɥɢɱɟ-ɧɢɟ ɞɢɭɪɟɡɚ ɩɪɢ ɨɥɢɝɭɪɢɢ ɜ ɩɨɫɥɟɪɨɞɨɜɨɦ ɩɟɪɢɨ-ɞɟ ɭ ɩɚɰɢɟɧɬɨɜ ɫ ɩɪɟɷɤɥɚɦɩɫɢɟɣ,ɤɨɬɨɪɵɟ ɧɟ ɪɟɚ-ɝɢɪɨɜɚɥɢ ɧɚ ɩɪɟɞɜɚɪɢɬɟɥɶɧɭɸ ɜɨɞɧɭɸ ɧɚɝɪɭɡɤɭ ɤɪɢɫɬɚɥɥɨɢɞɚɦɢ 300 ɦɥ, ɯɨɬɹ ɪɟɚɥɶɧɚɹ ɩɨɥɶɡɚ ɹɜɥɹɟɬɫɹ ɫɨɦɧɢɬɟɥɶɧɨɣ.
x Ɇɟɠɞɭ ɩɨɤɚɡɚɬɟɥɟɦ ɐȼȾ ɢ ɞɚɜɥɟɧɢɟɦ ɡɚɤɥɢɧɢɜɚ-ɧɢɹ ɥɟɝɨɱɧɨɣ ɚɪɬɟɪɢɢ (ȾɁɅȺ)ɩɨɹɜɥɹɟɬɫɹ ɪɚɫɯɨɠ-ɞɟɧɢɟ ɩɪɢ ɡɧɚɱɟɧɢɹɯ ɐȼȾ ɛɨɥɟɟ 6 ɦɦ ɪɬ.ɫɬ., ɤɨ-ɝɞɚ ȾɁɅȺ ɦɨɠɟɬ ɛɵɬɶ ɡɧɚɱɢɬɟɥɶɧɨ ɜɵɲɟ ɜ ɪɟ-ɡɭɥɶɬɚɬɟ ɞɢɫɮɭɧɤɰɢɢ ɥɟɜɨɝɨ ɠɟɥɭɞɨɱɤɚ.
Ʉɚɬɟɬɟɪɢɡɚɰɢɹ ɥɟɝɨɱɧɨɣ ɚɪɬɟɪɢɢ ɨɩɪɚɜɞɚɧɚ ɜ ɫɢɬɭɚ-ɰɢɹɯ, ɤɨɝɞɚ ɩɨɥɶɡɚ ɨɬ ɡɧɚɧɢɹ ȾɁɅȺ, ɫɟɪɞɟɱɧɨɝɨ ɜɵ-ɛɪɨɫɚ ɢ ɫɢɫɬɟɦɧɨɝɨ ɫɨɫɭɞɢɫɬɨɝɨ ɫɨɩɪɨɬɢɜɥɟɧɢɹ ɨɰɟ-ɧɢɜɚɟɬɫɹ ɜɵɲɟ ɪɢɫɤɚ ɨɫɥɨɠɧɟɧɢɣ.ɉɨɬɟɧɰɢɚɥɶɧɵɦɢ ɩɨɤɚɡɚɧɢɹɦɢ ɹɜɥɹɸɬɫɹ ɨɬɟɤ ɥɟɝɤɢɯ, ɪɟɡɢɫɬɟɧɬɧɵɣ ɤ ɞɢɭɪɟɬɢɤɚɦ, ɭɫɬɨɣɱɢɜɚɹ ɬɹɠɟɥɚɹ ɨɥɢɝɭɪɢɹ ɢ ɝɢɩɟɪ -ɬɟɧɡɢɹ, ɪɟɮɪɚɤɬɟɪɧɚɹ ɤ ɫɬɚɧɞɚɪɬɧɨɣ ɬɟɪɚɩɢɢ. ɏɨɬɹ ɩɪɢ ɱɪɟɫɩɢɳɟɜɨɞɧɨɣ ɞɨɩɩɥɟɪ-ɷɯɨɤɚɪɞɢɨɝɪɚɮɢɢ ɫɟɪ-ɞɟɱɧɵɣ ɜɵɛɪɨɫ ɧɟɞɨɨɰɟɧɢɜɚɟɬɫɹ ɜ ɫɪɚɜɧɟɧɢɢ ɫ ɞɚɧ-ɧɵɦɢ ɤɚɬɟɬɟɪɚ ɜ ɅȺ,ɧɚɩɪɚɜɥɟɧɢɟ ɢ ɜɟɥɢɱɢɧɚ ɩɨɫɥɟ-ɞɨɜɚɬɟɥɶɧɵɯ ɢɡɦɟɧɟɧɢɣ ɫɟɪɞɟɱɧɨɝɨ ɜɵɛɪɨɫɚ ɨɬɪɚɠɚ-ɸɬɫɹ ɬɨɱɧɨ [11].
ɐɇɋ
ɋɭɞɨɪɨɝɢ,ɜɨɡɧɢɤɲɢɟ ɧɚ ɩɨɡɞɧɢɯ ɫɪɨɤɚɯ ɛɟɪɟɦɟɧɧɨ-ɫɬɢ ɢɥɢ ɜ ɪɨɞɚɯ,ɞɨɥɠɧɵ ɪɚɫɫɦɚɬɪɢɜɚɬɶɫɹ ɤɚɤ ɷɤɥɚɦ-ɩɬɢɱɟɫɤɢɟ,ɟɫɥɢ ɧɟ ɞɨɤɚɡɚɧɚ ɢɧɚɹ ɢɯ ɷɬɢɨɥɨɝɢɹ. Ⱦɪɭ-ɝɢɟ ɜɨɡɦɨɠɧɵɟ ɩɪɢɱɢɧɵ ɜɤɥɸɱɚɸɬ ɷɩɢɥɟɩɫɢɸ, ɜɨɞ-ɧɭɸ ɢɧɬɨɤɫɢɤɚɰɢɸ, ɜɧɭɬɪɢɱɟɪɟɩɧɭɸ ɩɚɬɨɥɨɝɢɸ (ɨɩɭɯɨɥɶ, ɫɨɫɭɞɢɫɬɚɹ ɦɚɥɶɮɨɪɦɚɰɢɹ, ɤɪɨɜɨɢɡɥɢɹ -ɧɢɟ), ɬɨɤɫɢɱɧɨɫɬɶ ɦɟɫɬɧɵɯ ɚɧɟɫɬɟɬɢɤɨɜ ɢ ɷɦɛɨɥɢɸ ɚɦɧɢɨɬɢɱɟɫɤɨɣ ɠɢɞɤɨɫɬɶɸ (ɚɧɚɮɢɥɚɤɬɨɢɞɧɵɣ ɫɢɧ-ɞɪɨɦ ɛɟɪɟɦɟɧɧɨɫɬɢ).
ɗɤɥɚɦɩɫɢɹ ɨɫɥɨɠɧɹɟɬ ɨɤɨɥɨ 1:2000 ɫɥɭɱɚɟɜ ɦɚɬɟɪɢɧ-ɫɬɜɚ ɜ ȿɜɪɨɩɟ ɢ ɪɚɡɜɢɬɵɯ ɫɬɪɚɧɚɯ. Ɂɚ 10 ɥɟɬ ɜ ɞɜɭɯ ɚɦɟɪɢɤɚɧɫɤɢɯ ɰɟɧɬɪɚɯ ɜ 32 (60%) ɢɡ 53 ɫɥɭɱɚɟɜ ɷɤ-ɥɚɦɩɫɢɢ ɫɭɞɨɪɨɝɢ ɩɟɪɜɨɧɚɱɚɥɶɧɨ ɦɚɧɢɮɟɫɬɢɪɨɜɚɥɢ ɝɢɩɟɪɬɟɧɡɢɜɧɵɦɢ ɪɚɫɫɬɪɨɣɫɬɜɚɦɢ ɛɟɪɟɦɟɧɧɨɫɬɢ [12]. Ʉɨɝɞɚ ɠɟɧɳɢɧ ɫɩɪɚɲɢɜɚɥɢ ɨ ɩɪɨɞɪɨɦɚɥɶɧɵɯ ɫɢɦɩɬɨɦɚɯ, ɬɹɠɟɥɭɸ ɝɨɥɨɜɧɭɸ ɛɨɥɶ ɨɩɢɫɵɜɚɥɨ ɞɜɟ ɬɪɟɬɢ,ɚ ɡɪɢɬɟɥɶɧɵɟ ɪɚɫɫɬɪɨɣɫɬɜɚ ɨɞɧɚ ɬɪɟɬɶ ɩɚɰɢɟɧ-ɬɨɜ.Ɍɨɥɶɤɨ ɭ 7 ɠɟɧɳɢɧ ɛɵɥɚ ɬɹɠɟɥɚɹ ɩɪɟɷɤɥɚɦɩɫɢɹ. ɗɬɨ ɢɫɫɥɟɞɨɜɚɧɢɟ ɩɨɞɬɜɟɪɠɞɚɟɬ, ɱɬɨ ɩɪɟɷɤɥɚɦɩɫɢɹ ɧɟ ɨɛɹɡɚɬɟɥɶɧɨ ɩɪɟɞɲɟɫɬɜɭɟɬ ɷɤɥɚɦɩɫɢɢ, ɩɪɨɝɪɟɫɫɢ-ɪɭɹ ɢɡ ɥɟɝɤɨɣ ɮɨɪɦɵ ɜ ɬɹɠɟɥɭɸ.
ɉɪɢ ɪɚɡɜɢɬɢɢ ɷɤɥɚɦɩɫɢɢ ɪɟɤɨɦɟɧɞɭɟɬɫɹ ɫɥɟɞɭɸɳɚɹ ɬɚɤɬɢɤɚ:
x ɉɨɞɞɟɪɠɢɜɚɬɶ ɩɪɨɯɨɞɢɦɨɫɬɶ ɞɵɯɚɬɟɥɶɧɵɯ ɩɭɬɟɣ ɢ ɞɚɬɶ 100% ɤɢɫɥɨɪɨɞ. ɂɡɛɟɝɚɬɶ ɜɨɡɧɢɤɧɨɜɟɧɢɹ ɚɨɪɬɨɤɚɜɚɥɶɧɨɣ ɤɨɦɩɪɟɫɫɢɢ ɢ ɩɨɩɵɬɚɬɶɫɹ ɩɪɟɞɨɬ-ɜɪɚɬɢɬɶ ɝɢɩɨɤɫɢɸ ɦɚɬɟɪɢ ɢ ɩɥɨɞɚ.
x Ȼɨɥɶɲɢɧɫɬɜɨ ɩɟɪɜɨɧɚɱɚɥɶɧɵɯ ɫɭɞɨɪɨɝ ɡɚɤɚɧɱɢɜɚ-ɸɬɫɹ ɫɚɦɨɫɬɨɹɬɟɥɶɧɨ. ȿɫɥɢ ɷɬɨɝɨ ɧɟ ɩɪɨɢɫɯɨɞɢɬ, ɛɟɡ ɩɪɨɦɟɞɥɟɧɢɹ ɜɜɨɞɢɬɫɹ ɧɚɝɪɭɡɨɱɧɚɹ ɞɨɡɚ ɫɭɥɶ-ɮɚɬɚ ɦɚɝɧɢɹ (MgSɈ4) 5 ɝ (10 ɦɥ 50% ɪɚɫɬɜɨɪɚ) ɧɟ ɦɟɧɟɟ ɱɟɦ ɡɚ 5 ɦɢɧɭɬ. ȿɫɥɢ Mg ɜɧɭɬɪɢɜɟɧɧɨ ɭɠɟ ɛɵɥ ɫɞɟɥɚɧ, ɞɨɩɨɥɧɢɬɟɥɶɧɨ ɛɨɥɸɫɨɦ ɜɜɨɞɹɬ ɟɳɟ 2 ɝ ɩɪɟɩɚɪɚɬɚ,ɩɨɤɚ ɫɵɜɨɪɨɬɨɱɧɚɹ ɤɨɧɰɟɧɬɪɚ-ɰɢɹ ɢɨɧɚ ɧɟ ɛɭɞɟɬ ɧɚ ɜɟɪɯɧɟɣ ɝɪɚɧɢɰɟ
ɬɟɪɚɩɟɜɬɢ-Update In Anaesthesia ɱɟɫɤɨɝɨ ɞɢɚɩɚɡɨɧɚ (ɫɦ.ɧɢɠɟ).
x ȿɫɥɢ MgSɈ4ɧɟ ɞɨɫɬɭɩɟɧ,ɜ ɤɚɱɟɫɬɜɟ ɚɥɶɬɟɪɧɚɬɢɜ-ɧɨɝɨ ɩɪɨɬɢɜɨɫɭɞɨɪɨɠɚɥɶɬɟɪɧɚɬɢɜ-ɧɨɝɨ ɩɪɟɩɚɪɚɬɚ ɩɨɞɯɨɞɢɬ ɞɢɚɡɟɩɚɦ 10 ɦɝ ɜɧɭɬɪɢɜɟɧɧɨ ɜ ɬɟɱɟɧɢɟ 2 ɦɢɧ.
Ɏɟɧɢɬɨɢɧ ɫɱɢɬɚɟɬɫɹ ɭɫɬɚɪɟɜɲɢɦ ɩɪɟɩɚɪɚɬɨɦ ɞɥɹ ɥɟɱɟɧɢɹ ɩɪɟɷɤɥɚɦɩɫɢɢ/ɷɤɥɚɦɩɫɢɢ.
x ɉɨɫɥɟ ɩɪɟɤɪɚɳɟɧɢɹ ɫɭɞɨɪɨɝ ɧɟɨɛɯɨɞɢɦɨ ɨɛɫɥɟɞɨ-ɜɚɬɶ ɠɟɧɳɢɧɭ ɞɥɹ ɢɫɤɥɸɱɟɧɢɹ ɩɪɢɡɧɚɤɨɜ ɚɫɩɢɪɚ-ɰɢɢ ɥɟɝɤɢɯ (ɬɚɯɢɩɧɨɷ,ɯɪɢɩɵ)ɢ ɭɫɬɚɧɨɜɢɬɶ ɦɨɧɢ-ɬɨɪɢɧɝ SaO2.Ɍɚɤɠɟ ɛɟɡ ɩɪɨɦɟɞɥɟɧɢɹ ɫɥɟɞɭɟɬ ɩɪɢ-ɝɥɚɫɢɬɶ ɚɤɭɲɟɪɚ ɞɥɹ ɨɩɪɟɞɟɥɟɧɢɹ ɱɚɫɬɨɬɵ ɫɟɪɞɟɱ-ɧɵɯ ɫɨɤɪɚɳɟɧɢɣ ɩɥɨɞɚ.Ⱦɢɫɬɪɟɫɫ ɩɥɨɞɚ ɜɫɥɟɞɫɬɜɢɟ ɝɢɩɨɤɫɟɦɢɢ ɦɚɬɟɪɢ ɢɥɢ ɨɬɫɥɨɣɤɢ ɩɥɚɰɟɧɬɵ ɹɜɥɹɟɬ-ɫɹ ɩɨɤɚɡɚɧɢɟɦ ɞɥɹ ɜɵɩɨɥɧɟɧɢɹ ɷɤɫɬɪɟɧɧɨɝɨ ɤɟɫɚ-ɪɟɜɚ ɫɟɱɟɧɢɹ ɩɨɞ ɨɛɳɟɣ ɚɧɟɫɬɟɡɢɟɣ.
x ȼ ɪɟɞɤɢɯ ɫɥɭɱɚɹɯ, ɤɨɝɞɚ ɫɭɞɨɪɨɝɢ ɧɟ ɩɪɟɤɪɚɳɚ-ɸɬɫɹ ɢɥɢ ɜɨɡɧɢɤɚɸɬ ɬɪɭɞɧɨɫɬɢ ɜ ɩɨɞɞɟɪɠɚɧɢɢ ɨɤɫɢɝɟɧɚɰɢɢ ɦɚɬɟɪɢ,ɧɟɨɛɯɨɞɢɦɨ ɜɵɡɵɜɚɬɶ ɨɩɵɬ-ɧɨɝɨ ɩɨɦɨɳɧɢɤɚ ɢ ɛɵɫɬɪɨ ɩɨɞɚɬɶ ɩɚɰɢɟɧɬɤɭ ɜ ɨɩɟɪɚɰɢɨɧɧɭɸ.ɂɧɞɭɤɰɢɸ ɩɪɨɜɨɞɹɬ ɬɢɨɩɟɧɬɚɥɨɦ ɢɥɢ ɩɪɨɩɨɮɨɥɨɦ, ɢɫɩɨɥɶɡɭɸɬ ɞɚɜɥɟɧɢɟ ɧɚ ɩɟɪɫɬ-ɧɟɜɢɞɧɵɣ ɯɪɹɳ, ɬɪɚɯɟɸ ɢɧɬɭɛɢɪɭɸɬ ɩɨɫɥɟ ɧɟɪɜ-ɧɨ-ɦɵɲɟɱɧɨɣ ɛɥɨɤɚɞɵ ɫɭɤɰɢɧɢɥɯɨɥɢɧɨɦ.
x ɉɚɰɢɟɧɬɵ ɫ ɷɤɥɚɦɩɫɢɟɣ, ɩɟɪɟɧɟɫɲɢɟ ɷɤɫɬɪɟɧɧɨɟ ɤɟɫɚɪɟɜɨ ɫɟɱɟɧɢɟ ɩɨɞ ɨɛɳɟɣ ɚɧɟɫɬɟɡɢɟɣ, ɞɨɥɠɧɵ ɩɟɪɟɜɨɞɢɬɫɹ ɜ ɈɂɌ ɧɚ ɜɪɟɦɹ ɫɟɞɚɰɢɢ ɢ ɜɟɧɬɢɥɹ-ɰɢɢ ɥɟɝɤɢɯ. ȼ ɢɞɟɚɥɟ ɩɨ ɩɭɬɢ ɢɡ ɨɩɟɪɚɰɢɨɧɧɨɣ ɞɨɥɠɧɚ ɛɵɬɶ ɜɵɩɨɥɧɟɧɚ ɬɨɦɨɝɪɚɮɢɹ ɦɨɡɝɚ ɞɥɹ ɢɫɤɥɸɱɟɧɢɹ ɜɧɭɬɪɢɱɟɪɟɩɧɨɝɨ ɤɪɨɜɨɢɡɥɢɹɧɢɹ ɢ ɜɵɹɜɥɟɧɢɹ ɩɪɢɡɧɚɤɨɜ ɢɲɟɦɢɢ ɦɨɡɝɚ.
x ɉɪɢɧɰɢɩɵ ɥɟɱɟɧɢɹ ɬɚɤɢɟ ɠɟ,ɤɚɤ ɞɥɹ ɩɚɰɢɟɧɬɨɜ ɫ ɨɬɟɤɨɦ ɢ ɢɲɟɦɢɟɣ ɦɨɡɝɚ ɜɫɥɟɞɫɬɜɢɟ ɬɪɚɜɦɚɬɢɱɟ-ɫɤɨɝɨ ɩɨɜɪɟɠɞɟɧɢɹ. Ʉɨɝɞɚ ɢɫɩɨɥɶɡɭɟɬɫɹ ɧɟɪɜɧɨ-ɦɵɲɟɱɧɚɹ ɛɥɨɤɚɞɚ, ɩɪɨɞɨɥɠɚɸɳɭɸɫɹ ɫɭɞɨɪɨɠ-ɧɭɸ ɚɤɬɢɜɧɨɫɬɶ ɩɨɡɜɨɥɹɟɬ ɜɵɹɜɢɬɶ ɧɟɣɪɨɮɢɡɢɨ-ɥɨɝɢɱɟɫɤɢɣ ɦɨɧɢɬɨɪɢɧɝ (ɧɚɩɪɢɦɟɪ, ɷɥɟɤɬɪɨɷɧɰɟ-ɮɚɥɨɝɪɚɮɢɹ).
x ɉɪɢ ɬɟɪɚɩɟɜɬɢɱɟɫɤɨɣ ɤɨɧɰɟɧɬɪɚɰɢɢ Mg ɜ ɫɵɜɨ-ɪɨɬɤɟ ɤɪɨɜɢ ɞɨɡɚ ɧɟɞɟɩɨɥɹɪɢɡɭɸɳɢɯ ɦɢɨɪɟɥɚɤ-ɫɚɧɬɨɜ ɞɨɥɠɧɚ ɛɵɬɶ ɭɦɟɧɶɲɟɧɚ,ɚ ɫɬɟɩɟɧɶ ɛɥɨɤɚ ɤɨɧɬɪɨɥɢɪɨɜɚɬɶɫɹ ɫɬɢɦɭɥɹɬɨɪɨɦ ɩɟɪɢɮɟɪɢɱɟɫɤɨ-ɝɨ ɧɟɪɜɚ.
ɋɭɥɶɮɚɬ ɦɚɝɧɢɹ
MgSɈ4 ɭɦɟɧɶɲɚɟɬ ɪɢɫɤ ɜɨɡɧɢɤɧɨɜɟɧɢɹ ɷɤɥɚɦɩɫɢɢ ɩɪɢ ɬɹɠɟɥɨɣ ɩɪɟɷɤɥɚɦɩɫɢɢ ɢ ɫɧɢɠɚɟɬ ɫɭɞɨɪɨɠɧɭɸ ɚɤɬɢɜɧɨɫɬɶ ɭ ɛɨɥɶɧɵɯ.ȼ ɪɚɧɞɨɦɢɡɢɪɨɜɚɧɧɨɦ ɢɫɫɥɟ-ɞɨɜɚɧɢɢ Magpie [13] ɫɜɵɲɟ 10.000 ɠɟɧɳɢɧ ɫ ɝɢɩɟɪ -ɬɟɧɡɢɟɣ ɢ ɩɪɨɬɟɢɧɭɪɢɟɣ ɛɵɥɢ ɪɚɡɞɟɥɟɧɵ ɧɚ ɝɪɭɩɩɵ, ɩɨɥɭɱɚɸɳɢɟ ɫɭɥɶɮɚɬ ɦɚɝɧɢɹ ɢ ɩɥɚɰɟɛɨ. ɍ ɠɟɧɳɢɧ, ɤɨɬɨɪɵɦ ɧɚɡɧɚɱɚɥɢ Mg, ɷɤɥɚɦɩɫɢɹ ɜɫɬɪɟɱɚɥɚɫɶ ɜ ɞɜɚ ɪɚɡɚ ɪɟɠɟ ɜ ɫɪɚɜɧɟɧɢɢ ɫ ɩɚɰɢɟɧɬɚɦɢ,ɤɨɬɨɪɵɟ ɩɨɥɭ-ɱɚɥɢ ɩɥɚɰɟɛɨ [14].
Mgɭɦɟɧɶɲɚɟɬ ɫɢɫɬɟɦɧɵɣ ɢ ɰɟɪɟɛɪɚɥɶɧɵɣ ɜɚɡɨɫɩɚɡɦ ɡɚ ɫɱɟɬ ɚɧɬɚɝɨɧɢɡɦɚ ɤɚɥɶɰɢɸ. ɋɢɫɬɟɦɧɭɸ ɜɚɡɨɞɢɥɚ-ɬɚɰɢɸ ɫɨɩɪɨɜɨɠɞɚɟɬ ɭɜɟɥɢɱɟɧɢɟ ɞɨɫɬɚɜɤɢ ɢ ɩɨɬɪɟɛ-ɥɟɧɢɹ ɤɢɫɥɨɪɨɞɚ [4]. ɉɪɨɬɢɜɨɫɭɞɨɪɨɠɧɨɟ ɞɟɣɫɬɜɢɟ Mg ɫɨɝɥɚɫɭɟɬɫɹ ɫ ɬɟɨɪɢɟɣ, ɨɛɴɹɫɧɹɸɳɟɣ ɷɤɥɚɦɩɬɢ-ɱɟɫɤɢɟ ɩɪɢɩɚɞɤɢ ɜɨɡɧɢɤɧɨɜɟɧɢɟɦ ɰɟɪɟɛɪɚɥɶɧɨɝɨ ɜɚɡɨɫɩɚɡɦɚ. Ⱥɧɬɚɝɨɧɢɫɬ ɤɚɥɶɰɢɟɜɵɯ ɤɚɧɚɥɨɜ ɧɢɦɨ-ɞɢɩɢɧ (ɲɢɪɨɤɨ ɩɪɢɦɟɧɹɟɬɫɹ ɜ ɧɟɣɪɨɯɢɪɭɪɝɢɱɟɫɤɨɣ
ɩɪɚɤɬɢɤɟ ɞɥɹ ɭɦɟɧɶɲɟɧɢɹ ɢɲɟɦɢɢ ɦɨɡɝɚ ɩɨɫɥɟ ɫɭɛ-ɚɪɚɯɧɨɢɞɚɥɶɧɨɝɨ ɤɪɨɜɨɢɡɥɢɹɧɢɹ) ɬɚɤɠɟ ɭɫɩɟɲɧɨ ɢɫɩɨɥɶɡɭɟɬɫɹ ɜ ɥɟɱɟɧɢɢ ɷɤɥɚɦɩɫɢɢ.Ɋɚɡɪɟɲɟɧɢɟ ɢɲɟ-ɦɢɢ ɦɨɡɝɚ ɛɵɥɨ ɩɨɞɬɜɟɪɠɞɟɧɨ ɩɪɢ ɦɚɝɧɢɬɧɨ-ɪɟɡɨɧɚɧɫɧɨɣ ɬɨɦɨɝɪɚɮɢɢ.ȼ ɧɟɛɨɥɶɲɢɯ ɝɪɭɩɩɚɯ ɠɟɧ-ɳɢɧ ɫ ɷɤɥɚɦɩɫɢɟɣ ɜɧɭɬɪɢɜɟɧɧɚɹ ɢɧɮɭɡɢɹ ɧɢɦɨɞɢɩɢ-ɧɚ 1 ɦɝ/ɱ (ɭɜɟɥɢɱɢɜɚɹ ɞɨ 2 ɦɝ/ɱ ɱɟɪɟɡ 20 ɦɢɧɭɬ) ɫɨ-ɩɪɨɜɨɠɞɚɥɚɫɶ ɫɧɢɠɟɧɢɟɦ ɫɢɫɬɟɦɧɨɝɨ ɫɨɫɭɞɢɫɬɨɝɨ ɫɨɩɪɨɬɢɜɥɟɧɢɹ ɢ ȺȾ.ɇɚɡɧɚɱɟɧɢɟ ɧɢɦɨɞɢɩɢɧɚ ɜ ɬɚɛ-ɥɟɬɤɚɯ ɩɨ 30 ɦɝ ɱɟɪɟɡ 4 ɱɚɫɚ ɩɨɡɜɨɥɹɟɬ ɷɮɮɟɤɬɢɜɧɨ ɤɨɧɬɪɨɥɢɪɨɜɚɬɶ ȺȾ ɩɪɢ ɩɪɟɷɤɥɚɦɩɫɢɢ.
ɇɢɠɟ ɩɪɟɞɫɬɚɜɥɟɧ ɪɟɠɢɦ ɞɨɡɢɪɨɜɚɧɢɹ MgSɈ4, ɤɨɬɨ-ɪɵɣ ɢɫɩɨɥɶɡɭɟɬɫɹ ɜ ɭɫɥɨɜɢɹɯ ɥɚɛɨɪɚɬɨɪɧɨɝɨ ɤɨɧɬɪɨ-ɥɹ ɭɪɨɜɧɹ ɫɵɜɨɪɨɬɨɱɧɨɣ ɤɨɧɰɟɧɬɪɚɰɢɢ ɦɚɝɧɢɹ.
1. ɇɚɱɚɥɶɧɚɹ ɧɚɝɪɭɡɨɱɧɚɹ ɞɨɡɚ – 5 ɝ MgSɈ4 (10 ɦɥ 50% ɪɚɫɬɜɨɪɚ)ɜɧɭɬɪɢɜɟɧɧɵɦ ɛɨɥɸɫɧɵɦ ɜɜɟɞɟɧɢ-ɟɦ (ɧɟ ɦɟɧɟɟ 5 ɦɢɧɭɬ)ɥɢɛɨ ɜ ɜɢɞɟ ɢɧɮɭɡɢɢ, ɞɨɛɚ-ɜɢɜ 40 ɦɥ ɮɢɡɢɨɥɨɝɢɱɟɫɤɨɝɨ ɪɚɫɬɜɨɪɚ (ɨɛɳɢɣ ɨɛɴɟɦ 50 ɦɥ),ɧɟ ɦɟɧɟɟ 20 ɦɢɧɭɬ (150 ɦɥ/ɱ).
2. ɉɨɞɞɟɪɠɢɜɚɸɳɚɹ ɞɨɡɚ – ɢɧɮɭɡɢɹ MgSɈ4 2 ɝ/ɱ.
ɇɚɩɪɢɦɟɪ, ɪɚɡɜɟɫɬɢ 20 ɦɥ 50% ɪɚɫɬɜɨɪɚ ɜ 30 ɦɥ ɮɢɡɢɨɥɨɝɢɱɟɫɤɨɝɨ ɪɚɫɬɜɨɪɚ (ɨɛɳɢɣ ɨɛɴɟɦ 50 ɦɥ) ɢ ɜɜɨɞɢɬɶ ɫɨ ɫɤɨɪɨɫɬɶɸ ɢɧɮɭɡɢɢ 10 ɦɥ/ɱ. Ⱦɥɹ ɠɟɧɳɢɧ ɫ ɜɟɫɨɦ ɦɟɧɶɲɟ 50 ɤɝ ɫɤɨɪɨɫɬɶ ɢɧɮɭɡɢɢ1 ɝ/ɱ (5 ɦɥ/ɱ).
3. Ʉɨɧɬɪɨɥɶ ɤɨɧɰɟɧɬɪɚɰɢɢ Mg ɜ ɫɵɜɨɪɨɬɤɟ ɤɪɨɜɢ ɱɟɪɟɡ 60 ɦɢɧ ɩɨɫɥɟ ɧɚɝɪɭɡɨɱɧɨɣ ɞɨɡɵ,ɡɚɬɟɦ ɤɚɠ-ɞɵɟ 6 ɱɚɫɨɜ. Ɉɬɪɟɝɭɥɢɪɨɜɚɬɶ ɫɤɨɪɨɫɬɶ ɢɧɮɭɡɢɢ ɞɥɹ ɩɨɞɞɟɪɠɚɧɢɹ ɫɵɜɨɪɨɬɨɱɧɨɣ ɤɨɧɰɟɧɬɪɚɰɢɢ ɜ ɬɟɪɚɩɟɜɬɢɱɟɫɤɨɦ ɞɢɚɩɚɡɨɧɟ2-3,5 ɦɦɨɥɶ/ɥ.
4. ȿɫɥɢ ɤɨɧɰɟɧɬɪɚɰɢɹ < 2 ɦɦɨɥɶ/ɥ, ɞɨɩɨɥɧɢɬɟɥɶɧɨ ɜɜɟɫɬɢ 2 ɝ (ɭɜɟɥɢɱɢɬɶ ɫɤɨɪɨɫɬɶ ɞɨ 40 ɦɥ/ɱ ɜ ɬɟɱɟ-ɧɢɟɧɟ ɛɨɥɟɟ 15 ɦɢɧɭɬ).
5. ȿɫɥɢ ɫɵɜɨɪɨɬɨɱɧɚɹ ɤɨɧɰɟɧɬɪɚɰɢɹ 3,5-4 ɦɦɨɥɶ/ɥ, ɭɦɟɧɶɲɢɬɶ ɫɤɨɪɨɫɬɶ ɞɨ 5 ɦɥ/ɱ, ɟɫɥɢ > 4 ɦɦɨɥɶ/ɥ, ɨɫɬɚɧɨɜɢɬɶ ɢɧɮɭɡɢɸ,ɩɨɤɚ ɫɵɜɨɪɨɬɨɱɧɚɹ ɤɨɧɰɟɧ-ɬɪɚɰɢɹ Mg ɧɟ ɭɦɟɧɶɲɢɬɫɹ.
6. ɉɪɨɞɨɥɠɚɬɶ ɢɧɮɭɡɢɸ 24 ɱɚɫɚ,ɥɢɛɨ ɩɨɤɚ ɠɟɧɳɢ-ɧɚ ɢɦɟɟɬ ɫɢɦɩɬɨɦɵ ɡɚɛɨɥɟɜɚɧɢɹ ɢɥɢ ɧɟɭɫɬɨɣɱɢ-ɜɨɟ ȺȾ.
x ɉɪɢ ɬɟɪɚɩɟɜɬɢɱɟɫɤɨɣ ɫɵɜɨɪɨɬɨɱɧɨɣ ɤɨɧɰɟɧ-ɬɪɚɰɢɢ Mg ɦɨɝɭɬ ɜɨɡɧɢɤɧɭɬɶ ɢɡɦɟɧɟɧɢɹ ɧɚ ɗɄȽ (ɪɚɫɲɢɪɟɧɢɟ QRS). ɉɨɱɟɱɧɚɹ ɧɟɞɨɫɬɚɬɨɱ-ɧɨɫɬɶ ɦɨɠɟɬ ɭɦɟɧɶɲɢɬɶ ɤɥɢɪɟɧɫ Mg. Ʉ ɪɚɧ-ɧɢɦ ɩɪɢɡɧɚɤɚɦ ɬɨɤɫɢɱɧɨɫɬɢ ɨɬɧɨɫɹɬɫɹ ɬɨɲɧɨ-ɬɚ,ɪɜɨɬɚ ɢ ɱɭɜɫɬɜɨ ɩɪɢɥɢɜɚ ɤɪɨɜɢ.ɉɨɬɟɪɹ ɝɥɭ-ɛɨɤɢɯ ɫɭɯɨɠɢɥɶɧɵɯ ɪɟɮɥɟɤɫɨɜ ɢ ɫɥɚɛɨɫɬɶ ɞɵ -ɯɚɬɟɥɶɧɵɯ ɦɵɲɰ ɩɨɹɜɥɹɸɬɫɹ ɩɪɢ ɤɨɧɰɟɧɬɪɚ-ɰɢɢ Mg 5-7,5 ɦɦɨɥɶ/ɥ,ɨɫɬɚɧɨɜɤɚ ɫɟɪɞɰɚ ɨɤɨɥɨ 12,5 ɦɦɨɥɶ/ɥ.
x ȿɫɥɢ ɩɨɹɜɥɹɸɬɫɹ ɩɪɢɡɧɚɤɢ ɬɨɤɫɢɱɟɫɤɨɝɨ ɞɟɣ-ɫɬɜɢɹ MgSɈ4, ɫɥɟɞɭɟɬ ɩɪɟɤɪɚɬɢɬɶ ɢɧɮɭɡɢɸ ɢ ɩɪɢ ɧɟɨɛɯɨɞɢɦɨɫɬɢ ɩɪɨɜɨɞɢɬɶ ɩɨɞɞɟɪɠɤɭ ɞɵ-ɯɚɬɟɥɶɧɨɣ ɢ ɫɟɪɞɟɱɧɨ-ɫɨɫɭɞɢɫɬɨɣ ɫɢɫɬɟɦ. ɏɥɨ-ɪɢɞ ɢɥɢ ɝɥɸɤɨɧɚɬ ɤɚɥɶɰɢɹ (10-20 ɦɥ 10% ɪɚɫ-ɬɜɨɪɚ)ɩɪɟɩɹɬɫɬɜɭɟɬ ɷɮɮɟɤɬɚɦ ɦɚɝɧɢɹ ɧɚ ɧɟɪɜ-ɧɭɸ ɩɪɨɜɨɞɢɦɨɫɬɶ.
ɉɟɱɟɧɶ
HELLP-ɫɢɧɞɪɨɦ ɪɚɡɜɢɜɚɟɬɫɹ ɨɛɵɱɧɨ ɜ ɩɪɟɞɪɨɞɨɜɨɦ ɩɟɪɢɨɞɟ,ɨɞɧɚɤɨ (ɤɚɤ ɢ ɷɤɥɚɦɩɫɢɹ)ɦɨɠɟɬ ɜɨɡɧɢɤɧɭɬɶ
ɢ ɩɨɫɥɟ ɪɨɞɨɜ. ɉɚɰɢɟɧɬɵ ɩɪɟɞɴɹɜɥɹɸɬ ɠɚɥɨɛɵ ɧɚ ɧɟɞɨɦɨɝɚɧɢɟ, ɬɨɲɧɨɬɭ ɢ ɪɜɨɬɭ, ɛɨɥɟɡɧɟɧɧɨɫɬɶ ɢ ɧɚ-ɩɪɹɠɟɧɧɨɫɬɶ ɜ ɷɩɢɝɚɫɬɪɢɢ ɢɥɢ ɩɪɚɜɨɦ ɜɟɪɯɧɟɦ ɤɜɚɞ-ɪɚɧɬɟ ɠɢɜɨɬɚ. Ƚɢɩɟɪɬɟɧɡɢɹ ɢ ɩɪɨɬɟɢɧɭɪɢɹ ɦɨɝɭɬ ɛɵɬɶ ɦɢɧɢɦɚɥɶɧɵɦɢ ɢɥɢ ɨɬɫɭɬɫɬɜɨɜɚɬɶ.
x Ƚɟɦɨɥɢɡ ɢ ɫɧɢɠɟɧɢɟ ɤɨɥɢɱɟɫɬɜɚ ɬɪɨɦɛɨɰɢɬɨɜ <
100×109/ɥ ɦɨɝɭɬ ɛɵɬɶ ɫɜɹɡɚɧɵ ɫ Ⱦȼɋ-ɫɢɧɞɪɨɦɨɦ.
x ɉɨɜɵɲɟɧɢɟ ɤɨɧɰɟɧɬɪɚɰɢɢ ɛɢɥɢɪɭɛɢɧɚ, ɚɥɚɧɢɧɚ-ɦɢɧɨɬɪɚɧɫɮɟɪɚɡɵ ɢ ɥɚɤɬɚɬɞɟɝɢɞɪɨɝɟɧɚɡɵ ɹɜɥɹɟɬ-ɫɹ ɩɨɤɚɡɚɬɟɥɟɦ ɩɨɜɪɟɠɞɟɧɢɹ ɤɥɟɬɨɤ ɩɟɱɟɧɢ.
x Ʉ ɞɪɭɝɢɦ ɚɫɫɨɰɢɢɪɨɜɚɧɧɵɦ ɡɚɛɨɥɟɜɚɧɢɹɦ ɦɚɬɟɪɢ ɨɬɧɨɫɹɬɫɹ ɨɬɫɥɨɣɤɚ ɩɥɚɰɟɧɬɵ, ɩɨɞɤɚɩɫɭɥɶɧɚɹ ɝɟ-ɦɚɬɨɦɚ ɩɟɱɟɧɢ, ɨɫɬɪɚɹ ɩɨɱɟɱɧɚɹ ɧɟɞɨɫɬɚɬɨɱɧɨɫɬɶ ɢ ɨɬɟɤ ɥɟɝɤɢɯ.
Ⱦɢɮɮɟɪɟɧɰɢɚɥɶɧɚɹ ɞɢɚɝɧɨɫɬɢɤɚ ɩɪɨɜɨɞɢɬɫɹ ɫ ɬɪɨɦ-ɛɨɬɢɱɟɫɤɨɣ ɬɪɨɦɛɨɰɢɬɨɩɟɧɢɱɟɫɤɨɣ ɩɭɪɩɭɪɨɣ, ɦɢɤ-ɪɨɚɧɝɢɨɩɚɬɢɹɦɢ, ɝɟɦɨɥɢɬɢɤɨ-ɭɪɟɦɢɱɟɫɤɢɦ ɫɢɧɞɪɨ -ɦɨɦ ɢ ɨɫɬɪɵɦ ɠɢɪɨɜɵɦ ɝɟɩɚɬɨɡɨɦ ɛɟɪɟɦɟɧɧɵɯ. Ɇɟ-ɬɨɞɨɦ ɥɟɱɟɧɢɹ ɹɜɥɹɟɬɫɹ ɪɨɞɨɪɚɡɪɟɲɟɧɢɟ, ɩɪɢ ɧɟɨɛ-ɯɨɞɢɦɨɫɬɢ ɩɪɨɜɨɞɢɬɫɹ ɫɩɟɰɢɮɢɱɟɫɤɚɹ ɩɨɞɞɟɪɠɤɚ ɫɢɫɬɟɦ ɨɪɝɚɧɢɡɦɚ.ȿɫɬɶ ɞɨɤɚɡɚɬɟɥɶɫɬɜɚ, ɫɜɢɞɟɬɟɥɶɫɬ-ɜɭɸɳɢɟ ɨɛ ɭɫɤɨɪɟɧɢɢ ɜɨɫɫɬɚɧɨɜɥɟɧɢɹ ɢ ɭɦɟɧɶɲɟɧɢɢ ɬɹɠɟɫɬɢ ɡɚɛɨɥɟɜɚɧɢɹ ɩɪɢ ɜɧɭɬɪɢɜɟɧɧɨɦ ɜɜɟɞɟɧɢɢ ɜ ɩɨɫɥɟɪɨɞɨɜɨɦ ɩɟɪɢɨɞɟ ɞɟɤɫɚɦɟɬɚɡɨɧɚ (ɩɨ 10 ɦɝ ɱɟɪɟɡ 12ɱɚɫɨɜ).
Ɍɨɝɞɚ ɤɚɤ ɨɬɤɥɨɧɟɧɢɟ ɩɟɱɟɧɨɱɧɵɯ ɮɟɪɦɟɧɬɨɜ ɨɬ ɧɨɪ-ɦɵ ɨɛɵɱɧɨ ɛɨɥɟɟ ɜɵɪɚɠɟɧɨ ɩɪɢ HELLP-ɫɢɧɞɪɨɦɟ, ɩɪɢ ɨɫɬɪɨɦ ɠɢɪɨɜɨɦ ɝɟɩɚɬɨɡɟ ɛɟɪɟɦɟɧɧɵɯ ɱɚɳɟ ɜɨɡ-ɧɢɤɚɟɬ ɝɢɩɨɝɥɢɤɟɦɢɹ, ɝɢɩɟɪɚɦɦɨɧɢɟɦɢɹ ɢ ɤɨɚɝɭɥɨ-ɩɚɬɢɹ. Ʉɪɨɦɟ ɤɨɚɝɭɥɨɩɚɬɢɢ ɜɨɡɪɚɫɬɚɟɬ ɜɧɭɬɪɢɱɟɪɟɩ -ɧɨɟ ɞɚɜɥɟɧɢɟ (ɩɪɨɹɜɥɹɟɬɫɹ ɫɨɧɥɢɜɨɫɬɶɸ),ɱɬɨ ɞɟɥɚɟɬ ɨɛɳɭɸ ɚɧɟɫɬɟɡɢɸ ɩɪɟɞɩɨɱɬɢɬɟɥɶɧɟɣ ɪɟɝɢɨɧɚɪɧɨɝɨ ɛɥɨɤɚ ɩɪɢ ɤɟɫɚɪɟɜɨɦ ɫɟɱɟɧɢɢ. ɇɟɞɚɜɧɨ ɨɩɭɛɥɢɤɨɜɚ-ɧɨ ɫɨɨɛɳɟɧɢɟ ɨ ɬɨɦ,ɱɬɨ ɫɵɜɨɪɨɬɨɱɧɚɹ ɤɨɧɰɟɧɬɪɚɰɢɹ Mg ɧɚ ɜɟɪɯɧɟɣ ɝɪɚɧɢɰɟ ɬɟɪɚɩɟɜɬɢɱɟɫɤɨɝɨ ɞɢɚɩɚɡɨɧɚ ɛɵɥɚ ɫɜɹɡɚɧɚ ɫ ɞɟɩɪɟɫɫɢɟɣ ɞɵɯɚɧɢɹ ɢ ɧɟɨɛɯɨɞɢɦɨ-ɫɬɶɸ ɦɟɯɚɧɢɱɟɫɤɨɣ ɜɟɧɬɢɥɹɰɢɢ ɥɟɝɤɢɯ.Ȼɵɥɨ ɫɞɟɥɚ-ɧɨ ɡɚɤɥɸɱɟɧɢɟ,ɱɬɨ ɤɨɦɛɢɧɚɰɢɹ ɧɚɪɭɲɟɧɢɣ ɮɭɧɤɰɢɢ ɩɟɱɟɧɢ ɢ ɩɨɱɟɤ ɞɟɥɚɟɬ ɩɚɰɢɟɧɬɚ ɛɨɥɟɟ ɱɭɜɫɬɜɢɬɟɥɶ-ɧɵɦ ɤ ɬɨɤɫɢɱɟɫɤɢɦ ɷɮɮɟɤɬɚɦ Mg [2].
ȺɇȺɅɖȽȿɁɂə ɂ ȺɇȿɋɌȿɁɂə
ɍ ɠɟɧɳɢɧ ɫ ɩɪɟɷɤɥɚɦɩɫɢɟɣ ɪɢɫɤ ɪɚɡɜɢɬɢɹ ɞɢɫɬɪɟɫɫɚ ɩɥɨɞɚ ɢ ɨɬɫɥɨɣɤɢ ɩɥɚɰɟɧɬɵ ɜ ɪɨɞɚɯ ɭɜɟɥɢɱɢɜɚɟɬɫɹ,ɜ ɫɜɹɡɢ ɫ ɱɟɦ ɪɟɤɨɦɟɧɞɭɟɬɫɹ ɨɛɟɫɩɟɱɢɬɶ ɪɚɧɧɸɸ ɢ ɤɚɱɟɫɬɜɟɧɧɭɸ ɪɟɝɢɨɧɚɪɧɭɸ ɚɧɚɥɶɝɟɡɢɸ. Ʉɨɪɪɟɤɰɢɹ ȺȾ ɞɨɥɠɧɚ ɛɵɬɶ ɩɪɟɞɩɪɢɧɹɬɚ ɟɳɟ ɞɨ ɧɚɱɚɥɚ ɩɪɨɰɟ-ɞɭɪɵ (ɧɚɩɪɢɦɟɪ, ɫ ɩɨɦɨɳɶɸ ɝɢɞɪɚɥɚɡɢɧɚ). ɉɨɫɥɟ-ɞɭɸɳɚɹ ɫɢɦɩɚɬɢɱɟɫɤɚɹ ɛɥɨɤɚɞɚ ɢ ɭɦɟɧɶɲɟɧɢɟ ɛɨɥɢ ɩɪɟɞɨɬɜɪɚɳɚɸɬ ɩɨɜɵɲɟɧɢɟ ɚɪɬɟɪɢɚɥɶɧɨɝɨ ɞɚɜɥɟɧɢɹ ɜɨ ɜɪɟɦɹ ɫɯɜɚɬɨɤ. Ɋɚɧɧɹɹ ɤɨɨɪɞɢɧɚɰɢɹ ɞɟɣɫɬɜɢɣ ɦɟ-ɠɞɭ ɚɤɭɲɟɪɚɦɢ ɢ ɚɧɟɫɬɟɡɢɨɥɨɝɚɦɢ ɩɨɡɜɨɥɹɟɬ ɜɨɜɪɟ-ɦɹ ɩɟɪɟɣɬɢ ɧɚ ɯɢɪɭɪɝɢɱɟɫɤɢɣ ɭɪɨɜɟɧɶ ɚɧɟɫɬɟɡɢɢ ɩɪɢ ɧɟɨɛɯɨɞɢɦɨɫɬɢ ɜɵɩɨɥɧɟɧɢɹ ɤɟɫɚɪɟɜɚ ɫɟɱɟɧɢɹ. ɂɫ -ɩɨɥɶɡɨɜɚɧɢɟ ɷɩɢɞɭɪɚɥɶɧɨɝɨ ɤɚɬɟɬɟɪɚ ɞɚɟɬ ɜɨɡɦɨɠ-ɧɨɫɬɶ ɜ ɫɥɭɱɚɟ ɜɵɫɨɤɨɣ ɡɚɜɢɫɢɦɨɫɬɢ ɨɬ ɚɧɚɥɶɝɟɬɢɤɨɜ ɨɛɟɫɩɟɱɢɬɶ ɨɩɬɢɦɚɥɶɧɨɟ ɩɨɫɥɟɨɩɟɪɚɰɢɨɧɧɨɟ ɨɛɟɡɛɨ-ɥɢɜɚɧɢɟ ɩɪɢ ɩɨɦɨɳɢ ɩɨɫɬɨɹɧɧɨɣ ɢɥɢ ɤɨɧɬɪɨɥɢɪɭɟ-ɦɨɣ ɩɚɰɢɟɧɬɨɦ ɢɧɮɭɡɢɢ ɫɦɟɫɢ ɮɟɧɬɚɧɢɥ/ɛɭɩɢɜɚɤɚ-ɢɧ.
Ɉɫɨɛɟɧɧɨɫɬɢ ɪɟɝɢɨɧɚɪɧɨɣ ɚɧɟɫɬɟɡɢɢ ɩɪɢ ɤɟɫɚɪɟɜɨɦ ɫɟɱɟɧɢɢ ɭ ɠɟɧɳɢɧ ɫ ɩɪɟɷɤɥɚɦɩɫɢɟɣ ɜɤɥɸɱɚɸɬ:
x Ɋɢɫɤ ɜɨɡɧɢɤɧɨɜɟɧɢɹ ɝɟɦɚɬɨɦɵ ɩɨɡɜɨɧɨɱɧɨɝɨ ɤɚ-ɧɚɥɚ.ɉɨ ɞɚɧɧɵɦ ɬɪɨɦɛɨɷɥɚɫɬɨɝɪɚɮɢɢ ɭ ɠɟɧɳɢɧ ɫ ɩɪɟɷɤɥɚɦɩɫɢɟɣ ɤɨɥɢɱɟɫɬɜɨ ɬɪɨɦɛɨɰɢɬɨɜ >100×
109/ɥ ɫɨɨɬɜɟɬɫɬɜɭɟɬ ɝɢɩɟɪɤɨɚɝɭɥɹɰɢɢ. Ʉɨɥɢɱɟɫɬɜɨ ɬɪɨɦɛɨɰɢɬɨɜ ɧɢɠɟ 100×109/ɥ ɫɜɢɞɟɬɟɥɶɫɬɜɭɟɬ ɨ ɪɢɫɤɟ ɝɢɩɨɤɨɚɝɭɥɹɰɢɢ, ɩɪɢ ɷɬɨɦ ɩɨɤɚɡɚɧɨ ɩɪɨɜɟ-ɞɟɧɢɟ ɤɨɧɬɪɨɥɹ ɜɪɟɦɟɧɢ ɫɜɟɪɬɵɜɚɧɢɹ (ȺɑɌȼ/ Ⱥȼɋ) [15]. Ɍɪɨɦɛɨɷɥɚɫɬɨɝɪɚɮɢɱɟɫɤɢɟ ɩɨɤɚɡɚɬɟɥɢ ɫɜɟɪɬɵɜɚɧɢɹ ɤɪɨɜɢ ɢɡɦɟɧɹɸɬɫɹ ɧɟɡɧɚɱɢɬɟɥɶɧɨ ɩɪɢ ɞɨɫɬɢɠɟɧɢɢ ɬɟɪɚɩɟɜɬɢɱɟɫɤɨɣ ɫɵɜɨɪɨɬɨɱɧɨɣ ɤɨɧɰɟɧɬɪɚɰɢɢ ɦɚɝɧɢɹ ɭ ɩɚɰɢɟɧɬɨɜ ɫ ɩɪɟɷɤɥɚɦɩɫɢ-ɟɣ. Ʌɨɝɢɱɧɨ, ɱɬɨ ɪɢɫɤ ɜɨɡɧɢɤɧɨɜɟɧɢɹ ɝɟɦɚɬɨɦɵ ɩɨɡɜɨɧɨɱɧɨɝɨ ɤɚɧɚɥɚ ɞɨɥɠɟɧ ɛɵɬɶ ɦɟɧɶɲɟ ɩɪɢ ɨɞɢɧɨɱɧɨɦ ɩɪɨɤɨɥɟ ɫɩɢɧɚɥɶɧɨɣ ɢɝɥɨɣ 26G c
«ɤɚɪɚɧɞɚɲɧɵɦ» ɧɚɤɨɧɟɱɧɢɤɨɦ ɜ ɫɪɚɜɧɟɧɢɢ ɫ ɢɞɟɧɬɢɮɢɤɚɰɢɟɣ ɷɩɢɞɭɪɚɥɶɧɨɝɨ ɩɪɨɫɬɪɚɧɫɬɜɚ ɢɝɥɨɣ Tuohy 16G ɢ ɜɜɟɞɟɧɢɟɦ ɤɚɬɟɬɟɪɚ.
x Ƚɟɦɨɞɢɧɚɦɢɱɟɫɤɚɹ ɧɟɫɬɚɛɢɥɶɧɨɫɬɶ. ɉɟɪɜɨɧɚɱɚɥɶ-ɧɚɹ ɜɚɡɨɞɢɥɚɬɚɰɢɹ ɫ ɩɨɦɨɳɶɸ ɷɮɮɟɤɬɢɜɧɨɝɨ ɚɧ-ɬɢɝɢɩɟɪɬɟɧɡɢɜɧɨɝɨ ɥɟɱɟɧɢɹ (ɧɚɩɪɢɦɟɪ,ɦɟɬɢɥɞɨɩɚ per osɢɥɢ ɝɢɞɪɚɥɚɡɢɧ ɜɧɭɬɪɢɜɟɧɧɨ)ɞɚɟɬ ɜɨɡɦɨɠ-ɧɨɫɬɶ ɩɪɟɞɨɬɜɪɚɬɢɬɶ ɜɵɪɚɠɟɧɧɨɟ ɫɧɢɠɟɧɢɟ ɚɪɬɟ-ɪɢɚɥɶɧɨɝɨ ɞɚɜɥɟɧɢɹ ɩɪɢ ɷɩɢɞɭɪɚɥɶɧɨɣ ɢɥɢ ɫɩɢ-ɧɚɥɶɧɨɣ ɚɧɟɫɬɟɡɢɢ. Ɋɚɡɭɦɧɨɟ ɞɨɡɢɪɨɜɚɧɢɟ ɷɮɟɞ-ɪɢɧɚ ɢɥɢ ɦɟɡɚɬɨɧɚ ɩɨɡɜɨɥɹɟɬ ɢɡɛɟɠɚɬɶ ɡɧɚɱɢɦɵɯ ɨɬɤɥɨɧɟɧɢɣ ɚɪɬɟɪɢɚɥɶɧɨɝɨ ɞɚɜɥɟɧɢɹ.
ȼ ɧɟɞɚɜɧɟɦ ɢɫɫɥɟɞɨɜɚɧɢɢ ɛɵɥɨ ɩɪɨɞɟɦɨɧɫɬɪɢɪɨɜɚ-ɧɨ, ɱɬɨ ɭ ɠɟɧɳɢɧ ɫ ɷɤɥɚɦɩɬɢɱɟɫɤɢɦɢ ɩɪɢɩɚɞɤɚɦɢ, ɧɨ ɜ ɹɫɧɨɦ ɫɨɡɧɚɧɢɢ, ɫɨɬɪɭɞɧɢɱɚɸɳɢɯ ɫ ɩɟɪɫɨɧɚ -ɥɨɦ, ɩɨɥɭɱɚɸɳɢɯ ɦɚɝɧɢɣ ɢ ɢɦɟɸɳɢɯ ɤɨɥɢɱɟɫɬɜɨ ɬɪɨɦɛɨɰɢɬɨɜ > 100×109/ɥ,ɦɨɠɧɨ ɛɟɡ ɪɢɫɤɚ ɢɫɩɨɥɶɡɨ-ɜɚɬɶ ɪɟɝɢɨɧɚɥɶɧɭɸ ɚɧɟɫɬɟɡɢɸ [16].
Ɉɫɨɛɟɧɧɨɫɬɢ ɨɛɳɟɣ ɚɧɟɫɬɟɡɢɢ
x ɉɪɟɫɫɨɪɧɵɣ ɨɬɜɟɬ ɧɚ ɥɚɪɢɧɝɨɫɤɨɩɢɸ ɢ ɢɧɬɭɛɚ-ɰɢɸ/ɷɤɫɬɭɛɚɰɢɸ.Ɇɨɡɝɨɜɨɣ ɤɪɨɜɨɬɨɤ ɧɟɨɛɯɨɞɢɦɨ ɡɚɳɢɬɢɬɶ ɨɬ ɝɢɩɟɪɬɟɧɡɢɜɧɵɯ ɪɟɚɤɰɢɣ ɧɚ ɢɧɬɭɛɚ-ɰɢɸ ɢ ɷɤɫɬɭɛɚɢɧɬɭɛɚ-ɰɢɸ – ɤɚɤ ɜ ɧɟɣɪɨɚɧɟɫɬɟɡɢɨɥɨɝɢɢ ɩɪɢ ɤɥɢɩɢɪɨɜɚɧɢɢ ɚɧɟɜɪɢɡɦ ɝɨɥɨɜɧɨɝɨ ɦɨɡɝɚ.
ɉɪɢ ɢɫɫɥɟɞɨɜɚɧɢɢ ɠɟɧɳɢɧ ɫ ɩɪɟɷɤɥɚɦɩɫɢɟɣ ɛɵɥɨ ɜɵɹɜɥɟɧɨ, ɱɬɨ ɧɟɫɦɨɬɪɹ ɧɚ ɩɪɟɞɜɚɪɢɬɟɥɶɧɨɟ ɜɜɟ -ɞɟɧɢɟ ɦɚɝɧɢɹ ɢ ɥɚɛɟɬɚɥɨɥɚ,ȺȾ ɢ ɫɤɨɪɨɫɬɶ ɤɪɨɜɨ-ɬɨɤɚ ɜ ɫɪɟɞɧɟɣ ɦɨɡɝɨɜɨɣ ɚɪɬɟɪɢɢ (ɢɡɦɟɪɹɟɬɫɹ ɬɪɚɧɫɤɪɚɧɢɚɥɶɧɵɦ ɞɨɩɩɥɟɪɨɜɫɤɢɦ ɫɤɚɧɢɪɨɜɚɧɢ-ɟɦ ɢ ɩɪɢɧɢɦɚɟɬɫɹ ɡɚ ɩɨɤɚɡɚɬɟɥɶ ɦɨɡɝɨɜɨɝɨ ɤɪɨɜɨ-ɬɨɤɚ) ɡɧɚɱɢɬɟɥɶɧɨ ɜɨɡɪɚɫɬɚɸɬ ɩɨɫɥɟ ɢɧɬɭɛɚɰɢɢ ɬɪɚɯɟɢ [17].
x Ɉɬɟɤ ɝɨɪɬɚɧɢ. ɋɭɳɟɫɬɜɭɟɬ ɧɟɫɨɦɧɟɧɧɵɣ ɪɢɫɤ ɟɝɨ ɜɨɡɧɢɤɧɨɜɟɧɢɹ,ɨɫɨɛɟɧɧɨ ɭ ɩɚɰɢɟɧɬɨɜ ɫ ɬɪɚɜ-ɦɚɬɢɱɧɨɣ ɢɧɬɭɛɚɰɢɟɣ ɬɪɚɯɟɢ ɢɥɢ ɫɥɢɡɢɫɬɨɣ ɝɨɪ -ɬɚɧɢ, ɜɵɝɥɹɞɹɳɟɣ ɩɪɢ ɥɚɪɢɧɝɨɫɤɨɩɢɢ ɧɚɛɭɯɲɟɣ. ɉɟɪɫɨɧɚɥ, ɨɬɜɟɱɚɸɳɢɣ ɡɚ ɩɨɫɥɟɨɩɟɪɚɰɢɨɧɧɵɣ ɭɯɨɞ, ɞɨɥɠɟɧ ɛɵɬɶ ɝɨɬɨɜ ɤ ɭɝɪɨɡɟ ɪɚɡɜɢɬɢɹ ɫɬɪɢ-ɞɨɪɚ.
x ȼɡɚɢɦɨɞɟɣɫɬɜɢɟ ɦɚɝɧɢɹ ɫ ɦɢɨɪɟɥɚɤɫɚɧɬɚɦɢ. ɏɨ-ɬɹ ɧɚɱɚɥɨ ɢ ɞɥɢɬɟɥɶɧɨɫɬɶ ɞɟɣɫɬɜɢɹ ɫɭɤɫɚɦɟɬɨɧɢɹ ɧɟ ɢɡɦɟɧɹɸɬɫɹ ɩɪɢ ɬɟɪɚɩɟɜɬɢɱɟɫɤɨɣ ɤɨɧɰɟɧɬɪɚ-ɰɢɢ ɦɚɝɧɢɹ ɭ ɠɟɧɳɢɧ ɫ ɩɪɟɷɤɥɚɦɩɫɢɟɣ, Mg ɜɥɢɹ-ɟɬ ɧɚ ɞɟɣɫɬɜɢɟ ɜɫɟɯ ɧɟɞɟɩɨɥɹɪɢɡɭɸɳɢɯ
ɩɪɟɩɚɪɚ-Update In Anaesthesia ɬɨɜ.ɉɪɟɞɜɚɪɢɬɟɥɶɧɨɟ ɛɨɥɸɫɧɨɟ ɜɜɟɞɟɧɢɟ ɦɚɝɧɢɹ
ɭɦɟɧɶɲɚɟɬ ɜ ɞɜɚ ɪɚɡɚ ɜɪɟɦɹ ɧɚɱɚɥɚ ɞɟɣɫɬɜɢɹ ɜɟɤɭ-ɪɨɧɢɹ 0,1 ɦɝ/ɤɝ.ɉɨɫɥɟ ɜɨɫɫɬɚɧɨɜɥɟɧɢɹ ɦɵɲɟɱɧɨ-ɝɨ ɬɨɧɭɫɚ ɨɬ ɧɟɪɜɧɨ-ɦɵɲɟɱɧɨɦɵɲɟɱɧɨ-ɝɨ ɛɥɨɤɚ ɜɟɤɭɪɨɧɢ-ɟɦ (ɞɨ ɨɬɧɨɲɟɧɢɹ 0,7 ɜ TOF-ɪɟɠɢɦɟ) ɛɨɥɸɫɧɨɟ ɜɜɟɞɟɧɢɟ Mg ɦɨɠɟɬ ɜɵɡɜɚɬɶ ɡɧɚɱɢɦɭɸ ɪɟɤɭɪɚɪɢ-ɡɚɰɢɸ.ȼɪɟɦɹ ɧɚɱɚɥɚ ɞɟɣɫɬɜɢɹ ɪɨɤɭɪɨɧɢɹ 0,6 ɦɝ/ɤɝ ɧɟ ɭɤɨɪɚɱɢɜɚɟɬɫɹ ɩɪɢ ɩɪɟɞɜɚɪɢɬɟɥɶɧɨɦ ɜɜɟɞɟɧɢɢ ɦɚɝɧɢɹ,ɨɞɧɚɤɨ ɜ ɫɨɱɟɬɚɧɢɢ ɫ ɢɡɨɮɥɸɪɚɧɨɜɨɣ ɚɧɟ-ɫɬɟɡɢɟɣ ɧɚ 50% ɭɜɟɥɢɱɢɜɚɸɬɫɹ ɫɪɟɞɧɢɟ ɫɪɨɤɢ ɜɨɫ-ɫɬɚɧɨɜɥɟɧɢɹ Ɍ1ɞɨ 25%. ȿɫɥɢ ɞɥɹ ɥɟɱɟɧɢɹ ɠɟɧɳɢɧ ɫ ɩɪɟɷɤɥɚɦɩɫɢɟɣ ɢɫɩɨɥɶɡɭɟɬɫɹ ɦɚɝɧɢɣ, ɫɪɟɞɧɹɹ ɩɪɨɞɨɥɠɢɬɟɥɶɧɨɫɬɶ ɞɟɣɫɬɜɢɹ ɦɢɜɚɤɭɪɢɹ 0,15 ɦɝ/
ɤɝ,ɜɜɟɞɟɧɧɨɝɨ ɩɨɫɥɟ ɨɤɨɧɱɚɧɢɹ ɞɟɣɫɬɜɢɹ ɫɭɤɫɚɦɟ-ɬɨɧɢɹ,ɫɨɫɬɚɜɥɹɟɬ 35 ɦɢɧ.
ɋɨɯɪɚɧɹɸɳɚɹɫɹ ɤɨɚɝɭɥɨɩɚɬɢɹ ɢɥɢ ɩɪɢɡɧɚɤɢ ɧɚɞɜɢ-ɝɚɸɳɟɣɫɹ ɷɤɥɚɦɩɫɢɢ ɹɜɥɹɸɬɫɹ ɩɨɤɚɡɚɧɢɟɦ ɤ ɨɛɳɟɣ ɚɧɟɫɬɟɡɢɢ.ɉɪɟɞɜɚɪɢɬɟɥɶɧɚɹ ɤɨɨɪɞɢɧɚɰɢɹ ɞɟɣɫɬɜɢɣ ɫ ɧɟɨɧɚɬɨɥɨɝɨɦ ɢɦɟɟɬ ɫɭɳɟɫɬɜɟɧɧɨɟ ɡɧɚɱɟɧɢɟ ɞɥɹ ɩɨɞ-ɝɨɬɨɜɤɢ ɤ ɨɤɚɡɚɧɢɸ ɩɨɦɨɳɢ ɩɪɢ ɨɩɢɨɢɞɧɨɣ ɞɟɩɪɟɫ-ɫɢɢ ɞɵɯɚɧɢɹ (ɨɛɟɫɩɟɱɟɧɢɟ ɜɟɧɬɢɥɹɰɢɨɧɧɨɣ ɩɨɞɞɟɪɠ-ɤɨɣ).
x ɉɪɢ ɨɛɳɟɣ ɚɧɟɫɬɟɡɢɢ ɪɚɫɲɢɪɹɸɬɫɹ ɩɨɤɚɡɚɧɢɹ ɞɥɹ ɢɧɜɚɡɢɜɧɨɝɨ ɦɨɧɢɬɨɪɢɧɝɚ ɚɪɬɟɪɢɚɥɶɧɨɝɨ ɞɚɜɥɟɧɢɹ.
x Ⱦɥɹ ɫɦɹɝɱɟɧɢɹ ɩɪɟɫɫɨɪɧɨɝɨ ɨɬɜɟɬɚ ɧɚ ɢɧɬɭɛɚɰɢɸ ɦɨɠɧɨ ɢɫɩɨɥɶɡɨɜɚɬɶ ɚɥɶɮɟɧɬɚɧɢɥ 10 ɦɤɝ/ɤɝ ɢɥɢ ɪɟɦɢɮɟɧɬɚɧɢɥ 2 ɦɤɝ/ɤɝ ɞɨ ɧɚɱɚɥɚ ɛɵɫɬɪɨɣ ɩɨɫɥɟ-ɞɨɜɚɬɟɥɶɧɨɣ ɢɧɞɭɤɰɢɢ ɞɨɫɬɚɬɨɱɧɨ ɛɨɥɶɲɨɣ ɞɨɡɨɣ ɬɢɨɩɟɧɬɚɥɚ.
x ɇɟ ɨɝɪɚɧɢɱɢɜɚɬɶ ɤɨɧɰɟɧɬɪɚɰɢɸ ɢɧɝɚɥɹɰɢɨɧɧɵɯ ɚɧɟɫɬɟɬɢɤɨɜ ɢɡ-ɡɚ ɨɩɚɫɟɧɢɹ (ɧɟɨɛɨɫɧɨɜɚɧɧɨɝɨ) ɞɟɩɪɟɫɫɢɢ ɧɨɜɨɪɨɠɞɟɧɧɨɝɨ.
x ɉɟɪɟɞ ɷɤɫɬɭɛɚɰɢɟɣ ɨɰɟɧɢɬɶ ɞɨɫɬɚɬɨɱɧɨɫɬɶ ɩɪɨ-ɜɨɞɢɦɨɣ ɚɧɬɢɝɢɩɟɪɬɟɧɡɢɜɧɨɣ ɬɟɪɚɩɢɢ ɞɥɹ ɩɪɟ-ɞɨɬɜɪɚɳɟɧɢɹ ɩɪɟɫɫɨɪɧɨɣ ɪɟɚɤɰɢɢ (ɧɚɩɪɢɦɟɪ, ɢɫɩɨɥɶɡɨɜɚɬɶ ɥɚɛɟɬɚɥɨɥ 10-20 ɦɝ).
x Ⱦɥɹ ɨɩɪɟɞɟɥɟɧɢɹ ɫɬɟɩɟɧɢ ɧɟɪɜɧɨ-ɦɵɲɟɱɧɨɝɨ ɛɥɨɤɚ ɧɟɨɛɯɨɞɢɦɨ ɢɫɩɨɥɶɡɨɜɚɬɶ ɫɬɢɦɭɥɹɬɨɪ ɩɟ-ɪɢɮɟɪɢɱɟɫɤɨɝɨ ɧɟɪɜɚ.
ɇɟɫɬɟɪɨɢɞɧɵɟ ɩɪɨɬɢɜɨɜɨɫɩɚɥɢɬɟɥɶɧɵɟ ɩɪɟɩɚɪɚɬɵ (ɇɉȼɉ)ɚɛɫɨɥɸɬɧɨ ɩɪɨɬɢɜɨɩɨɤɚɡɚɧɵ,ɟɫɥɢ ɩɪɟɷɤɥɚɦ-ɩɫɢɹ ɨɫɥɨɠɧɹɟɬɫɹ ɤɪɨɜɨɬɟɱɟɧɢɟɦ ɢɥɢ ɟɫɬɶ ɨɩɚɫɧɨɫɬɶ ɧɟɚɞɟɤɜɚɬɧɨɝɨ ɝɟɦɨɫɬɚɡɚ (ɧɚɩɪɢɦɟɪ,ɚɬɨɧɢɹ ɦɚɬɤɢ).ȼ ɬɨ ɠɟ ɜɪɟɦɹ ɭ ɠɟɧɳɢɧ ɫ ɧɟɡɧɚɱɢɬɟɥɶɧɵɦ ɧɚɪɭɲɟɧɢɟɦ ɮɭɧɤɰɢɢ ɩɨɱɟɤ (ɫɨɯɪɚɧɟɧ ɞɢɭɪɟɡ ɢ ɧɟɬ ɫɵɜɨɪɨɬɨɱɧɵɯ ɦɚɪɤɟɪɨɜ ɩɨɱɟɱɧɨɣ ɧɟɞɨɫɬɚɬɨɱɧɨɫɬɢ)ɧɟ ɫɬɨɢɬ ɨɬɤɚɡɵ-ɜɚɬɶɫɹ ɨɬ ɩɨɥɨɠɢɬɟɥɶɧɵɯ ɤɚɱɟɫɬɜ ɇɉȼɉ.Ɉɞɧɚɤɨ ɩɨ-ɜɬɨɪɧɵɟ ɞɨɡɵ ɩɪɟɩɚɪɚɬɚ ɧɟ ɞɨɥɠɧɵ ɜɜɨɞɢɬɶɫɹ ɛɟɡ ɤɨɧɬɪɨɥɹ ɫɨɯɪɚɧɧɨɫɬɢ ɭɞɨɜɥɟɬɜɨɪɢɬɟɥɶɧɨɝɨ ɞɢɭɪɟɡɚ.
Ɇɚɬɟɪɢɧɫɤɚɹ ɥɟɬɚɥɶɧɨɫɬɶ
ȼ Ⱦɨɤɥɚɞɚɯ ɨ ɡɚɤɪɵɬɵɯ ɪɚɫɫɥɟɞɨɜɚɧɢɹɯ ɫɥɭɱɚɟɜ ɦɚ-ɬɟɪɢɧɫɤɨɣ ɫɦɟɪɬɧɨɫɬɢ ɜ ȼɟɥɢɤɨɛɪɢɬɚɧɢɢ ɪɟɝɭɥɹɪɧɨ ɩɨɜɬɨɪɹɟɬɫɹ ɡɚɤɥɸɱɟɧɢɟ ɨ ɧɟɨɛɯɨɞɢɦɨɫɬɢ ɫɨɡɞɚɧɢɹ ɩɪɨɬɨɤɨɥɨɜ ɜɟɞɟɧɢɹ ɪɨɞɨɜ ɢ ɪɚɧɧɟɝɨ ɩɪɢɝɥɚɲɟɧɢɹ ɤɨɧɫɭɥɶɬɚɧɬɨɜ, ɨɫɨɛɟɧɧɨ ɩɪɢ ɪɟɲɟɧɢɢ ɜɨɩɪɨɫɚ ɨ ɤɨɪɪɟɤɰɢɢ ɠɢɞɤɨɫɬɧɨɝɨ ɛɚɥɚɧɫɚ. ȼ 1994-1996 ɝɝ. [1]
ɝɢɩɟɪɬɟɧɡɢɜɧɵɟ ɪɚɫɫɬɪɨɣɫɬɜɚ ɛɟɪɟɦɟɧɧɨɫɬɢ ɛɵɥɢ ɨɬɧɟɫɟɧɵ ɤ ɧɟɩɨɫɪɟɞɫɬɜɟɧɧɵɦ ɩɪɢɱɢɧɚɦ ɫɦɟɪɬɢ ɜ 20 ɫɥɭɱɚɹɯ – ɬɚɤɠɟ,ɤɚɤ ɢ ɜ ɩɪɟɞɵɞɭɳɢɟ 3 ɝɨɞɚ.ɗɬɨ
ɫɨ-ɫɬɚɜɥɹɟɬ 1 ɫɥɭɱɚɣ ɫɦɟɪɬɢ ɧɚ 100.000 ɦɚɬɟɪɢɧɫɬɜ. Ʌɟ-ɝɨɱɧɚɹ ɩɚɬɨɥɨɝɢɹ (ɧɚɩɪɢɦɟɪ,ɈɊȾɋ)ɱɢɫɥɟɧɧɨ ɩɪɟɜɨɫ-ɯɨɞɢɥɚ ɜɧɭɬɪɢɱɟɪɟɩɧɵɟ ɤɪɨɜɨɢɡɥɢɹɧɢɹ ɜ ɤɚɱɟɫɬɜɟ ɩɪɢɱɢɧɵ ɫɦɟɪɬɢ.
ȼ Ⱦɨɤɥɚɞɚɯ 1997-1999 ɝɝ. [18] ɫɨɨɛɳɚɥɨɫɶ ɨ ɦɟɧɶ-ɲɟɦ ɤɨɥɢɱɟɫɬɜɟ ɫɦɟɪɬɟɣ [16], ɩɪɢ ɷɬɨɦ ɜɟɞɭɳɟɣ ɩɪɢ-ɱɢɧɨɣ ɥɟɬɚɥɶɧɨɝɨ ɢɫɯɨɞɚ ɹɜɥɹɥɢɫɶ ɜɧɭɬɪɢɱɟɪɟɩɧɵɟ ɤɪɨɜɨɢɡɥɢɹɧɢɹ [7]. Ɍɨɥɶɤɨ ɨɞɧɚ ɫɦɟɪɬɶ ɛɵɥɚ ɨɬɧɟɫɟ-ɧɚ ɤ ɈɊȾɋ.
Ʌɢɬɟɪɚɬɭɪɚ
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4. Belfort MA, Anthony J, Saade GR et al. The oxygen consumption/oxygen delivery curve in severe pree-clampsia: Evidence for a fixed oxygen extraction state.
American Journal of Obstetrics and Gynecology 1993;169:1448-55.
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11. Penny JA, Anthony J, Shennan AH, de Swiet M, Singer M. A comparison of hemodynamic data derived by pulmonary artery flotation catheter and the eso-phageal Doppler monitor in preeclampsia. American Journal of Obstetrics and Gynecology 2000;183:658-61.
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13. The Magpie Trial Collaborative Group. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial a randomised placebo-controlled trial. Lancet 2002;359:1877-90.
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15. Sharma SK, Philip J, Whitten CW, Padakandla UB, Landers DF. Assessment of changes in coagulation in parturients with preeclampsia using thromboelastogra-phy. Anesthesiology 1999;90:385-90.
16. Moodley J, Jjuuko G, Rout ɋ. Epidural compared with general anaesthesia for caesarean delivery in conscious
women with eclampsia. British Journal of Obstetrics and Gynaecology 2001:108:378-82.
17. Ramanathan J, Angel JJ, Bush AJ, Lawson P, Sibai B.
Changes in maternal middle cerebral artery blood flow velocity associated with general anaesthesia in obstet-rics.Anesthesia and Analgesia 1999;88:357-61.
18. Report on confidential enquiries into maternal deaths in the United Kingdom 1997-1999. London RCOG Press, 2001 http//:www.cemach.org.uk.
Ⱦɨɩɨɥɧɢɬɟɥɶɧɵɟ ɥɢɬɟɪɚɬɭɪɧɵɟ ɫɫɵɥɤɢ ɫɩɪɚɲɢɜɚɣɬɟ ɭ ɞ-ɪɚ Ⱦ.Ɇ.Ʌɟɜɢ:
Update In Anaesthesia
Ʉɨɫɨɝɥɚɡɢɟ ɜɢɡɭɚɥɶɧɨ ɨɩɪɟɞɟɥɹɟɬɫɹ ɤɚɤ ɨɬɤɥɨɧɟɧɢɟ ɨɫɢ ɝɥɚɡɧɨɝɨ ɹɛɥɨɤɚ. Ɂɚɛɨɥɟɜɚɧɢɟɦ ɩɪɟɢɦɭɳɟɫɬɜɟɧ-ɧɨ ɫɬɪɚɞɚɸɬ ɞɟɬɢ (2-5% ɞɟɬɫɤɨɝɨ ɧɚɫɟɥɟɧɢɹ).
ȼ ɤɨɫɨɝɥɚɡɢɟ ɦɨɝɭɬ ɜɨɜɥɟɤɚɬɶɫɹ ɨɞɧɨ ɢɥɢ ɨɛɚ ɝɥɚɡ -ɧɵɯ ɹɛɥɨɤɚ, ɫ ɩɨɜɨɪɨɬɨɦ ɢɯ ɜɧɭɬɪɶ, ɤɧɚɪɭɠɢ,ɜɜɟɪɯ ɢɥɢ ɜɧɢɡ. ɏɨɬɹ ɤɨɪɪɟɤɰɢɹ ɦɨɠɟɬ ɛɵɬɶ ɩɪɨɜɟɞɟɧɚ ɜ ɥɸɛɨɦ ɜɨɡɪɚɫɬɟ, ɪɟɡɭɥɶɬɚɬɵ ɨɩɟɪɚɰɢɣ ɜ ɪɚɧɧɟɦ ɜɨɡ-ɪɚɫɬɟ ɥɭɱɲɟ, ɩɪɢɱɟɦ ɧɚɢɛɨɥɟɟ ɩɨɥɨɠɢɬɟɥɶɧɵɟ ɪɟ-ɡɭɥɶɬɚɬɵ ɨɛɵɱɧɨ ɩɨɥɭɱɚɸɬ ɭ ɞɟɬɟɣ ɞɨ 6 ɥɟɬ, ɜ ɨɫɨ-ɛɟɧɧɨɫɬɢ ɜ ɜɨɡɪɚɫɬɟ ɦɥɚɞɲɟ 2 ɥɟɬ.
ɏɢɪɭɪɝɢɱɟɫɤɨɟ ɜɦɟɲɚɬɟɥɶɫɬɜɨ ɹɜɥɹɟɬɫɹ ɥɢɲɶ ɨɞɧɢɦ ɢɡ ɜɨɡɦɨɠɧɵɯ ɩɭɬɟɣ ɥɟɱɟɧɢɹ ɤɨɫɨɝɥɚɡɢɹ.Ⱦɪɭɝɢɟ ɦɟ-ɬɨɞɵ ɜɤɥɸɱɚɸɬ ɧɨɲɟɧɢɟ ɫɩɟɰɢɚɥɶɧɵɯ ɨɱɤɨɜ ɢɥɢ ɝɥɚɡɧɨɣ ɩɨɜɹɡɤɢ.ɏɢɪɭɪɝɢɹ ɤɨɫɨɝɥɚɡɢɹ ɜɤɥɸɱɚɟɬ ɷɤɫ-ɬɪɚɨɤɭɥɹɪɧɵɟ ɜɦɟɲɚɬɟɥɶɫɬɜɚ,ɤɨɬɨɪɵɟ ɩɪɟɞɭɫɦɚɬɪɢ-ɜɚɸɬ ɪɟɩɨɡɢɰɢɸ ɝɥɚɡɧɵɯ ɦɵɲɰ,ɜɵɡɵɜɚɸɳɢɯ ɨɬɤɥɨ-ɧɟɧɢɟ. Ɉɩɟɪɚɰɢɹ ɦɨɠɟɬ ɩɪɨɢɡɜɨɞɢɬɶɫɹ ɫ ɨɞɧɨɣ ɢɥɢ ɞɜɭɯ ɫɬɨɪɨɧ.
Ⱥɧɟɫɬɟɡɢɹ
Ʉɨɪɪɟɤɰɢɹ ɤɨɫɨɝɥɚɡɢɹ ɹɜɥɹɟɬɫɹ ɫɚɦɨɣ ɪɚɫɩɪɨɫɬɪɚ-ɧɟɧɧɨɣ ɨɩɟɪɚɰɢɟɣ ɜ ɞɟɬɫɤɨɣ ɝɥɚɡɧɨɣ ɯɢɪɭɪɝɢɢ.
Ɉɛɵɱɧɨ ɨɧɚ ɩɪɨɜɨɞɢɬɫɹ ɩɨɞ ɨɛɳɟɣ ɚɧɟɫɬɟɡɢɟɣ (ɭ ɞɟɬɟɣ ɜɫɟɝɞɚ), ɯɨɬɹ ɭ ɜɡɪɨɫɥɵɯ ɢɧɨɝɞɚ ɦɨɠɟɬ ɫ ɭɫɩɟ-ɯɨɦ ɢɫɩɨɥɶɡɨɜɚɬɶɫɹ ɦɟɫɬɧɚɹ ɚɧɟɫɬɟɡɢɹ.
ɋɭɳɟɫɬɜɭɟɬ ɧɟɫɤɨɥɶɤɨ ɫɩɨɫɨɛɨɜ ɩɪɨɜɟɞɟɧɢɹ ɨɛɳɟɣ ɚɧɟɫɬɟɡɢɢ ɜ ɯɢɪɭɪɝɢɢ ɤɨɫɨɝɥɚɡɢɹ. Ɉɛɵɱɧɨ ɢɫɩɨɥɶɡɭ-ɸɬ ɷɧɞɨɬɪɚɯɟɚɥɶɧɵɣ ɧɚɪɤɨɡ ɫ ɢɫɩɨɥɶɡɨɜɚɧɢɟɦ ɦɢɨ-ɪɟɥɚɤɫɚɧɬɨɜ,ɧɨ ɢɫɩɨɥɶɡɨɜɚɧɢɟ ɞɥɹ ɚɧɟɫɬɟɡɢɢ ɥɚɪɢɧ-ɝɟɚɥɶɧɨɣ ɦɚɫɤɢ (ɅɆ)ɬɚɤɠɟ ɞɨɫɬɚɬɨɱɧɨ ɩɨɩɭɥɹɪɧɨ.
ȼɨ ɜɪɟɦɹ ɯɢɪɭɪɝɢɱɟɫɤɨɝɨ ɜɦɟɲɚɬɟɥɶɫɬɜɚ ɨɱɟɧɶ ɜɚɠ-ɧɨ, ɱɬɨɛɵ ɝɥɚɡ ɨɫɬɚɜɚɥɫɹ ɧɟɩɨɞɜɢɠɧɵɦ.ɗɬɨ ɫɜɹɡɚɧɨ ɫ ɬɟɦ, ɱɬɨ ɯɢɪɭɪɝɭ ɞɥɹ ɜɵɩɨɥɧɟɧɢɹ ɬɟɫɬɚ ɩɪɢɧɭɞɢ-ɬɟɥɶɧɨɣ ɞɭɤɰɢɢ (forced duction test – FDT) ɧɟɨɛɯɨɞɢ-ɦɨ ɩɨɥɧɨɟ ɨɬɫɭɬɫɬɜɢɟ ɦɵɲɟɱɧɨɝɨ ɬɨɧɭɫɚ. Ɉɧ ɜɤɥɸ-ɱɚɟɬ ɨɰɟɧɤɭ ɦɟɯɚɧɢɱɟɫɤɨɝɨ ɨɝɪɚɧɢɱɟɧɢɹ ɞɜɢɠɟɧɢɣ ɝɥɚɡɧɨɝɨ ɹɛɥɨɤɚ ɩɨɫɪɟɞɫɬɜɨɦ ɟɝɨ ɩɪɢɧɭɞɢɬɟɥɶɧɨɝɨ ɞɜɢɠɟɧɢɹ ɜ ɧɚɩɪɚɜɥɟɧɢɢ ɜɫɟɯ ɩɨɥɟɣ ɡɪɟɧɢɹ, ɜɵɩɨɥ-ɧɹɟɦɨɟ ɫ ɩɨɦɨɳɶɸ ɡɚɯɜɚɬɚ ɫɤɥɟɪɵ ɜɛɥɢɡɢ ɤɪɚɹ ɪɨɝɨ-ɜɢɰɵ ɞɜɭɦɹ ɩɢɧɰɟɬɚɦɢ.ɗɬɨɬ ɬɟɫɬ ɩɨɡɜɨɥɹɟɬ ɯɢɪɭɪɝɭ ɞɢɮɮɟɪɟɧɰɢɪɨɜɚɬɶ ɦɢɨɩɚɪɚɥɢɬɢɬɢɱɟɫɤɭɸ ɪɟɫɬɪɢɤ-ɰɢɸ ɞɜɢɠɟɧɢɣ ɝɥɚɡɧɨɝɨ ɹɛɥɨɤɚ ɨɬ ɦɟɯɚɧɢɱɟɫɤɨɣ.
ȼ ɫɜɹɡɢ ɫ ɬɟɦ,ɱɬɨ ɦɵɲɟɱɧɵɣ ɬɨɧɭɫ ɦɨɠɟɬ ɨɬɥɢɱɚɬɶ-ɫɹ ɜ ɡɚɜɢɫɢɦɨɫɬɢ ɨɬ ɝɥɭɛɢɧɵ ɚɧɟɫɬɟɡɢɢ ɜ ɛɨɥɶɲɢɯ ɩɪɟɞɟɥɚɯ, ɧɟɤɨɬɨɪɵɟ ɯɢɪɭɪɝɢ ɩɪɟɞɩɨɱɢɬɚɸɬ ɩɪɨɜɨ-ɞɢɬɶ ɨɩɟɪɚɰɢɸ ɩɨɞ ɞɟɣɫɬɜɢɟɦ ɦɢɨɪɟɥɚɤɫɚɧɬɨɜ.
ɉɪɟɞɨɩɟɪɚɰɢɨɧɧɚɹ ɩɨɞɝɨɬɨɜɤɚ
Ⱦɟɬɹɦ ɞɨɫɬɚɬɨɱɧɨ ɩɪɨɜɟɫɬɢ ɩɪɟɦɟɞɢɤɚɰɢɸ ɩɚɪɚɰɟɬɚ-ɦɨɥɨɦ 20 ɦɝ ɧɚ ɤɝ,ɩɪɢ ɷɬɨɦ ɩɪɟɞɜɚɪɢɬɟɥɶɧɨ ɫɥɟɞɭɟɬ ɩɨɥɭɱɢɬɶ ɫɨɝɥɚɫɢɟ ɪɨɞɢɬɟɥɟɣ ɧɚ ɪɟɤɬɚɥɶɧɨɟ ɩɪɢɦɟ-ɧɟɧɢɟ ɇɉȼɉ ɜ ɫɜɟɱɚɯ. ɍ ɞɟɬɟɣ ɛɨɥɟɟ ɫɬɚɪɲɟɝɨ ɜɨɡ-ɪɚɫɬɚ, ɤɨɬɨɪɵɦ ɩɥɚɧɢɪɭɟɬɫɹ ɩɪɨɜɟɞɟɧɢɟ ɨɩɟɪɚɰɢɢ ɩɨɞ ɨɛɳɟɣ ɚɧɟɫɬɟɡɢɟɣ, ɩɪɨɜɨɞɹɬ ɪɭɬɢɧɧɵɟ
ɢɫɫɥɟɞɨ-ɜɚɧɢɹ.ɉɪɟɦɟɞɢɤɚɰɢɹ ɜɵɩɨɥɧɹɟɬɫɹ ɫ ɢɫɩɨɥɶɡɨɜɚɧɢɟɦ ɝɥɢɤɨɩɢɪɪɨɥɚɬɚ (200 ɦɤɝ ɭ ɜɡɪɨɫɥɵɯ, 5 ɦɤɝ/ɤɝ ɭ ɞɟ-ɬɟɣ), ɤɨɬɨɪɵɣ ɫɩɨɫɨɛɟɧ ɫɧɢɠɚɬɶ ɫɥɸɧɨɨɬɞɟɥɟɧɢɟ, ɱɬɨ ɨɫɨɛɟɧɧɨ ɩɨɥɟɡɧɨ ɩɪɢ ɢɫɩɨɥɶɡɨɜɚɧɢɢ ɅɆ. ɉɪɟ -ɩɚɪɚɬ ɬɚɤɠɟ ɫɩɨɫɨɛɫɬɜɭɟɬ ɫɧɢɠɟɧɢɸ ɱɚɫɬɨɬɵ ɨɤɭɥɨ-ɤɚɪɞɢɚɥɶɧɨɝɨ ɪɟɮɥɟɤɫɚ (ɫɦ.ɧɢɠɟ).
ȼɜɨɞɧɵɣ ɧɚɪɤɨɡ
Ɍɚɤɬɢɤɚ ɡɚɜɢɫɢɬ ɨɬ ɬɨɝɨ, ɛɭɞɟɬ ɩɚɰɢɟɧɬ ɧɚɯɨɞɢɬɶɫɹ ɩɨɞ ɜɨɡɞɟɣɫɬɜɢɟɦ ɦɢɨɪɟɥɚɤɫɚɧɬɨɜ ɢɥɢ ɞɵɲɚɬɶ ɫɩɨɧ-ɬɚɧɧɨ ɱɟɪɟɡ ɅɆ.
ɑɚɳɟ ɜɫɟɝɨ ɜɧɭɬɪɢɜɟɧɧɚɹ ɢɧɞɭɤɰɢɹ ɜɵɩɨɥɧɹɟɬɫɹ ɫ ɩɨɦɨɳɶɸ ɮɟɧɬɚɧɢɥɚ ɢɥɢ ɚɥɶɮɟɧɬɚɧɢɥɚ ɜ ɤɨɦɛɢɧɚ-ɰɢɢ ɫ ɩɪɨɩɨɮɨɥɨɦ ɢɥɢ ɬɢɨɩɟɧɬɚɥɨɦ. Ɍɚɤɠɟ ɫ ɭɫɩɟ-ɯɨɦ ɦɨɠɟɬ ɛɵɬɶ ɩɪɢɦɟɧɹɬɶɫɹ ɢɧɞɭɤɰɢɹ ɫ ɢɫɩɨɥɶɡɨ-ɜɚɧɢɟɦ ɢɧɝɚɥɹɰɢɨɧɧɵɯ ɚɧɟɫɬɟɬɢɤɨɜ ɝɚɥɨɬɚɧɚ ɢɥɢ ɫɟɜɨɮɥɸɪɚɧɚ, ɜ ɨɫɨɛɟɧɧɨɫɬɢ ɭ ɞɟɬɟɣ ɦɥɚɞɲɟɝɨ ɜɨɡ-ɪɚɫɬɚ.
ȼɵɛɨɪ ɦɟɠɞɭ ɅɆ ɢ ɢɧɬɭɛɚɰɢɟɣ ɬɪɚɯɟɢ ɡɚɜɢɫɢɬ ɨɬ ɧɟɫɤɨɥɶɤɢɯ ɮɚɤɬɨɪɨɜ. ɉɪɢɧɢɦɚɹ ɜɨ ɜɧɢɦɚɧɢɟ, ɱɬɨ ɅɆ ɢɦɟɟɬ ɛɨɥɶɲɟ ɜɟɪɨɹɬɧɨɫɬɟɣ ɪɚɡɜɢɬɢɹ ɩɪɨɛɥɟɦ ɭ ɞɟɬɟɣ ɦɥɚɞɲɟɝɨ ɜɨɡɪɚɫɬɚ, ɧɟɤɨɬɨɪɵɟ ɚɧɟɫɬɟɡɢɨɥɨɝɢ ɩɪɟɞɩɨɱɢɬɚɸɬ ɢɫɩɨɥɶɡɨɜɚɬɶ ɭ ɧɢɯ ɷɧɞɨɬɪɚɯɟɚɥɶɧɵɣ ɧɚɪɤɨɡ.Ɉɛɵɱɧɨ ɩɪɢ ɢɫɩɨɥɶɡɨɜɚɧɢɢ ɅɆ ɩɚɰɢɟɧɬ ɞɵ-ɲɢɬ ɫɩɨɧɬɚɧɧɨ,ɯɨɬɹ ɬɚɤɠɟ ɜɨɡɦɨɠɧɨ ɢɫɩɨɥɶɡɨɜɚɧɢɟ ɢɫɤɭɫɫɬɜɟɧɧɨɣ ɜɟɧɬɢɥɹɰɢɢ.ȼ ɩɨɫɥɟɞɧɟɦ ɫɥɭɱɚɟ ɫɥɟ-ɞɭɟɬ ɢɡɛɟɝɚɬɶ ɭɜɟɥɢɱɟɧɢɹ ɞɚɜɥɟɧɢɹ ɧɚ ɜɞɨɯɟ (ɛɨɥɟɟ 15ɫɦ ɜɨɞɧɨɝɨ ɫɬɨɥɛɚ)ɫ ɰɟɥɶɸ ɫɜɟɞɟɧɢɹ ɤ ɦɢɧɢɦɭɦɭ ɜɨɡɦɨɠɧɨɫɬɢ ɪɚɡɞɭɜɚɧɢɹ ɜɨɡɞɭɯɨɦ ɠɟɥɭɞɤɚ. ɂɫɩɨɥɶ-ɡɨɜɚɧɢɟ ɚɪɦɢɪɨɜɚɧɧɨɣ ɅɆ ɱɚɳɟ ɞɚɟɬ ɩɨɥɨɠɢɬɟɥɶ-ɧɵɟ ɪɟɡɭɥɶɬɚɬɵ,ɱɟɦ ɩɪɢɦɟɧɟɧɢɟ ɬɪɚɞɢɰɢɨɧɧɨɣ ɅɆ.
Ɉɛɵɱɧɵɦ ɩɪɨɬɢɜɨɩɨɤɚɡɚɧɢɟɦ ɞɥɹ ɢɫɩɨɥɶɡɨɜɚɧɢɹ ɅɆ ɫɥɭɠɢɬ ɧɟɤɨɧɬɪɨɥɢɪɭɟɦɵɣ ɪɟɮɥɸɤɫ.
Ɍɚɤɠɟ ɫɥɟɞɭɟɬ ɩɨɦɧɢɬɶ,ɱɬɨ ɜɨ ɜɪɟɦɹ ɯɢɪɭɪɝɢɱɟɫɤɢɯ ɜɦɟɲɚɬɟɥɶɫɬɜ ɩɨ ɩɨɜɨɞɭ ɤɨɫɨɝɥɚɡɢɹ ɞɨɫɬɭɩ ɤ ɞɵɯɚ-ɬɟɥɶɧɵɦ ɩɭɬɹɦ ɡɚɬɪɭɞɧɟɧ,ɩɨɷɬɨɦɭ ɫɥɟɞɭɟɬ ɭɛɟɞɢɬɶ-ɫɹ ɜ ɧɚɞɟɠɧɨɫɬɢ ɩɪɨɯɨɞɢɦɨɫɬɢ ɞɵɯɚɬɟɥɶɧɵɯ ɩɭɬɟɣ ɞɨ ɬɟɯ ɩɨɪ,ɩɨɤɚ ɩɚɰɢɟɧɬ ɧɟ ɭɤɪɵɬ.
Ⱦɥɹ ɨɛɟɫɩɟɱɟɧɢɹ ɢɧɬɭɛɚɰɢɢ ɬɪɚɯɟɢ (ɨɛɵɱɧɨ ɢɫɩɨɥɶ-ɡɭɸɬɫɹ ɚɪɦɢɪɨɜɚɧɧɵɟ ɬɪɭɛɤɢ – RAE) ɩɪɟɞɩɨɱɬɢɬɟɥɶ-ɧɟɣ ɢɫɩɨɥɶɡɨɜɚɬɶ ɧɟɞɟɩɨɥɹɪɢɡɭɸɳɢɟ ɦɢɨɪɟɥɚɤɫɚɧ-ɬɵ,ɚ ɧɟ ɫɭɤɫɚɦɟɬɨɧɢɣ.ɗɬɨɦɭ ɟɫɬɶ ɞɜɟ ɩɪɢɱɢɧɵ.ȼɨ -ɩɟɪɜɵɯ,ɩɚɰɢɟɧɬ ɩɨɫɥɟ ɜɜɟɞɟɧɢɹ ɫɭɤɫɚɦɟɬɨɧɢɹ ɢɦɟɟɬ ɩɪɨɞɥɟɧɧɨɟ ɭɜɟɥɢɱɟɧɢɟ ɷɤɫɬɪɚɨɤɭɥɹɪɧɨɝɨ ɦɵɲɟɱɧɨ-ɝɨ ɬɨɧɭɫɚ, ɤɨɬɨɪɵɣ ɦɟɲɚɟɬ ɩɪɨɜɟɞɟɧɢɸ ɬɟɫɬɚ FDT.
ɗɬɨɬ ɷɮɮɟɤɬ ɞɥɢɬɫɹ ɩɪɢɛɥɢɡɢɬɟɥɶɧɨ 15-20 ɦɢɧɭɬ.
ȼɨ-ɜɬɨɪɵɯ, ɩɚɰɢɟɧɬ,ɤɨɬɨɪɨɦɭ ɩɪɨɜɨɞɢɬɫɹ ɨɩɟɪɚɰɢɹ ɤɨɪɪɟɤɰɢɢ ɤɨɫɨɝɥɚɡɢɹ,ɦɨɠɟɬ ɛɵɬɶ ɨɩɚɫɟɧ ɜ ɨɬɧɨɲɟ-ɧɢɢ ɪɚɡɜɢɬɢɹ ɡɥɨɤɚɱɟɫɬɜɟɧɧɨɣ ɝɢɩɟɪɬɟɪɦɢɢ.
ɉɨɞɞɟɪɠɚɧɢɟ ɚɧɟɫɬɟɡɢɢ
Ʉɨɪɪɟɤɰɢɹ ɤɨɫɨɝɥɚɡɢɹ ɨɛɵɱɧɨ ɞɥɢɬɫɹ 60-90 ɦɢɧɭɬ ɜ ɩɨɥɨɠɟɧɢɢ ɧɚ ɫɩɢɧɟ. Ⱥɧɟɫɬɟɡɢɹ ɦɨɠɟɬ ɩɨɞɞɟɪɠɢ-ɜɚɬɶɫɹ ɥɢɛɨ ɫ ɩɨɦɨɳɶɸ ɥɟɬɭɱɢɯ ɚɧɟɫɬɟɬɢɤɨɜ (ɫ
ɢɫ-ǨǵǭǹǺǭǯǰȇ ǷǸǰ ǶǷǭǸǨǾǰǰ ǻǹǺǸǨǵǭǵǰȇ DzǶǹǶǫdzǨǯǰȇ
Ǽ. ǫȈȘȚȊȐȋ (ǷȐȚȍȘȔȈȘȐȞȉȍȘȋ, ȆȎȕȈȧ ǨȜȘȐȒȈ)