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Sudan PD guidebook Sudan PD guidebook Document Transcript

  • Sudan Peritoneal Dialysis Program Peritoneal Dialysis Guide Book Editors Hasan Abu-Aisha, FRCP Nephrologist, Sudan PD program Sarra Elamin, MRCP Physician, Sudan PD Program Elwaleed AM Elhassan, ABIM Internist, Sudan PD Program
  • First edition (2008) National Library Cataloging - Sudan 616.614 Hasan Abu Aisha Hamid H.P Peritoneal dialysis guide book = ‫الصفاقية‬ ‫الديلزة‬ ‫دليل‬ Hasan Abu Aisha Hamid Elwaleed Ali Mohamed Elhasan, Sarra Elamin Elhaj- Khartoum: ;2008. 242 P. :illus. ; 24 cm. ISBN : 978-99942-897-1-4 English + Arabic 1.Dialysis ,Patients - Guide Books, Handbooks, Manuals ... etc. 2.Acute Renal failure - Guide Books, Handbooks, Manuals... etc. A. Title
  • Contributors This book was prepared in the peritoneal dialysis unit of Ribat University Hospital, with the assistance of doctors: Jaafer MA El-Tahir, Osman-Mahir MA Mahir, Hisham M Ali, Aymun I Mobarak, Alaa O Elsammani, Maha A Hummeida, Sara Alsir Khalid, and nurses: Ihsan Bashir, Egbal A Elshareef, Jamal Abdel-Raheem, Um-Alhasan M Abdulla, Abeer A Salah, Osama Omer Ahmed, Haram Yousif, Afraa Abdelwahid, Hani Eltag, Angaila Badreldin, and IT technologists: Sailh Abdul-Kareem, Khalid M Elhassan Reviewers Hisham Hasan Nephrologist, Khartoum Teaching Hospital Mohamed B Abdelraheem Pediatric Nephrologist, Soba University Hospital Babiker J Kaballo Nephrologist, Military Hospital Mohammed B Ghalib Nephrologist, Ribat University Hospital Design Mohamed Abd Elazim Disclaimer The information provided in this guidebook is of general nature, and the unique situation of individual patients must always be taken into consideration by the medical team Copyright Copyrights are reserved for the Sudan Peritoneal Dialysis Program, no part of this book may be re-produced by any means without prior permission
  • 5 Table of Contents Acronyms 9 Introduction 11 The Sudan Peritoneal Dialysis Program 12 Chapter 1: Patient Selection for Peritoneal Dialysis 13 1.1. Goals and targets 13 1.2. Estimation of kidney function 13 1.3. Chronic kidney disease 14 1.4. Initiation of renal replacement therapy 15 1.5. The integrated renal care strategy 15 1.6. The suitable candidate for peritoneal dialysis 17 1.7. Patient counseling 18 Chapter 2: Peritoneal Dialysis Catheter Insertion 19 2.1. Goals and targets 19 2.2. Preparing the patient for catheter insertion 19 2.3. Catheter placement techniques 20 2.4. Procedure for surgical placement by dissection 22 2.5. Procedure for modified surgical placement with a guide wire 24 2.6. Post operative care 25 Chapter 3: Patient Training 28 3.1. Goals and targets 28 3.2. Pre-requisites to patient training 28 3.3. Important aspects of patient training 28 3.4. Aseptic technique 31 3.5. Proper hand washing technique 32 3.6. The double-bag system 33 3.7. The exchange procedure 34 3.8. Healthy exit site care 35 3.9. Exit site care procedure 36 Chapter 4: Dialysis Prescription and Monitoring 39 4.1. Goals and targets 39 4.2. Principles of peritoneal dialysis 39 4.3. Different peritoneal dialysis modalities 40 4.4. The optimal PD modality 41 4.5. Initial Dialysis Prescription 42
  • 6 4.6. Monitoring of PD adequacy 43 4.7. PD adequacy test 44 4.8. Procedure for the PD adequacy test 44 4.9. Peritoneal equilibration test (PET) 47 4.10. Procedure for the PET 47 4.11. Peritoneal membrane transport characteristics according to PET 49 4.12. Causes of UF failure according to PET 49 4.13. Optimizing solute clearance 50 4.14. Management of fluid overload 51 4.15. Assessing and preserving residual renal function 52 Chapter 5: Management of Exit Site Infections 54 5.1. Goals and targets 54 5.2. Prevention of exit site and tunnel infections 54 5.3. Diagnosis of exit site and tunnel infections 54 5.4. Treatment of exit site and tunnel infection 55 Algorithm 1: Management of Exit Site Infection 58 Chapter 6: Management of PD Related Peritonitis 59 6.1. Goals and targets 59 6.2. Prevention of PD related peritonitis 59 6.3. Diagnosis of PD related peritonitis 59 6.4. Sample processing 60 6.5. Treatment principles and steps 61 6.6. Indications for catheter removal 63 6.7. Preventing recurrence of peritonitis 64 6.8. Drug delivery 64 Algorithm 2: Management of PD Related Peritonitis 69 Algorithm 3: Management of PD Related Culture Negative Peritonitis 70 Algorithm 4: Management of Fungal Peritonitis 71 Chapter 7: Noninfectious Complications of PD 72 7.1. Goals and targets 72 7.2. Hernia 72 7.3. Fluid leak 72 7.4. Pleural effusion due to pleuro-peritoneal leak 73 7.5. Catheter malfunction 73 7.6. Pain on dialysate infusion 75 7.7. Catheter cuff extrusion 75 7.8. Bladder perforation 75 7.9. Intestinal perforation 75
  • 7 7.10. Hemoperitoneum 76 7.11. Gastroesophageal reflux disease 76 7.12. Back pain 76 7.13. Electrolyte abnormalities 76 7.14. Sclerosing encapsulating peritonitis 77 7.15. Abdominal surgery in a PD patient 77 Chapter 8: Management of Anemia 79 8.1. Goals and targets 79 8.2. Target hemoglobin level 79 8.3. Iron supplementation 80 8.4. Erythropoietin therapy 81 Chapter 9: Management of Bone Disease 83 9.1. Goals and targets 83 9.2. Target calcium, phosphorus and parathyroid hormone levels 83 9.3. Treatment of hyperphosphatemia 83 9.4. Vitamin D supplements 84 9.5. Treatment of hypocalcemia 85 9.6. Assessment of bone disease 85 9.7. Treatment of bone disease 86 9.8. Indications for parathyroidectomy 86 Algorithm 5: Management of Bone Disease 88 Chapter 10: Management of Malnutrition 89 10.1. Goals and targets 89 10.2. Evaluation and monitoring of nutritional status 89 10.3. Treatment of malnutrition 91 Chapter 11: Management of Hypertension 92 11.1. Goals and targets 92 11.2. Blood pressure monitoring 92 11.3. Blood pressure measurement 92 11.4. Management of hypertension 93 11.5. Evaluation for renal artery disease 95 Chapter 12: Management of Diabetes Mellitus 100 12.1. Goals and targets 100 12.2. Monitoring of blood sugar and diabetic complications 100 12.3. Managing diabetic patients on dialysis 100
  • 8 Chapter 13: Management of Dyslipidemia 103 13.1. Goals and targets 103 13.2. Monitoring of lipid profile 103 13.3. Treatment of dyslipidemia 103 Chapter 14: Rehabilitation 106 14.1. Goals and targets 106 14.2. The disability of dialysis 106 14.3. Employment and rehabilitation 106 Chapter 15: Peritoneal Dialysis in Children 108 15.1. Goals and targets 108 15.2. Initiation of dialysis therapy 108 15.3. Choice of dialysis modality 108 15.4. PD prescription and monitoring 109 15.5. Hypertension management 109 Chapter 16: Preparation for Kidney Transplantation 110 16.1. Goals and targets 110 16.2. Patient eligibility for kidney transplantation 110 16.3. Prospective live kidney donor evaluation 111 16.4. Preparing the patient for kidney transplantation 113 16.5. Peri-operative care of the PD patient 113 Chapter 17: Peritoneal Dialysis in Acute Renal Failure 115 17.1. Goals and targets 115 17.2. The utility of peritoneal dialysis in acute renal failure 115 17.3. Acute PD access 116 17.4. Technique for semirigid PD catheter insertion 116 17.5. Peritoneal dialysis prescription in acute renal failure 117 Chapter 18: Continuous Quality Improvement 119 18.1. Goals and targets 119 18.2. The continuous quality improvement process 119 18.3. Key performance indicators in PD 119 18.4. The central Sudan-PD data base 120 References 122
  • 9 Acronyms ACEi angiotensin converting enzyme inhibitors APD automated peritoneal dialysis ARB angiotensin receptor blocker ARF acute renal failure BMI body mass index BP blood pressure BSA body surface area BUN blood urea nitrogen CAPD continuous ambulatory peritoneal dialysis CCB calcium channel blocker CCPD continuous cycling peritoneal dialysis Ccreat creatinine clearance CHD coronary heart disease CKD chronic kidney disease CMV cytomegalovirus CVA cerebrovascular accident CVD cerebrovascular disease CXR chest X ray DEXA dual energy X ray analysis DM diabetes mellitus DOQI Dialysis Outcome Quality Initiative DPI dietary protein intake EBV Epstein Barr virus ECG electrocardiogram EPO erythropoietin ESRD end stage renal disease FSGS focal segmental glomerulosclerosis g gram GDP glucose degradation product GFR glomerular filtration rate Hb hemoglobin HBV hepatitis B virus HCV hepatitis C virus HD hemodialysis HIV human immunodeficiency virus HLA human leukocyte antigen HUS hemolytic uremic syndrome ICU intensive care unit
  • 10 IM intramuscular IP intraperitoneal IPD intermittent peritoneal dialysis IV intravenous K/DOQI Kidney Disease Outcomes Quality Initiative Kt/Vurea total urea clearance normalized for body size Krt/Vurea residual renal urea clearance normalized for body size Kpt/Vurea peritoneal urea clearance normalized for body size l liter LBM lean body mass LVH left ventricular hypertrophy mcg microgram MDRD modification of diet in renal disease mg milligram MI myocardial infarction ml milliliter mmol millimole MRI magnetic resonance imaging MRSA methicillin-resistant Staphylococcus aurius NIPD nocturnal intermittent peritoneal dialysis nPCR normalized protein catabolic rate NSAID non steroidal anti-inflammatory drugs PCR protein catabolic rate PD peritoneal dialysis PET peritoneal equilibration test PTH parathyroid hormone PVD peripheral vascular disease RRF residual renal function RRT renal replacement therapy SC subcutaneous SEP sclerosing encapsulating peritonitis SGA subjective global assessment Sudan-PD Sudan peritoneal dialysis program TBW total body water TLC therapeutic lifestyle changes U/S ultrasound UF ultrafiltration UKM urea kinetic modeling URR urea reduction ratio
  • 11 Introduction End stage renal disease (ESRD) is a medical and social problem that constitutes a heavy burden on communities worldwide. The incidence of this notorious disease is steadily increasing, partly due to a real increase in the incidence of different kidney diseases that eventually lead to ESRD, and partly due to the improvement achieved in treating other conditions, like diabetes mellitus and hypertension, that can lead after long periods to ESRD. The average global incidence of ESRD is estimated to be 100-200 new case per million population per year, and the global annual cost of treating ESRD is about 1000,000,000 US$. Expectedly, most developing countries are overwhelmed by this epidemic. However, countries with developing economics, like India and Mexico, have given us live examples on how to handle this notorious disease efficiently and in a cost effective way. The incidence of ESRD in Sudan is expected to be 5000 new case per year. The Sudan government has established the Sudan National Center for Kidney Disease and Transplantation as a national center for managing kidney diseases. This center has in turn established a large number of hemodialysis units all over the Sudan, functioning alongside an active national kidney transplantation program. Nevertheless, ESRD remains a problem for many citizens whose needs are not met by these limited services. Accordingly,peritonealdialysiswasstronglyneededasanothertreatmentmodalityfor ESRD in Sudan, to fulfill the needs of patients who are not suitable for hemodialysis. Peritoneal dialysis would also provide the child and working adult with more space for work, studying and travel; activities which are severely restricted by center based hemodialysis.
  • 12 The Sudan Peritoneal Dialysis Program The Sudan Peritoneal Dialysis Program (Sudan-PD) was established as a pioneer project in June 2005. It was founded with great efforts from Professor Hasan Abu-Aisha (president of the National Ribat University), Dr Mohammad Al-Mahdi Mandour (director of the Central Medical Supplies Corporation), Dr Khalifa Al-Awad (director of the National Center for Kidney Diseases and Transplantation) and Dr Babiker Jabir Kaballo (director of Renal Services, Sudan Military Medical Services). The unique structure of Sudan-PD relies on an integrated system for patient recruitment with a central database, along with unified management protocols and fluid transfer arrangements. Regular meetings are carried out to discuss all individual patient problems, update center reports and design protocols. Continuing staff education programs are also regularly provided. By year end 2007, seven maintenance PD units were sequentially established in seven major hospitals in Sudan, including six units in the capital of Khartoum and one unit in Jezeera state, serving about 200 patients. The most important criteria for center inclusion are “an enthusiastic nephrologist interested in PD and willing to work with PD in a team fashion” and a “willing hospital administration.” Ribat university hospital has provided the program with generous logistic support since its foundation, and Ribat PD center took the lead as the main training center for PD providers from other cities. The Central Medical Supplies Corporation has provided the medical supplies needed by participating patients since the program foundation. In 2006, the Sudan National Center for Kidney Disease and Transplantation has officially recognized the active role of Sudan-PD in the integrated management of chronic kidney diseases in Sudan. In October 2006, her Excellency the Minister of Health, Dr Tabita Butros, evaluated and accepted the program as a national project to be added to the National Kidney Foundation Program.
  • 13 Chapter 1: Patient Selection for Peritoneal Dialysis 1.1. Goals and targets To promote the timely initiation of renal replacement therapy (RRT).ֺֺ To stress the importance of the integrated renal care strategy in handling chronicֺֺ kidney disease (CKD) patients. To outline the criteria for selecting the suitable candidate for maintenance PDֺֺ 1.2. Estimation of kidney function The glomerular filtration rate (GFR), rather than serum creatinine or BUN is theֺֺ best measure of overall kidney function in health and disease. GFR is difficult to measure directly, and is best estimated using predictionֺֺ equations, such as Cockroft-Gault formula, MDRD formula or Schwartz formula. 24 hour urine collections for creatinine clearance may not be more accurate inֺֺ estimating the GFR than prediction equations except in certain situations (e.g. amputation). Cockroft-Gault formula Abbreviated MDRD formula GFR (ml/min) = _____________________________ (multiply by 0.85 for females) [140 - age (years)] x weight (kg) 72 x serum creatinine (mg/dl) GFR (ml/min/1.73m2 ) = 186.3 x [serum creatinine (mg/dl)]-1.154 x [age (years)] -0.203 (multiply by 0.742 for females)
  • 14 Schwartz formula (for children < 18 years) Creatinine clearance 1.3. Chronic kidney disease Chronic kidney disease (CKD) is defined by GFR less than 60 ml/mn/1.73ֺֺ m2 persisting for at least 3 months and/or evidence of kidney damage (e.g. albuminuria, hematuria or renal scarring) persisting for the same duration (see table 1). Every patient in stage 4 or 5 CKD should be seen by a nephrologist. He/she shouldֺֺ be informed on the likelihood of developing kidney failure, counseled about the available treatment options and offered hepatitis B vaccination. Construction of a permanent vascular access (AV fistula) is indicated at this stage if the patient is likely to require HD. Patients in stage 5 CKD are said to have kidney failure. The term end stage renalֺֺ disease (ESRD) is reserved for kidney failure patients who are being maintained on any form of renal replacement therapy (RRT). Table 1: Stages of chronic kidney disease Stage Description GFR (ml/mn/1.73 m2 ) 1 Kidney damage with normal or raised GFR > 90 2 Kidney damage with mildly reduced GFR 60 – 89 3 Moderately reduced GFR 30 – 59 4 Severely reduced GFR 15 – 29 5 Kidney failure less than 15 (or dialysis) GFR (ml/min) = ______________________0.55 x height (cm) serum creatinine (mg/dl) Ccreat (ml/min) = _____________________________________________________24 hr urine volume (liter) x urine creatinine concentration (mg/dl) serum creatinine concentration (mg/dl) x 1.44
  • 15 1.4. Initiation of renal replacement therapy RRT may be initiated for CKD patients when the GFR falls below 15 ml/min/1.73 mֺֺ 2 , after evaluating the expected benefits and risks. Early initiation of RRT is not of proven benefit, and treatment is usually deferredֺֺ until there is a clinical indication to start dialysis. Indications for dialysis include excessive fatigue, refractory fluid overload,ֺֺ refractory hypertension, pericarditis, uremic encephalopathy or neuropathy, bleeding diathesis, persistent nausea and evidence of malnutrition. Dialysis should not be delayed until the patient is very ill. An ill patient mayֺֺ deteriorate rapidly necessitating emergency initiation of dialysis, is more susceptible to complications during dialysis initiation, and may not tolerate further delay if the dialysis access does not function properly. 1.5. The integrated renal care strategy RRT encompasses different treatment modalities, including maintenance PD,ֺֺ maintenance HD and kidney transplantation. A single patient may well utilize all modalities of RRT during the course of his/ֺֺ her ESRD. Rather than thinking of one modality of treatment versus another, it is best to use each treatment to its optimal benefit. Ideally, selection of dialysis modality should be driven by patient choice, unlessֺֺ there is a medical or social contraindication to a particular modality. Kidney transplantation is the most cost effective mode of RRT and offers theֺֺ patient the best chance for long term survival and good quality of life. Suitable patients should be encouraged to have a kidney transplant if feasible, preferably before they become dialysis dependent. PD is most efficient when patients have significant residual renal function (RRF),ֺֺ i.e. when they first start RRT or when they transfer back to dialysis after trans- plantation. It has several medical and social advantages over HD as the initial dialysis modality (see table 2). Most patients will eventually require HD if they continue on long term dialysis.ֺֺ They would benefit from preserving the arm vessels for future vascular access placement if they start their RRT with PD.
  • 16 Table 2: Advantages and disadvantages of maintenance peritoneal dialysis compared to hemodialysis Advantages Disadvantages Provides continuous and uninterruptedֺֺ dialysis treatment, unlike HD. Better preservation of RRF than HD, withֺֺ a potential survival advantage. Better blood pressure and volume controlֺֺ with less dietary restriction. Safer for patients with poor cardiacֺֺ function, CHD or CVD. Suitable for patients with active diabeticֺֺ retinopathy, for whom heparin is contrain- dicated. PD access is easy to establish and canֺֺ be used after 2 weeks of placement or immediately if necessary. Even serious related infections usuallyֺֺ resolves after catheter removal and are rarely fatal. Less severe blood loss and less EPOֺֺ requirement. No needles are required, and treatment isֺֺ associated with a lower risk of blood-borne infections: HBV and HCV. Suitable for patient living far from HDֺֺ centers; transport to hospital is only needed for clinic or emergency visits. More flexible treatment schedule that canֺֺ fit into patient’s lifestyle. Care of dependent family member can beֺֺ easier if dialysis is carried out at home. Requires less equipment and staff.ֺֺ PD often relies on significant RRF toֺֺ achieve adequate dialysis. Adequate dialysis may be difficult toֺֺ achieve in large anuric patients. Less predictable UF that often reducesֺֺ with time. Lower technique survival, with manyֺֺ patients quitting PD after a few years. Requires a permanent catheter with the riskֺֺ of catheter related infection and problems of body image changes. May result in weight gain and poorlyֺֺ controlled hyperglycemia especially in diabetic patients. Requires good housing conditions withֺֺ running water supply and adequate space for storage. Requires arrangement to deliver dialysisֺֺ fluids to patients’ homes. Dependent on the patient or family memberֺֺ physical and mental ability to learn and comply with the technique. Dialysis is required every day and thatֺֺ may lead to patient or helper exhaustion and burnout.
  • 17 1.6. The suitable candidate for peritoneal dialysis Maintenance PD will be most successful in a motivated compliant patient whoֺֺ can maintain good personal hygiene and has good family support. Before accepting a patient for maintenance PD, he/she should undergo a com-ֺֺ prehensive clinical evaluation accompanied by assessment of the home and work environment and sources of financial and social support to identify any potential contraindications to PD (see table 3). Table 3: Contraindications for maintenance peritoneal dialysis Absolute Relative (major) contraindications Relative (minor) contraindications Encapsulatingֺֺ peritoneal sclerosis. Peritoneal adhesions.ֺֺ Pleuro-peritoneal leak.ֺֺ Colostomy/gastrostomy.ֺֺ Previous abdominal scar.ֺֺ Psychosis/mentalֺֺ retardation. Poor personal hygiene.ֺֺ Poor motivation.ֺֺ Poor housing conditions withֺֺ no running water or space for storage. Physical handicap, suchֺֺ as blindness or hemiplegia (contraindication for self treatment). Hernia.ֺֺ Obesity.ֺֺ Previous hard catheter IPD.ֺֺ Polycystic kidneys.ֺֺ Low back problems.ֺֺ
  • 18 1.7. Patient counseling After confirming that a particular patient is a suitable candidate for PD, he/sheֺֺ should be counseled about the proposed treatment modality. Patient counseling is of paramount importance and should be carried out by anֺֺ experienced member of the PD team in a quiet room, preferably in the presence of family members. Many times patients refuse PD because of preconceived ideas or misinformationֺֺ that can be allayed by appropriate explanation and, preferably, paying a visit to the PD unit. The principles of PD should be explained to the patient with the aid of picturesֺֺ and illustrations, including the need to place a permanent PD catheter and perform multiple exchanges every day. The patient should be informed about pros and cons of PD compared to HD,ֺֺ relating this to his/her particular medical and social conditions (e.g. work, school, home making). Before accepting a potential candidate, the PD team should ensure that he/she isֺֺ capable and willing to work on the system independently. Otherwise, they should check for the availability of a reliable helper. After accepting a patient for maintenance PD, he/she should be informed aboutֺֺ the sequence of events involved in PD initiation, and arrangements should be made for catheter insertion.
  • 19 Chapter 2: Peritoneal Dialysis Catheter Insertion 2.1. Goals and targets To standardize PD catheter insertion technique between all units of the Sudan-PDֺֺ program, with the aim of minimizing surgical complications and catheter malfunction. To ensure that the new patient enters the system in a smooth uncomplicated wayֺֺ in order to promote his/her confidence and compliance. 2.2. Preparing the patient for catheter insertion Ensure that the patient requires the catheter and obtain a written informed consentֺֺ after explaining the procedure. Examine the abdomen for hernias or abdominal wall defects that may be correctedֺֺ at the time of catheter insertion; in such cases PD should be delayed for 4 weeks to minimize leakage. Take a nasal swab culture for Staph aureus; if positive, apply mupirocin nasalֺֺ ointment three times daily for 5 days. After specifying a date for the procedure, ensure that the patient’s name is put onֺֺ the operation list. If catheter insertion will take place under general anesthesia, request an ECG and CXR and confirm that the anesthetist has approved the procedure. Prescribe a laxative (e.g. lactulose, macrogols) for a couple of days preopera-ֺֺ tively to ensure that the patient has 2-3 motions per day. Prescribe an enema if necessary. On the pre-operative day, instruct the patient to have nil orally for 6-8 hoursֺֺ before the procedure. The patient should have a bath using antiseptic soap in the morning of surgery Give prophylactic antibiotic approximately 1 hour before the procedure; use aֺֺ first or second generation cephalosporin (e.g. cefazolin, cefuroxime). The patient must empty his/her bladder immediately before catheter placementֺֺ to avoid accidental bladder perforation.
  • 20 2.3. Catheter placement techniques PD catheters are flexible tubes with multiple ports in the distal (intra-abdominal)ֺֺ segment which is ideally positioned in the pelvis; the mid-portion is implanted within the abdominal wall via one to two Dacron cuffs to minimize the risk of PD related peritonitis. There are different types of PD catheters; however, there is no conclusive evidence that any catheter type is superior to the standard two-cuff Tenckhoff catheter (see figure 1). Several techniques can be used for PD catheter placement in uncomplicatedֺֺ patients, including blind percutaneous insertion, surgical insertion by dissection, and modified surgical insertion with a guide wire. The percutaneous technique utilizes the Tenckhoff trocar or the Seldingerֺֺ technique to insert the PD catheter blindly. Since lateral placement may be associated with injury to the inferior or superficial epigastric arteries, the catheter is often inserted through the linea alba, imposing a higher risks of hernia formation. This blind technique is not suitable for extremely obese patients or patients who have had previous abdominal surgery, since adhesions greatly increase the risk of bowel perforation. Surgical placement by dissection does not require sophisticated equipment andֺֺ can be done under local anesthesia in a clean room or minor theater. It is an open technique with a very low incidence of bowel perforation or vessel injury. However, deep pelvic location of the catheter cannot be visualized, and the incision is relatively large requiring more healing time to avoid peritoneal leaks. Figure 1: Different types of PD catheters Swan neck catheter with straight and coiled tails Two cuffed Tenckhoff catheter with straight tail Two cuffed Tenckhoff catheter with coiled tail
  • 21 Modified surgical placement with a guide wire is associated with a lower risk ofֺֺ fluid leak compared to surgical placement by dissection, and is preferred when urgent dialysis is needed. Laparoscopic placement requires special equipment and expertise, but entails aֺֺ relatively small incision and minimizes the risk of bowel perforation. In addition, it permits the operator to deal with adhesions and perform omentectomy if necessary, and allows visualization of deep pelvic location of the catheter. If available, this technique is preferred for complex cases. To achieve good short and long term results, all PD catheters must be placed byֺֺ a competent and experienced team. Regardless of technique, the procedure must take place under aseptic conditions, using face masks, gowns and sterile gloves. PD catheters planned for chronic use should always be inserted in a paramedianֺֺ location rather than in the midline. This allows the deep cuff to be placed within or below the rectus muscle, providing better structural support for the catheter. This also minimizes the risk of peritoneal leak and hernia formation. To minimize the risk of catheter related infections, the inner cuff must be placedֺֺ deep to the rectus muscle, the subcutaneous tunnel must have a downward (or if necessary lateral) direction, and the exit site must be created with a puncture hole rather than a scalpel to produce a tight fit around the catheter and avoid the use of sutures. Chose a suitable location for the exit site with the patient in an upright (sitting orֺֺ standing) position and mark it with permanent ink. The exit site should be preferably placed in the right or left iliac fossa in a locationֺֺ that is easily accessible to the patient. It should not be placed on the belt line, on a scar or under an abdominal hang in obese patients. Considering individual variation of abdominal size, care is required to ensureֺֺ deep pelvic location of the catheter. Identify the suitable location for catheter insertion by using stencil (template of catheter shape and measures), or by putting the upper border of the coiled end of the catheter adjacent to the border of symphysis pubis with the catheter lying in the para-median plane and marking the site of catheter insertion at the level of the deep cuff (see figure 2).
  • 22 2.4. Procedure for surgical placement by dissection Let the patient lie flat on one pillow, and tell him/her what will happen at each1. stage of the procedure. Give IV sedation slowly (e.g. fentanyl, morphine or pethidine with metoclopramide). Scrub up and lay out catheter insertion set trolley.2. Anesthetize the catheter insertion site with lignocaine 2%, diluted 1:1 with3. normal saline. Inject down towards the peritoneum making sure that you aspirate before injecting. At the site previously marked for catheter insertion, make a 5-6 cm horizontal4. incision with its center being in the para-median plane. Dissect deeply until you reach the outer rectus sheath; open the sheath longi-5. tudinally to a length of 4-5 cm. Separate the rectus muscle fibers using blunt retractors until you find the inner rectus sheath just deep to the muscle fibers. Hold the inner rectus sheath using a blunt artery forceps, and use size 0 or 16. absorbable suture to make a purse-string through both the inner rectus sheath and the parietal peritoneum. Be careful to avoid puncturing the bowel or accidentally including the omentum in the stitch. Figure 2: Sellecting the suitable location for catheter insertion deep cuff symphysis pupis Figure 3: The subcutaneous tunnel and location of the exit site
  • 23 Make a small 1 cm long incision in the middle of the pre-formed purse-string.7. Gently introduce a blunt dissection forceps through this opening; if it moves freely in all directions then it is within the peritoneal cavity. Flush the PD catheter with heparinized saline, and then introduce a rigid stylet8. into it. To prevent twisting during insertion, check that the catheter is well aligned by looking at the white line that runs alongside the catheter. While holding the inner rectus sheath and the peritoneum by the blunt artery9. forceps, introduce the stylet gently though the opening. Direct the stylet caudally towards the pelvis. The stylet must be kept adherent to the inner surface of parietal peritoneum while advancing the catheter in; this would prevent the catheter being pushed between bowel loops which may result in mal-position or perforation. Stop advancing the catheter once the inner cuff is just superficial to the inner rectus sheath Remove the stylet and check the patency of the catheter by infusing 10 ml of10. heparinized saline. If the saline is not infused smoothly, withdraw and re-position the catheter. Close the purse-string knot and secure the deep cuff to the inner rectus sheath by11. two stitches; avoid puncturing the catheter during stitching. Assess the catheter inflow and outflow rate by infusing about 200 ml of normal saline. Suture the anterior rectus sheath continuously, with the catheter extruding from12. the most cranial edge of the incision. Feel for minor defects after closing the sheath and repair them to prevent the development of incisional hernia and early peri-catheter leak. After anesthetizing the area, use the curved metal tunnel device to make a curved/13. arcuate subcutaneous tunnel extending from the site of catheter insertion to the pre-marked exit site. When you reach the exit site, puncture the skin with the tip of the tunnel device. The exit site should be facing downward or laterally (see figure 3). Connect the tip of the catheter to the end of the tunnel device and secure it with a14. knot to prevent dislodgement. Pull the tunnel device through the exit site carefully. Insure that position of the superficial cuff is at least 2 cm deep the exit site to prevent cuff expulsion. The puncture at the exit site should tightly enclose the catheter to avoid the need for stitching. Close the incision at the catheter insertion site and cover it with sterile dressing.15.
  • 24 2.5. Procedure for modified surgical placement with a guide wire The procedure is similar to the surgical technique described above until the inner1. rectus sheath is identified (section 2.4: steps 1-5). 6. Once the inner rectus sheath is identified, hold it with small artery forceps and insert a 16-18 gauge introducing needle. It is safest to attach a syringe to the needle and inject normal saline while pushing the needle inside to minimize the risk of bowel perforation. If the tip of the needle is in the peritoneum, the plastic sheath should be advanced. If no sheath is found then use the needle in the catheter kit, but caution is required. 7. Infuse 300 ml of normal saline through the plastic sheath or the introducing needle while keeping its tip inside the peritoneum directed towards the pelvis. If the saline is infused smoothly, advance the guide wire through the plastic sheath or introducing needle. 8. The wire should feed in very easily. If there is resistance, the technique should be abandoned. The most common cause for this is a loop of bowel loaded with feces or the existence of adhesions. In this case, the surgical technique could be used. 9. Remove the plastic sheath or introducer needle over the wire. Use the rigid dilators over the guide wire to make track for the catheter; start with the smaller dilator. 10. Insert a larger dilator with a ‘peel-away’ sheath over the guide wire trying to direct it down into the pelvis. Remove the guide wire and dilator together leaving the large sheath. Insert the catheter through the sheath then peel it off. 11. Make the tunnel and the exit site and close the incision as described above (section 2.4: steps 12-15).
  • 25 2.6. Post operative care After implantation, the exit site should be covered with several layers of sterileֺֺ gauze; avoid transparent and occlusive dressings because drainage tends to pool at the exit site and in the wound therefore encouraging bacterial overgrowth. Connect the plastic adaptor and the transfer set immediately postoperatively;ֺֺ flush with small volumes of a 2 liter PD bag (4-5 quick cycles) until the effluent is clear, then leave 200 ml with 500-1000 units of heparin inside the peritoneal cavity and cap. If the effluent does not clear of blood clots and fibrin: admit the patient to theֺֺ ward, continue two hourly flushing by 500 ml of dialysate with heparin (500-1000 unit/liter) until it clears. Obtain an abdominal X ray (postero-anterior and lateral views) postoperativelyֺֺ to ascertain pelvic catheter location. Observe the patient in the ward for at least 2 hours, discharge home if no complications occur. Provide an analgesic prescription upon discharge (e.g. paracetamol, tramadol,ֺֺ nefopam). Use NSAIDs only if the patient has no significant RRF, i.e. if the patient is anuric (e.g. diclofenac, ibuprofen). Instruct the patient to keep the catheter immobilized until the exit site and tunnelֺֺ are completely healed (this usually takes at least 4-6 weeks) Instruct the patient to keep the dressing dry and clean. He/she should avoidֺֺ tub baths with a PD catheter in place and avoid showers until the exit site is well-healed (usually 2-3 weeks post-operative). Sponge baths should be used during this period. The patient should avoid constipation and straining by eating a high fiber-diet.ֺֺ He/she should avoid stair climbing or lifting heavy objects for 6 weeks post- operative. Severe cough or bleeding should be reported immediately. After one week of catheter placement, admit the patient for dressing change andֺֺ flushing with heparinized dialysate. Repeat once weekly until PD is begun. Dressing may be done sooner than one week if obvious bleeding or signs ofֺֺ infection occur, if sweating makes the exit site wet, if the patient feels itchy under the taped skin or if the stickiness of the tape is lost.
  • 26 Dressing changes should be restricted to trained nurses under aseptic techniqueֺֺ with face masks and sterile gloves. It should be followed by application of gentamicin ointment or drops. Remove sutures after 2 weeks if the wound is well healed.ֺֺ Unless otherwise indicated, it is advisable to postpone PD for 10-14 days afterֺֺ catheter placement to allow for better healing and prevent fluid leak. If dialysis is required immediately after catheter placement, use intermittentֺֺ PD with the patient in the supine or semi-recumbent position. Use small dwell volumes (500-1500 ml) and a dwell time of 3-4 hours for 6-8 cycles. The titanium adaptor should be connected when PD is initiated, after completingֺֺ training and ascertaining that the catheter is functional.
  • 27 Table 4: Drugs mentioned in this chapter Generic name Formulation Dose for adult PD patients Cefazolin Injection (IV) 1 g IV (prophylactic dose) Cefuroxime Injection (IV) 750 mg IV (prophylactic dose) Diclofenac Tabs, injection (IM) 25-50 mg PO, IM every 6 hours Fentanyl Injection (IV) 50 mcg IV slowly, repeated as needed Gentamicin Ointment Prn Ibuprofen Tabs, suspension 200-600 mg PO every 6 hours Lactulose Solution 15 ml PO every 12 hours starting dose Macrogols Oral powder 1–2 sachets/d, in 200 ml water Morphine Tabs, injection (SC, IV, IM) 5 mg PO, SC, IM or 2.5 mg IV q 4 hours Metoclopramide Tabs, injection (IV, IM) 5 mg PO, IV, IM tds Mupirocin Nasal ointment tds for 5 days Nefopam Tabs, injection (IV) 30-60 mg PO tds Pethidine Injection (SC, IV, IM) 25-50 mg SC, IM or 12.5-25 mg IV q 4 hours Paracetamol Tabs 0.5-1 gm PO every 6 hours Tradamol Caps, injections (IV, IM) 50 mg PO, IV, IM every 4 hour
  • 28 Chapter 3: Patient Training 3.1. Goals and targets To ensure that all important aspects of patient training are addressed adequately,ֺֺ with an emphasis on the patient’s role as an active member of the PD team. 3.2. Pre-requisites to patient training The exit site should be healed and the catheter should have been flushed within aֺֺ few days of the training period to ensure patency and functioning. For training to be successful there should be a dedicated training area away fromֺֺ the busy ward area. Training should be conducted on one-to-one basis with the same nurse. The training period should be utilized to highlight the active role of the patient asֺֺ a member of the PD team; this is the cornerstone for successful PD. 3.3. Important aspects of patient training The training period should be divided into 5 sessions of about 90 minutesֺֺ duration. The training period should be extended if necessary until the PD team is satisfied that the patient can reliably perform PD on his own (see table 5). The basic principles of PD should be explained to the patient with the aid ofֺֺ pictures and illustrations, including the name and function of parts of the PD catheter, transfer set, disconnect system, and dialysis solutions (see figure 4). Emphasis should be placed on the vital importance of the aseptic technique andֺֺ personal hygiene, including clipping fingernails at all times. The patient should be trained on the correct hand washing technique, exchange procedure and healthy exit site care procedure according to the standard protocol. The importance of strict adherence to the recommended procedure should be adequately explained to the patient. Training for patients who are going to use automated peritoneal dialysis (APD)ֺֺ should include explanation of the machine parts, the sequence of events for each cycle, how to clean and set the machine, how to connect and disconnect at the end of dialysis, and how to respond to alarms.
  • 29 The patient should be trained to recognize and report the following problems:ֺֺ contamination, cloudy effluent, unhealthy exit site, negative drain volume, fluid overload, dehydration, inflow or outflow obstruction, fibrin in the drained dialysate, leakage, and constipation. The patient should understand how to order and store supplies, how to recordֺֺ information in the log book, when to come for follow up, and how to contact the PD team in case of emergencies. The training period should also be utilized for addressing queries and worries,ֺֺ providing dietary advice, estimating the dry weight, and revising regular medications. The patient should be provided with printed educational material to take homeֺֺ after completion of training. Patients should have community visits by nurses soon after initiating PD to assessֺֺ the home environment and evaluate the patient’s PD technique. Subsequent visits should be arranged as the patient’s condition dictates and after episodes of peritonitis. Regular clinic visits should be arranged every 1-3 months or more oftenֺֺ according to the patient’s condition, in order to perform clinical assessment and check biochemical parameters. Figure 4: Dialysis equipment Y set and double bag clamp catheter titanium adaptor transfer set
  • 30 Table 5: Suggested training schedule (modify according to patient’s needs) First day Explain the principles of peritoneal dialysis and the names of catheter parts Explain the importance of good hygiene and the correct way for bathing Demonstrate the correct hand washing procedure Demonstrate the correct exchange procedure Demonstrate the correct exit site care procedure Second day Discuss with patient the effect of PD on his/her life style Provide patient with dietary advice Patient practices hand washing Patient practices the exchange procedure Patient practices exit site care Third day Explain how to record information in the log book Explain how to measure weight Explain how to inject EPO Patient practices hand washing Patient practices the exchange procedure Patient practices exit site care Fourth day Explain how to handle potential problems, including peritonitis Review patient ability to measure weight, record information and inject EPO Patient practices hand washing Patient practices the exchange procedure Patient practices exit site care Fifth day Ensure patient can perform all procedures independently Ensure patient knows how to handle potential problems, including peritonitis Review regular medication Explain how to order and store supplies Explain how to contact PD team in case of emergencies Explain when to come for follow up
  • 31 3.4. Aseptic technique Aseptic technique is a set of specific practices and procedures performed underֺֺ carefully controlled conditions with the goal of minimizing contamination by pathogens. Aseptic technique should be practiced every time the catheter or exit site areֺֺ handled. This includes proper hand washing, proper preparation of the work area, and proper handling of equipment and supplies Proper hand washing refers to scrubbing the hand for at least 15 seconds withֺֺ the six steps method outlined below, using clean tap water and antibacterial soap. If tap water is contaminated or is coming from a well, bottled or boiled water should be used instead. If liquid soap is not available, a soap bar can be used. If soap and water are not available, an alcohol based cleansing agent that contain at least 60% isopropanol or ethanol should be used instead. If a cleansing agent is used for hand washing, sufficient amounts should be usedֺֺ to wet the hands all over, followed by scrubbing the hand with the six steps method outlined below without using a towel to dry the hands. If hands are dry in less than 15 seconds, the user has not applied enough amount of sanitizer. Cleanser type may be individualized based upon allergies, but it should not be transferred to another container because of the risk of contamination. Exchanges and exit site care should be performed in a clean room, with the doorsֺֺ and windows closed and the fans turned off. There should be no animals in the room. Supplies should be collected on a clean table. The tips of the transfer set and the Y shaped giving set should not touchֺֺ anything while performing the exchanges. If the end of the Y shaped giving set is contaminated the double bag must be discarded and a new set used instead. If the end of the transfer set is contaminated, the patient must not continue with the exchange and he/she must present to the center for transfer set changing. Prophylactic antibiotics should be prescribed for two days in case of transfer set contamination. If medications are to be infused into the medication port of the bag, povidoneֺֺ iodine should be applied to the port until it dries, and the tip of the syringe should not be allowed to touch anything.
  • 32 3.5. Proper hand washing technique (see figure 5) 1. Remove your rings and watch and wet hands and wrists with running water 2. Apply liquid soap or leather soap bar. 3. Scrub hands well palm to palm (step 1). 4. Scrub back of each hand with palm of other hand (step 2). 5. Scrub between and around fingers (step 3). 6. Scrub back of fingers with palm of other hand with fingers interlocked (step 4). 7. Scrub each thumb in opposite hand clasped (step 5) 8. Scrub fingertips of each hand clasped in palm of other hand (step 6). 9. Rinse thoroughly under running water. 10. Pat hands dry with clean towel. 11. Turn off water using same towel. 12. Do not touch anything except supplies.  Figure 5: Correct hand washing technique (scrub for 15-20 seconds at least)
  • 33 3.6. The double-bag system The transfer set is a short 10-15 cm tube attached to the titanium adapter at the endֺֺ of the catheter to make the external part of the catheter longer and easier for the patient to handle. It should be changed every 6 months to avoid physical damage from heavy use. It should also be changed following an episode of peritonitis and if its tip is contaminated. The dialysis system comes in the form of a Y shaped giving set with two bagsֺֺ attached to its long arms: a full bag containing the dialysate and a sterile empty bag. During an exchange, the short arm of the Y shaped giving set (connector) shouldֺֺ be connected to the end of the transfer set without touching either end. The old dialysate is first allowed to drain from the peritoneum into the empty bagֺֺ through the transfer set and the Y shaped giving set. Following that, a small amount of fluid from the new bag is allowed to flowֺֺ directly into the drain bag through the giving set to flush away any bacteria at the end of the catheter. After flushing, the new dialysate is allowed to flow from the new bag into theֺֺ peritoneal cavity through the Y shaped giving set and the transfer set. When this is completed, the giving set is disconnected and a sterile cover isֺֺ placed on the tip of the transfer set. The use of the Y shaped giving set allows the patient to disconnect from the bagsֺֺ between the exchanges, hence it was called the disconnect system. Attaching a new dialysate bag to one arm of the Y shaped giving set while a drain bag is attached to its other arm is called the double-bag system. Both modifications of the exchange technique have dramatically reduced the incidence of PD related peritonitis. Different manufacturers of PD supplies use different mechanisms to controlֺֺ the flow of fluid through the Y shaped giving set (e.g. Baxter twist valve and Fresenius disk). The principles, however, are the same (see figure 6).
  • 34 3.7. The exchange procedure 1. Prepare: Make sure the environment is clean (closed doors and windows, fans turned off, good light, no animals), collect supplies on a clean table, wash hands with the six steps method, remove the dialysate bag from the protective packaging and inspect it, remove transfer set form clothing and make sure the twist valve is closed, clamp the tubing connected to the full dialysate bag, remove spike protector from new bag and spike it. 2. Connect: Hold the connector in your right (dominant) hand and remove the cover (pull ring or cap) from its tip with you left hand. Hold the transfer set in you left hand and remove the protective cover (mini-cap) from its tip with you right hand while still holding the connector. Firmly attach the connector to the transfer set by twisting without allowing either tip to touch anything, then cover them with a piece of gauze saturated with iodine. After that, hang the full dialysate bag from an elevated location (e.g. a coat hook) and place the empty bag on the floor (see figure 7). 3. Drain: Open the twist valve of the transfer set, and allow the effluent to drain from the peritoneum into the empty bag. This should take approximately 15-20 minutes. 4. Flush: Close the twist valve, open the clamp on the upper tubing connected to the new dialysate bag, and allow a small amount of dialysate to drain directly from the upper new dialysate bag into the lower drain bag to clear the line from air and other impurities (count 5 slowly). Figure 6: The double-bag system new dialysate bag drain bag catheter transfer set Y shaped giving set
  • 35 5. Fill: Clamp the drain line, open the twist valve, and allow the new dialysate to flow from the upper bag into the peritoneum. This should take about 10-15 minutes. 6. Disconnect: Close the twist valve, disconnect the connector from the transfer set, and place a new protective cover (mini-cap) on the tip of the transfer set without touching it. Inspect the effluent, record its volume, drain it into a toilet, and discard exhaust dialysis supplies. 3.8. Healthy exit site care The PD catheter and transfer set or extension should remain securely taped toֺֺ the abdomen at all times to minimize trauma. Some patients may use a belt or an immobilizer. When securing the PD catheter, ensure that the catheter follows its naturalֺֺ direction and does not bend at its connection to the adapter, as the catheter can crack over time and this puts the patient at risk for getting peritonitis. Tub baths should not be taken with a peritoneal catheter in place to avoid con-ֺֺ tamination with water borne organisms. Showers may be taken once the exit site is well healed, but the patient must avoid scrubbing the exit site. After showers, the exit site should be dried first with a clean personal towel, then the rest of the body. Figure 7: the correct method for connection
  • 36 Routine exit site care should be done daily by the patient and after each shower.ֺֺ Exit site care should be done twice daily during an infection episode. For cleaning the exit site care, it is preferred to use a piece of gauze saturatedֺֺ with normal saline. Alcohol based solutions can be used instead, but their prolonged use should beֺֺ avoided as it may cause catheter damage. Routine use of hydrogen peroxide should also be avoided because it is drying.ֺֺ Crusts should not be forcibly removed, and the exit site should never be handledֺֺ with sharp instruments. If the exit site is well healed there is no need for covering with gauze in adults.ֺֺ However, the use of sterile occlusive dressings is recommended for children and has been shown to result in fewer exit site infections in this group of patients. If the patient is admitted or unable to perform exit site care independently, itֺֺ should be done by a trained PD nurse and documented on the patients care records. Gloves are not required for clean dry exit sites, clean gloves (not sterile) may beֺֺ used if there is discharge at the exit site. Masks may be used if the person has a cold. 3.9. Exit site care procedure Make sure the environment is clean (closed doors and windows, fans turned off,1. no animals). Collect the following supplies on a clean table: normal saline, povidone iodine,2. gentamicin cream or eye drops, a package of small gauze, clean towel (may use gauze instead) and a tape for immobilization. Wash hands with the six steps method using water and antibacterial soap or3. cleansing agent. Expose the exit site leaving the PD catheter and transfer set taped to the4. abdomen. Examine the exit site for signs of infection, e.g. redness, swelling, bleeding,5. crusting or discharge.
  • 37 Saturate a piece of gauze with normal saline and gently clean the skin in a circular6. motion starting from the exit site and working outwards, and dry the exit site with a clean towel. Saturate a piece of gauze with iodine, paint a small circle around the exit site in7. a circular motion working from the exit site outwards, and allow to air dry for 30-60 seconds. Saturate a piece of gauze with gentamicin cream, paint a small circle around8. the exit site in a circular motion working from the exit site outwards, or apply gentamicin drops instead. Apply sterile occlusive dressings (recommended only for pediatric patients) and9. securely tape the PD catheter and transfer set to the abdomen
  • 38 Table 6: Drugs mentioned in this chapter Generic name Formulation Dose for adult PD patients Gentamicin Drops (0.3%) or ointment (0.1%) prn Povidone Iodine Solution prn
  • 39 Chapter 4: Dialysis Prescription and Monitoring 4.1. Goals and targets To promote individualization of dialysis prescription in order to achieve the bestֺֺ possible patient outcomes. To promote timely transfer to HD if the optimal PD dialysis prescription is noֺֺ longer adequate for an individual patient’s needs. To stress the importance of preserving residual renal function for as long asֺֺ possible. 4.2. Principles of peritoneal dialysis Solute transfer in PD occurs by diffusion through the peritoneal membrane downֺֺ a concentration gradient, usually form blood to dialysate, until equilibration is achieved. Fluid movement in PD is determined by osmosis; more fluid removal (UF)ֺֺ is achieved by increasing the osmotic pressure within dialysate, usually by increasing the dialysate dextrose concentration. Fluid movement in turn induces a movement of solutes by convection or solvent drag. Some dialysate is absorbed through peritoneal lymphatics into the systemic circulation. Accordingly, efficiency of PD depends on the total time on dialysis and the dwellֺֺ time of each exchange, number of exchanges, peritoneal membrane characteris- tics (surface area, blood flow and permeability) and UF rates. Urea clearance achieved on PD is much less than clearance achieved on HD, butֺֺ both dialysis modalities achieve similar clinical outcomes. The explanation may relate to clearance of middle sized and large molecules which is better in PD, or to the relation between peak urea level, which is higher in HD, and uremic symptoms. Available dextrose concentrations include 1.36%, 2.27% and 3.86% of dextroseֺֺ anhydrous, which is the preferred method of stating dextrose concentration in Europe. These concentrations are identical to 1.5%, 2.5% and 4.25% respectively of dextrose monohydrate, which is the preferred method of stating dextrose con- centration in the United States.
  • 40 4.3. Different peritoneal dialysis modalities Continuous ambulatory peritoneal dialysis (CAPD) is a continuous modality ofֺֺ PD that is performed manually; it involves multiple exchanges during the day (usually three) followed by an overnight dwell (a fourth exchange). Daytime ambulatory peritoneal dialysis (DAPD) is an intermittent modality ofֺֺ PD that is performed manually; it involves multiple exchanges during the day with a dry abdomen during the night. Automated peritoneal dialysis (APD) is a modality of PD that is performed withֺֺ the assistance of an electronic device. It has different variations, including NIPD, TPD, CCPD and OCPD. Nightly intermittent peritoneal dialysis (NIPD) is an intermittent APD techniqueֺֺ in which the patient is attached to a cycling machine for a number of hours (usually nine) at night during which time the cycler delivers a number of exchanges, leaving the abdomen dry during the day. Tidal peritoneal dialysis (TPD) is an intermittent APD technique in which theֺֺ patient remains attached to the cycling machine for the usual time overnight, but more frequent cycles are performed with only 50-75% of the dwell volume being exchanged at each cycle. This expensive modality is usually utilized for patients with inflow/outflow pain and for patients with slow peritoneal drainage. Continuous cycler peritoneal dialysis (CCPD) is a continuous APD technique inֺֺ which a cycler delivers 3 to 6 exchanges during the patient’s sleep, leaving some dialysate in the peritoneal cavity to dwell during the day. Optimized cycler peritoneal dialysis (OCPD) is a continuous APD technique inֺֺ which a cycler delivers 3 to 6 exchanges during the patient’s sleep, followed by a long daytime dwell, and an extra exchange that is usually performed manually during the day. Classic intermittent peritoneal dialysis (IPD) is a form of dialysis in whichֺֺ multiple short exchanges are performed on an intermittent basis, either manually or utilizing an automatic cycler. A regimen commonly used entails 1-2 sessions per week each of 48-72 hours duration, utilizing 24 liters of dialysate per 24 hours, in the form of 2 liter exchanges each of 2 hours duration. This regimen is rarely sufficient for long-term management. IPD is mostly used as a temporary form of dialysis in ARF or for the management of frail elderly patients who are not suitable for HD but are also unable to manage their own PD.
  • 41 Continuous flow peritoneal dialysis (CFPD) is an experimental modality wherebyֺֺ two peritoneal catheters or one catheter with two ports are used to provide a continuous inflow and outflow of dialysate; achieving clearances similar to those obtained with daily hemodialysis. 4.4. The optimal PD modality The peritoneal membrane transport characteristics (see section 4.11) can helpֺֺ guide the optimal PD modality choice. Rapid transporters remove solutes effectively even during short dwell times.ֺֺ However, they quickly absorb dialysate glucose thereby removing the osmotic stimulus to UF. Consequently, they may have low or negative UF during long dwells unless concentrated dextrose is used. On the other hand, slow transporters need long dwell times to adequately removeֺֺ small solutes from the blood, but UF is not a problem in this setting since glucose is also absorbed slowly and maintains the osmotic stimulus to UF for long durations. For rapid transporters, dialysis modalities with multiple short dwells (e.g. NIPD)ֺֺ are more suitable than modalities with long dwell times (e.g. CAPD). For slow transporters, dialysis modalities with long dwell times (e.g. CAPD) areֺֺ more suitable since they are unlikely to achieve adequacy targets on modalities with short dwell times (e.g. NIPD). Patients new to PD usually have some RRF that can provide additional UF andֺֺ augment the solute clearance achieved by dialysis. In this setting, it may not be necessary to match dwell time with transporter type. However, as RRF declines over time it becomes increasingly important to match dwell time to transport type in order to achieve adequate dialysis. Continuous rather than intermittent PD modalities should be utilized in a patientֺֺ with minimal RRF in order to maximize middle-sized molecule clearance. CAPD and CCPD usually achieve similar weekly clearances. If both forms areֺֺ available, the patient may choose the modality which is more suitable to his/her lifestyle.
  • 42 4.5. Initial Dialysis Prescription It is possible to initiate PD in small doses depending on the patient’s RRF andֺֺ gradually increase the dose as RRF declines. For example, a male who weighs 67 kg and has a urea clearance of 5-6 ml/min (weekly Krt/Vurea ~ 1.4) may need a single 2 liter overnight exchange per day (weekly Kpt/Vurea ~ 0.3) to achieve the required total small solute clearance (weekly Kt/Vurea ~ 1.7). If this incremental approach is adopted, residual GFR should be calculated asֺֺ the average of urea and creatinine clearances, and not estimated from prediction equations. The aim is to account for the overestimation of GFR induced by creatinine secretion. Another approach is to initiate PD empirically according to the patient’s bodyֺֺ surface area (BSA) and estimated GFR, to approximately provide a weekly Kpt/Vurea of around 2. The PD dose can be modified later according to adequacy measures (see tables 7 and 8). The BSA can be estimated using Mosteller formula.ֺֺ Mosteller formula Table 7: Empirical PD prescription at initiation of CAPD GFR > 2 ml/min GFR < 2 ml/min BSA < 1.7 m2 4 × 2.0 L exchange/day 4 × 2.5 L exchange/day BSA 1.7-2.0 m2 4 × 2.5 L exchange/day 4 × 3.0 L exchange/day BSA > 2.0 m2 4 × 3.0 L exchange/day 4 × 3.0 L exchange/day Table 8: Empirical PD prescription at initiation of CCPD GFR > 2 ml/min GFR < 2 ml/min BSA < 1.7 m2 4 × 2.0 L (9 hr/night) + 2.0 L/day 4 × 2.5 L (9 hr/night) + 2.0 L/day BSA 1.7-2.0 m2 4 × 2.5 L (9 hr/night) + 2.0 L/day 4 × 3.0 L (9 hr/night) + 2.5 L/day BSA > 2.0 m2 4 × 3.0 L (9 hr/night) + 3.0 L/day 4 × 3.0 L (10 hr/night) + 2×2.5 L/day BSA (m2 ) = _______________________ height (cm) x weight (kg) 3600
  • 43 4.6. Monitoring of PD adequacy An important measure of PD adequacy is the total small solute clearanceֺֺ expressed as the dimensionless parameter (Kt/Vurea), which is defined as either the total daily or weekly fractional clearance of body water from urea. The total solute clearance (Kt/Vֺֺ urea) is equal to the sum of the peritoneal solute clearance (Kpt/Vurea) and the residual kidney solute clearance (Krt/Vurea). In accordance with the KDOQI 2006 guidelines, the minimal “actually delivered”ֺֺ dose of small solute clearance for all patients should be a weekly Kt/Vurea of 1.7. The most common method to monitor delivered Kt/Vֺֺ urea is by the PD adequacy test, which should be performed within one month of dialysis initiation and every 6 months thereafter in order to ensure that targets are achieved and modify dialysis prescription if necessary. The test should also be done after any change in dialysis prescription and after any peritonitis episode. Monitoring Cֺֺ creat is not essential for CAPD patients, but the KDOQI guidelines recommend a weekly Ccreat of at least 45 L/week/1.73 m2 for APD patients. Ccreat can be measured during the PD adequacy tests. Attention should also be paid to urine and UF volume, with a fluid removalֺֺ target of at least 1 liter per day (combined urine and UF). UF volume is inversely related to survival, particularly in anuric patients. Clinical indicators of dialysis adequacy include uremic symptoms, nutritionalֺֺ status, energy level, hemoglobin concentration, response to erythropoietin (EPO) therapy, electrolytes and acid base balance, calcium and phosphate homeostasis, blood pressure control and fluid balance. If a patient is not thriving for no apparent cause other than uremia, an attemptֺֺ to increase the dialysis dose should be made, even if Kt/Vurea is well above the minimal target. However, poor patient compliance and a hypercatabolic state should not beֺֺ overlooked as possible causes for apparently inadequate dialysis. If solute clearance and/or UF volume are deteriorating despite optimal PDֺֺ prescription, an AV fistula should be created so that the patient can be electively transferred to HD in a timely manner.
  • 44 4.7. PD adequacy test PD adequacy test is utilized to measure delivered Kt/Vֺֺ urea and weekly Ccreat. It should be performed within one month of dialysis initiation and every 6 months thereafter. It should also be performed after episodes of peritonitis, after changing dialysis prescription, and whenever the patient’s clinical conditions deteriorates. PD adequacy test should only be performed when the patient is clinically stableֺֺ and at least 1 month after resolution of a peritonitis episode. If the patients has negligible RRF, indicated by a 24 hour urine volume less thanֺֺ 100 ml, then the 24 hour urine collection can be ignored and the Kt/Vurea should be considered equal to Kpt/Vurea. 4.8. Procedure for the PD adequacy test Ask the patient to collect 24 hr urine and bring it to hospital. Send this collection1. to the lab for urea and creatinine after recording its volume. Ask the patient to collect 24 hr dialysate sample by either of two ways:2. Take 10 ml from previous day’s lunch, evening, night and overnight drainֺֺ bags after mixing each bag by inverting it 2-3 times and recording the drain volume. Calculate the total 24 hr dialysate volume by summing the volume of individual drain volumes and record it as 24 hr dialysate volume. Mix the 4 samples together to make a 24 hr dialysate sample and send it to the lab for urea and creatinine. Or, ask the patient to bring the whole lunch, evening, night, and overnightֺֺ bags to hospital, mix together in a large jar and record the total volume as 24 hr dialysate volume. Draw a 10 ml sample from the mixture, label as 24 hr dialysate, and send to the lab for urea and creatinine. Withdraw a blood sample and send it to the lab for urea and creatinine.3. Calculate the patient’s volume of distribution as 60% of the weight for males and4. 55% of the weight for females, and use the following formulae: Weekly Kpt/Vurea = ____________________________________________________24 hr dialysate volume (liter) x dialysate urea (mg/dl) x 7 plasma urea (mg/dl) x volume of distribution (liter)
  • 45 A more simple approach would be to ask the patient to bring the whole lunch,5. evening, night, and overnight bags to hospital, mix together in a large jar and add to it the 24 hour urine volume. The resultant mixture would be the total 24 hour drain volume. Record this 24 hour drain volume, and send a 10 ml sample from it to the lab for urea and creatinine. Send a blood sample for urea and creatinine. Calculate the patient’s volume of distribution as above, and use the following formulae to calculate the total weekly Kt/Vurea and weekly Ccreat: Weekly Krt/Vurea = ____________________________________________________24 hr urine volume (liter) x urine urea (mg/dl) x 7 plasma urea (mg/dl) x volume of distribution (liter) Weekly Kt/Vurea = Weekly Kpt/Vurea + Weekly Krt/Vurea Weekly Ccreat (liter/week/1.73m2 ) = ______________________________________________________24 hr dialysate volume (liter) x dialysate creatinine (mg/dl) x 1.73 x 7 plasma creatinine (mg/dl) x BSA (m2 ) Weekly Kt/Vurea = ______________________________________________24 hr drain volume (liter) x drain urea (mg/dl) x 7 plasma urea (mg/dl) x volume of distribution (liter) Weekly Ccreat (liter/week/1.73m2 ) = ____________________________________________________24 hr drain volume (liter) x drain creatinine (mg/dl) x 1.73 x 7 plasma creatinine (mg/dl) x BSA (m2 )
  • 46 When performing the PD adequacy test, the obtained 24 hour urine and dialysate6. collections should be utilized in the estimation of dietary protein intake (DPI) by measuring protein equivalent of total nitrogen appearance (PNA) using the following formulae (see chapter 10): In stable patients for whom the membrane transfer characteristics has been7. previously established (see section 4.11), the delivered Kpt/Vurea, Ccreat and PNA can be calculated using commercially available computer programs such as PD AdequestTM (Baxter). All these calculations will require the mean dialysate concentration over 24 hours, which is obtained using the following formulae. PNA (g/day) = 6.25 x {urea appearance (g/day) + 1.81 + [0.031 x lean body mass (kg)]} Urea appearance (mg/day) = [24 hr dialysate volume (dl) x dialysate urea (mg/dl)] +[24 hr urine volume (dl) x urine urea (mg/dl)] Mean dialysate solute concentration in CAPD (mg/dl) = _______________________________________________sum of solute concentration of all exchanges (mg/dl) number of exchanges Mean dialysate solute concentration in APD (mg/dl) = _____________________________________________________sum of [solute concentration (mg/dl) x drain volume (liter)] of all exchanges sum of drain volume (liter) of all exchanges
  • 47 4.9. Peritoneal equilibration test (PET) The peritoneal equilibration test (PET) utilizes a standardized 4 hr exchangeֺֺ to quantify the rate of glucose absorption and the transport rates of different solutes across the peritoneal membrane as well as the UF volume in a particular patient. PET results are used to classify patients according to their peritoneal membraneֺֺ transport characteristics into 4 groups: low transporters, high transporters, low average transporters, and high average transporters (see section 4.11). PET results are also used to confirm UF failure and identify its cause, providingֺֺ an aid to further management (see section 4.12). PET results combined with the patient’s BSA allow calculation of predictedֺֺ Kpt/Vurea with a given PD regimen using UKM programs such as AdequestTM . If the predicted Kpt/Vurea is markedly different from the actually delivered Kpt/Vurea this may indicate patient incompliance. The PET test should be performed approximately one month after initiationֺֺ of PD to use as a baseline value and then repeated annually. The test is also performed when there is an unexpected change in UF volume or evidence of inadequate solute clearance, to help diagnose the cause of the problem and guide its management. 4.10. Procedure for the PET An overnight 8 to 12 hour exchange is performed using 2.27/2.5% solution. With1. the patient in an upright position, the overnight exchange is drained in the ward over no more than 25 minutes. Two liters of 2.27/2.5% dialysis solution are infused over 10 minutes with the2. patient in the supine position; the patient is rolled from side to side after every 400 ml infusion. At 0 time (just after the completion of infusion), drain 200 ml of dialysate, take a3. 10 ml sample and re-infuse the remaining 190 ml back into the peritoneal cavity. Label this as D0 and send to the lab for creatinine and glucose. Take a blood sample, label as P0 and send to the lab for creatinine and glucose. Allow the patient to ambulate freely during the 4 hours of the test.
  • 48 After 2 hours, drain 200 ml of dialysate, take a 10 ml sample and re-infuse the4. remaining 190 ml back into the peritoneal cavity. Label this as D2 and send to the lab for creatinine and glucose. Take a blood sample, label as P2 and send to the lab for creatinine and glucose. After 4 hours, drain the dialysate in the upright position over no more than 205. minutes, measure the drain volume then take a 10 ml sample, label this as D4 and send to the lab for creatinine and glucose. Take a blood sample, label as P4 and send to the lab for creatinine and glucose. The dialysate (D) to plasma (P) ratio for creatinine concentrations are calculated6. for different time points (D0/P0, D2/P2, D4/P4), as well as the ratio of dialysate glucose concentration at different time points to base line dialysate glucose con- centration (D2/D0, D4/D0). The results are plotted on the creatinine and glucose curves to determine the7. membrane type (see figure 8 and table 9). Table 9: Interpreting PET results according to D4 and P4 results Transport type D4/P4 urea D4/P4 creatinine D4/D0 glucose Drain volume High 0.98 – 1.09 0.82 – 1.03 0.12 – 0.25 1580 – 2084 High average 0.91 – 0.97 0.65 – 0.81 0.26 – 0.38 2085 – 2368 Low average 0.84 – 0.90 0.50 – 0.64 0.39 – 0.49 2369 – 2650 Low 0.75 – 0.83 0.34 – 0.49 0.50 – 0.61 2651 – 3326 Figure 8: Interpreting PET results
  • 49 4.11. Peritoneal membrane transport characteristics according to PET Low transporters: solute equilibration occurs late; as a result, the solute clearanceֺֺ and the UF volume increase almost linearly throughout long-dwell exchanges. Long dwell exchanges are suitable for this group of patients. High transporter: solute equilibration occurs early and dialysate glucose isֺֺ absorbed early, thereby removing the osmotic stimulus to UF. As a result, the solute clearance and UF volume begin to diminish after three to four hours of the exchange. Short dwell exchanges are suitable for this group of patients. Average transporter: the peak clearances are maintained for approximately 8-10ֺֺ hours. These patients can be effectively treated with either short or long dwell exchange techniques. Approximately two thirds of patients are expected to have average transport rates on baseline PET. 4.12. Causes of UF failure according to PET If a patient who has been maintained on PD for some time requires three orֺֺ more 3.86/4.25% dextrose solution exchanges to maintain dry weight, he/she is considered to have inadequate UF capacity. The PET test with 3.86/4.25% dextrose can be used to confirm UF failure (definedֺֺ as an UF volume of less than 400 ml after a four hour dwell with two liters of 3.86/4.25% dextrose) and to diagnose its cause. If the drain volume is low and the solute clearance has increased comparedֺֺ to base line (higher D/P creatinine ratio) in the absence of acute peritoneal inflammation, the patient is said to have type I membrane failure which is often related to long duration on PD or frequent prior peritonitis episodes. This may be managed by increasing the number of exchanges and reducing the dwell time in APD. Another approach would be to temporarily discontinue PD for four weeks, with the instillation of 100 to 200 ml of 1.36/1.5% dialysate containing 3500 units of heparin twice per week (allowed to dwell). This technique may allow the peritoneal function to return to earlier levels in 69% of cases. If the drain volume is low and the solute clearance has decreased compared to baseֺֺ line (lower D/P creatinine ratio) the patient is said to have type II membrane failure (e.g. peritoneal fibrosis, adhesions or sclerosing encapsulating peritonitis), which is often irreversible.
  • 50 If the dֺֺ rain volume is low and the solute clearance has not changed compared to base line (static D/P creatinine ratio), this indicates rapid lymphatic absorption, impaired free water transport, catheter malfunction or leakage of dialysate. If the patient is overloaded but the PET reveals a good drain volume and stableֺֺ membrane transport characteristics, this indicates loss of RRF, excessive fluid intake, or noncompliance with the dialysis prescription. 4.13. Optimizing solute clearance Solute clearance can be optimized by increasing the dialysis time, the dwellֺֺ volume (most effective approach) or the number of daily exchanges. UKM programs such as Adequestֺֺ TM can be used to predict the Kpt/Vurea obtainable with different PD regimens for a particular patient. These programs will require baseline membrane transport characteristics obtained from previous PET results and the patient’s BSA. After identifying the PD prescription that is expected to achieve the requiredֺֺ solute clearance for a particular patient, the PD dose is modified accordingly. Adequacy tests should be performed later to confirm adequate dose delivery. In CAPD, dialysis hours are fixed, and the dialysis dose can only be optimizedֺֺ by increasing the exchange volume as much as tolerated by the patient and by increasing the number of daily exchanges. There is, therefore, a practical limit to the amount of dialysis that can be delivered by CAPD. APD offers more flexibility in prescribing than CAPD; supine patients canֺֺ tolerate larger dialysate volumes, and the number of exchanges can be increased more easily as they are done by the machine and not by the patient. The limiting factors for increasing APD dose are the number of hours the patientֺֺ is prepared to remain attached to a machine and the cost of the dialysate. Adding one or two manual day time dwells is more cost effective than increasingֺֺ the number of night exchanges in APD. Large volume bags are also preferred because they are more economical and require fewer connections.
  • 51 4.14. Management of fluid overload Body weight monitoring is a simple way to monitor fluid status in the shortֺֺ term. However, if the patient is losing flesh weight, he/she can become fluid overloaded with little change in total body weight. Clinical features of fluid overload include high blood pressure, ankle edema,ֺֺ pulmonary edema and pleural effusions. Patients with coexisting cardiac disease will be at increased risk of developingֺֺ pulmonary edema with fluid overload. High BPindicates that fluid overload rather than heart failure is the main cause of pulmonary edema in a particular patient. Fluid balance is usually better on APD than on CAPD because less dextrose andֺֺ fluid is absorbed from the peritoneum during the short duration cycles. In patients who are hypertensive or who show evidence of volume overload, theֺֺ first step should always be dietary sodium and fluid restriction. In patients with significant RRF, loop diuretics can be utilized to increase theֺֺ urine output (e.g. furosemide). If diuresis fails to achieve the target dry weight, most patients will respond to anֺֺ increase of dextrose concentration in the dialysate. This is usually achieved by using concentrated dextrose during the overnight dwell in CAPD or during the long day dwell in APD. Increasing dextrose concentration in the dialysate may result in obesity andֺֺ peritoneal damage due to excessive exposure to glucose degradation products (GDPs). To preserve the peritoneal membrane, the lowest possible dialysate dextrose concentration should be used for as long as possible. If the patient is not responding adequately to concentrated dextrose, PET shouldֺֺ be performed to define the cause and guide further management (see section 4.12); optimizing the dwell time and exchange volume may effectively solve the issue. If available, the isotonic 7.5% icodextrin solution can be used in place ofֺֺ concentrated dextrose solutions in the management of overloaded patients. Icodextrin is a glucose polymer that penetrates the peritoneal membrane lessֺֺ effectively than dextrose, thereby maintaining the osmotic stimulus to UF for longer periods and achieving equivalent UF to hypertonic dextrose. It is usually used during the overnight dwell in CAPD or the long daytime dwell in APD.
  • 52 During an acute peritonitis episode, patients may have a transient increase inֺֺ peritoneal membrane permeability resulting in reduced drain volumes. They may benefit from temporally shortening the dwell time. Refrain from using concentrated fluids during episodes of peritonitis. 4.15. Assessing and preserving residual renal function RRF represents the residual function of the native kidneys or the in situ kidneyֺֺ allograft. Residual GFR is best estimated by the numerical average of the 24 hr creatinine clearance and urea clearance. There is a strong association between the presence of RRF and reduction ofֺֺ mortality in patients on PD therapy. In addition, even minimal RRF usually contributes significantly to the overall solute clearance and fluid balance. Hence, it is important to preserve RRF for as long as possible. In PD patients with RRF who need antihypertensive medication, preferenceֺֺ should be given to the use of ACEi or ARBs. In normotensive patient with RRF, consideration should be given to the use of ACEi or ARBs with the aim of kidney protection. Insults to GFR in patients with CKD should also be considered insults to RRFֺֺ in PD patients and should be avoided when possible. This includes the use of antibiotics with nephrotoxic potential (e.g. aminoglycosides), NSAIDs (including COX-2 inhibitors), intravenous contrast material, urinary obstruction, volume depletion and hypercalcemia. In addition, reducing the incidence of peritonitis may help conserve RRF sinceֺֺ peritonitis is associated with a faster decline in RRF. It is noteworthy that severe hypertension can cesult in acute kidney injuryֺֺ “malignant hypertension” as well as chronic kidney injury “hypertensive ar- teriosclerosis”. Adequate control of blood pressure with PD may lead to some improvement in kidney function, resulting in dialysis independency. Many patients who start PD therapy after a “failed” kidney transplant haveֺֺ significant RRF in the transplanted kidney. It is thought that the benefit of continued immunosuppressant (particularly with agents other than calcineurin inhibitors) on reserving RRF outweigh the risk when Ccreat is greater than approximately 1.5 ml/min.
  • 53 Table 10: Drugs mentioned in this chapter Generic name Formulation Dose in adult PD patients Furosemide Tabs, Injection (IV, IM) 40-1500 mg PO, IM or IV slowly in 1-2 doses
  • 54 Chapter 5: Management of Exit Site Infections 5.1. Goals and targets To promote effective and standardized management of exit site and tunnelֺֺ infections in all units of the Sudan PD program. 5.2. Prevention of exit site and tunnel infections Strict adherence to catheter insertion technique, aseptic technique, exchangeֺֺ technique, and healthy exit site care as outlined above is mandatory. 5.3. Diagnosis of exit site and tunnel infections Exit site infection is defined byֺֺ the presence of purulent drainage with or without erythema at the catheter-epidermal interface. A scoring system was developed for monitoring the exit site. Infection should be assumed with an exit site score of 4 or greater. Purulent drainage even if isolated is enough to indicate infection (see table 11). Isolated peri-catheter erythema is often a simple skin reaction to trauma, but mayֺֺ also be an early sign of infection.Ask the patient about accidental catheter trauma in the past few days. Advice the patient to perform exit site care twice daily using povidone iodine followed by dilute hydrogen peroxide, and to avoid occlusive dressing. Any worsening should be reported immediately, and reassessment by the PD team should be arranged within one week. Positive culture in the absence of abnormal appearance at the exit site is indicativeֺֺ of colonization rather than infection. More intensive exit site care is sufficient. Tunnel infection is characterized by erythema, edema or tenderness over theֺֺ subcutaneous pathway, but can be clinically occult. Tunnel infection usually occurs in the presence of an exit site infection and rarely occurs alone. During examination of the catheter exit site, the catheter tract should be milked to see if any drainage is present and observed for evidence of erythema overlying the tunnel. Staphylococcus aureus and Pseudomonas aeruginosa exit site infection are veryֺֺ often associated with concomitant tunnel infection, and these are the organisms that most often result in catheter infection related peritonitis; aggressive management is always indicated for these organisms.
  • 55 Table 11: Exit site scoring system 0 point 1 point 2 points Swelling No < 0.5 cm (exit only) > 0.5 cm (or tunnel) Crust No < 0.5 cm > 0.5 cm Redness No < 0.5 cm > 0.5 cm Pain No Slight Severe Drainage No Serous Purulent* * purulent drainage is diagnostic of exit site infection, even if isolated. 5.4. Treatment of exit site and tunnel infection Exit site infections can be managed initially by PD nurses using appropriateֺֺ protocols. If a clinical diagnosis of exit site and/or tunnel infection is made, take a swabֺֺ from drainage for Gram stain and culture. Oral therapy is as effective as intraperitoneal (IP) therapy, with the exception ofֺֺ Methicillin resistant Staphylococcal aurius (MRSA). Start empiric oral therapy with amoxicillin, cephalexin, or clarithromycin unless Gram negative infection is suspected, in which case oral ciprofloxacin should be used. Avoid ciprofloxa- cin in children less than 12 years old and use IP ceftazidime instead. If exit site infection is particularly severe, apply hypertonic saline dressingsֺֺ twice daily in addition to antibiotic therapy. The procedure involves adding 1 table spoon of salt to 500 ml of sterile water, applying this solution gauze and wrapping it around the exit site for 15 minutes. Modify treatment according to culture results. Treatment with two antibiotics,ֺֺ including ciprofloxacin, is indicated for Pseudomonas aeruginosa infection, with the addition of IP ceftazidime if the infection resolves slowly or recurs. Removal of the catheter is indicated if fungal infection is confirmed to preventֺֺ progression to fungal peritonitis. Continue treatment for at least 7 days after complete clinical resolution withֺֺ minimum treatment duration of two weeks. If the infection persists after two weeks of antibiotic therapy, ascertain that theֺֺ patient is complying with the therapeutic regimen and re-examine the catheter for evidence of tunnel infection.
  • 56 An ultrasound scan should be performed to exclude a small abscess formationֺֺ along the tunnel tract. An exposed external cuff should be completely shaved off under local anestheticֺֺ with debridement of the surrounding tissue to help clear the infection. Another two weeks of antibiotic therapy may be attempted provided the infectionֺֺ has not progressed, no abscess is present, and any exposed cuff has been trimmed. The catheter should be removed if the infection has progressed despite two weeksֺֺ of antibiotic therapy, an abscess is present, fungal infection has been confirmed, or peritonitis has developed. Catheter removal should be via surgical dissection rather than traction to avoidֺֺ retention of the cuffs. Antibiotics should be continued for one to two weeks after catheter removal. If the patient does not have peritonitis, a new catheter can be placed simultane-ֺֺ ously in the opposite lower quadrant. PD may be resumed immediately, initially in the supine position.
  • 57 Table 12: Drugs mentioned in this chapter Generic name Formulation Dose for adult PD patients Amoxicillin Caps, suspension, injection (IV, IM) 250-500 mg PO, IV, IM bd Cephalexin Caps, tabs, suspension 500 mg PO bd Clarithromycin Tabs, suspension, injection (IV) 250 mg PO, IV bd Ciprofloxacin Tabs, injection (IV) 500 mg PO bd Ceftazidime Injection (IV, IM) 0.5-1 g IV, IM od Hydrogen peroxide Solution (3-6%) prn Povidone iodine Aqueous solution, ointment (10%) prn
  • 58 Algorithm 1 Diagnosis and Management of Exit Site Infection
  • 59 Chapter 6: Management of PD Related Peritonitis 6.1. Goals and targets To promote effective and standardized management of PD related peritonitis inֺֺ all units of the Sudan PD program, in order to achieve a peritonitis rate of no more than 1 episode per 18 months at risk with minimal morbidity and mortality. 6.2. Prevention of PD related peritonitis Strict adherence to catheter insertion technique, aseptic technique, exchangeֺֺ technique, healthy exit site care and management of exit site infections as outlined above is mandatory. Adequate patient training reinforced by home visits is an effective tool in reducingֺֺ PD related infections. The abdomen should be dry and prophylactic antibiotics should be givenֺֺ before invasive procedure involving the abdomen or pelvis (e.g. PD catheter fluoroscopy, colonoscopy, renal transplant or endometrial biopsy) or extensive dental procedures. Patients should be instructed on the importance of regular bowel habits andֺֺ avoidance of constipation; a high fiber diet may be helpful but laxatives (e.g. lactulose, macrogols) are often required. To reduce the incidence of fungal peritonitis, patients should receive prophylacticֺֺ fluconazole with every antibiotic course of two weeks duration or more. Nystatin is a second line alternative to fluconazole. 6.3. Diagnosis of PD related peritonitis Cloudy effluent may be due to infectious or chemical peritonitis, effluentֺֺ eosinophilia, hemoperitoneum, malignancy, chylous effluent, or the specimen being taken from a dry abdomen. However, assume peritonitis in all patients presenting with cloudy effluent, andֺֺ attempt to confirm it by obtaining effluent cell count, differential, and culture. Consider the possibility of peritonitis in any PD patient presenting with abdominalֺֺ pain, fever, nausea or general ill health even if the effluent is clear.
  • 60 To prevent delay in treatment, peritonitis can be managed initially by PD nursesֺֺ using appropriate protocols. Start antibiotic therapy as soon as cloudy effluent is seen and a sample of the effluent has been taken, without waiting for confirmation by the cell count from the laboratory. In a suspected case of peritonitis, carefully inspect the exit site and the tunnel ofֺֺ the catheter for evidence of catheter infection; culture any drainage from the exit site along with the effluent. Effluent white blood cells of more than 100/µL, with at least 50% polymorpho-ֺֺ nuclear neutrophil cells, confirms the diagnosis of peritonitis. Patients who reside in remote locations should report symptoms suggestive ofֺֺ peritonitis immediately to the center, keep the cloudy effluent bag until they are able to bring in the sample for analysis, and possibly initiate IP antibiotics at home. 6.4. Sample Processing Send the whole bag to the microbiology department (preferably the first bagֺֺ noticed to contain a cloudy effluent); request effluent cell count and differential, gram stain, and culture. To attain the highest possible culture yield, centrifuge 50 ml of peritoneal effluentֺֺ at 3000g for 15 minutes, mix the sediment in 3–5 ml of sterile saline and inoculate this material both on solid culture media (incubated in aerobic, micro-aerophilic, and anaerobic environments) and into a standard blood culture medium. If equipment for centrifuging large amounts of fluid is not available; inject 5–10ֺֺ ml of effluent directly into blood culture bottles. If blood culture bottles and large centrifugation machine are not available; shake theֺֺ bag manually, take 5 ml of effluent and inoculate in solid culture media. Store the whole bag in an incubator to encourage growth and test the effluent daily if feasible. A positive culture in the absence of a significant WBCs count representsֺֺ contaminants and should not be considered as peritonitis. Gram stain is important in that it may indicate the presence of fungi, thus allowingֺֺ for prompt initiation of antifungal therapy and permitting timely arrangement of catheter removal. With this exception, empiric therapy should not be based on the Gram stain, but should follow the protocol as outlined below. Rate of culture negative peritonitis should not exceed 20%; otherwise, cultureֺֺ methodology should be reviewed and improvements instituted as required.
  • 61 6.5. Treatment principles and steps Relieve pain using paracetamol anֺֺ d opioid analgesics for patients with significant RRF (e.g. tramadol, morphine, pethidine). Use NSAIDs for patients without significant RRF (e.g. Ibuprofen, diclofenac). Start empirical IP treatment with a first and third generation cephalosporin (e.g.ֺֺ cefazolin plus ceftazidime). Aminoglycosides can be used as alternatives to third generation cephalosporins for gram negative coverage if third generation cepha- losporin are not available. Aminoglycosideusecarriestheriskofirreversiblecochlearandvestibularototoxicityֺֺ especially with large doses, prolonged or frequent administration and increasing age. To reduce this risk, use intermittent IP dosing. The above regimen is recommended for pediatric patients unless the child hasֺֺ fever, severe abdominal pain, or a risk factor for severe infection (e.g. history of MRSA infection, recent or current evidence of PD catheter infection, exit site or nasal colonization with Staphylococcus aureus, or age less than 2 years). In such cases use vancomycin or teicoplanin in combination with a third generation cephalosporin as initial therapy Patients with extremely cloudy effluent may benefit from heparinization of theֺֺ dialysate (500 units of heparin per liter) to prevent occlusion of the catheter by fibrin. Refrain from using concentrated fluids during episodes of peritonitis. Within 48 hours of initiating therapy, most patients will show considerableֺֺ clinical improvement and the effluent will be visibly clearing. By this time the initial culture results should have come allowing treatment to be modified accordingly. If there is no improvement after 48 hours, consider placing the patient on IPD forֺֺ 24 hours in an attempt to clear the effluent. Then, keep the abdomen dry for 2-3 days apart from a single daily exchange with antibiotics. There is some evidence that white cells in peritoneum function better in the absence of any dialysate. After 72 hours of initiating therapy, repeat peritoneal effluent WBC count andֺֺ differential. If the infection is resolving, continue treatment for two weeks and change the transfer set after completion of therapy.
  • 62 If the effluent WBC count reveals that the infection is not resolving and theֺֺ first culture result remains negative at 72 hours, send another effluent sample for culture and consider the possibility of fungal or mycobacterial peritonitis. Continue with the initial antibiotic regimen for another two days. Assess the patient at day five, if he/she has improved, leave the catheter in place.ֺֺ Modify the antibiotics according to culture results or continue with the initial regimen if the second culture is also negative. Continue treatment for at least two weeks and change the transfer set after completion of therapy. If the patient has not improved by day five and the second culture is positive,ֺֺ modify the antibiotics according to the second culture results. Assess the patient after another five days and remove the catheter if there is still no clinical improvement. If the patient has not improved by day five and the second culture is also negative,ֺֺ remove the catheter and change the antibiotic regimen to vancomycin plus gentamicin. Continue treatment for at least two weeks. Total duration of therapy should be at least two weeks. Peritonitis due to Staphy-ֺֺ lococcus aureus, Gram negative organisms, or enterococci should be treated for a minimum duration of 3 weeks whether the catheter was removed or not. Peritonitis due to Pseudomonas aeruginosa should always be treated with aֺֺ combination of two antibiotics. Peritonitis due to fungal organisms (diagnosed by microscopy or culture)ֺֺ mandates immediate catheter removal preceded by peritoneal lavage until the effluent is clear to avoid the formation of adhesion and lower the fungal burden. Fluconazole for four weeks (initially IP), is the drug of choice for fungalֺֺ peritonitis. For patients with severe infections and those who have had significant prior exposure to azole antifungals, add amphotericin B (test dose required) until the culture results are available with susceptibilities. Mycobacterial peritonitis should be suspected in any patient with prolongedֺֺ failure to thrive, prolonged symptoms despite antibiotic therapy, or relapsing peritonitis with negative bacterial cultures.
  • 63 6.6. Indications for catheter removal When indicated, early catheter removal is crucial to reduce the mortality andֺֺ morbidity. The primary goal should always be the optimal patient treatment and protection of the peritoneum, and not saving the catheter. Prolonged attempts to treat refractory peritonitis are associated with extended hospital stay, peritoneal membrane damage, and, in some cases, death. Death related to peritonitis, defined as death of a patient with active peritonitis, or admitted with peritonitis, or within 2 weeks of a peritonitis episode, should be a very infrequent event. The catheter should be removed in the following conditions: fungal peritonitis,ֺֺ refractory peritonitis, relapsing peritonitis, catheter related peritonitis, peritonitis related to an intra-abdominal pathology, and refractory exit site or tunnel infection (see table 13). If the catheter is removed because of relapsing peritonitis and the effluent hasֺֺ rapidly cleared, simultaneous catheter placement can be attempted. In case of refractory or fungal peritonitis, a minimum period of 4 weeks is recommended between the time of catheter removal and placement of a new catheter. It is preferred to re-insert PD catheters surgically or laparoscopically followingֺֺ an episode of peritonitis because of the risk of adhesions. The catheter should also be sutured into the pelvis at the first attempt of reinsertion. Table 13: Terminology of peritonitis Recurrent An episode that occurs within 4 weeks of completion of therapy of a prior episode but with a different organism Relapsing An episode that occurs within 4 weeks of completion of therapy of a prior episode with the same organism or one sterile episode Repeat An episode that occurs more than 4 weeks after completion of therapy of a prior episode with the same organism Refractory Failure of the effluent to clear after 5 days of appropriate antibiotics therapy Catheter related Peritonitis in conjunction with an exit-site or tunnel infection with the same organism or one site sterile
  • 64 6.7. Preventing recurrence of peritonitis Every episode of peritonitis should be perceived as a potentially preventableֺֺ event and thoroughly investigated by the PD team. Enquire from the patient carefully and in a non-threatening manner about theֺֺ possible mechanism of the episode (e.g. poor aseptic technique, lack of clean area to carry out exchanges, poor eyesight, recent exit-site infection, constipation or diarrhea) and advice accordingly. Re-train patients and arrange for a home visit after each episode of peritonitis,ֺֺ home visits are invaluable in detecting errors in the technique. Following each episode of peritonitis, fill out the Sudan-PD unified peritonitisֺֺ questionnaire. 6.8. Drug delivery With strict adherence to aseptic technique, IP administration of antibiotics andֺֺ antifungal agents is preferred to IV administration. IP antibiotics can be given in each exchange (continuous dosing) or once daily (intermittent dosing). Continuous dosing is preferred for inpatient treatment, while intermittent dosing is preferred for outpatient treatment (see tables 14 and 15). In intermittent dosing, the antibiotic-containing dialysis solution must be allowedֺֺ to dwell for at least 6 hours (utilizing the night exchange) to allow adequate absorption of the antibiotic into the systemic circulation. Vancomycin, aminoglycosides and cephalosporins can be mixed in the sameֺֺ dialysis solution bag without loss of bioactivity. However, aminoglycosides should not be added to the same exchange with penicillins because of chemical incompatibility. For any antibiotics that are to be mixed, separate syringes must be used forֺֺ adding the antibiotics. Some antibiotics are incompatible if combined in the same syringe but compatible when mixed in dialysis solutions, e.g. vancomycin and ceftazidime (1 liter or higher).
  • 65 Table 14: Recommendations for IP antibiotic dosing for anuric adult CAPD patients (increase dose by 25% for patients producing more than 100 ml of urine daily) Generic name Intermittent (one exchange per day) Continuous (all exchanges, mg per liter) Amikacin 2 mg/kg LD 25, MD 12 Amoxicillin ND LD 250-500, MD 50 Amphotericin ND MD 1.5 Ampicillin ND MD 125 Ampicillin/sulbactam 2 g every 12 hours LD 1000, MD 100 Aztreonam ND LD 1000, MD 250 Azlocillin ND LD 500, MD 250 Cefazolin 15 mg/kg LD 500, MD 125 Ceftazidime 1-1.5 g LD 500, MD 125 Ceftizoxime 1 g LD 250, MD 125 Cephalothin 15 mg/kg LD 500, MD 125 Cephradine 15 mg/kg LD 500, MD 125 Cifepime 1 g LD 500, MD 125 Ciprofloxacin ND LD 50, MD 25 Clindamycin ND LD 300, MD 125 Fluconazole 200 mg NA Gentamicin 0.6 mg/kg* LD 8, MD 4 Imipenem/cilastatin 1 g bd LD 500, MD 200 Nafcillin ND MD 125 Netilmicin 0.6 mg/kg LD 8, MD 4 Oxacillin ND MD 125 Penicillin G ND LD 50000, MD 25000 units Teicoplanin 15 mg/kg LD 400, MD 40 ** Tobramycin 0.6 mg/kg LD 8, MD 4 Vancomycin 30 mg/kg every 5-7 days *** LD 1000, MD 25 * Check blood level every 3-4 days (target 2-4 mg/l), if level < 2 mg/l increase dose by 0.2 mg/kg, if level > 4 mg/l decrease dose by 0.2 mg/kg, if level > 7 mg/l miss a day and reduce dose by 0.2 mg/kg. ** In each bag for 7 days, then in 2 bags/day for 7 days, then in 1 bag/day for 7 days. *** Check blood level on day 4 (target > 10 mg/l), if level < 12 mg/l give dose every 5 days, if level 13-14 mg/l give dose every 6 days, if level > 15 mg/l give dose every 7 days (usual dose for anuric patients). LD: loading dose in mg, MD: maintenance dose, ND: no data, NA: not applicable
  • 66 Table 15: Recommendations for IP antibiotic dosing for adult APD patients Generic name Intermittent dosing for APD patients (long dwell) Cefazolin 20 mg/kg once daily Cifepime 1 g once daily Fluconazole 200 mg once daily every 24-48 hours Tobramycin 1.5 mg/kg loading dose then 0.5 mg/kg once daily Vancomycin 30 mg/kg loading dose then 15 mg/kg once daily every 3-5 days
  • 67 Table16: Recommendations for systemic antibiotic dosing for adult PD patients Generic name Formulation Dose in kidney failure Amikacin Injection (IV, IM) 5 mg/kg OD (target blood level > 10 mg/l) Amoxicillin Caps, injection (IV) 250 - 500 mg bd Amphotericin Injection (IV) 0.25 mg/kg od Ampicilln Caps, injection (IV) 500 mg bd Aztreonam Injection (IV, IM) 2 g as loading dose, then 1 g od Cefazolin Injection (IV, IM) 1 g as loading dose, then 0.5 g od Ceftazidime Injection (IV) 0.5-1 g od Cefuroxime Injection (IV) 750 mg od Cephalexin Tabs 500 mg PO bd Ciprofloxacin Tabs, Injection (IV) 250-500 mg PO bd or 200 mg IV bd Clarithromycin Tabs 250-500 mg PD bd Clindamycin Tabs, injection (IV) 150-300 mg q6hr Co-amoxiclav Tabs, injection 375 mg PO bd or 1.2 g IV then 0.6 g IV od Dicloxacillin Tabs 250-500 PO bd Ethambutol Tabs 15-25 mg/kg PO q48h Fluconozaloe Caps, injection (IV) 200 mg IV or PO od Flucloxacillin Caps, injection 500 mg bd, injected IM or slowly IV Flucytocine Caps 2 g PO then 1 g PO od Gentamicin Injection (IV, IM) 1-2 mg/kg OD (target blood level 2-4 mg/l) Imipenem/cilastatin Injection (IV) 250-500 mg IV bd Isoniazid Tabs 300 mg PO od Itraconazole Tabs 100 mg PO bd Meropenem Injection (IV) 250 mg IV od Metronidazole Tabs, injection (IV) 500 mg bd Ofloxacin Tabs 400 then 200 mg PO od Piperacillin Injection (IV) 4 g IV bd Pyrazinamide Tabs 35 mg/kg PO od Rifampicin Tabs 450-600 mg PO od Septrin Tabs 480 PO od Teicoplanin Injection (IV, IM) 400 mg q12 hr for 3 doses, then 400 mg q72hr Tobramycin Injection (IV) 1-1.5 mg/kg OD (target blood level > 2 mg/l) Vancomycin Injection (IV) 1 g every 7-10 days, dilute to 5 mg/ml, infuse at 10 mg/min (target blood level > 10 mg/l)
  • 68 Table17: Other drugs mentioned in this chapter Generic name Formulation Dose for adult PD patients Diclofenac Tabs, injection (IM) 25-50 mg PO, IM every 6 hours Fluconazole Caps, suspension 50 mg PO daily (for prophylaxis) Ibuprofen Tabs, suspension 200-600 mg PO every 6 hours Lactulose Solution 15 ml PO every 12 hours then adjusted Macrogols Oral powder 1–2 sachets daily, dissolved in 200 ml water Morphine Tabs, injection (SC, IV, IM) 5 mg PO, SC, IM or 2.5 mg IV every 4 hours Nefopam Tabs, injection (IV) 30-60 mg PO every 8 hours Nystatin Tabs, suspension 500 000 unit PO q6 hours (for prophylaxis) Pethidine Injection (SC, IV, IM) 25-50 mg SC, IM or 12.5-25 mg IV q4 hours Paracetamol Tabs, suspension, sup. 0.5-1 gm PO, PR every 6 hours Tradamol Caps, injections (IV, IM) 50 mg PO, IV, IM every 4-6 hours
  • 69 Algorithm 2 Management of PD Related Peritonitis
  • 70 Algorithm 3 Management of PD Related Culture Negative Peritonitis
  • 71 Algorithm 4 Management of Fungal Peritonitis
  • 72 Chapter 7: Noninfectious Complications of PD 7.1. Goals and targets To standardize the management of noninfectious PD complications between allֺֺ units of the Sudan PD program. 7.2. Hernia Large hernias and abdominal wall defects should be corrected before PDֺֺ treatment, otherwise the increased intra-abdominal pressure will cause the hernia sac to enlarge resulting in inadequate drainage of the dialysate Incisional hernias through the catheter insertion site are more likely to developֺֺ if the catheter was inserted in the midline instead of the paramedian approach through the rectus muscle. Large hernias should primarily be repaired surgically. Post operatively, 3 to 4ֺֺ weeks of HD are advised to minimize their risk of recurrence. If PD is inevitable, intermittent PD with small volumes in the supine position may be attempted. 7.3. Fluid leak This complication may be related to catheter implantation technique or toֺֺ anatomical abnormalities. Early fluid leak occurs within 30 days of catheter placement and is more common when PD is commenced soon after implantation. Late leak occurs more than 30 days after catheter placement. Early leak usually takes the form of external fluid leakage through the woundֺֺ or the exit site. However, early leak can also occur subcutaneously at the site of catheter entry into the peritoneal cavity, resulting in lower abdominal wall edema or genital swelling. Late leak often takes the subcutaneous root and can be occult and difficult toֺֺ diagnose. It may present as diminished drainage volume which can be mistaken for UF failure. Besides the possibility of peritoneal membrane defects and subcutaneous leak,ֺֺ genital swelling after PD initiation can be due to a patent processus vaginalis (small inguinal hernia) which often requires surgical repair.
  • 73 The exact site of the leak can be determined by CT peritoneography performedֺֺ after adding contrast material to dialysate, or abdominal scintigraphy performed after adding technetium99m to the dialysate. External and subcutaneous leaks due to peritoneal membrane defects oftenֺֺ respond to conservative management by decreasing dialysate volume, using supine PD and avoiding strenuous exercise. Temporary hemodialysis may be required. Leaks that do not respond to conservative management can be treated surgically. It is rarely necessary to remove the catheter. If the leakage is apparent at the exit site or through the wound, the risk of a tunnelֺֺ infection or peritonitis is increased; prophylactic antibiotic therapy needs to be considered. 7.4. Pleural effusion due to pleuro-peritoneal leak Pleural effusion without other signs of heart failure or fluid overload may beֺֺ due to pleuro-peritoneal communication, particularly if the effusion is only right-sided. Most cases respond to drainage of the peritoneal cavity and avoidance of overnightֺֺ (supine) dwells. Pleurodesis may be offered to patients with recurrent pleural effusion who needs and/or desires to continue with PD. Surgical correction of an identified diaphragmatic defect is possible but will require thoracotomy. 7.5. Catheter malfunction A well functioning PD catheter will enable up to 3 liters of the dialysate to runֺֺ in over 5-10 minutes and drain out over 15-20 minutes under the force of gravity alone. Slower flow rate are inconvenient, they will cause the exchange to take too long and will result in decreased dwell time. Catheter malfunction is more common within 2 weeks after catheter implantation,ֺֺ but can occur later, e.g. during a peritonitis episode. Intraluminal factors leading to catheter malfunction include catheter blockageֺֺ with blood clot or fibrin. Extraluminal factors include catheter kinking, catheter malposition (tip migration out of the pelvis), and occlusion of the catheter holes (e.g. momental wrapping, adhesions or constipation leading to fecal loaded bowel loops).
  • 74 Combined outflow and inflow obstruction is characterized by poor flow of theֺֺ dialysate into the peritoneal cavity combined with poor drainage. It is often due to catheter blockage or kinking. Isolated outflow obstruction is more common, characterized by poor drainageֺֺ despite easy flow of the dialysate into the peritoneal cavity. It is often due to occlusion of the catheter holes or catheter malposition, but can also result from catheter blockage or kinking. It can lead to complications related to raised intra- abdominal pressure, e.g. fluid leaks and hernias. Isolated inflow obstruction is uncommon. It is characterized by poor flow of theֺֺ dialysate into the peritoneal cavity despite easy drainage. It can be due to catheter blockage or kinking. To guide management, the cause of obstruction must be established by plainֺֺ abdominalXrayand,ifnecessary,catheterfluoroscopy.Fluoroscopyisperformed by injecting 2 ml of contrast material into the catheter before obtaining multiplane X ray films. This must be preceded by prophylactic IP antibiotics. Patent catheters without kinking or malposition usually respond to treatment ofֺֺ constipation with laxatives and enemas, this reverses nearly 50% of all cases of outflow failure. Intraluminal obstruction by clots can be dissolved by instillation of fibrinolyticֺֺ agents (e.g. streptokinase 10 000 units in 2 ml left in the catheter for 2 hours), if successful, lysis may be followed by the instillation of heparin in the dialysate for several exchanges.Another approach is cleaning the lumen out with a Fogarty catheter or the use of an intraluminal brush. Malpositioned catheters may respond to laxative use and encouraging theֺֺ patient to move around. They may also respond to stiff wire manipulation under fluoroscopy guidance. Kinking usually requires catheter replacement. However, since kinking may beֺֺ due to the placement of the two catheter cuffs too near each other, removal of the superficial cuff may occasionally suffice. If conservative management fails, surgical or peritoneoscopic exploration mayֺֺ permit the operator, if necessary, to perform the following: catheter redirection, omentectomy, release of adhesions, or catheter replacement.
  • 75 7.6. Pain on dialysate infusion Many patients experience pain during dialysate infusion which diminishes inֺֺ the dwell period. This may be due to the acidic pH of the conventional lactate dialysate, catheter malposition (catheter tip abutting against the visceral or somatic peritoneum), or the high glucose concentration of hypertonic solutions. This discomfort frequently resolves shortly after PD initiation. Managementֺֺ options include adding sodium bicarbonate or a local anesthetic to the dialysate bag, slowing the infusion rate, incomplete drainage of dialysate, catheter replacement, or discontinuation of PD. 7.7. Catheter cuff extrusion Erosion of the catheter cuff through the skin may result from exit-site infectionֺֺ or excessive superficial cuff placement. If there is no evidence of infection, conservative measures may be attempted.ֺֺ Otherwise,theextrudingcuffshouldbetrimmedunderlocalanesthesiaandaseptic conditions. If signs of inflammation persist, the catheter must be removed. 7.8. Bladder perforation Bladder perforation is diagnosed when urine drains from the PD catheter, or theֺֺ patient experiences a desire to micturate following infusion of the dialysate. Treatment is by replacing the catheter and catheterizing the bladder for several days.ֺֺ 7.9. Intestinal perforation Intestinal perforation can result from direct injury at the time of catheterֺֺ implantation, or following bowel erosions that occur after weeks or months. This rare complication can be life-threatening and requires urgent attention. Diagnosis requires a high index of suspicion. Clues include feculent drainage,ֺֺ diarrhea with high glucose content occurring after dialysate instillation, and gram-negative peritonitis with multiple organisms. Therapy consists of dialysis cessation, intravenous antibiotics, and laparotomy toֺֺ identify and repair the perforated viscus.
  • 76 7.10. Hemoperitoneum Bleeding soon after catheter placement is most often due to trauma of smallֺֺ blood vessels located in the abdominal wall. A very small amount of blood (< 1 ml) can make two liters of peritoneal dialysate appear blood-tinged. Conservative management with observation is safe and effective if the effluent hematocrit is less than 2%. Rapid flushes and heparinization of the dialysate to prevent catheter clotting are usually done. Hemoperitoneum occurs in over one half of menstruating women due toֺֺ ovulation, retrograde menstruation, or endometriosis. Such episodes are likely to resolve spontaneously and the woman should be reassured. Rapid flushes and heparinization of the dialysate to prevent catheter clotting are usually done. Other causes of hemoperitoneum include renal cyst rupture, renal tumors, encap-ֺֺ sulating sclerosing peritonitis and other pathologies not related to PD. 7.11. Gastroesophageal reflux disease Persistent upper gastrointestinal symptoms in an adequately dialyzed patent mayֺֺ be due to gastroesophageal reflux disease (GERD) or gastroparesis. This can have significant adverse effects on the patient’s well-being and nutritional status. In addition to general measures, treatment may include minimizing the supineֺֺ intraperitoneal fluid volume. 7.12. Back pain Increased mechanical stress on the lumbar spine is common among PD patients.ֺֺ Besides general therapeutic measures, treatment includes decreasing the dialysate fill volume. 7.13. Electrolyte abnormalities Up to one third of PD patients develop hypokalemia, probably due to cellularֺֺ uptake of potassium prompted by the dialysate glucose load. For mild cases, liberalization of dietary potassium restriction often suffices. Oral or IVֺֺ potassium replacement (e.g. slow K, potassium chloride) can be used if necessary. Hypermagnesemia is also a common finding in PD patients due to the relativelyֺֺ high dialysate magnesium concentration.
  • 77 7.14. Sclerosing encapsulating peritonitis Sclerosing encapsulating peritonitis (SEP) is a devastating complication ofֺֺ long-term PD, whereby a thick-walled membranous cocoon wraps itself round loops of bowel causing intestinal obstruction and subsequent malnutrition. It may be related to recurrent peritonitis. SEP may initially present with high membrane transport status and poor UF, butֺֺ can also present with fever, intermittent small bowel obstruction, ascites and malnutrition. Symptoms may occur even after patient has been transferred to HD for several months. Diagnosis of SEP can be confirmed by peritoneal calcifica- tion on plain abdominal X ray or CT scan and thickened bowel wall on CT scan or barium studies. Treatmentincludesimmunosuppressant(prednisolone,cyclosporineorsirolimus),ֺֺ tamoxifen, and surgery to release loops of bowel from fibrous cocoon. 7.15. Abdominal surgery in a PD patient LaparoscopyisnotcontraindicatedwithaPDcatheterinplace.Ifamajorabdominalֺֺ surgery is planned, the incision should not be placed near the catheter insertion site and the possible need for extensive adhesiolysis should be anticipated. During the surgery, the catheter should be identified to ensure that it is notֺֺ displaced during the procedure. Care should also be taken in closing the abdomen to avoid trapping the catheter in sutures. Hemodialysis is preferred in the immediate post-operative period to avoidֺֺ leaks. If absolutely necessary, PD may be attempted with supine low volume exchanges.
  • 78 Table 18: Drugs mentioned in this chapter Generic name Formulation Dose for adult PD patient Potassium chloride Injection (IP) 2-4 mmol/liter IP (20 mmol in 10 ml vial) Slow K Tabs (600 mg) 1-6 tabs PO in divided doses (8 mmol per tab) Sodium bicarbonate Injection 8.4% (IP) 4 mmol/liter (25 mmol in 25 ml vial)
  • 79 Chapter 8: Management of Anemia 8.1. Goals and targets To promote achievement of target hemoglobin (Hb) level in the majority of PDֺֺ patients through proper utilization of iron supplements and erythropoietin (EPO) therapy. 8.2. Target hemoglobin level Anemia should be quantified using Hb rather than hematocrit. The target Hbֺֺ should be within the range 11-12 g/dl to improve survival, improve quality of life, reduce hospitalization and reduce transfusion needs. Hb targets greater than 13 g/dl may increase the risk of life threatening cardio-ֺֺ vascular events. Blood transfusion decisions should not be based on Hb targets alone. Reducingֺֺ blood transfusions is important particularly for patients planning to receive a kidney transplant. At baseline, the following investigations should be undertaken: complete bloodֺֺ count with blood cell indices, reticulocyte count, and serum iron, total iron binding capacity, transferrin saturation (serum iron divided by total iron binding capacity and multiplied by 100), serum ferritin, and stool for occult blood. EPO and iron supplements are often indicated to achieve and maintain targetֺֺ Hb. However, it may not be necessary to start EPO therapy during the first three months after beginning PD because Hb often rises during this period. Patients who have achieved target Hb and are on stable EPO doses should haveֺֺ their Hb measured at monthly intervals. Hb should be measured every two weeks after initiating, increasing or decreasingֺֺ EPO dose.
  • 80 8.3. Iron supplementation Sufficient iron should be administered to maintain transferrin saturation at 20%ֺֺ and serum ferritin level at 100 ng/ml. Additional iron should not be given when the serum ferritin concentration is above 800 ng/ml and/or transferrin saturation is above 50%. Ferritin and transferrin saturation should be measured every three months inֺֺ stable patients on maintenance iron therapy. Repeat testing every one to two months if iron parameters are not within the required range or if the patient has just started or increased the EPO dose. Oral iron supplements may suffice in PD patients, since anemia and blood lossֺֺ are less severe than HD and parenteral therapy is inconvenient. The simplest and least expensive formulation is ferrous sulfate. Ferrous gluconate can also be used. Parenteral iron should substitute oral iron if the latter is not enough to maintainֺֺ target Hb with modest doses of EPO (i.e. less than 100-150 unit/kg/week). Parenteral iron dextran, iron sucrose, or ferric gluconate are options in PD patients and can be given in weekly IV doses titrated according to response. Iron dextran may be given in large doses of 500-1000 mg every 1-3 months,ֺֺ diluted in 250 ml of normal saline and infused over one hour. To minimize the risk of hypersensitivity reaction, every IV dose of iron dextran should be preceded by a test dose of 25 mg given slowly IV (10 mg in children weighing less than10 kg and 15 mg in children weighing 10-20 kg). Observe the patient for 1 hour after the first test dose and for 15 minutes after subsequent test doses with adrenaline available at hand. Arthralgia and myalgia commonly occur as delayed reactions and should prompt a decrease in the dose. Iron sucrose and ferric gluconate have not been established to be safe and effectiveֺֺ in pediatric patients, and are not recommended in large bolus doses. Parenteral therapy with ferric gluconate should be preceded by a single test dose of 25 mg diluted in 50 ml of normal saline and administered over 60 minutes. Accurate measurements of iron parameters does not require interruptionֺֺ of parenteral iron therapy if the weekly dose is 100-125 mg or less. After IV infusions of 200-1000 mg of iron, an interval of 7-14 days should lapse before accurate results can be obtained.
  • 81 8.4. Erythropoietin therapy EPO therapy should only be initiated after ensuring that iron stores are replete.ֺֺ SC administration is preferred to IV administration in PD patients because it is convenient and cost effective. However, Eprex® should only be administered IV since SC administration has been associated with pure red cell aplasia. For patients in whom SC or IV administration is not feasible (e.g. some children),ֺֺ administer EPO IP into a dry abdomen. This usually requires higher doses. The initial SC dose of EPO should be 80-120 units/kg/wk divided into 2-3 dosesֺֺ per week (according to available vial dosage). Children less than 5 years old often require higher doses (300 units/kg/wk). If Hb rises by less than 1 g/dl over 2-4 weeks the EPO dose should be increasedֺֺ by 50%. If Hb rises by more than 2.5 g/dl over 4 weeks or exceeds targets the EPO dose should be reduced by 25-50%. Encourage patients to self-administer EPO when possible, using the smallestֺֺ possible gauge needle and rotating injection sites between upper arm, thigh and abdominal wall areas. Small doses can be administered in a single weekly injection, while larger doses are divided. A prior history of seizures, recent surgery, an intercurrent illness or a recentֺֺ blood transfusion are not contraindication for EPO use. EPO treatment does not require more intensive potassium monitoring in dialysis patients Inadequate response EPO should prompt a search for the following conditions:ֺֺ infection, inflammation, chronic blood loss, hemolysis, hyperparathyroidism, inadequate dialysis, aluminum toxicity, bone marrow fibrosis, occult malignancy, hemoglobinopathies, folate deficiency, vitamin B12 deficiency, or the use of ACE inhibitors. Blood pressure should be monitored particularly during initiation of EPO therapy.ֺֺ Initiating or increasing antihypertensive therapy may be required with or without reducing EPO dose.
  • 82 Table 19: Drugs mentioned in this chapter Generic name Formulation Dose adult PD patient Ferrous sulphate Tabs (200 mg) 200 mg PO tds Ferrous gluconate Tabs (300 mg) 300 mg, two tabs PO tds Iron dextran Injection (IM, IV) 2 ml (100 mg) IV or IM per dose Iron sucrose Injection (IV) 5-10 ml (100-200 mg) IV per dose, infused over 5 minute or diluted in 100 ml NS and infused over 15 mn Ferric gluconate Injection (IV) 10 ml (125 mg) IV per dose, diluted in 100 ml NS and infused over 60 minutes
  • 83 Chapter 9: Management of Bone Disease 9.1. Goals and targets To promote achievement of target calcium, phosphorus and parathyroid hormoneֺֺ level in the majority of PD patients through proper utilization of phosphate binders and vitamin D supplements. 9.2. Target calcium, phosphorus and parathyroid hormone levels For patients on maintenance PD, the target serum levels of phosphorus shouldֺֺ be 3.5-5.5 mg/dl, the target serum levels of corrected total calcium should be 8.5-9.5 mg/dl, the target serum calcium-phosphorus product should be less than 55 mg2 /dl2 and the target iPTH level should be 150-300 pg/ml. Serum levels of calcium and phosphorus should be measured every month andֺֺ levels of iPTH should be measured every three months, more frequent monitoring is warranted if levels are not within the target range. When measuring serum calcium level, the following formula should be used toֺֺ correct for any associated hypoalbuminemia: 9.3. Treatment of hyperphosphatemia Hyperphosphatemia is associated with increased morbidity and mortality inֺֺ CKD patients. It may lead to secondary hyperparathyroidism by lowering the levels of ionized calcium, interfering with the production of active vitamin D, and directly affecting PTH secretion. In addition, prolonged hyperphosphatemia causes soft-tissue and vascular calcification and contributes to cardiovascular disease. Corrected calcium (mg/dl) = total calcium (mg/dl) + {0.8 x [4 - serum albumin (mg/dl)]}
  • 84 Hyperphosphatemia can be exacerbated by excessive dietary phosphate intake,ֺֺ noncompliance with phosphate binders or dialysis treatment, excessive resorption of bone due to severe hyperparathyroidism or use of vitamin D agents. The first step in treatment is dietary phosphorus restriction to 800-1000 mg/dayֺֺ by restriction of food rich in phosphorus (e.g. dairy products, cola drinks, liver, meat and beans). If this is not adequate, oral phosphate binders are indicated. Calcium basedֺֺ phosphate binders (e.g. calcium carbonate, calcium citrate), sevelamer or lanthanum may be used as first line therapy, and their combinations may be used as a second line therapy. Calcium based phosphate binders should be given with meals. The total doseֺֺ of elemental calcium provided by them should not exceed 1500 mg/day. They should not be used when iPTH levels are less than 150 pg/ml. They are better avoided in patients with severe vascular or soft tissue calcifications (use sevelamer instead). In patients with serum phosphorus levels above 7.0 mg/dl, aluminum basedֺֺ phosphate binders may be used as a short term therapy for 4 weeks only. A last resort would be to increase dialysis dose, with emphasis on the long dwell,ֺֺ in order to optimize phosphate clearance. 9.4. Vitamin D supplements In kidney failure patients, the administration of small doses of the active vitaminֺֺ D reduces the serum levels of iPTH, improves bone histology, and leads to increased bone mineral density. Therapy with active vitamin D sterols like alfacalcidol (1-Hydroxycholecalcifer-ֺֺ ol) or calcitriol (1,25-Dihydroxycholecalciferol) is indicated when plasma levels of intact PTH are above 300 pg/ml, with the aim of reducing it to the target range of 150 to 300 pg/ml. The intermittent IV administration of active vitamin D is more effective thanֺֺ daily oral administration in lowering serum iPTH levels. To avoid the development of hypercalcemia, the total elemental calcium intake,ֺֺ including dietary calcium intake and calcium based phosphate binders, should not exceed 2000 mg/day.
  • 85 Treatment with an active vitamin D should be withheld if the serum levels ofֺֺ corrected total calcium are above 10.2 mg/dl, serum levels of phosphorus are above 6.0 mg/dl or serum levels of iPTH are less than 100 pg/ml. 9.5. Treatment of hypocalcemia Chronic low levels of corrected total calcium cause secondary hyperparathyroid-ֺֺ ism, have adverse effects on bone mineralization, and may be associated with increased mortality. Treatment is also warranted for symptomatic hypocalcemia, such as paresthesia,ֺֺ Chvostek’s and Trousseau’s signs, bronchospasm, laryngospasm, tetany, and/or seizures. Therapy for hypocalcemia should include the administration of calcium saltsֺֺ such as calcium carbonate (on an empty stomach) and/or oral vitamin D sterols. 9.6. Assessment of bone disease Different types of bone disease can occur in CKD patients, including dynamicֺֺ bone disease (osteitis fibrosa cystica), adynamic bone disease and osteomalcia. Irrespective of type, bone disease in CKD can lead to bone pain and an increasedֺֺ incidence of fractures. The most accurate diagnostic test for determining the type of bone diseaseֺֺ associated with CKD is iliac crest bone biopsy. It is not necessary to perform bone biopsy for most situations in clinical practice. However, a bone biopsy should be considered in patients with kidney failureֺֺ who have fractures with minimal or no trauma, inconclusive laboratory results or suspected aluminum bone disease. Bone radiographs are not indicated for the assessment of bone disease of CKD,ֺֺ but they are useful in detecting severe peripheral vascular calcification and bone disease due to ß2 microglobulin amyloidosis. Bone mineral density should be measured by dual energy X-ray absorptiom-ֺֺ etry (DEXA) in patients with fractures and in those with known risk factors for osteoporosis.
  • 86 9.7. Treatment of bone disease Patients who have elevated plasma levels of iPTH (dynamic or high turnoverֺֺ bone disease with or without mineralization defect) should be prescribed vitamin D sterols (e.g. calcitriol or alfacalcidol) to reverse bone features of iPTH overactivity and treat defective mineralization. Interventions to reduce the phosphorus level are also indicated. Adynamic bone disease diagnosed by bone biopsy or by iPTH levels less thanֺֺ 100 pg/ml should be treated by allowing plasma levels of iPTH to rise and increase bone turnover. This can be accomplished by decreasing or eliminating calcium based phosphate binders and vitamin D sterols. Osteomalacia due to aluminum toxicity could be prevented by avoiding the useֺֺ of aluminum containing compounds (including sucralfate) and should be treated with desferrioxamine. Osteomalacia due to vitamin D deficiency or phosphate depletion, thoughֺֺ uncommon, should be treated with vitamin D supplementation or phosphate ad- ministration, respectively. 9.8. Indications for parathyroidectomy Parathyroidectomy is indicated for the treatment of :ֺֺ Tertiary hyperparathyroidism: spontaneous hypercalcemia in the absence1. of vitamin D or calcium supplements and accompanied by elevated PTH level. Secondary hyperparathyroidism that cannot be suppressed by active2. vitamin D supplements without producing hypercalcemia. Calciphylaxis occurring despite optimal medical therapy.3.
  • 87 Table 20: Drugs mentioned in this chapter Generic name Formulation Dose for adult PD patient Alfacalcidol Caps 0.25-1 mcg PO od Aluminium hydroxide Caps (475 mg) 4-20 caps PO daily in divided doses Calcitriol Caps Injection (IV) 0.25-1 mcg PO od 0.5-8 mcg IV 3 times per week Calcium carbonate Tabs (500 mg) 1-7 tabs PO daily in divided doses (200 mg calcium per tab) Calcium acetate Tabs (1 g) 1-6 tabs PO daily in divided doses (250 mg calcium per tab) Desferrioxamine Tabs, Injection (SC) 10-30 mg/kg PO od 20-50 mg/kg SC infusion over 8-12 hours 3-7 times weekly Lanthanum (Fosrenol®) Tabs (500 mg) 3-6 tabs PO daily in divided doses Sevelamer (Renagel®) Tabs (800 mg) 3-15 tabs PO daily in divided doses
  • 88 Algorithm 5 Management of Bone Disease
  • 89 Chapter 10: Management of Malnutrition 10.1. Goals and targets To encourage effective monitoring of the nutritional status of PD patients andֺֺ promote effective management of malnutrition. 10.2. Evaluation and monitoring of nutritional status Malnutrition is common in PD patients, and is associated with increased mortalityֺֺ and morbidity. However, no single measurement can be used to determine the presence of malnutrition and a panel of measurements is recommended. Anthropometric measurements are simple and reproducible indicators ofֺֺ nutritional status. Body fat is estimated from the skin fold thickness at the triceps or sub scapular area, while mid upper arm circumference estimates muscle mass. Measurements above 95% of normal represent adequate nutrition, values between 70- 95% identify an increased risk for malnutrition, and values below 70% reflect significant malnutrition. Serum albumin levels are good indicator of nutritional status and should beֺֺ measured every month. Hypoalbuminemia is strongly correlated to mortality even at mildly decreased levels but is a late manifestation of malnutrition because of albumin’s long half life. Hypoalbuminemia can also occur secondary to volume expansion or acute phase response. Serum cholesterol levels are also indicators of nutritional status. In this setting,ֺֺ there is an inverse relationship between mortality and cholesterol concentration. BUN and creatinine concentration are other indicators of nutritional status. Lowֺֺ BUN and creatinine concentration are associated with increased mortality, and the gradual reduction of these values is an indication of malnutrition. Lean body mass (LBM) is another useful indicator of nutritional status. LBMֺֺ can be estimated from 24 hour dialysate and urine creatinine because creatinine is produced from all body muscles.
  • 90 Another important predictor of nutritional status is dietary protein intake (DPI)ֺֺ which is estimated as the protein equivalent of nitrogen appearance (PNA), previously referred to as the protein catabolic rate (PCR). The calculations used to estimate PNA assume that one gram of nitrogen is found in 6.25 grams of protein, and that the daily nitrogen losses are equal to the daily nitrogen intake when the patient is in nitrogen balance. LBM (kg) = [ 0.029 x creatinine production (mg/day)] + 7.38 Creatinine production (mg/day) = creatinine excretion (mg/day) + metabolic degradation (mg/day) Metabolic degradation (mg/day) = 0.38 x serum creatinine (mg/dl) x body weight (kg) Creatinine excretion (mg/day) = [24 hr dialysate volume (dl) x dialysate creatinine (mg/dl)] + [24 hr urine volume (dl) x urine creatinine (mg/dl)] PNA (g/day) = 6.25 x {urea appearance (g/day) + 1.81 + [0.031 x lean body mass (kg)]}
  • 91 When PNA is normalized to body weight it is called nPNA. A baseline nPNAֺֺ shouldbefollowedbyrepeatedmeasurementevery6monthsduringtheperitoneal adequacy tests. The recommended nPNA for PD patients is 1.2 to 1.3 g/kg/d, but change over time is more important than the absolute value. The nPNA would allow us to distinguish between a patient that has low BUNֺֺ because of adequate nutrition and adequate dialysis, and another patient that has low BUN because of malnutrition (often accompanied by inadequate dialysis). For the small percentage of patients who have a «high» nPNA, the appropriateֺֺ response should be to increase the dialysis prescription rather than to restrict dietary protein. 10.3. Treatment of malnutrition Patients who were previously on low protein diets must be instructed to increaseֺֺ their protein intake in order to counteract protein loss in the dialysate and prevent malnutrition. If surrogate markers suggest that the patient’s nutritional state is declining, oneֺֺ should consider evaluation for new comorbidity, additional dietary evaluation and dietary supplements. If no specific cause for malnutrition is identified, it is advisable to increase inֺֺ dialysis dose, although it has not been proven that increasing the dialysis dose would improve the nutritional status. Urea appearance (mg/day) = [24 hr dialysate volume (dl) x dialysate urea (mg/dl)] + [24 hr urine volume (dl) x urine urea (mg/dl)]
  • 92 Chapter 11: Management of Hypertension 11.1. Goals and targets To promote proper management of hypertension in PD patients in order toֺֺ improve their cardiovascular risk profile and preserve their RRF. 11.2. Blood pressure monitoring The CVD risk of dialysis patients is 10-100 folds higher than the generalֺֺ population, with younger patients having a higher relative risk than older patients compared to their peers in the general population. Reversible factors contributing to this high CVD risk should be addressed. The BP should be measured at each health encounter. The target BP for diabeticֺֺ or no diabetic patients should be < 130/80 mm Hg, except for patients with orthostatic hypotension, autonomic dysfunction, and severe peripheral vascular disease who may require higher BP targets. Patients with a systolic BPֺֺ > 130 and/or diastolic BP > 80 mmHg on at least two occasions are candidates for BP lowering interventions. Two agents may be considered as initial therapy for systolic BP >150 mm Hg. Immediate therapy is indicated when the BP is > 180 mm Hg. Patients with stable blood pressure may be monitored every 4-12 weeks. Followֺֺ up should be arranged within 4 weeks after initiating or increasing the dose of antihypertensive medication to monitor efficacy and adverse effects. Follow up should be arranged within 2 weeks if the systolic BP > 160 mm Hg, serum potassium > 4.5 mmol/l in patients taking agents that can cause hyperkalemia, or serum potassium < 4.5 mmol/l in patients taking agents than can cause hypokalemia. 11.3. Blood pressure measurement Accurate BP measurement is essential. The standard BP technique is to use theֺֺ auscultation method with a mercury manometer in the clinic setting. In each visit, at least two readings separated by 2 minutes should be taken and the average recorded. If the first two readings differ by more than 5 mm Hg additional readings should be obtained and averaged.
  • 93 Patients should be seated quietly for at least 5 minutes with their backsֺֺ supported and their arms bared and supported at heart level. Patients should refrain from smoking or ingesting caffeine during the 30 minutes preceding the measurement. The right arm is preferred for consistency and comparison with the standardֺֺ tables. Choose a cuff with a bladder width that is approximately 40% of the arm circumference midway between the olecranon and the acromion. The bladder within the cuff should encircle at least 80% of the arm. Small bladders can lead to falsely elevated readings while large bladders may lead to falsely low readings in the range of 10 to 30 mm Hg. The bell of the stethoscope should be lightly placed over the brachial arteryֺֺ pulse, proximal and medial to the cubital fossa, and below the bottom edge of the cuff which is placed about 2 cm above the cubital fossa. The cuff should be inflated to 30 mm Hg above palpated systolic BP and deflated at a rate of 2 to 3 mm Hg per second. The first appearance of sound (phase 1) is used to define systolic BP, the disap-ֺֺ pearance of sound (phase 5) is used to define diastolic BP. Systolic BP and pulse pressure are both a better predictor of end-organ damage than is diastolic BP alone. If autonomic dysfunction is suspected, measure blood pressure in the supine,ֺֺ sitting, and standing positions (standing quietly for 2 to 5 minutes). A decrease in standing systolic BP >10 mm Hg associated with dizziness or fainting indicates postural hypotension. 11.4. Management of hypertension Theinitialevaluationofahypertensivepatientshouldfocusonevidenceofcerbro-ֺֺ vascular disease (CVD), including heart failure, prior myocardial infarction (MI), angina, arrhythmias, left ventricular hypertrophy (LVH), stroke and peripheral vascular disease (PVD). Other CVD risk factors should also be identified and managed, including obesity, smoking, diabetes mellitus, and dyslipidemia. Non pharmacological treatment for hypertension include reducing dietary sodiumֺֺ intake to less than 2.4 g/d, moderate exercise for 30 minutes on most days of the week, weight reduction for overweight patients, smoke cessation and limiting alcohol consumption.
  • 94 The choice of antihypertensive medication should take into account otherֺֺ potential benefits besides reduction of blood pressure and possible side effects (see table 21, 22). ACEi or ARBs alone or in combination with each other are preferred first lineֺֺ agents in most patients because they also preserve RRF, reduce protienuria and reverse LVH. They should be withdrawn if the serum potassium exceeds 5.5 mmol/l or if the GFR declines by more than 30% within 4 months of starting therapy without other explanation. The patient should be advised to reduce dietary potassium intake if serum potassium level is 4.6-5.5 mmol/l, and additional measures to lower serum potassium (e.g. calcium resonium, loop diuretics) may be taken if serum potassium is 5.1-5.5 mmol/l. A loop diuretic should be added, provided the patient is not anuric, in theֺֺ presence of fluid overload or if the patient needs more than one antihypertensive drug. Diuretics potentiate the effects of ACEi and ARBs, but may lead to volume depletion. Unlike other thiazide diuretics, metolazone retains effectiveness at GFR belowֺֺ 30 ml/min/1.73 m2 . Once metolazone has effected a diuresis, it can typically be dosed as infrequently as two to three times a week because of its very long half-life. Most kidney failure patients require 3-4 drugs to achieve targets. In the absenceֺֺ of side effects, the dose of an antihypertensive agent should be increased before adding another agent. Dosage should not be escalated more frequently than every four weeks. Resistant (refractory) hypertension is diagnosed if BP goal cannot be achievedֺֺ in patients who are adhering to adequate and appropriate three drug regimens including a diuretic, with all three drugs prescribed in near maximal doses. Resistant hypertension may be due to the use of medications with BP raisingֺֺ effect (e.g. NSAIDs, antihistamines). However, a more common cause is nonadherence to salt and water restriction, to dialysis prescription and to antihy- pertensive medication Nonadherence may be due to lack of understanding of the goals of treatment,ֺֺ lack of resources for care, cognitive impairment, drug intolerance, cultural issues related to dependence on medication, inadequate support system or lack of motivation. To facilitate adherence, use long acting once daily medication, fixed dose combinations and low cost drugs with minimal side effects.
  • 95 11.5. Evaluation for renal artery disease Renal artery stenosis is often atherosclerotic in origin. It is defined anatomicallyֺֺ by more than 50% stenosis of the lumen of the renal artery and is considered to be hemodynamically significant if the stenosis exceeds 75% percent. Hemodynamically significant renal artery disease may result in renovascularֺֺ hypertension or ischemic nephropathy and is characterized clinically by the onset of rapidly progressive heart failure and flash pulmonary edema. Bilateral renal artery stenosis or renal artery stenosis in a single functioning kidney is often suggested by an acute more than 30% decline in GFR soon after initiation of ACEi or ARBs. Preferred screening tests include duplex ultrasonography which providesֺֺ anatomical and functional assessment of renal arteries without using potentially nephrotoxic contrast material. Other options include computed tomography angiography (CTA). The gold standard diagnostic test is renal angiography, which is an invasive procedure but offers the chance for immediate therapeutic intervention. The administration of gadolinium during magnetic resonance imaging (MRI)ֺֺ in patients with renal impairment has been strongly linked to an often severe disease called nephrogenic systemic fibrosis. As a result, it is recommended that gadolinium-based imaging be avoided, if possible, in such patients. GadoliniumisclearedveryslowlywithCAPD;ifMRIusinggadoliniumisdeemedֺֺ necessary, it is recommended to perform hemodialysis after the procedure. If hemodialysis cannot be performed, more frequent PD cycles for at least 48 hours after exposure, with no periods of dry abdomen may be considered. The first line of treatment relies on pharmacological control of hypertension,ֺֺ which is most effectively achieved with ACEi or ARBs (contraindicated in bilateral renal artery stenosis or renal artery stenosis in a single kidney), with the subsequent addition of diuretics and other antihypertensives as required. If hypertension proves to be refractory to medical treatment, other therapeuticֺֺ options include percutaneous transluminal renal arterioplasty (PTRA) with or without stenting and surgical revascularization.
  • 96 Table 21: Indication for antihypertensive medication other than blood pressure lowering effect Class Other indications Possible side effects Contraindications ACEi and ARBs Slow decline of RRFֺֺ Proteinuriaֺֺ Heart failureֺֺ LVHֺֺ Prevent CVD eventsֺֺ Cough (sp. ACEi)ֺֺ Angioeodema (rare)ֺֺ Hyperkalemiaֺֺ Leukopeniaֺֺ Rash (ACEi)ֺֺ Loss of taste (ACEi)ֺֺ Pregnancyֺֺ History ofֺֺ angioedema Loop diuretics Fluid overloadֺֺ Heart failureֺֺ Hyperkalemiaֺֺ Volume depletionֺֺ Electrolyteֺֺ disturbance Thiazide diuretics Fluid overloadֺֺ Heart failureֺֺ Prevent CVD eventsֺֺ Hyperkalemiaֺֺ Hypercalciuriaֺֺ Volume depletionֺֺ Electrolyteֺֺ disturbance Increase in bloodֺֺ glucose, uric acid and cholesterol Photosensitivityֺֺ Erectile dysfunctionֺֺ Not effective in stageֺֺ 4-5 CKD, except for metolazone Goutֺֺ Beta blockers Anginaֺֺ Prevent CVD eventsֺֺ Prevent arrhythmiaֺֺ Heart failureֺֺ (carvedilol, bisoprolol, and metoprolol) Migraine headacheֺֺ Glaucomaֺֺ Hyperthyroidismֺֺ Essential tremorֺֺ Bradycardiaֺֺ Bronchospasm,ֺֺ impaired peripheral circulation (non selective) Impotence, fatigueֺֺ and insomnia (lipid soluble) Mask hypoglycemiaֺֺ Hyperkalemiaֺֺ Bradycardiaֺֺ 2ֺֺ nd or 3rd degree heart block Severe heart failureֺֺ Liver diseaseֺֺ (labetalol) Depression (lipidֺֺ soluble) Asthma, COPD andֺֺ severe PVD (non selective) Dihydrope- dine CCBs Anginaֺֺ Diastolic dysfunctionֺֺ Raynaud’s phenomenaֺֺ Migraine headachesֺֺ Esophageal spasmֺֺ Ankle Edemaֺֺ Flushingֺֺ Headacheֺֺ Gingival hypertrophyֺֺ Dose dumpingֺֺ
  • 97 Non dihydrope- dine CC Bs Proteinuriaֺֺ Anginaֺֺ Prevent arrhythmiaֺֺ Diastolic dysfunctionֺֺ Migraine headachesֺֺ Esophageal spasmֺֺ Heart blockֺֺ Worsening of LVDֺֺ Nauseaֺֺ Headache (diltiazem)ֺֺ Constipationֺֺ (verapamil) Gingival hyperplasiaֺֺ conduction defectsֺֺ Severe heart failureֺֺ Alpha blockers Benign prostaticֺֺ hypertrophy May increase risk ofֺֺ adverse outcome in CVD Postural hypotensionֺֺ Diarrheaֺֺ Nasal congestion,ֺֺ sedation (reserpine) Incontinenceֺֺ Priapismֺֺ Depression or pepticֺֺ ulcer (reserpine) Centrally acting alpha blockers Sedationֺֺ Dry mouthֺֺ Bradycardiaֺֺ Withdrawalֺֺ hypertension Hepatitisֺֺ (methyldopa) Depressionֺֺ Liver diseaseֺֺ (methyldopa) Direct vasodilators Raynaud’sֺֺ phenomenon Headachesֺֺ Fluid retentionֺֺ Tachycardiaֺֺ Lupus (hydralazine)ֺֺ Hirsutism andֺֺ pericardial effusion (minoxidil) Lupus (hydralazine)ֺֺ Aldosterone antagonists Avoid in kidneyֺֺ failure Potassium sparing diuretics Avoid in kidneyֺֺ failure
  • 98 Table 22: Commonly used antihypertensive medications Generic name Formulation Usual dose in adult PD patients Angiotensin converting enzyme inhibitors Captopril Tabs (12.5,25,50 mg) 25-150 mg PO in 2-3 doses Enalapril Tabs (2.5,5,10,20 mg) 10-40 mg PO in 1-2 doses Lisinopril Tabs (2.5,5,10,20 mg) 10-40 mg PO od Ramipril Tabs (1.25,2.5,5,10 mg) 2.5-20 mg PO od Perindopril Tabs (4 mg) 4-8 mg PO in 1-2 doses Angiotensin II receptor blocker Candesartan Tabs (2,4,8,16,32 mg) 16-32 mg PO od Losartan Tabs (25,50,100 mg) 50-100 mg PO od Telmisartan Tabs (20,40,80 mg) 40-80 mg PO od Valsartan Tabs (80,160,320 mg) 80-320 mg PO od Beta blockers Atenolol Tabs (25,50 mg) 25-100 mg PO in 1-2 divided doses Bisoprolol Tabs (5,10 mg) 2.5-10 mg PO od Carvedilol Tabs (12.5,25,50 mg) 2.5-25 mg PO bd Metoprolol Tabs (100 mg) 50-300 mg PO in 1-2 divided doses Propranolol Tabs (10,40,80,160 mg) 40-480 mg PO od Calcium channel blockers Amlodipine Tabs (5,10 mg) 2.5-10 mg PO od Diltiazem Tabs (60 mg) 120-360 mg PO in 1-2 divided doses Felodipine Tabs (2.5,5,10 mg) 2.5-10 mg PO od Nifedipine R Tabs (10,20 mg) 10-40 mg PO bd Verapamil Tabs (40,80,120,160) 120-480 mg PO in 1-2 divided doses Alpha blockers Doxazocin Tabs (1,2,4 mg) 1-16 mg PO od Terazocin Tabs (2,5,10 mg) 1-20 mg PO od Others Furosemide Tabs (40 mg) 40-240 mg PO in 1-2 doses Hydralazine Tabs (25 mg), Injection (IV,IM) 25-150 mg PO bd or 5-10 mg IV or IM repeated in 20-30 minutes Metolazone Tabs (5 mg) 2.5 - 20 mg PO od Methyldopa Tabs (250 mg) 250-1500 mg PO bd
  • 99 Table 23: Other drugs mentioned in this chapter Generic name Formulation Dose for adult PD patient Calcium resonium Powder 15 g PO three to four times per day
  • 100 Chapter 12: Management of Diabetes Mellitus 12.1. Goals and targets To promote proper management of DM in PD patients in order to improve theirֺֺ CVD risk profile and slow the progression of non-renal diabetic complications. 12.2. Monitoring of blood sugar and diabetic complications Target HbA1c should be < 7.0%, target pre-prandial capillary glucose should beֺֺ 90-130 mg/dl, target postprandial capillary glucose should be < 180 mg/dl, and target BMI should be within the normal range (18.5-24.9 kg/m2 ). HbA1c level should be checked every 6 months after glycemic goals are achievedֺֺ and every 3 months when goals are not yet achieved. Self-monitoring of blood glucose is recommended 3 or more times daily forֺֺ patients receiving multiple insulin injections. Less frequent monitoring is accepted for patients receiving less frequent insulin injections, oral agents, or dietary control alone. Screening for retinopathy, foot pulses, and peripheral neuropathy should beֺֺ performed annually. Patients should be educated to visually inspect their feet for ulcers on daily basis. 12.3. Managing diabetic patients on dialysis Many of the non-renal complications of diabetes will continue to progressֺֺ after initiation of dialysis, including: CHD, CVD, PVD, retinopathy, cataracts, neuropathy and autonomic dysfunction. Survival of diabetic patients on dialysis is much worse than non-diabetic patients, and the major cause of death is CVD. PD is frequently the preferred dialysis option for diabetic patients who are moreֺֺ susceptible to hypotension because of cardiovascular instability. In addition, it is often difficult to create a permanent vascular access in diabetic patients. Diabetic patients on PD face the challenge of increased glucose loads and weightֺֺ gain. Visual disturbance may also impair the ability to perform PD exchanges. However, peritonitis rate is not higher than in non-diabetic patients.
  • 101 Insulin requirements in diabetic dialysis patients is variable. Patients on insulinֺֺ should check their blood sugars 1 h after each bag during the initiation of dialysis to identify their insulin requirements. A common regimen in CAPD patients is one or two daily injections of longֺֺ acting insulin plus an injection of short acting insulin prior to each exchange. Total daily insulin dose should be divided equally between the exchanges, with extra units added depending on the dextrose concentration of the bag (usually an extra 2 units for 1.36/1.5%, 4 units for 2.27/2.5%, and 6 units for 3.86/4.25% bag). Soluble insulin can be given via the IP rout. However, the required dose wouldֺֺ increase 2-3 times and the risk of peritonitis may be increased by multiple injections into the bags. Most sulphonylureas are contraindicated in kidney failure because these agentsֺֺ mainly rely on the kidney to eliminate both the parent drug and active metabolites and are associated with increased risk of hypoglycemia. However, gliclazide and glipizide can be used because they don’t have active metabolites and don’t increase the risk of hypoglycemia. Metformin does not cause hypoglycemia but should not be used because it isֺֺ cleared by the kidney and may build up with even modest impairment of kidney function, putting patients at risk of lactic acidosis. Repaglinide, rosiglitazone and pioglitazone do not cause hypoglycemia and mayֺֺ be used in patients with kidney failure. However, rosiglitazone and pioglitazone have the potential to worsen fluid retention and should be avoided in pregnancy or liver disease.
  • 102 Table 24: Drugs mentioned in this chapter Generic name Formulation Dose for adult PD patient Roziglitazone (Avandia®) Tabs (4,8 mg) 4-8 mg PO in 1-2 doses Pioglitazone (Actos®) Tabs (15 mg) 15–45 mg PO od Repaglinide (Prandin®) Tabs (0.5,1, 2 mg) 0.5-16 mg PO in 2-3 doses Gliclazide (Diamicron®) Tabs (80 mg) 40-320 mg PO, divide doses > 160 mg/d Glipizide (Minodiab®) Tabs (5 mg) 2.5-20 mg PO, divide doses > 15 mg/d Glibencliamide (Daonil®) Tabs Avoid Metformin (Glucophage®) Tabs Avoid Glimepiride (Amaryl®) Tabs Avoid Acarbose (Glucobay®) Tabs Avoid Tolbutamide Tabs Avoid Chlorpropamide Tabs Avoid
  • 103 Chapter 13: Management of Dyslipidemia 13.1. Goals and targets To promote proper management of dyslipidemia in PD patients in order toֺֺ improve their cardiovascular risk profile. 13.2. Monitoring of lipid profile All patients should be evaluated for dyslipidemia at presentation and at leastֺֺ annually thereafter. Evaluation should include a complete fasting lipid profile with total cholesterol,ֺֺ LDL, HDL, and triglycerides. Lipid profile should also be obtained within three months of starting or adjusting the dose of lipid lowering agents. Interventions are indicated in adults who have TG levelֺֺ > 500 mg/dl, LDL level > 100 mg/dl, TG levels > 200 mg/dl with non-HDL levels > 130 mg/dl, or HDL level < 40 mg/dl. Interventions are indicated in adolescents who have TG levelֺֺ > 500 mg/dl, LDL level > 130 mg/dl, TG levels > 200 mg/dl with non-HDL levels > 160 mg/dl, or HDL level < 40 mg/dl. 13.3. Treatment for dyslipidemia Identify and treat secondary causes of hyperlipidemia, such as the nephroticֺֺ syndrome, hypothyroidism, uncontrolled diabetes, excessive alcohol ingestion, chronic liver disease and medications. For patients with TGֺֺ > 500 mg/dl, TG reduction is the principal focus of treatment in order to prevent pancreatitis. Otherwise, LDL levels are the focus of treatment. Therapeutic lifestyle changes (TLC) are the first line of treatment of all types ofֺֺ dyslipidemia. TLC include diet, weight reduction, increased physical activity, abstinence fromֺֺ alcohol, and treatment of hyperglycemia.
  • 104 TLC should be tried for at least 3 months (6 months in adolescents) before phar-ֺֺ macological treatment is prescribed. Diet should be used judiciously, if at all, in individuals who are malnourished,ֺֺ and should be under the supervision of a dietitian experienced in the care of patients with CKD. For patients with TG > 500 mg/dl not controlled with TLC add gemfibrozilֺֺ (a fibrate) or nicotinic acid. Other fibrates (e.g. benzafibrate, clofibrate, fenofibrate) are better avoided in kidney failure. For patients with LDLֺֺ > 100 mg/dl not controlled with TLC add a statin (e.g. simvastatin, atorvastatin, pravastatin). If LDL targets are still not achieved add a bile acid sequestrant (e.g. cholestyramine) or, if a bile acid sequestrant cannot be used, add nicotinic acid. If statin is not tolerated use a bile acid sequestrant or nicotinic acid. For patients with TGֺֺ > 200 mg/dl and non-HDL > 130 mg/dl not controlled with TLC add a statin. If targets are not achieved or the statin is not tolerated substitute it with a fibrate or nicotinic acid. For patients with HDL < 40 mg/dl and no other lipid abnormality who are notֺֺ responding to TLC, pharmacological treatment is not recommended. To minimize adverse effects, start statins at a low dose and titrate upwards untilֺֺ the lowest effective dose is identified. Statins should not be used if there is evidence of liver disease. Both statin and fibrate can cause myositis, and CKD increases this risk. Avoidֺֺ combining statins and fibrates in kidney failure patients. Patients who develop muscle pain or tenderness should discontinue statin therapyֺֺ immediately and have their creatine kinase level checked. Creatine kinase levels greater than 10 times the upper limit of normal are indicative of myositis. Bile acid sequestrants should not be used if TGֺֺ > 400 mg/dl since they may increase TG level. The phosphate binding agent, sevelamer, can lower lipid levels by mechanisms similar to those of bile acid sequestrants.
  • 105 Table 25: Drugs mentioned in this chapter Generic name Formulation Dose in adult PD patients Statins Simvastatin Tabs (10,20,40 mg) 10-40 mg PO od Atorvastatin Tabs (10,20,40,80 mg) 10-80 mg PO od Pravastatin Tabs (10,20,40 mg) 10-40 mg PO od Fibrates Gemfibrozil Tabs (600 mg) 600 mg PO bd Bezafibrate Tabs Avoid Clofibrate Tabs Avoid Fenofibrate Tabs Avoid Others Cholestyramine Powder (4 g per sachet) 4-36 g PO in 1-4 divided doses Nicotinic acid Tabs (0.5,0.75,1 g) 0.25-2 g PO od (increase by 250 mg/week)
  • 106 Chapter 14: Rehabilitation 14.1. Goals and targets To highlight the role of the PD team in patients rehabilitation, in order to enableֺֺ ESRD patients on PD to live as normal a lifestyle as possible. 14.2. The disability of dialysis Quality of life is usually diminished in dialysis patients. They often feel hopeless,ֺֺ depressed and anxious. They worry about finances, family burden, loss of sexual function, and loss of independence. This can result in poor compliance on therapy, inattentiveness, and poor clinical outcomes. The limitations and disabilities that face dialysis patients result from theֺֺ disease itself as well as from comorbid conditions, the treatment regimen, and psychosocial problems. In addition, attitudes to chronic illness are very variable. Some patients areֺֺ determined to have normal lives as much as possible while others are satisfied to take on the sick role. The ultimate aim of dialysis is to give the patient as normal a lifestyle as possible.ֺֺ Patients should not simply live for dialysis, otherwise they will continue to have poor quality of life and will continue to depend heavily on social support programs. 14.3. Employment and rehabilitation The process of rehabilitation involves assessing the patient’s goals and desires,ֺֺ understanding his physical and mental capacities, appraising the resources available to provide support, and optimizing medical care. Most patients in full time employment chose PD; all attempts should be made toֺֺ enable dialysis patients to remain on or return to work or school. Attempts should be made to select dialysis schedules that fit with the patient’sֺֺ work. If necessary, exchanges may be done at work, e.g. in a medical area or separate room.
  • 107 Some employers are prejudiced, particularly if the patient has missed a lot ofֺֺ work before starting dialysis. Explanation from the PD team can change this attitude. Family support is important; family members should be encouraged to play anֺֺ active role in patient management. The PD team should draw the patient’s attention to available sources of socialֺֺ support and encourage him/her to benefit from them, e.g. national insurance scheme.
  • 108 Capter 15: Peritoneal dialysis in children 15.1. Goals and targets To highlight important aspects in the managements of children maintained onֺֺ regular PD. 15.2. Initiation of dialysis therapy Dialysis initiation in CKD children should be considered when GFR is 9-14 ml/ֺֺ min/1.73 m2 and should be recommended when GFR < 8 ml/min/1.73 m2 . The GFR can be estimated from serum creatinine using Schwartz formula orֺֺ by averaging creatinine and urea clearances as measured from a 24 hr urine collection. Clinical indications for dialysis initiation include malnutrition, refractory fluidֺֺ overload or hypertension, persistent hyperkalemia, hyperphosphatemia or acidosis, growth retardation, or uremic neuropathy. 15.3. Choice of dialysis modality The choice of PD as a dialysis modality for chldren should take into account theֺֺ patient and family choice, patient size, medical comorbidities, and the availability of family support. Absolute contraindications to PD in children include the presence of omphalocele,ֺֺ gastroschisis, bladder extrophy, diaphragmatic hernia and obliterated peritoneal cavity. Relative contraindications include inadequate home environment, lack of reliable caregiver, recent or impending major abdominal surgery and imminent kidney transplantation (within 6 months). APD is the preferred PD modality in children, mainly because this modalityֺֺ provides freedom from procedures during the daytime hours. If available, NIPD should be attempted first for children with significant RRF. Small children usualy require pediatric single cuff catheters. As the child grows,ֺֺ a two cuff catheter may have one or both cuffs pulled out of the tissue causing tissue damage. The preferred location for the single cuff is within or below the rectus muscle to anchor and support the catheter.
  • 109 15.4. PD prescription and monitoring Accurate estimation of total body water (TBW) and body surface area (BSA) areֺֺ of critical importance in children, and specific nomograms should be used. The initial prescribed dwell volume should be 600 to 800 ml/mֺֺ 2 BSA, increased in a stepwise manner as tolerated by the patient to 1000-1200 ml/m2 BSA. The maximum dwell volume should be 1400 ml/m2 BSA. When assessing dialysis adequacy, the minimal “delivered” dose of totalֺֺ small-solute clearance in children should be a Kt/Vurea of 1.8/wk. Growth and school performance are clinical indicators of adequate dialysis thatֺֺ should be monitored in addition to those recommended for adult patients. 15.5. Hypertension management BP should be measured using equipment of appropriate size, and values shouldֺֺ be interpreted according to age, gender, and height adjusted percentiles. Target BP in children should be lower than the adjusted 90th percentile or 130/80 mm Hg, whichever is lower
  • 110 Chapter 16: Preparation for Kidney Transplantation 16.1. Goals and targets To promote kidney transplantation as the most cost effective modality of RRTֺֺ for suitable patients. To promote proper preparation and effective post operative care of PD patientsֺֺ undergoing kidney transplantation. 16.2. Patient eligibility for kidney transplantation All ESRD patients should be assessed for eligibility for kidney transplantation,ֺֺ and encouraged to have a kidney transplant if feasible. Obtain a full clinical history and perform a detailed physical examination forֺֺ all patients to identify potential contraindications to kidney transplantation, assessment may be repeated if transplantation is delayed (see table 26). Investigations for all patients should include blood grouping, liver functionֺֺ tests, prothrombin time, partial thromboplastin time, screening for HIV, HBV and HCV, ECG, CXR, echocardiography, abdominal ultrasound scan, prostate specific antigen in males over the age of 50, and HLA tissue typing. Stress ECG with or without angiography is indicated for patients over the age ofֺֺ 40, diabetics, smokers, and patients with history of IHD. Doppler study with or without angiography is indicated for patients with absentֺֺ foot pulses, arterial bruit or intermittent claudication. Voiding cystourethrogram with or without cystoscopy is indicated for allֺֺ pediatric patients, patients with recurrent urinary tract infections, bladder outflow obstruction or vesico ureteric reflux. Liver biopsy is indicated for patients with HCV or HBV infection even if liverֺֺ function tests are normal.
  • 111 Table 26: Contraindications to kidney transplantation Absolute contraindications Relative contraindications Malignancy, excluding basal or cutaneousֺֺ squamous cell carcinomas. Active infection.ֺֺ Severe cardiac or respiratory failure.ֺֺ Positive HLA cross-match with potentialֺֺ donor. Extensive peripheral vascular disease orֺֺ coronary heart disease. Advanced age (biological age moreֺֺ important than chronological age). Renal diseases with high risk ofֺֺ recurrence (e.g. oxalosis, HUS, FSGS). Urological abnormalities.ֺֺ Active systemic illness (e.g. vasculitis).ֺֺ Active liver disease (HBV or HCV).ֺֺ HIV infection.ֺֺ Coagulopathy.ֺֺ Morbid obesity.ֺֺ Psychosis or dementia.ֺֺ Non-compliance.ֺֺ 16.3. Prospective live kidney donor evaluation Outcomes of transplantation from living donors are better than from cadavericֺֺ donors and should be encouraged if feasible. Payment for organ donation is illegal. A formal psychological assessment should be performed for all potential kidneyֺֺ donors by an experienced psychologist. Obtain a full clinical history and perform a detailed physical examination for allֺֺ potential kidney donors to identify potential contraindications to kidney donation (see table 27).
  • 112 Investigations should include blood grouping, urinalysis, 24 hr urine protein,ֺֺ BUN, serum creatinine, serum sodium, serum potassium, serum calcium, serum phosphorus, serum uric acid, serum cholesterol, complete blood count, fasting blood sugar, liver function tests, prothrombin time, partial thromboplastin time, screening for HIV, HBV and HCV, ECG, CXR, abdominal ultrasound scan, HLA tissue typing, and spiral CT or MR angiography of the renal vessels. Table 27: Contraindications to kidney donation Absolute contraindications Relative contraindications ABO blood group incompatibility (Rhesusֺֺ compatibility is unnecessary). Chronic diseases (e.g. hypertension,ֺֺ diabetes, rheumatic heart disease) Evidence of kidney damage (e.g. low GFR,ֺֺ proteinuria, hematuria, nephrocalcinosis, kidney stones). Mֺֺ arkedurologicabnormalities(e.g.bilateral pelviureteric junction obstruction). Active infection (including HIV, HBV andֺֺ HCV). Malignancy, excluding basal or cutaneousֺֺ squamous cell carcinomas. Family history of renal cell cancer.ֺֺ Psychosis, mental retardation or substanceֺֺ abuse. Pregnancy.ֺֺ Age greater than 65 or less than 18 years.ֺֺ Simple urological abnormalities (e.g.ֺֺ multiple renal vessels). Obesity, defined as body mass indexֺֺ greater than 30 kg/m2 . Active peptic ulcer disease.ֺֺ Family history of hypertension or diabetesֺֺ mellitus.
  • 113 16.4. Preparing the patient for kidney transplantation CKD patient should be encouraged to have a pre-emptive kidney transplantֺֺ if possible, before starting dialysis. This is particularly advisable for diabetic patients. Suitable patients who have already started dialysis therapy should be encouragedֺֺ to have a kidney transplant as soon as possible. Success rates of kidney trans- plantation are higher if the transplant is carried out within six months of starting dialysis. Patients should be informed on the potential risks and complications of kidneyֺֺ transplantation including possible drug side effects. Counseling should focus on the necessity of lifelong immunosuppressant and theֺֺ importance of compliance on treatment. Blood transfusions should be avoided as much as possible in potential kidneyֺֺ transplant recipients to minimize the risk of sensitization to HLA antigens. If blood transfusion is necessary, it is preferable to transfuse blood fromֺֺ unrelated donors in patients who are likely to receive live related kidney transplant. Leukocyte depleted blood or packed red blood cells are preferred if available. Femoral catheterization should be avoided in potential kidney transplantֺֺ recipient to minimize trauma to the femoral and external iliac veins. If absolutely necessary, the left femoral vein should be canulated rather than the right femoral vein. Renal stones and gall bladder stones are a nidus for infection, and are betterֺֺ removed prior to kidney transplantation. Both the donor and recipients are screened for CMV and EBV infection just priorֺֺ to the transplant, along with HLA cytotoxicity testing.
  • 114 16.5. Peri-operative care of the PD patient Dialysate should be drained prior to surgery to prevent respiratory compromiseֺֺ by high intra-abdominal pressure. Transplant surgery is usually extraperitoneal so there is little risk of fluid leakageֺֺ post-transplantation. PD may continue if dialysis is required post transplantation unless the peritoneum has been breached. This has the advantage of avoiding the use of heparin and reducing the risk ofֺֺ hypotension. However, most transplant nurses are better acquainted with HD than PD and fluid removal is also more predictable with HD than with PD. Unless there is evidence of catheter infection, PD catheter should be left in placeֺֺ with regular weekly dressings until transplant function is established (4-12 weeks post transplant). If peritoneal cultures are indicated, they should be obtained by infusing salineֺֺ into the peritoneal cavity and culturing the effluent; in this setting cell counts are not meaningful.
  • 115 Chapter 17: Peritoneal Dialysis in Acute Renal Failure 17.1. Goals and targets To promote safe and effective utilization of PD in the management of ARF whenֺֺ this is clinically indicated. 17.2. The utility of peritoneal dialysis in acute renal failure HD is generally preferred to PD in the management of ARF. Nevertheless, PDֺֺ can be a useful backup if HD facilities become restricted or unavailable. PD is particularly effective in small children, who have a peritoneal surface areaֺֺ per unit weight larger than the peritoneal surface area of adults. PD has many advantages to HD in children, as well as adults with poor cardiac function (see table 28). Non-renal indications for acute PD include peritoneal lavage in acute pancreatitis,ֺֺ severe hypothermia (utilizing warm dialysate) and fulminant hepatic failure. Table 28: Advantages and disadvantages of PD in ARF Advantages Disadvantages Widely available and easy to perform atֺֺ the bed side. Does not require expensive or complexֺֺ equipment. Gradual fluid removal minimizing the riskֺֺ of cardiovascular stress. Gentle dialysis minimizing the risk of dis-ֺֺ equilibrium syndrome. Glucose in dialysate may provide extraֺֺ calories for malnourished patients. Does not require a vascular access.ֺֺ Does not require systemic anticoagula-ֺֺ tion. Strongly contraindicated in case of recentֺֺ abdominal surgery with drains, peritonitis, abdominalhernia,intrabdominaladhesions, pleuroperitoneal fistula (following cardiac surgery), or pregnancy. Relatively contraindicated in case of recentֺֺ aortic graft, abdominal wall cellulites, adynamic ilius, or severe respiratory distress. Solute clearance may not be adequate inֺֺ hypercatabolic patients. Peritonitis in can be fatal in sick patients.ֺֺ Slow correction of hyperkalemia.ֺֺ
  • 116 17.3. Acute PD access Acute PD access can be achieved by placing a single cuff Tenckhoff catheter orֺֺ by inserting a semirigid catheter (figures 9 and 10). The hard catheter is associated with a very high incidence of peritonitis andֺֺ should not be left in place for longer than 72 hours. If prolonged dialysis is anticipated it is preferred to use the single cuff Tenckhoff catheter. The flexibility of the single cuff Tenckhoff catheter renders it more comfortableֺֺ for the patient, the operative insertion entails a lower risk of intestinal perforation, and the presence of the cuff reduces the incidence of PD related peritonitis compared to the semirigid catheter. The single cuff Tenckhoff catheter is usually inserted in a paramedian locationֺֺ utilizing the same techniques outlined above (chapter 2) for chronic PD catheter insertion. The single cuff is placed within or below the rectus muscle to anchor and support the catheter. 17.4. Technique for semirigid PD catheter insertion The semirigid PD catheter is often inserted in the midline approximately oneֺֺ inch below the umbilicus, but in very small children it can be inserted at two thirds of the distance from the umbilicus to the left lower rib (just lateral to the border of rectus muscle). Placement must take place in aseptic conditions, after emptying the bladder,ֺֺ cleaning the area with povidone iodine, draping the patient, and infiltrating the area with lignocaine with or without IV sedation. To prevent trauma to underlying organs, especially in small children, a small canulaֺֺ may be used to inflate the abdominal cavity with 10–15 ml/kg of dialysate. A small skin incision, slightly smaller than the diameter of the catheter, is madeֺֺ using a sharp pointed blade without cutting the muscle layer. After checking the integrity of catheter, introduce the catheter and stylet perpen-ֺֺ dicular to the abdominal wall until the peritoneum is pierced. The stylet is then withdrawn and the catheter gently pushed in towards either iliac fossa. Skin sutures are unnecessary if a retaining knob is present. Bleeding can beֺֺ stopped by a purse string suture. Dress with dry gauze or gauze impregnated with povidone iodine.
  • 117 17.5. Peritoneal dialysis prescription in acute renal failure IPD is the modality often used in ARF. The exchanges can be performedֺֺ manually, but it is preferable to use a cycling machine if available to reduce the risk of peritonitis. Usually, two dialysis sessions are given per week, each session of about 48 hoursֺֺ duration. A commonly used regimen utilizes short 2 liter exchange each of 2 hours duration. Session time can be interrupted to perform clinical procedures and can beֺֺ extended to optimize biochemical and fluid control. The exchange volume and dwell time can be modified according to patient sizeֺֺ to minimize leaks and discomfort. In children, a dwell volume of 20-50 ml/kg is typical. A dwell time of less than 30 minutes is usually not adequate. 1.36/1.5% dextrose is usually used, and will often achieve adequate UF.ֺֺ Concentrated dextrose can be used if necessary. In patients with pulmonary edema, 2-3 consecutive 2 liter exchanges ofֺֺ 3.86/4.25% dextrose without dwell time may remove approximately 1 liter over one hour. Dialysisadequacyshouldbeassessedondailybasisusingclinicalandbiochemicalֺֺ parameters. The dialysis prescription should be modified as necessary. Figure 9: Single cuff Tenckhoff catheter Figure 10: Semi-rigid acute PD catheter
  • 118 Heparin (1000 unit/2 liter) can be added to the dialysate to prevent catheterֺֺ obstruction by fibrin clots secondary to slight bleeding from the newly inserted catheter. Patients with diabetes may require additional intraperitoneal doses of regularֺֺ insulintocompensatefortheadditionaldextroseload:3–4units/literfor1.36/1.5% dextrose, 5–6 units/liter for 2.27/2.5%, and 7–10 units/liter for 3.86/4.25%. Hypokalemia is very common, and 2-4 mmol/l of potassium chloride may beֺֺ added to the dialysate if the patient is hypokalemic. Peritonitis is also very common, affecting up to 80% of patients using rigidֺֺ catheters. Patients have to be evaluated daily for evidence of peritonitis to allow prompt initiation of therapy. Increasing urine output and dropping predialysis creatinine levels from oneֺֺ session to the next suggest that renal function is improving. Dialysis can then be discontinued, and when clinically indicated, the PD catheter removed.
  • 119 Chapter 18: Continuous Quality Improvement 18.1. Goals and targets To promote improved outcomes for PD patients through the implementation of aֺֺ continuous quality improvement process. 18.2. The continuous quality improvement process The continuous quality improvement (CQI) process involves continuousֺֺ monitoring of clinical outcomes and the implementation of interventions that aim to improve patient care. All disciplines involved in the care of the PD patient should participate in qualityֺֺ improvement programs, including physicians, doctors, nurses, social workers, dietitians, and administrators. 18.3. Key performance indicators in PD In addition to the standard therapeutic targets outlined in this guidebook, thereֺֺ are key performance indicators in PD that the CQI process should focus on, including: o Peritonitis rate, with a target of less than one episode per 18 patient months. o Culture negative peritonitis rate, with a target of less than 20%. o Exit site infection rate. o Patient survival, with a target of 70% at 2 years. o Technique survival, with a target of 75% at 2 years. o Catheter survival, with a target of 80% at one year. o Hospitalization rate (admission/year, hospitalized days/year). o Patient satisfaction (quality of life: QOL). Regular meetings should be held to review the current status of the PD unitֺֺ regarding these indicators compared to previous years or months. Attempts should be made to identify the reason for any deviation from the desiredֺֺ targets in each domain of interest. Accordingly, a practical working plan should be constructed with the aim of improving clinical outcomes.
  • 120 18.4. The central Sudan-PD data base Accurate collection and analysis of data plays a fundamental role in the CQIֺֺ process. The integrated nature of the Sudan-PD program mandates a unified method of data management. It is the responsibility of the PD team in any particular unit to fill the requiredֺֺ data collection forms in the following situations: o Form (1): for every patient as he/she is enrolled into the program. o Form (2): for every patient as he/she quits the program. o Form (3): for every episode of peritonitis. Completed forms should be delivered without delay to the central Sudan-PD dataֺֺ base manager. Data pertaining to all PD units will be analyzed centrally, and an annual report will be prepared and disseminated to all units.
  • 121
  • 122 References Bailie G, Johnson CA, Mason NA, Peter WLS. Peritoneal dialysis 2003: a guideֺֺ to medication use [internet]. [place of publication not known]: Nephrology Pharmacy Associates, Inc; c2003 [cited in Apr 2008]. Available from:http:// Burkart JM,Schreiber M, Korbet SM, Churchill DN, Hamburger RJ, Moran J,ֺֺ Soderbloom R, Nolph KD. Solute clearance approach to adequacy of peritoneal dialysis. Perit Dial Int. 1996;16:457-70. Gokal R, Ash SR, Helfrich GB, Holmes CG, Joffe B, Nichols WK, Oreopoulosֺֺ DG, Riella MC, Slingeneyer A, Twardowski ZJ, Vas SE. Peritoneal catheters and exit site practices: Toward optimum peritoneal access. Perit Dial Int. 1993;13:29- 39. Judith Bernardini, Valerie Price, Ana Figueiredo. Peritoneal dialysis patientֺֺ training: 2006. Perit Dial Int. 2006;26:625–2. Joint Formulary Committee. British National Formulary. 55th ed. London:ֺֺ British Medical Association and Royal Pharmaceutical Society of Great Britain; 2008 Mar. Lameire N, BiesenWV,Vanholder R. Consequences of rsing glucose in peritonealֺֺ dialysis fluid. Seminars in Dialysis. 1998;11(5):271-5. Michael Flanigan and Ram Gokal. Peritoneal catheters and exit-site practicesֺֺ toward optimum Peritoneal access: a review of current developments. Perit Dial Int. 2005;25:132–9. National Kidney Foundation. The National Kidney Foundation Kidney Diseaseֺֺ Outcomes Quality Initiative (NKF KDOQI ™) [internet]. New York: National Kidney Foundation, inc; c2008 [cited Apr 2008]. Available at: http://www. Keshaviah PR, Nolph KD. Protein catabolic rate calculations in CAPD patients.ֺֺ ASAIO Trans 1991; 37:M400. Levy J, Morgan Julie, Brown E, editors. Oxford handbook of dialysis. 2nd ed.ֺֺ Oxford: Oxford university press; 2004. Passadakis PS, Oreopoulos DG. Peritoneal dialysis in patients with acute renalֺֺ failure. Advances in Peritoneal Dialysis. 2007;23:7-16.
  • 123 Piraino B, Bailie GR, Bernardini J, Boeschoten E, Gupta A, Holmes C, Kuijperֺֺ EJ, li PK, Lye W, Mujais S, Paterson DL, Fontan MP, Ramos A, Schaefer F, and Linda Uttley. Peritoneal dialysis-related infections recommendations: 2005 update. Perit Dial Int. 2005; 25:107-131 Prasad N, Gupta A. Fungal peritonitis in peritoneal dialysis patients. Periton Dialֺֺ Int. 2005; 25: 207–222. Schaefer F, Klaus G, Muller-Wiefel DE, Mehls O. Intermittent versus continuousֺֺ intraperitoneal glycopeptide/ceftazidime treatment in children with peritoneal dialysis-associated peritonitis. The Mid-European Pediatric Peritoneal Dialysis Study Group (MEPPS). J Am Soc Nephrol 1999; 10(1):136–45 Twardowski et al. Peritoneal equilibration test. Peritoneal Dialysis Bulletin.ֺֺ 1987;7(3):138-47. Twardowski TJ. Clinical value of standardized equilibration tests in CAPDֺֺ patients. Blood Purif. 1989;7:95-108. Warady BA, Schaefer F, Holloway M, Alexander S, Kandert M, Piraino B,ֺֺ Salusky I, Tranæus A, Divino J, Honda M, Mujais S, and Verrina E. Consensus guidelines for the treatment of peritonitis in Pediatric patients receiving peritoneal dialysis. Perit Dial Int. 2000;20:610–24.
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  • ١١٨ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﻟﻠﺪﻳﻠﺰﺓ‬ ‫ﺍﻟﺴﻮﺩﺍﻥ‬ ‫ﻟﺒﺮﻧﺎﻣﺞ‬ ‫ﺍﳌﺮﻛﺰﻳﺔ‬ ‫ﺍﻟﺒﻴﺎﻧﺎﺕ‬ ‫ﻗﺎﻋﺪﺓ‬ :٤-١٨ ‫اﳌﺴﺘﻤﺮ‬ ‫الﺘﺤﺴﲔ‬ ‫ﻋﻤلية‬ ‫ﻓﻲ‬ ‫ﹰ‬‫ا‬‫ﺃﺳاﺳي‬ ‫ﹰ‬‫ا‬‫دﻭﺭ‬ ‫ﻭﲢليلﻬا‬ ‫للﺒياﻧاﺕ‬ ‫الدقيﻖ‬ ‫الﺘﺠﻤيﻊ‬ ‫يلﻌﺐ‬ • ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫ﺗﺴﺘلزﻡ‬ ‫الصفاقية‬ ‫للديلزة‬ ‫الﺴﻮداﻥ‬ ‫لﺒﺮﻧاﻣﺞ‬ ‫اﳌﺘﻜاﻣلة‬ ‫ﻭالﻄﺒيﻌة‬ ،‫للﺠﻮدة‬ .‫الﺒياﻧاﺕ‬ ‫ﳌﻌاﳉة‬ ‫ﻣﻮﺣد‬ ‫ﻧﻈاﻡ‬ ‫للﺒﺮﻧاﻣﺞ‬ ‫الﺒياﻧاﺕ‬ ‫ﺑﺠﻤﻊ‬ ‫اﳋاﺻة‬ ‫اﻻﺳﺘﻤاﺭاﺕ‬ ‫ﻣلﺀ‬ ‫ﻣﺮﻛز‬ ‫ﻛل‬ ‫ﻓﻲ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻓﺮيﻖ‬ ‫ﻋلﻰ‬ ‫يﺘﻮﺟﺐ‬ • :‫اﻵﺗية‬ ‫اﳊاﻻﺕ‬ ‫ﻓﻲ‬ .‫الﺒﺮﻧاﻣﺞ‬ ‫ﺇلﻰ‬ ‫ﹰ‬‫ا‬‫ﺣديﺜ‬ ‫يﻨﺘﺴﺐ‬ ‫ﻣﺮيﺾ‬ ‫لﻜل‬ :( •١) ‫اﺳﺘﻤاﺭة‬ .‫الﺒﺮﻧاﻣﺞ‬ ‫يﺘﺮﻙ‬ ‫ﻣﺮيﺾ‬ ‫لﻜل‬ :( •٢) ‫اﺳﺘﻤاﺭة‬ .‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫يصاﺏ‬ ‫ﻣﺮيﺾ‬ ‫لﻜل‬ :( •٣) ‫اﺳﺘﻤاﺭة‬ ‫لﺒﺮﻧاﻣﺞ‬‫اﳌﺮﻛزية‬‫الﺒياﻧاﺕ‬‫قاﻋدة‬‫ﻣديﺮ‬‫ﺇلﻰ‬‫ﺗﺄﺧيﺮ‬‫ﺑدﻭﻥ‬‫اﳌﻜﺘﻤلة‬‫اﻻﺳﺘﻤاﺭاﺕ‬‫ﺗﺴليﻢ‬‫ﻣﻦ‬‫ﻻﺑد‬ • ،‫ﹰ‬‫ا‬‫ﻣﺮﻛزي‬ ‫الﺒﺮﻧاﻣﺞ‬ ‫ﻣﺮاﻛز‬ ‫ﺑﻜل‬ ‫اﳋاﺻة‬ ‫الﺒياﻧاﺕ‬ ‫ﲢليل‬ ‫ﻭﺳيﺘﻢ‬ ،‫الصفاقية‬ ‫للديلزة‬ ‫الﺴﻮداﻥ‬ .‫اﳌﺮاﻛز‬ ‫ﻛل‬ ‫ﻋلﻰ‬ ‫ﺗﻮﺯيﻌﻪ‬ ‫يﺘﻢ‬ ‫ﺳﻨﻮﻱ‬ ‫ﺗﻘﺮيﺮ‬ ‫ﺇﻋداد‬ ‫ﺫلﻚ‬ ‫يﺘﺒﻊ‬
  • ١١٧ ‫ﻟﻠﺠﻮﺩﺓ‬ ‫ﺍﳌﺴﺘﻤﺮ‬ ‫ﺍﻟﺘﺤﺴﲔ‬ :١٨ ‫ﻓﺼﻞ‬ ‫ﺍﻷﻫﺪﺍﻑ‬ :١-١٨ ‫الﺘﺤﺴﲔ‬ ‫ﻋﻤلية‬ ‫ﺗﻄﺒيﻖ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻧﺘاﺋﺞ‬ ‫ﲢﺴﲔ‬ ‫ﻋلﻰ‬ ‫الﺘﺸﺠيﻊ‬ • .‫للﺠﻮدة‬ ‫اﳌﺴﺘﻤﺮ‬ ‫ﻟﻠﺠﻮﺩﺓ‬ ‫ﺍﳌﺴﺘﻤﺮ‬ ‫ﺍﻟﺘﺤﺴﲔ‬ ‫ﻋﻤﻠﻴﺔ‬ :٢-١٨ ‫الﻘياﻡ‬ ‫ﺛﻢ‬ ،‫الﺴﺮيﺮية‬ ‫للﻨﺘاﺋﺞ‬ ‫اﳌﺘﻮاﺻلة‬ ‫اﳌﺮاقﺒة‬ ‫للﺠﻮدة‬ ‫اﳌﺴﺘﻤﺮ‬ ‫الﺘﺤﺴﲔ‬ ‫ﻋﻤلية‬ ‫ﺗﺸﻤل‬ • .‫ﺑاﳌﺮيﺾ‬ ‫الﻌﻨاية‬ ‫ﲢﺴﲔ‬ ‫ﺇلﻰ‬ ‫يﻬدﻑ‬ ‫ﺑﺘدﺧل‬ ‫الﺘﺤﺴﲔ‬ ‫ﻋﻤلية‬ ‫ﻓﻲ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﲟﺮيﺾ‬ ‫اﳌﻌﻨية‬ ‫الﺘﺨصصاﺕ‬ ‫ﻛل‬ ‫ﺗﺸﺘﺮﻙ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ • ،‫اﻻﺟﺘﻤاﻋيﲔ‬ ‫ﻭالﻌاﻣلﲔ‬ ،‫ﻭاﳌﻤﺮﺿﲔ‬ ،‫ﻭاﻷﻃﺒاﺀ‬ ،‫اﻻﺧﺘصاﺻيﲔ‬ ‫ﺫلﻚ‬ ‫ﻓﻲ‬ ‫ﲟا‬ ،‫للﺠﻮدة‬ ‫اﳌﺴﺘﻤﺮ‬ .‫اﻹداﺭة‬ ‫ﻭﺭﺟاﻝ‬ ،‫الﺘﻐﺬية‬ ‫ﻭاﺧﺘصاﺻيﻲ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻓﻲ‬ ‫ﺍﻟﺮﺋﻴﺴﻴﺔ‬ ‫ﺍﻷﺩﺍﺀ‬ ‫ﻣﺆﺷﺮﺍﺕ‬ :٣-١٨ ‫ﻫﻨاﻙ‬ ،‫الﻜﺘاﺏ‬ ‫ﻫﺬا‬ ‫ﻓﻲ‬ ‫ﻋﻨﻬا‬ ‫اﳊديﺚ‬ ‫ﺳﺒﻖ‬ ‫الﺘﻲ‬ ‫الﻘياﺳية‬ ‫الﻌﻼﺟية‬ ‫اﻷﻫداﻑ‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ • :‫ﺫلﻚ‬ ‫ﻭيﺸﻤل‬ ،‫للﺠﻮدة‬ ‫اﳌﺴﺘﻤﺮ‬ ‫الﺘﺤﺴﲔ‬ ‫ﻋﻤلية‬ ‫ﻋليﻬا‬ ‫ﺗﺮﻛز‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ ‫ﺭﺋيﺴية‬ ‫ﻣﺆﺷﺮاﺕ‬ .(‫ﺷﻬﺮ‬ •١٨ ‫ﻛل‬ ‫ﺇﺻاﺑة‬ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫)الﻬدﻑ‬ ‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫اﻹﺻاﺑة‬ ‫ﻣﻌدﻝ‬ .(٪ •٢٠ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫)الﻬدﻑ‬ ‫الزﺭﻉ‬ ‫ﺳالﺐ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﻣﻌدﻝ‬ .‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﺑﻌدﻭﻯ‬ ‫اﻹﺻاﺑة‬ ‫ﻣﻌدﻝ‬ • .(‫ﺳﻨﺘﲔ‬ ‫ﻣﺮﻭﺭ‬ ‫ﺑﻌد‬ ٪ •٧٠ ‫)الﻬدﻑ‬ ‫اﳊياة‬ ‫قيد‬ ‫ﻋلﻰ‬ ‫اﳌﺮيﺾ‬ ‫ﺑﻘاﺀ‬ ‫ﻣﻌدﻝ‬ .(‫ﺳﻨﺘﲔ‬ ‫ﻣﺮﻭﺭ‬ ‫ﺑﻌد‬ ٪ •٧٥ ‫)الﻬدﻑ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻋلﻰ‬ ‫اﳌﺮيﺾ‬ ‫ﺑﻘاﺀ‬ ‫ﻣﻌدﻝ‬ .(‫ﺳﻨة‬ ‫ﻣﺮﻭﺭ‬ ‫ﺑﻌد‬ ٪ •٨٠ ‫)الﻬدﻑ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺑﻘاﺀ‬ ‫ﻣﻌدﻝ‬ .‫ﺑاﳌﺴﺘﺸفﻰ‬ ‫الﺘﻨﻮﱘ‬ ‫ﻣﻌدﻝ‬ • .( •patient satisfaction) ‫اﳌﺮيﺾ‬ ‫ﺭﺿﻰ‬ ‫الﺮاﻫﻨة‬ ‫اﳊالة‬ ‫ﳌﺮاﺟﻌة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺮاﻛز‬ ‫ﻛل‬ ‫ﻓﻲ‬ ‫دﻭﺭية‬ ‫اﺟﺘﻤاﻋاﺕ‬ ‫ﺗﻌﻘد‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ • .‫اﳌاﺿية‬ ‫الﺴﻨﻮاﺕ‬ ‫ﺃﻭ‬ ‫الﺸﻬﻮﺭ‬ ‫ﺧﻼﻝ‬ ‫ﲢﻘيﻘﻬا‬ ‫ﰎ‬ ‫الﺘﻲ‬ ‫ﺑالﻨﺘاﺋﺞ‬ ‫ﻭﻣﻘاﺭﻧﺘﻬا‬ ،‫اﳌﺆﺷﺮاﺕ‬ ‫لﻬﺬﻩ‬ ،‫اﻷﺳﺒاﺏ‬ ‫ﲢديد‬ ‫ﻣﺤاﻭلة‬ ‫ﻣﻦ‬ ‫ﻓﻼﺑد‬ ‫اﳌﻨﺸﻮد‬ ‫الﻬدﻑ‬ ‫ﻋﻦ‬ ‫اﳌﺆﺷﺮاﺕ‬ ‫ﻫﺬﻩ‬ ‫ﻣﻦ‬ ‫ﻣﺆﺷﺮ‬ ‫ﺃﻱ‬ ‫ﺣاد‬ ‫ﺇﺫا‬ • .‫اﻷداﺀ‬ ‫لﺘﺤﺴﲔ‬ ‫اﳌﻨاﺳﺒة‬ ‫الﻌﻤلية‬ ‫اﳋﻄﻂ‬ ‫ﻭﻭﺿﻊ‬
  • ١١٦ ‫ﻣﻨﻊ‬ ‫ﺑﻬدﻑ‬ (‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ليﺘﺮيﻦ‬ ‫لﻜل‬ ‫ﻭﺣدة‬ •١٠٠٠) ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﺇلﻰ‬ ‫ﻫيﺒاﺭيﻦ‬ ‫ﺇﺿاﻓة‬ ‫ﳝﻜﻦ‬ ‫ﻧزﻑ‬ ‫ﻋﻦ‬ ‫ﺗﻨﺠﻢ‬ ‫قد‬ ‫ﻭالﺘﻲ‬ ،‫ﻭالفيﺒﺮيﻨية‬ ‫الدﻣﻮية‬ ‫اﳉلﻄاﺕ‬ ‫ﺑﺴﺒﺐ‬ ‫اﻻﻧﺴداد‬ ‫ﻣﻦ‬ ‫الﻘﺜﻄاﺭ‬ .‫اﻹدﺧاﻝ‬ ‫ﺣديﺚ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﻦ‬ ‫ﺑﺴيﻂ‬ ‫الصفاﻕ‬ ‫داﺧل‬ ‫ﺇﺿاﻓية‬ ‫ﺟﺮﻋاﺕ‬ ‫ﺇلﻰ‬ ‫يﺤﺘاﺟﻮﻥ‬ ‫قد‬ ‫الﺴﻜﺮﻱ‬ ‫داﺀ‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻮﻥ‬ ‫الﺬيﻦ‬ ‫اﳌﺮﺿﻰ‬ • ‫ﻭالﻜﻤية‬ ،‫الزاﺋد‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫ﻋﺐﺀ‬ ‫ﻋﻦ‬ ‫للﺘﻌﻮيﺾ‬ (regular insulin) ‫الﺬﻭاﺏ‬ ‫اﻹﻧﺴﻮلﲔ‬ ‫ﻣﻦ‬ ٦ - ٥ ،٪١٫٥/١٫٣٦ ‫ﺗﺮﻛيزﻩ‬ ‫الﺬﻱ‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ليﺘﺮ‬ ‫لﻜل‬ ‫ﻭﺣداﺕ‬ ٤ - ٣ ‫ﻫﻲ‬ ‫ﻋادة‬ ‫اﳌﺴﺘﻌﻤلة‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ليﺘﺮ‬ ‫لﻜل‬ ‫ﻭﺣداﺕ‬ ١٠ - ٧ ‫ﻭ‬ ،٪٢٫٥/٢٫٢٧ ‫ﺗﺮﻛيزﻩ‬ ‫الﺬﻱ‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ليﺘﺮ‬ ‫لﻜل‬ ‫ﻭﺣداﺕ‬ .٪٤٫٢٥/٣٫٨٦ ‫ﺗﺮﻛيزﻩ‬ ‫الﺬﻱ‬ ‫ليﺘﺮ‬ ‫لﻜل‬ ‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫ﻣﻦ‬ ‫ﳑﻮﻝ‬ •٤ - ٢ ‫قدﺭﻩ‬ ‫ﻣا‬ ‫ﺇﺿاﻓة‬ ‫ﻭﳝﻜﻦ‬ ،‫اﳊدﻭﺙ‬ ‫ﺷاﺋﻊ‬ ‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫ﻧﻘﺺ‬ .‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫ﻧﻘﺺ‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻲ‬ ‫اﳌﺮيﺾ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻦ‬ ‫يﺴﺘﻌﻤلﻮﻥ‬ ‫الﺬيﻦ‬ ‫اﳌﺮﺿﻰ‬ ‫ﻣﻦ‬ ٪ •٨٠ ‫قﺮاﺑة‬ ‫ﻭيصيﺐ‬ ،‫ﻛﺬلﻚ‬ ‫اﳊدﻭﺙ‬ ‫ﺷاﺋﻊ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫دﻻﺋل‬ ‫ﻋﻦ‬ ‫ﹰ‬‫ا‬‫ﺑﺤﺜ‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫اﳌﺮيﺾ‬ ‫ﻭﺿﻊ‬ ‫ﺗﻘييﻢ‬ ‫ﻣﻦ‬ ‫ﻭﻻﺑد‬ ،‫الصلﺒة‬ ‫الﻘﺜاﻃيﺮ‬ .‫اﻷﻣﺮ‬ ‫لزﻡ‬ ‫ﺇﺫا‬‫ﹰ‬‫ا‬‫ﻣﺒﻜﺮ‬ ‫الﻌﻼﺝ‬ ‫لﺒدﺀ‬ ‫الفﺮﺻة‬ ‫ﻹﺗاﺣة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﻦ‬ ‫ﺟلﺴاﺕ‬ ‫ﻋدة‬ ‫ﺑﻌد‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻭﲢﺴﻦ‬ ‫الﺒﻮﻝ‬ ‫ﺣﺠﻢ‬ ‫ﺯيادة‬ ‫ﺗدﻝ‬ • .‫الﻘﺜﻄاﺭ‬ ‫ﺇﺯالة‬ ‫ﺛﻢ‬ ‫الديلزة‬ ‫ﺇيﻘاﻑ‬ ‫ﳝﻜﻦ‬ ‫ﻭﻋﻨدﻫا‬ ،‫الﻜلﻰ‬ ‫ﻭﻇيفة‬ ‫ﲢﺴﻦ‬ ‫ﻋلﻰ‬
  • ١١٥ ‫ﺍﳊﺎﺩ‬ ‫ﺍﻟﻜﻠﻮﻱ‬ ‫ﺍﻟﻔﺸﻞ‬ ‫ﻓﻲ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻭﺻﻒ‬ :٥-١٧ ‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫ﳌﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫الﻌادة‬ ‫ﻓﻲ‬ ( •IPD) ‫اﳌﺘﻘﻄﻌة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺗﺴﺘﺨدﻡ‬ ‫ﺫلﻚ‬ ‫ﺗيﺴﺮ‬ ‫ﺇﺫا‬ ‫ديلزة‬ ‫ﺁلة‬ ‫اﺳﺘﺨداﻡ‬ ‫اﳌفﻀل‬ ‫ﻣﻦ‬ ‫ﻛاﻥ‬ ‫ﻭﺇﻥ‬ ،‫ﹰ‬‫ا‬‫يدﻭي‬ ‫اﶈلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﻭﳝﻜﻦ‬ ،‫اﳊاد‬ .‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫اﻹﺻاﺑة‬ ‫ﻧﺴﺒة‬ ‫ﺗﻘليل‬ ‫ﺑﻬدﻑ‬ ،‫ﺳاﻋة‬ •٤٨ ‫ﳌدة‬ ‫ﻣﻨﻬﻤا‬ ‫ﻛل‬ ‫ﲤﺘد‬ ‫الﻮاﺣد‬ ‫اﻷﺳﺒﻮﻉ‬ ‫ﻓﻲ‬ ‫ديلزة‬ ‫ﺟلﺴﺘا‬ ‫للﻤﺮيﺾ‬ ‫ﺗﻮﺻﻒ‬ ‫ﻋادة‬ ‫قدﺭﻫا‬ ‫ﻛﻤية‬ ‫اﺳﺘﺨداﻡ‬ ‫ﻣﻊ‬ ‫ﺳاﻋﺘﲔ‬ ‫ﻛل‬ ‫اﶈلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﻋلﻰ‬ ‫ﻋادة‬ ‫اﳌﺴﺘﺨدﻡ‬ ‫الﻨﻈاﻡ‬ ‫ﻭيﺸﻤل‬ .‫ﻣﺮة‬ ‫ﻛل‬ ‫ﻓﻲ‬ ‫ليﺘﺮ‬ ٢ ‫ﳝﻜﻦ‬ ‫ﻛﻤا‬ ‫الﻼﺯﻣة‬ ‫ﻭالﺘﺸﺨيصية‬ ‫الﻌﻼﺟية‬ ‫ﺑاﻹﺟﺮاﺀاﺕ‬ ‫للﻘياﻡ‬ ‫الديلزة‬ ‫ﺟلﺴة‬ ‫ﺇيﻘاﻑ‬ ‫ﳝﻜﻦ‬ • .‫ﻭاﳌﺬاﺑاﺕ‬ ‫الﺴﻮاﺋل‬ ‫ﺿﺒﻂ‬ ‫لﺘﺤﺴﲔ‬ ‫ﲤديدﻫا‬ ‫ﺗﻘليل‬ ‫ﺑﻬدﻑ‬ ‫ﻭﲢﻤلﻪ‬ ‫اﳌﺮيﺾ‬ ‫ﺣﺠﻢ‬ ‫ﺣﺴﺐ‬ ‫اﳌﻜﻮﺙ‬ ‫ﻭﻣدة‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻛﻤية‬ ‫ﺗﻌديل‬ ‫يﺘﻢ‬ • ‫ﻭﻻ‬ ،‫لﻸﻃفاﻝ‬ ‫ﻣﻨاﺳﺒة‬ ‫ﻛﻤية‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻣل/ﻛلﻎ‬ ٥٠ - ٢٠ ‫ﻭﺗﻌﺘﺒﺮ‬ ،‫اﶈلﻮﻝ‬ ‫ﺗﺴﺮﺏ‬ .‫اﻷﺣﻮاﻝ‬ ‫ﻛل‬ ‫ﻓﻲ‬ ‫دقيﻘة‬ ٣٠ ‫ﻋﻦ‬ ‫اﳌﻜﻮﺙ‬ ‫ﻓﺘﺮة‬ ‫ﺗﻨﻘﺺ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ ‫الﻐالﺐ‬ ‫ﻓﻲ‬ ‫يﻜفﻲ‬ ‫ﻭﻫﻮ‬ ،٪ •١٫٥/١٫٣٦ ‫ﺟلﻮﻛﻮﺯ‬ ‫ﺗﺮﻛيز‬ ‫ﺫﻱ‬ ‫ديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫الﻌادة‬ ‫ﻓﻲ‬ ‫يﺴﺘﺨدﻡ‬ ‫لزﻡ‬ ‫ﺇﺫا‬ ‫الﺘﺮﻛيز‬ ‫ﻋالﻲ‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫اﺳﺘﺨداﻡ‬ ‫ﳝﻜﻦ‬ ‫ﻭلﻜﻦ‬ ‫ﹴ‬‫ﻛاﻑ‬ ‫ﺳﻮاﺋل‬ ‫ﺭﺷﺢ‬ ‫لﺘﺤﻘيﻖ‬ .‫اﻷﻣﺮ‬ ‫قدﺭﻩ‬ ‫ﻣا‬ ‫ﺑﺘﺒديل‬ ‫الﻘياﻡ‬ ‫ﻓﺈﻥ‬ ( •pulmonary edema) ‫ﺭﺋﻮية‬ ‫ﻭﺫﻣة‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻲ‬ ‫اﳌﺮيﺾ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫لﻪ‬ ‫الﺴﻤاﺡ‬ ‫ﺑدﻭﻥ‬ ‫ﻣﺘﺘالياﺕ‬ ‫ﻣﺮاﺕ‬ ‫ﺛﻼﺙ‬ ‫ﺃﻭ‬ ‫ﻣﺮﺗﲔ‬ (٪٤٫٢٥/٣٫٨٦) ‫اﳌﺮﻛز‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ليﺘﺮاﻥ‬ .‫ﻭاﺣدة‬ ‫ﺳاﻋة‬ ‫ﺧﻼﻝ‬ ‫اﳉﺴﻢ‬ ‫ﺳﻮاﺋل‬ ‫ﻣﻦ‬‫ﹰ‬‫ا‬‫ليﺘﺮ‬ ‫يزيل‬ ‫قد‬ ‫ﺑاﳌﻜﻮﺙ‬ ‫ﻭالفﺤﻮﺻاﺕ‬ ‫الﺴﺮيﺮية‬ ‫اﳌﺆﺷﺮاﺕ‬ ‫ﺑاﺳﺘﺨداﻡ‬ ‫يﻮﻣية‬ ‫ﺑصﻮﺭة‬ ‫الديلزة‬ ‫ﻛفاية‬ ‫ﺗﻘديﺮ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • .‫اﻷﻣﺮ‬ ‫لزﻡ‬ ‫ﺇﺫا‬ ‫الديلزة‬ ‫ﻭﺻﻒ‬ ‫ﻭﺗﻌديل‬ ،‫اﳌﻌﻤلية‬ ‫ﺍﻟﺼﻠﺐ‬ ‫ﺷﺒﻪ‬ ‫ﺍﻟﺼﻔﺎﻗﻲ‬ ‫ﺍﻟﻘﺜﻄﺎﺭ‬ :١٠ ‫ﺷﻜﻞ‬ ‫ﺍﻟﻮﺍﺣﺪﺓ‬ ‫ﺍﻟﻜﻔﺔ‬ ‫ﺫﻱ‬ ‫ﺗﻨﻜﻮﻑ‬ ‫ﻗﺜﻄﺎﺭ‬ :٩ ‫ﺷﻜﻞ‬
  • ١١٤ ‫ﺍﳊﺎﺩ‬ ‫ﺍﻟﻜﻠﻮﻱ‬ ‫ﺍﻟﻔﺸﻞ‬ ‫ﳌﺮﻳﺾ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻗﺜﻄﺎﺭ‬ :٣-١٧ ‫قﺜﻄاﺭ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫اﳊاد‬ ‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫ﳌﺮﺿﻰ‬ ‫الصفاقية‬ ‫ﺑالديلزة‬ ‫الﻘياﻡ‬ ‫ﳝﻜﻦ‬ • .(١٠ ‫ﻭ‬ ٩ ‫)ﺷﻜل‬ ‫ﺻلﺐ‬ ‫ﺷﺒﻪ‬ ‫قﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﺃﻭ‬ ‫ﻭاﺣدة‬ ‫ﻛفة‬ ‫ﺫﻱ‬ ‫ﺗﻨﻜﻮﻑ‬ ‫يﺠﻮﺯ‬ ‫ﻭﻻ‬ ،‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫ﻋالية‬ ‫ﺇﺻاﺑة‬ ‫ﻧﺴﺒة‬ ‫الصلﺐ‬ ‫ﺷﺒﻪ‬ ‫الﻘﺜﻄاﺭ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫يصاﺣﺐ‬ • ‫لفﺘﺮة‬ ‫الديلزة‬ ‫ﺇلﻰ‬ ‫اﳌﺮيﺾ‬ ‫يﺤﺘاﺝ‬ ‫ﺃﻥ‬ ‫اﳌﺘﻮقﻊ‬ ‫ﻣﻦ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ .‫ﺳاﻋة‬ ٧٢ ‫ﻣﻦ‬ ‫ﻷﻛﺜﺮ‬ ‫ﻣﻜاﻧﻪ‬ ‫ﻓﻲ‬ ‫ﺗﺮﻛﻪ‬ .‫ﻭاﺣدة‬ ‫الﻜفة‬ ‫ﺫﻱ‬ ‫ﺗﻨﻜﻮﻑ‬ ‫قﺜﻄاﺭ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫اﻷﻓﻀل‬ ‫ﻓﻤﻦ‬ ‫ﻃﻮيلة‬ ‫ﺃﻥ‬ ‫ﻛﻤا‬ ،‫للﻤﺮيﺾ‬ ‫ﺑالﻨﺴﺒة‬ ‫ﹰ‬‫ا‬‫ﻣﺮيﺤ‬ ‫يﺠﻌلﻪ‬ ‫ﳑا‬ ‫ﺑاﳌﺮﻭﻧة‬ ‫الﻜفة‬ ‫ﻭﺣيد‬ ‫ﺗﻨﻜﻮﻑ‬ ‫قﺜﻄاﺭ‬ ‫ﳝﺘاﺯ‬ • ‫ﻧﺴﺒة‬ ‫يﻘلل‬ ‫الﻜفة‬ ‫ﻭﺟﻮد‬ ‫ﺃﻥ‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ ،‫اﻷﻣﻌاﺀ‬ ‫ﺛﻘﺐ‬ ‫اﺣﺘﻤاﻻﺕ‬ ‫ﻣﻦ‬ ‫يﻘلل‬‫ﹰ‬‫ا‬‫ﺟﺮاﺣي‬ ‫ﺇدﺧالﻪ‬ .‫الصلﺐ‬ ‫ﺷﺒﻪ‬ ‫ﺑالﻘﺜﻄاﺭ‬ ‫ﻣﻘاﺭﻧة‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﺣدﻭﺙ‬ ( •paramedian) ‫للﻨاﺻﻒ‬ ‫اﺠﻤﻟاﻭﺭ‬ ‫اﳋﻂ‬ ‫ﻓﻲ‬ ‫ﻋادة‬ ‫الﻜفة‬ ‫ﻭﺣيد‬ ‫ﺗﻨﻜﻮﻑ‬ ‫قﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫يﺘﻢ‬ ‫ﺛﻨاﺋﻲ‬ ‫ﺗﻨﻜﻮﻑ‬ ‫قﺜﻄاﺭ‬ ‫ﻹدﺧاﻝ‬ (٢ ‫)ﻓصل‬ ‫ﹰ‬‫ا‬‫ﺳاﺑﻘ‬ ‫ﻭﺻفﻬا‬ ‫ﰎ‬ ‫الﺘﻲ‬ ‫الﺘﻘﻨية‬ ‫ﻧفﺲ‬ ‫ﺑاﺳﺘﺨداﻡ‬ ‫الﺒﻄﻨية‬ ‫اﳌﺴﺘﻘيﻤة‬ ‫الﻌﻀلة‬ ‫ﲢﺖ‬ ‫ﺃﻭ‬ ‫داﺧل‬ ‫الﻮﺣيدة‬ ‫الﻜفة‬ ‫ﺗﻮﺿيﻊ‬ ‫يﺘﻢ‬ ‫ﺑﺤيﺚ‬ ،‫الﻜفة‬ .‫الﻘﺜﻄاﺭ‬ ‫ﻭﺗﺜﺒيﺖ‬ ‫لﺘدﻋيﻢ‬ ‫ﺍﻟﺼﻠﺐ‬ ‫ﺷﺒﻪ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻗﺜﻄﺎﺭ‬ ‫ﺇﺩﺧﺎﻝ‬ ‫ﺗﻘﻨﻴﺔ‬ :٤-١٧ ‫الﺴﺮة‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﲢﺖ‬ ‫الﻨاﺻﻒ‬ ‫اﳋﻂ‬ ‫ﻓﻲ‬ ‫ﻋادة‬ ‫الصلﺐ‬ ‫ﺷﺒﻪ‬ ‫الديلزة‬ ‫قﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫يﺘﻢ‬ • ‫ﺗﻘﻊ‬ ‫ﻧﻘﻄة‬ ‫ﻓﻲ‬ ‫ﺇدﺧالﻪ‬ ‫ﻓيﻤﻜﻦ‬ ‫اﳊﺠﻢ‬ ‫ﺻﻐيﺮﻱ‬ ‫لﻸﻃفاﻝ‬ ‫ﺑالﻨﺴﺒة‬ ‫ﺃﻣا‬ ،‫ﻭاﺣدة‬ ‫ﺑﻮﺻة‬ ‫ﺑﺤﻮالﻲ‬ ‫للﻌﻀلة‬ ‫اﳋاﺭﺟﻲ‬ ‫اﳊد‬ ‫ﺟاﻧﺐ‬ ‫)ﺇلﻰ‬ ‫اﻷيﺴﺮ‬ ‫الﺴفلﻲ‬ ‫ﻭالﻀلﻊ‬ ‫الﺴﺮة‬ ‫ﺑﲔ‬ ‫اﳌﺴاﻓة‬ ‫ﺛلﺜﻲ‬ ‫ﻋلﻰ‬ .(‫الﺒﻄﻨية‬ ‫اﳌﺴﺘﻘيﻤة‬ ‫اﳌﻨﻄﻘة‬ ‫ﻭﺗﻨﻈيﻒ‬ ،‫اﳌﺜاﻧة‬ ‫ﺇﻓﺮاﻍ‬ ‫ﺑﻌد‬ ‫الﺘﻌﻘيﻢ‬ ‫ﻛاﻣلة‬ ‫ﻇﺮﻭﻑ‬ ‫ﻓﻲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫يﺘﻢ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ • ‫اﳌﺮيﺾ‬ ‫ﻭﺣﻘﻦ‬ ،‫الليﻐﻨﻮﻛايﻦ‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫اﳌﻨﻄﻘة‬ ‫ﻭﺗﺨديﺮ‬ ،‫اﳌﺮيﺾ‬ ‫ﻭﺗﻐﻄية‬ ،‫اليﻮد‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ .‫اﻷﻣﺮ‬ ‫لزﻡ‬ ‫ﺇﺫا‬ ‫الﻮﺭيد‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﻣﻬدﺉ‬ ‫ﺑدﻭاﺀ‬ ‫قﻨية‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﳝﻜﻦ‬ ،‫الصﻐاﺭ‬ ‫لﻸﻃفاﻝ‬ ‫ﺑالﻨﺴﺒة‬ ‫ﹰ‬‫ا‬‫ﺧصﻮﺻ‬ ‫الداﺧلية‬ ‫اﻷﺣﺸاﺀ‬ ‫ﺗﻀﺮﺭ‬ ‫ﳌﻨﻊ‬ • .‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻣل/ﻛلﻎ‬ ١٥ - ١٠ ‫قدﺭﻩ‬ ‫ﲟا‬ ‫الﺒﻄﻦ‬ ‫لﻨفﺦ‬ (canula) ‫ﺻﻐيﺮة‬ ،‫الﻘﺜﻄاﺭ‬ ‫قﻄﺮ‬ ‫ﻋﻦ‬ ‫ﻋﺮﺿﻪ‬ ‫يﻘل‬‫ﹰ‬‫ا‬‫ﺻﻐيﺮ‬ ‫ﹰ‬‫ا‬‫ﺷﻘ‬ ‫اﳉلد‬ ‫لﺸﻖ‬ ‫الﻨصل‬ ‫ﻣﺴﺘدﻕ‬ ‫ﹰ‬‫ا‬‫ﻣﺒﻀﻌ‬ ‫اﺳﺘﺨدﻡ‬ • ‫ﺑداﺧلﻪ‬ (stylet) ‫ﻭاﳌﺮﻭد‬ ‫ﺃدﺧلﻪ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺳﻼﻣة‬ ‫ﻣﻦ‬ ‫الﺘﺄﻛد‬ ‫ﻭﺑﻌد‬ ،‫الﻌﻀﻼﺕ‬ ‫ﺟﺮﺡ‬ ‫ﺑدﻭﻥ‬ ‫اﳌﺮﻭد‬ ‫اﺳﺤﺐ‬ ‫ﺛﻢ‬ ،‫الصفاﻕ‬ ‫ﺛﻘﺐ‬ ‫يﺘﻢ‬ ‫ﺣﺘﻰ‬ ‫الﺒﻄﻦ‬ ‫ﳉداﺭ‬ (perpendicular) ‫ﻣﻌاﻣد‬ ‫ﺑﺸﻜل‬ .‫اﳊﻮﺽ‬ ‫ﻧﺤﻮ‬ ‫ﺑلﻄﻒ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻭادﻓﻊ‬ ،( •retaining knob) ‫ﺗﺜﺒيﺖ‬ ‫ﻛﻨﺐ‬ ‫ﻋلﻰ‬ ‫ﹰ‬‫ا‬‫ﻣﺤﺘﻮي‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻛاﻥ‬ ‫ﻃاﳌا‬ ‫اﳉلد‬ ‫ﺧياﻃة‬ ‫ﺇلﻰ‬ ‫ﺣاﺟة‬ ‫ﻻ‬ ‫اﳉﺮﺡ‬ ‫ﺿﻤد‬ .(purse string suture) ‫ﺻاﺭة‬ ‫ﺧياﻃة‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫الﻨزﻑ‬ ‫ﺇيﻘاﻑ‬ ‫ﳝﻜﻦ‬ ‫ﻭلﻜﻦ‬ .‫ﺑاليﻮد‬ ‫ﻣﺸﺒﻊ‬ ‫ﺷاﺵ‬ ‫ﺃﻭ‬ ‫ﺟاﻑ‬ ‫ﺷاﺵ‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬
  • ١١٣ ‫ﺍﳊﺎﺩ‬ ‫ﺍﻟﻜﻠﻮﻱ‬ ‫ﺍﻟﻔﺸﻞ‬ ‫ﻟﻌﻼﺝ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ :١٧ ‫ﻓﺼﻞ‬ ‫ﺍﻷﻫﺪﺍﻑ‬ :١-١٧ ‫ﺑالفﺸل‬ ‫اﳌصاﺑﲔ‬ ‫اﳌﺮﺿﻰ‬ ‫ﻋﻼﺝ‬ ‫ﻓﻲ‬ ‫الصفاقية‬ ‫للديلزة‬ ‫ﻭالفﻌاﻝ‬ ‫اﻵﻣﻦ‬ ‫اﻻﺳﺘﻌﻤاﻝ‬ ‫ﺗﺸﺠيﻊ‬ • .‫اللزﻭﻡ‬ ‫ﻋﻨد‬ ‫اﳊاد‬ ‫الﻜلﻮﻱ‬ ‫ﺍﳊﺎﺩ‬ ‫ﺍﻟﻜﻠﻮﻱ‬ ‫ﺍﻟﻔﺸﻞ‬ ‫ﻋﻼﺝ‬ ‫ﻓﻲ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﺩﻭﺭ‬ :٢-١٧ ‫ﻭلﻜﻦ‬،‫اﳊاد‬‫الﻜلﻮﻱ‬‫الفﺸل‬‫لﻌﻼﺝ‬‫الصفاقية‬‫الديلزة‬‫ﻋلﻰ‬‫الدﻣﻮﻱ‬‫اﻻﺳﺘصفاﺀ‬‫اﺳﺘﻌﻤاﻝ‬‫يفﻀل‬ • .‫ﻣﻌدﻭﻣة‬ ‫ﺃﻭ‬ ‫ﻣﺤدﻭدة‬ ‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫ﻓﺮﺹ‬ ‫ﺗﻜﻮﻥ‬ ‫ﻋﻨدﻣا‬ ‫ﻣفيدة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺗﺒﻘﻰ‬ ‫يﺘﻤﺘﻌﻮﻥ‬ ‫ﻭالﺬيﻦ‬ ،‫اﳊﺠﻢ‬ ‫ﺻﻐيﺮﻱ‬ ‫لﻸﻃفاﻝ‬ ‫ﺑالﻨﺴﺒة‬ ‫ﺧاﺹ‬ ‫ﺑﺸﻜل‬ ‫ﻓﻌالة‬ ‫الصفاقية‬ ‫الديلزة‬ • ‫اﳌﺮﺿﻰ‬ ‫ﻋﻨد‬ ‫الصفاﻕ‬ ‫ﻣﺴاﺣة‬ ‫ﺗفﻮﻕ‬ ‫ﻭﺯﻧﻬﻢ‬ ‫ﻣﻦ‬ ‫ﻛيلﻮﻏﺮاﻡ‬ ‫ﻛل‬ ‫ﻣﻘاﺑل‬ ‫ﺻفاﻕ‬ ‫ﲟﺴاﺣة‬ ‫ﺑالﻨﺴﺒة‬ ‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫ﻋلﻰ‬ ‫ﻋديدة‬ ‫ﻣيزاﺕ‬ ‫الصفاقية‬ ‫للديلزة‬ ‫ﺃﻥ‬ ‫ﻛﻤا‬ ،‫الﺒالﻐﲔ‬ .(٢٨ ‫ﺟدﻭﻝ‬ ‫)اﻧﻈﺮ‬ ‫الﻘلﺐ‬ ‫ﻭﻇيفة‬ ‫ﺿﻌﻒ‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻮﻥ‬ ‫الﺬيﻦ‬ ‫للﻤﺮﺿﻰ‬ ‫ﻭﺑالﻨﺴﺒة‬ ‫لﻸﻃفاﻝ‬ ‫الﺘﻬاﺏ‬ ‫ﺣاﻻﺕ‬ ‫ﻓﻲ‬ ‫الصفاﻕ‬ ‫ﻏﺴل‬ ‫الصفاقية‬ ‫للديلزة‬ ‫الﻜلﻮية‬ ‫ﻏيﺮ‬ ‫الدﻭاﻋﻲ‬ ‫ﺗﺸﻤل‬ • ‫الﻜﺒدﻱ‬ ‫ﻭالفﺸل‬ ،(‫داﻓﺊ‬ ‫ديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫)ﺑاﺳﺘﺨداﻡ‬ ‫الﺸديد‬ ‫اﳊﺮاﺭة‬ ‫ﻭاﻧﺨفاﺽ‬ ،‫الﺒﻨﻜﺮياﺱ‬ .(fulminant hepatic failure) ‫اﳌداﻫﻢ‬ ‫ﺍﳊﺎﺩ‬ ‫ﺍﻟﻜﻠﻮﻱ‬ ‫ﺍﻟﻔﺸﻞ‬ ‫ﻋﻼﺝ‬ ‫ﻓﻲ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻭﻋﻴﻮﺏ‬ ‫ﻣﺰﺍﻳﺎ‬ :٢٨ ‫ﺟﺪﻭﻝ‬ ‫ﺍﳌﺰﺍﻳﺎ‬‫ﺍﻟﻌﻴﻮﺏ‬ .‫اﳌﺮيﺾ‬ ‫ﺳﺮيﺮ‬ ‫ﺟاﻧﺐ‬ ‫ﺇلﻰ‬ ‫ﺗﺄديﺘﻬا‬ ‫ﻭيﺴﻬل‬ ‫ﻣﺘﻮﻓﺮة‬ • .‫الﺜﻤﻦ‬ ‫ﻏالية‬ ‫ﺃﻭ‬ ‫ﻣﻌﻘدة‬ ‫ﺃﺟﻬزة‬ ‫ﺗﺘﻄلﺐ‬ ‫ﻻ‬ • ‫يﻘلل‬ ‫ﳑا‬ ‫ﺗدﺭيﺠية‬ ‫ﺑصﻮﺭة‬ ‫الﺴﻮاﺋل‬ ‫ﺇﺯالة‬ ‫ﺗﺘﻢ‬ • .‫الﻮﻋاﺋﻲ‬ ‫الﻘلﺒﻲ‬ ‫اﻹﺟﻬاد‬ ‫ﺣدﻭﺙ‬ ‫اﺣﺘﻤاﻝ‬ ‫ﻣﻦ‬ ‫ﺗﻘلل‬ ‫للﻤﺬاﺑاﺕ‬ ‫الﺘدﺭيﺠية‬ ‫اﻹﺯالة‬ • disequilibrium) ‫الﺘﻮاﺯﻥ‬ ‫ﻋدﻡ‬ ‫ﻣﺘﻼﺯﻣة‬ ‫ﺣدﻭﺙ‬ .(syndrome ‫ﺣﺮاﺭية‬ ‫ﺳﻌﺮاﺕ‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻓﻲ‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫يﻮﻓﺮ‬ • .‫الﺘﻐﺬية‬ ‫ﺳﻮﺀ‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻮﻥ‬ ‫الﺬيﻦ‬ ‫للﻤﺮﺿﻰ‬ ‫ﺇﺿاﻓية‬ .‫ﻭﻋاﺋية‬ ‫ﻭﺻلة‬ ‫ﻭﺟﻮد‬ ‫ﺗﺘﻄلﺐ‬ ‫ﻻ‬ • ‫الﺸاﻣل‬ ‫الﺘﺨﺜﺮ‬ ‫ﻣﻨﻊ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﺗﺘﻄلﺐ‬ ‫ﻻ‬ • .(systemic anticoagulation) ‫الﺒﻄﻨية‬ ‫اﳉﺮاﺣاﺕ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ ‫ﹰ‬‫ا‬‫ﻣﻄلﻘ‬ ‫ﻣﻨﻬا‬ ‫ﳝﻨﻊ‬ • ‫الﺘﻬاﺏ‬ ‫ﺃﻭ‬ ،(drains) ‫ﻣﻨاﺯﺡ‬ ‫ﻭﺟﻮد‬ ‫ﻣﻊ‬ ‫اﳊديﺜة‬ ،‫الصفاقية‬‫اﻻلﺘصاقاﺕ‬‫ﺃﻭ‬،‫الﺒﻄﻦ‬‫ﻓﺘﻖ‬‫ﺃﻭ‬،‫الصفاﻕ‬ pleuroperitoneal) ‫الصفاقﻲ‬ ‫اﳉﻨﺒﻲ‬ ‫الﻨاﺳﻮﺭ‬ ‫ﺃﻭ‬ .‫اﳊﻤل‬ ‫ﺃﻭ‬ ،‫الﻘلﺐ‬ ‫ﺟﺮاﺣاﺕ‬ ‫ﻋﻦ‬ ‫الﻨاﺟﻢ‬ (fistula ‫ﺭقﻌة‬ ‫ﺣالة‬ ‫ﻓﻲ‬ ‫ﻧﺴﺒية‬ ‫ﺑصﻮﺭة‬ ‫ﻣﻨﻬا‬ ‫ﳝﻨﻊ‬ • ‫الﺒﻄﻦ‬‫ﺟداﺭ‬‫ﻫلل‬‫الﺘﻬاﺏ‬،‫اﳊديﺜة‬‫اﻷﺑﻬﺮ‬‫الﺸﺮياﻥ‬ adynamic) ‫الﺸللﻲ‬ ‫الﻌلﻮﺹ‬ ،(cellulitis) .‫الﺸديد‬ ‫الﺘﻨفﺴﻲ‬ ‫اﻹﺟﻬاد‬ ‫ﺃﻭ‬ ،(ileus ‫ﺃﺻاﺏ‬ ‫ﺇﺫا‬ ‫الﻮﻓاة‬ ‫ﺇلﻰ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫يﺆدﻱ‬ ‫قد‬ • .‫ﹰ‬‫ا‬‫ﻣﻨﻬﻜ‬ ‫ﹰ‬‫ا‬‫ﻣﺮيﻀ‬ .‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫لفﺮﻁ‬ ‫الﺒﻄﻲﺀ‬ ‫الﺘصﺤيﺢ‬ •
  • ١١٢ ‫الﻜلﻰ‬ ‫ﺯﺭﻉ‬ ‫ﺟﺮاﺣة‬ ‫ﺑﻌد‬ ‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫ﻋﻦ‬ ‫ﹰ‬‫ا‬‫ﻋﻮﺿ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫يﺘيﺢ‬ • ‫اﳌﻤﺮﺿﲔ‬‫ﻣﻌﻈﻢ‬‫ﻭلﻜﻦ‬،‫الدﻡ‬‫ﺿﻐﻂ‬‫ﺧفﺾ‬‫اﺣﺘﻤاﻻﺕ‬‫يﻘلل‬‫ﻛﻤا‬،‫الﻬيﺒاﺭيﻦ‬‫اﺳﺘﻌﻤاﻝ‬‫ﲡﻨﺐ‬ ‫الديلزة‬ ‫ﻣﻦ‬ ‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫ﻓﻲ‬ ‫ﺃﻓﻀل‬ ‫ﺧﺒﺮة‬ ‫ﳝلﻜﻮﻥ‬ ‫الﻜلﻰ‬ ‫ﺯﺭﻉ‬ ‫ﻣﺮاﻛز‬ ‫ﻓﻲ‬ ‫الﻌاﻣلﲔ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﺃدﻕ‬ ‫ﺑصﻮﺭة‬ ‫يﺘﻢ‬ ‫الﺴﻮاﺋل‬ ‫ﺇﺯالة‬ ‫ﻓﻲ‬ ‫الﺘﺤﻜﻢ‬ ‫ﺃﻥ‬ ‫ﻛﻤا‬ ‫الصفاقية‬ .‫الدﻣﻮﻱ‬ ‫ﻣﻊ‬ ‫ﻣﻜاﻧﻪ‬ ‫ﻓﻲ‬ ‫الصفاﻕ‬ ‫قﺜﻄاﺭ‬ ‫ﺗﺮﻙ‬ ‫ﻓيﺠﺐ‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﻋدﻭﻯ‬ ‫ﻋلﻰ‬ ‫دﻻلة‬ ‫ﻫﻨاﻙ‬ ‫ﺗﻜﻦ‬ ‫لﻢ‬ ‫ﻣا‬ • ‫ﲟا‬ ‫اﳉﺮاﺣة‬ ‫)ﺑﻌد‬ ‫ﺑفاﻋلية‬ ‫ﻭﻇيفﺘﻬا‬ ‫اﳌزﺭﻭﻋة‬ ‫الﻜلية‬ ‫ﺗﺆدﻱ‬ ‫ﺣﺘﻰ‬ ‫ﹰ‬‫ا‬‫ﺃﺳﺒﻮﻋي‬ ‫الﻀﻤاداﺕ‬ ‫ﺗﻐييﺮ‬ .(‫ﹰ‬‫ا‬‫ﺃﺳﺒﻮﻋ‬ ١٢ - ٤ ‫يﻘاﺭﺏ‬ ‫اﳌلﺢ‬ ‫ﻣﺤلﻮﻝ‬ ‫ﺣﻘﻦ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫الﻌيﻨة‬ ‫ﺃﺧﺬ‬ ‫ﻓيﺠﺐ‬ ،‫الصفاﻕ‬ ‫ﺳاﺋل‬ ‫لزﺭﻉ‬ ‫لزﻭﻡ‬ ‫ﻫﻨاﻙ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ • ‫ﻋدد‬ ‫ﻓﺤﺺ‬ ‫يﻜﻮﻥ‬ ‫اﳊالة‬ ‫ﻫﺬﻩ‬ ‫ﻭﻓﻲ‬ ،‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﺯﺭﻉ‬ ‫ﺛﻢ‬ ‫الصفاﻕ‬ ‫ﲡﻮيﻒ‬ ‫داﺧل‬ ‫الﻨﻈاﻣﻲ‬ .‫ﻣﻐزﻯ‬ ‫ﺫﻱ‬ ‫ﻏيﺮ‬ ‫اﳋﻼيا‬
  • ١١١ ‫ﺍﻟﻜﻠﻰ‬ ‫ﻟﺰﺭﻉ‬ ‫ﺍﳌﺮﻳﺾ‬ ‫ﺇﻋﺪﺍﺩ‬ :٤-١٦ ‫الفﺸل‬ ‫ﻣﺮﺣلة‬ ‫ﺇلﻰ‬ ‫الﻮﺻﻮﻝ‬ ‫قﺒل‬ ‫الﻜلﻰ‬ ‫ﺯﺭﻉ‬ ‫ﻋلﻰ‬ ‫اﳌﻨاﺳﺐ‬ ‫اﳌﺮيﺾ‬ ‫ﺗﺸﺠيﻊ‬ ‫ﺴﺘﺤﺴﻦ‬‫ﹸ‬‫ي‬ • ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫ﹰ‬‫ا‬‫ﺧصﻮﺻ‬ ،‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫ﺃﻭ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺑدﺀ‬ ‫قﺒل‬ ‫ﺃﻱ‬ ،‫الﻨﻬاﺋﻲ‬ ‫الﻜلﻮﻱ‬ .‫الﺴﻜﺮﻱ‬ ‫ﺑداﺀ‬ ‫ﹰ‬‫ا‬‫ﻣصاﺑ‬ ‫اﳌﺮيﺾ‬ ‫الﻜلﻰ‬ ‫ﺑزﺭﻉ‬ ‫الﺘﻌﺠيل‬ ‫ﺴﺘﺤﺴﻦ‬‫ﹸ‬‫ي‬ ،‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫ﺃﻭ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺑدﺀ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ • ‫الﺴﺘة‬ ‫الﺸﻬﻮﺭ‬ ‫ﺧﻼﻝ‬ ‫الزﺭﻉ‬ ‫ﺇﺟﺮاﺀ‬ ‫ﰎ‬ ‫ﺇﺫا‬ ‫ﺃﻓﻀل‬ ‫الﻜلية‬ ‫ﺯﺭﻉ‬ ‫ﻧﺘاﺋﺞ‬ ‫ﺗﻜﻮﻥ‬ ‫ﺣيﺚ‬ ،‫ﺫلﻚ‬ ‫ﺗيﺴﺮ‬ ‫ﺇﺫا‬ .‫الﺒديلة‬ ‫الﻜلﻮﻱ‬ ‫اﳌﻌاﳉة‬ ‫ﺑدﺀ‬ ‫ﺑﻌد‬ ‫اﻷﻭلﻰ‬ ‫ﺫلﻚ‬ ‫ﻓﻲ‬ ‫ﲟا‬ ،‫الﻜلﻰ‬ ‫لزﺭﻉ‬ ‫اﳌﻤﻜﻨة‬ ‫اﳉاﻧﺒية‬ ‫ﻭاﻵﺛاﺭ‬ ‫اﶈﺘﻤلة‬ ‫ﺑالفﻮاﺋد‬ ‫اﳌﺮيﺾ‬ ‫ﺗﻮﻋية‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • .‫الزﺭاﻋة‬ ‫ﺑﻌد‬ ‫اﳌﺴﺘﻌﻤلة‬ ‫للﻌﻘاقيﺮ‬ ‫اﶈﺘﻤلة‬ ‫اﳉاﻧﺒية‬ ‫اﻵﺛاﺭ‬ ‫اﳌﻨاﻋة‬ ‫لﻜاﺑﺘاﺕ‬ ‫اﳌﺴﺘﻤﺮ‬ ‫اﻻﺳﺘﻌﻤاﻝ‬ ‫ﺿﺮﻭﺭة‬ ‫ﻋلﻰ‬ ‫اﳌﺮيﺾ‬ ‫ﺗﻮﻋية‬ ‫ﺗﺮﻛز‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ • .‫ﺑالﻌﻼﺝ‬ ‫اﻻلﺘزاﻡ‬ ‫ﺃﻫﻤية‬ ‫ﻭﻋلﻰ‬ (immunosuppressants) ‫الﺘﺤﺴﺲ‬ ‫ﺧﻄﺮ‬ ‫لﺘﻘليل‬ ‫ﻭﺫلﻚ‬ ،‫الﻜلﻰ‬ ‫ﺯﺭﻉ‬ ‫يﻨﻮﻭﻥ‬ ‫الﺬيﻦ‬ ‫للﻤﺮﺿﻰ‬ ‫الدﻡ‬ ‫ﻧﻘل‬ ‫ﲡﻨﺐ‬ ‫يﺴﺘﺤﺴﻦ‬ • ،(sensitization to HLA antigens) ‫الﻨﺴيﺠﻲ‬ ‫الﺘﻮاﻓﻖ‬ ‫ﻣﺴﺘﻀداﺕ‬ ‫ﻣﻦ‬ ‫ﺃقﺮﺑاﺋﻪ‬ ‫ﺃﺣد‬ ‫ﻣﻦ‬ ‫ﻛلﻰ‬ ‫ﺯﺭاﻋة‬ ‫ﺇﺟﺮاﺀ‬ ‫يﻨﻮﻱ‬ ‫ﻣﺮيﺾ‬ ‫ﺇلﻰ‬ ‫الدﻡ‬ ‫ﻧﻘل‬ ‫ﻣﻦ‬ ‫ﺑد‬ ‫ﺛﻤة‬ ‫يﻜﻦ‬ ‫لﻢ‬ ‫ﺇﺫا‬ • ‫اﺳﺘﻌﻤاﻝ‬ ‫يﺴﺘﺤﺴﻦ‬ ‫ﻛﻤا‬ ،‫اﳌﺮيﺾ‬ ‫ﺃقﺮﺑاﺀ‬ ‫ﻏيﺮ‬ ‫ﻣﻦ‬ ‫ﺑالدﻡ‬ ‫اﳌﺘﺒﺮﻉ‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫ﻓيﺴﺘﺤﺴﻦ‬ leukocyte) ‫الﺒيﺾ‬ ‫الﻜﺮياﺕ‬ ‫ﻣﻨزﻭﻉ‬ ‫دﻡ‬ ‫ﺃﻭ‬ (pakced red blood cells) ‫ﻣﻜدﻭﺳة‬ ‫ﺣﻤﺮ‬ ‫ﻛﺮياﺕ‬ .‫ﺫلﻚ‬ ‫ﺗﻮﻓﺮ‬ ‫ﺇﺫا‬ (depleted ،‫اﳌﺴﺘﻘﺒل‬ ‫ﻓﻲ‬ ‫ﻛلﻰ‬ ‫ﺯﺭﻉ‬ ‫ﺇﺟﺮاﺀ‬ ‫للﻤﺮيﺾ‬ ‫يﺘﻮقﻊ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫الفﺨﺬﻱ‬ ‫الﻮﺭيد‬ ‫قﺜﻄﺮة‬ ‫ﲡﻨﺐ‬ ‫يﺠﺐ‬ • ‫ﻣﻦ‬ ‫ﻻﺑد‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ .‫الﻈاﻫﺮ‬ ‫اﳊﺮقفﻲ‬ ‫ﻭالﻮﺭيد‬ ‫الفﺨﺬﻱ‬ ‫الﻮﺭيد‬ ‫لﻪ‬ ‫يﺘﻌﺮﺽ‬ ‫قد‬ ‫الﺬﻱ‬ ‫الﺮﺽ‬ ‫لﺘﻘليل‬ .‫اﻷﳝﻦ‬ ‫ﻋﻦ‬ ‫ﹰ‬‫ا‬‫ﻋﻮﺿ‬ ‫اﻷيﺴﺮ‬ ‫الفﺨﺬﻱ‬ ‫الﻮﺭيد‬ ‫قﺜﻄﺮة‬ ‫ﻓيﺴﺘﺤﺴﻦ‬ ،‫ﺫلﻚ‬ .‫الﻜلﻰ‬ ‫ﺯﺭﻉ‬ ‫قﺒل‬ ‫ﺇﺯالﺘﻬا‬ ‫ﻦ‬ ‫ﹸ‬‫ﻭيﺤﺴ‬ ،‫للﻌدﻭﻯ‬‫ﹰ‬‫ا‬‫ﺑﺆﺭ‬ ‫اﳌﺮاﺭة‬ ‫ﻭﺣصﻮاﺕ‬ ‫الﻜلﻰ‬ ‫ﺣصﻮاﺕ‬ ‫ﲤﺜل‬ • ‫ﻭﺟيزة‬ ‫ﺑفﺘﺮة‬ ‫اﳉﺮاﺣة‬ ‫ﺇﺟﺮاﺀ‬ ‫قﺒل‬ ‫ﺑالﻜلﻰ‬ ‫ﻭاﳌﺘﺒﺮﻉ‬ ‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫ﻣﺮيﺾ‬ ‫ﻣﻦ‬ •‫ﹴ‬‫ﻛل‬ ‫ﻓﺤﺺ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ .(EBV) «‫ﺑاﺭ‬ ‫»ﺇﺑﺸﺘايﻦ‬ ‫ﺃﻭﻓيﺮﻭﺱ‬ (CMV) ‫للﺨﻼيا‬ ‫اﳌﻀﺨﻢ‬ ‫الفيﺮﻭﺱ‬ ‫ﻭﺟﻮد‬ ‫ﻋلﻰ‬ ‫دﻻلة‬ ‫ﻋﻦ‬ ‫ﹰ‬‫ا‬‫ﺑﺤﺜ‬ ‫ﺍﻟﻜﻠﻰ‬ ‫ﺯﺭﻉ‬ ‫ﻭﺑﻌﺪ‬ ‫ﻗﺒﻞ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﲟﺮﻳﺾ‬ ‫ﺍﻟﻌﻨﺎﻳﺔ‬ :٥-١٦ ‫لفﺮﻁ‬ ‫الﺴالﺐ‬ ‫الﺘﺄﺛيﺮ‬ ‫لﺘﻘليل‬ ‫اﳉﺮاﺣة‬ ‫ﺇﺟﺮاﺀ‬ ‫قﺒل‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻦ‬ ‫الصفاﻕ‬ ‫ﺗفﺮيﻎ‬ ‫يﺠﺐ‬ • .‫الﺘﻨفﺲ‬ ‫ﻋلﻰ‬ ‫الصفاﻕ‬ ‫داﺧل‬ ‫الﻀﻐﻂ‬ ‫اﳉﺮاﺣة‬ ‫ﺑﻌد‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﺗﺴﺮﺏ‬ ‫اﺣﺘﻤاﻝ‬ ‫ﻓﺈﻥ‬ ‫لﺬلﻚ‬ ،‫الصفاﻕ‬ ‫ﺧاﺭﺝ‬ ‫ﻋادة‬ ‫يﺘﻢ‬ ‫الﻜلﻰ‬ ‫ﺯﺭﻉ‬ • ‫ﺇﻻ‬ ‫الزﺭﻉ‬ ‫ﻋﻤلية‬ ‫ﺑﻌد‬ ‫الديلزة‬ ‫ﺇلﻰ‬ ‫اﳌﺮيﺾ‬ ‫اﺣﺘاﺝ‬ ‫ﺇﺫا‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﻮاﺻلة‬ ‫ﻭﳝﻜﻦ‬ ،‫قليل‬ .‫ﺛﻘﺐ‬ ‫قد‬ ‫الصفاﻕ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬
  • ١١٠ ‫ﻓﺤﺺ‬ ،‫الﺒﻮﻝ‬ ‫ﻓﺤﺺ‬ ،‫الدﻡ‬ ‫ﻓصيلة‬ ‫ﺑالﻜلﻰ‬ ‫اﶈﺘﻤل‬ ‫للﻤﺘﺒﺮﻉ‬ ‫الﻼﺯﻣة‬ ‫الفﺤﻮﺻاﺕ‬ ‫ﺗﺸﻤل‬ • ‫ﻣﺴﺘﻮﻯ‬ ،‫الصﻮديﻮﻡ‬ ‫ﻣﺴﺘﻮﻯ‬ ،‫الﻜﺮياﺗﻨﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ ،‫اليﻮﺭيا‬ ‫ﻣﺴﺘﻮﻯ‬ ،‫ﺑالﺒﻮﻝ‬ ‫الﺒﺮﻭﺗﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ ،(uric acid) ‫اليﻮﺭيﻚ‬ ‫ﺣﻤﺾ‬ ‫ﻣﺴﺘﻮﻯ‬ ،‫الفﺴفﻮﺭ‬ ‫ﻣﺴﺘﻮﻯ‬ ،‫الﻜالﺴيﻮﻡ‬ ‫ﻣﺴﺘﻮﻯ‬ ،‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫ﻓﺤﺺ‬ ،‫الصياﻡ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ ‫الﺴﻜﺮ‬ ‫ﻣﺴﺘﻮﻯ‬ ،‫الﻜاﻣل‬ ‫الدﻡ‬ ‫ﻓﺤﺺ‬ ،‫الﻜﻮليﺴﺘيﺮﻭﻝ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫اﳌﻨاﻋﻲ‬ ‫الﻌﻮﺯ‬ ‫ﻓيﺮﻭﺱ‬ ‫ﻓﺤﺺ‬ ،‫اﳉزﺋﻲ‬ ‫الﺜﺮﻭﻣﺒﻮﺑﻼﺳﺘﲔ‬ ‫ﺯﻣﻦ‬ ،‫الﺒﺮﻭﺛﺮﻭﻣﺒﲔ‬ ‫ﺯﻣﻦ‬ ،‫الﻜﺒد‬ ‫ﻭﻇاﺋﻒ‬ ‫الﺘصﻮيﺮ‬،‫الﻘلﺐ‬‫ﻛﻬﺮﺑية‬‫ﺗﺨﻄيﻂ‬،‫ﺝ‬‫الﻜﺒد‬‫ﻓيﺮﻭﺱ‬‫ﻓﺤﺺ‬،‫ﺏ‬‫الﻜﺒد‬‫ﻓيﺮﻭﺱ‬‫ﻓﺤﺺ‬،‫الﺒﺸﺮﻱ‬ ‫الﻨﻤﻂ‬ ‫ﻓﺤﺺ‬ ،‫الصﻮﺕ‬ ‫ﻓاﺋﻖ‬ ‫الﺒﻄﻦ‬ ‫ﺗصﻮيﺮ‬ ،‫الﻘلﺐ‬ ‫ﺻدﻯ‬ ‫ﺗﺨﻄيﻂ‬ ،‫للصدﺭ‬ ‫الﺸﻌاﻋﻲ‬ magnetic resonance renal) ‫اﳌﻐﻨاﻃيﺴﻲ‬ ‫ﺑالﺮﻧﲔ‬ ‫الﻜلﻮية‬ ‫الﺸﺮايﲔ‬ ‫ﻭﺗصﻮيﺮ‬ ،‫الﻨﺴيﺠﻲ‬ spiral computed tomography) ‫اﶈﻮﺳﺐ‬ ‫اﳊلزﻭﻧﻲ‬ ‫اﳌﻘﻄﻌﻲ‬ ‫الﺘصﻮيﺮ‬ ‫ﺃﻭ‬ (angiography .(angiography ‫ﺑﺎﻟﻜﻠﻰ‬ ‫ﺍﻟﺘﺒﺮﻉ‬ ‫ﻣﻮﺍﻧﻊ‬ :٢٧ ‫ﺟﺪﻭﻝ‬ ‫ﺍﳌﻄﻠﻘﺔ‬ ‫ﺍﳌﻮﺍﻧﻊ‬‫ﺍﻟﻨﺴﺒﻴﺔ‬ ‫ﺍﳌﻮﺍﻧﻊ‬ ‫ﺗﻮاﻓﻖ‬ ‫يﺸﺘﺮﻁ‬ ‫ﻻ‬ ‫ﻭلﻜﻦ‬ ،‫الدﻡ‬ ‫ﻓصيلة‬ ‫ﺗﻮاﻓﻖ‬ ‫ﻋدﻡ‬ • .(rhesus factor) ‫الﺮيﺴﻮﺳﻲ‬ ‫اﳌﺴﺘﻀد‬ ‫داﺀ‬ ،‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻓﺮﻁ‬ :‫)ﻣﺜاﻝ‬ ‫اﳌزﻣﻨة‬ ‫اﻷﻣﺮاﺽ‬ • .(‫الﺮﻭﻣاﺗيزﻣﻲ‬ ‫الﻘلﺐ‬ ‫ﻣﺮﺽ‬ ،‫الﺴﻜﺮﻱ‬ ‫ﺭﺷﺢ‬ ‫ﻣﻌدﻝ‬ :‫)ﻣﺜاﻝ‬ ‫الﻜلﻰ‬ ‫ﺗﻀﺮﺭ‬ ‫ﻋلﻰ‬ ‫دﻻلة‬ ‫ﻭﺟﻮد‬ • ،‫دﻣﻮية‬ ‫ﺑيلة‬ ،‫ﺑﺮﻭﺗيﻨية‬ ‫ﺑيلة‬ ،‫ﻣﻨﺨفﺾ‬ ‫ﻛﺒيﺒﻲ‬ .(‫الﻜلﻰ‬ ‫ﺣصﻮاﺕ‬ ،‫الﻜلﻰ‬ ‫ﺗﻜلﺲ‬ ‫الﺒﻮلﻲ‬ ‫اﳉﻬاﺯ‬ ‫ﻓﻲ‬ ‫الﺸديد‬ ‫اﳋلﻘﻲ‬ ‫الﺸﺬﻭﺫ‬ • ‫ﺛﻨاﺋﻲ‬ ‫ﺑاﳊالﺐ‬ ‫اﳊﻮﺽ‬ ‫ﻣﻮﺻل‬ ‫اﻧﺴداد‬ :‫)ﻣﺜاﻝ‬ bilateral pelviureteric junction) ‫اﳉاﻧﺐ‬ .(obstruction ‫اﳌﻨاﻋﻲ‬ ‫الﻌﻮﺯ‬ ‫ﻓيﺮﻭﺱ‬ ‫ﺫلﻚ‬ ‫ﻭيﺸﻤل‬ ،‫ﻋدﻭﻯ‬ ‫ﻭﺟﻮد‬ • .«‫»ﺝ‬ ‫ﺃﻭ‬ «‫»ﺏ‬ ‫الﻜﺒد‬ ‫الﺘﻬاﺏ‬ ‫ﻓيﺮﻭﺱ‬ ‫ﻭ‬ ‫الﺒﺸﺮﻱ‬ ‫الﻘاﻋدية‬ ‫اﳉلد‬ ‫ﺳﺮﻃاﻧة‬ ‫ﺑاﺳﺘﺜﻨاﺀ‬ ،‫ﺧﺒاﺛة‬ ‫ﻭﺟﻮد‬ • .‫ﻭاﳊﺮﺷفية‬ .‫الﻜلﻰ‬ ‫ﺑﺄﻭﺭاﻡ‬ ‫ﻋاﺋلﻲ‬ ‫ﺗاﺭيﺦ‬ ‫ﻭﺟﻮد‬ • ‫اﺳﺘﺨداﻡ‬ ‫ﺇﺳاﺀة‬ ‫ﺃﻭ‬ ‫ﻋﻘلﻲ‬ ‫ﺗﺨلﻒ‬ ‫ﺃﻭ‬ ‫ﺫﻫاﻥ‬ • .‫للﻌﻘاقيﺮ‬ .‫اﳊﻤل‬ • .‫ﻧﺸيﻄة‬ ‫ﻫﻀﻤية‬ ‫قﺮﺣة‬ ‫ﻭﺟﻮد‬ • ‫ﺗﻌدد‬ :‫)ﻣﺜاﻝ‬ ‫الﺒﻮلﻲ‬ ‫اﳉﻬاﺯ‬ ‫ﻓﻲ‬ ‫الﺒﺴيﻂ‬ ‫الﺸﺬﻭﺫ‬ • .(‫الﻜلﻮية‬ ‫اﻷﻭﻋية‬ ( •BMI) ‫اﳉﺴﻢ‬ ‫ﻛﺘلة‬ ‫ﲟﻨﺴﺐ‬ ‫ﻭﺗﻌﺮﻑ‬ ،‫الﺴﻤﻨة‬ .٢‫ﻛلﻎ/ﻡ‬ ٣٠ ‫ﻣﻦ‬ ‫ﺃﻛﺒﺮ‬ •١٨ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫ﺃﻭ‬ ‫ﹰ‬‫ا‬‫ﻋاﻣ‬ ٦٥ ‫ﻣﻦ‬ ‫ﺃﻛﺒﺮ‬ ‫الﻌﻤﺮ‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ .‫ﹰ‬‫ا‬‫ﻋاﻣ‬ ‫داﺀ‬ ‫ﺃﻭ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﺑفﺮﻁ‬ ‫ﻋاﺋلﻲ‬ ‫ﺗاﺭيﺦ‬ ‫ﻭﺟﻮد‬ • .‫الﺴﻜﺮﻱ‬
  • ١٠٩ ‫ﺍﻟﻜﻠﻰ‬ ‫ﺯﺭﻉ‬ ‫ﻣﻮﺍﻧﻊ‬ :٢٦ ‫ﺟﺪﻭﻝ‬ ‫ﺍﳌﻄﻠﻘﺔ‬ ‫ﺍﳌﻮﺍﻧﻊ‬‫ﺍﻟﻨﺴﺒﻴﺔ‬ ‫ﺍﳌﻮﺍﻧﻊ‬ ‫اﳉلد‬ ‫ﺳﺮﻃاﻧة‬ ‫ﺑاﺳﺘﺜﻨاﺀ‬ ،( •malignancy) ‫ﺧﺒاﺛة‬ .‫اﳊﺮﺷفية‬ ‫ﺃﻭ‬ ‫الﻘاﻋدية‬ .‫ﻧﺸﻄة‬ ‫ﻋدﻭﻯ‬ • .‫ﺷديد‬ ‫ﺗﻨفﺴﻲ‬ ‫ﺃﻭ‬ ‫قلﺒﻲ‬ ‫ﻓﺸل‬ • ‫اﶈﺘﻤل‬ ‫اﳌﺘﺒﺮﻉ‬ ‫ﻣﻊ‬ ‫ﻣﻮﺟﺐ‬ ‫ﻧﺴيﺠﻲ‬ ‫ﺗﻮاﻓﻖ‬ ‫اﺧﺘﺒاﺭ‬ • .((positive HLA cross-match) •peripheral) ‫ﺷاﻣل‬ ‫ﻣﺤيﻄﻲ‬ ‫ﻭﻋاﺋﻲ‬ ‫ﻣﺮﺽ‬ ‫الﺘاﺟﻲ‬ ‫الﻘلﺐ‬ ‫ﻣﺮﺽ‬ ‫ﺃﻭ‬ (vacular disease .(coronary heart disease) ‫ﻣﻦ‬ ‫ﺃﻫﻤية‬ ‫ﺃﻛﺜﺮ‬ ‫الﺒيﻮلﻮﺟﻲ‬ ‫)الﻌﻤﺮ‬ ‫الﻌﻤﺮ‬ ‫ﺗﻘدﻡ‬ • .(‫الزﻣﻨﻲ‬ ‫الﻌﻤﺮ‬ ‫الﻌالية‬ ‫الﻘاﺑلية‬ ‫ﺫاﺕ‬ ‫الﻜلﻮية‬ ‫اﻷﻣﺮاﺽ‬ • ،(oxalosis) ‫اﻷﻭﻛﺴالﻲ‬ ‫الداﺀ‬ ‫ﻣﺜل‬ ،‫لﻼﻧﺘﻜاﺱ‬ ‫ﻭﻣﺘﻼﺯﻣة‬ ،(FSGS) ‫الﺒﺆﺭﻱ‬ ‫الﻜﺒيﺒاﺕ‬ ‫ﺗصلﺐ‬ .(HUS) ‫اليﻮﺭﳝية‬ ‫الدﻡ‬ ‫اﻧﺤﻼﻝ‬ .‫الﺒﻮلﻲ‬ ‫اﳉﻬاﺯ‬ ‫ﺷﺬﻭﺫ‬ • •activesystemic)‫الﻨﺸيﻄة‬‫اﺠﻤﻟﻤﻮﻋية‬‫اﻷﻣﺮاﺽ‬ .(vasculitis) ‫الﻮﻋاﺋﻲ‬ ‫اﻻلﺘﻬاﺏ‬ ‫ﻣﺜل‬ ،(disease ‫ﻓيﺮﻭﺱ‬ ‫ﻋﻦ‬ ‫الﻨاﺟﻢ‬ •‫ﺍﻟﻨﺸﻴﻂ‬ ‫الﻜﺒد‬ ‫الﺘﻬاﺏ‬ .‫ﺝ‬ ‫الﻜﺒد‬ ‫الﺘﻬاﺏ‬ ‫ﻓيﺮﻭﺱ‬ ‫ﺃﻭ‬ ‫ﺏ‬ ‫الﻜﺒد‬ ‫الﺘﻬاﺏ‬ .( •HIV) ‫الﺒﺸﺮﻱ‬ ‫اﳌﻨاﻋﻲ‬ ‫الﻌﻮﺯ‬ ‫ﻓيﺮﻭﺱ‬ ‫ﻋدﻭﻯ‬ .( •coagulopathy) ‫اﳋﺜﺮﻱ‬ ‫اﻻﻋﺘﻼﻝ‬ .‫ية‬ ‫ﹺ‬‫ﺿ‬‫ﹶ‬‫ﺮ‬‫ﹶ‬‫ﳌ‬‫ا‬ ‫الﺴﻤﻨة‬ • .‫اﳋﺮﻑ‬ ‫ﺃﻭ‬ ‫الﺬﻫاﻥ‬ • .( •non-compliance) ‫اﳌﻄاﻭﻋة‬ ‫ﻋدﻡ‬ ‫ﺑﺎﻟﻜﻠﻰ‬ ‫ﺍﶈﺘﻤﻞ‬ ‫ﺍﳌﺘﺒﺮﻉ‬ ‫ﺗﻘﻴﻴﻢ‬ :٣-١٦ ‫ﻣﺘﺒﺮﻉ‬ ‫ﻣﻦ‬ ‫اﳌﻨﻘﻮلة‬ ‫الﻜلﻰ‬ ‫ﺯﺭﻉ‬ ‫ﻧﺘاﺋﺞ‬ ‫ﻣﻦ‬ ‫ﺃﻓﻀل‬ ‫ﺣﻲ‬ ‫ﻣﺘﺒﺮﻉ‬ ‫ﻣﻦ‬ ‫اﳌﻨﻘﻮلة‬ ‫الﻜلﻰ‬ ‫ﺯﺭﻉ‬ ‫ﻧﺘاﺋﺞ‬ • .‫قاﻧﻮﻧﻲ‬ ‫ﻏيﺮ‬ ‫ﻓﻬﻮ‬ ‫اﻷﻋﻀاﺀ‬ ‫ﺷﺮاﺀ‬ ‫ﺃﻣا‬ ،‫ﻣﺘاﺣة‬ ‫ﻛاﻧﺖ‬ ‫ﺇﺫا‬ ‫ﺗﺸﺠيﻌﻬا‬ ‫ﻣﻦ‬ ‫ﻭﻻﺑد‬ ،‫ﻣﺘﻮﻓﻰ‬ ‫ﻋلﻢ‬ ‫اﺧﺘصاﺻﻲ‬ ‫قﺒل‬ ‫ﻣﻦ‬ ،‫ﺑالﻜلﻰ‬ ‫ﻣﺤﺘﻤل‬ ‫ﻣﺘﺒﺮﻉ‬ ‫لﻜل‬ ‫دقيﻖ‬ ‫ﻧفﺴﻲ‬ ‫ﺗﻘييﻢ‬ ‫ﺇﺟﺮاﺀ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • ‫ﻣﻮاﻧﻊ‬ ‫ﺃﻱ‬ ‫اﻛﺘﺸاﻑ‬ ‫ﺑﻬدﻑ‬ ‫دقيﻖ‬ ‫ﻣﺮﺿﻲ‬ ‫ﺗاﺭيﺦ‬ ‫ﻭ‬ ‫ﻛاﻣل‬ ‫ﺳﺮيﺮﻱ‬ ‫ﻓﺤﺺ‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ ،‫الﻨفﺲ‬ .(٢٧ ‫ﺟدﻭﻝ‬ ‫)اﻧﻈﺮ‬ ‫ﺑالﻜلﻰ‬ ‫للﺘﺒﺮﻉ‬ ‫ﻣﺤﺘﻤلة‬
  • ١٠٨ ‫ﺍﻟﻜﻠﻰ‬ ‫ﻟﺰﺭﻉ‬ ‫ﺍﻟﺘﺤﻀﻴﺮ‬ :١٦ ‫ﻓﺼﻞ‬ ‫ﺍﻷﻫﺪﺍﻑ‬ :١-١٦ .‫ﻛفاﺀة‬ ‫الﻜلﻮية‬ ‫اﳌﻌاﳉة‬ ‫ﻭﺳاﺋل‬ ‫ﺃﻛﺜﺮ‬ ‫ﺑاﻋﺘﺒاﺭﻫا‬ ‫الﻜلﻰ‬ ‫ﺯﺭﻉ‬ ‫ﻋلﻰ‬ ‫اﳌﻨاﺳﺒﲔ‬ ‫اﳌﺮﺿﻰ‬ ‫ﺗﺸﺠيﻊ‬ • ‫ﺇﺟﺮاﺀ‬ ‫ﺑﻌد‬ ‫ﺑاﳌﺮيﺾ‬ ‫الفاﻋلة‬ ‫ﻭالﻌﻨاية‬ ،‫الﻜلﻰ‬ ‫لزﺭﻉ‬ ‫الصﺤيﺢ‬ ‫الﺘﺤﻀيﺮ‬ ‫ﻋلﻰ‬ ‫الﺘﺸﺠيﻊ‬ • .‫اﳉﺮاﺣة‬ ‫ﺍﻟﻜﻠﻰ‬ ‫ﻟﺰﺭﻉ‬ ‫ﺍﳌﺮﻳﺾ‬ ‫ﻗﺎﺑﻠﻴﺔ‬ :٢-١٦ ‫لزﺭﻉ‬ ‫قاﺑليﺘﻪ‬ ‫لﺘﺤديد‬ ‫ﺷاﻣل‬ ‫لﺘﻘييﻢ‬ ‫الﻜلﻮﻱ‬ ‫ﺑالفﺸل‬ ‫ﻣصاﺏ‬ ‫ﻛل‬ ‫يﺨﻀﻊ‬ ‫ﺃﻥ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • .‫ﺫلﻚ‬ ‫ﺗيﺴﺮ‬ ‫ﺇﺫا‬ ‫الﻜلﻰ‬ ‫ﺯﺭﻉ‬ ‫ﻋلﻰ‬ ‫اﳌﻨاﺳﺐ‬ ‫اﳌﺮيﺾ‬ ‫ﺗﺸﺠيﻊ‬ ‫يﺘﻢ‬ ‫ﻭﺃﻥ‬ ،‫الﻜلﻰ‬ ‫اﻛﺘﺸاﻑ‬ ‫ﺑﻬدﻑ‬ ‫ﻣﺮيﺾ‬ ‫لﻜل‬ ‫ﻣفصل‬ ‫ﻣﺮﺿﻲ‬ ‫ﺗاﺭيﺦ‬ ‫ﻭﺃﺧﺬ‬ ‫ﻛاﻣل‬ ‫ﺳﺮيﺮﻱ‬ ‫ﻓﺤﺺ‬ ‫ﺇﺟﺮاﺀ‬ ‫يﺘﻮﺟﺐ‬ • .(٢٦ ‫ﺟدﻭﻝ‬ ‫)اﻧﻈﺮ‬ ‫الزﺭﻉ‬ ‫ﺇﺟﺮاﺀ‬ ‫ﺗﺄﺧﺮ‬ ‫ﺇﺫا‬ ‫الﺘﻘييﻢ‬ ‫ﺇﻋادة‬ ‫ﻭيلزﻡ‬ ،‫الﻜلﻰ‬ ‫لزﺭﻉ‬ ‫ﻣﺤﺘﻤلة‬ ‫ﻣﻮاﻧﻊ‬ ‫ﺃﻱ‬ ‫ﺯﻣﻦ‬ ،‫الﻜﺒد‬ ‫ﻭﻇاﺋﻒ‬ ‫ﻓﺤﺺ‬ ،‫الدﻡ‬ ‫ﻓصيلة‬ ‫اﳌﺮﺿﻰ‬ ‫لﻜل‬ ‫الﻼﺯﻣة‬ ‫الفﺤﻮﺻاﺕ‬ ‫ﺗﺸﻤل‬ • ‫اﳌﻨاﻋﻲ‬ ‫الﻌﻮﺯ‬ ‫ﻓيﺮﻭﺱ‬ ‫ﻓﺤﺺ‬ ،(PTT) ‫اﳉزﺋﻲ‬ ‫الﺜﺮﻭﻣﺒﻮﺑﻼﺳﺘﲔ‬ ‫ﺯﻣﻦ‬ ،(PT) ‫الﺒﺮﻭﺛﺮﻭﻣﺒﲔ‬ ‫ﺗﺨﻄيﻂ‬ ،(HCV) ‫ﺝ‬ ‫الﻜﺒد‬ ‫ﻓيﺮﻭﺱ‬ ‫ﻓﺤﺺ‬ ،(HBV) ‫ﺏ‬ ‫الﻜﺒد‬ ‫ﻓيﺮﻭﺱ‬ ‫ﻓﺤﺺ‬ ،(HIV) ‫الﺒﺸﺮﻱ‬ ‫الﻘلﺐ‬ ‫ﺻدﻯ‬ ‫ﺗﺨﻄيﻂ‬ ،(CXR) ‫للصدﺭ‬ ‫الﺸﻌاﻋﻲ‬ ‫الﺘصﻮيﺮ‬ ،(ECG) ‫الﻘلﺐ‬ ‫ﻛﻬﺮﺑية‬ ‫اﳌﺴﺘﻀد‬ ‫ﻓﺤﺺ‬ ،(ultrasound scan) ‫الصﻮﺕ‬ ‫ﻓاﺋﻖ‬ ‫الﺒﻄﻦ‬ ‫ﺗصﻮيﺮ‬ ،(echocardiography) ‫الﻨﻤﻂ‬ ‫ﻭﻓﺤﺺ‬ ،‫ﹰ‬‫ا‬‫ﻋاﻣ‬ ٥٠ ‫ﻋﻦ‬ ‫ﻋﻤﺮﻫﻢ‬ ‫يزيد‬ ‫الﺬيﻦ‬ ‫الﺬﻛﻮﺭ‬ ‫ﻋﻨد‬ (PSA) ‫للﺒﺮﻭﺳﺘاﺗة‬ ‫اﳌﻨاﻭﻉ‬ .(HLA tissue typing) ‫الﻨﺴيﺠﻲ‬ ‫اﻷﻭﻋية‬ ‫ﺗصﻮيﺮ‬ ‫ﺑدﻭﻥ‬ ‫ﺃﻭ‬ ‫ﻣﻊ‬ ( •stress ECG) ‫اﻹﺟﻬادﻱ‬ ‫الﻘلﺐ‬ ‫ﻛﻬﺮﺑية‬ ‫ﻣﺨﻄﻂ‬ ‫ﺇﺟﺮاﺀ‬ ‫يلزﻡ‬ ‫ﻭاﳌصاﺑﲔ‬ ،‫ﹰ‬‫ا‬‫ﻋاﻣ‬ ٤٠ ‫ﻋﻦ‬ ‫ﻋﻤﺮﻫﻢ‬ ‫يزيد‬ ‫الﺬيﻦ‬ ‫للﻤﺮﺿﻰ‬ (coronary angiography) ‫الﺘاﺟية‬ .(IHD) ‫الﺘاﺟية‬ ‫الﺸﺮايﲔ‬ ‫ﺑﻘصﻮﺭ‬ ‫اﳌصاﺑﲔ‬ ‫ﻭاﳌﺮﺿﻰ‬ ،‫ﻭاﳌدﺧﻨﲔ‬ ،‫الﺴﻜﺮﻱ‬ ‫ﺑداﺀ‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻮﻥ‬ ‫الﺬيﻦ‬ ‫للﻤﺮﺿﻰ‬ ( •doppler study) ‫الدﻭﺑلﺮﻱ‬ ‫الصدﻯ‬ ‫ﺗﺨﻄيﻂ‬ ‫ﺇﺟﺮاﺀ‬ ‫يلزﻡ‬ inermittent) ‫اﳌﺘﻘﻄﻊ‬ ‫الﻌﺮﺝ‬ ‫ﺃﻭ‬ ،(arterial bruit) ‫الﺸﺮياﻧﻲ‬ ‫اللﻐﻂ‬ ‫ﺃﻭ‬ ،‫الﻘدﻡ‬ ‫ﻧﺒﺾ‬ ‫ﻏياﺏ‬ .(claudication ‫ﺗﻨﻈيﺮ‬ ‫ﺑدﻭﻥ‬ ‫ﺃﻭ‬ ‫ﻣﻊ‬ ( •voiding cystourethrogram) ‫الﺒﻮﻝ‬ ‫ﺃﺛﻨاﺀ‬ ‫ﻭاﻹﺣليل‬ ‫اﳌﺜاﻧة‬ ‫ﺗصﻮيﺮ‬ ‫يلزﻡ‬ ‫ﻭاﳌﺮﺿﻰ‬ ،‫اﳌﺘﻜﺮﺭة‬ ‫الﺒﻮﻝ‬ ‫ﺑﻌدﻭﻯ‬ ‫اﳌصاﺑﲔ‬ ‫ﻭاﳌﺮﺿﻰ‬ ،‫لﻸﻃفاﻝ‬ ‫ﺑالﻨﺴﺒة‬ (cystoscopy) ‫اﳌﺜاﻧة‬ ‫ﺑاﳉزﺭ‬ ‫اﳌصاﺑﲔ‬ ‫ﻭاﳌﺮﺿﻰ‬ ،(bladder outflow obstruction) ‫اﳌﺜاﻧة‬ ‫ﻣﺨﺮﺝ‬ ‫ﺑاﻧﺴداد‬ ‫اﳌصاﺑﲔ‬ .(vesico ureteric reflux) ‫اﳊالﺒﻲ‬ ‫اﳌﺜاﻧﻲ‬ ‫لﻮ‬ ‫ﺣﺘﻰ‬ ‫ﺝ‬ ‫ﺃﻭ‬ ‫ﺏ‬ ‫الﻜﺒد‬ ‫الﺘﻬاﺏ‬ ‫لفيﺮﻭﺱ‬ ‫اﳊاﻣلﲔ‬ ‫اﳌﺮﺿﻰ‬ ‫ﻋﻨد‬ ‫الﻜﺒد‬ ‫ﻣﻦ‬ ‫ﻋيﻨة‬ ‫ﺃﺧﺬ‬ ‫يلزﻡ‬ • .‫ﺳليﻤة‬ ‫الﻜﺒد‬ ‫ﻭﻇاﺋﻒ‬ ‫ﻓﺤﻮﺻاﺕ‬ ‫ﻛاﻧﺖ‬
  • ١٠٧ ‫يﺆدﻱ‬ ‫قد‬ ‫ﺇﺫ‬ ،‫ﻭاﺣدة‬ ‫ﻛفة‬ ‫ﺫﻱ‬ ‫ﺑاﻷﻃفاﻝ‬ ‫ﺧاﺹ‬ ‫قﺜﻄاﺭ‬ ‫ﺇلﻰ‬ ‫الﻐالﺐ‬ ‫ﻓﻲ‬ ‫الصﻐيﺮ‬ ‫الﻄفل‬ ‫يﺤﺘاﺝ‬ • ‫يﻨﺘﺞ‬ ‫قد‬ ‫ﳑا‬ ‫الﻄفل‬ ‫ﳕﻮ‬ ‫ﺃﺛﻨاﺀ‬ ‫ﻛلﺘاﻫﻤا‬ ‫ﺃﻭ‬ ‫الﻜفﺘﲔ‬ ‫ﺇﺣدﻯ‬ ‫ﺷد‬ ‫ﺇلﻰ‬ ‫ﻛفﺘﲔ‬ ‫ﺫﻱ‬ ‫قﺜﻄاﺭ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫الﻮﺣيدة‬ ‫الﻜفة‬ ‫ﺗﻮﺿﻊ‬ ‫ﻭاﺣدة‬ ‫ﻛفة‬ ‫ﺫﻱ‬ ‫قﺜﻄاﺭ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ .‫اﻷﻧﺴﺠة‬ ‫ﺗﻀﺮﺭ‬ ‫ﻋﻨﻪ‬ .‫الﻘﺜﻄاﺭ‬ ‫ﻭﺗدﻋيﻢ‬ ‫لﺘﺜﺒيﺖ‬ ‫الﺒﻄﻨية‬ ‫اﳌﺴﺘﻘيﻤة‬ ‫الﻌﻀلة‬ ‫ﲢﺖ‬ ‫ﺃﻭ‬ ‫داﺧل‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻭﻣﺮﺍﻗﺒﺔ‬ ‫ﻭﺻﻒ‬ :٤-١٥ •body) ‫اﳉﺴﻢ‬ ‫ﺳﻄﺢ‬ ‫ﻭﻣﺴاﺣة‬ (total body water) ‫اﳉﺴﻢ‬ ‫ﻣاﺀ‬ ‫ﳊﺠﻢ‬ ‫الدقيﻖ‬ ‫الﺘﻘديﺮ‬ ‫اﳌﻌادلة‬ ‫ﻣﺨﻄﻂ‬ ‫اﺳﺘﺨداﻡ‬ ‫ﻣﻦ‬ ‫ﻭﻻﺑد‬ ،‫لﻸﻃفاﻝ‬ ‫ﺑالﻨﺴﺒة‬ ‫ﺑالﻐة‬ ‫ﺃﻫﻤية‬ ‫ﺫﻭ‬ (surface area .‫اﳌﻨاﺳﺐ‬ (nomogram) ‫ﺳﻄﺢ‬ ‫ﻣﻦ‬ •٢‫ﻣل/ﻡ‬ ٨٠٠ - ٦٠٠ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫لﻜﻤية‬ ‫اﳌﺒدﺋﻲ‬ ‫الﻮﺻﻒ‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫يﺴﺘﺤﺴﻦ‬ ٢‫ﻣل/ﻡ‬ ١٢٠٠ - ١٠٠٠ ‫ﺇلﻰ‬ ‫ﺗصل‬ ‫ﺣﺘﻰ‬ ‫اﳌﺮيﺾ‬ ‫اﺣﺘﻤاﻝ‬ ‫ﺑﻘدﺭ‬ ‫ﹰ‬‫ا‬‫ﺗدﺭيﺠي‬ ‫الﻜﻤية‬ ‫ﻭﺗزاد‬ ،‫اﳉﺴﻢ‬ ‫ﻣﻦ‬ ٢‫ﻣل/ﻡ‬ ١٤٠٠ ‫ﻫﻮ‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻛﻤية‬ ‫ﻣﻦ‬ ‫ﻋادة‬ ‫اﻷقصﻰ‬ ‫ﻭاﳊد‬ ،‫اﳉﺴﻢ‬ ‫ﺳﻄﺢ‬ ‫ﻣﻦ‬ .‫اﳉﺴﻢ‬ ‫ﺳﻄﺢ‬ ‫اﻷﺳﺒﻮﻋية‬ ‫الﻜلية‬ ‫الﺘصفية‬ ‫ﻣﻌدﻝ‬ ‫ﻣﻦ‬ ‫اﳌﻘﺒﻮﻝ‬ ‫اﻷدﻧﻰ‬ ‫اﳊد‬ ‫ﻓﺈﻥ‬ ‫الديلزة‬ ‫ﻛفاية‬ ‫ﺗﻘييﻢ‬ ‫ﻋﻨد‬ • .١٫٨ ‫ﻫﻮ‬ (Kt/Vurea) ‫لليﻮﺭيا‬ ‫ﻭﻻﺑد‬ ،‫اﻷﻃفاﻝ‬ ‫ﻋﻨد‬ ‫الديلزة‬ ‫ﻛفاية‬ ‫ﻋلﻰ‬ ‫ﻣﻬﻤاﻥ‬ ‫ﺳﺮيﺮياﻥ‬ ‫ﻣﺆﺷﺮاﻥ‬ ‫الدﺭاﺳﻲ‬ ‫ﻭاﻹﳒاﺯ‬ ‫الﻨﻤﻮ‬ • .‫الﺒالﻐﲔ‬ ‫للﻤﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫ﺑﻬا‬ ‫اﳌﻮﺻﻰ‬ ‫اﳌﺆﺷﺮاﺕ‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ ‫ﻣﺮاقﺒﺘﻬﻤا‬ ‫ﻣﻦ‬ ‫ﺍﻟﺪﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻓﺮﻁ‬ ‫ﻣﻌﺎﳉﺔ‬ :٥-١٥ ‫الﻘﺮاﺀاﺕ‬ ‫ﺗﺮﺟﻤة‬ ‫ﻭيﺠﺐ‬ ،‫ﻣﻨاﺳﺐ‬ ‫ﺣﺠﻢ‬ ‫ﺫاﺕ‬ ‫ﺃﺟﻬزة‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫قياﺱ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • ‫ﺃﻥ‬ ‫يﺠﺐ‬ .‫الﻄفل‬ ‫ﻭﻃﻮﻝ‬ ‫ﻭﺟﻨﺲ‬ ‫لﻌﻤﺮ‬ ‫اﳌﻨاﺳﺒة‬ (percentile) ‫اﳌﺆية‬ ‫الﺸﺮيﺤة‬ ‫ﻋلﻰ‬ ‫ﹰ‬‫ا‬‫اﻋﺘﻤاد‬ ‫الﺘﺴﻌيﻨية‬ ‫اﳌﺌﻮية‬ ‫الﺸﺮيﺤة‬ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫اﻷﻃفاﻝ‬ ‫ﻋﻨد‬ ‫اﳌﺴﺘﻬدﻑ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫يﻜﻮﻥ‬ .‫ﺃقل‬ ‫ﺃيﻬﻤا‬ ،‫ﺯﺋﺒﻖ‬ ‫ﱈ‬ ٨٠/١٣٠ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫ﺃﻭ‬ (90th)
  • ١٠٦ ‫ﺍﻷﻃﻔﺎﻝ‬ ‫ﻋﻨﺪ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ :١٥ ‫ﻓﺼﻞ‬ ‫ﺍﻷﻫﺪﺍﻑ‬ :١-١٥ ‫للديلزة‬ ‫يﺨﻀﻌﻮﻥ‬ ‫الﺬيﻦ‬ ‫اﻷﻃفاﻝ‬ ‫ﻋﻼﺝ‬ ‫ﻓﻲ‬ ‫اﳌﻬﻤة‬ ‫اﳉﻮاﻧﺐ‬ ‫ﻋلﻰ‬ ‫الﻀﻮﺀ‬ ‫ﺗﺴليﻂ‬ • .‫الصفاقية‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﺑﺪﺀ‬ :٢-١٥ ‫يﻜﻮﻥ‬ ‫ﻋﻨدﻣا‬ ‫اﳌزﻣﻦ‬ ‫الﻜلﻮﻱ‬ ‫ﺑالﻘصﻮﺭ‬ ‫اﳌصاﺑﲔ‬ ‫لﻸﻃفاﻝ‬ ‫الديلزة‬ ‫ﺑدﺀ‬ ‫ﻓﻲ‬ ‫الﺘفﻜيﺮ‬ ‫يﺠﺐ‬ • ‫ﻋﻨدﻣا‬ ‫الديلزة‬ ‫ﻓﻲ‬ ‫ﺑالﺒدﺀ‬ ‫ﻭيﻨصﺢ‬ ٢‫ﻣل/دقيﻘة/٣٧٫١ﻡ‬ ١٤ - ٩ (GFR) ‫الﻜﺒيﺒﻲ‬ ‫الﺮﺷﺢ‬ ‫ﻣﻌدﻝ‬ .٢‫ﻣل/دقيﻘة/٣٧٫١ﻡ‬ ٨ ‫الﻜﺒيﺒﻲ‬ ‫الﺮﺷﺢ‬ ‫ﻣﻌدﻝ‬ ‫يﻜﻮﻥ‬ «‫»ﺷﻮاﺭﺗز‬ ‫ﻣﻌادلة‬ ‫ﺑاﺳﺘﺨداﻡ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻣﻦ‬ ‫الﻜﺒيﺒﻲ‬ ‫الﺮﺷﺢ‬ ‫ﻣﻌدﻝ‬ ‫ﺗﻘديﺮ‬ ‫ﳝﻜﻦ‬ • ‫ﲡﻤيﻊ‬ ‫ﻣﻦ‬ ‫قياﺳﻬﻤا‬ ‫ﺑﻌد‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﻭﺗصفية‬ ‫اليﻮﺭيا‬ ‫ﺗصفية‬ ‫ﻣﺘﻮﺳﻂ‬ ‫ﺣﺴاﺏ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﺃﻭ‬ .‫ﺳاﻋة‬ ٢٤ ‫ﳌدة‬ ‫الﺒﻮﻝ‬ •refractory) ‫اﳊﺮﻭﻥ‬ ‫الﺴﻮاﺋل‬ ‫اﺣﺘﺒاﺱ‬ ،‫الﺘﻐﺬية‬ ‫ﺳﻮﺀ‬ ‫ﺗﺸﻤل‬ ‫الديلزة‬ ‫لﺒدﺀ‬ ‫الﺴﺮيﺮية‬ ‫الدﻭاﻋﻲ‬ ‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫ﻓﺮﻁ‬ ،(refractory hypertension) ‫اﳊﺮﻭﻥ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻓﺮﻁ‬ ،(fluid overload ،‫اﳌﺴﺘﻤﺮ‬ (metabolic acidosis) ‫اﻻﺳﺘﻘﻼﺑﻲ‬ ‫اﳊﻤاﺽ‬ ،‫اﳌﺴﺘﻤﺮ‬ ‫الفﺴفﻮﺭ‬ ‫ﻓﺮﻁ‬ ،‫اﳌﺴﺘﻤﺮ‬ .(uremic encephalopathy) ‫اليﻮﺭﳝﻲ‬ ‫الﻌصﺒﻲ‬ ‫اﻻﻋﺘﻼﻝ‬ ‫ﺃﻭ‬ ،‫الﻨﻤﻮ‬ ‫ﺇﻋاقة‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﳕﻂ‬ ‫ﺍﺧﺘﻴﺎﺭ‬ :٣-١٥ ،‫اﳌﺮيﺾ‬ ‫ﻭﺣﺠﻢ‬ ،‫ﻭﺃﺳﺮﺗﻪ‬ ‫اﳌﺮيﺾ‬ ‫ﺭﻏﺒة‬ ‫الديلزة‬ ‫ﳕﻂ‬ ‫اﺧﺘياﺭ‬ ‫ﻋﻨد‬ ‫اﻻﻋﺘﺒاﺭ‬ ‫ﺑﻌﲔ‬ ‫يﺆﺧﺬ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ • .‫اﻷﺳﺮﻱ‬ ‫الدﻋﻢ‬ ‫ﻭﺗﻮﻓﺮ‬ ،‫اﳌصاﺣﺒة‬ ‫ﻭاﻷﻣﺮاﺽ‬ ‫ية‬‫ﱢ‬‫ﺮ‬ ‫ﱡ‬‫الﺴ‬ ‫الﻘيلة‬ ‫ﻭﺟﻮد‬ ‫اﻷﻃفاﻝ‬ ‫ﻋﻨد‬ ‫الصفاقية‬ ‫للديلزة‬ ‫اﳌﻄلﻘة‬ ‫اﳌﻮاﻧﻊ‬ ‫ﺗﺸﻤل‬ • bladder) ‫اﳌﺜاﻧﻲ‬ ‫ﻭاﻹﻛﺸاﻑ‬ ،(gastroschisis) ‫اﳋلﻘﻲ‬ ‫الﺒﻄﻦ‬ ‫ﻭاﻧﺸﻘاﻕ‬ ،(omphalocele) ‫الصفاﻕ‬ ‫ﲡﻮيﻒ‬ ‫ﻭاﺳﺘداد‬ ،(diaphragmatic hernia) ‫اﳊﺠاﺑﻲ‬ ‫ﻭالفﺘﻖ‬ ،(exstrophy ،‫اﳌﻨزلية‬ ‫الﺒيﺌة‬ ‫ﻛفاية‬ ‫ﻋدﻡ‬ ‫ﻓﺘﺸﻤل‬ ‫الﻨﺴﺒية‬ ‫اﳌﻮاﻧﻊ‬ ‫ﺃﻣا‬ ،(obliterated peritoneal cavity) ،‫الﻮﺷيﻜة‬ ‫ﺃﻭ‬ ‫اﳊديﺜة‬ ‫الﺒﻄﻨية‬ ‫ﻭاﳉﺮاﺣة‬ ،‫ﺑالديلزة‬ ‫للﻘياﻡ‬ ‫ﻋليﻪ‬ ‫يﻌﺘﻤد‬ ‫ﺷﺨﺺ‬ ‫ﺗﻮﻓﺮ‬ ‫ﻭﻋدﻡ‬ .(‫ﺃﺷﻬﺮ‬ ٦ ‫ﻏﻀﻮﻥ‬ ‫)ﻓﻲ‬ ‫الﻮﺷيﻚ‬ ‫الﻜلﻰ‬ ‫ﻭﺯﺭﻉ‬ ‫الديلزة‬ ‫ﻣﻦ‬ ‫الﻨﻤﻂ‬ ‫ﻫﺬا‬ ‫ﻷﻥ‬ ‫لﻸﻃفاﻝ‬ ‫ﺑالﻨﺴﺒة‬ ‫اﻵلية‬ ‫الصفاقية‬ ‫الديلزة‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫يفﻀل‬ • ‫الليلية‬ ‫الصفاقية‬ ‫الديلزة‬ ‫اﺧﺘياﺭ‬ ‫يفﻀل‬ ‫ﻛﻤا‬ ،‫الﻨﻬاﺭ‬ ‫ﺳاﻋاﺕ‬ ‫ﺃﺛﻨاﺀ‬ ‫اﳊﺮﻛة‬ ‫ﺣﺮية‬ ‫لﻬﻢ‬ ‫يﺘيﺢ‬ .‫ﻣﺘﺒﻘية‬ ‫ﻛلﻮية‬ ‫ﺑﻮﻇيفة‬ ‫ﹰ‬‫ا‬‫ﻣﺘﻤﺘﻌ‬ ‫ﺯاﻝ‬ ‫ﻣا‬ ‫اﳌﺮيﺾ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫ﺃﻭﻝ‬ ‫ﻛﺨياﺭ‬ ‫اﳌﺘﻘﻄة‬
  • ١٠٥ ‫ﻃﻮيلة‬ ‫لفﺘﺮة‬ ‫الﻌﻤل‬ ‫ﻋﻦ‬ ‫ﺗﻐيﺐ‬ ‫قد‬ ‫اﳌﺮيﺾ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫ﹰ‬‫ا‬‫ﺧصﻮﺻ‬ ،‫ﻣﺘﺤيزﻭﻥ‬ ‫الﻌﻤل‬ ‫ﺃﺭﺑاﺏ‬ ‫ﺑﻌﺾ‬ • ‫لﺘﻐييﺮ‬ ‫الديلزة‬ ‫ﻓﺮيﻖ‬ ‫ل‬‫ﹶ‬‫ﺒ‬‫ﹺ‬‫ق‬ ‫ﻣﻦ‬ ‫الﻮﺿﻊ‬ ‫ﺷﺮﺡ‬ ‫يﺆدﻱ‬ ‫قد‬ ‫اﳊالة‬ ‫ﻫﺬﻩ‬ ‫ﻭﻓﻲ‬ ،‫الديلزة‬ ‫ﺑدﺀ‬ ‫قﺒل‬ .‫ﻣﻮقفﻬﻢ‬ ‫ﻋﻼﺝ‬ ‫ﻓﻲ‬ ‫ﻓاﻋل‬ ‫دﻭﺭ‬ ‫لﻌﺐ‬ ‫ﻋلﻰ‬ ‫اﻷﺳﺮة‬ ‫ﺃﻓﺮاد‬ ‫ﺗﺸﺠيﻊ‬ ‫ﻣﻦ‬ ‫ﻭﻻﺑد‬ ،‫ﹰ‬‫ا‬‫ﺟد‬ ‫ﻣﻬﻢ‬ ‫اﻷﺳﺮﻱ‬ ‫الدﻋﻢ‬ • .‫اﳌﺮيﺾ‬ ‫ﻭيﺸﺠﻌﻪ‬ ،‫اﻻﺟﺘﻤاﻋﻲ‬ ‫للدﻋﻢ‬ ‫اﳌﺘاﺣة‬ ‫اﳌﻮاﺭد‬ ‫ﺇلﻰ‬ ‫اﳌﺮيﺾ‬ ‫اﻧﺘﺒاﻩ‬ ‫الديلزة‬ ‫ﻓﺮيﻖ‬ ‫يلفﺖ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ • .(‫الصﺤﻲ‬ ‫الﺘﺄﻣﲔ‬ ‫ﻣﺸﺮﻭﻉ‬ :‫)ﻣﺜاﻝ‬ ‫ﻣﻨﻬا‬ ‫اﻻﺳﺘفادة‬ ‫ﻋلﻰ‬
  • ١٠٤ ‫ﺍﻟﺘﺄﻫﻴﻞ‬ ‫ﺇﻋﺎﺩﺓ‬ :١٤ ‫ﻓﺼﻞ‬ ‫ﺍﻷﻫﺪﺍﻑ‬ :١-١٤ ‫ﺑﻬدﻑ‬ ،‫اﳌﺮيﺾ‬ ‫ﺗﺄﻫيل‬ ‫ﻓﻲ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫لفﺮيﻖ‬ ‫الفاﻋل‬ ‫الدﻭﺭ‬ ‫ﻋلﻰ‬ ‫الﻀﻮﺀ‬ ‫ﺗﺴليﻂ‬ • .‫اﻹﻣﻜاﻥ‬ ‫ﺑﻘدﺭ‬ ‫ﻃﺒيﻌية‬ ‫ﺣياة‬ ‫يﻌيﺶ‬ ‫ﺃﻥ‬ ‫ﻣﻦ‬ ‫ﲤﻜيﻨﻪ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻋﻦ‬ ‫ﺍﻟﻨﺎﰋ‬ ‫ﺍﻟﻌﺠﺰ‬ :٢-١٤ ‫يﺸﻌﺮﻭﻥ‬ ‫ﻓﻬﻢ‬ ،‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫ﻣﺮﺿﻰ‬ ‫ﻋﻨد‬ ‫اﳊياة‬ ‫ﺟﻮدة‬ ‫ﺗﻘليل‬ ‫ﺇلﻰ‬ ‫الﻐالﺐ‬ ‫ﻓﻲ‬ ‫الديلزة‬ ‫ﺗﺆدﻱ‬ • ‫ﻭالﻌﺐﺀ‬ ،‫اﳌالية‬ ‫ﺑاﻷﻣﻮﺭ‬‫ﹰ‬‫ا‬‫ﻣﻬﻤﻮﻣ‬ ‫ﻋادة‬ ‫الديلزة‬ ‫ﻣﺮيﺾ‬ ‫ﻭيﻜﻮﻥ‬ ،‫ﻭالﻘلﻖ‬ ،‫ﻭاﻻﻛﺘﺌاﺏ‬ ،‫ﺑاليﺄﺱ‬ ‫ﻋادة‬ ،‫اﻻﺳﺘﻘﻼلية‬ ‫ﻭﻓﻘداﻥ‬ ،‫اﳉﻨﺴية‬ ‫الﻘدﺭة‬ ‫ﻭﻓﻘداﻥ‬ ،‫اﻷﺳﺮﻱ‬ ‫الﻨﺘاﺋﺞ‬ ‫ﻭﺿﻌﻒ‬ ،‫اﻻﻧﺘﺒاﻩ‬ ‫ﻭﻋدﻡ‬ ،‫ﺑالﻌﻼﺝ‬ ‫اﳌﺮيﺾ‬ ‫الﺘزاﻡ‬ ‫ﺿﻌﻒ‬ ‫ﺇلﻰ‬ ‫ﻫﺬا‬ ‫ﻛل‬ ‫يﺆدﻱ‬ ‫قد‬ • .‫الﺴﺮيﺮية‬ ‫ﺇلﻰ‬ ،‫ﻧفﺴﻬا‬ ‫اﳌﺮﺽ‬ ‫ﻃﺒيﻌة‬ ‫ﻋﻦ‬ ‫ﻧاﺟﻤاﻥ‬ ‫الديلزة‬ ‫ﻣﺮيﺾ‬ ‫يﻮاﺟﻬﻬﻤا‬ ‫اللﺬيﻦ‬ ‫ﻭالﻌﺠز‬ ‫الﻘيﻮد‬ • .‫ﻭاﻻﺟﺘﻤاﻋية‬ ‫الﻨفﺴية‬ ‫ﻭاﳌﺸاﻛل‬ ،‫الﻌﻼﺟﻲ‬ ‫ﻭالﻨﻈاﻡ‬ ،‫اﳌصاﺣﺒة‬ ‫اﻷﻣﺮاﺽ‬ ‫ﺟاﻧﺐ‬ ‫اﳌﺮﺿﻰ‬ ‫ﻓﺒﻌﺾ‬ ،‫ﹰ‬‫ا‬‫ﺟد‬ ‫ﻣﺘﺒايﻦ‬ ‫اﳌزﻣﻨة‬ ‫ﺑاﻷﻣﺮاﺽ‬ ‫اﳌصاﺑﲔ‬ ‫ﻣﻮقﻒ‬ ‫ﻓﺈﻥ‬ ‫ﺳﺒﻖ‬ ‫ﻣا‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ • ‫يﻜﺘفﻮﻥ‬ ‫ﺁﺧﺮيﻦ‬ ‫ﺃﻥ‬ ‫ﺣﲔ‬ ‫ﻓﻲ‬ ‫اﻹﻣﻜاﻥ‬ ‫قدﺭ‬ ‫ﻃﺒيﻌﻲ‬ ‫ﺑﺸﻜل‬ ‫اﳊياة‬ ‫ﻣﻮاﺻلة‬ ‫ﻋلﻰ‬ ‫ﻣصﻤﻤﻮﻥ‬ .‫الﻌاﺟز‬ ‫اﳌﺮيﺾ‬ ‫دﻭﺭ‬ ‫ﺑلﻌﺐ‬ ‫ﻭﻻ‬ ،‫اﻹﻣﻜاﻥ‬ ‫قدﺭ‬ ‫ﻃﺒيﻌﻲ‬ ‫ﻧﺤﻮ‬ ‫ﻋلﻰ‬ ‫الﻌيﺶ‬ ‫ﻓﺮﺻة‬ ‫اﳌﺮيﺾ‬ ‫ﺇﻋﻄاﺀ‬ ‫ﻫﻮ‬ ‫للديلزة‬ ‫الﻨﻬاﺋﻲ‬ ‫الﻬدﻑ‬ • ‫اﳊياة‬ ‫ﺟﻮدة‬ ‫قلة‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻲ‬ ‫ﺳيﻈل‬ ‫ﻓﺈﻧﻪ‬ ‫ﻭﺇﻻ‬ ‫ﻓﻘﻂ‬ ‫الديلزة‬ ‫ﺃﺟل‬ ‫ﻣﻦ‬ ‫اﳌﺮيﺾ‬ ‫يﻌيﺶ‬ ‫ﺃﻥ‬ ‫يﺠﻮﺯ‬ .‫اﻻﺟﺘﻤاﻋﻲ‬ ‫الدﻋﻢ‬ ‫ﺑﺮاﻣﺞ‬ ‫ﻋلﻰ‬ ‫ﺑﺸدة‬ ‫اﻻﻋﺘﻤاد‬ ‫ﻓﻲ‬ ‫ﻭﺳيﺴﺘﻤﺮ‬ ‫ﺍﻟﺘﺄﻫﻴﻞ‬ ‫ﻭﺇﻋﺎﺩﺓ‬ ‫ﺍﻟﺘﻮﻇﻴﻒ‬ :٣-١٤ ‫الﺬﻫﻨية‬ ‫قدﺭاﺗﻪ‬ ‫ﻭﻓﻬﻢ‬ ،‫اﳌﺮيﺾ‬ ‫ﻭﺭﻏﺒاﺕ‬ ‫ﺃﻫداﻑ‬ ‫ﺗﻘييﻢ‬ ‫الﺘﺄﻫيل‬ ‫ﺇﻋادة‬ ‫ﻋﻤلية‬ ‫ﺗﺸﻤل‬ • .‫الﻄﺒية‬ ‫الﻌﻨاية‬ ‫ﻭﲢﺴﲔ‬ ،‫الدﻋﻢ‬ ‫لﺘﻘدﱘ‬ ‫اﳌﺘاﺣة‬ ‫اﳌﻮاﺭد‬ ‫ﻭﺗﻘديﺮ‬ ،‫ﻭاﳉﺴدية‬ ‫ﻣﻦ‬ ‫ﻭﻻﺑد‬ ،‫الصفاقية‬ ‫الديلزة‬ ‫ﻛاﻣل‬ ‫ﺑدﻭاﻡ‬ ‫يﻌﻤل‬ ‫الﺬﻱ‬ ‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫ﻣﺮيﺾ‬ ‫يﺨﺘاﺭ‬ ‫ﻣا‬‫ﹰ‬‫ا‬‫ﻛﺜيﺮ‬ • .‫ﺇليﻬﻤا‬ ‫الﻌﻮدة‬ ‫ﺃﻭ‬ ‫دﺭاﺳﺘﻪ‬ ‫ﺃﻭ‬ ‫ﻋﻤلﻪ‬ ‫ﻣﻮاﺻلة‬ ‫ﻣﻦ‬ ‫لﺘﻤﻜيﻨﻪ‬ ‫اﳌﻤﻜﻨة‬ ‫اﳉﻬﻮد‬ ‫ﻛل‬ ‫ﺑﺬﻝ‬ ‫ﻭﳝﻜﻦ‬ ،‫ﺫلﻚ‬ ‫ﺃﻣﻜﻦ‬ ‫ﻛلﻤا‬ ‫اﳌﺮيﺾ‬ ‫ﻋﻤل‬ ‫يﻨاﺳﺐ‬ ‫الﺬﻱ‬ ‫الديلزة‬ ‫ﺟدﻭﻝ‬ ‫اﺧﺘياﺭ‬ ‫يﺘﻢ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ • ‫ﻣﻜاﻥ‬ ‫ﻓﻲ‬ ‫اﶈلﻮﻝ‬ ‫ﺑﺘﺒديل‬ ‫اﳌﻨﺘﻈﻤة‬ ‫اﳉﻮالة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺮيﺾ‬ ‫يﻘﻮﻡ‬ ‫ﺃﻥ‬ ‫الﻀﺮﻭﺭة‬ ‫ﻋﻨد‬ .(‫ﻣﻨفصلة‬ ‫ﻏﺮﻓة‬ ‫ﻓﻲ‬ :‫)ﻣﺜاﻝ‬ ‫الﻌﻤل‬
  • ١٠٣ ‫ﺍﻟﻔﺼﻞ‬ ‫ﻫﺬﺍ‬ ‫ﻓﻲ‬ ‫ﺫﻛﺮﺕ‬ ‫ﺃﺩﻭﻳﺔ‬ :٢٥ ‫ﺟﺪﻭﻝ‬ ‫ﺍﻟﺪﻭﺍﺀ‬ ‫ﺍﺳﻢ‬‫ﺍﻟﺘﺮﻛﻴﺒﺔ‬‫ﺍﳉﺮﻋﺔ‬ ‫ﺳﺘﺎﺗﲔ‬ ‫ﺳﻤفاﺳﺘاﺗﲔ‬(‫ﻣلﻎ‬ ٤٠ ،٢٠ ،١٠) ‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ٤٠ – ١٠ ‫ﺃﺗﻮﺭﻓاﺳﺘاﺗﲔ‬(‫ﻣلﻎ‬ ٨٠ ،٤٠ ،٢٠ ،١٠) ‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ٨٠ – ١٠ ‫ﺑﺮاﻓاﺳﺘاﺗﲔ‬(‫ﻣلﻎ‬ ٤٠ ،٢٠ ،١٠) ‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ٤٠ – ١٠ ‫ﻓﻴﺒﺮﻳﺖ‬ ‫ﺟيﻤفيﺒﺮﻭﺯيل‬(‫ﻣلﻎ‬ ٦٠٠) ‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮﺗﲔ‬ ‫ﻣلﻎ‬ ٦٠٠ ‫ﺑيزاﻓيﺒﺮيﺖ‬‫ﺣﺒﻮﺏ‬‫ﺑﺘﺠﻨﺒﻪ‬ ‫يﻨصﺢ‬ ‫ﻛلﻮﻓيﺒﺮيﺖ‬‫ﺣﺒﻮﺏ‬‫ﺑﺘﺠﻨﺒﻪ‬ ‫يﻨصﺢ‬ ‫ﻓيﻨﻮﻓيﺒﺮيﺖ‬‫ﺣﺒﻮﺏ‬‫ﺑﺘﺠﻨﺒﻪ‬ ‫يﻨصﺢ‬ ‫ﺃﺧﺮﻯ‬ ‫ﻛﻮليﺴﺘايﺮاﻣﲔ‬(‫ﻛيﺲ‬ /‫ﻏﻢ‬ ٤) ‫ﻣﺴﺤﻮﻕ‬‫ﺟﺮﻋاﺕ‬ ٤-١ ‫ﻋلﻰ‬ ‫ﻣﻘﺴﻤة‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻏﻢ‬ ٣٦ – ٤ ‫الﻨيﻜﺘﻮﻧيﻚ‬ ‫ﺣﻤﺾ‬(‫ﻏﻢ‬ ١ ،٠٫٧٥ ،٠٫٥) ‫ﺣﺒﻮﺏ‬(‫ﺃﺳﺒﻮﻉ‬ ‫ﻛل‬ ‫ﻣلﻎ‬ ٢٥٠ ‫ﲟﻘداﺭ‬ ‫)ﺗدﺭﺝ‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻏﻢ‬ ٢ – ٠٫٢٥
  • ١٠٢ ‫ﺑالﻨﺴﺒة‬ ‫ﺃﺷﻬﺮ‬ ‫)ﺳﺘة‬ ‫اﻷقل‬ ‫ﻋلﻰ‬ ‫ﺃﺷﻬﺮ‬ ‫لﺜﻼﺛة‬ ‫اﳊياة‬ ‫لﻨﻤﻂ‬ ‫الﻌﻼﺟﻲ‬ ‫الﺘﻐييﺮ‬ ‫ﲡﺮﺑة‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • .‫الدﻭاﺋﻲ‬ ‫الﻌﻼﺝ‬ ‫ﻭﺻﻒ‬ ‫قﺒل‬ (‫للﻤﺮاﻫﻘﲔ‬ ‫يﻌاﻧﻮﻥ‬ ‫الﺬيﻦ‬ ‫للﻤﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬‫ﹰ‬‫ا‬‫ﺧصﻮﺻ‬ ‫ﺷديد‬ ‫ﺑﺤﺮﺹ‬ ‫الﻌﻼﺟية‬ ‫الﺘﻐﺬية‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫يﺠﺐ‬ • ‫الﻌﻨاية‬ ‫ﻓﻲ‬ ‫ﺧﺒﺮة‬ ‫ﺫﻱ‬ ‫ﺗﻐﺬية‬ ‫اﺧﺘصاﺻﻲ‬ ‫ﺇﺷﺮاﻑ‬ ‫ﲢﺖ‬ ‫ﺫلﻚ‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫ﻭيﺠﺐ‬ ،‫الﺘﻐﺬية‬ ‫ﺳﻮﺀ‬ ‫ﻣﻦ‬ .‫اﳌزﻣﻦ‬ ‫الﻜلﻮﻱ‬ ‫الﻘصﻮﺭ‬ ‫ﲟﺮﺿﻰ‬ ‫لﻨﻤﻂ‬‫الﻌﻼﺟﻲ‬‫للﺘﻐييﺮ‬‫يﺴﺘﺠﺐ‬‫ﻭلﻢ‬‫ﻣلﻎ/دﺳل‬ •٥٠٠<‫الدﻡ‬‫ﻏليﺴﺮيد‬‫ﺛﻼﺛﻲ‬‫ﻣﺴﺘﻮﻯ‬‫ﻛاﻥ‬‫ﺇﺫا‬ .‫الﻨيﻜﻮﺗيﻨيﻚ‬ ‫ﺣﻤﺾ‬ ‫ﺃﻭ‬ ((fibrate) ‫الفيﺒﺮيﺖ‬ ‫ﻧﻮﻉ‬ ‫ﻣﻦ‬ ‫)دﻭاﺀ‬ ‫ﺟﻤفيﺒﺮﻭﺯيل‬ ‫للﻤﺮيﺾ‬ ‫ﺻﻒ‬ ‫اﳊياة‬ (‫ﻓيﻨﻮﻓيﺒﺮيﺖ‬ ،‫ﻛلﻮﻓيﺒﺮيﺖ‬ ،‫ﺑﻨزﻭﻓيﺒﺮيﺖ‬ :‫)ﻣﺜاﻝ‬ ‫الفيﺒﺮيﺖ‬ ‫ﻧﻮﻉ‬ ‫ﻣﻦ‬ ‫اﻷﺧﺮﻯ‬ ‫اﻷدﻭية‬ ‫ﲡﻨﺐ‬ ‫ﻦ‬ ‫ﹸ‬‫يﺤﺴ‬ .‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫ﳌﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫يﺴﺘﺠﺐ‬ ‫ﻭلﻢ‬ ‫ﻣلﻎ/دﺳل‬ •١٠٠ < ‫الﻜﺜاﻓة‬ ‫ﻣﻨﺨفﺾ‬ ‫الﺸﺤﻤﻲ‬ ‫الﺒﺮﻭﺗﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ :‫)ﻣﺜاﻝ‬ (statin) ‫ﺳﺘاﺗﲔ‬ ‫ﻧﻮﻉ‬ ‫ﻣﻦ‬ ‫ﹰ‬‫ﺀ‬‫دﻭا‬ ‫للﻤﺮيﺾ‬ ‫ﺻﻒ‬ ‫اﳊياة‬ ‫لﻨﻤﻂ‬ ‫الﻌﻼﺟﻲ‬ ‫للﺘﻐييﺮ‬ ‫ﻣﻦ‬ ‫اﳌﺴﺘﻬدﻓة‬ ‫اﳌﺴﺘﻮياﺕ‬ ‫ﺗﺘﺤﻘﻖ‬ ‫لﻢ‬ ‫ﺇﺫا‬ .(‫ﺑﺮاﻓاﺳﺘاﺗﲔ‬ ،‫ﺃﺗﻮﺭﻓاﺳﺘاﺗﲔ‬ ،‫ﺳﻤفاﺳﺘاﺗﲔ‬ bile acid) ‫الصفﺮاﻭﻱ‬ ‫اﳊﻤﺾ‬ ‫ﻣﺤﺘﺠزاﺕ‬ ‫ﻓﺄﺿﻒ‬ ‫الﻜﺜاﻓة‬ ‫ﻣﻨﺨفﺾ‬ ‫الﺸﺤﻤﻲ‬ ‫الﺒﺮﻭﺗﲔ‬ ‫لﻢ‬ ‫ﺇﺫا‬ .‫الﻨيﻜﻮﺗيﻨيﻚ‬ ‫ﺣﻤﺾ‬ ‫ﻓﺄﺿﻒ‬ ‫ﺫلﻚ‬ ‫ﺗﻌﺬﺭ‬ ‫ﻭﺇﺫا‬ ،(‫ﻛﻮليﺴﺘايﺮاﻣﲔ‬ :‫)ﻣﺜاﻝ‬ (sequestrant ‫ﺣﻤﺾ‬ ‫ﺃﻭ‬ ‫الصفﺮاﻭﻱ‬ ‫اﳊﻤﺾ‬ ‫ﻣﺤﺘﺠزاﺕ‬ ‫ﻓاﺳﺘﻌﻤل‬ ‫ﺳﺘاﺗﲔ‬ ‫ﻧﻮﻉ‬ ‫ﻣﻦ‬ ‫ﹰ‬‫ﺀ‬‫دﻭا‬ ‫اﳌﺮيﺾ‬ ‫يﺘﺤﻤل‬ .‫ﻋﻨﻪ‬ ‫ﹰ‬‫ﻻ‬‫ﺑد‬ ‫الﻨيﻜﻮﺗيﻨيﻚ‬ ‫الﺒﺮﻭﺗﲔ‬‫ﺧﻼﻑ‬‫الﻜﻮليﺴﺘﺮﻭﻝ‬‫ﻭﻣﺴﺘﻮﻯ‬‫ﻣلﻎ/دﺳل‬ •٢٠٠<‫الدﻡ‬‫ﻏليﺴﺮيد‬‫ﺛﻼﺛﻲ‬‫ﻣﺴﺘﻮﻯ‬‫ﻛاﻥ‬‫ﺇﺫا‬ ‫اﳊياة‬ ‫لﻨﻤﻂ‬ ‫الﻌﻼﺟﻲ‬ ‫للﺘﻐييﺮ‬ ‫ﺫلﻚ‬ ‫يﺴﺘﺠﺐ‬ ‫ﻭلﻢ‬ ‫ﻣلﻎ/دﺳل‬ ١٣٠ < ‫الﻜﺜاﻓة‬ ‫ﻋالﻲ‬ ‫الﺸﺤﻤﻲ‬ ‫اﳌﺮيﺾ‬ ‫يﺘﺤﻤل‬ ‫لﻢ‬ ‫ﺃﻭ‬ ‫اﳌﺴﺘﻬدﻓة‬ ‫اﳌﺴﺘﻮياﺕ‬ ‫ﺗﺘﺤﻘﻖ‬ ‫لﻢ‬ ‫ﺇﺫا‬ .‫ﺳﺘاﺗﲔ‬ ‫ﻧﻮﻉ‬ ‫ﻣﻦ‬ ‫دﻭاﺀ‬ ‫ﻓﺄﺿﻒ‬ .‫الﻨيﻜﻮﺗﻨيﻚ‬ ‫ﺑﺤﻤﺾ‬ ‫ﺃﻭ‬ ‫ﻓيﺒﺮيﺖ‬ ‫ﻧﻮﻉ‬ ‫ﻣﻦ‬ ‫ﺑدﻭاﺀ‬ ‫اﺳﺘﺒدلﻪ‬ ‫ﺳﺘاﺗﲔ‬ ‫ﻧﻮﻉ‬ ‫ﻣﻦ‬ ‫الﺬﻱ‬ ‫الدﻭاﺀ‬ ‫ﻓﻲ‬ ‫ﺁﺧﺮ‬ ‫ﺧلل‬ ‫يصاﺣﺒﻪ‬ ‫ﻭﻻ‬ ‫ﻣلﻎ/دﺳل‬ •٤٠ > ‫الﻜﺜاﻓة‬ ‫ﻣﺮﺗفﻊ‬ ‫الﺸﺤﻤﻲ‬ ‫الﺒﺮﻭﺗﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ .‫الدﻭاﺋية‬ ‫للﻤﻌاﳉة‬ ‫لزﻭﻡ‬ ‫ﻓﻼ‬ ‫اﳊياة‬ ‫لﻨﻤﻂ‬ ‫الﻌﻼﺟﻲ‬ ‫للﺘﻐييﺮ‬ ‫يﺴﺘﺠﺐ‬ ‫ﻭلﻢ‬ ‫الدﻡ‬ ‫ﺷﺤﻤياﺕ‬ ‫ﺣﺘﻰ‬‫ﹰ‬‫ا‬‫ﺗدﺭيﺠي‬ ‫اﳉﺮﻋة‬ ‫ﻭﺯد‬ ‫ﺻﻐيﺮة‬ ‫ﺑﺠﺮﻋاﺕ‬ ‫ﺳﺘاﺗﲔ‬ ‫ﻧﻮﻉ‬ ‫ﻣﻦ‬ ‫اﻷدﻭية‬ ‫اﺑدﺃ‬ ،‫اﳉاﻧﺒية‬ ‫اﻵﺛاﺭ‬ ‫لﺘﻘليل‬ • ‫دﻻلة‬ ‫ﻫﻨاﻙ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫ﺳﺘاﺗﲔ‬ ‫ﻧﻮﻉ‬ ‫ﻣﻦ‬ ‫اﻷدﻭية‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫يﺠﻮﺯ‬ ‫ﻻ‬ .‫ﻓﻌالة‬ ‫ﺟﺮﻋة‬ ‫ﺃقل‬ ‫ﺇلﻰ‬ ‫ﺗصل‬ .‫الﻜﺒد‬ ‫ﻣﺮﺽ‬ ‫ﻋلﻰ‬ ‫ﻭﺇﺻاﺑة‬ ،‫الﻌﻀل‬ ‫الﺘﻬاﺏ‬ ‫ﺗﺴﺒﺐ‬ ‫قد‬ ‫ﻓيﺒﺮيﺖ‬ ‫ﻧﻮﻉ‬ ‫ﻣﻦ‬ ‫ﻭاﻷدﻭية‬ ‫ﺳﺘاﺗﲔ‬ ‫ﻧﻮﻉ‬ ‫ﻣﻦ‬ ‫اﻷدﻭية‬ ‫ﻣﻦ‬ ‫ﹲ‬‫ﻛل‬ • ‫ﹰ‬‫ا‬‫ﻣﻌ‬ ‫الدﻭاﺋﲔ‬ ‫ﻛﻼ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﲡﻨﺐ‬ .‫اﻻﺣﺘﻤاﻝ‬ ‫ﻫﺬا‬ ‫ﻣﻦ‬ ‫ﺗزيد‬ ‫اﳌزﻣﻦ‬ ‫الﻜلﻮﻱ‬ ‫ﺑالﻘصﻮﺭ‬ ‫اﳌﺮيﺾ‬ .‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫ﻣﺮﺿﻰ‬ ‫ﻋﻨد‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﺑﻘياﺱ‬ ‫ﻭقﻢ‬‫ﹰ‬‫ا‬‫ﻓﻮﺭ‬ ‫ﺳﺘاﺗﲔ‬ ‫ﻧﻮﻉ‬ ‫ﻣﻦ‬ ‫الدﻭاﺀ‬ ‫ﻓﺄﻭقﻒ‬ ‫الﻌﻀﻼﺕ‬ ‫ﻓﻲ‬ ‫ﺑﺄلﻢ‬ ‫اﳌﺮيﺾ‬ ‫ﺷﻌﺮ‬ ‫ﺇﺫا‬ • ‫اﳌﺴﺘﻮﻯ‬ ‫ﺿﻌﻒ‬ ‫ﻣﺮاﺕ‬ ١٠ ‫الﻜﺮياﺗﲔ‬ ‫ﻛيﻨاﺯ‬ ‫قياﺱ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ .(creatine kinase) ‫الﻜﺮياﺗﲔ‬ ‫ﻛيﻨاﺯ‬ .‫الﻌﻀل‬ ‫الﺘﻬاﺏ‬ ‫ﻋلﻰ‬ ‫يدﻝ‬ ‫ﻓﻬﺬا‬ ‫الﻄﺒيﻌﻲ‬ ‫اﻷﻋلﻰ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ( •bile acid sequestrants) ‫الصفﺮاﻭﻱ‬ ‫اﳊﻤﺾ‬ ‫ﻣﺤﺘﺠزاﺕ‬ ‫ﻭﺻﻒ‬ ‫يﺠﻮﺯ‬ ‫ﻻ‬ .‫الدﻡ‬ ‫ﻏليﺴﺮيد‬ ‫ﺛﻼﺛﻲ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻣﻦ‬ ‫ﺗزيد‬ ‫قد‬ ‫ﺃﻧﻬا‬ ‫ﺣيﺚ‬ ‫ﻣلﻎ/دﺳل‬ ٤٠٠ < ‫الدﻡ‬ ‫ﻏليﺴﺮيد‬ ‫ﺛﻼﺛﻲ‬ ‫ﺑﻄﺮيﻘة‬ ‫الدﻡ‬ ‫ﺷﺤﻤياﺕ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫يﺨفﺾ‬ ‫ﺃﻥ‬ (‫)ﺳفﻼﻣيﺮ‬ ‫الفﺴفﻮﺭ‬ ‫ﳑﺴﻜاﺕ‬ ‫ﻷﺣد‬ ‫ﳝﻜﻦ‬ .‫الصفﺮاﻭﻱ‬ ‫اﳊﻤﺾ‬ ‫زاﺕ‬ ‫ﹺ‬‫ﶈﺘﺠ‬ ‫ﳑاﺛلة‬
  • ١٠١ (dyslipidemia) ‫ﺍﻟﺪﻡ‬ ‫ﺷﺤﻤﻴﺎﺕ‬ ‫ﺧﻠﻞ‬ ‫ﻣﻌﺎﳉﺔ‬ :١٣ ‫ﻓﺼﻞ‬ ‫ﺍﻷﻫﺪﺍﻑ‬ :١-١٣ ‫الصفاقية‬ ‫الديلزة‬ ‫ﳌﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫الدﻡ‬ ‫ﺷﺤﻤياﺕ‬ ‫ﳋلل‬ ‫الصﺤيﺤة‬ ‫اﳌﻌاﳉة‬ ‫ﺗﺸﺠيﻊ‬ • .‫الﻮﻋاﺋﻲ‬ ‫الﻘلﺒﻲ‬ ‫اﺧﺘﻄاﺭﻫﻢ‬ ‫ﻋاﻣل‬ ‫ﲢﺴﲔ‬ ‫ﺑﻬدﻑ‬ ‫ﺍﻟﺪﻡ‬ ‫ﺷﺤﻤﻴﺎﺕ‬ ‫ﺷﺎﻛﻠﺔ‬ ‫ﻣﺮﺍﻗﺒﺔ‬ :٢-١٣ ‫ﹰ‬‫ا‬‫ﺳﻨﻮي‬ ‫ﺛﻢ‬ ‫الديلزة‬ ‫ﺑدﺀ‬ ‫ﻋﻨد‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺮﺿﻰ‬ ‫لﻜل‬ ‫الدﻡ‬ ‫ﺷﺤﻤياﺕ‬ ‫ﻓﺤﺺ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • ‫ﻣﻦ‬ ‫ﺃﺷﻬﺮ‬ ‫ﺛﻼﺛة‬ ‫ﻏﻀﻮﻥ‬ ‫ﻓﻲ‬ ‫الدﻡ‬ ‫ﺷﺤﻤياﺕ‬ ‫ﺷاﻛلة‬ ‫ﻓﺤﺺ‬ ‫يلزﻡ‬ ‫ﻛﻤا‬ ،‫اﻷقل‬ ‫ﻋلﻰ‬ ‫ﺫلﻚ‬ ‫ﺑﻌد‬ .‫الدﻡ‬ ‫لﺸﺤﻤياﺕ‬ ‫اﳋاﻓﻀة‬ ‫اﻷدﻭية‬ ‫ﺟﺮﻋة‬ ‫ﺗﻌديل‬ ‫ﺃﻭ‬ ‫ﺑدﺀ‬ ‫ﺫلﻚ‬‫ﻓﻲ‬‫ﲟا‬،‫الصياﻡ‬‫ﺣالة‬‫ﻓﻲ‬‫ﻛاﻣلة‬‫الدﻡ‬‫ﺷﺤﻤياﺕ‬‫ﺷاﻛلة‬‫قياﺱ‬‫الفﺤﺺ‬‫يﺸﻤل‬‫ﺃﻥ‬‫يﺠﺐ‬ • ‫الﺸﺤﻤﻲ‬ ‫الﺒﺮﻭﺗﲔ‬ ،(HDL) ‫الﻜﺜاﻓة‬ ‫ﻋالﻲ‬ ‫الﺸﺤﻤﻲ‬ ‫الﺒﺮﻭﺗﲔ‬ ،‫الﻜلﻲ‬ ‫الﻜﻮليﺴﺘﺮﻭﻝ‬ ‫قياﺱ‬ .(TGD) ‫الدﻡ‬ ‫ﻏليﺴﺮيد‬ ‫ﻭﺛﻼﺛﻲ‬ ،(LDL) ‫الﻜﺜاﻓة‬ ‫ﻣﻨﺨفﺾ‬ •٥٠٠ < ‫الدﻡ‬ ‫ﻏليﺴﺮيد‬ ‫ﺛﻼﺛﻲ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫الﺒالﻐﲔ‬ ‫اﳌﺮﺿﻰ‬ ‫ﻋﻨد‬ ‫الﻌﻼﺟﻲ‬ ‫الﺘدﺧل‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ‫ﻏليﺴﺮيد‬ ‫ﺛﻼﺛﻲ‬ ‫ﺃﻭ‬ ،‫ﻣلﻎ/دﺳل‬ ١٠٠ < ‫الﻜﺜاﻓة‬ ‫ﻣﻨﺨفﺾ‬ ‫الﺸﺤﻤﻲ‬ ‫الﺒﺮﻭﺗﲔ‬ ‫ﺃﻭ‬ ،‫ﻣلﻎ/دﺳل‬ /‫ﻣلﻎ‬ ١٣٠ < ‫الﻜﺜاﻓة‬ ‫ﻋالﻲ‬ ‫الﺸﺤﻤﻲ‬ ‫الﺒﺮﻭﺗﲔ‬ ‫ﺧﻼﻑ‬ ‫ﻛﻮليﺴﺘﺮﻭﻝ‬ ‫ﻣﻊ‬ ‫ﻣلﻎ/دﺳل‬ ٢٠٠ < ‫الدﻡ‬ .‫ﻣلﻎ/دﺳل‬ ٤٠ > ‫الﻜﺜاﻓة‬ ‫ﻋالﻲ‬ ‫الﺸﺤﻤﻲ‬ ‫الﺒﺮﻭﺗﲔ‬ ‫ﺃﻭ‬ ،‫دﺳل‬ < ‫الدﻡ‬ ‫ﻏليﺴﺮيد‬ ‫ﺛﻼﺛﻲ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫اﳌﺮاﻫﻘﲔ‬ ‫اﳌﺮﺿﻰ‬ ‫ﻋﻨد‬ ‫الﻌﻼﺟﻲ‬ ‫الﺘدﺧل‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • ‫ﻏليﺴﺮيد‬ ‫ﺛﻼﺛﻲ‬ ‫ﺃﻭ‬ ،‫ﻣلﻎ/دﺳل‬ ١٣٠ < ‫الﻜﺜاﻓة‬ ‫ﻣﻨﺨفﺾ‬ ‫الﺸﺤﻤﻲ‬ ‫ﺃﻭالﺒﺮﻭﺗﲔ‬ ،‫ﻣلﻎ/دﺳل‬ ٥٠٠ /‫ﻣلﻎ‬ ١٦٠ < ‫الﻜﺜاﻓة‬ ‫ﻋالﻲ‬ ‫الﺸﺤﻤﻲ‬ ‫الﺒﺮﻭﺗﲔ‬ ‫ﺧﻼﻑ‬ ‫ﻛﻮليﺴﺘﺮﻭﻝ‬ ‫ﻣﻊ‬ ‫ﻣلﻎ/دﺳل‬ ٢٠٠ < ‫الدﻡ‬ .‫ﻣلﻎ/دﺳل‬ ٤٠ > ‫الﻜﺜاﻓة‬ ‫ﻋالﻲ‬ ‫الﺸﺤﻤﻲ‬ ‫الﺒﺮﻭﺗﲔ‬ ‫ﺃﻭ‬ ،‫دﺳل‬ ‫ﺍﻟﺪﻡ‬ ‫ﺷﺤﻤﻴﺎﺕ‬ ‫ﺧﻠﻞ‬ ‫ﻣﻌﺎﳉﺔ‬ :٣-١٣ ‫الﻜﻼﺋية‬ ‫اﳌﺘﻼﺯﻣة‬ ‫ﻣﺜل‬ ،‫ﻭﻋاﳉﻬا‬ ‫الدﻡ‬ ‫ﺷﺤﻤياﺕ‬ ‫ﳋلل‬ ‫الﺜاﻧﻮية‬ ‫اﻷﺳﺒاﺏ‬ ‫ﻋﻦ‬ ‫اﺑﺤﺚ‬ • ،‫اﳌﻨﻀﺒﻂ‬ ‫ﻏيﺮ‬ ‫الﺴﻜﺮﻱ‬ ‫ﻭداﺀ‬ ،(hypothyroidism) ‫الدﺭقية‬ ‫ﻭقصﻮﺭ‬ ،(nephrotic syndrome) ‫الدﻡ‬ ‫ﺷﺤﻤية‬ ‫ﻓﺮﻁ‬ ‫ﺗﺴﺒﺐ‬ ‫قد‬ ‫الﺘﻲ‬ ‫ﻭاﻷدﻭية‬ ،‫اﳌزﻣﻦ‬ ‫الﻜﺒد‬ ‫ﻭﻣﺮﺽ‬ ،‫للﻜﺤﻮﻝ‬ ‫اﳌفﺮﻁ‬ ‫ﻭالﺘﻨاﻭﻝ‬ .(hyperlipidemia) ‫ﻣلﻎ/دﺳل‬ •٥٠٠ < ‫الدﻡ‬ ‫ﻏليﺴﺮيد‬ ‫ﺛﻼﺛﻲ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻮﻥ‬ ‫الﺬيﻦ‬ ‫للﻤﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫الﺘﻬاﺏ‬ ‫ﻣﻨﻊ‬ ‫ﺑﻬدﻑ‬ ‫ﻭﺫلﻚ‬ ‫اﻷﺳاﺳﻲ‬ ‫اﳌﻌاﳉة‬ ‫ﻣﺤﻮﺭ‬ ‫ﻫﻮ‬ ‫الدﻡ‬ ‫ﻏليﺴﺮيد‬ ‫ﺛﻼﺛﻲ‬ ‫ﺧفﺾ‬ ‫ﻓﺈﻥ‬ ‫اﳌﻌاﳉة‬ ‫ﻣﺤﻮﺭ‬ ‫ﻫﻮ‬ ‫الﻜﺜاﻓة‬ ‫ﻣﻨﺨفﺾ‬ ‫الﺸﺤﻤﻲ‬ ‫الﺒﺮﻭﺗﲔ‬ ‫ﻓﺈﻥ‬ ‫ﺫلﻚ‬ ‫ﺑﺨﻼﻑ‬ .‫الﺒﻨﻜﺮياﺱ‬ .‫اﻷﺳاﺳﻲ‬ ‫اﻷﻭﻝ‬ ‫الﻌﻼﺝ‬ ‫ﺧﻂ‬ ‫ﻫﻮ‬ ( •therapeutic lifestyle changes) ‫اﳊياة‬ ‫لﻨﻤﻂ‬ ‫الﻌﻼﺟﻲ‬ ‫الﺘﻐييﺮ‬ ‫اﺠﻤﻟﻬﻮد‬ ‫ﻭﺯيادة‬ ،‫الﻮﺯﻥ‬ ‫ﻭﺇﻧﻘاﺹ‬ ،‫الﻌﻼﺟية‬ ‫الﺘﻐﺬية‬ ‫ﻭيﺸﻤل‬ ،‫الدﻡ‬ ‫ﺷﺤﻤياﺕ‬ ‫ﺧلل‬ ‫ﺃﻧﻮاﻉ‬ ‫لﻜل‬ .‫الﺴﻜﺮ‬ ‫ﻓﺮﻁ‬ ‫ﻭﻣﻌاﳉة‬ ،‫الﻜﺤﻮﻝ‬ ‫ﻋﻦ‬ ‫ﻭاﻻﻣﺘﻨاﻉ‬ ،‫اﳉﺴﻤﻲ‬
  • ١٠٠ ‫ﺍﻟﻔﺼﻞ‬ ‫ﻫﺬﺍ‬ ‫ﻓﻲ‬ ‫ﺫﻛﺮﺕ‬ ‫ﺃﺩﻭﻳﺔ‬ :٢٤ ‫ﺟﺪﻭﻝ‬ ‫ﺍﻟﺪﻭﺍﺀ‬ ‫ﺍﺳﻢ‬‫ﺍﻟﺘﺮﻛﻴﺒﺔ‬‫ﺍﳉﺮﻋﺔ‬ (Avandia®) ‫ﺭﻭﺯيﻐليﺘاﺯﻭﻥ‬(‫ﻣﻐﻢ‬ ٨ ،٤) ‫ﺣﺒﻮﺏ‬‫اﺛﻨﺘﲔ‬ ‫ﺃﻭ‬ ‫ﺟﺮﻋة‬ ‫ﻋلﻰ‬ ‫ﻣﻘﺴﻤة‬ ‫ﻣلﻎ‬ ٨ – ٤ (Actos®) ‫ﺑيﻮﻏليﺘاﺯﻭﻥ‬(‫ﻣلﻎ‬ ١٥) ‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ٤٥ – ١٥ (Prandin®) ‫ﺭيﺒاﻏليﻨايد‬(‫ﻣلﻎ‬ ٢ ،١ ،٠٫٥) ‫ﺣﺒﻮﺏ‬‫ﺟﺮﻋاﺕ‬ ٣-٢ ‫ﻋلﻰ‬ ‫ﻣﻘﺴﻤة‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ١٦ – ٠٫٥ (Diamicron®) ‫ﺟليﻜﻼﺯايد‬(‫ﻣلﻎ‬ ٨٠) ‫ﺣﺒﻮﺏ‬‫ﻣلﻎ‬ ١٦٠ < ‫اﳉﺮﻋة‬ ‫ﺗﻘﺴﻢ‬ ،‫ﺑالفﻢ‬ ‫ﻣلﻎ‬ ٣٢٠ – ٤٠ (Minodiab®) ‫ﺟليﺒيزايد‬(‫ﻣلﻎ‬ ٥) ‫ﺣﺒﻮﺏ‬‫ﻣلﻎ‬ ١٥ < ‫اﳉﺮﻋة‬ ‫ﺗﻘﺴﻢ‬ ،‫ﺑالفﻢ‬ ‫ﻣلﻎ‬ ٢٠ – ٢٫٥ (Daonil®) ‫ﺟليﺒﻨﻜﻼﻣايد‬‫ﺣﺒﻮﺏ‬‫ﺑﺘﺠﻨﺒﻪ‬ ‫يﻨصﺢ‬ (Glucophage®) ‫ﻣﺘفﻮﺭﻣﲔ‬‫ﺣﺒﻮﺏ‬‫ﺑﺘﺠﻨﺒﻪ‬ ‫يﻨصﺢ‬ (Amaryl®) ‫ﻏليﻤيﺒﺮايد‬‫ﺣﺒﻮﺏ‬‫ﺑﺘﺠﻨﺒﻪ‬ ‫يﻨصﺢ‬ (Glucobay®) ‫ﺃﻛاﺭﺑﻮﺯ‬‫ﺣﺒﻮﺏ‬‫ﺑﺘﺠﻨﺒﻪ‬ ‫يﻨصﺢ‬ ‫ﺗﻮلﺒيﻮﺗاﻣايد‬‫ﺣﺒﻮﺏ‬‫ﺑﺘﺠﻨﺒﻪ‬ ‫يﻨصﺢ‬ ‫ﻛلﻮﺭﺑﺮﻭﺑاﻣايد‬‫ﺣﺒﻮﺏ‬‫ﺑﺘﺠﻨﺒﻪ‬ ‫يﻨصﺢ‬
  • ٩٩ ‫ﻭﻋلﻰ‬ ،‫ﻣﺘﺒايﻨة‬ ‫اﻹﻧﺴﻮلﲔ‬ ‫ﺇلﻰ‬ ‫الﺴﻜﺮﻱ‬ ‫ﺑداﺀ‬ ‫اﳌصاﺑﲔ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺮﺿﻰ‬ ‫ﺣاﺟة‬ • ‫ﺗﺒديل‬ ‫ﻛل‬ ‫ﻋلﻰ‬ ‫ﺳاﻋة‬ ‫ﻣﺮﻭﺭ‬ ‫ﺑﻌد‬ ‫الدﻡ‬ ‫ﺳﻜﺮ‬ ‫ﻓﺤﺺ‬ ‫اﻹﻧﺴﻮلﲔ‬ ‫يﺴﺘﻌﻤلﻮﻥ‬ ‫الﺬيﻦ‬ ‫اﳌﺮﺿﻰ‬ .‫اﻹﻧﺴﻮلﲔ‬ ‫ﻣﻦ‬ ‫ﺣاﺟﺘﻬﻢ‬ ‫ﲢديد‬ ‫ﻣﻦ‬ ‫يﺘﻤﻜﻨﻮا‬ ‫ﺣﺘﻰ‬ ‫الديلزة‬ ‫ﺑداية‬ ‫ﻓﻲ‬ ‫للﻤﺤلﻮﻝ‬ ‫ﻫﻮ‬ ‫اﳌﺴﺘﻤﺮة‬ ‫اﳉﻮالة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﳌﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫اﳌﺘﺒﻌة‬ ‫الﻌﻼﺟية‬ ‫الﻨﻈﻢ‬ ‫ﺃﺣد‬ • ‫اﻹﻧﺴﻮلﲔ‬ ‫ﻣﻦ‬ ‫ﺣﻘﻨة‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ ،‫اﳌفﻌﻮﻝ‬ ‫ﻃﻮيل‬ ‫اﻹﻧﺴﻮلﲔ‬ ‫ﻣﻦ‬ ‫اﺛﻨﺘﲔ‬ ‫ﺃﻭ‬ ‫ﺣﻘﻨة‬ ‫ﺇﻋﻄاﺀ‬ ‫ﺑالﺘﺴاﻭﻱ‬‫الﻜلية‬‫اﻹﻧﺴﻮلﲔ‬‫ﺟﺮﻋة‬‫ﺗﻘﺴﻢ‬‫ﺃﻥ‬‫يﺠﺐ‬.‫للﻤﺤلﻮﻝ‬‫ﺗﺒديل‬‫ﻛل‬‫قﺒل‬‫اﳌفﻌﻮﻝ‬‫ﺳﺮيﻊ‬ ‫الﻜيﺲ‬ ‫ﻓﻲ‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫ﺗﺮﻛيز‬ ‫ﻋلﻰ‬‫ﹰ‬‫ا‬‫اﻋﺘﻤاد‬ ‫ﺇﺿاﻓية‬ ‫ﻭﺣداﺕ‬ ‫ﺇﻋﻄاﺀ‬ ‫ﻣﻊ‬ ‫اﶈلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﻣﺮاﺕ‬ ‫ﻋلﻰ‬ ‫للﻤﺤلﻮﻝ‬ ‫ﻭﺣداﺕ‬ ‫ﺃﺭﺑﻊ‬ ،٪١٫٥/١٫٣٦ ‫ﺗﺮﻛيزﻩ‬ ‫الﺬﻱ‬ ‫للﻤﺤلﻮﻝ‬ ‫ﺇﺿاﻓيﺘاﻥ‬ ‫ﻭﺣدﺗاﻥ‬ ‫ﺗﻌﻄﻰ‬ ‫)ﻋادة‬ .(٪٤٫٢٥/٣٫٨٦ ‫ﺗﺮﻛيزﻩ‬ ‫الﺬﻱ‬ ‫للﻤﺤلﻮﻝ‬ ‫ﻭﺣداﺕ‬ ‫ﻭﺳﺖ‬ ،٪٢٫٥/٢٫٢٧ ‫ﺗﺮﻛيزﻩ‬ ‫الﺬﻱ‬ ‫ﺳﺘزيد‬ ‫الﻀﺮﻭﺭية‬ ‫اﳉﺮﻋة‬ ‫ﻭلﻜﻦ‬ ،‫الصفاﻕ‬ ‫داﺧل‬ ( •soluble) ‫الﺬﻭاﺏ‬ ‫اﻹﻧﺴﻮلﲔ‬ ‫يﻌﻄﻰ‬ ‫ﺃﻥ‬ ‫ﳝﻜﻦ‬ ‫داﺧل‬ ‫اﳌﺘﻜﺮﺭ‬ ‫اﳊﻘﻦ‬ ‫ﺑﺴﺒﺐ‬ ‫يزيد‬ ‫قد‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫اﺣﺘﻤاﻝ‬ ‫ﺃﻥ‬ ‫ﻛﻤا‬ ،‫ﺃﺿﻌاﻑ‬ ٣-٢ ‫ﲟﻌدﻝ‬ .‫اﻷﻛياﺱ‬ ‫ﺳلفﻮﻧايليﻮﺭيا‬ ‫ﻧﻮﻉ‬ ‫ﻣﻦ‬ ‫الدﻡ‬ ‫لﺴﻜﺮ‬ ‫اﳋاﻓﻀة‬ ‫الﺸفﻮية‬ ‫اﻷدﻭية‬ ‫ﻣﻌﻈﻢ‬ ‫ﺑﺘﺠﻨﺐ‬ ‫يﻨصﺢ‬ • ‫الدﻭاﺀ‬ ‫ﻣﻦ‬ ‫للﺘﺨلﺺ‬ ‫الﻜلﻮية‬ ‫الﺘصفية‬ ‫ﻋلﻰ‬ ‫ﺗﻌﺘﻤد‬ ‫الﻐالﺐ‬ ‫ﻓﻲ‬ ‫ﻷﻧﻬا‬ (sulphonyluria) ‫اﺳﺘﻌﻤاﻝ‬ ‫ﳝﻜﻦ‬ ‫ﻭلﻜﻦ‬ ،‫الﺸديد‬ ‫الدﻡ‬ ‫ﺳﻜﺮ‬ ‫ﺧفﺾ‬ ‫اﺣﺘﻤاﻻﺕ‬ ‫ﻣﻦ‬ ‫يزيد‬ ‫ﳑا‬ ‫اﺳﺘﻘﻼﺑﻪ‬ ‫ﻧﻮاﰋ‬ ‫ﺃﻭ‬ ‫ﻭﻻ‬ ‫الﺸديد‬ ‫الدﻡ‬ ‫ﺳﻜﺮ‬ ‫ﺧفﺾ‬ ‫اﺣﺘﻤاﻝ‬ ‫ﻣﻦ‬ ‫يزيداﻥ‬ ‫ﻻ‬ ‫ﺃﻧﻬﻤا‬ ‫ﺣيﺚ‬ ‫ﻭﺟليﺒيزايد‬ ‫ﺟليﻜﻼﺯايد‬ .‫ﻓﻌالة‬ ‫ﻣﻮاد‬ ‫اﺳﺘﻘﻼﺑﻬﻤا‬ ‫ﻋﻦ‬ ‫يﻨﺘﺞ‬ ‫اﳉﺴﻢ‬ ‫ﻷﻥ‬ ‫اﺳﺘﻌﻤالﻪ‬ ‫يﺠﻮﺯ‬ ‫ﻻ‬ ‫ﻭلﻜﻦ‬ ،‫الﺸديد‬ ‫الدﻡ‬ ‫ﺳﻜﺮ‬ ‫ﺧفﺾ‬ ‫اﳌﺘفﻮﺭﻣﲔ‬ ‫يﺴﺒﺐ‬ ‫ﻻ‬ • ‫اﻹﺻاﺑة‬ ‫ﺣالة‬ ‫ﻓﻲ‬ ‫ﺗﺮاﻛﻤﻪ‬ ‫ﺇلﻰ‬ ‫يﺆدﻱ‬ ‫قد‬ ‫ﳑا‬ ‫ﻣﻨﻪ‬ ‫للﺘﺨلﺺ‬ ‫الﻜلﻮية‬ ‫الﺘصفية‬ ‫ﻋلﻰ‬ ‫يﻌﺘﻤد‬ .‫الدﻡ‬ ‫ﺑﺤﻤﻮﺿة‬ ‫اﳌﺮيﺾ‬ ‫ﺇﺻاﺑة‬ ‫اﺣﺘﻤاﻝ‬ ‫ﻣﻦ‬ ‫يزيد‬ ‫ﳑا‬ ،‫ﹰ‬‫ا‬‫ﺑﺴيﻄ‬ ‫ﻛاﻥ‬ ‫لﻮ‬ ‫ﺣﺘﻰ‬ ،‫الﻜلﻮﻱ‬ ‫ﺑالﻘصﻮﺭ‬ ‫ﻭﳝﻜﻦ‬ ،‫الﺸديد‬ ‫الدﻡ‬ ‫ﺳﻜﺮ‬ ‫ﺧفﺾ‬ ‫ﻭﺑيﻮﺟليﺘاﺯﻭﻥ‬ ،‫ﺭﻭﺯيﺠليﺘاﺯﻭﻥ‬ ،‫ﺭيﺒاﺟليﻨايد‬ ‫يﺴﺒﺐ‬ ‫ﻻ‬ • ‫ﺭﻭﺯيﺠليﺘاﺯﻭﻥ‬ ‫يﺘﺴﺒﺐ‬ ‫قد‬ ‫ﻭلﻜﻦ‬ ،‫الﻜلﻮﻱ‬ ‫ﺑالفﺸل‬ ‫للﻤصاﺑﲔ‬ ‫ﺑالﻨﺴﺒة‬ ‫اﺳﺘﻌﻤالﻬا‬ ‫ﻭﻣﺮﺽ‬ ‫اﳊﻤل‬ ‫ﺣالة‬ ‫ﻓﻲ‬ ‫ﺑﺘﺠﻨﺒﻬﻤا‬ ‫يﻨصﺢ‬ ‫ﻛﻤا‬ ‫الﺴﻮاﺋل‬ ‫اﺣﺘﺒاﺱ‬ ‫ﺯيادة‬ ‫ﻓﻲ‬ ‫ﻭﺑيﻮﺟليﺘاﺯﻭﻥ‬ .‫الﻜﺒد‬
  • ٩٨ ‫ﺮﻱ‬ ‫ﹼ‬‫ﺍﻟﺴﻜ‬ ‫ﺩﺍﺀ‬ ‫ﻣﻌﺎﳉﺔ‬ :١٢ ‫ﻓﺼﻞ‬ ‫ﺍﻷﻫﺪﺍﻑ‬ :١-١٢ ‫ﺑﻬدﻑ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺮﺿﻰ‬ ‫ﻋﻨد‬ ‫الﺴﻜﺮﻱ‬ ‫لداﺀ‬ ‫الصﺤيﺤة‬ ‫اﳌﻌاﳉة‬ ‫ﻋلﻰ‬ ‫الﺘﺸﺠيﻊ‬ • ‫ﺗﻄﻮﺭ‬ ‫ﻭﺇﺑﻄاﺀ‬ (cardiovascular disease risk) ‫الﻮﻋاﺋﻲ‬ ‫الﻘلﺒﻲ‬ ‫اﺧﺘﻄاﺭﻫﻢ‬ ‫ﻋاﻣل‬ ‫ﲢﺴﲔ‬ .‫الﺴﻜﺮﻱ‬ ‫لداﺀ‬ ‫الﻜلﻮية‬ ‫ﻏيﺮ‬ ‫اﳌﻀاﻋفاﺕ‬ ‫ﺍﻟﺴﻜﺮﻱ‬ ‫ﺩﺍﺀ‬ ‫ﻋﻦ‬ ‫ﺍﻟﻨﺎﺟﻤﺔ‬ ‫ﻭﺍﳌﻀﺎﻋﻔﺎﺕ‬ ‫ﺍﻟﺪﻡ‬ ‫ﺳﻜﺮ‬ ‫ﻣﺮﺍﻗﺒﺔ‬ :٢-١٢ ‫ﻣﻦ‬ ‫اﳌﺴﺘﻬدﻑ‬ ‫ﻭاﳌﺴﺘﻮﻯ‬ ،٪ •٧ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ «HbA١c» ‫ﻣﻦ‬ ‫اﳌﺴﺘﻬدﻑ‬ ‫اﳌﺴﺘﻮﻯ‬ ‫ﺳﻜﺮ‬ ‫ﻣﻦ‬ ‫اﳌﺴﺘﻬدﻑ‬ ‫ﻭاﳌﺴﺘﻮﻯ‬ ،‫ﻣلﻎ/دﺳل‬ ١٣٠ - ٩٠ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ ‫اﻷﻛل‬ ‫قﺒل‬ ‫الدﻡ‬ ‫ﺳﻜﺮ‬ ‫ﻛﺘلة‬ ‫ﻣﻨﺴﺐ‬ ‫ﻣﻦ‬ ‫اﳌﺴﺘﻬدﻑ‬ ‫ﻭاﳌﺴﺘﻮﻯ‬ ،‫ﻣلﻎ/دﺳل‬ ١٨٠ > ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ ‫اﻷﻛل‬ ‫ﺑﻌد‬ ‫الدﻡ‬ .٢‫ﻛلﻎ/ﻡ‬ ٢٤٫٩ - ١٨٫٥ ‫الﻄﺒيﻌية‬ ‫اﳊدﻭد‬ ‫ﺿﻤﻦ‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ (BMI) ‫اﳉﺴﻢ‬ ،‫الدﻡ‬ ‫لﺴﻜﺮ‬ ‫اﳌﺴﺘﻬدﻓة‬ ‫اﳌﺴﺘﻮياﺕ‬ ‫ﲢﻘيﻖ‬ ‫ﺑﻌد‬ ‫ﺃﺷﻬﺮ‬ ‫ﺳﺘة‬ ‫ﻛل‬ « •HbA١c» ‫ﻣﺮاقﺒة‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ .‫اﳌﺴﺘﻮياﺕ‬ ‫ﺗلﻚ‬ ‫ﲢﻘيﻖ‬ ‫قﺒل‬ ‫ﺃﺷﻬﺮ‬ ‫ﺛﻼﺛة‬ ‫ﻭﻛل‬ ‫يﺘﻨاﻭلﻮﻥ‬ ‫الﺬيﻦ‬ ‫للﻤﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﺃﻛﺜﺮ‬ ‫ﺃﻭ‬ ‫ﻣﺮاﺕ‬ •٣ ‫الدﻡ‬ ‫لﺴﻜﺮ‬ ‫الﺬاﺗية‬ ‫ﺑاﳌﺮاقﺒة‬ ‫يﻮﺻﻰ‬ ‫للﻤﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫اﳌﺮاﺕ‬ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫لﻌدد‬ ‫ﻣﺮاقﺒﺘﻪ‬ ‫ﻭﺗﻘﺒل‬ ،‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫اﻹﻧﺴﻮلﲔ‬ ‫ﻣﻦ‬ ‫ﺟﺮﻋاﺕ‬ ‫ﻋدة‬ ‫ﻋﻦ‬ ‫الدﻡ‬ ‫لﺴﻜﺮ‬ ‫اﺨﻤﻟفﻀة‬ ‫اﻷدﻭية‬ ‫يﺘﻨاﻭلﻮﻥ‬ ‫ﺃﻭ‬ ،‫اﻹﻧﺴﻮلﲔ‬ ‫ﺟﺮﻋاﺕ‬ ‫ﻣﻦ‬ ‫ﺃقل‬‫ﹰ‬‫ا‬‫ﻋدد‬ ‫يﺘﻨاﻭلﻮﻥ‬ ‫الﺬيﻦ‬ .‫الﻐﺬاﺋﻲ‬ ‫الﺘﻨﻈيﻢ‬ ‫ﻋلﻰ‬ ‫اﳌﻌﺘﻤديﻦ‬ ‫ﺃﻭ‬ ،‫الفﻢ‬ ‫ﻃﺮيﻖ‬ ‫ﺍﻟﺴﻜﺮﻱ‬ ‫ﺑﺪﺍﺀ‬ ‫ﺍﳌﺼﺎﺑﲔ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻣﺮﺿﻰ‬ ‫ﻣﻌﺎﳉﺔ‬ :٣-١٢ ‫الديلزة‬ ‫ﺑدﺀ‬ ‫ﺑﻌد‬ ‫ﺑالﺘﻄﻮﺭ‬ ‫الﺴﻜﺮﻱ‬ ‫لداﺀ‬ ‫الﻜلﻮﻱ‬ ‫ﻏيﺮ‬ ‫اﳌﻀاﻋفاﺕ‬ ‫ﻣﻦ‬ ‫الﻌديد‬ ‫ﺗﺴﺘﻤﺮ‬ • ‫ﻭاﳌﺮﺽ‬ ،(CVD) ‫الﻮﻋاﺋﻲ‬ ‫الﻘلﺒﻲ‬ ‫ﻭاﳌﺮﺽ‬ ،(CHD) ‫الﺘاﺟية‬ ‫اﻷﻭﻋية‬ ‫ﻣﺮﺽ‬ ‫ﻣﺜل‬ ،‫الصفاقية‬ ‫اﻷﻋصاﺏ‬ ‫ﻭاﻋﺘﻼﻝ‬ ،(cataract) ‫ﹼ‬‫د‬‫ﻭالﺴا‬ ،‫الﺸﺒﻜية‬ ‫ﻭاﻋﺘﻼﻝ‬ ،(PVD) ‫اﶈيﻄﻲ‬ ‫الﻮﻋاﺋﻲ‬ ‫ﻭﻓياﺕ‬ ‫ﺇﻥ‬ .(autonomic dysfunction) ‫الﺬاﺗﻲ‬ ‫الﻮﻇيفﻲ‬ ‫ﻭاﳋلل‬ ،(peripheral neuropathy) ‫ﻏيﺮ‬ ‫الديلزة‬ ‫ﻣﺮﺿﻰ‬ ‫ﻋﻨد‬ ‫ﻣﻨﻬا‬ ‫ﺃﻛﺜﺮ‬ ‫الﺴﻜﺮﻱ‬ ‫ﺑداﺀ‬ ‫اﳌصاﺑﲔ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺮﺿﻰ‬ .(CVD) ‫الﻮﻋاﺋﻲ‬ ‫الﻘلﺒﻲ‬ ‫اﳌﺮﺽ‬ ‫ﻋﻦ‬ ‫ﻧاﺟﻤة‬ ‫ﻭﻣﻌﻈﻤﻬا‬ ،‫ﺑﻪ‬ ‫اﳌصاﺑﲔ‬ ‫اﳌصاﺑﲔ‬ ‫للﻤﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫ﺑديلة‬ ‫ﻛلﻮية‬ ‫ﻛﻤﻌاﳉة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺗفﻀل‬ ‫ﻣا‬ ‫ﹰ‬‫ا‬‫ﻛﺜيﺮ‬ • ‫الﻘلﺐ‬ ‫ﻣﺮﺽ‬ ‫ﺑﺴﺒﺐ‬ ‫الﻀﻐﻂ‬ ‫ﺑاﻧﺨفاﺽ‬ ‫لﻺﺻاﺑة‬ ‫ﻋﺮﺿة‬ ‫ﺃﻛﺜﺮ‬ ‫ﻷﻧﻬﻢ‬ ‫ﻭﺫلﻚ‬ ،‫الﺴﻜﺮﻱ‬ ‫ﺑداﺀ‬ .‫اﳌﺮﺿﻰ‬ ‫لﻬﺆﻻﺀ‬ ‫ﻭﺭيدﻱ‬ ‫ﺷﺮياﻧﻲ‬ ‫ﻧاﺳﻮﺭ‬ ‫ﺗﻜﻮيﻦ‬ ‫الﻌادة‬ ‫ﻓﻲ‬ ‫يصﻌﺐ‬ ‫ﺃﻧﻪ‬ ‫ﻛﻤا‬ ،‫الﻮﻋاﺋﻲ‬ ‫ﻭﺯيادة‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫ﻋﺐﺀ‬ ‫ﺯيادة‬ ‫ﻣﺸﻜلة‬ ‫الﺴﻜﺮﻱ‬ ‫ﺑداﺀ‬ ‫اﳌصاﺏ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺮيﺾ‬ ‫يﻮاﺟﻪ‬ • ‫ﻣﻌدﻝ‬ ‫ﺃﻥ‬ ‫ﺇﻻ‬ ،‫ﺑﻨفﺴﻪ‬ ‫اﶈلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﻋلﻰ‬ ‫اﳌﺮيﺾ‬ ‫قدﺭة‬ ‫الﺒصﺮ‬ ‫ﺿﻌﻒ‬ ‫يﻌيﻖ‬ ‫قد‬ ‫ﻛﻤا‬ ،‫الﻮﺯﻥ‬ .‫الﺴﻜﺮﻱ‬ ‫ﺑداﺀ‬ ‫اﳌصاﺑﲔ‬ ‫ﻏيﺮ‬ ‫اﳌﺮﺿﻰ‬ ‫ﻋﻨد‬ ‫ﻣﻨﻪ‬ ‫ﺃﻋلﻰ‬ ‫ليﺲ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬
  • ٩٧ ‫ﺍﻟﻔﺼﻞ‬ ‫ﻫﺬﺍ‬ ‫ﻓﻲ‬ ‫ﺫﻛﺮﺕ‬ ‫ﺃﺩﻭﻳﺔ‬ :٢٣ ‫ﺟﺪﻭﻝ‬ ‫ﺍﻟﺪﻭﺍﺀ‬ ‫ﺍﺳﻢ‬‫ﺍﻟﺘﺮﻛﻴﺒﺔ‬‫ﺍﳉﺮﻋﺔ‬ ‫ﺭﺯﻭﻧيﻮﻡ‬ ‫ﻛالﺴيﻮﻡ‬‫ﻣﺴﺤﻮﻕ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮاﺕ‬ ‫ﺃﺭﺑﻊ‬ ‫ﺃﻭ‬ ‫ﺛﻼﺙ‬ ‫ﺑالفﻢ‬ ‫ﻣلﻎ‬ ١٥
  • ٩٦ ‫ﺍﻻﺳﺘﻌﻤﺎﻝ‬ ‫ﺷﺎﺋﻌﺔ‬ ‫ﺍﻟﺪﻡ‬ ‫ﺿﻐﻂ‬ ‫ﺧﺎﻓﻀﺎﺕ‬ ‫ﺑﻌﺾ‬ :٢٢ ‫ﺟﺪﻭﻝ‬ ‫ﺍﻻﺳﻢ‬‫ﺍﻟﺘﺮﻛﻴﺒﺔ‬‫ﺍﳉﺮﻋﺔ‬ ‫ﻨﺴﲔ‬‫ﹶ‬‫ﺗ‬‫ﳒﻴﻮ‬‫ﹶ‬‫ﻟﻸ‬ ‫ﱢﻝ‬‫ﻮ‬‫ﹶ‬ ‫ﹸ‬‫ﺍﶈ‬ ‫ﺍﻹﻧﺰﱘ‬ ‫ﻣﺜﺒﻄﺎﺕ‬ ‫ﻛاﺑﺘﻮﺑﺮيل‬(‫ﻣلﻎ‬ ٥٠, ٢٥، ١٢٫٥) ‫ﺣﺒﻮﺏ‬‫ﺟﺮﻋاﺕ‬ ٣-٢ ‫ﻋلﻰ‬ ‫ﻣﻘﺴﻤة‬ ‫ﻣلﻎ‬ ١٥٠ – ٢٥ ‫ﺇﻧاﻻﺑﺮيل‬(‫ﻣلﻎ‬ ١٠ ،٥، ٢٫٥) ‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ٤٠ – ١٠ ‫ليزيﻨﻮﺑﺮيل‬(‫ﻣلﻎ‬ ٢٠ ،١٠ ،٥ ،٢٫٥) ‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ٤٠ – ١٠ ‫ﺭاﻣيﺒﺮيل‬(‫ﻣلﻎ‬ ١٠ ،٥ ،٢٫٥ ،١٫٢٥) ‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ٢٠ – ٢٫٥ ‫ﺑﺮيﻨدﻭﺑﺮيل‬(‫ﻣلﻎ‬ ٨-٤) ‫ﺣﺒﻮﺏ‬‫اﺛﻨﺘﲔ‬ ‫ﺃﻭ‬ ‫ﺟﺮﻋة‬ ‫ﻋلﻰ‬ ‫ﻣﻘﺴﻤة‬ ‫ﻣلﻎ‬ ٨-٤ ‫ﺍﻷﳒﻴﻮﺗﻨﺴﲔ‬ ‫ﻣﺴﺘﻘﺒﻼﺕ‬ ‫ﺮﺍﺕ‬ ‫ﹺ‬‫ﺼ‬ ‫ﹸﺤﹾ‬‫ﻣ‬ ‫ﻛاﻧدﺳاﺭﺗاﻥ‬(‫ﻣلﻎ‬ ٣٢ ،١٦ ،٨ ،٤ ،٢) ‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ٣٢ – ٤ ‫لﻮﺳاﺭﺗاﻥ‬(‫ﻣلﻎ‬ ١٠٠ ،٥٠ ،٢٥) ‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ١٠٠ – ٥٠ ‫ﺗلﻤﺴاﺭﺗاﻥ‬(‫ﻣلﻎ‬ ٨٠ ،٤٠ ،٢٠) ‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ٨٠ – ٤٠ ‫ﻓالﺴاﺭﺗاﻥ‬(‫ﻣلﻎ‬ ٣٢٠ ،١٦٠ ،٨٠) ‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ٣٢٠ – ٨٠ ‫ﺑﻴﺘﺎ‬ ‫ﻣﺴﺘﻘﺒﻼﺕ‬ ‫ﻣﺤﺼﺮﺍﺕ‬ ‫ﺃﺗيﻨﻮلﻮﻝ‬(‫ﻣلﻎ‬ ٥٠ ،٢٥) ‫ﺣﺒﻮﺏ‬‫اﺛﻨﺘﲔ‬ ‫ﺃﻭ‬ ‫ﺟﺮﻋة‬ ‫ﻋلﻰ‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ١٠٠ – ٢٥ ‫ﺑيزﻭﺑﺮﻭلﻮﻝ‬(‫ﻣلﻎ‬ ١٠ ،٥) ‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ١٠ – ٢٫٥ ‫ﻛاﺭﻓيدﻭلﻮﻝ‬(‫ﻣلﻎ‬ ٥٠ ،٢٥ ،١٢٫٥) ‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ٢٥ – ٢٫٥ ‫ﻣيﺘﻮﺑﺮﻭلﻮﻝ‬(‫ﻣلﻎ‬ ١٠٠) ‫ﺣﺒﻮﺏ‬‫اﺛﻨﺘﲔ‬ ‫ﺃﻭ‬ ‫ﺟﺮﻋة‬ ‫ﻋلﻰ‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ٣٠٠ - ٥٠ ‫ﺑﺮﻭﺑﺮاﻧﻮلﻮﻝ‬(‫ﻣلﻎ‬ ١٦٠ ،٨٠ ،٤٠ ،١٠) ‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ٤٨٠ - ٤٠ ‫ﺍﻟﻜﺎﻟﺴﻴﻮﻡ‬ ‫ﻗﻨﻮﺍﺕ‬ ‫ﻣﺤﺼﺮﺍﺕ‬ ‫ﺃﻣلﻮديﺒﲔ‬(‫ﻣلﻎ‬ ١٠ ،٥) ‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ١٠ –٢٫٥ ‫ديلﺘياﺯﻡ‬(‫ﻣلﻎ‬ ٦٠) ‫ﺣﺒﻮﺏ‬‫اﺛﻨﺘﲔ‬ ‫ﺃﻭ‬ ‫ﺟﺮﻋة‬ ‫ﻋلﻰ‬ ‫ﻣﻘﺴﻤة‬ ‫ﻣلﻎ‬ ٣٦٠ - ١٢٠ ‫ﻓيلﻮديﺒﲔ‬(‫ﻣلﻎ‬ ١٠ ،٥ ،٢٫٥) ‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ١٠ - ٢٫٥ (R) ‫ﻧيفيديﺒﲔ‬(‫ﻣلﻎ‬ ٢٠) ‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮﺗﲔ‬ ‫ﻣلﻎ‬ ٤٠ – ١٠ ‫ﻓيﺮاﺑاﻣيل‬(‫ﻣلﻎ‬ ١٦٠ ،١٢٠ ،٨٠ ،٤٠) ‫ﺣﺒﻮﺏ‬‫اﺛﻨﺘﲔ‬ ‫ﺃﻭ‬ ‫ﺟﺮﻋة‬ ‫ﻋلﻰ‬ ‫ﻣﻘﺴﻤة‬ ‫ﻣلﻎ‬ ٤٨٠ – ١٢٠ ‫ﺃﻟﻔﺎ‬ ‫ﻣﺴﺘﻘﺒﻼﺕ‬ ‫ﻣﺤﺼﺮﺍﺕ‬ ‫دﻭﻛﺴاﺯﻭﺳﲔ‬(‫ﻣلﻎ‬ ٤ ،٢ ،١) ‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ١٦ – ١ ‫ﺗيﺮاﺯﻭﺳﲔ‬(‫ﻣلﻎ‬ ١٠ ،٢٫٥) ‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ٢٠ – ١ ‫ﺃﺧﺮﻯ‬ ‫ﻓﺮﻭﺯﻣيد‬(‫ﻣلﻎ‬ ٤٠) ‫ﺣﺒﻮﺏ‬‫اﺛﻨﺘﲔ‬ ‫ﺃﻭ‬ ‫ﺟﺮﻋة‬ ‫ﻋلﻰ‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ٢٤٠ – ٤٠ ‫ﻫيدﺭاﻻﺯيﻦ‬(‫ﻣلﻎ‬ ٢٥) ‫ﺣﺒﻮﺏ‬ (‫ﻣلﻎ‬ ١٠) ‫ﺃﻭالﻮﺭيد‬ ‫ﺑالﻌﻀل‬ ‫ﺣﻘﻦ‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮﺗﲔ‬ ‫ﻣلﻎ‬ ١٥٠ – ٢٥ ‫دقيﻘة‬ ٣٠ – ٢٠ ‫ﻛل‬ ‫ﺗﻜﺮﺭ‬ ‫ﺃﻭالﻌﻀل‬ ‫ﺑالﻮﺭيد‬ ‫ﻣلﻎ‬ ١٠ – ٥ ‫ﻣيﺘﻮﻻﺯﻭﻥ‬(‫ﻣلﻎ‬ ٥) ‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ٢٠ – ٢٫٥ ‫دﻭﺑا‬ ‫ﻣيﺜيل‬(‫ﻣلﻎ‬ ٢٥٠) ‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮﺗﲔ‬ ‫ﻣلﻎ‬ ١٥٠٠ – ٢٥٠
  • ٩٥ ‫ﻣﺤصﺮاﺕ‬ ‫قﻨﻮاﺕ‬ ‫الﻜالﺴيﻮﻡ‬ ‫ﻧﻮﻉ‬ ‫ﻏيﺮ‬ ‫ﻣﻦ‬ ‫ديﻬيدﺭﻭﺑيديﻦ‬ ‫الﺒﺮﻭﺗيﻨية‬ ‫الﺒيلة‬ • ‫الﺬﺑﺤة‬ • ‫الﻨﻈﻢ‬ ‫اﺿﻄﺮاﺏ‬ ‫ﻣﻨﻊ‬ • ‫الﻘلﺐ‬ ‫ﻭﻇيفة‬ ‫ﺧلل‬ • ‫اﻻﻧﺒﺴاﻃية‬ ‫الﺸﻘيﻘة‬ • ‫اﳌﺮﻱﺀ‬ ‫ﺗﺸﻨﺞ‬ • ‫الﺘﻮﺻيل‬ ‫ﺧلل‬ • ‫الﺒﻄﲔ‬ ‫قصﻮﺭ‬ ‫ﺯيادة‬ • ‫اﻷيﺴﺮ‬ ‫الﻐﺜياﻥ‬ • (‫)ﻓيﺮاﺑاﻣيل‬ ‫اﻹﻣﺴاﻙ‬ • (‫)الديلﺘياﺯﻡ‬ ‫الصداﻉ‬ • ‫اللﺜة‬ ‫ﺗﻀﺨﻢ‬ • ‫الﺜاﻧﻮﻱ‬ ‫الﻘلﺐ‬ ‫ﺇﺣصاﺭ‬ • (heart block) ‫ﻭالﺜالﺜﻲ‬ ‫الﺸديد‬ ‫الﻘلﺐ‬ ‫ﻓﺸل‬ • ‫ﻣﺤصﺮاﺕ‬ ‫ﻣﺴﺘﻘﺒﻼﺕ‬ ‫ﺃلفا‬ ‫الﺒﺮﻭﺳﺘاﺗﻲ‬ ‫الﺘﻀﺨﻢ‬ • ‫اﳊﻤيد‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫اﻧﺨفاﺽ‬ • ‫اﻻﻧﺘصاﺑﻲ‬ ‫اﻹﺳﻬاﻝ‬ • (‫)ﺭﺯﺭﺑﲔ‬ ‫اﻷﻧﻒ‬ ‫اﺣﺘﻘاﻥ‬ • (‫)ﺭﺯﺭﺑﲔ‬ ‫الﺘﻬدﺋة‬ • ‫الﺒﻮﻝ‬ ‫ﺳلﺴل‬ • ( •priapism) ‫الﻘﺴاﺡ‬ (‫)ﺭﺯﺭﺑﲔ‬ ‫اﻻﻛﺘﺌاﺏ‬ • ‫الﻬﻀﻤية‬ ‫الﻘﺮﺣة‬ • (‫)ﺭﺯﺭﺑﲔ‬ ‫ﻣﺤصﺮاﺕ‬ ‫ﻣﺴﺘﻘﺒﻼﺕ‬ ‫اﳌﺮﻛزية‬ ‫ﺃلفا‬ ‫الﺘﻬدﺋة‬ • ‫الفﻢ‬ ‫ﺟفاﻑ‬ • ‫الﻘلﺐ‬ ‫ﺑﻂﺀ‬ • ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻓﺮﻁ‬ • ‫اﻻﻧﺴﺤاﺑﻲ‬ (‫دﻭﺑا‬ ‫)ﻣيﺜيل‬ ‫الﻜﺒد‬ ‫الﺘﻬاﺏ‬ • ‫اﻻﻛﺘﺌاﺏ‬ • ‫الﻜﺒد‬ ‫ﻣﺮﺽ‬ • ‫ﻣﻮﺳﻌاﺕ‬ ‫اﻷﻭﻋية‬ ‫ﺭيﻨﻮد‬ ‫ﻇاﻫﺮة‬ •‫الصداﻉ‬ • ‫الﺴﻮاﺋل‬ ‫اﺣﺘﺒاﺱ‬ • ‫الﻘلﺐ‬ ‫ﺗﺴﺮﻉ‬ • (‫)ﻫيدﺭاﻻﺯيﻦ‬ ‫الﺬﺋﺒة‬ • ‫اﻻﻧصﺒاﺏ‬ ،‫الﺸﻌﺮ‬ ‫ﻛﺜﺮة‬ • (‫)ﻣيﻨﻮﻛﺴيديل‬ ‫الﺘﺄﻣﻮﺭﻱ‬ (‫)ﻫديﺮاﻻﺯيﻦ‬ ‫الﺬﺋﺒة‬ • ‫ﻣﺜﺒﻄاﺕ‬ ‫اﻷلدﻭﺳﺘيﺮﻭﻥ‬ ‫ﻓﻲ‬ ‫ﺑﺘﺠﻨﺒﻬا‬ ‫يﻨصﺢ‬ • ‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫ﺣالة‬ ‫الﺒﻮﻝ‬ ‫ﻣدﺭاﺕ‬ ‫ﻋلﻰ‬ ‫اﳌﺒﻘية‬ ‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫ﻓﻲ‬ ‫ﺑﺘﺠﻨﺒﻬا‬ ‫يﻨصﺢ‬ • ‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫ﺣالة‬
  • ٩٤ ‫ﺍﻟﺪﻡ‬ ‫ﺿﻐﻂ‬ ‫ﺧﻔﺾ‬ ‫ﺑﺨﻼﻑ‬ ‫ﺍﻟﺪﻡ‬ ‫ﺿﻐﻂ‬ ‫ﺧﺎﻓﻀﺎﺕ‬ ‫ﻻﺳﺘﻌﻤﺎﻝ‬ ‫ﺍﻷﺧﺮﻯ‬ ‫ﺍﻟﺪﻭﺍﻋﻲ‬ :٢١ ‫ﺟﺪﻭﻝ‬ ‫ﺍﻟﻨﻮﻉ‬‫ﺍﻻﺳﺘﻌﻤﺎﻝ‬ ‫ﺩﻭﺍﻋﻲ‬‫ﺍﶈﺘﻤﻠﺔ‬ ‫ﺍﳉﺎﻧﺒﻴﺔ‬ ‫ﺍﻵﺛﺎﺭ‬‫ﺍﻻﺳﺘﻌﻤﺎﻝ‬ ‫ﻣﻮﺍﻧﻊ‬ ‫ﻣﺜﺒﻄاﺕ‬ ‫ﻝ‬‫ﱢ‬‫ﻮ‬‫ﹶ‬ ‫ﹸ‬‫اﶈ‬ ‫اﻹﻧزﱘ‬ ‫ﹶﻨﺴﲔ‬‫ﺗ‬‫ﳒيﻮ‬‫ﹶ‬‫لﻸ‬ ‫ﺮاﺕ‬ ‫ﹺ‬‫ص‬ ‫ﹾ‬‫ﺤ‬‫ﹸ‬‫ﻣ‬‫ﻭ‬ ‫ﻣﺴﺘﻘﺒﻼﺕ‬ ‫اﻷﳒيﻮﺗﻨﺴﲔ‬ ‫الﻮﻇيفة‬ ‫ﻓﻘداﻥ‬ ‫ﺇﺑﻄاﺀ‬ • ‫اﳌﺘﺒﻘية‬ ‫الﻜلﻮية‬ ‫الﺒﺮﻭﺗيﻨية‬ ‫الﺒيلة‬ • ‫الﻘلﺐ‬ ‫ﻓﺸل‬ • ‫اﻷيﺴﺮ‬ ‫الﺒﻄﲔ‬ ‫ﺗﻀﺨﻢ‬ • ‫الﻘلﺒية‬ ‫اﳊﻮادﺙ‬ ‫ﻣﻨﻊ‬ • ‫الﻮﻋاﺋية‬ ‫الﺴﻌاﻝ‬ • ‫ﻭﻋاﺋية‬ ‫ﻭﺫﻣة‬ • (angioedema) ‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫ﻓﺮﻁ‬ • ‫الﺒيﻀاﺀ‬ ‫الدﻡ‬ ‫ﻛﺮياﺕ‬ ‫ﻧﻘﺺ‬ • ‫اﳉلدﻱ‬ ‫الﻄفﺢ‬ • ‫الﺘﺬﻭﻕ‬ ‫ﻓﻘداﻥ‬ • ‫اﳊﻤل‬ • ‫ﺑﻮﺫﻣة‬ ‫ﺳاﺑﻘة‬ ‫ﺇﺻاﺑة‬ • ‫ﻭﻋاﺋية‬ ‫الﺒﻮﻝ‬ ‫ﻣدﺭاﺕ‬ ‫الﻌﺮﻭية‬ ‫الﺴﻮاﺋل‬ ‫اﺣﺘﺒاﺱ‬ • ‫الﻘلﺐ‬ ‫ﻓﺸل‬ • ‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫ﻓﺮﻁ‬ • ‫الﺴﻮاﺋل‬ ‫ﻓﻘداﻥ‬ • ‫الﻜﻬاﺭﻝ‬ ‫ﺧلل‬ • ‫الﺒﻮﻝ‬ ‫ﻣدﺭاﺕ‬ ‫الﺜياﺯيدية‬ ‫الﺴﻮاﺋل‬ ‫اﺣﺘﺒاﺱ‬ • ‫الﻘلﺐ‬ ‫ﻓﺸل‬ • ‫الﻘلﺒية‬ ‫اﳊﻮادﺙ‬ ‫ﻣﻨﻊ‬ • ‫الﻮﻋاﺋية‬ ‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫ﻓﺮﻁ‬ • ‫الﺒﻮﻝ‬ ‫ﻛالﺴيﻮﻡ‬ ‫ﻓﺮﻁ‬ • ‫الﺴﻮاﺋل‬ ‫ﻓﻘداﻥ‬ • ‫الﻜﻬاﺭﻝ‬ ‫ﺧلل‬ • ‫ﻭﺣﻤﺾ‬ ،‫الدﻡ‬ ‫ﺳﻜﺮ‬ ‫ﺯيادة‬ • ‫ﻭالﻜﻮليﺴﺘﺮﻭﻝ‬ ،‫اليﻮﺭيﻚ‬ ‫الﻀﻮﺀ‬ ‫ﻣﻦ‬ ‫الﺘﺤﺴﺲ‬ • •Erectile) ‫الﻨاﻋﻆ‬ ‫ﺧلل‬ (dysfunction ‫ﺣالة‬ ‫ﻓﻲ‬ ‫ﻓﻌالة‬ ‫ﻏيﺮ‬ • ،‫الﺸديد‬ ‫الﻜلﻮﻱ‬ ‫الﻘصﻮﺭ‬ ‫ﻣيﺘﻮﻻﺯﻭﻥ‬ ‫ﺑاﺳﺘﺜﻨاﺀ‬ ( •gout) ‫الﻨﻘﺮﺱ‬ ‫ﻣﺤصﺮاﺕ‬ ‫ﻣﺴﺘﻘﺒﻼﺕ‬ ‫ﺑيﺘا‬ ‫الﺬﺑﺤة‬ • ‫الﻘلﺒية‬ ‫اﳊﻮادﺙ‬ ‫ﻣﻨﻊ‬ • ‫الﻮﻋاﺋية‬ ‫الﻨﻈﻢ‬ ‫اﺿﻄﺮاﺏ‬ ‫ﻣﻨﻊ‬ • ،‫)ﻛاﺭﻓيدﻭلﻮﻝ‬ ‫الﻘلﺐ‬ ‫ﻓﺸل‬ • (‫ﻣيﺘﻮﺑﺮﻭلﻮﻝ‬ ،‫ﺑيزﻭﺑﺮﻭلﻮﻝ‬ ( •migraine) ‫الﺸﻘيﻘة‬ ( •glaucoma) ‫الزﺭﻕ‬ ‫الدﺭقية‬ ‫ﻓﺮﻁ‬ • (hyperthyroidism) ‫الﺴﺒﺐ‬ ‫ﻣﺠﻬﻮﻝ‬ ‫الﺮﻋاﺵ‬ • ‫الﻘلﺐ‬ ‫ﺑﻂﺀ‬ • ( •impotence) ‫الﻌﻨاﻧة‬ ‫الدﻡ‬ ‫ﺷﺤﻤياﺕ‬ ‫ﺧلل‬ • ‫الفﺘﻮﺭ‬ • ‫اﻷﺭﻕ‬ • ‫ﻧﻘﺺ‬ ‫ﺃﻋﺮاﺽ‬ ‫ﲤﻮيﻪ‬ • ‫الﺴﻜﺮ‬ ‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫ﻓﺮﻁ‬ • ‫الﻘصﺒﻲ‬ ‫الﺘﺸﻨﺞ‬ • (bronchospasm) ‫اﶈيﻄية‬ ‫اﻷﻭﻋية‬ ‫ﺿﻌﻒ‬ • ‫الﻘلﺐ‬ ‫ﺑﻂﺀ‬ • ‫الﺜاﻧﻮﻱ‬ ‫الﻘلﺐ‬ ‫ﺇﺣصاﺭ‬ • (heart block) ‫ﻭالﺜالﺜﻲ‬ ‫الﺸديد‬ ‫الﻘلﺐ‬ ‫ﻓﺸل‬ • (‫)ﻻﺑﺘﻮلﻮﻝ‬ ‫الﻜﺒد‬ ‫ﻣﺮﺽ‬ • ‫اﻻﻛﺘﺌاﺏ‬ • ‫الﺮﺑﻮ‬ • ‫الﺮﺋة‬ ‫ﻣﺮﺽ‬ • ‫اﶈيﻄية‬ ‫اﻷﻭﻋية‬ ‫ﻣﺮﺽ‬ • ‫الﺸديد‬ ‫ﻣﺤصﺮاﺕ‬ ‫قﻨﻮاﺕ‬ ‫الﻜالﺴيﻮﻡ‬ ‫ﻧﻮﻉ‬ ‫ﻣﻦ‬ ‫ديﻬيدﺭﻭﺑيديﻦ‬ ‫الﺬﺑﺤة‬ • ‫الﻘلﺐ‬ ‫ﻭﻇيفة‬ ‫ﺧلل‬ • ‫اﻻﻧﺒﺴاﻃية‬ ‫ﺭيﻨﻮد‬ ‫ﻇاﻫﺮة‬ • ‫الﺸﻘيﻘة‬ • ‫اﳌﺮﻱﺀ‬ ‫ﺗﺸﻨﺞ‬ • ‫الﻜاﺣل‬ ‫ﻭﺭﻡ‬ • ( •flushing) ‫الﺒيﻎ‬ ‫الصداﻉ‬ • ‫اللﺜة‬ ‫ﺗﻀﺨﻢ‬ • ( •dumping) ‫اﻹﻏﺮاﻕ‬
  • ٩٣ ‫ﺍﻟﻜﻠﻮﻱ‬ ‫ﺍﻟﺸﺮﻳﺎﻥ‬ ‫ﻣﺮﺽ‬ ‫ﺗﻘﻴﻴﻢ‬ :٥-١١ ،( •atherosclerotic) ‫ﻋصيدﻱ‬ ‫ﺗصلﺒﻲ‬ ‫ﻣﻨﺸﺄ‬ ‫ﺫا‬ ‫الﻌادة‬ ‫ﻓﻲ‬ ‫يﻜﻮﻥ‬ ‫الﻜلﻮﻱ‬ ‫الﺸﺮياﻥ‬ ‫ﺗﻀيﻖ‬ ‫ﻋﻦ‬ ‫ﺗزيد‬ ‫ﺑﻨﺴﺒة‬ (renal artery lumen) ‫الﻜلﻮﻱ‬ ‫الﺸﺮياﻥ‬ ‫ﳌﻌة‬ ‫ﺑﺘﻀيﻖ‬ ‫ﹰ‬‫ا‬‫ﺗﺸﺮيﺤي‬ ‫ﻌﺮﻑ‬‫ﹸ‬‫ي‬‫ﻭ‬ .٪٧٥ ‫ﻋﻦ‬ ‫الﺘﻀيﻖ‬ ‫ﻧﺴﺒة‬ ‫ﺯادﺕ‬ ‫ﺇﺫا‬ ‫ديﻨاﻣيﻜية‬ ‫ﺃﻫﻤية‬ ‫ﺫا‬ ‫ﻌﺘﺒﺮ‬‫ﹸ‬‫ي‬‫ﻭ‬ ،٪٥٠ ‫ﻡ‬‫ﱠ‬‫د‬‫ال‬ ‫ﺿﻐﻂ‬ ‫ﻓﺮﻁ‬ ‫ﺣدﻭﺙ‬ ‫ﻓﻲ‬ ‫الديﻨاﻣيﻜية‬ ‫اﻷﻫﻤية‬ ‫ﺫﻱ‬ ‫الﻜلﻮﻱ‬ ‫الﺸﺮياﻥ‬ ‫ﺗﻀيﻖ‬ ‫يﺘﺴﺒﺐ‬ ‫قد‬ • ‫اﻹقفاﺭﻱ‬ ‫الﻜلية‬ ‫اﻋﺘﻼﻝ‬ ‫ﺃﻭ‬ (renovascular hypertension) ‫ة‬‫ﱠ‬‫ي‬‫الﻜلﻮ‬ ‫ﻭﻋية‬‫ﹶ‬‫اﻷ‬ ‫ﻋﻦ‬ ‫الﻨاﺟﻢ‬ ‫ﻣفاﺟﺌة‬ ‫ﺭﺋﻮية‬ ‫ﻭﻭﺫﻣة‬ ‫الﺘﻄﻮﺭ‬ ‫ﺳﺮيﻊ‬ ‫قلﺒﻲ‬ ‫ﺑفﺸل‬‫ﹰ‬‫ا‬‫ﺳﺮيﺮي‬ ‫ﻭيﺘﻤيز‬ ،(ischemic nephropathy) ‫ﹰ‬‫ا‬‫ﺷﺮياﻧ‬ ‫ﺃﺻاﺏ‬ ‫ﺃﻭ‬ ‫الﻜلﻮيﲔ‬ ‫الﺸﺮياﻧﲔ‬ ‫ﻛﻼ‬ ‫الﺘﻀيﻖ‬ ‫ﺃﺻاﺏ‬ ‫ﺇﺫ‬ .(flash pulmonary edema) ‫الﺮﺷﺢ‬ ‫ﻣﻌدﻝ‬ ‫ﻧﻘصاﻥ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫اﻻﻧﺘﺒاﻩ‬ ‫يلفﺖ‬ ‫ﻋادة‬ ‫ﻓﺈﻧﻪ‬ ‫ﻭﺣيدة‬ ‫ﻓﻌالة‬ ‫ﻛلية‬ ‫يﻐﺬﻱ‬ ‫ﹰ‬‫ا‬‫ﻛلﻮي‬ (ACEi) ‫ﹶﻨﺴﲔ‬‫ﺗ‬‫ﳒيﻮ‬‫ﹶ‬‫لﻸ‬ ‫ﻝ‬‫ﱢ‬‫ﻮ‬‫ﹶ‬ ‫ﹸ‬‫اﶈ‬ ‫اﻹﻧزﱘ‬ ‫ﻣﺜﺒﻄاﺕ‬ ‫ﺑدﺀ‬ ‫ﲟﺠﺮد‬ ٪٣٠ ‫ﺗفﻮﻕ‬ ‫ﺑﻨﺴﺒة‬ (GFR) ‫الﻜﺒيﺒﻲ‬ . (ARBs) ‫اﻷﳒيﻮﺗﻨﺴﲔ‬ ‫ﻣﺴﺘﻘﺒﻼﺕ‬ ‫ﺮاﺕ‬ ‫ﹺ‬‫ص‬ ‫ﹾ‬‫ﺤ‬‫ﹸ‬‫ﻣ‬ ‫ﺃﻭ‬ ‫ﻛاﺧﺘﺒاﺭ‬ ( •duplex ultrasonography) ‫الدﻭﺑلﺮﻱ‬ ‫الصدﻯ‬ ‫ﺗﺨﻄيﻂ‬ ‫ﺇلﻰ‬ ‫اللﺠﻮﺀ‬ ‫يفﻀل‬ ‫اﺳﺘﻌﻤاﻝ‬‫ﺑدﻭﻥ‬‫الﻜلﻮية‬‫للﺸﺮايﲔ‬‫ﹰ‬‫ا‬‫ﻭﻭﻇيفي‬‫ﹰ‬‫ا‬‫ﺗﺸﺮيﺤي‬‫ﹰ‬‫ا‬‫ﺗﻘييﻤ‬‫يﻮﻓﺮ‬‫ﺃﻧﻪ‬‫ﺣيﺚ‬‫ﺃﻭلﻲ‬‫ﺗﺸﺨيصﻲ‬ ‫للﺸﺮايﲔ‬ ‫اﶈﻮﺳﺐ‬ ‫اﳌﻘﻄﻌﻲ‬ ‫الﺘصﻮيﺮ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﳝﻜﻦ‬ ‫ﻛﻤا‬ ،‫للﻜلﻰ‬ ‫ﺳاﻣة‬ ‫ﺗﺒايﻦ‬ ‫ﻣﻮاد‬ ‫ﺗصﻮيﺮ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﻓيﺘﻢ‬ ‫الﻨﻬاﺋﻲ‬ ‫الﺘﺸﺨيﺺ‬ ‫ﺃﻣا‬ .(computed tomography angiography) ‫ﻭلﻜﻨﻪ‬ (invasive) ‫ﺑاﺿﻊ‬ ‫ﺇﺟﺮاﺀ‬ ‫ﻭﻫﻮ‬ ،(renal angiography) ‫الﻜلﻮية‬ ‫الﺸﺮياﻧية‬ ‫اﻷﻭﻋية‬ .‫اﳌﺒاﺷﺮ‬ ‫الﻌﻼﺟﻲ‬ ‫للﺘدﺧل‬ ‫ﻓﺮﺻة‬ ‫يﻌﻄﻲ‬ ‫ﺑالﺮﻧﲔ‬ ‫الﺘصﻮيﺮ‬ ‫ﺃﺛﻨاﺀ‬ ( •gadolinium) ‫اﳉادﻭليﻨيﻮﻡ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﺑﲔ‬ ‫قﻮﻱ‬ ‫اﺭﺗﺒاﻁ‬ ‫يﻮﺟد‬ ‫ﻌﺮﻑ‬‫ﹸ‬‫ي‬ ‫ﺷديد‬ ‫ﲟﺮﺽ‬ ‫ﺇﺻاﺑﺘﻬﻢ‬ ‫ﻭﺑﲔ‬ ‫الﻜلﻮﻱ‬ ‫ﺑالﻘصﻮﺭ‬ ‫اﳌصاﺑﲔ‬ ‫ﻋﻨد‬ (MRI) ‫اﳌﻐﻨاﻃيﺴﻲ‬ ‫ﺑﺘﺠﻨﺐ‬ ‫يﻨصﺢ‬ ‫لﺬلﻚ‬ .(nephrogenic systemic fibrosis) ‫الﻜلﻮﻱ‬ ‫اﳉﻬاﺯﻱ‬ ‫ﺑالﺘليﻒ‬ .‫اﳌﺮﺿﻰ‬ ‫لﻬﺆﻻﺀ‬ ‫ﺑالﻨﺴﺒة‬ ‫اﻹﻣﻜاﻥ‬ ‫قدﺭ‬ ‫اﳉادﻭليﻨيﻮﻡ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﺑاللﺠﻮﺀ‬ ‫يﻨصﺢ‬ ‫لﺬلﻚ‬ ،‫الصفاقية‬ ‫الديلزة‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﺷديد‬ ‫ﺑﺒﻂﺀ‬ ‫اﳉادﻭليﻨيﻮﻡ‬ ‫ﺗصفية‬ ‫ﺗﺘﻢ‬ • ‫ﺑالﺮﻧﲔ‬ ‫الﺘصﻮيﺮ‬ ‫ﻓﻲ‬ ‫اﳉادﻭليﻨيﻮﻡ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﺇلﻰ‬ ‫اﻻﺿﻄﺮاﺭ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ ‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫ﺇلﻰ‬ ‫ﻣﺤلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﻣﺮاﺕ‬ ‫ﻋدد‬ ‫ﺯيادة‬ ‫ﻓيﻤﻜﻦ‬ ،‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫ﺇﺟﺮاﺀ‬ ‫ﺗﻌﺬﺭ‬ ‫ﺇﺫا‬ .‫اﳌﻐﻨاﻃيﺴﻲ‬ .‫ﹰ‬‫ا‬‫ﺟاﻓ‬ ‫الصفاﻕ‬ ‫ﺗﺮﻙ‬ ‫ﻋدﻡ‬ ‫ﻣﻊ‬ ،‫الﺘصﻮيﺮ‬ ‫ﺑﻌد‬ ‫اﻷقل‬ ‫ﻋلﻰ‬ ‫ﺳاﻋة‬ ٤٨ ‫ﳌدة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺿﻐﻂ‬ ‫ﻓﻲ‬ ‫الدﻭاﺋﻲ‬ ‫الﺘﺤﻜﻢ‬ ‫ﻋلﻰ‬ ‫الﻜلﻮﻱ‬ ‫الﺸﺮياﻥ‬ ‫ﳌﺮﺽ‬ ‫ﺑالﻨﺴﺒة‬ ‫اﻷﻭﻝ‬ ‫الﻌﻼﺝ‬ ‫ﺧﻂ‬ ‫يﻌﺘﻤد‬ • (ACEi) ‫ﹶﻨﺴﲔ‬‫ﺗ‬‫ﳒيﻮ‬‫ﹶ‬‫لﻸ‬ ‫ﻝ‬‫ﱢ‬‫ﻮ‬‫ﹶ‬ ‫ﹸ‬‫اﶈ‬ ‫اﻹﻧزﱘ‬ ‫ﻣﺜﺒﻄاﺕ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﺑفﻌالية‬ ‫ﺇﳒاﺯﻩ‬ ‫ﳝﻜﻦ‬ ‫ﻭالﺬﻱ‬ ،‫الدﻡ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫اﺳﺘﻌﻤالﻬا‬ ‫ﲡﻨﺐ‬ ‫ﻣﺮاﻋاة‬ ‫ﻣﻊ‬ (ARBs) ‫اﻷﳒيﻮﺗﻨﺴﲔ‬ ‫ﻣﺴﺘﻘﺒﻼﺕ‬ ‫ﺮاﺕ‬ ‫ﹺ‬‫ص‬ ‫ﹾ‬‫ﺤ‬‫ﹸ‬‫ﻣ‬ ‫ﺃﻭ‬ .‫ﻭﺣيدة‬ ‫ﻓﻌالة‬ ‫ﻛلية‬ ‫يﻐﺬﻱ‬‫ﹰ‬‫ا‬‫ﻛلﻮي‬‫ﹰ‬‫ا‬‫ﺷﺮياﻧ‬ ‫ﺃﺻاﺏ‬ ‫ﺃﻭ‬ ‫الﻜلﻮيﲔ‬ ‫الﺸﺮياﻧﲔ‬ ‫ﻛﻼ‬ ‫ﺃﺻاﺏ‬ ‫قد‬ ‫الﺘﻀيﻖ‬ .‫اللزﻭﻡ‬ ‫ﻋﻨد‬ ‫للﻀﻐﻂ‬ ‫ﻣﺨفﻀة‬ ‫ﺃﺧﺮﻯ‬ ‫ﺃدﻭية‬ ‫ﺃﻭ‬ ‫الﺒﻮﻝ‬ ‫ﻣدﺭاﺕ‬ ‫ﺇﺿاﻓة‬ ‫ﹰ‬‫ا‬‫ﻻﺣﻘ‬ ‫ﻭﳝﻜﻦ‬ ‫اﻷﺧﺮﻯ‬ ‫الﻌﻼﺟية‬ ‫اﳋياﺭاﺕ‬ ‫ﻓﺈﻥ‬ ،‫الدﻭاﺋية‬ ‫للﻤﻌاﳉة‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻓﺮﻁ‬ ‫يﺴﺘﺠﺐ‬ ‫لﻢ‬ ‫ﺇﺫا‬ • percutaneous transluminal) ‫اﳉلد‬ ‫ﺑﻄﺮيﻖ‬ ‫اللﻤﻌة‬ ‫ﻋﺒﺮ‬ ‫الﻜلﻮﻱ‬ ‫الﺸﺮياﻥ‬ ‫ﺭﺃﺏ‬ ‫ﺗﺸﻤل‬ surgical) ‫اﳉﺮاﺣية‬ ‫الﺘﻮﻋية‬ ‫ﻭﺇﻋادة‬ ،‫ﺑدﻭﻧﻬا‬ ‫ﺃﻭ‬ (stent) ‫دﻋاﻣة‬ ‫ﻣﻊ‬ ( renal arterioplasty .(revascularization
  • ٩٢ /‫ﻍ‬ •٢٫٤ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫ﺇلﻰ‬ ‫الﻄﻌاﻡ‬ ‫ﻣلﺢ‬ ‫ﺗﻘليل‬ ‫ﺗﺸﻤل‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫لفﺮﻁ‬ ‫الدﻭاﺋية‬ ‫ﻏيﺮ‬ ‫اﳌﻌاﳉة‬ ‫الﻮﺯﻥ‬ ‫ﺇﻧﻘاﺹ‬ ،‫اﻷﺳﺒﻮﻉ‬ ‫ﺃياﻡ‬ ‫ﺃﻏلﺐ‬ ‫ﻓﻲ‬ ‫دقيﻘة‬ ٣٠ ‫ﳌدة‬ ‫اﳌﻌﺘدلة‬ ‫الﺮياﺿية‬ ‫الﺘﻤاﺭيﻦ‬ ،‫ﹰ‬‫ا‬‫يﻮﻣي‬ .‫الﻜﺤﻮﻝ‬ ‫ﺗﻨاﻭﻝ‬ ‫ﻭﺗﻘليل‬ ،‫الﺘدﺧﲔ‬ ‫ﻋﻦ‬ ‫الﺘﻮقﻒ‬ ،‫الﺒديﻨﲔ‬ ‫للﻤﺮﺿﻲ‬ ‫ﺑالﻨﺴﺒة‬ ‫اﻷﺧﺮﻯ‬ ‫الفﻮاﺋد‬ ‫الدﻡ‬ ‫لﻀﻐﻂ‬ ‫اﺨﻤﻟفﻀة‬ ‫اﻷدﻭية‬ ‫ﻭﺻﻒ‬ ‫ﻋﻨد‬ ‫اﻻﻋﺘﺒاﺭ‬ ‫ﺑﻌﲔ‬ ‫يﺆﺧﺬ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ • .(٢٢ ‫ﻭ‬ ٢١ ‫ﺟدﻭلﻲ‬ ‫)اﻧﻈﺮ‬ ‫اﶈﺘﻤلة‬ ‫اﳉاﻧﺒية‬ ‫ﻭاﻵﺛاﺭ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﺧفﺾ‬ ‫ﺑﺠاﻧﺐ‬ ‫اﳌﺘﻮقﻌة‬ ‫ﻣﺴﺘﻘﺒﻼﺕ‬ ‫ﺮاﺕ‬ ‫ﹺ‬‫ص‬ ‫ﹾ‬‫ﺤ‬‫ﹸ‬‫ﻣ‬ ‫ﺃﻭ‬ ( •ACEi) ‫ﹶﻨﺴﲔ‬‫ﺗ‬‫ﳒيﻮ‬‫ﹶ‬‫لﻸ‬ ‫ﻝ‬‫ﱢ‬‫ﻮ‬‫ﹶ‬ ‫ﹸ‬‫اﶈ‬ ‫اﻹﻧزﱘ‬ ‫ﻣﺜﺒﻄاﺕ‬ ‫ﺗﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫يفﻀل‬ ‫ﳌﻌﻈﻢ‬ ‫ﺑالﻨﺴﺒة‬ ‫اﻷﻭﻝ‬ ‫الﻌﻼﺟﻲ‬ ‫اﳋياﺭ‬ ‫ﻫﻲ‬ ‫ﲟﺠﻤﻮﻋﻬا‬ ‫ﺃﻭ‬ ‫ﲟفﺮدﻫا‬ (ARBs) ‫اﻷﳒيﻮﺗﻨﺴﲔ‬ ‫اﳌﺘﺒﻘية‬ ‫الﻜلﻮية‬ ‫الﻮﻇيفة‬ ‫ﻋلﻰ‬ ‫ﲢاﻓﻆ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﺧفﺾ‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ ‫ﻷﻧﻬا‬ ،‫اﳌﺮﺿﻰ‬ .(LVH) ‫اﻷيﺴﺮ‬ ‫الﺒﻄﲔ‬ ‫ﺗﻀﺨﻢ‬ ‫ﻭﺗﻌﻜﺲ‬ ،(protienuria) ‫الﺒﺮﻭﺗيﻨية‬ ‫الﺒيلة‬ ‫ﻭﺗﻘلل‬ ،(RRF) ‫الﺮﺷﺢ‬ ‫ﻣﻌدﻝ‬ ‫ﻧﻘﺺ‬ ‫ﺇﺫا‬ ‫ﺃﻭ‬ ‫ﳑﻮﻝ/ﻝ‬ ٥٫٥ ‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﲡاﻭﺯ‬ ‫ﺇﺫا‬ ‫اﻷدﻭية‬ ‫ﻫﺬﻩ‬ ‫ﺇيﻘاﻑ‬ ‫يلزﻡ‬ .‫ﺁﺧﺮ‬ ‫ﺗفﺴيﺮ‬ ‫ﻭﺟﻮد‬ ‫ﺑدﻭﻥ‬ ‫الﻌﻼﺝ‬ ‫ﺑدﺀ‬ ‫ﻣﻦ‬ ‫ﺃﺷﻬﺮ‬ ٤ ‫ﻏﻀﻮﻥ‬ ‫ﻓﻲ‬ ‫ﺃﻛﺜﺮ‬ ‫ﺃﻭ‬ ٪٣٠ ‫ﲟﻘداﺭ‬ ‫الﻜﺒيﺒﻲ‬ ‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫الﻐﺬاﺋﻲ‬ ‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫ﻣدﺧﻮﻝ‬ ‫ﺑﺘﻘليل‬ ‫اﳌﺮيﺾ‬ ‫ﻨصﺢ‬‫ﹸ‬‫ي‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ :‫)ﻣﺜاﻝ‬ ‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﺇﻧﻘاﺹ‬ ‫ﺇلﻰ‬ ‫ﺗﻬدﻑ‬ ‫ﺑﺘﺤﻮﻃاﺕ‬ ‫الﻘياﻡ‬ ‫ﻣﻦ‬ ‫ﻭﻻﺑد‬ ،‫ﳑﻮﻝ/ﻝ‬ ٥٫٥ - ٤٫٦ .‫ﳑﻮﻝ/ﻝ‬ ٥٫٥ - ٥٫١ ‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ (‫الﻌﺮﻭية‬ ‫اﳌدﺭاﺕ‬ ،‫ﺭﺯﻭﻧيﻮﻡ‬ ‫ﻛالﺴيﻮﻡ‬ •loop) ‫الﻌﺮﻭية‬ ‫الﺒﻮﻝ‬ ‫ﻣدﺭاﺕ‬ ‫ﺇﺿاﻓة‬ ‫ﻓيﺠﺐ‬ ،(anuric) ‫الﺒﻮﻝ‬ ‫ﻣﻨﻘﻄﻊ‬ ‫اﳌﺮيﺾ‬ ‫يﻜﻦ‬ ‫لﻢ‬ ‫ﺇﺫا‬ ‫دﻭاﺀ‬ ‫ﻣﻦ‬ ‫ﺃﻛﺜﺮ‬ ‫ﺇلﻰ‬ ‫اﳌﺮيﺾ‬ ‫اﺣﺘياﺝ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ ‫ﺃﻭ‬ ‫الﺴﻮاﺋل‬ ‫اﺣﺘﺒاﺱ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ (diuretics ‫ﻝ‬‫ﱢ‬‫ﻮ‬‫ﹶ‬ ‫ﹸ‬‫اﶈ‬ ‫اﻹﻧزﱘ‬ ‫ﻣﺜﺒﻄاﺕ‬ ‫ﻓاﻋلية‬ ‫ﻣﻦ‬ ‫ﺗزيد‬ ‫ﺃﻧﻬا‬ ‫الﺒﻮﻝ‬ ‫ﻣدﺭاﺕ‬ ‫ﳑيزاﺕ‬ ‫ﻣﻦ‬ .‫الدﻡ‬ ‫لﻀﻐﻂ‬ ‫ﻣﺨفﺾ‬ ‫ﺇلﻰ‬ ‫ﺗﺆدﻱ‬ ‫قد‬ ‫ﻭلﻜﻨﻬا‬ (ARBs) ‫اﻷﳒيﻮﺗﻨﺴﲔ‬ ‫ﻣﺴﺘﻘﺒﻼﺕ‬ ‫ﺮاﺕ‬ ‫ﹺ‬‫ص‬ ‫ﹾ‬‫ﺤ‬‫ﹸ‬‫ﻣ‬‫ﻭ‬ (ACEi) ‫ﹶﻨﺴﲔ‬‫ﺗ‬‫ﳒيﻮ‬‫ﹶ‬‫لﻸ‬ .‫للﺴﻮاﺋل‬ ‫اﳉﺴﻢ‬ ‫ﻓﻘداﻥ‬ ‫ﻣﻌدﻝ‬ ‫يﻜﻮﻥ‬ ‫ﻋﻨدﻣا‬ ‫ﺣﺘﻰ‬ ‫ﹰ‬‫ﻻ‬‫ﻓﻌا‬ ‫يﻈل‬ ‫ﻣيﺘﻮﻻﺯﻭﻥ‬ ‫ﻓﺈﻥ‬ ،‫اﻷﺧﺮﻯ‬ ‫الﺜياﺯيدية‬ ‫الﺒﻮﻝ‬ ‫ﻣدﺭاﺕ‬ ‫ﺑﺨﻼﻑ‬ • ‫ﻣﺮﺗﲔ‬ ‫ﻣﻨﻪ‬ ‫ﻭاﺣدة‬ ‫ﺟﺮﻋة‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﻭﳝﻜﻦ‬ ،٢‫ﻡ‬ ١٫٧٣/‫ﻣل/دقيﻘة‬ ٣٠ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫الﻜﺒيﺒﻲ‬ ‫الﺮﺷﺢ‬ .‫الﻄﻮيل‬ ‫ﻋﻤﺮﻩ‬ ‫ﻧصﻒ‬ ‫ﺑﺴﺒﺐ‬ ‫ﹰ‬‫ا‬‫ﺃﺳﺒﻮﻋي‬ ‫ﻣﺮاﺕ‬ ‫ﺛﻼﺙ‬ ‫ﺃﻭ‬ ‫لﺘﺤﻘيﻖ‬ ‫للﻀﻐﻂ‬ ‫ﻣﺨفﻀة‬ ‫ﺃدﻭية‬ •٤ - ٣ ‫ﺇلﻰ‬ ‫يﺤﺘاﺟﻮﻥ‬ ‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫ﻣﺮﺿﻰ‬ ‫ﻣﻌﻈﻢ‬ ‫الدﻭاﺀ‬ ‫ﺟﺮﻋة‬ ‫ﺯيادة‬ ‫ﻦ‬ ‫ﹸ‬‫يﺤﺴ‬ ،‫اﳉاﻧﺒية‬ ‫اﻵﺛاﺭ‬ ‫ﻏياﺏ‬ ‫ﻓﻲ‬ .‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻣﻦ‬ ‫اﳌﺴﺘﻬدﻑ‬ ‫اﳌﺴﺘﻮﻯ‬ .‫ﺃﺳاﺑيﻊ‬ ٤ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫ﻏﻀﻮﻥ‬ ‫ﻓﻲ‬ ‫اﳉﺮﻋة‬ ‫ﺯيادة‬ ‫يﺠﻮﺯ‬ ‫ﻭﻻ‬ ،‫ﺁﺧﺮ‬ ‫دﻭاﺀ‬ ‫ﺇﺿاﻓة‬ ‫قﺒل‬ ‫للﻀﻐﻂ‬ ‫اﺨﻤﻟفﺾ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻣﺴﺘﻮياﺕ‬ ‫ﲢﻘيﻖ‬ ‫يﺘﻢ‬ ‫ﻻ‬ ‫ﻋﻨدﻣا‬ ( •refractory) ‫اﳊﺮﻭﻥ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻓﺮﻁ‬ ‫ﺺ‬ ‫ﺸﺨﱠ‬‫ﹸ‬‫ي‬ ‫ﺃﺣدﻫا‬ ‫للﻀﻐﻂ‬ ‫ﻀة‬‫ﱢ‬‫ف‬‫ﻣﺨ‬ ‫ﻣﻨاﺳﺒة‬ ‫ﺃدﻭية‬ ‫ﺛﻼﺛة‬ ‫يﺘﻨاﻭﻝ‬ ‫ﺑالﻌﻼﺝ‬ ‫ﻣلﺘزﻡ‬ ‫ﳌﺮيﺾ‬ ‫اﳌﺴﺘﻬدﻓة‬ .‫الﻘصﻮﻯ‬ ‫اﳉﺮﻋة‬ ‫يﻘاﺭﺏ‬ ‫ﲟا‬ ‫ﻣﻮﺻﻮﻓة‬ ‫اﻷدﻭية‬ ‫ﻛل‬ ‫ﺗﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫ﺷﺮيﻄة‬ ،‫للﺒﻮﻝ‬ ‫ﻣدﺭ‬ :‫)ﻣﺜاﻝ‬ ‫الدﻡ‬ ‫لﻀﻐﻂ‬ ‫ﺭاﻓﻌة‬ ‫ﺃدﻭية‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﻣﻦ‬ ‫ﹰ‬‫ا‬‫ﻧاﺟﻤ‬ ‫اﳊﺮﻭﻥ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻓﺮﻁ‬ ‫يﻜﻮﻥ‬ ‫قد‬ • ‫يﻜﻮﻥ‬ ‫الﻐالﺐ‬ ‫ﻓﻲ‬ ‫ﻭلﻜﻦ‬ ،(‫الﻬيﺴﺘاﻣﲔ‬ ‫ﻭﻣﻀاداﺕ‬ (NSAIDs) ‫الﻼﺳﺘيﺮﻭيدية‬ ‫اﻷلﻢ‬ ‫ﻣﺴﻜﻨاﺕ‬ ‫ﻋدﻡ‬ ‫ﺃﻭ‬ ،‫الديلزة‬ ‫ﺑﺠﺮﻋة‬ ‫اﻻلﺘزاﻡ‬ ‫ﻋدﻡ‬ ‫ﺃﻭ‬ ،‫ﻭالﺴﻮاﺋل‬ ‫اﳌلﺢ‬ ‫ﺑﺘﻘليل‬ ‫اﻻلﺘزاﻡ‬ ‫ﻋدﻡ‬ ‫ﻫﻮ‬ ‫الﺴﺒﺐ‬ .‫الدﻡ‬ ‫لﻀﻐﻂ‬ ‫اﺨﻤﻟفﻀة‬ ‫ﺑاﻷدﻭية‬ ‫ﺑﺠﺮﻋة‬ ‫اﻻلﺘزاﻡ‬ ،‫الﻌﻼﺝ‬ ‫ﻣﻮاﺭد‬ ‫ﺗﻮﻓﺮ‬ ‫ﻋدﻡ‬ ‫ﺃﻭ‬ ،‫الﻌﻼﺟية‬ ‫اﻷﻫداﻑ‬ ‫ﻓﻬﻢ‬ ‫ﻋدﻡ‬ ‫ﻣﻦ‬ ‫ﹰ‬‫ا‬‫ﻧاﺟﻤ‬ ‫اﻻلﺘزاﻡ‬ ‫ﻋدﻡ‬ ‫يﻜﻮﻥ‬ ‫قد‬ • ‫ﻋلﻰ‬ ‫ﺑاﻻﻋﺘﻤاد‬ ‫اﳌﺘﻌلﻘة‬ ‫الﺜﻘاﻓية‬ ‫اﳌﺸاﻛل‬ ‫ﺃﻭ‬ ،‫الدﻭاﺀ‬ ‫ﲢﻤل‬ ‫ﺃﻭﻋدﻡ‬ ،‫الﺬﻫﻨية‬ ‫اﻹﻋاقة‬ ‫ﺃﻭ‬ ‫ﻦ‬ ‫ﹸ‬‫يﺤﺴ‬ ‫ﺑالﻌﻼﺝ‬ ‫اﻻلﺘزاﻡ‬ ‫لﺘﺴﻬيل‬ .‫الﺘﺤفيز‬ ‫ﻋدﻡ‬ ‫ﺃﻭ‬ ،‫الدﻋﻢ‬ ‫ﻧﻈﻢ‬ ‫ﻛفاية‬ ‫ﻋدﻡ‬ ‫ﺃﻭ‬ ،‫اﻷدﻭية‬ ،‫اﳉﺮﻋاﺕ‬ ‫ﺛاﺑﺘة‬ ‫ﻣﺮﻛﺒة‬ ‫ﺃدﻭية‬ ‫ﺃﻭ‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻭاﺣدة‬ ‫ﻣﺮة‬ ‫ﺗﻨاﻭلﻬا‬ ‫يﺘﻢ‬ ‫اﳌفﻌﻮﻝ‬ ‫ﻃﻮيلة‬ ‫ﺃدﻭية‬ ‫ﻭﺻﻒ‬ .‫ﻛﺜيﺮة‬ ‫ﺟاﻧﺒية‬ ‫ﺁﺛاﺭ‬ ‫لﻬا‬ ‫ليﺲ‬ ‫الﻜلفة‬ ‫قليلة‬ ‫ﺃدﻭية‬ ‫ﻭﺻﻒ‬ ‫ﻦ‬ ‫ﹸ‬‫يﺤﺴ‬ ‫ﻛﻤا‬
  • ٩١ ‫ﺍﻟﺪﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻗﻴﺎﺱ‬ :٣-١١ ‫الﺘﺴﻤﻊ‬ ‫ﻃﺮيﻘة‬ ‫ﻫﻲ‬ ‫الﻘياﺳية‬ ‫ﻭالﻄﺮيﻘة‬ ،‫ﹰ‬‫ا‬‫ﺟد‬ ‫ﺿﺮﻭﺭﻱ‬ ‫الدﻡ‬ ‫لﻀﻐﻂ‬ ‫الدقيﻖ‬ ‫الﻘياﺱ‬ • ‫الﻀﻐﻂ‬ ‫قياﺱ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ،‫ﺯياﺭة‬ ‫ﻛل‬ ‫ﻓﻲ‬ .‫الﻌيادة‬ ‫ﻓﻲ‬ ‫الزﺋﺒﻘﻲ‬ ‫الﻀﻐﻂ‬ ‫ﻣﻘياﺱ‬ ‫ﺑاﺳﺘﺨداﻡ‬ ‫اﻷﻭليﲔ‬ ‫الﻘﺮاﺀﺗﲔ‬ ‫ﺑﲔ‬ ‫الفﺮﻕ‬ ‫ﻛاﻥ‬ ‫ﻭﺇﺫا‬ ،‫الﻘﺮاﺀﺗﲔ‬ ‫ﻣﺘﻮﺳﻂ‬ ‫ﻭﺗﺴﺠيل‬ ‫دقيﻘﺘاﻥ‬ ‫ﺑيﻨﻬﻤا‬ ‫ﻣﺮﺗﲔ‬ .‫اﳌﺘﻮﺳﻂ‬ ‫ﻭﺣﺴاﺏ‬ ‫ﺛالﺚ‬ ‫قياﺱ‬ ‫ﺃﺧﺬ‬ ‫ﻣﻦ‬ ‫ﻓﻼﺑد‬ ‫ﺯﺋﺒﻖ‬ ‫ﱈ‬ ٥ ‫ﻣﻦ‬ ‫ﺃﻛﺜﺮ‬ ‫ﻭﺫﺭاﻋاﻩ‬ ‫ﻣدﻋﻮﻡ‬ ‫ﻭﻇﻬﺮﻩ‬ ‫دقاﺋﻖ‬ •٥ ‫ﻋﻦ‬ ‫ﺗﻘل‬ ‫ﻻ‬ ‫ﳌدة‬ ‫ﺑاﺭﺗياﺡ‬ ‫ﹰ‬‫ا‬‫ﺟالﺴ‬ ‫اﳌﺮيﺾ‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ ‫ﺗﻨاﻭﻝ‬ ‫ﺃﻭ‬ ‫الﺘدﺧﲔ‬ ‫ﻋﻦ‬ ‫اﳌﺮيﺾ‬ ‫ﳝﺘﻨﻊ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ .‫الﻘلﺐ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻓﻲ‬ ‫ﻭﻣدﻋﻮﻣﺘاﻥ‬ ‫ﻣﻜﺸﻮﻓﺘاﻥ‬ .‫الﻘياﺱ‬ ‫قﺒل‬ ‫دقيﻘة‬ ٣٠ ‫ﳌدة‬ ‫الﻜاﻓيﲔ‬ ‫ﻛفة‬ ‫اﺧﺘﺮ‬ .‫الﻘياﺳية‬ ‫اﳉداﻭﻝ‬ ‫ﻣﻊ‬ ‫ﻭاﳌﻘاﺭﻧة‬ ‫اﻻﺗﺴاﻕ‬ ‫ﺑﻬدﻑ‬ ‫اليﻤﻨﻰ‬ ‫الﺬﺭاﻉ‬ ‫اﺳﺘﺨداﻡ‬ ‫يفﻀل‬ • ‫الزﺝ‬ ‫ﺑﲔ‬ ‫اﳌﺴاﻓة‬ ‫ﻣﻨﺘصﻒ‬ ‫ﻓﻲ‬ ‫الﺬﺭاﻉ‬ ‫ﻣﺤيﻂ‬ ‫ﻣﻦ‬ ٪٤٠ ‫يﻘاﺭﺏ‬ ‫ﻣا‬ ‫ﻋﺮﺿﻬا‬ ‫يﺒلﻎ‬ ‫ﻣﺜاﻧة‬ ‫ﺫاﺕ‬ ‫قد‬ ‫الﻼﺯﻡ‬ ‫ﻣﻦ‬ ‫ﺃﺻﻐﺮ‬ ‫ﻣﺜاﻧة‬ ‫ﺫاﺕ‬ ‫ﻛفة‬ ‫اﺳﺘﺨداﻡ‬ ‫ﺃﻥ‬ ‫ﺇﺫ‬ ،(acromion) ‫ﻭاﻷﺧﺮﻡ‬ (olecranon) ‫ﺇلﻰ‬ ‫يﺆدﻱ‬ ‫قد‬ ‫الﻼﺯﻡ‬ ‫ﻣﻦ‬ ‫ﺃﻛﺒﺮ‬ ‫ﻣﺜاﻧة‬ ‫ﺫاﺕ‬ ‫ﻛفة‬ ‫ﻭاﺳﺘﺨداﻡ‬ ،‫ﺧاﻃﺌة‬ ‫ﻋالية‬ ‫قياﺳاﺕ‬ ‫ﺇلﻰ‬ ‫يﺆدﻱ‬ .‫ﺯﺋﺒﻖ‬ ‫ﱈ‬ ٣٠ - ١٠ ‫ﺣدﻭد‬ ‫ﻓﻲ‬ ‫ﺧاﻃﺌة‬ ‫ﻣﻨﺨفﻀة‬ ‫قياﺳاﺕ‬ •proximal)‫ﹰ‬‫ا‬‫ﻭﺇﻧﺴي‬‫ﹰ‬‫ا‬‫داﻧي‬(brachial)‫الﻌﻀدﻱ‬‫الﺸﺮياﻥ‬‫ﻧﺒﺾ‬‫ﻓﻮﻕ‬‫ﺑﺨفة‬‫الﺴﻤاﻋة‬‫ﺟﺮﺱ‬‫ﺿﻊ‬ ‫الﺘﻲ‬ ‫للﻜفة‬ ‫الﺴفلية‬ ‫اﳊاﻓة‬ ‫ﻭﲢﺖ‬ ،(cubital fossa) ‫اﳌﺮﻓﻘية‬ ‫اﳊفﺮة‬ ‫ﻣﻦ‬ (and medial ‫ﻓﻮﻕ‬ ‫ﺯﺋﺒﻖ‬ ‫ﱈ‬ ٣٠ ‫ﲟﻘداﺭ‬ ‫الﻜفة‬ ‫اﻧفﺦ‬ .‫ﺳﻢ‬ ٢ ‫قدﺭﻩ‬ ‫ﲟا‬ ‫اﳌﺮﻓﻘية‬ ‫اﳊفﺮة‬ ‫ﻓﻮﻕ‬ ‫ﺗﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ .‫الﺜاﻧية‬ ‫ﻓﻲ‬ ‫ﺯﺋﺒﻖ‬ ‫ﱈ‬ ٣-٢ ‫ﺑﺴﺮﻋة‬ ‫ﻓﺮﻏﻬا‬ ‫ﺛﻢ‬ ،‫اﻻﻧﻘﺒاﺿﻲ‬ ‫الﻨﺒﺾ‬ ‫ﻭاﺧﺘفاﺀ‬ ‫اﻻﻧﻘﺒاﺿﻲ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫لﺘﻌﺮيﻒ‬ (‫اﻷﻭلﻰ‬ ‫)اﳌﺮﺣلة‬ ‫للصﻮﺕ‬ ‫ﻇﻬﻮﺭ‬ ‫ﺃﻭﻝ‬ ‫يﺴﺘﺨدﻡ‬ • ‫اﻻﻧﻘﺒاﺿﻲ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﺇﻥ‬ .‫اﻻﻧﺒﺴاﻃﻲ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫لﺘﻌﺮيﻒ‬ (‫اﳋاﻣﺴة‬ ‫)اﳌﺮﺣلة‬ ‫الصﻮﺕ‬ ‫ﻣﻦ‬ ‫ﺃﻓﻀل‬ ‫ﺑصﻮﺭة‬ ‫الﻨﻬاﺋﻲ‬ ‫اﻷﻋﻀاﺀ‬ ‫ﺿﺮﺭ‬ ‫ﻋﻦ‬ ‫يﻨﺒﺌاﻥ‬ (pulse pressure) ‫الﻨﺒﻀﻲ‬ ‫ﻭالﻀﻐﻂ‬ .‫ﲟفﺮدﻩ‬ ‫اﻻﻧﺒﺴاﻃﻲ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻣﻦ‬ ‫ﻓﻼﺑد‬ ( •autonomic dysfunction) ‫ﻣﺴﺘﻘل‬ ‫ﻭﻇيفﻲ‬ ‫ﺧلل‬ ‫ﻭﺟﻮد‬ ‫ﻓﻲ‬ ‫ﺷﻚ‬ ‫ﻫﻨاﻙ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ .(‫دقاﺋﻖ‬ ٥-٢ ‫ﳌدة‬ ‫ﺑﻬدﻭﺀ‬ ‫)الﻮقﻮﻑ‬ ‫ﻭالﻮقﻮﻑ‬ ،‫ﻭاﳉلﻮﺱ‬ ،‫اﻻﺳﺘلﻘاﺀ‬ ‫ﻭﺿﻊ‬ ‫ﻓﻲ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫قياﺱ‬ ‫ﺑالدﻭﺧة‬ ‫ﹰ‬‫ا‬‫ﻣصﺤﻮﺑ‬ ‫الﻮقﻮﻑ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ ‫ﺯﺋﺒﻖ‬ ‫ﱈ‬ ١٠ ‫ﻣﻦ‬ ‫ﺃﻛﺜﺮ‬ ‫اﻻﻧﻘﺒاﺿﻲ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫اﻧﺨفاﺽ‬ .(postural hypotension) ‫الﻮﺿﻌﻲ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻧﻘﺺ‬ ‫ﻋلﻰ‬ ‫يدﻝ‬ ‫اﻹﻏﻤاﺀ‬ ‫ﺃﻭ‬ ‫ﺍﻟﺪﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻓﺮﻁ‬ ‫ﻣﻌﺎﳉﺔ‬ :٤-١١ ‫الﻘلﺒية‬‫اﻷﻣﺮاﺽ‬‫دﻻﺋل‬‫ﻋلﻰ‬‫يﺮﻛز‬‫ﺃﻥ‬‫يﺠﺐ‬‫الدﻡ‬‫ﺿﻐﻂ‬‫ﺑفﺮﻁ‬‫اﳌصاﺏ‬‫للﻤﺮيﺾ‬‫اﻷﻭلﻲ‬‫الﺘﻘييﻢ‬ • ‫اﺿﻄﺮاﺏ‬ ،(angina) ‫الﺬﺑﺤة‬ ،(MI) ‫الﻘلﺐ‬ ‫ﻋﻀل‬ ‫اﺣﺘﺸاﺀ‬ ،‫الﻘلﺐ‬ ‫ﻓﺸل‬ ‫ﺫلﻚ‬ ‫ﻓﻲ‬ ‫ﲟا‬ ‫الﻮﻋاﺋية‬ ‫ﻭاﳌﺮﺽ‬ ،(stroke) ‫الدﻣاﻏية‬ ‫الﺴﻜﺘة‬ ،(LVH) ‫اﻷيﺴﺮ‬ ‫الﺒﻄﲔ‬ ‫ﺗﻀﺨﻢ‬ ،(arrhythmia) ‫الﻨﻈﻢ‬ ‫اﻷﺧﺮﻯ‬ ‫الﻮﻋاﺋية‬ ‫الﻘلﺒية‬ ‫اﻻﺧﺘﻄاﺭ‬ ‫ﻋﻮاﻣل‬ ‫ﻣﻌﺮﻓة‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ‫ﻛﺬلﻚ‬ .(PVD) ‫اﶈيﻄﻲ‬ ‫الﻮﻋاﺋﻲ‬ .‫الدﻡ‬ ‫ﺷﺤﻤياﺕ‬ ‫ﻭﺧلل‬ ،‫الﺴﻜﺮﻱ‬ ‫داﺀ‬ ،‫الﺘدﺧﲔ‬ ،‫الﺴﻤﻨة‬ ‫ﺫلﻚ‬ ‫ﻓﻲ‬ ‫ﲟا‬ ،‫ﻭﻣﻌاﳉﺘﻬا‬
  • ٩٠ ‫ﺍﻟﺪﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻓﺮﻁ‬ ‫ﻣﻌﺎﳉﺔ‬ :١١ ‫ﻓﺼﻞ‬ ‫ﺍﻷﻫﺪﺍﻑ‬ :١-١١ ‫ﺑﻬدﻑ‬ ،‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺮﺿﻰ‬ ‫ﻋﻨد‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫لفﺮﻁ‬ ‫الصﺤيﺤة‬ ‫اﳌﻌاﳉة‬ ‫ﺗﺸﺠيﻊ‬ • .‫اﳌﺘﺒﻘية‬ ‫الﻜلﻮية‬ ‫الﻮﻇيفة‬ ‫ﻋلﻰ‬ ‫ﻭاﶈاﻓﻈة‬ ‫الﻮﻋاﺋﻲ‬ ‫الﻘلﺒﻲ‬ ‫اﺧﺘﻄاﺭﻫﻢ‬ ‫ﺷاﻛلة‬ ‫ﲢﺴﲔ‬ ‫ﺍﻟﺪﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻣﺮﺍﻗﺒﺔ‬ :٢-١١ ‫يﺒلﻎ‬ ‫الديلزة‬ ‫ﳌﺮﺿﻰ‬ ( •cardiovascular disease risk) ‫الﻮﻋاﺋﻲ‬ ‫الﻘلﺒﻲ‬ ‫اﻻﺧﺘﻄاﺭ‬ ‫ﺇﻥ‬ ‫ﺃﻋلﻰ‬ (relative risk) ‫الﻨﺴﺒﻲ‬ ‫اﻻﺧﺘﻄاﺭ‬ ‫يﻜﻮﻥ‬ ‫ﺑﺤيﺚ‬ ،‫الﻨاﺱ‬ ‫ﻋاﻣة‬ ‫اﺧﺘﻄاﺭ‬ ‫ﺿﻌﻒ‬ ١٠٠ - ١٠ ‫ﻋاﻣة‬ ‫ﻣﻦ‬ ‫ﺑﺄقﺮاﻧﻬﻢ‬ ‫ﻣﻘاﺭﻧﺘﻬﻢ‬ ‫ﻋﻨد‬ ‫الﺴﻦ‬ ‫ﻛﺒاﺭ‬ ‫اﳌﺮﺿﻰ‬ ‫ﻋﻨد‬ ‫ﻣﻨﻪ‬ ‫الﺴﻦ‬ ‫ﺻﻐاﺭ‬ ‫اﳌﺮﺿﻰ‬ ‫ﻋﻨد‬ .‫الﻨاﺱ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫ﻭيﺠﺐ‬ ،‫ﺻﺤية‬ ‫ﻣﻘاﺑلة‬ ‫ﻛل‬ ‫ﻓﻲ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫قياﺱ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • ‫ﱈ‬ ٨٠/١٣٠ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫الﺴﻜﺮﻱ‬ ‫ﺑداﺀ‬ ‫اﳌصاﺑﲔ‬ ‫ﻭﻏيﺮ‬ ‫اﳌصاﺑﲔ‬ ‫للﻤﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫اﳌﺴﺘﻬدﻑ‬ .‫ﺯﺋﺒﻖ‬ •orthostatic) ‫اﻻﻧﺘصاﺑﻲ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻧﻘﺺ‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻮﻥ‬ ‫الﺬيﻦ‬ ‫اﳌﺮﺿﻰ‬ ‫ﺫلﻚ‬ ‫ﻣﻦ‬ ‫يﺴﺘﺜﻨﻰ‬ ‫ﻭﻋاﺋﻲ‬ ‫ﺧلل‬ ‫ﺃﻭ‬ ،(autonomic dysfunction) ‫ﻣﺴﺘﻘل‬ ‫ﻭﻇيفﻲ‬ ‫ﺧلل‬ ‫ﺃﻭ‬ ،(hypotension ‫اﺳﺘﻬداﻑ‬ ‫ﺇلﻰ‬ ‫يﺤﺘاﺟﻮﻥ‬ ‫قد‬ ‫ﻓﻬﺆﻻﺀ‬ ،(peripheral vascular disease) ‫ﺷديد‬ ‫ﻣﺤيﻄﻲ‬ .‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻣﻦ‬ ‫ﺃﻋلﻰ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫يﻜﻮﻥ‬ ‫الﺬيﻦ‬ ‫للﻤﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﳋفﺾ‬ ‫ﺑالﺘدﺧل‬ ‫يﻨصﺢ‬ • ‫ﱈ‬ ٨٠ < ‫لديﻬﻢ‬ ‫اﻻﻧﺒﺴاﻃﻲ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫يﻜﻮﻥ‬ ‫ﺃﻭ‬ ‫ﺯﺋﺒﻖ‬ ‫ﱈ‬ ١٣٠ < ‫لديﻬﻢ‬ ‫اﻻﻧﻘﺒاﺿﻲ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫ﻭاﺣد‬ ‫ﻭقﺖ‬ ‫ﻓﻲ‬ ‫للﻀﻐﻂ‬ ‫ﻣﺨفﻀﲔ‬ ‫دﻭاﺋﲔ‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫ﻭيﻨصﺢ‬ .‫اﻷقل‬ ‫ﻋلﻰ‬ ‫ﳌﺮﺗﲔ‬ ‫ﺯﺋﺒﻖ‬ ‫ﺿﻐﻂ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬‫ﹰ‬‫ا‬‫ﻓﻮﺭ‬ ‫الﻌﻼﺝ‬ ‫ﺑﺒدﺀ‬ ‫يﻨصﺢ‬ ‫ﻛﻤا‬ ،‫ﺯﺋﺒﻖ‬ ‫ﱈ‬ ١٥٠ < ‫اﻻﻧﻘﺒاﺿﻲ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ .‫ﺯﺋﺒﻖ‬ ‫ﱈ‬ ١٨٠ < ‫اﻻﻧﻘﺒاﺿﻲ‬ ‫الدﻡ‬ ‫ﻣﺮاقﺒة‬ ‫ﲡﺐ‬ ‫ﺣﲔ‬ ‫ﻓﻲ‬ ،‫ﺃﺳﺒﻮﻉ‬ •١٢ - ٤ ‫ﻛل‬ ‫اﳌﺴﺘﻘﺮ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﺫﻭﻱ‬ ‫اﳌﺮﺿﻰ‬ ‫ﻣﺮاقﺒة‬ ‫ﳝﻜﻦ‬ ‫الدﻡ‬ ‫لﻀﻐﻂ‬ ‫اﺨﻤﻟفﻀة‬ ‫اﻷدﻭية‬ ‫ﺟﺮﻋة‬ ‫ﺯيادة‬ ‫ﺃﻭ‬ ‫ﺑدﺀ‬ ‫ﺑﻌد‬ ‫ﺃﺳاﺑيﻊ‬ ٤ ‫ﻏﻀﻮﻥ‬ ‫ﻓﻲ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ،‫ﻋﻨﻬا‬ ‫ﻧاﺟﻤة‬ ‫ﺟاﻧﺒية‬ ‫ﺁﺛاﺭ‬ ‫ﻭﺃﻱ‬ ‫ﻛفايﺘﻬا‬ ‫ﳌﺮاقﺒة‬ ‫اﻻﻧﻘﺒاﺿﻲ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫ﺃﺳﺒﻮﻋﲔ‬ ‫ﻏﻀﻮﻥ‬ ‫ﻓﻲ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻣﺮاقﺒة‬ ‫ﲡﺐ‬ • ‫يﺘﻨاﻭلﻮﻥ‬ ‫الﺬيﻦ‬ ‫للﻤﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫ﳑﻮﻝ/ﻝ‬ ٤٫٥ < ‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻛاﻥ‬ ‫ﺃﻭ‬ ،‫ﺯﺋﺒﻖ‬ ‫ﱈ‬ ١٦٠ < ‫ﺑالﻨﺴﺒة‬ ‫ﳑﻮﻝ/ﻝ‬ ٤٫٥ > ‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻛاﻥ‬ ‫ﺃﻭ‬ ،‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫ﻓﺮﻁ‬ ‫ﺗﺴﺒﺐ‬ ‫قد‬ ‫ﺃدﻭية‬ .‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫ﻧﻘﺺ‬ ‫ﺗﺴﺒﺐ‬ ‫قد‬ ‫ﺃدﻭية‬ ‫يﺘﻨاﻭلﻮﻥ‬ ‫الﺬيﻦ‬ ‫للﻤﺮﺿﻰ‬
  • ٨٩ ‫اﺳﻤﻪ‬ ‫يصﺒﺢ‬ ‫اﳉﺴﻢ‬ ‫لﻮﺯﻥ‬ ‫ﺑالﻨﺴﺒة‬ ‫الﻨيﺘﺮﻭﺟﲔ‬ ‫لﻈﻬﻮﺭ‬ ‫الﺒﺮﻭﺗيﻨﻲ‬ ‫اﳌﻜاﻓﺊ‬ ‫ﻝ‬‫ﱠ‬‫د‬‫ﹶ‬‫ﻌ‬‫ي‬ ‫ﻋﻨدﻣا‬ • ‫الﺒﺮﻭﺗيﻨﻲ‬ ‫اﳌﻜاﻓﺊ‬ ‫ﺗﻘديﺮ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ .(nPNA) ‫الﻨيﺘﺮﻭﺟﲔ‬ ‫لﻈﻬﻮﺭ‬ ‫اﳌﻌدﻝ‬ ‫الﺒﺮﻭﺗيﻨﻲ‬ ‫اﳌﻜاﻓﺊ‬ ‫ﺃﺛﻨاﺀ‬ ‫ﺫلﻚ‬ ‫ﺑﻌد‬ ‫ﺃﺷﻬﺮ‬ ‫ﺳﺘة‬ ‫ﻛل‬ ‫ﺛﻢ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺑدﺀ‬ ‫ﻋﻨد‬ ‫الﻨيﺘﺮﻭﺟﲔ‬ ‫لﻈﻬﻮﺭ‬ ‫اﳌﻌدﻝ‬ .‫الديلزة‬ ‫ﻛفاية‬ ‫اﺧﺘﺒاﺭ‬ ‫ﺗﺄدية‬ ‫الديلزة‬ ‫ﳌﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫الﻨيﺘﺮﻭﺟﲔ‬ ‫لﻈﻬﻮﺭ‬ ‫اﳌﻌدﻝ‬ ‫الﺒﺮﻭﺗيﻨﻲ‬ ‫اﳌﻜاﻓﺊ‬ ‫ﻣﻦ‬ ‫ﺑﻪ‬ ‫اﳌﻮﺻﻰ‬ ‫الﻘدﺭ‬ • ‫قيﻤﺘﻪ‬ ‫ﻣﻦ‬ ‫ﺃﻫﻤية‬ ‫ﺃﻛﺜﺮ‬ ‫الزﻣﻦ‬ ‫ﲟﺮﻭﺭ‬ ‫قيﻤﺘﻪ‬ ‫ﺗﻐيﺮ‬ ‫ﻭلﻜﻦ‬ ،‫ﻏﻢ/ﻛلﻎ/يﻮﻡ‬ ١٫٣ - ١٫٢ ‫ﻫﻮ‬ ‫الصفاقية‬ .‫الﺘﻐﺬية‬ ‫ﺑﺴﻮﺀ‬ ‫اﻹﺻاﺑة‬ ‫ﻋلﻰ‬ ‫ﺗﻨاقصﻪ‬ ‫يدﻝ‬ ‫ﺣيﺚ‬ ‫اﳌﻄلﻘة‬ ‫الﻨاﺟﻢ‬ ‫اليﻮﺭيا‬ ‫ﻧﻘﺺ‬ ‫ﺑﲔ‬ ‫الﺘﻤييز‬ ‫ﻓﻲ‬ ‫ﹰ‬‫ا‬‫ﺃيﻀ‬ ( •nPNA) ‫ﻝ‬‫ﱠ‬‫د‬‫اﳌﻌ‬ ‫الﺒﺮﻭﺗيﻨﻲ‬ ‫اﳌﻜاﻓﺊ‬ ‫ﺣﺴاﺏ‬ ‫فيد‬‫ﹸ‬‫ي‬ .‫الﺘﻐﺬية‬ ‫ﺳﻮﺀ‬ ‫ﻋﻦ‬ ‫الﻨاﺟﻢ‬ ‫اليﻮﺭيا‬ ‫ﻭﻧﻘﺺ‬ ،‫الﺘﻐﺬية‬ ‫ﺣﺴﻦ‬ ‫ﻣﺮيﺾ‬ ‫ﻓﻲ‬ ‫الديلزة‬ ‫ﻛفاية‬ ‫ﻋﻦ‬ ‫لﻈﻬﻮﺭ‬ ‫اﳌﻌدﻝ‬ ‫الﺒﺮﻭﺗيﻨﲔ‬ ‫اﳌﻜاﻓﺊ‬ ‫يﻜﻮﻥ‬ ‫الﺬيﻦ‬ ‫اﳌﺮﺿﻰ‬ ‫ﻣﻦ‬ ‫الﺒﺴيﻂ‬ ‫للﻌدد‬ ‫ﺑالﻨﺴﺒة‬ • ‫ﺑﺘﻘليل‬ ‫ﻭليﺲ‬ ‫الديلزة‬ ‫ﺟﺮﻋة‬ ‫ﺑزيادة‬ ‫ﻫﻲ‬ ‫الصﺤيﺤة‬ ‫اﳌﻌاﳉة‬ ‫ﻓﺈﻥ‬ ،‫ﹰ‬‫ا‬‫ﻣﺮﺗفﻌ‬ ‫لديﻬﻢ‬ ‫الﻨيﺘﺮﻭﺟﲔ‬ .‫الﻐﺬاﺀ‬ ‫ﻓﻲ‬ ‫الﺒﺮﻭﺗﲔ‬ ‫ﻛﻤية‬ ‫ﺍﻟﺘﻐﺬﻳﺔ‬ ‫ﺳﻮﺀ‬ ‫ﻣﻌﺎﳉﺔ‬ :٣-١٠ ‫ﻣدﺧﻮلﻬﻢ‬ ‫ﺑزيادة‬ ‫الﺒﺮﻭﺗﲔ‬ ‫قليل‬ ‫ﹰ‬‫ﺀ‬‫ﻏﺬا‬ ‫يﺘﻨاﻭلﻮﻥ‬ ‫ﹰ‬‫ا‬‫ﺳاﺑﻘ‬ ‫ﻛاﻧﻮا‬ ‫الﺬيﻦ‬ ‫اﳌﺮﺿﻰ‬ ‫ﻧصﺢ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • ‫ﺑﺴﻮﺀ‬ ‫اﻹﺻاﺑة‬ ‫ﻭﻣﻨﻊ‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻓﻲ‬ ‫الﺒﺮﻭﺗﲔ‬ ‫ﻓﻘداﻥ‬ ‫لﺘﻌﻮيﺾ‬ ‫الﺒﺮﻭﺗﲔ‬ ‫ﻣﻦ‬ ‫الﻐﺬاﺋﻲ‬ .‫الﺘﻐﺬية‬ ‫ﻋﻦ‬ ‫يﺒﺤﺚ‬ ‫ﺃﻥ‬ ‫اﳌﺮﺀ‬ ‫ﻋلﻰ‬ ‫ﻓﺈﻥ‬ ‫الﻐﺬاﺋية‬ ‫اﳌﺮيﺾ‬ ‫ﺣالة‬ ‫ﺗدﻫﻮﺭ‬ ‫ﻋلﻰ‬ ‫ﺗدﻝ‬ ‫الﻌﻼﻣاﺕ‬ ‫ﻛاﻧﺖ‬ ‫ﺇﺫا‬ • .‫الﻐﺬاﺋية‬ ‫ﺑاﳌﻜﻤﻼﺕ‬ ‫ﳝدﻩ‬ ‫ﻭﺃﻥ‬ ،‫اﳌﺮيﺾ‬ ‫ﺗﻐﺬية‬ ‫ﺗﻘييﻢ‬ ‫يﻌيد‬ ‫ﻭﺃﻥ‬ ،‫ﻣصاﺣﺒة‬ ‫ﺟديدة‬ ‫ﺃﻣﺮاﺽ‬ ‫ﺃﻧﻪ‬ ‫ﺭﻏﻢ‬ ،‫الديلزة‬ ‫ﺟﺮﻋة‬ ‫ﺯيادة‬ ‫ﻓيﺤﺴﻦ‬ ‫الﺘﻐﺬية‬ ‫لﺴﻮﺀ‬ ‫ﻣﻌﲔ‬ ‫ﺳﺒﺐ‬ ‫ﻋلﻰ‬ ‫الﻌﺜﻮﺭ‬ ‫يﺘﻢ‬ ‫لﻢ‬ ‫ﺇﺫا‬ • .‫الﻐﺬاﺋية‬ ‫اﳊالة‬ ‫ﲢﺴﻦ‬ ‫ﺇلﻰ‬ ‫ﺗﺆدﻱ‬ ‫الديلزة‬ ‫ﺟﺮﻋة‬ ‫ﺯيادة‬ ‫ﺃﻥ‬ ‫الﺜاﺑﺖ‬ ‫ﻣﻦ‬ ‫ليﺲ‬ [(‫)ﻣلﻎ/دﺳل‬ ‫اﶈلﻮﻝ‬ ‫ﻓﻲ‬ ‫اليﻮﺭيا‬ ‫ﺗﺮﻛيز‬ x (‫)دﺳل‬ ‫ﺳاﻋة‬ ٢٤ ‫ﻓﻲ‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﺣﺠﻢ‬ ] [(‫)ﻣلﻎ/دﺳل‬ ‫الﺒﻮﻝ‬ ‫ﻓﻲ‬ ‫اليﻮﺭيا‬ ‫ﺗﺮﻛيز‬ x (‫)دﺳل‬ ‫ﺳاﻋة‬ ٢٤ ‫ﻓﻲ‬ ‫الﺒﻮﻝ‬ ‫]ﺣﺠﻢ‬ + = ‫اليﻮﺭيا‬ ‫ﻇﻬﻮﺭ‬ (‫يﻮﻡ‬ /‫)ﻣلﻎ‬
  • ٨٨ ،‫الﻐﺬاﺋية‬‫اﳊالة‬‫ﻋلﻰ‬‫ﺁﺧﺮ‬‫ﻣفيد‬‫ﻣﺆﺷﺮ‬‫ﻫﻮ‬( •dietaryproteinintake)‫الﻘﻮﺗﻲ‬‫الﺒﺮﻭﺗﲔ‬‫ﻣدﺧﻮﻝ‬ protein equivalent of) ‫الﻨيﺘﺮﻭﺟﲔ‬ ‫لﻈﻬﻮﺭ‬ ‫الﺒﺮﻭﺗيﻨﻲ‬ ‫اﳌﻜاﻓﺊ‬ ‫ﺑاﻋﺘﺒاﺭﻩ‬ ‫ﺗﻘديﺮﻩ‬ ‫ﻭﳝﻜﻦ‬ ‫الﺒﺮﻭﺗﲔ‬ ‫ﺗﻘﻮيﺾ‬ ‫ﲟﻌدﻝ‬ ‫الﺴاﺑﻖ‬ ‫ﻓﻲ‬ ‫يﻌﺮﻑ‬ ‫ﻛاﻥ‬ ‫ﻭالﺬﻱ‬ (nitrogen appearance: PNA ‫الﺒﺮﻭﺗﲔ‬ ‫ﻣدﺧﻮﻝ‬ ‫لﺘﻘديﺮ‬ ‫اﳌﺴﺘﺨدﻣة‬ ‫اﳌﻌادﻻﺕ‬ ‫ﺗفﺘﺮﺽ‬ .(protein catabolic rate: PCR) ‫ﻣﻌدﻝ‬ ‫ﻭﺃﻥ‬ ،‫الﻨيﺘﺮﻭﺟﲔ‬ ‫ﻣﻦ‬ ‫ﻭاﺣد‬ ‫ﻏﺮاﻡ‬ ‫ﻋلﻰ‬ ‫ﲢﺘﻮﻱ‬ ‫الﺒﺮﻭﺗﲔ‬ ‫ﻣﻦ‬ ‫ﹰ‬‫ا‬‫ﻏﺮاﻣ‬ ٦٫٢٥ ‫ﻛل‬ ‫ﺃﻥ‬ ‫الﻘﻮﺗﻲ‬ ‫ﻓﻲ‬ ‫اﳌﺮيﺾ‬ ‫يﻜﻮﻥ‬ ‫ﻋﻨدﻣا‬ ‫اليﻮﻣﻲ‬ ‫الﻨيﺘﺮﻭﺟﲔ‬ ‫ﻣدﺧﻮﻝ‬ ‫يﻌادﻝ‬ ‫للﻨيﺘﺮﻭﺟﲔ‬ ‫اليﻮﻣية‬ ‫اﳋﺴاﺭة‬ .‫ﻧيﺘﺮﻭﺟيﻨﻲ‬ ‫ﺗﻮاﺯﻥ‬ ‫ﺣالة‬ ٧,٣٨ + [ (‫)ﻣلﻎ/يﻮﻡ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﺇﻧﺘاﺝ‬ x ٠٫٠٢٩ ] = (‫)ﻛلﻎ‬ ‫الﻐﺚ‬ ‫اﳉﺴﻢ‬ ‫ﻛﺘلة‬ (‫)ﻣلﻎ/يﻮﻡ‬ ‫اﻻﺳﺘﻘﻼﺑﻲ‬ ‫الﺘدﺭﻙ‬ + (‫)ﻣلﻎ/يﻮﻡ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﺇﻓﺮاﻍ‬ = (‫)ﻣلﻎ/يﻮﻡ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﺇﻧﺘاﺝ‬ [(‫)ﻣلﻎ/دﺳل‬ ‫اﶈلﻮﻝ‬ ‫ﻓﻲ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﺗﺮﻛيز‬ x (‫)دﺳل‬ ‫ﺳاﻋة‬ ٢٤ ‫ﻓﻲ‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫]ﺣﺠﻢ‬ = ‫الﻜﺮياﺗﻨﲔ‬ ‫ﺇﻓﺮاﻍ‬ [(‫)ﻣلﻎ/دﺳل‬ ‫الﺒﻮﻝ‬ ‫ﻓﻲ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﺗﺮﻛيز‬ x (‫)دﺳل‬ ‫ﺳاﻋة‬ ٢٤ ‫ﻓﻲ‬ ‫الﺒﻮﻝ‬ ‫]ﺣﺠﻢ‬ + (‫)ﻣلﻎ/يﻮﻡ‬ (‫)ﻛلﻎ‬ ‫اﳉﺴﻢ‬ ‫ﻭﺯﻥ‬ x (‫)ﻣلﻎ/دﺳل‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ x ٠,٣٨ = (‫)ﻣلﻎ/يﻮﻡ‬ ‫اﻻﺳﺘﻘﻼﺑﻲ‬ ‫الﺘدﺭﻙ‬ {[(‫)ﻛلﻎ‬ ‫الﻐﺚ‬ ‫اﳉﺴﻢ‬ ‫ﻛﺘلة‬ x ٠,٠٣١] + ١,٨١ + (‫)ﻏﻢ/يﻮﻡ‬ ‫اليﻮﺭيا‬ ‫}ﻇﻬﻮﺭ‬ x ٦,٢٥ = ‫الﺒﺮﻭﺗيﻨﻲ‬ ‫اﳌﻜاﻓﺊ‬ ‫الﻨيﺘﺮﻭﺟيﻨﻲ‬ ‫للﻈﻬﻮﺭ‬ (‫)ﻏﻢ/يﻮﻡ‬
  • ٨٧ ‫ﺍﻟﺘﻐﺬﻳﺔ‬ ‫ﺳﻮﺀ‬ ‫ﻣﻌﺎﳉﺔ‬ :١٠ ‫ﻓﺼﻞ‬ ‫ﺍﻷﻫﺪﺍﻑ‬ :١-١٠ ‫لﺴﻮﺀ‬ ‫الفاﻋلة‬ ‫اﳌﻌاﳉة‬ ‫ﻭﺗﺸﺠيﻊ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﳌﺮﺿﻰ‬ ‫الﻐﺬاﺋية‬ ‫اﳊالة‬ ‫ﻣﺮاقﺒة‬ ‫ﺗﺸﺠيﻊ‬ • .‫الﺘﻐﺬية‬ ‫ﺍﻟﻐﺬﺍﺋﻴﺔ‬ ‫ﺍﳊﺎﻟﺔ‬ ‫ﻭﻣﺮﺍﻗﺒﺔ‬ ‫ﺗﻘﻴﻴﻢ‬ :٢-١٠ .‫ﻭاﳌﺮاﺿة‬‫الﻮﻓياﺕ‬‫ﻓﻲ‬‫ﺯيادة‬‫ﻭيصاﺣﺒﻪ‬،‫الصفاقية‬‫الديلزة‬‫ﻣﺮﺿﻰ‬‫ﻋﻨد‬‫ﺷاﺋﻊ‬‫ﺃﻣﺮ‬‫الﺘﻐﺬية‬‫ﺳﻮﺀ‬ • ‫ﻭﻻﺑد‬ ،‫الﺘﻐﺬية‬ ‫ﺳﻮﺀ‬ ‫ﻭﺟﻮد‬ ‫ﻣﻦ‬ ‫للﺘﺤﻘﻖ‬ ‫اﺳﺘﺨداﻣﻪ‬ ‫ﳝﻜﻦ‬ ‫ﻭاﺣد‬ ‫ﻣﻘياﺱ‬ ‫يﻮﺟد‬ ‫ﻻ‬ ‫ﺫلﻚ‬ ‫ﺭﻏﻢ‬ .‫اﳌﻘاييﺲ‬ ‫ﻣﻦ‬ ‫ﻣﺠﻤﻮﻋة‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﻣﻦ‬ ‫اﳊالة‬ ‫ﻋلﻰ‬ ‫للدﻻلة‬ ‫ﺑﺴيﻄة‬ ‫ﻃﺮيﻘة‬ ( •anthropometric measures) ‫الﺒﺸﺮية‬ ‫الﻘياﺳاﺕ‬ ‫ﻣﻨﻄﻘة‬ ‫ﻓﻲ‬ ‫اﳉلد‬ ‫ﻃية‬ ‫ﺛﺨاﻧة‬ ‫ﻣﻦ‬ ‫اﳉﺴﻢ‬ ‫ﻓﻲ‬ ‫الدﻫﻦ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﺗﻘديﺮ‬ ‫ﳝﻜﻦ‬ ‫ﺣيﺚ‬ ،‫الﻐﺬاﺋية‬ ،(infrascapular) ‫الﻜﺘﻒ‬ ‫ﻋﻈﻢ‬ ‫ﲢﺖ‬ ‫اﳌﻮﺟﻮدة‬ ‫اﳌﻨﻄﻘة‬ ‫ﺃﻭ‬ (triceps) ‫الﺮﺅﻭﺱ‬ ‫ﺛﻼﺛية‬ ‫الﻌﻀلة‬ ‫يفﻮﻕ‬ ‫اﳌﺬﻛﻮﺭ‬ ‫اﳌﻘاﺱ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ .‫الﻌﻀﻼﺕ‬ ‫ﻛﺘلة‬ ‫لﺘﻘديﺮ‬ ‫الﺬﺭاﻉ‬ ‫ﻣﺤيﻂ‬ ‫اﺳﺘﺨداﻡ‬ ‫ﳝﻜﻦ‬ ‫ﻛﻤا‬ ٪٧٠ ‫ﺑﲔ‬ ‫اﳌﻘاﺳاﺕ‬ ،‫الﺘﻐﺬية‬ ‫ﻛفاية‬ ‫ﻋلﻰ‬ ‫ﻣﺆﺷﺮ‬ ‫ﻓﻬﺬا‬ ‫الﻄﺒيﻌﻲ‬ ‫اﳌﻘاﺱ‬ ‫ﻣﻦ‬ ٪٩٥ ‫ﻧﺴﺒة‬ ‫اﳌﻘاﺱ‬ ‫ﻣﻦ‬ ٪٧٠ ‫دﻭﻥ‬ ‫ﻭاﳌﻘاﺳاﺕ‬ ،‫الﺘﻐﺬية‬ ‫لﺴﻮﺀ‬ ‫اﺧﺘﻄاﺭ‬ ‫ﻋﻼﻣة‬ ‫الﻄﺒيﻌﻲ‬ ‫اﳌﻘاﺱ‬ ‫ﻣﻦ‬ ٪٩٥‫ﻭ‬ .‫الﺘﻐﺬية‬ ‫ﺳﻮﺀ‬ ‫ﻭﺟﻮد‬ ‫ﻋلﻰ‬ ‫ﺗدﻝ‬ ‫الﻄﺒيﻌﻲ‬ ‫ﻧﻘﺺ‬ .‫ﹰ‬‫ا‬‫ﺷﻬﺮي‬ ‫قياﺳﻪ‬ ‫ﻭيﺠﺐ‬ ‫الﻐﺬاﺋية‬ ‫اﳊالة‬ ‫ﻋلﻰ‬ ‫يدﻝ‬ ‫ﻣفيد‬ ‫ﻣﺆﺷﺮ‬ ‫اﻷلﺒيﻮﻣﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ • ‫ﻋﻼﻣة‬ ‫ﻭلﻜﻨﻪ‬ ‫الﺒﺴيﻂ‬ ‫الﻨﻘصاﻥ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ ‫ﺣﺘﻰ‬ ‫ﺑالﻮﻓياﺕ‬ ‫ﹰ‬‫ا‬‫اﺿﻄﺮادي‬ ‫يﺮﺗﺒﻂ‬ ‫اﻷلﺒيﻮﻣﲔ‬ ‫ﻋﻦ‬ ‫ﹰ‬‫ا‬‫ﻧاﺟﻤ‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫ﳝﻜﻦ‬ ‫ﺃﻧﻪ‬ ‫ﻛﻤا‬ ،‫الﻄﻮيل‬ ‫ﻋﻤﺮﻩ‬ ‫ﻧصﻒ‬ ‫ﺑﺴﺒﺐ‬ ‫الﺘﻐﺬية‬ ‫ﺳﻮﺀ‬ ‫ﻋلﻰ‬ ‫ﻣﺘﺄﺧﺮة‬ .(acute phase response) ‫اﳊاد‬ ‫الﻄﻮﺭ‬ ‫اﺳﺘﺠاﺑة‬ ‫ﺃﻭ‬ ‫الدﻡ‬ ‫ﺣﺠﻢ‬ ‫ﲤدد‬ ‫ﻫﺬا‬ ‫ﻭﻣﻦ‬ ،‫الﻐﺬاﺋية‬ ‫اﳊالة‬ ‫ﻋلﻰ‬ ‫الدﻻلة‬ ‫ﻓﻲ‬ ‫ﻣفيد‬ ‫ﺁﺧﺮ‬ ‫ﻣﺆﺷﺮ‬ ‫ﻫﻮ‬ ‫الﻜﻮليﺴﺘيﺮﻭﻝ‬ ‫ﻣﺴﺘﻮﻯ‬ • ‫الديلزة‬ ‫ﻣﺮﺿﻰ‬ ‫ﻋﻨد‬ ‫ﻭالﻮﻓياﺕ‬ ‫الﻜﻮليﺴﺘيﺮﻭﻝ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﺑﲔ‬ ‫ﻋﻜﺴية‬ ‫ﻋﻼقة‬ ‫ﻫﻨاﻙ‬ ‫اﳌﻨﻄلﻖ‬ .‫الصفاقية‬ ،‫الﻐﺬاﺋية‬ ‫اﳊالة‬ ‫ﻋلﻰ‬ ‫ﺁﺧﺮاﻥ‬ ‫ﻣفيداﻥ‬ ‫ﻣﺆﺷﺮاﻥ‬ ‫ﻫﻤا‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﻭﻣﺴﺘﻮﻯ‬ ‫اليﻮﺭيا‬ ‫ﻣﺴﺘﻮﻯ‬ • ‫ﻓﻲ‬ ‫الﺘدﺭيﺠﻲ‬ ‫ﻭالﻨﻘصاﻥ‬ ،‫الﻮﻓياﺕ‬ ‫ﻓﻲ‬ ‫ﺯيادة‬ ‫يصاﺣﺒﻪ‬ ‫ﻭالﻜﺮياﺗﻨﲔ‬ ‫اليﻮﺭيا‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻓاﻧﺨفاﺽ‬ .‫الﺘﻐﺬية‬ ‫ﺳﻮﺀ‬ ‫ﻋلﻰ‬ ‫دﻻلة‬ ‫ﻣﺴﺘﻮاﻫﻤا‬ ‫ﻭﳝﻜﻦ‬ ،‫الﻐﺬاﺋية‬ ‫اﳊالة‬ ‫ﻋلﻰ‬ ‫ﺁﺧﺮ‬ ‫ﻣفيد‬ ‫ﻣﺆﺷﺮ‬ ‫ﻫﻲ‬ ( •lean body mass) ‫الﻐﺚ‬ ‫اﳉﺴﻢ‬ ‫ﻛﺘلة‬ ‫الﻜﺮياﺗﻨﲔ‬‫ﺃﻥ‬‫ﺣيﺚ‬‫ﺳاﻋة‬٢٤‫ﺧﻼﻝ‬‫اﳋاﺭﺟﲔ‬‫ﻭالﺒﻮﻝ‬‫اﶈلﻮﻝ‬‫ﻓﻲ‬‫الﻜﺮياﺗﻨﲔ‬‫ﻛﻤية‬‫ﻣﻦ‬‫ﺗﻘديﺮﻫا‬ ‫الﻐﺚ‬ ‫اﳉﺴﻢ‬ ‫ﻛﺘلة‬ ‫ﳊﺴاﺏ‬ ‫الﺘالية‬ ‫اﳌﻌادﻻﺕ‬ ‫ﹸﺴﺘﺨدﻡ‬‫ﺗ‬ .‫اﳉﺴﻢ‬ ‫ﻋﻀﻼﺕ‬ ‫ﻛل‬ ‫ﻣﻦ‬ ‫ﺇﻧﺘاﺟﻪ‬ ‫يﺘﻢ‬ metabolic) ‫اﻻﺳﺘﻘﻼﺑﻲ‬ ‫الﺘدﺭﻙ‬ ،(creatinine production) ‫الﻜﺮياﺗﻨﲔ‬ ‫ﺇﻧﺘاﺝ‬ ‫ﺣﺴاﺏ‬ ‫ﺑﻌد‬ .(creatinine excretion) ‫الﻜﺮياﺗﻨﲔ‬ ‫ﻭﺇﻓﺮاﻍ‬ ،(degradation
  • ٨٦ ‫ﺍﻟﻌﻈﻢ‬ ‫ﻣﺮﺽ‬ ‫ﻣﻌﺎﳉﺔ‬ :٥ ‫ﺧﻮﺍﺭﺯﻣﻴﺔ‬
  • ٨٥ ‫ﺍﻟﻔﺼﻞ‬ ‫ﻫﺬﺍ‬ ‫ﻓﻲ‬ ‫ﺫﻛﺮﺕ‬ ‫ﺃﺩﻭﻳﺔ‬ :٢٠ ‫ﺟﺪﻭﻝ‬ ‫الدﻭاﺀ‬ ‫اﺳﻢ‬‫الﺘﺮﻛيﺒة‬‫اﳉﺮﻋة‬ ‫ﺃلفاﻛالﺴيدﻭﻝ‬‫ﻛﺒﺴﻮﻻﺕ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﻜﻐﻢ‬ ١ - ٠٫٢٥ ‫اﻷﳌﻨيﻮﻡ‬ ‫ﻫيدﺭﻭﻛﺴيد‬(‫ﻣلﻎ‬ ٤٧٥) ‫ﻛﺒﺴﻮﻻﺕ‬‫ﺟﺮﻋاﺕ‬ ‫ﻋلﻰ‬ ‫ﻣﻘﺴﻤة‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻛﺒﺴﻮلة‬ ٢٠ - ٤ ‫ﻛالﺴيﺘﺮيﻮﻝ‬،‫ﻛﺒﺴﻮﻻﺕ‬ (‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﺑالفﻢ‬ ‫ﻣﻜﻐﻢ‬ ١ - ٠٫٢٥ ‫ﹰ‬‫ا‬‫ﺃﺳﺒﻮﻋي‬ ‫ﻣﺮاﺕ‬ ‫ﺛﻼﺙ‬ ‫ﺑالﻮﺭيد‬ ‫ﻣﻜﻐﻢ‬ ٨ - ٠٫٥ ‫الﻜالﺴيﻮﻡ‬ ‫ﻛﺮﺑﻮﻧاﺕ‬(‫ﻣلﻎ‬ ٥٠٠) ‫ﺣﺒﻮﺏ‬‫ﺟﺮﻋاﺕ‬ ‫ﻋلﻰ‬ ‫ﻣﻘﺴﻤة‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﺣﺒاﺕ‬ ٧ - ١ (‫الﻮاﺣدة‬ ‫اﳊﺒة‬ ‫ﻓﻲ‬ ‫ﻛالﺴيﻮﻡ‬ ‫ﻣلﻎ‬ ٢٠٠) ‫الﻜالﺴيﻮﻡ‬ ‫ﺃﺳيﺘاﺕ‬(‫)١ﻏﻢ‬ ‫ﺣﺒﻮﺏ‬‫ﺟﺮﻋاﺕ‬ ‫ﻋلﻰ‬ ‫ﻣﻘﺴﻤة‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﺣﺒاﺕ‬ ٦ - ١ (‫الﻮاﺣدة‬ ‫اﳊﺒة‬ ‫ﻓﻲ‬ ‫ﻛالﺴيﻮﻡ‬ ‫ﻣلﻎ‬ ٢٥٠) ‫دﺳفيﺮﻭﻛﺴاﻣﲔ‬‫ﺣﺒﻮﺏ‬ (‫اﳉلد‬ ‫)ﲢﺖ‬ ‫ﺣﻘﻦ‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﺑالفﻢ‬ ‫ﻣﻜﻎ/ﻛلﻎ‬ ٣٠-١٠ ١٢-٨ ‫ﺧﻼﻝ‬ ‫اﳉلد‬ ‫ﲢﺖ‬ ‫ﻣيﻜﺮﻭﻏﺮاﻡ/ﻛلﻎ‬ ٥٠-٢٠ ‫ﹰ‬‫ا‬‫ﺃﺳﺒﻮﻋي‬ ‫ﻣﺮاﺕ‬ ٧-٣ ‫ﺳاﻋة‬ (Fosrenol®) ‫ﻻﻧﺜاﱎ‬(‫ﻣلﻎ‬ ٥٠٠) ‫ﺣﺒﻮﺏ‬‫ﺟﺮﻋاﺕ‬ ‫ﻋلﻰ‬ ‫ﻣﻘﺴﻤة‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﺣﺒاﺕ‬ ٦ - ٣ (Renagel®) ‫ﺳفﻼﻣيﺮ‬(‫ﻣلﻎ‬ ٨٠٠) ‫ﺣﺒﻮﺏ‬‫ﺟﺮﻋاﺕ‬ ‫ﻋلﻰ‬ ‫ﻣﻘﺴﻤة‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﺣﺒة‬ ١٥ - ٣
  • ٨٤ ‫ﺍﻟﻌﻈﻢ‬ ‫ﻣﺮﺽ‬ ‫ﻣﻌﺎﳉﺔ‬ :٧-٩ ‫الديﻨاﻣيﻜﻲ‬ ‫الﻌﻈﻢ‬ ‫)ﻣﺮﺽ‬ ‫الدﺭيﻘاﺕ‬ ‫ﻫﺮﻣﻮﻥ‬ ‫ﻓﺮﻁ‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻮﻥ‬ ‫الﺬيﻦ‬ ‫اﳌﺮﺿﻰ‬ ‫ﻣﻌاﳉة‬ ‫ﲡﺐ‬ • ‫ﻛالﺴيﺘﺮيﻮﻝ‬ :‫)ﻣﺜاﻝ‬ ‫الﻨﺸﻄة‬ ‫د‬ ‫ﻓيﺘاﻣيﻨاﺕ‬ ‫ﻭﺻﻒ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ (‫ﺑدﻭﻧﻬا‬ ‫ﺃﻭ‬ ‫الﺘﻤﻌدﻥ‬ ‫ﻋيﻮﺏ‬ ‫ﻣﻊ‬ ‫ﻧﻘﺺ‬ ‫ﻭﻣﻌاﳉة‬ ‫الﻌﻈﻢ‬ ‫ﻋلﻰ‬ ‫الدﺭيﻘاﺕ‬ ‫ﻫﺮﻣﻮﻥ‬ ‫ﻓﺮﻁ‬ ‫ﺗﺄﺛيﺮ‬ ‫لﻌﻜﺲ‬ (‫ﺃلفاﻛالﺴيدﻭﻝ‬ ‫ﺃﻭ‬ .‫الفﺴفﻮﺭ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻹﻧﻘاﺹ‬ ‫ﺑالﺘدﺧل‬ ‫ﹰ‬‫ا‬‫ﺃيﻀ‬ ‫يﻨصﺢ‬ ‫ﻛﻤا‬ ،‫الﺘﻤﻌدﻥ‬ ‫الﻌﻈﻢ‬ ‫ﻣﻦ‬ ‫ﻋيﻨة‬ ‫ﺃﺧﺬ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﺗﺸﺨيصﻪ‬ ‫ﰎ‬ ‫)الﺬﻱ‬ ‫الﻮاﻫﻦ‬ ‫الﻌﻈﻢ‬ ‫ﻣﺮﺽ‬ ‫ﻣﻌاﳉة‬ ‫ﲡﺐ‬ • ‫الﺴﻤاﺡ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ (‫ﺑيﻜﻮﻏﺮاﻡ/ﻣل‬ ١٠٠ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫الدﺭيﻘاﺕ‬ ‫ﻫﺮﻣﻮﻥ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻛﻮﻥ‬ ‫ﺑﺴﺒﺐ‬ ‫ﺃﻭ‬ ‫ﲢﻘيﻖ‬ ‫ﻭﳝﻜﻦ‬ ،(bone turnover) ‫الﻌﻈﻢ‬ ‫ﺗﻘلﺐ‬ ‫ﻭﺯيادة‬ ‫ﺑاﻻﺭﺗفاﻉ‬ ‫الدﺭيﻘاﺕ‬ ‫ﻫﺮﻣﻮﻥ‬ ‫ﳌﺴﺘﻮﻯ‬ ‫ﺟﺮﻋة‬ ‫ﻭﺇﻧﻘاﺹ‬ ‫الﻜالﺴيﻮﻡ‬ ‫ﻋلﻰ‬ ‫اﶈﺘﻮية‬ ‫الفﺴفﻮﺭ‬ ‫ﳑﺴﻜاﺕ‬ ‫ﺟﺮﻋة‬ ‫ﺇﻧﻘاﺹ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﺫلﻚ‬ .‫ﹰ‬‫ا‬‫ﻣﺆقﺘ‬ ‫ﺇيﻘاﻓﻬﻤا‬ ‫ﺃﻭ‬ ‫الﻨﺸﻄة‬ ‫د‬ ‫ﻓيﺘاﻣيﻨاﺕ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﲡﻨﺐ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫اﻷﳌﻨيﻮﻡ‬ ‫ﺗﺴﻤيﻢ‬ ‫ﻋﻦ‬ ‫الﻨاﰋ‬ ‫الﻌﻈﻢ‬ ‫ﺗلﲔ‬ ‫ﻣﺮﺽ‬ ‫ﻣﻨﻊ‬ ‫ﳝﻜﻦ‬ • ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫ﻋﻼﺟﻪ‬ ‫ﻭﳝﻜﻦ‬ (‫الﺴﻜﺮلفيﺖ‬ ‫ﺫلﻚ‬ ‫ﻓﻲ‬ ‫)ﲟا‬ ‫اﻷﳌﻨيﻮﻡ‬ ‫ﻋلﻰ‬ ‫اﶈﺘﻮية‬ ‫اﳌﺮﻛﺒاﺕ‬ .‫دﺳفيﺮﻭﻛﺴاﻣﲔ‬ ‫ﻣﻌاﳉﺘﻪ‬ ‫ﺗلزﻡ‬ ‫ﻭلﻜﻦ‬ ،‫ﺷاﺋﻊ‬ ‫ﻏيﺮ‬ ‫الفﺴفﻮﺭ‬ ‫ﻧﻘﺺ‬ ‫ﺃﻭ‬ ‫د‬ ‫ﻓيﺘاﻣﲔ‬ ‫ﻧﻘﺺ‬ ‫ﻋﻦ‬ ‫الﻨاﰋ‬ ‫الﻌﻈﻢ‬ ‫ﺗلﲔ‬ • .‫الﺘﻮالﻲ‬ ‫ﻋلﻰ‬ ‫الفﺴفﻮﺭ‬ ‫ﺗﻌﻮيﺾ‬ ‫ﺃﻭ‬ ‫د‬ ‫ﻓيﺘاﻣﲔ‬ ‫ﺗﻌﻮيﺾ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ (parathyroidectomy) ‫ﺍﻟﺪﺭﻳﻘﺎﺕ‬ ‫ﺍﺳﺘﺌﺼﺎﻝ‬ ‫ﺩﻭﺍﻋﻲ‬ :٨-٩ :‫الﺘالية‬ ‫اﳊاﻻﺕ‬ ‫ﻓﻲ‬ ‫الدﺭيﻘاﺕ‬ ‫ﺑاﺳﺘﺌصاﻝ‬ ‫يﻨصﺢ‬ • ‫ﻓﺮﻁ‬ ‫ﺇليﻪ‬ ‫يﺸيﺮ‬ ‫الﺬﻱ‬ ( ١.tertiary hyperparathyroidism) ‫الﺜالﺜﻲ‬ ‫الدﺭيﻘاﺕ‬ ‫ﻓﺮﻁ‬ ‫الﻜالﺴيﻮﻡ‬ ‫ﺃﻣﻼﺡ‬ ‫ﺃﻭ‬ ‫الﻨﺸﻄة‬ ‫د‬ ‫ﻓيﺘاﻣيﻨاﺕ‬ ‫ﺗﻨاﻭﻝ‬ ‫ﻋﻦ‬ ‫الﻨاﰋ‬ ‫ﻏيﺮ‬ ‫الﻜالﺴيﻮﻡ‬ .‫الدﺭيﻘاﺕ‬ ‫ﻫﺮﻣﻮﻥ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﺑاﺭﺗفاﻉ‬ ‫ﺐ‬‫ﹶ‬‫ﻭاﳌصاﺣ‬ ‫ﺗﺜﺒيﻄﻪ‬ ‫ﳝﻜﻦ‬ ‫ﻻ‬ ‫الﺬﻱ‬ ( ٢.secondary hyperparathyroidism) ‫الﺜاﻧﻮﻱ‬ ‫الدﺭيﻘاﺕ‬ ‫ﻓﺮﻁ‬ ‫ﻓﺮﻁ‬ ‫ﻓﻲ‬ ‫الﺘﺴﺒﺐ‬ ‫ﺑدﻭﻥ‬ ‫الﻨﺸﻄة‬ ‫د‬ ‫ﻓيﺘاﻣيﻨاﺕ‬ ‫ﻣﻦ‬ ‫ﻋﻼﺟية‬ ‫ﺟﺮﻋاﺕ‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ .‫الﻜالﺴيﻮﻡ‬ .‫اﳌﺜلﻰ‬ ‫الدﻭاﺋية‬ ‫اﳌﻌاﳉة‬ ‫ﺭﻏﻢ‬ ‫اﳊادﺙ‬ ( ٣.calciphylaxis) ‫الﺘﻜلﺴﻲ‬ ‫الﺘﺄﻕ‬
  • ٨٣ ‫ﺍﻟﻜﺎﻟﺴﻴﻮﻡ‬ ‫ﻧﻘﺺ‬ ‫ﻣﻌﺎﳉﺔ‬ :٥-٩ •secondary) ‫الﺜاﻧﻮﻱ‬ ‫الدﺭيﻘاﺕ‬ ‫ﻓﺮﻁ‬ ‫ﺇلﻰ‬ ‫يﺆدﻱ‬ ‫ﻃﻮيلة‬ ‫لفﺘﺮاﺕ‬ ‫الﻜالﺴيﻮﻡ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻧﻘﺺ‬ ،(bone mineralization) ‫الﻌﻈﻢ‬ ‫ﲤﻌدﻥ‬ ‫ﻋلﻰ‬ ‫ﺳالﺒة‬ ‫ﺗﺄﺛيﺮاﺕ‬ ‫ﻭلﻪ‬ ،(hyperparathyroidism .‫الﻮﻓياﺕ‬ ‫ﻓﻲ‬ ‫ﺑزيادة‬ ‫ﹰ‬‫ا‬‫ﻣصاﺣﺒ‬ ‫يﻜﻮﻥ‬ ‫ﻭقد‬ ،( •paresthesia) ‫اﳌﺬﻝ‬ ‫ﻣﺜل‬ ،‫ﺑﺄﻋﺮاﺽ‬ ‫اﳌﺘﺴﺒﺐ‬ ‫الﻜالﺴيﻮﻡ‬ ‫ﻧﻘﺺ‬ ‫ﲟﻌاﳉة‬ ‫يﻨصﺢ‬ ‫ﻛﻤا‬ ‫ﺗﺸﻨﺞ‬ ‫ﺃﻭ‬ ،(bronchospasm) ‫الﻘصﺒﻲ‬ ‫الﺘﺸﻨﺞ‬ ‫ﺃﻭ‬ ،«‫«ﺗﺮاﻭﺳﻮ‬ ‫ﺃﻭ‬ «‫»ﺗﺸفﻮﺳﺘيﻚ‬ ‫ﻋﻼﻣاﺕ‬ ‫ﺃﻭ‬ .(seizures) ‫الصﺮﻉ‬ ‫ﻧﻮﺑاﺕ‬ ‫ﺃﻭ‬ ،(tetany) ‫الﺘﻜزﺯ‬ ‫ﺃﻭ‬ ،‫اﳊﻨﺠﺮة‬ ‫الﻜالﺴيﻮﻡ‬ ‫ﻛﺮﺑﻮﻧاﺕ‬ ‫ﻣﺜل‬ ‫الﻜالﺴيﻮﻡ‬ ‫ﺃﻣﻼﺡ‬ ‫ﺇﻋﻄاﺀ‬ ‫الﻜالﺴيﻮﻡ‬ ‫ﻧﻘﺺ‬ ‫ﻣﻌاﳉة‬ ‫ﺗﺸﻤل‬ • .‫د‬ ‫ﻓيﺘاﻣﲔ‬ ‫ﻣﻜﻤﻼﺕ‬ ‫ﺃﻭ‬ (‫ﻓاﺭﻏة‬ ‫ﻣﻌدة‬ ‫)ﻋلﻰ‬ ‫ﺍﻟﻌﻈﻢ‬ ‫ﻣﺮﺽ‬ ‫ﺗﻘﻴﻴﻢ‬ :٦-٩ ‫ﺫلﻚ‬ ‫ﻓﻲ‬ ‫ﲟا‬ ،‫الﻌﻈﻢ‬ ‫ﻣﺮﺽ‬ ‫ﻣﻦ‬ ‫ﻣﺨﺘلفة‬ ‫ﺑﺄﻧﻮاﻉ‬ ‫اﳌزﻣﻦ‬ ‫الﻜلﻮﻱ‬ ‫الﻘصﻮﺭ‬ ‫ﻣﺮيﺾ‬ ‫يصاﺏ‬ ‫قد‬ • ‫الليفﻲ‬ ‫الﻌﻈﻢ‬ ‫ﺑالﺘﻬاﺏ‬ ‫اﳌﻌﺮﻭﻑ‬ (dynamic bone disease) ‫الديﻨاﻣيﻜﻲ‬ ‫الﻌﻈﻢ‬ ‫ﻣﺮﺽ‬ ،(adynamic bone disease) ‫الﻮاﻫﻦ‬ ‫الﻌﻈﻢ‬ ‫ﻭﻣﺮﺽ‬ ،(osteitis fibrosa cystica) ‫الﻜيﺴﻲ‬ .(osteomalacia) ‫الﻌﻈاﻡ‬ ‫ﻭﺗلﲔ‬ ‫اﺣﺘﻤاﻝ‬ ‫ﻭﺯيادة‬ ‫الﻌﻈﻢ‬ ‫ﺃلﻢ‬ ‫ﺇلﻰ‬ ‫ﺗﺆدﻱ‬ ‫اﳌزﻣﻦ‬ ‫الﻜلﻮﻱ‬ ‫الﻘصﻮﺭ‬ ‫ﻣﺮﺿﻰ‬ ‫ﻋﻨد‬ ‫الﻌﻈﻢ‬ ‫ﺃﻣﺮاﺽ‬ ‫ﻛل‬ • .‫ﻧﻮﻋﻬا‬ ‫ﻋﻦ‬ ‫الﻨﻈﺮ‬ ‫ﺑﻐﺾ‬ ‫الﻜﺴﻮﺭ‬ ‫ﺣدﻭﺙ‬ ‫ﻫﻮ‬ ‫اﳌزﻣﻦ‬ ‫الﻜلﻮﻱ‬ ‫الﻘصﻮﺭ‬ ‫ﻣﺮﺿﻰ‬ ‫ﻋﻨد‬ ‫الﻌﻈﻢ‬ ‫ﻣﺮﺽ‬ ‫ﻧﻮﻉ‬ ‫لﺘﺤديد‬ ‫ﺗﺸﺨيصﻲ‬ ‫اﺧﺘﺒاﺭ‬ ‫ﺃدﻕ‬ • ‫الﻌيﻨة‬ ‫ﻫﺬﻩ‬ ‫ﺗﻜﻮﻥ‬ ‫ﻻ‬ ‫اﳊاﻻﺕ‬ ‫ﻣﻌﻈﻢ‬ ‫ﻓﻲ‬ .(iliac crest) ‫اﳊﺮقفﻲ‬ ‫الﻌﻈﻢ‬ ‫ﻋﺮﻑ‬ ‫ﻣﻦ‬ ‫ﻋيﻨة‬ ‫ﺃﺧﺬ‬ ‫ﻛﺴﻮﺭ‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻲ‬ ‫الﻜلﻮﻱ‬ ‫الﻘصﻮﺭ‬ ‫ﻣﺮيﺾ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫اﻻﻋﺘﺒاﺭ‬ ‫ﺑﻌﲔ‬ ‫ﺃﺧﺬﻫا‬ ‫يﺠﺐ‬ ‫ﻭلﻜﻦ‬ ،‫ﺿﺮﻭﺭية‬ ‫اﳌﻌﻤلية‬ ‫الفﺤﻮﺻاﺕ‬ ‫ﻧﺘاﺋﺞ‬ ‫ﻛاﻧﺖ‬ ‫ﺇﺫا‬ ‫ﺃﻭ‬ ،‫ﺭﺿﻮﺽ‬ ‫ﻋﻦ‬ ‫ﻧاﲡة‬ ‫ﻏيﺮ‬ ‫ﺃﻭ‬ ‫ﺑﺴيﻄة‬ ‫ﺭﺿﻮﺽ‬ ‫ﻋﻦ‬ ‫ﻧاﲡة‬ .‫اﻷﳌﻨيﻮﻡ‬ ‫ﻋﻦ‬ ‫الﻨاﰋ‬ ‫الﻌﻈﻢ‬ ‫ﻣﺮﺽ‬ ‫ﻭﺟﻮد‬ ‫ﻓﻲ‬ ‫ﺷﻚ‬ ‫ﻫﻨاﻙ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫ﺃﻭ‬ ،‫ﺣاﺳﻤة‬ ‫ﻏيﺮ‬ ‫الﻜلﻮﻱ‬ ‫الﻘصﻮﺭ‬ ‫ﻣﺮﺿﻰ‬ ‫ﻋﻨد‬ ‫الﻌﻈﻢ‬ ‫ﻣﺮﺽ‬ ‫لﺘﻘييﻢ‬ ‫للﻌﻈﻢ‬ ‫الﺸﻌاﻋﻲ‬ ‫ﺑالﺘصﻮيﺮ‬ ‫يﻨصﺢ‬ ‫ﻻ‬ • ‫ﻋﻦ‬ ‫الﻨاﰋ‬ ‫الﻌﻈﻢ‬ ‫ﻣﺮﺽ‬ ‫ﻭﻛﺸﻒ‬ ‫الﺸديد‬ ‫الﻮﻋاﺋﻲ‬ ‫الﺘﻜلﺲ‬ ‫ﻛﺸﻒ‬ ‫ﻓﻲ‬ ‫ﻣفيد‬ ‫ﻭلﻜﻨﻪ‬ ،‫اﳌزﻣﻦ‬ .‫٢-اﳌﻜﺮﻭﻏلﻮﺑﻮلﲔ‬ ‫ﺑيﺘا‬ ‫ﻋﻦ‬ ‫الﻨاﺟﻢ‬ (amyloidosis) ‫الﻨﺸﻮاﻧﻲ‬ ‫الداﺀ‬ ‫الﺸﻌاﻋﻲ‬ ‫ﺑالﺘصﻮيﺮ‬ ‫اﻻﻣﺘصاﺹ‬ ‫قياﺱ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫الﻌﻈﻢ‬ ‫ﲤﻌدﻥ‬ ‫ﻛﺜاﻓة‬ ‫قياﺱ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • ‫ﻋﻮاﻣل‬ ‫ﺃﺣد‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻮﻥ‬ ‫الﺬيﻦ‬ ‫ﺃﻭ‬ ‫ﺑﻜﺴﻮﺭ‬ ‫اﳌصاﺑﲔ‬ ‫اﳌﺮﺿﻰ‬ ‫ﻋﻨد‬ (DEXA scan) ‫الﻄاقة‬ ‫ﻣزدﻭﺝ‬ .(osteoporosis) ‫الﻌﻈﻢ‬ ‫ﺗﺨلﺨل‬ ‫اﺧﺘﻄاﺭ‬
  • ٨٢ ‫ﻣلﻎ‬ •١٠٠٠ - ٨٠٠ ‫قدﺭﻩ‬ ‫ﲟا‬ ‫اﳌﺘﻨاﻭلة‬ ‫الفﺴفﻮﺭ‬ ‫ﻛﻤية‬ ‫ﲢديد‬ ‫ﻫﻲ‬ ‫اﳌﻌاﳉة‬ ‫ﻓﻲ‬ ‫اﻷﻭلﻰ‬ ‫اﳋﻄﻮة‬ ‫ﻣﺸﺮﻭﺑاﺕ‬ ،‫اﻷلﺒاﻥ‬ ‫ﻣﻨﺘﺠاﺕ‬ :‫)ﻣﺜاﻝ‬ ‫ﺑالفﺴفﻮﺭ‬ ‫الﻐﻨية‬ ‫اﻷﻃﻌﻤة‬ ‫ﺗﻨاﻭﻝ‬ ‫ﺗﻘليل‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ،‫ﹰ‬‫ا‬‫يﻮﻣي‬ .(‫ﻭالﺒﻘﻮلياﺕ‬ ،‫اللﺤﻮﻡ‬ ،‫الﻜﺒد‬ ،‫الﻜﻮﻻ‬ ‫ﳑﺴﻜاﺕ‬‫ﺃﺣد‬‫اﺳﺘﻌﻤاﻝ‬‫ﻭﳝﻜﻦ‬،‫الفﺴفﻮﺭ‬‫ﳑﺴﻜاﺕ‬‫ﺑاﺳﺘﻌﻤاﻝ‬‫ﻓيﻨصﺢ‬‫ﹰ‬‫ا‬‫ﻛاﻓي‬‫ﻫﺬا‬‫يﻜﻦ‬‫لﻢ‬‫ﺇﺫا‬ • ،‫ﺳفﻼﻣيﺮ‬‫ﺃﻭ‬،(‫الﻜالﺴيﻮﻡ‬‫ﺳﺘﺮاﺕ‬‫ﺃﻭ‬‫الﻜالﺴيﻮﻡ‬‫)ﻛﺮﺑﻮﻧاﺕ‬‫الﻜالﺴيﻮﻡ‬‫ﻋلﻰ‬‫اﶈﺘﻮية‬‫الفﺴفﻮﺭ‬ .‫ﺛاﻧﻲ‬ ‫ﻋﻼﺟﻲ‬ ‫ﻛﺨياﺭ‬ ‫ﻣﺠﺘﻤﻌة‬ ‫اﺳﺘﻌﻤالﻬا‬ ‫ﳝﻜﻦ‬ ‫ﻛﻤا‬ ،‫ﺃﻭﻝ‬ ‫ﻋﻼﺟﻲ‬ ‫ﻛﺨياﺭ‬ ،‫ﻻﻧﺜاﱎ‬ ‫ﺃﻭ‬ ‫يﺠﺐ‬ ‫ﻭﻻ‬ ،‫الﻮﺟﺒاﺕ‬ ‫ﻣﻊ‬ ‫الﻜالﺴيﻮﻡ‬ ‫ﻋلﻰ‬ ‫اﶈﺘﻮية‬ ‫الفﺴفﻮﺭ‬ ‫ﳑﺴﻜاﺕ‬ ‫اﳌﺮيﺾ‬ ‫يﺘﻨاﻭﻝ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ • ‫ﳑﺴﻜاﺕ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫يﺠﻮﺯ‬ ‫ﻭﻻ‬ ،‫ﹰ‬‫ا‬‫يﻮﻣ‬ ‫ﻣلﻎ‬ ١٥٠٠ ‫قدﺭﻩ‬ ‫ﻣا‬ ‫ﻓيﻬا‬ ‫الﻜالﺴيﻮﻡ‬ ‫ﻛﻤية‬ ‫ﺗﺘﺠاﻭﺯ‬ ‫ﺃﻥ‬ /‫ﺑيﻜﻮﻏﺮاﻡ‬١٥٠‫ﻣﻦ‬‫ﺃقل‬‫الدﺭيﻘاﺕ‬‫ﻫﺮﻣﻮﻥ‬‫ﻣﺴﺘﻮﻯ‬‫ﻛاﻥ‬‫ﺇﺫا‬‫الﻜالﺴيﻮﻡ‬‫ﻋلﻰ‬‫اﶈﺘﻮية‬‫الفﺴفﻮﺭ‬ ‫الﺮﺧﻮة‬ ‫ﺑاﻷﻧﺴﺠة‬ ‫الﺸديد‬ ‫الﺘﻜلﺲ‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻲ‬ ‫اﳌﺮيﺾ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫ﲡﻨﺒﻬا‬ ‫يﺤﺴﻦ‬ ‫ﻛﻤا‬ ،‫ﻣل‬ .(‫ﻋﻨﻬا‬ ‫ﹰ‬‫ا‬‫ﻋﻮﺿ‬ ‫ﺳفﻼﻣيﺮ‬ ‫)اﺳﺘﺨدﻡ‬ ‫الدﻣﻮية‬ ‫اﻷﻭﻋية‬ ‫ﺃﻭ‬ ‫الفﺴفﻮﺭ‬ ‫ﳑﺴﻜاﺕ‬ ‫اﺳﺘﺨداﻡ‬ ‫ﻓيﻤﻜﻦ‬ ‫ﻣلﻎ/دﺳل‬ •٧ ‫ﻣﻦ‬ ‫ﺃﻋلﻰ‬ ‫الفﺴفﻮﺭ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ .‫ﺃﺳاﺑيﻊ‬ ٤ ‫ﺗﺘﺠاﻭﺯ‬ ‫ﻻ‬ ‫قصيﺮة‬ ‫لفﺘﺮة‬ ‫اﻷﳌﻨيﻮﻡ‬ ‫ﻋلﻰ‬ ‫اﶈﺘﻮية‬ ‫ﺗصفية‬ ‫لﺘﺤﺴﲔ‬ ‫الﻄﻮيل‬ ‫اﳌﻜﻮﺙ‬ ‫ﻋلﻰ‬ ‫الﺘﺮﻛيز‬ ‫ﻣﻊ‬ ‫الديلزة‬ ‫ﺟﺮﻋة‬ ‫ﺯيادة‬ ‫ﳝﻜﻦ‬ ‫ﺃﺧيﺮ‬ ‫ﻛﺤل‬ • .‫الفﺴفﻮﺭ‬ ‫ﺩ‬ ‫ﻓﻴﺘﺎﻣﲔ‬ ‫ﻣﻜﻤﻼﺕ‬ :٤-٩ ‫ﺇﻧﻘاﺹ‬ ‫ﺇلﻰ‬ ‫الﻜلﻮﻯ‬ ‫الفﺸل‬ ‫ﳌﺮﺿﻰ‬ ‫الﻨﺸﻂ‬ ‫د‬ ‫ﻓيﺘاﻣﲔ‬ ‫ﻣﻦ‬ ‫ﺻﻐيﺮة‬ ‫ﺟﺮﻋاﺕ‬ ‫ﻭﺻﻒ‬ ‫يﺆدﻱ‬ • bone) ‫اﳌﻌدﻧية‬ ‫الﻌﻈﻢ‬ ‫ﻛﺜاﻓة‬ ‫ﻭﺯيادة‬ ،‫الﻌﻈﻢ‬ ‫ﻧﺴيﺞ‬ ‫ﻭﲢﺴﲔ‬ ،‫الدﺭيﻘاﺕ‬ ‫ﻫﺮﻣﻮﻥ‬ ‫ﻣﺴﺘﻮﻯ‬ .(mieneral density ( •Hydroxycholecalciferol) ‫ﺃلفاﻛالﺴيدﻭﻝ‬ ‫ﻣﺜل‬ ‫الﻨﺸﻄة‬ ‫د‬ ‫ﺑفيﺘاﻣيﻨاﺕ‬ ‫ﺑاﳌﻌاﳉة‬ ‫يﻨصﺢ‬ ‫ﺃﻋلﻰ‬ ‫الدﺭيﻘاﺕ‬ ‫ﻫﺮﻣﻮﻥ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫يﻜﻮﻥ‬ ‫ﻋﻨدﻣا‬ (Dihydroxycholecalciferol) ‫ﻛالﺴيﺘﺮيﻮﻝ‬ ‫ﺃﻭ‬ .‫ﺑيﻜﻮﻏﺮاﻡ/ﻣل‬ ٣٠٠-١٥٠ ‫اﳌﻄلﻮﺏ‬ ‫اﳌﺴﺘﻮﻯ‬ ‫ﺇلﻰ‬ ‫ﺗﻘليلﻪ‬ ‫ﺑﻬدﻑ‬ ،‫ﺑيﻜﻮﻏﺮاﻡ/ﻣل‬ ٣٠٠ ‫ﻣﻦ‬ ‫ﻫﺮﻣﻮﻥ‬ ‫ﻣﺴﺘﻮياﺕ‬ ‫ﺗﻘليل‬ ‫ﻓﻲ‬ ‫ﻛفاﺀة‬ ‫ﺃﻛﺜﺮ‬ ‫الﻨﺸﻄة‬ ‫د‬ ‫لفيﺘاﻣيﻨاﺕ‬ ‫ﺑالﻮﺭيد‬ ‫اﳌﺘﻘﻄﻊ‬ ‫اﳊﻘﻦ‬ • .‫الفﻢ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫اﳌﺴﺘﻤﺮ‬ ‫ﺗﻨاﻭلﻬا‬ ‫ﻣﻦ‬ ‫الدﺭيﻘاﺕ‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫اﳌﺮيﺾ‬ ‫يﺘﻨاﻭلﻬا‬ ‫الﺘﻲ‬ ‫الﻜالﺴيﻮﻡ‬ ‫ﻛﻤية‬ ‫ﺗﺘﺠاﻭﺯ‬ ‫ﻻ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ ،‫الﻜالﺴيﻮﻡ‬ ‫ﻓﺮﻁ‬ ‫لﺘﺠﻨﺐ‬ • ‫ﻓﻲ‬ ‫اﳌﻮﺟﻮد‬ ‫ﻭالﻜالﺴيﻮﻡ‬ ‫الﻐﺬاﺀ‬ ‫ﻓﻲ‬ ‫اﳌﺘﻨاﻭﻝ‬ ‫الﻜالﺴيﻮﻡ‬ ‫ﺫلﻚ‬ ‫ﻓﻲ‬ ‫ﲟا‬ ،‫ﻣلﻎ‬ ٢٠٠٠ ‫قدﺭﻩ‬ ‫ﻣا‬ .‫الﻜالﺴيﻮﻡ‬ ‫ﻋلﻰ‬ ‫اﶈﺘﻮية‬ ‫الفﺴفﻮﺭ‬ ‫ﳑﺴﻜاﺕ‬ ‫يفﻮﻕ‬ ‫اﳌصﺤﺢ‬ ‫الﻜالﺴيﻮﻡ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫الﻨﺸﻄة‬ ‫د‬ ‫ﺑفيﺘاﻣيﻨاﺕ‬ ‫اﳌﻌاﳉة‬ ‫ﻭقﻒ‬ ‫يﺠﺐ‬ • ‫يﻘل‬ ‫الدﺭيﻘاﺕ‬ ‫ﻫﺮﻣﻮﻥ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﺃﻭ‬ ،‫ﻣلﻎ/دﺳل‬ ٦ ‫يفﻮﻕ‬ ‫الفﺴفﻮﺭ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﺃﻭ‬ ،‫ﻣلﻎ/دﺳل‬ ١٠٫٢ .‫ﺑيﻜﻮﻏﺮاﻡ/ﻣل‬ ١٠٠ ‫ﻋﻦ‬
  • ٨١ (bone disease) ‫ﺍﻟﻌﻈﻢ‬ ‫ﻣﺮﺽ‬ ‫ﻣﻌﺎﳉﺔ‬ :٩ ‫ﻓﺼﻞ‬ ‫ﺍﻷﻫﺪﺍﻑ‬ :١-٩ ‫ﻏالﺒية‬ ‫ﻓﻲ‬ ‫الدﺭيﻘاﺕ‬ ‫ﻭﻫﺮﻣﻮﻥ‬ ،‫ﻭالفﺴفﻮﺭ‬ ،‫الﻜالﺴيﻮﻡ‬ ‫ﻣﻦ‬ ‫اﳌﺴﺘﻬدﻓة‬ ‫اﳌﺴﺘﻮياﺕ‬ ‫ﲢﻘيﻖ‬ • ‫ﻭﻓيﺘاﻣﲔ‬ ،‫الفﺴفﻮﺭ‬ ‫ﳌﻤﺴﻜاﺕ‬ ‫الصﺤيﺢ‬ ‫اﻻﺳﺘﻌﻤاﻝ‬ ‫ﺧﻼﻝ‬ ‫ﻣﻦ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺮﺿﻰ‬ .‫الﺘﻜﻤيلﻲ‬ ‫د‬ ‫ﺍﻟﺪﺭﻳﻘﺎﺕ‬ ‫ﻭﻫﺮﻣﻮﻥ‬ ‫ﻭﺍﻟﻔﺴﻔﻮﺭ‬ ‫ﺍﻟﻜﺎﻟﺴﻴﻮﻡ‬ ‫ﻣﻦ‬ ‫ﺍﳌﺴﺘﻬﺪﻓﺔ‬ ‫ﺍﳌﺴﺘﻮﻳﺎﺕ‬ :٢-٩ ‫الفﺴفﻮﺭ‬ ‫ﻣﻦ‬ ‫اﳌﺴﺘﻬدﻑ‬ ‫اﳌﺴﺘﻮﻯ‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ ،‫الصفاقية‬ ‫الديلزة‬ ‫ﳌﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ • ،‫ﻣلﻎ/دﺳل‬ ٩٫٥ - ٨٫٥ ‫الﻜالﺴيﻮﻡ‬ ‫ﻣﻦ‬ ‫اﳌﺴﺘﻬدﻑ‬ ‫اﳌصﺤﺢ‬ ‫ﻭاﳌﺴﺘﻮﻯ‬ ،‫ﻣلﻎ/دﺳل‬ ٥٫٥ - ٣٫٥ /٢‫ﻣلﻎ‬ ٥٥ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫ﻭالفﺴفﻮﺭ‬ ‫الﻜالﺴيﻮﻡ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﺿﺮﺏ‬ ‫ﺣاﺻل‬ ‫ﻣﻦ‬ ‫اﳌﺴﺘﻬدﻑ‬ ‫ﻭاﳌﺴﺘﻮﻯ‬ ٣٠٠ - ١٥٠ (parathyroid hormon) ‫الدﺭيﻘاﺕ‬ ‫ﻫﺮﻣﻮﻥ‬ ‫ﻣﻦ‬ ‫اﳌﺴﺘﻬدﻑ‬ ‫ﻭاﳌﺴﺘﻮﻯ‬ ،٢‫دﺳل‬ .‫ﺑيﻜﻮﻏﺮاﻡ/ﻣل‬ ‫ﻫﺮﻣﻮﻥ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻭقياﺱ‬ ‫ﺷﻬﺮ‬ ‫ﻛل‬ ‫ﻭالفﺴفﻮﺭ‬ ‫الﻜالﺴيﻮﻡ‬ ‫ﻣﺴﺘﻮياﺕ‬ ‫قياﺱ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • ‫اﳌﺬﻛﻮﺭة‬ ‫اﳌﺴﺘﻮياﺕ‬ ‫ﺗﻜﻦ‬ ‫لﻢ‬ ‫ﺇﺫا‬ ‫الﻘياﺱ‬ ‫ﻣﺮاﺕ‬ ‫ﻋدد‬ ‫ﺯيادة‬ ‫ﻭيﺘﻮﺟﺐ‬ ،‫ﺃﺷﻬﺮ‬ ‫ﺛﻼﺛة‬ ‫ﻛل‬ ‫الدﺭيﻘاﺕ‬ ‫اﳌﻌادلة‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ،‫الﻜالﺴيﻮﻡ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫قياﺱ‬ ‫ﻭﻋﻨد‬ ،‫اﳌﺴﺘﻬدﻓة‬ ‫اﳌﺴﺘﻮياﺕ‬ ‫ﺿﻤﻦ‬ :‫اﻷلﺒيﻮﻣﲔ‬ ‫ﻧﻘﺺ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ ‫الﻜالﺴيﻮﻡ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫قياﺱ‬ ‫لﺘصﺤيﺢ‬ ‫الﺘالية‬ ‫الﺮياﺿية‬ ‫ﺍﻟﻔﺴﻔﻮﺭ‬ ‫ﻓﺮﻁ‬ ‫ﻣﻌﺎﳉﺔ‬ :٣-٩ ،‫اﳌزﻣﻦ‬ ‫الﻜلﻮﻱ‬ ‫الﻘصﻮﺭ‬ ‫ﻣﺮﺿﻰ‬ ‫ﻋﻨد‬ ‫ﻭالﻮﻓياﺕ‬ ‫اﳌﺮاﺿة‬ ‫ﻓﻲ‬ ‫ﺯيادة‬ ‫الفﺴفﻮﺭ‬ ‫ﻓﺮﻁ‬ ‫يصاﺣﺐ‬ • ‫ﻋﻦ‬ (secondary hyperparathyroidism) ‫الﺜاﻧﻮﻱ‬ ‫الدﺭيﻘاﺕ‬ ‫ﻓﺮﻁ‬ ‫ﺇلﻰ‬ ‫يﺆدﻱ‬ ‫قد‬ ‫ﺃﻧﻪ‬ ‫ﻛﻤا‬ ‫ﻋلﻰ‬ ‫الﺘﺄﺛيﺮ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﺃﻭ‬ ،(ionized calcium) ‫اﳌﺘﺄيﻦ‬ ‫الﻜالﺴيﻮﻡ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﺇﻧﻘاﺹ‬ ‫ﻃﺮيﻖ‬ ‫ﺑاﻹﺿاﻓة‬ .‫الدﺭيﻘاﺕ‬ ‫ﻫﺮﻣﻮﻥ‬ ‫ﺇﻓﺮاﺯ‬ ‫ﻋلﻰ‬ ‫اﳌﺒاﺷﺮ‬ ‫الﺘﺄﺛيﺮ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﺃﻭ‬ ،‫الﻨﺸﻂ‬ ‫د‬ ‫ﻓيﺘاﻣﲔ‬ ‫ﺇﻧﺘاﺝ‬ ‫الﺮﺧﻮة‬ ‫اﻷﻧﺴﺠة‬ ‫ﺗﻜلﺲ‬ ‫ﻓﻲ‬ ‫يﺘﺴﺒﺐ‬ ‫ﻃﻮيلة‬ ‫ﳌدة‬ ‫الفﺴفﻮﺭ‬ ‫ﻓﺮﻁ‬ ‫اﺳﺘﻤﺮاﺭ‬ ‫ﻓﺈﻥ‬ ‫ﺫلﻚ‬ ‫ﺇلﻰ‬ .‫الﻮﻋاﺋية‬ ‫الﻘلﺒية‬ ‫اﻷﻣﺮاﺽ‬ ‫ﺣدﻭﺙ‬ ‫ﻓﻲ‬ ‫ﻭيﺴاﻫﻢ‬ ‫الدﻣﻮية‬ ‫اﻷﻭﻋية‬ ‫ﻭﺗﻜلﺲ‬ ،‫الﻐﺬاﺀ‬ ‫ﻓﻲ‬ ‫للفﺴفﻮﺭ‬ ‫اﳌفﺮﻁ‬ ‫للﺘﻨاﻭﻝ‬ ‫ﻧﺘيﺠة‬ ‫الفﺴفﻮﺭ‬ ‫ﻓﺮﻁ‬ ‫يﺘفاقﻢ‬ ‫ﺃﻥ‬ ‫اﳌﻤﻜﻦ‬ ‫ﻣﻦ‬ • ،‫اﳌﻮﺻﻮﻓة‬ ‫الديلزة‬ ‫ﺑﺠﺮﻋة‬ ‫اﻻلﺘزاﻡ‬ ‫ﻋدﻡ‬ ‫ﺃﻭ‬ ،‫الفﺴفﻮﺭ‬ ‫ﳑﺴﻜاﺕ‬ ‫ﺑﺘﻨاﻭﻝ‬ ‫اﳌﺮيﺾ‬ ‫الﺘزاﻡ‬ ‫ﻋدﻡ‬ ‫ﺃﻭ‬ ‫ﻣﻦ‬ ‫ﺃﻭ‬ ‫الﺸديد‬ ‫الدﺭيﻘاﺕ‬ ‫ﻓﺮﻁ‬ ‫ﻣﻦ‬ ‫الﻨاﰋ‬ (bone resorption) ‫للﻌﻈﻢ‬ ‫اﳌفﺮﻁ‬ ‫اﻻﺭﺗﺸاﻑ‬ ‫ﺃﻭ‬ .‫د‬ ‫ﻓيﺘاﻣﲔ‬ ‫ﳌﻜﻤﻼﺕ‬ ‫اﳌفﺮﻁ‬ ‫اﻻﺳﺘﻌﻤاﻝ‬ {[(‫)ﻣلﻎ/دﺳل‬ ‫اﻷلﺒيﻮﻣﲔ‬ ‫]٤-ﻣﺴﺘﻮﻯ‬ x ٠٫٨} + (‫)ﻣلﻎ/دﺳل‬ ‫الﻜالﺴيﻮﻡ‬ ‫ﻣﺴﺘﻮﻯ‬ = ‫ﺢ‬‫ﱠ‬‫اﳌصﺤ‬ ‫الﻜالﺴيﻮﻡ‬ ‫ﻣﺴﺘﻮﻯ‬ (‫)ﻣلﻎ/دﺳل‬
  • ٨٠ ‫ﺍﻟﻔﺼﻞ‬ ‫ﻫﺬﺍ‬ ‫ﻓﻲ‬ ‫ﺫﻛﺮﺕ‬ ‫ﺃﺩﻭﻳﺔ‬ :١٩‫ﺟﺪﻭﻝ‬ ‫ﺍﻟﺪﻭﺍﺀ‬ ‫ﺍﺳﻢ‬‫ﺍﻟﺘﺮﻛﻴﺒﺔ‬‫ﺍﳉﺮﻋﺔ‬ ‫اﳊديد‬ ‫ﺳلفاﺕ‬(‫ﻣلﻎ‬ ٢٠٠) ‫ﺣﺒﻮﺏ‬‫ﺳاﻋاﺕ‬ ٨ ‫ﻛل‬ ‫ﻣلﻎ‬ ٢٠٠ ‫اﳊديد‬ ‫ﻏلﻮﻛﻮﻧاﺕ‬(‫ﻣلﻎ‬ ٣٠٠) ‫ﺣﺒﻮﺏ‬‫ﺳاﻋاﺕ‬ ٨ ‫ﻛل‬ ‫ﻣلﻎ‬ ٦٠٠ ‫الدﻛﺴﺘﺮاﻥ‬ ‫ﺣديد‬(‫الﻌﻀل‬ ،‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬‫الﻮاﺣدة‬ ‫اﳉﺮﻋة‬ ‫ﻓﻲ‬ (‫ﻣل‬ ٢) ‫ﻣلﻎ‬ ١٠٠ ‫الﺴﻜﺮﻭﺯ‬ ‫ﺣديد‬‫ﺑالﻮﺭيد‬ ‫ﺣﻘﻦ‬٥ ‫ﺧﻼﻝ‬ ‫ﲢﻘﻦ‬ ،‫الﻮاﺣدة‬ ‫اﳉﺮﻋة‬ ‫ﻓﻲ‬ (‫ﻣل‬ ١٠-٥) ‫ﻣلﻎ‬ ٢٠٠-١٠٠ ‫ﻭﲢﻘﻦ‬ ‫الﻨﻈاﻣﻲ‬ ‫اﳌلﺢ‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻣل‬ ١٠٠ ‫ﻓﻲ‬ ‫ﺗﺨفﻒ‬ ‫ﺃﻭ‬ ‫دقاﺋﻖ‬ ‫دقيﻘة‬ ١٥ ‫ﺧﻼﻝ‬ ‫الﻐلﻮﻛﻮﻧاﺕ‬ ‫ﺣديد‬‫ﺑالﻮﺭيد‬ ‫ﺣﻘﻦ‬١٠٠ ‫ﻓﻲ‬ ‫ﺗﺨفﻒ‬ ،‫الﻮاﺣدة‬ ‫اﳉﺮﻋة‬ ‫ﻓﻲ‬ (‫ﻣل‬ ١٠) ‫ﻣلﻎ‬ ١٢٥ ‫دقيﻘة‬ ٦٠ ‫ﺧﻼﻝ‬ ‫ﻭﲢﻘﻦ‬ ‫الﻨﻈاﻣﻲ‬ ‫اﳌلﺢ‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻣل‬
  • ٧٩ ‫ﺑﺎﻹﺭﻳﺜﺮﻭﺑﻮﻳﺘﲔ‬ ‫ﺍﳌﻌﺎﳉﺔ‬ :٤-٨ .‫ﺑاﳉﺴﻢ‬ ‫اﳊديد‬ ‫ﻣﺨزﻭﻥ‬ ‫ﻛفاية‬ ‫ﻣﻦ‬ ‫الﺘﺄﻛد‬ ‫ﺑﻌد‬ ‫ﺇﻻ‬ ‫ﺑاﻹﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫الﻌﻼﺝ‬ ‫يﺒدﺃ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ ‫ﻻ‬ • ‫ﺫلﻚ‬ ‫ﻷﻥ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺮﺿﻰ‬ ‫ﻓﻲ‬ ‫ﺑالﻮﺭيد‬ ‫ﻭليﺲ‬ ‫اﳉلد‬ ‫ﲢﺖ‬ ‫اﻹﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫ﺣﻘﻦ‬ ‫يفﻀل‬ ‫ﲢﺖ‬ ‫ﺣﻘﻨﻪ‬ ‫ﻷﻥ‬ ‫الﻮﺭيد‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﺇﻻ‬ ( Exprex® ) ‫اﻹيﺒﺮﻛﺲ‬ ‫ﺣﻘﻦ‬ ‫يﺠﻮﺯ‬ ‫ﻻ‬ ‫ﻭلﻜﻦ‬ ،‫ﻭﺃﻭﻓﺮ‬ ‫ﺃﺳﻬل‬ .(pure red cell aplasia) ‫الﻼﺗﻨﺴﺠﻲ‬ ‫الدﻡ‬ ‫ﺑفﻘﺮ‬ ‫اﻷﺣياﻥ‬ ‫ﺑﻌﺾ‬ ‫ﻓﻲ‬ ‫ﺻﻮﺣﺐ‬ ‫اﳉلد‬ ‫ﺑﻌﺾ‬ :‫)ﻣﺜاﻝ‬ ‫اﳉلد‬ ‫ﲢﺖ‬ ‫ﺃﻭ‬ ‫ﺑالﻮﺭيد‬ ‫اﻹﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫ﺣﻘﻦ‬ ‫يﺴﺘﻄيﻌﻮﻥ‬ ‫ﻻ‬ ‫الﺬيﻦ‬ ‫اﳌﺮﺿﻰ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ • .‫ﺃﻋلﻰ‬ ‫ﹰ‬‫ا‬‫ﺟﺮﻋ‬ ‫الﻌادة‬ ‫ﻓﻲ‬ ‫يﺘﻄلﺐ‬ ‫ﻫﺬا‬ ‫ﻭلﻜﻦ‬ ،‫اﳉاﻑ‬ ‫الصفاﻕ‬ ‫داﺧل‬ ‫ﺣﻘﻨﻪ‬ ‫ﳝﻜﻦ‬ (‫اﻷﻃفاﻝ‬ ‫ﻋلﻰ‬ ‫ﻣﻘﺴﻤة‬ ‫ﻭﺣدة/ﻛلﻎ/ﺃﺳﺒﻮﻉ‬ •١٢٠ - ٨٠ ‫اﻹﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫ﻣﻦ‬ ‫اﻷﻭلية‬ ‫اﳉﺮﻋة‬ ‫ﺗﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ ‫يﺤﺘاﺝ‬ ‫ﻣا‬‫ﹰ‬‫ا‬‫ﻏالﺒ‬ ‫ﻭ‬ ،(‫اﻹﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫ﻣﻦ‬ ‫اﳌﺘﻮﻓﺮة‬ ‫الﺘﺮاﻛيز‬ ‫)ﺣﺴﺐ‬ ‫اﻷﺳﺒﻮﻉ‬ ‫ﺧﻼﻝ‬ ‫ﺛﻼﺙ‬ ‫ﺃﻭ‬ ‫ﺟﺮﻋﺘﲔ‬ .(‫ﻭﺣدة/ﻛلﻎ/ﺃﺳﺒﻮﻉ‬ ٣٠٠) ‫ﺃﻛﺒﺮ‬ ‫ﺟﺮﻋاﺕ‬ ‫ﺇلﻰ‬ ‫ﺳﻨﻮاﺕ‬ ٥ ‫ﻋﻦ‬ ‫ﻋﻤﺮﻫﻢ‬ ‫يﻘل‬ ‫الﺬيﻦ‬ ‫اﻷﻃفاﻝ‬ ‫ﺟﺮﻋة‬ ‫ﺯيادة‬ ‫ﻓيﺠﺐ‬ ‫ﺃﺳاﺑيﻊ‬ •٤ - ٢ ‫ﺧﻼﻝ‬ ‫ﻏﻢ/دﺳل‬ ١ ‫ﻣﻦ‬ ‫ﺑﺄقل‬ ‫الﻬيﻤﻮﻏلﻮﺑﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﺯاد‬ ‫ﺇﺫا‬ ‫ﺧﻼﻝ‬ ‫ﻏﻢ/دﺳل‬ ٢٫٥ ‫ﻣﻦ‬ ‫ﺑﺄﻛﺜﺮ‬ ‫الﻬيﻤﻮﻏلﻮﺑﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﺯاد‬ ‫ﺇﺫا‬ ‫ﺃﻣا‬ ،٪٥٠ ‫ﺑﻨﺴﺒة‬ ‫اﻹﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ .٪٥٠-٢٥ ‫ﺑﻨﺴﺒة‬ ‫اﻹﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫ﺟﺮﻋة‬ ‫ﺗﻘليل‬ ‫ﻓيﺠﺐ‬ ‫اﳌﺴﺘﻬدﻑ‬ ‫اﳌﺴﺘﻮﻯ‬ ‫ﲡاﻭﺯ‬ ‫ﺃﻭ‬ ‫ﺃﺳاﺑيﻊ‬ ٤ ‫ﹰ‬‫ا‬‫ﻣﺴﺘﺨدﻣ‬ ،‫ﺫلﻚ‬ ‫ﺃﻣﻜﻨﻪ‬ ‫ﺇﺫا‬ ‫ﺑﻨفﺴﻪ‬ ‫اﻹﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫ﺣﻘﻦ‬ ‫ﻋلﻰ‬ ‫اﳌﺮيﺾ‬ ‫ﺗﺸﺠيﻊ‬ ‫يﺴﺘﺤﺴﻦ‬ • ‫ﳝﻜﻦ‬ .‫الﺒﻄﻦ‬ ‫ﻭﺟداﺭ‬ ‫ﻭالفﺨﺬ‬ ‫الﺬﺭاﻋﲔ‬ ‫ﺃﻋلﻰ‬ ‫ﺑﲔ‬ ‫اﳊﻘﻦ‬ ‫ﻣﻮاقﻊ‬ ‫ﹰ‬‫ا‬‫ﻭﻣدﻭﺭ‬ ‫ﳑﻜﻨة‬ ‫ﺇﺑﺮة‬ ‫ﺃﺻﻐﺮ‬ ‫يﺴﺘﺤﺴﻦ‬ ‫ﺣﲔ‬ ‫ﻓﻲ‬ ،‫ﺃﺳﺒﻮﻋية‬ ‫ﻭاﺣدة‬ ‫ﺣﻘﻨة‬ ‫ﻓﻲ‬ ‫اﻹﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫ﻣﻦ‬ ‫الصﻐيﺮة‬ ‫اﳉﺮﻋاﺕ‬ ‫ﺇﻋﻄاﺀ‬ .‫الﻜﺒيﺮة‬ ‫اﳉﺮﻋاﺕ‬ ‫ﺗﻘﺴيﻢ‬ ،‫ﺣديﺜة‬ ‫ﺟﺮاﺣة‬ ‫ﺃﻭ‬ ،‫ﺑالصﺮﻉ‬ ‫ﺳاﺑﻘة‬ ‫ﺇﺻاﺑة‬ ‫ﻭﺟﻮد‬ ‫اﻹﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﻣﻮاﻧﻊ‬ ‫ﻣﻦ‬ ‫ليﺲ‬ • ‫ﻣﺮاقﺒة‬ ‫ﺗﻜﺜيﻒ‬ ‫ﺑاﻹﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫الﻌﻼﺝ‬ ‫يﺴﺘﻮﺟﺐ‬ ‫ﻻ‬ ‫ﻛﻤا‬ ،‫ﺣديﺚ‬ ‫دﻡ‬ ‫ﻧﻘل‬ ‫ﺃﻭ‬ ،‫ﺣالﻲ‬ ‫ﻣﺮﺽ‬ ‫ﺃﻭ‬ .‫الديلزة‬ ‫ﳌﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫اﳌﻤﻜﻨة‬ ‫اﻷﺳﺒاﺏ‬ ‫ﻋﻦ‬ ‫الﺒﺤﺚ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ‫لﻺﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫الﻜاﻓية‬ ‫اﻻﺳﺘﺠاﺑة‬ ‫ﻋدﻡ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ • ‫الدﺭيﻘاﺕ‬ ‫ﻓﺮﻁ‬ ،(hemolysis) ‫الدﻡ‬ ‫اﻧﺤﻼﻝ‬ ،‫ﻣزﻣﻦ‬ ‫دﻡ‬ ‫ﻓﻘداﻥ‬ ،‫الﺘﻬاﺏ‬ ،‫ﻋدﻭﻯ‬ :‫الﺘالية‬ ‫الﻌﻈﻢ‬ ‫ﻘﻲ‬‫ﹺ‬‫ﻧ‬ ‫ﺗليﻒ‬ ،‫اﻷلﻮﻣﻨيﻮﻡ‬ ‫ﺗﺴﻤيﻢ‬ ،‫الديلزة‬ ‫ﻛفاية‬ ‫ﻋدﻡ‬ ،(hyperparathyroidism) ‫الﻬيﻤﻮﻏلﻮﺑﲔ‬ ‫اﻋﺘﻼﻝ‬ ،(occult malignancy) ‫ﺧفية‬ ‫ﺧﺒاﺛة‬ ،(bone marrow fibrosis) ‫اﺳﺘﻌﻤاﻝ‬ ‫اﻭ‬ ،«١٢‫»ﺏ‬ ‫ﻓيﺘاﻣﲔ‬ ‫ﻧﻘﺺ‬ ،(folic acid) ‫الفﻮﻻﺕ‬ ‫ﻧﻘﺺ‬ ،(hemoglobinopathies) .(ACEi) ‫لﻸﳒﻮﺗﻨﺴﲔ‬ ‫اﶈﻮﻝ‬ ‫اﻹﻧزﱘ‬ ‫ﻣﺜﺒﻄاﺕ‬ ‫ﻣﻦ‬ ‫يﻜﻮﻥ‬ ‫ﻭقد‬ ،‫ﺑاﻹﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫اﳌﻌاﳉة‬ ‫ﺑدﺀ‬ ‫ﺃﺛﻨاﺀ‬ ‫ﹰ‬‫ا‬‫ﺧصﻮﺻ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻣﺮاقﺒة‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • ‫ﺟﺮﻋة‬ ‫ﺇﻧﻘاﺹ‬ ‫ﺑدﻭﻥ‬ ‫ﺃﻭ‬ ‫ﻣﻊ‬ ‫ﺟﺮﻋاﺗﻬا‬ ‫ﺯيادة‬ ‫ﺃﻭ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻣﺨفﻀاﺕ‬ ‫ﻭﺻﻒ‬ ‫ﺑدﺀ‬ ‫الﻀﺮﻭﺭﻱ‬ .‫اﻹﺭيﺜﺮﻭﺑﻮيﺘﲔ‬
  • ٧٨ ‫ﺍﻟﺘﻜﻤﻴﻠﻲ‬ ‫ﺍﳊﺪﻳﺪ‬ :٣-٨ ٪ •٢٠ ‫الﺘﺮاﻧﺴفيﺮيﻦ‬ ‫ﺗﺸﺒﻊ‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫ﻋلﻰ‬ ‫للﻤﺤاﻓﻈة‬ ‫اﳊديد‬ ‫ﻣﻦ‬ ‫يﻜفﻲ‬ ‫ﻣا‬ ‫ﻭﺻﻒ‬ ‫يﺠﺐ‬ ‫ﻓﺮيﺘﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫اﳊديد‬ ‫ﻣﻦ‬ ‫اﳌزيد‬ ‫ﻭﺻﻒ‬ ‫يﺠﻮﺯ‬ ‫ﻭﻻ‬ ،‫ﻧﻐﻢ/ﻣل‬ ١٠٠ ‫الدﻡ‬ ‫ﻓﺮيﺘﲔ‬ ‫ﻭﻣﺴﺘﻮﻯ‬ .٪٥٠ ‫ﻣﻦ‬ ‫ﺃﻋلﻰ‬ ‫الﺘﺮاﻧﺴفﺮيﻦ‬ ‫ﺗﺸﺒﻊ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻛاﻥ‬ ‫ﺃﻭ‬ ‫ﻧﻐﻢ/ﻣل‬ ٨٠٠ ‫ﻣﻦ‬ ‫ﺃﻛﺜﺮ‬ ‫الدﻡ‬ ‫ﺑالﻨﺴﺒة‬ ‫ﺃﺷﻬﺮ‬ ‫ﺛﻼﺛة‬ ‫ﻛل‬ ‫الﺘﺮاﻧﺴفيﺮيﻦ‬ ‫ﻭﺗﺸﺒﻊ‬ ‫الدﻡ‬ ‫ﻓﺮيﺘﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫قياﺱ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • ‫ﻛل‬ ‫الفﺤﺺ‬ ‫ﺇﻋادة‬ ‫ﻣﻦ‬ ‫ﻭﻻﺑد‬ ،‫الﺘﻜﻤيلﻲ‬ ‫اﳊديد‬ ‫ﻣﻦ‬ ‫ﺛاﺑﺘة‬ ‫ﺟﺮﻋاﺕ‬ ‫ﻋلﻰ‬ ‫اﳌﺴﺘﻘﺮيﻦ‬ ‫للﻤﺮﺿﻰ‬ ‫لﺘﻮﻩ‬ ‫ﺑدﺃ‬ ‫قد‬ ‫اﳌﺮيﺾ‬ ‫ﻛاﻥ‬ ‫ﺃﻭ‬ ‫اﳌﻄلﻮﺑة‬ ‫اﳊدﻭد‬ ‫ﺿﻤﻦ‬ ‫اﳊديد‬ ‫ﻣﺆﺷﺮاﺕ‬ ‫ﺗﻜﻦ‬ ‫لﻢ‬ ‫ﺇﺫا‬ ‫اﺛﻨﲔ‬ ‫ﺃﻭ‬ ‫ﺷﻬﺮ‬ .‫ﹰ‬‫ا‬‫ﺣديﺜ‬ ‫ﺟﺮﻋﺘﻪ‬ ‫ﺯاد‬ ‫ﺃﻭ‬ ‫اﻹﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫ﺗﻨاﻭﻝ‬ ‫ﻓﻲ‬ ‫الديلزة‬ ‫ﳌﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫الﻌادة‬ ‫ﻓﻲ‬ ‫ﻛاﻓية‬ ‫الفﻢ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫اﳌﻌﻄاة‬ ‫اﳊديد‬ ‫ﻣﻜﻤﻼﺕ‬ ‫ﺗﻜﻮﻥ‬ • ‫ﺃﻥ‬ ‫ﻛﻤا‬ ،‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ ‫ﻣﻨﻬﻤا‬ ‫ﺃقل‬ ‫الدﻡ‬ ‫ﻭﻓﻘﺮ‬ ‫ﻓﻘداﻥ‬ ‫ﺃﻥ‬ ‫ﺣيﺚ‬ ،‫الصفاقية‬ ‫ﻣﻜﻤﻼﺕ‬ ‫ﻣﻦ‬ ‫ﺗﺮﻛيﺒة‬ ‫ﻭﺃﺭﺧﺺ‬ ‫ﺃﺑﺴﻂ‬ .‫اﳌﺮﺿﻰ‬ ‫لﻬﺆﻻﺀ‬ ‫ﹰ‬‫ا‬‫ﻣﺮيﺤ‬ ‫ليﺲ‬ ‫ﺑالﻮﺭيد‬ ‫اﳊديد‬ ‫ﻭﺻﻒ‬ ‫اﳊديد‬ ‫ﻏلﻮﻛﻮﻧاﺕ‬ ‫ﻭﺻﻒ‬ ‫ﹰ‬‫ا‬‫ﺃيﻀ‬ ‫ﳝﻜﻦ‬ ‫ﻛﻤا‬ ،(ferrous sulphate) ‫اﳊديد‬ ‫ﺳلفاﺕ‬ ‫ﻫﻲ‬ ‫اﳊديد‬ .(ferrous gluconate) ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫اﳌﻌﻄﻰ‬ ‫ﺑاﳊديد‬ ‫الفﻢ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫اﳌﻌﻄﻰ‬ ‫الﺘﻜﻤيلﻲ‬ ‫اﳊديد‬ ‫اﺳﺘﺒداﻝ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • ‫ﺑﺠﺮﻋاﺕ‬ ‫اﳌﺴﺘﻬدﻑ‬ ‫الﻬيﻤﻮﻏلﻮﺑﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻋلﻰ‬ ‫للﻤﺤاﻓﻈة‬‫ﹰ‬‫ا‬‫ﻛاﻓي‬ ‫اﻷﻭﻝ‬ ‫يﻜﻦ‬ ‫لﻢ‬ ‫ﺇﺫا‬ ‫اﳊﻘﻦ‬ ‫ﺣديد‬ ،‫الدﻛﺴﺘﺮاﻥ‬ ‫ﺣديد‬ .(‫ﻭﺣدة/ﻛلﻎ/ﺃﺳﺒﻮﻉ‬ ١٥٠-١٠٠ ‫ﻣﻦ‬ ‫)ﺃقل‬ ‫اﻹﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫ﻣﻦ‬ ‫ﻣﻌﺘدلة‬ ،‫الصفاقية‬ ‫الديلزة‬ ‫ﳌﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫ﻣﺘاﺣة‬ ‫ﺧياﺭاﺕ‬ ‫ﻛلﻬا‬ ‫الﻐلﻮﻛﻮﻧاﺕ‬ ‫ﻭﺣديد‬ ،‫الﺴﻜﺮﻭﺯ‬ .‫اﳌﺮيﺾ‬ ‫اﺳﺘﺠاﺑة‬ ‫ﺣﺴﺐ‬ ‫ﺗﺘدﺭﺝ‬ ‫ﺑﺠﺮﻋاﺕ‬ ‫ﺃﺳﺒﻮﻋية‬ ‫ﺣﻘﻦ‬ ‫ﺷﻜل‬ ‫ﻋلﻰ‬ ‫ﺗﻌﻄﻰ‬ ‫ﲢﻘﻦ‬ ‫ﺃﺷﻬﺮ‬ •٣ - ١ ‫ﻛل‬ ‫ﻣلﻎ‬ ١٠٠٠ - ٥٠٠ ‫ﻛﺒيﺮة‬ ‫ﺑﺠﺮﻋاﺕ‬ ‫الدﻛﺴﺘﺮاﻥ‬ ‫ﺣديد‬ ‫ﻭﺻﻒ‬ ‫ﳝﻜﻦ‬ ‫اﳌلﺤﻲ‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻣل‬ ٢٥٠ ‫قدﺭﻫا‬ ‫ﺑﻜﻤية‬ ‫ﺗﺨفيفﻬا‬ ‫ﺑﻌد‬ ‫ﻛاﻣلة‬ ‫ﺳاﻋة‬ ‫ﺧﻼﻝ‬ ‫ﺑالﻮﺭيد‬ ‫ﻻﺑد‬ (hypersensitivity reaction) ‫الﺘﺤﺴﺲ‬ ‫ﻓﺮﻁ‬ ‫ﺗفاﻋل‬ ‫ﺣدﻭﺙ‬ ‫اﺣﺘﻤاﻝ‬ ‫لﺘﻘليل‬ .‫الﻨﻈاﻣﻲ‬ ‫ﺗﻌﻄﻰ‬ ‫ﻣلﻎ‬ ٢٥ ‫قدﺭﻫا‬ ‫اﺧﺘﺒاﺭية‬ ‫ﺟﺮﻋة‬ ‫الدﻛﺴﺘﺮاﻥ‬ ‫ﺣديد‬ ‫ﻣﻦ‬ ‫ﺑالﻮﺭيد‬ ‫ﺟﺮﻋة‬ ‫ﻛل‬ ‫يﺴﺒﻖ‬ ‫ﺃﻥ‬ ‫ﻣﻦ‬ ‫ﻓﻲ‬ ‫ﻣلﻎ‬ ١٥‫ﻭ‬ ،‫ﻛلﻎ‬ ١٠ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫ﻭﺯﻧﻬﻢ‬ ‫الﺬيﻦ‬ ‫اﻷﻃفاﻝ‬ ‫ﻓﻲ‬ ‫ﻣلﻎ‬ ١٠) ‫الﻮﺭيد‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﺑﺒﻂﺀ‬ ‫اﻷﻭلﻰ‬ ‫اﻻﺧﺘﺒاﺭية‬ ‫اﳉﺮﻋة‬ ‫ﺑﻌد‬ ‫ﺳاﻋة‬ ‫ﳌدة‬ ‫اﳌﺮيﺾ‬ ‫ﻻﺣﻆ‬ .(‫ﻛلﻎ‬ ٢٠ - ١٠ ‫ﻭﺯﻧﻬﻢ‬ ‫الﺬيﻦ‬ ‫اﻷﻃفاﻝ‬ ‫ﻣﺘﻨاﻭﻝ‬ ‫ﻓﻲ‬ ‫اﻷدﺭيﻨالﲔ‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫ﻣﺮاﻋاة‬ ‫ﻣﻊ‬ ‫الﺘالية‬ ‫اﻻﺧﺘﺒاﺭية‬ ‫اﳉﺮﻋاﺕ‬ ‫ﺑﻌد‬ ‫دقيﻘة‬ ١٥ ‫ﻭﳌدة‬ ،‫الدﻛﺴﺘﺮاﻥ‬ ‫ﺣديد‬ ‫ﻣﻦ‬ ‫ﺁﺟل‬ ‫ﻛﺘفاﻋل‬ ‫ﻋﻀلﻲ‬ ‫ﺃﻭ‬ ‫لﻲ‬ ‫ﹺ‬‫ص‬‫ﹾ‬‫ف‬‫ﹶ‬‫ﻣ‬ ‫ﺃلﻢ‬ ‫ﻣﻦ‬ ‫اﳌﺮيﺾ‬ ‫يﺸﻜﻮ‬ ‫قد‬ .‫اليد‬ .‫اﳉﺮﻋة‬ ‫ﺑﺘﻘليل‬ ‫ﺫلﻚ‬ ‫ل‬‫ﹶ‬‫ﺑ‬‫يﻘا‬ ‫ﺃﻥ‬ ‫ﻭيﺠﺐ‬ ‫ﻛﻤا‬ ،‫لﻸﻃفاﻝ‬ ‫ﺑالﻨﺴﺒة‬ ‫الﻐلﻮﻛﻮﻧاﺕ‬ ‫ﻭﺣديد‬ ‫الﺴﻜﺮﻭﺯ‬ ‫ﺣديد‬ ‫ﻭﻛفاية‬ ‫ﺳﻼﻣة‬ ‫ﺑﻌد‬ ‫ﺗﺜﺒﺖ‬ ‫لﻢ‬ • ‫ﺟﺮﻋة‬ ‫الﻐلﻮﻛﻮﻧاﺕ‬ ‫ﺣديد‬ ‫ﺣﻘﻦ‬ ‫ﺗﺴﺒﻖ‬ ‫ﺃﻥ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ .‫ﻛﺒيﺮة‬ ‫ﺟﺮﻋاﺕ‬ ‫ﻓﻲ‬ ‫ﺑﻮﺻفﻬﻤا‬ ‫يﻨصﺢ‬ ‫ﻻ‬ ‫ﺑﻜﻤية‬ ‫ﺗﺨفيفﻬا‬ ‫ﺑﻌد‬ ‫دقيﻘة‬ ٦٠ ‫ﺧﻼﻝ‬ ‫ﲢﻘﻦ‬ ‫ﻣلﻎ‬ ٢٥ ‫قدﺭﻫا‬ ‫ﻭاﺣدة‬ ‫ﳌﺮة‬ ‫ﺗﻌﻄﻰ‬ ‫اﺧﺘﺒاﺭية‬ .‫الﻨﻈاﻣﻲ‬ ‫اﳌلﺤﻲ‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻣل‬ ٥٠ ‫قدﺭﻫا‬ ‫اﳉﺮﻋة‬ ‫ﺗﺘﺠاﻭﺯ‬ ‫لﻢ‬ ‫ﺇﺫا‬ ‫اﳊديد‬ ‫ﺣﻘﻦ‬ ‫ﺇيﻘاﻑ‬ ‫يﺴﺘلزﻡ‬ ‫ﻻ‬ ‫اﳊديد‬ ‫ﳌﺆﺷﺮاﺕ‬ ‫الدقيﻖ‬ ‫الﻘياﺱ‬ ‫ﺇﻥ‬ • ‫ﻻﺑد‬ ‫اﳊديد‬ ‫ﻣﻦ‬ ‫ﻣلﻎ‬ ١٠٠٠-٢٠٠ ‫قدﺭﻫا‬ ‫ﺟﺮﻋاﺕ‬ ‫ﺣﻘﻦ‬ ‫ﺑﻌد‬ ‫ﻭلﻜﻦ‬ ،‫ﻣلﻎ‬ ١٢٥-١٠٠ ‫اﻷﺳﺒﻮﻋية‬ .‫دقيﻘة‬ ‫ﻧﺘاﺋﺞ‬ ‫ﻋلﻰ‬ ‫اﳊصﻮﻝ‬ ‫ﳝﻜﻦ‬ ‫ﺃﻥ‬ ‫قﺒل‬ ‫ﹰ‬‫ا‬‫يﻮﻣ‬ ١٤-٧ ‫ﳌدة‬ ‫اﻻﻧﺘﻈاﺭ‬ ‫ﻣﻦ‬
  • ٧٧ ‫ﺍﻟﺪﻡ‬ ‫ﻓﻘﺮ‬ ‫ﻣﻌﺎﳉﺔ‬ :٨ ‫ﻓﺼﻞ‬ ‫ﺍﻷﻫﺪﺍﻑ‬ :١-٨ ‫ﺧﻼﻝ‬ ‫ﻣﻦ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺮﺿﻰ‬ ‫ﻏالﺒية‬ ‫ﻓﻲ‬ ‫الﻬيﻤﻮﻏلﻮﺑﲔ‬ ‫ﻣﻦ‬ ‫اﳌﻄلﻮﺏ‬ ‫اﳌﺴﺘﻮﻯ‬ ‫ﲢﻘيﻖ‬ • .‫ﻭلﻺﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫الﺘﻜﻤيلﻲ‬ ‫للﺤديد‬ ‫الصﺤيﺢ‬ ‫اﻻﺳﺘﻌﻤاﻝ‬ ‫ﺍﳌﺴﺘﻬﺪﻑ‬ (‫ﺍﻟﺪﻡ‬ ‫)ﺧﻀﺎﺏ‬ ‫ﺍﻟﻬﻴﻤﻮﻏﻠﻮﺑﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ :٢-٨ ‫ﺣﺠﻢ‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫ﻭليﺲ‬ ‫الﻬيﻤﻮﻏلﻮﺑﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫الدﻡ‬ ‫ﻓﻘﺮ‬ ‫ﺗﺸﺨيﺺ‬ ‫يﺠﺐ‬ • ‫اﳌﺴﺘﻬدﻑ‬ ‫الﻬيﻤﻮﻏلﻮﺑﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫ﻭيﺠﺐ‬ ،(hematocrit) ‫اﳌﻜدﺳة‬ ‫اﳊﻤﺮ‬ ‫الﻜﺮياﺕ‬ ،‫اﳌﺴﺘﺸفﻰ‬ ‫دﺧﻮﻝ‬ ‫ﺇلﻰ‬ ‫اﳊاﺟة‬ ‫ﻭﺗﻘليل‬ ،‫اﳌﺮيﺾ‬ ‫ﺣياة‬ ‫ﻓﺮﺹ‬ ‫لﺘﺤﺴﲔ‬ ‫ﻏﻢ/دﺳل‬ ١٢-١١ ‫ﺑﲔ‬ .‫الدﻡ‬ ‫ﻧﻘل‬ ‫ﺇلﻰ‬ ‫اﳊاﺟة‬ ‫ﻭﺗﻘليل‬ ‫ﻣﻦ‬ ‫ﺗزيد‬ ‫ﻏﻢ/دﺳل‬ •١٣ ‫ﺇلﻰ‬ ‫اﳌﺴﺘﻬدﻑ‬ ‫الﻬيﻤﻮﻏلﻮﺑﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﺯيادة‬ ‫ﺃﻥ‬ ‫ﻧﻼﺣﻆ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ .‫اﳌﺮيﺾ‬ ‫ﺣياة‬ ‫ﻋلﻰ‬ ‫اﳋﻄﺮة‬ ‫الﻮﻋاﺋية‬ ‫الﻘلﺒية‬ ‫اﳊﻮادﺙ‬ ‫اﺣﺘﻤاﻻﺕ‬ ‫ﻣﻦ‬ ‫ﺃﻥ‬ ‫ﺇﺫ‬ ،‫ﻓﻘﻂ‬ ‫اﳌﺴﺘﻬدﻑ‬ ‫الﻬيﻤﻮﻏلﻮﺑﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻋلﻰ‬ ‫الدﻡ‬ ‫ﻧﻘل‬ ‫قﺮاﺭاﺕ‬ ‫ﺗﺴﺘﻨد‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ ‫ﻻ‬ • .‫الﻜلﻰ‬ ‫ﺯﺭﻉ‬ ‫يﻨﻮﻭﻥ‬ ‫الﺬيﻦ‬ ‫للﻤﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫ﹰ‬‫ا‬‫ﺧصﻮﺻ‬ ‫الدﻡ‬ ‫ﻧﻘل‬ ‫ﺗﻘليل‬ ‫اﳌﻬﻢ‬ ‫الﻜﺮياﺕ‬ ‫ﻣﻨاﺳﺐ‬ ‫ﻣﻊ‬ ‫الﻜاﻣل‬ ‫الدﻡ‬ ‫ﻓﺤﺺ‬ :‫الﺘالية‬ ‫الفﺤﻮﺻاﺕ‬ ‫ﺇﺟﺮاﺀ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ،‫الﺒدﺀ‬ ‫ﻓﻲ‬ • ،‫ﺑالدﻡ‬ ‫اﳊديد‬ ‫ﻭﻣﺴﺘﻮﻯ‬ ،(reticulocyte) ‫الﺸﺒﻜية‬ ‫الﻜﺮياﺕ‬ ‫ﻭﻋدد‬ ،(red cell indices) ‫اﳊﻤﺮ‬ transferrin)‫الﺘﺮاﻧﺴفﺮيﻦ‬‫ﻭﺗﺸﺒﻊ‬،(ironbindingcapacity)‫ﺑالدﻡ‬‫للﺤديد‬‫الﺮاﺑﻄة‬‫ﻌة‬ ‫ﱠ‬‫ﻭالﺴ‬ ‫ﹰ‬‫ا‬‫ﻭﻣﻀﺮﻭﺑ‬ ‫ﺑالدﻡ‬ ‫للﺤديد‬ ‫الﺮاﺑﻄة‬ ‫الﺴﻌة‬ ‫ﻋلﻰ‬‫ﹰ‬‫ا‬‫ﻣﻘﺴﻮﻣ‬ ‫ﺑالدﻡ‬ ‫اﳊديد‬ ‫)ﻣﺴﺘﻮﻯ‬ (saturation .(occult blood) ‫اﳋفﻲ‬ ‫للدﻡ‬ ‫الﺒﺮاﺯ‬ ‫ﻓﺤﺺ‬ ‫ﻭﻛﺬلﻚ‬ ،‫ﺑالدﻡ‬ ‫الفﺮيﺘﲔ‬ ‫ﻭﻣﺴﺘﻮﻯ‬ ،(١٠٠ ‫ﻓﻲ‬ ‫الﻬيﻤﻮﻏلﻮﺑﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫لﺘﺤﻘيﻖ‬ ‫ﻭاﻹﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫الﺘﻜﻤيلﻲ‬ ‫اﳊديد‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫يﻮﺻﻰ‬ • ‫ﺧﻼﻝ‬ ‫اﻹﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫ﻭﺻﻒ‬ ‫الﻀﺮﻭﺭﻱ‬ ‫ﻣﻦ‬ ‫يﻜﻮﻥ‬ ‫ﻻ‬ ‫قد‬ ‫ﻭلﻜﻦ‬ ،‫ﻋليﻪ‬ ‫ﻭاﶈاﻓﻈة‬ ‫اﳌﺴﺘﻬدﻑ‬ ‫ﻓﻲ‬ ‫يزيد‬ ‫الﻬيﻤﻮﻏلﻮﺑﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﺃﻥ‬ ‫ﺣيﺚ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫لﺒدﺀ‬ ‫اﻷﻭلﻰ‬ ‫الﺜﻼﺛة‬ ‫اﻷﺷﻬﺮ‬ .‫الفﺘﺮة‬ ‫ﻫﺬﻩ‬ ‫ﺧﻼﻝ‬ ‫الﻐالﺐ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﺣﻘﻘﻮا‬ ‫الﺬيﻦ‬ ‫للﻤﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫ﹰ‬‫ا‬‫ﺷﻬﺮي‬ ‫الﻬيﻤﻮﻏلﻮﺑﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻓﺤﺺ‬ ‫يﺠﺐ‬ • ‫ﺣﲔ‬ ‫ﻓﻲ‬ ،‫اﻹﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫ﻣﻦ‬ ‫ﻣﺴﺘﻘﺮة‬ ‫ﺟﺮﻋاﺕ‬ ‫يﺘﻨاﻭلﻮﻥ‬ ‫ﻭالﺬيﻦ‬ ‫اﳌﺴﺘﻬدﻑ‬ ‫الﻬيﻤﻮﻏلﻮﺑﲔ‬ ‫اﻹﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﺑدﺀ‬ ‫ﻋﻨد‬ ‫ﺃﺳﺒﻮﻋﲔ‬ ‫ﻛل‬ ‫الﻬيﻤﻮﻏلﻮﺑﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻓﺤﺺ‬ ‫يﺠﺐ‬ .‫ﺟﺮﻋﺘﻪ‬ ‫ﺗﻐييﺮ‬ ‫ﺃﻭ‬
  • ٧٦ ‫ﺍﻟﻔﺼﻞ‬ ‫ﻫﺬﺍ‬ ‫ﻓﻲ‬ ‫ﺫﻛﺮﺕ‬ ‫ﺃﺩﻭﻳﺔ‬ :١٨ ‫ﺟﺪﻭﻝ‬ ‫ﺍﻟﺪﻭﺍﺀ‬ ‫ﺍﺳﻢ‬‫ﺍﻟﺘﺮﻛﻴﺒﺔ‬‫ﺍﳉﺮﻋﺔ‬ ‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫ﻛلﻮﺭيد‬(‫الصفاﻕ‬ ‫)داﺧل‬ ‫ﺣﻘﻦ‬‫ﻋﺒﻮة‬ ‫ﻓﻲ‬ ‫ﳑﻮﻝ‬ ٢٠) ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ليﺘﺮ‬ ‫ﻛل‬ ‫ﻓﻲ‬ ‫ﳑﻮﻝ‬ ٤-٢ (‫ﻣل‬ ١٠ ‫ﺳﻌة‬ ‫ﺳلﻮﻛﻲ‬(‫ﻣلﻎ‬ ٦٠٠) ‫ﺣﺒﻮﺏ‬‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫ﻣﻦ‬ ‫ﳑﻮﻝ‬ ٨) ‫ﺟﺮﻋاﺕ‬ ‫ﻋلﻰ‬ ‫ﻣﻘﺴﻤة‬ ‫ﺣﺒاﺕ‬ ٦-١ (‫ﺣﺒة‬ ‫ﻛل‬ ‫ﻓﻲ‬ ‫الصﻮديﻮﻡ‬ ‫ﺑيﻜﺮﺑﻮﻧاﺕ‬(‫الصفاﻕ‬ ‫)داﺧل‬ ‫ﺣﻘﻦ‬‫ﻣل‬ ٢٥ ‫ﺳﻌة‬ ‫ﻋﺒﻮة‬ ‫ﻓﻲ‬ ‫ﳑﻮﻝ‬ ٢٥) ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫لﺘﺮ‬ ‫لﻜل‬ ‫ﳑﻮﻝ‬ ٤ (٪٨٫٤ ‫ﺑﺘﺮﻛيز‬
  • ٧٥ (sclerosing encapsulating peritonitis) ‫ﺍﻟﻜﻴﺴﻲ‬ ‫ﺍﻟﺼﻔﺎﻕ‬ ‫ﺗﺼﻠﺐ‬ :١٤-٧ ‫الديلزة‬ ‫اﺳﺘﻤﺮاﺭ‬ ‫ﻋﻦ‬ ‫ﺗﻨﺠﻢ‬ ‫قد‬ ‫الﺘﻲ‬ ‫اﳋﻄيﺮة‬ ‫اﳌﻀاﻋفاﺕ‬ ‫ﺃﺣد‬ ‫ﻫﻮ‬ ‫الﻜيﺴﻲ‬ ‫الصفاﻕ‬ ‫ﺗصلﺐ‬ • ‫ﺗﻜﻮﻥ‬ ‫ﻓﻲ‬ ‫ﻭيﺘﻤﺜل‬ ،‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫اﳌﺘﻜﺮﺭة‬ ‫اﻹﺻاﺑة‬ ‫ﻋﻦ‬ ‫ﺃﻭ‬ ‫ﻃﻮيلة‬ ‫لفﺘﺮاﺕ‬ ‫الصفاقية‬ ‫ﺑﺴﻮﺀ‬ ‫اﻹﺻاﺑة‬ ‫ﺇلﻰ‬ ‫ﻭﻣﺆدية‬ ‫اﻧﺴدادﻫا‬ ‫ﻣﺴﺒﺒة‬ ‫اﻷﻣﻌاﺀ‬ ‫ﺑﻌﺮﻯ‬ ‫ﲢيﻂ‬ ‫ﺛﺨﲔ‬ ‫ﺟداﺭ‬ ‫ﺫاﺕ‬ ‫ﺷﺮﻧﻘة‬ .‫الﺘﻐﺬية‬ ‫الصفاﻕ‬ ‫ﻏﺸاﺀ‬ ‫ﻧﻘل‬ ‫ﺯيادة‬ ‫ﻫﻲ‬ ‫الﻜيﺴﻲ‬ ‫الصفاﻕ‬ ‫ﺗصلﺐ‬ ‫ﺃﻋﺮاﺽ‬ ‫ﺃﻭلﻰ‬ ‫ﺗﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫اﳌﻤﻜﻦ‬ ‫ﻣﻦ‬ • ،‫اﳌﺘﻘﻄﻊ‬ ‫اﻷﻣﻌاﺀ‬ ‫ﻭاﻧﺴداد‬ ،‫اﳊﻤﻰ‬ ‫اﻷﻋﺮاﺽ‬ ‫ﺗﺸﻤل‬ ‫قد‬ ‫ﻛﻤا‬ ،(UF) ‫الﺮاﺷﺢ‬ ‫ﺑﻘلة‬ ‫اﳌصﺤﻮﺑة‬ ‫ﺑﻌد‬ ‫الﻈﻬﻮﺭ‬ ‫ﻓﻲ‬ ‫اﻷﻋﺮاﺽ‬ ‫ﺗﺒدﺃ‬ ‫ﺃﻥ‬ ‫ﹰ‬‫ا‬‫ﺃيﻀ‬ ‫اﳌﻤﻜﻦ‬ ‫ﻣﻦ‬ .‫الﺘﻐﺬية‬ ‫ﻭﺳﻮﺀ‬ ،(ascites) ‫ﻭاﻻﺳﺘﺴﻘاﺀ‬ .‫الدﻣﻮﻱ‬ ‫لﻼﺳﺘصفاﺀ‬ ‫اﳌﺮيﺾ‬ ‫ﲢﻮيل‬ ‫ﻣﻦ‬ ‫ﺃﺷﻬﺮ‬ ‫ﻋدة‬ ‫الﺘصﻮيﺮ‬ ‫ﺃﻭ‬ ‫الﺴيﻨية‬ ‫اﻷﺷﻌة‬ ‫ﺻﻮﺭ‬ ‫ﻓﻲ‬ ‫ﺻفاقية‬ ‫ﺗﻜلﺴاﺕ‬ ‫ﺑﻈﻬﻮﺭ‬ ‫الﺘﺸﺨيﺺ‬ ‫يﺜﺒﺖ‬ • ‫اﳌﻘﻄﻌﻲ‬ ‫الﺘصﻮيﺮ‬ ‫ﻓﻲ‬ ‫اﻷﻣﻌاﺀ‬ ‫ﺟداﺭ‬ ‫ﻓﻲ‬ ‫ﺛﺨاﻧة‬ ‫ﺑﻈﻬﻮﺭ‬ ‫ﺃﻭ‬ ،(CT scan) ‫اﶈﻮﺳﺐ‬ ‫اﳌﻘﻄﻌﻲ‬ .(barium study) ‫الﺒاﺭيﻮﻡ‬ ‫دﺭاﺳة‬ ‫ﺃﻭ‬ ‫اﶈﻮﺳﺐ‬ (‫ﺳيﺮﻭليﻤﺲ‬ ،‫ﺳيﻜلﻮﺳﺒﻮﺭيﻦ‬ ،‫ﺑﺮدﻧﺴلﻮﻥ‬ :‫)ﻣﺜاﻝ‬ ‫اﳌﻨاﻋة‬ ‫ﻛاﺑﺘاﺕ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫الﻌﻼﺝ‬ ‫يﺸﻤل‬ • .‫الليفية‬ ‫الﺸﺮﻧﻘة‬ ‫ﻣﻦ‬ ‫اﻷﻣﻌاﺀ‬ ‫ﻋﺮﻯ‬ ‫لﺘﺨليﺺ‬ ‫اﳉﺮاﺣة‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ ،‫ﺗاﻣﻮﻛﺴيفﲔ‬ ‫ﺃﻭ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻣﺮﻳﺾ‬ ‫ﻓﻲ‬ ‫ﺍﻟﺒﻄﻦ‬ ‫ﺟﺮﺍﺣﺎﺕ‬ :١٥-٧ ‫ﺟﺮاﺣة‬ ‫ﺇﺟﺮاﺀ‬ ‫اﺨﻤﻟﻄﻂ‬ ‫ﻣﻦ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫لﻜﻦ‬ ،‫الﺒﻄﻦ‬ ‫ﺗﻨﻈيﺮ‬ ‫ﻣﻦ‬ ‫الصفاقﻲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻭﺟﻮد‬ ‫ﳝﻨﻊ‬ ‫ﻻ‬ • ‫ﺗﻮقﻊ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ‫ﻛﻤا‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﻣدﺧل‬ ‫ﻣﻦ‬ ‫ﹰ‬‫ا‬‫قﺮيﺒ‬ ‫يﻜﻮﻥ‬ ‫ﻻ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ ‫اﳉﺮاﺣﻲ‬ ‫الﺸﻖ‬ ‫ﻓﺈﻥ‬ ‫ﺑﻄﻨية‬ .‫اﻻلﺘصاقاﺕ‬ ‫ﺇﺯالة‬ ‫ﺇلﻰ‬ ‫اﳊاﺟة‬ ،‫اﳉﺮاﺣة‬ ‫ﺃﺛﻨاﺀ‬ ‫ﻣﻜاﻧﻪ‬ ‫ﻣﻦ‬ ‫ﲢﺮﻛﻪ‬ ‫ﻋدﻡ‬ ‫ﻣﻦ‬ ‫للﺘﺄﻛد‬ ‫اﳉﺮاﺣة‬ ‫ﺃﺛﻨاﺀ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﻮﺿﻊ‬ ‫ﲢديد‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • .‫ﺑاﳋياﻃاﺕ‬ ‫الﻘﺜﻄاﺭ‬ ‫اﺣﺘﺒاﺱ‬ ‫لﺘﺠﻨﺐ‬ ‫اﳉﺮﺡ‬ ‫قفل‬ ‫ﺃﺛﻨاﺀ‬ ‫اﻻﻧﺘﺒاﻩ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ‫ﻛﻤا‬ ‫ﺗﺴﺮﺏ‬ ‫لﺘﺠﻨﺐ‬ ‫ﻣﺒاﺷﺮة‬ ‫للﺠﺮاﺣة‬ ‫الﺘالية‬ ‫الفﺘﺮة‬ ‫ﻓﻲ‬ ‫الدﻣﻮﻱ‬ ‫لﻼﺳﺘصفاﺀ‬ ‫اللﺠﻮﺀ‬ ‫ﻦ‬ ‫ﹸ‬‫يﺤﺴ‬ • ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫قليلة‬ ‫ﻛﻤياﺕ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﻦ‬ ‫ﹸ‬‫ﻓيﺤﺴ‬ ،‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ‫ﻛاﻥ‬ ‫ﻭﺇﺫا‬ ،‫اﶈلﻮﻝ‬ .‫اﻻﺳﺘلﻘاﺀ‬ ‫ﻭﺿﻊ‬ ‫ﻓﻲ‬
  • ٧٤ (hemoperitoneum) ‫ﺍﻟﺼﻔﺎﻕ‬ ‫ﺗﺪﻣﻲ‬ :١٠-٧ ‫اﳌﻮﺟﻮدة‬ ‫الدﻣﻮية‬ ‫اﻷﻭﻋية‬ ‫ﺭﺽ‬ ‫ﻋﻦ‬ ‫ﹰ‬‫ا‬‫ﻧاﺟﻤ‬ ‫الﻌادة‬ ‫ﻓﻲ‬ ‫يﻜﻮﻥ‬ ‫ﻣﺒاﺷﺮة‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﺑﻌد‬ ‫الﻨزﻑ‬ • ‫ليﺘﺮيﻦ‬ ‫ﺟﻌل‬ ‫ﻋلﻰ‬ ‫قادﺭة‬ (‫ﻭاﺣد‬ ‫ﻣليليﺘﺮ‬ ‫ﻣﻦ‬ ‫)ﺃقل‬ ‫الدﻡ‬ ‫ﻣﻦ‬‫ﹰ‬‫ا‬‫ﺟد‬ ‫قليلة‬ ‫ﻛﻤية‬ ‫ﺇﻥ‬ .‫الﺒﻄﻦ‬ ‫ﺟداﺭ‬ ‫ﻓﻲ‬ ‫ﺣﺠﻢ‬ ‫ﻛاﻥ‬ ‫ﻃاﳌا‬‫ﹰ‬‫ﻻ‬‫ﻭﻓﻌا‬‫ﹰ‬‫ا‬‫ﺁﻣﻨ‬ ‫الﺘﺤفﻈﻲ‬ ‫الﻌﻼﺝ‬ ‫يﻜﻮﻥ‬ .‫ﺑالدﻡ‬ ‫ﻣﺨﻀﺒة‬ ‫ﺗﺒدﻭ‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻏﺴل‬ ‫ﺇلﻰ‬ ‫اللﺠﻮﺀ‬ ‫ﳝﻜﻦ‬ ‫ﻛﻤا‬ ،٪٢ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫ﺑاﶈلﻮﻝ‬ (hematocrit) ‫اﳌﻜدﺳة‬ ‫اﳊﻤﺮ‬ ‫الﻜﺮياﺕ‬ .‫الدﻣﻮية‬ ‫اﳉلﻄاﺕ‬ ‫ﺗﻜﻮﻥ‬ ‫ﳌﻨﻊ‬ ‫الﻬيﺒاﺭيﻦ‬ ‫ﺑﻌﺾ‬ ‫ﺇليﻪ‬ ‫اﳌﻀاﻑ‬ ‫الديلزة‬ ‫ﲟﺤلﻮﻝ‬ ‫الصفاﻕ‬ ‫اﳊيﺾ‬‫ﺃﻭ‬،‫لﻺﺑاﺿة‬‫ﻧﺘيﺠة‬‫ﻣﺘﻘﻄﻌة‬‫ﺃﻭقاﺕ‬‫ﻓﻲ‬‫الﻨﺴاﺀ‬‫ﻧصﻒ‬‫ﻣﻦ‬‫ﺃﻛﺜﺮ‬‫الصفاﻕ‬‫ﺗدﻣﻲ‬‫يصيﺐ‬ • .(endometriosis) ‫الﺮﺣﻤﻲ‬ ‫الﺒﻄاﻧﻲ‬ ‫اﻻﻧﺘﺒاﺫ‬ ‫ﺃﻭ‬ ،(retrograde menstruation) ‫الﺮﺟﻮﻋﻲ‬ ‫الصفاﻕ‬ ‫ﻏﺴل‬ ‫ﳝﻜﻦ‬ ‫ﻛﻤا‬ ،‫اﳌﺮيﻀة‬ ‫ﻃﻤﺄﻧة‬ ‫ﻭﳝﻜﻦ‬ ‫ﹰ‬‫ا‬‫ﺗلﻘاﺋي‬ ‫الﻌادة‬ ‫ﻓﻲ‬ ‫ﺗزﻭﻝ‬ ‫اﳊاﻻﺕ‬ ‫ﻫﺬﻩ‬ ‫ﻣﺜل‬ .‫الدﻣﻮية‬ ‫اﳉلﻄاﺕ‬ ‫ﺗﻜﻮﻥ‬ ‫ﳌﻨﻊ‬ ‫الﻬيﺒاﺭيﻦ‬ ‫ﺑﻌﺾ‬ ‫ﺇليﻪ‬ ‫اﳌﻀاﻑ‬ ‫الديلزة‬ ‫ﲟﺤلﻮﻝ‬ ،( •renal cyst) ‫ﻛلﻮية‬ ‫ﻛيﺴة‬ ‫ﲤزﻕ‬ ‫ﻣﻦ‬ ‫ﺳﺒﻖ‬ ‫ﻣا‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ ‫الصفاﻕ‬ ‫ﺗدﻣﻲ‬ ‫يﻨﺠﻢ‬ ‫ﺃﻥ‬ ‫ﳝﻜﻦ‬ ‫ﺃﻱ‬ ‫ﺃﻭ‬ ،(sclerosing encapsulating peritonitis) ‫الﻜيﺴﻲ‬ ‫الصفاﻕ‬ ‫ﺗصلﺐ‬ ‫ﺃﻭ‬ ،‫ﻛلﻮﻱ‬ ‫ﻭﺭﻡ‬ ‫ﺃﻭ‬ .‫الصفاقية‬ ‫ﺑالديلزة‬ ‫لﻪ‬ ‫ﻋﻼقة‬ ‫ﻻ‬ ‫ﺁﺧﺮ‬ ‫ﻣﺮﺿﻲ‬ ‫ﺳﺒﺐ‬ (gastroesophageal reflux) ‫ﺍﳌﺮﻳﺌﻲ‬ ‫ﺍﳌﻌﺪﻱ‬ ‫ﺍﳉﺰﺭ‬ :١١-٧ ‫اﳌﺮيﺾ‬ ‫ﻣﻨﻬا‬ ‫يﺸﻜﻮ‬ ‫الﺘﻲ‬ ‫الﻌلﻮية‬ ( •gastrointestinal) ‫اﳌﻌﻮية‬ ‫اﳌﻌدية‬ ‫اﻷﻋﺮاﺽ‬ ‫ﺗﻜﻮﻥ‬ ‫قد‬ ‫ﻝ‬‫ﹶ‬‫ز‬‫ﺧﹶ‬ ‫ﻣﻦ‬ ‫ﺃﻭ‬ (gastroesophageal reflux) ‫اﳌﺮيﺌﻲ‬ ‫اﳌﻌدﻱ‬ ‫اﳉزﺭ‬ ‫ﻣﻦ‬ ‫ﻧاﺟﻤة‬ ‫الديلزة‬ ‫ﻛفاية‬ ‫ﺭﻏﻢ‬ ‫ﻭﺗﻐﺬية‬ ‫ﻋاﻓية‬ ‫ﻋلﻰ‬ ‫ﺿاﺭة‬ ‫ﺁﺛاﺭ‬ ‫ﺇلﻰ‬ ‫اﻷﻋﺮاﺽ‬ ‫ﻫﺬﻩ‬ ‫ﺗﺆدﻱ‬ ‫ﺃﻥ‬ ‫ﻭﳝﻜﻦ‬ ،(gastroparesis) ‫اﳌﻌدة‬ ‫ﺃﺛﻨاﺀ‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻛﻤية‬ ‫ﺗﻘليل‬ ‫اﳌﻌاﳉة‬ ‫ﺗﺸﻤل‬ ،‫الﻌاﻣة‬ ‫الﺘداﺑيﺮ‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ .‫اﳌﺮيﺾ‬ .‫اﻻﺳﺘلﻘاﺀ‬ ‫ﻭﺿﻌية‬ ‫ﺍﻟﻈﻬﺮ‬ ‫ﺃﻟﻢ‬ :١٢-٧ ‫الديلزة‬ ‫ﻣﺮﺿﻰ‬ ‫ﺑﲔ‬ ‫ﺷاﺋﻊ‬ ( •lumbar spine) ‫ة‬‫ﱠ‬‫ي‬‫ﹺ‬‫ﻨ‬ ‫ﹶ‬‫ﹶﻄ‬‫ﻘ‬‫ال‬ ‫ﻘﺮاﺕ‬‫ﹺ‬‫ف‬‫ال‬ ‫ﻋلﻰ‬ ‫اﳌيﻜاﻧيﻜﻲ‬ ‫اﻹﺟﻬاد‬ ‫ﺯيادة‬ ‫الﺘداﺑيﺮ‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻛﻤية‬ ‫ﺗﻘليل‬ ‫اﳌﻌاﳉة‬ ‫ﻭﺗﺸﻤل‬ ،‫الصفاقية‬ .‫الﻌاﻣة‬ ‫الﻌﻼﺟية‬ (electrolyte abnormalities) ‫ﺍﻟﻜﻬﺎﺭﻝ‬ ‫ﺷﺬﻭﺫ‬ :١٣-٧ ‫ﺑﺴﺒﺐ‬ ‫ﺫلﻚ‬ ‫يﻜﻮﻥ‬ ‫ﻭﺭﲟا‬ ،‫الدﻡ‬ ‫ﺑﻮﺗاﺳيﻮﻡ‬ ‫ﺑﻨﻘﺺ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺮﺿﻰ‬ ‫ﺛلﺚ‬ ‫قﺮاﺑة‬ ‫يصاﺏ‬ • ‫ﺣاﻻﺕ‬ ‫ﻓﻲ‬ .‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻓﻲ‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫ﺗﺄﺛيﺮ‬ ‫ﻋﻦ‬ ‫الﻨاﺟﻢ‬ ‫اﳋﻼيا‬ ‫ﺇلﻰ‬ ‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫دﺧﻮﻝ‬ ‫ﻛﻤا‬ ،‫ﺑالﺒﻮﺗاﺳيﻮﻡ‬ ‫اﳌﺘﻌلﻘة‬ ‫الﻐﺬاﺋية‬ ‫الﻘيﻮد‬ ‫ﻣﻦ‬ ‫اﳌﺮيﺾ‬ ‫ﲢﺮيﺮ‬ ‫ﻋادة‬ ‫يﻜفﻲ‬ ،‫اﳋفيﻒ‬ ‫الﻨﻘﺺ‬ ‫ﻛلﻮﺭيد‬ ،‫ﺳلﻮﻛﻲ‬ :‫)ﻣﺜاﻝ‬ ‫الصفاﻕ‬ ‫داﺧل‬ ‫ﺑاﳊﻘﻦ‬ ‫ﺃﻭ‬ ‫الفﻢ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫ﺇﻋاﺿة‬ ‫ﳝﻜﻦ‬ .‫الﻀﺮﻭﺭة‬ ‫ﺣالة‬ ‫ﻓﻲ‬ (‫الﺒﻮﺗاﺳيﻮﻡ‬ ‫الﻌالﻲ‬ ‫للﺘﺮﻛيز‬ ‫ﻧﺘيﺠة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺮﺿﻰ‬ ‫ﺑﲔ‬ ‫ﹰ‬‫ا‬‫ﺃيﻀ‬ ‫ﺷاﺋﻊ‬ ‫الدﻡ‬ ‫ﻣﻐﻨيزيﻮﻡ‬ ‫ﻓﺮﻁ‬ • .‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻓﻲ‬ ‫للﻤﻐﻨيزيﻮﻡ‬ ‫ﹰ‬‫ا‬‫ﻧﺴﺒي‬
  • ٧٣ ‫ﺍﶈﻠﻮﻝ‬ ‫ﺗﺪﻓﻖ‬ ‫ﻋﻨﺪ‬ ‫ﺍﻷﻟﻢ‬ :٦-٧ ‫اﻷلﻢ‬ ‫ﻫﺬا‬ ‫يﺘﻼﺷﻰ‬ ‫ﺛﻢ‬ ‫الصفاﻕ‬ ‫داﺧل‬ ‫اﶈلﻮﻝ‬ ‫ﺗدﻓﻖ‬ ‫ﺃﺛﻨاﺀ‬ ‫ﺑاﻷلﻢ‬ ‫اﳌﺮﺿﻰ‬ ‫ﻣﻦ‬ ‫ﻛﺜيﺮ‬ ‫يﺸﻌﺮ‬ • ‫اﶈﺘﻮﻱ‬ ‫الﺘﻘليدﻱ‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﺣﻤﻮﺿة‬ ‫ﻋﻦ‬ ‫ﹰ‬‫ا‬‫ﻧاﺟﻤ‬ ‫ﻫﺬا‬ ‫يﻜﻮﻥ‬ ‫قد‬ ،‫اﳌﻜﻮﺙ‬ ‫ﻓﺘﺮة‬ ‫ﺃﺛﻨاﺀ‬ ‫اﻷﺣﺸاﺀ‬ ‫ﻷﺣد‬ ‫ﻃﺮﻓﻪ‬ ‫ﻭﻣﻼﻣﺴة‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺗﻮﺿﻊ‬ ‫ﺳﻮﺀ‬ ‫ﻋﻦ‬ ‫ﺃﻭ‬ ،(lactate) ‫الﻼﻛﺘاﺕ‬ ‫ﻋلﻰ‬ .‫اﶈلﻮﻝ‬ ‫ﻓﻲ‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫ﺗﺮﻛيز‬ ‫اﺭﺗفاﻉ‬ ‫ﻋﻦ‬ ‫ﺃﻭ‬ ،(somatic peritoneum) ‫اﳉﺴدﻱ‬ ‫للصفاﻕ‬ ‫ﺃﻭ‬ ‫اﳌﻌاﳉة‬ ‫ﻭﺧياﺭاﺕ‬ ،‫ﻭﺟيزة‬ ‫ﺑفﺘﺮة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺑدﺀ‬ ‫ﺑﻌد‬ ‫الﻌادة‬ ‫ﻓﻲ‬ ‫اﳌﺸﻜلة‬ ‫ﻫﺬﻩ‬ ‫ﺗزﻭﻝ‬ • ‫ﺳﺮﻋة‬ ‫ﺇﺑﻄاﺀ‬ ‫ﺃﻭ‬ ،‫الديلزة‬ ‫ﻛيﺲ‬ ‫ﺇلﻰ‬ ‫ﻣﻮﺿﻌﻲ‬ ‫ﻣﺨدﺭ‬ ‫ﺃﻭ‬ ‫الصﻮديﻮﻡ‬ ‫ﺑيﻜﺮﺑﻮﻧاﺕ‬ ‫ﺇﺿاﻓة‬ ‫ﺗﺸﻤل‬ ‫الديلزة‬ ‫ﺇيﻘاﻑ‬ ‫ﺃﻭ‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﺗﻐييﺮ‬ ‫ﺃﻭ‬ ،‫ﻛاﻣلة‬ ‫ﺑصﻮﺭة‬ ‫اﶈلﻮﻝ‬ ‫ﺗصﺮيﻒ‬ ‫ﻋدﻡ‬ ‫ﺃﻭ‬ ،‫اﶈلﻮﻝ‬ ‫ﺗدﻓﻖ‬ .‫الصفاقية‬ (cuff extrusion) ‫ﺍﻟﻘﺜﻄﺎﺭ‬ ‫ﻛﻔﺔ‬ ‫ﺑﺜﻖ‬ :٧-٧ ‫الﻜفة‬ ‫ﻭﺿﻊ‬ ‫ﻣﻦ‬ ‫ﺃﻭ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋدﻭﻯ‬ ‫ﻣﻦ‬ ‫ﹰ‬‫ا‬‫ﻧاﺟﻤ‬ ‫اﳉلد‬ ‫ﻋﺒﺮ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻛفة‬ ‫ﺑﺜﻖ‬ ‫يﻜﻮﻥ‬ ‫قد‬ • .‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻣﻦ‬‫ﹰ‬‫ا‬‫ﺟد‬ ‫قﺮيﺐ‬ ‫ﻣﻜاﻥ‬ ‫ﻓﻲ‬ ‫الﺴﻄﺤية‬ ‫ﻓﺈﻧﻪ‬ ‫ﺫلﻚ‬ ‫ﺑﺨﻼﻑ‬ ،‫الﺘﺤفﻈﻲ‬ ‫الﻌﻼﺝ‬ ‫ﲡﺮيﺐ‬ ‫ﻓيﻤﻜﻦ‬ ‫الﻌدﻭﻯ‬ ‫ﻋلﻰ‬ ‫دﻻلة‬ ‫ﻫﻨاﻙ‬ ‫ﺗﻜﻦ‬ ‫لﻢ‬ ‫ﺇﺫا‬ • ‫ﻋﻼﻣاﺕ‬ ‫ﺑﻘيﺖ‬ ‫ﻭﺇﺫا‬ ،‫الﺘﻌﻘيﻢ‬ ‫ﻣﺮاﻋاة‬ ‫ﻣﻊ‬ ‫اﳌﻮﺿﻌﻲ‬ ‫الﺘﺨديﺮ‬ ‫ﲢﺖ‬ ‫الﻨاﺗﺌة‬ ‫الﻜفة‬ ‫ﺇﺯالة‬ ‫يﺘﻮﺟﺐ‬ .‫الﻘﺜﻄاﺭ‬ ‫ﺇﺯالة‬ ‫ﻣﻦ‬ ‫ﻓﻼﺑد‬ ‫ﺫلﻚ‬ ‫ﺑﻌد‬ ‫اﻻلﺘﻬاﺏ‬ ‫ﺍﳌﺜﺎﻧﺔ‬ ‫ﺛﻘﺐ‬ :٨-٧ ‫اﳌﺮيﺾ‬ ‫يﺸﻌﺮ‬ ‫ﻋﻨدﻣا‬ ‫ﺃﻭ‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﻋﺒﺮ‬ ‫الﺒﻮﻝ‬ ‫ﺗصﺮيﻒ‬ ‫يﺘﻢ‬ ‫ﻋﻨدﻣا‬ ‫اﳌﺜاﻧة‬ ‫ﺛﻘﺐ‬ ‫ﺗﺸﺨيﺺ‬ ‫ﳝﻜﻦ‬ • .‫الﻘﺜﻄاﺭ‬ ‫داﺧل‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﺗدﻓﻖ‬ ‫ﺑﻌد‬ ‫الﺘﺒﻮﻝ‬ ‫ﻓﻲ‬ ‫ﻣلﺤة‬ ‫ﺑﺮﻏﺒة‬ .‫ﺃياﻡ‬ ‫لﻌدة‬ ‫اﳌﺜاﻧة‬ ‫ﻭقﺜﻄﺮة‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺗﻐييﺮ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫اﳌﻌاﳉة‬ ‫ﺗﺘﻢ‬ • ‫ﺍﻷﻣﻌﺎﺀ‬ ‫ﺛﻘﺐ‬ :٩-٧ ‫ﺗﺂﻛل‬ ‫ﻣﻦ‬ ‫يﻨﺠﻢ‬ ‫ﺃﻭ‬ ،‫ﻣﺒاﺷﺮة‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﻋﻤلية‬ ‫ﺃﺛﻨاﺀ‬ ‫ﺭﺿﻬا‬ ‫ﻣﻦ‬ ‫اﻷﻣﻌاﺀ‬ ‫ﺛﻘﺐ‬ ‫يﻨﺘﺞ‬ ‫قد‬ • ‫قد‬ ‫ﻭلﻜﻨﻪ‬ ‫اﳊدﻭﺙ‬ ‫ﻧادﺭ‬ ‫اﻷﻣﺮ‬ ‫ﻫﺬا‬ .‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﻣﻦ‬ ‫ﺷﻬﻮﺭ‬ ‫ﺃﻭ‬ ‫ﺃﺳاﺑيﻊ‬ ‫ﺑﻌد‬ ‫اﳊادﺙ‬ ‫اﻷﻣﻌاﺀ‬ .‫ﺳﺮيﻌة‬ ‫ﻣﻌاﳉة‬ ‫ﺇلﻰ‬ ‫ﻭيﺤﺘاﺝ‬ ‫اﳌﺮيﺾ‬ ‫ﺣياة‬ ‫يﻬدد‬ ‫ﻣﺤلﻮﻝ‬ ‫اﺣﺘﻮاﺀ‬ ‫ﻋليﻪ‬ ‫الدالة‬ ‫الﻌﻼﻣاﺕ‬ ‫ﻭﺗﺸﻤل‬ ،‫الﺸﻚ‬ ‫ﻣﻦ‬ ‫ﹴ‬‫ﻋاﻝ‬ ‫قدﺭ‬ ‫ﺇلﻰ‬ ‫الﺘﺸﺨيﺺ‬ ‫يﺤﺘاﺝ‬ • ‫ﺑﻌد‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫ﻣﻦ‬ ‫ﻋالية‬ ‫ﻧﺴﺒة‬ ‫ﻋلﻰ‬ ‫يﺤﺘﻮﻱ‬ ‫ﺑﺈﺳﻬاﻝ‬ ‫اﻹﺻاﺑة‬ ‫ﺃﻭ‬ ،‫ﺑﺮاﺯية‬ ‫ﻣادة‬ ‫ﻋلﻰ‬ ‫الﺘصﺮيﻒ‬ ‫ﻋدة‬ ‫ﻋﻦ‬ ‫الﻨاﺟﻢ‬ ‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫اﻹﺻاﺑة‬ ‫ﺃﻭ‬ ،‫الصفاﻕ‬ ‫ﲡﻮيﻒ‬ ‫داﺧل‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﺗدﻓﻖ‬ .‫الﻐﺮاﻡ‬ ‫ﺳالﺒة‬ ‫ﺟﺮاﺛيﻢ‬ ،‫الﻮﺭيد‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫اﳊيﻮية‬ ‫اﳌﻀاداﺕ‬ ‫ﻭﺇﻋﻄاﺀ‬ ،‫الصفاقية‬ ‫الديلزة‬ ‫ﺇيﻘاﻑ‬ ‫اﳌﻌاﳉة‬ ‫ﺗﺸﻤل‬ • .‫اﳌﺜﻘﻮﺏ‬ ‫اﳊﺸﻰ‬ ‫ﻭﺗصليﺢ‬ ‫لﺘﺤديد‬ ‫ﹰ‬‫ا‬‫ﺟﺮاﺣي‬ ‫الصفاﻕ‬ ‫ﲡﻮيﻒ‬ ‫ﻭاﺳﺘﻜﺸاﻑ‬
  • ٧٢ ‫ﹰ‬‫ا‬‫ﻣصﺤﻮﺑ‬ ‫الصفاﻕ‬ ‫ﲡﻮيﻒ‬ ‫داﺧل‬ ‫اﶈلﻮﻝ‬ ‫ﺗدﻓﻖ‬ ‫ﺑﺒﻂﺀ‬ ‫ﳝﺘاﺯ‬ ‫ﻭاﳋاﺭﺝ‬ ‫اﺧل‬ •‫الد‬ ‫الﺘدﻓﻖ‬ ‫ﺿﻌﻒ‬ .‫الﺘﻮاﺀﻩ‬ ‫ﺃﻭ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﳌﻌة‬ ‫اﻧﺴداد‬ ‫ﻋﻦ‬ ‫يﻨﺠﻢ‬ ‫ﻣا‬ ‫ﹰ‬‫ا‬‫ﻭﻏالﺒ‬ ،‫اﶈلﻮﻝ‬ ‫ﺗصﺮيﻒ‬ ‫ﺑﺒﻂﺀ‬ ‫ﺗصﺮيﻒ‬ ‫ﺑﺒﻂﺀ‬ ‫ﻭﳝﺘاﺯ‬ ،‫ﹰ‬‫ا‬‫ﺷيﻮﻋ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻭﻇيفة‬ ‫ﺧلل‬ ‫ﺃﻧﻮاﻉ‬ ‫ﺃﻛﺜﺮ‬ ‫ﻫﻮ‬ ‫اﳋاﺭﺝ‬ ‫الﺘدﻓﻖ‬ ‫ﺿﻌﻒ‬ • ‫ﻓﺘﺤاﺕ‬ ‫اﻧﺴداد‬ ‫ﻣﻦ‬ ‫ﻋادة‬ ‫ﻭيﻨﺠﻢ‬ ،‫الصفاﻕ‬ ‫داﺧل‬ ‫ﺗدﻓﻘﻪ‬ ‫ﺳﻬﻮلة‬ ‫ﺭﻏﻢ‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻭﳝﻜﻦ‬ ،‫الﺘﻮاﺀﻩ‬ ‫ﺃﻭ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﳌﻌة‬ ‫اﻧﺴداد‬ ‫ﻋﻦ‬ ‫ﹰ‬‫ا‬‫ﺃيﻀ‬ ‫يﻨﺠﻢ‬ ‫قد‬ ‫ﻭلﻜﻨﻪ‬ ،‫ﺗﻮﺿﻌﻪ‬ ‫ﺳﻮﺀ‬ ‫ﺃﻭ‬ ‫الﻘﺜﻄاﺭ‬ ‫الﺒﻄﻦ‬ ‫داﺧل‬ ‫الﻀﻐﻂ‬ ‫ﺑاﺭﺗفاﻉ‬ ‫اﳌﺘﻌلﻘة‬ ‫اﳌﻀاﻋفاﺕ‬ ‫ﺣدﻭﺙ‬ ‫ﺇلﻰ‬ ‫اﳋاﺭﺝ‬ ‫الﺘدﻓﻖ‬ ‫ﺿﻌﻒ‬ ‫يﺆدﻱ‬ ‫ﺃﻥ‬ .(‫ﻭالفﺘﻖ‬ ‫الﺴﻮاﺋل‬ ‫ﺗﺴﺮﺏ‬ :‫)ﻣﺜاﻝ‬ ‫ﺭﻏﻢ‬ ‫الصفاﻕ‬ ‫ﲡﻮيﻒ‬ ‫داﺧل‬ ‫الﺴاﺋل‬ ‫ﺗدﻓﻖ‬ ‫ﺑﺒﻂﺀ‬ ‫ﻭﳝﺘاﺯ‬ ،‫ﹰ‬‫ا‬‫ﺷاﺋﻌ‬ ‫ليﺲ‬ ‫الداﺧل‬ ‫الﺘدﻓﻖ‬ ‫ﺿﻌﻒ‬ • .‫الﺘﻮاﺀﻩ‬ ‫ﺃﻭ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﳌﻌة‬ ‫اﻧﺴداد‬ ‫ﻋﻦ‬ ‫يﻨﺠﻢ‬ ‫ﺃﻥ‬ ‫ﻭﳝﻜﻦ‬ ،‫ﺗصﺮيفﻪ‬ ‫ﺳﻬﻮلة‬ ‫الﺘصﻮيﺮ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻭﻇيفة‬ ‫ﺧلل‬ ‫ﺳﺒﺐ‬ ‫ﲢديد‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ،‫الﺴليﻤة‬ ‫اﳌﻌاﳉة‬ ‫ﻻﺧﺘياﺭ‬ • .(fluoroscopy) ‫الﺘﺄلﻘﻲ‬ ‫الﺘﻨﻈيﺮ‬ ‫ﺃﻭ‬ (plain X ray) ‫الﺸﻌاﻋﻲ‬ ‫داﺧل‬ ( •contrast material) ‫ﺗﺒايﻦ‬ ‫ﻣادة‬ ‫ﻣﻦ‬ ‫ﻣل‬ ٢ ‫ﺣﻘﻦ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫الﺘﺄلﻘﻲ‬ ‫الﺘﻨﻈيﺮ‬ ‫يﺘﻢ‬ ‫ﺟﺮﻋة‬ ‫ﺗﺴﺒﻘﻪ‬ ‫ﺃﻥ‬ ‫ﻣﻦ‬ ‫ﻭﻻﺑد‬ ،‫ﺟﻮاﻧﺐ‬ ‫ﻋدة‬ ‫ﻣﻦ‬ ‫الﺴيﻨية‬ ‫ﺑاﻷﺷﻌة‬ ‫الﺒﻄﻦ‬ ‫ﺗصﻮيﺮ‬ ‫قﺒل‬ ‫الﻘﺜﻄاﺭ‬ .‫الصفاﻕ‬ ‫داﺧل‬ ‫اﺗﻘاﺋﻲ‬ ‫ﺣيﻮﻱ‬ ‫ﻣﻀاد‬ ‫لﻌﻼﺝ‬ ‫الﻌادة‬ ‫ﻓﻲ‬ ‫يﺴﺘﺠيﺐ‬ ‫الﺘﻮﺿﻊ‬ ‫ﺳﻮﺀ‬ ‫ﺃﻭ‬ ‫لﻼلﺘﻮاﺀ‬ ‫يﺘﻌﺮﺽ‬ ‫لﻢ‬ ‫الﺬﻱ‬ ‫الﺴالﻚ‬ ‫الﻘﺜﻄاﺭ‬ • ‫ﺿﻌﻒ‬ ‫ﺣاﻻﺕ‬ ‫ﻣﻦ‬ ٪٥٠ ‫قﺮاﺑة‬ ‫اﻧﻌﻜاﺱ‬ ‫ﺇلﻰ‬ ‫يﺆدﻱ‬ ‫ﳑا‬ ،‫الﺸﺮﺟية‬ ‫ﻭاﳊﻘﻦ‬ ‫ﺑاﳌليﻨاﺕ‬ ‫اﻹﻣﺴاﻙ‬ .‫اﳋاﺭﺝ‬ ‫الﺘدﻓﻖ‬ ‫الدﻣﻮية‬ ‫ﺑاﳉلﻄاﺕ‬ ( •intraluminal obstruction) ‫الﻘﺜﻄاﺭ‬ ‫ﳌﻌة‬ ‫اﻧﺴداد‬ ‫يﺴﺘﺠيﺐ‬ ‫قد‬ ‫ﻭﺣدة‬ ١٠٠٠٠ ‫ﺳﺘﺮﺑﺘﻮﻛيﻨاﺯ‬ :‫)ﻣﺜاﻝ‬ ‫للفيﺒﺮيﻦ‬ ‫ﺣالة‬ ‫ﻣادة‬ ‫ﺣﻘﻦ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫لﻺﺫاﺑة‬ ‫الفيﺒﺮيﻨية‬ ‫ﺃﻭ‬ ‫الﻬيﺒاﺭيﻦ‬ ‫ﺑﺈﺿاﻓة‬ ‫ﺇﺗﺒاﻋﻪ‬ ‫ﻓيﻤﻜﻦ‬ ‫ﺫلﻚ‬ ‫ﳒﺢ‬ ‫ﻭﺇﺫا‬ ،(‫ﺳاﻋﺘﲔ‬ ‫ﳌدة‬ ‫الﻘﺜﻄاﺭ‬ ‫داﺧل‬ ‫ﺗﺘﺮﻙ‬ ‫ﻣل‬ ٢ ‫ﻓﻲ‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﳌﻌة‬ ‫ﺗﻨﻈيﻒ‬ ‫ﻫﻲ‬ ‫اﻷﺧﺮﻯ‬ ‫الﻄﺮيﻘة‬ .‫ﺗﺒديﻼﺕ‬ ‫لﻌدة‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﺇلﻰ‬ .‫ﺧاﺻة‬ ‫ﻓﺮﺷاة‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫ﺃﻭ‬ «‫»ﻓﻮﺟاﺭﺗﻲ‬ ‫قﺜﻄاﺭ‬ ‫اﳌﺮيﺾ‬ ‫ﻭﺗﺸﺠيﻊ‬ ‫اﳌليﻨاﺕ‬ ‫ﻻﺳﺘﻌﻤاﻝ‬ ( •tip migration) ‫الﻘﺜﻄاﺭ‬ ‫ﺗﻮﺿﻊ‬ ‫ﺳﻮﺀ‬ ‫يﺴﺘﺠيﺐ‬ ‫قد‬ ‫الﺘﻨﻈيﺮ‬ ‫ﺇﺭﺷاد‬ ‫ﲢﺖ‬ ‫ﺻلﺐ‬ ‫ﺑﺴلﻚ‬ ‫الﺘداﻭﻝ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﻣﻌاﳉﺘﻪ‬ ‫ﳝﻜﻦ‬ ‫ﻛﻤا‬ ،‫اﳊﺮﻛة‬ ‫ﻋلﻰ‬ .(fluoroscopy) ‫الﺘﺄلﻘﻲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻛفﺘﻲ‬ ‫ﺗﻮﺿﻊ‬ ‫ﻋﻦ‬‫ﹰ‬‫ا‬‫ﺃﺣياﻧ‬ ‫يﻨﺠﻢ‬ ‫ﻭلﻜﻨﻪ‬ ،‫الﻐالﺐ‬ ‫ﻓﻲ‬ ‫ﺗﻐييﺮﻩ‬ ‫الﻘﺜﻄاﺭ‬ ‫الﺘﻮاﺀ‬ ‫يﺴﺘدﻋﻲ‬ • .‫اﳌﺸﻜلة‬ ‫ﳊل‬ ‫اﻷﺣياﻥ‬ ‫ﺑﻌﺾ‬ ‫ﻓﻲ‬ ‫ﻛاﻓية‬ ‫الﺴﻄﺤية‬ ‫الﻜفة‬ ‫ﺇﺯالة‬ ‫يﺠﻌل‬ ‫ﳑا‬ ‫ﺑﻌﻀﻬﻤا‬ ‫ﺑﻘﺮﺏ‬ ‫ﳝﻜﻦ‬ ‫اﳌﻨاﻇيﺮ‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫ﺃﻭ‬ ‫اﳉﺮاﺣﻲ‬ ‫اﻻﺳﺘﻜﺸاﻑ‬ ‫ﻓﺈﻥ‬ ‫الﺘﺤفﻈية‬ ‫اﳌﻌاﳉة‬ ‫ﺗﻨﺠﺢ‬ ‫لﻢ‬ ‫ﺇﺫا‬ • ‫ﺇﺯالة‬ ‫ﺃﻭ‬ ،(omentectomy) ‫الﺜﺮﺏ‬ ‫ﺇﺯالة‬ ‫ﺃﻭ‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﺗﻮﺟيﻪ‬ ‫ﺇﻋادة‬ ‫ﻣﻦ‬ ‫الﻀﺮﻭﺭة‬ ‫ﻋﻨد‬ ‫اﳉﺮاﺡ‬ .‫الﻘﺜﻄاﺭ‬ ‫ﺗﻐييﺮ‬ ‫ﺃﻭ‬ ،‫اﻻلﺘصاقاﺕ‬
  • ٧١ ( •CTperitoneiography)‫للصفاﻕ‬‫ﻣﻘﻄﻌﻲ‬‫ﺗصﻮيﺮ‬‫ﺇﺟﺮاﺀ‬‫ﳝﻜﻦ‬‫ﺑدقة‬‫الﺘﺴﺮﺏ‬‫ﻣﻜاﻥ‬‫لﺘﺤديد‬ ‫ﻭﻣﻀاﻧﻲ‬ ‫ﺗصﻮيﺮ‬ ‫ﺃﻭ‬ ،‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﺇلﻰ‬ (contrast material) ‫ﺗﺒايﻦ‬ ‫ﻣادة‬ ‫ﺇﺿاﻓة‬ ‫ﺑﻌد‬ .‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﺇلﻰ‬ (technitium) ‫ﺗﻜﻨيﺸيﻮﻡ‬ ‫ﺇﺿاﻓة‬ ‫ﺑﻌد‬ (scintigraphy) (‫اﳉلد‬ ‫ﲢﺖ‬ ‫ﺃﻭ‬‫ﹰ‬‫ا‬‫ﻇاﻫﺮ‬‫ﹰ‬‫ا‬‫ﺗﺴﺮﺑ‬ ‫ﻛاﻥ‬ ‫)ﺳﻮاﺀ‬ ‫الصفاﻕ‬ ‫ﻏﺸاﺀ‬ ‫ﺛﻘﻮﺏ‬ ‫ﻋﻦ‬ ‫الﻨاﺟﻢ‬ ‫الﺘﺴﺮﺏ‬ ‫يﺴﺘﺠيﺐ‬ • ‫ﻓﻲ‬ ‫الديلزة‬ ‫ﻭﺇﺟﺮاﺀ‬ ،‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻛﻤية‬ ‫ﺗﻘليل‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫الﺘﺤفﻈية‬ ‫للﻤﻌاﳉة‬ ‫الﻌادة‬ ‫ﻓﻲ‬ ‫ﻭاللﺠﻮﺀ‬ ‫ﻣﺆقﺘة‬ ‫ﺑصﻮﺭة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺇيﻘاﻑ‬ ‫ﺃﻭ‬ ،‫الﺸاﻕ‬ ‫اﺠﻤﻟﻬﻮد‬ ‫ﻭﲡﻨﺐ‬ ،‫اﻻﺳﺘلﻘاﺀ‬ ‫ﻭﺿﻊ‬ .‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫ﺇلﻰ‬ ‫ﺇﺯالة‬ ‫ﺗلزﻡ‬ ‫ﻣا‬‫ﹰ‬‫ا‬‫ﻭﻧادﺭ‬ ،‫ﹰ‬‫ا‬‫ﺟﺮاﺣي‬ ‫ﻣﻌاﳉﺘﻪ‬ ‫ﻓيﻤﻜﻦ‬ ‫الﺘﺤفﻈية‬ ‫للﻤﻌاﳉة‬ ‫الﺘﺴﺮﺏ‬ ‫يﺴﺘﺠﺐ‬ ‫لﻢ‬ ‫ﺇﺫا‬ • .‫الﻘﺜﻄاﺭ‬ ‫الﻌدﻭﻯ‬ ‫اﺣﺘﻤاﻻﺕ‬ ‫ﻣﻦ‬ ‫يزيد‬ ‫ﻓﺈﻧﻪ‬ ‫اﳉﺮﺡ‬ ‫ﻋﺒﺮ‬ ‫ﺃﻭ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻣﻦ‬‫ﹰ‬‫ا‬‫ﻇاﻫﺮ‬ ‫اﶈلﻮﻝ‬ ‫ﺗﺴﺮﺏ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ • .‫اﳊالة‬ ‫ﻫﺬﻩ‬ ‫ﻓﻲ‬ ‫اﺗﻘاﺋﻲ‬ ‫ﺣيﻮﻱ‬ ‫ﻣﻀاد‬ ‫ﻭﺻﻒ‬ ‫ﻭيلزﻡ‬ (pleural effusion) ‫ﺍﳉﻨﺒﻲ‬ ‫ﺍﻻﻧﺼﺒﺎﺏ‬ :٤-٧ ‫قصﻮﺭ‬ ‫ﻋلﻰ‬ ‫ﺗدﻝ‬ ‫ﻋﻼﻣة‬ ‫ﺗصاﺣﺒﻪ‬ ‫ﻻ‬ ‫الﺬﻱ‬ ( •pleural effusion) ‫اﳉﻨﺒﻲ‬ ‫اﻻﻧصﺒاﺏ‬ ‫يﻜﻮﻥ‬ ‫قد‬ ‫ﺻفاقﻲ‬ ‫ﺟﻨﺒﻲ‬ ‫ﻧاﺳﻮﺭ‬ ‫ﻭﺟﻮد‬ ‫ﻋﻦ‬ ‫ﹰ‬‫ا‬‫ﻧاﺟﻤ‬ (fluid overload) ‫الﺴﻮاﺋل‬ ‫اﺣﺘﺒاﺱ‬ ‫ﻋلﻰ‬ ‫ﺃﻭ‬ ‫الﻘلﺐ‬ .‫ﻓﻘﻂ‬ ‫اليﻤﻨﻰ‬ ‫الﻨاﺣية‬ ‫ﻓﻲ‬ ‫اﻻﻧصﺒاﺏ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫ﺧاﺻة‬ ،(pleuroperitoneal fistula) ‫اﻻﺳﺘلﻘاﺀ‬ ‫ﻭﺿﻊ‬ ‫ﻓﻲ‬ ‫الديلزة‬ ‫ﻭﲡﻨﺐ‬ ‫اﳉﻨﺒﻲ‬ ‫الﺴاﺋل‬ ‫لﺘصﺮيﻒ‬ ‫اﳊاﻻﺕ‬ ‫ﻣﻌﻈﻢ‬ ‫ﺗﺴﺘﺠيﺐ‬ • ‫اﻻﻧصﺒاﺏ‬ ‫ﺗﻜﺮﺭ‬ ‫ﺇﺫا‬ (pleurodesis) ‫ﺟﻨﺒﻲ‬ ‫الﺘصاﻕ‬ ‫ﺇﺟﺮاﺀ‬ ‫ﳝﻜﻦ‬ ‫ﻛﻤا‬ ،(‫الليلﻲ‬ ‫)اﳌﻜﻮﺙ‬ ‫اﳊﺠاﺑية‬ ‫الﻌيﻮﺏ‬ .‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﻮاﺻلة‬ ‫ﻓﻲ‬ ‫ﹰ‬‫ا‬‫ﺭاﻏﺒ‬ ‫ﺃﻭ‬ ‫ﹰ‬‫ا‬‫ﻣﺤﺘاﺟ‬ ‫اﳌﺮيﺾ‬ ‫ﻭﻛاﻥ‬ ‫اﳉﻨﺒﻲ‬ ‫الصدﺭ‬ ‫ﺑﻀﻊ‬ ‫ﺇلﻰ‬ ‫يﺤﺘاﺝ‬ ‫ﻫﺬا‬ ‫ﻭلﻜﻦ‬ ‫ﹰ‬‫ا‬‫ﺟﺮاﺣي‬ ‫ﺗصليﺤﻬا‬ ‫ﳝﻜﻦ‬ (diaphragmatic defects) .(thoracotomy) (catheter malfunction) ‫ﺍﻟﻘﺜﻄﺎﺭ‬ ‫ﻭﻇﻴﻔﺔ‬ ‫ﺧﻠﻞ‬ :٥-٧ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻦ‬ ‫ليﺘﺮاﺕ‬ •٣ ‫ﺣﻮالﻲ‬ ‫ﺑﺘدﻓﻖ‬ ‫ﺳيﺴﻤﺢ‬ ‫ﻓﺈﻧﻪ‬ ‫ﺑﻜفاﺀة‬ ‫يﻌﻤل‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ،(‫ﻓﻘﻂ‬ ‫اﳉاﺫﺑية‬ ‫)ﺑﻘﻮة‬ ‫دقيﻘة‬ ٢٠ - ١٥ ‫ﺧﻼﻝ‬ ‫ﻭﺗصﺮيفﻬا‬ ‫دقاﺋﻖ‬ ١٠ - ٥ ‫ﺧﻼﻝ‬ ‫الصفاﻕ‬ ‫داﺧل‬ ‫ﺇلﻰ‬ ‫ﻓﺘﺮة‬ ‫ﻭﺳﺘﻄيل‬ ‫للﻤﺮيﺾ‬ ‫ﻣﺮيﺤة‬ ‫ﻏيﺮ‬ ‫ﺳﺘﻜﻮﻥ‬ ‫ﻓﺈﻧﻬا‬ ‫ﺫلﻚ‬ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫الﺘدﻓﻖ‬ ‫ﺳﺮﻋة‬ ‫ﻛاﻧﺖ‬ ‫ﺇﺫا‬ .‫اﳌﻜﻮﺙ‬ ‫ﻓﺘﺮة‬ ‫ﺮ‬ ‫ﹶ‬‫ص‬‫ﹺ‬‫ق‬ ‫ﻋﻨﻪ‬ ‫يﻨﺘﺞ‬ ‫ﳑا‬ ‫اﶈلﻮﻝ‬ ‫ﺗﺒديل‬ ‫قد‬ ‫ﻭلﻜﻨﻪ‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﻣﻦ‬ ‫ﺃﺳﺒﻮﻋﲔ‬ ‫ﻏﻀﻮﻥ‬ ‫ﻓﻲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻭﻇيفة‬ ‫ﺧلل‬ ‫يﺤدﺙ‬ ‫ﻣا‬ ‫ﹰ‬‫ا‬‫ﻏالﺒ‬ • .(‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫ﺇﺻاﺑة‬ ‫ﺃﺛﻨاﺀ‬ :‫)ﻣﺜاﻝ‬ ‫ﺫلﻚ‬ ‫ﺑﻌد‬ ‫يﺤدﺙ‬ ‫ﳌﻌﺘﻪ‬ ‫اﻧﺴداد‬ ‫ﺗﺸﻤل‬ ‫ﻭﻇيفﺘﻪ‬ ‫ﻓﻲ‬ ‫ﺧلل‬ ‫ﺇلﻰ‬ ‫ﺗﺆدﻱ‬ ‫قد‬ ‫الﺘﻲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﲡﻮيﻒ‬ ‫داﺧل‬ ‫الﻌﻮاﻣل‬ • ‫الﺘﻮاﺀ‬ ‫ﻓﺘﺸﻤل‬ ‫الﻘﺜﻄاﺭ‬ ‫ﲡﻮيﻒ‬ ‫ﺧاﺭﺝ‬ ‫الﻌﻮاﻣل‬ ‫ﺃﻣا‬ ،‫ﻓيﺒﺮيﻨية‬ ‫ﺃﻭ‬ ‫دﻣﻮية‬ ‫ﺑﺠلﻄة‬ (lumen) ،(omentum) ‫الﺜﺮﺏ‬ ‫ﺑﺴﺒﺐ‬ ‫ﻓﺘﺤاﺗﻪ‬ ‫اﻧﺴداد‬ ‫ﺃﻭ‬ ،(tip migration) ‫ﺗﻮﺿﻌﻪ‬ ‫ﺳﻮﺀ‬ ‫ﺃﻭ‬ ،‫الﻘﺜﻄاﺭ‬ .‫ﺑالﺒﺮاﺯ‬ ‫الﻘﻮلﻮﻥ‬ ‫ﻋﻘل‬ ‫ﺇﺛﻘاﻝ‬ ‫ﺇلﻰ‬ ‫اﳌﺆدﻱ‬ ‫اﻹﻣﺴاﻙ‬ ‫ﺃﻭ‬ ،‫الصفاﻕ‬ ‫الﺘصاقاﺕ‬ ‫ﺃﻭ‬
  • ٧٠ ‫ﻋﺪﻭﺍﺋﻴﺔ‬ ‫ﺍﻟﻼ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻣﻀﺎﻋﻔﺎﺕ‬ :٧ ‫ﻓﺼﻞ‬ ‫ﺍﻷﻫﺪﺍﻑ‬ :١-٧ ‫ﺑﲔ‬ ( •non-infectious) ‫الﻼﻋدﻭاﺋية‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﻀاﻋفاﺕ‬ ‫ﻣﻌاﳉاﺕ‬ ‫ﺧﻄﻮاﺕ‬ ‫ﺗﻮﺣيد‬ .‫الصفاقية‬ ‫للديلزة‬ ‫الﺴﻮداﻥ‬ ‫ﺑﺮﻧاﻣﺞ‬ ‫ﻣﺮاﻛز‬ ‫ﻛل‬ (hernia) ‫ﺍﻟﻔﺘﻖ‬ :٢-٧ ‫ﻓﺈﻥ‬ ‫ﻭﺇﻻ‬ ،‫الصفاقية‬ ‫الديلزة‬ ‫ﺑدﺀ‬ ‫قﺒل‬ ‫الﺒﻄﻦ‬ ‫ﺣاﺋﻂ‬ ‫ﻓﻲ‬ ‫ﻋيﺐ‬ ‫ﺃﻭ‬ ‫ﻛﺒيﺮ‬ ‫ﻓﺘﻖ‬ ‫ﺃﻱ‬ ‫ﺗصليﺢ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • ‫ﺗصﺮيﻒ‬ ‫ﻭﻋدﻡ‬ ‫الفﺘﻖ‬ ‫ﺣﺠﻢ‬ ‫ﺯيادة‬ ‫ﺇلﻰ‬ ‫ﺳﺘﺆدﻱ‬ ‫الديلزة‬ ‫ﻋﻦ‬ ‫الﻨاﲡة‬ ‫الﺒﻄﻦ‬ ‫داﺧل‬ ‫الﻀﻐﻂ‬ ‫ﺯيادة‬ .‫ﹰ‬‫ﻼ‬‫ﻛاﻣ‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫اﳋﻂ‬‫ﻓﻲ‬‫الﻘﺜﻄاﺭ‬‫ﺇدﺧاﻝ‬‫يﺘﻢ‬‫ﻋﻨدﻣا‬‫الﻐالﺐ‬‫ﻓﻲ‬‫الﻘﺜﻄاﺭ‬‫ﲟدﺧل‬‫اﳌﺘﻌلﻖ‬‫اﳉﺮاﺣﻲ‬‫الفﺘﻖ‬‫يﻨﺠﻢ‬ • .‫الﺒﻄﻨية‬ ‫اﳌﺴﺘﻘيﻤة‬ ‫الﻌﻀلة‬ ‫ﻋﺒﺮ‬ ‫للﻨاﺻﻒ‬ ‫اﺠﻤﻟاﻭﺭ‬ ‫اﳋﻂ‬ ‫ﻓﻲ‬ ‫ﺇدﺧالﻪ‬ ‫ﻣﻦ‬ ‫ﹰ‬‫ﻻ‬‫ﺑد‬ ‫الﻨاﺻﻒ‬ ‫ﲢﻮيل‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ‫الفﺘﻖ‬ ‫ﺣدﻭﺙ‬ ‫ﲡدد‬ ‫ﻭﳌﻨﻊ‬ ،‫ﹰ‬‫ا‬‫ﺟﺮاﺣي‬ ‫ﺗصليﺤﻪ‬ ‫ﻣﻦ‬ ‫ﻓﻼﺑد‬ ‫ﹰ‬‫ا‬‫ﻛﺒيﺮ‬ ‫الفﺘﻖ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ • ‫ﻣﻦ‬ ‫ﻻﺑد‬ ‫ﻛاﻥ‬ ‫ﻭﺇﺫا‬ ،‫اﳉﺮاﺣة‬ ‫ﺇﺟﺮاﺀ‬ ‫ﺑﻌد‬ ‫ﺃﺳاﺑيﻊ‬ ٤-٣ ‫ﳌدة‬ ‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫ﺇلﻰ‬ ‫اﳌﺮيﺾ‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﺻﻐيﺮة‬ ‫ﻛﻤياﺕ‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫ﻨصﺢ‬‫ﹸ‬‫ي‬‫ﻓ‬ ‫اﳉﺮاﺣة‬ ‫ﺑﻌد‬ ‫ﹰ‬‫ا‬‫ﻓﻮﺭ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺑدﺀ‬ .‫اﻻﺳﺘلﻘاﺀ‬ ‫ﻭﺿﻊ‬ ‫ﻓﻲ‬ ‫ﻭاﳌﺮيﺾ‬ ‫الديلزة‬ (fluid leak) ‫ﺍﶈﻠﻮﻝ‬ ‫ﺗﺴﺮﺏ‬ :٣-٧ ‫يﺤدﺙ‬ ‫الﺘﺸﺮيﺤية؛‬ ‫الﻌيﻮﺏ‬ ‫ﻣﻦ‬ ‫ﺃﻭ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﺗﻘﻨية‬ ‫ﻣﻦ‬ ‫اﳌﺸﻜلة‬ ‫ﻫﺬﻩ‬ ‫ﺗﻨﺠﻢ‬ ‫قد‬ • ‫ﺇﺫا‬ ‫ﹰ‬‫ا‬‫ﺷيﻮﻋ‬ ‫ﺃﻛﺜﺮ‬ ‫ﻭيﻜﻮﻥ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﻣﻦ‬ ‫ﹰ‬‫ا‬‫يﻮﻣ‬ ٣٠ ‫ﻏﻀﻮﻥ‬ ‫ﻓﻲ‬ ‫للﻤﺤلﻮﻝ‬ ‫اﳌﺒﻜﺮ‬ ‫الﺘﺴﺮﺏ‬ ‫ﺑﻌد‬ ‫ﻓيﺤدﺙ‬ ‫للﻤﺤلﻮﻝ‬ ‫اﳌﺘﺄﺧﺮ‬ ‫الﺘﺴﺮﺏ‬ ‫ﺃﻣا‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﲟﺠﺮد‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺑدﺋﺖ‬ .‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﻋلﻰ‬ ‫ﹰ‬‫ا‬‫يﻮﻣ‬ ‫ﺛﻼﺛﲔ‬ ‫ﻣﺮﻭﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻣﻦ‬ ‫ﺃﻭ‬ ‫اﳉﺮﺡ‬ ‫ﻣﻦ‬ ‫للﻤﺤلﻮﻝ‬ ‫ﺧاﺭﺟﻲ‬ ‫ﺳيﻼﻥ‬ ‫ﺷﻜل‬ ‫ﻋلﻰ‬ ‫ﻋادة‬ ‫اﳌﺒﻜﺮ‬ ‫الﺘﺴﺮﺏ‬ ‫يﻈﻬﺮ‬ • ‫الصفاﻕ‬ ‫ﲡﻮيﻒ‬ ‫ﺇلﻰ‬ ‫الﻘﺜﻄاﺭ‬ ‫دﺧﻮﻝ‬ ‫ﻣﻜاﻥ‬ ‫ﻓﻲ‬ ‫اﳉلد‬ ‫ﲢﺖ‬ ‫ﹰ‬‫ا‬‫ﺃيﻀ‬ ‫يﺤدﺙ‬ ‫قد‬ ‫ﻭلﻜﻨﻪ‬ ،‫الﻘﺜﻄاﺭ‬ .‫الﺘﻨاﺳلية‬ ‫اﻷﻋﻀاﺀ‬ ‫ﺃﻭ‬ ‫الﺒﻄﻦ‬ ‫ﺟلد‬ ‫ﺗﻮﺭﻡ‬ ‫ﺇلﻰ‬ ‫ﹰ‬‫ا‬‫ﻣﺆدي‬ ‫ﺗﻜﻮﻥ‬ ‫ﻭقد‬ ،‫الﺘﺸﺨيﺺ‬ ‫ﻭﺻﻌﺐ‬ ‫ﹰ‬‫ا‬‫ﺧفي‬ ‫يﻜﻮﻥ‬ ‫ﻭﺭﲟا‬ ،‫اﳉلد‬ ‫ﲢﺖ‬ ‫ﻋادة‬ ‫اﳌﺘﺄﺧﺮ‬ ‫الﺘﺴﺮﺏ‬ ‫يﺤدﺙ‬ • ‫ﺺ‬ ‫ﺗﺸﺨﱠ‬ ‫ﺃﻥ‬ ‫ﳝﻜﻦ‬ ‫ﻭالﺘﻲ‬ ‫الﺘصﺮيﻒ‬ ‫ﻛﻤية‬ ‫ﻧﻘصاﻥ‬ ‫ﻫﻲ‬ ‫الﺘﺴﺮﺏ‬ ‫ﺣدﻭﺙ‬ ‫ﻋلﻰ‬ ‫الﻮﺣيدة‬ ‫الدﻻلة‬ .‫الﺮاﺷﺢ‬ ‫ﺗﻜﻮيﻦ‬ ‫ﻓﻲ‬ ‫ﺿﻌﻒ‬ ‫ﺃﻧﻬا‬ ‫ﻋلﻰ‬ ‫ﺧﻄﺄ‬ ‫ﻏﺸاﺀ‬ ‫ﻓﻲ‬ ‫ﺛﻘﻮﺏ‬ ‫ﻭﺟﻮد‬ ‫ﻣﻦ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺑدﺀ‬ ‫ﺑﻌد‬ ‫الﺘﻨاﺳلية‬ ‫اﻷﻋﻀاﺀ‬ ‫ﺗﻮﺭﻡ‬ ‫يﻨﺠﻢ‬ ‫قد‬ • ‫ﺻﻐيﺮ‬ ‫ﺃﺭﺑﻲ‬ ‫ﻓﺘﻖ‬ ‫ﻣﻦ‬ ‫ﹰ‬‫ا‬‫ﺃيﻀ‬ ‫يﻨﺠﻢ‬ ‫ﺃﻥ‬ ‫ﳝﻜﻦ‬ ‫ﺃﻧﻪ‬ ‫ﺇﻻ‬ ،‫اﳉلد‬ ‫ﲢﺖ‬ ‫اﶈلﻮﻝ‬ ‫ﺗﺴﺮﺏ‬ ‫ﺇلﻰ‬ ‫ﺃدﺕ‬ ‫الصفاﻕ‬ ‫الﻐالﺐ‬ ‫ﻓﻲ‬ ‫يﺤﺘاﺝ‬ ‫ﻭﻫﺬا‬ ،‫ﺳالﻜة‬ (processus vaginalis) ‫اﻷﺭﺑية‬ ‫الﻘﻨاة‬ ‫ﺑﻘاﺀ‬ ‫ﺑﺴﺒﺐ‬ ‫ﺣدﺙ‬ .‫ﺟﺮاﺣﻲ‬ ‫ﺗصليﺢ‬ ‫ﺇلﻰ‬
  • ٦٩ ‫ﺍﻟﻔﻄﺮﻱ‬ ‫ﺍﻟﺼﻔﺎﻕ‬ ‫ﺍﻟﺘﻬﺎﺏ‬ ‫ﻣﻌﺎﳉﺔ‬ :٤ ‫ﺧﻮﺍﺭﺯﻣﻴﺔ‬
  • ٦٨ ‫ﺍﻟﺰﺭﻉ‬ ‫ﺳﺎﻟﺐ‬ ‫ﺍﻟﺼﻔﺎﻕ‬ ‫ﺍﻟﺘﻬﺎﺏ‬ ‫ﻣﻌﺎﳉﺔ‬ :٣ ‫ﺧﻮﺍﺭﺯﻣﻴﺔ‬
  • ٦٧ ‫ﺍﻟﺼﻔﺎﻕ‬ ‫ﺍﻟﺘﻬﺎﺏ‬ ‫ﻣﻌﺎﳉﺔ‬ :٢ ‫ﺧﻮﺍﺭﺯﻣﻴﺔ‬
  • ٦٦ ‫ﺍﻟﻔﺼﻞ‬ ‫ﻫﺬﺍ‬ ‫ﻓﻲ‬ ‫ﺫﻛﺮﻫﺎ‬ ‫ﰎ‬ ‫ﺃﺩﻭﻳﺔ‬ :١٧ ‫ﺟﺪﻭﻝ‬ ‫ﺍﻟﺪﻭﺍﺀ‬ ‫ﺍﺳﻢ‬‫ﺍﻟﺘﺮﻛﻴﺒﺔ‬‫ﺍﳉﺮﻋﺔ‬ ‫ديﻜلﻮﻓيﻨاﻙ‬‫ﺑالﻌﻀل‬ ‫ﺣﻘﻦ‬ ،‫ﺣﺒﻮﺏ‬‫ﺳاﻋاﺕ‬ ٦ ‫ﻛل‬ ‫ﻣلﻎ‬ ٥٠-٢٥ ‫ﻓلﻮﻛﻮﻧاﺯﻭﻝ‬‫ﻣﺴﺘﻌلﻖ‬ ،‫ﻛﺒﺴﻮﻻﺕ‬(‫اﺗﻘاﺋية‬ ‫)ﺟﺮﻋة‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﺑالفﻢ‬ ‫ﻣلﻎ‬ ٥٠ ‫ﺁيﺒﻮﺑﺮﻭﻓﲔ‬‫ﻣﺴﺘﻌلﻖ‬ ،‫ﺣﺒﻮﺏ‬‫ﺳاﻋاﺕ‬ ٦ ‫ﻛل‬ ‫ﻣلﻎ‬ ٦٠٠-٢٠٠ ‫ﻻﻛﺘيﻮلﻮﺯ‬‫ﻣﺤلﻮﻝ‬‫ﺫلﻚ‬ ‫ﺑﻌد‬ ‫ﺗﻌدﻝ‬ ‫ﺛﻢ‬ ‫ﺳاﻋة‬ ١٢ ‫ﻛل‬ ‫ﻣل‬ ١٥ ‫ﻣاﻛﺮﻭﻏﻮلز‬‫ﻣﺴﺤﻮﻕ‬‫اﳌاﺀ‬ ‫ﻣﻦ‬ ‫ﻣل‬ ٢٠٠ ‫ﻓﻲ‬ ‫ﲢل‬ ،‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻛيﺲ‬ ٢-١ ‫ﻣﻮﺭﻓﲔ‬(‫الﻌﻀل‬ ،‫الﻮﺭيد‬ ،‫اﳉلد‬ ‫)ﲢﺖ‬ ‫ﺣﻘﻦ‬ ،‫ﺣﺒﻮﺏ‬‫ﺳاﻋاﺕ‬ ٤ ‫ﻛل‬ (‫ﺑالﻮﺭيد‬ ‫ﻣلﻎ‬ ٢٫٥) ‫ﻣلﻎ‬ ٥ ‫ﻧيفﻮﺑاﻡ‬‫ﺑالﻮﺭيد‬ ‫ﺣﻘﻦ‬ ،‫ﺣﺒﻮﺏ‬‫ﺳاﻋاﺕ‬ ٨ ‫ﻛل‬ ‫ﻣلﻎ‬ ٦٠-٣٠ ‫ﻧيﺴﺘاﺗﲔ‬‫ﻣﺴﺘﻌلﻖ‬ ،‫ﺣﺒﻮﺏ‬(‫اﺗﻘاﺋية‬ ‫)ﺟﺮﻋة‬ ‫ﺳاﻋاﺕ‬ ٦ ‫ﻛل‬ ‫ﻭﺣدة‬ ٥٠٠٠٠٠ ‫ﺑﺜيديﻦ‬(‫الﻌﻀل‬ ،‫الﻮﺭيد‬ ،‫اﳉلد‬ ‫)ﲢﺖ‬ ‫ﺣﻘﻦ‬‫ﺳاﻋاﺕ‬ ٤ ‫ﻛل‬ (‫ﺑالﻮﺭيد‬ ‫ﻣلﻎ‬ ٢٥ – ١٢٫٥) ‫ﻣلﻎ‬ ٥٠-٢٥ ‫ﺑاﺭاﺳيﺘاﻣﻮﻝ‬‫ﲢاﻣيل‬ ،‫ﻣﺴﺘﻌلﻖ‬ ،‫ﺣﺒﻮﺏ‬‫ﺳاﻋاﺕ‬ ٦ ‫ﻛل‬ ‫ﻏﻢ‬ ١-٠٫٥ ‫ﺗﺮاﻣادﻭﻝ‬(‫،الﻌﻀل‬ ‫)الﻮﺭيد‬ ‫ﺣﻘﻦ‬ ،‫ﻛﺒﺴﻮﻻﺕ‬‫ﺳاﻋاﺕ‬ ٦-٤ ‫ﻛل‬ ‫ﻣلﻎ‬ ٥٠
  • ٦٥ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﳌﺮﺿﻰ‬ ‫ﺍﻟﺼﻔﺎﻕ‬ ‫ﻃﺮﻳﻖ‬ ‫ﻏﻴﺮ‬ ‫ﻋﻦ‬ ‫ﺍﳊﻴﻮﻳﺔ‬ ‫ﺍﳌﻀﺎﺩﺍﺕ‬ ‫ﻣﻦ‬ ‫ﺑﻬﺎ‬ ‫ﺍﳌﻮﺻﻰ‬ ‫ﺍﳉﺮﻋﺔ‬ :١٦ ‫ﺟﺪﻭﻝ‬ ‫ﺍﻟﺪﻭﺍﺀ‬‫ﺍﻟﺘﺮﻛﻴﺒﺔ‬‫ﺍﳉﺮﻋﺔ‬ ‫ﺃﻣيﻜاﺳﲔ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬(‫ﻣلﻎ/ﻝ‬ ١٠ < ‫ﺑالدﻡ‬ ‫)اﳌﺴﺘﻮﻯ‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ/ﻛلﻎ‬ ٥ ‫ﺃﻣﻮﻛﺴيﺴيلﲔ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬ ،‫ﺣﺒﻮﺏ‬‫ﺳاﻋة‬ ١٢ ‫ﻛل‬ ‫ﻣلﻎ‬ ٥٠٠ ‫ﺃﻣفﻮﺗيﺮيﺴﲔ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ/ﻛلﻎ‬ ٠٫٢٥ ‫ﺃﻣﺒيﺴيلﲔ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬ ،‫ﻛﺒﺴﻮﻻﺕ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮﺗﲔ‬ ‫ﻣلﻎ‬ ٥٠٠ ‫ﺃﺯﺗﺮيﻮﻧاﻡ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻏﻢ‬ ١ ‫ﺛﻢ‬ ‫ﺃﻭلﻰ‬ ‫ﺟﺮﻋة‬ ‫ﻏﻢ‬ ٢ ‫ﺳفاﺯﻭلﲔ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻏﻢ‬ ٠٫٥ ‫ﺛﻢ‬ ،‫ﺃﻭلﻰ‬ ‫ﺟﺮﻋة‬ ‫ﻏﻢ‬ ١ ‫ﺳفﺘاﺯدﱘ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﺑالﻮﺭيد‬ ‫ﻏﻢ‬ ١-٠٫٥ ‫ﺳفيﻮﺭﻭﻛﺴيﻢ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬ ،‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﺑالﻮﺭيد‬ ‫ﻣلﻎ‬ ٧٥٠ ‫ﺳفالﻜﺴﲔ‬‫ﺣﺒﻮﺏ‬‫ﺳاﻋة‬ ١٢ ‫ﻛل‬ ‫ﻣلﻎ‬ ٥٠٠ ‫ﺳﺒﺮﻭﻓلﻮﻛﺴاﺳﲔ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬ ،‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮﺗﲔ‬ ‫ﺑالﻮﺭيد‬ ‫ﻣلﻎ‬ ٢٠٠ ‫ﺃﻭ‬ ‫ﺑالفﻢ‬ ‫ﻣلﻎ‬ ٥٠٠-٢٥٠ ‫ﻛﻼﺭيﺜﺮﻭﻣيﺴﲔ‬‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮﺗﲔ‬ ‫ﻣلﻎ‬ ٥٠٠ - ٢٥٠ ‫ﻛليﻨداﻣيﺴﲔ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬ ،‫ﺣﺒﻮﺏ‬‫ﺳاﻋاﺕ‬ ٦ ‫ﻛل‬ ‫ﻣلﻎ‬ ٣٠٠-١٥٠ ‫ﻛﻮﺃﻣﻮﻛﺴيﻜﻼﻑ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬ ،‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ٠٫٦ ‫ﺛﻢ‬‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ‫ﺑالﻮﺭيد‬ ‫ﻏﻢ‬ ١٫٢ ‫ﺃﻭ‬ ،‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮﺗﲔ‬ ‫ﺑالفﻢ‬ ‫ﻣلﻎ‬ ٣٧٥ ‫ديﻜلﻮﻛﺴاﺳيلﲔ‬‫ﺣﺒﻮﺏ‬‫ﺳاﻋة‬ ١٢ ‫ﻛل‬ ‫ﻣلﻎ‬ ٥٠٠-٢٥٠ ‫ﺇﺛاﻣﺒيﻮﺗﻮﻝ‬‫ﺣﺒﻮﺏ‬‫ﺳاﻋة‬ ٤٨ ‫ﻛل‬ ‫ﻣلﻎ/ﻛلﻎ‬ ٢٥-١٥ ‫ﻓلﻮﻛﻮﻧاﺯﻭﻝ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬ ،‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ٢٠٠ ‫ﻓلﻮﻛلﻮﻛﺴاﺳيلﲔ‬‫ﺣﻘﻦ‬ ،‫ﻛﺒﺴﻮﻻﺕ‬‫ﺑالﻮﺭيد‬ ‫ﺑﺒﻂﺀ‬ ‫ﺃﻭ‬ ‫ﺑالﻌﻀل‬ ‫يﺤﻘﻦ‬ ،‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮﺗﲔ‬ ‫ﻣلﻎ‬ ٥٠٠ ‫ﻓلﻮﺳيﺘﻮﺳﲔ‬‫ﻛﺒﺴﻮﻻﺕ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﺫلﻚ‬ ‫ﺑﻌد‬ ‫ﻏﻢ‬ ١ ‫ﺛﻢ‬ ‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ‫ﻏﻢ‬ ٢ ‫ﺟﻨﺘاﻣيﺴﲔ‬(‫ﻋﻀل‬ ،‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬(‫ﻣلﻎ/ﻝ‬ ٤-٢ ‫ﺑالدﻡ‬ ‫)اﳌﺴﺘﻮﻯ‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ/ﻛلﻎ‬ ٢-١ ‫ﺇﻣيﺒيﻨيﻢ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮﺗﲔ‬ ‫ﻣلﻎ‬ ٥٠٠-٢٥٠ ‫ﺁيزﻭﻧياﺯايد‬‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ٣٠٠ ‫ﺇﺗﺮاﻛيﻨاﺯﻭﻝ‬‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮﺗﲔ‬ ‫ﻣلﻎ‬ ١٠٠ ‫ﻣيﺮﻭﺑيﻨيﻢ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ٢٥٠ ‫ﻣﺘﺮﻭﻧيداﺯﻭﻝ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬ ،‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮﺗﲔ‬ ‫ﺛﻼﺙ‬ ‫ﻣلﻎ‬ ٥٠٠ ‫ﺃﻭﻓلﻮﻛﺴاﺳﲔ‬‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﺫلﻚ‬ ‫ﺑﻌد‬ ‫ﻣلﻎ‬ ٢٠٠ ‫ﺛﻢ‬ ‫ﺑالفﻢ‬ ‫ﻣلﻎ‬ ٤٠٠ ‫ﺑيﺒﺮاﺳيلﲔ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮﺗﲔ‬ ‫ﻏﻢ‬ ٤ ‫ﺑايﺮاﺯيﻨاﻣيد‬‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ/ﻛلﻎ‬ ٣٥ ‫ﺭيفاﻣﺒيﺴﲔ‬‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ٦٠٠-٤٥٠ ‫ﺳﺒﺘﺮيﻦ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬ ،‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ٤٨٠ ‫ﺗيﻜﻮﺑﻼﻧﲔ‬(‫ﻋﻀل‬ ،‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬‫ﺳاﻋة‬ ٧٢ ‫ﻛل‬ ‫ﻣلﻎ‬ ٤٠٠ ‫ﺛﻢ‬ ،‫ﺟﺮﻋاﺕ‬ ‫لﺜﻼﺙ‬ ‫ﺳاﻋة‬ ١٢ ‫ﻛل‬ ‫ﻣلﻎ‬ ٤٠٠ ‫ﺗﻮﺑﺮاﻣيﺴﲔ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬(‫ﻣلﻎ/ﻝ‬ ٢ < ‫ﺑالدﻡ‬ ‫)اﳌﺴﺘﻮﻯ‬ ‫ﻣلﻎﻛلﻎ‬ ١٫٥-١ ‫ﻓاﻧﻜﻮﻣيﺴﲔ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬‫ﻭيﺤﻘﻦ‬ ،‫ﻣلﻎ/ﻣل‬ ٥ ‫ﺇلﻰ‬ ‫يﺨفﻒ‬ ،‫ﺃياﻡ‬ ١٠-٧ ‫ﻛل‬ ‫ﻏﻢ‬ ١ (‫ﻣلﻎ/ﻝ‬ ١٠ < ‫ﺑالدﻡ‬ ‫)اﳌﺴﺘﻮﻯ‬ ‫ﻣلﻎ/دقيﻘة‬ ١٠ ‫ﺑﺴﺮﻋة‬
  • ٦٤ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﳌﺮﺿﻰ‬ ‫ﺍﻟﺼﻔﺎﻕ‬ ‫ﺩﺍﺧﻞ‬ ‫ﺍﳌﻌﻄﺎﺓ‬ ‫ﺍﳊﻴﻮﻳﺔ‬ ‫ﺍﳌﻀﺎﺩﺍﺕ‬ ‫ﻣﻦ‬ ‫ﺑﻬﺎ‬ ‫ﺍﳌﻮﺻﻰ‬ ‫ﺍﳉﺮﻋﺔ‬ :١٥ ‫ﺟﺪﻭﻝ‬ ‫ﺍﻵﻟﻴﺔ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻭﺍﺀ‬ ‫ﺍﺳﻢ‬(APD) ‫ﻣﻨﺘﻈﻤﺔ‬ ‫ﺁﻟﻴﺔ‬ ‫ﺩﻳﻠﺰﺓ‬ ‫ﳌﺮﻳﺾ‬ ‫ﻣﺘﻘﻄﻌﺔ‬ ‫ﺟﺮﻋﺔ‬ ‫ﺳفاﺯﻭلﲔ‬‫الﻄﻮيل‬ ‫اﳌﻜﻮﺙ‬ ‫ﻓﻲ‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻭاﺣدة‬ ‫ﻣﺮة‬ ‫ﻣلﻎ/ﻛلﻎ‬ ٢٠ ‫ﻓلﻮﻛﻮﻧاﺯﻭﻝ‬(‫ﺳاﻋة‬ ٤٨-٢٤ ‫)ﻛل‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻭاﺣدة‬ ‫ﻣﺮة‬ ‫ﻣلﻎ‬ ٢٠٠ ‫ﺗﻮﺑﺮاﻣيﺴﲔ‬‫الﻄﻮيل‬ ‫اﳌﻜﻮﺙ‬ ‫ﻓﻲ‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻭاﺣدة‬ ‫ﻣﺮة‬ ‫ﻣلﻎ/ﻛلﻎ‬ ٠٫٥ ‫ﺛﻢ‬ ‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ‫ﻣلﻎ/ﻛلﻎ‬ ١٫٥ ‫ﻓاﻧﻜﻮﻣيﺴﲔ‬(‫ﺃياﻡ‬ ٥-٣ ‫)ﻛل‬ ‫الﻄﻮيل‬ ‫اﳌﻜﻮﺙ‬ ‫ﻓﻲ‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻭاﺣدة‬ ‫ﻣﺮة‬ ‫ﻣلﻎ/ﻛلﻎ‬ ١٥ ‫ﺛﻢ‬ ‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ‫ﻣلﻎ/ﻛلﻎ‬ ٣٠ ‫ﺳفيﺒيﻢ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻭاﺣدة‬ ‫ﻣﺮة‬ ‫ﻏﻢ‬ ١
  • ٦٣ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬‫ﺍﻟﺪﻳﻠﺰﺓ‬‫ﳌﺮﺿﻰ‬‫ﺍﻟﺼﻔﺎﻕ‬‫ﺩﺍﺧﻞ‬‫ﺍﳊﻴﻮﻳﺔ‬‫ﺍﳌﻀﺎﺩﺍﺕ‬‫ﻣﻦ‬‫ﺑﻬﺎ‬‫ﺍﳌﻮﺻﻰ‬‫ﺍﳉﺮﻋﺔ‬:١٤‫ﺟﺪﻭﻝ‬ (‫ﹰ‬‫ﻳﻮﻣﻴﺎ‬ ‫ﺍﻟﺒﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻣﻞ‬ ١٠٠ < ‫ﻳﻔﺮﺯ‬ ‫ﺍﳌﺮﻳﺾ‬ ‫ﻛﺎﻥ‬ ‫ﺇﺫﺍ‬ ٪٢٥ ‫ﲟﻘﺪﺍﺭ‬ ‫ﺍﳉﺮﻋﺔ‬ ‫)ﺯﺩ‬ ‫ﺍﻟﺒﻮﻝ‬ ‫ﻣﻨﻘﻄﻌﻲ‬ ‫ﺍﻟﺪﻭﺍﺀ‬ ‫ﺍﺳﻢ‬ ‫ﺩﻳﻠﺰﺓ‬ ‫ﳌﺮﻳﺾ‬ ‫ﻣﺘﻘﻄﻌﺔ‬ ‫ﺟﺮﻋﺔ‬ (CAPD) ‫ﻣﻨﺘﻈﻤﺔ‬ ‫ﺟﻮﺍﻟﺔ‬ ‫ﺻﻔﺎﻗﻴﺔ‬ (‫ﹰ‬‫ﻳﻮﻣﻴﺎ‬ ‫ﻭﺍﺣﺪ‬ ‫ﻣﺤﻠﻮﻝ‬ ‫)ﻛﻴﺲ‬ ‫ﺩﻳﻠﺰﺓ‬ ‫ﳌﺮﻳﺾ‬ ‫ﻣﺴﺘﻤﺮﺓ‬ ‫ﺟﺮﻋﺔ‬ (CAPD) ‫ﻣﻨﺘﻈﻤﺔ‬ ‫ﺟﻮﺍﻟﺔ‬ ‫ﺻﻔﺎﻗﻴﺔ‬ (‫)ﻣﻠﻎ/ﻝ‬ ‫ﺃﻣيﻜاﺳﲔ‬‫ﻣلﻎ/ﻛلﻎ‬ ٢‫ﺫلﻚ‬ ‫ﺑﻌد‬ ١٢ ‫ﺛﻢ‬ ‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ٢٥ ‫ﻣﻮﻛﺴيﺴيلﲔ‬ ‫ﺃ‬‫ﻌلﻢ‬‫ﹸ‬‫ي‬ ‫ﻻ‬‫ﺫلﻚ‬ ‫ﺑﻌد‬ ٥٠ ‫ﺛﻢ‬ ،‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ٥٠٠-٢٥٠ ‫ﺃﻣفﻮﺗيﺮيﺴﲔ‬‫ﻌلﻢ‬‫ﹸ‬‫ي‬ ‫ﻻ‬١٫٥ ‫ﺃﻣﺒيﺴيلﲔ‬‫ﻌلﻢ‬‫ﹸ‬‫ي‬ ‫ﻻ‬١٢٥ ‫ﺳلﺒاﻛﺘاﻡ‬ /‫ﺃﻣﺒيﺴيلﲔ‬‫ﺳاﻋة‬ ١٢ ‫ﻛل‬ ‫ﻏﻢ‬ ٢‫ﺫلﻚ‬ ‫ﺑﻌد‬ ١٠٠ ‫ﺛﻢ‬ ‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ١٠٠٠ ‫ﺃﺯﺗﺮيﻮﻧاﻡ‬‫ﻌلﻢ‬‫ﹸ‬‫ي‬ ‫ﻻ‬‫ﺫلﻚ‬ ‫ﺑﻌد‬ ٢٥٠ ‫ﺛﻢ‬ ‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ١٠٠٠ ‫ﺃﺯلﻮﺳيلﲔ‬‫ﻌلﻢ‬‫ﹸ‬‫ي‬ ‫ﻻ‬‫ﺫلﻚ‬ ‫ﺑﻌد‬ ٢٥٠ ‫ﺛﻢ‬ ‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ٥٠٠ ‫ﺳفاﺯﻭلﲔ‬‫ﻣلﻎ/ﻛلﻎ‬ ١٥‫ﺫلﻚ‬ ‫ﺑﻌد‬ ١٢٥ ‫ﺛﻢ‬ ‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ٥٠٠ ‫ﺳفﺘاﺯدﱘ‬‫ﻣلﻎ‬ ١٥٠٠-١٠٠٠‫ﺫلﻚ‬ ‫ﺑﻌد‬ ١٢٥ ‫ﺛﻢ‬ ‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ٥٠٠ ‫ﺳفﺘيزﻭﻛﺴيﻢ‬‫ﻣلﻎ‬ ١٠٠٠‫ﺫلﻚ‬ ‫ﺑﻌد‬ ١٢٥ ‫ﺛﻢ‬ ‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ٢٥٠ ‫ﺳفالﻮﺛﲔ‬‫ﻣلﻎ/ﻛلﻎ‬ ١٥‫ﺫلﻚ‬ ‫ﺑﻌد‬ ١٢٥ ‫ﺛﻢ‬ ‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ٥٠٠ ‫ﺳفﺮاديﻦ‬‫ﻣلﻎ/ﻛلﻎ‬ ١٥‫ﺫلﻚ‬ ‫ﺑﻌد‬ ١٢٥ ‫ﺛﻢ‬ ‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ٥٠٠ ‫ﺳفيﺒيﻢ‬‫ﻏﻢ‬ ١‫ﺫلﻚ‬ ‫ﺑﻌد‬ ١٢٥ ‫ﺛﻢ‬ ‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ٥٠٠ ‫ﺳﺒﺮﻭﻓلﻮﻛﺴاﺳﲔ‬‫ﻌلﻢ‬‫ﹸ‬‫ي‬ ‫ﻻ‬‫ﺫلﻚ‬ ‫ﺑﻌد‬ ٢٥ ‫ﺛﻢ‬ ‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ٥٠ ‫ﻛليﻨداﻣيﺴﲔ‬‫ﻌلﻢ‬‫ﹸ‬‫ي‬ ‫ﻻ‬‫ﺫلﻚ‬ ‫ﺑﻌد‬ ١٢٥ ‫ﺛﻢ‬ ‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ٣٠٠ ‫ﻓلﻮﻛﻮﻧاﺯﻭﻝ‬‫ﻣلﻎ‬ ٢٠٠‫ﺑﻪ‬ ‫يﻮﺻﻰ‬ ‫ﻻ‬ ‫ﺟﻨﺘاﻣيﺴﲔ‬*‫ﻛلﻎ‬/‫ﻣلﻎ‬ ٠٫٦‫ﺫلﻚ‬ ‫ﺑﻌد‬ ٤ ‫ﺛﻢ‬ ،‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ٨ ‫ﺳيﻼﺳﺘﲔ‬ /‫ﺇﻣيﺒيﻨيﻢ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮﺗﲔ‬ ‫ﻏﻢ‬ ١‫ﺫلﻚ‬ ‫ﺑﻌد‬ ٢٠٠ ‫ﺛﻢ‬ ‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ٥٠٠ ‫ﻧاﻓﺴيلﲔ‬‫ﻌلﻢ‬‫ﹸ‬‫ي‬ ‫ﻻ‬‫الﺒداية‬ ‫ﻣﻨﺬ‬ ١٢٥ ‫ﻧﺘيلﻤيﺴﲔ‬‫ﻣلﻎ/ﻛلﻎ‬ ٠٫٦‫ﺫلﻚ‬ ‫ﺑﻌد‬ ٤ ‫ﺛﻢ‬ ،‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ٨ ‫ﺃﻭﻛﺴاﺳيلﲔ‬‫ﻌلﻢ‬‫ﹸ‬‫ي‬ ‫ﻻ‬‫الﺒداية‬ ‫ﻣﻨﺬ‬ ١٢٥ ‫ﺝ‬ ‫ﺑﻨﺴلﲔ‬‫ﻌلﻢ‬‫ﹸ‬‫ي‬ ‫ﻻ‬(‫)ﻭﺣدة‬ ‫ﺫلﻚ‬ ‫ﺑﻌد‬ ٢٥٠٠٠ ‫ﺛﻢ‬ ‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ٥٠٠٠٠ ‫ﺗيﻜﻮﺑﻼﻧﲔ‬‫ﺃياﻡ‬ ٧-٥ ‫ﻛل‬ ‫ﻣلﻎ/ﻛلﻎ‬ ١٥**‫ﺫلﻚ‬ ‫ﺑﻌد‬ ٤٠ ‫ﺛﻢ‬ ‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ٤٠٠ ‫ﺗﻮﺑﺮاﻣيﺴﲔ‬‫ﻣلﻎ/ﻛلﻎ‬ ٠٫٦‫ﺫلﻚ‬ ‫ﺑﻌد‬ ٤ ‫ﺛﻢ‬ ،‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ٨ ‫ﻓاﻧﻜﻮﻣيﺴﲔ‬*** ‫ﺃياﻡ‬ ٧-٥ ‫ﻛل‬ ‫ﻣلﻎ/ﻛلﻎ‬ ٣٠٢٥ ‫ﺛﻢ‬ ،‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ‫ﻣلﻎ‬ ١٠٠٠ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ،‫ﻣلﻎ/ﻛلﻎ‬ ٠٫٢ ‫ﲟﻘداﺭ‬ ‫اﳉﺮﻋة‬ ‫ﺯد‬ ‫ﻣلﻎ/ﻝ‬ ٢ > ‫اﳌﺴﺘﻮﻯ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ،(‫ﻣلﻎ/ﻝ‬ ٤-٢ ‫)الﻬدﻑ‬ ‫ﺃياﻡ‬ ٤-٣ ‫ﻛل‬ ‫ﺑالدﻡ‬ ‫ﻣﺴﺘﻮاﻩ‬ ‫قﺲ‬ * .‫اﳉﺮﻋة‬ ‫اﻧﻘﺺ‬ ‫ﺛﻢ‬ ‫يﻮﻡ‬ ‫ﳌدة‬ ‫ﺗﻮقﻒ‬ ‫ﻣلﻎ/ﻝ‬ ٧ < ‫اﳌﺴﺘﻮﻯ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ .‫ﻣلﻎ/ﻛلﻎ‬ ٠٫٢ ‫ﲟﻘداﺭ‬ ‫اﳉﺮﻋة‬ ‫اﻧﻘﺺ‬ ‫ﻣلﻎ/ﻝ‬ ٤ < ‫اﳌﺴﺘﻮﻯ‬ .‫ﺃياﻡ‬ ‫ﺳﺒﻌة‬ ‫ﳌدة‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻭاﺣد‬ ‫ﻛيﺲ‬ ‫ﻓﻲ‬ ‫ﺛﻢ‬ ،‫ﺃياﻡ‬ ‫ﺳﺒﻌة‬ ‫ﳌدة‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻛيﺴﲔ‬ ‫ﻓﻲ‬ ‫ﺛﻢ‬ ،‫ﺃياﻡ‬ ‫ﺳﺒﻌة‬ ‫ﳌدة‬ ‫اﻷﻛياﺱ‬ ‫ﻛل‬ ‫ﻓﻲ‬ * ‫ﺇﺫا‬ ،‫ﺃياﻡ‬ ٥ ‫ﻛل‬ ‫اﳉﺮﻋة‬ ‫ﻛﺮﺭ‬ ‫ﻣلﻐﻢ/ﻝ‬ ١٢ > ‫اﳌﺴﺘﻮﻯ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ،(‫٠١ﻣلﻎ/ﻝ‬ < ‫)الﻬدﻑ‬ ‫الﺮاﺑﻊ‬ ‫اليﻮﻡ‬ ‫ﻓﻲ‬ ‫الدﻡ‬ ‫ﻓﻲ‬ ‫ﻣﺴﺘﻮاﻩ‬ ‫قﺲ‬ ** ‫اﳌﻌﺘادة‬ ‫)اﳉﺮﻋة‬ ‫ﺃياﻡ‬ ٧ ‫ﻛل‬ ‫اﳉﺮﻋة‬ ‫ﻛﺮﺭ‬ ‫ﻣلﻎ/ﻝ‬ ١٥ < ‫ﻣﺴﺘﻮاﻩ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ،‫ﺃياﻡ‬ ٦ ‫ﻛل‬ ‫اﳉﺮﻋة‬ ‫ﻛﺮﺭ‬ ‫ﻣلﻎ/ﻝ‬ ١٤-١٣ ‫اﳌﺴﺘﻮﻯ‬ ‫ﻛاﻥ‬ .(‫الﺒﻮﻝ‬ ‫ﻣﻨﻘﻄﻌﻲ‬ ‫للﻤﺮﺿﻰ‬
  • ٦٢ ‫ﺍﻟﺼﻔﺎﻕ‬ ‫ﺑﺎﻟﺘﻬﺎﺏ‬ ‫ﺍﻹﺻﺎﺑﺔ‬ ‫ﺗﻜﺮﺍﺭ‬ ‫ﻣﻨﻊ‬ :٧-٦ ‫قﺒل‬ ‫ﻣﻦ‬ ‫ﺃﺳﺒاﺑﻬا‬ ‫ﻭﺗﻘصﻲ‬ ‫للﻤﻨﻊ‬ ‫قاﺑلة‬ ‫ﺣادﺛة‬ ‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫ﺇﺻاﺑة‬ ‫ﻛل‬ ‫اﻋﺘﺒاﺭ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • .‫الصفاقية‬ ‫الديلزة‬ ‫ﻓﺮيﻖ‬ :‫)ﻣﺜاﻝ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﳊدﻭﺙ‬ ‫اﶈﺘﻤلة‬ ‫اﻷﺳﺒاﺏ‬ ‫ﻋﻦ‬ ‫لﺒﻘة‬ ‫ﺑﻄﺮيﻘة‬ ‫اﳌﺮيﺾ‬ ‫ﻣﻦ‬ ‫اﺳﺘﻌلﻢ‬ • ،‫اﻹﺑصاﺭ‬ ‫ﺿﻌﻒ‬ ،‫اﶈلﻮﻝ‬ ‫لﺘﺒديل‬ ‫ﻧﻈيﻒ‬ ‫ﻣﻜاﻥ‬ ‫ﺗﻮﻓﺮ‬ ‫ﻋدﻡ‬ ،‫الﺘﻌﻘيﻢ‬ ‫ﺗﻘﻨية‬ ‫ﻋلﻰ‬ ‫اﳊﺮﺹ‬ ‫ﻋدﻡ‬ .‫ﺣيالﻬا‬ ‫الﻼﺯﻡ‬ ‫الﻨصﺢ‬ ‫ﻭﻭﺟﻪ‬ (‫ﺇﺳﻬاﻝ‬ ‫ﺃﻭ‬ ‫ﺇﻣﺴاﻙ‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﺑﻌدﻭﻯ‬ ‫ﺣديﺜة‬ ‫ﺇﺻاﺑة‬ ‫اﳌﻨزلية‬ ‫ﻓالزياﺭاﺕ‬ ،‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫ﺇﺻاﺑة‬ ‫ﻛل‬ ‫ﺑﻌد‬ ‫اﳌﻨزﻝ‬ ‫ﻓﻲ‬ ‫ﺑزياﺭﺗﻪ‬ ‫ﻭقﻢ‬ ‫اﳌﺮيﺾ‬ ‫ﺗدﺭيﺐ‬ ‫ﺃﻋد‬ • .‫الﺘﻘﻨية‬ ‫اﻷﺧﻄاﺀ‬ ‫ﲢديد‬ ‫ﻓﻲ‬ ‫ﻋﻈيﻤة‬ ‫ﻓاﺋدة‬ ‫ﺫاﺕ‬ ‫الصفاقية‬ ‫للديلزة‬ ‫الﺴﻮداﻥ‬ ‫ﺑﺮﻧاﻣﺞ‬ ‫اﺳﺘﻤاﺭة‬ ‫ﲟلﺀ‬ ‫قﻢ‬ ،‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫ﺇﺻاﺑة‬ ‫ﻛل‬ ‫ﺑﻌد‬ • .‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫اﳌﺘﻌلﻘة‬ (٣) ‫ﺭقﻢ‬ ‫ﺍﻟﺪﻭﺍﺀ‬ ‫ﺇﻋﻄﺎﺀ‬ :٨-٦ ‫الﺘﻌﻘيﻢ‬ ‫لﺘﻘﻨية‬ ‫الدقيﻘة‬ ‫اﳌﺮاﻋاة‬ ‫ﻣﻊ‬ ‫الصفاﻕ‬ ‫داﺧل‬ ‫الفﻄﺮياﺕ‬ ‫ﻭﻣﻀاداﺕ‬ ‫اﻷدﻭية‬ ‫ﺇﻋﻄاﺀ‬ • ‫للﻤﺤلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﻛل‬ ‫ﻣﻊ‬ ‫الصفاﻕ‬ ‫داﺧل‬ ‫اﻷدﻭية‬ ‫ﺗﻮﺻﻒ‬ ‫ﺃﻥ‬ ‫ﳝﻜﻦ‬ .‫ﺑالﻮﺭيد‬ ‫ﺇﻋﻄاﺋﻬا‬ ‫ﻣﻦ‬ ‫ﺃﻓﻀل‬ ‫ﻋﻼﺝ‬ ‫ﻋﻨد‬ ‫اﳌﺴﺘﻤﺮة‬ ‫اﳉﺮﻋة‬ ‫ﺗفﻀل‬ .(‫ﻣﺘﻘﻄﻌة‬ ‫)ﺟﺮﻋة‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻭاﺣدة‬ ‫ﻣﺮة‬ ‫ﺃﻭ‬ (‫ﻣﺴﺘﻤﺮة‬ ‫)ﺟﺮﻋة‬ ‫)اﻧﻈﺮ‬ ‫اﳋاﺭﺟية‬ ‫اﳌﻌاﳉة‬ ‫ﻋﻨد‬ ‫اﳌﺘﻘﻄﻌة‬ ‫اﳉﺮﻋة‬ ‫ﺗفﻀل‬ ‫ﺣﲔ‬ ‫ﻓﻲ‬ ،‫ﺑاﳌﺴﺘﺸفﻰ‬ ‫اﳌﻨﻮﻡ‬ ‫اﳌﺮيﺾ‬ .(١٥ ‫ﻭ‬ ١٤ ‫ﺟدﻭلﻲ‬ ‫اﳊيﻮﻱ‬ ‫اﳌﻀاد‬ ‫ﻋلﻰ‬ ‫اﶈﺘﻮﻱ‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻜﻮﺙ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ‫اﳌﺘﻘﻄﻌة‬ ‫اﳉﺮﻋاﺕ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﻋﻨد‬ • ‫ﻛﻤياﺕ‬ ‫ﺑاﻣﺘصاﺹ‬ ‫للﺴﻤاﺡ‬ (‫الليلﻲ‬ ‫)اﳌﻜﻮﺙ‬ ‫ﺳاﻋاﺕ‬ ‫ﺳﺖ‬ ‫ﻋﻦ‬ ‫ﺗﻘل‬ ‫ﻻ‬ ‫ﳌدة‬ ‫الصفاﻕ‬ ‫داﺧل‬ .‫الدﻣﻮية‬ ‫الدﻭﺭة‬ ‫ﺇلﻰ‬ ‫اﳊيﻮﻱ‬ ‫اﳌﻀاد‬ ‫ﻣﻦ‬ ‫ﻛاﻓية‬ ‫ﻧفﺲ‬ ‫ﻓﻲ‬ ‫ﹰ‬‫ا‬‫ﻣﻌ‬ ‫ﻭالﺴفالﻮﺳﺒﻮﺭيﻨاﺕ‬ ‫ﻭاﻷﻣيﻨﻮﻏليﻜﻮﺳيداﺕ‬ ‫الفاﻧﻜﻮﻣيﺴﲔ‬ ‫ﺧلﻂ‬ ‫ﳝﻜﻦ‬ • ‫ﺇلﻰ‬ ‫اﻷﻣيﻨﻮﻏليﻜﻮﺳيداﺕ‬ ‫ﺇﺿاﻓة‬ ‫يﺠﻮﺯ‬ ‫ﻻ‬ ‫ﻭلﻜﻦ‬ ،‫ﻓﻌاليﺘﻬا‬ ‫ﺗفﻘد‬ ‫ﺃﻥ‬ ‫دﻭﻥ‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ .‫ﹰ‬‫ا‬‫ﻛيﻤياﺋي‬ ‫ﺗﻨاﻓﺮﻫﻤا‬ ‫ﺑﺴﺒﺐ‬ ‫الﺒﻨﺴلﲔ‬ ‫ﻣﻊ‬ ‫اﶈلﻮﻝ‬ ‫ﻧفﺲ‬ ‫ﻛل‬ ‫ﻓﻲ‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﺇلﻰ‬ ‫اﳊيﻮية‬ ‫اﳌﻀاداﺕ‬ ‫ﻹﺿاﻓة‬ ‫ﻣﺨﺘلفة‬ ‫ﻣﺤاقﻦ‬ ‫اﺳﺘﺨداﻡ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • ‫ﻻ‬ ‫ﻭلﻜﻨﻬا‬ ‫اﶈﻘﻨة‬ ‫ﻧفﺲ‬ ‫ﻓﻲ‬ ‫ﺧلﻄﺖ‬ ‫ﺇﺫا‬ ‫ﺗﺘﻨاﻓﺮ‬ ‫اﳊيﻮية‬ ‫اﳌﻀاداﺕ‬ ‫ﺑﻌﺾ‬ ‫ﺃﻥ‬ ‫ﺣيﺚ‬ ،‫اﻷﺣﻮاﻝ‬ ‫ﺣﺠﻤﻪ‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻓﻲ‬ ‫ﻭﺳفﺘاﺯدﱘ‬ ‫ﻓاﻧﻜﻮﻣيﺴﲔ‬ :‫)ﻣﺜاﻝ‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻓﻲ‬ ‫اﺧﺘلﻄﺖ‬ ‫ﺇﺫا‬ ‫ﺗﺘﻨاﻓﺮ‬ .(‫ﺃﻛﺜﺮ‬ ‫ﺃﻭ‬ ‫ليﺘﺮ‬
  • ٦١ ‫اﳌﺮيﺾ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫الدﺭﻥ‬ ‫ﺟﺮﺛﻮﻣة‬ ‫ﻋﻦ‬ ‫ﹰ‬‫ا‬‫ﻧاﺟﻤ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫ﺇﻣﻜاﻧية‬ ‫اﻋﺘﺒاﺭ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • ‫اﳌﻀاداﺕ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﺭﻏﻢ‬ ‫اﳌﺮﺿية‬ ‫اﻷﻋﺮاﺽ‬ ‫اﺳﺘﻤﺮاﺭ‬ ‫ﻣﻦ‬ ‫ﺃﻭ‬ ،‫ﻃﻮيلة‬ ‫لفﺘﺮة‬ ‫الﻬزاﻝ‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻲ‬ .‫ﺳالﺒة‬ ‫ﺯﺭﻉ‬ ‫ﻧﺘيﺠة‬ ‫ﻣﻊ‬ ‫ﹰ‬‫ا‬‫ﻧاﻛﺴ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫ﺃﻭ‬ ،‫اﳊيﻮية‬ ‫ﺍﻟﻘﺜﻄﺎﺭ‬ ‫ﺇﺯﺍﻟﺔ‬ ‫ﺩﻭﺍﻋﻲ‬ :٦-٦ ‫الﺘﻬاﺏ‬ ‫ﻣﻦ‬ ‫الﻨاﺟﻤة‬ ‫ﻭالﻮﻓياﺕ‬ ‫اﳌﺮاﺿة‬ ‫لﺘﻘليل‬ ‫ﺑالﻐة‬ ‫ﺃﻫﻤية‬ ‫ﺫاﺕ‬ ‫ﻓﺈﻧﻬا‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇﺯالة‬ ‫لزﻣﺖ‬ ‫ﺇﺫا‬ • ،‫الﻘﺜﻄاﺭ‬ ‫ﺑﻘاﺀ‬ ‫ﻭليﺲ‬ ‫الصفاﻕ‬ ‫ﻭﺳﻼﻣة‬ ‫اﳌﺮيﺾ‬ ‫ﺣياة‬ ‫ﻋلﻰ‬ ‫للﻤﺤاﻓﻈة‬ ‫ﻓاﻷﻭلﻮية‬ ،‫الصفاﻕ‬ ،‫اﳌﺴﺘﺸفﻰ‬‫ﻓﻲ‬‫اﳌﺮيﺾ‬‫ﺑﻘاﺀ‬‫ﻣدة‬‫ﺇﻃالة‬‫يصاﺣﺒﻬا‬‫اﳊﺮﻭﻥ‬‫الصفاﻕ‬‫الﺘﻬاﺏ‬‫ﻣﻌاﳉة‬‫ﺃﻣد‬‫ﻭﺇﻃالة‬ ‫ﺑﻮﻓاة‬ ‫)ﺗﻌﺮﻑ‬ ‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫اﳌﺮﺗﺒﻄة‬ ‫الﻮﻓاة‬ ‫ﺇﻥ‬ .‫اﳌﺮيﺾ‬ ‫ﻭﻓاة‬‫ﹰ‬‫ا‬‫ﻭﺃﺣياﻧ‬ ،‫الصفاﻕ‬ ‫ﻏﺸاﺀ‬ ‫ﻭﺗﻀﺮﺭ‬ ‫قﺒل‬ ‫ﺃﻭ‬ ،‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫لﻌﻼﺝ‬ ‫ﺑاﳌﺴﺘﺸفﻰ‬ ‫ﻭﺟﻮدﻩ‬ ‫ﺃﺛﻨاﺀ‬ ‫ﺃﻭ‬ ،‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻲ‬ ‫ﻣﺮيﺾ‬ .‫اﳊدﻭﺙ‬ ‫ﻧادﺭ‬‫ﹰ‬‫ا‬‫ﺃﻣﺮ‬ ‫ﺗﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ (‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﺗﺸﺨيﺺ‬ ‫ﻋلﻰ‬ ‫ﺃﺳﺒﻮﻋﲔ‬ ‫ﻣﺮﻭﺭ‬ ‫اﳊﺮﻭﻥ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ،‫الفﻄﺮﻱ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ :‫الﺘالية‬ ‫اﳊاﻻﺕ‬ ‫ﻓﻲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇﺯالة‬ ‫ﺗلزﻡ‬ • ‫ﺑﻌدﻭﻯ‬ ‫ﺐ‬‫ﹶ‬‫اﳌصاﺣ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ،(relapsing) ‫الﻨاﻛﺲ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ،(refractory) ‫الﻨفﻖ‬ ‫ﺃﻭ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻭﻋدﻭﻯ‬ ،‫الﺒﻄﻦ‬ ‫داﺧل‬ ‫ﲟﺮﺽ‬ ‫ﺐ‬‫ﹶ‬‫اﳌصاﺣ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ،‫الﻘﺜﻄاﺭ‬ .(١٣ ‫ﺟدﻭﻝ‬ ‫)اﻧﻈﺮ‬ ‫للﻌﻼﺝ‬ ‫اﳌﻘاﻭﻣة‬ ‫اﳉلدﻱ‬ ‫ﲢﺖ‬ ‫ﺑﺴﺮﻋة‬ ‫ﺻفا‬ ‫قد‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﻭﻛاﻥ‬ ‫الﻨاﻛﺲ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﺑﺴﺒﺐ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇﺯالة‬ ‫ﲤﺖ‬ ‫ﺇﺫا‬ • .‫الﻮقﺖ‬ ‫ﻧفﺲ‬ ‫ﻓﻲ‬ ‫ﺁﺧﺮ‬ ‫قﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﳝﻜﻦ‬ ‫ﻓﺈﻧﻪ‬ ‫ﺃﺳاﺑيﻊ‬ •٤ ‫ﻓﺘﺮة‬ ‫اﻻﻧﺘﻈاﺭ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ‫الفﻄﺮياﺕ‬ ‫ﻋﻦ‬ ‫الﻨاﺟﻢ‬ ‫ﺃﻭ‬ ‫اﳊﺮﻭﻥ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ .‫ﺟديد‬ ‫قﺜﻄاﺭ‬ ‫ﺑﺈدﺧاﻝ‬ ‫يﺴﻤﺢ‬ ‫ﺣﺘﻰ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇﺯالة‬ ‫ﺑﻌد‬ ‫اﻷقل‬ ‫ﻋلﻰ‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﺇﺻاﺑاﺕ‬ ‫ﺑﻌد‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﺇﻋادة‬ ‫ﺗﺘﻢ‬ ‫ﺃﻥ‬ ‫اﳌﺴﺘﺤﺴﻦ‬ ‫ﻣﻦ‬ • ‫ﻭﺟﻮد‬ ‫ﻻﺣﺘﻤاﻝ‬ ‫ﻭﺫلﻚ‬ ‫اﳌﻨاﻇيﺮ‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫ﺃﻭ‬ ‫الﺘﺸﺮيﺢ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫اﳉﺮاﺣﻲ‬ ‫اﻹدﺧاﻝ‬ ‫ﺗﻘﻨية‬ .‫ﺑاﳋياﻃاﺕ‬ ‫اﳊﻮﺽ‬ ‫ﻓﻲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺗﺜﺒيﺖ‬ ‫يﺴﺘﺤﺴﻦ‬ ‫اﳊالة‬ ‫ﻫﺬﻩ‬ ‫ﻭﻓﻲ‬ ،‫الﺘصاقاﺕ‬ ‫ﺍﻟﺼﻔﺎﻕ‬ ‫ﺍﻟﺘﻬﺎﺏ‬ ‫ﺃﻧﻮﺍﻉ‬ :١٣ ‫ﺟﺪﻭﻝ‬ ‫ﺭﺍﺟﻊ‬ (recurrent) ‫ﺳاﺑﻘة‬ ‫ﺇﺻاﺑة‬‫ﻋﻼﺝ‬ ‫اﻛﺘﻤاﻝ‬ ‫ﻣﻦ‬ ‫ﺃﺳاﺑيﻊ‬‫ﺃﺭﺑﻌة‬ ‫ﻣﺮﻭﺭ‬ ‫قﺒل‬ ‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫ﺇﺻاﺑة‬ ‫ﻣﺨﺘلفة‬ ‫ﺟﺮﺛﻮﻣة‬ ‫ﻋﻦ‬ ‫ﻧاﺟﻤة‬ ‫ﻧﺎﻛﺲ‬ (relapsing) ‫ﺳاﺑﻘة‬ ‫ﺇﺻاﺑة‬‫ﻋﻼﺝ‬ ‫اﻛﺘﻤاﻝ‬ ‫ﻣﻦ‬ ‫ﺃﺳاﺑيﻊ‬‫ﺃﺭﺑﻌة‬ ‫ﻣﺮﻭﺭ‬ ‫قﺒل‬ ‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫ﺇﺻاﺑة‬ ‫ﺳالﺒة‬ ‫ﺯﺭﻉ‬ ‫ﻧﺘيﺠة‬ ‫ﺫاﺕ‬ ‫ﺃﻭ‬ ‫اﳉﺮﺛﻮﻣة‬ ‫ﻧفﺲ‬ ‫ﻋﻦ‬ ‫ﻧاﺟﻤة‬ ‫ﻋﺎﺋﺪ‬ (repeat) ‫ﻋﻼﺝ‬ ‫اﻛﺘﻤاﻝ‬ ‫ﻋلﻰ‬ ‫ﺃﺳاﺑيﻊ‬ ‫ﺃﺭﺑﻌة‬ ‫ﻣﻦ‬ ‫ﺃﻛﺜﺮ‬ ‫ﻣﺮﻭﺭ‬ ‫ﺑﻌد‬ ‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫ﺇﺻاﺑة‬ ‫اﳉﺮﺛﻮﻣة‬ ‫ﻧفﺲ‬ ‫ﻋﻦ‬ ‫ﻧاﺟﻤة‬ ‫ﺳاﺑﻘة‬ ‫ﺇﺻاﺑة‬ ‫ﺣﺮﻭﻥ‬ (refractory) ‫ﻋلﻰ‬ ‫ﺃياﻡ‬ ٥ ‫ﻣﺮﻭﺭ‬ ‫ﺭﻏﻢ‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﻓيﻬا‬ ‫يصفﻮ‬ ‫ﻻ‬ ‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫ﺇﺻاﺑة‬ ‫اﳌﻨاﺳﺒة‬ ‫اﳊيﻮية‬ ‫ﺑاﳌﻀاداﺕ‬ ‫اﳌﻌاﳉة‬ ‫ﺑﻌﺪﻭﻯ‬ ‫ﺐ‬ ‫ﻣﺼﺎﺣﹶ‬ ‫ﺍﻟﻘﺜﻄﺎﺭ‬ ‫ﲢﺖ‬ ‫الﻨفﻖ‬ ‫ﺃﻭ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻓﻲ‬ ‫ﺑﻌدﻭﻯ‬ ‫ﺒة‬‫ﹶ‬‫ﻣصاﺣ‬ ‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫ﺇﺻاﺑة‬ ‫ﺳالﺒة‬ ‫ﺯﺭﻉ‬ ‫ﻧﺘيﺠة‬ ‫ﺫاﺕ‬ ‫ﺃﻭ‬ ‫اﳉﺮﺛﻮﻣة‬ ‫ﻧفﺲ‬ ‫ﻋﻦ‬ ‫ﻧاﺟﻤة‬ ‫اﳉلدﻱ‬
  • ٦٠ ‫ﺇلﻰ‬ ‫اﳌﺮيﺾ‬ ‫ﲢﻮيل‬ ‫ﳝﻜﻨﻚ‬ ،‫ﺳاﻋة‬ •٤٨ ‫ﻣﺮﻭﺭ‬ ‫ﺑﻌد‬ ‫الﺘﺤﺴﻦ‬ ‫ﻋﻼﻣاﺕ‬ ‫اﳌﺮيﺾ‬ ‫ﻋلﻰ‬ ‫ﺗﻈﻬﺮ‬ ‫لﻢ‬ ‫ﺇﺫا‬ ‫ﺑﻌد‬ ،‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫لﺘصفية‬ ‫ﻛﻤﺤاﻭلة‬ ‫ﺳاﻋة‬ ٢٤ ‫ﳌدة‬ (IPD) ‫اﳌﺘﻘﻄﻌة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻭاﺣدة‬ ‫ﻣﺮة‬ ‫اﶈلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﺑاﺳﺘﺜﻨاﺀ‬ ‫ﺛﻼﺛة‬ ‫ﺃﻭ‬ ‫يﻮﻣﲔ‬ ‫ﳌدة‬ ‫ﹰ‬‫ا‬‫ﺟاﻓ‬ ‫الصفاﻕ‬ ‫ﺘﺮﻙ‬‫ﹸ‬‫ي‬ ‫اﳌدة‬ ‫ﻫﺬﻩ‬ ‫الدﻡ‬ ‫ﻛﺮياﺕ‬ ‫ﺃﻥ‬ ‫ﻋلﻰ‬ ‫الدﻻﺋل‬ ‫ﺑﻌﺾ‬ ‫ﺗﻮﺟد‬ ‫ﺣيﺚ‬ ،‫الصفاﻕ‬ ‫داﺧل‬ ‫اﳊيﻮية‬ ‫اﳌﻀاداﺕ‬ ‫ﻹﻋﻄاﺀ‬ .‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻏياﺏ‬ ‫ﻓﻲ‬ ‫ﺃﻛﺒﺮ‬ ‫ﺑﻜفاﺀة‬ ‫ﺑﻮﻇيفﺘﻬا‬ ‫ﺗﻘﻮﻡ‬ ‫الصفاﻕ‬ ‫ﻓﻲ‬ ‫الﺒيﻀاﺀ‬ ‫ﻛاﻧﺖ‬ ‫ﺇﺫا‬ ،‫الﻌﻼﺝ‬ ‫ﺑدﺀ‬ ‫ﻋلﻰ‬ ‫ﺳاﻋة‬ •٧٢ ‫ﻣﺮﻭﺭ‬ ‫ﺑﻌد‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﻓﻲ‬ ‫اﳋﻼيا‬ ‫ﻭﻧﻮﻉ‬ ‫ﻋدد‬ ‫ﻓﺤﺺ‬ ‫د‬‫ﹺ‬‫ﻋ‬‫ﺃ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﻋﻦ‬ ‫ﺗﻮقﻒ‬ ‫ﻭلﻜﻦ‬ ‫ﺃﺳﺒﻮﻋﲔ‬ ‫ﳌدة‬ ‫الﻌﻼﺝ‬ ‫ﻓﻲ‬ ‫اﺳﺘﻤﺮ‬ ‫ﺑالﺘﺤﺴﻦ‬ ‫ﺑدﺃﺕ‬ ‫قد‬ ‫الﻌدﻭﻯ‬ ‫ﺑﺘﻐييﺮ‬ ‫قﻢ‬ ‫ﺛﻢ‬ .‫اﻷﻣﺮ‬ ‫ﺑادﺉ‬ ‫ﻓﻲ‬ ‫اﺳﺘﻌﻤلﺘﻬا‬ ‫قد‬ ‫ﻛﻨﺖ‬ ‫ﺇﺫا‬ ‫ﺃﻣيﻨﻮﻏليﻜﻮﺳيد‬ ‫ﻧﻮﻉ‬ ‫ﻣﻦ‬ ‫اﻷدﻭية‬ .‫الﻌﻼﺝ‬ ‫اﻛﺘﻤاﻝ‬ ‫ﺑﻌد‬ ‫الﺘﻮﺻيل‬ ‫ﺟﻬاﺯ‬ ‫ﻧﺘيﺠة‬‫ﻭﻛاﻧﺖ‬‫الﻌﻼﺝ‬‫ﺑدﺀ‬‫ﻋلﻰ‬‫ﺳاﻋة‬ •٧٢‫ﻣﺮﻭﺭ‬‫ﺑﻌد‬‫الﻌدﻭﻯ‬‫ﲢﺴﻦ‬‫ﻋلﻰ‬‫دﻻلة‬‫ﻫﻨاﻙ‬‫ﺗﻜﻦ‬‫لﻢ‬‫ﺇﺫا‬ ‫اﺣﺘﻤاﻝ‬ ‫اﻋﺘﺒاﺭﻙ‬ ‫ﻓﻲ‬ ‫ﹰ‬‫ا‬‫ﻭاﺿﻌ‬ ‫للزﺭﻉ‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﺃﺧﺮﻯ‬ ‫ﻋيﻨة‬ ‫ﺃﺭﺳل‬ ،‫ﺳالﺒة‬ ‫ﺗزاﻝ‬ ‫ﻣا‬ ‫الزﺭﻉ‬ .(mycobacterium) ‫ﺮة‬ ‫ﱢ‬‫ﻣﺘفﻄ‬ ‫ﺟﺮﺛﻮﻣة‬ ‫ﺃﻭ‬ (fungus) ‫ﹰ‬‫ا‬‫ﻓﻄﺮ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﺳﺒﺐ‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ .‫ﺁﺧﺮيﻦ‬ ‫يﻮﻣﲔ‬ ‫ﳌدة‬ ‫الﻌﻼﺝ‬ ‫ﺑﻬا‬ ‫ﺑدﺃﺕ‬ ‫الﺘﻲ‬ ‫اﳊيﻮية‬ ‫اﳌﻀاداﺕ‬ ‫ﻧفﺲ‬ ‫ﺇﻋﻄاﺀ‬ ‫ﻓﻲ‬ ‫اﺳﺘﻤﺮ‬ ‫ﻓاﺗﺮﻙ‬ ‫ﺑالﺘﺤﺴﻦ‬ ‫اﳌﺮيﺾ‬ ‫ﺑدﺃ‬ ‫ﺇﺫا‬ ،‫الﻌﻼﺝ‬ ‫ﺑدﺀ‬ ‫ﻋلﻰ‬ ‫ﺃياﻡ‬ ‫ﺧﻤﺴة‬ ‫ﻣﺮﻭﺭ‬ ‫ﺑﻌد‬ ‫اﳌﺮيﺾ‬ ‫ﺣالة‬ ‫ﻢ‬‫ﱢ‬‫ي‬‫ق‬ • ‫ﻭﺇﺫا‬،‫اﳊيﻮية‬‫اﳌﻀاداﺕ‬‫ﺑﺘﻌديل‬‫ﻓﻘﻢ‬‫ﻣﻮﺟﺒة‬‫الﺜاﻧية‬‫الزﺭﻉ‬‫ﻧﺘيﺠة‬‫ﻛاﻧﺖ‬‫ﺇﺫا‬.‫ﻣﻜاﻧﻪ‬‫ﻓﻲ‬‫الﻘﺜﻄاﺭ‬ ‫يﺴﺘﻤﺮ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ .‫اﳌﺒدﺋﻲ‬ ‫الﻌﻼﺝ‬ ‫ﻧفﺲ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﻓﻮاﺻل‬ ‫ﺳالﺒة‬ ‫الﺜاﻧية‬ ‫الزﺭﻉ‬ ‫ﻧﺘيﺠة‬ ‫ﻛاﻧﺖ‬ .‫الﻌﻼﺝ‬ ‫اﻛﺘﻤاﻝ‬ ‫ﺑﻌد‬ ‫الﺘﻮﺻيل‬ ‫ﺟﻬاﺯ‬ ‫ﺗﻐييﺮ‬ ‫ﻣﻦ‬ ‫ﻭﻻﺑد‬ ‫اﻷقل‬ ‫ﻋلﻰ‬ ‫ﺃﺳﺒﻮﻋﲔ‬ ‫ﳌدة‬ ‫الﻌﻼﺝ‬ ‫الزﺭﻉ‬ ‫ﻧﺘيﺠة‬ ‫ﻭﻛاﻧﺖ‬ ‫الﻌﻼﺝ‬ ‫ﺑدﺀ‬ ‫ﻋلﻰ‬ ‫ﺃياﻡ‬ ‫ﺧﻤﺴة‬ ‫ﻣﺮﻭﺭ‬ ‫ﺑﻌد‬ ‫ﺑالﺘﺤﺴﻦ‬ ‫اﳌﺮيﺾ‬ ‫يﺒدﺃ‬ ‫لﻢ‬ ‫ﺇﺫا‬ • ‫ﲢﺴﻦ‬ ‫ﻳﺤﺪﺙ‬ ‫ﻟﻢ‬ ‫ﺇﺫﺍ‬ ‫ﻭ‬ ،‫الزﺭﻉ‬ ‫ﻧﺘيﺠة‬ ‫ﺣﺴﺐ‬ ‫اﳊيﻮية‬ ‫اﳌﻀاداﺕ‬ ‫ﺑﺘﻌديل‬ ‫ﻓﻘﻢ‬ ‫ﻣﻮﺟﺒة‬ ‫الﺜاﻧية‬ ‫ﳌدة‬ ‫الﻌﻼﺝ‬ ‫يﺴﺘﻤﺮ‬ ‫ﺃﻥ‬ ‫ﻋلﻰ‬ ،‫ﺍﻟﻘﺜﻄﺎﺭ‬ ‫ﺇﺯﺍﻟﺔ‬ ‫ﻣﻦ‬ ‫ﻓﻼﺑﺪ‬ ‫ﺃﺧﺮﻯ‬ ‫ﺃﻳﺎﻡ‬ ‫ﺧﻤﺴﺔ‬ ‫ﻣﺮﻭﺭ‬ ‫ﺑﻌﺪ‬ ‫ﻭﺍﺿﺢ‬ .‫اﻷقل‬ ‫ﻋلﻰ‬ ‫ﺃﺳﺒﻮﻋﲔ‬ ‫الزﺭﻉ‬ ‫ﻧﺘيﺠة‬ ‫ﻭﻛاﻧﺖ‬ ‫الﻌﻼﺝ‬ ‫ﺑدﺀ‬ ‫ﻋلﻰ‬ ‫ﺃياﻡ‬ ‫ﺧﻤﺴة‬ ‫ﻣﺮﻭﺭ‬ ‫ﺑﻌد‬ ‫ﺑالﺘﺤﺴﻦ‬ ‫اﳌﺮيﺾ‬ ‫يﺒدﺃ‬ ‫لﻢ‬ ‫ﺇﺫا‬ • ‫اﳌﻌاﳉة‬ ‫ﺑﻬا‬ ‫ﺑدﺃﺕ‬ ‫الﺘﻲ‬ ‫اﳊيﻮية‬ ‫اﳌﻀاداﺕ‬ ‫ﻭاﺳﺘﺒدﻝ‬ ،‫ﺍﻟﻘﺜﻄﺎﺭ‬ ‫ﺑﺈﺯﺍﻟﺔ‬ ‫ﻓﻘﻢ‬ ‫ﺳالﺒة‬ ‫الﺜاﻧية‬ .‫اﻷقل‬ ‫ﻋلﻰ‬ ‫ﺃﺳﺒﻮﻋﲔ‬ ‫ﳌدة‬ ‫الﻌﻼﺝ‬ ‫يﺴﺘﻤﺮ‬ ‫ﺃﻥ‬ ‫ﻋلﻰ‬ ‫ﻭﺟﻨﺘاﻣيﺴﲔ‬ ‫ﺑفاﻧﻜﻮﻣيﺴﲔ‬ •Pseudomonas) ‫الزﳒاﺭية‬ ‫الزاﺋفة‬ ‫اﳉﺮﺛﻮﻣة‬ ‫ﻋﻦ‬ ‫الﻨاﰋ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﻣﻌاﳉة‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﻣﻌاﳉة‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ .‫ﻭاﺣد‬ ‫ﻭقﺖ‬ ‫ﻓﻲ‬ ‫اﳊيﻮية‬ ‫اﳌﻀاداﺕ‬ ‫ﻣﻦ‬ ‫ﺑﻨﻮﻋﲔ‬ (aeruginosa ،‫الﻐﺮاﻡ‬‫ﺳالﺒة‬‫ﺃﻭاﳉﺮاﺛيﻢ‬،(Staphylococcusaurius)‫الﺬﻫﺒية‬‫الﻌﻨﻘﻮدية‬‫اﳉﺮاﺛيﻢ‬‫ﻋﻦ‬‫الﻨاﰋ‬ .‫ﻻ‬ ‫ﺃﻭ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇﺯالة‬ ‫ﲤﺖ‬ ‫ﺳﻮاﺀ‬ ،‫اﻷقل‬ ‫ﻋلﻰ‬ ‫ﺃﺳاﺑيﻊ‬ ‫ﺛﻼﺛة‬ ‫ﳌدة‬ ‫ة‬‫ﱠ‬‫ي‬‫ﹺ‬‫ﻮ‬‫ﹶ‬‫ﻌ‬‫ﹺ‬‫ﳌ‬‫ا‬ ‫ﹸ‬‫ﺭاﺕ‬‫ﱠ‬‫ﻮ‬‫ﻜ‬‫ﹸ‬‫ﳌ‬‫ﺃﻭا‬ (‫ﺃﻭﺑالزﺭﻉ‬ ‫اﺠﻤﻟﻬﺮﻱ‬ ‫ﺑالفﺤﺺ‬ ‫ﺗﺸﺨيصﻪ‬ ‫ﰎ‬ ‫)ﺳﻮاﺀ‬ ‫الفﻄﺮياﺕ‬ ‫ﻋﻦ‬ ‫الﻨاﺟﻢ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ • ‫اﶈلﻮﻝ‬ ‫يصفﻮ‬ ‫ﺣﺘﻰ‬ ‫الصفاﻕ‬ ‫ﻏﺴل‬ ‫ﺫلﻚ‬ ‫يﺴﺒﻖ‬ ‫ﺃﻥ‬ ‫ﻋلﻰ‬ ،‫ﹰ‬‫ﻓﻮﺭﺍ‬ ‫ﺍﻟﻘﺜﻄﺎﺭ‬ ‫ﺇﺯﺍﻟﺔ‬ ‫ﻳﺴﺘﻮﺟﺐ‬ ‫الفلﻮﻛﻮﻧاﺯﻭﻝ‬ ‫يﻮﺻﻒ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ .‫الفﻄﺮﻱ‬ ‫الﻌﺐﺀ‬ ‫ﻭﺗﻘليل‬ ‫اﻻلﺘصاقاﺕ‬ ‫ﺗﻜﻮﻥ‬ ‫لﺘﺠﻨﺐ‬ ‫اﳋاﺭﺝ‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻲ‬ ‫اﳌﺮيﺾ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫ﺇﻻ‬ ‫الفﻄﺮﻱ‬ ‫الصفاﻕ‬ ‫ﻻلﺘﻬاﺏ‬ ‫ﻣﺒدﺋﻲ‬ ‫ﻛﻌﻼﺝ‬ ‫ﺃﺳاﺑيﻊ‬ ‫ﺃﺭﺑﻌة‬ ‫ﳌدة‬ ‫ﺑصﻮﺭة‬ (azole) ‫اﻵﺯﻭﻝ‬ ‫ﻧﻮﻉ‬ ‫ﻣﻦ‬ ‫الفﻄﺮياﺕ‬ ‫ﻣﻀاداﺕ‬ ‫اﺳﺘﻌﻤل‬ ‫قد‬ ‫ﻛاﻥ‬ ‫ﺃﻭ‬ ‫ﺷديدة‬ ‫ﻋدﻭﻯ‬ ‫ﺟﺮﻋة‬ ‫ﺇلﻰ‬ ‫)يﺤﺘاﺝ‬ ‫ﺑالﻮﺭيد‬ «‫»ﺏ‬ ‫ﺃﻣفﻮﺗيﺮيﺴﲔ‬ ‫ﺇﺿاﻓة‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ‫اﳊالة‬ ‫ﻫﺬﻩ‬ ‫ﻓفﻲ‬ ،‫ﻣﺘﻜﺮﺭة‬ .‫الﺘﺄﺛيﺮ‬ ‫قاﺑلية‬ ‫ﻣﻊ‬ ‫الزﺭﻉ‬ ‫ﻧﺘاﺋﺞ‬ ‫ﺗﻈﻬﺮ‬ ‫ﺣﺘﻰ‬ (‫ﺃﻭلية‬ ‫ﲡﺮيﺒية‬
  • ٥٩ ‫ﻣﺮاﺟﻌة‬ ‫ﻣﻦ‬ ‫ﻓﻼﺑد‬ ‫ﺫلﻚ‬ ‫ﺣدﺙ‬‫ﻭﺇﺫا‬،٪ •٢٠ ‫الزﺭﻉ‬‫ﺳالﺐ‬‫الصفاﻕ‬‫الﺘﻬاﺏ‬‫ﻧﺴﺒة‬‫ﺗﺘﺠاﻭﺯ‬‫ﺃﻥ‬‫يﺠﺐ‬‫ﻻ‬ .‫الﻼﺯﻣة‬ ‫الﺘﻌديﻼﺕ‬ ‫ﻭﺇدﺧاﻝ‬ ‫الزﺭﻉ‬ ‫ﺗﻘﻨية‬ ‫ﺍﻟﻌﻼﺝ‬ ‫ﻭﺧﻄﻮﺍﺕ‬ ‫ﻣﺒﺎﺩﺉ‬ :٥-٦ ‫ﺯاﻝ‬ ‫ﻣا‬ ‫اﳌﺮيﺾ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ( •opioids) ‫اﳌفﻌﻮﻝ‬ ‫ﻭﺃﻓيﻮﻧياﺕ‬ ‫الﺒاﺭاﺳيﺘاﻣﻮﻝ‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫اﻷلﻢ‬ ‫ﻦ‬‫ﱢ‬‫ﺳﻜ‬ ‫ﻭاﺳﺘﺨدﻡ‬ ،(‫ﺑﺜيديﻦ‬ ،‫ﻣﻮﺭﻓﲔ‬ ،‫ﺗﺮاﻣادﻭﻝ‬ :‫)ﻣﺜاﻝ‬ ‫قيﻤة‬ ‫ﺫاﺕ‬ ‫ﻣﺘﺒﻘية‬ ‫ﻛلﻮية‬ ‫ﺑﻮﻇيفة‬ ‫ﹰ‬‫ا‬‫ﻣﺘﻤﺘﻌ‬ ‫قيﻤة‬ ‫ﺫاﺕ‬ ‫ﻣﺘﺒﻘية‬ ‫ﻛلﻮية‬ ‫ﻭﻇيفة‬ ‫للﻤﺮيﺾ‬ ‫يﻜﻦ‬ ‫لﻢ‬ ‫ﺇﺫا‬ (NSAIDs) ‫ﹰ‬‫ا‬‫ﻻﺳﺘيﺮﻭيدي‬ ‫ﹰ‬‫ا‬‫ﻣﺴﻜﻨ‬ .(‫ديﻜلﻮﻓيﻨاﻙ‬ ،‫ﺁيﺒﻮﺑﺮﻭﻓﲔ‬ :‫)ﻣﺜاﻝ‬ ‫ﻭالﺜالﺚ‬ ‫الﺜاﻧﻲ‬ ‫اﳉيل‬ ‫ﻣﻦ‬ ‫ﺳفالﻮﺳﺒﻮﺭيﻦ‬ ‫ﻓصيلة‬ ‫ﻣﻦ‬ ‫ﹰ‬‫ا‬‫ﻣﻌ‬ ‫ﺑدﻭاﺋﲔ‬ ‫الﺘﺠﺮيﺒﻲ‬ ‫الﻌﻼﺝ‬ ‫اﺑدﺃ‬ • ‫ﹰ‬‫ا‬‫ﻋﻮﺿ‬ ‫ﺃﻣيﻨﻮﻏليﻜﻮﺳيد‬ ‫ﻣﺠﻤﻮﻋة‬ ‫ﻣﻦ‬ ‫دﻭاﺀ‬ ‫اﺳﺘﺨداﻡ‬ ‫ﳝﻜﻦ‬ .(‫ﺳفﺘاﺯدﱘ‬ ‫ﻣﻊ‬ ‫ﺳفاﺯﻭلﲔ‬ :‫)ﻣﺜاﻝ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﺗﻌﺬﺭ‬ ‫ﺇﺫا‬ ‫الﻐﺮاﻡ‬ ‫ﺳالﺒة‬ ‫اﳉﺮاﺛيﻢ‬ ‫لﺘﻐﻄية‬ ‫الﺜالﺚ‬ ‫اﳉيل‬ ‫ﻣﻦ‬ ‫الﺴفالﻮﺳﺒﻮﺭيﻦ‬ ‫ﻋﻦ‬ .‫الﺜالﺚ‬ ‫اﳉيل‬ ‫ﻣﻦ‬ ‫ﺳفالﻮﺳﺒﻮﺭيﻦ‬ ‫قﻮقﻌﻲ‬ ‫ﺃﻭ‬ ‫ﺃﺫﻧﻲ‬ ‫ﺗﺴﻤيﻢ‬ ‫ﺣدﻭﺙ‬ ‫اﺣﺘﻤاﻝ‬ ‫ﺃﻣيﻨﻮﻏليﻜﻮﺳيد‬ ‫ﻣﺠﻤﻮﻋة‬ ‫ﻣﻦ‬ ‫دﻭاﺀ‬ ‫ﺃﻱ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫يصاﺣﺐ‬ • ‫اﺳﺘﻌﻤالﻪ‬ ‫ﺃﻭ‬ ،‫ﻋالية‬ ‫ﺑﺠﺮﻋاﺕ‬ ‫اﺳﺘﻌﻤالﻪ‬ ‫ﻋﻨد‬ ‫ﺧاﺻة‬ ،‫ﻣﻨﻪ‬ ‫الﺸفاﺀ‬ ‫يﺘﻌﺬﺭ‬ (cochlear) ‫لﺘﻘليل‬ .‫اﳌﺴﻨﲔ‬ ‫اﳌﺮﺿﻰ‬ ‫ﻣﻊ‬ ‫ﺧاﺻة‬ ‫ﺑصفة‬ ‫ﻫﺬا‬ ‫ﻭيﺤدﺙ‬ ،‫ﻣﺘﻜﺮﺭة‬ ‫ﺑصﻮﺭة‬ ‫ﺃﻭ‬ ،‫ﻃﻮيلة‬ ‫لفﺘﺮاﺕ‬ .‫الصفاﻕ‬ ‫داﺧل‬ ‫اﳌﺘﻘﻄﻊ‬ ‫لﻼﺳﺘﻌﻤاﻝ‬ ‫اﳉﺄ‬ ‫اﻻﺣﺘﻤاﻝ‬ ‫ﻫﺬا‬ ‫الصفاقﻲ‬ ‫اﻻلﺘﻬاﺏ‬ ‫ﺣاﻻﺕ‬ ‫ﻓﻲ‬ ‫لﻸﻃفاﻝ‬ ‫ﻻﺳﺘﻌﻤالﻪ‬ ‫يصلﺢ‬ ‫ﺫﻛﺮﻩ‬ ‫الﺴاﺑﻖ‬ ‫الﻌﻼﺟﻲ‬ ‫الﻨﻈاﻡ‬ • ‫ﺃلﻢ‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻲ‬ ‫ﺃﻭ‬ ،‫ﻣﺤﻤﻮﻡ‬ ‫الﻄفل‬ ‫ﺃﻥ‬ ‫ﺑدليل‬‫ﹰ‬‫ا‬‫ﺷديد‬ ‫الصفاقﻲ‬ ‫اﻻلﺘﻬاﺏ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫ﺃﻣا‬ .‫الﻌادية‬ (riskfactorforsevereinfection)‫الﻌدﻭﻯ‬‫اﺧﺘﻄاﺭ‬‫ﻋﻮاﻣل‬‫ﺃﺣد‬‫ﻣﻦ‬‫يﻌاﻧﻲ‬‫ﺃﻭ‬،‫ﺑالﺒﻄﻦ‬‫ﺷديد‬ ‫ﻭﺟﻮد‬ ‫ﺃﻭ‬ ،(MRSA) ‫للﻤﺜيﺴيلﲔ‬ ‫اﳌﻘاﻭﻣة‬ ‫الﺬﻫﺒية‬ ‫الﻌﻨﻘﻮدية‬ ‫ﺑاﳉﺮاﺛيﻢ‬ ‫ﺳاﺑﻘة‬ ‫ﻋدﻭﻯ‬ :‫)ﻣﺜاﻝ‬ ‫ﻣﺨﺮﺝ‬ ‫ﺃﻭ‬ ‫ﺑاﻷﻧﻒ‬ ‫ﺟﺮﺛﻮﻣﻲ‬ ‫اﺳﺘﻌﻤاﺭ‬ ‫ﻭﺟﻮد‬ ‫ﺃﻭ‬ ،‫ﺑالﻘﺜﻄاﺭ‬ ‫ﺣديﺜة‬ ‫ﺃﻭ‬ ‫ﺣالية‬ ‫ﻋدﻭﻯ‬ ‫ﻋلﻰ‬ ‫دﻻلة‬ ‫ﻣﺜل‬ ‫ﻓﻲ‬ .(‫ﻋاﻣﲔ‬ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫الﻄفل‬ ‫ﻋﻤﺮ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫ﺃﻭ‬ ،‫الﺬﻫﺒية‬ ‫الﻌﻨﻘﻮدية‬ ‫ﺑاﳉﺮﺛﻮﻣة‬ ‫الﻘﺜﻄاﺭ‬ ‫اﳉيل‬ ‫ﻣﻦ‬ ‫ﺳفالﻮﺳﺒﻮﺭيﻦ‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ ‫ﺗايﻜﻮﺑﻼﻧﲔ‬ ‫ﺃﻭ‬ ‫ﻓاﻧﻜﻮﻣيﺴﲔ‬ ‫اﺳﺘﻌﻤل‬ ‫اﳊاﻻﺕ‬ ‫ﻫﺬﻩ‬ .‫ﲡﺮيﺒﻲ‬ ‫ﻛﻌﻼﺝ‬ ‫الﺜالﺚ‬ ‫ﻣﺤلﻮﻝ‬ ‫ﺇلﻰ‬ ‫الﻬيﺒاﺭيﻦ‬ ‫ﺇﺿاﻓة‬ ‫ﻣﻦ‬ ‫اﳌﺮيﺾ‬ ‫يﺴﺘفيد‬ ‫ﻓﻘد‬ ‫ﹰ‬‫ا‬‫ﺟد‬ ‫ﹰ‬‫ا‬‫ﻋﻜﺮ‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ • ‫ﲡﻨﺐ‬ ‫يﺴﺘﺤﺴﻦ‬ ‫ﻛﻤا‬ ،(fibrin) ‫ﺑالفيﺒﺮيﻦ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﳌﻌة‬ ‫اﻧﺴداد‬ ‫ﳌﻨﻊ‬ (‫ﻭﺣدة/ﻝ‬ ٥٠٠) ‫الديلزة‬ .‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫اﻹﺻاﺑة‬ ‫ﺃﺛﻨاﺀ‬ ‫الﺘﺮﻛيز‬ ‫ﻋالﻲ‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫ﻣﺤلﻮﻝ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﻭيﺒدﺃ‬ ،‫الﺘﺤﺴﻦ‬ ‫ﻋﻼﻣاﺕ‬ ‫اﳌﺮﺿﻰ‬ ‫ﻣﻌﻈﻢ‬ ‫ﻋلﻰ‬ ‫ﺗﻈﻬﺮ‬ ‫الﻌﻼﺝ‬ ‫ﺑدﺀ‬ ‫ﻋلﻰ‬ ‫ﺳاﻋة‬ •٤٨ ‫ﻣﺮﻭﺭ‬ ‫ﺑﻌد‬ .‫الﺘدﺭيﺠﻲ‬ ‫الصفﻮ‬ ‫ﻓﻲ‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﻓﻘﻢ‬ ‫ﺇيﺠاﺑية‬ ‫الزﺭﻉ‬ ‫ﻧﺘيﺠة‬ ‫ﻛاﻧﺖ‬ ‫ﺇﺫا‬ ‫ﻇﻬﺮﺕ؛‬ ‫قد‬ ‫الزﺭﻉ‬ ‫ﻧﺘيﺠة‬ ‫ﺗﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫ﻻﺑد‬ ‫اﻷﺛﻨاﺀ‬ ‫ﻫﺬﻩ‬ ‫ﻓﻲ‬ • .‫الﻨﺘيﺠة‬ ‫ﺣﺴﺐ‬ ‫الﻌﻼﺝ‬ ‫ﺑﺘﻌديل‬
  • ٥٨ ،‫ﺣﻤﻰ‬ ‫ﺃﻭ‬ ،‫ﺑالﺒﻄﻦ‬ ‫ﺃلﻢ‬ ‫ﻣﻦ‬ ‫ﹰ‬‫ا‬‫ﺷاﻛي‬ ‫اﳌﺮيﺾ‬ ‫ﺣﻀﺮ‬ ‫ﺇﺫا‬ ‫ﺑالصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﻭﺟﻮد‬ ‫ﺇﻣﻜاﻧية‬ ‫ﻓﻲ‬ ‫ﻓﻜﺮ‬ • .‫ﹰ‬‫ا‬‫ﺻاﻓي‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﻛاﻥ‬ ‫لﻮ‬ ‫ﺣﺘﻰ‬ ،‫ﻋاﻡ‬ ‫ﺿﻌﻒ‬ ‫ﺃﻭ‬ ،‫ﻏﺜياﻥ‬ ‫ﺃﻭ‬ ‫ﺣﺴﺐ‬ ‫اﳌﻤﺮﺽ‬ ‫ﺑﻮاﺳﻄة‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﻋﻼﺝ‬ ‫يﺒدﺃ‬ ‫ﺃﻥ‬ ‫ﳝﻜﻦ‬ ‫الﻌﻼﺝ‬ ‫ﺑدﺀ‬ ‫ﻓﻲ‬ ‫ﺗﺄﺧيﺮ‬ ‫ﺃﻱ‬ ‫ﳌﻨﻊ‬ • ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﺗﻌﻜﺮ‬ ‫ﺭﺅية‬ ‫ﲟﺠﺮد‬ ‫اﳊيﻮية‬ ‫اﳌﻀاداﺕ‬ ‫ﺑدﺀ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ‫ﺇﺫ‬ ،‫اﶈددة‬ ‫الﻌﻼﺝ‬ ‫ﺧﻄﻮاﺕ‬ ‫ﻣﻦ‬ ‫الﺘﺤﻘﻖ‬ ‫ليﺘﻢ‬ ‫ﺃﺧﺬﺕ‬ ‫الﺘﻲ‬ ‫للﻌيﻨاﺕ‬ ‫الفﺤﻮﺹ‬ ‫لﻨﺘاﺋﺞ‬ ‫اﻻﻧﺘﻈاﺭ‬ ‫ﺑدﻭﻥ‬ ‫ﻣﻨﻪ‬ ‫ﻋيﻨة‬ ‫ﻭﺃﺧﺬ‬ .‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﻓﻲ‬ ‫اﳋﻼيا‬ ‫ﻋدد‬ ‫ﻓﺤﺺ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫الﺘﺸﺨيﺺ‬ ‫اﳉلدﻱ‬ ‫ﲢﺖ‬ ‫ﻭالﻨفﻖ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫اﻓﺤﺺ‬ ،‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﻭﺟﻮد‬ ‫اﺣﺘﻤاﻝ‬ ‫ﻓﻲ‬ ‫ﺷﻜﻜﺖ‬ ‫ﺇﺫا‬ • ‫ﻣﻦ‬ ‫ﻓﻼﺑد‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻣﻦ‬ ‫ﳒيﺞ‬ ‫ﺃﻱ‬ ‫ﺟد‬‫ﹸ‬‫ﻭ‬ ‫ﻭﺇﺫا‬ ،‫ﻋدﻭﻯ‬ ‫ﻭﺟﻮد‬ ‫ﻋﻼﻣاﺕ‬ ‫ﻋﻦ‬‫ﹰ‬‫ا‬‫ﺑﺤﺜ‬ ‫دقيﻘة‬ ‫ﺑصﻮﺭة‬ .‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﺯﺭﻉ‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ ‫ﺯﺭﻋﻪ‬ ٪ •٥٠ ‫ﻭﻛاﻥ‬ ،‫٠٠١/ﻣيﻜﺮﻭليﺘﺮ‬ ‫ﻣﻦ‬ ‫ﺃﻛﺜﺮ‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﻓﻲ‬ ‫الﺒيﻀاﺀ‬ ‫الدﻡ‬ ‫اﺕ‬‫ﱠ‬‫ي‬‫ﻛﺮ‬ ‫ﻋدد‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫يﺆﻛد‬ ‫ﻓﻬﺬا‬ ،(polymorphonuclear neutrophils) ‫ﻯ‬‫ﹶ‬‫ﻮ‬‫الﻨ‬ ‫دة‬‫ﱢ‬‫د‬‫ﹶ‬‫ﻌ‬‫ﹶ‬‫ﺘ‬‫ﹸ‬‫ﻣ‬ ‫ﻻﺕ‬‫ﹺ‬‫د‬‫ﹶ‬‫ﻋ‬ ‫اﻷقل‬ ‫ﻋلﻰ‬ ‫ﻣﻨﻬا‬ .‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﺗﺸﺨيﺺ‬ ‫ﺃية‬ ‫ﻋﻦ‬‫ﹰ‬‫ا‬‫ﻓﻮﺭ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺮﻛز‬ ‫يﺒلﻎ‬ ‫ﺃﻥ‬ ‫ﻣﻦ‬ ‫ﻓﻼﺑد‬ ،‫ﻧاﺀ‬ ‫ﻣﻜاﻥ‬ ‫ﻓﻲ‬ ‫يﻌيﺶ‬ ‫اﳌﺮيﺾ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ • ‫يﺒﻄﺊ‬ ‫ﺣﺘﻰ‬ ‫اد‬‫ﱠ‬‫ﺮ‬‫الﺒ‬ ‫ﻓﻲ‬ ‫الﻌﻜﺮ‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﻛيﺲ‬ ‫يﻀﻊ‬ ‫ﻭﺃﻥ‬ ،‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﻋلﻰ‬ ‫ﺗدﻝ‬ ‫ﺃﻋﺮاﺽ‬ ،‫للفﺤﺺ‬ ‫ﻋيﻨة‬ ‫ﺇﺣﻀاﺭ‬ ‫ﻓيﻪ‬ ‫ﳝﻜﻨﻪ‬ ‫الﺬﻱ‬ ‫الﻮقﺖ‬ ‫ﺇلﻰ‬ ‫الﺒيﻀاﺀ‬ ‫اﳋﻼيا‬ ‫ﻭﻣﻮﺕ‬ ‫اﳉﺮاﺛيﻢ‬ ‫ﺗﻜاﺛﺮ‬ .‫اﳌﻨزﻝ‬ ‫ﻓﻲ‬ ‫الصفاﻕ‬ ‫داﺧل‬ ‫اﳊيﻮية‬ ‫اﳌﻀاداﺕ‬ ‫ﺗﻨاﻭﻝ‬ ‫ﺑدﺀ‬ ‫ﳝﻜﻨﻪ‬ ‫قد‬ ‫ﻛﻤا‬ ‫ﺍﻟﻌﻴﻨﺔ‬ ‫ﻣﻌﺎﳉﺔ‬ ‫ﻃﺮﻳﻘﺔ‬ :٤-٦ ‫ﺗﻼﺣﻆ‬ ‫ﻛيﺲ‬ ‫ﺃﻭﻝ‬ ‫ﺇﺭﺳاﻝ‬ ‫)يﺴﺘﺤﺴﻦ‬ ‫الدقيﻘة‬ ‫اﻷﺣياﺀ‬ ‫ﻣﺨﺘﺒﺮ‬ ‫ﺇلﻰ‬‫ﹰ‬‫ﻼ‬‫ﻛاﻣ‬ ‫اﶈلﻮﻝ‬ ‫ﻛيﺲ‬ ‫ﺃﺭﺳل‬ • .‫ﻭالزﺭﻉ‬ ‫ﻏﺮاﻡ‬ ‫لﻄﺨة‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ ‫ﻭﻧﻮﻋﻬا‬ ‫اﳋﻼيا‬ ‫ﻋدد‬ ‫ﻓﺤﺺ‬ ‫ﻭاﻃلﺐ‬ ،(‫ﻋﻜاﺭﺗﻪ‬ ‫ﻣل‬ •٥٠ ‫لﻨﺒﺬ‬ (centrifuge) ‫اﳌﻨﺒﺬة‬ ‫اﺳﺘﺨدﻡ‬ ،‫الزﺭﻉ‬ ‫ﻣﻦ‬ ‫ﳑﻜﻨة‬ ‫ﻧﺘيﺠة‬ ‫ﺃﻓﻀل‬ ‫ﻋلﻰ‬ ‫للﺤصﻮﻝ‬ ‫ﺑﻜﻤية‬ (sedement) ‫الﻨفالة‬ ‫اﺧلﻂ‬ ‫ﺛﻢ‬ ،‫دقيﻘة‬ ١٥ ‫ﳌدة‬ ‫ﻏﻢ‬ ٣٠٠٠ ‫ﺑﺴﺮﻋة‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ solid) ‫ﺻلﺒة‬ ‫ﻣﺴﺘﻨﺒﺘاﺕ‬ ‫ﻓﻲ‬ ‫الﻨاﰋ‬ ‫ﻭلﻘﺢ‬ ،‫الﻨﻈاﻣﻲ‬ ‫اﳌلﺤﻲ‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻣل‬ ٥ - ٣ ‫قدﺭﻫا‬ ‫ﺑاﻹﺿاﻓة‬ ،‫الﻘليل‬ ‫الﻬﻮاﺀ‬ ‫ﻭﺃليفة‬ ،‫الﻬﻮاﺀ‬ ‫ﺃليفة‬ ،‫ﻫﻮاﺋية‬ ‫ﻇﺮﻭﻑ‬ ‫ﻓﻲ‬ ‫ﲢﻀﻦ‬ (culture media .‫الﻘياﺳﻲ‬ (blood culture media) ‫الدﻡ‬ ‫ﻣﺴﺘﻨﺒﺖ‬ ‫ﺇلﻰ‬ ‫ﻣﻨﻪ‬ ‫ﻣل‬ •١٠ - ٥ ‫اﺣﻘﻦ‬ ،‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻛﺒيﺮة‬ ‫ﻛﻤياﺕ‬ ‫لﻨﺒﺬ‬ ‫الﻼﺯﻣة‬ ‫اﳌﻌداﺕ‬ ‫ﺗﺘﻮﻓﺮ‬ ‫لﻢ‬ ‫ﺇﺫا‬ .‫الدﻡ‬ ‫ﻣﺴﺘﻨﺒﺖ‬ ‫ﺯﺟاﺟاﺕ‬ ‫ﻓﻲ‬ ‫ﻣﺒاﺷﺮة‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻣل‬ •٥ ‫ﺧﺬ‬ ‫ﺛﻢ‬ ،‫ﹰ‬‫ا‬‫يدﻭي‬ ‫الﻜيﺲ‬ ‫ﱠ‬‫ﺝ‬‫ﹸ‬‫ﺭ‬ ،‫الﻜﺒيﺮة‬ ‫اﳌﻨﺒﺬة‬ ‫ﻭﻻ‬ ‫الدﻡ‬ ‫ﻣﺴﺘﻨﺒﺘاﺕ‬ ‫ﺗﺘﻮﻓﺮ‬ ‫لﻢ‬ ‫ﺇﺫا‬ ‫ﳕﻮ‬ ‫لﺘﺸﺠيﻊ‬ (incubator) ‫اﳊاﺿﻨة‬ ‫ﻓﻲ‬‫ﹰ‬‫ﻼ‬‫ﻛاﻣ‬ ‫الﻜيﺲ‬ ‫ﻭﺧزﻥ‬ ،‫ﺻلﺒة‬ ‫ﻣﺴﺘﻨﺒﺘاﺕ‬ ‫ﻓﻲ‬ ‫ﻭاﺣﻘﻨﻬا‬ .‫ﺫلﻚ‬ ‫ﺗيﺴﺮ‬ ‫ﺇﺫا‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫اﶈلﻮﻝ‬ ‫ﻓﺤﺺ‬ ‫ﻭﺇﻋادة‬ ‫اﳉﺮاﺛيﻢ‬ ‫ﺑالﺒدﺀ‬ ‫يﺴﻤﺢ‬ ‫ﳑا‬‫ﹰ‬‫ا‬‫ﺑاﻛﺮ‬ ‫الفﻄﺮياﺕ‬ ‫ﻭﺟﻮد‬ ‫ﻋﻦ‬ ‫ﺗﻜﺸﻒ‬ ‫قد‬ ‫ﺃﻧﻬا‬ ‫ﺇلﻰ‬ ‫الﻐﺮاﻡ‬ ‫لﻄﺨة‬ ‫ﺃﻫﻤية‬ ‫ﺗﺮﺟﻊ‬ • ‫الﻌﻼﺝ‬ ‫اﺧﺘياﺭ‬ ‫ﻓﺈﻥ‬ ‫ﺫلﻚ‬ ‫ﺑﺨﻼﻑ‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﻹﺯالة‬ ‫ﻭالﺘﺮﺗيﺐ‬ ‫للفﻄﺮياﺕ‬ ‫اﳌﻀاد‬ ‫ﺑالﻌﻼﺝ‬ ‫الفﻮﺭﻱ‬ .‫الﻐﺮاﻡ‬ ‫لﻄﺨة‬ ‫ﻧﺘيﺠة‬ ‫ﻋلﻰ‬‫ﹰ‬‫ا‬‫ﻣﻌﺘﻤد‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫يﻨﺒﻐﻲ‬ ‫ﻻ‬ ‫الﺘﺠﺮيﺒﻲ‬
  • ٥٧ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﻟﻠﺪﻳﻠﺰﺓ‬ ‫ﺍﳌﺼﺎﺣﺐ‬ ‫ﺍﻟﺼﻔﺎﻕ‬ ‫ﺍﻟﺘﻬﺎﺏ‬ ‫ﻣﻌﺎﳉﺔ‬ :٦ ‫ﻓﺼﻞ‬ ‫ﺍﻷﻫﺪﺍﻑ‬ :١-٦ ‫ﺑﺮﻧاﻣﺞ‬ ‫ﻣﺮاﻛز‬ ‫ﻛل‬ ‫ﻓﻲ‬ ‫الصفاقية‬ ‫للديلزة‬ ‫اﳌصاﺣﺐ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﻣﻌاﳉة‬ ‫ﺧﻄﻮاﺕ‬ ‫ﺗﻮﺣيد‬ • ‫ﻓﻲ‬ ‫ﻭاﺣدة‬ ‫ﺇﺻاﺑة‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﺣاﻻﺕ‬ ‫ﺗﺘﺠاﻭﺯ‬ ‫ﻻ‬ ‫ﺃﻥ‬ ‫ﺑﻬدﻑ‬ ،‫الصفاقية‬ ‫للديلزة‬ ‫الﺴﻮداﻥ‬ .‫ﻭالﻮﻓياﺕ‬ ‫اﳌﺮاﺿة‬ ‫ﺗﻘليل‬ ‫ﻣﻊ‬‫ﹰ‬‫ا‬‫ﺷﻬﺮ‬ ‫ﻋﺸﺮ‬ ‫ﺛﻤاﻧية‬ ‫ﻛل‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﻟﻠﺪﻳﻠﺰﺓ‬ ‫ﺍﳌﺼﺎﺣﺐ‬ ‫ﺍﻟﺼﻔﺎﻕ‬ ‫ﺍﻟﺘﻬﺎﺏ‬ ‫ﻣﻨﻊ‬ :٢-٦ ،‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﻭﺧﻄﻮاﺕ‬ ،‫الﺘﻌﻘيﻢ‬ ‫ﻭﺗﻘﻨية‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﺑﺘﻘﻨية‬ ‫الﺸديد‬ ‫اﻻلﺘزاﻡ‬ • ‫ﺗفصيلﻬا‬ ‫ﰎ‬ ‫ﻛﻤا‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋدﻭﻯ‬ ‫ﻣﻌاﳉة‬ ‫ﻭﺧﻄﻮاﺕ‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﲟﺨﺮﺝ‬ ‫الﻌﻨاية‬ ‫ﻭﺧﻄﻮاﺕ‬ .‫ﹰ‬‫ا‬‫ﺳاﺑﻘ‬ ‫ﻛﻮﺳيلة‬ ‫اﳌﻨزلية‬ ‫ﺑالزياﺭاﺕ‬ ‫الﺘدﺭيﺐ‬ ‫ﻫﺬا‬ ‫ﺗدﻋيﻢ‬ ‫ﻣﻊ‬ ‫ﻛاﻓية‬ ‫ﺑصﻮﺭة‬ ‫اﳌﺮيﺾ‬ ‫ﺑﺘدﺭيﺐ‬ ‫اﻻﻫﺘﻤاﻡ‬ • .‫الﻌدﻭﻯ‬ ‫ﺗﻘليل‬ ‫ﻓﻲ‬ ‫ﻓﻌالة‬ ‫ﺗصﻮيﺮ‬ :‫)ﻣﺜاﻝ‬ ‫اﳊﻮﺽ‬ ‫ﺃﻭ‬ ‫ﺑالﺒﻄﻦ‬ ‫ﻣﺘﻌلﻖ‬ ‫ﺟﺮاﺣﻲ‬ ‫ﺇﺟﺮاﺀ‬ ‫ﺃﻱ‬ ‫ﺃﻭ‬ ‫لﻸﺳﻨاﻥ‬ ‫ﻣﻌاﳉة‬ ‫ﺃﻱ‬ ‫قﺒل‬ • ‫ﲡفيﻒ‬ ‫ﻣﻦ‬ ‫الﺘﺄﻛد‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ (‫الﺮﺣﻢ‬ ‫ﺑﻄاﻧة‬ ‫ﻋيﻨة‬ ،‫الﻜلﻰ‬ ‫ﺯﺭﻉ‬ ،‫الﻘﻮلﻮﻥ‬ ‫ﺗﻨﻈيﺮ‬ ،‫الﻘﺜﻄاﺭ‬ .‫الصفاﻕ‬ ‫داﺧل‬ ‫اﺗﻘاﺋية‬ ‫ﺣيﻮية‬ ‫ﻣﻀاداﺕ‬ ‫ﻭاﺳﺘﻌﻤاﻝ‬ ‫الصفاﻕ‬ ‫الﻐﺬاﺋية‬ ‫اﻷلياﻑ‬ ‫ﺯيادة‬ ‫ﺗﻜﻮﻥ‬ ‫قد‬ ،‫ﺑاﻹﻣﺴاﻙ‬ ‫اﻹﺻاﺑة‬ ‫ﲡﻨﺐ‬ ‫ﺃﻫﻤية‬ ‫للﻤﺮيﺾ‬ ‫يﻮﺿﺢ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ • ‫اﳌﺴﻬلة‬ ‫اﻷدﻭية‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﺇلﻰ‬ ‫يﺤﺘاﺟﻮﻥ‬ ‫ﺃﻏلﺒﻬﻢ‬ ‫ﻭلﻜﻦ‬ ‫اﳌﺮﺿﻰ‬ ‫لﺒﻌﺾ‬ ‫ﺑالﻨﺴﺒة‬ ‫ﻛاﻓية‬ .‫ﻣﻨﺘﻈﻤة‬ ‫ﺑصﻮﺭة‬ (‫ﻣاﻛﺮﻭﺟﻮلز‬ ،‫ﻻﻛﺘيﻮلﻮﺯ‬ :‫)ﻣﺜاﻝ‬ ‫ﻣﻦ‬ ‫اﺗﻘاﺋية‬ ‫ﺟﺮﻋة‬ ‫للﻤﺮيﺾ‬ ‫ﺗﻮﺻﻒ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ ،‫الفﻄﺮﻱ‬ ‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫اﻹﺻاﺑة‬ ‫لﺘﻘليل‬ • ‫اﺳﺘﺨداﻡ‬ ‫ﻭﳝﻜﻦ‬ ،‫ﺃﻛﺜﺮ‬ ‫ﺃﻭ‬ ‫ﺃﺳﺒﻮﻋﲔ‬ ‫ﳌدة‬ ‫يﻮﺻﻒ‬ ‫ﺣيﻮﻱ‬ ‫ﻣﻀاد‬ ‫ﺃﻱ‬ ‫ﲟصاﺣﺒة‬ ‫الفلﻮﻛﻮﻧاﺯﻭﻝ‬ .‫اﻷﺧيﺮ‬ ‫ﻭﺻﻒ‬ ‫ﺗﻌﺬﺭ‬ ‫ﺇﺫا‬ ‫للفلﻮﻛﻮﻧاﺯﻭﻝ‬ ‫ﺑديل‬ ‫ﻛﺨياﺭ‬ ‫ﻧيﺴﺘاﺗﲔ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﻟﻠﺪﻳﻠﺰﺓ‬ ‫ﺍﳌﺼﺎﺣﺐ‬ ‫ﺍﻟﺼﻔﺎﻕ‬ ‫ﺍﻟﺘﻬﺎﺏ‬ ‫ﺗﺸﺨﻴﺺ‬ :٣-٦ ‫الﺘﻬاﺏ‬ ‫ﺃﻭ‬ ،‫الﻌدﻭﻯ‬ ‫ﻋﻦ‬ ‫الﻨاﰋ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﻋﻦ‬ ‫ﹰ‬‫ا‬‫ﻧاﲡ‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﺗﻌﻜﺮ‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫ﳝﻜﻦ‬ • ‫ﺧﺒاﺛة‬ ‫ﺃﻭ‬ ،‫الصفاﻕ‬ ‫ﺗدﻣﻲ‬ ‫ﺃﻭ‬ ،(eosinophilia) ‫اﺕ‬‫ﱠ‬‫ي‬‫ﹺ‬‫ﻨ‬‫ﻮﺯي‬‫ﹸ‬‫ي‬‫ال‬ ‫ﻛﺜﺮة‬ ‫ﺃﻭ‬ ،‫الﻜيﻤياﺋﻲ‬ ‫الصفاﻕ‬ ‫ﲡﻮيﻒ‬ ‫ﻣﻦ‬ ‫الﻌيﻨة‬ ‫ﺃﺧﺬ‬ ‫ﻋﻦ‬ ‫ﹰ‬‫ا‬‫ﻧاﲡ‬ ‫ﺃﻭ‬ ،(chylous effluent) ‫ﻛيلﻮﺳﻲ‬ ‫ﺻﺒﻮﺏ‬ ‫ﺃﻭ‬ ،(malignancy) .‫ﺟفاﻓﻪ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ ‫الصفاﻕ‬ ‫لﻢ‬ ‫ﻣا‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﺗﻌﻜﺮ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﻭﺟﻮد‬ ‫اﻓﺘﺮاﺽ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ‫ﻋاﻣة‬ ‫ﺑصفة‬ • ‫اﶈلﻮﻝ‬ ‫ﻓﻲ‬ ‫اﳋﻼيا‬ ‫ﻭﻧﻮﻉ‬ ‫ﻋدد‬ ‫ﻓﺤﺺ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﺫلﻚ‬ ‫ﺇﺛﺒاﺕ‬ ‫ﻣﺤاﻭلة‬ ‫ﻣﻦ‬ ‫ﻭﻻﺑد‬ ،‫الﻌﻜﺲ‬ ‫يﺜﺒﺖ‬ .‫الزﺭﻉ‬ ‫ﻃﺮيﻖ‬ ‫ﻭﻋﻦ‬ ‫اﳋاﺭﺝ‬
  • ٥٦ ‫ﺍﻟﻘﺜﻄﺎﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋﺪﻭﻯ‬ ‫ﻣﻌﺎﳉﺔ‬ :١ ‫ﺧﻮﺍﺭﺯﻣﻴﺔ‬
  • ٥٥ ‫ﺍﻟﻔﺼﻞ‬ ‫ﻫﺬﺍ‬ ‫ﻓﻲ‬ ‫ﺫﻛﺮﻫﺎ‬ ‫ﰎ‬ ‫ﺃﺩﻭﻳﺔ‬ :١٢ ‫ﺟﺪﻭﻝ‬ ‫ﺍﻟﺪﻭﺍﺀ‬ ‫ﺍﺳﻢ‬‫ﺍﻟﺘﺮﻛﻴﺒﺔ‬‫ﺍﳉﺮﻋﺔ‬ ‫ﺃﻣﻮﻛﺴيﺴيلﲔ‬(‫ﺻفاﻕ‬ ،‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬ ،‫ﻛﺒﺴﻮﻻﺕ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮﺗﲔ‬ ‫ﻣلﻎ‬ ٥٠٠-٢٥٠ ‫ﺳفالﻜﺴﲔ‬‫ﻣﺤلﻮﻝ‬ ،‫ﻛﺒﺴﻮﻻﺕ،ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮﺗﲔ‬ ‫ﻣلﻎ‬ ٥٠٠ ‫ﻛﻼﺭيﺜﺮﻭﻣايﺴﲔ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬ ،‫ﻣﺤلﻮﻝ‬ ،‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮﺗﲔ‬ ‫ﻣلﻎ‬ ٢٥٠ ‫ﺳﺒﺮﻭﻓلﻮﻛﺴاﺳﲔ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬ ،‫ﺣﺒﻮﺏ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮﺗﲔ‬ ‫ﺑالﻮﺭيد‬ ‫ﻣلﻎ‬ ٢٠٠‫ﺃﻭ‬ ‫ﺑالفﻢ‬ ‫ﻣلﻎ‬ ٥٠٠ ‫ﺳفﺘاﺯدﱘ‬(‫ﻋﻀل‬ ،‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻏﻢ‬ ١ -٠٫٥ ‫الﻬيدﺭﻭﺟﲔ‬ ‫ﺑيﺮﻭﻛﺴيد‬‫ﻣﺤلﻮﻝ‬‫اللزﻭﻡ‬ ‫ﻋﻨد‬ ‫يﻮد‬‫ﻣﺮﻫﻢ‬ ،‫ﻣﺤلﻮﻝ‬‫اللزﻭﻡ‬ ‫ﻋﻨد‬
  • ٥٤ ،‫الﺴﺮيﺮية‬ ‫الﻌدﻭﻯ‬ ‫ﻋﻼﻣاﺕ‬ ‫ﻛل‬ ‫ﺯﻭاﻝ‬ ‫ﺑﻌد‬ ‫اﻷقل‬ ‫ﻋلﻰ‬ ‫ﺃياﻡ‬ ‫لﺴﺒﻌة‬ ‫الﻌﻼﺝ‬ ‫ﻣﻮاﺻلة‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • .‫اﻷقل‬ ‫ﻋلﻰ‬ ‫ﺃﺳﺒﻮﻋﲔ‬ ‫الﻜلية‬ ‫الﻌﻼﺝ‬ ‫ﻣدة‬ ‫ﺗﻜﻮﻥ‬ ‫ﺑﺤيﺚ‬ ‫الﺘزاﻡ‬ ‫ﻣﻦ‬ ‫ﺗﺄﻛد‬ ،‫اﳊيﻮية‬ ‫اﳌﻀاداﺕ‬ ‫اﺳﺘﺨداﻡ‬ ‫ﻋلﻰ‬ ‫ﺃﺳﺒﻮﻋﲔ‬ ‫ﻣﻀﻲ‬ ‫ﺑﻌد‬ ‫الﻌدﻭﻯ‬ ‫اﺳﺘﻤﺮﺕ‬ ‫ﺇﺫا‬ • ‫ﲢﺖ‬ ‫الﻨفﻖ‬ ‫ﻋدﻭﻯ‬ ‫ﻋلﻰ‬ ‫دﻻلة‬ ‫ﺃﻱ‬ ‫ﻋﻦ‬ ‫ﹰ‬‫ا‬‫ﺑﺤﺜ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻓﺤﺺ‬ ‫ﻭﺃﻋد‬ ‫الدﻭاﺋﻲ‬ ‫ﺑالﻨﻈاﻡ‬ ‫اﳌﺮيﺾ‬ ،‫اﳉلدﻱ‬ ‫ﻣﺠﺮﻯ‬ ‫ﻓﻲ‬ ‫ﺻﻐيﺮ‬ ‫اﺝ‬‫ﹶ‬‫ﺮ‬‫ﺧﹸ‬ ‫ﻭﺟﻮد‬ ‫ﻋدﻡ‬ ‫ﻣﻦ‬ ‫للﺘﺤﻘﻖ‬ ( •U/S) ‫الصﻮﺕ‬ ‫ﻓاﺋﻖ‬ ‫ﻓﺤﺺ‬ ‫ﺇﺟﺮاﺀ‬ ‫ﳝﻜﻦ‬ .‫الﻨفﻖ‬ ‫ﻣﻊ‬ ‫اﳌﻮﺿﻌﻲ‬ ‫الﺘﺨديﺮ‬ ‫ﲢﺖ‬ ‫ﺑالﻜاﻣل‬ ‫ﺇﺯالﺘﻬا‬ ‫ﻓيﺠﺐ‬ ‫ﻣﻜﺸﻮﻓة‬ ‫الﺴﻄﺤية‬ ‫ة‬‫ﱠ‬‫ف‬‫ﹸ‬‫الﻜ‬ ‫ﻛاﻧﺖ‬ ‫ﺇﺫا‬ • .‫الﻌدﻭﻯ‬ ‫ﺇﺯالة‬ ‫ﻋلﻰ‬ ‫للﻤﺴاﻋدة‬ ‫ﺑﻬا‬ ‫اﶈيﻂ‬ ‫الﻨﺴيﺞ‬ ‫ﺇﺯالة‬ ‫ﺷﺮيﻄة‬ ‫الﻌدﻭﻯ‬ ‫اﺳﺘﻤﺮاﺭ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ ‫ﺁﺧﺮيﻦ‬ ‫ﺃﺳﺒﻮﻋﲔ‬ ‫ﳌدة‬ ‫اﳊيﻮية‬ ‫اﳌﻀاداﺕ‬ ‫ﺗﻮﺻﻒ‬ ‫ﺃﻥ‬ ‫ﳝﻜﻦ‬ • ‫ﲤﺖ‬ ‫قد‬ ‫ﺗﻜﻮﻥ‬ ‫ﻭﺃﻥ‬ ،‫ﺧﺮاﺝ‬ ‫ﻭﺟﻮد‬ ‫ﻋدﻡ‬ ‫ﻣﻦ‬ ‫الﺘﺤﻘﻖ‬ ‫يﺘﻢ‬ ‫ﻭﺃﻥ‬ ،‫ﺗفاقﻤﺖ‬ ‫قد‬ ‫الﻌدﻭﻯ‬ ‫ﺗﻜﻮﻥ‬ ‫ﻻ‬ ‫ﺃﻥ‬ .‫اﳌﻜﺸﻮﻓة‬ ‫اﳋاﺭﺟية‬ ‫الﻜفة‬ ‫ﺇﺯالة‬ ‫للﻤﻀاداﺕ‬ ‫اﳌﺮيﺾ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﺭﻏﻢ‬ ‫ﺗفاقﻤﺖ‬ ‫قد‬ ‫الﻌدﻭﻯ‬ ‫ﻛاﻧﺖ‬ ‫ﺇﺫا‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇﺯالة‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • ‫ﻓﻲ‬ ‫ﺃﻭ‬ ،‫الفﻄﺮية‬ ‫الﻌدﻭﻯ‬ ‫ﺛﺒﻮﺕ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ ‫ﺃﻭ‬ ،‫ﺧﺮاﺝ‬ ‫ﻭﺟﻮد‬ ‫ﺣالة‬ ‫ﻓﻲ‬ ‫ﺃﻭ‬ ،‫ﺃﺳﺒﻮﻋﲔ‬ ‫ﳌدة‬ ‫اﳊيﻮية‬ .‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﺣدﻭﺙ‬ ‫ﺣالة‬ ‫لﺘﺠﻨﺐ‬ ‫الﺸد‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﻭليﺲ‬ ‫اﳉﺮاﺣﻲ‬ ‫الﺘﺸﺮيﺢ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇﺯالة‬ ‫ﺗﺘﻢ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ • ‫ﺇﺯالة‬ ‫ﺑﻌد‬ ‫اﺛﻨﲔ‬ ‫ﺃﻭ‬ ‫ﺃﺳﺒﻮﻉ‬ ‫ﳌدة‬ ‫اﳊيﻮية‬ ‫اﳌﻀاداﺕ‬ ‫ﻣﻮاﺻلة‬ ‫ﻣﻦ‬ ‫ﻭﻻﺑد‬ ،‫الﻜفﺘﲔ‬ ‫اﺣﺘﺒاﺱ‬ .‫الﻘﺜﻄاﺭ‬ ‫ﻧفﺲ‬ ‫ﻓﻲ‬ ‫ﺟديد‬ ‫قﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫يﺘﻢ‬ ‫ﺃﻥ‬ ‫ﳝﻜﻦ‬ ،‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫ﹰ‬‫ا‬‫ﻣصاﺑ‬ ‫اﳌﺮيﺾ‬ ‫يﻜﻦ‬ ‫لﻢ‬ ‫ﺇﺫا‬ • ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫ﻋلﻰ‬ ،‫ﻣﺒاﺷﺮة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﻮاﺻلة‬ ‫ﳝﻜﻦ‬ ‫ﻛﻤا‬ ،‫اﳌﻘاﺑلة‬ ‫اﳉﻬة‬ ‫ﻓﻲ‬ ‫الﻮقﺖ‬ .‫اﻷﻣﺮ‬ ‫ﺃﻭﻝ‬ ‫اﻻﺳﺘلﻘاﺀ‬ ‫ﻭﺿﻊ‬ ‫ﻓﻲ‬ ‫ﻭاﳌﺮيﺾ‬ ‫ﺫلﻚ‬
  • ٥٣ ‫ﺍﻟﻘﺜﻄﺎﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻧﻘﺎﻁ‬ ‫ﺣﺮﺯ‬ ‫ﻧﻈﺎﻡ‬ :١١ ‫ﺟﺪﻭﻝ‬ ‫ﻧﻘﻄﺔ‬ ‫ﺻﻔﺮ‬‫ﻭﺍﺣﺪﺓ‬ ‫ﻧﻘﻄﺔ‬‫ﻧﻘﻄﺘﺎﻥ‬ ‫ﻭﺭﻡ‬‫يﻮﺟد‬ ‫ﻻ‬(‫ﻓﻘﻂ‬ ‫الﻘﺜﻄاﺭ‬ ‫)ﻣﺨﺮﺝ‬ ‫ﺳﻢ‬ ٠٫٥ >(‫الﻨفﻖ‬ ‫)ﺃﻭ‬ ‫ﺳﻢ‬ ٠٫٥ < ‫قﺸﺮة‬‫يﻮﺟد‬ ‫ﻻ‬‫ﺳﻢ‬ ٠٫٥ >‫ﺳﻢ‬ ٠٫٥ < ‫اﺣﻤﺮاﺭ‬‫يﻮﺟد‬ ‫ﻻ‬‫ﺳﻢ‬ ٠٫٥ >‫ﺳﻢ‬ ٠٫٥ < ‫ﺃلﻢ‬‫يﻮﺟد‬ ‫ﻻ‬‫ﺑﺴيﻂ‬‫ﺷديد‬ ‫ﳒيﺞ‬‫يﻮﺟد‬ ‫ﻻ‬‫ﻣصلﻲ‬ ‫ﳒيﺞ‬*‫قيﺤﻲ‬ ‫ﳒيﺞ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋدﻯ‬ ‫لﺘﺸﺨيﺺ‬ ‫ﲟفﺮدﻩ‬ ‫يﻜفﻲ‬ ‫الﻘيﺤﻲ‬ ‫الﻨﺠيﺞ‬ * ‫ﺍﳉﻠﺪﻱ‬ ‫ﲢﺖ‬ ‫ﺍﻟﻨﻔﻖ‬ ‫ﻋﺪﻭﻯ‬ ‫ﺃﻭ‬ ‫ﺍﻟﻘﺜﻄﺎﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋﺪﻭﻯ‬ ‫ﻣﻌﺎﳉﺔ‬ :٤-٥ ‫اﳌﻮﺿﻮﻋة‬ ‫اﳋﻄة‬ ‫ﺣﺴﺐ‬ ‫اﳌﻤﺮﺽ‬ ‫ﺑﻮاﺳﻄة‬ ‫ﺑدايﺘﻬا‬ ‫ﻓﻲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋدﻭﻯ‬ ‫ﻣﻌاﳉة‬ ‫ﳝﻜﻦ‬ • .‫الﺒﺮﻧاﻣﺞ‬ ‫قﺒل‬ ‫ﻣﻦ‬ ‫ﻣﻦ‬ ‫ﻣﺴﺤة‬ ‫ﺃﺧﺬ‬ ‫ﻓيﺠﺐ‬ ،‫ﹰ‬‫ا‬‫ﺳﺮيﺮي‬ ‫اﳉلدﻱ‬ ‫ﲢﺖ‬ ‫الﻨفﻖ‬ ‫ﺃﻭ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋدﻭﻯ‬ ‫ﺗﺸﺨيﺺ‬ ‫ﰎ‬ ‫ﺇﺫا‬ • .‫ﻭالزﺭﻉ‬ (Gram stain) ‫ﻏﺮاﻡ‬ ‫لﻄﺨة‬ ‫لﻌﻤل‬ ‫اﳌﻌﻤل‬ ‫ﺇلﻰ‬ ‫ﻭﺇﺭﺳالﻬا‬ ‫الﻨﺠيﺞ‬ ‫ﻓﻲ‬ ‫الصفاﻕ‬ ‫داﺧل‬ ‫ﺣﻘﻨﻪ‬ ‫يﺘﻢ‬ ‫الﺬﻱ‬ ‫الﻌﻼﺝ‬ ‫ﻋﻦ‬ ‫ﻛفاﺀة‬ ‫يﻘل‬ ‫ﻻ‬ ‫الفﻢ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﻌﻄﻰ‬‫ﹸ‬‫ﳌ‬‫ا‬ ‫الﻌﻼﺝ‬ • ‫للﻤﺜيﺴيلﲔ‬ ‫اﳌﻘاﻭﻣة‬ ‫الﺬﻫﺒية‬ ‫الﻌﻨﻘﻮدية‬ ‫اﳉﺮاﺛيﻢ‬ ‫ﺑاﺳﺘﺜﻨاﺀ‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋدﻭﻯ‬ ‫ﻣﻌاﳉة‬ ‫الﻜﻼﺭيﺜﺮﻭﻣايﺴﲔ‬ ‫ﺃﻭ‬ ،‫الﺴفالﻜﺴﲔ‬ ‫ﺃﻭ‬ ،‫ﺑاﻷﻣﻮﻛﺴيﺴيلﲔ‬ ‫الﺘﺠﺮيﺒﻲ‬ ‫الﻌﻼﺝ‬ ‫اﺑدﺃ‬ .(MRSA) ‫يﺠﺐ‬ ‫اﳊالة‬ ‫ﻫﺬﻩ‬ ‫ﻓفﻲ‬ ،‫ﺳالﺒة‬ ‫ﻏﺮاﻡ‬ ‫لﻄﺨة‬ ‫ﺫاﺕ‬ ‫ﻋدﻭﻯ‬ ‫لﻮﺟﻮد‬ ‫اﺣﺘﻤاﻝ‬ ‫ﻫﻨاﻙ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫ﺇﻻ‬ ‫ﺳﺒﺮﻭﻓلﻮﻛﺴاﺳﲔ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﲡﻨﺐ‬ .‫الفﻢ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﺳﺒﺮﻭﻓلﻮﻛﺴاﺳﲔ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫داﺧل‬ ‫ﺳفﺘاﺯدﱘ‬ ‫ﻭاﺳﺘﺨدﻡ‬ ‫ﹰ‬‫ا‬‫ﻋاﻣ‬ ‫ﻋﺸﺮ‬ ‫اﺛﻨﻲ‬ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫ﺃﻋﻤاﺭﻫﻢ‬ ‫الﺬيﻦ‬ ‫اﻷﻃفاﻝ‬ ‫ﺑالﻨﺴﺒة‬ .‫ﻋﻨﻪ‬ ‫ﹰ‬‫ا‬‫ﻋﻮﺿ‬ ‫الصفاﻕ‬ ‫ﻓليﺴﺘﺨدﻡ‬،‫ﺷديدة‬‫الﻌدﻭﻯ‬‫ﻛاﻧﺖ‬‫ﻭﺇﺫا‬،‫ﹰ‬‫ا‬‫يﻮﻣي‬‫ﻣﺮﺗﲔ‬‫الﻘﺜﻄاﺭ‬‫ﻣﺨﺮﺝ‬‫ﺑﺘﻨﻈيﻒ‬‫اﳌﺮيﺾ‬‫اﻧصﺢ‬ • ،‫اﳊيﻮية‬ ‫اﳌﻀاداﺕ‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮﺗﲔ‬ ‫الﺘﺮﻛيز‬ ‫ﻋالﻲ‬ ‫الﻨﻈاﻣﻲ‬ ‫اﳌلﺤﻲ‬ ‫اﶈلﻮﻝ‬ ‫ﺿﻤاداﺕ‬ ‫ﻭﺗﺸﺒيﻊ‬ ‫اﳌﻌﻘﻢ‬ ‫اﳌاﺀ‬ ‫ﻣﻦ‬ ‫ﻣل‬ ٥٠٠ ‫ﺇلﻰ‬ ‫اﳌلﺢ‬ ‫ﻣﻦ‬ ‫ﻃﻌاﻡ‬ ‫ﻣلﻌﻘة‬ ‫ﺇﺿاﻓة‬ ‫ﻫﻲ‬ ‫ﺫلﻚ‬ ‫ﻋﻤل‬ ‫ﻭﻃﺮيﻘة‬ .‫دقيﻘة‬ ‫ﻋﺸﺮة‬ ‫ﺧﻤﺲ‬ ‫ﳌدة‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﺣﻮﻝ‬ ‫لفﻬا‬ ‫ﺛﻢ‬ ‫اﶈلﻮﻝ‬ ‫ﺑﻬﺬا‬ ‫الﺸاﺵ‬ ‫ﻣﻦ‬ ‫قﻄﻌة‬ ‫ﺳﺒﺮﻭﻓلﻮﻛﺴاﺳﲔ‬ ‫ﺃﺣدﻫﻤا‬ ‫ﺣيﻮيﻦ‬ ‫ﻣﻀاديﻦ‬ ‫اﺳﺘﺨدﻡ‬ .‫الزﺭﻉ‬ ‫ﻧﺘيﺠة‬ ‫ﺣﺴﺐ‬ ‫الﻌﻼﺝ‬ ‫ﻝ‬‫ﱢ‬‫د‬‫ﻋ‬ • ‫ﺇﺿاﻓة‬ ‫ﻣﻊ‬ ،(Pseudomonas aeruginosa) ‫الزﳒاﺭية‬ ‫الزاﺋفة‬ ‫ﺑاﳉﺮاﺛيﻢ‬ ‫اﻹﺻاﺑة‬ ‫ﺣالة‬ ‫ﻓﻲ‬ .‫ﺑﻄيﺌة‬ ‫اﻻﺳﺘﺠاﺑة‬ ‫ﻛاﻧﺖ‬ ‫ﺇﺫا‬ ‫الصفاﻕ‬ ‫داﺧل‬ ‫ﺳفﺘاﺯدﱘ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﺇلﻰ‬ ‫ﺗفاقﻤﻬا‬ ‫ﳌﻨﻊ‬ ‫ﺮية‬ ‫ﹾ‬‫ﻄ‬‫ﹸ‬‫ﻓ‬ ‫ﻋدﻭﻯ‬ ‫ﻭﺟﻮد‬ ‫ﺛﺒﺖ‬ ‫ﺇﺫا‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇﺯالة‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • .‫الفﻄﺮﻱ‬
  • ٥٢ ‫ﺍﻟﻘﺜﻄﺎﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋﺪﻭﻯ‬ ‫ﻣﻌﺎﳉﺔ‬ :٥ ‫ﻓﺼﻞ‬ ‫ﺍﻷﻫﺪﺍﻑ‬ :١-٥ ‫ﺑﺮﻧاﻣﺞ‬ ‫ﻣﺮاﻛز‬ ‫ﻛل‬ ‫ﻓﻲ‬ ‫اﳉلدﻱ‬ ‫ﲢﺖ‬ ‫ﻭالﻨفﻖ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋدﻭﻯ‬ ‫ﻣﻌاﳉة‬ ‫ﺧﻄﻮاﺕ‬ ‫ﺗﻮﺣيد‬ • .‫الصفاقية‬ ‫للديلزة‬ ‫الﺴﻮداﻥ‬ ‫ﺍﻟﻘﺜﻄﺎﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋﺪﻭﻯ‬ ‫ﻣﻨﻊ‬ :٢-٥ ،‫اﶈلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﻭﺧﻄﻮاﺕ‬ ،‫الﺘﻌﻘيﻢ‬ ‫ﻭﺗﻘﻨية‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﺑﺘﻘﻨية‬ ‫الدقيﻖ‬ ‫اﻻلﺘزاﻡ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • .‫قﺒل‬ ‫ﻣﻦ‬ ‫ﺗفصيلﻬا‬ ‫ﰎ‬ ‫ﻛﻤا‬ ‫الﻘﺜﻄاﺭ‬ ‫ﲟﺨﺮﺝ‬ ‫الﻌﻨاية‬ ‫ﻭﺧﻄﻮاﺕ‬ ‫ﺍﻟﻘﺜﻄﺎﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋﺪﻭﻯ‬ ‫ﺗﺸﺨﻴﺺ‬ :٣-٥ ( •purulent discharge) ‫قيﺤﻲ‬ ‫ﳒيﺞ‬ ‫ﻭﺟﻮد‬ ‫ﻋلﻰ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋدﻭﻯ‬ ‫ﺗﺸﺨيﺺ‬ ‫يﻌﺘﻤد‬ ‫ﺗﻄﻮيﺮ‬ ‫ﰎ‬ ‫ﻭقد‬ ،‫ﻭالﺒﺸﺮة‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺑﲔ‬ ‫الﺘﻲ‬ ‫اﳌﻨﻄﻘة‬ ‫ﻓﻲ‬ ‫اﺣﻤﺮاﺭ‬ - ‫يﺮاﻓﻘﻪ‬ ‫ﻻ‬ ‫ﻭقد‬ - ‫يﺮاﻓﻘﻪ‬ ‫ﻋدﻭﻯ‬ ‫ﻭﺟﻮد‬ ‫الﻨﻈاﻡ‬ ‫ﻫﺬا‬ ‫يفﺘﺮﺽ‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻣﺮاقﺒة‬ ‫ﺗﺴﻬيل‬ ‫ﺑﻐﺮﺽ‬ ‫الﻨﻘاﻁ‬ ‫ﳊﺮﺯ‬ ‫ﻧﻈاﻡ‬ ‫ﻓﻬﻮ‬ ‫الﻘيﺤﻲ‬ ‫الﻨﺠيﺞ‬ ‫ﺃﻣا‬ ،‫ﺃﻛﺜﺮ‬ ‫ﺃﻭ‬ ‫ﻧﻘاﻁ‬ ‫ﺃﺭﺑﻊ‬ ‫الﻨﻘاﻁ‬ ‫ﻣﺤصلة‬ ‫ﻛاﻧﺖ‬ ‫ﺇﺫا‬ ‫الﻘﺜﻄاﺭ‬ ‫ﲟﺨﺮﺝ‬ .(١١ ‫ﺟدﻭﻝ‬ ‫)اﻧﻈﺮ‬ ‫الﻌدﻭﻯ‬ ‫لﺘﺸﺨيﺺ‬ ‫ﲟفﺮدﻩ‬ ‫ﹴ‬‫ﻛاﻑ‬ ‫اﺳﺘﺠاﺑة‬ ‫ﻋﻦ‬ ‫ﹰ‬‫ا‬‫ﻧاﲡ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻣﺤيﻂ‬ ‫ﻓﻲ‬ ‫الﺒﺴيﻂ‬ ‫اﻻﺣﻤﺮاﺭ‬ ‫يﻜﻮﻥ‬ ‫اﻷﺣياﻥ‬ ‫ﺃﻏلﺐ‬ ‫ﻓﻲ‬ • ‫ﺭﺿﻮﺽ‬ ‫ﺃﻱ‬ ‫ﻋﻦ‬ ‫اﳌﺮيﺾ‬ ‫اﺳﺄﻝ‬ .‫الﻌدﻭﻯ‬ ‫ﻋلﻰ‬ ‫ﻣﺒﻜﺮة‬ ‫ﻋﻼﻣة‬ ‫يﻜﻮﻥ‬ ‫قد‬ ‫ﻭلﻜﻨﻪ‬ ،‫للﺮﺿﻮﺽ‬ ‫اﳉلد‬ ‫ﻣﺨﺮﺝ‬ ‫ﺑﺘﻨﻈيﻒ‬ ‫ﺑالﻘياﻡ‬ ‫ﻭاﻧصﺤﻪ‬ ،‫الفاﺋﺘة‬ ‫اﻷياﻡ‬ ‫ﺧﻼﻝ‬ ‫ﹰ‬‫ا‬‫ﻋﺮﺿ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫لﻬا‬ ‫ﺗﻌﺮﺽ‬ ‫ﲡﻨﺐ‬ ‫ﻣﻊ‬ ‫اﺨﻤﻟفﻒ‬ ‫الﻬيدﺭﻭﺟﲔ‬ ‫ﺑﺒيﺮﻭﻛﺴيد‬ ‫ﹰ‬‫ا‬‫ﻣﺘﺒﻮﻋ‬ ‫اليﻮد‬ ‫ﺑاﺳﺘﺨداﻡ‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮﺗﲔ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻭﻋلﻰ‬ ،‫ﹰ‬‫ا‬‫ﻓﻮﺭ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ ‫ﺗدﻫﻮﺭ‬ ‫ﺃﻱ‬ ‫ﻋﻦ‬ ‫يﺒلﻎ‬ ‫ﺃﻥ‬ ‫اﳌﺮيﺾ‬ ‫ﻋلﻰ‬ .‫ة‬‫ﱠ‬‫د‬‫الﺴا‬ ‫الﻀﻤاداﺕ‬ .‫ﻭاﺣد‬ ‫ﺃﺳﺒﻮﻉ‬ ‫ﺑﻌد‬ ‫اﳊالة‬ ‫ﺗﻘييﻢ‬ ‫يﻌيد‬ ‫ﺃﻥ‬ ‫الديلزة‬ ‫ﻓﺮيﻖ‬ ‫ﻫﺬا‬ ‫ﻓﺈﻥ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋدﻭﻯ‬ ‫ﻋلﻰ‬ ‫الدالة‬ ‫اﳌﻈاﻫﺮ‬ ‫ﻏياﺏ‬ ‫ﻓﻲ‬ ‫ﺇيﺠاﺑية‬ ‫الزﺭﻉ‬ ‫ﻧﺘيﺠة‬ ‫ﻛاﻧﺖ‬ ‫ﺇﺫا‬ • ‫ﻭيﻜفﻲ‬ ،‫الﻌدﻭﻯ‬ ‫ﻋلﻰ‬ ‫ﻭليﺲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺨﻤﻟﺮﺝ‬ (colonization) ‫اﳉﺮﺛﻮﻣﻲ‬ ‫اﻻﺳﺘﻌﻤاﺭ‬ ‫ﻋلﻰ‬ ‫يدﻝ‬ .‫الﻘﺜﻄاﺭ‬ ‫ﲟﺨﺮﺝ‬ ‫الﻌﻨاية‬ ‫ﺑﺘﻜﺜيﻒ‬ ‫اﳌﺮيﺾ‬ ‫ﻧصﺢ‬ ‫ﻣﺴلﻚ‬ ‫ﻓﻮﻕ‬ ‫ﺇيﻼﻡ‬ ‫ﺃﻭ‬ ،‫ﻭﺭﻡ‬ ،‫اﺣﻤﺮاﺭ‬ ‫ﺑﻮﺟﻮد‬ ‫ﺗﺘﻤيز‬ ( •tunnel infection) ‫اﳉلدﻱ‬ ‫ﲢﺖ‬ ‫الﻨفﻖ‬ ‫ﻋدﻭﻯ‬ ‫ﻋادة‬ ‫اﳉلدﻱ‬ ‫ﲢﺖ‬ ‫الﻨفﻖ‬ ‫ﻋدﻭﻯ‬ ‫ﲢدﺙ‬ .‫ﺧفية‬ ‫ﺗﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫ﳝﻜﻦ‬ ‫ﻭلﻜﻨﻬا‬ ،‫اﳉلد‬ ‫ﲢﺖ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺑﻌدﻭﻯ‬ ‫ﻣصاﺏ‬ ‫ﻣﺮيﺾ‬ ‫ﻓﺤﺺ‬ ‫ﻋﻨد‬ .‫ﲟفﺮدﻫا‬ ‫ﲢدﺙ‬ ‫ﻣا‬‫ﹰ‬‫ا‬‫ﻭﻧادﺭ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋدﻭﻯ‬ ‫ﲟصاﺣﺒة‬ ‫ﺃﻱ‬ ‫ﻭﻣﻼﺣﻈة‬ ‫ﳒيﺞ‬ ‫ﺃﻱ‬ ‫ﻭﺟﻮد‬ ‫ﻣﻦ‬ ‫للﺘﺤﻘﻖ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺴلﻚ‬ ‫ﺣلﺐ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ .‫الﻨفﻖ‬ ‫ﻓﻮﻕ‬ ‫اﺣﻤﺮاﺭ‬ •Staphylococcus) ‫الﺬﻫﺒية‬ ‫الﻌﻨﻘﻮدية‬ ‫اﳉﺮاﺛيﻢ‬ ‫ﻋﻦ‬ ‫الﻨاﺟﻤة‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋدﻭﻯ‬ ‫الﻐالﺐ‬ ‫ﻓﻲ‬ ‫يصاﺣﺒﻬا‬ (Pseudomonas aeruginosa) ‫الزﳒاﺭية‬ ‫الزاﺋفة‬ ‫ﻭاﳉﺮاﺛيﻢ‬ (aurius ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﻓﻲ‬ ‫ﻋادة‬ ‫ﺐ‬‫ﱠ‬‫ﺒ‬‫ﺗﺘﺴ‬ ‫الﺘﻲ‬ ‫اﳉﺮاﺛيﻢ‬ ‫ﻧفﺲ‬ ‫ﻭﻫﻲ‬ ،‫اﳉلدﻱ‬ ‫ﲢﺖ‬ ‫الﻨفﻖ‬ ‫ﻋدﻭﻯ‬ ‫اﻷﻋﻢ‬ .‫ﺣاﺳﻤة‬ ‫ﺑﻄﺮيﻘة‬ ‫ﻣﻌاﳉﺘﻬا‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ‫ﻭلﺬلﻚ‬ ،‫الﻘﺜﻄاﺭ‬ ‫لﻌدﻭﻯ‬ ‫اﳌصاﺣﺐ‬
  • ٥١ ‫ﺍﻟﻔﺼﻞ‬ ‫ﻫﺬﺍ‬ ‫ﻓﻲ‬ ‫ﺫﻛﺮﺕ‬ ‫ﺃﺩﻭﻳﺔ‬ :١٠‫ﺟﺪﻭﻝ‬ ‫ﺍﻟﺪﻭﺍﺀ‬ ‫ﺍﺳﻢ‬‫ﺍﻟﺘﺮﻛﻴﺒﺔ‬‫ﺍﳉﺮﻋﺔ‬ ‫ﻓﺮﻭﺯﻣايد‬(‫ﻋﻀل‬ ،‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬ ،(‫ﻣلﻎ‬ ٤٠) ‫ﺣﺒﻮﺏ‬‫ﺟﺮﻋﺘﲔ‬ ‫ﺃﻭ‬ ‫ﻭاﺣدة‬ ‫ﺟﺮﻋة‬ ‫ﻓﻲ‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣلﻎ‬ ١٥٠٠-٤٠
  • ٥٠ ‫لفﺘﺮة‬ ‫الصفاﻕ‬ ‫ﻏﺸاﺀ‬ ( •permeability) ‫ﻧفﻮﺫية‬ ‫ﺗزيد‬ ‫قد‬ ‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫اﻹﺻاﺑة‬ ‫ﺃﺛﻨاﺀ‬ ‫ﻓﻲ‬ ،‫ﻣﺆقﺘة‬ ‫ﺑصﻮﺭة‬ ‫الﺮاﺷﺢ‬ ‫الﺴاﺋل‬ ‫ﻛﻤية‬ ‫ﻭﻧﻘﺺ‬ ‫اﳌﺬاﺑاﺕ‬ ‫ﻧﻘل‬ ‫ﺯيادة‬ ‫ﻋﻨﻪ‬ ‫يﻨﺘﺞ‬ ‫ﳑا‬ ‫ﻣﺆقﺘة‬ ‫ﺑزيادة‬ ‫ﻭليﺲ‬ ‫اﳌﻜﻮﺙ‬ ‫ﻓﺘﺮة‬ ‫ﺑﺘﻘليل‬ (fluid overload) ‫الﺴﻮاﺋل‬ ‫اﺣﺘﺒاﺱ‬ ‫ﻌالﺞ‬‫ﹸ‬‫ي‬ ‫اﳊالة‬ ‫ﻫﺬﻩ‬ ‫ﺃﺛﻨاﺀ‬ ‫للﺠلﻮﻛﻮﺯ‬ ‫الﻌالﻲ‬ ‫الﺘﺮﻛيز‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﲡﻨﺐ‬ ‫يﺴﺘﺤﺴﻦ‬ ‫ﺇﺫ‬ ،‫اﶈلﻮﻝ‬ ‫ﻓﻲ‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫ﺗﺮﻛيز‬ .‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﻋﻠﻴﻬﺎ‬ ‫ﻭﺍﶈﺎﻓﻈﺔ‬ ‫ﺍﳌﺘﺒﻘﻴﺔ‬ ‫ﺍﻟﻜﻠﻮﻳﺔ‬ ‫ﺍﻟﻮﻇﻴﻔﺔ‬ ‫ﺗﻘﺪﻳﺮ‬ :١٥-٤ ‫اﳌزﺭﻭﻋة‬ ‫ﺃﻭالﻜلية‬ ‫اﻷﺻليﺘﲔ‬ ‫الﻜليﺘﲔ‬ ‫ﻭﻇيفة‬ ‫ﻣﻦ‬ ‫ﺗﺒﻘﻰ‬ ‫ﻣا‬ ‫ﻫﻲ‬ ‫اﳌﺘﺒﻘية‬ ‫الﻜلﻮية‬ ‫الﻮﻇيفة‬ • ‫ﻭﺗصفية‬ ‫اليﻮﺭيا‬ ‫ﺗصفية‬ ‫ﻣﻌدﻝ‬ ‫ﺑﺤﺴاﺏ‬ ‫ﻋادة‬ ‫ﻭﺗﻘدﺭ‬ ،‫الﻜلﻮﻱ‬ ‫ﺑالفﺸل‬ ‫اﳌﺮيﺾ‬ ‫ﺇﺻاﺑة‬ ‫ﺑﻌد‬ .‫الﻜﺮياﺗﻨﲔ‬ ‫الديلزة‬ ‫ﻣﺮيﺾ‬ ‫ﺑﻘاﺀ‬ ‫ﻭﻓﺮﺹ‬ ‫اﳌﺘﺒﻘية‬ ‫الﻜلﻮية‬ ‫الﻮﻇيفة‬ ‫ﺑﲔ‬ ‫ﻭﺛيﻘة‬ ‫ﻃﺮدية‬ ‫ﻋﻼقة‬ ‫ﻫﻨاﻙ‬ • ‫ﻋلﻰ‬ ‫ﻣلﺤﻮﻇة‬ ‫ﺑدﺭﺟة‬ ‫ﺗﺴاﻋد‬ ‫اﳌﺘﺒﻘية‬ ‫الﻮﻇيفة‬ ‫ﻫﺬﻩ‬ ‫ﺃﻥ‬ ‫ﻛﻤا‬ ،‫اﳊياة‬ ‫قيد‬ ‫ﻋلﻰ‬ ‫الصفاقية‬ ‫اﳌﻬﻢ‬ ‫ﻣﻦ‬ ‫ﻓﺈﻧﻪ‬ ‫لﺬلﻚ‬ ،‫اﳉﺴﻢ‬ ‫ﺳﻮاﺋل‬ ‫ﺗﻮاﺯﻥ‬ ‫ﻭﻋلﻰ‬ ‫لليﻮﺭيا‬ ‫اﳌﻄلﻮﺑة‬ ‫الﻜلية‬ ‫الﺘصفية‬ ‫ﲢﻘيﻖ‬ .‫ﳑﻜﻨة‬ ‫ﻓﺘﺮة‬ ‫ﻷﻃﻮﻝ‬ ‫ﻋليﻬا‬ ‫اﶈاﻓﻈة‬ ‫الدﻡ‬ ‫لﻀﻐﻂ‬ ‫ﻣﺨفﻀة‬ ‫ﺃدﻭية‬ ‫ﺇلﻰ‬ ‫يﺤﺘاﺟﻮﻥ‬ ‫الﺬيﻦ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﳌﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ • ‫ﻣﺴﺘﻘﺒﻼﺕ‬ ‫ﺮاﺕ‬ ‫ﹺ‬‫ص‬ ‫ﹾ‬‫ﺤ‬‫ﹸ‬‫ﻣ‬‫ﺃﻭ‬ (ACEi) ‫ﹶﻨﺴﲔ‬‫ﺗ‬‫ﳒيﻮ‬‫ﹶ‬‫لﻸ‬ ‫ﻝ‬‫ﱢ‬‫ﻮ‬‫ﹶ‬ ‫ﹸ‬‫اﶈ‬ ‫اﻹﻧزﱘ‬ ‫ﻣﺜﺒﻄاﺕ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﻦ‬ ‫ﹸ‬‫يﺤﺴ‬ ‫ﻓﺈﻧﻪ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫اﺭﺗفاﻉ‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻮﻥ‬ ‫ﻻ‬ ‫الﺬيﻦ‬ ‫للﻤﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫ﺃﻣا‬ ، (ARBs) ‫اﻷﳒيﻮﺗﻨﺴﲔ‬ .‫اﳌﺘﺒﻘية‬ ‫الﻜلﻮية‬ ‫الﻮﻇيفة‬ ‫ﻋلﻰ‬ ‫اﶈاﻓﻈة‬ ‫ﺑﻬدﻑ‬ ‫الدﻭاﺋﲔ‬ ‫ﻫﺬيﻦ‬ ‫اﺳﺘﺨداﻡ‬ ‫ﳝﻜﻦ‬ ‫ﺑاﻋﺘﺒاﺭﻫا‬ ‫اﳌزﻣﻦ‬ ‫الﻜلﻮية‬ ‫الﻘصﻮﺭ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ ‫للﻜلﻰ‬ ‫اﳌﺆﺫية‬ ‫الﻌﻮاﻣل‬ ‫ﻣﻊ‬ ‫الﺘﻌاﻣل‬ ‫ﻦ‬ ‫ﹸ‬‫يﺤﺴ‬ • ‫اﳌﻀاداﺕ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﺫلﻚ‬ ‫ﻭيﺸﻤل‬ ،‫اﻹﻣﻜاﻥ‬ ‫قدﺭ‬ ‫ﻭﲡﻨﺒﻬا‬ ‫اﳌﺘﺒﻘية‬ ‫الﻜلﻮية‬ ‫للﻮﻇيفة‬ ‫ﻣﺆﺫية‬ NSAIDs, including COX-2) ‫الﻼﺳﺘيﺮﻭيدية‬ ‫اﻷلﻢ‬ ‫ﻭﻣﺴﻜﻨاﺕ‬ ،‫للﻜلﻰ‬ ‫اﳌﺆﺫية‬ ‫اﳊيﻮية‬ ،‫الﺴﻮاﺋل‬ ‫ﻭﻓﻘداﻥ‬ ،‫الﺒﻮﻝ‬ ‫ﻣﺠﺮﻯ‬ ‫ﻭاﻧﺴداد‬ ،(contrast material) ‫الﺘﺒايﻦ‬ ‫ﻭﻣﻮاد‬ ،(inhibitors .‫الدﻡ‬ ‫ﻓﻲ‬ ‫الﻜالﺴيﻮﻡ‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻭاﺭﺗفاﻉ‬ ،‫الﺸديد‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻭﻓﺮﻁ‬ ‫الﻮﻇيفة‬‫ﻋلﻰ‬‫اﶈاﻓﻈة‬‫ﻓﻲ‬‫يﺴاﻋد‬‫قد‬‫الصفاﻕ‬‫ﺑالﺘﻬاﺏ‬‫اﻹﺻاﺑة‬‫ﺗﻘليل‬‫ﻓﺈﻥ‬‫ﺫلﻚ‬‫ﺇلﻰ‬‫ﺑاﻹﺿاﻓة‬ • .‫الﻮﻇيفة‬ ‫ﻫﺬﻩ‬ ‫ﻓﻲ‬ ‫ﺳﺮيﻊ‬ ‫ﺗدﻫﻮﺭ‬ ‫الﻌادة‬ ‫ﻓﻲ‬ ‫يصاﺣﺒﻪ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﻷﻥ‬ ‫اﳌﺘﺒﻘية‬ ‫الﻜلﻮية‬ ‫ﻭﺟيزة‬ ‫ﺯﻣﻨية‬ ‫ﻓﺘﺮة‬ ‫ﺧﻼﻝ‬ ‫الﻜلﻰ‬ ‫يﻀﺮ‬ ‫قد‬ ‫الﺸديد‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻓﺮﻁ‬ ‫ﺃﻥ‬ ‫ﺑاﳌﻼﺣﻈة‬ ‫يﺠدﺭ‬ • ‫يﺆدﻱ‬ ‫ﻭقد‬ ‫الدﻡ(؛‬ ‫ﺿﻐﻂ‬ ‫ﻓﺮﻁ‬ ‫ﻋﻦ‬ ‫الﻨاﰋ‬ ‫الﻜلﻰ‬ ‫)ﺗصلﺐ‬ ‫ﻃﻮيلة‬ ‫ﺃﻭ‬ (‫اﳋﺒيﺚ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫)ﻓﺮﻁ‬ ‫ﺑدﺭﺟة‬ ‫اﳌﺘﺒﻘية‬ ‫الﻜلﻮية‬ ‫الﻮﻇيفة‬ ‫ﲢﺴﻦ‬ ‫ﺇلﻰ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺑدﺀ‬ ‫ﺑﻌد‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﺿﺒﻂ‬ .‫الديلزة‬ ‫ﻋﻦ‬ ‫ﺑاﻻﺳﺘﻐﻨاﺀ‬ ‫ﺗﺴﻤﺢ‬ ‫ﻭﻓﻲ‬ ،‫اﳌزﺭﻭﻋة‬ ‫الﻜلﻰ‬ ‫ﻓﺸل‬ ‫ﺑﻌد‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺇلﻰ‬ ‫اﳌﺮﺿﻰ‬ ‫يﻌﻮد‬ ‫اﻷﺣياﻥ‬ ‫ﻣﻦ‬ ‫ﻛﺜيﺮ‬ ‫ﻓﻲ‬ • ‫ﺗفﻮﻕ‬ ‫ﻭقد‬ ،‫ﻣﺘﺒﻘية‬ ‫ﻛلﻮية‬ ‫ﺑﻮﻇيفة‬ ‫ﻣﺤﺘفﻈة‬ ‫ﺗﻜﻮﻥ‬ ‫قد‬ ‫اﳌزﺭﻭﻋة‬ ‫الﻜلﻰ‬ ‫ﻫﺬﻩ‬ ‫ﻓﺈﻥ‬ ‫اﳊالة‬ ‫ﻫﺬﻩ‬ ‫ﻣﻦ‬ ‫اﶈﺘﻤل‬ ‫الﻀﺮﺭ‬ (immunosuppression) ‫اﳌﻨاﻋة‬ ‫ﻛاﺑﺘاﺕ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﻓﻲ‬ ‫اﻻﺳﺘﻤﺮاﺭ‬ ‫ﻓاﺋدة‬ .‫ﻣل/الدقيﻘة‬ ١٫٥ ‫ﻋﻦ‬ ‫ﺗزيد‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﺗصفية‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫اﺳﺘﻌﻤالﻬا‬
  • ٤٩ (fluid overload) ‫ﺍﻟﺴﻮﺍﺋﻞ‬ ‫ﺍﺣﺘﺒﺎﺱ‬ ‫ﻣﻌﺎﳉﺔ‬ :١٤-٤ ‫اﳌﺮيﺾ‬ ‫ﺃﻥ‬ ‫ﺇﻻ‬ ،‫الﻘﺮيﺐ‬ ‫اﳌدﻯ‬ ‫ﻋلﻰ‬ ‫الﺴﻮاﺋل‬ ‫اﺣﺘﺒاﺱ‬ ‫لﺘﺸﺨيﺺ‬ ‫ﺳﻬلة‬ ‫ﻃﺮيﻘة‬ ‫الﻮﺯﻥ‬ ‫ﻣﺮاقﺒة‬ • ‫ﻭﺯﻧﻪ‬ ‫يﺘﻐيﺮ‬ ‫ﺃﻥ‬ ‫ﺑدﻭﻥ‬ ‫الﺴﻮاﺋل‬ ‫ﺑاﺣﺘﺒاﺱ‬ ‫يصاﺏ‬ ‫ﺃﻥ‬ ‫ﳝﻜﻨﻪ‬ ‫اﳉﺴﻢ‬ ‫ﻛﺘلة‬ ‫ﻓﻘداﻥ‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻲ‬ ‫الﺬﻱ‬ .‫ﹰ‬‫ا‬‫ﻇاﻫﺮي‬ ،‫الﻜاﺣل‬ ‫ﺗﻮﺭﻡ‬ ،‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫اﺭﺗفاﻉ‬ ‫الﺴﻮاﺋل‬ ‫اﺣﺘﺒاﺱ‬ ‫ﻋلﻰ‬ ‫الدالة‬ ‫الﺴﺮيﺮية‬ ‫الﻌﻼﻣاﺕ‬ ‫ﺗﺸﻤل‬ • .(pleural effusion) ‫اﳉﻨﺒﻲ‬ ‫ﻭاﻻﻧصﺒاﺏ‬ ،(pulmonary edema) ‫الﺮﺋﻮية‬ ‫الﻮﺫﻣة‬ •pulmonary) ‫الﺮﺋﻮية‬ ‫ﺑالﻮﺫﻣة‬ ‫لﻺﺻاﺑة‬ ‫ﻋﺮﺿة‬ ‫ﺃﻛﺜﺮ‬ ‫الﻘلﺐ‬ ‫ﺃﻣﺮاﺽ‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻮﻥ‬ ‫الﺬيﻦ‬ ‫اﳌﺮﺿﻰ‬ ‫ﻋلﻰ‬‫ﹰ‬‫ا‬‫ﻣﺆﺷﺮ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫اﺭﺗفاﻉ‬ ‫يﻌﺘﺒﺮ‬ ‫اﳊالة‬ ‫ﻫﺬﻩ‬ ‫ﻓﻲ‬ ،‫الﺴﻮاﺋل‬ ‫اﺣﺘﺒاﺱ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ (edema .‫الﻘلﺐ‬ ‫ﻓﺸل‬ ‫ﻭليﺲ‬ ‫الﺮﺋﻮية‬ ‫للﻮﺫﻣة‬ ‫الﺮﺋيﺲ‬ ‫الﺴﺒﺐ‬ ‫ﻫﻮ‬ ‫الﺴﻮاﺋل‬ ‫اﺣﺘﺒاﺱ‬ ‫ﺃﻥ‬ ‫ﻣﻨﻪ‬ ( •APD) ‫اﻵلية‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺮﺿﻰ‬ ‫ﻋﻨد‬ ‫ﺃﻓﻀل‬ ‫الﻌادة‬ ‫ﻓﻲ‬ ‫الﺴﻮاﺋل‬ ‫ﺗﻮاﺯﻥ‬ ‫يﻜﻮﻥ‬ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫ﻛﻤياﺕ‬ ‫ﳝﺘصﻮﻥ‬ ‫ﻷﻧﻬﻢ‬ ،(CAPD) ‫اﳌﺴﺘﻤﺮة‬ ‫اﳉﻮالة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺮﺿﻰ‬ ‫ﻋﻨد‬ .‫الﻘصيﺮة‬ ‫اﳌﻜﻮﺙ‬ ‫ﻓﺘﺮاﺕ‬ ‫ﺧﻼﻝ‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫اﳋﻄﻮة‬ ‫ﻓﺈﻥ‬ ،‫الﺴﻮاﺋل‬ ‫اﺣﺘﺒاﺱ‬ ‫ﻣﻦ‬ ‫ﺃﻭ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫اﺭﺗفاﻉ‬ ‫ﻓﺮﻁ‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻲ‬ ‫اﳌﺮيﺾ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ • .‫ﻭالﺴﻮاﺋل‬ ‫اﳌلﺢ‬ ‫ﺗﻨاﻭﻝ‬ ‫ﺗﻘليل‬ ‫ﺗﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ ‫اﻷﻭلﻰ‬ ‫الﻌﻼﺟية‬ ‫الﺒﻮﻝ‬ ‫ﺣﺠﻢ‬ ‫ﺯيادة‬ ‫ﻓﻲ‬ ‫ﺗفيد‬ ‫الﺒﻮﻝ‬ ‫ﻣدﺭاﺕ‬ ‫ﻓﺈﻥ‬ ‫ﻣﺘﺒﻘية‬ ‫ﻛلﻮية‬ ‫ﺑﻮﻇيفة‬ ‫يﺘﻤﺘﻊ‬ ‫اﳌﺮيﺾ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ • .(‫ﻓﺮﻭﺯﻣايد‬ :‫)ﻣﺜاﻝ‬ ‫لزيادة‬ ‫يﺴﺘﺠيﺒﻮﻥ‬ ‫اﳌﺮﺿﻰ‬ ‫ﻣﻌﻈﻢ‬ ‫ﻓﺈﻥ‬ ‫اﳌﻄلﻮﺏ‬ ‫الﺘﻮاﺯﻥ‬ ‫ﲢﻘيﻖ‬ ‫ﻓﻲ‬ ‫الﺒﻮﻝ‬ ‫ﻣدﺭاﺕ‬ ‫ﺗﻨﺠﺢ‬ ‫لﻢ‬ ‫ﺇﺫا‬ • ‫الﺘﺮﻛيز‬ ‫ﺫﻱ‬ ‫اﶈلﻮﻝ‬ ‫اﺳﺘﺨداﻡ‬ ‫يﺘﻢ‬ ‫ﻭﻋادة‬ ،‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻓﻲ‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫ﺗﺮﻛيز‬ ‫اﳌﺴﺘﻤﺮة‬ ‫اﳉﻮالة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﳌﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫الﻄﻮيل‬ ‫الليلﻲ‬ ‫اﳌﻜﻮﺙ‬ ‫ﺧﻼﻝ‬ ‫الﻌالﻲ‬ .‫اﻵلية‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﳌﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫الﻄﻮيل‬ ‫الﻨﻬاﺭﻱ‬ ‫اﳌﻜﻮﺙ‬ ‫ﻭﺧﻼﻝ‬ ‫الصفاﻕ‬ ‫ﻏﺸاﺀ‬ ‫ﻭﺗﻀﺮﺭ‬ ‫الﻮﺯﻥ‬ ‫ﺯيادة‬ ‫ﺇلﻰ‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻓﻲ‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫ﺗﺮﻛيز‬ ‫ﺯيادة‬ ‫ﺗﺆدﻱ‬ ‫قد‬ • ‫ﻏﺸاﺀ‬ ‫ﻭﻇيفة‬ ‫ﻋلﻰ‬ ‫للﻤﺤاﻓﻈة‬ ‫(؛‬GDP) ‫اﳉلﻮﻛﻮﺯ‬ ‫ﺗﻜﺴﺮ‬ ‫ﻣﻨﺘﺠاﺕ‬ ‫ﺇلﻰ‬ ‫الﺘﻌﺮﺽ‬ ‫ﺯيادة‬ ‫ﺑﺴﺒﺐ‬ .‫ﳑﻜﻨة‬ ‫ﻓﺘﺮة‬ ‫ﻷﻃﻮﻝ‬ ‫للﺠلﻮﻛﻮﺯ‬ ‫ﳑﻜﻦ‬ ‫ﺗﺮﻛيز‬ ‫ﺃقل‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫يﻨصﺢ‬ ‫ﳝﻜﻦ‬ ‫ﻣا‬ ‫ﻷﻃﻮﻝ‬ ‫الصفاﻕ‬ ‫اﺧﺘﺒاﺭ‬‫ﺇﺟﺮاﺀ‬‫ﻣﻦ‬‫ﻓﻼﺑد‬‫اﶈلﻮﻝ‬‫ﻓﻲ‬‫اﳉلﻮﻛﻮﺯ‬‫ﺗﺮﻛيز‬‫لزيادة‬‫ﻛاﻓية‬‫ﺑصﻮﺭة‬‫اﳌﺮيﺾ‬‫يﺴﺘﺠﺐ‬‫لﻢ‬‫ﺇﺫا‬ • ‫قد‬ ‫ﺇﺫ‬ ،(١٢-٤ ‫ﻓﻘﺮة‬ ‫)اﻧﻈﺮ‬ ‫اﳌﻨاﺳﺒة‬ ‫اﳌﻌاﳉة‬ ‫ﻭﲢديد‬ ‫اﻷﺳﺒاﺏ‬ ‫ﳌﻌﺮﻓة‬ (PET) ‫الصفاﻕ‬ ‫ﺗﻮاﺯﻥ‬ .‫اﳌﺸﻜلة‬ ‫ﺣل‬ ‫ﺇلﻰ‬ ‫الصفاﻕ‬ ‫ﻏﺸاﺀ‬ ‫ﻧﻘل‬ ‫ﺧصاﺋﺺ‬ ‫ﺗﻼﺋﻢ‬ ‫ﺑﺤيﺚ‬ ‫اﳌﻜﻮﺙ‬ ‫ﻓﺘﺮة‬ ‫ﺗﻌديل‬ ‫يﺆدﻱ‬ ‫اﳌﺮﻛز‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻋﻦ‬ ‫ﹰ‬‫ﻻ‬‫ﺑد‬ ‫اﺳﺘﺨداﻣﻪ‬ ‫ﳝﻜﻦ‬ ‫ﻓﺈﻧﻪ‬ ‫ﺁيﻜﻮدﻛﺴﺘﺮيﻦ‬ ‫ﻣﺤلﻮﻝ‬ ‫ﺗﻮﻓﺮ‬ ‫ﺇﺫا‬ • ‫ﻋﻦ‬ ‫ﻋﺒاﺭة‬ ‫ﻫﻮ‬ ‫ﺁيﻜﻮدﻛﺴﺘﺮيﻦ‬ .‫الﺴﻮاﺋل‬ ‫اﺣﺘﺒاﺱ‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻮﻥ‬ ‫الﺬيﻦ‬ ‫اﳌﺮﺿﻰ‬ ‫ﻣﻌاﳉة‬ ‫ﻓﻲ‬ ‫ﻋلﻰ‬ ‫يﺤاﻓﻆ‬ ‫ﻓﺈﻧﻪ‬ ‫ﻭلﺬلﻚ‬ ،‫الصفاﻕ‬ ‫ﻏﺸاﺀ‬ ‫ﻣﻦ‬ ‫ﺑصﻌﻮﺑة‬ ‫يﻨفﺬ‬ ‫اﳊﺠﻢ‬ ‫ﻛﺒيﺮ‬ ‫ﺟلﻮﻛﻮﺯ‬ ‫ﻣﺮﻛﺐ‬ ‫اﺳﺘﻤﺮاﺭية‬ ‫ﻋلﻰ‬ ‫ﻭيﺤاﻓﻆ‬ ‫ﺃﻃﻮﻝ‬ ‫لفﺘﺮة‬ ‫للﻤﺤلﻮﻝ‬ (osmotic pressure) ‫الﺘﻨاﺿﺤﻲ‬ ‫الﻀﻐﻂ‬ ‫ﻣﺤلﻮﻝ‬ ‫يﺴﺘﺨدﻡ‬ .‫الﺘﺮﻛيز‬ ‫ﻋالﻲ‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻛفاﺀة‬ ‫ﺗﻌادﻝ‬ ‫ﺑﻜفاﺀة‬ ‫الﺴﻮاﺋل‬ ‫ﺭﺷﺢ‬ ‫اﳉﻮالة‬‫الصفاقية‬‫الديلزة‬‫ﳌﺮﺿﻰ‬‫ﺑالﻨﺴﺒة‬‫الﻄﻮيل‬‫الليلﻲ‬‫اﳌﻜﻮﺙ‬‫ﺧﻼﻝ‬‫ﻋادة‬‫ﺁيﻜﻮدﻛﺴﺘﺮيﻦ‬ .‫اﻵلية‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﳌﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫الﻄﻮيل‬ ‫الﻨﻬاﺭﻱ‬ ‫اﳌﻜﻮﺙ‬ ‫ﻭﺧﻼﻝ‬ ‫اﳌﺴﺘﻤﺮة‬
  • ٤٨ ‫الﺴاﺑﻘة‬‫قيﻤﺘﻪ‬‫ﻋﻦ‬‫اﳌﺬاﺑاﺕ‬‫ﻧﻘل‬‫يﺘﻐيﺮ‬‫لﻢ‬‫ﺣﲔ‬‫ﻓﻲ‬‫ﹰ‬‫ا‬‫ﻣﻨﺨفﻀ‬‫الﺮاﺷﺢ‬‫الﺴاﺋل‬‫ﺣﺠﻢ‬‫ﻛاﻥ‬‫ﺇﺫا‬ • ‫اﻷﻭﻋية‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫اﻣﺘصاﺹ‬ ‫ﺳﺮﻋة‬ ‫ﻋلﻰ‬ ‫يدﻝ‬ ‫قد‬ ‫ﻫﺬا‬ ‫ﻓﺈﻥ‬ (‫ﺛاﺑﺘة‬ ‫د/ﻡ‬ ‫)ﻧﺴﺒة‬ .‫اﶈلﻮﻝ‬ ‫ﺗﺴﺮﺏ‬ ‫ﺃﻭ‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﺗﻌﻄل‬ ‫ﺃﻭ‬ ،‫الصفاﻕ‬ ‫ﻏﺸاﺀ‬ ‫ﻋﺒﺮ‬ ‫اﳌاﺀ‬ ‫ﻧﻘل‬ ‫ﺿﻌﻒ‬ ‫ﺃﻭ‬ ،‫الليﻤفية‬ ‫ﺗﻮاﺯﻥ‬ ‫اﺧﺘﺒاﺭ‬ ‫ﺃﻇﻬﺮ‬ ‫ﺣﲔ‬ ‫ﻓﻲ‬ ،( •fluid overload) ‫الﺴﻮاﺋل‬ ‫اﺣﺘﺒاﺱ‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻲ‬ ‫اﳌﺮيﺾ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫الﺴاﺑﻘة‬ ‫قيﻤﺘﻪ‬ ‫ﻋﻦ‬ ‫اﳌﺬاﺑاﺕ‬ ‫ﻧﻘل‬ ‫ﺗﻐيﺮ‬ ‫ﻭﻋدﻡ‬ ‫الﺮاﺷﺢ‬ ‫الﺴاﺋل‬ ‫ﺣﺠﻢ‬ ‫ﻧﻘصاﻥ‬ ‫ﻋدﻡ‬ ‫الصفاﻕ‬ ‫ﻓﻲ‬ ‫اﻹﻓﺮاﻁ‬ ،‫اﳌﺘﺒﻘية‬ ‫الﻜلﻮية‬ ‫الﻮﻇيفة‬ ‫ﻓﻘداﻥ‬ ‫ﻋلﻰ‬ ‫يدﻝ‬ ‫قد‬ ‫ﻫﺬا‬ ‫ﻓﺈﻥ‬ ،(‫ﺛاﺑﺘة‬ ‫د/ﻡ‬ ‫)ﻧﺴﺒة‬ .‫الصفاقية‬ ‫الديلزة‬ ‫ﺑﻮﺻفة‬ ‫اﳌﺮيﺾ‬ ‫الﺘزاﻡ‬ ‫ﻋدﻡ‬ ‫ﺃﻭ‬ ،‫الﺴﻮاﺋل‬ ‫ﺗﻨاﻭﻝ‬ ‫ﺍﳌﺬﺍﺑﺎﺕ‬ ‫ﺗﺼﻔﻴﺔ‬ ‫ﲢﺴﲔ‬ :١٣-٤ ‫اﶈلﻮﻝ‬ ‫ﻛﻤية‬ ‫ﺯيادة‬ ،‫الصفاقية‬ ‫الديلزة‬ ‫ﻭقﺖ‬ ‫ﺯيادة‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫اﳌﺬاﺑاﺕ‬ ‫ﺗصفية‬ ‫ﲢﺴﲔ‬ ‫ﳝﻜﻦ‬ • .‫اﶈلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﻣﺮاﺕ‬ ‫ﻋدد‬ ‫ﺯيادة‬ ‫ﺃﻭ‬ (‫ﻓاﻋلية‬ ‫الﻄﺮﻕ‬ ‫)ﺃﻛﺜﺮ‬ ‫اﳌﺴﺘﺨدﻡ‬ ‫ﻣﻌدﻝ‬ ‫ﳊﺴاﺏ‬ « •AdequestTM » ‫ﺑﺮﻧاﻣﺞ‬‫ﻣﺜل‬ ‫ﺑالديلزة‬‫اﳋاﺻة‬ ‫اﳊاﺳﻮﺏ‬‫ﺑﺮاﻣﺞ‬‫اﺳﺘﺨداﻡ‬‫ﳝﻜﻦ‬ ‫للديلزة‬ ‫ﻣﺨﺘلفة‬ ‫ﻭﺻفاﺕ‬ ‫ﺑاﺳﺘﺨداﻡ‬ ‫ﲢﻘيﻘﻬا‬ ‫ﳝﻜﻦ‬ ‫الﺘﻲ‬ ‫لليﻮﺭيا‬ ‫الصفاقية‬ ‫الﺘصفية‬ ‫ﺧصاﺋﺺ‬ ‫ﻣﻌﺮﻓة‬ ‫ﺇلﻰ‬ ‫ﲢﺘاﺝ‬ ‫اﳊﺴاﺑاﺕ‬ ‫ﻫﺬﻩ‬ ‫ﻣﺜل‬ ‫ﻭلﻜﻦ‬ ،‫ﻣﻌﲔ‬ ‫ﳌﺮيﺾ‬ ‫ﺑالﻨﺴﺒة‬ ‫الصفاقية‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ (‫الصفاﻕ‬ ‫ﺗﻮاﺯﻥ‬ ‫اﺧﺘﺒاﺭ‬ ‫ﻧﺘاﺋﺞ‬ ‫ﻣﻦ‬ ‫ﻋليﻬا‬ ‫اﳊصﻮﻝ‬ ‫)ﳝﻜﻦ‬ ‫الصفاﻕ‬ ‫ﻏﺸاﺀ‬ ‫ﻧﻘل‬ .‫اﳉﺴﻢ‬ ‫ﺳﻄﺢ‬ ‫ﻣﺴاﺣة‬ ‫ﻣﻌﺮﻓة‬ ،‫اﳌﻄلﻮﺑة‬‫الصفاقية‬‫الﺘصفية‬‫ﲢﻘﻖ‬‫ﺃﻥ‬‫لﻬا‬‫يﺘﻮقﻊ‬‫الﺘﻲ‬‫الصفاقية‬‫الديلزة‬‫ﻭﺻفة‬‫ﲢديد‬‫ﺑﻌد‬ • ‫ﻣﻦ‬ ‫للﺘﺄﻛد‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻛفاية‬ ‫اﺧﺘﺒاﺭ‬ ‫ﺇﺟﺮاﺀ‬ ‫ﺫلﻚ‬ ‫يﺘﺒﻊ‬ ‫ﺛﻢ‬ ‫الديلزة‬ ‫ﻭﺻفة‬ ‫ﺗﻌديل‬ ‫يﺘﻢ‬ .‫اﳌﻄلﻮﺑة‬ ‫الﺘصفية‬ ‫ﻋلﻰ‬ ‫اﳊصﻮﻝ‬ ،‫ﺛاﺑﺘة‬ ‫اليﻮﻣية‬ ‫الديلزة‬ ‫ﺳاﻋاﺕ‬ ‫ﺗﻜﻮﻥ‬ ( •CAPD) ‫اﳌﺴﺘﻤﺮة‬ ‫اﳉﻮالة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺣالة‬ ‫ﻓﻲ‬ ‫ﺃقصﻰ‬ ‫ﺇلﻰ‬ ‫اﳌﺴﺘﺨدﻡ‬ ‫اﶈلﻮﻝ‬ ‫ﻛﻤية‬ ‫ﺑزيادة‬ ‫ﻫﻲ‬ ‫الديلزة‬ ‫ﺟﺮﻋة‬ ‫لزيادة‬ ‫الﻮﺣيدة‬ ‫ﻭالﻄﺮيﻘة‬ ‫ﻓﺈﻥ‬ ‫اﻷﺳﺒاﺏ‬ ‫لﻬﺬﻩ‬ .‫اﶈلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﻣﺮاﺕ‬ ‫ﻋدد‬ ‫ﺯيادة‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ ،‫ﲢﻤلﻪ‬ ‫للﻤﺮيﺾ‬ ‫ﳝﻜﻦ‬ ‫ﺣد‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﳌﺮيﺾ‬ ‫ﻭﺻفﻬا‬ ‫ﳝﻜﻦ‬ ‫الﺘﻲ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﳉﺮﻋة‬ ‫ﻋﻤلية‬‫ﹰ‬‫ا‬‫ﺣدﻭد‬ ‫ﻫﻨاﻙ‬ .‫اﳌﺴﺘﻤﺮة‬ ‫اﳉﻮالة‬ ‫ﻓﻲ‬ ‫للﻤﺮيﺾ‬ ‫ﳝﻜﻦ‬ ‫ﺣيﺚ‬ ،‫ﺃﻛﺒﺮ‬ ‫ﻣﺮﻭﻧة‬ ‫ﻓﺘﺘيﺢ‬ ( •APD) ‫اﳌﺴﺘﻤﺮة‬ ‫اﻵلية‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺃﻣا‬ ‫ﺃﻥ‬ ‫ﻛﻤا‬ ،‫الصفاﻕ‬ ‫ﲡﻮيﻒ‬ ‫داﺧل‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﺃﻛﺒﺮ‬ ‫ﻛﻤياﺕ‬ ‫يﺘﺤﻤل‬ ‫ﺃﻥ‬ ‫اﻻﺳﺘلﻘاﺀ‬ ‫ﻭﺿﻊ‬ .‫اﳌﺮيﺾ‬ ‫ﺑﻮاﺳﻄة‬ ‫ﻭليﺲ‬ ‫اﻵلة‬ ‫ﺑﻮاﺳﻄة‬ ‫يﺘﻢ‬ ‫اﶈلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﳝﻜﻦ‬ ‫الﺘﻲ‬ ‫الﺴاﻋاﺕ‬ ‫ﻋدد‬ ‫ﻫﻮ‬ ‫اﻵلية‬ ‫الديلزة‬ ‫ﺟﺮﻋة‬ ‫لزيادة‬ ‫اﳌﻘيد‬ ‫الﻌاﻣل‬ ‫يﻜﻮﻥ‬ ‫ﻣا‬ ‫ﹰ‬‫ا‬‫ﻏالﺒ‬ • .‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻛلفة‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ ‫الديلزة‬ ‫ﺑﺂلة‬ ‫ﻓيﻬا‬ ‫ﹰ‬‫ا‬‫ﻣﺮﺗﺒﻄ‬ ‫يﻈل‬ ‫ﺃﻥ‬ ‫للﻤﺮيﺾ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺟﺮﻋة‬ ‫لزيادة‬ ‫الﻨﻬاﺭ‬ ‫ﺧﻼﻝ‬ ‫ﻣﺮﺗﲔ‬ ‫ﺃﻭ‬ ‫ﻣﺮة‬‫ﹰ‬‫ا‬‫يدﻭي‬ ‫اﶈلﻮﻝ‬ ‫ﺑﺘﺒديل‬ ‫اﳌﺮيﺾ‬ ‫قياﻡ‬ ‫ﺇﻥ‬ • ‫ﺃﺛﻨاﺀ‬ ‫اﶈلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﻣﺮاﺕ‬ ‫ﻋدد‬ ‫ﺯيادة‬ ‫ﻣﻦ‬ ‫ﻛلفة‬ ‫ﻭﺃقل‬ ‫ﻛفاﺀة‬ ‫ﺃﻛﺜﺮ‬ ‫الﻐالﺐ‬ ‫ﻓﻲ‬ ‫يﻜﻮﻥ‬ ‫اﻵلية‬ ‫ﺃﻥ‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ ،‫ﹰ‬‫ا‬‫ﺳﻌﺮ‬ ‫ﺃقل‬ ‫ﻷﻧﻬا‬ ‫اﳊﺠﻢ‬ ‫ﻛﺒيﺮة‬ ‫اﻷﻛياﺱ‬ ‫اﺳﺘﺨداﻡ‬ ‫يفﻀل‬ ‫ﻛﺬلﻚ‬ .‫الليل‬ .‫ﻭالﺘﻮﺻيل‬ ‫الفﻚ‬ ‫ﻣﺮاﺕ‬ ‫ﻋدد‬ ‫ﻣﻦ‬ ‫يﻘلل‬ ‫اﺳﺘﺨداﻣﻬا‬
  • ٤٧ ‫ﺍﻟﺼﻔﺎﻕ‬ ‫ﺗﻮﺍﺯﻥ‬ ‫ﺍﺧﺘﺒﺎﺭ‬ ‫ﻟﻨﺘﺎﺋﺞ‬ ‫ﹰ‬‫ﻃﺒﻘﺎ‬ ‫ﺍﻟﺼﻔﺎﻕ‬ ‫ﻏﺸﺎﺀ‬ ‫ﻧﻘﻞ‬ ‫ﺧﺼﺎﺋﺺ‬ :١١-٤ ‫لﺬلﻚ‬ ‫ﻭﻧﺘيﺠة‬ ،‫ﻃﻮيل‬ ‫ﻭقﺖ‬ ‫ﺑﻌد‬ ‫الﺘﻮاﺯﻥ‬ ‫ﺇلﻰ‬ ‫الﻮﺻﻮﻝ‬ ‫يﺘﻢ‬ :‫اﳌﻨﺨفﺾ‬ ‫الﻨﻘل‬ ‫ﺫﻭﻱ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ • ‫ﻛاﻧﺖ‬ ‫لﻮ‬ ‫ﺣﺘﻰ‬ ‫اﳌﻜﻮﺙ‬ ‫ﻓﺘﺮة‬ ‫ﻃﻮاﻝ‬ ‫ﻣﻀﻄﺮدة‬ ‫ﺑصﻮﺭة‬ ‫الﺴﻮاﺋل‬ ‫ﻭﺭﺷﺢ‬ ‫اﳌﺬاﺑاﺕ‬ ‫ﺗصفية‬ ‫ﺗزيد‬ .‫الﻄﻮيلة‬ ‫اﳌﻜﻮﺙ‬ ‫ﻓﺘﺮاﺕ‬ ‫اﺠﻤﻟﻤﻮﻋة‬ ‫ﻫﺬﻩ‬ ‫ﺗﻨاﺳﺐ‬ ‫ﻃﻮيلة؛‬ ‫اﻣﺘصاﺹ‬ ‫يﺘﻢ‬ ‫ﻛﻤا‬ ،‫قصيﺮ‬ ‫ﻭقﺖ‬ ‫ﺑﻌد‬ ‫الﺘﻮاﺯﻥ‬ ‫ﺇلﻰ‬ ‫الﻮﺻﻮﻝ‬ ‫يﺘﻢ‬ :‫اﳌﺮﺗفﻊ‬ ‫الﻨﻘل‬ ‫ﺫﻭﻱ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ • ‫الﺴﻮاﺋل‬ ‫لﺮﺷﺢ‬ ‫اﶈفز‬ ‫الﺘﻨاﺿﺤﻲ‬ ‫الﻀﻐﻂ‬ ‫يزﻭﻝ‬ ‫ﻭلﺬلﻚ‬ ،‫قصيﺮ‬ ‫ﻭقﺖ‬ ‫ﺑﻌد‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫ﺳاﻋاﺕ‬ ٤ - ٣ ‫ﻣﺮﻭﺭ‬ ‫ﺑﻌد‬ ‫ﺑاﻻﻧﺨفاﺽ‬ ‫الﺴﻮاﺋل‬ ‫ﻭﺭﺷﺢ‬ ‫اﳌﺬاﺑاﺕ‬ ‫ﺗصفية‬ ‫ﻭﺗﺒدﺃ‬ ‫ﺑﺴﺮﻋة‬ (UF) .‫الﻘصيﺮة‬ ‫اﳌﻜﻮﺙ‬ ‫ﻓﺘﺮاﺕ‬ ‫اﺠﻤﻟﻤﻮﻋة‬ ‫ﻫﺬﻩ‬ ‫ﺗﻨاﺳﺐ‬ ‫الصفاﻕ؛‬ ‫ﲡﻮيﻒ‬ ‫داﺧل‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻜﻮﺙ‬ ‫ﻋلﻰ‬ ،‫ﺳاﻋاﺕ‬ •١٠ - ٨ ‫ﳌدة‬ ‫ﺑﻜفاﺀة‬ ‫اﳌﺬاﺑاﺕ‬ ‫ﺗصفية‬ ‫ﺗﺴﺘﻤﺮ‬ :‫اﳌﺘﻮﺳﻂ‬ ‫الﻨﻘل‬ ‫ﺫﻭﻱ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ ‫الﻄﻮيلة‬ ‫اﳌﻜﻮﺙ‬ ‫ﻓﺘﺮاﺕ‬ ‫ﻣﻊ‬ ‫ﺑفﻌالية‬ ‫الﺘﻌاﻣل‬ ‫ﳝﻜﻨﻬا‬ ‫اﳌﺮﺿﻰ‬ ‫ﻣﻦ‬ ‫اﺠﻤﻟﻤﻮﻋة‬ ‫ﻫﺬﻩ‬ ‫ﻓﺈﻥ‬ ‫ﻭلﺬلﻚ‬ .‫ﻣﺮة‬ ‫ﻷﻭﻝ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺑدﺀ‬ ‫ﻋﻨد‬ ‫اﺠﻤﻟﻤﻮﻋة‬ ‫لﻬﺬﻩ‬ ‫ﹰ‬‫ا‬‫ﺗﻘﺮيﺒ‬ ‫اﳌﺮﺿﻰ‬ ‫ﺛلﺜا‬ ‫يﻨﺘﻤﻲ‬ ‫الﻘصيﺮة؛‬ ‫ﺃﻭ‬ ‫ﺍﻟﺼﻔﺎﻕ‬ ‫ﺗﻮﺍﺯﻥ‬ ‫ﺍﺧﺘﺒﺎﺭ‬ ‫ﻟﻨﺘﺎﺋﺞ‬ ‫ﹰ‬‫ﻃﺒﻘﺎ‬ ‫ﺍﻟﺴﻮﺍﺋﻞ‬ ‫ﺭﺷﺢ‬ ‫ﺿﻌﻒ‬ ‫ﺃﺳﺒﺎﺏ‬ :١٢-٤ ‫ﻣﺮاﺕ‬ ‫ﺛﻼﺙ‬ ٪ •٣٫٨٦/٤٫٢٥ ‫الﺘﺮﻛيز‬ ‫ﻋالﻲ‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫ﻣﺤلﻮﻝ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﺇلﻰ‬ ‫يﺤﺘاﺝ‬ ‫اﳌﺮيﺾ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫اﻧﺨفاﺽ‬ ‫ﻋلﻰ‬ ‫دﻻلة‬ ‫ﺗﻌﺘﺒﺮ‬ ‫ﻫﺬﻩ‬ ‫ﻓﺈﻥ‬ ‫اﳉﺴﻢ‬ ‫ﺳﻮاﺋل‬ ‫ﺗﻮاﺯﻥ‬ ‫ﻋلﻰ‬ ‫للﻤﺤاﻓﻈة‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﺃﻛﺜﺮ‬ ‫ﺃﻭ‬ .(UF failure) ‫الﺴﻮاﺋل‬ ‫ﺭﺷﺢ‬ ‫ﻛفاﺀة‬ ‫للﺘﺤﻘﻖ‬ ٪ •٤٫٢٥/٣٫٨٦ ‫ﺗﺮﻛيزﻩ‬ ‫ﺟلﻮﻛﻮﺯ‬ ‫ﻣﺤلﻮﻝ‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫الصفاﻕ‬ ‫ﺗﻮاﺯﻥ‬ ‫اﺧﺘﺒاﺭ‬ ‫ﺇﺟﺮاﺀ‬ ‫ﳝﻜﻦ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫الﺴﻮاﺋل‬ ‫ﺭﺷﺢ‬ ‫ﺿﻌﻒ‬ ‫ﺗﺸﺨيﺺ‬ ‫ﻭيﺘﻢ‬ ،‫ﺃﺳﺒاﺑﻪ‬ ‫ﻭﲢديد‬ ‫الﺴﻮاﺋل‬ ‫ﺭﺷﺢ‬ ‫ﺿﻌﻒ‬ ‫ﻣﻦ‬ ٪٤٫٢٥/٣٫٨٦ ‫ﺗﺮﻛيزﻩ‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻦ‬ ‫ليﺘﺮيﻦ‬ ‫ﻣﻜﻮﺙ‬ ‫ﺑﻌد‬ ‫ﻣل‬ ٤٠٠ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫الﺮاﺷﺢ‬ ‫الﺴاﺋل‬ ‫ﺣﺠﻢ‬ .‫الصفاﻕ‬ ‫ﲡﻮيﻒ‬ ‫داﺧل‬ ‫ﺳاﻋاﺕ‬ ٤ ‫ﳌدة‬ ‫)اﺭﺗفﻌﺖ‬ ‫الﺴاﺑﻘة‬ ‫قيﻤﺘﻪ‬ ‫ﻋﻦ‬ ‫اﳌﺬاﺑاﺕ‬ ‫ﻧﻘل‬ ‫ﺯاد‬ ‫ﺣﲔ‬ ‫ﻓﻲ‬ ‫ﹰ‬‫ﻼ‬‫قلي‬ ‫الﺮاﺷﺢ‬ ‫الﺴاﺋل‬ ‫ﺣﺠﻢ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ • ‫ﻓﺸل‬ ‫ﺗﺴﻤﻰ‬ ‫اﳊالة‬ ‫ﻫﺬﻩ‬ ‫ﻓﺈﻥ‬ ،‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﻋلﻰ‬ ‫دﻻلة‬ ‫ﻫﻨاﻙ‬ ‫ﺗﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫دﻭﻥ‬ (‫د/ﻡ‬ ‫ﻧﺴﺒة‬ ‫لفﺘﺮاﺕ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﻣﻦ‬ ‫ﻧاﲡة‬ ‫الﻐالﺐ‬ ‫ﻓﻲ‬ ‫ﻭﺗﻜﻮﻥ‬ ،‫اﻷﻭﻝ‬ ‫الﻨﻮﻉ‬ ‫ﻣﻦ‬ ‫الصفاﻕ‬ ‫ﺯيادة‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫اﳌﺸﻜلة‬ ‫ﻫﺬﻩ‬ ‫ﻣﻌاﳉة‬ ‫ﳝﻜﻦ‬ .‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫اﳌﺘﻜﺮﺭة‬ ‫اﻹﺻاﺑاﺕ‬ ‫ﺃﻭ‬ ‫ﻃﻮيلة‬ .‫اﳌﺴﺘﻤﺮة‬ ‫اﻵلية‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻓﻲ‬ ‫اﳌﻜﻮﺙ‬ ‫ﻓﺘﺮة‬ ‫ﻭﺇﻧﻘاﺹ‬ ‫اﶈلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﻣﺮاﺕ‬ ‫ﻋدد‬ ‫ﺃﺭﺑﻌة‬ ‫ﳌدة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺇيﻘاﻑ‬ ‫ﻫﻲ‬ ‫اﳌﺸﻜلة‬ ‫ﻫﺬﻩ‬ ‫ﻣﻊ‬ ‫للﺘﻌاﻣل‬ ‫الﺜاﻧية‬ ‫الﻄﺮيﻘة‬ ‫ﻣل‬ ٢٠٠ - ١٠٠ ‫قدﺭﻫا‬ ‫ﻛﻤية‬ ‫ﺇدﺧاﻝ‬ ‫ﻣﻊ‬ ،‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫ﺇلﻰ‬ ‫ﹰ‬‫ا‬‫ﻣﺆقﺘ‬ ‫ﺑالﺘﺤﻮﻝ‬ ‫ﺃﺳاﺑيﻊ‬ ‫الصفاﻕ‬ ‫ﺇلﻰ‬ ‫الﻬيﺒاﺭيﻦ‬ ‫ﻣﻦ‬ ‫ﻭﺣدة‬ ٣٥٠٠ ‫ﻋلﻰ‬ ‫يﺤﺘﻮﻱ‬ ٪١٫٥/١٫٣٦ ‫ﺗﺮﻛيزﻩ‬ ‫ﺟلﻮﻛﻮﺯ‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻏﺸاﺀ‬ ‫ﺇﻋادة‬ ‫ﻓﻲ‬ ‫الﺘﻘﻨية‬ ‫ﻫﺬﻩ‬ ‫ﳒاﺡ‬ ‫اﺣﺘﻤاﻻﺕ‬ ‫ﻭﺗﺒلﻎ‬ ،‫ﺑاﳌﻜﻮﺙ‬ ‫لﻬا‬ ‫ﻭالﺴﻤاﺡ‬ ‫ﹰ‬‫ا‬‫ﺃﺳﺒﻮﻋي‬ ‫ﻣﺮﺗﲔ‬ .٪٦٩ ‫اﻷﻭلﻰ‬ ‫ﺣالﺘﻪ‬ ‫ﺇلﻰ‬ ‫الصفاﻕ‬ ‫)ﻧﻘصﺖ‬ ‫الﺴاﺑﻘة‬ ‫قيﻤﺘﻪ‬ ‫ﻋﻦ‬ ‫اﳌﺬاﺑاﺕ‬ ‫ﻧﻘل‬ ‫ﻭﻧﻘﺺ‬ ‫ﹰ‬‫ﻼ‬‫قلي‬ ‫الﺮاﺷﺢ‬ ‫الﺴاﺋل‬ ‫ﺣﺠﻢ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ • ،‫الصفاﻕ‬ ‫ﺗليﻒ‬ :‫)ﻣﺜاﻝ‬ ‫الﺜاﻧﻲ‬ ‫الﻨﻮﻉ‬ ‫ﻣﻦ‬ ‫الصفاﻕ‬ ‫ﻓﺸل‬ ‫ﺗﺴﻤﻰ‬ ‫اﳊالة‬ ‫ﻫﺬﻩ‬ ‫ﻓﺈﻥ‬ (‫د/ﻡ‬ ‫ﻧﺴﺒة‬ .‫لﻼﻧﻌﻜاﺱ‬ ‫قاﺑلة‬ ‫ﻏيﺮ‬ ‫ﺣالة‬ ‫الﻐالﺐ‬ ‫ﻓﻲ‬ ‫ﻭﻫﻲ‬ ،(‫الﻜيﺴﻲ‬ ‫الصفاﻕ‬ ‫ﺗصلﺐ‬ ‫ﺃﻭ‬ ،‫اﻻلﺘصاقاﺕ‬
  • ٤٦ ‫ﺧﻼﻝ‬ ‫قاﺋﻢ‬ ‫ﻭﺿﻊ‬ ‫ﻓﻲ‬ ‫ﻭاﳌﺮيﺾ‬ ‫الصفاﻕ‬ ‫ﲡﻮيﻒ‬ ‫ﻣﻦ‬ ‫اﶈلﻮﻝ‬ ‫ﺑﺘصﺮيﻒ‬ ‫قﻢ‬ ‫ﺳاﻋاﺕ‬ ٥.٤ ‫ﻣﺮﻭﺭ‬ ‫ﺑﻌد‬ ‫ﻣل‬ ١٠ ‫ﺣﺠﻤﻬا‬ ‫ﻋيﻨة‬ ‫ﻣﻨﻬا‬ ‫ﺧﺬ‬ ‫ﺛﻢ‬ ،‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﻛﻤية‬ ‫اﺣﺴﺐ‬ ،‫دقيﻘة‬ ٢٠ ‫ﻋﻦ‬ ‫ﺗزيد‬ ‫ﻻ‬ ‫ﻓﺘﺮة‬ ‫ﻣﻦ‬ ‫ﻋيﻨة‬ ‫ﹰ‬‫ا‬‫ﺃيﻀ‬ ‫ﺧﺬ‬ .‫ﻭاﳉلﻮﻛﻮﺯ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫لﻘياﺱ‬ ‫اﳌﻌﻤل‬ ‫ﺇلﻰ‬ ‫ﻭﺃﺭﺳلﻬا‬ (٤‫)ﻡ‬ ‫ﻋليﻬا‬ ‫ﻭاﻛﺘﺐ‬ .‫ﻭاﳉلﻮﻛﻮﺯ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫لﻘياﺱ‬ ‫اﳌﻌﻤل‬ ‫ﺇلﻰ‬ ‫ﻭﺃﺭﺳلﻬا‬ (٤‫)د‬ ‫ﻋليﻬا‬ ‫ﻭاﻛﺘﺐ‬ ‫الدﻡ‬ ‫لﻜل‬ ‫الدﻡ‬ ‫ﻓﻲ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﺗﺮﻛيز‬ ‫ﻧﺴﺒة‬ ‫ﺇلﻰ‬ ‫اﶈلﻮﻝ‬ ‫ﻓﻲ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﺗﺮﻛيز‬ ‫ﻧﺴﺒة‬ ‫ﺑﺤﺴاﺏ‬ ‫قﻢ‬ ٦. ‫اﳉلﻮﻛﻮﺯ‬ ‫ﺗﺮﻛيز‬ ‫ﻧﺴﺒة‬ ‫ﺑﺤﺴاﺏ‬ ‫ﹰ‬‫ا‬‫ﺃيﻀ‬ ‫ﻭقﻢ‬ ، (٤‫ﻡ٤/د‬ ،٢‫ﻡ٢/د‬ ،‫ﺻفﺮ‬ ‫/د‬‫ﺻفﺮ‬ ‫)ﻡ‬ ‫ﺯﻣﻨية‬ ‫ﻧﻘﻄة‬ ‫اﻻﺧﺘﺒاﺭ‬ ‫ﺑداية‬ ‫ﻋﻨد‬ ‫اﶈلﻮﻝ‬ ‫ﻓﻲ‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫ﺗﺮﻛيز‬ ‫ﻧﺴﺒة‬ ‫ﺇلﻰ‬ ‫ﺯﻣﻨية‬ ‫ﻧﻘﻄة‬ ‫ﻛل‬ ‫ﻓﻲ‬ ‫اﶈلﻮﻝ‬ ‫ﻓﻲ‬ ‫ﻧﻮﻉ‬ ‫لﺘﺤديد‬ ‫ﺑاﻻﺧﺘﺒاﺭ‬ ‫اﳋاﺻة‬ ‫اﳌﻨﺤﻨياﺕ‬ ‫ﻋلﻰ‬ ‫الﻨﺘاﺋﺞ‬ ‫اﺭﺳﻢ‬ ‫ﺛﻢ‬ ،(‫ﺻفﺮ‬ ‫ﻡ٤/ﻡ‬ ،‫ﺻفﺮ‬ ‫)ﻡ٢/ﻡ‬ .(٩ ‫ﻭﺟدﻭﻝ‬ ٨ ‫ﺷﻜل‬ ‫)اﻧﻈﺮ‬ ‫الصفاﻕ‬ ‫ﻏﺸاﺀ‬ ‫ﺍﻟﺼﻔﺎﻕ‬ ‫ﺗﻮﺍﺯﻥ‬ ‫ﺍﺧﺘﺒﺎﺭ‬ ‫ﻧﺘﺎﺋﺞ‬ ‫ﺗﻔﺴﻴﺮ‬ :٩ ‫ﺟﺪﻭﻝ‬ ‫ﺍﻟﻨﻘﻞ‬ ‫ﻧﻮﻋﻴﺔ‬‫ﻟﻠﻴﻮﺭﻳﺎ‬ ٤‫ﺩ‬ /٤‫ﻡ‬‫ﻟﻠﻜﺮﻳﺎﺗﻨﲔ‬ ٤‫ﻡ٤/ﺩ‬‫ﻟﻠﺠﻠﻮﻛﻮﺯ‬ ‫ﺻﻔﺮ‬ ‫ﻡ٤/ﻡ‬‫ﺍﻟﺮﺍﺷﺢ‬ ‫ﻛﻤﻴﺔ‬ ‫ﻣﺮﺗفﻊ‬١٫٠٩ – ٠٫٩٨١٫٠٣ – ٠٫٨٢٠٫٢٥ – ٠٫١٢٢٠٨٤ – ١٥٨٠ ‫ﻣﺮﺗفﻊ‬ ‫ﻣﺘﻮﺳﻊ‬٠٫٩٧ – ٠٫٩١٠٫٨١ – ٠٫٦٥٠٫٣٨ – ٠٫٢٦٢٣٦٨ – ٢٠٨٥ ‫ﻣﻨﺨفﺾ‬ ‫ﻣﺘﻮﺳﻂ‬٠٫٩ – ٠٫٨٤٠٫٦٤ – ٠٫٥٠٫٤٩ – ٠٫٣٩٢٦٥٠ – ٢٣٦٩ ‫ﻣﻨﺨفﺾ‬٠٫٨٣ – ٠٫٧٥٠٫٤٩ – ٠٫٣٤٠٫٦١ – ٠٫٥٣٣٢٦ - ٢٦٥١ ‫ﺍﻟﺼﻔﺎﻕ‬ ‫ﺗﻮﺍﺯﻥ‬ ‫ﺍﺧﺘﺒﺎﺭ‬ ‫ﻧﺘﺎﺋﺞ‬ ‫ﺗﻔﺴﻴﺮ‬ :٨ ‫ﺷﻜﻞ‬
  • ٤٥ (PET) ‫ﺍﻟﺼﻔﺎﻕ‬ ‫ﺗﻮﺍﺯﻥ‬ ‫ﺍﺧﺘﺒﺎﺭ‬ :٩-٤ ‫اﶈلﻮﻝ‬ ‫ﻓيﻬا‬ ‫ﳝﻜﺚ‬ ‫قياﺳية‬ ‫ﻣﺤلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﺑﺠلﺴة‬ ‫الﻘياﻡ‬ ‫ﻋلﻰ‬ ‫الصفاﻕ‬ ‫ﺗﻮاﺯﻥ‬ ‫اﺧﺘﺒاﺭ‬ ‫يﻌﺘﻤد‬ • ‫ﻋﺒﺮ‬ ‫اﺨﻤﻟﺘلفة‬ ‫اﳌﺬاﺑاﺕ‬ ‫ﻭﻧﻘل‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫اﻣﺘصاﺹ‬ ‫ﺳﺮﻋة‬ ‫ﺣﺴاﺏ‬ ‫ﺛﻢ‬ ،‫الصفاﻕ‬ ‫داﺧل‬ ‫ﺳاﻋاﺕ‬ ٤ .‫اﻻﺧﺘﺒاﺭ‬ ‫ﻣدة‬ ‫ﺧﻼﻝ‬ ‫الﺮاﺷﺢ‬ ‫الﺴاﺋل‬ ‫ﺣﺠﻢ‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ ‫الصفاﻕ‬ ‫ﻏﺸاﺀ‬ ‫ﺧصاﺋﺺ‬ ‫ﺣﺴﺐ‬ ‫ﻣﺠﻤﻮﻋاﺕ‬ ‫ﺇلﻰ‬ ‫اﳌﺮﺿﻰ‬ ‫لﺘﻘﺴيﻢ‬ ‫الصفاﻕ‬ ‫ﺗﻮاﺯﻥ‬ ‫اﺧﺘﺒاﺭ‬ ‫ﻧﺘاﺋﺞ‬ ‫ﺗﺴﺘﻌﻤل‬ • ‫ﱡ‬‫ﻭﺗﺒﲔ‬ ،‫الﺴﻮاﺋل‬ ‫ﺭﺷﺢ‬ ‫ﺿﻌﻒ‬ ‫ﻣﻦ‬ ‫للﺘﺤﻘﻖ‬ ‫ﺗﺴﺘﺨدﻡ‬ ‫ﻛﻤا‬ ،(١١-٤ ‫ﻓﻘﺮة‬ ‫)اﻧﻈﺮ‬ ‫الصفاﻕ‬ ‫ﻧﻘل‬ .(١٢-٤ ‫ﻓﻘﺮة‬ ‫)اﻧﻈﺮ‬ ‫للﻤﻌاﳉة‬ ‫اﳌﺜلﻰ‬ ‫الﻄﺮيﻘة‬ ‫ﲢديد‬ ‫ﻓﻲ‬ ‫يﺴاﻋد‬ ‫ﳑا‬ ،‫الﻀﻌﻒ‬ ‫ﻫﺬا‬ ‫ﺃﺳﺒاﺏ‬ ‫ﻓﻲ‬ ‫الصفاﻕ‬ ‫ﺗﻮاﺯﻥ‬ ‫اﺧﺘﺒاﺭ‬ ‫ﻧﺘاﺋﺞ‬ ‫ﻣﻦ‬ ‫اﻻﺳﺘفادة‬ ‫ﳝﻜﻦ‬ ‫اﳌﺮيﺾ‬ ‫ﺳﻄﺢ‬ ‫ﻣﺴاﺣة‬ ‫ﻣﻌﺮﻓة‬ ‫ﻋﻨد‬ • ‫ديلزة‬ ‫ﻭﺻفة‬ ‫ﺑﻮاﺳﻄة‬ ‫ﲢﻘيﻘﻬا‬ ‫ﳝﻜﻦ‬ ‫الﺘﻲ‬ ‫لليﻮﺭيا‬ ‫اﳌﺘﻮقﻌة‬ ‫اﻷﺳﺒﻮﻋية‬ ‫الﺘصفية‬ ‫ﺣﺴاﺏ‬ ‫ﻣﺜل‬ ‫الصفاقية‬ ‫ﺑالديلزة‬ ‫اﳋاﺻة‬ ‫اﳊاﺳﻮﺑية‬ ‫الﺒﺮاﻣﺞ‬ ‫ﺑاﺳﺘﺨداﻡ‬ ‫ﻭﺫلﻚ‬ ،‫ﻣﻌيﻨة‬ ‫ﺻفاقية‬ ‫الﺘﻲ‬ ‫الﺘصفية‬ ‫ﻋﻦ‬ ‫ﹰ‬‫ا‬‫ﻛﺜيﺮ‬ ‫ﺗﺨﺘلﻒ‬ ‫اﳌﺘﻮقﻌة‬ ‫الﺘصفية‬ ‫ﺃﻥ‬ ‫اﺗﻀﺢ‬ ‫ﺇﺫا‬ .«AdequestTM » ‫ﺑﺮﻧاﻣﺞ‬ .‫اﶈددة‬ ‫ﺑالﻮﺻفة‬ ‫اﳌﺮيﺾ‬ ‫الﺘزاﻡ‬ ‫ﻋدﻡ‬ ‫ﻋلﻰ‬ ‫ﻫﺬا‬ ‫يدﻝ‬ ‫ﻓﻘد‬ ‫ﹰ‬‫ا‬‫ﻓﻌلي‬ ‫ﲢﻘيﻘﻬا‬ ‫ﰎ‬ ‫ﺑﻌد‬ ‫ﹰ‬‫ا‬‫ﺳﻨﻮي‬ ‫ﺛﻢ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺑدﺀ‬ ‫ﻣﻦ‬ ‫ﺷﻬﺮ‬ ‫ﺑﻌد‬ ‫الصفاﻕ‬ ‫ﺗﻮاﺯﻥ‬ ‫اﺧﺘﺒاﺭ‬ ‫ﺇﺟﺮاﺀ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • ‫ﺣﺠﻢ‬ ‫ﻓﻲ‬ ‫ﻣﺘﻮقﻊ‬ ‫ﻏيﺮ‬ ‫ﺮ‬‫ﱡ‬‫ي‬‫ﺗﻐ‬ ‫ﻫﻨاﻙ‬ ‫يﻜﻮﻥ‬ ‫ﻋﻨدﻣا‬ ‫اﻻﺧﺘﺒاﺭ‬ ‫ﻫﺬا‬ ‫ﺇﺟﺮاﺀ‬ ‫ﻛﺬلﻚ‬ ‫يﺴﺘﺤﺴﻦ‬ ،‫ﺫلﻚ‬ ‫ﻣﻌﺮﻓة‬ ‫ﻋلﻰ‬ ‫للﻤﺴاﻋدة‬ ‫ﻭﺫلﻚ‬ ،‫اليﻮﺭيا‬ ‫ﺗصفية‬ ‫ﻛفاية‬ ‫ﻋدﻡ‬ ‫ﻋلﻰ‬ ‫دﻻلة‬ ‫ﺃﻭ‬ ‫الﺮاﺷﺢ‬ ‫الﺴاﺋل‬ .‫ﳌﻌاﳉﺘﻬا‬ ‫اﳌﺜلﻰ‬ ‫الﻄﺮيﻘة‬ ‫ﻭﺑالﺘالﻲ‬ ‫اﳌﺸﻜلة‬ ‫ﺳﺒﺐ‬ ‫ﺍﻟﺼﻔﺎﻕ‬ ‫ﺗﻮﺍﺯﻥ‬ ‫ﺍﺧﺘﺒﺎﺭ‬ ‫ﺧﻄﻮﺍﺕ‬ :١٠-٤ ٪ ١.٢٫٥/٢٫٢٧ ‫ﺟلﻮﻛﻮﺯ‬ ‫ﻣﺤلﻮﻝ‬ ‫ﺑاﺳﺘﺨداﻡ‬ ‫اﳌﺴاﺋية‬ ‫الفﺘﺮة‬ ‫ﻓﻲ‬ ‫اﶈلﻮﻝ‬ ‫ﺗﺒديل‬ ‫اﳌﺮيﺾ‬ ‫ﻣﻦ‬ ‫ﻄلﺐ‬‫ﹸ‬‫ي‬ ‫ﻓﻲ‬ ‫ﻭاﳌﺮيﺾ‬ ‫اﳌﺴﺘﺸفﻰ‬ ‫ﻓﻲ‬ ‫اﶈلﻮﻝ‬ ‫ﻫﺬا‬ ‫ﺗصﺮيﻒ‬ ‫يﺘﻢ‬ ‫ﺛﻢ‬ ،‫ﺳاﻋة‬ ١٢-٨ ‫قدﺭﻫا‬ ‫ﻣﻜﻮﺙ‬ ‫ﻭﻓﺘﺮة‬ .‫دقيﻘة‬ ٢٥ ‫ﻋﻦ‬ ‫ﺗزيد‬ ‫ﻻ‬ ‫ﻓﺘﺮة‬ ‫ﺧﻼﻝ‬ ‫قاﺋﻢ‬ ‫ﻭﺿﻊ‬ ‫ﻓﺘﺮة‬ ‫ﺧﻼﻝ‬ ‫الصفاﻕ‬ ‫ﲡﻮيﻒ‬ ‫داﺧل‬ ‫ﺑالﺘدﻓﻖ‬ ٪ ٢.٢٫٥/٢٫٢٧ ‫ﺟلﻮﻛﻮﺯ‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻦ‬ ‫لليﺘﺮيﻦ‬ ‫يﺴﻤﺢ‬ ‫ﺑﻌد‬ ‫ﺁﺧﺮ‬ ‫ﺇلﻰ‬ ‫ﺟاﻧﺐ‬ ‫ﻣﻦ‬ ‫اﳌﺮيﺾ‬ ‫ﺗﻘليﺐ‬ ‫ﻣﺮاﻋاة‬ ‫ﻣﻊ‬ ،‫اﻻﺳﺘلﻘاﺀ‬ ‫ﻭﺿﻊ‬ ‫ﻓﻲ‬ ‫ﻭاﳌﺮيﺾ‬ ‫دقاﺋﻖ‬ ‫ﻋﺸﺮ‬ .‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻣل‬ ٤٠٠ ‫ﻛل‬ ‫ﺗدﻓﻖ‬ ‫ﲡﻮيﻒ‬ ‫ﻣﻦ‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻣل‬ ٣.٢٠٠ ‫ﺑﺴﺤﺐ‬ ‫قﻢ‬ (‫اﶈلﻮﻝ‬ ‫ﺗدﻓﻖ‬ ‫اﻛﺘﻤاﻝ‬ ‫)ﲟﺠﺮد‬ ‫الصفﺮ‬ ‫ﺳاﻋة‬ ‫ﻓﻲ‬ ‫ﲡﻮيﻒ‬ ‫داﺧل‬ (‫ﻣل‬ ١٩٠) ‫اﳌﺘﺒﻘﻲ‬ ‫اﶈلﻮﻝ‬ ‫ﺣﻘﻦ‬ ‫ﻭﺃﻋد‬ ‫ﻣل‬ ١٠ ‫ﺣﺠﻤﻬا‬ ‫ﻋيﻨة‬ ‫ﻣﻨﻬا‬ ‫ﺧﺬ‬ ،‫الصفاﻕ‬ .‫ﻭاﳉلﻮﻛﻮﺯ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫لﻘياﺱ‬ ‫اﳌﻌﻤل‬ ‫ﺇلﻰ‬ ‫ﻭﺃﺭﺳلﻬا‬ (‫ﺻفﺮ‬ ‫)ﻡ‬ ‫الﻌيﻨة‬ ‫ﻫﺬﻩ‬ ‫ﻋلﻰ‬ ‫اﻛﺘﺐ‬ ،‫الصفاﻕ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫لﻘياﺱ‬ ‫اﳌﻌﻤل‬ ‫ﺇلﻰ‬ ‫ﻭﺃﺭﺳلﻬا‬ (‫ﺻفﺮ‬ ‫)د‬ ‫ﻋليﻬا‬ ‫ﻭاﻛﺘﺐ‬ ‫الدﻡ‬ ‫ﻣﻦ‬ ‫ﻋيﻨة‬ ‫ﺑﺄﺧﺬ‬‫ﹰ‬‫ا‬‫ﺃيﻀ‬ ‫قﻢ‬ ‫ﺳيﺴﺘﻐﺮقﻬا‬ ‫الﺘﻲ‬ ‫اﻷﺭﺑﻊ‬ ‫الﺴاﻋاﺕ‬ ‫ﺧﻼﻝ‬ ‫ﺑﺤﺮية‬ ‫ﺑاﳊﺮﻛة‬ ‫للﻤﺮيﺾ‬ ‫اﺳﻤﺢ‬ .‫ﻭاﳉلﻮﻛﻮﺯ‬ .‫اﻻﺧﺘﺒاﺭ‬ ‫ﻋيﻨة‬ ‫ﻣﻨﻬا‬ ‫ﺧﺬ‬ ،‫الصفاﻕ‬ ‫ﲡﻮيﻒ‬ ‫ﻣﻦ‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻣل‬ ٤.٢٠٠ ‫ﺑﺴﺤﺐ‬ ‫قﻢ‬ ‫ﺳاﻋﺘﲔ‬ ‫ﻣﺮﻭﺭ‬ ‫ﺑﻌد‬ ‫ﻫﺬﻩ‬ ‫ﻋلﻰ‬ ‫اﻛﺘﺐ‬ ،‫الصفاﻕ‬ ‫ﲡﻮيﻒ‬ ‫داﺧل‬ (‫ﻣل‬ ١٩٠) ‫اﳌﺘﺒﻘﻲ‬ ‫اﶈلﻮﻝ‬ ‫ﺣﻘﻦ‬ ‫ﻭﺃﻋد‬ ‫ﻣل‬ ١٠ ‫ﺣﺠﻤﻬا‬ ‫الدﻡ‬ ‫ﻣﻦ‬ ‫ﻋيﻨة‬ ‫ﹰ‬‫ا‬‫ﺃيﻀ‬ ‫ﺧﺬ‬ .‫ﻭاﳉلﻮﻛﻮﺯ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫لﻘياﺱ‬ ‫اﳌﻌﻤل‬ ‫ﺇلﻰ‬ ‫ﻭﺃﺭﺳلﻬا‬ (٢‫)ﻡ‬ ‫الﻌيﻨة‬ .‫ﻭاﳉلﻮﻛﻮﺯ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫لﻘياﺱ‬ ‫اﳌﻌﻤل‬ ‫ﺇلﻰ‬ ‫ﻭﺃﺭﺳلﻬا‬ (٢‫)د‬ ‫ﻋليﻬا‬ ‫ﻭاﻛﺘﺐ‬
  • ٤٤ ‫ﻭﲡﻤيﻊ‬ ‫الﺒﻮﻝ‬ ‫ﲡﻤيﻊ‬ ‫ﻣﻦ‬ ‫اﻻﺳﺘفادة‬ ‫يﺴﺘﺤﺴﻦ‬ ،‫الصفاقية‬ ‫الديلزة‬ ‫ﻛفاية‬ ‫اﺧﺘﺒاﺭ‬ ‫ﺗﺄدية‬ ‫ﻋﻨد‬ ٦. ‫الﺒﺮﻭﺗيﻨﻲ‬ ‫اﳌﻜاﻓﺊ‬ ‫قياﺱ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ (DPI) ‫الﻐﺬاﺀ‬ ‫ﻓﻲ‬ ‫الﺒﺮﻭﺗﲔ‬ ‫ﻛﻤية‬ ‫لﺘﻘديﺮ‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ :(١٠ ‫ﻓصل‬ ‫)اﻧﻈﺮ‬ ‫الﺘالية‬ ‫اﳌﻌادﻻﺕ‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫ﻭﺫلﻚ‬ ،(PNA) ‫الﻨيﺘﺮﻭﺟيﻨﻲ‬ ‫للﻈﻬﻮﺭ‬ ‫ﳝﻜﻦ‬ ‫ﻓﺈﻧﻪ‬ ‫ﻣﻌﺮﻭﻓة‬ ‫لديﻪ‬ ‫الصفاﻕ‬ ‫ﻧﻘل‬ ‫ﺧصاﺋﺺ‬ ‫ﻭﻛاﻧﺖ‬ ‫ﻣﺴﺘﻘﺮة‬ ‫اﳌﺮيﺾ‬ ‫ﺣالة‬ ‫ﻛاﻧﺖ‬ ‫ﺇﺫا‬ ٧. ‫اﳊاﺳﻮﺏ‬ ‫ﺑﺮاﻣﺞ‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﻭﺗصفية‬ ‫لليﻮﺭيا‬ ‫الﻜلية‬ ‫الﺘصفية‬ ‫ﻣﻌدﻝ‬ ‫ﺗﻘديﺮ‬ ‫الﺘﻘديﺮاﺕ‬ ‫ﻫﺬﻩ‬ ‫ﻣﺜل‬ ‫ﲢﺘاﺝ‬ ‫ﻭلﻜﻦ‬ ،«AdequestTM » ‫ﺑﺮﻧاﻣﺞ‬ ‫ﻣﺜل‬ ،‫الصفاقية‬ ‫ﺑالديلزة‬ ‫اﳋاﺻة‬ ‫ﺣﺴاﺑﻪ‬ ‫ﳝﻜﻦ‬ ‫ﻭالﺬﻱ‬ ،‫ﺳاﻋة‬ ٢٤ ‫ﺧﻼﻝ‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻓﻲ‬ ‫اﳌﺬاﺑاﺕ‬ ‫ﺗﺮﻛيز‬ ‫ﻣﻌدﻝ‬ ‫ﻣﻌﺮﻓة‬ ‫ﺇلﻰ‬ :‫الﺘالية‬ ‫الﺮياﺿية‬ ‫اﳌﻌادﻻﺕ‬ ‫ﺑاﺳﺘﺨداﻡ‬ {[(‫)ﻛلﻎ‬ ‫الﻐﺚ‬ ‫اﳉﺴﻢ‬ ‫ﻛﺘلة‬ x ٠,٠٣١] + ١,٨١ + (‫)ﻏﻢ/يﻮﻡ‬ ‫اليﻮﺭيا‬ ‫}ﻇﻬﻮﺭ‬ x ٦,٢٥ = ‫الﺒﺮﻭﺗيﻨﻲ‬ ‫اﳌﻜاﻓﺊ‬ ‫الﻨيﺘﺮﻭﺟيﻨﻲ‬ ‫للﻈﻬﻮﺭ‬ (‫)ﻏﻢ/يﻮﻡ‬ [(‫)ﻣلﻎ/دﺳل‬ ‫اﶈلﻮﻝ‬ ‫ﻓﻲ‬ ‫اليﻮﺭيا‬ ‫ﺗﺮﻛيز‬ x (‫)دﺳل‬ ‫ﺳاﻋة‬ ٢٤ ‫ﻓﻲ‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﺣﺠﻢ‬ ] [(‫)ﻣلﻎ/دﺳل‬ ‫الﺒﻮﻝ‬ ‫ﻓﻲ‬ ‫اليﻮﺭيا‬ ‫ﺗﺮﻛيز‬ x (‫)دﺳل‬ ‫ﺳاﻋة‬ ٢٤ ‫ﻓﻲ‬ ‫اﳋاﺭﺝ‬ ‫الﺒﻮﻝ‬ ‫]ﺣﺠﻢ‬ + = ‫اليﻮﺭيا‬ ‫ﻇﻬﻮﺭ‬ (‫يﻮﻡ‬ /‫)ﻣلﻎ‬ (‫)ﻣلﻎ/دﺳل‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﺃﻛياﺱ‬ ‫ﻛل‬ ‫ﻓﻲ‬ ‫الﺬﻭاﺋﺐ‬ ‫ﺗﺮﻛيز‬ ‫ﻣﺠﻤﻮﻉ‬ ‫اﻷﻛياﺱ‬ ‫ﻋدد‬ = ‫اﳌﺬاﺑاﺕ‬ ‫ﺗﺮﻛيز‬ ‫ﻣﻌدﻝ‬ ‫اﳉﻮالة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻓﻲ‬ (‫)ﻣلﻎ/دﺳل‬ ‫اﳌﺴﺘﻤﺮة‬ ‫اﻷﻛياﺱ‬ ‫لﻜل‬ [(‫)ﻝ‬ ‫الﻜيﺲ‬ ‫ﺣﺠﻢ‬ x (‫)ﻣلﻎ/دﺳل‬ ‫ﻛيﺲ‬ ‫ﻛل‬ ‫ﻓﻲ‬ ‫الﺬﻭاﺋﺐ‬ ‫ﺗﺮﻛيز‬ ] ‫ﻣﺠﻤﻮﻉ‬ (‫)ﻝ‬ ‫اﻷﻛياﺱ‬ ‫ﻛل‬ ‫ﻓﻲ‬ ‫اﳋاﺭﺝ‬ ‫الﺴاﺋل‬ ‫ﺣﺠﻢ‬ = ‫اﳌﺬاﺑاﺕ‬ ‫ﺗﺮﻛيز‬ ‫ﻣﻌدﻝ‬ ‫اﻵلية‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻓﻲ‬ (‫)ﻣلﻎ/دﺳل‬
  • ٤٣ ‫ﺟلﺴاﺕ‬ ‫ﻓﻲ‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﺃﻛياﺱ‬ ‫ﺇﺣﻀاﺭ‬ ‫اﳌﺮيﺾ‬ ‫ﻣﻦ‬ ‫يﻄلﺐ‬ ‫ﺃﻥ‬ ‫ﻫﻲ‬ ،‫ﺃﺳﻬل‬ ‫ﻃﺮيﻘة‬ ‫ﻭﺛﻤة‬ ٥. ‫ﻀاﻑ‬‫ﹸ‬‫ي‬‫ﻭ‬ ،‫اﳌﺴﺘﺸفﻰ‬ ‫ﻓﻲ‬ ‫ﻛﺒيﺮ‬‫ﻭﻋاﺀ‬‫ﻓﻲ‬ ‫ﺗﺨلﻂ‬‫ﺑﺤيﺚ‬‫ﺳاﻋة‬٢٤ ‫ﺧﻼﻝ‬‫ﲤﺖ‬‫الﺘﻲ‬‫اﶈلﻮﻝ‬‫ﺗﺒديل‬ ‫ﻭﺗﺮﺳل‬ ،‫اﳋاﺭﺝ‬ ‫ﺑالﺴاﺋل‬ ‫الﻨاﰋ‬ ‫اﳋليﻂ‬ ‫ﺴﻤﻰ‬‫ﹸ‬‫ي‬ ‫ﺛﻢ‬ ،‫ﺳاﻋة‬ ٢٤ ‫ﺧﻼﻝ‬ ‫اﳋاﺭﺝ‬ ‫الﺒﻮﻝ‬ ‫ﻛﻤية‬ ‫ﺇليﻬا‬ ‫ﻛﻤا‬ ،‫ﺣﺠﻤﻪ‬ ‫قياﺱ‬ ‫ﺑﻌد‬ ‫ﻭالﻜﺮياﺗﻨﲔ‬ ‫اليﻮﺭيا‬ ‫لﻘياﺱ‬ ‫اﺨﻤﻟﺘﺒﺮ‬ ‫ﺇلﻰ‬ ‫ﻣل‬ ١٠ ‫ﺑﺤﺠﻢ‬ ‫ﻋيﻨة‬ ‫ﻣﻨﻪ‬ :‫الﺘالية‬ ‫اﳌﻌادﻻﺕ‬ ‫ﺗﺴﺘﻌﻤل‬ ‫ﺛﻢ‬ ،‫ﻭالﻜﺮياﺗﻨﲔ‬ ‫اليﻮﺭيا‬ ‫ﻣﺴﺘﻮﻯ‬ ‫لﻘياﺱ‬ ‫الدﻡ‬ ‫ﻣﻦ‬ ‫ﻋيﻨة‬ ‫ﺗﺮﺳل‬ ٧ x (‫)ﻣلﻎ/دﺳل‬ ‫اﶈلﻮﻝ‬ ‫ﻓﻲ‬ ‫اليﻮﺭيا‬ ‫ﺗﺮﻛيز‬ x (‫)ﻝ‬ ‫ﺳاﻋة‬ ٢٤ ‫ﻓﻲ‬ ‫اﶈلﻮﻝ‬ ‫ﺣﺠﻢ‬ (‫)ﻝ‬ ‫اﳉﺴﻢ‬ ‫ﻣاﺀ‬ ‫ﺣﺠﻢ‬ x (‫)ﻣلﻎ/دﺳل‬ ‫الدﻡ‬ ‫ﻓﻲ‬ ‫اليﻮﺭيا‬ ‫ﺗﺮﻛيز‬ = ‫الصفاقية‬ ‫الﺘصفية‬ ‫ﻣﻌدﻝ‬ ‫لليﻮﺭيا‬ ‫اﻷﺳﺒﻮﻋية‬ (Kp t/Vurea ) ٧ x (‫)ﻣلﻎ/دﺳل‬ ‫الﺒﻮﻝ‬ ‫ﻓﻲ‬ ‫اليﻮﺭيا‬ ‫ﺗﺮﻛيز‬ x (‫)ﻝ‬ ‫ﺳاﻋة‬ ٢٤ ‫ﻓﻲ‬ ‫الﺒﻮﻝ‬ ‫ﺣﺠﻢ‬ (‫)ﻝ‬ ‫اﳉﺴﻢ‬ ‫ﻣاﺀ‬ ‫ﺣﺠﻢ‬ x (‫)ﻣلﻎ/دﺳل‬ ‫الدﻡ‬ ‫ﻓﻲ‬ ‫اليﻮﺭيا‬ ‫ﺗﺮﻛيز‬ = ‫الﻜلﻮية‬ ‫الﺘصفية‬ ‫ﻣﻌدﻝ‬ ‫لليﻮﺭيا‬ ‫اﻷﺳﺒﻮﻋية‬ (Kr t/Vurea ) ‫اﻷﺳﺒﻮﻋية‬ ‫الﻜلﻮية‬ ‫الﺘصفية‬ ‫ﻣﻌدﻝ‬ + ‫اﻷﺳﺒﻮﻋية‬ ‫الصفاقية‬ ‫الﺘصفية‬ ‫ﻣﻌدﻝ‬ = ‫الﻜلية‬ ‫الﺘصفية‬ ‫ﻣﻌدﻝ‬ ‫لليﻮﺭيا‬ ‫اﻷﺳﺒﻮﻋية‬ (Kt/Vurea ) ٧ x ١,٧٣ x (‫)ﻣلﻎ/دﺳل‬ ‫اﶈلﻮﻝ‬ ‫ﻓﻲ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﺗﺮﻛيز‬ x (‫)ﻝ‬ ‫ﺳاﻋة‬ ٢٤ ‫ﻓﻲ‬ ‫اﶈلﻮﻝ‬ ‫ﺣﺠﻢ‬ (٢‫)ﻡ‬ ‫اﳉﺴﻢ‬ ‫ﺳﻄﺢ‬ ‫ﻣﺴاﺣة‬ x (‫)ﻣلﻎ/دﺳل‬ ‫الدﻡ‬ ‫ﻓﻲ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﺗﺮﻛيز‬ = ‫الصفاقية‬ ‫الﺘصفية‬ ‫للﻜﺮياﺗﻨﲔ‬ ‫اﻷﺳﺒﻮﻋية‬ (٢‫ﻝ/٣٧٫١ﻡ‬ ) ٧ x (‫)ﻣلﻎ/دﺳل‬ ‫اﳋاﺭﺝ‬ ‫الﺴاﺋل‬ ‫ﻓﻲ‬ ‫اليﻮﺭيا‬ ‫ﺗﺮﻛيز‬ x (‫)ﻝ‬ ‫ﺳاﻋة‬ ٢٤ ‫ﻓﻲ‬ ‫اﳋاﺭﺝ‬ ‫الﺴاﺋل‬ ‫ﺣﺠﻢ‬ (‫)ﻝ‬ ‫اﳉﺴﻢ‬ ‫ﻣاﺀ‬ ‫ﺣﺠﻢ‬ x (‫)ﻣلﻎ/دﺳل‬ ‫الدﻡ‬ ‫ﻓﻲ‬ ‫اليﻮﺭيا‬ ‫ﺗﺮﻛيز‬ = ‫الﻜلية‬ ‫الﺘصفية‬ ‫ﻣﻌدﻝ‬ ‫لليﻮﺭيا‬ ‫اﻷﺳﺒﻮﻋية‬ (Kt/Vurea ) ٧ x ١,٧٣ x (‫)ﻣلﻎ/دﺳل‬ ‫اﳋاﺭﺝ‬ ‫الﺴاﺋل‬ ‫ﻓﻲ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﺗﺮﻛيز‬ x (‫)ﻝ‬ ‫ﺳاﻋة‬ ٢٤ ‫ﻓﻲ‬ ‫اﳋاﺭﺝ‬ ‫الﺴاﺋل‬ ‫ﺣﺠﻢ‬ (٢‫)ﻡ‬ ‫اﳉﺴﻢ‬ ‫ﺳﻄﺢ‬ ‫ﻣﺴاﺣة‬ x (‫)ﻣلﻎ/دﺳل‬ ‫الدﻡ‬ ‫ﻓﻲ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﺗﺮﻛيز‬ = ‫الﻜلية‬ ‫الﺘصفية‬ ‫للﻜﺮياﺗﻨﲔ‬ ‫اﻷﺳﺒﻮﻋية‬ (٢‫/٣٧٫١ﻡ‬ ‫)ﻝ‬
  • ٤٢ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻛﻔﺎﻳﺔ‬ ‫ﺍﺧﺘﺒﺎﺭ‬ :٧-٤ ‫ﻭﺗصفية‬‫لليﻮﺭيا‬‫الﻜلية‬‫الﺘصفية‬‫ﻣﻌدﻝ‬‫لﻘياﺱ‬‫الصفاقية‬‫الديلزة‬‫ﻛفاية‬‫اﺧﺘﺒاﺭ‬‫يﺴﺘﻌﻤل‬ • ‫ﺃﺷﻬﺮ‬ ‫ﺳﺘة‬ ‫ﻛل‬ ‫ﺛﻢ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺑدﺀ‬ ‫ﻣﻦ‬ ‫ﻭاﺣد‬ ‫ﺷﻬﺮ‬ ‫ﺑﻌد‬ ‫ﺗﺄديﺘﻪ‬ ‫ﻭﺗلزﻡ‬ ،‫الﻜﺮياﺗﻨﲔ‬ ‫الديلزة‬ ‫ﻭﺻفة‬ ‫ﺗﻐييﺮ‬ ‫ﻭﺑﻌد‬ ،‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫ﺇﺻاﺑة‬ ‫ﻛل‬ ‫ﺑﻌد‬ ‫ﺗﺄديﺘﻪ‬ ‫ﺗلزﻡ‬ ‫ﻛﻤا‬ ،‫ﺫلﻚ‬ ‫ﺑﻌد‬ .‫الﺴﺮيﺮية‬ ‫اﳌﺮيﺾ‬ ‫ﺣالة‬ ‫ﺗﺘدﻫﻮﺭ‬ ‫ﻭﻋﻨدﻣا‬ ،‫الصفاقية‬ ،‫ﻣﺴﺘﻘﺮة‬ ‫اﳌﺮيﺾ‬ ‫ﺣالة‬ ‫ﻓيﻪ‬ ‫ﺗﻜﻮﻥ‬ ‫ﻭقﺖ‬ ‫ﻓﻲ‬ ‫الصفاية‬ ‫الديلزة‬ ‫ﻛفاية‬ ‫اﺧﺘﺒاﺭ‬ ‫ﺗﺄدية‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • .‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫ﺇﺻاﺑة‬ ‫ﺃﻱ‬ ‫ﻣﻦ‬ ‫اﻷقل‬ ‫ﻋلﻰ‬ ‫ﺷﻬﺮ‬ ‫ﻭﺑﻌد‬ ‫ﻣاﺋة‬ ‫ﻋﻦ‬ ‫ﺗﻘل‬ ‫الﺒﻮﻝ‬ ‫ﻛﻤية‬ ‫ﺃﻥ‬ ‫ﺑدﻻلة‬ ،‫ﺑﺴيﻄة‬ ‫للﻤﺮيﺾ‬ ‫اﳌﺘﺒﻘية‬ ‫الﻜلﻮية‬ ‫الﻮﻇيفة‬ ‫ﻛاﻧﺖ‬ ‫ﺇﺫا‬ • ‫الصفاقية‬ ‫الديلزة‬ ‫ﻛفاية‬ ‫اﺧﺘﺒاﺭ‬ ‫ﺗﺄدية‬ ‫ﺃﺛﻨاﺀ‬ ‫الﺒﻮﻝ‬ ‫ﲡﻤيﻊ‬ ‫ﲡاﻫل‬ ‫ﳝﻜﻦ‬ ‫ﻓﺈﻧﻪ‬ ،‫اليﻮﻡ‬ ‫ﻓﻲ‬ ‫ﻣل‬ .‫لليﻮﺭيا‬ ‫الصفاقية‬ ‫الﺘصفية‬ ‫ﳌﻌدﻝ‬ ‫ﹰ‬‫ا‬‫ﻣﺴاﻭي‬ ‫لليﻮﺭيا‬ ‫الﻜلية‬ ‫الﺘصفية‬ ‫ﻣﻌدﻝ‬ ‫ﻭاﻋﺘﺒاﺭ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻛﻔﺎﻳﺔ‬ ‫ﺍﺧﺘﺒﺎﺭ‬ ‫ﺧﻄﻮﺍﺕ‬ :٨-٤ ‫الﺒﻮﻝ‬ ‫ﺃﺭﺳل‬ ،‫اﳌﺴﺘﺸفﻰ‬ ‫ﺇلﻰ‬ ‫ﻭيﺤﻀﺮﻩ‬ ‫ﻛاﻣل‬ ‫يﻮﻡ‬ ‫ﳌدة‬ ‫الﺒﻮﻝ‬ ‫يﺠﻤﻊ‬ ‫ﺃﻥ‬ ‫اﳌﺮيﺾ‬ ‫ﻣﻦ‬ ‫اﻃلﺐ‬ ١. .‫ﻛﻤيﺘﻪ‬ ‫ﺗﺴﺠيل‬ ‫ﺑﻌد‬ ‫ﻓيﻪ‬ ‫ﻭالﻜﺮياﺗﻨﲔ‬ ‫اليﻮﺭيا‬ ‫ﺗﺮﻛيز‬ ‫لﻘياﺱ‬ ‫اﺨﻤﻟﺘﺒﺮ‬ ‫ﺇلﻰ‬ ‫ﲡﻤيﻌﻪ‬ ‫ﰎ‬ ‫الﺬﻱ‬ ‫ﻣﻦ‬ ‫ﺑﻮاﺣدة‬ ‫ﺳاﻋة‬ ٢.٢٤ ‫ﺧﻼﻝ‬ ‫الصفاﻕ‬ ‫ﻣﻦ‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﻛل‬ ‫يﺠﻤﻊ‬ ‫ﺃﻥ‬ ‫اﳌﺮيﺾ‬ ‫ﻣﻦ‬ ‫اﻃلﺐ‬ :‫الﺘاليﺘﲔ‬ ‫الﻄﺮيﻘﺘﲔ‬ ‫ﲤﺖ‬ ‫الﺘﻲ‬ ‫اﶈلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﻋﻤلياﺕ‬ ‫ﻣﻦ‬ ‫ﻭاﺣدة‬ ‫ﻛل‬ ‫ﺃﺛﻨاﺀ‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻣل‬ •١٠ ‫يﺄﺧﺬ‬ ‫ﺃﻥ‬ ‫ﻓﻲ‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﺣﺠﻢ‬ ‫ﻭﺗﺴﺠيل‬ ‫ﹰ‬‫ا‬‫ﺛﻼﺛ‬ ‫ﺃﻭ‬ ‫ﻣﺮﺗﲔ‬ ‫الﻜيﺲ‬ ‫ﺗﻘليﺐ‬ ‫ﺑﻌد‬ ‫ﺳاﻋة‬ ٢٤ ‫ﺧﻼﻝ‬ ‫ﺛﻢ‬ ،‫ﹰ‬‫ا‬‫ﻣﻌ‬ ‫اﺨﻤﻟﺘلفة‬ ‫الﻜﻤياﺕ‬ ‫ﺑﺠﻤﻊ‬ ‫ﺳاﻋة‬ ٢٤ ‫ﺧﻼﻝ‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﻛﻤية‬ ‫ﲢﺴﺐ‬ ‫ﻣﺮة؛‬ ‫ﻛل‬ .‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﻋيﻨة‬ ‫ﻋلﻰ‬ ‫للﺤصﻮﻝ‬ ‫ﹰ‬‫ا‬‫ﻣﻌ‬ ‫اﺨﻤﻟﺘلفة‬ ‫الﻌيﻨاﺕ‬ ‫ﺗﺨلﻂ‬ ‫الﺘﻲ‬ ‫اﶈلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﺟلﺴاﺕ‬ ‫ﺃﺛﻨاﺀ‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﺃﻛياﺱ‬ ‫اﳌﺴﺘﺸفﻰ‬ ‫ﺇلﻰ‬ ‫ﻣﻌﻪ‬ ‫يﺤﻀﺮ‬ ‫ﺃﻥ‬ • ‫ﺣﺠﻤﻬا‬ ‫ﺤﺴﺐ‬‫ﹸ‬‫ي‬‫ﻭ‬ ‫ﻛﺒيﺮ‬ ‫ﻭﻋاﺀ‬ ‫ﻓﻲ‬ ‫ﹰ‬‫ا‬‫ﻣﻌ‬ ‫اﺨﻤﻟﺘلفة‬ ‫اﶈاليل‬ ‫ﺗﺨلﻂ‬ ‫ﺛﻢ‬ ،‫ﺳاﻋة‬ ٢٤ ‫ﺧﻼﻝ‬ ‫ﲤﺖ‬ ‫ﻋيﻨة‬ ‫اﳋليﻂ‬ ‫ﻫﺬا‬ ‫ﻣﻦ‬ ‫ﺗﺆﺧﺬ‬ ‫ﺛﻢ‬ ،‫ﺳاﻋة‬ ٢٤ ‫ﺧﻼﻝ‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﻛﻤية‬ ‫ﺑاﻋﺘﺒاﺭﻩ‬ ‫الﻜلﻲ‬ .‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﻋيﻨة‬ ‫ﺑاﻋﺘﺒاﺭﻫا‬ ‫ﻣل‬ ١٠ ‫ﺑﺤﺠﻢ‬ ‫ﻋيﻨة‬ ‫ﻭاﺳﺤﺐ‬ ،‫ﻭالﻜﺮياﺗﻨﲔ‬ ‫اليﻮﺭيا‬ ‫ﺗﺮﻛيز‬ ‫لﻘياﺱ‬ ‫اﺨﻤﻟﺘﺒﺮ‬ ‫ﺇلﻰ‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻋيﻨة‬ ‫ﺃﺭﺳل‬ ٣. .‫ﻭالﻜﺮياﺗﻨﲔ‬ ‫اليﻮﺭيا‬ ‫ﺗﺮﻛيز‬ ‫لﻘياﺱ‬ ‫اﺨﻤﻟﺘﺒﺮ‬ ‫ﺇلﻰ‬ ‫ﻭﺃﺭﺳلﻬا‬ ‫اﳌﺮيﺾ‬ ‫دﻡ‬ ‫ﻣﻦ‬ ،‫اﻹﻧاﺙ‬ ‫ﻭﺯﻥ‬ ‫ﻣﻦ‬ ٪ ٤.٥٥ ‫ﻭ‬ ‫الﺬﻛﻮﺭ‬ ‫ﻭﺯﻥ‬ ‫ﻣﻦ‬ ٪٦٠ ‫يﻌادﻝ‬ ‫ﻭالﺬﻱ‬ ،‫اﳌﺮيﺾ‬ ‫ﺟﺴﻢ‬ ‫ﻓﻲ‬ ‫اﳌاﺀ‬ ‫ﺣﺠﻢ‬ ‫اﺣﺴﺐ‬ :‫الﺘالية‬ ‫الﺮياﺿية‬ ‫اﳌﻌادﻻﺕ‬ ‫اﺳﺘﻌﻤل‬ ‫ﺛﻢ‬
  • ٤١ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻛﻔﺎﻳﺔ‬ ‫ﻣﺮﺍﻗﺒﺔ‬ :٦-٤ ‫الديلزة‬ ‫ﻛفاية‬ ‫ﻣﻌاييﺮ‬ ‫ﺃﻫﻢ‬ ‫ﻣﻦ‬ ( •Kt/Vurea) ‫لليﻮﺭيا‬ ‫الﻜلية‬ ‫الﺘصفية‬ ‫ﻣﻌدﻝ‬ ‫يﻌﺘﺒﺮ‬ ‫يﻮﻡ‬ ‫ﺧﻼﻝ‬ ‫اليﻮﺭيا‬ ‫ﻣﻦ‬ ‫ﺗصفيﺘﻪ‬ ‫ﺗﺘﻢ‬ ‫الﺬﻱ‬ ‫اﳉﺴﻢ‬ ‫ﻣاﺀ‬ ‫ﺣﺠﻢ‬ ‫ﻧﺴﺒة‬ ‫ﺑﺄﻧﻬا‬ ‫ﻑ‬‫ﱠ‬‫ﺮ‬‫ﹸﻌ‬‫ﺗ‬‫ﻭ‬ ،‫الصفاقية‬ .‫ﹰ‬‫ﻼ‬‫ﻛاﻣ‬ ‫اﳉﺴﻢ‬ ‫ﻣاﺀ‬ ‫ﺣﺠﻢ‬ ‫ﺇلﻰ‬ ‫ﻣﻨﺴﻮﺑة‬ ‫ﻭاﺣد‬ ‫ﺃﺳﺒﻮﻉ‬ ‫ﺃﻭ‬ ‫ﻭاﺣد‬ ‫الصفاقية‬ ‫الﺘصفية‬ ‫ﻣﻌدﻝ‬ ‫ﻣﺠﻤﻮﻉ‬ ( •Kt/Vurea) ‫لليﻮﺭيا‬ ‫الﻜلية‬ ‫الﺘصفية‬ ‫ﻣﻌدﻝ‬ ‫يﺴاﻭﻱ‬ .(Krt/Vurea) ‫لليﻮﺭيا‬ ‫الﻜلﻮية‬ ‫الﺘصفية‬ ‫ﻭﻣﻌدﻝ‬ (Kpt/Vurea) ‫لليﻮﺭيا‬ ‫الﺘصفية‬ ‫ﻣﻌدﻝ‬ ‫ﻣﻦ‬ ‫اﳌﻘﺒﻮﻝ‬ ‫اﻷدﻧﻰ‬ ‫اﳊد‬ ‫ﻓﺈﻥ‬ •٢٠٠٦ ‫للﻌاﻡ‬ «KDOQI» ‫ﺇﺭﺷاداﺕ‬ ‫ﻣﻊ‬ ‫ﹰ‬‫ا‬‫ﲤاﺷي‬ .١٫٧ ‫ﻋﻦ‬ ‫يﻨﻘﺺ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ ‫ﻻ‬ ‫لليﻮﺭيا‬ ‫الﻜلية‬ ‫اﻷﺳﺒﻮﻋية‬ ‫ﻛفاية‬ ‫اﺧﺘﺒاﺭ‬ ‫ﺇﺟﺮاﺀ‬ ‫ﻫﻲ‬ ‫لليﻮﺭيا‬ ‫الﻜلية‬ ‫الﺘصفية‬ ‫ﻣﻌدﻝ‬ ‫ﳌﺮاقﺒة‬ ‫ﹰ‬‫ا‬‫ﺷيﻮﻋ‬ ‫اﻷﻛﺜﺮ‬ ‫الﻄﺮيﻘة‬ • ‫ﻛل‬ ‫ﺛﻢ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺑدﺀ‬ ‫ﻣﻦ‬ ‫ﻭاﺣد‬ ‫ﺷﻬﺮ‬ ‫ﺧﻼﻝ‬ ‫ﺗﺄديﺘﻪ‬ ‫يﺠﺐ‬ ‫ﻭالﺬﻱ‬ ،‫الصفاقية‬ ‫الديلزة‬ ‫لزﻡ‬ ‫ﺇﺫا‬ ‫الديلزة‬ ‫ﻭﺻفة‬ ‫ﻭﺗﻌديل‬ ‫الديلزة‬ ‫ﻛفاية‬ ‫ﻣﻦ‬ ‫الﺘﺤﻘﻖ‬ ‫ﺑﻐﺮﺽ‬ ‫ﺫلﻚ‬ ‫ﺑﻌد‬ ‫ﺃﺷﻬﺮ‬ ‫ﺳﺘة‬ ‫ﺇﺻاﺑة‬ ‫ﻛل‬ ‫ﻭﺑﻌد‬ ‫الديلزة‬ ‫لﻮﺻفة‬ ‫ﺗﻐييﺮ‬ ‫ﻛل‬ ‫ﺑﻌد‬ ‫الديلزة‬ ‫ﻛفاية‬ ‫اﺧﺘﺒاﺭ‬ ‫ﺗﺄدية‬ ‫يﺠﺐ‬ ‫ﻛﻤا‬ ،‫اﻷﻣﺮ‬ .‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ،‫اﳌﺴﺘﻤﺮة‬‫اﳉﻮالة‬‫الصفاقية‬‫للديلزة‬‫ﺑالﻨﺴﺒة‬‫الﻜﺮياﺗﻨﲔ‬‫ﺗصفية‬‫ﻣﺮاقﺒة‬‫الﻀﺮﻭﺭﻱ‬‫ﻣﻦ‬‫ليﺲ‬ • ‫ﻋﻦ‬ ‫اﻷﺳﺒﻮﻋية‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﺗصفية‬ ‫ﺗﻘل‬ ‫ﻻ‬ ‫ﺃﻥ‬ ‫لزﻭﻡ‬ ‫ﻋلﻰ‬ ‫ﺗﻨﺺ‬ «KDOQI» ‫ﺇﺭﺷاداﺕ‬ ‫ﻭلﻜﻦ‬ ‫ﻭﳝﻜﻦ‬ ،‫اﻵلية‬ ‫الصفاقية‬ ‫للديلزة‬ ‫ﺑالﻨﺴﺒة‬ ‫اﳉﺴﻢ‬ ‫ﺳﻄﺢ‬ ‫ﻣﺴاﺣة‬ ‫ﻣﻦ‬ ٢‫ﻡ‬ ١٫٧٣/‫ﻝ‬ ٤٥ .‫الصفاقية‬ ‫الديلزة‬ ‫ﻛفاية‬ ‫اﺧﺘﺒاﺭ‬ ‫ﺃﺛﻨاﺀ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﺗصفية‬ ‫ﺣﺴاﺏ‬ ‫ﺃﻥ‬ ‫ﻣﺮاﻋاة‬ ‫ﻣﻊ‬ ،( •ultrafiltration) ‫الﺮاﺷﺢ‬ ‫الﺴاﺋل‬ ‫ﻭﻛﻤية‬ ‫الﺒﻮﻝ‬ ‫لﻜﻤية‬ ‫ﹰ‬‫ا‬‫ﺃيﻀ‬ ‫اﻻﻧﺘﺒاﻩ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ‫ﺣيﺚ‬ ،(‫الﺮاﺷﺢ‬ ‫ﻭالﺴاﺋل‬ ‫الﺒﻮﻝ‬ ‫)ﻣﺠﻤﻮﻉ‬ ‫ﻛاﻣل‬ ‫ليﺘﺮ‬ ‫ﻋﻦ‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫زاﻝ‬‫ﹸ‬‫ﳌ‬‫ا‬ ‫الﺴاﺋل‬ ‫ﻛﻤية‬ ‫ﺗﻘل‬ ‫ﻻ‬ ‫قيد‬ ‫ﻋلﻰ‬ ‫اﳌﺮيﺾ‬ ‫ﺑﻘاﺀ‬ ‫ﻓﺮﺹ‬ ‫ﻣﻊ‬ ‫ﻋﻜﺴية‬ ‫ﺑصﻮﺭة‬ ‫ﺗﺘﻨاﺳﺐ‬ ‫الﺮاﺷﺢ‬ ‫الﺴاﺋل‬ ‫ﻛﻤية‬ ‫ﺃﻥ‬ ‫ﺛﺒﺖ‬ .‫اﳊياة‬ ،‫الﻐﺬاﺋية‬ ‫اﳊالة‬ ،‫اليﻮﺭﳝية‬ ‫اﻷﻋﺮاﺽ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫لﻜفاية‬ ‫الﺴﺮيﺮية‬ ‫اﳌﻌاييﺮ‬ ‫ﺗﺸﻤل‬ • ‫ﻭﺃﺣﻤاﺽ‬ ‫ﻛﻬاﺭﻝ‬ ‫ﺗﻮاﺯﻥ‬ ،‫لﻺﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫اﻻﺳﺘﺠاﺑة‬ ،‫الﻬيﻤﻮﻏلﻮﺑﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ ،‫اﳌﺮيﺾ‬ ‫ﺣيﻮية‬ .‫اﳉﺴﻢ‬ ‫ﺳﻮاﺋل‬ ‫ﻭﺗﻮاﺯﻥ‬ ،‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﺿﺒﻂ‬ ، ‫ﻭالفﺴفﻮﺭ‬ ‫الﻜالﺴيﻮﻡ‬ ‫ﺗﻮاﺯﻥ‬ ،‫الدﻡ‬ «‫اليﻮﺭﳝية‬ ‫»اﳊالة‬ ‫ﺳﻮﻯ‬ ‫لﺬلﻚ‬ ‫ﻭاﺿﺢ‬ ‫ﺳﺒﺐ‬ ‫ﻫﻨاﻙ‬ ‫يﻜﻦ‬ ‫ﻭلﻢ‬ ‫ﺟيدة‬ ‫اﳌﺮيﺾ‬ ‫ﺣالة‬ ‫ﺗﻜﻦ‬ ‫لﻢ‬ ‫ﺇﺫا‬ • ‫لليﻮﺭيا‬ ‫الﻜلية‬ ‫الﺘصفية‬ ‫ﻣﻌدﻝ‬ ‫ﻛاﻥ‬ ‫لﻮ‬ ‫ﺣﺘﻰ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺟﺮﻋة‬ ‫ﺯيادة‬ ‫ﻓيﺴﺘﺤﺴﻦ‬ .‫اﳌﻄلﻮﺏ‬ ‫اﳌﺴﺘﻮﻯ‬ ‫ﻓﻮﻕ‬ ‫الﺘﻘﻮيﺾ‬ ‫ﻭﻓﺮﻁ‬ ‫الديلزة‬ ‫ﺑﻮﺻفة‬ ‫اﳌﺮيﺾ‬ ‫الﺘزاﻡ‬ ‫ﻋدﻡ‬ ‫ﲡاﻫل‬ ‫يﺠﺐ‬ ‫ﻻ‬ ،‫اﻷﺣﻮاﻝ‬ ‫ﻛل‬ ‫ﻓﻲ‬ • .‫الصفاقية‬ ‫الديلزة‬ ‫ﻛفاية‬ ‫لﻌدﻡ‬ ‫ﻣﺤﺘﻤلة‬ ‫ﻛﺄﺳﺒاﺏ‬ (hypercatabolism) ‫ﻣﻦ‬ ‫ﺑالﺮﻏﻢ‬ ‫الﺘﻨاقﺺ‬ ‫ﻓﻲ‬ ‫الﺮاﺷﺢ‬ ‫الﺴاﺋل‬ ‫ﻭﺣﺠﻢ‬ ‫لليﻮﺭيا‬ ‫الﻜلية‬ ‫الﺘصفية‬ ‫ﻣﻌدﻝ‬ ‫اﺳﺘﻤﺮ‬ ‫ﺇﺫا‬ • (AV fistula) ‫ﻭﺭيدﻱ‬ ‫ﺷﺮياﻧﻲ‬ ‫ﻧاﺳﻮﺭ‬ ‫ﲡﻬيز‬ ‫ﻓيﺴﺘﺤﺴﻦ‬ ،‫الصفاقية‬ ‫الديلزة‬ ‫ﻭﺻفة‬ ‫ﺗﻌديل‬ .‫ﻣﺮيﺤة‬ ‫ﺑصﻮﺭة‬ ‫اﳌﻨاﺳﺐ‬ ‫الﻮقﺖ‬ ‫ﻓﻲ‬ ‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫ﺇلﻰ‬ ‫اﳌﺮيﺾ‬ ‫ﲢﻮيل‬ ‫ﳝﻜﻦ‬ ‫ﺣﺘﻰ‬
  • ٤٠ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﻟﻠﺪﻳﻠﺰﺓ‬ ‫ﺍﻷﻭﻟﻴﺔ‬ ‫ﺍﻟﻮﺻﻔﺔ‬ :٥-٤ ‫ﻭﻇيفﺘﻪ‬ ‫ﻋلﻰ‬ ‫ﹰ‬‫ا‬‫اﻋﺘﻤاد‬ ‫ﺻﻐيﺮة‬ ‫ﺑﺠﺮﻋاﺕ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫اﳌﺮيﺾ‬ ‫يﺒﺘدﺉ‬ ‫ﺃﻥ‬ ‫اﳌﻤﻜﻦ‬ ‫ﻣﻦ‬ • ‫ﻣﻦ‬ ‫ﺗﺒﻘﻰ‬ ‫ﻣا‬ ‫ﻓﻘداﻥ‬ ‫ﻓﻲ‬ ‫اﳌﺮيﺾ‬ ‫يﺒدﺃ‬ ‫ﺣﲔ‬ ‫الديلزة‬ ‫ﺟﺮﻋة‬ ‫ﺯيادة‬ ‫ﻣﺮاﻋاة‬ ‫ﻣﻊ‬ ،‫اﳌﺘﺒﻘية‬ ‫الﻜلﻮية‬ ‫ﻛلﻮية‬ ‫ﺑﺘصفية‬ ‫يﺘﻤﺘﻊ‬ ‫ﺯاﻝ‬ ‫ﻭﻣا‬ ‫ﻛلﻎ‬ ٦٧ ‫ﻭﺯﻧﻪ‬ ‫ﺭﺟل‬ ‫يﺤﺘاﺝ‬ ،‫اﳌﺜاﻝ‬ ‫ﺳﺒيل‬ ‫ﻋلﻰ‬ .‫الﻮﻇيفة‬ ‫ﻫﺬﻩ‬ ‫الصفاﻕ‬ ‫داﺧل‬ ‫ﲤﻜﺚ‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻓﻘﻂ‬ ‫ليﺘﺮيﻦ‬ ‫ﺇلﻰ‬ ‫ﻣل/دقيﻘة‬ ٦-٥ ‫قدﺭﻫا‬ ‫لليﻮﺭيا‬ .‫اﳌﻄلﻮﺏ‬ ‫اﻷﺳﺒﻮﻋﻲ‬ ‫الﺘصفية‬ ‫ﻣﻌدﻝ‬ ‫لﺘﺤﻘيﻖ‬ ‫الليل‬ ‫ﻓﺘﺮة‬ ‫ﺧﻼﻝ‬ ‫الﻀﺮﻭﺭﻱ‬ ‫ﻣﻦ‬ ‫يﻜﻮﻥ‬ ،‫الصفاقية‬ ‫الديلزة‬ ‫ﻭﺻﻒ‬ ‫ﻓﻲ‬ ‫الﺘدﺭيﺠية‬ ‫الﻄﺮيﻘة‬ ‫ﻫﺬﻩ‬ ‫اﺗﺒاﻉ‬ ‫ﰎ‬ ‫ﺇﺫا‬ • ‫ﻭﺗصفية‬ ‫اليﻮﺭيا‬ ‫لﺘصفية‬ ‫اﳊﺴاﺑﻲ‬ ‫اﳌﺘﻮﺳﻂ‬ ‫ﺑاﻋﺘﺒاﺭﻫا‬ ‫اﳌﺘﺒﻘية‬ ‫الﻜلﻮية‬ ‫الﻮﻇيفة‬ ‫قياﺱ‬ ‫ﻣﻦ‬ ‫الﻨاﰋ‬ ‫الفﺮﻕ‬ ‫ﻣﺮاﻋاة‬ ‫ﺑﻬدﻑ‬ ‫ﻭﺫلﻚ‬ ،‫الﺮياﺿية‬ ‫اﳌﻌادﻻﺕ‬ ‫ﻣﻦ‬ ‫ﺗﻘديﺮﻫا‬ ‫ﻋﻦ‬ ‫ﹰ‬‫ا‬‫ﻋﻮﺿ‬ ‫الﻜﺮياﺗﻨﲔ‬ .‫الﻜﺒيﺒاﺕ‬ ‫ﻓﻲ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﺇﻓﺮاﺯ‬ ‫ﹰ‬‫ا‬‫اﻋﺘﻤاد‬ ‫ﺗﻘديﺮية‬ ‫ﺟﺮﻋة‬ ‫للﻤﺮيﺾ‬ ‫ﺗﻮﺻﻒ‬ ‫ﺃﻥ‬ ‫ﻫﻲ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫لﻮﺻﻒ‬ ‫الﺜاﻧية‬ ‫الﻄﺮيﻘة‬ • ،‫اﳌﺘﺒﻘية‬ ‫الﻜلﻮية‬ ‫ﻭﻭﻇيفﺘﻪ‬ (‫الصفاﻕ‬ ‫ﻣﺴاﺣة‬ ‫ﺗﻘاﺭﺏ‬ ‫)الﺘﻲ‬ ‫ﺟﺴﻤﻪ‬ ‫ﺳﻄﺢ‬ ‫ﻣﺴاﺣة‬ ‫ﻋلﻰ‬ ‫ﻫﺬﻩ‬ ‫ﺗﻌديل‬ ‫ﻭﳝﻜﻦ‬ ،٢ ‫يﻘاﺭﺏ‬ ‫ﺃﺳﺒﻮﻋﻲ‬ ‫يﻮﺭيا‬ ‫ﺗصفية‬ ‫ﻣﻌدﻝ‬ ‫اﳉﺮﻋة‬ ‫ﻫﺬﻩ‬ ‫لﻪ‬ ‫ﺗﻮﻓﺮ‬ ‫ﺑﺤيﺚ‬ .(٨ ‫ﻭﺟدﻭﻝ‬ ٧ ‫ﺟدﻭﻝ‬ ‫)اﻧﻈﺮ‬ ‫الديلزة‬ ‫ﻛفاية‬ ‫اﺧﺘﺒاﺭ‬ ‫ﻧﺘاﺋﺞ‬ ‫ﺣﺴﺐ‬ ‫ﹰ‬‫ا‬‫ﻻﺣﻘ‬ ‫اﳉﺮﻋة‬ «Mosteller» ‫ﻣﻌﺎﺩﻟﺔ‬ ‫ﺍﳌﺴﺘﻤﺮﺓ‬ ‫ﺍﳉﻮﺍﻟﺔ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﻟﻠﺪﻳﻠﺰﺓ‬ ‫ﺍﳌﻘﺘﺮﺣﺔ‬ ‫ﺍﻷﻭﻟﻴﺔ‬ ‫ﺍﻟﻮﺻﻔﺔ‬ :٧ ‫ﺟﺪﻭﻝ‬ ‫ﺍﳉﺴﻢ‬ ‫ﺳﻄﺢ‬ ‫ﻣﺴﺎﺣﺔ‬‫ﻣﻞ/ﺩﻗﻴﻘﺔ‬ ٢ < ‫ﺍﻟﻜﺒﻴﺒﻲ‬ ‫ﺍﻟﺮﺷﺢ‬ ‫ﻣﻌﺪﻝ‬‫ﻣﻞ/ﺩﻗﻴﻘﺔ‬ ٢ > ‫ﺍﻟﻜﺒﻴﺒﻲ‬ ‫ﺍﻟﺮﺷﺢ‬ ‫ﻣﻌﺪﻝ‬ ٢‫ﻡ‬ ١٫٧ ‫ﻣﻦ‬ ‫ﺃقل‬‫ﻝ‬ ٢ × ٤‫ﻝ‬ ٢٫٥ × ٤ ٢‫ﻡ‬ ٢٫٠ - ١٫٧ ‫ﺑﲔ‬‫ﻝ‬ ٢٫٥ × ٤‫ﻝ‬ ٣ × ٤ ٢‫ﻡ‬ ٢ ‫ﻣﻦ‬ ‫ﺃﻛﺜﺮ‬‫ﻝ‬ ٣ × ٤‫ﻝ‬ ٣ × ٤ ‫ﺍﳌﺴﺘﻤﺮﺓ‬ ‫ﺍﻵﻟﻴﺔ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﻟﻠﺪﻳﻠﺰﺓ‬ ‫ﺍﳌﻘﺘﺮﺣﺔ‬ ‫ﺍﻷﻭﻟﻴﺔ‬ ‫ﺍﻟﻮﺻﻔﺔ‬ :٨ ‫ﺟﺪﻭﻝ‬ ‫ﺍﳉﺴﻢ‬ ‫ﺳﻄﺢ‬ ‫ﻣﺴﺎﺣﺔ‬‫ﻣﻞ/ﺩﻗﻴﻘﺔ‬ ٢ < ‫ﺍﻟﻜﺒﻴﺒﻲ‬ ‫ﺍﻟﺮﺷﺢ‬ ‫ﻣﻌﺪﻝ‬‫ﻣﻞ/ﺩﻗﻴﻘﺔ‬ ٢ > ‫ﺍﻟﻜﺒﻴﺒﻲ‬ ‫ﺍﻟﺮﺷﺢ‬ ‫ﻣﻌﺪﻝ‬ ٢‫ﻡ‬ ١٫٧ ‫ﻣﻦ‬ ‫ﺃقل‬‫ﹰ‬‫ا‬‫ﻧﻬاﺭ‬ ‫ﻝ‬ ٢ + (‫ﹰ‬‫ﻼ‬‫لي‬ ‫ﺳاﻋاﺕ‬ ٩) ‫ﻝ‬ ٢ × ٤‫ﹰ‬‫ا‬‫ﻧﻬاﺭ‬ ‫ﻝ‬ ٢ + (‫ﹰ‬‫ﻼ‬‫لي‬ ‫ﺳاﻋاﺕ‬ ٩) ‫ﻝ‬ ٢٫٥ × ٤ ٢‫ﻡ‬ ٢٫٠-١٫٧ ‫ﺑﲔ‬‫ﹰ‬‫ا‬‫ﻧﻬاﺭ‬ ‫ﻝ‬ ٢ + (‫ﹰ‬‫ﻼ‬‫لي‬ ‫ﺳاﻋاﺕ‬ ٩) ‫ﻝ‬ ٢٫٥ × ٤‫ﹰ‬‫ا‬‫ﻧﻬاﺭ‬ ‫ﻝ‬ ٢٫٥ + (‫ﹰ‬‫ﻼ‬‫لي‬ ‫ﺳاﻋاﺕ‬ ٩) ‫ﻝ‬ ٣ × ٤ ٢‫ﻡ‬ ٢ ‫ﻣﻦ‬ ‫ﺃﻛﺜﺮ‬‫ﹰ‬‫ا‬‫ﻧﻬاﺭ‬ ‫ﻝ‬ ٣ + (‫ﹰ‬‫ﻼ‬‫لي‬ ‫ﺳاﻋاﺕ‬ ٩) ‫ﻝ‬ ٣ × ٤‫ﹰ‬‫ا‬‫ﻧﻬاﺭ‬ ‫ﻝ‬ ٢٫٥ × ٢ + (‫ﹰ‬‫ﻼ‬‫لي‬ ‫ﺳاﻋاﺕ‬ ٩) ‫ﻝ‬ ٣ × ٤ (‫)ﻛلﻎ‬ ‫الﻮﺯﻥ‬ x (‫)ﺳﻢ‬ ‫الﻄﻮﻝ‬ ٣٦٠٠ = (٢‫)ﻡ‬ ‫اﳉﺴﻢ‬ ‫ﺳﻄﺢ‬ ‫ﻣﺴاﺣة‬
  • ٣٩ ‫ﻓيﻪ‬ ‫يﺘﻢ‬ ‫الديلزة‬ ‫ﻣﻦ‬ ‫ﲡﺮيﺒﻲ‬ ‫ﳕﻂ‬ ‫ﻫﻲ‬ ( •CFPD) ‫اﳌﺴﺘﻤﺮ‬ ‫الﺘدﻓﻖ‬ ‫ﺫاﺕ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫داﺧل‬ ‫اﶈلﻮﻝ‬ ‫ﺗدﻓﻖ‬ ‫يﺘﻢ‬ ‫ﺑﺤيﺚ‬ ‫ﻣﺴاﺭيﻦ‬ ‫ﺫﻱ‬ ‫ﻭاﺣد‬ ‫قﺜﻄاﺭ‬ ‫ﺃﻭ‬ ‫ﺻفاقيﲔ‬ ‫قﺜﻄاﺭيﻦ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﲢﻘيﻘﻪ‬ ‫ﳝﻜﻦ‬ ‫ﻣا‬ ‫ﺗﻘاﺭﺏ‬ ‫ﻣﺬاﺑاﺕ‬ ‫ﺗصفية‬ ‫ﻋﻨﻪ‬ ‫يﻨﺘﺞ‬ ‫ﳑا‬ ،‫ﻣﺴﺘﻤﺮة‬ ‫ﺑصﻮﺭة‬ ‫الصفاﻕ‬ ‫ﻭﺧاﺭﺝ‬ .‫اليﻮﻣﻲ‬ ‫الدﻣﻮﻱ‬ ‫ﺑاﻻﺳﺘصفاﺀ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻣﻦ‬ ‫ﺍﳌﺜﺎﻟﻲ‬ ‫ﺍﻟﻨﻤﻂ‬ :٤-٤ ‫الديلزة‬ ‫ﳕﻂ‬ ‫اﺧﺘياﺭ‬ ‫ﻓﻲ‬ ( •١١-٤ ‫قﺴﻢ‬ ‫)اﻧﻈﺮ‬ ‫الصفاﻕ‬ ‫ﻏﺸاﺀ‬ ‫ﻧﻘل‬ ‫ﺧصاﺋﺺ‬ ‫ﲢديد‬ ‫يفيد‬ .‫ﻣﺮيﺾ‬ ‫لﻜل‬ ‫اﳌﻨاﺳﺐ‬ ‫الصفاقية‬ ‫ﻣﻜﻮﺙ‬ ‫ﻓﺘﺮاﺕ‬ ‫ﺑﻌد‬ ‫ﺣﺘﻰ‬ ‫ﻋالية‬ ‫ﺑﻜفاﺀة‬ ‫اﳌﺬاﺑاﺕ‬ ‫ﺑﺘصفية‬ «‫الﻨﻘل‬ ‫»ﺳﺮيﻌﻮ‬ ‫اﳌﺮﺿﻰ‬ ‫يﻘﻮﻡ‬ • ‫يﻨﺘﺞ‬ ‫ﳑا‬ ،‫ﺑﺴﺮﻋة‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻦ‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫ﳝﺘصﻮﻥ‬ ‫الﻮقﺖ‬ ‫ﻧفﺲ‬ ‫ﻓﻲ‬ ‫ﻭلﻜﻨﻬﻢ‬ ،‫قصيﺮة‬ .‫الﺴﻮاﺋل‬ ‫ﺭﺷﺢ‬ ‫ﻋلﻰ‬ ‫اﶈفز‬ ‫ﻭﻓﻘداﻥ‬ ‫الديلزة‬ ‫ﶈلﻮﻝ‬ ‫الﺘﻨاﺿﺤﻲ‬ ‫الﻀﻐﻂ‬ ‫ﺗﻨاقﺺ‬ ‫ﺳﺮﻋة‬ ‫ﻋﻨﻪ‬ ‫ﺗصفية‬ ‫ﻣﻦ‬ ‫يﺘﻤﻜﻨﻮا‬ ‫ﺣﺘﻰ‬ ‫ﻃﻮيلة‬ ‫ﻣﻜﻮﺙ‬ ‫ﻓﺘﺮاﺕ‬ ‫ﺇلﻰ‬ ‫ﻓيﺤﺘاﺟﻮﻥ‬ «‫الﻨﻘل‬ ‫»ﺑﻄيﺌﻮ‬ ‫اﳌﺮﺿﻰ‬ ‫ﺃﻣا‬ • ‫لﻬﺬﻩ‬ ‫ﺑالﻨﺴﺒة‬ ‫ﻣﺸﻜلة‬ ‫يﺸﻜل‬ ‫ﻻ‬ ‫الﺴﻮاﺋل‬ ‫ﺭﺷﺢ‬ ‫لﻜﻦ‬ ،‫الدﻡ‬ ‫ﻣﻦ‬ ‫ﹴ‬‫ﻛاﻑ‬ ‫ﺑﺸﻜل‬ ‫اﳌﺬاﺑاﺕ‬ ‫ﻋلﻰ‬ ‫يﺤاﻓﻆ‬ ‫ﳑا‬ ‫اﻵﺧﺮ‬ ‫ﻫﻮ‬ ‫ﺑﺒﻂﺀ‬ ‫يﺘﻢ‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻦ‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫اﻣﺘصاﺹ‬ ‫ﻷﻥ‬ ‫اﺠﻤﻟﻤﻮﻋة‬ ‫ﻣدة‬ ‫ﻃﻮاﻝ‬ ‫الﺴﻮاﺋل‬ ‫ﺭﺷﺢ‬ ‫ﲟﻮاﺻلة‬ ‫ﺗﺴﻤﺢ‬ ‫ﻃﻮيلة‬ ‫لفﺘﺮة‬ ‫للﻤﺤلﻮﻝ‬ ‫الﺘﻨاﺿﺤﻲ‬ ‫الﻀﻐﻂ‬ .‫اﶈلﻮﻝ‬ ‫ﻣﻜﻮﺙ‬ ‫الﻘصيﺮة‬ ‫اﳌﻜﻮﺙ‬ ‫ﻓﺘﺮاﺕ‬ ‫ﺫاﺕ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺃﳕاﻁ‬ «‫الﻨﻘل‬ ‫»ﺳﺮيﻌﻲ‬ ‫اﳌﺮﺿﻰ‬ ‫ﺗﻨاﺳﺐ‬ • ‫الﻄﻮيلة‬ ‫اﳌﻜﻮﺙ‬ ‫ﻓﺘﺮاﺕ‬ ‫ﺫاﺕ‬ ‫اﻷﳕاﻁ‬ ‫ﻣﻦ‬ ‫ﺃﻛﺜﺮ‬ ،(‫اﳌﺘﻘﻄﻌة‬ ‫اﳌﺴاﺋية‬ ‫الصفاقية‬ ‫الديلزة‬ :‫)ﻣﺜاﻝ‬ .(‫اﳌﺴﺘﻤﺮة‬ ‫اﳉﻮالة‬ ‫الصفاقية‬ ‫)الديلزة‬ :‫)ﻣﺜاﻝ‬ ‫الﻄﻮيلة‬ ‫اﳌﻜﻮﺙ‬ ‫ﻓﺘﺮاﺕ‬ ‫ﺫاﺕ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺃﳕاﻁ‬ «‫الﻨﻘل‬ ‫»ﺑﻄيﺌﻲ‬ ‫اﳌﺮﺿﻰ‬ ‫ﺗﻨاﺳﺐ‬ • ‫ﺗصفية‬ ‫ﻣﻦ‬ ‫يﺘﻤﻜﻨﻮا‬ ‫ﺃﻥ‬ ‫اﶈﺘﻤل‬ ‫ﻏيﺮ‬ ‫ﻣﻦ‬ ‫ﺃﻧﻪ‬ ‫ﺣيﺚ‬ ،(‫اﳌﺴﺘﻤﺮة‬ ‫اﳉﻮالة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫الديلزة‬ :‫)ﻣﺜاﻝ‬ ‫الﻘصيﺮة‬ ‫اﳌﻜﻮﺙ‬ ‫ﻓﺘﺮاﺕ‬ ‫ﺫاﺕ‬ ‫اﻷﳕاﻁ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﻋﻨد‬ ‫ﻛاﻓية‬ ‫ﺑصﻮﺭة‬ ‫اﳌﺬاﺑاﺕ‬ .(‫اﳌﺘﻘﻄﻌة‬ ‫اﳌﺴاﺋية‬ ‫الصفاقية‬ ‫ﻛلﻮية‬ ‫ﺑﻮﻇيفة‬ ‫الﻐالﺐ‬ ‫ﻓﻲ‬ ‫يﺘﻤﺘﻌﻮﻥ‬ ‫لﺘﻮﻫﻢ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫يﺒﺘدﺋﻮﻥ‬ ‫الﺬﻱ‬ ‫اﳌﺮﺿﻰ‬ • ‫ﻻ‬ ‫اﳊالة‬ ‫ﻫﺬﻩ‬ ‫ﻓﻲ‬ ‫الﺴﻮاﺋل؛‬ ‫ﻭﺭﺷﺢ‬ ‫اﳌﺬاﺑاﺕ‬ ‫ﺗصفية‬ ‫ﻋلﻰ‬ ‫يﺴاﻋد‬ ‫ﳑا‬ ،‫ﺑﻬا‬ ‫ﺑﺄﺱ‬ ‫ﻻ‬ ‫ﻣﺘﺒﻘية‬ .‫الصفاﻕ‬ ‫ﻏﺸاﺀ‬ ‫ﻧﻘل‬ ‫ﺧصاﺋﺺ‬ ‫ﻣﻊ‬ ‫اﳌﻜﻮﺙ‬ ‫ﻭﻓﺘﺮة‬ ‫الديلزة‬ ‫ﳕﻂ‬ ‫ﻣﻼﺋﻤة‬ ‫الﻀﺮﻭﺭﻱ‬ ‫ﻣﻦ‬ ‫يﻜﻮﻥ‬ ‫ﻣﻦ‬ ‫يصﺒﺢ‬ ‫ﻓﺈﻧﻪ‬ ‫الزﻣﻦ‬ ‫ﻣﺮﻭﺭ‬ ‫ﻣﻊ‬ ‫اﳌﺘﺒﻘية‬ ‫الﻜلﻮية‬ ‫ﻭﻇيفﺘﻪ‬ ‫ﻓﻘداﻥ‬ ‫ﻓﻲ‬ ‫اﳌﺮيﺾ‬ ‫يﺒدﺃ‬ ‫ﺣﲔ‬ ‫ﺃﻣا‬ ‫يﺘﻤﻜﻦ‬ ‫ﺣﺘﻰ‬ ‫الصفاﻕ‬ ‫ﻏﺸاﺀ‬ ‫ﻧﻘل‬ ‫ﺧصاﺋﺺ‬ ‫ﻣﻊ‬ ‫اﳌﻜﻮﺙ‬ ‫ﻭﻓﺘﺮة‬ ‫الديلزة‬ ‫ﳕﻂ‬ ‫ﻣﻼﺋﻤة‬ ‫الﻀﺮﻭﺭﻱ‬ .‫ﻣﺮﺿية‬ ‫ﻧﺘاﺋﺞ‬ ‫ﲢﻘيﻖ‬ ‫ﻣﻦ‬ ‫اﳌﺮيﺾ‬ ‫ﻻ‬ ‫الﺬيﻦ‬ ‫للﻤﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫اﳌﺘﻘﻄﻌة‬ ‫ﻭليﺲ‬ ‫اﳌﺴﺘﻤﺮة‬ ‫الديلزة‬ ‫ﺃﳕاﻁ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫يفﻀل‬ • .‫اﳊﺠﻢ‬ ‫ﻣﺘﻮﺳﻄة‬ ‫اﳌﺬاﺑاﺕ‬ ‫ﺗصفية‬ ‫ﲢﺴﲔ‬ ‫ﺑﻬدﻑ‬ ‫ﻭﺫلﻚ‬ ،‫ﻣﺘﺒﻘية‬ ‫ﻛلﻮية‬ ‫ﺑﻮﻇيفة‬ ‫يﺘﻤﺘﻌﻮﻥ‬ ‫ﺗصفية‬ ‫اﳌﺴﺘﻤﺮة‬ ‫اﻵلية‬ ‫الصفاقية‬ ‫ﻭالديلزة‬ ‫اﳌﺴﺘﻤﺮة‬ ‫اﳉﻮالة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﲢﻘﻖ‬ • ‫اﻻﺧﺘياﺭ‬ ‫يﺘﺮﻙ‬ ‫ﺃﻥ‬ ‫ﻦ‬ ‫ﹸ‬‫يﺤﺴ‬ ‫ﻓﺈﻧﻪ‬ ‫ﹰ‬‫ا‬‫ﻣﺘاﺣ‬ ‫الديلزة‬ ‫ﳕﻄﻲ‬ ‫ﻛﻼ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫لﺬلﻚ‬ ،‫ﻣﺘﻤاﺛلة‬ ‫ﺃﺳﺒﻮﻋية‬ .‫اﳌﺮيﺾ‬ ‫لﺮﻏﺒة‬ ‫ﺑيﻨﻬﻤا‬
  • ٣٨ ‫ﺍﺨﻤﻟﺘﻠﻔﺔ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﺃﳕﺎﻁ‬ :٣-٤ ‫يﺆدﻯ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﻦ‬ ‫ﻣﺴﺘﻤﺮ‬ ‫ﳕﻂ‬ ‫ﻫﻲ‬ ( •CAPD) ‫اﳌﺴﺘﻤﺮة‬ ‫اﳉﻮالة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺮة‬ ‫ﺗﺒديلﻪ‬ ‫ﺛﻢ‬ (‫الﻌادة‬ ‫ﻓﻲ‬ ‫)ﺛﻼﺛة‬ ‫الﻨﻬاﺭ‬ ‫ﺧﻼﻝ‬ ‫ﻣﺮاﺕ‬ ‫ﻋدة‬ ‫اﶈلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﻭﺗﺸﻤل‬ ،‫يدﻭية‬ ‫ﺑصﻮﺭة‬ .‫الليل‬ ‫ﻓﺘﺮة‬ ‫ﻃﻮاﻝ‬ ‫الصفاﻕ‬ ‫داﺧل‬ ‫ليﻤﻜﺚ‬ ‫يﺘﺮﻙ‬ ‫ﺑﺤيﺚ‬ ‫اﳌﺴاﺀ‬ ‫ﻓﻲ‬ ‫ﺃﺧﺮﻯ‬ ‫يﺆدﻯ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﻦ‬ ‫ﻣﺘﻘﻄﻊ‬ ‫ﳕﻂ‬ ‫ﻫﻲ‬ ( •DAPD) ‫الﻨﻬاﺭية‬ ‫اﳉﻮالة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺧﻼﻝ‬ ‫ﹰ‬‫ا‬‫ﺟاﻓ‬ ‫الصفاﻕ‬ ‫ﺗﺮﻙ‬ ‫ﻣﻊ‬ ،‫الﻨﻬاﺭ‬ ‫ﺧﻼﻝ‬ ‫ﻣﺮاﺕ‬ ‫ﻋدة‬ ‫اﶈلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﻭﺗﺸﻤل‬ ،‫يدﻭية‬ ‫ﺑصﻮﺭة‬ .‫الليل‬ ،‫ﺇلﻜﺘﺮﻭﻧية‬‫ﺁلة‬‫ﲟﺴاﻋدة‬‫يﺆدﻯ‬‫الصفاقية‬‫الديلزة‬‫ﻣﻦ‬‫ﳕﻂ‬‫ﻫﻲ‬( •APD)‫اﻵلية‬‫الصفاقية‬‫الديلزة‬ ،‫اﳌدية‬ ‫الصفاقية‬ ‫الديلزة‬ ، ‫اﳌﺘﻘﻄﻌة‬ ‫اﳌﺴاﺋية‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﻨﻬا‬ ،‫ﺃﻧﻮاﻉ‬ ‫ﻋدة‬ ‫ﻭﺗﺸﻤل‬ .‫اﶈﺴﻨة‬ ‫اﻵلية‬ ‫الصفاقية‬ ‫ﻭالديلزة‬ ،‫اﳌﺴﺘﻤﺮة‬ ‫اﻵلية‬ ‫الصفاقية‬ ‫الديلزة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﻦ‬ ‫ﻣﺘﻘﻄﻊ‬ ‫ﳕﻂ‬ ‫ﻫﻲ‬ ( •NIPD) ‫اﳌﺘﻘﻄﻌة‬ ‫اﳌﺴاﺋية‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺧﻼﻝ‬ (‫ﺳاﻋاﺕ‬ ‫ﺗﺴﻊ‬ ‫)ﻋادة‬ ‫الﺴاﻋاﺕ‬ ‫ﻣﻦ‬ ‫لﻌدد‬ ‫الديلزة‬ ‫ﺑﺂلة‬ ‫ﹰ‬‫ﻼ‬‫ﻣﺘص‬ ‫اﳌﺮيﺾ‬ ‫ﻓيﻬا‬ ‫يﻈل‬ ‫اﻵلية‬ ‫ﺧﻼﻝ‬ ‫ﹰ‬‫ا‬‫ﺟاﻓ‬ ‫الصفاﻕ‬ ‫ﺘﺮﻙ‬‫ﹸ‬‫ي‬ ‫ﺛﻢ‬ ،‫ﻣﺮاﺕ‬ ‫ﻋدة‬ ‫اﶈلﻮﻝ‬ ‫ﺑﺘﺒديل‬ ‫الديلزة‬ ‫ﺁلة‬ ‫ﺃﺛﻨاﺀﻫا‬ ‫ﺗﻘﻮﻡ‬ ‫الليل‬ .‫الﻨﻬاﺭ‬ ‫ﻓيﻬا‬ ‫يﻈل‬ ‫اﻵلية‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﻦ‬ ‫ﻣﺘﻘﻄﻊ‬ ‫ﳕﻂ‬ ‫ﻫﻲ‬ ( •TPD) ‫اﳌدية‬ ‫الصفاقية‬ ‫الديلزة‬ ‫اﳌﺴاﺋية‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻓﻲ‬ ‫اﳌﻌﺘاد‬ ‫الﺴاﻋاﺕ‬ ‫ﻋدد‬ ‫لﻨفﺲ‬ ‫الديلزة‬ ‫ﺑﺂلة‬ ‫ﹰ‬‫ﻼ‬‫ﻣﺘص‬ ‫اﳌﺮيﺾ‬ ‫الﺘﺒديل‬ ‫يﻜﻮﻥ‬ ‫ﺑﺤيﺚ‬ ،‫اﳌﺮاﺕ‬ ‫ﻣﻦ‬ ‫ﺃﻛﺒﺮ‬ ‫ﹰ‬‫ا‬‫ﻋدد‬ ‫اﶈلﻮﻝ‬ ‫ﺑﺘﺒديل‬ ‫اﻵلة‬ ‫ﺗﻘﻮﻡ‬ ‫ﺣﲔ‬ ‫ﻓﻲ‬ ‫اﳌﺘﻘﻄﻌة‬ ‫ﺴﺘﺨدﻡ‬‫ﹸ‬‫ي‬ ‫الديلزة‬ ‫ﻣﻦ‬ ‫اﳌﻜلﻒ‬ ‫الﻨﻤﻂ‬ ‫ﻫﺬا‬ .(‫الﻮاﺣدة‬ ‫اﳌﺮة‬ ‫ﻓﻲ‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ٪٧٥-٥٠) ‫ﻓﻘﻂ‬‫ﹰ‬‫ا‬‫ﺟزﺋي‬ ‫اﶈلﻮﻝ‬ ‫ﺗصﺮيﻒ‬ ‫يﻜﻮﻥ‬ ‫الﺬيﻦ‬ ‫ﺃﻭ‬ ‫اﶈلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﺃﺛﻨاﺀ‬ ‫اﻷلﻢ‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻮﻥ‬ ‫الﺬيﻦ‬ ‫للﻤﺮﺿﻰ‬ ‫ﻋادة‬ .‫ﹰ‬‫ا‬‫ﺑﻄيﺌ‬ ‫لديﻬﻢ‬ ‫اﻵلية‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﻦ‬ ‫ﻣﺴﺘﻤﺮ‬ ‫ﳕﻂ‬ ‫ﻫﻲ‬ ( •CCPD) ‫اﳌﺴﺘﻤﺮة‬ ‫اﻵلية‬ ‫الصفاقية‬ ‫الديلزة‬ ‫لﺘﻤﻜﺚ‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻛﻤية‬ ‫ﺗاﺭﻛة‬ ،‫اﳌﺮيﺾ‬ ‫ﻧﻮﻡ‬ ‫ﺧﻼﻝ‬ ‫ﻣﺮاﺕ‬ ٦ -٣ ‫اﶈلﻮﻝ‬ ‫ﺑﺘﺒديل‬ ‫اﻵلة‬ ‫ﻓيﻬا‬ ‫ﺗﻘﻮﻡ‬ .‫الﻨﻬاﺭ‬ ‫ﺧﻼﻝ‬ ‫الصفاﻕ‬ ‫داﺧل‬ ‫اﻵلية‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﻦ‬ ‫ﻣﺴﺘﻤﺮ‬ ‫ﳕﻂ‬ ‫ﻫﻲ‬ ( •OCPD) ‫اﶈﺴﻨة‬ ‫اﻵلية‬ ‫الصفاقية‬ ‫الديلزة‬ ‫لﺘﻤﻜﺚ‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻛﻤية‬ ‫ﺗاﺭﻛة‬ ،‫اﳌﺮيﺾ‬ ‫ﻧﻮﻡ‬ ‫ﺧﻼﻝ‬ ‫ﻣﺮاﺕ‬ ٦-٣ ‫اﶈلﻮﻝ‬ ‫ﺑﺘﺒديل‬ ‫اﻵلة‬ ‫ﻓيﻬا‬ ‫ﺗﻘﻮﻡ‬ ‫ﺧﻼﻝ‬ ‫اﳌﺮيﺾ‬ ‫ﺑﻪ‬ ‫يﻘﻮﻡ‬ ‫للﻤﺤلﻮﻝ‬ ‫يدﻭﻱ‬ ‫ﺗﺒديل‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ ،‫الﻨﻬاﺭ‬ ‫ﺧﻼﻝ‬ ‫الصفاﻕ‬ ‫داﺧل‬ .‫الﻨﻬاﺭ‬ ‫يﺘﻢ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﻦ‬ ‫ﻣﺘﻘﻄﻊ‬ ‫ﳕﻂ‬ ‫ﻫﻲ‬ ( •IPD) ‫الﺘﻘليدية‬ ‫اﳌﺘﻘﻄﻌة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫الﻄﺮيﻘة‬ .‫الديلزة‬ ‫ﺁلة‬ ‫ﺑاﺳﺘﺨداﻡ‬ ‫ﻭﺇﻣا‬ ‫ﹰ‬‫ا‬‫يدﻭي‬ ‫ﺇﻣا‬ ،‫ﻣﺘﻘﻄﻌة‬ ‫ﻓﺘﺮاﺕ‬ ‫ﻋلﻰ‬ ‫اﶈلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﻓيﻪ‬ ٧٢ – ٤٨ ‫ﻣﻨﻬﻤا‬ ‫ﻛل‬ ‫ﻣدة‬ ‫اﻷﺳﺒﻮﻉ‬ ‫ﻓﻲ‬ ‫ﺟلﺴﺘﲔ‬ ‫ﺃﻭ‬ ‫ﺟلﺴة‬ ‫ﺗﺸﻤل‬ ‫الﻐالﺐ‬ ‫ﻓﻲ‬ ‫اﳌﺴﺘﺨدﻣة‬ ‫يﺘﻢ‬ ‫ﺑﺤيﺚ‬ ،‫الﻮاﺣد‬ ‫اليﻮﻡ‬ ‫ﻓﻲ‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻦ‬‫ﹰ‬‫ا‬‫لﺘﺮ‬ ٢٤ ‫ﺟلﺴة‬ ‫ﻛل‬ ‫ﻓﻲ‬ ‫يﺴﺘﺨدﻡ‬ ،‫ﺳاﻋة‬ ‫اﳌدﻯ‬ ‫ﻋلﻰ‬ ‫ﻛاﻓية‬ ‫ﺗﻜﻮﻥ‬ ‫ﻣا‬ ‫ﹰ‬‫ا‬‫ﻧادﺭ‬ ‫الﻄﺮيﻘة‬ ‫ﻫﺬﻩ‬ .‫ﺳاﻋﺘﲔ‬ ‫ﻛل‬ ‫ﻓﻲ‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ليﺘﺮيﻦ‬ ‫ﺗﺒديل‬ ‫ﳌﻌاﳉة‬ ‫ﺃﻭ‬ ،‫اﳊاد‬ ‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫ﳌﺮﺿﻰ‬ ‫ﻣﺆقﺖ‬ ‫ﻛﻌﻼﺝ‬ ‫الﻐالﺐ‬ ‫ﻓﻲ‬ ‫ﺗﺴﺘﺨدﻡ‬ ‫ﻭلﺬلﻚ‬ ،‫الﻄﻮيل‬ ‫الديلزة‬ ‫ﺗﺄدية‬ ‫ﻋلﻰ‬ ‫يﻘدﺭﻭﻥ‬ ‫ﻭﻻ‬ ‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫يﻨاﺳﺒﻬﻢ‬ ‫ﻻ‬ ‫الﺬيﻦ‬ ‫الﺴﻦ‬ ‫ﻛﺒاﺭ‬ ‫اﳌﺮﺿﻰ‬ .‫ﺑﺄﻧفﺴﻬﻢ‬ ‫الﻌادية‬ ‫الصفاقية‬
  • ٣٧ ‫ﻭﻣﺮﺍﻗﺒﺘﻬﺎ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻭﺻﻒ‬ :٤ ‫ﻓﺼﻞ‬ ‫ﺍﻷﻫﺪﺍﻑ‬ :١-٤ ‫ﻋلﻰ‬ ‫ﻣﺮيﺾ‬ ‫ﻛل‬ ‫اﺣﺘياﺟاﺕ‬ ‫ﺗﻨاﺳﺐ‬ ‫الﺘﻲ‬ ‫ﺑالصﻮﺭة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻭﺻﻒ‬ ‫ﻋلﻰ‬ ‫الﺘﺸﺠيﻊ‬ • .‫اﳌﻤﻜﻨة‬ ‫الﻨﺘاﺋﺞ‬ ‫ﺃﻓﻀل‬ ‫ﲢﻘيﻖ‬ ‫ﺑﻬدﻑ‬ ‫ﻭﺫلﻚ‬ ،‫ﺣدة‬ ‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫ﺇلﻰ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﻦ‬ ‫اﳌﺮيﺾ‬ ‫لﺘﺤﻮيل‬ ‫اﳌﻨاﺳﺐ‬ ‫الﻮقﺖ‬ ‫ﺗﻮﺿيﺢ‬ • .‫ﻻﺣﺘياﺟاﺗﻪ‬ ‫ﻛاﻓية‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺗﻌﻮد‬ ‫ﻻ‬ ‫ﺣيﻨﻤا‬ .‫ﳑﻜﻨة‬ ‫ﻓﺘﺮة‬ ‫ﻷﻃﻮﻝ‬ ‫اﳌﺘﺒﻘية‬ ‫الﻜلﻮية‬ ‫الﻮﻇيفة‬ ‫ﻋلﻰ‬ ‫اﶈاﻓﻈة‬ ‫ﺿﺮﻭﺭة‬ ‫ﻋلﻰ‬ ‫الﺘﺄﻛيد‬ • ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻣﺒﺎﺩﺉ‬ :٢-٤ ‫ﻏﺸاﺀ‬ ‫ﻋﺒﺮ‬ ( •diffusion) ‫اﻻﻧﺘﺸاﺭ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻓﻲ‬ ‫اﳌﺬاﺑاﺕ‬ ‫اﻧﺘﻘاﻝ‬ ‫يﺘﻢ‬ ‫يﺘﻢ‬ ‫ﺣﺘﻰ‬ (‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﺇلﻰ‬ ‫الدﻡ‬ ‫ﻣﻦ‬ ‫اﻻﻧﺘﻘاﻝ‬ ‫يﺘﻢ‬ ‫)ﻋادة‬ ‫الﺘﺮاﻛيز‬ ‫ﺗدﺭﺝ‬ ‫ﺣﺴﺐ‬ ‫الصفاﻕ‬ .‫اﻻﺗزاﻥ‬ ‫ﺣالة‬ ‫ﺇلﻰ‬ ‫الﻮﺻﻮﻝ‬ ‫ﺇﺯالة‬ ‫ﺗﺘﻢ‬ ‫ﺣيﺚ‬ ،( •osmosis) ‫الﺘﻨاﺿﺢ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻓﻲ‬ ‫الﺴﻮاﺋل‬ ‫اﻧﺘﻘاﻝ‬ ‫يﺘﻢ‬ (osmotic pressure) ‫الﺘﻨاﺿﺤﻲ‬ ‫الﻀﻐﻂ‬ ‫ﺯاد‬ ‫ﻛلﻤا‬ ‫الدﻡ‬ ‫ﻣﻦ‬ (‫)الﺮاﺷﺢ‬ ‫الﺴﻮاﺋل‬ ‫ﻣﻦ‬ ‫اﳌزيد‬ ‫اﳊﻤل‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫اﳌﺬاﺑاﺕ‬ ‫ﲢﺮﻙ‬ ‫ﺇلﻰ‬ ‫ﺑدﻭﺭﻫا‬ ‫ﻫﺬﻩ‬ ‫الﺴﻮاﺋل‬ ‫ﺣﺮﻛة‬ ‫ﻭﺗﺆدﻱ‬ ‫الديلزة؛‬ ‫ﶈلﻮﻝ‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﺟزﺀ‬ ‫اﻣﺘصاﺹ‬ ‫يﺘﻢ‬ ‫ﺳﺒﻖ‬ ‫ﻣا‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ .‫اﳌﺬيﺐ‬ ‫ﺟﺮ‬ ‫ﺃﻭ‬ (convection) .‫الدﻣﻮية‬ ‫الدﻭﺭة‬ ‫ﺇلﻰ‬ ‫ﻭﻧﻘلﻪ‬ ‫ﺑالصفاﻕ‬ ‫الليﻤفية‬ ‫اﻷﻭﻋية‬ ‫ﻋﺒﺮ‬ ‫ﻣﻜﻮﺙ‬ ‫ﻭﻭقﺖ‬ ،‫للديلزة‬ ‫الﻜلﻲ‬ ‫الﻮقﺖ‬ ‫ﻋلﻰ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻛفاﺀة‬ ‫ﺗﻌﺘﻤد‬ ‫لﺬلﻚ‬ ‫ﻧﺘيﺠة‬ • ‫)ﻣﺴاﺣة‬ ‫الصفاﻕ‬ ‫ﻏﺸاﺀ‬ ‫ﻭﺧصاﺋﺺ‬ ،‫اﶈلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﻣﺮاﺕ‬ ‫ﻭﻋدد‬ ،‫الصفاﻕ‬ ‫داﺧل‬ ‫اﶈلﻮﻝ‬ .‫الﺮاﺷﺢ‬ ‫ﺣﺠﻢ‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ ،(‫ﻭﻧفﻮﺫيﺘﻪ‬ ،‫ﻓيﻪ‬ ‫الدﻡ‬ ‫ﺟﺮياﻥ‬ ،‫ﺳﻄﺤﻪ‬ ‫ﺗصفية‬ ‫ﻣﻦ‬ ‫ﺑﻜﺜيﺮ‬ ‫ﺃقل‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﲢﻘيﻘﻬا‬ ‫ﳝﻜﻦ‬ ‫الﺘﻲ‬ ‫اليﻮﺭيا‬ ‫ﺗصفية‬ • ‫ﻧﻮﻋﻲ‬ ‫ﻛﻼ‬ ‫ﻓﺈﻥ‬ ‫ﺫلﻚ‬ ‫ﻣﻦ‬ ‫ﻭﺑالﺮﻏﻢ‬ ،‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﲢﻘيﻘﻬا‬ ‫ﳝﻜﻦ‬ ‫الﺘﻲ‬ ‫اليﻮﺭيا‬ ‫ﻛﺒيﺮة‬ ‫اﳌﺬاﺑاﺕ‬ ‫ﺗصفية‬ ‫ﺇلﻰ‬ ‫ﹰ‬‫ا‬‫ﺃﺣياﻧ‬ ‫ﺫلﻚ‬ ‫ﻌزﻯ‬‫ﹸ‬‫ي‬ .‫ﳑاﺛلة‬ ‫ﺳﺮيﺮية‬ ‫ﻧﺘاﺋﺞ‬ ‫ﺇلﻰ‬ ‫يﺆدياﻥ‬ ‫الديلزة‬ ‫ﺇلﻰ‬ ‫ﻋزﻭﻩ‬ ‫ﳝﻜﻦ‬ ‫ﻛﻤا‬ ،‫الصفاقية‬ ‫الديلزة‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﺃﻛفﺄ‬ ‫ﺑصﻮﺭة‬ ‫ﺗﺘﻢ‬ ‫ﻭالﺘﻲ‬ ‫اﳊﺠﻢ‬ ‫ﻭﻣﺘﻮﺳﻄة‬ ‫لليﻮﺭيا‬ ‫ﺗﺮﻛيز‬ ‫ﺃقصﻰ‬ ‫ﺃﻥ‬ ‫ﺣيﺚ‬ ،‫اليﻮﺭﳝية‬ ‫ﻭاﻷﻋﺮاﺽ‬ ‫الدﻡ‬ ‫ﻓﻲ‬ ‫لليﻮﺭيا‬ ‫ﺗﺮﻛيز‬ ‫ﺃقصﻰ‬ ‫ﺑﲔ‬ ‫الﻌﻼقة‬ ‫الﺬﻱ‬ ‫اﳌﺮيﺾ‬ ‫ﻋﻨد‬ ‫لليﻮﺭيا‬ ‫ﺗﺮﻛيز‬ ‫ﺃقصﻰ‬ ‫يفﻮﻕ‬ ‫الدﻣﻮﻱ‬ ‫لﻼﺳﺘصفاﺀ‬ ‫يﺨﻀﻊ‬ ‫الﺬﻱ‬ ‫اﳌﺮيﺾ‬ ‫ﻋﻨد‬ .‫الصفاقية‬ ‫للديلزة‬ ‫يﺨﻀﻊ‬ ‫ﻣﻦ‬ ٪ •٣٫٨٦‫ﻭ‬ ٪٢٫٢٧‫ﻭ‬ ٪١٫٣٦ ‫ﻫﻲ‬ ،‫ﻣﺨﺘلفة‬ ‫ﺗﺮاﻛيز‬ ‫ﺑﺜﻼﺛة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺤاليل‬ ‫ﺗﺘﻮﻓﺮ‬ ‫الﺘﺮاﻛيز‬ ‫ﻫﺬﻩ‬ .‫ﺃﻭﺭﻭﺑا‬ ‫ﻓﻲ‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫ﺗﺮﻛيز‬ ‫لﻘياﺱ‬ ‫اﳌفﻀلة‬ ‫الﻄﺮيﻘة‬ ‫ﻭﻫﻲ‬ ، ‫الﻼﻣاﺋﻲ‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫ﻭﻫﻲ‬ ،‫الﺘﻤيﻪ‬ ‫ﺃﺣادﻱ‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫ﻣﻦ‬ ‫الﺘﻮالﻲ‬ ‫ﻋلﻰ‬ ٪٤٫٢٥‫ﻭ‬ ٪٢٫٥‫ﻭ‬ ٪١٫٥ ‫للﺘﺮاﻛيز‬ ‫ﻣﻄاﺑﻘة‬ .‫اﳌﺘﺤدة‬ ‫الﻮﻻياﺕ‬ ‫ﻓﻲ‬ ‫اﳉلﻮﻛﻮﺯ‬ ‫ﺗﺮﻛيز‬ ‫لﻘياﺱ‬ ‫اﳌفﻀلة‬ ‫الﻄﺮيﻘة‬
  • ٣٦ ‫ﺍﻟﻔﺼﻞ‬ ‫ﻫﺬﺍ‬ ‫ﻓﻲ‬ ‫ﺫﻛﺮﺕ‬ ‫ﺃﺩﻭﻳﺔ‬ :٦ ‫ﺟﺪﻭﻝ‬ ‫ﺍﻟﺪﻭﺍﺀ‬ ‫ﺍﺳﻢ‬‫ﺍﻟﺘﺮﻛﻴﺒﺔ‬‫ﺍﳉﺮﻋﺔ‬ ‫ﺟﻨﺘاﻣيﺴﲔ‬(٪٠٫٣) ‫ﻧﻘﻂ‬ ‫ﺃﻭ‬ (٪٠٫١) ‫ﻛﺮﱘ‬‫اللزﻭﻡ‬ ‫ﻋﻨد‬ ‫يﻮد‬‫ﻣﺤلﻮﻝ‬‫اللزﻭﻡ‬ ‫ﻋﻨد‬
  • ٣٥ ‫ﺑﺤﺮﻛة‬ ‫ﺑﺮﻓﻖ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﺣﻮﻝ‬ ‫اﳉلد‬ ‫ﻭﻧﻈﻒ‬ ‫اﳌلﺢ‬ ‫ﲟﺤلﻮﻝ‬ ‫الﺸاﺵ‬ ‫ﻣﻦ‬ ‫قﻄﻌة‬ ‫ﻊ‬‫ﱢ‬‫ﺒ‬‫ﺷ‬ ٦. ‫ﻧﻈيفة‬ ‫ﻣﻨﺸفة‬ ‫ﺑاﺳﺘﺨداﻡ‬ ‫ﺟففﻪ‬ ‫ﺛﻢ‬ ،‫اﳋاﺭﺝ‬ ‫ﻧﺤﻮ‬‫ﹰ‬‫ا‬‫ﻭﻣﺘﺠﻬ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻣﻦ‬ ‫ﹰ‬‫ا‬‫ﺑادﺋ‬ ‫داﺋﺮية‬ .‫الﺸاﺵ‬ ‫ﻣﻦ‬ ‫قﻄﻌة‬ ‫ﺃﻭ‬ ‫ﺑﺤﺮﻛة‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﺣﻮﻝ‬ ‫اﳉلد‬ ‫لدﻫﻦ‬ ‫ﻭاﺳﺘﺨدﻣﻬا‬ ،‫ﺑاليﻮد‬ ‫الﺸاﺵ‬ ‫ﻣﻦ‬ ‫قﻄﻌة‬ ‫ﻊ‬‫ﱢ‬‫ﺒ‬‫ﺷ‬ ٧. ٦٠ - ٣٠ ‫ﻏﻀﻮﻥ‬ ‫ﻓﻲ‬ ‫لﺘﺠﻒ‬ ‫اﺗﺮﻛﻬا‬ ‫ﺛﻢ‬ ،‫اﳋاﺭﺝ‬ ‫ﺇلﻰ‬ ‫ﹰ‬‫ا‬‫ﻭﻣﺘﺠﻬ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻣﻦ‬ ‫ﹰ‬‫ا‬‫ﺑادﺋ‬ ‫داﺋﺮية‬ .‫ﺛاﻧية‬ ‫ﺑﺤﺮﻛة‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫لدﻫﻦ‬ ‫ﻭاﺳﺘﺨدﻣﻬا‬ ،‫ﺟﻨﺘاﻣايﺴﲔ‬ ‫ﺑﻜﺮﱘ‬ ‫الﺸاﺵ‬ ‫ﻣﻦ‬ ‫قﻄﻌة‬ ‫ﻊ‬‫ﱢ‬‫ﺒ‬‫ﺷ‬ ٨. .‫اﳉﻨﺘاﻣايﺴﲔ‬ ‫ﻣﻦ‬ ‫ﹰ‬‫ا‬‫ﻧﻘﻄ‬ ‫ﺿﻊ‬ ‫ﺃﻭ‬ ،‫اﳋاﺭﺝ‬ ‫ﺇلﻰ‬ ‫ﹰ‬‫ا‬‫ﻭﻣﺘﺠﻬ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻣﻦ‬ ‫ﹰ‬‫ا‬‫ﺑادﺋ‬ ‫داﺋﺮية‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺗﺜﺒيﺖ‬ ‫ﻣﻦ‬ ‫ﻭﺗﺄﻛد‬ ،(‫ﻓﻘﻂ‬ ‫لﻸﻃفاﻝ‬ ‫ﺑﻬا‬ ‫)يﻨصﺢ‬ ‫اﳌﻌﻘﻤة‬ ‫ة‬‫ﱠ‬‫د‬‫الﺴا‬ ‫الﻀﻤادة‬ ‫ﺿﻊ‬ ٩. .‫الﺒﻄﻦ‬ ‫ﻋلﻰ‬ ‫الﺘﻮﺻيل‬ ‫ﻭﺟﻬاﺯ‬
  • ٣٤ ‫ﺑﺬلﻚ‬ ‫الﻘياﻡ‬ ‫يﺠﺐ‬ ‫ﻛﻤا‬ ،‫اﺳﺘﺤﻤاﻡ‬ ‫ﻛل‬ ‫ﻭﺑﻌد‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﺑﺘﻨﻈيﻒ‬ ‫الﻘياﻡ‬ ‫يﺠﺐ‬ • .‫الﺘﻬاﺏ‬ ‫ﺃﻭ‬ ‫ﻋدﻭﻯ‬ ‫ﻭﺟﻮد‬ ‫ﺣالة‬ ‫ﻓﻲ‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮﺗﲔ‬ .‫اﳌلﺢ‬ ‫ﲟﺤلﻮﻝ‬ ‫ﻣﺸﺒﻌة‬ ‫الﺸاﺵ‬ ‫ﻣﻦ‬ ‫قﻄﻌة‬ ‫اﺳﺘﺨداﻡ‬ ‫يﺴﺘﺤﺴﻦ‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫لﺘﻨﻈيﻒ‬ • ‫ﻻ‬ ‫ﻭلﻜﻦ‬ ،‫اﳌلﺢ‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻋﻦ‬ ‫ﹰ‬‫ﻻ‬‫ﺑد‬ ‫الﻜﺤﻮﻝ‬ ‫ﻋلﻰ‬ ‫اﶈﺘﻮية‬ ‫اﳌﻄﻬﺮة‬ ‫الﺴﻮاﺋل‬ ‫اﺳﺘﺨداﻡ‬ ‫ﳝﻜﻦ‬ ‫يﺴﺘﺤﺴﻦ‬ ‫ﻛﻤا‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﺗﻀﺮﺭ‬ ‫ﻋﻨﻪ‬ ‫يﻨﺘﺞ‬ ‫قد‬ ‫ﻫﺬا‬ ‫ﻷﻥ‬ ‫ﻣﺘﻜﺮﺭة‬ ‫ﺑصﻮﺭة‬ ‫اﺳﺘﻌﻤالﻬا‬ ‫يﺠﻮﺯ‬ ‫قد‬ ‫ﻷﻧﻪ‬ ‫ﺑاﺳﺘﻤﺮاﺭ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﺗﻨﻈيﻒ‬ ‫ﻓﻲ‬ ‫الﻬيدﺭﻭﺟﲔ‬ ‫ﺑيﺮﻭﻛﺴيد‬ ‫اﺳﺘﺨداﻡ‬ ‫ﲡﻨﺐ‬ .‫ﻣﺮﻭﻧﺘﻪ‬ ‫ﻭيفﻘدﻩ‬ ‫الﻘﺜﻄاﺭ‬ ‫يﺠفﻒ‬ ‫اﻷدﻭاﺕ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫يﺠﻮﺯ‬ ‫ﻻ‬ ‫ﻛﻤا‬ ‫ﺑالﻘﻮة‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋلﻰ‬ ‫اﳌﻮﺟﻮدة‬ ‫الﻘﺸﻮﺭ‬ ‫ﺇﺯالة‬ ‫يﺠﻮﺯ‬ ‫ﻻ‬ • .‫الﻘﺜﻄاﺭ‬ ‫ﲟﺨﺮﺝ‬ ‫الﻌﻨاية‬ ‫ﻓﻲ‬ ‫اﳊادة‬ ،‫الﺒالﻎ‬ ‫للﻤﺮيﺾ‬ ‫ﺑالﻨﺴﺒة‬ ‫ﺑالﺸاﺵ‬ ‫لﺘﻐﻄيﺘﻪ‬ ‫ﺣاﺟة‬ ‫ﻓﻼ‬‫ﹰ‬‫ا‬‫ﲤاﻣ‬‫ﹰ‬‫ا‬‫ﻣلﺘﺌﻤ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ • ‫ﺑالﻨﺴﺒة‬ ‫اﳌﻌﻘﻤة‬ (occlusive dressing) ‫ة‬‫ﱠ‬‫د‬‫الﺴا‬ ‫الﻀﻤاداﺕ‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫يﻨصﺢ‬ ‫ﻭلﻜﻦ‬ .‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋدﻭﻯ‬ ‫ﻣﻦ‬ ‫يﻘلل‬ ‫ﻫﺬا‬ ‫ﺃﻥ‬ ‫ﺣالﺘﻬﻢ‬ ‫ﻓﻲ‬ ‫ﺛﺒﺖ‬ ‫ﺣيﺚ‬ ‫لﻸﻃفاﻝ‬ ‫ﳑﺮﺽ‬ ‫ﺑﺬلﻚ‬ ‫يﻘﻮﻡ‬ ‫ﺃﻥ‬ ‫ﻓيﺠﺐ‬ ‫الﻘﺜﻄاﺭﺑﻨفﺴﻪ‬ ‫ﲟﺨﺮﺝ‬ ‫الﻌﻨاية‬ ‫ﻋلﻰ‬ ‫ﹰ‬‫ا‬‫قادﺭ‬ ‫اﳌﺮيﺾ‬ ‫يﻜﻦ‬ ‫لﻢ‬ ‫ﺇﺫا‬ • .‫اﳌﺮيﺾ‬ ‫ﺳﺠﻼﺕ‬ ‫ﻓﻲ‬ ‫ﺗدﻭيﻨﻪ‬ ‫يﺘﻢ‬ ‫ﻭﺃﻥ‬ ‫ﻣدﺭﺏ‬ ‫اﺳﺘﺨداﻡ‬ ‫ﳝﻜﻦ‬ ‫ﻭلﻜﻦ‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﲟﺨﺮﺝ‬ ‫للﻌﻨاية‬ ‫الﻘفاﺯاﺕ‬ ‫اﺳﺘﺨداﻡ‬ ‫الﻀﺮﻭﺭﻱ‬ ‫ﻣﻦ‬ ‫ليﺲ‬ • ‫ﻛﻤا‬ ،(purulent discharge) ‫قيﺤﻲ‬ ‫ﳒيﺞ‬ ‫ﻫﻨاﻙ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ (‫اﳌﻌﻘﻤة‬ ‫)ﻏيﺮ‬ ‫الﻨﻈيفة‬ ‫الﻘفاﺯاﺕ‬ .‫ﺑالزﻛاﻡ‬ ‫ﹰ‬‫ا‬‫ﻣصاﺑ‬ ‫الﺸﺨﺺ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫الﻜﻤاﻣاﺕ‬ ‫اﺳﺘﺨداﻡ‬ ‫ﳝﻜﻦ‬ ‫ﺍﻟﻘﺜﻄﺎﺭ‬ ‫ﲟﺨﺮﺝ‬ ‫ﺍﻟﻌﻨﺎﻳﺔ‬ ‫ﺧﻄﻮﺍﺕ‬ :٩-٣ ‫ﻓﻲ‬ ‫ﺣيﻮاﻧاﺕ‬ ‫ﻭﺟﻮد‬ ‫ﻋدﻡ‬ ،‫اﳌﺮﻭﺣة‬ ‫ﺇﻏﻼﻕ‬ ،‫ﻭالﻨﻮاﻓﺬ‬ ‫اﻷﺑﻮاﺏ‬ ‫)ﺇﻏﻼﻕ‬ ‫اﳌﻜاﻥ‬ ‫ﻧﻈاﻓة‬ ‫ﻣﻦ‬ ‫ﺗﺄﻛد‬ ١. .(‫الﻐﺮﻓة‬ ،‫ﺟﻨﺘاﻣايﺴﲔ‬ ‫قﻄاﺭة‬ ‫ﺃﻭ‬ ‫ﻣﺮﻫﻢ‬ ،‫يﻮد‬ ،‫اﳌلﺢ‬ ‫ﻣﺤلﻮﻝ‬ :‫ﻧﻈيفة‬ ‫ﻃاﻭلة‬ ‫ﻋلﻰ‬ ‫الﺘالية‬ ‫اﻷدﻭاﺕ‬ ‫ﺣﻀﺮ‬ ٢. ‫ﻭﺷﺮيﻂ‬ ،(‫ﻋﻨﻬا‬ ‫ﹰ‬‫ﻻ‬‫ﺑد‬ ‫الﺸاﺵ‬ ‫اﺳﺘﺨداﻡ‬ ‫)ﳝﻜﻦ‬ ‫ﻧﻈيفة‬ ‫ﻣﻨﺸفة‬ ،‫الصﻐيﺮ‬ ‫الﺸاﺵ‬ ‫ﻣﻦ‬ ‫ﻋﺒﻮة‬ .‫الﻘﺜﻄاﺭ‬ ‫لﺘﺜﺒيﺖ‬ ‫ﻻﺻﻖ‬ ‫اﳌﻌﻘﻢ‬ ‫ﻭالصاﺑﻮﻥ‬ ‫الﻨﻈيﻒ‬ ‫اﳌاﺀ‬ ‫ﹰ‬‫ا‬‫ﻣﺴﺘﺨدﻣ‬ ‫الﺴﺖ‬ ‫اﳋﻄﻮاﺕ‬ ‫ﺑﻄﺮيﻘة‬ ‫يديﻚ‬ ‫اﻏﺴل‬ ٣. .‫اﳌﻄﻬﺮ‬ ‫الﺴاﺋل‬ ‫ﺃﻭ‬ .‫الﺒﻄﻦ‬ ‫ﺇلﻰ‬ ‫ﻣﺜﺒﺘﲔ‬ ‫الﺘﻮﺻيل‬ ‫ﻭﺟﻬاﺯ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﹰ‬‫ا‬‫ﺗاﺭﻛ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫اﻛﺸﻒ‬ ٤. ،‫ﻧزﻑ‬ ،‫ﺗﻮﺭﻡ‬ ،‫اﺣﻤﺮاﺭ‬ :‫)ﻣﺜاﻝ‬ ‫اﻻلﺘﻬاﺏ‬ ‫ﺃﻭ‬ ‫الﻌدﻭﻯ‬ ‫ﻋﻼﻣاﺕ‬ ‫ﻋﻦ‬ ‫ﹰ‬‫ا‬‫ﺑاﺣﺜ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫اﻓﺤﺺ‬ ٥. .(‫قيﺤﻲ‬ ‫ﳒيﺞ‬ ‫ﺃﻭ‬ ،‫قﺸﻮﺭ‬
  • ٣٣ ‫الصﻤاﻡ‬ ‫اﻓﺘﺢ‬ ‫ﺛﻢ‬ ،‫الﺘصﺮيﻒ‬ ‫ﺑﻜيﺲ‬ ‫اﳌﺘصل‬ ‫الﻮﺻلة‬ ‫ﻓﺮﻉ‬ ‫ﻋلﻰ‬ ‫اﳌﺸﺒﻚ‬ ‫ﺃﻏلﻖ‬ : ٥.‫ﺍﻟﺘﻌﺒﺌﺔ‬ ‫ﻫﺬا‬ ‫ﺳيﺴﺘﻐﺮﻕ‬ ،‫الﺒﻄﻦ‬ ‫ﲡﻮيﻒ‬ ‫ﺇلﻰ‬ ‫الﻌلﻮﻱ‬ ‫الﻜيﺲ‬ ‫ﻣﻦ‬ ‫ﺑالﺘدﻓﻖ‬ ‫اﳉديد‬ ‫للﻤﺤلﻮﻝ‬ ‫ﻭاﺳﻤﺢ‬ .‫دقيﻘة‬ ١٥ – ١٠ ‫ﺣﻮالﻲ‬ ٦.‫ﹰ‬‫ا‬‫ﺟديد‬ ‫ﹰ‬‫ا‬‫ﻭاقي‬‫ﹰ‬‫ا‬‫ﻏﻄاﺀ‬ ‫ﻭﺿﻊ‬ ‫الﺘﻮﺻيل‬ ‫ﺟﻬاﺯ‬ ‫ﻣﻦ‬ ‫الﻮﺻلة‬ ‫اﻓصل‬ ‫ﺛﻢ‬ ‫اللﻒ‬ ‫ﺻﻤاﻡ‬ ‫ﺃﻏلﻖ‬ :‫ﺍﻟﻔﺼﻞ‬ ‫ﺑﻘياﺱ‬ ‫ﻭقﻢ‬ ‫الﺘفﺮيﻎ‬ ‫ﻛيﺲ‬ ‫ﻓﻲ‬ ‫اﳌﻮﺟﻮد‬ ‫اﶈلﻮﻝ‬ ‫اﻓﺤﺺ‬ .‫ﳌﺴﻪ‬ ‫ﺑدﻭﻥ‬ ‫الﺘﻮﺻيل‬ ‫ﺟﻬاﺯ‬ ‫ﻃﺮﻑ‬ ‫ﻋلﻰ‬ ‫ﻣﻦ‬ ‫ﻭﺗﺨلﺺ‬ ،‫اﳌﺮﺣاﺽ‬ ‫ﻓﻲ‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫اﺳﻜﺐ‬ ‫ﺛﻢ‬ ،‫اﳌﺘاﺑﻌة‬ ‫دﻓﺘﺮ‬ ‫ﻓﻲ‬ ‫ﻭﺗﺴﺠيلﻬا‬ ‫ﻛﻤيﺘﻪ‬ .‫الﻨفاياﺕ‬ ‫ﺃﻛياﺱ‬ ‫ﻓﻲ‬ ‫اﳌﺴﺘﻌﻤلة‬ ‫اﻷدﻭاﺕ‬ ‫ﺍﻟﻘﺜﻄﺎﺭ‬ ‫ﲟﺨﺮﺝ‬ ‫ﺍﻟﻌﻨﺎﻳﺔ‬ :٨-٣ ‫لﺘﻘليل‬‫الﻮقﺖ‬‫ﻃﻮاﻝ‬‫الﺒﻄﻦ‬‫ﺇلﻰ‬‫ﺟيد‬‫ﺑﺸﻜل‬‫ﻣﺜﺒﺘﲔ‬‫الﺘﻮﺻيل‬‫ﻭﺟﻬاﺯ‬‫الﻘﺜﻄاﺭ‬‫يﻈل‬‫ﺃﻥ‬‫يﺠﺐ‬ • ‫ﺗﺜﺒيﺖ‬ ‫ﻋﻨد‬ .‫ﺑﺬلﻚ‬ ‫للﻘياﻡ‬ ‫ﹰ‬‫ا‬‫ﻣﺜﺒﺘ‬ ‫ﹰ‬‫ا‬‫ﺣزاﻣ‬ ‫يﺴﺘﺨدﻣﻮﻥ‬ ‫اﳌﺮﺿﻰ‬ ‫ﻭﺑﻌﺾ‬ ،‫للﺮﺿﻮﺽ‬ ‫ﺗﻌﺮﺿﻬﻤا‬ ‫اﺗصالﻪ‬ ‫ﻧﻘﻄة‬ ‫ﻋﻨد‬ ‫يﻨﺤﻦ‬ ‫ﻭلﻢ‬ ‫الﻄﺒيﻌﻲ‬ ‫ﺷﻜلﻪ‬ ‫ﺃﺧﺬ‬ ‫قد‬ ‫ﺃﻧﻪ‬ ‫ﻣﻦ‬ ‫الﺘﺄﻛد‬ ‫يﺠﺐ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺑالﺘﻬاﺏ‬ ‫اﻹﺻاﺑة‬ ‫اﺣﺘﻤاﻝ‬ ‫ﻣﻦ‬ ‫يزيد‬ ‫ﻭﻫﺬا‬ ‫الﻮقﺖ‬ ‫ﲟﺮﻭﺭ‬ ‫يﺘصدﻉ‬ ‫قد‬ ‫ﺃﻧﻪ‬ ‫ﺣيﺚ‬ ،‫الﺘﻮﺻيل‬ ‫ﺑﺠﻬاﺯ‬ .‫الصفاﻕ‬ ‫ﺗلﻮﺛﻪ‬ ‫لﺘﺠﻨﺐ‬ ‫ﻣﻜاﻧﻪ‬ ‫ﻓﻲ‬ ‫الصفاﻕ‬ ‫قﺜﻄاﺭ‬ ‫ﻭﺟﻮد‬ ‫ﺃﺛﻨاﺀ‬ ‫اﳊﻮﺽ‬ ‫ﻓﻲ‬ ‫اﻻﺳﺘﺤﻤاﻡ‬ ‫ﲡﻨﺐ‬ ‫يﺠﺐ‬ • ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫الدﺵ‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫اﻻﺳﺘﺤﻤاﻡ‬ ‫ﳝﻜﻦ‬ .‫اﳌاﺀ‬ ‫ﻓﻲ‬ ‫اﳌﻮﺟﻮدة‬ ‫ﺑاﳉﺮاﺛيﻢ‬ ‫ﺑﻌد‬ ‫ﲡفيفﻪ‬ ‫ﻭيﺘﻮﺟﺐ‬ ‫اﻻﺳﺘﺤﻤاﻡ‬ ‫ﺃﺛﻨاﺀ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻓﺮﻙ‬ ‫ﲡﻨﺐ‬ ‫يﺠﺐ‬ ‫ﻭلﻜﻦ‬ ،‫ﹰ‬‫ا‬‫ﲤاﻣ‬‫ﹰ‬‫ا‬‫ﻣلﺘﺌﻤ‬ .‫ﻧﻈيفة‬ ‫ﺷﺨصية‬ ‫ﻣﻨﺸفة‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫اﳉﺴﻢ‬ ‫ﺑاقﻲ‬ ‫قﺒل‬ ‫اﻻﺳﺘﺤﻤاﻡ‬ ‫ﻟﻠﺘﻮﺻﻴﻞ‬ ‫ﺍﻟﺼﺤﻴﺤﺔ‬ ‫ﺍﻟﻄﺮﻳﻘﺔ‬ :٧ ‫ﺷﻜﻞ‬
  • ٣٢ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻣﺤﻠﻮﻝ‬ ‫ﺗﺒﺪﻳﻞ‬ ‫ﺧﻄﻮﺍﺕ‬ :٧-٣ ‫ﺣيﻮاﻧاﺕ‬ ‫ﻭﺟﻮد‬ ‫ﻋدﻡ‬ ،‫ﻭاﳌﺮاﻭﺡ‬ ‫ﻭالﻨﻮاﻓﺬ‬ ‫اﻷﺑﻮاﺏ‬ ‫)ﺇﻏﻼﻕ‬ ‫اﳌﻜاﻥ‬ ‫ﻧﻈاﻓة‬ ‫ﻣﻦ‬ ‫ﺗﺄﻛد‬ : ١.‫ﺍﻻﺳﺘﻌﺪﺍﺩ‬ ‫ﺑاﳌاﺀ‬ ‫يديﻚ‬ ‫اﻏﺴل‬ ،‫ﻧﻈيفة‬ ‫ﻃاﻭلة‬ ‫ﻋلﻰ‬ ‫ﻛلﻬا‬ ‫اﻷدﻭاﺕ‬ ‫اﺟﻤﻊ‬ ،(‫اﳉيدة‬ ‫اﻹﺿاﺀة‬ ،‫الﻐﺮﻓة‬ ‫ﻓﻲ‬ ‫ﺃﺧﺮﺝ‬ ،‫ﻭاﻓﺤصﻪ‬ ‫الﻮاقﻲ‬ ‫الﻐﻼﻑ‬ ‫ﻣﻦ‬ ‫اﶈلﻮﻝ‬ ‫ﻛيﺲ‬ ‫ﺃﺧﺮﺝ‬ ،‫الﺴﺘة‬ ‫اﳋﻄﻮاﺕ‬ ‫ﺑﻄﺮيﻘة‬ ‫ﻭالصاﺑﻮﻥ‬ ‫ﺃﻏلﻖ‬ ،‫ﻃﺮﻓﻪ‬ ‫ﻓﻲ‬ ‫اﳌﻮﺟﻮد‬ ‫اللﻒ‬ ‫ﺻﻤاﻡ‬ ‫ﺇﻏﻼﻕ‬ ‫ﻣﻦ‬ ‫ﻭﺗﺄﻛد‬ ‫ﻣﻼﺑﺴﻚ‬ ‫ﺑﲔ‬ ‫ﻣﻦ‬ ‫الﺘﻮﺻيل‬ ‫ﺟﻬاﺯ‬ ‫ﻭادﻓﻊ‬ ‫الﻮاقية‬ ‫الﻘﻄﻌة‬ ‫اﻛﺴﺮ‬ ‫ﺛﻢ‬ ‫اﳉديد‬ ‫اﶈلﻮﻝ‬ ‫ﺑﻜيﺲ‬ ‫اﳌﺘصل‬ ‫الﻮﺻلة‬ ‫ﻓﺮﻉ‬ ‫ﻋلﻰ‬ ‫اﳌﺸﺒﻚ‬ .‫لفﺘﺤﻪ‬ ‫اﳉديد‬ ‫الﻜيﺲ‬ ‫داﺧل‬ ‫اﻷﻧﺒﻮﺏ‬ ‫ﺑيدﻙ‬ ‫ﻃﺮﻓﻬا‬ ‫ﻓﻲ‬ ‫اﳌﻮﺟﻮدة‬ ‫اﳊلﻘة‬ ‫ﻭاﺳﺤﺐ‬ ‫اليﻤﻨﻰ‬ ‫ﺑيدﻙ‬ ‫الﻮﺻلة‬ ‫ﻃﺮﻑ‬ ‫اﻣﺴﻚ‬ : ٢.‫ﺍﻟﺘﻮﺻﻴﻞ‬ ‫ﺑاﺳﺘﺨداﻡ‬ ‫الﻮاقﻲ‬ ‫الﻐﻄاﺀ‬ ‫ﻋﻨﻪ‬ ‫ﻭاﻧزﻉ‬ ‫اليﺴﺮﻯ‬ ‫ﺑيدﻙ‬ ‫الﺘﻮﺻيل‬ ‫ﺟﻬاﺯ‬ ‫اﻣﺴﻚ‬ ‫ﺛﻢ‬ ،‫اليﺴﺮﻯ‬ ‫ﺟﻬاﺯ‬ ‫ﺇلﻰ‬ ‫الﻮﺻلة‬ ‫ﺑﺘﺜﺒيﺖ‬ ‫قﻢ‬ ‫ﺫلﻚ‬ ‫ﺑﻌد‬ ،‫ﺑالﻮﺻلة‬ ‫ﳑﺴﻜة‬ ‫ﺯالﺖ‬ ‫ﻣا‬ ‫الﺘﻲ‬ ‫اليﻤﻨﻰ‬ ‫يدﻙ‬ ،‫ﺁﺧﺮ‬ ‫ﺷﻲﺀ‬ ‫ﺃﻱ‬ ‫ﺑلﻤﺲ‬ ‫ﻣﻨﻬﻤا‬ ‫ﻷﻱ‬ ‫ﺗﺴﻤﺢ‬ ‫ﺃﻥ‬ ‫دﻭﻥ‬ ‫اللﻒ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﻣﺤﻜﻤة‬ ‫ﺑصﻮﺭة‬ ‫الﺘﻮﺻيل‬ ‫ﻣﻦ‬ ‫اﳌلﻲﺀ‬ ‫الﻜيﺲ‬ ‫ﻋلﻖ‬ ‫ﺫلﻚ‬ ‫ﺑﻌد‬ ،‫ﺑاليﻮد‬ ‫اﳌﺸﺒﻊ‬ ‫الﺸاﺵ‬ ‫ﻣﻦ‬ ‫ﺑﻘﻄﻌة‬ ‫ﺑﺘﻐﻄيﺘﻬﻤا‬ ‫قﻢ‬ ‫ﺛﻢ‬ .(٧ ‫ﺷﻜل‬ ‫)اﻧﻈﺮ‬ ‫اﻷﺭﺽ‬ ‫ﻋلﻰ‬ ‫الفاﺭﻍ‬ ‫الﺘصﺮيﻒ‬ ‫ﻛيﺲ‬ ‫ﻭﺿﻊ‬ ‫ﻋالﻲ‬ ‫ﻣﻜاﻥ‬ ‫ﺇلﻰ‬ ‫الﺒﻄﻦ‬ ‫ﲡﻮيﻒ‬ ‫ﻣﻦ‬ ‫ﺑالﺘصﺮيﻒ‬ ‫الﻘدﱘ‬ ‫للﻤﺤلﻮﻝ‬ ‫ﻭاﺳﻤﺢ‬ ‫اللﻒ‬ ‫ﺻﻤاﻡ‬ ‫اﻓﺘﺢ‬ : ٣.‫ﺍﻟﺘﻔﺮﻳﻎ‬ .‫دقيﻘة‬ ٢٠ – ١٥ ‫ﺣﻮالﻲ‬ ‫ﻫﺬا‬ ‫ﺳيﺴﺘﻐﺮﻕ‬ ،‫الفاﺭﻍ‬ ‫الﻜيﺲ‬ ‫ﺑﻜيﺲ‬ ‫اﳌﺘصل‬ ‫الﻮﺻلة‬ ‫ﻓﺮﻉ‬ ‫ﻋلﻰ‬ ‫اﳌﺜﺒﺖ‬ ‫اﳌﺸﺒﻚ‬ ‫اﻓﺘﺢ‬ ‫ﺛﻢ‬ ،‫اللﻒ‬ ‫ﺻﻤاﻡ‬ ‫ﺃﻏلﻖ‬ : ٤.‫ﺍﻟﺸﻄﻒ‬ ‫اﳉديد‬ ‫اﶈلﻮﻝ‬ ‫ﻛيﺲ‬ ‫ﻣﻦ‬ ‫ﻣﺒاﺷﺮة‬ ‫ﺑالﺘدﻓﻖ‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﺑﺴيﻄة‬ ‫لﻜﻤية‬ ‫ﻭاﺳﻤﺢ‬ ‫اﳉديد‬ ‫اﶈلﻮﻝ‬ ‫ﺣﺘﻰ‬ ‫ﺑﺒﻂﺀ‬ ‫ﱠ‬‫د‬‫ﹸ‬‫ﻋ‬) ‫اﻷﻧﺒﻮﺏ‬ ‫ﻣﻦ‬ ‫ﺷﻮاﺋﺐ‬ ‫ﺃﻱ‬ ‫ﻃﺮيﻘﻬا‬ ‫ﻓﻲ‬ ‫ﺗﻐﺴل‬ ‫ﺑﺤيﺚ‬ ‫الﺘصﺮيﻒ‬ ‫ﻛيﺲ‬ ‫ﺇلﻰ‬ .(٥ ‫الﺮقﻢ‬ ‫ﺍﳌﺰﺩﻭﺝ‬ ‫ﺍﻟﻜﻴﺲ‬ ‫ﺗﻘﻨﻴﺔ‬ :٦ ‫ﺷﻜﻞ‬ ‫اﳉديد‬ ‫اﶈلﻮﻝ‬ ‫ﻛيﺲ‬ ‫الﻮﺻلة‬ ‫ﺫاﺕ‬ ‫الفﺮﻋﲔ‬ ‫الﺘصﺮيﻒ‬ ‫ﻛيﺲ‬ ‫ﺟﻬاﺯ‬ ‫الﺘﻮﺻيل‬ ‫الﻘﺜﻄاﺭ‬
  • ٣١ ‫ﺍﳌﺰﺩﻭﺝ‬ ‫ﺍﻟﻜﻴﺲ‬ ‫ﺗﻘﻨﻴﺔ‬ :٦-٣ ‫ﻃﺮﻓﻬا‬ ‫ﺗﺜﺒيﺖ‬ ‫يﺘﻢ‬ ‫ﹰ‬‫ا‬‫ﺳﻨﺘﻤﺘﺮ‬ •١٥ - ١٠ ‫ﻃﻮلﻬا‬ ‫قصيﺮة‬ ‫ﺃﻧﺒﻮﺑة‬ ‫ﻋﻦ‬ ‫ﻋﺒاﺭة‬ ‫ﻫﻮ‬ ‫الﺘﻮﺻيل‬ ‫ﺟﻬاﺯ‬ ‫اﳌﺮيﺾ‬ ‫ﻋلﻰ‬ ‫يﺴﻬل‬ ‫ﳑا‬ ‫ﺃﻃﻮﻝ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﻦ‬ ‫الﻈاﻫﺮ‬ ‫اﳉزﺀ‬ ‫يصﺒﺢ‬ ‫ﺣﺘﻰ‬ ‫الﺘيﺘاﻧيﻮﻡ‬ ‫ﻭﺻلة‬ ‫ﺇلﻰ‬ ‫يﺘﻌﺮﺽ‬ ‫قد‬ ‫الﺬﻱ‬ ‫الﻀﺮﺭ‬ ‫لﺘفادﻱ‬ ‫ﺃﺷﻬﺮ‬ ‫ﺳﺘة‬ ‫ﻛل‬ ‫اﳉﻬاﺯ‬ ‫ﻫﺬا‬ ‫ﺗﻐييﺮ‬ ‫ﻣﻦ‬ ‫ﻭﻻﺑد‬ ،‫ﻣﻌﻪ‬ ‫الﺘﻌاﻣل‬ ‫ﻭﻓﻲ‬ ‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫ﺇﺻاﺑة‬ ‫ﻛل‬ ‫ﺑﻌد‬ ‫ﺗﻐييﺮﻩ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ‫ﻛﻤا‬ ،‫اﳌﺘﻮاﺻل‬ ‫اﻻﺳﺘﺨداﻡ‬ ‫ﻣﻦ‬ ‫لﻪ‬ .‫ﺗلﻮﺛﻪ‬ ‫ﺣالة‬ ‫ﻛل‬ ‫ﺑﻨﻬاية‬ ‫يﺘصل‬ ‫ﻃﻮيلﲔ‬ ‫ﻓﺮﻋﲔ‬ ‫ﺫاﺕ‬ ‫قصيﺮة‬ ‫ﻭﺻلة‬ ‫ﻣﻦ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺃدﻭاﺕ‬ ‫ﺗﺘﻜﻮﻥ‬ • ‫ﻋﺒاﺭة‬ ‫ﻫﻮ‬ ‫الﺜاﻧﻲ‬ ‫ﻭالﻜيﺲ‬ ،‫اﳉديد‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻋلﻰ‬ ‫يﺤﺘﻮﻱ‬ ‫اﻷﻭﻝ‬ ‫الﻜيﺲ‬ ،‫ﻛيﺲ‬ ‫ﻣﻨﻬﻤا‬ .‫للﺘصﺮيﻒ‬ ‫ﻓاﺭﻍ‬ ‫ﻛيﺲ‬ ‫ﻋﻦ‬ ‫ﻣﻊ‬ ‫ﻏﻄاﺋﻪ‬ ‫ﺇﺯالة‬ ‫ﺑﻌد‬ ‫الﺘﻮﺻيل‬ ‫ﺟﻬاﺯ‬ ‫ﺑﻄﺮﻑ‬ ‫الﻮﺻلة‬ ‫ﻃﺮﻑ‬ ‫ﺗﺜﺒيﺖ‬ ‫يﺘﻢ‬ ‫اﶈلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﻋﻨد‬ • .‫ﺁﺧﺮ‬ ‫ﹰ‬‫ا‬‫ﺷيﺌ‬ ‫الﻄﺮﻓﲔ‬ ‫ﻣﻦ‬ ‫ﺃﻱ‬ ‫يلﻤﺲ‬ ‫ﻻ‬ ‫ﺃﻥ‬ ‫ﻣﺮاﻋاة‬ ‫الﺘﻮﺻيل‬ ‫ﺟﻬاﺯ‬ ‫ﻋﺒﺮ‬ ‫ﺑالﺘصﺮيﻒ‬ ‫الصفاﻕ‬ ‫ﲡﻮيﻒ‬ ‫داﺧل‬ ‫اﳌﻮﺟﻮد‬ ‫الﻘدﱘ‬ ‫للﻤﺤلﻮﻝ‬ ‫ﹰ‬‫ﻻ‬‫ﺃﻭ‬ ‫يﺴﻤﺢ‬ • .‫الفاﺭﻍ‬ ‫الﻜيﺲ‬ ‫ﺇلﻰ‬ ‫الفﺮﻋﲔ‬ ‫ﺫاﺕ‬ ‫ﻭالﻮﺻلة‬ ‫ﺫاﺕ‬ ‫الﻮﺻلة‬ ‫ﻋﺒﺮ‬ ‫ﺑالﺘدﻓﻖ‬ ‫اﳉديد‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﺻﻐيﺮة‬ ‫لﻜﻤية‬ ‫يﺴﻤﺢ‬ ‫ﺫلﻚ‬ ‫ﺑﻌد‬ • ‫ﻣﺮﻭﺭﻩ‬ ‫ﺃﺛﻨاﺀ‬ ‫يﻐﺴل‬ ‫ﺣﺘﻰ‬ ‫ﻭﺫلﻚ‬ ،‫ﻣﺒاﺷﺮة‬ ‫الﺘصﺮيﻒ‬ ‫ﻛيﺲ‬ ‫ﺇلﻰ‬ ‫اﳌﻤﺘلﺊ‬ ‫الﻜيﺲ‬ ‫ﻣﻦ‬ ‫الفﺮﻋﲔ‬ .‫الﻘﺜﻄاﺭ‬ ‫ﻃﺮﻑ‬ ‫ﻓﻲ‬ ‫ﻣﻮﺟﻮدة‬ ‫ﺗﻜﻮﻥ‬ ‫قد‬ ‫ﺟﺮاﺛيﻢ‬ ‫ﺃﻱ‬ ‫ﻋﺒﺮ‬ ‫الصفاﻕ‬ ‫ﲡﻮيﻒ‬ ‫ﺇلﻰ‬ ‫اﳉديد‬ ‫اﶈلﻮﻝ‬ ‫ﻛيﺲ‬ ‫ﻣﻦ‬ ‫ﺑالﺘدﻓﻖ‬ ‫للﻤﺤلﻮﻝ‬ ‫يﺴﻤﺢ‬ ‫ﺫلﻚ‬ ‫ﺑﻌد‬ • .‫الﺘﻮﺻيل‬ ‫ﻭﺟﻬاﺯ‬ ‫الفﺮﻋﲔ‬ ‫ﺫاﺕ‬ ‫الﻮﺻلة‬ ‫ﺗﻐﻄية‬ ‫ﻭﺗﺘﻢ‬ ‫الفﺮﻋﲔ‬ ‫ﺫاﺕ‬ ‫الﻮﺻلة‬ ‫ﻣﻦ‬ ‫الﺘﻮﺻيل‬ ‫ﺟﻬاﺯ‬ ‫فصل‬‫ﹸ‬‫ي‬ ‫اﶈلﻮﻝ‬ ‫ﺗدﻓﻖ‬ ‫اﻛﺘﻤاﻝ‬ ‫ﺑﻌد‬ • .‫ﻣﻌﻘﻢ‬ ‫ﺟديد‬ ‫ﺑﻐﻄاﺀ‬ ‫ﻃﺮﻓﻪ‬ ‫ﺟلﺴاﺕ‬ ‫ﺑﲔ‬ ‫الديلزة‬ ‫ﺃﻛياﺱ‬ ‫ﻣﻦ‬ ‫ﺑاﻻﻧفﻜاﻙ‬ ‫للﻤﺮيﺾ‬ ‫الفﺮﻋﲔ‬ ‫ﺫاﺕ‬ ‫الﻮﺻلة‬ ‫اﺳﺘﺨداﻡ‬ ‫يﺴﻤﺢ‬ • ‫ﺃﻣا‬ ،(disconnect system) ‫الفصل‬ ‫ﺑﺘﻘﻨية‬ ‫الﺘﻘﻨية‬ ‫ﻫﺬﻩ‬ ‫ﺳﻤيﺖ‬ ‫ﻭلﺬلﻚ‬ ،‫اﶈلﻮﻝ‬ ‫ﺗﺒديل‬ ‫الﺘصﺮيﻒ‬ ‫ﻛيﺲ‬ ‫ﻭاﺗصاﻝ‬ ‫الفﺮﻋﲔ‬ ‫ﺫاﺕ‬ ‫الﻮﺻلة‬ ‫ﺫﺭاﻋﻲ‬ ‫ﺑﺄﺣد‬ ‫اﳉديد‬ ‫اﶈلﻮﻝ‬ ‫ﻛيﺲ‬ ‫اﺗصاﻝ‬ ‫ﻫﺬاﻥ‬ ‫ﺃدﻯ‬ ‫ﻭقد‬ .(double-bag system) ‫اﳌزدﻭﺝ‬ ‫الﻜيﺲ‬ ‫ﺑﺘﻘﻨية‬ ‫ﻌﺮﻑ‬‫ﹸ‬‫ي‬‫ﻓ‬ ‫اﻵﺧﺮ‬ ‫ﺑفﺮﻋﻬا‬ .‫ﻛﺒيﺮة‬ ‫ﺑصﻮﺭة‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﻧﺴﺒة‬ ‫ﺗﻘليل‬ ‫ﺇلﻰ‬ ‫اﶈلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﺗﻘﻨية‬ ‫ﻓﻲ‬ ‫الﺘﻌديﻼﻥ‬ ‫ﻓﻲ‬ ‫للﺘﺤﻜﻢ‬ ‫ﻣﺨﺘلفة‬ ‫ﹰ‬‫ا‬‫ﻃﺮق‬ ‫الديلزة‬ ‫ﻭﺃدﻭاﺕ‬ ‫ﻣﺤاليل‬ ‫ﺑﺘﻮﻓيﺮ‬ ‫ﺗﻘﻮﻡ‬ ‫الﺘﻲ‬ ‫اﳌصاﻧﻊ‬ ‫ﺗﺴﺘﺨدﻡ‬ • ‫ﺑﺸﺮﻛة‬ ‫اﳋاﺹ‬ ‫اللﻒ‬ ‫ﺻﻤاﻡ‬ :‫)ﻣﺜاﻝ‬ ‫الﺘﻮﺻيل‬ ‫ﻭﺟﻬاﺯ‬ ‫الفﺮﻋﲔ‬ ‫ﺫاﺕ‬ ‫الﻮﺻلة‬ ‫ﻋﺒﺮ‬ ‫اﶈلﻮﻝ‬ ‫ﺗدﻓﻖ‬ .(٦ ‫ﺷﻜل‬ ‫)اﻧﻈﺮ‬ ‫ﻭاﺣد‬ ‫اﻷﺳاﺳﻲ‬ ‫اﳌﺒدﺃ‬ ‫ﺃﻥ‬ ‫ﺇﻻ‬ ،(‫ﻓﺮﺯﻧيﻮﺱ‬ ‫ﺑﺸﺮﻛة‬ ‫اﳋاﺹ‬ ‫ﻭالﻘﺮﺹ‬ ،‫ﺑاﻛﺴﺘﺮ‬
  • ٣٠ (٥ ‫ﺷﻜﻞ‬ ‫)ﺍﻧﻈﺮ‬ ‫ﺍﻟﻴﺪﻳﻦ‬ ‫ﻏﺴﻞ‬ ‫ﺧﻄﻮﺍﺕ‬ :٥-٣ .‫اﳉاﺭﻱ‬ ‫ﺑاﳌاﺀ‬ ‫يديﻚ‬ ‫ﻭﺑلل‬ ‫ﻭاﳋﻮاﰎ‬ ‫الﺴاﻋة‬ ‫اﻧزﻉ‬ ١. .‫الصاﺑﻮﻥ‬ ‫ﺑلﻮﺡ‬ ‫اﻓﺮﻛﻬﻤا‬ ‫ﺃﻭ‬ ‫يديﻚ‬ ‫ﻋلﻰ‬ ‫الﺴاﺋل‬ ‫الصاﺑﻮﻥ‬ ‫ﺑﻌﺾ‬ ‫ﺿﻊ‬ ٢. .( ٣.١ ‫)ﺧﻄﻮة‬ ‫ﹰ‬‫ا‬‫ﻣﻌ‬ ‫ﺑفﺮﻛﻬﻤا‬ ‫يديﻚ‬ ‫ﺭاﺣﺘﻲ‬ ‫ﻧﻈﻒ‬ .(٢ ‫)ﺧﻄﻮة‬ ‫اﻷﺻاﺑﻊ‬ ‫ﺗداﺧل‬ ‫ﻣﺮاﻋاة‬ ‫ﻣﻊ‬ ‫اﻷﺧﺮﻯ‬ ‫اليد‬ ‫ﺑﺒاﻃﻦ‬ ‫ﺑفﺮﻛﻪ‬ ‫يد‬ ‫ﻛل‬ ‫ﻇاﻫﺮ‬ ‫ﻧﻈﻒ‬ ٤. .( ٥.٣ ‫)ﺧﻄﻮة‬ ‫اﻷﺻاﺑﻊ‬ ‫ﻭﺣﻮﻝ‬ ‫ﺑﲔ‬ ‫ﻣا‬ ‫ﻧﻈﻒ‬ .( ٦.٤ ‫)ﺧﻄﻮة‬ ‫اﻷﺻاﺑﻊ‬ ‫ﺗﺸاﺑﻚ‬ ‫ﻣﻊ‬ ‫اﻷﺧﺮﻯ‬ ‫اليد‬ ‫ﺭاﺣة‬ ‫ﻓﻲ‬ ‫ﺑفﺮﻛﻬا‬ ‫يد‬ ‫ﻛل‬ ‫ﺃﺻاﺑﻊ‬ ‫ﻇاﻫﺮ‬ ‫ﻧﻈﻒ‬ .( ٧.٥ ‫)ﺧﻄﻮة‬ ‫ﻣﻀﻤﻮﻣة‬ ‫اﻷﺧﺮﻯ‬ ‫اليد‬ ‫ﺑﺮاﺣة‬ ‫ﺑفﺮﻛﻪ‬ ‫ﺇﺑﻬاﻡ‬ ‫ﻛل‬ ‫ﻧﻈﻒ‬ ( ٨.٦ ‫)ﺧﻄﻮة‬ ‫اﻷﺧﺮﻯ‬ ‫اليد‬ ‫ﺭاﺣة‬ ‫ﻓﻲ‬ ‫ﻣﻀﻤﻮﻣة‬ ‫ﺑفﺮﻛﻬا‬ ‫يد‬ ‫ﻛل‬ ‫ﺃﺻاﺑﻊ‬ ‫ﺃﻃﺮاﻑ‬ ‫ﻧﻈﻒ‬ .‫اﳉاﺭﻱ‬ ‫اﳌاﺀ‬ ‫ﲢﺖ‬‫ﹰ‬‫ا‬‫ﺟيد‬ ‫يديﻚ‬ ‫اﺷﻄﻒ‬ ٩. .‫ﻧﻈيفة‬ ‫ﻭﺭقية‬ ‫ﲟﻨﺸفة‬ ‫يديﻚ‬ ‫ﺟفﻒ‬ ١٠. .‫اﳌﻨﺸفة‬ ‫ﻧفﺲ‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫الصﻨﺒﻮﺭ‬ ‫ﺃﻏلﻖ‬ ١١. .‫الديلزة‬ ‫ﺃدﻭاﺕ‬ ‫ﺑﺨﻼﻑ‬ ‫ﹰ‬‫ا‬‫ﺷيﺌ‬ ‫ﺗلﻤﺲ‬ ‫ﻻ‬ ١٢. (‫ﺍﻷﻗﻞ‬ ‫ﻋﻠﻰ‬ ‫ﺛﺎﻧﻴﺔ‬ ٢٠-١٥ ‫ﳌﺪﺓ‬ ‫)ﺍﻓﺮﻙ‬ ‫ﺍﻟﻴﺪﻳﻦ‬ ‫ﻟﻐﺴﻞ‬ ‫ﺍﻟﺼﺤﻴﺤﺔ‬ ‫ﺍﻟﻄﺮﻳﻘﺔ‬ :٥ ‫ﺷﻜﻞ‬
  • ٢٩ ‫ﺍﻟﺘﻌﻘﻴﻢ‬ ‫ﺗﻘﻨﻴﺔ‬ :٤-٣ ‫ﻇﺮﻭﻑ‬ ‫ﲢﺖ‬ ‫اﺗﺨاﺫﻫا‬ ‫يﺘﻢ‬ ‫الﺘﻲ‬ ‫ﻭاﻹﺟﺮاﺀاﺕ‬ ‫اﻷﺳاليﺐ‬ ‫ﻣﺠﻤﻮﻋة‬ ‫ﻋﻦ‬ ‫ﻋﺒاﺭة‬ ‫ﻫﻲ‬ ‫الﺘﻌﻘيﻢ‬ ‫ﺗﻘﻨية‬ • .‫ﺑاﳉﺮاﺛيﻢ‬ ‫الﺘلﻮﺙ‬ ‫اﺣﺘﻤاﻝ‬ ‫ﺗﻘليل‬ ‫ﺑﻬدﻑ‬ ‫ﻣﻌيﻨة‬ ‫ﻣﺨﺮﺝ‬ ‫ﺃﻭ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﻊ‬ ‫الﺘﻌاﻣل‬ ‫ﻓيﻬا‬ ‫يﺘﻢ‬ ‫ﻣﺮة‬ ‫ﻛل‬ ‫ﻓﻲ‬ ‫الﺘﻌﻘيﻢ‬ ‫ﺑﺘﻘﻨية‬ ‫اﻻلﺘزاﻡ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • ‫ﺑﻄﺮيﻘة‬ ‫الﻌﻤل‬ ‫ﻣﻜاﻥ‬ ‫ﲢﻀيﺮ‬ ،‫ﺻﺤيﺤة‬ ‫ﺑصﻮﺭة‬ ‫اليديﻦ‬ ‫ﻏﺴل‬ ‫ﺫلﻚ‬ ‫ﻭيﺸﻤل‬ ،‫الﻘﺜﻄاﺭ‬ .‫ﺻﺤيﺤة‬ ‫ﺑﻄﺮيﻘة‬ ‫ﻭاﻷدﻭاﺕ‬ ‫اﶈاليل‬ ‫ﻣﻊ‬ ‫ﻭالﺘﻌاﻣل‬ ،‫ﺻﺤيﺤة‬ ‫ﻋلﻰ‬ ‫ﺛاﻧية‬ ‫ﻋﺸﺮة‬ ‫ﺧﻤﺲ‬ ‫ﳌدة‬ ‫اليداﻥ‬ ‫ﺗفﺮﻙ‬ ‫ﺃﻥ‬ ‫ﺻﺤيﺤة‬ ‫ﺑﻄﺮيﻘة‬ ‫اليديﻦ‬ ‫ﺑﻐﺴل‬ ‫ﻘصد‬‫ﹸ‬‫ي‬ • ‫ﻭالصاﺑﻮﻥ‬ ‫الﻨﻈيﻒ‬ ‫الصﻨﺒﻮﺭ‬ ‫ﻣاﺀ‬ ‫ﺑاﺳﺘﺨداﻡ‬ ‫ﺃدﻧاﻩ‬ ‫اﳌﻮﺿﺤة‬ ‫الﺴﺖ‬ ‫اﳋﻄﻮاﺕ‬ ‫ﺑﻄﺮيﻘة‬ ‫اﻷقل‬ ‫ﻓﻲ‬ ‫اﳌﻌﺒﺄ‬ ‫اﳌاﺀ‬ ‫اﺳﺘﺨداﻡ‬ ‫ﻓيﺠﺐ‬ ‫ﺑﺌﺮ‬ ‫ﻣصدﺭﻩ‬ ‫ﺃﻭ‬ ‫ﹰ‬‫ا‬‫ﻣلﻮﺛ‬ ‫الصﻨﺒﻮﺭ‬ ‫ﻣاﺀ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ .‫الﺴاﺋل‬ ‫اﳌﻄﻬﺮ‬ ‫اﺳﺘﺨداﻡ‬ ‫ﻓيﻤﻜﻦ‬ ‫الﺴاﺋل‬ ‫اﳌﻄﻬﺮ‬ ‫الصاﺑﻮﻥ‬ ‫يﺘﻮﻓﺮ‬ ‫لﻢ‬ ‫ﺇﺫا‬ .‫ﻋﻨﻪ‬ ‫ﹰ‬‫ﻻ‬‫ﺑد‬ ‫اﳌﻐلﻲ‬ ‫اﳌاﺀ‬ ‫ﺃﻭ‬ ‫ﺯﺟاﺟاﺕ‬ ‫ﻣﻄﻬﺮ‬ ‫ﺳاﺋل‬ ‫اﺳﺘﺨداﻡ‬ ‫ﻓيﻤﻜﻦ‬ ‫ﻭالصاﺑﻮﻥ‬ ‫اﳌاﺀ‬ ‫يﺘﻮﻓﺮ‬ ‫لﻢ‬ ‫ﺇﺫا‬ .‫ﻋﻨﻪ‬‫ﹰ‬‫ﻻ‬‫ﺑد‬ ‫اﳌﻄﻬﺮ‬ ‫الصاﺑﻮﻥ‬ ‫لﻮﺡ‬ .‫اﻷقل‬ ‫ﻋلﻰ‬ ٪٦٠ ‫ﺑﻨﺴﺒة‬ ‫الﻜﺤﻮﻝ‬ ‫ﻋلﻰ‬ ‫يﺤﺘﻮﻱ‬ ‫ﺑصﻮﺭة‬ ‫اليديﻦ‬ ‫لﺘﺒليل‬ ‫ﻛاﻓية‬ ‫ﻛﻤية‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ‫اﳌﻄﻬﺮ‬ ‫الﺴاﺋل‬ ‫اﺳﺘﺨداﻡ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ • ‫ﻋدﻡ‬ ‫ﻣﺮاﻋاة‬ ‫ﻣﻊ‬ ‫ﺃدﻧاﻩ‬ ‫اﳌﻮﺿﺤة‬ ‫الﺴﺖ‬ ‫اﳋﻄﻮاﺕ‬ ‫ﺑﻄﺮيﻘة‬ ‫اليديﻦ‬ ‫ﺗﻨﻈيﻒ‬ ‫ﺫلﻚ‬ ‫يﺘﺒﻊ‬ ،‫ﻛاﻣلة‬ ‫ﻋﺸﺮة‬ ‫ﺧﻤﺲ‬ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫ﻏﻀﻮﻥ‬ ‫ﻓﻲ‬ ‫اليداﻥ‬ ‫ﺟفﺖ‬ ‫ﺇﺫا‬ .‫اليديﻦ‬ ‫لﺘﺠفيﻒ‬ ‫اﳌﻨﺸفة‬ ‫اﺳﺘﺨداﻡ‬ .‫اﳌﻄﻬﺮ‬ ‫الﺴاﺋل‬ ‫ﻣﻦ‬ ‫ﻛاﻓية‬ ‫ﻛﻤية‬ ‫يﺴﺘﺨدﻡ‬ ‫لﻢ‬ ‫الﺸﺨﺺ‬ ‫ﺃﻥ‬ ‫يﻌﻨﻲ‬ ‫ﻓﻬﺬا‬ ‫ﺛاﻧية‬ ،‫ﻣﺮيﺾ‬ ‫ﻛل‬ ‫يﻨاﺳﺐ‬ ‫ﻣا‬ ‫ﺣﺴﺐ‬ ‫اﳌﻄﻬﺮة‬ ‫الﺴﻮاﺋل‬ ‫ﻣﻦ‬ ‫ﻣﺨﺘلفة‬ ‫ﺃﻧﻮاﻉ‬ ‫اﺳﺘﺨداﻡ‬ ‫اﳌﻤﻜﻦ‬ ‫ﻣﻦ‬ • .‫ﺑاﳉﺮاﺛيﻢ‬ ‫ﺗلﻮﺛﻪ‬ ‫ﻋﻨﻪ‬ ‫يﻨﺘﺞ‬ ‫قد‬ ‫ﻫﺬا‬ ‫ﻷﻥ‬ ‫ﺁﺧﺮ‬ ‫ﺇلﻰ‬ ‫ﻭﻋاﺀ‬ ‫ﻣﻦ‬ ‫اﳌﻄﻬﺮ‬ ‫الﺴاﺋل‬ ‫ﻧﻘل‬ ‫يﺠﻮﺯ‬ ‫ﻻ‬ ‫ﻭلﻜﻦ‬ ‫ﻣﻐلﻘة‬ ‫ﻧﻈيفة‬ ‫ﻏﺮﻓة‬ ‫ﻓﻲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﲟﺨﺮﺝ‬ ‫ﻭالﻌﻨاية‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﺗﺒديل‬ ‫يﺘﻢ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ • ‫يﺠﺐ‬ ‫ﻛﻤا‬ ،‫الﻐﺮﻓة‬ ‫ﻓﻲ‬ ‫ﺣيﻮاﻧاﺕ‬ ‫ﻭﺟﻮد‬ ‫ﻭﻋدﻡ‬ ‫اﳌﺮﻭﺣة‬ ‫ﺇﻏﻼﻕ‬ ‫ﻣﺮاﻋاة‬ ‫ﻣﻊ‬ ،‫ﻭالﻨﻮاﻓﺬ‬ ‫اﻷﺑﻮاﺏ‬ .‫ﻧﻈيفة‬ ‫ﻃاﻭلة‬ ‫ﻋلﻰ‬ ‫ﻭاﻷدﻭاﺕ‬ ‫اﶈاليل‬ ‫ﲢﻀيﺮ‬ ‫الﻘياﻡ‬ ‫ﺃﺛﻨاﺀ‬ ‫ﺷﻲﺀ‬ ‫ﺃﻱ‬ ‫الفﺮﻋﲔ‬ ‫ﺫاﺕ‬ ‫الﻮﺻلة‬ ‫ﻃﺮﻑ‬ ‫ﺃﻭ‬ ‫الﺘﻮﺻيل‬ ‫ﺟﻬاﺯ‬ ‫ﻃﺮﻑ‬ ‫يلﻤﺲ‬ ‫ﻻ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ • ‫الﺘﻬاﺏ‬ ‫ﺇلﻰ‬ ‫ﺗﺆدﻱ‬ ‫قد‬ ‫ﺑﺠﺮاﺛيﻢ‬ ‫اﳉزﺀ‬ ‫ﺫلﻚ‬ ‫ﺗلﻮﺙ‬ ‫يﻌﻨﻲ‬ ‫اللﻤﺲ‬ ‫ﺃﻥ‬ ‫ﺇﺫ‬ ،‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﺑﺘﺒديل‬ ‫ﺗلﻮﺙ‬ ‫ﺇﺫا‬ ‫ﺃﻣا‬ ،‫اﳌزدﻭﺝ‬ ‫الﻜيﺲ‬ ‫ﺗﻐييﺮ‬ ‫ﻣﻦ‬ ‫ﻓﻼﺑد‬ ‫الفﺮﻋﲔ‬ ‫ﺫاﺕ‬ ‫الﻮﺻلة‬ ‫ﻃﺮﻑ‬ ‫ﺗلﻮﺙ‬ ‫ﺇﺫا‬ .‫الصفاﻕ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ ‫ﻛﻤا‬ ،‫لﺘﻐييﺮﻩ‬ ‫الديلزة‬ ‫ﻣﺮﻛز‬ ‫ﺇلﻰ‬‫ﹰ‬‫ا‬‫ﻓﻮﺭ‬ ‫اﳌﺮيﺾ‬ ‫ﺣﻀﻮﺭ‬ ‫ﻣﻦ‬ ‫ﻓﻼﺑد‬ ‫الﺘﻮﺻيل‬ ‫ﺟﻬاﺯ‬ ‫ﻃﺮﻑ‬ .‫يﻮﻣﲔ‬ ‫ﳌدة‬ ‫اﺗﻘاﺋﻲ‬ ‫ﺣيﻮﻱ‬ ‫ﻣﻀاد‬ ‫لﻪ‬ ‫يﻮﺻﻒ‬ ‫ﻋلﻰ‬ ‫اليﻮد‬ ‫ﺑﻌﺾ‬ ‫ﻭﺿﻊ‬ ‫ﻓيﺠﺐ‬ ،‫اﶈلﻮﻝ‬ ‫ﺑﻜيﺲ‬ ‫اﻷدﻭية‬ ‫ﻣﻨفﺬ‬ ‫ﻋﺒﺮ‬ ‫دﻭاﺀ‬ ‫ﺣﻘﻦ‬ ‫ﺇلﻰ‬ ‫اﺣﺘيﺞ‬ ‫ﺇﺫا‬ • ‫اﶈﻘﻨة‬ ‫لﻄﺮﻑ‬ ‫الﺴﻤاﺡ‬ ‫ﻋدﻡ‬ ‫يﺠﺐ‬ ‫ﻛﻤا‬ ،‫الدﻭاﺀ‬ ‫ﺣﻘﻦ‬ ‫قﺒل‬ ‫يﺠﻒ‬ ‫ﺣﺘﻰ‬ ‫ﻭاﻧﺘﻈاﺭﻩ‬ ‫اﻷدﻭية‬ ‫ﻣﻨفﺬ‬ .‫ﺁﺧﺮ‬ ‫ﺷﻲﺀ‬ ‫ﺃﻱ‬ ‫ﺑلﻤﺲ‬
  • ٢٨ ‫ﺍﻟﺘﺪﺭﻳﺒﻴﺔ‬ ‫ﻟﻠﻔﺘﺮﺓ‬ ‫ﺍﳌﻘﺘﺮﺡ‬ ‫ﺍﳌﻨﻬﺞ‬ :٥ ‫ﺟﺪﻭﻝ‬ ‫ﺍﻟﻴﻮﻡ‬ ‫ﺍﻷﻭﻝ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻭﺃﺟزاﺀ‬ ‫الصفاقية‬ ‫للديلزة‬ ‫اﻷﺳاﺳية‬ ‫اﳌﺒادﺉ‬ ‫ﺗﻮﺿيﺢ‬ ‫لﻼﺳﺘﺤﻤاﻡ‬ ‫الصﺤيﺤة‬ ‫ﻭالﻄﺮيﻘة‬ ،‫اﳌﻜاﻥ‬ ‫ﻭﻧﻈاﻓة‬ ،‫الﺸﺨصية‬ ‫الﻨﻈاﻓة‬ ‫ﺃﻫﻤية‬ ‫ﺗﻮﺿيﺢ‬ ‫اليديﻦ‬ ‫لﻐﺴل‬ ‫الصﺤيﺤة‬ ‫الﻄﺮيﻘة‬ ‫ﻋﺮﺽ‬ ‫اﶈلﻮﻝ‬ ‫لﺘﺒديل‬ ‫الصﺤيﺤة‬ ‫الﻄﺮيﻘة‬ ‫ﻋﺮﺽ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﲟﺨﺮﺝ‬ ‫لﻼﻫﺘﻤاﻡ‬ ‫الصﺤيﺤة‬ ‫الﻄﺮيﻘة‬ ‫ﻋﺮﺽ‬ ‫ﺍﻟﻴﻮﻡ‬ ‫ﺍﻟﺜﺎﻧﻲ‬ ‫اﳌﺮيﺾ‬ ‫ﺣياة‬ ‫ﳕﻂ‬ ‫ﻋلﻰ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺗﺄﺛيﺮ‬ ‫ﻣﻨاقﺸة‬ ‫للﻤﺮيﺾ‬ ‫اﳌﻨاﺳﺐ‬ ‫الﻐﺬاﺋﻲ‬ ‫الﻨﻤﻂ‬ ‫ﺗﻮﺿيﺢ‬ ‫اليديﻦ‬ ‫لﻐﺴل‬ ‫الﻌﻤلﻲ‬ ‫الﺘﻄﺒيﻖ‬ ‫اﶈلﻮﻝ‬ ‫لﺘﺒديل‬ ‫الﻌﻤلﻲ‬ ‫الﺘﻄﺒيﻖ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﲟﺨﺮﺝ‬ ‫للﻌﻨاية‬ ‫الﻌﻤلﻲ‬ ‫الﺘﻄﺒيﻖ‬ ‫ﺍﻟﻴﻮﻡ‬ ‫ﺍﻟﺜﺎﻟﺚ‬ ‫الﺴﺠل‬ ‫ﻓﻲ‬ ‫اﳌﻌلﻮﻣاﺕ‬ ‫ﺗﺴﺠيل‬ ‫ﻃﺮيﻘة‬ ‫ﺗﻮﺿيﺢ‬ ‫الﻮﺯﻥ‬ ‫قياﺱ‬ ‫ﻃﺮيﻘة‬ ‫ﺗﻮﺿيﺢ‬ ‫اﻹﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫ﺣﻘﻦ‬ ‫ﻃﺮيﻘة‬ ‫ﺗﻮﺿيﺢ‬ ‫اليديﻦ‬ ‫لﻐﺴل‬ ‫الﻌﻤلﻲ‬ ‫الﺘﻄﺒيﻖ‬ ‫اﶈلﻮﻝ‬ ‫لﺘﺒديل‬ ‫الﻌﻤلﻲ‬ ‫الﺘﻄﺒيﻖ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﲟﺨﺮﺝ‬ ‫للﻌﻨاية‬ ‫الﻌﻤلﻲ‬ ‫الﺘﻄﺒيﻖ‬ ‫ﺍﻟﻴﻮﻡ‬ ‫ﺍﻟﺮﺍﺑﻊ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﺫلﻚ‬ ‫ﻓﻲ‬ ‫ﲟا‬ ،‫ﻣﻌﻬا‬ ‫الﺘﻌاﻣل‬ ‫ﻭﻃﺮيﻘة‬ ‫اﶈﺘﻤلة‬ ‫اﳌﺸاﻛل‬ ‫ﺗﻮﺿيﺢ‬ ‫اﻹﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫ﻭﺣﻘﻦ‬ ،‫الﺴﺠل‬ ‫ﻓﻲ‬ ‫اﳌﻌلﻮﻣاﺕ‬ ‫ﻭﺗﺴﺠيل‬ ،‫الﻮﺯﻥ‬ ‫قياﺱ‬ ‫ﻃﺮيﻘة‬ ‫ﻣﺮاﺟﻌة‬ ‫اليديﻦ‬ ‫لﻐﺴل‬ ‫الﻌﻤلﻲ‬ ‫الﺘﻄﺒيﻖ‬ ‫اﶈلﻮﻝ‬ ‫لﺘﺒديل‬ ‫الﻌﻤلﻲ‬ ‫الﺘﻄﺒيﻖ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﲟﺨﺮﺝ‬ ‫للﻌﻨاية‬ ‫الﻌﻤلﻲ‬ ‫الﺘﻄﺒيﻖ‬ ‫ﺍﻟﻴﻮﻡ‬ ‫ﺍﳋﺎﻣﺲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﲟﺨﺮﺝ‬ ‫ﻭالﻌﻨاية‬ ،‫اﶈلﻮﻝ‬ ‫ﻭﺗﺒديل‬ ،‫اليديﻦ‬ ‫ﻏﺴل‬ ‫ﻓﻲ‬ ‫اﳌﺮيﺾ‬ ‫ﻛفاﺀة‬ ‫ﻣﻦ‬ ‫الﺘﺄﻛد‬ ‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﺗﻌﻜﺮ‬ ‫ﹰ‬‫ا‬‫ﺧصﻮﺻ‬ ،‫اﶈﺘﻤلة‬ ‫اﳌﺸاﻛل‬ ‫ﻣﻊ‬ ‫الﺘﻌاﻣل‬ ‫لﻄﺮيﻘة‬ ‫اﳌﺮيﺾ‬ ‫ﻓﻬﻢ‬ ‫ﻣﻦ‬ ‫الﺘﺄﻛد‬ ‫اﳌﺮيﺾ‬ ‫يﺘﻨاﻭلﻬا‬ ‫الﺘﻲ‬ ‫اﻷدﻭية‬ ‫ﻣﺮاﺟﻌة‬ ‫اﶈاليل‬ ‫ﻃلﺐ‬ ‫ﻛيفية‬ ‫ﺗﻮﺿيﺢ‬ ‫الﻄﻮاﺭﺉ‬ ‫ﺣاﻻﺕ‬ ‫ﻓﻲ‬ ‫الديلزة‬ ‫ﲟﺮﻛز‬ ‫اﻻﺗصاﻝ‬ ‫ﻛيفية‬ ‫ﺗﻮﺿيﺢ‬ ‫للﻌيادة‬ ‫اﳊﻀﻮﺭ‬ ‫ﻣﻮاﻋيد‬ ‫ﺗﻮﺿيﺢ‬
  • ٢٧ ،‫الﺘلﻮﺙ‬ :‫ﻋﻨﻬا‬ ‫ﻭاﻹﺑﻼﻍ‬ ‫الﺘالية‬ ‫اﳌﺸاﻛل‬ ‫ﻋلﻰ‬ ‫الﺘﻌﺮﻑ‬ ‫ﻋلﻰ‬ ‫اﳌﺮيﺾ‬ ‫ﺗدﺭيﺐ‬ ‫يﺘﻢ‬ ‫ﺃﻥ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • ‫الﺴﻮاﺋل‬ ‫اﺣﺘﺒاﺱ‬ ،‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﻛﻤية‬ ‫ﻧﻘصاﻥ‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋدﻭﻯ‬ ،‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﺗﻌﻜﺮ‬ ‫الداﺧل‬ ‫اﶈلﻮﻝ‬ ‫ﺗدﻓﻖ‬ ‫ﺿﻌﻒ‬ ،‫الﺴﻮاﺋل‬ ‫ﻓﻘداﻥ‬ ،(‫الﻨفﺲ‬ ‫ﻭﺿيﻖ‬ ،‫الﻜاﺣل‬ ‫ﺗﻮﺭﻡ‬ ،‫الﻮﺯﻥ‬ ‫)ﺯيادة‬ .‫ﻭاﻹﻣﺴاﻙ‬ ،‫اﶈلﻮﻝ‬ ‫ﺗﺴﺮﺏ‬ ،‫اﳋاﺭﺝ‬ ‫اﶈلﻮﻝ‬ ‫ﻓﻲ‬ ‫ﻓيﺒﺮيﻦ‬ ‫ﻭﺟﻮد‬ ،‫اﳋاﺭﺝ‬ ‫ﺃﻭ‬ ‫ﺗﺴﺠيل‬‫ﻭﻃﺮيﻘة‬،‫لﺘﺨزيﻨﻬا‬‫الصﺤيﺤة‬‫ﻭالﻄﺮيﻘة‬،‫اﶈاليل‬‫ﻃلﺐ‬‫ﺁلية‬‫اﳌﺮيﺾ‬‫يفﻬﻢ‬‫ﺃﻥ‬‫يﺠﺐ‬ • .‫الﻄﻮاﺭﺉ‬ ‫ﺣاﻻﺕ‬ ‫ﻓﻲ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺑفﺮيﻖ‬ ‫اﻻﺗصاﻝ‬ ‫ﻭﻃﺮيﻘة‬ ،‫الﺴﺠل‬ ‫ﻓﻲ‬ ‫اﳌﻌلﻮﻣاﺕ‬ ‫قد‬ ‫الﺬﻱ‬ ‫الﻘلﻖ‬ ‫ﻭﻣﻌاﳉة‬ ‫اﳌﺮيﺾ‬ ‫ﺗﺴاﺅﻻﺕ‬ ‫ﻋلﻰ‬ ‫لﻺﺟاﺑة‬ ‫الﺘدﺭيﺐ‬ ‫ﻓﺘﺮة‬ ‫ﻣﻦ‬ ‫اﻻﺳﺘفادة‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • ،‫اﳌﺮيﺾ‬ ‫ﻭﺯﻥ‬ ‫ﻭﺗﻘديﺮ‬ ،‫الصﺤيﺤة‬ ‫ﺑالﺘﻐﺬية‬ ‫اﳌﺘﻌلﻘة‬ ‫الﻨصاﺋﺢ‬ ‫ﺗﻘدﱘ‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ ،‫ﺑﻪ‬ ‫يﺸﻌﺮ‬ .‫ﻣﻨﺘﻈﻤة‬ ‫ﺑصﻮﺭة‬ ‫يﺘﻨاﻭلﻬا‬ ‫الﺘﻲ‬ ‫اﻷدﻭية‬ ‫ﻭﻣﺮاﺟﻌة‬ ‫الصفاقية‬ ‫ﺑالديلزة‬ ‫اﳌﺘﻌلﻘة‬ ‫اﻹﺭﺷادية‬ ‫الﻜﺘيﺒاﺕ‬ ‫ﺃﻭ‬ ‫الﻨﺸﺮاﺕ‬ ‫ﺑﺒﻌﺾ‬ ‫اﳌﺮيﺾ‬ ‫ﺇﻣداد‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • .‫الﻀﺮﻭﺭة‬ ‫ﻋﻨد‬ ‫ﺇليﻬا‬ ‫للﺮﺟﻮﻉ‬ ،‫الﺘدﺭيﺐ‬ ‫ﻓﺘﺮة‬ ‫اﻛﺘﻤاﻝ‬ ‫ﺑﻌد‬ ‫ﺑفﺘﺮة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻭﺑدﺀ‬ ‫الﺘدﺭيﺐ‬ ‫ﻓﺘﺮة‬ ‫اﻧﺘﻬاﺀ‬ ‫ﺑﻌد‬ ‫ﻣﻨزلﻪ‬ ‫ﻓﻲ‬ ‫اﳌﺮيﺾ‬ ‫ﺯياﺭة‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • .‫لﺬلﻚ‬ ‫اﳊاﺟة‬ ‫دﻋﺖ‬ ‫ﺇﺫا‬ ‫الزياﺭة‬ ‫ﺗﻜﺮاﺭ‬ ‫ﻣﺮاﻋاة‬ ‫ﻣﻊ‬ ،‫اﳌﻨزلية‬ ‫ﻭﺑيﺌﺘﻪ‬ ‫اﳌﺮيﺾ‬ ‫ﺃداﺀ‬ ‫لﺘﻘييﻢ‬ ‫ﻭﺟيزة‬ ‫ﺣاﺟة‬ ‫ﺣﺴﺐ‬ ‫ﺫلﻚ‬ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫ﺃﻭ‬ ‫ﺃﺷﻬﺮ‬ •٣ – ١ ‫ﻛل‬ ‫الدﻭﺭية‬ ‫اﳌﺘاﺑﻌة‬ ‫ﻣﻮاﻋيد‬ ‫ﲢديد‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ .‫الﻼﺯﻣة‬ ‫اﳌﻌﻤلية‬ ‫الفﺤصﻮﺻاﺕ‬ ‫ﻭﺇﺟﺮاﺀ‬ ‫ﺣالﺘﻪ‬ ‫ﺗﻘييﻢ‬ ‫ﺑﻬدﻑ‬ ،‫اﳌﺮيﺾ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﺃﺩﻭﺍﺕ‬ :٤ ‫ﺷﻜﻞ‬ ‫الفﺮﻋﲔ‬ ‫ﺫاﺕ‬ ‫الﻮﺻلة‬ ‫اﳌزدﻭﺝ‬ ‫ﻭالﻜيﺲ‬ ‫اﳌﺸﺒﻚ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻭﺻلة‬ ‫الﺘيﺘاﻧيﻮﻡ‬ ‫ﺟﻬاﺯ‬ ‫الﺘﻮﺻيل‬
  • ٢٦ ‫ﺍﳌﺮﻳﺾ‬ ‫ﺗﺪﺭﻳﺐ‬ :٣ ‫ﻓﺼﻞ‬ ‫ﺍﻷﻫﺪﺍﻑ‬ :١-٣ ‫ﻋلﻰ‬ ‫الﺘﺮﻛيز‬ ‫ﻣﻊ‬ ،‫ﺮﺿية‬‫ﹸ‬‫ﻣ‬ ‫ﺑصﻮﺭة‬ ‫اﳌﺮيﺾ‬ ‫لﺘدﺭيﺐ‬ ‫اﳌﻬﻤة‬ ‫اﳉﻮاﻧﺐ‬ ‫ﺟﻤيﻊ‬ ‫ﺗﻐﻄية‬ ‫ﻣﻦ‬ ‫الﺘﺄﻛد‬ • .‫الصفاقية‬ ‫الديلزة‬ ‫ﻓﺮيﻖ‬ ‫ﻓﻲ‬ ‫ﻛﻌﻀﻮ‬ ‫للﻤﺮيﺾ‬ ‫الفاﻋل‬ ‫الدﻭﺭ‬ ‫ﺍﻟﺘﺪﺭﻳﺐ‬ ‫ﻣﺘﻄﻠﺒﺎﺕ‬ :٢-٣ ‫ﺑدﺀ‬ ‫قﺒل‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺳالﻜية‬ ‫ﻣﻦ‬ ‫الﺘﺄﻛد‬ ‫يﺘﻢ‬ ‫ﻭﺃﻥ‬ ،‫ﹰ‬‫ا‬‫ﲤاﻣ‬ ‫الﺘﺄﻡ‬ ‫قد‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ • .‫قليلة‬ ‫ﺑﺄياﻡ‬ ‫الﺘدﺭيﺐ‬ ‫ﺑﻨﺴﺒة‬ ‫الﺘدﺭيﺐ‬ ‫يﺘﻢ‬ ‫ﺃﻥ‬ ‫ﻣﺮاﻋاة‬ ‫ﻣﻊ‬ ،‫اﻻﺯدﺣاﻡ‬ ‫ﻋﻦ‬ ‫ﺑﻌيد‬ ‫ﻣﻜاﻥ‬ ‫للﺘدﺭيﺐ‬ ‫يﺨصﺺ‬ ‫ﺃﻥ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • ‫اﳌﻤﺮﺽ‬ ‫ﻧفﺲ‬ ‫الﻮاﺣد‬ ‫اﳌﺮيﺾ‬ ‫ﺑﺘدﺭيﺐ‬ ‫يلﺘزﻡ‬ ‫ﻭﺃﻥ‬ (‫ﻣﺮيﺾ‬ ‫لﻜل‬ ‫ﻭاﺣد‬ ‫)ﻣدﺭﺏ‬ ‫ﻭاﺣد‬ ‫ﺇلﻰ‬ ‫ﻭاﺣد‬ .‫الﺘدﺭيﺐ‬ ‫ﻓﺘﺮة‬ ‫ﻃﻮاﻝ‬ ‫الديلزة‬ ‫ﻓﺮيﻖ‬ ‫ﻓﻲ‬ ‫ﻛﻌﻀﻮ‬ ‫للﻤﺮيﺾ‬ ‫الفاﻋل‬ ‫الدﻭﺭ‬ ‫ﻹﺑﺮاﺯ‬ ‫الﺘدﺭيﺐ‬ ‫ﻓﺘﺮة‬ ‫ﻣﻦ‬ ‫اﻻﺳﺘفادة‬ ‫يﺠﺐ‬ • .‫الديلزة‬ ‫لﻨﺠاﺡ‬ ‫اﻷﺳاﺱ‬ ‫ﺣﺠﺮ‬ ‫ﻫﻮ‬ ‫ﻓﻬﺬا‬ ،‫الصفاقية‬ ‫ﺍﳌﺮﻳﺾ‬ ‫ﻟﺘﺪﺭﻳﺐ‬ ‫ﺍﳌﻬﻤﺔ‬ ‫ﺍﳉﻮﺍﻧﺐ‬ :٣-٣ ‫ﻭﳝﻜﻦ‬ ،‫ﻭﻧصﻒ‬ ‫ﺳاﻋة‬ ‫ﻣﻨﻬا‬ ‫ﻛل‬ ‫ﻣدة‬ ‫ﺟلﺴاﺕ‬ ‫ﺧﻤﺲ‬ ‫ﺇلﻰ‬ ‫الﺘدﺭيﺐ‬ ‫ﻓﺘﺮة‬ ‫ﺗﻘﺴيﻢ‬ ‫يﺴﺘﺤﺴﻦ‬ • ‫الديلزة‬ ‫ﺑﻌﻤلية‬ ‫الﻘياﻡ‬ ‫ﻋلﻰ‬ ‫اﳌﺮيﺾ‬ ‫قدﺭة‬ ‫ﻣﻦ‬ ‫الديلزة‬ ‫ﻓﺮيﻖ‬ ‫يﻄﻤﺌﻦ‬ ‫ﺣﺘﻰ‬ ‫الﺘدﺭيﺐ‬ ‫ﻓﺘﺮة‬ ‫ﲤديد‬ .(٥ ‫ﺟدﻭﻝ‬ ‫)اﻧﻈﺮ‬ ‫ﺗاﻡ‬ ‫ﻭاﺳﺘﻘﻼﻝ‬ ‫ﻣﺮﺿية‬ ‫ﺑصﻮﺭة‬ ،‫الﺸﺨصية‬ ‫ﻭالﻨﻈاﻓة‬ ،‫الﺘﻌﻘيﻢ‬ ‫ﺑﺘﻘﻨية‬ ‫اﻻلﺘزاﻡ‬ ‫ﺃﻫﻤية‬ ‫ﻋلﻰ‬ ‫اﳌﺴﺘﻤﺮ‬ ‫الﺘﺄﻛيد‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • .‫اﻷﻭقاﺕ‬ ‫ﺟﻤيﻊ‬ ‫ﻓﻲ‬ ‫اﻷﻇاﻓﺮ‬ ‫ﺑﺘﻘليﻢ‬ ‫ﻭالﻌﻨاية‬ ‫ﺑالصﻮﺭ‬ ‫اﻻﺳﺘﻌاﻧة‬ ‫ﻣﻊ‬ ‫للﻤﺮيﺾ‬ ‫الصفاقية‬ ‫للديلزة‬ ‫اﻷﺳاﺳية‬ ‫اﳌﺒادﺉ‬ ‫ﺗﻮﺿيﺢ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • ،‫الﺘﻮﺻيل‬‫ﺟﻬاﺯ‬،‫الﻘﺜﻄاﺭ‬‫ﺃﺟزاﺀ‬‫ﻣﻦ‬‫ﺟزﺀ‬‫ﻛل‬‫ﻭﻭﻇيفة‬‫اﺳﻢ‬‫ﺫلﻚ‬‫ﻓﻲ‬‫ﲟا‬،‫الﺘﻮﺿيﺤية‬‫ﻭالﺮﺳﻮﻡ‬ .(٤ ‫ﺷﻜل‬ ‫)اﻧﻈﺮ‬ ‫الديلزة‬ ‫ﶈلﻮﻝ‬ ‫اﺨﻤﻟﺘلفة‬ ‫ﻭالﺘﺮاﻛيز‬ ،‫الفﺮﻋﲔ‬ ‫ﺫاﺕ‬ ‫الﻮﺻلة‬ ،‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﻭﻃﺮيﻘة‬ ،‫اليديﻦ‬ ‫ﻏﺴل‬ ‫ﻃﺮيﻘة‬ ‫ﻋلﻰ‬ ‫اﳌﺮيﺾ‬ ‫ﺗدﺭيﺐ‬ ‫يﺘﻢ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ • ‫للﻤﺮيﺾ‬ ‫يﻮﺿﺢ‬ ‫ﺃﻥ‬ ‫ﻣﺮاﻋاة‬ ‫ﻣﻊ‬ ،‫الصﺤيﺤة‬ ‫اﳋﻄﻮاﺕ‬ ‫ﺣﺴﺐ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﲟﺨﺮﺝ‬ ‫الﻌﻨاية‬ ‫ﻭﻃﺮيﻘة‬ .‫ﺑﻬا‬ ‫اﳌﻮﺻﻰ‬ ‫ﺑاﳋﻄﻮاﺕ‬ ‫الدقيﻖ‬ ‫لﻼلﺘزاﻡ‬ ‫الﻘصﻮﻯ‬ ‫اﻷﻫﻤية‬ ‫ﹴ‬‫ﻛاﻑ‬ ‫ﺑﺸﻜل‬ ‫ﻋلﻰ‬ ‫اﻵلية‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺗﻘﻨية‬ ‫ﺳيﺴﺘﺨدﻡ‬ ‫الﺬﻱ‬ ‫اﳌﺮيﺾ‬ ‫ﺗدﺭيﺐ‬ ‫يﺸﺘﻤل‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ • ،‫اﻵلة‬ ‫ﻭﺿﺒﻂ‬ ‫ﺗﻨﻈيﻒ‬ ‫ﳝﻜﻨﻪ‬ ‫ﻛيﻒ‬ ،‫دﻭﺭة‬ ‫ﻛل‬ ‫ﻓﻲ‬ ‫اﻷﺣداﺙ‬ ‫ﺗﺴلﺴل‬ ،‫اﻵلة‬ ‫ﺃﺟزاﺀ‬ ‫ﻣﻌﺮﻓة‬ .‫لﻺﻧﺬاﺭاﺕ‬ ‫يﺴﺘﺠيﺐ‬ ‫ﻭﻛيﻒ‬ ،‫ديلزة‬ ‫ﺟلﺴة‬ ‫ﻛل‬ ‫ﻭﻧﻬاية‬ ‫ﺑداية‬ ‫ﻓﻲ‬ ‫ﻭالفصل‬ ‫الﺘﻮﺻيل‬ ‫ﻛيفية‬
  • ٢٥ ‫ﺍﻟﻔﺼﻞ‬ ‫ﻫﺬﺍ‬ ‫ﻓﻲ‬ ‫ﺫﻛﺮﺕ‬ ‫ﺃﺩﻭﻳﺔ‬ :٤ ‫ﺟﺪﻭﻝ‬ ‫ﺍﻟﺪﻭﺍﺀ‬ ‫ﺍﺳﻢ‬‫ﺍﻟﺘﺮﻛﻴﺒﺔ‬‫ﺍﳉﺮﻋﺔ‬ ‫ﺳفاﺯﻭلﲔ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬(‫اﺗﻘاﺋية‬ ‫)ﺟﺮﻋة‬ ‫ﻭاﺣد‬ ‫ﻏﻢ‬ ‫ﺳفيﻮﺭﻭﻛﺴيﻢ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬(‫اﺗﻘاﺋية‬ ‫)ﺟﺮﻋة‬ ‫ﻣلﻎ‬ ٧٥٠ ‫ديﻜلﻮﻓيﻨاﻙ‬(‫)ﻋﻀل‬ ‫ﺣﻘﻦ‬ ،‫ﺣﺒﻮﺏ‬‫ﺳاﻋاﺕ‬ ‫ﺳﺖ‬ ‫ﻛل‬ ‫ﻣلﻎ‬ ٥٠-٢٥ ‫ﻓﻨﺘاﻧيل‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬‫اللزﻭﻡ‬ ‫ﻋﻨد‬ ‫ﺗﻜﺮﺭ‬ ،‫ﺑﺒﻂﺀ‬ ‫ﻣيﻜﺮﻭﻏﺮاﻡ‬ ٥٠ ‫ﺟﻨﺘاﻣايﺴﲔ‬‫ﻧﻘاﻁ‬ ،‫ﻣﺮﻫﻢ‬‫اللزﻭﻡ‬ ‫ﻋﻨد‬ ‫ﺁيﺒﻮﺑﺮﻭﻓﲔ‬‫ﻣﺤلﻮﻝ‬ ،‫ﺣﺒﻮﺏ‬‫ﺳاﻋاﺕ‬ ٦ ‫ﻛل‬ ‫ﻣلﻎ‬ ٦٠٠ - ٢٠٠ ‫ﻻﻛﺘيﻮلﻮﺯ‬‫ﻣﺤلﻮﻝ‬‫اﻻﺳﺘﺠاﺑة‬ ‫ﺣﺴﺐ‬ ‫ﺗﻌدﻝ‬ ‫ﺳاﻋة‬ ١٢ ‫ﻛل‬ ‫ﻣل‬ ١٥ ‫ﻣاﻛﺮﻭﺟﻮلز‬‫ﻣﺴﺤﻮﻕ‬‫ﺳاﺋل‬ ‫ﺃﻱ‬ ‫ﻣﻦ‬ ‫ﻣل‬ ٢٠٠ ‫ﻓﻲ‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻛيﺲ‬ ٢-١ ‫ﻣﻮﺭﻓﲔ‬(‫اﳉلد‬ ‫ﲢﺖ‬ ،‫ﻋﻀل‬ ،‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬ ،‫ﺣﺒﻮﺏ‬‫ﺳاﻋاﺕ‬ ٤ ‫ﻛل‬ (‫ﺑالﻮﺭيد‬ ‫ﻣلﻎ‬ ٢٫٥) ‫ﻣلﻎ‬ ٥ ‫ﻣيﺘﻮﻛلﻮﺑﺮاﻣايد‬(‫ﻋﻀل‬ ،‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬ ،‫ﺣﺒﻮﺏ‬‫ﺳاﻋاﺕ‬ ٨ ‫ﻛل‬ ‫ﻣلﻎ‬ ٥ ‫ﻣﻮﺑيﺮﻭﺳﲔ‬‫ﺃﻧفﻲ‬ ‫ﻣﺮﻫﻢ‬‫ﺃياﻡ‬ ٥ ‫ﳌدة‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮاﺕ‬ ٣ ‫ﻧيفﻮﺑاﻡ‬(‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬ ،‫ﺣﺒﻮﺏ‬‫ﺳاﻋاﺕ‬ ٨ ‫ﻛل‬ ‫ﻣلﻎ‬ ٦٠-٣٠ ‫ﺑﺜيديﻦ‬(‫اﳉلد‬ ‫ﲢﺖ‬ ،‫ﻋﻀل‬ ،‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬‫ﺳاﻋاﺕ‬ ٤ ‫ﻛل‬ (‫ﺑالﻮﺭيد‬ ‫ﻣلﻎ‬ ٢٥-١٢٫٥) ‫ﻣلﻎ‬ ٥٠-٢٥ ‫ﺑاﺭاﺳيﺘاﻣﻮﻝ‬‫ﺣﺒﻮﺏ‬‫ﺳاﻋاﺕ‬ ٦ ‫ﻛل‬ ‫ﻏﻢ‬ ١-٠٫٥ ‫ﺗﺮاﻣادﻭﻝ‬(‫ﻋﻀل‬ ،‫)ﻭﺭيد‬ ‫ﺣﻘﻦ‬ ،‫ﻛﺒﺴﻮﻻﺕ‬‫ﺳاﻋاﺕ‬ ٤ ‫ﻛل‬ ‫ﻣلﻎ‬ ٥٠
  • ٢٤ ‫ﺇﺫا‬ ‫ﺃﻭ‬ ،‫ﻧزﻑ‬ ‫ﻫﻨاﻙ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫اﳉﺮاﺣة‬ ‫ﺇﺟﺮاﺀ‬ ‫ﻋلﻰ‬ ‫ﺃﺳﺒﻮﻉ‬ ‫ﻣﺮﻭﺭ‬ ‫قﺒل‬ ‫الﻀﻤادة‬ ‫ﺗﻐييﺮ‬ ‫اﳌﻤﻜﻦ‬ ‫ﻣﻦ‬ • ‫ﻓﻘد‬ ‫ﺇﺫا‬ ‫ﺃﻭ‬ ،‫الﻼﺻﻖ‬ ‫الﺸﺮيﻂ‬ ‫ﲢﺖ‬ ‫ﺑاﳊﻜة‬ ‫اﳌﺮيﺾ‬ ‫ﺷﻌﺮ‬ ‫ﺇﺫا‬ ‫ﺃﻭ‬ ،‫الﻌﺮﻕ‬ ‫ﺑﺴﺒﺐ‬ ‫الﻀﻤادة‬ ‫اﺑﺘلﺖ‬ .‫ﻓاﻋليﺘﻪ‬ ‫الﻼﺻﻖ‬ ‫الﺸﺮيﻂ‬ ‫اﺭﺗداﺀ‬ ‫ﻣﻊ‬ ،‫اﳌﻌﻘﻢ‬ ‫اﻷﺳلﻮﺏ‬ ‫ﺑاﺳﺘﺨداﻡ‬ ‫ﻣدﺭﺏ‬ ‫ﳑﺮﺽ‬ ‫الﻀﻤادة‬ ‫ﺑﺘﻐييﺮ‬ ‫يﻘﻮﻡ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ • .‫ﺟﻨﺘاﻣايﺴﲔ‬ ‫ﻧﻘﻂ‬ ‫ﺃﻭ‬ ‫ﻣﺮﻫﻢ‬ ‫ﻭﺿﻊ‬ ‫ﺫلﻚ‬ ‫يﺘﺒﻊ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ ‫ﻛﻤا‬ ،‫اﳌﻌﻘﻤة‬ ‫ﻭالﻘفاﺯاﺕ‬ ‫الﻜﻤاﻣاﺕ‬ .‫ﺟيدة‬ ‫ﺑصﻮﺭة‬ ‫الﺘﺄﻡ‬ ‫قد‬ ‫اﳉﺮﺡ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫ﺃﺳﺒﻮﻋﲔ‬ ‫ﻣﺮﻭﺭ‬ ‫ﺑﻌد‬ ‫اﳋياﻃاﺕ‬ ‫ﺑﺈﺯالة‬ ‫قﻢ‬ • ،‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﻋلﻰ‬ ‫ﹰ‬‫ا‬‫يﻮﻣ‬ •١٤ - ١٠ ‫ﳝﺮ‬ ‫ﺣﺘﻰ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺑدﺀ‬ ‫ﺗﺄﺟيل‬ ‫اﳌﺴﺘﺤﺴﻦ‬ ‫ﻣﻦ‬ .‫اﶈلﻮﻝ‬ ‫ﺗﺴﺮﺏ‬ ‫لﺘﺠﻨﺐ‬ ‫ﺟيدة‬ ‫ﺑصﻮﺭة‬ ‫يلﺘﺌﻢ‬ ‫ﺑﺄﻥ‬ ‫للﺠﺮﺡ‬ ‫للﺴﻤاﺡ‬ ‫ﻭﺫلﻚ‬ ‫اﺳﺘﺨدﻡ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﺑﻌد‬ ‫ﻣﺒاﺷﺮة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫لﺒدﺀ‬ ‫ﺿﺮﻭﺭة‬ ‫ﻫﻨاﻙ‬ ‫ﻛاﻧﺖ‬ ‫ﺇﺫا‬ • ،‫ﻣﺴﺘلﻖ‬ ‫ﺷﺒﻪ‬ ‫ﺃﻭ‬‫ﹰ‬‫ا‬‫ﻣﺴﺘلﻘي‬ ‫اﳌﺮيﺾ‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫ﻣﺮاﻋاة‬ ‫ﻣﻊ‬ ‫اﳌﺘﻘﻄﻌة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺗﻘﻨية‬ ‫ﺗﺘﺮاﻭﺡ‬ ‫ﻣﻜﻮﺙ‬ ‫ﻭﻓﺘﺮاﺕ‬ (‫ﻣل‬ ١٠٠٠ - ٥٠٠) ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﺻﻐيﺮة‬ ‫ﻛﻤياﺕ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﻭيﺴﺘﺤﺴﻦ‬ .‫اليﻮﻡ‬ ‫ﻓﻲ‬ ‫دﻭﺭاﺕ‬ ٨ - ٦ ‫ﺃﻱ‬ ،‫ﺳاﻋاﺕ‬ ٤ - ٣ ‫ﺑﲔ‬ ‫ﻓﺘﺮة‬ ‫اﻛﺘﻤاﻝ‬ ‫ﺑﻌد‬ ،‫الصفاقية‬ ‫الديلزة‬ ‫ﺑدﺀ‬ ‫ﻋﻨدﺀ‬ ‫الﺘيﺘاﻧيﻮﻡ‬ ‫ﻭﺻلة‬ ‫ﺗﺮﻛيﺐ‬ ‫يﺘﻢ‬ ‫ﺃﻥ‬ ‫يﺴﺘﺤﺴﻦ‬ • .‫ﺟيدة‬ ‫ﺑصﻮﺭة‬ ‫يﻌﻤل‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺃﻥ‬ ‫ﻣﻦ‬ ‫ﻭالﺘﺄﻛد‬ ‫الﺘدﺭيﺐ‬
  • ٢٣ ‫ﻟﻠﺠﺮﺍﺣﺔ‬ ‫ﺍﻟﺘﺎﻟﻴﺔ‬ ‫ﺍﻟﻌﻨﺎﻳﺔ‬ :٦-٢ ‫ﻣﻊ‬ ،‫اﳌﻌﻘﻢ‬ ‫الﺸاﺵ‬ ‫ﻣﻦ‬ ‫ﻃﺒﻘاﺕ‬ ‫ﺑﻌدة‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﺗﻐﻄية‬ ‫يﺠﺐ‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﺑﻌد‬ • ‫ﻓﻲ‬ ‫ﳝيل‬ (discharge) ‫الﻨزﺡ‬ ‫ﻷﻥ‬ ‫ة‬‫ﱠ‬‫د‬‫ﻭالﺴا‬ ‫الﺸفاﻓة‬ ‫الﻼﺻﻘة‬ ‫الﻀﻤاداﺕ‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﺗفادﻱ‬ .‫اﳉﺮاﺛيﻢ‬ ‫ﳕﻮ‬ ‫يﺸﺠﻊ‬ ‫ﳑا‬ ‫اﳉﺮﺡ‬ ‫ﻭﻋﻨد‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋﻨد‬ ‫الﺘﺠﻤﻊ‬ ‫ﺇلﻰ‬ ‫اﳊالة‬ ‫ﻫﺬﻩ‬ ‫اﻏﺴل‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﺑﻌد‬ ‫ﻣﺒاﺷﺮة‬ ‫الﺘﻮﺻيل‬ ‫ﻭﺟﻬاﺯ‬ ‫الﺒﻼﺳﺘيﻜية‬ ‫الﻮﺻلة‬ ‫ﺑﺘﺮﻛيﺐ‬ ‫قﻢ‬ • ‫اﶈلﻮﻝ‬ ‫لﻮﻥ‬ ‫يصفﻮ‬ ‫ﺣﺘﻰ‬ (‫ﺳﺮيﻌة‬ ‫دﻭﺭاﺕ‬ ٥-٤) ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﺻﻐيﺮة‬ ‫ﺑﻜﻤياﺕ‬ ‫الصفاﻕ‬ ‫ﻭﺣدة‬ ١٠٠٠ - ٥٠٠ ‫ﺇليﻪ‬ ‫اﳌﻀاﻑ‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻣل‬ ٢٠٠ ‫قدﺭﻫا‬ ‫ﻛﻤية‬ ‫اﺗﺮﻙ‬ ‫ﺛﻢ‬ ،‫الﺮاﺟﻊ‬ .‫الﻐﻄاﺀ‬ ‫ﻏلﻖ‬ ‫ﻭﺃﺣﻜﻢ‬ ‫الصفاﻕ‬ ‫داﺧل‬ ‫الﻬيﺒاﺭيﻦ‬ ‫ﻣﻦ‬ ‫ﻓﻲ‬ ‫اﳌﺮيﺾ‬ ‫ﺃﺑﻖ‬ ( •fibrin) ‫ﻭالفيﺒﺮيﻦ‬ ‫الدﻣﻮية‬ ‫اﳉلﻄاﺕ‬ ‫ﻣﻦ‬ ‫الﺮاﺟﻊ‬ ‫اﶈلﻮﻝ‬ ‫ﹸ‬‫يصﻒ‬ ‫لﻢ‬ ‫ﺇﺫا‬ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻣل‬ ٥٠٠ ‫قدﺭﻫا‬ ‫ﺑﻜﻤياﺕ‬ ‫الصفاﻕ‬ ‫ﻏﺴل‬ ‫ﻓﻲ‬ ‫ﻭاﺳﺘﻤﺮ‬ ،‫اﳌﺴﺘﺸفﻰ‬ .‫يصفﻮ‬ ‫ﺣﺘﻰ‬ (‫ﻭﺣدة/ﻝ‬ ١٠٠٠ - ٥٠٠) ‫ﻫيﺒاﺭيﻦ‬ ‫ﺇليﻪ‬ ‫اﳌﻀاﻑ‬ ‫ﻣﻦ‬ ‫لﺘﺘﺄﻛد‬ ‫اﳉﺮاﺣة‬ ‫ﺑﻌد‬ (‫ﻭﺟاﻧﺒﻲ‬ ‫)ﺃﻣاﻣﻲ‬ ‫للﺒﻄﻦ‬ ‫ﺷﻌاﻋﻲ‬ ‫ﺗصﻮيﺮ‬ ‫ﻋﻤل‬ ‫اﳌﺮيﺾ‬ ‫ﻣﻦ‬ ‫اﻃلﺐ‬ • ‫ﺛﻢ‬ ،‫اﻷقل‬ ‫ﻋلﻰ‬ ‫ﺳاﻋﺘﲔ‬ ‫ﳌدة‬ ‫اﳌﺴﺘﺸفﻰ‬ ‫ﻓﻲ‬ ‫ﲟﺮاقﺒﺘﻪ‬ ‫ﻭقﻢ‬ ،‫اﳊﻮﺽ‬ ‫داﺧل‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺗﻮﺿﻊ‬ .‫ﻣﻀاﻋفاﺕ‬ ‫ﺣدﻭﺙ‬ ‫ﻋدﻡ‬ ‫ﺇلﻰ‬ ‫اﻻﻃﻤﺌﻨاﻥ‬ ‫ﺑﻌد‬ ‫ﺑاﳋﺮﻭﺝ‬ ‫لﻪ‬ ‫اﺳﻤﺢ‬ ‫ﻻ‬ ‫ﻭلﻜﻦ‬ ،(‫ﻧيفﻮﺑاﻡ‬ ،‫ﺗﺮاﻣادﻭﻝ‬ ،‫ﺑاﺭاﺳيﺘاﻣﻮﻝ‬ :‫)ﻣﺜاﻝ‬ ‫ﺧﺮﻭﺟﻪ‬ ‫ﻋﻨد‬ ‫لﻸلﻢ‬ ‫ﹰ‬‫ا‬‫ﻣﺴﻜﻨ‬ ‫للﻤﺮيﺾ‬ ‫ﺻﻒ‬ • ‫ﻛلﻮية‬ ‫ﻭﻇيفة‬ ‫ﻭﺟﻮد‬ ‫ﻋدﻡ‬ ‫ﺣالة‬ ‫ﻓﻲ‬ ‫ﺇﻻ‬ (NSAIDs) ‫الﻼﺳﺘيﺮﻭيدية‬ ‫اﻷلﻢ‬ ‫ﻣﺴﻜﻨاﺕ‬ ‫ﺗﺴﺘﺨدﻡ‬ .(‫ﺁيﺒﻮﺑﺮﻭﻓﲔ‬ ،‫ديﻜلﻮﻓيﻨاﻙ‬ :‫)ﻣﺜاﻝ‬ ‫الﺒﻮﻝ‬ ‫اﻧﻘﻄاﻉ‬ ‫ﺑدﻻلة‬ ‫ﻣﺘﺒﻘية‬ ‫ﻭالﻨفﻖ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫يلﺘﺌﻢ‬ ‫ﺣﺘﻰ‬ ‫ﻣﻜاﻧﻪ‬ ‫ﻓﻲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺛﺒاﺕ‬ ‫ﻋلﻰ‬ ‫ﺑاﶈاﻓﻈة‬ ‫اﳌﺮيﺾ‬ ‫اﻧصﺢ‬ • .(‫ﺃﺳاﺑيﻊ‬ ٦-٤ ‫الﻌادة‬ ‫ﻓﻲ‬ ‫ﻫﺬا‬ ‫)يﺴﺘﻐﺮﻕ‬ ‫ﺗاﻣة‬ ‫ﺑصﻮﺭة‬ ‫اﳉلدﻱ‬ ‫ﲢﺖ‬ ‫اﻻﺳﺘﺤﻤاﻡ‬ ‫ﲡﻨﺐ‬ ‫ﺑﻀﺮﻭﺭة‬ ‫ﻭﺃﺧﺒﺮﻩ‬ ،‫ﻭﻧﻈيفة‬ ‫ﺟاﻓة‬ ‫الﻀﻤاداﺕ‬ ‫ﻋلﻰ‬ ‫ﺑاﶈاﻓﻈة‬ ‫اﳌﺮيﺾ‬ ‫اﻧصﺢ‬ • ‫يلﺘﺌﻢ‬ ‫ﺣﺘﻰ‬ ‫ﺑالدﺵ‬ ‫اﻻﻏﺘﺴاﻝ‬ ‫ﻭﲡﻨﺐ‬ ،‫ﻣﻜاﻧﻪ‬ ‫ﻓﻲ‬ ‫الصفاقﻲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻛاﻥ‬ ‫ﻃاﳌا‬ ‫اﳊﻮﺽ‬ ‫ﻓﻲ‬ ‫ﺑاﺳﺘﺨداﻡ‬ ‫الﺘﻨﻈﻒ‬ ‫ﻭﳝﻜﻨﻪ‬ ،(‫ﺃﺳاﺑيﻊ‬ ٣-٢ ‫الﻌادة‬ ‫ﻓﻲ‬ ‫ﻫﺬا‬ ‫)يﺴﺘﻐﺮﻕ‬ ‫ﹰ‬‫ا‬‫ﲤاﻣ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ .‫الفﺘﺮة‬ ‫ﻫﺬﻩ‬ ‫ﺧﻼﻝ‬ ‫ﻣﺒللة‬ ‫ﻣﻨﺸفة‬ ‫ﻏﻨية‬ ‫ﺃﻃﻌﻤة‬ ‫ﺗﻨاﻭﻝ‬ ‫ﺫلﻚ‬ ‫ﻋلﻰ‬ ‫يﺴاﻋد‬ ‫ﻭﳑا‬ ،‫ﺑاﻹﻣﺴاﻙ‬ ‫اﻹﺻاﺑة‬ ‫ﺑﺘﺠﻨﺐ‬ ‫اﳌﺮيﺾ‬ ‫اﻧصﺢ‬ • ‫ﺑﻌد‬ ‫ﺃﺳاﺑيﻊ‬ ‫ﺳﺘة‬ ‫ﳌدة‬ ‫الﺜﻘيلة‬ ‫اﻷﺷياﺀ‬ ‫ﺭﻓﻊ‬ ‫ﻭﲡﻨﺐ‬ ‫الدﺭﺝ‬ ‫ﺻﻌﻮد‬ ‫ﺑﺘﺠﻨﺐ‬ ‫ﻭاﻧصﺤﻪ‬ ،‫ﺑاﻷلياﻑ‬ ‫ﻭﺣدة‬ ‫ﺃﻭ‬ ‫لﻄﺒيﺒﻪ‬‫ﹰ‬‫ا‬‫ﻓﻮﺭ‬ ‫ﻭالﻨزﻑ‬ ‫الﺸديدة‬ ‫الﺴﻌاﻝ‬ ‫ﻧﻮﺑاﺕ‬ ‫ﻋﻦ‬ ‫اﻹﺑﻼﻍ‬ ‫ﻋليﻪ‬ ‫ﺃﻧﻪ‬ ‫ﻭﺃﺧﺒﺮﻩ‬ ،‫اﳉﺮاﺣة‬ .‫الصفاقية‬ ‫الديلزة‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﻋلﻰ‬ ‫ﻭاﺣد‬ ‫ﺃﺳﺒﻮﻉ‬ ‫ﻣﺮﻭﺭ‬ ‫ﺑﻌد‬ ‫اﳌﺴﺘﺸفﻰ‬ ‫ﺇلﻰ‬ ‫يﻌﻮد‬ ‫ﺃﻥ‬ ‫اﳌﺮيﺾ‬ ‫ﻣﻦ‬ ‫اﻃلﺐ‬ • ‫ﺑصﻮﺭة‬ ‫ﺫلﻚ‬ ‫ﺗﻜﺮاﺭ‬ ‫ﻣﻊ‬ ،‫ﻫيﺒاﺭيﻦ‬ ‫ﺇليﻪ‬ ‫اﳌﻀاﻑ‬ ‫ﺑاﶈلﻮﻝ‬ ‫الصفاﻕ‬ ‫ﻭﻏﺴل‬ ‫الﻀﻤادة‬ ‫لﺘﻐييﺮ‬ .‫الصفاقية‬ ‫الديلزة‬ ‫ﺗﺒدﺃ‬ ‫ﺣﺘﻰ‬ ‫ﺃﺳﺒﻮﻋية‬
  • ٢٢ ‫ﺍﳌﺮﺷﺪ‬ ‫ﺍﻟﺴﻠﻚ‬ ‫ﺑﺎﺳﺘﺨﺪﺍﻡ‬ ‫ﺍﳌﻌﺪﻝ‬ ‫ﺍﳉﺮﺍﺣﻲ‬ ‫ﺍﻹﺩﺧﺎﻝ‬ ‫ﺧﻄﻮﺍﺕ‬ :٥-٢ ‫الﻮﺻﻮﻝ‬ ‫ﻣﺮﺣلة‬ ‫ﺣﺘﻰ‬ ‫ﻭﺻفﻬا‬ ‫ﺳﺒﻖ‬ ‫الﺘﻲ‬ ‫اﳉﺮاﺣﻲ‬ ‫اﻹدﺧاﻝ‬ ‫لﺘﻘﻨية‬ ‫ﻣﺸاﺑﻬة‬ ‫الﺘﻘﻨية‬ ‫ﻫﺬﻩ‬ ١. .(٥-١ ‫اﳋﻄﻮاﺕ‬ :٤-٢ ‫)ﻓﻘﺮة‬ ‫الﺒﻄﻨية‬ ‫اﳌﺴﺘﻘيﻤة‬ ‫للﻌﻀلة‬ ‫الداﺧلﻲ‬ ‫الﻐﻤد‬ ‫ﺇلﻰ‬ ‫ﺑاﺳﺘﺨداﻡ‬ ‫ﺃﻣﺴﻜﻪ‬ ،‫الﺒﻄﻨية‬ ‫اﳌﺴﺘﻘيﻤة‬ ‫للﻌﻀلة‬ ‫الداﺧلﻲ‬ ‫الﻐﻤد‬ ‫ﺇلﻰ‬ ‫الﻮﺻﻮﻝ‬ ‫ﺑﻌد‬ .٦ ‫اﻹﺑﺮة‬ ‫ﺗﻮﺻيل‬ ‫يﺘﻢ‬ ‫ﺃﻥ‬ ‫اﻷﺳلﻢ‬ ‫ﻣﻦ‬ .١٨-١٦ ‫قياﺱ‬ ‫ﺇدﺧاﻝ‬ ‫ﺇﺑﺮة‬ ‫ﻓيﻪ‬ ‫ﻭﺃدﺧل‬ ‫ﺷﺮياﻧﻲ‬ ‫ﻣلﻘﻂ‬ ‫ﺛﻘﺐ‬ ‫اﺣﺘﻤاﻝ‬ ‫ﺗﻘليل‬ ‫ﺑﻬدﻑ‬ ‫اﻹﺑﺮة‬ ‫ﺇدﺧاﻝ‬ ‫ﺃﺛﻨاﺀ‬ ‫الﻨﻈاﻣﻲ‬ ‫اﳌلﺢ‬ ‫ﻣﺤلﻮﻝ‬ ‫ﺤﻘﻦ‬‫ﹸ‬‫ي‬ ‫ﻭﺃﻥ‬ ‫ﲟﺤﻘﻨة‬ .‫الﺒﻼﺳﺘيﻜﻲ‬ ‫الﻐﻤد‬ ‫ﺇدﺧاﻝ‬ ‫ﻭاﺻل‬ ‫الصفاﻕ‬ ‫ﲡﻮيﻒ‬ ‫ﺇلﻰ‬ ‫اﻹﺑﺮة‬ ‫ﻃﺮﻑ‬ ‫يصل‬ ‫ﻋﻨدﻣا‬ .‫اﻷﻣﻌاﺀ‬ ‫ﺗﺮﻛيﺐ‬ ‫ﺃدﻭاﺕ‬ ‫ﻓﻲ‬ ‫اﳌﻮﺟﻮدة‬ ‫اﻹﺑﺮة‬ ‫اﺳﺘﺨدﻡ‬ ‫ﺑﻼﺳﺘيﻜﻲ‬ ‫ﻏﻤد‬ ‫ﻋلﻰ‬ ‫اﳊصﻮﻝ‬ ‫يﺘيﺴﺮ‬ ‫لﻢ‬ ‫ﺇﺫا‬ .‫اﳊﺬﺭ‬ ‫الزﻡ‬ ‫ﻭلﻜﻦ‬ ،‫الﻘﺜﻄاﺭ‬ ‫اﻹﺑﺮة‬ ‫ﺃﻭ‬ ‫الﺒﻼﺳﺘيﻜﻲ‬ ‫الﻐﻤد‬ ‫ﻋﺒﺮ‬ ‫الﻨﻈاﻣﻲ‬ ‫اﳌلﺢ‬ ‫ﻣﺤلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻣل‬ ٣٠٠ ‫قدﺭﻫا‬ ‫ﻛﻤية‬ ‫اﺣﻘﻦ‬ .٧ ‫اﳌلﺢ‬ ‫ﻣﺤلﻮﻝ‬ ‫اﻧدﻓﻊ‬ ‫ﺇﺫا‬ ،‫اﳊﻮﺽ‬ ‫ﻧﺤﻮ‬ ‫ﹰ‬‫ا‬‫ﻣﺘﺠﻬ‬ ‫الصفاﻕ‬ ‫داﺧل‬ ‫اﻹﺑﺮة‬ ‫ﺃﻭ‬ ‫الﻐﻤد‬ ‫ﻃﺮﻑ‬ ‫ﺇﺑﻘاﺀ‬ ‫ﻣﻊ‬ .‫اﻹﺑﺮة‬ ‫ﺃﻭ‬ ‫الﺒﻼﺳﺘيﻜﻲ‬ ‫الﻐﻤد‬ ‫ﻋﺒﺮ‬ ‫اﳌﺮﺷد‬ ‫الﺴلﻚ‬ ‫ﺑﺈدﺧاﻝ‬ ‫قﻢ‬ ‫ﺑﺴﻬﻮلة‬ ‫الﻨﻈاﻣﻲ‬ .‫الﻄﺮيﻘة‬ ‫ﻫﺬﻩ‬ ‫ﺗﺮﻙ‬ ‫ﻓيلزﻡ‬ ‫ﻣﻘاﻭﻣة‬ ‫ﻫﻨاﻙ‬ ‫ﻛاﻧﺖ‬ ‫ﻭﺇﺫا‬ ،‫ﺑﺴﻬﻮلة‬ ‫اﳌﺮﺷد‬ ‫الﺴلﻚ‬ ‫يدﺧل‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ .٨ ‫ﻭﺟﻮد‬ ‫ﺃﻭ‬ ‫ﺑالﺒﺮاﺯ‬ ‫ﻣﺜﻘلة‬ ‫اﻷﻣﻌاﺀ‬ ‫ﻣﻦ‬ ‫ﻋﺮﻭة‬ ‫ﻭﺟﻮد‬ ‫ﻫﻮ‬ ‫ﺫلﻚ‬ ‫ﳊدﻭﺙ‬ ‫ﹰ‬‫ا‬‫ﺷيﻮﻋ‬ ‫اﻷﺳﺒاﺏ‬ ‫ﺃﻛﺜﺮ‬ .‫اﳉﺮاﺣﻲ‬ ‫اﻹدﺧاﻝ‬ ‫ﺗﻘﻨية‬ ‫ﺇلﻰ‬ ‫اللﺠﻮﺀ‬ ‫ﳝﻜﻦ‬ ‫اﳊالة‬ ‫ﻫﺬﻩ‬ ‫ﻭﻓﻲ‬ ،‫الﺘصاقاﺕ‬ ‫ﻊ‬ ‫ﱢ‬‫اﳌﻮﺳ‬ ‫اﺳﺘﺨدﻡ‬ ‫ﺛﻢ‬ ،‫اﳌﺮﺷد‬ ‫الﺴلﻚ‬ ‫ﻓﻮﻕ‬ ‫ﻣﻦ‬ ‫اﻹﺑﺮة‬ ‫ﺃﻭ‬ ‫الﺒﻼﺳﺘيﻜﻲ‬ ‫الﻐﻤد‬ ‫ﺑﺈﺧﺮاﺝ‬ ‫قﻢ‬ .٩ ‫اﳌﻘاﺱ‬ ‫ﺫﻱ‬ ‫ﻊ‬ ‫ﱢ‬‫ﺑاﳌﻮﺳ‬ ‫ﹰ‬‫ا‬‫ﺑادﺋ‬ ‫للﻘﺜﻄاﺭ‬ ‫ﹰ‬‫ا‬‫ﳑﺮ‬ ‫لﺘصﻨﻊ‬ ‫اﳌﺮﺷد‬ ‫الﺴلﻚ‬ ‫ﻓﻮﻕ‬ (dilator) ‫الصلﺐ‬ .‫اﻷﺻﻐﺮ‬ ‫ﻓﻮﻕ‬ (peeal away sheath) ‫للﺘﻘﺸيﺮ‬ ‫الﻘاﺑل‬ ‫الﻐﻤد‬ ‫ﻣﻊ‬ ‫الﻜﺒيﺮ‬ ‫اﳌﻘاﺱ‬ ‫ﺫا‬ ‫اﳌﻮﺳﻊ‬ ‫ﺃدﺧل‬ .١٠ ‫ﻊ‬ ‫ﱢ‬‫ﻭاﳌﻮﺳ‬ ‫اﳌﺮﺷد‬ ‫الﺴلﻚ‬ ‫ﺃﺧﺮﺝ‬ ‫ﺛﻢ‬ ،‫اﳊﻮﺽ‬ ‫ﻧﺤﻮ‬ ‫اﻷﺳفل‬ ‫ﺇلﻰ‬ ‫ﺗﻮﺟيﻬﻪ‬ ‫ﻭﺣاﻭﻝ‬ ‫اﳌﺮﺷد‬ ‫الﺴلﻚ‬ ‫الﻘاﺑل‬ ‫الﻐﻤد‬ ‫ﻋﺒﺮ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺃدﺧل‬ ‫ﺫلﻚ‬ ‫ﺑﻌد‬ ،‫ﻣﻜاﻧﻪ‬ ‫ﻓﻲ‬ ‫للﺘﻘﺸيﺮ‬ ‫الﻘاﺑل‬ ‫الﻐﻤد‬ ‫ﹰ‬‫ا‬‫ﺗاﺭﻛ‬ ‫ﹰ‬‫ا‬‫ﻣﻌ‬ .‫ﻣﻜاﻧﻪ‬ ‫ﻓﻲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﹰ‬‫ا‬‫ﺗاﺭﻛ‬ ‫الﻐﻤد‬ ‫ﺑﺘﻘﺸيﺮ‬ ‫ﻭقﻢ‬ ‫للﺘﻘﺸيﺮ‬ ‫ﻭﺻفﻪ‬ ‫ﰎ‬ ‫ﻛﻤا‬ ‫اﳉﺮاﺣﻲ‬ ‫الﺸﻖ‬ ‫ﻭﺧياﻃة‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻭﻣﺨﺮﺝ‬ ‫اﳉلد‬ ‫ﲢﺖ‬ ‫اﳌﻘﻮﺱ‬ ‫الﻨفﻖ‬ ‫ﺑصﻨﻊ‬ ‫قﻢ‬ .١١ .(١٥ -١٢ ‫اﳋﻄﻮاﺕ‬ :٤-٢ ‫)ﻓﻘﺮة‬ ‫ﹰ‬‫ا‬‫ﺁﻧف‬
  • ٢١ ‫ﺳﺒﻖ‬ ‫الﺘﻲ‬ ‫الصاﺭة‬ ‫اﳋياﻃة‬ ‫ﻣﻨﺘصﻒ‬ ‫ﻓﻲ‬ ‫ﻭاﺣد‬ ‫ﺳﻨﺘيﻤﺘﺮ‬ ‫ﺑﻄﻮﻝ‬ ‫ﹰ‬‫ا‬‫ﺻﻐيﺮ‬ ‫ﹰ‬‫ا‬‫ﺷﻘ‬ ‫اﺻﻨﻊ‬ ٧. ‫ﺃﻧﻪ‬ ‫ﻣﻦ‬ ‫لﺘﺘﺄﻛد‬ ‫اﻻﲡﻬاﺕ‬ ‫ﺟﻤيﻊ‬ ‫ﻓﻲ‬ ‫ﻭﺣﺮﻛﻪ‬ ‫الفﺘﺤة‬ ‫ﻫﺬﻩ‬ ‫ﻓﻲ‬ ‫ﹰ‬‫ﻼ‬‫ﻛلي‬‫ﹰ‬‫ا‬‫ﻣﺒﻌاد‬ ‫ﺃدﺧل‬ ،‫ﺗﺸﻜيلﻬا‬ .‫الصفاﻕ‬ ‫ﲡﻮيﻒ‬ ‫داﺧل‬ ‫ﺛﻢ‬ ‫الﻬيﺒاﺭيﻦ‬ ‫ﺑﻌﺾ‬ ‫ﺇليﻪ‬ ‫اﳌﻀاﻑ‬ ‫الﻨﻈاﻣﻲ‬ ‫اﳌلﺢ‬ ‫ﲟﺤلﻮﻝ‬ ( ٨.lumen) ‫الﻘﺜﻄاﺭ‬ ‫ﳌﻌة‬ ‫اﻏﺴل‬ ‫اﺳﺘﻘاﻣة‬ ‫ﻣﻦ‬ ‫ﺗﺄﻛد‬ ‫اﳌﺮﻭد‬ ‫ﺇدﺧاﻝ‬ ‫ﺃﺛﻨاﺀ‬ ‫الﻘﺜﻄاﺭ‬ ‫الﺘفاﻑ‬ ‫ﳌﻨﻊ‬ ،(stylet) ‫ﹰ‬‫ا‬‫ﺻلﺒ‬ ‫ﹰ‬‫ا‬‫ﻣﺮﻭد‬ ‫ﻓيﻬا‬ ‫ﺃدﺧل‬ .‫الﻘﺜﻄاﺭ‬ ‫ﺟاﻧﺐ‬ ‫ﻋلﻰ‬ ‫اﳌﺮﺳﻮﻡ‬ ‫اﻷﺑيﺾ‬ ‫اﳋﻂ‬ ‫ﺃدﺧل‬ ،‫الﺸﺮياﻧﻲ‬ ‫اﳌلﻘﻂ‬ ‫ﺑاﺳﺘﺨداﻡ‬ ‫اﳌﺴﺘﻘيﻤة‬ ‫للﻌﻀلة‬ ‫الداﺧلﻲ‬ ‫الﻐﻤد‬ ‫ﺇﻣﺴاﻙ‬ ‫ﹰ‬‫ﻼ‬‫ﻣﻮاﺻ‬ ٩. ‫اﳌﺮﻭد‬ ‫يﺒﻘﻰ‬ ‫ﺃﻥ‬ ‫ﻣﺮاﻋاة‬ ‫ﻣﻊ‬ ،‫اﳊﻮﺽ‬ ‫ﻧاﺣية‬ ‫ﻃﺮﻓﻪ‬ ‫ﹰ‬‫ا‬‫ﻣﻮﺟﻬ‬ ‫ﻋﻤلﻬا‬ ‫ﺳﺒﻖ‬ ‫الﺘﻲ‬ ‫الفﺘﺤة‬ ‫ﻓﻲ‬ ‫اﳌﺮﻭد‬ ‫الﻘﺜﻄاﺭ‬ ‫ﳝﻨﻊ‬ ‫ﻓﻬﺬا‬ ‫الداﺧل‬ ‫ﺇلﻰ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺗﻘدﻡ‬ ‫ﺃﺛﻨاﺀ‬ ‫للصفاﻕ‬ ‫الداﺧلﻲ‬ ‫للﺴﻄﺢ‬ ‫ﹰ‬‫ا‬‫ﻣﻼﺻﻘ‬ ‫ﺛﻘﺐ‬ ‫ﺃﻭ‬ ‫ﺻﺤيﺤة‬ ‫ﻏيﺮ‬ ‫ﺑﻄﺮيﻘة‬ ‫ﺗﻮﺿﻌﻪ‬ ‫ﻋﻨﻪ‬ ‫يﻨﺘﺞ‬ ‫قد‬ ‫ﻭالﺬﻱ‬ ‫اﻷﻣﻌاﺀ‬ ‫ﻋﺮﻯ‬ ‫ﺑﲔ‬ ‫الدﺧﻮﻝ‬ ‫ﻣﻦ‬ ‫الداﺧلﻲ‬ ‫الﻐﻤد‬ ‫ﲟﺤاﺫاة‬ ‫الﻌﻤيﻘة‬ ‫الﻜفة‬ ‫ﺗﻜﻮﻥ‬ ‫ﻋﻨدﻣا‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﻋﻦ‬ ‫ﺗﻮقﻒ‬ .‫اﻷﺣﺸاﺀ‬ .‫الﺒﻄﻨية‬ ‫اﳌﺴﺘﻘيﻤة‬ ‫للﻌﻀلة‬ ١٠.١٠ ‫قدﺭﻫا‬ ‫ﺑﻜﻤية‬ ‫ﺣﻘﻨﻪ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺳالﻜية‬ ‫ﻣﻦ‬ ‫ﻭﺗﺄﻛد‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﻦ‬ ‫اﳌﺮﻭد‬ ‫ﺃﺧﺮﺝ‬ ‫اﳌلﺤﻲ‬ ‫اﶈلﻮﻝ‬ ‫يﻨدﻓﻊ‬ ‫لﻢ‬ ‫ﺇﺫا‬ ،‫الﻬيﺒاﺭيﻦ‬ ‫ﺑﻌﺾ‬ ‫ﺇليﻪ‬ ‫اﳌﻀاﻑ‬ ‫الﻨﻈاﻣﻲ‬ ‫اﳌلﺤﻲ‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻣل‬ .‫ﺟديد‬ ‫ﻣﻦ‬ ‫ﺇدﺧالﻪ‬ ‫ﻭﺃﻋد‬ ‫ﺃﺧﺮﺟﻪ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻋﺒﺮ‬ ‫ﺑﺴﻬﻮلة‬ ‫الﻨﻈاﻣﻲ‬ ‫للﻌﻀلة‬ ‫الداﺧلﻲ‬ ‫الﻐﻤد‬ ‫ﺇلﻰ‬ ‫الﻌﻤيﻘة‬ ‫الﻜفة‬ ‫ﻭﺛﺒﺖ‬ ‫الصاﺭة‬ ‫اﳋياﻃة‬ ‫ﻋﻘد‬ ‫ﺃﺣﻜﻢ‬ ١١. ‫ﺛﻢ‬ ،‫اﳋياﻃة‬ ‫ﺃﺛﻨاﺀ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺛﻘﺐ‬ ‫ﻋدﻡ‬ ‫ﻣﺮاﻋاة‬ ‫ﻣﻊ‬ ‫ﺧياﻃﺘﲔ‬ ‫ﺑﻮاﺳﻄة‬ ‫الﺒﻄﻨية‬ ‫اﳌﺴﺘﻘيﻤة‬ ‫ﻣل‬ ٢٠٠ ‫قدﺭﻫا‬ ‫ﻛﻤية‬ ‫ﺇﻣﺮاﺭ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﻦ‬ ‫ﻭاﳋاﺭﺝ‬ ‫الداﺧل‬ ‫اﶈلﻮﻝ‬ ‫ﺗدﻓﻖ‬ ‫ﺳﺮﻋة‬ ‫ﺭ‬‫ﱢ‬‫د‬‫ق‬ .‫الﻨﻈاﻣﻲ‬ ‫اﳌلﺤﻲ‬ ‫اﶈلﻮﻝ‬ ‫ﻣﻦ‬ ‫ﻣﺮاﻋاة‬ ‫ﻣﻊ‬ ‫ﻣﺘﻮاﺻلة‬ ‫ﺧياﻃة‬ ‫الﺒﻄﻨية‬ ‫اﳌﺴﺘﻘيﻤة‬ ‫للﻌﻀلة‬ ‫اﻷﻣاﻣﻲ‬ ‫الﻐﻤد‬ ‫ﺑﺨياﻃة‬ ‫قﻢ‬ ١٢. ‫ﺻﻐيﺮة‬ ‫ﺛﻘﻮﺏ‬ ‫ﺃﻱ‬ ‫ﻋﻦ‬ ‫ﹰ‬‫ا‬‫ﺑاﺣﺜ‬ ‫ﺗلﻤﺲ‬ ‫ﺛﻢ‬ ،‫اﺨﻤﻟيﻂ‬ ‫للﺸﻖ‬ ‫الﻌلﻮﻱ‬ ‫الﻄﺮﻑ‬ ‫ﻣﻦ‬ ‫الﻘﺜﻄاﺭ‬ ‫يﺒﺜﻖ‬ ‫ﺃﻥ‬ ‫الفﺘﻖ‬ ‫ﺣدﻭﺙ‬ ‫ﲤﻨﻊ‬ ‫ﺣﺘﻰ‬ ‫ﻭﺟدﺕ‬ ‫ﺇﻥ‬ ‫ﺑﺘصليﺤﻬا‬ ‫ﻭقﻢ‬ ‫الﻐﻤد‬ ‫ﺇﻏﻼﻕ‬ ‫ﺑﻌد‬ ‫الﻌﻀلة‬ ‫ﻏﻤد‬ ‫ﻓﻲ‬ .‫اﳉﺮاﺣة‬ ‫ﺑﻌد‬ ‫للﻤﺤلﻮﻝ‬ ‫اﳌﺒﻜﺮ‬ ‫ﻭالﺘﺴﺮﺏ‬ ‫لﺘصﻨﻊ‬ ( ١٣.tunnel device) ‫اﳋاﺻة‬ ‫اﳌﻨﺤﻨية‬ ‫اﳌﻌدﻧية‬ ‫اﻷداة‬ ‫اﺳﺘﺨدﻡ‬ ،‫اﳌﻨﻄﻘة‬ ‫ﺗﺨديﺮ‬ ‫ﺑﻌد‬ ‫ﻣﺨﺮﺝ‬ ‫لﻌﻤل‬ ‫ﲢديدﻩ‬ ‫ﰎ‬ ‫الﺬﻱ‬ ‫اﳌﻜاﻥ‬ ‫ﺇلﻰ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣدﺧل‬ ‫ﻣﻦ‬ ‫ﳝﺘد‬ ،‫اﳉلد‬ ‫ﲢﺖ‬ ‫ﹰ‬‫ا‬‫ﻣﻘﻮﺳ‬ ‫ﹰ‬‫ا‬‫ﻧفﻘ‬ ‫اﳌﻌدﻧية‬ ‫اﻷداة‬ ‫ﻃﺮﻑ‬ ‫ﺑﻮاﺳﻄة‬ ‫اﳉلد‬ ‫اﺛﻘﺐ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻣﻜاﻥ‬ ‫ﺇلﻰ‬ ‫ﺗصل‬ ‫ﻋﻨدﻣا‬ ،‫الﻘﺜﻄاﺭ‬ .(٣ ‫ﺷﻜل‬ ‫)اﻧﻈﺮ‬ ‫اﻷﺳفل‬ ‫ﻧﺤﻮ‬‫ﹰ‬‫ا‬‫ﻣﻨﺤدﺭ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫ﹰ‬‫ا‬‫ﻣﺮاﻋي‬ ‫اﳋاﺻة‬ ‫اﳌﻨﺤﻨية‬ ،‫اﻧفﻜاﻛﻪ‬‫لﺘﻤﻨﻊ‬‫ﺑﻌﻘدة‬‫ﻭﺛﺒﺘﻪ‬‫اﳌﻨﺤﻨية‬‫اﳌﻌدﻧية‬‫اﻷداة‬‫ﻧﻬاية‬‫ﺇلﻰ‬‫الﻘﺜﻄاﺭ‬‫ﻃﺮﻑ‬‫ﺑﺘﻮﺻيل‬‫قﻢ‬ ١٤. ‫ﺗﺘﻮﺿﻊ‬ ‫ﺃﻥ‬ ‫ﻋلﻰ‬ ‫اﺣﺮﺹ‬ .‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻓﺘﺤة‬ ‫ﻋﺒﺮ‬ ‫ﺷديد‬ ‫ﺑﺤﺬﺭ‬ ‫اﳌﻌدﻧية‬ ‫اﻷداة‬ ‫اﺳﺤﺐ‬ ‫ﺛﻢ‬ ‫ﻓﻲ‬ ‫ﺑﺜﻘﻬا‬ ‫لﺘﻤﻨﻊ‬ ‫اﻷقل‬ ‫ﻋلﻰ‬ ‫ﺳﻢ‬ ٢ ‫قدﺭﻫا‬ ‫ﲟﺴاﻓة‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫قﺒل‬ ‫الﺴﻄﺤية‬ ‫الﻜفة‬ ‫ﺷديد‬ ‫ﺑﺈﺣﻜاﻡ‬ ‫ﺑالﻘﺜﻄاﺭ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻓﺘﺤة‬ ‫ﲢيﻂ‬ ‫ﺃﻥ‬ ‫ﻭﻋلﻰ‬ (cuff extrusion) ‫اﳌﺴﺘﻘﺒل‬ .‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﳋياﻃة‬ ‫ﺣاﺟة‬ ‫ﻫﻨاﻙ‬ ‫ﺗﻜﻮﻥ‬ ‫ﻻ‬ ‫ﺣﺘﻰ‬ .‫ﻣﻌﻘﻤة‬ ‫ﺑﻀﻤادة‬ ‫ﻭﺗﻐﻄيﺘﻪ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣدﺧل‬ ‫ﻋﻨد‬ ‫اﳉﺮاﺣﻲ‬ ‫الﺸﻖ‬ ‫ﺑﺨياﻃة‬ ‫قﻢ‬ ١٥.
  • ٢٠ ‫ﺑﺎﻟﺘﺸﺮﻳﺢ‬ ‫ﺍﳉﺮﺍﺣﻲ‬ ‫ﺍﻹﺩﺧﺎﻝ‬ ‫ﺧﻄﻮﺍﺕ‬ :٤-٢ ‫ﺃﻋﻄﻪ‬ ‫ﺛﻢ‬ ،‫الﺘالية‬ ‫اﳋﻄﻮاﺕ‬ ‫ﻋﻦ‬ ‫ﻭﺃﺧﺒﺮﻩ‬ ،‫ﻭاﺣدة‬ ‫ﻭﺳادة‬ ‫ﻋلﻰ‬ ‫يﺴﺘلﻘﻲ‬ ‫ﺃﻥ‬ ‫اﳌﺮيﺾ‬ ‫ﻣﻦ‬ ‫اﻃلﺐ‬ ١. .(‫ﻣيﺘﻮﻛلﻮﺑﺮاﻣايد‬ ‫ﻣﻊ‬ ‫ﺑﺜيديﻦ‬ ‫ﺃﻭ‬ ‫ﻣﻮﺭﻓﲔ‬ ‫ﺃﻭ‬ ‫ﻓﻨﺘاﻧيل‬ :‫)ﻣﺜاﻝ‬ ‫ﺑالﻮﺭيد‬ ‫ﹰ‬‫ا‬‫ﻣﻬدﺋ‬ .‫اﳌﺘﺤﺮﻙ‬ ‫اﳊاﻣل‬ ‫ﻋلﻰ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﺃدﻭاﺕ‬ ‫ﺮ‬ ‫ﱢ‬‫ﻀ‬‫ﹶ‬‫ﻭﺣ‬ ‫ﻒ‬ ‫ﱠ‬‫ﹶﻈ‬‫ﻨ‬‫ﹶ‬‫ﺗ‬ ٢. ‫ﺑﻨﺴﺒة‬ ‫الﻨﻈاﻣﻲ‬ ‫اﳌلﺤﻲ‬ ‫ﺑاﶈلﻮﻝ‬ ‫ﻣﺨفﻒ‬ ‫ليﻐﻨﻮﻛﲔ‬ ‫ﺑاﺳﺘﺨداﻡ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﻣﻜاﻥ‬ ‫ﺭ‬‫ﱢ‬‫د‬‫ﺧ‬ ٣. .‫اﳊﻘﻦ‬ ‫قﺒل‬ ‫الﺴﺤﺐ‬ ‫ﻣﺮاﻋاة‬ ‫ﻣﻊ‬ ‫الصفاﻕ‬ ‫ﻧﺤﻮ‬ ‫ﺳفلﻲ‬ ‫ﺑاﲡاﻩ‬ ‫اﺣﻘﻦ‬ ،‫ﻭاﺣد‬ ‫ﺇلﻰ‬ ‫ﻭاﺣد‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﳌدﺧل‬‫ﹰ‬‫ا‬‫ﺳاﺑﻘ‬ ‫ﲢديدﻩ‬ ‫ﰎ‬ ‫الﺬﻱ‬ ‫اﳌﻜاﻥ‬ ‫ﻓﻲ‬ ‫ﺳﻨﺘﻤﺘﺮاﺕ‬ ٤.٦ - ٥ ‫ﺑﻌﺮﺽ‬‫ﹰ‬‫ا‬‫ﺃﻓﻘي‬‫ﹰ‬‫ا‬‫ﺷﻘ‬ ‫اﺻﻨﻊ‬ .‫للﻨاﺻﻒ‬ ‫اﺠﻤﻟاﻭﺭ‬ ‫اﳋﻂ‬ ‫ﻓﻲ‬ ‫ﻣﺮﻛزﻩ‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫ﹰ‬‫ا‬‫ﻣﺮاﻋي‬ ٥.outer rectus) ‫الﺒﻄﻨية‬ ‫اﳌﺴﺘﻘيﻤة‬ ‫للﻌﻀلة‬ ‫اﳋاﺭﺟﻲ‬ ‫الﻐﻤد‬ ‫ﺇلﻰ‬ ‫ﺗصل‬ ‫ﺣﺘﻰ‬ ‫ﹰ‬‫ا‬‫ﻋﻤيﻘ‬ ‫ﺡ‬‫ﱢ‬‫ﺮ‬‫ﺷ‬ ‫ﺃلياﻑ‬ ‫ﻕ‬‫ﱢ‬‫ﺮ‬‫ﻓ‬ ‫ﺛﻢ‬ ،‫ﺳﻨﺘﻤﺘﺮاﺕ‬ ٥-٤ ‫ﺑﻄﻮﻝ‬ ‫الﻐﻤد‬ ‫ﻫﺬا‬ ‫ﻓﻲ‬ ‫ﹰ‬‫ا‬‫ﻃﻮلي‬ ‫ﹰ‬‫ا‬‫ﺷﻘ‬ ‫اﺻﻨﻊ‬ ‫ﺛﻢ‬ ،(sheath ‫ﺇلﻰ‬ ‫ﺗصل‬ ‫ﺣﺘﻰ‬ (blunt retractor) ‫ﻛليل‬ ‫ﻣﺒﻌاد‬ ‫ﺑاﺳﺘﺨداﻡ‬ ‫الﺒﻄﻨية‬ ‫اﳌﺴﺘﻘيﻤة‬ ‫الﻌﻀلة‬ .(inner rectus sheath) ‫الداﺧلﻲ‬ ‫ﻏﻤدﻫا‬ ٦.blunt) ‫ﻛليل‬ ‫ﺷﺮياﻧﻲ‬ ‫ﻣلﻘﻂ‬ ‫ﺑاﺳﺘﺨداﻡ‬ ‫اﳌﺴﺘﻘيﻤة‬ ‫للﻌﻀلة‬ ‫الداﺧلﻲ‬ ‫الﻐﻤد‬ ‫اﻣﺴﻚ‬ ‫ﺧياﻃة‬ ‫لﻌﻤل‬ (‫ﻭاﺣد‬ ‫ﺃﻭ‬ ‫ﺻفﺮ‬ ‫)قياﺱ‬ ‫لﻼﻣﺘصاﺹ‬ ‫ﹰ‬‫ﻼ‬‫قاﺑ‬ ‫ﹰ‬‫ا‬‫ﺧيﻄ‬ ‫ﻭاﺳﺘﺨدﻡ‬ ،(artery forceps ‫ﻭﻏﺸاﺀ‬ ‫اﳌﺴﺘﻘيﻤة‬ ‫للﻌﻀلة‬ ‫الداﺧلﻲ‬ ‫الﻐﻤد‬ ‫ﻣﻦ‬ ‫ﻛل‬ ‫ﻓﻲ‬ (purse string suture) ‫ﺻاﺭة‬ .(omentum) ‫الﺜﺮﺏ‬ ‫ﺧياﻃة‬ ‫ﻭﻋدﻡ‬ ‫اﳋياﻃة‬ ‫ﺃﺛﻨاﺀ‬ ‫اﻷﻣﻌاﺀ‬ ‫ﺛﻘﺐ‬ ‫ﻋدﻡ‬ ‫ﻣﺮاﻋاة‬ ‫ﻣﻊ‬ ،‫الصفاﻕ‬ ‫ﻭﻣﻜﺎﻥ‬ ‫ﺍﳉﻠﺪﻱ‬ ‫ﲢﺖ‬ ‫ﺍﻟﻨﻔﻖ‬ ‫ﺷﻜﻞ‬ :٣ ‫ﺷﻜﻞ‬ ‫ﺍﻟﻘﺜﻄﺎﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻹﺩﺧﺎﻝ‬ ‫ﺍﳌﻨﺎﺳﺐ‬ ‫ﺍﳌﻜﺎﻥ‬ ‫ﺍﺧﺘﻴﺎﺭ‬ :٢ ‫ﺷﻜﻞ‬ ‫ﺍﻟﻘﺜﻄﺎﺭ‬ ‫الﻜفة‬ ‫الﻌﻤيﻘة‬ ‫اﻻﺭﺗفاﻕ‬ ‫الﻌاﻧﻲ‬
  • ١٩ ‫ﻣﻘاﺭﻧة‬ ‫اﶈلﻮﻝ‬ ‫ﺗﺴﺮﺏ‬ ‫اﺣﺘﻤاﻝ‬ ‫ﻣﻦ‬ ‫يﻘلل‬ ‫د‬ ‫ﹺ‬‫اﳌﺮﺷ‬ ‫الﺴلﻚ‬ ‫ﺑاﺳﺘﺨداﻡ‬ ‫اﳌﻌدﻝ‬ ‫اﳉﺮاﺣﻲ‬ ‫اﻹدﺧاﻝ‬ • ‫ﺑدﺀ‬ ‫ﺇلﻰ‬ ‫يﺤﺘاﺝ‬ ‫اﳌﺮيﺾ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫ﺇليﻪ‬ ‫اللﺠﻮﺀ‬ ‫ﻭيفﻀل‬ ،‫الﺘﺸﺮيﺢ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫اﳉﺮاﺣﻲ‬ ‫ﺑاﻹدﺧاﻝ‬ .‫ﻃاﺭﺋة‬ ‫ﺑصﻮﺭة‬ ‫الديلزة‬ ‫اﳉﺮﺡ‬ ‫ﺑﺄﻥ‬ ‫ﳝﺘاﺯ‬ ‫ﻭلﻜﻨﻪ‬ ،‫ﻭﺧﺒﺮة‬ ‫ﺧاﺻة‬ ‫ﺃدﻭاﺕ‬ ‫ﺇلﻰ‬ ‫اﳌﻨاﻇيﺮ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫يﺤﺘاﺝ‬ • ‫ﻣﻊ‬ ‫ﺑالﺘﻌاﻣل‬ ‫للﺠﺮاﺡ‬ ‫يﺴﻤﺢ‬ ‫ﻭﺑﺄﻧﻪ‬ ،‫اﻷﻣﻌاﺀ‬ ‫ﺛﻘﺐ‬ ‫اﺣﺘﻤاﻝ‬ ‫ﻣﻦ‬ ‫يﻘلل‬ ‫ﻭﺑﺄﻧﻪ‬ ،‫ﺻﻐيﺮ‬ ‫ﻋﻨﻪ‬ ‫الﻨاﰋ‬ ‫ﻭﺿﻊ‬ ‫ﻣﻦ‬ ‫ﺑالﺘﺤﻘﻖ‬ ‫للﺠﺮاﺡ‬ ‫يﺴﻤﺢ‬ ‫ﻭﺑﺄﻧﻪ‬ ،‫اﻷﻣﺮ‬ ‫لزﻡ‬ ‫ﺇﺫا‬ (omentum) ‫الﺜﺮﺏ‬ ‫ﻭﺇﺯالة‬ ‫اﻻلﺘصاقاﺕ‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫يﺘﻢ‬ ‫ﺃﻥ‬ ‫يفﻀل‬ ‫اﻷﺳﺒاﺏ‬ ‫ﻫﺬﻩ‬ ‫لﻜل‬ .‫اﳊﻮﺽ‬ ‫داﺧل‬ ‫ﹰ‬‫ا‬‫ﻋﻤيﻘ‬ ‫الﻘﺜﻄاﺭ‬ .‫اﳌﻌﻘدة‬ ‫اﳊاﻻﺕ‬ ‫ﻓﻲ‬ ‫اﳌﻨاﻇيﺮ‬ ‫الديلزة‬ ‫قﺜاﻃيﺮ‬ ‫ﻛل‬ ‫ﺇدﺧاﻝ‬ ‫يﺘﻢ‬ ‫ﺃﻥ‬ ‫يلزﻡ‬ ‫ﻭالﺒﻌيد‬ ‫الﻘﺮيﺐ‬ ‫اﳌديﲔ‬ ‫ﻋلﻰ‬ ‫ﺟيدة‬ ‫ﻧﺘاﺋﺞ‬ ‫لﺘﺤﻘيﻖ‬ • ‫ﻣﻌﻘﻤة‬ ‫ﻇﺮﻭﻑ‬ ‫ﻓﻲ‬ ‫اﻹدﺧاﻝ‬ ‫يﺘﻢ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ ‫ﻛﻤا‬ ،‫ﺧﺒﺮة‬ ‫ﻭﺫﻱ‬ ‫ﻛﻒﺀ‬ ‫ﻓﺮيﻖ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫الصفاقية‬ .‫اﳌﺴﺘﺨدﻣة‬ ‫الﺘﻘﻨية‬ ‫ﻋﻦ‬ ‫الﻨﻈﺮ‬ ‫ﺑﻐﺾ‬ ‫اﳌﻌﻘﻤة‬ ‫ﻭالﻘفاﺯاﺕ‬ ‫ﻭاﻷﺭدية‬ ‫الﻜﻤاﻣاﺕ‬ ‫ﺑاﺳﺘﺨداﻡ‬ ( •paramedian) ‫للﻨاﺻﻒ‬ ‫اﺠﻤﻟاﻭﺭ‬ ‫اﳋﻂ‬ ‫ﻓﻲ‬ ‫الصفاقﻲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫يﺘﻢ‬ ‫ﺃﻥ‬ ‫يﺴﺘﺤﺴﻦ‬ ‫ﲢﺖ‬ ‫ﺃﻭ‬ ‫داﺧل‬ ‫ﺑالﺘﻮﺿﻊ‬ ‫الداﺧلية‬ ‫للﻜفة‬ ‫يﺴﻤﺢ‬ ‫ﻓﻬﺬا‬ ،(midline) ‫الﻨاﺻﻒ‬ ‫اﳋﻂ‬ ‫ﻓﻲ‬ ‫ﻭليﺲ‬ ‫ﻣﻦ‬ ‫ﻭيﻘلل‬ ‫للﻘﺜﻄاﺭ‬ ‫ﺃقﻮﻯ‬ ‫ﹰ‬‫ا‬‫دﻋﻤ‬ ‫يﻮﻓﺮ‬ ‫ﳑا‬ (rectus muscle) ‫الﺒﻄﻨية‬ ‫اﳌﺴﺘﻘيﻤة‬ ‫الﻌﻀلة‬ .‫اﶈلﻮﻝ‬ ‫ﺗﺴﺮﺏ‬ ‫اﺣﺘﻤاﻻﺕ‬ ‫ﻋﻤيﻖ‬ ‫ﻣﻜاﻥ‬ ‫ﻓﻲ‬ ‫ﺗﻮﺿﻊ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ ‫للﻘﺜﻄاﺭ‬ ‫الﻌﻤيﻘة‬ ‫الﻜفة‬ ‫ﻓﺈﻥ‬ ‫الﻌدﻭﻯ‬ ‫اﺣﺘﻤاﻻﺕ‬ ‫لﺘﻘليل‬ • ‫ﹰ‬‫ا‬‫ﻣﻘﻮﺳ‬ ‫ﹰ‬‫ﻼ‬‫ﺷﻜ‬ ‫اﳉلدﻱ‬ ‫ﲢﺖ‬ ‫الﻨفﻖ‬ ‫يﺄﺧﺬ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ ‫ﻛﻤا‬ ،‫الﺒﻄﻨية‬ ‫اﳌﺴﺘﻘيﻤة‬ ‫الﻌﻀلة‬ ‫ﲢﺖ‬ ‫ﺛﻘﺐ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻌﻤل‬‫ﹸ‬‫ي‬ ‫ﻭﺃﻥ‬ ،(‫ﺫلﻚ‬ ‫ﺗﻌﺬﺭ‬ ‫ﺇﺫا‬ ‫اﳉاﻧﺐ‬ ‫ﺇلﻰ‬ ‫)ﺃﻭ‬ ‫اﻷﺳفل‬ ‫ﺇلﻰ‬‫ﹰ‬‫ا‬‫ﻣﻨﺤدﺭ‬ ‫ﻋﻦ‬ ‫ﻋﺒاﺭة‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫يﻜﻮﻥ‬ ‫ﺑﺤيﺚ‬ ،‫اﳌﺸﺮﻁ‬ ‫ﺑﻮاﺳﻄة‬ ‫ﺟﺮﺣﻪ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﻭليﺲ‬ ‫اﳉلد‬ .‫اﳋياﻃة‬ ‫ﻻﺳﺘﻌﻤاﻝ‬ ‫ﺣاﺟة‬ ‫ﻫﻨاﻙ‬ ‫ﺗﻜﻮﻥ‬ ‫ﻭﻻ‬ ‫ﺑالﻘﺜﻄاﺭ‬ ‫ﻣﺤيﻄة‬ ‫ﺿيﻘة‬ ‫ﻓﺘﺤة‬ ‫ﹰ‬‫ا‬‫)ﺟالﺴ‬‫قاﺋﻢ‬ ‫ﻭﺿﻊ‬ ‫ﻓﻲ‬ ‫ﻭاﳌﺮيﺾ‬( •exitsite)‫الﻘﺜﻄاﺭ‬‫ﺨﻤﻟﺮﺝ‬‫اﳌﻨاﺳﺐ‬‫اﳌﻜاﻥ‬‫اﺧﺘياﺭ‬‫يﺘﻢ‬‫ﺃﻥ‬‫يﺠﺐ‬ ‫اﳊﺮقفية‬ ‫اﳊفﺮة‬ ‫ﻓﻲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫يﻮﺿﻊ‬ ‫ﺃﻥ‬ ‫يﺴﺘﺤﺴﻦ‬ .‫الﺜاﺑﺖ‬ ‫ﺑالﻘلﻢ‬ ‫ﻭﺗﻌليﻤﻪ‬ (‫ﹰ‬‫ا‬‫ﻭاقف‬ ‫ﺃﻭ‬ ‫ﻭﻻ‬ ،‫ﺑﻪ‬ ‫للﻌﻨاية‬ ‫ﺇليﻪ‬ ‫الﻮﺻﻮﻝ‬ ‫اﳌﺮيﺾ‬ ‫ﻋلﻰ‬ ‫يﺴﻬل‬ ‫ﻣﻜاﻥ‬ ‫ﻓﻲ‬ ‫ﺃﻭاليﺴﺮﻯ‬ ‫اليﻤﻨﻰ‬ (iliac fossa) .‫اﳌفﺮﻃة‬ ‫الﺒداﻧة‬ ‫ﺣالة‬ ‫ﻓﻲ‬ ‫ﺑﻄﻨية‬ ‫ﺛﻨية‬ ‫ﲢﺖ‬ ‫ﺃﻭ‬ ‫ﻧدﺑة‬ ‫ﻓﻮﻕ‬ ‫ﺃﻭ‬ ‫اﳊزاﻡ‬ ‫ﺧﻂ‬ ‫ﻋلﻰ‬ ‫يﻮﺿﻊ‬ ‫ﺃﻥ‬ ‫يﺠﻮﺯ‬ ‫ﻣﻜاﻥ‬ ‫ﺑاﺧﺘياﺭ‬ ‫اﻻﻫﺘﻤاﻡ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ،‫اﳌﺮﺿﻰ‬ ‫ﺑﲔ‬ ‫الﺒﻄﻦ‬ ‫ﺣﺠﻢ‬ ‫ﻓﻲ‬ ‫الﻜﺒيﺮ‬ ‫اﻻﺧﺘﻼﻑ‬ ‫ﳌﺮاﻋاة‬ • ‫داﺧل‬ ‫ﹰ‬‫ا‬‫ﻋﻤيﻘ‬ ‫اﻹدﺧاﻝ‬ ‫ﺑﻌد‬ ‫ﻃﺮﻓﻪ‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫يﻀﻤﻦ‬ (insertion site) ‫الﻘﺜﻄاﺭ‬ ‫ﳌدﺧل‬ ‫ﻣﻨاﺳﺐ‬ ‫)قالﺐ‬ ‫ﺮﺳاﻡ‬‫ﹺ‬‫ﳌ‬‫ا‬ ‫اﺳﺘﺨداﻡ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﳌدﺧل‬ ‫اﳌﻨاﺳﺐ‬ ‫اﳌﻜاﻥ‬ ‫ﲢديد‬ ‫ﻭﳝﻜﻦ‬ ،‫اﳊﻮﺽ‬ ‫للﻘﺜﻄاﺭ‬ ‫اﳌلفﻮﻑ‬ ‫الﺬيل‬ ‫ﻣﻦ‬ ‫الﻌلﻮﻱ‬ ‫الﻄﺮﻑ‬ ‫ﻭﺿﻊ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﺃﻭ‬ (‫الﻘﺜﻄاﺭ‬ ‫ﻭﺃﺑﻌاد‬ ‫ﺷﻜل‬ ‫يﺤدد‬ ‫ﹰ‬‫ا‬‫ﻣﺤاﺫي‬ ‫الﻘﺜﻄاﺭ‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫ﻣﺮاﻋاة‬ ‫ﻣﻊ‬ (symphysis pupis) ‫الﻌاﻧﻲ‬ ‫اﻻﺭﺗفاﻕ‬ ‫ﻋﻈﻢ‬ ‫ﲟﺤاﺫاة‬ ‫الﻌﻤيﻘة‬ ‫الﻜفة‬ ‫ﲟﺤاﺫاة‬ ‫الﻘﺜﻄاﺭ‬ ‫ﳌدﺧل‬ ‫اﳌﻨاﺳﺐ‬ ‫اﳌﻜاﻥ‬ ‫ﺗﻌليﻢ‬ ‫ﺛﻢ‬ ،‫للﻨاﺻﻒ‬ ‫اﺠﻤﻟاﻭﺭ‬ ‫للﺨﻂ‬ .(٢ ‫ﺷﻜل‬ ‫)اﻧﻈﺮ‬ ‫للﻘﺜﻄاﺭ‬ (deep cuff)
  • ١٨ ‫ﺍﻟﺼﻔﺎﻗﻲ‬ ‫ﺍﻟﻘﺜﻄﺎﺭ‬ ‫ﺇﺩﺧﺎﻝ‬ ‫ﺗﻘﻨﻴﺎﺕ‬ :٣-٢ ‫ﻭﺿﻌﻬا‬ ‫ﺳيﺘﻢ‬ ‫الﺘﻲ‬ ‫ﻧﻬايﺘﻪ‬ ‫ﻓﻲ‬ ‫ﻓﺘﺤاﺕ‬ ‫ﻋدة‬ ‫لﻪ‬ ‫ﻣﺮﻥ‬ ‫ﺃﻧﺒﻮﺏ‬ ‫ﻋﻦ‬ ‫ﻋﺒاﺭة‬ ‫ﻫﻮ‬ ‫الصفاقﻲ‬ ‫الﻘﺜﻄاﺭ‬ • (cuffs) ‫ﻛفﺘﲔ‬ ‫ﺃﻭ‬ ‫ﻛفة‬ ‫ﻋلﻰ‬ ‫ﻣﻨﻪ‬ ‫اﻷﻭﺳﻂ‬ ‫اﳉزﺀ‬ ‫ﻭيﺤﺘﻮﻱ‬ ،‫اﳊﻮﺽ‬ ‫داﺧل‬ ‫الصفاﻕ‬ ‫ﲡﻮيﻒ‬ ‫ﻓﻲ‬ ‫ﺑالﺘﻬاﺏ‬ ‫اﻹﺻاﺑة‬ ‫اﺣﺘﻤاﻝ‬ ‫ﺗﻘليل‬ ‫ﻭﻋلﻰ‬ ‫الﺒﻄﻦ‬ ‫ﺟداﺭ‬ ‫ﻓﻲ‬ ‫اﳉزﺀ‬ ‫ﻫﺬا‬ ‫ﺗﺜﺒيﺖ‬ ‫ﻋلﻰ‬ ‫ﺗﺴاﻋداﻥ‬ ‫ﺃﻥ‬ ‫ﻋلﻰ‬ ‫قاﻃﻊ‬ ‫دليل‬ ‫يﻮﺟد‬ ‫ﻻ‬ ‫ﻭلﻜﻦ‬ ،‫الصفاقية‬ ‫الﻘﺜاﻃيﺮ‬ ‫ﻣﻦ‬ ‫ﻣﺨﺘلفة‬ ‫ﺃﻧﻮاﻉ‬ ‫ﺗﻮﺟد‬ .‫الصفاﻕ‬ .(١ ‫ﺷﻜل‬ ‫)اﻧﻈﺮ‬ ‫الﻜفﺘﲔ‬ ‫ﺫﻱ‬ ‫الﻘياﺳﻲ‬ «‫»ﺗﻨﻜﻮﻑ‬ ‫قﺜﻄاﺭ‬ ‫ل‬ ‫ﹸ‬‫فﻀ‬‫ﹶ‬‫ي‬ ‫اﳌﺴﺘﺤدﺛة‬ ‫اﻷﻧﻮاﻉ‬ ‫ﻣﻦ‬ ‫ﹰ‬‫ا‬‫ﺃي‬ ‫ﻣﺜل‬ ،‫الﻌاديﲔ‬ ‫للﻤﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫الصفاقﻲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻹدﺧاﻝ‬ ‫ﺗﻘﻨياﺕ‬ ‫ﻋدة‬ ‫اﺳﺘﺨداﻡ‬ ‫ﳝﻜﻦ‬ • ‫اﳌﻌدﻝ‬ ‫اﳉﺮاﺣﻲ‬ ‫اﻹدﺧاﻝ‬ ‫ﺃﻭ‬ ،‫ﺑالﺘﺸﺮيﺢ‬ ‫اﳉﺮاﺣﻲ‬ ‫اﻹدﺧاﻝ‬ ‫ﺃﻭ‬ ،‫اﳉلد‬ ‫ﺛﻘﺐ‬ ‫ﺑﻄﺮيﻖ‬ ‫اﻷﻋﻤﻰ‬ ‫اﻹدﺧاﻝ‬ ،‫د‬ ‫ﹺ‬‫اﳌﺮﺷ‬ ‫الﺴلﻚ‬ ‫ﺑاﺳﺘﺨداﻡ‬ «‫»ﺳيلدﻧﻐﺮ‬ ‫ﺗﻘﻨية‬ ‫ﺃﻭ‬ «‫»ﺗﻨﻜﻮﻑ‬ ‫ﻣﺒزﻝ‬ ‫ﺴﺘﻌﻤل‬‫ﹸ‬‫ي‬ ‫اﳉلد‬ ‫ﺑﻄﺮيﻖ‬ ‫اﻷﻋﻤﻰ‬ ‫اﻹدﺧاﻝ‬ ‫ﺗﻘﻨية‬ ‫ﻓﻲ‬ • ‫للﻨاﺻﻒ‬ ‫اﺠﻤﻟاﻭﺭ‬ ‫اﳋﻂ‬ ‫ﻓﻲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﻭﻷﻥ‬ .‫ﻋﻤياﺀ‬ ‫ﺑصﻮﺭة‬ ‫الصفاقﻲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻹدﺧاﻝ‬ ‫الﺴﻄﺤﻲ‬ ‫ﺃﻭ‬ ‫الﺴفلﻲ‬ ‫الﺸﺮﺳﻮﻓﻲ‬ ‫الﺸﺮياﻥ‬ ‫ﺭﺽ‬ ‫ﻋﻨﻪ‬ ‫يﻨﺠﻢ‬ ‫قد‬ (paramedian plane) ‫ﻋﺒﺮ‬ ‫الﻐالﺐ‬ ‫ﻓﻲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫يﺘﻢ‬ ‫ﻓﺈﻧﻪ‬ ،(inferior or superficial epigastric arteries) ‫يﺠﻮﺯ‬ ‫ﻻ‬ .‫اﳉﺮاﺣة‬ ‫ﺑﻌد‬ ‫ﻓﺘﻖ‬ ‫ﺣدﻭﺙ‬ ‫اﺣﺘﻤاﻻﺕ‬ ‫ﻣﻦ‬ ‫يزيد‬ ‫ﳑا‬ (linea alba) ‫الﺒﻄﻨﻲ‬ ‫اﻷﺑيﺾ‬ ‫اﳋﻂ‬ ‫الﺬيﻦ‬ ‫اﳌﺮﺿﻰ‬ ‫ﺃﻭ‬ ‫الﺴﻤﻨة‬ ‫ﻣفﺮﻃﻲ‬ ‫للﻤﺮﺿﻰ‬ ‫ﺑالﻨﺴﺒة‬ ‫اﻷﻋﻤﻰ‬ ‫اﻹدﺧاﻝ‬ ‫ﺗﻘﻨية‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫اﺣﺘﻤاﻻﺕ‬ ‫ﻣﻦ‬ ‫ﹰ‬‫ﹰ‬‫ا‬‫ﻛﺜيﺮ‬ ‫يزيد‬ ‫اﻻلﺘصاقاﺕ‬ ‫ﻭﺟﻮد‬ ‫ﺃﻥ‬ ‫ﺣيﺚ‬ ‫ﺳاﺑﻘة‬ ‫ﺑﻄﻨية‬ ‫ﺟﺮاﺣاﺕ‬ ‫لﻬﻢ‬ ‫ﺃﺟﺮيﺖ‬ .‫الﺘﻘﻨية‬ ‫ﻫﺬﻩ‬ ‫اﺳﺘﻌﻤلﺖ‬ ‫ﺇﺫا‬ ‫اﻷﻣﻌاﺀ‬ ‫ﺛﻘﺐ‬ ‫اﺨﻤﻟدﺭ‬ ‫ﲢﺖ‬ ‫يﺘﻢ‬ ‫ﺃﻥ‬ ‫ﻭﳝﻜﻦ‬ ‫ﻣﻌﻘدة‬ ‫ﺃدﻭاﺕ‬ ‫ﺇلﻰ‬ ‫يﺤﺘاﺝ‬ ‫ﻻ‬ ‫الﺘﺸﺮيﺢ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫اﳉﺮاﺣﻲ‬ ‫اﻹدﺧاﻝ‬ • ‫ﹰ‬‫ا‬‫ﻧادﺭ‬ ‫ﻣفﺘﻮﺣة‬ ‫ﺗﻘﻨية‬ ‫ﺃﻧﻬا‬ ‫ﻛﻤا‬ ،‫ﺻﻐيﺮة‬ ‫ﻋﻤلياﺕ‬ ‫ﻏﺮﻓة‬ ‫ﺃﻭ‬ ‫ﻧﻈيفة‬ ‫ﻏﺮﻓة‬ ‫ﺃﻱ‬ ‫ﻓﻲ‬ ‫اﳌﻮﺿﻌﻲ‬ ‫الﺘﻘﻨية‬ ‫ﻫﺬﻩ‬ ‫ﻓﺈﻥ‬ ‫ﺃﺧﺮﻯ‬ ‫ﻧاﺣية‬ ‫ﻣﻦ‬ .‫الدﻣﻮية‬ ‫اﻷﻭﻋية‬ ‫ﱡ‬‫ﺭﺽ‬ ‫ﺃﻭ‬ ‫اﻷﻣﻌاﺀ‬ ‫ﺛﻘﺐ‬ ‫ﻋﻨﻬا‬ ‫يﻨﺠﻢ‬ ‫ﻣا‬ ‫ﻛﺒيﺮ‬ ‫اﳉﺮاﺣﻲ‬ ‫الﺸﻖ‬ ‫ﺃﻥ‬ ‫ﻛﻤا‬ ،‫اﳊﻮﺽ‬ ‫داﺧل‬ ‫ﹰ‬‫ا‬‫ﻋﻤيﻘ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻭﺿﻊ‬ ‫ﻣﻦ‬ ‫ﺑالﺘﺤﻘﻖ‬ ‫ﺗﺴﻤﺢ‬ ‫ﻻ‬ .‫اﶈلﻮﻝ‬ ‫ﺗﺴﺮﺏ‬ ‫ﺇلﻰ‬ ‫يﺆدﻱ‬ ‫ﻭﻻ‬ ‫يﺒﺮﺃ‬ ‫ﺣﺘﻰ‬ ‫ﺃﻃﻮﻝ‬ ‫ﻭقﺖ‬ ‫ﺇلﻰ‬ ‫ﻭيﺤﺘاﺝ‬ ‫ﹰ‬‫ا‬‫ﻧﺴﺒي‬ ‫ﺍﻟﺼﻔﺎﻗﻲ‬ ‫ﺍﻟﻘﺜﻄﺎﺭ‬ ‫ﻣﻦ‬ ‫ﻣﺨﺘﻠﻔﺔ‬ ‫ﺃﻧﻮﺍﻉ‬ :١ ‫ﺷﻜﻞ‬ ‫ﻣﻊ‬ ‫الﻜفﺘﲔ‬ ‫ﺫﻱ‬ «‫»ﺗﻨﻜﻮﻑ‬ ‫قﺜﻄاﺭ‬ ‫ﻣﺴﺘﻘيﻢ‬ ‫ﺫيل‬ ‫الﻜفﺘﲔ‬ ‫ﺫﻱ‬ ‫الﺒﺠﻌة‬ ‫ﻋﻨﻖ‬ ‫قﺜﻄاﺭ‬ ‫ﺃﻭﻣلفﻮﻑ‬ ‫ﻣﺴﺘﻘيﻢ‬ ‫ﺫيل‬ ‫ﻣﻊ‬ ‫ﻣﻊ‬ ‫الﻜفﺘﲔ‬ ‫ﺫﻱ‬ «‫»ﺗﻨﻜﻮﻑ‬ ‫قﺜﻄاﺭ‬ ‫ﻣلفﻮﻑ‬ ‫ﺫيل‬
  • ١٧ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻗﺜﻄﺎﺭ‬ ‫ﺗﺮﻛﻴﺐ‬ :٢ ‫ﻓﺼﻞ‬ ‫ﺍﻷﻫﺪﺍﻑ‬ :١-٢ ،‫الصفاقية‬ ‫للديلزة‬ ‫الﺴﻮداﻥ‬ ‫ﺑﺮﻧاﻣﺞ‬ ‫ﻣﺮاﻛز‬ ‫ﻛل‬ ‫ﻓﻲ‬ ‫الصفاقﻲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﺗﻘﻨية‬ ‫ﺗﻮﺣيد‬ • .‫الﻘﺜﻄاﺭ‬ ‫ﻭﺗﻌﻄل‬ ‫اﳉﺮاﺣية‬ ‫اﳌﻀاﻋفاﺕ‬ ‫ﺗﻘليل‬ ‫ﺑﻬدﻑ‬ ‫ﺛﻘﺘﻪ‬ ‫ﻧﻀﻤﻦ‬ ‫لﻜﻲ‬ ‫ﺳلﺴة‬ ‫ﺑﻄﺮيﻘة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫اﳉديد‬ ‫اﳌﺮيﺾ‬ ‫يﺒدﺃ‬ ‫ﺃﻥ‬ ‫ﻋلﻰ‬ ‫الﻌﻤل‬ • .‫ﻭﻣﻄاﻭﻋﺘﻪ‬ ‫ﺍﻟﺼﻔﺎﻗﻲ‬ ‫ﺍﻟﻘﺜﻄﺎﺭ‬ ‫ﻹﺩﺧﺎﻝ‬ ‫ﺍﳌﺮﻳﺾ‬ ‫ﺇﻋﺪﺍﺩ‬ :٢-٢ ‫ﺗﻮﺿيﺢ‬ ‫ﺑﻌد‬ ‫ﺇدﺧالﻪ‬ ‫ﻋلﻰ‬ ‫اﳌﻜﺘﻮﺑة‬ ‫ﻣﻮاﻓﻘﺘﻪ‬ ‫ﻋلﻰ‬ ‫ﻭاﺣصل‬ ‫للﻘﺜﻄاﺭ‬ ‫اﳌﺮيﺾ‬ ‫ﺣاﺟة‬ ‫ﻣﻦ‬ ‫ﺗﺄﻛد‬ • .‫الﻼﺯﻡ‬ ‫اﳉﺮاﺣﻲ‬ ‫اﻹﺟﺮاﺀ‬ ‫ﺇدﺧاﻝ‬ ‫ﺃﺛﻨاﺀ‬ ‫ﺗصﺤيﺤﻪ‬ ‫ﳝﻜﻦ‬ ‫الﺒﻄﻦ‬ ‫ﺟداﺭ‬ ‫ﻓﻲ‬ ‫ﻋيﺐ‬ ‫ﺃﻭ‬ ‫ﻓﺘﻖ‬ ‫ﺃﻱ‬ ‫ﻋﻦ‬ ‫ﹰ‬‫ا‬‫ﺑﺤﺜ‬ ‫اﳌﺮيﺾ‬ ‫اﻓﺤﺺ‬ • ‫ﺃﺳاﺑيﻊ‬ ‫ﺃﺭﺑﻌة‬ ‫ﻣدة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺑدﺀ‬ ‫ﺗﺄﺧيﺮ‬ ‫يﺴﺘﻮﺟﺐ‬ ‫ﻓﺈﻧﻪ‬ ‫ﺫلﻚ‬ ‫ﺣدﺙ‬ ‫ﻭﺇﺫا‬ ،‫الﻘﺜﻄاﺭ‬ .‫اﶈلﻮﻝ‬ ‫ﺗﺴﺮﺏ‬ ‫اﺣﺘﻤاﻻﺕ‬ ‫لﺘﻘليل‬ ‫اﳉﺮاﺣة‬ ‫ﺑﻌد‬ ‫الﺬﻫﺒية‬ ‫الﻌﻨﻘﻮدية‬ ‫اﳉﺮﺛﻮﻣة‬ ‫ﻋﻦ‬ ‫ﹰ‬‫ا‬‫ﺑﺤﺜ‬ ‫ﻭﺯﺭﻋﻬا‬ ( •nasal swab) ‫ﺃﻧفية‬ ‫ﻣﺴﺤة‬ ‫ﺑﺄﺧﺬ‬ ‫قﻢ‬ ‫ﻣﻮﺑيﺮﻭﺳﲔ‬ ‫ﻣﺮﻫﻢ‬ ‫للﻤﺮيﺾ‬ ‫ﻓصﻒ‬ ‫ﺇيﺠاﺑية‬ ‫الﻨﺘيﺠة‬ ‫ﻛاﻧﺖ‬ ‫ﻭﺇﺫا‬ ،(Staphylococcus aurius) .‫اﻷﻧفﻲ‬ ‫ﺇدﺧاﻝ‬ ‫ﻛاﻥ‬ ‫ﻭﺇﺫا‬ ،‫الﻌﻤلياﺕ‬ ‫قاﺋﻤة‬ ‫ﻋلﻰ‬ ‫اﳌﺮيﺾ‬ ‫اﺳﻢ‬ ‫ﺇدﺭاﺝ‬ ‫ﻣﻦ‬ ‫ﺗﺄﻛد‬ ‫الﻌﻤلية‬ ‫ﻣﻮﻋد‬ ‫ﲢديد‬ ‫ﺑﻌد‬ • (CXR)‫للصدﺭ‬ ‫ﺷﻌاﻋﻲ‬ ‫ﺗصﻮيﺮ‬ ‫ﻋﻤل‬ ‫اﳌﺮيﺾ‬ ‫ﻣﻦ‬ ‫ﻓاﻃلﺐ‬ ‫الﻌاﻡ‬ ‫الﺘﺨديﺮ‬ ‫ﲢﺖ‬ ‫ﺳيﺘﻢ‬ ‫الﻘﺜﻄاﺭ‬ .‫ﻭﻣﻮاﻓﻘﺘﻪ‬ ‫الﺘﺨديﺮ‬ ‫ﻃﺒيﺐ‬ ‫ﺇﺑﻼﻍ‬ ‫ﻣﻦ‬ ‫ﻭﺗﺄﻛد‬ (ECG) ‫الﻘلﺐ‬ ‫ﻛﻬﺮﺑية‬ ‫ﻭﻣﺨﻄﻂ‬ ‫ﺣﺘﻰ‬ ‫الﻌﻤلية‬ ‫قﺒل‬ ‫يﻮﻣﲔ‬ ‫ﳌدة‬ (‫ﻣاﻛﺮﻭﺟﻮلز‬ ‫ﺃﻭ‬ ‫ﻻﻛﺘيﻮلﻮﺯ‬ :‫)ﻣﺜل‬ ‫للﻤﺮيﺾ‬ ‫ﹰ‬‫ﻼ‬‫ﻣﺴﻬ‬ ‫ﹰ‬‫ﺀ‬‫دﻭا‬ ‫ﺻﻒ‬ • .‫ﺷﺮﺟية‬ ‫ﺣﻘﻨة‬ ‫لﻪ‬ ‫ﺻﻒ‬ ‫اﻷﻣﺮ‬ ‫لزﻡ‬ ‫ﻭﺇﺫا‬ ،‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮاﺕ‬ ‫ﺛﻼﺙ‬ ‫ﺃﻭ‬ ‫ﻣﺮﺗﲔ‬ ‫يﺘﺒﺮﺯ‬ •٨-٦ ‫ﳌدة‬ ‫الفﻢ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﺷﻲﺀ‬ ‫ﺃﻱ‬ ‫يﺘﻨاﻭﻝ‬ ‫ﻻ‬ ‫ﺃﻥ‬ ‫للﺠﺮاﺣة‬ ‫الﺴاﺑﻖ‬ ‫اليﻮﻡ‬ ‫ﻓﻲ‬ ‫اﳌﺮيﺾ‬ ‫ﻣﻦ‬ ‫اﻃلﺐ‬ ‫ﻓﻲ‬ ‫ﻣﻄﻬﺮ‬ ‫ﺻاﺑﻮﻥ‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫يﺴﺘﺤﻢ‬ ‫ﺃﻥ‬ ‫ﻣﻨﻪ‬ ‫اﻃلﺐ‬ ‫ﻛﻤا‬ ،‫الﻌﻤلية‬ ‫ﻣﻮﻋد‬ ‫قﺒل‬ ‫ﺳاﻋاﺕ‬ .‫للﺠﺮاﺣة‬ ‫اﶈدد‬ ‫اليﻮﻡ‬ ‫ﺻﺒاﺡ‬ ‫ﻣﻦ‬ ‫ﺳاﻋة‬ ‫ﺣﻮالﻲ‬ ‫قﺒل‬ ‫ﺑالﻮﺭيد‬ ‫اﳊيﻮية‬ ‫اﳌﻀاداﺕ‬ ‫ﻣﻦ‬ ‫ﻭقاﺋية‬ ‫ﺟﺮﻋة‬ ‫اﳌﺮيﺾ‬ ‫ﺇﻋﻄاﺀ‬ ‫يﺠﺐ‬ • ‫ﺳفاﺯﻭلﲔ‬ ‫)ﻣﺜل‬ ‫الﺜاﻧﻲ‬ ‫ﺃﻭ‬ ‫اﻷﻭﻝ‬ ‫اﳉيل‬ ‫ﻣﻦ‬ ‫ﺳيفالﻮﺳﺒﻮﺭيﻦ‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫ﻭيﻨصﺢ‬ ،‫اﳉﺮاﺣة‬ .(‫ﺳفيﻮﺭﻭﻛﺴيﻢ‬ ‫ﺃﻭ‬ .‫اﳌﺜاﻧة‬ ‫ﺛﻘﺐ‬ ‫لﺘفادﻱ‬ ‫ﻣﺒاﺷﺮة‬ ‫اﳉﺮاﺣة‬ ‫قﺒل‬ ‫ﻣﺜاﻧﺘﻪ‬ ‫اﳌﺮيﺾ‬ ‫يفﺮﻍ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ •
  • ١٦ ‫ﺍﳌﺮﻳﺾ‬ ‫ﺗﻮﻋﻴﺔ‬ :٧-١ ‫ﺑﻨﻮﻉ‬ ‫اﳌﺮيﺾ‬ ‫ﺗﻮﻋية‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ ،‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﻦ‬ ‫ﳝﻨﻊ‬ ‫ﻣا‬ ‫ﻭﺟﻮد‬ ‫ﻋدﻡ‬ ‫ﻣﻦ‬ ‫الﺘﺄﻛد‬ ‫ﺑﻌد‬ • .‫اﳌﻘﺘﺮﺣة‬ ‫اﳌﻌاﳉة‬ ‫ﻓﻲ‬ ‫ﺧﺒيﺮ‬ ‫ﻋﻀﻮ‬ ‫قﺒل‬ ‫ﻣﻦ‬ ‫ﻫادﺉ‬ ‫ﻣﻜاﻥ‬ ‫ﻓﻲ‬ ‫ﺗﺘﻢ‬ ‫ﺃﻥ‬ ‫ﻭيﺠﺐ‬ ‫ﻋﻈﻤﻰ‬ ‫ﺃﻫﻤية‬ ‫لﻬا‬ ‫اﳌﺮيﺾ‬ ‫ﺗﻮﻋية‬ • .‫الﻌاﺋلة‬ ‫ﺃﻓﺮاد‬ ‫ﺃﺣد‬ ‫ﺣﻀﻮﺭ‬ ‫يﺴﺘﺤﺴﻦ‬ ‫ﻛﻤا‬ ، ‫الصفاقية‬ ‫الديلزة‬ ‫ﻓﺮيﻖ‬ ‫اﳌﺴﺒﻘة‬ ‫اﻷﻓﻜاﺭ‬ ‫ﺑﻌﺾ‬ ‫ﺑﺴﺒﺐ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫اﳌﺮيﺾ‬ ‫يﺮﻓﺾ‬ ‫اﻷﺣياﻥ‬ ‫ﻣﻦ‬ ‫ﻛﺜيﺮ‬ ‫ﻓﻲ‬ • ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﺃﻭ‬ ‫ﻭالﺘﻮﺿيﺢ‬ ‫الﺸﺮﺡ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﺗصﺤيﺤﻬا‬ ‫ﳝﻜﻦ‬ ‫ﻭالﺘﻲ‬ ‫الدقيﻘة‬ ‫ﻏيﺮ‬ ‫ﻭاﳌﻌلﻮﻣاﺕ‬ .‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺮاﻛز‬ ‫ﺃﺣد‬ ‫ﺯياﺭة‬ ‫ﺑالصﻮﺭ‬ ‫اﻻﺳﺘﻌاﻧة‬ ‫ﻣﻊ‬ ‫الصفاقية‬ ‫للديلزة‬ ‫اﻷﺳاﺳية‬ ‫اﳌﺒادﺉ‬ ‫للﻤﺮيﺾ‬ ‫ﺢ‬ ‫ﱠ‬‫ﺗﻮﺿ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ • ‫ﻣﺤلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﻭﺇلﻰ‬ ‫الﺒﻄﻦ‬ ‫ﺟداﺭ‬ ‫ﻓﻲ‬ ‫داﺋﻢ‬ ‫قﺜﻄاﺭ‬ ‫ﺗﺮﻛيﺐ‬ ‫ﺇلﻰ‬ ‫اﳊاﺟة‬ ‫ﺫلﻚ‬ ‫ﻓﻲ‬ ‫ﲟا‬ ،‫ﻭالﺮﺳﻮﻡ‬ .‫ﻣﺴﺘﻤﺮة‬ ‫ﺑصﻮﺭة‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫ﻣﺮاﺕ‬ ‫ﻋدة‬ ‫الديلزة‬ ‫الصﺤية‬ ‫ﺑﻈﺮﻭﻓﻪ‬ ‫ﺫلﻚ‬ ‫ﺭﺑﻂ‬ ‫ﻣﻊ‬ ،‫الصفاقية‬ ‫الديلزة‬ ‫ﻭﻋيﻮﺏ‬ ‫ﻓﻮاﺋد‬ ‫للﻤﺮيﺾ‬ ‫ﺢ‬ ‫ﱠ‬‫ﺗﻮﺿ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ • .(‫ﺑاﳌﻨزﻝ‬ ‫الﻌﻨاية‬ ،‫الﻌﻤل‬ ،‫اﳌدﺭﺳة‬ :‫)ﻣﺜاﻝ‬ ‫اﳋاﺻة‬ ‫ﻭاﻻﺟﺘﻤاﻋية‬ ‫ﻣﻦ‬ ‫الديلزة‬ ‫ﻓﺮيﻖ‬ ‫يﺘﺤﻘﻖ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ ،‫الصفاقية‬ ‫الديلزة‬ ‫ﺑﺮﻧاﻣﺞ‬ ‫ﺇلﻰ‬ ‫اﳌﺮيﺾ‬ ‫اﻧﺘﺴاﺏ‬ ‫قﺒﻮﻝ‬ ‫قﺒل‬ • ‫ﳝﻜﻨﻪ‬ ‫ﺑﻪ‬ ‫ﻣﻮﺛﻮﻕ‬ ‫ﺷﺨﺺ‬ ‫ﺗﻮﻓﺮ‬ ‫ﻣﻦ‬ ‫ﺃﻭ‬ ،‫ﻣﺴﺘﻘلة‬ ‫ﺑصﻮﺭة‬ ‫ﺑالديلزة‬ ‫الﻘياﻡ‬ ‫ﻋلﻰ‬ ‫ﻭقدﺭﺗﻪ‬ ‫ﺭﻏﺒﺘﻪ‬ .‫ﻣﺴﺘﻤﺮة‬ ‫ﺑصفة‬ ‫ﺑالديلزة‬ ‫للﻘياﻡ‬ ‫اﳌﺮيﺾ‬ ‫ﻣﺴاﻋدة‬ ‫يلزﻡ‬ ‫الﺘﻲ‬ ‫ﺑاﳋﻄﻮاﺕ‬ ‫ﺇﻋﻼﻣﻪ‬ ‫يﺠﺐ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺑﺮﻧاﻣﺞ‬ ‫ﺇلﻰ‬ ‫اﳌﺮيﺾ‬ ‫اﻧﺘﺴاﺏ‬ ‫قﺒﻮﻝ‬ ‫ﺑﻌد‬ • .‫الصفاقﻲ‬ ‫الﻘﺜﻄاﺭ‬ ‫لﺘﺮﻛيﺐ‬ ‫الﻼﺯﻣة‬ ‫الﺘﺮﺗيﺒاﺕ‬ ‫ﻭﺇﺟﺮاﺀ‬ ،‫الديلزة‬ ‫لﺒدﺀ‬ ‫ﺑﻬا‬ ‫الﻘياﻡ‬
  • ١٥ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﻟﻠﺪﻳﻠﺰﺓ‬ ‫ﺍﳌﻨﺎﺳﺐ‬ ‫ﺍﳌﺮﻳﺾ‬ :٦-١ ،‫ﺑالﻌﻼﺝ‬ ‫ﻭﻣلﺘزﻡ‬ ‫ﻣﺘﺤﻤﺲ‬ ‫ﻣﺮيﺾ‬ ‫يﺴﺘﺨدﻣﻬا‬ ‫ﻋﻨدﻣا‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﳒاﺡ‬ ‫ﻓﺮﺹ‬ ‫ﺗزيد‬ • .‫ﺟيد‬ ‫ﻋاﺋلﻲ‬ ‫ﺑدﻋﻢ‬ ‫ﻭيﺘﻤﺘﻊ‬ ،‫الﺸﺨصية‬ ‫ﻧﻈاﻓﺘﻪ‬ ‫ﻋلﻰ‬ ‫اﶈاﻓﻈة‬ ‫ﻋلﻰ‬ ‫قادﺭ‬ ‫ﺷاﻣل‬ ‫ﺳﺮيﺮﻱ‬ ‫لﺘﻘييﻢ‬ ‫يﺨﻀﻊ‬ ‫ﺃﻥ‬ ‫يﺠﺐ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫لﺒﺮﻧاﻣﺞ‬ ‫اﳌﺮيﺾ‬ ‫اﻧﺘﺴاﺏ‬ ‫قﺒل‬ • ‫ﻭﺫلﻚ‬ ،‫اﳌﺘاﺣة‬ ‫ﻭاﻻﺟﺘﻤاﻋﻲ‬ ‫اﳌالﻲ‬ ‫الدﻋﻢ‬ ‫ﻭﳌصادﺭ‬ ‫ﻭالﻌﻤل‬ ‫الﺒيﺖ‬ ‫لﺒيﺌة‬ ‫ﺑﺘﻘييﻢ‬ ‫ﻣصﺤﻮﺏ‬ .(٣ ‫ﺟدﻭﻝ‬ ‫)اﻧﻈﺮ‬ ‫اﳌﻨﺘﻈﻤة‬ ‫الصفاقية‬ ‫للديلزة‬ ‫ﻣﺤﺘﻤلة‬ ‫ﻣﻮاﻧﻊ‬ ‫ﺃية‬ ‫اﻛﺘﺸاﻑ‬ ‫يﺘﻢ‬ ‫ﺣﺘﻰ‬ ‫ﺍﳌﻨﺘﻈﻤﺔ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﻟﻠﺪﻳﻠﺰﺓ‬ ‫ﺍﶈﺘﻤﻠﺔ‬ ‫ﺍﳌﻮﺍﻧﻊ‬ :٣ ‫ﺟﺪﻭﻝ‬ ‫ﻣﻄﻠﻘﺔ‬ ‫ﻣﻮﺍﻧﻊ‬‫ﺃﺳﺎﺳﻴﺔ‬ ‫ﻧﺴﺒﻴﺔ‬ ‫ﻣﻮﺍﻧﻊ‬‫ﺛﺎﻧﻮﻳﺔ‬ ‫ﻧﺴﺒﻴﺔ‬ ‫ﻣﻮﺍﻧﻊ‬ ‫الﻜيﺴﻲ‬ ‫الصفاﻕ‬ ‫ﺗصلﺐ‬ • sclerosing encapsulating) .(peritonitis ‫الصفاﻕ‬ ‫الﺘصاقاﺕ‬ • .(adhesions) ‫الصفاقﻲ‬ ‫اﳉﻨﺒﻲ‬ ‫الﻨاﺳﻮﺭ‬ • .(pleuroperitoneal fistula) ( •gastrostomy) ‫اﳌﻌدة‬ ‫ﻓﻐﺮ‬ .(colostomy) ‫ﺃﻭالﻘﻮلﻮﻥ‬ .‫الﺒﻄﻦ‬ ‫ﻓﻲ‬ ‫ﺳاﺑﻘة‬ ‫ﺟﺮاﺣة‬ • .‫الﻌﻘلﻲ‬ ‫ﻭالﺘﺨلﻒ‬ ‫الﺬﻫاﻥ‬ • ‫ﻧﻈاﻓة‬ ‫ﻣﺴﺘﻮﻯ‬ ‫ﺿﻌﻒ‬ • .‫الﺸﺨصية‬ ‫اﳌﺮيﺾ‬ ‫اﳌﺮيﺾ‬ ‫ﲢﻤﺲ‬ ‫ﺿﻌﻒ‬ • .‫الصفاقية‬ ‫للديلزة‬ ،‫اﳌﻨزﻝ‬ ‫ﺑيﺌة‬ ‫ﻣﻼﺋﻤة‬ ‫ﻋدﻡ‬ • ‫اﳉاﺭﻱ‬ ‫اﳌاﺀ‬ ‫ﺗﻮﻓﺮ‬ ‫ﻋدﻡ‬ ‫ﻣﺜل‬ ‫ﻛاﻓية‬ ‫ﻣﺴاﺣة‬ ‫ﻭﺟﻮد‬ ‫ﻋدﻡ‬ ‫ﺃﻭ‬ .‫للﺘﺨزيﻦ‬ .( •hernia) ‫الفﺘﻖ‬ .‫الﺴﻤﻨة‬ • ‫الﺴاﺑﻖ‬ ‫اﻻﺳﺘﺨداﻡ‬ • .‫الصلﺐ‬ ‫الصفاقﻲ‬ ‫للﻘﺜﻄاﺭ‬ ‫الﻜلﻰ‬ ‫ﺗﻜيﺲ‬ ‫داﺀ‬ • .(polycystic kidneys) .‫الﻈﻬﺮ‬ ‫ﺃﺳفل‬ ‫ﻣﺸاﻛل‬ •
  • ١٤ ‫ﺍﻟﺪﻣﻮﻱ‬ ‫ﺍﻻﺳﺘﺼﻔﺎﺀ‬ ‫ﻣﻘﺎﺑﻞ‬ ‫ﻓﻲ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻭﻋﻴﻮﺏ‬ ‫ﻣﺰﺍﻳﺎ‬ :٢ ‫ﺟﺪﻭﻝ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻣﺰﺍﻳﺎ‬‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻋﻴﻮﺏ‬ ،‫ﻣﺘﻘﻄﻌة‬ ‫ﻭﻏيﺮ‬ ‫ﻣﺴﺘﻤﺮة‬ ‫الديلزة‬ ‫ﻋﻤلية‬ • .‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫ﺑﺨﻼﻑ‬ ‫لفﺘﺮة‬ ‫اﳌﺘﺒﻘية‬ ‫الﻜلﻮية‬ ‫الﻮﻇيفة‬ ‫ﻋلﻰ‬ ‫ﲢاﻓﻆ‬ • .‫الﻮﻓاة‬ ‫اﺣﺘﻤاﻻﺕ‬ ‫يﻘلل‬ ‫قد‬ ‫ﳑا‬ ،‫ﺃﻃﻮﻝ‬ ‫ﻭﺗﻮاﺯﻥ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻋلﻰ‬ ‫ﺃﻓﻀل‬ ‫ﺑﺸﻜل‬ ‫ﺗﺴيﻄﺮ‬ • .‫ﺷديدة‬ ‫ﻏﺬاﺋية‬ ‫قيﻮد‬ ‫دﻭﻥ‬ ‫اﳉﺴﻢ‬ ‫ﺳﻮاﺋل‬ ‫ﺃﻭاﻻﻋﺘﻼﻻﺕ‬‫الﻘلﺐ‬‫ﺑفﺸل‬‫للﻤصاﺑﲔ‬‫ﹰ‬‫ا‬‫ﺃﻣاﻧ‬‫ﺃﻛﺜﺮ‬ • .‫الﺸﺮياﻧية‬ ‫الﺬيﻦ‬ ‫الﺴﻜﺮﻱ‬ ‫ﺑداﺀ‬ ‫للﻤصاﺑﲔ‬ ‫ﻣﻨاﺳﺒة‬ • ‫ﻭالﺬيﻦ‬ ‫الﻨﺸﻂ‬ ‫الﺸﺒﻜية‬ ‫اﻋﺘﻼﻝ‬ ‫ﻣﻦ‬ ‫يﻌاﻧﻮﻥ‬ .‫الﻬيﺒاﺭيﻦ‬ ‫ﺑاﺳﺘﻌﻤاﻝ‬ ‫يﻨصﺤﻮﻥ‬ ‫ﻻ‬ ‫ﻭﳝﻜﻦ‬ ،‫ﺳﻬل‬ ‫الصفاقﻲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ • ‫ﹰ‬‫ا‬‫ﻓﻮﺭ‬ ‫ﺃﻭ‬ ‫ﺇدﺧالﻪ‬ ‫ﻣﻦ‬ ‫ﺃﺳﺒﻮﻋﲔ‬ ‫ﺑﻌد‬ ‫اﺳﺘﻌﻤالﻪ‬ .‫اﻷﻣﺮ‬ ‫لزﻡ‬ ‫ﺇﺫا‬ ‫اﳌصاﺣﺒة‬ ‫الﺸديدة‬ ‫اﳉﺮﺛﻮﻣية‬ ‫الﻌدﻭﻯ‬ ‫ﺣﺘﻰ‬ • ‫ﺇﺯالة‬ ‫ﺑﻌد‬ ‫الﻌادة‬ ‫ﻓﻲ‬ ‫ﺗزﻭﻝ‬ ‫الصفاقية‬ ‫للديلزة‬ .‫الﻮﻓاة‬ ‫ﺇلﻰ‬ ‫ﺗﺆدﻱ‬ ‫ﻣا‬‫ﹰ‬‫ا‬‫ﻭﻧادﺭ‬ ،‫الﻘﺜﻄاﺭ‬ ‫ﺑاﻻﺳﺘصفاﺀ‬‫ﻣﻘاﺭﻧة‬‫للدﻡ‬‫ﺃقل‬‫ﻓﻘداﻥ‬‫يصاﺣﺒﻬا‬ • .‫لﻺﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫ﺃقل‬ ‫ﻭﺣاﺟة‬ ‫الدﻣﻮﻱ‬ ‫اﻹﺻاﺑة‬‫ﻓﺮﺹ‬‫يﻘلل‬‫ﳑا‬،‫اﻹﺑﺮ‬‫ﻻﺳﺘﻌﻤاﻝ‬‫ﲢﺘاﺝ‬‫ﻻ‬ • .«‫»ﺝ‬ ‫ﺃﻭ‬ «‫»ﺏ‬ ‫الﻨﻮﻉ‬ ‫ﻣﻦ‬ ‫الﻜﺒد‬ ‫الﺘﻬاﺏ‬ ‫ﺑفيﺮﻭﺱ‬ ‫ﻣﺮاﻛز‬‫ﻋﻦ‬‫ﹰ‬‫ا‬‫ﺑﻌيد‬‫يﻌيﺶ‬‫الﺬﻱ‬‫للﻤﺮيﺾ‬‫ﻣﻨاﺳﺒة‬ • ‫ﺇلﻰ‬ ‫اﻻﻧﺘﻘاﻝ‬ ‫يﻜﻮﻥ‬ ‫ﺣيﺚ‬ ،‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫الدﻭﺭية‬ ‫اﳌﺮاﺟﻌة‬ ‫ﺑﻐﺮﺽ‬ ‫ﹰ‬‫ا‬‫ﺿﺮﻭﺭي‬ ‫اﳌﺴﺘﺸفﻰ‬ .‫ﻓﻘﻂ‬ ‫الﻄاﺭﺋة‬ ‫اﳊاﻻﺕ‬ ‫ﺃﻭ‬ ‫ﳌﻼﺀﻣة‬ ‫ﻭقاﺑلية‬ ‫ﻣﺮﻭﻧة‬ ‫ﺃﻛﺜﺮ‬ ‫اﳌﻌاﳉة‬ ‫ﺃﻭقاﺕ‬ • .‫اﳌﺮيﺾ‬ ‫ﺣياة‬ ‫ﺃﺳلﻮﺏ‬ ‫ﺑالفﺸل‬ ‫اﳌصاﺑﲔ‬ ‫الﻌاﺋلة‬ ‫ﺑﺄﻓﺮاد‬ ‫الﻌﻨاية‬ ‫ﲡﻌل‬ • ‫الﺒديلة‬ ‫الﻜلﻮية‬ ‫اﳌﻌاﳉة‬ ‫ﺗﺘﻢ‬ ‫ﺇﺫ‬ ‫ﺃﺳﻬل‬ ‫الﻜلﻮﻱ‬ .‫الﺒيﺖ‬ ‫ﻓﻲ‬ ‫ﻛﺒيﺮة‬ ‫ﺃﻋداد‬ ‫ﺇلﻰ‬ ‫ﺃﻭ‬ ‫ﻣﻌﻘدة‬ ‫ﺃﺟﻬزة‬ ‫ﺇلﻰ‬ ‫ﲢﺘاﺝ‬ ‫ﻻ‬ • .‫الصﺤيﲔ‬ ‫الﻌاﻣلﲔ‬ ‫ﻣﻦ‬ ‫ﻛلﻮية‬ ‫ﻭﻇيفة‬ ‫ﻭﺟﻮد‬ ‫ﻋلﻰ‬ ‫الﻐالﺐ‬ ‫ﻓﻲ‬ ‫ﺗﻌﺘﻤد‬ • .‫الﻌﻼﺟية‬ ‫اﻷﻫداﻑ‬ ‫لﺘﺤﻘيﻖ‬ ‫ﻣﺘﺒﻘية‬ ‫اﳌﺮﺿﻰ‬‫ﻓﻲ‬‫الﻌﻼﺟية‬‫اﻷﻫداﻑ‬‫ﲢﻘيﻖ‬‫يصﻌﺐ‬‫قد‬ • .‫الﺒﻮﻝ‬ ‫ﺑاﻧﻘﻄاﻉ‬ ‫اﳌصاﺑﲔ‬ ‫اﳊﺠﻢ‬ ‫ﻛﺒيﺮﻱ‬ ‫ﻭالﺬﻱ‬ ،‫الﺮاﺷﺢ‬ ‫الﺴاﺋل‬ ‫ﺑﺤﺠﻢ‬ ‫الﺘﻨﺒﺆ‬ ‫يصﻌﺐ‬ • .‫الزﻣﻦ‬ ‫ﲟﺮﻭﺭ‬ ‫الﻐالﺐ‬ ‫ﻓﻲ‬ ‫يﻘل‬ ‫ﺣيﺚ‬ ،‫ﻋالية‬ ‫ليﺴﺖ‬ ‫الﺘﻘﻨية‬ ‫اﺳﺘﻤﺮاﺭية‬ • .‫ﺳﻨﻮاﺕ‬ ‫ﺑﻀﻊ‬ ‫ﺑﻌد‬ ‫اﳌﺮﺿﻰ‬ ‫ﺃﻏلﺐ‬ ‫يﺘﺮﻛﻬا‬ ‫يصاﺣﺒﻪ‬ ‫ﳑا‬ ،‫داﺋﻢ‬ ‫ﺻفاقﻲ‬ ‫قﺜﻄاﺭ‬ ‫ﺇلﻰ‬ ‫ﲢﺘاﺝ‬ • ‫ﻭﻣﺸاﻛل‬ ‫ﺟﺮﺛﻮﻣية‬ ‫ﺑﻌدﻭﻯ‬ ‫اﻹﺻاﺑة‬ ‫اﺣﺘﻤاﻝ‬ .‫اﳉﺴﻢ‬ ‫ﺷﻜل‬ ‫ﺗﻐيﺮ‬ ‫الﻮﺯﻥ‬ ‫ﺯيادة‬ ‫ﺇلﻰ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺗﺆدﻱ‬ ‫قد‬ • ‫اﳌصاﺑﲔ‬ ‫ﻋﻨد‬ ‫ﹰ‬‫ا‬‫ﺧصﻮﺻ‬ ،‫الدﻡ‬ ‫ﺳﻜﺮ‬ ‫ﻭاﺭﺗفاﻉ‬ .‫الﺴﻜﺮﻱ‬ ‫ﺑداﺀ‬ ‫ﺳﻜﻨية‬ ‫ﻇﺮﻭﻑ‬ ‫ﺇلﻰ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﲢﺘاﺝ‬ • ‫اﳌﻨاﺳﺐ‬ ‫ﻭاﳊيز‬ ‫اﳉاﺭﻱ‬ ‫اﳌاﺀ‬ ‫ﻓيﻬا‬ ‫يﺘﻮﻓﺮ‬ ‫ﹶ‬‫ة‬‫ﺟيد‬ .‫اﶈاليل‬ ‫لﺘﺨزيﻦ‬ ‫اﳌﺮﺿﻰ‬ ‫ﻣﻨاﺯﻝ‬ ‫ﺇلﻰ‬ ‫اﶈاليل‬ ‫لﻨﻘل‬ ‫الﺘﺮﺗيﺐ‬ ‫يلزﻡ‬ • .‫ﻣﻨﺘﻈﻤة‬ ‫ﺑصﻮﺭة‬ ‫ﻋاﺋلﺘﻪ‬ ‫ﻣﻦ‬ ‫ﻓﺮد‬ ‫ﺃﻭ‬ ‫اﳌﺮيﺾ‬ ‫قدﺭة‬ ‫ﻋلﻰ‬ ‫ﺗﻌﺘﻤد‬ • .‫ﺑﻬا‬ ‫ﻭاﻻلﺘزاﻡ‬ ‫الﺘﻘﻨية‬ ‫ﺗﻌلﻢ‬ ‫ﻋلﻰ‬ ‫ﹰ‬‫ا‬‫ﻭﺫﻫﻨي‬ ‫ﹰ‬‫ا‬‫ﺑدﻧي‬ ‫ﺇﻋياﺀ‬ ‫ﺇلﻰ‬ ‫يﺆدﻱ‬ ‫ﳑا‬ ‫ﹰ‬‫ا‬‫يﻮﻣي‬ ‫الديلزة‬ ‫ﺇﺟﺮاﺀ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • .‫يﺴاﻋدﻩ‬ ‫ﻣﻦ‬ ‫ﺃﻭ‬ ‫اﳌﺮيﺾ‬
  • ١٣ ‫ﺍﻟﺒﺪﻳﻠﺔ‬ ‫ﺍﻟﻜﻠﻮﻳﺔ‬ ‫ﺍﳌﻌﺎﳉﺔ‬ ‫ﺑﺪﺀ‬ :٤-١ /‫ﻣل‬ •١٥ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫الﻜﺒيﺒﻲ‬ ‫الﺮﺷﺢ‬ ‫ﻣﻌدﻝ‬ ‫يﻜﻮﻥ‬ ‫ﻋﻨدﻣا‬ ‫الﺒديلة‬ ‫الﻜلﻮية‬ ‫ﺑاﳌﻌاﳉة‬ ‫الﺒدﺀ‬ ‫يﺠﻮﺯ‬ .‫ﻋﻨﻬا‬ ‫الﻨاﺟﻢ‬ ‫ﻭالﻌﺐﺀ‬ ‫اﳌﻌاﳉة‬ ‫ﻫﺬﻩ‬ ‫ﻣﻦ‬ ‫اﳌﺘﻮقﻌة‬ ‫الفﻮاﺋد‬ ‫ﺑﲔ‬ ‫اﳌﻮاﺯﻧة‬ ‫ﺑﻌد‬ ،٢‫دقيﻘة/٣٧٫١ﻡ‬ ‫ﺳﺮيﺮية‬ ‫ﺁﺛاﺭ‬ ‫ﻫﻨاﻙ‬ ‫ﺗﻜﻦ‬ ‫لﻢ‬ ‫ﺇﺫا‬ ‫ﺛاﺑﺘة‬ ‫ﻓاﺋدة‬ ‫الﺒديلة‬ ‫الﻜلﻮية‬ ‫ﺑاﳌﻌاﳉة‬ ‫اﳌﺒﻜﺮ‬ ‫للﺒدﺀ‬ ‫ليﺲ‬ • ‫اﳌﻘاﺑل‬ ‫ﻭﻓﻲ‬ ،‫ﺳﺮيﺮية‬ ‫دﻭاﻋﻲ‬ ‫لﻬا‬ ‫ﺗﻜﻮﻥ‬ ‫ﺣﺘﻰ‬ ‫الﻌادة‬ ‫ﻓﻲ‬ ‫اﳌﻌاﳉة‬ ‫ﻫﺬﻩ‬ ‫ﻭﺗﺮﺟﺄ‬ ،‫الﻜلﻮﻱ‬ ‫للﻘصﻮﺭ‬ .‫ﻛﺜيﺮة‬ ‫ﺳالﺒة‬ ‫ﻧﺘاﺋﺞ‬ ‫لﻪ‬ ‫الﺘﺄﺧيﺮ‬ ‫ﺃﻥ‬ ‫ﺇﺫ‬ ،‫اﳌﻌاﳉة‬ ‫لﺘﺄﺧيﺮ‬ ‫الﺴﺮيﺮية‬ ‫اﻷﻋﺮاﺽ‬ ‫ﺗﻬﻮيﻦ‬ ‫يﺠﺐ‬ ‫ﻻ‬ ‫الﺴﻮاﺋل‬ ‫اﺣﺘﺒاﺱ‬ ،‫اﳌفﺮﻁ‬ ‫اﻹﻋياﺀ‬ ‫الﺒديلة‬ ‫الﻜلﻮية‬ ‫ﺑاﳌﻌاﳉة‬ ‫للﺒدﺀ‬ ‫الﺴﺮيﺮية‬ ‫الدﻭاﻋﻲ‬ ‫ﺗﺸﻤل‬ • ‫الدﻣاﻏية‬ ‫اﻻﻋﺘﻼﻻﺕ‬ ،‫الﺘاﻣﻮﺭ‬ ‫ﻏﺸاﺀ‬ ‫الﺘﻬاﺏ‬ ،‫لﻸدﻭية‬ ‫اﳌﻘاﻭﻡ‬ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻓﺮﻁ‬ ،‫لﻸدﻭية‬ ‫اﳌﻘاﻭﻡ‬ .‫الﺘﻐﺬية‬ ‫ﻭﺳﻮﺀ‬ ،‫الداﺋﻢ‬ ‫الﻐﺜياﻥ‬ ،‫الﻨزﻓية‬ ‫اﻻﻋﺘﻼﻻﺕ‬ ،‫الﻌصﺒية‬ ‫ﺃﻭ‬ ‫اﳌزﻣﻦ‬ ‫الﻜلﻮﻱ‬ ‫ﺑالﻘصﻮﺭ‬ ‫اﳌصاﺏ‬ ‫يصﺒﺢ‬ ‫ﺣﺘﻰ‬ ‫الﺒديلة‬ ‫الﻜلﻮية‬ ‫ﺑاﳌﻌاﳉة‬ ‫الﺒدﺀ‬ ‫ﺗﺄﺧيﺮ‬ ‫يﺠﺐ‬ ‫ﻻ‬ • ‫الديلزة‬ ‫ﺑدﺀ‬ ‫يﺴﺘدﻋﻲ‬ ‫قد‬ ‫الﺬﻱ‬ ‫اﳌفاﺟﺊ‬ ‫الﺘدﻫﻮﺭ‬ ‫اﺣﺘﻤاﻻﺕ‬ ‫ﻣﻦ‬ ‫ﺫلﻚ‬ ‫يزيد‬ ‫ﺣيﺚ‬ ،‫ﹰ‬‫ا‬‫ﺟد‬ ‫ﹰ‬‫ا‬‫ﻣﺮيﻀ‬ ‫ﹰ‬‫ا‬‫قادﺭ‬ ‫يﻜﻮﻥ‬ ‫ﻻ‬ ‫اﳌﺮيﺾ‬ ‫ﻫﺬا‬ ‫ﻣﺜل‬ ‫ﺃﻥ‬ ‫ﻛﻤا‬ ،‫للﻤﻀاﻋفاﺕ‬ ‫ﻋﺮﺿة‬ ‫ﺃﻛﺜﺮ‬ ‫اﳌصاﺏ‬ ‫ﲡﻌل‬ ‫ﻃاﺭﺋة‬ ‫ﺑصﻮﺭة‬ .‫ﺟيدة‬ ‫ﺑصﻮﺭة‬ (dialysis access) ‫الديلزة‬ ‫ﻣﻨفﺬ‬ ‫يﻌﻤل‬ ‫لﻢ‬ ‫ﺇﺫا‬ ‫ﺁﺧﺮ‬ ‫ﺗﺄﺧيﺮ‬ ‫ﺃﻱ‬ ‫اﺣﺘﻤاﻝ‬ ‫ﻋلﻰ‬ ‫ﺍﳌﺘﻜﺎﻣﻠﺔ‬ ‫ﺍﻟﻜﻠﻮﻳﺔ‬ ‫ﺍﻟﻌﻨﺎﻳﺔ‬ ‫ﺧﻄﺔ‬ :٥-١ ،‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫ﻫﻲ‬ ،‫الﻌﻼﺟية‬ ‫اﳋياﺭاﺕ‬ ‫ﻣﻦ‬ ‫ﹰ‬‫ا‬‫ﻋدد‬ ‫الﺒديلة‬ ‫الﻜلﻮية‬ ‫اﳌﻌاﳉة‬ ‫ﺗﺸﻤل‬ • ‫اﻷﳕاﻁ‬ ‫ﻫﺬﻩ‬ ‫ﻛل‬ ‫ﻣﻦ‬ ‫الﻮاﺣد‬ ‫اﳌﺮيﺾ‬ ‫يﺴﺘفيد‬ ‫ﻣا‬ ‫ﹰ‬‫ا‬‫ﻭﻛﺜيﺮ‬ ،‫الﻜلﻰ‬ ‫ﻭﺯﺭﻉ‬ ،‫الصفاقية‬ ‫ﻭالديلزة‬ ‫ﻣﺘاﺡ‬ ‫ﻋﻼﺟﻲ‬ ‫ﳕﻂ‬ ‫ﻛل‬ ‫اﺳﺘﻌﻤاﻝ‬ ‫ﻦ‬ ‫ﹸ‬‫يﺤﺴ‬ ‫لﺬلﻚ‬ ،‫ﻋﻼﺟﻪ‬ ‫ﻓﺘﺮة‬ ‫ﺃﺛﻨاﺀ‬ ‫الﺘﻮالﻲ‬ ‫ﻋلﻰ‬ ‫الﺜﻼﺛة‬ .‫ﺑاﻵﺧﺮ‬ ‫ﳕﻂ‬ ‫ﻛل‬ ‫ﻣﻘاﺭﻧة‬ ‫ﻋلﻰ‬ ‫الﺘﺮﻛيز‬ ‫ﻣﻦ‬ ‫ﹰ‬‫ﻻ‬‫ﺑد‬ ‫الﻘصﻮﻯ‬ ‫اﳌﺮيﺾ‬ ‫ﳌﻨفﻌة‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫ﺇﻻ‬ ،‫اﳌﺮيﺾ‬ ‫لﺮﻏﺒة‬ •‫ﹰ‬‫ا‬‫ﺧاﺿﻌ‬ ‫الﺒديلة‬ ‫الﻜلﻮية‬ ‫اﳌﻌاﳉة‬ ‫ﳕﻂ‬ ‫اﺧﺘياﺭ‬ ‫يﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫اﻷﻓﻀل‬ ‫ﻣﻦ‬ .‫اﻷﳕاﻁ‬ ‫ﻫﺬﻩ‬ ‫ﺃﺣد‬ ‫ﻣﻦ‬ ‫اﺟﺘﻤاﻋﻲ‬ ‫ﺃﻭ‬ ‫ﻃﺒﻲ‬ ‫ﻣاﻧﻊ‬ ‫ﻫﻨاﻙ‬ ‫ﻛﻤا‬ ،‫الﻄﻮيل‬ ‫اﳌدﻯ‬ ‫ﻋلﻰ‬ ‫ﻛلفة‬ ‫ﻭﺃقلﻬا‬ ‫ﻛفاﺀة‬ ‫الﻜلﻮية‬ ‫اﳌﻌاﳉة‬ ‫ﺃﳕاﻁ‬ ‫ﺃﻛﺜﺮ‬ ‫الﻜلﻰ‬ ‫ﺯﺭﻉ‬ ‫يﻌﺘﺒﺮ‬ • ‫ﺃﻱ‬ ‫ﺗﺸﺠيﻊ‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ .‫ﺃﻃﻮﻝ‬ ‫ﻭﳌدة‬ ‫ﺟيدة‬ ‫ﺑصﻮﺭة‬ ‫للﻌيﺶ‬ ‫ﺃﻓﻀل‬ ‫ﻓﺮﺻة‬ ‫للﻤﺮيﺾ‬ ‫يﺘيﺢ‬ ‫ﺃﻧﻪ‬ ‫ﺫلﻚ‬ ‫يﺘﻢ‬ ‫ﺃﻥ‬ ‫يﺴﺘﺤﺴﻦ‬ ‫ﻛﻤا‬ ،‫لﻪ‬ ‫ﹰ‬‫ا‬‫ﻣﺘاﺣ‬ ‫اﳋياﺭ‬ ‫ﻫﺬا‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ‫الﻜلﻰ‬ ‫ﺯﺭﻉ‬ ‫ﻋلﻰ‬ ‫ﹰ‬‫ا‬‫ﻃﺒي‬ ‫ﻻﺋﻖ‬ ‫ﻣﺮيﺾ‬ .‫الﻨﻬاﺋﻲ‬ ‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫ﻣﺮﺣلة‬ ‫ﺇلﻰ‬ ‫اﳌﺮيﺾ‬ ‫يصل‬ ‫ﺃﻥ‬ ‫قﺒل‬ ‫ﻛلﻮية‬ ‫ﺑﻮﻇيفة‬ ‫ﹰ‬‫ا‬‫ﻣﺘﻤﺘﻌ‬ ‫ﺯاﻝ‬ ‫ﻣا‬ ‫اﳌﺮيﺾ‬ ‫يﻜﻮﻥ‬ ‫ﻋﻨدﻣا‬ ‫ﻛفاﺀة‬ ‫ﺃﻛﺜﺮ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺗﻜﻮﻥ‬ • ‫الﺒديلة‬ ‫الﻜلﻮية‬ ‫اﳌﻌاﳉة‬ ‫اﳌﺮيﺾ‬ ‫يﺒدﺃ‬ ‫ﻋﻨدﻣا‬ ‫ﺃﻱ‬ ،(residual renal function: RRF) ‫ﻣﺘﺒﻘية‬ ‫ﻣزايا‬ ‫ﻋدة‬ ‫لﻬا‬ ‫ﺃﻥ‬ ‫ﻛﻤا‬ ،‫اﳌزﺭﻭﻋة‬ ‫الﻜلية‬ ‫ﻓﺸل‬ ‫ﺑﻌد‬ ‫الديلزة‬ ‫ﺇلﻰ‬ ‫يﺤﻮﻝ‬ ‫ﻋﻨدﻣا‬ ‫ﺃﻭ‬ ‫اﻷﻭلﻰ‬ ‫للﻤﺮة‬ .(٢ ‫ﺟدﻭﻝ‬ ‫)اﻧﻈﺮ‬ ‫للديلزة‬ ‫ﺃﻭﻝ‬ ‫ﻛﺨياﺭ‬ ‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫ﻋلﻰ‬ ‫ﻭاﺟﺘﻤاﻋية‬ ‫ﻃﺒية‬ ‫ﺇﺫا‬ ‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫ﺇلﻰ‬ ‫اﻷﻣﺮ‬ ‫ﺁﺧﺮ‬ ‫ﻓﻲ‬ ‫الﻨﻬاﺋﻲ‬ ‫الﻜلﻮﻱ‬ ‫ﺑالفﺸل‬ ‫اﳌصاﺑﲔ‬ ‫ﺃﻏلﺐ‬ ‫ﺳيﺤﺘاﺝ‬ • ‫للﻤﻌاﳉة‬ ‫ﺃﻭﻝ‬ ‫ﻛﺨياﺭ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﻦ‬ ‫اﺳﺘفادﻭا‬ ‫ﻭﺇﺫا‬ ،‫ﻃﻮيلة‬ ‫ﳌدة‬ ‫الديلزة‬ ‫ﻓﻲ‬ ‫اﺳﺘﻤﺮﻭا‬ ‫الﻨاﺳﻮﺭ‬ ‫لﺘﻜﻮيﻦ‬ ‫الﺬﺭاﻉ‬ ‫ﺃﻭﺭدة‬ ‫ﻋلﻰ‬ ‫اﶈاﻓﻈة‬ ‫ﻣﻦ‬ ‫ﺳيﺘﻤﻜﻨﻮﻥ‬ ‫ﻓﺈﻧﻬﻢ‬ ‫الﺒديلة‬ ‫الﻜلﻮية‬ .‫اﳌﺴﺘﻘﺒل‬ ‫ﻓﻲ‬ ‫الﻮﺭيدﻱ‬ ‫الﺸﺮياﻧﻲ‬
  • ١٢ (‫ﺳﻨﺔ‬ ١٨ ‫ﻣﻦ‬ ‫ﺃﻗﻞ‬ ‫)ﻟﻸﻃﻔﺎﻝ‬ «Schwartz» ‫ﻣﻌﺎﺩﻟﺔ‬ ‫ﺍﻟﻜﺮﻳﺎﺗﻨﲔ‬ ‫ﺗﺼﻔﻴﺔ‬ ‫ﺍﳌﺰﻣﻦ‬ ‫ﺍﻟﻜﻠﻮﻱ‬ ‫ﺍﻟﻘﺼﻮﺭ‬ :٣-١ ‫ﻣﻌدﻝ‬ ‫ﻛاﻥ‬ ‫ﺇﺫا‬ ( •chronic kidney disease: CKD) ‫اﳌزﻣﻦ‬ ‫الﻜلﻮﻱ‬ ‫الﻘصﻮﺭ‬ ‫ﺗﺸﺨيﺺ‬ ‫يﺘﻢ‬ ‫الﻜلﻰ‬ ‫ﺗﺄﺫﻱ‬ ‫ﻋلﻰ‬ ‫دﻻلة‬ ‫ﻫﻨاﻙ‬ ‫ﻛاﻧﺖ‬ ‫ﺇﺫا‬ ‫ﺃﻭ‬ ٢‫ﻣل/دقيﻘة/٣٧٫١ﻡ‬ ٦٠ ‫ﻣﻦ‬ ‫ﺃقل‬ ‫الﻜﺒيﺒﻲ‬ ‫الﺮﺷﺢ‬ .(١ ‫ﺟدﻭﻝ‬ ‫)اﻧﻈﺮ‬ ‫ﺃﺷﻬﺮ‬ ‫ﺛﻼﺛة‬ ‫ﻋﻦ‬ ‫ﺗﻘل‬ ‫ﻻ‬ ‫ﳌدة‬ (‫الدﻣﻮية‬ ‫الﺒيلة‬ ،‫الﺒﺮﻭﺗيﻨية‬ ‫الﺒيلة‬ :‫)ﻣﺜل‬ ‫الﻜلﻮﻱ‬ ‫الﻘصﻮﺭ‬ ‫ﻣﺮاﺣل‬ ‫ﻣﻦ‬ ‫اﳋاﻣﺴة‬ ‫ﺃﻭ‬ ‫الﺮاﺑﻌة‬ ‫اﳌﺮﺣلة‬ ‫ﻓﻲ‬ ‫ﻣﺮيﺾ‬ ‫ﻛل‬ ‫ﻣﺘاﺑﻌة‬ ‫ﻣﻦ‬ ‫ﻻﺑد‬ • ،‫الﻜلﻮﻱ‬ ‫ﺑالفﺸل‬ ‫ﺇﺻاﺑﺘﻪ‬ ‫اﺣﺘﻤاﻻﺕ‬ ‫ﻋﻦ‬ ‫ﺇﺧﺒاﺭﻩ‬ ‫يﺠﺐ‬ ‫ﻛﻤا‬ ،‫ﻛلﻰ‬ ‫اﺧﺘصاﺻﻲ‬ ‫قﺒل‬ ‫ﻣﻦ‬ ‫اﳌزﻣﻦ‬ ‫لﻘاﺡ‬ ‫ﺑﺘﻨاﻭﻝ‬ ‫ﻭﻧصﺤﻪ‬ ،‫اﳊالة‬ ‫ﺗلﻚ‬ ‫ﻓﻲ‬ ‫لﻪ‬ ‫اﳌﺘاﺣة‬ ‫الﺒديلة‬ ‫الﻜلﻮية‬ ‫اﳌﻌاﳉة‬ ‫ﺧياﺭاﺕ‬ ‫ﻭﺗﻮﺿيﺢ‬ ‫ﺃﻥ‬ ‫الﻄﺒيﺐ‬ ‫ﺗﻮقﻊ‬ ‫ﺇﺫا‬ ‫الﻮﺭيدﻱ‬ ‫الﺸﺮياﻧﻲ‬ ‫الﻨاﺳﻮﺭ‬ ‫ﺑﻌﻤل‬ ‫ﻭﻧصﺤﻪ‬ ،«‫»ﺏ‬ ‫الﻮﺑاﺋﻲ‬ ‫الﻜﺒد‬ ‫ﻓيﺮﻭﺱ‬ .‫اﳌﺴﺘﻘﺒل‬ ‫ﻓﻲ‬ ‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫ﺇلﻰ‬ ‫يﺤﺘاﺝ‬ ‫ﹰ‬‫ا‬‫ﻣصاﺑ‬ ‫يﻌﺘﺒﺮ‬ ‫ﻓﺈﻧﻪ‬ ‫اﳌزﻣﻦ‬ ‫الﻜلﻮﻱ‬ ‫الﻘصﻮﺭ‬ ‫ﻣﺮاﺣل‬ ‫ﻣﻦ‬ ‫اﳋاﻣﺴة‬ ‫اﳌﺮﺣلة‬ ‫ﺇلﻰ‬ ‫اﳌﺮيﺾ‬ ‫ﻭﺻل‬ ‫ﺇﺫا‬ • end stage) ‫الﻨﻬاﺋﻲ‬ ‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫ﻣﺴﻤﻰ‬ ‫يﻄلﻖ‬ ‫ﻭﻻ‬ ،(kidney failure) ‫الﻜلﻮﻱ‬ ‫ﺑالفﺸل‬ ‫الﻜلﻮية‬ ‫اﳌﻌاﳉة‬ ‫ﻋلﻰ‬ ‫اﳌﻌﺘﻤد‬ ‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫ﻣﺮيﺾ‬ ‫ﻋلﻰ‬ ‫ﺇﻻ‬ (renal disease: ESRD .(renal replacement therapy: RRT) ‫الﺒديلة‬ ‫ﺍﳌﺰﻣﻦ‬ ‫ﺍﻟﻜﻠﻮﻱ‬ ‫ﺍﻟﻘﺼﻮﺭ‬ ‫ﻣﺮﺍﺣﻞ‬ :١ ‫ﺟﺪﻭﻝ‬ ‫ﺍﳌﺮﺣﻠﺔ‬‫ﺍﻟﻮﺻﻒ‬ ‫ﺍﻟﻜﺒﻴﺒﻲ‬ ‫ﺍﻟﺮﺷﺢ‬ ‫ﻣﻌﺪﻝ‬ (٢‫ﻡ‬ ١٫٧٣/‫)ﻣﻞ/ﺩﻗﻴﻘﺔ‬ ١‫ﻃﺒيﻌﻲ‬ ‫ﻛﺒيﺒﻲ‬ ‫ﺭﺷﺢ‬ ‫ﻣﻌدﻝ‬ ‫ﻣﻊ‬ ‫الﻜلﻰ‬ ‫ﺗﺄﺫﻱ‬ ‫ﻋلﻰ‬ ‫دﻻلة‬٩٠ < ٢‫الﻜﺒيﺒﻲ‬ ‫الﺮﺷﺢ‬ ‫ﻣﻌدﻝ‬ ‫ﻓﻲ‬ ‫ﺑﺴيﻂ‬ ‫اﻧﺨفاﺽ‬ ‫ﻣﻊ‬ ‫الﻜلﻰ‬ ‫ﺗﺄﺫﻱ‬ ‫ﻋلﻰ‬ ‫دﻻلة‬٨٩ – ٦٠ ٣‫الﻜﺒيﺒﻲ‬ ‫الﺮﺷﺢ‬ ‫ﻣﻌدﻝ‬ ‫ﻓﻲ‬ ‫ﻣﺘﻮﺳﻂ‬ ‫اﻧﺨفاﺽ‬٥٩ – ٣٠ ٤‫الﻜﺒيﺒﻲ‬ ‫الﺮﺷﺢ‬ ‫ﻣﻌدﻝ‬ ‫ﻓﻲ‬ ‫ﺷديد‬ ‫اﻧﺨفاﺽ‬٢٩ – ١٥ ٥‫ﻛلﻮﻱ‬ ‫ﻓﺸل‬١٥ > (‫)ﺳﻢ‬ ‫الﻄﻮﻝ‬ x ٠٫٥٥ (‫)ﻣلﻎ/دﺳل‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ = (‫)ﻣل/دقيﻘة‬ ‫الﻜﺒيﺒﻲ‬ ‫الﺮﺷﺢ‬ ‫ﻣﻌدﻝ‬ (‫)ﻣلﻎ/دﺳل‬ ‫الﺒﻮﻝ‬ ‫ﻓﻲ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ x (‫)ﻝ‬ ‫ﺳاﻋة‬ ٢٤ ‫ﻓﻲ‬ ‫الﺒﻮﻝ‬ ‫ﺣﺠﻢ‬ ١٫٤٤ x (‫)ﻣلﻎ/دﺳل‬ ‫الدﻡ‬ ‫ﻓﻲ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ = (‫)ﻣل/دقيﻘة‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﺗصفية‬
  • ١١ ‫ﺍﳌﻨﺘﻈﻤﺔ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﻟﻠﺪﻳﻠﺰﺓ‬ ‫ﺍﳌﻨﺎﺳﺐ‬ ‫ﺍﳌﺮﻳﺾ‬ ‫ﺍﺧﺘﻴﺎﺭ‬ :١ ‫ﻓﺼﻞ‬ ‫ﺍﻷﻫﺪﺍﻑ‬ :١-١ .‫ﻣﻨاﺳﺐ‬ ‫ﹴ‬‫ﻭقﺖ‬ ‫ﻓﻲ‬ ‫الﺒديلة‬ ‫الﻜلﻮية‬ ‫اﳌﻌاﳉة‬ ‫ﺑدﺀ‬ ‫ﻋلﻰ‬ ‫الﺘﺸﺠيﻊ‬ • .‫اﳌزﻣﻦ‬ ‫الﻜلﻮﻱ‬ ‫الﻘصﻮﺭ‬ ‫ﲟﺮﺿﻰ‬ ‫للﻌﻨاية‬ ‫اﳌﺘﻜاﻣل‬ ‫الﺘﺨﻄيﻂ‬ ‫ﺃﻫﻤية‬ ‫ﻋلﻰ‬ ‫الﺘﺄﻛيد‬ • .‫اﳌﻨﺘﻈﻤة‬ ‫الصفاقية‬ ‫للديلزة‬ ‫اﳌﻨاﺳﺐ‬ ‫اﳌﺮيﺾ‬ ‫اﺧﺘياﺭ‬ ‫ﻣﻌاييﺮ‬ ‫اﺳﺘﻌﺮاﺽ‬ • ‫ﺍﻟﻜﻠﻴﺔ‬ ‫ﻭﻇﻴﻔﺔ‬ ‫ﺗﻘﺪﻳﺮ‬ :٢-١ ‫ﻣﺴﺘﻮﻯ‬ ‫ﻭليﺲ‬ ،( •glomerular filtration rate: GFR) ‫الﻜﺒيﺒﻲ‬ ‫الﺮﺷﺢ‬ ‫ﻣﻌدﻝ‬ ‫يﻌﺘﺒﺮ‬ ‫ﻭالﻘصﻮﺭ‬ ‫الصﺤة‬ ‫ﺣالﺘﻲ‬ ‫ﻓﻲ‬ ‫الﻜلﻰ‬ ‫لﻮﻇيفة‬ ‫قياﺱ‬ ‫ﺃﻓﻀل‬ ‫ﻫﻮ‬ ،‫اليﻮﺭيا‬ ‫ﺃﻭ‬ ‫الﻜﺮياﺗيﻨﲔ‬ .‫الﻜلﻮﻱ‬ ‫ﻃﺮيﻖ‬ ‫ﻋﻦ‬ ‫ﺗﻘديﺮﻩ‬ ‫اﻷﻓﻀل‬ ‫ﻭﻣﻦ‬ ،‫ﻣﺒاﺷﺮة‬ ‫ﺑصﻮﺭة‬ ‫الﻜﺒيﺒﻲ‬ ‫الﺮﺷﺢ‬ ‫ﻣﻌدﻝ‬ ‫قياﺱ‬ ‫الصﻌﺐ‬ ‫ﻣﻦ‬ • modification of» ‫ﻭﻣﻌادلة‬ ،«‫ﻏﻮلﺖ‬ ‫»ﻛﻮﻛﺮﻭﻓﺖ‬ ‫ﻣﻌادلة‬ ‫ﻣﺜل‬ ‫الﺮياﺿية‬ ‫اﳌﻌادﻻﺕ‬ ‫اﺳﺘﺨداﻡ‬ .«‫»ﺷﻮاﺭﺗز‬ ‫ﻭﻣﻌادلة‬ «diet in renal disease: MDRD ‫ﺗﻘديﺮ‬ ‫ﻓﻲ‬ ‫دقة‬ ‫ﺃﻛﺜﺮ‬ ‫ليﺲ‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﺗصفية‬ ‫ﺣﺴاﺏ‬ ‫ﺑﻐﺮﺽ‬ ‫ﺳاﻋة‬ •٢٤ ‫ﳌدة‬ ‫الﺒﻮﻝ‬ ‫ﲡﻤيﻊ‬ ‫اﳋاﺻة‬ ‫اﳊاﻻﺕ‬ ‫ﺑﻌﺾ‬ ‫ﻓﻲ‬ ‫ﺇﻻ‬ ،‫الﺴاﺑﻘة‬ ‫الﺮياﺿية‬ ‫اﳌﻌادﻻﺕ‬ ‫ﻣﻦ‬ ‫الﻜﺒيﺒﻲ‬ ‫الﺮﺷﺢ‬ ‫ﻣﻌدﻝ‬ .(‫اﻷﻃﺮاﻑ‬ ‫ﺑﺒﺘﺮ‬ ‫اﳌصاﺑﲔ‬ :‫)ﻣﺜاﻝ‬ «‫ﻏﻮﻟﺖ‬ ‫»ﻛﻮﻛﺮﻭﻓﺖ‬ ‫ﻣﻌﺎﺩﻟﺔ‬ ‫ﺍﺨﻤﻟﺘﺼﺮﺓ‬ “MDRD” ‫ﻣﻌﺎﺩﻟﺔ‬ (‫)ﻛلﻎ‬ ‫الﻮﺯﻥ‬ x [(‫]٠٤١-الﻌﻤﺮ)ﺳﻨة‬ ٧٢ x (‫)ﻣلﻎ/دﺳل‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ (‫لﻺﻧاﺙ‬ ٠٫٨٥ ‫ﻓﻲ‬ ‫)اﺿﺮﺏ‬ = (‫)ﻣل/دقيﻘة‬ ‫الﻜﺒيﺒﻲ‬ ‫الﺮﺷﺢ‬ ‫ﻣﻌدﻝ‬ ٠٫٢٠٣- [(‫)ﺳﻨة‬ ‫]الﻌﻤﺮ‬ × ١٫١٥٤ -[(‫)ﻣلﻎ/دﺳل‬ ‫الﻜﺮياﺗﻨﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ ] × ١٨٦٫٣ = ‫الﻜﺒيﺒﻲ‬ ‫الﺮﺷﺢ‬ ‫ﻣﻌدﻝ‬ (‫لﻺﻧاﺙ‬ ٠٫٧٤٢ ‫ﻓﻲ‬ ‫ﹰ‬‫ا‬‫)ﻣﻀﺮﻭﺑ‬ (٢‫ﻡ‬ ١٫٧٣/‫)ﻣل/دقيﻘة‬
  • ١٠ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﻟﻠﺪﻳﻠﺰﺓ‬ ‫ﺍﻟﺴﻮﺩﺍﻥ‬ ‫ﺑﺮﻧﺎﻣﺞ‬ ‫ﺑﺠﻬﻮد‬ ‫٥٠٠٢ﻡ‬ ‫ﻋاﻡ‬ ‫ﻣﻦ‬ ‫يﻮﻧيﻮ‬ ‫ﻓﻲ‬ ‫ﺗﺄﺳيﺴﻪ‬ ‫ﰎ‬ ‫ﺭاﺋد‬ ‫ﺑﺮﻧاﻣﺞ‬ ‫الصفاقية‬ ‫للديلزة‬ ‫الﺴﻮداﻥ‬ ‫ﺑﺮﻧاﻣﺞ‬ ‫ﻣﺤﻤد‬ ‫الدﻛﺘﻮﺭ‬ ،(‫الﻮﻃﻨﻲ‬ ‫الﺮﺑاﻁ‬ ‫ﺟاﻣﻌة‬ ‫)ﺭﺋيﺲ‬ ‫ﻋاﺋﺸة‬ ‫ﺃﺑﻮ‬ ‫ﺣﺴﻦ‬ ‫الدﻛﺘﻮﺭ‬ ‫اﻷﺳﺘاﺫ‬ ‫ﻣﻦ‬ ‫ﻣﻘدﺭة‬ ‫اﳌﺮﻛز‬ ‫)ﻣديﺮ‬ ‫الﻌﻮﺽ‬ ‫ﺧليفة‬ ‫الدﻛﺘﻮﺭ‬ ،(‫الﻄﺒية‬ ‫لﻺﻣداداﺕ‬ ‫الﻌاﻣة‬ ‫الﻬيﺌة‬ ‫)ﻣديﺮ‬ ‫ﻣﻨدﻭﺭ‬ ‫اﳌﻬدﻱ‬ ‫الﻄﺒية‬ ‫ﺑاﳋدﻣاﺕ‬ ‫الﻜلﻰ‬ ‫قﺴﻢ‬ ‫)ﻣديﺮ‬ ‫ﻛﺒلﻮ‬ ‫ﺟاﺑﺮ‬ ‫ﺑاﺑﻜﺮ‬ ‫ﻭالدﻛﺘﻮﺭ‬ ،(‫الﻜلﻰ‬ ‫ﻭﺯﺭﻉ‬ ‫ﻷﻣﺮاﺽ‬ ‫الﻘﻮﻣﻲ‬ .(‫الﺴﻮداﻧية‬ ‫الﻌﺴﻜﺮية‬ ‫ﺑياﻧاﺕ‬ ‫ﻭقاﻋدة‬ ،‫اﳌﺮﺿﻰ‬ ‫ﻻﺳﺘﻘﻄاﺏ‬ ‫ﻣﺘﻜاﻣل‬ ‫ﺑﻨﻈاﻡ‬ ‫الصفاقية‬ ‫للديلزة‬ ‫الﺴﻮداﻥ‬ ‫ﺑﺮﻧاﻣﺞ‬ ‫ﻭﳝﺘاﺯ‬ ،‫الديلزة‬ ‫ﻭﻣﺴﺘﻬلﻜاﺕ‬ ‫ﻣﺤاليل‬ ‫لﻨﻘل‬ ‫ﻣﺸﺘﺮﻛة‬ ‫ﻭﺗﺮﺗيﺒاﺕ‬ ،‫ﻣﻮﺣدة‬ ‫ﻋﻼﺟية‬ ‫ﻭﺧﻄﻂ‬ ،‫ﻣﺮﻛزية‬ ‫ﺃداﺀ‬ ‫ﻭﻣﺘاﺑﻌة‬ ،‫اﳌﺮﺿﻰ‬ ‫ﻣﺸاﻛل‬ ‫ﳌﻨاقﺸة‬ ‫دﻭﺭية‬ ‫ﺑصﻮﺭة‬ ‫ﺗﻌﻘد‬ ‫ﻣﻨﺘﻈﻤة‬ ‫اﺟﺘﻤاﻋاﺕ‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ .‫ﳌﻨﺘﺴﺒيﻪ‬ ‫ﻣﺴﺘﻤﺮة‬ ‫ﺗدﺭيﺒية‬ ‫دﻭﺭاﺕ‬ ‫الﺒﺮﻧاﻣﺞ‬ ‫يﻮﻓﺮ‬ ‫ﻛﻤا‬ .‫الﻌﻼﺟية‬ ‫اﳋﻄﻂ‬ ‫ﻭﻭﺿﻊ‬ ،‫اﳌﺮاﻛز‬ ‫ﺑﺸﻜل‬ ‫اﳌﻨﺘﻈﻤة‬ ‫الصفاقية‬ ‫للديلزة‬ ‫ﻣﺮاﻛز‬ ‫ﺳﺒﻊ‬ ‫ﺗﺄﺳيﺲ‬ ‫ﰎ‬ ‫قد‬ ‫ﻛاﻥ‬ ‫٧٠٠٢ﻡ‬ ‫ﻋاﻡ‬ ‫ﻧﻬاية‬ ‫ﺑﺤلﻮﻝ‬ ‫اﳋﺮﻃﻮﻡ‬ ‫الﻌاﺻﻤة‬ ‫ﻓﻲ‬ ‫ﻣﻨﻬا‬ ‫ﺳﺖ‬ ،‫الﺴﻮداﻥ‬ ‫ﻓﻲ‬ ‫ﺭﺋيﺴية‬ ‫ﻣﺴﺘﺸفياﺕ‬ ‫ﺳﺒﻊ‬ ‫ﻓﻲ‬ ‫ﻣﺘﺴلﺴل‬ ‫ﺗﺄﺳيﺲ‬ ‫ﻣﻌاييﺮ‬ ‫ﺃﻫﻢ‬ ‫ﻭﻛاﻧﺖ‬ ،‫ﻣﺮيﺾ‬ ‫ﻣاﺋﺘﻲ‬ ‫ﺣﻮالﻲ‬ ‫ﲟﺠﻤﻮﻋﻬا‬ ‫ﺗﺨدﻡ‬ ،‫اﳉزيﺮة‬ ‫ﻭﻻية‬ ‫ﻓﻲ‬ ‫ﻭﻭاﺣد‬ ‫ﻓﻲ‬ ‫ﻭﺭاﻏﺐ‬ ‫الصفاقية‬ ‫ﺑالديلزة‬ ‫ﻭﻣﻬﺘﻢ‬ ‫ﻣﺘﺤﻤﺲ‬ ‫الﻜلﻰ‬ ‫لﻄﺐ‬ ‫اﺧﺘصاﺻﻲ‬ ‫ﺗﻮﻓﺮ‬ ‫اﳌﺮاﻛز‬ ‫ﻫﺬﻩ‬ .‫اﳌﻌﻨية‬ ‫اﳌﺴﺘﺸفياﺕ‬ ‫ﻓﻲ‬ ‫ﻣﺘﻌاﻭﻧة‬ ‫ﺇداﺭة‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ ،‫الفﺮيﻖ‬ ‫ﺑﺮﻭﺡ‬ ‫اﺠﻤﻟاﻝ‬ ‫ﻫﺬا‬ ‫ﻓﻲ‬ ‫الﻌﻤل‬ ‫ﻭﻛاﻥ‬ ،‫الﺴﺨﻲ‬ ‫ﺑالدﻋﻢ‬ ‫ﺗﺄﺳيﺴﻪ‬ ‫ﻣﻨﺬ‬ ‫اﳌﺸﺮﻭﻉ‬ ‫ﻣﺸﻜﻮﺭة‬ «‫الﻮﻃﻨﻲ‬ ‫الﺮﺑاﻁ‬ ‫»ﺟاﻣﻌة‬ ‫ﺗﺒﻨﺖ‬ ‫ﻭقد‬ ،‫اﻷﺧﺮﻯ‬ ‫اﳌدﻥ‬ ‫ﻣﻦ‬ ‫ﺑالﺒﺮﻧاﻣﺞ‬ ‫الﻌاﻣلﲔ‬ ‫ﺗدﺭيﺐ‬ ‫ﻓﻲ‬ ‫الﺴﺒﻖ‬ ‫قصﺐ‬ ‫اﳉاﻣﻌﻲ‬ ‫الﺮﺑاﻁ‬ ‫ﻣﺴﺘﺸفﻰ‬ ‫ﳌﺮﻛز‬ ‫الﻄﺒية‬ ‫ﻭاﳌﺴﺘﻬلﻜاﺕ‬ ‫اﶈاليل‬ ‫ﺑﺘﻮﻓيﺮ‬ ‫اﳌﺮﻛزية‬ ‫الﻄﺒية‬ ‫لﻺﻣداداﺕ‬ ‫الﻌاﻣة‬ ‫الﻬيﺌة‬ ‫الﺘزﻣﺖ‬ ‫ﻛﻤا‬ .‫ﺗﺄﺳيﺴﻪ‬ ‫ﻣﻨﺬ‬ ‫اﳌﺸﺮﻭﻉ‬ ‫ﺇلﻰ‬ ‫اﳌﻨﺘﺴﺒﲔ‬ ‫للﻤﺮﺿﻰ‬ ‫الﻼﺯﻣة‬ ‫للﺒﺮﻧاﻣﺞ‬ ‫الفاﻋل‬ ‫الدﻭﺭ‬ ‫ﺭﺳﻤية‬ ‫ﺑصﻮﺭة‬ ‫الﻜلﻰ‬ ‫ﻭﺯﺭﻉ‬ ‫ﻷﻣﺮاﺽ‬ ‫الﻘﻮﻣﻲ‬ ‫اﳌﺮﻛز‬ ‫ﺃقﺮ‬ ‫٦٠٠٢ﻡ‬ ‫ﻋاﻡ‬ ‫ﻓﻲ‬ ‫٦٠٠٢ﻡ‬ ‫ﻋاﻡ‬ ‫ﻣﻦ‬ ‫ﺃﻛﺘﻮﺑﺮ‬ ‫ﺷﻬﺮ‬ ‫ﻭﻓﻲ‬ ،‫الﺴﻮداﻥ‬ ‫ﻓﻲ‬ ‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫ﲟﺮﺿﻰ‬ ‫اﳌﺘﻜاﻣلة‬ ‫الﻌﻨاية‬ ‫ﻓﻲ‬ ‫قﻮﻣﻲ‬ ‫ﻛﺒﺮﻧاﻣﺞ‬ ‫ﻭﺗﺒﻨﺘﻪ‬ ،‫الﺒﺮﻧاﻣﺞ‬ ‫ﺑﻄﺮﺱ‬ ‫ﺗاﺑيﺘا‬ ‫الدﻛﺘﻮﺭة‬ ‫اﻻﲢادية‬ ‫الصﺤة‬ ‫ﻭﺯيﺮة‬ ‫الﺴيدة‬ ‫قيﻤﺖ‬ .‫الﻜلﻰ‬ ‫ﻭﺯﺭﻉ‬ ‫ﻷﻣﺮاﺽ‬ ‫الﻘﻮﻣﻲ‬ ‫اﳌﺮﻛز‬ ‫ﻣﻨﻈﻮﻣة‬ ‫ﺇلﻰ‬ ‫ﺇﺿاﻓﺘﻪ‬ ‫يﺠﺐ‬
  • ٩ ‫ﻣﻘﺪﻣﺔ‬ ‫ﻋلﻰ‬ ‫ﹰ‬‫ﻼ‬‫ﺛﻘي‬ ‫ﹰ‬‫ا‬‫ﻋﺒﺌ‬ ‫ﺗﺸﻜل‬ ‫الﺘﻲ‬ ‫ﻭاﻻﺟﺘﻤاﻋية‬ ‫الصﺤية‬ ‫اﳌﺸﻜﻼﺕ‬ ‫ﻣﻦ‬ ‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫يﻌﺘﺒﺮ‬ ‫ﻫﺬﻩ‬ ‫ﺗﻌزﻯ‬ .‫ﻣﻀﻄﺮدة‬ ‫ﺑصﻮﺭة‬ ‫ﺑﻬا‬ ‫اﻹﺻاﺑة‬ ‫ﻧﺴﺒة‬ ‫ﺗﺘزايد‬ ‫ﻭالﺘﻲ‬ ،‫الﻌالﻢ‬ ‫ﺃﻧﺤاﺀ‬ ‫ﻛل‬ ‫ﻓﻲ‬ ‫اﺠﻤﻟﺘﻤﻌاﺕ‬ ‫الﻜلﻮية‬ ‫ﺑاﻻﻋﺘﻼﻻﺕ‬ ‫اﻹﺻاﺑة‬ ‫ﻧﺴﺒة‬ ‫ﻓﻲ‬ ‫ﺣﻘيﻘية‬ ‫ﺯيادة‬ ‫ﻫﻨاﻙ‬ ‫ﺃﻥ‬ ‫ﻣﻨﻬا‬ ،‫ﻋﻮاﻣل‬ ‫لﻌدة‬ ‫الزيادة‬ ‫اﻷﻣﺮاﺽ‬ ‫ﻣﻦ‬ ‫الﻌﻼﺝ‬ ‫ﻭﺳاﺋل‬ ‫ﲢﺴﻦ‬ ‫ﻭﻣﻨﻬا‬ ،‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫ﺇلﻰ‬ ‫اﻷﻣﺮ‬ ‫ﻧﻬاية‬ ‫ﻓﻲ‬ ‫ﺗﺆدﻱ‬ ‫الﺘﻲ‬ ‫اﺨﻤﻟﺘلفة‬ ‫ﺇلﻰ‬ ‫ﻣﺘﻄاﻭلة‬ ‫ﻣدد‬ ‫ﺑﻌد‬ ‫ﺑﻬا‬ ‫اﻹﺻاﺑة‬ ‫ﺗﻘﻮد‬ ‫قد‬ ‫ﻭالﺘﻲ‬ ،‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻭﻓﺮﻁ‬ ‫الﺴﻜﺮﻱ‬ ‫داﺀ‬ ‫ﻣﺜل‬ ،‫اﻷﺧﺮﻯ‬ .‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫لﻜل‬ ‫ﺟديدة‬ ‫ﺣالة‬ ‫ﻣاﺋﺘﻲ‬ ‫ﺇلﻰ‬ ‫ﻣاﺋة‬ ‫ﺑﻨﺤﻮ‬ ‫الﻜلﻮﻱ‬ ‫ﺑالفﺸل‬ ‫اﻹﺻاﺑة‬ ‫لﻨﺴﺒة‬ ‫الﻌاﳌﻲ‬ ‫اﳌﻌدﻝ‬ ‫ﺭ‬‫ﱠ‬‫د‬‫يﻘ‬ ‫ﺑﻨﺤﻮ‬ ‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫لﻌﻼﺝ‬ ‫الﻌاﳌية‬ ‫الﺴﻨﻮية‬ ‫الﻜلفة‬ ‫ﺭ‬‫ﱠ‬‫د‬‫ﺗﻘ‬ ‫ﻛﻤا‬ ،‫الﻌاﻡ‬ ‫ﻓﻲ‬ ‫ﻧﺴﻤة‬ ‫ﻣليﻮﻥ‬ ‫ﻏيﺮ‬ ،‫الﻮﺑاﺀ‬ ‫ﻫﺬا‬ ‫ﺃﻣاﻡ‬ ‫ﺣاﺋﺮة‬ ‫ﺗﻘﻒ‬ ‫الﻨاﻣية‬ ‫الدﻭﻝ‬ ‫ﻣﻌﻈﻢ‬ ‫ﳒد‬ ‫ﺃﻥ‬ ‫ﺇﺫﻥ‬ ‫ﹰ‬‫ا‬‫ﻏﺮيﺒ‬ ‫ليﺲ‬ .‫دﻭﻻﺭ‬ ‫ﺗﺮيلﻮﻥ‬ ‫ﻛيفية‬ ‫ﻋﻦ‬ ‫ﺣية‬ ‫ﺃﻣﺜلة‬ ‫ﺃﻋﻄﺘﻨا‬ ،‫ﻭاﳌﻜﺴيﻚ‬ ‫الﻬﻨد‬ ‫ﻣﺜل‬ ،‫الﻨاﻣﻲ‬ ‫اﻻقﺘصاد‬ ‫ﺫاﺕ‬ ‫الدﻭﻝ‬ ‫ﺑﻌﺾ‬ ‫ﺃﻥ‬ .‫ﻣﻌﻘﻮلة‬ ‫اقﺘصادية‬ ‫ﻛلفة‬ ‫ﻭﺫاﺕ‬ ‫ﻓﻌالة‬ ‫ﺑﻄﺮيﻘة‬ ‫ﻀاﻝ‬‫ﹸ‬‫الﻌ‬ ‫الداﺀ‬ ‫ﻫﺬا‬ ‫ﻣﻊ‬ ‫الﺘﻌاﻣل‬ ‫الﺴﻮداﻥ‬ ‫ﻓﻲ‬ ‫الﻜلﻮﻱ‬ ‫ﺑالفﺸل‬ ‫اﻹﺻاﺑة‬ ‫ﻧﺴﺒة‬ ‫ﺗﻜﻮﻥ‬ ‫ﺃﻥ‬ ‫اﳌﺘﻮقﻊ‬ ‫ﻣﻦ‬ ،‫الﻌاﳌية‬ ‫اﳌﻌدﻻﺕ‬ ‫ﺣﺴﺐ‬ ‫الﻜلﻰ‬ ‫ﻭﺟﺮاﺣة‬ ‫ﻷﻣﺮاﺽ‬ ‫الﻘﻮﻣﻲ‬ ‫اﳌﺮﻛز‬ ‫الدﻭلة‬ ‫ﺃﻧﺸﺄﺕ‬ ‫ﻭقد‬ ،‫ﹰ‬‫ا‬‫ﺳﻨﻮي‬ ‫ﺟديدة‬ ‫ﺣالة‬ ٥٠٠٠ ‫ﻧﺤﻮ‬ ‫ﺑدﻭﺭﻩ‬ ‫الﻘﻮﻣﻲ‬ ‫اﳌﺮﻛز‬ ‫ﻭاﺟﺘﻬد‬ ،‫الﻘﻄﺮ‬ ‫ﻓﻲ‬ ‫الﻜلﻰ‬ ‫ﺃﻣﺮاﺽ‬ ‫ﻭﻣﻌاﳉة‬ ‫ﲟﻜاﻓﺤة‬ ‫ﻌﻨﻰ‬‫ﹸ‬‫ي‬ ‫قﻮﻣﻲ‬ ‫ﻛﻤﺮﻛز‬ ‫ﺇلﻰ‬ ‫ﺑاﻹﺿاﻓة‬ ،‫الﺴﻮداﻥ‬ ‫ﻣدﻥ‬ ‫ﻣﻦ‬ ‫ﻛﺜيﺮ‬ ‫ﻓﻲ‬ ‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫ﻣﺮاﻛز‬ ‫ﻣﻦ‬ ‫ﻛﺒيﺮ‬ ‫ﻋدد‬ ‫ﺇﻧﺸاﺀ‬ ‫ﻓﻲ‬ ‫الﻜﺜيﺮ‬ ‫ﻕ‬‫ﱢ‬‫ﺭ‬‫ﺗﺆ‬ ‫ﺯالﺖ‬ ‫ﻣا‬ ‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫ﻣﺸﻜلة‬ ‫ﻓﺈﻥ‬ ‫ﺫلﻚ‬ ‫ﺭﻏﻢ‬ .‫الﻜلﻰ‬ ‫لزﺭﻉ‬ ‫ﻧﺸﻂ‬ ‫قﻮﻣﻲ‬ ‫ﺑﺮﻧاﻣﺞ‬ .‫ﺑاﺣﺘياﺟاﺗﻬﻢ‬ ‫اﶈدﻭدة‬ ‫الﻄﺒية‬ ‫اﳋدﻣاﺕ‬ ‫ﻫﺬﻩ‬ ‫ﺗفﻲ‬ ‫ﻻ‬ ‫ﻭالﺬيﻦ‬ ،‫اﳌﻮاﻃﻨﲔ‬ ‫ﻣﻦ‬ ‫الفﺸل‬ ‫لﻌﻼﺝ‬ ‫ﺁﺧﺮ‬ ‫ﻛﺨياﺭ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫لﺘﻮﻓيﺮ‬ ‫ﻣاﺳة‬ ‫ﺣاﺟة‬ ‫ﻫﻨاﻙ‬ ‫ﻛاﻧﺖ‬ ‫اﻷﺳﺒاﺏ‬ ‫لﻬﺬﻩ‬ ‫ﺣالﺘﻬﻢ‬ ‫الدﻣﻮﻱ‬ ‫اﻻﺳﺘصفاﺀ‬ ‫يﻨاﺳﺐ‬ ‫ﻻ‬ ‫الﺬيﻦ‬ ‫اﳌﺮﺿﻰ‬ ‫اﺣﺘياﺟاﺕ‬ ‫لﺘﻐﻄية‬ ،‫الﺴﻮداﻥ‬ ‫ﻓﻲ‬ ‫الﻜلﻮﻱ‬ ‫ﻣﻦ‬ ‫ﺃﻛﺒﺮ‬ ‫ﹰ‬‫ا‬‫قدﺭ‬ ‫الﻌاﻣل‬ ‫ﻭللﺸﺨﺺ‬ ‫الصﻐيﺮ‬ ‫للﻄفل‬ ‫ﺗﻮﻓﺮ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺃﻥ‬ ‫ﻛﻤا‬ .‫الصﺤية‬ ‫ﺃﻣﻮﺭ‬ ‫ﻭﻫﻲ‬ ،‫ﻃﺒيﻌية‬ ‫ﺷﺒﻪ‬ ‫ﺑصﻮﺭة‬ ‫ﻭالﺴفﺮ‬ ‫ﻭالﻌﻤل‬ ‫الدﺭاﺳة‬ ‫ﻓﺮﺻة‬ ‫لﻬﻢ‬ ‫يﺘيﺢ‬ ‫ﳑا‬ ،‫اﳊﺮﻛة‬ ‫ﺣﺮية‬ ‫ﻣﻀﻄﺮﻭﻥ‬ ‫ﻫﻢ‬ ‫ﻭالﺬيﻦ‬ ‫الدﻣﻮﻱ‬ ‫ﺑاﻻﺳﺘصفاﺀ‬ ‫يﻌاﳉﻮﻥ‬ ‫الﺬيﻦ‬ ‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫ﳌﺮﺿﻰ‬ ‫ﻣﺘاﺣة‬ ‫ﻏيﺮ‬ .‫الﻌﻼﺝ‬ ‫ﺑﻐﺮﺽ‬ ‫الﻮقﺖ‬ ‫ﻃيلة‬ ‫ﺑاﳌﺴﺘﺸفياﺕ‬ ‫لﻼﺭﺗﺒاﻁ‬
  • ٨ ١٠١ (dyslipidemia) ‫ﺍﻟﺪﻡ‬ ‫ﺷﺤﻤﻴﺎﺕ‬ ‫ﺧﻠﻞ‬ ‫ﻣﻌﺎﳉﺔ‬ :١٣ ‫ﻓﺼﻞ‬ ١٠١ ‫اﻷﻫداﻑ‬ :١-١٣ ١٠١ ‫الدﻡ‬ ‫ﺷﺤﻤياﺕ‬ ‫ﺷاﻛلة‬ ‫ﻣﺮاقﺒة‬ :٢-١٣ ١٠١ ‫الدﻡ‬ ‫ﺷﺤﻤياﺕ‬ ‫ﺧلل‬ ‫ﻣﻌاﳉة‬ :٣-١٣ ١٠٤ ‫ﺍﻟﺘﺄﻫﻴﻞ‬ ‫ﺇﻋﺎﺩﺓ‬ :١٤ ‫ﻓﺼﻞ‬ ١٠٤ ‫اﻷﻫداﻑ‬ :١-١٤ ١٠٤ ‫الديلزة‬ ‫ﻋﻦ‬ ‫الﻨاﰋ‬ ‫الﻌﺠز‬ :٢-١٤ ١٠٤ ‫الﺘﺄﻫيل‬ ‫ﻭﺇﻋادة‬ ‫الﺘﻮﻇيﻒ‬ :٣-١٤ ١٠٦ ‫ﺍﻷﻃﻔﺎﻝ‬ ‫ﻋﻨﺪ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ :١٥ ‫ﻓﺼﻞ‬ ١٠٦ ‫اﻷﻫداﻑ‬ :١-١٥ ١٠٦ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺑدﺀ‬ :٢-١٥ ١٠٦ ‫الديلزة‬ ‫ﳕﻂ‬ ‫اﺧﺘياﺭ‬ :٣-١٥ ١٠٧ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻭﻣﺮاقﺒة‬ ‫ﻭﺻﻒ‬ :٤-١٥ ١٠٧ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻓﺮﻁ‬ ‫ﻣﻌاﳉة‬ :٥-١٥ ١٠٨ ‫ﺍﻟﻜﻠﻰ‬ ‫ﻟﺰﺭﻉ‬ ‫ﺍﻟﺘﺤﻀﻴﺮ‬ :١٦ ‫ﻓﺼﻞ‬ ١٠٨ ‫اﻷﻫداﻑ‬ :١-١٦ ١٠٨ ‫الﻜلﻰ‬ ‫لزﺭﻉ‬ ‫اﳌﺮيﺾ‬ ‫قاﺑلية‬ :٢-١٦ ١٠٩ ‫ﺑالﻜلﻰ‬ ‫اﶈﺘﻤل‬ ‫اﳌﺘﺒﺮﻉ‬ ‫ﺗﻘييﻢ‬ :٣-١٦ ١١١ ‫الﻜلﻰ‬ ‫لزﺭﻉ‬ ‫اﳌﺮيﺾ‬ ‫ﺇﻋداد‬ :٤-١٦ ١١١ ‫الﻜلﻰ‬ ‫ﺯﺭﻉ‬ ‫ﻭﺑﻌد‬ ‫قﺒل‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﲟﺮيﺾ‬ ‫الﻌﻨاية‬ :٥-١٦ ١١٣ ‫ﺍﳊﺎﺩ‬ ‫ﺍﻟﻜﻠﻮﻱ‬ ‫ﺍﻟﻔﺸﻞ‬ ‫ﻟﻌﻼﺝ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ :١٧ ‫ﻓﺼﻞ‬ ١١٣ ‫اﻷﻫداﻑ‬ :١-١٧ ١١٣ ‫اﳊاد‬ ‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫ﻋﻼﺝ‬ ‫ﻓﻲ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫دﻭﺭ‬ :٢-١٧ ١١٤ ‫اﳊاد‬ ‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫ﳌﺮيﺾ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫قﺜﻄاﺭ‬ :٣-١٧ ١١٤ ‫الصلﺐ‬ ‫ﺷﺒﻪ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫قﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﺗﻘﻨية‬ :٤-١٧ ١١٥ ‫اﳊاد‬ ‫الﻜلﻮﻱ‬ ‫الفﺸل‬ ‫ﻓﻲ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻭﺻﻒ‬ :٥-١٧ ١١٧ ‫ﻟﻠﺠﻮﺩﺓ‬ ‫ﺍﳌﺴﺘﻤﺮ‬ ‫ﺍﻟﺘﺤﺴﲔ‬ :١٨ ‫ﻓﺼﻞ‬ ١١٧ ‫اﻷﻫداﻑ‬ :١-١٨ ١١٧ ‫للﺠﻮدة‬ ‫اﳌﺴﺘﻤﺮ‬ ‫ﹺ‬‫الﺘﺤﺴﲔ‬ ‫ﻋﻤلية‬ :٢-١٨ ١١٧ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻓﻲ‬ ‫الﺮﺋيﺴية‬ ‫اﻷداﺀ‬ ‫ﻣﺆﺷﺮاﺕ‬ :٣-١٨ ١١٨ ‫الصفاقية‬ ‫للديلزة‬ ‫الﺴﻮداﻥ‬ ‫لﺒﺮﻧاﻣﺞ‬ ‫اﳌﺮﻛزية‬ ‫الﺒياﻧاﺕ‬ ‫قاﻋدة‬ :٤-١٨
  • ٧ ٧٤ (hemoperitoneum) ‫الصفاﻕ‬ ‫ﺗدﻣﻲ‬ :١٠-٧ ٧٤ (gastroesophageal reflux) ‫اﳌﺮيﺌﻲ‬ ‫اﳌﻌدﻱ‬ ‫اﳉزﺭ‬ :١١-٧ ٧٤ ‫الﻈﻬﺮ‬ ‫ﺃلﻢ‬ :١٢-٧ ٧٥ (electrolyte abnormalities) ‫الﻜﻬاﺭﻝ‬ ‫ﺷﺬﻭﺫ‬ :١٣-٧ ٧٥ (sclerosing encapsulating peritonitis) ‫الﻜيﺴﻲ‬ ‫الصفاﻕ‬ ‫ﺗصلﺐ‬ :١٤-٧ ٧٥ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺮيﺾ‬ ‫ﻓﻲ‬ ‫الﺒﻄﻦ‬ ‫ﺟﺮاﺣاﺕ‬ :١٥-٧ ٧٧ ‫ﺍﻟﺪﻡ‬ ‫ﻓﻘﺮ‬ ‫ﻣﻌﺎﳉﺔ‬ :٨ ‫ﻓﺼﻞ‬ ٧٧ ‫اﻷﻫداﻑ‬ :١-٨ ٧٧ ‫اﳌﺴﺘﻬدﻑ‬ (‫الدﻡ‬ ‫)ﺧﻀاﺏ‬ ‫الﻬيﻤﻮﻏلﻮﺑﲔ‬ ‫ﻣﺴﺘﻮﻯ‬ :٢-٨ ٧٨ ‫الﺘﻜﻤيلﻲ‬ ‫اﳊديد‬ :٣-٨ ٧٩ ‫ﺑاﻹﺭيﺜﺮﻭﺑﻮيﺘﲔ‬ ‫اﳌﻌاﳉة‬ :٤-٨ ٨١ (bone disease) ‫ﺍﻟﻌﻈﻢ‬ ‫ﻣﺮﺽ‬ ‫ﻣﻌﺎﳉﺔ‬ :٩ ‫ﻓﺼﻞ‬ ٨١ ‫اﻷﻫداﻑ‬ :١-٩ ٨١ ‫الدﺭيﻘاﺕ‬ ‫ﻭﻫﺮﻣﻮﻥ‬ ‫ﻭالفﺴفﻮﺭ‬ ‫الﻜالﺴيﻮﻡ‬ ‫ﻣﻦ‬ ‫اﳌﺴﺘﻬدﻓة‬ ‫اﳌﺴﺘﻮياﺕ‬ :٢-٩ ٨١ ‫الفﺴفﻮﺭ‬ ‫ﻓﺮﻁ‬ ‫ﻣﻌاﳉة‬ :٣-٩ ٨٢ ‫د‬ ‫ﻓيﺘاﻣﲔ‬ ‫ﻣﻜﻤﻼﺕ‬ :٤-٩ ٨٣ ‫الﻜالﺴيﻮﻡ‬ ‫ﻧﻘﺺ‬ ‫ﻣﻌاﳉة‬ :٥-٩ ٨٣ ‫الﻌﻈﻢ‬ ‫ﻣﺮﺽ‬ ‫ﺗﻘييﻢ‬ :٦-٩ ٨٤ ‫الﻌﻈﻢ‬ ‫ﻣﺮﺽ‬ ‫ﻣﻌاﳉة‬ :٧-٩ ٨٤ (parathyroidectomy) ‫الدﺭيﻘاﺕ‬ ‫اﺳﺘﺌصاﻝ‬ ‫دﻭاﻋﻲ‬ :٨-٩ ٨٦ ‫ﺍﻟﻌﻈﻢ‬ ‫ﻣﺮﺽ‬ ‫ﻣﻌﺎﳉﺔ‬ :٥ ‫ﺧﻮﺍﺭﺯﻣﻴﺔ‬ ٨٧ ‫ﺍﻟﺘﻐﺬﻳﺔ‬ ‫ﺳﻮﺀ‬ ‫ﻣﻌﺎﳉﺔ‬ :١٠ ‫ﻓﺼﻞ‬ ٨٧ ‫اﻷﻫداﻑ‬ :١-١٠ ٨٧ ‫الﻐﺬاﺋية‬ ‫اﳊالة‬ ‫ﻭﻣﺮاقﺒة‬ ‫ﺗﻘييﻢ‬ :٢-١٠ ٨٩ ‫الﺘﻐﺬية‬ ‫ﺳﻮﺀ‬ ‫ﻣﻌاﳉة‬ :٣-١٠ ٩٠ ‫ﺍﻟﺪﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻓﺮﻁ‬ ‫ﻣﻌﺎﳉﺔ‬ :١١ ‫ﻓﺼﻞ‬ ٩٠ ‫اﻷﻫداﻑ‬ :١-١١ ٩٠ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻣﺮاقﺒة‬ :٢-١١ ٩١ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫قياﺱ‬ :٣-١١ ٩١ ‫الدﻡ‬ ‫ﺿﻐﻂ‬ ‫ﻓﺮﻁ‬ ‫ﻣﻌاﳉة‬ :٤-١١ ٩٣ ‫الﻜلﻮﻱ‬ ‫الﺸﺮياﻥ‬ ‫ﻣﺮﺽ‬ ‫ﺗﻘييﻢ‬ :٥-١١ ٩٨ ‫ﺮﻱ‬ ‫ﹼ‬‫ﺍﻟﺴﻜ‬ ‫ﺩﺍﺀ‬ ‫ﻣﻌﺎﳉﺔ‬ :١٢ ‫ﻓﺼﻞ‬ ٩٨ ‫اﻷﻫداﻑ‬ :١-١٢ ٩٨ ‫الﺴﻜﺮﻱ‬ ‫داﺀ‬ ‫ﻋﻦ‬ ‫الﻨاﺟﻤة‬ ‫ﻭاﳌﻀاﻋفاﺕ‬ ‫الدﻡ‬ ‫ﺳﻜﺮ‬ ‫ﻣﺮاقﺒة‬ :٢-١٢ ٩٨ ‫الﺴﻜﺮﻱ‬ ‫ﺑداﺀ‬ ‫اﳌصاﺑﲔ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺮﺿﻰ‬ ‫ﻣﻌاﳉة‬ :٣-١٢
  • ٦ ٤٢ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻛفاية‬ ‫اﺧﺘﺒاﺭ‬ :٧-٤ ٤٢ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻛفاية‬ ‫اﺧﺘﺒاﺭ‬ ‫ﺧﻄﻮاﺕ‬ :٨-٤ ٤٥ (PET) ‫الصفاﻕ‬ ‫ﺗﻮاﺯﻥ‬ ‫اﺧﺘﺒاﺭ‬ :٩-٤ ٤٥ ‫الصفاﻕ‬ ‫ﺗﻮاﺯﻥ‬ ‫اﺧﺘﺒاﺭ‬ ‫ﺧﻄﻮاﺕ‬ :١٠-٤ ٤٧ ‫الصفاﻕ‬ ‫ﺗﻮاﺯﻥ‬ ‫اﺧﺘﺒاﺭ‬ ‫لﻨﺘاﺋﺞ‬ ‫ﹰ‬‫ا‬‫ﻃﺒﻘ‬ ‫الصفاﻕ‬ ‫ﻏﺸاﺀ‬ ‫ﹺ‬‫ﻧﻘل‬ ‫ﺧصاﺋﺺ‬ :١١-٤ ٤٧ ‫الصفاﻕ‬ ‫ﺗﻮاﺯﻥ‬ ‫اﺧﺘﺒاﺭ‬ ‫لﻨﺘاﺋﺞ‬ ‫ﹰ‬‫ا‬‫ﻃﺒﻘ‬ ‫الﺴﻮاﺋل‬ ‫ﺭﺷﺢ‬ ‫ﺿﻌﻒ‬ ‫ﺃﺳﺒاﺏ‬ :١٢-٤ ٤٨ ‫اﳌﺬاﺑاﺕ‬ ‫ﺗصفية‬ ‫ﲢﺴﲔ‬ :١٣-٤ ٤٩ (fluid overload) ‫الﺴﻮاﺋل‬ ‫اﺣﺘﺒاﺱ‬ ‫ﻣﻌاﳉة‬ :١٤-٤ ٥٠ ‫ﻋليﻬا‬ ‫ﻭاﶈاﻓﻈة‬ ‫اﳌﺘﺒﻘية‬ ‫الﻜلﻮية‬ ‫الﻮﻇيفة‬ ‫ﺗﻘديﺮ‬ :١٥-٤ ٥٢ ‫ﺍﻟﻘﺜﻄﺎﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋﺪﻭﻯ‬ ‫ﻣﻌﺎﳉﺔ‬ :٥ ‫ﻓﺼﻞ‬ ٥٢ ‫اﻷﻫداﻑ‬ :١-٥ ٥٢ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋدﻭﻯ‬ ‫ﻣﻨﻊ‬ :٢-٥ ٥٢ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋدﻭﻯ‬ ‫ﺗﺸﺨيﺺ‬ :٣-٥ ٥٣ ‫اﳉلدﻱ‬ ‫ﲢﺖ‬ ‫الﻨفﻖ‬ ‫ﻋدﻭﻯ‬ ‫ﺃﻭ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋدﻭﻯ‬ ‫ﻣﻌاﳉة‬ :٤-٥ ٥٣ ‫ﺍﻟﻘﺜﻄﺎﺭ‬ ‫ﻣﺨﺮﺝ‬ ‫ﻋﺪﻭﻯ‬ ‫ﻣﻌﺎﳉﺔ‬ :١ ‫ﺧﻮﺍﺭﺯﻣﻴﺔ‬ ٥٤ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﻟﻠﺪﻳﻠﺰﺓ‬ ‫ﺍﳌﺼﺎﺣﺐ‬ ‫ﺍﻟﺼﻔﺎﻕ‬ ‫ﺍﻟﺘﻬﺎﺏ‬ ‫ﻣﻌﺎﳉﺔ‬ :٦ ‫ﻓﺼﻞ‬ ٥٤ ‫اﻷﻫداﻑ‬ :١-٦ ٥٤ ‫الصفاقية‬ ‫للديلزة‬ ‫اﳌصاﺣﺐ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﻣﻨﻊ‬ :٢-٦ ٥٤ ‫الصفاقية‬ ‫للديلزة‬ ‫اﳌصاﺣﺐ‬ ‫الصفاﻕ‬ ‫الﺘﻬاﺏ‬ ‫ﺗﺸﺨيﺺ‬ :٣-٦ ٥٨ ‫الﻌيﻨة‬ ‫ﻣﻌاﳉة‬ ‫ﻃﺮيﻘة‬ :٤-٦ ٥٩ ‫الﻌﻼﺝ‬ ‫ﻭﺧﻄﻮاﺕ‬ ‫ﻣﺒادﺉ‬ :٥-٦ ٦١ ‫الﻘﺜﻄاﺭ‬ ‫ﺇﺯالة‬ ‫دﻭاﻋﻲ‬ :٦-٦ ٦٢ ‫الصفاﻕ‬ ‫ﺑالﺘﻬاﺏ‬ ‫اﻹﺻاﺑة‬ ‫ﺗﻜﺮاﺭ‬ ‫ﻣﻨﻊ‬ :٧-٦ ٦٢ ‫الدﻭاﺀ‬ ‫ﺇﻋﻄاﺀ‬ :٨-٦ ٦٧ ‫ﺍﻟﺼﻔﺎﻕ‬ ‫ﺍﻟﺘﻬﺎﺏ‬ ‫ﻣﻌﺎﳉﺔ‬ :٢ ‫ﺧﻮﺍﺭﺯﻣﻴﺔ‬ ٦٨ ‫ﺍﻟﺰﺭﻉ‬ ‫ﺳﺎﻟﺐ‬ ‫ﺍﻟﺼﻔﺎﻕ‬ ‫ﺍﻟﺘﻬﺎﺏ‬ ‫ﻣﻌﺎﳉﺔ‬ :٣ ‫ﺧﻮﺍﺭﺯﻣﻴﺔ‬ ٦٩ ‫ﺍﻟﻔﻄﺮﻱ‬ ‫ﺍﻟﺼﻔﺎﻕ‬ ‫ﺍﻟﺘﻬﺎﺏ‬ ‫ﻣﻌﺎﳉﺔ‬ :٤ ‫ﺧﻮﺍﺭﺯﻣﻴﺔ‬ ٧٠ ‫ﻋﺪﻭﺍﺋﻴﺔ‬ ‫ﺍﻟﻼ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻣﻀﺎﻋﻔﺎﺕ‬ :٧ ‫ﻓﺼﻞ‬ ٧٠ ‫اﻷﻫداﻑ‬ :١-٧ ٧٠ (hernia) ‫الفﺘﻖ‬ :٢-٧ ٧٠ (fluid leak) ‫اﶈلﻮﻝ‬ ‫ﺗﺴﺮﺏ‬ :٣-٧ ٧١ (pleural effusion) ‫اﳉﻨﺒﻲ‬ ‫اﻻﻧصﺒاﺏ‬ :٤-٧ ٧١ (catheter malfunction) ‫الﻘﺜﻄاﺭ‬ ‫ﻭﻇيفة‬ ‫ﺧلل‬ :٥-٧ ٧٣ ‫اﶈلﻮﻝ‬ ‫ﺗدﻓﻖ‬ ‫ﻋﻨد‬ ‫اﻷلﻢ‬ :٦-٧ ٧٣ (cuff extrusion) ‫الﻘﺜﻄاﺭ‬ ‫ﻛفة‬ ‫ﺑﺜﻖ‬ :٧-٧ ٧٣ ‫اﳌﺜاﻧة‬ ‫ﺛﻘﺐ‬ :٨-٧ ٧٣ ‫اﻷﻣﻌاﺀ‬ ‫ﺛﻘﺐ‬ :٩-٧
  • ٥ ‫ﺍﻟﻔﻬﺮﺱ‬ ٩ ‫ﻣﻘﺪﻣﺔ‬ ١٠ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﻟﻠﺪﻳﻠﺰﺓ‬ ‫ﺍﻟﺴﻮﺩﺍﻥ‬ ‫ﺑﺮﻧﺎﻣﺞ‬ ١١ ‫ﺍﳌﻨﺘﻈﻤﺔ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﻟﻠﺪﻳﻠﺰﺓ‬ ‫ﺍﳌﻨﺎﺳﺐ‬ ‫ﺍﳌﺮﻳﺾ‬ ‫ﺍﺧﺘﻴﺎﺭ‬ :١ ‫ﻓﺼﻞ‬ ١١ ‫اﻷﻫداﻑ‬ :١-١ ١١ ‫الﻜلية‬ ‫ﻭﻇيفة‬ ‫ﺗﻘديﺮ‬ :٢-١ ١٢ ‫اﳌزﻣﻦ‬ ‫الﻜلﻮﻱ‬ ‫الﻘصﻮﺭ‬ :٣-١ ١٣ ‫الﺒديلة‬ ‫الﻜلﻮية‬ ‫اﳌﻌاﳉة‬ ‫ﺑدﺀ‬ :٤-١ ١٣ ‫اﳌﺘﻜاﻣلة‬ ‫الﻜلﻮية‬ ‫الﻌﻨاية‬ ‫ﺧﻄة‬ :٥-١ ١٥ ‫الصفاقية‬ ‫للديلزة‬ ‫اﳌﻨاﺳﺐ‬ ‫اﳌﺮيﺾ‬ :٦-١ ١٦ ‫اﳌﺮيﺾ‬ ‫ﺗﻮﻋية‬ :٧-١ ١٧ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻗﺜﻄﺎﺭ‬ ‫ﺗﺮﻛﻴﺐ‬ :٢ ‫ﻓﺼﻞ‬ ١٧ ‫اﻷﻫداﻑ‬ :١-٢ ١٧ ‫الصفاقﻲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﻹدﺧاﻝ‬ ‫اﳌﺮيﺾ‬ ‫ﺇﻋداد‬ :٢-٢ ١٨ ‫الصفاقﻲ‬ ‫الﻘﺜﻄاﺭ‬ ‫ﺇدﺧاﻝ‬ ‫ﺗﻘﻨياﺕ‬ :٣-٢ ٢٠ ‫ﺑالﺘﺸﺮيﺢ‬ ‫اﳉﺮاﺣﻲ‬ ‫اﻹدﺧاﻝ‬ ‫ﺧﻄﻮاﺕ‬ :٤-٢ ٢٢ ‫اﳌﺮﺷد‬ ‫الﺴلﻚ‬ ‫ﺑاﺳﺘﺨداﻡ‬ ‫اﳌﻌدﻝ‬ ‫اﳉﺮاﺣﻲ‬ ‫اﻹدﺧاﻝ‬ ‫ﺧﻄﻮاﺕ‬ :٥-٢ ٢٣ ‫للﺠﺮاﺣة‬ ‫الﺘالية‬ ‫الﻌﻨاية‬ :٦-٢ ٢٦ ‫ﺍﳌﺮﻳﺾ‬ ‫ﺗﺪﺭﻳﺐ‬ :٣ ‫ﻓﺼﻞ‬ ٢٦ ‫اﻷﻫداﻑ‬ :١-٣ ٢٦ ‫الﺘدﺭيﺐ‬ ‫ﻣﺘﻄلﺒاﺕ‬ :٢-٣ ٢٦ ‫اﳌﺮيﺾ‬ ‫لﺘدﺭيﺐ‬ ‫اﳌﻬﻤة‬ ‫اﳉﻮاﻧﺐ‬ :٣-٣ ٢٩ ‫الﺘﻌﻘيﻢ‬ ‫ﺗﻘﻨية‬ :٤-٣ ٣٠ ‫اليديﻦ‬ ‫ﻏﺴل‬ ‫ﺧﻄﻮاﺕ‬ :٥-٣ ٣١ ‫اﳌزدﻭﺝ‬ ‫الﻜيﺲ‬ ‫ﺗﻘﻨية‬ :٦-٣ ٣٢ ‫الديلزة‬ ‫ﻣﺤلﻮﻝ‬ ‫ﺗﺒديل‬ ‫ﺧﻄﻮاﺕ‬ :٧-٣ ٣٣ ‫الﻘﺜﻄاﺭ‬ ‫ﲟﺨﺮﺝ‬ ‫الﻌﻨاية‬ :٨-٣ ٣٤ ‫الﻘﺜﻄاﺭ‬ ‫ﲟﺨﺮﺝ‬ ‫الﻌﻨاية‬ ‫ﺧﻄﻮاﺕ‬ :٩-٣ ٣٧ ‫ﻭﻣﺮﺍﻗﺒﺘﻬﺎ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﻭﺻﻒ‬ :٤ ‫ﻓﺼﻞ‬ ٣٧ ‫اﻷﻫداﻑ‬ :١-٤ ٣٧ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﺒادﺉ‬ :٢-٤ ٣٨ ‫اﺨﻤﻟﺘلفة‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﺃﳕاﻁ‬ :٣-٤ ٣٩ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻣﻦ‬ ‫اﳌﺜالﻲ‬ ‫الﻨﻤﻂ‬ :٤-٤ ٤٠ ‫الصفاقية‬ ‫للديلزة‬ ‫اﻷﻭلية‬ ‫الﻮﺻفة‬ :٥-٤ ٤١ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻛفاية‬ ‫ﻣﺮاقﺒة‬ :٦-٤
  • ‫ﺍﻹﻋﺪﺍﺩ‬ ‫ﻓﻲ‬ ‫ﺳﺎﻫﻢ‬ ‫الﻜﺘاﺏ‬ ‫ﻫﺬا‬ ‫ﺇﻋداد‬ ‫ﰎ‬ ‫اﳉاﻣﻌﻲ‬ ‫الﺮﺑاﻁ‬ ‫ﲟﺴﺘﺸفﻰ‬ ‫الصفاقية‬ ‫الديلزة‬ ‫ﻭﺣدة‬ ‫ﻓﻲ‬ ،‫ﻣصﻄفﻰ‬ ‫ﻣاﻫﺮ‬ ‫ﻋﺜﻤاﻥ‬ ،‫الﻄاﻫﺮ‬ ‫ﻣﺤﻤد‬ ‫ﺟﻌفﺮ‬ :‫اﻷﻃﺒاﺀ‬ ‫ﻣﻦ‬ ‫ﻛل‬ ‫ﲟﺴاﻫﻤة‬ ،‫ﺣﻤيدة‬ ‫ﻋلﻲ‬ ‫ﻣﻬا‬ ،‫الﺴﻤاﻧﻲ‬ ‫ﻋﻤﺮ‬ ‫ﺁﻻﺀ‬ ،‫ﻣﺒاﺭﻙ‬ ‫ﺇﺑﺮاﻫيﻢ‬ ‫ﺃﳝﻦ‬ ،‫ﻋلﻲ‬ ‫ﻣﺤﻤد‬ ‫ﻫﺸاﻡ‬ ،‫الﺸﺮيﻒ‬ ‫ﺃﺣﻤد‬ ‫ﺇقﺒاﻝ‬ ،‫ﺑﺸيﺮ‬ ‫ﺇﺣﺴاﻥ‬ :‫الﺘﻤﺮيﺾ‬ ‫ﻭﺗﻘﻨيﻲ‬ ،‫ﺧالد‬ ‫الﺴﺮ‬ ‫ﺳاﺭة‬ ‫ﺃﺳاﻣة‬ ،‫ﺻﻼﺡ‬ ‫اﷲ‬ ‫ﻋﺒد‬ ‫ﻋﺒيﺮ‬ ،‫اﷲ‬ ‫ﻋﺒد‬ ‫ﻣﺤﻤد‬ ‫اﳊﺴﻦ‬ ‫ﺃﻡ‬ ،‫الﺮﺣيﻢ‬ ‫ﻋﺒد‬ ‫ﺟﻤاﻝ‬ ،‫الديﻦ‬ ‫ﺑدﺭ‬ ‫ﺃﳒيﻼ‬ ،‫الﺘاﺝ‬ ‫ﻫاﻧﻲ‬ ،‫الﻮاﺣد‬ ‫ﻋﺒد‬ ‫ﻋفﺮاﺀ‬ ،‫يﻮﺳﻒ‬ ‫ﺣﺮﻡ‬ ،‫ﺃﺣﻤد‬ ‫ﻋﻤﺮ‬ ‫اﳊﺴﻦ‬ ‫ﻣﺤﻤد‬ ‫ﺧالد‬ ،‫الﻜﺮﱘ‬ ‫ﻋﺒد‬ ‫ﺻالﺢ‬ :‫اﳌﻌلﻮﻣاﺕ‬ ‫ﻭﺗﻘﻨيﻲ‬ ‫ﻣﺮﺍﺟﻌﺔ‬ ‫ﺣﺴﻦ‬ ‫ﻫﺸاﻡ‬ ‫الﺘﻌليﻤﻲ‬ ‫اﳋﺮﻃﻮﻡ‬ ‫ﲟﺴﺘﺸفﻰ‬ ‫الﻜلﻰ‬ ‫ﻃﺐ‬ ‫اﺧﺘصاﺻﻲ‬ ‫الﺮﺣيﻢ‬ ‫ﻋﺒد‬ ‫ﺑاﺑﻜﺮ‬ ‫ﻣﺤﻤد‬ ‫اﳉاﻣﻌﻲ‬ ‫ﺳﻮﺑا‬ ‫ﲟﺴﺘﺸفﻰ‬ ‫اﻷﻃفاﻝ‬ ‫ﻛلﻰ‬ ‫ﻃﺐ‬ ‫اﺧﺘصاﺻﻲ‬ ‫ﻛﺒلﻮ‬ ‫ﺟاﺑﺮ‬ ‫ﺑاﺑﻜﺮ‬ ‫الﻄﺒﻲ‬ ‫الﺴﻼﺡ‬ ‫ﲟﺴﺘﺸفﻰ‬ ‫الﻜلﻰ‬ ‫ﻃﺐ‬ ‫اﺧﺘصاﺻﻲ‬ ‫ﻏالﺐ‬ ‫ﺑﺸيﺮ‬ ‫ﻣﺤﻤد‬ ‫اﳉاﻣﻌﻲ‬ ‫الﺮﺑاﻁ‬ ‫ﲟﺴﺘﺸفﻰ‬ ‫الﻜلﻰ‬ ‫ﻃﺐ‬ ‫اﺧﺘصاﺻﻲ‬ ‫ﻭﺇﺧﺮﺍﺝ‬ ‫ﺗﺼﻤﻴﻢ‬ ‫الﻌﻈيﻢ‬ ‫ﻋﺒد‬ ‫ﻣﺤﻤد‬ ‫ﺗﻨﻮﻳﻪ‬ ‫الﻜﺘاﺏ‬ ‫ﻫﺬا‬ ‫ﻓﻲ‬ ‫الﻮاﺭدة‬ ‫الﺘﻌليﻤاﺕ‬ ‫ﻣﺮيﺾ‬ ‫لﻜل‬ ‫اﳋاﺻة‬ ‫الﻈﺮﻭﻑ‬ ‫ﻣﺮاﻋاة‬ ‫ﻣﻦ‬ ‫ﻭﻻﺑد‬ ،‫ﻋاﻣة‬ ‫ﻃﺒيﻌة‬ ‫ﺫاﺕ‬ ‫اﳌﻌالﺞ‬ ‫الفﺮيﻖ‬ ‫يﺮاﻩ‬ ‫ﻣا‬ ‫ﺣﺴﺐ‬ ‫ﺍﻟﻄﺒﻊ‬ ‫ﺣﻘﻮﻕ‬ ‫ﻣﺤفﻮﻇة‬ ‫الﻄﺒﻊ‬ ‫ﺣﻘﻮﻕ‬ ‫ﺇﻋادة‬ ‫يﺠﻮﺯ‬ ‫ﻭﻻ‬ ،‫الصفاقية‬ ‫للديلزة‬ ‫الﺴﻮداﻥ‬ ‫لﺒﺮﻧاﻣﺞ‬ ‫ﺻﻮﺭة‬ ‫ﺑﺄﻱ‬ ‫الﻜﺘاﺏ‬ ‫ﻫﺬا‬ ‫ﻣﻦ‬ ‫ﺟزﺀ‬ ‫ﺃﻱ‬ ‫ﺇﺻداﺭ‬ ‫ﻣﺴﺒﻖ‬ ‫ﺇﺫﻥ‬ ‫ﺑدﻭﻥ‬
  • ٢٠٠٨ ‫اﻷﻭلﻰ‬ ‫الﻄﺒﻌة‬ National Library Cataloging - Sudan 616.614 Hasan Abu Aisha Hamid H.P Peritoneal dialysis guide book = ‫الصفاقية‬ ‫الديلزة‬ ‫دليل‬ Hasan Abu Aisha Hamid Elwaleed Ali Mohamed Elhasan, Sarra Elamin Elhaj- Khartoum: ;2008. 242 P. :illus. ; 24 cm. ISBN : 978-99942-897-1-4 English + Arabic 1.Dialysis ,Patients - Guide Books, Handbooks, Manuals ... etc. 2.Acute Renal failure - Guide Books, Handbooks, Manuals... etc. A. Title
  • ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﻟﻠﺪﻳﻠﺰﺓ‬ ‫ﺍﻟﺴﻮﺩﺍﻥ‬ ‫ﺑﺮﻧﺎﻣﺞ‬ ‫ﺍﻟﺼﻔﺎﻗﻴﺔ‬ ‫ﺍﻟﺪﻳﻠﺰﺓ‬ ‫ﺩﻟﻴﻞ‬ ‫ﺇﻋﺪﺍﺩ‬ ‫ﻋاﺋﺸة‬ ‫ﺃﺑﻮ‬ ‫ﺣﺴﻦ‬ ‫الصفاقية‬ ‫للديلزة‬ ‫الﺴﻮداﻥ‬ ‫ﺑﺒﺮﻧاﻣﺞ‬ ‫الﻜلﻰ‬ ‫ﻃﺐ‬ ‫اﺧﺘصاﺻﻲ‬ ‫اﳊاﺝ‬ ‫اﻷﻣﲔ‬ ‫ﺳاﺭة‬ ‫الصفاقية‬ ‫للديلزة‬ ‫الﺴﻮداﻥ‬ ‫ﺑﺒﺮﻧاﻣﺞ‬ ‫الﺒاﻃﻦ‬ ‫الﻄﺐ‬ ‫اﺧﺘصاﺻﻲ‬ ‫اﳊﺴﻦ‬ ‫ﻣﺤﻤد‬ ‫ﻋلﻲ‬ ‫الﻮليد‬ ‫الصفاقية‬ ‫للديلزة‬ ‫الﺴﻮداﻥ‬ ‫ﺑﺒﺮﻧاﻣﺞ‬ ‫الﺒاﻃﻦ‬ ‫الﻄﺐ‬ ‫اﺧﺘصاﺻﻲ‬