Practical Dialysis in the Year 2009

Practical Dialysis in the Year 2009 ‡Õ° “√Õ“â ßÕß‘ 1. United States Renal Data Systems (USRDS). Treatment Modalities. 2008 USRDS annual data report III. www.usrds.org/ 2008. 2. Currier H, Brewer ED. Pediatric hemodialysis. In: Gutch CF, Stoner MH, Corea AL, eds, Review of hemodialysis for nurses and dialysis personnal. 1998:288-99. 3. Krueger A, Allsteadt A. Dialyzing children in the adult world. Nephrol Nurs J. 2008;35:216-20. 4. Currier H, Bargo PD, Brewer ED. The pediatric renal failure-dialysis-transplant patient. In: Lancaster ed. Core curriculum for nephrology nursing. ANNA 2001:377-416. 5. Daschner M, Schaefer FS. Technical aspects of the hemodialysis proceduse. In: Warady BA, Shaefer FS, Fine RN Alexander SR, eds. Pediatric Dialysis. Dordrecht: Kluwer Academic Publishers, 2004;91-111. 6. Saltissi D. management of anticoagulant for hemodialysis. In: Nessenson AR, Fine RN eds. Dialysis Therapy. USA Hanley & Belfus Inc, 2002:82-6. 7. Õÿ¥¡ ‰°√ƒ∑∏‘™—¬.Anticoagulation for hemodialysis „π  ¡™“¬ ‡Õ’ˬ¡ÕàÕß, ‡°√’¬ß μ—Èß ßà“, ‡°◊ÈÕ‡°’¬√μ‘ ª√–¥‘…∞åæ√ »‘≈ªá, ‡∂≈‘ß»—°¥‘Ï °“≠®π∫ÿ…¬å. Clinical dialysis. Text and Journal Publication. °√ÿ߇∑æ2550 ;353-98. 238

Prevention, Diagnosis and Treatment of Acute Complications during Hemodialysis Prevention, Diagnosis 13 and Treatment of Acute Complications during Hemodialysis  √‘ ¿‘ “ ™â“ß»√‘ ‘°ÿ≈™¬— Drugs : Metabolic : Uremic Disequilibrium syndrome Dialysis remove Hypocalcemia encephalopathy anticonvulsants Hypomagnesemia Epileptogenic drugs Hypoglycemia (theophylline, Hyperosmolarity caused meperidine) by hypernatremia Severe acid-base disturbances Hemodialysis-associated seizures Hypertensive encephalopathy Other toxin : Focal neurological disease Cerebral anoxia due to sustained hypotension Acute aluminum intoxication Intracranial hemorrhage Cardiac arrhythmia Hypersensitivity reaction Alcohol withdrawal Atheroembolism Sepsis, hemorrhage Hemolytic-uremic syndrome Glucose 6-phosphate Interference with rbc metabolism Traumatic fragmentation deficiency copper, aluminum, formaldehyde Dialyzer roller pump exacerbated by hypophosphatemia Excessive suction at oxidants eg. quinine arterial access site Single needle dialysis High blood flow through Drug induced small needle; Kinked microangiopathy catheter/tubing eg. quinine Incorrect osmolarity Intradialytic hemolysis Thermal damage of dialysate Overheated dialysate (>47 °C) 1. ∫∑π” 2. ¿“«–·∑√°´âÕπ∑“ß√–∫∫À«— „®·≈–À≈Õ¥‡≈Õ◊ ¥ Underheated dialysate (<35 °C) (Cardiovascular complications) Cell membrane Reductive damage Oxidative damage 3. ¿“«–·∑√°´Õâ π∑“ß√–∫∫ª√– “∑ (Neuromuscular complications) 4. ¿“«–·∑√°´Õâ π∑“ß√–∫∫‚≈Àμ‘ (Hematological complications) fragility formaldehyde (methemoglobinemia): copper 5. ¿“«–·∑√°´Õâ π∑‡’Ë °¬Ë’ «‡πËÕ◊ ß®“°°√–∫«π°“√øÕ°‡≈◊Õ¥ Dialysis insufficient nitrite/nitrate, quinine (Dialysis process complications) 6. ¿“«–·∑√°´Õâ π„π√–À«à“ß°“√øÕ°‡≈Õ◊ ¥ÕËπ◊ Ê Zinc deficiency 7. ∫∑ √ªÿ 239

Practical Dialysis in the Year 2009 1. ∫∑π” ·¡«â “à „πª®í ®∫ÿ π— °“√∫”∫¥— ∑¥·∑π‰μ¥«â ¬«∏‘ °’ “√øÕ°‡≈Õ◊ ¥¥«â ¬‡§√Õ◊Ë ß‰μ‡∑¬’ ¡®–¡«’ «‘ ≤— π“°“√ ∑’Ë°â“«ÀπⓉª°«à“„πÕ¥’μ„π¥â“πμà“ßÊ ‡™àπ °“√æ—≤π“ª√– ‘∑∏‘¿“æ¢Õ߇§√◊ËÕ߉μ‡∑’¬¡ (hemodialysis machine), °“√ª√—∫ª√ÿߧÿ≥¿“æ√–∫∫πÈ” (dialysate water purification) À√◊Õμ—«°√Õß (dialyzer) ºâŸªÉ«¬∑’ˉ¥â √—∫°“√øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡°ÁÕ“®‡°‘¥¿“«–·∑√°´âÕπ‡©’¬∫æ≈—π„π√–À«à“ß°“√øÕ°‡≈◊Õ¥‰¥â (intradialytic acute complication) ≈”¥—∫Õÿ∫—μ‘°“√≥å¢Õß¿“«–·∑√°´âÕπ∑’Ëæ∫‰¥â§◊Õ §«“¡¥—π‚≈À‘μμË” (hypotension) 15-50%, μ–§√‘« (cramps) 5-20%, §≈◊Ëπ‰ â/Õ“‡®’¬π (nausea/vomiting) 5-15%, ª«¥»’√…– (headache) 5%, ‡®Á∫Àπâ“Õ° (chest pain) 2-5%, ª«¥À≈—ß (back pain) 2-5%, Õ“°“√§—πμ“¡μ—« (itching) 5%, ‰¢âÀπ“« —Ëπ (fever and chill) πâÕ¬°«à“ 1% ´÷Ëß¿“«–·∑√°´âÕπ‡À≈à“π’È “¡“√∂·∫àßÕÕ°μ“¡√–∫∫‰¥â §◊Õ - ¿“«–·∑√°´âÕπ∑“ß√–∫∫À—«„®·≈–À≈Õ¥‡≈◊Õ¥ (Cardiovascular complications) - ¿“«–·∑√°´âÕπ∑“ß√–∫∫ª√– “∑ (Neuromuscular complications) - ¿“«–·∑√°´âÕπ∑“ß√–∫∫‚≈À‘μ (Hematological complications) - ¿“«–·∑√°´âÕπ∑’ˇ°’ˬ«‡π◊ËÕß®“°°√–∫«π°“√øÕ°‡≈◊Õ¥ (Dialysis process complications) 2. ¿“«–·∑√°´Õâ π∑“ß√–∫∫À«— „®·≈–À≈Õ¥‡≈◊Õ¥ (Cardiovascular complications) 2.1 ¿“«–§«“¡¥π— ‚≈Àμ‘ μ”Ë „π√–À«à“ß°“√øÕ°‡≈◊Õ¥ (Intradialytic hypotension) ¿“«–§«“¡¥—π‚≈À‘μμË”„π√–À«à“ß°“√øÕ°‡≈◊Õ¥‡ªìπ¿“«–·∑√°´âÕπ∑’Ëæ∫∫àÕ¬∑’Ë ÿ¥„π√–À«à“ß °“√øÕ°‡≈◊Õ¥1 ‚¥¬¡’𑬓¡§◊Õ√–¥—∫§«“¡¥—π´‘ ‚μ≈‘° ≤ 90 mmHg ºâŸªÉ«¬∑’Ë¡’§«“¡¥—π‚≈À‘μμ˔Փ®®– μ√«®æ∫√–¥—∫§«“¡¥—π‚≈À‘μμË”°«à“ª°μ‘ ·μà‰¡à¡’Õ“°“√®π∂÷ß¡’Õ“°“√√ÿπ·√ß∑’ˇªìπº≈®“°°“√∑’Ë¢“¥ ‡≈◊Õ¥‰ª¬—ßÕ«—¬«–μà“ßÊ ‡™àπ °≈â“¡‡π◊ÈÕÀ—«„®¢“¥‡≈◊Õ¥, À—«„®‡μâπº‘¥®—ßÀ«–, ‡ âπ‡≈◊Õ¥μ’∫, À¡¥ μ‘, ™—° ·≈–‡ ’¬™’«‘μ „πºŸâªÉ«¬∑’ˇªìπ‰μ«“¬‡©’¬∫æ≈—π∑’ˉ¥â√—∫°“√øÕ°‡≈◊Õ¥·≈â«¡’§«“¡¥—π‚≈À‘μμË” ®–∑”„Àâ¡’ °“√øóôπμ—«¢Õ߉μ™â“≈ß ‡π◊ËÕß®“°‡≈◊Õ¥‰ª‡≈’È¬ß‰μ‰¡à‡æ’¬ßæÕ (renal ischemia) ºŸâªÉ«¬∑’Ë¡’§«“¡‡ ’ˬßμàÕ ¿“«–§«“¡¥π— ‚≈Àμ‘ μË”„π√–À«“à ß°“√øÕ°‡≈Õ◊ ¥ ‰¥·â °à ‡æ»À≠ß‘ , º Ÿâ ߟ Õ“¬∑ÿ ¡’Ë §’ «“¡¥π— ´ ‘ ‚μ≈°‘  ßŸ (isolated systolic hypertension) ‡æ√“–®–¡’À≈Õ¥‡≈◊Õ¥·¢Áßμ—«, ºŸâªÉ«¬‡∫“À«“π, ºŸâªÉ«¬∑’Ë¡’¿“«–º‘¥ª°μ‘„π√–∫∫ ª√– “∑Õ—μ‚π¡—μ‘ (autonomic neuropathy)  “‡Àμÿ∑’Ë∑”„À⧫“¡¥—π‚≈À‘μμË”„π√–À«à“ß°“√øÕ°‡≈◊Õ¥ Õ“®‡°’ˬ«¢âÕß°—∫ª√‘¡“≥πÈ”„π√à“ß°“¬ (volume related), °“√À¥μ—«¢ÕßÀ≈Õ¥‡≈◊Õ¥ à«πª≈“¬‰¡à ¡¥ÿ≈ °—∫§«“¡¥—π‚≈À‘μ∑’ËμË” (inadequate vasoconstriction), ºâŸªÉ«¬∑’Ë¡’§«“¡º‘¥ª°μ‘¢ÕßÀ—«„® (cardiac factor) À√◊Õ “‡Àμÿ∑’ˇ°’ˬ«¢âÕß°—∫°“√øÕ°‡≈◊Õ¥Õ◊ËπÊ (dialysis-related cause)  “‡Àμÿμà“ßÊ  √ÿª‰¥â¥—ßμ“√“ß∑’Ë 12 240

Prevention, Diagnosis and Treatment of Acute Complications during Hemodialysis μ“√“ß∑Ë’ 1  “‡Àμÿ¿“«–§«“¡¥—π‚≈À‘μμË”„π√–À«à“ß°“√øÕ°‡≈◊Õ¥ 1. Volume related - large weight gain - short dialysis - low dry weight - inaccurate ultrafiltration - intracellular fluid shift from low dialysis solution sodium 2. Inadequate vasoconstriction - high dialysis solution temperature - eating during treatment induced splanchnic vasodilatation - anemia - autonomic neuropathy - antihypertensive medication - acetate buffer 3. Cardiac factors - diastolic dysfunction - arrhythmia - ischemia 4. Dialysis-related factors - complement activation (C3a- and C5a-mediated) - cytokine generation (IL-1 and nitric oxide-mediated) - dialyzer reaction - air embolism - hemolysis 5. Uncommon causes - pericardial tamponade - myocardial infarction - occult hemorrhage - septicemia 241

Practical Dialysis in the Year 2009 欓∏‘°”‡π¥‘ ¿“«–§«“¡¥π— ‚≈À‘μμ”Ë „π√–À«“à ß°“√øÕ°‡≈Õ◊ ¥ °≈‰°°“√§«∫§ÿ¡§«“¡¥—π‚≈À‘μ„π√à“ß°“¬®–¢÷ÈπÕ¬àŸ°—∫ª√‘¡“≥‡≈◊Õ¥∑’Ë∫’∫ÕÕ°®“°À—«„® (cardiac output) ·≈–°“√À¥μ—«¢ÕßÀ≈Õ¥‡≈◊Õ¥ à«πª≈“¬ (peripheral vascular resistant) „π¿“«–∑’Ë √“à ß°“¬¡√’ –¥∫— §«“¡¥π— ‚≈Àμ‘ ≈¥≈ß ®–¡°’ “√‡æ¡‘Ë cardiac output ‚¥¬°“√‡æ¡‘Ë Õμ— √“°“√‡μπâ ¢ÕßÀ«— „® (heart rate) ·≈–À—«„®∫’∫μ—«·√ߢ÷Èπ ∑”„Àâª√‘¡“≥‡≈◊Õ¥∑’Ë∫’∫ÕÕ°®“°À—«„®·μà≈–§√—Èß (stroke volume) ‡æ‘Ë¡¢÷Èπ  à«πÀ≈Õ¥‡≈◊Õ¥ à«πª≈“¬®–À¥μ—«¡“°¢÷Èπ ∑”„Àâª√‘¡“≥‡≈◊Õ¥∫’∫‡¢â“À≈Õ¥‡≈◊Õ¥ à«π°≈“ß¡“°¢÷Èπ ∑”„Àâ‡æ‘Ë¡√–¥—∫§«“¡¥—π‚≈À‘μ „π°“√øÕ°‡≈Õ◊ ¥®–¡°’ “√¥ß÷ πÈ” (ultrafiltration) ÕÕ°®“°À≈Õ¥‡≈Õ◊ ¥ (intravascular compartment) ∂â“Õ—μ√“°“√¥÷ßπÈ”ÕÕ°¡“°‡°‘π°«à“°“√∑’Ë√à“ß°“¬ª√—∫μ—«‚¥¬¥÷ßπÈ”πÕ°À≈Õ¥‡≈◊Õ¥°≈—∫‡¢â“¡“„πÀ≈Õ¥ ‡≈◊Õ¥ (plasma refilling) ´÷ËßÕ“®®–‡°‘¥√à«¡°—∫°“√∑’ËÀ≈Õ¥‡≈◊Õ¥‰¡à “¡“√∂À¥μ—«‰¥â∑”„Àâª√‘¡“≥πÈ”„π À≈Õ¥‡≈◊Õ¥®–≈¥μË”¡“° ºŸâªÉ«¬®–¡’§«“¡¥—π‚≈À‘μμË”„π√–À«à“ß°“√øÕ°‡≈◊Õ¥‰¥â ¥—ßπ—Èπ®÷ß¡’§«“¡ ‡ ¬’Ë ß∑®’Ë –‡°¥‘ §«“¡¥π— ‚≈Àμ‘ μË”„π√–À«“à ß°“√øÕ°‡≈Õ◊ ¥„πºªâŸ «É ¬∑¡’Ë π’ È”Àπ°— μ«— ‡æ¡‘Ë ¡“°°Õà π°“√øÕ°‡≈Õ◊ ¥ ‡æ√“–®–∑”„Àâ¡’°“√¥÷ßπÈ”ÕÕ°‡√Á«·≈–¡“°‡°‘π°«à“ plasma filling ºâŸªÉ«¬∑’Ë¡’§«“¡º‘¥ª°μ‘¢Õß√–∫∫ ª√– “∑Õ—μ‚π¡—μ‘À√◊Õ¡’¿“«–´’¥ ®–∑”„Àâ°“√À¥μ—«¢ÕßÀ≈Õ¥‡≈◊Õ¥‰¡à¥’ (impaired vasoconstriction) 欓∏‘°”‡π‘¥¿“«–§«“¡¥—π‚≈À‘μμË”„π√–À«à“ß°“√øÕ°‡≈◊Õ¥ √ÿª¥—ß√Ÿª∑’Ë 12 Excessive fluid removal Patient-related factors: autonomic neuropathy, Ultrafiltration rate >0.35 ml/min/kg food ingestion, anemia, increase core body Decrease in plasma volume >20% temperature, antihypertensive medications Reduced plasma refilling rate Dialysis-related factors: acetate dialysate, Hemorrhage low dialysate sodium and/or ionized calcium concentration, complement activation, cytokine generation Reduced effective circulating volume Impaired vasoconstriction Intradialytic hypotension Cardiac factors: Dialyzer reaction Hemolysis Air embolism myocardial infarction arrhythmias, pericardial tamponade √Ÿª∑’Ë 1 欓∏‘°”‡π‘¥·≈– “‡Àμÿ°“√‡°‘¥¿“«–§«“¡¥π— ‚≈À‘μμË”„π√–À«“à ß°“√øÕ°‡≈Õ◊ ¥ 242

Prevention, Diagnosis and Treatment of Acute Complications during Hemodialysis ·π«∑“ß°“√√°— …“¿“«–§«“¡¥—π‚≈Àμ‘ μË”„π√–À«“à ß°“√øÕ°‡≈◊Õ¥ ºâŸªÉ«¬∑’Ë¡’§«“¡¥—π‚≈À‘μμ˔Փ®¡’Õ“°“√‡√‘Ë¡·√°§◊Õ ¡÷π»’√…– (dizzy), ßÿπßß (light-headed), §≈◊Ëπ‰ â ∫“ß√“¬Õ“®®–¡’Õ“°“√μ–§√‘«‰¥â ∫“ß√“¬Õ“®‰¡à¡’Õ“°“√π” ·μà«—¥§«“¡¥—π‚≈À‘μμË”¡“° ®π Õ¬àŸ„π√–¥—∫Õ—πμ√“¬‰¥â ¥—ßπ—Èπ§«√«—¥§«“¡¥—π‚≈À‘μ„πºâŸªÉ«¬øÕ°‡≈◊Õ¥∑ÿ°™—Ë«‚¡ß ºâŸªÉ«¬∑’Ë¡’§«“¡‡ ’Ë¬ß μàÕ¿“«–§«“¡¥—π‚≈À‘μμË”§«√æ‘®“√≥“«—¥§«“¡¥—π‚≈À‘μ∂’Ë¢÷Èπ Õ“®®–∑ÿ°§√÷Ëß™—Ë«‚¡ß À≈—°°“√√—°…“ ¿“«–§«“¡¥—π‚≈À‘μμË”§◊Õ „Àâ‡≈◊Õ¥°≈—∫‡¢â“„πÀ≈Õ¥‡≈◊Õ¥Õ¬à“߇√Á« ‚¥¬≈¥À√◊ÕÀ¬ÿ¥°“√¥÷ßπÈ” (ultrafiltration), ®—¥∑à“ºŸâªÉ«¬„Àâ»’√…–μË”-‡∑â“ Ÿß (Trendelenburg position), „Àâ “√πÈ” isotonic normal saline 100 ml À√◊Õ¡“°°«à“‡¢â“∑“ß blood line Õ“®„™â “√πÈ”Õ◊Ëπ‡™àπ glucose, mannitol, albumin, hypertonic saline °“√„™â albumin ¡√’ “§“·æß·≈–º≈„°≈‡â §¬’ ß°∫— °“√„Àâ normal saline3  «à π°“√„™â hypertonic saline ‰¡à‰¥â¥’°«à“ 0.9% normal saline ·≈–§«√‡≈’ˬ߄πºŸâªÉ«¬∑’Ë„™â high dialysate solution sodium ‰¡à®”‡ªìπ μâÕß„ÀâÕÕ°´‘‡®πºâŸªÉ«¬∑ÿ°√“¬ æ‘®“√≥“„À⇩擖„π∫“ß√“¬‡™àπ ¡’¿“«–À—«„®¢“¥‡≈◊Õ¥  —߇°μÕ“°“√ ·≈– —≠≠“≥™’æ (vital sign) ºâŸªÉ«¬Õ¬à“ß„°≈♑¥ ‡¡◊ËÕ§«“¡¥—π‚≈À‘μ‡æ‘Ë¡„π‡°≥±åª°μ‘ “¡“√∂∑”°“√ ¥÷ßπÈ”μàÕ‰¥â„πÕ—μ√“∑’Ë™â“≈ß ·π«∑“ß°“√ªÕÑ ß°π— ¿“«–§«“¡¥π— ‚≈À‘μμ”Ë „π√–À«à“ß°“√øÕ°‡≈◊Õ¥ 1. À≈’°‡≈’ˬ߰“√‡æ‘Ë¡πÈ”Àπ—°μ—«¡“°°àÕπ°“√øÕ°‡≈◊Õ¥ (large interdialytic weight gain) ‡æ◊ËÕ ‡≈’ˬ߰“√¥÷ßπÈ”ÕÕ°Õ¬à“ß¡“°·≈–√«¥‡√Á« ºâŸªÉ«¬§«√‰¥â√—∫§”·π–π”®”°—¥Õ“À“√√ ‡§Á¡ πÈ”Àπ—°μ—«°àÕπ °“√øÕ°‡≈Õ◊ ¥‰¡§à «√‡æ¡‘Ë ‡°π‘ 1 °‚‘ ≈°√¡— /«π— °“√®”°¥— ‡°≈Õ◊ ®–™«à ¬§«∫§¡ÿ πÈ”Àπ°— μ«— ‰¥¡â “°°«“à °“√®”°¥— πÈ”4 „πºªâŸ «É ¬∑¡Ë’ π’ ”È Àπ°— μ«— ‡æ¡Ë‘ ¡“°°Õà π°“√øÕ°‡≈Õ◊ ¥ §«√‡æ¡Ë‘ √–¬–‡«≈“„π°“√øÕ°‡≈Õ◊ ¥„Àπâ “π¢πÈ÷ ®– ≈¥§«“¡‡ ’ˬßμàÕ¿“«–§«“¡¥—π‚≈À‘μμË” ‡æ√“–Õ—μ√“°“√¥÷ßπÈ”≈¥≈ß·μàª√‘¡“≥πÈ”∑’Ë¥÷ßÕÕ°‡∑à“‡¥‘¡ ®“°°“√‡æ‘Ë¡√–¬–‡«≈“„π°“√¥÷ßπÈ”ÕÕ° πÕ°®“°π’È √–¬–‡«≈“„π°“√øÕ°‡≈◊Õ¥‰¡à§«√μË”°«à“ 3 ™—Ë«‚¡ß „πºŸâªÉ«¬∑’ˉ¥â√—∫°“√øÕ°‡≈◊Õ¥Õ¬à“ßπâÕ¬ 3 §√—Èß/ —ª¥“Àå ·≈– ‰¡à¡’ªí  “«–À√◊Õ¡’ªí  “«–ÕÕ°πâÕ¬ ·¡â«à“®–«—¥ Kt/V ‰¥âÕ¬àŸ„π‡°≥±å∑’Ë°”Àπ¥ 2. §«√„™âμ—«§«∫§ÿ¡Õ—μ√“°“√¥÷ßπÈ”„π‡§√◊ËÕ߉μ‡∑’¬¡ (ultrafiltration controller) ‡æ◊ËÕ§«∫§ÿ¡ „ÀÕâ μ— √“°“√¥ß÷ πÈ” ¡Ë”‡ ¡Õ „π°√≥∑’ „’Ë ™â ultrafiltration controller ‰¡‰à ¥â §«√‡≈Õ◊ °μ«— °√Õß∑’Ë low permeability μàÕπÈ”μË” ‡æ◊ËÕ§«∫§ÿ¡º≈¢Õß transmembrane pressure ∑’ˇª≈’ˬπ·ª≈ß„π√–À«à“ß°“√øÕ°‡≈◊Õ¥μàÕ°“√ ¥÷ßπÈ” 3. ª√—∫πÈ”Àπ—°μ—« (dry weight) Õ¬à“߇À¡“– ¡ „π∑“ߧ≈‘π‘°Õ“»—¬°“√μ√«®√à“ß°“¬§◊Õ √–¥—∫§«“¡¥—π‚≈À‘μ, Õ“°“√∫«¡, °“√∑πμàÕ°“√¥÷ßπÈ”„π√–À«à“ß°“√øÕ°‡≈◊Õ¥ ´÷Ëß„π°√≥’ºâŸªÉ«¬¡’πÈ” Àπ—°μ—«∑’ˇÀ¡“– ¡ ·≈â«¥÷ßπÈ”¡“°‡°‘π‰ª ºâŸªÉ«¬®–¡’§«“¡¥—π‚≈À‘μμË”„π√–À«à“ß°“√øÕ°‡≈◊Õ¥ À√◊Õ À≈—߇ √Á® ‘Èπ°“√øÕ°‡≈◊Õ¥ √«¡∑—ÈßÕ“®¡’Õ“°“√ÕàÕπ‡æ≈’¬, ¡÷π»’√…–, ßÿπßß, ‡ªìπμ–§√‘«‰¥â §«√¡’°“√ ª√–‡¡‘π‡æ◊ËÕª√—∫πÈ”Àπ—°μ—«ºŸâªÉ«¬‡ªìπ√–¬– πÕ°®“°°“√ª√—∫πÈ”Àπ—°μ—« ‚¥¬Õ“»—¬°“√ —߇°μÕ“°“√ ∑“ߧ≈‘π‘° ·≈â«Õ“®ª√–‡¡‘π‚¥¬«‘∏’Õ◊ËπÊ ´÷ËߧàÕπ¢â“߬ÿà߬“°§◊Õ °“√«—¥ bioimpedance, °“√«—¥‡ âπºà“ »Ÿπ¬å°≈“ߢÕß inferior vena cava ¥â«¬Õ—≈μ√“´“«¥å, °“√«—¥√–¥—∫ atrial natriuretic factor, °“√«—¥√–¥—∫ hematocrit „π√–À«à“ß°“√øÕ°‡≈◊Õ¥ ‡ªìπμâπ 243

Practical Dialysis in the Year 2009 4. „™â dialysate sodium ∑’ˇÀ¡“– ¡ ∂â“ dialysate sodium μË”°«à“√–¥—∫ sodium „π‡≈◊Õ¥ ‡≈◊Õ¥∑’ËÕÕ°®“°μ—«°√Õ߇¢â“ ŸàÀ≈Õ¥‡≈◊Õ¥®–∑”„Àâ‡≈◊Õ¥„πÀ≈Õ¥‡≈◊Õ¥π—Èπ¡’§«“¡‡¢â¡¢âππâÕ¬°«à“πÈ”∑’ËÕ¬àŸ „π‡πÕÈ◊ ‡¬ÕË◊ √Õ∫Ê (tissue space) √“à ß°“¬®–¡°’ “√ª√∫—  ¡¥≈ÿ §«“¡‡¢¡â ¢πâ ‚¥¬π”È „πÀ≈Õ¥‡≈Õ◊ ¥®–´¡÷ (shift) ºà“π‡¢â“„π‡π◊ÈÕ‡¬◊ËÕ√Õ∫Ê ∑”„Àâª√‘¡“≥πÈ”„πÀ≈Õ¥‡≈◊Õ¥≈¥≈ß ´÷Ëߪ√“°Æ°“√≥åπ’È¡—°®–‡°‘¥„π√–¬–·√° ¢Õß°“√øÕ°‡≈◊Õ¥ ‡π◊ËÕß®“°√–¥—∫ sodium „π‡≈◊Õ¥≈¥≈ßÕ¬à“ß√«¥‡√Á« °“√μ—Èß§à“ dialysate sodium  Ÿß ®–≈¥°“√´÷¡¢ÕßπÈ”‰ª¬—߇π◊ÈÕ‡¬◊ËÕ‰¥â ·μàÕ“®®–∑”„ÀâπÈ”Àπ—°μ—«°àÕπ°“√øÕ°‡≈◊Õ¥§√—ÈßμàÕ‰ª Ÿß¢÷Èπ, √–¥—∫§«“¡¥—π‚≈À‘μÀ≈—ß°“√øÕ°‡≈◊Õ¥ Ÿß¢÷Èπ, °√–À“¬πÈ”À≈—ß°“√øÕ°‡≈◊Õ¥ Õ“®„™â sodium modeling À√◊Õ sodium gradient dialysis ‚¥¬μ—Èß dialysate solution sodium „Àâ ßŸ (145-155 mM) „π√–¬–·√°¢Õß °“√øÕ°‡≈Õ◊ ¥ ·≈«â §Õà ¬Ê ≈¥≈ß (progressive fall ·∫∫ linear, step À√Õ◊ logarithmic) ®πÕ¬„àŸ π√–¥∫— ª√–¡“≥ 135-140 mM ‡¡◊ËÕ ‘Èπ ÿ¥°“√øÕ°‡≈◊Õ¥ ºŸâªÉ«¬·μà≈–√“¬μâÕß°“√°“√ª√—∫ dialysate solution sodium ∑’Ë ‡À¡“– ¡¢Õßμ—«‡Õß ‰¡à¡’§à“·πàπÕπ§à“„¥§à“Àπ÷Ëß∑’Ë„™â‰¥â°—∫ºŸâªÉ«¬∑ÿ°√“¬ (individualize dialysate sodium) 5. ≈¥Õÿ≥À¿¡Ÿ ‘„π dialysate solution ‡æ◊ËÕ‡æ‘Ë¡°“√À¥μ—«¢ÕßÀ≈Õ¥‡≈◊Õ¥ ‚¥¬„π√–¬–·√°μ—Èß Õ¬àŸ∑’Ë√–¥—∫ 35.5-36.0°C ·≈⫪√—∫Õÿ≥À¿¡Ÿ ‘¢÷ÈπÀ√◊Õ≈ß„π√–À«à“ß°“√øÕ°‡≈◊Õ¥„Àâ‡À¡“– ¡ ‚¥¬æ‘®“√≥“ ®“°Õ“°“√Àπ“«À√◊Õ —Ëπ (chill) √–¥—∫§«“¡¥—π‚≈À‘μ ‡π◊ËÕß®“°„π√–À«à“ß°“√øÕ°‡≈◊Õ¥Õÿ≥À¿Ÿ¡‘¢Õß √à“ß°“¬®– Ÿß¢÷Èπ®“°°“√¥÷ßπÈ”ÕÕ°∑”„ÀâÀ≈Õ¥‡≈◊Õ¥À¥μ—« √à“ß°“¬√–∫“¬§«“¡√âÕπ≈¥≈ß °“√μ—Èßμâπ øÕ°‡≈◊Õ¥¥â«¬Õÿ≥À¿Ÿ¡‘ 37°C ®–∑”„ÀâÕÿ≥À¿Ÿ¡‘√à“ß°“¬ Ÿß·≈–®–¡’°“√¢¬“¬μ—«¢ÕßÀ≈Õ¥‡≈◊Õ¥∑”„Àâ¡’ §«“¡¥—π‚≈À‘μμË”μ“¡¡“ 6. „ÀâºâŸªÉ«¬∑’Ë¡’§«“¡‡ ’ˬßμàÕ¿“«–§«“¡¥—π‚≈À‘μμË” À≈’°‡≈’ˬ߰“√√—∫ª√–∑“πÕ“À“√„π √–À«à“ß°“√øÕ°‡≈◊Õ¥ ‡æ√“–À≈Õ¥‡≈◊Õ¥ splanchnic ¡’°“√¢¬“¬μ—« ‚¥¬®–¡’‡°‘¥‰¥â„π 30 π“∑’ ·≈–º≈ π’È®–Õ¬Ÿà‰¥âª√–¡“≥ 2 ™—Ë«‚¡ß 7. À≈’°‡≈’ˬ߿“«–‡π◊ÈÕ‡¬◊ËÕ¢“¥‡≈◊Õ¥„π√–À«à“ß°“√øÕ°‡≈◊Õ¥‚¥¬°“√‡≈’ˬ߿“«–§«“¡¥—π ‚≈À‘μμË” ‡æ√“–„π¢≥–∑’˧«“¡¥—π‚≈À‘μμË” ‡π◊ÈÕ‡¬◊ËÕ¢“¥‡≈◊Õ¥®–ª≈àÕ¬ adenosine ´÷Ëß adenosine ®– ¬—∫¬—Èß°“√À≈—Ëß norepinephrine ®“°√–∫∫ª√– “∑ sympathetic ∑”„ÀâÀ≈Õ¥‡≈◊Õ¥À¥μ—«≈¥≈ß ·≈– adenosine ‡Õß®–¡’§ÿ≥ ¡∫—μ‘„π°“√¢¬“¬À≈Õ¥‡≈◊Õ¥ ∑”„À⧫“¡¥—π‚≈À‘μ∑’ËμË”Õ¬àŸ·≈â«√ÿπ·√ß¡“°¢÷Èπ πÕ°®“°π’ȧ«√‡≈’ˬ߿“«–´’¥ (anemia) ‡æ√“–¿“«–´’¥∑”„Àâ¡’§«“¡¥—π‚≈À‘μμË”„π√–À«à“ß°“√øÕ°‡≈◊Õ¥ ‰¥â ºŸâªÉ«¬§«√„Àâ¡’√–¥—∫ hematocrit ª√–¡“≥ 11-12 g/dL5 8. °“√ª√—∫√–¥—∫ calcium „π dialysate ª√–¡“≥ 1.75 mM ®–≈¥°“√‡°‘¥§«“¡¥—π‚≈À‘μμË” √–À«à“ß°“√øÕ°‡≈◊Õ¥‰¥â¥’°«à“√–¥—∫ calcium „π dialysate 1.25 mM ‚¥¬‡©æ“–„πºŸâªÉ«¬∑’Ë¡’ªí≠À“°“√ ∫∫’ μ«— ¢ÕßÀ«— „®‰¡¥à ’‡πÕ◊Ë ß®“°®–∑”„ÀÀâ «— „®¡°’ “√∫∫’ μ«— ¥¢’ π÷È ·μÕà “®‡æ¡‘Ë §«“¡‡ ¬’Ë ßμÕà °“√‡°¥‘ calcification ∑’ËÀ≈Õ¥‡≈◊Õ¥ ‡π◊ËÕß®“°¡’¥ÿ≈ calcium ‡ªìπ∫«° ‚¥¬‡©æ“–ºâŸªÉ«¬∑’Ë„™â¬“ calcium-containing phosphate binder 9. °“√„Àâ selective α-adrenergic agonist ‡æ◊ËÕ‡æ‘Ë¡°“√À¥μ—«¢ÕßÀ≈Õ¥‡≈◊Õ¥ ‡™àπ midodrine ∑“π 10 mg °àÕπ°“√øÕ°‡≈◊Õ¥ 1/2-2 ™—Ë«‚¡ß Õ“®®–¡’°“√‡æ‘Ë¡¢π“¥‰¥â®π∂÷ß 40 mg º≈¢â“߇§’¬ß§◊Õ§«“¡ ¥—π‚≈À‘μ Ÿß„π∑à“πÕπ (supine hypertension), ª«¥»’√…–, §—πμ“¡º‘«Àπ—ß, °≈—Èπªí  “«–‰¡àÕ¬Ÿà ‰¡à§«√„™â midodrine „πºâŸªÉ«¬∑’Ë¡’Õ“°“√°≈â“¡‡π◊ÈÕÀ—«„®¢“¥‡≈◊Õ¥‡æ√“–∑”„ÀâÕ“°“√‚√§À—«„®√ÿπ·√ߢ÷Èπ À√◊Õ„πºâŸ 244

Prevention, Diagnosis and Treatment of Acute Complications during Hemodialysis ªÉ«¬∑’Ë„™â¬“ alpha-adrenergic blocker ‡æ√“–ª√– ‘∑∏‘¿“欓 midodrine ≈¥≈ß 10. æ‘®“√≥“„À⬓ sertraline 50-100 mg/«—𠇪ìπ√–¬–‡«≈“ 6  —ª¥“Àå sertraline ®–¡’º≈ ‡æ‘Ë¡√–¥—∫ serotonin ‚¥¬¬—∫¬—Èß serotonin uptake ∑’Ë postsynaptic receptor √–¥—∫ serotonin ∑’ˇæ‘Ë¡¢÷Èπ ∑”„Àâ√à“ß°“¬μÕ∫ πÕßμàÕ catecholamine ‰¥â¥’¢÷Èπ ·≈–Õ“®™à«¬≈¥¿“«–§«“¡¥—π‚≈À‘μμË”„πºŸâªÉ«¬∑’Ë¡’ autonomic neuropathy ¥â«¬6,7  à«π°“√ªÑÕß°—πÕ◊ËπÊ ∑’Ë®–≈¥§«“¡‡ ’ˬßμàÕ¿“«–§«“¡¥—π‚≈À‘μμË” §◊Õ §«√„À⬓≈¥§«“¡¥—π ‚≈À‘μ∑’Ë„™â«—π≈–§√—ÈßÀ≈—ß°“√øÕ°‡≈◊Õ¥, „™â bicarbonate dialysate solution, ‡≈◊Õ°„™â biocompatible dialyzer membrane ‡æ◊ËÕ≈¥ complement activation ∑’Ë∑”„Àâ¡’‡¡Á¥‡≈◊Õ¥¢“«Õÿ¥μ—π„π‡ âπ‡≈◊Õ¥ªÕ¥ (intrapulmonary leukoaggregation) ´÷Ëß∑”„À⇰‘¥°“√¢“¥ÕÕ°´‘‡®π·≈â«°√–μÿâπ cytokine ∑”„ÀâÀ≈Õ¥‡≈◊Õ¥¢¬“¬μ—«, √–¡—¥√–«—߇∑§π‘§°“√øÕ°‡≈◊Õ¥Õ¬à“„À⇰‘¥ air embolism, septicemia ∂â“¡’ occult hemorrhage §«√À“  “‡Àμÿ·≈–„Àâ°“√√—°…“ 2.2 ¿“«–§«“¡¥—π‚≈Àμ‘  ßŸ „π√–À«à“ß°“√øÕ°‡≈Õ◊ ¥ (Intradialytic hypertension) §«“¡¥—π‚≈À‘μ∑’Ë Ÿß„π√–À«à“ß°“√øÕ°‡≈◊Õ¥À√◊ÕÀ≈—ß ‘Èπ ÿ¥°“√øÕ°‡≈◊Õ¥‡ªìπªí®®—¬‡ ’ˬßμàÕ °“√‡ ¬’ ™«’ μ‘ ®“°√–∫∫À«— „®·≈–À≈Õ¥‡≈Õ◊ ¥ (cardiovascular mortality) ´ßË÷ 欓∏°‘ ”‡π¥‘ ‡°¬Ë’ «¢Õâ ß°∫— volume ºâŸªÉ«¬∫“ß√“¬¡’§«“¡¥—π‚≈À‘μ ŸßÀ≈—ß®“°¡’°“√¥÷ßπÈ”ÕÕ°‡√’¬° dialysis-refractory hypertension ¡—°®– æ∫„πºâŸªÉ«¬Õ“¬ÿπâÕ¬ ¡’ª√–«—μ‘°“√‡ªì𧫓¡¥—π‚≈À‘μ Ÿß¡“°àÕπ ¡’πÈ”Àπ—°μ—«°àÕπ°“√øÕ°‡≈◊Õ¥ Ÿß °“√μÕ∫ πÕߢÕß√–∫∫ renin-angiotensin μàÕ°“√¥÷ßπÈ”ÕÕ° ßŸ (hyperactive renin-angiotensin system response to fluid removal)8  “‡ÀμÿÕ◊Ëπ∑’Ë∑”„À⧫“¡¥—π‚≈À‘μ Ÿß‰¥â§◊Õ °“√„™â dialysate sodium  Ÿß9, °“√ ∑’ˬ“≈¥§«“¡¥—π‚≈À‘μ∂Ÿ°¢®—¥ÕÕ°„π√–À«à“ß°“√øÕ°‡≈◊Õ¥, °“√„À⬓ erythropoietin ∑“߇ âπ‡≈◊Õ¥ (intravenous route) ‡π◊ËÕß®“°®–¡’√–¥—∫ endothelin-1 ‡æ‘Ë¡¢÷Èπ ∑”„Àâ¡’°“√À¥μ—«¢ÕßÀ≈Õ¥‡≈◊Õ¥¡“°¢÷È𠧫“¡¥—π‚≈À‘μ„π√–À«à“ß°“√øÕ°‡≈◊Õ¥®– ßŸ ¢÷Èπ ·π«∑“ß°“√ªÑÕß°—π§◊Õ ª√–‡¡‘π dry weight ºŸâªÉ«¬Õ¬à“ß∂Ÿ°μâÕß, Õ“®®–≈Õß≈¥ dry weight ºâŸªÉ«¬§√—Èß≈– 0.5 °‘‚≈°√—¡ ·≈â« —߇°μÕ“°“√∑“ߧ≈‘π‘°, „™â sodium modeling ∑’ˇÀ¡“– ¡, ª√—∫¬“≈¥ §«“¡¥—π‚≈À‘μ„Àâ‡À¡“– ¡ 2.3 ¿“«–À—«„®‡μâπº‘¥®ß— À«–„π√–À«à“ß°“√øÕ°‡≈Õ◊ ¥ (Intradialytic cardiac arrhythmias) ¿“«–À«— „®‡μπâ º¥‘ ®ß— À«–„π√–À«“à ß°“√øÕ°‡≈Õ◊ ¥¡°— ®–‡°¬’Ë «¢Õâ ß°∫— ¡§’ «“¡º¥‘ ª°μ„‘ π√–∫∫ À—«„®·≈–À≈Õ¥‡≈◊Õ¥¡“°àÕπ10,11 ‡™àπ left ventricular hypertrophy, congestive cardiomyopathy, uremic pericarditis, silent myocardial ischemia, calcification „π conducting system ªí®®—¬‡ √‘¡Õ◊Ëπ∑’Ë∑”„Àâ‡æ‘Ë¡ §«“¡‡ ¬’Ë ßμÕà °“√‡°¥‘ ¿“«–À«— „®‡μπâ º¥‘ ®ß— À«–§Õ◊ ¬“∫“ßÕ¬“à ß,°“√‡ª≈¬’Ë π·ª≈ß„πª√¡‘ “≥πÈ”À≈ß— °“√¥ß÷ πÈ”, ¿“«–º‘¥ª°μ‘¢Õ߇°≈◊Õ·√à ‡™àπ hypocalcemia, hypomagnesemia, hypokalemia „πºâŸªÉ«¬∑’ˉ¥â√—∫¬“ digoxin ∂â“¡’ hypokalemia ®–‡æ‘Ë¡§«“¡‡ ’ˬßμàÕ°“√‡°‘¥À—«„®‡μâπº‘¥®—ßÀ«– „πºâŸªÉ«¬∑’Ë¡’ªí≠À“‚√§ °≈â“¡‡π◊ÈÕÀ—«„®¢“¥‡≈◊Õ¥∂â“¡’ª√‘¡“≥πÈ”„π√à“ß°“¬‡°‘π¡“° ®–‡æ‘Ë¡§«“¡μâÕß°“√„™âÕÕ°´‘‡®π∑”„Àâ ‡ ’ˬßμàÕ°“√‡°‘¥À—«„®‡μâπº‘¥®—ßÀ«–‰¥â 245

Practical Dialysis in the Year 2009 ·π«∑“ß°“√ªÕÑ ß°π— ¿“«–À«— „®‡μπâ º¥‘ ®ß— À«–§Õ◊ „™â bicarbonate dialysate solution, À≈°’ ‡≈¬Ë’ ß °“√„™â zero potassium dialysate „πºâŸªÉ«¬∑’ˇ ’ˬßμàÕ¿“«–À—«„®‡μâπº‘¥®—ßÀ«– „πºâŸªÉ«¬∑’Ë„™â¬“ digoxin §«√¡’°“√«—¥√–¥—∫¬“ digoxin ‡ªìπ√–¬–·≈–μ‘¥μ“¡√–¥—∫ potassium „À≡àμË”°«à“ 3.5 mmol/L, √–¥—∫ hematocrit §«√¡’§à“ 11-12 g/dL, √—°…“¿“«– congestive heart failure ·≈–§«“¡¥—π‚≈À‘μ Ÿß 2.4 ¿“«–‡ ¬’ ™’«‘μ©—∫æ≈—π (Sudden death) ºâŸªÉ«¬∑’ˇ ’¬™’«‘μ©—∫æ≈—π„π√–À«à“ß°“√øÕ°‡≈◊Õ¥ 80%‡°‘¥®“° ventricular fibrillation ´÷Ëß¡—°‡°‘¥„πºŸâªÉ«¬∑’ˇ«âπ√–¬–‡«≈“°“√øÕ°‡≈◊Õ¥π“π12,13 ºâŸªÉ«¬∑’Ë¡’¿“«–°≈â“¡‡π◊ÈÕÀ—«„®¢“¥‡≈◊Õ¥, ºâŸªÉ«¬∑’Ë¡’¿“«– life-threatening hyperkalemia ´÷Ëߺ⟪ɫ¬Õ“®®–¡’Õ“°“√π”§◊Õ °≈â“¡‡π◊ÈÕÕàÕπ·√ß ∑—Ë«∑—Èßμ—« (generalized muscle weakness) ºŸâªÉ«¬∑’ËÀ—«„®À¬ÿ¥‡μâπ°–∑—πÀ—π„π√–À«à“ß°“√øÕ°‡≈◊Õ¥ (cardiopulmonary arrest) §«√√’∫∑”°“√°âŸ™’«‘μ ·≈–ª√–‡¡‘π«à“‡°‘¥®“°‚√§‡¥‘¡¢ÕߺŸâªÉ«¬‡ÕßÀ√◊Õ‡°‘¥ ®“°¡’§«“¡º‘¥æ≈“¥„π‡∑§π‘§°“√øÕ°‡≈◊Õ¥ ‡™àπ air embolism, unsafe dialysate composition, overheated dialysate, line disconnection ´÷Ëß®–‡ÀÁπ air „π dialysate À√◊Õ hemolyzed blood ∂Ⓣ¡à·πà„® «à“ “‡Àμÿ‡°‘¥®“°Õ–‰√ ‰¡à§«√§◊π‡≈◊Õ¥°≈—∫μ—«ºŸâªÉ«¬ ‚¥¬‡©æ“–À—«„®À¬ÿ¥‡μâπ∑—π∑’À≈—ß®“°‡√‘Ë¡ °“√øÕ°‡≈◊Õ¥ ºâŸªÉ«¬∑’Ë¡’ line disconnection ·≈â« —¡º— °—∫ formaldehyde ®–¡’Õ“°“√π”§◊Õ · ∫√âÕπ (burning) ∫√‘‡«≥ access site „π°√≥’∑’Ë·πà„®«à“ “‡Àμÿ‰¡à‰¥â‡°‘¥®“°§«“¡º‘¥æ≈“¥∑“߇∑§π‘§§«√§◊π ‡≈◊Õ¥°≈—∫μ—«ºŸâªÉ«¬ Õ¬à“߉√°Áμ“¡§«√ à߇≈◊Õ¥·≈– dialysate «—¥√–¥—∫ electrolyte, ‡°Á∫μ—«°√Õß·≈– blood line ‰«âμ√«®À“ “‡ÀμÿÕ’°§√—Èß, ‰¡à§«√„™â‡§√◊ËÕ߉μ‡∑’¬¡‡¥‘¡®π°«à“®–‰¥âμ√«® Õ∫∑—Èß√–∫∫«à“‰¡à¡’ ¢âÕº‘¥æ≈“¥ 2.5 Dialysis-associated steal syndrome14,15 ºŸâªÉ«¬∑’Ë∑” arteriovenous fistula (AVF) À√◊Õ graft (AVG) ®–¡’°“√≈¥≈ߢÕ߇≈◊Õ¥‰ª∑’Ë¡◊Õ¥â“π π—Èπ‰¥â ºâŸªÉ«¬∑’ˇ ’ˬßμàÕ¿“«–°“√¢“¥‡≈◊Õ¥∑’Ë¡◊Õ§◊Õ ºŸâªÉ«¬‡∫“À«“π, ºŸâªÉ«¬Õ“¬ÿ¡“°∑’Ë¡’ªí≠À“À≈Õ¥ ‡≈◊Õ¥ à«πª≈“¬ (peripheral vascular disease) ¿“«– dialysis-associated steal syndrome æ∫‰¥â 6.4% „πºâŸªÉ«¬∑’Ë∑” radiocephalic fistulas ·≈– 1% „πºâŸªÉ«¬∑’Ë∑” radiocephalic grafts °“√øÕ°‡≈◊Õ¥®–°√–μÿâπ (aggravate) „À⇰‘¥ºŸâªÉ«¬¡’Õ“°“√¢“¥‡≈◊Õ¥¡“°¢÷Èπ‰¥â ´÷ËßÕ“°“√∑’Ëæ∫‰¥â§◊Õ ¡◊Õ™“ ª«¥À√◊ÕÕàÕπ·√ß (hand numbness, pain or weakness), ª≈“¬¡◊Õ‡¬Áπ (coolness of distal arm), ™’æ®√‡∫“≈ß (diminished pulse), ¡◊Õ¡’ ’§≈È” (acrocyanosis, gangrene) μâÕß·¬°®“°Õ“°“√®“°°“√‡ªìπμ–§√‘«„π√–À«à“ß°“√øÕ°‡≈◊Õ¥ §«√ª√–‡¡π‘ §«“¡√πÿ ·√ߢÕß°“√‡°¥‘ steal ‚¥¬ pulse oximetry, plethysmography, doppler flow, angiography °“√√—°…“¢÷ÈπÕ¬Ÿà°—∫§«“¡√ÿπ·√ß „π°√≥’∑’Ë¡’Õ“°“√¢“¥‡≈◊Õ¥‰¡à¡“° (mild ischemia) ¡—°¡’Õ“°“√¡◊Õ‡¬Áπ À√◊Õ™“ ·μà‰¡à‡ ’¬§«“¡√Ÿâ ÷° (no loss of sensation) À√◊ÕÕàÕπ·√ß „Àâ√—°…“μ“¡Õ“°“√ ‚¥¬„ à∂ÿß¡◊Õ ´÷Ëß  à«π„À≠àÕ“°“√¢“¥‡≈◊Õ¥¡—°®–¥’¢÷Èπμ“¡√–¬–‡«≈“ §«√ª√–‡¡‘πÕ“°“√¢“¥‡≈◊Õ¥∫àÕ¬Ê ∂â“¡’°≈â“¡‡π◊ÈÕ ÕàÕπ·√ߧ«√∑”°“√ºà“μ—¥·°â‰¢ 246

Prevention, Diagnosis and Treatment of Acute Complications during Hemodialysis 3. ¿“«–·∑√°´âÕπ∑“ß√–∫∫ª√– “∑ (Neuromuscular complications) 3.1 μ–§√‘« (Muscle cramps) ¡°— ‡°¥‘ „π√–¬–∑“â ¬¢Õß°“√øÕ°‡≈Õ◊ ¥ ‚¥¬¡°— ‡ªπì ∑¢Ë’ “ ·≈–‡ªπì ª®í ®¬—  ”§≠— ∑∑Ë’ ”„Àºâ ªŸâ «É ¬ πÈ‘  ÿ¥°“√øÕ°‡≈◊Õ¥°àÕπ‡«≈“∑’Ë°”À𥉥â∂÷ß 15% (premature discontinuation of dialysis À√◊Õ sign-off)16 欓∏‘°”‡π‘¥‰¡à∑√“∫ ¡’ªí®®—¬‡ ’Ë¬ß 4 ª√–°“√ ∑’Ë°√–μÿâπ„À⇰‘¥μ–§√‘«‰¥â §◊Õ hypotension, hypovolemia (low dry weight), high ultrafiltration rate (‡™àπ „π°√≥’ large weight gain), „™â low sodium dialysate solution ªí®®—¬‡ ’ˬ߇À≈à“π’È∑”„ÀâÀ≈Õ¥‡≈◊Õ¥À¥μ—« °≈â“¡‡π◊ÈÕ¢“¥‡≈◊Õ¥∑”„Àâ¡’°“√§≈“¬μ—«‰¥â‰¡à¥’ (impairment of muscle relaxation) πÕ°®“°π’È°“√¢“¥ carnitine (carnitine deficiency), ¿“«–‡°≈◊Õ·√àμË” ∫“ß™π‘¥°Á∑”„À⇰‘¥μ–§√‘«‰¥â §◊Õ hypomagnesemia, hypokalemia, hypocalcemia °“√√°— …“ ∂“â ºªâŸ «É ¬‡°¥‘ μ–§√«‘ ®“°¡§’ «“¡¥π— ‚≈Àμ‘ μ”Ë §«√‡æ¡Ë‘ √–¥∫— §«“¡¥π— ‚≈Àμ‘ ¥«â ¬°“√ „Àâ normal saline °“√„™â hypertonic solution ®–‡æ‘Ë¡ plasma osmolality ∑”„ÀâÕ“°“√μ–§√‘«¥’¢÷Èπ‡√Á« ‡™àπ hypertonic saline 15-20 ml, 25% mannitol 50-100 ml À√◊Õ 50% glucose 25-50 ml °“√„™â hypertonic saline ®–∑”„Àâ°√–À“¬πÈ”À≈—ßøÕ°‡≈◊Õ¥ mannitol ·≈– hypertonic saline ®–∑”„À⇰‘¥√âÕπ«Ÿ∫«“∫ √–À«“à ß°“√„Àâ (warmth/flushing), ∑”„Àπâ È”Àπ°— μ«— °Õà π°“√øÕ°‡≈Õ◊ ¥§√ß—È μÕà ‰ª ßŸ ®ß÷ 𬑠¡„™â 50% glucose ¡“°°«à“„πºŸâªÉ«¬∑’ˉ¡à‰¥â‡ªìπ‡∫“À«“π17 Õ“®„Àâ nifedipine 10 mg „πºŸâªÉ«¬μ–§√‘«∑’˧«“¡¥—π‚≈À‘μª°μ‘ √«¡∑—Èß∑”°“√¬◊¥°≈â“¡‡π◊ÈÕÀ√◊Õπ«¥°≈â“¡‡π◊ÈÕ„πμ”·Àπàß∑’ˇªìπμ–§√‘« °“√ªÕÑ ß°π— °“√‡°¥‘ μ–§√‘«„π√–À«à“ß°“√øÕ°‡≈Õ◊ ¥ 1. ºªŸâ «É ¬§«√§«∫§¡ÿ πÈ”Àπ°— μ«— °Õà π°“√øÕ°‡≈Õ◊ ¥„πºªâŸ «É ¬∑‡’Ë ªπì μ–§√«‘ ·≈–‰¡¡à ¿’ “«–πÈ”‡°π‘ Õ“®®–≈Õ߇æ‘Ë¡ dry weight §√—Èß≈– 0.5 °‘‚≈°√—¡·≈â« —߇°μÕ“°“√ 2. ‡æ‘Ë¡√–¥—∫ dialysate solution sodium 145-155 mM „π√–¬–·√°¢Õß°“√øÕ°‡≈◊Õ¥ ·≈â« §àÕ¬Ê≈¥√–¥—∫ sodium ≈߇À≈◊Õ 135-140 mM ‡¡◊ËÕ ‘Èπ ÿ¥°“√øÕ°‡≈◊Õ¥ 3. À≈’°‡≈’ˬ߿“«– hypokalemia, hypocalcemia, hypomagnesemia °àÕπ°“√øÕ°‡≈◊Õ¥ 4. °“√„À⬓∫“ßÕ¬à“ß ‡™àπ quinine sulfate 250-325 mg, oxazepam 5-10 mg 2 ™—Ë«‚¡ß°àÕπ °“√øÕ°‡≈◊Õ¥, „Àâ carnitine 20 mg/kg/dialysis session ®–≈¥°“√‡°‘¥μ–§√‘«‰¥â ∂⓺ŸâªÉ«¬∑’ˉ¥â quinine sulfate ¡’Õ“°“√ÀÕŸ ◊ÈÕ (tinnitus) ®–‡°‘¥√–¥—∫¬“ ßŸ ‡°‘π‰ªμâÕß≈¥¢π“¥¬“≈ß ·≈– quinine sulfate ∑”„Àâ ‡°√Á¥‡≈◊Õ¥μË”‰¥â (thrombocytopenia) 5. ·π–π”∑” stretching exercise „πμ”·Àπàß°≈â“¡‡π◊ÈÕ∑’ˇ°‘¥μ–§√‘« 3.2 Restless legs syndrome ºªâŸ «É ¬®–¡Õ’ “°“√¢“°√–μ°ÿ ‚¥¬§«∫§¡ÿ ‰¡‰à ¥¢â ≥–Õ¬„àŸ π¿“«–æ°— ∫“ß√“¬Õ“®®–¡Õ’ “°“√ª«¥ √«à ¡¥«â ¬ 欓∏°‘ ”‡π¥‘ Õ“®‡°¬’Ë «¢Õâ ß°∫— ¿“«–´¥’ ®“°°“√¢“¥‡À≈°Á , §«“¡º¥‘ ª°μ¢‘ ÕßÀ≈Õ¥‡≈Õ◊ ¥ (vascular insufficiency), ‚√§ªÕ¥ (chronic lung disease), caffeine abuse 247

Practical Dialysis in the Year 2009 °“√√—°…“ „À⬓ short acting benzodiazepine, carbamazepine, levodopa ·μà°“√„™â carbamazepine ·≈– levodopa ®–¡’°“√¥◊ÈÕ¬“‡°‘¥‡√Á« §«√„À⬓ ≈—∫°—π∑ÿ° 1-2  —ª¥“Àå ·≈–§«√„Àâ°àÕπ ‡√‘Ë¡°“√øÕ°‡≈◊Õ¥‡æ◊ËÕ„Àâ¡’°“√¥¥Ÿ ´÷¡¢Õ߬“ 3.3 Dialysis disequilibrium syndrome 欓∏°‘ ”‡π¥‘ Õ“®®–‡°¥‘ ®“°¡°’ “√¢®¥— ¬‡Ÿ √¬’ ÕÕ°®“°√“à ß°“¬‡√«Á ‡°π‘ ‰ª ∑”„À¬â ‡Ÿ √¬’ „π‡≈Õ◊ ¥∂°Ÿ ¢®—¥ÕÕ°¡“°°«à“¬‡Ÿ √’¬„ππÈ”‰¢ —πÀ≈—ß (cerebrospinal fluid; CSF) ∑”„À⇰‘¥ osmotic disequilibrium ®“° °“√∑’Ë„π‡≈◊Õ¥¡’ hypotonic °«à“‡´≈ ¡Õß ∑”„Àâ¡’°“√‡§≈◊ËÕπ¬â“¬¢ÕßπÈ”®“°‡≈◊Õ¥‡¢â“‡´≈ ¡Õß À√◊Õ‡°‘¥ ®“°°“√·°‰â ¢¿“«–§«“¡‡ªπì °√¥ (acidosis) ‡√«Á ‡°π‘ ‰ª ·μ„à ππÈ”‰¢ π— À≈ß— ¬ß— ¡§’ «“¡‡ªπì °√¥Õ¬àŸ (paradoxical CSF acidosis) À√Õ◊ ‡°¥‘ ®“°¡°’ “√ – ¡¢Õß idiogenic osmole ∫“ßÕ¬“à ß„π‡´≈ ¡Õß ‡™πà inositol, glutamine, glutamate18 ºªŸâ «É ¬∑¡Ë’ §’ «“¡‡ ¬Ë’ ßμÕà °“√‡°¥‘ dialysis disequilibrium syndrome §Õ◊ ºªŸâ «É ¬Õ“¬πÿ Õâ ¬, ¡¿’ “«– severe uremia, pre-existing neurological disorders, ∑”°“√øÕ°‡≈◊Õ¥§√—Èß·√°‚¥¬„™â large surface area/ high flux dialyzer, „™â low dialysate sodium concentration Õ“°“√ diaysis disequilibrium syndrome ‰¥â·°à °√– —∫°√– à“¬ (restlessness), ª«¥»’√…– (headache), §≈◊Ëπ‰ â/Õ“‡®’¬π (nausea/vomiting), μ“¡—« (blurred vision), °≈â“¡‡π◊ÈÕ°√–μÿ° (muscle twitching),  —∫ π (disorientation) ∂â“√ÿπ·√ß¡“°Õ“®™—°À√◊ÕÀ¡¥ μ‘‰¥â ∂â“μ√«® CT scan ®–‡ÀÁπ ¡Õß∫«¡∑—Ë«‰ª (cerebral edema) °“√√—°…“¿“«– dialysis disequilibrium syndrome 1. mild disequilibrium ºâŸªÉ«¬®–¡’Õ“°“√§≈◊Ëπ‰ â/Õ“‡®’¬π, °√– —∫°√– à“¬, ª«¥»’√…– „Àâ°“√√—°…“μ“¡Õ“°“√ §«√≈¥ blood flow rate ‡æ◊ËÕ≈¥Õ—μ√“°“√¢®—¥¢Õ߇ ’¬·≈–Õ—μ√“°“√‡ª≈’ˬπ·ª≈ß pH æ‘®“√≥“À¬ÿ¥°“√øÕ°‡≈◊Õ¥°àÕπ°”À𥇫≈“ æ‘®“√≥“„Àâ hypertonic saline À√◊Õ glucose ‡™àπ‡¥’¬« °—∫°“√√—°…“¿“«–μ–§√‘« 2. severe disequilibrium ºŸâªÉ«¬®–¡’Õ“°“√™—° À¡¥ μ‘ ®–μâÕßÀ¬ÿ¥°“√øÕ°‡≈◊Õ¥  ◊∫À“  “‡ÀμÿÕ◊Ëπ∑’Ë∑”„Àâ™—°À√◊ÕÀ¡¥ μ‘ ¥Ÿ·≈°“√À“¬„®¢ÕߺŸâªÉ«¬ ∂â“Õ“°“√À¡¥ μ‘‡ªìπ®“° disequilibrium syndrome ®–¥’¢÷Èπ‡Õß„π 24 ™—Ë«‚¡ß °“√ªÕÑ ß°—π¿“«– dialysis disequilibrium syndrome 1. „π acute hemodialysis ‰¡à§«√∑”°“√øÕ°‡≈◊Õ¥§√—Èß·√°‡æ◊ËÕ¢®—¥¢Õ߇ ’¬¡“°Ê ‡ªÑ“ À¡“¬°“√≈¥√–¥—∫¬‡Ÿ √’¬„π‡≈◊Õ¥‰¡à§«√‡°‘π 40% À≈’°‡≈’ˬ߰“√„™â low sodium dialysate solution „πºâŸ ªÉ«¬∑’Ë¡’¿“«– hypernatremia √à«¡°—∫¿“«–¬Ÿ√’‡¡’¬ ‰¡à§«√·°â‰¢§«“¡º‘¥ª°μ‘∑—Èß 2 Õ¬à“ß „Àâ°≈—∫ àŸª°μ‘ „π°“√øÕ°‡≈Õ◊ ¥§√ßÈ— ‡¥¬’ « °“√øÕ°‡≈Õ◊ ¥„πºªâŸ «É ¬∑¡Ë’ ’ hypernatremia √«à ¡¥«â ¬ §«√μßÈ— §“à dialysate solution sodium „°≈⇧’¬ß°—∫√–¥—∫ sodium „π‡≈◊Õ¥ ®“°π—Èπ·°â‰¢¿“«– hypernatremia ¥â«¬°“√„Àâ 5% glucose 2. „π chronic hemodialysis §«√„™â volumetric controller, bicarbonate dialysate, „™â sodium modeling ‚¥¬μ—Èß§à“ dialysate solution sodium  ßŸ „π™à«ß·√°¢Õß°“√øÕ°‡≈◊Õ¥ ·≈⫧àÕ¬≈¥≈ß„π√–¬– ∑⓬¢Õß°“√øÕ°‡≈◊Õ¥ ®–™¥‡™¬º≈¢Õß osmolality ∑’ˇª≈’ˬπ·ª≈ß®“°°“√¢®—¥¬Ÿ‡√’¬À√◊Õ “√Õ◊ËπÕÕ°‰¥â 248

Prevention, Diagnosis and Treatment of Acute Complications during Hemodialysis 3.4 ª«¥»’√…– (Headache) Õ“°“√ª«¥»’√…–„π√–À«à“ß°“√øÕ°‡≈◊Õ¥æ∫‰¥â∫àÕ¬ ‚¥¬¡—°ª«¥∫√‘‡«≥Àπ⓺“° (bifrontal) ª«¥Àπ—°Ê À√◊Õª«¥μÿâ∫Ê Õ“®¡’Õ“°“√§≈◊Ëπ‰ â/Õ“‡®’¬π√à«¡¥â«¬ ¡—°‡ªìπ¡“°‡«≈“πÕπ ‰¡à¡’Õ“°“√¡Õß ‡ÀÁπº‘¥ª°μ‘√à«¡¥â«¬  “‡ÀμÿÕ“®‡°‘¥®“° dialysis disequilibrium syndrome, „πºŸâ∑’Ë¥◊Ë¡°“·ø®–‡ªìπ®“° √–¥—∫§“‡øÕ’π„π‡≈◊Õ¥≈¥≈ß„π√–À«à“ß°“√øÕ°‡≈◊Õ¥ ∂⓺⟪ɫ¬¡’Õ“°“√ª«¥√ÿπ·√ߧ«√ ß —¬§«“¡º‘¥ ª°μ‘„π√–∫∫ª√– “∑ °“√√°— …“ ®–„À¬â “·°ªâ «¥ acetaminophen °“√ªÕÑ ß°π— ‚¥¬≈¥ blood flow rate, „™â bicarbonate dialysate solution, „πºŸâªÉ«¬∑’Ëμ‘¥°“·ø„Àâ¥◊Ë¡°“·ø„π√–À«à“ß°“√øÕ°‡≈◊Õ¥‡æ◊ËÕ≈¥ caffeine withdrawal 3.5 ¿“«–™°— (Seizures) Õ“°“√™—°„π√–À«à“ß°“√øÕ°‡≈◊Õ¥Õ“®®–‡°‘¥‰¥â®“°À≈“¬ “‡Àμÿ ‚¥¬Õ“®‡ªìπ°“√™—°∑—Èßμ—« À√◊Õ∫“ßμ”·ÀπàߢÕß√à“ß°“¬ ºŸâªÉ«¬∑’Ë™—°∫“ßμ”·ÀπàߢÕß√à“ß°“¬À√◊Õ™—°´È” §«√À“ “‡Àμÿ∑“ß√–∫∫ ª√– “∑ ‚¥¬‡©æ“– intracranial hemorrhage (√ªŸ ∑’Ë 2) °“√√—°…“ºŸâªÉ«¬∑’Ë™—°§◊Õ ¥·Ÿ ≈°“√À“¬„®  ◊∫§â𠓇Àμÿ™—° „À⬓§«∫§ÿ¡°“√™—°§◊Õ diazepam, clonazepam, dilantin „π°√≥’ ß —¬¿“«–πÈ”μ“≈„π‡≈◊Õ¥μË” §«√„Àâ 50% glucose Drugs : Metabolic : Uremic Disequilibrium syndrome Dialysis remove Hypocalcemia encephalopathy anticonvulsants Hypomagnesemia Epileptogenic drugs Hypoglycemia (theophylline, Hyperosmolarity caused meperidine) by hypernatremia Severe acid-base disturbances Hemodialysis-associated seizures Hypertensive encephalopathy Other toxin : Focal neurological disease Cerebral anoxia due to sustained hypotension Acute aluminum intoxication Intracranial hemorrhage Cardiac arrhythmia Hypersensitivity reaction Alcohol withdrawal Atheroembolism Sepsis, hemorrhage Hemolytic-uremic syndrome √ªŸ ∑’Ë 2  “‡Àμ¿ÿ “«–™—°„π√–À«à“ß°“√øÕ°‡≈◊Õ¥2 249

Practical Dialysis in the Year 2009 4. ¿“«–·∑√°´Õâ π∑“ß√–∫∫‚≈À‘μ (Hematological complications) 4.1 ¿“«–‡¡Á¥‡≈Õ◊ ¥¢“«μ”Ë (Dialysis-associated neutropenia) dialyzer membrane ∑’ˇªìπ unsubstituted cellulose ®–¡’ hydroxyl group Õ¬Ÿà∑’Ë membrane ´÷Ëß  “¡“√∂°√–μÿâπ complement ∑“ß alternative pathway19 ∑”„Àâ¡’°“√‡§≈◊ËÕπ¢Õ߇¡Á¥‡≈◊Õ¥¢“«®“°À≈Õ¥ ‡≈◊Õ¥‰ª∑’˪ե ∑”„À⇡Á¥‡≈◊Õ¥¢“«μË”™—Ë«§√“« (transient neutropenia) ‚¥¬®–¡’√–¥—∫μË” ÿ¥ (nadir) À≈—ß °“√øÕ°‡≈◊Õ¥ 15 π“∑’ ®“°π—Èπ‡¡Á¥‡≈◊Õ¥¢“«®–‡æ‘Ë¡¢÷ÈπÀ≈—ß°“√øÕ°‡≈◊Õ¥ 1 ™—Ë«‚¡ß °“√„™âμ—«°√Õß∑’ˇªìπ substituted cellulose ‡™àπ cellulose acetate, hemophan ®–°√–μÿâπ complement πâÕ¬ ®–¡’‚Õ°“ ‡°‘¥ neutropenia πâÕ¬°«à“ unsubstituted cellulose À√◊Õ synthetic membrane ‡™àπ polysulfone, polycarbonate, polymethylmethacrylate ®–°√–μÿâπ complement πâÕ¬¡“° ®÷߇°‘¥ neutropenia πâÕ¬ º≈¢Õß°“√°√–μÿâπ complement ·≈–‡¡Á¥‡≈◊Õ¥¢“«μË” Õ“®®– —¡æ—π∏å°—∫Õ“°“√º‘¥ª°μ‘Õ◊ËπÊ „π√–À«à“ß°“√øÕ°‡≈◊Õ¥ ‡™à𠧫“¡¥—π‚≈À‘μμË”, §≈◊Ëπ‰ â, ‡®Á∫Àπâ“Õ°, ª«¥À≈—ß „πºŸâªÉ«¬∑’ˇªìπ‰μ«“¬‡©’¬∫æ≈—π ®–∑”„Àâ°“√øóôπμ—« ¢Õ߉μ™â“≈ß °“√·ª≈º≈μ√«®‡¡Á¥‡≈◊Õ¥§≈“¥‡§≈◊ËÕπ‰¥â ®÷ߧ«√¥Ÿ¥‡≈◊Õ¥‡æ◊ËÕ àßμ√«®°àÕπ‡√‘Ë¡∑”°“√ øÕ°‡≈◊Õ¥ 4.2 ¿“«–‡¡Á¥‡≈◊Õ¥·¥ß·μ° (Intradialytic hemolysis)  “‡Àμÿ°“√‡°‘¥‡¡Á¥‡≈◊Õ¥·¥ß·μ°„π√–À«à“ß°“√øÕ°‡≈◊Õ¥¡’‰¥âÀ≈“¬Õ¬à“ß ‡™àπ ®“°¬“, ®“°°“√‰¥â√—∫ “√‡§¡’∫“ßÕ¬à“ß, ®“°‡∑§π‘§°“√øÕ°‡≈◊Õ¥‰¡à‡À¡“– ¡, ®“°‚√§‡≈◊Õ¥ ∑’˺⟪ɫ¬‡ªìπÕ¬àŸ‡¥‘¡ (√Ÿª∑’Ë 3) ‡π◊ËÕß®“°„πªí®®ÿ∫—πÕÿª°√≥å„π°“√øÕ°‡≈◊Õ¥¥’¢÷Èπ ¡’°“√„™â√–∫∫ deionization ∑”„À≡àæ∫°“√‡°‘¥ methemoglobinemia ®“°°“√ªπ‡ªóôÕπ¢Õß√–∫∫πÈ”¥â«¬ chlorine À√◊Õ copper ·≈–‰¡àæ∫°“√‡°‘¥ traumatic rbc (rbc fragmentation) Õ¬à“߉√°Áμ“¡ dialyzer reprocessing Õ“®®–¡’ formaldehyde  – ¡∑”„À⇡Á¥‡≈◊Õ¥·¥ß·μ°®“°°“√‡°‘¥ cold agglutinin À√◊Õ¬—∫¬—Èß rbc metabolism °“√«‘π‘®©—¬¿“«–‡¡Á¥‡≈◊Õ¥·¥ß·μ° ®–‡ÀÁπ hemolyzed blood „𠓬 à߇≈◊Õ¥ ºâŸªÉ«¬ ∑’ˇ°‘¥ methemoglobinemia ®–¡’Õ“°“√§≈◊Ëπ‰ â, Õ“‡®’¬π, §«“¡¥—π‚≈À‘μμË”, ‡¢’¬«, ‡≈◊Õ¥ ’§≈È” °“√„Àâ ÕÕ°´‘‡®π®–‰¡à “¡“√∂·°â‰¢‰¥â ºŸâªÉ«¬∑’ˇ°‘¥®“°°“√ªπ‡ªóôÕπ copper ®–¡’Õ“°“√√âÕπ∑’˺‘«Àπ—ß (skin flushing), ª«¥∑âÕß (abdominal pain), ∑âÕ߇ ’¬ (diarrhea) °“√ª√–‡¡‘π§«√μ√«® reticulocyte count, haptoglobin, lactate dehydrogenase, blood smear, Coombs test, «—¥√–¥—∫ methemoglobin §«√ μ√«®À“ª√‘¡“≥ chlorine/ ‚≈À–Àπ—°Õ◊ËπÊ „ππÈ” √«¡∑—Èßμ√«® blood turbulence „πÕÿª°√≥å·≈–‡§√◊ËÕß øÕ°‡≈◊Õ¥ º≈¢Õ߇¡Á¥‡≈◊Õ¥·¥ß·μ°®–∑”„Àâ¡’ hyperkalemia, muscle weakness, EKG ‡ª≈’ˬπ·ª≈ß, À—«„®À¬ÿ¥‡μâπ °“√√°— …“ À¬¥ÿ blood pump ·≈– clamp blood line ∑π— ∑’ ‡¡¥Á ‡≈Õ◊ ¥·¥ß·μ°∑”„À¡â ’ potassium „π‡≈◊Õ¥ ßŸ ®÷߉¡à§«√§◊π‡≈◊Õ¥°≈—∫ àŸºŸâªÉ«¬ §«√√—∫ºŸâªÉ«¬‰«â„π‚√ß欓∫“≈ μ‘¥μ“¡√–¥—∫ potassium ·≈– hematocrit ·≈–§«√ àß dialysate solution ‡æ◊ËÕÀ“ “‡Àμÿ∑’ˇ¡Á¥‡≈◊Õ¥·¥ß·μ° 250

Prevention, Diagnosis and Treatment of Acute Complications during Hemodialysis Glucose 6-phosphate Interference with rbc metabolism Traumatic fragmentation deficiency copper, aluminum, formaldehyde Dialyzer roller pump exacerbated by hypophosphatemia Excessive suction at oxidants eg. quinine arterial access site Single needle dialysis High blood flow through Drug induced small needle; Kinked microangiopathy catheter/tubing eg. quinine Incorrect osmolarity Intradialytic hemolysis Thermal damage of dialysate Overheated dialysate (>47 °C) Underheated dialysate (<35 °C) Cell membrane Reductive damage Oxidative damage fragility formaldehyde (methemoglobinemia): copper Dialysis insufficient nitrite/nitrate, quinine Zinc deficiency √Ÿª∑’Ë 3  “‡Àμÿ°“√‡°¥‘ ¿“«–‡¡Á¥‡≈◊Õ¥·¥ß·μ°„π√–À«à“ß°“√øÕ°‡≈◊Õ¥2 4.3 ¿“«–‡≈Õ◊ ¥ÕÕ° (Hemorrhage) ºâŸªÉ«¬¬Ÿ√’‡¡’¬®–¡’‚Õ°“ ‡°‘¥‡≈◊Õ¥ÕÕ°ßà“¬ (bleeding diathesis) ·≈–¿“«–‡≈◊Õ¥ÕÕ°„π√–À«à“ß °“√øÕ°‡≈Õ◊ ¥¡°—  ¡— æπ— ∏°å ∫— °“√„™¬â “≈–≈“¬≈¡‘Ë ‡≈Õ◊ ¥μ”·Àπßà ‡≈Õ◊ ¥ÕÕ°Õ“®®–‡ªπì √–∫∫∑“߇¥π‘ Õ“À“√, subdural hemorrhage, hepatic subcapsular space, ocular anterior chamber °“√μ√«® bleeding time ®– ‡ªìπ°“√ª√–‡¡‘𧫓¡‡ ’ˬßμàÕ°“√‡°‘¥‡≈◊Õ¥ÕÕ°®“°¿“«–¬Ÿ√’‡¡’¬ ºŸâªÉ«¬∑’Ë¡’ severe bleeding ‰¡à§«√„™â ¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥ §«√„™â normal saline flush ∑ÿ° 15-30 π“∑’ √à«¡°—∫ª√—∫°“√¥÷ßπÈ”„Àâ‡À¡“– ¡ À√◊Õ Õ“®„À⬓≈–≈“¬≈‘Ë¡‡≈◊Õ¥·∫∫ regional heparin, citrate anticoagulant 5. ¿“«–·∑√°´âÕπ∑’ˇ°Ë’¬«‡πË◊Õß®“°°√–∫«π°“√øÕ°‡≈◊Õ¥ (Dialysis process complications)20 5.1 Dialyzer reaction ‡ªìπÕ“°“√·æâ∑’ˇ°‘¥®“°‡≈◊Õ¥ —¡º— μ—«°√Õß ‚¥¬¡—°®–‡°‘¥„π°“√„™âμ—«°√Õߧ√—Èß·√° ‡√’¬° 251

Practical Dialysis in the Year 2009 first-use syndrome ·μà°Áæ∫Õ“°“√·æ≥â„πμ—«°√Õß∑’Ë¡’°“√„™â´È” ≈—°…≥–Õ“°“√·æâ¡—°‡°‘¥„π 5-20 π“∑’ ·√°¢Õß°“√øÕ°‡≈◊Õ¥ ·≈–·∫à߉¥â‡ªìπ 2 ·∫∫μ“¡§«“¡√ÿπ·√ߢÕßÕ“°“√§◊Õ 1. Anaphylactic type (type A reaction) ®–¡’Õ“°“√¢Õß anaphylaxis §◊Õ ÀÕ∫‡Àπ◊ËÕ¬®“°°“√μ’∫¢ÕßÀ≈Õ¥≈¡, √âÕπ∫√‘‡«≥‡ âπ∑’Ë øÕ°‡≈◊Õ¥, §—πμ“¡μ—«, ¡’º◊Ëπ≈¡æ‘…, ®“¡, §≈◊Ëπ‰ â/Õ“‡®’¬π, ª«¥∑âÕß, ∑âÕ߇ ’¬ Õ“®√ÿπ·√ß®π§«“¡¥—π ‚≈À‘μμË”, À—«„®À¬ÿ¥‡μâπ‡ ’¬™’«‘쉥â Õ“°“√®–‡°‘¥„π 2-3 π“∑’·√°¢Õß°“√øÕ°‡≈◊Õ¥ „π∫“ß√“¬Õ“® ‡°‘¥À≈—ß°“√øÕ°‡≈◊Õ¥π“π∂÷ß 30 π“∑’‰¥â  “‡Àμÿ Õ“®‡°‘¥®“° - ¡ ’ “√ ethylene oxide μ°§“â ß„πμ«— °√ÕßÀ≈ß— °“√∑”§«“¡ –Õ“¥μ«— °√Õß ‚¥¬ ethylene oxide ‡¢â“„π√à“ß°“¬®–°√–μÿâπ„Àâ¡’°“√ √â“ß IgE antibody μàÕ ethylene oxide ´÷Ëß®–‰ª°√–μÿâπ‡´≈„Àâ¡’°“√À≈—Ëß histamine ∑”„À⇰‘¥°“√·æâ¢÷Èπ μ√«®‡≈◊Õ¥®–¡’ eosinophil ·≈–√–¥—∫ IgE  Ÿß - ‡°‘¥®“°ªØ‘°‘√‘¬“¢Õßμ—«°√Õß AN69 μàÕ¬“ ACE inhibitor ‚¥¬ªØ‘°‘√‘¬“ºà“π∑“ß√–∫∫ bradykinin ®“°ª√–®ÿ≈∫∑’˺‘« AN69 membrane ®–°√–μÿâπ bradykinin ·≈–º≈®–¡“°¢÷Èπ„πºŸâªÉ«¬∑’Ë„™â¬“ ACE inhibitor √à«¡¥â«¬ ∑”„Àâ‡æ‘Ë¡√–¥—∫ bradykinin ¢÷ÈπÕ’° bradykinin ®–¡’º≈„ÀâÀ≈Õ¥‡≈◊Õ¥¢¬“¬μ—« °“√„™âμ—«°√Õß AN69 „πºŸâªÉ«¬∑’ˉ¥â√—∫¬“ angiotensin receptor blocker (ARB) °Á∑”„À⇰‘¥Õ“°“√·æ≥â ∑—Èß∑’ˬ“ ARB ‰¡à¡’º≈μàÕ√–¥—∫ bradykinin - ¡’°“√ªπ‡ªóôÕπ„π dialysate solution ¥â«¬·∫§∑’‡√’¬À√◊Õ endotoxin ¡—°‡°‘¥„π 2 π“∑’·√° À≈—ßøÕ°‡≈◊Õ¥ ·μàÕ“®®–π“π∂÷ß 15-30 π“∑’‰¥â ºâŸªÉ«¬¡—°¡’Õ“°“√‰¢â Àπ“« —Ëπ√à«¡¥â«¬ - ‡°‘¥®“°°√–∫«π°“√ reuse dialyzer ‚¥¬Õ“®∑”§«“¡ –Õ“¥μ—«°√Õ߉¡à¥’æÕ - ‡°‘¥®“°°“√„™â heparin ºâŸªÉ«¬Õ“®¡’º◊Ëπ≈¡æ‘…, ·πàπ®¡°Ÿ , ®“¡ À√◊Õ‡°‘¥ anaphylaxis ‰¥â ´÷Ëß “¡“√∂¡’ªØ‘°‘√‘¬“¢â“¡ (cross react) °—∫ low molecular weight heparin ‰¥â - ‡°‘¥®“°°“√„Àâ iron dextran Õ“°“√·æâ®–‡ªìπ dose dependent ‚¥¬°“√„Àâ iron dextran ¢π“¥¡“°°«à“ 250 mg ®–‡°‘¥¡’§«“¡¥—π‚≈À‘μμË”·≈– serum sickness-like syndrome‰¥â §«√ ‡√‘Ë¡¥â«¬ test dose ¢Õß iron dextran ¢π“¥ 25 mg ∂Ⓣ¡à¡’Õ“°“√‡æ‘Ë¡‡ªìπ 100 mg/dialysis session ®π §√∫ 10 §√—Èß °“√√°— …“ À¬ÿ¥∑”°“√øÕ°‡≈◊Õ¥∑—π∑’ clamp blood line ‚¥¬‰¡à§◊π‡≈◊Õ¥°≈—∫μ—«ºŸâªÉ«¬ ∑‘Èßμ—« °√Õß·≈– blood line‰ª °“√„À⬓‡æ◊ËÕ√—°…“Õ“°“√·æâ®–¢÷ÈπÕ¬àŸ°—∫§«“¡√ÿπ·√ß ∂â“¡’À≈Õ¥≈¡μ’∫μâÕß„Àâ ¬“ epinephrine 0.2-0.5 mg ©’¥„μ⺑«Àπ—ßÀ√◊Õ°≈â“¡‡π◊ÈÕ∑—π∑’ „Àâ´È”‰¥â„πÕ’° 5 π“∑’∂â“Õ“°“√‰¡à¥’¢÷Èπ ∂â“ ¡’º◊ËπÕ¬à“߇¥’¬« “¡“√∂„Àâ antihistamine ·≈– steroid °“√ªÕÑ ß°π— §«√¡’°“√≈â“ßμ—«°√Õߥ⫬ normal saline Õ¬à“߇撬ßæÕ ‡æ◊ËÕ‰¡à„Àâ¡’°“√μ°§â“ß ¢Õß ethylene oxide 殑 “√≥“‡ª≈¬’Ë π«∏‘ ∑’ ”§«“¡ –Õ“¥μ«— °√Õß„À¡à ‡™πà „™â gamma irradiation À√Õ◊ stream sterilized dialyzer À≈’°‡≈’ˬ߰“√„™âμ—«°√Õß AN69 „πºâŸªÉ«¬∑’ˉ¥â√—∫¬“ ACE inhibitor À√◊Õ ARB ∂⓬—ß¡’ Õ“°“√·æâÕ¬Ÿà§«√„Àâ antihistamine °àÕπ°“√øÕ°‡≈◊Õ¥ „πºâŸªÉ«¬∑’Ë·æâ iron dextran §«√‡ª≈’ˬπ‡ªìπ iron gluconate À√◊Õ iron saccharate ‡æ√“–¡’°“√‡°‘¥ anaphylactoid reaction πâÕ¬ 2. Nonspecific type B reaction Õ“°“√√ÿπ·√ßπâÕ¬°«à“ type A reaction ·μàæ∫‰¥â∫àÕ¬ 252

Prevention, Diagnosis and Treatment of Acute Complications during Hemodialysis °«à“ ºŸâªÉ«¬¡—°¡’Õ“°“√·πàπÀπâ“Õ°, ª«¥À≈—ß √–¬–‡«≈“°“√· ¥ßÕ“°“√®–™â“°«à“ type A reaction §◊Õ ¡—°‡°‘¥À≈—ß∑”°“√øÕ°‡≈◊Õ¥π“π 20-40 π“∑’  “‡Àμ°ÿ “√‡°¥‘ ¬—߉¡à∑√“∫·πà™—¥ ·μà®–¡’°“√°√–μÿâπ√–∫∫ complement æ∫„π°√≥’„™âμ—« °√Õß„À¡à∫àÕ¬°«à“°“√„™âμ—«°√Õß´È” æ∫Õ“°“√·æâ„πμ—«°√Õߪ√–‡¿∑ unsubstituted cellulose ¡“°°«à“ substituted cellulose ‡π◊ËÕß®“° hydroxyl group ∑’˺‘«μ—«°√Õß™π‘¥ unsubstituted cellulose ®–¡’°“√  —¡º— °—∫‡≈◊Õ¥∑”„Àâ¡’°“√°√–μÿâπ complement ·≈–°“√„™âμ—«°√Õß„À≠àæ◊Èπ∑’˺‘«¡“°®–¡’§«“¡‡ ’ˬßμàÕ °“√‡°‘¥ type B reaction ¡“°¥â«¬ °“√√—°…“ ®–„Àâμ“¡Õ“°“√ ‡™àπ„ÀâÕÕ°´‘‡®π, „À⬓·°â·æâ°≈ÿà¡ antihistamine ·≈– “¡“√∂ ∑”°“√øÕ°‡≈◊Õ¥μàÕ‰ª‰¥â ‚¥¬ºŸâªÉ«¬¡—°¡’Õ“°“√ª°μ‘„π 1 ™—Ë«‚¡ß °“√ªÑÕß°π— ‚¥¬„™âμ—«°√Õß´È”®–≈¥Õ“°“√·æâ ‡æ√“–º‘«°√Õß©“∫¥â«¬‚ª√μ’π„π‡≈◊Õ¥ ∂â“ ºâŸªÉ«¬¬—ß¡’Õ“°“√·æâÕ’° §«√‡ª≈’Ë¬π‰ª„™â biocompatibility dialyzer 5.2 Air embolism ‡πÕË◊ ß®“°¡√’ –∫∫¥°— ®∫— øÕßÕ“°“»∑ Ë’ “¬ ßà ‡≈Õ◊ ¥ ∑”„Àøâ ÕßÕ“°“»À≈¥ÿ ‡¢“â „π venous blood line πâÕ¬ ·μà∂â“¡’°“√‡¢â“¢ÕßøÕßÕ“°“»„π√–∫∫°“√øÕ°‡≈◊Õ¥®–‡¢â“‰ª„πμ”·Àπàß prepump tubing segment ‚¥¬Õ“®®“°¡’øÕßÕ“°“»‡¢â“®“°μ”·Àπàß°“√·∑߇¢Á¡∑“ß arterial side, °“√„Àâ “√πÈ”ºà“π ∑“ߢ«¥·°â«, øÕßÕ“°“»®“° dialysis catheter , ¡’°“√À≈ÿ¥¢Õß√–∫∫ “¬ à߇≈◊Õ¥ °“√„™â blood flow rate  Ÿß®–∑”„Àâª√‘¡“≥øÕßÕ“°“»‡¢â“„π√–∫∫¡“°·¡â«à“√Õ¬√—Ë«¡’¢π“¥‡≈Á°°Áμ“¡ Õ“°“√∑“ߧ≈‘π‘°®–¢÷ÈπÕ¬Ÿà°—∫ª√‘¡“≥øÕßÕ“°“»∑’ˇ¢â“, μ”·Àπàß∑’ËøÕßÕ“°“»‡¢â“, ∑à“ºâŸªÉ«¬¢≥–∑’ËøÕßÕ“°“»‡¢â“ ∂â“øÕßÕ“°“»‡¢â“„π¢≥–ºŸâªÉ«¬Õ¬àŸ„π∑à“π—Ëß øÕßÕ“°“»®–ºà“π‡¢â“ À≈Õ¥‡≈◊Õ¥¥”‰ª¬—ßÀ—«„®‡¢â“ àŸÀ≈Õ¥‡≈◊Õ¥·¥ß‰ªÕÿ¥μ—π∑’Ë ¡Õß ºâŸªÉ«¬®–¡’Õ“°“√™—°∑—π∑’ À¡¥ μ‘ ∂â“ øÕßÕ“°“»‡¢â“„π¢≥–ºâŸªÉ«¬Õ¬Ÿà„π∑à“πÕπ øÕßÕ“°“»®–‡¢â“„πÀ—«„®™àÕߢ«“ (right ventricle) ‰ªÕÿ¥μ—π ∑’˪ե∑”„Àâ¡’Õ“°“√·πàπÀπâ“Õ°, ÀÕ∫‡Àπ◊ËÕ¬, À—«„®‡μâπº‘¥®—ßÀ«–, ‰Õ øÕßÕ“°“»Õ“®®–ºà“π ‡ âπ‡≈◊Õ¥∑’˪ե‰ª¬—ßÀ—«„®¥â“π´â“¬ (left ventricle) ®–∑”„À⇰‘¥ air embolization ‰ª‡ âπ‡≈◊Õ¥·¥ß∑’Ë  ¡Õß·≈–À—«„® ∑”„Àâ°“√∑”ß“π¢Õß√–∫∫ª√– “∑·≈–√–∫∫À—«„®º‘¥ª°μ‘ Õ“®®–øí߉¥â‡ ’¬ßÀ—«„®º‘¥ ª°μ‘ (peculiar churning sound) °“√«‘π‘®©—¬®–Õ“»—¬°“√μ√«®æ∫øÕßÕ“°“»„𠓬 à߇≈◊Õ¥¥” (venous blood line) °“√√°— …“ (√ªŸ ∑’Ë 4) §◊ÕÀ¬ÿ¥°“√øÕ°‡≈◊Õ¥∑—π∑’ ‚¥¬°“√ clamp venous blood line, À¬ÿ¥ blood pump ®—¥∑à“ºŸâªÉ«¬„Àâ»’√…–μË”·≈–μ–·§ß´â“¬¢÷Èπ √—°…“√–∫∫°“√À“¬„®¥â«¬°“√„ÀâÕÕ°´‘‡®π 100% ·≈–√—°…“√–∫∫°“√‰À≈‡«’¬π‚≈À‘μ °“√ªÕÑ ß°π— ‡§√Õ◊Ë ßøÕ°‡≈Õ◊ ¥§«√¡√’ –∫∫¥°— ®∫— øÕßÕ“°“»μÕà Õ¬∑àŸ  ’Ë «à π∑“â ¬¢Õßμ«— °√Õß(distal to dialyzer) ·≈–§«√¡’μ—«μ‘¥μ“¡·√ߥ—πÀ≈Õ¥‡≈◊Õ¥¥” (venous pressure monitor) μ—«¥—°®—∫øÕßÕ“°“» §«√¡’√–∫∫‡μ◊Õπ‡¡◊ËÕ¡’øÕßÕ“°“» ·≈–ªî¥ blood pump ∑—π∑’ À≈’°‡≈’ˬ߰“√„™â “√πÈ”„π¢«¥·°â« ‡æ√“–®–‡°‘¥ vacuum effect ¥¥Ÿ øÕßÕ“°“»‡¢â“„π√–∫∫°“√øÕ°‡≈◊Õ¥‰¥â „π°√≥’øÕ°‡≈◊Õ¥∑“ß dialysis catheter §«√®–¥Ÿ¥øÕßÕ“°“»·≈– flush  “¬¥â«¬ normal saline °àÕπ‡√‘Ë¡μàÕ‡§√◊ËÕ߉μ‡∑’¬¡ 253

Practical Dialysis in the Year 2009 1. Clamp venous blood line 2. Stop blood pump 3. Place patient in a left Trendelenburg position with left-side up 4. Provide cardiopulmonary support: high-flow oxygen administration, endotracheal tube intubation, mechanical ventilation 5. Aspirate air from right ventricle using: percutaneous inserted needle, right atrial dialysis catheter 6. Consider hyperbaric oxygenation treatment, if available √ªŸ ∑’Ë 4 ·π«∑“ß°“√√—°…“ air embolism2 5.3 Incorrect dialysate composition dialysate solution ∑’Ë¡’ à«πº ¡∑’ˉ¡à‡À¡“– ¡ Õ“®‡°‘¥®“° technical error À√◊Õ human error „π√–À«à“ß°“√øÕ°‡≈◊Õ¥ §«√«—¥ electrical conductivity ·≈–μ—Èß√–∫∫°“√‡μ◊Õπ‡¡◊ËÕ¡’§à“ conductivity μà“ß®“°‰ª®“°§à“∑’Ë°”Àπ¥ ‡§√◊ËÕ߉μ‡∑’¬¡∑’Ë¡’√–∫∫ conductivity-controlled mixing √–∫∫®–‡ª≈’ˬπ°“√ º ¡ —¥ à«π§«“¡‡¢â¡¢âπ¢Õ߇°≈◊Õ·√àÕ—μ‚π¡—쑇¡◊ËÕ dialysate solution ¡’§à“ conductivity ·μ°μà“߉ª®“° ∑’Ë°”Àπ¥ ´÷Ëß∫“ߧ√—Èß„π dialysate Õ“®‰¡à¡’ bicarbonate Õ¬àŸ‡≈¬ ‚¥¬∑’Ë§à“ conductivity Õ¬Ÿà„π°”Àπ¥∑’Ëμ—Èß ‰«â ¥—ßπ—Èπ§«√∑”°“√«—¥ dialysate pH °àÕπ‡√‘Ë¡∑”°“√øÕ°‡≈◊Õ¥¥â«¬  à«πº ¡„π dialysate solution ∑’ˉ¡à ∂Ÿ°μâÕß Õ“®∑”„À⇰‘¥¥ÿ≈‡°≈◊Õ·√à ·≈–¥ÿ≈°√¥-¥à“ß„π√à“ß°“¬º‘¥ª°μ‘‰¥â¥—ßπ’È 1. hypernatremia ‡°‘¥®“° —¥ à«ππÈ”∑’˺ ¡‰¡à∂Ÿ°μâÕß ·≈–√–∫∫‡μ◊Õπ conductivity ‰¡à ∑”ß“π ºŸâªÉ«¬®–‡°‘¥¿“«– hyperosmolarity ∑”„Àâ¡’°“√‡§≈◊ËÕπ¢ÕßπÈ”ÕÕ°®“°‡´≈ ºŸâªÉ«¬®–¡’Õ“°“√ °√–À“¬πÈ”, ª«¥»’√…–, §≈◊Ëπ‰ â/Õ“‡®’¬π, ™—°, À¡¥ μ‘·≈–‡ ’¬™’«‘μ‰¥â °“√√—°…“§◊Õ À¬ÿ¥°“√øÕ°‡≈◊Õ¥ ∑—π∑’ √—∫ºŸâªÉ«¬‰«â„π‚√ß欓∫“≈ ·≈–„Àâ 5% dextrose in water ∂â“®–∑”°“√øÕ°‡≈◊Õ¥§«√‡ª≈’Ë¬π ‡§√ÕË◊ ߉μ‡∑¬’ ¡„À¡à μßÈ— §“à dialysate sodium μ”Ë °«“à §“à sodium „π‡≈Õ◊ ¥ª√–¡“≥ 2 mM °“√μßÈ— §“à dialysate sodium μË”°«à“§à“ sodium „π‡≈◊Õ¥ 3-5 mM Õ“®®–∑”„À⇰‘¥ dialysis disequilibrium syndrome ‰¥â 2. hyponatremia Õ“®®–‡°‘¥®“°¿“™π–∑’Ë„ à‡°≈◊Õ·√à„π°“√º ¡ dialysate solution À¡¥ º≈¢Õß hyponatremia ®–∑”„À⇰‘¥ hypoosmolarity ∑”„À⇡Á¥‡≈◊Õ¥·¥ß·μ° ¡’ hyperkalemia, hemodilution ºâŸªÉ«¬®–¡’Õ“°“√°√– —∫°√– à“¬, ·πàπÀπâ“Õ°, ª«¥»’√…–, §≈◊Ëπ‰ â/Õ“‡®’¬π, ™—°‰¥â °“√ 254

Prevention, Diagnosis and Treatment of Acute Complications during Hemodialysis √—°…“§◊Õ À¬ÿ¥°“√øÕ°‡≈◊Õ¥‚¥¬‰¡à§◊π‡≈◊Õ¥°≈—∫ºâŸªÉ«¬, clamp blood line ·≈–„Àâ°“√√—°…“μ“¡¿“«– ‡¡Á¥‡≈◊Õ¥·¥ß·μ° 3. metabolic alkalosis æ∫πÕâ ¬ Õ“®‡°¥‘ ®“°°“√ ≈∫— ¿“™π–∑∫Ë’ √√®ÿ bicarbonate ·≈– acid ‡¢â“ port ‡§√◊ËÕ߉μ‡∑’¬¡, √–∫∫‡μ◊Õπ§à“ pH ‰¡à∑”ß“π °“√√—°…“„πºâŸªÉ«¬∑’Ë¡’§à“ bicarbonate  ßŸ ¡“° §◊Õ „™â chloride ·∑π alkali À√◊Õ„™â acetate dialysate ·∑π bicarbonate, ∑”°“√øÕ°‡≈◊Õ¥¥â«¬ bicarbonate dialysate ∑’ËμË”≈ß §◊Õª√–¡“≥ 25-30 mM 5.4 Blood loss °“√‡ ’¬‡≈◊Õ¥„π√–À«à“ß°“√øÕ°‡≈◊Õ¥ Õ“®‡°‘¥®“°‡¢Á¡∑’Ë·∑߇ âπÀ≈ÿ¥ÕÕ°πÕ°‡ âπ, line disconnection, perforation ¢Õß femoral À√◊Õ central catheter, dialyzer membrane rupture Õ“°“√∑’Ëæ∫ ‰¥â·°à §«“¡¥—π‚≈À‘μμË”, À¡¥ μ‘, À—«„®À¬ÿ¥‡μâπ „π°√≥’∑’ˇ°‘¥®“°°“√·∑ß catheter ®–¡’°âÕπ‡≈◊Õ¥∫«¡ (hematoma) °“√√—°…“§◊Õ À¬ÿ¥°“√øÕ°‡≈◊Õ¥∑—π∑’, ∑”°“√°¥Àâ“¡‡≈◊Õ¥„πμ”·Àπàß∑’Ë “¡“√∂°¥Àâ“¡ ‡≈◊Õ¥‰¥â, √—°…“√–∫∫°“√‰À≈‡«’¬π¢Õß√à“ß°“¬ (hemodynamic support), „ÀâÕÕ°´‘‡®π „π∫“ß√“¬Õ“® μâÕß∑”°“√ºà“μ—¥ 5.5 Microbial contamination ºâŸªÉ«¬Õ“®μ‘¥‡™◊ÈÕ„π√–À«à“ß°“√øÕ°‡≈◊Õ¥‰¥â ‚¥¬¡’ “‡Àμÿ®“°¡’°“√ªπ‡ªóôÕπ„π dialysate, sterilized dialyzer ‰¡à¥’, ¡’°“√μ‘¥‡™◊ÈÕ„π√–À«à“ß°“√·∑߇¢Á¡∑’Ë AVF À√◊Õ AVG ºâŸªÉ«¬®–¡’Õ“°“√‰¢â Àπ“«  —Ëπ‰¥â §«√μ√«® dialysis access, ∑”°“√‡æ“–‡™◊ÈÕ®“°‡≈◊Õ¥ °“√√—°…“§◊Õ„À⬓ªØ‘™’«π– ¬“≈¥‰¢â ·≈– æ‘®“√≥“√—∫ºâŸªÉ«¬√—°…“„π‚√ß欓∫“≈ „π°√≥’∑’Ë¡’¿“«–μ‘¥‡™◊ÈÕ„πºâŸªÉ«¬À≈“¬√“¬¥â«¬‡™◊ÈÕ™π‘¥‡¥’¬«°—π Õ“®¡’·∫§∑’‡√’¬ªπ‡ªóôÕπ„πÕÿª°√≥å∑’Ë„™âøÕ°‡≈◊Õ¥ ‡™àπ ¢«¥¬“∑’Ë„™â√à«¡°—πÀ≈“¬§π‡æ√“–μâÕß·∑ß À≈“¬§√—Èß 6. ¿“«–·∑√°´âÕπ„π√–À«à“ß°“√øÕ°‡≈◊Õ¥ÕË◊πÊ 6.1 ‡®Á∫Àπ“â Õ°, ª«¥À≈ß— (chest pain, back pain) ¬—߉¡à∑√“∫ “‡Àμÿ·πà™—¥ °“√√—°…“μ“¡Õ“°“√·≈–‰¡à¡’«‘∏’ªÑÕß°—π‚¥¬‡©æ“– 6.2 §≈◊Ëπ‰ ,â Õ“‡®¬’ π (nausea, vomiting) ‡°‘¥‰¥â®“°À≈“¬ “‡Àμÿ ‡™à𠧫“¡¥—π‚≈À‘μμË”, disequilibrium syndrome, type A ·≈– type B dialyzer reaction, gastroparesis ´÷Ëßæ∫‰¥â„πºâŸªÉ«¬∑’ˉ¡à‡ªìπ‡∫“À«“π¡“°àÕπ, dialysate solution ‰¡à ‡À¡“– ¡ °“√√—°…“§◊Õ·°â‰¢¿“«–§«“¡¥—π‚≈À‘μμË” „À⬓·°âÕ“‡®’¬π °“√ªÑÕß°—π§◊ÕÀ≈’°‡≈’ˬ߿“«– §«“¡¥—π‚≈À‘μμË” „πºâŸªÉ«¬∑’Ë hemodynamic ª°μ‘ °“√„Àâ metoclopramide 5-10 mg °àÕπ°“√øÕ°‡≈◊Õ¥ ®–™à«¬≈¥Õ“°“√‰¥â 255

Practical Dialysis in the Year 2009 6.3 Õ“°“√§—π (itching) ‡°‘¥‰¥â®“°À≈“¬ “‡Àμÿ ‡™àπ low sensitivity μàÕ dialyzer À√◊Õ blood circuit, Õ“®‡°‘¥®“°°“√ ·æâ heparin, erythropoietin, formaldehyde À√Õ◊ acetate, À√Õ◊ ®“° hyperparathyroidism, inadequate dialysis, ·æ â “√∑”§«“¡ –Õ“¥ (antiseptic solution) °“√√°— …“„Àâ antihistamine, „À â “√‡æ¡‘Ë §«“¡™¡ÿà ™π◊È (moisturizing agent), UVB therapy, ≈¥√–¥—∫øÕ ‡øμ, ketotifen ´÷Ëß®–‰ª stabilize mast cell, ‡æ‘Ë¡ dialysis dose „Àâ ¡“°¢÷Èπ  à«π°“√„™â high flux À√◊Õ polymethylmethacrylate membrane (PMMA), capsaicin cream, oral activated charcoal μâÕß»÷°…“‡æ‘Ë¡‡μ‘¡ 6.4 °“√‡ ¬’ °“√‰¥¬â π‘ ·≈–‡ ¬’ °“√¡Õ߇ÀÁπ (hearing and visual loss) °“√ Ÿ≠‡ ’¬°“√‰¥â¬‘π„π√–À«à“ß°“√øÕ°‡≈◊Õ¥ Õ“®‡°‘¥®“°°“√¡’‡≈◊Õ¥ÕÕ°„πÀ™Ÿ —Èπ„π (inner ear) ®“°º≈°“√„™â¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥ (anticoagulant) À√◊Õ‡°‘¥®“°‡°‘¥Õ—πμ√“¬°—∫ cochlear hair cell ®“°°“√∫«¡ °“√ ≠Ÿ ‡ ’¬°“√¡Õ߇ÀÁπ„π√–À«à“ß°“√øÕ°‡≈◊Õ¥ Õ“®‡°‘¥®“° central retinal vein occlusion, acute glaucoma, ischemic optic neuropathy ®“°¿“«–§«“¡¥—π‚≈À‘μμË” °“√„™â cellulose acetate dialyzer ∑’ËÀ¡¥Õ“¬ÿ®–∑”„À⇰‘¥Õ—πμ√“¬μàÕ°“√‰¥â¬‘π·≈–°“√¡Õ߇ÀÁπ 6.5 Dialysis-associated hypoxemia ºâŸªÉ«¬∑’ˉ¥â√—∫°“√øÕ°‡≈◊Õ¥ ®–¡’√–¥—∫ÕÕ°´‘‡®π„πÀ≈Õ¥‡≈◊Õ¥·¥ß≈¥≈ß 5-20 mmHg ‚¥¬ √–¥—∫ÕÕ°´‘‡®π®–≈¥μË” ÿ¥À≈—ß°“√øÕ°‡≈◊Õ¥ 30-60 π“∑’ ·≈–√–¥—∫ÕÕ°´‘‡®π®–‡æ‘Ë¡¢÷Èπ„π‡«≈“ 60-120 π“∑’À≈—ßÀ¬ÿ¥°“√øÕ°‡≈◊Õ¥ °“√≈¥≈ߢÕß√–¥—∫ÕÕ°´‘‡®π à«π„À≠à‰¡à¡’§«“¡ ”§—≠„π∑“ߧ≈‘π‘° ¬°‡«âπ„πºâŸªÉ«¬∑’Ë¡’ªí≠À“‚√§√–∫∫∑“߇¥‘πÀ“¬„®‡√◊ÈÕ√—ßÕ¬Ÿà  “‡Àμÿ∑’Ë¡’√–¥—∫ÕÕ°´‘‡®π≈¥≈ß ‰¥â·°à hypoventilation ·≈– intrapulmonary diffusion block „π°√≥’‡°‘¥®“° hypoventilation æ∫‰¥â∑—Èß„π acetate dialysate solution ·≈– bicarbonate dialysate solution ‚¥¬°“√„™â acetate dialysate solution ‡¡◊ËÕ‡≈◊Õ¥ ºà“πμ—«°√Õß®–‡ ’¬ carbon dioxide ‡¢â“„π dialysate solution ∑”„À⺟âªÉ«¬À“¬„®™â“≈ß πÕ°®“°π’È acetate ®–‡Àπ’ˬ«π”„Àâ°≈â“¡‡π◊ÈÕ∑’Ë„™â„π°“√À“¬„®ÕàÕπ·√ß °“√„™â bicarbonate dialysate solution ‚¥¬‡©æ“–‡¡◊ËÕ bicarbonate  ßŸ °«à“ 35 mM bicarbonate ®–´÷¡ºà“π®“° dialysate solution ‡¢â“‰ª„π°√–· ‡≈◊Õ¥ ∑”„Àâ ‡≈◊Õ¥¡’§«“¡‡ªìπ¥à“ß (pH  ßŸ ) ®÷ß°¥°“√À“¬„®∑”„Àâ¡’ hypoxemia „π°√≥’∑’ˇ°‘¥®“° intrapulmonary diffusion block ®“°°“√„™â unsubstituted cellulose °√–μÿâπ complement ∑”„À‡â ¡¥Á ‡≈Õ◊ ¥¢“«‡§≈Õ◊Ë π‰ª∑ª’Ë Õ¥ ·≈– cardiac output ≈¥≈ß®“° acetate-induced myocardial depression °“√√°— …“®–„ÀÕâ Õ°´‡‘ ®π„πºªâŸ «É ¬∑¡’Ë ‚’ √§À«— „®À√Õ◊ ‚√§ªÕ¥°“√ªÕÑ ß°π— „πºªŸâ «É ¬∑§’Ë «“¡‡ ¬’Ë ß §«√‡≈’ˬ߰“√„™â unsubstituted cellulose membrane, „ÀâÕÕ°´‘‡®π„π√–À«à“ß°“√øÕ°‡≈◊Õ¥, ª√—∫√–¥—∫ bicarbonate „π dialysate solution „Àâ‡À¡“– ¡∑’Ë®–‡≈’ˬ߰“√‡°‘¥ alkalemia 256

Prevention, Diagnosis and Treatment of Acute Complications during Hemodialysis 6.6 Postdialysis syndrome ºâŸªÉ«¬ª√–¡“≥Àπ÷Ëß„π “¡®–¡’Õ“°“√ÕàÕπ‡æ≈’¬, ª«¥‡¡◊ËÕ¬μ—«À≈—ß°“√øÕ°‡≈◊Õ¥ ´÷Ë߇ªìπ Õ“°“√∑’ˉ¡à®”‡æ“– ‡°‘¥‰¥â®“°À≈“¬ “‡Àμÿ ‡™àπ postdialysis hypotension, hypokalemia, hypoglycemia, mild uremic encephalopathy, membrane bioincompatibility, myopathy ®“°°“√¢“¥ carnitine °“√„™â glucose/ bicarbonate dialysate solution À√◊Õ„Àâ L-carnitine 20 mg/kg/day ®–™à«¬≈¥Õ“°“√μà“ßʇÀ≈à“π’ȉ¥â 7. ∫∑ √ªÿ °“√øÕ°‡≈Õ◊ ¥¥«â ¬‡§√Õ◊Ë ß‰μ‡∑¬’ ¡„πª®í ®∫ÿ π—  “¡“√∂∑”‰¥∑â ß—È „π‚√ß欓∫“≈·≈–∑∫’Ë “â π(home hemodialysis) ‡π◊ËÕß®“°¡’°“√æ—≤π“Õÿª°√≥åμà“ßÊ ∑’Ë„™â„π°“√øÕ°‡≈◊Õ¥„Àâ¡’‚Õ°“ ‡°‘¥§«“¡º‘¥æ≈“¥ ∑“߇∑§π‘§„π√–À«à“ß°“√øÕ°‡≈◊Õ¥≈¥≈ß Õ¬à“߉√°Áμ“¡¿“«–·∑√°´âÕπ„π√–À«à“ß°“√øÕ°‡≈◊Õ¥°Á¬—ß  “¡“√∂æ∫‰¥â ´÷ËßÕ“®®–‡ªìπ®“°ºâŸªÉ«¬¡’‚√§Õ◊ËπÊ √à«¡¥â«¬ °“√‡¢â“„®„π°≈‰°°“√‡°‘¥¿“«–·∑√°´âÕπ √«¡∑—Èߺ⟪ɫ¬°≈ÿࡇ ’ˬ߮–∑”„Àâ°“√‡ΩÑ“μ‘¥μ“¡‡æ◊ËÕªÑÕß°—π¿“«–·∑√°´âÕπμà“ßÊ ‡À≈à“π’ȉ¥â¥’¢÷Èπ ‡Õ° “√Õ“â ßÕß‘ 1. Donauer J. Hemodialysis-induced hypotension: impact of technologic advances. Semin Dial. 2004;17:333-5. 2. Jaber BL, Pereira BJ. Acute complications of hemodialysis. In: Johnson RJ, Feehally J, editors. Comprehensive clinical nephrology. 2nd ed: Mosby; 2003. p. 991-1001. 3. Knoll GA, Grabowski JA, Dervin GF, OûRourke K. A randomized, controlled trial of albumin versus saline for the treatment of intradialytic hypotension. J Am Soc Nephrol. 2004;15:487-92. 4. Tomson CR. Advising dialysis patients to restrict fluid intake without restricting sodium intake is not based on evidence and is a waste of time. Nephrol Dial Transplant. 2001;16:1538-42. 5. Sherman RA, Torres F, Cody RP. The effect of red cell transfusion on hemodialysis-related hypotension. Am J Kidney Dis. 1988;11:33-5. 6. Dheenan S, Venkatesan J, Grubb BP, Henrich WL. Effect of sertraline hydrochloride on dialysis hypotension. Am J Kidney Dis. 1998;31:624-30. 7. Yalcin AU, Kudaiberdieva G, Sahin G, Gorenek B, Akcar N, Kuskus S, et al. Effect of sertraline hydrochloride on cardiac autonomic dysfunction in patients with hemodialysis-induced hypotension. Nephron Physiol. 2003;93:P21-8. 8. Rahman M, Dixit A, Donley V, Gupta S, Hanslik T, Lacson E, et al. Factors associated with inadequate blood pressure control in hypertensive hemodialysis patients. Am J Kidney Dis. 1999;33:498-506. 9. Sang GL, Kovithavongs C, Ulan R, Kjellstrand CM. Sodium ramping in hemodialysis: a study of beneficial and adverse effects. Am J Kidney Dis. 1997;29:669-77. 10. Bailey RA, Kaplan AA. Intradialytic cardiac arrhythmias: I. Semin Dial. 1994;7:57-8. 11. Kant KS. Intradialytic cardiac arrhythmias: II. Semin Dial. 1994;7:58-60. 12. Bleyer AJ, Russell GB, Satko SG. Sudden and cardiac death rates in hemodialysis patients. Kidney Int. 1999;55:1553- 9. 13. Chazan J. Sudden deaths in patients with chronic renal failure on hemodialysis. Dial Transplant. 1987;16:447-8. 257

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Infectious Control Requirements for Hemodialysis Facilities 14 Infectious Control Requirements for Hemodialysis Facilities  “∏μ‘ §Ÿ√–∑Õß ∏ππ— ¥“ μ√–°“√«π™‘ 1. ∫∑π” 2. °“√ªÕÑ ß°—π°“√μ‘¥μÕà ¢Õß‚√§μ‘¥‡™Õ◊È „π ∂“π„À∫â √°‘ “√øÕ°‡≈◊Õ¥ 3. °“√쥑 ‡™◊ÕÈ ‰«√ — μ∫— Õ°— ‡ ∫™π‘¥∫’„πºªŸâ «É ¬øÕ°‡≈◊Õ¥ 4. °“√쥑 ‡™ÕÈ◊ ‰«√— μ∫— Õ—°‡ ∫™π‘¥´’„πºŸªâ «É ¬øÕ°‡≈◊Õ¥ 5. °“√쥑 ‡™ÕÈ◊ ‰«√— μ∫— Õ°— ‡ ∫™π¥‘ ®’„πºŸªâ «É ¬øÕ°‡≈Õ◊ ¥ 6. °“√μ‘¥‡™◊ÈÕ·≈–°“√ªÑÕß°π— ‡™ÈÕ◊ ·∫§∑’‡√¬’ „πÀπ«à ¬‰μ‡∑¬’ ¡ 7. °“√·æ√√à –∫“¥¢Õ߇™ÈÕ◊ HIV „πÀπ«à ¬‰μ‡∑’¬¡ 8. °“√„À⫧— ´π’ „πºâªŸ «É ¬‰μ«“¬ 9.  √ÿª 259

Practical Dialysis in the Year 2009 1. ∫∑π” ®”π«πºªŸâ «É ¬‚√§‰μ«“¬‡√Õ◊È √ß— √–¬– ¥ÿ ∑“â ¬∑‰’Ë ¥√â ∫— °“√øÕ°‡≈Õ◊ ¥‡æ¡‘Ë ¡“°¢π÷È Õ¬“à ßμÕà ‡πÕ◊Ë ß1 ‚¥¬ ºŸâªÉ«¬°≈ÿà¡π’È¡’§«“¡‡ ’ˬß∑’Ë®–μ‘¥‡™◊Èՠߟ ‡π◊ËÕß®“°¿“«–‰μ«“¬‡√◊ÈÕ√—߇Õß2 ·≈–°√–∫«π°“√øÕ°‡≈◊Õ¥≈â“ß ‰μ´÷ËßμâÕßÕ“»—¬ vascular access ¥—ßπ—Èπ „π ∂“π„Àâ∫√‘°“√øÕ°‡≈◊Õ¥´÷Ëߪ√–°Õ∫‰ª¥â«¬ºŸâªÉ«¬®”π«π¡“° ®ß÷ ‡æ¡Ë‘ ‚Õ°“ ∑®Ë’ –¡°’ “√쥑 μÕà ¢Õ߇™ÕÈ◊ ‚√§√–À«“à ߺªâŸ «É ¬ ‰¡«à “à ∑“ßμ√ßÀ√Õ◊ ∑“ßÕÕâ ¡ º“à π∑“ß« — ¥Õÿ ªÿ °√≥å  ‘Ëß·«¥≈âÕ¡ À√◊Õ·¡â·μà∫ÿ§≈“°√∑“ß°“√·æ∑¬å‡Õß „πÕ¥’μ °“√‡ΩÑ“√–«—ß°“√μ‘¥‡™◊ÈÕ„π ∂“π„Àâ∫√‘°“√øÕ°‡≈◊Õ¥®–¡ÿà߉ª∑’ˉ«√— μ—∫Õ—°‡ ∫ ‚¥¬ ‡©æ“–™π‘¥∫’ ‚¥¬∑“ß»Ÿπ¬å§«∫§ÿ¡‚√§μ‘¥μàÕ¢Õß À√—∞Õ‡¡√‘°“‰¥â√‘‡√‘Ë¡π‚¬∫“¬„π°“√‡ΩÑ“√–«—ß°“√μ‘¥ ‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫™π‘¥∫’®“°°“√øÕ°‡≈◊Õ¥μ—Èß·μàªï æ.». 25153 ‚¥¬√à«¡°—∫ Health Care Financing Administration (HCFA)4 √–À«à“ß°“√ ”√«® ∂“π„Àâ∫√‘°“√øÕ°‡≈◊Õ¥ª√–®”ªï ·≈–„π√–¬–À≈—߉¥â¡’°“√  ”√«®·≈–‡Ω“Ñ √–«ß— ª®í ®¬— ÕπË◊ Ê ´ßË÷ Õ“®¡º’ ≈μÕà °“√쥑 ‡™ÕÈ◊ 5 ‡™πà °“√‰¥√â ∫— «§— ´π’ 6 °“√쥑 ‡™ÕÈ◊ ·∫§∑‡’ √¬’ °“√ μ‘¥‡™◊ÈÕ¢Õß vascular access °“√„™âμ—«°√Õß´È” √«¡∂÷ß°“√„™â¬“ªØ‘™’«π– ‡™àπ vancomycin7 §”·π–π” ”À√—∫°“√μ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫™π‘¥∫’ ∂°Ÿ μ’æ‘¡æå§√—Èß·√°„πªï æ.». 25208 ·≈– π”¡“´ß÷Ë °“√≈¥≈ßÕ¬“à ß√«¥‡√«Á ¢ÕßÕ∫ÿ μ— °‘ “√≥°å “√쥑 ‡™Õ◊È „À¡à∑ß—È „πºªŸâ «É ¬·≈–∫§ÿ ≈“°√∑“ß°“√·æ∑¬å „πªï 2525¡°’ “√·π–π”„Àºâ ªŸâ «É ¬·≈–∫§ÿ ≈“°√∑“ß°“√·æ∑¬‰å ¥√â ∫— «§— ´π’ ªÕÑ ß°π— °“√쥑 ‡™ÕÈ◊ ‰«√ — μ∫— Õ°— ‡ ∫™π¥‘ ∫’9 Õ¬à“߉√°Áμ“¡ °“√√–∫“¥¢Õ߉«√— μ—∫Õ—°‡ ∫™π‘¥∫’¬—ߧ߇°‘¥¢÷Èπ ‚¥¬°“√μ√«® Õ∫∑“ß√–∫“¥«‘∑¬“ æ∫«“à ¡§’ «“¡º¥‘ æ≈“¥√–¥∫—  ßŸ „π°“√ªÕÑ ß°π— °“√쥑 ‡™Õ◊È √«¡∂ß÷ °“√„À«â §— ´π’ 10 ‡®“â Àπ“â ∑À’Ë ≈“¬√“¬‰¡‡à ™Õ◊Ë «à“°“√©’¥«—§´’π®–™à«¬ªÑÕß°—π°“√μ‘¥μàÕ¢Õ߇™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫™π‘¥∫’‰¥1â 1 „πª√–‡∑»‰∑¬ ¡’√“¬ß“π„π ªï æ.». 2550 ®“°°“√∑∫∑«πª√–«—μ‘ºâŸªÉ«¬øÕ°‡≈◊Õ¥ 5,179 √“¬ æ∫«à“§«“¡™ÿ°¢Õß°“√μ√«®æ∫‰«√—  μ—∫Õ—°‡ ∫™π‘¥∫’·≈–´’„πªï 2545 ‡∑à“°—∫√âÕ¬≈– 6.3 ·≈– 4.8 μ“¡≈”¥—∫ „π¢≥–∑’Ë„πªï 2546 §«“¡™ÿ° ¢Õß°“√μ√«®æ∫‰«√— μ—∫Õ—°‡ ∫™π‘¥∫’·≈–´’ ‡∑à“°—∫√âÕ¬≈– 6.5 ·≈– 4.3 ‚¥¬§”π«≥Õÿ∫—μ‘°“√≥å¢Õß °“√μ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫∫’·≈–´’ ‡∑à“°—∫ 1.5 ·≈– 2.4 √“¬μàÕæ—π§πμàÕª1ï 2 °“√μ‘¥‡™◊ÈÕ·∫§∑’‡√’¬ ‚¥¬‡©æ“–Õ¬à“߬‘Ëß∑’ˇ°’ˬ«¢âÕß°—∫ vascular access ‡ªìπ°“√μ‘¥‡™◊ÈÕ∑’Ëæ∫ ∫Õà ¬·≈–‡ªπì  “‡Àμ ÿ ”§≠— ¢ÕßÕμ— √“°“√ª«É ¬·≈–‡ ¬’ ™«’ μ‘ „πºªâŸ «É ¬∑‰Ë’ ¥√â ∫— °“√øÕ°‡≈Õ◊ ¥13 ‡™◊ÕÈ ‚√§¥È◊Õ¬“ ∑—Èß Staphylococcus aureus ∑’Ë¥◊ÈÕμàÕ methicillin (MRSA) ·≈– Enterococci ∑’Ë¥◊ÈÕμàÕ vancomycin (VRE) ‡æ‘Ë¡¢÷ÈπÕ¬à“ß√«¥‡√Á«∑—Èß„π ∂“π∫√‘°“√ “∏“√≥ ÿ¢∑—Ë«‰ª·≈– ∂“π„Àâ∫√‘°“√øÕ°‡≈◊Õ¥14, 15 ∂÷ß·¡â®–¡’ √“¬ß“π°“√√–∫“¥¢Õ߇™Õ◊È ·∫§∑‡’ √¬’ „π ∂“π„À∫â √°‘ “√øÕ°‡≈Õ◊ ¥¡“°¡“¬16 ·μ°à “√»°÷ …“∂ß÷ √–∫“¥«∑‘ ¬“ ·≈–°“√ªÑÕß°—π°“√μ‘¥‡™◊ÈÕ‡À≈à“π’È¡’πâÕ¬¡“° ·≈–‰¡à¡’§”·π–π”Õ¬à“߇ªìπ∑“ß°“√„π°“√ªÑÕß°—π ®π °√–∑—Ëß„πªï æ.». 2542 »Ÿπ¬å§«∫§ÿ¡‚√§μ‘¥μàÕ¢Õß À√—∞Õ‡¡√‘°“‰¥â‡√‘Ë¡√–∫∫‡ΩÑ“√–«—ß°“√μ‘¥‡™◊ÈÕ„π °√–· ‡≈◊Õ¥·≈– vascular access „πºâŸªÉ«¬∑’ˉ¥â√—∫°“√øÕ°‡≈◊Õ¥ ‡æ◊ËÕª√–¡“≥§«“¡™ÿ°·≈–ªí®®—¬‡ ’Ë¬ß ¢Õߺ≈·∑√°´âÕπ‡À≈à“π’È ‡æ◊ËÕ«“ß¡“μ√°“√„π°“√ªÑÕß°—πμàÕ‰ª17 ‚¥¬∑—Ë«‰ª  ‘Ëß·«¥≈âÕ¡„π ∂“π欓∫“≈¡’§«“¡‡°’ˬ«¢âÕß„π°“√√–∫“¥¢Õß‚√§μ‘¥‡™◊ÈÕ ‚¥¬ ‡©æ“–Õ¬à“߬‘Ëß„πºâŸªÉ«¬∑’Ë¡’¿Ÿ¡‘§ÿâ¡°—πμË” ‡™àπ ºŸâªÉ«¬‰μ«“¬‡√◊ÈÕ√—ß√–¬– ÿ¥∑⓬ πÕ°®“°π’È °“√§«∫§ÿ¡ ‚√§μ‘¥‡™◊ÈÕÕ¬à“߉¡à‡À¡“– ¡ ‚¥¬‡©æ“–Õ¬à“߬‘Ë߇™◊ÈÕ°àÕ‚√§∑’ËÕ¬àŸ„π ‘Ëß·«¥≈âÕ¡ ‡™àπ Aspergillus ·≈– 260

Infectious Control Requirements for Hemodialysis Facilities Legionella spp. À√◊Õ‡™◊ÈÕ°àÕ‚√§∑’Ëμ‘¥μàÕºà“π∑“ß≈¡À“¬„® ‡™àπ «—≥‚√§ Õ“®°àÕ„À⇰‘¥º≈‡ ’¬·°àºŸâªÉ«¬ √«¡∑—Èß°àÕ‚√§„π∫ÿ§≈“°√ “∏“√≥ ÿ¢‰¥â º≈‡ ’¬‡À≈à“π’È “¡“√∂ªÑÕß°—π‰¥â‚¥¬¡“μ√°“√§«∫§ÿ¡‚√§μ‘¥ ‡™◊ÈÕ∑’Ë¡’ª√– ‘∑∏‘¿“æ18 ‰¥â·°à 1) °“√„™â “√∑”§«“¡ –Õ“¥·≈–¶à“‡™◊ÈÕ∑’ˇÀ¡“– ¡ 2) °“√¥·Ÿ ≈«— ¥ÿÕÿª°√≥å∑“ß°“√·æ∑¬å∑’Ë¥’ 3) °“√§«∫§ÿ¡§ÿ≥¿“æ¢Õß√–∫∫πÈ”∑’Ë„™â„π°“√øÕ°‡≈◊Õ¥ 4) °“√∫√‘À“√®—¥°“√ ‘Ëߪπ‡ªóôÕπ∑’ˇ°‘¥¢÷Èπ¿“¬„πÀπ૬ 2. °“√ªÑÕß°π— °“√쥑 μÕà ¢Õß‚√§μ‘¥‡™Õ◊È „π ∂“π„Àâ∫√°‘ “√øÕ°‡≈◊Õ¥ §”·π–π”·≈–·π«∑“ß„π°“√ªÕÑ ß°π— °“√쥑 μÕà ¢Õß‚√§„πºªŸâ «É ¬∑‰’Ë ¥√â ∫— °“√øÕ°‡≈Õ◊ ¥‚¥¬‡ππâ ∂÷ß°“√ªÑÕß°—π°“√μ‘¥μàÕ¢Õ߇™◊ÈÕ‰«√— ·≈–·∫§∑’‡√’¬ºà“π∑“߇≈◊Õ¥ §”·π–π”π’È®–‰¡à√«¡∂÷ß °“√ªπ ‡ªóôÕπ¢Õ߇™◊ÈÕ‚√§·≈– “√‡§¡’„π√–∫∫øÕ°‡≈◊Õ¥ √–∫∫πÈ” °“√π”μ—«°√Õß¡“„™â´È” §”·π–π”∑—Ë«‰ª¥—ß μ“√“ß∑’Ë 1 3. °“√μ‘¥‡™◊ÈÕ‰«√— μ∫— Õ—°‡ ∫™π‘¥∫’„πºªâŸ É«¬øÕ°‡≈Õ◊ ¥ ·μ‡à ¥¡‘ ‚√§‰«√ — μ∫— Õ°— ‡ ∫™π¥‘ ∫‡’ ªπì  “‡Àμ¢ÿ Õß‚√§μ∫— Õ°— ‡ ∫∑æ’Ë ∫‰¥∫â Õà ¬∑ ’Ë ¥ÿ „π‰μ«“¬‡√Õ◊È √ß— √–¬– ÿ¥∑⓬ ·μà¥â«¬¡“μ√°“√°“√§«∫§ÿ¡‚√§∑’Ë¥’¢÷Èπ ∑”„ÀâÕÿ∫—μ‘°“√≥å¢Õß‚√§≈¥≈ßÕ¬à“ßμàÕ‡π◊ËÕß 3.1 Õ“°“√∑“ߧ≈π‘ ‘° ‰«√ — μ∫— Õ°— ‡ ∫™π¥‘ ∫ ’ “¡“√∂°Õà „À‡â °¥‘ ‚√§μ∫— Õ°— ‡ ∫∑ß—È ™π¥‘ ‡©¬’ ∫æ≈π— ·≈–‡√Õ◊È √ß— ‚√§μ∫— ·¢ßÁ ·≈–¡–‡√Áßμ—∫„πºâŸªÉ«¬´÷Ëßμ‘¥‡™◊ÈÕÀ√◊Õ‡ªìπæ“À–  ”À√—∫ºâŸªÉ«¬øÕ°‡≈◊Õ¥∑’Ë¡’°“√μ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫ ™π¥‘ ∫„’ À¡¡à °— ¡Õ’ “°“√§Õà π¢“â ßπÕâ ¬À√Õ◊ ‰¡¡à Õ’ “°“√ ¡‡’ 欒 ß 30% ∑¡’Ë °’ “√‡æ¡‘Ë ¢π÷È ¢Õߧ“à ‡Õπ‰´¡μå ∫— ‡≈°Á πÕâ ¬ Õ¬“à ߉√°¥Á ’ ¡“°°«“à 80% ∑‡’Ë ¢“â  √àŸ –¬–μ∫— Õ°— ‡ ∫‡√Õ◊È √ß— À√Õ◊ æ“À– ‡æ¬’ ß 20% ‡∑“à ππ—È ∑ ’Ë “¡“√∂°”®¥— HBsAg ÕÕ°‰ª‰¥â19 ª≠í À“Àπß÷Ë „π°“√«π‘ ®‘ ©¬— μ∫— Õ°— ‡ ∫„πºªâŸ «É ¬øÕ°‡≈Õ◊ ¥§Õ◊ √–¥∫— ‡Õπ‰´¡åtransaminase(alanine aminotransferases (AST) ·≈– aspartate aminotransferases (ALT) ¡§’ “à μË”≈ßμß—È ·μ√à Õâ ¬≈– 20-50 „πºªâŸ «É ¬øÕ° ‡≈◊Õ¥20, 21 ‚¥¬‡™◊ËÕ«à“∂Ÿ°°¥‚¥¬ uremic toxin ·≈–¬—ßæ∫«à“ AST ®–¡’§à“ Ÿß¢÷ÈπÀ≈—߉¥â√—∫°“√øÕ°‡≈◊Õ¥ ®÷ß “¡“√∂æ∫«à“ºŸâªÉ«¬μ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫∫’¡’§à“‡©≈’ˬ¢Õß transaminase Õ¬àŸ„π‡°≥±åª°μ‘ ·¡â«à“®–  ßŸ °«à“§à“‡©≈’ˬºâŸªÉ«¬øÕ°‡≈◊Õ¥∑’ˉ¡à¡’‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫™π‘¥∫’ 22 ¥—ßπ—Èπ ·æ∑¬å§«√μ√«®À“ “‡Àμÿ¢Õß °“√‡æ‘Ë¡¢÷Èπ·¡â‡æ’¬ß‡≈Á°πâÕ¬¢Õß§à“‡Õπ‰´¡å transaminase ‡ ¡Õ ‚¥¬‡©æ“–∑’ˇæ‘Ë¡¢÷Èπ√–À«à“ß°“√μ√«® ª√–®”„πºªâŸ «É ¬øÕ°‡≈Õ◊ ¥∑ÕË’ “°“√§ß∑Ë’ º‡Ÿâ ™¬Ë’ «™“≠∫“ß∑“à π·π–π”„À‡â ª≈¬Ë’ π§“à  ßŸ  ¥ÿ ¢Õß AST ·≈– ALT ‡ªìπ 18 ·≈– 16 IU/L μ“¡≈”¥—∫23 261

Practical Dialysis in the Year 2009 ºŸâªÉ«¬μ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫™π‘¥∫’‡©’¬∫æ≈—π¡—°‰¡à¡’Õ“°“√ §à“ transaminase Õ“®ª°μ‘À√◊Õ ‡æ‘Ë¡‡æ’¬ß‡≈Á°πâÕ¬ ¥—ß∑’Ë°≈à“«¡“·≈â« ·μà¡—°π”‰ª àŸ‚√§μ—∫Õ—°‡ ∫‡√◊ÈÕ√—߉¥â¡“°°«à“  ”À√—∫°“√μ‘¥‡™◊ÈÕ ‰«√ — μ∫— Õ°— ‡ ∫™π¥‘ ∫·’ ∫∫‡√Õ◊È √ß— ππ—È §≈“â ¬°π— °∫— ºªâŸ «É ¬∑«—Ë ‰ª√«¡∑ß—È ‚√§μ∫— ·¢ßÁ ·≈–º≈¢“â ߇§¬’ ßμ“à ßʉ¥·â °à ¿“«–‡≈◊Õ¥ÕÕ°ßà“¬, ∑âÕß¡“π, hypersplenism, varices „π°√–‡æ“–·≈–À≈Õ¥Õ“À“√ ·≈– hepatic μ“√“ß∑Ë’ 1 Infectious Control Precautions for All Patients 1. „ à∂ÿß¡◊Õ™π‘¥„™â·≈â«∑‘Èߢ≥–¥·Ÿ ≈À√◊Õ —¡º — ºŸâªÉ«¬À√Õ◊ Õÿª°√≥å„π‡§√ËÕ◊ ßøÕ°‡≈Õ◊ ¥ ∂Õ¥∂ÿß¡◊Õ·≈– ≈â“ß¡◊Õ∑ÿ°§√—Èß∑’Ë¥·Ÿ ≈ºâŸªÉ«¬√“¬„À¡à 2. À≈—ß„™âÕÿª°√≥å∑’Ëπ”¡“¬—߇§√◊ËÕßøÕ°‡≈◊Õ¥ §«√°”®—¥∑‘ÈßÀ√◊Õ„™â°—∫ºŸâªÉ«¬‡æ’¬ß√“¬‡¥’¬« À“° ®”‡ªπì μÕâ ßπ”¡“„™´â È”À√Õ◊ 𔉪¬ß— ∫√‡‘ «≥∑ ’Ë –Õ“¥§«√º“à π°“√∑”§«“¡ –Õ“¥·≈–°”®¥— ‡™Õ◊È °Õà π 3. Õÿª°√≥å∑“ß°“√·æ∑¬å∑’Ë„™â‰¥âÀ≈“¬§√—Èß ‡™àπ ‡∑ª°“« À√◊Õ·∂∫ºâ“æ—π·¢π ”À√—∫«—¥§«“¡¥—π À“°‰¡à “¡“√∂∑”§«“¡ –Õ“¥·≈–°”®—¥‡™◊ÈÕ‰¥â §«√·¬°„™â ”À√—∫ºâŸªÉ«¬§π‡¥’¬«‡∑à“π—Èπ 4. ¬“À√◊ÕÕÿª°√≥å∑’Ëπ”‡¢â“‰ª¬—߇§√◊ËÕß≈â“ß‰μ ·¡â®–¬—߉¡à‰¥â„™â °Á‰¡à§«√π”°≈—∫‰ª¬—ß∫√‘‡«≥ –Õ“¥ À√◊Õ„™â°—∫ºâŸªÉ«¬√“¬Õ◊Ëπ 5. ‡¡◊ËÕ„™â¬“∑’Ë “¡“√∂π”°≈—∫¡“„™â‰¥âÀ≈“¬§√—Èß §«√μ√–‡μ√’¬¡¬“ ”À√—∫ºŸâªÉ«¬·μà≈–√“¬„π ∫√‘‡«≥ –Õ“¥´÷Ë߇ªìπ à«π°≈“ß ·≈–·¬°®“°∫√‘‡«≥‡§√◊ËÕß≈â“߉μ·≈–∫√‘‡«≥∑’Ë„™â¥·Ÿ ≈ºŸâªÉ«¬ ‰¡à §«√π”À≈Õ¥¬“‡À≈à“π’ȉª¬—߇§√◊ËÕß≈â“߉μ 6. ‰¡§à «√„™√â ∂‡¢πÁ ‡μ√¬’ ¡¬“ (common medication carts) ‡æÕ◊Ë π”¬“‰ª¬ß— ºªŸâ «É ¬ À≈°’ ‡≈¬’Ë ß°“√„ ¢à «¥¬“ ‡¢Á¡©’¥¬“À√◊ÕÕÿª°√≥åÕ◊ËπÊ „π°√–‡ªÜ“‡ ◊ÈÕ À“°„™â∂“¥„ à¬“ §«√∑”§«“¡ –Õ“¥°àÕπ®–𔉪 „™â°—∫ºâŸªÉ«¬√“¬Õ◊Ëπ 7. §«√®—¥„Àâ¡’∫√‘‡«≥ –Õ“¥‡©æ“–  ”À√—∫°“√‡°Á∫·≈–‡μ√’¬¡¬“·≈–Õÿª°√≥å∑“ß°“√·æ∑¬å ∫√‘‡«≥¥—ß°≈à“«π’ȧ«√·¬°‡ªìπ —¥ à«π®“°∫√‘‡«≥∑’Ë¡’°“√ªπ‡ªóôÕπ¢Õ߇≈◊Õ¥·≈–Õÿª°√≥å∑’Ë„™â·≈â« 8. §«√„™âÕÿª°√≥åªÑÕß°—π external venous ·≈– arterial pressure transducer filters/protectors  ”À√—∫ºâŸªÉ«¬·μà≈–√“¬ ‡æ◊ËÕªÑÕß°—π°“√ªπ‡ªóôÕπ¢Õ߇≈◊Õ¥μàÕμ—««—¥§«“¡¥—π„π‡§√◊ËÕßøÕ°‡≈◊Õ¥ §«√‡ª≈’ˬπμ—«ªÑÕß°—π√–À«à“ߺŸâªÉ«¬·μà≈–√“¬ ·≈–‰¡à§«√𔉪„™â°—∫ºâŸªÉ«¬¡“°°«à“Àπ÷Ëß√“¬ ·μà‰¡à®”‡ªìπμâÕ߇ª≈’ˬπ internal transducer filters √–À«à“ߺ⟪ɫ¬·μà≈–√“¬ 9. ∑”§«“¡ –Õ“¥·≈–°”®—¥‡™◊ÈÕ∫√‘‡«≥‡§√◊ËÕß≈â“߉μ √«¡∑—Èß ‡°â“Õ’È ‡μ’¬ß·≈–‚μä– ‡¡◊ËÕ‡ª≈’ˬπ ºâŸªÉ«¬√“¬„À¡à 10. ∑”§«“¡ –Õ“¥μ—«‡§√◊ËÕßøÕ°‡≈◊Õ¥ ‚¥¬‡©æ“–∫√‘‡«≥∑’Ë¡’°“√ —¡º— ∫àÕ¬ ·≈–Õ“®ªπ‡ªóôÕπ¥â«¬ ‡≈◊Õ¥¢ÕߺŸâªÉ«¬ 11. ∑‘ÈߢÕ߇À≈«∑ÿ°™π‘¥·≈–∑”§«“¡ –Õ“¥¿“™π–∑’Ë„ àπÈ”‡ ’¬∑’ËÕÕ°®“°‡§√◊ËÕß 12. π”μ—«°√Õß·≈–∑àÕπ”‡≈◊Õ¥∑’Ë®–𔉪„™â„À¡à √«¡∑—Èß cap dialyzer ports ·≈– clamp tubing „ à„π ¿“™π–∑’ˉ¡à√—Ë« √–À«à“ßπ” à߉ª¬—ß∫√‘‡«≥∑”§«“¡ –Õ“¥ 262

Infectious Control Requirements for Hemodialysis Facilities encephalopathy °“√μ‘¥‡™◊ÈÕ√à«¡°—∫‰«√— μ—∫Õ—°‡ ∫™π‘¥¥’ (hepatitis D virus) ∑”„Àâ‚√§μ—∫¡’§«“¡√ÿπ·√ß  ßŸ ¢÷Èπ ®“°°“√μ√«®™‘Èπ‡π◊ÈÕμ—∫ æ∫«à“¡’≈—°…≥–‡À¡◊ÕπºŸâªÉ«¬μ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫∫’∑—Ë«‰ª∑’ˉ¡à¡’ ‚√§‰μ ‰¡à«à“®–‡ªìπ°“√Õ—°‡ ∫À√◊Õ°“√‡°‘¥º—ߺ◊¥√Õ∫‡ âπ‡≈◊Õ¥¥”ªÕ√åμ—≈ (portal inflammation or fibrosis)24,25 À√Õ◊ piecemeal necrosis ∫“ß°“√»°÷ …“√“¬ß“π«“à °“√¥”‡ππ‘ ‚√§‡√«Á °«“à „πºªâŸ «É ¬øÕ°‡≈Õ◊ ¥ 26 ·μàÕ—μ√“°“√ªÉ«¬·≈–‡ ’¬™’«‘μ‰¡à·μ°μà“ß°—π√–À«à“ߺ⟪ɫ¬øÕ°‡≈◊Õ¥∑’Ë¡’À√◊Õ‰¡à¡’ HBsAg27 ´÷ËßÕ“®‡ªìπ ‡æ√“–Õ—μ√“‡ ’¬™’«‘μ∑’ˠߟ Õ¬Ÿà·≈â«¢Õߺ⟪ɫ¬øÕ°‡≈◊Õ¥ °“√μ‘¥μ“¡∑’ˉ¡àÕ“®∑”‰¥âπ“π‡æ’¬ßæÕ À√◊Õ°“√¡’ ª®í ®¬— Õπ◊Ë Ê ∑¡’Ë º’ ≈√∫°«π ‡™πà ¿“«–∑æÿ ‚¿™π“°“√ ‚√§À«— „®·≈–À≈Õ¥‡≈Õ◊ ¥ ·μ„à π°√≥∑’ ‡’Ë ¢“â  √Ÿà –¬–μ∫— ·¢ßÁ ®–¡’°“√‡æ‘Ë¡¢ÕßÕ—μ√“°“√‡ ’¬™’«‘μ√âÕ¬ 3528,29 3.2 °“√μ√«®§—¥°√Õß·≈–«π‘ ‘®©—¬ °“√«‘π‘®©—¬°“√μ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫™π‘¥∫’ ‚¥¬∑—Ë«‰ªÕ“»—¬°“√μ√«®·Õπ쑇®πμà“ßÊ ¢Õß ‰«√— ·≈–¿Ÿ¡‘§ÿâ¡°—π ‰¥â·°à HBsAg, anti-HBs (HBsAb), anti-HBc, anti-HBc IgM, HBeAg ·≈– anti-HBe (HBeAb) ‚¥¬®– “¡“√∂∫ßà ™∂’È ß÷ √–¬–¢Õß‚√§ °“√‡æ¡‘Ë ®”π«π¢Õ߉«√ — ·≈–§«“¡ “¡“√∂„π°“√쥑 μÕà 30,31 °“√μ√«®æ∫ HBeAg  “¡“√∂∫àß∂÷ß°“√·æ√à®”π«π¢Õ߉«√—  ¬°‡«âπ„π°≈ÿࡉ«√— °≈“¬æ—π∏å™π‘¥ precore À√◊Õ core promoter HBV mutants ´÷Ëß¡’°“√‡æ‘Ë¡®”π«π‰«√—  ·¡â®–‰¡à¡’ HBeAg32 „π°√≥’π’È °“√μ√«®À“ √–¥∫— DNA ¢Õ߉«√ — μ∫— Õ°— ‡ ∫™π¥‘ ∫‚’ ¥¬μ√ß®–‰¥ºâ ≈¥°’ «“à 33,34 ‚¥¬Õ“®„™«â ∏‘ ’ polymerase chain reaction (PCR) À√◊Õ direct nucleic acid hybridization «‘∏’°“√μ√«®∑’Ë„™â real time-PCR æ∫«à“¡’§«“¡‰« ßŸ ∂÷ß√–¥—∫ 200 copies/mL35,36 ºâŸªÉ«¬øÕ°‡≈◊Õ¥∑’Ë¡’ª√–«—μ‘°“√μ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫™π‘¥∫’ ·¡â®–μ√«®‰¡àæ∫ HBsAg ·≈â« ·μà°“√μ√«® polymerase chain reaction (PCR) ®“°‡≈◊Õ¥·≈–‡¡Á¥‡≈◊Õ¥¢“« ®– “¡“√∂æ∫ DNA ¢Õß ‰«√— μ—∫Õ—°‡ ∫™π‘¥∫’‰¥âª√–¡“≥§√÷ËßÀπ÷Ëß37 √“¬ß“π®“°·§π“¥“ æ∫ºâŸªÉ«¬øÕ°‡≈◊Õ¥∑’ˉ¡à¡’ HBsAg ·μà æ∫«à“¡’ DNA ¢Õ߉«√— μ—∫Õ—°‡ ∫™π‘¥∫’„π‡≈◊Õ¥‰¥â∂÷ß 3.8%38 ‚¥¬Õ“®‡°‘¥®“°°“√ deletion ¢Õß pre-S1 region ¢Õß viral genome ´÷Ë߇°’ˬ«¢âÕß°—∫°“√ √â“ß antigen ‚¥¬∑—Ë«‰ª °“√μ√«®À“ HBsAg ‡æ’¬ßæÕ  ”À√∫— °“√«π‘ ®‘ ©¬— °“√쥑 ‡™Õ◊È „πºªâŸ «É ¬øÕ°‡≈Õ◊ ¥ «à π¡“°·¡ªâ √¡‘ “≥‰«√ — „πºªâŸ «É ¬°≈¡ÿà π§’È Õà π¢“â ßμË”(102- 104 viral copies/mL) ·μà°Á™’È„Àâ‡ÀÁπ∂÷ߪí≠À“„π°“√«‘π‘®©—¬‚¥¬„™â HBsAg ‡æ’¬ßÕ¬à“߇¥’¬«„π°“√«‘π‘®©—¬ º‡âŸ ¢¬’ π‡ÀπÁ «“à Õ“®æ®‘ “√≥“ ßà μ√«® HBV DNA „πºŸªâ É«¬μ—∫Õ°— ‡ ∫´÷Ëß HBsAg ·≈– anti-HBs ‡ªìπ≈∫ ‚¥¬∑’Ë anti-HBc ‡ªìπ∫«° ‚¥¬‰¡àæ∫‰«√— μ—∫Õ—°‡ ∫™π‘¥´’ 3.3 °“√μ√«®μ¥‘ μ“¡‰«√— μ∫— Õ°— ‡ ∫™π¥‘ ∫’ §«√쥑 μ“¡·≈–‡Ω“Ñ √–«ß— „πºªâŸ «É ¬μ¥‘ ‡™Õ◊È ‰«√ — μ∫— Õ°— ‡ ∫∫Õ’ ¬“à ß ¡Ë”‡ ¡Õ‚¥¬°“√μ√«®√–¥∫— ‡Õπ‰´¡åμ—∫·≈–Õ—≈∫Ÿ¡‘π ∑ÿ° 1-2 ‡¥◊Õπ μ√«® prothrombin time ‡ªìπ√–¬–Ê ‡æ◊ËÕ¥Ÿ°“√‡ª≈’ˬπ·ª≈ß àŸ ¿“«–μ—∫·¢Áß μ√«®√–¥—∫ alpha fetoprotein (AFP) ∑ÿ° 3-4 ‡¥◊Õπ·≈–μ√«® ultrasound μ—∫Õ¬à“ßπâÕ¬ªï≈– §√ß—È ‡æÕ◊Ë ‡Ω“Ñ √–«ß— °“√‡°¥‘ ¡–‡√ßÁ μ∫— Õ¬“à ߉√°¥Á ’º≈°“√μ√«®‡À≈“à π‰’È ¡‰à ¥∫â ßà ™∂’È ß÷ º≈∑“ß欓∏«‘ ∑‘ ¬“¢Õßμ∫— 39 ·æ∑¬å∫“ß∑à“π®÷ß·π–π”„Àâμ√«®™‘Èπ‡π◊ÈÕμ—∫¥â«¬ ‚¥¬‡©æ“–°àÕπ®–‡√‘Ë¡°“√√—°…“¥â«¬¬“μâ“π‰«√— À√◊Õ 263

Practical Dialysis in the Year 2009 μ“√“ß∑’Ë 2 §”·π–π”„π°“√μ√«®§—¥°√Õß ”À√—∫‰«√— μ—∫Õ—°‡ ∫™π‘¥∫’  ∂“π–ºªŸâ «É ¬ ‡√‘Ë¡μâπ ∑°ÿ ‡¥Õ◊ π ∑°ÿ 6 ‡¥Õ◊ π ∑ÿ° 1 ªï ºâŸªÉ«¬∑ÿ°√“¬ HBsAg, Anti-HBc (total), Anti-HBs, ALT AntiHBs ‡ªìπ≈∫ HBsAg AntiHBs ‡ªìπ∫«° (≥10 mIU/mL) Anti-HBs AntiHBc ‡ªìπ≈∫ ‰¡à®”‡ªìπμâÕßμ√«®‡æ‘Ë¡‡μ‘¡ AntiHBs ‡ªìπ∫«° (≥10 mIU/mL) AntiHBc ‡ªπì ∫«° HBsAg=hepatitis B surface antigen; Anti-HBc=antibody to hepatitis B core antigen; Anti-HBs=antibody to hepatitis B surface antigen; ALT=alanine aminotransferase. μ“√“ß∑’Ë 3 °“√μ√«®μ‘¥μ“¡·≈–‡ΩÑ“√–«—ß„πºâŸªÉ«¬μ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫∫’ Liver enzyme (AST, ALT, ALP, (GGT)) ∑ÿ° 1-2 ‡¥◊Õπ Prothrombin time (PT) Õ¬à“ßπâÕ¬ªï≈–§√—Èß Alpha fetoprotein (AFP) ∑ÿ° 3-4 ‡¥◊Õπ Ultrasound Hepatobiliary Õ¬à“ßπâÕ¬ªï≈–§√—Èß Liver biopsy ¬—߉¡à¡’§”·π–π” °àÕπ∑”°“√ª≈Ÿ°∂à“¬‰μ40 ·μଗ߉¡à¡’§”·π–π”∑’Ë™—¥‡®π∂÷ß°“√μ√«®™‘Èπ‡π◊ÈÕμ—∫„πºŸâªÉ«¬∑’ˉ¡à¡’Õ“°“√ (μ“√“ß∑’Ë 2 ·≈– 3) 3.4 °“√√°— …“‰«√— μ∫— Õ°— ‡ ∫™π‘¥∫’ °“√√—°…“¢÷ÈπÕ¬Ÿà°—∫°“√Õ—°‡ ∫„π‡π◊ÈÕμ—∫ (º≈μ√«®™‘Èπ‡π◊ÈÕμ—∫·≈–√–¥—∫ ALT) °“√‡æ‘Ë¡®”π«π ¢Õ߉«√— „π‡≈◊Õ¥ (HBV DNA À√◊Õ HBeAg) ºŸâ‡™’ˬ«™“≠À≈“¬∑à“π·π–π”„Àâ‡√‘Ë¡°“√√—°…“„πºŸâªÉ«¬∑’Ë¡’ √–¥—∫‰«√— „π‡≈◊Õ¥ Ÿß°«à“ 105 copies/mL41 ‰¡à«à“ HBeAg ®–‡ªìπ∫«°À√◊Õ≈∫ 3.4.1 Interferon-alfa ¡’¢âÕ¡≈Ÿ ‰¡à¡“°∂÷ß°“√„™â¬“ interferon „πºŸâªÉ«¬øÕ°‡≈◊Õ¥42 ‚¥¬°“√ „™â¬“„π¢π“¥ 3 mU 3 §√—ÈßμàÕ —ª¥“À凪ìπ‡«≈“ 3 ‡¥◊ÕπÕ“®‰¥âº≈¥’ 43 ·μà¡’√“¬ß“π∂÷ߺ≈¢â“߇§’¬ß«à“ Ÿß °«“à „πºªâŸ «É ¬μ¥‘ ‡™ÕÈ◊ ‰«√ — μ∫— Õ°— ‡ ∫∫∑’ «Ë— ‰ª ‚¥¬‡©æ“– ¿“«–‚≈Àμ‘ ®“ß44,45 ®ß÷ ∑”„À·â æ∑¬Àå ≈“¬∑“à π𬑠¡ „™â¬“°≈ÿà¡ Nucleoside/nucleotide analogues ¡“°°«à“ 3.4.2 Lamivudine 46 ‡ªì𬓄π°≈ÿà¡ nucleoside analogue ´÷Ë߬—∫¬—È߇Õπ‰´¡å reverse transcriptase ¢Õ߉«√— μ—∫Õ—°‡ ∫™π‘¥∫’ ¬“μ—«π’ȇªì𬓙𑥷√°∑’ˉ¥â√—∫°“√√—∫√Õß„Àâ„™â„π°“√√—°…“ 264

Infectious Control Requirements for Hemodialysis Facilities ‰«√— μ—∫Õ—°‡ ∫™π‘¥∫’„πºŸâªÉ«¬∑—Ë«‰ª ‚¥¬™à«¬≈¥ HBV DNA ≈¥√–¥—∫ transaminase ·≈–≈¥°“√Õ—°‡ ∫ „π‡π◊ÈÕ‡¬◊ËÕμ—∫47,48 ·≈–¬—ß¡’√“¬ß“π∂÷ߪ√– ‘∑∏‘¿“æ„πºŸâªÉ«¬øÕ°‡≈◊Õ¥·≈–ª≈°Ÿ ∂à“¬‰μ ‚¥¬°¥°“√‡æ‘Ë¡ ®”π«π‰«√— ·≈–≈¥√–¥—∫ transaminase „À⇪ìπª°μ‘ „πºªâŸ «É ¬‚√§‰μ«“¬∑¡’Ë ’ HBsAg/HBeAg ‡ªπì ∫«°·≈–¡√’ –¥∫— ‡Õπ‰´¡å 3-6 ‡∑“à ¢Õߧ“à ª°μ‘ æ∫«“à °“√„À⬓ lamivudine ‡ªìπ‡«≈“ 10 ‡¥◊Õπ ™à«¬„Àâ√–¥—∫ ALT °≈—∫¡“ª°μ‘·≈–°”®—¥‡™◊ÈÕ‰«√— ®“°‡≈◊Õ¥49  ”À√—∫ºŸâªÉ«¬øÕ°‡≈◊Õ¥ °“√„Àâ lamivudine 100 mg 3 §√—ÈßμàÕ —ª¥“Àå μ‘¥μàÕ°—π 1 ªï  “¡“√∂°”®—¥‡™◊ÈÕ ‰«√— ®“°‡≈◊Õ¥‰¥âª√–¡“≥§√÷ËßÀπ÷Ëß50 ¡’°“√»÷°…“· ¥ß„Àâ‡ÀÁπ«à“À≈—ß°“√„À⬓π“π 14 ‡¥◊Õπ √–¥—∫ transaminase °≈—∫‡ªìπª°μ‘„πºŸâªÉ«¬∑ÿ°√“¬ ·≈– HBeAg À“¬‰ª„π√âÕ¬≈– 20 ¢Õߺ⟪ɫ¬ ·μà‰¡à¡’ √“¬ß“π∂÷ߺ≈μ√«®™‘Èπ‡π◊ÈÕ¢Õßμ—∫51 ‚¥¬∑—Ë«‰ª®÷ß·π–π”„Àâ„Àâ°“√√—°…“¥â«¬ lamivudine ‡ªìπ‡«≈“ 1-2 ªï 3.4.3 ¬“°≈à¡ÿ Nucleoside/nucleotide analogues °≈ÿà¡„À¡à °“√„™¬â “ lamivudine ‡ªπì √–¬–‡«≈“π“π°Õà „À‡â °¥‘  “¬æπ— ∏¢å Õ߉«√ — ¥ÕÈ◊ ¬“ 52,53 ‚¥¬æ∫Õμ— √“ °“√¥◊ÈÕ¬“√âÕ¬≈– 15 μàÕªï °“√¥◊ÈÕ¬“πÈ’‡°’ˬ«¢âÕß°—∫°“√‡ª≈’ˬπ·ª≈ß∑’Ë YMDD (tyrosine, methionine, aspartate, aspartate) nucleotide-binding motif ¢Õß HBV DNA polymerase „πºªŸâ «É ¬∑«—Ë ‰ª∑¥’Ë Õ◊È ¬“ lamivudine  “¡“√∂„™â¬“ adefovir dipivoxil √—°…“‰¥â54,55 ·μà‰¡à§«√„™â„πºŸâªÉ«¬∑’ˬ—ß¡’°“√∑”ß“π¢Õ߉μ‡À≈◊ÕÕ¬Ÿà ‡π◊ËÕß®“°¬“μ—«π’È¡’º≈‡ ’¬μàÕ‰μ ¡’√“¬ß“π°“√„™â¬“Õ◊ËπÊ „π°“√√—°…“‰«√— μ—∫Õ—°‡ ∫™π‘¥∫’∑’Ë¥◊ÈÕ¬“ lamivudine (YMDD Mutant) ‡™àπ famcyclovir56, interferon57, entecavir58 ·≈–°“√„™â¬“ lamivudine √à«¡ °∫— famcyclovir59·μ°à “√»°÷ …“ª√– ∑‘ ∏¿‘ “æ¢Õ߬“‡À≈“à π„’È πºªâŸ «É ¬‰μ«“¬‡√Õ◊È √ß— √–¬– ¥ÿ ∑“â ¬¬ß— ¡π’ Õâ ¬¡“° ·μà‡ªìπ‰ª‰¥â«à“„πÕπ“§μ ¬“°≈ÿà¡„À¡àÊ ‡À≈à“π’È ‡™àπ entecavir ¡“∑¥·∑π lamivudine „π°“√‡ªìπ first- line „π°“√√°— …“‰«√ — μ∫— Õ°— ‡ ∫™π¥‘ ∫„’ πºªâŸ «É ¬‚√§‰μ‡√ÕÈ◊ √ß— 60 ‡πÕË◊ ß®“°πÕ°®“° lamivudine ®–°Õà „À‡â °¥‘ ‡™◊ÈÕ¥◊ÈÕ¬“·≈â« °“√¥◊ÈÕ¬“¬—ß “¡“√∂¢â“¡‰ª¬—߬“™π‘¥Õ◊ËπÊ Õ’°¥â«¬ 3.5 °“√ªÑÕß°—π°“√μ‘¥‡™◊ÕÈ ‰«√ — μ—∫Õ—°‡ ∫™π¥‘ ∫’ ‰«√— μ—∫Õ—°‡ ∫™π‘¥∫’ “¡“√∂μ‘¥μàÕ‰¥â‚¥¬°“√ —¡º— °—∫‡≈◊Õ¥À√◊Õ “√§—¥À≈—Ëß∑’Ë¡’‰«√—  ºà“π ∑“ß∫“¥·º≈À√◊Õ‡¬◊ËÕ∫ÿº‘« ‚¥¬æ“À–π”‚√§¡—°®–‡ªìπºâŸªÉ«¬´÷Ëß¡’ HBsAg ‡ªìπ∫«° ·¡âºâŸªÉ«¬°≈ÿà¡π’È  “¡“√∂·æ√à‡™◊ÈÕ‰«√— ‰¥â ·μà‚Õ°“ μË”°«à“ºŸâªÉ«¬´÷Ëß¡’ HBeAg ‡ªìπ∫«° ´÷Ëß®–¡’√–¥—∫‰«√— „π‡≈◊Õ¥ Ÿß °«à“ (108-9 virions/mL)61 Õ¬à“߉√°Áμ“¡  “¡“√∂æ∫‰«√— μ—∫Õ—°‡ ∫™π‘¥∫’®”π«π‡æ’¬ß 102-3 virions/mL „π ‘Ëß·«¥≈âÕ¡´÷Ëߪ√“»®“°‡≈◊Õ¥‰¥â¡“°°«à“ 7 «—π„πÕÿ≥À¿¡Ÿ ‘ÀâÕß62 ·≈– “¡“√∂μ‘¥μàÕ‰ª¬—ߺ⟪ɫ¬‰¥6â 3 πÕ°®“°π’Ȭ—ß¡’√“¬ß“πæ∫‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫™π‘¥∫’„πμ”·Àπàßμà“ßÊ „π ∂“π„Àâ∫√‘°“√øÕ°‡≈◊Õ¥ √«¡ ∑—Èß ‡§√◊ËÕß≈â“ß‰μ °√√‰°√ ª“°§’∫ À√◊Õ·¡â°√–∑—Ëß≈Ÿ°∫‘¥ª√–μŸ 64 ¥—ßπ—Èπæ◊Èπº‘«μà“ßÊ ∑’Ë¡’‚Õ°“ ªπ‡ªóôÕπ ‡≈Õ◊ ¥·≈–‰¡∂à °Ÿ ∑”§«“¡ –Õ“¥Õ¬“à ߇À¡“– ¡ “¡“√∂‡ªπì ·À≈ßà ·æ√°à √–®“¬‡™Õ◊È ‰«√ — μ∫— Õ°— ‡ ∫™π¥‘ ∫‰’ ¥â ·≈–¡’√“¬ß“π«à“‡™◊ÈÕ “¡“√∂ºà“πμ—«°√Õß™π‘¥ high flux ‰¥â ·μà𔬓 dialysate ·≈– ultrafiltrate ®–‡ªìπ ·À≈à߇擖‡™◊ÈÕÀ√◊Õ‰¡à¬—߉¡à™—¥‡®π65,66 (μ“√“ß∑’Ë 4 ·≈– 5) ‡®â“Àπâ“∑’Ë„π ∂“π„Àâ∫√‘°“√øÕ°‡≈◊Õ¥  “¡“√∂‡ªìπæ“À–𔇙◊ÈÕ‰«√— μ—∫Õ—°‡ ∫™π‘¥∫’®“° ºŸâªÉ«¬√“¬Àπ÷Ë߉ª àŸÕ’°√“¬‰¥â‡™àπ°—π ‚¥¬ºà“π∑“ß¡◊ÕÀ√◊Õ∂ÿß¡◊Õ∑’Ë¡’°“√ªπ‡ªóôÕπ‡™◊ÈÕ ¡’√“¬ß“π°“√·æ√à 265

Practical Dialysis in the Year 2009 μ“√“ß∑Ë’ 4 ªí®®—¬∑’Ë¡’º≈μàÕ°“√·æ√à√–∫“¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫™π‘¥∫’„πºâŸªÉ«¬øÕ°‡≈◊Õ¥68 1. «— ¥ÿ Õÿª°√≥å´÷Ë߉¡à‰¥â√—∫°“√∑”§«“¡ –Õ“¥Õ¬à“߇À¡“– ¡ 2. °“√„™â¢«¥¬“√à«¡°—π69 3. °“√‡μ√’¬¡¬“„πª√‘‡«≥∑’ËÕ“®ªπ‡ªóôÕπ‡≈◊Õ¥70 4. ‡®â“Àπâ“∑’Ë´÷ËߥŸ·≈ºâŸªÉ«¬71 μ“√“ß∑Ë’ 5 §”·π–π”„π°“√§«∫§ÿ¡°“√·æ√à√–∫“¥¢Õ߉«√— μ—∫Õ—°‡ ∫™π‘¥∫’ (¥—¥·ª≈ß®“°§”·π–π”¢Õß CDC72) ë ≈â“ß¡◊Õ∑ÿ°§√—ÈßÀ≈—ߥŸ·≈ºâŸªÉ«¬À√◊Õ —¡º— Õÿª°√≥å¢ÕߺŸâªÉ«¬ ë „ à∂ÿß¡◊Õ∑ÿ°§√—Èß∑’Ë„Àâ°“√¥Ÿ·≈ºŸâªÉ«¬ ·≈–‡ª≈’ˬπ∂ÿß¡◊Õ∑ÿ°§√—ÈßÀ“°‡ª≈’ˬπºâŸªÉ«¬∑’Ë¥Ÿ·≈ ë „ àÀπâ“°“°·≈–‡ ◊ÈÕ§≈ÿ¡‡ ¡Õ ‡¡◊ËÕ —¡º— °—∫‡≈◊Õ¥À√◊Õ “√§—¥À≈—Ëß73 ë °“√μ√«®‡™◊ÈÕ·≈–¿¡Ÿ ‘§ÿâ¡°—π „πºâŸªÉ«¬·≈–‡®â“Àπâ“∑’ˇªìπª√–®” (√«¡∑—Èßμ√«®√“¬‡¥◊Õπ„πºŸâªÉ«¬∑’ˇ ’ˬßμàÕ°“√μ‘¥‡™◊ÈÕ) ë ·¬°ºâŸªÉ«¬∑’Ë¡’ HBsAg ‡ªìπ∫«°ÕÕ° ë ·¬°‡®â“Àπâ“∑’Ë´÷Ëß„Àâ°“√¥Ÿ·≈ºâŸªÉ«¬∑’Ë¡’ HBsAg ‡ªìπ∫«° ÕÕ°μà“ßÀ“°„πÀπ÷Ëß°– ë ·¬°Õÿª°√≥å„π°“√øÕ°‡≈◊Õ¥‡©æ“–¢ÕߺŸâªÉ«¬∑’Ë¡’ HBsAg ‡ªìπ∫«°ÕÕ° ë ‰¡§à «√„™μâ «— °√Õß´”È ·¡®â “°∫“ß°“√»°÷ …“®–‰¡æà ∫«“à ‚Õ°“ °“√쥑 ‡™ÕÈ◊ ‰«√ — μ∫— Õ°— ‡ ∫™π¥‘ ∫‡’ æ¡Ë‘ ¢÷Èπ®“°°“√„™âμ—«°√Õß´È”74 ë ·¬°∂“¥¢Õߺ⟪ɫ¬·μà≈–§πÕÕ°‡©æ“–μ—« (‰¡à«à“®–¡’‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫™π‘¥∫’À√◊Õ‰¡à) ë ≈â“ß∑”§«“¡ –Õ“¥·≈–°”®—¥‡™◊ÈÕÕÿª°√≥åÕ¬à“߇À¡“– ¡°àÕπ𔉪„™â°—∫ºŸâªÉ«¬√“¬Õ◊Ëπ ë ∑”§«“¡ –Õ“¥·≈–°”®—¥‡™◊ÈÕ®“°Õÿª°√≥å·≈– ‘Ëß·«¥≈âÕ¡μà“ßÊ  ¡Ë”‡ ¡Õ ë À≈’°‡≈’ˬ߰“√„™â√∂‡¢Áπ ”À√—∫„ à¬“·≈–Õÿª°√≥å∑“ß°“√·æ∑¬å (medication supply cart) ´÷ËßÕ“® °àÕ„À⇰‘¥°“√ªπ‡ªóôÕπ¢Õ߇™◊ÈÕ √–∫“¥¢Õ߇™◊ÈÕ„π‚√ß欓∫“≈ (nosocomial infection) „πª√–‡∑»∫√“´‘≈ ´÷Ë߬◊π¬—π subtype ¢Õ߇™◊ÈÕ∑’Ë √–∫“¥„π ∂“π„À∫â √°‘ “√øÕ°‡≈Õ◊ ¥«“à μ√ß°π— °∫— ‡™Õ◊È ∑√’Ë –∫“¥„π‚√ß欓∫“≈„π¢≥–ππ—È ·≈–¡√’ “¬ß“π®“° DOPPS (Dialysis Outcomes and Practice Patterns Study) «à“°“√μ‘¥‡™◊ÈÕ (HBV seroconversion) ≈¥≈ß À“°¡’°“√„Àâ°“√√—°…“ºŸâªÉ«¬∑’ˉ¥â√—∫‡™◊ÈÕ„π‚√ß欓∫“≈Õ¬à“߇À¡“– ¡67 æ∫«à“°“√·¬°ºâŸªÉ«¬·≈–Õÿª°√≥凩擖¢Õߺ⟪ɫ¬∑’Ë¡’ HBsAg ‡ªìπ∫«°ÕÕ°®“°ºâŸªÉ«¬∑—Ë«‰ª ®–™«à ¬≈¥‚Õ°“ „π°“√·æ√‡à ™ÕÈ◊ ≈߉¥â 70-80%75 ª®í ®∫ÿ π— ·¡«â “à Õ∫ÿ μ— °‘ “√≥¢å Õß°“√‡°¥‘ °“√√–∫“¥¢Õ߉«√ — μ—∫Õ—°‡ ∫™π‘¥∫’®–μË” ·μଗߠ“¡“√∂æ∫‰¥âª√–ª√“¬ ‚¥¬®“°°“√μ√«® Õ∫ ¡—°æ∫«à“‡ªìπº≈¡“®“° §«“¡º‘¥æ≈“¥„π¡“μ√°“√§«∫§ÿ¡°“√μ‘¥‡™◊ÈÕ ‡™àπ ‰¡à‰¥â‡®“–‡≈◊Õ¥μ√«® HBsAg ¢Õߺ⟪ɫ¬μ“¡°”Àπ¥ 266

Infectious Control Requirements for Hemodialysis Facilities °“√„™â∫ÿ§≈“°√À√◊ÕÕÿª°√≥å∑“ß°“√·æ∑¬å√à«¡°—π √–À«à“ߺ⟪ɫ¬∑’Ëμ‘¥‡™◊ÈÕ·≈–ºâŸªÉ«¬ª°μ‘ √«¡∂÷ß °“√„™â ¢«¥¬“©’¥™π‘¥„™â§√—È߇¥’¬«√à«¡°—π76 ®“°°“√‡ΩÑ“√–«—ß æ∫«à“ªí®®—¬‡ ’ˬߢÕß°“√μ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫ ™π‘¥∫’ ‰¥â·°à °“√¡’ºŸâªÉ«¬μ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫™π‘¥∫’¡“°°«à“ 1 §π „π ∂“π„Àâ∫√‘°“√øÕ°‡≈◊Õ¥´÷Ë߉¡à ‰¥√â ∫— °“√·¬°ÕÕ°Õ¬“à ߇À¡“– ¡·≈–Õμ— √“°“√©¥’ «§— ´π’ ‰«√ — μ∫— Õ°— ‡ ∫™π¥‘ ∫μ’ ”Ë °«“à §√ßË÷ ÀπßË÷ ¢ÕߺªŸâ «É ¬ ∑—ÈßÀ¡¥77,78 3.6 «§— ´’πªÕÑ ß°—π‰«√— μ—∫Õ°— ‡ ∫™π‘¥∫’ °“√©¥’ «§— ´π’ ªÕÑ ß°π— ‰«√ — μ∫— Õ°— ‡ ∫™π¥‘ ∫Õ’ “®™«à ¬≈¥§«“¡‡ ¬’Ë ß„π°“√쥑 μÕà ≈߉¥∂â ß÷ √Õâ ¬≈– 7079 ·≈– ¡§«√„Àâ«—§´’πμ—Èß·μà‡√‘Ë¡¡’°“√≈¥≈ߢÕß°“√∑”ß“π¢Õß‰μ ‡π◊ËÕß®“°Õ—μ√“°“√‡°‘¥¿Ÿ¡‘§ÿâ¡°—π ·ª√º—πμ“¡√–¥—∫°“√∑”ß“π¢Õ߉μ80 (μ“√“ß∑’Ë 6) «—§´’πªÑÕß°—π‰«√— μ—∫Õ—°‡ ∫™π‘¥∫’„πª√–‡∑»‰∑¬ ¡’À≈“¬™π‘¥ ‡™àπ Recombivax HB™ ¢Õß Merck ·≈– Engerix-B® ¢Õß SmithKline-Beecham Recombivax HB™ ∫√√®ÿ10-40 μg/mL „π¢≥–∑’Ë Engerix-B® Õ¬àŸ„π√Ÿª·∫∫§«“¡‡¢â¡¢âπ 20 μg/mL °“√„Àâ«—§´’π·∫∫ª∞¡¿Ÿ¡‘ª√–°Õ∫‰ª¥â«¬¬“©’¥ 3 §√—Èß ∑’Ë 0, 1 ·≈– 6 ‡¥◊Õπμ“¡≈”¥—∫  ”À√—∫ºâŸªÉ«¬øÕ°‡≈◊Õ¥ Õ“®©’¥«—§´’π 4 §√—Èß ∑’Ë 0, 1, 2 ·≈– 12 ‡¥◊Õπ ‚¥¬ª°μ‘ °“√μÕ∫ πÕßμàÕ«—§´’π„π§πª°μ‘ (𑬓¡‚¥¬√–¥—∫ antibody ¡“°°«à“ 10 milli-International Units [mIU]/mL) æ∫‰¥â¡“°°«à“ 90-95% ‚¥¬μ—«·ª√ ”§—≠∑’Ë¡’º≈≈¥°“√μÕ∫ πÕßμàÕ«—§´’π ‰¥â·°à °“√  ∫Ÿ ∫ÿÀ√’Ë §«“¡Õâ«π ¿“«–¿¡Ÿ ‘μâ“π∑“πμË” ·≈–Õ“¬ÿ ‚¥¬®–°“√μÕ∫ πÕßμàÕ«—§´’π≈¥≈߇À≈◊Õ‡æ’¬ß 75% „πºâŸªÉ«¬Õ“¬ÿ¡“°°«à“ 60 ª8ï 1,82  ”À√—∫ºŸâªÉ«¬øÕ°‡≈◊Õ¥æ∫«à“°“√μÕ∫ πÕßμàÕ«—§´’π≈¥≈߇™àπ‡¥’¬«°—π ·¡â®–„Àâ«—§´’π¢π“¥ Ÿß ‚¥¬∑—Ë«‰ª °“√μÕ∫ πÕßμàÕ«—§´’π‰«√— μ—∫Õ—°‡ ∫™π‘¥∫’‡æ’¬ß 64% ‡∑à“π—Èπ (¡√’ “¬ß“πμßÈ— ·μà 34-88%)83-88 À“°√∫— «§— ´π’ ‡æ¡Ë‘ ‡μ¡‘ ‡ªπì 4 §√ßÈ— Õ“®‡æ¡Ë‘ °“√μÕ∫ πÕ߇ªπì 86% (√“¬ß“π μ—Èß·μà 40-98%) 89,90  ”À√—∫„πª√–‡∑»‰∑¬ ∑«’ ™“≠™—¬√ÿ®‘√“ ·≈–§≥–91 √“¬ß“π°“√„Àâ recombinant hepatitis B vaccine 10 mcg ‡¢â“∑“ߺ‘«Àπ—ß (intradermal) ∑ÿ° 2  —ª¥“Àå 7 §√—Èß „πºâŸªÉ«¬øÕ°‡≈◊Õ¥  “¡“√∂°Õà ¿¡Ÿ ª‘ ÕÑ ß°π— ‰¥¡â “°°«“à ·≈–‡√«Á °«“à °“√„À«â §— ´π’ ¢π“¥ 40 mcg ‡¢“â °≈“â ¡‡πÕ◊È 4 ‡¢¡Á Õ¬“à ß™¥— ‡®π 3.7 §”·π–π”‡æË¡‘ ‡μ¡‘ ®“° CDC „πªï æ.». 2551 »Ÿπ¬å∫√‘°“√ Medicare ·≈– Medicaid (CMS) ·Ààß À√—∞Õ‡¡√‘°“ ‰¥â°”Àπ¥ °Ø‡°≥±‡å ßÕ◊Ë π‰¢„π°“√§√Õ∫§≈¡ÿ §“à „™®â “à ¬„π°“√√°— …“欓∫“≈ ”À√∫— ºªŸâ «É ¬‰μ«“¬‡√Õ◊È √ß— √–¬– ¥ÿ ∑“â ¬92 ‚¥¬‰¥°â ”Àπ¥§≥ÿ  ¡∫μ— ´‘ ß÷Ë  ∂“π„À∫â √°‘ “√øÕ°‡≈Õ◊ ¥®”‡ªπì μÕâ ß¡‡’ æÕ◊Ë „Àºâ “à π°“√√∫— √Õß®“°∑“ß‚§√ß°“√ Medicare ·≈–¬—ßμ—Èß„®„À⇪ìπ°“√ª√—∫ª√ÿß ¡“μ√∞“π°“√„Àâ∫√‘°“√·°àºŸâªÉ«¬øÕ°‡≈◊Õ¥Õ¬à“ß¡’§ÿ≥¿“æ ©∫—∫‡¥‘¡¢Õß CMS πÕ°®“°π’Ȭ—߉¥â√«¡‡Õ“ §”·π–π”„π°“√ªÑÕß°—π°“√μ‘¥μàÕ¢Õß‚√§μ‘¥‡™◊ÈÕ√–À«à“ß ºªŸâ «É ¬øÕ°‡≈Õ◊ ¥¢Õß»πŸ ¬§å «∫§¡ÿ ‚√§μ¥‘ μÕà 93 (Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients) „πªï æ.». 2544 ‡¢â“¡“‡ªìπ‡ß◊ËÕπ‰¢„π°“√§√Õ∫§≈ÿ¡§à“„™â®à“¬ Õ’°¥â«¬ ¥—ßπ—Èπ μ—Èß·μà«—π∑’Ë 14 μÿ≈“§¡ æ.». 2551 ‡ªìπμâπ‰ª  ∂“π„Àâ∫√‘°“√øÕ°‡≈◊Õ¥∑ÿ°·Ààß®”‡ªìπ μâÕߪؑ∫—μ‘μ“¡§”·π–π”¢Õß»πŸ ¬å§«∫§ÿ¡‚√§μ‘¥μàÕ ‡æ◊ËÕ∑’Ë®–‰¥â√—∫§à“™¥‡™¬ ”À√—∫ºâŸªÉ«¬øÕ°‡≈◊Õ¥ 267

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Infectious Control Requirements for Hemodialysis Facilities μ“√“ß∑’Ë 6 °“√„Àâ«—§´’π‰«√— μ—∫Õ—°‡ ∫™π‘¥∫’ ë „Àâ«—§´’π·°àºâŸªÉ«¬∑’Ë¡’‚Õ°“ μ‘¥‡™◊ÈÕ∑ÿ°√“¬ ë μ√«®À“ anti-HBs 1-2 ‡¥◊Õπ À≈—߉¥â√—∫«—§´’π‡¢Á¡ ÿ¥∑⓬  À“° anti-HBs πâÕ¬°«à“ 10 mIU/mL „Àâ«—§´’π´È” 3 §√—Èß ·≈–μ√«® anti-HBs ´È”  À“° anti-HBs ¡“°°«à“ 10 mIU/mL ∂◊Õ«à“ºŸâªÉ«¬¡’¿¡Ÿ ‘§ÿâ¡°—π „Àâμ√«®ªï≈–§√—Èß ë „Àâ«—§´’π‡ √‘¡ (booster dose) À“° anti-HBs ≈¥≈ßμË”°«à“ 10 mIU/mL ë μ√«®‡≈◊Õ¥¥Ÿ anti-HBs ªï≈–§√—Èß μ“√“ß∑Ë’ 7 §”·π–π”¢Õß CDC  ”À√—∫°“√„™â¬“∑’Ë„™â§√—È߇¥’¬«∑‘Èß„πºâŸªÉ«¬‚√§‰μ«“¬‡√◊ÈÕ√—ß√–¬– ÿ¥∑⓬ ë °“√∫√‘À“√¬“©’¥∑”‚¥¬∫ÿ§≈“°√∑’Ë¡’§«“¡‡™’ˬ«™“≠·≈–¡’§«“¡√⟇°’ˬ«°—∫ aseptic technique ë ¬“©’¥∑ÿ°¢«¥§«√∂Ÿ°„™â¿“¬„π 4 ™—Ë«‚¡ßÀ≈—߇ªî¥„™â ë ∫ÿ§≈“°√∑“ß°“√·æ∑¬å§«√‡ªî¥¬“©’¥‡æ’¬ß·§à¢«¥‡¥’¬«„π‡«≈“‡¥’¬«°—π À≈’°‡≈’ˬ߰“√‡ªî¥¬“©’¥ À≈“¬¢«¥æ√âÕ¡°—𠧫√‡√‘Ë¡‡ªî¥¬“©’¥¢«¥∑’Ë ÕßÀ≈—ß®“°∑‘È߬“¢«¥·√°‰ª·≈â« ë ¬“©’¥„π¢«¥∑’ˇªî¥„™â·≈â«À√◊Õ°√–∫Õ°©’¥¬“ (√«¡∑—Èß erythropoietin alpha, ‡À≈Á° À√◊Õ «‘μ“¡‘π¥’) μâÕß∂Ÿ°∑‘Èß¿“¬„π 4 ™—Ë«‚¡ß À≈—ß®“°„™â§√—Èß·√° ¥—ßπ—Èπ®÷ߧ«√®¥∫—π∑÷°·≈–μ‘¥ ≈“°∫Õ°‡«≈“°“√ „™â§√—Èß·√°∫π¢«¥¬“‡ ¡Õ ·≈–‡°Á∫¢«¥¬“‰«â∑’ËÕÿ≥À¿Ÿ¡‘ √–À«à“ß 2-8 Õß»“‡´≈‡´’¬  (36-46 Õß»“ø“‡√π‰Œ∑å) √–À«à“ß∑’ˉ¡à‰¥â„™â ë Àâ“¡‡°Á∫√«¡¬“©’¥∑’ˇÀ≈◊Õ®“°°“√„™â‡¢â“¥â«¬°—π‚¥¬‡¥Á¥¢“¥ (‰¡à«à“¬“©’¥™π‘¥¢«¥À√◊Õ∫√√®ÿ‡¢Á¡) À“°ºŸâªÉ«¬μâÕß°“√ª√‘¡“≥¬“¡“°°«à“Àπ÷ËßÀ≈Õ¥ §«√„™âÀ≈Õ¥©’¥¬“„À¡àÀπ÷ËßÀ≈Õ¥ ”À√—∫¬“ ©’¥®“°·μà≈–¢«¥ ë  ∂“π„Àâ∫√‘°“√øÕ°‡≈◊Õ¥·μà≈–·Ààߧ«√¡’√–∫∫μ√«® Õ∫·≈–ª√–°—π§ÿ≥¿“æ ‡æ◊ËÕ„À⇪ìπ‰ªμ“¡ §”·π–π”¥—ß°≈à“« ‚¥¬√«¡∂÷ß ë °“√∫—π∑÷°¢âÕ¡≈Ÿ °“√μ‘¥‡™◊ÈÕ„πºŸâªÉ«¬øÕ°‡≈◊Õ¥ ë °“√μ√«® Õ∫°“√ªØ∫‘ μ— ß‘ “π ‚¥¬¡∫’ §ÿ ≈“°√μ√«®ª√–°π— §≥ÿ ¿“æ ‡Ω“Ñ  ß— ‡°μ°“√ªØ∫‘ μ— ß‘ “π‚¥¬‡ππâ re-use technique ë °“√‰¡àªØ‘∫μ‘μ“¡§”·π–π”π’È„π√–¬–‡«≈“μ‘¥μàÕ°—π Õ“®π”¡“´÷Ëߧ«“¡‡ ’ˬ߷≈–Õ—πμ√“¬Õ—π‡°‘¥ ¢÷Èπ·°àºâŸªÉ«¬ ‡Õπ‰´¡åμ—∫104 „π™«à ß∑¡’Ë °’ “√쥑 ‡™Õ◊È ‡©¬’ ∫æ≈π— ®– “¡“√∂æ∫ HCV RNA ‰¥„â π‡≈Õ◊ ¥À√Õ◊ ‡πÕ◊È μ∫— ‚¥¬¡°— μ√«® æ∫‰¥â¥â«¬«‘∏’ PCR μ—Èß·μà 1-8  —ª¥“ÀåÀ≈—߉¥â√—∫‡™◊ÈÕ „π¢≥–∑’ˇÕπ‰´¡åμ—∫ (transaminase) ®–‡æ‘Ë¡¢÷ÈπÀ≈—ß ‰¥â√—∫‡™◊ÈÕª√–¡“≥ 6-12  —ª¥“Àå ·μàæ∫«à“§«“¡ —¡æ—π∏å√–À«à“߇Õπ‰´¡åμ—∫·≈–º≈μ√«®™‘Èπ‡π◊ÈÕμ—∫§àÕπ 269

Practical Dialysis in the Year 2009 ¢â“ßμË” æ∫«à“ºâŸªÉ«¬Àπ÷Ëß„π “¡¡’§à“‡Õπ‰´¡åμ—∫ª°μ‘ ·μàÀ“°μ√«®™‘Èπ‡π◊ÈÕμ—∫®–æ∫«à“¡—°®–æ∫°“√ Õ—°‡ ∫·∫∫‡√◊ÈÕ√—ß„πμ—∫‡ ¡Õ ∫“ß°“√»÷°…“æ∫«à“ Õ—μ√“ à«π√–À«à“ß AST μàÕ ALT ∑’Ë¡“°°«à“ 1 Õ“® ™à«¬æ¬“°√≥å∂÷ß°“√¡’¿“«–μ—∫·¢Á߉¥â 4.2 °“√μ√«®§—¥°√Õß·≈–«‘π®‘ ©¬— ‚¥¬∑«—Ë ‰ª∑“ß»πŸ ¬§å «∫§¡ÿ ‚√§μ¥‘ μÕà ¢Õß À√∞— Õ‡¡√°‘ “·π–π”„À¡â °’ “√μ√«®§¥— °√Õß„πºªâŸ «É ¬ øÕ°‡≈◊Õ¥À√◊Õ‡§¬¡’ª√–«—μ‘øÕ°‡≈◊Õ¥‡√◊ÈÕ√—ß∑ÿ°√“¬ ¢âÕ∫àß™’ÈÕ◊ËπÊ ¢Õß°“√μ√«®§—¥°√Õ߉¥â·°à ‡§¬„™â¬“ ‡ æμ‘¥™π‘¥©’¥‡¢â“‡ â𠇧¬‰¥â√—∫‡≈◊Õ¥À√◊Õª≈°Ÿ ∂à“¬Õ«—¬«–°àÕπªï æ.». 2535 ·≈–ºâŸ∑’Ë¡’ª√–«—쑇ªìπ‚√§μ—∫ ·π–π”„Àâ àßμ√«® Anti-HCV ‚¥¬«‘∏’ enzyme-linked immunosorbent assay (ELISA) ‚¥¬„π ªí®®ÿ∫—π¡’°“√æ—≤π“°“√μ√«®„π generation ∑’Ë 3 ´÷Ëß¡’§«“¡‰« ßŸ ·≈–§«“¡®”‡æ“–‡æ‘Ë¡¡“°¢÷Èπ105 ·μà„π ºŸâªÉ«¬∑’Ëμ√«®æ∫ Anti-HCV ·μà‰¡à¡’ªí®®—¬‡ ’ˬߠ”À√—∫‰«√— μ—∫Õ—°‡ ∫™π‘¥´’ Õ“®æ‘®“√≥“ àßμ√«® ¬◊π¬—π¥â«¬°“√μ√«®À“ HCV RNA À√◊Õ«‘∏’ recombinant immunoblot assay √ÿàπ∑’Ë 2 (RIBA-2) ∑“ß American Association for the Study of Liver Diseases (AASLD) ·π–π”„Àâ àßμ√«® HCV RNA ∑ÿ°√“¬À“°º≈μ√«® antibody ‡ªπì ∫«°·≈–«“ß·ºπ®–„À¬â “√°— …“106 πÕ°®“°πÈ’ ¬ß— ·π–π”„À â ßà ·¡â Anti-HCV ‡ªπì ≈∫ ·μ à ß ¬— «“à ‡ªπì °“√쥑 ‡™Õ◊È ·∫∫‡©¬’ ∫æ≈π— À√Õ◊ ºªŸâ «É ¬¡¿’ ¡Ÿ §‘ ¡ÿâ °π— μË” »μ«√√… ∑Õß « — ¥‘Ï ‰¥√â “¬ß“π„πªï æ.». 2551107 ∂÷ß°“√μ√«® HCV RNA ®“° peripheral blood mononuclear cells (PBMCs) æ∫«à“™à«¬‡æ‘Ë¡§«“¡‰«„π °“√«‘π‘®©—¬·≈–Õ“®π”¡“„™â‡¡◊ËÕ¡’°“√√–∫“¥¢Õß‚√§ 4.3 °“√μ√«®μ‘¥μ“¡ ‡π◊ËÕß®“°ºâŸªÉ«¬¡—°‰¡à¡’Õ“°“√ ®”‡ªìπμâÕß¡’°“√μ√«®§—¥°√ÕßÀ“°“√μ‘¥‡™◊ÈÕ‡ªìπ√–¬–Ê „πºŸâ ∑’Ë¡’§«“¡‡ ’ˬß108 (√«¡∂÷ߺ⟪ɫ¬øÕ°‡≈◊Õ¥) ¥—ßμ“√“ß∑’Ë 8 ·≈– 9 4.4 °“√√—°…“ ªí®®ÿ∫—π·π–π”„Àâ‡√‘Ë¡°“√√—°…“‚¥¬„™â pegylated interferon √à«¡°—∫ ribavirin ´÷Ëß¡’°“√»÷°…“ æ∫«à“¥’°«à“¬“‡¥’ˬ«Ê À√◊Õ interferon ∏√√¡¥“ ¢π“¥¥—ß„πμ“√“ß∑’Ë 10 μ“√“ß∑’Ë 8 §”·π–π”„π°“√μ√«®§—¥°√Õß ”À√—∫‰«√— μ—∫Õ—°‡ ∫™π‘¥´’  ∂“π–ºŸªâ «É ¬ ‡√Ë‘¡μâπ ∑ÿ°‡¥◊Õπ ∑°ÿ 6 ‡¥Õ◊ π Anti-HCV ºâŸªÉ«¬∑ÿ°√“¬ Anti-HCV, ALT Anti-HCV ‡ªìπ≈∫ ALT Anti-HCV = antibody to hepatitis C virus; ALT = alanine aminotransferase 270

Infectious Control Requirements for Hemodialysis Facilities μ“√“ß∑Ë’ 9 ªí®®—¬‡ ’ˬߢÕß°“√μ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫™π‘¥´’ ª®í ®¬— ‡ ¬’Ë ß §”Õ∏∫‘ “¬ °“√‰¥â√—∫‡≈◊Õ¥ √–¬–‡«≈“∑’ˉ¥â√—∫°“√≈â“߉μ æ∫«“à ‚Õ°“ ∑ºË’ ªâŸ «É ¬μ¥‘ ‰«√ — μ∫— Õ°— ‡ ∫™π¥‘ ´‡’ æ¡‘Ë ¢π÷È ·ª√ºπ— °∫— ™π‘¥¢Õß°“√≈â“ß‰μ ®”π«π‡≈◊Õ¥∑’ˉ¥â√—∫109 ‡©æ“–„πºŸâªÉ«¬øÕ°‡≈◊Õ¥110 ·≈–·ª√º—π‚¥¬μ√ß°—∫√–¬–  ∂“π„Àâ∫√‘°“√øÕ°‡≈◊Õ¥ ‡«≈“111 12% „πºŸâªÉ«¬øÕ°‡≈◊Õ¥πâÕ¬°«à“ 5 ªï ·≈– 37% „πºâŸªÉ«¬øÕ°‡≈◊Õ¥¡“°°«à“ 5 ª1ï 12,113,114 °“√ª≈Ÿ°∂à“¬Õ«—¬«– °“√≈â“߉μ∑“ß™àÕß∑âÕß®–¡’§«“¡‡ ’ˬßμË”°«à“°“√øÕ°‡≈◊Õ¥ ª√–¡“≥ 5 ‡∑à“115 ‡π◊ËÕß®“°‚Õ°“ ªπ‡ªóôÕπÀ√◊Õ‰¥â√—∫‡≈◊Õ¥ μË”°«à“ °“√øÕ°‡≈◊Õ¥∑’Ë∑”∑’Ë∫â“π (home hemodialysis) ¡’§«“¡‡ ’ˬßμË”°«à“∑”„π ∂“π„Àâ∫√‘°“√øÕ°‡≈◊Õ¥ ‚Õ°“ μ‘¥‡™◊ÈÕ≈¥≈ßÀ“°‰¥â√—∫°“√√—°…“„π»πŸ ¬å´÷Ëß¡’°“√ §«∫§ÿ¡‚√§¥’ ·≈–¡’§«“¡™ÿ°¢Õߺ⟪ɫ¬μ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫ ™π‘¥´’μË” ‚Õ°“ μ‘¥‡™◊ÈÕ‡æ‘Ë¡¢÷Èπ À“° —¥ à«π¢Õß∫ÿ§≈“°√ ∑“ß°“√·æ∑¬åμàպ⟪ɫ¬μË”116 ºŸâªÉ«¬∑’ˇ§¬‰¥â√—∫°“√ª≈°Ÿ ∂à“¬Õ«—¬«–®–¡’‚Õ°“ μ‘¥‡™◊ÈÕ‰«√—  μ—∫Õ—°‡ ∫™π‘¥´’ Ÿß°«à“ μ“√“ß∑’Ë 10 ¢π“¥¬“∑’Ë„™â„π°“√√—°…“ºâŸªÉ«¬μ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫´’ ë  ”À√—∫ºŸâªÉ«¬∑’Ë¡’§«“¡‡ ’ˬߠߟ ‰¥â·°à genotype 1 À√◊Õ 4, ‡™◊ÈÕ™“μ‘ African American À√◊Õ¡’μ—∫·¢Áß √à«¡¥â«¬ §«√„Àâ Pegylated interferon √à«¡°—∫ ribavirin 48  —ª¥“Àå ë ¢π“¥¬“ ribavirin ∑’Ë„™â §◊Õ 1,000 ¡°  ”À√—∫ºŸâªÉ«¬πÈ”Àπ—°πâÕ¬°«à“ 75 °° ·≈– 1,200 ¡“°  ”À√—∫πÈ”Àπ—°¡“°°«à“ 75 °° ë  ”À√—∫ºâŸªÉ«¬∑’Ë¡’§«“¡‡ ’ˬßμË” ‡™àπ genotype 2 À√◊Õ 3 °“√√—°…“¥â«¬ ribavirin 800 mg μàÕ«—𠇪ìπ‡«≈“ 24  —ª¥“Àå 4.5 °“√ªÑÕß°π— °“√쥑 ‡™ÕÈ◊ ‰«√ — μ∫— Õ°— ‡ ∫™π‘¥´’ ‰«√— μ—∫Õ—°‡ ∫™π‘¥´’ “¡“√∂μ‘¥μàÕ‰¥â‚¥¬‡≈◊Õ¥∑’Ë¡’‡™◊ÈÕ ºà“π∑“ß∫“¥·º≈∑’˺‘«Àπ—ß ºŸâªÉ«¬∑’Ë ¡’°“√μ‘¥‡™◊ÈÕ·∫∫‡√◊ÈÕ√—߇ªìπæ“À–„π°“√μ‘¥μàÕ„π ∂“π„Àâ∫√‘°“√øÕ°‡≈◊Õ¥ √“¬ß“π°“√·æ√à√–∫“¥  à«π¡“°‡°’ˬ«¢âÕß°—∫§«“¡º‘¥æ≈“¥„π°“√§«∫§ÿ¡‚√§117 ‰¥â·°à ë ‰¡à‰¥â°”®—¥‡™◊ÈÕ„πÕÿª°√≥å∑’Ë„™â„πºŸâªÉ«¬·μà≈–√“¬ ë °“√„™â√∂‡¢Áπ®à“¬¬“·≈–Õÿª°√≥å„ÀâºâŸªÉ«¬√à«¡°—π118 271

Practical Dialysis in the Year 2009 ë °“√„™âÀ≈Õ¥¬“©’¥√à«¡°—π„πºŸâªÉ«¬À≈“¬√“¬ ·¡â«à“®–‡ªìπ™π‘¥„™â‰¥âÀ≈“¬§√—Èß ë ∂—ß„ àπÈ”¬“∑’Ë„™â√à«¡°—π‚¥¬‰¡à‰¥â¡’°“√°”®—¥‡™◊ÈÕ ë ‰¡à‰¥â≈â“ß∑”§«“¡ –Õ“¥·≈–¶à“‡™◊ÈÕ ∫√‘‡«≥∑’˪π‡ªóôÕπ‡≈◊Õ¥∑’ˇ§√◊ËÕßøÕ°‡≈◊Õ¥ ë ‰¡à‰¥â∑”§«“¡ –Õ“¥‡¡◊ËÕ¡’°“√ªπ‡ªóôÕπ¢Õ߇≈◊Õ¥„π∑—π∑’ ë §«“¡º‘¥æ≈“¥„π universal precautions119 πÕ°®“°π’ȉ«√— μ—∫Õ—°‡ ∫™π‘¥´’¬—ß “¡“√∂μ‘¥μàÕ¡“¬—ß∫ÿ§≈“°√∑“ß°“√·æ∑¬å∑’Ë¥Ÿ·≈ºâŸªÉ«¬ ‚¥¬º“à π∑“ßÕ∫ÿ μ— ‡‘ Àμ®ÿ “°‡¢¡Á ©¥’ ¬“ (needle-stick injury) ‚¥¬§«“¡‡ ¬Ë’ ß„π°“√쥑 ‡™ÕÈ◊ ª√–¡“≥√Õâ ¬≈– 2.7 ∂ß÷ 10120,121 Õ¬“à ߉√°μÁ “¡ ¥«â ¬¡“μ√°“√ªÕÑ ß°π— ∑¥’Ë ’ æ∫«“à ‚Õ°“ μ¥‘ ‡™Õ◊È ‰«√ — μ∫— Õ°— ‡ ∫™π¥‘ ´„’ π∫§ÿ ≈“°√ ‰¡à·μ°μà“ß®“°ºŸâ∫√‘®“§‡≈◊Õ¥∑—Ë«‰ª122 ¡’√“¬ß“π®“°»Ÿπ¬å≈â“߉μ„π´“Õÿ¥‘Õ“√–‡∫’¬«à“  “¡“√∂æ∫ RNA ¢Õ߉«√— μ—∫Õ—°‡ ∫™π‘¥´’ ‰¥â∫π¡◊Õ¢Õß∫ÿ§≈“°√∑“ß°“√·æ∑¬å ·¡â®–‡§√àߧ√—¥μàÕ¡“μ√°“√ªÑÕß°—π123 ¥—ßπ—Èπ·¡â«à“®–¡’¡“μ√°“√ ªÑÕß°—π∑’Ë¥’ ∫ÿ§≈“°√∑“ß°“√·æ∑¬å¬—ß “¡“√∂∑’Ë®–‡ªìπæ“À–·æ√à‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫™π‘¥´’√–À«à“ß ºâŸªÉ«¬øÕ°‡≈◊Õ¥ ¡°’ “√»°÷ …“®“°‡∫≈‡¬¬’Ë ¡æ∫«“à √Õâ ¬≈– 38 ¢ÕߺªŸâ «É ¬øÕ°‡≈Õ◊ ¥∑μ’Ë ¥‘ ‡™Õ◊È ‰«√ — μ∫— Õ°— ‡ ∫™π¥‘ ´’ ‰¡à‡§¬‰¥â√—∫‡≈◊Õ¥·≈–‰¡à¡’ªí®®—¬‡ ’ˬßÕ◊Ëπ¢Õß°“√μ‘¥‡™◊ÈÕ ·μàæ∫«à“°“√μ‘¥‡™◊ÈÕ‡°‘¥¢÷Èπ„πºŸâªÉ«¬∑’ˉ¥â√—∫°“√ øÕ°‡≈Õ◊ ¥„°≈°â ∫— ºªŸâ «É ¬μ¥‘ ‡™Õ◊È ‰«√ — μ∫— Õ°— ‡ ∫´1’ 24 ´ß÷Ë  π∫—  ππÿ ‚¥¬Õ°’ °“√»°÷ …“´ß÷Ë æ∫«“à Õ∫ÿ μ— °‘ “√≥¢å Õß °“√쥑 ‡™ÕÈ◊ ‰«√ — μ∫— Õ°— ‡ ∫™π¥‘ ´≈’ ¥≈ß™¥— ‡®π„π ∂“π„À∫â √°‘ “√øÕ°‡≈Õ◊ ¥∑¡Ë’ °’ “√·¬°ÀÕâ ߇©æ“–(isolated room)  ”À√—∫„Àâ°“√√—°…“ºŸâªÉ«¬∑’Ë¡’ Anti-HCV ‡ªìπ∫«°125 4.6  ‘Ëß∑Ë’¬ß— ‰¡à™¥— ‡®π„π°“√ªÑÕß°π— °“√μ‘¥‡™◊ÕÈ ‰«√ — μ∫— Õ—°‡ ∫™π¥‘ ´’ 4.6.1 °“√쥑 μàÕº“à π∑“߇§√◊ÕË ßøÕ°‡≈◊Õ¥ ¡√’ “¬ß“π°“√쥑 μÕà ¢Õ߉«√ — μ∫— Õ°— ‡ ∫™π¥‘ ´º’ “à π∑“߇§√Õ◊Ë ßøÕ°‡≈Õ◊ ¥‡™πà ‡¥¬’ «°π— ‚¥¬ºªŸâ «É ¬ ∑„Ë’ ™‡â §√ÕË◊ ßøÕ°‡≈Õ◊ ¥√«à ¡°∫— ºªŸâ «É ¬μ¥‘ ‡™ÕÈ◊ ‰«√ — μ∫— Õ°— ‡ ∫´’®–¡§’ «“¡‡ ¬Ë’ ß„π°“√쥑 ‡™ÕÈ◊  ßŸ °«“à ª°μ1‘ 26,127 °“√„™â‡§√◊ËÕßøÕ°‡≈◊Õ¥·¬° ”À√—∫ºŸâªÉ«¬μ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫´’ √à«¡°—∫¡“μ√°“√ªÑÕß°—π universal precautions ∑¥Ë’ ’ ®–™«à ¬≈¥°“√쥑 μÕà ‰¥â 128,129,130 °“√°”®¥— ‡™ÕÈ◊ ∑∂Ë’ °Ÿ μÕâ ß ‡™πà °“√∑” autoclave μ«— circuit °Á®– “¡“√∂≈¥‰«√— μ—∫Õ—°‡ ∫™π‘¥´’∑’ˇ§√◊ËÕ߉¥â‡™àπ°—π 131 ·μàÕ¬à“߉√°Á¥’ °“√μ‘¥μàÕ¢Õ߇™◊ÈÕºà“π‡§√◊ËÕß øÕ°‡≈◊Õ¥¬—߉¡à™—¥‡®π ‡π◊ËÕß®“°¡’À≈“¬°“√»÷°…“∑’ˬ—ß„Àâº≈¢—¥·¬âß ‚¥¬‰¡à· ¥ß„Àâ‡ÀÁπª√–‚¬™πå∑’Ë ™¥— ‡®π132,133 º‡âŸ ¢¬’ 𧥑 «“à °“√쥑 μÕà ¢Õ߇™ÕÈ◊ ‰«√ — μ∫— Õ°— ‡ ∫™π¥‘ ´º’ “à π∑“߇§√ÕË◊ ßøÕ°‡≈Õ◊ ¥·¡®â –‡ªπì ‰ª ‰¥â ·μ§à «“¡‡ ¬’Ë ß‰¡ à ߟ π°— À“° “¡“√∂§«∫§¡ÿ °“√쥑 μÕà ·≈–·æ√°√–®“¬¢Õ߇™Õ◊È ‰¥Õâ ¬“à ß¡ª’ √– ∑‘ ∏¿‘ “æ ‡™àπ ¡’°“√·¬°Õÿª°√≥å ∫ÿ§≈“°√∑’Ë¥·Ÿ ≈ºâŸªÉ«¬μ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫´’ÕÕ°Õ¬à“ß™—¥‡®π 4.6.2 ™π¥‘ ¢Õßμ—«°√Õß °“√ reuse ·≈–°“√쥑 μÕà ¢Õ߉«√—   ”À√∫— ™π¥‘ μ«— °√ÕßÕ“®¡º’ ≈μÕà °“√·æ√°à √–®“¬¢Õ߇™ÕÈ◊ ÕÕ°¡“„π ultrafiltrate ‚¥¬æ∫«“à ‰¡à «à“®–„™âμ—«°√Õß low-flux (cellulose) À√◊Õ high-flux (cellulose-diacetate, polysulfone À√◊Õ polyacrylonitrile) ®–π”¡“„™â´”È À√◊Õ‰¡à (reused) °‰Á ¡‰à ¥â∑”„Àâ¡’°“√ªπ‡ªÕóô π¢Õß HCV RNA „π ultrafiltrate134,135 ‚¥¬‡©æ“– 272

Infectious Control Requirements for Hemodialysis Facilities À“°„™â§«“¡¥—π transmembrane pressure μË”°«à“ 18.72 mmHg136 „π∑“ßμ√ß°—π¢â“¡ ¡’∫“ß√“¬ß“πæ∫ «à“¡’°“√ªπ‡ªóôÕπ¢Õß HCV RNA ºà“π polyacrylonitrile membranes ·μà‰¡àªπ‡ªóôÕπÀ“°„™â cellulose membranes137 Õ¬“à ߉√°μÁ “¡ ∫∑∫“∑¢Õßμ«— °√Õß·≈–°“√쥑 ‡™Õ◊È ‰«√ — μ∫— Õ°— ‡ ∫™π¥‘ ´§’ ßμÕâ ß¡°’ “√»°÷ …“ ‡æ‘Ë¡‡μ‘¡μàÕ‰ª 4.6.3 °“√μ√«®§—¥°√Õß Anti-HCV °“√μ√«® Anti-HCV ‡ªìπ non-neutralizing antibodies ·≈–‰¡à “¡“√∂·¬°√–À«à“ß°“√μ‘¥‡™◊ÈÕ ‡©’¬∫æ≈—π ·≈–°“√μ‘¥‡™◊ÈÕ„πÕ¥’μ‰¥â ·≈–∂÷ß·¡â«à“°“√μ√«®‡ªìπ≈∫°ÁÕ“®®–‰¡à “¡“√∂·¬°‰¥â·πàπÕπ (¬°‡«âπ„π°√≥’∑’˺≈°“√μ√«®∑’ˇ§¬‡ªìπ≈∫‡ª≈’ˬπ‡ªìπº≈∫«°  “¡“√∂„™â„π°“√«‘π‘®©—¬·≈–®–¡’ ª√–‚¬™πå„π°“√ªÑÕß°—π°“√·æ√à√–∫“¥μàÕ‰ª) °“√μ√«®∑’Ë·¡à𬔰«à“§◊Õ μ√«®À“ HCV RNA ‚¥¬«‘∏’ polymerase chain reaction (PCR) ·μà°Á¬—ß¡’√“§“·æß·≈–‰¡à·æ√àÀ≈“¬ „𧔷π–π”„πªï 2544 ¢Õß CDC ‰¥â·π–π”„Àâ¡’°“√μ√«®§—¥°√Õß°“√μ‘¥‡™◊ÈÕ‰«√— μ—∫ Õ—°‡ ∫™π‘¥´’ ‚¥¬°“√μ√«®À“ Anti-HCV ·≈–μ√«®´È”∑ÿ° 6 ‡¥◊Õπ À“°º≈μ√«®‡ªìπ≈∫ 4.6.4 °“√·¬°ºŸâª«É ¬∑μ’Ë ¥‘ ‡™ÕÈ◊ √«¡∑—ßÈ Õªÿ °√≥·å ≈–‡§√◊ËÕß¡Õ◊ „π‡™ÕÈ◊ ‰«√ — μ∫— Õ°— ‡ ∫™π¥‘ ∫´’ ßË÷ ‡ªπì ‡™ÕÈ◊ ∑μË’ ¥‘ μÕà º“à π∑“߇≈Õ◊ ¥‡™πà °π— æ∫«“à °“√μ√«®§¥— °√Õß ‰¥âº≈¥’„π°“√≈¥‚Õ°“ °“√μ‘¥μàÕ¢Õ߇™◊ÈÕ ·μà ”À√—∫‰«√— μ—∫Õ—°‡ ∫™π‘¥´’π—È𠧫“¡ “¡“√∂„π°“√ 쥑 μÕà μ”Ë °«“à ‰«√ — μ∫— Õ°— ‡ ∫™π¥‘ ∫’·≈–¡ª’ √¡‘ “≥„π‡≈Õ◊ ¥μ”Ë °«“à ·≈–∂°Ÿ ∑”≈“¬‰¥ßâ “à ¬°«“à ∑ÕË’ ≥ÿ À¿¡Ÿ À‘ Õâ ß ®÷߇ªìπ§”∂“¡«à“ ®”‡ªìπμâÕß·¬°„π·∫∫‡¥’¬«°—∫ºâŸªÉ«¬μ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫∫’À√◊Õ‰¡à πÕ°®“°π—Èπ °“√·¬°ºâŸªÉ«¬μ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫´’ÕÕ° ·¡â®–ªÑÕß°—πºŸâªÉ«¬√“¬Õ◊ËπÊ ·μà°Á®–∑”„À⇠’ˬßμàÕ°“√‡°‘¥ °“√μ‘¥‡™◊ÈÕ´âÕπ (superinfection) „πºâŸªÉ«¬∑’Ëμ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫´’Õ¬Ÿà·≈â« ‚¥¬¡’√“¬ß“πæ∫°“√μ‘¥‡™◊ÈÕ ‰«√ — μ∫— Õ°— ‡ ∫™π¥‘ ´Õ’ ¬“à ßπÕâ ¬ Õß “¬æπ— ∏‰å ¥„â πºªŸâ «É ¬øÕ°‡≈Õ◊ ¥√Õâ ¬≈–13138 ·μ§à «“¡ ”§≠— ∑“ߧ≈π‘ °‘ ¢Õß¿“«–π’Ȭ—߉¡à™—¥‡®π „πªí®®ÿ∫—π CDC ¢Õß À√—∞Õ‡¡√‘°“¬—߉¡à·π–π”„Àâ¡’°“√·¬°ºŸâªÉ«¬μ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫´’ ·¬°‡§√Õ◊Ë ßøÕ°‡≈Õ◊ ¥À√Õ◊ À“â ¡°“√ reuse μ«— °√Õß·μÕà ¬“à ß„¥ §ß·π–π”‡æ¬’ ß·μ„à À¬â ¥÷ universal precautions ·≈–≈â“ß∑”§«“¡ –Õ“¥·≈–°”®—¥‡™◊ÈÕ®“°‡§√◊ËÕßøÕ°‡≈◊Õ¥Õ¬à“߇À¡“– ¡ 5. °“√μ‘¥‡™Õ◊È ‰«√ — μ—∫Õ°— ‡ ∫™π¥‘ ®„’ πºŸªâ «É ¬øÕ°‡≈◊Õ¥ 5.1 Õ“°“√∑“ߧ≈π‘ °‘ πÕ°®“°‰«√— μ—∫Õ—°‡ ∫‡Õ ∫’ ´’ ¥’ ·≈–Õ’ ∑’Ë·æ∑¬å§ÿâπ‡§¬ „π√–¬–À≈—ß ¡’√“¬ß“π°“√æ∫‰«√—   “¬æπ— ∏„å À¡∑à °Ë’ Õà „À‡â °¥‘ ¿“«–μ∫— Õ°— ‡ ∫‡™πà ‡¥¬’ «°π—  Õß™π¥‘ ´ßË÷ ‰¥„â À™â ÕË◊ «“à Hepatitis G virus (HGV) ·≈– Hepatitis GB virus type C (HGBV-C) ´÷Ëß®—¥‡ªìπ flaviviruses π—°«‘®—¬®“° Genelabs ‰¥â§âπæ∫«à“‡™◊ÈÕ‰«√—  ∑ß—È  Õß “¬æπ— ∏πå ‡’È ªπì ‰«√ — ™π¥‘ ‡¥¬’ «°π— 139 ‰«√ — μ∫— Õ°— ‡ ∫ GB-C  “¡“√∂쥑 μÕà ‰¥ºâ “à π∑“߇≈Õ◊ ¥·≈–‡æ»  —¡æ—π∏å ®“°°“√μ√«®§—¥°√Õß„πºŸâ∫√‘®“§‚≈À‘μ æ∫«à“§«“¡™ÿ°¢Õ߉«√— ™π‘¥π’ÈÕ“® Ÿß°«à“‰«√— μ—∫ Õ—°‡ ∫™π‘¥´’‡ ’¬Õ’° °“√«‘π‘®©—¬ ‰«√— μ—∫Õ—°‡ ∫ GB-C ∑”‰¥â‚¥¬°“√μ√«® RNA ¢Õ߉«√— ®“°‡≈◊Õ¥¥â«¬«‘∏’ 273

Practical Dialysis in the Year 2009 polymerase chain reaction (PCR) °“√»°÷ …“∂ß÷ §«“¡‰«·≈–§«“¡®”‡æ“–¬ß— ‰¡™à ¥— ‡®π140 ‚¥¬∫“ß°“√»°÷ …“ æ∫«à“Õ“®¡’§«“¡‰«‰¡à∂÷ß√âÕ¬≈– 50 À“°„™â°“√‡°‘¥ antibody ‡ªìπ¡“μ√∞“π Õ¬à“߉√°Áμ“¡ RNA ¬—ß§ß ‡ªìπ gold standard  ”À√—∫°“√«‘π‘®©—¬„πªí®®ÿ∫—π ‚¥¬ anti-GBV-C antibody ‡ªìπμ—«™’È∫àß∂÷ß°“√°”®—¥ ‰«√— ®“°‡≈◊Õ¥·≈–¿Ÿ¡‘§ÿâ¡°—π®“°°°“√μ‘¥‡™◊ÈÕ ºªŸâ «É ¬∑¡’Ë ‰’ «√ — μ∫— Õ°— ‡ ∫ GB-C  «à π¡“° (ª√–¡“≥ “¡„π )’Ë ‰¡¡à Õ’ “°“√141 ·μ‰à «√ — μ∫— Õ°— ‡ ∫ GB-C  “¡“√∂°àÕ„À⇰‘¥μ—∫Õ—°‡ ∫∑—Èß™π‘¥‡©’¬∫æ≈—π·≈–‡√◊ÈÕ√—ß ¿“«–μ—∫·¢Áß·≈–¡–‡√Áßμ—∫ ªí≠À“À≈—° §◊Õ °“√«‘π‘®©—¬«à“‰«√— μ—∫Õ—°‡ ∫ GB-C ‡ªì𠓇Àμÿ‚¥¬μ√ߢÕß°“√‡°‘¥‚√§‡À≈à“π’È ºŸâªÉ«¬∑’Ë¡’‡™◊ÈÕ‰«√—  μ—∫Õ—°‡ ∫ GB-C ¡—°¡’ªí®®—¬‡ ’ˬßÕ◊ËπÊ ¢Õß°“√‰¥â√—∫‡™◊ÈÕ‚√§Õ◊ËπÊ ºà“π∑“߇≈◊Õ¥ √«¡∑—È߉«√— μ—∫Õ—°‡ ∫ ™π‘¥∫’·≈–´’ ºŸâ‡™’ˬ«™“≠∫“ß∑à“π‡™◊ËÕ«à“ ‰«√— μ—∫Õ—°‡ ∫ GB-C ‡ªìπ‡æ’¬ß·§à çOrphan virusé ·≈–‰¡à°àÕ ‚√§μ—∫Õ—°‡ ∫„π¡πÿ…¬1å 42,143 ‚¥¬æ∫«à“‰«√— μ—∫Õ—°‡ ∫ GB-C ‰¡à‡ª≈’ˬπ·ª≈ß°“√¥”‡π‘π‚√§„πºâŸªÉ«¬∑’Ë ‰¥√â ∫— °“√ª≈°Ÿ ∂“à ¬Õ«¬— «–144 À√Õ◊ ºªŸâ «É ¬∑¡Ë’ ‰’ «√ — ®√’ «à ¡°∫— ´’ ∑‰Ë’ ¥√â ∫— °“√√°— …“145 πÕ°®“°π∫È’ “ß°“√»°÷ …“ æ∫«à“‰«√— μ—∫Õ—°‡ ∫ GB-C æ∫‰¥â„π‡≈◊Õ¥‡ªìπÀ≈—°¡“°°«à“„π‡π◊ÈÕμ—∫ ´÷Ëß·μ°μà“ß®“°‰«√— Õ◊ËπÊ ´÷Ë߇ªìπ hepatotropism ‡™à𠉫√— μ—∫Õ—°‡ ∫™π‘¥∫’À√◊Õ´’ §ßμâÕß√Õ°“√»÷°…“·∫∫ prospective ´÷Ëß®–æ‘ Ÿ®πå §«“¡ —¡æ—π∏å‚¥¬μ√ß√–À«à“ß°“√μ‘¥‡™◊ÈÕ°—∫欓∏‘ ¿“æ„πªÕ¥μàÕ‰ª„πÕπ“§μ ¡’√“¬ß“π∑’Ëπà“ π„®‡°’ˬ«°—∫ª√–‚¬™πå¢Õ߉«√— μ—∫Õ—°‡ ∫ GB-C „πºâŸªÉ«¬μ‘¥‡™◊ÈÕ‰«√—  HIV ‚¥¬æ∫«à“ ‰«√— μ—∫Õ—°‡ ∫ GB-C Õ“®°√–μÿâπ cytokine ∫“ßμ—«∑’ˬ—∫¬—È߉«√—  HIV146 √«¡∑—È߇æ‘Ë¡ CD4 T Helper lymphocyte cytokine ¥â«¬147 Õ¬à“߉√°Áμ“¡‰«√— μ—∫Õ—°‡ ∫ GB-C ‰¡à àߺ≈°—∫°“√„Àâ°“√√—°…“ ¥â«¬¬“μâ“π‰«√— 148 ·≈–‰¡à¡’º≈ªÑÕß°—π°“√μ‘¥μàÕ¢Õ߇™◊ÈÕ149 5.2 °“√μ√«®§—¥°√Õ߉«√— μ∫— Õ°— ‡ ∫ GB-C °“√μ√«®§¥— °√Õ߉«√ — μ∫— Õ°— ‡ ∫GB-C„πºªâŸ «É ¬øÕ°‡≈Õ◊ ¥À√Õ◊ º∫Ÿâ √®‘ “§‡≈Õ◊ ¥¬ß— ‡ªπì ∑∂’Ë °‡∂¬’ ß °—π ·¡â®–æ∫«à“‰«√— μ—∫Õ—°‡ ∫ GB-C  “¡“√∂μ‘¥μàÕºà“π∑“߇≈◊Õ¥‰¥â ·μàº≈¢Õ߉«√— μ—∫Õ—°‡ ∫ GB-C μàÕ°“√‡°‘¥μ—∫Õ—°‡ ∫‡©’¬∫æ≈—π·≈–‡√◊ÈÕ√—ß √«¡∂÷ßμ—∫·¢Áß·≈–¡–‡√Áßμ—∫¬—߉¡à™—¥‡®π πÕ°®“°π’È ‚Õ°“  „π°“√‡°¥‘ μ∫— Õ°— ‡ ∫‡©¬’ ∫æ≈π— À≈ß— °“√‰¥√â ∫— ‡≈Õ◊ ¥¡μ’ ”Ë ¡“°‡¡ÕË◊ 殑 “√≥“®“°§«“¡™°ÿ ∑√Ë’ “¬ß“π„πºªŸâ «É ¬ °“√μ√«®æ∫‰«√— μ—∫Õ—°‡ ∫ GB-C Õ“®∑”„ÀâμâÕß ‘Èπ‡ª≈◊Õßß∫ª√–¡“≥„π°“√·¬°ºŸâªÉ«¬ √«¡∑—Èß≈¥ ®”π«πºâŸ∫√‘®“§‚≈À‘μ≈ßÕ¬à“ß¡“° ªí®®ÿ∫—π¬—߉¡à¡’°“√·π–π”„Àâμ√«®§—¥°√Õ߉«√— μ—∫Õ—°‡ ∫ GB-C ‡ªìπª√–®”„πºâŸªÉ«¬øÕ°‡≈◊Õ¥À√◊ÕºŸâ∫√‘®“§‚≈À‘μ 5.3 ‰«√— μ∫— Õ°— ‡ ∫ GB-C ·≈–ºâªŸ «É ¬øÕ°‡≈Õ◊ ¥ §«“¡™°ÿ ¢Õß°“√쥑 ‡™ÕÈ◊ ‰«√ — μ∫— Õ°— ‡ ∫ GB-C „πºªŸâ «É ¬øÕ°‡≈Õ◊ ¥‰¡·à μ°μ“à ß®“°ºªŸâ «É ¬∑≈Ë’ “â ß ‰μ∑“ß™àÕß∑âÕß ‚¥¬¡’√“¬ß“π°“√μ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫ GB-C ‰¡à·πàπÕπ √“¬ß“πμ—Èß·μà√âÕ¬≈– 3.1-29 „πºªŸâ «É ¬øÕ°‡≈Õ◊ ¥·∫∫‡√Õ◊È √ß— 150 «à π¡“°√“¬ß“π«“à §«“¡™°ÿ  ßŸ °«“à „πº∫Ÿâ √®‘ “§‡≈Õ◊ ¥∑«—Ë ‰ª´ß÷Ë Õ¬ªàŸ √–¡“≥ √âÕ¬≈– 1-2151 ·≈–‡™àπ‡¥’¬«°—∫„π§π∑—Ë«‰ª ∫∑∫“∑¢Õ߉«√— μ—∫Õ—°‡ ∫ GB-C μàÕ°“√‡°‘¥μ—∫Õ—°‡ ∫„π ºâŸªÉ«¬øÕ°‡≈◊Õ¥¬—߇ªìπ∑’Ë∂°‡∂’¬ß°—πÕ¬à“ß¡“° °“√»÷°…“®“°ª√–‡∑»®’π„πºâŸªÉ«¬øÕ°‡≈◊Õ¥æ∫«à“ °“√ μ‘¥μàÕ¢Õ߉«√— μ—∫Õ—°‡ ∫ GB-C æ∫‰¥â∂÷ß√âÕ¬≈– 16.2-28.8 ·μà°≈—∫‰¡àæ∫«à“°àÕ„À⇰‘¥Õ“°“√À√◊Õ§«“¡ 274

Infectious Control Requirements for Hemodialysis Facilities º¥‘ ª°μ¢‘ Õ߇Õπ‰´¡μå ∫— ·μÕà ¬“à ߉√152 º«Ÿâ ®‘ ¬—  √ªÿ «“à ‰«√ — μ∫— Õ°— ‡ ∫ GB-C ‰¡πà “à ®–‡ªπì ‰«√ — ∑°Ë’ Õà „À‡â °¥‘ μ∫— Õ—°‡ ∫ ∫“ß°“√»÷°…“æ∫«à“‰«√— μ—∫Õ—°‡ ∫ GB-C Õ“®¡’∫∑∫“∑·μà‡æ’¬ß‡≈Á°πâÕ¬„π°“√‡°‘¥μ—∫Õ—°‡ ∫ ·∫∫‡©¬’ ∫æ≈π— ·¡„â πºªŸâ «É ¬∑¡’Ë ¿’ ¡Ÿ §‘ ¡ÿâ °π— μË”153πÕ°®“°π¬’È ß— æ∫°“√쥑 ‡™Õ◊È √«à ¡°π— √–À«“à ߉«√ — μ∫— Õ°— ‡ ∫ GB-C ·≈–´‰’ ¥∫â Õà ¬ ·μæà ∫«“à °“√쥑 ‡™ÕÈ◊ √«à ¡‰¡‰à ¥‡â ª≈¬Ë’ π·ª≈ß°“√¥”‡ππ‘ ‚√§¢Õ߉«√ — μ∫— Õ°— ‡ ∫™π¥‘ ´·’ μà Õ¬à“߉√154,155 5.4 °“√ªÕÑ ß°π— °“√μ‘¥‡™◊ÈÕ‰«√— μ—∫Õ°— ‡ ∫ GB-C ¥—ß∑’Ë°≈à“«¡“·≈â««à“∫∑∫“∑¢Õ߉«√— μ—∫Õ—°‡ ∫ GB-C μàÕ°“√‡°‘¥‚√§μ—∫„πºŸâªÉ«¬øÕ°‡≈◊Õ¥ ¬—߉¡à™—¥‡®π „πªí®®ÿ∫—π ®÷߬—߉¡à¡’§”·π–π”„Àâμ√«®§—¥°√ÕßÀ√◊Õ·¬°ºŸâªÉ«¬∑’Ë¡’‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫ GB-C ºŸâ‡¢’¬π§‘¥«à“‚¥¬∑—Ë«‰ª ¡“μ√°“√§«∫§ÿ¡‚√§μ‘¥‡™◊ÈÕ∑—Ë«‰ª¥—ß°≈à“«¡“πà“®–‡æ’¬ßæÕ·≈â« 6. °“√쥑 ‡™Õ◊È ·≈–°“√ªÑÕß°—π‡™◊ÈÕ·∫§∑’‡√¬’ „πÀπ૬‰μ‡∑¬’ ¡ ‚√§μ¥‘ ‡™Õ◊È ‡ªπì  “‡Àμ°ÿ “√쓬Õπ— ¥∫— 2¢ÕߺªŸâ «É ¬∑√’Ë °— …“¥«â ¬°“√øÕ°‡≈Õ◊ ¥‚¥¬æ∫Õ∫ÿ μ— °‘ “√≥å ‰¥â√âÕ¬≈– 15 ¢Õß “‡Àμÿ°“√쓬∑—ÈßÀ¡¥156  à«π„À≠à°“√μ‘¥‡™◊ÈÕ®–‡°‘¥®“° vascular access157 (√âÕ¬≈– 28), √Õß≈߉ª§◊ÕªÕ¥ (√âÕ¬≈– 25), ∑“߇¥‘πªí  “«– (√âÕ¬≈– 23), √âÕ¬≈– 9 ‡°‘¥®“°º‘«Àπ—ß ·≈– √âÕ¬≈– 15 ‰¡à∑√“∫μ”·Àπàß™—¥‡®π °“√μ‘¥‡™◊ÈÕ∑’Ë vascular access ¡’§«“¡ ”§—≠ ‡æ√“–°àÕ„À⇰‘¥°“√·æ√à °√–®“¬ àŸ°√–· ‚≈À‘μ‰¥â ·≈–Õ“®¡’º≈„À⇠âπ vascular access ‡ ’¬‰¥â 6.1 °“√쥑 ‡™◊ÕÈ ¢Õß vascular access ‡™◊ÈÕ°àÕ‚√§∑’Ëæ∫∫àÕ¬∑’Ë ÿ¥‰¥â·°à S. aureus, coagulates-negative staphylococci (CNS), ‡™◊ÈÕ ·∫§∑’‡√’¬°√—¡≈∫, ‡™◊ÈÕ·∫§∑’‡√’¬°√—¡∫«° (√«¡∂÷ß enterococci) ·≈– ‡™◊ÈÕ√“ æ∫°“√μ‘¥‡™◊ÈÕ CNS ®“° °“√„™â catheter ¡“°°«à“°“√„™â AVF À√◊Õ graft μ“√“ß∑’Ë 11 ªí®®—¬Õ◊Ëπ∑’˺≈μàÕ°“√μ‘¥‡™◊ÈÕ¢Õß vascular access ë μ”·ÀπàߢÕß vascular access ∂Ⓡªìπ∑’Ë à«π≈à“ߢÕß√à“ß°“¬®–μ‘¥‡™◊ÈÕßà“¬°«à“ ë Trauma, √Õ¬ø°™È”, º‘«Àπ—ßÕ—°‡ ∫, °“√·°–‡°“∑’ˇ âπ ë  ÿ¢Õπ“¡—¬∑’ˉ¡à‡À¡“– ¡ ë Õ“¬ÿ¡“° ë ‡∫“À«“π ë ¡’¿¡Ÿ ‘§ÿâ¡°—π∫°æ√àÕß ë ‡À≈Á°‡°‘π 275

Practical Dialysis in the Year 2009 Õÿ∫—μ‘°“√≥å°“√μ‘¥‡™◊ÈÕ®“° vascular access æ∫‰¥â®“° catheter ¡“°∑’Ë ÿ¥ √Õß≈߉ª§◊Õ graft ·≈– ∑’ËπâÕ¬∑’Ë ÿ¥§◊Õ AVF158 °“√쥑 ‡™Õ◊È ¢Õß catheter Õ“®‡√¡‘Ë ®“°°“√쥑 ‡™Õ◊È ∑∫’Ë √‡‘ «≥™Õà ß∑“ßÕÕ° (exit site Infection) ‚¥¬ ≈—°…≥–∑’Ëæ∫®–‡ªìπ≈—°…≥–∫«¡·¥ßÕ“®æ∫ –‡°Á¥ ·≈–ÀπÕß ·≈–Õ“®¬—߇擖‡™◊ÈÕ‰¡à¢÷Èπ‰¥1â 59 ‡¡◊ËÕ ¡’°“√μ‘¥‡™◊ÈÕ∫√‘‡«≥π’È®–‡æ‘Ë¡‚Õ°“ ‡ ’ˬß∑’Ë®–‡æ‘Ë¡‡¢â“ àŸ°√–· ‡≈◊Õ¥ ®πÕ“®μâÕßπ”‡Õ“ “¬ÕÕ° The Canadian Society Nephrology ·≈– NKF-KDOQI (2000) ‰¥â·π–π”„Àâ„™âæ≈“ ‡μÕ√å„  ª¥î ∑Ë’ exit site À√Õ◊ Õ“®„™ºâ “â °Õ´·Àßâ °‰Á ¥â CDC ·π–π”„À„â ™â 2% chlorhexidine, 70% alcohol À√Õ◊ tincture iodine ∑”§«“¡ –Õ“¥∫√‘‡«≥ exit site ‰¥1â 60 Health Canada ·π–π”„Àâ„™â 2% chlorhexidine alcohol ∑”§«“¡ –Õ“¥∑’Ë “¬ artery ·≈– venous ‡æ√“–¡’°“√»÷°…“æ∫«à“°“√„™â chlorhexidine ™à«¬≈¥ Õÿ∫—μ‘°“√≥å°“√μ‘¥‡™◊ÈÕ‰¥â¥’°«à“ 10% povidone iodine À√◊Õ 70% alcohol161 ·≈–§«√μ√«®¥Ÿ exit site ∑ÿ° §√—Èß∑’˺⟪ɫ¬¡“√—∫°“√øÕ°‡≈◊Õ¥ «à“¡’√àÕß√Õ¬°“√μ‘¥‡™◊ÈÕÀ√◊Õ‰¡à 6.2 °“√·æ√°à √–®“¬¢Õ߇™ÈÕ◊ °“√μ‘¥μàÕ¢Õ߇™◊ÈÕ·∫§∑’‡√’¬„πÀπ૬‰μ‡∑’¬¡ Õ“®‡°‘¥®“° - ¿“¬πÕ° (®“°°“√ªπ‡ªóôÕπ¢ÕßπÈ”¬“ dialysate) À√◊ÕÕÿª°√≥åμà“ß Ê - ¿“¬„π (®“°μ—«ºâŸªÉ«¬‡Õß) °“√μ‘¥‡™◊ÈÕ®“°¿“¬πÕ°  à«π„À≠à‡°‘¥®“°°“√≈â“ßμ—«°√Õ߉¡à∂Ÿ°«‘∏’ À√◊Õ¡’°“√ªπ‡ªóôÕπ¢Õß √–∫∫π”È „πÀπ«à ¬ ¥ß— ‡§¬¡√’ “¬ß“π°“√·æ√√à –∫“¥¢Õ߇™ÕÈ◊ Burkholderia πÕ°®“°ππÈ— Õ“®‡°¥‘ ®“° Cepacia „πÀπ«à ¬‰μ‡∑¬’ ¡·Àßà ÀπßË÷ ®“°°“√쥑 ‡™ÕÈ◊ „π√–∫∫π”È 162 ‡æ√“–¡√’ Õ¬√«Ë— ¢Õß∑Õà „π√–∫∫ reverse osmosis πÕ°®“°π’È°“√μ‘¥‡™◊ÈÕ¬—߇°‘¥®“°Õÿª°√≥å°“√·æ∑¬å∑’Ë„™â√à«¡°—π‡™àπ À≈Õ¥¬“©’¥ ¬“ erythopoietin ‡ªì𠬓™π‘¥Àπ÷Ëß´÷Ëß„™â°—π∫àÕ¬„πÀπ૬‰μ‡∑’¬¡ ‡¡◊ËÕ„™â·≈⫧«√∑‘È߉ª‡≈¬‰¡à§«√·∫à߇°Á∫‰«â À√◊Õ„™â√à«¡°—∫ºâŸ ªÉ«¬√“¬Õ◊Ëπ °“√μ‘¥‡™◊ÈÕ®“°¿“¬„π√à“ß°“¬ Õ“®¡“®“°‡™◊ÈÕ‚√§∑’ËÕ“»—¬Õ¬Ÿà„πμ—«ºŸâªÉ«¬ (colonization) ‚¥¬ ‰¡à∑”„À⇰‘¥Õ“°“√°—∫§π ·μà®–°àÕ„À⇰‘¥‚√§·°àºŸâÕ◊Ëπ‰¥â ∑’Ëæ∫∫àÕ¬§◊Õ ‡™◊ÈÕ°àÕ‚√§‡À≈à“π—ÈπÕ“®Õ¬àŸ„π ‚æ√ß®¡°Ÿ À√◊Õ≈”‰ â¢Õß∫ÿ§≈“°√„πÀπ૬‰μ‡∑’¬¡ ·μà∂Ⓣ¡à¡’°“√ªÑÕß°—πÀ√◊Õ≈â“ß¡◊Õ‰¡à –Õ“¥°Á®–‡°‘¥ °“√·æ√à°√–®“¬‡™◊ÈÕ àŸºŸâÕ◊Ëπ‰¥â πÕ°®“°π—Èπ°“√·æ√à°√–®“¬‡™◊ÈÕÕ“®‡°‘¥®“°‡™◊ÈÕ‚√§‡°“–μ‘¥μ“¡Õÿª°√≥å μà“ßÊ ‡™àπ ¢Õ∫‡μ’¬ß ‚μä– °“√ªÑÕß°—π°“√μ‘¥‡™◊ÈÕ«‘∏’Àπ÷Ëߧ◊Õ μâÕß≈¥ª√‘¡“≥·∫§∑’‡√’¬ – ¡ (colonization) ‡À≈à“π’È„ÀâπâÕ¬∑’Ë ÿ¥ ·≈–„™â‡∑§π‘§ª√“»®“°‡™◊ÈÕ (aseptic technique) ∑ÿ°§√—Èß„πÀπ૬‰μ‡∑’¬¡ 6.3 ¿“«–‡™◊ÈÕ¥È◊Õ¬“ æ∫¿“«–‡™ÕÈ◊ ¥ÕÈ◊ ¬“„πºªŸâ «É ¬∑∑Ë’ ”°“√øÕ°‡≈Õ◊ ¥ ‡™ÕÈ◊ ∑æ’Ë ∫‰¥·â °à MRSA, VRE ·≈–‡™ÕÈ◊ ·∫§∑‡’ √¬’ °√¡— ≈∫∑¥’Ë Õ◊È ¬“À≈“¬™π¥‘ ‡™πà Pseudomonas aeruginosa, Stenotrophomonas maltophilia ·≈– Acinetobacter species ‡√Á«Ê π’È æ∫√“¬ß“π‡™◊ÈÕ S. aureus ∑’Ë¡’º≈‰«ª“π°≈“ßμàÕ vancomycin (vancomycin intermediate S. aureus, VISA) À√◊Õ glycopeptide -intermediate S. Aureus (GISA) ‡§¬¡’√“¬ß“π°“√·æ√à√–∫“¥¢Õ߇™◊ÈÕ VISA „πÀπ૬‰μ‡∑’¬¡∑’ËÕ—ß°ƒ… ·≈–À≈—ß®“°π—Èπæ∫√“¬ß“π„πª√–‡∑»Õ◊Ëπ¡“°¢÷Èπ‡√◊ËÕ¬Ê ‡™àπ„π 276

Infectious Control Requirements for Hemodialysis Facilities  À√—∞Õ‡¡√‘°“  “‡Àμÿ‡™◊ËÕ«à“‡ªìπ°“√·æ√à°√–®“¬√–À«à“ߺ⟪ɫ¬¥â«¬°—π·≈–‡ªìπ°“√‡§≈◊ËÕπ¬â“¬¢Õ߬’π∑’Ë ¥âÕ¬√–À«à“߇™◊ÈÕ enterococci ºŸâªÉ«¬∑’ËøÕ°‡≈◊Õ¥¡’Õ—μ√“°“√„™â¬“ vancomycin §àÕπ¢â“ß Ÿß ®÷ß¡’ºŸâ·π–π” „À⇠’ˬߡ“„™â cefazolin ·∑π ∂â“æ‘ Ÿ®π剥â«à“‡™◊ËÕ°àÕ‚√§‰«μàÕ¬“π’È ·≈–¬“π’È¡’§à“§√÷Ëß™’«‘쬓« 48-72 ™—Ë«‚¡ß ®÷ß “¡“√∂„™â©’¥‡ªìπ§√—Èߧ√“«À≈—ß°“√øÕ°‡≈◊Õ¥‰¥â‡™àπ°—π 6.4 °“√μ‘¥‡™◊ÕÈ º“à π∑“ßÕÿª°√≥å‰μ‡∑¬’ ¡ Õªÿ °√≥μå “à ßÊ ∑„Ë’ ™„â πÀÕâ ߉μ‡∑¬’ ¡ “¡“√∂‡ªπì ·À≈ßà ·æ√°à √–®“¬‡™ÕÈ◊ ‚√§‰¥â ‚¥¬‡©æ“–æπÈ◊ º«‘ ¥â“ππÕ°¢Õ߇§√◊ËÕ߉μ‡∑’¬¡ ‡™àπ ∫√‘‡«≥ªÿÉ¡ —¡º—  (control panel) √«¡‰ª®π∂÷ß∂—ߢ¬–∑’Ë√Õß√—∫πÈ”∑‘Èß ®“°°“√≈â“ßμ—«°√Õß ·≈–Õÿª°√≥åμà“ßÊ ∑’Ë«“߉«â∫π‡§√◊ËÕ߉μ‡∑’¬¡ 6.5 °“√∑”§«“¡ –Õ“¥ °“√≈“â ßÕ∫‡§√ÕË◊ ߉μ‡∑¬’ ¡·≈–μ«— °√Õß™«à ¬∑”≈“¬‡™ÕÈ◊ ·∫§∑‡’ √¬’  “√∑„Ë’ ™„â π°“√Õ∫≈“â ߇§√ÕË◊ ß ‰μ‡∑’¬¡ Õ“®∑”≈“¬‡™◊ÈÕ‰«√— ·≈–·∫§∑’‡√’¬‰¥â ·μà‰¡à∑”≈“¬ ªÕ√å¢Õß·∫§∑’‡√’¬ §«√∑”§«“¡ –Õ“¥ ∫√‘‡«≥¿“¬πÕ°‡§√◊ËÕߥ⫬πÈ”¬“∑”§«“¡ –Õ“¥∑—Ë«‰ª ·μàÕ¬à“„™â antiseptics ‡™àπ povidone-iodine, hexachlorophene À√◊Õ chlorhexidine ‡æ√“– “√‡§¡’‡À≈à“π’È„™â ”À√—∫°“√∑”§«“¡ –Õ“¥‡π◊ÈÕ‡¬◊ËÕ·≈– º‘«Àπ—߇∑à“π—Èπ ‚¥¬∑—Ë«‰ª ∑àÕ„π‡§√◊ËÕ߉μ‡∑’¬¡®–‰¡à¡’‚Õ°“ ‰¥âªπ‡ªóôÕπ°—∫‡≈◊Õ¥¢Õߺ⟪ɫ¬ ¬°‡«âπ∂â“¡’°“√ √—Ë«¢Õßμ—«°√Õß (dialyzer leak) ·μàÕ¬à“߉√°Á¥’ πÈ”¬“ dialysate ∑’˪π‡ªóôÕπ‡≈◊Õ¥π’È ®–∂°Ÿ ¢®—¥ÕÕ°∑“ßπÈ” ∑‘Èß·≈–‰¡à‰À≈°≈—∫‡¢â“‡§√◊ËÕ߉μ‡∑’¬¡ ¬°‡«âπ‡§√◊ËÕ߉μ‡∑’¬¡∑’Ë„™â√–∫∫ recirculating system °“√∑’Ë¡’ blood level ®–∑”„À⇰‘¥°“√ªπ‡ªóôÕπ¢Õ߇≈◊Õ¥¿“¬„πμ—«‡§√◊ËÕ߉¥â ®–μâÕß√—∫∑”°“√ disinfect ‡§√◊ËÕß∑—π∑’ ‡§√◊ËÕ߉μ‡∑’¬¡®–¡’μ—« pressure transducer ‡æ◊ËÕªÑÕß°—π°“√ªπ‡ªóôÕπ·≈–«—¥§«“¡¥—π¥â“π arterial ·≈– venous ·≈–¡∑’ ß—È pressure transducer ¥“â ππÕ°·≈–¥“â π„π ‡æÕ◊Ë ªÕÑ ß°π— ‡≈Õ◊ ¥ªπ‡ªÕóô π 2 ™π—È ‡¡Õ◊Ë μ«— pressure transducer ™—ÈππÕ°¡’°“√‡ªï¬°™◊Èπ ®–μâÕß√—∫‡ª≈’ˬπ ‡æ√“–¡‘©–π—Èπ®–¡’°“√ªπ‡ªóôÕπ¡“∂÷ß transducer ™—Èπ„π‰¥â Õ¬à“߉√°Á¥’¬—߉¡à¡’À≈—°∞“π¬◊π¬—π«à“°“√ªπ‡ªóôÕπ¢Õß transducer μ—«„π®–°àÕ„À⇰‘¥°“√·æ√à √–∫“¥¢Õ߇™◊ÈÕ·∫§∑’‡√’¬ 6.6 ·π«∑“ß°“√ªÕÑ ß°—π°“√μ‘¥‡™Õ◊È ·∫§∑‡’ √¬’ „πºŸâªÉ«¬øÕ°‡≈Õ◊ ¥ ‡π◊ËÕß®“°°“√·æ√à°√–®“¬¢Õß°“√μ‘¥‡™◊ÈÕ®–‡°‘¥ºà“π∑“ß°“√ —¡º— ¥â«¬¡◊Õ®“°∫ÿ§≈“°√„π Àπ૬‡ªìπ à«π„À≠à √Õß≈߉ª§◊Õ°“√μ‘¥μàÕºà“π∑“߇™◊ÈÕ‚√§∑’Ë – ¡∑’Ë∫√‘‡«≥μà“ßÊ ‡™àπ¢Õ∫‡μ’¬ß ¥—ßπ—Èπ °“√ªÑÕß°—π§◊Õ°“√≈â“ß¡◊ÕÕ¬à“ß∂Ÿ°«‘∏’ ·¡â®–„ à∂ÿß¡◊Õ°Áμ“¡ ‡æ√“– “¡“√∂æ∫‡™◊ÈÕ‚√§∑’ËÕ¬àŸ∫π∂ÿß¡◊Õ¡“ ª√“°Ø∑¡’Ë Õ◊ ‰¥Àâ ≈ß— ®“°∂Õ¥∂ßÿ ¡Õ◊ ‰ª·≈«â ∑ß—È πÕ’È “®‡ªπì ‡æ√“–¡√’ √Ÿ «—Ë À√Õ◊ ¡°’ “√ ¡— º — °∫— ¡Õ◊ ¢≥–∂Õ¥∂ßÿ ¡Õ◊ 163 §«√¡°’ “√„™â standard precaution ¥ß— ∑„’Ë ™„â πÀ≈°— °“√ªØ∫‘ μ— ‡‘ æÕ◊Ë ªÕÑ ß°π— °“√쥑 ‡™Õ◊È Õπ◊Ë ‚¥¬∑«—Ë ‰ª ‡™àπ „ à∂ÿß¡◊Õ ‡ ◊ÈÕ§≈ÿ¡ ºâ“ªî¥ª“° ‡¡◊ËÕμâÕß —¡º— ‡≈◊Õ¥ À√◊Õ “√§—¥À≈—Ëß√«¡∑—ÈßÕÿª°√≥å ∑’˧“¥«à“®–¡’ °“√ªπ‡ªóôÕπ „π°√≥’∑’Ë¡’ºâŸªÉ«¬μ‘¥‡™◊ÈÕ√ÿπ·√߇™àπ MRSA À√◊Õ VRE ®–μâÕß„™âÀ≈—° contact precaution ‚¥¬‡¢â¡ß«¥‚¥¬·¬°ºŸâªÉ«¬∑’ËÕ¬Ÿà„πÀâÕß·¬° ·≈–„Àâ∫ÿ§≈“°√ «¡‡ ◊ÈÕ§≈ÿ¡ ∂ÿß¡◊Õ·≈–ºâ“ªî¥ª“°∑ÿ°§√—Èß 277

Practical Dialysis in the Year 2009 ∂â“μâÕß —¡º— ºŸâªÉ«¬ Õ¬à“߉√°Á¥’  ”À√—∫ºâŸªÉ«¬„πÀπ૬‰μ‡∑’¬¡∑’Ë¡’ºŸâªÉ«¬∑’Ë¡’°“√μ‘¥‡™◊ÈÕ·∫§∑’‡√’¬Õ¬Ÿà ‰¡à®”‡ªìπ μâÕß·¬°ºâŸªÉ«¬ÕÕ° ‡æ√“–Õÿ∫—μ‘°“√≥å°“√·æ√à°√–®“¬‚√§‰¡à‰¥â Ÿß„π°√≥’π’È ·≈–„πÀπ૬‰μ‡∑’¬¡‡Õß°Á ¡’¡“μ√∞“π„π°“√ªÑÕß°—π°“√μ‘¥‡™◊ÈÕÕ¬à“߇¢â¡ß«¥Õ¬àŸ‡ ¡Õ 6.7 °“√·æ√à√–∫“¥¢Õ߇™◊ÕÈ mycobacterium „πÀπ૬‰μ‡∑¬’ ¡ ªí®®ÿ∫—ππ’È¡’ºâŸªÉ«¬∑’ˇªìπ«—≥‚√§‡æ‘Ë¡¢÷Èπ Õ“®‡ªìπ‡æ√“–¡’°“√·æ√à√–∫“¥¢Õ߇™◊ÈÕ HIV ‡æ‘Ë¡¢÷Èπ ¡’√“¬ß“πæ∫«à“Õÿ∫—μ‘°“√≥å¢Õß«—≥‚√§ Ÿß°«à“ª√–™“°√∑—Ë«‰ª164 ‡æ√“–ºâŸªÉ«¬‰μ«“¬®–¡’¿Ÿ¡‘§ÿâ¡°—π√–∫∫ ‡´≈≈å≈¥≈ß (cellular immunity) ·≈–‡ªìπ‡∫“À«“π√à«¡¥â«¬ ºâŸªÉ«¬∑’Ë∑”°“√øÕ°‡≈◊Õ¥¡—°‰¡à· ¥ßÕ“°“√ ¢Õß°“√μ‘¥‡™◊ÈÕ«—≥‚√§ Õ“®¡’Õ“°“√· ¥ß∑’ËÕ«—¬«–Õ◊Ëπ∑’ˉ¡à„™à∑’˪ե Õ¬à“߉√°Á¥’ ·π–π”„Àâ∑” tuberculin skin test „πºŸâªÉ«¬∑’ËøÕ°‡≈◊Õ¥ √à«¡°—∫°“√μ√«®‡Õ°‡√¬å ªÕ¥ ®–™à«¬„Àâμ√«®§âπºâŸªÉ«¬∑’ˇªìπ‚√§‰¥âßà“¬¢÷Èπ165 ∂â“μ√«®æ∫«à“ºŸâªÉ«¬‡ªìπ«—≥‚√§§«√·¬°ºŸâªÉ«¬ÕÕ° ®“°ºŸâªÉ«¬Õ◊Ëπ ®π°«à“®–μ√«®‡ ¡À–‰¡àæ∫‡™◊ÈÕ 7. °“√·æ√√à –∫“¥¢Õ߇™ÈÕ◊ HIV „πÀπ«à ¬‰μ‡∑’¬¡ Õ∫ÿ μ— °‘ “√≥¢å Õß°“√쥑 ‡™ÕÈ◊ HIV „πÀπ«à ¬‰μ‡∑¬’ ¡Õ¬√Ÿà –À«“à ß√Õâ ¬≈– 0-39166 ·≈–‡§¬¡√’ “¬ß“π °“√쥑 μÕà ‡™Õ◊È HIV „πÀπ«à ¬‰μ‡∑¬’ ¡167‡™Õ◊Ë «“à Õ“®‡°¥‘ ®“°¢∫«π°“√≈“â ßμ«— °√Õß„™´â È”·μ¬à ß— ‰¡¡à °’ “√쥑 μÕà ¢Õ߇™◊ÈÕ®“°°“√„™â‡§√◊ËÕ߉μ‡∑’¬¡√à«¡°—π ‚¥¬∑—Ë«‰ªμâÕßμ√«®‡≈◊Õ¥À“ HIV antibody °àÕπ∑”°“√øÕ° ‡≈Õ◊ ¥∑°ÿ §√ß—È „πμ“à ߪ√–‡∑»æ∫«“à ‡§¬¡√’ “¬ß“π°“√·æ√®à “°ºªâŸ «É ¬øÕ°‡≈Õ◊ ¥ ∫Ÿà §ÿ ≈“°√º“à π∑“߇¢¡Á μ”168 ·μଗ߉¡à¡’‡§¬¡’√“¬ß“π°“√·æ√ஓ°ºŸâªÉ«¬ àŸºŸâªÉ«¬ À√◊Õ®“°∫ÿ§≈“°√∑“ß°“√·æ∑¬å àŸºŸâªÉ«¬ ®÷ßμ√ß°—∫ ¢âÕ¡Ÿ≈∑—Ë«‰ª ‡™◊ÈÕ HIV ·æ√à√–∫“¥¬“°°«à“‰«√— μ—∫Õ—°‡ ∫∫’ √âÕ¬≈– 2-40 ‰«√— μ—∫Õ—°‡ ∫´’√âÕ¬≈– 3-10 ·≈– HIV √âÕ¬≈– 0.2-0.5 ‡∑à“π—Èπ CDC ‰¥â·π–π”«à“∂â“μâÕß∑”°“√øÕ°‡≈◊Õ¥·°àºŸâªÉ«¬ HIV „Àℙ⡓μ√°“√§«∫§ÿ¡·≈–ªÑÕß°—π ¡“μ√∞“π‚¥¬∑—Ë«‰ª ‰¡à®”‡ªìπμâÕß·¬°‡§√◊ËÕß „™â∑”§«“¡ –Õ“¥‡§√◊ËÕß·∫∫ª°μ‘ ∂â“¡’Õÿ∫—쑇Àμÿ‚¥π‡¢Á¡ μË” „À⥔‡π‘π°“√μ“¡ protocol ∑—Ë«‰ª 8. °“√„À⫧— ´’π„πºâªŸ «É ¬‰μ«“¬ 8.1 Staphylococcal vaccine ‡ªìπ conjugate vaccine ∑’˪√–°Õ∫¥â«¬ S. aureus type F ·≈– type 8 capsular polysaccharides (staph vax®) ‚¥¬„™â S. aureus type 5 ·≈– 8 conjugate °—∫æ“À–‚ª√μ’π (recombinant exoprotein A) ‰¥â ¡’°“√∑¥≈Õß©’¥ staph vax® ‡¢â“°≈â“¡ 1 §√—Èß „πºâŸªÉ«¬‰μ«“¬‡√◊ÈÕ√—ß ‡∑’¬∫°—∫πÈ”‡°≈◊Õ æ∫«à“ºŸâªÉ«¬¡’º≈ ¢â“߇§’¬ßπâÕ¬ «—§´’π°√–μÿâπ„À⇰‘¥¿¡Ÿ ‘μâ“π∑“π‰¥â¥’ ·μàºâŸ∑’Ë©’¥«—§´’π°Á¬—ß “¡“√∂‡°‘¥°“√μ‘¥‡™◊ÈÕ®“° S. aureus ‰¥â∫â“ß À≈—ß®“°©’¥¬“π“π‡°‘π 40  —ª¥“À1å 69 ¢≥–π’È«—§´’ππ’ȉ¥âºà“π°“√»÷°…“ æ∫«à“®–‰¥âº≈¥’ 278

Infectious Control Requirements for Hemodialysis Facilities ∑’Ë ÿ¥„π 1 ªï ·√°À≈—ß®“°‰¥â√—∫¬“ ¥—ßπ—Èπ®÷߉¥â¡’°“√»÷°…“ phase III µàÕ„πª√–‡∑» phase III „π  À√—∞Õ‡¡√‘°“‡√’¬∫√âÕ¬·≈â« æ∫«à“ª√– ‘∑∏‘¿“æÕ◊ËπÊ ‡æ◊ËÕ»÷°…“ª√– ‘∑∏‘¿“æ¢Õß«—§´’π170 8.2 «—§´’πªÕÑ ß°π— ‰¢Àâ «¥— „À≠à (Influenza vaccine) ºŸâªÉ«¬‚√§‰µ¡’‚Õ°“ ‡≈’ˬߠŸß∑’Ë®–µ‘¥‡™◊ÈÕ‰«√— ‰¢âÀ«—¥„À≠à¡“°°«à“ª√–™“°√∑—Ë«‰ª ‡π◊ËÕß®“° °“√©’¥«—§´’π‰¢âÀ«—¥„À≠à®–™à«¬≈¥Õÿ∫—µ‘°“√≥å°“√‡°‘¥‚√§‰¥â§àÕπ¢â“ߥ’„πª√–™“°√∑—Ë«‰ª ®“°°“√ »÷°…“°“√©’¥«—§´’ππ’È„πºâŸªÉ«¬‰µ«“¬∑’ˉ¥â∑” HD æ∫«à“¿Ÿ¡‘§ÿâ¡°—π¢÷Èπ‰¥âπâÕ¬°«à“§πª°µ‘ ·µà√–¥—∫°Á Ÿß æÕ∑’Ë®–ªÑÕß°—π‚√§‰¥1â 71,172 8.3 «—§´’πªÑÕß°—π‡™◊ÈÕ pneumococcal (pneumococcal vaccine) ‡™◊ÈÕ streptococcus pneumonia ‡ªìπ‡™◊ÈÕ∑’Ëæ∫‰¥â∫àÕ¬·≈–∑”„À⇰‘¥¿“«–·∑√°´âÕπ‰¥â¡“° §” ·π–π”ª®í ®∫ÿ π— ®“° Advisory committee on Immunization „Àºâ ªŸâ «É ¬∑¡’Ë ª’ ®í ®¬— ‡ ¬’Ë ßµÕà °“√‡°¥‘ ‚√§µ¥‘ ‡™Õ◊È ®“° pneumococcal ‡™àπ ºŸâ∑’ˇªìπ‚√§ªÕ¥Õ¬àŸ‡¥‘¡ ‡∫“À«“π·≈–ºâŸ∑’Ë¡’¿¡Ÿ ‘§ÿâ¡°—π∫°æ√àÕß ·≈–‡¥Á°∑’ËÕ“¬ÿ¡“°°«à“ 2 ªï √«¡∑—Èߺ⟪ɫ¬‡ªìπ‚√§‰µ«“¬‡√◊ÈÕ√—ß ‚√§ nephritic syndrome ·≈–ºâŸ∑’ˉ¥â√—∫¬“°¥¿Ÿ¡‘§ÿâ¡°—πÀ≈—ß°“√ ª≈Ÿ°∂à“¬Õ«—¬«– °Á§«√‰¥â√—∫«—§´’ππ’ȥ⫬‡™àπ°—π ®“°°“√»÷°…“„Àâ«—§´’ππ’È„π°≈ÿࡺ⟪ɫ¬‚√§‰µ„π‡¥Á°·≈– «—¬√ÿàπ¥â«¬ vaccine 23-valent pneumococcal vaccine æ∫«à“√–¥—∫¿¡Ÿ ‘§ÿâ¡°—π¢÷Èπ‰¥â¡“°°«à“ 200 ∂÷ß√âÕ¬≈– 83 ¿“¬„π 6 ‡¥◊Õπ ·≈–√âÕ¬≈– 48 „π 1 ªï «—§´’ππ’ȉ¡à¡’º≈¢â“߇§’¬ß„¥Ê ·µàµâÕß√–«—ß¿¡Ÿ ‘§ÿâ¡°—π®–≈¥≈ß ¿“¬„π 6 ‡¥◊Õπ 9.  √ªÿ ºâŸªÉ«¬‰µ«“¬∑’ˉ¥â√—∫°“√øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉µ‡∑’¬¡ ¡’‚Õ°“ ‡°‘¥°“√µ‘¥‡™◊ÈÕ‰¥âßà“¬∑—È߉«√—  ·∫§∑’‡√’¬ ·≈–‡™◊ÈÕ√“ ‚¥¬°“√·æ√à‡™◊ÈÕ®“°ºâŸªÉ«¬§πÀπ÷Ëß àŸÕ’°§πÀπ÷Ëß ºà“π∑“ßÕÿª°√≥åµà“ßÊ ∑’Ë„™â„π ÀâÕ߉µ‡∑’¬¡ À√◊Õºà“π∑“ß∫ÿ§≈“°√„πÀâÕ߉µ‡∑’¬¡°“√ªÑÕß°—π·≈–¡“µ√°“√§«∫§ÿ¡‚√§µ‘¥µàÕ∑’Ë¥’ ®– ™à«¬≈¥Õÿ∫—µ‘°“√≥å¢Õß°“√µ‘¥‡™◊ÈÕ ·≈–¬—ߺ≈„Àâ≈¥Õ—µ√“°“√‡®Á∫ªÉ«¬·≈–‡ ’¬™’«‘µ¢ÕߺŸâªÉ«¬øÕ°‰µ‰¥â ‡Õ° “√Õ“â ßÕß‘ 1. Õπÿµµ√ ®‘µµ‘π—π∑å (‚§√ß°“√≈ß∑–‡∫’¬π°“√√—°…“∑¥·∑π‰µ„πª√–‡∑»‰∑¬  ¡“§¡‚√§‰µ·Ààߪ√–‡∑»‰∑¬). °“√≈ß ∑–‡∫’¬π°“√√—°…“∑¥·∑π‰µ„πª√–‡∑»‰∑¬ (Thailand Renal Replacement Therapy Registry, TRT Registry): √“¬ß“π ªï 2540-2543. «“√ “√ ¡“§¡‚√§‰µ·Ààߪ√–‡∑»‰∑¬ 2545; 8: 167-179. 2. Hörl WH. Neutrophil function and infections in uremia. Am J Kidney Dis 1999;33:xlv-ii. 3. Snydman DR, Bryan JA, Hanson B. Hemodialysis-associated hepatitis in the United States-1972. J Infect Dis 1975;132:109-13. 4. Snydman DR, Bregman D, Bryan J. Hemodialysis-associated hepatitis in the United States, 1974. J Infect Dis 1977;135:687-91. 279

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