Practical Dialysis in the Year 2009

Practical Dialysis in the Year 2009 4. °“√쥑 μ“¡·≈–ª√–‡¡π‘ √–À«“à ß°“√øÕ°‡≈Õ◊ ¥ (Monitoring during Dialysis) 4.1 °“√¥·Ÿ ≈ºŸªâ «É ¬ 1. ª√–‡¡‘π·≈–∫—π∑÷° vital signs À≈—߇√‘Ë¡°“√øÕ°‡≈◊Õ¥  Õ∫∂“¡Õ“°“√∑ÿ° 30-60 π“∑’ À√◊Õ μ√«®«—¥∫àÕ¬¢÷Èπ ‡¡◊Ëպ⟪ɫ¬¡’Õ“°“√º‘¥ª°μ‘À√◊Õ‡°‘¥¿“«–·∑√°´âÕπ 2. μ√«® Õ∫μ”·ÀπàߢÕ߇¢Á¡·≈–¢âÕμàÕ«ß®√‰μ‡∑’¬¡ ‡æ◊ËÕªÑÕß°—π°“√À≈ÿ¥¢Õ߇¢Á¡À√◊Õ°“√ À—°ßÕ¢Õß “¬ à߇≈◊Õ¥ „À⧔·π–π”ºâŸªÉ«¬°“√‡ª≈’ˬπ∑à“ ¢≥–¡’‡¢Á¡À√◊Õ “¬ «π§“À≈Õ¥‡≈◊Õ¥¥” 3. ®—¥∑à“ºâŸªÉ«¬„Àâ‡À¡“– ¡°—∫Õ“°“√·≈–§«“¡ ÿ¢ ∫“¬¢Õߺ⟪ɫ¬ ®—¥∫√√¬“°“» ·≈– ‘Ëß ·«¥≈âÕ¡„Àâ –Õ“¥‡√’¬∫√âÕ¬ „ÀâºâŸªÉ«¬ºàÕπ§≈“¬ ‡™àπ °“√¥‚Ÿ ∑√∑—»πå À√◊Õøí߇æ≈߇∫“Ê 4. 楟 §¬ÿ °∫— ºªŸâ «É ¬·≈–≠“μ‘ ∂ß÷ Õ“°“√À√Õ◊ ª≠í À“°“√‡®∫Á ª«É ¬μ“à ßÊ ‡æÕ◊Ë §≈“¬§«“¡«μ‘ °°ß— «≈ ∑’ˇ°‘¥¢÷Èπ ‡ªî¥‚Õ°“ „ÀâºâŸªÉ«¬´—°∂“¡‡æ‘Ë¡‡μ‘¡„π ‘Ëß∑’˺⟪ɫ¬ ß —¬À√◊Õ‰¡à ∫“¬„® „Àâ ÿ¢»÷°…“¥â«¬«‘∏’°“√ ∑’ˇÀ¡“– ¡·°àºâŸªÉ«¬·≈–≠“μ‘ 5.  —߇°μæƒμ‘°√√¡ ‡™àπ Õ“°“√‡∫◊ËÕÀπà“¬ ´÷¡‡»√â“ «‘μ°°—ß«≈ ‡æ◊ËÕÀ“ “‡Àμÿ¢Õßæƒμ‘°√√¡ ¥—ß°≈à“«·≈–«“ß·ºπ°“√·°â‰¢ªí≠À“ 6. ‡Ω“Ñ √–«ß— Õ“°“√º¥‘ ª°μÀ‘ √Õ◊ ¿“«–·∑√°´Õâ π∑ÕË’ “®‡°¥‘ ¢πÈ÷ °∫— ºªŸâ «É ¬ ‡æÕË◊ „À°â “√ªÕÑ ß°π— ·≈– ·°â‰¢ 4.2 ¥â“π‡§√Ë◊Õß·≈–«ß®√‰μ‡∑’¬¡ 1. μ√«®‡§√◊ËÕ߉μ‡∑’¬¡„Àâ∑”ß“πª°μ‘μ≈Õ¥‡«≈“ ‚¥¬°“√μ√«®‡™Á§§à“μà“ßÊ ¥—ßπ’È - Conductivity §«√Õ¬Ÿà√–À«à“ß 13.5-14.5 À√◊Õ μ“¡§à“∑’Ë set variation ‰«â - Dialysate flow rate 500 ml/min À√◊Õ 700-800 ml/min  ”À√—∫ high efficiency dialysis - Temperature μ“¡·ºπ°“√√—°…“¢Õß·æ∑¬å·≈–‰¡à§«√‡°‘π 40°C ‡æ√“–®–∑”„À⇰‘¥ hemolysis ‰¥â - UFR ·≈– UF remove μ√ßμ“¡‡«≈“∑’˺à“π‰ª - μ√«® BFR „Àμâ √ß·ºπ°“√√°— …“¢Õß·æ∑¬μå ≈Õ¥°“√øÕ°‡≈Õ◊ ¥ ‡æÕ◊Ë ªÕÑ ß°π— μ«— °√Õ߇≈Õ◊ ¥ μ—π·≈–„Àâ°“√øÕ°‡≈◊Õ¥¡’ª√– ‘∑∏‘¿“æ ßŸ  ÿ¥ - μ√«®·≈–∫—π∑÷°°“√‡ª≈’ˬπ·ª≈ß§à“„ÀâÕ¬àŸ„π normal limit (arterial pressure / venous pressure / TMP À√◊Õ dialysate pressure) - μ√«®¥§Ÿ «“¡º‘¥ª°μ‘ ”§≠— ¢Õß«ß®√‰μ‡∑¬’ ¡‡ªìπ√–¬– (microbubbles of air / blood leak / blood line kink /  —߇°μ≈—°…≥–§«“¡º‘¥ª°μ‘¢Õß ’‡≈◊Õ¥„π«ß®√‰μ‡∑’¬¡ À“°¡’ ’‡¢â¡¢÷Èπ· ¥ß«à“Õ“®¡’ blood clotted „πμ—«°√Õ߇≈◊Õ¥) 338

Hemodialysis Procedures: Step by Step 5. °“√ªØ‘∫—μ‘À≈ß— °“√øÕ°‡≈◊Õ¥ (Postdialysis) 5.1 °“√¥Ÿ·≈ºâªŸ «É ¬ 1. ·®âß„ÀâºâŸªÉ«¬√—∫∑√“∫ æ√âÕ¡∑—Èß®—¥∑à“∑’ˇÀ¡“– ¡ ”À√—∫ºŸâªÉ«¬ 2. ª√–‡¡‘π vital sign °àÕπ ‘Èπ ÿ¥°“√øÕ°‡≈◊Õ¥ æ√âÕ¡ª√–‡¡‘πÕ“°“√ºŸâªÉ«¬∑ÿ°§√—Èß 3. §◊π‡≈◊Õ¥‡¢â“ Ÿà√à“ß°“¬ºâŸªÉ«¬¥â«¬«‘∏’∑’˪≈Õ¥¿—¬ ‚¥¬„™â BFR ‰¡à‡°‘π 200 ml/min „™âª√‘¡“≥ 0.9% NSS 100-200 ml/min À“°ºâªŸ «É ¬¡’§«“¡¥π— ‚≈Àμ‘ μË”°«à“ª°μ‘ §«√殑 “√≥“„Àâ‡æË¡‘ μ“¡·π«∑“ß°“√ √—°…“¢ÕßÕ“¬ÿ√·æ∑¬å‚√§‰μ 4. ª√–‡¡‘πÕ“°“√¢Õߺ⟪ɫ¬À≈—ß°“√øÕ°‡≈◊Õ¥ ‚¥¬°“√«—¥ vital sign ·≈–μ√«®¥ÕŸ “°“√º‘¥ ª°μ‘∑’ËÕ“®‡°‘¥¢÷Èπ¿“¬À≈—ß°“√øÕ°‡≈◊Õ¥ ‡™àπ - °√≥º’ ªŸâ «É ¬¡¿’ “«–§«“¡¥π— ‚≈Àμ‘ º¥‘ ª°μ‘ „Àºâ ªŸâ «É ¬πÕπæ°— ·≈–«¥— §«“¡¥π— ‚≈Àμ‘ ´”È ∂“â ¬—ßæ∫«à“¡’§«“¡º‘¥ª°μ‘Õ¬Ÿà„Àâ√“¬ß“π·æ∑¬å - ºŸâªÉ«¬∑’Ë¡’¿“«–º‘¥ª°μ‘Õ◊ËπÊ ‡™àπ μ–§√‘«‡ªìπ¡“°, ¡’ chest pain „Àâ√“¬ß“π·æ∑¬å∑—π∑’ ‡æ◊ËÕ·°â‰¢ - ºªŸâ «É ¬∑¡Ë’ Õ’ ≥ÿ À¿¡Ÿ °‘ “¬‡æ¡Ë‘ ¢πÈ÷ ¡“°°«“à 0.5°C2,3,8 „Àªâ √–‡¡π‘ ºªŸâ «É ¬«“à  ¡— æπ— ∏°å ∫— °“√쥑 ‡™◊ÈÕ®“°°“√∑”‰μ‡∑’¬¡À√◊Õ‰¡àæ√âÕ¡√“¬ß“π·æ∑¬å∑√“∫°àÕπ®”Àπà“¬ 5. ª√–‡¡‘π vascular access ‚¥¬ - §≈” thrill ·≈–øí߇ ’¬ß bruit -  —߇°μ bleeding ∫√‘‡«≥√Õ¬‡¢Á¡À√◊Õ exit site ¢Õß catheter °√≥’ AVF / AVG æ∫«à“¡’ hematoma „À°â ¥μÕà ¥«â ¬μ”·Àπßà °“√°¥·≈–πÈ”Àπ°— ∑‡’Ë À¡“– ¡«“ß cold pad  ß— ‡°μ¢π“¥¢Õß hematoma §≈” thrill ·≈–øí߇ ’¬ß bruit ´È”‡¡◊ËÕÕ“°“√§ß∑’Ë - °√≥’∑’ˇ≈◊Õ¥À¬ÿ¥¬“°·≈–æ∫∫àÕ¬ „Àâ√“¬ß“π·æ∑¬å 6. ™ßË— π”È Àπ°— ºªâŸ «É ¬À≈ß— øÕ°‡≈Õ◊ ¥ ‡¡ÕË◊ ºªâŸ «É ¬‰¡¡à Õ’ “°“√º¥‘ ª°μ‘ ·≈– vital signs stable æ√Õâ ¡ ª√–‡¡‘πº≈°“√øÕ°‡≈◊Õ¥ 7.  √ÿªº≈°“√øÕ°‡≈◊Õ¥ ·≈–ªí≠À“¢ÕߺŸâªÉ«¬æ√âÕ¡∑—Èß≈ß∫—π∑÷°„π hemodialysis flow chart 8. ·π–π”°“√ªØ∫‘ μ— μ‘ «— ∑ Ë’ Õ¥§≈Õâ ß°∫— Õ“°“√¢≥–ºªŸâ «É ¬Õ¬∑Ÿà ∫Ë’ “â π æ√Õâ ¡π¥— À¡“¬‡«≈“øÕ° ‡≈◊Õ¥§√—ÈßμàÕ‰ª 5.2 ‡§√Ë◊Õ߉μ‡∑’¬¡·≈–«ß®√‰μ‡∑¬’ ¡ 1. ªî¥ clamp  “¬ à߇≈◊Õ¥·≈–ªî¥®ÿ°∫√‘‡«≥ª≈“¬ “¬ ª≈¥«ß®√‰μ‡∑’¬¡ÕÕ°®“°‡§√◊ËÕß‰μ ‡∑’¬¡ ≈â“߇°Á∫μ“¡·π«∑“ß°“√π”μ—«°√Õ߇≈◊Õ¥·≈– “¬ à߇≈◊Õ¥°≈—∫¡“„™â´È” 2. ‡°Á∫ “¬πÈ”¬“·≈– rinse ‡§√◊ËÕ߉μ‡∑’¬¡ 3. ∑”§«“¡ –Õ“¥‡§√Õ◊Ë ß‰μ‡∑¬’ ¡μ“¡§¡Ÿà Õ◊ ·π«∑“ß°“√ªØ∫‘ μ— °‘ “√∑”§«“¡ –Õ“¥·≈–Õ∫¶“à ‡™◊ÈÕ‡§√◊ËÕ߉μ‡∑’¬¡·≈–μ“¡«‘∏’°“√¢Õ߇§√◊ËÕß·μà≈–√ÿàπ 339

Practical Dialysis in the Year 2009 5.2.1 °“√π”μ—«°√Õ߇≈◊Õ¥°≈—∫¡“„™â´”È ¥â«¬«‘∏’ manual (manual dialyzer reprocessing) ¢Õâ æ‘®“√≥“°àÕπ°“√π”μ«— °√Õß¡“„™â´”È -  ∂“π∑ ’Ë ”À√∫— „™∑â ”°“√≈“â ßμ«— °√Õ߇≈Õ◊ ¥·≈– “¬ ßà ‡≈Õ◊ ¥§«√¡°’ “√√–∫“¬Õ“°“»∑¥’Ë ’ ‡æÕ◊Ë ≈¥°“√ —¡º—  “√‡§¡’∑’ˇ°‘¥®“°°“√øÿÑß°√–®“¬¢Õß disinfectant - ®—¥·¬°Õà“ß≈â“ß√«¡∂÷ßÕÿª°√≥åª√–°Õ∫°“√≈â“߉«â‡ªìπ —¥ à«π‡©æ“– ”À√—∫ºâŸªÉ«¬μ‘¥‡™◊ÈÕ ‡™àπ ºŸâªÉ«¬‰«√— μ—∫Õ—°‡ ∫∫’ (HBV) ºŸâªÉ«¬‰«√— μ—∫Õ—°‡ ∫´’ (HCV) ‡æ◊ËÕªÑÕß°—π cross contamination - μ√«® Õ∫§«“¡‡À¡“– ¡ ”À√∫— ºªâŸ «É ¬∑¡Ë’ °’ “√쥑 ‡™ÕÈ◊ À√Õ◊ ºªâŸ «É ¬∑®Ë’ ”‡ªπì μÕâ ß∑”°“√øÕ° ‡≈◊Õ¥°√≥’‡√àߥà«π ‡æ◊ËÕæ‘®“√≥“°“√≈â“ßμ—«°√Õ߇≈◊Õ¥·≈– “¬ à߇≈◊Õ¥‡æ◊ËÕ„™â´È” À“°¬—߉¡à∑√“∫º≈ infectious marker ‰¡à§«√π”Õÿª°√≥套߰≈à“«¡“„™â´È” - ‡ª≈’ˬπ∂ÿß¡◊Õ„π°“√≈â“ßμ—«°√Õ߇≈◊Õ¥ºâŸªÉ«¬·μà≈–√“¬ - ¡’°“√∫—π∑÷°§ÿ≥¿“æμ—«°√Õ߇≈◊Õ¥„™â´È”·≈–ºŸâªØ‘∫—μ‘∑ÿ°§√—Èß «∏‘ ª’ Ø∫‘ μ— ‘ 1. ºŸâªØ‘∫—μ‘ºŸ° mask  «¡À¡«°  «¡·«àπμ“°—π°√–‡¥Áπ „ à‡ ◊ÈÕ°—π‡ªóôÕπ·≈– «¡∂ÿß¡◊Õ 2. π”μ«— °√Õ߇≈Õ◊ ¥·≈– “¬ ßà ‡≈Õ◊ ¥À≈ß— „™°â ∫— ºªŸâ «É ¬„ ¿à “™π–√Õß√∫— ¡“∑Õ’Ë “à ß≈“â ß (‚¥¬ clamp  “¬·≈–ªî¥®ÿ°ª≈“¬ “¬) 3. μ√«® Õ∫μ«— °√Õ߇≈Õ◊ ¥«“à ¡‚’ §√ß √“â ߪ°μ‘ ‰¡·à μ°√«Ë— ¡™’ ÕË◊ - °≈ÿ ºªâŸ «É ¬‡¢¬’ π쥑 ∑μË’ «— °√Õß ‡≈◊Õ¥‰«âÕ¬à“ß∂Ÿ°μâÕß ™—¥‡®π 4. ‡æÕ◊Ë „À°â “√≈“â ߧ√“∫‡≈Õ◊ ¥ß“à ¬¢π÷È „À∑â ”reverse-ultrafiltration °Õà π ‚¥¬π”ª≈“¬ “¬ ßà ‡≈Õ◊ ¥ ∑—Èß 2 ¥â“πμàÕ≈ß∑àÕπÈ”∑‘Èß (‡ªî¥ clamp ∑“ßμ√ß∑—Èß 2 ¥â“π·≈–ªî¥ clamp ¥â“π¢â“ß∑ÿ° “¬) μàÕπÈ” RO °—∫ dialysate compartment ¢â“ßÀπ÷Ëß  à«πÕ’°¢â“ßÀπ÷ËßμàÕ “¬·≈– clamp „™â·√ߥ—ππÈ” 15-20 psi ‡æ◊ËÕ„À⇰‘¥ ·√ßÕ—¥¥—ππÈ”®“° dialysate compartment ‰ª¬—ß blood compartment ®–∑”„Àâ‡≈◊Õ¥∑’˧â“ß„π pore site ¢Õß membrane À≈ÿ¥‡¢â“¡“„π blood compartment 5. ≈“â ߧ√“∫‡≈Õ◊ ¥ «à π blood compartment ‚¥¬μÕà ª≈“¬ “¬ ßà ‡≈Õ◊ ¥¥“â πÀπßË÷ °∫— ∑“ßπ”È RO ª≈“¬ “¬ à߇≈◊Õ¥Õ’°¥â“πÀπ÷ËßμàÕ≈ß∑àÕπÈ”∑‘Èß (μ√«® clamp ¥â“π¢â“ß„Àâªî¥‰«â∑ÿ° “¬·≈–ªî¥ clamp ∑“ß μ√ß ‡æ◊ËÕªÑÕß°—π‡≈◊Õ¥°√–®“¬„πÕà“ß≈â“ß) ‡ªî¥πÈ” RO ‰≈à‡≈◊Õ¥®π„  6. ª≈¥ “¬ à߇≈◊Õ¥®“°μ—«°√Õ߇≈◊Õ¥ ∑”§«“¡ –Õ“¥ “¬ à߇≈◊Õ¥‚¥¬‰≈àπÈ” RO ºà“π∑ÿ°  à«π „™â¶âÕπ¬“ß·≈– clamp ∑’ËÀÿâ¡ “¬¬“ß ‡§“– ·≈–∫’∫‰≈à clotted blood ·≈– fibrin μ“¡ à«πμà“ßÊ ¢Õß  “¬ à߇≈◊Õ¥∑—Èß∑“ßμ√ß·≈–∑“ß·¬°ÕÕ°®πÀ¡¥ 7. ≈â“ßμ—«°√Õ߇≈◊Õ¥¥â“π blood compartment  ≈—∫°—∫ dialysate compartment À≈“¬Ê §√—Èß ‚¥¬∑” reverse-ultrafiltration „™â·√ߥ—ππÈ” 15-20 psi „π·μà≈–§√—È߉¡à‡°‘π 15 π“∑’2 ‡æ◊ËÕ„Àâ°“√≈â“ߧ√“∫ ‡≈◊Õ¥∑’Ëμ°§â“߇ªìπ‰ªÕ¬à“ß ¡∫Ÿ√≥å¡“°¢÷Èπ 8. «—¥ TCV ¢Õßμ—«°√Õ߇≈◊Õ¥ ∂â“πâÕ¬°«à“ 80% „Àâ∑‘Èßμ—«°√Õ߇≈◊Õ¥π—Èπ 340

Hemodialysis Procedures: Step by Step 9. μ√«® Õ∫°“√√—Ë«¢Õßμ—«°√Õ߇≈◊Õ¥ (leak test) ¢Õßμ—«°√Õ߇≈◊Õ¥ ∂â“ leak „Àâ∑‘Èßμ—«°√Õß ‡≈◊Õ¥π—Èπ 10. μàÕ “¬ à߇≈◊Õ¥°—∫μ—«°√Õ߇≈◊Õ¥ fill πÈ” RO ¥â“π blood compartment ·≈– “¬·¬°¢Õß  “¬ à߇≈◊Õ¥„Àâ‡μÁ¡‚¥¬‰¡à¡’øÕßÕ“°“» ·≈â« clamp  “¬·¬°¢Õß “¬ à߇≈◊Õ¥∑—ÈßÀ¡¥ 11. º ¡ disinfectant °—∫ 0.9% NSS À√◊ÕπÈ” RO „Àâ¡’ª√‘¡“μ√ 1,000 ml ¥—ßπ’È  Ÿμ√§”π«≥π”È ¬“ (C1V1 = C2V2) Conc.¢ÕßπÈ”¬“‡¥¡‘ × ª√¡‘ “μ√¢ÕßπÈ”¬“‡¥¡‘ = Conc.¢ÕßπÈ”¬“„À¡à × ª√¡‘ “μ√¢ÕßπÈ”¬“„À¡à - 4% Formaldehyde: „™â 37% Formaldehyde = 4% × 1,000 = 108 ml 37% - 3% Peracetic acid mixture(PAM): „™â 100% PAM = 3%×1,000 = 30 ml 100% - 4% Peracetic acid mixture(PAM): „™â 100% PAM = 4%×1,000 = 40 ml 100% 12. π” disinfectant ·∑π∑’ËπÈ” RO ª√‘¡“μ√‰¡àπâÕ¬°«à“ 2 ‡∑à“¢Õߪ√‘¡“μ√μ—«°√Õ߇≈◊Õ¥·≈–  “¬ à߇≈◊Õ¥ ‚¥¬‰¡à¡’øÕßÕ“°“»„πμ—«°√Õ߇≈◊Õ¥ ·≈â« clamp ª≈“¬ “¬ à߇≈◊Õ¥Õ’°¥â“πÀπ÷Ëß„Àâ π‘∑ 13. ‡ªî¥ clamp ∑“ß·¬°¥â“π¢â“ß “¬ à߇≈◊Õ¥®“°„°≈≪‰°≈ „Àâ disinfectant ·∑π∑’ËπÈ” RO ∑’≈– “¬ ·≈–π”®ÿ°ªî¥ª≈“¬·≈– clamp  “¬∑“ß·¬°∑’ˉ≈à disinfectant „Àâ π‘∑ 14. Fill ¥â“π dialysate compartment ¥â«¬ disinfectant ®π‡μÁ¡ªî¥®ÿ°„Àâ π‘∑ 15. μ√«® Õ∫∑°ÿ  «à π¢Õßμ«— °√Õ߇≈Õ◊ ¥·≈– “¬ ßà ‡≈Õ◊ ¥´È”Õ°’ §√ß—È «“à º“à π°“√ fill disinfectant Õ¬à“ß ¡∫Ÿ√≥å 16. ‡°Á∫μ—«°√Õ߇≈◊Õ¥„π∑’Ë·Àâß·≈–æâπ· ß·¥¥ ‡¡◊ËÕ®–π”μ—«°√Õ߇≈◊Õ¥‰ª„™â§√—ÈßμàÕ‰ª μâÕß ¥Ÿ√–¬–‡«≈“°“√¶à“‡™◊ÈÕμâÕ߉¡àπâÕ¬°«à“¡“μ√∞“π°”Àπ¥ §◊Õ πÈ”¬“¶à“‡™◊ÈÕ §«“¡‡¢â¡¢âπ Õÿ≥À¿¡Ÿ ‘ √–¬–‡«≈“ Formaldehyde 4% 20°C 24 ™¡. Peracetic acid mixture (PAM) 3-4 % 20°C 11 ™¡. 5.2.2 °“√«¥— ª√‘¡“μ√μ—«°√Õ߇≈◊Õ¥ (Total cell volume measurement) ¥«â ¬«‘∏’ manual «∏‘ ª’ Ø∫‘ μ— ‘ 1. π”μ«— °√Õ߇≈Õ◊ ¥∑≈’Ë “â ß –Õ“¥·≈«â fill πÈ” RO „À‡â μ¡Á ∑ß—È „π blood compartment ·≈– dialysate compartment ‰≈àøÕßÕ“°“»ÕÕ°„ÀâÀ¡¥ 2. ªî¥ cap ∑“ߥâ“π blood compartment ·≈– dialysate compartment 3. μ—Èßμ—«°√Õ߇≈◊Õ¥·π«μ—Èß ‡ªî¥ cap ¢Õß blood compartment «“ß blood port ∑’˪“°°√–∫Õ° μ«ß 341

Practical Dialysis in the Year 2009 4. μàÕ “¬μàÕ≈°Ÿ ¬“ß°—∫ blood port ¥â“π∫π ∫’∫≈Ÿ°∫Õ≈¬“߉≈àπÈ”≈ß„π°√–∫Õ°μ«ß®πÀ¡¥ 5. ¥ªŸ √‘¡“μ√πÈ” ∂â“ TCV < 80 % ¢Õß§à“ TCV μ—«°√Õ߇≈◊Õ¥„À¡à ‰¡à§«√π”¡“„™â´È” 5.2.3 °“√μ√«® Õ∫°“√√«Ë— ¢Õßμ—«°√Õ߇≈◊Õ¥ (leakage testing) ¥â«¬«∏‘ ’ manual «∏‘ ª’ Ø∫‘ μ— ‘ 1. π”μ—«°√Õ߇≈◊Õ¥∑’Ë≈â“ß –Õ“¥·≈â« ‰≈àπÈ”¥â“π blood compartment ·≈– dialysate compartment ÕÕ°®πÀ¡¥ ‡ªî¥ dialysate port ∑—Èß 2 ¥â“π 2. μàÕ “¬ pressure gauge ‡¢â“°—∫ blood port ¥â“π„¥¥â“πÀπ÷Ëß·≈–μàÕ “¬∑’Ë¡’≈Ÿ°∫Õ≈¬“ß ‡¢â“°—∫ blood port Õ’°¥â“πÀπ÷Ëß (√–«—ߢâÕμàÕ “¬À≈«¡∑”„Àâ¡’°“√√—Ë«¢ÕßÕ“°“») 3. ∫’∫≈Ÿ°∫Õ≈¬“ß„Àâ pressure §â“߉«â∑’Ë 250 mmHg „™â arterial clamps Àπ’∫ “¬μàÕ≈Ÿ°∫Õ≈ ¬“ß„Àâ π‘∑ ®—∫‡«≈“ 1 π“∑’ pressure §«√À¬ÿ¥π‘Ëߧß∑’Ë À“° pressure ≈¥≈ß¡“°°«à“ 10 mmHg · ¥ß«à“ ¡’°“√√—Ë«¢Õßμ—«°√Õ߇≈◊Õ¥ 4. °√≥’ pressure ≈¥≈ß¡“° §«√¡’°“√μ√«® Õ∫´È” 2-3 §√—Èß À“°≈¥≈ß∑ÿ°§√—Èß· ¥ß«à“μ—« °√Õ߇≈◊Õ¥√—Ë«®√‘ß 5.2.4 °“√π”μ—«°√Õ߇≈◊Õ¥°≈—∫¡“„™â´È”¥â«¬‡§√Ë◊Õß≈â“ßμ—«°√Õ߇≈◊Õ¥Õ—μ‚π¡—μ‘ (Automated reprocessing system) - ‡§√◊ËÕß≈â“ßμ—«°√Õ߇≈◊Õ¥·μà≈–¬’ËÀâÕ®– reuse ‡©æ“–μ—«°√Õ߇≈◊Õ¥ °√≥’∑’Ë¡’°“√π” “¬ àß ‡≈◊Õ¥°≈—∫¡“„™â´È”μâÕß reuse  “¬ à߇≈◊Õ¥¥â«¬«‘∏’ manual - ‡§√Õ◊Ë ß≈“â ßμ«— °√Õ߇≈Õ◊ ¥Õμ— ‚π¡μ— μ‘ Õâ ß¡°’ “√‡∑¬’ ∫«¥— ª√¡‘ “μ√¢Õß™¥ÿ ∑¥ Õ∫∑°ÿ «π— °Õà π°“√ „™âß“π À“°‰¥âº≈º‘¥æ≈“¥¡“°°«à“ ± 3 „Àâ∑”∑¥ Õ∫´È”ª√–¡“≥ 3 §√—Èß À“°‰¥âº≈º‘¥æ≈“¥∑ÿ°§√—Èß„Àâ μ“¡™à“ß¡“·°â‰¢ ‡æ√“–°“√«—¥§à“ TCV ¢Õßμ—«°√Õ߇≈◊Õ¥‰¡àμ√ߧ«“¡®√‘ß - ‡§√◊ËÕß≈â“ßμ—«°√Õ߇≈◊Õ¥Õ—μ‚π¡—μ‘®–¡’°“√≈â“ß ≈—∫‰ª¡“∑—Èߥâ“π blood compartment ·≈– dialysate compartment ¡’°“√«—¥ TCV ¡’°“√μ√«® Õ∫ leak test ·≈– fill disinfectant À“° leak test ‰¡à ºà“𠇧√◊ËÕß®–‰¡à„Àâºà“π‡¢â“ Ÿà¢—ÈπμÕπ fill disinfectant «∏‘ ª’ Ø∫‘ —μ‘ (μ—«Õ¬à“ß) °“√„™â‡§√◊ËÕß≈â“ßμ—«°√Õ߇≈◊Õ¥Õ—μ‚π¡—μ‘ Renatron ·≈– reuse  “¬ à߇≈◊Õ¥ ´÷Ëß„™â Peracetic acid mixture (PAM) ‡ªìπ disinfectant ¥—ßπ’È 1. ‡ªî¥∑“ßπÈ” RO ‡¢â“‡§√◊ËÕß≈â“ßμ—«°√Õ߇≈◊Õ¥Õ—μ‚π¡—μ‘ ‡ªî¥ switch ‡§√◊ËÕß 2. ∑¥ Õ∫ª√‘¡“μ√ cell volume °àÕπ„™âß“π ª√‘¡“μ√ cell volume Õ¬àŸ„π™à«ß ± 3 3. 欓∫“≈º°Ÿ mask  «¡À¡«°  «¡·«πà μ“°π— ‡≈Õ◊ ¥°√–‡¥πÁ „ ºà “â °π— ‡ªÕôó π·≈– «¡∂ßÿ ¡Õ◊ 4. π”μ—«°√Õ߇≈◊Õ¥·≈– “¬ à߇≈◊Õ¥À≈—ß°“√„™âß“π°—∫ºâŸªÉ«¬ „ à¿“™π–√Õß√—∫¡“∑’ËÕà“ß≈â“ß 5. μ√«® Õ∫μ«— °√Õ߇≈Õ◊ ¥«“à ¡‚’ §√ß √“â ߪ°μ‰‘ ¡·à μ°√«Ë— ®°ÿ μ“à ßÊ Õ¬μàŸ “¡μ”·Àπßà ª°μ‘ ¡™’ ÕË◊ ºŸâªÉ«¬‡¢’¬π‰«â∂Ÿ°μâÕß ™—¥‡®π 342

Hemodialysis Procedures: Step by Step 6. ≈â“ߧ√“∫‡≈◊Õ¥¥â“π blood compartment ‚¥¬μàÕª≈“¬ “¬ à߇≈◊Õ¥¥â“πÀπ÷Ëß°—∫πÈ” RO ª≈“¬Õ’°¥â“πμàÕ≈ß∑àÕπÈ”∑‘Èß (ªî¥ clamp ∑“ß·¬° “¬ à߇≈◊Õ¥¥â“π¢â“ß·≈–‡ªî¥ clamp ∑“ßμ√߇æ◊ËÕ‰¡à„Àâ ‡≈◊Õ¥°√–®“¬„πÕà“ß≈â“ß) 7. ª≈¥μ—«°√Õ߇≈◊Õ¥ÕÕ°®“° “¬ à߇≈◊Õ¥ π”μ—«°√Õ߇≈◊Õ¥„ à‡§√◊ËÕß≈â“ßμ—«°√Õ߇≈◊Õ¥ Õ—μ‚π¡—μ‘ „ à§à“ 80% TCV μ“¡™π‘¥μ—«°√Õ߇≈◊Õ¥ (§à“ TCV ∑’Ë 80% ¢Õߪ√‘¡“μ√μ—«°√Õ߇≈◊Õ¥„À¡à) - ‡≈◊Õ° çCHé  ”À√—∫ conventional ·≈– low flux dialyzer („™â‡«≈“≈â“ß 8-10 π“∑’) - ‡≈◊Õ° çHFé  ”À√—∫ High flux dialyzer („™â‡«≈“≈â“ß 10-12 π“∑’) 8. μ√«®§à“∑’ˇ§√◊ËÕß«—¥‰¥â ∂â“ TCV <80% ‡§√◊ËÕß®–√âÕ߇μ◊Õπ· ¥ß volume fail „Àâ∑‘Èßμ—«°√Õß ‡≈◊Õ¥π—Èπ (‰¡àπ”°≈—∫¡“„™â´È”Õ’°) ∂Ⓣ¥â§à“ TCV >80% ‡§√◊ËÕß®–∑”¢—ÈπμÕπμ√«® Õ∫ leak test μàÕ‰ª 9. °√≥’μ—«°√Õ߇≈◊Õ¥√—Ë«´÷¡ ‡§√◊ËÕß®–√âÕ߇μ◊Õπ· ¥ß pressure fail ·≈–®–‰¡à∑”μàÕ¢—ÈπμÕπ disinfectant „Àâ∑‘Èßμ—«°√Õ߇≈◊Õ¥π—Èπ 10. À“°ºà“π¢—ÈπμÕπ 8 ·≈– 9 ‡§√◊ËÕß®–‡¢â“¢—ÈπμÕπ disinfection ‡¡◊ËÕ®∫¢—ÈπμÕπ®–√âÕ߇μ◊Õπ · ¥ß process complete 11. π”μ«— °√Õ߇≈Õ◊ ¥∑≈’Ë “â ߶“à ‡™Õ◊È ·≈«â ÕÕ°®“°‡§√Õ◊Ë ß≈“â ߪ¥î ®°ÿ  «à π blood compartment ·≈– dialysate compartment „Àâ·πàπ 12. ∑”§«“¡ –Õ“¥ “¬ ßà ‡≈Õ◊ ¥¥«â ¬«∏‘ ’ manual (°√≥ ’ “¬ ßà ‡≈Õ◊ ¥„™´â È”) ·≈– fill  “¬ ßà ‡≈Õ◊ ¥ ¥â«¬ 3% PAM ∑—Èß∑“ßμ√ß·≈–∑“ß·¬° “¬ à߇≈◊Õ¥ clamp ·≈–ªî¥®ÿ°ª≈“¬ “¬„Àâ·πàπ·≈–𔉪μàÕ°—∫ μ«— °√Õ߇≈Õ◊ ¥∑¶’Ë “à ‡™Õ◊È ‡√¬’ ∫√Õâ ¬·≈«â **°√≥‰’ ¡μà Õà  “¬ ßà ‡≈Õ◊ ¥°∫—  “¬ ßà ‡≈Õ◊ ¥μÕâ ߇¢¬’ π™Õ◊Ë - °≈ÿ ∑’Ë  “¬ ßà ‡≈◊Õ¥∑ÿ°§√—Èß ·≈–‡°Á∫μ—«°√Õ߇≈◊Õ¥·≈– “¬ à߇≈◊Õ¥√«¡°—π‰¡à§«√·¬°‡°Á∫ 13. ‡°Á∫ dialyzer ·≈– blood line ∑’˺à“π¢∫«π°“√π”°≈—∫¡“„™â´È” „π∑’ˇ°Á∫‡©æ“–¢ÕߺŸâªÉ«¬ ·≈–æâπ· ß·¥¥ 5.2.5 °“√∑”§«“¡ –Õ“¥·≈–¶à“‡™◊ÈÕ‡§√ËÕ◊ ߉μ‡∑¬’ ¡ 1.  “√≈–≈“¬∑’Ë„™â°”®—¥§√“∫‰¢¡—π·≈–‚ª√μ’π®“°μ—«°√Õ߇≈◊Õ¥¢ÕߺŸâªÉ«¬ (cleaning) - 5% sodium hypochlorite (¡’§ÿ≥ ¡∫—μ‘ cleaning + disinfection ∑’ËÕÿ≥À¿¡Ÿ ‘ 37°c) ·μà‰¡à §«√§â“ßπÈ”¬“‰«â„π‡§√◊ËÕß ‡æ√“–πÈ”¬“®–°—¥°√àÕπÕÿª°√≥å ·≈–∑”„Àâ O-ring ‡ ◊ËÕ¡ ¿“æ ‚¥¬∂â“Õÿ≥À¿¡Ÿ ‘ > 37°c ®–‡°‘¥°ä“´æ‘…‰¥â 2.  “√≈–≈“¬∑’Ë„™â„π°“√°”®—¥μ–°√—π·§≈‡´’¬¡®“° dialysate concentrate (decalcification) - 5-10% acetic acid - 10-30% citric acid - °≈ÿà¡ “√≈–≈“¬∑’Ë¡’ à«πª√–°Õ∫¢Õß peracetic acid mixture 3.  “√≈–≈“¬∑’Ë„™â„π°“√¶à“‡™◊ÈÕ‚√§„π‡§√◊ËÕ߉μ‡∑’¬¡ (disinfection) - 5% sodium hypochlorite - 37% formaldehyde - °≈ÿà¡¢Õß “√≈–≈“¬∑’Ë¡’ à«πª√–°Õ∫¢Õß hydrogen peroxide 343

Practical Dialysis in the Year 2009 «∏‘ ª’ Ø∫‘ μ— ‘ 1. ¿“¬πÕ°‡§√Õ◊Ë ß‰μ‡∑¬’ ¡∑”§«“¡ –Õ“¥‚¥¬‡™¥Á §√“∫ °ª√°·≈–ΩπÿÉ ≈–ÕÕߥ«â ¬ detergent À√◊Õ detergent germicide ∑ÿ°§√—ÈßÀ≈—߇ √Á® ‘Èπ°“√„™âß“π°—∫ºŸâªÉ«¬·μà≈–√“¬ 2. √–∫∫¿“¬„π‡§√◊ËÕß ∑”°“√ decalcification ·≈– disinfection μ“¡«‘∏’°“√¢Õ߇§√◊ËÕß·μà≈– ™π‘¥·≈–·μà≈–√ÿàπ ´÷Ëß¡’∑—Èß°“√„™â√–∫∫ manual ·≈– disinfection program ‚¥¬¬÷¥À≈—°ªØ‘∫—μ‘ ¥—ßπ’È - ∑”°“√¢®—¥§√“∫‰¢¡—π Õ¬à“ßπâÕ¬ —ª¥“Àå≈– 1 §√—Èß - ∑”°“√ decalcification ∑ÿ°§√—ÈßÀ≈—ß„™âß“π„π·μà≈–«—π - §«√∑”°“√ disinfection ∑ÿ°§√—ÈßÀ≈—߇ √Á® ‘Èπ°“√„™âß“π°—∫ºŸâªÉ«¬„π·μà≈–√“¬ - ‡§√◊ËÕß∑’˺à“π chemical disinfection „Àâ rinse ‡§√◊ËÕß ‡æ◊ËÕ≈â“ß disinfectant ÕÕ°®“°‡§√◊ËÕß °àÕπ°“√„™âß“π°—∫ºŸâªÉ«¬∑ÿ°§√—Èß 3. ®¥— ∑”μ“√“ß°“√¥·Ÿ ≈‡§√Õ◊Ë ß·μ≈à –‡§√Õ◊Ë ß „À§â √Õ∫§≈¡ÿ ∑°ÿ Ê ‡§√Õ◊Ë ß‚¥¬¬¥÷ À≈°— °“√μ“¡¢Õâ 2 4. °“√‡≈◊Õ°„™â disinfectant μâÕߧ”π÷ß∂÷ߧÿ≥ ¡∫—μ‘¢Õß disinfectant ‡À≈à“π—Èπ ·≈– °“√∑’Ë®– ∑”„Àâ disinfectant ‰¥ªâ √– ∑‘ ∏¿‘ “æ ßŸ  ¥ÿ §«√殑 “√≥“ «à πª√–°Õ∫Õπ◊Ë √«à ¡¥«â ¬ ‚¥¬®–μÕâ ß¡ª’ √¡‘ “≥·≈– §«“¡‡¢â¡¢âπ∑’ˇÀ¡“– ¡ ¡’Õÿ≥À¿Ÿ¡‘·≈–√–¬–‡«≈“∑’Ë∂°Ÿ μâÕß ·≈–μâÕߪ√–°Õ∫°—∫π‚¬∫“¬‚√ß欓∫“≈ ¥â«¬ 6. ªí®®—¬‡ ’¬Ë ßμÕà °“√μ‘¥‡™ÕÈ◊ „πÀπ૬‰μ‡∑¬’ ¡ 1. °“√ªØ‘∫—μ‘ß“πμâÕß —¡º— °—∫‡≈◊Õ¥·≈– “√§—¥À≈—ËߢÕߺ⟪ɫ¬‚¥¬μ√ß 2. ≈—°…≥–ºâŸªÉ«¬∑’Ë¡“√—∫∫√‘°“√‡ªìπºâŸªÉ«¬‚√§‡√◊ÈÕ√—ß´÷ËßÕ“®¡’ºŸâªÉ«¬μ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫ ∫’(HBV) À√◊Õ‰«√— μ—∫Õ—°‡ ∫´’ (HCV) ∑’Ë√—∫°“√√—°…“¥â«¬°“√øÕ°‡≈◊Õ¥‡ªìπª√–®” —ª¥“Àå≈– 2-3 §√—Èß 3. ¡’°“√ªØ‘∫—μ‘ß“π∑’ˇ°’ˬ«¢âÕß°—∫°“√„ àÕÿª°√≥åÀ√◊Õ°“√·∑߇¢Á¡‡¢â“‡ âπ‡≈◊Õ¥ºŸâªÉ«¬ √«¡∂÷ß °“√π”Õÿª°√≥å∑’Ë —¡º— ‡≈◊Õ¥À√◊Õ “√§—¥À≈—ËߢÕߺŸâªÉ«¬‰ª„™â´È”À√◊Õ°“√°”®—¥‡™◊ÈÕ‚√§°àÕπ°“√∑‘Èß 4. ¡’°“√ªØ‘∫—μ‘ß“π∑’ˇ°’ˬ«°—∫√–∫∫∫”∫—¥πÈ” √–∫∫º≈‘μπÈ”∫√‘ ÿ∑∏‘Ï √–∫∫∑àÕπÈ”μà“ßÊ ‡§√◊ËÕß ‰μ‡∑’¬¡ Õÿª°√≥å·≈–‡«™¿—≥±åμà“ßÊ ´÷ËßÕ“®‡ªìπ·À≈àߢÕß°“√ – ¡‡™◊ÈÕ‚√§ °“√ªÕÑ ß°π— ·≈–°“√§«∫§ÿ¡°“√쥑 ‡™È◊Õ„πÀπ૬‰μ‡∑’¬¡ 1. ªØ∫‘ μ— μ‘ “¡·π«∑“ß ”À√∫— °“√‡μ√¬’ ¡π”È ∫√ ‘ ∑ÿ ∏‡å æÕË◊ °“√øÕ°‡≈Õ◊ ¥¥«â ¬‡§√ÕË◊ ߉μ‡∑¬’ ¡¢Õß  ¡“§¡‚√§‰μ·Ààߪ√–‡∑»‰∑¬ 2. ‡§√◊ËÕ߉μ‡∑’¬¡ - ‡™Á¥¿“¬πÕ°‡§√◊ËÕß (surface machine) ¥â«¬ detergent À√◊Õ detergent germicide - À“°¡’°“√ªπ‡ªóôÕπ¿“¬πÕ°‡§√◊ËÕß (blood spills, visible blood, body fluid) „À⇙Á¥¥â«¬ 0.5-1% sodium hypochlorite ·≈–‡™Á¥¥â«¬πÈ” –Õ“¥Õ’°§√—Èß À√◊ժؑ∫—μ‘μ“¡¡“μ√∞“π°“√μ‘¥‡™◊ÈÕ¢Õß‚√ß æ¬“∫“≈ 344

Hemodialysis Procedures: Step by Step - ¶“à ‡™ÕÈ◊ ¿“¬„π‡§√ÕË◊ ß (internal pathway) À≈ß— „™ßâ “π°∫— ºªŸâ «É ¬∑°ÿ √“¬ μ“¡·π«∑“ߪÆ∫‘ μ— ‘ ·≈–μ“¡≈—°…≥–¢Õ߇§√◊ËÕ߉μ‡∑’¬¡·μà≈–™π‘¥ - ‰¡à§«√«“ßÕÿª°√≥å∑’ˇ°’ˬ«¢âÕß°—∫°“√ —¡º— ‡≈◊Õ¥À√◊Õ “√§—¥À≈—Ëß®“°ºŸâªÉ«¬ ‡™àπ AVF needle, syringe, ¢«¥‡°Á∫μ—«Õ¬à“߇≈◊Õ¥ ∑’ˇ§√◊ËÕ߉μ‡∑’¬¡ (top of machine) ´÷Ë߇ªìπ®ÿ¥ ”§—≠·ÀàßÀπ÷ËߢÕß °“√·æ√à°√–®“¬‡™◊ÈÕ - ‡¡Õ◊Ë ∑”°“√¶“à ‡™Õ◊È „π√–∫∫πÈ”∑ß—È À¡¥ (disinfection in line) „À∑â ”°“√¶“à ‡™Õ◊È ‡§√Õ◊Ë ß‰μ ‡∑¬’ ¡ ∑°ÿ ‡§√ÕË◊ ߉ªæ√Õâ ¡°∫— °“√¶“à ‡™ÕÈ◊ √–∫∫π”È ‚¥¬‡ª¥î ‡§√ÕË◊ ߉μ‡∑¬’ ¡„π¢πÈ— μÕπ rinse ‡æÕË◊ „Àâ disinfectant º“à π ‡¢â“‡§√◊ËÕß„π à«πμàÕ¢Õß valve πÈ”®“°∑àÕ àßπÈ”‰ª¬—߇§√◊ËÕ߉μ‡∑’¬¡ ´÷Ëß°“√¶à“‡™◊ÈÕ∑’˪ؑ∫—쑪√–®”«—π disinfectant ®–‰¡àºà“𠓬∑“ßπÈ”‡¢â“‡§√◊ËÕ߉μ‡∑’¬¡„π®ÿ¥π’È - ‡°∫Á μ«— Õ¬“à ßπ”È ∑ºË’ “à π‡¢“â ¿“¬„π‡§√ÕË◊ ߉μ‡∑¬’ ¡ (internal pathway) ‡æÕË◊  ßà μ√«®‡æ“–‡™ÕÈ◊ ‡ªìπª√–®”∑ÿ°‡¥◊Õπ ‡æ◊ËÕ‡ΩÑ“√–«—ß°“√ªπ‡ªóôÕπ‡™◊ÈÕ¿“¬„π‡§√◊ËÕ߉μ‡∑’¬¡ ë „™â tryptic soy agar ‡ªìπ media  ”À√—∫°“√‡æ“–‡™◊ÈÕ ë „ππÈ” RO §«√μ√«®æ∫‡™◊ÈÕ·∫§∑’‡√’¬ < 200 cfu/ml ë „π dialysate §«√μ√«®æ∫‡™◊ÈÕ·∫§∑’‡√’¬ < 2000 cfu/ml - §«√∑”°“√‡ª≈’ˬπ filter ª√–®”‡§√◊ËÕßμ“¡Õ“¬ÿ°“√„™âß“π 3. Õÿª°√≥å·≈–‡«™¿—≥±åμà“ßÊ -  ‘Ëß∑’˪π‡ªóôÕπ‡≈◊Õ¥À√◊Õ “√§—¥À≈—Ëßμà“ßÊ ®—¥‡ªìπª√–‡¿∑¢¬–μ‘¥‡¢◊ÈÕ - Õÿª°√≥å·≈–‡«™¿—≥±å∑’Ëπ”°≈—∫¡“„™â´È” „ÀâªØ‘∫—μ‘μ“¡¢—ÈπμÕπ°“√∑”≈“¬‡™◊ÈÕ·≈–°“√ ∑”„Àâª√“»®“°‡™◊ÈÕ∑’Ë∂°Ÿ μâÕß - °Õà πª≈¥μ«— °√Õ߇≈Õ◊ ¥·≈– “¬ ßà ‡≈Õ◊ ¥®“°‡§√Õ◊Ë ß‰μ‡∑¬’ ¡À≈ß— „™°â ∫— ºªŸâ «É ¬μÕâ ßμ√«® Õ∫ °“√ªî¥ π‘∑¢ÕߢâÕμàÕ·≈– clamps μà“ßÊ ªÑÕß°—π°“√À°ªπ‡ªóôÕπ æ√âÕ¡∑—Èß„™â¿“™π–√Õß√—∫¢≥–‡§≈◊ËÕπ ¬â“¬ - μ—«°√Õ߇≈◊Õ¥∑’Ë„™â°—∫ºâŸªÉ«¬ HBV / HCV ¡’¢âÕ§«√æ‘®“√≥“¥—ßπ’È ë No reuse dialyzer ∑’Ë„™â°—∫ºâŸªÉ«¬ HBV ‡ªìπ¢âÕ·π–π”∑’˪ÑÕß°—π cross- transmission ‰¥â¥’∑’Ë ÿ¥ ‡æ◊ËÕÀ≈’°‡≈’ˬߢâÕº‘¥æ≈“¥®“°°“√‰¡àªØ‘∫—μ‘μ“¡ Universal Precautions Õ¬à“߇§√àߧ√—¥ ë HbeAg ¡’º≈‡ªìπ≈∫ (-)  “¡“√∂ reuse dialyzer ‰¥â ë HbeAg ¡’º≈‡ªìπ∫«° (+) ‰¡à§«√ reuse dialyzer ‡æ√“–ºŸâªÉ«¬ HbeAg (+)  “¡“√∂·æ√à ‡™◊ÈÕ‰ª àŸºŸâÕ◊Ëπ‰¥â„πÕ—μ√“ Ÿß ‡æ√“–¡’°“√·∫àßμ—«¢Õß HBV Õ¬à“ß¡“° ë °√≥’ºŸâªÉ«¬ HCV  “¡“√∂ reuse dialyzer ‰¥â ‡æ√“–‡™◊ÈÕ HCV ∑”„À⇰‘¥ cross- transmission ‰¥â¬“°°«à“‡™◊ÈÕ HBV ‡æ√“– “¡“√∂∑”≈“¬ßà“¬·≈–쓬ßà“¬„πÕÿ≥À¿Ÿ¡‘ÀâÕß - §«√·¬°Õ“à ß≈“â ßμ«— °√Õ߇≈Õ◊ ¥„πºªâŸ «É ¬∑‰Ë’ ¡¡à °’ “√쥑 ‡™ÕÈ◊ ÕÕ°®“°ºªâŸ «É ¬∑μË’ ¥‘ ‡™ÕÈ◊ ·≈–‰¡à „™âÕà“ß≈â“ßμ—«°√Õߪ–ªπ°—π√–À«à“ߺŸâªÉ«¬ HBV ·≈– HCV - ∑”§«“¡ –Õ“¥Õà“ß≈â“ßμ—«°√Õ߇≈◊Õ¥ ë „πºâŸªÉ«¬∑’ˉ¡à¡’°“√μ‘¥‡™◊ÈÕ„Àâ∑”°“√¶à“‡™◊Èե⫬ 0.5-1% sodium hypochlorite À≈—ß °“√„™âß“π§√—Èß ÿ¥∑⓬„π·μà≈–√Õ∫¢Õß°“√øÕ°‡≈◊Õ¥ 345

Practical Dialysis in the Year 2009 ë ºŸâªÉ«¬ HBV ·≈– HCV „Àâ∑”°“√¶à“‡™◊Èե⫬ 0.5-1% sodium hypochlorite À≈—ß°“√„™â ß“π∑ÿ°§√—Èß - ∑”§«“¡ –Õ“¥Õÿª°√≥å∑’Ë„™â„π°“√≈â“ßμ—«°√Õ߇≈◊Õ¥·≈– “¬ à߇≈◊Õ¥¥â«¬ 0.5-1% sodium hypochlorite À≈—ß°“√„™âß“π∑ÿ°§√—Èß - §«√„™â external venous ·≈– arterial pressure transducer ‡©æ“–°—∫ºŸâªÉ«¬‡ªìπ√“¬Ê‰ª ·≈–‰¡à§«√π”°≈—∫¡“„™â´È” - √–¡—¥√–«—ß°“√„™â vial ¬“√à«¡°—π√–À«à“ߺŸâªÉ«¬À≈“¬√“¬ ‡™àπ anticoagulant ë ¬÷¥À≈—° Aseptic technique „π°“√‡μ√’¬¡¬“·≈–©’¥¬“ ë §«√®—¥·¬°∫√‘‡«≥ ”À√—∫°“√‡μ√’¬¡¬“©’¥‡ªìπ‡¢μæ◊Èπ∑’Ë –Õ“¥ - À¡—Ëπ∑”§«“¡ –Õ“¥·≈–∑”°“√¶à“‡™◊ÈÕÕÿª°√≥å«—¥§«“¡¥—π‚≈À‘μ ‡™àπ pressure cuff 4. ∫ÿ§≈“°√ºâŸ¥Ÿ·≈ºâŸªÉ«¬ - ¬÷¥À≈—° standard precaution ·≈– basic hand washing Õ¬à“߇§√àߧ√—¥ - ∑”°“√欓∫“≈ºªâŸ «É ¬„À‡â  √®Á  πÈ‘ „πºªŸâ «É ¬·μ≈à –√“¬ ‡æÕË◊ ªÕÑ ß°π— cross-transmission ‚¥¬ ‡©æ“–¢≥–‡√‘Ë¡μâπ- ‘Èπ ÿ¥°“√øÕ°‡≈◊Õ¥ ·≈–¢≥– reuse dialyzer - ≈â“ß¡◊Õ„Àâ –Õ“¥°àÕπ·≈–À≈—ß„Àâ°“√欓∫“≈ºâŸªÉ«¬·μà≈–√“¬ ·≈–≈â“ß¡◊Õ∑ÿ°§√—ÈßÀ≈—ß ∂Õ¥∂ÿß¡◊Õ -  «¡‡§√◊ËÕߪÑÕß°—π√à“ß°“¬¢≥–ªØ‘∫—μ‘ß“π ‰¥â·°à ∂ÿß¡◊Õ, mask, ·«àπμ“·≈–‡ ◊ÈÕ§≈ÿ¡ „Àâ ‡À¡“– ¡°—∫≈—°…≥–ß“π - º°Ÿ mask À“°∫§ÿ ≈“°√¡°’ “√쥑 ‡™ÕÈ◊ ∑“߇¥π‘ À“¬„®À√Õ◊ ¡Õ’ “°“√‰Õ ®“¡ ‡æÕË◊ ªÕÑ ß°π— °“√ ·æ√à°√–®“¬‡™◊ÈÕ∑“ßÕ“°“» - ∫ÿ§≈“°√μâÕ߉¥â√—∫°“√μ√«® HBsAg, AntiHBs, AntiHBc À“°‰¡à¡’¿Ÿ¡‘§ÿâ¡°—πμàÕ‰«√— μ—∫ Õ—°‡ ∫∫’ μâÕ߉¥â√—∫°“√©’¥«—§´’π ·≈–μ‘¥μ“¡º≈À≈—ß°“√©’¥ √«¡∂÷ß°“√©’¥°√–μÿâπμ“¡°”À𥇫≈“ - ∫§ÿ ≈“°√§«√‰¥√â ∫— °“√Õ∫√¡‡æÕË◊ „À‰â ¥√â ∫— §«“¡√‡Ÿâ °¬Ë’ «°∫— °“√ªÕÑ ß°π— °“√쥑 ‡™ÕÈ◊ ·≈–§«√ ¡’ μ«— ·∑π¢ÕßÀπ«à ¬ß“π∑”Àπ“â ∑‡Ë’ °¬Ë’ «°∫— Infection control ‰¥·â °à Infection Control Nurse (ICN), Infection Control Ward Nurse (ICWN) 5. ºâŸªÉ«¬∑’Ë¡“√—∫°“√øÕ°‡≈◊Õ¥ - ·π–π”·≈–Ωñ°°“√≈â“ß¡◊Õ„Àâ°—∫ºâŸªÉ«¬∑ÿ°√“¬∑’Ë¡’ permanent vascular access - §«√·¬°ºâŸªÉ«¬ HBV ·≈– HCV ‚¥¬®—¥·¬°‡§√◊ËÕ߉μ‡∑’¬¡ ®—¥·¬° ∂“π∑’ËÀ√◊Õ¡ÿ¡ÀâÕß ®—¥·¬°Õÿª°√≥å∑“ß°“√·æ∑¬å ®—¥·¬°¿“™π–À√◊Õ‡§√◊ËÕß„™â à«πμ—«¢ÕߺŸâªÉ«¬ ·≈–§«√®—¥„À⺟âªÉ«¬Õ¬àŸ„π √Õ∫ ÿ¥∑⓬¢Õß°“√øÕ°‡≈◊Õ¥ - ºŸâªÉ«¬§«√‰¥â√—∫°“√μ√«® viral study ∑ÿ°Ê 3-6 ‡¥◊Õπ ·≈– LFT ∑ÿ°‡¥◊Õπ - ºªâŸ «É ¬∑‰’Ë ¡¡à ¿’ ¡Ÿ §‘ ¡ÿâ °π— μÕà ‰«√ — μ∫— Õ°— ‡ ∫∫§’ «√‰¥√â ∫— °“√©¥’ «§— §π’ ·≈–쥑 μ“¡º≈À≈ß— °“√ ©’¥ √«¡∂÷ß°“√©’¥°√–μÿâπμ“¡°”À𥇫≈“ - ºâŸªÉ«¬∑’Ë¡’°“√μ‘¥‡™◊ÈÕ∑“߇¥‘πÀ“¬„® ¡’Õ“°“√‰Õ ®“¡ §«√·π–π”„À⺟âªÉ«¬º°Ÿ mask ‡æ◊ËÕ ªÑÕß°—π°“√·æ√à‡™◊ÈÕ∑“ßÕ“°“» 346

Hemodialysis Procedures: Step by Step 6. Vascular access 6.1 Temporary vascular access (double lumen catheter) - „™âÀ≈—° sterile technique „π∑ÿ°¢—ÈπμÕπ°“√ªØ‘∫—μ‘ß“π°—∫ºŸâªÉ«¬ - º°Ÿ mask ∑—ÈߺŸâªÉ«¬·≈–∫ÿ§≈“°√ ¢≥–ªØ‘∫—μ‘ß“π‡°’Ë¬«°—∫ catheter √–«—ß°“√º°Ÿ mask ºŸâ ªÉ«¬ ·≈â«¡’≈¡¥—πÕÕ°¥â“π≈à“ßμ√ß°—∫μ”·Àπàß exit site æÕ¥’ ®–∑”„À⇪ìπ°“√∫—ߧ—∫≈¡À“¬„®„Àâ≈ß¡“ μ√ß·º≈æÕ¥’ -  —߇°μ·≈–ª√–‡¡‘π°“√μ‘¥‡™◊ÈÕ¢Õß exit site ∑ÿ°§√—Èß°àÕπøÕ°‡≈◊Õ¥ - „À§â ”·π–π”ºªâŸ «É ¬‡°¬’Ë «°∫— °“√¥·Ÿ ≈·º≈À≈°’ ‡≈¬’Ë ß·º≈‡ª¬ï °πÈ”‚¥¬¢≥–∑”§«“¡ –Õ“¥ √“à ß°“¬  √–º¡„À„â ™ºâ “â ª¥î ∫√‡‘ «≥ catheter‡æÕ◊Ë ªÕÑ ß°π— Õ°’ ™π—È Àπß÷Ë À≈°’ ‡≈¬’Ë ß°®‘ °√√¡°≈“ß·®ßâ À√Õ◊ °®‘ °√√¡ ∑’Ë¡’‡Àß◊ËÕÕÕ°¡“° À“°√Ÿâ ÷°‡®Á∫·≈–§—π·º≈¡“°¢÷ÈπμâÕß·®âß欓∫“≈‰μ‡∑’¬¡∑√“∫¥â«¬ °“√À—πÀπⓉª μ√ߢⓡ‡¡◊ËÕ¡’°“√Õ“‡®’¬π ·≈–°“√æ∫·æ∑¬å‡¡◊ËÕ¡’°“√μ‘¥‡™◊ÈÕ - ∑”·º≈∫√‡‘ «≥ catheter ∑°ÿ §√ß—È ∑∑’Ë ”°“√øÕ°‡≈Õ◊ ¥·≈–‡¡Õ◊Ë ¡·’ º≈‡ª¬ï °‚¥¬μÕâ ߪØ∫‘ μ— ‚‘ ¥¬ 欓∫“≈∑’ˉ¥â√—∫°“√Õ∫√¡ 6.2 Permanent vascular access ª√–‡¿∑ AVF ·≈– AVG - „™âÀ≈—° aseptic technique „π°“√·∑߇¢Á¡ ·≈–„™â 70% alcohol ·≈–/À√◊Õ 10% povidone iodine ‡ªìπ antiseptic -  —߇°μ·≈–ª√–‡¡‘π°“√μ‘¥‡™◊ÈÕ¢Õß access ∑ÿ°§√—Èß°àÕπøÕ°‡≈◊Õ¥ - ·π–π”ºâŸªÉ«¬≈â“ß·¢π∫√‘‡«≥ vascular access ¥â«¬ detergent À√◊Õ hibiscrub „Àâ –Õ“¥ °àÕπ°“√·∑߇¢Á¡ -  «¡∂ßÿ ¡Õ◊ ∑°ÿ §√ß—È °Õà π„À°â “√欓∫“≈∑¡’Ë ‚’ Õ°“ ‡ ¬’Ë ßμÕà °“√ ¡— º — ‡≈Õ◊ ¥À√Õ◊  “√§¥— À≈ß—Ë ®“°ºŸâªÉ«¬ - „™â sterile gauze °¥·º≈À≈—ß°“√ª≈¥‡¢Á¡ - „™â sterile gauze μ—¥À√◊Õæ—∫‡ªìπ™‘Èπ‡≈Á° À√◊Õæ≈“ ‡μÕ√åª≈Õ¥‡™◊ÈÕ ”À√—∫ªî¥·º≈ ªî¥ ∫√‘‡«≥∑’Ë·∑߇¢Á¡°àÕπªî¥∑—∫¥â«¬æ≈“ ‡μÕ√å ‡æ◊ËÕªÑÕß°—π°“√μ‘¥‡™◊ÈÕ®“°∫√‘‡«≥º‘«Àπ—߇¢â“ àŸ°√–· ‚≈À‘μ 7.  ‘Ëß·«¥≈âÕ¡·≈– ∂“π∑’Ë - §«√®—¥‡§√◊ËÕ߉μ‡∑’¬¡·≈–‡μ’¬ßºâŸªÉ«¬„Àâ¡’√–¬–Àà“ß·μà≈–√“¬‰¡àπâÕ¬°«à“ 4 øÿμ ‡æ◊ËÕ ªÑÕß°—π cross-contamination ·≈– –¥«°μàÕ°“√∑”§«“¡ –Õ“¥ - ∑”§«“¡ –Õ“¥æ◊Èπ∫√‘‡«≥øÕ°‡≈◊Õ¥∑ÿ°§√—ÈßÀ≈—߇ √Á® ‘Èπ°“√øÕ°‡≈◊Õ¥‚¥¬∑”§«“¡  –Õ“¥ à«π∑’ˉ¡àμ‘¥‡™◊ÈÕ°àÕπ ·≈–·¬°‰¡â∂æŸ ◊Èπ ”À√—∫‡μ’¬ß∑’Ë¡’°“√μ‘¥‡™◊ÈÕ - ·¬°ºâ“ ”À√—∫∑”§«“¡ –Õ“¥‡μ’¬ßÀ√◊Õ‡°â“ՒȺŸâªÉ«¬À≈—ß°“√øÕ°‡≈◊Õ¥ºŸâªÉ«¬∑ÿ°√“¬ - ∑”§«“¡ –Õ“¥æπ◊È º«‘ ‚¥¬∑«—Ë ‰ª¢ÕßÀÕâ ß∑¡’Ë °’ “√ ¡— º — ¥«â ¬¡Õ◊ ∫Õà ¬§√ß—È ¥«â ¬detergent ‡™πà ≈°Ÿ ∫‘¥ª√–μŸ ‡§“πå‡μÕ√å∑”ß“π °äÕ°πÈ” ∑’Ë®—∫ ”À√—∫‡ªî¥-ªî¥¢Õßμ⟇¬Á𠇪ìπμâπ - „™â 0.5-1% sodium hypochlorite ∑”§«“¡ –Õ“¥æ◊Èπ ‡μ’¬ß ‡°â“Õ’È ∑—π∑’‡¡◊ËÕ¡’‡≈◊Õ¥ªπ ‡ªóôÕπ - ®—¥·¬°Õà“ß≈â“ß¡◊Õ ”À√—∫ºâŸªÉ«¬ Õà“ß≈â“ßÕÿª°√≥å·≈–‡«™¿—≥±å 347

Practical Dialysis in the Year 2009 - ®¥— ·¬°∫√‡‘ «≥ÀÕâ ßμ“à ßÊ ‡ªπì  ¥—  «à 𠉥·â °à ÀÕâ ߺ≈μ‘ πÈ”°√Õß∫√ ‘ ∑ÿ ∏‘Ï ÀÕâ ßøÕ°‡≈Õ◊ ¥ ÀÕâ ß ≈â“ßμ—«°√Õ߇≈◊Õ¥·≈–Õÿª°√≥åμà“ßÊ ÀâÕßπÈ” ÀâÕß√—∫ª√–∑“πÕ“À“√ ‡ªìπμâπ - ¡’√–∫∫√–∫“¬Õ“°“»„ÀâÕ“°“»∂à“¬‡∑‰¥â¥’ 8. °“√°”®—¥¢¬–·≈– ‘Ëߪؑ°Ÿ≈ - ¡°’ “√·¬°ª√–‡¿∑¢¬–Õ¬“à ß∂°Ÿ μÕâ ß ‚¥¬Õªÿ °√≥·å ≈– ßË‘ ¢Õß∑ªË’ π‡ªÕôó π‡≈Õ◊ ¥À√Õ◊  “√§¥— À≈—ËߢÕߺŸâªÉ«¬ „Àâ®—¥‡ªìπª√–‡¿∑¢¬–μ‘¥‡™◊ÈÕ - ®—¥À“¿“™π–√Õß√—∫¢Õß¡’§¡ ‡™àπ ‡¢Á¡, blade, hematocrit tube ·≈–¡’§ÿ≥ ¡∫—μ‘·¢Áß ·√ß ‰¡à·μ°∑–≈ÿßà“¬·≈–¡’Ω“ªî¥¡‘¥™‘¥ - ∫ÿ§≈“°√§«√‰¥â√—∫§«“¡√Ÿâ‡√◊ËÕß°“√°”®—¥·≈–·¬°ª√–‡¿∑¢Õߢ¬–Õ¬à“ß∂Ÿ°μâÕß ¢Õâ ‡ πÕ·π– Àπ૬‰μ‡∑’¬¡·μà≈–·Ààߧ«√¡’°“√μ‘¥μ“¡ ‡ΩÑ“√–«—ß·≈–§âπÀ“ “‡Àμÿ¢Õß°“√μ‘¥‡™◊ÈÕ ‚¥¬®—¥ ∑” ∂‘쑇°’ˬ«°—∫°“√μ‘¥‡™◊ÈÕμà“ßÊ ·≈–§«√¡’°“√ª√—∫ª√ÿߢâÕ¡Ÿ≈‡°’ˬ«°—∫°“√‡ΩÑ“√–«—ß·≈–°“√ªÑÕß°—π°“√ μ‘¥‡™◊ÈÕ„À⇪ìπªí®®ÿ∫—πÕ¬Ÿà‡ ¡Õ ‡™àπ ë ·¬°ª√–‡¿∑°“√μ‘¥‡™◊ÈÕ¢ÕߺŸâªÉ«¬·≈–™π‘¥¢Õ߇™◊ÈÕ ë °“√‡°‘¥ cross-infection √–À«à“ߺ⟪ɫ¬„πÀπà«¬ß“π‡¥’¬«°—π ë °“√μ‘¥‡™◊ÈÕ¢Õß vascular access ë °“√μ‘¥‡™◊ÈÕ¢Õß√–∫∫πÈ” ·≈–πÈ”¬“ dialysate 7. ·π«∑“ß°“√„À â ¢ÿ »°÷ …“ºâŸª«É ¬∑ˉ’ ¥â√—∫°“√øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑¬’ ¡ À—«¢âÕ°“√„Àâ ÿ¢»÷°…“ 1. °“√„À⧫“¡√⟇√◊ËÕß‰μ«“¬‡√◊ÈÕ√—ß√–¬– ÿ¥∑⓬ Õ“°“√ °“√√—°…“·≈–°“√∫”∫—¥∑¥·∑π‰μ 2. °“√¥·Ÿ ≈À≈Õ¥π”‡≈◊Õ¥ (vascular access) 3. °“√ªØ‘∫—μ‘μ—«¢Õߺ⟪ɫ¬°àÕπ-¢≥–-À≈—ß°“√øÕ°‡≈◊Õ¥ 4. ¿“«–·∑√°´âÕπ·≈–°“√ªÑÕß°—π√–À«à“ß°“√øÕ°‡≈◊Õ¥∑’˧«√∑√“∫ 5. §«“¡√⟇√◊ËÕ߬“ 6. ¿“«–‚¿™π“°“√ 7. °“√ÕÕ°°”≈—ß°“¬ 8. °“√ªØ‘∫—μ‘μ—«‡¡◊ËÕ‡°‘¥¿“«–©ÿ°‡©‘π 9. °“√¥·Ÿ ≈‡√◊ËÕß®‘μ —ß§¡¢Õߺ⟪ɫ¬·≈–≠“μ‘ 10. °“√‡μ√’¬¡μ—«‡æ◊ËÕæ√âÕ¡√—∫°“√ª≈°Ÿ ∂à“¬‰μ μ“¡‡°≥±å¢Õß ∂“∫—π∑’Ë¡’°“√ª≈°Ÿ ∂à“¬‰μ «∏‘ ª’ Ø∫‘ μ— ‘ 1.  √â“ß —¡æ—π∏¿“æ°—∫ºâŸªÉ«¬·≈–≠“μ‘ 348

Hemodialysis Procedures: Step by Step 2. ª√–‡¡‘𧫓¡æ√âÕ¡¢ÕߺŸâªÉ«¬·≈–≠“μ‘ 3. ª√–‡¡‘𧫓¡√⟰àÕπ°“√„Àâ ÿ¢»÷°…“ 4. „Àâ ÿ¢»÷°…“·°àºâŸªÉ«¬·≈–≠“쑧√Õ∫§≈ÿ¡∑ÿ°¢âÕμ“¡§«“¡‡À¡“– ¡ 5. ª√–‡¡‘𧫓¡√ŸâÀ≈—ß°“√„Àâ ÿ¢»÷°…“ 6. §«√¡’°“√μ‘¥μ“¡ª√–‡¡‘πº≈Õ¬à“ßπâÕ¬∑ÿ° 6 ‡¥◊Õπ ‡Õ° “√Õ“â ßÕß‘ 1. ©—μ√ ÿ¥“ ‡Õ◊ÈÕ¡“π–æß…å, Õ—®©√“ ∫ÿ≠°“≠®πå, ªîòπ·°â« °≈⓬ª√–¬ß§å, ®—π∑π“ ™◊Ëπ«‘ ‘∑∏‘Ï, (∫√√≥“∏‘°“√). ·π«∑“ß ªØ‘∫—μ‘°“√欓∫“≈ ”À√—∫°“√øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡·≈–°“√≈â“߉μ∑“ß™àÕß∑âÕß. ™¡√¡æ¬“∫“≈‚√§‰μ·Ààß ª√–‡∑»‰∑¬. 2550. ‡Õ .æ’.‡ÕÁ¡°“√æ‘¡æå: °√ÿ߇∑æ¡À“π§√. 2. Daugirdas J, Blake PG, Ing TS. Handbook of dialysis, 4thed. 2001. Lippincott Williams & Wilkins. USA 3. K/DOQI Clinical practice Guideline for hemodialysis: http:// www. kidney.org. 4. Gutch CF. Review of Hemodialysis for Nurse and Dialysis Personnel. (6 thed). 1999. St.Louis: Mosby. 5. Patricia Y Sohoenf, ed. The Reuse of Hemodialyzer for Chronic Dislysis Therapy. Principles and Practice of Dialysis; 1999. 6. Bull LK. Improving arteriovenous fistula cannulation skills. Nephrol Nurses J 2005; 32: 611-617. 7.  ¡À«—ß ¥à“π«‘™—¬®‘μ√ ·≈–§≥–. ‚√§μ‘¥‡™◊ÈÕ„π‚√ß欓∫“≈. (æ‘¡æå§√—Èß∑’Ë 2). ‚√ßæ‘¡æå‡√◊Õπ·°â«°“√æ‘¡æå. °√ÿ߇∑æ¡À“π§√. 2539. 8. Center for Disease Control (CDC). Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients. MMWR. 2001;50:5. 9. ªîòπ·°â« °≈⓬ª√–¬ß§å. General Care of Vascular Access. „π: ∏π‘μ ®‘√π—π∑å∏«—™,  ‘√‘¿“ ™â“ß»‘√‘°ÿ≈™—¬, ∏π—𥓠μ√– °“√«π‘™, « —πμå  ÿ‡¡∏°ÿ≈. ∫√√≥“∏‘°“√. New Frontiers in Dialysis. °√ÿ߇∑æœ. ∫√‘…—∑ ‡∑Á°´å ·Õπ¥å ‡®Õ√åπ—≈ æ—∫≈‘ ‡§™—Ëπ ®”°—¥. 2551. 10. K/DOQI clinical practice guideline for vascular access update 2006. http:www.kidney.org. 11. Lancaster Larry E. (editor). ANNA Core Curriculum for NEPPHROLOGY NURSING, 4thed. 2001. New Jersey. USA. 12. Nissenson Allen R, Fine Richard N. (editor). Dialysis Therapy, 3rded. 2001. Canada. 349



Get to Know çIntradialytic Parenteral Nutritioné 19 Get to Know çIntradialytic Parenteral Nutritioné Õÿª∂¡— ¿å »ÿ¿ π‘ ∏ÿå 1. ∫∑π” 2. ·π«∑“ß°“√¥·Ÿ ≈¿“«–‚¿™π“°“√¢ÕߺªâŸ «É ¬∑Ë’‰¥â√—∫°“√∫”∫—¥∑¥·∑π‰μ 3. ¢Õâ ∫àß™¢È’ Õß°“√„Àâ intradialytic parenteral nutrition 4. «‘∏’°“√„Àâ intradialytic parenteral nutrition 5. °“√쥑 μ“¡º≈¢â“߇§’¬ß·≈–ª√–‡¡π‘ º≈°“√„À â “√Õ“À“√∑“ß À≈Õ¥‡≈Õ◊ ¥¥”√–À«“à ß°“√øÕ°‡≈◊Õ¥ 6. ∫∑ √ªÿ 351

Practical Dialysis in the Year 2009 1. ∫∑π” „π°“√¥·Ÿ ≈ºªâŸ «É ¬øÕ°‡≈Õ◊ ¥¥«â ¬‡§√ÕË◊ ߉μ‡∑¬’ ¡∑¡Ë’ ª’ ≠í À“∑“ß‚¿™π“°“√·æ∑¬πå ¬‘ ¡ ßË— „À â “√ Õ“À“√∑“ßÀ≈Õ¥‡≈Õ◊ ¥¥”√–À«“à ß°“√øÕ°‡≈Õ◊ ¥ (intradialytic parenteral nutrition, IDPN) ‡πÕË◊ ß®“°¡§’ «“¡  –¥«°∑—ÈߺŸâ —Ëß°“√√—°…“·≈–ºâŸ√—∫°“√√—°…“ ·μ৔∂“¡∑’Ëæ∫∫àÕ¬ §◊Õ 1. ºŸâªÉ«¬¡’§«“¡®”‡ªìπÀ√◊Õ¡’¢âÕ∫àß ™’È«à“®”‡ªìπμâÕ߉¥â√—∫ “√Õ“À“√√–À«à“ß°“√øÕ°‡≈◊Õ¥À√◊Õ‰¡à 2. §«“¡§ÿâ¡§à“„π°“√√—°…“°—∫ª√–‚¬™πå∑’Ë ‡°‘¥¢÷Èπ‡À¡“– ¡À√◊Õ‰¡à 3. «‘∏’°“√„Àâ “√≈–≈“¬∂Ÿ°μâÕßÀ√◊Õ‰¡à 4. ¡’°“√μ‘¥μ“¡º≈°“√√—°…“·≈–°“√ ‡ΩÑ“√–«—ß¿“«–·∑√°´âÕπ∑’ËÕ“®æ∫‰¥â À√◊Õ‰¡à ‡√‘Ë¡¡’°“√„™â IDPN ‡ªìπ§√—Èß·√° ‚¥¬ Heidland ·≈– Kult „πªï 1975 ·μàμàÕ¡“¡’√“¬ß“π«à“ °“√ „Àâ “√≈–≈“¬∑’ˇªìπ°√¥Õ–¡‘‚π √–À«à“ß°“√øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡®–¡’°“√ Ÿ≠‡ ’¬°√¥Õ–¡‘‚π‰ª ª√–¡“π 1.5-2 °√¡— μÕà ™«Ë— ‚¡ß Wiffson ·≈–§≥–æ∫«“à À“°¡°’ “√„À â “√≈–≈“¬°≈‚Ÿ § √«à ¡¥«â ¬ ®–≈¥°“√  Ÿ≠‡ ’¬°√¥Õ–¡‘‚π„π°“√øÕ°‡≈◊Õ¥‰¥â ‚¥¬∑”„ÀâºâŸªÉ«¬‰¥â√—∫°√¥Õ–¡‘‚πª√–¡“≥√âÕ¬≈– 70-75 2. ·π«∑“ß°“√¥·Ÿ ≈¿“«–‚¿™π“°“√¢ÕߺªâŸ «É ¬∑Ë’‰¥√â ∫— °“√∫”∫—¥∑¥·∑π‰μ ª®í ®∫ÿ π— ¡·’ π«∑“ß„π°“√¥·Ÿ ≈¿“«–‚¿™π“°“√„πºªŸâ «É ¬∑‰’Ë ¥√â ∫— °“√øÕ°‡≈Õ◊ ¥À√Õ◊ ≈“â ß™Õà ß∑Õâ ß À≈“¬·π«∑“ߢπ÷È Õ¬°Ÿà ∫— ·μ≈à –ª√–‡∑» ‡™πà „π À√∞— Õ‡¡√°‘ “¡’ KDOQI guideline (Kidney Disease Outcomes Quality Initiative), EBPG guideline (European Best Practice Guideline) ¢Õ߬ÿ‚√ª ·≈– CARI Guideline (Caring for Australians with Renal Impairment) ¢Õߪ√–‡∑»ÕÕ ‡μ√‡≈’¬ ·π«∑“ß KDOQI ªï 2000 ‰¥â·π–π”°“√¥Ÿ·≈¥â“π‚¿™π“°“√  √ÿª‰¥â¥—ßπ’È ·π«∑“ß∑’Ë 18 °“√„À⧔ª√÷°…“¥â“π‚¿™π“°“√·≈–°“√¥·Ÿ ≈·°àºŸâªÉ«¬∑’ˉ¥â√—∫°“√∫”∫—¥∑¥·∑π‰μ - ºâŸªÉ«¬‚√§‰μ‡√◊ÈÕ√—ߧ«√‰¥â√—∫§”·π–π”¥â“π‚¿™π“°“√Õ¬à“߇μÁ¡∑’Ë μ—Èß·μà°àÕπ À√◊Õ ‡¡◊ËÕ¡’ °“√∫”∫—¥∑¥·∑π‰μ(Opinion) - °“√«“ß·ºπ¥“â π‚¿™π“°“√·æ∑¬·å ≈–π°— ‚¿™π“°“√§«√«“ß·ºπ„À·â °ºà ªâŸ «É ¬Õ¬“à ßμÕà ‡πÕ◊Ë ß ∑ÿ° 3-4 ‡¥◊Õπ - °“√„À⧔·π–π”·°àºŸâªÉ«¬§«√·π–π”Õ¬à“ßπâÕ¬∑ÿ° 1-2 ‡¥◊Õπ À√◊Õ∂’Ë°«à“ ¢÷ÈπÕ¬Ÿà°—∫ ¿“«– ‚¿™π“°“√¢Õߺ⟪ɫ¬„π¢≥–π—Èπ ·π«∑“ß∑’Ë 19 ¢âÕ∫àß™’È¢Õß°“√„Àâ nutrition support - ºªŸâ «É ¬‰μ‡√ÕÈ◊ √ß— ∑‰Ë’ ¥√â ∫— °“√∫”∫¥— ∑¥·∑π‰μ ·≈–‰¡ à “¡“√∂‰¥√â ∫—  “√Õ“À“√∑ßÈ— ‚ª√μπ’ ·≈– æ≈—ßß“π‰¥â‡æ’¬ßæÕμàÕ§«“¡μâÕß°“√¢Õß√à“ß°“¬¥â«¬μπ‡Õß §«√‰¥â√—∫ nutrition support (Evidence ·≈– Opinion) - ·æ∑¬μå Õâ ßÀ“ “‡Àμ·ÿ ≈–·°‰â ¢ “‡Àμ¢ÿ Õß¿“«–∑æÿ ‚¿™π“°“√À√Õ◊ ¬“∑¡’Ë º’ ≈μÕà §«“¡Õ¬“° 352

Get to Know çIntradialytic Parenteral Nutritioné Õ“À“√¢ÕߺŸâªÉ«¬ - §«√‡√‘Ë¡®“°°“√„Àâ√—∫ª√–∑“πÕ“À“√„Àâ∂°Ÿ μâÕ߇À¡“– ¡°àÕπ‡ ¡Õ - À“°ºâŸªÉ«¬‰¡à “¡“√∂‰¥â√—∫ “√Õ“À“√‡æ’¬ßæÕ‚¥¬°“√√—∫ª√–∑“π ®÷ßæ‘®“√≥“°“√„ à∑àÕ  “¬¬“ߺà“π∑“ß®¡°Ÿ ‡æ◊ËÕ„ÀâÕ“À“√ - ∂⓺⟪ɫ¬ªØ‘‡ ∏∑àÕ “¬¬“ߺà“π∑“ß®¡Ÿ°‡æ◊ËÕ„ÀâÕ“À“√ À√◊Õ‰¡à “¡“√∂√—∫ “√Õ“À“√‰¥â ‡æ’¬ßæÕ „Àâæ‘®“√≥“ Intradialytic parenteral nutrition À√◊Õ intraperitoneal amino acids - À“°°“√„ÀâÕ“À“√∑“ߪ“°·≈–„Àâ IDPN ¬—߉¡à‰¥âμ“¡∑’˺ŸâªÉ«¬μâÕß°“√ À√◊Õ¡’‚√¥Õ◊ËπÊ √à«¡ ®÷ßæ‘®“√≥“„Àâ total parenteral nutrition (TPN) ·π«∑“ߢÕß EBPG (2007) ¡’¥—ßπ’È ·π«∑“ß∑’Ë 5 °“√√—°…“¿“«–∑ÿæ‚¿™π“°“√ 5.1 °“√¥·Ÿ ≈¿“«–‚¿™π“°“√ - ºŸâªÉ«¬øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡∑’Ë¡’¿“«–∑ÿæ‚¿™π“°“√μâÕ߉¥â√—∫§”·π–π”¥â“π ‚¿™π“°“√Õ¬à“ß∂°Ÿ μâÕß (Evidence level III) - ºâŸªÉ«¬„π‚√ß欓∫“≈ §«√®–‰¥â√—∫§”·π–π”¥â“π‚¿™π“°“√¿“¬„π√–¬–‡«≈“ 3 «—π À≈—ß ®“°√—∫ºâŸªÉ«¬‰«â„π‚√ß欓∫“≈ ·≈–∂⓺⟪ɫ¬¡’§«“¡‡ ’ˬßμàÕ¿“«–∑ÿæ‚¿™π“°“√ Ÿß §«√¡’°“√μ‘¥μ“¡ Õ“°“√·≈–æƒμ‘°√√¡°“√∫√‘‚¿§¢ÕߺŸâªÉ«¬∑ÿ°«—π ·μà∂â“¡’§«“¡‡ ’ˬßμË” Õ“®®–μ‘¥μ“¡ºâŸªÉ«¬ —ª¥“Àå≈– §√—Èß 5.2 °“√„ÀâÕ“À“√‡ √‘¡‚¥¬°“√√—∫ª√–∑“π ·≈– °“√„Àâ “√Õ“À“√∑“ß∑àÕ “¬¬“ß - §«√¡’°“√„ÀâÕ“À“√‡ √‘¡·°àºŸâªÉ«¬‡ ¡Õ ∂â“°“√„À⧔·π–π”¥â“π‚¿™π“°“√‰¡à‡æ’¬ßæÕ ∑’Ë ®–∑”„Àºâ ªâŸ «É ¬‰¥√â ∫—  “√Õ“À“√‰¥Õâ ¬“à ߇欒 ßæÕμ“¡§«“¡μÕâ ß°“√¢Õß√“à ß°“¬ºªŸâ «É ¬„π¢≥–ππ—È (Evidence level III) - Õ“À“√‡ √¡‘  ”À√∫— ºªŸâ «É ¬§«√‡≈Õ◊ °„™Õâ “À“√‡©æ“–‚√§¡“°°«“à ∑®’Ë –„ÀÕâ “À“√‡ √¡‘  ”À√∫— ºâŸªÉ«¬∑—Ë«Ê ‰ª (Evidence level III) - §«√殑 “√≥“°“√„ ∑à Õà „ÀÕâ “À“√ (º“à π∑“ß®¡°Ÿ À√Õ◊ º“à πÀπ“â ∑Õâ ߇¢“â °√–‡æ“–Õ“À“√) ·≈– „ÀâÕ“À“√‡ √‘¡‡©æ“–‚√§„π¢π“¥·≈–ª√‘¡“≥∑’ˇÀ¡“– ¡ ∂â“°“√„ÀâÕ“À“√‡ √‘¡‚¥¬°“√√—∫ª√–∑“π‡Õß ‰¡à “¡“√∂·°â‰¢¿“«–∑ÿæ‚¿™π“°“√¢Õߺ⟪ɫ¬‰¥â (Evidence level IV) 5.3 °“√„Àâ “√Õ“À“√∑“ßÀ≈Õ¥‡≈◊Õ¥¥”√–À«à“ß°“√øÕ°‡≈◊Õ¥ (IDPN) - §«√殑 “√≥“„À â “√Õ“À“√∑“ßÀ≈Õ¥‡≈Õ◊ ¥¥”·°ºà ªŸâ «É ¬ À“°°“√„À§â ”·π–𔥓â π‚¿™π“°“√ °“√„ÀâÕ“À“√‡ √‘¡‡©æ“–‚√§‚¥¬°“√√—∫ª√–∑“π À√◊Õ „Àâºà“π∑“ß∑àÕ„ÀâÕ“À“√·∫∫μà“ßÊ ‰¡à “¡“√∂ ™à«¬·°â‰¢¿“«–∑ÿæ‚¿™π“°“√¢ÕߺŸâªÉ«¬‰¥â (Evidence level IV) 353

Practical Dialysis in the Year 2009 - °“√殑 “√≥“„À â “√Õ“À“√∑“ßÀ≈Õ¥‡≈Õ◊ ¥¥”√–À«“à ß°“√øÕ°‡≈Õ◊ ¥ ·°ºà ªŸâ «É ¬∑¡Ë’ ¿’ “«–∑æÿ ‚¿™π“°“√®–·π–π”„Àâ∑”°ÁμàÕ‡¡◊ËÕ ºŸâªÉ«¬√“¬π—Èπ ¬—ß “¡“√∂‰¥â√—∫ “√Õ“À“√‡¢â“√à“ß°“¬‰¥â¡“°°«à“ 20 °‘‚≈·§≈Õ√’μàÕπÈ”Àπ—°μ—«¡“μ√∞“π‡ªìπ°‘‚≈°√—¡μàÕ«—π ·≈–‰¥â√—∫‚ª√μ’π¡“°°«à“ 0.8 °√—¡μàÕπÈ”Àπ—°μ—« ¡“μ√∞“π‡ªìπ°‘‚≈°√—¡μàÕ«—π À“°ºŸâªÉ«¬‰¥â√—∫ “√Õ“À“√μË”°«à“§«“¡μâÕß°“√¥—ß°≈à“« §«√æ‘®“√≥“„Àâ total parenteral nutrition (Opinion) 5.4 °“√„ÀâŒÕ√å‚¡π·Õπ‚¥√‡®π - „π°√≥∑’ º’Ë ªâŸ «É ¬¡¿’ “«–∑æÿ ‚¿™π“°“√¢π—È √πÿ ·√ß·≈–μÕ∫ πÕßμÕà °“√„À‚â ¿™π–∫”∫¥— ‰¥‰â ¡à ¥’ §«√æ‘®“√≥“„Àâ ŒÕ√å‚¡π·Õπ‚¥√‡®π π“πÕ¬à“ßπâÕ¬ 3 ∂÷ß 6 ‡¥◊Õπ (Evidence level II) - °“√„Àâ ŒÕ√å‚¡π·Õπ‚¥√‡®π §«√„ÀâÕ¬à“ßπâÕ¬‡¥◊Õπ≈–§√—Èß À√◊Õ  Õߧ√—ÈßμàÕ‡¥◊Õπ - ºŸâªÉ«¬∑’ˉ¥â√—∫ ŒÕ√å‚¡π·Õπ‚¥√‡®π §«√‰¥â√—∫°“√‡ΩÑ“√–«—ßÀ√◊Õμ‘¥μ“¡º≈¢â“߇§’¬ß¢Õ߬“ ‡ªìπ√–¬– ¡Ë”‡ ¡Õ (hirsutism, voice change, priaprism, plasma lipids, liver tests ·≈– prostatic markers) (Evidence level II) - ºâŸªÉ«¬∑’ˇªìπ ¡–‡√ÁߢÕßμàÕ¡≈°Ÿ À¡“° ‰¡à§«√‰¥â√—∫ ŒÕ√å‚¡π·Õπ‚¥√‡®π (Evidence level II) 5.5 «‘∏’°“√øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡∑ÿ°«—π (daily dialysis) - °“√∑” daily dialysis (∑—Èß·∫∫ short dialysis À√◊Õ long nocturnal dialysis) „π√–¬–‡«≈“ 6-12 ‡¥◊Õπ Õ“®‡ªìπ«‘∏’™à«¬ºâŸªÉ«¬∑’ˉ¡à “¡“√∂øÕ°‡≈◊Õ¥‰¥âÕ¬à“߇撬ßæե⫬°“√øÕ°‡≈◊Õ¥∑—˫ʉª ·≈–¡’ ¿“«–∑ÿæ‚¿™π“°“√∑’Ë¡’Õ“°“√‡∫◊ËÕÕ“À“√√à«¡¥â«¬·≈–‰¡àμÕ∫ πÕßμàÕ°“√„Àâ‚¿™π∫”∫—¥¥â«¬«‘∏’μà“ßÊ (Opinion) πÕ°®“°π’Ȭ—ß¡’ §”·π–π”®“° American Society of Enteral and Parenteral Nutrition „πªï 2002 ∑’Ë°≈à“«„π¢âÕ (7) «à“ ®–„Àâ IDPN μàÕ‡¡◊Ëպ⟪ɫ¬¡’¿“«–∑ÿæ‚¿™π“°“√·≈–‰¡à “¡“√∂„ÀâÕ“À“√∑“ß ª“°‰¥â ‡π◊ËÕß®“°≈”‰ â‰¡à∑”ß“π À√◊Õ„Àâ total parenteral nutrition ‰¥â (Level C) ‡πÕ◊Ë ß®“°§”·π–π”¥ß— °≈“à «‡ªπì ¢Õßμ“à ߪ√–‡∑»∑¡’Ë »’ °— ¬¿“æ„π°“√ªØ∫‘ μ— ‘®ß÷  “¡“√∂∑”ÕÕ° ¡“‡ªì𧔷π–π”‰¥â ·μà„πª√–‡∑»‰∑¬ °“√¢“¥·§≈ππ—°°”Àπ¥Õ“À“√‡©æ“–‚√§‰μ ·≈–∫ÿ§§≈“°√ ∑“ß°“√·æ∑¬å¥â“π‚√§‰μ √«¡∑—Èß ¿“æ∑“߇»√…∞°‘®·≈– —ߧ¡„π√–¥—∫§√Õ∫§√—«·≈–ª√–‡∑» ∑”„Àâ ‰¡à “¡“√∂„Àâ‚¿™π–∫”∫—¥·°àºŸâªÉ«¬‰¥âÕ¬à“ß¡’ª√– ‘∑∏‘¿“æ Õ¬à“߉√°Áμ“¡ ·æ∑¬å·≈–欓∫“≈∑’Ë„°≈â ™‘¥°—∫ºŸâªÉ«¬μâÕß “¡“√∂ —߇°μÕ“°“√ºâŸªÉ«¬ „À⧔·π–π”‡∫◊ÈÕßμâπ °“√√—°…“·≈–°“√μ‘¥μ“¡ª√–‡¡‘π º≈‰¥âÕ¬à“ß∂Ÿ°μâÕß ‚¥¬æ‘®“√≥“§«“¡‡À¡“– ¡ ·≈–§«“¡§ÿâ¡§à“„π°“√„Àâ°“√√—°…“ºâŸªÉ«¬ ¬°μ—«Õ¬à“ß ‡™àπ ∂⓺⟪ɫ¬øÕ°‡≈◊Õ¥‡æ’¬ß·§à 2 §√—ÈßμàÕ —ª¥“Àå §√—Èß≈– 4 ™—Ë«‚¡ß ·≈–¡’Õ“°“√‡∫◊ËÕÕ“À“√‡π◊ËÕß®“° ¿“«–¬Ÿ√’‡¡’¬ À√◊Õ ¡’πÈ”Àπ—°μ—«‡°‘π®“°°“√ – ¡¢ÕßπÈ”„π√à“ß°“¬ §«√æ‘®“√≥“„À⺟âªÉ«¬∑” 3 §√—Èß∂â“  “¡“√∂∑”‰¥â ·¡â™à«ß√–¬–‡«≈“ —ÈπÊ À√◊Õ Õ¬à“ßπâÕ¬‡æ‘Ë¡‡ªìπ 5 ™—Ë«‚¡ß ‡æ√“–Õ¬à“ßπâÕ¬‡√“®–‰¡à ≠Ÿ ‡ ’¬ ºŸâªÉ«¬‰ª°àÕπ‡«≈“Õ—π§«√ À√◊Õ∂⓺ŸâªÉ«¬øÕ°‡≈◊Õ¥‰¥âÕ¬à“߇撬ßæÕ·≈â« ·μà√—∫ª√–∑“πÕ“À“√‰¥â‰¡àμ√ß μ“¡§«“¡μâÕß°“√¢Õß√à“ß°“¬ ·¡â®–„ÀâÕ“À“√ªíòπ Ÿμ√‡©æ“–‚√§ À√◊Õ Õ“À“√‡ √‘¡‡©æ“–‚√§ ·æ∑¬å 354

Get to Know çIntradialytic Parenteral Nutritioné §«√§ÿ¬°—∫ºâŸªÉ«¬À√◊Õ≠“쑇æ◊ËÕæ‘®“√≥“ °“√„ à∑àÕ∑“ß®¡Ÿ°‡æ◊ËÕ„ÀâÕ“À“√„π√–¬–‡«≈“Àπ÷Ëß ®πºŸâªÉ«¬¡’ ¿“«–‚¿™π“°“√¥’¢÷Èπ®÷ß„Àâ°≈—∫¡“√—∫ª√–∑“πÕ“À“√‚¥¬°“√√—∫ª√–∑“π‡À¡◊Õπ‡¥‘¡ 3. ¢âÕ∫ßà ™È¢’ Õß°“√„Àâ intradialytic parenteral nutrition „π™«à ß∑»«√√…∑ºË’ “à π¡“ ·¡®â –¡°’ “√„Àâ IDPN ¡“°¢πÈ÷ ·μ°à ¡Á °’ “√»°÷ …“„π‡√ÕË◊ ߪ√–‚¬™π·å ≈– §«“¡§ÿâ¡§à“¢Õß°“√„Àâ IDPN πâÕ¬¡“° ¡’∑—Èß°“√»÷°…“∑’Ë π—∫ πÿπ·≈–‰¡à π—∫ πÿπ°“√„Àâ IDPN ¥—ßπ—Èπ ®÷߉¡à§àÕ¬®–ª√“°Æ¢âÕ∫àß™’È∑’Ë™—¥‡®π„π°“√∑’Ë®–„Àâ IDPN ‡∑à“∑’Ë¡’°“√μ’æ‘¡æå ‰¥â·°à The American Dietitic Association (1994), NKF (The National Kidney Foundation 1999) guideline ‚¥¬ Lazarus J, K/DOQI guideline (2000) ·≈– EBPG (2007) ¢âÕ∫àß™’È°“√„Àâ IDPN ‚¥¬ Lazarus J. ‰¥â√—∫°“√√—∫√Õß‚¥¬ NKF ¢Õß À√—∞Õ‡¡√‘°“ (Proposed Health Care Financing Administration Guidelines for Reimbursement of Enteral and Parenteral Nutrition) ¡’¥—ßπ’È 1. √–¥—∫¢ÕßÕ—≈∫¡Ÿ ‘π„π‡≈◊Õ¥ < 3.4 °√—¡/‡¥´‘≈‘μ√ π“πμ‘¥μàÕ°—π 3 ‡¥◊Õπ 2. √–¥—∫¢Õߧ√’‡Õμ‘π‘π„π‡≈◊Õ¥ < 8 ¡‘≈≈‘°√—¡/‡¥´‘≈‘μ√ π“πμ‘¥μàÕ°—π 3 ‡¥◊Õπ 3. πÈ”Àπ—°≈¥ > √âÕ¬≈– 10 ¢ÕßπÈ”Àπ—°¡“μ√∞“π¢Õߺ⟪ɫ¬ À√◊Õ > √âÕ¬≈– 20 ¢ÕßπÈ”Àπ—° ªí®®ÿ∫—π 4. μ√«®√à“ß°“¬ æ∫¿“«–∑ÿæ‚¿™π“°“√√–¥—∫ª“π°≈“ß∂÷ß√ÿπ·√ß 5. ª√¡‘ “≥‚ª√μπ’ ∑∫’Ë √‚‘ ¿§ < 0.8°√¡— /πÈ”Àπ°— μ«— ‡ªπì °‚‘ ≈°√¡— /«π— À√Õ◊ ‰¥√â ∫— æ≈ß— ß“π®“°Õ“À“√ < 25 °‘‚≈·§≈Õ√’πÈ”Àπ—°μ—«‡ªìπ°‘‚≈°√—¡/«—π 6. Subjective global assessment Õ¬Ÿà„π√–¥—∫ C (¢“¥ “√Õ“À“√¢—Èπ√ÿπ·√ß) ‚¥¬Õ¬à“ßπâÕ¬æ∫ 3 „π 6 ¢âÕ√à«¡°—∫ 1. ‰¡à “¡“√∂„ÀâÕ“À“√‡ √‘¡‚¥¬°“√√—∫ª√–∑“π À√◊Õ 2. ºâŸªÉ«¬ªØ‘‡ ∏°“√„ à∑àÕÕ“À“√  à«π¢âÕ∫àß™’È„π°“√À¬ÿ¥°“√„Àâ IPDN ‰¥â·°à 1. √–¥—∫¢ÕßÕ—≈∫Ÿ¡‘π„π‡≈◊Õ¥ ≥ 3.8 °√—¡/‡¥´‘≈‘μ√ μ‘¥μàÕ°—πÕ¬à“ßπâÕ¬ 3 ‡¥◊Õπ 2. √–¥—∫¢Õߧ√’‡Õμ‘π‘π„π‡≈◊Õ¥ ≥ 10 ¡‘≈≈‘°√—¡/‡¥´‘≈‘μ√ μ‘¥μàÕ°—πÕ¬à“ßπâÕ¬ 3 ‡¥◊Õπ 3. πÈ”Àπ—°μ—«∑’Ë·∑â®√‘ߢÕߺ⟪ɫ¬ (dry weight) ‡æ‘Ë¡¢÷Èπ À√◊Õ μ√«®√à“ß°“¬æ∫«à“ºâŸªÉ«¬¡’¿“«– ‚¿™π“°“√∑’Ë¥’¢÷Èπ 4. ºâŸªÉ«¬ “¡“√∂√—∫ª√–∑“πÕ“À“√‚¥¬‰¥â√—∫‚ª√μ’π®“°Õ“À“√ > 1 °√—¡/πÈ”Àπ—°μ—«‡ªìπ °‘‚≈°√—¡/«—π À√◊Õ‰¥â√—∫æ≈—ßß“π®“°Õ“À“√ > 30 °‘‚≈·§≈Õ√’/πÈ”Àπ—°μ—«‡ªìπ°‘‚≈°√—¡/«—π 5. Subjective global assessment Õ¬Ÿà„π√–¥—∫ A À√◊Õ B ‚¥¬Õ¬à“ßπâÕ¬æ∫ 3 „π 5 À√◊Õ 355

Practical Dialysis in the Year 2009 1. „Àâ IDPN μ‘¥μàÕ°—π 6 ‡¥◊Õπ·≈â« ¿“«–∑ÿæ‚¿™π“°“√¢ÕߺÿâªÉ«¬‰¡à¥’¢÷Èπ À√◊Õ 2. ¡’¿“«–·∑√°´âÕπ∑’ˇ°‘¥®“°°“√„Àâ IDPN  ”À√—∫¢âÕ∫àß™’È¢Õß°“√„Àâ “√≈–≈“¬∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ‚¥¬ KDOQI ¡’¥—ßπ’È 1. ºŸâªÉ«¬¡’πÈ”Àπ—°μ—«≈¥≈ß > √âÕ¬≈– 10 „π 6 ‡¥◊Õπ 2. Triceps skinfold thickness < 6 ¡‘≈≈‘‡¡μ√ „π‡æ»™“¬ ·≈– < 12 ¡‘≈≈‘‡¡μ√ „π‡æ»À≠‘ß 3. √–¥—∫Õ—≈∫¡Ÿ ‘π„π‡≈◊Õ¥ < 3.4 °√—¡/≈‘μ√ 4. Protein catabolic rate < 0.8 °√—¡/πÈ”Àπ—°μ—«‡ªìπ°‘‚≈°√—¡/«—π  «à π¢Õâ ∫ßà ™¢È’ Õß°“√„À â “√≈–≈“¬∑“ßÀ≈Õ¥‡≈Õ◊ ¥¥” ‚¥¬ The American Dietetic Association (A Clinical Guide to Nutritional Care in End Stage Renal Disease) ¡’¥—ßπ’È 1. ºŸâªÉ«¬¡’πÈ”Àπ—°μ—« < √âÕ¬≈– 90 ¢ÕßπÈ”Àπ—°μ—«¡“μ√∞“π∑’˧«√®–‡ªìπ 2. ºâŸªÉ«¬¡’πÈ”Àπ—°μ—«≈¥≈ß > √âÕ¬≈– 10 „π 6 ‡¥◊Õπ 3. Triceps skinfold thickness < 6 ¡‘≈≈‘‡¡μ√ „π‡æ»™“¬ ·≈– < 12 ¡‘≈≈‘‡¡μ√ „π‡æ»À≠‘ß 4. √–¥—∫Õ—≈∫¡Ÿ ‘π„π‡≈◊Õ¥ < 3.4 °√—¡/≈‘μ√ 5. Protein catabolic rate < 0.8 °√—¡/πÈ”Àπ—°μ—«‡ªìπ°‘‚≈°√—¡/«—π Õ¬“à ߉√°μÁ “¡IDPN‡ªπì ‡æ¬’ ß «à π™«à ¬‡ √¡‘ „Àºâ ªŸâ «É ¬‰¥√â ∫—  “√Õ“À“√‰¥§â √∫∂«â π‡©æ“–„π°√≥’ ∑’˺ŸâªÉ«¬¬—ß√—∫ª√–∑“π‰¥â∫â“ß ·μà IDPN ‰¡à “¡“√∂„™â∑¥·∑π TPN ‰¥â∂⓺ŸâªÉ«¬¡’§«“¡μâÕß°“√ TPN 4. «‘∏’°“√„Àâ intradialytic parenteral nutrition ‡π◊ËÕß®“° “√Õ“À“√À≈—°∑’Ë√à“ß°“¬μâÕß°“√‡æË◊Õ„À⇪ìπ·À≈àßæ≈—ßß“π ”À√—∫°“√∑”ß“π¢Õß Õ«—¬«–μà“ßÊ ‰¥â·°à §“√å‚∫‰Œ‡¥√μ ¥—ßπ—Èπ °“√∑’Ë®– —Ëß IDPN „ÀⷰຟâªÉ«¬„π°“√·°â‰¢¿“«–∑ÿæ ‚¿™π“°“√Õ¬à“ß∂°Ÿ μâÕß §◊Õ μâÕß¡’ “√≈–≈“¬‡¥°´å‚μ√ √à«¡¥â«¬‡ ¡Õ ¥—ßπ—Èπ Ÿμ√¢Õß°“√„Àâ “√Õ“À“√ ∑“ßÀ≈Õ¥‡≈Õ◊ ¥¥”„π√–À«“à ß°“√øÕ°‡≈Õ◊ ¥®–¡Õ’ ¬‡Ÿà 欒 ß Õß«∏‘ À’ ≈°— §Õ◊ 1.  “√≈–≈“¬ dextrose ·≈– amino acids À√◊Õ 2.  “√≈–≈“¬ dextrose, amino acids ·≈– lipids (μ“√“ß∑’Ë 1) 4.1  “√≈–≈“¬ dextrose dextrose ‡ªìπ·À≈àßÀ≈—°¢Õߧ“√å‚∫‰Œ‡¥√μ∑’Ë„Àâæ≈—ßß“π ´÷Ëß®”‡ªìπμàÕ°“√∑”ß“π¢Õß√–∫∫ ª√– “∑ ‡¡Á¥‡≈◊Õ¥·¥ß, ‡¡Á¥‡≈◊Õ¥¢“«·≈–Õ«—¬«–Õ◊ËπÊ „Àâ∑”ß“π‰¥âÕ¬à“ß¡’ª√– ‘∑∏‘¿“æ æ≈—ßß“π∑’ˇ°‘¥ ¢÷Èπ®“° dextrose 1 °√—¡ ‡∑à“°—∫ 3.4 °‘‚≈·§≈Õ√’ ·≈–‚¥¬ª°μ‘Õ—μ√“°“√„Àâ “√≈–≈“¬ dextrose ∑’Ë ‡À¡“– ¡§◊Õ 5 ¡‘≈≈‘°√—¡/πÈ”Àπ—°μ—«‡ªìπ°‘‚≈°√—¡/π“∑’ ∂â“„Àâ„πÕ—μ√“ Ÿß°«à“π’È ®–¡’‚Õ°“ ‡°‘¥¿“«– πÈ”μ“≈„π‡≈◊Õ¥ Ÿß (hyperglycemia) ‰¥â Õ¬à“߉√°Áμ“¡¡’ºâŸ∑”°“√»÷°…“„πºâŸªÉ«¬∑’ËøÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕß‰μ ‡∑¬’ ¡æ∫«“à ª√¡‘ “≥¢Õß dextrose  “¡“√∂„À‰â ¥„â π√–¬–‡«≈“ 4 ™«Ë— ‚¡ß∑øË’ Õ°‡≈Õ◊ ¥‚¥¬‰¡‡à °¥‘ º≈¢“â ߇§¬’ ß 356

Get to Know çIntradialytic Parenteral Nutritioné μ“√“ß∑’Ë 1 · ¥ß™π‘¥·≈–æ≈—ßß“π∑’ˉ¥â®“°°“√„Àâ “√Õ“À“√·∫∫μà“ßÊ ™π‘¥¢Õß ª√¡‘ “≥¢Õß °‚‘ ≈·§≈Õ√’ °‘‚≈·§≈Õ√’μàÕ ª√¡‘ “μ√ °‚‘ ≈·§≈Õ√’  “√≈–≈“¬  “√Õ“À“√ μàÕ°√—¡ ª√‘¡“μ√∑Ë„’ Àâ ∑ß—È À¡¥ ∑ßÈ— À¡¥ 250 ml D50W 125 g dextrose 3.4 425 500 525 250 ml 10%AA 25 g protein 4 100 750 1025 250 ml D50W 125 g dextrose 3.4 425 1000 1450 250 ml 10%AA 25 g protein 4 100 250 ml 20% lipids 50 g fat 10 500 450 480 750 570 500 ml D50W 250 g dextrose 3.4 850 1000 1070 250 ml 10%AA 25 g protein 4 100 250 ml 20% lipids 50 g fat 10 500 1250 1500 250 ml D50W 125 g dextrose 3.4 425 200 ml 7.2%AA 14.4 g protein 4 58 250 ml D50W 125 g dextrose 3.4 425 500 ml 7.2%AA 36 g protein 4 144 250 ml D50W 125 g dextrose 3.4 425 500 ml 7.2%AA 36 g protein 4 144 250 ml 20% lipids 50 g fat 10 500 500 ml D50W 250 g dextrose 3.4 850 500 ml 7.2%AA 36 g protein 4 144 250 ml 20% lipids 50 g fat 10 500 D, dextrose; AA, amino acid ¥â«¬‡Àμÿº≈∑’ËÕ“®‡ªìπ®“°°“√‰À≈‡«’¬π¢Õ߇≈◊Õ¥‡°‘¥¢÷Èπ‡√Á« Õ¬à“߉√°Áμ“¡ª√‘¡“≥¢Õß dextrose ∑’Ë„Àâ‰¡à §«√‡°‘πª√‘¡“≥∑’Ë√à“ß°“¬ºŸâªÉ«¬μâÕß°“√ ·μàÕ¬à“ßπâÕ¬ºŸâªÉ«¬§«√‰¥â√—∫„πª√‘¡“≥ 100 °√—¡μàÕ«—π „π ª√–‡∑»‰∑¬ º≈‘μ¿—≥±å dextrose ¡’„π¢π“¥ 5%, 10%, 25% ·≈– 50% „πª√‘¡“μ√ 500 ¡‘≈≈‘≈‘μ√ «‘∏’°“√„Àâ „À⧔π«≥ª√‘¡“≥¢Õß°≈‚Ÿ § ∑’ËμâÕß°“√ §◊Õ ¢π“¥‰¡à§«√‡°‘π 5-6 °√—¡/πÈ”Àπ—°μ—« ‡ªìπ°‘‚≈°√—¡/«—π À√◊Õ‰¡à§«√‡°‘π 250 °√—¡/«—π „Àâ∑“ß venous chamber ‚¥¬Õ“»—¬ infusion pump ª√—∫ ¢π“¥∑’Ë„Àâ„πÕ—μ√“ 1-2 ¡‘≈≈‘≈‘μ√/π“∑’ „π√–¬–‡«≈“ 4 ™—Ë«‚¡ß√–À«à“ßøÕ°‡≈◊Õ¥ ¢Õâ §«√√–«ß— §Õ◊ °“√„À„â πª√¡‘ “≥∑¡’Ë “°‡°π‘ §«“¡μÕâ ß°“√ ®–∑”„À‡â °¥‘ ¿“«– hyperglycemia, fatty liver, excessive CO2 production À√◊Õ hyperosmolarity ‰¥â „π°√≥’∑’ˇ°‘¥¿“«– hyperglycemia ‚¥¬¡’ √–¥—∫πÈ”μ“≈„π‡≈◊Õ¥ Ÿß‡°‘π 300 ¡‘≈≈‘°√—¡/‡¥´‘≈‘μ√ °àÕπ°“√øÕ°‡≈◊Õ¥„Àâ º ¡ regular insulin „π¢π“¥ 2-6 ¬Ÿπ‘μ„π “√≈–≈“¬ dextrose 4.2  “√≈–≈“¬°√¥Õ–¡‚‘ π (crystalline amino acids)  “√≈–≈“¬°√¥Õ–¡‚‘ π„Àæâ ≈ß— ß“π„π¢π“¥ 4 °‚‘ ≈·§≈Õ√/’ °√¡— ‡¡Õ◊Ë ∂°Ÿ ÕÕ°´‰‘ ¥´‰å ª‡ªπì æ≈ß— ß“π 357

Practical Dialysis in the Year 2009 ¥—ßπ—Èπ®÷ßμâÕß„Àâæ≈—ßß“π®“° dextrose „Àâ‡æ’¬ßæÕ ∑’Ë√à“ß°“¬®–π”‡Õ“°√¥Õ–¡‘‚πÀ√◊Õ‰π‚μ√‡®π‰ª √â“ß ‡ªìπ‚ª√μ’π„π√à“ß°“¬·∑π ‚¥¬∑—Ë«‰ªª√‘¡“≥¢Õßæ≈—ßß“π∑’ËμâÕß°“√μàÕ‰π‚μ√‡®π∑’ËæÕ‡À¡“–μàÕ°“√  √â“ß‚ª√μ’π„π√à“ß°“¬ (calorie-to-nitrogen ratio) §◊Õ 120-150:1 „π§πª°μ‘, 200-220:1 „πºŸâªÉ«¬‚√§μ—∫ ·≈–‚√§‰μ ·≈–„πºŸâªÉ«¬∑’ˇ®Á∫ªÉ«¬Àπ—°‡©’¬∫æ≈—πμâÕß°“√„π√–¥—∫ 80-90:1 ¥—ßπ—Èπ®÷ßμâÕߧ”π«≥∑—Èß ª√‘¡“≥¢Õß°√¥Õ–¡‘‚π·≈–ª√‘¡“≥ dextrose ∑’Ë®–„ÀâºâŸªÉ«¬‡ ¡Õ º≈μ‘ ¿≥— ±¢å Õß “√≈–≈“¬°√¥Õ–¡‚‘ π∑¡’Ë „’ π∑Õâ ßμ≈“¥ ·∫ßà ÕÕ°‰¥‡â ªπì 2 ª√–‡¿∑ §Õ◊ standard amino acid ·≈– modified amino acid ‚¥¬ standard amino acid ¡’∑’Ë„™â ”À√—∫ºŸâªÉ«¬∑’Ë¡’°“√∑”ß“π¢Õßμ—∫ ·≈–‰μ‡ªìπª°μ‘ ‚¥¬¡’¢π“¥¢Õß°√¥Õ–¡‘‚π·∫∫°‘Ëß (branched-chain amino acids, BCAA) Õ¬Ÿà√–À«à“ß√âÕ¬ ≈– 19-21 ¢Õß°√¥Õ–¡‘‚π∑—ÈßÀ¡¥ ‚¥¬ª√‘¡“≥°√¥Õ–¡‘‚π√«¡ ¡’μ—Èß·μà√âÕ¬≈– 7-10  à«π modified amino acid  ”À√∫— ‚√§‰μ ¡°’ “√ª√∫— „π·ß¢à ÕßÕμ— √“ «à π√–À«“à ß °√¥Õ–¡‚‘ 𮔇ªπì ·≈–‰¡®à ”‡ªπì √«¡∑ßÈ— ª√¡‘ “≥ ¢Õß BCAA ¥«â ¬ πÕ°®“°π∑’È  ’Ë ”§≠— §Õ◊ ª√¡‘ “≥¢Õß‚´‡¥¬’ ¡ ·≈–‚ª·μ ‡´¬’ ¡ ∑¡’Ë π’ Õâ ¬¡“°μ“à ß®“°standard amino acid  à«πª√–°Õ∫∑’Ë®”‡ªìπ„π “√≈–≈“¬°√¥Õ–¡‘‚π ”À√—∫ºâŸªÉ«¬‚√§‰μ §◊Õ  —¥ à«π¢Õß°√¥Õ– ¡‘‚𮔇ªìπ·≈–‰¡à®”‡ªìπ ‡π◊ËÕß®“°°“√„Àâ°√¥Õ–¡‘‚𮔇ªìπ·μà‡æ’¬ßÕ¬à“߇¥’¬«·°àºŸâªÉ«¬„π√–¬–‡«≈“ π“π‡ªìπ 2-3  —ª¥“Àå¢÷Èπ‰ª ®–∑”„À⇰‘¥¿“«– hyperammonemia ·≈– metabolic encephalopathy ‰¥â πÕ°®“°π’ȧ«√μâÕß¡’ arginine, ornithine ·≈– citrulline „π “√≈–≈“¬‡æ◊ËÕ∑”Àπâ“∑’ˇªìπμ—«≈¥°“√‡°‘¥æ‘… ®“°·Õ¡‚¡‡π’¬„π«ß®√‡§√ª (Krebûs urea cycle) º≈‘μ¿—≥±å∑’Ë®”Àπà“¬¡’ª√‘¡“≥¢Õß°√¥Õ–¡‘‚𮔇ªìπ μàÕ°√¥Õ–¡‘‚π‰¡à®”‡ªìπ ª√–¡“≥ 40-50:50-60 (μ“√“ß∑’Ë 2) «‘∏’°“√„Àâ §”π«≥ª√‘¡“≥¢ÕßÕ—μ√“ à«π¢Õß æ≈—ßß“πμàÕ‰π‚μ√‡®π ∑’Ë®–„ÀâºÿâªÉ«¬ ‚¥¬‡©≈’ˬ ¢Õß°√¥Õ–¡‘‚π∑’Ë®–„ÀâÕ¬àŸ√–À«à“ß 200-500 ¡‘≈≈‘≈‘μ√μàÕ§√—Èß ‡√‘Ë¡„Àâ„π°≈“ß™—Ë«‚¡ß∑’Ë 3 À√◊Õ ‡√‘Ë¡μâπ™—Ë«‚¡ß ∑’Ë 4 (À√◊Õ 90-60 π“∑’ °àÕπÀ¬ÿ¥∑”°“√øÕ°‡≈◊Õ¥) ‚¥¬„Àâºà“π∑“ß infusion pump μ“√“ß∑Ë’ 2 · ¥ß§ÿ≥ ¡∫—μ‘¢Õߺ≈‘μ¿—≥±å “√≈–≈“¬°√¥Õ–¡‘‚π™π‘¥μà“ßÊ º≈‘μ¿—≥±å ª√‘¡“μ√ ª√¡‘ “≥ %EAA/ °‘‚≈ ÕÕ ‚¡≈“√‘μ’/ §“√å‚∫‰Œ‡¥√μ Õ‡‘ ≈§‚μ√‰≈μå Standard AA (¡‘≈≈‘≈‘μ√) °√¥Õ–¡‚‘ π AA ·§≈Õ√’ ≈‘μ√ (¡≈‘ ≈‘Õ‘§««‘ “‡≈π∑å) 10%Aminosteril 10%Aminosol (°√¡— ) ‚´‡¥¬’ ¡ ‚ª·μ ‡´¬’ ¡ Õ–´‡‘ μ∑ 500 50 25 200 920 Sorbitol 50 25 12.5 500 50 39 200 1590 Sorbitol 50 24 12.5 30 Liver Formula AA 500 50 52 200 960 7 10%Aminoleban 500 50 59 200 1 60 10%Amiparen Renal Formula AA 6.1%Neoamiyu 400 24.4 72.95 98 ‰¡à¡’¢âÕ¡Ÿ≈ 4 72 140 580 2 22.5 7.2%Kidmin 500 36 64.7 140 322 7%Nephrosteril 500 35 AA, Amino acid; EAA, Essential amino acid 358

Get to Know çIntradialytic Parenteral Nutritioné 4.3 ‰¢¡—π (fat emulsions) °“√„À≢¡—π∑“ßÀ≈Õ¥‡≈◊Õ¥ ¡’«—μ∂ÿª√– ß§å‡æ◊ËÕ „Àâæ≈—ßß“π„Àâ‡æ’¬ßæÕ·≈–„Àâ°√¥‰¢¡—π∑’Ë ®”‡ªπì ‰¥·â °à ‰≈‚π‡≈Õ§‘ (linoleic acid) ·≈– ‚Õ‡≈Õ§‘ (oleic acid) πÕ°®“°π¬’È ß— ¡°’ √¥‰¢¡π— Õπ◊Ë Ê ‡™πà æ“≈¡μ‘ §‘ (palmitic) ‰≈‚π‡≈𑧠(linolenic acid) ·≈–‡ μ’¬√‘§ (stearic acid) Õߧåª√–°Õ∫¢Õߺ≈‘μ¿—≥±å‰¢¡—π ¡’∑—Èß à«π∑’ˇªìπ long chain triglyceride (LCT) ·≈– medium chain triglyceride (MCT) ´÷Ëß√à“ß°“¬®–¬àÕ¬ ≈“¬·≈–π”‡Õ“ MCT ‰ª„™â‰¥âßà“¬°«à“ ·≈–‡¢â“ Ÿà‰¡‚μ§Õ𠇥√’¬‡æ◊ËÕ°àÕ„À⇰‘¥æ≈—ßß“π‰¥â‡√Á«°«à“ «∏‘ °’ “√„Àâ «à π„À≠®à –殑 “√≥“„Àºâ ≈μ‘ ¿≥— ±‰å ¢¡π— μÕà ‡¡Õ◊Ë ºªŸâ «É ¬∑ø’Ë Õ°‡≈Õ◊ ¥¥«â ¬‡§√Õ◊Ë ß‰μ‡∑¬’ ¡ ‰¡à “¡“√∂®–√—∫ “√Õ“À“√‡¢â“ Ÿà√à“ß°“¬‰¥â‡æ’¬ßæÕπ“πμàÕ‡π◊ËÕß¡“°°«à“ 2  —ª¥“Àå¢÷Èπ‰ª À√◊Õ„π°√≥’∑’Ë ºŸâªÉ«¬‡ªìπ‡∫“À«“π∑’˧ÿ¡‰¥â¬“° ∑”„Àâ‡≈’ˬߡ“„™â‰¢¡—π‡æ◊ËÕ≈¥ª√‘¡“≥°“√„™â “√≈–≈“¬ dextrose ≈߉¥â ¢π“¥‚¥¬∑—Ë«‰ª„πºŸâ„À≠à §◊Õ 0.5-1 °√—¡/πÈ”Àπ—°μ—«‡ªìπ°‘‚≈°√—¡/«—π „π°√≥’∑’ˇªìπ TPN Õ“®®–„À≥⠟ߠÿ¥∂÷ß 2.5 °√—¡/πÈ”Àπ—°μ—«‡ªìπ°‘‚≈°√—¡/«—π ¢π“¥∑’Ë„À⧔π«≥„À≥âª√‘¡“≥¢Õß°√¥‰¢¡—π linoleic √âÕ¬≈– 2-4 ¢Õßæ≈—ßß“π∑—ÈßÀ¡¥ À√◊Õ§‘¥‡ªìπæ≈—ßß“π√âÕ¬≈– 20-35 ¢Õßæ≈—ßß“π∑—ÈßÀ¡¥ °“√„Àâ “√≈–≈“¬‰¢¡—π „Àâ∑“ß venous chamber ‡™àπ°—π·≈–‡√‘Ë¡„Àâμ—Èß·μà™—Ë«‚¡ß·√°¢Õß°“√øÕ°‡≈◊Õ¥√à«¡°—∫ “√≈–≈“¬ dextrose §«√„Àâ 20% ¡“°°«à“ 10% ∑—Èß„π·ßà¢Õߪ√‘¡“μ√∑’Ë®–„Àâ·≈–¢âÕ‡ ’¬¢Õß 10% lipid §◊Õ ∑”„À⺟âªÉ«¬‡ ’ˬßμàÕ°“√‡°‘¥√–¥—∫‰μ√° ≈’‡´Õ‰√¥å„π‡≈◊Õ¥ Ÿß‡°‘π‰¥âßà“¬°«à“¢π“¥ 20% ∑—Èßπ’ȇπ◊ËÕß®“°Õߧåª√–°Õ∫¢Õß 10% ®–¡’ à«π¢Õß phospholipids  Ÿß°«à“ ¢Õâ §«√√–«ß— ¡’¢âÕ∑’˧«√æ‘®“√≥“«à“ ºŸâªÉ«¬‰¡à ¡§«√®–‰¥â√—∫ “√≈–≈“¬‰¢¡—π ‰¥â·°à 1. √–¥—∫‰μ√°≈’‡´Õ‰√¥å„π‡≈◊Õ¥ ßŸ ¡“°°«à“ 350 ¡‘≈≈‘°√—¡/‡¥´‘≈‘μ√ 2. §«“¡¥—π‚≈À‘μμË” À√◊Õ Õ¬àŸ„π ¿“«–™ÁÕ° (impaired hemodynamic) 3. ¢“¥ÕÕ°´‘‡®π (hypoxemia) 4. ¿“«–‡≈◊Õ¥‡ªìπ°√¥ (metabolic acidosis pH < 7.25) 5. Activated intravascular coagulation 6. ºŸâªÉ«¬∑’Ë¡’‚√§μ—∫¢—Èπ√ÿπ·√ß 7. ¿“«– respiratory distress syndrome ‡¡Õ◊Ë ºªŸâ «É ¬‰¥√â ∫—  “√≈–≈“¬‰¢¡π— ‡ªπì §√ß—È ·√°§«√μ√«® Õ∫ ‰¢â Àπ“« π—Ë (®“°°“√·æ∂â «—Ë ‡À≈Õ◊ ß ´÷Ë߇ªìπÕߧåª√–°Õ∫¢Õß “√≈–≈“¬) À√◊ÕÕ“°“√ª«¥»’√…– ª«¥À≈—ß (®“°ÕÕ ‚¡√“≈‘μ’„π‡≈◊Õ¥ ßŸ ) ºâŸªÉ«¬§«√‰¥â√—∫ “√≈–≈“¬ dextrose ·≈– amino acid √à«¡¥â«¬‡ ¡Õ ‡æ◊Ëՙ૬‡√◊ËÕß ¡¥ÿ≈ ‰π‚μ√‡®π ·≈–§«√¡’°“√μ√«® Õ∫√–¥—∫‰μ√°≈’‡´Õ‰√¥å„π‡≈◊Õ¥Õ¬à“ßπâÕ¬‡¥◊Õπ≈– 1 §√—Èß ∂â“√–¥—∫ ‰μ√°≈’‡´Õ‰√¥å„π‡≈◊Õ¥ ßŸ ‡°‘π 400 ¡‘≈≈‘°√—¡/‡¥´‘≈‘μ√ §«√À¬ÿ¥°“√„Àâ “√≈–≈“¬‰¢¡—π Õ’°«‘∏’‡æ◊ËÕ®–¥Ÿ«à“ ºâŸªÉ«¬¡’§«“¡‡ ’ˬßμàÕ°“√„Àâ “√≈–≈“¬‰¢¡—πÀ√◊Õ‰¡à §◊Õ μ√«®√–¥—∫‰μ√°≈’‡´Õ‰√¥å„π‡≈◊Õ¥∑’Ë 6 ™—Ë«‚¡ß À≈—ß®“°„Àâ “√≈–≈“¬‰¢¡—π·≈â« ∂â“√–¥—∫√–¥—∫‰μ√°≈’‡´Õ‰√¥å„π‡≈◊Õ¥ Ÿß°«à“ 250 ¡‘≈≈‘°√—¡/‡¥´‘≈‘μ√ · ¥ß«à“ °“√¢®—¥‰¢¡—π„π‡≈◊Õ¥¢Õߺ⟪ɫ¬‰¡à¥’ ¡’§«“¡‡ ’ˬßμàÕ°“√‡°‘¥√–¥—∫‰¢¡—π„π‡≈◊Õ¥ ßŸ μàÕ‰ª 359

Practical Dialysis in the Year 2009 μ“√“ß∑’Ë 3 · ¥ßº≈‘μ¿—≥±å‰¢¡—π·≈–§ÿ≥ ¡∫—μ‘ º≈μ‘ ¿≥— ±å Emulsifier ·À≈ßà ‰¢¡π— ÕÕ ‚¡≈“√‘μ’/≈‘μ√ °‚‘ ≈·§≈Õ√’ ª√¡‘ “μ√ (¡≈‘ ≈≈‘ μ‘ √) 20% Intralipid Egg yolk Soy bean 200 g 350 500 20% Lipofundin MCT/LCT Egg yolk Soy bean 100 g 380 477 250 20% Lipofundin Egg yolk Soy bean 200 g 380 1000 250 500 4.4 «‘μ“¡‘π·≈–‡°≈◊Õ·√à (vitamins & trace elements) ¬—߉¡à¡’¢âÕ·π–π”À√◊Õ¢âÕ∫àß™’È∑’Ë™—¥‡®π„π°“√„Àâ «‘μ“¡‘πÀ√◊Õ·√à∏“μÿÕ◊ËπÊ „π°√≥’¢Õß IDPN ‡π◊ËÕß®“°ºâŸªÉ«¬ à«π„À≠à®–‰¥â√—∫ “√Õ“À“√À√◊Õ·√à∏“μÿ∫“ß à«π ‚¥¬°“√√—∫ª√–∑“πÀ√◊Õ∑“ß∑àÕ «π ∑“ß®¡°Ÿ Õ¬Ÿà·≈â« ´÷Ëßμà“ß®“°°“√„Àâ total parenteral nutrition ´÷ËßμâÕß„Àâ “√Õ“À“√∑ÿ°Õ¬à“ßμ“¡∑’˺⟪ɫ¬ ·μ≈à –‚√§§«√®–‰¥â Õ¬“à ߉√°μÁ “¡À“°®–¡°’ “√殑 “√≥“„À«â μ‘ “¡π‘ §«√‡≈Õ◊ °‡©æ“–«μ‘ “¡π‘ ∑≈Ë’ –≈“¬π”È ‰¥â ‰¥â·°à «‘μ“¡‘π∫’μà“ßÊ ·≈–«‘μ“¡‘π´’ §«√À≈’°‡≈’ˬ߫‘μ“¡‘π‡Õ  à«π«‘μ“¡‘π‡§ À√◊Õ «‘μ“¡‘πÕ’ æ‘®“√≥“ μ“¡‚√§√à«¡‡∑à“π—Èπ 4.5 Õ—≈∫Ÿ¡‘π (human albumin) ¡’·æ∑¬å‡ªìπ®”π«π¡“°∑’ˇ¢â“„®º‘¥‡°’ˬ«°—∫°“√„Àâ human albumin ‚¥¬§‘¥«à“‡ªìπ°“√„Àâ‡æ◊ËÕ ‡æ‘Ë¡√–¥—∫Õ—≈∫¡Ÿ ‘π„π‡≈◊Õ¥‡æ◊ËÕ·°â‰¢¿“«–‚¿™π“°“√  ‘Ëß∑’˧«√æ‘®“√≥“§◊Õ human albumin ∑’Ë¡’®”Àπà“¬ „π∑âÕßμ≈“¥¡’√“§“·æß¡“°·≈–§ÿ≥ ¡∫—μ‘¢Õß°“√‡ªìπ “√Õ“À“√‡°◊Õ∫‰¡à¡’‡≈¬ πÕ°®“°π’Ȭ—ß∂Ÿ°¬àÕ¬  ≈“¬‰¥âßà“¬¿“¬„π√à“ß°“¬ „πμ”√“‡°’ˬ«°—∫‚¿™π“°“√„πμà“ߪ√–‡∑» À√◊Õ §”·π–π”¥â“π‚¿™π“°“√ ®–‰¡à¡’°“√°≈à“«∂÷ß human albumin ¢âÕ∫àß™’È (∑’ˉ¡à„™à§”·π–π”) ¢Õß°“√„Àâ human albumin „π°√≥’ºâŸªÉ«¬øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕß‰μ ‡∑’¬¡ §◊Õ ¡’§«“¡¥—π‚≈À‘μμË”‡π◊ËÕß¡“®“°√–¥—∫¢ÕßÕ—≈∫Ÿ¡‘π„π‡≈◊Õ¥μË” ‡æ√“–¢“¥Õ—≈∫Ÿ¡‘π„π‡≈◊Õ¥®π ª√‘¡“μ√¢Õß “√πÈ”„πÀ≈Õ¥‡≈◊Õ¥ (intravascular volume) μË”‡∑à“π—Èπ ®π‰¡à “¡“√∂∑”°“√øÕ°‡≈◊Õ¥‰¥â Õ¬à“ß¡’ª√– ‘∑∏‘¿“æ ´÷Ëßμà“ß®“°Õ“°“√∫«¡πÈ”¡“°®π‡°‘¥¿“«– redistribution ¢ÕßÕ—≈∫¡Ÿ ‘π 5. °“√μ‘¥μ“¡º≈¢“â ߇§’¬ß·≈–ª√–‡¡π‘ º≈°“√„À â “√Õ“À“√∑“ßÀ≈Õ¥‡≈◊Õ¥¥” √–À«à“ß°“√øÕ°‡≈Õ◊ ¥ ‡π◊ËÕß®“°°“√„Àâ IDPN Õ“®∑”„À⇰‘¥º≈¢â“߇§’¬ß‰¥â ∑’Ëæ∫∫àÕ¬¡’¥—ßπ’È 1. √–¥∫— π”È μ“≈„π‡≈Õ◊ ¥ ßŸ ´ßË÷ æ∫‰¥∫â Õà ¬„π°√≥¢’ ÕߺªâŸ «É ¬∑‡Ë’ ªπì ‚√§‡∫“À«“πÕ¬‡Ÿà ¥¡‘ À√Õ◊ „π °√≥’∑’ˇªìπ‰μ«“¬‡©’¬∫æ≈—π√à«¡°—∫¿“«–¥◊ÈÕμàÕÕ‘π ÿ≈‘π (insulin resistance) „π‡Àμÿ°“√≥凙àππ’È Õ“®®–„Àâ regular insulin 2-6 ¬Ÿπ‘μ ‡¢â“∑“ßÀ≈Õ¥‡≈◊Õ¥¥” À√◊Õ º ¡≈ß„π “√≈–≈“¬ dextrose ‚¥¬À«—ߺ≈„Àâ√–¥—∫ πÈ”μ“≈„π‡≈◊Õ¥À≈—ßøÕ°‡≈◊Õ¥Õ¬àŸ∑’˪√–¡“≥ 200-300 ¡‘≈≈‘°√—¡/‡¥´‘≈‘μ√ 360

Get to Know çIntradialytic Parenteral Nutritioné 2. √–¥—∫πÈ”μ“≈„π‡≈◊Õ¥μË” (rebound hypoglycemia) Õ“®®–æ∫‰¥â„π°√≥’∑’Ë„À⇩擖  “√≈–≈“¬ dextrose ·≈– °√¥Õ–¡‘‚π ‚¥¬‰¡à‰¥â “√≈–≈“¬‰¢¡—π Õ∏‘∫“¬«à“‡°‘¥®“° °“√°√–μÿâπ°“√À≈—Ëß Õπ‘  ≈ÿ π‘ ®“°μ∫— ÕÕà πÀ≈ß— „Àâ  “√≈–≈“¬ dextrose ·≈–‡¡ÕË◊ À¬¥ÿ „À√â –¥∫— ¢ÕßÕπ‘  ≈ÿ π‘ ∑¬Ë’ ß—  ßŸ Õ¬„àŸ π‡≈Õ◊ ¥Õ“® ®–∑”„Àâ√–¥—∫πÈ”μ“≈„π‡≈◊Õ¥μË”‰¥â «‘∏’°“√ªÑÕß°—π§◊Õ Õ“®„ÀâºâŸªÉ«¬√—∫ª√–∑“π§“√å‚∫‰Œ‡¥√μ —°‡≈Á° πâÕ¬À≈—ß®“°À¬ÿ¥°“√øÕ°‡≈◊Õ¥ 3. º≈¢“â ߇§¬’ ßμÕà √–∫∫À«— „®°“√„À â “√≈–≈“¬∑¡Ë’ æ’ ≈ß— ß“π ßŸ ¡“°Ê„π§√ßÈ— ·√°·°ºà ªŸâ «É ¬Õ“¬ÿ ¡“° À√◊Õ¡’‚√§À—«„® Õ“®®–‡°‘¥º≈¢â“߇§’¬ß‰¥â ‰¥â·°à „® —Ëπ ™’æ®√‡μâπ‡√Á« ‰¢â À—«„®≈⡇À≈«‡©’¬∫æ≈—π „π¢≥–∑’ËøÕ°‡≈◊Õ¥ (ºŸâªÉ«¬®–¡’Õ“°“√‡Àπ◊ËÕ¬‡©’¬∫æ≈—𠧫√øíߪե‡æ◊ËÕøí߇ ’¬ß crepitation) ∑—Èßπ’ȇæ√“– æ≈—ßß“π∑’Ë„À≪‡°‘¥‡ªì𧫓¡√âÕπ„π√à“ß°“¬·≈–°√–μÿâπ√–∫∫ª√– “¡´‘¡æ“‡μ쑧 ¥—ßπ—ÈπμâÕßæ‘®“√≥“ ∂÷ߧ«“¡‡ ’ˬߢÕߺŸâªÉ«¬°àÕπ·≈–μâÕߧ”π«≥ª√‘¡“≥æ≈—ßß“π„ÀâæÕ¥’°—∫∑’˺ŸâªÉ«¬§«√®–‰¥â√—∫ ‰¡à§«√ ¡“°‡°‘π‰ª πÕ°®“°π’ȧ«√„Àâæ≈—ßß“π„π¢π“¥πâÕ¬Ê °àÕπ „πÕ—μ√“ª√–¡“≥ 1 ¡‘≈≈‘≈‘μ√/π“∑’ „π 30 π“∑’·√° √«¡∑—Èßμ√«®«—¥ —≠≠“≥™’æ∫àÕ¬Ê À≈—ß®“°π—Èπ„π§√—Èß∂—¥‰ª®÷ߧàÕ¬‡æ‘Ë¡ª√‘¡“≥‰¥â 4. Refeeding syndrome ‡°‘¥®“°°“√∑’˺⟪ɫ¬¡’¿“«–∑ÿæ‚¿™π“°“√¡“π“π °“√„Àâ “√Õ“À“√ ∑’Ë¡’∑—Èßæ≈—ßß“π·≈–°√¥Õ–¡‘‚π ®–∑”„Àâ¡’°“√π”‡Õ“ “√Õ“À“√‰ª„™â„π°“√ √â“ß‚ª√μ’π„π√à“ß°“¬À√◊Õ ‡´≈≈å®”π«π¡“° ®π∑”„Àâ√–¥—∫¢Õß‚ª·μ ‡´’¬¡„π‡≈◊Õ¥μË” ·≈– øÕ øÕ√— „π‡≈◊Õ¥μË”‰¥â Õ—πμ√“¬∑’Ë Õ“®®–‡°‘¥¢÷Èπ§◊Õ ‡°‘¥¿“«–À—«„®‡μâπº‘¥ª°μ‘ (cardiac arrhythmia) À—«„®À¬ÿ¥‡μâπ (sudden cardiac arrest) À√◊Õ °“√À“¬„®≈⡇À≈« (respiratory failure) °“√‡Ω“Ñ √–«ß— ·≈–°“√·°‰â ¢‰¥·â °à À“§«“¡‡ ¬’Ë ß¢ÕߺªŸâ «É ¬ ‰¥·â °à ºªâŸ «É ¬Õ“¬¡ÿ “° ºªâŸ «É ¬‚√§À«— „® ∑’Ëμ√«®√à“ß°“¬æ∫«à“¡’Õ“°“√¢Õß∑ÿæ‚¿™π“°“√‡¥àπ™—¥ ‰¥â·°à ¥—™π’¡«≈°“¬μË” (body mass index < 18) À√◊Õ wasting syndrome ‡™àπ ‰¡à¡’ temporal fat pad, ‰¡à¡’·√߬◊π®“°°≈â“¡‡π◊ÈÕ≈’∫ À√◊Õ ¡’Õ“°“√´÷¡‡»√â“ ®“°¢“¥Õ“À“√ μ√«®‡≈◊Õ¥æ∫ Õ—≈∫¡Ÿ ‘π„π‡≈◊Õ¥μË”, ‚ª·μ ‡´’¬¡·≈–øÕ øÕ√— „π‡≈◊Õ¥μË” À“°μ√«® æ∫ ‘Ëߥ—ß°≈à“«μâÕß¡’§«“¡√–¡—¥√–«—ß°“√„Àâ IDPN ‡ ¡Õ „π°√≥’‡™àππ’È §«√„À⺟âªÉ«¬√—∫ª√–∑“π oral blenderized diet À√Õ◊ commercial renal nutrition supplement °Õà π ·°‰â ¢¿“«–‚ª·μ ‡´¬’ ¡·≈–øÕ øÕ√—  „π‡≈◊Õ¥μË” À√◊Õª√—∫‚ª·μ ‡´’¬¡„ππÈ”¬“øÕ°‡≈◊Õ¥‰«â∑’Ë 3-4 ¡‘≈≈‘Õ‘§«‘«“‡≈π∑å/≈‘μ√ À√◊Õ º ¡‚ª·μ  ‡´’¬¡ ‚¥¬°“√§”π«≥„π IDPN °Á‰¥â  à«πøÕ øÕ√— Õ“®®–„Àâ√—∫ª√–∑“π À√◊Õº ¡„π IDPN ª√–¡“≥ 10-20 ¡≈‘ ≈‚‘ ¡≈μÕà æ≈ß— ß“π 1000 °‚‘ ≈·§≈Õ√∑’ ºË’ ªâŸ «É ¬‰¥√â ∫— Õ¬“à ߉√°μÁ “¡§«√쥑 μ“¡¥°Ÿ “√√∫— ª√–∑“π¢Õß ºâŸªÉ«¬ À“°ºâŸªÉ«¬√—∫ª√–∑“π‰¥â¡“°¢÷ÈπÕ“®®–‡°‘¥‚ª·μ ‡´’¬¡·≈–øÕ øÕ√— „π‡≈◊Õ¥ ßŸ ‰¥â 5. ¿“«–‰¢¡—π‡°“–μ—∫ (fatty liver, hepatic steatosis) ‡°‘¥®“°°“√∑’˺⟪ɫ¬‰¥â√—∫æ≈—ßß“π¡“° ‡°‘𧫓¡μâÕß°“√ ∑—Èß®“°°“√√—∫ª√–∑“πÕ“À“√√à«¡°—∫°“√‰¥â IDPN À√◊Õ·æ∑¬å„Àâ IDPN ¡“°‡°‘π°«à“ √à“ß°“¬ºŸâªÉ«¬®–√—∫‰¥â πÕ°®“°π’È Õ“®‡°‘¥®“°°“√∑’Ë√à“ß°“¬‰¡à “¡“√∂¬àÕ¬ ≈“¬‰¢¡—π∑’Ë„Àâ∑“ßÀ≈Õ¥ ‡≈◊Õ¥¥”‰ª„™â‰¥âÀ¡¥ ®π‰¢¡—πÀ√◊Õ æ≈—ßß“π à«π‡°‘π∂Ÿ°π”¡“‡°Á∫‰«â∑’Ëμ—∫„π√ªŸ ¢Õ߉°≈‚§‡®π °“√μ√«® ‡≈◊Õ¥®–æ∫ ‡ÕÁπ‰´¡å¢Õßμ—∫º‘¥ª°μ‘ ‰¥â·°à °“√‡æ‘Ë¡¢÷Èπ¢Õß transaminase ·≈– alkali phosphatase 6. º≈¢“â ߇§¬’ ß∑‡’Ë °¥‘ ®“°¿“«–ÕÕ ‚¡≈“√μ‘ „’ π‡≈Õ◊ ¥¢π÷È  ßŸ ‰¥·â °à Õ“°“√ª«¥»√’ …– μ–§√«‘ À√Õ◊ §«“¡¥π— ‚≈Àμ‘  ßŸ √–À«“à ß°“√øÕ°‡≈Õ◊ ¥ Õ“®®–·°‰â ¢‚¥¬°“√ª√∫— ¢π“¥ IDPN À√Õ◊ „Àâ quinine sulfate °Õà π °“√øÕ°‡≈◊Õ¥ À√◊Õ„™â«‘∏’ª√—∫‚´‡¥’¬¡„ππÈ”¬“øÕ°‡≈◊Õ¥ (sodium profiling) 361

Practical Dialysis in the Year 2009 μ“√“ß∑Ë’ 4 °“√μ√«®‡≈◊Õ¥‡æ◊ËÕ„™âμ‘¥μ“¡º≈¢â“߇§’¬ß·≈–°“√√—°…“ Serum 1 hr Pre-dialysis Post-dialysis 2 Weeks Monthly X X Glucose X X X X X X Sodium X X X Potassium X X X Phosphorus X Cholesterol Triglyceride Liver function Kt/V (or URR) ºŸâªÉ«¬∑’ˉ¥â√—∫ IDPN ¡—°®–μÕ∫ πÕßμàÕ°“√√—°…“„π 90-180 «—π ·≈–·æ∑¬å§«√®–À¬ÿ¥°“√ „Àâ IDPN ‰¥â °“√μÕ∫ πÕߥ—ß°≈à“«‰¥â·°à ºâŸªÉ«¬‡√‘Ë¡¡’§«“¡Õ¬“°Õ“À“√¡“°¢÷Èπ πÈ”Àπ—°μ—«·Àâß∑’ˉ¡à‰¥â ‡°‘¥®“°πÈ”‡æ‘Ë¡¢÷Èπ À√◊Õμ√«®æ∫√–¥—∫Õ—≈∫¡Ÿ ‘π„π‡≈◊Õ¥¥’¢÷Èπ ‚¥¬∑—Ë«‰ª∑’Ëπ‘¬¡„™â°—π §◊Õ°“√∑’Ëæ∫«à“ºŸâªÉ«¬  “¡“√∂√—∫ª√–∑“πÕ“À“√‰¥âμ“¡§«“¡μâÕß°“√¢Õß√à“ß°“¬¡“°°«à“√âÕ¬≈– 90 ¥—ßπ—Èπ°“√∑’Ë·æ∑¬åÀ√◊Õ æ¬“∫“≈ („π°√≥’∑’ˉ¡à¡’π—°°”Àπ¥Õ“À“√„πÀπ૬‰μ‡∑’¬¡) ®–∑√“∫ª√‘¡“≥°“√√—∫ª√–∑“πÕ“À“√ ¢ÕߺŸâªÉ«¬‰¥â §◊ÕμâÕß„À⺟âªÉ«¬∑” dietary recall 6. ∫∑ √ªÿ °“√„Àâ “√Õ“À“√∑“ßÀ≈Õ¥‡≈◊Õ¥¥”√–À«à“ß°“√øÕ°‡≈◊Õ¥ ¬—߉¡à¡’∫∑ √ÿª∑’Ë·πà™—¥‡°’ˬ«°—∫ ª√–‚¬™πå∑’Ë®–‰¥â√—∫°—∫§«“¡§ÿâ¡§à“„π°“√≈¥Õ—μ√“°“√쓬¢ÕߺŸâªÉ«¬ ‡π◊ËÕß®“°°“√„Àâ “√≈–≈“¬¥—ß °≈à“«¡’√“§“·æß„π¢π“¥∑’Ë “¡“√∂𔉪„™â‡æ◊ËÕ°“√øÕ°‡≈◊Õ¥‡æ‘Ë¡‰¥âÕ’° ¥—ßπ—Èπ®÷ßÕ¬Ÿà∑’Ë·æ∑¬å∑’Ë®–™à«¬ ·°‰â ¢ “‡ÀμÀÿ ≈°— ¢Õß°“√‡°¥‘ ¿“«–∑æÿ ‚¿™π“°“√°Õà π°“√øÕ°‡≈Õ◊ ¥„À‡â 欒 ßæÕ°“√„ÀÕâ “À“√∑∂’Ë °Ÿ μÕâ ßÀ√Õ◊ „ÀâÕ“À“√‡ √‘¡·∫∫ªíòπ Ÿμ√√—∫ª√–∑“π∑’Ë∑”ßà“¬ √“§“‰¡à·æß √«¡∑—Èß°“√§ÿ¬°—∫ºŸâªÉ«¬·≈–≠“μ‘„π°√≥’∑’Ë ºâŸªÉ«¬¢“¥ “√Õ“À“√¡“°·≈–®”‡ªìπμâÕß„™â “¬ «π®¡Ÿ° À√◊Õºà“π∑“ßÀπâ“∑âÕ߇¢â“≈”‰ â °“√„™â¬“ °√–μÿâ𧫓¡Õ¬“°Õ“À“√ ‡™àπ cyproheptadine À√◊Õ magestrol acetate ∑’Ë¡’√“§“·æß Õ“®π”¡“„™â‰¥â∂â“ ‰¡à¡’¢âÕÀâ“¡ §«√‡°Á∫ IDPN ‰«â„™â„π°√≥’∑’Ë®”‡ªìπ®√‘ßÊ ‡∑à“π—Èπ·≈–·æ∑¬å‰¡à¡’∑“߇≈◊Õ° ‡Õ° “√Õ“â ßÕß‘ 1. Clinical practice guidelines for nutrition in chronic renal failure. K/DOQI, National Kidney Foundation. Am J Kidney Dis. 2000 Jun;35(6 Suppl 2):S1-140. 2. Kopple JD, Foulks CJ, Piraino B, Beto JA, Goldstein J. Proposed Health Care Financing Administration guidelines for reimbursement of enteral and parenteral nutrition. Am J Kidney Dis. 1995 Dec;26(6):995-7. 362

Get to Know çIntradialytic Parenteral Nutritioné 3. Foulks CJ. An evidence-based evaluation of intradialytic parenteral nutrition. Am J Kidney Dis. 1999 Jan;33(1):186- 92. 4. Lazarus JM. Recommended criteria for initiating and discontinuing intradialytic parenteral nutrition therapy. Am J Kidney Dis. 1999 Jan;33(1):211-6. 5. Moore E, Celano J. Challenges of providing nutrition support in the outpatient dialysis setting. Nutr Clin Pract. 2005 Apr;20(2):202-12. 6. ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and Pediatric patients. J Parenter Enteral Nutr. 2002 Jan-Feb;26(1 Suppl):1SA-138SA. 7. Rombeau JL, Rolandelli RH. Clinical Nutritio: Parenteral Nutrition. 3rd edition. W.B.Saunders Company 2001. 8. Kopple JD, Massry SG. Nutritional Management of Renal Disease. 2nd edition. Lippincott Williams and Wilkins 2004. 9. Shills ME, Shike M, Ross AC, Caballero B, Cousins RJ. Modern Nutrition in Health and Disease. 10th edition. Lippincott Williams and Wilkins 2006. 10. Bayham-Gray LD, Burrowes JD, Chertow GM. Nutrition in Kidney Disease. Humana Press 2008. 363



Work Instruction: Automated Peritoneal Dialysis 20 Work Instruction: Automated Peritoneal Dialysis ∏πμ‘ ®√‘ ππ— ∑∏å «™—  ™ÿ “¬ »√’∑æ‘ ¬«√√≥ πæ¡“» ¢” ¡∫μ— ‘  ÿªπí ™ÿ≥À–π—π∑πå π¿‘ “ Õ—¬ “ππ∑å ª“π∑‘æ¬å ‡®μπ«π‘™¬å 1. §”π” 2. ¢âÕ¥¢’ Õß°“√≈“â ߉μ∑“ß™àÕß∑âÕߥ«â ¬‡§√ËÕ◊ ßÕ—μ‚π¡—μ‘ 3. ¢âÕ∫àß™’È·≈–¢âÕ¥Õâ ¬¢Õß°“√√°— …“¥â«¬«‘∏’°“√≈“â ߉μ∑“ß™Õà ß∑Õâ ß ¥«â ¬‡§√◊ËÕßÕμ— ‚π¡μ— ‘ 4. «‘∏’°“√√°— …“μ“à ßÊ ¢Õß°“√≈â“߉μ∑“ß™Õà ß∑âÕߥ⫬‡§√ËÕ◊ ßÕ—μ‚π¡μ— ‘ 5. «‘∏°’ “√∑”≈“â ߉μ∑“ß™àÕß∑Õâ ߥ⫬‡§√◊ÕË ßÕμ— ‚π¡μ— ‘ 6. «∏‘ °’ “√„™â‡§√Õ◊Ë ß≈“â ߉μ∑“ß™Õà ß∑Õâ ß·∫∫Õ—μ‚π¡—μ‘ √àÿπ HomeChoice™ 7. «∏‘ °’ “√„™â‡§√Õ◊Ë ß≈â“߉μ∑“ß™Õà ß∑âÕß·∫∫Õ—μ‚π¡μ— ‘ √πÿà PD Night™ 8.  √ÿª 365

Practical Dialysis in the Year 2009 1. §”π” °“√≈â“߉μ∑“ß™àÕß∑âÕß (Peritoneal Dialysis, PD) ‡ªìπ°“√√—°…“∑¥·∑π‰μ«‘∏’Àπ÷Ëß ‚¥¬ Õ“»¬— °“√·≈°‡ª≈¬’Ë π “√μ“à ßÊ √–À«“à ߇≈Õ◊ ¥ ‡¬Õ◊Ë ∫™ÿ Õà ß∑Õâ ß ·≈– “√„ππÈ”¬“≈“â ߉μ∑„’Ë  ‡à ¢“â ‰ª„π™Õà ß∑Õâ ß ∑”„À⇰‘¥°“√¢®—¥¢Õ߇ ’¬·≈–πÈ” à«π‡°‘πÕÕ°®“°√à“ß°“¬¢ÕߺŸâªÉ«¬‰μ«“¬√–¬– ÿ¥∑⓬ °“√≈â“߉μ ∑“ß™àÕß∑âÕߥ⫬‡§√◊ËÕßÕ—μ‚π¡—μ‘ (Automated Peritoneal Dialysis, APD) À¡“¬∂÷ß °“√≈â“߉μ∑“ß™àÕß ∑âÕß∑ÿ°√ªŸ ·∫∫∑’Ë„™â‡§√◊ËÕßÕ—μ‚π¡—쑇¢â“™à«¬„π°“√‡ª≈’ˬπ∂à“¬πÈ”¬“≈â“ß‰μ‡¢â“·≈–ÕÕ°®“°ºŸâªÉ«¬ «‘∏’°“√ (mode) ∑’Ë„™â‡§√◊ËÕßÕ—μ‚π¡—μ‘™à«¬„π°“√≈â“߉μ∑“ß™àÕß∑âÕß ¥—ßμ“√“ß∑’Ë 1 1-3 μ“√“ß∑Ë’ 1 «‘∏’°“√√—°…“μà“ßÊ ¢Õß°“√≈â“߉μ∑“ß™àÕß∑âÕߥ⫬‡§√◊ËÕßÕ—μ‚π¡—μ‘ 1. °“√≈â“߉μ∑“ß™àÕß∑âÕß™π‘¥μàÕ‡π◊ËÕß (Continuous Peritoneal Dialysis) 1. Continuous Cyclic Peritoneal Dialysis (CCPD) 2. Continuous Ambulatory Peritoneal Dialysis (CAPD) with additional nocturnal exchanges by device 2. °“√≈â“߉μ∑“ß™àÕß∑âÕ߇ªìπ™à«ßÊ (Intermittent Peritoneal Dialysis) 1. Nocturnal Intermittent Peritoneal Dialysis (NIPD) 2. Daytime Intermittent Peritoneal Dialysis (DIPD) 3. °“√≈â“߉μ∑“ß™àÕß∑âÕß·∫∫ tidal (Tidal Peritoneal Dialysis) 1. Nightly Tidal PD (NTPD) 2. Continuous Tidal PD (CTPD) 2. ¢âÕ¥’¢Õß°“√≈â“߉μ∑“ß™Õà ß∑Õâ ߥ«â ¬‡§√◊ÕË ßÕ—μ‚π¡—μ‘ „πÀ≈“¬ª√–‡∑»¡°’ “√≈“â ߉μ∑“ß™Õà ß∑Õâ ߥ«â ¬‡§√Õ◊Ë ßÕμ— ‚π¡μ— ‡‘ æ¡‘Ë ¢π÷È Õ¬“à ß√«¥‡√«Á 4-7 ·≈–Õ“® ®—¥‰¥â«à“‡ªìπ°“√√—°…“∑¥·∑π‰μ∑’Ë¡’Õ—μ√“°“√‡æ‘Ë¡¢÷Èπ¡“°∑’Ë ÿ¥„π∫√√¥“°“√√—°…“∑¥·∑π‰μÀ≈“¬Ê «‘∏’ ∑’ˇªìπ‡™àππ’ȇπ◊ËÕß®“° 1. °“√√—°…“¥â«¬«‘∏’°“√≈â“߉μ∑“ß™àÕß∑âÕß™π‘¥μàÕ‡π◊ËÕß¡“μ√∞“π‡¥‘¡ §◊Õ CAPD ¡’¢âÕ ®”°—¥À≈“¬ª√–°“√‡™àπ ¡’Õ—μ√“°“√μ‘¥‡™◊ÈÕ Ÿß, μâÕß¡’°“√‡ª≈’ˬππÈ”¬“≈â“ß‰μ‡ªìπ™à«ß‡«≈“μ≈Õ¥«—π, æ∫ªí≠À“°“√¥÷ßπÈ”ÕÕ°‰¥â∫àÕ¬ (ultrafiltration failure), ¿“«–·∑√°´âÕπ∑’ˇ°‘¥®“°§«“¡¥—π„π™àÕß∑âÕß ‡æ‘Ë¡ Ÿß¢÷Èπ¡“°, §«“¡∑âÕ∂Õ¬μàÕ°“√√—°…“‡π◊ËÕß®“°μâÕ߇ª≈’ˬπ∂à“¬πÈ”¬“≈â“߉μ∫àÕ¬, ªí≠À“§«“¡≈â¡ ‡À≈«∑’Ë®–≈â“߉μ‡æ◊ËÕ¢®—¥¢Õ߇ ’¬„À≥âμ“¡‡ªÑ“À¡“¬∑’Ë°”Àπ¥‰«â ‡ªìπμâπ 2. §«“¡°â“«Àπâ“¢Õß°“√æ—≤π“·≈–ÕÕ°·∫∫‡§√◊ËÕßÕ—μ‚π¡—μ‘∑’Ë„™â –¥«°·≈–ßà“¬¢÷È𠇙à𠇧√◊ËÕßÕ—μ‚π¡—μ‘√ÿàπ„À¡à¡’¢π“¥‡≈Á°·≈–¡’√Ÿª·∫∫∑’Ë„™âß“πßà“¬¢÷Èπ ·≈– “¡“√∂æ°æ“‡¥‘π∑“߉ª¥â«¬‰¥â, software ·≈– hardware æ—≤π“¥’¢÷Èπ ∑”„À⇧√◊ËÕßÕ—μ‚π¡—μ‘¡’§«“¡ª≈Õ¥¿—¬ Ÿß, ‚ª√·°√¡∑’Ë¡’Õ¬àŸ„π 366

Work Instruction: Automated Peritoneal Dialysis ‡§√◊ËÕß¡“æ√âÕ¡°—∫«‘∏’°“√¬àÕ¬∑ÿ°«‘∏’¢Õß°“√√—°…“„Àâ‡≈◊Õ°„™âμ“¡§«“¡μâÕß°“√, ∫“ß√ÿàπ¡’°“√„™âªíö¡‡æ◊ËÕ §«∫§ÿ¡°“√‡ª≈’ˬπ∂à“¬πÈ”¬“≈â“߉μ ∑”„Àâ¡’§«“¡·¡àπ¬”¡“°¢÷Èπ 3. §à“√—°…“‚¥¬«‘∏’°“√≈â“߉μ∑“ß™àÕß∑âÕߥ⫬‡§√◊ËÕßÕ—μ‚π¡—μ‘¡’·π«‚πâ¡√“§“≈¥≈ß °“√ ≈â“߉μ∑“ß™àÕß∑âÕߥ⫬‡§√◊ËÕßÕ—μ‚π¡—μ‘¡’§à“„™â®à“¬ Ÿß°«à“ ‡π◊ËÕß®“°√“§“‡§√◊ËÕßÕ—μ‚π¡—μ‘  “¬¬“߇™◊ËÕ¡ μÕà 懑 »…∑„Ë’ ™§â √ßÈ— ‡¥¬’ «∑ßÈ‘ ·≈–πÈ”¬“≈“â ߉μ Õ¬“à ߉√°μÁ “¡√“§“¡·’ π«‚π¡â ∑®Ë’ –≈¥≈߇¡ÕË◊ ¡º’ „⟠™«â ∏‘ π’ ¡È’ “°¢πÈ÷ °“√„™â𔬓≈â“ß‰μ‡ªìπ∂ÿߪ√‘¡“μ√¡“°Õ“®™à«¬„Àâ§à“„™â®à“¬≈¥≈ß „πª√–‡∑» À√—∞Õ‡¡√‘°“°“√≈â“߉μ ∑“ß™àÕß∑âÕߥ⫬‡§√◊ËÕßÕ—μ‚π¡—μ‘¡’§à“„™â®à“¬ Ÿß°«à“«‘∏’ CAPD ª√–¡“≥√âÕ¬≈– 10-30 ‡¡◊ËÕ„™â«‘∏’°“√≈â“ß ‰μ∑“ß™àÕß∑âÕߥ⫬‡§√◊ËÕßÕ—μ‚π¡—μ‘√–¬–¬“«Õ“®∑”„Àâ¡’§à“„™â®à“¬‚¥¬√«¡∂Ÿ°≈ß ‡π◊ËÕß®“°¡’Õ—μ√“°“√ μ‘¥‡™◊ÈÕ·≈–Õ—μ√“°“√πÕπ√—°…“μ—«„π‚√ß欓∫“≈πâÕ¬°«à“ 4. °“√„™â™’«‘μª√–®”«—π –¥«°¢÷Èπ °“√≈â“߉μ∑“ß™àÕß∑âÕߥ⫬‡§√◊ËÕßÕ—μ‚π¡—μ‘∑”„Àâ™à«ß °≈“ß«—π‰¡àμâÕß≈â“ß‰μ  “¡“√∂∑”ß“πÀ√◊Õ∑”°‘®°√√¡‰¥âÕ¬à“ßÕ‘ √–„π™à«ß‡«≈“°≈“ß«—π ®÷߇À¡“– ¡ °—∫π—°‡√’¬π π—°»÷°…“ æπ—°ß“π ·≈–¬—߇À¡“– ¡Õ¬à“߬‘Ëß„πºâŸªÉ«¬∑’ˉ¡à “¡“√∂∑”°“√≈â“߉μ∑“ß™àÕß ∑âÕߥ⫬μπ‡Õ߉¥â μâÕßæ÷Ëßæ“≠“μ‘∑”≈â“߉μ„Àâ ¥—ßπ—Èπ∂Ⓡª≈’Ë¬π‰ª„™â«‘∏’°“√≈â“߉μ∑“ß™àÕß∑âÕߥ⫬ ‡§√◊ËÕßÕ—μ‚π¡—μ‘ ®–∑”„Àâ≠“μ‘¡’‡«≈“·≈– “¡“√∂∑”°‘®°√√¡‰¥âÕ¬à“ßÕ‘ √–„π™à«ß‡«≈“°≈“ß«—π ¥—ßπ—Èπ ®÷߇À¡“– ¡„πºŸâªÉ«¬∑’Ë ŸßÕ“¬ÿ ¡’ªí≠À“¥â“π “¬μ“ À√◊պ⟪ɫ¬∑’ËÕ¬Ÿà„π ∂“π√—∫¥Ÿ·≈ºâŸªÉ«¬‡√◊ÈÕ√—ß πÕ°®“°π—Èπ®“°°“√»÷°…“æ∫«à“ºâŸªÉ«¬∑’Ë√—°…“¥â«¬«‘∏’°“√≈â“߉μ∑“ß™àÕß∑âÕߥ⫬‡§√◊ËÕßÕ—μ‚π¡—μ‘®–¡’ Õ—μ√“°“√®â“ßß“π¡“°°«à“«‘∏’ CAPD 5. ·æ∑¬å·≈–欓∫“≈‡√‘Ë¡‡¢â“„®·≈–¬Õ¡√—∫‡∑§π‘§°“√√—°…“¥â«¬°“√≈â“߉μ∑“ß™àÕß∑âÕß ¥â«¬‡§√◊ËÕßÕ—μ‚π¡—μ‘¡“°¢÷Èπ 3. ¢âÕ∫àß™’È·≈–¢âÕ¥âÕ¬¢Õß°“√√—°…“¥â«¬«‘∏’°“√≈â“߉μ∑“ß™àÕß∑âÕߥ⫬‡§√Ë◊Õß Õμ— ‚π¡—μ‘ ‰¥â √ÿª‰«â„πμ“√“ß∑’Ë 2 μ“√“ß∑Ë’ 2 ¢âÕ∫àß™’È·≈–¢âÕ¥âÕ¬¢Õß°“√√—°…“¥â«¬«‘∏’°“√≈â“߉μ∑“ß™àÕß∑âÕߥ⫬‡§√◊ËÕßÕ—μ‚π¡—μ‘ Indication of APD Disadvantages of APD 1. Patients preference 1. Machine dependent feel 2. Special age groups: pediatric, elderly or 2. More complex patients requiring assistance 3. English interface 3. High transporter 4. Cycler transportation for traveler 4. Achieve higher small solute clearance 5. Sleep disturbance: sense of fluid movement, 5. Quality of life noises and alarms 6. Constraining at night 367

Practical Dialysis in the Year 2009 4. «‘∏°’ “√√°— …“μ“à ßÊ ¢Õß°“√≈“â ߉μ∑“ß™Õà ß∑âÕߥ⫬‡§√Õ◊Ë ßÕ—μ‚π¡μ— ‘ ®–°≈à“«√“¬≈–‡Õ’¬¥∂÷ß«‘∏’°“√À≈—°¢Õß°“√√—°…“¥â«¬«‘∏’ APD ¥—ßπ’È 4.1 Continuous Cyclic Peritoneal Dialysis (CCPD) ‡ªìπ°“√√—°…“¥â«¬«‘∏’ APD ™π‘¥‡¥’¬«∑’Ë¡’°“√≈â“߉μÕ¬à“ßμàÕ‡π◊ËÕßμ≈Õ¥ 24 ™—Ë«‚¡ß8-9 ¥—ß√Ÿª∑’Ë 1 ‚¥¬∑”°“√‡ª≈’ˬπ∂à“¬πÈ”¬“≈â“߉μ 3-5 √Õ∫ „π™à«ß‡«≈“°≈“ߧ◊πª√–¡“≥ 9 ™—Ë«‚¡ß √à«¡°—∫°“√·™à πÈ”¬“≈â“ß‰μ‰«â„π™àÕß∑âÕß„π‡«≈“°≈“ß«—πÕ’° 15 ™—Ë«‚¡ß∑’ˇÀ≈◊Õ ‚¥¬μ—Èß‚ª√·°√¡¢Õ߇§√◊ËÕß„Àâª≈àÕ¬ πÈ”¬“≈â“ß‰μ‡¢â“™àÕß∑âÕßÕ¬à“߇¥’¬«„π√Õ∫ ÿ¥∑⓬¢Õß™à«ß∑’Ë∑”¥â«¬‡§√◊ËÕß (last fill bag) ∑”„Àâ«‘∏’π’È¥Ÿ ‡À¡◊Õπ‡ªìπ«‘∏’∑’ˬâÕπ°≈—∫°—∫«‘∏’ CAPD «‘∏’ CCPD ‡ªìπ«‘∏’°“√√—°…“¥â«¬«‘∏’ APD ∑’Ëπ‘¬¡„™â°—π¡“°∑’Ë ÿ¥ °“√·≈°‡ª≈¬’Ë π¢Õ߇ ¬’ ‚¡‡≈°≈ÿ ‡≈°Á (small solutes clearance) ¢Õß«∏‘ ’ CCPD ®–μË”°«“à «∏‘ ’ CAPD ‡≈Á°πâÕ¬ „πºâŸªÉ«¬∑’Ë¡’Õ—μ√“°“√‰À≈‡«’¬π¢ÕßπÈ”¬“≈â“߉μ‡∑à“°—π §à“Õ—μ√“°“√¢®—¥¢Õ߇ ’¬™π‘¥ middle molecules „πÀπß÷Ë  ª— ¥“À¢å Õß«∏‘ ’ CCPD ®–‡∑“à °∫— «∏‘ ’ CAPD °“√‡æ¡‘Ë ª√¡‘ “≥°“√¢®¥— ¢Õ߇ ¬’ ¢Õß«∏‘ ’ CCPD Õ“®∑”‰¥‚â ¥¬‡æ¡‘Ë ª√¡‘ “μ√¢ÕßπÈ”¬“≈“â ߉μ∑·’Ë ™‰à «„â π™Õà ß∑Õâ ß‡æ¡‘Ë ®”π«π‡ª≈¬’Ë π∂“à ¬πÈ”¬“„π™«à ß°≈“ߧπ◊ À√◊Õ‡ √‘¡°“√‡ª≈’ˬπ∂à“¬πÈ”¬“≈â“ß‰μ‚¥¬‰¡à„™â‡§√◊ËÕ߇æ‘Ë¡¢÷Èπ„π™à«ß‡«≈“°≈“ß«—π «‘∏’°“√ CCPD π’ȇÀ¡“– ¡¡“°∑’Ë ÿ¥ ”À√—∫‡¥Á°π—°‡√’¬π·≈–æπ—°ß“π∫√‘…—∑´÷Ë߇ªìπ°≈ÿࡧπ∑’Ë ‰¡à –¥«°À√◊Õ‰¡àμâÕß°“√∑’Ë®–‡ª≈’ˬπ∂à“¬πÈ”¬“≈â“߉μ„π™à«ß‡«≈“°≈“ß«—π ºŸâªÉ«¬≈â“߉μ∑“ß™àÕß∑âÕß∑’Ë ‰¡à “¡“√∂∑”‡Õ߉¥â μâÕß¡’ºâŸ¥·Ÿ ≈¥”‡π‘π°“√„Àâ ‡ªìπ°≈ÿࡺŸâªÉ«¬∑’ˇÀ¡“– ¡°—∫«‘∏’ CCPD ¡“°°«à“ CAPD ‡™àπ‡¥’¬«°—π ®”π«π¢Õß°“√μàÕ·≈–°“√ª≈¥¢âÕμàÕ ”À√—∫∑”°“√≈â“߉μ∑“ß™àÕß∑âÕß∑’Ë≈¥πâÕ¬≈ß¡“° ∑”„Àâ –¥«°·°à°“√∑”·≈–≈¥‚Õ°“ °“√μ‘¥‡™◊ÈÕ≈߉¥â¡“° ∑”„Àâ«‘∏’°“√ CCPD Õ“®‡À¡“– ¡°—∫‚√ß æ¬“∫“≈¢π“¥„À≠à∑’ËμâÕߥŸ·≈ºŸâªÉ«¬≈â“߉μ∑“ß™àÕß∑âÕ߇ªìπ®”π«π¡“° πÕ°®“°π—Èπ«‘∏’ CCPD Õ“®„™â √«à ¡°∫— «∏‘ ’ CAPD  ”À√∫— ºªŸâ «É ¬∑¡Ë’ §’ ≥ÿ  ¡∫μ— °‘ “√´¡÷ º“à π¢Õ߇¬ÕË◊ ∫™ÿ Õà ß∑Õâ ßμ”Ë °«“à §“à ‡©≈¬Ë’ (below-average peritoneal membrane permeability) ·≈–‰¡à “¡“√∂≈â“ß‰μ‰¥âÕ¬à“߇撬ßæÕ‚¥¬«‘∏’ CAPD Õ¬à“߇¥’¬« √Ÿª∑’Ë 1 √Ÿª·∫∫°“√‡ª≈¬Ë’ π∂à“¬πÈ”¬“≈“â ߉μ¢Õß«‘∏’°“√√°— …“ CCPD 368

Work Instruction: Automated Peritoneal Dialysis ¢âÕ®”°—¥¢Õß«‘∏’°“√ CCPD ‰¥â·°à Õ—μ√“¢®—¥§√’Õ–μ‘π’π·≈–¢Õ߇ ’¬™π‘¥ middle molecules ®–πâÕ¬°«à“°“√√—°…“¥â«¬«‘∏’ CAPD ºâŸªÉ«¬∑’Ë¡’§ÿ≥ ¡∫—μ‘°“√´÷¡ºà“π¢Õ߇¬◊ËÕ∫ÿ™àÕß∑âÕ߇ªìπ™π‘¥ low transporter Õ“®¡’°“√¢®—¥¢Õ߇ ’¬∑’ˉ¡à‡æ’¬ßæÕ ‡π◊ËÕß®“°√–¬–‡«≈“°“√·™àπÈ”¬“≈â“߉μ„π™àÕß∑âÕß™à«ß ‡«≈“°≈“ߧ◊π —Èπ 4.2 Nightly Intermittent Peritoneal Dialysis (NIPD) ‡ªπì °“√√°— …“¥«â ¬«∏‘ ’ APD ∑¡’Ë °’ “√≈“â ß‰μ‡©æ“–™«à ߇«≈“°≈“ߧπ◊ ‰¡μà Õà ‡πÕ◊Ë ßμ≈Õ¥ 24 ™«—Ë ‚¡ß ·≈–‰¡à¡’°“√·™àπÈ”¬“≈â“ß‰μ‰«â„π™àÕß∑âÕß™à«ß‡«≈“°≈“ß«—π ∑”„Àâ∑âÕß·Àâß„π‡«≈“°≈“ß«—π (dry-day abdomen)10-12 ¥—ß√Ÿª∑’Ë 2 ‚¥¬∑”°“√‡ª≈’ˬπ∂à“¬πÈ”¬“‚¥¬„™â‡§√◊ËÕßÕ—μ‚π¡—μ‘„π‡«≈“°≈“ߧ◊π ª√–¡“≥ 9-12 ™—Ë«‚¡ß ·≈–„™âª√‘¡“μ√πÈ”¬“≈â“߉μ∑—ÈßÀ¡¥ª√–¡“≥ 8-12 ≈‘μ√ «‘∏’°“√ NIPD π’ȉ¥âº≈¥’„πºŸâªÉ«¬∑’Ë¡’§ÿ≥ ¡∫—μ‘°“√´÷¡ºà“π¢Õ߇¬◊ËÕ∫ÿ™àÕß∑âÕ߇ªìπ™π‘¥ high transporter ´ß÷Ë À“°·™πà È”¬“≈“â ß‰μ‰«„â π™Õà ß∑Õâ ßπ“π ®–∑”„ÀÕâ μ— √“°“√¥ß÷ πÈ”ÕÕ°‰¥πâ Õâ ¬≈ß ·μ«à ∏‘ °’ “√ NIPD π’ÈÕ“®¡’¢âÕ®”°—¥∑’Ë ”§—≠§◊Õ ‡π◊ËÕß®“°°“√‰¡à·™àπÈ”¬“≈â“ß‰μ‰«â„π™àÕß∑âÕß™à«ß‡«≈“°≈“ß«—π ®–∑”„Àâ °“√¢®¥— ¢Õ߇ ¬’ ‚¡‡≈°≈ÿ ‡≈°Á ≈¥≈ß√Õâ ¬≈– 20 ·≈–°“√¢®¥— ¢Õ߇ ¬’ ™π¥‘ middle molecules ≈¥≈߉¥∂â ß÷ √Õâ ¬≈– 50 (‡¡◊ËÕ‡∑’¬∫°—∫«‘∏’ NIPD ∑’Ë·™àπÈ”¬“≈â“ß‰μ‰«â„π™àÕß∑âÕß™à«ß‡«≈“°≈“ß«—π¥â«¬) ∑”„ÀâμâÕß√–«—ߪ√‘¡“≥ °“√≈â“߉μ∑’ËÕ“®®–‰¡à‡æ’¬ßæÕ ´÷ËßÕ“®æ∫„πºâŸªÉ«¬∑’Ë¡’§ÿ≥ ¡∫—μ‘°“√´÷¡ºà“π¢Õ߇¬◊ËÕ∫ÿ™àÕß∑âÕ߇ªìπ™π‘¥ low, low average ·≈– high average transporter ‚¥¬‡©æ“–Õ¬à“߬‘Ëß„πºŸâªÉ«¬∑’Ë¡’Õ—μ√“°“√∑”ß“π¢Õ߉μ ∑’ˇÀ≈◊ÕÕ¬àŸμË”¡“° √ªŸ ∑’Ë 2 √Ÿª·∫∫°“√‡ª≈ˬ’ π∂“à ¬πÈ”¬“≈“â ߉μ¢Õß«‘∏’°“√√°— …“ NIPD 369

Practical Dialysis in the Year 2009 «‘∏’°“√ NIPD π’È ®÷߇À¡“– ”À√—∫ºâŸªÉ«¬∑’Ë¡’§ÿ≥ ¡∫—μ‘°“√´÷¡ºà“π¢Õ߇¬◊ËÕ∫ÿ™àÕß∑âÕ߇ªìπ™π‘¥ high transporter ™÷Ëß≈â“ß‰μ‚¥¬«‘∏’Õ◊Ëπ·≈â«¡’Õ—μ√“°“√¥÷ßπÈ”ÕÕ°‰¥âπâÕ¬ ·≈–‡À¡“–Õ¬à“߬‘Ëß°—∫ºŸâªÉ«¬∑’Ë¡’ ¿“«–·∑√°´âÕπ®“°°“√¡’§«“¡¥—π„π™àÕß∑âÕß Ÿß ´÷Ë߇°‘¥®“°°“√·™àπÈ”¬“≈â“ß‰μ‰«â„π™àÕß∑âÕß™à«ß‡«≈“ °≈“ß«—π  ”À√—∫ºâŸªÉ«¬∑’Ë¡’Õ—μ√“°“√∑”ß“π¢Õ߉μ∑’ˇÀ≈◊ÕÕ¬Ÿà¡“°  “¡“√∂π”«‘∏’π’ȉª„™â‡ªìπ«‘∏’‡√‘Ë¡μâπ≈â“ß ‰μ„π™à«ß·√° «‘∏’π’È¡’Õ—μ√“°“√¥Ÿ¥´÷¡°≈Ÿ‚§ „π™à«ß‡«≈“°≈“ß«—ππâÕ¬°«à“ ∑”„À⧫“¡√⟠÷°Õ¬“°Õ“À“√ ·≈–‰¡à√⟠÷°Õ‘Ë¡ßà“¬„π™à«ß‡«≈“°≈“ß«—π ·≈–‡À¡“–°—∫ºâŸªÉ«¬∑’ËμâÕß°“√„Àâ∫ÿ§≈‘°¿“楟¥’ ‚¥¬‰¡àμâÕß°“√ ·™àπÈ”¬“≈â“ß‰μ‰«â„π™àÕß∑âÕß™à«ß‡«≈“°≈“ß«—π ¢âÕ®”°—¥¢Õß«‘∏’°“√ NIPD ‰¥â·°à «‘∏’π’ÈÕ“®‰¡à‡À¡“– ¡°—∫ºŸâªÉ«¬μ—«„À≠à ºŸâªÉ«¬∑’Ë¡’ §ÿ≥ ¡∫—μ‘°“√´÷¡ºà“π¢Õ߇¬◊ËÕ∫ÿ™àÕß∑âÕ߇ªìπ™π‘¥ low, low average ·≈– high average transporter ∑’Ë¡’ Õ—μ√“°“√∑”ß“π¢Õ߉μ∑’ˇÀ≈◊ÕÕ¬àŸμË”¡“° ·≈–Õ“®∑”„À⺟âªÉ«¬μâÕß„™â‡«≈“πÕπÕ¬Ÿà°—∫‡μ’¬ßπ“π¢÷Èπ 4.3 Tidal Peritoneal Dialysis (TPD) ‡ªìπ°“√√—°…“¥â«¬«‘∏’ APD ∑’˺ ¡º “π«‘∏’°“√≈â“ß‰μ‡©æ“–™à«ß √à«¡°—∫ ‡∑§‚π‚≈¬’§«∫§ÿ¡ °“√‰À≈¢ÕßπÈ”¬“≈â“߉μÕ¬à“ßμàÕ‡π◊ËÕß ‚¥¬®–√—°…“√–¥—∫πÈ”¬“≈â“ß‰μ‰«â„π™àÕß∑âÕ߉«â√–¥—∫Àπ÷Ë߇ ¡Õ (reserve volume) ∑”„Àâ¡’°“√·≈°‡ª≈’ˬπ¢Õ߇ ’¬ºà“π‡¬◊ËÕ∫ÿ™àÕß∑âÕ߇°‘¥¢÷Èπμ≈Õ¥‡«≈“ «—μÿª√– ß§å¢Õß«‘∏’°“√π’ȇæ◊ËÕ„À⇰‘¥ª√‘¡“≥°“√≈â“ß‰μ Ÿß ÿ¥ ‚¥¬°”®—¥™à«ß√–¬–‡«≈“‡ª≈à“ ª√–‚¬™πå∑’ˉ¡à¡’πÈ”¬“≈â“߉μÕ¬àŸ„π™àÕß∑âÕ߇≈¬ ‡π◊ËÕß®“°°“√≈â“ß‰μ«‘∏’°“√Õ◊Ëπ ®–¡’™à«ß‡«≈“°“√‡ª≈’ˬπ ∂à“¬πÈ”¬“≈â“ß‰μ‡¢â“-ÕÕ°®“°™àÕß∑âÕß ´÷Ë߇ªìπ‡«≈“∑’Ë Ÿ≠‡ª≈à“‡π◊ËÕß®“°‰¡à‡°‘¥°“√≈â“߉μ¢÷Èπ °“√≈â“ß‰μ ¥â«¬«‘∏’ TPD ®–√—°…“√–¥—∫ reserve volume ‰«âª√–¡“≥√âÕ¬≈– 50 ¢Õߪ√‘¡“μ√πÈ”¬“∑’ËÕ¬àŸ„π™àÕß∑âÕß ·≈–¡’°“√∂à“¬πÈ”¬“‡¢â“·≈–ÕÕ°„πª√‘¡“≥∑’ˇÀ≈◊Õ (tidal volume) 13-15 ¥—ß√ªŸ ∑’Ë 3 ∑”„Àâ¡’πÈ”¬“≈â“߉μ·≈– ¡’°“√·≈°‡ª≈’ˬπ¢Õ߇ ’¬Õ¬àŸμ≈Õ¥‡«≈“°“√‡ª≈’ˬπ∂à“¬πÈ”¬“≈â“ß‰μ‡¢â“-ÕÕ°®“°™àÕß∑âÕß √Ÿª∑Ë’ 3 √ªŸ ·∫∫°“√‡ª≈’ˬπ∂“à ¬π”È ¬“≈â“߉μ¢Õß«∏‘ ’°“√√—°…“ TPD 370

Work Instruction: Automated Peritoneal Dialysis «‘∏’ TPD π’È¡’¢âÕ®”°—¥∑’Ë ”§—≠§◊Õ À“°πÈ”¬“≈â“߉μ∑’˧â“ßÕ¬àŸ„π™àÕß∑âÕß¡’ª√‘¡“≥¢Õ߇ ’¬ ¡“°„°≈â∂÷ß®ÿ¥Õ‘Ë¡μ—« ®–∑”„À≡ࡒ°“√·≈°‡ª≈’ˬπ¢Õ߇ ’¬‡°‘¥¢÷Èπ·¡â®–¡’πÈ”¬“≈â“߉μ§â“߉«â„π™àÕß∑âÕß μ≈Õ¥‡«≈“ ∑”„Àâª√– ‘∑∏‘¿“æ¢Õß°“√≈â“߉μμË”≈߉¥â¡“° ´÷ËßÕ“®·°â‰¢‚¥¬μâÕ߇æ‘Ë¡ª√‘¡“μ√¢Õß°“√ ≈â“߉μ·μà≈–√Õ∫„Àâ¡“°¢÷Èπ «‘∏’°“√ TPD π’È °”≈—ß Ÿ≠‡ ’¬§«“¡π‘¬¡≈߉ª ‡π◊ËÕß®“°®“°°“√»÷°…“„π ªí®®ÿ∫—πæ∫«à“‰¡à “¡“√∂¢®—¥¢Õ߇ ’¬‰¥â‡æ‘Ë¡¢÷Èπ¡“°π—° Õ¬à“߉√°Áμ“¡«‘∏’ TPD Õ“®‡À¡“– ¡∑’Ë®–π”¡“ „™â„πºŸâªÉ«¬ APD ∑’Ë¡’°“√√–∫“¬πÈ”¬“≈â“߉μÕÕ°™â“À√◊Õ‰¡àÀ¡¥ ∑”„À⇰‘¥ªí≠À“‡§√◊ËÕ߇μ◊Õπ (alarms) ∫àÕ¬Ê16 5. «∏‘ ’°“√∑”≈“â ߉μ∑“ß™àÕß∑Õâ ߥ«â ¬‡§√ÕË◊ ßÕ—μ‚π¡—μ‘ (APD) „πªí®®ÿ∫—π‡§√◊ËÕß≈â“߉μ∑“ß™àÕß∑âÕß·∫∫Õ—μ‚π¡—μ‘∑’Ëπ‘¬¡„™â„πª√–‡∑»‰∑¬¡’Õ¬Ÿà 2 √ÿàπ §◊Õ HomeChoice™ ¢Õß∫√‘…—∑ Baxter ¥—ß√Ÿª∑’Ë 4 ·≈– PD Night™ ¢Õß∫√‘…—∑ Fresenius ¥—ß√ªŸ ∑’Ë 5 §«“¡·μ° μà“ߢÕ߇§√◊ËÕß∑—Èß 2 √ÿàπ∑’Ë ”§—≠§◊Õ √–∫∫§«∫§ÿ¡°“√‡ª≈’ˬπ∂à“¬πÈ”¬“≈â“ß‰μ‡¢â“-ÕÕ°®“°™àÕß∑âÕß ‚¥¬ ‡§√◊ËÕß HomeChoice™ „™â√–∫∫ªíö¡ PD Night™ „™â√–∫∫·√ß‚πâ¡∂à«ß μàÕ‰ª®–°≈à“«∂÷ß«‘∏’°“√„™â‡§√◊ËÕß≈â“ß ‰μ∑“ß™àÕß∑âÕß·∫∫Õ—μ‚π¡—μ‘∑—Èß Õß√ÿàπ √ªŸ ∑Ë’ 4 ‡§√Ë◊Õß HomeChoice™ ¢Õß∫√…‘ —∑ Baxter 371

Practical Dialysis in the Year 2009 √ªŸ ∑Ë’ 5 ‡§√Õ◊Ë ß PD Night™ ¢Õß∫√…‘ —∑ Fresenius 372

Work Instruction: Automated Peritoneal Dialysis 6. «∏‘ ’°“√„™‡â §√Õ◊Ë ß≈“â ߉μ∑“ß™Õà ß∑Õâ ß·∫∫Õ—μ‚π¡μ— ‘ √ÿàπ HomeChoice™ 1. °“√μ—ßÈ §“à μ—«·ª√μ“¡·ºπ°“√√—°…“ (CHANGE PROGRAM) 1. ‡ª¥î ‡§√Õ◊Ë ß·≈–√ÕÀπ“â ®Õ· ¥ß§”«“à çPRESS GO TO STARTé „À°â ¥ W À“§”«“à çCHANGE PROGRAMé „Àâ°¥ªÿÉ¡«ß°≈¡ ’πÈ”‡ß‘π (ENTER) 2. Àπâ“®Õ®–· ¥ß§à“μ—«·ª√„Àâμ—Èß§à“ (‚¥¬‡≈◊Õ°°¥ W, V ·≈– «ß°≈¡ ’πÈ”‡ß‘π (ENTER)) 2.1. THERAPY (CCPD/IPD, TIDAL, HI-CCPD, HI-TIDAL) = √Ÿª·∫∫°“√√—°…“ (ª°μ‘„Àâ‡≈◊Õ° CCPD/IPD) 2.2. TOTAL VOLUME (200 - 80,000 ml) = ª√‘¡“≥πÈ”¬“∑—ÈßÀ¡¥∑’Ë„™â„π·ºπ°“√√—°…“ 2.3. THERAPY TIME (10 min. - 48 hr.) = ‡«≈“∑’Ë„™â„π·ºπ°“√√—°…“ 2.4. FILL VOLUME (100 - 3,000 ml.) = ª√‘¡“≥πÈ”¬“∑’Ë‡μ‘¡„π·μà≈–√Õ∫ 2.5. LAST FILL VOLUME (0 - 3,000 ml.) = ª√‘¡“≥πÈ”¬“∑’Ë‡μ‘¡§â“ß∑âÕ߉«âÀ≈—ß ‘Èπ ÿ¥ °“√√—°…“ (wet day therapy) 2.6. DEXTROSE (SAME OR DIFFERENT) = §«“¡·μ°μà“ߢÕß % πÈ”¬“∂ÿß ÿ¥∑⓬  “¬μ—«Àπ’∫ ’øÑ“ (LAST FILL BAG) °—∫ % ¢ÕßπÈ”¬“∂ÿßÕ◊ËπÊ „π‡§√◊ËÕß (®–· ¥ß‡¡◊ËÕμ—Èß§à“ LAST FILL VOLUME > 0) 2.7. I-DRAIN ALARM (OFF - 3,000 ml.) = °“√°”Àπ¥ª√‘¡“≥ DRAIN VOLUME „Àâ ‡§√◊ËÕß DRAIN πÈ”¬“∑‘Èß°àÕπ‡√‘Ë¡°“√√—°…“ (®–· ¥ß„Àâμ—Èß§à“‡¡◊ËÕ§à“ LAST FILL VOLUME > 0) 3. °¥ªÿÉ¡ ’·¥ß (STOP) ‡§√◊ËÕß®–°≈—∫‰ªÀπâ“®Õ‡¥‘¡ çPRESS GO TO STARTé 4. À≈ß— °¥ª¡ÿÉ  ·’ ¥ß (STOP) ‡§√Õ◊Ë ßæ√Õâ ¡„™ßâ “π·≈–®–§”π«≥§“à °“√∑”ß“π„ÀÕâ μ— ‚π¡μ— ‘ 2 §“à §◊Õ 4.1. NUMBER OF CYCLE (®”π«π√Õ∫∑—ÈßÀ¡¥„π·ºπ°“√√—°…“) 4.2. DWELL TIME (√–¬–‡«≈“∑’ËπÈ”¬“§â“ß„π™àÕß∑âÕß·μà≈–√Õ∫) À¡“¬‡Àμÿ: °“√μ—Èß§à“·ºπ°“√√—°…“‡¡◊ËÕμ—È߇ √Á®‡§√◊ËÕß®–∫—π∑÷°‰«â∂“«√·≈– “¡“√∂„™â‰¥â μ≈Õ¥‚¥¬‰¡àμâÕßμ—ÈߴȔՒ° ¬°‡«âπ¡’°“√‡ª≈’ˬπ·ª≈ߧà“μ—«·ª√μ“¡·ºπ°“√√—°…“¢Õß·æ∑¬å 373

Practical Dialysis in the Year 2009 2. °“√‡√Ë¡‘ μπâ °“√√°— …“μ“¡ª°μ‘ (START THERAPY) ≈â“ß¡Õ◊ §√ß—È ∑Ë’ 1 - „ àºâ“ªî¥ª“°/®¡°Ÿ ‡™Á¥‚μä–‡μ√’¬¡Õÿª°√≥å (∂ÿßπÈ”¬“, ™ÿ¥μ≈—∫ “¬, ®ÿ°ªî¥ ’¢“«, ∂—ßπÈ”∑‘Èß) - μ√«®∂ÿßπÈ”¬“ («π— À¡¥Õ“¬,ÿ ª√¡‘ “≥, §«“¡‡¢¡â ¢πâ , ª≈Õ°æ≈“ μ°‘ ª¥î ®°ÿ , ‡¥Õ◊ ¬ ‡’ ¢¬’ «, §«“¡„ ¢Õßπ”È ¬“) - ·°–∂ÿßπÈ”¬“«“ß∫π‡§√◊ËÕßæ√âÕ¡∂ÿßπÈ”¬“ ”√Õß - ‡ªî¥ «‘∑™å‡§√◊ËÕß Àπâ“®Õ®–· ¥ß....... 1. PLEASE WAIT (√Õ —°§√àŸ) STANDARD MODE ON (‡ªî¥√ªŸ ·∫∫¡“μ√∞“π) PLEASE WAIT (√Õ —°§√àŸ) 2. PRESS GO TO START („Àâ°¥ ªÿÉ¡ ’‡¢’¬«) 374

Work Instruction: Automated Peritoneal Dialysis 3. LOAD THE SET („ àμ≈—∫ “¬) - ‡ªî¥ª√–μ„Ÿ  àμ≈—∫ “¬·≈–ªî¥ª√–μŸ ·¢«π·ºß ’πÈ”‡ß‘πæ√âÕ¡™ÿ¥ “¬‰«âÀπ⓪√–μŸ - ªî¥μ—«Àπ’∫∑’Ë™ÿ¥ “¬∑ÿ°μ—« (6 μ—«) - π” “¬ª≈àÕ¬πÈ”¬“∑‘Èß≈ß∂—ß ( “¬¢«“ ÿ¥) ‡ √Á®·≈â« °¥ªÿÉ¡ ‡’ ¢’¬« 4. SELF TESTING - √Õ —°§√Ÿà (~ 3 π“∑’) ‡§√◊ËÕß°”≈—ß∑¥ Õ∫μπ‡Õß 5. CONNECT BAGS ≈â“ß¡Õ◊ §√È—ß∑Ë’ 2 - μÕà ∂ßÿ π”È ¬“‚¥¬ “¬ μ«— Àπ∫’  ·’ ¥ß „Àμâ Õà ∂ßÿ π”È ¬“∫π‡§√ÕË◊ ß À°— ¢Õâ μÕà  ‡’ ¢¬’ « ‡ª¥î μ«— Àπ∫’ ·≈–μÕà  “¬μ«— Àπ’∫ ’¢“«À√◊ÕπÈ”‡ß‘π „π∂ÿßπÈ”¬“∂ÿß∂—¥‰ª À—°¢âÕμàÕ ’‡¢’¬« ‡ªî¥μ—«Àπ’∫ - ‡ªî¥μ—«Àπ’∫ “¬∑’ËμàÕ°—∫ºŸâªÉ«¬ ( “¬´â“¬ ÿ¥) 375

Practical Dialysis in the Year 2009 6. PRIMING - √Õ —°§√àŸ (~ 10 π“∑’) ‡§√◊ËÕß°”≈—߉≈àÕ“°“»ÕÕ°®“°μ≈—∫ “¬ - ‡μ√’¬¡ºâ“°ÁÕ  æ≈“ ‡μÕ√å  “¬Àπâ“∑âÕߺ⟪ɫ¬„Àâæ√âÕ¡ 7. CONNECT YOURSELF / CHECK PATIENT LINE ≈â“ß¡Õ◊ §√—Èß∑Ë’ 3 - μàÕ “¬ºŸâªÉ«¬ ‡ªî¥«“≈å« (®—∫ ’øÑ“ À¡ÿπ ’¢“«‡ªî¥) ‡ √Á®·≈â« °¥ªÿÉ¡ ’‡¢’¬« 8. VERIFY I-DRAIN = 0 ML (OFF) °¥ªÉÿ¡ ’‡¢’¬« 9. INITIAL DRAIN ‡§√◊ËÕ߇√‘Ë¡μâπ°“√√—°…“‚¥¬ª≈àÕ¬πÈ”¬“ÕÕ°®“°∑âÕß°àÕπ 376

Work Instruction: Automated Peritoneal Dialysis ‡¡◊ËÕ‡§√◊ËÕ߇√‘Ë¡∑”ß“π Àπâ“®Õª°μ‘®–· ¥ß ∂“π– °“√∑”ß“π‡ªìπ«ß®√ §◊Õ 1. FILL nn. OF nn.; ‡μ‘¡πÈ”¬“√Õ∫∑’Ë............ ®“°∑—ÈßÀ¡¥... √Õ∫ 2. DWELL nn. OF nn.; §â“ßπÈ”¬“„π∑âÕß√Õ∫∑’Ë... ®“°∑—ÈßÀ¡¥... √Õ∫ 3. DRAIN nn. OF nn.; ª≈àÕ¬πÈ”¬“ÕÕ°√Õ∫∑’Ë.... ®“°∑—ÈßÀ¡¥... √Õ∫ √–À«à“߇§√◊ËÕß°”≈—ß∑”ß“π “¡“√∂°¥ W ‡æ◊ËÕ¥°Ÿ “√∑”ß“π·μà≈–«ß®√·≈–∫—π∑÷° TOTAL UF (°”‰√ / ¢“¥∑ÿπ∑—ÈßÀ¡¥ μ—Èß·μà√Õ∫∑’Ë 1 - ªí®®ÿ∫—π) ·≈â«°¥ V ‡æ◊ËÕ°≈—∫‰ªÀπâ“®Õª°μ‘ °“√‡¢â“ MANUAL DRAIN 1. °¥ªÿÉ¡ ’·¥ß (STOP) ‡æ◊ËÕÀ¬ÿ¥‡ ’¬ß‡μ◊Õπ 2. °¥ À“§”«à“ çMANUAL DRAINé 3. °¥ ENTER ‡æ◊ËÕª≈àÕ¬πÈ”¬“ÕÕ° Àπâ“®Õ®–· ¥ß§”«à“ çDRAIN VOLUME ... MLé 4. °¥ªÿÉ¡ ’·¥ß (STOP) ‡æ◊ËÕ ‘Èπ ÿ¥°“√ª≈àÕ¬πÈ”¬“ 5. °¥ªÿÉ¡ ’‡¢’¬« ‡æ◊ËÕ‡√‘Ë¡°“√√—°…“μàÕ‰ª °“√ BYPASS ‡æÕË◊ ¢â“¡¢—ÈπμÕπ 1. °¥ªÿÉ¡ ’·¥ß STOP 2. °¥ À“§”«à“ BYPASS 3. °¥ ENTER ‡æ◊Ëբⓡ¢—ÈπμÕπ (∂Ⓡ§√◊ËÕ߬—߉¡à„Àâºà“π„Àâ°¥‡À¡◊Õπ‡¥‘¡Õ’°§√—Èß ‡æ◊ËÕ¬◊π¬—π°“√¢â“¡¢—ÈπμÕπ) 3. °“√ πÈ‘  ¥ÿ °“√√°— …“μ“¡ª°μ‘ (END OF THERAPHY) ≈“â ß¡Õ◊ §√—Èß∑1’Ë ‡μ√’¬¡´Õß®ÿ°ªî¥ ’¢“« „ àºâ“ªî¥ª“°ªî¥®¡°Ÿ 1. END THE THERAPY °“√°¥¥Ÿº≈√«¡°“√¥÷ßπ”È ®“°ºŸâªÉ«¬ (TOTAL UF) °¥ W À“ I-DRAIN ·≈â«∫—π∑÷° °¥ W À“ TOTAL UF ·≈â«∫—π∑÷° °¥ª¡Éÿ  ’‡¢’¬« 377

Practical Dialysis in the Year 2009 2. CLOSE ALL CLAMPS ªî¥«“≈嫺⟪ɫ¬ (®—∫ ’øÑ“ À¡ÿπ ’¢“«ªî¥) ªî¥μ—«Àπ’∫∑ÿ°μ—« ‡ √Á®·≈â« °¥ªÉÿ¡ ’‡¢’¬« 3. DISCONNECT YOURSELF / CLOSE ALL CLAMPS ≈“â ß¡◊Õ§√—Èß∑’Ë 2 ‡ªî¥´Õß®ÿ° ’¢“« ª≈¥ “¬ºŸâªÉ«¬ ªî¥®ÿ° ’¢“«‡ √Á®·≈â« °¥ªÿÉ¡ ‡’ ¢¬’ « 4. TURN ME OFF ‡ªî¥ª√–μŸ π”μ≈—∫πÈ”¬“ÕÕ° ªî¥ª√–μŸ ªî¥‡§√◊ËÕß 4. °“√‡√Ë‘¡°“√√—°…“·∫∫ IPD ‚¥¬„™μâ ≈—∫ “¬π”È ¬“‡¥‘¡ À≈ß— ®“°‡§√Õ◊Ë ß π‘È  ¥ÿ °“√√°— …“ (END OF THERAPY) „Àªâ Ø∫‘ μ— ‡‘ À¡Õ◊ π°“√ π‘È  ¥ÿ °“√√°— …“ª°μ‘ ·μà‰¡àμâÕߪ≈¥ “¬ºâŸªÉ«¬·≈–‰¡à‡Õ“μ≈—∫ “¬πÈ”¬“ÕÕ°·≈–„Àâ§â“ß∂ÿßπÈ”¬“‡¥‘¡‰«â ·≈⫪§√◊ËÕß∑‘È߉«â ~ 5-10 π“∑’ ®÷߇ªî¥‡§√◊ËÕß„À¡à·≈–ªØ‘∫—쑇À¡◊Õπ°“√‡√‘Ë¡°“√√—°…“μ“¡ª°μ‘®π∂÷ߢ—ÈπμÕπ çCONNECT BAGSé ↓„ÀâμàÕ‡ª≈’ˬπ∂ÿßπÈ”¬“‡°à“ÕÕ°∑‘Èß ↓À—°‡¥◊Õ¬ ’‡¢’¬«∑’˪“°∂ÿßπÈ”¬“ (‡©æ“–∂ÿßπÈ”¬“√–∫∫‡°≈’¬«À¡ÿπ) ↓‡ªî¥μ—«Àπ’∫‡©æ“– “¬∑’Ë„™â ↓μàÕ “¬πÈ”∑‘Èß≈ß∂—ß ↓°¥ªÿÉ¡ ’‡¢’¬« (GO) çPRIMINGé ↓√Õ ~ 10 π“∑’ çCONNECT YOURSELFé ↓‡ªî¥μ—«Àπ’∫ “¬πÈ”¬“¥â“πºâŸªÉ«¬ 378

Work Instruction: Automated Peritoneal Dialysis ↓‡ªî¥«“≈å«∑àÕ≈â“߉μ (°√≥’„™â mini transfer set) ↓°¥ªÿÉ¡ ’‡¢’¬« (GO) çINITIAL DRAINé = ‡√‘Ë¡μâπ°“√∑”ß“πÕ—μ‚π¡—μ‘... À¡“¬‡Àμÿ 1. À≈ß— °“√μÕà ∂ßÿ πÈ”¬“„À¡„à À∑â “ povidine ·≈–À¡ÿâ °ÕÁ  ∫√‡‘ «≥ª“°∂ßÿ πÈ”¬“∑°ÿ §√ß—È ( ”À√∫— ∂ßÿ πÈ”¬“√–∫∫ ‡ ’¬∫; Spike) 2. °“√μàÕ‡ª≈’ˬπ∂ÿßπÈ”¬“„À¡à„Àâ∑“ povidine °àÕπ·≈–À≈—ß ·≈–Àÿâ¡°ÁÕ ∫√‘‡«≥ª“°∂ÿßπÈ”¬“∑ÿ°§√—Èß ( ”À√—∫∂ÿßπÈ”¬“√–∫∫‡ ’¬∫; Spike) 3. °“√μàÕ∂ÿßπÈ”¬“·∫∫§«“¡‡¢â¡¢âπ Ÿß (HYPERTONIC) 1:1= 1.5% : 4.25% 1. °√≥’ TOTAL VOLUME = 10 L / THERAPY „ÀâμàÕ “¬μ—«Àπ’∫ ’·¥ß‡ªìπ 4.25%, μ—«Àπ’∫ ’¢“«‡ªìπ 1.5% 2. °√≥’ TOTAL VOLUME = 20 L / THERAPY „ÀâμàÕ “¬μ—«Àπ’∫ ’·¥ß·≈–¢“«‡ªìπ 4.25%,  à«π  “¬μ—«Àπ’∫ ’¢“«·≈–øÑ“∑’ˇÀ≈◊Õ‡ªìπ 1.5% 3. °√≥’ TOTAL VOLUME = 30 L / THERAPY μàÕ‡À¡◊Õπ 20 L / THERAPY ·μà„ÀâμàÕπÈ”¬“‡æ‘Ë¡‡¡◊ËÕ  “¬ SUPPLY LINE À¡¥ ‚¥¬μàÕ “¬μ—«Àπ’∫ ’¢“«¥â«¬ 4.25%,  “¬μ—«Àπ’∫ ’øÑ“¥â«¬ 1.5% 4. °“√‡μ‘¡¬“„π∂ÿßπÈ”¬“„Àâ„™â povidine ∑“∫√‘‡«≥®ÿ°‡μ‘¡¬“∑ÿ°§√—Èß 5. °“√∑” IPD ¥â«¬‡§√◊ËÕß HomeChoice  “¡“√∂„™âμ≈—∫ “¬πÈ”¬“‡¥‘¡μàÕ‡π◊ËÕ߉¥â‰¡à‡°‘π 3 «—π 6. °“√‡°Á∫πÈ”¬“ àßμ√«® 1. ∑”‰¥â√–À«à“߇§√◊ËÕß°”≈—ß DRAIN πÈ”¬“∑‘Èß·μà≈–√Õ∫ 2. ‚¥¬‡ªî¥μ—«Àπ’∫·≈–®ÿ°ªî¥∑’Ë “¬‡°Á∫ SAMPLE ª≈àÕ¬„À⇧√◊ËÕß DRAIN πÈ”¬“∑‘Èß —°§√Ÿà°àÕπ‡°Á∫ ~ 10-20 CC. 3. „Àâ∑“ povidine ∑ÿ°§√—ÈßÀ≈—߇°Á∫·≈–ªî¥®ÿ° 5. °“√ πÈ‘  ¥ÿ °“√√°— …“ (END THE THERAPY) ∑“ß≈¥— ªî¥‡§√◊ËÕß·≈⫇ªî¥„À¡à Àπâ“®Õ®–· ¥ß§”«à“ çPLEASE WAITé ↓√Õ —°§√àŸ çPOWER RESTOREDé ↓°¥ªÿÉ¡ ’·¥ß (STOP) À¬ÿ¥‡ ’¬ß√âÕß ↓°¥ W ∫—π∑÷° I-DRAIN VOLUME ↓°¥ W Õ’°§√—Èß∫—π∑÷° TOTAL UF ↓°¥ W À“§”«à“ çEND THE THERAPYé çEND THE THERAPYé ↓°¥ªÿÉ¡ ’πÈ”‡ß‘π (ENTER) çCLOSE ALL CLAMPSé = „ÀâªØ‘∫—μ‘μàÕ‰ª‡À¡◊Õπ°“√ ‘Èπ ÿ¥°“√√—°…“ª°μ‘ 379

Practical Dialysis in the Year 2009 6. ªí≠À“∑’Ëæ∫‰¥â∫àÕ¬·≈–°“√·°â‰¢ (TROUBLE SHOOTING) °“√ àß —≠≠“≥‡μ◊Õπ¡’ 3 ·∫∫ ‚¥¬ªí≠À“∑’ˇ°‘¥¢÷Èπ®–· ¥ß∑“ßÀπâ“®Õ 1. AUTO RESTART ALARM; ‡§√◊ËÕß®–√âÕ߇μ◊Õπ 2 √Õ∫·≈–·°â‰¢ªí≠À“‡ÕßÕ—μ‚π¡—μ‘ ‚¥¬‰¡à μâÕß°¥ªÿÉ¡„¥Ê ‡¡◊ËÕªí≠À“·°â‰¢‰¡à‰¥â ‡§√◊ËÕß®– àß —≠≠“≥‡μ◊Õπ‡ªìπ·∫∫ MANUAL RESTART ALARM - √Õ∫∑’Ë 1 √âÕ߇μ◊Õπ 3 §√—Èß ·≈â«°≈—∫¡“·°âªí≠À“‡ÕßÕ—μ‚π¡—μ‘ - √Õ∫∑’Ë 2 √âÕ߇μ◊Õπ 6 §√—Èß ·≈â«°≈—∫¡“·°âªí≠À“‡ÕßÕ—μ‚π¡—μ‘ - √Õ∫∑’Ë 3 √âÕ߇μ◊Õπ·∫∫ MANUAL RESTART ALARM 2. MANUAL RESTART ALARM; ‡§√◊ËÕß®–√âÕ߇μ◊ÕπμàÕ‡π◊ËÕ߉¡àÀ¬ÿ¥®π°«à“®–°¥ªÿÉ¡ ’·¥ß (STOP) 3. SYSTEM ERROR ALARM; ‡§√Õ◊Ë ß®–√Õâ ߇μÕ◊ πμÕà ‡πÕ◊Ë ß‰¡Àà ¬¥ÿ ®π°«“à ®–°¥ª¡ÿÉ  ·’ ¥ß (STOP) 6.1 LOW DRAIN VOLUME 1.  “‡Àμÿ ‡°‘¥®“°ª√‘¡“≥πÈ”¬“∑’˪≈àÕ¬ÕÕ°¡“„π√Õ∫π—ÈπÊ πâÕ¬°«à“§à“∑’Ë°”Àπ¥„π NURSEûS MENU (%MIN DRAIN VOLUME; 60-125%) ´÷Ëßμ—È߉«â°àÕπ°“√√—°…“ °“√ àß —≠≠“≥‡ªìπ·∫∫ AUTO RESTART ALARM 2. °“√·°‰â ¢ 1. „Àâæ≈‘°μ–·§ßμ—«‡ª≈’ˬπ∑à“ºŸâªÉ«¬ ·≈⫇§√◊ËÕß®–·°â‰¢ªí≠À“‡Õß 2. ‡¡ÕË◊ ª≠í À“·°‰â ¡‰à ¥°â “√ ßà  ≠— ≠“≥®–‡ªπì ·∫∫ MANUAL RESTART ALARM „À°â ¥ª¡Éÿ  ’·¥ß (STOP) ·≈–°¥ª≈àÕ¬πÈ”¬“‚¥¬‰¡à„™â‡§√◊ËÕß (MANUAL DRAIN) μ“¡¢—ÈπμÕπ¢â“ßμâπ ‡¡◊ËÕμâÕß°“√  ‘Èπ ÿ¥°“√ª≈àÕ¬πÈ”¬“„Àâ°¥ªÿÉ¡ ’·¥ß (STOP) ·≈â«°¥ªÿÉ¡ ’‡¢’¬« (GO) „À⇧√◊ËÕß∑”ß“πμàÕ 3. ∂â“·°âªí≠À“‰¡à‰¥â„Àâ¢â“¡¢—ÈπμÕπ ( BYPASS) μ“¡¢—ÈπμÕπ¢â“ßμâπ À¡“¬‡Àμ:ÿ °“√¢“â ¡¢π—È μÕπ°“√ª≈Õà ¬πÈ”∑ß‘È (DRAIN) Õ“®∑”„À¡â π’ È”§“â ߇À≈Õ◊ „π™Õà ß∑Õâ ß ·≈– ‡ªìπÕ—πμ√“¬μàպ⟪ɫ¬‰¥â §«√ª√÷°…“‡®â“Àπâ“∑’Ë°àÕπ∑ÿ°§√—Èß 6.2 CHECK DRAIN LINE, CHECK FINAL LINE, CHECK HEATER LINE, CHECK PATIENT LINE, CHECK SUPPLY LINE 1.  “‡Àμÿ ‡°¥‘ ®“° “¬À°— æ∫— ßÕ,  “¬∂°Ÿ Õ¥ÿ °πÈ— , ‰¡‰à ¥‡â ª¥î μ«— Àπ∫’ À√Õ◊ «“≈«å ∑Õà ≈“â ߉μ, π”È ¬“ À¡¥∂ÿß °“√ àß —≠≠“≥‡ªìπ·∫∫ AUTO RESTART ALARM 2. °“√·°‰â ¢ 1. μ√«® Õ∫ “¬, μ—«Àπ’∫, «“≈å«∑àÕ≈â“߉μ, ·∑à߇¥◊Õ¬ ’‡¢’¬«, ‡¬◊ËÕ«ÿâπÀ√◊Õ™‘Èπ‡≈◊Õ¥·≈– ∂ÿßπÈ”¬“ ·≈â«·°âªí≠À“∑’Ëæ∫ ·≈–‰¡àμâÕß°¥ªÿÉ¡„¥Ê 2. ∂Ⓡ§√◊ËÕß√âÕ߉¡àÀ¬ÿ¥‡ªìπ·∫∫ MANUAL RESTART ALARM „Àâ°¥ªÿÉ¡ ’·¥ß (STOP) ·≈â«·°âªí≠À“μ“¡∑’ËÀπâ“®Õ· ¥ß ·≈â«°¥ªÿÉ¡ ’‡¢’¬« (GO) „Àâ∑”ß“πμàÕ 380

Work Instruction: Automated Peritoneal Dialysis 6.3 CHECK LINE AND BAGS 1.  “‡Àμÿ ‡°‘¥®“° “¬„¥ “¬Àπ÷Ëß∂Ÿ°Õÿ¥°—ÈπÀ√◊Õ∂ÿßπÈ”¬“À¡¥ °“√ àß —≠≠“≥‡ªìπ·∫∫ MANUAL RESTAR ALARM 2. °“√·°‰â ¢ 1. °¥ªÿÉ¡ ’·¥ß (STOP) 2. μ√«® Õ∫ “¬, μ—«Àπ’∫, «“≈å«∑àÕ≈â“߉μ, ·∑à߇¥◊Õ¬ ’‡¢’¬«, ‡¬◊ËÕ«ÿâπÀ√◊Õ™‘Èπ‡≈◊Õ¥·≈– ∂ÿßπÈ”¬“ ·≈â«·°âªí≠À“∑’Ëæ∫ 3. °¥ªÿÉ¡ ’‡¢’¬« (GO) „Àâ∑”ß“πμàÕ 6.4 CHECK THERAPY TIME, CHECK TOTAL VOLUME, CHECK TIDAL VOLUME %, CHECK TOTAL UF 1.  “‡Àμÿ ‡°¥‘ ®“°°“√μßÈ— §“à μ«— ·ª√º¥‘ ‡§√ÕË◊ ߉¡ à “¡“√∂§”π«≥μßÈ— ‚ª√·°√¡∑”ß“π‰¥â °“√  àß —≠≠“≥‡ªìπ·∫∫ MANUAL RESTART ALARM 2. °“√·°â‰¢ 1. °¥ªÿÉ¡ ’·¥ß (STOP) 2. ‡ª≈’ˬπ§à“μ—«·ª√∑’˺‘¥ 3. °¥ªÿÉ¡ ’·¥ß (STOP) ‡æ◊ËÕÕÕ°®“°°“√μ—Èß‚ª√·°√¡°“√∑”ß“π 6.5 DRAIN NOT FINISHED, FILL NOT FINISHED, REFILL NOT FINISHED, TESTING NOT FINISHED 1.  “‡Àμÿ ‡°¥‘ ®“°¡°’ “√°¥¢“â ¡¢π—È μÕπ BYPASS √–À«“à ߇§√Õ◊Ë ß°”≈ß— ∑”ß“π¢π—È μÕπππ—È Ê °“√  àß —≠≠“≥‡ªìπ·∫∫ MANUAL RESTART ALARM 2. °“√·°‰â ¢ 1. °¥ªÿÉ¡ ’·¥ß (STOP) 2. μ√«® Õ∫°“√¢â“¡¢—ÈπμÕπ BYPASS «à“ºŸâªÉ«¬®–ª≈Õ¥¿—¬À√◊Õ‰¡à 3. ∂“â ¬π◊ ¬π— ¢“â ¡¢π—È μÕπ BYPASS „À°â ¥ ? À“§”«“à çBYPASSé ·≈«â °¥ª¡ÿÉ  π’ È”‡ßπ‘ (ENTER) 6.6 SLOW FLOW HEATER, SLOW FLOW PATIENT, SLOW FLOW SUPPLY, SLOW FLOW DRAIN 1.  “‡Àμÿ ‡°¥‘ ®“° “¬μ∫’ æ∫— ßÕ, ¡ ’ ß‘Ë °¥’ ¢«“ß ∑”„Àπâ È”¬“‰À≈μ“¡ “¬μ“à ßÊ ‰¥™â “â ¡“° ∑”„Àâ ‡«≈“„π°“√§â“ßπÈ”¬“„π™àÕß∑âÕß (DEWELL TIME) ≈¥≈ß ·≈–ª√– ‘∑∏‘¿“æ„π°“√≈â“߉μ≈¥≈ß °“√ àß  —≠≠“≥‡ªìπ·∫∫ AUTO RESTART ALARM 2. °“√·°â‰¢ 1. μ√«® Õ∫ “¬, μ—«Àπ’∫, «“≈å«∑àÕ≈â“߉μ, ·∑à߇¥◊Õ¬ ’‡¢’¬«, ‡¬◊ËÕ«ÿâπÀ√◊Õ™‘Èπ‡≈◊Õ¥·≈– ∂ÿßπÈ”¬“ ·≈â«·°âªí≠À“∑’Ëæ∫ ‚¥¬‰¡àμâÕß°¥ªÿÉ¡„¥Ê 381

Practical Dialysis in the Year 2009 2. ∂Ⓡ§√◊ËÕß√âÕ߉¡àÀ¬ÿ¥‡ªìπ·∫∫ MANUAL RESTART ALARM „Àâ°¥ªÿÉ¡ ’·¥ß (STOP) ·≈â«·°âªí≠À“μ“¡∑’ËÀπâ“®Õ· ¥ß ·≈â«°¥ªÿÉ¡ ’‡¢’¬« (GO) „Àâ∑”ß“πμàÕ 6.7 MACHINE TILTED 1.  “‡Àμÿ ‡°¥‘ ®“°°“√«“߇§√Õ◊Ë ß∫πæπ◊È ∑‰’Ë ¡√à “∫‡√¬’ ∫ ‡§√Õ◊Ë ß π—Ë  –‡∑Õ◊ π °“√ ßà  ≠— ≠“≥‡ªπì ·∫∫ AUTO RESTART ALARM ∂Ⓡ°‘¥¢≥–Àπâ“®Õ· ¥ß çPRESS GO TO STARTé °“√ àß —≠≠“≥ ‡ªìπ·∫∫ MANUAL RESTART ALARM 2. °“√·°â‰¢ 1. ®—¥μ”·Àπà߇§√◊ËÕß„Àâ¡—Ëπ§ß 2. ∂Ⓡ§√◊ËÕß√âÕ߉¡àÀ¬ÿ¥‡ªìπ·∫∫ MANUAL RESTART ALARM „Àâ°¥ªÿÉ¡ ’·¥ß (STOP) ·≈â«·°âªí≠À“μ“¡∑’ËÀπâ“®Õ· ¥ß ·≈â«°¥ªÿÉ¡ ’‡¢’¬« (GO) „Àâ∑”ß“πμàÕ 6.8 CHECK YOUR POSITION 1.  “‡Àμÿ ‡°‘¥®“°μ”·Àπà߇§√◊ËÕß ŸßÀ√◊ÕμË”°«à“μ—«ºŸâªÉ«¬¡“°°«à“ 1 øÿμ °“√ àß —≠≠“≥ ‡ªìπ·∫∫ AUTO RESTART ALARM 2. °“√·°‰â ¢ 1. ®—¥μ”·Àπà߇§√◊ËÕß„ÀâÕ¬Ÿà„π√–¥—∫‡¥’¬«°—∫ºâŸªÉ«¬À√◊ՠߟ μË”‰¡à‡°‘π 1 øÿμ 2. ∂Ⓡ§√◊ËÕß√âÕ߉¡àÀ¬ÿ¥‡ªìπ·∫∫ MANUAL RESTART ALARM „Àâ°¥ªÿÉ¡ ’·¥ß (STOP) ·≈â«·°âªí≠À“μ“¡∑’ËÀπâ“®Õ· ¥ß ·≈â«°¥ªÿÉ¡ ’‡¢’¬« (GO) „Àâ∑”ß“πμàÕ 6.9 RELOAD THE SET 1.  “‡Àμÿ ‡°‘¥§«“¡º‘¥ª°μ‘∑’Ë°“√„ àμ≈—∫πÈ”¬“À√◊Õ∑’Ë√–∫∫ °“√ àß —≠≠“≥‡ªìπ·∫∫ MANUAL RESTART ALARM 2. °“√·°‰â ¢ 1. °¥ªÿÉ¡ ’·¥ß (STOP) 2. ªî¥μ—«Àπ’∫∑ÿ°μ—« 3. ‡ªî¥ª√–μŸ„ àμ≈—∫πÈ”¬“„À¡àÕ’°§√—Èß 4. ‡ªî¥μ—«Àπ’∫∑ÿ°μ—«·≈â«°¥ªÿÉ¡ ’‡¢’¬« (GO) „Àâ∑”ß“πμàÕ 6.10 CAUTION NEGATIVE UF 1.  “‡Àμÿ ‡°‘¥®“°°”‰√/¢“¥∑ÿπ μ—Èß·μà‡√‘Ë¡°“√√—°…“ (TOTAL UF) ¢“¥∑ÿπ¡“°°«à“ 50% ¢Õß FILL VOLUME/CYCLE °“√ àß —≠≠“≥‡ªìπ·∫∫ MANUAL RESTART ALARM 2. °“√·°â‰¢ 1. °¥ªÿÉ¡ ’·¥ß (STOP) 2. æ≈‘°μ–·§ßμ—«‡ª≈’ˬπ∑à“ºŸâªÉ«¬ 382

Work Instruction: Automated Peritoneal Dialysis 3. °¥ª¡ÿÉ  ‡’ ¢¬’ « (GO) „À∑⠔ߓπμÕà À“â ¡°¥¢“â ¡¢π—È μÕπ BYPASS ‡¥¥Á ¢“¥ ¬°‡«πâ ‡®“â Àπ“â ∑’Ë Õπÿ≠“μ 6.11 SYSTEM ERROR 1.  “‡Àμÿ ‡°‘¥®“°√–∫∫¢—¥¢âÕß °“√ àß —≠≠“≥‡ªìπ·∫∫ MANUAL RESTART ALARM 2. °“√·°â‰¢ 1. °¥ªÿÉ¡ ’·¥ß (STOP) ·≈â«®¥∫—π∑÷°μ—«‡≈¢∫πÀπâ“®Õ 2. ªî¥‡§√◊ËÕß·≈–‚∑√μ‘¥μàÕ‡®â“Àπâ“∑’Ë∫√‘…—∑ 6.12 WARMING SOLUTION 1.  “‡Àμÿ ‡°‘¥®“°Õÿ≥À¿Ÿ¡‘∂ÿßπÈ”¬“∫π‡§√◊ËÕ߬—߉¡à∂÷ߧà“∑’Ë°”À𥉫â 2. °“√·°‰â ¢ 1. „Àâμ√«® Õ∫∂ÿßπÈ”¬“∫π‡§√◊ËÕß«à“«“ß∑—∫ªÿÉ¡ heater À√◊Õ‰¡à 2. ‰¡àμâÕß°¥ªÿÉ¡„¥Ê ‡§√◊ËÕß®–ÕÿàππÈ”¬“·≈–°≈—∫¡“∑”ß“π‡ÕßÕ—μ‚π¡—μ‘ 6.13 POWER FAILURE 1.  “‡Àμÿ ‡°‘¥®“°‰øøÑ“¢—¥¢âÕßÀ√◊Õ¥—∫ ‡§√◊ËÕß®–À¬ÿ¥∑”ß“π·≈–ªî¥μ—«‡ÕßÕ—μ‚π¡—μ‘ 2. °“√·°â‰¢ 1. ∂ⓉøøÑ“¡“¿“¬„π 30 π“∑’ °“√ àß —≠≠“≥‡ªìπ·∫∫ AUTO RESTART ALARM ‡§√◊ËÕß ®–°≈—∫¡“∑”ß“πμàÕ®“°¢—ÈπμÕπ∑’˧â“߉«â‡ÕßÕ—μ‚π¡—μ‘ ‰¡àμâÕß°¥ªÿÉ¡„¥Ê 2. ∂“â ‰øø“Ñ ¡“À≈ß— 30 π“∑’ ·μ‰à ¡‡à °π‘ 2 ™¡. °“√ ßà  ≠— ≠“≥‡ªπì ·∫∫ MANUAL RESTART ALARM „Àâ°¥ªÿÉ¡ ’·¥ß (STOP) ·≈â«°¥ªÿÉ¡‡¢’¬« (GO) ‡§√◊ËÕß®–°≈—∫¡“∑”ß“πμàÕ®“°¢—ÈπμÕπ∑’˧â“߉«â 3. ∂ⓉøøÑ“¡“À≈—ß 2 ™¡. Àπâ“®Õ®–· ¥ß çPRESS GO TO STARTé μâÕ߇√‘Ë¡°“√√—°…“ „À¡à (START THERAPY) μ“¡¢—ÈπμÕπ¢â“ßμâπ „Àâ‚∑√μ‘¥μàÕ‡®â“Àπâ“∑’Ë∫√‘…—∑ 383

Practical Dialysis in the Year 2009 7. «‘∏°’ “√„™‡â §√ËÕ◊ ß≈â“߉μ∑“ß™Õà ß∑Õâ ß·∫∫Õμ— ‚π¡μ— ‘ √ÿàπ PD Night™ 384

Work Instruction: Automated Peritoneal Dialysis 385

Practical Dialysis in the Year 2009 386

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