CPG Acute Pain

·π«∑“ßæ≤— π“ °“√√–ß∫— ª«¥‡©’¬∫æ≈—π (Clinical Guidance for Acute Pain Management) ©∫∫— ∑Ë’ 1 æ.». 2552 (æ‘¡æå§√È—ß∑’Ë 1) ISBN: 978-974-8285-72-6 ®¥— ∑”‚¥¬  ¡“§¡°“√»°÷ …“‡√◊ÕË ß§«“¡ª«¥·Àßà ª√–‡∑»‰∑¬ ACUTEPAIN

Thai Association for the Study of Pain (TASP) √“™«‘∑¬“≈¬— « ‘ —≠≠·’ æ∑¬Ï·ÀßË ª√–‡∑»‰∑¬ √“™«‘∑¬“≈¬— »≈— ¬·æ∑¬·Ï ÀßË ª√–‡∑»‰∑¬ √“™«∑‘ ¬“≈—¬·æ∑¬ÕÏ Õ√Ï‚∏ª¥‘ °‘  ·Ï ÀËߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈¬—  μŸ π‘ √·’ æ∑¬Ï·ÀËߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈¬— ‚ μ »Õ π“ °‘ ·æ∑¬·Ï ÀßË ª√–‡∑»‰∑¬ √“™«‘∑¬“≈¬— ®°— …ÿ·æ∑¬Ï·ÀËߪ√–‡∑»‰∑¬ √“™«∑‘ ¬“≈¬— ·æ∑¬‡Ï «™»“ μ√øÏ πÈ◊ øŸ·ÀËߪ√–‡∑»‰∑¬ ™¡√¡‡«™»“ μ√©Ï °ÿ ‡©π‘ ·ÀËߪ√–‡∑»‰∑¬ ‚√ß欓∫“≈¡À“√“™π§√√“™ ¡’ “ ‚√ß欓∫“≈À“¥„À≠Ë ‚√ß欓∫“≈æ√–πËß— ‡°≈È“  ∂“∫π—  ÿ¢¿“懥°Á ·ÀßË ™“μ¡‘ À“√“™π‘ ’ ©∫∫— ∑Ë’ 1 æ.». 2552 (æ¡‘ æ§Ï √Èß— ∑’Ë 1) ISBN: 978-974-8285-72-6

 ¡“§¡°“√»°÷ …“‡√◊ËÕߧ«“¡ª«¥·Àßà ª√–‡∑»‰∑¬ *** ¢Õâ ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß∫— ª«¥π’ȉ¡à„™¢à âÕ∫—ߧ∫— ¢Õß°“√ªØ‘∫—μ‘ *** ·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥„π∑’ËπÈ’‡ªìπ‡æ’¬ß¢âÕ·π–π”„π°“√√–ß—∫ª«¥ ™π¥‘ ‡©¬’ ∫æ≈π— ‡æÕ◊Ë  ßà ‡ √¡‘ §≥ÿ ¿“æ¢Õß°“√∫√°‘ “√¥“â π ¢ÿ ¿“æ¢Õߧπ‰∑¬ °“√π” ‰ª„™âμâÕß¡’°“√ª√–¬ÿ°μå„Àâ‡À¡“– ¡°—∫∫√‘∫∑¢Õß·μà≈–·Ààß ºŸâ„™â “¡“√∂ªØ‘∫—μ‘ ·μ°μ“à ߉ª®“°¢Õâ ·π–π”π’ȉ¥â ¢π÷È Õ¬°Ÿà ∫— °√≥À’ √Õ◊  ∂“π°“√≥∑å ·’Ë μ°μ“à ßÕÕ°‰ª À√Õ◊ ¡’‡Àμºÿ ≈∑Ë’ ¡§«√ ‚¥¬„™â«®‘ “√≥≠“≥ ·≈–°“√μ¥—  π‘ „®∑ˇ’ ªπì ∑¬’Ë Õ¡√—∫„π —ߧ¡ ii

§”π” Õ“°“√ª«¥‡©’¬∫æ≈—π À¡“¬∂÷ߧ«“¡ª«¥∑’ˇ°‘¥¢÷Èπ„πªí®®ÿ∫—𠇪ì𧫓¡ª«¥∑Ë’¡’ “‡Àμÿ®“°°“√ ∫“¥‡®Á∫À√◊Õ°“√Õ°— ‡ ∫‡ªπì  à«π„À≠à μ«— Õ¬à“߇™à𠧫“¡ª«¥®“°°“√ºà“μ¥— Õ∫ÿ μ— ‘‡Àμÿ ‰ø‰À¡â π”È √Õâ π≈«° ‰ μâ ß‘Ë Õ°— ‡ ∫ ·≈–Õ◊ËπÊ „π∑°ÿ ‡æ»·≈–∑°ÿ °≈à¡ÿ Õ“¬ÿ ´Ëß÷ Õ“°“√ª«¥πÈ’Õ“®∑”„À‡â °¥‘ º≈‡ ¬’ μàÕºªŸâ É«¬À≈“¬Õ¬à“ß ‡™πà ∑”„Àâ ‰¡ à ¢ÿ  ∫“¬ ¡Õ’ “°“√·∑√°´âÕπμàÕ√–∫∫μà“ßÊ ¢Õß√à“ß°“¬ ·≈–Õ“®π”‰ª ÕŸà “°“√ª«¥‡√◊ÈÕ√ß— ‰¥â °“√√—°…“Õ“°“√ª«¥‡©’¬∫æ≈π— ¬ß— ‡ªπì ª≠í À“ ”À√∫— ∑ÿ°ª√–‡∑» ªí®®∫ÿ π— Àπ«à ¬ß“πμà“ßÊ ∑Ë—«‚≈° ¡§’ «“¡μâÕß°“√∑Ë’®–æ≤— π“°“√∫√°‘ “√„À≥â§≥ÿ ¿“æÕ¬à“ßμàÕ‡πÕË◊ ß ·≈–¡À’ ≈—°∞“π∑ Ë’ “¡“√∂μ√«® Õ∫‰¥â ¥â«¬‡Àμÿ π®’È ß÷ ‰¥¡â ’°“√®—¥∑”·π«∑“ßæ—≤π“ (Clinical Guidance) ¢Õß·μà≈–·Àßà ¢÷Èπ ·¡â«à“„πÀ≈“¬ª√–‡∑»®–¡’°“√®—¥∑”·π«∑“ß°“√√–ß—∫ª«¥¡“‡°◊Õ∫ 20 ªï·≈â«°Áμ“¡ ·μà„π ª√–‡∑»‰∑¬¬—߉¡à¡’°“√®—¥∑”·π«∑“ߥ—ß°≈à“«¡“°àÕπ ¥—ßπ—Èπ ¡“§¡°“√»÷°…“‡√Ë◊Õߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬®÷ß ‰¥â®—¥∑”·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—π¢÷Èπ ‚¥¬¡’«—μ∂ÿª√– ß§å ‡æË◊Õ‡ªìπ·π«∑“ß„π°“√¥Ÿ·≈ºâŸªÉ«¬∑Ë’¡’ Õ“°“√ª«¥‡©¬’ ∫æ≈—π·≈– “¡“√∂„™âÕâ“ßÕß‘ ‰¥μâ Õà ‰ª Õ¬“à ߉√°μÁ “¡·π«∑“ßæ≤— π“°“√√–ß∫— ª«¥‡©¬’ ∫æ≈π— ©∫∫— π‡È’ ªπì ‡æ¬’ ߧ”·π–π”„π°“√ªØ∫‘ μ— ‡‘ ∑“à ππ—È ¡‘‰¥â‡ªìπ¢âÕ∫—ߧ—∫À√◊հƇ°≥±å∑Ë’∫—ߧ—∫„ÀâμâÕߪؑ∫—μ‘μ“¡ ‡πË◊Õß®“°„π°“√ªØ‘∫—μ‘®√‘ßπ—Èπ®–μâÕßÕ“»—¬∑—°…–·≈– ¥≈ÿ ¬æπ‘ ®‘ ¢Õß·æ∑¬∑å Ë’„À°â “√√—°…“„π‚√ß欓∫“≈·μ≈à –·Àßà ´ß÷Ë ·μ°μ“à ß°—π‰ª ‡ªìπÕߧªå √–°Õ∫∑’Ë ”§—≠¥«â ¬ „π·π«∑“ßπÈ’ Õ“®¡°’ “√„™§â ”»æ— ∑å∑Ë’‡ªπì ¿“…“Õ—ß°ƒ…„πÀ≈“¬∑Ë’ ∑ßÈ— π’‡È æÕË◊ §«“¡ –¥«°·≈–§«“¡ °√–™—∫¢Õ߇π◊ÈÕÀ“  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬À«—ß«à“·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥ ‡©¬’ ∫æ≈π— ©∫∫— π’®È –¡°’ “√𔉪ª√–¬ÿ°μå„™â„π‚√ß欓∫“≈μà“ßÊ Õ¬à“ß°«“â ߢ«“ß ´÷ßË ®–¡’ à«π™à«¬„Àâ§≥ÿ ¿“æ™’«μ‘ ¢ÕߺŸâªÉ«¬¥¢’ π÷È ·≈–¢Õ¢Õ∫§≥ÿ ºŸ‡â °’ˬ«¢âÕß∑ÿ°∑“à π∑’Ë¡’ à«π„π°“√®—¥∑”·π«∑“ß©∫∫— πÈ®’ 𠔇√Á®≈≈ÿ «à ߥ⫬¥’ »“ μ√“®“√¬å𓬷æ∑¬å  ¡∫Ÿ√≥å ‡∑¬’ π∑Õß ª√–∏“π§≥–ºâ®Ÿ ¥— ∑”·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©¬’ ∫æ≈π— iii

 ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Àßà ª√–‡∑»‰∑¬ √“¬π“¡§≥–ºâŸ®—¥∑” ∑˪’ √°÷ …“ ª√–∏“π 1. √».πæ.ª√–¥…‘ ∞å ª√–∑’ª–«≥‘™ ‡≈¢“πÿ°“√ 𓬰 ¡“§¡°“√»÷°…“‡√ËÕ◊ ߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ °√√¡°“√ °√√¡°“√ 2. ».πæ. ¡∫Ÿ√≥å ‡∑’¬π∑Õß °√√¡°“√ Õªÿ 𓬰 ¡“§¡°“√»°÷ …“‡√◊ÕË ß§«“¡ª«¥·Àßà ª√–‡∑»‰∑¬ °√√¡°“√ °√√¡°“√ 3. æ.μ.πæ.™“≠ƒ∑∏‘Ï ≈âÕ∑«’ «— ¥Ï‘ °√√¡°“√ ‡≈¢“∏‘°“√ ¡“§¡°“√»°÷ …“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ °√√¡°“√ °√√¡°“√ 4. √».æ≠.«‘¡≈≈—°…≥å  π—πË »‘≈ªá §≥–·æ∑¬»“ μ√廑√√‘ “™æ¬“∫“≈ ¡À“«‘∑¬“≈¬— ¡À‘¥≈ 5. √».πæ.«‘™¬— Õ∑‘ ∏™‘ ¬— °≈ÿ ±≈ §≥–·æ∑¬»“ μ√å‚√ß欓∫“≈√“¡“∏∫‘ ¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈ 6. √».æ≠. ÿª√“≥’ π‘√μÿ μ‘»“ πå §≥–·æ∑¬»“ μ√å ®Ãÿ “≈ß°√≥å¡À“«‘∑¬“≈—¬ 7. æ.Õ.πæ.πæ¥≈ ™◊πË »√‘ ‡‘ °…¡ «∑‘ ¬“≈¬— ·æ∑¬»“ μ√æå √–¡ß°ÿƇ°≈“â 8. º».æ≠. À—∑¬“ ‰æ∫Ÿ≈¬«å √™“μ‘ §≥–·æ∑¬»“ μ√å ¡À“«‘∑¬“≈¬— ‡™¬’ ß„À¡à 9. º».æ≠.»»°‘ “πμå π‘¡¡“π√—™μå §≥–·æ∑¬»“ μ√å ¡À“«∑‘ ¬“≈¬—  ß¢≈“π§√‘π∑√å 10. º».æ≠.≈°— …¡’ ™“≠‡«™™å °√√¡°“√ ¡“§¡°“√»÷°…“‡√Õ◊Ë ß§«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ 11. √».¥√.πæ.ª√–«∑‘ ¬å Õ—§√‡ √π’ π∑å §≥–·æ∑¬»“ μ√»å √‘ √‘ “™æ¬“∫“≈ ¡À“«∑‘ ¬“≈—¬¡À¥‘ ≈ iv

°μ‘ μ°‘ √√¡ª√–°“» „ππ“¡¢Õß ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ ¢Õ¢Õ∫§ÿ≥μ—«·∑π®“° √“™«∑‘ ¬“≈¬— μ“à ßÊ ‰¥·â °à √“™«∑‘ ¬“≈¬— « ‘ ≠— ≠·’ æ∑¬·å Àßà ª√–‡∑»‰∑¬ √“™«∑‘ ¬“≈¬— »≈— ¬·æ∑¬·å Àßà ª√–‡∑»‰∑¬ √“™«‘∑¬“≈¬— ·æ∑¬Õå Õ√å‚∏ª¥î °‘  å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈¬—  μŸ ‘π√·’ æ∑¬å·Àßà ª√–‡∑»‰∑¬ √“™«∑‘ ¬“≈¬— ‚ μ »Õ π“ ‘°·æ∑¬å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬®—°…ÿ·æ∑¬å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬·æ∑¬å ‡«™»“ μ√åøóôπøŸ·Ààߪ√–‡∑»‰∑¬ ·≈– ™¡√¡‡«™»“ μ√å©ÿ°‡©‘π·Ààߪ√–‡∑»‰∑¬ √«¡∑—Èßμ—«·∑π®“° ‚√ß欓∫“≈„π°√–∑√«ß “∏“√≥ ¢ÿ Õ°’  ·Ë’ Àßà ‰¥·â °à √æ.¡À“√“™π§√√“™ ¡’ “ √æ.À“¥„À≠à √æ.æ√–πßË— ‡°≈“â ·≈– ∂“∫π—  ¢ÿ ¿“懥°Á ·Àßà ™“μ¡‘ À“√“™π‘ ’ ∑™’Ë «à ¬μ√«® Õ∫§«“¡∂°Ÿ μÕâ ß·≈–‡À¡“– ¡¢Õß·π«∑“ß„π§√ß—È πÈ’ v

 ¡“§¡°“√»÷°…“‡√◊ÕË ß§«“¡ª«¥·Àßà ª√–‡∑»‰∑¬ 1 1  “√∫≠— 1 2 ∫∑π” 2 Õ∫ÿ μ— °‘ “√≥¢å Õߧ«“¡ª«¥‡©’¬∫æ≈π— §”®”°—¥§«“¡ 4 °≈¡àÿ ‡ª“Ñ À¡“¬ 4 ·π«∑“ßæ≤— π“°“√√–ß—∫ª«¥‡©’¬∫æ≈π— 5 §”Õ∏‘∫“¬·π«∑“ßæ—≤π“°“√√–ß∫— ª«¥‡©’¬∫æ≈—π : 6 7 ë °“√√°— …“ “‡Àμ∑ÿ ‡’Ë °’¬Ë «¢âÕß°∫— Õ“°“√ª«¥ 11 ë °“√ª√–‡¡‘π√–¥∫— §«“¡ª«¥ 11 ë °“√√–ß—∫ª«¥‡©’¬∫æ≈—π ë °“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬„™â¬“ 13 ë °“√√–ß—∫ª«¥‡©¬’ ∫æ≈—π‚¥¬‰¡à„™¬â “ 14 ë °“√√–ß∫— ª«¥·∫∫º ¡º “π 23 ë «∏‘ °’ “√√—°…“Õ“°“√·∑√°´âÕπ 32 ¿“§ºπ«° : 36 ë  “‡Àμÿ·≈–°“√√—∫√‡Ÿâ √◊ËÕߧ«“¡ª«¥‡©’¬∫æ≈—π 38 ë ‡§√Õ◊Ë ß¡Õ◊  ”À√—∫ª√–‡¡‘π√–¥∫— §«“¡ª«¥ ë μ“√“ß√“¬≈–‡Õ¬’ ¥°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬„™â¬“ ë μ“√“ß√“¬≈–‡Õ¬’ ¥°“√√–ß∫— ª«¥‡©’¬∫æ≈π— ‚¥¬‰¡à„™¬â “ ‡Õ° “√Õâ“ßÕß‘ ·À≈ßà ¢âÕ¡Ÿ≈‡æË¡‘ ‡μ¡‘ ∑Ë’πà“ π„® vi

∫∑π” ‡ªπì ∑∑’Ë √“∫¥«’ “à Õ“°“√ª«¥∑”„À‡â °¥‘ º≈‡ ¬’ μÕà ºªâŸ «É ¬À≈“¬Õ¬“à ß ‡™πà ∑”„À≡ à ¢ÿ  ∫“¬ ¡Õ’ “°“√·∑√°´Õâ π μàÕ√–∫∫μà“ßÊ ¢Õß√à“ß°“¬ ·≈–‡ ’¬§“à „™â®à“¬„π°“√√°— …“¡“°¢÷πÈ ªí®®ÿ∫—πÀπ૬ߓπμ“à ßÊ ∑Ë«— ‚≈°∑Ë’¡’ à«π„π °“√√–ß—∫ª«¥‡©’¬∫æ≈—π¡’§«“¡μâÕß°“√∑’Ë®–æ—≤π“°“√∫√‘°“√„À≥â§ÿ≥¿“æÕ¬à“ßμàÕ‡π◊ËÕß ·≈–¡’À≈—°∞“π∑Ë’  “¡“√∂μ√«® Õ∫‰¥â ¥â«¬‡Àμπÿ ’È®ß÷ ‰¥¡â °’ “√®¥— ∑”·π«∑“ßæ—≤π“ (Clinical Guidance: „π∑’ËπÈ’®–¢Õ‡¢¬’ π —ÈπÊ «à“ ç·π«∑“ßé) ¢Õß·μ≈à –·Ààß ‡™àπ The American Society of Anesthesiologists (ASA:2004)1, The American Pain Society (2005)2, Australian and New Zealand College of Anaesthetists (2005)3, British Pain Society (2007)4, Institute for Clinical Systems Improvement (ICSI:2008)5 ·≈–·π«∑“ß ÕπË◊ Ê Õ°’ À≈“¬·Àßà ·¡â«à“„πÀ≈“¬ª√–‡∑»®–¡°’ “√®¥— ∑”·π«∑“ß°“√√–ß—∫ª«¥¡“‡°Õ◊ ∫ 20 ªï·≈â«°Áμ“¡ ·μà„πª√–‡∑»‰∑¬ ¬—߉¡¡à ’°“√®—¥∑”·π«∑“ߥ—ß°≈“à «¡“°Õà π ¥—ßπÈπ—  ¡“§¡°“√»÷°…“‡√Õ◊Ë ß§«“¡ª«¥·Àßà ª√–‡∑»‰∑¬ ®ß÷ ‰¥®â ¥— ∑” ·π«∑“ßæ≤— π“π¢È’ π÷È ‚¥¬¡«’ μ— ∂ªÿ √– ß§å ‡æÕ◊Ë ‡ªπì ·π«∑“ß„π°“√¥·Ÿ ≈ºªâŸ «É ¬∑¡Ë’ §’ «“¡ª«¥‡©¬’ ∫æ≈π— ·≈– “¡“√∂ „™Õâ “â ßÕß‘ ‰¥μâ Õà ‰ª‚¥¬À«ß— «“à ·π«∑“ßπ®’È –™«à ¬„À§â ≥ÿ ¿“晫’ μ‘ ¢ÕߺªâŸ «É ¬¥¢’ πÈ÷  ßà ‡ √¡‘ „Àºâ ªŸâ «É ¬øπôó μ«— ·≈– “¡“√∂ °≈∫— ¡“∑”Àπ“â ∑Ë’‰¥μâ “¡ª°μ‡‘ √«Á ¢π÷È ≈¥‚Õ°“ ‡°¥‘ Õ“°“√·∑√°´Õâ π·≈–Õ“®™«à ¬„Àºâ ªâŸ «É ¬ÕÕ°®“°‚√ß欓∫“≈‰¥â ‡√«Á ¢πÈ÷ Õÿ∫μ— ‘°“√≥¢å Õߧ«“¡ª«¥‡©¬’ ∫æ≈—π ¡’°“√»÷°…“Õÿ∫—μ‘°“√≥å¢ÕßÕ“°“√ª«¥À≈—ߺà“μ—¥¢Õß ∂“∫—πμà“ßÊ „πª√–‡∑»‰∑¬ æ∫Õÿ∫—μ‘°“√≥å∑’Ë ·μ°μ“à ß°π— ‰ª ‡™àπ ºâªŸ É«¬„πÀÕâ ßæ°— øôπó ∑¡’Ë ’Õ“°“√ª«¥¡“°°«à“ 5 §–·ππ æ∫√âÕ¬≈– 246 ºªŸâ «É ¬À≈—ߺ“à μ¥— ∑“ß ÕÕ√å‚∏ªî¥°‘  å∑Ë’¡’Õ“°“√ª«¥ >7 §–·ππ æ∫√âÕ¬≈– 28.77 ºªâŸ É«¬ºà“μ—¥§≈Õ¥∑“ßÀπâ“∑âÕß¡’Õ“°“√ª«¥¡“°„π ¢≥–¢¬—∫μ«— √Õâ ¬≈– 228 ·μଗ߉¡à¡√’ “¬ß“π∑Ë™’ ¥— ‡®π‡°’ˬ«°—∫§«“¡™°ÿ ¢Õߧ«“¡ª«¥‡©’¬∫æ≈π— ∑’πË ”ºâªŸ É«¬¡“æ∫ ·æ∑¬∑å ’Ë‚√ß欓∫“≈ §”®”°—¥§«“¡ §«“¡ª«¥·∫ßà μ“¡√–¬–‡«≈“ÕÕ°‡ªìπ Õߪ√–‡¿∑ §Õ◊ §«“¡ª«¥‡©¬’ ∫æ≈—π (acute pain) ·≈–§«“¡ ª«¥‡√◊ÕÈ √—ß (chronic pain) °“√√–ß∫— ª«¥μ“¡·π«∑“ß∑Ë’®¥— ∑”πÈ’ ®”°¥— ‡©æ“–§«“¡ª«¥™π¥‘ ‡©’¬∫æ≈π— ´÷ËßÀ¡“¬∂÷ߧ«“¡ª«¥∑’ˇ°¥‘ ¢πÈ÷ „πª®í ®∫ÿ π— ‡ªπì ¡“‰¡‡à °π‘ 6 ‡¥Õ◊ 𠇪πì §«“¡ª«¥∑¡Ë’  ’ “‡Àμ®ÿ “°°“√∫“¥‡®∫Á À√Õ◊ °“√Õ°— ‡ ∫‡ªπì  «à π„À≠à √–¬– ‡«≈“∑ª’Ë «¥®–Õ¬Ÿà‰¡πà “π ‚¥¬Õ“°“√ª«¥®–∑‡ÿ ≈“‡¡Õ◊Ë  “‡Àμ‰ÿ ¥√â ∫— °“√·°â‰¢À√Õ◊ À“¬·≈«â μ«— Õ¬“à ߢÕߧ«“¡ª«¥ ‡©’¬∫æ≈π— ‡™à𠧫“¡ª«¥®“°°“√º“à μ¥— Õ∫ÿ μ— ‘‡Àμÿ ‰ø‰À¡â π”È √âÕπ≈«° ‰ μâ ßË‘ Õ—°‡ ∫ ·≈–Õ◊ËπÊ „π∑°ÿ ‡æ»·≈– ∑°ÿ °≈¡ÿà Õ“¬ÿ «∏‘ °’ “√√–ß—∫ª«¥‚¥¬„™¬â “μ“¡·π«∑“ßπ’È ®–‡πâπ‡©æ“–«∏‘ ’°“√∑’Ë¡’„™â°—π∑Ë—«‰ª ‡™πà °“√©’¥¬“∑“ßÀ≈Õ¥ ‡≈Õ◊ ¥¥” ©¥’ „μºâ «‘ Àπß— À√Õ◊ ‡¢“â °≈“â ¡ √«¡∑ß—È «∏‘ °’ “√√∫— ª√–∑“π  ”À√∫— ‡∑§π§‘ ÕπË◊ Ê ∑μ’Ë Õâ ßÕ“»¬— ∑°— …–懑 »… ‡™πà *** ¢Õâ ·π–π”μ“à ßÊ „π·π«∑“ßæ≤— π“°“√√–ß—∫ª«¥πÈ’‰¡à„™à¢Õâ ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 1

 ¡“§¡°“√»÷°…“‡√ÕË◊ ߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ °“√∑” epidural block √«¡∑ßÈ— °“√„™‡â §√ÕË◊ ß¡Õ◊ μ“à ßÊ „π°“√√–ß∫— ª«¥ ‡™πà ‡§√Õ◊Ë ß patient-controlled analge- sia (PCA) ®–‰¡à‰¥°â ≈“à «∂÷ß„π∑Ë’πÈ’ °≈¡àÿ ‡ª“Ñ À¡“¬ °≈ÿ¡à ‡ªÑ“À¡“¬ ”À√—∫ºŸâ„™·â π«∑“ßπ’È ‰¥â·°à ·æ∑¬å ·≈–欓∫“≈ ∑ª’Ë Ø∫‘ μ— ß‘ “π„π‚√ß欓∫“≈∑ÿ°√–¥∫— „π ª√–‡∑»‰∑¬ ∑’Ë„À°â “√¥·Ÿ ≈ºªâŸ É«¬´÷Ëß¡’Õ“°“√ª«¥‡©¬’ ∫æ≈π— ·π«∑“ßæ—≤π“°“√√–ß∫— ª«¥‡©’¬∫æ≈—π ·ºπ¿¡Ÿ ∑‘ ’Ë 1 ·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©¬’ ∫æ≈π— ºÈŸª«Ë ¬¡Õ’ “°“√ª«¥‡©¬’ ∫æ≈π— 1 ¡’ “‡Àμÿ∑’Ë∑”„À‡È °‘¥ √°— …“ “‡Àμÿ ¢ÕßÕ“°“√ª«¥ Õ“°“√ª«¥√«Ë ¡¥È«¬ 2 ª√–‡¡π‘ √–¥∫— §«“¡ª«¥ ‰¡Ë„™Ë 3 Õ“°“√ª«¥μÈÕß°“√°“√√°— …“ „™Ë 4 °“√√–ß∫— ª«¥‡©’¬∫æ≈—π : ë °“√√–ß∫— ª«¥‡©¬’ ∫æ≈π— ‚¥¬„™â¬“ ë °“√√–ß∫— ª«¥‡©’¬∫æ≈π— ‚¥¬‰¡à„™â¬“ ë °“√√–ß—∫ª«¥·∫∫º ¡º “π 5 °“√√–ß—∫ª«¥‰¥Èº≈¥’ ‰¡Ë„™Ë ‡≈Õ◊ °«∏‘ °’ “√√—°…“∑’‡Ë À¡“– ¡ „™Ë À√◊Õª√÷°…“ºÈ‡Ÿ ™’ˬ«™“≠ (∂È“¡’) 6 ‡°‘¥Õ“°“√·∑√°´ÕÈ π „™Ë 7 √°— …“Õ“°“√·∑√°´ÕÈ π ®“°°“√√—°…“À√◊Õ‰¡Ë ‰¡Ë„™Ë 8 ª√–‡¡π‘ ´È”·≈–∫—π∑÷° 2 *** ¢Õâ ·π–π”μ“à ßÊ „π·π«∑“ßæ—≤π“°“√√–ß∫— ª«¥πÈ’‰¡à„™à¢Õâ ∫ß— §∫— ¢Õß°“√ªØ∫‘ —μ‘ ***

 √ªÿ §”·π–π” ”À√—∫°“√√–ß∫— ª«¥‡©’¬∫æ≈π— μ“¡·π«∑“ß·ºπ¿¡Ÿ ‘∑’Ë 1 1. °≈Õà ß∑’Ë 1: ºªâŸ É«¬¡’‚√§ª√–®”μ—«∑’ˇ°’ˬ«¢Õâ ß°∫— Õ“°“√ª«¥À√◊Õ‰¡à §”·π–π”: §«√ª√–‡¡π‘  ¿“溪Ÿâ «É ¬‡æÕ◊Ë À“ “‡Àμ∑ÿ ‡Ë’ °¬Ë’ «¢Õâ ß·≈–„À°â “√√°— …“Õ“°“√ª«¥μ“¡ “‡Àμÿ 2. °≈Õà ß∑Ë’ 2: °“√ª√–‡¡‘π√–¥∫— §«“¡ª«¥¢ÕߺŸâªÉ«¬ (pain assessment) §”·π–π”: 1) §«√‡≈Õ◊ °„™â‡§√◊ÕË ß¡Õ◊ „π°“√ª√–‡¡‘𧫓¡ª«¥„Àâ‡À¡“– ¡°∫— ºŸâªÉ«¬·μ≈à –√“¬ 2) ∑”°“√ª√–‡¡π‘ §«“¡ª«¥°àÕπ°“√√—°…“·≈–À≈ß— „À°â “√√°— …“Õ¬à“ß ¡”Ë ‡ ¡Õ 3) §«√∫—π∑÷°§«“¡ª«¥„À‡â ÀπÁ ™¥— ‡®π 3. °≈Õà ß∑Ë’ 3: Õ“°“√ª«¥μÕâ ß°“√°“√√°— …“À√Õ◊ ‰¡à §”·π–π”: §«√„À§â «“¡√·âŸ °ºà ªâŸ «É ¬‡√ÕË◊ ß°“√√–ß∫— ª«¥·≈–„Àºâ ªŸâ «É ¬‰¥¡â  ’ «à π√«à ¡„π°“√μ¥—  π‘ „®‡≈Õ◊ ° «‘∏’°“√√–ß—∫ª«¥¥â«¬μ—«‡Õß 4. °≈àÕß∑Ë’ 4: °“√√–ß—∫ª«¥‡©’¬∫æ≈—π (acute pain treatment) 4.1 °“√√–ß—∫ª«¥‡©¬’ ∫æ≈—π‚¥¬„™â¬“ (pharmacological therapy) §”·π–π”: 1) ºŸâ„À°â “√√°— …“§«√¡§’ «“¡√‡âŸ °¬Ë’ «°∫— ¬“·°ªâ «¥ª√–‡¿∑μ“à ßÊ ∑ßÈ— °≈‰°°“√ÕÕ°ƒ∑∏Ï‘ ¢π“¥¬“ ¢âÕ§«√√–«—ß ¢âÕÀ“â ¡ Õ“°“√·∑√°´âÕπ œ≈œ 2) ‡≈Õ◊ °„™¬â “·°ªâ «¥μ“¡√–¥∫— §«“¡√πÿ ·√ߢÕßÕ“°“√ª«¥∑‡’Ë °¥‘ ¢πÈ÷ ®√ß‘ À√Õ◊ §“¥«“à ®–‡°‘¥¢÷Èπ 3) „™â«∏‘ °’ “√º ¡º “π„π°“√√–ß—∫ª«¥‡©’¬∫æ≈—π (multimodal pain therapy) 4) §«√¡’·π«∑“ß„π°“√∫√‘À“√¬“·°ªâ «¥ (opioid) ‰¡à«“à ®–∫√À‘ “√∑“ß IM À√◊Õ IV 4.2 °“√√–ß∫— ª«¥‡©’¬∫æ≈π— ‚¥¬‰¡à„™â¬“ (non-pharmacological therapy) §”·π–π”: 1) °“√√–ß∫— ª«¥‡©¬’ ∫æ≈π— ‚¥¬‰¡à„™¬â “¡®’ ¥ÿ ¡ßÿà À¡“¬‡æÕ◊Ë  π∫—  ππÿ „À°â “√√°— …“§«“¡ ª«¥®“°°“√„™¬â “‰¥ºâ ≈¥’¢π÷È ‚¥¬‰¡à¡®’ ÿ¥¡àÿßÀ¡“¬∑Ë’®–∑¥·∑π°“√„™â¬“·°ªâ «¥ 5. °≈àÕß∑Ë’ 5: Õ“°“√ª«¥¥¢’ πÈ÷ À√◊Õ‰¡àÀ≈ß— ‰¥√â ∫— °“√√°— …“ §”·π–π”: ∑”°“√ª√–‡¡‘𧫓¡ª«¥À≈—ß„Àâ°“√√—°…“Õ¬à“ß ¡”Ë ‡ ¡Õ‡æ◊ËÕª√–‡¡‘πª√– ‘∑∏‘¿“æ¢Õß °“√√—°…“ 6. °≈Õà ß∑Ë’ 6: °“√ª√–‡¡π‘ Õ“°“√·∑√°´âÕπ®“°°“√√–ß∫— ª«¥ §”·π–π”: §«√¡’°“√‡ΩÑ“√–«—ßÕ“°“√·∑√°´âÕπ ·≈–¡’§” Ë—ß°“√√—°…“ ”À√—∫Õ“°“√·∑√°´âÕπ„π ºŸªâ É«¬∑ÿ°√“¬Õ¬“à ß™¥— ‡®π 7. °≈àÕß∑Ë’ 7: «∏‘ °’ “√√—°…“Õ“°“√·∑√°´Õâ 𠧔·π–π”: 1)  “¡“√∂„À¬â “√—°…“Õ“°“√·∑√°´Õâ π‰¥âμÈ—ß·μ‡à √Ë‘¡¡Õ’ “°“√ 2) À“°„™¬â “¢π“π‡¥¬’ «‰¡à‰¥ºâ ≈ “¡“√∂„™¬â “∑¡Ë’ °’ ≈‰°ÕÕ°ƒ∑∏μ‘Ï “à ß°π— ¡“„™‡â  √¡‘ ƒ∑∏°‘Ï π— ‰¥â 8. °≈Õà ß∑’Ë 8: °“√ª√–‡¡‘πÕ“°“√ª«¥´”È ·≈–°“√∫π— ∑°÷ º≈°“√ª√–‡¡π‘ §”·π–π”: ∑”°“√ª√–‡¡π‘ §«“¡ª«¥À≈ß— „À°â “√√°— …“Õ¬“à ß ¡”Ë ‡ ¡Õ·≈–∫π— ∑°÷ §«“¡ª«¥„À‡â ÀπÁ ™¥— ‡®π (¥Ÿ§”·π–π”∑’Ë 2, 3 „π°≈Õà ß∑’Ë 2) *** ¢Õâ ·π–π”μà“ßÊ „π·π«∑“ßæ≤— π“°“√√–ß∫— ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ∫— ¢Õß°“√ªØ‘∫μ— ‘ *** 3

 ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Àßà ª√–‡∑»‰∑¬ §”Õ∏∫‘ “¬·π«∑“ßæ≤— π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—π 1. °“√√°— …“ “‡Àμÿ∑‡’Ë °Ë’¬«¢âÕß°∫— Õ“°“√ª«¥ (°≈Õà ß∑’Ë 1) §”·π–π”: §«√ª√–‡¡π‘  ¿“溪⟠«É ¬‡æË◊ÕÀ“ “‡Àμÿ∑’ˇ°¬’Ë «¢Õâ ß·≈–„Àâ°“√√°— …“Õ“°“√ª«¥μ“¡ “‡Àμÿ °“√√–ß∫— ª«¥‡©’¬∫æ≈π— „À≥âº≈¥’ μÕâ ß√°— …“ “‡Àμÿ∑Ë∑’ ”„À⇰¥‘ «“¡ª«¥πÈπ— ‚¥¬μ√ß ‡™à𠪫¥∑âÕß®“° ·º≈„π°√–‡æ“–Õ“À“√μÕâ ß¡¬’ “√°— …“·º≈„π°√–‡æ“–Õ“À“√ À√Õ◊ ª«¥·º≈∑μË’ ¥‘ ‡™Õ◊È μÕâ ß√°— …“°“√쥑 ‡™Õ◊È ‡ªπì μπâ °√≥∑’ ’¡Ë ’§«“¡ª«¥‡©’¬∫æ≈—π ‚¥¬ºŸªâ «É ¬Õ¬àŸ„π ¿“æ∑’ˉ¡à¡¿’ “«–§ÿ°§“¡μÕà √–∫∫ ¡ÕßÀ√Õ◊ °“√‰À≈‡«¬’ π ¢Õ߇≈Õ◊ ¥ ·≈–Õ¬àŸ„π√–À«“à ß°“√√°— …“ “‡Àμ¢ÿ Õߧ«“¡ª«¥ §«√„À°â “√√–ß∫— §«“¡ª«¥‡©¬’ ∫æ≈π— ®πÕ“°“√ª«¥ ∫√√‡∑“‰ª°àÕπ‡æ◊ËÕ≈¥§«“¡∑ÿ°¢å∑√¡“π¢Õߺ⟪ɫ¬ 2. °“√ª√–‡¡π‘ √–¥—∫§«“¡ª«¥ (°≈àÕß∑’Ë 2)9 §”·π–π”: 1) §«√‡≈Õ◊ °„™‡â §√Ë◊Õß¡Õ◊ „π°“√ª√–‡¡π‘ §«“¡ª«¥„À‡â À¡“– ¡°∫— ºŸâª«É ¬·μ≈à –√“¬ 2) ∑”°“√ª√–‡¡‘𧫓¡ª«¥Õ¬à“ß ¡”Ë ‡ ¡Õμ“¡·π«ªØ‘∫—μ‘¢Õß·μà≈–·Ààß √«¡∑—Èß°àÕπ·≈– À≈—ß„Àâ°“√√°— …“ 3) §«√∫π— ∑°÷ §«“¡ª«¥„À‡â ÀÁπ™—¥‡®π °“√√–ß—∫ª«¥„À≥âº≈¥’μâÕ߇√‘Ë¡®“°°“√ª√–‡¡‘𧫓¡ª«¥¢Õߺ⟪ɫ¬„Àâ∂Ÿ°μâÕß°àÕπ ‚¥¬μâÕߪ√–‡¡‘π μßÈ— ·μ‡à √¡Ë‘ μπâ √°— …“ ·≈–ª√–‡¡π‘ À≈ß— „À°â “√√°— …“ ∑ß—È ¢≥–ºªŸâ «É ¬æ°— ·≈–¢≥–¡°’ “√¢¬∫— μ«— ´ßË÷ §«“¡ª«¥‡ªπì §«“¡ √ âŸ ÷° à«π∫§ÿ §≈ ·≈–‰¡‡à À¡Õ◊ π°—π∑ÿ°§π ·μà≈–∫§ÿ §≈®–¡’ª®í ®¬— ÕËπ◊ ‡¢“â ¡“‡°’¬Ë «¢Õâ ß ‡™àπ Õ“√¡≥å ª√– ∫°“√≥å ‡¥¡‘ ¥ß— ππÈ— °“√∫Õ°√–¥∫— §«“¡ª«¥¥«â ¬μ«— ¢ÕߺªâŸ «É ¬®ß÷ ‡ªπì «∏‘ ª’ √–‡¡π‘ ∑‡’Ë À¡“– ¡∑ Ë’ ¥ÿ ‡§√Õ◊Ë ß¡Õ◊  ”À√∫— ª√–‡¡π‘ §«“¡√πÿ ·√ߢÕߧ«“¡ª«¥¥„Ÿ π√ªŸ ∑Ë’ 1 3. Õ“°“√ª«¥μâÕß°“√°“√√°— …“À√Õ◊ ‰¡à (°≈àÕß∑Ë’ 3) §”·π–π”: §«√„À⧫“¡√⟷°àºŸâªÉ«¬‡√Ë◊Õß°“√√—°…“Õ“°“√ª«¥·≈–„ÀâºâŸªÉ«¬‰¥â¡’ à«π√à«¡„π°“√μ—¥ ‘π„® ‡≈◊Õ°«∏‘ ’°“√√°— …“Õ“°“√ª«¥¥â«¬μ«— ‡Õß ºªâŸ «É ¬∑¡’Ë §’ «“¡ª«¥·¡‡â ≈°Á πÕâ ¬·μ∂à “â μÕâ ß°“√°“√√–ß∫— ª«¥ „Àæâ ®‘ “√≥“‡≈Õ◊ °«∏‘ °’ “√μ“¡§«“¡‡À¡“– ¡ „π°√≥∑’ º’Ë ªŸâ «É ¬¡ª’ ≠í À“‡√Õ◊Ë ß°“√ Õ◊Ë  “√μÕâ ߉¥√â ∫— °“√¥·Ÿ ≈‡ªπì 懑 »…´ß÷Ë „π·π«∑“ßπ¬È’ ß— ‰¡à‰¥√â «∫√«¡‰«â ·æ∑¬ºå Ÿâ „À°â “√√—°…“§«√æ‘®“√≥“°“√¥Ÿ·≈‡ªπì √“¬Ê ‰ª °√≥∑’ ∑’Ë √“∫≈«à ßÀπ“â «“à ®–¡§’ «“¡ª«¥‡°¥‘ ¢πÈ÷ ‡™πà §«“¡ª«¥®“°°“√º“à μ¥— °“√„À§â «“¡√‡Ÿâ °¬’Ë «°∫— §«“¡ª«¥ ·°ºà ªâŸ «É ¬μßÈ— ·μ°à Õà πº“à μ¥—  “¡“√∂™«à ¬„À§â «“¡ª«¥¢ÕߺªâŸ «É ¬≈¥≈ß ºªâŸ «É ¬§≈“¬§«“¡«μ‘ °°ß— «≈ ·≈–‡æ¡Ë‘ §«“¡ æß÷ æÕ„®μàÕ°“√√°— …“‰¥â  ”À√∫— °√≥∑’ ˺’ ªŸâ É«¬¡Õ’ “°“√ª«¥‡°‘¥¢Èπ÷ ·≈â« °“√„À⧔·π–π”¬—ß§ß¡’ª√–‚¬™πå ‚¥¬ ™«à ¬„Àºâ ªŸâ «É ¬‡¢“â „®·≈–„À§â «“¡√«à ¡¡Õ◊ „π°“√√°— …“¡“°¢π÷È ºâŸ„À°â “√√°— …“®ß÷ §«√„À§â ”·π–π”ºªŸâ «É ¬‡°¬’Ë «°∫— °“√ √—°…“Õ“°“√ª«¥¥—ßμàÕ‰ªπ’È ºªâŸ «É ¬§«√‰¥√â ∫— °“√Õ∏∫‘ “¬∂ß÷ §«“¡ª«¥À≈ß— º“à μ¥— «“à §«“¡ª«¥¢Õß·μ≈à –§π®–‰¡‡à À¡Õ◊ π°π— ¢πÈ÷ °∫— ™π¥‘ À√Õ◊ ¢π“¥¢Õß·º≈º“à μ¥— ·μ∂à ß÷ ·¡«â “à ®–‰¥√â ∫— °“√º“à μ¥— ™π¥‘ ‡¥¬’ «°π— °ÕÁ “®®–ª«¥‰¡‡à À¡Õ◊ π°π— ‰¥·â ≈–§«“¡ª«¥ 4 *** ¢Õâ ·π–π”μ“à ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥πÈ’‰¡à„™¢à âÕ∫—ߧ∫— ¢Õß°“√ªØ‘∫μ— ‘ ***

Numerical ‰¡àª«¥ ª«¥ª“π°≈“ß ª«¥¡“°∑’Ë ÿ¥ rating scale (NRS) 0 1 2 3 4 5 6 7 8 9 10 ‡§√◊ËÕß¡Õ◊ ºŸâªÉ«¬ Õ◊Ë  “√ Verbal ‰¡ªà «¥ ª«¥ ª«¥ ª«¥¡“° ª«¥ ª√–‡¡π‘ ‰¥¥â ’ rating scale √–¥∫— ‡≈Á°πâÕ¬ ª“π°≈“ß ¡“°∑Ë ’ ¥ÿ §«“¡ª«¥ ºŸâª«É ¬ ÕË◊  “√ (VRS) ‰¥â®”°—¥ ‰¡ªà «¥ ª«¥¡“°∑’ Ë ÿ¥ Visual analog scale (VAS) Face pain assessment scale 0 2 4 6 8 10 ‰¡àª«¥ ª«¥¡“°∑’Ë ¥ÿ √ªŸ ∑’Ë 1 °“√‡≈◊Õ°„™â‡§√Ë◊Õß¡◊Õª√–‡¡‘π√–¥—∫§«“¡ª«¥μ“¡§«“¡ “¡“√∂„π°“√ Ë◊Õ “√¢Õߺ⟪ɫ¬ (¥¥— ·ª≈ß®“° European society of regional anaesthesia and pain therapy ·≈– Newman CJ10) À≈ß— ºà“μ—¥®–≈¥≈߇¡ÕË◊ ‡«≈“ºà“π‰ª °“√√–ß∫— ª«¥ “¡“√∂∑”‰¥∑â —ßÈ °“√„™¬â “·≈–‰¡à„™â¬“ ºŸªâ «É ¬§«√∫Õ°·æ∑¬∑å ¥Ë’ ·Ÿ ≈«à“ μπ¡’ª√– ∫°“√≥å μÕà °“√∫”∫¥— §«“¡ª«¥À≈ß— º“à μ¥— Õ¬“à ߉√∫“â ß ·≈–¡¿’ “«–·∑√°´Õâ πÕ¬“à ߉√ °“√√–ß∫— ª«¥∑¥Ë’ ®’ –∑”„Àºâ ªŸâ «É ¬øπôó μ—«‰¥‡â √Á«¢÷πÈ ºªŸâ «É ¬¡ ’ ∑‘ ∏·‘ ≈–§«“¡™Õ∫∏√√¡„π°“√√∫— °“√∫”∫¥— §«“¡ª«¥Õ¬“à ߇μ¡Á ∑’Ë·μ∂à ß÷ ·¡«â “à §«“¡ª«¥À≈ß— º“à μ¥— ®–‰¥â√—∫°“√∫”∫—¥Õ¬à“ߥ·’ ≈«â ºªâŸ É«¬Õ“®¡’§«“¡ª«¥Õ¬∫Ÿà “â ß´ß÷Ë §«√®–Õ¬àŸ„π√–¥—∫∑ˬ’ Õ¡√—∫‰¥â ºâªŸ «É ¬§«√‡ªπì ºªŸâ √–‡¡‘𧫓¡ª«¥À≈—ߺà“μ¥— ¥«â ¬μπ‡Õß ¬°‡«âπºŸâ∑’ˉ¡ à “¡“√∂ª√–‡¡‘𧫓¡ª«¥‰¥â „Àâ „™‡â §√Õ◊Ë ß¡Õ◊ ∑‡’Ë À¡“– ¡°∫— ºªŸâ «É ¬·μ≈à –§π·≈–„Àºâ ªâŸ «É ¬∫Õ°√–¥∫— §«“¡ª«¥‡¡Õ◊Ë ‰¥√â ∫— °“√ Õ∫∂“¡®“°‡®“â Àπ“â ∑’Ë ºªŸâ «É ¬‰¡§à «√«μ‘ °°ß— «≈‡°¬Ë’ «°∫— §«“¡‡ ¬’Ë ß„π°“√쥑 ¬“·°ªâ «¥ ‡πÕË◊ ß®“°√–¬–‡«≈“„π°“√„À¬â “‡ªπì √–¬– ‡«≈“ πÈ— ·μàºâªŸ «É ¬Õ“®¡¿’ “«–·∑√°´Õâ π®“°°“√„™â¬“‰¥â ‡™πà ∑Õâ ߺŸ° §≈Ëπ◊ ‰ Õâ “‡®¬’ π ·≈–¿“«–ß«à ß´÷¡ ∂“â ºªŸâ «É ¬¡Õ’ “°“√ª«¥¡“°¢π÷È ·≈–‰¡ à “¡“√∂∫”∫¥— ‰¥¥â «â ¬¬“∑Ë’‰¥√â ∫— À√Õ◊ ¡¿’ “«–·∑√°´Õâ π§«√·®ßâ „À·â æ∑¬å º¥âŸ ·Ÿ ≈∑√“∫∑π— ∑’ 4. °“√√–ß∫— ª«¥‡©¬’ ∫æ≈—π (°≈Õà ß∑’Ë 4) §«√™·’È ®ß„Àºâ ªŸâ «É ¬∑√“∫«“à μ«— ºªŸâ «É ¬¡§’ «“¡ ”§≠— ¡“°„π°“√√–ß∫— ª«¥„À≥ºâ ≈¥’ ‚¥¬ºªâŸ «É ¬μÕâ ß„À§â «“¡ *** ¢Õâ ·π–π”μà“ßÊ „π·π«∑“ßæ≤— π“°“√√–ß∫— ª«¥π’ȉ¡à„™¢à âÕ∫ß— §—∫¢Õß°“√ªØ‘∫μ— ‘ *** 5

 ¡“§¡°“√»÷°…“‡√Õ◊Ë ß§«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ √«à ¡¡Õ◊ „π°“√„Àªâ √–«μ— §‘ «“¡ª«¥·≈–‚√§μ“à ßÊ ∑‡’Ë ªπì Õ¬“à ß≈–‡Õ¬’ ¥ √«¡∑ß—È ¡ ’ «à π√«à ¡„π°“√ª√–‡¡π‘ √–¥∫— §«“¡ √πÿ ·√ߢÕߧ«“¡ª«¥∑°’Ë ”≈ß— ª√– ∫·≈–·®ßâ „À·â æ∑¬Àå √Õ◊ 欓∫“≈∑√“∫‡¡Õ◊Ë °“√√–ß∫— ª«¥¬ß— ‰¥ºâ ≈‰¡¥à æ’ ÕÀ√Õ◊ ¡¿’ “«–·∑√°´Õâ π‡°‘¥¢Èπ÷ ‡æËÕ◊ „Àâ°“√¥Ÿ·≈√—°…“∑”‰¥â∑—π∑à«ß∑’ °“√«“ß·ºπ°“√√°— …“„À§â ”πß÷ ∂ß÷ ª®í ®¬— μÕà ‰ªπ’È ¥«â ¬ ‡™πà §«“¡‡™Õ◊Ë ¢ÕߺªâŸ «É ¬ ·≈–¢π∫∏√√¡‡π¬’ ¡ª√–‡æ≥’ §«“¡°≈—«¢ÕߺŸâªÉ«¬ (‡™àπ °≈—«μ‘¥¬“) º≈°√–∑∫¢Õߧ«“¡ª«¥ (‡™àπ μàÕ™’«‘짫“¡‡ªìπÕ¬àŸ ·≈–Õ“√¡≥å) ®ÿ¥¡àÿßÀ¡“¬¢ÕߺŸâªÉ«¬ (‡™àπ √–¥—∫§«“¡ª«¥∑’˺⟪ɫ¬¬Õ¡√—∫‰¥â) °“√„™â«‘∏’°“√√—°…“Õ◊Ëπ∑Ë’‰¡à„™â¬“·≈–§«“¡√⟠¢ÕߺŸâª«É ¬‡°’¬Ë «°∫— ‚√§·≈–§«“¡ª«¥ ‡ªìπμπâ À≈°— °“√√–ß∫— ª«¥‡©’¬∫æ≈π— ª√–°Õ∫¥«â ¬ ë √—°…“ “‡Àμ∑ÿ ’∑Ë ”„Àªâ «¥·≈–√–ß∫— Õ“°“√ª«¥‡©¬’ ∫æ≈π— (°≈Õà ß∑’Ë 1) ë ª√–‡¡‘π√–¥∫— §«“¡√ÿπ·√ߢÕߧ«“¡ª«¥°Õà π·≈–À≈—ß°“√√—°…“ (°≈àÕß∑Ë’ 2) ë „™â«∏‘ ’°“√√–ß∫— ª«¥∑È—ß°“√„™¬â “·≈–/À√Õ◊ √à«¡°—∫°“√‰¡à„™¬â “ ·≈–/À√Õ◊ „™â«‘∏’°“√√–ß—∫ª«¥·∫∫ º ¡º “π (multimodal analgesia) μ“¡·μà‚Õ°“  °“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬„™¬â “ (Pharmacological therapy) ¬“∑Ë’„™â„π°“√√–ß∫— ª«¥ ‰¥·â °¬à “„π°≈¡àÿ paracetamol, nonsteroidal anti-inflammatory drugs, opioids, local anesthetic ·≈–¬“„π°≈¡àÿ adjuvants 殑 “√≥“°“√„™¬â “·°ªâ «¥¥ß— πÈ’ 1. ‡≈◊Õ°„™™â π‘¥¢Õ߬“·≈–°“√∫√À‘ “√¬“μ“¡§«“¡√ÿπ·√ߢÕߧ«“¡ª«¥ (√ªŸ ∑Ë’ 2) 3 2 1 √ªŸ ∑’Ë 2 ∫π— ‰¥ 3 ¢πÈ—  ”À√∫— ‡≈Õ◊ °„™™â 𥑠¢Õ߬“·≈–°“√∫√À‘ “√¬“μ“¡§«“¡√πÿ ·√ߢÕߧ«“¡ª«¥  “¡“√∂„™¬â “‡ √¡‘ ·≈–¬“™“‡©æ“–∑’Ë ‡ √‘¡ƒ∑∏‘¬Ï “·°ªâ «¥‰¥â 6 *** ¢âÕ·π–π”μ“à ßÊ „π·π«∑“ßæ≤— π“°“√√–ß—∫ª«¥πÈ’‰¡à„™¢à âÕ∫—ߧ∫— ¢Õß°“√ªØ‘∫μ— ‘ ***

2. ¢π“¥¢Õ߬“∑ˇ’ À¡“– ¡ §Õ◊ ¢π“¥∑ ’Ë “¡“√∂·°âª«¥‰¥¥â ’‚¥¬¡’º≈¢â“߇§’¬ßπÕâ ¬∑Ë ’ ¥ÿ 3. °√≥’∑∑’Ë √“∫«“à ¡’°“√∫“¥‡®Á∫≈à«ßÀπ“â ‡™àπ °“√ºà“μ¥—  “¡“√∂„À¬â “·°âª«¥°àÕπ°“√ºà“μ—¥ ‡æÕË◊ ™«à ¬ ≈¥°“√√∫— √⧟ «“¡ª«¥·≈–Õ“® “¡“√∂≈¥ª√‘¡“≥°“√„™â¬“·°ªâ «¥≈߉¥â 4. §«√„™â¬“·°âª«¥À≈“¬¢π“π∑’Ë¡’°≈‰°°“√ÕÕ°ƒ∑∏‘Ïμà“ß°—πº ¡º “π°—π ‡æ◊ËÕ„Àâº≈√–ß—∫ª«¥¥’¢÷Èπ ≈¥¢π“¥¢Õ߬“·≈–≈¥º≈¢“â ߇§’¬ß¢Õ߬“·°ªâ «¥·μ≈à –¢π“π≈ß °“√∫√‘À“√¬“ Opioid °“√∫√À‘ “√¬“ opioid ∑“ßÀ≈Õ¥‡≈Õ◊ ¥¥” (IV) ·≈–∑“ß°≈“â ¡‡πÕÈ◊ À√Õ◊ „μºâ «‘ Àπß— (IM/SC) · ¥ß„π·ºπ¿¡Ÿ ‘ ∑Ë’ 2, 3 ·≈– 4 °“√√–ß∫— ª«¥‡©¬’ ∫æ≈—π‚¥¬‰¡à„™¬â “ (Non-pharmacological therapy) °“√√–ß—∫ª«¥‚¥¬‰¡à„™¬â “ Õ“®·∫à߉¥â‡ªìπ psychological therapy ·≈– physical therapy Psychological therapy ‰¥â·°à 1. °“√„À¢â âÕ¡Ÿ≈ (Provision of information) 2. °“√ºÕà π§≈“¬·≈–°“√¡ÿà߇πâ𧫓¡ π„® (Relaxation and attention strategies) 3. °“√ –°¥®‘μ (Hypnosis) 4. °“√ª√—∫‡ª≈¬’Ë π§«“¡§‘¥·≈–æƒμ‘°√√¡ (Cognitive-behavioral therapy) ‡ª“Ñ À¡“¬¢Õß°“√„™â psychological therapy §Õ◊ °“√ª√—∫‡ª≈¬Ë’ π°“√√∫— √§âŸ «“¡ª«¥ °“√ª√∫— ‡ª≈Ë’¬π §«“¡§¥‘ ·≈–æƒμ°‘ √√¡¢Õߺ⪟ É«¬ ´÷ßË ®–™à«¬„Àºâ Ÿâª«É ¬ “¡“√∂§«∫§ÿ¡§«“¡ª«¥‰¥â¥¢’ ÷πÈ Physical therapy ‰¥â·°à 1. °“√ª√–§∫√Õâ π·≈–‡¬Áπ (Applications of heat and cold) 2. °“√°¥®ÿ¥·≈–°“√π«¥ (Manual and massage therapy) 3. Transcutaneous electrical nerve stimulation (TENS) 4. °“√Ωßí ‡¢Á¡ (Acupuncture) ‡ª“Ñ À¡“¬¢Õß°“√„™â physical therapy §Õ◊ ™«à ¬„Àºâ ªŸâ «É ¬ ∫“¬ ·°â‰¢§«“¡º¥‘ ª°μ„‘ π°“√∑”ß“π¢Õß√“à ß°“¬ ∑“ß°“¬¿“æ ‡™àπ -°≈â“¡‡π◊ÈÕ·≈–‡ª≈’ˬπ·ª≈ß°“√μÕ∫ πÕß∑“ß √’√«‘∑¬“ √«¡∑È—ß≈¥§«“¡°≈—«§«“¡ª«¥ ®“°°“√‡§≈Õ◊Ë π‰À«‡æÕ◊Ë „À⺪Ÿâ É«¬‡§≈◊ËÕπ‰À«‰¥‡â √«Á ¢π÷È ¥ß— ππÈ— °“√„™â non-pharmacological therapy „π°“√√–ß∫— ª«¥‡©¬’ ∫æ≈π— ®ß÷ ¡®’ ¥ÿ ¡ßÿà À¡“¬‡æÕË◊  π∫—  ππÿ „À°â “√√—°…“§«“¡ª«¥®“°°“√„™¬â “‰¥¥â ’¢πÈ÷ ‚¥¬‰¡¡à ’®ÿ¥¡àÿßÀ¡“¬∑Ë®’ –∑¥·∑π°“√„™¬â “·°âª«¥ °“√√–ß—∫ª«¥‡©’¬∫æ≈π— ‚¥¬‰¡à„™¬â “‡À¡“–°—∫ºâŸª«É ¬∑’¡Ë ≈’ —°…≥–¥—ßμÕà ‰ªπ’§È Õ◊ 1.  π„®°“√√—°…“«‘∏’π’È 2. °≈«— À√Õ◊ °—ß«≈¡“° 3. ¡Õ’ “°“√¢â“߇§¬’ ß®“°¬“·°ªâ «¥¡“° ‡æÕ◊Ë ®–™à«¬≈¥ª√¡‘ “≥°“√„À¬â “·°âª«¥ 4. §«“¡ª«¥¬ß— ¡’Õ¬Ÿà¥«â ¬°“√√—°…“μ“¡ª°μ‘ *** ¢Õâ ·π–π”μ“à ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫ß— §—∫¢Õß°“√ªØ∫‘ μ— ‘ *** 7

 ¡“§¡°“√»÷°…“‡√◊ÕË ß§«“¡ª«¥·Àßà ª√–‡∑»‰∑¬ ·ºπ¿Ÿ¡∑‘ Ë’ 2 °“√∫√‘À“√¬“ opioid ∑“ßÀ≈Õ¥‡≈Õ◊ ¥¥”·∫∫§√ȗߧ√“« (IV titration)3 ºªŸÈ Ë«¬μÕÈ ß°“√¬“·°ªÈ «¥ °“√‡μ√¬’ ¡¬“ ë Morphine ‡μ√¬’ ¡‡ªπì 1 mg/ml ª√–‡¡π‘ ´”È ë Pethidine ‡μ√¬’ ¡‡ªπì 10 mg/ml լ˓ߠ¡”Ë ‡ ¡Õ ‰¡Ë„™Ë ߥ¬“¡ÕÈ◊ μÕË ‰ª√Õ®π°«“Ë Sedation score < 2 „™Ë Sedation score < 2 ‰¡Ë„™Ë √“¬ß“π ·≈– RR > 10/min ¬ß— ¡’Õ“°“√ª«¥ Õ“®μÕÈ ß„À¬È “ naloxone RR > 10/min1 §√È—ß≈– 0.1 mg IV ·æ∑¬Ï ‰¡Ë¡’ hypotension „™Ë ‰¡Ë„™Ë √“¬ß“π ªØ‘∫—μμ‘ “¡·π«∑“ßæ≤— π“ ·æ∑¬Ï °“√√–ß∫— ª«¥¢Õß TASP ‰¥¬È “ < 3 §√Èß— (·ºπ¿¡Ÿ ‘∑Ë’ 1) „π 15 π“∑’ „™Ë ‰¡Ë„™Ë ‰¡Ë„™Ë Õ“¬ÿ < 70 ª’ ª«¥¡“° §Õ¬ ~ 5 π“∑’ „™Ë pain score ≥ 7 „™Ë ‰¡Ë„™Ë ª«¥¡“° „ÀȬ“ 1 ¡≈. „ÀȬ“ 0.5 ¡≈. pain score ≥ 7 „ÀȬ“ 1 ¡≈. „™Ë „ÀȬ“ 2 ¡≈. À¡“¬‡Àμÿ 1. RR = respiratory rate À“°≈¥≈ßπÕÈ ¬°«“Ë 10 §√—Èß/π“∑’ Õ“®‡ªÁπÕπ— μ√“¬μËÕºŸÈª«Ë ¬‰¥ßÈ Ë“¬ Sedation score 0-3 (0 = √Ÿ È °÷ μ—«¥’, 1 = ß«Ë ß‡≈°Á πÕÈ ¬, 2 = ß«Ë ß¡“°·μªË ≈ÿ°μ◊Ëπß“Ë ¬, 3 = ª≈°ÿ μË◊𬓰, S = πÕπÀ≈∫— ª°μ‘) 8 *** ¢Õâ ·π–π”μ“à ßÊ „π·π«∑“ßæ≤— π“°“√√–ß—∫ª«¥πÈ’‰¡à„™¢à Õâ ∫—ߧ∫— ¢Õß°“√ªØ‘∫—μ‘ ***

·ºπ¿Ÿ¡∑‘ ’Ë 3 °“√∫√‘À“√¬“ opioid ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”·∫∫μ“¡‡«≈“ (IV around the clock)3 ∂÷߇«≈“©¥’ ¬“μ“¡‡«≈“∑°Ë’ ”Àπ¥ ‰¡Ë„™Ë ª√–‡¡π‘ ´È” Õ¬“Ë ß ¡”Ë ‡ ¡Õ ºªŸÈ Ë«¬μÈÕß°“√¬“·°ªÈ «¥ §” ß—Ë °“√√°— …“ Morphine IV „™Ë (μ“¡‡«≈“∑’Ë°”Àπ¥) (殑 “√≥“μ“¡Õ“¬ÿ π”È Àπ°— μ—« Sedation score < 2, RR > 10/min1 ·≈–√–¥∫— §«“¡ª«¥) ‰¡Ë¡’ hypotension ë 1-2 mg iv 2 hr ë 2-3 mg iv 3 hr „™Ë ë 3-4 mg iv 4 hr ©’¥¬“μ“¡§” ß—Ë °“√√—°…“2 ª√–‡¡‘πºŸªÈ Ë«¬´”È À≈—ß©’¥¬“ 5-10 π“∑’ Sedation score < 2 ‰¡Ë„™Ë √“¬ß“π RR > 10/min ·æ∑¬Ï „™Ë ‰¡Ë„™Ë ª√–‡¡π‘ ´È” ߥ¬“¡È◊ÕμËÕ‰ª ºªÈŸ Ë«¬¢Õ¬“Õ’° Õ¬“Ë ß ¡”Ë ‡ ¡Õ √Õ®π°«Ë“ Sedation score < 2 „™Ë ‰¡Ë„™Ë √“¬ß“π ·≈– RR > 10/min Sedation score < 2 ·æ∑¬Ï Õ“®μÈÕß„À¬È “ naloxone §√Èß— ≈– 0.1 mg IV RR > 10/min √“¬ß“π·æ∑¬Ï ‰¡Ë„™Ë ∂“È ºŸªÈ Ë«¬¢Õ¬“‡°‘π „™Ë 2 §√—ßÈ „π‡«≈“∑Ë°’ ”Àπ¥ §√∫‡«≈“©¥’ ¬“μ“¡§” —Ëß°“√√°— …“ μ“¡§” ßË— „™Ë ë §” Ë—ß BTP ≈¥¢π“¥¬“≈ß 25% „ÀȬ“´”È „π¢π“¥‡¥‘¡ √–À«à“ß¡È◊Õ3 „π§√Èß— μÕË ‰ª ë ‡æ‘Ë¡¢π“¥¬“Õ°’ 50% „π§√Èß— μàÕ‰ª À¡“¬‡Àμÿ 1. RR = respiratory rate À“°≈¥≈ßπÕâ ¬°«“à 10 §√Èß— /π“∑’ Õ“®‡ªπì Õπ— μ√“¬μÕà ºŸâª«É ¬‰¥ßâ “à ¬ 2. ¥Ÿ§” ßË— °“√√°— …“ ”À√∫— opioid IV μ“¡‡«≈“∑Ë°’ ”Àπ¥ 3. BTP = breakthrough pain (Õ“°“√ª«¥∑‡Ë’ °¥‘ ¢π÷È √–À«“à ß¡ÕÈ◊ Õ“® ßË— ¬“„Àâ„π¢π“¥ 25-50% ¢Õߪ°μ)‘ Sedation score 0-3 (0 = √â Ÿ ÷°μ«— ¥,’ 1 = ß«à ߇≈°Á πâÕ¬, 2 = ß«à ß¡“°·μªà ≈ÿ°μ◊Ëπßà“¬, 3 = ª≈°ÿ μË◊𬓰, S = πÕπÀ≈∫— ª°μ)‘ *** ¢âÕ·π–π”μ“à ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥πÈ’‰¡à„™à¢âÕ∫ß— §—∫¢Õß°“√ªØ∫‘ μ— ‘ *** 9

 ¡“§¡°“√»°÷ …“‡√ÕË◊ ߧ«“¡ª«¥·Àßà ª√–‡∑»‰∑¬ ·ºπ¿Ÿ¡∑‘ Ë’ 4 °“√∫√À‘ “√¬“ opioid ∑“ß°≈â“¡‡πÕ◊È À√Õ◊ „μ⺫‘ Àπ—ß (IM/SC PRN)3 ºÈªŸ Ë«¬μÕÈ ß°“√¬“·°ªÈ «¥ Sedation score < 2 §” ß—Ë °“√√°— …“ IM prn q 2 hr RR > 10 /min1 Õ“¬ÿ (ª’) Morphine (mg) Pethidine (mg) „™Ë ©’¥¬“μ“¡¢π“¥∑’Ë°”Àπ¥2 20-59 5.0-10.0 50-100 60-85 2.5-5.0 25-50 > 85 2.0-3.0 20-30 ª√–‡¡π‘ ºŸªÈ «Ë ¬´È”À≈—ß©’¥¬“ 30 π“∑’ Sedation score < 2 ‰¡Ë„™Ë √“¬ß“π RR > 10 /min ·æ∑¬Ï „™Ë ‰¡Ë„™Ë ª√–‡¡π‘ ´”È ß¥¬“¡ÕÈ◊ μËÕ‰ª √Õ®π°«Ë“ ºªÈŸ «Ë ¬¢Õ¬“Õ’° լ˓ߠ¡Ë”‡ ¡Õ Sedation score < 2 ·≈– RR > 10 /min „™Ë ‰¡Ë„™Ë √“¬ß“π Õ“®μÕÈ ß„ÀȬ“ naloxone Sedation score < 2 ·æ∑¬Ï §√È—ß≈– 0.1 mg IV RR > 10 /min „™Ë ‰¡Ë„™Ë √“¬ß“π·æ∑¬Ï ∂È“ºªŸÈ «Ë ¬¢Õ¬“‡°‘π ©’¥¬“§√—ßÈ  ¥ÿ ∑È“¬ 2 §√ß—È „π 2 ™¡. ‡°‘π 2 ™—Ë«‚¡ß·≈«È ‡æ‘Ë¡¢π“¥¬“Õ°’ 50% „™Ë „π§√È—ßμËÕ‰ª ≈¥¢π“¥¬“≈ß 25% „À¬È “´”È ‰¥È„π¢π“¥‡¥‘¡®π∑ÿ‡≈“ „π§√ß—È μÕË ‰ª À¡“¬‡Àμÿ 1. RR = respiratory rate À“°≈¥≈ßπÕÈ ¬°«“Ë 10 §√ßÈ— /π“∑’ Õ“®‡ªπÁ Õ—πμ√“¬μÕË ºªÈŸ «Ë ¬‰¥ßÈ Ë“¬ 2. ¥§Ÿ ” Ë—ß°“√√°— …“ ”À√∫— opioid IM prn q 2 hr (¢π“¥¬“μ“¡Õ“¬ºÿ ªÈŸ Ë«¬) Sedation score 0-3 (0 = √ ÈŸ °÷ μ«— ¥’, 1 = ß«Ë ß‡≈°Á πÕÈ ¬, 2 = ß«Ë ß¡“°·μªË ≈°ÿ μ◊πË ß“Ë ¬, 3 = ª≈°ÿ μ◊πË ¬“°, S = πÕπÀ≈∫— ª°μ)‘ 10 *** ¢Õâ ·π–π”μ“à ßÊ „π·π«∑“ßæ≤— π“°“√√–ß—∫ª«¥πÈ’‰¡à„™¢à Õâ ∫—ߧ—∫¢Õß°“√ªØ∫‘ —μ‘ ***

°“√√–ß∫— ª«¥·∫∫º ¡º “π (Multimodal analgesia) °“√„À¬â “·°ªâ «¥‡æ¬’ ߢπ“π‡¥¬’ «Õ“®√–ß∫— ª«¥‰¥â‰¡¥à ‡’ ∑“à ∑§’Ë «√ °“√‡æ¡Ë‘ ¢π“¥¬“·°ªâ «¥∑Ë’„™â„À¡â “°¢π÷È ‡æË◊Õ欓¬“¡√–ß—∫ª«¥„À≥âº≈‡μÁ¡∑’Ë °ÁÕ“®‡°‘¥Õ“°“√·∑√°´âÕπ®“°¬“π—Èπ‰¥â ‡™àπ Õ“°“√§≈Ë◊π‰ â Õ“‡®’¬π ∑Õâ ßÕ¥◊ ·≈–°¥°“√À“¬„® ‡ªìπμπâ 11 ®ß÷ ¡°’ “√„™¬â “·°ªâ «¥‚¥¬«∏‘ º’  ¡º “πÀ√◊Õ„™â¬“À≈“¬¢π“π√à«¡°—π¢È÷π12 ‚¥¬¡«’ μ— ∂ªÿ √– ß§‡å æÕË◊ „À°â “√√–ß∫— ª«¥‰¥ºâ ≈¥¢’ π÷È ‚¥¬°“√‡≈Õ◊ °„™¬â “À≈“¬¢π“π∑Õ’Ë Õ°ƒ∑∏¥Ï‘ «â ¬«∏‘ °’ “√∑μË’ “à ß°π— À√Õ◊ ÕÕ°ƒ∑∏‘Ïμà“ß∑Ë°’ π— ‚¥¬∑’ˬ“·μà≈–¢π“π®–‡ √¡‘ ƒ∑∏‘°Ï —π ·≈–≈¥¢π“¥¬“¢Õß·μ≈à –¢π“π≈ß Õ’°∑ßÈ— ¬—ߙ૬ ≈¥Õ“°“√·∑√°´Õâ π∑ÕË’ “®®–‡°¥‘ ®“°¬“·μ≈à –¢π“π≈߉¥¥â «â ¬11 μ«— Õ¬“à ß ‡™πà °“√„™¬â “™“√«à ¡°∫— NSAIDs ·≈– opioids ‡ªπì μâπ ‚¥¬∑’¬Ë “™“ ·≈– opioids ®–¬∫— ¬ßÈ— °“√π” ßà  ≠— ≠“≥ª«¥∑Èß— ∑’Ë√–¥∫— peripheral, spinal ·≈– supraspinal  «à π NSAIDs ®–¬—∫¬—Èß —≠≠“≥ª«¥∑’Ë peripheral À√Õ◊ ∑∫Ë’ √‡‘ «≥·º≈ºà“μ—¥ ·≈– NSAIDs ∫“ß™π‘¥ “¡“√∂ÕÕ°ƒ∑∏∑‘Ï Ë√’ –∫∫ª√– “∑ «à π°≈“ß‚¥¬‡©æ“–∑√’Ë –¥∫— spinal cord ‰¥¥â «â ¬ 5. Õ“°“√ª«¥¥¢’ πÈ÷ À√Õ◊ ‰¡àÀ≈—߉¥â√∫— °“√√—°…“ (°≈àÕß∑Ë’ 5) §”·π–π”: ∑”°“√ª√–‡¡π‘ √–¥—∫§«“¡ª«¥À≈ß— „Àâ°“√√—°…“Õ¬“à ß ¡”Ë ‡ ¡Õ‡æ◊ÕË ª√–‡¡π‘ º≈°“√√°— …“ º≈°“√√–ß∫— ª«¥Õ“®¡°’ “√ª√–‡¡π‘ ‰¥Àâ ≈“¬√ªŸ ·∫∫‡™πà ‡¥¬’ «°∫— °“√ª√–‡¡π‘ √–¥∫— §«“¡√πÿ ·√ߢÕßÕ“°“√ ª«¥ μ«— Õ¬à“ß°“√ª√–‡¡π‘ º≈°“√√–ß∫— ª«¥‡ªπì 5 √–¥—∫ ‰¥·â °à: none (0), slight (1), moderate (2), good or lots (3) ·≈– complete (4) À√Õ◊ ª√–‡¡‘πº≈°“√√–ß—∫ª«¥¥«â ¬ numeric rating scale (0-10): 0 À¡“¬∂ß÷ √–ß—∫ª«¥‰¡à‰¥â‡≈¬ ·≈– 10 À¡“¬∂÷ß√–ß—∫ª«¥‰¥â∑È—ßÀ¡¥ À√◊Õ®–ª√–‡¡‘π‚¥¬„Àâ∑”‡§√Ë◊ÕßÀ¡“¬∫π visual analogue scale ‡™πà ‡¥’¬«°—∫°“√ª√–‡¡π‘ √–¥—∫§«“¡ª«¥°Á‰¥â º≈°“√√–ß∫— ª«¥®–¡§’ «“¡ ¡— æπ— ∏å‚¥¬μ√ß°∫— √–¥∫— §«“¡æß÷ æÕ„®„π°“√√–ß∫— ª«¥¢ÕߺªâŸ «É ¬ ‚¥¬æ∫«“à ºâŸª«É ¬®–¡’§«“¡æ÷ßæÕ„®¡“°À“°°“√√–ß—∫ª«¥‰¥âº≈¥·’ ≈–¡’√–¥∫— §«“¡ª«¥πÕâ ¬°«“à 4 §–·ππ13 6. Õ“°“√·∑√°´âÕπ∑Ë’‡°‘¥®“°°“√√–ß—∫ª«¥ (°≈Õà ß∑Ë’ 6) §”·π–π”: §«√¡’°“√‡ΩÑ“√–«ß— Õ“°“√·∑√°´âÕπ ·≈–¡§’ ” —ßË °“√√°— …“ ”À√—∫Õ“°“√·∑√°´Õâ π„πºŸâª«É ¬ ∑°ÿ √“¬Õ¬“à ß™—¥‡®π (¥Ÿ√“¬≈–‡Õ’¬¥„π°≈Õà ß∑Ë’ 7) Õ“°“√·∑√°´Õâ π∑Ëæ’ ∫∫àÕ¬ ‡™àπ §≈◊πË ‰ Õâ “‡®’¬π «‘߇«’¬π»√’ …– ∑âÕßÕ¥◊ ßà«ß´¡÷ §«“¡¥—π‡≈Õ◊ ¥≈¥≈ß ·≈–§π—  à«πÕ“°“√·∑√°´âÕπ∑æË’ ∫πâÕ¬·μ√à ÿπ·√ß ‡™àπ °¥°“√À“¬„® ‡ªìπμπâ 7. «‘∏’°“√√°— …“Õ“°“√·∑√°´Õâ π (°≈Õà ß∑Ë’ 7) §”·π–π”: 1)  “¡“√∂„À⬓√°— …“Õ“°“√·∑√°´âÕπ‰¥âμ—ßÈ ·μ‡à √Ë¡‘ ¡’Õ“°“√ 2) À“°„™¬â “¢π“π‡¥¬’ «‰¡à‰¥ºâ ≈ “¡“√∂„™¬â “∑¡Ë’ °’ ≈‰°ÕÕ°ƒ∑∏μ‘Ï “à ß°π— ¡“„™‡â  √¡‘ ƒ∑∏°‘Ï π— ‰¥â «‘∏°’ “√√—°…“Õ“°“√·∑√°´Õâ π „π∑Ë’π’È®–°≈“à «∂ß÷ ‡©æ“–Õ“°“√·∑√°´âÕπ®“° opioid ‡∑“à πÈ—π  à«π°“√ √°— …“Õ“°“√·∑√°´âÕπÕπ◊Ë Ê  “¡“√∂¥√Ÿ “¬≈–‡Õ’¬¥‰¥â„π¿“§ºπ«° *** ¢Õâ ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥πÈ’‰¡à„™¢à âÕ∫ß— §∫— ¢Õß°“√ªØ‘∫—μ‘ *** 11

 ¡“§¡°“√»÷°…“‡√ËÕ◊ ߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ º≈‰¡àæß÷ ª√– ß§å¢Õß opioids ∑Ë ’ ”§—≠ ¡’¥ß— π’È 1. Õ“°“√√πÿ ·√ß·μæà ∫‰¡∫à Õà ¬ §Õ◊ °“√°¥°“√À“¬„® æ∫‰¥â„π°√≥’„À¬â “‡°π‘ ¢π“¥ À√Õ◊ ¡°’ “√„™¬â “ seda- tive ÕËπ◊ √«à ¡¥«â ¬ √°— …“‚¥¬°“√„À¬â “ naloxone 0.001-0.004 mg/kg ‡¢â“À≈Õ¥‡≈◊Õ¥¥” ∑°ÿ 2-3 π“∑’ ®π°«“à ®–¥’¢π÷È À√Õ◊ „ÀâÀ¬¥μàÕ‡π◊ËÕß„π¢π“¥ 0.003-0.005 mg/kg/hr ®÷ßμâÕß¡°’ “√‡ΩÑ“√–«ß— °“√À“¬„®¿“¬À≈—ß°“√‰¥â √∫— ¬“°≈à¡ÿ opioids √«à ¡°∫— ª√–‡¡π‘ sedation scores (¥ŸÀ«— ¢âÕÕ“°“√ß«à ß´÷¡) 2. Õ“°“√‰¡√à ÿπ·√ß·μæà ∫∫Õà ¬ 2.1 ßà«ß´÷¡ §«√‡ΩÑ“√–«ß— ‚¥¬ª√–‡¡π‘ sedation scores (0-3) ¥ß— πÈ’ 0 = √ Ÿâ °÷ μ«— ¥’, 1 = ßà«ß‡≈°Á πÕâ ¬, 2 = ßà«ß¡“°·μàª≈ÿ°μπ◊Ë ßà“¬, 3 = ª≈ÿ°¬“°À√Õ◊ ‰¡àμπË◊ 2.2 §≈πË◊ ‰ Õâ “‡®¬’ π ºªâŸ «É ¬∑’ˉ¥â opioids ®–‡°¥‘ Õ“°“√§≈π◊Ë ‰ Õâ “‡®¬’ πß“à ¬À“°‡ªπì ºªâŸ «É ¬À≠ß‘ ¡ª’ √–«μ— ‘ ‡¡“√∂ßà“¬ ‰¡à‡§¬ Ÿ∫∫Àÿ √Ë’ ºªâŸ É«¬‡À≈“à π®È’ ß÷ §«√‰¥â√∫— ¬“·°Õâ “‡®’¬π„π¢π“¥∑’‡Ë 欒 ßæÕ ‚¥¬„Àâμ“¡‡«≈“ ·≈–Õ“® μâÕß„™â¬“·°âÕ“‡®’¬π√à«¡°π— ¡“°°«“à 1 ™π¥‘ ‡™àπ ondansetron √«à ¡°—∫ metoclopramide ®ß÷ ®– “¡“√∂ √°— …“·≈–ªÕÑ ß°π— Õ“°“√§≈πË◊ ‰ âÕ“‡®¬’ π®“° opioids ‰¥ºâ ≈¥’ 2.3 Õ“°“√ÕπË◊ Ê ‰¥â·°à ∑Õâ ßÕ¥◊ Õ“°“√§π— ·≈– ªí  “«–‰¡àÕÕ°  “¡“√∂„Àâ°“√√—°…“μ“¡Õ“°“√‰¥â 8. °“√ª√–‡¡‘π√–¥∫— §«“¡ª«¥À≈ß— „Àâ°“√√°— …“·≈–°“√∫—π∑°÷ º≈°“√ª√–‡¡π‘ (°≈Õà ß∑’Ë 8) §”·π–π”: ∑”°“√ª√–‡¡‘π√–¥∫— §«“¡ª«¥À≈—ß„Àâ°“√√—°…“Õ¬à“ß ¡Ë”‡ ¡Õ·≈–∫π— ∑°÷ §«“¡ª«¥„À‡â ÀÁ𠙥— ‡®π (¥§Ÿ ”·π–π”∑’Ë 2, 3 „π°≈àÕß∑Ë’ 2) °“√ª√–‡¡‘π√–¥—∫§«“¡ª«¥´”È ·π–π”„Àâª√–‡¡‘π‡ªìπ√–¬– À≈—ß®“°‰¥â„Àâ°“√√—°…“§«“¡ª«¥ ‡™àπ °“√∫√‘À“√¬“ opioid ∑“ßÀ≈Õ¥‡≈Õ◊ ¥¥” (IV) §«√ª√–‡¡π‘ ´”È ¿“¬„π 5-10 π“∑’ °“√∫√À‘ “√¬“ opioid ∑“ß °≈â“¡‡π◊ÈÕÀ√Õ◊ „μ⺫‘ Àπß— (IM/SC) §«√ª√–‡¡‘π´È”¿“¬„π 30 π“∑’  ”À√∫— ¬“√∫— ª√–∑“π·≈–°“√√–ß—∫ª«¥ ∑’ˉ¡à„™â¬“ §«√ª√–‡¡‘π´È”¿“¬„π 60 π“∑’ À“° “¡“√∂∑”‰¥â §«√ª√–‡¡‘π·≈–∫π— ∑÷°√–¥∫— §«“¡ª«¥‡ªπì √–¬– ‡™àπ‡¥¬’ «°—∫ ≠— ≠“≥™’æÕπ◊Ë Ê ‚¥¬ °”Àπ¥„À√â –¥∫— §«“¡ª«¥‡ªπì  —≠≠“≥™æ’ ∑ËÀ’ “â ·≈–§«√∫π— ∑÷°ª®í ®—¬ÕË◊πÊ ∑‡Ë’ °’¬Ë «¢Õâ ß°∫— §«“¡ª«¥¢ÕߺªâŸ «É ¬ ‰¥·â °à μ”·Àπßà ·≈–≈°— …≥–¢Õߧ«“¡ª«¥ Õ–‰√∑”„Àâ√–¥∫— §«“¡ª«¥¡“°¢Èπ÷ ∂“â ª√–‡¡π‘ ·≈«â æ∫«“à √–¥∫— §«“¡ª«¥¬ß— ‰¡¥à ¢’ πÈ÷ 欓∫“≈§«√ª√°÷ …“·æ∑¬‡å æÕË◊ ª√∫— ·ºπ°“√√°— …“μÕà ‰ª 12 *** ¢âÕ·π–π”μ“à ßÊ „π·π«∑“ßæ≤— π“°“√√–ß∫— ª«¥π’ȉ¡à„™à¢Õâ ∫ß— §—∫¢Õß°“√ªØ‘∫—μ‘ ***

¿“§ºπ«°  “‡Àμ·ÿ ≈–°“√√∫— √Ÿâ‡√ÕË◊ ߧ«“¡ª«¥‡©¬’ ∫æ≈—π14 §«“¡ª«¥‡©¬’ ∫æ≈π— ‡°¥‘ ®“°°√–∫«π°“√Õ°— ‡ ∫ ¡ ’ “‡ÀμÀÿ ≈“¬Õ¬“à ß ‡™πà ‡°¥‘ ®“°§«“¡√Õâ π °“√∫“¥‡®∫Á ·≈– “√‡§¡’ °√–∫«π°“√Õ°— ‡ ∫∑”„Àâ√à“ß°“¬À≈—ßË  “√‡§¡À’ ≈“¬™π‘¥ (‡™πà prostaglandin, substance-P, histamine, H+ ‡ªπì μπâ ) ÕÕ°¡“  “√‡§¡‡’ À≈“à π®È’ –°√–μπÿâ ª≈“¬ª√– “∑√∫— √§âŸ «“¡√ âŸ °÷ ·≈–∂°Ÿ ·ª≈߇ªπì  ≠— ≠“≥ §«“¡ª«¥‡°¥‘ ¢πÈ÷ §«“¡ª«¥∑‡’Ë °¥‘ ¢π÷È ®–∂°Ÿ ∂“à ¬∑Õ¥‰ªμ“¡‡ πâ ª√– “∑ C fiber ·≈– Aδ fiber ‡¢“â  Ÿà‰¢ π— À≈ß— ∫√‘‡«≥ dorsal horn ·≈–∂à“¬∑Õ¥°√–· ª√– “∑´Ë÷߇ªìπ —≠≠“≥§«“¡ª«¥π’È „Àâ°—∫‡´≈≈åª√– “∑μ—«∑Ë’ 2 ‡æÕ◊Ë  ßà  ≠— ≠“≥§«“¡ª«¥º“à π∑“ß spinothalamic tract ‰ª¬ß— √–∫∫ª√– “∑ «à π°≈“ß·≈– ¡Õß„π√–¥∫— μ“à ßÊ ‡™πà thalamus ·≈– cerebral cortex ‡æ◊ËÕ„À¡â °’ “√√—∫√·Ÿâ ≈–μÕ∫ πÕßμÕà §«“¡ª«¥∑‡Ë’ °‘¥¢Èπ÷ μàÕ‰ª (√ªŸ ∑’Ë 3) √Ÿª∑Ë’ 3 μ”·Àπàß„π°“√ÕÕ°ƒ∑∏Ï‘¢Õ߬“·°âª«¥™π‘¥μ“à ßÊ (NSAIDs = Nonsteroidal anti-inflammatory drugs, COXIBs = COX-II specific inhibitors) *** ¢âÕ·π–π”μ“à ßÊ „π·π«∑“ßæ—≤π“°“√√–ß∫— ª«¥πÈ’‰¡à„™à¢Õâ ∫ß— §∫— ¢Õß°“√ªØ∫‘ μ— ‘ *** 13

 ¡“§¡°“√»°÷ …“‡√ÕË◊ ߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ °√–∫«π°“√Õ—°‡ ∫∑Ë’‡°‘¥¢È÷π∑Ë’ª≈“¬‡ âπª√– “∑ À“°¡’°“√À≈Ë—ß “√‡§¡’ÕÕ°¡“Õ¬à“ßμàÕ‡π◊ËÕß ®–∑”„Àâ Õ“°“√ª«¥·≈–∫«¡¢¬“¬«ß‰ª√Õ∫Ê ∫√‡‘ «≥∑Ë’‰¥√â ∫— ∫“¥‡®∫Á ·≈–∑”„À∫â √‡‘ «≥√Õ∫Ê °“√∫“¥‡®∫Á ¡Õ’ “°“√ª«¥ ¡“°°«“à ª°μ‘ ‡√’¬°°√–∫«π°“√π’È«“à peripheral sensitization „π¢≥–‡¥¬’ «°—π∑Ë∫’ √‡‘ «≥ dorsal horn ¢Õß ‰¢ —πÀ≈ß— °Á®–‰¥â√—∫ ≠— ≠“≥§«“¡ª«¥‡¢“â ¡“Õ¬“à ßμàÕ‡πÕ◊Ë ß ·≈–‡°¥‘ °√–∫«π°“√∂à“¬∑Õ¥ —≠≠“≥§«“¡ª«¥ ‰ª¬—ß√–∫∫ª√– “∑ à«π°≈“߇æ¡Ë‘ ¢È÷π ‡√’¬°°√–∫«π°“√πÈ’«“à central sensitization ¥ß— ππ—È „π°“√√°— …“Õ“°“√ ª«¥‡©¬’ ∫æ≈π— ®ß÷ μÕâ ß欓¬“¡≈¥·≈–ªÕÑ ß°π— ‰¡à„À‡â °¥‘ °√–∫«π°“√ peripheral ·≈– central sensitization ¢π÷È ‡§√Ë◊Õß¡◊Õ ”À√∫— ª√–‡¡π‘ √–¥—∫§«“¡ª«¥ (√Ÿª∑’Ë 1) 1. Numerical rating scale (NRS) ‡ªìπ‡§√ËÕ◊ ß¡◊Õ∑Ë’π¬‘ ¡„™â„π∑“ߧ≈‘π°‘ ‡æ√“– –¥«° „Àºâ ªâŸ «É ¬∫Õ° §–·π𧫓¡ª«¥‡ªπì μ«— ‡≈¢ ‚¥¬ 0 §–·ππ À¡“¬∂÷߉¡àª«¥ 1-9 §–·ππ À¡“¬∂ß÷ ª«¥¡“°¢÷Èπμ“¡≈”¥—∫ ·≈–10 §–·ππ À¡“¬∂÷ߪ«¥¡“°∑ Ë’ ÿ¥‡∑à“∑Ë’®–§¥‘ ‰¥â 2. Verbal rating scale (VRS) „™ â ”À√∫— ºªâŸ «É ¬∑’ˉ¡ à “¡“√∂∫Õ°√–¥∫— §«“¡ª«¥‡ªπì μ«— ‡≈¢‰¥â ‚¥¬ Õ“® ·∫ßà ÕÕ°‡ªìπ 5 √–¥∫— §◊Õ 0 §–·ππ À¡“¬∂÷߉¡ªà «¥, 1-3 §–·ππ À¡“¬∂ß÷ ª«¥πâÕ¬, 4-6 §–·ππ À¡“¬ ∂÷ߪ«¥ª“π°≈“ß, 7-9 §–·ππ À¡“¬∂ß÷ ª«¥¡“° ·≈– 10 §–·ππ À¡“¬∂ß÷ ª«¥¡“°∑ ’Ë ÿ¥‡∑“à ∑’Ë®–§¥‘ ‰¥â 3. Visual analog scale (VAS) „™â‰¡∫â √√∑—¥À√Õ◊ ‡ πâ μ√ß∑’Ë¡’§«“¡¬“« 10 ‡´π쇑 ¡μ√ ‚¥¬‡√‘Ë¡®“° 0 ‡´π쑇¡μ√ À¡“¬∂ß÷ ‰¡ªà «¥ ∂ß÷ 10 ‡´π쇑 ¡μ√ À¡“¬∂ß÷ ª«¥¡“°∑Ë’ ¥ÿ ‡∑à“∑’®Ë –§‘¥‰¥â ‚¥¬„À⺟ªâ É«¬°“°∫“∑ (X) ∫π‡ πâ μ√ß μ“¡√–¥—∫§«“¡ª«¥®√‘ߢÕߺ⪟ «É ¬ 4. Face pain scale ‡ªπì visual pain analogue „™√â Ÿª· ¥ß§«“¡√⟠°÷ ∑“ß„∫Àπ“â ‡À¡“– ”À√∫— ‡¥Á°Õ“¬ÿ 5-8 ªï À√◊ÕºªâŸ «É ¬∑Ë’‰¡à “¡“√∂∫Õ°§«“¡ª«¥‡ªπì μ«— ‡≈¢‰¥â ¢âÕ·π–π” * °“√„À⧖·ππ‰¡à„™à¥Ÿ≈—°…≥– ’Àπâ“¢Õ߇¥Á°‡∑’¬∫°—∫„∫Àπâ“„π√Ÿª ·μà„ÀâºâŸªÉ«¬™È’√ŸªÀπâ“∑’Ë· ¥ß √–¥∫— §«“¡ª«¥¢Õßμπ‡Õß „À⧖·ππμ“¡√ªŸ Àπ“â ∑’‡Ë ≈◊Õ° 0, 2, 4, 6, 8, 10 μ“¡≈“Ì ¥—∫ * μ—«Õ¬à“ß°“√ Õ𠇙πà ç√ŸªÀπ“â μÕà ‰ªπ’®È –· ¥ß„Àâ‡ÀÁπ«à“¡’§«“¡ª«¥¡“°‡∑“à ‰√ √ªŸ ´“â ¬ ÿ¥· ¥ß «“à ‰¡ªà «¥‡≈¬ √ŸªÀπ“â ∂¥— ¡“· ¥ß«“à ª«¥¡“°¢π÷È ¡“°¢È÷π (™’È√ªŸ Àπâ“®“°´â“¬¡“¢«“) ®π∂ß÷ √Ÿª¢«“ ¥ÿ · ¥ß«à“ ª«¥¡“°Ê „ÀâÀπ™Ÿ ’√È ªŸ Àπ“â ∑’Ë· ¥ß«à“ μÕππÀÈ’ πŸª«¥¡“°·§à‰Àπé * „Àâ„™â§“Ì «à“ 燮Á∫é À√Õ◊ 窫¥é μ“¡§«“¡‡À¡“– ¡·°àºŸªâ «É ¬‡¥Á°·μà≈–§π 5. ‡§√◊ËÕß¡Õ◊ ª√–‡¡‘π√–¥—∫§«“¡ª«¥ÕπË◊ Ê ‰¥·â °à 5.1 The FLACC behavioral pain scale (μ“√“ß∑Ë’ 1) ‡À¡“– ”À√∫— ‡¥°Á ‡≈Á°À√◊ÕºªâŸ É«¬∑’ˉ¡‡à ¢â“„® ¿“…“ ª√–°Õ∫¥â«¬ 5  à«π ‰¥â·°à °“√ª√–‡¡‘π°“√· ¥ßÕÕ°∑“ß„∫Àπâ“ °“√¢¬—∫¢Õߢ“ °“√‡§≈◊ËÕπ‰À« (activity) √Õâ ߉Àâ ·≈–°“√μÕ∫ πÕßμÕà °“√ª≈Õ∫‚¬π (consolability) ´ßË÷ ·μ≈à – «à π¡§’ –·ππ 0-2 √«¡∑ß—È À¡¥ 10 §–·ππ 5.2 The CHEOPS behavioral pain scale15 (μ“√“ß∑’Ë 2) ‡À¡“– ”À√∫— ‡¥°Á ‡≈Á°À√Õ◊ ºâŸªÉ«¬∑’ˉ¡à ‡¢“â „®¿“…“ ‡§√ÕË◊ ß¡◊Õ¡§’ –·ππμßÈ— ·μà 4-13 14 *** ¢âÕ·π–π”μ“à ßÊ „π·π«∑“ßæ≤— π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫ß— §∫— ¢Õß°“√ªØ∫‘ —μ‘ ***

μ“√“ß∑Ë’ 1 The FLACC behavioral pain scale15 Categories Definition Scoring 0  À’ π“â ‡©¬ ‰¡à¬¡È‘ 1 Àπâ“쓇∫– À√Õ◊ ¢¡«¥§È‘« ∂Õ¬Àπ’ 2 0 ‰¡à π„® ‘Ëß·«¥≈âÕ¡‡ªìπ∫“ߧ√—ßÈ 1 2 §“ß Ëπ— °—¥øπí ·πà𠇪ìπ∫àÕ¬Ê À√◊Õμ≈Õ¥‡«≈“ 0 1 ¢“ Õ¬Ÿà„π∑à“ª°μ‘ À√Õ◊ ∑à“ ∫“¬Ê 2 0 Õ¬àŸ„π∑“à ‰¡à ∫“¬ °√– ∫— °√– “à ¬ ‡°√Áß 1 2 ‡μ–À√Õ◊ ßÕ¢“¢πÈ÷ 0 1 °“√‡§≈Ë◊Õπ‰À« πÕπ‡ß’¬∫Ê ∑“à ª°μ‘ ‡§≈Ë◊Õπ‰À« ∫“¬Ê 2 ∫‘¥μ«— ‰ª¡“ ·Õπà Àπ“â ·Õπà À≈ß— ‡°√Áß μ—«ßÕ ‡°√Áß®πμ«— ·¢ßÁ À√Õ◊  —Ëπ°√–μÿ° √âÕ߉Àâ ‰¡à√âÕß (μπ◊Ë À√◊ÕÀ≈—∫°Á‰¥â) §√“ߌÕ◊ Ê À√◊Õ§√“߇∫“Ê ∫πà ‡ªìπ∫“ߧ√—ßÈ √Õâ ߉Àâμ≈Õ¥ À«¥’ √Õâ ß  –Õ÷° –Õπ◊È ∫πà ∫àÕ¬Ê °“√μÕ∫ πÕßμÕà °“√ª≈Õ∫‚¬π ‡™Ë◊Õøíߥ’  ∫“¬Ê  “¡“√∂ª≈Õ∫‚¬π¥â«¬°“√ ¡— º — ‚Õ∫°Õ¥ 楟 §ÿ¬¥â«¬ ‡æ◊ÕË ¥÷ߥŸ¥§«“¡ π„®‡ªπì √–¬–Ê ¬“°∑Ë®’ –ª≈Õ∫‚¬πÀ√Õ◊ ∑”„À â ∫“¬ μ“√“ß∑Ë’ 2 The CHEOPS behavioral pain scale15 ‡«≈“ √âÕ߉Àâ  À’ π“â °“√ à߇ ’¬ß ∑“à ∑“ß(≈”μ«— )  —¡º — ·º≈ ¢“ §–·ππ 1=‰¡√à Õâ ß 0=¬¡È‘ 0=楟  πÿ°√à“‡√ß‘ 1=∏√√¡¥“ 1=‰¡à —¡º—  1= ∑“à  ∫“¬ √«¡ 2=§√“ß/√âÕ߉Àâ 1=‡©¬ À√◊Õ‰¡à查  ∫“¬Ê 2=‡ÕÈÕ◊ ¡¡◊Õ¡“/ 2= ∫¥‘ μ«— /‡μ–/¥ß÷ 3=À«’¥√âÕß 2=‡∫â 1=∫πà Õ◊πË Ê ‡™àπ 2=¥π‘È /‡°√ßÁ / ·μ–‡∫“Ê/μ–ª∫ ¢“Àπ/’ ‡°√ßÁ / À«‘ , À“·¡à  —Ëπ/¬◊π/¥È‘π /‡ÕÈ◊Õ¡¡Õ◊ ¡“®π ¬◊π/¥‘Èπ®π∂Ÿ° 2=∫à𪫥 + ∫àπ ®π∂°Ÿ ®∫— μ√ß÷ μâÕß®—∫¡◊Õ À√◊Õ ®∫— μ√ß÷ ‰«â ÕË◊πÊ ‰«â ·¢π‰«â 06.00 10.00 14.00 6. ‡§√◊ËÕß¡◊Õª√–‡¡‘𧫓¡ª«¥ ”À√—∫ºâŸªÉ«¬∑’ˉ¡à “¡“√∂ Ë◊Õ “√¥â«¬μ—«‡Õ߉¥â „πÀÕ«‘°ƒμ À√◊ÕºŸâªÉ«¬ √–¥∫— §«“¡√ Ÿâ °÷ μ«— πÕâ ¬≈ß §«√„™°â “√ª√–‡¡π‘ ®“°°“√ ß— ‡°μæƒμ°‘ √√¡·≈–°“√‡ª≈¬Ë’ π·ª≈ߢÕß ≠— ≠“≥™æ’ ‡ªπì √“¬Ê ‰ª *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ≤— π“°“√√–ß∫— ª«¥π’ȉ¡à„™¢à âÕ∫ß— §∫— ¢Õß°“√ªØ∫‘ μ— ‘ *** 15

 ¡“§¡°“√»÷°…“‡√ËÕ◊ ߧ«“¡ª«¥·Àßà ª√–‡∑»‰∑¬ °“√√–ß∫— ª«¥‡©¬’ ∫æ≈π— ‚¥¬„™¬â “ (Pharmacological therapy) ¬“·°ªâ «¥™π¥‘ μà“ßÊ ∑’Ë “¡“√∂‡≈Õ◊ °„™â ¡’¥—ßπÈ’ 1. Paracetamol À√◊Õ Acetaminophen Paracetamol ‡ªπì ¬“·°ªâ «¥·≈–≈¥‰¢â (·μ‰à ¡≈à ¥°“√Õ°— ‡ ∫) ∑¡Ë’ ’„™°â π— Õ¬“à ß·æ√Àà ≈“¬‡πÕ◊Ë ß®“°¡§’ «“¡ª≈Õ¥¿¬—  ßŸ  “¡“√∂„™â‰¥â∑°ÿ °≈à¡ÿ Õ“¬ÿ paracetamol ¡’ƒ∑∏√‘Ï –ß∫— ª«¥∑Õ’Ë Õà π ®ß÷ §«√‡≈Õ◊ °„™â„π°√≥∑’ ’Ë¡’Õ“°“√ª«¥‡≈°Á πÕâ ¬ À√◊Õª«¥ª“π°≈“ß Paracetamol ¬ß— ‰¡à∑√“∫°≈‰°°“√ÕÕ°ƒ∑∏‘∑Ï ·Ë’ πà™—¥ ªí®®∫ÿ —π‡™Ë◊Õ«à“ÕÕ°ƒ∑∏Ϻ‘ “à π∑“ß descending serotonergic pathways16 ‚¥¬°≈‰°À≈°— §Õ◊ ¬∫— ¬ß—È °“√ √“â ß prostaglandins „π ¡Õß ®“°°“√ √“â ß “√ AM404 (´ßË÷ ¡ƒ’ ∑∏‘¬Ï ß— ¬È—߇Õπ‰´¡å COX ‚¥¬μ√ß) ´Ëß÷ μÕâ ß¡’ fatty acid amide hydrolase (FAAH) ‡ªπì μ—«°√–μπÿâ °“√  √â“ß πÕ°®“°πÈ’¬—ßæ∫«“à AM404 ¬ß— ‰ª°√–μÿâπ TRPV1 receptor ´Ëß÷ ¡’ ligand √«à ¡°∫— CB1 receptor  ßà º≈„À‡â °¥‘ °“√¬∫— ¬È—ß anadamide (‡ªπì endogenous canabinoid) ‡¢â“‡´≈≈å ‡°‘¥°“√‡æ‘¡Ë ¢Èπ÷ ¢Õß endoge- nous canabinoid ´ß÷Ë ‡™Ë◊Õ«à“‡ªπì °≈‰°ÀπËß÷ „π°“√Õ∏∫‘ “¬º≈¢“â ߇§’¬ß‡√◊ËÕßßà«ßπÕπ„πºŸâ„™¬â “∫“ß√“¬ Paracetamol ¥¥Ÿ ´¡÷ ∑“ß√–∫∫∑“߇¥π‘ Õ“À“√‰¥¥â ·’ ≈–‡√«Á ‚¥¬√–¥∫— ¬“„π‡≈Õ◊ ¥ ßŸ  ¥ÿ ®–‡°¥‘ ¢π÷È ¿“¬„π §√ß÷Ë ™—Ë«‚¡ß ®“°ππ—È ®–∂Ÿ°∑”≈“¬∑Ë’μ∫— ·≈–¢—∫ÕÕ°∑“ßªí  “«–μÕà ‰ª ‡¡ËÕ◊ ¡’°“√„™â¬“μ«— πμÈ’ ¥‘ μàÕ°π— ‡ªìπ‡«≈“π“π À√◊Õ‰¥â√—∫¬“π’Ȫ√‘¡“≥¡“° Õ“®∑”„À‡â °¥‘ μ∫— «“¬‰¥â paracetamol ¡’§à“§√÷ßË ™’«μ‘ ª√–¡“≥ 2 ™—Ë«‚¡ß «‘∏’„™â¬“: ºâŸ„À≠à √∫— ª√–∑“π§√ßÈ— ≈– 500-1,000 ¡°. ∑°ÿ 4-6 ™Ë«— ‚¡ß ‡¡Õ◊Ë ¡Õ’ “°“√ª«¥À√Õ◊ ¡’‰¢â ‰¡à §«√√—∫ª√–∑“π‡°π‘ 4 °√¡— /«—π À√◊Õ 8 ‡¡¥Á (¢π“¥ 500 ¡°.)/«—𠇥°Á „Àâ√—∫ª√–∑“π§√È—ß≈– 10-20 ¡°.μàÕ π”È Àπ—°μ—« 1 °°. ∑°ÿ 4-6 ™—Ë«‚¡ß À√◊Õμ“¡¢π“¥∑’Ë·π–π”„πμ“√“ß∑Ë’ 3 paracetamol  “¡“√∂„™â‰¥∑â ß—È „Àâ ¬“‡æ¬’ ߢπ“π‡¥¬’ « À√Õ◊ „Àâ„π√Ÿª·∫∫º ¡°—∫¬“™π¥‘ ÕπË◊ ‡™πà codeine, NSAIDs ·≈– tramadol √Ÿª·∫∫¬“∑Ë’¡®’ ”Àπà“¬ ¬“‡¡Á¥ ¢π“¥ 325 ¡°. ·≈– 500 ¡°. ¬“πÈ” ”À√—∫‡¥Á°·≈–∑“√° ™π‘¥ πÈ”‡™Ë◊Õ¡ ¡‡’ π◊ÈÕ¬“ 120 ·≈– 125 ¡°./ 5 ¡≈. ™π‘¥À¬¥ 60 ¡°./0.6 ¡≈. §”‡μÕ◊ π·≈–¢Õâ §«√√–«—ß ‰¡à§«√√—∫ª√–∑“π¬“πμ’È ‘¥μàÕ°π— π“π‡°‘π 7 «π— ‰¡à„™â‡°‘πª√‘¡“≥∑°Ë’ ”Àπ¥ ‰¡à§«√¥Ë¡◊ ‡À≈“â √–À«à“ß ∑’Ë„™â¬“πÈ’ ·≈–‰¡§à «√„™¬â “π’°È ∫— ºŸªâ É«¬‚√§μ—∫  “¡“√∂„™¬â “πÈ°’ —∫ μ√¡’ ’§√√¿å·≈– μ√∑’ Ë°’ ”≈ß— „Àâπ¡∫μÿ √‰¥â μ“√“ß∑’Ë 3 ¢π“¥¬“ paracetamol „π‡¥Á°·μ≈à –™«à ßÕ“¬1ÿ 7 ¢π“¥¬“∑’Ë„™â„π‡¥Á° Õ“¬ÿ ¢π“¥ (¡°.) Õ“¬ÿ ¢π“¥ (¡°.) 0 - 3 ‡¥◊Õπ 320 4 - 11 ‡¥◊Õπ 40 6 - 8 ªï 400 480 1 - 2 ªï 80 9 - 10 ªï 640 2 - 3 ªï 650 4 - 5 ªï 120 11 ªï 160 12 - 14 ªï 240 > 14 ªï 16 *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ≤— π“°“√√–ß∫— ª«¥πÈ’‰¡à„™¢à âÕ∫ß— §∫— ¢Õß°“√ªØ∫‘ —μ‘ ***

º≈¢“â ߇§¬’ ߢÕ߬“ ‡°¥‘ πÕâ ¬¡“° ·μà„Àâ√–«ß— „π§π∑¡’Ë ’Õ“°“√·æâ ‚¥¬Õ“®¡º’ Ë◊π·¥ß∑˺’ ‘«Àπß— §—π À√Õ◊ ¡§’ ≈π◊Ë ‰ â Õ“‡®¬’ 𠬓π®’È –‰¡‡à °¥‘ Õ“°“√¢“â ߇§¬’ ß„¥Ê À“°√∫— ª√–∑“πÕ¬“à ß∂°Ÿ μÕâ ß„π√–¬–‡«≈“ πÈ— Ê  ”À√∫— ºŸªâ É«¬∑‡’Ë ªìπ‚√§μ—∫§«√≈¥¢π“¥¬“≈ß ‡æ√“–Õ“®∑”„À‡â °¥‘ æ‘…®“°¬“‰¥âßà“¬ 2. Nonsteroidal anti-inflammatory drugs (NSAIDs) °“√„™¬â “ NSAIDs „π°“√√–ß∫— ª«¥À≈ß— °“√º“à μ¥— Õ“®„™‡â 欒 ߢπ“π‡¥¬’ «„π°√≥∑’ §Ë’ «“¡ª«¥‰¡√à πÿ ·√ß À√Õ◊ „™â√à«¡°—∫¬“·°âª«¥Õ◊ËπÊ ∂“â §«“¡ª«¥√πÿ ·√ß¡“° NSAIDs πÕ°®“°¡’ƒ∑∏Ï‘√–ß—∫ª«¥·≈⫬—ß¡’ƒ∑∏Ï‘μâ“π°“√Õ—°‡ ∫·≈–≈¥‰¢â¥â«¬°“√ÕÕ°ƒ∑∏Ï‘¥—ß°≈à“« ‡°‘¥®“°°“√¬—∫¬È—ß°“√ √â“ß prostaglandins ‚¥¬¬—∫¬—Èß°“√∑”ß“π¢Õ߇Õπ‰´¡å cyclooxygenase ∑Ë’∫√‘‡«≥ ‡π◊ÈÕ‡¬ËÕ◊ ∑’ˉ¥â√—∫°“√∫“¥‡®∫Á ∑√’Ë –∫∫ª√– “∑∑—Èß∑’Ë à«πª≈“¬·≈– «à π°≈“ß ‡Õπ‰´¡å cyclooxygenase ¡’ 2 isoenzymes §◊Õ cyclooxygenase-1 (COX-1) ·≈– cyclooxy- genase-2 (COX-2) ‚¥¬‡Õπ‰´¡å COX-1 ®–æ∫„π¿“«–ª°μ‘„π‡π◊ÕÈ ‡¬Õ◊Ë À≈“¬™π‘¥ ‡™à𠇬◊ËÕ∫ÿ°√–‡æ“–Õ“À“√ ‡¬ÕË◊ ∫ÿÀ≈Õ¥‡≈Õ◊ ¥·≈–‰μ ´ß÷Ë ‡Õπ‰´¡å COX-1 ®–∑”Àπâ“∑Ë’§«∫§ÿ¡ ¡¥≈ÿ ¢Õß√“à ß°“¬  «à π‡Õπ‰´¡å COX-2 ®– ∂°Ÿ °√–μπâÿ „À â √“â ߢπ÷È ‡¡ÕË◊ ¡°’ √–∫«π°“√Õ°— ‡ ∫‡°¥‘ ¢π÷È ®–æ∫‰¥â„π‡¡¥Á ‡≈Õ◊ ¥¢“« À≈Õ¥‡≈Õ◊ ¥ ·≈–‡πÕÈ◊ ‡¬ÕË◊ ª√– “∑ NSAIDs ·μ≈à –™π¥‘ ¡§’ «“¡ “¡“√∂„π°“√¬∫— ¬ßÈ— ‡Õπ‰´¡å COX-1 ·≈– COX-2 ‰¥â‰¡‡à ∑“à °π— Õμ— √“ «à π °“√¬—∫¬È—߇Õπ‰´¡å COX-1 μàÕ COX-2 πÕ°®“°®–¡’º≈μàÕ°“√ÕÕ°ƒ∑∏Ï‘·≈â« ¬—ß®–∫Õ°∂÷ß‚Õ°“ ‡°‘¥¿“«– ·∑√°´Õâ π¥«â ¬ „π∑πË’ ®È’ –·∫ßà NSAIDs ÕÕ°‡ªπì  Õß°≈¡àÿ „À≠Êà §Õ◊ °≈¡ÿà conventional NSAIDs ‡™πà diclofenac, aspirin, ibuprofen, ketoprofen, naproxen, mefenamic, piroxicam ·≈– meloxicam ·≈–°≈àÿ¡ COX-2 specific inhibitors18 ‡™πà celecoxib, valdecoxib, parecoxib, ·≈– etoricoxib ‚¥¬∑’Ë°≈ÿà¡ conventional NSAIDs π—πÈ „π¢π“¥∑Ë’„™â„π°“√√—°…“ ®–¬∫— ¬Èß— °“√∑”ß“π¢Õ߇Õπ‰´¡å COX-1 ·≈– COX-2 ¥«â ¬‡ ¡Õ „π ¢≥–∑’Ë°≈àÿ¡ COX-2 specific inhibitors ¢π“¥¢Õ߬“∑Ë’„™â„π°“√√—°…“®–¬—∫¬È—ß°“√∑”ß“π¢Õ߇Õπ‰´¡å COX-2 ‚¥¬‰¡¡à º’ ≈¬∫— ¬ßÈ— °“√∑”ß“π¢Õ߇Õπ‰´¡å COX-1 ®“°°≈‰°∑Õ’Ë Õ°ƒ∑∏μÏ‘ “à ß°π— ∑”„Àâ conventional NSAIDs ¡’¢âÕ®”°—¥À≈“¬ª√–°“√∑’Ë®–π”¡“„™â‡æË◊Õ√–ß—∫ª«¥√–À«à“ß·≈–À≈—ߺà“μ—¥ „π¢≥–∑Ë’°≈ÿà¡ COX-2 specific inhibitors ¡¢’ Õâ ¥°’ «“à conventional NSAIDs „π‡√Õ◊Ë ßº≈¢“â ߇§¬’ ßμÕà √–∫∫∑“߇¥π‘ Õ“À“√·≈–‰¡¬à ∫— ¬ßÈ— °“√∑”ß“π ¢Õ߇°≈¥Á ‡≈Õ◊ ¥ ·μ¡à º’ ≈‰¡àæß÷ ª√– ß§Àå ≈“¬Õ¬“à ß∑Ë∑’ ”„Àºâ ⟄™μâ Õâ ß√–¡—¥√–«—߇™πà ‡¥’¬«°—π °“√‡≈Õ◊ °„™â NSAIDs ‡πÕ◊Ë ß®“°°“√„™â NSAIDs ‡æÕË◊ ≈¥Õ“°“√ª«¥À≈ß— °“√º“à μ¥— ¡°— „Àâ„π√–¬–‡«≈“ π—È Ê∂“â ‡ªπì °“√º“à μ¥— ‡≈°Á Õ“®„À⬓‡æ’¬ß§√ßÈ— ‡¥¬’ « ·μà∂“â ‡ªπì °“√º“à μ—¥„À≠àÕ“®„À⬓‰¡‡à °‘π 3-7 «—π °“√‡≈Õ◊ °™π¥‘ ¢Õ߬“®ß÷ §«√‡≈Õ◊ °¬“ ∑’¡Ë ª’ √– ‘∑∏‘¿“æ „™âßà“¬ ÕÕ°ƒ∑∏Ï‘‡√Á« ·≈–¡’¿“«–·∑√°´Õâ ππâÕ¬ §«√‡≈◊Õ°„™â¬“‡æ’¬ß¢π“π‡¥’¬«„π°“√„™â¬“ ·μà≈–§√—Èß ·≈–À≈°’ ‡≈’¬Ë ß°“√„™¬â “À“°ºâªŸ É«¬¡’ª√–«μ— °‘ “√·æ⬓„π°≈ÿà¡ NSAIDs ¢π“¥·≈–«∏‘ ∫’ √À‘ “√¬“ ª√‘¡“≥°“√„™â¬“®”‡ªπì μÕâ ߪ√—∫„À‡â À¡“– ¡°—∫ºªâŸ É«¬·μà≈–√“¬ ‚¥¬¥®Ÿ “° °“√μÕ∫ πÕߢÕߺ⟪ɫ¬‡ªìπÀ≈—° °“√„À⬓§«√„Àâμ“¡™à«ß‡«≈“∑Ë’°”Àπ¥®–√–ß—∫ª«¥‰¥â¥’°«à“„À⬓‡¡◊ËÕºŸâªÉ«¬ ¡’Õ“°“√ª«¥·≈â« «‘∏’∫√‘À“√¬“¢È÷π°—∫™π‘¥°“√ºà“μ—¥ «‘∏’°“√√–ß—∫ª«¥„π°“√ºà“μ—¥ ·≈–√Ÿª·∫∫¢Õ߬“∑’Ë¡’„™â *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ≤— π“°“√√–ß—∫ª«¥πÈ’‰¡à„™¢à âÕ∫—ߧ∫— ¢Õß°“√ªØ∫‘ μ— ‘ *** 17

 ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Àßà ª√–‡∑»‰∑¬ ´ß÷Ë ·∫ßà ÕÕ°‡ªπì °“√©¥’ ‡ªìπ«‘∏’°“√∫√‘À“√¬“∑Ë’‰¥ºâ ≈¥∑’ ’Ë ¥ÿ ¡’∑È—ß©’¥‡¢“â À≈Õ¥‡≈Õ◊ ¥¥”·≈–©’¥‡¢â“°≈â“¡ °“√©¥’ ‡¢â“°≈â“¡ ‡ªπì «∏‘ ∑’ Ë’„™¡â “°∑’Ë ¥ÿ ‡πÕË◊ ß®“°¬“ à«π„À≠ºà ≈μ‘ ¡“„π√ªŸ ¢Õ߬“©’¥‡¢“â °≈â“¡ ·μ¢à âÕ‡ ¬’ §◊Õª«¥¢≥–©’¥¬“ ®ß÷ ‰¡à ‡À¡“– ”À√—∫°“√„™â„π‡¥Á° ¬“∑’ Ë “¡“√∂„™â«‘∏©’ ¥’ ‰¥â·°à diclofenac, ketoprofen, ketorolac, piroxicam, tenoxicam ·≈– parecoxib °“√√∫— ª√–∑“𠇪πì «∏‘ ∑’ Ë’„™ßâ “à ¬·≈–√∫°«πºªŸâ «É ¬πÕâ ¬∑ ’Ë ¥ÿ NSAIDs  «à π„À≠ à “¡“√∂„™«â ∏‘ √’ ∫— ª√–∑“π‰¥â  ”À√∫— ºªŸâ É«¬À≈—ߺ“à μ¥— ∑Ë’¡Õ’ “°“√§≈Ëπ◊ ‰ âÕ“‡®¬’ π À√◊Õ®”‡ªπì μâÕßߥՓÀ“√·≈–π”È ®–‰¡ à “¡“√∂„™â«∏‘ π’ ’È‰¥â °“√‡ÀπÁ∫∑«“√ ‡ªìπ«‘∏’∑Ë’‡À¡“– ”À√—∫‡¥Á° „πºâŸªÉ«¬ºâŸ„À≠àÕ“®‰¡à™Õ∫«‘∏’π’È·≈–Õ“®‡°‘¥ªí≠À“°“√ Õ—°‡ ∫¢Õß∑«“√Àπ°— (‡¡◊Õ߉∑¬‰¡¡à ’¬“‡ÀπÁ∫∑«“√) º≈¢“â ߇§’¬ß º≈¢“â ߇§¬’ ߢÕß NSAIDs  «à π„À≠à®–æ∫¡“°„π°√≥∑’ Ë’„™âμÕà ‡πÕ◊Ë ß√–¬–¬“« °“√„™â‡æÕË◊ √–ß∫— ª«¥À≈—ß º“à μ¥— ‡ªπì °“√„™â„π™«à ß πÈ— Ê ·μ°à ¬Á ß— æ∫º≈¢“â ߇§¬’ ߉¥â ‡™πà √–∫∫∑“߇¥π‘ Õ“À“√ Õ“®∑”„À‡â °¥‘ °“√√–§“¬‡§Õ◊ ß μÕà °√–‡æ“–Õ“À“√ ‚¥¬‡©æ“–„πºŸ â ŸßÕ“¬ÿ∑’ˇ§¬¡’·º≈„π°√–‡æ“–Õ“À“√ À√Õ◊ ‡§¬μ°‡≈Õ◊ ¥„π°√–‡æ“–Õ“À“√ À√◊Õ°”≈—߉¥â√∫— ¬“ ‡μ’¬√Õ¬¥å ®–¡’‚Õ°“ ‡°‘¥º≈¢“â ߇§¬’ ßπÈ’‰¥â ¬“„π°≈à¡ÿ COX-2 specific inhibitors ∑”„Àâ ‡°‘¥¿“«–·∑√°´âÕπμàÕ√–∫∫πÈ’πÕâ ¬°«“à °≈ÿ¡à conventional NSAIDs19 º≈μÕà ‰μ º≈¢Õß conventional NSAIDs ·≈– COX-2 specific inhibitors μàÕ°“√∑”ß“π¢Õß‰μ·ª√ μ“¡ª√‘¡“≥·≈–√–¬–‡«≈“¢Õß°“√„™¬â “ ‡¡◊ÕË À¬ÿ¥°“√„™â¬“ ƒ∑∏Ï‘¢Õ߬“°®Á –À¡¥‰ª¥â«¬ „πºâŸªÉ«¬∑Ë°’ “√∑”ß“π ¢Õß‰μª°μ‘  «à π„À≠®à –‰¡‡à °¥‘ º≈¢“â ߇§¬’ ß®“°°“√„™¬â “20 ·μ∂à “â °“√∑”ß“π¢Õ߉μ∫°æ√Õà ß ¡°’ “√‡ ¬’ ‡≈Õ◊ ¥¡“° À√Õ◊ ¡’¿“«–¢“¥πÈ” ·≈–„πºªŸâ É«¬ ŸßÕ“¬Õÿ “®∑”„À°â “√∑”ß“π¢Õ߉μ∫°æ√Õà ßÀ√Õ◊ ‡°‘¥¿“«–‰μ«“¬‡©¬’ ∫æ≈π— ‰¥â º≈μÕà √–∫∫°“√·¢ßÁ μ—«¢Õ߇≈Õ◊ ¥ ‡πË◊Õß®“°¬“°≈ÿ¡à conventional NSAIDs ¡’ƒ∑∏¬Ï‘ —∫¬ß—È °“√‡°“–μ«— ¢Õß ‡°≈¥Á ‡≈Õ◊ ¥´ßË÷ Õ“»¬— ‡Õπ‰´¡å COX-1 ‡ªπì À≈°— ∑”„Àºâ ªâŸ «É ¬∫“ß°≈¡àÿ ‡™πà ºªŸâ «É ¬º“à μ¥— °√–¥°Ÿ ºªâŸ «É ¬º“à μ¥— ∑Õπ´≈‘ ºâŸªÉ«¬ºà“μ—¥ ¡Õß ºŸâªÉ«¬∑’ˉ¥â√—∫¬“μâ“π°“√·¢Áßμ—«¢Õ߇≈◊Õ¥¡“°àÕπ ‡¡Ë◊Õ‰¥â√—∫¬“·°âª«¥°≈àÿ¡ conventional NSAIDs ®–¡’‚Õ°“ ‡≈Õ◊ ¥ÕÕ°‰¥ßâ “à ¬21 „π¢≥–∑Ë°’ ≈¡ÿà COX-2 specific inhibitors ¡’‚Õ°“ ∑Ë’®–∑”„À⇰‘¥ thrombosis ¥—ßππÈ— §«√‡≈’¬Ë ß°“√„™¬â “°≈¡àÿ COX-2 specific inhibitors „πºŸªâ É«¬∑’˺“à μ¥— ‡°¬’Ë «°∫— À≈Õ¥‡≈◊Õ¥ ¢ÕßÀ—«„®·≈– ¡Õß22 º≈μàÕ√–∫∫°“√À“¬„®·≈–¿Ÿ¡‘·æâ °“√„™â¬“ conventional NSAIDs „πºâŸªÉ«¬∑’Ë¡’ª√–«—μ‘ÀÕ∫À◊¥À√◊Õ ‚√§¿Ÿ¡‘·æâÕ“®∑”„À⇰‘¥Õ“°“√ÀÕ∫À◊¥‰¥â ºâŸªÉ«¬∑’Ë¡’ª√–«—μ‘ aspirin-exacerbated respiratory disease Àâ“¡„™¬â “ conventional NSAIDs √–ß—∫ª«¥ ·μà„™â°≈¡ÿà COX-2 specific inhibitors ‰¥2â 3 NSAIDs ∑—Èß 2 °≈ÿà¡ ¡ª’ √– ‘∑∏‘¿“楒„π°“√√–ß∫— ª«¥À≈ß— º“à μ¥— Õ’°∑ßÈ— ‡¡◊ÕË „™â√«à ¡°∫— ¬“°≈àÿ¡ opioid °Á ®–‡ √‘¡ƒ∑∏‘Ï„π°“√√–ß∫— ª«¥¡“°¢÷πÈ ·≈–≈¥º≈¢“â ߇§’¬ß¢Õß opioid ‡æ√“–„™â opioid πâÕ¬≈ß24,25 ·μºà ≈¢“â ß ‡§’¬ß¢Õß NSAIDs ∑È—ß 2 °≈ÿ¡à °Á‡ªìπ¢âÕ®”°¥— „π°“√„™â¬“ μÕâ ß„™¥â «â ¬§«“¡√–¡¥— √–«—ß·≈–‡≈Ë’¬ß°“√„™â„π°≈ÿà¡ ‡ Ë’¬ß∑—ÈßÀ≈“¬ 18 *** ¢Õâ ·π–π”μ“à ßÊ „π·π«∑“ßæ≤— π“°“√√–ß∫— ª«¥π’ȉ¡à„™¢à Õâ ∫ß— §∫— ¢Õß°“√ªØ‘∫μ— ‘ ***

3. Opioids ‡ªìπ¬“∑’Ë„™â„π°“√√–ß—∫ª«¥√ÿπ·√ß ·μà¡’º≈‰¡àæ÷ߪ√– ß§å‰¥â (¥Ÿ√“¬≈–‡Õ’¬¥°≈àÕß∑Ë’ 7) opioid ·∫ßà ÕÕ°‡ªìπ 2 °≈ÿà¡ §Õ◊ opioid ∑Ë’¡ƒ’ ∑∏ÕÏ‘ Õà π·≈–∑¡’Ë ’ƒ∑∏·‘Ï √ß A. Opioids ∑Ë¡’ ƒ’ ∑∏ÏÕ‘ àÕπ A1. Codeine Codeine ‡ªìπμâπ·∫∫¢Õß opioid ∑’Ë¡ƒ’ ∑∏Ï‘ÕÕà π5 ∂Ÿ°¥¥Ÿ ´¡÷ ‰¥â¥®’ “°∑“߇¥π‘ Õ“À“√ ¡§’ «“¡ ·√߇ªπì 1/10 ¢Õß morphine26 ª√–¡“≥√Õâ ¬≈– 10 ¢Õß codeine ∂Ÿ°‡ª≈’¬Ë π√ªŸ ∑’Ëμ—∫ ‰¥‡â ªìπ morphine27 ¢π“¥¬“∑Ë’„™§â Õ◊ 30-120 ¡°. „À´â ”È ‰¥∑â °ÿ 4 ™«Ë— ‚¡ß26 °“√„À¬â “√«à ¡°π— √–À«“à ß codeine 60 ¡°. °∫— paracetamol 600-1,000 ¡°. „Àâº≈√–ß—∫ª«¥∑’¥Ë °’ «à“ paracetamol Õ¬“à ߇¥¬’ «28 °“√√–ß∫— ª«¥®“° codeine ¢÷Èπ°—∫¢π“¥¬“∑’ˉ¥â√—∫28 ·μà‰¡§à «√„™â¬“‡°‘π°«à“¢π“¥∑Ë’·π–π” ‡πË◊Õß®“°®–‡°¥‘ º≈¢“â ߇§’¬ß‡æË‘¡¢Èπ÷ ´÷Ë߉¥â·°à ∑Õâ ߺŸ° §≈◊Ëπ‰ âÕ“‡®’¬π ·≈– ∫—  π A2. Tramadol Tramadol ‡ªì𬓷°ªâ «¥∑’ËÕÕ°ƒ∑∏ºÏ‘ à“π 2 °≈‰° °≈‰°·√°§◊Õ ®∫— °—∫ μ-opioid receptor  «à π°≈‰°∑Ë’ 2 §◊Õ ¬—∫¬—Èß°“√π”°≈—∫¢Õß serotonin ·≈– norepinephrine „π√–∫∫ª√– “∑ à«π°≈“ß29,30 ƒ∑∏Ï‘√–ß∫— ª«¥  à«π„À≠à¢Õß tramadol º“à π¡“∑“ß°≈‰°∑’Ë 2 tramadol ¡§’ «“¡·√߇ªìπ 1/20-1/5 ¢Õß mor- phine º≈¢â“߇§¬’ ß∑Ëæ’ ∫∫Õà ¬¢Õß tramadol §◊Õ §≈π◊Ë ‰ âÕ“‡®¬’ π26  «à πº≈¢â“߇§¬’ ßÕË◊πæ∫‰¥πâ âÕ¬ ‡™àπ °¥°“√ À“¬„®·≈–∑âÕߺŸ°26,31 ¢π“¥¬“∑·Ë’ π–π”„Àâ„™§â ◊Õ 50-100 ¡°. „À´â ”È ‰¥∑â °ÿ 4 ™Ë«— ‚¡ß26 ·μà‰¡à§«√‡°‘π 400 ¡°. μÕà «—π ·≈–„πºªâŸ «É ¬∑Ë’¡’ªí≠À“¢Õßμ—∫À√Õ◊ ‰μ§«√≈¥¢π“¥≈ß ‚¥¬„Àâ‰¡à‡°‘π 200 ¡°. μÕà «π— B. Opioids ∑¡Ë’ ’ƒ∑∏‘Ï·√ß Opioids ∑¡’Ë ’ƒ∑∏‘·Ï √ß ‰¥â·°à morphine, pethidine ·≈– fentanyl ¬“„π°≈¡ÿà πÈ’∑ÿ°μ—«„Àºâ ≈°“√ √–ß—∫ª«¥‡∑à“°—π∂â“„Àâ„π¢π“¥∑‡’Ë √’¬°«à“ çequianalgesic doseé (μ“√“ß∑Ë’ 4) ®ß÷ §«√ª√∫— ¢π“¥¬“ opioids „Àâ‡À¡“– ¡°—∫ºªŸâ «É ¬·μ≈à –√“¬ ‡™πà ª√∫— μ“¡ Õ“¬ÿ ‚√§μ“à ßÊ ∑Ë’ºªâŸ É«¬‡ªπì ¬“μ“à ßÊ ∑’ºË Ÿªâ «É ¬‰¥√â ∫— ·≈–«∏‘ ’ °“√„À¬â “ ”À√∫— ºªâŸ «É ¬Õ“¬μÿ ß—È ·μà 20 ª¢ï π÷È ‰ª §«√§¥‘ ¢π“¥¬“ morphine μ“¡Õ“¬¥ÿ °’ «“à §¥‘ μ“¡πÈ”Àπ°— μ«— 3 ‡æ√“– §«“¡μâÕß°“√ morphine ¡’§«“¡·μ°μà“ß°—π¡“°„π·μà≈–™à«ßÕ“¬ÿ (Õ“® Ÿß∂÷ß 10 ‡∑à“) „πºâŸ ŸßÕ“¬ÿ§«“¡ μÕâ ß°“√¢π“¥¢Õß morphine ≈¥≈ß·≈–√–¬–‡«≈“°“√ÕÕ°ƒ∑∏π‘Ï “π¢π÷È  «à π„πºªŸâ «É ¬‡¥°Á §«√„™πâ È”Àπ°— μ«— ‡ªπì μ—«°”Àπ¥¢π“¥¢Õß morphine μ“√“ß∑Ë’ 4 Equianalgesic doses of opioids5 ™π‘¥©¥’ (Parenteral) Opioids 10 mg Morphine 100 mg Pethidine Fentanyl 100 microgram Tramadol 100 mg *** ¢Õâ ·π–π”μ“à ßÊ „π·π«∑“ßæ≤— π“°“√√–ß—∫ª«¥πÈ’‰¡à„™¢à âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 19

 ¡“§¡°“√»°÷ …“‡√◊ÕË ß§«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ À≈ß— ‰¥â√∫— opioids §«√¡’°“√μ‘¥μ“¡ª√–‡¡π‘ º≈°“√μÕ∫ πÕߢÕߺŸâªÉ«¬ ‡æÕ◊Ë ª√—∫¢π“¥·≈– §«“¡∂’ËÀà“ߢÕß°“√∫√‘À“√¬“ opioids „Àâ‡À¡“– ¡°—∫ºâŸªÉ«¬·μà≈–√“¬3 √«¡∑ȗߪ√–‡¡‘πÕ“°“√·∑√°´âÕπ∑’Ë Õ“®‡°‘¥®“° opioids ¥«â ¬ μ“¡§”·π–π”„π·ºπ¿Ÿ¡‘∑’Ë 2, 3 ·≈– 4 B1. Morphine Morphine ‡ªìπ opioid ¡“μ√∞“π  “¡“√∂∫√À‘ “√‰¥Àâ ≈“¬∑“ß morphine ∑’Ë∫√À‘ “√¥«â ¬«‘∏’ ©’¥‡¢â“À≈Õ¥‡≈◊Õ¥¥” °≈â“¡‡πÈ◊Õ ·≈–„μºâ ‘«Àπ—ß ¡√’ –¬–‡«≈“°“√‡√Ë¡‘ ÕÕ°ƒ∑∏Ï‘ ¥—ßπ’È 5-20 π“∑,’ 20-60 π“∑’ ·≈– 20-60 π“∑’ μ“¡≈”¥—∫ morphine ¡√’ –¬–‡«≈“°“√ÕÕ°ƒ∑∏Ï‘π“π 2-4 ™¡. Morphine ∂°Ÿ ∑”≈“¬∑μË’ ∫— ‰¥‡â ªπì morphine-3-glucuronide (M3G) ·≈– morphine-6-glu- curonide (M6G) ´Ë÷ß M6G ¡ƒ’ ∑∏‘Ï„π°“√√–ß∫— ª«¥‡™àπ‡¥’¬«°∫— morphine °“√∑”≈“¬¢Õß morphine ∑μË’ ∫— Õ“®¡’°“√‡ª≈’ˬπ·ª≈ß„π°√≥’∑’Ë°“√∑”ß“π¢Õßμ—∫∫°æ√àÕßÕ¬à“ß√ÿπ·√ß  à«π°“√∑”ß“π¢Õ߉μ∑’Ë∫°æ√àÕß®– ∑”„Àâ°”®¥— morphine ·≈– metabolites (M6G) ÕÕ°®“°√à“ß°“¬‰¡à‰¥â ®÷ßÕ“®¡º’ ≈°¥°“√À“¬„®‰¥3â 2 B2. Pethidine ‡ªπì opioid  ß— ‡§√“–À∑å ¡Ë’ ƒ’ ∑∏‘Ï anticholinergic √«à ¡¥«â ¬§Õ◊ Õ“®∑”„ÀÀâ «— „®‡μπâ ‡√«Á ª“°§Õ·Àßâ pethidine ¡§’ à“§√Ëß÷ ™’«‘μ 2-2.5 ™¡. ·≈–√–¬–‡«≈“°“√ÕÕ°ƒ∑∏Ï‘ 2-4 ™¡. pethidine ∂Ÿ°∑”≈“¬∑’μË —∫‰¥â meta- bolite ∑Ë’ ”§—≠ §◊Õ norpethidine ´÷ËßÕÕ°ƒ∑∏‘Ï°√–μÿâπ√–∫∫ª√– “∑ à«π°≈“ßÕ¬à“ß¡“° ∑”„À⇰‘¥Õ“°“√ °√– —∫°√– à“¬ ¡◊Õ —Ëπ °≈“â ¡‡πÈ◊Õ‡°√ßÁ °√–μÿ° ·≈–™—°‰¥â ®÷߉¡à§«√„™â pethidine „πºâªŸ «É ¬∑Ë¡’ ’°“√∑”ß“π¢Õß ‰μÀ√Õ◊ μ∫— ∫°æ√àÕß32 B3. Fentanyl ‡ªπì opioid  —߇§√“–Àå ÕÕ°ƒ∑∏‘χ√«Á ¿“¬„π 2-3 π“∑À’ ≈ß— ©¥’ ‡¢â“À≈Õ¥‡≈Õ◊ ¥¥” √–¬–‡«≈“ °“√ÕÕ°ƒ∑∏ Ï‘ π—È ª√–¡“≥ 30-60 π“∑’ fentanyl ∂°Ÿ ∑”≈“¬∑μË’ ∫— ‰¥‡â ªπì norfentanyl ·≈–∂°Ÿ ¢∫— ÕÕ°∑“ߪ í  “«– ‚¥¬¡¬’ “∫“ß à«π (‰¡à‡°π‘ √Õâ ¬≈– 7) ∂°Ÿ ¢∫— ÕÕ°∑“ßªí  “«–‚¥¬‰¡à‡ª≈¬’Ë π√Ÿª32 4. Local anesthetics (¬“™“) ¬“™“ÕÕ°ƒ∑∏‘¬Ï —∫¬Èß— ∑Ë’ sodium channels ∑’˺π—߇´≈≈å¢Õ߇ âπª√– “∑ ®ß÷ ¢¥— ¢«“ß°“√°√–μâπÿ °“√ ‡°‘¥ depolarization ·≈–°“√π”ª√– “∑ ∑”„À≈â ¥Õ“°“√ª«¥‰¥â °“√‡≈◊Õ°„™â¬“™“μâÕß∑√“∫¢π“¥ ßŸ  ¥ÿ ∑’Ë„™â‰¥ªâ ≈Õ¥¿—¬ √–¬–°“√ÕÕ°ƒ∑∏Ï‘ «‘∏°’ “√„Àâ ‡™àπ °“√æàπ °“√©’¥¬“™“‡©æ“–∑Ë’ ©’¥∑Ë’‡ âπª√– “∑ ©’¥‡¢â“À≈Õ¥‡≈◊Õ¥¥”∑’Ë·¢πÀ√◊Õ¢“ ©’¥∑“ß spinal ·≈– epidural ¬“™“∑Ë¡’ ’„™â∫àÕ¬33,34 ·∫ßà μ“¡√–¬–‡«≈“°“√ÕÕ°ƒ∑∏§Ï‘ Õ◊ 1. ¬“™“°≈¡ÿà ÕÕ°ƒ∑∏ Ï‘ π—È „™∑â «Ë— ‰ª„π°“√≈¥ª«¥‡©¬’ ∫æ≈π— ∑¡’Ë ’„™â„πª®í ®∫ÿ π— ‰¥·â °à lignocaine (lidocaine) ·≈– prilocaine (prilocaine ¡’„™πâ âÕ¬¡“° ‡æ√“–Õ“®∑”„À⇰‘¥ methemoglobinemia ∂“â „™‡â °‘π¢π“¥ §◊Õ 600 ¡°.) Lidocaine ÕÕ°ƒ∑∏Ï‘‰¥‡â √«Á ®∫— °∫— ‚ª√μπ’ πÕâ ¬®ß÷ ¡√’ –¬–‡«≈“ÕÕ°ƒ∑∏ Ï‘ πÈ— √–¬–‡«≈“∑ÕË’ Õ°ƒ∑∏¢‘Ï π÷È Õ¬°àŸ ∫— «‘∏’°“√„Àâ ∫√‡‘ «≥∑Ë’„Àâ·≈–¢π“¥¬“ °“√„Àâ lidocaine ‚¥¬°“√À¬¥μÕà ‡πËÕ◊ ß (infusion) „πºŸªâ «É ¬∑Ë’¡§’ «“¡ ª«¥‡©¬’ ∫æ≈π— Õ“®æ∫¡’¿“«–¥ÕÈ◊ ¬“ (tachyphylaxis) ®ß÷ ‰¡§à «√„™â 20 *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ≤— π“°“√√–ß∫— ª«¥π’ȉ¡à„™¢à Õâ ∫ß— §∫— ¢Õß°“√ªØ‘∫—μ‘ ***

2. ¬“™“°≈¡ÿà ÕÕ°ƒ∑∏‘¬Ï “« ‰¥·â °à bupivacaine, levobupivacaine ·≈– ropivacaine ´ßË÷ ¡§’ «“¡‡°¬Ë’ «¢Õâ ß°π— §Õ◊ bupivacaine ‡ªìπ¬“∑’Ë¡’ à«πº ¡¢Õß racemic ∑—Èß S-enantiomer ·≈– R-enantiomer  à«π levobupivacaine ·≈– ropivacaine ‡ªπì S-enantiomer ¢Õß bupivacaine ‡¡◊ËÕ„Àâ„π¢π“¥∑Ë∑’ ”„À⇠âπª√– “∑™“∑’ˇ∑“à °π— æ∫«à“ S-enantiomer ¢Õ߬“™“¡º’ ≈μÕà √–∫∫ª√– “∑ «à π°≈“ß·≈–‡ªπì æ…‘ μÕà À«— „®πÕâ ¬°«“à ¬“™“∑‡’Ë ªπì R-enantio- mer À√◊Õ¬“™“∑¡’Ë  ’ «à πº ¡ racemic °“√©¥’ bupivacaine „π¢π“¥ ßŸ ·∫∫‰¡àμÈ—ß„®‡¢“â À≈Õ¥‡≈◊Õ¥¡º’ ≈°¥°≈â“¡‡πÕÈ◊ À«— „®Õ¬à“ß√ÿπ·√ß ·≈–¡’ ventricular fibrillation ™π‘¥¬“°μàÕ°“√√—°…“ ´÷Ë߇°‘¥‡æ√“–°“√ ≈“¬μ—«¢Õß bupivacaine ®“° sodium channel ¢Õß°≈“â ¡‡πÈ◊ÕÀ«— „®‡ªìπ‰ªÕ¬à“ß™â“Ê ∑”„Àâ bupivacaine ¡’æ…‘ ¡“°°«“à levobupivacaine ·≈– ropivacaine35 º≈¢â“߇§¬’ ߢÕ߬“™“ 1. ªØ‘°√‘ ‘¬“¿¡Ÿ ‘·æâ æ∫„𬓙“°≈ÿà¡ ester ®“° “√ para aminobenzoic acid Õ“°“√ºËπ◊ §—π ∫«¡ À“¬„®≈”∫“° À≈Õ¥≈¡‡°√Áß §«“¡¥π— ‡≈◊Õ¥μË” À«— „®À¬¥ÿ ‡μâπ 2. æ‘…®“°¬“™“‡°‘¥‡¡Ë◊Õ„À⇰‘π¢π“¥À√◊Õ©’¥‡¢â“À≈Õ¥‡≈◊Õ¥‚¥¬‰¡àμ—Èß„® º≈μàÕ√–∫∫ª√– “∑ à«π°≈“ß ‡√Ë‘¡®“°«‘߇«¬’ π ÀŸÕÕÈ◊ ™“√Õ∫ª“°·≈–≈‘Èπ μ“æ√à“ °≈“â ¡‡πÕÈ◊ °√–μÿ° ·≈â«´÷¡ À¡¥ μ‘ À¬¥ÿ À“¬„® º≈μÕà √–∫∫ À«— „®·≈–À≈Õ¥‡≈◊Õ¥ §Õ◊ ¢¬“¬À≈Õ¥‡≈◊Õ¥·≈–°¥°≈“â ¡‡πÕÈ◊ À—«„®‡¡ÕË◊ „™¬â “„π¢π“¥ ßŸ «‘∏°’ “√„™â¬“™“„π°“√√–ß—∫ª«¥‡©’¬∫æ≈π— 1. °“√„™¬â “‡©æ“–∑’Ë (topical anesthesia) EMLA cream (eutectic mixture of local anesthetics) ‡ªπì ¬“™“¡≈’ °— …≥–‡ªπì §√¡’ ∑º’Ë  ¡√–À«“à ß 2.5% lidocaine ·≈– 2.5% prilocaine 𬑠¡∑“„ÀÀâ π“∑º’Ë «‘ Àπß— ‡æÕ◊Ë ≈¥ª«¥®“°°“√·∑߇¢¡Á ‡ª¥î À≈Õ¥‡≈Õ◊ ¥¥” ·π–π”„Àâ„™â 1-2 °√—¡μÕà æπ◊È ∑º’Ë ‘« 10 μ√.´¡. ‡√Ë¡‘ ÕÕ°ƒ∑∏‘Ï„π 45-60 π“∑’ √–¬–‡«≈“§ßƒ∑∏Ï‘π“π 1-2 ™¡. 2-4% lidocaine, 4-10% cocaine „™æâ àπ À√Õ◊ ∑“∫√‘‡«≥‡¬◊ËÕ‡¡◊Õ° ‡™àπ „π°“√ºà“μ¥— ™Õà ß®¡°Ÿ ·≈–™àÕߪ“° ‡æÕË◊ „À™â “ ·≈–≈¥Õ“°“√ª«¥®“°°“√∑”Àμ— ∂°“√ 2. °“√©’¥¬“™“‡©æ“–∑’Ë (local infiltration) „™¬â “™“ 0.5-1% lidocaine, 0.25% bupivacaine, À√Õ◊ 0.2-0.5% ropivacaine ©¥’ ¬“∑Ë’º‘«Àπ—ß ∫√‡‘ «≥∑Ë∑’ ”°“√º“à μ¥— À√◊Õ‡¬Á∫·º≈ 3. °“√©’¥¬“™“∑’ˇ âπª√– “∑ (peripheral nerve block) ‡ªπì °“√©¥’ ¬“„°≈‡â  πâ ª√– “∑∑Ë’‰ª‡≈¬È’ ß∫√‡‘ «≥º“à μ¥— ‡™πà brachial plexus block, intercostal nerve block, femoral nerve block ‚¥¬‡ âπª√– “∑°≈¡àÿ „À≠à®”‡ªπì μÕâ ß„™â¬“¡“°¢πÈ÷ ·μàμÕâ ߉¡à‡°‘π¢π“¥∑’°Ë ”Àπ¥ ¬“™“∑Ë’„™â‰¥â·°à 1-1.5% lidocaine, 0.25-0.5% bupivacaine ·≈– 0.5-1% ropivacaine 4. °“√©’¥¬“™“‡¢â“À≈Õ¥‡≈◊Õ¥¥”∑Ë·’ ¢πÀ√◊Õ¢“ (intravenous regional anesthesia) °“√©¥’ ¬“™“∑“ß spinal ·≈– epidural  à«π„À≠à„™â„π°“√∑”º“à μ—¥ ¬°‡«πâ epidural analgesia ∑Ë’„™â√–ß—∫ª«¥À≈ß— ºà“μ—¥‰¥â ¥â«¬ °“√©’¥¬“™“¥«â ¬‡∑§π‘§‡À≈à“π’‡È ªìπÀμ— ∂°“√∑Ëμ’ âÕßÕ“»—¬§«“¡™”π“≠ ´ß÷Ë ®–‰¡°à ≈“à «∂÷ß„π∑’Ëπ’È *** ¢Õâ ·π–π”μ“à ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥πÈ’‰¡à„™à¢Õâ ∫ß— §∫— ¢Õß°“√ªØ‘∫—μ‘ *** 21

 ¡“§¡°“√»°÷ …“‡√ÕË◊ ߧ«“¡ª«¥·Àßà ª√–‡∑»‰∑¬ 5. ¬“ÕË◊πÊ ∑Ë’¡’ƒ∑∏‘χ √¡‘ °“√√–ß—∫ª«¥ (Adjuvants) ‡ªπì ¬“∑Õ’Ë “®π”¡“„™‡â  √¡‘ ƒ∑∏°Ï‘ “√√–ß∫— ª«¥√«à ¡°∫— ¬“·°ªâ «¥À≈°— ∑°Ë’ ≈“à «¡“¢“â ßμπâ ‰¡·à π–π”„Àℙ⠬“„π°≈¡ÿà π‡’È æ¬’ ß≈”æß— ‡æ√“–‰¡ à “¡“√∂√–ß∫— ª«¥‰¥‡â 欒 ßæÕ¬“„π°≈¡àÿ πÈ’‰¥·â °à N-methyl-D-aspartate (NMDA) receptor antagonists (‰¥·â °à ketamine36,37 ·≈– dextromethorphan37,38), antidepressant, anticonvul- sant (gabapentin)39, membrane stabilizers (lidocaine), alpha-2 agonists (clonidine ·≈– dexme- detomidine)38,40 °“√‡≈◊Õ°„™â¬“„π°≈àÿ¡πÈ’‡æ◊ËÕ„™â√à«¡„π°“√√–ß—∫ª«¥·∫∫‡©’¬∫æ≈—ππ—Èπ μâÕßæ‘®“√≥“∂÷ß ª√– ∑‘ ∏‘¿“æ §«“¡‡À¡“– ¡ §«“¡®”‡ªπì ¢Õâ ¥’ ·≈–¢âÕ‡ ’¬¢Õ߬“√à«¡¥«â ¬ μ“√“ß √ªÿ °“√√–ß—∫ª«¥‡©’¬∫æ≈π— μ“√“ß∑’Ë 5 · ¥ß√“¬≈–‡Õ¬’ ¥°“√√–ß∫— ª«¥‡©¬’ ∫æ≈π— ‚¥¬„™¬â “ μ“√“ß∑’Ë 6 · ¥ß√“¬≈–‡Õ’¬¥°“√√–ß∫— ª«¥‡©’¬∫æ≈π— ‚¥¬‰¡à„™â¬“ 22 *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß∫— ª«¥πÈ’‰¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ∫‘ —μ‘ ***

*** ¢âÕ·π–π”μ“à ßÊ „π·π«∑“ßæ≤— π“°“√√–ß∫— ª«¥πÈ’‰¡à„™¢à Õâ ∫ß— §—∫¢Õß°“√ªØ‘∫μ— ‘ *** μ“√“ß∑Ë’ 5 √“¬≈–‡Õ¬’ ¥°“√√–ß∫— ª«¥‡©¬’ ∫æ≈π— ‚¥¬„™¬â “ (‡√’¬ßμ“¡Õ°— …√) ¬“ √“¬≈–‡Õ’¬¥·≈–¢âÕ∫àß™’È ¢Õâ §«√√–«ß— /¢Õâ À“â ¡ Õ“°“√·∑√°´âÕπ ¢π“¥¬“„π‡¥°Á ¢π“¥¬“„πºâŸ„À≠à Bupivacaine ‡ªì𬓙“°≈àÿ¡ amide, - ¡’ cardiotoxicity §àÕπ¢“â ß Toxicity: ¡’Õ“°“√ - Infiltration/Epidural: - Infiltration/Epidural: „™â ”À√∫— local infiltration,  ßŸ °«“à ¬“™“™π¥‘ ÕË◊π ™“≈πÈ‘ √Õ∫ª“° ¢π“¥·π–π” 2 mg/kg, 4-hourly epidural block ·≈– - ‰¡à§«√„™â∑” IV regional °√–«π°√–«“¬ 2 mg/kg, 4-hourly - Max dose ¢πÈ÷ °∫— spinal anesthesia analgesia ÀÕŸ Õ◊È ™°— À«— „®À¬¥ÿ ‡μπâ - Max dose ¢÷Èπ°—∫ μ”·Àπàß∑Ë’©’¥ duration 200-400 π“∑’ - ¡°’ “√º ¡ adrenaline μ”·Àπßà ∑©Ë’ ’¥ - „πª√–‡∑»‰∑¬¡ ’ “√≈–≈“¬ 0.25-0.5% Celecoxib NSAIDs ∑’ˬ∫— ¬ßÈ— ®”‡æ“– - ·æâ sulfonamide À√◊Õ - ‰¡·à π–π”„Àâ„™â - PO: 400 mg initially μàÕ Cyclooxygenase-II (COX-II) aspirin ¥«â ¬ 200 mg od À√◊Õ bid ≈¥º≈¢“â ߇§’¬ßμàÕ√–∫∫∑“ß - ‰μ«“¬Õ¬à“ß√πÿ ·√ß ‡¥‘πÕ“À“√ Õ“°“√À≈Õ¥≈¡ - ·º≈„π°√–‡æ“–Õ“À“√ μ∫’ ·≈–‡°≈¥Á ‡≈Õ◊ ¥ - ‚√§À≈Õ¥‡≈◊Õ¥À—«„®·≈–‚√§ À≈Õ¥‡≈◊Õ¥ ¡Õß - À≈—ß°“√º“à μ¥— CABG/Stent - À≠‘ß¡§’ √√¿å „Àâπ¡∫ÿμ√ Codeine Opioid ∑ÕË’ Õ°ƒ∑∏‘ÕÏ àÕπ §≈π◊Ë ‰ Õâ “‡®¬’ π - PO: 1 mg/kg, - PO: 30-60 mg, 4-hourly „™ â ”À√∫— Õ“°“√ª«¥‡≈°Á πÕâ ¬ ßà«ß´÷¡  —∫ π ‡Õ–Õ– 6-hourly - Max dose 240 mg/day ∂ß÷ ª«¥ª“π°≈“ß ‚«¬«“¬ - Max dose 3 mg/kg/ ∑Õâ ߺ°Ÿ day Codeine ¥Ÿ paracetamol ·≈– °“√‡æË‘¡¢π“¥‚¥¬°“√‡æË¡‘ ¥Ÿ paracetamol ·≈– - ¥Ÿ paracetamol ·≈– 15/30 mg + codeine ®”π«π‡¡¥Á ¬“ Õ“®∑”„À¬â “μ«— „¥ codeine codeine Paracetamol μ—«ÀπË÷߇°‘π¢π“¥‰¥â 23 300 mg

 ¡“§¡°“√»°÷ …“‡√ÕË◊ ߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬μ“√“ß∑’Ë 5 √“¬≈–‡Õ’¬¥°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬„™¬â “ (‡√’¬ßμ“¡Õ—°…√) (μÕà ) 24 *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™¢à Õâ ∫ß— §∫— ¢Õß°“√ªØ∫‘ μ— ‘ *** ¬“ √“¬≈–‡Õ’¬¥·≈–¢Õâ ∫àß™’È ¢Õâ §«√√–«ß— /¢Õâ À“â ¡ Õ“°“√·∑√°´Õâ π ¢π“¥¬“„π‡¥°Á ¢π“¥¬“„πºâŸ„À≠à Diclofenac NSAIDs ∑Ë’¡’ª√– ‘∑∏‘¿“æ Ÿß - ·æâ aspirin - ¬—∫¬—Èß°“√∑”ß“π¢Õß PO: (Õ“¬ÿ > 1 ªï) - PO: 25-50 mg, 8-hourly  ”À√—∫§«“¡ª«¥‡≈Á°πâÕ¬∂÷ß - ÀÕ∫À◊¥ ‡°≈Á¥‡≈Õ◊ ¥ √∫°«π 1 mg/kg, 8-hourly - deep IM: 75 mg od ª“π°≈“ß - ‰μº¥‘ ª°μ‘√πÿ ·√ß À√Õ◊ ∑”„À‡â ≈Õ◊ ¥ÕÕ° Max dose 3 mg/kg/ - IV infusion: - ·º≈„π°√–‡æ“–Õ“À“√ „π√–∫∫∑“߇¥‘π day ë °√≥’ª«¥√ÿπ·√ß: Õ“À“√ „Àâ 75 mg IV infusion - bronchospasm „π 15-30 π“∑’ Õ“®‡æ¡Ë‘ Õ°’ - ÀÕŸ ÈÕ◊ ∫«¡ 75 mg ‚¥¬‡«âπ√–¬–°“√ ©’¥ 2-3 ™«Ë— ‚¡ß ë °√≥ª’ «¥À≈ß— º“à μ¥— : 25-50 mg IV infusion „π 15-30 π“∑’ μ“¡¥«â ¬ 5 mg/hour - Max dose 150 mg/day - IV/IM ‰¡§à «√π“π‡°π‘ 2 «π— ∂â“π“π„À⇪≈¬’Ë π‡ªìπ PO EMLA §√’¡º ¡ 2.5% lidocaine + - °“√¥Ÿ¥´÷¡¢È÷π°—∫∫√‘‡«≥·≈– √–«—ß°“√‡°‘¥ Methe- ‰¡à§«√„™â„π‡¥°Á μ”Ë °«“à ∑“Àπ“Ê ·≈–ª¥î ‰«â 1-2 ™¡. (Eutectic 2.5% prilocaine  ”À√—∫∑“ √–¬–‡«≈“∑Ë’∑“ moglobinemia 1 ªï °àÕπ∑”À—μ∂°“√ Mixture of Àπ“Ê ·≈–ª¥î ∑˺’ «‘ Àπ—ß - ‰¡à§«√„™â„π∫√‘‡«≥º‘«Àπ—ß∑’Ë „πºŸâªÉ«¬∑Ë’¡’¿“«–‡ Ë’¬ß Local Anes- ¡’·º≈À√Õ◊ ∑Ë’ mucous mem- ‡™πà G6PD deficiency thetic) brane

*** ¢âÕ·π–π”μ“à ßÊ „π·π«∑“ßæ≤— π“°“√√–ß∫— ª«¥πÈ’‰¡à„™¢à Õâ ∫ß— §—∫¢Õß°“√ªØ‘∫μ— ‘ *** μ“√“ß∑Ë’ 5 √“¬≈–‡Õ¬’ ¥°“√√–ß∫— ª«¥‡©¬’ ∫æ≈—π‚¥¬„™â¬“ (‡√¬’ ßμ“¡Õ°— …√) (μàÕ) ¬“ √“¬≈–‡Õ¬’ ¥·≈–¢âÕ∫àߙȒ ¢Õâ §«√√–«ß— /¢Õâ À“â ¡ Õ“°“√·∑√°´Õâ π ¢π“¥¬“„π‡¥°Á ¢π“¥¬“„πºŸâ„À≠à Etoricoxib ‰¡à·π–π”„Àâ„™â - PO: 60-120 mg od NSAIDs ∑¬Ë’ —∫¬ß—È ®”‡æ“– - ·æâ aspirin - (¢π“¥ 120 mg  ”À√—∫ Fentanyl ª«¥‡©’¬∫æ≈—π cyclooxygenase-II (COX-II) - ‰μ«“¬Õ¬à“ß√πÿ ·√ß ‰¡§à «√„™âπ“π°«“à 8 «—π) ≈¥º≈¢â“߇§’¬ßμàÕ√–∫∫∑“ß - ·º≈„π°√–‡æ“–Õ“À“√ ‡¥‘πÕ“À“√ Õ“°“√À≈Õ¥≈¡ - §«“¡¥—π‚≈À‘μ Ÿß∑’ˬ—ߧ«∫§ÿ¡ μ’∫ ·≈–‡°≈Á¥‡≈Õ◊ ¥ ‰¡¥à ’ - ‚√§À≈Õ¥‡≈◊Õ¥À—«„®·≈–‚√§ À≈Õ¥‡≈Õ◊ ¥ ¡Õß - À≈ß— °“√ºà“μ—¥ CABG/Stent - À≠‘ß¡§’ √√¿å „Àπâ ¡∫ÿμ√ Opioid ™π¥‘  ß— ‡§√“–Àå - ≈¥¢π“¥„πºâ Ÿ ߟ Õ“¬ÿ °¥°“√À“¬„®·≈– - IV bolus:  ”À√—∫‡¥°Á - IV bolus:0.001-0.005 mg/ ≈–≈“¬„π‰¢¡π— ‰¥â¥’ - °¥°“√À“¬„® √–∫∫°“√‰À≈‡«¬’ π ‰∑¬∑’ˉ¡à‰¥â on venti- kg (up to 0.05 mg/kg) cardiostability Epidural/spinal: §—π ·≈– ‡≈Õ◊ ¥„π¢π“¥ ŸßÕ“® lator „Àμâ “¡Õ“¬ÿ: - Epidural: 0.025-0.1 mg duration 30-60 π“∑’ delayed respiratory ‡°¥‘ muscle rigidity ë ∑“√°§≈Õ¥°àÕπ (º ¡°∫— ¬“™“À√Õ◊ saline) depression °”Àπ¥ „Àâ 0.0003 - Spinal: 0.005-0.02 mg mg/kg p.r.n. q 2 hr ë ∑“√°§≈Õ¥§√∫ °”Àπ¥ „Àâ 0.0003-0.0005 mg/ kg p.r.n. q 2 hr ë Õ“¬ÿ >1 ‡¥◊Õπ ·≈– ‡¥Á°‚μ „Àâ 0.0005- 0.001 mg/kg p.r.n. 25 q 2 hr

μ“√“ß∑’Ë 5 √“¬≈–‡Õ’¬¥°“√√–ß—∫ª«¥‡©¬’ ∫æ≈π— ‚¥¬„™â¬“ (‡√¬’ ßμ“¡Õ—°…√) (μÕà )  ¡“§¡°“√»°÷ …“‡√ÕË◊ ߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ ¬“26 *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™¢à Õâ ∫ß— §∫— ¢Õß°“√ªØ∫‘ μ— ‘ ***√“¬≈–‡Õ¬’ ¥·≈–¢âÕ∫ßà ™’È¢Õâ §«√√–«ß— /¢Õâ À“â ¡Õ“°“√·∑√°´âÕπ¢π“¥¬“„π‡¥°Á¢π“¥¬“„πºâŸ„À≠à Fentanyl ë ‡¡ÕË◊ on ventilator „Àªâ √∫— ‡æË¡‘ ¢π“¥„Àâ ‡À¡“– ¡ - IV Infusion:  ”À√∫— ‡¥Á°‰∑¬∑Ë’‰¡à ‰¥â on ventilator „Àμâ “¡Õ“¬:ÿ ë ∑“√°§≈Õ¥°àÕπ °”Àπ¥ „Àâ 0.0003 mg/kg/hr ë ∑“√°§≈Õ¥§√∫ °”Àπ¥ „Àâ 0.0003- 0.0005 mg/kg/hr ë Õ“¬ÿ >1 ‡¥◊Õπ ·≈– ‡¥Á°‚μ „Àâ 0.0005- 0.001 mg/kg/hr ë ‡¡ËÕ◊ on ventilator „Àâª√∫— ‡æ¡Ë‘ ¢π“¥„Àâ ‡À¡“– ¡

*** ¢âÕ·π–π”μ“à ßÊ „π·π«∑“ßæ≤— π“°“√√–ß∫— ª«¥πÈ’‰¡à„™¢à Õâ ∫ß— §—∫¢Õß°“√ªØ‘∫μ— ‘ *** μ“√“ß∑Ë’ 5 √“¬≈–‡Õ¬’ ¥°“√√–ß—∫ª«¥‡©’¬∫æ≈π— ‚¥¬„™¬â “ (‡√’¬ßμ“¡Õ°— …√) (μàÕ) ¬“ √“¬≈–‡Õ¬’ ¥·≈–¢Õâ ∫ßà ™’È ¢Õâ §«√√–«ß— /¢Õâ À“â ¡ Õ“°“√·∑√°´Õâ π ¢π“¥¬“„π‡¥°Á ¢π“¥¬“„πºâŸ„À≠à Ibuprofen NSAIDs  ”À√∫— §«“¡ª«¥ - ·æâ aspirin ‡≈°Á πÕâ ¬∂ß÷ ª“π°≈“ß - ÀÕ∫À◊¥ - ¬∫— ¬ßÈ— °“√∑”ß“π¢Õß - PO: 6-10 mg/kg tid - PO: 400 mg qid º≈¢“â ߇§’¬ßπÕâ ¬∑Ë’ ¥ÿ „π - ‰μº¥‘ ª°μ√‘ πÿ ·√ß °≈ÿà¡ NSAIDs - ·º≈„π°√–‡æ“–Õ“À“√ ‡°≈Á¥‡≈◊Õ¥ √∫°«π À√◊Õ 5 mg/kg qid À√Õ◊ ∑”„À‡â ≈Õ◊ ¥ÕÕ°„π (BW >7 kg) √–∫∫∑“߇¥π‘ Õ“À“√ - bronchospasm - ÀÕŸ È◊Õ ∫«¡ Indometha- NSAIDs  ”À√—∫§«“¡ª«¥ - ·æâ aspirin - ¬∫— ¬ß—È °“√∑”ß“π¢Õß - - PO: 50-100 mg bid cin ª“π°≈“ß Õ∫ÿ —μ‘°“√≥¢å Õß - ÀÕ∫À◊¥ - ‰μº‘¥ª°μ‘√πÿ ·√ß ‡°≈Á¥‡≈◊Õ¥ √∫°«π Õ“°“√·∑√°´âÕπ ßŸ - ·º≈„π°√–‡æ“–Õ“À“√ À√Õ◊ ∑”„À‡â ≈Õ◊ ¥ÕÕ°„π √–∫∫∑“߇¥π‘ Õ“À“√ - bronchospasm - ÀŸÕ◊ÈÕ ∫«¡ Ketamine Phencyclidine derivative - §«“¡¥—π‚≈Àμ‘  Ÿß - §«“¡¥π— ‚≈Àμ‘ §«“¡ - -  ”À√—∫√–ß—∫ª«¥ ∑”„À‡â °‘¥ dissociative - ‡Õ–Õ–‚«¬«“¬ ¥—π„π°–‚À≈°»’√…– 0.05-0.1 mg/kg/hr √«à ¡°∫— anesthesia - πÈ”≈“¬¡“° ·≈–·√ßμ÷ßμ—«¢Õß opioid °≈â“¡‡π◊ÈÕ¡¥≈Ÿ°‡æ‘Ë¡ („™â‚¥¬º‡Ÿâ ™¬Ë’ «™“≠) ¢πÈ÷ - π”È ≈“¬¡“° - °¥°“√À“¬„®∂â“„Àâ Õ¬à“ß√«¥‡√Á« Levobupiva- Levorotatory (S) enan- ‡™àπ‡¥’¬«°∫— bupivacaine ‡™àπ‡¥’¬«°—∫ ‡™àπ‡¥’¬«°—∫ - ‡™àπ‡¥’¬«°∫— bupivacaine caine tiomer of bupivacaine bupivacaine bupivacaine Max dose 150 mg, ´ßË÷ ¡ƒ’ ∑∏‘Ï cardiotoxicity ·≈– 27 CNS toxicity ≈¥≈ß Max dose 400 mg/day

μ“√“ß∑Ë’ 5 √“¬≈–‡Õ’¬¥°“√√–ß—∫ª«¥‡©¬’ ∫æ≈—π‚¥¬„™â¬“ (‡√’¬ßμ“¡Õ—°…√) (μàÕ)  ¡“§¡°“√»°÷ …“‡√ÕË◊ ߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬¬“√“¬≈–‡Õ¬’ ¥·≈–¢âÕ∫àߙȒ¢Õâ §«√√–«ß— /¢Õâ À“â ¡Õ“°“√·∑√°´âÕπ ¢π“¥¬“„π‡¥°Á¢π“¥¬“„πºŸâ„À≠à Lidocaine 28 *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™¢à Õâ ∫ß— §∫— ¢Õß°“√ªØ∫‘ μ— ‘ ***Morphine ‡ªπì ¬“™“™π¥‘ amide, ÕÕ°  “√≈–≈“¬∑’˺ ¡ adrenaline Toxicity: ¡Õ’ “°“√™“≈πÈ‘ -  “√≈–≈“¬ 0.5-2% -  “√≈–≈“¬ 0.5-2% Naloxone ƒ∑∏‡‘Ï √«Á duration 30-90 π“∑’ ®–¡’ preservative √Õ∫ª“° °√–«π - Max dose ¢÷Èπ°—∫ - Max dose ¢πÈ÷ °∫— μ”·Àπßà °“√º ¡ adrenaline ∑”„Àâ °√–«“¬ ÀÕŸ Õ◊È ™°— À«— „® μ”·Àπßà ∑Ë’©¥’ ∑Ë’©’¥ ÕÕ°ƒ∑∏πÏ‘ “π¢πÈ÷ À¬¥ÿ ‡μπâ - 3 mg/kg, 4-hourly - 3 mg/kg, 4-hourly (with adrenaline: (with adrenaline: 6 mg/ 6 mg/kg, 4-hourly) kg, 4-hourly) Opioid analgesic 1. °“√„À¬â “∑“ß epidural/spi- - À≈—ßË histamine - PO: 0.3-0.5 mg/kg, - IV: 2-5 mg p.r.n. q 2 hr nal Õ“®¡’‚Õ°“ ‡°‘¥°¥°“√ - §«“¡¥π— ‡≈Õ◊ ¥≈¥≈ß 4-hourly ‰¡à·π–π” - IM/SC: 5-10 mg, 4-hourly À“¬„® §π— §≈π◊Ë ‰ â Õ“‡®’¬π - bronchospasm „Àâ„™∂â “â ∑Õâ ßÕ¥◊ À√Õ◊ p.r.n. q 2 hr ‰¥âπ“π°«“à „Àâ«∏‘ ’Õ◊Ëπ - §π— §≈Ëπ◊ ‰ â Õ“‡®’¬π - IV bolus:  ”À√—∫ ¢π“¥¬“„Àâæ‘®“√≥“μ“¡ 2. ‰¡§à «√„™â„π biliary colic -  ∫—  π ‡Õ–Õ–‚«¬«“¬ ‡¥°Á Õ“¬ÿ > 1 ªï: 0.03- Õ“¬ÿ §«“¡√ÿπ·√ߢÕß°“√ ‡æ√“– morphine ∑”„À‡â °¥‘ 0.05 mg/kg p.r.n. q ∫“¥‡®∫Á ·≈– ¿“æ¢Õß spasm ¢Õß sphincter of 2-4 hr ºªŸâ «É ¬ Oddi §«√„™â pethidine ·∑π - IV infusion  ”À√—∫ - PO: 10-30 mg, 4-hourly 3. ‰¡§à «√„™â„π renal colic pain ‡¥Á°Õ“¬ÿ > 1 ªï: 0.01- ‰¡à·π–π”„Àâ„™â∂â“∑âÕßÕ◊¥ ‡æ√“– morphine ∑”„À‡â °¥‘ 0.03 mg/kg/hr ª√—∫ - Epidural: 2-4 mg* spasm ¢Õß ureter ‰¥â §«√„™â ‰¥âμ“¡Õ“°“√ºŸâªÉ«¬ - Spinal: 0.1-0.3 mg* NSAIDs À√◊Õ pethidine ·∑π (* preservative free) Pure opioid antagonist Duration of action 30 π“∑’ - IV bolus:-0.005-0.01 - IV bolus: 0.1-0.4 mg „™â·°âƒ∑∏Ï‘°¥°“√À“¬„®¢Õß √–«—ß„π°“√·°âƒ∑∏‘Ï opioid ∑Ë¡’ ’ mg/kg titrated to desired effect opioid ƒ∑∏πÏ‘ “π Õ“®‡°¥‘ renarcotisa- - Infusion: 0.005-0.02 - ·°§â π— ®“° epidural opioid: „™â„π¢π“¥μ”Ë ‡æ◊ËÕ·°âƒ∑∏‘Ï tion Õ“®‡°¥‘ acute withdrawal mg/kg/hr 0.1 mg bolus + 0.3 mg Õ“°“√§—π®“° epidural „πº∑Ÿâ ’μË ‘¥¬“ opioid - IM in Newborn: 0.2 º ¡„π IV fluid opioid ·≈–„Àâ IM „π‡¥°Á mg ·√°‡°¥‘ ∑¡Ë’ “√¥“‰¥√â ∫— opioid - ·°â§—π®“° epidural opioid: 0.005 mg/kg

*** ¢âÕ·π–π”μ“à ßÊ „π·π«∑“ßæ≤— π“°“√√–ß∫— ª«¥πÈ’‰¡à„™¢à Õâ ∫ß— §—∫¢Õß°“√ªØ‘∫μ— ‘ *** μ“√“ß∑Ë’ 5 √“¬≈–‡Õ¬’ ¥°“√√–ß∫— ª«¥‡©’¬∫æ≈π— ‚¥¬„™â¬“ (μàÕ) ¬“ √“¬≈–‡Õ’¬¥·≈–¢âÕ∫ßà ™’È ¢Õâ §«√√–«ß— /¢Õâ À“â ¡ Õ“°“√·∑√°´âÕπ ¢π“¥¬“„π‡¥°Á ¢π“¥¬“„πºâŸ„À≠à Naproxen NSAIDs  ”À√∫— ª«¥‡≈Á° - ·æâ aspirin - ¬∫— ¬ßÈ— °“√∑”ß“π¢Õß - PO: 5 mg/kg bid - PO: 500 mg bid πâÕ¬∂÷ߪ“π°≈“ß - ÀÕ∫À◊¥ ‡°≈Á¥‡≈◊Õ¥ √∫°«π (>5 yr) Paracetamol Õ“°“√ª«¥‡≈°Á πÕâ ¬∂ß÷ ª«¥ª“π°≈“ß - ‰μº¥‘ ª°μ√‘ ÿπ·√ß À√Õ◊ ∑”„À‡â ≈Õ◊ ¥ÕÕ°„π ≈¥‰¢â - ·º≈„π°√–‡æ“–Õ“À“√ √–∫∫∑“߇¥π‘ Õ“À“√ Paracetamol ¥Ÿ paracetamol ·≈– 300 mg codeine - bronchospasm + codeine 15 /30 mg - ÀŸÕ◊ÈÕ ∫«¡ Paracetamol ¥Ÿ paracetamol 325 mg + ·≈– tramadol ‡¥Á°·√°‡°‘¥ μ—∫∂Ÿ°∑”≈“¬∂â“„™â‡°‘π - PO: 10-20 mg/kg, - PO: 0.5-1 g , 4-6 hourly tramadol 37.5 mg ºªâŸ É«¬ G-6-PD deficiency ¢π“¥ 4-6 hourly - Slow IV: 0.5-1 g qid - PR: loading dose - Max dose 6 gm/day 30-40 mg/kg (>44 wk post conception) °“√‡æ‘Ë¡¢π“¥‚¥¬°“√‡æ‘Ë¡ ¥Ÿ paracetamol ·≈– ¢π“¥¬“§”π«≥‚¥¬„™â ¥Ÿ paracetamol ·≈– ®”π«π‡¡¥Á ¬“ Õ“®∑”„À¬â “μ«— „¥ codeine dose codeine codeine μ—«ÀπË÷߇°π‘ ¢π“¥‰¥â °“√‡æ‘¡Ë ¢π“¥‚¥¬°“√‡æ‘Ë¡ ¥Ÿ paracetamol ·≈– - ¥Ÿ paracetamol ®”π«π‡¡¥Á ¬“ Õ“®∑”„À¬â “μ«— „¥ tramadol ·≈– tramadol μ—«Àπ÷ßË ‡°π‘ ¢π“¥‰¥â 29

μ“√“ß∑Ë’ 5 √“¬≈–‡Õ’¬¥°“√√–ß∫— ª«¥‡©’¬∫æ≈π— ‚¥¬„™¬â “ (‡√’¬ßμ“¡Õ°— …√) (μÕà )  ¡“§¡°“√»°÷ …“‡√ÕË◊ ߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ ¬“30 *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™¢à Õâ ∫ß— §∫— ¢Õß°“√ªØ∫‘ μ— ‘ ***√“¬≈–‡Õ¬’ ¥·≈–¢Õâ ∫àߙȒ¢Õâ §«√√–«ß— /¢Õâ À“â ¡Õ“°“√·∑√°´Õâ π ¢π“¥¬“„π‡¥°Á¢π“¥¬“„πºâŸ„À≠à Parecoxib - Pro-drug ¢Õß valdecoxib - ·æâ sulfonamide À√◊Õ - - - IV/IM: 40 mg, then Pethidine ‡ªìπ NSAIDs ∑¬Ë’ —∫¬—Èß aspirin 20-40 mg, 12-hourly Piroxicam ®”‡æ“– Cyclooxygenase- - À≈—ß°“√ºà“μ¥— CABG/Stent - Max dose 80 mg/day II (COX-II) - ‚√§À≈Õ¥‡≈◊Õ¥À—«„®·≈–‚√§ - ≈¥º≈¢â“߇§¬’ ßμàÕ√–∫∫ À≈Õ¥‡≈Õ◊ ¥ ¡Õß ∑“߇¥π‘ Õ“À“√ ·≈– - ‰μ«“¬Õ¬“à ß√πÿ ·√ß ‡°≈¥Á ‡≈Õ◊ ¥ - √–¡¥— √–«—ß„πºŸªâ «É ¬ ŸßÕ“¬ÿ - „™ â ”À√—∫√–ß∫— ª«¥À≈—ß - À≠ß‘ ¡’§√√¿å „Àπâ ¡∫ÿμ√ ºà“μ—¥‰¡‡à °π‘ 3 «π— - ·º≈„π°√–‡æ“–Õ“À“√ Opioid ™π¥‘  ß— ‡§√“–Àå Õ“®™—°®“°¬“¢π“¥ ßŸ - °¥°“√À“¬„® - IV/IM/SC: - IV: 20-50 mg p.r.n. 1. √–ß—∫ª«¥ - Max dose 1g/day (20 mg/ - §«“¡¥—π‡≈◊Õ¥μË” 0.5-1 mg/kg q 2 hr 2. ºŸâªÉ«¬Àπ“« πË— À≈ß— º“à μ¥— kg/day) -  ∫—  π ‡Õ–Õ–‚«¬«“¬ - Infusion: Õ“°“√Àπ“« πË— : 10-25 mg 3. Biliary colic ºâªŸ É«¬‰¥â√∫— MAOI 5 mg/kg in 50 ml - IM/SC: 25-100 mg, 4. Renal colic NSS 3-hourly À√Õ◊ p.r.n. q 2 rate 1-3 ml/hr hr ¢π“¥¬“„Àâæ‘®“√≥“ (0.1-0.3 mg/kg/hr) μ“¡Õ“¬ÿ §«“¡√πÿ ·√ߢÕß °“√∫“¥‡®∫Á ·≈– ¿“æ ¢ÕߺªŸâ «É ¬ NSAID  ”À√∫— §«“¡ª«¥ - ·æâ aspirin ¬—∫¬È—ß°“√∑”ß“π¢Õß - - PO: 10-30 mg od ª“π°≈“ß Õ∫ÿ μ— °‘ “√≥å¢Õß - ÀÕ∫À◊¥ ‡°≈¥Á ‡≈Õ◊ ¥ √∫°«πÀ√Õ◊ Õ“°“√·∑√°´Õâ π ßŸ - ‰μº¥‘ ª°μ‘√πÿ ·√ß ∑”„À‡â ≈Õ◊ ¥ÕÕ°„π√–∫∫ - ·º≈„π°√–‡æ“–Õ“À“√ ∑“߇¥‘πÕ“À“√ - À≈°’ ‡≈¬Ë’ ß„πºªŸâ «É ¬ porphyria bronchospasm ÀÕŸ È◊Õ ∫«¡

*** ¢âÕ·π–π”μ“à ßÊ „π·π«∑“ßæ≤— π“°“√√–ß∫— ª«¥πÈ’‰¡à„™¢à Õâ ∫ß— §—∫¢Õß°“√ªØ‘∫μ— ‘ *** μ“√“ß∑’Ë 5 √“¬≈–‡Õ¬’ ¥°“√√–ß—∫ª«¥‡©’¬∫æ≈π— ‚¥¬„™¬â “ (‡√¬’ ßμ“¡Õ°— …√) (μàÕ) ¬“ √“¬≈–‡Õ¬’ ¥·≈–¢Õâ ∫ßà ™’È ¢Õâ §«√√–«ß— /¢Õâ À“â ¡ Õ“°“√·∑√°´Õâ π ¢π“¥¬“„π‡¥°Á ¢π“¥¬“„πºâŸ„À≠à PO: 20 mg od Tenoxicam NSAIDs  ”À√—∫§«“¡ª«¥ - ·æâ aspirin - ¬∫— ¬ßÈ— °“√∑”ß“π¢Õß ‰¡·à π–π”„Àâ„™â - PO: 50-100 mg, 4-hourly ‡≈Á°πâÕ¬ ∂÷ߪ“π°≈“ß - ÀÕ∫À◊¥ ‡°≈¥Á ‡≈Õ◊ ¥ √∫°«π - Slow IV/IM: 50-100 mg - ‰μº¥‘ ª°μ√‘ πÿ ·√ß À√Õ◊ ∑”„À‡â ≈Õ◊ ¥ÕÕ°„π 4-hourly - Max dose 400 mg/day - ·º≈„π°√–‡æ“–Õ“À“√ √–∫∫∑“߇¥π‘ Õ“À“√ ¥Ÿ paracetamol - bronchospasm ·≈– tramadol - ÀŸÕÕÈ◊ ∫«¡ Tramadol - Opioid ∑’§Ë “¥«“à ¡º’ ≈μàÕ - ·°âƒ∑∏¥Ï‘ «â ¬ naloxone ‰¥â §≈◊Ëπ‰ â «‘߇«’¬π - PO: 1-2 mg/kg, °“√°¥°“√À“¬„® ∑Õâ ߺ°Ÿ ‡æ¬’ ß 30% ª“°·Àâß 6-hourly euphoria À√◊Õμ‘¥¬“πâÕ¬ - √–«—ß„π epilepsy °«à“ opioid ™π‘¥ÕË◊π - ‰¡à·π–π”„Àâ„™â„πºâŸªÉ«¬∑’ˉ¥â - °“√ÕÕ°ƒ∑∏¡‘Ï ∑’ ßÈ— °≈‰°·∫∫ √—∫¬“ MAOI opioid ·≈– non-opioid Tramadol ¥Ÿ paracetamol °“√‡æ‘¡Ë ¢π“¥‚¥¬°“√‡æ‘Ë¡ ¥Ÿ paracetamol ·≈– - 37.5 mg + ·≈– tramadol ®”π«π‡¡¥Á ¬“ Õ“®∑”„À¬â “μ«— „¥ tramadol paracetamol μ—«ÀπËß÷ ‡°π‘ ¢π“¥‰¥â 325 mg À¡“¬‡Àμÿ : ë od = once daily, bid = twice daily, tid = three times daily, qid = four times daily ë Max = maximum, MAOI = monoamine oxidase inhibitors, NSS = normal saline ë PO = per oral, PR = per rectal, SC = subcutaneous, SL = sublingual, IM = intramuscular, IV = intravenous ë ¬“∑Ë’„À∑â “ß PR ∫“ß™π‘¥ª®í ®ÿ∫π— „πª√–‡∑»‰∑¬¬—߉¡¡à ’„™â 31

μ“√“ß∑’Ë 6 √“¬≈–‡Õ¬’ ¥°“√√–ß∫— ª«¥‡©¬’ ∫æ≈π— ‚¥¬‰¡à„™¬â “5  ¡“§¡°“√»°÷ …“‡√ÕË◊ ߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬Non-pharmacological√“¬≈–‡Õ¬’ ¥¢âÕ¡Ÿ≈∑“ß ∂‘쑪√–‡¥Á𠔧≠— therapy 32 *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™¢à Õâ ∫ß— §∫— ¢Õß°“√ªØ∫‘ μ— ‘ *** A: Psychological Procedural information §◊Õ¢âÕ¡Ÿ≈∑’Ë·®âß„ÀâºâŸªÉ«¬ Combined sensory-procedural information °“√„À¢â Õâ ¡≈Ÿ therapy (Sensory-proce- 1. °“√„À¢â Õâ ¡≈Ÿ ∑√“∫°Õà π„À°â “√√°— …“„¥Ê ´ßË÷  √ªÿ «“à ®–‡°¥‘ Õ–‰√¢π÷È „π ®–∑”„À‡â °¥‘ ª√– ∑‘ ∏¿‘ “楡’ “°‚¥¬≈¥°“√∑∫°√–‡∑Õ◊ π dural informa- (Provision of tion) ™à«¬≈¥ information) √–À«à“ß°“√√—°…“ ®μ‘ „®„π∑“ß≈∫¢ÕߺªâŸ «É ¬·≈–≈¥°“√√“¬ß“π«“à ¡§’ «“¡ Õ“°“√ª«¥·≈– «‘μ°°—ß«≈‰¥âÕ¬à“ß Sensory information §Õ◊ ¢Õâ ¡≈Ÿ ∑Õ’Ë ∏∫‘ “¬ª√– ∫°“√≥å ª«¥∑ Ë’ ¡— æπ— ∏°å ∫— Àμ— ∂°“√„π°“√√°— …“·≈–¬ß— ¡ ’ «à π™«à ¬ ¡ª’ √– ∑‘ ∏¿‘ “æ ‡°’ˬ«°—∫§«“¡√Ÿâ ÷°„π√–À«à“ß°“√√—°…“∑Ë’ºâŸªÉ«¬§“¥«à“ ≈¥§«“¡«‘μ°°—ß«≈¢ÕߺŸâªÉ«¬μàÕÀ—μ∂°“√À≈“¬Õ¬à“ß ®–‰¥â√—∫ ∑∑’Ë ”„À‡â °¥‘ §«“¡ª«¥ ‡™πà Àμ— ∂°“√∑π— μ°√√¡ Àμ— ∂°“√ °“√„Àâ¢âÕ¡Ÿ≈·∫∫ procedural ·≈–À√◊Õ sensory „π°“√μ√«®«‘π‘®©—¬·≈–À—μ∂°“√„π°“√∑¥≈Õß∑“ß ®–‰¥ºâ ≈∑·’Ë μ°μ“à ß°—π¢÷ÈπÕ¬Ÿà°∫— °≈à¡ÿ ºâªŸ «É ¬·μ≈à –°≈¡ÿà «∑‘ ¬“»“ μ√μå “à ßÊ 2. °“√ºàÕπ§≈“¬·≈– °“√Ω°ñ ºÕà π§≈“¬ ‡ªπì ‡∑§π§‘ ∑Ë’„™∑â ”„Àºâ ªŸâ «É ¬√ âŸ °÷  ß∫ °“√„™â«‘∏’Ωñ°ºàÕπ§≈“¬„πºâŸªÉ«¬¡–‡√Áß∑’Ë¡“√—∫°“√∑” °“√¡ÿà߇ππâ §«“¡ π„® (Relaxation ≈ß®“°§«“¡ª«¥À≈—ߺà“μ—¥‚¥¬„™â«‘∏’°“√øí߇ ’¬ß®“° À—μ∂°“√∑’Ë∑”„À⇰‘¥§«“¡ª«¥®–™à«¬≈¥§«“¡ª«¥‰¥â and Attention Strategies) ‡§√Ë◊Õß∫—π∑÷°‡ ’¬ßÀ√◊Õ°“√Ωñ°‡¢’¬πÀ√◊ÕæŸ¥μ“¡·∫∫ Õ¬à“ß¡’ª√– ‘∑∏‘¿“æ ‚¥¬ —߇°μ®“°°“√«—¥™’æ®√ Ω°ñ À¥— ∫“ß«∏‘ ’ °“√Ω°ñ ®–‡πâπ„À⧫“¡ π„®μÕà °“√μß÷ §«“¡¥π— ‚≈Àμ‘ ¢ÕߺªâŸ «É ¬·≈– ß— ‡°μ§«“¡‡ª≈¬Ë’ π·ª≈ß μ«— ¢Õß°≈â“¡‡π◊ÈÕμ“¡®ß— À«–°“√À“¬„® ¥—ßπÈπ— ‡∑§π‘§ ∑“ßÕ“√¡≥¢å ÕߺªŸâ «É ¬ ‡™πà Õ“°“√´¡÷ ‡»√“â Õ“°“√«μ‘ ° °“√Ω°ñ ºÕà π§≈“¬¡°— ®–¡§’ «“¡ ¡— æπ— ∏°å ∫— °“√∑” ¡“∏‘ °ß— «≈ ‰¡‡à ªìπ¡‘μ√ ·≈–°“√ –°¥®μ‘ Õ¬“à ߉¡ à “¡“√∂·¬°§«“¡·μ°μ“à ߉¥â  π—∫ πÿπ„Àâ„™â‡∑§π‘§°“√‡∫Ë’¬ß‡∫𧫓¡ π„®√à«¡ °“√„™â¥πμ√’™à«¬„π°“√ºàÕπ§≈“¬‡ªìπ«‘∏’∑Ë’‰¥âº≈ ‚¥¬ °∫— °“√Ω°ñ ºÕà π§≈“¬ ‡æÕ◊Ë ≈¥°“√√“¬ß“π«“à ¡§’ «“¡ª«¥ ‡ ¬’ ‡«≈“ ÕπºªŸâ «É ¬‡æ¬’ ߇≈°Á πÕâ ¬ ·μμà Õâ ß∑”∫Õà ¬Ê ·≈– ·≈–≈¥°“√„™¬â “·°âª«¥‰¥â ≠“μº‘ Ÿâª«É ¬§«√ π∫—  ππÿ °‘®°√√¡‡À≈“à πÈ’¥â«¬ „π¢≥–∑∫’Ë “ßß“π«®‘ ¬— æ∫«“à ¥πμ√’‰¡ à “¡“√∂≈¥§«“¡ Attention techniques ‡ªìπ‡∑§π‘§„π°“√‡∫Ë’¬ß‡∫π «‘μ°°—ß«≈À√◊Õ≈¥§«“¡ª«¥„πºŸâªÉ«¬∑Ë’‰¥â√—∫°“√ºà“μ—¥ §«“¡ π„®¢ÕߺªŸâ «É ¬∑¡’Ë §’ «“¡ª«¥‰ª¬ß—  ß‘Ë °√–μπâÿ ¿“¬ À√◊ÕÀμ— ∂°“√‰¥â πÕ° ‡™àπ ‡ ’¬ß¥πμ√’ √Ÿª¿“æ∑’ˇÀÁπÀ√◊Õ°“√‰¥â°≈Ë‘π μà“ßÊ ‡ªì𧫓¡æ¬“¬“¡∑Ë’®–ª√—∫ ¿“«–Õ“√¡≥å∑’Ë¡’ §«“¡‡§√’¬¥À√◊Õ§«“¡À«“¥°≈—«¡“‡ªìπÕ“√¡≥å∑Ë’√Ÿâ ÷°  ∫“¬ ß∫ ÿ¢

μ“√“ß∑’Ë 6 √“¬≈–‡Õ’¬¥°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬‰¡à„™¬â “5 (μÕà ) *** ¢âÕ·π–π”μ“à ßÊ „π·π«∑“ßæ≤— π“°“√√–ß∫— ª«¥πÈ’‰¡à„™¢à Õâ ∫ß— §—∫¢Õß°“√ªØ‘∫μ— ‘ *** Non-pharmacological √“¬≈–‡Õ’¬¥ ¢âÕ¡Ÿ≈∑“ß ∂‘μ‘ ª√–‡¥πÁ  ”§—≠ therapy  à«πª√–°Õ∫ ”§—≠„π°“√Ωñ° –°¥®‘μ§◊Õ °“√∑”„Àâ °“√ –°¥®μ‘ ¡ª’ √– ∑‘ ∏¿‘ “楒„π°“√≈¥§«“¡ª«¥‡©¬’ ∫ °“√ –°¥®μ‘ ·≈– 3. °“√ –°¥®μ‘ °“√¡àßÿ ‡πâ𧫓¡ (Hypnosis) ®ÿ¥ π„®μà“ßÊ ·§∫≈ß °“√≈¥°“√μ√–Àπ—°√—∫√⟠◊ËÕ æ≈—π∑Ë’‡°Ë’¬«°—∫À—μ∂°“√∑“ß°“√·æ∑¬åμà“ßÊ ‡™àπ  π„® ™«à ¬≈¥ Õ“°“√ª«¥®“° 4. °“√ª√∫— ‡ª≈¬Ë’ 𧫓¡ °√–μâÿπ¿“¬πÕ°‚¥¬°“√¥Ÿ¥´—∫·≈–°“√‡æ‘Ë¡°“√μÕ∫ °“√∑”À—μ∂°“√„πºŸâªÉ«¬∑Ë’¡’∫“¥·º≈‰ø‰À¡â À—μ∂°“√ °“√∑”Àμ— ∂°“√∑’Ë §¥‘ ·≈–æƒμ‘°√√¡ ¡’§«“¡ª«¥‰¥â (Cognitive-  πÕßμàÕ°“√™—°π” –°¥®‘μ ‡®“–°√–¥Ÿ° ·≈–°“√∑”§≈Õ¥ Behavioral therapy) °“√Ωñ°Ωπ„π°“√  à«π„πºŸâªÉ«¬¡–‡√Áß°“√ –°¥®‘μ¡’ à«π™à«¬≈¥§«“¡ ®—¥°“√°—∫§«“¡ ª«¥ ·≈–ª√—∫ ª«¥„πÀ≈“¬À—μ∂°“√ ‡™àπ °“√‡®“–‡πÈ◊ÕßÕ°‡μâ“π¡ æƒμ‘°√√¡°àÕπ °“√º“à μ—¥®–™«à ¬ ‡®“–π”È ‰¢ —πÀ≈ß— °“√‡®“–‰¢°√–¥°Ÿ ≈¥Õ“°“√ª«¥, ≈¥°“√„™¬â “·°â °“√ –°¥®‘μ„π¡“√¥“∑Ë’§≈Õ¥∫ÿμ√æ∫«à“™à«¬≈¥§«“¡ ª«¥ ·≈–≈¥º≈ °√–∑∫„π∑“ß≈∫ μÕâ ß°“√¬“·°ªâ «¥·≈–™«à ¬‡æ¡Ë‘ ‚Õ°“ „π°“√§≈Õ¥∫μÿ √ ®“°§«“¡ª«¥μàÕ ºªâŸ «É ¬≈߉¥â ‡Õß∑“ß™àÕߧ≈Õ¥‰¥â ‡¡ÕË◊ ºªŸâ «É ¬¡§’ «“¡°≈«— ·≈–«μ‘ °°ß— «≈ §«√ª√–‡¡π‘ ¿“«– °“√Ωñ°Ωπ„π°“√®—¥°“√‡º™‘≠Àπâ“°—∫§«“¡ª«¥·≈– ®‘μ„®¢Õߺ⟪ɫ¬ ·≈– Õπ«‘∏’∑’Ë®–‡º™‘≠Àπâ“°—∫§«“¡ ª√—∫æƒμ‘°√√¡°àÕπ∑Ë’®–¡“√—∫°“√ºà“μ—¥®–™à«¬„Àâ°“√ ª«¥π—ÈπÊ (coping skills) ‰¥â·°à °“√ Õπ„ÀâºâŸªÉ«¬ ª√–‡¡‘𧫓¡√ÿπ·√ߢÕߧ«“¡ª«¥À≈—ߺà“μ—¥¡’ ¡Õß‚≈°„π·ß॒ °“√ºàÕπ§≈“¬ °“√ √â“ß®‘πμπ“°“√ ª√– ‘∑∏‘¿“楒¢÷Èπ ≈¥§«“¡°√–∑∫ °√–‡∑◊Õπ®‘μ„® ‡æÕ◊Ë ≈¥§«“¡°≈«— ππ—È Ê ·μà„πºªŸâ «É ¬∫“ß√“¬°“√„À¢â Õâ ¡≈Ÿ „π∑“ß≈∫¢Õߺ⟪ɫ¬·≈–≈¥§«“¡μâÕß°“√¬“·°âª«¥ ¡“°‡°‘π‰ª°Á®–∑”„À⺟âªÉ«¬‡°‘¥§«“¡°≈—«·≈–°—ß«≈®π ‰¥â¥â«¬ ‡°‘π°«à“‡Àμÿ °“√„Àâ¢âÕ¡Ÿ≈°—∫ºŸâªÉ«¬®÷ß¡’§«“¡®”‡ªìπ∑’Ë æ∫«à“ºŸâªÉ«¬∑Ë’¡—°· ¥ß°“√μÕ∫ πÕߧ«“¡ª«¥Õ¬à“ß ®–μâÕߪ√–‡¡‘𧫓¡√⟠§«“¡‡¢â“„®·≈–„À⧫“¡√Ÿâ„π ‡°‘𧫓¡‡ªìπ®√‘ߧ≈⓬Փ°“√μ◊ËπμŸ¡À√◊Õ°“√· ¥ß ª√¡‘ “≥æÕ‡À¡“–„π·μ≈à –√“¬ ‡æÕË◊ ®–‰¥â‰¡∑à ”„Àºâ ªŸâ «É ¬ ∑—»π§μ‘∑Ë’‰¡à∂Ÿ°μâÕß ¡—°¡’·π«‚πâ¡∑’Ë®–¡’§«“¡«‘μ° °≈—«À√Õ◊ °ß— «≈®π‡°π‘ ‰ª °“√„À§â «“¡√§âŸ «“¡‡¢â“„®·°à °—ß«≈·≈–¡’ª√– ∫°“√≥åμàÕ§«“¡ª«¥∑Ë’¡“°°«à“§π ºŸâªÉ«¬„π‡√◊ËÕß°“√ºà“μ—¥ °“√„À⬓√–ß—∫§«“¡√⟠÷° ª°μ‘ °“√√—°…“§«“¡ª«¥À≈—ߺà“μ—¥μ“¡ºŸâªÉ«¬μâÕß°“√√à«¡ °—∫°“√ Õπ«‘∏’°“√À“¬„®≈÷°Ê °“√‰Õ °“√¢¬—∫μ—« °“√‡¥π‘ ‡æÕË◊ ≈¥Õ“°“√‰¡ à ∫“¬μ«— À≈ß— º“à μ¥—  “¡“√∂ ≈¥§«“¡μÕâ ß°“√„™¬â “·°ªâ «¥À≈ß— º“à μ¥— ≈ß ·≈–ºªŸâ «É ¬  “¡“√∂‡§≈Ë◊Õπ‰À«‰¥â¥’¢È÷π ·π«∑“ß„π°“√ Õπ«‘∏’∑’Ë 33 ®–‡º™≠‘ Àπ“â °∫— §«“¡ª«¥ππÈ— Ê¡°— „™∑â °ÿ «∏‘ ∑’ ßÈ— °√–∫«π °“√§‘¥·≈–æƒμ‘°√√¡

μ“√“ß∑Ë’ 6 √“¬≈–‡Õ’¬¥°“√√–ß∫— ª«¥‡©¬’ ∫æ≈π— ‚¥¬‰¡à„™¬â “5 (μàÕ)  ¡“§¡°“√»°÷ …“‡√ÕË◊ ߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ Non-pharmacological34 *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™¢à Õâ ∫ß— §∫— ¢Õß°“√ªØ∫‘ μ— ‘ ***√“¬≈–‡Õ¬’ ¥¢âÕ¡Ÿ≈∑“ß ∂‘쑪√–‡¥πÁ  ”§≠— therapy °“√ª√–§∫√âÕπ-‡¬Áπ ®–≈¥§«“¡ª«¥‚¥¬™à«¬„Àâ ª√–‚¬™πå¢Õß°“√ª√–§∫‡¬Áπ∫√‘‡«≥∑Ë’∑”°“√ºà“μ—¥ B: Physical therapy °≈“â ¡‡πÈÕ◊ §≈“¬μ«— ·≈– ≈¥Õ“°“√∫«¡¢Õß·º≈ºà“μ—¥ ¡’ à«π™à«¬≈¥°“√„™â¬“·°âª«¥‰¥â·≈–≈¥√–¥—∫§«“¡ 1. °“√ª√–§∫√Õâ π-‡¬πÁ °“√ª√–§∫‡¬πÁ ®–∂°Ÿ „™â„π¢πÈ— μÕπ·√°‡æÕ◊Ë ≈¥°“√μÕ∫ √ÿπ·√ߢÕߧ«“¡ª«¥‰¥â„πÀ≈“¬°“√ºà“μ—¥ ‡™àπ °“√ (Applications of  πÕߢÕ߇πÕÈ◊ ‡¬Ë◊Õ  «à π°“√ª√–§∫√âÕππ”¡“„™â„π¢π—È ºà“μ—¥°√–¥Ÿ°·≈–¢âÕ ·μà∫“ß°“√«‘®—¬æ∫«à“‰¡à™à«¬≈¥ heat and cold) μÕπÀ≈ß— ‡æÕ◊Ë ™«à ¬¢®¥—  “√æ…‘ ·≈–°“√¬∫ÿ ∫«¡ °“√π«¥ §«“¡ª«¥ ‡™àπ °“√ºà“μ—¥§≈Õ¥∑“ßÀπâ“∑âÕß ·≈– ·≈–°“√ÕÕ°°”≈ß— ‡æÕ◊Ë „À°â ≈“â ¡‡πÕ◊È §≈“¬μ«— ·≈–‡ πâ ‡ÕπÁ °“√º“à μ¥— ¡¥≈°Ÿ 2. °“√°¥®ÿ¥·≈– ¢¬“¬μ—« °“√¥“¡«∏‘ ’μà“ßÊ ¡°— ®–„™μâ “¡À≈ß— °“√ºà“μ—¥ °“√π«¥ (Manual °≈â“¡‡πÈ◊Õ·≈–°√–¥Ÿ° ‡æ◊ËÕ„Àâ√Ÿª∑√ߢÕßÕ«—¬«–§ß∑’Ë and massage ‰¡àº‘¥√Ÿª‰ª °“√„™â physical modalities ‡À≈à“πÈ’ therapy) ¡—°®–¡’®ÿ¥À¡“¬„π∑“ß √’√«‘∑¬“¡“°°«à“°“√√—°…“ §«“¡ª«¥‚¥¬μ√ß ¢âÕ¡Ÿ≈∑Ë’‰¥â√—∫°“√μ’æ‘¡æå à«π„À≠à‡°Ë’¬«°—∫°“√°¥®ÿ¥ ·≈–°“√π«¥ ∑È—ß°“√∑”°“¬¿“æ∫”∫—¥·≈–°“√®—¥ °√–¥Ÿ° (chiropractic)  π—∫ πÿπ«à“¡’ª√–‚¬™πå„π °“√√°— …“Õ“°“√ª«¥À≈ß— ·≈–ª«¥°≈“â ¡‡π◊ÈÕμà“ßÊ ¡’ ¢âÕ¡Ÿ≈ à«ππâÕ¬∑’Ë«‘®—¬‡°’ˬ«°—∫ª√–‚¬™πå¢Õß°“√π«¥ μàÕ§«“¡ª«¥À≈—ß°“√ºà“μ—¥ μ—«Õ¬à“ß∑Ë’æ∫‰¥â§◊Õ °“√ 𫥇∑“â ‰¡à‰¥â™«à ¬≈¥§«“¡ª«¥À≈—ß°“√º“à μ—¥À«— „®

*** ¢âÕ·π–π”μ“à ßÊ „π·π«∑“ßæ≤— π“°“√√–ß∫— ª«¥πÈ’‰¡à„™¢à Õâ ∫ß— §—∫¢Õß°“√ªØ‘∫μ— ‘ *** μ“√“ß∑’Ë 6 √“¬≈–‡Õ¬’ ¥°“√√–ß∫— ª«¥‡©’¬∫æ≈—π‚¥¬‰¡à„™â¬“5 (μÕà ) Non-pharmacological √“¬≈–‡Õ¬’ ¥ ¢âÕ¡Ÿ≈∑“ß ∂‘μ‘ ª√–‡¥Á𠔧—≠ therapy °“√√—°…“‚¥¬„™â TENS ‡ªπì «∏‘ ’ noninvasive ∑Ëß’ à“¬ „πºªâŸ «É ¬·¢ßÁ ·√ß°“√°√–μπâÿ ¥«â ¬°√–· ø“Ñ ‚¥¬„™§â «“¡ TENS Õ“®®–¡’ 3. Transcutaneous ª≈Õ¥¿—¬‰¡à¡’º≈¢â“߇§’¬ß ∑”„ÀâºâŸªÉ«¬‡§≈Ë◊Õπ‰À«‰¥â ·√ß (amplitude) ¡“°°«à“ 15 mA  “¡“√∂≈¥§«“¡ ª√– ∑‘ ∏¿‘ “æ„π electrical nerve ‡√«Á ¢π÷È μÕâ ß°“√¬“·°âª«¥À≈ß— º“à μ¥— ‰¥Õâ ¬“à ß¡’π—¬ ”§≠— °“√√–ß—∫ª«¥ stimulation (TENS) ∂÷ß·¡ßâ “π«‘®¬— ∑ Ë’ π∫—  πÿπ«“à TENS ¡’ª√– ∑‘ ∏¿‘ “楒 ‡¡◊ËÕ„™â TENS ∑˧’ «“¡∂’Ë (frequency) 50 Hz ·≈– ‡©’¬∫æ≈π— ∫“ß „π°“√√–ß—∫§«“¡ª«¥‡©’¬∫æ≈—π¬—߉¡à¡“° ·μà°Á¡’ 100 Hz ®–™à«¬‡ √‘¡ƒ∑∏‘Ï¢Õ߬“·°âª«¥‰¥â ‡¡◊ËÕ„™â ª√–‡¿∑ 4. °“√Ωßí ‡¢¡Á ª√–‚¬™πå„π°“√≈¥§«“¡μâÕß°“√¬“·°âª«¥„π°“√ TENS √à«¡°—∫ PCA morphine À≈—ß°“√ºà“μ—¥ (Acupuncture) º“à μ—¥‰¥â ‚¥¬‡©æ“–°“√ºà“μ—¥∑¡’Ë ’‚Õ°“ ‡°‘¥‡ªπì neu- Àπâ“∑âÕßæ∫«à“™à«¬≈¥§«“¡μâÕß°“√ morphine ‰¥â °“√Ωí߇¢Á¡Õ“®®– ropathic pain μ“¡¡“ ≈¥√–¬–‡«≈“„π°“√√°— …“¥«â ¬ PCA morphine ·≈– ¡’ª√– ‘∑∏¿‘ “æ„π ‚¥¬∑—Ë«‰ª¡—°„™â TENS ‡ªìπ«‘∏’°“√‡ √‘¡√à«¡°—∫«‘∏’ Õ∫ÿ μ— °‘ “√≥凰‘¥Õ“°“√§≈Ë◊π‰ âÕ“‡®¬’ 𠇫¬’ π»√’ …–·≈– °“√√–ß—∫ª«¥ °“√Õ◊ËπÊ „π°“√√°— …“§«“¡ª«¥‡©’¬∫æ≈π— Õ“°“√ §—πμ“à ßÊ ‡©¬’ ∫æ≈π— ∫“ß ¡¢’ Õâ Àâ“¡„™â TENS „πºªŸâ É«¬∑’Ëμ—ßÈ §√√¿å„π™«à ß 3 ‡¥◊Õπ TENS §«“¡∂Ë’ Ÿß¡’ª√–‚¬™πå„π°“√≈¥§«“¡ª«¥ ª√–‡¿∑ ·√° ·≈–„πºªâŸ «É ¬∑Ë’„ ‡à §√Õ◊Ë ß°√–μπÿ⠮ߗ À«–°“√‡μπâ ¢Õß ª√–®”‡¥◊Õπ‰¥â À«— „® °“√Ωí߇¢Á¡„π°“√√–ß—∫ª«¥‡©’¬∫æ≈—π ®–‰¥âº≈¥’„π °“√§«∫§ÿ¡§«“¡ª«¥„π°“√§≈Õ¥∫ÿμ√ √—°…“Õ“°“√ ª«¥»’√…–∑Ë’‰¡à∑√“∫ “‡Àμÿ ·≈–√—°…“§«“¡ª«¥øíπ  à«π°“√√–ß—∫ª«¥À≈—ß°“√ºà“μ—¥™àÕß∑âÕß °“√Ωí߇¢Á¡ °àÕπ·≈–À≈—ß°“√ºà“μ—¥ ¡’ à«π™à«¬≈¥§«“¡μâÕß°“√ ¬“·°ªâ «¥·≈–≈¥º≈¢“â ߇§¬’ ߢÕ߬“·°ªâ «¥‰¥â 35

 ¡“§¡°“√»÷°…“‡√Õ◊Ë ß§«“¡ª«¥·Àßà ª√–‡∑»‰∑¬ ‡Õ° “√Õ“â ßÕß‘ 1. American Society of Anesthesiologists Task Force on Acute Pain Management. Clinical Guidances for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 2004;100(6):1573-81. 2. Gordon DB, Dahl JL, Miaskowski C, McCarberg B, Todd KH, Paice JA, et al. American pain society recommendations for improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force. Arch Intern Med. 2005;165(14):1574-80. 3. Australian and New Zealand College of Anaesthetists, Faculty of Pain Medicine. Acute Pain Management: Scientific Evidence. 2nd ed. Melbourne: Australian and New Zealand College of Anaesthetists, 2005. Available from http://www. anzca.edu.au/publications/acutepain.htm. Access 25/7/08. 4. Recommended guidelines for pain management programmes for adults. British Pain Society. 2007. Available from http://www.britishpainsociety_org/pub_professional.htm #pmp Access 4/8/08 5. Assessment and management of acute pain. Institute for clinical systems improvement 6th edition; 2008. Available from http://www.icsi.org/pain_acute/pain__acute__assessment_and_management_of__3.html Access 14/9/08 6. ¬ÿ«¥’ À—πμ≈ÿ “, æπ“√μ— πå √μ— π ÿ«√√≥ ¬‘È¡·¬¡â ,  ¡∫√Ÿ ≥å ‡∑¬’ π∑Õß, ‡¥◊Õπ‡æÁ≠ ÀàÕ√—μπ“‡√Ë◊Õß, √¥— ¥“ °”ÀÕ¡. °“√μ√«® Õ∫§≥ÿ ¿“æ °“√∫√‘°“√√–ß—∫ª«¥„πÀâÕßæ—°øôóπ μ“¡·π«∑“ß°“√√–ß—∫ª«¥∑Ë’ª√—∫ª√ÿß„À¡à„π‚√ß欓∫“≈»√’π§√‘π∑√å. «‘ —≠≠’ “√ 2005;31(2): 144- 52. 7. Thienthong S, Pongchapoa P, Reawsa N, ChangJam S, Kaewkot S, Uraiwan K, et al. An evaluation of pain score record form as the fifth vital sign for postoperative cares of orthopedic patients. Srinagarind Medical J 2005;20(2):78-83. 8. Numjaitaharn S, Tharnprisan P, Rongtonggul R, Chouwajaroen P, Prasertcharoensuk W, Thienthong S. Postoperative pain survey two days after Cesarean section. Srinagarind Medical J 2006;21(1):9-16. 9. Louisina State University Health Sciences Center -Shreveport. Policy: Pain Management. Available from www.sh.lsuhsc.edu/ policies/policy_manuals_via_ms_word/hospital_policy/h_5.34.0.pdf . Access on April 20, 2008 10. Newman CJ, Lolekha R, Limkittikul K, Luangxay K, Chotpitayasunondh T, Chanthavanich P. A comparison of pain scales in Thai children. Arch Dis Child 2005;90(3):269-70. 11. Dahl JB, Rosenberg J, Dirkes WE, Mogensen T, Kehlet H. Prevention of postoperative pain by balanced analgesia. Br J Anaesth 1990;64(4):518-20. 12. Jin F, Chung F. Multimodal analgesia for postoperative pain control. J Clin Anesth 2001;13(7):524-39. 13. Jensen MP, Martin SA, Cheung R. The meaning of pain relief in a clinical trial. J Pain 2005;6(6):400-6. 14. Morgan Jr. GE, Mikhail MS, Murray MJ. Clinical anesthesiology. 4th ed. Pain management. New York: Lange Medical Books; 2006.p.359-71. 15. Suraseranivongse S, Santawat U, Kraiprasit K, Petcharatana S, Prakkamodom S, Muntraporn N. Cross-validation of a composite pain scale for preschool children within 24 hours of surgery. Br J Anaesth 2001;87(3):400-5. 16. Högestätt ED, Jönsson BA, Ermund A, Andersson DA, Björk H, Alexander JP, Cravatt BF, Basbaum AI, Zygmunt PM. Conversion of acetaminophen to the bioactive N-acylphenolamine AM404 via fatty acid amide hydrolase-dependent 36 *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ≤— π“°“√√–ß∫— ª«¥π’ȉ¡à„™¢à âÕ∫—ߧ∫— ¢Õß°“√ªØ∫‘ μ— ‘ ***

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ACUTEPAIN Thai Association for the Study of Pain ISBN: 978-974-8285-72-6