Practical Dialysis in the Year 2009

Practical Dialysis in the Year 2009 „À¡à∑ÿ°§√—Èß ‚¥¬‡©æ“–πÈ”¬“ bicarbonate ´÷Ë߇™◊ÈÕ·∫§∑’‡√’¬ “¡“√∂‡®√‘≠‡μ‘∫‚쉥âÕ¬à“ß√«¥‡√Á« ‚¥¬¢âÕ °”Àπ¥¢Õ߇™◊ÈÕ·∫§∑’‡√’¬¢ÕßπÈ”¬“ concentrate π—Èπ AAMI °”Àπ¥„Àâ < 200 CFU μàÕ ¡‘≈≈‘≈‘μ√ ·≈–§à“ endotoxin π—Èπ Italian Pharmacopoeia °”Àπ¥„Àâ < 0.5 EUμàÕ¡‘≈≈‘≈‘μ√ 2 ¥—ßπ—Èπ ®÷ߧ«√∑”°“√‡æ“–‡™◊ÈÕ ·∫§∑’‡√’¬·≈–μ√«®À“ endotoxin ¢ÕßπÈ”¬“ bicarbonate Õ¬à“ß ¡Ë”‡ ¡Õ ‡π◊ËÕß®“°ª√‘¡“≥‡™◊ÈÕ ·∫§∑’‡√’¬∑’Ë¡’®”π«π¡“°‡°‘π°«à“‡°≥±å∑’Ë°”Àπ¥ Õ“®∑”„Àâ filter °√ÕßπÈ”¬“ dialysate ‰¡à “¡“√∂ °√Õß “√πÈ”∑¥·∑π‰¥âμ“¡‡°≥±å¢Õß ultrapure ∂â“ “¡“√∂„™â bicarbonate ™π‘¥ºß®–™à«¬≈¥®”π«π ‡™◊ÈÕ·∫§∑’‡√’¬‰¥âÕ¬à“ß¡“° 4. ‡§√ÕË◊ ß·≈–Õߧªå √–°Õ∫¢Õ߇§√◊ÕË ß‰μ‡∑¬’ ¡ Fresenius √àπÿ 4008H 3 ‡§√◊ËÕ߉μ‡∑’¬¡ Fresenius √ÿàπ 4008H π’ȇªìπ‡§√◊ËÕ߉μ‡∑’¬¡∑’Ë “¡“√∂∑”°“√øÕ°‡≈◊Õ¥·∫∫ Hemodiafiltration ‚¥¬·∫àß à«π°“√„™âß“πÀ≈—°„π°“√øÕ°‡≈◊Õ¥¥—ßπ’È 1.  à«π¢ÕßÀπâ“®Õ‡ªìπ à«π¢Õß°“√ªî¥/‡ªî¥‡§√◊ËÕß °“√μ—Èߧà“μà“ßÊ ‡™àπ UF, dialysate, OCM, alarm limits, disinfection ‡ªìπμâπ ´÷Ëß®–‰¡à°≈à“«„π∑’Ëπ’È 2. Online module ‡ªìπ à«π∑’˧«∫§ÿ¡°“√º≈‘μ “√πÈ” (substitute fluid) ∑’Ë„™â„π ”À√—∫°“√ ≈â“ßμ—«°√Õß °“√‡μ‘¡‡¢â“√à“ß°“¬ °“√§◊π‡≈◊Õ¥‡¡◊ËÕ‡ √Á® ‘Èπ°“√øÕ°‡≈◊Õ¥ ‡ªìπμâπ ´÷Ëߪ√–°Õ∫¥â«¬ 2.1 ªÿÉ¡ Start/stop ‡ªìπ à«π∑’Ë„™â„π°“√‡√‘Ë¡∑” HDF À√◊ÕÀ¬ÿ¥∑” HDF 2.2 ªÿÉ¡ enter ‡ªìπªÿÉ¡°¥μÕ∫√—∫„Àâ Online module ∑”ß“πμ“¡ message μà“ßÊ ∑’Ë· ¥ß ∫πÀπâ“®Õ¢Õß online module 2.3 ªÿÉ¡ bolus ‡ªìπªÿÉ¡°¥°“√„Àâ replace fluid ∑—π∑’ ‡¡◊Ëպ⟪ɫ¬¡’¿“«– hypotension ‚¥¬°¥ 1 §√—Èß ®–¡’ substitute fluid ∑’Ë∑¥·∑π„Àâ∑—ÈßÀ¡¥ 210 ¡‘≈≈‘≈‘μ√ (Àπâ“®Õ®–· ¥ßª√‘¡“≥°“√„Àâ§√—Èß≈– 30 ¡‘≈≈‘≈‘μ√ ∑—ÈßÀ¡¥ 7 §√—Èß) 2.4 ªÿÉ¡ volume ‡ªìπªÿÉ¡‡æ◊ËÕ‡¢â“ Ÿà°“√μ—Èߪ√‘¡“≥¢Õß substitute fluid ∑’ËμâÕß°“√„ÀâºâŸªÉ«¬ 2.5 ªÿÉ¡≈Ÿ°»√¢÷Èπ-≈ß ‡ªìπªÿÉ¡‡≈◊Õ° mode ¢Õß°“√øÕ°‡≈◊Õ¥ ·≈– ªÿÉ¡≈¥À√◊Õ‡æ‘Ë¡ª√‘¡“≥ ¢Õß substitute fluid ∑’ËμâÕß°“√„ÀâºâŸªÉ«¬ ‡ªìπμâπ √Ÿª∑’Ë 1 · ¥ß online module 438

Work Instruction: Online Hemodiafiltration 5. ¢π—È μÕπ°“√‡μ√¬’ ¡‡§√◊ÕË ß‰μ‡∑¬’ ¡ Fresenius √àÿπ 4008H Online HDF ¢âÕ§«“¡ √Ÿª· ¥ß 1. ‡§√◊ËÕ߉μ‡∑’¬¡√ÿàππ’È¡’ filter °√ÕßπÈ”¬“ dialysate ®”π«π 2 μ—« (Diasafe plus) ·≈–°àÕπ®–‡√‘Ë¡°“√„™â‡§√◊ËÕß≈â“ß μ—«°√Õß·≈–Õÿª°√≥åμà“ßÊ ∑ÿ°§√—ÈßμâÕß∑”°“√¶à“‡™◊ÈÕ ‡§√◊ËÕ߉μ‡∑’¬¡°àÕπ 2. ‡μ√’¬¡μ—«°√Õß·≈–Õÿª°√≥åμà“ßÊ °“√øÕ°‡≈◊Õ¥ ¥—ßπ’È 1.μ—«°√Õß™π‘¥ High flux ´÷Ëߧ«√¡’§à“ Kuf  ßŸ 2. “¬ blood line ∑’Ë¡’ “¬«—¥¥â“π negative pressure, positive pressure ·≈– “¬ ”À√—∫„Àâ pre ·≈– post dilution 3.Tranducer protector 2 μ—« 4. “¬ Safe line æ√âÕ¡ rinse connector 3. ∑”°“√μàÕπÈ”¬“ A, B ·≈– °¥ çtesté 1 §√—Èß ‡§√◊ËÕß®–∑” °“√∑¥ Õ∫√–∫∫μà“ßÊ ‚¥¬¡’¢âÕ§«“¡∂“¡«à“ çtest override?é ´÷Ëß∂â“°¥ çtesté Õ’°§√—Èß ‡§√◊ËÕß®–∑”°“√¢â“¡ °“√∑¥ Õ∫√–∫∫μà“ßÊ ·≈–¡’¢âÕ§«“¡«à“ ONLINE plus disable  à«π online module ®–· ¥ßº≈ çT1 test Error no.: 9é ¥—ßπ—Èπ®÷߉¡à§«√¢â“¡°“√∑¥ Õ∫‡§√◊ËÕß ·≈–∂â“ μâÕß°“√∑” hemodiafiltration ‡§√◊ËÕß®–μâÕß∑¥ Õ∫∑ÿ°§√—Èß ´÷Ëߢ≥–‡§√◊ËÕß∑”°“√∑¥ Õ∫®–ª√“°Ø¢âÕ§«“¡∑—ÈßÀπâ“®Õ ‡§√◊ËÕß·≈– online module «à“ çTest in Progressé 4. ‡¡◊ËÕ√–∫∫°“√∑”ß“π¢Õ߇§√◊ËÕß ¡∫Ÿ√≥å ‡§√◊ËÕß®–· ¥ß ¢âÕ§«“¡ çT1 test passedé ·≈– online module ®–· ¥ß ¢âÕ§«“¡ çSelect mode .....?é ´÷Ëß¡’∑—Èß mode HDF, HD, HF ‚¥¬°¥‡≈◊Õ°®“°ªÉÿ¡≈°Ÿ »√¢÷ÈπÀ√◊Õ≈ß ¥â“π¢â“߮բÕß online module °√≥’√–∫∫°“√∑”ß“π¢Õ߇§√◊ËÕ߉¡à ¡∫√Ÿ ≥å ®–· ¥ß ¢âÕ§«“¡ çT1 test failedé §«√∑”°“√∑¥ Õ∫„À¡à ∂Ⓣ¡à ºà“π§«√·®âßμàÕ∫√‘…—∑∑’Ë√—∫º‘¥™Õ∫ À≈—ß T1 test passed À“â ¡ °¥ªÿÉ¡„¥Ê „πÀπâ“®Õ‡§√◊ËÕß 439

Practical Dialysis in the Year 2009 √ªŸ · ¥ß ¢Õâ §«“¡ 5. ¢≥–∑’Ë√Õ°“√∑¥ Õ∫¢Õ߇§√◊ËÕß æ¬“∫“≈ “¡“√∂‡μ√’¬¡ «“ß “¬ blood line μàÕ°—∫μ—«°√Õß®π§√∫«ß®√ ‚¥¬ª≈“¬  “¬ bloodline ¥â“π AV ·≈– “¬¥â“π negative pressure, positive pressure ‰¡àμâÕß clamp  “¬‰«â 6. π”ª≈“¬ “¬ blood line A μàÕ°—∫  “¬ safe line ¥â“π A (®–· ¥ß —≠≈—°…≥å ’·¥ß) ‚¥¬‡ªî¥ clamp  “¬ ’·¥ß·≈–  “¬ blood line A 7. π” “¬ safe line ¥â“π V (®–· ¥ß —≠≈—°…≥å ’πÈ”‡ß‘π) μàÕ°—∫ “¬ blood line ¥â“π pre, mid À√◊Õ post dilution μ“¡°“√√—°…“¢Õß·æ∑¬å ‚¥¬ªî¥ clamp ‰«â°àÕπ 8. π”ª≈“¬ “¬ blood line V μàÕ°—∫ rinse connector ‚¥¬‡ªî¥ clamp  “¬ blood line V 9. ‡¡◊ËÕ T1 test passed ·≈– online module ®–· ¥ß¢âÕ§«“¡ çSelect mode HDF?é „Àâ∑”°“√μàÕ dialysate connector ‡¢â“°—∫ dialyzer ‚¥¬®—¥„Àâ°“√‰À≈¢Õ߇≈◊Õ¥„π«ß®√  «π∑“ß°—∫°“√‰À≈¢ÕßπÈ”¬“ dialysate ‰≈àøÕßÕ“°“» ·≈– πÈ”¬“Õ∫¶à“‡™◊ÈÕÕÕ°®“°¥â“π dialysate compartment Õ“®ª√—∫°“√‰À≈¢ÕßπÈ”¬“ dialysate ‡ªìπ 800 ¡‘≈≈‘≈‘μ√ μàÕπ“∑’ ‰«â°àÕπ‰¥â 440

Work Instruction: Online Hemodiafiltration ¢âÕ§«“¡ √ªŸ · ¥ß 10. μàÕ®“°π—Èπ„Àâ‡≈◊Õ° mode HDF ‚¥¬°¥ªÿÉ¡ enter ∑’Ë online module (μâÕßμ√«® Õ∫Àπâ“®Õ online module «à“Õ¬àŸ„π mode ∑’ËμâÕß°“√À√◊Õ‰¡à ∂Ⓣ¡à„™à mode ∑’Ë μâÕß°“√„Àâ‡≈◊Õ°‚¥¬°¥ªÿÉ¡≈°Ÿ »√¢÷Èπ/≈߇æ◊ËÕ‡≈◊Õ° mode °àÕ𰥪ÿÉ¡ enter) 11. À≈—ß®“°°“√°¥ªÿÉ¡ enter ‡≈◊Õ° mode ·≈â« Àπâ“®Õ®–¡’ ¢âÕ§«“¡«à“ çConnect sub. tubing?é ‡ªìπ°“√∂“¡«à“®– ∑”°“√μàÕ “¬ safe line ‡¢â“°—∫‡§√◊ËÕßÀ√◊Õ‰¡à „Àâ∑”°“√°¥ ªÿÉ¡ enter ®–ª√“°Ø¢âÕ§«“¡„Àâ √Õ —°§√àŸ çPlease wait!é 12. À≈—ß®“°π—Èπ®–ª√“°Ø¢âÕ§«“¡ çOpen sub. port!é „Àâ À¡ÿπ·°π sub port  ’πÈ”‡ß‘π¥â“π´â“¬¡◊Õ¢Õß online module μ“¡‡¢Á¡π“Ãî°“ 90 Õß»“ ‡æ◊ËÕ‡ªî¥™àÕß substitute port 13. μàÕ¡“®–ª√“°Ø¢âÕ§«“¡ çOpen pump door!é „Àâ‡ªî¥ ª√–μ¢Ÿ Õß online module ®–ª√“°Ø¢âÕ§«“¡ çConnect sub. tubing!é 441

Practical Dialysis in the Year 2009 √Ÿª· ¥ß ¢âÕ§«“¡ 14. ‡¡◊ËÕ‡ªî¥ª√–μŸ online module ®–ª√“°Ø¢âÕ§«“¡ çConnect sub. tubing!é 15. π” “¬ safe line connector „ à‡¢â“„π™àÕß substitute port ·≈â«À¡ÿπ·°π sub port μ“¡‡¢Á¡π“Ãî°“ 90 Õß»“ ªî¥ safe line connector ‰«â 16. À≈—ß®“°π—Èπ®–¡’¢âÕ§«“¡ çInsert sub. tubing!é „Àâ„ à  “¬ safe line ‡¢â“„π substitute fluid pump ·≈⫪√–μŸ pump 17. À≈—ߪ√–μŸ substitute fluid pump ®–¡’¢âÕ§«“¡ çOpen rinse port!é 18. „Àâ∑”°“√À¡ÿπ·°π rinse port  ’‡∑“¥â“π¢«“¡◊Õ¢Õß online module μ“¡‡¢Á¡π“Ãî°“ 90 Õß»“ ‡æ◊ËÕ‡ªî¥™àÕß rinse port 19. π” “¬ blood line V ´÷ËßμàÕ rinse connector (ª≈“¬ ¥â“π Vein) ‡ ’¬∫‡¢â“™àÕß rinse port μ“¡¢âÕ§«“¡ çConnect rinse connector!é 442

¢Õâ §«“¡ Work Instruction: Online Hemodiafiltration √ªŸ · ¥ß 20. ªî¥ rinse port ‚¥¬À¡ÿπμ“¡‡¢Á¡π“Ãî°“ 90 Õß»“ 21. ‡§√◊ËÕß®–· ¥ß¢âÕ§«“¡ çPriming blood linesé „Àâ°¥ªÿÉ¡ prime ∑’ËÀπâ“®Õ‡§√◊ËÕ߉μ‡∑’¬¡ ∂â“ blood pump À√◊Õ online pump ¬—߉¡àÀ¡ÿπ„Àâ°¥ªÿÉ¡ start ∑’Ë blood pump ·≈â«√Õ —°§√Ÿà ‡¡◊ËÕ blood pump À¡ÿπ·≈â«„Àâ‡æ‘Ë¡§«“¡‡√Á« ‚¥¬‰¡à‡°‘π 250 ml/min 22. ‡§√◊ËÕ߉μ‡∑’¬¡®–º≈‘μ substitute fluid ÕÕ°®“° sub. port ºà“𠓬 safe line ‰ª Ÿà«ß®√øÕ°‡≈◊Õ¥®“° “¬ blood line A  àŸ blood line V ·≈– drain ÕÕ°∑“ß rinse port ‚¥¬· ¥ß ª√‘¡“≥¢ÕßπÈ”¬“ rinse ∑’ËÀπâ“®Õ¥—ßπ’È Rinse Vol: 00 ml. · ¥ßª√‘¡“≥ substitute fluid ∑’Ë rinse ºà“πμ—«°√Õß®”π«π 1000 ¡‘≈≈‘≈‘μ√ ‚¥¬‰¡à¡’ dialysate ºà“π¥â“π dialysate compartment UF - Vol: 00 ml. · ¥ßª√‘¡“≥°“√¥÷ß UF ®”π«π 500 ¡‘≈≈‘≈‘μ√ À≈—ß°“√ rinse ®”π«π 1000 ¡‘≈≈‘≈‘μ√·√°§√∫ ‚¥¬¢≥–∑”°“√ UF π—Èπ μ—« clamp ¢Õß optical sensor ¢Õ߇§√◊ËÕ߉μ‡∑’¬¡ ®–Àπ’∫ “¬‰«â‰¡à„Àâ “√πÈ”‰À≈ºà“π 443

Practical Dialysis in the Year 2009 √ªŸ · ¥ß ¢Õâ §«“¡ blood line V ·≈–‚√ß欓∫“≈®ÿÓ≈ß°√≥å®–∑”°“√ prime heparin 5000 unit „π¢≥–∑” UF ‚¥¬©’¥‡¢â“ ∫√‘‡«≥ port ∑’Ë„™â‡®“–‡≈◊Õ¥¢Õß “¬ blood line A 23. ‡¡◊ËÕ∑” UF §√∫ 500 ¡‘≈≈‘≈‘μ√ √–∫∫¢Õ߇§√◊ËÕß®–∑”°“√ ≈â“ßμ—«°√ÕßμàÕ‚¥¬∑”„Àâ¡’°“√‰À≈¢Õß∑—Èß substitute fluid ºà“πμ—«°√Õß ·≈– dialysate fluid ºà“π dialysate compartment (§«√ª√—∫πÈ”¬“ dialysate ‡ªìπ 800 ¡‘≈≈‘≈‘μ√ ‡æ◊ËÕ„Àâ¡’ª√‘¡“≥πÈ”®”π«π¡“°‰À≈ºà“πμ—«°√Õß∑—Èß 2 compartment) ‚¥¬°”Àπ¥ª√‘¡“≥¢Õß “√πÈ”∑’Ë≈â“ß μ—«°√Õ߇∑à“°—∫°“√≈â“ߥ⫬«‘∏’ manual 24. ‡¡◊ËÕ≈â“ßμ—«°√Õߧ√∫μ“¡®”π«π∑’Ë°”Àπ¥ „Àâ∑”°“√ ∑¥ Õ∫ “√Õ∫¶à“‡™◊ÈÕμ“¡‡°≥±å∑’Ë°”Àπ¥ ‡¡◊ËÕº≈°“√ ∑¥ Õ∫‡ªìπ≈∫ „ÀâÀ¬ÿ¥°“√≈â“ßμ—«°√Õß·≈–‡√‘Ë¡∑”°“√ øÕ°‡≈◊Õ¥ ‚¥¬°¥ªÿÉ¡ stop Àπâ“®Õ online module ®–ª√“°Ø¢âÕ§«“¡ çTerminate rinse?é ‡ªìπ¢âÕ§«“¡∂“¡ °“√À¬ÿ¥≈â“ßμ—«°√Õß „Àâ°¥ªÿÉ¡ enter 25. À≈—ß®“°π—Èπ online module ®–· ¥ß¢âÕ§«“¡ çRemove rinse connector!é „ÀâÀ¡ÿπ‡ªî¥ rinse port π” rinse connector ·≈– “¬ blood line V ÕÕ° (§«√ clamp  “¬ blood line V °àÕππ” rinse connector ÕÕ°) 26. ‡¡◊ËÕπ” rinse connector ÕÕ° ®–¡’¢âÕ§«“¡ çClose rinse porté „ÀâÀ¡ÿπªî¥ rinse port 444

Work Instruction: Online Hemodiafiltration ¢Õâ §«“¡ √Ÿª· ¥ß 27. ª≈¥ rinse connector μ√ߪ≈“¬ blood line V ÕÕ°μàÕ ¥â«¬ connector drain ·≈– π”≈ß∂—ß drain À≈—ß®“°π—Èπ „Àâª≈¥ clamp ∑’ËÀπ’∫ “¬ blood line V 28. Àπ’∫ “¬ blood line A ·≈– safe line ¥â«¬ clamp ¢Õß  “¬ ·≈⫪≈¥ÕÕ°®“°°—π ®“°π—Èππ” “¬ blood line A ‰ªμàÕ°—∫ arterial vascular access ª≈¥ clamp ∑—Èß 2  “¬ ‡ªî¥ blood pump „Àâ‡≈◊Õ¥‰À≈ºà“π√–∫∫®π∂÷ß venous drip chamber ªî¥ blood pump æ√âÕ¡Àπ’∫ “¬ blood line V ·≈â«π”¡“μàÕ°—∫ venous vascular access (√–¡—¥√–«—ßøÕß Õ“°“»∑’ËÕ“®μ°§â“ß„π “¬ blood line V ¢≥–μàÕ “¬«ß®√)  à«πª≈“¬ “¬ safe line π”®ÿ° sterile ªî¥ª≈“¬ “¬ 29. ª≈¥ clamp Àπ’∫ “¬ blood line V ·≈– venous vascular access ·≈⫇ªî¥ blood pump „Àâ‡≈◊Õ¥‰À≈Õ¬à“ßμàÕ‡π◊ËÕß „π«ß®√øÕ°‡≈◊Õ¥ ·≈–ª√—∫„À⧫“¡‡√Á«ª√–¡“≥ 400 ¡‘≈≈‘≈‘μ√μàÕπ“∑’ Àπâ“®Õ online module ®–ª√“°Ø ¢âÕ§«“¡ çEnter UF time!é ‡ªìπ°“√·®âß„Àâ¡’°“√μ—Èß§à“ ¢Õß UF ·≈–‡«≈“øÕ°‡≈◊Õ¥„π§√—Èßπ’È (∂â“μ—Èß§à“‰«â°àÕπ °“√≈â“ß®–‡ √Á® ‘Èπ ¢âÕ§«“¡π’È®–‰¡àæ∫) 30. ‡¡◊ËÕμ—Èß§à“ UF ·≈–‡«≈“øÕ°‡≈◊Õ¥·≈â« Àπâ“®Õ®–· ¥ß ¢âÕ§«“¡ çEnter sub. volume!é „Àâ°¥ªÿÉ¡ volume ∑’Ë Àπâ“®Õ online module ®–ª√“°Ø¢âÕ§«“¡ 2 ∫√√∑—¥ §◊Õ 1. ª√‘¡“≥ substitute fluid ∑’Ë„À⇪ìπ¡‘≈≈‘≈‘μ√μàÕπ“∑’ ‚¥¬ °”Àπ¥ post dilution „Àâª√–¡“≥ 25-30% ¢Õß BFR 2. º≈√«¡¢Õߪ√‘¡“≥ substitute fluid ∑’Ë„Àâ¢≥–∑’Ë∑”°“√ øÕ°‡≈◊Õ¥ „Àâ°¥ªÿÉ¡≈Ÿ°»√¢÷Èπ‡æ◊ËÕ‡æ‘Ë¡ª√‘¡“≥¢Õß substitute fluid μ“¡·ºπ°“√√—°…“¢Õß·æ∑¬å ·≈â«°¥ªÿÉ¡ enter 445

Practical Dialysis in the Year 2009 √ªŸ · ¥ß ¢Õâ §«“¡ 31. À≈—ß®“°°¥ªÿÉ¡ enter ®–¡’¢âÕ§«“¡ çStart HDF!é „Àâ °¥ªÿÉ¡ start/stop ∑’ˇ§√◊ËÕß online module  à«π∑’ËÀπâ“®Õ HD „Àâ‡√‘Ë¡°“√øÕ°‡≈◊Õ¥‚¥¬°¥ªÿÉ¡ UF 32. „π¢≥–øÕ°‡≈◊Õ¥ ∂⓺ŸâªÉ«¬¡’¿“«– hypotension ·≈– μâÕß°“√„Àâ “√πÈ”  “¡“√∂„À≥₥¬√–∫∫ online ‚¥¬ °¥ªÿÉ¡ bolus ®–¡’¢âÕ§«“¡ çcumBolus: 00 ml / Bolus start?é „Àâ°¥ªÿÉ¡ enter ‡§√◊ËÕß®–À¬ÿ¥°“√¥÷ß UF ·≈–‡μ‘¡ “√πÈ”„Àâ ‚¥¬· ¥ßª√‘¡“≥¢Õß “√πÈ”∫π Àπâ“®Õ online module «à“ çactBolus: 0 mlé ·≈–· ¥ß ¢âÕ§«“¡∂“¡ çterminate bolus?é §◊Õ®–À¬ÿ¥°“√„Àâ “√ πÈ”°àÕπ§√∫μ“¡®”π«πÀ√◊Õ‰¡à ∂â“À¬ÿ¥„Àâ°¥ªÿÉ¡ enter ‡§√◊ËÕß®–À¬ÿ¥°“√„Àâ “√πÈ” ·≈–¡’¢âÕ§«“¡· ¥ßª√‘¡“≥ ∑’Ë„Àâ çactBolus: 30 mlé ·≈–· ¥ß¢âÕ§«“¡°“√®∫°“√ „Àâ “√πÈ” §◊Õ çfinishing bolusé ·μà∂â“„Àâ “√πÈ”§√∫μ“¡ ®”π«π∑’Ë°”À𥉫â√–∫∫®–‡¢â“ Ÿà°“√øÕ°‡≈◊Õ¥μàÕ‰ª∑—π∑’ ·μà∂â“¡’°“√ alarm ¢Õ߇§√◊ËÕß°àÕπ§√∫®”π«π¢Õß “√πÈ” √–∫∫ online ®–À¬ÿ¥°“√ bolus ¥—ßπ—ÈπμâÕߧ«∫§ÿ¡√–∫∫ °“√øÕ°‡≈◊Õ¥¥”‡π‘πÕ¬à“ßμàÕ‡π◊ËÕß 33. ‡¡◊ËÕ ‘Èπ ÿ¥°“√øÕ°‡≈◊Õ¥ Àπâ“®Õ‡§√◊ËÕ߉μ‡∑’¬¡®–· ¥ß UF-Goal reached °¥ªÿÉ¡ start/reset 1 §√—Èß 34. Àπâ“®Õ¢÷Èπ çReinfusion?é „Àâ°¥ªÿÉ¡ conf. Àπâ“®Õ ‡§√◊ËÕ߉μ‡∑’¬¡ ´÷Ëß∑”„Àâ blood pump ∑ÿ°μ—«À¬ÿ¥À¡ÿπ 446

Work Instruction: Online Hemodiafiltration ¢âÕ§«“¡ √ªŸ · ¥ß 35. Àπâ“®Õ¢Õß online module · ¥ß¢âÕ§«“¡ çReinfusion online?é „Àâ°¥ªÿÉ¡ enter (°√≥’μâÕß°“√§◊π ‡≈◊Õ¥¥â«¬ NSS „Àâ°¥ªÿÉ¡≈Ÿ°»√¢÷ÈπÀ√◊Õ≈ß®–æ∫¢âÕ§«“¡ çReinfusion NaCl?é „Àâ°¥ªÿÉ¡ enter ·≈⫧◊π‡≈◊Õ¥ ‡™àπ‡¥’¬«°—∫°“√§◊π‡≈◊Õ¥·∫∫ convention HD) 36. ∂Ⓡ≈◊Õ° reinfusion online ®–æ∫¢âÕ§«“¡ çReinfusion prepared?é ‡ªìπ°“√‡μ√’¬¡°“√§◊π‡≈◊Õ¥‚¥¬ clamp  “¬ safe line V  “¬ blood line A ·≈– arterial needle ®“°π—Èπª≈¥ “¬ blood line A ∑’ËμàÕ°—∫ arterial needle ¥â“π A ·≈–π” “¬ blood line A μàÕ°—∫ “¬ safe line A „Àâ‡ªî¥ clamp ∑—Èß 2 ¥â“π ·≈â«°¥ªÿÉ¡ enter 37. Àπâ“®Õ online module ®–· ¥ß¢âÕ§«“¡ çReinfusion Reinf. Vol: 0 ml.é ´÷Ëß√–∫∫ online ®–º≈‘μ substitute fluid §◊π‡≈◊Õ¥°≈—∫‡¢â“ºâŸªÉ«¬®“°ª≈“¬ “¬ blood line A ∂÷ß venous vascular access ®π§√∫®”π«π 240 ml. Àπâ“ ®Õ‡§√◊ËÕ߉μ‡∑’¬¡®–¢÷Èπ· ¥ß¢âÕ§«“¡ çReinfusion?é Õ’°§√—Èß„ÀâªØ‘∫—μ‘μ“¡¢âÕ 34-37 Õ’°§√—Èß ‡¡◊ËÕ‡≈◊Õ¥∑’˺à“π ∫√‘‡«≥ venous drip chamber ®“ß≈ß ‡§√◊ËÕß®–√âÕß·≈– À¬ÿ¥°“√º≈‘μ substitute fluid ∂â“μâÕß°“√ “√πÈ” substitute fluid ‡æ‘Ë¡Õ’°„Àâ°¥ªÿÉ¡ start/reset ÀπⓇ§√◊ËÕß ‰μ‡∑’¬¡ 38. ‡¡◊ËÕ§◊π‡≈◊Õ¥§√∫μ“¡§«“¡μâÕß°“√ „Àâ°¥ªÿÉ¡ start/stop ∫π online module ®–· ¥ß¢Õâ §«“¡ çStart reinfusion?é ‡ªìπ°“√∂“¡«à“μâÕß°“√ reinfusion Õ’°§√—ÈßÀ√◊Õ‰¡à ∂Ⓣ¡à μâÕß°“√„Àâ°¥ªÿÉ¡≈Ÿ°»√¢÷ÈπÀ√◊Õ≈ß 39. ‡¡◊ËÕ°¥ªÿÉ¡≈°Ÿ »√¢÷ÈπÀ√◊Õ≈ß Àπâ“®Õ online module · ¥ß¢âÕ§«“¡ çDiscontinue reinfusion?é ‡ªìπ°“√ ∂“¡«à“μâÕß°“√À¬ÿ¥°“√ reinfusion À√◊Õ‰¡à ∂â“μâÕß°“√À¬ÿ¥ „Àâ°¥ªÿÉ¡ enter ®–ª√“°Ø¢âÕ§«“¡ çAre you sure?é ‡ªìπ°“√∂“¡§«“¡μâÕß°“√Õ’°§√—Èß„Àâ°¥ªÿÉ¡ enter 447

Practical Dialysis in the Year 2009 √Ÿª· ¥ß ¢âÕ§«“¡ 40. Àπâ“®Õ online module ®–· ¥ß¢âÕ§«“¡ çSub Vol: 38.50 lé À¡“¬∂÷ß®”π«π∑—ÈßÀ¡¥¢Õß substitute fluid ∑’Ë„À⺟âªÉ«¬μ≈Õ¥°“√øÕ°‡≈◊Õ¥  à«π reinf. Vol: 330 ml. À¡“¬∂÷ß®”π«π∑—ÈßÀ¡¥¢Õß substitute fluid ∑’Ë„™â„π°“√ §◊π‡≈◊Õ¥‡¢â“ àŸ√à“ß°“¬ºâŸªÉ«¬ ®“°π—Èπ„À⥔‡π‘π°“√ª≈¥  “¬ blood line V ÕÕ°®“° AV needle ·≈–∑”°“√ off AV needle μàÕ‰ª 448

Work Instruction: Online Hemodiafiltration 6. ‡§√◊ËÕß·≈–Õߧåª√–°Õ∫¢Õ߇§√◊ÕË ß‰μ‡∑¬’ ¡ NIKKISO √πàÿ DBB 05 4 449

Practical Dialysis in the Year 2009 7. ¢—ÈπμÕπ°“√‡μ√¬’ ¡‡§√Õ◊Ë ß‰μ‡∑’¬¡ NIKKISO √àÿπ DBB 05 online HDF ¢âÕ§«“¡ √ªŸ · ¥ß 1. °“√‡μ√’¬¡Õªÿ °√≥å 1 set 1.1 Blood line 1 μ—« 1.2 Dialyzer ™π‘¥ high flux 1 set 1.3 Pyrogen filter 1 set 1.4 IV set 1 ¢«¥ 1.5 0.9% NSS 1000 ml 2 μ—« 1.6 Transducer protector 2 μ—« 1.7 Connector recirculation 2. ¢πÈ— μÕπ°“√‡μ√¬’ ¡‡§√◊ËÕß NIKKISO √ÿàπ DBB 05 ‡æËÕ◊ ∑” online HDF 2.1 °“√‡ªî¥‡§√◊ËÕ߉μ‡∑’¬¡„Àâ°¥ªÿÉ¡ switch On 2.2 ‡§√◊ËÕß®–∑”°“√ Self Test CPU ‚¥¬Àπâ“®Õ · ¥ß¢âÕ§«“¡ Start up test running ‡¡◊ËÕ∑” °“√ self test ‡√’¬∫√âÕ¬·≈â« ‡§√◊ËÕß®–‡¢â“ Mode DM Test ‚¥¬Õ—μ‚π¡—μ‘ 2.3 ¢≥–∑’Ë DM Test °”≈—ß test π—Èπ ¿“¬„π°√Õ∫ ¢Õß DM test ®–· ¥ß ’‡¢’¬« ·≈–‡¡◊ËÕ¢âÕ§«“¡ çConcentrate probes incorrectly positioned (Concentrate A/B port)é ª√“°Ø∑’Ë¥â“π≈à“ߢÕß®Õ monitor „Àâ®ÿà¡ πÈ”¬“ A ·≈– πÈ”¬“ B 450

Work Instruction: Online Hemodiafiltration ¢âÕ§«“¡ √Ÿª· ¥ß 2.4 ™à«ß√–À«à“ß√Õ DM Test „Àâ«“ß “¬ blood line μ—«°√Õß ·≈– pyrogen filter μ“¡μ”·ÀπàߢÕß ‡§√◊ËÕ߉μ‡∑’¬¡ ·≈–‡¡◊ËÕ√–∫∫¢Õ߇§√◊ËÕß∑”°“√ DM Test §√∫∂â«π·≈â« ®–ª√“°Ø¢âÕ§«“¡ DM Test end ·≈– ¢âÕ§«“¡ If On line - HDF/HF isnût used connect the dialyser couplings ¥â“π≈à“ߢÕ߮ՄÀâ°¥ªÿÉ¡ Treat. Data 2.5 Àπâ“®Õ®–ª√“°Ø mode ¢Õß°“√√—°…“ „Àâ°¥ ªÿÉ¡ OHDF ®πªÿÉ¡‡ªìπ ’‡¢’¬« ·≈–°¥ªÿÉ¡ ESC ‡æ◊ËÕ°≈—∫‡¢â“ ŸàÀπâ“®Õ¢Õß°“√μ—Èß§à“¢Õß °“√øÕ°‡≈◊Õ¥ ·≈–°¥ªÿÉ¡ Back ‡æ◊ËÕ°≈—∫¡“ ∑’ËÀπâ“ preparation 2.6 Àπâ“®Õ®–ª√“°Ø¢âÕ§«“¡ Connect substitution fluid line to port. After priming - Connect the dialyser couplings and press Fill Dialyser ‡æ◊ËÕ·®âß„ÀâμàÕ substitution fluid line ¢Õß pyrogen filter ¥â“π°àÕπ‡¢â“ HDF pump ‡¢â“°—∫ substitution port ¢Õ߇§√◊ËÕß 451

Practical Dialysis in the Year 2009 √Ÿª· ¥ß ¢âÕ§«“¡ 2.7 μàÕ substitution fluid line ¢Õß pyrogen filter ¥â“πÀ≈—ßÕÕ°®“° HDF pump ‡¢â“°—∫ª≈“¬  “¬ blood line A ∑’Ë¡’ rinse connector ‡ªìπ μ—«‡™◊ËÕ¡ ‡æ◊ËÕ„™â substitution fluid „π°“√≈â“ß μ—«°√Õß·≈– blood line 2.8 °¥ªÿÉ¡ Prim-art ®πª√“°Ø ’‡¢’¬« ‡æ◊ËÕ„Àâ ‡§√◊ËÕ߉μ‡∑’¬¡º≈‘μ substitution fluid ≈â“ß  “¬ blood line A (´÷Ëß set volume „π°“√≈â“ß  “¬ blood line A ‰«â∑’Ë 200 ml.) 2.9 ‡¡◊ËÕ‡§√◊ËÕ߉μ‡∑’¬¡º≈‘μ substitution fluid ≈â“ß “¬ blood line A §√∫μ“¡®”π«π Àπâ“®Õ®–ª√“°Ø‰ø ’‡¢’¬«∑’Ë Prim-ven ‡§√◊ËÕ߉μ‡∑’¬¡º≈‘μ substitution fluid ≈â“ß  “¬ blood line V (´÷Ëß set volume „π°“√ ≈â“ß “¬ blood line V ‰«â∑’Ë 2000 ml.) 2.10 ‡¡◊ËÕ°“√≈â“ß “¬ blood line ·≈–μ—«°√Õß ¥â«¬ substitution fluid §√∫μ“¡°”Àπ¥ Àπâ“®Õ®–ª√“°Ø‰ø ’ â¡∑’˪ÿÉ¡ Circ. 452

¢âÕ§«“¡ Work Instruction: Online Hemodiafiltration 2.11 π” dialysate coupler μàÕ‡¢â“¥â“π √ªŸ · ¥ß dialysate compartment μ“¡ ’¢Õß “¬ blood line ∑’ËμàÕ°—∫μ—«°√Õß 2.12 ª≈¥ “¬ blood line A ÕÕ°®“° “¬ substitution fluid line ¢Õß pyrogen filter ¥â“πÀ≈—ßÕÕ°®“° HDF pump ¡“μàÕ‡¢â“ °—∫ “¬ blood line V ‡æ◊ËÕ‡μ√’¬¡°“√∑” recirculation 2.13  à«π “¬ substitution fluid line ¢Õß pyrogen filter ¥â“πÀ≈—ßÕÕ°®“° HDF pump 𔉪μàÕ°—∫ venous drip chamber (μàÕ·∫∫ post dilution) À√◊Õ𔉪μàÕ°—∫ arterial drip chamber (μàÕ·∫∫ pre dilution) 2.14 °¥ªÿÉ¡ Fill Dialyser ®π‡ªìπ ’‡¢’¬« ‡æ◊ËÕ ≈â“ߥâ“π dialysate compartment ‡ªìπ‡«≈“ 5 π“∑’ 453

Practical Dialysis in the Year 2009 √ªŸ · ¥ß ¢âÕ§«“¡ 2.15 ‡ªî¥ clamp ¢Õß arterial pressure ·≈– venous pressure ·≈â« °¥ªÿÉ¡ BM test ‡§√◊ËÕß®–∑”°“√ test √–∫∫ 2.16 ‡¡◊ËÕ‡§√◊ËÕ߉μ‡∑’¬¡∑”°“√ BM test ®π  ¡∫√Ÿ ≥å Àπâ“®Õ®–ª√“°Ø‰ø ’‡¢’¬«∑’˪ÿÉ¡ Dialyser rinse 2.17 ª≈¥ substitution fluid line ¢Õß pyrogen filter ¥â“π°àÕπ‡¢â“ HDF pump ÕÕ°®“° substitution port ¢Õ߇§√◊ËÕß·≈â«π” connector recirculation ¡“ªî¥ª≈“¬ “¬‰«â 2.18 °¥ªÿÉ¡ Treat. Data ∑’ËÀπâ“®Õ®–ª√“°Ø ¢âÕ§«“¡„Àâ‡≈◊Õ° Treatment mode „Àâ°¥ªÿÉ¡ mode HD ‡æ◊ËÕ°“√∑” recirculation ·≈â«°¥ ªÿÉ¡ ESC ‡æ◊ËÕ°≈—∫‡¢â“ àŸÀπâ“®Õ Treat. Data 454

Work Instruction: Online Hemodiafiltration ¢âÕ§«“¡ √Ÿª· ¥ß 2.19 °¥ªÿÉ¡ Back ‡æ◊ËÕ°≈—∫¡“Àπâ“®Õ preparation ‡ªî¥ pump BP1 ‡æ◊ËÕ∑”°“√ recirculation ¥â«¬ 0.9% NSS (´÷Ëß set dialyser rinse ‰«â∑’Ë 10 π“∑’ volume 500 ml.) ©’¥ heparin 5000 ¬Ÿπ‘μ ‡¢â“∑“ß “¬ blood line A 2.20 ‡¡◊ËÕ recirculation §√∫∂â«πμ“¡‡°≥±å Àπâ“®Õ®–ª√“°Ø Rinsing end „Àâ clamp  “¬ IV fluid 2.21 „Àâ°≈—∫¡“μàÕ substitution fluid line ¢Õß pyrogen filter ¥â“π°àÕπ‡¢â“ blood pump ‡¢â“°—∫ substitution port ¢Õ߇§√◊ËÕ߉μ‡∑’¬¡ ‡™àπ‡¥‘¡ 2.22 °¥ªÿÉ¡ Treat. Data ∑’ËÀπâ“®Õ®–ª√“°Ø ¢âÕ§«“¡„Àâ‡≈◊Õ° Treatment mode „Àâ°¥ªÿÉ¡ mode OHDF ·≈â«°¥ªÿÉ¡ ESC ‡æ◊ËÕ°≈—∫ ‡¢â“ àŸÀπâ“®Õ¢Õß°“√μ—Èß§à“¢Õß°“√øÕ°‡≈◊Õ¥ 455

Practical Dialysis in the Year 2009 √ªŸ · ¥ß ¢Õâ §«“¡ 2.23 °¥ªÿÉ¡ Subs.-port ‡æ◊ËÕ‡≈◊Õ° substitution ‡ªìπ Pre À√◊Õ Post μ“¡·ºπ°“√√—°…“ ¢Õß·æ∑¬å 2.24 °¥ªÿÉ¡ Treat. time ‡æ◊ËÕμ—È߇«≈“„π°“√ øÕ°‡≈◊Õ¥ ·≈–°¥ªÿÉ¡ UF goal ‡æ◊ËÕμ—Èß UF μ“¡ weight gain ¢Õߺ⟪ɫ¬ ‡§√◊ËÕß®–∑” °“√§”π«≥ UF rate ‚¥¬Õ—μ‚π¡—μ‘ 2.25 °¥ªÿÉ¡ Subs. ratio (Subs./BP) ‡æ◊ËÕμ—Èß§à“ substitute fluid μ“¡·ºπ°“√√—°…“¢Õß·æ∑¬å 2.26 ‡¡◊ËÕμ—Èߧà“μà“ßÊ ®π§√∫∂â«π Àπâ“®Õ®– · ¥ß¥—ß√ªŸ „Àâ°¥ªÿÉ¡ Connect 456

Work Instruction: Online Hemodiafiltration ¢âÕ§«“¡ √Ÿª· ¥ß 2.27 Àπâ“®Õ®–· ¥ß¥—ß√ªŸ æ√âÕ¡°—∫ blood pump À¬ÿ¥À¡ÿπ „ÀâμàÕ√–∫∫«ß®√øÕ°‡≈◊Õ¥μ“¡ À≈—°°“√μàÕ«ß®√ ·≈–°“√ drain 0.9% NSS ÕÕ°®“°«ß®√ ·≈â«¥”‡π‘π°“√øÕ°‡≈◊Õ¥¥â«¬ √–∫∫ online hemodiafiltration ‚¥¬°¥ªÿÉ¡ Start Treatmût (μ√«® Õ∫ clamp μà“ßÊ ¢Õß√–∫∫∑—ÈßÀ¡¥«à“μ”·Àπàß„¥§«√‡ªî¥À√◊Õ §«√ªî¥) 2.28 °¥ªÿÉ¡ HP Prime ‡æ◊ËÕμ—Èß rate heparin μ“¡§” —Ëß°“√√—°…“¢Õß·æ∑¬å 2.29 ‡¡◊ËÕ‡√‘Ë¡°“√∑” online hemodiafiltration Àπâ“®Õ®–· ¥ß¥—ß√Ÿª 457

Practical Dialysis in the Year 2009 8.  √ÿª °“√∑” hemodiafiltration ¡«’ ∏‘ °’ “√À≈“°À≈“¬√ªŸ ·∫∫·≈–‰¥√â ∫— °“√æ≤— π“·≈–ª√∫— ª√ßÿ «∏‘ °’ “√ μà“ßÊ ¡“Õ¬à“ßμàÕ‡π◊ËÕßμ“¡§«“¡‡À¡“– ¡¢ÕßÀπ૬ߓπ·≈– ∂“π°“√≥å„π¢≥–π—Èπ ´÷Ëßªí®®ÿ∫—π°“√ øÕ°‡≈◊Õ¥·∫∫ hemodiafiltration ‰¥âæ—≤π“¡“‡ªìπ√–∫∫ online hemodiafiltration ¡“°¢÷Èπ ‡π◊ËÕß®“°¡’ °“√æ—≤𓇧√◊ËÕ߉μ‡∑’¬¡∑’Ë∑—π ¡—¬·≈–„™âß“π‰¥âÕ¬à“ß –¥«° ¥—ßπ—ÈπÀπ૬ߓπ„πª√–‡∑»‰∑¬∑’ËμâÕß°“√ æ—≤π“«‘∏’°“√øÕ°‡≈◊Õ¥·∫∫ hemodiafiltration  “¡“√∂°√–∑”‰¥â‚¥¬μ√«® Õ∫§«“¡æ√âÕ¡¢ÕßÀπ૬ ß“π¥â“π√–∫∫πÈ” °“√‡æ“–‡™◊ÈÕ °“√‡μ√’¬¡‡§√◊ËÕ߉μ‡∑’¬¡·≈–Õÿª°√≥åμà“ßÊ ∑’Ë„™â°—∫°“√øÕ°‡≈◊Õ¥™π‘¥ π’È °“√Ωñ°Ωπ欓∫“≈„Àâ¡’§«“¡™”π“≠„π°“√„™â‡§√◊ËÕ߉μ‡∑’¬¡™π‘¥π’È·≈–°“√¥Ÿ·≈ºâŸªÉ«¬∑’ˉ¥â√—∫°“√ øÕ°‡≈◊Õ¥¥â«¬«‘∏’°“√π’È ‡æ◊ËÕ„ÀâºâŸªÉ«¬‰¥â√—∫°“√øÕ°‡≈◊Õ¥·≈–ªØ‘∫—μ‘Õ¬à“ß∂Ÿ°μâÕß ‡Õ° “√Õ“â ßÕß‘ 1. ∏π‘μ ®‘√π—π∑å∏«—™. How to Achieve Ultrapure Dialysate. „π: ∏π‘μ ®‘√π—π∑å∏«—™, ∏π—𥓠μ√–°“√«π‘™,  ‘√‘¿“ ™â“ß»‘√‘°ÿ≈ ™—¬, « —πμå  ÿ‡¡∏°ÿ≈, ∫√√≥“∏‘°“√. Comprehensive Review of Dialysis. °√ÿ߇∑æ: Text and Journal Publication, 2550:8. 2. AAMI Standard and Recommended Practice Dialysis (2001 edition). AAMI, Arlington 2001. 3. §Ÿà¡◊Õ Hemodialysis Machine Operating Instruction (4008 H Fresenius) 4. §Ÿà¡◊Õ Hemodialysis Machine Operating Instruction (DBB 05 Nikkiso) 458

Work Instruction: Physical Examination, Pressure and Flow Monitoring of Vascular Access Work Instruction: Physical Examination, 23 Pressure and Flow Monitoring of Vascular Access °”∏√ ≈≈’ “¡–≈‘ ∏μ‘ ‘¬“ æ—««‘‰≈ ¡“¥’ μÿ≈¬«»π‘ æß…å «≈— ¬“ ª≈Õ¥®“°‡¢Á≠ æ‘®‘μ√“ ∑Ÿ≈¡“≈“ æ𑥓 °«π‘ ‚Õ¿“°≈Ÿ æ√æ√√≥ ™§∂— ∏“¥“ 1. «—μ∂ÿª√– ß§å 2. ∫∑π” 3. ‡Àμÿº≈∑Ëμ’ Õâ ߪ√–‡¡‘π°“√∑”ß“π¢Õ߇ πâ øÕ°‡≈◊Õ¥ 4.  √ÿª 459

Practical Dialysis in the Year 2009 1. «μ— ∂ÿª√– ß§å 1. ‡æÕË◊ „Àºâ ‡Ÿâ ¢“â √«à ¡ª√–™¡ÿ ‡™ß‘ ªØ∫‘ μ— °‘ “√ ∑√“∫«∏‘ °’ “√„π°“√ª√–‡¡π‘ °“√∑”ß“π¢Õ߇ πâ øÕ° ‡≈◊Õ¥Õ¬à“ßßà“¬Ê ∑’Ë “¡“√∂𔉪„™â„πÀâÕ߉μ‡∑’¬¡¢Õß·μà≈– ∂“π∑’ˉ¥â 2. ‡æ◊ËÕ„ÀâºâŸ‡¢â“√à«¡ª√–™ÿ¡‡™‘ߪؑ∫—μ‘°“√ √Ÿâ¢—ÈπμÕπ„π°“√∑¥ Õ∫·≈–°“√·ª≈º≈ °“√ ª√–‡¡‘π°“√∑”ß“π¢Õ߇ âπøÕ°‡≈◊Õ¥„π·μà≈–«‘∏’ 3. ‡æ◊ËÕ„À⺟⇢â“√à«¡ª√–™ÿ¡‡™‘ߪؑ∫—μ‘°“√ μ—¥ ‘π„®‰¥â«à“®–π”«‘∏’°“√ª√–‡¡‘π·∫∫„¥ ¡“„™â °—∫ºâŸªÉ«¬ª√–‡¿∑„¥„πÀâÕ߉μ‡∑’¬¡ 2. ∫∑π” „π∑’Ëπ’È®–‡√’¬° çHemodialysis vascular accessé «à“ ç‡ âπøÕ°‡≈◊Õ¥ ”À√—∫°“√≈â“߉μ¥â«¬ ‡§√◊ËÕ߉μ‡∑’¬¡é À√◊Õ‡√’¬°¬àÕÊ «à“ 燠âπøÕ°‡≈◊Õ¥é ¡’¥â«¬°—π 3 ™π‘¥ 1. A-V fistula (arteriovenous fistula) ‡√’¬°¬àÕÊ «à“ AVF 2. A-V Graft (arteriovenous graft) ‡√’¬°¬àÕÊ «à“ AVG 3. Hemodialysis catheter À√◊Õ HD-Cath ∫∑π’È®–°≈à“«∂÷ß°“√ª√–‡¡‘π°“√∑”ß“π¢Õ߇ âπøÕ°‡≈◊Õ¥™π‘¥ AVF ·≈– AVG ‡π◊ËÕß®“° ‡ªìπ‡ âπøÕ°‡≈◊Õ¥∑’Ëæ∫‰¥â∫àÕ¬∑’Ë ÿ¥„πÀâÕ߉μ‡∑’¬¡ ªí≠À“ à«π„À≠à¢Õ߇ âπøÕ°‡≈◊Õ¥∑—Èß™π‘¥ AVF À√◊Õ AVG §◊Õ°“√μ’∫μ—π¢Õ߇ âπøÕ°‡≈◊Õ¥ ‡¡◊ËÕ¡’°“√μ’∫μ—π®–‡°‘¥°“√‡ª≈’ˬπ·ª≈ß∑’Ë ”§—≠‡°‘¥¢÷Èπ §◊Õª√‘¡“≥°“√‰À≈¢Õ߇≈◊Õ¥ºà“π‡ âπøÕ°‡≈◊Õ¥ ®–≈¥≈ß μ“¡·√ßμâ“π∑“π∑’Ë Ÿß¢÷Èπ ·√ߥ—π¿“¬„π‡ âπøÕ°‡≈◊Õ¥°àÕπ√Õ¬μ’∫μ—π®– Ÿß‡æ‘Ë¡¢÷Èπ ·≈–·√ß ¥π— ¿“¬„π‡ πâ øÕ°‡≈Õ◊ ¥À≈ß— √Õ¬μ∫’ μπ— ®–≈¥πÕâ ¬≈ß ß‘Ë ‡À≈“à π‡’È √¬’ °«“à °“√‡ª≈¬’Ë π·ª≈ß∑“ßhemodynamic ´÷Ëß “¡“√∂μ√«®«—¥‰¥â¥â«¬°“√μ√«®‡ âπøÕ°‡≈◊Õ¥¥â«¬°“√¥Ÿ §≈”·≈–øíß (physical examination) °“√ «—¥·√ߥ—π¿“¬„π‡ âπøÕ°‡≈◊Õ¥ (pressure monitoring) ·≈–°“√«—¥ª√‘¡“≥°“√‰À≈¢Õ߇≈◊Õ¥ (flow monitoring) ¥—ßπ—Èπ®÷߉¥â¡’°“√„™â‡§√◊ËÕß¡◊Õ‡À≈à“π’ȇæ◊ËÕª√–‡¡‘π°“√∑”ß“π¢Õ߇ âπøÕ°‡≈◊Õ¥  ”À√—∫ ªí≠À“Õ¬à“ßÕ◊ËπÊ ¢Õ߇ âπøÕ°‡≈◊Õ¥ ‡™àπ°“√μ‘¥‡™◊ÈÕ °“√∫«¡¢Õß·¢π∑’ˇ°’ˬ«¢âÕß°—∫‡ âπøÕ°‡≈◊Õ¥ (arm edema) ‡≈◊Õ¥‰ª‡≈’Ȭߡ◊Õ‰¡à‡æ’¬ßæÕ (hand ischemia) ®–‰¡à°≈à“«≈–‡Õ’¬¥„π∑’Ëπ’È ‰¥â¡’°“√·∫àßμ”·ÀπàߢÕ߇ âπøÕ°‡≈◊Õ¥™π‘¥ AVF ‡ªìπ 3 μ”·Àπàß„À≠àÊ ‰¥â·°à 1. Inflow À√◊Õ∑“߇¢â“À≈—°¢Õ߇≈◊Õ¥ ‰¥â·°à ‡ âπ‡≈◊Õ¥·¥ß∑’Ë à߇≈◊Õ¥ºà“π‡ âπøÕ°‡≈◊Õ¥ ∫√‘‡«≥√Õ¬μàÕ ·≈– ‡ âπ‡≈◊Õ¥¥”„°≈â√Õ¬μàÕ (Juxta anastomosis vein, JAV) ´÷Ëߧ◊Õ∫√‘‡«≥ 3-5 ´.¡.À≈—ß√Õ¬μàÕ¢Õ߇ âπøÕ° ‡≈◊Õ¥ 2. Body À√◊Õ∫√‘‡«≥∑’Ë„™â‡ªìπ·π«À≈—°„π°“√·∑ß ·≈– 3. Outflow À√◊Õ∑“ßÕÕ°¢Õ߇≈◊Õ¥ ‡ªìπ ∫√‘‡«≥∑’ËμàÕ‡π◊ËÕß®“° Body ∫√‘‡«≥ Outflow ®–μàÕ‡π◊ËÕ߉ª∂÷߇ âπ‡≈◊Õ¥¥”„À≠à∫√‘‡«≥∑√«ßÕ°  ”À√—∫‡ âπøÕ°‡≈◊Õ¥™π‘¥ AVG °Á·∫à߇ªìπ 3 μ”·Àπàß„À≠àÊ ‡™àπ°—π‰¥â·°à 1. Inflow À√◊Õ ∑“߇¢â“À≈—°¢Õ߇≈◊Õ¥ ‰¥â·°à ‡ âπ‡≈◊Õ¥·¥ß∑’Ë à߇≈◊Õ¥ºà“π AVG ·≈–√Õ¬μàÕ√–À«à“߇ âπ‡≈◊Õ¥·¥ß°—∫ AVG 460

Work Instruction: Physical Examination, Pressure and Flow Monitoring of Vascular Access √Ÿª∑’Ë 1 √ªŸ ¥â“π´“â ¬ · ¥ß‡ âπøÕ°‡≈Õ◊ ¥™π¥‘ radiocephalic AVF ∑’ªË ≈“¬·¢π ·≈–√Õ¬μ’∫∑¡Ë’ °— æ∫∫àÕ¬∑’Ë inflow ∑’Ë ∫√‡‘ «≥ juxta-anastomosis vein √Ÿª°≈“ß · ¥ß‡ âπøÕ°‡≈Õ◊ ¥™π‘¥ brachiocephalic AVF ∑μ’Ë âπ·¢π À√◊Õ transposed brachiobasilic AVF ∑Ë’μπâ ·¢π ´Ëß÷ ¡—°®–æ∫√Õ¬μ’∫∑Ë’ outflow √Ÿª¥â“π¢«“ · ¥ß‡ âπøÕ°‡≈◊Õ¥™π¥‘ AVG ´ß÷Ë ¡—°®–æ∫√Õ¬μ∫’ ∑Ë’ outflow 2. Body À√◊Õ∫√‘‡«≥∑’Ë„™â‡ªìπ·π«À≈—°„π°“√·∑ß §◊Õμ—« AVG ∑—È߇ âπ ·≈– 3. Outflow À√◊Õ∑“ßÕÕ°¢Õß ‡≈Õ◊ ¥ ‡√¡Ë‘ ®“°√Õ¬μÕà √–À«“à ß AVG °∫— ‡ πâ ‡≈Õ◊ ¥¥” ·≈–‡ πâ ‡≈Õ◊ ¥¥”∑‡Ë’ ªπì ∑“ßÕÕ°¢Õ߇≈Õ◊ ¥®π∂ß÷ À«— ‰À≈à ‡ âπøÕ°‡≈◊Õ¥∑’˪≈“¬·¢π™π‘¥ radio-cephalic AVF ¡—°®–¡’°“√μ’∫μ—π∫àÕ¬∑’Ë∫√‘‡«≥ inflow ‚¥¬‡©æ“–‡ âπ‡≈◊Õ¥¥”∑’ËÕ¬Ÿà„°≈â√Õ¬μàÕÀ√◊Õ‡√’¬°«à“ juxta-anastomosis vein  ”À√—∫‡ âπøÕ°‡≈◊Õ¥∑’Ëμâπ ·¢π™π‘¥ brachiocephalic AVF ¡—°®–¡’°“√μ’∫μ—π∑’Ë outflow ∫√‘‡«≥‡ âπ‡≈◊Õ¥¥” cephalic arch °àÕπ‡∑ ‡¢â“‡ âπ‡≈◊Õ¥¥” subclavian ·≈–‡ âπøÕ°‡≈◊Õ¥∑’Ëμâπ·¢π™π‘¥ transposed brachiobasilic AVF ¡—°®–¡’°“√ μ’∫μ—π∑’Ë outflow ∫√‘‡«≥∑’Ë∑”°“√ transposition À√◊Õ∫√‘‡«≥≈‘Èπ‡ âπ‡≈◊Õ¥ ®–‡ÀÁπ«à“∫√‘‡«≥‡À≈à“π’È¡’‡ âπ ∑“߇¥‘π¢Õ߇≈◊Õ¥∑’Ë‚§âß ´÷Ëßßà“¬μàÕ°“√‡°‘¥°“√μ’∫μ—π  ”À√—∫‡ âπøÕ°‡≈◊Õ¥™π‘¥ AVG ¡—°¡’√Õ¬μ’∫μ—π∑’Ë μ”·Àπàß√Õ¬μàÕ√–À«à“ß AVG °—∫‡ âπ‡≈◊Õ¥¥” (¥√Ÿ ªŸ ∑’Ë 1) 3. ‡Àμºÿ ≈∑μ’Ë âÕߪ√–‡¡‘π°“√∑”ß“π¢Õ߇ πâ øÕ°‡≈◊Õ¥ ∂â“æ∫«à“¡’√Õ¬μ’∫μ—π¿“¬„π‡ âπøÕ°‡≈◊Õ¥ ·≈–√Õ¬μ’∫μ—π∑”„À⇰‘¥°“√‡ª≈’ˬπ·ª≈ßÕ¬à“ß ¡“°μàÕ hemodynamic ¢Õ߇ âπøÕ°‡≈◊Õ¥ (hemodynamic mediated significant vascular access stenosis) ∂â“√Õ¬μ’∫μ—ππ’ȉ¡à‰¥â√—∫°“√¥Ÿ·≈·≈–«“ß·ºπ·°â‰¢ °“√μ’∫μ—π®–‡æ‘Ë¡¡“°¢÷Èπ „π∑’Ë ÿ¥®–∑”„À⇰‘¥°“√Õÿ¥ μπ— ·≈–‰¡ à “¡“√∂„™‡â  πâ øÕ°‡≈Õ◊ ¥‰¥â ºªŸâ «É ¬Õ“®®–μÕâ ߇≈ÕË◊ π°“√øÕ°‡≈Õ◊ ¥ ´ßË÷ ¡°— ®–¡Õ’ π— μ√“¬μÕà ºªâŸ «É ¬ ‡π◊ËÕß®“°¿“«–πÈ”‡°‘𠧫“¡º‘¥ª°μ‘¢Õ߇°≈◊Õ·√à ·≈–°“√¡’¢Õ߇ ’¬§—Ëߧâ“ß¿“¬„π√à“ß°“¬ À√◊ÕºŸâªÉ«¬ μâÕ߉¥â√—∫°“√„ à “¬ HD Cath ‡æ◊ËÕ„™âøÕ°‡≈◊Õ¥™—Ë«§√“« ´÷Ë߉¡à∑’Ë™◊Ëπ™Õ∫¢ÕߺŸâªÉ«¬ ·≈–¡’‚√§·∑√°´âÕπ ®“° HD Cath  ßŸ ·≈–‡¡◊ËÕ‡ âπøÕ°‡≈◊Õ¥‡°‘¥°“√Õÿ¥μ—π °“√°âŸ‡ âπøÕ°‡≈◊Õ¥¥â«¬°“√‡Õ“°âÕπ‡≈◊Õ¥ÕÕ° 461

Practical Dialysis in the Year 2009 ·≈–·°â‰¢√Õ¬μ’∫μ—π Õ“®®–‰¡àª√– ∫§«“¡ ”‡√Á® ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫°“√·°â‰¢°àÕπ∑’Ë®–¡’°“√Õÿ¥μ—π ·≈–°àÕπ∑’Ë®–‡°‘¥≈‘Ë¡‡≈◊Õ¥¢÷Èπ  ÿ¥∑⓬μâÕß∑”‡ âπøÕ°‡≈◊Õ¥∑’Ëμ”·Àπàß„À¡à °“√ª√–‡¡‘π°“√∑”ß“π¢Õ߇ âπøÕ°‡≈◊Õ¥¡’«—μ∂ÿª√– ß§å ‡æ◊Ëՙ૬«‘π‘®©—¬«à“‡ âπøÕ°‡≈◊Õ¥¡’ √Õ¬μ∫’ μπ— ∑ ’Ë ”§≠— ∑„’Ë ¥·≈–‡¡Õ◊Ë ‰√®ß÷ §«√ ßà ·°‰â ¢À√Õ◊ ∂“â ‡§¬‡°¥‘ ´È”À≈“¬§√ß—È À√Õ◊ §¥‘ «“à ‰¡ à “¡“√∂·°‰â ¢‰¥â °Á‡ªìπ°“√μ√«®‡æ◊ËÕ«“ß·ºπ„π°“√∑”‡ âπøÕ°‡≈◊Õ¥∑’Ëμ”·Àπàß„À¡à≈à«ßÀπâ“ °àÕπ∑’ˇ âπøÕ°‡≈◊Õ¥‡¥‘¡π’È ®–„™âß“π‰¡à‰¥â À√◊Õ‡°‘¥°“√Õÿ¥μ—π¢÷Èπ „π∑’Ëπ’È®–¢Õ·π–π”°“√ª√–‡¡‘π°“√∑”ß“π¢Õ߇ âπøÕ°‡≈◊Õ¥ 3 «‘∏’ ‰¥â·°à 3.1 °“√μ√«®‡ âπøÕ°‡≈◊Õ¥¥â«¬°“√¥Ÿ §≈” ·≈–øíß (physical examination) 3.2 °“√«¥— √–¥∫— ·√ß¥π— ¢Õ߇ πâ øÕ°‡≈Õ◊ ¥∑μ’Ë ”·Àπßà ª≈“¬‡¢¡Á øÕ°‡≈Õ◊ ¥(pressuremonitoring) ë °“√«—¥ static intra-access pressure ‚¥¬μ√ß√–À«à“ß°“√øÕ°‡≈◊Õ¥ ë °“√«—¥ static intra-access pressure ‚¥¬ÕâÕ¡√–À«à“ß°“√øÕ°‡≈◊Õ¥ ë °“√«—¥ dynamic arterial pressure ·≈– dynamic venous pressure √–À«à“ß°“√øÕ° ‡≈◊Õ¥ 3.3 °“√«—¥ª√‘¡“≥°“√‰À≈¢Õ߇≈◊Õ¥ºà“π‡ âπøÕ°‡≈◊Õ¥·≈–°“√«—¥°“√‰À≈¬âÕπ¢Õ߇≈◊Õ¥ (Flow monitoring) ë °“√«—¥ access recirculation ¥â«¬«‘∏’ urea-based √–À«à“ß°“√øÕ°‡≈◊Õ¥ ë °“√«—¥ access blood flow ¥â«¬«‘∏’ urea-based √–À«à“ß°“√øÕ°‡≈◊Õ¥ ë °“√«—¥ access recirculation ·≈– access blood flow ¥â«¬‡§√◊ËÕß Transonic √–À«à“ß °“√øÕ°‡≈◊Õ¥ 3.1 °“√μ√«®‡ πâ øÕ°‡≈Õ◊ ¥¥«â ¬°“√¥Ÿ §≈” ·≈–øßí (Physical examination of vascular Access) ¥¢Ÿ —ÈπμÕπ°“√μ√«®·≈–°“√·ª≈º≈¢â“ß∑⓬ 3.1.1 æ◊Èπ∞“π°“√μ√«®‡ âπøÕ°‡≈◊Õ¥™π‘¥ AVF ∑’ªË °μ‘ „π∑π’Ë ®’È –°≈“à «∂ß÷ °“√μ√«®‡ πâ øÕ°‡≈Õ◊ ¥™π¥‘ AVF ‡ªπì À≈°— ·≈–®–°≈“à «∂ß÷ °“√μ√«®‡ πâ øÕ° ‡≈◊Õ¥™π‘¥ AVG ‡ √‘¡„πμÕπ∑⓬ ‚¥¬∑—Ë«‰ª‡ âπøÕ°‡≈◊Õ¥™π‘¥ AVF ‡°‘¥®“°°“√μàÕ√–À«à“߇ âπ‡≈◊Õ¥ ·¥ß·≈–‡ âπ‡≈◊Õ¥¥” μ”·Àπàß√Õ¬μàÕ√–À«à“߇ âπ‡≈◊Õ¥·¥ß·≈–¥”®–¡’ turbulent flow ´÷Ë߇°‘¥®“°°“√ ‰À≈¢Õ߇≈◊Õ¥®“°∫√‘‡«≥∑’Ë¡’·√ßμâ“π¢Õ߇≈◊Õ¥ Ÿß§◊Õ‡ âπ‡≈◊Õ¥·¥ß ‡¢â“ àŸ∫√‘‡«≥∑’Ë¡’·√ßμâ“π¢Õ߇≈◊Õ¥μË” §◊Õ‡ âπ‡≈◊Õ¥¥”  “¡“√∂μ√«®ª√‘¡“≥¢Õß turbulent flow ‰¥â¥â«¬°“√§≈”æ∫·√ß —Ëπ –‡∑◊Õπ (thrill) ·≈–øí߉¥â¬‘π‡ ’¬ß —Ëπ –‡∑◊Õπ (bruit) ·≈–‡ âπ‡≈◊Õ¥¥” à«π∑’ËμàÕ®“°‡ âπ‡≈◊Õ¥·¥ß®–¡’‡μâπμ“¡·√ߥ—π ‡≈◊Õ¥À√◊Õ™’æ®√ (pulse) ·μà‰¡à·√ß ‡√’¬°«à“ soft pulse ´÷Ëß·μ°μà“ß®“° pulse ∑’˧≈”‰¥â∑’ˇ âπ‡≈◊Õ¥·¥ß ‡π◊ËÕß®“°™à«ß diastolic phase ¡’·√ßμâ“π®“°‡ âπ‡≈◊Õ¥¥”πâÕ¬°«à“‡ âπ‡≈◊Õ¥·¥ß¡“° §«“¡·√ߢÕß thrill ·≈– bruit ¢÷ÈπÕ¬Ÿà°—∫ª√‘¡“≥‡≈◊Õ¥∑’ˉÀ≈ºà“π‡ âπøÕ°‡≈◊Õ¥ (Access Blood Flow À√◊Õ ABF À√◊Õ‡√’¬°¬àÕÊ «à“ Flow) À≈—ß®“°μ”·Àπàß√Õ¬μàÕ §«“¡·√ߢÕß thrill ·≈– bruit √«¡∑—Èߪ√‘¡“≥¢Õß pulse ®–≈¥πâÕ¬ ≈ß·≈–À“¬‰ª„π∑’Ë ÿ¥ ¥—ßπ—Èπ‡ âπøÕ°‡≈◊Õ¥∑’Ë¡’ flow ¥’ §«√§≈”‰¥â thrill ·√ß øí߉¥â bruit ™—¥ ∑—Èß systolic 462

Work Instruction: Physical Examination, Pressure and Flow Monitoring of Vascular Access ·≈– diastolic phase (continuous thrill À√◊Õ bruit) ·≈–¡’ soft pulse ∑’Ë∫√‘‡«≥√Õ¬μàÕ¢Õ߇ âπøÕ°‡≈◊Õ¥ ·≈–‡¡◊ËÕ¬°·¢π Ÿß‡Àπ◊ÕÀ—«„® ‡ âπøÕ°‡≈◊Õ¥®–¬ÿ∫μ—«≈ßÀ¡¥·≈–¡’ pulse ·√ߢ÷Èπ·μà‰¡à¡“° (¥Ÿμ“√“ß∑’Ë 1) 3.1.2 æ◊πÈ ∞“π°“√‡ª≈¬Ë’ π·ª≈߇¡Ë◊Õ‡ âπøÕ°‡≈Õ◊ ¥ AVF μ’∫μπ— ‡¡◊ËÕ¡’√Õ¬μ’∫‡°‘¥¢÷Èπ¿“¬„π‡ âπøÕ°‡≈◊Õ¥ √Õ¬μ’∫®–∑”„Àâ¡’·√ßμâ“π∑“π‡æ‘Ë¡¡“°¢÷Èπ º≈§◊Õ ∑”„Àâ flow ≈¥≈ß ∑”„Àμâ √«®æ∫«“à ¡’ thrill ·≈– bruit ‡∫“≈ß ·≈–§«“¡™¥— ‡®π®–πÕâ ¬≈ß¡“°„π™«à ß diastolic phase À√◊ÕÕ“®®–‡ß’¬∫ß“¬‰ª„π™à«ßπ’È „π∑“ßμ√ß°—π¢â“¡®–¡’ pulse ·√ߢ÷Èπ À√◊Õ‡√’¬°«à“¡’ strong pulse ‡ πâ øÕ°‡≈Õ◊ ¥ «à π∑Õ’Ë ¬°Ÿà Õà π√Õ¬μ∫’ ®–‚μ¡“°«“à ‡ πâ ‡≈Õ◊ ¥∑Õ’Ë ¬ÀàŸ ≈ß— √Õ¬μ∫’ ‚¥¬‡©æ“–‡¡Õ◊Ë ‡«≈“º“à π‰ªπ“π ‡π◊ËÕß®“°¡’·√ߥ—π¿“¬„π‡ âπ‡≈◊Õ¥ Ÿß ‡ âπøÕ°‡≈◊Õ¥À≈—ß√Õ¬μ’∫®–§àÕπ¢â“ß·∫π‰¡àμ÷ß ‡π◊ËÕß®“°¡’·√ß ¥—π¿“¬„π‡ âπ‡≈◊Õ¥μË” μ”·Àπàß∑’Ëμ’∫®– —߇°μ‰¥â‡ âπøÕ°‡≈◊Õ¥∑’Ë¡’¢π“¥·≈–·√ßμ÷ßμ—«∑’Ë≈¥πâÕ¬≈ß ·≈–‡ªìπμ”·Àπàß∑’Ë pulse ≈¥πâÕ¬≈ßÀ√◊ÕÀ“¬‰ª ·≈–‡π◊ËÕß®“°∫√‘‡«≥π’È¡’À≈Õ¥‡≈◊Õ¥μ’∫μ—π ®÷߇°‘¥°“√ ‰À≈¢Õ߇≈◊Õ¥·∫∫ turbulent flow ¢÷Èπ„À¡à ∑”„Àâ§≈”æ∫ thrill ·√ߢ÷Èπ À√◊Õøí߉¥â bruit ™—¥‡®π¡“°¢÷Èπ ´÷Ëß ‚¥¬∑—Ë«‰ª∫√‘‡«≥À≈—ß√Õ¬μàÕ‡ âπøÕ°‡≈◊Õ¥  ‘Ë߇À≈à“π’È®–≈¥πâÕ¬≈߉ª‡√◊ËÕ¬Ê ·μà∂â“¡’‡ âπ‡≈◊Õ¥ collateral °àÕπ√Õ¬μ’∫·≈– “¡“√∂π”‡≈◊Õ¥‰À≈‡¢â“°≈—∫ àŸÀ—«„®ºà“π‡ âπ‡≈◊Õ¥ collateral ‡À≈à“π’È °Á®–∑”„Àâ°“√ μ√«®æ∫§«“¡√ÿπ·√ߢÕß°“√μ’∫μ—π≈¥πâÕ¬≈ß ·μà∂â“ “¡“√∂°¥‡ âπ‡≈◊Õ¥ collateral ®π‰¡à¡’‡≈◊Õ¥ºà“𠉥â∑ÿ°·¢πß °Á®–μ√«®æ∫Õ“°“√· ¥ß¢Õß°“√μ’∫μ—π¢Õ߇ âπøÕ°‡≈◊Õ¥¥—ß°≈à“«¡“¢â“ßμâπ ·≈–°“√¬° ·¢π ßŸ ‡Àπ◊ÕÀ—«„® ®–æ∫«à“‡ âπøÕ°‡≈◊Õ¥ à«π∑’ËÕ¬àŸ°àÕπ√Õ¬μ’∫μ—π ®–‰¡à¬ÿ∫·≈–¡’ pulse ∑’Ë·√ß¡“°¢÷Èπ (¥Ÿμ“√“ß∑’Ë 1 ·≈–√ªŸ ∑’Ë 2) 3.1.2.1 °“√μ√«®°“√‰À≈‡¢“â ¢Õ߇≈Õ◊ ¥ àŸ‡ πâ øÕ°‡≈Õ◊ ¥ (Inflow) ‡¡◊ËÕ¡’√Õ¬μ’∫μ—πÕ¬àŸ∑’ˇ âπ‡≈◊Õ¥·¥ß°àÕπ√Õ¬μàÕ À√◊Õ∫√‘‡«≥√Õ¬μàÕ‚¥¬μ√ß À√◊Õ∫√‘‡«≥ ‡ âπ‡≈◊Õ¥¥”À≈—ß√Õ¬μàÕ·μàÕ¬Ÿà„°≈â°—∫√Õ¬μàÕ¡“° (inflow obstruction) ®–‰¡à “¡“√∂μ√«®æ∫°“√ ‡ª≈’ˬπ·ª≈ߥ—߉¥â°≈à“«¡“¢â“ßμâπ „π°√≥’π’È “¡“√∂∑”°“√μ√«®‡™Á§¥â«¬°“√„™âπ‘È«°¥≈ß∫π‡ âπøÕ° ‡≈◊Õ¥‚¥¬„™â·√ß°¥„Àâ‡≈◊Õ¥À¬ÿ¥‰À≈ ‡ ¡◊ÕπÀπ÷Ë߇ âπøÕ°‡≈◊Õ¥¡’°“√μ’∫Õ¬à“ß¡“° μâÕß·πà„®«à“‡ªìπ‡ âπ øÕ°‡≈◊Õ¥À≈—°∑’ˇ≈◊Õ¥‰À≈ºà“π ∂â“æ∫«à“‡ âπøÕ°‡≈◊Õ¥°àÕπ√Õ¬°¥ ¡’°“√‡μâπ¢Õ߇ âπøÕ°‡≈◊Õ¥À√◊Õ‡°‘¥ pulse ·√ß¡“°¢÷ÈπÕ¬à“ß¡“° · ¥ß«à“°”≈—ß à߇≈◊Õ¥®“°À—«„®ºà“π¡“¬—߇ âπøÕ°‡≈◊Õ¥¥’ (inflow) ·μà∂â“ μ“√“ß∑’Ë 1 · ¥ß°“√μ√«®æ∫ thrill, bruit ·≈– pulse  ”À√∫— ‡ πâ øÕ°‡≈Õ◊ ¥∑ª’Ë °μ‘ ·≈–‡ πâ øÕ°‡≈Õ◊ ¥∑¡’Ë °’ “√μ∫’ μπ— μ«— ™«È’ ¥— ¿“«–ª°μ‘ ¿“«–∑¡’Ë °’ “√μ∫’ μπ— Thrill æ∫‡©æ“–∑’Ë√Õ¬μàÕ°—∫‡ âπ‡≈◊Õ¥·¥ß æ∫∑’Ë∫√‘‡«≥√Õ¬μ’∫μ—π Pulse Soft ·≈–°¥„Àâ¬ÿ∫‰¥âßà“¬ Water hammer Bruit Continuous ∑—Èß Systolic ·≈– Diastolic Systolic only ·≈– High pitch Low pitch 463

Practical Dialysis in the Year 2009 √ªŸ ∑Ë’ 2 · ¥ßÕ“°“√· ¥ß¢Õ߇ πâ øÕ°‡≈Õ◊ ¥ AVF ∑¡’Ë √’ Õ¬μ∫’ μπ— ‡ πâ øÕ°‡≈Õ◊ ¥°Õà πμ”·Àπßà μ∫’ ®–¡°’ “√¢¬“¬μ«— ¡“°·≈– ¡’ pulse ·√ß ‡ πâ ‡≈◊Õ¥À≈—ß√Õ¬μ’∫®–·ø∫·≈–‰¡à¡’ pulse ∫√‘‡«≥√Õ¬μ∫’ ®–§≈”‰¥â thrill ·≈–øßí ‰¥â‡ ’¬ß bruit √Ÿª∑’Ë 3 · ¥ß°“√°¥„À⇠πâ øÕ°‡≈◊Õ¥ AVF À¬ÿ¥‡¥‘π∑’Ëμ”·Àπàß A ·≈–§≈”§«“¡·√ߢÕß pulse ∑μË’ ”·Àπßà B (pulse augmentation) §«“¡·√ߢÕß pulse ‰¡à·√ßÀ√◊Õ‰¡à‡æ‘Ë¡¢÷Èπ · ¥ß«à“‡°‘¥°“√μ’∫μ—πÕ¬à“ß¡“° À√◊ÕÕ“®®–‰¡à¡’°“√μ’∫μ—π ·μ¡à ‡’  πâ ‡≈Õ◊ ¥¥” collateral π”‡≈Õ◊ ¥‰À≈º“à π‰ª∑“ßÕπË◊ ´ßË÷ Õ“®®–¡Õ߇ÀπÁ §≈”·≈–√ âŸ °÷ ‰¥â À√Õ◊ Õ¬≈Ÿà °÷ ≈߉ª ‰¡à‡ÀÁπ®“°¿“¬πÕ° À√◊ÕÕ“®®–¡’À≈“¬‡ âπ „π°√≥’‡À≈à“π’ÈÕ“®®–μâÕß欓¬“¡°¥„Àâ„°≈â√Õ¬μàÕ¡“° ∑’Ë ÿ¥‡æ◊ËÕÀ≈’°‡≈’ˬ߇ âπ‡≈◊Õ¥ collateral «‘∏’π’ȇ√’¬°«à“ çPulse augmentationé (¥√Ÿ Ÿª∑’Ë 3) 3.1.2.2 °“√μ√«®∑“ßÕÕ°¢Õ߇ πâ øÕ°‡≈Õ◊ ¥ ‡Ÿà  πâ ‡≈Õ◊ ¥¥”„À≠∑à ÀË’ «— ‰À≈à (Outflow) ∂“â ¡‡’  πâ ‡≈Õ◊ ¥μ∫’ μπ— ∑∫’Ë √‡‘ «≥‡ πâ ‡≈Õ◊ ¥∑Õ’Ë ¬≈Ÿà °÷ ≈߉ª∑μ’Ë πâ ·¢π «à π∫πÀ«— ‰À≈à·≈–„μ‰â Àª≈“√“â ®–∑”„À‰â ¡ à “¡“√∂§≈”μ”·Àπßà ∑μ’Ë ∫’ μπ— ‰¥·â μ√à ‰Ÿâ ¥®â “°°“√∑‡’Ë  πâ øÕ°‡≈Õ◊ ¥°Õà π∑‡’Ë ÀπÁ ·≈–§≈”‰¥∑â μ’Ë πâ ·¢π ¡’¢π“¥„À≠à ¡’·√ßμ÷ßμ—«¡“° ·≈–¡’ pulse ·√ß ¬°·¢π·≈⫇ âπ‰¡à¬ÿ∫≈ßÀ¡¥ · ¥ß«à“¡’√Õ¬μ’∫μ—πÕ¬àŸ ≈÷°≈߉ª ¡—°®–‡ªìπ√Õ¬μ’∫¢Õ߇ âπ‡≈◊Õ¥¥” cephalic arch ‡ âπ‡≈◊Õ¥¥” axillary ‚¥¬‡©æ“–∫√‘‡«≥≈‘Èπ ‡ âπ‡≈◊Õ¥ ·≈–∫√‘‡«≥‚§âߢÕ߇ âπ ∂â“¡’°“√∑” transposition §≈”·≈–øíß∑’˺‘«Àπ—߇Àπ◊Õ‡ âπ‡≈◊Õ¥¥” ‡À≈à“π’ÈÕ“®®–æ∫ thrill ·≈– bruit ‰¥â πÕ°®“°π’È°Á®–‡ªìπ‡ âπ‡≈◊Õ¥¥”„À≠à subclavian ‡ âπ‡≈◊Õ¥¥” brachiocephalic ·≈–‡ âπ‡≈◊Õ¥¥” superior vena cava ´÷Ëß∑—Èß 3 ‡ âππ’È¡—°®–μ√«®æ∫‡ âπ‡≈◊Õ¥¢Õ¥®”π«π 464

Work Instruction: Physical Examination, Pressure and Flow Monitoring of Vascular Access ¡“°∑’ËÀ—«‰À≈à Àπâ“Õ° à«π∫π¥â“πÀπâ“·≈–¥â“πÀ≈—ß ·≈–¡—°∑”„Àâ·¢π∫«¡√à«¡¥â«¬ 3.1.3 °“√μ√«®‡ πâ øÕ°‡≈Õ◊ ¥ AVF ¥â«¬«‘∏≈’ ¥— ¡’ºâŸ·π–π”„Àâ∑”°“√ screening ‡ âπøÕ°‡≈◊Õ¥Õ¬à“߇√Á« ¥â«¬°“√∑” pulse augmentation ‡æ◊ËÕ∑¥ Õ∫«à“ inflow ¥’À√◊Õ‰¡à ·≈–„À⬰·¢π Ÿß‡æ◊ËÕ∑¥ Õ∫«à“ out flow ¥’À√◊Õ‰¡à ∂⓪°μ‘°Á‰¡àμâÕß μ√«®μàÕ ·μà∂⓺‘¥ª°μ‘ „Àâ∑”°“√μ√«®À“μ”·ÀπàߢÕß√Õ¬μ’∫ ·≈–§«“¡√ÿπ·√ß∑’ˇ°‘¥®“°√Õ¬μ’∫μàÕ‰ª 3.1.4 ‡¡Ë◊Õ‡ πâ øÕ°‡≈Õ◊ ¥™π¥‘ AVF ‡°¥‘ Õÿ¥μ—π ‡¡◊ËÕ‡ âπøÕ°‡≈◊Õ¥™π‘¥ AVF Õÿ¥μ—π ®–§≈”‰¡à‰¥â thrill øí߉¡à‰¥â bruit ∑’Ë√Õ¬μàÕ‡ âπøÕ°‡≈◊Õ¥ ·≈–∑’Ëμ”·ÀπàßÕ◊ËπÊ ¢Õ߇ âπøÕ°‡≈◊Õ¥ ‚¥¬‡©æ“–μ”·Àπàß√Õ¬μ’∫ Õ“®®–¬—ßμ√«®æ∫ pulse ∂Ⓡ≈◊Õ¥∑’Ë ‰À≈ºà“π¬—߉¡à°≈“¬‡ªìπ°âÕπ‡≈◊Õ¥ ´÷Ëß∫àß«à“‡°‘¥‡≈◊Õ¥‰À≈«π¿“¬„π‡ âπøÕ°‡≈◊Õ¥ ·μà∂â“¡’°âÕπ‡≈◊Õ¥‡æ‘Ë¡ ¡“°¢÷È𠧫“¡·√ߢÕß pulse ®–≈¥πâÕ¬≈ß„π∑’Ë ÿ¥ 3.1.5 °“√μ√«®‡ âπøÕ°‡≈◊Õ¥™π‘¥ AVG  ”À√—∫‡ âπøÕ°‡≈◊Õ¥™π‘¥ AVG ‚¥¬∑—Ë«‰ª¡—°„™â‡ âπ‡≈◊Õ¥ PTFE ‡ªìπ‡ âπ‡≈◊Õ¥‡∑’¬¡´÷Ëß∑”„Àâ ‰¡ à “¡“√∂μ√«®°“√‡ª≈¬’Ë π·ª≈߉¥‡â À¡Õ◊ π‡ πâ ‡≈Õ◊ ¥¥”ª°μ∑‘ «—Ë Ê‰ª¥ß— ∑‡’Ë °¥‘ ¢π÷È „π°√≥¢’ Õ߇ πâ øÕ°‡≈Õ◊ ¥ AVF À≈—°°“√∑’Ë ”§—≠ §◊Õ∂Ⓣ¡à¡’·√ßμâ“π∑“π‡°‘¥‡æ‘Ë¡¢÷Èπ¿“¬„πμ—« AVG À√◊Õ∑’Ë outflow ®–¡’ turbulent flow ∑’Ë∫√‘‡«≥√Õ¬μàÕ√–À«à“߇ âπ‡≈◊Õ¥·¥ß·≈– AVG ‡∑à“π—Èπ §◊Õ§≈”‰¥â thrill ·≈–øí߉¥â bruit ∑’Ë√Õ¬μàÕπ’È ®“°π—Èπ®–≈¥≈߇√◊ËÕ¬Ê ·μà‡π◊ËÕß®“°‡ âπ‡≈◊Õ¥¥”∑’Ëπ”¡“μàÕ°—∫ AVG Õ“®®–¡’¢π“¥‡≈Á° À√◊Õ‡°‘¥√Õ¬μ’∫μ—π∑’Ë ‡ âπ‡≈◊Õ¥¥”∫√‘‡«≥√Õ¬μàÕÀ√◊Õ„°≈â√Õ¬μàÕ ´÷Ë߇ªìπªí≠À“∑’Ëæ∫‰¥â∫àÕ¬ (venous anastomosis stenosis) °Á ®–∑”„À⇰‘¥·√ßμâ“π∑“π¢÷Èπ∑’Ëμ”·Àπàßπ’È ∑”„Àâμ√«®æ∫ thrill ·≈– bruit ∑’Ë√Õ¬μàÕ·Ààßπ’ȇ ¡Õ §«“¡·√ß ¢Õß thrill ·≈– bruit πÕ°®“°¢÷Èπ°—∫ª√‘¡“≥°“√‰À≈¢Õ߇≈◊Õ¥À√◊Õ flow ºà“π AVG ·≈â« ¬—ߢ÷Èπ°—∫§«“¡ √ÿπ·√ߢÕß√Õ¬μ’∫μ—π∑’Ëμ”·Àπàßπ’È ∂â“μ’∫¡“°¢÷Èπ°Á®–∑”„Àâμ√«®æ∫ thrill ·≈– bruit ·√ß¡“°¢÷Èπ ‡¡◊ËÕ¡’·√ßμâ“π∑“π‡°‘¥¢÷Èπ¡“°∑’Ëμ”·Àπàßπ’È °Á®–∑”„Àâ·√ߥ—π¿“¬„πμ—« AVG  ßŸ ¢÷Èπ·≈–¡—°®– ∑”„À·â √ߥπ— √–À«“à ߇ πâ ‡≈Õ◊ ¥·¥ß·≈– AVG ‰¡μà “à ß°π— ¡“° ∑”„À°â “√μ√«®æ∫ thrill ·≈– bruit ∑√’Ë Õ¬μÕà ‡ âπ‡≈◊Õ¥·¥ß·≈– AVG À“¬‰ª ¥—ßπ—Èπ°“√μ√«®æ∫ continuous thrill ·≈– bruit ∑’Ë√Õ¬μàÕ√–À«à“߇ πâ ‡≈Õ◊ ¥ ·¥ß·≈– AVG ∫ßà «“à flow π“à ®–¥·’ ≈–¡·’ √ßμ“â π∑“ππÕâ ¬ ‡¡ÕË◊ μ√«®æ∫§«“¡·√ßπÕâ ¬≈ßÀ√Õ◊ ‰¡¡à ’ · ¥ß«à“¡’ ·√ßμâ“π∑“π‡°‘¥¢÷Èπ∑’Ë„¥∑’ËÀπ÷Ëß¿“¬„π‡ âπøÕ°‡≈◊Õ¥ AVG À√◊Õ∑’ˠߟ ¢÷Èπ‰ª ·≈–∂â“μ√«®æ∫«à“ thirll À√◊Õ bruit ∑’Ë√Õ¬μàÕ AVG °—∫‡ âπ‡≈◊Õ¥¥”≈¥πâÕ¬≈ß · ¥ß«à“¡’°“√μ’∫μ—π∑’Ëμ”·Àπàßπ’ÈÕ¬à“ß¡“° (intra-graft stenosis) Õ¬à“߉√°Áμ“¡°“√μ√«®æ∫ thrill ·≈– bruit ∑’Ëμ”·Àπàßπ’È ‰¡à‰¥â∫Õ°«à“ flow ¥’ ¥—ßπ—ÈπμâÕß„™â §«“¡√–¡¥— √–«ß— „π°“√·ª≈º≈°“√μ√«®·π–π”„Àμâ √«®¥«â ¬«∏‘ Õ’ π◊Ë √«à ¡¥«â ¬ ”À√∫— ‡ πâ øÕ°‡≈Õ◊ ¥™π¥‘ AVG 3.1.6 ¢πÈ— μÕπ°“√μ√«®·≈–°“√·ª≈º≈ ‡ πâ øÕ°‡≈Õ◊ ¥ AVF ¥«â ¬°“√¥Ÿ §≈” ·≈– øíß (physical examination) 1. À“√Õ¬μàÕ√–À«à“߇ âπ‡≈◊Õ¥·¥ß·≈–‡ âπ‡≈◊Õ¥¥” ¢Õ߇ âπøÕ°‡≈◊Õ¥ AVF ‚¥¬¥Ÿ®“° 465

Practical Dialysis in the Year 2009 μ”·Àπàß·º≈ºà“μ—¥ 2. À“μ”·Àπàß∑’Ë·∑ߪ√–®” ”À√—∫‡¢Á¡ artery ·≈– vein Õ¬àŸ∑’Ë„¥ μ”·Àπà߇À≈à“π’È¡—°®–¡’ ·º≈‡ªìπ¢Õß√Õ¬·∑߇¢Á¡øÕ°‡≈◊Õ¥„Àâ‡ÀÁπ ·≈–‡ âπ‡≈◊Õ¥¡—°®–ªŸ¥‡ªìπ aneurysm Õ“®®– Õ∫∂“¡®“° ºŸâªÉ«¬‚¥¬μ√ß 3. À“∑‘»∑“ß°“√‰À≈¢Õ߇≈◊Õ¥ μ—Èß·μà√Õ¬μàÕ‰ª¬—ßÀ—«‰À≈à∑—Èß∑’˪≈“¬·¢π·≈–μâπ·¢π«à“ „™â ‡ âπ‡≈◊Õ¥À≈—°·π«„¥‡ªìπ·π«À≈—° ´÷Ëß®– —߇°μ‰¥â®“°°“√¡’¢π“¥¢Õ߇ âπ‡≈◊Õ¥∑’Ë‚μ¢÷Èπ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫ °—∫‡ âπ‡≈◊Õ¥¥â“π¢â“ß Õ“®®–μâÕß√—¥¥â«¬ tourniquet ‡æ◊Ëՙ૬∑”„À⇠âπøÕ°‡≈◊Õ¥‡ÀÁπ™—¥‡®π¢÷Èπ 4. „Àâ¡ÕßÀ“√Õ¬μ’∫¢Õ߇ âπøÕ°‡≈◊Õ¥ ë μ”·Àπàßπ—Èπ¡—°æ∫«à“‡ªìπμ”·Àπàß∑’Ë¡’¢π“¥¢Õ߇ âπ‡≈◊Õ¥∑’ˇª≈’ˬπ·ª≈߉ª§◊Õ®“° ¢π“¥„À≠à·≈â«¡’¢π“¥∑’ˇ≈Á°≈ß μâÕß√–«—ß«à“Õ“®®–‰¡à„™à√Õ¬§Õ¥ ·μà‡ªìπ‡æ√“–‡ âπ∑’Ë¡’¢π“¥„À≠à‡ªìπ aneurysm ë μ”·Àπàßπ—Èπ¡—°®–‡ªìπμ”·Àπàß∑’˧«“¡μ÷ßμ—«¢Õ߇ âπøÕ°‡≈◊Õ¥≈¥≈ßÕ¬à“ß¡“° ‡π◊ËÕß®“° Ÿ≠‡ ’¬·√ߥ—π¢Õ߇≈◊Õ¥‡¡◊ËÕºà“π√Õ¬μ’∫μ—π ë μ”·Àπàßπ—Èπ¡—°®–‡ªìπμ”·Àπàß∑’Ë¡’°“√‡ª≈’ˬπ·ª≈ߢÕß pulse §◊Õ‡ âπøÕ°‡≈◊Õ¥°àÕπ μ”·Àπàßπ’È®–¡’ pulse ∑’Ë·√ß ·≈–‡ âπøÕ°‡≈◊Õ¥À≈—ßμ”·Àπàßπ’È®–¡’ pulse ≈¥πâÕ¬≈ßÀ√◊ÕÀ“¬‰ª °“√∑’Ë¡’ pulse ·√ß∫àß«à“ inflow ¢Õ߇ âπøÕ°‡≈◊Õ¥°àÕπÀπâ“π’È¥’¡“° ë „À⬰·¢π Ÿß‡Àπ◊ÕÀ—«„® ‚¥¬∑—Ë«‰ª‡ âπøÕ°‡≈◊Õ¥®–¬ÿ∫μ—«≈ßÀ¡¥ ∂⓬ÿ∫‰¡àÀ¡¥∑’Ë μ”·Àπàß„¥· ¥ß«à“¡’√Õ¬μ’∫μ—π¢Õ߇ âπøÕ°‡≈◊Õ¥∑’Ëπ—Èπ  ”À√—∫ aneurysm ¡—°®–‰¡à¬ÿ∫À¡¥·μà®–π‘Ë¡≈ß ë μ”·Àπà߇À≈à“π’È¡—°®–§≈”‰¥â thrill ∑’Ë·√ߢ÷Èπ ·≈–¡—°®–‡ªìπ continuous thrill §◊Õ§≈” ‰¥â∑—Èß™à«ß systolic ·≈– diastolic phase ‰¡à¡’ pulse ¬°‡«âπ«à“¡’√Õ¬μ’∫μ—π¢Õ߇ âπ‡≈◊Õ¥‡æ‘Ë¡‡μ‘¡À≈—ß®“° μ”·Àπàßπ’È ë μ”·Àπà߇ âπøÕ°‡≈◊Õ¥∑’Ëμ’∫π’È ∂â“Õ¬Ÿà„°≈â√Õ¬μàÕ‡ âπ‡≈◊Õ¥·¥ß·≈–¥” À√◊ÕÕ¬Ÿà≈÷° ‡¢â“‰ª∑’Ëμâπ·¢π à«π∫π®–μ√«®‰¥â¬“° μâÕß„À⧫“¡√–¡—¥√–«—ß„π°“√μ√«® 5. °“√μ√«® inflow ¢Õ߇ âπøÕ°‡≈◊Õ¥ «à“¡’°“√μ’∫μ—π¢Õ߇ âπ‡≈◊Õ¥·¥ß À√◊Õ°“√μ’∫μ—π∑’ √Õ¬μàÕ‡ âπ‡≈◊Õ¥·¥ß·≈–‡ âπ‡≈◊Õ¥¥” À√◊Õ‡ âπøÕ°‡≈◊Õ¥¥”À≈—ß√Õ¬μàÕ·μàÕ¬àŸ„°≈â√Õ¬μàÕ¡“° ´÷Ë߉¡à  “¡“√∂μ√«®æ∫√Õ¬μ’∫μ—π¥â«¬«‘∏’¥—߉¥â°≈à“«¢â“ßμâπ (pulse augmentation) ë ∑”„À⇰‘¥°“√μ’∫μ—π¢Õ߇ âπøÕ°‡≈◊Õ¥„°≈â°—∫√Õ¬μàÕ¢Õ߇ âπøÕ°‡≈◊Õ¥ ¥â«¬°“√„™â π‘È«Õÿ¥∑“߇¥‘π¢Õ߇≈◊Õ¥„Àâ π‘∑ ∂â“¡’ª√‘¡“≥¢Õß pulse ·√ߢ÷ÈπÕ¬à“ß¡“° · ¥ß«à“°”≈—ß àߢÕ߇≈◊Õ¥ ºà“π‡ âπøÕ°‡≈◊Õ¥¥’ ´÷ËßÕπÿ¡“π«à“‰¡àπà“®–¡’√Õ¬μ’∫μ—π∑’Ë ”§—≠¢Õ߇ âπ‡≈◊Õ¥·¥ß √Õ¬μàÕ‡ âπ‡≈◊Õ¥·¥ß ·≈–¥” ·≈–‡ âπ‡≈◊Õ¥¥”°àÕπμ”·Àπàß∑’Ë∑”„À⇰‘¥°“√Õÿ¥μ—π ë ∂⓪√‘¡“≥¢Õß pulse ‰¡à·√ß · ¥ß«à“ ‡ âπ‡≈◊Õ¥·¥ß √Õ¬μàÕ‡ âπ‡≈◊Õ¥·¥ß·≈–¥” ·≈–‡ âπ‡≈◊Õ¥¥”°àÕπμ”·Àπàß∑’Ë∑”„À⇰‘¥°“√Õÿ¥μ—π ¡’°“√μ’∫μ—π¢÷Èπ À√◊Õ‡≈◊Õ¥ “¡“√∂ºà“π‡ âπ‡≈◊Õ¥¥” collateral ‰ª„π∑‘»∑“ßÕ◊ËπÊ ´÷ËßÕ“®®–¡Õ߇ÀÁπ·¢π߇ âπ‡≈◊Õ¥¥”Õ◊Ëπ¥â«¬μ“‡ª≈à“ À√◊ÕÕ“®®–¡Õ߉¡à‡ÀÁπ °Á‰¥â «‘∏’°“√·°â‰¢§◊Õ„À⢬—∫μ”·Àπàß°“√Õÿ¥∑“߇¥‘π¢Õ߇ âπøÕ°‡≈◊Õ¥„°≈â√Õ¬μàÕ¢Õ߇ âπøÕ°‡≈◊Õ¥„Àâ ¡“°∑’Ë ÿ¥ ∂â“¡’ pulse ·√ߢ÷Èπ· ¥ß«à“ inflow ¥’ ·μà¡’‡ âπ‡≈◊Õ¥¥” collateral π”‡≈◊Õ¥√—¥‰À≈‰ª∑“ßÕ◊Ëπ ∂â“ 466

Work Instruction: Physical Examination, Pressure and Flow Monitoring of Vascular Access pulse ‰¡à·√ߢ÷Èπ· ¥ß«à“ inflow ¡’ªí≠À“ 6. °“√μ√«® outflow ¢Õ߇ âπøÕ°‡≈◊Õ¥ «à“¡’°“√μ’∫μ—πÀ√◊Õ‰¡à „Àâμ√«®μ“¡«‘∏’ª°μ‘¥—ß °≈à“«„π¢âÕ 5 ∂â“¡’‡ âπøÕ°‡≈◊Õ¥∑’Ë outflow μ’∫μ—π ‡ âπøÕ°‡≈◊Õ¥∑’Ëμâπ·¢π®–¡’¢π“¥„À≠à μ÷ß·≈–¡—° ®–¡’ pulse ·√ß ¬°·¢π·≈⫉¡à¬ÿ∫ ë °√≥’∂â“¡’°“√μ’∫μ—π∑’ˇ âπøÕ°‡≈◊Õ¥¥” cephalic  à«π∫π®π∂÷ß cephalic arch °àÕπ‡¢â“ ‡ âπ‡≈◊Õ¥¥” subclavian À√◊Õ‡ âπ‡≈◊Õ¥¥” axillary μ√ß∫√‘‡«≥‚§âß∑’Ë∑” transposition À√◊Õ ≈÷°≈߉ª°àÕπ ∂÷߇ âπ‡≈◊Õ¥¥” subclavian ®–§≈”æ∫ thrill À√◊Õøí߉¥â¬‘π‡ ’¬ß bruit ™—¥‡®π¡“°∫√‘‡«≥º‘«Àπ—߇Àπ◊Õ ‡ âπ‡≈◊Õ¥¥—ß°≈à“« ·¢π‰¡à∫«¡·≈–μ√«®‰¡àæ∫‡ âπ‡≈◊Õ¥¥” collateral ∑’ËÀ—«‰À≈à·≈–Àπâ“Õ° ë °√≥’∂â“¡’°“√μ’∫μ—π∑’ˇ âπøÕ°‡≈◊Õ¥¥”„À≠à subclavian, brachiocephalic, À√◊Õ superior venacava ¡—°®–æ∫‡ âπ‡≈◊Õ¥¥” collateral ®”π«π¡“°∑’ËÀ—«‰À≈à ·≈–Àπâ“Õ° ·¢π¡—°®–∫«¡ ·≈–μ√«® ‰¡àæ∫ thrill À√◊Õ bruit ‡Àπ◊Õ‡ âπ‡≈◊Õ¥¥”∑’ËμË”®“°‡ âπ‡≈◊Õ¥‡À≈à“π’È 7. μ√«®ª√‘¡“≥°“√‰À≈¢Õ߇≈◊Õ¥ºà“π AVF ë ∑μË’ ”·Àπßà √Õ¬μÕà ‡ πâ ‡≈Õ◊ ¥·¥ß·≈–‡ πâ ‡≈Õ◊ ¥¥” „À§â ≈”ª√¡‘ “≥ thrill ·≈–øßí ‡ ¬’ ß bruit ∑—Èß™à«ß systolic ·≈– diastolic phase ¢≥–§≈”„Àâ§≈”§«“¡·√ߢÕß pulse ·≈–¢≥–øí߇ ’¬ß bruit „Àâøíß «“à ¡‡’  ¬’ ß∑¡ÿâ À√Õ◊ ·À≈¡∂“â inflow¥’·≈–∫√‡‘ «≥‡ πâ øÕ°‡≈Õ◊ ¥ «à π∑‡’Ë À≈Õ◊ ‰¡¡à √’ Õ¬μ∫’ μπ— ∑ ’Ë ”§≠— ®–§≈”‰¥â continuous thrill ·≈– bruit ∑’Ë√Õ¬μàÕ§àÕπ¢â“ß·√ß·≈–¡’ pulse ∑’ˉ¡à·√ß ë ∂â“¡’√Õ¬μ’∫μ—π¢Õ߇ âπøÕ°‡≈◊Õ¥ „Àâ§≈” thrill ·≈–øíß bruit ∑’Ëμ”·Àπàßπ’È ·¡â«à“®– ‡ªìπμ”·Àπàßμ’∫ ·μà∂ⓧ≈”‰¥â thrill ·≈–øí߉¥â bruit ·√ß ∫àߪ√‘¡“≥‡≈◊Õ¥∑’ˉÀ≈ºà“π®ÿ¥π’Ȭ—ߥ’ ·¡â«à“ ª√‘¡“≥‡≈◊Õ¥∑’ˉÀ≈ºà“π‡ âπøÕ°‡≈◊Õ¥®–≈¥≈ß®π∑”„Àâμ√«® thrill ·≈– bruit ‰¡à‰¥â∑’Ë√Õ¬μàÕ¢Õ߇ âπ øÕ°‡≈◊Õ¥ ·μà¡—°®–‡æ’¬ßæÕ∑’Ë®–∑”„Àâ§≈” thrill ·≈–øíß bruit ‰¥â™—¥‡®π∑’Ëμ”·Àπàß√Õ¬μ’∫ °àÕπ∑’Ë ‡ âπ‡≈◊Õ¥®–Õÿ¥μ—π 8. πÕ°®“°°“√¡ÕßÀ“√Õ¬μ’∫μ—π¢Õ߇ âπøÕ°‡≈◊Õ¥ „Àâμ√«® ‘ËßμàÕ‰ªπ’ȇæ‘Ë¡‡μ‘¡ (‰¡à≈ß√“¬ ≈–‡Õ’¬¥) ë μ√«®¥Ÿ«à“¡’ aneurysm À√◊Õ pseudoaneurysm À√◊Õ‰¡à ´÷Ëß¡—°®–‡ªìπμ”·Àπàß„°≈â√Õ¬ ·∑߇¢¡Á øÕ°‡≈Õ◊ ¥ ·≈–μ”·Àπßà „°≈√â Õ¬μÕà ‡ πâ øÕ°‡≈Õ◊ ¥ „À â ”√«®«“à ¢π“¥„À≠à ·≈–/À√Õ◊ ºπß— ∫“ßÀ√Õ◊ ‰¡à ´÷ËßÕ“®®–¡’·π«‚πâ¡°“√·μ°¢Õ߇ âπøÕ°‡≈◊Õ¥‰¥â ë μ√«®¥Ÿ«à“¡’°“√μ‘¥‡™◊ÈÕ∑’ˇ âπøÕ°‡≈◊Õ¥À√◊Õ∫√‘‡«≥„°≈⇠âπøÕ°‡≈◊Õ¥À√◊Õ‰¡à ë μ√«®¥Ÿ«à“¡’·¢π∫«¡À√◊Õ‰¡à ∑’ˉÀπ ¡’‡ âπ‡≈◊Õ¥¢Õ¥ (collateral) ∑’Ë∫√‘‡«≥§Õ·≈– Àπâ“Õ°∑—Èߥâ“πÀπâ“·≈–À≈—ßÀ√◊Õ‰¡à ·≈–‡§¬∂Ÿ°·∑߇ âπ‡≈◊Õ¥¥”„À≠à¥â«¬ hemodialysis catheter À√◊Õ ‰¡à∑’Ë·¢π¢â“߇¥’¬«°—ππ’È ‡ªìπ°“√μ√«®À“ central vein occlusion ·μà∂â“¡’¡◊ÕÀ√◊Õ·¢π à«π≈à“ß∫«¡‡∑à“π—Èπ Õ“®®–‡°‘¥®“°¿“«– venous hypertension ‡π◊ËÕß®“°°“√μàÕ‡ âπ‡≈◊Õ¥·∫∫ side-to-side anastomosis À√◊Õ¡’°“√μ’∫μ—π¢Õ߇ âπøÕ°‡≈◊Õ¥·≈–¡’‡ âπ‡≈◊Õ¥¥” collateral π”‡≈◊Õ¥‰À≈°≈—∫¡“¬—ß¡◊Õ·≈–ÕâÕ¡°≈—∫ ‡¢â“À“‡ âπ‡≈◊Õ¥¥”·¢πßÕ◊Ëπ°àÕπ°≈—∫ àŸÀ—«„® ë μ√«®§≈”§«“¡·√ߢÕ߇ âπ‡≈◊Õ¥·¥ß brachial, radial ·≈– ulnar ·≈–μ√«®¥Ÿ«à“¡◊Õ¡’ Õ“°“√´’¥‡¢’¬«À√◊Õ‰¡à ‡ªìπ°“√μ√«®‡°’ˬ«°—∫¿“«– hand ischemia 467

Practical Dialysis in the Year 2009 ë μ√«®°”≈—ߢÕß°≈â“¡‡π◊ÈÕ¡◊Õ ·≈–·¢π«à“‡ âπª√– “∑∑’Ë —Ëß°“√∑”ß“π¢Õß¡◊Õ·≈–·¢π ¬—ߥ’À√◊Õ‰¡à (neuropathy related vascular access) 9. ®¥∫π— ∑°÷ °“√‡ª≈¬’Ë π·ª≈ß∑μ’Ë √«®æ∫‡æÕ◊Ë π”‰ªμ¥‘ μ“¡°“√‡ª≈¬’Ë π·ª≈ß„π§√ß—È μÕà ʉª·≈– „Àâ√–«—ß«à“ „π¢≥–μ√«®∂⓺ŸâªÉ«¬¡’§«“¡¥—π‚≈À‘μμË” ®–‰¥âº≈°“√μ√«®‡À¡◊Õπªí≠À“∑’Ë inflow ·≈–∂â“ ¡’§«“¡¥—π‚≈À‘μ ßŸ ¡“°Õ“®®–μ√«®æ∫ª√‘¡“≥ flow ºà“π‡ âπøÕ°‡≈◊Õ¥‡æ‘Ë¡¡“°¢÷Èπ „πªí®®ÿ∫—π¬—߉¡à¡’ °“√°”Àπ¥Õ¬à“߇ªìπ¡“μ√∞“π«à“  ‘Ëßμ√«®æ∫„¥∑’˧«√√’∫ àßμ√«®«‘π‘®©—¬ ·≈–√—°…“ °àÕπ∑’ˇ âπøÕ° ‡≈◊Õ¥®–‡°‘¥°“√Õÿ¥μ—π ¡—°®–μâÕß„™â°“√‡ª≈’ˬπ·ª≈ß™π‘¥Õ◊ËπÊ ¡“ª√–°Õ∫√à«¡¥â«¬ 3.2 °“√«—¥√–¥∫— ·√ß¥π— ¢Õ߇ πâ øÕ°‡≈Õ◊ ¥∑Ë’μ”·Àπàߪ≈“¬‡¢¡Á øÕ°‡≈Õ◊ ¥ (Pressure monitoring) ‡¡◊ËÕ‡ âπøÕ°‡≈◊Õ¥¡’°“√μ’∫μ—π ·√ߥ—π¢Õ߇ âπøÕ°‡≈◊Õ¥°àÕπ√Õ¬μ’∫μ—π®– ßŸ ·≈– “¡“√∂ «—¥‡ªìπμ—«‡≈¢‰¥â  à«π„À≠à®–∑”°“√«—¥¢≥–∑’Ë·∑߇¢Á¡øÕ°‡≈◊Õ¥·≈â« §◊Õ‡ªìπ§à“·√ߥ—π¿“¬„π‡ âπøÕ° ‡≈◊Õ¥∑’Ëμ”·Àπà߇¢Á¡∑’Ë·∑ß Õ“®®–‡ªìπ‡¢Á¡øÕ°‡≈◊Õ¥¥â“π artery À√◊Õ vein ∂â“∑”°“√«—¥°àÕπμàÕ°—∫‡§√◊ËÕß øÕ°‡≈◊Õ¥ À√◊Õ¢≥–øÕ°‡≈◊Õ¥·μàÀ¬ÿ¥ blood pump ‡√’¬°§à“∑’Ë«—¥‰¥â«à“ Static intra-access pressure (S-IAP) ¢Õ߇¢Á¡¥â“π artery À√◊Õ vein μ“¡≈”¥—∫ (S-IAP/A À√◊Õ S-IAP/V) ∂â“∑”°“√«—¥„π¢≥–∑’Ë°”≈—ß øÕ°‡≈◊Õ¥·≈–‰¡à‰¥âÀ¬ÿ¥ blood pump ‡√’¬°·√ߥ—π∑’Ë«—¥‰¥â«à“ dynamic pressure °“√«—¥∑’Ë –¥«°∑’Ë ÿ¥§◊Õ °“√«—¥‚¥¬μ√ß°àÕπ∑”°“√μàÕ‡¢Á¡øÕ°‡≈◊Õ¥‡¢â“°—∫ “¬øÕ°‡≈◊Õ¥ ·μà∂Ⓣ¥âμàÕ°—∫ “¬øÕ°‡≈◊Õ¥·≈– ∑”°“√øÕ°‡≈◊Õ¥‰ª·≈â« ¢≥–«—¥μâÕßÀ¬ÿ¥ blood pump ·≈–Õà“π§à“·√ߥ—π®“°‡§√◊ËÕßøÕ°‡≈◊Õ¥‚¥¬μ√ß ·μàμ”·Àπàß·√ߥ—π∑’ËÕà“π‰¥â®–‡ªìπμ”·ÀπàߢÕßμ—«¥—°Õ“°“» ´÷Ëß®–¡’§à“πâÕ¬°«à“∑’ˇ âπøÕ°‡≈◊Õ¥μ“¡ §«“¡ Ÿß√–À«à“ßμ—«¥—°Õ“°“»·≈–‡ âπøÕ°‡≈◊Õ¥ ¥—ßπ—Èπ§à“·√ߥ—π∑’Ë«—¥‰¥â®÷߇ªìπ§à“·√ߥ—π∑’Ëμ”·Àπàßμ—« ¥—°Õ“°“»®÷ßμâÕß∂Ÿ°·ª≈ß¡“‡ªìπ§à“·√ߥ—π∑’Ë∫√‘‡«≥‡ âπøÕ°‡≈◊Õ¥Õ’°∑’ ®÷߇æ‘Ë¡§«“¡¬ÿà߬“°¡“°¢÷Èπ «‘∏’ À≈—ßπ’ȇªìπ®÷߇ªìπ«‘∏’°“√«—¥‚¥¬ÕâÕ¡  ”À√—∫°“√«—¥ dynamic pressure °Á‡ªìπ°“√Õà“π§à“·√ߥ—π‡≈◊Õ¥∑’ˇ§√◊ËÕßøÕ°‡≈◊Õ¥‚¥¬μ√ß ¢≥–øÕ°‡≈◊Õ¥  ”À√—∫¥â“π vein §à“·√ߥ—π∑’Ë«—¥‰¥â§◊Õ·√ߥ—π∑’Ëμ—«¥—°Õ“°“»¥â“π vein ´÷Ëß®–¡’§à“¡“°«à“ §à“·√ߥ—π∑’ˇ âπøÕ°‡≈◊Õ¥¢≥–À¬ÿ¥ blood pump ¥â“π vein Õ¬à“ß¡“° ‡π◊ËÕß®“°·√ߥ—π∑’ˇæ‘Ë¡¢÷Èπ®“° ·√ßÀ¡ÿπ¢Õß blood pump ·√ßμâ“π∑“π‡π◊ËÕß®“°§«“¡Àπ◊¥¢Õ߇≈◊Õ¥ ·≈–¢π“¥¢Õ߇¢Á¡øÕ°‡≈◊Õ¥ ∂â“ ®–„™â§à“·√ߥ—ππ’ȇªìπμ—«ª√–‡¡‘𧫓¡√ÿπ·√ߢÕß°“√μ’∫¢Õ߇ âπøÕ°‡≈◊Õ¥∑’Ëμ”·Àπàß Ÿß°«à“μ”·Àπàß ¢Õ߇¢Á¡¥â“π vein ¡—°®–„™âμ‘¥μ“¡°“√‡ª≈’ˬπ·ª≈ß„π√–¬–¬“«¡“°°«à“®–„™â§à“„¥§à“Àπ÷Ëß ·≈–∑ÿ°§√—Èß ∑’Ë«—¥®–μâÕß·πà„®«à“ªí®®—¬∑ÿ°Õ¬à“ߧߠ¿“懥‘¡ ‡™à𠧫“¡‡√Á«¢Õß blood pump, §«“¡Àπ◊¥¢Õ߇≈◊Õ¥ ‚¥¬¥Ÿ®“°§à“ hematocrit ·≈–¢π“¥¢Õ߇¢Á¡øÕ°‡≈◊Õ¥  ”À√—∫°“√«—¥ dynamic pressure ¥â“π artery §à“∑’ˉ¥â§◊Õ·√ߥ—π∑’Ëμ—«¥—°Õ“°“» μâÕß·πà„®«à“ ‡ªπì  “¬øÕ°‡≈Õ◊ ¥™π¥‘ ∑¡Ë’ μ’ «— ¥°— Õ“°“»Õ¬°Ÿà Õà π blood pump §“à ∑‰Ë’ ¥®â –‡ªπì §“à 쥑 ≈∫‡πÕË◊ ß®“°·√ߥß÷ ®“° blood pump ®÷ß·∑∫®–‰¡à¡’§«“¡ —¡æ—π∏å°—∫§à“·√ߥ—π∑’ˇ âπøÕ°‡≈◊Õ¥¢≥–À¬ÿ¥ blood pump ¥â“π artery ‡≈¬ ·μà®–‡ªìπμ—«‡≈¢∑’Ë∫àß∂÷ߪ√‘¡“≥‡≈◊Õ¥∑’ˉÀ≈ºà“π‡ âπøÕ°‡≈◊Õ¥«à“¥’¡“°‡æ’¬ß„¥ ∂â“μ‘¥≈∫πâÕ¬ · ¥ß«à“ª√‘¡“≥°“√‰À≈¢Õ߇≈◊Õ¥‡æ’¬ßæÕμàÕ§«“¡‡√Á«¢Õß blood pump ∑’ˉ¥âμ—Èß§à“‰«â 468

Work Instruction: Physical Examination, Pressure and Flow Monitoring of Vascular Access √Ÿª∑Ë’ 4 · ¥ß°“√«—¥ Static intra-access pressure ‚¥¬μ√ß √Ÿª´â“¬∫π · ¥ßμ—««¥— ·√ß¥π— ‡≈Õ◊ ¥ √ªŸ ´â“¬°≈“ß · ¥ßμ«— filter √ªŸ ´“â ¬¥“â π≈“à ß · ¥ßμ—««¥— ·√ß¥π— ‡≈◊Õ¥∑Ë’¡’ filter ∑Ë’ª≈“¬ “¬ ·≈– √Ÿª¥â“π¢«“ · ¥ß°“√μàÕ‡¢â“°—∫‡¢Á¡øÕ°‡≈◊Õ¥‡æË◊Õ«¥— ·√ß¥π— ‡≈Õ◊ ¥ 3.2.1 ¢πÈ— μÕπ°“√«—¥ Static intra-access pressure (S-IAP) ‚¥¬μ√ß «¥— °àÕπ°“√ øÕ°‡≈◊Õ¥ (√ªŸ ∑’Ë 4) 1. À≈ß— ®“°·∑߇¢¡Á artery ·≈–‡¢¡Á vein ‡¢“â °∫— ‡ πâ øÕ°‡≈Õ◊ ¥ 欓¬“¡Õ¬“à „À‡â ≈Õ◊ ¥‰À≈ÕÕ° ®“°ª≈“¬‡¢Á¡‡¢â“ Ÿàμ—« “¬¢Õߪ≈“¬‡¢Á¡øÕ°‡≈◊Õ¥¥â«¬°“√Àπ’∫¥â«¬μ—«Àπ’∫ 2. „Àâπ”ª≈“¬ “¬μ—««—¥·√ߥ—π‡≈◊Õ¥μàÕ‡¢â“°—∫μ—« filter μ—«„À¡à∑’Ë sterile (‡ªìπμ—« filter μ—« ‡¥’¬«°—π∑’ËμâÕß„™âμàÕ‡¢â“°—∫‡§√◊ËÕ߉μ‡∑’¬¡‡æ◊ËÕ«—¥·√ߥ—π‡≈◊Õ¥¿“¬„𠓬øÕ°‡≈◊Õ¥¥â“π vein  ”À√—∫ ºŸâªÉ«¬·μà≈–§π) ‡æ◊ËÕªÑÕß°—π°“√ªπ‡ªóôÕπ¢Õ߇™◊ÈÕ‚√§®“°μ—««—¥·√ߥ—π‡≈◊Õ¥‡¢â“ “¬¢Õ߇¢Á¡øÕ°‡≈◊Õ¥ ·≈–ªÑÕß°—π‰¡à„Àâ‡≈◊Õ¥‰À≈®“°‡¢Á¡øÕ°‡≈◊Õ¥‡¢â“ Ÿàμ—««—¥·√ߥ—π‡≈◊Õ¥ ·πà„®«à“°àÕπ∑”°“√«—¥ ‡¢Á¡¢Õß μ—««—¥·√ߥ—π‡≈◊Õ¥Õ¬Ÿà∑’Ë»Ÿπ¬å 3. μàÕ filter ∑’Ëμ‘¥Õ¬Ÿà°—∫ª≈“¬ “¬μ—««—¥·√ߥ—π‡≈◊Õ¥‡¢â“°—∫ “¬¢Õ߇¢Á¡øÕ°‡≈◊Õ¥¥â“π artery ·≈–§≈“¬μ—«Àπ’∫®“° “¬¢Õ߇¢Á¡øÕ°‡≈◊Õ¥ Õà“π§à“·√ߥ—π´÷Ëß¡’∑—Èß§à“ systolic ·≈– diastolic ®“°μ—««—¥ ·√ߥ—π‡≈◊Õ¥‡ªìπ¡‘≈≈‘‡¡μ√ª√Õ∑ √–«—߇≈◊Õ¥‰À≈‡¢â“μ—««—¥·√ߥ—π‡≈◊Õ¥ ®“°π—Èπ„ÀâÀπ’∫ “¬¢Õ߇¢Á¡øÕ° ‡≈◊Õ¥¥â“π artery §à“ systolic pressure ∑’Ë«—¥‰¥â§◊Õ§à“ S-IAP/A 4. ∑”´È”°—∫ “¬¢Õ߇¢Á¡øÕ°‡≈◊Õ¥¥â“π vein §à“ systolic pressure ∑’Ë«—¥‰¥â§◊Õ§à“ S-IAP/V 5. «—¥§«“¡¥—π‡≈◊Õ¥®“°·¢π¥â“πμ√ߢⓡ ∫—π∑÷°§à“ systolic blood pressure (SBP) ·≈– diastolic blood pressure (DBP) ·≈–§”π«≥§à“ mean arterial pressure (MAP) MAP = DBP + (SBP - DBP) / 3 6. §”π«≥À“§à“ normalized S-IAP ¥â“π artery ·≈– vein ¥—ßπ’È Normalized S-IAP/A = S-IAP/A / MAP 469

Practical Dialysis in the Year 2009 Normalized S-IAP/V = S-IAP/V / MAP 7. ‡À¡“– ”À√∫— ‡ πâ øÕ°‡≈Õ◊ ¥™π¥‘ AVG ·≈–μ√«®À“§«“¡√πÿ ·√ߢÕß°“√μ∫’ ∑∑Ë’ “ßÕÕ°¢Õß AVG À√◊Õ¿“¬„πμ—« AVG §à“ normalized S-IAP ¥â“π‡¢Á¡ artery ‰¡à§«√¡“°°«à“ 0.75 ·≈–¥â“π‡¢Á¡ vein ‰¡à§«√‡°‘π 0.50 μ—«Õ¬à“ß «—¥§à“·√ߥ—π‡≈◊Õ¥®“°‡¢Á¡¥â“π artery ‰¥â§à“ 60/40 ¡‘≈≈‘‡¡μ√ª√Õ∑ ·≈–«—¥§à“·√ߥ—π‡≈◊Õ¥ ®“°‡¢Á¡¥â“π vein ‰¥â§à“ 30/20 ¡‘≈≈‘‡¡μ√ μ“¡≈”¥—∫ «—¥·√ߥ—π‡≈◊Õ¥¢Õß·¢πÕ’°¢â“߉¥â 140/80 ¡‘≈≈‘‡¡μ√ª√Õ∑ MAP = 80 + (140 - 80) / 3 = 80 + 20 = 100 ¡‘≈≈‘‡¡μ√ª√Õ∑ Normalized S-IAP/A = 60 / 100 = 0.60 Normalized S-IVP/V = 30 / 100 = 0.30 3.2.2 ¢—ÈπμÕπ°“√«—¥ Static intra-access pressure (S-IAP) ‚¥¬ÕâÕ¡ «—¥„π √–À«à“ßøÕ°‡≈Õ◊ ¥ (√ªŸ ∑’Ë 5) 1. ‡ªìπ°“√«—¥„π¢≥–∑”°“√øÕ°‡≈◊Õ¥ §«√®–∑”¿“¬„π‡«≈“ 30-60 π“∑’·√° ¢Õß°“√øÕ° ‡≈◊Õ¥ ‡π◊ËÕß®“° “¬øÕ°‡≈◊Õ¥∑’Ë¡’„™â„πª√–‡∑»‰∑¬ μ—«°√–‡ª“–¥—°Õ“°“»¢Õß “¬øÕ°‡≈◊Õ¥¥â“π artery Õ¬Ÿà„πμ”·ÀπàßÀ≈—ßμ—« blood pump ∑”„À≡ࠓ¡“√∂«—¥§à“ S-IAP ¥â“π artery ‰¥â (¥Ÿ√ªŸ ∑’Ë 6) 2. ¢—ÈπμÕπ·√°„ÀâÀ¬ÿ¥ blood pump ‡ªìπ‡«≈“ 30 «‘π“∑’ À¬ÿ¥°“√∑” ultrafiltration °√≥’‰¡à ‰¥âÀ¬ÿ¥ ultrafiltration ®–μâÕßÀπ’∫ “¬øÕ°‡≈◊Õ¥¥â“π vein ∑’ËμàÕ√–À«à“ß°√–‡ª“–¥—°Õ“°“»°—∫μ—«°√Õß ‡≈◊Õ¥ √–«—ß®–¡’°“√Àπ’∫√—¥ “¬¥â“π≈à“ߢÕß°√–‡ª“–¥—°Õ“°“»¢≥–À¬ÿ¥ blood pump „Àâ§≈“¬ÕÕ° ‡π◊ËÕß®“°·√ߥ—π‡≈◊Õ¥∑’Ë«—¥‰¥â®“°°√–‡ª“–¥—°Õ“°“»μâÕß¡’§«“¡μàÕ‡π◊ËÕß∂÷ßμ—«‡¢Á¡øÕ°‡≈◊Õ¥ (¥√Ÿ Ÿª∑’Ë 7) 3. Õà“π§à“·√ߥ—π‡≈◊Õ¥¢Õß “¬¥â“π vein ∑’ËÀπâ“®Õ¢Õßμ—«‡§√◊ËÕ߉μ‡∑’¬¡ ´÷ËßÕ“®®–· ¥ß √Ÿª∑Ë’ 5 · ¥ß«ß®√∑¡’Ë ’°√–‡ª“–¥—°Õ“°“»¥â“π artery Õ¬°àŸ Õà π blood pump ·≈–¢È—πμÕπ°“√«—¥ S-IAP/A ·≈– /V (√“¬≈–‡Õ¬’ ¥¢ÕߢȗπμÕπ„À¥â „Ÿ π‡πÕÈ◊ À“) 470

Work Instruction: Physical Examination, Pressure and Flow Monitoring of Vascular Access √Ÿª∑’Ë 6 √ªŸ ∫π · ¥ß«ß®√¢Õß°“√øÕ°‡≈◊Õ¥∑’¡Ë °’ √–‡ª“–¥°— Õ“°“»¥“â π artery Õ¬°Ÿà àÕπ blood pump ∑”„À â “¡“√∂ «—¥ S-IAP ∑—Èߥ“â π artery ·≈–¥â“π vein ‰¥âæ√âÕ¡°π— ‡¡ÕË◊ À¬ÿ¥ blood pump ‡π◊ÕË ß®“°·√ß¥π— ‡≈Õ◊ ¥ ¿“¬„π°√–‡ª“–¡’§«“¡ ¡— æ—π∏å°—∫§“à S-IAP/A ·≈– /V √ªŸ ≈“à ß · ¥ß«ß®√¢Õß°“√øÕ°‡≈Õ◊ ¥∑¡Ë’ °’ √–‡ª“–¥°— Õ“°“»¥“â π artery Õ¬ÀàŸ ≈ß— blood pump ∑”„À≡ à “¡“√∂ «¥— S-IAP/A ‰¥‡â æ√“–¡μ’ «— blood pump ¢«“ß∑“ßÕ¬Ÿà¥â“πÀπâ“ ‡ªìπμ—«‡≈¢‚¥¬μ√ß À√◊Õ ‡ªìπ°√“ø·≈–¡’¢’¥μ—«‡≈¢„ÀâÕà“π (¥Ÿ√ªŸ ∑’Ë 8) §à“∑’ËÕà“π‰¥â®–¡’∑—Èß§à“ systolic ·≈– diastolic „Àâ∫—π∑÷°‡©æ“–§à“ systolic ‡ªìπ¡‘≈≈‘‡¡μ√ª√Õ∑ §à“∑’ËÕà“π‰¥â§◊Õ§à“·√ߥ—π‡≈◊Õ¥¢Õß°√–‡ª“–¥—° Õ“°“»¢Õß “¬øÕ°‡≈◊Õ¥¥â“π vein ‡√’¬°«à“ venous drip chamber pressure (venous drip chamber P) 4. §à“∑’Ë«—¥‰¥â¬—߉¡à„™à§à“ S-IAP ‚¥¬μ√ß ®–μâÕß∫«°·√ߥ—πÕ—π‡π◊ËÕß®“°§«“¡·μ°μà“ß √–À«à“ߧ«“¡ Ÿß¢Õ߇¢Á¡øÕ°‡≈◊Õ¥·≈–°√–‡ª“–¥—°Õ“°“» ´÷Ë߇°‘¥¢÷Èπ®“°·√ß‚πâ¡∂à«ß‚≈° À√◊Õ‡√’¬°«à“ P-Offset ·≈–®–μâÕß∫«°≈∫§à“§«“¡º‘¥æ≈“¥Õ—π‡π◊ËÕß®“° zero pressure (P-0) ‡π◊ËÕß®“°μ—««—¥·√ß ¥—π‡≈◊Õ¥Õ“®®–¬—߉¡à‰¥â∑” zero calibration 471

Practical Dialysis in the Year 2009 √ªŸ ∑’Ë 7 · ¥ß°√–‡ª“–¥—°Õ“°“»¥“â π vein „À â —߇°μ≈Ÿ°»√ ´ßË÷ · ¥ßμ—«Àπ∫’ √—¥ “¬øÕ°‡≈Õ◊ ¥ √ªŸ ´â“¬¡Õ◊ ¢≥–∑Ë’ blood pump °”≈—ßÀ¡ÿπ √ªŸ ¢«“¡Õ◊ ‡¡Ë◊ÕÀ¬ÿ¥ blood pump ∑”„Àâμ—«Àπ’∫ “¬√—¥ “¬øÕ°‡≈◊Õ¥‰«â μâÕߧ≈“¬μ—«Àπ’∫ÕÕ°®“° “¬ øÕ°‡≈Õ◊ ¥ √Ÿª∑’Ë 8 · ¥ßÀπâ“®Õ¢Õ߇§√Ë◊Õ߉μ‡∑’¬¡ 3 √ÿàπ ·μ°μà“ß°—π∑μË’ —«Õ“à π§à“·√ß¥π— ‡≈◊Õ¥ √Ÿª∫π´â“¬ Àπ“â ®Õ· ¥ßμ«— Õ“à π ∑’ˇªìπ™àÕß ≠— ≠“≥ ´ßË÷ μÕâ ßÕ“à πμ«— ‡≈¢„À∂â °Ÿ μÕâ ߇Õß √ªŸ ∫π¢«“ Àπâ“®Õ· ¥ßμ—«Õ“à π∑Ë’‡ªπì ™Õà ß ≠— ≠“≥ ·≈–μ«— ‡≈¢∑Õ’Ë “à π‰¥âÕÕ°ª√“°Ø∑“ßÀπâ“®Õ √Ÿª≈à“ß Àπâ“®Õ· ¥ß‡©æ“–§“à μ«— ‡≈¢∑Õ’Ë “à π‰¥â (√ÿπà π’ÈÕ“à π‰¥‡â ©æ“–¥â“π vein) 472

Work Instruction: Physical Examination, Pressure and Flow Monitoring of Vascular Access 5. «—¥§«“¡ Ÿß√–À«à“߇¢Á¡øÕ°‡≈◊Õ¥¥â“π vein °—∫ à«π∫π¢Õß√–¥—∫‡≈◊Õ¥„π°√–‡ª“–¥—° Õ“°“»¥â“π vein „Àâ«—¥‡ªìπ‡´π쑇¡μ√ ·≈⫧Ÿ≥¥â«¬ 0.76 ®–‰¥â·√ߥ—π P-Offset ´÷Ëß¡’Àπ૬‡ªìπ ¡‘≈≈‘‡¡μ√ª√Õ∑ 6. „ÀâÀπ’∫ “¬√–À«à“ßμ—«°√–‡ª“–¥—°Õ“°“»°—∫‡§√◊ËÕßøÕ°‡≈◊Õ¥ ·≈–ª≈¥ “¬ÕÕ°®“° ‡§√◊ËÕßøÕ°‡≈◊Õ¥ Õà“π§à“·√ߥ—π¥â“π vein ®“°Àπâ“®Õ¢Õ߇§√◊ËÕ߉μ‡∑’¬¡ §«√‡∑à“°—∫»Ÿπ¬å ∂Ⓣ¡à‡∑à“°—∫ »Ÿπ¬å „Àâ∫—π∑÷°μ—«‡≈¢‰«âÕ“®®–‡ªìπ∫«°À√◊Õ≈∫°Á‰¥â ®–‰¥â§à“·√ߥ—π P-0 7. π”¡“À“§à“ S-IAP ¥â“π Vein (S-IAP/V) ¥—ßπ’È S-IAP/V = Venous drip chamber P + P-Offset - P-0 8. ∂“â ®–«¥— S-IAP ¥“â π artery ®–μÕâ ß∑”°“√ ≈∫—  “¬øÕ°‡≈Õ◊ ¥ ·≈–„À‡â §√Õ◊Ë ßøÕ°‡≈Õ◊ ¥∑”ß“π  —°æ—° °àÕπ∑’Ë®–∑”°“√«—¥μ“¡¢—ÈπμÕπ∑’Ë 1-7 ®–‰¥â§à“ S-IAP ¢Õߥâ“π artery 9. «—¥§«“¡¥—π‡≈◊Õ¥®“°·¢π¥â“πμ√ߢⓡ ∫—π∑÷°§à“ systolic blood pressure (SBP) ·≈– diastolic blood pressure (DBP) ·≈–§”π«≥§à“ mean arterial pressure (MAP) MAP = DBP + (SBP - DBP) / 3 10. §”π«≥À“§à“ normalized S-IAP ¥â“π artery ·≈– vein ¥—ßπ’È Normalized S-IAP/A = S-IAP/A / MAP Normalized S-IAP/V = S-IAP/V / MAP 11.  ”À√—∫‡ âπøÕ°‡≈◊Õ¥ AVG §à“ normalized S-IAP ¥â“π‡¢Á¡ artery ‰¡à§«√¡“°°«à“ 0.75 ·≈–¥â“π‡¢Á¡ vein ‰¡à§«√‡°‘π 0.50 μ—«Õ¬à“ß «—¥§à“·√ߥ—π‡≈◊Õ¥®“°Àπâ“®Õ‡§√◊ËÕ߉μ‡∑’¬¡¥â“π vein ‰¥â 5 ¡‘≈≈‘‡¡μ√ª√Õ∑ ·≈–‡¡◊ËÕ∑”°“√  ≈—∫ “¬øÕ°‡≈◊Õ¥«—¥·√ߥ—π®“°Àπâ“®Õ‡§√◊ËÕ߉μ‡∑’¬¡¥â“π vein ‰¥â 25 ¡‘≈≈‘‡¡μ√ª√Õ∑ «—¥§«“¡ Ÿß √–À«à“߇¢Á¡øÕ°‡≈◊Õ¥¥â“π vein ·≈–°√–‡ª“–¥—°Õ“°“»‰¥â 50 ‡´π쑇¡μ√ ·≈–¢≥–ª≈¥ “¬®“°°√– ‡ª“–¥—°Õ“°“»ÕÕ°®“°‡§√◊ËÕßøÕ°‡≈◊Õ¥ «—¥·√ߥ—π®“°Àπâ“®Õ‡§√◊ËÕ߉μ‡∑’¬¡¥â“π vein ‰¥â 3 ¡‘≈≈‘‡¡μ√ª√Õ∑ «—¥·√ߥ—π‡≈◊Õ¥¢Õß·¢πÕ’°¢â“߉¥â 140/80 ¡‘≈≈‘‡¡μ√ª√Õ∑ Venous drip chamber P ¥â“π vein = 5 ¡‘≈≈‘‡¡μ√ª√Õ∑ Venous drip chamber P ¥â“π artery = 25 ¡‘≈≈‘‡¡μ√ª√Õ∑ (‡π◊ËÕß®“°°“√ ≈—∫ “¬) P-Offset = 50 × 0.76 = 38 ¡‘≈≈‘‡¡μ√ª√Õ∑ P-0 = +3 ¡‘≈≈‘‡¡μ√ª√Õ∑ S-IAP/V = 5 + 38 - 3 = 40 ¡‘≈≈‘‡¡μ√ª√Õ∑ S-IAP/A = 25 + 38 - 3 = 60 ¡‘≈≈‘‡¡μ√ª√Õ∑ MAP = 80 + (140 - 80) / 3 = 80 + 20 = 100 ¡‘≈≈‘‡¡μ√ª√Õ∑ Normalized S-IAP/V = 40 / 100 = 0.40 Normalized S-IVP/A = 60 / 100 = 0.60 473

Practical Dialysis in the Year 2009 3.2.3 °“√·ª≈º≈°“√«¥— §“à S-IAP/A ·≈– S-IAP/V 1. ‡À¡“– ”À√∫— ‡ πâ øÕ°‡≈Õ◊ ¥™π¥‘ AVG À√Õ◊ ∂“â ‡ªπì AVF §«√®–‡ªπì ™π¥‘ upper arm brachio- cephalic AVF ∑’ˉ¡à¡’ collateral vein À√◊Õ transposed brachio-basilic AVF ´÷Ë߉¥â∑”°“√μ—¥‡ âπ‡≈◊Õ¥ collateral À¡¥·≈â« ∂Ⓡªìπ AVF ∑—Ë«Ê ‰ª ®–¡’ collateral vein ¡“°∑”„Àâ·√ߥ—π∑’Ë«—¥‰¥â‰¡à “¡“√∂∑”𓬧«“¡ √ÿπ·√ߢÕß√Õ¬μ’∫μ—π‰¥â 2. §à“ S-IAP ®–∫Õ°∂÷ߧ«“¡√ÿπ·√ߢÕß√Õ¬μ’∫μ—π ·≈–μ”·ÀπàߢÕß√Õ¬μ’∫μ—π ·μàμâÕß«—¥ ∑—Èß Õß§à“ §◊Õ§à“ S-IAP/A ·≈– S-IAP/V 3. ∂â“¡’°“√μ’∫∑’Ë∑“߇¢â“¢Õ߇≈◊Õ¥ (Inflow) À√◊Õ√Õ¬μàÕ‡ âπ‡≈◊Õ¥·¥ß°—∫ AVG Õ¬à“ß√ÿπ·√ß ®–æ∫«à“§à“ ë Normalized S-IAP/A < 0.30 ·≈–§à“ Normalized S-IAP/V < 0.15 4. ∂â“¡’°“√μ’∫√–À«à“߇¢Á¡øÕ°‡≈◊Õ¥ artery ·≈– vein (Intra-graft stenosis) Õ¬à“ß√ÿπ·√ß®– æ∫«à“§à“ ë Normalized S-IAP/A > 0.75 ·≈–§à“ Normalized S-IAP/V < 0.15 5. ∂â“¡’°“√μ’∫∑’Ë∑“ßÕÕ°¢Õ߇≈◊Õ¥ (outflow) À√◊Õ√Õ¬μàÕ‡ âπ‡≈◊Õ¥¥”°—∫ AVG Õ¬à“ß√ÿπ·√ß ®–æ∫«à“ ë Normalized S-IAP/A > 0.75 ·≈–§à“ Normalized S-IAP/V > 0.50 6. ‡π◊ËÕß®“°°“√«—¥·√ߥ—π∑’Ë¡’§à“μË”Ê ¡—°¡’§«“¡·¡àπ¬”πâÕ¬ √à«¡°—∫μ—«‡§√◊ËÕß«—¥·√ߥ—π‡Õß Õ“®®–‰¡à “¡“√∂«—¥‰¥â¥’ ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫°“√«—¥„π°√≥’∑’Ë¡’§à“·√ߥ—π∑’ˠߟ °«à“ ®÷߉¡à‡ªìπ∑’Ëπ‘¬¡∑’Ë®– «—¥‡æ◊ËÕ«‘π‘®©—¬¿“«–∑’Ë¡’°“√μ’∫¢Õß Inflow ¥—ßπ—Èπ ë „À„â ™§â “à S-IAP/A ∑ Ë’ ߟ ¡“°°«“à 0.75 ‡ªπì μ«— ™«È’ “à ¡°’ “√μ∫’ Õ¬“à ß√πÿ ·√ߢÕß Intragraft À√Õ◊ Outflow ∑’Ë Ÿß°«à“‡¢Á¡ artery ë „Àâ„™â§à“ S-IAP/V ∑’Ë Ÿß¡“°°«à“ 0.50 ‡ªìπμ—«∫àß™’È«à“¡’°“√μ’∫Õ¬à“ß√ÿπ·√ß∑’Ëμ”·Àπàß Outflow  Ÿß°«à“‡¢Á¡ vein 7. ·≈–∂“â ¡°’ “√«¥— Õ¬“à ßμÕà ‡πÕË◊ ß·≈–æ∫«“à §“à S-IAP/A À√Õ◊ S-IAP/V ‡æ¡Ë‘ ¢πÈ÷ ¡“°°«“à ‡¥¡‘ 0.25 Àπ૬ ∫àß«à“¡’°“√μ’∫μ—πÕ¬à“ß√ÿπ·√ß∑’Ë∫√‘‡«≥‡Àπ◊ÕμàÕ‡¢Á¡ artery À√◊Õ‡¢Á¡ vein 8. ¢âÕ‡ ’¬¢Õß«‘∏’π’ȧ◊Õ∂â“¡’°“√μ’∫μ—πÀ≈“¬μ”·Àπàß®–∑”„Àâ°“√·ª≈º≈§≈“¥‡§≈◊ËÕ𠇙àπ ë ¡’√Õ¬μ’∫∑’Ë Inflow ·≈– Outflow „𧫓¡√ÿπ·√߇∑à“Ê °—π °Á®–∑”„Àâ·√ߥ—π‡≈◊Õ¥∑’Ë«—¥ ‰¥â∑—Èß S-IAP/A ·≈– S-IAP/V ‰¡à‡ª≈’ˬπ·ª≈ß ë ¡’√Õ¬μ’∫μ—π°àÕπ·≈–À≈—߇¢Á¡¥â“π artery °Á®–∑”„Àâ·√ߥ—π S-IAP/A ‰¡à‡ª≈’ˬπ·ª≈ß ë ¡’√Õ¬μ’∫μ—π°àÕπ·≈–À≈—߇¢Á¡¥â“π vein °Á®–∑”„Àâ·√ߥ—π S-IAP/V ‰¡à‡ª≈’ˬπ·ª≈ß 9. Õ¬à“߉√°Áμ“¡μ”·Àπàß∑’Ëμ’∫¢Õ߇ âπøÕ°‡≈◊Õ¥ AVG ¡—°¡’§«“¡√ÿπ·√ß¡“°∑’Ëμ”·Àπà߇¥’¬« ·≈–¡—°®–Õ¬àŸ∑’Ë outflow ¥—ßπ—Èπ°“√«—¥§à“ S-IAP/A À√◊Õ S-IAP/V Õ¬à“ß„¥Õ¬à“ßÀπ÷Ëß°Á‡æ’¬ßæÕ 10. ·μຟâªÉ«¬∑’Ë„™â AVG ¡“‡ªìπ√–¬–‡«≈“π“π À√◊Õ·∑ß´È”∑’ˇ¥‘¡∫àÕ¬ À√◊Õ·∑ßæ≈“¥∫àÕ¬ ®–æ∫«à“¡’°“√μ’∫¿“¬„πμ—« AVG √à«¡¥â«¬ Õ“®®–Õ¬àŸ„°≈⇢Á¡ artery À√◊Õ‡¢Á¡ vein √à«¡°—∫°“√μ’∫∑’Ë∑“ß ÕÕ° ∑”„ÀâμâÕß·ª≈º≈°“√μ√«® S-IAP/A ·≈– S-IAP/V √à«¡°—πÕ¬à“ß√Õ∫§Õ∫ 474

Work Instruction: Physical Examination, Pressure and Flow Monitoring of Vascular Access 11. ∂â“μ”·Àπàß∑’Ë·∑߇¢Á¡ vein ‡≈◊Õ°·∑ß∑’ˇ âπ‡≈◊Õ¥ª°μ‘‡Àπ◊ÕμàÕ AVG ®–π”§à“ S-IAP/V ¡“·ª≈º≈μ“¡∑’Ë· ¥ß¢â“ßμâπ‰¡à‰¥â 12. ·π–π”„Àâ«—¥§à“ S-IAP ∑ÿ° 1-2  —ª¥“Àå ·≈–°àÕπ∑’Ë®–μ—¥ ‘π„®«à“¡’§«“¡º‘¥ª°μ‘‡°‘¥¢÷Èπ ®√‘ß §«√μ√«®æ∫§«“¡º‘¥ª°μ‘Õ¬à“ßπâÕ¬ 2-3 §√—Èßμ‘¥μàÕ°—π ·¡â«à“°“√·ª≈º≈®–„™â§à“ normalized S-IAP ‡æ◊ËÕÀ≈’°‡≈’ˬߧ«“¡·ª√ª√«π¢Õß§à“§«“¡¥—π‡≈◊Õ¥∑’Ë¡’º≈‚¥¬μ√ßμàÕ§à“ S-IAP ·μ৫“¡¥—π‚≈À‘μ∑’Ë ‡ª≈’ˬπ·ª≈߉ªÕ¬à“ß¡“°Ê ∑—Èߧà“∑’ˠߟ ·≈–μË” °Á∑”„Àâ§à“ Normalized S-IAP ¡’°“√‡ª≈’ˬπ·ª≈߉¥â 3.2.4 ¢—πÈ μÕπ°“√«—¥·≈–°“√·ª√º≈ Dynamic Arterial Pressure (D-AP À√◊Õ Pre- pump arterial pressure) ·≈– Dynamic Venous Pressure (D-VP) ¢≥–øÕ°‡≈Õ◊ ¥ 3.2.4.1 D-AP 1. Dynamic Arterial Pressure (D-AP) À√◊Õ negative arterial pressure §◊Õ°“√Õà“π§à“·√ߥ—π ‡≈◊Õ¥∑’ËÀπâ“®Õ¢Õ߇§√◊ËÕßøÕ°‡≈◊Õ¥¥â“π artery ‚¥¬°“√μàÕ “¬øÕ°‡≈◊Õ¥∑’ËÕ¬Ÿà°àÕπ blood pump ‡¢â“°—∫ ®ÿ¥«—¥·√ߥ—π¥â“π artery ¢Õ߇§√◊ËÕßøÕ°‡≈◊Õ¥ ´÷Ëß à«π„À≠à®–‰¡à‰¥â∑”°“√μàÕ “¬‡æ◊ËÕ«—¥·√ߥ—π ‡π◊ËÕß®“°‰¡à¡’°√–‡ª“–¥—°Õ“°“» ¥—ßπ—Èπ∂â“∑”°“√«—¥„Àâ√–«—ß°“√‡°‘¥¡’øÕßÕ“°“»·≈–∂Ÿ°¥Ÿ¥‡¢â“ Ÿà«ß®√ ¢Õß “¬øÕ°‡≈◊Õ¥ ‡§√◊ËÕß∫“ß√ÿàπ‰¡à¡’μ—«Õà“π·√ߥ—π‡≈◊Õ¥¥â“π artery ∑”„À≡ࠓ¡“√∂Õà“π§à“ D-AP ‰¥â 2. §à“ D-AP À√◊Õ Pre-pump arterial pressure ∑’Ë«—¥‰¥â®–‡ªìπ§à“μ‘¥≈∫ ‡π◊ËÕß®“°μ”·ÀπàßÕ¬Ÿà °àÕπ blood pump ¥—ßπ—Èπ®–¡’§à“μ‘¥≈∫¡“°¢÷Èπ∂Ⓡªî¥ blood pump ¡“°¢÷Èπ ·≈–®–μ‘¥≈∫¡“°¢÷ÈπÕ’°‡¡◊ËÕ ¢π“¥¢Õ߇¢Á¡øÕ°‡≈◊Õ¥‡≈Á° μ”·Àπàß∑’Ë·∑ßÕ¬àŸ„°≈âºπ—ßÀ≈Õ¥‡≈◊Õ¥ ·≈–∑’Ë ”§—≠§◊Õ access blood flow (ABF) §◊Õ®–¡’§à“μ‘¥≈∫¡“°‡¡◊ËÕ§à“ ABF ¡’§à“„°≈âÀ√◊ÕπâÕ¬°«à“§«“¡‡√Á«¢Õß blood pump ‚¥¬∑—Ë«‰ª§à“ D- AP ®÷߉¡à‡°’ˬ«¢âÕß°—∫§à“ S-IAP/A ∑’ˉ¥â°≈à“«„π¢â“ßμâπ 3. ∂Ⓡªî¥ Blood pump ¥â«¬§«“¡‡√Á«ª°μ‘ ·≈–§à“ D-AP μ‘¥≈∫¡“°°«à“ 250 μ‘¥μàÕ°—π À≈“¬§√ß—È ‚¥¬‰¥·â °‰â ¢‡√Õ◊Ë ßμ”·Àπßà ª≈“¬‡¢¡Á ∑™’Ë ¥‘ ºπß— ·≈«â ∫ßà «“à §“à ABF π“à ®–μË”°«“à §«“¡‡√«Á ¢Õß blood pump ∑’Ë¡’Õ¬àŸ ‚¥¬∑—Ë«‰ªμâÕß≈¥§«“¡‡√Á«¢Õß blood pump ‡æ◊ËÕ„Àâ§à“ D-AP μ‘¥≈∫πâÕ¬≈ß ¥—ßπ—Èπ°“√„™â§à“ D-AP ‡ªìπμ—««—¥°“√∑”ß“π¢Õ߇ âπøÕ°‡≈◊Õ¥ ®–æ∫§«“¡º‘¥ª°μ‘‡¡◊ËÕ‡ âπøÕ°‡≈◊Õ¥¡’°“√μ’∫μ—πÕ¬à“ß ¡“°·≈â« ‡™àπ‡¥’¬«°—∫°“√«—¥§à“ recirculation 4. °“√«—¥ D-AP ®÷߇À¡“– ”À√—∫‡ âπøÕ°‡≈◊Õ¥ AVF ´÷Ëß®–‰¡àÕÿ¥μ—πßà“¬Ê ·¡â«à“®–¡’ ABF „°≈âÀ√◊ÕπâÕ¬°«à“§«“¡‡√Á«¢Õß blood pump ∑’Ë°”À𥉫â 3.2.4.2 D-VP 1. Dynamic Venous Pressure (D-VP) §◊Õ°“√Õà“π§à“·√ߥ—π‡≈◊Õ¥∑’ËÀπâ“®Õ¢Õ߇§√◊ËÕßøÕ° ‡≈◊Õ¥¥â“π vein ‚¥¬°“√μàÕ “¬øÕ°‡≈◊Õ¥∑’Ë°√–‡ª“–¥—°Õ“°“»¥â“π vein °—∫®ÿ¥«—¥·√ߥ—π¥â“π vein ¢Õß ‡§√◊ËÕßøÕ°‡≈◊Õ¥ ´÷Ëß∑”°“√μàÕ‡ªìπª°μ‘Õ¬àŸ·≈â« 2. §à“ D-VP ∑’Ë«—¥‰¥â¡’§«“¡·ª√ª√«π¡“° ‡π◊ËÕß®“°ªí®®—¬À≈“¬Õ¬à“ß ‡™àπ ¢π“¥¢Õ߇¢Á¡ ·∑߇ âπ‡≈◊Õ¥ √«¡∑—Èßμ”·ÀπàߢÕ߇¢Á¡·∑߇ âπ‡≈◊Õ¥«à“Õ¬Ÿà™‘¥μ‘¥ºπ—ß¡“°πâÕ¬‡æ’¬ß„¥ ¢π“¥·≈–§«“¡ ¬“«¢Õß “¬øÕ°‡≈◊Õ¥ ™π‘¥¢Õ߇§√◊ËÕßøÕ°‡≈◊Õ¥ §«“¡‡√Á«¢Õß blood pump §«“¡Àπ◊¥¢Õ߇≈◊Õ¥‚¥¬ 475

Practical Dialysis in the Year 2009 ‡©æ“–§«“¡‡¢â¡¢âπ¢Õ߇≈◊Õ¥ ·≈–·πàπÕπ¢÷Èπ°—∫§à“ S-IAP/V ¥â«¬ 3. °“√∑’Ë®–π”§à“ D-VP ¡“·ª≈º≈‡À¡◊Õπ S-IAP/V ®–μâÕß¡’‡ß◊ËÕπ‰¢À≈“¬Õ¬à“ß „Àâ«—¥„π ™à«ß‡«≈“ 5 π“∑’·√°‡¡◊ËÕ‡√‘Ë¡∑”°“√øÕ°‡≈◊Õ¥ ‡≈◊Õ°°“√À¡ÿπ¢Õß blood pump ∑’Ë 200 ¡≈./π“∑’ ·≈–„™â ¢π“¥¢Õ߇¢Á¡∑’˧ß∑’Ë ∂â“§à“ D-VP ¡’§à“ Ÿßμ‘¥μàÕ°—π¡“°°«à“ 3 §√—Èß ∫àß«à“πà“®–¡’°“√μ’∫μ—π¢Õ߇ âπøÕ° ‡≈◊Õ¥∑’Ëμ”·Àπàß outflow  ßŸ ®“°‡¢Á¡øÕ°‡≈◊Õ¥¥â“π vein ë  ”À√—∫‡¢Á¡‡∫Õ√å 14 §à“ threshold pressure  ”À√—∫ AVG Õ¬Ÿà∑’Ë 90 ¡‘≈≈‘‡¡μ√ª√Õ∑ ë  ”À√—∫‡¢Á¡‡∫Õ√å 15 §à“ threshold pressure  ”À√—∫ AVG Õ¬àŸ∑’Ë 120 ¡‘≈≈‘‡¡μ√ª√Õ∑ ë  ”À√—∫‡¢Á¡‡∫Õ√å 16 §à“ threshold pressure  ”À√—∫ AVG Õ¬Ÿà∑’Ë 150 ¡‘≈≈‘‡¡μ√ª√Õ∑ ë. °“√«—¥ D-VP ‡™àπ‡¥’¬«°—∫°“√«—¥ S-IAP/V ‡À¡“–°—∫°“√μ‘¥μ“¡°“√∑”ß“π¢Õ߇ âπøÕ° ‡≈◊Õ¥™π‘¥ AVG ‡π◊ËÕß®“°¡—°¡’°“√μ’∫μ—π∑’Ë outflow  ”À√—∫‡ âπøÕ°‡≈◊Õ¥ AVF ‰¡à¡’§à“ threshold ∑’Ë√–∫ÿ ‰«â‡ªìπ¡“μ√∞“π ·≈–‰¡àπ‘¬¡„™âμ‘¥μ“¡°“√∑”ß“π ‡π◊ËÕß®“°¡’‡ âπ‡≈◊Õ¥ collateral ¡“° ¥—ßπ—Èπ·¡â®–¡’ ‡ âπøÕ°‡≈◊Õ¥μ’∫μ—π¡“°°ÁÕ“®®–¡’·√ߥ—π‡≈◊Õ¥∑’Ë«—¥‰¥â®“°§à“ D-VP ‰¡àº‘¥ª°μ‘¡“° 5. ·π–π”„Àâ«—¥ D-AP ·≈– D-VP ∑ÿ°§√—Èß∑’Ë∑”°“√øÕ°‡≈◊Õ¥ 3.3 °“√«¥— ª√¡‘ “≥°“√‰À≈¢Õ߇≈Õ◊ ¥º“à π‡ πâ øÕ°‡≈Õ◊ ¥ ·≈–°“√«¥— °“√‰À≈¬Õâ π¢Õ߇≈Õ◊ ¥ (Flow monitoring) °“√«—¥ª√‘¡“≥°“√‰À≈¢Õ߇≈◊Õ¥ºà“π‡ âπøÕ°‡≈◊Õ¥ (access blood flow À√◊Õ ABF À√◊Õ Flow) ‡ªìπ ‘Ëß∑’Ë¥’∑’Ë ÿ¥„π°“√ª√–‡¡‘π°“√∑”ß“π¢Õ߇ âπøÕ°‡≈◊Õ¥ ∂â“¡’·√ßμâ“π∑“π¿“¬„π‡ âπøÕ°‡≈◊Õ¥ flow ®–≈¥πâÕ¬≈ß °“√«—¥°“√‰À≈¬âÕπ°≈—∫¢Õ߇≈◊Õ¥¿“¬„π‡ âπøÕ°‡≈◊Õ¥ (access recirculation À√◊Õ R) ‚¥¬ª°μ‘∂Ⓣ¡à‰¥â ≈—∫ “¬‰¡à§«√¡’§à“ recirculation ·μà∂â“¡’· ¥ß«à“§«“¡‡√Á«¢Õß blood pump ¡“°°«à“ flow ¢Õ߇ âπøÕ°‡≈◊Õ¥ ¥—ßπ—Èπ°“√μ√«®§à“ recirculation ®÷߇ªìπ°“√μ√«® flow ∑“ßÕâÕ¡ ·≈–¡—°®–‡ªìπ  ‘Ëßμ√«®æ∫„π√–¬–∑â“¬Ê  ”À√—∫‡ âπøÕ°‡≈◊Õ¥™π‘¥ AVG ‡¡◊ËÕ flow ≈¥≈ßπâÕ¬°«à“ 600 ¡≈./π“∑’ ¡—°®–¡’‚Õ°“ „π °“√Õÿ¥μ—π Ÿß ·≈–¡—°®–æ∫°àÕπ∑’˪√‘¡“≥¢Õß flow ®–≈¥πâÕ¬°«à“§«“¡‡√Á«¢Õß blood pump ¥—ßπ—Èπ®÷ß ‰¡à¡’ª√–‚¬™πå„π°“√„™â§à“ recirculation „π°“√ª√–‡¡‘π‡ âπøÕ°‡≈◊Õ¥™π‘¥ AVG ·μà‡ âπøÕ°‡≈◊Õ¥™π‘¥ AVF ®–¡’§«“¡·μ°μà“ß°—π‡π◊ËÕß®“°‡ªìπ‡ âπ‡≈◊Õ¥∏√√¡™“μ‘ ®÷ß¡’ °≈‰°¿“¬„πμ—«‡ âπ‡≈◊Õ¥∑’Ë®–ªÑÕß°—π°“√Õÿ¥μ—π ¥—ßπ—Èπ®÷ßæ∫‰¥â∫àÕ¬«à“„π¢≥–∑’Ë§à“ flow ≈¥πâÕ¬≈ß°«à“ §«“¡‡√Á«¢Õß blood pump ®π∑”„À⇰‘¥ recirculation ¢÷Èπ À√◊Õ∫àÕ¬§√—ÈßμâÕß≈¥§«“¡‡√Á«¢Õß blood pump ≈߇π◊ËÕß®“° ¡’·√ߥ—πμ‘¥≈∫ ßŸ ∑’ˇ âπøÕ°‡≈◊Õ¥¥â“π artery ´÷Ë߇ªìπμ—«∫Õ°∑“ßÕâÕ¡‡™àπ°—π«à“ flow ∑’˺à“π ‡ âπøÕ°‡≈◊Õ¥μË”¡“° ·μà‡ âπøÕ°‡≈◊Õ¥°Á‰¡à‡°‘¥°“√Õÿ¥μ—π §à“ flow ∑’Ë„™âμ—¥ ‘π„®«à“πà“®–μâÕß√’∫ àß «‘π‘®©—¬·≈–·°â‰¢§◊Õ§à“∑’ˇ∑à“°—∫À√◊ÕπâÕ¬°«à“§«“¡‡√Á«¢Õß blood pump ∑’˧«√®–À¡ÿπ‰¥â ”À√—∫ºâŸªÉ«¬ ·μà≈–√“¬ „π°√≥’∂â“«—¥ flow ‰¡à‰¥â °“√«—¥§à“ recirculation °Á¡’ª√–‚¬™π套߉¥â°≈à“«„π¢â“ßμâπ ·μàºâŸªÉ«¬ „π√–¬–π’È®–‡ ’ˬßμàÕ°“√øÕ°‡≈◊Õ¥∑’ˉ¡à‡æ’¬ßæÕ ·≈–∫àÕ¬§√—Èß∑’Ë≈–‡≈¬„Àℙ⇠âπøÕ°‡≈◊Õ¥μàÕ‰ª∑—ÈßÊ ∑’Ë¡’ recirculation ‡°‘¥¢÷Èπ ‚¥¬‰¡à‰¥â àß«‘π‘®©—¬·≈–·°â‰¢√Õ¬μ’∫  ÿ¥∑⓬®–‡°‘¥°“√Õÿ¥μâπ·≈– Ÿ≠‡ ’¬‡ âπøÕ° ‡≈◊Õ¥ 476

Work Instruction: Physical Examination, Pressure and Flow Monitoring of Vascular Access °“√«—¥ flow ¡’À≈“¬«‘∏’ ∑—Èß°“√«—¥„π¢≥–∑’ˉ¡à‰¥â≈߇¢Á¡øÕ°‡≈◊Õ¥ °“√«—¥À≈—ß®“°≈߇¢Á¡ øÕ°‡≈◊Õ¥ ·μà°àÕπ°“√‡ªî¥„™â‡§√◊ËÕßøÕ°‡≈◊Õ¥ ·≈–°“√«—¥„π¢≥–∑”°“√øÕ°‡≈◊Õ¥ «‘∏’°“√«—¥∑’Ë∂◊Õ‡ªìπ ¡“μ√∞“π„πªí®®ÿ∫—π§◊Õ °“√«—¥¥â«¬‡§√◊ËÕß Transonic ´÷Ëß„™âμ—« ultrasound ‡ªìπμ—«®—∫§«“¡‡ª≈’ˬπ·ª≈ß ¢Õ߇≈◊Õ¥ ·≈–„™â saline dilution ∑”„À⇰‘¥°“√‡ª≈’ˬπ·ª≈ߢ÷Èπ  ”À√—∫°“√«—¥§à“ recirculation μâÕß«—¥ „π¢≥–øÕ°‡≈◊Õ¥·≈–À¡ÿ𧫓¡‡√Á«¢Õß blood pump μ“¡ª°μ‘ ´÷Ë߇§√◊ËÕß Transonic °Á„™â‡ªìπ¡“μ√∞“𠇙πà ‡¥¬’ «°π— „π∑π’Ë ®’È –·π–π”°“√«¥— recirculation ·≈– flow ¥«â ¬«∏‘ ’ urea-based ·≈–«∏‘ ∑’ „’Ë ™‡â §√Õ◊Ë ß Transonic 3.3.1 ¢—πÈ μÕπ°“√«—¥ Access recirculation (R) ¥â«¬«‘∏’ Urea-based √–À«à“ß°“√ øÕ°‡≈Õ◊ ¥ 1. §«√∑”°“√«—¥ çRé ¿“¬„π‡«≈“ 30 π“∑’·√°À≈—ß®“°‡√‘Ë¡∑”°“√øÕ°‡≈◊Õ¥ ª≈“¬‡¢Á¡øÕ° ‡≈◊Õ¥§«√Àà“ß°—π¡“°°«à“ 5 ´¡. À√◊Õ 3 π‘È«¡◊Õ ‡¢Á¡ artery §«√À—π√—∫ flow ·≈–‡¢Á¡ vein §«√À—πμ“¡ flow ‡¢Á¡∑—Èß Õߧ«√Õ¬Ÿà„π∫√‘‡«≥μ”·Àπà߇¥‘¡∑’Ë·∑ߪ√–®” 2. μÕâ ß«—¥„π¢≥–∑’ˇªî¥§«“¡‡√Á«¢Õß blood pump μ“¡ª°μ‘ ‡æ◊ËÕ«—¥«à“¡’ çRé À√◊Õ‰¡à‡¡◊ËÕ„™â §«“¡‡√Á«¢Õß blood pump π’È §«“¡‡√Á«¢Õß dialysate ª°μ‘ ·μÀà ¬¥ÿ °“√∑” ultrafiltration ™—Ë«§√“« 3. ¥¥Ÿ ‡≈◊Õ¥®“° “¬øÕ°‡≈◊Õ¥¥â“π artery ·≈– vein æ√âÕ¡Ê °—π ‡æ◊ËÕ àßμ√«®«—¥§à“ BUN-A ·≈– BUN-V μ“¡≈”¥—∫ 4. ∑—π∑’∑’Ë®∫„π¢—ÈπμÕπ∑’Ë 3 „Àâ≈¥§«“¡‡√Á«¢Õß blood pump ‡À≈◊Õ 120 ¡≈./π“∑’ π“π 10 «‘π“∑’ À√◊Õ 50 ¡≈./π“∑’ π“π 30 «‘π“∑’ 5. ‡¡◊ËÕ§√∫‡«≈“„Àâªî¥§«“¡‡√Á«¢Õß blood pump ∑—π∑’ ·≈–Àπ’∫ “¬øÕ°‡≈◊Õ¥¥â“π artery ‡Àπ◊Õ∫√‘‡«≥∑’Ë¥Ÿ¥‡≈◊Õ¥‰ª∑“ßμ—«°√Õ߇≈◊Õ¥ (slow and stop pump technique) À√◊Õ‰¡àªî¥§«“¡‡√Á«¢Õß blood pump ·μà„Àâ∑”¢—ÈπμÕπμàÕ‰ª‡≈¬ (slow flow technique) 6. ¥Ÿ¥‡≈◊Õ¥®“° “¬øÕ°‡≈◊Õ¥¥â“π artery ‡æ◊ËÕ àßμ√«®«—¥§à“ BUN-S 7. ‡¡◊ËÕ®∫¢—ÈπμÕπ„Àâ∑”°“√øÕ°‡≈◊Õ¥μ“¡ª°μ‘μàÕ‰ª 8. §”π«≥§à“ recirculation (R) ®“° μŸ √ R = (BUN-S - BUN-A) / (BUN-S - BUN-V) À√◊Õ ·ª≈߇ªìπ‡ªÕ√凴Áπμå¥â«¬°“√§≥Ÿ ¥â«¬ 100 (%R) μ—«Õ¬à“ß «—¥§à“ BUN-A ‰¥â 65 ¡‘≈≈‘°√—¡/‡¥´‘≈‘μ√ BUN-V ‰¥â 5 ¡‘≈≈‘°√—¡/‡¥´‘≈‘μ√ ·≈– BUN-S ‰¥â 85 ¡‘≈≈‘°√—¡/‡¥´‘≈‘μ√ R = (85 - 65) / (85 - 5) = (20) / (80) = 0.25 %R = 100 x 0.25 = 25% °“√·ª√º≈§“à Access Recirculation (R) 1. ∂â“§à“ %R ¡’§à“¡“°°«à“ 5-10% · ¥ß«à“‡°‘¥‡≈◊Õ¥‰À≈¬âÕπÀ√◊Õ‡°‘¥ access recirculation (R) ´÷Ëß∫Õ°∑“ßÕâÕ¡«à“ ª√‘¡“≥‡≈◊Õ¥∑’ˉÀ≈„π‡ âπøÕ°‡≈◊Õ¥πâÕ¬°«à“ ª√‘¡“≥‡≈◊Õ¥∑’Ë à߇¢â“μ—«°√Õ߇≈◊Õ¥ 477

Practical Dialysis in the Year 2009 (access blood flow < blood pump flow)  “‡Àμÿ∑’ˉ¡à„™â§à“¡“°°«à“§à“ ç0%é ‡π◊ËÕß®“°Õ“®¡’§«“¡º‘¥ æ≈“¥„π°“√μ√«®«—¥§à“ BUN ·≈–°“√μ√«®¥â«¬«‘∏’π’ȉ¡à “¡“√∂À≈’°‡≈’Ë¬ß cardiopulmonary recirculation (CPR) À√◊Õ arteriovenous disequilibrium 2.  ”À√—∫«‘∏’π’ȇ√’¬°«à“ two-needle urea-based method ®–„Àâ§à“¡“μ√∞“π‰«â∑’ˉ¡à‡°‘π 10%  à«π«‘∏’ Non-urea based method ¡’§«√‡°‘π 5% ‚¥¬‡©æ“–«‘∏’∑’Ë„™â‡§√◊ËÕß Transonic ‰¡à§«√‡°‘π 0% 3. °√≥’∂â“§à“ %R ¡“°°«à“ 20% „Àâ√–«—ß«à“¡’°“√ ≈—∫ “¬øÕ°‡≈◊Õ¥‚¥¬‰¡à‰¥âμ—Èß„® À√◊Õ‰¡à 3.3.2 ¢π—È μÕπ°“√«¥— Access Blood Flow (ABF) ¥â«¬«∏‘ ’ Urea-based √–À«à“ß°“√ øÕ°‡≈Õ◊ ¥ 1. §«√∑”°“√«—¥ çABFé „π™à«ß 90 π“∑’·√°¢Õß°“√øÕ°‡≈◊Õ¥ ¥â«¬°“√ ≈—∫ “¬øÕ°‡≈◊Õ¥ §◊Õ “¬øÕ°‡≈◊Õ¥¥â“π artery μàÕ°—∫‡¢Á¡ vein ·≈– “¬øÕ°‡≈◊Õ¥¥â“π vein μàÕ°—∫‡¢Á¡ artery ·≈–ª≈“¬ ‡¢Á¡∑—Èß ÕßμâÕßÕ¬àŸ„π‡ âπøÕ°‡≈◊Õ¥‡ âπÀ≈—°‡ âπ‡¥’¬«°—π (¥√Ÿ Ÿª∑’Ë 9) 2. „À⇪«“¡‡√Á«¢Õß blood pump ·§à 200 ¡≈./π“∑’ ‡ªî¥§«“¡‡√Á«¢Õß dialysate ª°μ‘ ·≈– À¬ÿ¥ ultrafiltration ™—Ë«§√“« °àÕπ∑”°“√«—¥§«√ ≈—∫ “¬Õ¬à“ßπâÕ¬ 5-10 π“∑’ 3.¥Ÿ¥‡≈◊Õ¥®“° “¬øÕ°‡≈◊Õ¥¥â“π artery (´÷Ëߢ≥–π’ÈμàÕ°—∫‡¢Á¡ vein) ·≈–¥â“π vein (´÷Ëߢ≥– π’ÈμàÕ°—∫‡¢Á¡ artery) æ√âÕ¡Ê °—π ‡æ◊ËÕ àßμ√«®«—¥§à“ BUN-A ·≈– BUN-V μ“¡≈”¥—∫ 4. ∑—π∑’∑’Ë®∫¢—ÈπμÕπ∑’Ë 3 „ÀâÀ¬ÿ¥§«“¡‡√Á«¢Õß blood pump ∑—π∑’ 5. ª≈¥ “¬øÕ°‡≈◊Õ¥¥â“π vein ÕÕ°®“°‡¢Á¡ artery (À≈—ß®“°‰¥âÀπ’∫ “¬∑—Èß Õß·≈â«) 6. §≈“¬μ—«Àπ’∫®“°‡¢Á¡ artery æ√âÕ¡°—∫¥Ÿ¥‡≈◊Õ¥®”π«πª√–¡“≥‡∑à“°—∫§«“¡®ÿ¢Õ߇¢Á¡ ·∑߇ âπ‡≈◊Õ¥ À√◊Õ ª√–¡“≥ 5 ¡≈. ∑‘Èß (À√◊ÕÕ“®®–§◊π‡≈◊Õ¥°≈—∫„π¿“¬À≈—ß‚¥¬‰¡àμâÕß∑‘È߇≈◊Õ¥) ®“° π—Èπ¥Ÿ¥‡≈◊Õ¥®“°‡¢Á¡ artery ‡æ◊ËÕ àßμ√«®«—¥§à“ BUN-S 7. ‡¡◊ËÕ‡ √Á®¢—ÈπμÕπ∑’Ë 6 „Àâ ≈—∫ “¬°≈—∫‡ªìπ«ß®√μ“¡ª°μ‘ ·≈–∑”°“√øÕ°‡≈◊Õ¥μàÕ‰ª 8. π”§à“ BUN-A, BUN-V ·≈– BUN-S ¡“§”π«≥À“§à“ access recirculation (R) ®“° Ÿμ√ R = (BUN-S - BUN-A) / (BUN-S - BUN-V) 9. π”§à“ R ·≈–§«“¡‡√Á«¢Õß blood pump ´÷Ëß„π∑’Ëπ’ȧ◊Õ 200 ¡≈./π“∑’ ¡“§”π«≥À“§à“ ABF ®“° μŸ √ ABF = 200 x (1 - R) / (R) μ—«Õ¬à“ß «—¥§à“ BUN-A ‰¥â 65 ¡‘≈≈‘°√—¡/‡¥´‘≈‘μ√ BUN-V ‰¥â 5 ¡‘≈≈‘°√—¡/‡¥´‘≈‘μ√ ·≈– BUN-S ‰¥â 85 ¡‘≈≈‘°√—¡/ ‡¥´‘≈‘μ√ R = (85 - 65) / (85 - 5) = (20) / (80) = 0.25 ABF = 200 x (1-0.25) / (0.25) = 200 x 3 = 600 ¡≈./π“∑’ 478

Work Instruction: Physical Examination, Pressure and Flow Monitoring of Vascular Access √Ÿª∑’Ë 9 √Ÿª∫π · ¥ß«ß®√ª°μ‘ √Ÿª≈à“ß · ¥ß«ß®√∑Ë’‰¥ â ≈∫—  “¬øÕ°‡≈Õ◊ ¥ ‡æÕË◊ ∑”„À‡â °¥‘ ‡≈Õ◊ ¥‰À≈¬Õâ πÀ√Õ◊ access recirculation (%R) ¿“¬„π «ß®√°“√øÕ°‡≈Õ◊ ¥ °“√·ª√º≈§“à Access Blood Flow (ABF) 1.  ”À√—∫‡ âπøÕ°‡≈◊Õ¥ AVG §à“∑’Ë∫àß«à“‡ âπøÕ°‡≈◊Õ¥¡’ªí≠À“·≈–μâÕß√’∫·°â‰¢ ë §à“ ABF §«√¡“°°«à“ 600 ¡≈./π“∑’ „π°“√·ª√º≈§√—ÈßμàÕ§√—Èß ë ∂â“μ‘¥μ“¡«—¥Õ¬à“ßμàÕ‡π◊ËÕß ·≈–æ∫«à“ ABF ¡’§à“πâÕ¬°«à“ 1000 ¡≈./π“∑’ ·≈–¡’§à“≈¥ ≈ß¡“°°«à“ 25% ¿“¬„π√–¬–‡«≈“ 4 ‡¥◊Õπ À√◊Õ∫“ß√“¬ß“π„Àâ¡’§à“≈¥≈ß¡“°°«à“ 20% ¿“¬„π 1 ‡¥◊Õπ 2.  ”À√—∫‡ âπøÕ°‡≈◊Õ¥ AVF §à“∑’Ë∫àß«à“‡ âπøÕ°‡≈◊Õ¥¡’ªí≠À“·≈–μâÕß√’∫·°â‰¢ ë §à“ ABF ¡’§à“πâÕ¬°«à“§à“§«“¡‡√Á«¢Õß blood pump ∑’˺ŸâªÉ«¬„™â‡ªìπª√–®”‡™àππâÕ¬°«à“ 300-400 ¡≈./π“∑’ 479

Practical Dialysis in the Year 2009 3.3.3 À≈—°°“√∑”ß“π¢Õ߇§√Ë◊Õß Transonic ‚¥¬ —߇¢ª  ”À√—∫‡§√◊ËÕß Transonic ®–„™â§«“¡‡√Á«¢Õß ultrasound ∑’Ë¡’‡≈◊Õ¥‰À≈ºà“π‡ªìπμ—««—¥ À≈—° °“√§◊Õ ‡§√◊ËÕß®–¡’ sensor Àπ’∫Õ¬àŸ∑’Ë “¬øÕ°‡≈◊Õ¥∑—Èߥâ“π artery ·≈–¥â“π vein ‚¥¬ sensor ·μà≈–μ—« ®–¡’μ—« àß —≠≠“≥ ultrasound ·≈–μ—«√—∫ —≠≠“≥ ultrasound ·¬°®“°°—π  “¡“√∂«—¥ delivered blood flow ∑’Ë·∑â®√‘߉¥â ®“°°“√‡ª≈’ˬπ·ª≈ߢÕß§à“ transit-time À√◊Õ√–¬–‡«≈“„π°“√‡¥‘π∑“ߢÕß ultrasound ®“°μ—« àß —≠≠“≥‰ª¬—ßμ—«√—∫ —≠≠“≥ §à“ transit-time „π™à«ß∑’Ëμ—« àß —≠≠“≥ ultrasound μ“¡°“√ ‰À≈¢Õ߇≈◊Õ¥®–‡√Á«°«à“§à“∑’ˉ¥â®“°°“√ àß —≠≠“≥ «π°“√‰À≈¢Õ߇≈◊Õ¥ §à“∑—Èß Õß®–∂Ÿ°π”¡“ §”π«≥§à“ delivered blood flow (¥Ÿ√ªŸ ∑’Ë 10)  ”À√—∫°“√«—¥§à“ recirculation μâÕßÀ¬¥ saline ‡¢â“ àŸ‡ âπøÕ°‡≈◊Õ¥¥â“π vein ‡¡◊ËÕ‡≈◊Õ¥∑’Ë¡’ saline ‰À≈ºà“πμ—« sensor ¥â“π vein μ—« sensor ®–μ√«®æ∫§«“¡‡√Á«¢Õß ultrasound ∑’˺à“π‡≈◊Õ¥≈¥≈ß ·≈–∂°Ÿ π”¡“ plot ‡ªìπ dilution curve ¢Õß sensor ¥â“π vein (S-ven „π√ªŸ ∑’Ë 11) ∂â“¡’ recirculation ‡°‘¥¢÷Èπ ‡≈◊Õ¥∑’Ë¡’ saline ®–‰À≈ºà“π‡¢â“‰ª¬—߇¢Á¡øÕ°‡≈◊Õ¥¥â“π artery ·≈–ºà“π sensor ¥â“π artery ´÷Ëß®–∑”„Àâ ‡°¥‘ dilution curve ¢Õß sensor ¥“â π artery (S-art „π√ªŸ ∑Ë’ 11) ‡™πà ‡¥¬’ «°π— ‡§√ÕË◊ ß®–§”π«≥§“à recirculation ®“°Õ—μ√“ à«π¢Õßæ◊Èπ∑’Ë dilution curve ∑—Èß Õß (¥√Ÿ ªŸ ∑’Ë 11) √Ÿª∑Ë’ 10 · ¥ß‡§√Õ◊Ë ß Transonic ·≈–«ß®√°“√μÕà ‡¢“â °∫—  “¬øÕ°‡≈◊Õ¥ √ªŸ ∫π · ¥ß°“√μàÕ sensor ‡¢â“°—∫ “¬øÕ°‡≈◊Õ¥¥“â π artery ·≈–¥“â π vein √ªŸ ≈à“ߥâ“π´“â ¬ ÿ¥ · ¥ßμ«— ‡§√Ë◊Õß Transonic √πÿà 02 ´Ëß÷ μàÕ°—∫§Õ¡æ‘«‡μÕ√å Notebook √ªŸ ≈à“ߥ“à π´â“¬°≈“ß · ¥ßμ«— ‡§√ÕË◊ ß Transonic √ÿàπ 03 √Ÿª≈à“ߥ“â π¢«“°≈“ß · ¥ßμ«— sensor  ”À√—∫®—∫°—∫ “¬øÕ°‡≈Õ◊ ¥ √ªŸ ≈“à ߥ“â π¢«“ ¥ÿ · ¥ßμ«— sensor ®–¡μ’ «—  àß·≈–√—∫ —≠≠“≥°“√‡ª≈¬Ë’ π·ª≈ߢÕß ultrasound ¢≥–‡≈Õ◊ ¥ ‰À≈º“à 𠓬øÕ°‡≈Õ◊ ¥ 480

Work Instruction: Physical Examination, Pressure and Flow Monitoring of Vascular Access  ”À√—∫°“√«—¥§à“ access blood flow (ABF) μâÕß∑”°“√ ≈—∫ “¬øÕ°‡≈◊Õ¥‡æ◊ËÕ„À⇰‘¥ recirculation ·≈–∑”°“√À¬¥ saline ‡¢“â  ‡Ÿà  πâ øÕ°‡≈Õ◊ ¥¥“â π vein ´ßË÷ ¢≥–πμÈ’ Õà °∫— ‡¢¡Á øÕ°‡≈Õ◊ ¥¥“â π artery ´ß÷Ë ®–‰À≈º“à π sensor ¥“â π vein ·≈–‰ªº“à π‡¢¡Á øÕ°‡≈Õ◊ ¥¥“â π vein ‡¢“â   Ÿà “¬øÕ°‡≈Õ◊ ¥¥“â π artery ·≈–º“à π sensor ¥â“π artery Õ’°§√—Èß ∑”„À⇧√◊ËÕߧ”π«≥§à“ recirculation ÕÕ°¡“‰¥â ·≈–𔉪À“§à“ access blood flow Õ’°§√—ÈßÀπ÷Ëß ‡§√◊ËÕß Transonic  “¡“√∂Õà“π§à“ delivery blood flow ¥—ߧà“∑’˪√“°Ø¥â“π¡ÿ¡¢«“≈à“ß ¢Õß√ªŸ ≈à“ߢÕß√ªŸ ∑’Ë 12 ‡§√◊ËÕß®–‰¡à· ¥ß§à“ recirculation ∑’˧”π«≥‰¥â ·μà®–· ¥ß§à“ access blood flow ¥—ߪ√“°Ø„π√Ÿª≈à“ߢÕß√ªŸ ∑’Ë 12 √ªŸ ∑Ë’ 11 · ¥ß°“√«—¥ %R ¥â«¬‡§√Õ◊Ë ß Transonic √Ÿª∑Ë’ 12 · ¥ß°“√«—¥ access blood flow ¥â«¬‡§√ËÕ◊ ß Transonic 481

Practical Dialysis in the Year 2009 3.3.3 ¢π—È μÕπ°“√«¥— ·≈–°“√·ª≈º≈§“à Recirculation (R) ·≈– Access Blood Flow (ABF) ¥â«¬‡§√◊ËÕß Transonic „π¢≥–øÕ°‡≈◊Õ¥ 1. §«√∑”°“√«—¥„π™à«ß 60-90 π“∑’·√°¢Õß°“√øÕ°‡≈◊Õ¥ ‚¥¬°“√‡ªî¥§«“¡‡√Á«¢Õß blood pump ª°μ‘ §«“¡‡√Á«¢Õß dialysate ª°μ‘ ·≈– ultrafiltration ª°μ‘ ·≈–„π°√≥’∂â“®–«—¥ ABF √à«¡¥â«¬ ª≈“¬‡¢Á¡∑—Èß ÕßμÕâ ßÕ¬àŸ„π‡ âπøÕ°‡≈◊Õ¥‡ âπÀ≈—°‡ âπ‡¥’¬«°—π 2. ∑”°“√‡ªî¥‡§√◊ËÕß Transonic ·≈–π” probe ¢Õ߇§√◊ËÕß Transonic ´÷Ëß¡’ sensor ¡“®—∫∑’Ë “¬ øÕ°‡≈◊Õ¥¥â“π arterial ·≈–¥â“π vein „ÀâÀà“ß®“°√Õ¬μàÕ¢Õ߇¢Á¡øÕ°‡≈◊Õ¥·≈– “¬øÕ°‡≈◊Õ¥ª√–¡“≥ ¡“°°«à“ 5-10 ‡´π쑇¡μ√ ‚¥¬„Àâ≈Ÿ°»√¢Õß sensor Õ¬Ÿà„π∑‘»∑“ß°“√‰À≈¢Õ߇≈◊Õ¥ ®“°π—Èπ„Àâ≈ß ∑–‡∫’¬π™◊Ëպ⟪ɫ¬„À¡à À√◊ÕÀ“√“¬™◊ËÕ∑–‡∫’¬πºŸâªÉ«¬∂Ⓡ§¬∑”¡“°àÕπ ·≈–‡≈◊Õ°∫√‘…—∑‡®â“¢Õß º≈‘μ¿—≥±å “¬øÕ°‡≈◊Õ¥∑’Ë¡’Õ¬Ÿà„π list À√◊Õ‡∑’¬∫‡∑à“ ‡π◊ËÕß®“°º≈‘μ¿—≥±å¢Õß “¬øÕ°‡≈◊Õ¥·μà≈– ∫√‘…—∑®–¡’º≈μàÕ°“√«—¥ 3. „Àâ set ‡§√◊ËÕ߇æ◊ËÕ∑”°“√«—¥ delivered blood pump flow ‡æ◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫ blood pump flow ´÷Ë߉¡à§«√μà“ß°—π¡“°°«à“ 10% ‚¥¬ª°μ‘¬‘ËßÀ¡ÿπ blood pump ‡√Á«¡“°‡∑à“‰√ §à“∑’Ë·∑â®√‘ß®–πâÕ¬ °«à“§à“∑’Ëμ—Èß§à“‰«â 4. „Àâ set ‡§√◊ËÕ߇æ◊ËÕ∑”°“√«—¥§à“ R ‡¡◊ËÕ‰¥â√—∫ —≠≠“≥°“√«—¥ „Àâª≈àÕ¬πÈ”‡°≈◊Õ∑’ËμàÕ°—∫  “¬øÕ°‡≈◊Õ¥¥â“π vein ‡¢â“ àŸ “¬øÕ°‡≈◊Õ¥ª√–¡“≥ 5-6 «‘π“∑’ À√◊Õ©’¥πÈ”‡°≈◊Õ 10 ¡≈. ‡¢â“‰ª∑’Ë°√– ‡ª“–¥°— Õ“°“»¥“â π vein ®“°ππ—È ‡§√Õ◊Ë ß®–§”π«≥§“à R ‡ªπì percent ∂“â §“à %R = 0  √ªÿ «“à ‰¡¡à ’ recirculation 5. §à“ %R ∑’Ë«—¥‰¥â®“°‡§√◊ËÕß Transonic ¡’§«“¡‡∑’ˬßμ√ß ∂â“«—¥‰¥â¡“°°«à“ 0 ‚¥¬‰¡à‰¥â ≈—∫  “¬· ¥ß«à“¡’ recirculation ‡°‘¥®√‘ß ‡π◊ËÕß®“°‰¡à‰¥â«—¥ cardiopulmonary recirculation ‡¢â“‰ª¥â«¬ ´÷Ëß ·μ°μà“ß®“°«‘∏’Õ◊ËπÊ ∑”„Àâ§à“ %R ª°μ‘¢Õß«‘∏’Õ◊ËπÊ μâÕß¡’§à“¡“°°«à“ 5-10% ®÷ߺ‘¥ª°μ‘ ∑”„Àâ sensitivity ¢Õß«‘∏’Õ◊ËπÊ ≈¥πâÕ¬≈ß 6. ∂â“§à“ %R ¡’§à“¡“°°«à“ 0 μ‘¥μàÕ°—π 2 §√—Èß „ÀâÀ¬ÿ¥ blood pump ·≈– ≈—∫ “¬øÕ°‡≈◊Õ¥ ·≈–∑”°“√«—¥§à“ R Õ’°§√—Èß ë ∂Ⓣ¥â§à“ %R = 0 · ¥ß«à“¡’°“√μàÕ “¬øÕ°‡≈◊Õ¥ ≈—∫°—π ë ∂â“§à“ %R > 0 ·≈–¡’§à“¡“°°«à“§à“ %R §√—Èß·√° · ¥ß«à“¡’°“√μàÕ “¬øÕ°‡≈◊Õ¥ ≈—∫°—π ë ∂â“§à“ %R > 0 ·≈–¡’§à“πâÕ¬°«à“§à“ %R §√—Èß·√° · ¥ß«à“‰¡à‰¥âμàÕ “¬øÕ°‡≈◊Õ¥ ≈—∫°—π  ”À√—∫‡ âπøÕ°‡≈◊Õ¥ AVG ‚¥¬‡©æ“–∑’Ë¡’≈—°…≥–‡ªìπ Loop ∂Ⓣ¡à‰¥â¥Ÿ∫—π∑÷°À√◊Õ∑¥ Õ∫ ∑‘»∑“ߢÕ߇ âπøÕ°‡≈◊Õ¥°àÕπ·∑߇¢Á¡ Õ“®®–·∑߇¢Á¡ ≈—∫∑“ß°—π‰¥â  à«π‡ âπøÕ°‡≈◊Õ¥ AVF ¡—°®– ‰¡à¡’ªí≠À“„π°“√·∑ß ≈—∫∑“߬°‡«âπ‡ âπøÕ°‡≈◊Õ¥∫“ß≈—°…≥–∑’Ë¡’∑‘»∑“ß°“√‰À≈¬âÕπ¢÷Èπ·≈–≈ß 7. „Àâ set ‡§√◊ËÕ߇æ◊ËÕ∑”°“√«—¥ ABF ·≈–μâÕß ≈—∫ “¬øÕ°‡≈◊Õ¥ ·≈–„™â§«“¡‡√Á«¢Õß blood pump ª√–¡“≥ 150-300 ¡≈./π“∑’ ®“°π—Èπ„Àâª≈àÕ¬πÈ”‡°≈◊Õ∑’ËμàÕ°—∫ “¬øÕ°‡≈◊Õ¥¥â“π vein ‡¢â“ Ÿà “¬ øÕ°‡≈◊Õ¥ª√–¡“≥ 5-6 «‘π“∑’ À√◊Õ©’¥πÈ”‡°≈◊Õ 10 ml ‡¢â“‰ª∑’Ë°√–‡ª“–¥—°Õ“°“»¥â“π vein ‡§√◊ËÕß®– «¥— §“à %R ´ß÷Ë μÕâ ß¡ª’ √“°Ø·ππà Õπ‡πÕ◊Ë ß®“°°“√μÕà  ≈∫—  “¬ ·μ‰à ¡√à “¬ß“πÕÕ°¡“ ·≈–®–√“¬ß“π§“à ABF ´÷Ëߺà“π°“√§”π«≥·≈⫇ªìπ ¡≈./π“∑’ „Àâ∑” 2 §√—Èß·≈–À“§à“‡©≈’ˬ §à“‰¡à§«√μà“ß°—π¡“°°«à“ 10% 8. §«“¡ —¡æ—π∏å√–À«à“ß§à“ %R ·≈–§à“ ABF 482

Work Instruction: Physical Examination, Pressure and Flow Monitoring of Vascular Access ë ∂â“§à“ ABF ¡“°°«à“§à“§«“¡‡√Á«¢Õß blood pump §à“ %R ®–‡∑à“°—∫ 0 ë ∂â“§à“ ABF πâÕ¬°«à“§à“§«“¡‡√Á«¢Õß blood pump §à“ %R ®–¡“°°«à“ 0 ë ∂â“§à“ ABF πâÕ¬°«à“§à“§«“¡‡√Á«¢Õß blood pump ·≈–§à“ %R = 0 · ¥ß«à“¡’√Õ¬μ’∫μ—π Õ¬àŸ√–À«à“߇¢Á¡∑—Èß Õß ·¡â«à“ ABF ®–πâÕ¬°«à“§«“¡‡√Á«¢Õß blood pump ·μà‡¡◊ËÕ·∑߇¢Á¡øÕ°‡≈◊Õ¥ ‡≈◊Õ¥®“°‡¢Á¡ artery ®–∂Ÿ° àߢⓡ√Õ¬μ’∫μ—πºà“π«ß®√¢Õß “¬øÕ°‡≈◊Õ¥‰ª àŸ‡¢Á¡¥â“π vein ‰¥â¥’‚¥¬‰¡à æ∫ recirculation ë ∂Ⓣ¡à “¡“√∂«—¥§à“ ABF ‰¥â ·≈–«—¥§à“ %R ‰¥â¡“°°«à“ 0 · ¥ß«à“‡§√◊ËÕ߉¡à “¡“√∂«—¥ §à“ %R À≈—ß®“° ≈—∫ “¬øÕ°‡≈◊Õ¥‰¥â ¡—°‡°‘¥®“°μ”·ÀπàߢÕß “¬øÕ°‡≈◊Õ¥„π§√—Èß·√°‡ªìπ°“√·∑ß º‘¥∑“ß §◊Õ¡’°“√ ≈—∫ “¬·μàμâπ ·≈–μ”·ÀπàßÀ≈—ß®“° ≈—∫ “¬‡æ◊ËÕ«—¥ ABF ‡ªìπμ”·Àπàߪ°μ‘ æ‘ ®Ÿ πå ¥â«¬°“√§à“ %R °àÕπ·≈–À≈—ß ≈—∫ “¬‡æ◊ËÕ‡ª√’¬∫‡∑’¬∫°—π ¥—ß„πÀ—«¢âÕ∑’Ë 6 ë ∂Ⓣ¡à “¡“√∂«—¥§à“ ABF ‰¥â ·≈–«—¥§à“ %R ‰¥â‡∑à“°—∫ 0 · ¥ß«à“‡§√◊ËÕ߉¡à “¡“√∂«—¥§à“ %R À≈—ß®“° ≈—∫ “¬øÕ°‡≈◊Õ¥ ´÷Ë߇°‘¥®“°°“√∑’ËπÈ”‡°≈◊Õ∑’ˇ®◊Õ®“ߧ«“¡‡¢â¡¢âπ¢Õ߇≈◊Õ¥ ‡¡◊ËÕÕÕ°®“° ‡¢Á¡ artery ∑’Ëμâπ∑“ß ‰¡à∂°Ÿ  à߉ªÀ“‡¢Á¡ Vein ∑’ËÕ¬àŸª≈“¬∑“ß ¡—°®–æ∫„π‡ âπøÕ°‡≈◊Õ¥ AVF ·≈–·∑ß ‡ âπ‡≈◊Õ¥μà“ß·¢πß°—π ·°â‰¢¥â«¬°“√μ√«®‡ âπøÕ°‡≈◊Õ¥·≈–≈߇¢Á¡„À¡à 9.„À√â –«ß— «“à °“√¡√’ –¥∫— §«“¡¥π— ‚≈Àμ‘  ßŸ ¡“°ÊÀ√Õ◊ ¡§’ «“¡¥π— ‚≈Àμ‘ μË”„π¢≥–∑”°“√«¥— ABF §à“®–‡ª≈’ˬπ·ª≈߉¥âμ“¡√–¥—∫§«“¡¥—π‚≈À‘μ„π√à“ß°“¬ 欓¬“¡«—¥„π¢≥–∑’Ë¡’§«“¡¥—π‚≈À‘μ∑’˧ß∑’Ë 10. ‚¥¬∑—Ë«‰ª‡ âπøÕ°‡≈◊Õ¥ AVG §«√¡’§à“ ABF ¡“°«à“ 600 ¡≈./π“∑’ ·≈–∂â“¡’°“√«—¥μàÕ ‡π◊ËÕß §«√¡’§à“≈¥≈ßπâÕ¬°«à“ 25% ¿“¬„π 4 ‡¥◊Õπ „π∫“ß√“¬ß“π„™â§à“≈¥≈ßπâÕ¬°«à“ 20% ¿“¬„π√– ‡«≈“ 1 ‡¥◊Õπ  ”À√—∫‡ âπøÕ°‡≈◊Õ¥ AVF §«√¡’§à“¡“°°«à“§«“¡‡√Á«¢Õß blood pump ∑’Ë°”À𥉫â À√◊Õ ¡“°°«à“ 300-400 ¡≈./π“∑’ 11. ·π–π”„Àâ«—¥∑ÿ°‡¥◊Õπ ‚¥¬‡©æ“–‡ âπøÕ°‡≈◊Õ¥ AVG  ”À√—∫‡ âπøÕ°‡≈◊Õ¥ AVF ¡’§” ·π–π”®“°∫“ß guideline „Àâ«—¥∑ÿ° 1 ‡¥◊Õπ À√◊Õ∑ÿ° 3 ‡¥◊Õπ 12. „πªí®®ÿ∫—π‡§√◊ËÕß Transonic ∂◊Õ‡ªìπ gold standard  ”À√—∫°“√«—¥ %R ·≈– ABF √«¡∑—Èß delivered blood pump flow 4.  √ÿª 4.1 °√≥‰’ ¡à¡’‡§√Ë◊Õß Transonic  ”À√—∫‡ âπøÕ°‡≈◊Õ¥™π‘¥ AVG „Àâ„™â Static intra-access pressure monitoring ∑—Èߥâ“π artery ·≈– vein ¥â«¬«‘∏’°“√«—¥·√ߥ—π‚¥¬μ√ß°àÕπ∑”°“√øÕ°‡≈◊Õ¥ ∂Ⓣ¡à “¡“√∂∑”‰¥â„Àℙ⫑∏’°“√«—¥‚¥¬ ÕâÕ¡®“°°√–‡ª“–¥—°Õ“°“»¥â“π vein ·≈–∂Ⓣ¡à “¡“√∂∑”«‘∏’π’ȉ¥â „Àℙ⫑∏’°“√«—¥ Dynamic venous pressure ∑’Ë°√–‡ª“–¥—°Õ“°“»¥â“π vein ·μàμâÕß∫—π∑÷°§à“μ—«·ª√μà“ßÊ ∑’Ë®–¡’º≈μàÕ°“√«—¥‰«â¥â«¬ Õ“® ®–ª√–‡¡‘π¥â«¬ pressure monitoring ‡æ’¬ßÕ¬à“߇¥’¬« À√◊Õª√–‡¡‘π√à«¡°—∫°“√μ√«®‡ âπøÕ°‡≈◊Õ¥¥â«¬ °“√¥Ÿ §≈”·≈–øíß °√≥’∂Ⓣ¡à¡—Ëπ„®„π§à“∑’Ë«—¥‰¥â „ÀℙⰓ√«—¥ Flow ¥â«¬«‘∏’ Urea-based ‡ªìπ√–¬–Ê ‡ªìπ μ—«√à«¡„π°“√μ—¥ ‘π„® 483

Practical Dialysis in the Year 2009  ”À√—∫‡ âπøÕ°‡≈◊Õ¥™π‘¥ AVF ‰¡à·π–π”„Àâª√–‡¡‘π°“√∑”ß“π¥â«¬ pressure monitoring ¬°‡«âπ„π∫“ß°√≥’∑’Ë ¿“懠âπøÕ°‡≈◊Õ¥ AVF §≈⓬°—∫ AVG ·μà„ÀℙⰓ√μ√«®‡ âπøÕ°‡≈◊Õ¥¥â«¬°“√¥Ÿ §≈”·≈–øíß ‡ªìπ√–¬–Ê ∂â“ ß —¬«à“¡’ªí≠À“ „Àâ∑”°“√«—¥§à“ recirculation À√◊Õ flow ¥â«¬ Urea-based ‡ªìπμ—«√à«¡„π°“√μ—¥ ‘π„®°àÕπ àßμ√«®«‘π‘®©—¬·≈–·°â‰¢ ‰¡à·π–π”„ÀℙⰓ√μ√«® flow À√◊Õ recirculation ¥â«¬«‘∏’ Urea-based ‡ªìπ‡æ’¬ß‡§√◊ËÕß«—¥ ™π‘¥‡¥’¬« „π°“√μ‘¥μ“¡ª√–‡¡‘π°“√∑”ß“π¢Õ߇ âπøÕ°‡≈◊Õ¥ ‡π◊ËÕß®“°°“√«—¥¥â«¬ Urea-based ¡’§«“¡ ·ª√ª√«π§àÕπ¢â“ß¡“° ¥—ßπ—Èπ®÷ßπ”¡“„™âª√–°Õ∫√à«¡°—∫«‘∏’Õ◊ËπÊ ¥—߉¥â°≈à“«„π¢â“ßμâπ 4.2 °√≥’∑¡’Ë ‡’ §√ËÕ◊ ß Transonic  “¡“√∂π”¡“„™âμ‘¥μ“¡ª√–‡¡‘π°“√∑”ß“π¢Õ߇ âπøÕ°‡≈◊Õ¥™π‘¥ AVG ·≈– AVF ‰¥â¥’ ‚¥¬ Õ“®®–„™â‡ªìπ‡§√◊ËÕß¡◊Õ™π‘¥‡¥’¬«„π°“√μ‘¥μ“¡ª√–‡¡‘π‡ âπøÕ°‡≈◊Õ¥‡ªìπ√–¬–Ê ´÷Ëß¡—°®–∑”„Àâ skill „π°“√μ√«®‡ âπøÕ°‡≈◊Õ¥¢Õß欓∫“≈À√◊Õ·æ∑¬åÀâÕ߉μ‡∑’¬¡≈¥πâÕ¬≈ß ‡π◊ËÕß®“°°“√æ÷Ëß擇§√◊ËÕß¡◊Õ ¥—ß°≈à“« Õ¬à“߉√°Áμ“¡ ¥—߉¥â°≈à“«„π¢â“ßμâπ ª√–‚¬™πåπà“®–¡’¡“° ”À√—∫‡ âπøÕ°‡≈◊Õ¥ AVG ·μà‡ âπ øÕ°‡≈◊Õ¥ AVF  “¡“√∂π”¡“„™â‡ªìπμ—«‡ √‘¡ ‡¡◊ËÕ°“√μ√«®‡ âπøÕ°‡≈◊Õ¥¥â«¬«‘∏’ ¥Ÿ §≈” ·≈–øíß ‰¥â º≈‰¡à™—¥‡®π ‡Õ° “√Õ“â ßÕß‘ 1. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006;48 Suppl 1:S176-247. 2. Tordoir J, Canaud B, Haage P, et al. EBPG on Vascular Access. Nephrol Dial Transplant 2007;22 Suppl 2:ii88-117. 3. Ethier JH, Lindsay RM, Barre PE, Kappel JE, Carlisle EJ, Common A. Clinical practice guidelines for vascular access. Canadian Society pf Nephrology. J Am Soc Nephrol 1999;10 Suppl 13:S297-305. 4. Beathard GA. An algorithm for the physical examination of early fistula failure. Semin Dial 2005;18:331-5. 5. Susan Eymann. Flow-based vascular access management. United States of America: Transonic Systems Inc., 2007. 484

Work Instruction: Buttonhole Cannulation: New Insight 24 Work Instruction: Buttonhole Cannulation: New Insight °”∏√ ≈≈’ “¡–≈‘ Õ‘…≥’ æ∑ÿ ∏¡‘ πμ√’ ¿“«‘≥’¬å ∞μ‘ ‘¡‚πæ≤— πå ª√“√∂π“ μπ—  ÿ∏≠— ≈°— …≥å ª«’≥“  ‘ßÀ∑å ‘» 1. «—μ∂ÿª√– ß§å 2. °“√·∑߇¢Á¡øÕ°‡≈◊Õ¥·∫∫ Buttonhole 3. ¢Õâ ¥·’ ≈–¢Õâ ‡ ¬’ ¢Õß°“√·∑߇ πâ ¥«â ¬«∏‘ ’ Constant-site À√Õ◊ Buttonhole 4. ‡∑§π‘§°“√·∑ß AVF ¥«â ¬«‘∏’ Constant-site À√◊Õ Buttonhole 5. Õªÿ  √√§·≈–°“√·°â ‰¢ 485

Practical Dialysis in the Year 2009 1. «—μ∂ªÿ √– ß§å 1. ‡æ◊ËÕ„ÀâºâŸ‡¢â“Õ∫√¡‡™‘ߪؑ∫—μ‘°“√‡¢â“„®∂÷ß«‘∏’°“√, ¢âÕ¥’ ·≈–¢âÕ‡ ’¬ √«¡∑—ÈߢâÕ∫àß™’È ·≈–¢âÕ Àâ“¡ ¢Õß°“√·∑߇¢Á¡øÕ°‡≈◊Õ¥·∫∫ Buttonhole 2. ‡æ◊ËÕ„ÀâºâŸ‡¢â“Õ∫√¡‡™‘ߪؑ∫—μ‘°“√√⟢—ÈπμÕπ°“√·∑߇¢Á¡øÕ°‡≈◊Õ¥·∫∫ Buttonhole ·≈–  “¡“√∂π”°≈—∫‰ªªØ‘∫—쑇Õ߉¥â 3. ‡æ◊ËÕ„À⺟⇢â“Õ∫√¡‡™‘ߪؑ∫—μ‘°“√∑’Ë π„®°“√·∑߇¢Á¡øÕ°‡≈◊Õ¥·∫∫ Buttonhole ·μଗ߉¡à ¡—Ëπ„®«à“®–∑”‰¥â À√◊Õ‡§¬∑”·≈â«·μàæ∫Õÿª √√§ À√◊Õ‡§¬¡’ª√– ∫°“√≥å„π°“√∑”¡“°àÕπÀπâ“π’È·≈â« ‰¥â·≈°‡ª≈’ˬπª√– ∫°“√≥å°—∫«‘∑¬“°√ºŸâ¡’ª√– ∫°“√≥å„π°“√·∑߇¢Á¡¥â«¬«‘∏’π’È‚¥¬μ√ß 2. °“√·∑߇¢Á¡øÕ°‡≈Õ◊ ¥·∫∫ Buttonhole ‡ âπ‡≈◊Õ¥ AVF §◊Õ‡ âπ‡≈◊Õ¥¥”∑’Ë∂Ÿ°π”¡“μàÕ‡¢â“°—∫‡ âπ‡≈◊Õ¥·¥ß ‡¡◊ËÕ‡≈◊Õ¥‰À≈ºà“π®“° ‡ âπ‡≈◊Õ¥·¥ß‡¢â“ Ÿà‡ âπ‡≈◊Õ¥¥”‚¥¬μ√ß ®–∑”„Àâºπ—߇ âπ‡≈◊Õ¥¥”¡’°“√‡ª≈’ˬπ·ª≈ß®π¡’≈—°…≥–§≈⓬ ºπ—߇ âπ‡≈◊Õ¥·¥ß §◊Õ¡’ºπ—ß∑’ËÀπ“¢÷Èπ·≈–¡’¢π“¥√ŸÀ≈Õ¥‡≈◊Õ¥∑’Ë„À≠à¢÷Èπ ‡√’¬°«à“¡’ maturation ´÷Ëß ≥ ®ÿ¥π’È®– “¡“√∂·∑ߥ⫬‡¢Á¡øÕ°‡≈◊Õ¥ (AVF Needle) ¢π“¥‡©≈’ˬ‡∫Õ√å 16 ‰¥â ‡∑§π‘§°“√·∑߇¢Á¡øÕ°‡≈◊Õ¥‚¥¬∑ƒ…Æ’ (√Ÿª∑’Ë 1) §«√®–·∑ß·∫∫ Rope-ladder À√◊Õ·∑ß ·∫∫°√–®“¬´È”∑’ˇ¥‘¡πâÕ¬§√—Èß∑’Ë ÿ¥ (√Ÿª∑’Ë 2) ‡æ◊ËÕ„Àâºπ—߇ âπ‡≈◊Õ¥¡’‡«≈“„π°“√ ¡“π·º≈∑’Ë∂Ÿ°·∑ß ‡π◊ËÕß®“°°“√·∑ߺπ—߇ âπ‡≈◊Õ¥∑’Ë„°≈âμ”·Àπà߇¥‘¡À√◊Õ´È”μ”·Àπà߇¥‘¡Õ¬àŸ‡√◊ËÕ¬Ê À√◊Õ‡√’¬°°“√·∑ß ≈—°…≥–π’È«à“°“√·∑ß·∫∫ Area (√Ÿª∑’Ë 3) ®–∑”„Àâºπ—ߢÕßÀ≈Õ¥‡≈◊Õ¥„π∫√‘‡«≥π’È¡’§«“¡ÕàÕπ·Õ ·≈– μàÕ¡“®–¡’°“√¢¬“¬μ—«·≈–æÕßÕÕ° À√◊Õ‡°‘¥ aneurysm dilatation (√Ÿª∑’Ë 3) ∫“ß à«π¢Õ߇≈◊Õ¥∑’ˉÀ≈ ºà“π‡ âπ‡≈◊Õ¥∑’ËæÕßπ’È ®–¡’°“√‰À≈«π¿“¬„π aneurysm Õ“®°àÕ„À⇰‘¥°“√®—∫μ—«¢Õß≈‘Ë¡‡≈◊Õ¥ ·≈–¬÷¥ 쥑 ∑º’Ë πß— ‡ πâ ‡≈Õ◊ ¥∑æ’Ë Õßπ’È ·≈–Õ“®∑”„À‡â  πâ ‡≈Õ◊ ¥‡°¥‘ °“√Õ¥ÿ μπ— ‰¥„â π∑ ’Ë ¥ÿ  «à π°“√·∑ß·∫∫ Rope-ladder ®–‰¡à∑”„À⇰‘¥°“√¢¬“¬μ—«¢Õ߇ âπ‡≈◊Õ¥ À√◊Õ∂Ⓡ°‘¥°Á‡ªìπ°“√¢¬“¬μ—«∑’Ë ¡Ë”‡ ¡Õ (√ªŸ ∑’Ë 2) ·¡â«à“°“√ ·∑ß·∫∫ Rope-ladder ®–¥’∑’Ë ÿ¥ ·μà∫“ߧ√—Èß ¿“懠âπ‡≈◊Õ¥ AVF ¢Õߺ⟪ɫ¬‰¡à‡Õ◊ÈÕÕ”π«¬μàÕ°“√·∑ß ¥â«¬«‘∏’¥—ß°≈à“« ‡™àπ ·∑ߢ≥–∑’ˇ âπ¬—߉¡à‚μ‡μÁ¡∑’Ë À√◊Õ‡ âπ‡≈◊Õ¥‰¡à mature μ≈Õ¥≈”¢Õ߇ âπ‡≈◊Õ¥ À√◊Õ ‡ âπ‡≈◊Õ¥Õ¬Ÿà≈÷° ∑”„Àâ¡’μ”·Àπàß∑’Ë®–·∑߉¥â®”°—¥ πÕ°®“°π’Èμ—«¢Õߺ⟪ɫ¬Õ“®‰¡àμâÕß°“√„Àâ·∑ß μ”·Àπàß„À¡àÊ ‡π◊ËÕß®“°‡¡◊ËÕ¡’°“√·∑ß„πμ”·Àπàß„À¡à®–ª«¥¡“°°«à“°“√·∑ß„πμ”·Àπà߇¥‘¡ ∑—ÈßÀ¡¥ π’È∑”„ÀâºâŸªÉ«¬¡—°∂Ÿ°·∑ß·∫∫´È”„°≈â∑’ˇ¥‘¡‡ªìπ®”π«π¡“° ‡∑§π‘§°“√·∑ß∑’Ë®–°≈à“«∂÷ßμàÕ‰ªπ’ȇªìπÕ’°«‘∏’ ∑’ˇ√’¬°«à“°“√·∑ß·∫∫ Constant-site À√◊Õ Buttonhole (√ªŸ ∑’Ë 1 ·≈– 4) ´÷Ë߇°‘¥®“°°“√·∑ß∑’Ë√Ÿ‡¥‘¡Õ¬àŸμ≈Õ¥ ®π°≈“¬‡ªìπ√àÕß (tract) ∑ÿ°§√—Èß∑’Ë·∑ß∑’Ë ‡¥‘¡®–μâÕß –°‘¥§√“∫πÈ”‡À≈◊Õß∑’Ë·Àâß°√—ß∑’˪“°·º≈ (crust) ÕÕ° ·≈–„™â‡¢Á¡øÕ°‡≈◊Õ¥§àÕ¬Ê  Õ¥ ‡¢â“√àÕß∑’Ë¡’Õ¬àŸ ·≈–‡¡◊ËÕ‡Õ“‡¢Á¡ÕÕ°‡≈◊Õ¥°Á®–·¢Áßμ—«„π√àÕߪî¥∫“¥·º≈∑’ˇ°‘¥®“°°“√·∑ß 486

Work Instruction: Buttonhole Cannulation: New Insight √ªŸ ∑Ë’ 1 · ¥ß°“√·∑߇ πâ ‡≈Õ◊ ¥ AVF ·∫∫μà“ßÊ ë √Ÿª´“â ¬¡Õ◊  ÿ¥§Õ◊ ‡ âπ‡≈◊Õ¥ AVF ∑’ˬ—߉¡∂à Ÿ°·∑߇ πâ ¡“°Õà π ë √ªŸ ¢«“¡Õ◊ √ªŸ ∑’Ë 1 §Õ◊ º≈°“√·∑߇ πâ ·∫∫ Rope-ladder ë √Ÿª¢«“¡◊Õ√ªŸ ∑Ë’ 2 §Õ◊ º≈°“√·∑߇ âπ·∫∫ Area ë √Ÿª¢«“¡◊Õ√ªŸ ∑’Ë 3 §Õ◊ º≈°“√·∑߇ âπ·∫∫ Constant-site À√◊Õ Buttonhole √ªŸ ∑’Ë 2 · ¥ßº≈°“√·∑߇ πâ ‡≈◊Õ¥·∫∫ Rope-ladder 487