كراسة العلاج بالأدوية المضادة للتخثر by Akram Al-Hilali

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‫اﻟﻌﻼج‬ ‫ﺑﺎﻷدوﻳﺔ اﻟﻤﻀﺎدة ﻟﻠﺘﺨﺜﺮ‬ ‫ﻣﻌﻠﻭﻣﺎﺕ ﻟﻠﻁﺑﻳﺏ‬ ‫ﻭﺇﺭﺷﺎﺩﺍﺕ ﻟﻠﻣﺭﻳﺽ‬ ‫ﺩ‪.‬ﺃﻛﺮﻡ ﺍﻟﻬﻼﻟﻲ‬

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‫ﺑﺳﻡ ﷲ ﺍﻟﺭﺣﻣــــــــﻥ ﺍﻟﺭﺣﻳﻡ‬

‫ﻣﻘ ّﺪﻣﺔ‬ ‫ﺇﻥ ﻭﺟﻭﺩ َﻣ ْﻳﻝ ﻟﺩﻯ ﺑﻌﺽ ﺍﻟﻣﺭﺿﻰ ﻟﻺﺻﺎﺑﺔ ﺑﺗﺧﺛﺭ ﺍﻟﺩﻡ ﻧﺗﻳﺟﺔ ﻟﻌﻠﺔ ﻓﻲ ﺍﻟﺩﻡ ﻧﻔﺳ�ﻪ ﺃﻭ ﻟﻭﺟ�ﻭﺩ ﺗﻐ ّﻳ�ﺭﺍﺕ ﻓ�ﻲ ﻣﻭﺍﺿ�ﻊ ﻣﺣ�ﺩّ ﺩﺓ‬ ‫ﻣﻥ ﺍﻷﻭﺭﺩﺓ ﺃﻭ ﺍﻟﺷﺭﺍﻳﻳﻥ ﺗﺟﻌﻝ ﺗﺧﺛﺭ ﺍﻟﺩﻡ ﻓﻲ ﺗﻠﻙ ﺍﻟﻣﻭﺍﺿﻊ ﻣﺣﺗﻣﻼً‪ ،‬ﻫﻣﺎ ﺍﻟﺳﺑﺑﺎﻥ ﺍﻟﺭﺋﻳﺳ�ﻳﺎﻥ ﻟﺣﺻ�ﻭﻝ ﺍﻟﺟﻠﻁ�ﺎﺕ ﺍﻟﻭﺭﻳﺩﻳ�ﺔ‬ ‫ﺃﻭ ﺍﻟﺷﺭﻳﺎﻧﻳﺔ‪ .‬ﻭﺇﺫﺍ ﺍﺟﺗﻣﻊ ﻋﺎﻣﻼﻥ ﻣﻊ ﺑﻌﺿﻬﻣﺎ‪ ،‬ﻛﺄﻥ ﻳﻛﻭﻥ ﻟ�ﺩﻯ ﺍﻟﻣ�ﺭﻳﺽ ﻣ�ﺭﺽ ﻣ�ﻥ ﺃﻣ�ﺭﺍﺽ ﻓ�ﺭﻁ ﺍﻟﺗﺧﺛ�ﺭ‪ ،‬ﺍﻟﻭﺭﺍﺛﻳ�ﺔ ﺃﻭ‬ ‫ﺍﻟﻣﻘﻌﺩﻳﻥ‬ ‫ﺍﻟﻣﻛﺗﺳﺑﺔ‪ ،‬ﻣﻊ ﻭﺟﻭﺩ ﺗﻐ ّﻳﺭﺍﺕ ﻓﻲ ﺟﺩﺭﺍﻥ ﺷﺭﻳﺎﻥ ﺃﻭ ﺃﻛﺛﺭ ﺃﻭ ﻣﺷﻛﻠﺔ ﺗﻣﻧﻊ ﺣﺭﻳﺔ ﺳﺭﻳﺎﻥ ﺍﻟﺩﻡ ﻓﻲ ﺍﻷﻭﺭﺩﺓ )ﻛﺣﺎﻻﺕ‬ ‫َ‬ ‫ﺑﺎﻟﻔﺭﺍﺵ ﺃﻭ ﺍﻟﻣﺭﺿﻰ ﺑﻌﺩ ﺍﻟﻌﻣﻠﻳﺎﺕ ﺍﻟﻛﺑﺭﻯ( ﻓﺈﻥ ﺍﺣﺗﻣﺎﻝ ﺣﺻﻭﻝ ﺍﻟﺟﻠﻁﺎﺕ ﻳﺯﺩﺍﺩ ﺑﻁﺑﻳﻌﺔ ﺍﻟﺣﺎﻝ‪.‬‬ ‫ﻓﻲ ﺑﻌﺽ ﻫﺫﻩ ﺍﻟﺣﺎﻻﺕ ﻗﺩ ﻳﻘﺭﺭ ﺍﻟﻁﺑﻳﺏ ﺍﻟﻣﻌﺎﻟﺞ ﺍﺳﺗﻌﻣﺎﻝ ﺃﺩﻭﻳﺔ ﻣﺿ�ﺎﺩﺓ ﻟﻠﺗﺧﺛ�ﺭ‪ ،‬ﻛﻭﻗﺎﻳ�ﺔ ﻣ�ﻥ ﺍﺣﺗﻣ�ﺎﻝ ﻭﻗ�ﻭﻉ ﺍﻟﺟﻠﻁ�ﺎﺕ‪ ،‬ﺃﻭ‬ ‫ﻟﻣﻧﻊ ﺣﺻﻭﻝ ﺟﻠﻁﺎﺕ ﺇﺿﺎﻓﻳﺔ ﺑﻌﺩ ﺃﻥ ﻳﺻﺎﺏ ﺍﻟﻣﺭﻳﺽ ﺑﺟﻠﻁﺔ ﻭﺭﻳﺩﻳﺔ ﺃﻭ ﺷﺭﻳﺎﻧﻳﺔ‪ ،‬ﻭﻛﺫﻟﻙ ﻟﻣﻧ�ﻊ ﺗﻭﺳ�ﻊ ﺍﻟﺟﻠﻁ�ﺔ ﺍﻷﻭﻟ�ﻰ ﻓ�ﻲ‬ ‫ﺍﻟﻭﺭﻳﺩ ﺃﻭ ﺍﻟﺷﺭﻳﺎﻥ ﺍﻟﺫﻱ ﺣﺻﻠﺕ ﻓﻳﻪ‪.‬‬ ‫ﻭﻫﻧﺎﻙ ﺑﻌﺽ ﺍﻷﺩﻭﻳﺔ ُﺗﻌﻁﻰ ﺑﺻﻭﺭﺓ ﻓﻭﺭﻳﺔ ﻟﻣﺣﺎﻭﻟﺔ ﺗﺫﻭﻳﺏ ﺟﻠﻁﺔ ﺣﺻﻠﺕ ﻓﻌﻼً‪ ،‬ﺇﺫﺍ ﺗ ّﻡ ﺗﺷﺧﻳﺻﻬﺎ ﺑﻌ�ﺩ ﺣﺻ�ﻭﻟﻬﺎ ﺑﺳ�ﺎﻋﺎﺕ‪.‬‬ ‫ﻓﻬﺫﻩ ﻟﻳﺳﺕ ﻣﺿﺎﺩﺍﺕ ﻟﻠﺗﺧﺛﺭ ﺑﻝ ﻫﻲ ﻣﺫﻳﺑﺎﺕ ﻟﻠﺟﻠﻁﺎﺕ‪ ،‬ﻛﻣﺎ ﺃﻥ ﻫﻧﺎﻙ ﺍﻷﺳﺑﺭﻳﻥ ﺍﻟﻣﺿﺎﺩ ﻟﻠﺻﻔﻳﺣﺎﺕ‪.‬‬ ‫ﻫﺫﺍ ﺍﻟﻛﺭﺍﺱ ﻫ�ﻭ ﻟﺗﻧ�ﻭﻳﺭ ﺍﻟﻘﺎﺭﺉ‪،‬ﺍﻟﻁﺑﻳ�ﺏ ﺃﻭ ﺍﻟﻣﻣ�ﺭﺽ ﺃﻭ ﺍﻟﻣ�ﺭﻳﺽ ﺃﻭ ﻣ�ﻥ ﻳﺭﻋ�ﺎﻩ ﻓ�ﻲ ﺍﻟﻣﻧ�ﺯﻝ‪ ،‬ﻋ�ﻥ ﻫ�ﺫﻩ ﺍﻷﺩﻭﻳ�ﺔ ﻟﻠﻔﺎﺋ�ﺩﺓ‬ ‫ﻭﺍﻟﻣﺳﺎﻋﺩﺓ ﻋﻠﻰ ﺣﺳﻥ ﺍﺳﺗﻌﻣﺎﻟﻬﺎ ﻭﺩﺭء ﺍﻷﺧﻁﺎﺭ ﺍﻟﺗﻲ ﻗﺩ ﺗﻧﺗﺞ ﻣﻥ ﺍﻟﺧﻁﺄ ﻓﻲ ﺗﻧﺎﻭﻟﻬﺎ‪.‬‬ ‫ﻭﻗﺩ ﻭﺿﻌﺕ ﻓﻲ ﺁﺧﺭ ﺍﻟﻛﺭﺍﺱ ﻗﺎﻣﻭﺳﺎ ً ﺻﻐﻳﺭﺍً ﺑﺎﻟﻣﺻﻁﻠﺣﺎﺕ ﺍﻟﻁﺑﻳﺔ ﺍﻟﻭﺍﺭﺩﺓ ﻓﻳﻪ ﻟﻔﺎﺋﺩﺓ ﺍﻷﻁﺑﺎء‪.‬‬ ‫ﻛﻣﺎ ﺃﻟﺣﻘﺕ ﺍﻟﻛﺭﺍﺱ ﺑﺟﺩﻭﻝ ﻣﻔﺻﻝ ﺑﺎﻹﻧﻛﻠﻳﺯﻳﺔ ﺑﺎﻷﻣﺭﺍﺽ ﻭﺍﻷﺩﻭﻳﺔ ﻭﺍﻷﻋﺷﺎﺏ ﺍﻟﺗﻲ ﻗﺩ ﺗﺅﺛﺭ ﻋﻠﻰ ﻋﻣﻝ ﻣﻭﺍﻧﻊ ﺍﻟﺗﺧﺛ�ﺭ ﺍﻟﺗ�ﻲ‬ ‫ﺗﺅﺧﺫ ﻋﻥ ﻁﺭﻳﻕ ﺍﻟﻔﻡ‪ ،‬ﻣﻊ ﺍﻟﺗﺭﺟﻣﺔ ﺍﻟﻌﺭﺑﻳﺔ ﺍﻟﺗﻲ ﺗﻣﻛﻧﺕ ﻣﻥ ﺍﻟﺣﺻﻭﻝ ﻋﻠﻳﻬﺎ‪ .‬ﺛﻡ ﺃﺩﺧﻠﺕ ﺟﺩﻭﻻً ﺑﺎﻹﻧﻛﻠﻳﺯﻳﺔ ﺑﺄﺳﻣﺎء ﺍﻷﺩﻭﻳ�ﺔ‬ ‫ﺍﻟﺗﻲ ُﻳﻌﺭﻑ ﻋﻧﻬﺎ ﺗﺄﺛﻳﺭ ﻋﻠﻰ ﻣﻭﺍﻧﻊ ﺍﻟﺗﺧﺛﺭ‪.‬‬ ‫ﺃﺭﺟﻭ ﷲ ﺗﻌﺎﻟﻰ ﺃﻥ ﻳﺟﻌﻝ ﺍﻟﻛﺭﺍﺱ ﻣﻔﻳﺩﺍً ﻭﺧﺎﻟﺻﺎ ً ﻟﻭﺟﻬﻪ ﺍﻟﻛﺭﻳﻡ‪.‬‬ ‫ﺩ‪.‬ﺃﻛﺭﻡ ﺍﻟﻬﻼﻟﻲ‬ ‫‪2014-2010‬‬

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‫ﻣﺿﺎﺩﺍﺕ ﺍﻟﺗﺧﺛﺭ ﻧﻭﻋﺎﻥ ﺃﺳﺎﺳﻳﺎﻥ‪:‬‬ ‫ﺍﻷﻭﻝ‪ :‬ﻳﻘﻭﻡ ﺑﺻﻭﺭﺓ ﻣﺑﺎﺷﺭﺓ ﺑﺈﺑﻁﺎﻝ ﻣﻔﻌﻭﻝ ﻭﺍﺣﺩ ﺃﻭ ﺃﻛﺛﺭ ﻣ�ﻥ ﻋﻭﺍﻣ�ﻝ ﺍﻟﺗﺧﺛ�ﺭ ﻟﻭﻗ�ﻑ ﺍﻟﻌﻣﻠﻳ�ﺔ‬ ‫ﺍﻟﺗﺧﺛﺭﻳﺔ‪ .‬ﻭﺃﻫﻡ ﻭﺃﺷﻬﺭ ﻋﻘﺎﺭ ﻣﻥ ﻫﺫﻩ ﺍﻟﻣﺟﻣﻭﻋﺔ ﻫﻭ ﺍﻟﻬﻳﺑﺎﺭﻳﻥ‪.‬‬ ‫ﺍﻟﺛﺎﻧﻲ‪ :‬ﻳﻘﻭﻡ ﺑﺎﻟﺗﺄﺛﻳﺭ ﻋﻠﻰ ﺇﻧﺗﺎﺝ ﻭﺍﺣﺩ ﺃﻭ ﺃﻛﺛﺭ ﻣﻥ ﻋﻭﺍﻣ�ﻝ ﺍﻟﺗﺧﺛ�ﺭ‪ ،‬ﺑﺣﻳ�ﺙ ُﺗﻧ�ﺗﺞ ﺑﺗﺭﻛﻳ�ﺏ ﻏﻳ�ﺭ‬ ‫ﻓﻌّﺎﻝ‪ .‬ﻭﻫﺫﺍ ﺍﻟﻧ�ﻭﻉ ﻫ�ﻭ ﻣﺿ�ﺎﺩﺍﺕ ﻓﻳﺗ�ﺎﻣﻳﻥ ﻙ‪ ،‬ﻭﺃﻛﺛ�ﺭ ﻋﻘ�ﺎﺭ ﻣﺳ�ﺗﻌﻣﻝ ﻣ�ﻥ ﻫ�ﺫﻩ ﺍﻟﻣﺟﻣﻭﻋ�ﺔ ﻫ�ﻭ‬ ‫ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ ﺃﻭ ﺍﻟﻛﻭﻣﺎﺩﻳﻥ‬ ‫ﺃﻣﺎ ﺍﻷﺳﺑﺭﻳﻥ ﻓﻣﻔﻌﻭﻟﻪ ﻣﺿﺎﺩ ﻟﻠﺻﻔﻳﺣﺎﺕ ﻭﺳﻳﺭﺩ ﺫﻛﺭﻩ ﻓﻳﻣﺎ ﺑﻌﺩ‪.‬‬ ‫ﻭﺃﻣ��ﺎ ﻣ��ﺫﻳﺑﺎﺕ ﺍﻟﺧﺛ��ﺭﺓ ﻓﻌﻣﻠﻬ��ﺎ ﻳﺧﺗﻠ��ﻑ ﻋ��ﻥ ﻣﺿ��ﺎﺩﺍﺕ ﺍﻟﺗﺧﺛ��ﺭ‪ ،‬ﺣﻳ��ﺙ ﻻ ُﺗﻌﻁ��ﻰ ﻟﻣﻧ��ﻊ ﺣﺻ��ﻭﻝ‬ ‫ﺍﻟﺟﻠﻁﺔ ﺑﻝ ﻟﻠﻣﺳﺎﻋﺩﺓ ﻓﻲ ﺳﺭﻋﺔ ﺗﺫﻭﻳﺑﻬﺎ ﻭﺇﻋﺎﺩﺓ ﺳﺭﻳﺎﻥ ﺍﻟﺩﻡ ﻓ�ﻲ ﺍﻟﺷ�ﺭﻳﺎﻥ ﺃﻭ ﺍﻟﻭﺭﻳ�ﺩ ﺍﻟﻣﺳ�ﺩﻭﺩ‬ ‫ﺑﻬ��ﺎ‪ ،‬ﻭﺳ��ﺄﺗﺣ ّﺩﺙ ﺑﺈﻳﺟ��ﺎﺯ ﻋ��ﻥ ﺍﺳ��ﺗﻌﻣﺎﻟﻬﺎ ﻛﻌ��ﻼﺝ ﻁﺑ��ﻲ‪ .‬ﻭﺃﻛﺛ��ﺭ ﻫ��ﺫﻩ ﺍﻟﻣﺟﻣﻭﻋ��ﺔ ﺍﺳ��ﺗﻌﻣﺎﻻً ﻫ��ﻭ‬ ‫ﺳﺗﺭﺑﺗﻭﻛﺎﻳﻧﻳﺯ‪.‬‬ ‫‪.1‬ﻣﺟﻣﻭﻋﺔ ﺍﻟﻬﻳﺑﺎﺭﻳﻥ‬ ‫ﻫ��ﺫﻩ ﺍﻟﻌﻼﺟ��ﺎﺕ ﻣﺿ��ﺎﺩﺓ ﺍﻟﺗﺧﺛ��ﺭ ُﺗﻌﻁ��ﻰ ﺑ��ﺎﻟﺣﻘﻥ‪ ،‬ﺇ ّﻣ��ﺎ ﺑﺎﻟﻭﺭﻳ��ﺩ ﺃﻭ ﺗﺣ��ﺕ ﺍﻟﺟﻠ��ﺩ‪ .‬ﻭﺣﻳﻧﻣ��ﺎ ﺗﻌﻁ��ﻰ‬ ‫ﺑﺎﻟﻭﺭﻳﺩ ﻓﺈﻣﺎ ﺃﻥ ﺗﻌﻁﻰ ﺗﻘﻁﻳﺭﺍً ﺑﺻﻭﺭﺓ ﻣﺳ�ﺗﻣﺭﺓ ﺃﻭ ﻋﻠ�ﻰ ﺷ�ﻛﻝ ﺟﺭﻋ�ﺎﺕ ﻛﺑﻳ�ﺭﺓ ﻋﻠ�ﻰ ﻓﺗ�ﺭﺍﺕ‪.‬‬ ‫ﻭﻻ ﺗﻛﻭﻥ ﻓﻌﺎﻟﺔ ﺇﺫﺍ ﺃُﺧﺫﺕ ﺑﻁﺭﻳﻕ ﺍﻟﻔﻡ‪.‬‬ ‫ﻣﺻﺩﺭ ﺍﻟﻬﻳﺑﺎﺭﻳﻥ ﻫ�ﻭ ﺃﻧﺳ�ﺟﺔ ﺍﻟﺣﻳﻭﺍﻧ�ﺎﺕ‪ ،‬ﻛ�ﺎﻟﺑﻘﺭ ﻭﺍﻟﺧﻧﺯﻳ�ﺭ‪ ،‬ﻭﻳُﺳ�ﺗﺧﻠﺹ ﺇﻣ�ﺎ ﺑﺷ�ﻛﻝ ﺟﺯﻳﺋ�ﺎﺕ‬ ‫ﻣﺗﻔﺎﻭﺗ��ﺔ ﺍﻟ��ﻭﺯﻥ ﺑﺣﻳ��ﺙ ﻳﻛ��ﻭﻥ ﺍﻟﻧ��ﺎﺗﺞ ﺧﻠﻳﻁ �ﺎ ً ﻣ��ﻥ ﺟﺯﻳﺋ��ﺎﺕ ﺍﻟﻬﻳﺑ��ﺎﺭﻳﻥ ﺫﺍﺕ ﺍﻷﻭﺯﺍﻥ ﺍﻟﺟﺯﻳﺋﻳ��ﺔ‬ ‫ﺍﻟﻌﺎﻟﻳﺔ ﻭﺍﻟﻣﺗﻭﺳ�ﻁﺔ ﻭﺍﻟﻭﺍﻁﺋ�ﺔ‪ ،‬ﺃﻭ ُﺗﺳ�ﺗﺧﻠَﺹ ﺍﻟﺟﺯﻳﺋ�ﺎﺕ ﺫﻭﺍﺕ ﺍﻟ�ﻭﺯﻥ ﺍﻟﺟﺯﻳﺋ�ﻲ ﺍﻟ�ﻭﺍﻁﺊ ﻓﻘ�ﻁ‪.‬‬ ‫ﺍﻟﻣﺟ ّﺯﺃ ﻭﺃﺻﺑﺢ ﺍﺳﺗﻌﻣﺎﻟﻪ ﻳﺯﺩﺍﺩ ﺷﻳﻭﻋﺎ ً ﻳﻭﻣ�ﺎ ً‬ ‫ﻭﺍﻟﻧﻭﻉ ﺍﻷﺧﻳﺭ ﺃﺛﺑﺕ ﻛﻔﺎءﺗﻪ ﺃﻛﺛﺭ ﻣﻥ ﺍﻟﻧﻭﻉ ﻏﻳﺭ‬ ‫َ‬ ‫ﺑﻌﺩ ﻳﻭﻡ‪ ،‬ﻭﻟﻛﻥ ﻣﺻﺩﺭﻩ ﻋﺎﺩﺓ ﻣﻥ ﺍﻟﺧﻧﺯﻳﺭ‪.‬‬ ‫ﺍﻟﻬﻳﺑﺎﺭﻳﻥ ﻳﻣﻧ�ﻊ ﺗﺧﺛ�ﺭ ﺍﻟ�ﺩﻡ ﺑﺈﺑﻁ�ﺎﻝ ﻣﻔﻌ�ﻭﻝ ﺍﻟﺧﺛ�ﺭﻳﻥ)ﺑﺎﻟﺗﻌ�ﺎﻭﻥ ﻣ�ﻊ ﻣﺿ�ﺎﺩ ﺍﻟﺧﺛ�ﺭﻳﻥ ﺍﻟﻁﺑﻳﻌ�ﻲ(‬ ‫ﻭﻣﻔﻌﻭﻝ ﻋﺎﻣﻝ ‪ 10‬ﺍﻟﻔﻌّﺎﻝ‪ ،‬ﻭﺇﻥ ﻛﺎﻧﺕ ﺍﻟﻣﺳﺗﺣﺿﺭﺍﺕ ﺍﻟﻣﺧﺗﻠﻔ�ﺔ ﻣﻧ�ﻪ ﺗﺗﻔ�ﺎﻭﺕ ﻓ�ﻲ ﻣ�ﺩﻯ ﺍﻟﺗ�ﺄﺛﻳﺭ‬ ‫ﻋﻠﻰ ﻛﻝ ﻣﻥ ﻫﺫﻳﻥ ﺍﻟﻌﺎﻣﻠﻳﻥ‪ .‬ﻓﺎﻟﻬﻳﺑﺎﺭﻳﻥ ﺫﻭ ﺍﻟ�ﻭﺯﻥ ﺍﻟﺟﺯﻳﺋ�ﻲ ﺍﻟ�ﻭﺍﻁﺊ ﺃﺷ�ﺩ ﺗ�ﺄﺛﻳﺭﺍً ﻋﻠ�ﻰ ﻋﺎﻣ�ﻝ‬ ‫ﺍﻟﻣﺟ ّﺯﺃ ﻭﺑﺎﻟﻌﻛﺱ ﻳﻛﻭﻥ ﻏﻳﺭ ﺍﻟﻣﺟ ّﺯﺃ ﺃﺷﺩ ﺗﺛﺑﻳﻁﺎ ً ﻟﻠﺧﺛﺭﻳﻥ‪.‬‬ ‫‪ 10‬ﻣﻥ ﺍﻟﻬﻳﺑﺎﺭﻳﻥ ﻏﻳﺭ َ‬ ‫ﻳُﻌﻁﻰ ﺍﻟﻬﻳﺑﺎﺭﻳﻥ ﻋﺎﺩ ًﺓ ﺑﺎﻟﻣﺳﺗﺷﻔﻳﺎﺕ‪ ،‬ﻟﻛﻥ ﻫﻧﺎﻙ ﻣﺭﺿﻰ ﻳﺄﺧﺫﻭﻥ ﺣﻘ�ﻥ ﺍﻟﻬﻳﺑ�ﺎﺭﻳﻥ ﺗﺣ�ﺕ ﺍﻟﺟﻠ�ﺩ‬ ‫ﻓﻲ ﺑﻳﻭﺗﻬﻡ‪.‬‬ ‫ﺟﺭﻋﺔ ﺍﻟﻬﻳﺑﺎﺭﻳﻥ ُﺗﻌﻁ�ﻰ ﻓ�ﻲ ﺍﻟﺑﺩﺍﻳ�ﺔ ﺑﺻ�ﻭﺭﺓ ﺗﻘﺭﻳﺑﻳ�ﺔ ﺗﺗﻧﺎﺳ�ﺏ ﻣ�ﻊ ﻭﺯﻥ ﺍﻟﻣ�ﺭﻳﺽ‪ ،‬ﺛ�ﻡ ﻳُﺟ�ﺭﻯ‬ ‫ﻟﻠﻣﺭﻳﺽ ﻓﺣﺹ) ﻭﻗﺕ ﺗﻭﻟﺩ ﺍﻟﺧﺛ�ﺭﺓ ﺍﻟﺟﺯﺋ�ﻲ(‪ ،‬ﻭﻋﻠ�ﻰ ﺿ�ﻭء ﻧﺗﻳﺟﺗ�ﻪ ُﺗﻘ�ﺭّﺭ ﺍﻟﺟﺭﻋ�ﺔ ﺍﻟﻣﻧﺎﺳ�ﺑﺔ‬ ‫ﻟﻠﻣﺭﻳﺽ‪.‬‬

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‫ﻭﻣﻔﻌﻭﻝ ﺍﻟﻬﻳﺑﺎﺭﻳﻥ ﺍﻟﻣﺎﻧﻊ ﻟﻠﺗﺧﺛﺭ ﻓ�ﻭﺭﻱ ﻭﻳﺧﺗﻔ�ﻲ ﻣ�ﻥ ﺍﻟ�ﺩﻡ ﺑﻌ�ﺩ ﺣﻘﻧ�ﻪ ﺑﻣﻌ� ّﺩﻝ ‪ %50‬ﻛ�ﻝ ﺳ�ﺕ‬ ‫ﺳﺎﻋﺎﺕ‪ ،‬ﻭﺍﻟﻧ�ﻭﻉ ﺫﻭ ﺍﻟ�ﻭﺯﻥ ﺍﻟﺟﺯﻳﺋ�ﻲ ﺍﻟ�ﻭﺍﻁﺊ ﻳﻣﻛ�ﺙ ﻭﻗﺗ�ﺎ ً ﺃﻁ�ﻭﻝ ﻓ�ﻲ ﺍﻟﺟﺳ�ﻡ‪ ،‬ﻭﻣ�ﻥ ﺛ� ّﻡ ﺗ�ﺩﻭﻡ‬ ‫ﺍﻟﻣﺟ� ّﺯﺃ ﻓ�ﻳُﺣﻘﻥ‬ ‫ﻓﻌﺎﻟﻳﺗﻪ ﺃﻛﺛﺭ ﻟﺫﻟﻙ ﻓﺈﻧﻪ ﻳُﻌﻁﻰ ﻣﺭﺓ ﻛﻝ ‪ 12‬ﺳ�ﺎﻋﺔ ﺃﻭ ﻛ�ﻝ ‪ 24‬ﺳ�ﺎﻋﺔ‪ .‬ﺃﻣ�ﺎ ﻏﻳ�ﺭ َ‬ ‫ﻣﺭﺓ ﻛﻝ ‪ 8‬ﺳﺎﻋﺎﺕ ﺃﻭ ‪ 12‬ﺳﺎﻋﺔ‪.‬‬ ‫ﺇﻥ ﺯﻳﺎﺩﺓ ﺍﻟﺟﺭﻋﺔ ﺍﻟﻣﻌﻁﺎﺓ ﻣﻥ ﺍﻟﻬﻳﺑﺎﺭﻳﻥ ﻋ�ﻥ ﺍﻟﻣﻁﻠ�ﻭﺏ ﻗ�ﺩ ﺗ�ﺅﺩﻱ ﺇﻟ�ﻰ ﺃﻧﺯﻓ�ﺔ ﻟ�ﺩﻯ ﺍﻟﻣ�ﺭﻳﺽ‪.‬‬ ‫ﺃﻣ�ﺎ ﺇﺫﺍ ﻛﺎﻧ��ﺕ ﺍﻟﺟﺭﻋ��ﺔ ﻧﺎﻗﺻ��ﺔ ﻋﻣ��ﺎ ﻳﺟ��ﺏ ﻓﻘ�ﺩ ﻻ ﺗﺳ��ﺗﻁﻳﻊ ﺇﻳﻘ��ﺎﻑ ﺃﻭ ﻣﻧ��ﻊ ﺍﻟﺗﺧﺛ��ﺭ ﺍﻟ��ﺫﻱ ﺑﺳ��ﺑﺑﻪ‬ ‫ﺃُﻋﻁ��ﻲ ﺍﻟﻬﻳﺑ��ﺎﺭﻳﻥ ﺃﺻ��ﻼً‪ .‬ﻭﻳﻣﻛ��ﻥ ﺿ��ﺑﻁ ﺟﺭﻋ��ﺔ ﺍﻟﻬﻳﺑ��ﺎﺭﻳﻥ ﺑ��ﺈﺟﺭﺍء ﻓﺣ��ﺹ )ﻣﻭﻟّ��ﺩ ﺍﻟﺧﺛ��ﺭﺓ‬ ‫ﺍﻟﺟﺯﺋﻲ( ﻟﻠﺗﺄﻛﺩ ﻣﻥ ﻣﺩﻯ ﻣﻔﻌﻭﻝ ﺍﻟﻬﻳﺑﺎﺭﻳﻥ ﻋﻠﻳﻪ‪.‬‬ ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﻬﻤﺔ ﺍﻟﺘﻲ ﻳﺴﺘَﻌ َﻤﻞ ﻓﻴﻬﺎ ﺍﻟﻬﻴﺒﺎﺭﻳﻦ‬

‫ ﻭﻗﺎﻳﺔ ﻣﻥ ﺍﻟﺗﺧﺛﺭ ﻣﺑﺎﺷﺭﺓ ﺑﻌﺩ ﺍﻟﻌﻣﻠﻳﺎﺕ ﺍﻟﺭﺋﻳﺳﻳﺔ ﻭﺍﻟﻛﺳﻭﺭ ﺍﻟﻛﺑﻳﺭﺓ‪.‬‬‫ ﻭﻗﺎﻳﺔ ﻣﻥ ﺗﻛﺭﺭ ﺍﻟﺟﻠﻁﺔ ﻋﻧﺩ ﻣﻥ ﺣﺻ�ﻝ ﻟﺩﻳ�ﻪ ﺟﻠﻁ�ﺔ ﺑ�ﺎﻷﻭﺭﺩﺓ ﺍﻟﺭﺋﻳﺳ�ﻳﺔ ﻟﻠﺳ�ﺎﻕ ﺃﻭ ﺻ�ﻣّﺎﺕ‬‫ﻓﻲ ﺷﺭﺍﻳﻳﻥ ﺍﻟﺭﺋﺔ‪ ،‬ﻛﺈﺣﺩﻯ ﻣﺿﺎﻋﻔﺎﺕ ﺍﻟﺗﺧﺛﺭ ﻓﻲ ﺃﻭﺭﺩﺓ ﺍﻟﺳﺎﻗﻳﻥ‪ ،‬ﻭﺫﻟﻙ ﻓﻲ ﺑﺩﺍﻳ�ﺔ ﺍﻟﻌ�ﻼﺝ‪،‬‬ ‫ﻭﻣﻥ ﺛﻡ ﻳُﺳﺗﺑﺩَﻝ ﺑﺎﻟﻭﺍﺭﻓﺎﺭﻳﻥ‪.‬‬ ‫ ﻟﻠﻭﻗﺎﻳﺔ ﻣﻥ ﺗﻛﺭﺭ ﺍﻟﺟﻠﻁﺔ ﻟﻣﻥ ﺣﺻﻠﺕ ﻋﻧﺩﻩ ﺟﻠﻁﺔ ﺑﺎﻟﻣﺦ ﺃﻭ ﺍﻟﺷﺭﺍﻳﻳﻥ ﺍﻟﺗﺎﺟﻳﺔ ﻟﻠﻘﻠﺏ ﺃﻭ ﺃﻱ‬‫ﺷﺭﻳﺎﻥ ﺁﺧﺭ ﺑﺎﻟﺟﺳﻡ‪.‬‬ ‫ ﺧﻼﻝ ﺍﻟﺣﻣﻝ ﻟﻠﺳﻳﺩﺍﺕ ﺍﻟﻼﺗ�ﻲ ﺣﺻ�ﻝ ﻋﻧ�ﺩﻫﻥ ﺟﻠﻁ�ﺎﺕ ﺧ�ﻼﻝ ﺣﻣ�ﻝ ﺳ�ﺎﺑﻕ‪ .‬ﺑﻌ�ﺽ ﺍﻷﻁﺑ�ﺎء‬‫ﻳﻌﻁ��ﻲ ﺍﻟﻬﻳﺑ��ﺎﺭﻳﻥ ﺑ��ﺩﻝ ﺍﻟﻭﺍﺭﻓ��ﺎﺭﻳﻥ ﻁﻳﻠ��ﺔ ﻓﺗ��ﺭﺓ ﺍﻟﺣﻣ��ﻝ )ﺇﺫﺍ ﻛﺎﻧ��ﺕ ﺍﻟﻣﺭﻳﺿ��ﺔ ﺗﺗﻧ��ﺎﻭﻝ‬ ‫ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ ﻗﺑﻝ ﺍﻟﺣﻣﻝ(‪ ،‬ﺣﻳﺙ ﺃﻧﻪ ﻻ ﻳﺿﺭ ﺍﻟﺟﻧ�ﻳﻥ ﻛﺎﻟﻭﺍﺭﻓ�ﺎﺭﻳﻥ‪ .‬ﻭﺍﻟ�ﺑﻌﺽ ﺍﻵﺧ�ﺭ ﻳﻌﻁﻳ�ﻪ‬ ‫ﻟﻬ��ﻥ ﺧ��ﻼﻝ ﺍﻟﺛﻼﺛ��ﺔ ﺷ��ﻬﻭﺭ ﺍﻷﻭﻟ��ﻰ ﻓﻘ��ﻁ ﺛ��ﻡ ﻳﺳ��ﺗﺄﻧﻑ ﺇﻋﻁ��ﺎء ﺍﻟﻭﺍﺭﻓ��ﺎﺭﻳﻥ‪ ،‬ﻷﻧ��ﻪ ﻻ ﻳﺿ��ﺭ‬ ‫ﺑﺎﻟﺟﻧﻳﻥ ﺑﻌﺩ ﺗﻠﻙ ﺍﻟﻣﺭﺣﻠﺔ ﻣﻥ ﺍﻟﺣﻣﻝ‪.‬‬ ‫ ﻭﻓﻲ ﺃﻳّﺔ ﺣﺎﻟﺔ ﻣﺭﺿﻳﺔ ﺃﺧﺭﻯ ﺗﺣﺗ�ﺎﺝ ﺇﻟ�ﻰ ﻣﻧ�ﻊ ﺗﺧﺛ�ﺭ ﻳُﺑ�ﺩﺃ ﻋ�ﺎﺩﺓ ﺑﺎﻟﻬﻳﺑ�ﺎﺭﻳﻥ‪ ،‬ﺣﺗ�ﻰ ﻟ�ﻭ ﻛ�ﺎﻥ‬‫ﺍﻟﻣ�ﺭﻳﺽ ﺳ�ﻳﺗﻧﺎﻭﻝ ﺍﻟﻭﺍﺭﻓ�ﺎﺭﻳﻥ ﻣﺳ��ﺗﻘﺑﻼً‪ ،‬ﻭﺍﻟﺳ�ﺑﺏ ﻫ�ﻭ ﺃﻥ ﺍﻟﻬﻳﺑ��ﺎﺭﻳﻥ ﻳﺑ�ﺩﺃ ﻣﻔﻌﻭﻟ�ﻪ ﺑﺻ��ﻭﺭﺓ‬ ‫ﻣﺑﺎﺷﺭﺓ ﻭﻓﻭﺭﻳﺔ ﻓﻳﺳﺗﻁﻳﻊ ﻣﻧﻊ ﺍﻟﺗﺧﺛ�ﺭ ﻣﺑﺎﺷ�ﺭﺓ ﺑﻌ�ﺩ ﺣﻘﻧ�ﻪ ﻭﻳﺧﺗﻠ�ﻑ ﺑ�ﺫﻟﻙ ﻋ�ﻥ ﺍﻟﻭﺍﺭﻓ�ﺎﺭﻳﻥ‪،‬‬ ‫ﻛﻣﺎ ﺳﻳﻅﻬﺭ ﻣﻥ ﺍﻟﺣﺩﻳﺙ ﻋﻥ ﺍﻷﺧﻳﺭ ﻓﻲ ﺍﻟﻔﻘﺭﺓ ﺍﻟﺗﺎﻟﻳﺔ‪.‬‬ ‫ﺇﻥ ﺍﻟﻧﺯﻑ ﺍﻟﻧﺎﺗﺞ ﻋﻥ ﺯﻳ�ﺎﺩﺓ ﺟﺭﻋ�ﺔ ﺍﻟﻬﻳﺑ�ﺎﺭﻳﻥ ﻫ�ﻭ ﻟ�ﻳﺱ ﺍﻟﻣﺷ�ﻛﻠﺔ ﺍﻟﻭﺣﻳ�ﺩﺓ ﻓ�ﻲ ﻫ�ﺫﺍ ﺍﻟﻌﻘ�ﺎﺭ‪ .‬ﺇﻥ‬ ‫ﻧﺳﺑﺔ ﻗﻠﻳﻠﺔ ﻣﻥ ﺍﻟﻣﺭﺿﻰ ﻳﺣﺻﻝ ﻟﺩﻳﻬﻡ ﻧﻘﺹ ﺻ�ﻔﻳﺣﺎﺕ ﺍﻟ�ﺩﻡ ﺑﺳ�ﺑﺏ ﺗﺣﺳّﺳ�ﻬﻡ ﻟﻠﻬﻳﺑ�ﺎﺭﻳﻥ‪ .‬ﻭﻓ�ﻲ‬ ‫ﺣﺎﻻﺕ ﻧﺎﺩﺭﺓ ﻳﺣﺻﻝ ﻣﻊ ﻧﻘﺹ ﺍﻟﺻﻔﻳﺣﺎﺕ ّ‬ ‫ﺗﺧﺛﺭﺍﺕ ﺷﺩﻳﺩﺓ ﻧﺗﻳﺟﺔ ﻟﻠﻌﻼﺝ ﺑﺎﻟﻬﻳﺑﺎﺭﻳﻥ‪ ،‬ﺍﻟﺫﻱ ﻫ�ﻭ‬ ‫ﺑﺎﻷﺻﻝ ﻣﺎﻧﻊ ﻟﻠﺗﺧﺛﺭ‪ .‬ﻛﺫﻟﻙ ﻓﺈﻥ ﺇﻋﻁﺎء ﺍﻟﻬﻳﺑﺎﺭﻳﻥ ﻟﻣﺩﺓ ﻁﻭﻳﻠﺔ)ﺳﺗﺔ ﺷ�ﻬﻭﺭ ﺃﻭ ﺃﻛﺛ�ﺭ( ﻗ�ﺩ ﻳ�ﺅﺩﻱ‬ ‫ﺇﻟﻰ ﺗﻧ ّﺧﺭ) ﻫﺷﺎﺷﺔ( ﻓﻲ ﺍﻟﻌﻅﺎﻡ‪.‬‬ ‫ﺃﺩﻭﻳﺔ ﺃﺧﺭﻯ ﻣﺷﺎﺑﻬﺔ ﻟﻠﻬﻳﺑﺎﺭﻳﻥ‬ ‫ﻫﻧﺎﻙ ﺍﻵﻥ ﺃﺩﻭﻳﺔ ﺃﺧﺭﻯ ﻣﺷﺎﺑﻬﺔ ﺃﻭ ﻣﻘﺎﺭﺑﺔ ﻟﻠﻬﻳﺑﺎﺭﻳﻥ ﻓﻲ ﻣﻔﻌﻭﻟﻬ�ﺎ ﻭ ُﺗﻧ� َﺗﺞ ﻋ�ﻥ ﻁﺭﻳ�ﻕ ﺍﻟﻬﻧﺩﺳ�ﺔ‬ ‫ﺍﻟﻭﺭﺍﺛﻳﺔ ﺑﻛﻣﻳﺎﺕ ﺗﺟﺎﺭﻳﺔ‪ .‬ﻭﻗﺩ ﺑﺩﺃﺕ ﺗﺩﺧﻝ ﺍﻟﺳﻭﻕ ﺍﻟﻁﺑﻲ ﺗﺩﺭﻳﺟ ّﻳﺎ ً‪ .‬ﻭﻣﺛﺎﻝ ﻋﻠﻰ ﻫﺫﻩ ﺍﻟﻣﺟﻣﻭﻋ�ﺔ‬ ‫)ﻫﻳﺭﻭﺩﻳﻥ( ﻭﻫ�ﻲ ﺍﻟﻣ�ﺎﺩﺓ ﺍﻟﻁﺑﻳﻌﻳ�ﺔ ﺍﻟﺗ�ﻲ ﺗﻔﺭﺯﻫ�ﺎ ﺩﻭﺩﺓ) ﺍﻟﻌﻠ�ﻕ ﺍﻟﻁﺑّ�ﻲ( ﺣﻳﻧﻣ�ﺎ ﺗﻣ�ﺗﺹ ﺍﻟ�ﺩﻡ ﻣ�ﻥ‬ ‫ﺍﻹﻧﺳ��ﺎﻥ ﺃﻭ ﺍﻟﺣﻳ��ﻭﺍﻥ ﺍﻟ��ﺫﻱ ﺗﻠﺗﺻ��ﻕ ﻋﻠ��ﻰ ﺟﻠ��ﺩﻩ‪ .‬ﻭﻗ��ﺩ ﺍﺳ��ﺗﻧﺑﻁ ﺍﻟﻌﻠﻣ��ﺎء ﺗﺭﻛﻳ��ﺏ ﺍﻟﻬﻳ��ﺭﻭﺩﻳﻥ‬ ‫‪4‬‬

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‫ﻭﺍﺳ��ﺗﻁﺎﻋﻭﺍ ﺗﺻ��ﻧﻳﻌﻪ ﺑﺎﻟﻬﻧﺩﺳ��ﺔ ﺍﻟﻭﺭﺍﺛﻳ��ﺔ ﺑﻭﺍﺳ��ﻁﺔ ﻣﻭﺭّﺛ��ﻪ ﺍﻟ��ﺫﻱ ُﻳ� َ‬ ‫�ﺩﺧﻝ ﻓ��ﻲ ﺍﻟﺧﻼﻳ��ﺎ ﺍﻟﺟﺭﺛﻭﻣﻳ��ﺔ‬ ‫ﻓﺗﻘﻭﻡ ﺑﺈﻧﺗﺎﺟﻪ ﺑﻛﻣﻳﺎﺕ ﻛﺑﻳﺭﺓ‪.‬‬ ‫ﻛﺫﻟﻙ ﻓﻘﺩ ﺗ�ﻡ ﺗﺻ�ﻧﻳﻊ ﺃﺩﻭﻳ�ﺔ ﺻ�ﻐﻳﺭﺓ ﺍﻟ�ﻭﺯﻥ ﺍﻟﺟﺯﻳﺋ�ﻲ ﺗﻌﻣ�ﻝ ﻋﻣ�ﻝ ﺍﻟﻬﻳﺑ�ﺎﺭﻳﻥ ﻟﻛﻧﻬ�ﺎ ﻟ�ﻡ ﺗﺣﺻ�ﻝ‬ ‫ﻋﻠﻰ ﺍﻟﻘﺑﻭﻝ ﺍﻟﻣﺗﻭﻗﻊ ﻁﺑﻳﺎ ً‪.‬‬

‫‪.2‬ﻣﺟﻣﻭﻋﺔ ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ‬ ‫ﻭﻫ��ﻲ ﻣﺿ��ﺎ ّﺩﺍﺕ ﻟﻔﻳﺗ��ﺎﻣﻳﻥ ﻙ‪ ،‬ﻭﺃﺷ��ﻬﺭﻫﺎ ﺍﻟﻭﺍﺭﻓ��ﺎﺭﻳﻥ)ﻛﻭﻣ��ﺎﺩﻳﻥ( ﺛ��ﻡ )ﺩﻧ��ﺩﻳﻔﺎﻥ(‪ ،‬ﻭﺗﺳ��ﻣّﻰ‬ ‫ﺃﻳﺿﺎ ً)ﻣﺿﺎﺩﺍﺕ ﺍﻟﺗﺧﺛﺭ ﺍﻟﻔﻣﻳّﺔ( ﻷﻧﻬﺎ ﺗﺅﺧﺫ ﻋ�ﻥ ﻁﺭﻳ�ﻕ ﺍﻟﻔ�ﻡ‪ ،‬ﺧﻼﻓ�ﺎ ً ﻟﻣﺟﻣﻭﻋ�ﺔ ﺍﻟﻬﻳﺑ�ﺎﺭﻳﻥ ﺍﻟﺗ�ﻲ‬ ‫ﻟﻳﺱ ﻟﻬﺎ ﺗﺄﺛﻳﺭ ﺇﻻ ﺇﺫﺍ ﺃُﺧﺫﺕ َﺣﻘﻧﺎ ً ﺑﺎﻟﻭﺭﻳﺩ ﺃﻭ ﺗﺣﺕ ﺍﻟﺟﻠﺩ‪.‬‬ ‫ﺳﺑﻕ ﺃﻥ ﺫﻛﺭﺕ ﺃﻥ ﻫﺫﻩ ﺍﻟﻣﺟﻣﻭﻋﺔ‪ ،‬ﺑﻌﻣﻠﻬﺎ ﺿﺩ ﻓﻳﺗﺎﻣﻳﻥ ﻙ‪ ،‬ﻓﺈﻧﻬﺎ ﺗﻣﻧﻊ ﺍﻟﻔﻳﺗ�ﺎﻣﻳﻥ ﺍﻟﻣ�ﺫﻛﻭﺭ ﻣ�ﻥ‬ ‫ﺍﻟﻣﺳﺎﻋﺩﺓ ﻓﻲ ﺇﻧﺗﺎﺝ ﻋﻭﺍﻣﻝ ﺗﺧﺛﺭ ﻁﺑﻳﻌﻳﺔ ﻣﻥ ﻗﺑﻝ ﺍﻟﻛﺑﺩ‪ .‬ﻭﺍﻟﻌﻭﺍﻣﻝ ﺍﻷﺭﺑﻌ�ﺔ ﺍﻟﺗ�ﻲ ﻳﺗ�ﺄﺛﺭ ﺇﻧﺗﺎﺟﻬ�ﺎ‬ ‫ﻟﺩﻯ ﺗﻧﺎﻭﻝ ﻭﺍﺭﻓﺎﺭﻳﻥ ﻫﻲ ﻋﺎﻣﻝ‪)2‬ﺧﺛﺭﻳﻥ ﻏﻳﺭ ﻓﻌّﺎﻝ(‪ ،‬ﻋﺎﻣ�ﻝ‪،7‬ﻋﺎﻣ�ﻝ‪ 9‬ﻭﻋﺎﻣ�ﻝ‪ .10‬ﻭﺍﻷﺭﺑﻌ�ﺔ‬ ‫ُﺗﻧﺗﺞ ﻓﻲ ﺍﻟﻛﺑﺩ‪ .‬ﻛﺫﻟﻙ ﻓﺈﻥ ﺑﺭﻭﺗﻳﻥ ﺝ ﻭﺑﺭﻭﺗﻳﻥ ﺃﺱ ّ‬ ‫ﻳﺗ�ﺄﺛﺭﺍﻥ ﺑﺗﻧ�ﺎﻭﻝ ﺍﻟﻭﺍﺭﻓ�ﺎﺭﻳﻥ‪ .‬ﺇﻥ ﻓﻳﺗ�ﺎﻣﻳﻥ ﻙ‬ ‫ﻳﺳﺎﻋﺩ ﻓﻲ ﺗﻁﻭﻳﺭ ﺗﺭﻛﻳﺏ ﺍﻟﺟﺯﻳﺋﺎﺕ ﺍﻟﺑﺭﻭﺗﻳﻧﻳﺔ ﻟﻠﻌﻭﺍﻣ�ﻝ ﺍﻟﻣ�ﺫﻛﻭﺭﺓ‪ ،‬ﺑﺣﻳ�ﺙ ﺗﺳ�ﺗﻁﻳﻊ ﺃﻥ ﺗﺳ�ﺗﻔﻳﺩ‬ ‫ﻣ��ﻥ ﺁﻳ��ﻭﻥ ﺍﻟﻛﺎﻟﺳ��ﻳﻭﻡ ﻓ��ﻲ ﻋﻣﻠﻳ��ﺔ ﺍﻟﺗﺧﺛ��ﺭ‪ .‬ﻭﺑ��ﺩﻭﻥ ﻓﻳﺗ��ﺎﻣﻳﻥ ﻙ )ﺃﻭ ﺑﺗﻧ��ﺎﻭﻝ ﻣﺿ��ﺎﺩﺍﺗﻪ( ﻳ��ﺗﻡ ﺇﻧﺗ��ﺎﺝ‬ ‫ﺍﻟﻌﻭﺍﻣﻝ ﺍﻷﺭﺑﻌﺔ ﻓ�ﻲ ﺧﻼﻳ�ﺎ ﺍﻟﻛﺑ�ﺩ ﻟﻛﻧﻬ�ﺎ ﺗﻛ�ﻭﻥ ﻏﻳ�ﺭ ﻓﻌﺎﻟ�ﺔ‪ .‬ﻟ�ﺫﻟﻙ ﻓ�ﺈﻥ ﻣﻔﻌ�ﻭﻝ ﺍﻟﻭﺍﺭﻓ�ﺎﺭﻳﻥ ﻫ�ﻭ‬ ‫ﺇﻧﻘﺎﺹ ﻓﻌﻝ ﺍﻟﻌﻭﺍﻣﻝ ﺍﻟﻣﺫﻛﻭﺭﺓ ﻓﻲ ﺍﻟﺩﻡ‪ ،‬ﻭﻟﻳﺱ ﻣﻘﺩﺍﺭﻫﺎ‪.‬‬ ‫ﺇﺫﺍ ﺃُﻋﻁﻲ ﺍﻟﻬﻳﺑﺎﺭﻳﻥ ﺃﻭ ﻋﻘ�ﺎﺭ ﺁﺧ�ﺭ ﻣ�ﻥ ﻣﺟﻣﻭﻋﺗ�ﻪ ﻓﺈﻧﻬ�ﺎ ﺗ�ﺅﺛﺭ ﻓ�ﻲ ﺍﻟﺗﺧﺛ�ﺭ ﺣ�ﺎﻝ ﺩﺧﻭﻟﻬ�ﺎ ﺍﻟ�ﺩﻡ‪،‬‬ ‫ﺣﻳ��ﺙ ﻳﻣﻧ��ﻊ ﻋﺎﻣ��ﻝ‪ 10‬ﻭﻋﺎﻣ��ﻝ ﺍﻟﺧﺛ��ﺭﻳﻥ ﻣ��ﻥ ﺍﻟﻌﻣ��ﻝ‪ ،‬ﺭﻏ��ﻡ ﺃﻧﻬﻣ��ﺎ ﻣﻭﺟ��ﻭﺩﺍﻥ ﻓ��ﻲ ﺍﻟ��ﺩﻡ ﺑﻣﻘ��ﺩﺍﺭ‬ ‫ﻁﺑﻳﻌﻲ‪ ،‬ﺛﻡ ﺇﺫﺍ ﺍﺧﺗﻔﻰ ﺍﻟﻬﻳﺑﺎﺭﻳﻥ ﻣﻥ ﺍﻟﺩﻡ ﻓﻲ ﺳﺎﻋﺎﺕ ﻋﺎﺩ ﻛ�ﻝ ﺷ�ﺊ ﻟﺣﺎﻟﺗ�ﻪ ﺍﻟﻁﺑﻳﻌﻳ�ﺔ‪ .‬ﻛ�ﺫﻟﻙ ﺇﺫﺍ‬ ‫ﻭﺿ��ﻌﺕ ﻗﻁ��ﺭﺓ ﻣ��ﻥ ﺍﻟﻬﻳﺑ��ﺎﺭﻳﻥ ﻓ��ﻲ ﻋﻳﻧ��ﺔ ﺩﻡ ﻓﺈﻧﻬ��ﺎ ﺗﻣﻧ��ﻊ ﺗﺧﺛﺭﻫ��ﺎ ﻣﺑﺎﺷ��ﺭﺓ ﻭﺗ��ﺅﺛﺭ ﻋﻠ��ﻰ ﻧﺗ��ﺎﺋﺞ‬ ‫ﻓﺣﻭﺹ ﺍﻟﺗﺧﺛﺭ ﺍﻟﻣﺧﺑﺭﻳﺔ‪.‬‬ ‫ﻓﻲ ﻣﻘﺎﺑﻝ ﺫﻟﻙ‪ ،‬ﻓﺈﻥ ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ ﻳﺣﺗﺎﺝ ﺇﻟ�ﻰ ﻭﻗ�ﺕ ﻟﻳ�ﺅﺛﺭ ﻋﻠ�ﻰ ﺗﺧﺛ�ﺭ ﺩﻡ ﺍﻟﻣ�ﺭﻳﺽ ﺑﻌ�ﺩ ﺗﻧﺎﻭﻟ�ﻪ‪،‬‬ ‫ﺣﻳﺙ ﻳﺟﺏ ﺃﻥ ﺗﺧﺗﻔﻲ ﺍﻟﺟﺯﻳﺋﺎﺕ ﺍﻟﻔﻌّﺎﻟﺔ ﻣﻥ ﺍﻟﻌﻭﺍﻣﻝ ﺍﻟﻣﻭﺟ�ﻭﺩﺓ ﻓ�ﻲ ﺍﻟ�ﺩﻡ ﻟﻳﺣ�ﻝ ﻣﺣﻠّﻬ�ﺎ ﺗ�ﺩﺭﻳﺟﻳﺎ ً‬ ‫ﺟﺯﻳﺋﺎﺕ ﻣُﻧ َﺗﺟﺔ ﺣﺩﻳﺛﺎ ً ﻭﻏﻳﺭ ﻓﻌّﺎﻟﺔ‪ ،‬ﺑﺗﺄﺛﻳﺭ ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ‪ ،‬ﻭﻫﺫﺍ ﻳﺳﺗﻐﺭﻕ ‪ 48-24‬ﺳﺎﻋﺔ ﻟﻳﺗﻡ‪ .‬ﻛﻣﺎ‬ ‫ﺃﻥ ﺗﻭﻗ�ﻑ ﺍﻟﻣ�ﺭﻳﺽ ﻋ�ﻥ ﺗﻧ�ﺎﻭﻝ ﺍﻟﻭﺍﺭﻓ�ﺎﺭﻳﻥ ﻟ�ﻥ ﻳﻅﻬ�ﺭ ﺗ�ﺄﺛﻳﺭﻩ ﻭﺍﺿ�ﺣﺎ ً ﺇﻻ ﺑﻌ�ﺩ ‪ 48-24‬ﺳ�ﺎﻋﺔ‬ ‫ﺣﻳﺙ ﺃﻥ ﺍﺧﺗﻔﺎء ﺍﻟﻌﻭﺍﻣﻝ ﻏﻳﺭ ﺍﻟﻔﻌّﺎﻟﺔ ﺗﺩﺭﻳﺟﻲ ﻭﺣﻠﻭﻝ ﺟﺯﻳﺋﺎﺕ ﻓﻌﺎﻟﺔ ﻣﺣﻠﻬﺎ ﺗﺩﺭﻳﺟﻲ ﺃﻳﺿﺎ ً‪.‬‬ ‫ﺃﻣ��ﺎ ﻣﻘ��ﺩﺍﺭ ﺍﻧﺧﻔ��ﺎﺽ ﺍﻟﻌﻭﺍﻣ��ﻝ ﺍﻟﻔﻌﺎﻟ��ﺔ ﻭﻅﻬ��ﻭﺭ ﻋﻭﺍﻣ��ﻝ ﻏﻳ��ﺭ ﻓﻌﺎﻟ��ﺔ ﻓﻳﺗﻭﻗ��ﻑ ﻋﻠ��ﻰ ﺟﺭﻋ��ﺔ‬ ‫ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ ﺍﻟﺗﻲ ﻳﺄﺧﺫﻫﺎ ﺍﻟﻣﺭﻳﺽ‪ .‬ﻟﻛﻥ ﺍﻟﻧﺎﺱ ﻳﺧﺗﻠﻔﻭﻥ ﻛﺛﻳﺭﺍً ﻓﻲ ﻣﻘﺩﺍﺭ ﺍﻟﺟﺭﻋ�ﺔ ﺍﻟﺗ�ﻲ ﺗﻧﺎﺳ�ﺏ‬ ‫ﺃﺟﺳﺎﻣﻬﻡ‪ ،‬ﻓﻣﻧﻬﻡ ﻣﻥ ﻳﺣﺗﺎﺝ ﺇﻟﻰ ﻣﻠّﻐﺭﺍﻡ ﻭﺍﺣﺩ ﻳﻭﻣﻳﺎ ً ﻟﺗﺻﻝ ﺳﻳﻭﻟﺔ ﺩﻣﻪ ﺇﻟﻰ ﺍﻟﻣﺳﺗﻭﻯ ﺍﻟﻣﻁﻠ�ﻭﺏ‬ ‫ﺑﻳﻧﻣﺎ ﻗﺩ ﺗﺻﻝ ﺣﺎﺟﺔ ﺁﺧﺭﻳﻥ ﺇﻟﻰ ‪ 15‬ﺃﻭ ﺣﺗﻰ ‪ 20‬ﻣﻠّﻐﺭﺍﻡ ﻳﻭﻣﻳﺎ ً ﻟﻠﻭﺻﻭﻝ ﺇﻟ�ﻰ ﻧﻔ�ﺱ ﺍﻟﻣﺳ�ﺗﻭﻯ‪،‬‬ ‫ﺭﻏﻡ ﺃﻥ ﺃﻭﺯﺍﻧﻬﻡ ﻗﺩ ﺗﻛﻭﻥ ﻣﺗﻘﺎﺭﺑﺔ‪ .‬ﻛﺫﻟﻙ ﻓﺈﻥ ﺍﻟﺣﺎﺟﺔ ﺗﺧﺗﻠﻑ ﻗﻠ�ﻳﻼً ﻣ�ﻥ ﻳ�ﻭﻡ ﺇﻟ�ﻰ ﺁﺧ�ﺭ ﺑﺣﺳ�ﺏ‬ ‫ﻣ��ﺎ ﻳﺗﻧﺎﻭﻟ��ﻪ ﺍﻟﻣ��ﺭﻳﺽ ﻣ��ﻥ ﻓﻳﺗ��ﺎﻣﻳﻥ ﻙ ﻓ��ﻲ ﻁﻌﺎﻣ��ﻪ‪ .‬ﻭﻓﻳﺗ��ﺎﻣﻳﻥ ﻙ ﻣﺗﻭﺍﺟ��ﺩ ﻓ��ﻲ ﻣﺷ��ﺗﻘﺎﺕ ﺍﻟﺣﻠﻳ��ﺏ‪،‬‬

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‫ﻻﺳﻳّﻣﺎ ﻣﻊ ﺯﻳﺎﺩﺓ ﺍﻟﺩﻫﻥ ﻓﻳﻬ�ﺎ‪ ،‬ﻭﺍﻟﺧﺿ�ﺭﺍﻭﺍﺕ ﻛ�ﺎﻟﺧﺱ ﻭﻏﻳ�ﺭﻩ‪ .‬ﻭﻫ�ﻭ ﻣﻭﺟ�ﻭﺩ ﺑﻛﻣﻳ�ﺎﺕ ﺃﻗ�ﻝ ﻓ�ﻲ‬ ‫ﺍﻟﺩﻫﻭﻥ ﻋﻣﻭﻣﺎ ً ﻭﻓﻲ ﺍﻟﺧﺿﺭﺍﻭﺍﺕ ﺍﻷﺧﺭﻯ‪.‬‬ ‫ﻫﻧﺎ ﺃﻭﺩ ﺃﻥ ﺃﺷ�ﻳﺭ ﺇﻟ�ﻰ ﺧﻁ�ﺄ ﺷ�ﺎﺋﻊ‪ ،‬ﻓﺗﻭﺍﺟ�ﺩ ﻓﻳﺗ�ﺎﻣﻳﻥ ﻙ ﻓ�ﻲ ﺍﻷﻁﻌﻣ�ﺔ ﺍﻟﺗ�ﻲ ﺫﻛﺭﺗﻬ�ﺎ ﻻ ﻳﻌﻧ�ﻲ ﺃﻥ‬ ‫ﺍﻟﻣﺭﻳﺽ ﻳﺟﺏ ﺃﻥ ﻳﺗﻭﻗﻑ ﻋﻥ ﺗﻧﺎﻭﻟﻬﺎ ﻷﻧ�ﻪ ﻳﺄﺧ�ﺫ ﺃﻗ�ﺭﺍﺹ ﺍﻟﻭﺍﺭﻓ�ﺎﺭﻳﻥ‪ .‬ﺻ�ﺣﻳﺢ ﺃﻧﻬ�ﺎ ﺗﻘﻠ�ﻝ ﻣ�ﻥ‬ ‫ﻣﻔﻌﻭﻟﻪ ﺑﺳﺑﺏ ﻓﻳﺗﺎﻣﻳﻥ ﻙ ﺍﻟﻣﻭﺟﻭﺩ ﻓﻳﻬﺎ‪ ،‬ﻟﻛﻧﻬﺎ ﺃﻏﺫﻳ�ﺔ ﻣﻔﻳ�ﺩﺓ ﺟ� ّﺩﺍً ﻟﻠﺟﺳ�ﻡ ﻭﻻ ﻳﺟ�ﻭﺯ ﻣﻧﻌﻬ�ﺎ ﻋ�ﻥ‬ ‫ﺍﻟﻣ��ﺭﻳﺽ‪ .‬ﻭﺍﻟﺑ��ﺩﻳﻝ ﺍﻟﺑﺳ��ﻳﻁ ﻋ��ﻥ ﻣﻧﻌﻬ��ﺎ ﻫ��ﻭ ﺯﻳ��ﺎﺩﺓ ﺑﺳ��ﻳﻁﺔ ﻓ��ﻲ ﺟﺭﻋ��ﺔ ﺍﻟﻭﺍﺭﻓ��ﺎﺭﻳﻥ ﺍﻟﻳﻭﻣﻳ��ﺔ‪،‬‬ ‫ﻭﺑﺣﺳﺏ ﻣﺎ ﻳﻅﻬﺭ ﻣﻥ ﺗﺄﺛﻳﺭ ﻋﻠﻰ ﻧﺗﺎﺋﺞ ﻓﺣﺹ)ﻭﻗﺕ ﻣﻭﻟّﺩ ﺍﻟﺧﺛﺭﻳﻥ(‪.‬‬ ‫ﺍﻟﻭﺍﺭﻓ��ﺎﺭﻳﻥ ﻋﻘ��ﺎﺭ ﺷ��ﺎﺋﻊ ﺍﻻﺳ��ﺗﻌﻣﺎﻝ ﻟﺣ��ﺎﻻﺕ ﻛﺛﻳ��ﺭﺓ ﻣﻧﻬ��ﺎ ﺟﻠﻁ��ﺎﺕ ﺃﻭﺭﺩﺓ ﺍﻟﺳ��ﺎﻗﻳﻥ ﻭﺻ �ﻣّﺎﺕ‬ ‫ﺷﺭﺍﻳﻳﻥ ﺍﻟﺭﺋﺗﻳﻥ ﻭﺟﻠﻁﺎﺕ ﺍﻟﻘﻠﺏ ﻭﺍﻟﻣ�ﺦ ﻭﺍﻟﺻ�ﻣّﺎﻣﺎﺕ ﺍﻟﻣﻌﺩﻧﻳ�ﺔ ﺍﻟﻣﺯﺭﻭﻋ�ﺔ ﻓ�ﻲ ﺍﻟﻘﻠ�ﺏ ﻭﺣ�ﺎﻻﺕ‬ ‫ﻓﺭﻁ ﺍﻟﺗﺧﺛﺭ ﺍﻟﻣﻭﺭﻭﺛﺔ ﻭﺍﻟﻣﻛ َﺗ َﺳﺑﺔ‪ .‬ﻟﻛﻥ ﻫﺫﺍ ﺍﻟﻌﻘﺎﺭ ﻻ ﻳﺧﻠﻭ ﻣﻥ ﻣﺧﺎﻁﺭ ﺟﺎﻧﺑﻳ�ﺔ ّ‬ ‫ﺗ�ﺅﺛﺭ ﻋﻠ�ﻰ ﻣ�ﻥ‬ ‫ﺃﺳﺎء ﺍﺳﺗﺧﺩﺍﻣﻪ ﺃﻭ ﺃﺧﻁﺄ ﺃﻳﺎﻣﺎ ً ﻣﺗﻌﺩﺩﺓ ﻓﻲ ﺟﺭﻋﺗﻪ ﺃﻭ ﻧﺳﻳﻬﺎ ﻋﺩﺓ ﻣﺭﺍﺕ ﺃﻭ ﺗﺳ�ﺎﻫﻝ ﻓ�ﻲ ﺿ�ﺑﻁﻬﺎ‬ ‫ﺑﺎﻟﻔﺣﺹ ﺍﻟﻣﺧﺑﺭﻱ‪.‬‬ ‫ﻣﻼﺣﻈﺎﺕ ﺣﻮﻝ ﺍﺳﺘﻌﻤﺎﻝ ﺍﻟﻮﺍﺭﻓﺎﺭﻳﻦ‪:‬‬

‫‪ .1‬ﺇﻥ ﺗﻧ��ﺎﻭﻝ ﺣﺑ��ﻭﺏ ﻭﺍﺭﻓ��ﺎﺭﻳﻥ ﺑﻭﺻ��ﻔﺔ ﻣ��ﻥ ﻁﺑﻳ��ﺏ‪ ،‬ﻭﺑﺟﺭﻋ��ﺔ ﺗﺗﻧﺎﺳ��ﺏ ﻣ��ﻊ ﻧﺗ��ﺎﺋﺞ ﻓﺣ��ﻭﺹ‬ ‫ﺍﻟﺗﺧﺛ��ﺭ‪ ،‬ﻟ��ﻪ ﻓﺎﺋﺩﺗ��ﻪ ﻭﺃﻫﻣﻳﺗ��ﻪ‪ ،‬ﻟ��ﺫﺍ ﻳﺟ��ﺏ ﺃﻻ ّ ﻳﺗﺭﺍﺧ��ﻰ ﺍﻟﻣ��ﺭﻳﺽ ﻓ��ﻲ ﺗﻧ��ﺎﻭﻝ ﺍﻟﺟﺭﻋ��ﺔ ﺣﺳ��ﺏ‬ ‫ﻭﺻﻔﺔ ﺍﻟﻁﺑﻳﺏ ﻭﻓﻲ ﺃﻭﻗﺎﺗﻬﺎ ﻭﺑﺷﻛﻝ ﻣﻧﺗﻅﻡ‪.‬‬ ‫‪ .2‬ﻻ ﺣﺎﺟ��ﺔ ﻟﺗﻘﺳ��ﻳﻡ ﺟﺭﻋ��ﺔ ﻭﺍﺭﻓ��ﺎﺭﻳﻥ ﻋﻠ��ﻰ ﺍﻟﻳ��ﻭﻡ‪ ،‬ﺃﻱ ﺗﺅﺧ��ﺫ ﻛ��ﻝ ﺟﺭﻋ��ﺔ ﺍﻟﻳ��ﻭﻡ ﺍﻟﻭﺍﺣ��ﺩ ﺩﻓﻌ��ﺔ‬ ‫ﻭﺍﺣﺩﺓ‪.‬‬ ‫‪ .3‬ﺃﻧﺳﺏ ﻭﻗﺕ ﻷﺧﺫ ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ ﻫ�ﻭ ﻧﻬﺎﻳ�ﺔ ﺍﻟﻳ�ﻭﻡ‪ ،‬ﻛ�ﺎﻟﻣﻐﺭﺏ ﺃﻭ ﺍﻟﻌﺷ�ﺎء ﺃﻭ ﻓ�ﻲ ﺳ�ﺎﻋﺔ ﻣﺣ�ﺩﺩﺓ‬ ‫ﻣﻥ ﻭﻗﺕ ﺍﻟﻠﻳﻝ‪ .‬ﻭﺍﻟﺳﺑﺏ ﻓﻲ ﺗﻔﺿﻳﻝ ﻫﺫﺍ ﺍﻟﻭﻗﺕ ﺳﻳﺄﺗﻲ ﻓﻲ ﺍﻟﻧﻘﻁﺔ ‪.6‬‬ ‫‪ .4‬ﻫﻧﺎﻙ ﺃﻗﺭﺍﺹ ﻭﺍﺭﻓﺎﺭﻳﻥ ﻣﻥ ﻗﻭﺓ ‪ 7,5 ،5 ،3 ،2,5 ،2 ،1‬ﻣﻠﻐﺭﺍﻡ‪ .‬ﻭﻛ�ﻝ ﻗ�ﺭﺹ ﻣﻧﻬ�ﺎ ﻟ�ﻪ‬ ‫ﻟﻭﻥ ﻳﻣﻳّﺯﻩ‪ .‬ﻭﺍﻟﻐﺎﻳﺔ ﻣﻥ ﻭﺟﻭﺩ ﻛﻝ ﻫﺫﻩ ﺍﻟﻔﺋﺎﺕ ﻫﻲ ﺇﻋﻁﺎء ﻣﺭﻭﻧﺔ ﻟﻠﻁﺑﻳﺏ ﻻﺧﺗﻳﺎﺭ ﺍﻟﺟﺭﻋﺔ‬ ‫ﺍﻟﻣﻁﻠﻭﺑﺔ ﺑﺄﺑﺳﻁ ﻁﺭﻳﻘﺔ ﻣﻧﻌﺎ ً ﻟﺧﻁﺄ ﺍﻟﻣﺭﻳﺽ‪.‬‬ ‫‪ .5‬ﺑﻣ��ﺎ ﺃﻥ ﻣﻔﻌ��ﻭﻝ ﺣﺑ��ﺔ ﺍﻟﻭﺍﺭﻓ��ﺎﺭﻳﻥ ﻳﺗ��ﺄﺧﺭ ﻋ��ﻥ ﻳ��ﻭﻡ ﺗﻧﺎﻭﻟﻬ��ﺎ ﻭﻻ ﻳ��ﺯﻭﻝ ﺇﻻ ﺗ��ﺩﺭﻳﺟﻳﺎً‪ ،‬ﻓ��ﺈﻥ‬ ‫ﺍﺧﺗﻼﻑ ﺍﻟﺟﺭﻋﺔ ﺑﻳﻥ ﺃﻳﺎﻡ ﺍﻷﺳﺑﻭﻉ ﻻ ﻳﻌﻧﻲ ﻓﻌﻼً ﺍﺧﺗﻼﻑ ﺍﻟﺳﻳﻭﻟﺔ ﺑﻳﻥ ﻳﻭﻡ ﻭﺁﺧﺭ‪ ،‬ﻓﻣﻔﻌ�ﻭﻝ‬ ‫ﺍﻟﻘﺭﺹ ﻳﻣﺗﺩ ﻟﻳﺟﻌﻝ ﺍﻟﺗﺧﺛﺭ ﻛﻝ ﺃﻳﺎﻡ ﺍﻷﺳﺑﻭﻉ ﻣﺗﺟﺎﻧﺳﺎ ً ﺗﻘﺭﻳﺑﺎً‪ ،‬ﺭﻏ�ﻡ ﺍﻻﺧ�ﺗﻼﻑ ﺍﻟﺑﺳ�ﻳﻁ ﻓ�ﻲ‬ ‫ﺟﺭﻋﺎﺕ ﺍﻷﻳﺎﻡ‪ .‬ﻭﺍﻟﺣﻘﻳﻘﺔ ﺃﻥ ﺍﻟﻁﺑﻳﺏ ﻳﺣﺳﺏ ﺍﻟﺟﺭﻋﺔ ﺍﻷﺳﺑﻭﻋﻳﺔ ﺍﻟﻣﻁﻠﻭﺑﺔ ﺛﻡ ﻳﻘﺳﻣﻬﺎ ﻋﻠ�ﻰ‬ ‫ﺍﻷﻳﺎﻡ ﺍﻟﺳﺑﻌﺔ ﻓﻳﻪ‪.‬‬ ‫ﻓﻣﺛﻼً‪ ،‬ﺇﺫﺍ ﺭﺃﻯ ﺍﻟﻁﺑﻳﺏ ﺃﻥ ﺟﺭﻋﺔ ‪ 30‬ﻣﻠﻐﻡ ﺃﺳﺑﻭﻋﻳﺎ ً ﺗﻧﺎﺳﺏ ﻣﺭﻳﺿﺎ ً ﻓﺈﻧﻪ ﻳﻘ�ﻭﻡ ﺑﺗﻘﺳ�ﻳﻣﻬﺎ ﻋﻠ�ﻰ‬ ‫ﺳﺑﻌﺔ ﺃﻳﺎﻡ‪ .‬ﻭﻟﻣﺎ ﻛﺎﻥ ﺍﻟﻌﺩﺩ ‪ 30‬ﻻ ﻳُﻘ َﺳﻡ ﻋﻠﻰ ‪ 7‬ﻓﻳﻣﻛﻥ ﻭﺻ�ﻑ ‪ 4‬ﻣﻠﻐ�ﻡ ﻓ�ﻲ ﺧﻣﺳ�ﺔ ﺃﻳ�ﺎﻡ )=‪20‬‬ ‫ﻣﻠﻐﻡ( ﻭ‪ 5‬ﻣﻠﻐﻡ ﻓﻲ ﻳﻭﻣﻳﻥ)=‪ 10‬ﻣﻠﻐﻡ(‪ .‬ﻭﻳﺑﺎﻋﺩ ﺍﻟﻁﺑﻳﺏ ﺑ�ﻳﻥ ﺍﻟﻳ�ﻭﻣﻳﻥ ﺍﻟﻠ�ﺫ ْﻳﻥ ﻳﺗﻧ�ﺎﻭﻝ ﺍﻟﻣ�ﺭﻳﺽ‬ ‫ﻓﻳﻬﻣﺎ ‪ 5‬ﻣﻠﻐﻡ‪ ،‬ﻛﺄﻥ ﻳﺟﻌﻠﻬﺎ ﻓﻲ ﻳ�ﻭﻣﻲ ﺍﻻﺛﻧ�ﻳﻥ ﻭﺍﻟﺧﻣ�ﻳﺱ ﻣ�ﻥ ﻛ�ﻝ ﺃﺳ�ﺑﻭﻉ‪ .‬ﺑﻬ�ﺫﺍ ﺍﻟﺟ�ﺩﻭﻝ ﻳﻛ�ﻭﻥ‬ ‫ﻟ��ﺩﻯ ﺍﻟﻣ��ﺭﻳﺽ ﻧﻭﻋ��ﺎﻥ ﻣ��ﻥ ﺍﻟﺣﺑ��ﻭﺏ)ﻓﺋ��ﺔ ‪ 2‬ﻣﻠﻐ��ﻡ ﻭﻓﺋ��ﺔ ‪ 5‬ﻣﻠﻐ��ﻡ(‪ .‬ﻭﻗ��ﺩ ﻻ ﺗﺗ��ﻭﻓﺭ ﻓﺋ��ﺔ ‪ 2‬ﻣﻠﻐ��ﻡ‬ ‫ﺑﺎﻟﻣﺳﺗﺷﻔﻰ ﻓﻳُﻌﻁﻰ ﺍﻟﻣﺭﻳﺽ ﺛﻼﺛﺔ ﺃﻧﻭﺍﻉ ﻣﻥ ﺍﻟﺣﺑﻭﺏ)‪ 3+1‬ﻣﻠﻐﻡ ﺧﻣﺳﺔ ﺃﻳﺎﻡ ﻓ�ﻲ ﺍﻷﺳ�ﺑﻭﻉ ﻭ‪5‬‬ ‫ﻣﻠﻐﻡ ﻳﻭﻣﻳﻥ ﻓﻲ ﺍﻷﺳﺑﻭﻉ(‪ .‬ﻭﻧﻔﺱ ﺍﻟﺟﺭﻋﺔ)‪ 30‬ﻣﻠﻐﻡ ﺃﺳ�ﺑﻭﻋﻳﺎ ً( ﻳﻣﻛ�ﻥ ﺃﻥ ُﺗﻌﻁ�ﻰ ﺑﺷ�ﻛﻝ ﺃﺑﺳ�ﻁ‪،‬‬

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‫ﻛﺄﻥ ﻳﺗﻧﺎﻭﻝ ﺍﻟﻣﺭﻳﺽ ﺣﺑﺔ ﻓﺋﺔ ‪5‬ﻣﻠﻐﻡ ﺳﺗﺔ ﺃﻳﺎﻡ ﻓ�ﻲ ﺍﻷﺳ�ﺑﻭﻉ ﻓﻘ�ﻁ ﻭﻻ ﻳﺄﺧ�ﺫ ﺷ�ﻳﺋﺎ ً ﻓ�ﻲ ﺃﺣ�ﺩ ﺃﻳ�ﺎﻡ‬ ‫ﺍﻷﺳﺑﻭﻉ‪ ،‬ﻛﺎﻟﺟﻣﻌﺔ ﻣﺛﻼً‪.‬‬ ‫ﻭﻟﻥ ﻳﻛﻭﻥ ﺗﺧﺛﺭ ﺍﻟﺩﻡ ﻓﻲ ﺍﻟﺣﺎﻟﺔ ﺍﻷﺧﻳ�ﺭﺓ ﻣﺧﺗﻠﻔ�ﺎ ً ﺑﺷ�ﻛﻝ ﻣﺣﺳ�ﻭﺱ ﻳ�ﻭﻡ ﺍﻟﺟﻣﻌ�ﺔ ﻋﻧ�ﻪ ﻓ�ﻲ ﺍﻷﻳ�ﺎﻡ‬ ‫ﺍﻷﺧﺭﻯ‪ ،‬ﻷﻥ ﻣﻔﻌﻭﻝ ﺍﻟﺣﺑﻭﺏ‪-‬ﻛﻣﺎ ﺫﻛﺭﺕ‪ -‬ﻳﻣﺗﺩ ﻣﺗﺟﺎﻧﺳ ٍﺎ ﻋﻠﻰ ﺍﻷﺳﺑﻭﻉ ﻛﻠﻪ‪.‬‬ ‫‪ .6‬ﺇﺫﺍ ﺣﺻﻝ ﻟﻠﻣﺭﻳﺽ ﻧﺯﻑ ﺩﻡ ﻏﻳﺭ ﻣﺗﻭ ﱠﻗﻊ‪ ،‬ﺃﻱ ﺩﻭﻥ ﺳﺑﺏ ﻣﻥ ﺷﺩﺓ ﺃﻭ ﺟ�ﺭﺡ‪ ،‬ﻭﻳﻛ�ﻭﻥ ﻋ�ﺎﺩﺓ‬ ‫ﻣ��ﻥ ﺍﻟﻠﺛ��ﺔ ﺃﻭ ﺍﻷﻧ��ﻑ‪ ،‬ﺃﻭ ﺇﺫﺍ ﺣﺻ��ﻠﺕ ﻛ��ﺩﻣﺎﺕ ﺯﺭﻗ��ﺎء ﻓ��ﻲ ﺍﻟﺟﻠ��ﺩ‪ ،‬ﻓﻘ��ﺩ ﺗﻛ��ﻭﻥ ﻧﺳ��ﺑﺔ ﺍﻟﺳ��ﻳﻭﻟﺔ‬ ‫ﺯﺍﺩﺕ ﻋﻥ ﺍﻟﻣﻁﻠﻭﺏ ﻟﺳﺑﺏ ﻣﺎ)ﺍﻧﻅ�ﺭ ﺍﻟﻔﻘ�ﺭﺓ‪ .(7‬ﺣﻳﻧﺋ�ﺫ ﻳﻣﺗﻧ�ﻊ ﺍﻟﻣ�ﺭﻳﺽ ﻋ�ﻥ ﺗﻧ�ﺎﻭﻝ ﺟﺭﻋ�ﺔ‬ ‫ﺫﻟﻙ ﺍﻟﻳﻭﻡ ﻓﻘﻁ‪ ،‬ﺛﻡ ﻳﺳﺗﺄﻧﻑ ﻓﻲ ﺍﻟﻳﻭﻡ ﺍﻟﺗﺎﻟﻲ ﺣﺳﺏ ﺍﻟﺟﺩﻭﻝ‪ .‬ﻓﺈﺫﺍ ﻋﺎﺩ ﺍﻟﻧﺯﻑ ﺑﻌ�ﺩ ﺫﻟ�ﻙ ﻣ�ﺭﺓ‬ ‫ﺃﺧﺭﻯ ﻳﺭﺍﺟﻊ ﺍﻟﻣ�ﺭﻳﺽ ﻹﺟ�ﺭﺍء ﻓﺣ�ﺹ ﺍﻟﺗﺧﺛ�ﺭ ﻓ�ﻲ ﻗﺳ�ﻡ ﺍﻟﻁ�ﻭﺍﺭﺉ ﻣ�ﻥ ﺍﻟﻣﺳﺗﺷ�ﻔﻰ ﺩﻭﻧﻣ�ﺎ‬ ‫ﺣﺎﺟﺔ ﻟﻣﻭﻋﺩ ﻣﺳﺑﻕ‪.‬‬ ‫ﻭﻟﻣﺎ ﻛﺎﻧﺕ ﻣﻌﻅﻡ ﺣﺎﻻﺕ ﺍﻟﻧﺯﻑ ﺗﺣﺻﻝ ﺧﻼﻝ ﺍﻟﻧﻬﺎﺭ‪ ،‬ﺃﺻﺑﺢ ﻣﻭﻋﺩ ﺗﻧ�ﺎﻭﻝ ﺍﻟﻘ�ﺭﺹ ﻣﺳ�ﺎ ًء‬ ‫ﻣﻧﻁﻘ ّﻳﺎً‪ ،‬ﺣﻳﺙ ﻳﻛﻭﻥ ﻟﻠﻣﺭﻳﺽ ﺍﺧﺗﻳﺎﺭ ﺍﻻﻣﺗﻧﺎﻉ ﻋ�ﻥ ﺍﻟ�ﺩﻭﺍء ﻟ�ﺫﻟﻙ ﺍﻟﻳ�ﻭﻡ‪ ،‬ﻓ�ﻲ ﺣﺎﻟ�ﺔ ﺣﺻ�ﻭﻝ‬ ‫ﻧﺯﻑ‪ .‬ﻭﻟﻥ ﻳﻛﻭﻥ ﺫﻟﻙ ﻣﻣﻛﻧﺎ ً ﺇﺫﺍ ﻛﺎﻥ ﻗﺩ ﺗﻧﺎﻭﻝ ﺍﻟﻘﺭﺹ ﺻﺑﺎﺣﺎ ً‪.‬‬ ‫‪ .7‬ﻫﻧﺎﻙ ﺃﺩﻭﻳﺔ ﺗﺯﻳ�ﺩ ﻣ�ﻥ ﻣﻔﻌ�ﻭﻝ ﻗ�ﺭﺹ ﺍﻟﻭﺍﺭﻓ�ﺎﺭﻳﻥ)ﻭﺑﻁ�ﺭﻕ ﻣﺧﺗﻠﻔ�ﺔ ﻻ ﻣﺟ�ﺎﻝ ﻫﻧ�ﺎ ﻟ�ﺫﻛﺭﻫﺎ(‬ ‫ﻭﺃﺧﺭﻯ ﺗﻧﻘﺹ ﻣﻥ ﻣﻔﻌﻭﻟﻪ‪ ،‬ﻭﺑﻁﺭﻕ ﻣﺧﺗﻠﻔﺔ ﺃﻳﺿﺎ ً‪ .‬ﻟﺫﻟﻙ ﻓﻌﻠﻰ ﺍﻟﻣﺭﻳﺽ ﺃﻥ ﻳﺧﺑ�ﺭ ﺍﻟﻁﺑﻳ�ﺏ‬ ‫ﺍﻟ��ﺫﻱ ﻳﺻ��ﻑ ﻟ��ﻪ ﺩﻭﺍ ًء ﺟﺩﻳ��ﺩﺍً ﺑﺄﻧ��ﻪ)ﺃﻱ ﺍﻟﻣ��ﺭﻳﺽ( ﻳﺗﻧ��ﺎﻭﻝ ﺍﻟﻭﺍﺭﻓ��ﺎﺭﻳﻥ ﻟﻳﻛ��ﻭﻥ ﺣ��ﺫﺭﺍً ﻓﻳﻣ��ﺎ‬ ‫ﻳﺻﻑ ﻣﻥ ﺩﻭﺍء‪ .‬ﻛﻣﺎ ﺃﻥ ﻗﻁﻊ ﺩﻭﺍء ﺑﻌ�ﺩ ﺃﺧ�ﺫﻩ ﻟﻣ�ﺩﺓ ﻣ�ﺎ ﻗ�ﺩ ﻳ�ﺅﺩﻱ ﻟﺯﻳ�ﺎﺩﺓ‪ ،‬ﺃﻭ ﻧﻘﺻ�ﺎﻥ‪ ،‬ﻓ�ﻲ‬ ‫ﻣﻔﻌﻭﻝ ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ‪ ،‬ﺇﺫﺍ ﻛﺎﻥ ﺫﻟﻙ ﺍﻟﻌﻼﺝ ﺫﺍ ﺗﺄﺛﻳﺭ ﻋﻠ�ﻰ ﻓﻌﺎﻟﻳ�ﺔ ﺍﻟﻭﺍﺭﻓ�ﺎﺭﻳﻥ‪ .‬ﺃﺷ�ﻬﺭ ﺍﻷﺩﻭﻳ�ﺔ‬ ‫ﺍﻟﺗﻲ ﺗﺯﻳﺩ ﻣﻥ ﻓﻌﺎﻟﻳّﺔ ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ ﻫﻣﺎ ﺍﻷﺳﺑﺭﻳﻥ ﻭﺍﻟﺑﻧﺎﺩﻭﻝ‪.‬‬ ‫‪ .8‬ﺗﻘﻭﻡ ﻛﺛﻳﺭ ﻣﻥ ﺍﻟﻣﺳﺗﺷ�ﻔﻳﺎﺕ ﺑﺗﺯﻭﻳ�ﺩ ﺍﻟﻣ�ﺭﻳﺽ ﺑﻛﺗﻳّ�ﺏ ﺃﻭ ﺑﻁﺎﻗ�ﺔ ﺧﺎﺻ�ﺔ ﻟﻌ�ﻼﺝ ﺍﻟﻭﺍﺭﻓ�ﺎﺭﻳﻥ‬ ‫ﻟﺳﺑﺑﻳﻥ‪ ،‬ﺍﻷﻭﻝ ﻫﻭ ﻛﻲ ﻳﻌﻭﺩ ﺇﻟﻳﻬ�ﺎ ﺍﻟﻣ�ﺭﻳﺽ ﻓ�ﻲ ﺍﻟﺑﻳ�ﺕ ﻭﻳﺗﺛﺑّ�ﺕ ﻣ�ﻥ ﺍﻟﺟ�ﺩﻭﻝ ﺍﻟ�ﺫﻱ ﻭﺿ�ﻌﻪ‬ ‫ﺍﻟﻁﺑﻳﺏ ﻟ�ﻪ‪ ،‬ﺇﺫﺍ ﺣﺻ�ﻝ ﻟﺩﻳ�ﻪ ﺷ�ﻙ ‪ .‬ﻭﺍﻟﺳ�ﺑﺏ ﺍﻟﺛ�ﺎﻧﻲ ﻫ�ﻭ ﻟﻳﺣﻣﻠ�ﻪ ﻣﻌ�ﻪ ﺇﺫﺍ ﺭﺍﺟ�ﻊ ﺃﻱ ﻁﺑﻳ�ﺏ‬ ‫ﺁﺧﺭ ﺃﻭ ﻁﺑﻳﺏ ﺃﺳﻧﺎﻥ ﻭﻳﻁﻠﻌﻪ ﻋﻠﻳ�ﻪ ﻟﻳﻛ�ﻭﻥ ﻋﻠ�ﻰ ﺑﻳّﻧ�ﺔ ﻣ�ﻥ ﺍﻟﻌ�ﻼﺝ ﻭﻣ�ﻥ ﺍﻟﻣ�ﺭﺽ ﺍﻷﺻ�ﻠﻲ‬ ‫ﺍﻟﺫﻱ ﻣﻥ ﺃﺟﻠﻪ ﻭُ ﺻِ ﻑ ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ‪.‬‬ ‫‪ .9‬ﺇﻥ ﺇﺟ��ﺭﺍء ﺃﻳ��ﺔ ﻋﻣﻠﻳ��ﺔ ﺟﺭﺍﺣﻳ��ﺔ ﺃﻭ ﻗﻠ��ﻊ ﺳ��ﻥ ﻣ��ﻊ ﺗﻧ��ﺎﻭﻝ ﺍﻟﻭﺍﺭﻓ��ﺎﺭﻳﻥ ﺳﻳﺻ��ﺎﺣﺑﻪ ﻧ��ﺯﻑ ﻏﻳ��ﺭ‬ ‫ﻋﺎﺩﻱ‪ ،‬ﻷﻥ ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ ﻳﻘﻠﻝ ﻣﻥ ﺗﺧﺛﺭ ﺍﻟﺩﻡ ﻭﻳﺯﻳﺩ ﺳﻳﻭﻟﺗﻪ‪ .‬ﻟ�ﺫﺍ ﻓﻬﻧ�ﺎﻙ ﺇﺟ�ﺭﺍءﺍﺕ ﺗﺗﺧ�ﺫ ﻗﺑ�ﻝ‬ ‫ﺍﻟﻌﻣﻠﻳﺔ ﺃﻭ ﻗﻠﻊ ﺍﻟﺳﻥ ﻟﻘﻁﻊ ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ ﻭﺇﺑﺩﺍﻟﻪ ﺑﺎﻟﻬﻳﺑﺎﺭﻳﻥ‪ ،‬ﺣﻘﻧ�ﺎ ً ﺗﺣ�ﺕ ﺍﻟﺟﻠ�ﺩ ﻋ�ﺎﺩﺓ‪ .‬ﻭﻳﺟ�ﺏ‬ ‫ﺃﻥ ﻳﺗﻡ ﺫﻟﻙ ﺑﺈﺷﺭﺍﻑ ﻣﺑﺎﺷﺭ ﻣﻥ ﺍﻟﻁﺑﻳﺏ ﺍﻟﺫﻱ ﻭﺻﻑ ﻣﺎﻧﻊ ﺍﻟﺗﺧﺛﺭ ﻟﻠﻣﺭﻳﺽ‪.‬‬ ‫‪ .10‬ﺇﻥ ﻣﺩﻯ ﺳﻳﻭﻟﺔ ﺍﻟﺩﻡ ﺍﻟﻣﻁﻠﻭﺑﺔ ﺑﺎﺳﺗﻌﻣﺎﻝ ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ ﺗﺧﺗﻠﻑ ﺑﺣﺳ�ﺏ ﺍﻟﻣ�ﺭﺽ ﺍﻟ�ﺫﻱ ﻣ�ﻥ‬ ‫ﺃﺟﻠﻪ ﻭُ ﺻِ ﻑ‪ .‬ﻓﺎﻟﺻﻣﺎﻡ ﺍﻟﻣﻌ�ﺩﻧﻲ ﻓ�ﻲ ﺍﻟﻘﻠ�ﺏ ﺗﺧﺗﻠ�ﻑ ﺍﻟﺳ�ﻳﻭﻟﺔ ﺍﻟﻣﻁﻠﻭﺑ�ﺔ ﻟ�ﻪ ﻋ�ﻥ ﺣﺎﻟ�ﺔ ﺗﺟﻠ�ﻁ‬ ‫ﻭﺭﻳﺩ ﺍﻟﺳﺎﻕ‪ ،‬ﻭﺍﻷﺧﻳﺭﺓ ﺗﺧﺗﻠﻑ ﻋﻥ ﺣﺎﻟﺔ ﻧﻘﺹ ﺑ�ﺭﻭﺗﻳﻥ ﺝ ﺍﻟ�ﻭﺭﺍﺛﻲ‪ ،‬ﻭﻫﻛ�ﺫﺍ…ﻭ ُﻳ َﻌﺑﱠ�ﺭ ﻋ�ﻥ‬ ‫ﻣﻘﺩﺍﺭ ﺍﻟﺳ�ﻳﻭﻟﺔ ﺑ�ﺭﻗﻡ ﻳﺳ�ﻣﻰ )ﻧﺳ�ﺑﺔ ﺍﻟﺳ�ﻳﻭﻟﺔ( ﻭﻳﻣﺛ�ﻝ ﻧﺳ�ﺑﺔ ﺳ�ﻳﻭﻟﺔ ﺩﻡ ﺍﻟﻣ�ﺭﻳﺽ ﺇﻟ�ﻰ ﺳ�ﻳﻭﻟﺔ‬ ‫ﺍﻟﺩﻡ ﺍﻟﻁﺑﻳﻌﻲ‪ ،‬ﺑﺎﺳﺗﻌﻣﺎﻝ ﻧﻔﺱ ﺍﻟﻔﺣﺹ‪ .‬ﺗﺧﺗﻠﻑ ﺍﻟﻧﺳﺑﺔ ﺍﻟﻣﻁﻠﻭﺑﺔ ﻣﻥ‪ 1,5‬ﺇﻟ�ﻰ ‪ 3,5‬ﺃﻭ ﺣﺗ�ﻰ‬ ‫‪ ، 4‬ﻭﺑﺣﺳ��ﺏ ﺍﻟﺣﺎﻟ��ﺔ‪ -‬ﻛﻣ��ﺎ ﺫﻛ��ﺭﺕ‪ .-‬ﻭﻋﻠ��ﻰ ﺍﻟﻣ��ﺭﻳﺽ ﺃﻥ ﻳ��ﺩﺭﻙ ﺃﻥ ﺍﺣﺗﻣ��ﺎﻝ ﺍﻟﻧ��ﺯﻑ ﻋﻧ��ﺩﻩ‬ ‫ﻳ��ﺯﺩﺍﺩ ﻛﻠﻣ��ﺎ ﺍﺭﺗﻔﻌ��ﺕ ﻧﺳ��ﺑﺔ ﺳ��ﻳﻭﻟﺔ ﺩﻣ��ﻪ‪ ،‬ﻛﻣ��ﺎ ﺃﻥ ﻧﻘﺻ��ﺎﻥ ﺍﻟﻧﺳ��ﺑﺔ ﻋ��ﻥ ﺍﻟﻣﻁﻠ��ﻭﺏ ﻟﺣﺎﻟﺗ��ﻪ ﻗ��ﺩ‬ ‫ﻳﺅﺩﻱ ﺇﻟ�ﻰ ﺣﺻ�ﻭﻝ ﺗﺟﻠ�ﻁ‪ ،‬ﻭﻫ�ﻭ ﺍﻷﻣ�ﺭ ﺍﻟ�ﺫﻱ ﻛ�ﺎﻥ ﺍﻟﻁﺑﻳ�ﺏ ﻳﺭﻳ�ﺩ ﺗﺟﻧﺑ�ﻪ ﺑﺎﻷﺻ�ﻝ ﻓﻭﺻ�ﻑ‬ ‫ﻋﻘﺎﺭ ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ‪.‬‬

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‫‪ .11‬ﻳﻌﻁﻰ ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ ﺑﺻﻭﺭﺓ ﻣﺅﻗﺗﺔ ﻟﺑﻌﺽ ﺍﻟﺣﺎﻻﺕ‪ ،‬ﻭﺣﺳﺏ ﺇﺭﺷ�ﺎﺩ ﺍﻟﻁﺑﻳ�ﺏ‪ ،‬ﻭﺑﺻ�ﻭﺭﺓ‬ ‫ﺩﺍﺋﻣﺔ) ﻣﺩﻯ ﺍﻟﻌﻣﺭ( ﻟﺣﺎﻻﺕ ﺃﺧﺭﻯ‪.‬‬ ‫‪ .12‬ﻳﺗﻔﻕ ﺍﻷﻁﺑﺎء‪ ،‬ﻛﻣﺎ ﺫﻛﺭﺕ ﻋﻧﺩ ﺍﻟﺣﺩﻳﺙ ﻋﻥ ﺍﻟﻬﻳﺑﺎﺭﻳﻥ‪ ،‬ﻋﻠﻰ ﺿﺭﻭﺭﺓ ﻗﻁﻊ ﺍﻟﻭﺍﺭﻓ�ﺎﺭﻳﻥ‬ ‫ﺧ��ﻼﻝ ﺍﻷﺳ��ﺎﺑﻳﻊ ﺍﻟﻌﺷ��ﺭﺓ ﺃﻭ ﺍﻻﺛﻧ��ﻲ ﻋﺷ��ﺭ ﺍﻷﻭﻟ��ﻰ ﻣ��ﻥ ﺍﻟﺣﻣ��ﻝ ﻭﺇﺑﺩﺍﻟ��ﻪ ﺑﺣﻘ��ﻥ ﺍﻟﻬﻳﺑ��ﺎﺭﻳﻥ‪،‬‬ ‫ﻭﺑﻌ��ﺽ ﺍﻷﻁﺑ��ﺎء ﻳﻣﻧﻌ��ﻭﻥ ﺍﻟﻭﺍﺭﻓ��ﺎﺭﻳﻥ ﻋ��ﻥ ﺍﻟﻣﺭﻳﺿ��ﺎﺕ ﻁﻳﻠ��ﺔ ﻓﺗ��ﺭﺓ ﺍﻟﺣﻣ��ﻝ ﻭﻳﻌﻭﺿ��ﻭﻧﻬﺎ‬ ‫ﺑﺎﻟﻬﻳﺑ�ﺎﺭﻳﻥ‪ .‬ﻭﺳ�ﺑﺏ ﺫﻟ�ﻙ ﻫ�ﻭ ﺍﺣﺗﻣ�ﺎﻝ ﺣﺻ�ﻭﻝ ﺣ�ﺎﻻﺕ ﺗﺷ�ﻭّ ﻩ ﺟﻧﻳﻧﻳّ�ﺔ ﺇﺫﺍ ﻛﺎﻧ�ﺕ ﺍﻷﻡ ﺗﺗﻧ�ﺎﻭﻝ‬ ‫ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ ﺧﻼﻝ ﺍﻷﺳ�ﺎﺑﻳﻊ ﺍﻟﻌﺷ�ﺭﺓ ﺍﻷﻭﻟ�ﻰ ﻣ�ﻥ ﺍﻟﺣﻣ�ﻝ‪ .‬ﻟ�ﺫﻟﻙ‪ ،‬ﻓﻌﻠ�ﻰ ﺃﻳ�ﺔ ﻣﺭﻳﺿ�ﺔ ﺗﺗﻧ�ﺎﻭﻝ‬ ‫ﺍﻟﻭﺍﺭﻓ��ﺎﺭﻳﻥ ﻭﺗﺷ��ﻙ ﺃﻥ ﻟ��ﺩﻳﻬﺎ ﺣﻣ�ﻼً‪ ،‬ﻋﻠﻳﻬ��ﺎ ﺃﻥ ﺗﺭﺍﺟ��ﻊ ﺑ��ﺩﻭﻥ ﺇﺑﻁ��ﺎء ﻟﻌﻣ��ﻝ ﻓﺣ��ﺹ ﺍﻟﺣﻣ��ﻝ‪،‬‬ ‫ﺣﺗﻰ ﻳﻣﻛﻥ ﺇﻳﻘﺎﻑ ﺍﻟﻭﺍﺭﻓ�ﺎﺭﻳﻥ ﻭﺇﺑﺩﺍﻟ�ﻪ ﺑﺎﻟﻬﻳﺑ�ﺎﺭﻳﻥ‪ ،‬ﻋﻠ�ﻰ ﺍﻷﻗ�ﻝ ﻟﻠﻌﺷ�ﺭ ﺃﺳ�ﺎﺑﻳﻊ ﺍﻷﻭﻟ�ﻰ ﻣ�ﻥ‬ ‫ﺍﻟﺣﻣﻝ ﻭﺣﺳﺏ ﺭﺃﻱ ﺍﻟﻁﺑﻳﺏ ﺍﻟﻣﻌﺎﻟﺞ‪.‬‬ ‫‪ .13‬ﻻ ﻳﻅﻬ��ﺭ ﺍﻟﻭﺍﺭﻓ��ﺎﺭﻳﻥ ﻓ��ﻲ ﺣﻠﻳ��ﺏ ﺍﻷﻡ ﺍﻟﻣﺭﺿ��ﻊ ﺇﻻ ﺑﻛﻣﻳ��ﺎﺕ ﺑﺳ��ﻳﻁﺔ ﺟ��ﺩﺍً ﻻ ﺗ��ﺅﺛﺭ ﻋﻠ��ﻰ‬ ‫ﺍﻟﺭﺿﻳﻊ‪.‬‬ ‫ﺍﻟﻣﺿﺎﺩﺍﺕ ﺍﻟﻣﺑﺎﺷﺭﺓ ﻟﻠﺧﺛﺭﻳﻥ ﻭﻟﻌﺎﻣﻝ ‪10‬‬ ‫ﺗﻡ ﻣﺅﺧﺭﺍً ﺇﻧﺗﺎﺝ ﻋﻘﺎﺭﺍﺕ ﺗﺑﻁﻝ ﻓﻌﺎﻟﻳﺔ ﺍﻟﺧﺛﺭﻳﻥ ﺃﻭ ﻋﺎﻣﻝ ‪ ،10‬ﻭﺗﺅﺧﺫ ﺑﺎﻟﻔﻡ ﻭﻗﺩ ﺑﺩﺃﺕ ﺗﻛﺳﺏ ﺍﻫﺗﻣﺎﻣﺎ ً‬ ‫ﺑﺻﻭﺭﺓ ﺗﺩﺭﻳﺟﻳﺔ ﻭﻳﺑﺩﻭ ﺃﻧﻬﺎ ﺃﻣﻳﻧﺔ ﻓﻲ ﺍﻻﺳﺗﻌﻣﺎﻝ ﻭﺫﺍﺕ ﻧﺗﺎﺋﺞ ﻁﻳﺑﺔ‪.‬‬

‫ﺍﻷﺳﺑﺭﻳﻥ ﻛﻣﺎ ﻧﻊ ﻟﻠﺗﺟﻠﻁ‬ ‫ﻫﺫﺍ ﺍﻟﺩﻭﺍء ﺍﻟﺑﺳﻳﻁ ﺍﻟﺗﺭﻛﻳﺏ ﻟﻪ ﺍﺳﺗﻌﻣﺎﻻﺕ ﻣﺧﺗﻠﻔﺔ‪ ،‬ﻣﻧﻬﺎ ﺧﻔ�ﺽ ﺣ�ﺭﺍﺭﺓ ﺍﻟﺟﺳ�ﻡ ﻭﺗﺧﻔﻳ�ﻑ ﺍﻷﻟ�ﻡ‬ ‫ﻭﺗﺛﺑ��ﻳﻁ ﺍﻻﻟﺗﻬﺎﺑ��ﺎﺕ ﻭﻏﻳﺭﻫ��ﺎ‪ .‬ﻭﻗ��ﺩ ﺗﺑ �ﻳّﻥ ﺃﻳﺿ �ﺎ ً ﺍﻧ��ﻪ ﻳﻣﻧ��ﻊ ﻋﻣ��ﻝ ﺍﻟﺻ��ﻔﻳﺣﺎﺕ ﺑ��ﺄﻥ ﻳﺛ �ﺑّﻁ ﺑﻌ��ﺽ‬ ‫ﺍﻹﻧﻅﻳﻣﺎﺕ ﻓﻳﻬﺎ‪ ،‬ﻣﻣﺎ ﻳﺅﺩﻱ ﺇﻟﻰ ﻣﻧﻊ ﺗﺭﺍﻛﻣﻬ�ﺎ‪ .‬ﻭﻗ�ﺩ ﺫﻛ�ﺭﺕ ﺫﻟ�ﻙ ﻓ�ﻲ ﺍﻟﻔﺻ�ﻝ ﺍﻟﺛ�ﺎﻧﻲ ﻣ�ﻥ ﻛﺗ�ﺎﺏ‬ ‫ﺗﺧﺛﺭ ﺍﻟﺩﻡ ﻋﻧﺩ ﺍﻟﺣﺩﻳﺙ ﻋﻥ ﺃﻣﺭﺍﺽ ﺍﻟﻧﺯﻑ ﺍﻟﻣﻛﺗﺳﺑﺔ‪.‬‬ ‫ﺇﻥ ﺗﻧﺎﻭﻝ ﻗ�ﺭﺹ ﺃﺳ�ﺑﺭﻳﻥ ﻭﺍﺣ�ﺩ ﻳﻭﻣﻳ�ﺎً‪ ،‬ﺣﺗ�ﻰ ﻟ�ﻭ ﻛ�ﺎﻥ ﻣ�ﻥ ﺍﻟﻧ�ﻭﻉ ﺍﻟﺻ�ﻐﻳﺭ ﺍﻟﺧ�ﺎﺹ ﺑﺎﻷﻁﻔ�ﺎﻝ‪،‬‬ ‫ﻳﺳﺑﺏ ﻧﻘﺻﺎ ً ﻓﻲ ﻋﻣﻝ ﺍﻟﺻﻔﻳﺣﺎﺕ ﺍﻟﻣﻭﺟﻭﺩﺓ ﺑﺎﻟﺩﻡ ﻋﻧﺩ ﺗﻧﺎﻭﻝ ﺍﻟﺩﻭﺍء‪ ،‬ﻭﻳﺳﺗﻣﺭ ﺫﻟﻙ ﻟﻌﺩﺓ ﺃﻳﺎﻡ‪.‬‬ ‫ﻭﻗﺩ ﺍﺳ ُﺗﻌﻣِﻝ ﺍﻷﺳﺑﺭﻳﻥ ﻛﻣﺎﻧﻊ ﺗﺧﺛﺭ ﻟﻭﺣﺩﻩ ﻓﻠﻡ ﻳﻛﻥ ﻧﺎﺟﺣ�ﺎ ً ﻟﻣﻧ�ﻊ ﺍﻟﺗﺧﺛ�ﺭ ﻓ�ﻳﻣﻥ ﻋﻧ�ﺩﻫﻡ ﺍﺳ�ﺗﻌﺩﺍﺩ‬ ‫ﻛﺎﻟﻣﺻﺎﺑﻳﻥ ﺑﺄﻣﺭﺍﺽ ﻓﺭﻁ ﺍﻟﺗﺧﺛﺭ ﺃﻭ ﻣﻥ ﻋﻧﺩﻫﻡ ﺻﻣﺎﻡ ﻣﻌﺩﻧﻲ ﻓﻲ ﺍﻟﻘﻠﺏ‪ .‬ﻟﻛﻧ�ﻪ ﻳﺿ�ﺎﻑ ﺃﺣﻳﺎﻧ�ﺎ ً‬ ‫ﺇﻟﻰ ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ ﻟﻳﻌﻣﻝ ﻣﻌﻪ ﻋﻠﻰ ﻣﻧﻊ ﺣﺻﻭﻝ ﺗﺧﺛﺭﺍﺕ ﺷﺭﻳﺎﻧﻳﺔ‪ ،‬ﻻﺳﻳّﻣﺎ ﻓ�ﻲ ﺍﻟﺷ�ﺭﺍﻳﻳﻥ ﺍﻟﺗﺎﺟﻳ�ﺔ‬ ‫ﻓ��ﻲ ﺍﻟﻣﺭﺿ��ﻰ ﺍﻟ��ﺫﻳﻥ ﻳُﺧﺷ��ﻰ ﻣ��ﻥ ﺗﻛ��ﺭﺭ ﺍﻟﺟﻠﻁ��ﺔ ﺍﻟﺗﺎﺟﻳ��ﺔ ﻟ��ﺩﻳﻬﻡ‪ .‬ﻛ��ﺫﻟﻙ ﻳﺗﻧﺎﻭﻟ��ﻪ ﺍﻟﻛﺛﻳ��ﺭﻭﻥ ﻣ��ﻥ‬ ‫ﺍﻷﻓﺭﺍﺩ ﺍﻷﺻﺣﺎء‪ ،‬ﺑﻧﺻﻳﺣﺔ ﻣﻥ ﺃﻁﺑ�ﺎﺋﻬﻡ‪ ،‬ﻟﻠﻭﻗﺎﻳ�ﺔ ﻣ�ﻥ ﺣﺻ�ﻭﻝ ﺗﻐﻳّ�ﺭﺍﺕ ﻓ�ﻲ ﺟ�ﺩﺭﺍﻥ ﺍﻟﺷ�ﺭﺍﻳﻳﻥ‬ ‫ﺍﻟﺗﺎﺟﻳ��ﺔ‪ ،‬ﻭﻣ��ﻥ ﺛ��ﻡ ﺟﻠﻁ��ﺔ ﻓﻳﻬ��ﺎ‪ ،‬ﺣﻳ��ﺙ ﺃﻥ ﺍﻟﺻ��ﻔﻳﺣﺎﺕ ﺗﻠﻌ��ﺏ ﺑﻌ��ﺽ ﺍﻟ��ﺩﻭﺭ ﻓ��ﻲ ﺍﻟﺗﻐﻳ��ﺭﺍﺕ‬ ‫ﺍﻻﻧﺣﻁﺎﻁﻳﺔ ﺑﺎﻟﺷﺭﺍﻳﻳﻥ ﻟﺩﻯ ﻣﻥ ﻋﻧﺩﻫﻡ ﺍﺳﺗﻌﺩﺍﺩ ﻭﺭﺍﺛﻲ ﺃﻭ ﺑﺳﺑﺏ ﺍﻟﺗﺩﺧﻳﻥ ﺃﻭ ﺯﻳ�ﺎﺩﺓ ﺍﻟ�ﺩﻫﻭﻥ ﺃﻭ‬ ‫ﻏﻳﺭﻫﺎ‪.‬‬ ‫ﺃﺭﺟﻭ ﺃﻥ ﻳﺗﺫﻛﺭ ﺍﻟﻘﺎﺭﺉ ﺃﻥ ﺍﻷﺳﺑﺭﻳﻥ ﻻ ﻳﺧﻠﻭ ﻣ�ﻥ ﺑﻌ�ﺽ ﺍﻷﺿ�ﺭﺍﺭ‪ ،‬ﻣﻧﻬ�ﺎ ﺗ�ﺄﺛﻳﺭﻩ ﻋﻠ�ﻰ ﺍﻟﻣﻌ�ﺩﺓ‬ ‫ﻣﺳﺑﺑﺎ ً ﺗﻘﺭﺣﺎ ً ﻓﻳﻬﺎ ﻟﺩﻯ ﺑﻌﺽ ﺍﻷﻓﺭﺍﺩ‪.‬‬ ‫‪8‬‬

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‫ﻛ��ﺫﻟﻙ ﻓﻣ��ﻥ ﺍﻟﻣﻬ��ﻡ ﺗ��ﺫ ّﻛﺭ ﺃﻥ ﺍﻷﺳ��ﺑﺭﻳﻥ ﻳﺯﻳ��ﺩ ﻣ��ﻥ ﺍﻟﻣﻔﻌ��ﻭﻝ ﺍﻟﻣﺿ��ﺎﺩ ﻟﻠﺗﺧﺛ��ﺭ ﺍﻟ��ﺫﻱ ﻳﺳ��ﺑﺑﻪ‬ ‫ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ‪ .‬ﻓﺈﺫﺍ ﺃﺧﺫ ﺍﻟﻣﺭﻳﺽ ﺍﻟﻌﻘﺎﺭﻳﻥ ﻣﻌﺎ ً ﺑﺻﻭﺭﺓ ﻣﺳﺗﻣﺭﺓ ﺃﻣﻛﻥ ﺿﺑﻁ ﺟﺭﻋﺔ ﺍﻟﻭﺍﺭﻓ�ﺎﺭﻳﻥ‬ ‫ﺍﻟﻣﻧﺎﺳﺑﺔ‪ .‬ﻟﻛﻥ ﺇﺫﺍ ﺗﻧﺎﻭﻝ ﺍﻷﺳﺑﺭﻳﻥ ﺑﺻﻭﺭﺓ ﻏﻳﺭ ﻣﻧﺗﻅﻣﺔ‪ ،‬ﺃﻭ ﺑﻛﻣﻳ�ﺔ ﺗﺯﻳ�ﺩ ﻋ�ﻥ ﺍﻟﻘ�ﺭﺹ ﺍﻟﻭﺍﺣ�ﺩ‬ ‫ﺍﻟﻣﻘﺭﱠ ﺭ ﻟﻠﻳﻭﻡ ﺍﻟﻭﺍﺣﺩ‪ ،‬ﻓﻘﺩ ﻳﺅﺩﻱ ﺫﻟﻙ ﺇﻟﻰ ﺯﻳﺎﺩﺓ ﻏﻳﺭ ﻣﺗﻭ ﱠﻗﻌﺔ ﻓﻲ ﻧﺳﺑﺔ ﺍﻟﺳﻳﻭﻟﺔ‪.‬‬ ‫ﻣﺫﻳﺑﺎﺕ ﺍﻟﺧﺛﺭﺓ‬ ‫ﻫﺫﻩ ﺍﻟﻣﺟﻣﻭﻋﺔ ﻣﻥ ﺍﻟﻌﻘﺎﺭﺍﺕ ﻫﻲ ﻟﻳﺳﺕ ﻣﻥ ﻣﻭﺍﻧﻊ ﺍﻟﺗﺧﺛﺭ‪ ،‬ﻟﻛﻧﻬﺎ ﻗ�ﺩ ُﺗﻌﻁ�ﻰ ﻟﻠﻣ�ﺭﻳﺽ ﻣﺑﺎﺷ�ﺭﺓ‬ ‫ﺑﻌﺩ ﺣﺻﻭﻝ ﺟﻠﻁﺔ ﺷﺭﻳﺎﻧﻳﺔ )ﺧﻼﻝ ﺳﺎﻋﺎﺕ( ﻟﻣﺣﺎﻭﻟﺔ ﺗﺫﻭﻳﺑﻬﺎ ﻭﺇﻋﺎﺩﺓ ﻓﺗﺢ ﺍﻟﺷﺭﻳﺎﻥ ﺍﻟ�ﺫﻱ ﺗﺳ� ّﺩﻩ‬ ‫ﺗﻠ��ﻙ ﺍﻟﺟﻠﻁ��ﺔ‪ .‬ﻭﺃﻛﺛ��ﺭ ﻣ��ﺎ ﺗﺳ��ﺗﻌﻣﻝ ﻓ��ﻲ ﺟﻠﻁ��ﺎﺕ ﺍﻟﺷ��ﺭﺍﻳﻳﻥ ﺍﻟﺗﺎﺟﻳ��ﺔ‪ ،‬ﺇﺫﺍ ﻭﺻ��ﻝ ﺍﻟﻣ��ﺭﻳﺽ ﺇﻟ��ﻰ‬ ‫ﺍﻟﻣﺳﺗﺷﻔﻰ ﻓﻲ ﺍﻟﻭﻗﺕ ﺍﻟﻣﻧﺎﺳﺏ‪.‬‬ ‫ﺃﺷ��ﻬﺭ ﻫ��ﺫﻩ ﺍﻟﻣﺟﻣﻭﻋ��ﺔ ﻫ��ﻭ ﺍﻟﺳ��ﺗﺭﺑﺗﻭﻛﺎﻳﻧﻳﺯ ﺍﻟﻣﺷ��ﺗﻕ ﻣ��ﻥ ﺑﻌ��ﺽ ﺍﻟﺟ��ﺭﺍﺛﻳﻡ ﻭﻫﻧ��ﺎﻙ ﻣﻔ ّﻌ��ﻝ ﻣ�ﺫﻳﺏ‬ ‫ﺍﻟﺧﺛﺭﺓ ﺍﻟﻁﺑﻳﻌﻲ ﺍﻟﻣُﻧ َﺗﺞ ﺑﺎﻟﻬﻧﺩﺳﺔ ﺍﻟﻭﺭﺍﺛﻳﺔ‪.‬‬ ‫ﻣﺨﺘﺼﺮ ﻷﺳﺎﻟﻴﺐ ﺍﺳﺘﻌﻤﺎﻝ ﻣﻀﺎﺩﺍﺕ ﺍﻟﺘﺨﺜﺮ ﻓﻲ ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺨﺘﻠﻔﺔ )ﻣﻊ ﺍﺧﺘﻼﻓﺎﺕ ﺑﺴﻴﻄﺔ ﻣﻦ ﻁﺒﻴﺐ ﻵﺧﺮ(‪:‬‬

‫ﺍ‪ .‬ﺟﻠﻁﺎﺕ ﺷﺭﺍﻳﻳﻥ ﺍﻟﻘﻠﺏ‪:‬‬ ‫ ﺳﺗﺭﺑﺗﻭﻛﺎﻳﻧﻳﺯ ﺃﻭ ﻣﺫﻳﺏ ﺁﺧﺭ ﻟﻠﺧﺛﺭﺓ‪.‬‬‫ ﻫﻳﺑﺎﺭﻳﻥ ﻟﻔﺗﺭﺓ ﺃﺳﺑﻭﻉ ﺃﻭ ﺃﻛﺛﺭ‪.‬‬‫ ﺃﺳﺑﺭﻳﻥ ﻟﻔﺗﺭﺓ ﻁﻭﻳﻠﺔ‪.‬‬‫ﺏ‪ .‬ﺟﻠﻁﺎﺕ ﺃﻭﺭﺩﺓ ﺍﻟﺳﺎﻗﻳﻥ ﺃﻭ ﺻ ّﻣ ﺔ ﺍﻟﺷﺭﺍﻳﻳﻥ ﺍﻟﺭﺋﻭﻳﺔ ‪:‬‬ ‫ ﻫﻳﺑﺎﺭﻳﻥ ﻓﻲ ﺍﻟﺑﺩﺍﻳﺔ‪.‬‬‫ ﺍﻟﺗﺣﻭﻝ ﺇﻟﻰ ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ ﺧﻼﻝ ﺃﻳﺎﻡ ﻭﻟﻣﺩﺓ ﺃﺭﺑﻌﺔ ﺃﺷﻬﺭ ﺇﻟﻰ ﺳﻧﺔ‪.‬‬‫ﺝ‪ .‬ﺍﻟﺻﻣﺎﻣﺎﺕ ﺍﻻﺻﻁﻧﺎﻋﻳﺔ ﻓﻲ ﺍﻟﻘﻠﺏ ‪:‬‬ ‫ ﻫﻳﺑﺎﺭﻳﻥ ﻓﻲ ﺍﻟﺑﺩﺍﻳﺔ‬‫ ﺍﻟﺗﺣﻭﻝ ﺇﻟﻰ ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ ﺧﻼﻝ ﺃﻳﺎﻡ ﻭﺍﻻﺳﺗﻣﺭﺍﺭ ﻋﻠﻳﻪ ﻣﺩﻯ ﺍﻟﻌﻣﺭ‪.‬‬‫ﺩ‪ .‬ﺃﻣﺭﺍﺽ ﻓﺭﻁ ﺍﻟﺗﺧﺛﺭ ﺍﻟﻭﺭﺍﺛﻳﺔ‬ ‫ ﻭﺍﺭﻓﺎﺭﻳﻥ ﻣﺩﻯ ﺍﻟﻌﻣﺭ‪.‬‬‫ﻫـ‪ .‬ﺣﺎﻟﺔ ﺍﻟﺣﻣﻝ ﻋﻧﺩ ﻣﻥ ﺗﺣﺗﺎﺝ ﺇﻟﻰ ﻣﺎﻧﻊ ﺗﺧﺛﺭ ‪:‬‬ ‫ ﻗﻁﻊ ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ ﻓﻭﺭﺍً‬‫ ﺍﻟﺑﺩء ﺑﺎﻟﻬﻳﺑﺎﺭﻳﻥ‪.‬‬‫ ﺍﻻﺳﺗﻣﺭﺍﺭ ﻋﻠﻰ ﺍﻟﻬﻳﺑﺎﺭﻳﻥ ﻁﻳﻠﺔ ﺍﻟﺣﻣﻝ ‪.‬‬‫ﺃﻭ‬ ‫ﺍﻟﻌﻭﺩﺓ ﺇﻟﻰ ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ ﺑﻌﺩ ‪ 12‬ﺃﺳﺑﻭﻉ‪ ،‬ﺛﻡ ﺍﻟﺭﺟﻭﻉ ﻟﻠﻬﻳﺑﺎﺭﻳﻥ ﺁﺧﺭ ﺃﺳﺑﻭﻋﻳﻥ ﻣﻥ ﺍﻟﺣﻣﻝ‪.‬‬ ‫ﻭ‪ .‬ﻋﻣﻠﻳﺔ ﺟﺭﺍﺣﻳﺔ ﺃﻭ ﻗﻠﻊ ﺳﻥ ‪:‬‬ ‫ ﻗﻁﻊ ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ ﺛﻼﺛﺔ ﺃﻳﺎﻡ ﻗﺑﻝ ﺍﻟﻌﻣﻠﻳﺔ‪.‬‬‫ ﺍﻟﺑﺩء ﺑﺎﻟﻬﻳﺑﺎﺭﻳﻥ ﺗﺣﺕ ﺍﻟﺟﻠﺩ ﻳﻭﻣﻳﻥ ﻗﺑﻝ ﺍﻟﻌﻣﻠﻳﺔ‪.‬‬‫ ﻋﺩﻡ ﺃﺧﺫ ﺍﻟﻬﻳﺑﺎﺭﻳﻥ ﺻﺑﺎﺡ ﻳﻭﻡ ﺍﻟﻌﻣﻠﻳﺔ‬‫‪9‬‬

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‫ ﺍﻟﻌﻭﺩﺓ ﺇﻟﻰ ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ ﻣﻊ ﺍﻟﻬﻳﺑﺎﺭﻳﻥ ﻣﺳﺎء ﻳﻭﻡ ﺍﻟﻌﻣﻠﻳﺔ‪.‬‬‫‪ -‬ﻗﻁﻊ ﺍﻟﻬﻳﺑﺎﺭﻳﻥ ﻓﻲ ﺍﻟﻳﻭﻡ ﺍﻟﺛﺎﻧﻲ ﺑﻌﺩ ﺍﻟﻌﻣﻠﻳﺔ ﻭﺍﻻﺳﺗﻣﺭﺍﺭ ﻋﻠﻰ ﺍﻟﻭﺍﺭﻓﺎﺭﻳﻥ‪.‬‬

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‫ﺍﻟﻣﺻﻁﻠﺣﺎﺕ ﺍﻟﻁﺑﻳﺔ ﻭﺗﺭﺟﻣﺗﻬﺎ‬ Thrombophilias Enzyme Vein/s Protein C Clotting(Coagulation) Platelet aggregation Atherosclerosis Osteoporosis Injection Clot, Thrombus Thrombin Thrombosis Dindevan Streptokinase Arteries Trauma Coronary artery Platelets Embolus Clotting factor Plasmin Antithrombin Medicinal leech Prothrombin time(PT) Partial Throboplastin Time (PTT) Vitamin K Bruise(Ecchymosis) Inherited disease Plasminogen activator Anticoagulant Oral anticoagulants Bleeding, haemorrhage PT ratio (INR) Warfarin(Coumadin) Heparin Unfractionated Heparin Low molecular weight heparin(LMWH) Hirudin

‫ﺃﻣﺭﺍﺽ ﻓﺭﻁ ﺍﻟﺗﺧﺛﺭ‬ ‫ﺇﻧﻅﻳﻡ‬ ‫ ﻭﺭﻳﺩ‬/‫ﺃﻭﺭﺩﺓ‬ ‫ﺑﺭﻭﺗﻳﻥ ﺝ‬ ‫ﺗﺧﺛﺭ‬ ‫ﺗﺭﺍﻛﻡ ﺍﻟﺻﻔﻳﺣﺎﺕ‬ ‫ﺗﻐ ّﻳﺭﺍﺕ ﺍﻧﺣﻁﺎﻁﻳﺔ‬ ّ (‫ﺗﻧﺧﺭ)ﻫﺷﺎﺷﺔ‬ ‫ﺣﻘﻥ‬ ‫ﺧﺛﺭﺓ‬ ‫ﺧﺛﺭﻳﻥ‬ ‫ﺟﻠﻁﺔ‬ ‫ﺩﻧﺩﻳﻔﺎﻥ‬ ‫ﺳﺗﺭﺑﺗﻭﻛﺎﻳﻧﻳﺯ‬ ‫ﺷﺭﺍﻳﻳﻥ‬ ‫ﺷ ّﺩ ﺓ‬ ‫ﺷﺭﻳﺎﻥ ﺗﺎﺟﻲ‬ ‫ﺻﻔﻳﺣﺎﺕ ﺍﻟﺩﻡ‬ ‫ﺻ ّﻣ ﺔ‬ ‫ﻋﺎﻣﻝ ﺗﺧﺛﺭ‬ ‫ﻋﺎﻣﻝ ﻣﺫﻳﺏ ﺍﻟﺧﺛﺭﺓ‬ ‫ﻋﺎﻣﻝ ﻣﺿﺎﺩ ﺍﻟﺧﺛﺭﻳﻥ‬ ‫ﻋﻠﻕ ﻁﺑﻲ‬ ‫ﻓﺣﺹ ﻭﻗﺕ ﻣﻭﻟﺩ ﺍﻟﺧﺛﺭﻳﻥ‬ ‫ﻓﺣﺹ ﻭﻗﺕ ﻣﻭﻟّﺩ ﺍﻟﺧﺛﺭﺓ ﺍﻟﺟﺯﺋﻲ‬ ‫ﻓﻳﺗﺎﻣﻳﻥ ﻙ‬ ‫ﻛﺩﻣﺔ‬ ‫ﻣﺭﺽ ﻣﻭﺭﻭﺙ‬ ‫ﻣﻔ ّﻌﻝ ﻣﺫﻳﺏ ﺍﻟﺧﺛﺭﺓ‬ ‫ﻣﺿﺎﺩ)ﻣﺎﻧﻊ( ﺍﻟﺗﺧﺛﺭ‬ ‫ﻣﺿﺎﺩﺍﺕ ﺍﻟﺗﺧﺛﺭ ﺍﻟﻔﻣﻳﺔ‬ ‫ﻧﺯﻑ‬ ‫ﻧﺳﺑﺔ ﺳﻳﻭﻟﺔ ﺍﻟﺩﻡ‬ (‫ﻭﺍﺭﻓﺎﺭﻳﻥ)ﻛﻭﻣﺎﺩﻳﻥ‬ ‫ﻫﻳﺑﺎﺭﻳﻥ‬ ّ ‫ﻣﺟﺯﺃ‬ ‫ﻫﻳﺑﺎﺭﻳﻥ ﻏﻳﺭ‬ ‫ﻫﻳﺑﺎﺭﻳﻥ ﻭﺍﻁﺊ ﺍﻟﻭﺯﻥ ﺍﻟﺟﺯﻳﺋﻲ‬ ‫ﻫﻳﺭﻭﺩﻳﻥ‬

WARFARIN (COUMADIN) INTERACTIONS I.

FACTORS POTENTIATING WARFARIN EFFECT (exaggerating INR rise caused by warfarin or raising the likelihood of bleeding caused by the high INR without affecting INR level)

Endogenous Clinical Conditions 1. Blood dyscrasias, especially those with thrombocytopenia and DIC, but including inherited hemorrhagic disorders. 2. Cancer, especially of epithelial surfaces, as they could easily bleed. 3. Collagen vascular diseases. Vessel wall weakness allows bleeding at the therapeutic INR. 4. Congestive Heart Failure- basically due to retarded liver cell function caused by congestion. 5. Diarrhea- due to loss of food vitamin K. This potentiated warfarin effect, as it is anti-vitamin K. 6. Fever: less food intake, effect on liver function. 7. Hepatocellular diseases, including hepatitis and cirrhosis: lower coagulation factors production and inhibited metabolism of vitamin K (reduction of epoxy vitamin K for reuse) 8. Obstructive jaundice: less vitamin K absorption from gut. Vitamin K is a fat soluble substance in food. 9. Hyperthyroidism 10. Poor nutrition: Low vitamin K intake. 11. Steatorrhea: Less vitamin K absorption because it is fat-soluble in food. 12. Vitamin K deficiency for any other reason.

b. Drugs Drug Name Acetaminophen Alcohol

Category-action Analgesic/antipyretic

Notes Effect on liver function (paracetamol) Liver toxicity, â&#x2020;&#x201C; vitamin K absorption

Allopurinol Aminosalicylic Acid Amiodarone

Uricosuric Anti inflammatory Anti-arrhythmia

Just caution. No dose change at first Antiplatelet effect. No effect in INR

Argatroban Aspirin

Direct thrombin inhibitor

Ampicillin Atenolol

Antibiotic Î˛ blocker

Additional anticoagulant effect Antiplatelet effect + additional local cause of bleeding. No effect on INR Caution only. No definite effect.

Atorvastatin

Cholesterol-lowering

Azapropazone Azithromycin

NSAID Antibiotic

Serious interaction

Bicalutamide Bivalirudin

Hormone antagonist

BSI Additional anticoagulant effect

NSAID

Direct thrombin inhibitor

Capecitabine

Cytotoxic drug

Cefamandole Cefazolin Cefoperazone Cefotetan Cefotoxitin Ceftriaxone Celecoxib

Antibiotic Antibiotic Antibiotic Antibiotic Antibiotic Antibiotic NSAID

Cerivastatin

Cholesterol-lowering

Cephamandole Chenodiol

Antibiotic Anti-cholelithic

BSI

Chloral hydrate Chloramphenicol Chlorpropramide

Anxiolytic Antibiotic Antidiabetic

Transient effect BSI

Cholestyramine Cimetidine

Exchange resin H2 receptor antagonist

Conflicting reports. Caution!

Ciprofloxacin Cisapride

Antibacterial Anti-gastric reflux

BSI

Citalpram Clarithomycin Clofibrate Clopidogrel Co-Trimoxazole Cyclophosphamide Danazol Dapoxetine Dextran Dextropropoxyphene Dextrothyroxine Diazoxide

Anti-depressant Antibiotic Cholesterol-lowering Anti platelets Antibacterial Cytotoxic Hormone antagonist Antidepressant Polysaccharide Analgesic Hormone Antihypertensive

Serotonin inhibitor BSI Vitamin K absorption reduction No interference in INR BSI by sulpha component Reports of inhibition as well Effect on liver Serotonin inhibitor ?Inhibits coagulation ?Doubtful effect Refer to point 9 above

Diclofenac

NSAID

Effect on platelet function + additional effect

Diflunisal

NSAID

Dipyridamole Disulfiram Doxycycline Erythromycin Esomeprazole Ethacrynic acid

Anti-platelet agent Anti-alcohol abuse Antibiotic Antibiotic Peptic ulcer healing Diuretic

Effect on platelet function

Ezetimibe Fenofibrate Fenoprofen

Cholesterol- lowering Cholesterol-lowering NSAID

Vitamin K absorption lowering See clofibrate Effect on platelet function + additional effect

Flosequinan Fluconazole Fluorouracil

Vasodilator Antifungal Cytotoxic

?Probable effect Possible BSI

Flurbiprofen

NSAID

Effect on platelet function + additional effect

Fluoxetine

Anti depression (Prozac)

BSI BSI BSI BSI BSI BSI Antiplatelet effect + additional effect of local bleeding. No effect on INR

of local bleeding Effect on platelet function + additional effect

of local bleeding Enzyme inhibitor in warfarin metabolism BSI BSI ?Possible effect

of local bleeding

Flutamide Fluorouracil

Hormone Antagonist Cytotoxic

?Effect on liver

Fluvastatin Fluvoxamine

Cholesterol-lowering Psychiatry drug (Luvox)

Vitamin K absorption lowering

Gefitinib

Anti-cancer drug

Gemfibrozil Glucagon

Cholesterol lowering Hormone

Halothane

Anesthetic

Heparin Hydantoin Ibuprofen Ifosfamide Imatinib

Anticoagulant Anti-epileptic NSAID Cytotoxic CML therapy

Additional bleeding potential Variable effect reported Effect on platelet function ? Possible effect

Indomethacin

NSAID

Effect on platelet function + additional effect

Influenza vaccine Itraconazole Ketoconazole Ketoprofen

Vaccine Anti-fungal Anti-fungal NSAID

Ketorolac

NSAID(Toradol, Acular)

Lansoprazole

Peptic ulcer healing

Lepirudin (Refludan) Levamisole

Anticoagulant Anti-neoplastic adjunct

Additional anticoagulant effect

Levofloxacin Levothyroxine

Antibacterial Hormone

Possible BSI

Liothyronine

Hormone

Liquid paraffin Lovastatin Mefenamic acid

Purgative Cholesterol-lowering NSAID

Meloxicam

NSAID

Methimazole

Anti-thyroid

Methyldopa

Anti-hypertension

Methyl phenidate

Psychostimulant

Methyl salicylate Metronidazole Miconazole Mifepristone

NSAID Antibacterial Anti-fungal Labour inducer

Moricizine

Anti-arrhythmia

Nabumetazone

NSAID

Nalidixic acid Naproxen Neomycin Norfloxacin

Antibacterial NSAID Antibiotic Antibacterial

Vitamin K absorption lowerin

of local bleeding Effect by some constituent Possible BSI Possible BSI Effect on platelet function + additional effect

of local bleeding Anti-platelet effect + additional effect of

local bleeding

Vitamin K absorption reduction Vitamin K absorption lowering Possible antiplatelet effect + additional effect

of local bleeding Possible antiplatelet effect + additional effect

of local bleeding

Anti-platelet effect- topical drug Possible BSI effect Possible BSI effect

Possible effect on platelets + additional effect

of local bleeding Possible BSI effect Possible effect on platelets Possible BSI effect Possible BSI effect

Ofloxacin Olsalazine Omeprazole

Antibacterial Anti-inflammatory Ulcer healing

BSI effect Anti-platelet effect- ASA-related

Oxandrolone Oxaprozin

Anabolic steroid NSAID (Daypro)

Probable effect on the liver Anti-platelet effect + additional effect of

Oxymetholone Pantoprazole

Anabolic hormone Ulcer healing

Effect on liver

Paroxetine Penicillin G (iv)

Anti-depressant Antibiotic

Serotonin inhibitor (Paxil)

Pentoxifylline Phenylbutazone

Arterial dilator NSAID

Phenytoin Piperacillin

Anti-epileptic Antibiotic

(Tental) Competition with warfarin in binding with serum proteins+ Inhibitor of enzyme in warfarin metabolism- serious interaction with warfarin Effect variable. Caution!

Piroxicam Pravastatin Prednisone Proguanil Propafenone Propoxyphene Propranolol

NSAID Cholesterol lowering Hormone Anti-malarial Anti-arrhythmia Analgesic/narcotic Î˛ blocker

?doubtful effect Vitamin K absorption reduction Conflicting reports. Caution! Isolated reports Doubtful interaction (Dravon)

Propylthiouracil Quinidine Quinine

Anti-thyroid Anti-arrhythmia Anti-malarial

Conflicting reports. Caution! Probable interaction. Caution!

Rabeprazole

Anti-esophageal reflux

Ranitidine

H2 receptor blocker

Some reports of lowering warfarin action. Caution!

Ritonavir Rofecoxib

Antiviral NSAID

Competes with warfarin in protein binding Anti-platelet effect + additional effect of local bleeding

Serotonin inhibitors Sertraline Simvastatin

Anti-hypertensive Antidepressant

Stanozolol Streptokinase Sulphonamides Sulfinpyrazone Sulphonylureas Sulindac

Anabolic steroid Fibrinolysis activator Antibacterial Uricosuric, antiplatelet Anti-diabetic NSAID

Tamoxifen Testosterone Tetracycline Thyroxine Ticarcillin Ticlopidine Tissue Plasminogen Activator (tPA)

Hormone antagonist Hormone Antibiotic Hormone Antibiotic Antiplatelet Fibrinolysis activator

local bleeding

Serotonin inhibitor Probably effect on liver Adds to bleeding effect of warfarin Competes with warfarin in protein binding Anti-platelet aggregation effect Possible antiplatelet effect + additional effect of local bleeding Probable effect on liver BSI.

Additional factor to cause hemorrhage Additional factor to cause hemorrhage

Tolbutamide Anti-diabetic Tolterodine Bladder frequency Serious interaction Tramadol Analgesic (Ultram) Triclofos Hypnotic Transient effect Trimethoprim+ Antibacterial (co-trimoxazole, Bactrim, septrin) effect of Sulphamethoxazole sulphamoxazole on vitamin K absorption Urokinase Fibrinolysis activator Additional factor to cause hemorrhage Valdecoxib NSAID Discontinued in USA Valproate Anti-epileptic Vitamin E Anti-oxidant Zafirlukast Asthma therapy (Accolate) Zileuton Anti-asthma Leukotriene inhibitor BSI: Probable inhibition of bacterial vitamin K synthesis in large bowel.

NOTE: Warfarin may interfere with the action of some drugs due to interference with their metabolism or their excretion, leading to their accumulation. These include hypoglycemic agents (chlorpropamide and tolbutamide) and anticonvulsants (phenytoin and phenobarbitone)

c. Herbs and plants Lists are not complete; effects are not always documented or studied scientifically. Names differ from one part of the world to the other. Effect of taking a herbal medicine with warfarin should always be watched closely. 1. Those which may contain coumarins with potential anticoagulant effects: Agrimony

Cassia

Parsley

Alfaalfa

Celery

Passion Flower

Angelica

Chamomile

Prickly Ash

Aniseed

Dandelion

Red Clover

Arnica

Fenugreek

Sweet Clover

Asafoetida

Horse chest nut

Sweet Woodruff

Bogbean

Horseradish

Tonka beans

Boldo

Licorice

Wild carrot

Buchu

Meadowsweet

Wild lettuce

Capsicum

Nettle

2. Bladder Wrack and Pau dâ&#x20AC;&#x2122;arco have anticoagulant property as well. 3. The following have salicylate content or have antiplatelet property Agrimony

Cassia

Ginger

Policosanol

Aloe Gel

Clove

Ginkgo Biloba

Poplar

Aspen

Dandelion

Ginseng (Panaz)

Senega

Black Cohosh

Feverfew

Licorice

Tamarind

Black Haw

Garlic

Meadowsweet

Willow

Bogbean

German Sarsaparilla

Onion

Wintergreen

4. The following have fibrinolytic property Bromelains

Garlic

Inositol Nicotinate

Capsicum

Ginseng (Panax)

Onion

FACTORS REDUCING WARFARIN EFFECT (decreasing INR rise caused by warfarin)

a. Endogenous Clinical Conditions 1.Edema 2.Hyperlipidemia 3.Hypothyroidism 4. Nephrotic Syndrome 5. Inherited coumarin resistance

b. Drugs Name of drug Acitretin Alcohol

Category/action Retinoid Toxic agent

Notes

Aminoglutethimide

Hormone antagonist

Amobarbital

Sedative/hypnotic

Atrovastatin

Cholesterol reducing

Azothioprine

Immune suppressant

Aztreonam Butabarbital

Antibiotic Sedative/hypnotic

Metabolic effect

Butalbetal Carbamezapine

Sedative/hypnotic Anti-epileptic

Short action barbiturate

Chloral hydrate

Anxiolytic

Most reports are of transient potentiation of action. Caution!

Chlordiazepoxide

Sedative/hypnotic

Chlorthalidone

Diuretic

Cholestyramine Clozapine

Resin Psychosis therapy

Corticotropin ACTH

Hormone

? Probable Reduction of effect could be due to reduced absorption of warfarin. Few reports

Few reports. Usually cause accentuation of warfarin effect

Conflicting results. Caution!

Cortisone Cyclophosphamide Dicloxacillin Ethchlorvynol

Hormone Cytotoxic Antibiotic Sedative/hypnotic

Caution only. Reports of potentiation of effect as well Metabolic action is likely

Etretinate

Retinoid

Glutethimide Griseofulvin Haloperidol Meprobamate 6-Mercaptopurine

Hypnotic/sedative Anti-fungal Psychosis therapy Anxiolytic Cytotoxic

Methimazole

Anti-thyroid

Moricizine HCl Nafcillin

Anti-arrhythmia Antibiotic

Paraldehyde

Sedative

Penicillins Pentobarbital

Antibiotics Sedative/hypnotic

Phenobarbital

Sedative/hypnotic

Phenytoin Pravastatin Prednisone Primidone

Anti-epileptic Cholesterol lowering Hormone Anti-epileptic

Variable reports. Caution! Usual reports of potentiation. Caution! Conflicting reports. Caution!

Propylthiouracil Raloxifene Ranitidine Rifampicin Rowachol Secobarbital

Anti-thyroid Hormone H2 receptor blocker Antibiotic Retinoid Sedative/hypnotic

Conflicting reports. Caution! For osteoporosis (Evista) Conflicting results. Caution. Serious interaction Probable reduction effect

Spironolactone

Diuretic

Sucralfate Trazodone

Ulcer healing Anti-depressant

Not a definite interaction

Vitamin C Vitamin K

Vitamin Vitamin

High dose only Serious interaction. Can be part of multivitamin tablets.

(Doriden) Probable metabolic affect (Halodol) (Miltown, Equanil)

(Ethmozine)

Penicillinase-resistant penicillins

c. Herbs: The following has procoagulant activity: Agrimony (vit K content)

Goldenseal

Mistletoe

Onion

d. Food items Some food items cause an inhibition of warfarin effect, simply by their high vitamin K content. 1. Agrimony- as in the above table. 2. Fatty cheese and other animal fat-rich items

3. Green vegetables, when taken in large quantities. An outstanding example is lettuce

1-5

6-9

10-13

14-25

26-28

2-4

Coagulant herbs

KEY TO HERB PICTURES: Picture # 1

English Name Agrimony

Alfalfa

Anis seed

Angelica

Arnica

Asafoetida

Bog Bean

Boldo

Buchu

Capsicum

Cassia

Celery

Chamomile

Dandelion

Fenu greek

Horse chest nut

Meadow sweet

Arabic Name

‫ﻏﺎﻓﺙ‬ ‫ﺑﺭﺳﻳﻡ‬ ‫ﻳﺎﻧﺳﻭﻥ‬ ‫ﺍﻧﺟﻠﻳﻛﺎ‬ ‫ﺯﻫﺭﺓ ﻋﻁﺎﺱ‬ ‫ﺃﺳﺎﻓﻭﺗﻳﺩﺍ‬ ‫ﺑﻭﻏﺑﻳﻥ‬ ‫ﺑﻭﻟﺩﻭ‬ ‫ﺑﻭﮀﻭ‬ ‫ﻓﻠﻳﻔﻠﺔ‬ ‫ﺍﺑﻳﺎﻧﺗﻳﻛﺎ‬ ‫ﻛﺭﻓﺱ‬ ‫ﺑﺎﺑﻭﻧﮓ‬ ‫ﻫﻧﺩﺑﺎء‬ ‫ﺣﻠﺑﺔ‬ ‫ﻛﺳﺗﻧﺎء ﺍﻟﺣﺻﺎﻥ‬ ‫ﺇﻛﻠﻳﻠﺔ ﺍﻟﻣﺭﻭﺝ‬

Horse radish

Licorice

Nettle

Parsley

Passion flower

Prickly ash

Red clover

Sweet Clover

Tonka beans

Wild carrot

Wild lettuce

‫ﻓﺟﻝ‬ ‫ﻋﺭﻕ ﺳﻭﺱ‬ ‫ﻗﺭﺍﺹ‬ ّ ‫ﺑﻘﺩﻭﻧﺱ‬ ‫ﺯﻫﺭﺓ ﭜﺎﺷﻥ‬ ‫ﺭ ّﻣﺎﺩ‬ ‫ﺑﺭﺳﻳﻡ ﺃﺣﻣﺭ‬ ‫ﺑﺭﺳﻳﻡ ﺣﻠﻭ‬ ‫ﻓﺎﺻﻭﻟﻳﺎ ﺗﻭﻧﻛﺎ‬ ‫ﺑﺭﻱ‬ ّ ‫ﺟﺯﺭ‬ ‫ﺑﺭﻱ‬ ّ ‫ﺧﺱ‬

Herbs with coagulant activity 1

Agrimony -See #1 above

Goldenseal

Mistletoe

Yarrow

‫ﻏﺎﻓﺙ‬ ‫ﻋﺷﺏ ﻏﻭﻟﺩﻥ ﺳﻳﻝ‬ ‫ﻫﺩﺍﻝ‬ ‫ﻋﺷﺏ ﻳﺎﺭﻭ‬

‫ﻣﻠﺤﻖ ﺇﺿﺎﻓﻲ‬ WARFARIN DRUG INTERACTIONS DRUG

EFFECT ON ANTICOGULANT ACTION OF WARFARIN

Acitretin