Practical Dialysis in the Year 2009

Practical Dialysis in the Year 2009 28. Manns B, Doig CJ, Lee H, et al. Cost of acute renal failure requiring dialysis in the intensive care unit: clinical and resource implications of renal recovery. Crit Care Med 2003; 31:449-55. 29. Jacka MJ, Ivancinova X, Gibney RT. Continuous renal replacement therapy improves renal recovery from acute renal failure. Can J Anaesth 2005; 52:327-32. 30. Mehta RL, McDonald B, Gabbai FB, et al. A randomized clinical trial of continuous versus intermittent dialysis for acute renal failure. Kidney Int 2001; 60:1154-63. 31. Ronco C, Bellomo R, Homel P, et al. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet 2000; 356:26-30. 32. VA/NIH Acute Renal Failure Trial Network. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med 2008; 359:7-20. 88

Practical Recommendations for Central Vein Occlusion 6 Practical Recommendations for Central Vein Occlusion °”∏√ ≈≈’ “¡–≈‘ 1. ∫∑π” 2. Õ“°“√·≈–Õ“°“√· ¥ß 3. °“√«‘π‘®©¬— 4.  “‡Àμ¢ÿ Õ߇ πâ ‡≈◊Õ¥¥”„À≠àμ’∫À√Õ◊ Õ¥ÿ μ—π 5. °“√√—°…“‡ âπ‡≈Õ◊ ¥¥”„À≠àμ∫’ À√Õ◊ Õ¥ÿ μ—π 6. °“√ªÑÕß°—π°“√‡°¥‘ ‡ πâ ‡≈Õ◊ ¥¥”„À≠àμ∫’ À√◊ÕÕÿ¥μπ— 89

Practical Dialysis in the Year 2009 1. ∫∑π” ‡ âπøÕ°‡≈◊Õ¥∑’Ë·¢π∑—Èß™π‘¥ arterio-venous fistula (AVF) À√◊Õ arterio-venous graft (AVG) μà“ß °πÁ ”‡≈Õ◊ ¥º“à π∑“߇ πâ ‡≈Õ◊ ¥¥”„À≠¿à “¬„π∑√«ßÕ°¢Õß·¢π¢“â ßππ—È Ê °Õà π°≈∫—  ÀàŸ «— „® ∂“â ¡°’ “√μ∫’ À√Õ◊ Õ¥ÿ μ—π¢Õ߇ âπ‡≈◊Õ¥¥”„À≠à‡À≈à“π’È ®–∑”„Àâ°“√‰À≈¢Õ߇≈◊Õ¥‰¡à –¥«° ∑”„Àâ·√ߥ—π¿“¬„π‡ âπøÕ°‡≈◊Õ¥  ßŸ ¢π÷È (venous hypertension) ·≈–∑”„À‡â °¥‘ Õ“°“√∫«¡ Õ“°“√ª«¥·≈–Õ“°“√™“¢Õß·¢π¢“â ßππ—È Ê πÕ°®“° π’Ȭ—ßÕ“®®–∑”„À⇠âπøÕ°‡≈◊Õ¥ AVF À√◊Õ AVG  à߇≈◊Õ¥‰¥âπâÕ¬≈ß·≈– Ÿ≠‡ ’¬°“√∑”ß“π„π∑’Ë ÿ¥ ‡ âπ‡≈◊Õ¥¥”„À≠à¿“¬„π∑√«ßÕ°‰¥â·°à ‡ âπ‡≈◊Õ¥¥” subclavian (SCV), brachiocephalic (BCV) À√◊Õ innominate vein (INV) ·≈– superior vena cava (SVC) À√◊Õ‡√’¬°‚¥¬√«¡«à“ ‡ âπ‡≈◊Õ¥¥” mediastinal À√◊Õ‡ âπ‡≈◊Õ¥¥” central §”«à“ central vein ®÷ßÀ¡“¬∂÷߇ âπ‡≈◊Õ¥¥”‡À≈à“π’È ‡ âπ‡≈◊Õ¥ SCV ∑—Èߴ⓬·≈– ¢«“®–√∫— ‡≈Õ◊ ¥®“°·¢π´“â ¬·≈–·¢π¢«“º“à π∑“߇ πâ ‡≈Õ◊ ¥¥” cephalic ·≈–‡ πâ ‡≈Õ◊ ¥¥” axillary ®“°·¢π ·μ≈à –¢“â ß ·≈–√«¡°∫— ‡ πâ ‡≈Õ◊ ¥¥” internal jugular (IJV) ´ß÷Ë √∫— ‡≈Õ◊ ¥®“° «à π»√’ …– ‡ªπì ‡ âπ‡≈◊Õ¥ BCV ‡ âπ‡≈◊Õ¥ BCV ¥â“π¢«“®– ¡’≈—°…≥– —Èπ·≈–∑”¡ÿ¡‰¡à¡“°π—°°—∫ ‡ âπ‡≈◊Õ¥ IJV ·μà®–∑”¡ÿ¡ª√–¡“≥ 90 Õß»“°∫— ‡ πâ ‡≈Õ◊ ¥ SVC ‡ πâ ‡≈Õ◊ ¥ BCV ¥“â π ´â“¬®–¬“«°«à“ ‚¥¬ à«πμâπ®–∑”¡ÿ¡ ª√–¡“≥ 100 Õß»“°—∫‡ âπ‡≈◊Õ¥ IJV ·≈– SCV ¥â“π´â“¬ ®“°π—Èπ®–æ“¥‡©’¬ß‡¢â“À“ ≈”μ—« ·≈–√«¡μ—«°—∫‡ âπ‡≈◊Õ¥ BCV ¥â“π ¢«“ ‡ªìπ‡ âπ‡≈◊Õ¥ SVC ‚¥¬®–∑”¡ÿ¡ ª√–¡“≥ 100 Õß»“°∫— ‡ πâ ‡≈Õ◊ ¥ BCV ¥“â π ¢«“·≈– SVC ‡™àπ‡¥’¬«°—π ®“°π—Èπ ‡ âπ‡≈◊Õ¥ SVC ®–π”‡≈◊Õ¥‡¢â“ ŸàÀ—«„®ÀâÕß ∫π¥â“π¢«“ (right atrium) (√Ÿª∑’Ë 1) ‡ âπ‡≈◊Õ¥¥”„À≠à®–¡’°“√μ’∫ √Ÿª∑’Ë 1 (stenosis À√Õ◊ incomplete obstruction) ‡¡ÕË◊ · ¥ß‡ πâ ‡≈Õ◊ ¥¥”„À≠¿à “¬„π∑√«ßÕ° ¡’ ¢ π “ ¥ ≈ ¥ ≈ ß ‡ ¡◊Ë Õ ‡ ª √’ ¬ ∫ ‡ ∑’ ¬ ∫ °— ∫ ‡ âπ‡≈◊Õ¥¢â“߇§’¬ß∑’Ë¥’ ‚¥¬∑—Ë«‰ª®–„Àâ A ‡ πâ ‡≈◊Õ¥¥” subclavian (SCV) 𑬓¡¢Õß°“√μ’∫‡¡◊ËÕ¡’¢π“¥‡≈Á°≈ß¡“° B ‡ âπ‡≈Õ◊ ¥¥” internal jugular (IJV) °«à“ 50% À√◊Õª√“°Ø‡ âπ‡≈◊Õ¥¥” C ‡ πâ ‡≈Õ◊ ¥¥” brachiocephalic (BCV) À√Õ◊ innominate collateral ‡ÀÁπ™—¥‡®π√à«¡¥â«¬ ∂â“μ’∫ π‘∑ ·≈–‡≈◊Õ¥‰¡à “¡“√∂‰À≈ºà“π‰¥â‡√’¬°«à“ (IMV) ‡°‘¥°“√Õÿ¥μ—π (occlusion À√◊Õ complete D ‡ πâ ‡≈◊Õ¥¥” superior venacava (SVC) E À«— „®¥“â π¢«“∫π (right atrium) 90

Practical Recommendations for Central Vein Occlusion obstruction) „π°√≥’π’È ∂Ⓡ âπ‡≈◊Õ¥¥” collateral π”‡≈◊Õ¥°≈—∫ àŸÀ—«„®∑“ßÕ◊Ëπ‰¡à¥’‡æ’¬ßæÕ ¡—°®–æ∫°âÕπ ‡≈◊Õ¥Õ¬àŸ‡Àπ◊ÕμàÕ√Õ¬μ’∫À√◊ÕÕÿ¥μ—π√à«¡¥â«¬ 2. Õ“°“√·≈–Õ“°“√· ¥ß ∂Ⓡ âπ‡≈◊Õ¥ SCV μ’∫À√◊ÕÕÿ¥μ—π®–∑”„Àâ‡≈◊Õ¥®“°·¢π¢â“߇¥’¬«°—π‰¡à “¡“√∂‰À≈°≈—∫‡¢â“ Ÿà À—«„®‰¥â –¥«° ·≈–∂Ⓡ âπ‡≈◊Õ¥ BCV μ’∫À√◊ÕÕÿ¥μ—π®–∑”„Àâ‡≈◊Õ¥®“°·¢π·≈–»’√…–¢â“߇¥’¬«°—π‰¡à  “¡“√∂‰À≈°≈—∫ àŸÀ—«„®‰¥â –¥«°‡™àπ°—π ·μà∂Ⓡ âπ‡≈◊Õ¥ SVC μ’∫À√◊ÕÕÿ¥μ—π ‡≈◊Õ¥®“°·¢π·≈–»’√…– ∑—Èß Õߢâ“ß®–‰À≈°≈—∫‰¥â¬“° ∑”„À⇠âπ‡≈◊Õ¥¥” à«πª≈“¬≈”¥—∫°àÕπ‡ âπ‡≈◊Õ¥¥”„À≠à¡’·√ߥ—π¿“¬„π ‡ âπ‡≈◊Õ¥ Ÿß ‡°‘¥°“√æÕß‚μ ‡°‘¥°“√·¢Áßμ÷ß ·≈–∑”„À⇰‘¥Õ“°“√∫«¡¢Õß·¢π·≈–„∫Àπâ“μ“¡·μà μ”·Àπàß°“√μ’∫À√◊ÕÕÿ¥μ—π¢Õ߇ âπ‡≈◊Õ¥ Õ¬à“߉√°Áμ“¡ºŸâªÉ«¬¡—°®–‰¡à¡’Õ“°“√ À√◊Õ¡’Õ“°“√∫«¡ ·μà ∫«¡§ß∑’Ë ·≈–ºŸâªÉ«¬∑πÕ“°“√∫«¡‰¥â ‡°‘¥‡π◊ËÕß®“°ª√‘¡“≥‡≈◊Õ¥∑’ˉÀ≈ºà“π¡’ª√‘¡“≥∑’ËπâÕ¬ ·≈– ‡ âπ‡≈◊Õ¥¥” collateral  à߇≈◊Õ¥ºà“π°≈—∫ ŸàÀ—«„®∑“ßÕ◊Ëπ‰¥âÕ¬à“ßæÕ‡æ’¬ß 2.1 ºªŸâ «É ¬¡‡’  πâ øÕ°‡≈Õ◊ ¥∑·’Ë ¢π¢“â ߇¥¬’ «°∫— ∑¡Ë’ ‡’  πâ ‡≈Õ◊ ¥¥”„À≠μà ∫’ À√Õ◊ Õ¥ÿ μπ— ·≈–‰¡¡à Õ’ “°“√ ∫«¡ ª√–¡“≥ 50% ¢ÕߺªâŸ «É ¬®–‰¡æà ∫Õ“°“√∫«¡ Õ∏∫‘ “¬‰¥®â “° 1) °“√μ∫’ §Õà ¬‡ªπì §Õà ¬‰ª·≈– ¡’‡ âπ‡≈◊Õ¥¥” collateral §àÕ¬Ê ª√—∫μ—«∑—π À√◊Õ 2) ‡ âπøÕ°‡≈◊Õ¥¡’ª√– ‘∑∏‘¿“扡॒ ‡™àπ ‡°‘¥°“√μ’∫μ—π ¢Õ߇ âπøÕ°‡≈◊Õ¥√à«¡¥â«¬ ∑”„Àâª√‘¡“≥‡≈◊Õ¥∑’ˉÀ≈ºà“π√Õ¬μ’∫¡’‰¡à¡“° ·≈–‡ âπ‡≈◊Õ¥¥” collateral  “¡“√∂√–∫“¬‡≈◊Õ¥‰¥â∑—π „π°√≥’À≈—ßπ’È ∂Ⓡ âπøÕ°‡≈◊Õ¥‰¥â√—∫°“√·°â‰¢√Õ¬μ’∫À√◊ÕÕÿ¥μ—π ª√‘¡“≥ ‡≈◊Õ¥®–‰À≈‡æ‘Ë¡¡“°¢÷Èπ ·≈–∑”„À⇰‘¥Õ“°“√∫«¡¢÷Èπ 2.2 ºªŸâ «É ¬¡‡’  πâ øÕ°‡≈Õ◊ ¥∑·Ë’ ¢π¢“â ߇¥¬’ «°∫— ∑¡’Ë ‡’  πâ ‡≈Õ◊ ¥¥”„À≠μà ∫’ À√Õ◊ Õ¥ÿ μπ— ·≈–¡Õ’ “°“√∫«¡ °√≥π’ ‡’È  πâ øÕ°‡≈Õ◊ ¥¡°— ®–¡°’ “√∑”ß“π¥’∑”„À¡â ª’ √¡‘ “≥‡≈Õ◊ ¥‰À≈º“à π¡“°‚¥¬∑«—Ë ‰ª®–¡“° °«à“‡¡◊ËÕ‰¡à¡’‡ âπøÕ°‡≈◊Õ¥Õ¬à“ßπâÕ¬ 10 ‡∑à“ ª√‘¡“≥‡≈◊Õ¥∑’Ë¡“°π’È¡—°®–‰¡à “¡“√∂‰À≈ºà“π√Õ¬μ’∫À√◊Õ Õÿ¥μ—π¢Õ߇ âπ‡≈◊Õ¥¥”„À≠à‰¥â‡æ’¬ßæÕ ‡ âπ‡≈◊Õ¥¥” collateral ®”π«π¡“°®–π”‡≈◊Õ¥°≈—∫∑“ßÕ◊Ëπ ∑”„Àâ ¡’‡ âπ‡≈◊Õ¥¢Õ¥‡°‘¥¢÷Èπ‡ªìπ®”π«π¡“°∑’Ë∫√‘‡«≥À—«‰À≈à Àπâ“Õ° ·≈–§Õ ∂â“√–∫“¬‰¥â∑—π°Á‰¡à‡°‘¥Õ“°“√ ∫«¡ ∂Ⓣ¡à “¡“√∂√–∫“¬‰¥â∑—π°Áª√“°ØÕ“°“√∫«¡¢Õß·¢πÀ√◊Õ„∫Àπâ“ ‚¥¬∑—Ë«‰ªÕ“°“√μ’∫®–§àÕ¬Ê ‡æ‘Ë¡¡“°¢÷Èπ·≈–‡ âπ‡≈◊Õ¥¥” collateral  “¡“√∂ª√—∫μ—«∑—π ®÷ß∫«¡‰¡à¡“°·≈–ºâŸªÉ«¬∑πÕ“°“√‰¥â „π∫“ߧ√ßÈ— ®–¡Õ’ “°“√∫«¡Õ¬“à ß©∫— æ≈π— ·≈–ºªâŸ «É ¬∑πμÕà Õ“°“√∫«¡‰¡‰à ¥â ¡°— ‡°¥‘ „π 3 °√≥’ ¥ß— μÕà ‰ªπÈ’ 1) ‡°¥‘ ®“°°“√∑”‡ πâ øÕ°‡≈Õ◊ ¥„À¡·à ≈–‡ πâ ‡≈Õ◊ ¥¡ª’ √– ∑‘ ∏¿‘ “æÕ¬“à ß¡“° §Õ◊ ¡ª’ √¡‘ “≥‡≈Õ◊ ¥ ‰À≈ºà“π¡“° ∑’Ë·¢π¢â“߇¥’¬«°—π°—∫∑’Ë¡’‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫μ—π 2) ‡°‘¥„π°√≥’∑’ˇ âπøÕ°‡≈◊Õ¥‡¥‘¡‰¥â√—∫ °“√·°â‰¢ ∑”„Àâ¡’ª√‘¡“≥‡≈◊Õ¥‰À≈ºà“π¡“°¢÷Èπ „π·¢π¢â“߇¥’¬«°—∫∑’Ë¡’‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫μ—π ·≈– 3) ‡°‘¥°âÕπ‡≈◊Õ¥Õÿ¥μ—πÕ¬à“ß©—∫æ≈—π∑’ˇ âπ‡≈◊Õ¥¥”„À≠à∑’Ëμ’∫μ—πÕ¬Ÿà·≈â« ∑—ÈßÀ¡¥π’È®–‡°‘¥Õ“°“√∫«¡Õ¬à“ß ¡“°‡πÕË◊ ß®“°‡ πâ ‡≈Õ◊ ¥¥” collateral ¬ß— ‰¡ à “¡“√∂ª√∫— μ«— ∑”ß“π∑¥·∑𠉥∑â π— ·≈–μÕâ ß„™‡â «≈“ª√–¡“≥ 91

Practical Dialysis in the Year 2009 1-2  —ª¥“Àå ·¢π®–¬ÿ∫∫«¡≈ßμ“¡ª√– ‘∑∏‘¿“æ¢Õ߇ âπ‡≈◊Õ¥¥” collateral „π∫“ß√“¬Õ“®®–¬ÿ∫∫«¡ ‡À¡◊Õπª°μ‘∑—ÈßÊ ∑’Ë¡’‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥μ—πÕ¬à“ß¡“° πÕ°®“°Õ“°“√∫«¡∑’Ë·¢π·≈–„∫Àπâ“ ¬—ßæ∫Õ“°“√∫«¡∑’ˇμâ“π¡‰¥â ‡π◊ËÕß®“°‡ âπ‡≈◊Õ¥¥”∑’Ë √—∫‡≈◊Õ¥®“°∫√‘‡«≥‡μâ“π¡ ®–π”‡≈◊Õ¥°≈—∫ ŸàÀ—«„®∑“߇ âπ‡≈◊Õ¥¥” axillary ·≈– internal thoracic ´÷Ëß®– μÕâ ߉À≈º“à π∑“߇ πâ ‡≈Õ◊ ¥ BCV1 Õ“°“√Õπ◊Ë Ê ∑æ’Ë ∫‰¡∫à Õà ¬ ‰¥·â °à °“√‡°¥‘ πÈ”„π‡¬Õ◊Ë À¡ÿâ ªÕ¥¢“â ß´“â ¬Õ∏∫‘ “¬ ®“°‡ âπ‡≈◊Õ¥¥” intercostal ∑“ߥâ“π´â“¬´÷Ëß√—∫‡≈◊Õ¥®“°‡¬◊ËÕÀÿ⡪ե®–‰À≈‡¢â“ Ÿà‡ âπ‡≈◊Õ¥¥” superior intercostal ·≈–‡ âπ‡≈◊Õ¥‡ âππ’È®–°≈—∫ àŸÀ—«„®ºà“π∑“߇ âπ‡≈◊Õ¥ SCV ·≈–À√◊Õ BCV ¥â“π´â“¬ ¥—ßπ—Èπ‡¡◊ËÕ¡’ °“√μ’∫μ—π®–∑”„À⇰‘¥πÈ”„π‡¬◊ËÕÀÿ⡪ե‰¥1â Õ“°“√Õ◊ËπÊ ∑’Ë¡—°®–μ√«®æ∫‰¥â·°àÕ“°“√∑’ˇ°‘¥„π√–À«à“ß∑”°“√øÕ°‡≈◊Õ¥ ®–μ√«®æ∫«à“¡’ ·√ߥ—π„π‡ âπ‡≈◊Õ¥¥” Ÿß Õ“®∑”„Àâ°¥‡≈◊Õ¥À≈—ß®“°∂Õπ‡¢Á¡øÕ°‡≈◊Õ¥À¬ÿ¥‰¥â¬“° ·≈–Õ“®∑”„Àâ‰¡à  “¡“√∂„™â blood pump flow ‰¥âμ“¡∑’ËμâÕß°“√ ‡π◊ËÕß®“°¡’‡ ’¬ß‡μ◊Õπ®“°‡§√◊ËÕß Õ—π‡π◊ËÕß®“°·√ߥ—π„π ‡ πâ ‡≈Õ◊ ¥¥” ßŸ ∑”„À°â “√øÕ°‡≈Õ◊ ¥‰¡‡à 欒 ßæÕ ºªŸâ «É ¬Õ“®®–¡Õ’ “°“√ª«¥·¢πÀ√Õ◊ ¡’ paresthesia √«à ¡¥«â ¬ πÕ°®“°π—Èπ¬—ßÕ“®®–æ∫Õ“°“√∫«¡·¥ß∑’˺‘«Àπ—ߧ≈⓬°“√μ‘¥‡™◊ÈÕ ·≈–∂â“¡’·º≈‡°‘¥°—∫·¢π¢â“ß∑’Ë¡’ °“√Õÿ¥μ—π¢Õ߇ âπ‡≈◊Õ¥¥”„À≠à ·º≈®–À“¬™â“ ·≈–„π∫“ß√“¬‡ âπøÕ°‡≈◊Õ¥Õ“®®–‡°‘¥°“√Õÿ¥μ—π (thrombosis) ‡°‘¥¢÷Èπ ‡¡◊ËÕ¡’°“√ªî¥‡ âπøÕ°‡≈◊Õ¥À√◊Õ‡°‘¥°“√Õÿ¥μ—π¢Õ߇ âπøÕ°‡≈◊Õ¥ Õ“°“√μà“ßÊ ‡À≈à“ π’È¡—°®–À“¬‰ª‡°◊Õ∫À¡¥ 3. °“√«‘π®‘ ©¬— 3.1 °“√«π‘ ‘®©¬— ¥â«¬ venogram °“√«π‘ ®‘ ©¬— ∑”‰¥¥â «â ¬°“√©¥’ iodine based contrast media ‡¢“â ∑“߇ πâ ‡≈Õ◊ ¥¥”∑·’Ë ¢π¢“â ߇¥¬’ « °—∫∑’Ë ß —¬«à“¡’‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫μ—π (venogram) ‡æ◊ËÕ„Àâ‡ÀÁπ‡ âπ‡≈◊Õ¥¥”„À≠à¿“¬„π∑√«ßÕ° ∑” venogram ∑“߇ πâ ‡≈Õ◊ ¥¥” femoral ∑¢’Ë “Àπ∫’ ‡™πà ‡¥¬’ «°π— ·μ¿à “æ∑‡’Ë °¥‘ ®“°°“√‰À≈¬Õâ π∑“ߢÕ߇ πâ ‡≈Õ◊ ¥ ∑”„À‰â ¡ à “¡“√∂‡ÀπÁ §«“¡º¥‘ ª°μ‰‘ ¥‡â À¡Õ◊ π°“√∑”venogram ®“°·¢π ´ß÷Ë ¡°’ “√‰À≈μ“¡°“√‰À≈¢Õ߇≈Õ◊ ¥ ®–«‘π‘®©—¬«à“¡’°“√μ’∫ ‡¡◊ËÕ‡ âπ‡≈◊Õ¥‡≈Á°≈ß¡“°°«à“ 50%2 „π∫“ߧ√—Èß¿“æ X-ray ∑’ˇÀÁπ‰¥â®“°°“√∂à“¬ ¿“æ 2 ¡‘μ‘ ·¡â«à“®–∑”°“√≈∫¿“æ background ÕÕ°‰ª·≈â«°Áμ“¡ (digital subtraction angiogram À√◊Õ venogram) Õ“®®–‡ÀÁπ√Õ¬μ’∫μ—𬓰 ‡π◊ËÕß®“°‡ âπ‡≈◊Õ¥¥”¡—°®–¡’¢π“¥∑’Ë„À≠à·≈–§¥‡§’Ȭ« ∑”„Àâ‡ÀÁπ ·≈–ª√–‡¡‘π√Õ¬μ’∫À√◊ÕÕÿ¥μ—π‰¥â¬“° ¥—ßπ—Èπ¡—°„™â°“√«‘π‘®©—¬∑“ßÕâÕ¡«à“¡’°“√μ’∫À√◊ÕÕÿ¥μ—π∑’Ë√ÿπ·√ß ®“°°“√¡‡’  πâ ‡≈Õ◊ ¥¥” collateral ®”π«π¡“°·≈–‡¥πà ™¥— √«à ¡°∫— °“√æ∫«“à ¡·’ √ß¥π—  ßŸ „π‡ πâ ‡≈Õ◊ ¥¥”°Õà π μ”·Àπà߇ âπ‡≈◊Õ¥¥”„À≠àμ’∫μ—π 3.2 °“√«‘π‘®©—¬¥â«¬‡§√ËÕ◊ ß ultrasound  ”À√—∫°“√„™â‡§√◊ËÕß ultrasound ´÷Ë߇ªìπ non-invasive „π°“√™à«¬«‘π‘®©—¬‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫ À√◊ÕÕÿ¥μ—π∑”‰¥â¬“° ‡π◊ËÕß®“°‡§√◊ËÕß ultrasound ‰¡à«à“®–‡ªìπ mode gray scale À√◊Õ mode color-flow duplex ®–‡ÀÁπ‰¥â‡©æ“–‡ âπ‡ âπ‡≈◊Õ¥ SCV  à«πª≈“¬ ¬°‡«âπ¡’°“√μ’∫À√◊ÕÕÿ¥μ—π À√◊Õ¡’°âÕπ‡≈◊Õ¥Õ¬ÿà∑’Ë 92

Practical Recommendations for Central Vein Occlusion ‡ âπ‡≈◊Õ¥ SCV  à«πª≈“¬ ®÷ß®–„Àâ°“√«‘π‘®©—¬‰¥â ‰¥â¡’ß“π«‘®—¬‡ª√’¬∫‡∑’¬∫°“√„™â‡§√◊ËÕß ultrasound °—∫ °“√∑” digital subtraction venogram æ∫«à“‡§√◊ËÕß ultrasound ¡’ sensitivity μË” μàÕ¡“‰¥â¡’°“√„™â ultrasound ™à«¬„π°“√«‘π‘®©—¬∑“ßÕâÕ¡ ¥â«¬°“√„™â mode ¢Õß doppler ®—∫ ∑’ˇ âπ‡≈◊Õ¥ IJV ·≈–‡ âπ‡≈◊Õ¥¥” axillary À√◊Õ‡ âπ‡≈◊Õ¥ SCV  à«πª≈“¬ ‡ª√’¬∫‡∑’¬∫°—π∑—Èߢâ“ߢ«“·≈– ¢â“ߴ⓬ ∂Ⓡ âπ‡≈◊Õ¥¥”„À≠àª°μ‘¥’ §≈◊Ëπ doppler ®–¡’°“√‡ª≈’ˬπ·ª≈ßμ“¡°“√À“¬„® (respiratory phasicity) ¡’°“√‡ª≈’ˬπ·ª≈ßμ“¡°“√‡μâπ¢ÕßÀ—«„® (cardiac pulsatility) ·≈–æ∫«à“ “¡“√∂μ√«®æ∫°“√  –∑âÕπ°≈—∫¢Õߧ≈◊Ëπ®“°À—«„®ÀâÕß∫π¢«“ (polyphasic atrial waveform) ∂Ⓡ âπ‡≈◊Õ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥ μπ— ∑‡Ë’  πâ ‡≈Õ◊ ¥ SCV ®–æ∫§«“¡º¥‘ ª°μ¢‘ Õß doppler ∑’‡Ë  πâ ‡≈Õ◊ ¥¥” axillary À√Õ◊ ‡ πâ ‡≈Õ◊ ¥ SCV  «à πª≈“¬ ∂â“¡’°“√μ’∫À√◊ÕÕÿ¥μ—π¢Õ߇ âπ‡≈◊Õ¥¥” BCV ®–æ∫§«“¡º‘¥ª°μ‘¢Õß doppler ∑’ˇ âπ‡≈◊Õ¥ IJV ·≈– SCV ·≈–∂“â ¡°’ “√μ∫’ À√Õ◊ Õ¥ÿ μπ— ∑‡’Ë  πâ ‡≈Õ◊ ¥BCV ∑ß—È  Õߢ“â ßÀ√Õ◊ ∑‡’Ë  πâ ‡≈Õ◊ ¥SVC ®–æ∫§«“¡º¥‘ ª°μ¢‘ Õß doppler ∑’ˇ âπ‡≈◊Õ¥¥”∑—Èß ’ˇ âπ (¥Ÿ√Ÿª∑’Ë 2)3, 4 √ªŸ ∑Ë’ 2 · ¥ß°“√„™â Doppler ultrasound „π°“√«π‘ ®‘ ©¬— ‡ âπ‡≈Õ◊ ¥¥”„À≠μà ’∫À√Õ◊ Õ¥ÿ μπ— 93

Practical Dialysis in the Year 2009 æ∫«à“°“√μ√«®‰¡àæ∫ polyphasic atrial waveform ∑’ˇ âπ‡≈◊Õ¥ IJV ·≈–/À√◊Õ axillary vein ®–¡’ sensitivity 79.60%4 „π°“√«‘π‘®©—¬‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥μâπ ·≈–æ∫«à“°“√μ√«®‰¡àæ∫ respiratory phasicity À√◊Õ cardiac pulsatility ¡’ sensitivity ·≈– specificity „π°“√«‘π‘®©—¬‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥ μ—π ‡∑à“°—∫ 75% ·≈– 100%  ”À√—∫°“√μ√«®∑’ˇ âπ‡≈◊Õ¥ IJV ·≈–‡∑à“°—∫ 100% ·≈– 100%  ”À√—∫ ‡ âπ‡≈◊Õ¥ SCV μ“¡≈”¥—∫3 Õ¬à“߉√°Áμ“¡®–μ√«®æ∫§«“¡º‘¥ª°μ‘¢Õß doppler ‡¡◊ËÕ¡’°“√μ’∫Õ¬à“ß¡“° À√◊Õ‡°‘¥°“√Õÿ¥μ—π¢÷Èπ·≈â« §◊Õ¡’§«“¡√ÿπ·√ß¡“° æ∫«à“°“√¡’ “¬ hemodialysis catheter ∑’˧Չ¡à‰¥â∑”„Àâ doppler waveform ‡À≈à“π’ȇª≈’ˬπ·ª≈߉ª ·μàß“π«‘®—¬¢â“ßμâππ’È∑”„πºŸâªÉ«¬∑’ˬ—߉¡à‰¥â∑”‡ âπøÕ°‡≈◊Õ¥∑’Ë ·¢π ®÷ß¡’ª√–‚¬™πå„π°“√ª√–‡¡‘π‡ âπ‡≈◊Õ¥¥”„À≠à°àÕπÀ√◊ÕÀ≈—ß°“√„ à “¬ hemodialysis catheter À√◊Õ ª√–‡¡π‘ °Õà π°“√∑”‡ πâ øÕ°‡≈Õ◊ ¥ AVF À√Õ◊ AVG ∑·’Ë ¢π«“à ¡‡’  πâ ‡≈Õ◊ ¥¥”„À≠‡à  πâ „¥μ∫’ À√Õ◊ Õ¥ÿ μπ— À√Õ◊ ‰¡à 3.3 °“√«‘π‘®©—¬¥«â ¬«∏‘ Õ◊ ◊ËπÊ πÕ°‡Àπ◊Õ®“° 2 «‘∏’¥—߉¥â°≈à“«„π¢â“ßμâπ ªí®®ÿ∫—π°“√∑” MR angiogram ·≈– CT venogram  “¡“√∂ √â“ß¿“æ “¡¡‘μ‘¢Õ߇ âπ‡≈◊Õ¥¥”„À≠à ·≈– “¡“√∂«‘π‘®©—¬‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥μ—π‰¥â ¥’‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫°“√∑” venogram πÕ°®“°π—Èπ¬—ß “¡“√∂∫Õ° “‡Àμÿ°“√μ’∫À√◊ÕÕÿ¥μ—π∑’ˇ°‘¥®“° extraluminal ‰¥â¥’5-7 4.  “‡Àμ¢ÿ Õ߇ âπ‡≈◊Õ¥¥”„À≠μà ∫’ À√Õ◊ Õÿ¥μ—π 4.1 Hemodialysis catheter: Risk factors °“√μ∫’ À√Õ◊ Õ¥ÿ μπ— ¢Õ߇ πâ ‡≈Õ◊ ¥¥”„À≠¡à °— ‡°¥‘ ®“°°“√‡§¬„  à “¬ hemodialysis catheter (HD Cath) ‚¥¬‡©æ“–∂â“„ àºà“π‡ âπ‡≈◊Õ¥ SCV À√◊Õ„π∫“ߧ√—È߇°‘¥®“°°“√„ àºà“π‡ âπ‡≈◊Õ¥ IJV „π¬ÿ§μâπÊ ∑’Ë ‡√‘Ë¡„ à “¬ HD Cath ¡—°®–·π–π”„Àâ„ à∑’ˇ âπ‡≈◊Õ¥ SCV ‡π◊ËÕß®“°μ”·ÀπàߢÕ߇ âπ‡≈◊Õ¥∑’Ë„™â·∑ß¡’∑“ß ‡¥‘π∑’Ë·πàπÕπ∑”„Àâ·∑߇ âπ‰¥âßà“¬ ·≈–‡¡◊ËÕ„ à‡ √Á®  à«π¢Õß HD Cath ∑’ËÕ¬ŸàπÕ°√à“ß°“¬ “¡“√∂À≈∫Õ¬àŸ „μâ‰Àª≈“√â“·≈–„μâ√ࡺⓉ¥â ·μàÀ≈—ß®“°π—Èπ‰¡àπ“π°Á¡’√“¬ß“π°“√‡°‘¥¿“«–‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥ μπ— ¡“°¢π÷È μÕà ¡“®ß÷ ‰¥·â π–π”„À„â   à “¬ HD Cath ∑“߇ πâ ‡≈Õ◊ ¥ IJV ¢“â ߢ«“ ∂“â ‰¡ à “¡“√∂„ ∑à “ß‡ πâ ‡≈Õ◊ ¥ IJV ¢â“ߢ«“ „Àâ‡≈◊Õ°‡ âπ‡≈◊Õ¥ IJV ¥â“π´â“¬°àÕπ ´÷Ëß°Á¡’¢âÕ‡ ’¬¥—ß®–‰¥â°≈à“«μàÕ‰ª ‡¡◊ËÕ‰¡à “¡“√∂„ à∑“ß ‡ âπ‡≈◊Õ¥ IJV ‰¥â·≈â« ®÷ߧ‘¥∂÷ß°“√„ à∑“߇ âπ‡≈◊Õ¥ SCV ´÷Ëߧ«√‡≈◊Õ°‡¡◊ËÕ§‘¥«à“‰¡à∑”‡ âπøÕ°‡≈◊Õ¥∑’Ë·¢π ¢â“ßπ—Èπ À√◊Õ‰¡à¡’∑“߇≈◊Õ°Õ◊Ëπ·≈â« ¡’√“¬ß“π°“√∑” venogram „πºŸâªÉ«¬À≈—ß®“°∂Õ¥ “¬ HD Cath ∑“߇ âπ‡≈◊Õ¥ SCV 24-48 ™—Ë«‚¡ß ®”π«π 42 √“¬ ·≈–∑” venogram μàÕ¡“ 1 ‡¥◊Õπ 3 ‡¥◊Õπ ·≈– 6 ‡¥◊Õπμ“¡≈”¥—∫ æ∫«à“¡’ ‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥μ—π‚¥¬„Àâ𑬓¡«à“μ’∫¡“°°«à“ 30% ®”π«π 52.4% °“√∑” venogram ∑’Ë √–¬–‡«≈“ 1 ‡¥◊Õπ æ∫«à“¡’®”π«π°“√μ’∫μ—π‡∑à“‡¥‘¡ ·μà∑’Ë√–¬–‡«≈“ 3 ‡¥◊Õπ æ∫«à“¡’°“√´àÕ¡·´¡·≈– ∑”„Àâ√Õ¬μ’∫À√◊ÕÕÿ¥μ—πÀ“¬‰ª‰¥â∂÷ß 45.4% ·≈–∑’Ë√–¬–‡«≈“ 6 ‡¥◊Õπ æ∫«à“‡À¡◊Õπ‡¥‘¡ ∑⓬∑’Ë ÿ¥¡’ °“√μ’∫À√◊ÕÕÿ¥μ—π‡À≈◊ÕÕ¬Ÿà®”π«π 29% ºâŸªÉ«¬∑’Ë¡’‡ âπ‡≈◊Õ¥¥”„À≠àª°μ‘·μàμâπ ®–‰¡àæ∫§«“¡º‘¥ª°μ‘ „π√–¬–μàÕ¡“ ªí®®—¬∑’Ë∑”„À⇰‘¥°“√μ’∫À√◊ÕÕÿ¥μ—π„π¢—ÈπμÕπ ÿ¥∑⓬§◊Õ √–¬–‡«≈“∑’Ë„ à “¬ (‡ª√’¬∫ 94

Practical Recommendations for Central Vein Occlusion ‡∑’¬∫√–À«à“ß 49 «—π ·≈– 29 «—π) √–¬–‡«≈“∑’Ë∑”°“√øÕ°‡≈◊Õ¥ºà“π∑“ß “¬ HD Cath ®”π«π§√—Èß„π °“√„ à “¬ ·≈–°“√μ‘¥‡™◊ÈÕ¢Õß “¬ HD Cath8 ‡√◊ËÕß°“√μ‘¥‡™◊ÈÕ¢Õß “¬ HD Cath π—Èπ¡’√“¬ß“π 1 ©∫—∫ ‰¥â ∑” venogram À≈—ß®“°∂Õ¥ “¬ HD Cath ∑“ß SCV ¡“°°«à“ 6 ‡¥◊Õπ ®”π«π 2 °≈ÿà¡ °≈ÿà¡·√°∂Õ¥  “¬‡π◊ËÕß®“°¡’°“√μ‘¥‡™◊ÈÕ∑—Èß®“°°“√μ‘¥‡™◊ÈÕ„π°√–· ‡≈◊Õ¥ °“√μ‘¥‡™◊ÈÕ√Õ∫√ÕŸ Õ°¢Õß “¬ ·≈–°“√¡’‰¢â ‰¡à∑√“∫ “‡Àμÿ·μàæ∫‡™◊ÈÕ∑’˪≈“¬ “¬ ®”π«π 16 √“¬ °≈ÿà¡ Õß∂Õ¥ “¬®“° “‡ÀμÿÕ◊ËπÊ 14 √“¬ æ∫«à“ ¡’°“√μ’∫À√◊ÕÕÿ¥μ—π∑’ˇ âπ‡≈◊Õ¥ SCV „π°≈ÿà¡·√°®”π«π 75% ·≈–„π°≈ÿà¡ Õß®”π«π 25% ®÷ßμ—È߇ªìπ¢âÕ  —߇°μ«à“°“√μ‘¥‡™◊ÈÕ®–∑”„Àâæ∫‚Õ°“ ‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥μ—π¡“°¢÷Èπ9  ”À√∫— °“√‡ª√¬’ ∫‡∑¬’ ∫√–À«“à ß°“√„  à “¬∑“߇ πâ ‡≈Õ◊ ¥ SCV ·≈– IJV ¡º’ ∑⟠” venogram À≈ß— ®“°∂Õ¥ “¬ HD Cath ∑’Ë„ à„π‡ âπ‡≈◊Õ¥ SCV π“πª√–¡“≥ 12 «—π ®”π«π 32 √“¬ ‡ª√’¬∫‡∑’¬∫°—∫∑’Ë„ à „π‡ âπ‡≈◊Õ¥ IJV π“πª√–¡“≥ 16 «—π ®”π«π 20 √“¬ æ∫«à“¡’‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥μ—π„π°≈ÿà¡ SCV 50% ·μà‰¡àæ∫‡≈¬„π°≈ÿà¡ IJV10 μàÕ¡“‰¥â¡’°“√∑” venogram „πºŸâªÉ«¬∑’ˬ—ß¡’ “¬ HD Cath ∑’Ë IJV ·≈– SCV °≈ÿà¡≈– 50 √“¬ ·≈–„ àπ“πª√–¡“≥ 31 «—π æ∫‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥μ—π„π°≈ÿà¡ SCV 42% ·≈–°≈ÿà¡ IJV 10% „π°“√»÷°…“π’È¡’°“√„ à “¬ HD Cath ∑’Ë SCV ¢â“ߢ«“ 58% ·≈– IJV ¢â“ߢ«“ 78%8 · ¥ß„Àâ‡ÀÁπ«à“°“√„ à “¬ HD Cath ∑“߇ âπ‡≈◊Õ¥ IJV ¡’‚Õ°“ æ∫‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥μ—π πÕâ ¬ Õ¬“à ߉√°μÁ “¡√“¬ß“πμÕà ¡“æ∫«“à °“√„  à “¬∑“߇ πâ ‡≈Õ◊ ¥ IJV °æÁ ∫Õ∫ÿ μ— °‘ “√≥¢å Õ߇ πâ ‡≈Õ◊ ¥¥”„À≠à μ’∫¡“°‡™àπ°—π‚¥¬‡©æ“–°“√„ à∑“ߥâ“π´â“¬11-14 πÕ°®“°μ”·Àπßà ‡ πâ ‡≈Õ◊ ¥∑„Ë’  ¥à ß— °≈“à «¢“â ßμπâ æ∫«“à √–¬–‡«≈“„π°“√„  à “¬ ®”π«π§√ßÈ— „π °“√„ à “¬‚¥¬‡©æ“–∑’Ëμ”·Àπà߇¥‘¡ ·≈–°“√μ‘¥‡™◊ÈÕ¢Õß “¬‡ªìπªí®®—¬ ”§—≠∑’Ë¡’º≈μàÕ‡ âπ‡≈◊Õ¥¥” „À≠μà ∫’ À√Õ◊ Õ¥ÿ μπ— ¥ß— °≈“à «¢“â ßμπâ  ”À√∫— ¢π“¥¢Õß “¬ HD Cath ¬ß— ‰¡¡à √’ “¬ß“π«“à ‡æ¡‘Ë °“√‡°¥‘ ‡ πâ ‡≈Õ◊ ¥ ¥”„À≠àμ’∫À√◊ÕÕÿ¥μ—π ·μà‡™◊ËÕ«à“πà“®–¡’§«“¡‡°’ˬ«¢âÕß°—π  ”À√—∫™π‘¥¢Õß “¬ HD Cath ‰¥â¡’°“√«‘®—¬ „π —μ«å∑¥≈Õßæ∫«à“ “¬∑’Ë¡’≈—°…≥–∑’Ë·¢Áß∑’Ë∑”®“° Polyethylene À√◊Õ Teflon ´÷Ëß¡—°®–∑”‡ªì𠓬·∫∫ „ à™—Ë«§√“«™π‘¥‰¡à¡’ cuff ‡ª√’¬∫‡∑’¬∫°—∫ “¬∑’Ëπ‘Ë¡°«à“∑’Ë∑”®“° silicone À√◊Õ polyurethane ´÷Ëß¡—°∑”‡ªìπ  “¬∑Õ’Ë ¬πàŸ “π·≈–¡’ cuff ®–‡æ¡‘Ë Õ∫ÿ μ— °‘ “√≥°å “√‡°¥‘ ‡ πâ ‡≈Õ◊ ¥¥”„À≠μà ∫’ À√Õ◊ Õ¥ÿ μπ— ¡“°°«“à Õ“®®–Õ∏∫‘ “¬ ®“°°“√Õ—°‡ ∫∑’ˇ°‘¥¡“°°«à“15 4.2 Hemodialysis Catheter: The cause of obstruction  “‡Àμÿ∑’Ë “¬ HD Cath ∑”„À⇠âπ‡≈◊Õ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥μ—𠇙◊ËÕ«à“‡°‘¥®“°°“√∑”„Àâºπ—ß ‡ âπ‡≈◊Õ¥∫“¥‡®Á∫ μ”·Àπàß·√°§◊Õμ”·πàß∑’Ë„ à‚¥¬μ√ß μ”·ÀπàßμàÕ¡“§◊Õμ”·Àπàß∑’Ëμ—« “¬ —¡º— °—∫ ‡ âπ‡≈◊Õ¥ ‚¥¬‡©æ“–„π¢≥–ºà“π√Õ¬‚§âßμà“ßÊ À√◊Õ‡¡◊ËÕ¡’¢π“¥¢Õß HD Cath ∑’Ë„À≠à¢÷Èπ´÷Ë߇ªìπ∑’Ëπ‘¬¡„π ªí®®ÿ∫—π ‡π◊ËÕß®“° “¡“√∂ àߪ√‘¡“≥‡≈◊Õ¥„π°“√øÕ°‰¥â¡“°¢÷Èπ ∂ⓉªÕ¬àŸ„π‡ âπ‡≈◊Õ¥¥”∑’ˉ¡à„À≠à‡æ’¬ß æÕ °Á¡’‚Õ°“ ∑’Ëμ—« “¬®– —¡º— °—∫ºπ—߇ âπ‡≈◊Õ¥¥”¡“°¢÷Èπ ·≈– ÿ¥∑⓬§◊Õª≈“¬ “¬∑’ËÕ“®®–‰ª —¡º—  °—∫ºπ—߇ âπ‡≈◊Õ¥À√◊Õºπ—ßÀ—«„®¥â“π¢«“∫π ‰¥â¡’°“√∑¥≈Õß„ à “¬ catheter ™π‘¥ silicone ∑“߇ âπ‡≈◊Õ¥ IJV „Àâª≈“¬‰ªÕ¬àŸ∑’ˇ âπ‡≈◊Õ¥ SVC Õ¬à“ßÕ‘ √–‡ª√’¬∫‡∑’¬∫°—∫°“√∑”„Àâ “¬Õ¬Ÿà°≈“ßÀ≈Õ¥‡≈◊Õ¥μ≈Õ¥ ‡«≈“ æ∫«“à ∑√Ë’ –¬–‡«≈“ 8  ª— ¥“Àå °≈¡àÿ ∑ªË’ ≈Õà ¬ “¬Õ¬“à ßÕ ‘ √– ¡°’ Õâ π‡≈Õ◊ ¥∑ªË’ ≈“¬ “¬μ¥‘ °∫— ºπß— À≈Õ¥ ‡≈◊Õ¥·≈–∑”„ÀâÀ≈Õ¥‡≈◊Õ¥Õÿ¥μ—π∑ÿ°√“¬  à«π°≈ÿà¡∑’Ë∑”„Àâμ—« “¬Õ¬Ÿà°≈“߇ âπ‡≈◊Õ¥μ≈Õ¥¡’°“√ 95

Practical Dialysis in the Year 2009 ‡ª≈’ˬπ·ª≈ßπâÕ¬¡“°16 πÕ°®“°π’Ȭ—ß¡’√“¬ß“π°“√∑” autopsy ºŸâªÉ«¬∑’Ë„ à “¬ central line catheter 3 √“¬∑’Ë„ àπâÕ¬°«à“ 14 «—π æ∫«à“ºπ—߇ âπ‡≈◊Õ¥¡’¡’°“√∫“¥‡®Á∫∑’Ë™—Èπ intimal ·≈–¡’°âÕπ‡≈◊Õ¥„À¡àμ‘¥Õ¬Ÿà∑’Ë μ”·Àπßà  “¬ catheter  ¡— º — °∫— ºπß— ‡ πâ ‡≈Õ◊ ¥ ·≈–Õ°’ 3 √“¬∑„Ë’   à “¬π“π°«“à 90 «π— æ∫«“à ºπß— ‡ πâ ‡≈Õ◊ ¥ ¡’°“√Àπ“μ—«¢Õß™—Èπ smooth muscle cell √à«¡°—∫°âÕπ‡≈◊Õ¥‡°à“∑’Ëμ‘¥Õ¬àŸ„π∫√‘‡«≥∑’Ë “¬ catheter  —¡º—  ºπ—߇ âπ‡≈◊Õ¥17 °“√ —¡º— √–À«à“ß “¬ HD Cath ·≈–ºπ—߇ âπ‡≈◊Õ¥®–‡æ‘Ë¡¡“°¢÷Èπ ‡π◊ËÕß®“°À—«„®¡’°“√‡μâπ Õ¬μŸà ≈Õ¥‡«≈“ ∑”„À‡â  πâ ‡≈Õ◊ ¥¥”„À≠´à ß÷Ë ¡º’ πß— μÕà ‡πÕ◊Ë ß°∫— À«— „®¡°’ “√‡§≈Õ◊Ë π‰À«μ“¡°“√‡μπâ ¢ÕßÀ«— „®¥«â ¬ °“√À“¬„®°Á∑”„Àâ¢π“¥¢Õ߇ âπ‡≈◊Õ¥¥”„À≠à¡’°“√À¥À√◊Õ¢¬“¬μ—«Õ¬àŸμ≈Õ¥‡«≈“ ·≈– ÿ¥∑⓬°“√Õ¬Ÿà „π∑à“π—ËßÀ√◊Õ¬◊π®–∑”„Àâ¢π“¥¢Õß∑√«ßÕ°„À≠à·≈–Õ¬àŸ Ÿß¢÷Èπ ´÷Ëß®–∑”„Àâ “¬ HD Catheter ≈Õ¬ Ÿß¢÷Èπ °«à“∑à“πÕπÕ’° 3-4 ‡´π쑇¡μ√ ‚¥¬‡©æ“–„πºâŸÀ≠‘ß∑’Ë¡’‡μâ“π¡„À≠à §πÕâ«π ·≈–ºâŸ∑’Ë„ à “¬∑“߇ âπ‡≈◊Õ¥ SCV ∑—ÈßÀ¡¥π’È®–∑”„À⇰‘¥°“√ —¡º— √–À«à“ß “¬ HD Catheter °—∫ºπ—߇ âπ‡≈◊Õ¥¥”∑’Ë¡’Õ¬àŸ·≈⫇æ‘Ë¡¡“° ¢÷Èπ18, 19  ”À√—∫ª≈“¬ “¬ HD Cath ·¡â®–‰¡à —¡º— ‚¥¬μ√ß°—∫ºπ—ßÀ≈Õ¥‡≈◊Õ¥ ·μà„π√–À«à“ß∑”°“√ øÕ°‡≈◊Õ¥ ºπ—ߢÕßÀ≈Õ¥‡≈◊Õ¥∑’ËÕ¬àŸ„°≈âª≈“¬ “¬¡’‚Õ°“ ‰¥â√—∫°“√∫“¥‡®Á∫ ‡™àπª≈“¬¥â“π∑’Ëπ”‡≈◊Õ¥ ÕÕ°®“°√à“ß°“¬®–¥Ÿ¥‡≈◊Õ¥ÕÕ° ·μà∂⓪√‘¡“≥¢Õ߇≈◊Õ¥‰À≈ºà“πª≈“¬¥â“ππ’ȉ¡à‡æ’¬ßæÕ ºπ—ߢÕß ‡ âπ‡≈◊Õ¥∑’ËÕ¬àŸ„°≈â°Á®–∂Ÿ°¥Ÿ¥‰ª™‘¥°—∫ª≈“¬ “¬øÕ°‡≈◊Õ¥ ·≈–„π¢≥–∑’Ë à߇≈◊Õ¥°≈—∫ àŸ√à“ß°“¬∑“ß ª≈“¬ “¬Õ’°¥â“π ∂⓪≈“¬¥â“ππ—ÈπÕ¬Ÿà„°≈âºπ—߇ âπ‡≈◊Õ¥ ºπ—ߥâ“ππ—Èπ°Á®–‰¥â√—∫·√ߥ—π°√–·∑°μ≈Õ¥ ‡«≈“„π¢≥–øÕ°‡≈◊Õ¥ πÕ°®“°π—Èπ„π¢≥–øÕ°‡≈◊Õ¥ °“√‰À≈¢Õ߇≈◊Õ¥‡¢â“À√◊ÕÕÕ°®“°ª≈“¬ “¬®– ¡’≈—°…≥–°“√‰À≈·∫∫ turbulent flow ¡’√“¬ß“π«à“Õ“®®–∑”„À⇠âπ‡≈◊Õ¥¥”‚¥¬√Õ∫‡°‘¥°“√∫“¥‡®Á∫‰¥â  “‡Àμÿ∑’Ë°“√„ à∑“߇ âπ‡≈◊Õ¥ IJV ¢â“ߢ«“‡°‘¥‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥μ—ππâÕ¬ ‡π◊ËÕß®“° ∑“߇¥‘π¢Õ߇ âπ‡≈◊Õ¥‡ªìπ·π«μ√ß∂÷߇ âπ‡≈◊Õ¥ SVC ∑”„Àâ‚Õ°“ ∑’Ëμ—« “¬ HD Cath ®– —¡º— °—∫ºπ—ß ‡ âπ‡≈◊Õ¥πâÕ¬°«à“°“√„ à∑’ËÕ◊Ëπ ∂â“„ à∑“߇ âπ‡≈◊Õ¥ SCV ¢â“ߢ«“ ‡ âπ‡≈◊Õ¥®–∑”¡ÿ¡‡°◊Õ∫®– 90 Õß»“°—∫ ‡ âπ‡≈◊Õ¥ BCV ¢â“ߢ«“∑”„Àâ “¬ HD Cath ®– —¡º— °—∫μ”·Àπàßπ’È ·≈–∑”„À⇰‘¥°“√μ’∫À√◊ÕÕÿ¥μ—π„𠇫≈“μàÕ¡“ ∂â“„ à∑’ˇ âπ‡≈◊Õ¥ SCV ¢â“ߴ⓬ ‡ âπ‡≈◊Õ¥‡ âππ’È®–∑”¡ÿ¡§√—Èß·√°°—∫‡ âπ‡≈◊Õ¥ BCV ¢â“ߴ⓬ ª√–¡“≥ 117 Õß»“ ´÷Ëߥ’°«à“¡ÿ¡∑’ˇ âπ‡≈◊Õ¥ SCV ∑”°—∫‡ âπ‡≈◊Õ¥ BCV ¥â“π¢«“ ·≈–®–∑”¡ÿ¡Õ’°§√—Èß°—∫ ‡ âπ‡≈◊Õ¥ SVC ª√–¡“≥ 106 Õß»“ ªí®®ÿ∫—π‡¡◊ËÕ»÷°…“¥â«¬¿“æ CT  “¡¡‘μ‘ æ∫«à“¿“¬„π‡ âπ‡≈◊Õ¥ BCV ¢“â ß´“â ¬¢≥–æ“¥º“à π‡ πâ ‡≈Õ◊ ¥·¥ßbrachiocephalic ¢“â ß´“â ¬ ·≈–‡ πâ ‡≈Õ◊ ¥·¥ß aorta ®–∑”¡¡ÿ °∫— ‡ πâ ‡≈Õ◊ ¥ ·¥ßπ’ÈÕ’° 106 Õß»“ ∑”„Àâ¡’‚Õ°“ ‡°‘¥°“√μ’∫À√◊ÕÕÿ¥μ—π¢Õ߇ âπ‡≈◊Õ¥¢÷Èπ∂÷ß 3 μ”·Àπàß20 ∂⓪≈“¬ “¬ ¡“≈÷°∂÷߇ âπ‡≈◊Õ¥ SVC ·μà∂ⓧ«“¡¬“«¢Õß HD Cath  —Èπ °ÁÕ“®®– ‘Èπ ÿ¥∑’ˇ âπ‡≈◊Õ¥ BCV ¢â“ߴ⓬ ´÷Ëß¡—° ®–‰¥âª√‘¡“≥°“√‰À≈¢Õ∫‡≈◊Õ¥‰¡à¥’æÕ ‡π◊ËÕß®“°ª≈“¬ “¬¥â“π„¥¥â“πÀπ÷Ëß¡—°®–·π∫μ‘¥ºπ—ߢÕß ‡ âπ‡≈◊Õ¥ ·≈–∂⓪≈“¬ “¬‰¡à —ÈπÀ√◊Õ¬“«‡æ’¬ßæÕ ª≈“¬ “¬Õ“®®–¡“ —¡º— °—∫ºπ—߇ âπ‡≈◊Õ¥ SVC ‚¥¬μ√ß μ√ß¡ÿ¡√–À«à“߇ âπ‡≈◊Õ¥ BCV ¢â“ߴ⓬°—∫‡ âπ‡≈◊Õ¥ SVC „π∑”πÕ߇¥¬’ «°π— ®–æ∫«“à °“√„  à “¬ HD Cath ∑“߇ πâ ‡≈Õ◊ ¥ IJV ¥“â π´“â ¬ °¡Á  ’ ¿“æ‡À¡Õ◊ π SCV ¥â“π´â“¬ §◊Õ®–ºà“π 3 ‚§âß ®÷ß∑”„Àâ¡’‚Õ°“ ‡°‘¥‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥μ—π‰¥â‡™àπ°—π πÕ°®“° 96

Practical Recommendations for Central Vein Occlusion π¬È’ ß— ¡√’ “¬ß“π«“à ª√–¡“≥ 30% ‡ πâ ‡≈Õ◊ ¥ IJV ¥“â π´“â ¬®–¡¢’ 𓥇≈°Á °«“à ¥“â π¢«“ „π®”π«ππ¡È’ ª’ √–¡“≥ 1/3 ∑¡Ë’ ¢’ 𓥇≈°Á °«“à ¢“â ߢ«“¡“°°«“à 50%21 ´ß÷Ë π“à ®–∑”„À‡â °¥‘ °Õâ π‡≈Õ◊ ¥Õ¥ÿ μπ— ∑√’Ë Õ¬·∑߇ πâ ‰¥¡â “°°«“à °“√·∑߇ âπ∑“ß IJV ¥â“π´â“¬¡’¢âÕ¥’°«à“°“√„ à∑“ß SCV ¥â“π´â“¬ §◊Õ∂Ⓡ°‘¥°âÕπ‡≈◊Õ¥Õÿ¥μ—π∑’Ëμ”·Àπàß ·∑߇ âπ°Á‡°‘¥∑’ˇ âπ‡≈◊Õ¥ IJV ¥â“π´â“¬ ´÷Ë߉¡à¢«“ß∑“߇¥‘π¢Õ߇ âπøÕ°‡≈◊Õ¥ ·μà∂Ⓡ°‘¥°âÕπ‡≈◊Õ¥Õÿ¥μ—π ∑’ˇ âπ‡≈◊Õ¥ SCV ¥â“π´â“¬ ®–¢«“ß∑“߇¥‘π¢Õ߇≈◊Õ¥®“°·¢π¢â“ߴ⓬‰¥â °“√„ à “¬ HD Cath ∑“ߥâ“π ´â“¬¡’ 2 ‚§âß∑’Ë ”§Ì≠∑”„Àâ°“√„ à‡°‘¥¿“«–·∑√°´âÕπ¡“°°«à“∑“ߥâ“π¢«“ 4.3 Transvenous permanent pacemaker and defibrillator wire πÕ°®“° “¬ HD Cath ∑”„À⇰‘¥‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥μ—π·≈â«  “¬≈«¥®“°‡§√◊ËÕß permanent pacemaker ·≈–‡§√◊ËÕß defibrillator °Á‡ªì𠓇Àμÿ¢Õ߇ âπ‡≈◊Õ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥μ—π ¡’√“¬ß“π °“√‡°‘¥‡ âπ‡≈◊Õ¥¥”„À≠àÕÿ¥μ—π´÷Ëßæ∫√à«¡°—∫°“√¡’ “¬≈«¥¢Õ߇§√◊ËÕß permanent pacemaker22, 23 ·≈– μàÕ¡“¡’ºâŸ∑” venogram „πºâŸªÉ«¬°≈ÿà¡π’È®”π«π 202 √“¬ æ∫§«“¡º‘¥ª°μ‘¢Õ߇ âπ‡≈◊Õ¥¥”„À≠à®”π«π 64% ·≈–§«“¡‡ ’ˬ߮–‡æ‘Ë¡¢÷Èπ∂Ⓡ§¬¡’ª√–«—쑇§¬∂Ÿ°„ à “¬¡“°àÕπ24  ”À√—∫ “¬≈«¥®“°‡§√◊ËÕß defibrillator æ∫«à“‰¥â¡’°“√∑” venogram ∑’Ë·¢π∑—Èß Õߢâ“ߢÕߺ⟪ɫ¬∑’ËμâÕß¡“‡ª≈’ˬπ·∫μ‡μÕ√’Ë®”π«π 32 §π „ àπ“π 45 ‡¥◊Õπ æ∫‡ âπ‡≈◊Õ¥ SCV μ’∫À√◊ÕÕÿ¥μ—πª√–¡“≥ 50 √“¬25 ¥—ßπ—Èπ‰¡à§«√∑”‡ âπøÕ°‡≈◊Õ¥ ∑’Ë·¢π¢â“߇¥’¬«°—∫¢â“ß∑’Ë„ à≈«¥‡À≈à“π’È À√◊Õ∂⓺⟪ɫ¬øÕ°‡≈◊Õ¥Õ¬àŸ·≈â«°Á§«√„ à “¬≈«¥‡À≈à“π’Èμπ≈– ¢â“ß°—∫·¢π∑’Ë„™â∑”°“√øÕ°‡≈◊Õ¥ 4.4 Central catheter and peripheral inserted central catheters πÕ°®“°π°’È “√„  à “¬ central catheter ·≈– peripheral inserted central catheters (PICC) catheter °¡Á √’ “¬ß“π«“à ‡ªπì  “‡Àμ¢ÿ Õ߇ πâ ‡≈Õ◊ ¥¥”„À≠μà ∫’ À√Õ◊ Õ¥ÿ μπ— ‰¥â ¡√’ “¬ß“πºªâŸ «É ¬∑‰’Ë ¥√â ∫— °“√„  à “¬ tunneled infusion catheter ∑’ˇ âπ‡≈◊Õ¥ SCV ®”π«π 166 √“¬ „ àπ“π 103 «—π æ∫«à“‡°‘¥°âÕπ‡≈◊Õ¥Õÿ¥μ—π®”π«π 13% ¿“¬„π√–¬–‡«≈“ 36 «—π ·≈–∑’ˇ âπ‡≈◊Õ¥ IJV ®”π«π 113 √“¬ „ àπ“π 79 «—π æ∫«à“‡°‘¥°âÕπ‡≈◊Õ¥ Õÿ¥μ—π®”π«π 3% ¿“¬„π√–¬–‡«≈“ 142 «—π ‚¥¬‰¡à¡’§«“¡ —¡æ—π∏å°—∫¢π“¥¢Õß “¬·≈–¢â“ß∑’Ë„ à “¬ °âÕπ‡≈◊Õ¥Õÿ¥μ—π‡À≈à“π’ÈÕ“®®–∑”„À⇰‘¥‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥μ—πμàÕ¡“‰¥2â 6  ”À√—∫ “¬ PICC ¡’ √“¬ß“π°“√∑” venogram ·°àºâŸªÉ«¬∑’Ë„ à “¬ PICC À√◊Õ venous port catheter ∑’Ëμâπ·¢π®”π«π 150 √“¬ ´÷Ëß¡’‡ âπ‡≈◊Õ¥¥”„À≠àª°μ‘·μàμâπ ·≈–μàÕ¡“‰¥â∑” venogram ´È”„À¡à ‡π◊ËÕß®“°μâÕß„ àÕÿª°√≥å∫“ßÕ¬à“ß ‡æ¡Ë‘ ‡μ¡‘ æ∫«“à ¡‡’  πâ ‡≈Õ◊ ¥¥”„À≠μà ∫’ À√Õ◊ Õ¥ÿ μπ— ®”π«π 7%27 æ∫«“à ª®í ®¬— ∑ Ë’ ”§≠— §Õ◊ √–¬–‡«≈“∑„Ë’  à ·≈– ‰¡¢à π÷È °∫— ¢π“¥¢Õß “¬πÕ°®“°π¬’È ß— ¡√’ “¬ß“π°“√‡°¥‘ °Õâ π‡≈Õ◊ ¥Õ¥ÿ μπ— ∑‡’Ë  πâ ‡≈Õ◊ ¥¥”¢Õßμπâ ·¢π®“° “¬ PICC 3.9% ¥«â ¬°“√μ√«®∑“ß ultrasound ·≈–æ∫«“à ¢π“¥¢Õß “¬¡§’ «“¡‡°¬Ë’ «¢Õâ ß°∫— °“√‡°¥‘ °Õâ π‡≈Õ◊ ¥ Õÿ¥μ—π28 Õ’°√“¬ß“πæ∫ 38% ¥â«¬°“√μ√«® venogram29 ´÷Ëß®–∑”„À⇠âπ‡≈◊Õ¥¥” peripheral  ”À√—∫°“√ ∑”‡ πâ øÕ°‡≈Õ◊ ¥‡ ¬’ ‰ª ¥ß— ππÈ— ºªŸâ «É ¬∑¡Ë’ ·’ π«‚π¡â ®–μÕâ ßøÕ°‡≈Õ◊ ¥„πÕπ“§μ‰¡§à «√ “à ¬ PICC  ”À√∫—  “¬ central line catheter ·π–π”„Àâ„ à∑“߇ âπ‡≈◊Õ¥ IJV 97

Practical Dialysis in the Year 2009 4.5 Extrinsic causes  “‡ÀμÕÿ π◊Ë Ê ¢Õ߇ πâ ‡≈Õ◊ ¥¥”„À≠μà ∫’ À√Õ◊ Õ¥ÿ μπ— ∑‰’Ë ¡‡à °¬’Ë «°∫— °“√ “¬ catheter À√Õ◊ wire μ“à ßÊ ‰¥â·°à °“√°¥∑—∫®“°μàÕ¡πÈ”‡À≈◊Õß„π‚√§ lymphoma °“√°¥∑—∫®“°μ—« thyroid ‡Õß °“√°¥∑—∫ thoracic aortic aneurysm ·≈– thoracic outlet obstruction ´ß÷Ë ‡°¥‘ ®“°°“√°¥∑∫— √–À«“à ß´‚’Ë §√ß´·’Ë √°°∫— °√–¥°Ÿ clavicle πÕ°®“°π’È¿“«– mediastinal fibrosis °Á∑”„À⇠âπ‡≈◊Õ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥μ—π  “‡Àμÿ‡À≈à“π’È∂Ⓣ¥â√—∫°“√ ·°â‰¢ Õ“°“√μ’∫μ—π¢Õ߇ âπ‡≈◊Õ¥¥”„À≠à®–¥’¢÷Èπ °“√ àßμ√«® X-ray ∑√«ßÕ° ·≈– CT scan ‚¥¬‡©æ“– CT angiogram ·≈– MR angiogram ®–™à«¬À“ “‡Àμÿ¢Õß extraluminal compression ‡À≈à“π’ȉ¥â¥5’ -7 ¡’ºâŸπ” ¿“æ venogram ¢ÕߺŸâªÉ«¬∑’ËøÕ°‡≈◊Õ¥®”π«π 106 ™ÿ¥ ¡“‡æ◊ËÕ¥Ÿ extraluminal compression ¢Õ߇ âπ‡≈◊Õ¥ BCV ¢â“ߴ⓬ æ∫«à“¡’§«“¡º‘¥ª°μ‘Õ—π‡π◊ËÕß®“° extraluminal compression ®”π«π 44% ¡’§«“¡√ÿπ·√ß ‰¡à¡“° 25% √ÿπ·√ߪ“π°≈“ß 13% ·≈–√ÿπ·√ß¡“° 6% ºâŸ∑’Ë√ÿπ·√ß¡“°μâÕß∑”°“√·°â‰¢¥â«¬°“√¢¬“¬ ¥â«¬ balloon ·≈–„ à stent16 4.6 Acute thrombosis °“√‡°‘¥ acute thrombosis ¡—°®–‡°‘¥°—∫‡ âπ‡≈◊Õ¥¥”„À≠à∑’Ë¡’°“√μ’∫μ—πÕ¬Ÿà‡¥‘¡ μàÕ¡“°“√μ’∫ μπ— ‡ªπì ¡“°¢πÈ÷ ·≈–‡°¥‘ ≈¡Ë‘ ‡≈Õ◊ ¥¢πÈ÷ ∑”„À‡â °¥‘ °“√Õ¥ÿ μπ—  π∑‘ (complete occlusion) „π∫“ß√“¬®–¡°’ “√Õ¥ÿ μ—π π‘∑‚¥¬‰¡à‡°‘¥≈‘Ë¡‡≈◊Õ¥ °√≥’∂â“¡’°“√‡°‘¥≈‘Ë¡‡≈◊Õ¥Õ¬à“ß©—∫æ≈—π ¡—°®–¡’Õ“°“√·¢π∫«¡Õ¬à“ß √πÿ ·√ß·≈–„π√–¬–‡«≈“Õπ—  πÈ— „π∫“ß°√≥®’ –‡°¥‘ ≈¡Ë‘ ‡≈Õ◊ ¥‚¥¬‰¡¡à ‡’  πâ ‡≈Õ◊ ¥¥”„À≠μà ∫’ μπ— π”¡“°Õà 𠇙πà ¡’ hypercoagulable state À√◊Õ¡’°“√‡°‘¥≈‘Ë¡‡≈◊Õ¥ßà“¬ ´÷ËßμâÕßÀ“ “‡Àμÿ·≈–„Àâ°“√√—°…“μàÕ‰ª 5. °“√√°— …“‡ πâ ‡≈Õ◊ ¥¥”„À≠àμ’∫À√◊ÕÕ¥ÿ μ—π 5.1 °√≥∑’ Ë’ºªŸâ «É ¬‰¡¡à Õ’ “°“√ §”«“à Õ“°“√„π∑πË’ ÀÈ’ ¡“¬∂ß÷ Õ“°“√∫«¡∑·Ë’ ¢π Àπ“â À√Õ◊ ∑√«ßÕ° ∂“â ‰¡¡à Õ’ “°“√¥ß— °≈“à «∫ßà «“à ‡ âπ‡≈◊Õ¥¥”„À≠àÕ“®®–‰¡àμ’∫¡“° ¬—ß “¡“√∂π”‡≈◊Õ¥°≈—∫ àŸÀ—«„®‰¥â‡æ’¬ßæÕ À√◊Õ∂Ⓡ âπ‡≈◊Õ¥¥”„À≠à μ’∫¡“° °Á¡’‡ âπ‡≈◊Õ¥¥” collateral π”‡≈◊Õ¥°≈—∫ ŸàÀ—«„®∑“ßÕ◊Ëπ‰¥âÕ¬à“߇撬ßæÕ‡™àπ°—π „π°√≥’À≈—ßπ’ÈÕ“® ®–μ√«®æ∫«“à ¡‡’  πâ ‡≈Õ◊ ¥¥” collateral ‡¥πà ™¥— ∑∫Ë’ √‡‘ «≥À«— ‰À≈à Àπ“â Õ° «à π∫π ·≈–/À√Õ◊ ∫√‡‘ «≥À≈ß—  «à π ∫π¢“â ߇¥¬’ «°π— °∫— √Õ¬μ∫’ Õ“°“√ÕπË◊ Ê §Õ◊ °“√¡·’ √ß¥π— „π‡ πâ ‡≈Õ◊ ¥ ßŸ ∂“â  ßŸ ¡“°®π∑”„À‰â ¡ à “¡“√∂‡ª¥î blood pump flow ‰¥âμ“¡°”Àπ¥ À√◊Õ∑”„Àâ°¥‡≈◊Õ¥À¬ÿ¥¬“°°Á‡ªìπ¢âÕ∫àß™’È«à“¡’Õ“°“√· ¥ß‡°‘¥¢÷Èπ·≈â« ‡πÕ◊Ë ß®“°ºªŸâ «É ¬°≈¡ÿà π¡’È °— ®–‰¡¡à Õ’ “°“√„¥Ê ª√“°Ø°“√μ√«®æ∫√Õ¬μ∫’ ¢Õ߇ πâ ‡≈Õ◊ ¥¥”„À≠¡à °— ®–‡ªπì °“√ μ√«®æ∫‚¥¬∫—߇Ց≠„π¢≥–∑” venogram ¢Õ߇ âπøÕ°‡≈◊Õ¥¥â«¬‡Àμÿº≈Õ◊ËπÊ ¡’ºâŸ»÷°…“·∫∫ retrospective „πºâŸªÉ«¬ 35 √“¬ ∑’Ë¡’‡ âπøÕ°‡≈◊Õ¥™π‘¥ AVG 38 ‡ âπ „π¢≥– ∑”°“√·°â‰¢‡ âπøÕ°‡≈◊Õ¥ AVG ¥â«¬¢âÕ∫àß™’ÈÕ◊ËπÊ ·≈–¡’°“√∑” venogram ·≈–μ√«®æ∫«à“¡’‡ âπ‡≈◊Õ¥¥” „À≠μà ∫’ μπ— 86 μ”·Àπßà ‚¥¬∫ß— ‡Õ≠‘ ª√¡‘ “≥°“√μ∫’ ¡§’ “à ‡©≈¬Ë’ ª√–¡“≥ 70 °«“à ‡ªÕ√‡å ´πÁ μå ·≈–„π®”π«π π’È¡’∫“ß√“¬¡’°“√μ’∫μ—π π‘∑ ·μà‰¡àæ∫Õ“°“√∫«¡„¥Ê ºâŸªÉ«¬‡À≈à“π’Ȫ√–¡“≥ 2/3 ‰¥â√—∫°“√·°â‰¢¥â«¬«‘∏’ PTA (percutaneous transluminal angioplasty) ‚¥¬À≈—ß°“√·°â‰¢æ∫«à“ °“√μ’∫μ—π≈¥≈߇À≈◊Õ 40% ·≈–ºŸâ 98

Practical Recommendations for Central Vein Occlusion ª«É ¬ª√–¡“≥ 1/3 ‰¡‰à ¥√â ∫— °“√·°‰â ¢„¥Ê ‰¥μâ ¥‘ μ“¡¿“æ∂“à ¬∑“ß√ß—  ¢’ Õßμ”·Àπßà ∑μË’ ∫’ μπ— ‡À≈“à π„È’ π√–¬– ‡«≈“μàÕ¡“ æ∫«à“°≈ÿà¡∑’ˉ¥â√—∫°“√∑” PTA  à«π„À≠à®–¡’ª√‘¡“≥°“√μ’∫μ—π‡æ‘Ë¡¡“°¢÷Èπ ∫“ß√“¬μâÕßπ” ¡“„ à stent ∫“ß√“¬æ∫«“à ¡√’ Õ¬μ∫’ μπ— ¢Õ߇ πâ ‡≈Õ◊ ¥¥”„À≠μà ”·Àπßà „À¡‡à °¥‘ ¢πÈ÷ ·≈–∫“ß√“¬‡°¥‘ Õ“°“√ ·¢π∫«¡  ”À√∫— ºªŸâ «É ¬°≈¡àÿ ∑‰Ë’ ¡‰à ¥√â ∫— °“√∑” PTA æ∫«“à ª√¡‘ “≥°“√μ∫’ μπ— ‚¥¬‡©≈¬Ë’ ‰¡‡à ª≈¬Ë’ π·ª≈ß ·≈– ‰¡à¡’ºâŸ„¥‡°‘¥Õ“°“√·¢π∫«¡ ¢âÕ®”°—¥∑’Ë ”§—≠¢Õß°“√»÷°…“π’ȧ◊Õ ¡’‡æ’¬ß 50% ¢Õߺ⟪ɫ¬·μà≈–°≈ÿà¡∑’Ë¡’ °“√μ‘¥μ“¡°“√‡ª≈’ˬπ·ª≈ߢÕß√Õ¬μ’∫¢Õ߇ âπ‡≈◊Õ¥∑“ß√—ß 3’ 0 ‚¥¬ √ÿª ∂⓺⟪ɫ¬¡’‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫μ—π·μà‰¡à¡’Õ“°“√ ‰¡à·π–π”„Àⷰ≢√Õ¬μ’∫μ—π °“√ ·°‰â ¢‚¥¬‡©æ“–«∏‘ ’ PTA ®–∑”„À‡â °¥‘ ¿¬π— μ√“¬μÕà ‡ πâ ‡≈Õ◊ ¥¥” ·≈–∑”„Àªâ √¡‘ “≥¢Õß√Õ¬μ∫’ μπ— ‡ªπì ¡“° ¢πÈ÷ ·≈–∑”„À‡â °¥‘ Õ“°“√ª√“°Ø‡√«Á °«“à °“√‰¡∑à ” PTA Õ¬“à ߉√°μÁ “¡‡ªπì °“√¬“°∑®Ë’ –·¬°«“à ‡ πâ ‡≈Õ◊ ¥¥” „À≠à∑’Ëμ’∫À√◊ÕÕÿ¥μ—ππ—Èπ‡ªìπªí≠À“∑”„À⇠âπøÕ°‡≈◊Õ¥¡’ª√‘¡“≥°“√‰À≈¢Õ߇≈◊Õ¥πâÕ¬≈ßÕ¬à“ß¡’π—¬  ”§—≠À√◊Õ‰¡à ∂â“¡’°Á§«√®–μâÕß·°â‰¢‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥μ—π ‡æ◊ËÕ‰¡à„À⇠âπøÕ°‡≈◊Õ¥‡°‘¥ªí≠À“ ¢÷Èπ ·≈–∫àÕ¬§√—È߇ âπøÕ°‡≈◊Õ¥¡’ªí≠À“‡Õß ·≈–‡¡◊ËÕ‰¥â√—∫°“√·°â‰¢·≈–¡’ª√‘¡“≥‡≈◊Õ¥‰À≈ºà“π¡“°¢÷Èπ ®–‡°¥‘ Õ“°“√·¢π∫«¡∂“â ‰¡‰à ¥°â “√·°‰â ¢‡ πâ ‡≈Õ◊ ¥¥”„À≠∑à μË’ ∫’ À√Õ◊ Õ¥ÿ μπ— √«à ¡¥«â ¬ ∑”„Àμâ Õâ ß∑”Àμ— ∂°“√  Õߧ√—Èß 5.2 °√≥’ºâŸªÉ«¬¡’Õ“°“√∫«¡ (·ºπ¿Ÿ¡‘∑’Ë 1 ·≈– 2) · ¥ß«à“‡ âπ‡≈◊Õ¥¥”„À≠à·≈–‡ âπ‡≈◊Õ¥¥” collateral ‰¡à “¡“√∂π”‡≈◊Õ¥°≈—∫ ÀŸà «— „®‰¥âÕ¬“à ß æÕ‡æ’¬ß ∂Ⓡªìπ°“√∫«¡Õ¬à“ß©—∫æ≈—πÕ“®®–μâÕß√Õ„À⇠âπ‡≈◊Õ¥¥” collateral ª√—∫μ—«°àÕπ∑’Ë®– √ÿª«à“ ‡ πâ ‡≈Õ◊ ¥¥” collateral ‰¡ à “¡“√∂π”‡≈Õ◊ ¥°≈∫—  ÀàŸ «— „®‰¥Õâ ¬“à ßæՇ欒 ß ·μ„à π°√≥π’ ¡’È °— ®–¡°’ “√Õ¥ÿ μπ— Õ¬“à ß  ¡∫Ÿ√≥å¢Õ߇ âπ‡≈◊Õ¥¥”„À≠à (total occlusion) ·≈–¡—°®–¡’°âÕπ‡≈◊Õ¥ (thrombosis) √à«¡¥â«¬ ´÷Ëß∂â“·°â‰¢ ™â“Õ“®®–‰¡à “¡“√∂∑”„Àâ√Õ¬μ’∫μ—π¥’¢÷Èπ‰¥â °√≥’∂Ⓡªìπ acute thrombosis ¢Õ߇ âπ‡≈◊Õ¥¥”„À≠à „Àâ√—°…“¥â«¬ local thrombolysis Õ“® ®–„™â¬“ urokinase À√◊Õ tPA °Á‰¥â À√◊Õ°“√∑” thromboaspiration ∂â“∑” ”‡√Á®„Àâ©’¥ contrast ‡æ◊ËÕ ”√«® ¡’°“√μ’∫μ—π√à«¡¥â«¬À√◊Õ‰¡à ∂Ⓣ¡àæ∫°“√μ’∫μ—π„ÀâÀ“¿“«–°“√‡°‘¥≈‘Ë¡‡≈◊Õ¥ßà“¬ ∂â“¡’°“√μ’∫μ—π „ÀâÀ“  “‡Àμÿ¢Õß°“√μ’∫·≈–¥”‡π‘π°“√√—°…“μàÕ‰ª °√≥’∂â“¡’°“√μ’∫μ—π¢Õ߇ âπ‡≈◊Õ¥¥”„À≠à ·μà‰¡à¡’‡Àμÿ∑’Ë™—¥‡®π À√◊Õ‡°‘¥®“°°“√‡§¬„ à “¬ hemodialysis catheter √«¡∑ß—È catheter ™π¥‘ Õπ◊Ë ÊÀ√Õ◊ ‰¥√â ∫— °“√√°— …“μπâ ‡Àμ·ÿ ≈«â ·μ¬à ß— ¡Õ’ “°“√μ∫’ μπ— „À°â “√ √—°…“‡√‘Ë¡μâπ¥â«¬°“√∑” PTA±Stent ‡π◊ËÕß®“°‡ªìπÀ—μ∂°“√∑’Ë∑”‰¥âßà“¬·≈–ºâŸªÉ«¬¡—°®–∑πμàÕ°“√∑” Àμ— ∂°“√‰¥â ∂“â ‰¡ à ”‡√®Á À√Õ◊ ¡Õ’ “°“√°”‡√∫‘ ∫Õà ¬´ß÷Ë ‡ªπì ¢Õâ ‡ ¬’ ¢Õß°“√∑” PTA °æÁ ®‘ “√≥“∑”°“√·°‰â ¢‚¥¬ «∏‘ ∑’ “ß»≈— ¬°√√¡ ‡æÕ◊Ë ‰ª·°‰â ¢√Õ¬μ∫’ μπ— ‚¥¬μ√ßÀ√Õ◊ „™«â ∏‘ ’ bypass ´ß÷Ë Õ“®®–∑”‰¥ßâ “à ¬À√Õ◊ Õ“®®–¡¢’ π—È μÕπ  ≈—∫´—∫´âÕπ ·≈–∫“ߧ√—ÈßÕ“®®–μâÕß∑”°“√ºà“μ—¥‡ªî¥°√–¥°Ÿ Àπâ“Õ° ´÷Ëߺ⟪ɫ¬Õ“®®–∑π°“√ºà“μ—¥‰¡à‰¥â ·≈– ¥ÿ ∑“â ¬∂“â ºªâŸ «É ¬¬ß— ¡Õ’ “°“√∫«¡‰¡ à “¡“√∂·°‰â ¢¥«â ¬«∏‘ Õ’ π◊Ë Ê·≈–‰¡ à “¡“√∂∑πμÕà Õ“°“√∫«¡‰¥â‡™πà ∫«¡¡“°À√◊Õ¡’Õ“°“√ª«¥√à«¡¥â«¬ °Á§ßμâÕß∑”°“√ªî¥‡ âπøÕ°‡≈◊Õ¥ °àÕπ∑’Ë®–ªî¥‡ âπøÕ°‡≈◊Õ¥ ®– μâÕßÀ“·≈–∑”‡ âπøÕ°‡≈◊Õ¥„À¡à∑’ˇÀ¡“– ¡¢Õß·¢πÀ√◊Õ¢“Õ’°¢â“ß„Àâ ”‡√Á®‡ ’¬°àÕπ ‡æ◊ËÕÀ≈’°‡≈’ˬ߰“√ μâÕß„ à “¬ hemodialysis catheter ´÷ËßÕ“®®–∑”„À⇠âπ‡≈◊Õ¥¥”„À≠à‡°‘¥°“√μ’∫μ—π„πÕπ“§μ‰¥âÕ’° 99

Practical Dialysis in the Year 2009 ·ºπ¿Ÿ¡∑‘ Ë’ 1: °“√√—°…“‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥μ—π (Central Vein Obstruction) ผปู วยที่มอี าการบวมแขนขา งทีม่ เี สนฟอกเลือด การประเมนิ การตรวจรางกาย oมีอาการบวมทแี่ ขน และอาจจะบวมที่หนาหรอื เตา นมรวมดวย oมีเสน เลอื ดดาํ Collateral เห็นชดั เจนท่ีหวั ไหลแ ละบรเิ วณทรวงอก การตรวจดว ยภาพทางรงั สี oฉีด Contrast แขนทม่ี ีเสน ฟอกเลอื ดใหเหน็ เสน เลือดดําภายในทรวงอก Central vein No Management obstruction ? หาสาเหตอุ ่ืน Yes ใหการรักษาตาม เหตุ สาเหต:ุ Yes Thoracic outlet syndrome Management Hypercoagulable state ใหก ารรกั ษาตาม สาเหตุ No Central Central vein stenosis vein occlusion with thrombosis Management Management PTA +/- Stent Local thrombolysis + PTA Thromboaspiration + PTA Yes Yes Follow up No Unmasked Yes Stenosis ดีขน้ึ stenosis Thrombosis ดขี นึ้ No No ดู Central Vein Obstruction แผนภมู ิท่ี 2 100

Practical Recommendations for Central Vein Occlusion ·ºπ¿Ÿ¡∑‘ Ë’ 2: °“√√—°…“‡ âπ‡≈◊Õ¥¥”„À≠àÕÿ¥μ—π (Central Vein Obstruction) ผูป ว ยที่มี Persistent Central Vein Stenosis or Occlusion การประเมนิ การประเมินเทคนคิ การผาตัด ทบทวนภาพถา ยทางรังสขี องเสนเลอื ดดําขางเดยี วกับทีแ่ ขนบวม ฉีด Contrast เพื่อประเมินเสนเลอื ดดําของแขนอีกขางที่ไมบ วม จัดลาํ ดบั ความเสี่ยง ASA II ASA III ASA IV Superior vena cava No Superior vena cava No No Superior vena cava patent patent และ Subclavina vein ดานตรงขา ม Patent Yes Yes Yes Management Management Management Axillary-to-Internal jugular vein bypass Axillary-to-Internal jugular ทาํ เสนฟอกเลือดใหมทแี่ ขนอกี Axillary-to-Internal jugular vein bypass ขาง และปดเสนฟอกเลอื ดเดิม vein cross-over bypass Axillary-to-Internal jugular Axillary-to-superior caval vein cross-over bypass vein bypass ทําเสนฟอกเลอื ดใหมท่ีแขนอีก ทาํ เสน ฟอกเลือดใหมท แ่ี ขนอกี ขาง และปด เสนฟอกเลือดเดมิ ขาง และปด เสนฟอกเลือดเดิม Management Management ทําเสน ใหมทต่ี นขา และปด เสนฟอกเลือดเดมิ ทําเสน ใหมที่ตนขา และปด Axillary vein-to-right atrial bypass เสน ฟอกเลือดเดมิ 101

Practical Dialysis in the Year 2009 ºŸâªÉ«¬∫“ß√“¬¡’‡ âπ‡≈◊Õ¥·¥ß·≈–‡ âπ‡≈◊Õ¥¥”¢Õß·¢πÕ’°¢â“ß∑’Ë¥’¡“° ·≈–·¢π¢â“ßπ—Èπ‰¡à¡’ ‡ âπ‡≈◊Õ¥¥”„À≠àÕÿ¥μ—π ºâŸªÉ«¬°≈ÿà¡π’È “¡“√∂∑”‡ âπøÕ°‡≈◊Õ¥„À¡à‰¥âßà“¬·≈–πà“®–„™âß“π‰¥âπ“π ºâŸ ªÉ«¬°≈ÿà¡π’ÈÕ“®‰¡àμâÕß àß∑” PTA±Stent À√◊Õ∑”°“√ºà“μ—¥ bypass ·μà “¡“√∂¢â“¡¢—ÈπμÕπ‰ª∑”‡ âπøÕ° ‡≈◊Õ¥„À¡à·≈–√ժ âπøÕ°‡≈◊Õ¥‡¥‘¡‰¥â ºâŸªÉ«¬∫“ß√“¬Õ“®®–欓°√≥几âπøÕ°‡≈◊Õ¥„À¡à¢Õß·¢πÕ’° ¢â“߉¡à‰¥â«à“®–¥’¡“°¢π“¥‰Àπ À√◊ÕμâÕß∑”‡ âπøÕ°‡≈◊Õ¥„À¡à∑’Ëμâπ¢“ ºâŸªÉ«¬°≈ÿà¡π’ȧ«√®–μâÕ߬◊¥√–¬– ‡«≈“°“√„™â‡ âπøÕ°‡≈◊Õ¥∑’Ë¡’ªí≠À“π’È „À⬓«π“π∑’Ë ÿ¥¥â«¬°“√∑” PTA±Stent À√◊Õ∑”°“√ºà“μ—¥ bypass °àÕπ∑’Ë®–μ—¥ ‘π„®∑”‡ âπøÕ°‡≈◊Õ¥‡ âπ„À¡à À√◊ÕμâÕß√Õ®π‡ âπøÕ°‡≈◊Õ¥‡ âπ„À¡à„™âß“π‰¥âÕ¬à“ߥ’°àÕπ ®–μ—¥ ‘π„®ªî¥‡ âπøÕ°‡≈◊Õ¥∑’Ë¡’ªí≠À“‡ âππ’È ·≈–ºâŸªÉ«¬°≈ÿà¡ ÿ¥∑⓬§◊Õ¡’‡ âπøÕ°‡≈◊Õ¥∑’Ë¡’ªí≠À“‡ âππ’È ‡ªπì ‡ πâ  ¥ÿ ∑“â ¬∑”„À®â ”‡ªπì μÕâ ßΩπó „™ßâ “π‰ª‡√Õ◊Ë ¬Ê√«à ¡°∫— °“√·°‰â ¢¥«â ¬«∏‘ °’ “√∑”PTA±Stent À√Õ◊ ∑”°“√ ºà“μ—¥ bypass ‡ªìπ°“√¬“°„π°“√μ—¥ ‘π„®∑’Ë®–ªî¥‡ âπøÕ°‡≈◊Õ¥‡ âππ’È ·≈–ºâŸªÉ«¬Õ“®®–μâÕßøÕ°‡≈◊Õ¥ ¥â«¬ hemodialysis catheter μ≈Õ¥‰ª À√◊Õ‡ª≈’ˬπ«‘∏’°“√øÕ°‡≈◊Õ¥‡ªìπ peritoneal dialysis 5.2.1 °“√√°— …“¥«â ¬«∏‘ ’ PTA±Stent (·ºπ¿Ÿ¡‘∑’Ë 1) °“√√—°…“´÷Ëß∂◊Õ‡ªìπ¡“μ√∞“π„πªí®®ÿ∫—π§◊Õ °“√∑” percutaneous transluminal angioplasty (PTA) ´÷Ëßæ∫«à“∑”‰¥âßà“¬ ¡’Õ—μ√“§«“¡ ”‡√Á® Ÿß ·≈–¡’¿“«–·∑√°´âÕπμË” ·μà¡’¢âÕ‡ ’¬§◊Õ √Õ¬μ’∫¡—°®– °”‡√‘∫‰¥â∫àÕ¬ ‡π◊ËÕß®“°¡’ myointimal hyperplasia ·≈–¡’ elastic recoil ∑”„ÀâμâÕß∑”À—μ∂°“√‡æ◊ËÕ·°â‰¢ °“√μ’∫μ—π¢Õ߇ âπ‡≈◊Õ¥∫àÕ¬ ·≈–¡’§«“¡‡™◊ËÕ«à“°“√„ à stent √à«¡¥â«¬À≈—ß∑” PTA πà“®–∑”„Àâ¡’§«“¡  ”‡√Á®„π°“√∑” ßŸ ¢÷Èπ·≈–∑”„Àâ¡’°“√°”‡√‘∫¢Õß√Õ¬‚√§πâÕ¬≈ß æ∫«à“√“¬ß“π primary ·≈– secondary patency ∑’Ë√–¬–‡«≈“ 1 ªï  ”À√—∫°“√∑” PTA À√◊Õ PTA √à«¡°—∫°“√„ à stent ‡∑à“°—∫ 11-70% ·≈– 47-100% μ“¡≈”¥—∫31-33 ¡’ºâŸ‡ª√’¬∫‡∑’¬∫°—∫°“√¢¬“¬∑’ˇ âπ‡≈◊Õ¥μ”·ÀπàßÕ◊ËπÊ ‡™àπ‡ âπ‡≈◊Õ¥·¥ß coronary ‡ âπ‡≈◊Õ¥·¥ß peripheral ‡ âπ‡≈◊Õ¥¥” peripheral ‡ âπøÕ°‡≈◊Õ¥ ‰¥â √ÿª«à“‡ âπ‡≈◊Õ¥¥”„À≠à¡’ §«“¡ ”‡√Á®μË” ÿ¥34, 35 ·μà°Á¡’√“¬ß“π∫“ß°“√»÷°…“‡ª√’¬∫‡∑’¬∫°“√∑” PTA √–À«à“߇ âπ‡≈◊Õ¥¥”„À≠à ·≈–‡ âπ‡≈◊Õ¥¥” peripheral ¢Õ߇ âπøÕ°‡≈◊Õ¥ ·≈–‰¡àæ∫«à“¡’§«“¡·μ°μà“ß°—π32 §«“¡ ”‡√Á®„π°“√∑” PTA Õ—π¥—∫·√°§◊Õ μâÕß„ à guidewire ºà“π√Õ¬μ’∫À√◊ÕÕÿ¥μ—π‡æ◊ËÕ∑’Ë®– ‡ª¥î ‡ πâ „À‰â ¥â ¡√’ “¬ß“𧫓¡ ”‡√®Á μß—È ·μà 83-100%35,36  «à π„À≠∑à ‰’Ë ¡ à ”‡√®Á §Õ◊ ‡ªπì √Õ¬Õ¥ÿ μπ— (occlusion) ´÷Ëß∂â“Õÿ¥μ—π¡“π“π¡—°®–‰¡à “¡“√∂π” guidewire ºà“π√Õ¬‚√§‰¥â ¥—ßπ—Èπ∂â“®–μ—¥ ‘π„®√—°…“§«√√’∫∑” ‡πÕË◊ ß®“°°“√√Õπ“π √Õ¬μ∫’ μπ— ®–°≈“¬‡ªπì √Õ¬μ∫’ μπ—  π∑‘ À√Õ◊ √Õ¬Õ¥ÿ μπ— ·≈–‰¡ à “¡“√∂„ à guidewire º“à π‰¥â ‡¡ÕË◊ ∑”°“√¢¬“¬¥«â ¬ balloon ®–¡°’ “√‡°¥‘ °“√μ∫’ À√Õ◊ Õ¥ÿ μπ— ´”È ‡πÕË◊ ß®“°√Õ¬‚√§∑‡Ë’ ªπì myointimal hyperplasia ·≈– elastic recoil 𑬓¡¢Õß√Õ¬μ’∫∑’Ë¡’π—¬ ”§—≠∑“ß√—ß ’«‘∑¬“§◊Õ¡’ª√‘¡“≥°“√μ’∫¡“°°«à“ 50% §«“¡ ”‡√Á®„π°“√¢¬“¬¥â«¬ balloon §◊ÕÀ≈—ß®“°¢¬“¬·≈â«®–¡’ª√‘¡“≥¢Õß√Õ¬μ’∫πâÕ¬°«à“ 30% (residual stenosis <30%) ªí≠À“¢Õß°“√¢¬“¬‡ âπ‡≈◊Õ¥¥”„À≠à§◊Õ°“√¡’ elastic recoil °≈à“«§◊Õ “¡“√∂ ¢¬“¬¥â«¬ balloon ‰¥â¥’ ·μàæÕ∂Õ¥ balloon ÕÕ° æ∫«à“¡’°“√À¥μ—«¢Õß√Õ¬μ’∫„À¡à∑”„Àâ¡’°“√μ’∫μ—π¡“° °«à“ 30% ‡√’¬°«à“¡’ immediate elastic recoil ·¡â«à“Õ“®®–∑”„ÀâÕ“°“√·¢π∫«¡¬ÿ∫≈߉¥â ·μà®–°”‡√‘∫ „À¡„à π‰¡™à “â ·≈–∂“â ¡’ delay elastic recoil ®–¡°’ “√°”‡√∫‘ „À¡¡à °— ®–‡°¥‘ ¿“¬„π√–¬–‡«≈“ 3 ‡¥Õ◊ π (√ªŸ ∑’Ë 3) 102

Practical Recommendations for Central Vein Occlusion √Ÿª∑’Ë 3 · ¥ß°“√√—°…“‡ πâ ‡≈Õ◊ ¥ SCV μ∫’ ¥«â ¬°“√∑” PTA alone √ªŸ A. ‡ πâ ‡≈◊Õ¥ SCV μ∫’ ¡“°«à“ 90% ·≈–¡‡’  âπ‡≈Õ◊ ¥¥” collateral ®”π«π¡“° √ªŸ B. ¢¬“¬‡ âπ‡≈Õ◊ ¥ SCV ¥«â ¬ balloon ¢π“¥ 10x40 ¡.¡. √Ÿª C. ‡ πâ ‡≈◊Õ¥ SCV °≈∫—  ªàŸ °μ‘ ·≈–‰¡¡à ‡’  âπ‡≈◊Õ¥¥” collateral 5.2.1.1 PTA alone À√◊Õ PTA with stent ‰¥¡â √’ “¬ß“π°“√∑” PTA Õ¬“à ߇¥¬’ «®”π«π 30 √“¬ æ∫«“à °≈¡àÿ ∑‰Ë’ ¡¡à ’ immediate elastic recoil ¡’°“√μ’∫μ—π´È” 81% „π√–¬–‡«≈“‡©≈’ˬ 7.6 ‡¥◊Õπ ·μà°≈ÿà¡∑’Ë¡’ immediate elastic recoil ¡’°“√Õÿ¥μ—π´È” 100% „π√–¬–‡«≈“‡©≈’ˬ 2.9 ‡¥◊Õπ ·≈–°≈ÿà¡∑’Ë„ à stent ®”π«π 10 √“¬ æ∫«à“°≈ÿà¡∑’ˉ¡à¡’ immediate elastic recoil ¡’°“√μ’∫μ—π´È” 80% „π√–¬–‡«≈“‡©≈’ˬ 4.2 ‡¥◊Õπ ·≈–°≈ÿà¡∑’Ë¡’ immediate elastic recoil ¡’ °“√μ’∫μ—π´È” 80% „π√–¬–‡«≈“‡©≈’ˬ 8.6 ‡¥◊Õπ · ¥ß„Àâ‡ÀÁπ«à“°“√„ à stent ®–¡’ª√–‚¬™πåμàÕ√Õ¬‚√§∑’Ë ¡’ elastic recoil ·μà°≈—∫∑”„Àâ√Õ¬‚√§∑’Ë “¡“√∂¢¬“¬¥â«¬ balloon ‰¥â¥’¡’°“√μ’∫μ—π„À¡à‡√Á«¢÷Èπ37 Õ’°°“√ »÷°…“‰¥â∑”°“√»÷°…“·∫∫ prospective randomization √–À«à“ß°“√∑” PTA ®”π«π 47 §√—Èß ·≈–„ à stent ®”π«π 40 §√—Èß ‡ªìπ°“√∑” intervention √«¡√–À«à“߇ âπ‡≈◊Õ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥μ—π·≈–‡ âπ‡≈◊Õ¥¥” peripheral  ”À√—∫°≈ÿà¡∑’ˇªìπ‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥μ—π æ∫«à“¡’ primary ·≈– secondary patency ∑’Ë 1 ªï ‡∑à“°—∫ 12% ·≈– 100%  ”À√—∫°≈ÿà¡ PTA ·≈– 11% ·≈– 78%  ”À√—∫°≈ÿà¡ stent ´÷Ë߉¡à·μ°μà“ß °—π32 Õ’°√“¬ß“π‰¥â»÷°…“·∫∫ retrospective „πºŸâªÉ«¬∑’Ë∑” PTA ‡æ’¬ßÕ¬à“߇¥’¬« 32 √“¬ °≈ÿà¡π’È∂â“¡’°“√ °”‡√‘∫„À¡à®–∑” PTA ‡æ’¬ßÕ¬à“߇¥’¬« ·≈–°≈ÿà¡∑’Ë„ à stent ´÷Ëß®–∑”‡©æ“–ºâŸ∑’Ë¡’ immediate elastic recoil ®”π«π 23 √“¬ æ∫«à“∑’Ë√–¬–‡«≈“ 1 ªï ¡’ primary (unassisted) patency ‡∑à“°—∫ 20%  ”À√—∫°≈ÿà¡ PTA ·≈– 19%  ”À√—∫°≈ÿà¡ stent ·≈–¡’ secondary (assisted) patency ∑’Ë 1 ªï ‡∑à“°—∫ 64%  ”À√—∫°≈ÿà¡ stent √–¬–‡«≈“∑’˪≈Õ¥®“°°“√μ’∫À√◊ÕÕÿ¥μ—π´È”‚¥¬‡©≈’ˬ‡∑à“°—∫ 147 «—π  ”À√—∫°≈ÿà¡ PTA ·≈– 138 «—π  ”À√—∫°≈ÿà¡ stent ´÷Ë߉¡à·μ°μà“ß°—π35 (¥Ÿ√ªŸ ∑’Ë 4) ¥ß— ππÈ— „π°√≥∂’ “â ∑” PTA ·≈«â ‡ πâ ‡≈Õ◊ ¥¥”¬ß— ¡√’ Õ¬μ∫’ §“â ß¡“°°«“à 30% ∑ßÈ— Ê ∑ Ë’ “¡“√∂¢¬“¬ ‡ âπ‡≈◊Õ¥¥”‰¥â¥’ À√◊Õ¡’Õ“°“√‡π◊ËÕß®“°°“√μ’∫À√◊ÕÕÿ¥μ—π·≈–μâÕß∑” PTA ´È”¿“¬„π√–¬–‡«≈“ 3 ‡¥◊Õ𠧫√‡≈◊Õ°°“√„ à stent ¢âÕ¥’¢Õß stent §◊Õ “¡“√∂·°â‰¢‡√◊ËÕß elastic recoil ‰¥â¥’ ·μà°≈—∫ √â“ߪí≠À“„À¡à 103

Practical Dialysis in the Year 2009 √ªŸ ∑Ë’ 4 · ¥ßº≈°“√√°— …“‡ πâ ‡≈Õ◊ ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥μ—π¥«â ¬ PTA alone √Ÿª´â“¬ · ¥ß primary patency ¢Õß°“√„ à stent ·≈– PTA alone (control) √ªŸ ¢«“ · ¥ß primary ·≈– secondary patency ¢Õß°“√„ à stent ‡°‘¥¢÷Èπ§◊Õ ¡’°“√μ’∫‡°‘¥¢÷Èπ¿“¬„πμ—« stent (In stent À√◊Õ central stent stenosis) ·≈–∫√‘‡«≥∑’˪≈“¬ stent (adjacent stent À√◊Õ peripheral end stent stenosis) Õ—π‡π◊ËÕß®“°°“√‡°‘¥ neointinal hyperplasia „π ∫√‘‡«≥∑’Ë stent  —¡º— °—∫‡ âπ‡≈◊Õ¥¥” ¥—ßπ—Èπ∂Ⓣ¡à¡’¢âÕ∫àß™’È¥—߉¥â°≈à“«„π¢â“ßμâπ ®÷߉¡à§«√‡≈◊Õ°∑’Ë®–„ à stent ∑ÿ°√“¬ 5.2.1.2 Bare stent À√◊Õ Covered stent  ”À√—∫™π‘¥¢Õß stent „πªí®®ÿ∫—π ∂Ⓡªìπ bare stent §◊Õ stent ‡ª≈◊Õ¬ ¡’ 2 ·∫∫§◊Õ ·∫∫∑’Ë„ à æ√âÕ¡°—∫ balloon ·≈–„™âμ—« balloon ‡ªî¥ stent ·π∫°—∫μ—«‡ âπ‡≈◊Õ¥ (balloon-expandable flexible stent) ·≈–·∫∫∑’Ë “¡“√∂‡ªî¥μ—«·π∫°—∫‡ âπ‡≈◊Õ¥‰¥â‡Õß (self-expanding rigid stent) ´÷Ëß¡’∑—Èß∑”®“° stainless steel ·≈– nitinol π‘¬¡„™â stent ∑’Ë∑”®“° nitinol ¡“°°«à“ stainless steel ‡π◊ËÕß®“°¡’§«“¡¬◊¥À¬ÿàπ‰ªμ“¡ ‡ âπ‡≈◊Õ¥∑’˧¥‡§’Ȭ«‰¥â¥’°«à“ ·≈–¡’§«“¡·¡àπ¬”μàÕμ”·Àπàß∑’Ë„ à¡“°°«à“ ·μଗ߉¡à¡’°“√»÷°…“∑’Ë∫àß«à“ ™π‘¥„¥¥’°«à“°—π33, 35  ”À√—∫ stent graft À√◊Õ covered stent §◊Õ bare stent ∑’Ë¡’ PTFE graft ·π∫Õ¬àŸ¥â«¬ ‡™◊ËÕ«à“ “¡“√∂≈¥°“√‡°‘¥ neointimal hyperplasia ¿“¬„πμ—« stent (central stent stenosis) ‰¥â ·μà®–¡’ ªí≠À“°—∫ bare stent ∑’Ë‚º≈à∑’˪≈“¬∑—Èß ÕߢÕß PTFE graft ®÷߉¡àªÑÕß°—π°“√‡°‘¥°“√μ’∫∑’˪≈“¬ stent (peripheral end stent stenosis) ·μà design „πªí®®ÿ∫—π®–‰¡à¡’ free bare stent ∑’˪≈“¬∑—Èß Õߢâ“ß Õ¬à“߉√ °Áμ“¡¡’√“§“·æß°«à“ bare stent ‡∑à“μ—« ·≈–μâÕß„™â profile „π°“√ àßμ—« stent „À≠à∑”„Àâ√·Ÿ ∑ß¡’¢π“¥ „À≠à¡“° „πªí®®ÿ∫—π¬—߉¡à¡’√“¬ß“π«à“ bare stent À√◊Õ covered stent ·∫∫„¥¥’°«à“°—πÕ¬à“߉√ ¡’√“¬ß“π „πºŸâªÉ«¬®”π«π 14 √“¬ „πºâŸªÉ«¬∑’Ë¡’‡ âπøÕ°‡≈◊Õ¥ ‚¥¬¡’¢âÕ∫àß™’ȧ◊Õ ‡ âπ‡≈◊Õ¥¥”©’°¢“¥®”π«π 3 √“¬ ‡ âπ‡≈◊Õ¥¥”¡’ pseudoaneurysm ®”π«π 1 √“¬ ‡ âπ‡≈◊Õ¥¥”∑’Ëμ’∫¡’ residual stenosis ®”π«π 2 √“¬ ·≈– ¡’°“√μ’∫μ—π´È”„À¡à‡√Á«®”π«π 8 √“¬ æ∫«à“„π√–¬–‡«≈“ 6 ‡¥◊Õπ ¡’ primary ·≈– secondary patency rate 104

Practical Recommendations for Central Vein Occlusion ‡∑à“°—∫ 28.5% ·≈– 67.8% μ“¡≈”¥—∫ ºâŸªÉ«¬∑’Ë„ à stent ‡π◊ËÕß®“°¡’√Õ¬μ’∫μ—πÕ¬Ÿà‡¥‘¡®–¡’°“√μ’∫μ—π´È” ¿“¬„π 6 ‡¥Õ◊ πº«Ÿâ ®‘ ¬—  √ªÿ «“à ‰¡ªà ÕÑ ß°π— °“√μ∫’ μπ— ¢Õ߇ πâ ‡≈Õ◊ ¥38 Õߧ°å “√ FDA ¢Õߪ√–‡∑» À√∞— Õ‡¡√°‘ “ ¬ß— ‰¡àÕπÿ¡μ— ‘¢Õâ ∫ßà ™È’ ”À√∫— °“√„™â stent „π‡ âπ‡≈◊Õ¥¥”„À≠à∑Ë’μ’∫μπ— À√Õ◊ ‡ πâ øÕ°‡≈◊Õ¥ ¬°‡«âπ¡’‡ πâ ‡≈◊Õ¥ ©’°¢“¥À√◊Õ·μ° ·≈–‰¡à “¡“√∂Àâ“¡‡≈◊Õ¥‰¥â¥â«¬«‘∏’Õ◊Ëπ °“√„™â stent  ”À√—∫‡ âπ‡≈◊Õ¥¥”„À≠à„πªí®®ÿ∫—π ®÷߇ªìπ°“√„™âπÕ°¢âÕ∫àß™’È (·∫∫ off label) 5.2.1.3 Precaution for stenting ¡’¢âÕæ÷ß√–«—ß„π°“√„ à stent §◊Õ∂â“®–„ à∑’ˇ âπ‡≈◊Õ¥ SCV ®–μâÕ߉¡à„Àâμ—« stent æ“¥‡≈¬√Ÿ‡ªî¥ ¢Õ߇ âπ‡≈◊Õ¥ IJV ´÷Ëß„πÕπ“§μ¬—ß “¡“√∂„™â‡ªìπ∑“ß„ à “¬ HD-Catheter ‰¥â ·≈–∂â“„ à stent ∑’ˇ âπ‡≈◊Õ¥ BCV ®–μâÕ߉¡àªî¥√Ÿ‡ªî¥¢Õ߇ âπ‡≈◊Õ¥ BCV Õ’°¢â“ß ´÷ËßÕ“®®–μâÕß„™â‡ªìπ∑“ßÕÕ°¢Õ߇ âπøÕ°‡≈◊Õ¥‡ âπ ∂¥— ‰ª¢Õß·¢πÕ°’ ¢“â ß„πÕπ“§μ ·≈–„π∫“ߧ√ßÈ— ‡ªπì °“√¬“°∑®Ë’ –À≈°’ ‡≈¬Ë’ ß°“√æ“¥‰ªª¥î ‡ πâ ‡≈Õ◊ ¥¥”ÕπË◊ ‡π◊ËÕß®“°√Õ¬μ’∫μ—πÕ¬Ÿà„°≈â∑“ߺà“π¢Õ߇ âπ‡≈◊Õ¥¥”„À≠à‡ âπÕ◊Ëπ °“√„ à stent ∂â“¡’¢π“¥‡≈Á°‰ª®–∑”„Àâ ¡‚’ Õ°“ ‡°¥‘ °“√‡§≈Õ◊Ë πμ«— ¢Õß stent ÕÕ°®“°μ”·Àπßà ∑„’Ë  ‰à ¥â(stent migration) ·≈–Õ“®®–‡¢“â ‰ª ‡Ÿà  πâ ‡≈Õ◊ ¥ „πªÕ¥ ∂“â ¢π“¥„À≠‰à ª®–∑”„À‡â °¥‘ Õπ— μ√“¬μÕà ‡ πâ ‡≈Õ◊ ¥¥”∑¥Ë’ ’ ·≈–Õ“®®–‡°¥‘ °“√À¥μ«— ‰¥â (shortening) ´÷Ëß®–∑”„À≡à·π∫∂÷ß√Õ¬μ’∫∑’Ë¡’ªí≠À“ ®÷ßμâÕßμ‘¥μ“¡¥â«¬ X-ray ‡ªìπ√–¬–Ê33 5.2.2 °“√√—°…“¥â«¬«‘∏’°“√ºà“μ—¥ (surgical intervention) (·ºπ¿¡Ÿ ‘∑’Ë 2) 5.2.2.1 °“√º“à μ¥— ·°‰â ¢‡ πâ ‡≈Õ◊ ¥¥”„À≠μà ∫’ À√Õ◊ Õ¥ÿ μπ— ‚¥¬μ√ß(surgicalangioplasty) °“√√—°…“¥â«¬°“√ºà“μ—¥‡æ◊ËÕ·°â‰¢‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫μ—πÀ√◊ÕÕÿ¥μ—π ¥â«¬°“√∑” surgical angioplasty ‡ªìπ°“√ºà“μ—¥„À≠à·≈–μâÕß∑”°“√‡ªî¥°√–¥°Ÿ ‡™àπ ∂⓺à“μ—¥´àÕ¡‡ âπ‡≈◊Õ¥ SCV ´÷Ëß à«π„À≠à ®–μ’∫∑’Ë∫√‘‡«≥μ√ß°≈“ß®π∂÷ß∫√‘‡«≥„°≈â°—∫√Õ¬μàÕ°—∫‡ âπ‡≈◊Õ¥¥” innominate ∑”„ÀâμâÕß∑”°“√ºà“μ—¥ °√–¥Ÿ° clavicle ÕÕ°¥â«¬ (medial claviculectomy) °“√ºà“μ—¥Õ“®®–‡ªìπ°“√∑” endovenectomy √à«¡°—∫ vein patch À√◊Õ PTFE patch À√◊Õ°“√∑” vein resection √à«¡°—∫°“√∑” end-to-end anastomosis À√◊Õ PTFE interposition 39 „π∑”πÕ߇¥¬’ «°π— ∂“â ®–´Õà ¡‡ πâ ‡≈Õ◊ ¥¥”∑Õ’Ë ¬≈Ÿà °÷ °«“à π’È μÕâ ß∑”°“√‡ª¥î °√–¥°Ÿ Àπ“â Õ°(open chest surgery) ‡æ◊ËÕ‡¢â“À“‡ âπ‡≈◊Õ¥¥”„À≠à ∑”„À⺟âªÉ«¬¡’§«“¡‡ ’ˬߠߟ „π°“√ºà“μ—¥ ·≈–º≈°“√ºà“μ—¥°Á Õ“®®–‰¡à‰¥â¥’°«à“«‘∏’°“√Õ◊Ëπ∑’ˬÿà߬“°πâÕ¬°«à“ ‡™àπ°“√∑”°“√ºà“μ—¥ bypass ∑”„Àâ‰¡à‡ªìπ∑’Ëπ‘¬¡ 5.2.2.2 °“√ºà“μ—¥·°â‰¢‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫À√Õ◊ Õÿ¥μ—π¥â«¬°“√∑” bypass °“√ºà“μ—¥ bypass ¡—°®–„™â‡ âπ‡≈◊Õ¥¥” saphenous À√◊Õ‡ âπ‡≈◊Õ¥‡∑’¬¡ ‡™àπ PTFE graft μàÕ √–À«à“߇ âπ‡≈◊Õ¥¥” à«π∑’Ë¥’°àÕπ√Õ¬μ’∫°—∫‡ âπ‡≈◊Õ¥¥”„À≠àμ”·ÀπàßÕ◊Ëπ∑’Ë¥’ ∑’Ë “¡“√∂π”‡≈◊Õ¥°≈—∫ àŸ À—«„®‰¥â –¥«° ¡—°®–„™â PTFE graft ‡ªìπμ—«‡™◊ËÕ¡μàÕ ·≈–¡—°∑”°“√μàÕ√–À«à“߇ âπ‡≈◊Õ¥¥” axillary ∑’ˉ¡à μ’∫μ—π¢Õß·¢π¢â“ß∑’Ë¡’‡ âπ‡≈◊Õ¥¥”„À≠àμ’∫ °—∫‡ âπ‡≈◊Õ¥¥”„À≠à IJV ¢Õß√à“ß°“¬´’°‡¥’¬«°—π À√◊Õ´’°μ√ß ¢â“¡ À√◊Õ°—∫‡ âπ‡≈◊Õ¥¥”„À≠à SVC À√◊Õ°—∫ right atrium √«¡∑—Èß°“√μàÕ≈߉ª¬—߇ âπ‡≈◊Õ¥¥” saphenous ∑’Ë μâπ¢“ „π°√≥’∂â“¡’‡ âπ‡≈◊Õ¥¥” axillary μ’∫μ—π Õ“®®–μâÕß„™â‡ âπ‡≈◊Õ¥¥”∑’ËÕ¬àŸμâπ∑“ß §◊Õ‡ âπ‡≈◊Õ¥¥” brachial ·∑π (√Ÿª∑’Ë 5) 105

Practical Dialysis in the Year 2009 √Ÿª∑’Ë 5 · ¥ß°“√ bypass √–À«à“߇ πâ ‡≈◊Õ¥¥” axillary ·≈–‡ âπ‡≈◊Õ¥ IJV ¥â“πμ√ߢ“â ¡¥â«¬ PTFE graft ‡πËÕ◊ ß®“° ‡ âπ‡≈◊Õ¥ SCV μ’∫μ—π °àÕπ∑” bypass μâÕߪ√–‡¡‘π‡ âπ‡≈◊Õ¥¥”„À≠à¥â«¬°“√∑” venogram ¢Õ߇ âπ‡≈◊Õ¥¥”„À≠à «“à  “¡“√∂‡≈Õ◊ °„™‡â  πâ ‡≈Õ◊ ¥¥”„¥¿“¬„π¢“â ߇¥¬’ «°π— °∫— ∑·’Ë ¢π∫«¡‰¥Àâ √Õ◊ ‰¡à∂“â ¡‡’  πâ ‡≈Õ◊ ¥ SCV μ∫’ ‡æ¬’ ß ‡ âπ‡¥’¬« ®–‡≈◊Õ°‡ âπ‡≈◊Õ¥ IJV ¢Õß·¢π¢â“߇¥’¬«°—π‡ªìπ∑“߇≈◊Õ°Õ—π¥—∫·√°40 À√◊Õ∑” transposition ‡ âπ‡≈◊Õ¥ IJV ¡“¬—߇ âπ‡≈◊Õ¥ SCV À√◊Õ‡ âπ‡≈◊Õ¥¥” axillary ‚¥¬μ√ߢÕß·¢π¢â“߇¥’¬«°—π41-43 ‚¥¬‰¡àμâÕß „™â PTFE graft ™à«¬ °√≥’∂Ⓡ âπ‡≈◊Õ¥ IJV ¢â“߇¥’¬«°—πμ’∫ À√◊Õ¡’‡ âπ‡≈◊Õ¥ BCV ¢â“߇¥’¬«°—πμ’∫√à«¡¥â«¬ ®–‡≈◊Õ° ‡ âπ‡≈◊Õ¥ IJV ¢Õß·¢π¥â“πμ√ߢⓡ ‡¡◊ËÕ∂÷ß®ÿ¥π’ÈμâÕß∑”°“√©’¥ contrast media ¢Õ߇ âπ‡≈◊Õ¥¥”„À≠à¢Õß ·¢πÕ°’ ¢“â ß ‡æÕ◊Ë „À¡â π—Ë „®«“à ‡ πâ ‡≈Õ◊ ¥¥”„À≠¢à Õß·¢πÕ°’ ¢“â ߪ°μ¥‘ ’ ° Á “¡“√∂∑” bypass √–À«“à ߇ πâ ‡≈Õ◊ ¥ ¥” axillary ¢Õß·¢π¢â“ß∑’Ë∫«¡‰ª¬—߇ âπ‡≈◊Õ¥ IJV ¢Õß·¢πÕ’°¢â“ß44 Àâ“¡π”‰ªμàÕ°—∫‡ âπ‡≈◊Õ¥¥”„À≠à ‡ âπÕ◊Ëπ¢Õß·¢πÕ’°¢â“ß ‡π◊ËÕß®“°Õ“®®–μâÕß„™â‡ªìπ∑“ßÕÕ°¢Õ߇ âπøÕ°‡≈◊Õ¥¢Õß·¢π¥â“πμ√ߢⓡ„π Õπ“§μ ∂“â ‡ πâ ‡≈Õ◊ ¥¥” IJV ¢Õß·¢π¥“â πμ√ߢ“â ¡°∫— ·¢π∑¡’Ë ‡’  πâ ‡≈Õ◊ ¥¥”„À≠μà ∫’ μπ— À√Õ◊ ¡ª’ ≠í À“À√Õ◊ ‡ âπ‡≈Õ◊ ¥¥”„À≠à brachiocephalic ¥“â πμ√ߢ“â ¡¡’ªí≠À“√à«¡¥â«¬ °®Á –μÕâ ß bypass ºà“π∑“߇ âπ‡≈◊Õ¥ SVC ·≈–°√≥’∂Ⓡ âπ‡≈◊Õ¥ SVC ¡’ªí≠À“°ÁÕ“®®– bypass ‡¢â“ right atrium45, 46 ´÷Ëß∑—Èß Õß«‘∏’π’È®”‡ªìπμâÕß ºà“μ—¥‡ªî¥°√–¥Ÿ°Àπâ“Õ° ®÷߉¡à‡ªìπ∑’Ëπ‘¬¡∑”°—π„πªí®®ÿ∫—π °“√∑’Ë®–μâÕߺà“μ—¥‡ªî¥°√–¥Ÿ°Àπâ“Õ°´÷Ëß 106

Practical Recommendations for Central Vein Occlusion ‡ªìπ°“√ºà“μ—¥„À≠à¡’§«“¡‡ ’ˬߠŸß ·≈–ºâŸªÉ«¬‚√§‰μ«“¬‡√◊ÈÕ√—ß∑’ËμâÕßøÕ°‡≈◊Õ¥°Á∂Ÿ°®—¥μ“¡¡“μ√“∞“π ASA47 Õ¬„àŸ π°≈¡ÿà ∑¡’Ë §’ «“¡‡ ¬’Ë ß√–¥∫— √πÿ ·√߉¡¡à “°∂ß÷ ¢π—È √πÿ ·√ß¡“°¥ß— ª√“°Ø„πμ“√“ß∑’Ë1 ®ß÷ μÕâ ߪ√–‡¡π‘ §«“¡‡ ’ˬߢÕߺ⟪ɫ¬°àÕπ∑”°“√ºà“μ—¥ ºâŸªÉ«¬∑’Ë¡’§«“¡‡ ’ˬ߄π√–¬– ASA-III ¢÷Èπ‰ª ‰¡à·π–π”„Àâ∑”°“√ ºà“μ—¥‡ªî¥°√–¥Ÿ°Àπâ“Õ° ‡π◊ËÕß®“°§«“¡‡ ’ˬߠŸß¡“°‡°‘π‰ª πÕ°®“°π—Èπ¬—ß “¡“√∂𔉪μàÕ°—∫ ‡ âπ‡≈◊Õ¥¥”∑’Ëμâπ¢“ ‡™àπ ‡ âπ‡≈◊Õ¥¥” Saphenous ‰¥4â 8 5.2.2.3 ·π«∑“ß„π°“√ºà“μ—¥ ”À√—∫‡ âπ‡≈◊Õ¥¥”„À≠à∑’Ëμâπ·¢πμ’∫À√◊ÕÕÿ¥μ—πμ“¡ √–∫∫ ASA ∂⓺ŸâªÉ«¬¡’Õ—μ√“§«“¡‡ ’ˬ߄π√–¥—∫ ASA-II ´÷Ë߇ªìπ√–¬–∑’˧“¥À«—ß«à“®–¡’™’«‘μ√Õ¥∑’ˬ“«π“π ·≈–¡’§«“¡‡ ’ˬßμàÕ°“√ºà“μ—¥μË” ®÷ßμâÕß欓¬“¡∑”∑ÿ°«‘∂’∑“߇æ◊ËÕ„À⇠âπøÕ°‡≈◊Õ¥∑’Ë¡’Õ¬àŸ„πªí®®ÿ∫—π ¡’Õ“¬ÿ°“√„™âß“ππ“π∑’Ë ÿ¥ ¥—ßπ—Èπ§«√‡°Á∫√—°…“‡ âπ‡≈◊Õ¥¢Õß·¢πÕ’°¢â“ß ”À√—∫‡ªìπ‡ âπøÕ°‡≈◊Õ¥„π Õπ“§μ ·≈–∑”°“√ºà“μ—¥ bypass ‡æ◊ËÕ„À⇠âπøÕ°‡≈◊Õ¥¢Õß·¢π¢â“ß∑’Ë∫«¡¬—ß„™âß“πμàÕ‰¥â Õ¬à“߉√°Áμ“¡ ∂â“μâÕß∑”°“√ºà“μ—¥„À≠à‡æ◊ËÕ‡ªî¥°√–¥Ÿ°Àπâ“Õ° °“√∑”‡ âπøÕ°‡≈◊Õ¥„À¡à∑’Ë·¢πÕ’°¢â“ßπà“®–ßà“¬°«à“ ·μà∂ⓇÀ≈◊Õ‡©æ“–°“√∑”‡ âπøÕ°‡≈◊Õ¥∑’Ëμâπ¢“ Õ“®®–μâÕߪ√–‡¡‘𧫓¡‡ ’Ë¬ß ‡π◊ËÕß®“°‡ âπøÕ°‡≈◊Õ¥ ∑’Ëμâπ¢“‡ªìπ‡ âπøÕ°‡≈◊Õ¥ ÿ¥∑⓬∑’ˇÀ≈◊ÕÕ¬àŸ  ”À√∫— ºªŸâ «É ¬∑¡Ë’ §’ «“¡‡ ¬Ë’ ß„π√–¥∫— ASA-III ‰¡·à π–π”„À∑â ”°“√º“à μ¥— ‡ª¥î °√–¥°Ÿ Àπ“â Õ° ·μà ºªâŸ «É ¬¬ß—  “¡“√∂∑”°“√º“à μ¥— ∑«—Ë ‰ª‰¥â ¥ß— ππ—È ®ß÷ ‡≈Õ◊ °°“√º“à μ¥— bypass ‰ª¬ß— ‡ πâ ‡≈Õ◊ ¥¥”„À≠„à πμ”·Àπßà μà“ßÊ ∑’ˇÀ¡“– ¡μ“¡ ¿“æ¢Õ߇ âπ‡≈◊Õ¥¥”„À≠àπ—ÈπÊ ‡™àπ ‡ âπ‡≈◊Õ¥¥”„À≠à IJV ¢Õß·¢π¢â“߇¥’¬«°—∫ ∑’Ë∫«¡ À√◊Õ∂â“¡’°“√μ’∫μ—π¢Õ߇ âπ‡≈◊Õ¥ BCV „Àâ‡≈◊Õ°μàÕ bypass ‰ª¬—߇ âπ‡≈◊Õ¥ IJV ¥â“πμ√ߢⓡ À√◊Õ ∂â“¡’°“√μ’∫¢Õ߇ âπ‡≈◊Õ¥¥”„À≠à brachiochephalic ∑—Èß Õߢâ“ß À√◊Õ¡’°“√μ’∫¢Õ߇ âπ‡≈◊Õ¥¥”„À≠à SVC °ÁÕ“®®– bypass ‰ª¬—߇ âπ‡≈◊Õ¥¥” saphenous ∑’Ëμâπ¢“  ”À√∫— ºªâŸ «É ¬∑¡’Ë §’ «“¡‡ ¬’Ë ß„π√–¥∫— ASA-IV ´ß÷Ë §“¥«“à ®–¡Õ’ μ— √“°“√Õ¬√Ÿà Õ¥‰¡πà “π·≈–¡§’ «“¡ ‡ ¬’Ë ß ßŸ μÕà °“√º“à μ¥— ¡“° „À∑â ”‡ πâ øÕ°‡≈Õ◊ ¥„À¡∑à ·’Ë ¢πÕ°’ ¢“â ßÀ√Õ◊ ∑μ’Ë πâ ¢“ ·≈–‡¡Õ◊Ë mature ·≈«â „À∑â ”°“√ ªî¥‡ âπøÕ°‡≈◊Õ¥¢â“ß∑’Ë∫«¡∑‘Èß μ“√“ß∑’Ë 1 °“√ª√–‡¡‘𧫓¡‡ ’ˬߢÕߺ⟪ɫ¬μ“¡ ASA (The American Society of Anesthesiologists) ë ASA-I §◊Õ ºŸâªÉ«¬·¢Áß·√ߪ°μ‘ ë ASA-II §◊Õ ºâŸªÉ«¬∑’Ë¡’‚√§ª√–®”μ—«∑’Ë√ÿπ·√߉¡à¡“° ë ASA-III §◊Õ ºâŸªÉ«¬∑’Ë¡’‚√§ª√–®”μ—«∑’Ë√ÿπ·√ß¡“° ë ASA-IV §◊Õ ºâŸªÉ«¬∑’Ë¡’‚√§ª√–®”μ—«∑’Ë√ÿπ·√ß¡“°·≈–¡’º≈μàÕ°“√Õ¬Ÿà√Õ¥¢Õߺ⟪ɫ¬ ë ASA-V §◊Õ ºŸâªÉ«¬Õ“°“√Àπ—°Õ¬à“ß¡“° ∂Ⓣ¡à‰¥â√—∫°“√ºà“μ—¥μâÕ߇ ’¬™’«‘μ·πàπÕπ ë ASA-VI §◊Õ ºâŸªÉ«¬∑’Ë¡’ ¡Õß쓬 ·μàÕ«—¬«–Õ◊Ëπ¬—ß∑”ß“π‰¥â·≈– “¡“√∂π”Õ«—¬«–‰ª∫√‘®“§‰¥â 107

Practical Dialysis in the Year 2009 5.2.3 °“√‡ª√’¬∫‡∑’¬∫°“√∑” PTA±Stent ·≈–°“√∑” bypass  ”À√—∫°“√‡ª√’¬∫‡∑’¬∫°“√ºà“μ—¥·∫∫ bypass °—∫°“√∑” PTA±Stent æ∫«à“¡’°“√»÷°…“„πºŸâ ªÉ«¬®”π«π‰¡à¡“°Õ¬àŸ 2 √“¬ß“π √“¬ß“π·√°‡ª√’¬∫‡∑’¬∫°“√ bypass ¥â«¬‡ âπ‡≈◊Õ¥¥” saphenous À√◊Õ PTFE 13 √“¬ ·≈–°“√„ à stent 13 √“¬ æ∫«à“ primary assisted patency ∑’Ë√–¬–‡«≈“ 6 ‡¥◊Õπ ·≈– 1 ªï ‰¡à·μ°μà“ß°—π49 Õ’°√“¬ß“π‰¥â‡ª√’¬∫‡∑’¬∫°“√∑” bypass 10 √“¬ ·≈–°“√∑” PTA 30 §√—Èß æ∫«à“°“√ bypass ¡’ primary patency 75% ·≈–°“√∑” PTA ¡’ primary unassisted patency ·≈– secondary patency ‡∑à“°—∫ 50% ·≈– 63% μ“¡≈”¥—∫ ´÷Ë߉¡à·μ°μà“ß°—π50 ¥—ßπ—Èπ°“√®–„™âª√–‚¬™π宓°‡ âπøÕ°‡≈◊Õ¥„À≥â π“π∑ Ë’ ¥ÿ §«√·°‰â ¢¥â «â ¬°“√∑” PTA±Stent °àÕπ ´÷Ëß·πàπÕπ∑’ËμâÕß∑”°“√·°â‰¢´È”°àÕπ∑’Ë®–‡ª≈’Ë¬π‰ª·°â‰¢ ¥â«¬°“√∑” bypass °“√‡≈◊Õ°°“√·°â‰¢¥â«¬°“√∑” bypass °àÕπ ‰¡à‰¥â∑”„Àâª≈Õ¥Õ“°“√π“π°«à“°“√∑” PTA±Stent ·μà¡’¢âÕ¥’§◊Õ ‰¡àμâÕß∑”À—μ∂°“√´È”À≈“¬§√—Èß ·μà®–∑”„Àâæ≈“¥‚Õ°“ „π°“√·°â‰¢¥â«¬«‘∏’ PTA±Stent ‡π◊ËÕß®“°∂â“«‘∏’ bypass ≈⡇À≈« ´÷Ëß¡—°‡°‘¥®“°°“√μ’∫À√◊ÕÕÿ¥μ—π¢Õßμ—« bypass graft °“√®– °≈∫— ¡“∑”°“√·°‰â ¢¥«â ¬«∏‘ ’ PTA Õ“®®–™“â ‰ª ‡πÕË◊ ß®“°√–¬–‡«≈“∑πË’ “π®–∑”„À°â “√μ∫’ μπ— °≈“¬‡ªπì °“√ Õÿ¥μ—π π‘∑·≈–‰¡à “¡“√∂„ à guidewire ºà“π‰¥â ∑”„À≡ࠓ¡“√∂·°â‰¢‰¥â 6. °“√ªÑÕß°—π°“√‡°‘¥‡ âπ‡≈◊Õ¥¥”„À≠μà ∫’ À√◊ÕÕ¥ÿ μ—π ºŸâªÉ«¬∑ÿ°√“¬∑’Ë¡’§«“¡‡ ’ˬß∑’Ë®–μâÕßøÕ°‡≈◊Õ¥„πÕπ“§μ ‰¡à§«√„ à PICC À√◊Õ “¬ catheter „¥Ê ∑’˺à“π ∑“߇ âπ‡≈◊Õ¥¥”„À≠à ·≈–‡¡◊ËÕ∂÷ß√–¬–‡«≈“„°≈â®–μâÕßøÕ°‡≈◊Õ¥®–μâÕß∑”‡ âπøÕ°‡≈◊Õ¥≈à«ßÀπâ“ ‡æ◊ËÕ ‰¡àμâÕß„ à “¬ HD Cath ‡π◊ËÕß®“° “¬ HD Cath ‡ªì𠓇Àμÿ ”§—≠¢Õ߇ âπ‡≈◊Õ¥¥”„À≠àμ’∫À√◊ÕÕÿ¥μ—π °√≥’μâÕß„ à “¬ HD Cath §«√„ à∑’ˇ âπ‡≈◊Õ¥ IJV ¥â“π¢«“ ·≈–欓¬“¡∂Õ¥ÕÕ°‡√Á«∑’Ë ÿ¥ §«√‡≈◊Õ°∑”  “¬øÕ°‡≈◊Õ¥∑’Ë·¢π§π≈–¢â“ß°—∫¢â“ß∑’Ë¡’ª√–«—쑇§¬„ à “¬øÕ°‡≈◊Õ¥ À√◊Õ “¬ catheter μà“ßÊ √«¡∑—Èß  “¬ pacemaker À√◊Õ “¬®“°‡§√◊ËÕß defibrillator ∂â“®”‡ªìπμâÕß„ à„π¢â“߇¥’¬«°—𠧫√∑” venogram ¢Õß ·¢π¢â“ßπ—Èπ‡æ◊ËÕ„Àâ·πà„®«à“‰¡à¡’°“√μ’∫À√◊ÕÕÿ¥μâπ¢Õ߇ âπ‡≈◊Õ¥¥”„À≠à °√≥’μâÕß„ à “¬ pacemaker À√◊Õ  “¬®“°‡§√◊ËÕß defibrillator „Àâ„ à∑’Ë·¢π§π≈–¢â“ß°—∫·¢π∑’Ë¡’‡ âπøÕ°‡≈◊Õ¥ ‡Õ° “√Õ“â ßÕß‘ 1. Wright RS, Quinones-Baldrich WJ, Anders AJ, Danovitch GM. Pleural effusion associated with ipsilateral breast and arm edema as a complication of subclavian vein catheterization and arteriovenous fistula formation for hemodialysis. Chest 1994; 106: 950-2. 2. Schwab SJ, Quarles LD, Middleton JP, Cohan RH, Saeed M, Dennis VW. Hemodialysis-associated subclavian vein stenosis. Kidney Int 1988; 33: 1156-9. 3. Patel MC, Berman LH, Moss HA, McPherson SJ. Subclavian and internal jugular veins at Doppler US: abnormal cardiac pulsatility and respiratory phasicity as a predictor of complete central occlusion. Radiology 1999; 211: 579-83. 4. Rose SC, Kinney TB, Bundens WP, Valji K, Roberts AC. Importance of Doppler analysis of transmitted atrial waveforms prior to placement of central venous access catheters. J Vasc Interv Radiol 1998; 9: 927-34. 108

Practical Recommendations for Central Vein Occlusion 5. Kim CY, Merkle EM. Time-resolved MR angiography of the central veins of the chest. AJR Am J Roentgenol 2008; 191: 1581-8. 6. Kim H, Chung JW, Park JH, et al. Role of CT venography in the diagnosis and treatment of benign thoracic central venous obstruction. Korean J Radiol 2003; 4: 146-52. 7. Paksoy Y, Gormus N, Tercan MA. Three-dimensional contrast-enhanced magnetic resonance angiography (3-D CE- MRA) in the evaluation of hemodialysis access complications, and the condition of central veins in patients who are candidates for hemodialysis access. J Nephrol 2004; 17: 57-65. 8. Schillinger F, Schillinger D, Montagnac R, Milcent T. Post catheterisation vein stenosis in haemodialysis: comparative angiographic study of 50 subclavian and 50 internal jugular accesses. Nephrol Dial Transplant 1991; 6: 722-4. 9. Hernandez D, Diaz F, Suria S, et al. Subclavian catheter-related infection is a major risk factor for the late development of subclavian vein stenosis. Nephrol Dial Transplant 1993; 8: 227-30. 10. Cimochowski GE, Worley E, Rutherford WE, Sartain J, Blondin J, Harter H. Superiority of the internal jugular over the subclavian access for temporary dialysis. Nephron 1990; 54: 154-61. 11. Jassal SV, Pierratos A, Roscoe JM. Venous stenosis and thrombosis associated with the use of internal jugular vein catheters for hemodialysis. ASAIO J 1999; 45: 356-9. 12. MacRae JM, Ahmed A, Johnson N, Levin A, Kiaii M. Central vein stenosis: a common problem in patients on hemodialysis. ASAIO J 2005; 51: 77-81. 13. Salgado OJ, Urdaneta B, Colmenares B, Garcia R, Flores C. Right versus left internal jugular vein catheterization for hemodialysis: complications and impact on ipsilateral access creation. Artif Organs 2004; 28: 728-33. 14. Taal MW, Chesterton LJ, McIntyre CW. Venography at insertion of tunnelled internal jugular vein dialysis catheters reveals significant occult stenosis. Nephrol Dial Transplant 2004; 19: 1542-5. 15. di Costanzo J, Sastre B, Choux R, Kasparian M. Mechanism of thrombogenesis during total parenteral nutrition: role of catheter composition. J Parenter Enteral Nutr 1988; 12: 190-4. 16. Itkin M, Kraus MJ, Trerotola SO. Extrinsic compression of the left innominate vein in hemodialysis patients. J Vasc Interv Radiol 2004; 15: 51-6. 17. Forauer AR, Theoharis C. Histologic changes in the human vein wall adjacent to indwelling central venous catheters. J Vasc Interv Radiol 2003; 14: 1163-8. 18. Kowalski CM, Kaufman JA, Rivitz SM, Geller SC, Waltman AC. Migration of central venous catheters: implications for initial catheter tip positioning. J Vasc Interv Radiol 1997; 8: 443-7. 19. Nazarian GK, Bjarnason H, Dietz CA, Jr., Bernadas CA, Hunter DW. Changes in tunneled catheter tip position when a patient is upright. J Vasc Interv Radiol 1997; 8: 437-41. 20. Salik E, Daftary A, Tal MG. Three-dimensional anatomy of the left central veins: implications for dialysis catheter placement. J Vasc Interv Radiol 2007; 18: 361-4. 21. Lobato EB, Sulek CA, Moody RL, Morey TE. Cross-sectional area of the right and left internal jugular veins. J Cardiothorac Vasc Anesth 1999; 13: 136-8. 22. Chuang CL, Tarng DC, Yang WC, Huang TP. An occult cause of arteriovenous access failure: central vein stenosis from permanent pacemaker wire. Report of three cases and review of the literature. Am J Nephrol 2001; 21: 406- 9. 23. Korzets A, Chagnac A, Ori Y, Katz M, Zevin D. Subclavian vein stenosis, permanent cardiac pacemakers and the haemodialysed patient. Nephron 1991; 58: 103-5. 109

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Pitfalls in Vascular Access for Dialysis Nurses 7 Pitfalls in Vascular Access for Dialysis Nurses ª«’≥“  ‘ßÀå∑‘» 1. ∫∑π” 2. ™π¥‘ ¢Õß Vascular access 3. ¿“«–·∑√°´âÕπ¢Õß Vascular access 4. ∫∑∫“∑¢Õß欓∫“≈‰μ‡∑’¬¡„π°“√®¥— °“√ Vascular access 5. °“√‡Ω“Ñ √–«ß— Vascular access 6. Clinical outcome goals 7.  √ÿª 113

Practical Dialysis in the Year 2009 1. ∫∑π” °“√∫”∫¥— ∑¥·∑π‰μ‚¥¬°“√øÕ°‡≈Õ◊ ¥¥«â ¬‡§√ÕË◊ ߉μ‡∑¬’ ¡ (hemodialysis) „πºªâŸ «É ¬‚√§‰μ«“¬ ‡√◊ÈÕ√—ßπ—Èπ Õߧåª√–°Õ∫∑’Ë ”§—≠ª√–°“√Àπ÷Ëß §◊Õ vascular access ´÷Ë߇ªìπ™àÕß∑“ßπ”‡≈◊Õ¥ àŸμ—«°√Õ߇≈◊Õ¥ (dialyzer) ‡æ◊ËÕ„À⇰‘¥°“√øÕ°‡≈◊Õ¥‰¥âÕ¬à“߇撬ßæÕ (adequacy of hemodialysis) ∑’Ë®– àߺ≈„ÀâºâŸªÉ«¬¡’ §ÿ≥¿“æ∑’Ë¥’·≈–¡’Õ“¬ÿ¬◊𬓫„°≈⇧’¬ßª°μ‘¡“°∑’Ë ÿ¥ vascular access ∑’Ë¥’μ“¡Õÿ¥¡§μ‘π—Èπ μâÕß¡’°“√‰À≈ ‡«¬’ π‡≈Õ◊ ¥∑¥Ë’ ’·≈–·√ßæÕ∑Ë’®–‡ªπì ™àÕß∑“ßπ”‡≈◊Õ¥ àŸμ«— °√Õ߇≈◊Õ¥‰¥âÕ¬“à ߇撬ßæÕμ“¡·ºπ°“√√°— …“„π ºªâŸ «É ¬·μ≈à –√“¬  “¡“√∂„™ßâ “π‰¥¬â “«π“π·≈–¡¿’ “«–·∑√°´Õâ ππÕâ ¬ „π∑“ßμ√ß°π— ¢“â ¡ vascular access ∑’Ë¡’¿“«–≈⡇À≈« (failure) ®–‡ªì𠓇Àμÿ„À≠à¢ÕßÕ—μ√“°“√‡®Á∫ªÉ«¬·≈–Õ—μ√“°“√쓬 (morbidity and mortality)1,2,3 ‡ªπì º≈„Àºâ ªâŸ «É ¬μÕâ ߇¢“â πÕπ‚√ß欓∫“≈∫Õà ¬§√ß—È ¡“°∑ ’Ë ¥ÿ ·≈–„π À√∞— Õ‡¡√°‘ “¡§’ “à „™®â “à ¬ „π°“√√—°…“¿“«–·∑√°´âÕπ¢Õß vascular access ‡ªìπ®”π«π∂÷ß√âÕ¬≈– 14 ¢Õß§à“„™â®à“¬∑—ÈßÀ¡¥¢Õߺ⟠ª«É ¬‰μ«“¬‡√ÕÈ◊ √ß— (1,000 ≈“â π¥Õπ≈“à μÕà ª)ï 1  ”À√∫— ª√–‡∑»‰∑¬ √∞— ∫“≈‰¥‡â √¡Ë‘ ¡°’ “√„À â « — ¥°‘ “√§“à √°— …“ °“√∫”∫—¥∑¥·∑π‰μ·°àºâŸªÉ«¬„πÀ≈—°ª√–°—π ÿ¢¿“æ´÷Ë߇ªìπºâŸªÉ«¬°≈ÿà¡„À≠à¢Õߪ√–‡∑» ‚¥¬®à“¬‡ß‘π ∑¥·∑π„π°“√∑”À√◊Õ´àÕ¡·´¡ vascular access ‡ªìπ®”π«π‡ß‘π 20,000 ∫“∑μàÕ 2 ªï μ—Èß·μà‡¥◊Õπμÿ≈“§¡ ªï 2551 欓∫“≈‰μ‡∑’¬¡„π∞“𖇪ìπºŸâªØ‘∫—μ‘ß“π∑’ˇ°’ˬ«¢âÕß°—∫°“√„™â vascular access ‚¥¬μ√ߧ«√ μ√–Àπ—°∂÷ߧ«“¡ ”§—≠ „π∫∑π’È®–°≈à“«∂÷ß∫∑∫“∑¢Õß欓∫“≈‰μ‡∑’¬¡„π°“√‡¢â“∂÷ߪí≠À“μà“ßÊ ¢Õß vascular access ·μà≈–™π‘¥ °“√®—¥°“√·≈–°“√ªÑÕß°—πªí≠À“ °“√‡ΩÑ“√–«—ß√«¡∑—È߇ªÑ“À¡“¬∑“ߧ≈‘π‘° ‡æ◊ËÕ𔉪 àŸ°“√¥·Ÿ ≈ºâŸªÉ«¬„Àâ¡’ vascular access ∑’Ë¥’ 2. ™π‘¥¢Õß Vascular access 3,4 ™π‘¥¢Õß vascular access ∑’Ë ”§—≠‰¥â·°à 2.1 Central Venous Catheter (CVC) 2.2 Arteriovenous Fistula (AVF) 2.3 Arteriovenous Graft (AVG) 2.1 Central Venous Catheter (CVC) 4,5 ≈°— …≥–‡ªπì  “¬ «π ”À√∫—  «π‡¢“â ‡ πâ ‚≈Àμ‘ ¥”„À≠à∑”¢π÷È ®“°« — ¥·ÿ ¢ßÁ À√Õ◊ °ß÷Ë ·¢ßÁ ¡§’ «“¡ ¬“«À≈“¬¢π“¥ ·≈–¡’°“√ÕÕ°·∫∫μà“ßÊ °—π ‰¥â·°à 1. Double-lumen catheter - ª≈“¬¢Õß arterial lumen ®–Õ¬Ÿàμ◊Èπ°«à“ ª≈“¬¢Õß venous lumen ‡æ◊ËÕ≈¥ recirculation - √¢Ÿ Õß catheter ¡¢’ π“¥μ“à ßÊ ¢π“¥„À≠à ®– ßà ‡ √¡‘ °“√‰À≈‡«¬’ π¢Õ߇≈Õ◊ ¥„πª√¡‘ “≥¡“° - ¡’∑—Èß·∫∫∑’Ë„™â„π√–¬– —Èπ (temporary) ·≈–√–¬–¬“« (permanent) 2. Twin catheter - Recirculation πâÕ¬ ‡π◊ËÕß®“°ª≈“¬ “¬ “¡“√∂«“߉¥âμ“¡μâÕß°“√ 114

Pitfalls in Vascular Access for Dialysis Nurses - ¡’¢π“¥„À≠à«—¥®“°‡ âπ√Õ∫«ß¿“¬πÕ° - °“√·¬°‡ªìπ 2  “¬ ∑”„Àâ “¡“√∂·¬°∂Õ¥ÕÕ°∑’≈– “¬ „π°√≥’∑’Ë¡’°“√μ’∫μ—π °“√μ‘¥ ‡™◊ÈÕÀ√◊Õ§«“¡º‘¥ª°μ‘∑’ˇ°‘¥¢÷Èπ„π·μà≈– “¬ - ¡—°„™â„π√–¬–¬“« catheter ∑’Ë„™â‡°‘π°«à“ 2-3  —ª¥“Àå ®–„™â™π‘¥∑’Ë¡’ Dacron cuff ‡æ◊ËÕ≈¥°“√μ‘¥‡™◊ÈÕ ‚¥¬ª°μ‘ ∑—Ë«‰ª CVC ®–„ÀâÕ—μ√“°“√‰À≈¢Õ߇≈◊Õ¥‰¥â 300 ml/min 6 2.1.1 ¢Õâ ∫àß™’¢È Õß CVC 7,8,9 √–¬– —Èπ (Short-term) - „™â„π‡«≈“ ≤ 1-3  —ª¥“Àå -  ”À√—∫ºâŸªÉ«¬∑’ËμâÕß∑” temporary hemodialysis ‡æ◊ËÕ√Õ permanent vascular access ‚μ, plasmapheresis À√◊Õ acute hemodialysis „πºŸâªÉ«¬ acute renal failure - „™â„πºâŸªÉ«¬ peritonitis ∑’ËμâÕߺà“μ—¥‡Õ“ “¬ PD catheter ÕÕ° - ºâŸªÉ«¬À≈—ß°“√ª≈°Ÿ ∂à“¬‰μ∑’ˉ¡à¡’ vascular access - ºŸâªÉ«¬∑’Ë permanent vascular access μ‘¥‡™◊ÈÕ·≈–μâÕߺà“μ—¥‡Õ“ÕÕ° - ºâŸªÉ«¬∑’Ë√Õ thrombectomy ·≈–/À√◊Õ √Õ·°â‰¢ªí≠À“ permanent vascular access Õ◊ËπÊ √–¬–¬“« (Long-term) - „™â„π‡«≈“‡°‘π°«à“ 3  —ª¥“Àå ‡™àπ prolonged acute renal failure, ºŸâªÉ«¬∑’ËμâÕß„™â‡«≈“ √—°…“°“√μ‘¥‡™◊Èե⫬¬“ªØ‘™’«π–°àÕπ„ à AV graft „À¡à À√◊Õ«“ß “¬ PD catheter „À¡à - „™â‡¡◊ËÕ‰¡à “¡“√∂„™â permanent access Õ◊ËπÊ ‰¥âÕ’°·≈â« ‡™àπ ºŸâªÉ«¬‡∫“À«“π - „™â‡æ◊ËÕ√Õ permanent vascular access ‚μ 2.1.2 ¢Õâ ¥¢’ Õß CVC √–¬– Èπ— (Short-term) - „ à‰¥â∑—π∑’‡¡◊ËÕμâÕß°“√ „πμ”·Àπàß internal jugular, femoral À√◊Õ subclavian vein -  “¡“√∂∑”À—μ∂°“√∑’Ë‡μ’¬ßºŸâªÉ«¬‰¥â -  “¡“√∂„™â‰¥â∑—π∑’À≈—ß®“°∑’ˉ¥â¬◊π¬—πμ”·Àπàß∂°Ÿ μâÕß®“°°“√ X-ray √–¬–¬“« (Long-term) - „ à‰¥â∑—π∑’‡¡◊ËÕμâÕß°“√ „πμ”·Àπàß Rt internal jugular, Rt external jugular, Lt internal jugular, Lt external jugular, subclavian vein, femoral À√◊Õ translumbar to inferior vena cava - «— ¥ÿÕàÕππÿࡪÑÕß°—π°“√‡ ’¬À“¬μàÕ‡π◊ÈÕ‡¬◊ËÕ ∂â“μâÕß„ à„π™à«ß‡«≈“Õ—π¬“«π“π - Dacron cuff ™à«¬æ¬ÿß “¬ catheter ·≈–ªÑÕß°—π°“√μ‘¥‡™◊ÈÕ àŸ CVC tunnel - Tunnel catheter ®–„ ºà “à πº«‘ Àπß— „π subcutaneous ·≈«â ‡¢“â  ‡âŸ  πâ ‡≈Õ◊ ¥¥”„π®¥ÿ ∑‡’Ë ≈Õ◊Ë ¡≈È” °—∫·º≈∑’˺‘«Àπ—߇æ◊ËÕ≈¥°“√μ‘¥‡™◊ÈÕ 115

Practical Dialysis in the Year 2009 2.1.3 ¢âÕ‡ ’¬¢Õß CVC √–¬– π—È (Short-term) - μ‘¥‡™◊ÈÕßà“¬ ∑”„ÀâºâŸªÉ«¬‰¡à ÿ¢ ∫“¬ ¬“°„π°“√¥Ÿ·≈·º≈ - Õÿ∫—μ‘°“√≥å°“√μ’∫μ—π Ÿß ∂â“„™â subclavian vein √–¬–¬“« (Long-term) - μâÕß∑”„πÀâÕߺà“μ—¥À√◊Õ√à«¡°—∫°“√∑” ultrasound ·≈–«‘∏’√—ß ’«‘∑¬“ - ‡ ’ˬßμàÕ permanent central venous μ’∫μ—πÀ√◊ÕÕÿ¥μ—π (stenosis or occlusion) - „™â subclavian vein μàÕ‡¡◊ËÕ jugular vein ∑—ÈßÀ¡¥‰¡à “¡“√∂„™â‰¥â·≈⫇π◊ËÕß®“°¡’°“√μ’∫ μ—π ßŸ 2.1.4 °“√„  à “¬ CVC „π¡¡ÿ ¡ÕߢÕß欓∫“≈‰μ‡∑¬’ ¡ (Nursing view point for CVC placement) √–¬– Èπ— (Short-term) ë Internal jugular vein -  “¡“√∂„ à§“‰«â‰¥â∂÷ß 3  —ª¥“Àå ‡ ’ˬßμàÕ pneumothorax √–À«à“ß°“√„ àπâÕ¬°«à“„™â subclavian vein °¥Àâ“¡‡≈◊Õ¥‰¥â À≈—ß∂Õ¥ “¬ÕÕ°À√◊Õ‡¡◊ËÕ¡’‡ âπ‡≈◊Õ¥∑–≈ÿ - Õ—μ√“°“√μ’∫μ—ππâÕ¬ Õ—μ√“°“√μ’∫μ—π„°≈⇧’¬ß°—∫ subclavian À√◊Õ femoral catheter - μâÕ߬◊π¬—πμ”·Àπàß°“√«“ß “¬‚¥¬ chest X-ray - ‰¡à –¥«°„π°“√∑”·º≈ Õ—μ√“°“√μ‘¥‡™◊ÈÕ„°≈⇧’¬ß°—∫ subclavian catheter ë Femoral vein - μâÕß∂Õ¥ÕÕ°¿“¬„π 3-5 «—π ßà“¬μàÕ°“√„ à “¬ ¿“«–·∑√°´âÕπ®“°°“√„ à¡’πâÕ¬ - „™â‰¥â∑—π∑’À≈—ß°“√„ à - ∑”„À⺟âªÉ«¬‰¡à ÿ¢ ∫“¬ μâÕß„ÀâπÕπÀß“¬μ≈Õ¥·≈–Àâ“¡ßÕ¢“¢â“ß∑’Ë„ à “¬‰«â - μ‘¥‡™◊ÈÕßà“¬ ∂â“„ à§“‰«â‡°‘π 3 «—π - ¢Õâ À“â ¡¢Õß°“√„ à ‰¥·â °à iliofemoral thrombosis À√Õ◊ deep vein thrombosis À√Õ◊ iliofemoral bypass - °“√·∑ß∂°Ÿ ‡ πâ ‡≈Õ◊ ¥‡ªπì  “‡Àμ„ÿ À‡â °¥‘ ‡≈Õ◊ ¥ÕÕ°πÕ°‡¬ÕË◊ ∫™ÿ Õà ß∑Õâ ß ‚¥¬¡∫’ ßà ™È’ §Õ◊ §«“¡ ¥—π‚≈À‘μμ°„π∑—π∑’ §≈”‰¡àæ∫™’æ®√À√◊Õ§≈”‰¥â‡∫“„π¢â“ßπ—Èπ ë Subclavian vein - Õ“®„ à§“‰«â‰¥âÀ≈“¬ —ª¥“Àå ∑”·º≈‰¥âßà“¬ - π‘¬¡„ àπâÕ¬∑’Ë ÿ¥ - §«√À≈’°‡≈’ˬß∂⓺ŸâªÉ«¬μâÕß∑” permanent access - ‡ ’ˬßμàÕ pneumothorax ‰¥â ßŸ - ‰¡à “¡“√∂°¥Àâ“¡‡≈◊Õ¥ ∂â“·∑ß∑–≈ÿ‡ âπ‡≈◊Õ¥·¥ß¢≥–„ à “¬ - μâÕ߬◊π¬—πμ”·Àπàß°“√«“ß “¬‚¥¬ chest X-ray °àÕπ„™â 116

Pitfalls in Vascular Access for Dialysis Nurses - „ à¬“°„π√“¬À“¬„®μ◊Èπ μâÕß„ à„π∑à“ recumbent position - Õ—μ√“°“√μ’∫μ—π ßŸ √–¬–¬“«(Long-term) ë Internal jugular - π‘¬¡„™â‡π◊ËÕß®“°Õ—μ√“°“√μ’∫μ—ππâÕ¬ - μâÕ߬◊π¬—πμ”·Àπàß°“√«“ß “¬‚¥¬ chest X-ray °àÕπ„™â ë Subclavian vein - Õ—μ√“°“√μ’∫μ—π¢Õ߇ âπ‡≈◊Õ¥¥” Ÿß - „™â subclavian vein μàÕ‡¡◊ËÕ jugular vein ∑—ÈßÀ¡¥‰¡à “¡“√∂„™â‰¥â ë Femoral vein - ‡ ’ˬßμàÕ°“√μ‘¥‡™◊ÈÕ‰¥â Ÿß - „™â‡ªìπ∑“߇≈◊Õ° ÿ¥∑⓬ ”À√—∫ vascular access ë Translumbar / Transthorasic - μâÕß·∑߇¢â“‡ âπ‡≈◊Õ¥ vena cava - „™âπâÕ¬ 2.2 Arteriovenous Fistula (AVF) 4,10,11 ‡ªìπ‡ âπ‡≈◊Õ¥·¥ß (artery) ·≈– ¥” (vein) ¢ÕߺªâŸ «É ¬‡Õß ∑∂Ë’ °Ÿ π”¡“μÕà ‡™ÕË◊ ¡ °—π‚¥¬«‘∏’∑“ß»—≈¬°√√¡À≈Õ¥‡≈◊Õ¥ ‡≈◊Õ¥ ®–ºà“π®“°‡ âπ‡≈◊Õ¥·¥ß‡¢â“ àŸ‡ âπ‡≈◊Õ¥¥” ∑”„À⇠âπ‡≈◊Õ¥¥”∑’Ëπ”¡“μàÕ‰«âπ—Èπ‚μ¢¬“¬ „À≠à¢÷Èπ ºπ—ßÀπ“¢÷Èπ ‡√’¬°¢∫«π°“√π’È«à“ arterialization ‡¡ÕË◊ „™øâ Õ°‡≈Õ◊ ¥®–·∑߇¢¡Á ∑Ë’ ‡ πâ ‡≈Õ◊ ¥¥”∑‚’Ë μ¢π÷È À“â ¡·∑߇¢¡Á ∫π√Õ¬μÕà (anastomosis) À√◊Õ∑’ˇ âπ‡≈◊Õ¥·¥ß ∫√‘‡«≥ ∑‡’Ë ≈Õ◊ °∑” AVF ¢π÷È °∫— ≈°— …≥–‡ πâ ‡≈Õ◊ ¥¢Õß ºâŸªÉ«¬ ∑—°…–·≈–°“√ÕÕ°·∫∫¢Õß·æ∑¬å ∫√‘‡«≥∑’Ëπ‘¬¡„™â∑” AVF ¥—ß√ªŸ ∑’Ë 1 2.2.1 ¢âÕ∫ßà ™’¢È Õß AVF √Ÿª∑’Ë 1 „™„â πºªŸâ «É ¬‰μ«“¬‡√ÕÈ◊ √ß— ∑‡Ë’ ≈Õ◊ ° · ¥ß„Àâ‡ÀÁπ∫√‡‘ «≥∑πË’ ‘¬¡„™â∑” AVF «‘∏’°“√∫”∫—¥∑¥·∑π‰μ‚¥¬°“√øÕ°‡≈◊Õ¥ ¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡ §«√‰¥â√—∫°“√‡μ√’¬¡‰«â ≈à«ßÀπâ“ ‡¡◊Ëպ⟪ɫ¬¡’°“√¥”‡π‘π¢Õß‚√§‰μ 117

Practical Dialysis in the Year 2009 ‡√◊ÈÕ√—ß„π√–¬–∑’Ë 410 ∑’Ë¡’ GFR < 30 ml/min/1.73m2 ‡π◊ËÕß®“°‡ âπ‡≈◊Õ¥¥”μâÕß¡’™à«ß‡«≈“„π°“√¢¬“¬„À≠à ¢÷Èπ „Àâºπ—ßÀπ“¢÷Èπ·≈–·¢Áß·√ß ®–μâÕß„™â‡«≈“ 2-6 ‡¥◊Õπ °“√„™â‡ âπ‡≈◊Õ¥¥”‡√Á«‡°‘π‰ª®–¡’º≈„À⇰‘¥ thrombosis ‰¥â ‡ πâ ‡≈Õ◊ ¥Õ“®‰¡·à ¢ßÁ ·√ß ‰À≈‡«¬’ π‰¥™â “â ®π∂ß÷ ¢π—È ≈¡â ‡À≈« §«√«“ß·ºπ°“√‡μ√¬’ ¡‡ πâ ‡≈Õ◊ ¥ AVF ‰«â 6-12 ‡¥◊Õπ°àÕπ„™âß“π AVF ∑’Ë¥’ ‚¥¬„™â°Æ 6s ¢Õß K-DOQI §◊Õ ¡’ vascular flow > 600 ml/min ¢π“¥‡ âπºà“»πŸ ¬å°≈“ߪ√–¡“≥ 0.6 cm. ·≈–¡’§«“¡≈÷°®“°º‘«Àπ—ß 0.6 cm10 2.2.2 ¢Õâ ¥¢’ Õß AVF - Õÿ∫—μ‘°“√≥å¢Õß°“√Õÿ¥μ—π (clotting) πâÕ¬°«à“ AV Graft ·≈– CVC - Õÿ∫—μ‘°“√≥å¢Õß°“√μ‘¥‡™◊ÈÕπâÕ¬°«à“ AV Graft ·≈– CVC - ª≈Õ¥¿—¬°«à“·≈–μâÕß°“√°“√¥·Ÿ ≈ª√–®”«—ππâÕ¬°«à“ CVC - ‰¡àμâÕ߇º™‘≠°—∫°“√·æâ “√ —߇§√“–Àå - ¡’Õ“¬ÿ°“√„™âß“π¬“«∑’Ë ÿ¥ (‚¥¬ª√–¡“≥ 70% ¬—ß¡’ª√– ‘∑∏‘¿“楒À≈—ß 3 ªï) „π∫“ß√“¬¡’ √“¬ß“π«à“¡’Õ“¬ÿ„™âß“π∂÷ß 20 ªï - ¡’Õÿ∫—μ‘°“√≥å¢Õß¿“«–·∑√°´âÕππâÕ¬°«à“„π®”π«π vascular access ∑—ÈßÀ¡¥ - °“√À“¬¢Õß·º≈√Õ¬‡¢Á¡®–‡ªìπ≈—°…≥– heal ¢Õß tissue  à«π graft ®–‡ªìπ·∫∫ seal ¢Õß fibrin plug 2.2.3 ¢Õâ ‡ ¬’ ¢Õß AVF - μÕâ ß„™‡â «≈“„π°“√‚μ¢¬“¬„À≠à „Àºâ πß— ‡ πâ ‡≈Õ◊ ¥·¢ßÁ ·√ß°Õà π„™ßâ “π ‡æÕ◊Ë ≈¥¿“«–·∑√°´Õâ π ´÷Ëß¡—°„™â‡«≈“ª√–¡“≥ 3-6 ‡¥◊Õπ ¢÷Èπ°—∫§ÿ≥¿“æ¢Õ߇ âπ‡≈◊Õ¥¢Õߺ⟪ɫ¬ √Õ¬μàÕ ·≈–°“√∫√‘À“√∑’Ë¡’ ª√– ‘∑∏‘¿“æ¢ÕߺŸâªÉ«¬ - º„Ÿâ ™â AVF μÕâ ߇©æ“–‡®“–®ß‡ªπì º∑⟠‰’Ë ¥√â ∫— °“√Ω°ñ  Õπ¡“‡ªπì Õ¬“à ߥ’¡ª’ √– ∫°“√≥·å ≈–§«“¡ ™”π“≠ Ÿß ºŸâ∑’Ë¡’§«“¡‡™’ˬ«™“≠„π “¢“Õ◊Ëπ°Á‰¡à “¡“√∂„™â AVF ‰¥â - AVF „π∫“ß√“¬Õ“®‚쉥‡â √«Á ·≈–‡ÀπÁ ™¥— „π 6  ª— ¥“Àå ·μºà πß— À≈Õ¥‡≈Õ◊ ¥¬ß— ‰¡Àà π“·≈–·¢ßÁ ·√ßæÕ∑’Ë®–μâ“π∑“π°“√‰À≈¢Õ߇≈◊Õ¥„π¢≥–øÕ°‡≈◊Õ¥‰¥â ∂â“¡’°“√·∑߇¢Á¡„™âß“π®–‡°‘¥°“√√—Ë«¢Õß ‡≈◊Õ¥ÕÕ°®“°‡ âπ‡≈◊Õ¥‰¥â 2.2.4 ¢Õâ æ‘®“√≥“„π«“ß·ºπ°“√∑” AVF - ‚¥¬À≈—°°“√∑—Ë«‰ª‡√‘Ë¡∑’Ëμ”·Àπàß Radiocephalic °àÕπ ∂—¥¡“§◊Õ Brachiocephalic ·≈– Brachiobasilic (Transposed basilic vein)  ÿ¥∑⓬ - ∑”„π¢â“ß∑’ˉ¡à∂π—¥ - ºâŸªÉ«¬μâÕ߉¥â√—∫§«“¡√Ÿâ°àÕπ°“√∑”‡ âπ‡≈◊Õ¥ AVF ·≈–¡’°“√‡μ√’¬¡√à“ß°“¬‚¥¬ o À≈’°‡≈’ˬ߰“√‡®“–‡≈◊Õ¥ „ÀâπÈ”‡°≈◊Õ ·≈–«—¥§«“¡¥—π„π·¢π∑’ˇμ√’¬¡∑” AVF o ∫√‘À“√‰«â≈à«ßÀπⓇæ◊ËÕ„À⇠âπ‡≈◊Õ¥‚쉥â‡√Á«À≈—ߺà“μ—¥ 118

Pitfalls in Vascular Access for Dialysis Nurses 2.3 Arteriovenous Graft (AVG) 12,13,14 ‡ªπì À≈Õ¥‡≈Õ◊ ¥‡∑¬’ ¡∑∑Ë’ ”®“°« — ¥∑ÿ ‡Ë’ ªπì biologic, semibiologic À√Õ◊ synthetic μÕà ‡¢“â √–À«“à ß ‡ âπ‡≈◊Õ¥·¥ß (arterial anastomosis) ·≈–‡ âπ‡≈◊Õ¥¥” (venous anastomosis) „μ⺑«Àπ—ß √Õ®π„À⇰‘¥°“√ ª√– “πμ—«°—∫‡π◊ÈÕ‡¬◊ËÕ¢Õߺ⟪ɫ¬¥’·≈â« ®÷ß„™â‡¢Á¡·∑ß∑’Ëμ—« AV graft ‡æ◊ËÕπ”‡≈◊Õ¥‡¢â“ Ÿà«ß®√‰μ‡∑’¬¡ Àâ“¡ „™â∫√‘‡«≥√Õ¬μàÕ (anastomosis) ∑—ÈߧŸà AVG ∑¥’Ë §’ «√¡’ BFR ¡“°°«“à 800 ml/min ∂“â πÕâ ¬°«“à 600-800 ml/min ¡‚’ Õ°“ ‡°¥‘ thrombosis ‰¥âßà“¬ 6 2.3.1 ¢âÕ∫ßà ™È¢’ Õß AVG - ºâŸªÉ«¬∑’Ë¡’≈—°…≥–‡ âπ‡≈◊Õ¥‰¡à “¡“√∂‡μ√’¬¡ AV Fistula ‰¥â - ºŸâªÉ«¬∑’Ë AV Fistula ≈⡇À≈«‰¡à “¡“√∂´àÕ¡‰¥â·≈–‰¡à¡’‡ âπ‡≈◊Õ¥„πμ”·ÀπàßÕ◊ËπÊ „Àℙ≥â 2.3.2 ¢Õâ ¥’¢Õß AVG -  “¡“√∂„™â‰¥â‡√Á«°«à“ AVF Õ¬à“ßπâÕ¬ 2  —ª¥“Àå „π°“√ maturation ºâŸ ßŸ Õ“¬ÿ ºŸâªÉ«¬‡∫“ À«“π §π∑’Ë¢“¥Õ“À“√ ®–μâÕß„™â‡«≈“¡“°¢÷Èπ -  “¡“√∂ÕÕ°·∫∫„Àâ¡’æ◊Èπ∑’˺‘«„π°“√·∑߇¢Á¡‰¥â¡“° - ·∑߇¢Á¡‰¥âßà“¬°«à“ AVF 2.3.3 ¢âÕ‡ ’¬¢Õß AVG - ¡’¿“«–·∑√°´âÕπ ßŸ ‡¡◊ËÕ‡∑’¬∫°—∫ AVF ‰¥â·°à Õ—μ√“°“√‡°‘¥ thrombosis ·≈– °“√μ‘¥‡™◊ÈÕ - ¡’Õ“¬ÿ„™âß“π —Èπ°«à“ AVF ‡©≈’ˬ 3-5 ªï √–¬–‡«≈“∑”ºà“μ—¥´àÕ¡·´¡‚¥¬‡©≈’ˬ 12-18 ‡¥◊Õπ - ‡°‘¥°“√·æâ “√ —߇§√“–Àå∑’Ë∑” graft ‰¥â - °“√À“¬¢Õß√Ÿ‡¢Á¡‡ªìπ·∫∫ seal ‚¥¬ fibrin plug Õ“®√—Ë«´÷¡·≈–μ‘¥‡™◊ÈÕßà“¬ ‰¡à‡À¡“–°—∫ buttonhole technique 2.3.4 ™π‘¥«— ¥ÿ∑Ë„’ ™∑â ” AVG ë Biologic - Autogenous À√◊Õ Saphenous vein graft - Transplanted native vessel Õ◊ËπÊ ë Semibiologic - Bovine heterograft: Bovine carotid artery - Modified human umbilical vein graft ë Synthetic - Polytetrafluorethylene (PTFE) - expanded PTFE (ePTFE) „™â¡“°∑’Ë ÿ¥ - Dacron graft 119

Practical Dialysis in the Year 2009 2.3.5 °“√º“à μ—¥«“ß AVG »—≈¬·æ∑¬å®–«“ß graft ‚¥¬‡√‘Ë¡∑’Ë à«π≈à“ߢÕß√¬“ߧå¥â“π∫π≈”μ—«°àÕπ ‰¥â·°à forearm ·≈– upper arm °“√«“ß∑’Ë¢“Àπ’∫®–¡’§«“¡‡ ’ˬßμàÕ ischemia ·≈–°“√μ‘¥‡™◊ÈÕ‰¥â ßŸ 3. ¿“«–·∑√°´âÕπ¢Õß Vascular access 15,16 3.1 ¿“«–·∑√°´Õâ π¢Õß CVC 3.1.1 ‡°‘¥‰¥„â π∑π— ∑’∑Ë’„ à CVC ‰¥â·°à 1. Pneumothorax 2. Hemothorax 3. Arterial puncture 4. Tissue perforation - Brachial plexus - Trachea - Superior vena cava - Myocardium 5. Catheter Õÿ¥μ—π®“°≈‘Ë¡‡≈◊Õ¥ 6. Dysrhythmias 3.1.2 ‡°¥‘ ¿“¬À≈ß— ®“°„ à CVC 1. Air embolism 2. Infection a. exit site - æ∫√âÕ¬≈– 8-20 ¢Õß subclavian catheters - ¡’ÀπÕß À√◊Õ cellulitis ∑’Ë exit site, ª«¥·º≈ - ∑”°“√‡æ“–‡™◊ÈÕ - „À⬓ªØ‘™’«π–‡©æ“–∑’Ë - „À⬓ªØ‘™’«π–∑“߇ âπ‡≈◊Õ¥ ∂â“¡’ tunnel drainage - Õ“®μâÕß∂Õ¥ “¬ÕÕ°∂â“®”‡ªìπ b. catheter-related septicemia - æ∫√âÕ¬≈– 2-20 ¢Õß catheters ∑—ÈßÀ¡¥ - ‡™◊ÈÕ¡“®“° exit site À√◊Õ∑’ËÕ◊ËπÊ - ¡’ÀπÕß À√◊Õ cellulitis ∑’Ë exit site - ¡’‰¢â Àπ“« —Ëπ - clinical signs of sepsis 120

Pitfalls in Vascular Access for Dialysis Nurses - Õ“®μâÕß∂Õ¥ “¬ÕÕ°‡ªìπ¢âÕ∫àß™’È ¬°‡«âπæ∫·À≈àßμ‘¥‡™◊ÈÕ∑’ËÕ◊Ëπ - μâÕß∂Õ¥ “¬ÕÕ° ∂â“∫àß™’È«à“°“√‡æ“–‡™◊ÈÕ®“°‡≈◊Õ¥„Àâº≈∫«° - „À⬓ªØ‘™’«π–∑“߇ âπ‡≈◊Õ¥·∫∫§√Õ∫®—°√«“≈®π°«à“®–‰¥âº≈°“√‡æ“–‡™◊ÈÕ - „ „à À¡‰à ¥Àâ ≈ß— 24-48 ™«Ë— ‚¡ß „πμ”·Àπßà „À¡à À√Õ◊ „ ·à ≈–∂Õ¥ femoral catheter ®π°«“à º≈‡æ“–‡™◊ÈÕ®–‡ªìπ≈∫ 3. Thrombosis ™π‘¥ - mural: μ≈Õ¥ºπ—߇ âπ‡≈◊Õ¥¥”®“°√Õ¬·∑ß ‡°‘¥®“° epithelial injury - catheter thrombus: ¿“¬„πæ◊Èπº‘«¢Õß catheter - fibrin sheath: ≈—°…≥–‡ªìπ·ºà𠇧≈◊Õ∫μ“¡æ◊Èπº‘«¿“¬πÕ°¢Õß catheter ®“°√Õ¬ ·∑ß®πÕ“®∂÷ߪ≈“¬ “¬ °“√«‘π‘®©—¬ - ¬“°μàÕ°“√¥·Ÿ ≈√—°…“Õ—μ√“°“√‰À≈¢Õ߇≈◊Õ¥ - ¬“°μàÕ°“√ aspirate / flush catheter - ∑” Doppler ultrasound - ∑” Angiogram °“√√—°…“ - ∂Õ¥ / ‡ª≈’Ë¬π “¬„À¡à ∂â“®”‡ªìπ - ¢®—¥ fibrin sheath - „™â anticoagulation therapy - „ à thrombolytic agent ¿“¬„π catheter - Systemic thrombolytic therapy  ”À√—∫ fibrin sheath ·≈– catheter thrombus ∑’˧ßÕ¬àŸ π“π 4. Stenosis of involved vessel Õ“®μâÕß®”°—¥°“√„™â‡ªìπ vascular access „πÕπ“§μ °“√«‘π‘®©—¬ - Õ“®‰¡àæ∫Õ“°“√∑“ߧ≈‘π‘° - Õ“°“√∫«¡∑’Ë·¢π¢â“ß∑’Ë„ à “¬ - ºπ—ßÀπâ“Õ°¢â“߇¥’¬«°—π¡’‡ âπ‡≈◊Õ¥·μ°·¢πß - ∑” Angiogram, Doppler ultrasound °“√√—°…“ - Angioplasty - Cardiovascular stenting 5. Catheter malposition  “‡Àμÿ 121

Practical Dialysis in the Year 2009 - catheter §È”¬—π°—∫ºπ—߇ âπ‡≈◊Õ¥ (abutting) ∫‘¥ßÕ (kinking) - ‡¬Á∫®π‡ªìπ√Õ¬§Õ¥ - catheter ‡≈◊ËÕπÕÕ°®“°μ”·ÀπàßÀ≈—ß®“°„ à °“√«‘π‘®©—¬ - chest X-ray - ∑” Angiogram °“√√—°…“ - ®—¥μ”·Àπàß„À¡à - ‡ª≈’Ë¬π “¬„À¡à - μ—¥‰À¡∑’ˇ¬Á∫ 3.2 ¿“«–·∑√°´Õâ π¢Õß AVF 3.2.1 Early failure: AVF ∑’ˉ¡à∑”ß“πμ—Èß·μà·√° ‡°‘¥®“° (1) ‚§√ß √â“ߢÕ߇ âπ‡≈◊Õ¥∑’ˉ¡à ¡∫Ÿ√≥å -  “‡Àμÿ: poor arterial flow, small vein size, depth of vessels - Õ“°“√·≈–Õ“°“√· ¥ß: §≈”‰¡àæ∫™’æ®√, øí߉¡à‰¥â¬‘π‡ ’¬ß bruit - °“√√—°…“: Surgical revision (2) °“√‰À≈‡«¬’ π¢Õ߇≈◊Õ¥∑Ë’‰¡ à –¥«° (Disturbances in flow dynamics) -  “‡Àμÿ: ë Venous stenosis ªí≠À“∑’Ë¡’§«“¡ —¡æ—π∏å√à«¡¥â«¬ §◊Õ (a) Venous hypertension: ¡’°“√¢¬“¬„À≠à¢Õ߇ âπ‡≈◊Õ¥„μâ anastomosis ‡¡◊ËÕ¡’√Õ¬ μ’∫¢Õ߇ âπ‡≈◊Õ¥¥”‡Àπ◊Õ anastomosis (b) Sore thumb syndrome: ¡’°“√¢¬“¬„À≠à¢Õß thumb vein À—«·¡à¡◊Õ∫«¡¢÷Èπ¡’ ‡≈Á∫‡¢’¬«§≈È” πÈ”‡À≈◊Õß´÷¡ÕÕ°√Õ∫Ê ‡≈Á∫ ¡’Õ“°“√ª«¥À—«·¡à¡◊Õ (c) Subclavian vein syndrome: º‘«Àπ—߇ª≈’Ë¬π‰ª¡’≈—°…≥–·∫∫ eczematous ‡ âπ‡≈◊Õ¥∑’Ë·¢π‚μ ¡’º≈„Àâ·¢π∫«¡ Àπâ“∫«¡ §Õ∫«¡ ë Multiple collateral vein: ‡≈◊Õ¥·¥ß®–‰À≈‡¢â“ ŸàÀ≈Õ¥‡≈◊Õ¥¥”·¢πß ∑”„ÀâÀ≈Õ¥‡≈◊Õ¥ ¥”∑’ËμàÕ‰«â‰¡à‚μ¢÷Èπ ∑—Èß∑’Ë¡’ thrill, bruit - °“√«‘π‘®©—¬ ë ª√–‡¡‘πÕ“°“√∑“ߧ≈‘π‘°¥—ß°≈à“«¡“¢â“ßμâπ ë Doppler ultrasound À√◊Õ fistulogram / venogram ‡æ◊ËÕ¥°Ÿ “√‰À≈¢Õ߇≈◊Õ¥·≈–°“√μ’∫ μ—π∑’ËÕ¬Ÿà‡Àπ◊Õ°«à“ - °“√√—°…“ ë  ”À√—∫ venous hypertension: „À⺟âªÉ«¬°“ß·¢π¥â“π∑’Ë¡’ AVF ∑” venography ë ∂â“∫«¡π“π°«à“ 2  —ª¥“Àå: balloon angioplasty √Õ¬μ’∫¢Õ߇ âπ‡≈◊Õ¥ 122

Pitfalls in Vascular Access for Dialysis Nurses (3) °“√μ‘¥‡™◊ÈÕ ∑’ˇ°‘¥¢÷Èπ¿“¬„π 3  —ª¥“Àå·√°¢Õß°“√ºà“μ—¥ ‚¥¬∑—Ë«‰ª‡°‘¥®“°°“√μ‘¥‡™◊ÈÕ¢≥–ºà“μ—¥ ªÑÕß°—π‚¥¬„À⬓ªØ‘™’«π–„π‡«≈“ºà“μ—¥ 3.2.2 Late failure (1) Thrombosis -  “‡Àμÿ 1) Stenosis of main outflow vein without collateral circulation 2) Hypotention 3) Volume depletion 4) Hypercoagulable states 5) Occlusive compression of access: πÕπ∑—∫·¢π πÕπÀπÿπ·¢π °¥Àâ“¡‡≈◊Õ¥º‘¥«‘∏’ „ à‡ ◊ÈÕ√—¥ ¬°¢ÕßÀπ—°‚¥¬„™â·¢π√Õß√—∫ - Õ“°“√·≈–Õ“°“√· ¥ß: 1) ‡ ’¬ß bruit ‡ª≈’Ë¬π‰ª 2) ·∑߇¢Á¡‰¥â¬“° 3) ª√—∫·≈–√—°…“°“√‰À≈‡«’¬π¢Õ߇≈◊Õ¥‰¥â¬“° 4) ¡’ venous pressure ∑’ˠߟ ¢÷Èπ À√◊Õ arterial pressure ∑’Ë≈¥≈ßÀ√◊ÕÀ“¬‰ª 5) ‡≈◊Õ¥À¬ÿ¥¬“° À≈—ß°“√øÕ°‡≈◊Õ¥ 6) °“√‡æ‘Ë¡¢÷Èπ¢Õß BUN, Cr ·≈–≈¥≈ߢÕß Kt/V ∑’ˉ¡à “¡“√∂Õ∏‘∫“¬‰¥â 7) ®—∫™’æ®√‰¡à‰¥â ‰¡à‰¥â¬‘π‡ ’¬ß bruit - °“√√—°…“ 1) ªÑÕß°—π°“√‡°‘¥§«“¡¥—π‚≈À‘μμË”·≈–¢“¥πÈ” 2)  ÕπºâŸªÉ«¬„ÀâÀ≈’°‡≈’ˬ߰“√°¥√—¥‡ âπ‡≈◊Õ¥ 3) Õ“®≈Õß„™â thrombolytic therapy ·μà‰¡à§àÕ¬‰¥âº≈„π AVF 4) ºà“μ—¥´àÕ¡·´¡ AVF (2) Infection -  “‡Àμÿ: 1) ‰¡à„™âÀ≈—° Aseptic technique „π¢≥–·∑߇¢Á¡¢Õß∫ÿ§≈“°√‰μ‡∑’¬¡ 2)  ÿ¢Õπ“¡—¬‰¡à¥’¢ÕߺŸâªÉ«¬·≈–‰¡à√—°…“§«“¡ –Õ“¥¢Õß·¢π∑’Ë¡’ AV graft - Õ“°“√·≈–Õ“°“√· ¥ß: 1) Õ—°‡ ∫ ª«¥ ¡’ÀπÕß 2) ¡’°“√√—Ë«´÷¡„π∫“ß®ÿ¥μ“¡·π«¢Õß AVF 3) ‰¢â‰¡à∑√“∫ “‡Àμÿ §«√μ√«®¥Ÿ AVF „Àâ≈–‡Õ’¬¥ - °“√√—°…“ 1) „À⬓ªØ‘™’«π–μ“¡·ºπ°“√√—°…“¢Õß·æ∑¬å 123

Practical Dialysis in the Year 2009 2) À≈’°‡≈’ˬ߰“√·∑߇¢Á¡ venous „μâ√Õ¬Õ—°‡ ∫μ‘¥‡™◊ÈÕ 3) ‰¡à„™â„π®ÿ¥∑’Ë¡’°“√Õ—°‡ ∫μ‘¥‡™◊ÈÕ‡æ◊ËÕªÑÕß°—π septic emboli 4) CQI ‡æ◊ËÕ≈¥Õ—μ√“°“√‡°‘¥°“√μ‘¥‡™◊ÈÕ (3) High output cardiac failure -  “‡Àμÿ: °“√‡æ‘Ë¡¢÷Èπ¢Õß cardiac output ‡°‘π¢π“¥∑’˺⟪ɫ¬®–√—∫‰¥â ®“°Àπ÷Ëß„πÀ≈“¬ “‡ÀμÿμàÕ‰ªπ’È 1) AVF ¡’¢π“¥„À≠à ®“°°“√ºà“μ—¥À√◊Õ‚μ¢÷Èπ‡Õß 2) ¿“«–´’¥∑’Ë√ÿπ·√ß 3) ‡ªìπ‚√§À—«„®·≈–À≈Õ¥‡≈◊Õ¥¡“°àÕπ - Õ“°“√·≈–Õ“°“√· ¥ß: 1) øíߪե®–‰¥â¬‘π‡ ’¬ß crepitation 2) ¡’ tachycardia 3) peripheral edema (Õ“®‰¡àæ∫‰¥â) 4) À“¬„®μ◊Èπ, hypoxemia, confusion 5) Jugular vein dilatation 6) ∑—ÈßÀ¡¥¢â“ßμâπ‡°‘¥„π ¿“«– dry weight - Õ“°“√·∑√°´âÕπ√à«¡ 1) pulmonary edema 2) angina ·≈– cardiac dysrhythmias - °“√«‘π‘®©—¬ ‚¥¬ Echocardiography √à«¡°—∫∑”À√◊Õ‰¡à∑” AV fistula compression - °“√√—°…“ 1) Banding at arterial anastomosis 2) Ligation of AVF - °“√欓∫“≈ 1) ª√–‡¡‘π cardiopulmonary status ∑ÿ°§√—Èß∑’˺ŸâªÉ«¬¡“øÕ°‡≈◊Õ¥ 2) ‡ΩÑ“√–«—ß hemoglobin ·≈– hematocrit Õ¬à“ß„°≈♑¥ 3) ∂⓺⟪ɫ¬¡’Õ“°“√„Àâ√—¥ AVF ¥â«¬ elastic bandage ‡æ◊ËÕ≈¥ cardiac output ‚¥¬μâÕß·πà„®«à“‰¡à√—¥·πàπ®π‡°‘π‰ª ®“°°“√∑’Ë “¡“√∂„™âπ‘È«™’È Õ¥ºà“π‰¥â ∫“¬ - °“√ ÕπºâŸªÉ«¬ 1)  Õπ°“√„™â elastic bandage √—¥ AVF ‡æ◊ËÕ≈¥ cardiac output ‚¥¬‰¡à∑”„Àâ AVF Õÿ¥μ—π 2)  ÕπºŸâªÉ«¬„Àâª√—∫‡ª≈’Ë¬π°‘®«—μ√ª√–®”«—π ®π°«à“ªí≠À“®–‰¥â√—∫°“√·°â‰¢ 3)  Õπ„ÀâºâŸªÉ«¬§«∫§ÿ¡πÈ”Àπ—°‡æ‘Ë¡√–À«à“ß«—π∑’ˉ¡à‰¥âøÕ°‡≈◊Õ¥Õ¬à“߇§√àߧ√—¥ 4)  Õπ°“√√“¬ß“πÕ“°“√‡ª≈’ˬπ·ª≈ß∑’Ëæ∫„π∑—π∑’ 124

Pitfalls in Vascular Access for Dialysis Nurses 3.3 ¿“«–·∑√°´Õâ π¢Õß AVG 3.3.1 Thrombosis: anatomic causes (1) Stenosis outflow AVG À√Õ◊ Vein ∑Õ’Ë ¬Ÿà Ÿß°«à“ -  “‡Àμÿ ‡°‘¥®“°¡’ intimal hyperplasia ∑”„À⇠âπºà“»πŸ ¬å°≈“ߢÕ߇ âπ‡≈◊Õ¥‡≈Á°≈ß ‡ªìπ  “‡Àμÿ¢Õß°“√‡°‘¥ thrombosis °«à“ 80% ¢Õß graft ∑—ÈßÀ¡¥ - Õ“°“√·≈–Õ“°“√· ¥ß 1) ‡ ’¬ß bruit ∑’ˇª≈’Ë¬π‰ª 2) ·∑߇¢Á¡‰¥â¬“°¢÷Èπ 3) ª√—∫·≈–√—°…“°“√‰À≈‡«’¬π¢Õ߇≈◊Õ¥‰¥â¬“° 4) ¡’ venous pressure ∑’ˠߟ ¢÷Èπ À√◊Õ arterial pressure ∑’Ë≈¥≈ß 5) ¡’ recirculation ¡“°¢÷Èπ ‡°‘¥ª√“°Ø°“√≥å∑’ˇ√’¬°«à“ Black blood syndrome ‡≈◊Õ¥®–¡’  ’§≈È”¢÷Èπ·≈–‡¢â¡¢âπ¢÷Èπ‡¡◊ËÕ‡«≈“ºà“π‰ª¢≥– HD ‚¥¬∑’Ë recirculation  —߇°μ‰¥â®“°°“√„Àâ normal saline ¢≥–∑” HD ®–‡°‘¥°“√¬âÕπ°≈—∫¡“∑’Ë¥â“π arterial line ´÷Ëß∑”„Àâ ’¢Õ߇≈◊Õ¥®“ß≈ß 6) ‡≈◊Õ¥À¬ÿ¥¬“° À≈—ß°“√øÕ°‡≈◊Õ¥ 7) °“√‡æ‘Ë¡¢÷Èπ¢Õß BUN, Cr ∑’ˉ¡à “¡“√∂Õ∏‘∫“¬‰¥â - °“√«‘π‘®©—¬ 1) Õ“°“√∑“ߧ≈‘π‘° μ“¡¢â“ßμâπ∑’Ë°≈à“«¡“∑—ÈßÀ¡¥ 2) percent recirculation > 10% (‰¡à§«√‡°‘π 15%) 3) °“√≈¥≈ߢÕß§à“ Kt/V ®πμË”°«à“‡°≥±å¡“μ√∞“π 4) ∑” Doppler ultrasound 5) Fistulogram ‡ªìπ«‘∏’∑’Ë¡“μ√∞“π∑’Ë ÿ¥„π°“√«‘π‘®©—¬ - °“√√—°…“ 1) Percutaneous transluminal angiopathy 2) ºà“μ—¥´àÕ¡·´¡ 3) ‡ΩÑ“√–«—ßÕ¬à“ßμàÕ‡π◊ËÕß - °“√欓∫“≈ 1) ª√–‡¡‘π°“√μ’∫μ—π∑ÿ°§√—Èß∑’˺ŸâªÉ«¬¡“øÕ°‡≈◊Õ¥ 2) ‡ΩÑ“√–«—ßÕ¬à“ßμàÕ‡π◊ËÕß 3) √“¬ß“π·æ∑¬å‡¡◊ËÕæ∫Õ“°“√·≈–Õ“°“√· ¥ß¢Õß stenosis (2) Pseudoaneurysm: ‡ªìπ°“√¢¬“¬μ—«∑’˺‘¥ª°μ‘¢Õß AVG -  “‡Àμÿ ‡°‘¥®“°√Ÿ‡¢Á¡∑’˪¡à π‘∑®“°°“√Àâ“¡‡≈◊Õ¥‰¡à∂°Ÿ μâÕß ‰¡à ¡∫Ÿ√≥å ®÷߇°‘¥°“√¢¬“¬μ—« ´÷Ëß “¡“√∂‡°‘¥‰¥âμ≈Õ¥·π«¢Õß graft ·≈–Õ“®‡°‘¥‰¥â®“°°“√μ’∫μ—π„π à«πμà“ßÊ ¢Õß·π« graft ∑”„Àâ ¡’·√ߥ—π ßŸ „π à«π≈à“ß≈ß¡“ ®÷߇°‘¥°“√‚ªÉßøÕߢÕß graft ‰¥â - °“√«‘π‘®©—¬ 125

Practical Dialysis in the Year 2009 1) Õ“°“√∑“ߧ≈‘π‘° 2) ∑” Doppler ultrasound 3) Fistulogram - °“√√—°…“ ‚¥¬ºà“μ—¥„π à«π∑’Ë¡’ªí≠À“ ‡¡◊ËÕ 1) ¡’°“√¢¬“¬‚μ¢÷ÈπÕ¬à“ß√«¥‡√Á« 2) ‡ âπºà“»Ÿπ¬å°≈“ߢ¬“¬‡°‘π°«à“ 2 ‡∑à“ 3) °“√ª«¥À√◊ÕÕ“®‡°‘¥°“√·μ°∑’˺‘«Àπ—ß 4) °“√μ‘¥‡™◊ÈÕ - °“√欓∫“≈ 1) ªÑÕß°—π‰¡à„À⇰‘¥ pseudoaneurysm ‚¥¬‡ª≈’ˬπ∑’Ë·∑߇¢Á¡ ·∫∫ Rope ladder À√◊Õ„™â «‘∏’ buttonhole 2) ‰¡à·∑߇¢Á¡∫√‘‡«≥ pseudoaneurysm 3) À≈’°‡≈’ˬ߰“√·∑߇¢Á¡„μâ√Õ¬μ’∫∑’Ë¡’·√ߥ—π„π vein  Ÿß 4) °¥Àâ“¡‡≈◊Õ¥‚¥¬„Àâ·√ß°¥§≈ÿ¡∑—Èß√Õ¬‡¢Á¡∑’˺‘«Àπ—ß·≈–∑’˺π—ß graft ¿“¬„π´÷Ëß¡—°®– Õ¬Ÿà„°≈⇧’¬ß°—π ·≈–°¥®π‡≈◊Õ¥À¬ÿ¥  —߇°μ·º≈√Õ¬‡¢Á¡·≈–º‘«∫√‘‡«≥„°≈⇧’¬ß‰¡à¡’°“√πŸπ¢÷Èπ §≈” tissue ‰¥âπÿà¡ ‰¡à·¢Áßμ÷ß À≈—ßÀâ“¡‡≈◊Õ¥‡ √Á® 5) ª√–‡¡‘π°“√‡ª≈’ˬπ·ª≈ߢÕß pseudoaneurysm ∑ÿ°§√—Èß∑’˺⟪ɫ¬¡“∑” HD (3) Traumatic AVG -  “‡Àμÿ ‡°¥‘ ®“°°“√·∑߇¢¡Á ∑–≈ºÿ “à π graft ‡¢“â ‰ª„π artery ∑Õ’Ë ¬¥àŸ “â π≈“à ߇°¥‘ ‡ªπì fistula √–À«“à ß ºπ—߇ âπ‡≈◊Õ¥¢÷Èπ ‡≈◊Õ¥®“° artery ®–ºà“π‡¢â“¡“¬—ß graft ¢«“ß°“√‰À≈‡«’¬π‡≈◊Õ¥‡¥‘¡∑’Ë¡’Õ¬àŸ°àÕπ - Õ“°“√·≈–Õ“°“√· ¥ß 1) §≈” graft ‰¥™â æ’ ®√∑·’Ë √ߢπ÷È Õ¬“à ß∑‰’Ë ¡‡à §¬‡ªπì ¡“°Õà π ·≈–¡°— ®–·√ß°«“à ™æ’ ®√∫√‡‘ «≥ arterial anastomosis 2) ¡’ venous pressure ∑’Ë Ÿß¢÷Èπ∑—π∑’ ‚¥¬‰¡àª√“°Ø„π°“√∑” HD §√—Èß°àÕπ - °“√«‘π‘®©—¬ 1) Õ“°“√∑“ߧ≈‘π‘° 2) ∑” Doppler ultrasound 3) Fistulogram - °“√√—°…“ ‚¥¬ºà“μ—¥´àÕ¡·´¡ μâÕß àßæ∫»—≈¬·æ∑¬å∑—π∑’ 3.3.2 Thrombosis: nonanatomic causes -  “‡Àμÿ: (1) Hypotension 126

Pitfalls in Vascular Access for Dialysis Nurses (2) Volume depletion (3) Hypercoagulable states (4) Occlusive compression of access (‡™àπ °¥°—Èπ°“√‰À≈‡«’¬π®π π‘∑‡æ◊ËÕÀâ“¡‡≈◊Õ¥, πÕπÀπÿπ·¢πÀ√◊Õ∑—∫·¢π, „ à‡ ◊ÈÕºâ“√—¥, ∂◊Õ¢ÕßÀπ—°‚¥¬„™â·¢π√Õß√—∫) - °“√«‘π‘®©—¬ ‚¥¬∑” Doppler ultrasound ·≈– Fistulogram ‰¡àæ∫ “‡Àμÿ¢Õß thrombosis: anatomic causes - °“√√—°…“ (1) μ“¡ “‡Àμÿ (2) ∂â“æ∫«à“‡°‘¥®“° hypercoagulopathy ·æ∑¬å®–æ‘®“√≥“„Àâ antiplatelet or anticoagulation therapy - °“√欓∫“≈ (1) °“√μßÈ— UF ‚¥¬§”πß÷ ∂ß÷ §«“¡‡À¡“– ¡¢Õß ¿“溪⟠«É ¬„πª®í ®∫ÿ π— ¡“°°«“à μßÈ— μ“¡ dry weight ∑’Ë·æ∑¬å —Ë߇撬ßÕ¬à“߇¥’¬« (2) μâÕ߉¡àμ—Èß UF μË”°«à“ dry weight ‚¥¬‰¡àª√–‡¡‘πÕ“°“√„Àâ‡À¡“– ¡ ∂Ÿ°μâÕß (3) √“¬ß“π·æ∑¬å‡æ◊ËÕª√—∫ dry weight „Àâ‡À¡“– ¡ (4) „À⧔ª√÷°…“·°àºâŸªÉ«¬‡æ◊ËÕ®”°—¥πÈ”Àπ—°‡æ‘Ë¡„π«—π∑’ˉ¡à‰¥âøÕ°‡≈◊Õ¥ ‚¥¬‰¡à‡°‘π 1 °‘‚≈°√—¡μàÕ«—π (5) „™â ultrafiltration modeling, sodium modeling, lower temperature dialysate ‡æ◊ËÕ ªÑÕß°—π hypotension (6) ª√–‡¡‘π ¿“«–¢Õß‚ª√μ’π„πºŸâªÉ«¬‡æ◊ËÕ„À⇰‘¥ anticipate capacity ‡°‘¥ vascular refilling ‰¥â¥’ (7) 쥑 μ“¡°“√√∫— ª√–∑“𬓠antihypertensive drug √“¬ß“π·æ∑¬‡å æÕ◊Ë ª√∫— ¬“„À‡â À¡“–  ¡ ∂â“æ∫Õ“°“√§«“¡¥—πμË”∫àÕ¬Ê (8) °√≥’ºâŸªÉ«¬‰¥â√—∫¬“ antiplatelet À√◊Õ anticoagulation μâÕßμ‘¥μ“¡º≈·≈–‡ΩÑ“√–«—ß ¿“«–‡≈◊Õ¥À¬ÿ¥¬“° ·≈–μ‘¥μ“¡º≈‡≈◊Õ¥ PT, PTT, INR μ“¡·ºπ°“√√—°…“ (9) ºŸâªÉ«¬∑ÿ°√“¬μâÕ߉¥â√—∫°“√«—¥§«“¡¥—π‚≈À‘μ∑—Èß∑à“π—Ëß·≈–∑à“¬◊πÀ≈—ß°“√øÕ°‡≈◊Õ¥ (∑à“¬◊πμâÕ߬◊π¢÷ÈπÕ¬à“ßπâÕ¬ 1 π“∑’ °àÕπ∑”°“√«—¥) ‡æ◊ËÕªÑÕß°—π orthostatic hypotension post HD (10)  àß echocardiogram μ“¡·ºπ°“√√—°…“‡æ◊ËÕª√–‡¡‘π left ventricular function ·≈– pericardial effusion „πºŸâªÉ«¬∑’Ë¡’ persistent hypotension 3.3.3 Infection -  “‡Àμÿ (1) ‰¡à„™âÀ≈—° aseptic technique „π¢≥–·∑߇¢Á¡ (2) μ‘¥‡™◊ÈÕ®“°·À≈àßÕ◊ËπÊ ¢Õß√à“ß°“¬ 127

Practical Dialysis in the Year 2009 (3)  ÿ¢Õπ“¡—¬¢ÕߺŸâªÉ«¬‰¡à¥’·≈–‰¡à√—°…“§«“¡ –Õ“¥¢Õß·¢π∑’Ë¡’ AV graft - Õ“°“√·≈–Õ“°“√· ¥ß (1) ª«¥ ∫«¡ ·¥ß À√◊Õ ¡’¢Õ߇À≈«´÷¡®“°∫“ß à«π¢Õß AV graft (2) ª«¥ ∫«¡ ·¥ß∑’Ë√Õ¬‡¢Á¡À√◊Õ√Õ¬μàÕ (3) ‰¢â Àπ“« —Ëπ - Õ“°“√·∑√°´âÕπ (1) Thrombosis (2) ¡’°“√·μ°¢Õߺ‘«∫√‘‡«≥∑’Ëμ‘¥‡™◊ÈÕ∑”„Àâ¡’‡≈◊Õ¥ÕÕ° (3) Septic emboli ·≈–/À√◊Õ sepsis Õ“®∂÷ß·°à™’«‘쉥â - °“√«‘π‘®©—¬ (1) °“√μ√«®√à“ß°“¬ (2) °“√‡æ“–‡™◊ÈÕ‡©æ“–∑’ËÀ√◊Õ®“°‡≈◊Õ¥ - °“√√—°…“ (1) „À⬓ªØ‘™’«π–μ“¡§” —Ëß·æ∑¬å (2) ºà“μ—¥´àÕ¡·´¡ ∂â“∑”‰¥â (3) À≈’°‡≈’ˬ߰“√·∑߇¢Á¡ venous „μâμàÕ∫√‘‡«≥∑’Ëμ‘¥‡™◊ÈÕ (4) ºà“μ—¥π” graft ÕÕ°‡ªìπ∑“߇≈◊Õ° ”À√—∫ºâŸªÉ«¬∑’Ë¡’ bacteremia ∑’Ë¡’μâπμÕ®“° AV graft ´ßË÷ ‡μ√¬’ ¡«“ß·ºπ∑” vascular access „À¡à À≈ß— ®“°„À°â “√√°— …“¥«â ¬¬“ªØ™‘ «’ π–Õ¬“à ß ¡∫√Ÿ ≥å ·≈– º≈°“√‡æ“–‡™◊ÈÕ®“°‡≈◊Õ¥‡ªìπ≈∫ - °“√欓∫“≈ (1) ‡§√àߧ√—¥„πÀ≈—° aseptic technique ¢≥–·∑߇¢Á¡ (2) μ√«®À“∫√‘‡«≥∑’Ë¡’°“√μ‘¥‡™◊ÈÕ‡©æ“–∑’Ë (3) ‰¡à·∑߇¢Á¡„π∫√‘‡«≥∑’Ë¡’°“√Õ—°‡ ∫μ‘¥‡™◊ÈÕ∫π AV graft Õ¬àŸ (4) ·∑߇¢¡Á artery „μμâ Õà ∫√‡‘ «≥∑¡’Ë °’ “√Õ°— ‡ ∫쥑 ‡™Õ◊È ∫π AV graft ·≈–‡¢¡Á venous ‡ÀπÕ◊ μàÕ∫√‘‡«≥∑’Ë¡’°“√Õ—°‡ ∫μ‘¥‡™◊ÈÕ∫π AV graft À≈’°‡≈’ˬ߰“√ªπ‡ªóôÕπ‡™◊ÈÕ Ÿà°√–· ‡≈◊Õ¥ (5) ‡æ“–‡™◊ÈÕ¢Õ߇À≈«∑’Ë´÷¡ÕÕ°®“° AV graft (6) ‡æ“–‡™◊ÈÕ®“°‡≈◊Õ¥∂⓺ŸâªÉ«¬¡’Õ“°“√ systemic infection (7) ®—¥°“√„À⇢â“πÕπ‚√ß欓∫“≈ ‡ΩÑ“√–«—ߺ≈°“√„À⬓ªØ‘™’«π– (8) ‡ΩÑ“√–«—ß WBC counts ·≈–√“¬ß“πÕ“°“√‡ª≈’ˬπ·ª≈ß 3.3.4 Steal syndrome -  “‡Àμÿ (1) ¢“¥‡≈◊Õ¥‡≈’Ȭߠà«π≈à“ßμàÕ AV graft ®“°°“√‡∫’ˬߢÕß∑‘»∑“ß°“√‰À≈¢Õ߇≈◊Õ¥ ‡π◊ËÕß®“° AV graft (2) ‡ªìπ¿“«–·∑√°´âÕπ¢ÕßÀ≈Õ¥‡≈◊Õ¥ à«πª≈“¬∑’ˇªìπÕ¬Ÿà°àÕπ·≈â« 128

Pitfalls in Vascular Access for Dialysis Nurses (3) ‡°¥‘ ¢π÷È ‰¥∫â Õà ¬„πºªŸâ «É ¬‡∫“À«“πÀ√Õ◊ º âŸ ߟ Õ“¬·ÿ ≈–„πºªŸâ «É ¬∑‡’Ë §¬∑”‡ πâ ‡≈Õ◊ ¥¡“°Õà π À≈“¬§√—Èß„πμ”·Àπà߇¥’¬«°—π À√◊Õ√¬“ߧ凥’¬«°—π - Õ“°“√·≈–Õ“°“√· ¥ß (1) ¡’Õ“°“√ª«¥∫√‘‡«≥„μâμàÕ anastomosis (2) Paresthesia: numbness, tingling (pins and needles) (3) ¡’ paresthesia ¡“°¢÷Èπ ¢≥–∑” HD (4) ´’¥ (pallor) ·≈–¡’ capillary refill ‰¡à¥’ ∑’Ë¡◊Õ·≈–π‘È«¡◊Õ∑’Ë¡’ AV graft (5) Õ“®∑”„À⇰‘¥°“√¢“¥‡≈◊Õ¥∑’˪≈“¬π‘È«¡◊Õ - °“√«‘π‘®©—¬ ‚¥¬∑—Ë«‰ª«‘π‘®©—¬‰¥â®“°Õ“°“√· ¥ß - °“√√—°…“ (1) Surgical banding of AV anastomosis (2) º°Ÿ ªî¥‡ âπ‡≈◊Õ¥ ∂â“Õ“°“√‡≈«≈ßÀ√◊Õ‰¡à¥’¢÷Èπ - °“√欓∫“≈ (1) ª√–§∫√Õâ π μÕâ ß‡Ω“Ñ √–«ß— ‡æ√“–¡Õ◊ ¢ÕߺªâŸ «É ¬®–™“®“°°“√¢“¥‡≈Õ◊ ¥ ´ßË÷ Õ“® burns ‰¥â (2) ®—¥∑à“¢≥–πÕπøÕ°‡≈◊Õ¥„Àâ‡≈◊Õ¥‰À≈‡«’¬π‰¥â –¥«° (3) °√–μÿâπ„ÀâºâŸªÉ«¬∫√‘À“√¡◊Õ‡æ◊ËÕ„Àâ‡≈◊Õ¥‰À≈‡«’¬π‰¥â¥’ 4. ∫∑∫“∑¢Õß欓∫“≈‰μ‡∑’¬¡„π°“√®—¥°“√ Vascular access 4,17,18,19 4.1 °“√®—¥°“√∑“ß°“√欓∫“≈ ”À√—∫ºâªŸ É«¬∑’Ë„ à CVC 4.1.1 °“√ªØ∫‘ μ— °‘ “√欓∫“≈ 1. °“√™à«¬„ à “¬„™âÀ≈—° aseptic technique Õ¬à“߇§√àߧ√—¥ ®—¥ºŸâªÉ«¬„π∑à“ Trendelenburg position  —߇°μÕ“°“√º‘¥ª°μ‘ ™à«¬≈¥§«“¡μ√÷߇§√’¬¥¢ÕߺŸâªÉ«¬‡æ◊ËÕ≈¥ strain ¢Õß vessel 2. ª√–‡¡‘πÕ“°“√ºâŸªÉ«¬∑ÿ°§√—Èß°àÕπ„™â CVC - ¥ŸÕ“°“√‰¢â °“√ª«¥∑’Ë exit site À√◊Õ∫√‘‡«≥∑√«ßÕ° - °“√∫«¡¢Õß√¬“ߧå μ√«®™’æ®√ à«πª≈“¬√¬“ߧå∑’Ë„ à “¬ femoral catheter - μ√«®≈—°…≥–¢Õߺ⓪º≈, discharge, bleeding ·≈–°≈‘Ëπ 3. °“√∑”§«“¡ –Õ“¥·º≈·≈– “¬ catheter μÕâ ß∑”‚¥¬∫§ÿ ≈“°√¢ÕßÀπ«à ¬‰μ‡∑“à ππÈ— ·≈– ∑”∑ÿ°§√—Èß∑’˺⟪ɫ¬¡“∑”°“√øÕ°‡≈◊Õ¥ „™âÀ≈—° aseptic technique ¢≥–‡√‘Ë¡·≈– ‘Èπ ÿ¥°“√∑”‰μ‡∑’¬¡ - ‡π◊ËÕß®“°æ∫Õÿ∫—μ‘°“√≥å¢Õß nasal staphylococcus aureus ·≈– methicillin-resistant staphylococcus aureus „πºŸâªÉ«¬ ∑—Èß欓∫“≈·≈–ºâŸªÉ«¬§«√„ à mask - ‡ªî¥·º≈ª√–‡¡‘π exit site «à“¡’√Õ¬·¥ß·≈–°“√√—Ë«´÷¡ ∑” culture drainage ®“° exit site ∂â“¡’ 129

Practical Dialysis in the Year 2009 - ∑”§«“¡ –Õ“¥‡π◊ÈÕ쓬√Õ∫ exit site ¥â«¬ hydrogen peroxide ∑“¥â«¬ povidone-iodine ª≈àÕ¬„Àâ·Àâß°àÕπªî¥·º≈ - „™â sterile gauze 4×4 ™ÿ∫ povidone-iodine „Àâ™ÿà¡Àÿâ¡ ports 5 π“∑’ °àÕπ‡ªî¥·≈–∑”´È” ‡™àπ°—π °àÕπª≈¥ blood line „π¢≥– ‘Èπ ÿ¥°“√∑”‰μ‡∑’¬¡ - ‰¡à‡ªî¥„Àâª≈“¬ catheter  —¡º— Õ“°“»‚¥¬μ√ßÕ¬Ÿàπ“π μâÕߪÿ°‰«âÀ√◊Õ§“ sterile syringe ‰«â 4. °àÕπ„™â catheter μâÕߥŸ¥ heparin ∑’Ë„ à§â“߉«âÕÕ°°àÕπ‡ ¡Õ ‰¡à§«√ flush ∂â“¥¥Ÿ ‰¥â¥’ 5. Flush catheter μ≈Õ¥ “¬¥â«¬ NSS À≈—ß∑” HD °àÕπ„ à heparin 6. °“√„ à heparin „π catheter lumen ·μà≈–¢â“ß - ¢π“¥¢Õß heparin ¡’À≈“°À≈“¬¢÷Èπ°—∫·æ∑¬å protocol ¢ÕßÀπ૬‰μ ·≈– ¿“«–¢Õß ºâŸªÉ«¬ - „™ªâ √¡‘ “μ√¢Õß heparin §«√‡∑“à °∫— À√Õ◊ ¡“°°«“à ª√¡‘ “μ√ catheter lumen ·μ≈à –¢“â ߇≈°Á πâÕ¬ (μ—«Õ¬à“ß μ“¡·ºπ°“√√—°…“„Àâ„™â heparin 5000 U/lumen ‚¥¬∑’˪√‘¡“μ√¢Õß catheter lumen ¥â“π artery ·≈– vein §◊Õ 1.1 ml ·≈– 1.2 ml μ“¡≈”¥—∫ ¥—ßπ—Èπ®–μâÕ߇μ√’¬¡ heparin 5000 U ∫«°°—∫ normal saline ‡ªìπ 1.3 ml „ à„π catheter lumen ·μà≈–¢â“߇≈Á° ‡ªìπμâπ) - ¢âÕ¡Ÿ≈¢Õߪ√‘¡“μ√„π catheter lumen ·μà≈–¢â“߇≈Á°®–¡“®“°∫√‘…—∑ºâŸº≈‘μ ‚¥¬¡—°®– æ‘¡æåμ‘¥‰«â∑’Ëμ—« “¬ catheter 7. À≈—ß°“√∑”‰μ‡∑’¬¡ ªî¥·º≈‚¥¬·πà„®«à“‰¡à∑”„À⇰‘¥°“√¥÷ß√—Èß “¬ catheter 8. ∫—π∑÷°√“¬ß“π ™π‘¥¢Õß catheter μ”·Àπàß∑’Ë„ à ·≈–º≈°“√ª√–‡¡‘π 9. μâÕß¡’ªÑ“¬∫Õ°¢π“¥¢Õß heparin ∑’Ë„™â„π·μà≈– catheter lumen 10. °“√·°âªí≠À“ poor blood flow - ®—¥„À⺟âªÉ«¬πÕπ»’√…–μË” ‡æ◊ËÕ‡æ‘Ë¡·√ߥ—π„π central vein - „ÀâºâŸªÉ«¬‰Õ„π¢≥–¥ Ÿ “¬ catheter - ‡ª≈’ˬπ∑à“ºâŸªÉ«¬ 欓¬“¡∑”„πÀ≈“¬Ê ∑à“ - °¥≈ß∑’Ë exit site ¥â“ππÕ°¢≥–¡’ºâ“ªî¥·º≈Õ¬àŸ μ√«®¥°Ÿ “√∫‘¥ßÕ¢Õß “¬∑’Ë exit site - À¡ÿπ catheter ‰ª√Õ∫·°π 180 Õß»“ „π temporary catheter ∂Ⓡªìπ‰ª‰¥â (‰¡à§«√μ—¥ ‰À¡∑’ˇ¬Á∫μ√÷߉«â‡æ◊ËÕ∑”°“√À¡ÿπ) - °“√ ≈—∫ “¬„À⇪ìπ∑“߇≈◊Õ° ÿ¥∑⓬ - „™â fibrinolytic agent μ“¡§” —Ëß·æ∑¬å - √“¬ß“π·æ∑¬å / interventional radiologist ‡æ◊ËÕ‡ª≈’ˬπ catheter 11. Àâ“¡„Àâ IV ∑“ß catheter lumen √–À«à“ß«—π∑’ˉ¡à‰¥âøÕ°‡≈◊Õ¥ 12. °“√∂Õ¥ “¬ CVC - ®—¥ºŸâªÉ«¬„ÀâÕ¬Ÿà„π∑à“πÕπÀß“¬»’√…–μË” ‡æ◊ËÕ‡æ‘Ë¡·√ߥ—π„πÀ≈Õ¥‡≈◊Õ¥¥”™à«¬ªÑÕß°—π øÕßÕ“°“»‡¢â“ àŸÀ≈Õ¥‡≈◊Õ¥¢≥–¥÷ß catheter ÕÕ° - °¥Àâ“¡‡≈◊Õ¥∑’Ë exit site π“π 20 π“∑’ 130

Pitfalls in Vascular Access for Dialysis Nurses - ªî¥ exit site ¥â«¬ antibiotic ointment ‡æ◊ËÕ°—πÕ“°“»´÷¡‡¢â“‡ âπ‡≈◊Õ¥ - §àÕ¬Ê ª√—∫»’√…–„À⠟ߢ÷Èπ∑’≈–πâÕ¬ ªî¥·º≈„Àâ‡√’¬∫√âÕ¬ √Õ —߇°μÕ“°“√ 30 π“∑’ À≈—ß ∂Õ¥ “¬ 4.1.2 °“√ ÕπºªâŸ É«¬ (Patient Teaching) 1. °Õà π°“√„ à CVC „Àºâ ªŸâ «É ¬∑√“∫∂ß÷ §«“¡®”‡ªπì «∏‘ °’ “√„ à ¿“«–·∑√°´Õâ π·≈–°“√ªÕÑ ß°π— °“√ªØ‘∫—μ‘μ—«‡¡◊ËÕ„ à CVC 2. ¥·Ÿ ≈√—°…“ºâ“ªî¥·º≈„Àâ·Àâß ‰¡à„À⇪אּ™◊Èπ 3. ¥·Ÿ ≈√—°…“ catheter „Àâμ√÷ßμ‘¥°—∫º‘«Àπ—ߪÑÕß°—π°“√¥÷ßÀ≈ÿ¥ 4. ¥·Ÿ ≈®ÿ°ª≈“¬ “¬ ·≈– clamps æ“ ‡μÕ√å∑’Ëμ√÷ß “¬ ªÑÕß°—πÕÿ∫—쑇Àμÿ‡≈◊ËÕπÀ≈ÿ¥ 5. Àâ“¡∫ÿ§§≈Õ◊ËππÕ°‡À≈◊Õ®“°æ¬“∫“≈‰μ‡∑’¬¡„™â catheter 6. ªî¥ mask ‡¡◊ËÕ¡’°“√‡ªî¥ catheter 7. Õ“°“√·≈–Õ“°“√· ¥ß¢Õß°“√μ‘¥‡™◊ÈÕ ´÷ËßμâÕß√“¬ß“π 8. °“√ªØ‘∫—μ‘μ—«∂â“ “¬À≈ÿ¥À√◊Õ “¬∂°Ÿ μ—¥¢“¥ - ªî¥ clamp ∑’˪≈“¬ “¬∑’ˬ—߇À≈◊ÕÕ¬àŸ∑—π∑’ - °¥ exit site ¥â«¬ºâ“ªî¥·º≈∑’Ë –Õ“¥·≈–√’∫¡“‚√ß欓∫“≈ 4.2 °“√®—¥°“√∑“ß°“√欓∫“≈ ”À√—∫ºâŸªÉ«¬∑Ë¡’ ’ AV Fistula 4.2.1 °“√ª√–‡¡π‘ AVF (1) °“√¥Ÿ (Inspection) - Suture line: aneurysm inflammation - ·π«‡ âπ AVF: §«“¡™—¥‡®π ¢π“¥ μ◊Èπ ≈÷° μ√ß §¥‚§âß ‚ªÉßæÕß √Õ¬μ’∫ - Õ“°“√·≈–Õ“°“√· ¥ß¢Õß°“√μ‘¥‡™◊ÈÕ - Õ“°“√∫«¡: ‡©æ“–∑’Ë, ∑—Èß·¢π - æ◊Èπ∑’Ë∑’Ë¡’§«“¡°√–¥â“ß (induration) - Collateral vessels (2) °“√§≈” (Palpation) - Thrill μßÈ— ·μà anastomosis ‰ªμ≈Õ¥·π«‡ πâ AVF: ª√–‡¡π‘ §«“¡·√ß·≈–°“√ πË—  –‡∑Õ◊ π ¢π“¥ μ◊Èπ ≈÷° μ√ß §¥‚§âß ‚ªÉßæÕß √Õ¬μ’∫ ¢Õß vein §«√‡ª√’¬∫‡∑’¬∫°—∫§√—Èß°àÕπ - √—¥ tourniquet ‡∫“Ê μ√«®¥Ÿ vein ‡æ◊ËÕ‡≈◊Õ°‡ âπ∑’Ë„À≠àæÕ ¡’·π«μ√ß ·≈–Õ¬àŸμ◊Èπ´÷Ëß ‡À¡“– ¡„π°“√·∑߇¢Á¡ À≈’°‡≈’Ë¬ß vein ∑’ˇ≈Á°¬—߉¡à‚μ·≈–·¢Áß·√ß §«√√Õ„Àâ‚μ¢÷Èπ°àÕπ„™â - §≈”À“∫√‘‡«≥∑’Ë¡’°âÕπ‚μ¢÷Èπ°«à“¥â“π√Õ∫Ê ·≈–·¢Áß ¡—°®–‡ªìπ°âÕπ hematoma ´÷Ëߧ«√ À≈’°‡≈’ˬ߄π°“√·∑߇¢Á¡ - §≈”À“ aneurysm §«√À≈’°‡≈’ˬ߄π°“√·∑߇¢Á¡ 131

Practical Dialysis in the Year 2009 (3) °“√øíß (Auscultation) - Bruit §«√øí߉¥â™—¥‡®π∑’Ë anastomosis ¢Õß AVF §«√‡ª√’¬∫‡∑’¬∫°—∫§√—Èß°àÕπ - øí߇ ’¬ß bruit ®“° anastomosis ‰ªμ“¡·π«¢Õß vein ∑’ËμàÕ‡™◊ËÕ¡°—∫ artery ª√–‡¡‘𠧫“¡¥ß— §«“¡ ¡”Ë ‡ ¡Õ¢Õ߇ ¬’ ß ∂“â ¡‡’  ¬’ ߥߗ ¢πÈ÷ ‡ªπì ™«à ßÊ · ¥ß«“à Õ“®¡°’ “√μ∫’ ¿“¬„π ´ßË÷ §«√ª√–‡¡π‘ √à«¡°—∫°“√§≈” 4.2.2 °“√∫—π∑°÷ ¢Õâ ¡≈Ÿ æπ◊È ∞“π (Baseline documentation) (1) Condition of anastomosis ∫—π∑÷°∑ÿ°§√—Èß∑’Ë·∑߇¢Á¡ (2) Percent of recirculation in AVF ∑—π∑’∑’Ë„™â‡ âπ (3) Size and condition of veins (4) √–¬–®“° anastomosis ∑’ˉ¥â¬‘π‡ ’¬ß bruit (5) Collateral vein ∑’Ë¡’ 4.2.3 °“√·∑߇¢Á¡ (Cannulation) (1) ∑”°“√‡μ√¬’ ¡º‘«Àπ—ß°àÕπ°“√·∑߇¢Á¡ - „À⺟âªÉ«¬∑”§«“¡ –Õ“¥·¢π¥â«¬ ∫Ÿà¬“¶à“‡™◊ÈÕ - °√≥’ buttonhole technique μâÕߢ®—¥ –‡°Á¥∑’˪“°√‡Ÿ ¢Á¡ÕÕ°°àÕπ„ÀâÀ¡¥ ‡æ◊ËÕªÑÕß°—π °“√μ‘¥‡™◊ÈÕ - „™â 10% povidone-iodine, 2% clorhexidine À√◊Õ 70%alcohol ‡™Á¥∫√‘‡«≥∑’Ë®–·∑߇¢Á¡ ‚¥¬‡√‘Ë¡μâπ®“°®ÿ¥∑’Ë®–·∑߇¢Á¡«π‡ªìπ«ß°≈¡ÕÕ°√Õ∫πÕ° ‚¥¬‰¡à¬âÕπ°≈—∫ - Àâ“¡§≈”∫√‘‡«≥∑’Ë®–·∑߇¢Á¡Õ’° À≈—߇μ√’¬¡º‘«Àπ—ß·≈â« - μâÕ߇§√àߧ√—¥„πÀ≈—° aseptic technique (2) ‡∑§π‘§°“√·∑߇¢¡Á - °“√„™â AVF ‡√Á«‡°‘π°«à“‡«≈“∑’˧«√ (‡«≈“∑’ˇÀ¡“– ¡ 2-3 ‡¥◊Õπ) ®–∑”„À⇠’ˬßμàÕ°“√ √—Ë« (infiltration) ¢Õ߇≈◊Õ¥ÕÕ°πÕ°‡ âπ‡≈◊Õ¥‰¥â ‡π◊ËÕß®“°ºπ—߇ âπ‡≈◊Õ¥ AVF ¬—߉¡à‡®√‘≠æÕ - °“√„™â tourniquet √—¥∑’Ëμ—π·¢π‡æ’¬ß‡∫“Ê ‡æ◊Ëժ—Èπ°“√‰À≈¢Õ߇≈◊Õ¥¥”„Àâ™â“≈ß ·μà ‰¡à∂÷ߢ—ÈπÀ¬ÿ¥°“√‰À≈‡«’¬π ®–‡°‘¥°“√§—ËߢÕ߇≈◊Õ¥¥”·≈–‡ âπ‡≈◊Õ¥¥”¢¬“¬„À≠à¢÷ÈπÕ’° ∑”„Àâ·∑߇¢Á¡ ‰¥â –¥«°·≈–ßà“¬¢÷Èπ ·≈–∑’Ë ”§—≠®–™à«¬≈¥ trauma μàÕ intima ¢Õß vein ∑’ËÕ“®‡°‘¥®“°ª≈“¬‡¢Á¡∑’Ë ·À≈¡§¡ ¥—ßπ—Èπ°“√„™â tourniquet „πºâŸªÉ«¬∑’ˉ¡à§àÕ¬‡ÀÁπ·π«‡ âπ‡≈◊Õ¥‡π◊ËÕß®“°¡’¢π“¥§àÕπ¢â“߇≈Á° ®÷ß ‡ªìπª√–‚¬™πå¡“°·≈–∑”„À⇰‘¥§«“¡ª≈Õ¥¿—¬μàÕ vein ªí≠À“π’È®–À¡¥‰ª‰¥â„π°√≥’„™â‡¢Á¡∑Ÿà (blunt needle) - ¥÷ߺ‘«Àπ—ß„Àâμ÷ß „π∑‘»∑“ßμ√ß°—π¢â“¡°—∫°“√·∑߇¢Á¡¥â«¬π‘È«À—«·¡à¡◊Õ¥â“π∑’ˉ¡à∂π—¥ „πμ”·Àπàß„μâμàÕ®ÿ¥∑’Ë®–·∑߇¢Á¡ ·≈–∑”°“√·∑߇¢Á¡¥—ßπ’È o °¥ peripheral nerve ending ´ß÷Ë Õ¬√Ÿà –À«“à ß epidermis ·≈– dermis ‡æÕ◊Ë „À‡â °¥‘ anesthetic effect ™à«¬≈¥§«“¡‡®Á∫ª«¥≈߉¥â¢≥–·∑߇¢Á¡ 132

Pitfalls in Vascular Access for Dialysis Nurses o ·∑߇¢Á¡Õ¬à“ßπÿà¡π«≈ „Àâª≈“¬μ—¥¢Õ߇¢Á¡∑’Ë¡’§«“¡·À≈¡§¡μ—¥ºà“π‡π◊ÈÕ‡¬◊ËÕ„ÀâπâÕ¬ ∑’Ë ÿ¥ ‚¥¬„™âÕß»“¢Õ߇¢Á¡∑’ˇÀ¡“– ¡ §«√·∑߇¢Á¡„Àâºà“π‡¢â“‡ âπ‡≈◊Õ¥‰¥â„π§√—È߇¥’¬«®–∑”„Àâ√Õ¬·º≈ À“¬‰¥â‡√Á«·≈– «¬°«à“√Õ¬·º≈∑’Ë∂Ÿ°·∑ßÀ≈“¬§√—Èß„π√Õ¬‡¥’¬«À√◊Õ™Õπ‡¢Á¡À≈“¬∑’ o  ”À√∫— buttonhole technique μÕâ ߥ∑Ÿ »‘ ∑“ß∑∫Ë’ π— ∑°÷ ‰«·â ≈–·∑ßμ“¡∑»‘ ∑“߇¥¡‘ Õß»“ ‡¥‘¡ „™·â √ß¥π— ‡¢¡Á „À‡â ¢“â √Õà ß (track) ∂“â ‰¡‡à ¢“â ‰¡§à «√™Õπ‡¢¡Á ‰ªμ“¡·π«‡ πâ „À≈â ¥·√ߥπ— ≈ß·≈–ª√—∫∑‘»∑“ßÀ√◊ÕÕß»“‡≈Á°πâÕ¬ À√◊Õª√—∫·√ß„π°“√√—Èߺ‘«Àπ—ß ·≈–‡√‘Ë¡¥—π‡¢Á¡„À¡à ∂â“μ√ß√àÕ߇¢Á¡ ®– “¡“√∂º“à πºπß— ‡¢“â ‰ª‰¥∑â π— ∑‚’ ¥¬‰¡‡à °¥‘ °“√ trauma À√Õ◊ infiltration „π°“√™Õπ‡¢¡Á πÕ°®“°®–∑”„Àâ ºŸâªÉ«¬‡®∫Á ª«¥¡“°·≈–Õ“®∑”„Àâ√àÕß„π‡ âπ‡≈◊Õ¥∑’ Ë √“â ߉«â‡ ¬’ À“¬ °“√·∑ߧ√È—ßμÕà ‰ªÕ“®·∑߉¡à‰¥â À√◊Õ „™â‰¡à‰¥âÕ’°μàÕ‰ª πÕ°®“°π’ÈÕ“®æ∫°âÕπ·¢Áߢâ“ß√àÕßÀ√◊Õ„π·π«‡ âπ∫√‘‡«≥∑’Ë∂°Ÿ ‡¢Á¡™Õπ∫àÕ¬Ê ®“°°“√ ‡°‘¥fibrous tissue ‡π◊ËÕß®“° trauma ∑”„Àâ‡∫’¬¥ diameter ¢Õ߇ âπ‡≈◊Õ¥¢«“ß°“√‰À≈¢Õ߇≈◊Õ¥ ¡’º≈„Àâ ‡ πâ ‡≈Õ◊ ¥ÕÕà π·Õ≈ß ‚¥¬‡©æ“–°“√‰À≈‡«¬’ π¢Õ߇≈Õ◊ ¥∑™’Ë “â ≈ß∫√‡‘ «≥∑¡’Ë ’trauma  ßà ‡ √¡‘ „À‡â °¥‘ thrombosis ‰¥â o °“√·∑߇¢Á¡®–∑”‰¥â¥’¢÷Èπ ∂â“μ√÷߇ âπ‡≈◊Õ¥‰«â„Àâπ‘Ëß o ‡¡◊ËÕ‡¢Á¡ºà“π‡¢â“‡ âπ‡≈◊Õ¥ ≈¥°“√μ√÷ߺ‘«·≈– Õ¥‡¢Á¡‰ªμ“¡·π«‡ âπ - ¡ÿ¡¢Õ߇¢Á¡„π°“√·∑ß AVF §«√ª√–¡“≥ 10-25 Õß»“ o °“√·∑߇¢¡Á „πÕß»“∑™’Ë π— ¡“° ®–‡æ¡‘Ë Õπ— μ√“¬„π°“√‡°¥‘ infiltration „π peripheral vein o ∑—π∑’∑’ˇÀÁπ‡≈◊Õ¥ºà“π‡¢â“ Ÿà‡¢Á¡„Àâª√—∫≈¥Õß»“¢Õ߇¢Á¡√“∫≈ß°—∫º‘«Àπ—ß - °“√‡ª≈¬’Ë πμ”·Àπßà °“√·∑߇¢¡Á (rotation) ¬ß— ‰¡ à “¡“√∂∑”‰¥®â √ß‘ ®ß— ·μ°à ¡Á §’ «“¡ ”§≠— „π°√≥’„™â‡¢Á¡·À≈¡ (sharp needle) o ¢÷Èπ°—∫æ◊Èπ∑’˺‘«¢Õß AVF ∑’Ë “¡“√∂„™âß“π‰¥â o ¬◊¥Õ“¬ÿ°“√„™âß“π¢Õß AVF o 50% ¢Õßæ◊Èπ∑’˺‘«¢Õß AVF ∑’Ë “¡“√∂„™âß“π‰¥â§«√„™â‡ªìπ arterial site ·≈–Õ’° 50% „™â‡ªìπ venous site o ªÑÕß°—π°“√‡°‘¥ aneurysm ·≈– pseudoaneurysm - ·∑߇¢Á¡„À⇰‘¥ recirculation „ÀâπâÕ¬∑’Ë ÿ¥‚¥¬√–¬–√–À«à“߇¢Á¡ artery ·≈–‡¢Á¡ vein „Àâ Àà“ß°—π 1.5-2.0 π‘È« ‡¢Á¡ artery À—π‡¢â“À“ anastomosis ·≈–‡¢Á¡ vein À—πμ√ß°—π¢â“¡°—∫ anastomosis „Àâ ·∑߇¢Á¡‰ªμ“¡∑‘»∑“ß·≈–√–¬–√–À«à“߇¢Á¡„ÀâÀà“ß°—π¡“°∑’Ë ÿ¥‡∑à“∑’Ë®–∑”‰¥â - °“√μ√÷߇¢Á¡„Àâª≈Õ¥¿—¬ o μ√«®‡™§Á ª≈“¬‡¢¡Á μÕâ ߉¡‡à ∫¬’ ¥ºπß— ‡ πâ ‡≈Õ◊ ¥¥“â π„𠧫√„Àªâ ≈“¬‡¢¡Á ‡ªπì Õ ‘ √– ‚¥¬ °“√ª√—∫Õß»“¢Õ߇¢Á¡™â“Ê 0-45 Õß»“ ∂â“¡’°“√μ‘¥¢—¥¡’·√ßμâ“π· ¥ß«à“ª≈“¬‡¢Á¡μ‘¥°—∫ºπ—߇ âπ‡≈◊Õ¥ „Àâ‡≈◊ËÕπ‡¢Á¡ÕÕ°™â“Ê ª√–¡“≥ 1-2 mm ‡¡◊ËÕ‰¡à¡’·√ßμâ“π®÷ߪ√—∫‡¢Á¡√“∫μ‘¥°—∫º‘«Àπ—ß·≈–μ‘¥æ“ ‡μÕ√å o 쥑 æ“ ‡μÕ√μå √ß÷ ‡¢¡Á °∫— º«‘ Àπß— „À·â ππà °π— ‡≈Õ◊Ë πÀ≈¥ÿ ‚¥¬μ¥‘ „À§â ≈¡ÿ ª°ï ‡¢¡Á ∑ß—È À¡¥·≈– μ‘¥¢«“ߪﰇ¢Á¡Õ’° 1 §√—Èß ‡æ◊ËÕ°—π‡¢Á¡‡≈◊ËÕπÕÕ°¡“ À√◊Õμ‘¥‡ªìπ√Ÿªªï°º’‡ ◊ÈÕ 133

Practical Dialysis in the Year 2009 o ‡æ◊ËÕªÑÕß°—π°“√‡≈◊ËÕπÀ≈ÿ¥¢Õ߇¢Á¡Õ’° 1 ™—Èπ „Àâμ√÷ß blood line ∑—Èß 2 ‡ âπ°—∫º‘«Àπ—ß À√◊Õ‡ ◊ÈÕ¢ÕߺŸâªÉ«¬ ‰¡à§«√μ√÷ß à«π¢Õß extension tube ¢Õ߇¢Á¡ ª≈àÕ¬„À⇪ìπÕ‘ √– ‡æ◊ËÕ„ÀâºâŸªÉ«¬ “¡“√∂ ‡§≈◊ËÕπ‰À«‰¥â∫â“ß‚¥¬‰¡à‡°‘¥°“√¥÷ß√—È߇¢Á¡ 4.2.4 °“√ ÕπºªŸâ É«¬ (Patient Teaching) (1) °Õà π°“√º“à μ¥— AVF „Àºâ ªâŸ «É ¬‡¢“â „®∂ß÷ §«“¡®”‡ªπì °“√‡μ√¬’ ¡√“à ß°“¬ Àμ— ∂°“√°“√ªØ∫‘ μ— ‘ μ—«À≈—ß°“√ºà“μ—¥ ¿“«–·∑√°´âÕπμà“ßÊ ·≈–°“√¥Ÿ·≈ AVF (2)  Õπ„ÀâºâŸªÉ«¬‡μ√’¬¡√à“ß°“¬°àÕπºà“μ—¥ ‚¥¬ - À≈’°‡≈’ˬ߰“√‡®“–‡≈◊Õ¥ „ÀâπÈ”‡°≈◊Õ ·≈–«—¥§«“¡¥—π·¢π¥â“π∑’Ë®–∑” AVG - ∫√‘À“√‡æ◊ËÕ„À⇠âπ‡≈◊Õ¥∑’Ë·¢π¥â“π∑’Ë®–∑” AVG ‚쉥â‡√Á«À≈—ߺà“μ—¥ (3)  —߇°μÕ“°“√º‘¥ª°μ‘À≈—ß°“√ºà“μ—¥ ‰¥â·°à μ‘¥‡™◊ÈÕ μ’∫μ—π ‡≈◊Õ¥ÕÕ° „Àâ°“ß·¢π·≈– Àπÿπ·¢π ßŸ ¢÷Èπ‡≈Á°πâÕ¬¥â«¬À¡Õπ (4) ∫√‘À“√‡æ◊ËÕ„À⇠âπ‡≈◊Õ¥‚μ¢÷ÈπÀ≈—ߺà“μ—¥ - ‡√‘Ë¡ª√–¡“≥«—π∑’Ë 10-14 À≈—ߺà“μ—¥ √Õ¬·º≈·Àâߥ’·≈–‰¡à¡’°“√´÷¡√—Ë« ‰¡à¡’°“√∫«¡∑’Ë anastomosis - „ÀâºâŸªÉ«¬∫’∫≈Ÿ°∫Õ≈¬“ߥ⫬¡◊Õ∑’Ë¡’ AVF ·≈–„™â¡◊ÕÕ’°¢â“ß∫’∫μâπ·¢π‰«â„Àâ·πàπæÕ ª√–¡“≥ ‚¥¬‰¡à„À⇰‘¥°“√ªî¥°—Èπ°“√‰À≈¢Õ߇≈◊Õ¥∑—ÈßÀ¡¥ ∂â“„™â tourniquet √—¥μâÕߧ≈”™’æ®√‡Àπ◊Õ¢÷È𠉪‰¥â - ∑”°“√∫√‘À“√«—π≈– 4 §√—ÈßÊ ≈–ª√–¡“≥ 5-10 π“∑’ Õ¬à“ß ¡Ë”‡ ¡Õ (5) °“√§≈” thrill ·≈–øí߇ ’¬ß bruit (6) À≈’°‡≈’ˬ߰“√°¥∑—∫‡ âπ‡≈◊Õ¥ - ‰¡à„™â·¢π¥â“π∑’Ë¡’ AVF Àπÿπ»’√…– ·≈–‰¡àπÕπ∑—∫ - ‰¡à «¡‡§√◊ËÕߪ√–¥—∫√—¥∫π‡ âπ‡≈◊Õ¥ ‡™àπ °”‰√ π“Ãî°“ ‡ªìπμâπ - ‰¡à «¡‡ ◊ÈÕ√—¥®π‡°‘π‰ª - ‰¡à¬°¢ÕßÀπ—°‚¥¬„™â·¢π∑’Ë¡’ AVF √Õß√—∫ (7) „Àâ∑”§«“¡ –Õ“¥·¢π¥â«¬ ∫Ÿà¬“¶à“‡™◊ÈÕ°àÕπ°“√·∑߇¢Á¡ (8) ·πà„®«à“∫ÿ§≈“°√‰μ‡∑’¬¡∑”°“√¶à“‡™◊ÈÕÕ¬à“ß ¡∫Ÿ√≥å°àÕπ°“√·∑߇¢Á¡ (9) ¬È”„Àâ∫ÿ§≈“°√‰μ‡∑’¬¡‡ª≈’ˬπ∑’Ë·∑߇¢Á¡ ∂â“„™â‡¢Á¡§¡ (9) °¥À“â ¡‡≈Õ◊ ¥¥«â ¬·√ß¥π— ‡©æ“–∑Ë’ ∑‡Ë’ À¡“– ¡‚¥¬¬ß— ¡Õ’ μ— √“‰À≈¢Õ߇≈Õ◊ ¥„π‡ πâ AVF Õ¬àŸ μ≈Õ¥‡«≈“ (10) √“¬ß“π欓∫“≈ÀÕâ ߉μ‡∑¬’ ¡À√Õ◊ ÀÕâ ß©°ÿ ‡©π‘ ‡æÕË◊ ¢Õ§«“¡™«à ¬‡À≈Õ◊ ‡¡ÕË◊ ¡‡’ ≈Õ◊ ¥ÕÕ°·≈– °“√Àâ“¡‡≈◊Õ¥¥â«¬μπ‡ÕßÕ¬à“ß∂°Ÿ μâÕß (11) °“√√“¬ß“πÕ“°“√·≈–Õ“°“√· ¥ß¢Õß°“√μ‘¥‡™◊ÈÕ ‰¡àæ∫ thrill ‰¡à‰¥â¬‘π‡ ’¬ß bruit 134

Pitfalls in Vascular Access for Dialysis Nurses 4.3 °“√®¥— °“√∑“ß°“√欓∫“≈ ”À√—∫ºâŸª«É ¬∑’¡Ë ’ AV grafts 4.3.1 °“√ª√–‡¡‘π ¿“æ( Assessment) (1) °“√¥Ÿ (Inspection) ¥Ÿ ¿“æ∑“ß°“¬¿“æ∑—Ë«‰ª - Approximation of suture line: aneurysm inflammation - Õ“°“√·≈–Õ“°“√· ¥ß¢Õß°“√Õ—°‡ ∫·≈–μ‘¥‡™◊ÈÕ - §«“¡ ¡∫Ÿ√≥å¢Õߺ‘«Àπ—߇Àπ◊Õ AV graft: fibrosis - ¡’°“√∫«¡¢Õß·¢π¥â“π∑’Ë¡’ AV graft - ¡’‡ âπ‡≈◊Õ¥·μ°·¢πß (collaterals) - §«“¡≈÷°¢Õß AV graft ®“°º‘«Àπ—ß (2) °“√§≈” (Palpation) - Thrill ∑’Ë anastomosis ∑—Èß§àŸ - §≈”À“∫√‘‡«≥∑’Ë∫àß™’È«à“‰¡àª°μ‘ §«√À≈’°‡≈’ˬ߰“√·∑߇¢Á¡: aneurysm, stenosis - §≈”À“®ÿ¥∑’Ë AV graft ‰¡à ¡Ë”‡ ¡Õ°—∫º‘«Àπ—ß §«√À≈’°‡≈’ˬ߰“√·∑߇¢Á¡„π∫√‘‡«≥¥—ß °≈à“« ´÷Ëß®–‡ªìπªí≠À“„π√–À«à“ß°“√·∑߇¢Á¡ °“√ª√—∫Õß»“·≈–°“√ Õ¥‡¢Á¡‰ªμ“¡·π«‡ âπÕ“®º‘¥‰¥â „π√–¬– —ÈπÊ ‡æ’¬ß 2-3 ´.¡. - §≈”À“®ÿ¥∑’Ëμ—« graft ∑”¡ÿ¡À—°≈ß Ÿà√Õ¬μàÕ∑—Èß artery ·≈– vein ´÷Ëß¡—°æ∫‰¥â∫àÕ¬·≈– ‡ªìπªí≠À“„π§πÕâ«π μâÕßÀ≈’°‡≈’ˬ߰“√·∑߇¢Á¡∫√‘‡«≥π—Èπ - §≈”™’æ®√·≈–≈—°…≥–¢Õß™’æ®√„μâμàÕ®ÿ¥∑’Ë®–·∑߇¢Á¡ - §≈”‡ª√’¬∫‡∑’¬∫Õÿ≥À¿¡Ÿ ‘ª≈“¬√¬“ߧå∑’Ë graft °—∫Õ’°¥â“πÀπ÷Ëß - §≈”·π«¢Õß graft ‰¥âßà“¬ ™—¥‡®π À√◊Õ ∂Ÿ°∫¥∫—ߥ⫬ soft tissue À√◊Õ dense tissue -  “¡“√∂°¥‰¥âßà“¬À√◊Õ¡’·√ßμâ“π Ÿß (3) °“√øíß (Auscultation) - Bruit §«√øí߉¥â™—¥‡®π∑’Ë anastomosis ∑—Èß§àŸ ·≈–μ≈Õ¥·π« graft - øßí bruit Õ¬“à ß ¡”Ë ‡ ¡Õ·≈–‡ª√¬’ ∫‡∑¬’ ∫°∫— ∑ºË’ “à π¡“∑°ÿ §√ßÈ— «‡‘ §√“–À°å “√‡ª≈¬Ë’ π·ª≈ß ´÷Ëß “¡“√∂∫Õ°∂÷ß¿“«–·∑√°´âÕπ‰¥â 4.3.2 °“√∫π— ∑÷°√“¬ß“π¢—πÈ æπ◊È ∞“π (Baseline documentation) (1) ™π‘¥¢Õß graft μ”·Àπàß √Ÿªæ√√≥ —≥∞“π (configuration) (2)  ¿“«–¢Õß anastomosis ·≈– graft  ¿“«–¢Õߺ‘«Àπ—ß (3) ≈—°…≥–¢Õ߇ ’¬ß bruit, thrill (4) √–¥—∫°“√∫«¡¢Õß√¬“ߧå (5) §«“¡¬“°-ßà“¬¢Õß°“√·∑߇¢Á¡ (6) °“√μ√«®«—¥ blood flow (7) Percent recirculation 135

Practical Dialysis in the Year 2009 (8) Venous dialysis pressure (Õ¬à“ß„¥Õ¬à“ßÀπ÷ËßÀ√◊Õ∑—ÈߧŸà) - Static venous pressure o Venous pressure ∑’Ë BFR 0 ml/min o „π°“√«—¥·μà≈–§√—ÈßμâÕß·∑߇¢Á¡∑’ˇ¥‘¡ o ‡ΩÑ“√–«—ß·π«‚πâ¡ - Dynamic venous pressure o Venous pressure ∑’Ë 2-5 π“∑’·√°¢Õß°“√∑” HD ∑’Ë BFR 200 ml/min o „π°“√«—¥·μà≈–§√—ÈßμâÕß·∑߇¢Á¡∑’ˇ¥‘¡ o ‡ΩÑ“√–«—ß·π«‚πâ¡ (9) Descriptive term: - πÿà¡ °—∫ ·¢Áß (soft & hard) - ·∫π °—∫ ‚ªÉßμ÷ß (flat & full) - ·§∫ °—∫ °«â“ß (narrow & wide) - μ√ß °—∫ §¥‚§âß (straight & tortuous) - ™—¥‡®π¥’ °—∫ ‰¡à™—¥‡®π (well defined & poorly defined) - ∫“ß °—∫ Àπ“ (thin & thick) - μ◊Èπ °—∫ ≈÷° (superficial & deep) -  —Ëπ –‡∑◊Õπ °—∫ ™’æ®√ (thrill & pulsation) - √–¬– ¡Ë”‡ ¡Õ °—∫ ‰¡à ¡Ë”‡ ¡Õ®“°º‘«Àπ—ß (equidistant & nonequidistant from skin) 4.3.3 °“√·∑߇¢¡Á (Cannulation) 1. «‘‡§√“–Àå∑‘»∑“߉À≈¢Õ߇≈◊Õ¥ (direction of flow) ‚¥¬°¥≈ß∫π®ÿ¥√–¬–°÷Ëß°≈“ߢÕßμ—« graft ‡æ◊ËÕÀ¬ÿ¥°“√‰À≈‡«’¬π¢Õ߇≈◊Õ¥™—Ë«§√“«‰¡à‡°‘π 1 π“∑’ ¥â“π∑’ˬ—ߧ≈”‰¥â™’æ®√ §◊Õ arterial 2. ∑”°“√‡μ√’¬¡º‘«Àπ—ß°àÕπ°“√≈߇¢Á¡ - „ÀâºâŸªÉ«¬∑”§«“¡ –Õ“¥·¢π¥â«¬ ∫Ÿà¬“¶à“‡™◊ÈÕ - „™â 10% povidone-iodine, 2% clorhexidine À√◊Õ 70% alcohol ‡™Á¥∫√‘‡«≥∑’Ë®–·∑߇¢Á¡ ‚¥¬‡√‘Ë¡μâπ®“°®ÿ¥∑’Ë®–·∑߇¢Á¡«π‡ªìπ«ß°≈¡ÕÕ°√Õ∫πÕ° ‚¥¬‰¡à¬âÕπ°≈—∫ - Àâ“¡§≈”∫√‘‡«≥∑’Ë®–·∑߇¢Á¡Õ’° À≈—߇μ√’¬¡º‘«Àπ—ß·≈â« - μâÕ߇§√àߧ√—¥„πÀ≈—° aseptic technique 3. ‡∑§π‘§°“√·∑߇¢Á¡ - Àâ“¡·∑߇¢Á¡ ∂Ⓣ¡à‰¥â¬‘π‡ ’¬ß bruit ‡æ√“–¢≥–·∑߇¢Á¡μâÕß®”°—¥ °“√„™â lytic agents - °“√·∑߇¢¡Á °Õà π‡«≈“∑°Ë’ ”Àπ¥ ®–¡§’ «“¡‡ ¬Ë’ ß¡“°μÕà °“√√«Ë— ¢Õ߇≈Õ◊ ¥º“à π√Õ¬μ¥— ¢Õß ‡¢Á¡‡¢â“ Ÿà tunnel ®–‡°‘¥°“√‡ ’¬À“¬μàÕμ—« graft ·≈–‡ âπ‡≈◊Õ¥√Õ∫Ê ‡π◊ËÕß®“°μ—« graft ¬—߉¡àª√– “π°—∫ ‡π◊ÈÕ‡¬◊ËÕ¢Õß√à“ß°“¬‰¥â¥’æÕ (adequate granulation of the tunnel) 136

Pitfalls in Vascular Access for Dialysis Nurses - ∂â“μâÕß„™â graft ¢≥–∑’ˬ—ߪ√“°ØÕ“°“√∫«¡Õ¬Ÿà „Àâ°¥≈ß∫πμ—« graft Õ¬à“ßπÿà¡π«≈®π ¬ÿ∫≈ß ®–∑”„Àâ‡ÀÁπ·π«‡ âπ·≈–§≈”‰¥â™—¥¢÷Èπ °“√·∑߇¢Á¡μâÕß∑”Õ¬à“ß√–¡—¥√–«—߇π◊ËÕß®“°Õ“®‡°‘¥ °“√·∑ß∑–≈ÿ posterior wall ‰¥â ºâŸ·∑߇¢Á¡§«√¡’§«“¡™”π“≠°“√‡ªìπÕ¬à“ߥ’ - ¥÷ߺ‘«„Àâμ÷߉ª∑“ßμ√ߢⓡ°—∫∑‘»∑“ß∑’Ë®–·∑߇¢Á¡ o °¥∑’Ë peripheral nerve endings ´÷ËßÕ¬Ÿà√–À«à“ß epidermis ·≈– dermis ®–∑”„À⇰‘¥ anesthetic effect o ·∑߇¢Á¡μ—¥º“à πºß‘ Àπß— Õ¬“à ßπÿ¡à π«≈ ‚¥¬„ÀâÀπ“â μ—¥¢Õ߇¢Á¡μ¥— º“à πº‘«Àπß— πâÕ¬∑’ Ë ÿ¥ o μ√÷ß graft À√◊Õ ‡ âπ‡≈◊Õ¥„ÀâÕ¬àŸπ‘Ëß„π¢≥–·∑߇¢Á¡ ®–·∑߉¥â·¡àπ¬”¢÷Èπ - ¡ÿ¡‡¢Á¡„π°“√·∑ß graft „™âª√–¡“≥ 45 Õß»“ o °“√„™âÕß»“πâÕ¬ ‡æ‘Ë¡Õ—πμ√“¬„π°“√μ—¥ºà“πºπ—ß graft ¢Õߪ≈“¬‡¢Á¡ ∑”„Àâºπ—ߢÕß graft ∂Ÿ°∑”≈“¬‡æ‘Ë¡¢÷Èπ o °“√„™âÕß»“∑’Ë™—π¡“° ∑”„Àâ‡æ‘Ë¡§«“¡‡ ’ˬßμàÕ°“√·∑ß∑–≈ÿºπ—ߥâ“π≈à“ߢÕß graft - °“√·∑߇¢â“μ—« graft o ∑—π∑’∑’ˇ¢Á¡ºà“π‡¢â“º‘«Àπ—ß μ√÷ß graft ¥â«¬¡◊Õ¢â“ß∑’ˉ¡à∂𗥄Àâ graft Õ¬Ÿà√–À«à“ßπ‘È«À—« ·¡à¡◊Õ°—∫π‘È«™’È¢≥–·∑߇¢Á¡ºà“π graft °“√μ√÷ß„Àâπ‘Ëߙ૬„Àâ Õ¥‡¢Á¡μ“¡∑‘»∑“ß°“√·∑߉¥â¥’°«à“ o ∂â“·∑ߧ√—È߇¥’¬«‰¡à‰¥âÀ√◊Õ·∑ß∑–∑ÿ „Àâ∂Õπ‡¢Á¡ÕÕ°·≈–°¥Àâ“¡‡≈◊Õ¥®πÀ¬ÿ¥ π‘∑¥’ ·≈â«®÷߇√‘Ë¡„À¡àÕ’°§√—Èß ‰¡à§«√™Õπ‡¢Á¡À≈“¬§√—Èß®–∑”„Àâºπ—ß graft ‡ ’¬À“¬ - °“√‡ª≈’ˬπ∑’Ë·∑ß (rotation) ¬—߉¡à “¡“√∂∑”‰¥â®√‘ß®—ß ·μà°Á¡’§«“¡ ”§—≠ o ™à«¬„Àâ¡’Õ“¬ÿ„™âß“ππ“π¢÷Èπ o æ◊Èπ∑’˺‘«∑—ÈßÀ¡¥¢Õß graft §«√·∫àß 50% „™â‡ªìπ arterial ·≈– Õ’° 50% ‡ªìπ venous o ªÑÕß°—π°“√‡°‘¥ pseudoaneurysm - ≈¥°“√‡°¥‘ recirculation ‚¥¬„À√â –¬–√–À«“à ߇¢¡Á À“à ß°π— Õ¬“à ßπÕâ ¬ 1.5-2.0 π«‘È ‡¢¡Á artery ·∑߇¢â“À“ arterial anastomosis  à«π‡¢Á¡ vein ·∑߇¢â“À“ venous anastomosis ·≈–„Àâ√–¬–√–À«à“߇¢Á¡ Àà“ß°—π„Àâ¡“°∑’Ë ÿ¥‡∑à“®–∑”‰¥â - °“√μ√÷߇¢Á¡„Àâª≈Õ¥¿—¬ o μ√«®‡™§Á ª≈“¬‡¢¡Á μÕâ ߉¡‡à ∫¬’ ¥ºπß— ‡ πâ ‡≈Õ◊ ¥¥“â π„𠧫√„Àªâ ≈“¬‡¢¡Á ‡ªπì Õ ‘ √– ‚¥¬ °“√ª√∫— Õß»“¢Õ߇¢¡Á ™“â Ê 0-45 Õß»“ ∂“â ¡°’ “√쥑 ¢¥— ¡·’ √ßμ“â π· ¥ß«“à ª≈“¬‡¢¡Á 쥑 °∫— ºπß— graft „À‡â ≈Õ◊Ë π ‡¢Á¡ÕÕ°™â“Ê ª√–¡“≥ 1-2 mm ‡¡◊ËÕ‰¡à¡’·√ßμâ“π®÷ߪ√—∫‡¢Á¡√“∫μ‘¥°—∫º‘«Àπ—ß·≈–μ‘¥æ“ ‡μÕ√å o 쥑 æ“ ‡μÕ√μå √ß÷ ‡¢¡Á °∫— º«‘ Àπß— „À·â ππà °π— ‡≈Õ◊Ë πÀ≈¥ÿ ‚¥¬μ¥‘ „À§â ≈¡ÿ ª°ï ‡¢¡Á ∑ß—È À¡¥·≈– μ‘¥¢«“ߪﰇ¢Á¡Õ’° 1 §√—È߇æ◊ËÕ°—π‡¢Á¡‡≈◊ËÕπÕÕ°¡“ À√◊Õμ‘¥‡ªìπ√Ÿªªï°º’‡ ◊ÈÕ o ‡æ◊ËÕªÑÕß°—π°“√‡≈◊ËÕπÀ≈ÿ¥¢Õ߇¢Á¡Õ’° 1 ™—Èπ „Àâμ√÷ß blood line ∑—Èß 2 ‡ âπ°—∫º‘«Àπ—ß À√◊Õ‡ ◊ÈÕ¢ÕߺŸâªÉ«¬ ‰¡à§«√μ√÷ß à«π¢Õß extension tube ¢Õ߇¢Á¡ ª≈àÕ¬„À⇪ìπÕ‘ √– ‡æ◊ËÕ„ÀâºâŸªÉ«¬ “¡“√∂ ‡§≈◊ËÕπ‰À«‰¥â∫â“ß‚¥¬‰¡à‡°‘¥°“√¥÷ß√—È߇¢Á¡ - ¢≥–∂Õπ‡¢Á¡ Àâ“¡„™â·√ß°¥≈ß∫π‡ âπ graft ®π°«à“®–∂Õπ‡¢Á¡ÕÕ°Õ¬à“ß ¡∫√Ÿ ≥å ‡æ◊ËÕ ªÑÕß°—𧫓¡§¡¢Õ߇¢Á¡∫“¥ºπ—ߥâ“π„π¢Õß graft ®“°·√ß°¥ 137