Practical Dialysis in the Year 2009

Practical Dialysis in the Year 2009 388

Work Instruction: Automated Peritoneal Dialysis 389

Practical Dialysis in the Year 2009 390

Work Instruction: Automated Peritoneal Dialysis 391

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Work Instruction: Automated Peritoneal Dialysis 393

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Work Instruction: Automated Peritoneal Dialysis 395

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Work Instruction: Automated Peritoneal Dialysis 397

Practical Dialysis in the Year 2009 398

Work Instruction: Automated Peritoneal Dialysis 399

Practical Dialysis in the Year 2009 400

Work Instruction: Automated Peritoneal Dialysis 401

Practical Dialysis in the Year 2009 402

Work Instruction: Automated Peritoneal Dialysis 403

Practical Dialysis in the Year 2009 8.  √ÿª °“√≈â“߉μ∑“ß™àÕß∑âÕߥ⫬‡§√◊ËÕßÕ—μ‚π¡—μ‘ (Automated Peritoneal Dialysis, APD) ‡ªìπ«‘∏’°“√ ≈â“߉μ∑“ß™àÕß∑âÕß∑’ˉ¥âæ—≤π“¢÷Èπ ‚¥¬„™â‡§√◊ËÕßÕ—μ‚π¡—쑇¢â“™à«¬„π°“√‡ª≈’ˬπ∂à“¬πÈ”¬“≈â“ß‰μ‡¢â“·≈– ÕÕ°®“°ºŸâªÉ«¬ ∑”„À⢮—¥¢âÕªí≠À“·≈–¢âÕ®”°—¥¢Õß«‘∏’°“√≈â“߉μ∑“ß™àÕß∑âÕߥ—È߇¥‘¡‰¥â¡“° «‘∏’°“√„™â ‡§√◊ËÕßÕ—μ‚π¡—μ‘®”‡ªìπμâÕ߉¥â√—∫°“√Ωñ°Ωπ ·μࢗÈπμÕπ‰¡à¬ÿà߬“°π—° ‚¥¬¡’Àπâ“®Õ°“√∑”ß“π¢Õ߇§√◊ËÕß §Õ¬·π–π” §«“¡‡¢â“„®·≈–°“√¬Õ¡√—∫∑“߇∑§π‘§°“√√—°…“¥â«¬°“√≈â“߉μ∑“ß™àÕß∑âÕߥ⫬‡§√◊ËÕß Õ—μ‚π¡—μ‘¢Õß·æ∑¬å·≈–欓∫“≈¡’§«“¡ ”§—≠¬‘Ëß „π°“√∑’Ë®–∂à“¬∑Õ¥¢—ÈπμÕπ°“√∑”ß“π¢Õ߇§√◊ËÕß Õ—μ‚π¡—μ‘π’ȉª ŸàºŸâªÉ«¬·≈–≠“μ‘μàÕ‰ª 404

Work Instruction: Automated Peritoneal Dialysis ‡Õ° “√Õ“â ßÕß‘ 1. ∏π‘μ ®‘√π—π∑å∏«—™. Automated Peritoneal Dialysis and Its role in Peritoneal Dialysis. „π:  ¡™“¬ ‡Õ’ˬ¡ÕàÕß, ‡°√’¬ß μ—Èß  ßà“, Õπÿμμ√ ®‘μμ‘π—π∑πå, ‡∂≈‘ß»—°¥‘Ï °“≠®π∫ÿ…¬å, ¥ÿ ‘μ ≈È”‡≈‘»°ÿ≈, ª√–‡ √‘∞ ∏π°‘®®“√ÿ, ∫√√≥“∏‘°“√. Textbook of Peritoneal Dialysis. °√ÿ߇∑æ: Text and Journal Publication, 2551: 537-52. 2. Twardowski ZJ. Peritoneal dialysis glossary III. Perit Dial Int 1990; 10: 173-5. 3. Cruz C, Dumler F, Schmidt R, Gotch F. Enhanced peritoneal dialysis delivery with PD PlusTM. Adv Perit Dial 1992; 8: 288-90. 4. United States Renal Data System. USRDS 1998. Annual Report. National Institutes of Health, National Institute of Diabetes and Kidney Disease, Bethesda, MD, 1998. 5. United States Renal Data System. USRDS 1997. Annual Data Report. The USRDS Dialysis Morbidity and Mortality Study (Wave 2). National Institutes of Health, National Institute of Diabetes and Kidney Disease, Bethesda, MD, 1997. 6. Warady BA, Hebert D, Sullivan EK, Alexander SR, Tejani A. Renal transplantation, chronic dialysis, and chronic renal insufficiency in children and adolescents. The 1995 Annual Report of the North American Pediatric Renal Transplant Cooperative Study. Pediatr Nephrol 1997; 11(1): 49-64. 7. Correa-Rotter R. APD in the developing world: is there a future? Semin Dial. 2002; 15(6): 385-7. 8. Diaz-Buxo JA, Farmer CD, Chandler JD, et al. Continuous cyclic perioneal dialysis (CCPD)-ùwetû is better than dry. Perit Dial Bull 1987; 7: S22. 9. Nissensen AR. Dialysis modality selection: harsh realities. Perit Dial Int 1996; 16: 343-4. 10. Twardowski ZJ. Nightly peritoneal dialysis. Why, who, how, and when? ASAIO Trans 1990; 36: 8-16. 11. Goel S, Saran R, Nolph KD, Moran J, Vonesh EF, Dunham T. Dry days in chronic peritoneal dialysis: whether whiter or wither? Semin Dial 1997; 10: 134-6. 12. Twardowski ZJ, Prowant BF, Nolph KD, Khanna R, Schmidt LM, Satalowich RJ. Chronic nightly tidal peritoneal dialysis. ASAIO Trans 1990; 36: M584-8. 13. Flanigan MJ, Doyle C, Lim VS, Ullrich G. Tidal peritoneal dialysis: preliminary experience. Perit Dial Int 1992; 12: 304- 8. 14. Flanigan MJ, Lim VS, Pflederer TA. Tidal peritoneal dialysis: kinetic and protein balance. Am J Kidney Dis 1993; 22: 700-7. 15. Aasarod K, Wideroe TE, Flakne SC. A comparison of solute clearances and ultrafiltration volume in peritoneal dialysis with total or fractional (50%) intraperitoneal volume exchange with the same dialysate flow rate. Nephrol Dial Transplant 1997; 12: 2128-32. 16. Enoch C, Aslam N, Piraino B. Intra-abdominal pressure, peritoneal dialysis exchange volume, and tolerance in APD. Semin Dial 2002; 15(6): 403-406. 405



Work Instruction: Machine Continuous Renal Replacement Therapy 21 Work Instruction: Machine Continuous Renal Replacement Therapy ∑«’æß…å ª“®√’¬å æß»∏√ §™‡ π’ Õππ— μå ‡™◊ÈÕ «ÿ √√≥ æ𥑠“ ™Ëπ◊ ¡’»√’ ∏√’ –πÿ™ ‡æ™√√àÿß  “¬Ωπ π‘≈®ÿ≈°– Õ“√‘¬“ æß»“∫≠ÿ ¡“ 1. Work Instruction ‡√ÕË◊ ß °“√„™‡â §√◊ÕË ß Aquarius Machine CRRT 2. Work Instruction ‡√Õ◊Ë ß °“√„™‡â §√◊ËÕß Prisma Flex machine CRRT 3. Work Instruction ‡√◊ËÕß °“√„™â‡§√◊ËÕß Infomed HF440 Blood purification 407

Practical Dialysis in the Year 2009 Continuous renal replacement therapy (CRRT) ‰¥â‡√‘Ë¡μâπ¢÷Èπ§√—Èß·√°„πªï 1977 „π√Ÿª·∫∫ ¢Õß continuous arterio-venous hemofiltration (CAVH) ªí®®ÿ∫—π CRRT ‰¥â¡’°“√æ—≤π“¡“‡ªìπ integrated machine ∑’Ë¡’√Ÿª·∫∫°“√√—°…“∑’ËÀ≈“°À≈“¬μ≈Õ¥®π¡’√–∫∫√—°…“§«“¡ª≈Õ¥¿—¬·≈– —≠≠“π‡μ◊Õπ∑’Ë §«∫§ÿ¡‚¥¬μ—«‡§√◊ËÕ߇Õß ∑”„Àâ “¡“√∂≈¥ work load ¢Õß·æ∑¬å·≈–欓∫“≈ºŸâ¥Ÿ·≈≈߉¥â¡“° machine CRRT ®÷߉¥â√—∫§«“¡π‘¬¡¡“°¢÷Èπ„π°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‡«™∫”∫—¥«‘°ƒμ∑’Ë¡’¿“«–‰μ∫“¥‡®Á∫‡©’¬∫æ≈—π (acute kidney injury) Õ¬à“߉√°Áμ“¡‡§√◊ËÕß CRRT ‡ªìπ‡§√◊ËÕß¡◊Õ∑’˧àÕπ¢â“ß´—∫´âÕπ·≈–¬“°μàÕ°“√‡√’¬π√⟠«‘∏’°“√„™â¥â«¬μ—«‡Õß μ≈Õ¥®πºŸâªÉ«¬∑’ˉ¥â√—∫°“√∑” CRRT  à«π„À≠à®–‡ªìπºâŸªÉ«¬‡«™∫”∫—¥«‘°ƒμ∑’Ë¡’ ªí≠À“À≈“¬¥â“π ®÷ß®”‡ªìπμâÕß¡’∫ÿ§≈“°√∑’Ë¡’§«“¡√Ÿâ§«“¡™”π“≠§«∫§ÿ¡¥Ÿ·≈ ∑“ß ¡“§¡‚√§‰μ·Ààß ª√–‡∑»‰∑¬‰¥â‡≈Á߇ÀÁ𧫓¡ ”§—≠„π¢âÕπ’È ®÷߉¥â®—¥°“√Õ∫√¡‡™‘ߪؑ∫—μ‘°“√ (workshop) ‡√◊ËÕß machine CRRT „Àâ·°àºâŸ∑’Ë π„®‡æ◊ËÕ𔉪æ—≤π“°“√¥Ÿ·≈√—°…“ºâŸªÉ«¬°≈ÿà¡π’È„À⇰‘¥ª√–‚¬™πå Ÿß ÿ¥ „π§Ÿà¡◊Õ©∫—∫π’ȉ¥â∑”·∫àßÕÕ°‡ªìπ 3  à«π ‰¥â·°à 1. Work Instruction ‡√◊ËÕß °“√„™â‡§√◊ËÕß Aquarius Machine CRRT 2. Work Instruction ‡√◊ËÕß °“√„™â‡§√◊ËÕß Prisma Flex machine CRRT 3. Work Instruction ‡√◊ËÕß °“√„™â‡§√◊ËÕß Infomed HF440 Blood purification 1. Work Instruction ‡√Ë◊Õß °“√„™‡â §√ËÕ◊ ß Aquarius Machine CRRT 1. °“√ set-up ·≈–°“√¥Ÿ·≈ºªâŸ É«¬ 1.1 °“√‡μ√’¬¡Õÿª°√≥å·≈–‡§√◊ËÕß¡◊Õ∑’Ë„™â ¡’¥—ßπ’È - Aquarius CRRT machine - Aqualine tubing set (adult or pediatric) - Filter (Aquamax or plasmafilter) - Manifold set (1set) - Replacement/Dialysate bags (1 to 4) - Filtrate bags (1 to 4) - 1 or 2 liters saline solution (including 5000 IU heparin) - T-way stop-cock or saline bag with 2 connector + Aquasafe - Heparin syringe (50 ml) 1.2 ¢—ÈπμÕπ«‘∏’ªØ‘∫—μ‘·≈–√“¬≈–‡Õ’¬¥ ¢—ÈπμÕπ°“√∑”ß“π¢Õß AQUARIUS ¡’Õ¬àŸ 8 ¢—ÈπμÕπ§◊Õ 1. System test 5. Connecting the patient 2. Preparation 6. Treatment 3. Priming 7. Disconnecting the patient 4. Recirculation 8. End of treatment 408

Work Instruction: Machine Continuous Renal Replacement Therapy 1.2.1 System test: ‡¡ÕË◊ ‡ª¥î ‡§√ÕË◊ ß®–‡ªπì ¢πÈ— μÕπμ√«® Õ∫°“√∑”ß“π‡Õß¿“¬„π‡§√ÕË◊ ß ‡¡Õ◊Ë ‡§√ÕË◊ ß∑¥ Õ∫‡√¬’ ∫√Õâ ¬·≈«â ®–¡‡’  ¬’ ߇μÕ◊ π∫Õ° ·≈–¡‰’ ø ‡’ ¢¬’ «·≈– ‡’ À≈Õ◊ ß· ¥ßÕ¬¥àŸ “â π∫π¢Õ߮տ“æ ªíö¡À¬ÿ¥„πμ”·Àπàß∑’Ë∂°Ÿ μâÕß Àπâ“®Õ¿“æ„Àâ‡≈◊Õ° Treatment ¥—ßπ’È „Àâ‡≈◊Õ° Treatment ∑’ËμâÕß°“√ 1.2.2 Preparation mode ‡ªìπ¢—ÈπμÕπ°“√„ à™ÿ¥ “¬¬“ß·≈–„ à filter ¥—ßπ’È Insert cassette, System and bags, Close pump doors Àπâ“®Õ®–· ¥ß¢âÕ§«“¡«à“ ¥â“π¢«“∫πÀπâ“®Õ¿“æ„π·∂∫ ’‡À≈◊Õß · ¥ß¢—ÈπμÕπ°“√∑”ß“πμ“¡≈”¥—∫ À¡“¬‡Àμÿ: ∂â“μâÕß°“√√“¬≈–‡Õ’¬¥„π°“√‡μ√’¬¡·μà≈–¢—ÈπμÕπ „Àâ‡≈◊Õ° Zoom graphic 409

Practical Dialysis in the Year 2009 1.2.3 Priming mode - μâÕß·πà„®«à“‰¥â‡ªî¥ clamp ∑—ÈßÀ¡¥·≈â« - À¡ÿπ selector button ‡≈◊Õ° Start Priming - ‡§√◊ËÕß®–‡√‘Ë¡ priming Õ—μ‚π¡—μ‘ ‡«≈“∑’Ë®–„™â√–À«à“ß°“√ prime ª√–¡“≥ 9 π“∑’ ‚¥¬ Õ—μ√“°“√‰À≈¢Õß blood pump ‡√‘Ë¡®“° 80 ml/min „π‡«≈“ª√–¡“≥ 5 π“∑’ ·≈–À≈—ß®“°π—Èπ ®–‡æ‘Ë¡‡ªìπ 150 ml/min ‡¡◊ËÕ§√∫‡«≈“‡§√◊ËÕß®–¡’‡ ’¬ß‡μ◊Õπ À≈—ß®“° priming ‡ √Á®·≈â« ‡§√◊ËÕß®–· ¥ß 1.2.4 Recirculation  “¡“√∂‡≈Õ◊ ° recirculation ‰¥Àâ ≈ß— ®“°º“à π priming completed ·≈«â À√Õ◊ √–À«“à ß treatment ‡¡ÕË◊ μÕâ ß°“√®–π”ºªŸâ «É ¬‰ª∑”Àμ— ∂°“√πÕ° ward ™«Ë— §√“«Õªÿ °√≥∑å μË’ Õâ ß„™„â π°“√‡≈Õ◊ ° recirculation mode - NSS 1,000 ml ®”π«π 1 ∂ÿß - T-way À√◊Õ Y-connector °àÕπ°“√∑” recirculation mode μâÕ߉≈à‡≈◊Õ¥§◊πºâŸªÉ«¬„ÀâÀ¡¥®“° blood line °àÕπ À≈—ß ®“°π—Èπ ∂Õ¥ “¬ ’·¥ß (access line) ·≈– “¬ ’πÈ”‡ß‘π (return line) ÕÕ°®“° catheter ¢ÕߺŸâªÉ«¬·≈â«π” ¡“μàÕ°—∫ T-way À√◊Õ Y-connector ∑’Ë∂ÿß NSS 1,000 ml ·≈⫧àÕ¬‡√‘Ë¡ recirculation ‚¥¬‡≈◊Õ° 410

Work Instruction: Machine Continuous Renal Replacement Therapy ‡æ◊ËÕ‡¢â“ Ÿà recirculation mode ·≈â« confirm window °¥ Yes ‡æ◊ËÕ¬◊π¬—π°“√‡≈◊Õ° recirculation À√◊Õ No ‡æ◊ËÕ°≈—∫‰ª ŸàÀπⓇ¥‘¡ °¥ Start Blood pump ‡æË◊Õ„Àâ “√≈–≈“¬‰À≈®“° “¬ access °≈—∫¡“¬—ß “¬ return „π√–À«à“ß recirculation mode À√◊Õ √–À«à“ß treatment mode  “¡“√∂μ—Èß program °“√∑”ß“π‰¥â‚¥¬‡≈◊Õ°·≈–¬◊π¬—π „ à¢âÕ¡Ÿ≈°“√√—°…“¢Õß·æ∑¬å‚¥¬„™â selector button ‰ª highlight °¥ ·≈– „ à¢âÕ¡Ÿ≈ ‡¡◊ËÕ„ à¢âÕ¡Ÿ≈‡ √Á®·≈â« °¥ main selector ‡æ◊ËÕ¬◊π¬—π√“¬°“√ 1.2.5 Start connection - connecting the patient Àπâ“®Õ¿“æ®–· ¥ß¢—ÈπμÕπ°“√ªØ‘∫—μ‘μ“¡≈”¥—∫ ‡≈◊Õ°·≈–¬◊π¬—π ‡≈◊Õ°μàÕ·∫∫ double connection À√◊Õ single connection 411

Practical Dialysis in the Year 2009 1.2.6 Treatment ‡≈◊Õ° start treatment ‡æ◊ËÕ‡√‘Ë¡°“√√—°…“μ“¡ parameters ∑’Ëμ—È߉«â Àπâ“®Õ®–· ¥ß ·≈–· ¥ß‡«≈“∑’ˇÀ≈◊Õ¢Õß°“√ treatment °¥ start blood pump ·≈– balance pump μ“¡≈”¥—∫ „π√–À«à“ß treatment mode  “¡“√∂‡≈◊Õ° 412

Work Instruction: Machine Continuous Renal Replacement Therapy ‡§√◊ËÕß “¡“√∂‡°Á∫¢âÕ¡Ÿ≈¢Õß°“√√—°…“‰¥â 3 treatment ‚¥¬·μà≈– Treatment ®–¡’°“√‡°Á∫¢âÕ¡≈Ÿ ¥—ßπ’È - Pressure parameter - Program parameter - Patient data - Event - Graphic °√≥’∑’ËμâÕß°“√À¬ÿ¥ treatment ™—Ë«§√“« Àπâ“®Õ®–· ¥ß ¢—ÈπμÕπ‚¥¬≈–‡Õ’¬¥ ·≈–¢âÕ¡≈Ÿ ®–∂°Ÿ ‡°Á∫∫—π∑÷°‰«â ºŸâªÉ«¬ “¡“√∂ treatment ®–¥”‡π‘πμàÕ‰ª‰¥â ‡≈◊Õ°„™â„π°√≥’μâÕß°“√À¬ÿ¥°“√√—°…“ ‚¥¬‡≈◊Õ° Yes ‡æ◊ËÕ¬◊π¬—π End Treatment Àπâ“®Õ®–· ¥ß¢—ÈπμÕπ disconnect ‡¡◊ËÕμâÕß°“√‡ª≈’ˬπ syringe À√◊ÕÀ¬ÿ¥„Àâ anticoagulant (clamp  “¬ anticoagulant °àÕπ∂Õ¥ÕÕ°®“° anticoagulant pump)  “¡“√∂‡ª≈’ˬπ treatment ‰¥â√–À«à“ß SCUF, CVVH, CVVHD ·≈– CVVHDF ‚¥¬‰¡àμâÕ߇ª≈’ˬπ set À√◊Õ§◊π‡≈◊Õ¥ºŸâªÉ«¬√–À«à“ß∑’Ë∑”°“√‡ª≈’ˬπ mode 1.2.7 Disconnecting the patient - ∂Õ¥ª≈“¬ “¬ access ( ·’ ¥ß) ÕÕ°®“°μ—«ºâŸªÉ«¬ ·≈–𔉪μàÕ°—∫∂ÿßπÈ”‡°≈◊Õ NSS - ‡≈Õ◊ ° start ‡æÕË◊ „À‡â ≈Õ◊ ¥∑‡Ë’ À≈Õ◊ Õ¬„Ÿà π™¥ÿ  “¬¬“ߪ¡öí °≈∫—  √àŸ “à ß°“¬ºªâŸ «É ¬∑“ß “¬ return ( ’πÈ”‡ß‘π) ‚¥¬„™âπÈ”‡°≈◊Õ∑’ˇ¢â“¡“∑“ß “¬ access ( ’·¥ß) ‡ªìπμ—«¥—π°≈—∫ ‚¥¬®–ªíö¡°≈—∫®π°«à“‡´Áπ ‡´Õ√å¢Õß air detector æ∫«à“¡’πÈ”‡°≈◊Õ¡“∑¥·∑π‡≈◊Õ¥·≈â« ªíö¡®–À¬ÿ¥∑”ß“π - °¥ start ‡¡◊ËÕºŸâ„™âμâÕß°“√∑’Ë®–ªíö¡‡≈◊Õ¥°≈—∫μàÕ‰ª¥â«¬μπ‡Õß 1.2.8 End of treatment - °¥¬◊π¬—π°“√‡≈◊Õ° 413

Practical Dialysis in the Year 2009 ¬◊π¬—π°“√‡≈◊Õ° - ∂Õ¥ “¬ Return ( ’πÈ”‡ß‘π) ®“°μ—«ºŸâªÉ«¬ - ∂Õ¥ “¬∑—ÈßÀ¡¥ÕÕ°®“°μ—«‡§√◊ËÕß - π”∂ÿß “√≈–≈“¬μà“ßÊ ÕÕ°®“°‡§√◊ËÕß™—Ëß - π”‡¢Á¡©’¥¬“ÕÕ°®“° anticoagulant pump 1.3 ¢âÕ·π–π”Õ◊ËπÊ √–À«à“ß°“√¥·Ÿ ≈ºŸâªÉ«¬∑’Ë∑” CRRT treatment 1.3.1 ‡¡◊ËÕ¡’°“√‡μ√’¬¡Õÿª°√≥å‡√’¬∫√âÕ¬·≈â«°àÕπ°“√π” set ¡“μàÕ°—∫ºŸâªÉ«¬ ¡’¢âÕ·π–π” „π°“√ªØ‘∫—μ‘ ¥—ßπ’È - μ√«® Õ∫ program ∑’Ëμ—Èß«à“∂Ÿ°μâÕßÀ√◊Õ‰¡à (following the 35ml/kg/hr) - „™â syringe ∑¥ Õ∫¥«Ÿ à“ catheter ¡’ flow ∑’Ë¥’À√◊Õ‰¡à - ‡™Á§ degassing ·≈– drip chamber «à“¡’πÈ”‡μÁ¡¥’À√◊Õ‰¡à - ‡™Á§¥μŸ “¡ line μà“ßÊ «à“‰¡à¡’À—° æ—∫ ßÕ - Õ¬à“≈◊¡‡ªî¥ clamp μà“ß „π circuit ÕÕ°„ÀâÀ¡¥ 1.3.2 °“√μàÕ‡§√◊ËÕ߇¢â“°—∫ºâŸªÉ«¬ ¡’ 2 «‘∏’ - Double connection (μÕà  “¬ ·’ ¥ß·≈– “¬ π’ È”‡ßπ‘ æ√Õâ ¡°π— ∑’Ë catheter ºªâŸ «É ¬) „™„â π°√≥’ ∑’˺⟪ɫ¬§«“¡¥—πμË” ·≈– hemodynamic ‰¡à§ß∑’Ë - Single connection (μÕà  “¬ ·’ ¥ß°Õà π·≈«â §Õà ¬μÕà  “¬ π’ È”‡ßπ‘ ) „™„â π°√≥∑’ º’Ë ªâŸ «É ¬¡§’ «“¡ ¥—π∑’Ë¥’·≈–‡¢â¡ß«¥¥â“π°“√‡æ‘Ë¡ NSS „Àâ°—∫ºŸâªÉ«¬ 1.3.3 ‡¡◊ËÕ‡√‘Ë¡μàÕ‡§√◊ËÕß°—∫ºŸâªÉ«¬„Àâ§àÕ¬Ê ‡æ‘Ë¡ blood flow ∑’≈– 2-3 step ™â“Ê ®π‰¥â blood flow ∑’ËμâÕß°“√·≈â«®÷ß°¥„ÀâªÿÉ¡ balance pump „Àâ∑”ß“π ∑—Èßπ’ȇæ◊ËÕªÑÕß°—πª≈“¬ “¬ catheter ‰¡à„À⥟¥ μ‘¥°—∫ºπ—߇ âπ‡≈◊Õ¥∑—π∑’„πμÕπ‡√‘Ë¡μâπ 1.3.4 ‡™Á§§«“¡ —¡æ—π∏å√–À«à“ß blood flow rate °—∫ filtration rate «à“ —¡æ—π∏å°—π¥’À√◊Õ‰¡à ∑—Èßπ’ȇæ◊ËÕªÑÕß°—πªí≠À“∑“ߥâ“π hemoconcentration ‡√Á«‡°‘π‰ª ‚¥¬μ√«® Õ∫§à“ FF (filtration fraction) ∑’Ë Àπâ“®Õ more ¢Õ߇§√◊ËÕߥ—ßπ’È - Filtration Fraction ~ 20% „π CVVH - Filtration Fraction ~ 30% „π HVHF 414

Work Instruction: Machine Continuous Renal Replacement Therapy 1.3.5 ª√–‡¡π‘ ¿“«–¢Õß membrane bio-incompatibility ®“°‡≈Õ◊ ¥∑”ªØ°‘ √‘ ¬‘ “°∫— membrane ¢Õ߇ âπ„¬¢Õßμ—«°√Õß Õ“°“√‡À≈à“π’È®–‡°‘¥À≈—ß®“°‡√‘Ë¡∑”ª√–¡“≥ 5-15 π“∑’ «—¥ vital sign À≈—ß®“° ‡√‘Ë¡∑” CRRT 15 π“∑’, 30 π“∑’ ·≈– 1 ™—Ë«‚¡ß μ“¡≈”¥—∫ 1.3.6 ª√–‡¡‘𠧫∫§ÿ¡ ·≈–∫—π∑÷° ª√–¡“≥πÈ”‡¢â“ / ÕÕ° ®“°√à“ß°“¬ ª√–‡¡‘π∑ÿ°Ê 30 π“∑’ „π 2 ™—Ë«‚¡ß·√°¢Õß°“√∑” À≈—ß®“°π—Èπ „Àâª√–‡¡‘π∑ÿ° 1 ™—Ë«‚¡ßμàÕ‡π◊ËÕ߉ª 1.3.7 „™Àâ ≈°— aseptic technique „π°“√‡μ√¬’ ¡ replacement fluid μ“à ßÊ μ“¡·ºπ°“√√°— …“ 1.3.8 §«√∑”·º≈∫√‘‡«≥ exit site ∑ÿ°«—π ·≈–∑ÿ°§√—Èß∑’Ë¡’°“√‡ªï¬°™◊Èπ 1.3.9 √–À«à“ß∑” CRRT §«√ —߇°μ§à“ PD (pressure drop) ∑’ˇæ‘Ë¡¢÷ÈπÕ¬à“ß√«¥‡√Á« ´÷Ëß· ¥ß ∂÷ß°“√‡°‘¥ clot „πμ—«°√Õß ‡√“Õ“®ª√—∫Õ—μ√“ à«π√–À«à“ß pre-dilution ·≈– post-dilution ‡æ◊ËÕ¬◊¥Õ“¬ÿ °“√„™âß“π¢Õßμ—«°√Õß 1.3.10 √–À«à“ß∑” CRRT §«√ —߇°μ§à“ TMP (transmembrane pressure) ∑’ˇæ‘Ë¡¢÷ÈπÕ¬à“ß √«¥‡√Á« ´÷Ëß· ¥ß∂÷ß°“√‡°‘¥ membrane saturation ‡√“Õ“®ª√—∫ filtration rate ‡æ◊ËÕ¬◊¥Õ“¬ÿ°“√„™âß“π¢Õß μ—«°√Õß À√◊Õ ‡μ√’¬¡μ—«°√Õß¡“‡ª≈’ˬπ„À¡à 1.3.11 √–À«“à ß∑¡Ë’ °’ “√欓∫“≈ºªâŸ «É ¬∑”„Àºâ ªâŸ «É ¬‡§≈ÕË◊ π‰À« §«√¡°’ “√≈¥ blood flow ≈ß ª√–¡“≥ 10 ∂÷ß 20 ‡ªÕ√凴Áπμå ‡æ◊ËÕ≈¥°“√‡°‘¥ alarm ®“°‡§√◊ËÕß À√◊Õ °¥„ÀâªÿÉ¡ balance pump À¬ÿ¥ ∑”ß“π°àÕπ 2. ªí≠À“·≈–«∏‘ °’ “√·°â‰¢∑ËÕ’ “®®–‡°¥‘ ¢π÷È √–À«à“ß∑” CRRT ¡¥’ ß— μÕà ‰ªπ’È 415

Practical Dialysis in the Year 2009 416

Work Instruction: Machine Continuous Renal Replacement Therapy 417

Practical Dialysis in the Year 2009 418

Work Instruction: Machine Continuous Renal Replacement Therapy 2. Work Instruction ‡√ËÕ◊ ß°“√„™â‡§√ËÕ◊ ß PRISMA FLEX machine CRRT  «à πª√–°Õ∫¢Õ߇§√ÕË◊ ß PRISMA FLEX 2. Status Light 1. Display 4. Replacement Solution Pump 3. Effluent Pump 6. Pinch Clamp 5. Dialysate Pump 8. Pre-blood Pump (PBP) 7. Blood Pump 10. Tubing Guides 9. Scales 12. Syringe Pump Assembly 11. Pressure Sensor Housing 14. Bar Code Reader 13. Syringe Pump Control Panel 16. Discharger Ring Guide 15. Blood Leak Detector (BLD) 18. Deaeration chamber Support 17. Return Pressure Port 20. Return Line Clamp 19. Air Bubble Detector 22. Brake Pedal 21. Power Switch 24. Carrying Bar 23. Recessed Handles 25. Side hook 419

Practical Dialysis in the Year 2009 2. „Àâ‡≈◊Õ° NEW PATIENT ‡æ◊ËÕ∑”°“√√—°…“ 1. ‡¡◊ËÕ‡ªî¥‡§√◊ËÕß Àπâ“®Õ®–· ¥ßμ“¡√Ÿª¢â“ß≈à“ß „Àâ‡≈◊Õ° CONTINUE 3. ‡§√◊ËÕß®–„Àâ„ à™◊ËÕ·≈–πÈ”Àπ—°¢Õߧπ‰¢â 4. „Àâ‡≈◊Õ° MODE °“√√—°…“ (PATIENT ID. & PATIENT WEIGHT) ∂Ⓣ¡àμâÕß°“√„ à™◊ËÕ§π‰¢â„Àâ‡≈◊Õ° CONTINUE 5. Àπâ“®Õπ’È®–· ¥ß«‘∏’°“√„ à SET ‚¥¬¡’¢—ÈπμÕπ 6. ‡§√◊ËÕß®–· ¥ßÀπâ“®Õμ“¡√ªŸ ¢â“ß≈à“ß μ“¡«’¥’‚Õ∑’Ë®–𔇠πÕ ‡¡◊ËÕ„ à SET ‡√’¬∫√âÕ¬ „Àâ√Õ´—°§√àŸ ·≈â«„Àâ‡≈◊Õ° LOAD ‡æ◊ËÕ„™âß“π‡§√◊ËÕßμàÕ‰ª 420

Work Instruction: Machine Continuous Renal Replacement Therapy 7. Àπâ“®Õπ’È®–· ¥ß√“¬≈–‡Õ’¬¥¢Õß SET 8. Àπâ“®Õπ’È®–· ¥ß«‘∏’°“√„ àπÈ”¬“ ‚¥¬¡’ ∑’Ë„™âß“π ®“°π—Èπ„Àâ‡≈◊Õ° CONTINUE ¢—ÈπμÕπμ“¡«’¥’‚Õ∑’Ë®–𔇠πÕ ‡¡◊ËÕ∑”μ“¡ ¢—ÈπμÕπ·≈â« „Àâ‡≈◊Õ° PRIME ‡æ◊ËÕ‰≈à AIR ¿“¬„π SET 9. ‡¡◊ËÕ‡§√◊ËÕß· ¥ßÀπâ“®Õπ’È„Àâ√Õ®π°√–∑—Ë߉≈à 10. „Àâ‡≈◊Õ° PRIME TEST AIR ¿“¬„π SET À¡¥ ®“°π—ÈπÀπâ“®Õ®– · ¥ßμ“¡√ªŸ ¢â“ß≈à“ß 11. ‡§√◊ËÕß®–∑”°“√μ√«® Õ∫°“√„ à SET «à“ 12. ‡¡◊ËÕ‡§√◊ËÕß· ¥ßÀπâ“®Õπ’È· ¥ß«à“‡§√◊ËÕß ∂Ÿ°μâÕßÀ√◊Õ‰¡à „Àâ√Õª√–¡“≥ 5-10 π“∑’ æ√âÕ¡∑’Ë®–„™âß“π·≈â« „Àâ‡≈◊Õ° ®“°π—Èπ‡§√◊ËÕß®–· ¥ßμ“¡√Ÿª¢â“ß≈à“ß CONTINUE 421

Practical Dialysis in the Year 2009 14. Àπâ“®Õπ’È®–· ¥ß¢âÕ¡≈Ÿ ∑’˺Ÿâ„™â‰¥â∑”°“√ ‡≈◊Õ° §à“∑’Ë„™â„π°“√√—°…“‰«â „Àâ‡≈◊Õ° 13. „Àâμ—Èß§à“°“√√—°…“μ“¡ ORDER ∑’Ë·æ∑¬å —Ëß CONTINUE ‡æ◊ËÕ¬◊π¬—π§à“∑’ˇ≈◊Õ°‰«â ‚¥¬„™âÀπâ“®Õμ“¡√Ÿª¢â“ß≈à“ß ‡¡◊ËÕ‡√’¬∫√âÕ¬ ·≈â«„Àâ‡≈◊Õ° ENTER ‡æ◊ËÕ‰ª∑’Ë¢—ÈπμÕπμàÕ‰ª 15. Àπâ“®Õπ’È®–· ¥ß«‘∏’°“√μàÕ SET ‡¢â“°—∫ 16. Àπâ“®Õπ’ȇªìπÀπâ“®ÕÀ≈—°¢Õ߇§√◊ËÕß‚¥¬ §π‰¢â ‚¥¬®–Õ∏‘∫“¬μ“¡«’¥’‚Õ ‡¡◊ËÕμàÕ‡ √Á® ®–· ¥ß§“à º„Ÿâ ™‰â ¥∑â ”°“√‡≈Õ◊ °§“à ∑„’Ë ™„â π°“√ ‡√’¬∫√âÕ¬„Àâ‡≈◊Õ° START ‡æ◊ËÕ∑”°“√√—°…“ √—°…“‰«â·≈–§à“·√ߥ—πμà“ßÊ 17. ‡¡◊ËÕμâÕß°“√À¬ÿ¥°“√√—°…“„Àâ‡≈◊Õ° STOP ∑’ËÀπâ“®ÕÀ≈—° 18. °¥ çReturn Bloodé À√◊Õ Disconnect 19. Disconnect ºâŸªÉ«¬ 20. ª≈¥ Set ÕÕ°®“°‡§√◊ËÕß 422

Work Instruction: Machine Continuous Renal Replacement Therapy 3. Work Instruction ‡√ÕË◊ ß °“√„™‡â §√Õ◊Ë ß Infomed √πàÿ HF440 Blood purification ‡§√◊ËÕß Infomed √ÿàπ HF440 º≈‘μ„πª√–‡∑» «‘μ‡´Õ√å·≈π¥å ‡ªìπ‡§√◊ËÕß ”À√—∫„™â„π°“√∫”∫—¥ ∑¥·∑π‰μ„πºªŸâ «É ¬¿“«–«°‘ ƒμ‡™πà ‡¥¬’ «°∫— ‡§√Õ◊Ë ß CRRT ∑«—Ë ‰ª √«¡‰ª∂ß÷  “¡“√∂„À°â “√√°— …“¥«â ¬«∏‘ ’ DFPP (Double Filtration Plasmapheresis) ·≈– CPFA (Couple Plasma Filtration Adsorption) ´÷Ë߇πâπ„πºâŸªÉ«¬∑’Ë¡’ ¿“«–쥑 ‡™Õ◊È „π°√–· ‡≈Õ◊ ¥ (Septic shock) À√Õ◊ ºªŸâ «É ¬Õπ◊Ë Ê ∑®’Ë ”‡ªπì μÕâ ߉¥√â ∫— °“√√°— …“¥«â ¬«∏‘ °’ “√¥ß— °≈“à « 1. °“√‡μ√’¬¡§«“¡æ√âÕ¡ (Preparation) ª√–°Õ∫¥â«¬ 1.1 °“√‡μ√’¬¡‡§√◊ËÕß ≈—°…≥–∑—Ë«‰ª¢Õ߇§√◊ËÕß (Display and data capture) 1.2 °“√‡μ√’¬¡Õÿª°√≥å - Pre-assemble tubing set (Adult/Pediatric) ¡’¥—ßπ’È Hemofiltration set Plasma exchange set Cascade set CPFA complete set - Filter ª√–°Õ∫¥â«¬ Hemofilter Plasmafilter Cascade filter Sorbent - Syringe ¢π“¥ 10-60 ml - Replacement Solution - 0.9 NSS 1,000 ml - Heparin 423

Practical Dialysis in the Year 2009 ¢âÕ —߇°μ Õªÿ °√≥μå “à ßÊ º“à π°√–∫«π°“√ sterilization ¥«â ¬ ETO §«√μ√«® Õ∫«π— À¡¥Õ“¬°ÿ Õà π„™·â ≈– Àâ“¡„™â°—∫ºâŸªÉ«¬ À“°æ∫«à“¡’°“√©’°¢“¥À√◊Õ™”√ÿ¥ 2. ¢—ÈπμÕπ°“√∑”ß“π¢Õ߇§√◊ËÕß (Step by step instruction) ¡’√“¬≈–‡Õ’¬¥¥—ßπ’È §Õ◊ 2.1 The Power-on tests ‡¡◊ËÕ‡ªî¥‡§√◊ËÕß √–∫∫®–μ√«® Õ∫ Function μà“ßÊ ¿“¬„π‡§√◊ËÕß ‚¥¬Õ—μ‚π¡—μ‘ ‡¡◊ËÕ°“√μ√«® Õ∫‡ √Á® ‘Èπ ¡∫Ÿ√≥å ®–¡’‡ ’¬ß‡μ◊Õπ À≈—ß®“°π—ÈπÀπâ“®Õ®–¢÷Èπ¿“æ ¥—ß√ªŸ 424

Work Instruction: Machine Continuous Renal Replacement Therapy - ‡≈◊Õ° Treatment ∑’ËμâÕß°“√ °¥ Next Àπâ“®Õ®–ª√“°Ø¿“æ Previous treatment ¥—ß√Ÿª - ‡§√ÕË◊ ß®–· ¥ß®”π«π¢Õâ ¡≈Ÿ (Log files) 20 √“¬°“√ À√Õ◊ ¢Õâ ¡≈Ÿ ∑‡Ë’ °¥‘ ¢πÈ÷ „π‡«≈“ 300 ™«Ë— ‚¡ß - °¥ Back ‡æ◊ËÕ°≈—∫Àπâ“ Treatment ‡¥‘¡ - ‡≈◊Õ° Treatment ∑’ËμâÕß°“√ ·≈– - ‡≈◊Õ° New ‡¢â“ àŸÀπâ“ Treatment μàÕ‰ª 425

Practical Dialysis in the Year 2009 - §≈‘°∑’Ë™àÕß«à“ß ·≈–æ‘¡æå™◊ËÕ∑’ËμâÕß°“√ - ‡≈◊Õ°™π‘¥°“√√—°…“ (Treatment) „Àâμ√ß°—π - ‡≈◊Õ°‡§√◊ËÕßÀ¡“¬∂Ÿ° (/) ‡æ◊ËÕ¬◊π¬—π Àπâ“®Õ¢÷Èπ¿“æ μ√«® Õ∫§«“¡∂°Ÿ μÕâ ßÕ°’ §√ß—È À“°‰¡¡à °’ “√‡ª≈¬’Ë π·ª≈ß„¥Ê ‡≈Õ◊ °‡§√Õ◊Ë ßÀ¡“¬ (/) ‡æÕ◊Ë ¬π◊ ¬π— 2.2 Preparing ‡ªìπ°“√‡μ√’¬¡Õÿª°√≥å™ÿ¥ “¬¬“ß (tubing set) ·≈– μ—«°√Õß (filter) Àπâ“ ®Õ¢÷Èπ¿“æ ¥—ßπ’È - μàÕÕÿª°√≥åμà“ßÊ μ“¡√Ÿª∑’˪√“°Ø æ√âÕ¡μ√«®‡™Á§§«“¡∂Ÿ°μâÕß‚¥¬‡≈◊Õ°¥Ÿ·μà≈–Àπâ“ - °¥‡≈◊Õ° Heparin pump ‡æ◊ËÕ‡μ√’¬¡ syringe 426

Work Instruction: Machine Continuous Renal Replacement Therapy - ‡≈◊Õ°¬’ËÀâÕ ·≈– ª√‘¡“≥ (ml) - „ à syringe ≈ß„πμ”·Àπàß∑’Ë°”Àπ¥ °¥‡≈◊Õ° ≈°Ÿ »√ < À√◊Õ > ®π syringe ‡¢â“∑’Ë - „ àª√‘¡“≥ anticoagulant (ml) ∑’Ë∫√√®ÿ„π Syringe ¢Õâ §«√√–«—ß - μ√«® Õ∫¥Ÿ«à“ ∑ÿ°¢âÕμàÕÀ¡ÿπ·πàπ ∂ÿßπÈ”¬“ ·≈–∂ÿßπÈ”∑‘Èß Õ¬àŸ„πμ”·Àπàß∑’Ë∂Ÿ°μâÕß - μ—«°√Õ߇≈◊Õ¥·≈–Õÿª°√≥å∑—ÈßÀ¡¥Õ¬Ÿà„πμ”·Àπàß∑’Ë∂Ÿ°μâÕß -  “¬μà“ßÊ ‰¡àÀ—° æ—∫ ßÕ ·≈–‡ªî¥ Clamp ∑—ÈßÀ¡¥ ¥—ß√ªŸ - °¥‡≈◊Õ° Start ‡æ◊ËÕ∑”°“√ priming/rinsing 427

Practical Dialysis in the Year 2009 2.3 Priming/Rinsing ‡§√◊ËÕß®–∑”ß“π‚¥¬Õ—μ‚π¡—μ‘„™â‡«≈“ª√–¡“≥ 8-20 π“∑’ ¢÷Èπ°—∫ Treatment mode ∑’ˇ≈◊Õ° ¢≥–‡¥’¬«°—π√–∫∫¡’°“√μ√«® Õ∫μ—«‡Õß (Self test) ‰ªæ√âÕ¡°—π ¥—ß√ªŸ °àÕπ§√∫°”À𥇫≈“¢—ÈπμÕπ Priming/Rinsing ‡ √Á® ¡∫Ÿ√≥å 2 π“∑’ Àπâ“®Õ®–· ¥ß Bubble trap adjustment (¥—ß√Ÿª) ‡æ◊ËÕª√—∫√–¥—∫ “√≈–≈“¬„π venous chamber μ“¡§«“¡μâÕß°“√ À“°μâÕß°“√‡æ‘Ë¡√–¥—∫πÈ”„π venous chamber „Àâ‡ªî¥ clamp ·≈–°¥≈Ÿ°»√¢÷Èπ ‡¡◊ËÕ‰¥â√–¥—∫ ∑’ËμâÕß°“√ ªî¥ clamp ·≈–‡≈◊Õ°‡§√◊ËÕßÀ¡“¬ (/) ‡æ◊ËÕ¬◊π¬—𠇧√◊ËÕß®–∑”ß“πμàÕ®π§√∫°”À𥇫≈“ Àπâ“ ®Õ· ¥ß Rinsing finished ¥—ß√ªŸ 428

Work Instruction: Machine Continuous Renal Replacement Therapy - ‡≈◊Õ° Treatment ‡æ◊ËÕ‡√‘Ë¡°“√√—°…“ 2.4 Running μ—Èߧà“μà“ßÊ μ“¡·ºπ°“√√—°…“ „π°√≥’∑’Ë„™â Heater ‡æ◊ËÕª√—∫Õÿ≥À¿Ÿ¡‘πÈ”¬“ °¥‡≈◊Õ° Heater æ√âÕ¡μ—Èߧà“∑’ËμâÕß°“√ - °¥ Back ‡æ◊ËÕ°≈—∫ àŸÀπⓇ¥‘¡ 429

Practical Dialysis in the Year 2009 °“√μ—Èß§à“ Heparin °¥‡≈◊Õ° Heparin pump Àπâ“®Õ¢÷Èπ√Ÿª¢â“ß≈à“ßπ’È - ‡≈◊Õ° New Syringe  “¡“√∂„™â‰¥â∑ÿ°¢π“¥ (10-60 ml) μ—Èߪ√‘¡“≥∑’ËμâÕß°“√„Àâ§√∫∂â«π ·≈– fixed syringe „À⇢â“∑’Ë - °¥ Start Bolus doses ∑’Ëμ—È߉«âμ“¡·ºπ°“√√—°…“ - °¥ Start Continuous ‡§√◊ËÕß®–ª≈àÕ¬πÈ”¬“μ“¡∑’Ëμ—Èß§à“‰«âÕ¬à“ßμàÕ‡π◊ËÕß - °¥ Back °≈—∫ àŸÀπⓇ¥‘¡ 430

Work Instruction: Machine Continuous Renal Replacement Therapy - ‡≈◊Õ°‡§√◊ËÕßÀ¡“¬ (/) ‡æ◊ËÕ¬◊π¬—π ‡¢â“ àŸÀπâ“ Treatment status ¥—ß√Ÿª ¢âÕ —߇°μ - Blood pump ®–À¡ÿπ¥â«¬§«“¡‡√Á«μË”„π 5 π“∑’·√° ‡æ◊ËÕª√–‡¡‘π ¿“æ‡ âπ‡≈◊Õ¥ºŸâªÉ«¬ À≈—ß®“°π—Èπ®–§àÕ¬Ê ‡æ‘Ë¡§«“¡‡√Á«®π∂÷ߧ«“¡‡√Á«∑’Ë°”Àπ¥ - À“°‡§√Õ◊Ë ß‰¡ à “¡“√∂¥ß÷ ‡≈Õ◊ ¥‰¥μâ “¡∑°’Ë ”À𥇧√Õ◊Ë ß®–ª√∫— ≈¥Õμ— √“‡√«Á ‚¥¬Õμ— ‚π¡μ— ‘·≈– √âÕ߇μ◊Õπ„Àâ∑”°“√·°â‰¢μàÕ‰ª °“√√Õâ ߇μÕ◊ π (Alarms) - ‡¡◊ËÕ¡’°“√√âÕ߇μ◊Õπ¢Õ߇§√◊ËÕß Àπâ“®Õ®–‡ªìπ ’·¥ß ªíö¡‡≈◊Õ¥À¬ÿ¥À¡ÿπ ·≈–¡’¢âÕ§«“¡ ™’È·®ßæ√âÕ¡·π«∑“ß·°â‰¢ - °√≥°’ “√‡ª≈¬’Ë π∂ßÿ πÈ”¬“‡§√Õ◊Ë ß®–‡μÕ◊ πæ√Õâ ¡∫Õ°¢π—È μÕπ°“√ªØ∫‘ μ— ‘‡¡Õ◊Ë §√∫°”À𥇫≈“ À√Õ◊ ª√¡‘ “≥π”È ¬“∑μË’ ßÈ— ‰«â πÕ°®“°π¢È’ ≥–∑‡Ë’ §√ÕË◊ ßÕ¬„àŸ πÀπ“â °“√√°— …“ (Treatment)  “¡“√∂‡≈Õ◊ °¥Ÿ option μà“ßÊ ‰¥â ‚¥¬°¥‡≈◊Õ° Data ‡™àπ 431

Practical Dialysis in the Year 2009 ¢âÕ¡Ÿ≈ (Data) μà“ßÊ - Àπâ“¥—ß°≈à“«· ¥ß∂÷ߢâÕ¡Ÿ≈°“√√—°…“∑’ˇ°‘¥¢÷Èπ®√‘ß μ—Èß·μà‡√‘Ë¡®π∂÷ß ≥ ¢≥–π—Èπ À“° μâÕß°“√¥Ÿ graphic, arterial/venous pressure °¥‡≈◊Õ° pressure æ√âÕ¡μ—Èß§à“ (setting pressure limits) - °¥ Back °≈—∫ àŸÀπⓇ¥‘¡ ‡Àμÿ°“√≥/å ª√–«—μ‘ (Historic Window) μ“à ßÊ - · ¥ß∂÷߇Àμÿ°“√≥å∑’ˇ°‘¥¢÷Èπμ“¡≈”¥—∫‡«≈“°àÕπÀ≈—ß 2.5 Ending Treatment ¢—ÈπμÕπ ‘πÈ  ÿ¥°“√√—°…“ - ‡≈◊Õ° Terminate Treatment 432

Work Instruction: Machine Continuous Renal Replacement Therapy - ‡≈◊Õ°‡§√◊ËÕßÀ¡“¬ (/) ‡æ◊ËÕ¬◊π¬—π μàÕ®“°π—Èπ ∑”μ“¡¢—ÈπμÕπ ¥—ßπ’È - °¥ Stop blood pump - ª≈¥ “¬¥â“π Artery line ÕÕ°®“°μ—«ºâŸªÉ«¬ μàÕ°—∫ “√≈–≈“¬ 0.9% NSS ∑’ˇμ√’¬¡‰«â - °¥ Blood return ªíö¡À¡ÿπ §◊π‡≈◊Õ¥°≈—∫ ŸàºâŸªÉ«¬ °¥ Stop blood pump - °¥ End treatment ‡æ◊Ëժ§√◊ËÕß - ª≈¥ “¬ Venous line ÕÕ°®“°ºâŸªÉ«¬ - ª≈¥Õÿª°√≥å∑—ÈßÀ¡¥ÕÕ°®“°‡§√◊ËÕß 433



Work Instruction: Online Hemodiafiltration 22 Work Instruction: Online Hemodiafiltration ™Õà º°“  °ÿ≈»√’®π‘ ¥“ ¬«ÿ ¥’ ∏√’ »≈‘ ªá 1. ∫∑π” 2. ‡∑§π‘§°“√∑” hemodiafiltration 3. Õߧåª√–°Õ∫„π°“√∑” online hemodiafiltration 4. ‡§√ÕË◊ ß·≈–Õߧªå √–°Õ∫¢Õ߇§√◊ËÕ߉μ‡∑’¬¡ Fresenius √πàÿ 4008H 5. ¢Èπ— μÕπ°“√‡μ√¬’ ¡‡§√ËÕ◊ ߉μ‡∑¬’ ¡ Fresenius √πÿà 4008H Online HDF 6. ‡§√◊ËÕß·≈–Õߧåª√–°Õ∫¢Õ߇§√ËÕ◊ ߉μ‡∑¬’ ¡ NIKKISO √πàÿ DBB 05 7. ¢πÈ— μÕπ°“√‡μ√’¬¡‡§√◊ËÕ߉μ‡∑¬’ ¡ NIKKISO √πàÿ DBB 05 online HDF 8.  √ÿª 435

Practical Dialysis in the Year 2009 1. ∫∑π” °“√∑” hemodialysis π—Èπ„™â°√–∫«πÀ≈—° 2 °√–∫«π°“√ §◊Õ °√–∫«π°“√·æ√à (diffusion) ´÷Ëß ¢®—¥ uremic toxin ™π‘¥ small molecule ‚¥¬°“√´÷¡ºà“π semipermeable membrane ®“°¥â“π∑’Ë¡’§«“¡ ‡¢â¡¢âπ¡“°‰ª àŸ¥â“π∑’Ë¡’§«“¡‡¢â¡¢âππâÕ¬ ·≈–°√–∫«π°“√æ“ (convection) ´÷Ëߢ®—¥ uremic toxin ™π‘¥ middle molecule μ“¡°“√ºà“πÕÕ°¢ÕßπÈ” (ultrafiltration) ¥—ßπ—Èπ‡æ◊ËÕ‡ªìπ°“√‡æ‘Ë¡°“√¢®—¥ uremic toxin ™π‘¥ middle molecule „Àâ¡“°¢÷Èπ ®÷ß¡’°“√æ—≤π“«‘∏’°“√μà“ßÊ „Àâ “¡“√∂‡æ‘Ë¡°√–∫«π°“√æ“„Àâ¡“°¢÷Èπ ‚¥¬Õ“®μâÕ߇æ‘Ë¡·√ߥ—π (positive pressure) ∑“ߥâ“π‡≈◊Õ¥ À√◊ÕÕ“®‡æ‘Ë¡·√ߥ÷ߥŸ¥ (negative pressure) ∑“ߥâ“π dialysate À√◊Õ°“√„Àâ “√πÈ”∑¥·∑π (replacement fluid / substitute fluid) ·≈–¥÷ßÕÕ°∑“ߥâ“π dialysate „π√ªŸ ¢Õß ultrafiltration ´÷Ë߇√’¬°«à“ Hemodiafiltration (HDF) 2. ‡∑§π‘§°“√∑” hemodiafiltration  “¡“√∂·∫ßà ‡∑§π§‘ „π°“√∑” HDF μ“¡≈°— …≥–°“√‡μ¡‘  “√π”È ∑¥·∑π‰¥‡â ªπì 2 ·∫∫„À≠Êà ¥—ßπ’È 1. External infusion ‡ªìπ°“√øÕ°‡≈◊Õ¥·∫∫ HDF ∑’Ë„Àâ “√∑¥·∑ππÈ”∑’˺≈‘μ®“°μ—«°√Õß ¢Õ߇§√◊ËÕ߉μ‡∑’¬¡·≈–„Àâ‡¢â“ àŸºŸâªÉ«¬‚¥¬μ√ß ‚¥¬‡√’¬°°“√∑” hemodiafiltration ·∫∫π’È«à“ online hemodiafiltration (online HDF) ´÷Ëß¡’«‘∏’°“√„Àâ “√πÈ”∑¥·∑πÀ≈“¬«‘∏’ ¥—ßπ’È 1.1 Pre dilution §◊Õ °“√„Àâ “√πÈ”∑¥·∑π¥â“π arterial drip chamber À√◊Õ¥â“π°àÕπ‡≈◊Õ¥ ‡¢â“μ—«°√Õß 1.2 Post dilution §◊Õ °“√„Àâ “√πÈ”∑¥·∑π¥â“π venous drip chamber À√◊Õ ¥â“πÀ≈—߇≈◊Õ¥ ºà“πμ—«°√Õß 1.3 Mid dilution §◊Õ °“√„Àâ “√πÈ”∑¥·∑π√–À«à“ßμ—«°√Õß 2 μ—«∑’ËμàÕ·∫∫Õπÿ°√¡ 1.4 Mix dilution §◊Õ °“√„Àâ “√πÈ”∑¥·∑π∑—Èß pre dilution ·≈– post dilution æ√âÕ¡Ê °—π À√◊Õ ¥â“π arterial drip chamber ·≈– venous drip chamber æ√âÕ¡Ê °—π 2. Internal infusion ‡ªπì °“√øÕ°‡≈Õ◊ ¥·∫∫ HDF ™π¥‘ Àπß÷Ë ´ß÷Ë ¡ ’ “√πÈ”∑¥·∑π‡°¥‘ ¢π÷È ¿“¬„π ¿“¬„πμ—«°√Õß ”À√—∫øÕ°‡≈◊Õ¥‡Õß ‚¥¬«‘∏’ backfiltration ¡’À≈“¬‡∑§π‘§ ‡™àπ 2.1 Push-pull HDF ‡ªìπ·∫∫∑’Ë¡’∑—Èß ultrafiltration ·≈– backfiltration „πμ—«°√Õ߇¥’¬«°—𠧫∫§ÿ¡‚¥¬ double chamber piston pump 2.2 Internal filtration ‡ªìπ·∫∫„™âμ—«°√Õß摇»… ‚¥¬¡’ ultrafiltration ∑’Ë à«πμâπ¢Õßμ—«°√Õß ·≈–¡’ backfiltration ∑’Ë à«π∑⓬ 2.3 Double high-flux HDF ‡ªìπ·∫∫„™âμ—«°√Õß 2 μ—«μàÕ°—π·∫∫Õπÿ°√¡ ‚¥¬¡’ “¬π”‡≈◊Õ¥ ·≈– “¬π”πÈ”¬“‡™◊ËÕ¡μ—«°√Õß∑—Èß Õß  “¬π”πÈ”¬“ dialysate ®–¡’ dialysate flow restrictor ∫—ߧ—∫°“√ Õ—μ√“°“√‰À≈¢ÕßπÈ”¬“ dialysate „Àâºà“π‰ªμ—«°√Õßμ—«·√°πâÕ¬°«à“μ—«∑’Ë Õß (πÈ”¬“ dialysate ‰À≈ «π ∑“ß°—∫°“√‰À≈¢Õ߇≈◊Õ¥) ∑”„Àâ¡’°“√¥÷ß ultrafiltration ºà“πμ—«°√Õß·√° ·≈–¡’°“√„Àâ “√πÈ”∑¥·∑π 436

Work Instruction: Online Hemodiafiltration (substitute fluid) ºà“πμ—«°√Õß∑’Ë Õß‚¥¬«‘∏’ backfiltration „πªí®®ÿ∫—π ª√–‡∑»‰∑¬¡’»Ÿπ¬å‰μ‡∑’¬¡∑’Ë„Àâ∫√‘°“√ HDF μ“¡‡∑§π‘§¡“μ√∞“π 2 «‘∏’ ‰¥â·°à °“√∑” online HDF ·≈– double high-flux °“√∑” HDF ∑—Èß 2 «‘∏’¡’À≈—°°“√∑’˧≈⓬§≈÷ß°—π §◊Õ ¡’°“√ °”®—¥¢Õ߇ ’¬‚¥¬À≈—°°“√ diffusion „°≈⇧’¬ß°—∫ HD ¥—È߇¥‘¡ ·≈–¡’°“√°”®—¥¢Õ߇ ’¬‚¥¬À≈—°°“√ convection Õ¬à“ß¡’ª√– ‘∑∏‘¿“æ√à«¡¥â«¬ ´÷Ëß∑“ß‚√ß欓∫“≈®ÿÓ≈ß°√≥剥â„Àâ∫√‘°“√°“√∑” HDF ∑—Èß 2 ‡∑§π‘§ 3. Õߧªå √–°Õ∫„π°“√∑” online hemodiafiltration 1. Dialyzer §«√‡ªìπ dialyzer ∑’Ë¡’√Ÿ°√Õß¢π“¥„À≠à ·≈–¡’§à“ —¡ª√– ‘∑∏‘Ï°“√¬Õ¡„ÀâπÈ”ºà“π μ—«°√Õß (ultrafiltration coefficient: Kuf)  Ÿß°«à“ 20 ¡‘≈≈‘‡¡μ√μàÕ™—Ë«‚¡ßμàÕ¡‘≈≈‘‡¡μ√ª√Õ∑ ‡æ◊ËÕ„Àâ uremic toxin ™π‘¥ middle molecule ∂Ÿ°¢®—¥ÕÕ°‰¥â‚¥¬°√–∫«π°“√æ“ (convection) ·≈– “¡“√∂‡μ‘¡ “√πÈ” ‡¢â“ Ÿà√à“ß°“¬ºâŸªÉ«¬‰¥â„π®”π«π¡“° (replacement fluid / substitute fluid) ‚¥¬‰¡à‡°‘¥¿“«– TMP high alarm ‚¥¬‡√’¬° dialyzer μ“¡§ÿ≥ ¡∫—μ‘π’È«à“ high-flux dialyzer 2. Hemodialysis machine μâÕß„™â‡§√◊ËÕß‚¥¬‡©æ“– ‡™àπ Fresenius 4008H, Grambo 200 Ultra series, Nikkizo DBB05 ´÷Ë߇§√◊ËÕ߇À≈à“π’È®–μâÕß¡’≈—°…≥–¥—ßπ’È 2.1 ¡’Õÿª°√≥åæ◊Èπ∞“π‡™àπ‡¥’¬«°—∫‡§√◊ËÕß hemodialysis ∑—Ë«‰ª 2.2  “¡“√∂§«∫§ÿ¡ ultrafiltration ‰¥âÕ¬à“ß·¡à𬔠‡π◊ËÕß®“°‡ªìπ°√–∫«π°“√√—°…“∑’Ë¡’ °“√¥÷ßπÈ”ÕÕ°®“°ºŸâªÉ«¬®”π«π¡“° ‚¥¬‡©≈’ˬՓ® Ÿß∂÷ß 20 ≈‘μ√ 2.3 ¡’ substitute fluid pump ‡æ◊ËÕ„™â¢—∫‡§≈◊ËÕπ replacement fluid ®“°„π√–∫∫¢Õ߇§√◊ËÕß ‰μ‡∑’¬¡‡¢â“ àŸ√à“ß°“¬ºâŸªÉ«¬ ‚¥¬ “¡“√∂°”Àπ¥Õ—μ√“°“√‡μ‘¡ “√πÈ”∑¥·∑π‰¥â 2.4 √–∫∫ filter ´÷Ë߇ªìπμ—«¥—°°“√ªπ‡ªóôÕπ¢Õß·∫§∑’‡√’¬·≈– endotoxin, filter ∑’Ë„™â¡’¢π“¥ πâÕ¬°«à“À√◊Õ‡∑à“°—∫ 0.2 ‰¡§√Õ𠇪ìπ¢π“¥∑’Ë “¡“√∂°√Õß endotoxin ‰¥â ‚¥¬∑—Ë«‰ª„™â filter 2 μ—« ·μà¡’ ‡§√◊ËÕß hemodialysis ∫“ß™π‘¥„™â filter 3 μ—« ´÷Ëß·μà≈– filter ®–∑”Àπâ“∑’Ëμ“¡«—μ∂ÿª√– ß§å¥—ßπ’È μ—«°√Õß∑’Ë 1 ®–°√ÕßπÈ”¬“ dialysate ‡æ◊ËÕ„À≥⇰≥±å¡“μ√∞“π μ—«°√Õß∑’Ë 2 ·≈– 3 ®–°√ÕßπÈ”¬“ dialysate ‡æ◊ËÕ„Àâ  “√πÈ”∑¥·∑π„π√–¥—∫ ultrapure ·≈–¬—߇ªìπμ—«°√Õß∑’˙૬ªÑÕß°—π°“√‡°‘¥ ‘Ëß∑’ˉ¡àæ÷ߪ√– ß§å ‡™àπ μ—« °√Õßμ—«∑’Ë 1 ¡’°“√√—Ë«À√◊Õ·μ° 3. √–∫∫πÈ” πÈ”∑’Ë„™âμâÕß¡’§ÿ≥ ¡∫—μ‘ ultrapure μ“¡¢âÕ°”Àπ¥¢Õß European Pharmacopoeia °”Àπ¥ §ÿ≥ ¡∫—μ‘¢Õß ultrapure ‡πâπ∑’Ë°“√ªπ‡ªóôÕπ¢Õß·∫§∑’‡√’¬πâÕ¬°«à“ 0.1 CFU μàÕ¡‘≈≈‘≈‘μ√ ·≈–ª√‘¡“≥ endotoxin ‰¡à‡°‘π 0.03 EUμàÕ¡‘≈≈‘≈‘μ√1 ‡π◊ËÕß®“°°“√∑” HDF ¡’°“√„Àâ “√πÈ”∑¥·∑π®”π«π¡“° À“° √–∫∫πÈ”¡’°“√ªπ‡ªóôÕπ¢Õß·∫§∑’‡√’¬·≈– endotoxin ¡“°°«à“‡°≥±å∑’Ë°”Àπ¥°Á‡∑à“°—∫‡ªìπ°“√‡μ‘¡ ·∫§∑’‡√’¬‡¢â“°√–· ‡≈◊Õ¥ºâŸªÉ«¬‚¥¬μ√ß„π®”π«π¡“°‡™àπ‡¥’¬«°—π 4. πÈ”¬“ acid ·≈– bicarbonate πÈ”¬“ acid ·≈– bicarbonate ∑’Ëπ”¡“„™â„π°“√∑” hemodiafiltration μâÕ߇ªìππÈ”¬“∑’ˇªî¥„™â 437