Practical Dialysis in the Year 2009

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Anti-EPO Associated Pure Red Cell Aplasia: The Updated Situation in Thailand Anti-EPO Associated 15 Pure Red Cell Aplasia: The Updated Situation in Thailand ‡°◊ÈÕ‡°¬’ √μ‘ ª√–¥‘…∞æå √»‘≈ªá 1. ∫∑π” 2. ¿“«– anti-rEPO associated PRCA 3. °“√μ√«® anti-rEPO antibody 4. °“√μ√«® neutralization assay 5.  “‡Àμ¢ÿ Õß anti-rEPO associated PRCA 6. ‚§√ß°“√ Prospective, Immunogenicity Surveillance Registry of Erythropoiesis Stimulating Agent (ESA) with Subcutaneous Exposure in Thailand (Thai ESA registry) 7. ·π«∑“ß°“√√°— …“ºªâŸ «É ¬¿“«– anti-rEPO associated PRCA 8. °“√„À¬â “°¥¿¡Ÿ §‘ ¡ÿâ °π— ‡æÕË◊ √°— …“¿“«– anti-rEPO associated PRCA 289

Practical Dialysis in the Year 2009 1. ∫∑π” Erythropoietin (EPO) ∂°Ÿ §πâ æ∫„πªï §.». 1893 ‚¥¬æ∫«“à  “√ °¥— ®“°‰μ¢Õß°√–μ“à ¬ “¡“√∂ °√–μÿâπ„À≢°√–¥Ÿ° √â“߇¡Á¥‡≈◊Õ¥·¥ß ·≈–μàÕ¡“æ∫«à“ “‡Àμÿ¢Õß¿“«–´’¥„πºâŸªÉ«¬‰μ«“¬‡√◊ÈÕ√—߇°‘¥ ®“°°“√≈¥≈ߢÕß EPO ∑’Ë √â“ß®“°‰μ EPO ‡ªìπ “√‰°≈‚§‚ª√μ’π¢π“¥ 34,000 ¥“≈μ—π ∂Ÿ° √â“ß®“° interstitial cell ¢Õ߉μ EPO ª√–°Õ∫¥â«¬ amino acid ®”π«π 165 amino acid ·≈–¡’√–¥—∫§«“¡‡¢â¡¢âπ ¢Õß√–¥—∫ EPO „π°√–· ‡≈◊Õ¥„π§πª°μ‘ª√–¡“≥ 10-15 mu/mL Recombinant EPO (rEPO) ∂°Ÿ  —߇§√“–À凪ìπ¬“∑’Ë„™â√—°…“¿“«–´’¥„πºâŸªÉ«¬‰μ«“¬‡√◊ÈÕ√—ß‚¥¬ °√–∫«π°“√ biotechnology °“√§âπæ∫¬“π’ș૬∑”„ÀâºâŸªÉ«¬‰μ«“¬‡√◊ÈÕ√—ß¡’§ÿ≥¿“æ™’«‘μ∑’Ë¥’·≈–¡’Õ—μ√“ °“√‡°¥‘ cardiovascular morbidity ≈¥≈ß ·≈–∑”„Àºâ ªâŸ «É ¬¿“«–‰μ«“¬‡√ÕÈ◊ √ß—  “¡“√∂À≈°’ ‡≈¬Ë’ ß°“√√∫— ‡≈Õ◊ ¥ ´ß÷Ë ∑”„À‡â °¥‘ º≈·∑√°´Õâ π√–¬–¬“«®“°°“√‰¥‡â ≈Õ◊ ¥‡ªπì √–¬–‡«≈“π“πÊ ¬“ rEPO ‡ªπì ¬“∑¡’Ë ’ safety profile §àÕπ¢â“ߥ’ ¢âÕ¡Ÿ≈®“°°“√„™â¬“„π√–¬–·√°æ∫«à“ºŸâªÉ«¬∑’ˉ¥â√—∫¬“ EPO Õ“®¡’§«“¡¥—π‚≈À‘μ Ÿß¢÷Èπ‡≈Á° πâÕ¬·≈– “¡“√∂§«∫§ÿ¡‰¥â‚¥¬°“√ª√—∫¬“≈¥§«“¡¥—π‚≈À‘μ ·¡â«à“ rEPO ¡’‡ªìπ¬“∑’˧àÕπ¢â“ߪ≈Õ¥¿—¬ ¢âÕ¡Ÿ≈®“°°“√„™â¬“ rEPO „π√–¬–μàÕ¡“æ∫«à“ ºâŸªÉ«¬∫“ß√“¬Õ“®‡°‘¥¿“«– pure red cell aplasia (PRCA) ´÷Ë߇°‘¥®“° anti-rEPO antibody ∑”„ÀâºâŸªÉ«¬ ‡°¥‘ ¿“«–´¥’ √πÿ ·√ß®πÕ“®∑”„À‡â °¥‘ ¿“«–·∑√°´Õâ π∑“ßÀ«— „®·≈–À≈Õ¥‡≈Õ◊ ¥®πÕ“®∑”„Àºâ ªâŸ «É ¬‡ ¬’ ™«’ μ‘ 2. ¿“«– anti-rEPO associated PRCA 1-5 ¿“«– anti-rEPO associated PRCA æ∫„πºªŸâ «É ¬‚√§‰μ«“¬‡√ÕÈ◊ √ß— ∑‰Ë’ ¥√â ∫— ¬“ rEPO ·≈–‡°¥‘ ¿“«– ‰¡àμÕ∫ πÕßμàÕ¬“Õ¬à“߇©’¬∫æ≈—π (loss of efficacy: LOE) À≈—ß®“°‡§¬μÕ∫ πÕßμàÕ¬“¥’ ºâŸªÉ«¬¿“«– π’È®–‡°‘¥¿“«–´’¥Õ¬à“ß√ÿπ·√ß¡“°°«à“ºâŸªÉ«¬¿“«–‰μ«“¬‡√◊ÈÕ√—ß∑’ˉ¡à‡§¬‰¥â√—∫¬“ rEPO ‡π◊ËÕß®“° antibody μàÕ rEPO ∑’ˇ°‘¥„πºŸâªÉ«¬ “¡“√∂ cross reaction °—∫ native EPO ®“°‰μºŸâªÉ«¬ ∑”„À⺟âªÉ«¬¿“«– anti-rEPO associated PRCA ¡’√–¥—∫ haemoglobin ª√–¡“≥ 5-6 g/dLÀ√◊ÕπâÕ¬°«à“ ‡∑’¬∫°—∫√–¥—∫ haemoglobin„πºâŸªÉ«¬‰μ«“¬‡√◊ÈÕ√—ß∑’ˉ¡à‡§¬‰¥â√—∫¬“ rEPO ´÷Ëß®–¡’§à“ª√–¡“≥ 7-8 g/dL ¿“«– anti-rEPO associated PRCA ∂°Ÿ √“¬ß“π§√—Èß·√°„πªï §.».1981 ·≈–¡’®”π«πºŸâªÉ«¬∑’Ë ‰¥â√—∫°“√«‘π‘®©—¬‡æ‘Ë¡¢÷Èπ ‚¥¬‡©æ“–Õ¬à“߬‘Ëß„π™à«ßªï §.».1998-2000 æ∫«à“¿“«– anti-rEPO associated PRCA ‡°‘¥‰¥â∑—Èß®“° αrEPO ·≈– βrEPO Õ¬à“߉√°Áμ“¡ αrEPO ¡’‚Õ°“ ‡°‘¥¿“«– anti-rEPO associated PRCA ¡“°°«à“ βrEPO ¡“° ‡°≥±„å π°“√«‘π®‘ ©¬— ¿“«– anti-rEPO associated PRCA ª√–°Õ∫¥â«¬ 1) ºâŸªÉ«¬‰¥â√—∫ rEPO ‚¥¬√–¬–‡«≈“∑’ˉ¥â√—∫ rEPO ‡©≈’ˬª√–¡“≥ 9-12 ‡¥◊Õπ ‚¥¬‡ªìπºâŸªÉ«¬∑’Ë ‰¥â√—∫¬“©’¥‡¢â“∑“ß„μ⺑«Àπ—ß ªí®®ÿ∫—π¬—߉¡à¡’√“¬ß“πºŸâªÉ«¬¿“«– anti-rEPO associated PRCA ®“°°“√ ‰¥â√—∫¬“©’¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 2) ºŸâªÉ«¬‡°‘¥¿“«– LOE Õ¬à“߇©’¬∫æ≈—π ‚¥¬ºŸâªÉ«¬¡’¿“«–´’¥√ÿπ·√߇ª≈’ˬπ·ª≈ß®“°‡¥‘¡ 290

Anti-EPO Associated Pure Red Cell Aplasia: The Updated Situation in Thailand ´÷Ë߇§¬μÕ∫ πÕßμàÕ rEPO ¥’ 3) ¡’§à“ absolute reticulocyte μË” ‚¥¬∑—Ë«‰ªμË”°«à“ 10,000 ‡´≈≈åμàÕ‰¡‚§√≈‘μ√ ¢≥–∑’Ë ®”π«π‡¡Á¥‡≈◊Õ¥¢“«·≈–®”π«π‡°≈Á¥‡≈◊Õ¥Õ¬Ÿà„π‡°≥±åª°μ‘ 4) μ√«®‡®“–‰¢°√–¥°Ÿ ‡¢â“‰¥â°—∫¿“«– PRCA ‚¥¬‰¡àæ∫ erythroblast ¢≥–∑’ˇ´≈≈凡Á¥‡≈◊Õ¥ ¢“«·≈–‡´≈≈凰√Á¥‡≈◊Õ¥„π‰¢°√–¥Ÿ°¡’≈—°…≥–·≈–®”π«πª°μ‘ 5) μ√«®æ∫ anti rEPO „π°√–· ‡≈◊Õ¥ ´÷Ë߇ªìπ‡°≥±å„π°“√«‘π‘®©—¬∑’Ë ”§—≠∑’Ë ÿ¥„π°“√√–∫ÿ ¿“«– anti-rEPO associated PRCA 6) μ√«®æ‘ ®Ÿ πåæ∫«à“ anti-rEPO ∑’Ëμ√«®æ∫¡’ neutralization effect ‚¥¬ neutralization assay „π°“√‡æ“–‡≈’Ȭ߇´≈≈å∑’Ëæ÷Ëßæ“ EPO „π°“√‡®√‘≠‡μ‘∫‚μ 3. °“√μ√«® anti-rEPO antibody Anti-rEPO ‡ªìπ immunoglobulin G μàÕ∑—Èß rEPO ·≈– native EPO °“√μ√«® anti-rEPO ∑”‰¥â 3 «‘∏’ ‰¥â·°à 1. «‘∏’ Radio-immunoprecipitation test (RIP) 2. «‘∏’ ELISA 3. «‘∏’ Biocore 3.1 °“√μ√«® anti-rEPO ¥«â ¬«‘∏’ RIP (√ªŸ ∑Ë’ 1) °“√μ√«® anti-rEPO ¥â«¬«‘∏’ RIP ∑”‚¥¬„™â sera ∑’ËμâÕß°“√μ√«® incubate °—∫ 125Iodinated EPO À“° sera ¡’ antibody §à“ EPO ®–‡°‘¥ binding √–À«à“ß anti-rEPO ·≈– 125Iodinated EPO ·≈â«∑”°“√ precipitate binding ¥«â ¬ protein G ∑”°“√«¥— √–¥∫— radioactivity ´ßË÷ ∂°Ÿ precipitate ‡ª√¬’ ∫‡∑¬’ ∫°∫— negative control ·≈– positive control √ªŸ ∑’Ë 1 · ¥ß¢—ÈπμÕπ„π°“√∑¥ Õ∫ RIPA ‡æÕ◊Ë μ√«®À“ anti-rEPO antibody 291

Practical Dialysis in the Year 2009 °“√μ√«® anti-rEPO ¥«â ¬«∏‘ ’ RIP ‡ªπì «∏‘ ¡’ “μ√∞“π ´ß÷Ë  “¡“√∂μ√«®‡ª√¬’ ∫‡∑¬’ ∫®”π«πª√¡‘ “≥ anti-rEPO „π·μà≈– sample ‰¥â¥â«¬°“√‡ª√’¬∫‡∑’¬∫ dilution ªí®®ÿ∫—π°“√μ√«® anti-rEPO „πª√–‡∑»‰∑¬  “¡“√∂ àßμ√«®‰¥â∑’ËÀπ૬‚√§‰μ ¿“§«‘™“Õ“¬ÿ√»“ μ√å ‚√ß欓∫“≈®ÿÓ≈ß°√≥å 3.2 °“√μ√«® anti-rEPO ¥«â ¬«‘∏’ ELISA (√Ÿª∑’Ë 2) °“√μ√«® anti-rEPO ¥â«¬«‘∏’ ELISA ∑”„π∑”πÕ߇¥’¬«°—∫°“√μ√«® ELISA ‚¥¬∑—Ë«‰ª ‚¥¬°“√ ‡§≈Õ◊ ∫ plastic plate ¥«â ¬ EPO ‚¡‡≈°≈ÿ ·≈–μ√«®«¥— °“√‡°“–쥑 ¢Õß anti EPO ‚¥¬Õ“»¬— enzymatic reaction ªí≠À“¢Õß°“√μ√«® anti-rEPO ¥â«¬«‘∏’ ELISA §◊Õªí≠À“ false positive ∑”„Àâ¡’§«“¡¬ÿà߬“°„π°“√·ª≈ º≈ æ∫«à“ false positive ¢Õß anti-rEPO ¥â«¬«‘∏’ ELISA πâÕ¬≈ß À“°„™â«‘∏’ Bridging ELISA ´÷Ë߇æ‘Ë¡‡μ‘¡¢—Èπ μÕπ®“° ELISA ‚¥¬∑—Ë«‰ª ∑”„Àâ°“√‡°“–μ‘¥¢Õß antibody ¡’§«“¡‡©æ“–‡®“–®ß¡“°¢÷Èπ ªí®®ÿ∫—π°“√μ√«® anti-rEPO ¥â«¬«‘∏’ ELISA ‰¡à¡’¡“μ√∞“π·πàπÕπ ¢÷Èπ°—∫ÀâÕߪؑ∫—μ‘°“√ ·μà≈–·Ààß·≈–¬—߉¡à¡’ commercial ELISA kit ®”Àπà“¬ 3.3 °“√μ√«® anti-rEPO ¥â«¬«‘∏’ Biocore °“√μ√«® anti-rEPO ¥â«¬«‘∏’ biocore ‡ªìπ«‘∏’´÷Ëß “¡“√∂μ√«®«—¥ affinity ¢Õß antibody binding μàÕ EPO ‚¡‡≈°ÿ≈ ´÷Ë߇ªìπ¢âÕ¡≈Ÿ ∑’Ë≈–‡Õ’¬¥¡“°¢÷Èπ ‡π◊ËÕß®“°πÕ°®“°®–μ√«®∑√“∫«à“¡’ antibody ´÷Ëß®—∫ °—∫ EPO ‚¡‡≈°ÿ≈À√◊Õ‰¡à·≈â« ¬—ß∑√“∫§«“¡‡®“–®ß·≈– affinity ¢Õß°“√ binding ¥â«¬ «‘∏’ Biocore ‡ªìπ «‘∏’¡“μ√∞“π¢Õ߇¿ —™«‘∑¬“„π°“√«—¥ affinity ¢Õß molecule Àπ÷ËßμàÕ molecule Àπ÷Ëß Õ¬à“߉√°Áμ“¡°“√ μ√«® anti-rEPO ¥â«¬«‘∏’ Biocore μâÕßÕ“»—¬‡§√◊ËÕß¡◊Õ´÷Ëß¡’√“§“·æß ·≈–μâÕßÕ“»—¬ technician ´÷Ëß¡’ √Ÿª∑’Ë 2 · ¥ß«‘∏°’ “√μ√«®À“ Anti-EPO antibody ‚¥¬«‘∏’ ELISA ·≈– Bridging ELISA 292

Anti-EPO Associated Pure Red Cell Aplasia: The Updated Situation in Thailand §«“¡™”π“≠„π°“√„™â‡∑§π‘§π’È„π°“√μ√«®«—¥ Õπ’Ë߉¡à«à“®–μ√«® anti-rEPO ¥â«¬«‘∏’„¥ °“√ àßμ√«® anti-rEPO §«√∑”‚¥¬„™â sera À≈—ßÀ¬ÿ¥ rEPO ‡ªìπ‡«≈“Õ¬à“ßπâÕ¬ 1-2  —ª¥“Àå ‚¥¬¡’ “‡Àμÿ ”§—≠∑’Ë®”‡ªìπμâÕßÀ¬ÿ¥¬“°àÕπ àßμ√«® 2 ª√–°“√ §◊Õ 1) °“√μ√«®À“ anti-rEPO ¢≥–∑¬’Ë ß— ¡√’ –¥∫— EPO „π‡≈Õ◊ ¥ ßŸ Õ“®∑”„À¡â ª’ ≠í À“ false negative ‡π◊ËÕß®“° anti-rEPO ∑’Ë¡’Õ¬àŸÕ“® binding °—∫ EPO ®πμ√«®‰¡àæ∫ free antibody 2) √–¥—∫ EPO ´÷Ë߬—ß ŸßÕ¬àŸ„π‡≈◊Õ¥ ¢≥–∑’Ë anti-rEPO „Àâº≈∫«° ∑”„ÀâÕ“®¡’ªí≠À“„π°“√ μ√«® neutralization assay ‡π◊ËÕß®“°√–¥—∫ EPO ∑’ˠߟ Õ“®∑”„Àâ neutralization assay „Àâº≈≈∫ °“√μ√«®√–¥∫— anti-rEPO πÕ°®“°®–„™„â π°“√«π‘ ®‘ ©¬— ¿“«– anti-rEPO associated PRCA ·≈«â ¬—ß„™âμ√«®μ‘¥μ“¡º≈°“√√—°…“ ·≈–μ‘¥μ“¡§«“¡√ÿπ·√ߢÕß¿“«– anti-rEPO associated PRCA ·≈–∂◊Õ ‡ªìπ°“√μ√«®¡“μ√∞“π„π°“√¥Ÿ·≈ºŸâªÉ«¬ 4. °“√μ√«® neutralization assay °“√μ√«® neutralization assay ‡ªìπ°“√μ√«®‡æ◊ËÕ¬◊π¬—πº≈ neutralization ¢Õß anti-rEPO °“√ μ√«® neutralization assay ∑”‚¥¬„™â sera ´÷Ëß¡’º≈∫«°μàÕ anti-rEPO ∑¥ Õ∫º≈ neutralization μàÕ EPO dependent cell line ‡™àπ UT-7 cell line ‚¥¬«—¥ proliferation ¢Õß UT-7 cell line ´÷Ëß∂°Ÿ ¬—∫¬—È߉¥â¥â«¬ anti- rEPO °“√μ√«® neutralization assay §«√∂◊Õ‡ªìπ à«πÀπ÷Ëß„π°“√«‘π‘®©—¬¿“«– anti-rEPO associated PRCA ·≈–„πªí®®ÿ∫—π “¡“√∂ àßμ√«®‰¥â∑’Ë Àπ૬‚√§‰μ ¿“§«‘™“Õ“¬ÿ√»“ μ√å ‚√ß欓∫“≈®ÿÓ≈ß°√≥å 5.  “‡Àμÿ¢Õß anti-rEPO associated PRCA6-7 ¬—߉¡à∑√“∫ “‡Àμÿ¢Õß anti-rEPO associated PRCA ∑’Ë·πà™—¥ Õ¬à“߉√°Áμ“¡¡’ ¡¡ÿμ‘∞“π∑’Ëπà“  π„®À≈“¬ “‡Àμÿ ‰¥â·°à 1.  ¡¡ÿμ‘∞“π leacheat therapy 2. ∫∑∫“∑¢Õß cold chain 3. ∫∑∫“∑¢Õßªí®®—¬∑“ßæ—π∏ÿ°√√¡ 5.1  ¡¡μÿ ∞‘ “π¢Õß Leacheat therapy  ¡¡μÿ ∞‘ “ππ¡È’ “®“°¢Õâ  ß— ‡°μ∑æË’ ∫«“à Õ∫ÿ μ— °‘ “√≥¢å Õß anti-rEPO associated PRCA ‡æ¡Ë‘ ¢πÈ÷ ¡“° „πª√–‡∑»μ–«—πμ° ‡¡◊ËÕ¡’°“√‡ª≈’ˬπ·ª≈ß formula ¢Õß arEPO À≈—ß®“°∑’Ë¡’°“√„™â polysorbate 80 ‡ªìπ preservative material ·∑π human serum albumin (HSA) ‡π◊ËÕß®“°¡’§«“¡°—ß«≈°“√ªπ‡ªóôÕπ¢Õ߇™◊ÈÕ HIV ·≈– prion ´÷Ë߇ªì𠓇Àμÿ¢Õß Creutzfeldt-Jacob disease ∑”„À⇰‘¥ ¡¡ÿμ‘∞“π«à“°“√„™â polysorbate 80 Õ“®¡’§«“¡ —¡æ—π∏å°—∫°“√‡°‘¥ anti-rEPO associated PRCA 293

Practical Dialysis in the Year 2009 °“√»÷°…“¥â«¬«‘∏’ high pressure liquid chomatography (HPLC) „π rEPO ´÷Ëß„™â polysorbate 80 ‡ªπì preservative material æ∫«“à °“√„™â polysorbate 80 ∑”„À‡â °¥‘  “√‚¡‡≈°≈ÿ Õπ◊Ë πÕ°‡ÀπÕ◊ ®“° polysorbate 80 ·≈– rEPO ‚¥¬æ∫«à“ polysorbate 80 Õ“®∑”ªØ‘°‘√‘¬“°—∫ rubber plunger „π°√–∫Õ°©’¥¬“∑”„Àâ ‡°‘¥ “√‚¡‡≈°ÿ≈Õ◊Ëπ ∑”Àπâ“∑’˧≈⓬ “√ adjuvant ‡™àπ‡¥’¬«°—∫ “√ adjuvant „π«—§´’π ¡’º≈∑”„À⇰‘¥ immunogenicity ®“° rEPO molecule ¢Õâ ¡≈Ÿ ‡À≈“à ππ’È ”‰ª °Ÿà “√‡ª≈¬’Ë π·ª≈ß°√–∫Õ°©¥’ ¬“‡æÕ◊Ë ·°‰â ¢ª≠í À“ anti-rEPO associated PRCA ‚¥¬∫√‘…—∑ºâŸº≈‘μ ∑”°“√‡§≈◊Õ∫ rubber plunger ¥â«¬ Teflon (coated syringe) ∑”„Àâ polysorbate 80 ‰¡à —¡º— °—∫ rubber plunger ‡ªìπ°“√ªÑÕß°—π°“√‡°‘¥ leacheat ·≈–æ∫«à“¿“¬À≈—ß ¡’°“√„™â coated syringe ®”π«πºâŸªÉ«¬ anti-rEPO associiated PRCA ¡’®”π«π≈¥≈ß Õ¬à“߉√®”π«π ºâŸªÉ«¬∑’Ë≈¥≈ß®”°—¥‡©æ“–„πºŸâªÉ«¬μ–«—πμ° À“°æ‘®“√≥“®”π«πºŸâªÉ«¬„πª√–‡∑»‰∑¬æ∫«à“®”π«π ºâŸªÉ«¬¡‘‰¥â≈¥≈ß · ¥ß„Àâ‡ÀÁπ«à“πÕ°‡Àπ◊Õªí®®—¬ leacheat therapy Õ“®¡’ªí®®—¬Õ◊Ëπ‡°’Ë¬«¢âÕß 5.2 ∫∑∫“∑¢Õß cold chain ‡π◊ËÕß®“° rEPO ‡ªì𬓰≈ÿà¡ Biotechnology drug  à«π¢Õß cold chain ®÷ß¡’∫∑∫“∑ ”§—≠„π °“√‡°Á∫√—°…“ ¿“欓 biotechnology drug ¡’§«“¡·μ°μà“ß®“° chemical drug ‡π◊ËÕß®“° biotechnology ¡’°√–∫«π°“√º≈‘μ∑’Ë´—∫´âÕπ ‰¥â·°à μâÕß¡’°“√‡æ“–‡≈’È¬ß host cell ·≈–„™â DNA vector ‡æ◊ËÕπ” human EPO gene  Õ¥·∑√°‡¢â“„π host cell ‡æ◊ËÕ„Àâ host cell  —߇§√“–Àå rEPO ®“°‡´≈≈å πÕ°®“°π—Èπ¬—ßμâÕß „™°â √–∫«π°“√§¥— ·¬° (purification) rEPO „À∫â √ ‘ ∑ÿ ∏Ï‘ °“√∑Ë’ rEPO ‡ªπì ¬“ glycoprotein ·≈–„™°â √–∫«π°“√ biotechnology ∑’Ë´—∫´âÕπ∑”„Àâ cold chain ¡’∫∑∫“∑ ”§—≠ ‡π◊ËÕß®“°À“°‰¡à‰¥â√—∫°“√§«∫§ÿ¡Õÿ≥À¿Ÿ¡‘ „Àâ‡À¡“– ¡ Õ“®∑”„À⇰‘¥ protein aggregation ∑”„À⇰‘¥ immunogenicity ®“°§«“¡ ”§—≠¢Õß cold chain ¥—ß°≈à“« ÀâÕ߬“∑’Ë∑”°“√®à“¬¬“ rEPO ·°àºâŸªÉ«¬ μ≈Õ¥®π∫√‘…—∑∑’˺≈‘μ ®—¥®”Àπà“¬ À√◊Õ ‡°’ˬ«¢âÕß°—∫°“√¢π à߬“ §«√μ√–Àπ—°·≈–§«√„À⧫“¡ ”§—≠„π‡√◊ËÕß cold chain Õ¬à“߇§√àߧ√—¥ ·≈– §«√·π–π”«‘∏’°“√¥Ÿ·≈„Àâ cold chain ‰¡à„Àâ∂Ÿ°≈–‡¡‘¥ ‚¥¬„™â¿“™π–∫√√®ÿ¬“∑’ˇÀ¡“– ¡ àß¡Õ∫¬“®“° ÀâÕ߬“„ÀⷰຟâªÉ«¬π”°≈—∫∫â“π πÕ°®“°π—Èπ∫ÿ§≈“°√∑’ˇ°’ˬ«¢âÕß°—∫°“√√—°…“ ∑—Èß·æ∑¬å 欓∫“≈§«√ ¥Ÿ·≈‡√◊ËÕß cold chain Õ¬à“߇¢â¡ß«¥®π∂÷ߢ∫«π°“√ ÿ¥∑⓬©’¥¬“·°àºâŸªÉ«¬ 5.3 ∫∑∫“∑¢Õßªí®®¬— ∑“ßæ—π∏°ÿ √√¡1, 8 ®“°¢âÕ —߇°μ§«“¡·μ°μà“ß√–À«à“ßÕÿ∫—μ‘°“√≥å¢Õß¿“«– anti-rEPO associated PRCA „πºŸâªÉ«¬μ–«—πμ°·≈–ºâŸªÉ«¬‰∑¬ ∑”„À⇰‘¥§”∂“¡«à“ªí®®—¬∑“ßæ—π∏ÿ°√√¡¡’∫∑∫“∑μàÕ°“√‡°‘¥¿“«– anti-rEPO associated PRCA À√◊Õ‰¡à ¢âÕ¡≈Ÿ °“√»÷°…“∫∑∫“∑¢Õß HLA „πºâŸªÉ«¬¿“«– anti-rEPO associated PRCA æ∫«à“ HLA DR B1*09 Õ“®¡’§«“¡ —¡æ—π∏åμàÕ°“√‡°‘¥¿“«– anti-rEPO associated PRCA ‚¥¬¡’ odd ratio ‡∑à“°—∫ 2.89 πÕ°®“°°“√»÷°…“„πºŸâªÉ«¬μ–«—πμ°„π≈—°…≥– case-controled æ∫«à“ HLA DR B B1*09 ¡’§«“¡  —¡æ—π∏å°—∫°“√‡°‘¥¿“«– anti-rEPO associated PRCA ‚¥¬¡’ odd ratio ‡∑à“°—∫ 10.8 Õ¬à“߉√°Áμ“¡¢âÕ¡≈Ÿ π’È®”‡ªìπμâÕß»÷°…“¡“°¢÷Èπ Õ—π‡ªìπ∑’Ë¡“¢Õß ‚§√ß°“√ Prospective, Immunogenicity Surveillance Registry of Erythropoiesis Stimulating Agent (ESA) with Subcutaneous Exposure in Thailand „π≈—°…≥– registry 294

Anti-EPO Associated Pure Red Cell Aplasia: The Updated Situation in Thailand study „πª√–‡∑»‰∑¬ 6. ‚§√ß°“√ Prospective, Immunogenicity Surveillance Registry of Erythropoiesis Stimulating Agent (ESA) with Subcutaneous Exposure in Thailand (Thai ESA registry) ‚§√ß°“√ Thai ESA registry ‰¥â‡√‘Ë¡¢÷Èπ„πªï æ.». 2550 ‚¥¬§«“¡√à«¡¡◊Õ¢Õß 4 Õߧå°√«‘™“™’æ ‰¥â·°à  ¡“§¡‚√§‰μ·Ààߪ√–‡∑»‰∑¬  ¡“§¡‚≈À‘μ«‘∑¬“·Ààߪ√–‡∑»‰∑¬ §≥–°√√¡°“√Õ“À“√·≈–¬“ ·≈–‡¿ —™°√√¡ ¡“§¡·Ààߪ√–‡∑»‰∑¬ ‚¥¬¡’«—μ∂ÿª√– ß§å‡æ◊ËÕ»÷°…“Õÿ∫—μ‘°“√≥å¢Õß¿“«– anti-rEPO associated PRCA ®“°°“√„™¬â “ ESA „πª√–‡∑»‰∑¬ ‡ª√¬’ ∫‡∑¬’ ∫√–À«“à ß ESA °≈¡ÿà μ“à ßÊ ∑ß—È Immunovative EPO ‰¥â·°à EPO μâπ·∫∫∑—Èß αrEPO ·≈– βrEPO ·≈– Biosimilar EPO √«¡∑—Èß ESA ™π‘¥„À¡àÊ πÕ°®“°π—Èπ ¬—ß¡’«—μ∂ÿª√– ß§å‡æ◊ËÕ»÷°…“ª√– ‘∑∏‘¿“æ¢Õß°“√„™â¬“ EPO „πª√–‡∑»‰∑¬ ‚§√ß°“√ Thai ESA registry Õ“»—¬§«“¡√à«¡¡◊Õ¢Õß»Ÿπ¬å‰μ‡∑’¬¡·≈–‚√ß欓∫“≈μà“ßÊ ∑—Ë«ª√–‡∑»¡“°°«à“ 60 ·Ààß investigator ·μà≈–·Ààߪ√–°Õ∫¥â«¬ ·æ∑¬åºâŸ„™â¬“ 欓∫“≈ ·≈– ‡¿ —™°√ ‚¥¬ºŸâªÉ«¬∑’ËÕ¬àŸ„π‚§√ß°“√»÷°…“‰¥â·°à ºŸâªÉ«¬∑’Ë„™â rEPO √“¬„À¡à∑’ˉ¥â√—∫¬“ rEPO ‰¡à‡°‘π 1 ‡¥◊Õπ ·≈–∑”°“√μ‘¥μ“¡ºŸâªÉ«¬‡ªìπ‡«≈“Õ¬à“ßπâÕ¬ 2 ªï ‡æ◊ËÕμ‘¥μ“¡°“√‡°‘¥¿“«– loss of efficacy (LOE) ·≈–°“√‡°‘¥¿“«– anti-rEPO associated PRCA √«¡∂÷ߢâÕ¡Ÿ≈ª√– ‘∑∏‘¿“æ¢Õ߬“„π°“√√—°…“¿“«– renal anemia §“¥«à“º≈°“√»÷°…“π’È®–∑”„Àâ∑√“∫Õÿ∫—μ‘°“√≥å¢Õß¿“«– anti-rEPO associated PRCA ∑’Ë·∑â ®√‘ß„πª√–‡∑»‰∑¬ ‚¥¬‡©æ“–Õ¬à“߬‘Ë߇¡◊ËÕ‡ª√’¬∫‡∑’¬∫√–À«à“ß rEPO ™π‘¥μà“ßÊ ·≈–∑√“∫ ª√– ‘∑∏‘¿“æ¢Õß°“√„™â¬“‡æ◊ËÕ‡ªìπ·π«∑“ß„π°“√æ‘®“√≥“∫√‘À“√¬“·°àºŸâªÉ«¬μàÕ‰ª μ≈Õ¥®πÕ“® ∑”„Àâ∑√“∫ªí®®—¬‡ ’ˬߢÕߺŸâªÉ«¬„π°“√‡°‘¥¿“«–π’È 7. ·π«∑“ß°“√√—°…“ºªŸâ «É ¬¿“«– anti-rEPO associated PRCA ªí®®ÿ∫—π¬—߉¡à¡’°“√»÷°…“„π≈—°…≥– clinical trial ∂÷ß·π«∑“ß°“√√—°…“ºŸâªÉ«¬¿“«– anti-rEPO associated PRCA Õ¬à“߉√°Áμ“¡¢âÕ¡Ÿ≈μà“ßÊ ∑’Ë¡’· ¥ß„Àâ‡ÀÁπ«à“ ºâŸªÉ«¬∑ÿ°√“¬§«√À¬ÿ¥¬“ rEPO ‚¥¬‰¡à §«√‡ª≈’ˬπº≈‘μ¿—≥±å rEPO ·≈–§«√μ‘¥μ“¡√–¥—∫ anti-rEPO ‡ªìπ√–¬– πÕ°®“°π—Èπ§«√æ‘®“√≥“ª≈Ÿ° ∂à“¬‰μ·°àºŸâªÉ«¬„πºŸâªÉ«¬∑’ˉ¡à¡’¢âÕÀâ“¡ª≈°Ÿ ∂à“¬‰μ ¢âÕ¡Ÿ≈„π≈—°…≥– case study · ¥ß„Àâ‡ÀÁπ«à“ºâŸªÉ«¬ anti-rEPO associated PRCA  “¡“√∂À“¬‡ªìπª°μ‘¿“¬À≈—ß®“°ª≈°Ÿ ∂à“¬‰μ ‚¥¬ºâŸªÉ«¬∑ÿ°√“¬‰¡à®”‡ªìπ μâÕ߉¥â√—∫‡≈◊Õ¥¿“¬À≈—߉¥â√—∫°“√ª≈Ÿ°∂à“¬‰μÕ’°‡≈¬ (√Ÿª∑’Ë 3) „πºŸâªÉ«¬∑’ˉ¡à “¡“√∂ª≈Ÿ°∂à“¬‰μ ‡π◊ËÕß®“°¡’¢âÕÀâ“¡À√◊ÕÕ¬àŸ„π√–À«à“ß√Õ°“√ª≈Ÿ°∂à“¬‰μ §«√‰¥â√—∫°“√æ‘®“√≥“„À⬓°¥¿Ÿ¡‘§ÿâ¡°—π ‡π◊ËÕß®“°¬—߉¡à¡’¢âÕ¡Ÿ≈· ¥ß„Àâ‡ÀÁπ«à“ºâŸªÉ«¬¿“«– anti-rEPO associated PRCA  “¡“√∂À“¬‰¥â‡Õß‚¥¬ ‰¡à‰¥â√—∫°“√√—°…“ 295

Practical Dialysis in the Year 2009 √Ÿª∑Ë’ 3 · ¥ßμ—«Õ¬“à ß°“√¥”‡π‘π‚√§¢Õߺ⟪ɫ¬ PRCA 1√“¬ ´Ë÷ßÀ“¬®“°‚√§ PRCA ¿“¬À≈ß— ®“°‰¥√â ∫— °“√ª≈°Ÿ ∂“à ¬‰μ 8. °“√„À⬓°¥¿¡Ÿ §‘ âÿ¡°—π‡æÕË◊ √—°…“¿“«– anti-rEPO associated PRCA9 °“√„™â immunosuppressive ‡æ◊ËÕ√—°…“¿“«– anti-rEPO associated PRCA „™â ¡¡ÿμ‘∞“π¢Õß °“√‡°‘¥ anti-rEPO „π≈—°…≥–‡¥’¬«°—π°—∫ autoimmune disease ·¡â«à“„πªí®®ÿ∫—π¬—߉¡à¡’¢âÕ¡Ÿ≈°“√ »÷°…“„π≈—°…≥– randomized control trial ¢âÕ¡Ÿ≈∑’Ë¡’Õ¬àŸ· ¥ß„Àâ‡ÀÁπ immunosuppressive ¡’ ª√– ‘∑∏‘¿“æ„π°“√√—°…“ ∑—Èßπ’È¢÷Èπ°—∫ regimen ¢Õ߬“∑’Ë„™â ¬“ immunosuppressive drug  à«π„À≠à‰¥â·°à ¬“ ‡μ’¬√Õ¬¥å ·≈–/À√◊Õ cyclophosphamide, intravenous immunoglobulin (IVIG), cyclosporine A ·≈– Õ“®„™â plasmapheresis √à«¡¥â«¬ „π√–À«à“ß∑”°“√√—°…“ ºŸâªÉ«¬§«√®–‰¥â¡’°“√μ√«®μ‘¥μ“¡√–¥—∫Œ’‚¡ ‚°≈∫‘π∑ÿ° —ª¥“Àå ·≈–μ√«®À“ anti-EPO antibody ∑ÿ°Ê 1-2  —ª¥“Àå ·≈–√–«—ß¿“«–μ‘¥‡™◊ÈÕ·∑√°´âÕπ ®“°°“√„À⬓ ‡Õ° “√Õ“â ßÕß‘ 1. Praditpornsilpa K, Buranasot S, Bhokaisuwan N et al. Recovery from anti-recombinant-human-erythropoietin associated pure red cell aplasia in end-stage renal disease patients after renal transplantation. Nephrol Dial Transplant. 20, 626- 630 (2005). 2. Bergrem H, Danielson BG, Eckardt KU, Kurtz A, Stridsberg M. A case of antierythropoietin antibodies following recombinant human erythropoietin treatment. in: Erythropoietin: Molecular Physiology and Clinical Application. New York: Marcel Dekker, 1993:266-75. 296

Anti-EPO Associated Pure Red Cell Aplasia: The Updated Situation in Thailand 3. Pece R, de la Torre M, Alcazar R, Urra JM. Antibodies against recombinant human erythropoietin in a patient with erythropoietin-resistant anemia. N Engl J Med. 335, 523-524 (1996). 4. Prabhakar S, Muhlfelder T. Antibodies to recombinant human erythropoietin causing pure red cell aplasia. Clin Nephrol. 47, 331-335 (1997). 5. Rossert J, Casadevall N, Eckardt K-U. Anti-erythropoietin antibodies and pure red cell aplasia. J Am Soc Nephrol. 15, 398-406 (2004). 6. Sharma B, Bader F, Templeman T, Lisi P, Ryan M, Heavner GA. Technical investigations into the cause of the increased incidence of antibody-mediated pure red cell aplasia associated with EPREX®. EJHP. 5, 86-91 (2004). 7. Boven K, Stryker S, Knight J et al. The increased incidence of pure red cell aplasia with an Eprex formulation in uncoated rubber stopper syringes. Kidney Int. 67, 2346-2353 (2005). 8. Ryan MH, Heavner GA, Brigham-Burke M, et al. An in vivo model to assess factors that may stimulate the generation of an immune reaction to erythropoietin. Int Immunopharmacology. 6, 647-655 (2006). 9. Macdougall IC. Antibody-mediated pure red cell aplasia (Ab-positive PRCA): epidemiology, immunogenicity and risks. Nephrol Dial Transplant. 20(suppl 4), iv9-iv15 (2005). 297



Past, Present and Future of Peritoneal Dialysis 16 Past, Present and Future of Peritoneal Dialysis ∑«’ »‘√‘«ß»å 1. ∫∑π” 2. §«“¡‡ªπì ¡“¢Õß´’‡Õæ’¥’ 3. ´’‡Õ楒 ’„πª√–‡∑»‰∑¬¬§ÿ pre CAPD-UC era (æ.». 2525-2549) 4. ´’‡Õæ’¥’„π¬§ÿ ª®í ®ÿ∫—π (CAPD-UC era) æ.». 2550-2552 5. ·π«‚π¡â ¢Õß´‡’ Õæ’¥’„πÕπ“§μÕπ— „°≈â (æ.». 2553-2558) 6.  √ªÿ 299

Practical Dialysis in the Year 2009 1. ∫∑π” Continuous ambulatory peritoneal dialysis (CAPD) ´÷Ëßªí®®ÿ∫—π¡—°„™â™◊ËÕ‰∑¬«à“ ç°“√≈â“߉μ ∑“ß™àÕß∑âÕßÕ¬à“ßμàÕ‡π◊ËÕßé ·≈–‡√’¬°°—πÕ¬à“߬àÕ«à“ ç´’‡Õæ’¥’é ‡ªìπ«‘∏’°“√√—°…“¿“«–‰μ«“¬√–¬–  ÿ¥∑⓬«‘∏’Àπ÷Ëß ∑’Ëæ—≤π“¢÷Èπ®“°∑“ßμ–«—πμ° ‚¥¬√Ÿª·∫∫¢Õß°“√√—°…“§◊Õ „™âπÈ”¬“´’‡Õæ’¥’ 2000 ¡≈. „ à‡¢â“™àÕß∑âÕß«—π≈– 4 «ß®√ §â“ßπÈ”¬“„π™àÕß∑âÕß«ß®√≈– 4-8 ™¡. „π∑“߇∑§π‘§ ´’‡Õæ’¥’¥Ÿ‡À¡◊Õπ‡ªìπ«‘∏’√—°…“∑’Ëßà“¬ ·μà·æ∑¬å¡—°‰¡àπ‘¬¡·π–π”„À⺟âªÉ«¬ ®π °√–∑ß—Ë ¡º’ °âŸ ≈“à ««“à ´‡’ Õ楒 ‡’ ªπì çsecond-class treatment for second-class patients by second-class doctorsé „π§«“¡‡ªìπ®√‘ß°“√∫”∫—¥∑¥·∑π‰μ∑—Èß´’‡Õæ’¥’·≈–°“√øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡ ‰¥â√—∫°“√æ—≤π“ ¢π÷È ¡“‰≈‡à ≈¬’Ë °π— 1 ·μ°à ≈∫— æ∫«“à ´‡’ Õ楒 ‰’ ¥√â ∫— °“√𬑠¡πÕâ ¬°«“à Õ¬“à ß™¥— ‡®π ®π°√–∑ß—Ë μ«— ‡≈¢Õμ— √“°“√𬑠¡ „™â¢Õß´’‡Õæ’¥’Õ¬Ÿà∑’˪√–¡“≥ 10% ¢ÕߺŸâªÉ«¬√—∫°“√≈â“߉μ∑—Ë«‚≈°  ”À√—∫ª√–‡∑»‰∑¬ ºâŸªÉ«¬∑’Ë√—°…“ ¥â«¬«‘∏’´’‡Õæ’¥’°Á¡’ —¥ à«ππâÕ¬‡™àπ°—π „π¢≥–∑’˺⟪ɫ¬√—∫°“√øÕ°‡≈◊Õ¥°≈—∫¡’®”π«π¡“°¢÷Èπ∑ÿ°ªï ®π °√–∑—Ëß„πªï æ.». 2551 ®÷ß¡’ª√“°Ø°“√≥å∑’Ë¡’®”π«πºŸâªÉ«¬´’‡Õæ’¥’‡æ‘Ë¡¢÷Èπ¡“°°«à“ 2 ‡∑à“ ‡¡◊ËÕ‡∑’¬∫°—∫ ºâŸªÉ«¬„πªï æ.». 2550 ´÷Ë߇ªìπº≈®“°°“√Õπÿ¡—μ‘„Àâ°“√≈â“߉μ∑“ß™àÕß∑âÕß ®—¥Õ¬àŸ„π ‘∑∏‘ª√–‚¬™πå¢Õß ºâŸªÉ«¬„π‚§√ß°“√ª√–°—π ÿ¢¿“æ∂â«πÀπâ“ ®“°¡μ‘§≥–√—∞¡πμ√’≈ß«—π∑’Ë 30 μÿ≈“§¡ 2550 ‚¥¬„Àâ‡√‘Ë¡¡’ º≈∫—ߧ—∫„™âμ—Èß·μà«—π∑’Ë 1 ¡°√“§¡ 2551 ‡ªìπμâπ¡“ ´÷Ë߇ªìπ∑’Ë¡“¢Õß çThai PD first policyé ®“°°“√≥å ¥—ß°≈à“«®÷ß¡’º≈°√–∑∫μàÕ°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‰μ«“¬√–¬– ÿ¥∑⓬„πª√–‡∑»‰∑¬ ∑—Èß„πªí®®ÿ∫—π·≈– Õπ“§μ ¥—ßπ—Èπ „π∫∑π’È®–‰¥â®—¥·∫à߇π◊ÈÕÀ“ÕÕ°‡ªìπ ¬ÿ§°àÕπ∑’Ë®–‡√‘Ë¡„Àâ°“√∫√‘°“√´’‡Õæ’¥’‚¥¬‰¡à‡ ’¬§à“ „™â®à“¬·°àºŸâªÉ«¬∫—μ√∑Õß (pre CAPD-UC era), ¬ÿ§ªí®®ÿ∫—π æ.». 2550-2552 (CAPD-UC era) ·≈–·π«‚πâ¡ „πÕπ“§μÕ—π„°≈â æ.». 2553-2558 2. §«“¡‡ªìπ¡“¢Õß´’‡Õ楒 1’ ´’‡Õæ’¥’‰¥â∂Ÿ°æ—≤π“¢÷Èπ„À⇪ìπ«‘∏’∫”∫—¥∑¥·∑π‰μ ¡“μ—Èß·μà∑»«√√…∑’Ë 1970 ·μà‡π◊ËÕß®“° μ‘¥¢—¥∑’ˇ∑§‚π‚≈¬’„π°“√ªÑÕß°—π°“√μ‘¥‡™◊ÈÕ¬—߉¡à‰¥âæ—≤π“ ∑”„Àâ´’‡Õæ’¥’„π™à«ß·√°Ê ¡’Õÿª √√§¡“°¡“¬ ‚¥¬‡©æ“–°“√„™¢â «¥·°«â ∫√√®πÿ ”È ¬“ ·≈–‡∑§π§‘ °“√‡™ÕË◊ ¡μÕà (Connectology) ¬ß— ‡ªπì √–∫∫‡ª¥î ∑”„À‡â °¥‘ catheter related peritonitis ∫Õà ¬¡“° ®π«ß°“√·æ∑¬∂å Õ◊ «“à ‡ªπì ¢Õâ ¥Õâ ¬ ”§≠— ¢Õß°“√√°— …“«∏‘ π’ ’È μÕà ¡“„πªï æ.». 2517 ‰¥â¡’°“√æ—≤π“∂ÿßæ≈“ μ‘°ÕàÕπ (Collapsible bag) ·≈–‡∑§‚π‚≈¬’°“√‡™◊ËÕ¡μàÕ∑’Ë¥’¢÷Èπ¡“° Õ“∑‘ manual spike® ·≈– Safelock® ∑”„ÀâÕ—μ√“°“√μ‘¥‡™◊ÈÕ≈¥≈ßÕ¬à“ß¡“° ®÷ß∑”„Àâ´’‡Õæ’¥’°≈—∫¡“¡’∫∑∫“∑ Õ’°§√—Èß „π∞“π–∑“߇≈◊Õ°Àπ÷Ëß ”À√—∫ºâŸªÉ«¬‰μ«“¬√–¬– ÿ¥∑⓬  ∂‘μ‘°“√√Õ¥™’«‘μ®“°°“√»÷°…“√–¬–¬“« „πºâŸªÉ«¬´’‡Õæ’¥’„π∑»«√√…∑’Ë 1990s æ∫«à“¡’ Õ—μ√“°“√√Õ¥™’«‘μ∑’Ë 5 ªï ‡∑à“°—∫ 50-70%2,3 ·≈–º≈≈—æ∏å¡’·π«‚πâ¡¥’¢÷Èπ ‡¡◊ËÕ¡’°“√æ—≤π“‡∑§π‘§μà“ßÊ ∑’Ë ¡’ª√– ‘∑∏‘¿“欑ËßÊ ¢÷Èπ ·≈– “¡“√∂𔉪„™â„π°“√¥Ÿ·≈ºŸâªÉ«¬ „π¢≥–∑’Ë ¡“§¡π“π“™“μ‘∑’ˇ°’ˬ«¢âÕß°—∫´’‡Õæ’¥’‰¥â·°à International Society for Peritoneal Dialysis (ISPD) ‰¥â°àÕμ—Èߢ÷Èπ„π™à«ß∑»«√√…∑’Ë 1980 ‚¥¬¡’°“√ª√–™ÿ¡π“π“™“μ‘„π™à«ß·√°∑ÿ° 4 ªï μàÕ¡“ 300

Past, Present and Future of Peritoneal Dialysis ‰¥âª√—∫„Àâª√–™ÿ¡∂’Ë¢÷Èπ‡ªìπ∑ÿ° 3 ªï √«¡∑—Èß¡’°“√ π—∫ πÿπ„Àâ¡’°“√ª√–™ÿ¡„π¿Ÿ¡‘¿“§‰¥â·°à Asian chapter meeting, North American chapter meeting ·≈– Latin American chapter meeting πÕ°®“°π’È„π ª√–‡∑» À√—∞Õ‡¡√‘°“‡Õß University of Missouri at Columbia ‰¥â®—¥ª√–™ÿ¡«‘™“°“√∑’ˇπâπ°“√≈â“߉μ∑“ß ™àÕß∑âÕß∑ÿ°ªï μ—Èß·μàªï §.».1980 ‚¥¬‡ª≈’ˬπ∑’Ë®—¥°“√ª√–™ÿ¡‰ª¬—ß√—∞μà“ßÊ ∑—Ë«ª√–‡∑» À√—∞Õ‡¡√‘°“ ®“°°“√ª√–™ÿ¡μà“ßÊ ¥—ß°≈à“« ∑”„Àâ¡’°“√æ—≤π“‡∑§π‘§°“√√—°…“„Àâ¡’ª√– ‘∑∏‘¿“æ¡“°¢÷Èπ‡ªìπ≈”¥—∫ Õ“∑‘ Õ—μ√“°“√‡°‘¥ Catheter related peritonitis ®“°‡¥‘¡∑’ˇ°‘¥ 1 §√—Èß „π‡«≈“ 12 ‡¥◊Õπ ®πªí®®ÿ∫—π ¡’Õ—μ√“°“√‡°‘¥¡“μ√∞“πÕ¬Ÿà∑’Ë 1 §√—Èß „π‡«≈“ 36 ‡¥◊Õπ4-6 ‚¥¬Õߧåª√–°Õ∫∑’Ë ”§—≠ à«πÀπ÷Ëß ‡°‘¥®“° °“√æ—≤π“‡∑§π‘§°“√‡ª≈’ˬπ∂ÿßπÈ”¬“∑’Ëæ—≤π“®“° single bag ‡∑§π‘§ manual spike® ‡ªìπ Safelock® μàÕ¡“¡’°“√„™â‡∑§π‘§°“√¶à“‡™◊ÈÕª√–°Õ∫¥â«¬ ultraviolet ·≈–°“√¶à“‡™◊Èե⫬§«“¡√âÕπ (Thermoclav) „π∑’Ë ÿ¥¡’°“√π” Double bag æ√âÕ¡‡∑§π‘§ çFlush before fillé ¡“„™â ∑”„Àâ°“√√—°…“¡’§«“¡ª≈Õ¥¿—¬ ¬‘Ëߢ÷Èπ ISPD ‰¥âÕÕ°·π«ªØ‘∫—μ‘∑’ˇ°’ˬ«°—∫°“√√—°…“ÕÕ°¡“À≈“¬©∫—∫7 ¥—ß„πμ“√“ß∑’Ë 1 ´÷ËßπÕ°®“° π’Ȭ—ß¡’·π«ªØ‘∫—μ‘∑’ˇ°’ˬ«°—∫´’‡Õæ’¥’„πºâŸªÉ«¬‡¥Á°Õ’° 2 À—«¢âÕ  ”À√—∫·π«ªØ‘∫—μ‘ PD related infection recommendation ©∫—∫ 2005 §ß‡ªìπ©∫—∫∑’Ë„™âμàÕ‰ªÕ’°π“π ‡æ√“–‡π◊ÈÕÀ“μà“ßÊ „π©∫—∫π’ȉ¥âæ—≤π“¡“ ¡“°·≈â« √«¡∑—Èß°“√‡≈◊Õ°„™â empiric antibiotics °Á¬—ß·π–π”„Àℙ⬓ªØ‘™’«π–μ“¡§«“¡‡À¡“– ¡°—∫ ∫√‘∫∑¢Õß·μà≈–‚√ß欓∫“≈ ‚¥¬∑’Ë°“√»÷°…“ à«π„À≠à„πºŸâªÉ«¬´’‡Õæ’¥’ ∑”„π√ªŸ ·∫∫ descriptive study ·≈– analytic study „π¢≥–∑’Ë randomized control trials (RCTs) ¡’‰¡à¡“°π—° ·≈–¡—°¡’®”π«πμ—«Õ¬à“ߧàÕπ¢â“ßπâÕ¬ ∑”„Àâ ·π«ªØ‘∫—μ‘∑’Ë°”Àπ¥ÕÕ°¡“¡’À≈—°∞“π‡™‘ßª√–®—°…剡ࡓ°  à«π„À≠à‡ªìπ°“√‡ΩÑ“ —߇°μ¢Õß·æ∑¬åºŸâ ‡™’ˬ«™“≠ ‡¡◊ËÕæ‘®“√≥“º≈°“√»÷°…“ systematic review (SR) ´÷Ëß„™â¢âÕ¡Ÿ≈®“°°“√»÷°…“™π‘¥ RCTs ‚¥¬ Cochrane Renal Review8 ∑’ˇ°’ˬ«°—∫°“√≈â“߉μ∑“ß™àÕß∑âÕß æ∫«à“¡’‡æ’¬ß 7 °“√»÷°…“∑’Ë„Àâº≈≈—æ∏å·≈â« ·μàæ∫«à“ à«π„À≠à √ÿªº≈«à“ 笗ߡ’¢âÕ¡≈Ÿ ‰¡à‡æ’¬ßæÕé ¥—ß· ¥ß„πμ“√“ß∑’Ë 2 · ¥ß«à“ «ß°“√«‘™“°“√¬—ß ¡’§«“¡μâÕß°“√¢âÕ¡≈Ÿ °“√»÷°…“™π‘¥ RCTs ∑’ˇ°’ˬ«°—∫´’‡Õæ’¥’Õ’°¡“° μ“√“ß∑Ë’ 1 · ¥ß ISPD guideline ∑’ˇº¬·æ√à„π website: www.ispd.org Guidelines ª∑ï ‡Ë’ º¬·æ√à À¡“¬‡Àμÿ 1. Recommendation for the treatment of lipid 1999 disorder in patients on peritoneal dialysis 2005 ©∫—∫°àÕπÊ ‡º¬·æ√à„πªï 2. PD related infection recommendation 1996, 2000 3. Peritoneal catheter and exit site practice 2005 ©∫—∫°àÕπ ‡º¬·æ√à„πªï 1998 toward optimal peritoneal access 2006 4. Guideline on solute and fluid removal 2000 5. Peritoneal dialysis training 301

Practical Dialysis in the Year 2009 μ“√“ß∑’Ë 2 · ¥ßº≈°“√»÷°…“ Systematic review ‚¥¬ Cochrane Renal Review No. Studies Authorsû conclusions 1. Antimicrobial agents for preventing Nasal mupirocin reduces exit-site/tunnel infection but not peritonitis. Pre-op intravenous prophylaxis reduces early peritonitis in peritoneal dialysis peritonitis but not exit-site/tunnel infection. No other patients9 antimicrobial intravenous have proven efficacy. Given the large number of patients on PD and the importance of 2. Catheter type, placement and peritonitis, the lack of adequately powered RCTs to inform insertion techniques for decision making about strategies to prevent peritonitis is preventing peritonitis in striking. peritoneal dialysis patients10 No major advantages from any of the catheter-related interventions which have been purported to reduce the risk 3. Treatment for peritoneal of PD peritonitis could be demonstrated in this review. dialysis-associated peritonitis11 The frequency and quality of available trials are suboptimal. Based on one study, IP administration of antibiotics is superior 4. Continuous ambulatory to IV dosing for treating PD peritonitis. Intermittent and peritoneal dialysis (CAPD) continuous dosing of antibiotics are equally efficacious. There versus hospital or home is no role shown for routine peritoneal lavage or use of haemodialysis for end-stage urokinase. No interventions were found to be associated with renal disease in adults12 significant harm. There is insufficient data to allow conclusions to be drawn 5. Continuous ambulatory about the relative effectiveness of CAPD compared with peritoneal dialysis versus hospital or home haemodialysis for adults with ESRD. automated peritoneal Efforts should be made to start and complete adequately dialysis for ESRD13 powered RCTs, which compare the different dialysis modalities. 6. Double bag or Y-set versus APD has not been shown to have significant advantages standard transfer systems for over CAPD in terms of important clinical outcomes. CAPD in ESRD14 APD may however be considered advantageous in selected groups of patients such as in the younger PD population and 7. Psychosocial interventions those in employment or education due to its psychosocial for depression in dialysis advantages. patients15 Disconnect systems should be the preferred exchange systems in CAPD. Data were not available to draw conclusions about the effectiveness of psychosocial interventions in the treatment of depression in the chronic dialysis population, as we did not find any RCTs of psychosocial interventions to treat depression in dialysis patients. 302

Past, Present and Future of Peritoneal Dialysis Õπ÷Ëß „π∑»«√√…∑’˺à“π¡“ ‡π◊ËÕß®“°¡’§«“¡‡¢â“„®¡“°¢÷Èπ „π°“√™–≈Õ°“√‡ ◊ËÕ¡¢Õ߇¬◊ËÕ∫ÿ ™àÕß∑âÕß ´÷Ë߇ªìπμ—«°√ÕߢÕ߇ ’¬∏√√¡™“μ‘ ∑”„Àâ¡’§«“¡æ¬“¬“¡ 2 ·π«∑“ß ‰¥â·°à 1. ≈¥°“√„™âπÈ”μ“≈‡¥Á°‚μ√  ‚¥¬º≈‘μπÈ”¬“„π√Ÿª·∫∫ non-dextrose ‰¥â·°à 1.1 Polyglucose (Icodextrin) „™â ”À√—∫ºŸâªÉ«¬∑’Ë¡’ rapid membrane transport ¢Õ߇¬◊ËÕ∫ÿ™àÕß ∑âÕß ‚¥¬„™â„π«ß®√°≈“ߧ◊π 1.2 Amino acid „™â‡æ◊ËÕ≈¥°“√ Ÿ≠‡ ’¬°√¥Õ¡‘‚πÕÕ°‰ª°—∫πÈ”¬“ ¡’¢âÕ∫àß™’È„π√“¬∑’Ë¡’ ¿“«–∑ÿæ‚¿™π“°“√ 2. „™â‡∑§π‘§∑’Ë∑”„À⇰‘¥ glucose degradation product (GDP) „À⇰‘¥πâÕ¬∑’Ë ÿ¥ ‚¥¬„™â°“√ ª√—∫πÈ”¬“„Àâ¡’√–¥—∫ pH „°≈â 7.0 ‚¥¬„™â‰∫§“√å∫Õ‡π쇪ìπÕߧåª√–°Õ∫, „™â∂ÿß™π‘¥ two or three compartments «‘∏’À≈—߇æ◊ËÕ„ÀâπÈ”μ“≈‡¢â¡¢âπº ¡°—∫πÈ”‡°≈◊Õ·√à °àÕπ„ à‡¢â“™àÕß∑âÕߺŸâªÉ«¬ ‡æ◊ËÕ≈¥°“√‡°‘¥ GDP Õ¬à“߉√°Áμ“¡ πÈ”¬“‡À≈à“π’È à«π„À≠à·æ√àÀ≈“¬æÕ ¡§«√„πª√–‡∑»∑“ßμ–«—πμ° „π¢≥– ∑¬’Ë ß— ‰¡¡à °’ “√π”πÈ”¬“‡À≈“à π‡’È ¢“â ¡“®”Àπ“à ¬„πª√–‡∑»‰∑¬‡πÕ◊Ë ß®“°¬ß— ¡√’ “§“·æß°«“à πÈ”¬“¡“μ√∞“π¡“°  ”À√—∫ Automated peritoneal dialysis (APD)16 ‡ªìπ‡∑§π‘§°“√≈â“߉μ∑“ß™àÕß∑âÕß∑’Ë„™â‡§√◊ËÕß ¡◊ÕÕ—μ‚π¡—μ‘´÷Ë߉¥âæ—≤π“¡“π“π„π‡«≈“‡¥’¬«°—π°—∫´’‡Õæ’¥’ ·μà‡√‘Ë¡æ‘®“√≥“„™âß“π„π∑“ߧ≈‘π‘°„πªï §.».1981 ·≈– „π∑»«√√…π’È¡’°“√„™âß“π°—π·æ√àÀ≈“¬¡“°¢÷Èπμ“¡≈”¥—∫ ‚¥¬¡’¢âÕ∫àß™’È ”§—≠‰¥â·°à ºŸâªÉ«¬∑’ˉ¡àμâÕß°“√‡ª≈’ˬππÈ”¬“¥â«¬μπ‡Õß, „™â‡ªìπ nightly dialysis  ”À√—∫ºâŸªÉ«¬°≈ÿà¡ rapid membrane transport ªí®®ÿ∫—π∑—Ë«‚≈°¡’Õ—μ√“°“√„™â APD Õ¬àŸ∑’Ë 30-35% ¢Õߺ⟪ɫ¬≈â“߉μ∑“ß™àÕß∑âÕß 3. ´‡’ Õæ’¥„’ πª√–‡∑»‰∑¬¬§ÿ pre CAPD-UC era (æ.». 2525-2549) „πª√–‡∑»‰∑¬‰¥â‡√‘Ë¡„Àâ∫√‘°“√´’‡Õæ’¥’¡“μ—Èß·μàªï æ.». 2525 ‚¥¬°àÕπÀπâ“π—Èπ¡’°“√√—°…“ °“√≈â“߉μ∑“ß™àÕß∑âÕß·∫∫™—Ë«§√“«‰¥â·æ√àÀ≈“¬Õ¬àŸ·≈â« ».æ≠.  ÿ¡“≈’ π‘¡¡“ππ‘μ¬å ·≈–§≥– ®“° √æ.»‘√‘√“™17 ‰¥â‡ πÕ√“¬ß“π°“√√—°…“„πºŸâªÉ«¬®”π«π 11 √“¬ ´÷Ëßπ—∫‡ªìπ√“¬ß“π·√°¢Õß°“√»÷°…“´’ ‡Õæ’¥’„πª√–‡∑»‰∑¬ ‚¥¬„π°“√»÷°…“π’ȇ√‘Ë¡‚¥¬„™âπÈ”¬“∫√√®ÿ„π¢«¥·°â«´÷Ëߺ≈‘μ‡Õß„π‚√ß欓∫“≈ μàÕ ¡“®÷߉¥âª√—∫‡ª≈’Ë¬π¡“„™â‡ªìπ∂ÿßπÈ”¬“æ≈“ μ‘°·¢Áß À≈—ß®“°π—Èπ‰¡àπ“ππ—° √æ. æ√–¡ß°ÿƇ°≈â“‚¥¬ æ≈ μ√’À≠‘ß Õÿ…≥“ ≈ÿ«’√– ·≈–„πªïμàÕ¡“ √æ. √“™«‘∂’ ‚¥¬ æ≠. π—π∑°“ ®—π∑«“π‘™ °Á‰¥â‡√‘Ë¡„Àâ°“√√—°…“ ·°àºŸâªÉ«¬‚¥¬„™âπÈ”¬“„π∂ÿßæ≈“ μ‘°·¢Á߇™àπ°—π ®π°√–∑—Ëß„πªï æ.». 2527 ®÷߉¥â¡’°“√π”‡¢â“πÈ”¬“„π∂ÿß æ≈“ μ‘°ÕàÕπ®“°μà“ߪ√–‡∑» ·≈–°“√√—°…“¥—ß°≈à“«‰¥â·æ√à°√–®“¬‰ª¬—ß‚√ß欓∫“≈μà“ßÊ Õ“∑‘ √æ.»√’π§√‘π∑√å „πªï æ.». 2528 ·≈–‚√ß欓∫“≈ ß¢≈“π§√‘π∑√å„πªï æ.». 2530 μàÕ¡“„πªï æ». 2535 ®÷߉¥â‡√‘Ë¡°“√º≈‘μπÈ”¬“∂ÿßæ≈“ μ‘°ÕàÕπ„πª√–‡∑»‰∑¬‚¥¬„™â‡∑§‚π‚≈¬’ Safelock® ®”π«πºâŸªÉ«¬´’‡Õæ’¥’‰¥â‡æ‘Ë¡®”π«π¢÷Èπ¡“‡ªìπ≈”¥—∫μ—Èß·μàªï æ.». 2526 ·≈–„πªï æ.». 2535  ¡“§¡‚√§‰μœ ‰¥â»÷°…“æ∫ºâŸªÉ«¬‰¥â√—∫°“√≈â“߉μ∑“ß™àÕß∑âÕß 577 √“¬ 18 μàÕ¡“‰¥â¡’®”π«πºâŸªÉ«¬‡æ‘Ë¡ ¢÷Èπ¡“‡ªìπ≈”¥—∫®π∂÷ߠߟ  ÿ¥¡“°°«à“ 1000 √“¬ „πªï æ.». 2542 ·μàÀ≈—ß®“°π—Èπ®”π«πºŸâªÉ«¬§àÕ¬Ê ≈¥ πâÕ¬≈߇ªìπ≈”¥—∫ μ√ߢⓡ°—∫ºâŸªÉ«¬√—∫°“√øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡∑’Ë¡’®”π«π‡æ‘Ë¡¢÷Èπ¡“° ®π 303

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Practical Dialysis in the Year 2009 ‚¥¬®—¥‡ªìπ çÀπ૬∫√‘°“√μâπ·∫∫√–¬–∑’Ë 1é ®”π«π 23 ‚√ß欓∫“≈ (μ“√“ß∑’Ë 4) 2. ¥”‡ππ‘ °“√°∫— Õߧ°å “√‡¿ ™— °√√¡ ®¥— ª√–¡≈Ÿ πÈ”¬“¡“μ√∞“π™π¥‘ double bag „π√“§“∂ßÿ ≈– 95 ∫“∑ ·≈–®”Àπà“¬„Àâ°—∫Àπ૬∫√‘°“√„π‚§√ß°“√œ æ√âÕ¡®—¥ àß∂÷ß∫â“πºâŸªÉ«¬„π√“§“∂ÿß≈– 105 ∫“∑ ´÷Ë߬—ߺ≈„ÀâπÈ”¬“Õ◊ËπÊ ∑’˪√–¡≈Ÿ ‰¡à‰¥â μâÕß®”Àπà“¬„π√“§“‡¥’¬«°—π „Àâ·°àÀπ૬∫√‘°“√„π‚§√ß°“√œ 3.  π—∫ πÿπ‡ß‘π≈ß∑ÿπ„Àâ°—∫√æ.∑’ˬ‘π¥’‡¢â“√à«¡‚§√ß°“√œ „π™à«ß‡«≈“ ¡°√“§¡-μÿ≈“§¡ 2551 4. ª√– “πß“π„Àâ‚√ß欓∫“≈»√’π§√‘π∑√å ¥”‡π‘π°“√„Àâ°“√Õ∫√¡·∫∫‡√àß√—¥ a. ®—¥∑”‡Õ° “√ ·∫∫øÕ√å¡μà“ßÊ ‡æ◊ËÕ„™â‡ªìπμâπ·∫∫„π°“√„Àâ∫√‘°“√ b. Õ∫√¡æ¬“∫“≈®“°Àπ૬∫√‘°“√μâπ·∫∫ 1  —ª¥“Àå μ“√“ß∑Ë’ 4 · ¥ß‚√ß欓∫“≈∑’ˇªìπÀπ૬∫√‘°“√μâπ·∫∫ 23 ·Ààß ·∫àßμ“¡¿“§ ¿“§ ‚√ß欓∫“≈ ‡Àπ◊Õ ¡À“√“™π§√‡™’¬ß„À¡à π§√æ‘ߧå ≈”ª“ß ·¡à Õ¥ ®.μ“° æÿ∑∏™‘π√“™æ‘…≥ÿ‚≈° μ–«—πÕÕ°‡©’¬ß‡Àπ◊Õ Õÿ¥√∏“π’ ¡À“ “√§“¡ »√’π§√‘π∑√å ®.¢Õπ·°àπ ¡À“√“™π§√√“™ ’¡“  √√æ ‘∑∏‘ª√– ß§å ®.Õÿ∫≈√“™∏“π’ ¿“§°≈“ß  «√√§åª√–™“√—°…åπ§√ «√√§å ‡®â“æ√–¬“¬¡√“™ ÿæ√√≥∫ÿ√’ æ√–π§√»√’Õ¬ÿ∏¬“ ∫â“π·æâ« (æ√âÕ¡¡‘μ√) °√ÿ߇∑æœ πæ√—μπå√“™∏“π’ °√ÿ߇∑æœ μ–«—πÕÕ° ∫â“π·æâ«  ¡ÿ∑√ “§√ ™≈∫ÿ√’ ©–‡™‘߇∑√“ √–¬Õß ¿“§„μâ  ÿ√“…Æ√å∏“π’  ß¢≈“π§√‘π∑√å ®. ß¢≈“ π§√»√’∏√√¡√“™ «™‘√–¿Ÿ‡°Áμ 306

Past, Present and Future of Peritoneal Dialysis c. Õ∫√¡·æ∑¬å®“°Àπ૬∫√‘°“√μâπ·∫∫ 1  —ª¥“Àå æ√âÕ¡»÷°…“¥Ÿß“π‚§√ß°“√ PD first ¢Õ߇¢μª°§√Õß摇»…ÕàÕß°ß d. „Àâ°“√Õ∫√¡æ¬“∫“≈·≈–·æ∑¬å®“°Àπ૬∫√‘°“√μà“ßÊ ∑’Ë√âÕß¢Õ 5. ®—¥∑” website ‡æ◊ËÕ„Àâ¡’°“√≈ß∑–‡∫’¬π ‚¥¬°”Àπ¥„Àâ·μà≈–‚√ß欓∫“≈¡’ case manager nurse √—∫º‘¥™Õ∫√æ.≈– 1 §π 6. ª√– “πß“π°—∫°√–∑√«ß “∏“√≥ ÿ¢ „Àâ¡’§≥–∑”ß“π·≈–§≥–°√√¡°“√®“°ºâŸ∫√‘À“√ √–¥—∫ Ÿß ·≈–®“° ∂“∫—π°“√»÷°…“∑’ˇ°’ˬ«¢âÕߥ”‡π‘π°“√μà“ßÊ ∑’ˇ°’ˬ«¢âÕ߇æ◊ËÕº≈—°¥—ππ‚¬∫“¬ ¬—ߺ≈ „À⇰‘¥ a. °“√ª√–™ÿ¡ºŸâ∫√‘À“√√–¥—∫ºâŸÕ”𫬰“√√æ. √–¥—∫®—ßÀ«—¥¢÷Èπ‰ª b. °“√ª√–™ÿ¡À—«Àπâ“欓∫“≈¢Õß√–¥—∫®—ßÀ«—¥¢÷Èπ‰ª c. ¡’°“√·μàßμ—Èߧ≥–°√√¡°“√√–¥—∫√æ. ‡æ◊ËÕ§—¥‡≈◊Õ°ºŸâªÉ«¬ ‘∑∏‘Ï∫—μ√∑Õß ‡æ◊ËÕ‡¢â“√—∫°“√ √—°…“‚¥¬„™â‡°≥±å°≈“ß μàÕ¡“‰¥âª√—∫‡ª≈’ˬπ‡ªìπ §≥–°√√¡°“√√–¥—∫®—ßÀ«—¥ ‡æ◊ËÕ„Àâ§√Õ∫§≈ÿ¡°“√ øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡¥â«¬ 7. ª√– “πß“π°—∫«‘∑¬“≈—¬æ¬“∫“≈ ¿“°“™“¥ ·≈–  “¢“«‘™“‚√§‰μ √æ.®ÿÓ≈ß°√≥å ‡ªìπ·°π°≈“ß„π°“√Ωñ°Õ∫√¡æ¬“∫“≈μ“¡À≈—° μŸ √ 4 ‡¥◊Õπ ‚¥¬ª√–°Õ∫¥â«¬°“√∫√√¬“¬ 6  —ª¥“Àå ·≈– °√–®“¬°“√Ωñ°Õ∫√¡„π‚√ß欓∫“≈μà“ßÊ ∑—Ë«ª√–‡∑»Õ’° 10  —ª¥“Àå 8.  ª ™. ‰¥â·μàßμ—Èß„Àâ‚√ß欓∫“≈»√’π§√‘π∑√凪ìπ PD technology and training center ‡æ◊ËÕ °“√√—°…“¡“μ√∞“π¢Õß°“√„Àâ°“√∫√‘°“√„πÀπ૬∫√‘°“√μâπ·∫∫ 23 √æ. „Àâ°“√Ωñ°Õ∫√¡μ“¡À≈—° Ÿμ√ ¢Õß ¿“°“√欓∫“≈ √«¡∑—È߇ªìπ∑’˪√÷°…“∑“ß«‘™“°“√∑’ˇ°’ˬ«°—∫´’‡Õæ’¥’·°àÀπ૬∫√‘°“√μà“ßÊ ´÷Ëß„π °‘®°√√¡¥—ß°≈à“«∑’Ë¥”‡π‘π°“√·≈⫉¥â·°à a. ®—¥∑”·∫∫øÕ√å¡°“√‡¬’ˬ¡∫â“π  ”À√—∫‡®â“Àπâ“∑’ËÀπ૬∫√‘°“√ª∞¡¿¡Ÿ ‘ b. ®—¥∑”Àπ—ß ◊Õ„À⧫“¡√⟠”À√—∫ºâŸªÉ«¬´’‡Õæ’¥’ c. ®—¥∑”Àπ—ß ◊Õ§àŸ¡◊Õ´’‡Õæ’¥’  ”À√—∫欓∫“≈ 1 ™ÿ¥ d. √«∫√«¡¢âÕ¡Ÿ≈°“√„Àâ∫√‘°“√¢ÕßÀπ૬∫√‘°“√μâπ·∫∫ μ—Èß·μà 1 ¡°√“§¡ 2551 e. ª√– “πß“π°—∫  ª ™. „π°“√®—¥°“√ª√–™ÿ¡μ‘¥μ“¡¥Ÿ§«“¡°â“«Àπâ“¢Õß欓∫“≈ Àπ૬∫√‘°“√μâπ·∫∫∑ÿ° 3 ‡¥◊Õπ ∑’Ë  ¡ÿ¬ ( ÿ√“…Æ√å∏“π’), °√ÿ߇∑æœ,  ‘ߧ‚ª√å ·≈–‡¢“„À≠à (π§√√“™ ’¡“) μ“¡≈”¥—∫ μ—Èß·μà‡√‘Ë¡‚§√ß°“√„π«—π∑’Ë 1 ¡°√“§¡ 2551 æ∫«à“ ¡’®”π«πºŸâªÉ«¬∫—μ√∑Õ߇¢â“√—∫∫√‘°“√ ‡æ‘Ë¡¡“°¢÷ÈπÕ¬à“ß√«¥‡√Á« ‚¥¬æ∫«à“¡’®”π«πºâŸªÉ«¬∑’Ë≈ß∑–‡∫’¬π‡¢â“√—∫°“√∫√‘°“√∂÷ß 1100 √“¬ „π 10 ‡¥◊Õπ·√° ®“°Àπ૬∫√‘°“√μà“ßÊ ª√–¡“≥ 50 ·Ààß ‚¥¬‡©≈’ˬ¡’ºŸâªÉ«¬‡¢â“√—∫√‘°“√‡©≈’ˬ‡¥◊Õπ≈– 100-120 √“¬ ®“°¢âÕ¡≈Ÿ ∑’Ë√«∫√«¡®“°Àπ૬∫√‘°“√μâπ·∫∫ 23 ·Ààß μ—Èß·μà ¡°√“§¡-μÿ≈“§¡ 2551 ¡’º≈√“¬ß“π ‡∫◊ÈÕßμâπ¥—ßπ’È29 ë ®”π«πºŸâªÉ«¬∑’Ë»÷°…“ 782 √“¬ ®“°∑’Ë≈ß∑–‡∫’¬π∑—Èß ‘Èπ 1100 √“¬ ë  —¥ à«π ™“¬μàÕÀ≠‘ß = 1:1.08 ë Õ“¬ÿ‡©≈’ˬ 44.8 ªï ‚¥¬‡ªìπ‡∫“À«“π 25.9 % 307

Practical Dialysis in the Year 2009 ë ‰¥â√—∫°“√øÕ°‡≈◊Õ¥°àÕπ°“√«“ß “¬ 37.97 % ë ‰¥â√—∫°“√«“ß “¬¢â“ß‡μ’¬ß 11.37 % ë ºâŸªÉ«¬‰¥â√—∫°“√„ à “¬: 1 §√—Èß ®”π«π 90.4 %, 2 §√—Èß 8.43 % (66 √“¬), 3 §√—Èß 0.89 % (7 √“¬) ·≈–¡“°°«à“ 3 §√—Èß 2 √“¬ ë §“à „™®â “à ¬„π°“√«“ß “¬‡©≈¬Ë’ √“¬≈– 14,802.17 ∫“∑  «à π„À≠Õà ¬∑àŸ ªË’ √–¡“≥ 6,000-7,000 ∫“∑ ë °“√ Õπ„™â‡«≈“ª√–¡“≥ 3-5 «—π ë ¡’Õ—μ√“°“√‡°‘¥ peritonitis ¿“¬„π 30 «—π·√° ¢Õß°“√√—°…“„π 23 √“¬ (2.94 %) ë ¡’Õ—μ√“°“√‡°‘¥ peritonitis ª√–¡“≥ 0.43 §√—Èß/√“¬/ªï ë §à“√—°…“ peritonitis ‡©≈’ˬ§√—Èß≈– 11,279.38 ∫“∑  à«π„À≠àÕ¬Ÿà∑’Ë 3,000-5,000 ∫“∑ ë ‡°‘¥ exit site infection = 0.12 §√—Èß/√“¬/ªï ë ∂Õ¥ “¬™—Ë«§√“« √—∫°“√øÕ°‡≈◊Õ¥„π 38 √“¬ (4.86 %) ë ÕÕ°®“°‚§√ß°“√ 124 §π (15.8%) √“¬≈–‡Õ’¬¥· ¥ß„πμ“√“ß∑’Ë 5 º≈®“°°“√»÷°…“¢â“ßμâππ’ÈÕ¬Ÿà„π‡°≥±å¡“μ√∞“π §à“„™â®à“¬Õ¬Ÿà„πß∫ª√–¡“≥∑’Ëμ—È߉«â  à«π Àπ÷ËßÕ“®‡ªìπ‡æ√“–Àπ૬∫√‘°“√μâπ·∫∫¡’ª√– ∫°“√≥å„π°“√¥Ÿ·≈ºâŸªÉ«¬Õ¬àŸ·≈â« ·≈– à«πÀπ÷Ë߇°‘¥®“° Àπ૬∫√‘°“√ à«π„À≠à„À⧫“¡√–¡—¥√–«—ß„π°“√§—¥‡≈◊Õ°ºâŸªÉ«¬‡¢â“√à«¡‚§√ß°“√œ ¢âÕ —߇°μæ∫«à“ ªí≠À“°“√«“ß “¬∑’ˇ§¬§‘¥«à“‡ªìπªí≠À“μ—Èß·μàμâπ°≈—∫¡’‰¡à¡“°π—° „π¢≥–∑’Ë°“√¥Ÿ·≈ catheter related peritonitis ¬—߇ªìπªí≠À“ ‡æ√“–¬—ßæ∫«à“‡ªì𠓇Àμÿ¢Õß°“√‡ª≈’ˬπ«‘∏’°“√√—°…“ ‚¥¬¿“æ√«¡ ´’‡Õæ’¥’„πªí®®ÿ∫—π¬—ßμâÕß°“√·°â‰¢ª√—∫ª√ÿß ‰¥â·°à Õÿª √√§„π°“√„À⧫“¡√⟠·≈– Õπ ºŸâªÉ«¬·≈–§√Õ∫§√—«„π°“√¥Ÿ·≈μπ‡Õß ªí≠À“‡√◊ËÕ߇∑§π‘§ °“√·°â‰¢¿“«–∑ÿæ‚¿™π“°“√ Õ—μ√“쓬®“°‚√§À—«„®·≈–À≈Õ¥‡≈◊Õ¥∑’ˬ—ߠߟ ¡“° ªí≠À“ drop out rate ∑’ˬ—ß¡“°∂÷ß 10% ·μà∑’Ë ”§—≠ §◊Õ °“√À“¡“μ√°“√„Àâ∫ÿ§≈“°√∑“ß°“√·æ∑¬å¡’§«“¡¡—Ëπ„®·≈–√à«¡¡◊Õ„π°“√„Àâ∫√‘°“√´’‡Õæ’¥’·°à ºŸâªÉ«¬¿“«–‰μ«“¬√–¬– ÿ¥∑⓬ ‰¡à«à“®–„™â ‘∑∏‘Ï„¥°Áμ“¡ μ“√“ß∑Ë’ 5 · ¥ß “‡Àμÿ¢Õߺ⟪ɫ¬´’‡Õæ’¥’ ∑’ËÕÕ°®“°‚§√ß°“√ CAPD-UC „π 10 ‡¥◊Õπ·√° º≈≈æ— ∏¢å ÕߺªŸâ «É ¬ ®“°®”π«πºŸâªÉ«¬ 782 √“¬ ÕÕ°®“°‚§√ß°“√ 124 √“¬ 15.8 % - ‡ ’¬™’«‘μ 75 √“¬ 9.6 % - øÕ°‡≈◊Õ¥∂“«√ 38 √“¬ 4.9 % - ª≈Ÿ°∂à“¬‰μ 5 √“¬ 0.6 % - Õ◊ËπÊ Õ“∑‘ ‡ª≈’ˬπ ‘∑∏‘Ï 6 √“¬ 0.7 % 308

Past, Present and Future of Peritoneal Dialysis μ“√“ßμàÕ‰ªπ’È· ¥ß¢—ÈπμÕπ¡“μ√∞“π∑’ˇ™◊ËÕ«à“ ¡’º≈∑”„Àâ°“√√—°…“¥â«¬«‘∏’´’‡Õæ’¥’¡’ ª√– ‘∑∏‘¿“æ ‚¥¬„π∑ÿ°¢—ÈπμÕπ ∫ÿ§≈“°√∑“ß°“√·æ∑¬åμâÕß¡’§«“¡„ à„®„π°“√√—°…“ μ“√“ß∑Ë’ 6 · ¥ß 14 ¢—ÈπμÕπ¡“μ√∞“π∑’ˇ™◊ËÕ«à“ ¡’º≈∑”„Àâ°“√√—°…“¥â«¬«‘∏’´’‡Õæ’¥’¡’ª√– ‘∑∏‘¿“æ 1. ºâŸªÉ«¬§«√‰¥â√—∫§«“¡√⟷≈–§”ª√÷°…“Õ¬à“߇ªìπ√–∫∫ ·≈–ºâŸªÉ«¬μâÕß¡’ à«π ”§—≠„π°“√‡≈◊Õ° «‘∏’√—°…“ 2. ºâŸªÉ«¬μâÕ߉¥â√—∫°“√ª√–‡¡‘π«à“ 秫√®–∑”é ·≈–ª√–‡¡‘π«à“ çπà“®–∑”‰¥âé 3. ¡’°“√‡μ√’¬¡ºŸâªÉ«¬Õ¬à“ß∂Ÿ°μâÕß°àÕπ°“√«“ß “¬ √«¡∑—Èß°“√·°â‰¢¿“«–¬Ÿ√’‡¡’¬ (Õ“®μâÕß∑”°“√ ≈â“߉μ∑“ß™àÕß∑âÕß·∫∫™—Ë«§√“« À√◊Õ°“√øÕ°‡≈◊Õ¥°àÕπ) 4. ºŸâªÉ«¬·≈–ºŸâ™à«¬¥Ÿ·≈μâÕ߉¥â√—∫°“√ Õπ ·≈–ºà“π°“√∑¥ Õ∫«à“ “¡“√∂¥Ÿ·≈ºâŸªÉ«¬∑’Ë∫â“π‰¥â ‚¥¬°“√ ÕπμâÕß¡’°“√∑∫∑«π´È”Ê 5. °“√„  à “¬≈“â ß™Õà ß∑Õâ ßμÕâ ß∑”‚¥¬·æ∑¬ºå ¡âŸ ª’ √– ∫°“√≥·å ≈–‡¢“â „®∑ß—È «∏‘ °’ “√·≈–Õªÿ °√≥‡å ∑“à ππ—È 6. §«√¡’ Break-In period ¬°‡«âπ „π°√≥’ºâŸªÉ«¬¡’Õ“°“√¢Õ߬Ÿ√’‡¡’¬ Õ“®æ‘®“√≥“„ àπÈ”¬“∑—π∑’ ‚¥¬„Àâ§àÕ¬Ê ‡æ‘Ë¡ª√‘¡“≥¡“°¢÷Èπ ‡æ◊ËÕªÑÕß°—π°“√√—Ë« ´÷Ëß®–π”¡“´÷Ëß°“√μ‘¥‡™◊ÈÕ ·≈–„π∫“ß °√≥’Õ“®μâÕßæ‘®“√≥“∑”°“√øÕ°‡≈◊Õ¥™—Ë«§√“« 7. À≈ß— ‡√¡‘Ë „ πà È”¬“ 2  ª— ¥“Àå „À°â √–μπÿâ ºªâŸ «É ¬„À‰â ¥â high protein diet ‡æÕ◊Ë ªÕÑ ß°π— ¿“«–∑æÿ ‚¿™π“°“√ 8. ≥ ‡«≈“ 1 ‡¥◊Õπ „Àâ∑” PET ·≈–æ‘®“√≥“ª√—∫‡ª≈’ˬπ°“√√—°…“μ“¡º≈°“√μ√«®«—¥ adequacy 9. „π 3 ‡¥◊Õπ·√° §«√π—¥ºâŸªÉ«¬¡“∑ÿ° 4  —ª¥“Àå ‚¥¬„Àâ°“√¥·Ÿ ≈Õ¬à“ߪ√–≥’μ À≈—ß®“°π—Èπ Õ“® 𗥇ªìπ∑ÿ° 8  —ª¥“À剥â ∂⓺ŸâªÉ«¬ ∫“¬¥’ 10.  àßμ√«®∑“ßÀâÕߪؑ∫—μ‘°“√μ“¡·π«ªØ‘∫—μ‘ ‡æ◊ËÕ„™â„π°“√ª√–‡¡‘πºâŸªÉ«¬ 11. „π°√≥’ ∂⓺ŸâªÉ«¬¡’ hypokalemia ·≈– hypoalbuminemia „À⥟·≈ºâŸªÉ«¬·∫∫¡’¿“«–∑ÿæ‚¿™π“°“√ 12. ºŸâªÉ«¬∑’Ë¡’ exit site infection „Àâ√’∫√—°…“μ“¡·π«ªØ‘∫—μ‘¢Õß ¡“§¡œ 13. °√≥’¡’ peritonitis „Àâ√—°…“μ“¡·π«ªØ‘∫—μ‘ ∂Ⓣ¡àμÕ∫ πÕßμ“¡¢—ÈπμÕπ „Àâ∂Õ¥ “¬‚¥¬‰¡à ™—°™â“‚¥¬√–¬–‡«≈“¢Õß°“√√—°…“‚¥¬√«¡‰¡à§«√‡°‘π 7 «—π Õπ÷Ëß §ß„À⬓ªØ‘™’«π–∑“ßÀ≈Õ¥ ‡≈◊Õ¥μàÕ‰ªÕ’° 7 «—π ·≈–„Àâæ—°∑âÕß 2-4  —ª¥“Àå ·≈â«·μà°√≥’ 14. √“¬∑’Ë¡’ frequent peritonitis ¡’Õ—μ√“°“√‡°‘¥ 3 §√—Èß„π 3-6 ‡¥◊Õπ ‚¥¬‰¡à∑√“∫ “‡ÀμÿÀ√◊Õ·°â‰¢  “‡Àμÿ‰¡à‰¥â „Àâæ‘®“√≥“À¬ÿ¥√—°…“¥â«¬«‘∏’´’‡Õæ’¥’ 5. ·π«‚πâ¡¢Õß´‡’ Õæ’¥’„πÕπ“§μÕ—π„°≈â (æ.». 2553-2558) „π¿“æ√«¡¢Õß°“√≈â“߉μ∑“ß™àÕß∑âÕß∑—Ë«‚≈° ®“°¿“«–‡»√…∞°‘®∑’ˉ¡à·πàπÕπ ¿“«–‚≈° √âÕπ∑’Ë®–¬—ߧߧÿ°§“¡‚≈°μàÕ‰ª ·≈–§«“¡æ¬“¬“¡∑’Ë®–„Àâ ºŸâªÉ«¬∑’Ë¥âÕ¬‚Õ°“ ‡¢â“∂÷ß°“√∫√‘°“√≈â“ß‰μ ¡“°¢÷È𠇙◊ËÕ‰¥â«à“À≈“¬ª√–‡∑»„π‚≈°®–¥”‡π‘π°“√ PD first policy ¥—ß∑’Ë∑”„πª√–‡∑»‰∑¬ √«¡∑—Èß¡’ 309

Practical Dialysis in the Year 2009 °“√¢¬“¬μ—«¢Õß´’‡Õæ’¥’Õ¬à“ßμàÕ‡π◊ËÕß„πª√–‡∑»Õ‘π‡¥’¬·≈–®’π´÷Ëß¡’ª√–™“°√√«¡°—π∂÷ß 40% ¢Õß æ≈‡¡Õ◊ ß‚≈° π“à ®–∑”„À´â ‡’ Õ楒 ¡’ Õ’ μ— √“°“√¢¬“¬μ«— ‡æ¡Ë‘ ¢πÈ÷ ¡“° ·≈–‡™ÕË◊ «“à ®–¡°’ “√„™πâ ”È ¬“™π¥‘ reduced GDP ·≈–πÈ”¬“™π‘¥ non-dextrose ¡“°¢÷Èπ ‡π◊ËÕß®“°√“§“∑’Ë∂Ÿ°≈ß μ≈Õ¥®ππà“®–¡’°“√‡√‘Ë¡„™âπÈ”¬“ º≈‘μ¿—≥±å„À¡à ∑’Ë„™â “√Õ◊Ëπ‡ªìπÕߧåª√–°Õ∫·∑ππÈ”μ“≈‡¥Á°‚μ√  ´÷Ëß “¡“√∂¥÷ßπÈ”·≈–‡°≈◊ÕÕ°®“° √à“ß°“¬‰¥â¡“°¢÷Èπ ¿“«–·∑√°´âÕπμà“ßÊ ‚¥¬‡©æ“– catheter related peritonitis ®–¡’Õ—μ√“°“√‡°‘¥≈¥ ≈ß®π‡À≈◊Õ‡æ’¬ß 1 §√—Èß„π 48 ‡¥◊Õπ ´÷Ëß®–∑”„À⇪ìπ¿“«–·∑√°´âÕπ∑’ˉ¡àπà“°≈—«Õ’°μàÕ‰ª  ”À√—∫º≈‡ ’¬ ∑’ˇ°‘¥¢÷Èπ„π√–¬–¬“« Õ“∑‘ ¿“«–∑ÿæ‚¿™π“°“√ Õ—μ√“쓬®“°‚√§À≈Õ¥‡≈◊Õ¥·≈–À—«„® μ≈Õ¥®π §ÿ≥¿“æ™’«‘μ ®–‰¥â√—∫°“√¥Ÿ·≈ ®π°√–∑—Ë߉¡à‡ªìπ¿—¬§ÿ°§“¡μàÕ™’«‘μ¢Õߺ⟪ɫ¬Õ’°μàÕ‰ª  ”À√—∫ „πª√–‡∑»‰∑¬ ∂â“‚§√ß°“√ PD first  ”À√—∫ºŸâªÉ«¬∫—μ√∑Õ߬—ߥ”‡π‘π°“√μàÕ‰ª‰¥â¥’ ®π∂÷ß æ.». 2553 ´÷Ëß®–∑”„Àâ¡’®”π«πºâŸªÉ«¬¡“°¢÷Èπ  àߺ≈„Àâ∫ÿ§≈“°√∑“ß°“√·æ∑¬å‡°‘¥§«“¡¡—Ëπ„®μàÕ «‘∏’°“√√—°…“ ∫√‘…—∑πÈ”¬“¡’§«“¡¡—Ëπ„®∑’Ë®–¡’°“√≈ß∑ÿπ„π°“√º≈‘μπÈ”¬“„πª√–‡∑»‰∑¬ ·≈–¡’°“√π” πÈ”¬“™π¥‘ Õπ◊Ë Ê πÕ°®“°πÈ”¬“¡“μ√∞“π‡¢“â ¡“®”Àπ“à ¬„πª√–‡∑»‰∑¬ ‡À≈“à ππ’È “à ®–¬ß— º≈„À‡â °¥‘  ß‘Ë μ“à ßÊ μàÕ‰ªπ’È 1. ‚√ß欓∫“≈¢Õß°√–∑√«ß “∏“√≥ ÿ¢ √–¥—∫∑—Ë«‰ª¢÷Èπ‰ª∑ÿ°·Ààß „Àâ°“√∫√‘°“√´’‡Õæ’¥’ 2.  ∂“∫—πΩñ°Õ∫√¡∑ÿ°·Ààß „À⧫“¡ ”§—≠°—∫´’‡Õæ’¥’ 3. ¡’ºâŸªÉ«¬´’‡Õæ’¥’∑—Èß„π°≈ÿࡺŸâªÉ«¬∫—μ√∑Õß·≈–ºâŸªÉ«¬∑’Ë„™â ‘∑∏‘ÏÕ◊ËπÊ ‡æ‘Ë¡¡“°¢÷Èπ ‚¥¬§“¥«à“ ®–¡’ºŸâªÉ«¬´’‡Õæ’¥’∂÷ß 3,000 √“¬ „πªï æ.». 2553 ·≈– 5,000 √“¬ „πªï æ.». 2556 4. ¡’®”π«π°“√„™â APD ‡æ‘Ë¡¢÷Èπ®π∂÷ß 50% „π°≈ÿࡺ⟪ɫ¬  ‘∑∏‘Ï¢â“√“™°“√ √—∞«‘ “À°‘® ∑’ˇ∫‘°®à“¬‰¥â®“°¿“§√—∞ „π°√≥’∑’ˬ—߉¡à¡’¡’°“√§«∫§ÿ¡‡æ¥“π§à“„™â®à“¬®“°°√¡∫—≠™’°≈“ß ·≈–‚¥¬ ‡©æ“–Õ¬à“߬‘Ëß ∂â“μâπ∑ÿπ√—°…“¢Õß APD ∂°Ÿ ≈ß 5. ‚¥¬¿“æ√«¡ ºªâŸ «É ¬®–¡¿’ “«–·∑√°´Õâ π∑ß—È √–¬–‡©¬’ ∫æ≈π— ·≈–√–¬–¬“«≈¥≈ß æ√Õâ ¡°∫— ¡’ drop out rate ≈¥≈ß 6. ¡’°“√π”πÈ”¬“™π‘¥ reduced GDP ·≈– non-dextrose ¡“„™â‡ªìπ∑“߇≈◊Õ°  ”À√—∫ºŸâªÉ«¬∑’Ë ‡À¡“– ¡„π√“§“∑’Ë∂Ÿ°≈ß 7. ¡’°“√≈ß∑ÿπº≈‘μπÈ”¬“¡“μ√∞“π·≈–πÈ”¬“Õ◊ËπÊ „πª√–‡∑»‰∑¬ ·≈– “¡“√∂®”Àπà“¬„π √“§“∑’Ë∂Ÿ°≈ß 8. ¡’°“√°àÕμ—Èß™¡√¡∫ÿ§≈“°√∑“ß°“√·æ∑¬å∑’ˇ°’ˬ«°—∫´’‡Õæ’¥’ 9. ª√–‡∑»‰∑¬¡’º≈ß“π°“√»÷°…“‡°’ˬ«°—∫´’‡Õæ’¥’æ‘¡æ出¬·æ√à¡“°¢÷Èπ 10. ¡’°“√®—¥°“√ª√–™ÿ¡«‘™“°“√∑’ˇ°’ˬ«°—∫´’‡Õæ’¥’‚¥¬ ¡“§¡‚√§‰μœ ·≈– ∂“∫—πμà“ßÊ ‡ªìπª√–®”∑ÿ°ªï ·≈–ª√–‡∑»‰∑¬¡’‚Õ°“ ∑’Ë®–‰¥â®—¥°“√ª√–™ÿ¡π“π“™“μ‘ ∑—Èß„π√–¥—∫ Southeast Asia meeting, Asian chapter meeting ·≈– ISPD congress 6.  √ÿª ´’‡Õæ’¥’‡ªìπ«‘∏’°“√√—°…“∑’Ë¥’  ”À√—∫ºŸâªÉ«¬‰μ«“¬√–¬– ÿ¥∑⓬ ·≈–§«√æ‘®“√≥“‡≈◊Õ°„™â 310

Past, Present and Future of Peritoneal Dialysis Õ¬“à ߬ßË‘ „πºªâŸ «É ¬‡©æ“–°≈¡àÿ „π¬§ÿ ¢Õß CAPD-UC ®–¬ß— º≈„ÀÀâ π«à ¬∫√°‘ “√μ“à ßÊ ¡§’ «“¡§πâÿ ‡§¬°∫— «∏‘ °’ “√ ·≈–®– àߺ≈„À⇰‘¥º≈≈—æ∏å∑’Ë¥’μ“¡¡“ Õπ÷Ëß °“√æ—≤π“°“√μà“ßÊ ‡°’ˬ«°—∫´’‡Õæ’¥’ ‚¥¬‡©æ“–°“√º≈‘μ πÈ”¬“´’‡Õæ’¥’„πª√–‡∑»‰∑¬ √“§“πÈ”¬“∑’Ë≈¥≈ß √«¡∑—Èß¡’°‘®°√√¡∑“ß«‘™“°“√μà“ßÊ ®–‡°‘¥¢÷Èπ‰¥â ®“° °“√√à«¡¡◊Õ·≈–°“√¥”‡π‘π°“√¢Õß∫ÿ§≈“°√∑“ß°“√·æ∑¬å∑’ˇ°’ˬ«¢âÕ߇∑à“π—Èπ ‡Õ° “√Õ“â ßÕß‘ 1. Gokal R. History of peritoneal dialysis. In: Textbook of Peritoneal Dialysis, edited by Gokal R, Khanna R, Krediet R, Nolph K, Dordrecht, Kluwer, 2000,p 1-18. 2. US Renal Data System: Excerpts from the USRDS 2000 Annual Data Report: Atlas of end-stage renal disease in the United States. Am J Kidney Dis 2000; 36 [Suppl 2]: S1-S238. 3. Maiorca R, Cancarini GC. Outcome with peritoneal dialysis compared to haemodialysis. In: Textbook of Peritoneal Dialysis, edited by Gokal R, Khanna R, Krediet R, Nolph K, Dordrecht, Kluwer, 2000,p 755-84. 4. Whaley-Connell A, Pavey BS, Satalowich R, Prowant BF, Misra M, Twardowski ZJ et al. Rates of continuous ambulatory peritoneal dialysis associated peritonitis at the University of Missouri. Advances in Peritoneal Dialysis, Vol. 21, 2005 p.72-5. 5. ∑«’ »‘√‘«ß»å , »‘√‘æ√ «‘∑¬®√√¬“æß»å , °π°°√ »√’∑“‚  , πÿ™®√’¬å ÀÕ¡π“π. Catheter Related Infection „πºŸâªÉ«¬≈â“߉μ ∑“ß™Õà ß∑Õâ ß™π¥‘ μÕà ‡πÕË◊ ß: »°÷ …“‡ª√¬’ ∫‡∑¬’ ∫√–À«“à ß 2 √–∫∫π”π”È ¬“. «“√ “√ ¡“§¡‚√§‰μ·Àßà ª√–‡∑»‰∑¬ 2546; 9(3): 251-6. 6. Õ¥‘»√ «—ß»‘√‘‰æ»“≈, æ߻廗°¥‘Ï ¥à“π‡¥™“, æ√‡æÁ≠ · ß∂«—≈¬å, πßπÿ™ ‡Õ◊ÈÕ ÿ®√‘μ«ß»å,  ÿ¿√ ∫ÿ…ª«π‘™,  ¡π÷° ∑Õß»‘√‘, ·≈–§≥–. °“√≈“â ߉μ∑“ß™Õà ß∑Õâ ßÕ¬“à ßμÕà ‡πÕË◊ ߥ«â ¬π”È ¬“√–∫∫∂ßÿ §·Ÿà ≈–™– “¬°Õà πª≈Õà ¬π”È ¬“‡¢“â ™Õà ß∑Õâ ß (Double bag, Flush-before-fill System): ª√– ∫°“√≥å„π‚√ß欓∫“≈ ß¢≈“π§√‘π∑√å «“√ “√ ¡“§¡‚√§‰μ·Ààߪ√–‡∑»‰∑¬ 2546; 9(3): 241-50. 7. website: www.ispd.org 8. website: www.cochrane-renal.org/reviews.php. 9. Strippoli GFM, Tong A, Johnson D, Schena FP, Craig JC. Antimicrobial agents for preventing peritonitis in peritoneal dialysis patients. Cochrane Database of Systematic Reviews 2004, Issue 4. 10. Strippoli GFM, Tong A, Johnson D, Schena FP, Craig JC. Catheter type, placement and insertion techniques for preventing peritonitis in peritoneal dialysis patients. Cochrane Database of Systematic Reviews 2004, Issue 4. 11. Wiggins KJ, Craig JC, Johnson DW, Strippoli GFM. Treatment for peritoneal dialysis-associated peritonitis. Cochrane Database of Systematic Reviews 2008, Issue 1. 12. Vale L, Cody J, Wallace S, Daly C, Campbell M, Grant A, et al. Continuous ambulatory peritoneal dialysis (CAPD) versus hospital or home haemodialysis for end-stage renal disease in adults. Cochrane Database of Systematic Reviews 2004, Issue 4. 13. Rabindranath KS, Adams J, Ali TZ, MacLeod AM, Vale L, Cody JD, Wallace SA, Daly C. Continuous ambulatory peritoneal dialysis versus automated peritoneal dialysis for end-stage renal disease. Cochrane Database of Systematic Reviews 2007, Issue 2. 14. Daly C, Campbell M, Cody JD, Donaldson C, Grant A, Khan I, et al. Double bag or Y-set versus standard transfer systems for continuous ambulatory peritoneal dialysis in end-stage renal disease. Cochrane Database of Systematic Reviews 2000, Issue 3. 311

Practical Dialysis in the Year 2009 15. Rabindranath KS, Daly C, Butler JA, Roderick PJ, Wallace S, MacLeod AM. Psychosocial interventions for depression in dialysis patients. Cochrane Database of Systematic Reviews 2005, Issue 3. 16. Kathuria P, Twardowski ZJ. Automated peritoneal dialysis. In: Textbook of Peritoneal Dialysis, edited by Gokal R, Khanna R, Krediet R, Nolph K, Dordrecht, Kluwer, 2000,p 435-65. 17. Nimmannit S, Nilwarankur S, Sindhvananda K, Kobwanthanakun S, Lelarasamee A. Continuous ambulatory peritoneal dialysis: Two years experience in Siriraj hospital. J Mes ASS Thailand 1986; 69(3): 125-30. 18. Õ…ÿ ≥“ ≈«ÿ √’ –. °“√√°— …“‚√§‰μ«“¬‡√Õ◊È √ß— √–¬– ¥ÿ ∑“â ¬‚¥¬«∏‘ ∑’ ¥·∑π‰μ„πª√–‡∑»‰∑¬ „π°“√√°— …“‚¥¬«∏‘ ’ hemodialysis ·≈– CAPD. Õÿ…≥“ ≈ÿ«’√– ∫√√≥“∏‘°“√. °√ÿ߇∑æœ:  ”π—°æ‘¡æå°√ÿ߇∑懫™ “√, 2536:147. 19. ∑«’ »‘√‘«ß»å. CAPD in Thailand: current data & how to apply ‡ πÕμàÕ ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘ „ππ“¡  ¡“§¡‚√§‰μ·Ààߪ√–‡∑»‰∑¬ 18 μÿ≈“§¡ 2547 (‰¡à‰¥âæ‘¡æ出¬·æ√à). 20. Roel M. Huisman, Martin G. M. Nieuwenhuizen and Frank Th. de Charro. Patient-related and centre-related factors influencing technique survival of peritoneal dialysis in The Netherlands. Nephrol Dial Transplant 2002;17: 1655-60. 21. ∑«’ »√‘ «‘ ß»å ∫√√≥“∏°‘ “√. ·π«ªØ∫‘ μ— „‘ π°“√¥·Ÿ ≈√°— …“ºªŸâ «É ¬‰μ≈“â ߉μ∑“ß™Õà ß∑Õâ ß æ.». 2550  ¡“§¡‚√§‰μ·Àßà ª√–‡∑» ‰∑¬. ∫√‘…—∑∑’øî≈å¡ ®°. ππ∑∫ÿ√’ 2550. 22. Grassmann A, Gioberge S, Moeller S, Brown G. ESRD patients in 2004: global overview of patient numbers, treatment modalities and associated trends. Nephrol Dial Transplant 2005 20(12):2587-93. 23. Oreopoulos DG. Peritoneal dialysis in the Far East: an awaking giant. Perit Dial Int. 2004; 24(6): 528-30. 24. Bouvier N, Durand PY, Testa A, Albert C, Planquois V, Ryckelynck JP et al. Regional discrepancies in peritoneal dialysis utilization in France: the role of the nephrologistûs opinion about peritoneal dialysis. Nephrol Dial Transplant (2008) 1 of 5 doi: 10.1093/ndt/gfn648. 25. Sirivongs D. Factors Influencing Decision-Making On Modality Selection In Pre-Dialysis Patients. Perit Dial Int 2004: 26(Suppl 1): S186. 26. Õ“√’«√√≥ ‡™’ˬ«™“≠«—≤π“, ®ÿÓ¿√≥å ≈‘¡«—≤π“ππ∑å,  ÿæ≈ ≈‘¡«—≤π“ππ∑å, «‘‚√®πå μ—È߇®√‘≠‡ ∂’¬√, ∑«’ »‘√‘«ß»å, ·≈– ™≈∏‘ª æ߻堰ÿ≈. °“√«‘‡§√“–Àåμâπ∑ÿπÕ√√∂ª√–‚¬™πå¢Õß°“√øÕ°‡≈◊Õ¥°—∫°“√≈â“߉μ∑“ß™àÕß∑âÕßÕ¬à“ßμàÕ ‡π◊ËÕß„πºâŸªÉ«¬‰μ«“¬√–¬– ÿ¥∑⓬„πª√–‡∑»‰∑¬. «“√ “√ ¡“§¡‚√§‰μ·Ààߪ√–‡∑»‰∑¬. 2546 9(2): 158-169. 27. °—≠®π“ μ‘…¬“∏‘§¡, √—™μ– μ—Èß»‘√‘æ—≤πå, ·≈– «‘‚√®πå μ—È߇®√‘≠‡ ∂’¬√. °“√¢¬“¬°“√∫”∫—¥∑¥·∑π‰μ„π‚§√ß°“√ ª√–°—π ÿ¢¿“æ∂â«πÀπâ“:¢âÕæ‘®“√≥“∑“ßπ‚¬∫“¬. „π: ∑«’ »‘√‘«ß»å, ∫√√≥“∏‘°“√. °“√≈â“߉μ„π¬ÿ§ æ√∫.À≈—° ª√–°—π ÿ¢¿“æ.¢Õπ·°àπ: ‚√ßæ‘¡æå¡À“«‘∑¬“≈—¬¢Õπ·°àπ; 2546. Àπâ“ 15-20. 28. ∑«’ »‘√‘«ß»å. ‚§√ß°“√»÷°…“μâπ·∫∫°“√„Àâ∫√‘°“√√—°…“ºŸâªÉ«¬¥â«¬«‘∏’ CAPD „π√–∫∫ª√–°—π ÿ¢¿“æ∂â«πÀπâ“ ¥”‡π‘π°“√‚¥¬¡À“«‘∑¬“≈—¬¢Õπ·°àπ. ‡Õ° “√‡ πÕμàÕ ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘ 28 ‡¡…“¬π 2548. 29. ∑«’ »‘√‘«ß»å ·≈–§≥–. Preliminary result of 23 first phase CAPD-UC units by PD technology and training center, Srinagarind hospital. ‡ πÕμàÕ ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘. 惻®‘°“¬π 2551. 312

Nursing Intervention in Hemodialysis 17 Nursing Intervention in Hemodialysis Õ√«√√≥ ¢π—  ”√’ 1. ∫∑π” 2. °√–∫«π°“√欓∫“≈ (Nursing Process) 3. °“√欓∫“≈°Õà π°“√øÕ°‡≈◊Õ¥¥«â ¬‡§√◊ÕË ß‰μ‡∑’¬¡ 4. °“√欓∫“≈ºŸâªÉ«¬¢≥–øÕ°‡≈Õ◊ ¥¥«â ¬‡§√◊ËÕ߉μ‡∑’¬¡ 5. °“√欓∫“≈À≈—ß°“√øÕ°‡≈◊Õ¥¥â«¬‡§√ËÕ◊ ߉μ‡∑¬’ ¡ 6. ¢âÕ«‘π®‘ ©¬— °“√欓∫“≈„πºâªŸ «É ¬‰μ«“¬‡√ÕÈ◊ √—ß∑’ËøÕ°‡≈◊Õ¥¥«â ¬‡§√ËÕ◊ ߉μ‡∑¬’ ¡ 7.  √ÿª 313

Practical Dialysis in the Year 2009 1. ∫∑π” 欓∫“≈‡ªπì ∫§ÿ §≈∑ Ë’ ”§≠— ¡“° ”À√∫— ºªâŸ «É ¬‰μ«“¬‡√ÕÈ◊ √ß— ∑øË’ Õ°‡≈Õ◊ ¥¥«â ¬‡§√ÕË◊ ߉μ‡∑¬’ ¡„π °“√∑’Ë„Àâ°“√¥Ÿ·≈ºâŸªÉ«¬μ—Èß·μà√–¬–°àÕπ°“√øÕ°‡≈◊Õ¥ ‚¥¬°“√‡μ√’¬¡μ—«ºŸâªÉ«¬‡æ◊ËÕ„Àâ¡’§«“¡æ√âÕ¡°àÕπ °“√øÕ°‡≈◊Õ¥ √–¬–øÕ°‡≈◊Õ¥·≈–√–¬–À≈—ß°“√øÕ°‡≈◊Õ¥ ‚¥¬¡’®ÿ¥ª√– ß§å‡æ◊ËÕ„ÀâºâŸªÉ«¬ª≈Õ¥¿—¬ ®“°¿“«–·∑√°´Õâ π„À§â «“¡√«à ¡¡Õ◊ „π°“√√°— …“¡§’ ≥ÿ ¿“晫’ μ‘ ∑¥’Ë ’ “¡“√∂Õ¬„àŸ π ß— §¡‰¥Õâ ¬“à ß¡§’ «“¡ ¢ÿ ‚¥¬„™â°√–∫«π°“√欓∫“≈ (Nursing Process) ·≈–°“√欓∫“≈·∫∫Õߧå√«¡ §◊Õ °“¬ ®‘μ  —ߧ¡ ®‘μ «‘≠≠“≥ ‡æ◊ËÕ· ¥ß∂÷ߧ«“¡‡ªìπ«‘™“™’æ ¥—ßπ—Èπ欓∫“≈ºâŸ‡™’ˬ«™“≠¥â“π‰μ‡∑’¬¡®–μâÕß¡’§«“¡√Ÿâ §«“¡ ™”π“≠ ¡’∑—°…–„π°“√‡°Á∫√«∫√«¡¢âÕ¡Ÿ≈®“°ºâŸªÉ«¬ ·≈–π”¢âÕ¡Ÿ≈∑’ˉ¥â¡“«‘‡§√“–Àå ·≈– —߇§√“–Àå μ“¡°√–∫«π°“√欓∫“≈·≈–®¥∫π— ∑°÷ ‰¥Õâ ¬“à ߧ√∫∂«â π‡æ√“–∫π— ∑°÷ ∑“ß°“√欓∫“≈‡À≈“à π®’È –· ¥ß∂ß÷ §ÿ≥¿“æ°“√ªØ‘∫—μ‘ß“π¢Õß欓∫“≈ °“√æ—≤π“«‘™“™’æ°“√欓∫“≈√«¡∑—Èß„™âª√–°Õ∫‡ªìπÀ≈—°∞“π ∑“ß°ÆÀ¡“¬‰¥â ·≈–¬ß— ¡ª’ √–‚¬™π„å π¥“â π°“√∫√À‘ “√°“√欓∫“≈ °“√»°÷ …“ °“√«®‘ ¬— ∑“ß°“√欓∫“≈Õ°’ ¥â«¬1 ·μà„π ¿“æ§«“¡‡ªìπ®√‘ß æ¬“∫“≈≈–‡≈¬°“√‡¢’¬π∫—π∑÷°∑“ß°“√欓∫“≈ ‡π◊ËÕß®“°¿“√–ß“π ¡“° ∑”„À‰â ¡¡à À’ ≈°— ∞“π¬π◊ ¬π— «“à ‰¥¡â °’ “√ªØ∫‘ μ— ß‘ “π®√ß‘ ‰¡¡à ¿’ “√–ß“π∑ ’Ë “¡“√∂«¥— ‰¥∑â ‡’Ë ªπì √ªŸ ∏√√¡ ∑ß—È Ê ∑’Ë欓∫“≈∑”ß“πÕ¬à“ßÀπ—° ·≈–„™â°√–∫«π°“√欓∫“≈„π°“√„Àâ°“√欓∫“≈‡ªìπ°‘®«—μ√ª√–®”«—π ‚¥¬‰¡à√Ÿâμ—«  àߺ≈„Àâ¥â“π°“√∫√‘À“√¿“√–ß“π≈¥≈ß °“√¢ÕÕ—μ√“°”≈—ߧπ‡æ‘Ë¡‡ªìπ‰ª‰¥â¬“°  ¿“°“√ 欓∫“≈®÷߉¥â¡’ª√–°“» ¿“°“√欓∫“≈ ‡√◊ËÕß ¡“μ√∞“π°“√欓∫“≈·≈–º¥ÿߧ√√¿å æ.».2524 „π ¡“μ√∞“π∑Ë’ 5 ‰««â “à “æ¬“∫“≈μÕâ ß∫π— ∑°÷ ·≈–√“¬ß“π°“√欓∫“≈·≈–º¥ßÿ §√√¿„å À§â √Õ∫§≈¡ÿ °“√¥·Ÿ ≈ ºŸâ√—∫∫√‘°“√μ“¡°√–∫«π°“√欓∫“≈ ‚¥¬§√∫∂â«π ∂Ÿ°μâÕßμ“¡§«“¡‡ªìπ®√‘ß ™—¥‡®π °–∑—¥√—¥ ¡’ §«“¡μàÕ‡π◊ËÕß·≈– “¡“√∂„™â‡æ◊ËÕª√–‡¡‘π§ÿ≥¿“æ∫√‘°“√欓∫“≈·≈–º¥ÿߧ√√¿å‰¥”È 2 ¥—ßπ—Èπ欓∫“≈ºâŸ ‡™’ˬ«™“≠‰μ‡∑’¬¡∑ÿ°∑à“πμâÕß„À⧫“¡ ”§—≠ ·≈–§«√ à߇ √‘¡ „Àâ¡’°“√„™â°√–∫«π°“√欓∫“≈„π Àπ૬‰μ‡∑’¬¡¢Õß∑à“π‡ªìπÕ¬à“߬‘Ëß ´÷Ëß„π∫∑π’È®–°≈à“«∂÷ß°√–∫«π°“√欓∫“≈ °“√„™â°√–∫«π°“√ 欓∫“≈„π°“√¥·Ÿ ≈ºªâŸ «É ¬∑ø’Ë Õ°‡≈Õ◊ ¥¥«â ¬‡§√Õ◊Ë ß‰μ‡∑¬’ ¡ °Õà π ¢≥– ·≈–À≈ß— øÕ°‡≈Õ◊ ¥¥«â ¬‡§√Õ◊Ë ß‰μ‡∑¬’ ¡ ‡æ◊ËÕ„Àâ欓∫“≈ºŸâ‡™’ˬ«™“≠¥â“π‰μ‡∑’¬¡π”‰ª‡ªìπ·π«∑“ß„π°“√„Àâ°“√欓∫“≈ ·≈–®¥∫—π∑÷° ∑“ß°“√欓∫“≈μàÕ‰ª 2. °√–∫«π°“√欓∫“≈ (Nursing Process) ª√–°Õ∫¥â«¬ 5 ¢—ÈπμÕπ 3 2.1 °“√ª√–‡¡‘π∑“ß°“√欓∫“≈ (Nursing assessment) ‡ªìπ¢—ÈπμÕπ·√°¢Õß°√–∫«π°“√ 欓∫“≈ ´÷Ë߇ªìπ°“√‡°Á∫√«∫√«¡¢âÕ¡Ÿ≈‡°’ˬ«°—∫∫ÿ§§≈ §√Õ∫§√—« ·≈–™ÿ¡™πÕ¬à“ß¡’√–∫∫ ‚¥¬„™â·∫∫ ª√–‡¡‘π¿“«– ÿ¢¿“æ (μ“¡·μà≈– ∂“∫—π°”Àπ¥„Àâ„™â·μ°μà“ß°—π) √Ÿª·∫∫¢Õß NANDA ¡’°“√ª√–‡¡‘π ∑—ÈßÀ¡¥ 13 ¥â“π3 ·≈â«π”¢âÕ¡≈Ÿ ∑’ˉ¥â®“°°“√ª√–‡¡‘π¿“«– ÿ¢¿“æ¡“æ‘®“√≥“¥Ÿ«à“ºŸâ√—∫∫√‘°“√ª°μ‘ À√◊Õ º‘¥ª°μ‘ À√◊Õ¡’¿“«–‡ ’Ë¬ß ·≈â««‘‡§√“–Àå¢âÕ¡Ÿ≈‡À≈à“π—Èπ àŸ¢—ÈπμÕπ°“√«‘π‘®©—¬°“√欓∫“≈ 314

Nursing Intervention in Hemodialysis 2.2 °“√«π‘ ®‘ ©¬— ∑“ß°“√欓∫“≈ (Nursing diagnosis) ‡ªπì ¢πÈ— μÕπ¢Õß°“√¥”‡ππ‘ °“√‡°¬Ë’ «°∫— ¢âÕ¡Ÿ≈ °”Àπ¥¿“«– ÿ¢¿“æ ·≈–°“√°”Àπ¥À√◊Õ°“√‡¢’¬π«‘π‘®©—¬∑“ß°“√欓∫“≈ °“√«‘π‘®©—¬ ∑“ß°“√欓∫“≈ §◊Õ °“√√–∫ÿÀ√◊Õ‡¢’¬πªí≠À“·≈– “‡ÀμÿÀ√◊Õªí®®—¬‡ ’ˬߢÕߺŸâ√—∫∫√‘°“√π—Ëπ‡Õß ‚¥¬√Ÿª ·∫∫¢Õß°“√‡¢’¬π¢âÕ«‘π‘®©—¬∑“ß°“√欓∫“≈μ“¡√Ÿª·∫∫¢Õß NANDA (American Nursing Diagnosis Association, NANDA)4 ¡’¥—ßπ’È 2.2.1 Actual Diagnosis §◊Õ¡’¢âÕ¡≈Ÿ À≈—°∞“π· ¥ßÕ“°“√· ¥ß™—¥‡®π 2.2.2 Risk Diagnosis §Õ◊ ¡¢’ Õâ ¡≈Ÿ ¢ÕߺªŸâ «É ¬∑‡’Ë °¬’Ë «¢Õâ ß°∫— ª®í ®¬— ‡ ¬’Ë ß·μ¬à ß— ‰¡¡à À’ ≈°— ∞“π· ¥ß ™—¥‡®π 2.2.3 Possible Diagnosis §◊Õ ‰¡à¡’¢âÕ¡Ÿ≈À≈—°∞“π ·μஓ° —≠™“μ≠“≥∫Õ°«à“ ªí≠À“Õ“® ∑’Ë®–‡°‘¥2 μ—«Õ¬“à ß √ªŸ ·∫∫°“√°”Àπ¥¢âÕ«‘π‘®©—¬∑“ß°“√欓∫“≈2 √ªŸ ·∫∫∑’Ë 1 ‡°‘¥ªí≠À“ ÿ¢¿“æ‡æ√“–æ∫ªí®®—¬‡ ’Ë¬ß ªí≠À“ ÿ¢¿“æ + ‡π◊ËÕß®“° + ªí®®—¬∑’ˇ°’ˬ«¢âÕß (ªí®®—¬ à߇ √‘¡) ‡™àπ ¡’§«“¡ “¡“√∂„π°“√¥Ÿ·≈μπ‡Õß≈¥≈ß ‡π◊ËÕß®“°°≈â“¡‡π◊ÈÕÕàÕπ·√ß §«“¡‡Àπ◊ËÕ¬≈â“ √Ÿª·∫∫∑Ë’ 2 §“¥«à“®–‡°‘¥ªí≠À“ ÿ¢¿“æ‡æ√“–æ∫ªí®®—¬‡ ’Ë¬ß ‡ ’ˬßμàÕ°“√‡°‘¥+ ªí≠À“ ÿ¢¿“æ + ‡π◊ËÕß®“° + ªí®®—¬∑’ˇ°’ˬ«¢âÕß (ªí®®—¬ à߇ √‘¡) ‡™àπ ‡ ’ˬßμàÕ°“√μ‘¥‡™◊ÈÕ‡π◊ËÕß®“°√–∫∫¿¡Ÿ ‘§ÿâ¡°—π¢Õß√à“ß°“¬ºŸâªÉ«¬∫°æ√àÕß √ªŸ ·∫∫∑Ë’ 3 ¡’‚Õ°“ ‡°‘¥ªí≠À“ ÿ¢¿“æ ¡’‚Õ°“ ‡°‘¥ + ªí≠À“ ÿ¢¿“æ + ‡π◊ËÕß®“° + ªí®®—¬∑’ˇ°’ˬ«¢âÕß (ªí®®—¬ à߇ √‘¡) ‡™àπ ¡’‚Õ°“ ‡°‘¥°“√ Ÿ≠‡ ’¬¿“æ≈—°…≥å ‡π◊ËÕß®“°‰¥â√—∫°“√ºà“μ—¥‡ âπ‡≈◊Õ¥‡∑’¬¡ 2.3 °“√«“ß·ºπ°“√欓∫“≈ (Planning) ª√–°Õ∫¥â«¬°“√®—¥≈”¥—∫§«“¡ ”§—≠¢Õߪí≠À“ °“√°”À𥮥ÿ ¡ßàÿ À¡“¬°“√欓∫“≈ °“√°”À𥇰≥±°å “√ª√–‡¡π‘ º≈ °“√°”Àπ¥°®‘ °√√¡°“√欓∫“≈ ·≈–°“√‡¢’¬π·ºπ°“√欓∫“≈≈ß„π·∫∫øÕ√å¡·ºπ°“√欓∫“≈„À⇪ìπ≈“¬≈—°…≥åÕ—°…√∑’Ë™—¥‡®π 2.4 °“√ªØ∫‘ μ— °‘ “√欓∫“≈ (Nursing intervention) ‡ªπì ¢π—È μÕπ∑®’Ë –π”·ºπ„π¢π—È ∑’Ë 3 ¡“ªØ∫‘ μ— ‘ ®√‘ß°—∫ºâŸªÉ«¬Õ¬à“ßμàÕ‡π◊ËÕß ‡æ◊ËÕ„Àâ∫√√≈ÿ®ÿ¥¡ÿàßÀ¡“¬∑’Ëμ—È߉«â ¥—ßπ—Èπ„π¢—ÈπμÕππ’È æ¬“∫“≈μâÕß¡’§«“¡√⟠§«“¡‡¢â“„® „™â∑—Èß»“ μ√å·≈–»‘≈ªá„π°“√欓∫“≈ ·≈–¡’°“√μ‘¥μ“¡»÷°…“º≈°“√«‘®—¬ ·≈– „™â evident base practice „π°“√欓∫“≈‡æ◊ËÕ„Àâ¡’§«“¡∑—π ¡—¬ ·≈–¡’ª√– ‘∑∏‘¿“æ‡æ‘Ë¡¡“°¢÷Èπ ·≈–∫—π∑÷° √ÿª°“√ 315

Practical Dialysis in the Year 2009 ªØ‘∫—μ‘°“√欓∫“≈‡ªìπ≈“¬≈—°…≥åÕ—°…√ 2.5 °“√ª√–‡¡‘πº≈≈—æ∏å∑“ß°“√欓∫“≈ (Nursing outcomes) ‡ªìπ¢—ÈπμÕπ ÿ¥∑⓬¢Õß °√–∫«π°“√欓∫“≈ ‡ªìπ°“√ª√–‡¡‘π«à“ºŸâªÉ«¬‰¥â√—∫°“√¥Ÿ·≈·≈–¡’°“√æ—≤𓉪 àŸ®ÿ¥¡ÿàßÀ¡“¬∑’Ë«“߉«â À√◊Õ‰¡à ‚¥¬‡°≥±å°“√ª√–‡¡‘πº≈π—Èπ ª√–°Õ∫¥â«¬ æƒμ‘°√√¡ºŸâ√—∫∫√‘°“√ ‡°≥±å∑’˧“¥À«—ß √–¬–‡«≈“ ·≈–‡ß◊ËÕπ‰¢(∂â“¡’)5-7 ‡°≥±å°“√ª√–‡¡‘πº≈ = æƒμ‘°√√¡ºâŸ√—∫∫√‘°“√ + ‡°≥±å∑’˧“¥À«—ß + √–¬–‡«≈“ + ‡ß◊ËÕπ‰¢ μ—«Õ¬à“ß ®ÿ¥¡ÿàßÀ¡“¬∑“ß°“√欓∫“≈ : ºâŸªÉ«¬‰¥â√—∫°“√øÕ°‡≈◊Õ¥Õ¬à“߇撬ßæÕ§√∫ 4 ™—Ë«‚¡ß‚¥¬ ‰¡à‡°‘¥¿“«–·∑√°´âÕπ ‡°≥±å°“√ª√–‡¡‘πº≈ : 1. øÕ°‡≈◊Õ¥§√∫ 4 ™—Ë«‚¡ß 2. §à“ Kt/v ¡“°°«à“ 1.2 (3 §√—Èß/ —ª¥“Àå) 3. ‰¡à¡’¿“«–·∑√°´âÕπ‡°‘¥¢÷Èπ 3. °“√欓∫“≈°àÕπ°“√øÕ°‡≈Õ◊ ¥¥«â ¬‡§√◊ËÕ߉μ‡∑¬’ ¡ °“√„Àâ°“√欓∫“≈¢Õß欓∫“≈ºŸâ‡™’ˬ«™“≠‰μ‡∑’¬¡π—Èπ‰¡à‡æ’¬ß·μàμâÕß„Àâ°“√¥Ÿ·≈ºâŸªÉ«¬ ‡∑à“π—Èπ 欓∫“≈μâÕߥŸ·≈‡§√◊ËÕ߉μ‡∑’¬¡¡‘„À⇰‘¥§«“¡º‘¥ª°μ‘Õ’°¥â«¬ ºŸâªÉ«¬®÷ß®–‰¥â√—∫°“√øÕ°‡≈◊Õ¥ Õ¬à“߇撬ßæÕ ·≈–‰¡à‡°‘¥¿“«–·∑√°´âÕπ√–À«à“ßøÕ°‡≈◊Õ¥ ¥—ßπ—Èπ°àÕπ∑”°“√øÕ°‡≈◊Õ¥ μâÕß¡’°“√ ª√–‡¡‘π∑—Èߺ⟪ɫ¬ ·≈–‡§√◊ËÕ߉μ‡∑’¬¡¥—ßπ’È 3.1 °“√‡μ√’¬¡‡§√◊ËÕ߉μ‡∑’¬¡°àÕπ°“√øÕ°‡≈◊Õ¥ §«√ªØ‘∫—μ‘μ“¡§”·π–π”¢Õß∫√‘…—∑Õ¬à“ß ‡§√àߧ√—¥ ¡’°“√ test ‡§√◊ËÕß°àÕπ∑ÿ°§√—Èß  ‘Ëß∑’Ë ”§—≠§◊ÕμâÕß¡’°“√≈â“߇§√◊ËÕß·≈–μ—«°√Õß°àÕπ ‡æ◊ËÕ®–™à«¬ ™–≈â“ß  “√μà“ßÊ ∑’Ë„™â¶à“‡™◊ÈÕ„πμ—«°√Õß ‡™àπ øÕ√å¡“≈‘π ‡Õ∑‘≈’πÕÕ°‰´¥å ´÷Ë߇ªìπμ—«∑’Ë∑”„À⇰‘¥ªØ‘°‘√‘¬“ °“√·æâμ—«°√Õß √–À«à“ß°“√≈â“ßμ—«°√Õߥ⫬πÈ”¬“ dialysate §«√¡’°“√≈â“ߥâ“π blood compartment ¥â«¬ NSS Õ¬à“ßμË” 2 ≈‘μ√ ·≈–À≈—ß®“°°“√≈â“ß·≈⫧«√¡’°“√‡√‘Ë¡∑”°“√øÕ°‡≈◊Õ¥¿“¬„π 5-10 π“∑’ ∂â“„Àâ «ß®√øÕ°‡≈◊Õ¥À¬ÿ¥π‘Ë߇ªìπ‡«≈“π“π¡“°°«à“ 10 π“∑’ §«√∑”°“√≈â“ßÕ’°§√—Èß ‡π◊ËÕß®“° “√‡Õ∑‘≈’πÕÕ° ‰´¥å®–°≈—∫‡¢â“¡“„π«ß®√Õ’° Õ“® àߺ≈„À⺟âªÉ«¬‡°‘¥Õ“°“√·æâ 7 ·≈–§«√¡’°“√ test  “√¶à“‡™◊ÈÕμ°§â“ß °àÕπ°“√μàÕ«ß®√‡¢â“°—∫ºâŸªÉ«¬∑ÿ°§√—Èß 3.2 °“√ª√–‡¡‘π·≈–°“√‡μ√’¬¡ºŸâªÉ«¬°àÕπ°“√øÕ°‡≈◊Õ¥ 3.2.1 °“√´—°ª√–«—μ‘ 316

Nursing Intervention in Hemodialysis ¥â“π®‘μ —ß§¡  ¿“«–∑’ËμâÕ߇ªìπºâŸªÉ«¬‰μ«“¬‡√◊ÈÕ√—ß μâÕ߇º™‘≠°—∫§«“¡∑ÿ°¢å∑√¡“π®“°‚√§ ´÷Ëß°àÕ„À⇰‘¥º≈°√–∑∫§√Õ∫§≈ÿ¡∑—Èߥâ“π √à“ß°“¬ ®‘μ„® Õ“√¡≥å·≈– —ߧ¡ 欓∏‘ ¿“æ¢Õß‚√§∑’ˇ°‘¥ ªí≠À“∑“ß°“¬ ®“°¿“«–·∑√°´âÕπ√–À«à“ß°“√øÕ°‡≈◊Õ¥ ∑”„ÀâμâÕß¡’°“√®”°—¥°‘®°√√¡μà“ßÊ μâÕß¡’ °“√ª√—∫‡ª≈’ˬπ«‘∂’™’«‘μ®“°°“√¥”‡π‘π¢Õß‚√§ ®“°°√–∫«π°“√√—°…“ ·≈–‡æ◊ËÕªÑÕß°—π¿“«–·∑√°´âÕπ πÕ°®“°π’Ȭ—ß∑”„Àâ∫∑∫“∑„π§√Õ∫§√—«·≈– —ߧ¡‡ª≈’ˬπ·ª≈߉ª ‰¡à “¡“√∂¥”√ß∫∑∫“∑∑’Ëμπ·≈– ∫§ÿ §≈Õπ◊Ë §“¥À«ß— ‰¥â ‰¡ à “¡“√∂ª√–°Õ∫°®‘ °√√¡πÕ°∫“â π‰¥‡â ™πà ‡¥¡‘ ∑ß—È ¬ß— ¡§’ “à „™®â “à ¬‡æ¡‘Ë ¡“°¢π÷È ∑”„À⠺⟪ɫ¬√⟠÷°Àßÿ¥Àß‘¥ ∑âÕ·∑â ´÷Ëß®“°ß“π«‘®—¬∑—Èß„πμà“ߪ√–‡∑»·≈–¿“¬„πª√–‡∑»æ∫«à“ ªí≠À“∑“ߥâ“π ®‘μ —ß§¡∑’Ëæ∫∫àÕ¬„πºŸâªÉ«¬∑’ËøÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡ à«π„À≠à‰¥â·°à ¿“«–´÷¡‡»√â“ «‘μ°°—ß«≈8,9 ´÷Ëß æ¬“∫“≈‰μ‡∑¬’ ¡∑°ÿ §π®ß÷ μÕâ ß„À§â «“¡ ”§≠— °∫— ‡√Õ◊Ë ßπ’È‚¥¬°“√ª√–‡¡π‘ „À≈â °÷ ∂ß÷ ·∫∫·ºπ°“√¥”‡ππ‘ ™«’ μ‘ °“√‡º™‘≠ªí≠À“ §«“¡‡¢â“„®„π°“√‡®Á∫ªÉ«¬¢Õßμπ ª√–«—μ‘°“√‡®Á∫ªÉ«¬∑“ß®‘μ °“√‡ª≈’ˬπ·ª≈ß„π °“√¥”‡π‘π™’«‘μ ·≈–º≈°√–∑∫∑’ˇ°‘¥®“°§«“¡‡®Á∫ªÉ«¬ ‡æ◊ËÕπ”¡“À“∑“ß·°â‰¢ ∑”„Àâ§ÿ≥¿“æ™’«‘μ¢Õߺ⟠ªÉ«¬¥’¢÷Èπ ·≈– àߺ≈¥’μàÕ§ÿ≥¿“æ°“√欓∫“≈¥â«¬ ¥â“π√à“ß°“¬ ´—°ª√–«—μ‘„π°“√øÕ°‡≈◊Õ¥§√—Èß°àÕπ ·≈–Õ“°“√¢Õߺ⟪ɫ¬‡¡◊ËÕÕ¬àŸ∑’Ë∫â“π ª√–«—μ‘°“√√—∫ª√–∑“πÕ“À“√ °“√√—∫ª√–∑“𬓠‡ªìπμâπ ‡æ◊ËÕ§âπÀ“·≈–·¬°·¬– ‘Ëß∑’˪°μ‘ ·≈–º‘¥ª°μ‘ „À§â √∫∂«â π∑ßÈ— ∑“ߥ“â π °“¬ ®μ‘  ß— §¡ ®μ‘ «≠‘ ≠“≥·≈–π”¡“‡¢¬’ π‡ªπì ¢Õâ «π‘ ®‘ ©¬— ∑“ß°“√欓∫“≈ ‰¥·â °à 3.2.2  —≠≠“≥™’æ Õÿ≥À¿Ÿ¡‘¢Õß√à“ß°“¬°àÕπ°“√øÕ°‡≈◊Õ¥‡ªìπ ‘Ëß∑’Ë ”§—≠∑’Ë∂Ÿ°¡Õߢⓡ Õÿ≥À¿Ÿ¡‘¢ÕߺŸâªÉ«¬ √–À«“à ß°“√øÕ°‡≈Õ◊ ¥®–μ”Ë ≈߇≈°Á πÕâ ¬ À√Õ◊ „π∫“ߧ√ßÈ— Õ“®®– ßŸ °«“à ª°μ‘ 0.5 Õß»“‡´≈‡´¬’   ´ßË÷ ‡ªπì ‡√ÕË◊ ß ª°μ‘ 7 °“√¡’‰¢â°àÕπ°“√øÕ°‡≈◊Õ¥ ‡ªìπ ‘Ëß∑’Ë欓∫“≈‰μ‡∑’¬¡μâÕßμ√–Àπ—°·≈–À“ “‡Àμÿ¢Õ߉¢â ‡æ√“–ºâŸ ªÉ«¬Õ“®®–μ‘¥‡™◊ÈÕ„π√à“ß°“¬ μâÕ߉¥â√—∫°“√«‘π‘®©—¬Õ¬à“߇√àߥà«π °“√‡μâπ¢ÕßÀ—«„® ‡ªìπ°“√«—¥∑’Ë®–™à«¬ª√–‡¡‘π °“√∑”ß“π¢ÕßÀ—«„®„π‡∫◊ÈÕßμâπ«à“ ¡’°“√‡μâπ ∑’˺‘¥ª°μ‘  ¡Ë”‡ ¡ÕÀ√◊Õ‰¡à ‡√Á«À√◊ՙⓠ‡æ√“–°“√‡μâπ¢ÕßÀ—«„®∑’˙⓺‘¥ª°μ‘Õ“®∫àß∫Õ°«à“ºâŸªÉ«¬¡’¿“«– ‚æ·∑ ‡´’¬¡ Ÿß„π‡≈◊Õ¥‰¥â 欓∫“≈μâÕß∑”°“√‡°Á∫‡≈◊Õ¥ºâŸªÉ«¬μ√«® À√◊Õμ√«®§≈◊Ëπ‰øøÑ“À—«„®‡æ◊ËÕ μ√«®¥§Ÿ ≈◊Ëπ‰øøÑ“¢ÕßÀ—«„®∑’˺‘¥ª°μ‘ §◊Õæ∫ Tall peak T wave ·≈–‰¥â„Àâ°“√«“ß·ºπ°“√„Àâ°“√欓∫“≈ μàÕ‰ª §«“¡¥—π‚≈À‘μ ¿“«–§«“¡¥—π‚≈À‘μ Ÿß°àÕπ°“√øÕ°‡≈◊Õ¥  à«π„À≠à®–¡’§«“¡ —¡æ—π∏å°—∫ ª√‘¡“≥πÈ”„π√à“ß°“¬„π·∫∫·ª√º—πμ“¡°—π ¥—ßπ—Èπ„π°“√øÕ°‡≈◊Õ¥À“°μâÕß°“√¥÷ßπÈ”ÕÕ°®“°ºŸâªÉ«¬ ®”π«π¡“° ·≈–ªÑÕß°—π¿“«–§«“¡¥—π‚≈À‘μμË”√–À«à“ß°“√øÕ°‡≈◊Õ¥Õ“®æ‘®“√≥“ߥ¬“≈¥§«“¡¥—π ¡Õ◊È ‡™“â °Õà π°“√øÕ°‡≈Õ◊ ¥·μ„à π∑“ßμ√ß°π— ¢“â ¡∂“â ºªâŸ «É ¬¡¿’ “«–§«“¡¥π— ‚≈Àμ‘ μË” §«√√“¬ß“π·æ∑¬°å Õà π ‡√‘Ë¡°“√øÕ°‡≈◊Õ¥ 3.2.3 πÈ”Àπ—°μ—«¢Õߺ⟪ɫ¬ ‡ªìπ à«πª√–°Õ∫ ”§—≠∑’ËμâÕߪ√–‡¡‘πºŸâªÉ«¬°àÕπ°“√øÕ°‡≈◊Õ¥ ‡æ◊ËÕ„™â„π°“√æ‘®“√≥“§”π«≥ª√‘¡“≥πÈ”∑’Ë®–¥÷ßÕÕ°®“°μ—«ºâŸªÉ«¬„π§√—Èßπ—Èπ ‚¥¬§”π«≥®“° 317

Practical Dialysis in the Year 2009 ª√‘¡“≥πÈ”∑’Ë¥÷ßÕÕ° (Weight gain) = πÈ”Àπ—°μ—«¢ÕߺŸâªÉ«¬ - πÈ”Àπ—°·Àâß (Dry weight) ¥—ßπ—Èπ °“√ª√–‡¡‘ππÈ”Àπ—°·ÀâߢÕߺŸâªÉ«¬®÷߇ªìπ ‘Ëß ”§—≠ ·≈–‡ªìπ ‘Ëß∑’Ë∑”‰¥â¬“°μâÕß¡’°“√ ª√—∫πÈ”Àπ—°·Àâß„Àâ‡À¡“– ¡°—∫ºâŸªÉ«¬ „πªí®®ÿ∫—π‰¥â¡’ºâŸ∑’Ë欓¬“¡§‘¥‡§√◊ËÕß¡◊Õ∑’Ë®–™à«¬ª√–‡¡‘ππÈ” Àπ°— ·Àßâ ¢ÕߺªŸâ «É ¬ ·μ‡à §√Õ◊Ë ß¡Õ◊ ‡À≈“à ππ—È °¡Á ¢’ Õâ ®”°¥— „π‡√Õ◊Ë ßμ“à ßÊ ‡™πà ‡√Õ◊Ë ß√“§“¢Õ߇§√Õ◊Ë ß´ß÷Ë ¡√’ “§“·æß ¥—ßπ—Èπ ‘Ëß∑’ˇªìπª√–‚¬™πå°—∫ºŸâªÉ«¬ ·≈–‡ ’¬§à“„™â®à“¬πâÕ¬∑’Ë ÿ¥ πà“®–‡ªìπ«‘∏’∑’ˉ¥â®“°°“√μ√«®√à“ß°“¬ ¢Õߺ⟪ɫ¬À≈—ß°“√øÕ°‡≈◊Õ¥«à“¡’¿“«–∫«¡À√◊Õ‰¡à √–À«à“ß°“√øÕ°¡’¿“«–·∑√°´âÕπÀ√◊Õ‰¡à ‡™àπ ¿“«–§«“¡¥π— ‚≈Àμ‘ μË” μ–§√«‘ ®“°°“√´°— ª√–«μ— ‘ √∫— ª√–∑“πÕ“À“√‰¥¥â ¢’ π÷È ·≈–ª√∫— μ“¡§«“¡‡À¡“– ¡ 3.2.4 °“√μ√«®√à“ß°“¬∑’Ë ”§—≠ ‰¥â·°à μ“ ‡ª≈◊Õ°μ“«à“¡’¿“«–´’¥À√◊Õ‰¡à ≈‘Èπ ª√–‡¡‘π¿“«–´’¥ ¡’ΩÑ“À√◊Õ‰¡à øíπ ¡ø’ πí ºÀÿ √Õ◊ ‰¡àÕ“®®–‡ªπì ·À≈ßà  – ¡¢Õ߇™Õ◊È ‚√§¡º’ ≈μÕà °“√√∫— ª√–∑“πÕ“À“√¢Õß ºâŸªÉ«¬ §«“¡Õ¬“°Õ“À“√ ªÕ¥ øßí ‡ ¬’ ß°“√À“¬„®¢Õߪե∑ß—È  Õߢ“â ß «“à ¡‡’  ¬’ ߺ¥‘ ª°μÀ‘ √Õ◊ ‰¡à ‡™πà ‡ ¬’ ß crepitation ∑’˪ե∑—Èß Õߢâ“ßÀ√◊Õ‰¡à ´÷Ë߇ªìπ°“√· ¥ß∂÷ß¿“«–∑’Ë¡’πÈ”‡°‘π„π√à“ß°“¬ À«— „® øßí ‡ ¬’ ß°“√‡μπâ ¢ÕßÀ«— „® ®ß— À«–°“√‡μπâ ¢ÕßÀ«— „® «“à ¡‡’  ¬’ ߺ¥‘ ª°μÀ‘ √Õ◊ ‰¡à ¡°’ “√ §≈”«à“¡’¿“«–À—«„®‚μÀ√◊Õ‰¡à º‘«Àπ—ß  —߇°μ®ÿ¥®È”‡≈◊Õ¥ÕÕ° º◊Ëπ§—𠧫“¡μ÷ßμ—«¢Õߺ‘«Àπ—ß ∫«¡ ‰μ ª√–‡¡‘π°“√∑”Àπâ“∑’Ë¢Õ߉μ‡∫◊ÈÕßμâπ ‚¥¬°“√ Õ∫∂“¡ª√‘¡“≥ªí  “«–¢Õߺ⟪ɫ¬ „π·μà≈–«—π  ’¢Õßªí  “«–¡’‡≈◊Õ¥ÕÕ°À√◊Õ‰¡à √–∫∫∑“߇¥‘πÕ“À“√ ª√–‡¡‘π°“√‡§≈◊ËÕπ‰À«¢Õß≈”‰ â °“√¢—∫∂à“¬ Õ“°“√§≈◊Ëπ‰ â Õ“‡®’¬π 3.2.5 ¿“«–‡≈◊Õ¥ÕÕ° (Bleeding) °àÕπ°“√øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡μâÕß¡’°“√´—°ª√–«—μ‘ ºªŸâ «É ¬‡°¬’Ë «°∫— °“√‰¥√â ∫— ¬“ªÕÑ ß°π— °“√·¢ßÁ μ«— ¢Õ߇≈Õ◊ ¥‡ ¬’ °Õà π«“à À≈ß— ®“°øÕ°‡≈Õ◊ ¥§√ß—È °Õà π ·º≈∑∑’Ë ”°“√ Àâ“¡‡≈◊Õ¥À¬ÿ¥¬“°À√◊Õ‰¡à ‰¥â√—∫°“√ºà“μ—¥À√◊Õ‰¡à À√◊Õ¡’·ºπ°“√√—°…“∑’Ë®–μâÕ߉¥â√—∫°“√ºà“μ—¥À√◊Õ‰¡à ‚¥¬‡©æ“–ºªâŸ «É ¬∑®’Ë –μÕâ ߉¥√â ∫— °“√º“à μ¥— ª≈°Ÿ ∂“à ¬‰μ ª í  “«–‡ªπì ‡≈Õ◊ ¥À√Õ◊ ‰¡à ∂“à ¬‡ªπì ‡≈Õ◊ ¥ ‰Õ‡ªπì ‡≈Õ◊ ¥  ‘Ë߇À≈à“π’ȇªìπ ‘Ëß∑’Ë欓∫“≈μâÕß√–«—ß ·≈–æ‘®“√≥“ߥ°“√„Àâ “√ªÑÕß°—π°“√·¢Áßμ—«¢Õ߇≈◊Õ¥μ“¡§«“¡ ‡À¡“– ¡ 3.2.6 °“√ª√–‡¡‘π vascular access °àÕπ°“√øÕ°‡≈◊Õ¥§«√ª√–‡¡‘π«à“¡’Õ“°“√·≈–Õ“°“√ · ¥ß¢Õß°“√Õ—°‡ ∫μ‘¥‡™◊ÈÕÀ√◊Õ‰¡à∑ÿ°§√—Èß ∂â“æ∫Õ“°“√Õ—°‡ ∫ ª«¥∫«¡ ·¥ß√âÕπ μâÕß√’∫√“¬ß“π·æ∑¬å ‡æ◊ËÕæ‘®“√≥“ߥ°“√øÕ°‡≈◊Õ¥„π§√—Èßπ—Èπ À√◊ÕÕ“®æ‘®“√≥“„À⬓ ·≈–∑”°“√μ√«®«‘π‘®©—¬μàÕ‰ª ·≈– °àÕπ·∑߇¢Á¡μâÕß¡’°“√∑”§«“¡ –Õ“¥¶à“‡™◊ÈÕ°àÕπ∑ÿ°§√—Èß μ“¡·π«∑“ß°“√ªØ‘∫—μ‘¢Õß·μà≈– ∂“∫—π À≈—ß®“°π—ÈπμâÕߪ√–‡¡‘π‚¥¬°“√øíß bruit §≈” thrill μ≈Õ¥·π«¢Õ߇ âπ‡≈◊Õ¥ ‡æ◊ËÕÀ“¿“«–‡ âπ‡≈◊Õ¥μ’∫ 318

Nursing Intervention in Hemodialysis μ—π ∂Ⓡ âπ‡≈◊Õ¥øíß¡’‡ ’¬ß‰¡à ¡Ë”‡ ¡Õ À√◊Õ‡ªìπ‡ ’¬ß™’æ®√ Õ“®®–‡°‘¥°“√μ’∫∫√‘‡«≥π—Èπ‰¥â §«√∑”°“√ «‘π‘®©—¬‡æ‘Ë¡‚¥¬°“√μ√«®«—¥ ‡ âπ‡≈◊Õ¥ ´÷Ëß„πªí®®ÿ∫—πÀπ૬‰μ‡∑’¬¡ ‚√ß欓∫“≈®ÿÓ≈ß°√≥å ‰¥â‡ªî¥„Àâ ∫√‘°“√Õ¬Ÿà ‚¥¬„™â‡§√◊ËÕß HD 03 §à“∫√‘°“√§√—Èß≈– 4,000 ∫“∑ ·≈–§«√μ√«®¥ Ÿ ’º‘«∫√‘‡«≥ª≈“¬π‘È«¡◊Õ¥â“π ∑¡Ë’ ’ vascular access «“à ¡ ’ ‡’ ¢¬’ «§≈”È À√Õ◊ ‰¡à ¡Õ’ “°“√™“À√Õ◊ ‰¡à ´¥’ ‡¬πÁ º¥‘ ª°μÀ‘ √Õ◊ ‰¡à „À√â ∫’ √“¬ß“π·æ∑¬å ‡æ√“–‡ªìπÕ“°“√¢Õß°“√¢“¥‡≈◊Õ¥‰ª‡≈’Ȭß∫√‘‡«≥ª≈“¬π‘È« „π°√≥’∑’˺⟪ɫ¬„™â vascular access ™π‘¥ temporary ππ—È μÕâ ß¡°’ “√ª√–‡¡π‘ ∫√‡‘ «≥ exit site ¥«â ¬«“à ¡°’ “√Õ°— ‡ ∫ ª«¥∫«¡·¥ß√Õâ πÀ√Õ◊ ‰¡à ¡’ discharge À√◊Õ‰¡à 3.2.7 ª√–‡¡π‘ º≈°“√μ√«®∑“ßÀÕâ ߪØ∫‘ μ— °‘ “√ §«√¡°’ “√ª√–‡¡π‘ °Õà π„πºªŸâ «É ¬øÕ°‡≈Õ◊ ¥ ‡æÕ◊Ë ª√—∫°“√«“ß·ºπ°“√øÕ°‡≈◊Õ¥„Àâ‡À¡“– ¡°—∫ºâŸªÉ«¬ ‡æ◊ËÕªÑÕß°—π¿“«–·∑√°´âÕπ∑’ËÕ“®®–‡°‘¥√–À«à“ß °“√øÕ°‡≈◊Õ¥‰¥â ¥—ßμ“√“ß∑’Ë 1 μ“√“ß∑Ë’ 1 · ¥ßº≈°“√μ√«®∑“ßÀâÕߪؑ∫—μ‘°“√∑’Ë ”§—≠„πºâŸªÉ«¬∑” Hemodialysis °“√μ√«®∑“ß §“à ª°μ‘ Nursing Intervention and Rationale ÀÕâ ߪØ∫‘ μ— °‘ “√ Glucose 70-110 mg/dl Õ“®μâÕß¡’°“√ª√–‡¡‘π∑ÿ°§√—Èß„πºŸâªÉ«¬ DM ‡Àμºÿ ≈ ∂â“√–¥—∫πÈ”μ“≈„π‡≈◊Õ¥μË” ºâŸªÉ«¬Õ“®¡’ Õ“°“√ §≈◊Ëπ„ â Õ“‡®’¬π ‡Àß◊ËÕÕÕ°μ“¡μ—«  —∫ π μâÕߥ·Ÿ ≈„Àâ 50% glucose 50 cc vein push ‡æ◊ËÕ ªÑÕß°—π¿“«– shock ·≈– —߇°μÕ“°“√Õ¬à“ß „°≈♑¥ §à“μË”°«à“ª°μ‘ · ¥ß∂÷ß¿“«– Hypoglycemia §à“ ßŸ °«à“ª°μ‘ · ¥ß∂÷ß¿“«– Hyperglycemia BUN 60-100 mg/dl §«√μ√«®∑ÿ° 1 ‡¥◊Õπ °àÕπ·≈–À≈—ß°“√øÕ°‡≈◊Õ¥ ‡Àμÿº≈ ‡æ◊ËÕª√–‡¡‘π¿“«–‚¿™π“°“√ ·≈– ª√–‡¡‘𧫓¡‡æ’¬ßæÕ„π°“√øÕ°‡≈◊Õ¥ §à“μ”Ë °«“à ª°μ‘ ¡—°‡°‘¥®“°¿“«–πÈ”‡°‘π ·≈– ¿“«–¢“¥‚ª√μ’π §“à  Ÿß°«“à ª°μ‘ ‡°‘¥®“°°“√∑”Àπâ“∑’Ë¢Õß‰μ‡ ’¬ ‰ª ·≈–¡’°“√ √â“߬‡Ÿ √’¬¡“°°«à“ª°μ‘‡π◊ËÕß®“°¡’ °“√√—∫ª√–∑“πÕ“À“√ª√–‡¿∑‚ª√μ’π¡“° Albumin 3.5-5.5 g/dl §«√μ√«®‡¥◊Õπ≈– 1 §√—Èß ‡Àμºÿ ≈ ‡æ◊ËÕ‡ªìπ°“√ª√–‡¡‘π¿“«–‚¿™π“°“√ 319

Practical Dialysis in the Year 2009 °“√μ√«®∑“ß §“à ª°μ‘ Nursing Intervention and Rationales ÀÕâ ߪØ∫‘ μ— °‘ “√ 12-15 g/dl §“à μ”Ë °«à“ª°μ‘ ∑”„Àâ·√ߥ÷ßπÈ”¿“¬„π‡≈◊Õ¥≈¥≈ß Creatinine 0-5 mg/l ‰¡à‡æ’¬ßæÕ∑’Ë®–¥÷ßπÈ”‰«â¿“¬„πÀ≈Õ¥‡≈◊Õ¥ πÈ”®÷ß CRP 200-250 mg/dl ‡§≈◊ËÕπºà“πºπ—ßÀ≈Õ¥‡≈◊Õ¥ÕÕ°‰ª∑’Ë∫√‘‡«≥ Total Cholesterol ™àÕß«à“ß√–À«à“߇´≈≈å¡“°°«à“ª°μ‘ ∑”„À⇰‘¥ 3.5-5.5 mmol/l Õ“°“√∫«¡ ·≈–¡’Õ—μ√“°“√쓬 Ÿß¢÷Èπ¥â«¬ §«√¡’ Serum Potassium °“√„À⧔·π–π”„π°“√√—∫ª√–∑“πÕ“À“√®”æ«° ‰¢à¢“«„Àâ¡“°¢÷Èπ À√◊Õ„Àâ “√≈–≈“¬ ‡™àπ Albumin ∑¥·∑𠧫√μ√«®∑ÿ° 1 ‡¥◊Õπ ‡Àμºÿ ≈ ‡æ◊ËÕª√–‡¡‘π¿“«–‚¿™π“°“√ æ∫«à“∂â“§à“ Cr „π‡≈◊Õ¥ Ÿß ®–∑”„ÀâÕ—μ√“°“√쓬≈¥≈ß Õ“® ‡ªìπ‡æ√“–«à“ ∂â“§à“ Cr  Ÿß ¿“«–‚¿™π“°“√®–¥’ §«√μ√«®∑ÿ° 3 ‡¥◊Õπ ‡Àμÿº≈ ‡æ◊ËÕª√–‡¡‘π°“√μ‘¥‡™◊ÈÕ„π√à“ß°“¬ ´÷Ëß§à“ Õ“®®– ßŸ ¡“°°«à“ 100 ‡∑à“ „π°√≥’∑’Ë¡’°“√μ‘¥‡™◊ÈÕ ·∫§∑’‡√’¬„π√à“ß°“¬ ·≈–¡—°®–·ª√º°º—π°—∫§à“ Albumin „π‡≈◊Õ¥ ´÷Ëß¡’º≈μàÕ‡ âπ‡≈◊Õ¥¢ÕßÀ—«„® ∑”„Àâ¡’°“√Õ—°‡ ∫‡æ‘Ë¡¢÷È𠧫√μ√«®∑ÿ° 3 ‡¥◊Õπ ‡Àμÿº≈ ‡æ◊ËÕª√–‡¡‘π¿“«–‚¿™π“°“√¢ÕߺŸâªÉ«¬ ·≈–√–¥—∫‰¢¡—π„π‡≈◊Õ¥ §à“μ”Ë °«“à ª°μ‘ Õ“®· ¥ß∂÷ß¿“«–‚¿™π“°“√∑’Ë μË” Õ—μ√“°“√쓬 ßŸ ¢÷Èπ §à“ ßŸ °«à“ª°μ‘ · ¥ß∂÷ßªí®®—¬‡ ’¬ß„π°“√‡°‘¥ ‚√§À—«„®·≈–À≈Õ¥‡≈◊Õ¥‰¥â §«√„À⧔·π–π”‡√◊ËÕß°“√√—∫ª√–∑“πÕ“À“√ ·≈– °“√ÕÕ°°”≈—ß°“¬°—∫ºâŸªÉ«¬ °“√√—∫ª√–∑“𬓠§«√μ√«®∑ÿ°‡¥◊Õπ À√◊Õ‡¡◊ËÕ¡’Õ“°“√º‘¥ª°μ‘ ‡Àμºÿ ≈ ¿“«–‡≈◊Õ¥‡ªìπ°√¥ ∑”„À⇰‘¥°≈‰°°“√ ¥÷ߪ√–®ÿ‰Œ‚¥√‡®π‡¢â“‡´≈≈åæ√âÕ¡°—∫°“√¢—∫ª√–®ÿ ‚æ·∑ ‡´’¬¡ÕÕ°®“°‡´≈≈å®÷ß¡—°∑”„Àâ√–¥—∫ ‚æ·∑ ‡´’¬¡„π‡≈◊Õ¥ ßŸ ¢÷Èπ 320

Nursing Intervention in Hemodialysis °“√μ√«®∑“ß §“à ª°μ‘ Nursing Intervention and Rationales ÀÕâ ߪØ∫‘ μ— °‘ “√ 19-21 mEq/l §à“ Ÿß°«“à ª°μ‘ ∑”„ÀâÀ—«„®‡μâπ™â“≈ß ECG æ∫ Serum Bicarbonate10 3.5-5.5 mg/dl tall peak T wave §«√¥Ÿ·≈„À≥â√—∫¬“ Serum Phosphorus11 Kayexalate °—∫ sorbitol √—∫ª√–∑“π ·μà∂⓺⟪ɫ¬ ¡’ bowel sound πâÕ¬ §«√À≈’°‡≈’ˬ߫‘∏’∫√‘À“√¬“ ∑“ߪ“° ·≈–Àâ“¡√—∫ª√–∑“πæ√âÕ¡°—∫πÈ” â¡ À≈’°‡≈’ˬßÕ“À“√∑’Ë¡’‚æ·∑ ‡´’ˬ¡ ßŸ ·≈–Àâ“¡„Àâ  “√≈–≈“¬∑’˺ ¡‚æ·∑ ‡´’ˬ¡∑“ßÀ≈Õ¥‡≈◊Õ¥ ·≈–§«√√–«—ß„πºâŸ∑’Ë√—∫ª√–∑“π¬“∫“ß°≈ÿà¡ ‡™àπ ACE inhibitor À√◊Õ beta-adrenergic blocker §à“μ”Ë °«à“ª°μ‘ æ∫„πºâŸªÉ«¬∑’Ë¡’Õ“°“√∑âÕ߇¥‘π Õ“‡®’¬π¡“° ∑”„À⇰‘¥ arrhythmia Õ“®∂÷ߢ—Èπ √ÿπ·√ß cardiac arrest ‚¥¬‡©æ“–ºâŸªÉ«¬∑’Ë √—∫ª√–∑“𬓠digoxin Õ¬àŸ §«√μ√«®∑ÿ° 1 ‡¥◊Õπ ‡Àμÿº≈ ª°μ‘ºŸâªÉ«¬®–‰¡à “¡“√∂¢—∫¢Õ߇ ’¬∑’ˇªìπ °√¥ÕÕ°®“°√à“ß°“¬‰¥â®÷ß∑”„ÀâºâŸªÉ«¬¡’¿“«– ‡≈◊Õ¥‡ªìπ°√¥ §“à μË”°«à“ª°μ‘ ¡’Õ—μ√“°“√쓬‡æ‘Ë¡ ¢÷Èπ‡π◊ËÕß®“° ¡’¿“«– Hypercatabolism ®“°°“√Õ—°‡ ∫À√◊Õ °“√μ‘¥‡™◊ÈÕ´àÕπÕ¬Ÿà ∑”„Àâ¡’°“√ ≈“¬‚ª√μ’π„π √à“ß°“¬ ºŸâªÉ«¬Õ“®‡°‘¥¿“«–∑ÿæ‚¿™π“°“√ §«√μ√«®∑ÿ° 1 ‡¥◊Õπ ‡Àμºÿ ≈ ª°μ‘øÕ ‡øμ®–∂°Ÿ ¢—∫ÕÕ°∑“ßªí  “«– ·≈–Õÿ®®“√– ·μà„πºâŸªÉ«¬∑’ËøÕ°‡≈◊Õ¥‰¡à “¡“√∂ ¢—∫ÕÕ°∑“ßªí  “«–‰¥â §à“ Ÿß°«à“ª°μ‘ ®–¡’°“√®—∫μ—«°—π¢Õß Ca × P ‡°‘¥ calcification ‡°“–μ“¡Õ«—¬«–μà“ßÊ À√◊Õ‡°‘¥ ®“°°“√√—∫ª√–∑“πÕ“À“√∑’Ë¡’øÕ ‡øμ Ÿß ¥—ßπ—Èπ 欓∫“≈μâÕß„À⧔·π–𔇰’ˬ«°—∫°“√√—∫ª√–∑“π Õ“À“√„Àâ‡À¡“– ¡ ‚¥¬‰¥â√—∫‰¡à‡°‘π 800-1000 mg/day ‡æ◊ËÕªÑÕß°—π¿“«–·∑√°´âÕπ„π√–¬–¬“« ·≈–·π–π”‡√◊ËÕß°“√√—∫ª√–∑“𬓠phosphate 321

Practical Dialysis in the Year 2009 °“√μ√«®∑“ß §“à ª°μ‘ Nursing Intervention and Rationales ÀÕâ ߪØ∫‘ μ— °‘ “√ blinder ‚¥¬√—∫ª√–∑“πæ√âÕ¡Õ“À“√§”·√° ·≈– Serum Calcium 11 „πª√‘¡“≥∑’Ë∂Ÿ°μâÕß ‡«≈“∑’Ë∂°Ÿ μâÕß ·≈–Õ“®‡æ‘Ë¡ Serum PTH 11 ¢π“¥μ—«°√Õß„π°“√øÕ°‡≈◊Õ¥‡ªìπ high-flux ·≈– Hemoglobin (Hb) Hematocrit(Hct) ‡æ‘Ë¡®”π«π§√—Èß„π°“√øÕ°‡≈◊Õ¥„Àâ∫àÕ¬¢÷Èπ Serum ferritin TSAT §à“μ”Ë °«“à ª°μ‘ Õ“®®–‡°‘¥®“°ºŸâªÉ«¬¡’Õ“°“√ º‘¥ª°μ‘„π√à“ß°“¬ ‡™àπ ∑âÕ߇ ’¬ Õ“‡®’¬π 8.4-9.5 mg/ml §«√μ√«®∑ÿ° 1 ‡¥◊Õπ ∂â“¡’§à“ ßŸ °«à“ª°μ‘ Õ“® ª√—∫‡ª≈’ˬπ·§≈‡´’¬¡„ππÈ”¬“ dialysate „Àâ¡’§à“ μË”≈ß ·μàμâÕß√–«—ß¿“«–·∑√°´âÕπ∑’ËÕ“®®–‡°‘¥ μ“¡¡“‰¥â‡™àπ ¿“«–§«“¡¥—π‚≈À‘μμË” ‡ªìπμâπ ·≈–§«√·π–π”‡√◊ËÕß°“√√—∫ª√–∑“πÕ“À“√ ºŸâªÉ«¬ ∑’ËøÕ°‡≈◊Õ¥§«√‰¥â√—∫·§≈‡´’¬¡√«¡®“°Õ“À“√ ·≈–¬“‰¡à‡°‘π 2,000 mg/day 150-300 æ‘‚§ §«√μ√«®∑ÿ° 3 ‡¥◊Õπ ∂â“¡’ª√‘¡“≥¡“°¢÷Èπ μâÕß °√—¡/¡‘≈≈‘≈‘μ√ §«∫§ÿ¡√–¥—∫øÕ ‡øμ„Àâ¡’√–¥—∫≈¥≈߇æ◊ËÕ≈¥°“√ °√–μÿâπ„Àâ¡’°“√À≈—ߌÕ√å‚¡π PTH ·μà∂â“√–¥—∫ PTH  ßŸ ¡“°∂÷ß 800 æ‘‚§°√—¡/¡‘≈≈‘≈‘μ√ ·≈–‰¡à μÕ∫ πÕßμàÕ°“√√—°…“¥â«¬¬“ ‡ªìπ¢âÕ∫àß™’È„π°“√ ∑”ºà“μ—¥ 11-12 g/dl μ√«®∑ÿ°‡¥◊Õπ ‡æ◊ËÕª√–‡¡‘π¿“«–‚≈À‘μ®“ß·≈– 33-36% ‡æ◊ËÕæ‘®“√≥“„Àâ‡À≈Á°∑¥·∑πμ“¡ Guideline ∂â“ ¡“°°«à“ 200 π“ ¡’§à“μË”°«à“ª°μ‘ §«√∑”°“√À“ “‡Àμÿ ·≈–μ√«® ‚π°√—¡/¡‘≈≈‘≈‘μ√ «‘π‘®©—¬„π∑—π∑’ ‡æ◊ËÕÀ“∑“ß·°â‰¢ ¡“°°«à“ 20 % 4. °“√欓∫“≈ºâŸªÉ«¬¢≥–øÕ°‡≈Õ◊ ¥¥«â ¬‡§√ÕË◊ ߉μ‡∑¬’ ¡ °“√欓∫“≈ºªŸâ «É ¬¢≥–øÕ°‡≈Õ◊ ¥¥«â ¬‡§√ÕË◊ ߉μ‡∑¬’ ¡ºªâŸ «É ¬‡ ¬Ë’ ßμÕà ¿“«–·∑√°´Õâ π∑ÕË’ “®®– ‡°‘¥°—∫ºâŸªÉ«¬¢≥–øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡ ¥—ßμ“√“ß∑’Ë 2 322

Nursing Intervention in Hemodialysis μ“√“ß∑’Ë 2 · ¥ß¿“«–·∑√°´âÕπ√–À«à“ß°“√øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡ Complication Sign/Symptoms Nursing Intervention 1. Hypotension Àπâ“´’¥ §≈◊Ëπ„ â ë „À⺟âªÉ«¬πÕπ∑à“ Trendelenburg position Õ“‡®’¬π Àπâ“¡◊¥ ‡æ◊ËÕ„Àâ‡≈◊Õ¥‰ª‡≈’Ȭ߻’√…– ·≈–À—«„®¡“°¢÷Èπ ‡Àß◊ËÕÕÕ° À¡¥ μ‘ À—«„®‡μâπ‡√Á« Õ“®À¡¥ ë ≈¥ UF Rate ‡æ◊ËÕ≈¥°“√¥÷ßπÈ”ÕÕ°®“°À≈Õ¥  μ‘ ·≈–™—°‰¥â ‡≈◊Õ¥ ë ∂â“®”‡ªìπ„Àâ NSS À√◊Õ hypertonic solution ‡™àπ albumin, glucose ‡æ◊ËÕ‡æ‘Ë¡ª√‘¡“≥πÈ”„πÀ≈Õ¥‡≈◊Õ¥ ·≈–¥÷ßπÈ”πÕ°À≈Õ¥‡≈◊Õ¥°≈—∫‡¢â“‡´≈≈å¡“°¢÷Èπ °“√ªÑÕß°—π (Prevention)12 ë §«√√–¡—¥√–«—߇°’ˬ«°—∫°“√™—ËßπÈ”Àπ—°¢Õß ºŸâªÉ«¬°àÕπ°“√øÕ°‡≈◊Õ¥∂Ÿ°μâÕßÀ√◊Õ‰¡à ‡æ√“–∂â“ ºŸâªÉ«¬™—ËßπÈ”Àπ—°º‘¥Õ“®∑”„Àâ°“√¥÷ßπÈ”¡“°¢÷Èπ ë ¡’°“√ª√–‡¡‘ππÈ”Àπ—°·ÀâߢÕߺ⟪ɫ¬„Àâ ‡À¡“– ¡Õ¬Ÿà‡ ¡Õ ‡π◊ËÕß®“°∂â“¥÷ßπÈ”¡“°‰ªºŸâªÉ«¬ Õ“®®–‡°‘¥§«“¡¥—π‚≈À‘μμË”‰¥â ë §«√ߥ¬“≈¥§«“¡¥—π°àÕπøÕ°‡≈◊Õ¥ ‡æ√“–¬“ ∫“ßμ—«‰¡à “¡“√∂≈â“ßÕÕ°¥â«¬«‘∏’°“√øÕ°‡≈◊Õ¥‰¥â ∑”„Àâ√–À«à“ßøÕ°‡≈◊Õ¥ ¬“ÕÕ°ƒ∑∏‘Ï∑”„À⧫“¡¥—π ‚≈À‘μμË” ë ¡’°“√ª√–‡¡‘π·≈–μ‘¥μ“¡¿“«–´’¥ ∑”„Àâ‡≈◊Õ¥ ‰ª‡≈’ȬßÕ«—¬«– ”§—≠‰¡à‡æ’¬ßæÕ ë ·π–π”ºŸâªÉ«¬‡°’ˬ«°—∫°“√®”°—¥πÈ” ·≈–°“√ √—∫ª√–∑“πÕ“À“√ ‡æ◊ËÕ„À⺟âªÉ«¬¡’πÈ”Àπ—°μ—«‡æ‘Ë¡¢÷Èπ ‰¡à¡“° ë ߥ„™âπÈ”¬“ dialysate ∑’Ë¡’ calcium μË” ‡π◊ËÕß®“° calcium ¡’º≈μàÕ°“√∫’∫μ—«¢ÕßÀ—«„® ë ·π–π”„ÀâºâŸªÉ«¬ —߇°μÕ“°“√¢Õߧ«“¡¥—π ‚≈À‘μμË” ‡¡◊ËÕ‡°‘¥Õ“°“√‰¥â·®âß欓∫“≈∑√“∫Õ¬à“ß ∑—π∑à«ß∑’ ë À≈’°‡≈’ˬ߰“√√—∫ª√–∑“πÕ“À“√√–À«à“ß°“√ øÕ°‡≈◊Õ¥ ‡æ√“–‡≈◊Õ¥‰ª‡≈’Ȭ߰√–‡æ“–∑”„À⇰‘¥ ¿“«–§«“¡¥—π‚≈À‘μμË”‰¥â 323

Practical Dialysis in the Year 2009 Complication Sign/Symptoms Nursing Intervention 2. Muscle cramps 3. Chest Pain ë „™â cool dialysate ∑”„Àâ vasoconstriction 4. Fever/chills ë „™â Na profile and UF profile ∑”„Àâ¡’°“√¥÷ß πÈ”‡¢â“ ŸàÀ≈Õ¥‡≈◊Õ¥¡“°¢÷Èπ „π¢≥–∑’Ë‚´‡¥’¬¡„π √à“ß°“¬ ßŸ ¢÷È𠪫¥ ·≈–μ÷ß ‡®Á∫ ë ¥Ÿ·≈π«¥ºàÕπ§≈“¬°≈â“¡‡π◊ÈÕ ∫√‘‡«≥°≈â“¡‡π◊ÈÕ ë À¬ÿ¥°“√¥÷ßπÈ”ÕÕ°®“°√à“ß°“¬ ë ª√–§∫√âÕπ‡æ◊ËÕ„Àâ°≈â“¡‡π◊ÈÕºàÕπ§≈“¬ ë ¥Ÿ·≈„Àâ “√≈–≈“¬∑¥·∑𠇙àπ NSS, glucose ‡ªìπμâπ °“√ªÑÕß°—π (Prevention) ë ¥·Ÿ ≈„Àâ°≈â“¡‡π◊ÈÕ à«π∑’ˇªìπμ–§√‘«Õ∫Õÿàπ‡ ¡Õ ë ª√–‡¡‘ππÈ”Àπ—°·Àâß ¡Ë”‡ ¡Õ ·≈–‡À¡“– ¡ ë Õ“®®–„™â dialysate ∑’˪°μ‘ À√◊Õ„™â Na profile ™à«¬ ë ‰¡à¥÷ßπÈ”ÕÕ°®“°√à“ß°“¬‡√Á«‡°‘π‰ª ‡®Á∫ À√◊Õ μ÷ß∫√‘‡«≥ ë ¥Ÿ·≈„À≥â√—∫ÕÕ°´‘‡®π ‡æ◊ËÕ„Àâπ”‡≈◊Õ¥‰ª‡≈’È¬ß Àπâ“Õ° Õ“®¡’Õ“°“√ À—«„®‡æ‘Ë¡¡“°¢÷Èπ Àπâ“¡◊¥ ‡ªìπ≈¡ ë ªî¥ UF rate ‡æ◊ËÕ≈¥°“√¥÷ßπÈ”ÕÕ°®“°√à“ß°“¬ §≈◊Ëπ‰ âÕ“‡®’¬π√à«¡ ªÑÕß°—π¿“«–§«“¡¥—π‚≈À‘μμË”  à߇ √‘¡„Àâ‡≈◊Õ¥‰ª ¥â«¬ ‡≈’ȬßÀ—«„®‡æ‘Ë¡¢÷Èπ ë ¥·Ÿ ≈„À≥â√—∫¬“ nitroglycerin æàπ À√◊ÕÕ¡„μâ≈‘Èπ μ“¡·ºπ°“√√—°…“ ë μ√«®§≈◊Ëπ‰øøÑ“À—«„® ‡æ◊ËÕ§âπÀ“§«“¡º‘¥ª°μ‘ °“√ªÕÑ ß°—π (Prevention) ë ª√–‡¡‘π¿“«–´’¥ ‡æ√“–‡ªì𠓇Àμÿ„À⇰‘¥ Õ“°“√‡®Á∫Àπâ“Õ°‰¥â ë ·π–π”„ÀâºâŸªÉ«¬√—∫ª√–∑“π¬“Õ¬à“ß ¡Ë”‡ ¡Õ Õÿ≥À¿Ÿ¡‘√à“ß°“¬ ßŸ °«à“ ë μ‘¥μ“¡Õ“°“√ ·≈–À“·À≈àß∑’Ë¡“¢Õß°“√μ‘¥ 37.5 Õß»“‡´≈‡´’¬  ‡™◊ÈÕ ¥â«¬°“√‡°Á∫ ‘Ëß àßμ√«® μ√«®«‘π‘®©—¬ ®“°‡≈◊Õ¥ ¢≥–øÕ°‡≈◊Õ¥ À√◊Õ ªí  “«– ·º≈∑“߇ªî¥μà“ßÊ πÈ”¬“∑’Ë„™âøÕ°‡≈◊Õ¥  ßŸ ¢÷ÈπÀ≈—ß°“√øÕ° √–∫∫ πÈ” RO ‡≈◊Õ¥ (‡°‘¥°“√μ‘¥‡™◊ÈÕ ë ¥·Ÿ ≈„À≥â√—∫¬“μ“¡°“√√—°…“ „π√à“ß°“¬) ∂â“Õÿ≥À¿¡Ÿ ‘ °“√ªÑÕß°—π (Prevention) 324

Nursing Intervention in Hemodialysis Complication Sign/Symptoms Nursing Intervention 5. Hemolysis √à“ß°“¬ ŸßÀ≈—ß®“° ë μ√«® Õ∫√–∫∫πÈ” 6. Air embolism ‡√‘Ë¡°“√øÕ°‡≈◊Õ¥ ë μ√«® Õ∫μ—«°√Õß∑’Ëπ”¡“„™â´È” ·≈–·π«∑“ß 45-75 π“∑’ Õ“®‡°‘¥ °“√ªØ‘∫—μ‘„π°“√≈â“ßμ—«°√Õß ®“° pyrogen À√◊Õ endotoxin Õ“®æ∫ Õ“°“√Àπ“«  —Ëπ√à«¡ ¥â«¬ ‡®Á∫Àπâ“Õ° À√◊Õª«¥ ë À¬ÿ¥°“√øÕ°‡≈◊Õ¥∑—π∑’ ‚¥¬‰¡à§◊π‡≈◊Õ¥°≈—∫ Ÿà À≈—ß À“¬„®≈”∫“°, ºŸâªÉ«¬ ‡π◊ËÕß®“°„π‡≈◊Õ¥®–¡’ª√‘¡“≥‚æ·∑ ‡´’¬¡ ‡≈◊Õ¥„π°√–‡ª“– “¬ ®”π«π¡“° ∑”„À⇪ìπÕ—πμ√“¬‰¥â bloodline ‡ªìπ ’¡à«ß , ë μ√«®«—¥ —≠≠“≥™’æ ·≈–ª√–‡¡‘𧫓¡º‘¥ª°μ‘ À—«„®‡μâπº‘¥ª°μ‘, ¢Õß°“√‡μâπ¢ÕßÀ—«„® ¿“«–§«“¡¥—π‚≈À‘μμË” hyperkalemia, ë μ√«®Õ‘‡≈Á§‚∑√‰≈∑å ·≈–‡¡Á¥‡≈◊Õ¥ ∂â“¡’ª√‘¡“≥ hematocrit ≈¥≈ß ≈¥≈ß „Àâ “√≈–≈“¬∑¥·∑π º‘¥ª°μ‘, æ≈“ ¡“„π ë À“ “‡Àμÿ¢Õß°“√‡°‘¥‡¡Á¥‡≈◊Õ¥·¥ß·μ° ´÷Ëß À≈Õ¥ centrifuged Õ“®®–‡°‘¥®“° hypotonic/hypertonic dialysate ‡ªìπ ’™¡æŸ solutions, Õÿ≥À¿¡Ÿ ‘„ππÈ”¬“ Ÿß‡°‘π‰ª, ‡°‘¥°“√ ªπ‡ªóôÕπ¢Õß “√ copper, §≈Õ≈“¡’π, ‰π‡μ√¥, øÕ√å¡“≈’π, beach À√◊Õ‡°‘¥®“°°“√∫¥¢Õߪíö¡ À√◊Õ °“√¡’ negative pressure arterial  Ÿß ‡ªìπμâπ °“√ªÑÕß°—π (Prevention) ë μ√«® Õ∫°“√μ—ÈßÕÿ≥À¿¡Ÿ ‘¢Õ߇§√◊ËÕß πÈ”¬“∑’Ë„™â øÕ°‡≈◊Õ¥ ë μâÕß¡’°“√μ√«® Õ∫ “√μ°§â“ß ë ¡’°“√μ—Èß alarms Õ¬à“߇§√àߧ√—¥ ë monitor pre-pump arterial pressure ‡®Á∫Àπâ“Õ° À“¬„®‰¡à ë À¬ÿ¥°“√øÕ°‡≈◊Õ¥‚¥¬∑—π∑’ ÕÕ° ‰Õ ‡¢’¬« °“√‡μâπ ë ®—¥∑à“πÕπ »’√…–μË” μ–·§ß´â“¬„ÀâÀ—«„®Õ¬àŸ ¢ÕßÀ—«„®º‘¥ª°μ‘ °“√ ¥â“π≈à“ß ¡Õ߇ÀÁπ¡’ªí≠À“ ë √“¬ß“π·æ∑¬å  —∫ π ‡ ’¬™’«‘μ ë ¥·Ÿ ≈„ÀâÕÕ°´‘‡®π 100 % ë ª≈¥«ß®√°“√øÕ°‡≈◊Õ¥ÕÕ°®“°ºâŸªÉ«¬ ë ∑”°“√¥¥Ÿ Õ“°“»„𠓬 à߇≈◊Õ¥®“°ºâŸªÉ«¬„Àâ ¡“°∑’Ë ÿ¥ 325

Practical Dialysis in the Year 2009 Complication Sign/Symptoms Nursing Intervention °“√ªÕÑ ß°—π (Prevention) ë μ√«® Õ∫§«“¡æ√âÕ¡·≈–§«“¡∂Ÿ°μâÕߢÕß °“√„ à air detector ë √–¡—¥√–«—ߢâÕμàÕ¢Õß “¬∑ÿ°¢âÕμàÕ ë §◊π‡≈◊Õ¥°≈—∫ ŸàºâŸªÉ«¬ ‚¥¬„™â NSS ‰¡à„™âÕ“°“» ë √–À«à“ß°“√øÕ°‡≈◊Õ¥μâÕß√–¡—¥√–«—ß°“√„Àâ  “√≈–≈“¬Õ¬à“߇¢â¡ß«¥ 5. °“√欓∫“≈À≈—ß°“√øÕ°‡≈◊Õ¥¥«â ¬‡§√Õ◊Ë ß‰μ‡∑¬’ ¡ 欓∫“≈‰μ‡∑’¬¡μâÕß∑”Àπâ“∑’Ë„π°“√ª√–‡¡‘πºâŸªÉ«¬´È”Õ’°§√—Èß À≈—ß®“°°“√„Àâ°“√欓∫“≈ μ“¡·ºπ°“√欓∫“≈∑«’Ë “߉«â‡æÕ◊Ë π”¡“ √ªÿ ª√–‡¡π‘ º≈«“à ·ºπ°“√欓∫“≈∑„’Ë À„â π«π— π ’È ”‡√®Á μ“¡·ºπ∑’Ë «“߉«âÀ√◊Õ‰¡à ∂Ⓣ¡à ”‡√Á® §√—ÈßμàÕ‰ª®–μâÕߪ√—∫‡ª≈’ˬπ·ºπ°“√欓∫“≈Õ¬à“߉√ À√◊Õ∂⓪í≠À“¢âÕ «‘π‘®©—¬∑“ß°“√欓∫“≈π—Èπ‰¥â√—∫°“√·°â‰¢·≈â«°ÁÀ¡¥‰ª Õ“®®–ª√–‡¡‘π‚¥¬√«¡ ‰¥â·°à πÈ”Àπ—°¢Õߺ⟠ªÉ«¬¿“¬À≈—ß°“√øÕ°‡≈◊Õ¥  —≠≠“≥™’æ °“√À“¬„® ¿“«–∫«¡ Õ“°“√º‘¥ª°μ‘√–À«à“ßøÕ° À√◊Õ ¿“«–·∑√°´âÕπ °“√μ√«® Õ∫∫√‘‡«≥ vascular access 6. ¢Õâ «π‘ ®‘ ©¬— °“√欓∫“≈„πºªâŸ «É ¬‰μ«“¬‡√ÕÈ◊ √ß— ∑ø’Ë Õ°‡≈Õ◊ ¥¥«â ¬‡§√Õ◊Ë ß‰μ‡∑¬’ ¡ ¢âÕ«‘π‘®©—¬°“√欓∫“≈∑’Ë 113 ‡ ¬Ë’ ßμÕà °“√°”´“∫¢Õ߇πÕÈ◊ ‡¬ÕË◊ ∑«Ë— √“à ß°“¬≈¥≈ß ‡πÕË◊ ß®“°¡ª’ √¡‘ “≥ ¢âÕ«‘π‘®©—¬°“√欓∫“≈∑’Ë 213 ‡¡Á¥‡≈◊Õ¥·¥ß„π√à“ß°“¬πâÕ¬°«à“ª°μ‘ ¢âÕ«‘π‘®©—¬°“√欓∫“≈∑’Ë 313 ‡ ’ˬßμàÕ°“√‡°‘¥¿“«–·∑√°´âÕπ√–À«à“ß°“√øÕ°‡≈◊Õ¥ ¢âÕ«‘π‘®©—¬°“√欓∫“≈∑’Ë 413 ‡ ¬’Ë ßμÕà °“√‡°¥‘ Õπ— μ√“¬ ®“° AV shunt ‡ ¬’ Àπ“â ∑®’Ë “°°“√Õ¥ÿ μπ— À≈¥ÿ ¢âÕ«‘π‘®©—¬°“√欓∫“≈∑’Ë 513 À√◊Õμ‘¥‡™◊ÈÕ ¢âÕ«‘π‘®©—¬°“√欓∫“≈∑’Ë 614 ‡ ’ˬßμàÕ§«“¡ ¡∫Ÿ√≥å¢Õߺ‘«Àπ—ß∫°æ√àÕß ‡π◊ËÕß®“°¡’¿“«–¬Ÿ√’‡¡’¬ ¢âÕ«‘π‘®©—¬°“√欓∫“≈∑’Ë 7 ®“°‰μ‡ ◊ËÕ¡Àπâ“∑’Ë ºªâŸ «É ¬¡¿’ “«–´¡÷ ‡»√“â ‡πÕË◊ ß®“°μÕâ ߉¥√â ∫— °“√√°— …“∑ Ë’ ßà º≈°√–∑∫μÕà ¢âÕ«‘π‘®©—¬°“√欓∫“≈∑’Ë 8 ·∫∫·ºπ°“√¥”‡π‘π™’«‘μ 326 ‡ ’ˬßμàÕ¿“«–¢“¥ “√Õ“À“√ ‡π◊ËÕß®“°Õ“°“√‡∫◊ËÕÕ“À“√ §≈◊Ëπ‰ â Õ“‡®’¬π ·≈–°“√®”°—¥Õ“À“√ ºªŸâ «É ¬æ√Õà ߧ«“¡√„⟠π°“√ªØ∫‘ μ— μ‘ π‡πÕË◊ ß®“°‰¥√â ∫— °“√øÕ°‡≈Õ◊ ¥ º≈ °√–∑∫®“°°“√øÕ°‡≈◊Õ¥ ‰¥â√—∫¢âÕ¡≈Ÿ ‰¡à‡æ’¬ßæÕ ·≈–√–¥—∫°“√√—∫ √âŸ≈¥≈ß ‡ ’ˬßμàÕ¿“«–πÈ”‡°‘π ‡π◊ËÕß®“°ªØ‘∫—μ‘μπ‰¡à∂°Ÿ μâÕß

Nursing Intervention in Hemodialysis 7.  √ªÿ °“√„Àâ°“√欓∫“≈ºâŸªÉ«¬‰μ«“¬‡√◊ÈÕ√—ß∑’ËøÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡π—Èπ μâÕߥŸ·≈„Àâ §√Õ∫§≈ÿ¡∑—Èß∑“ߥâ“𰓬 ®‘μ  —ߧ¡ «‘≠≠“≥ ‡æ◊ËÕ„À⺟âªÉ«¬„𧫓¡¥Ÿ·≈¡’§ÿ≥¿“æ™’«‘μ∑’Ë¥’ ‚¥¬„™â °√–∫«π°“√欓∫“≈∑—Èß 5 ¢—ÈπμÕ𠇪ìπ ‘Ëß∑’˙૬„Àâ欓∫“≈¡’·π«∑“ß„π°“√¥Ÿ·≈ºâŸªÉ«¬·μà≈–√“¬Õ¬à“ß ¡§’ ≥ÿ ¿“æ §√Õ∫§≈¡ÿ ‡À¡“– ¡°∫— ºªŸâ «É ¬·μ≈à –√“¬ ·≈–¬ß— „™‡â ªπì À≈°— ∞“π∑“ß°ÆÀ¡“¬„π°“√¥·Ÿ ≈ºªŸâ «É ¬ ·≈–¬—߇ªìπ°“√· ¥ß∂÷ߧ«“¡‡ªìπ«‘™“™’æ∑“ß°“√欓∫“≈Õ¬à“߇ÀÁπ‰¥â™—¥ ·≈–¬—߇ªìπ°“√æ—≤π“ «‘™“™’æ∑“ßÕâÕ¡Õ’°¥â«¬ ¥—ßπ—Èπ 欓∫“≈ºâŸ‡™’ˬ«™“≠¥â“π‰μ‡∑’¬¡§«√®–¡’∑—°…– ·≈–§«“¡™”π“≠„π °“√π”°√–∫«π°“√欓∫“≈¡“„Àâ°“√¥Ÿ·≈ºâŸªÉ«¬ ‡æ◊ËÕ‡æ‘Ë¡»—°¬¿“æ„π°“√¥Ÿ·≈ºŸâªÉ«¬·≈–‡ªìπμ“¡ ¡“μ√∞“π«‘™“™’æμàÕ‰ª ‡Õ° “√Õ“â ßÕß‘ 1. æ— ¡≥±å §ÿâ¡∑«’æ√. °“√欓∫“≈ºâŸ„À≠à ·≈–ºâŸ ŸßÕ“¬ÿ 2. °√ÿ߇∑æœ: ‚√ßæ‘¡æ匓¬“∫ÿ –°√“øøî°; 2550. 2. ¬ÿ«¥’ ‡°μ —¡æ—π∏å. [Online]. ·À≈àß∑’Ë¡“ http://hph4.anamai.moph.go.th/hph/data/news_ha/07/nur_doc.pdf. 2551. 3.  ÿ√–æ√√≥ æπ¡ƒ∑∏‘Ï. °√–∫«π°“√欓∫“≈. ππ∑∫ÿ√’: ∫√‘…—∑ª√–™ÿ¡™à“ß; 2541. 4. NANDA international NANDA I. [Online]. ·À≈àß∑’Ë¡“ http://nanda.org/ .2008. 5. Murrary, M.E. and Atkinson, L.D. Understanding Nursing process: The Next Generation. New York: Mc Graw. Hill Inc; 1994. 6. «‘®‘μ√“ °ÿ ÿ¡¿å, Õ√ÿ≥’ ‡Œß¬»¡“°. ¢âÕ«‘π‘®©—¬∑“ß°“√欓∫“≈μ“¡√Ÿª·∫∫ NANDA. °√ÿ߇∑æœ: ∫√‘…—∑∫æ‘∏°“√æ‘¡æå ®”°—¥; 2551. 7. Patricia Baltz. Contemporary Nephrology nursing. New Jersey: Anthony J.Jannetti Inc; 1998. 8. Mara HR, Martha HS. Psychosocial of dialysis therapy. New York: Mosby; 2001. 9. Õ¿— √“ Õ√—≠«—≤πå. Psychosocial Aspects of Dialysis Therapy. New Frontiers in dialysis. °√ÿ߇∑æœ: ‡∑Á°´å ·Õπ¥å ‡®Õ√åπ—≈ æ—∫≈‘‡§™—Ëπ ®”°—¥; 2551. 10. Bommer J, Locatelli F, Satayathum S et al. Association of predialysis serum bicarbonate level with risk of mortality and hospitalization in the Dialysis Outcome and Practice Patterns Study. Am J Kidney Dis. 2004; 44(4). 11. NKF-K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease. Am J Kidney Dis. 2003; 42(supply 4). 12. Biff F, William L. Hanrich. Recent Advances in the Prevention and Management of Intradialytic Hypotension. J Am Soc Nephrol . 2008;19. 13. «“√ÿ≥’ ¡’‡®√‘≠. ·π«∑“ß°“√«“ß·ºπ°“√欓∫“≈ ‡≈à¡ 1.  √–∫ÿ√’: ‚√ßæ‘¡æ媓°‡æ√’¬«°“√™à“ß; 2548. 14. Nancy M. Medical surgical care planning. USA: Lippincott Company; 2004. 327



Hemodialysis Procedures: Step by Step 18 Hemodialysis Procedures: Step by Step »√‘ Ï°‘ “≠®πå ·™¡à ≈”‡®¬’ ° 1. ∫∑π” 2. °“√ªØ‘∫—μ°‘ Õà π°“√øÕ°‡≈◊Õ¥ (Predialysis) 3. °“√‡√‘Ë¡μâπøÕ°‡≈Õ◊ ¥ (Initiation of Dialysis) 4. °“√쥑 μ“¡·≈–ª√–‡¡π‘ √–À«“à ß°“√øÕ°‡≈Õ◊ ¥ (Monitoring during Dialysis) 5. °“√ªØ∫‘ —μ‘À≈ß— °“√øÕ°‡≈◊Õ¥ (Postdialysis) 6. ªí®®¬— ‡ ’ˬßμàÕ°“√쥑 ‡™ÕÈ◊ „πÀπ૬‰μ‡∑’¬¡ 7. ·π«∑“ß°“√„À â ÿ¢»°÷ …“ºâŸª«É ¬∑Ë’‰¥√â ∫— °“√øÕ°‡≈Õ◊ ¥¥«â ¬‡§√◊ÕË ß‰μ‡∑¬’ ¡ 329

Practical Dialysis in the Year 2009 1. ∫∑π” °“√¥·Ÿ ≈ºªâŸ «É ¬∑∑’Ë ”°“√øÕ°‡≈Õ◊ ¥¥«â ¬‡§√Õ◊Ë ß‰μ‡∑¬’ ¡ (hemodialysis) ¡Õ’ ߧªå √–°Õ∫À≈“¬ «à π ¡’À≈“¬¢—ÈπμÕπ·≈–«‘∏’°“√ ‡√‘Ë¡μ—Èß·μà°“√æ√âÕ¡„π°“√®—¥μ—ÈßÀπ૬ π‚¬∫“¬¢ÕßÀπ૬ߓπ √–∫∫°“√‡μ√’ ¬¡πÈ”∫√‘ ÿ∑∏‘Ï °“√‡≈◊Õ°„™â‡§√◊ËÕß¡◊Õ·≈–Õÿª°√≥å ∏√√¡™“μ‘¢ÕߺŸâªÉ«¬„π·μà≈–æ◊Èπ∑’Ë ≈—°…≥–°“√¥”‡π‘π ™’«‘μ °“√√—∫ª√–∑“πÕ“À“√ √«¡‰ª∂÷ß ¡√√∂π–¢Õß∫ÿ§≈“°√∑’Ë¡’„πÀπ૬ߓπ Õߧåª√–°Õ∫‡À≈à“π’È®–  ßà º≈Õ¬“à ߬ßË‘ μÕà §«“¡ ”‡√®Á ¢Õß°“√øÕ°‡≈Õ◊ ¥¥«â ¬‡§√◊ÕË ß‰μ‡∑¬’ ¡„À∫â √√≈‡ÿ ª“Ñ À¡“¬°“√√°— …“ „π∑πË’ È’ ¢Õ °≈à“«∂÷ß„π à«π¢Õߢ—ÈπμÕπ°“√ªØ‘∫—μ‘‚¥¬ √ÿª „π°“√∑” hemodialysis ´÷Ëß·∫à߇ªìπ 4  à«πÀ≈—°§◊Õ °“√ ªØ‘∫—μ‘ß“π°àÕπ°“√øÕ°‡≈◊Õ¥ °“√ªØ‘∫—μ‘¢≥–øÕ°‡≈◊Õ¥ °“√ªØ‘∫—μ‘À≈—ß°“√øÕ°‡≈◊Õ¥ °“√„Àâ ÿ¢ »÷°…“·°àºŸâªÉ«¬ 2. °“√ªØ‘∫—μ‘°àÕπ°“√øÕ°‡≈Õ◊ ¥ (Predialysis) 2.1 °“√¥Ÿ·≈ºªŸâ É«¬ 1. ∑—°∑“¬ºŸâªÉ«¬ ‚¥¬°“√‡√’¬°™◊ËÕ ·≈–π“¡ °ÿ≈ æ√âÕ¡∑—Èß —߇°μ  ’Àπâ“ ∑à“∑“ß ·≈–°“√ ‡§≈◊ËÕπ‰À« 2. ™—ËßπÈ”Àπ—°ºâŸªÉ«¬ ‡æ◊ËÕ«“ß·ºπ¥÷ßπÈ”√–À«à“ß°“√øÕ°‡≈◊Õ¥ ‚¥¬æ‘®“√≥“®“° πÈ”Àπ—°μ—« °àÕπøÕ°‡≈◊Õ¥ / πÈ”Àπ—°μ—«À≈—ßøÕ°‡≈◊Õ¥§√—Èß∑’Ë·≈â« / dry weight ∑’Ë·æ∑¬å°”À𥉫â 3. ª√–‡¡‘π vital signs ·≈–≈ß∫—π∑÷°„π Hemodialysis flow chart 4. ´—°ª√–«—μ‘ ·≈– Õ∫∂“¡Õ“°“√ - ¥â“π√à“ß°“¬ 1. Õ“°“√À≈ß— °“√øÕ°‡≈Õ◊ ¥§√ßÈ— ∑ºË’ “à π¡“Õ“°“√¢≥–Õ¬∑àŸ ∫Ë’ “â π·≈–°Õà π¡“‚√ß欓∫“≈ ‡™àπ ÕàÕπ‡æ≈’¬ Àπâ“¡◊¥ ‡«’¬π»’√…– πÕπ√“∫‰¡à‰¥â ‡®Á∫Àπâ“Õ° §≈◊Ëπ‰ â Õ“‡®’¬π ∑âÕ߇ ’¬ ∑âÕߺ°Ÿ ª«¥ ∑âÕß ¡’‰¢âÀπ“« —Ë𠪫¥°≈â“¡‡π◊ÈÕ °≈â“¡‡π◊ÈÕÕàÕπ·√ß ª«¥¢âÕ ª«¥°√–¥°Ÿ §—πμ“¡μ—« ¡’‡≈◊Õ¥ÕÕ°º‘¥ ª°μ‘ °“√¡’ª√–®”‡¥◊Õπ„πºŸâªÉ«¬À≠‘ß ª√–«—μ‘°“√‡∫◊ËÕÕ“À“√ ∑âÕ߇ ’¬ °“√©’¥¬“Õ‘π´Ÿ≈‘π°àÕπ°“√øÕ° ‡≈◊Õ¥ ‚¥¬‡©æ“–Õ¬à“߬‘Ëß„πºŸâªÉ«¬‡∫“À«“πμâÕß√–¡—¥√–«—߇ªìπ摇»… 2. ª√–«μ— °‘ “√∫“¥‡®∫Á ·≈–Õ∫ÿ μ— ‡‘ Àμÿ‡™πà ≈¡â »√’ …–ø“¥æπ◊È ¡∫’ “¥·º≈À√Õ◊ ‰¥√â ∫— °“√º“à μ¥— °“√∂Õπøíπ °“√‰¥â√—∫°“√¬‘߇≈‡´Õ√åμ“ œ≈œ - ¥â“π®‘μ„® 1. §«“¡√Ÿâ ÷°μàÕ°“√‡®Á∫ªÉ«¬·≈–Õ“°“√¢≥–μ√«® 2.  —¡æ—π∏¿“æμàÕ‡æ◊ËÕπ ·≈–‡æ◊ËÕπ√à«¡ß“π 3.  —¡æ—π∏¿“æμàÕ§√Õ∫§√—« ·≈–≠“μ‘æ’ËπâÕß 5. μ√«®√à“ß°“¬‡∫◊ÈÕßμâπ -  ¿“æ√à“ß°“¬∑—Ë«‰ª  ÿ¢≈—°…≥– ·≈–§«“¡ –Õ“¥¢Õß√à“ß°“¬ ‡™àπ Õ“°“√∫«¡ ‡¬◊ËÕ∫ÿ μ“´’¥ ‡ âπ‡≈◊Õ¥¥”∑’˧ՂªÉßæÕß ∑âÕß∫«¡‚μ ¡’·º≈∑’˪≈“¬¡◊Õª≈“¬‡∑â“ ‡ªìπμâπ 330

Hemodialysis Procedures: Step by Step - º‘«Àπ—ß·Àâß ‡À≈◊Õß´’¥ ¡’º◊Ëπ§—π À√◊Õ¡’®ÿ¥‡≈◊Õ¥ÕÕ° -  ß— ‡°μ≈°— …≥–¢Õß°“√À“¬„® ·≈–¢π“¥¢Õß∑√«ßÕ° øßí ‡ ¬’ ß°“√À“¬„®¢Õߪե∑ß—È  Õß ¢â“ß«à“¡’§«“¡º‘¥ª°μ‘À√◊Õ‰¡à - øí߇ ’¬ß·≈–®—ßÀ«–°“√‡μâπ¢ÕßÀ—«„® ·≈–π—∫Õ—μ√“°“√‡μâπ¢ÕßÀ—«„® - ∫—π∑÷°Õ“°“√¢Õߺ⟪ɫ¬ æ√âÕ¡√“¬ß“π·æ∑¬å‡¡◊ËÕ¡’Õ“°“√º‘¥ª°μ‘ 6. ª√–‡¡‘π vascular access - AVF À√◊Õ AVG ª√–‡¡‘π‚¥¬ °“√øí߇ ’¬ß bruit ·≈–§≈” thrill ‚¥¬øíß·≈–§≈”‡ªìπ·π« √–¬–Àà“ß®“° anastomosis  —߇°μÕ“°“√¢Õß°“√Õ—°‡ ∫ ‡™àπ Õ“°“√ª«¥ ∫«¡ ·¥ß √âÕπÀ√◊Õ¡’ discharge - Double lumen catheter ª√–‡¡π‘  ¿“æ°“√쥑 ‡™Õ◊È À√Õ◊ ‡°¥‘ °“√Õ°— ‡ ∫¢Õß·º≈∫√‡‘ «≥exit site °√≥’¡’°“√μ‘¥‡™◊ÈÕ„Àâ∑” septic work-up ·≈–√“¬ß“π·æ∑¬å∑√“∫°àÕπ°“√øÕ°‡≈◊Õ¥μ“¡·π«∑“ߢÕß Àπ૬ߓπ 7. μ√«® Õ∫¢Õâ ¡≈Ÿ ∑‡Ë’ °¬Ë’ «¢Õâ ߉¥·â °à §” ßË— ·≈–·ºπ°“√√°— …“¢Õß·æ∑¬å ¢Õâ ¡≈Ÿ °“√øÕ°‡≈Õ◊ ¥ ∑’˺à“π¡“ º≈μ√«®∑“ßÀâÕߪؑ∫—μ‘°“√·≈–¬“∑’˺ŸâªÉ«¬√—∫ª√–∑“π 8. «“ß·ºπ°“√欓∫“≈·≈–°“√øÕ°‡≈◊Õ¥ ‚¥¬§”π÷ß∂÷ß - Adequacy of dialysis, BFR, UF, anticoagulant œ≈œ - ¿“«–º‘¥ª°μ‘μà“ßÊ ¢ÕߺŸâªÉ«¬ ‡™àπ cardiac arrhythmia, hypotension, hypertension, hyperkalemia, bleeding ‡ªìπμâπ ∂â“æ∫§«“¡º‘¥ª°μ‘§«√√“¬ß“π·æ∑¬å‡æ◊ËÕ·°â‰¢·≈–«“ß·ºπ°“√√—°…“ ∑’ˇÀ¡“– ¡°—∫ºŸâªÉ«¬ 9. ∫—π∑÷°¢âÕ¡≈Ÿ ·≈–·ºπ°“√øÕ°‡≈◊Õ¥≈ß„π Hemodialysis flow chart 10. „À⺟âªÉ«¬∑”§«“¡ –Õ“¥·¢π¢â“ß vascular access ®—¥„À⺟âªÉ«¬Õ¬àŸ„π∑à“∑’Ë ÿ¢ ∫“¬ ‡™àπ ∂“â ºªŸâ «É ¬¡Õ’ “°“√‡ÀπÕ◊Ë ¬ À“¬„®≈”∫“° §«√®¥— „Àºâ ªâŸ «É ¬πÕπ„π∑“à »√’ …– ßŸ ·≈–„ÀÕâ Õ°´‡‘ ®π ®¥— ·¢π¥“â π ∑·’Ë ∑߇¢¡Á „À‡â À¡“– ¡ Õ∏∫‘ “¬∂ß÷ ·ºπ°“√√°— …“·≈–‡ª“Ñ À¡“¬ª√¡‘ “≥πÈ”∑®’Ë –¥ß÷ ÕÕ°·π–π”„Àºâ ªâŸ «É ¬·®ßâ 欓∫“≈„Àâ∑√“∫∑—π∑’∑’Ë¡’Õ“°“√º‘¥ª°μ‘ ‡æ◊ËÕ„ÀâºâŸªÉ«¬‡°‘¥§«“¡¡—Ëπ„®·≈–§≈“¬§«“¡«‘μ°°—ß«≈ 2.2 ¥â“π‡§√Õ◊Ë ß‰μ‡∑¬’ ¡·≈–«ß®√‰μ‡∑¬’ ¡ 1. μ√«® Õ∫§«“¡æ√Õâ ¡„™¢â Õß√–∫∫πÈ”∫√ ‘ ∑ÿ ∏·‘Ï ≈–‡§√Õ◊Ë ß‰μ‡∑¬’ ¡ μÕâ ß test º“à π∑°ÿ §√ß—È °Õà π °“√„™âß“π μ√«® Õ∫√–¥—∫¢Õß conductivity ™π‘¥¢ÕßπÈ”¬“ dialysate, dialysate flow rate (DFR) ·≈– dialysate temperature (DT) μ“¡·ºπ°“√√—°…“¢Õß·æ∑¬å 2. μ√«® Õ∫™π¥‘ μ«— °√Õ߇≈Õ◊ ¥μ“¡·ºπ°“√√°— …“¢Õß·æ∑¬å ·≈–μ√«® Õ∫™ÕË◊ π“¡ °≈ÿ ¢Õß ºŸâªÉ«¬∑’Ëμ—«°√Õ߇≈◊Õ¥„Àâμ√ß°—∫ºŸâªÉ«¬ μ—«°√Õ߇≈◊Õ¥·≈– “¬ à߇≈◊Õ¥μâÕ߉¥â√—∫°“√‡μ√’¬¡Õ¬à“ß∂Ÿ°μâÕß μ“¡·π«∑“ߪؑ∫—μ‘°“√‡μ√’¬¡μ—«°√Õ߇≈◊Õ¥·≈– “¬ à߇≈◊Õ¥°àÕπ°“√øÕ°‡≈◊Õ¥ 3. μ√«® Õ∫¢âÕμàÕμà“ßÊ ¢Õß “¬ à߇≈◊Õ¥ ‡æ◊ËÕªÑÕß°—π°“√À≈ÿ¥À√◊Õ√—Ë«´÷¡ ´÷ËßÕ“®∑”„ÀâøÕß Õ“°“»‡¢â“‰ª„π√–∫∫«ß®√‰μ‡∑’¬¡‰¥â æ√âÕ¡∑—Èß„ à venous line clamp °àÕπ‡√‘Ë¡μâπøÕ°‡≈◊Õ¥·≈–μ≈Õ¥ °“√øÕ°‡≈◊Õ¥ 331

Practical Dialysis in the Year 2009 2.3 °“√‡μ√’¬¡μ—«°√Õ߇≈Õ◊ ¥·≈– “¬ ßà ‡≈◊Õ¥„À¡à «∏‘ ª’ Ø∫‘ μ— ‘ 1. ¬÷¥À≈—° aseptic technique „π°“√ªØ‘∫—μ‘ß“π∑ÿ°¢—ÈπμÕπ 2. μ√«® Õ∫μ—«°√Õ߇≈◊Õ¥„Àâμ√ßμ“¡§” —Ëß·æ∑¬å (™π‘¥¢Õß membrane, surface area, Kuf, sterile technique ·≈–«—πÀ¡¥Õ“¬ÿ) 3. ‡¢’¬π™◊ËÕ-π“¡ °ÿ≈ºŸâªÉ«¬ ·≈–«—π∑’ˇ√‘Ë¡„™â∫πμ—«°√Õ߇≈◊Õ¥„Àâ™—¥‡®π 4. μ√«® Õ∫∑ÿ°√Õ¬μàÕ ®ÿ°ªî¥ “¬ à߇≈◊Õ¥ ·≈–ªî¥ clamp ∑“ß·¬°„Àâ π‘∑ ‡æ◊ËÕªÑÕß°—π°“√ √—Ë«´÷¡¢ÕßøÕßÕ“°“»‡¢â“ Ÿà«ß®√·≈–ªÑÕß°—π‡≈◊Õ¥´÷¡ÕÕ°®“°«ß®√ 5. ≈â“ß à«π blood compartment ¥â«¬ 0.9%NSS 1,000-1,500 ml ** Àâ“¡„™πâ È” RO ≈“â ß ‡π◊ËÕß®“°‡ªìπ à«πª≈Õ¥‡™◊ÈÕ ¥—ßπ’È °. „™â 0.9% NSS 1,000 ml (¢«¥∑’Ë1) fill ¥â“π blood compartment „Àâ‡μÁ¡ §«√„™â BFR ‰¡à ‡°‘π 150 ml/min ‡æ◊ËÕªÑÕß°—π micro-air ‰¥â¡“°°«à“°“√‡ªî¥ BFR  Ÿß ¢. fill dialysate „Àâ‡μÁ¡ dialysate compartment ·≈â«μ—Èßμ—«°√Õ߇≈◊Õ¥¥â“π vein ¢÷Èπ‡æ◊ËÕ‰≈à øÕßÕ“°“» §. ∑” recirculation ¥â«¬ 0.9% NSS 1,000 ml (¢«¥∑’Ë2) μ—Èß BFR 300-400 ml/min, UF goal 500 ml ‚¥¬„™â UFR 2-3 L/hr (¢÷Èπ°—∫ Kuf ¢Õßμ—«°√Õ߇≈◊Õ¥·μà≈–™π‘¥) ** °“√∑” recirculation §«√μàÕ‡π◊ËÕß°àÕπøÕ°‡≈◊Õ¥ ‰¡à§«√„Àâ blood pump À¬ÿ¥ °√≥’∑’Ë¡’ °“√‡μ√’¬¡μ—«°√Õ߇≈◊Õ¥≈à«ßÀπâ“„Àâ∑”¢âÕ °. ‡∑à“π—Èπ  à«π¢âÕ ¢. ·≈– §. „Àâ∑”™à«ß°àÕπøÕ°‡≈◊Õ¥ºâŸªÉ«¬ ‡æ◊ËÕªÑÕß°—π°“√ rebound ¢Õß “√‡§¡’¶à“‡™◊ÈÕ„π blood compartment ** °√≥’∑’Ëμ—«°√Õ߇≈◊Õ¥„™â«‘∏’ª≈Õ¥‡™◊ÈÕ·∫∫ stream sterilization  “¡“√∂„™â 0.9% NSS √«¡ 1,000 ml (‚¥¬ fill 500 ml ·≈–∑” recirculation 500 ml) 2.4 °“√‡μ√¬’ ¡μ«— °√Õ߇≈Õ◊ ¥·≈– “¬ ßà ‡≈◊Õ¥„™´â ”È «∏‘ ª’ Ø∫‘ μ— ‘ 1. ¬÷¥À≈—° aseptic technique „π°“√ªØ‘∫—μ‘ß“π∑ÿ°¢—ÈπμÕπ 2. μ√«® Õ∫μ«— °√Õ߇≈Õ◊ ¥·≈– “¬ ßà ‡≈Õ◊ ¥„™´â È”°Õà ππ”¡“‡μ√¬’ ¡ ¥ß— π’È ™Õ◊Ë - °≈ÿ μ√ß°∫— ºªâŸ «É ¬ ‰¡à¡’√Õ¬™”√ÿ¥ ·μ°√â“« À√◊Õ®ÿ°ªî¥À≈ÿ¥ ¡’ TCV ‰¡àμË”°«à“ 80% ¢Õß priming volume ‰¡à¡’°“√·μ°√—Ë«¢Õß membrane ‚¥¬¡™’ ÕË◊ ºªâŸ Ø∫‘ μ— √‘ ∫— √Õß ·≈–º“à π°“√¶“à ‡™Õ◊È Õ¬“à ß ¡∫√Ÿ ≥å §Õ◊ ‰¡¡à ø’ ÕßÕ“°“»§“â ß®”π«π¡“° ·≈–¡’√–¬–‡«≈“°“√¶à“‡™◊ÈÕμ√ßμ“¡¡“μ√∞“π 1,12 - 4% Formaldehyde √–¬–‡«≈“°“√¶“à ‡™Õ◊È ‰¡πà Õâ ¬°«“à 24 ™¡. ‰¡‡à °π‘ 1  ª— ¥“Àå ‡°∫Á ªÕÑ ß°π— · ß·¥¥ - 3-4% Peracetic acid mixture (PAM) √–¬–‡«≈“°“√¶“à ‡™ÕÈ◊ ‰¡πà Õâ ¬°«“à 11 ™¡. ‡°∫Á ªÕÑ ß°π— · ß·¥¥ 3. °“√≈â“ßμ—«°√Õ߇≈◊Õ¥¥â“π dialysate compartment  “¡“√∂∑”‰¥â 2 ·∫∫ §◊Õ - ≈â“ߥ⫬ dialysate ®“°‡§√◊ËÕ߉μ‡∑’¬¡∑’Ë¡’ conductivity ª°μ‘ ‚¥¬μàÕ dialysate port ¢Õß 332

Hemodialysis Procedures: Step by Step ‡§√◊ËÕ߉μ‡∑’¬¡æ√âÕ¡„™â°—∫ dialysate compartment ¢Õßμ—«°√Õ߇≈◊Õ¥ ‡æ◊ËÕ≈â“ß “√Õ∫¶à“‡™◊ÈÕ¿“¬πÕ° membrane - ≈â“ߥ⫬πÈ” RO „™â pressure πÈ”ª√–¡“≥ 1/2 Bar ºà“ππÈ” RO ‰¡àμË”°«à“ 1 π“∑’ ‚¥¬μàÕ  “¬ drain πÈ”∑‘Èß°—∫ dialysate compartment ‡æ◊ËÕªÑÕß°—π°“√øÿÑß°√–®“¬¢Õß “√Õ∫¶à“‡™◊ÈÕ 4. μàÕμ—«°√Õ߇≈◊Õ¥·≈– “¬ à߇≈◊Õ¥°—∫‡§√◊ËÕ߉μ‡∑’¬¡ ≈â“ߥâ“π blood compartment μ“¡ ·π«∑“ߪØ∫‘ μ— ™‘ ¡√¡æ¬“∫“≈‚√§‰μ·Àßà ª√–‡∑»‰∑¬ ·π–π”„À„â ™â 0.9% NSS ‰¡πà Õâ ¬°«“à 2,500 ml (°√≥’ ∑’ËÀπ૬ߓπ‰¡à reuse  “¬ à߇≈◊Õ¥ Õ“®„™â 0.9% NSS πâÕ¬°«à“∑’Ë°”À𥉫â·μàμâÕß “¡“√∂μ√«® Õ∫°“√ ª√“»®“° “√‡§¡¢’ Õßμ«— °√Õ߇≈Õ◊ ¥‰¥)â À“â ¡„™πâ ”È RO ≈“â ß ‡æ√“–‡ªπì  «à π∑ª’Ë √“»®“°‡™Õ◊È (sterile) ∑”°“√ ≈â“ߥâ“π blood compartment ¥â«¬ 0.9% NSS ¥—ßπ’È 4.1 0.9% NSS 2,000 ml ·√° „™â BFR ‰¡à‡°‘π 200 ml/min ≈â“ß blood compartment æ√âÕ¡ ∑“ß·¬° “¬ à߇≈◊Õ¥∑—ÈßÀ¡¥ ‚¥¬„Àâ dialysate ºà“πμ—«°√Õ߇≈◊Õ¥¥â“π dialysate compartment ‰ªæ√âÕ¡ °—π ‚¥¬μ—Èߥâ“π vein ¢Õßμ—«°√Õ߇≈◊Õ¥¢÷Èπ‡æ◊ËÕ‰≈àøÕßÕ“°“» 4.2 ∑” recirculation ‚¥¬„™â 0.9% NSS μ—Èß BFR 400 ml/min, UF goal 500 ml „Àâ¡’ UFR 2-3 L/hr (¢π÷È °∫— Kuf ¢Õßμ«— °√Õ߇≈Õ◊ ¥·μ≈à –™π¥‘ ) „π√–À«“à ß∑” recirculation §«√‰≈øà ÕßÕ“°“»„π dialysate ‡ªìπ√–¬–‡æ◊ËÕ„Àâ°“√ diffusion  Ÿß ÿ¥ 5. μ√«® Õ∫ residual sterilant „À¡â º’ ≈ negative °Õà π‡√¡Ë‘ øÕ°‡≈Õ◊ ¥∑°ÿ §√ß—È ´ß÷Ë ·∂∫«¥— ·μ≈à – ™π‘¥¡’§à“§«“¡≈–‡Õ’¬¥„π°“√«—¥‰¡à‡À¡◊Õπ°—π§◊Õ Residual formaldehyde test strip ¡’§à“§«“¡≈–‡Õ’¬¥„π‡°≥±å 0-5 ppm Residual peroxide test strip ¡’§à“§«“¡≈–‡Õ’¬¥„π„π‡°≥±å 0-1 ppm ¢Õâ §«√√–«ß— °√≥‡’ μ√¬’ ¡μ«— °√Õ߇≈Õ◊ ¥·≈– “¬ ßà ‡≈Õ◊ ¥„™´â ”È ‡ √®Á ·≈«â ·≈–·¡μâ √«® residual sterilant º“à π ·≈â«°Áμ“¡ ·μଗ߉¡à‰¥â„™â∑—π∑’ ·≈–¡’°“√ªî¥‡§√◊ËÕ߉μ‡∑’¬¡‰«âÀ√◊Õ‰¡à¡’ dialysate ºà“π¥â“π dialysate compartment Õ“®∑”„À⇰‘¥ rebound ¢Õß “√‡§¡’¶à“‡™◊ÈÕÕÕ°¡“„π blood compartment ‰¥â ´÷Ë߬—߉¡à ∑√“∫°≈‰°∑’Ë·πà™—¥ ‡æ◊ËÕ§«“¡ª≈Õ¥¿—¬¢Õߺ⟪ɫ¬„Àâ∑” recirculation ´È” ‚¥¬„Àâ¡’πÈ”¬“ dialysate ºà“π ¥â“π dialysate compartment μ≈Õ¥‡«≈“‰¡àπâÕ¬°«à“ 5 π“∑’·≈–μâÕßμ√«® residual sterilant ´È”Õ’°§√—Èß °àÕπ°“√„™âß“π 3. °“√‡√‘Ë¡μπâ øÕ°‡≈Õ◊ ¥ (Initiation of Dialysis) °“√‡√‘¡Ë øÕ°‡≈◊Õ¥ 1. μ√«®‡§√Õ◊Ë ß‰μ‡∑¬’ ¡·≈–Õªÿ °√≥Õå π◊Ë Ê „Àμâ √ßμ“¡·ºπ°“√√°— …“¢Õß·æ∑¬·å ≈–ºªâŸ «É ¬ (™π¥‘ ¢Õß dialyzer / μ√«® Õ∫‰¡à„Àâ¡’ “√‡§¡’μ°§â“ß„πμ—«°√Õß·≈– “¬ à߇≈◊Õ¥ / ™π‘¥¢Õß dialysate / §à“ conductivity ·≈–Õÿ≥À¿¡Ÿ ‘¢Õ߇§√◊ËÕßÕ¬àŸ„π‡°≥±åª°μ‘) 2. Double clamp IV line ¢âÕμàÕ·≈–®ÿ°ªî¥μà“ßÊ 333

Practical Dialysis in the Year 2009 3. μ√«® Õ∫μ—«°√Õ߇≈◊Õ¥·≈– “¬ à߇≈◊Õ¥‰¡à„Àâ¡’øÕßÕ“°“»¢π“¥‡≈Á° °àÕπ‡√‘Ë¡μâπμ—« °√Õ߇≈◊Õ¥ §«√μ—Èߥâ“π vein ‰«âμ≈Õ¥‡«≈“‡æ◊ËÕ‰≈àøÕßÕ“°“»¢π“¥‡≈Á°∑’˧—Ëߧâ“ß„πμ—«°√Õ߇≈◊Õ¥ („Àâ∫’∫  “¬ à߇≈◊Õ¥‡Àπ◊Õ¥â“π vein ‡ªìπ√–¬–‡æ◊ËÕ¥÷ßøÕßÕ“°“»¢π“¥‡≈Á°∑’Ë pore site ¢Õß membrane „À⇢ⓡ“ ¥â“π„π °“√À¡ÿπªíòπμ—«°√Õ߇≈◊Õ¥¥â“π¢â“ß·≈–‡§“–‡∫“Ê ∑’Ë¡◊ÕºŸâªØ‘∫—μ‘®–∑”„Àâ‰≈àøÕßÕ“°“»¢π“¥‡≈Á° „πμ—«°√Õßßà“¬¢÷Èπ) 4. À“°¡’§” —Ë߇®“–‡≈◊Õ¥°àÕπ°“√øÕ°‡≈◊Õ¥ „À⇰Á∫‡≈◊Õ¥°àÕπ°“√„Àâ “√°—π‡≈◊Õ¥·¢Áß·≈– °àÕπμàÕ«ß®√‰μ‡∑’¬¡‡¢â“°—∫ºŸâªÉ«¬ 5. π”‡≈◊Õ¥ÕÕ°®“°μ—«ºâŸªÉ«¬μ“¡·π«∑“ߪؑ∫—μ‘ √–«—߉¡à„Àâ¡’ contamination ·≈– air bubble √–À«à“ß°“√μàÕ«ß®√øÕ°‡≈◊Õ¥ 6. ‡√‘Ë¡°“√øÕ°‡≈◊Õ¥‚¥¬‡ªî¥ blood pump 100-200 ml/min ·≈–„Àâμ—Èß BFR, DFR, UF goal, dialysis time, ª√—∫√–¥—∫§«“¡‡¢â¡¢âπ¢Õß dialysate μ“¡·ºπ°“√√—°…“¢Õß·æ∑¬å 7. μ√«®∫—π∑÷° arterial pressure (AP), venous pressure (VP), transmembrane pressure (TMP) ‡¡◊ËÕμàÕ “¬§√∫«ß®√ 8. „Àâ anticoagulant μ“¡·ºπ°“√√—°…“¢Õß·æ∑¬å - Initial dose §◊Õ °“√„À⬓‡¡◊ËÕ‡√‘Ë¡øÕ°‡≈◊Õ¥ - Maintenance dose ‡ªπì °“√„À¬â “√–À«“à ß°“√øÕ°‡≈Õ◊ ¥ ·≈–À¬¥ÿ „À°â Õà π πÈ‘  ¥ÿ °“√øÕ° ‡≈◊Õ¥ 30-60 π“∑’ 3.1 °“√μàÕ “¬ à߇≈◊Õ¥°—∫ DLC «∏‘ ª’ Ø∫‘ μ— ‘ 1. ºŸ° mask ∑—ÈߺŸâªØ‘∫—μ‘·≈–ºâŸªÉ«¬ ≈â“ß¡◊Õ„Àâ –Õ“¥  «¡∂ÿß¡◊Õ –Õ“¥ 2. ‡ªî¥ºâ“ªî¥·º≈¢Õߺ⟪ɫ¬ÕÕ°„ÀâÀ¡¥  —߇°μ¥Ÿ exit site «à“º‘¥ª°μ‘À√◊Õ‰¡à ‡™àπ °“√Õ—°‡ ∫ ∫«¡·¥ß ‡≈◊Õ¥ÕÕ°¡“° ‰À¡‡¬Á∫À≈ÿ¥ ‡ªìπμâπ 3. ‡ª≈’ˬπ„™â∂ÿß¡◊Õª≈Õ¥‡™◊ÈÕ 4. Scrub  “¬ DLC ¥â«¬πÈ”¬“¶à“‡™◊ÈÕ„Àâ∑—Ë« “¬ √–«—߉¡à„Àâ¡’ contaminate ·≈⫪Ÿºâ“ ’ˇÀ≈’ˬ¡ ‡®“–°≈“ߪ≈Õ¥‡™◊ÈÕ≈ß∫π catheter (°√≥’„™â‡ªìπºâ“ ’ˇÀ≈’ˬ¡ª≈Õ¥‡™◊ÈÕ „Àâ√Õß„μâ DLC ‚¥¬¬° “¬„Àâ Ÿß À≈—ß scrub ·≈â«√Õߥ⫬§«“¡√–¡—¥√–«—ß) 5. ∑”§«“¡ –Õ“¥·º≈√Õ∫Ê catheter ¥â«¬πÈ”¬“¶à“‡™◊ÈÕ ‡™Á¥„π≈—°…≥–‡ªìπ«ß°≈¡ÕÕ°‰ª ®“° exit site Õ¬à“ßπâÕ¬ 2 §√—Èß ªî¥¥â«¬°äÕ´ sterile 6. ∑”§«“¡ –Õ“¥ª≈“¬ cap (°àÕπ‡ªî¥) ·≈–√Õ∫∑àÕ∑—Èß 2 ∑àÕ ¥â«¬πÈ”¬“¶à“‡™◊ÈÕ 7. ‡ªî¥ cap ∑’≈–¢â“ß·≈–∑”§«“¡ –Õ“¥ª≈“¬ catheter ¥â«¬πÈ”¬“¶à“‡™◊ÈÕÕ’°§√—Èß „™â syringe 5 ml ¥Ÿ¥ heparin ∑’ËÀ≈àÕ “¬ÕÕ°¢â“ß≈–ª√–¡“≥ 3 ml ·≈–∑”°“√ flush ‡≈◊Õ¥‡¢â“-ÕÕ° 3-5 §√—Èß„π·μà≈– ¢“â ß ‡æÕË◊ ∑¥ Õ∫°“√‰À≈¢Õ߇≈Õ◊ ¥ À“°‰¡μà ¥‘ ¢¥— · ¥ß«“à DLC „™‰â ¥¥â ’ (§«√„Àªâ ≈“¬ “¬ DLC ª¥î ‰«μâ ≈Õ¥ ‡«≈“∑’˪ؑ∫—μ‘) 8. μàÕ “¬ à߇≈◊Õ¥¥â“π artery ‡¢â“°—∫ catheter ¥â“π artery „Àâ π‘∑ 334

Hemodialysis Procedures: Step by Step 9. ‡ªî¥ BFR 100-200 ml/min ‡æ◊ËÕ à߇≈◊Õ¥‡¢â“«ß®√‰μ‡∑’¬¡·∑π∑’Ë 0.9% NSS ‡¡◊ËÕ‡≈◊Õ¥∂÷ß venous chamber „ÀâμàÕª≈“¬ “¬ à߇≈◊Õ¥°—∫¥â“π vein ¢Õß DLC „Àâ π‘∑ 10. ‡√‘Ë¡∑”°“√øÕ°‡≈◊Õ¥μ“¡·ºπ°“√√—°…“ 11. ªî¥·º≈„Àâ‡√’¬∫√âÕ¬ ·≈–§«√¬÷¥ “¬ DLC ‰«â°—∫º‘«Àπ—ß„À⥒ (immobilization) ‡æ◊ËÕªÑÕß°—π °“√¥÷ß√—Èß exit site ∑”„À⇠’ˬßμàÕ°“√μ‘¥‡™◊ÈÕ∑’Ë exit site ‡æ‘Ë¡¢÷Èπ 3.2 °“√ª≈¥ “¬ ßà ‡≈◊Õ¥®“° DLC «∏‘ ª’ Ø∫‘ μ— ‘ 1. º°Ÿ mask ∑—Èߺ⟪ؑ∫—μ‘·≈–ºâŸªÉ«¬ ≈â“ß¡◊Õ„Àâ –Õ“¥  «¡∂ÿß¡◊Õª≈Õ¥‡™◊ÈÕ 2. ‡μ√¬’ ¡ heparin ¥«â ¬«∏‘ ª’ ≈Õ¥‡™ÕÈ◊ „𧫓¡‡¢¡â ¢πâ 1000-5000 units/ml 2,3,10 (μ“¡¡“μ√∞“π ¢Õß·μà≈–Àπ૬ߓπ) ‚¥¬·¬° syringe ‡æ◊ËÕ fill μ“¡ª√‘¡“μ√ “¬ DLC ·μà≈–¢â“ß ‚¥¬„Àâ∫«°‡æ‘Ë¡¢â“ß≈– 0.1-0.2 ml °√≥’ºŸâªÉ«¬¡’§«“¡‡ ’ˬßÀ√◊Õ°“√·¢Áßμ—«¢Õ߇≈◊Õ¥º‘¥ª°μ‘ §«√√–¡—¥√–«—ß·≈–§«√„™â§«“¡‡¢â¡ ¢âπμË”∑’Ë ÿ¥ 3. Scrub  “¬ DLC ·≈– “¬ ßà ‡≈Õ◊ ¥ ¥«â ¬π”È ¬“¶“à ‡™ÕÈ◊ „À∑â «Ë— ¢Õâ μÕà  “¬·≈–∫√‡‘ «≥ “¬∑μË’ Õâ ß ªŸºâ“ª≈Õ¥‡™◊ÈÕ√–«—߉¡à„Àâ¡’ contaminate ·≈⫪Ÿºâ“ ’ˇÀ≈’ˬ¡‡®“–°≈“ߪ≈Õ¥‡™◊ÈÕ≈ß∫π catheter (°√≥’„™â ‡ªìπºâ“ ’ˇÀ≈’ˬ¡ª≈Õ¥‡™◊ÈÕ „Àâ√Õß„μâ DLC ‚¥¬¬° “¬„Àâ ßŸ À≈—ß scrub ·≈â«√Õߥ⫬§«“¡√–¡—¥√–«—ß) 4. §◊π‡≈◊Õ¥‡¢â“μ—«ºŸâªÉ«¬‚¥¬ clamp ¥â“π artery ¢Õß DLC ·≈– “¬ à߇≈◊Õ¥ ª≈¥ “¬ à߇≈◊Õ¥ ÕÕ° ∑”°“√§◊π‡≈◊Õ¥°≈—∫‡¢â“μ—«ºŸâªÉ«¬ ®π‡≈◊Õ¥„π«ß®√®“ß„Àâ clamp ¥â“π vein ¢Õß catheter ·≈– “¬ àß ‡≈◊Õ¥ ª≈¥ “¬ à߇≈◊Õ¥ÕÕ° 5. ∑”§«“¡ –Õ“¥ª≈“¬ DLC ¥â«¬πÈ”¬“¶à“‡™◊ÈմȔՒ°§√—Èß 6. Flush DLC ¥â«¬ 0.9% NSS ¢â“ß≈– 10 ml 7. Fill μ“¡¥â«¬ heparin solution ∑’˺ ¡‡Õ“‰«â„π¢âÕ∑’Ë 2 ¢≥– flush §«√∑”Õ¬à“ß√«¥‡√Á« (quick bolus) ‡æ◊ËÕ àß„Àâ heparin solution ‰ª∂÷ß à«πª≈“¬¢Õß∑àÕ·≈– clamp ∑—π∑’ ‡æ◊ËÕªÑÕß°—π‡≈◊Õ¥‰À≈¬âÕπ°≈—∫ ·≈–ªî¥ª≈“¬ DLC ¥â«¬ cap ª≈Õ¥‡™◊ÈÕÕ—π„À¡à 8. ∑”§«“¡ –Õ“¥ exit site Õ’°§√—ÈßÀπ÷Ëß ·≈⫪î¥æ≈“ ‡μÕ√å ‡™àπ Fixomull À√◊Õ adhesive plaster ‚¥¬®—¥∑‘»∑“ߢÕß “¬„Àâ∂Ÿ°μâÕß √–«—ß°“√À—°ßÕ¢Õß catheter ¢âÕ§«√√–«—ß 1. ¬÷¥À≈—° aseptic technique ∑ÿ°§√—Èß ∑’Ë„Àâ°“√欓∫“≈ºâŸªÉ«¬ 2. μ√«®¥∫Ÿ √‘‡«≥ exit site ∑ÿ°§√—Èß ∑’Ë∑”°“√‡ªî¥·º≈«à“¡’°“√μ‘¥‡™◊ÈÕÀ√◊Õ§«“¡º‘¥ª°μ‘„¥Ê À√◊Õ‰¡à 3. μ√«®¥Ÿ‰À¡‡¬Á∫∑’Ë∫√‘‡«≥ suture wing ‰¡à„Àâ‡≈◊ËÕπÀ≈ÿ¥À√◊Õ¢“¥ ‡æ◊ËÕªÑÕß°—π catheter ‡≈◊ËÕπ À≈ÿ¥ÕÕ°¡“®“°ª“°·º≈ (°√≥’„™â temporary DLC) 4. °“√‡°‘¥ one-way obstruction ( “¡“√∂ flush 0.9% NSS À√◊Õ‡≈◊Õ¥‡¢â“‰¥â ·μ॥Ÿ ÕÕ°‰¡à‰¥â À√Õ◊ μÕâ ß„™·â √ߥ¥Ÿ ¡“° Õ“®‡°¥‘ ®“° blood clot À√Õ◊ ª≈“¬¢Õß catheter Õ¬„Ÿà πμ”·Àπßà ∑‰’Ë ¡¥à )’ „À·â °‰â ¢¥ß— π’È 335

Practical Dialysis in the Year 2009 - ®¥— ∑“à ºªâŸ «É ¬„À¡à ‡™πà „Àπâ Õπ√“∫ Àπ— Àπ“â ´“â ¬À√Õ◊ ¢«“ À√Õ◊ „™°â “√Àππÿ ‰À≈à ·≈«â ∑¥≈Õß flush ‡¢â“ÕÕ°Õ’°§√—ÈßÀπ÷Ëß - À“°¬—߉¡à¥’¢÷Èπ °√≥’ temporary DLC „ÀâÀ¡ÿπ catheter ‚¥¬„Àâ¥â“π arterial À—πÕÕ°®“° ºπ—ߢÕßÀ≈Õ¥‡≈◊Õ¥ ‡æ◊ËÕ„Àâ¡’°“√‰À≈¢Õ߇≈◊Õ¥‰¥â –¥«°¡“°¢÷Èπ - ∂â“ flow ¬—߉¡à‡æ’¬ßæÕ ·æ∑¬åÕ“®®–æ‘®“√≥“‡æ‘Ë¡§«“¡‡¢â¡¢âπ¢Õß heparin solution „π catheter „Àâ¡“°¢÷ÈπÀ√◊Õ‡ª≈’ˬπ catheter „À¡à 5. Àâ“¡¢¬—∫ catheter „Àâ≈÷°‡¢â“‰ª„πÀ≈Õ¥‡≈◊Õ¥¡“°¢÷Èπ ‡æ√“–®–𔇙◊ÈÕ‡¢â“ àŸÀ≈Õ¥‡≈◊Õ¥ ‚¥¬μ√ß 6. À“â ¡°√≥’ flush catheter ∑ÕË’ ¥ÿ μπ— ‚¥¬‡¥¥Á ¢“¥ ‡æ√“–®–∑”„Àâ blood clotted À≈¥ÿ ‡¢“â °√–·  ‡≈◊Õ¥‰¥â 7. „π°√≥’∑’ˉ¡à‰¥â∑”°“√øÕ°‡≈◊Õ¥μâÕß clamp catheter ‰«âμ≈Õ¥‡«≈“ ªÑÕß°—π‡≈◊Õ¥‰À≈¬âÕπ °≈∫— ‡¢“â ¡“„𠓬∑”„À â “¬Õ¥ÿ μπ— À√Õ◊ ¡’ poor BFR ∑”„À°â “√øÕ°‡≈Õ◊ ¥‰¡‡à 欒 ßæÕ ·≈–§«√‡≈Õ◊Ë πμ”·Àπßà ¢Õß clamp ∑ÿ°§√—Èß ‡æ◊ËÕªÑÕß°—π°“√μ’∫À√◊ÕÀ—°¢Õß “¬®“°°“√°¥∑—∫‡ªìπ‡«≈“π“π 3.3 °“√„™â permanent vascular access (AV fistula, AVF; AV graft, AVG) «∏‘ ª’ Ø∫‘ μ— ‘ 1. „™âÀ≈—° aseptic technique „π°“√·∑߇¢Á¡ 2. §«√¡°’ “√®¥—  Õπ·≈–∑∫∑«πÀ≈°— aseptic technique ·≈– standard precaution ·°æà ¬“∫“≈ ·≈–∫ÿ§≈“°√„πÀâÕ߉μ‡∑’¬¡‡ªìπ√–¬–Ê Õ¬à“ß ¡Ë”‡ ¡Õ 3. ≈“â ß¡Õ◊  «¡∂ßÿ ¡Õ◊  –Õ“¥°Õà π·∑߇¢¡Á ·≈–‡ª≈¬Ë’ π∂ßÿ ¡Õ◊ ‡¡ÕË◊ ¡’ contamination °Õà π·∑߇¢¡Á ·≈–‡ª≈’ˬπ∂ÿß¡◊Õ ”À√—∫°“√·∑߇¢Á¡ºŸâªÉ«¬·μà≈–§π 4. º°Ÿ mask ¢≥–„Àâ°“√欓∫“≈ºŸâªÉ«¬ 5. μ√«® Õ∫ permanent vascular access °Õà π‡μ√¬’ ¡º«‘ Àπß— ∑°ÿ §√ß—È ·≈–‡ππâ ‡√Õ◊Ë ß°“√‡Ω“Ñ √–«ß— ¿“«–μ’∫μ—π·≈–ª√–‡¡‘𧫓¡º‘¥ª°μ‘‡∫◊ÈÕßμâπ¢Õß AVF/ AVG (§≈” thrill À√◊Õøí߇ ’¬ß bruit æ∫«à“≈¥≈ß À√◊Õ°√≥’ AVG ‰¡à‡ªìπ continuous thrill, ·¢π¢â“ß∑’Ë¡’ vascular access ∫«¡, ª√–«—μ‘°“√·∑߇¢Á¡≈”∫“°, ¡’ °“√Õ°— ‡ ∫·≈–쥑 ‡™Õ◊È ∫√‡‘ «≥º«‘ Àπß— , ª≈“¬¡Õ◊ ª≈“¬·¢πª«¥ ‡¬πÁ ™“, ‡≈Õ◊ ¥À¬¥ÿ ¬“°À≈ß— ∂Õπ‡¢¡Á , ¢π“¥ ¢Õß pseudoaneurysm ‚μ¢÷Èπ‡ªìπ 2 ‡∑à“¢Õß¢π“¥ grafts) 6. μ√«® Õ∫°“√Õ—°‡ ∫∫√‘‡«≥ vascular access À“°¡’°“√Õ—°‡ ∫ Àâ“¡„™â vascular access π—Èπ·≈–√“¬ß“π·æ∑¬å‡æ◊ËÕ°“√·°â‰¢μàÕ‰ª 7. ∑”§«“¡ –Õ“¥º«‘ Àπß— ∫√‡‘ «≥∑·’Ë ∑߇¢¡Á ‚¥¬«π ”≈‡’ ªπì «ß°≈¡ √Õ∫μ”·Àπßà ·∑߇¢¡Á ®“° »Ÿπ¬å°≈“ß«πÕÕ°πÕ°¥â«¬ - 70% alcohol √Õ·Àâß 1 π“∑’ ·≈–À√◊Õ 10% povidone iodine √Õ·Àâß 2›3 π“∑’ À√◊Õ - 2% chlorhexidine gluconate with 70% isopropyl alcohol √Õ·Àâß 30 «‘π“∑’ 8. «‘∏’°“√·∑߇¢Á¡ AVF / AVG - ‰¡à·∑߇¢Á¡∫√‘‡«≥∑’Ë¡’ aneurysm À√◊Õ pseudoaneurysm ‡æ√“–¡’‚Õ°“ ‡ ’ˬßμàÕ°“√·μ° 336

Hemodialysis Procedures: Step by Step ¢Õß aneurysm ·≈–®–∑”„À⇰‘¥ªí≠À“‡≈◊Õ¥‰À≈‰¡àÀ¬ÿ¥À≈—ß∂Õπ‡¢Á¡ ∑”„Àâ vascular access ‡ ’¬ - ‰¡à§«√„™âß“π permanent vascular access ∑’ˬ—߉¡à ¡∫√Ÿ ≥å‡μÁ¡∑’Ë ‡æ√“–‡ ’ˬßμàÕ°“√‡°‘¥ hematoma ‡ªì𠓇Àμÿ¢Õß°“√ ≠Ÿ ‡ ’¬ vascular access π—Èπ - AVF §«√√Õ„Àâ ¡∫√Ÿ ≥å§◊Õª√–¡“≥ 6 ‡¥◊Õπ (‰¡à§«√„™âß“π°àÕπ 4-6  —ª¥“Àå ‡æ◊ËÕ√Õ„Àâ ‡ âπ¬ÿ∫∫«¡ ¡’§«“¡Àπ“·≈–‡À𒬫‡æ’¬ßæÕ∑’Ë®–·∑߇¢Á¡ §«√‡√‘Ë¡„™â AVF ‡¡◊ËÕ§≈” thrill ‰¥âÀà“ß®“° anastomosis 8-10 ‡´π쑇¡μ√) 2,9,12 - AVG §«√√Õ 3-6  —ª¥“Àå (‰¡à§«√„™âß“πÀ≈—ߺà“μ—¥πâÕ¬°«à“ 2  —ª¥“Àå ‡æ√“–¬—ß¡’°“√§—Ëß ¢ÕßπÈ”·≈–‡≈◊Õ¥√Õ∫ grafts ∑”„Àâ°“√μ‘¥¢Õ߇π◊ËÕ‡¬◊ËÕ‚¥¬√Õ∫¬—߉¡à¥’æÕ) 3,9 - ‡ª≈’ˬπμ”·Àπàß°“√·∑߇¢Á¡∑ÿ°§√—Èß (rope cannulation) ‡æ◊ËÕªÑÕß°—π°“√‡°‘¥ aneurysm (°√≥’‰¡à„™â buttonhole technique) - °√≥’ AVF §«√·∑߇¢Á¡Àà“ß®“°®ÿ¥‡¥‘¡Õ¬à“ßπâÕ¬ 1 π‘È« °√≥’ AVG §«√¡’μ“√“ß°“√·∑ß ‡¢Á¡Àà“ß®“°®ÿ¥‡¥‘¡ 1 ‡´π쑇¡μ√ ¥â“ππÕ°«π≈ß·≈–«π¢÷Èπ∑“ߥâ“π„π - ·∑߇¢Á¡Àà“ß®“° anastomosis Õ¬à“ßπâÕ¬ 3 ‡´π쑇¡μ√ - °√≥’·∑߇¢Á¡„π‡ âπ‡¥’¬«°—π μ”·Àπàß 2 ‡¢Á¡ §«√Àà“ß°—πÕ¬à“ßπâÕ¬ 5 ‡´π쑇¡μ√ 2 - ·∑߇¢Á¡Àà“ß®“° à«π‚§âߢÕß loop graft Õ¬à“ßπâÕ¬ 1 π‘È« - ‡≈◊Õ°‡¢Á¡„Àâ‡À¡“– ¡°—∫°“√‡ªî¥ blood flow rate ( BFR ) BFR < 350 ml/min „™â‡¢Á¡ AVF No.16 BFR > 350 ml/min „™â‡¢Á¡ AVF No.15 BFR > 500 ml/min „™â‡¢Á¡ AVF No.14 - ¢≥–·∑߇¢¡Á „Àμâ √ß÷ ‡ πâ ‡≈Õ◊ ¥„ÀÕâ ¬°Ÿà ∫— ∑Ë’ ‡æÕË◊ ªÕÑ ß°π— °“√©°’ ¢“¥¢Õߺπß— À≈Õ¥‡≈Õ◊ ¥‚¥¬ 1. °√≥’·∑߇¢Á¡ AVF „Àâ√—¥ “¬ tourniquet ‡Àπ◊Õ∫√‘‡«≥∑’Ë®–≈߇¢Á¡ 1,2,9 2. ·∑߇¢Á¡Õ¬à“ßπÿà¡π«≈·≈–√–¡—¥√–«—ß 3. ·∑߇¢Á¡∑”¡ÿ¡ 25 Õß»“  ”À√—∫ AVF °“√·∑ß∑”¡ÿ¡¡“°‡°‘πª≈“¬‡¢Á¡®–∑–≈ÿºπ—ß À≈Õ¥‡≈◊Õ¥¥â“π≈à“ß 4. ·∑߇¢Á¡∑”¡ÿ¡ 45 Õß»“  ”À√—∫ AVG ‡¡◊ËÕ‡¢Á¡ºà“πºπ—ßÀ≈Õ¥‡≈◊Õ¥„ÀâÀ¡ÿπ‡¢Á¡ 180 Õß»“ „Àâª≈“¬μ—¥¢Õ߇¢Á¡À¡ÿπ≈߇æ◊ËÕªÑÕß°—𪓰엥¢Õ߇¢Á¡∑”„Àâ™—Èπºπ—ßÀ≈Õ¥‡≈◊Õ¥¥â“π≈à“ß©’°¢“¥ ·≈–§Õà ¬Ê  Õ¥‡¢¡Á  ‡àŸ  πâ ‡≈Õ◊ ¥®π ¥ÿ ‡¢¡Á À≈ß— ®“°ππ—È À¡πÿ ‡¢¡Á °≈∫— 180 Õß»“μ√ß÷ ‡¢¡Á ¥«â ¬æ≈“ ‡μÕ√å ‚¥¬ „Àâ·π«‡¢Á¡Õ¬Ÿà„π·π«‡¥’¬«°—∫‡ âπ‡≈◊Õ¥ §«√·∑߇¢Á¡∑’Ë AVG ∑—Èß 2 ‡¢Á¡ ‰¡à§«√·∑߇¢Á¡∑’Ë peripheral vein ¢ÕߺŸâªÉ«¬‡æ√“–§«√√—°…“ proximal vein ‰«â‡æ◊ËÕ„π°√≥’Õ“®μâÕß∑” vascular access „À¡à À“°‡°‘¥ªí≠À“ - °“√∂Õπ‡¢¡Á „À∂â Õπ‡¢¡Á „π¡¡ÿ ‡¥¬’ «∑·’Ë ∑߇¢¡Á À“â ¡ÕÕ°·√ß°¥º«‘ Àπß— °Õà π®–¥ß÷ ‡¢¡Á ÕÕ° À¡¥ ‡æ√“–®–∑”„Àâª≈“¬μ—¥¢Õ߇¢Á¡§√Ÿ¥°—∫™—Èπ¢ÕßÀ≈Õ¥‡≈◊Õ¥©’°¢“¥‰¥â - „™âπ‘È«°¥Àâ“¡‡≈◊Õ¥¥â«¬πÈ”Àπ—°æÕ‡À¡“– (πÈ”Àπ—°æÕ∑’ˇ≈◊Õ¥À¬ÿ¥·≈–¬—ߧ≈” thrill ‰¥â)  ”À√—∫ AVF „™â‡«≈“°¥ª√–¡“≥ 10-15 π“∑’·≈– AVG §«√„™â‡«≈“°¥π“π°«à“ 15 π“∑’ - „™â sterile gauze ªî¥∫√‘‡«≥·∑߇¢Á¡°àÕπªî¥∑—∫¥â«¬æ≈“ ‡μÕ√å 337