Practical Dialysis in the Year 2009

Practical Dialysis in the Year 2009 2.1.4 Prescribed Kt/V ·≈– delivered Kt/V ë Prescribed Kt/V ‡ªìπ§à“ Kt/V ∑’ˇ√“°”Àπ¥°“√√—°…“„Àâ·°àºâŸªÉ«¬ ‚¥¬„™â§à“ dialyzer urea clearance (Kd) ∑’Ë√–∫ÿ®“°∫√‘…—∑ºâŸº≈‘μ (in vitro Kd) À√◊Õ Õ“®À“§à“ Kd ‚¥¬μ√ß®“°°“√‡®“– BUN √–À«à“ß°“√øÕ°‡≈◊Õ¥ (in vivo Kd) ´÷Ëߧ”π«≥®“° μŸ √ K = Qb × BUNart − BUNvein BUNart Qb = blood flow rate (BFR), BUNart & BUNvein = BUN ∑’ˇ®“–®“° blood line ∑“ß “¬ arterial ·≈– venous ‚¥¬‡®“–À≈—ß®“°∑”°“√øÕ°‡≈◊Õ¥‰ª‰¥â 30 π“∑’´÷Ë߇ªìπ™à«ß∑’ˇªî¥ BFR §ß∑’Ë·≈â« ·≈–„Àâªî¥ UF °àÕπ‡®“– BUN ‡πÕ◊Ë ß®“°„π√–À«“à ß°“√øÕ°‡≈Õ◊ ¥Õ“®‡°¥‘ ª≠í À“μ“à ßÊ∑Õ’Ë “®∑”„À§â “à Kt/VμË”°«“à ∑°’Ë ”Àπ¥‰«â ‡™àπ √–¬–‡«≈“øÕ°‡≈◊Õ¥®√‘ßÕ“®πâÕ¬°«à“∑’Ë°”Àπ¥ ¥—ßπ—Èπ (NKF-DOQI) ·π–π”«à“§«√°”Àπ¥°“√√—°…“ (prescribed Kt/V) ‡º◊ËÕ‡æ‘Ë¡¢÷Èπ‰«âª√–¡“≥√âÕ¬≈– 15 μ—«Õ¬à“ß «‘∏°’ “√°”Àπ¥ª√¡‘ “≥°“√øÕ°‡≈◊Õ¥ (prescribed Kt/V) ºâŸªÉ«¬‰μ«“¬‡√◊ÈÕ√—ß√–¬– ÿ¥∑⓬∑”°“√øÕ°‡≈◊Õ¥ §√—Èß≈– 4 ™—Ë«‚¡ß 3 §√—Èß/ —ª¥“Àå  ¡¡ÿμ‘«à“ „™âμ—«°√Õß∑’Ë¡’§à“ urea clearance (Kd) = 150 ¡≈./π“∑’ (∑’Ë Qb 200 ¡≈./π“∑’) ∂⓺⟪ɫ¬¡’πÈ”Àπ—°μ—« 60 °°. ª√–‡¡‘π§à“ V §√à“«Ê ‰¥â®“° 0.6 × πÈ”Àπ—°μ—« = 0.6 x 60 = 36 ≈‘μ√ = 36000 ¡≈. ¥—ßπ—Èπ®–‰¥â§à“ Kt/V = 150 × (4×60) / 36000 = 1.0 ∂â“μâÕß°“√‡æ‘Ë¡ Kt/V ‡ªìπ 1.4 ‚¥¬μâÕß°“√§ß‡«≈“°“√øÕ°‡≈◊Õ¥‡∑à“‡¥‘¡∑’Ë 4 ™—Ë«‚¡ß ®–μâÕß „™âμ—«°√Õß∑’Ë¡’§à“ K ‡∑à“‰√ Kt/V = 1.4 ¥—ßπ—Èπ K = 1.4 × V / t = 1.4 × 36000 / (4 × 60) K = 210 ¡≈./π“∑’ ë Delivered Kt/V Delivered Kt/V §◊Õ ª√‘¡“≥°“√øÕ°‡≈◊Õ¥∑’˺⟪ɫ¬‰¥â√—∫®√‘ß ´÷Ëߧ”π«≥À“ spKt/V ®“° μŸ √ UKM À√◊Õ®“° Ÿμ√Õ¬à“ßßà“¬ ( ¡°“√ 1) ‚¥¬„™â§à“ BUN °àÕπ·≈–À≈—ß°“√øÕ°‡≈◊Õ¥ §à“¢Õß delivered Kt/ V Õ“®πâÕ¬°«à“ prescribed Kt/V ´÷ËßÕ“®‡°‘¥®“°¢âÕº‘¥æ≈“¥ K, t À√◊Õ V ‡™àπ ¢âÕº‘¥æ≈“¥Õ“®‡°‘¥®“° dialyzer clearance ´÷ËßÕ“®‡°‘¥®“° access recirculation, blood pump calibration error, urea clearance ∑’Ë ∫√‘…—∑√–∫ÿ‰«â Ÿß°«à“§«“¡‡ªìπ®√‘ß, dialyzer clotting, reuse dialyzer ‰¡à‰¥â√—∫°“√μ√«® Õ∫∑’Ë¥’æÕ°àÕππ” ¡“„™â´È”  ”À√—∫√–¬–‡«≈“øÕ°‡≈◊Õ¥μâÕ߇ªìπ‡«≈“∑’˺⟪ɫ¬‰¥â√—∫°“√øÕ°‡≈◊Õ¥®√‘ß (effective time) ∂â“¡’ °“√≈¥ blood flow rate, isolate ultrafiltration, ‡ªî¥ by pass À√◊ÕÀ¬ÿ¥ dialysis ™—Ë«¢≥–®“° alarm μà“ßÊ À√◊պ⟪ɫ¬¡“ “¬·μà‡≈‘°μ“¡‡«≈“ (wall clock syndrome) ¥—ßπ—Èπ effective time ®÷ßÕ“®‰¡à‡∑à“‡«≈“∑’Ëμ—Èß ‰«â·μà·√°  à«π volume distribution of urea (V) ´÷Ë߇∑à“°—∫ª√‘¡“μ√πÈ”„π√à“ß°“¬ ¡—°„™â§à“‡©≈’ˬ 58 % ¢ÕßπÈ”Àπ—°μ—«À√◊Õª√–‡¡‘π®“° Ÿμ√ Watson À√◊Õ Hume-Wayers ·μàºâŸªÉ«¬·μà≈–§πª√‘¡“μ√πÈ”„π √à“ß°“¬‰¡à‡∑à“°—π¡’§à“·μ°μà“ßμ—Èß·μà√âÕ¬≈– 40-70 ¢ÕßπÈ”Àπ—°μ—« ¥—ßπ—Èπ°“√μ‘¥μ“¡°“√√—°…“ §«√„™â delivered Kt/V ´÷Ëß°“√‡ª≈’ˬπ·ª≈ߢÕß delivered Kt/V ∑’ˉ¥â„π·μà≈–§√—Èߢ÷Èπ°—∫§à“ K, t, V „π°“√∑”°“√ øÕ°‡≈◊Õ¥∑’Ë·∑â®√‘ß 38

Know How! Know Why!! in Chronic Hemodialysis Prescription «‘∏’ª√–‡¡‘π§à“ V Õ“®§”π«≥®“° Ÿμ√∑’Ëπ‘¬¡„™â§◊Õ Watson À√◊Õ Hume-Wayers method ¥—ßπ’È Watson method For men: V (liters) = 2.447+ [0.3362 × Wt(kg)] +[0.1074 × Ht(cm)] - [0.09516 × Age (yr)] From women: V (liter) = -2.097 + [0.2466 × Wt] + [0.1069 × Ht(cm)] Hume-Wayers method For men: V = -14.02934 + (0.296785 × Wt) + (0.192786 × Ht) From women: V = -35.270121 + (0.183809 × Wt) + (0.344547 × Ht) „π°√≥’∑’Ë∑√“∫§à“πÈ”Àπ—°μ—« (Wt) Àπ૬‡ªìπ°‘‚≈°√—¡  à«π ßŸ (Ht) Àπ૬‡ªìπ‡´π쑇¡μ√ ·≈– Õ“¬ÿÀπ૬‡ªìπªï ‡≈◊Õ°„™â Watson method ∂â“∑√“∫‡©æ“–πÈ”Àπ—°·≈– à«π ßŸ ‡≈◊Õ°„™â Hume-Wayers 3. §” ß—Ë °“√√°— …“ºâŸªÉ«¬øÕ°‡≈Õ◊ ¥ (Chronic hemodialysis prescription) „π°“√ ß—Ë °“√√°— …“ºªâŸ «É ¬øÕ°‡≈Õ◊ ¥„π·μ≈à –√“¬Õ“®¡√’ “¬≈–‡Õ¬’ ¥∑·’Ë μ°μ“à ß°π— ‚¥¬∑«—Ë ‰ª§”  —Ëß°“√√—°…“„πºŸâªÉ«¬øÕ°‡≈◊Õ¥ ®–ª√–°Õ∫¥â«¬ 2  à«π ”§—≠ 3.1 Standing order ‡ªì𧔠—Ëß°“√√—°…“øÕ°‡≈◊Õ¥∑’Ë„™âª√–®” ”À√—∫ºâŸªÉ«¬∑’ËÕ¬àŸ„π ¿“æ§ß∑’Ë (stable state) ´÷Ëß¡’Õߧåª√–°Õ∫ ”§—≠4 · ¥ß¥—ßμ“√“ß∑’Ë 2 μ—«Õ¬à“ß standing order · ¥ß¥—ß√ªŸ 2 3.2 Specific order ‡ªì𧔠—Ëß°“√√—°…“‡©æ“– ”À√—∫ªí≠À“‡©æ“–¢Õߺ⟪ɫ¬·μà≈–√“¬ ‡™àπ °“√„Àâ “√Õ“À“√∑“ßÀ≈Õ¥‡≈◊Õ¥ (parenteral hyperalimentation) √–À«à“ß∑”°“√øÕ°‡≈◊Õ¥ „π°√≥’∑’Ë ºâŸªÉ«¬¡’¿“«–∑ÿæ‚¿™π“°“√·≈–‰¡à “¡“√∂√—∫ª√–∑“πÕ“À“√‡Õ߉¥â‡æ’¬ßæÕ μ“√“ß∑’Ë 2 Õߧåª√–°Õ∫ ”§—≠¢Õߧ” —Ëß°“√√—°…“øÕ°‡≈◊Õ¥ 1. ‡§√◊ËÕ߉μ‡∑’¬¡∑’Ë„™â ·≈–™π‘¥¢Õß°“√øÕ°‡≈◊Õ¥ (conventional HD, high-efficiency HD, high flux HD or hemodiafiltration) 2. √–¬–‡«≈“„π°“√øÕ°‡≈◊Õ¥ (§√—Èß≈–°’Ë™—Ë«‚¡ß) §«“¡∂’Ë (°’˧√—ÈßμàÕ —ª¥“Àå) 3. Dialyzer (™π‘¥, ¢π“¥æ◊Èπ∑’˺‘«) 4. Õ—μ√“°“√‰À≈¢Õ߇≈◊Õ¥ 5. Õ—μ√“°“√‰À≈¢ÕßπÈ”¬“øÕ°‡≈◊Õ¥ 6.  à«πª√–°Õ∫¢ÕßπÈ”¬“øÕ°‡≈◊Õ¥ √«¡∂÷ßÕÿ≥À¿Ÿ¡‘¢ÕßπÈ”¬“øÕ°‡≈◊Õ¥ 7. ™π‘¥·≈–¢π“¥¢Õß anticoagulant ∑’Ë„™â 8. ª√–‡¡‘π ideal À√◊Õ dry weight ·≈–Õ—μ√“°“√¥÷ßπÈ” 9. ‚¿™π∫”∫—¥ (nutritional management) ‡™àπ ª√‘¡“≥‚ª√μ’π∑’˧«√‰¥â√—∫ 10. °“√ àßμ√«®∑“ßÀâÕߪؑ∫—μ‘°“√ °àÕπ°“√øÕ°‡≈◊Õ¥·≈–À≈—ß°“√øÕ°‡≈◊Õ¥ 11. ¬“∑’ËμâÕß„Àâ√–À«à“ß°“√øÕ°‡≈◊Õ¥ À√◊ÕÀ≈—ßøÕ°‡≈◊Õ¥ ‡™àπ erythropoietin 12. §” —Ëß°“√√—°…“¡“μ√“∞“π∑’Ë®”‡ªìπ‡æ◊ËÕ„Àâ欓∫“≈ªØ‘∫—μ‘μ“¡‡¡◊ËÕ¡’‡Àμÿ©ÿ°‡©‘𠇙àπ °√≥’‡°‘¥ §«“¡¥—π‚≈À‘μμË”„Àâ “√πȔլà“߉√ ·≈–§«√√“¬ß“π·æ∑¬å„π°√≥’‰Àπ∫â“ß 39

Practical Dialysis in the Year 2009 √Ÿª∑Ë’ 2 · ¥ßμ«— Õ¬“à ߧ” ßË— standing order „πºâªŸ «É ¬øÕ°‡≈Õ◊ ¥ 40

Know How! Know Why!! in Chronic Hemodialysis Prescription 4. Õߧåª√–°Õ∫∑μË’ âÕߧ”πß÷ „π°“√ Ë—ß°“√√°— …“„πºªŸâ É«¬øÕ°‡≈◊Õ¥ 4.1 ™π‘¥¢Õß°“√øÕ°‡≈◊Õ¥ ·≈–√–¬–‡«≈“„π°“√øÕ°‡≈Õ◊ ¥ „π°“√ —Ëß°“√√—°…“øÕ°‡≈◊Õ¥ °“√‡≈◊Õ°™π‘¥¢Õß°“√øÕ°‡≈◊Õ¥«à“‡ªìπ conventional hemodialysis (HD) À√◊Õ low-efficiency HD, high-efficiency HD, high-flux HD À√◊Õ hemodiafiltration ®”‡ªìπμâÕ߇≈◊Õ° dialyzer ∑’Ë„™â„Àâ∂Ÿ°μâÕß „™âÕ—μ√“°“√‰À≈¢Õ߇≈◊Õ¥·≈–Õ—μ√“°“√‰À≈¢ÕßπÈ”¬“øÕ° ‡≈◊Õ¥∑’ˇÀ¡“– ¡ ª√–‡¡‘π vascular access «à“¡’§«“¡ ¡∫√Ÿ ≥å‡æ’¬ßæÕ„π°“√„™âß“πÀ√◊Õ‰¡à ‡π◊ËÕß®“°„π high-efficiency HD À√◊Õ high-flux HD μâÕß„™â dialyzer ∑’Ë¡’ KoA  Ÿß ·≈–μâÕß„™âÕ—μ√“°“√‰À≈¢Õ߇≈◊Õ¥∑’Ë Ÿß (>350 ¡≈./π“∑’) ¥—ßμ“√“ß∑’Ë 3 πÕ°®“°π’ÈμâÕß¡’√–∫∫πÈ”∑’Ë¡’§ÿ≥¿“æ Ÿß·≈–‡≈◊Õ°„™â‡§√◊ËÕ߉μ‡∑’¬¡„Àâ ‡À¡“– ¡°—∫™π‘¥¢Õß°“√øÕ°‡≈◊Õ¥  ”À√—∫√–¬–‡«≈“„π°“√øÕ°‡≈◊Õ¥·≈–§«“¡∂’Ë¢Õß°“√øÕ°‡≈◊Õ¥ ¢÷Èπ°—∫ª√‘¡“≥°“√øÕ° ‡≈◊Õ¥∑’˺⟪ɫ¬§«√‰¥â√—∫ §«“¡∂’Ë¢Õß°“√øÕ°‡≈◊Õ¥·≈–Àπâ“∑’ˉμ∑’ˬ—߇À≈◊ÕÕ¬àŸ (¥—ßμ“√“ß∑’Ë 1) „π°“√øÕ° ‡≈◊Õ¥§√—Èß·√°„πºâŸªÉ«¬∑’Ë¡’§à“ BUN  ŸßÊ μâÕß√–«—ߪí≠À“ disequilibrium syndrome (DDS) §«√„™â√–¬– ‡«≈“°“√øÕ°‡≈◊Õ¥§√—Èß·√°ª√–¡“≥ 2 ™—Ë«‚¡ß „™â dialyzer ∑’Ë¡’§à“ KoA < 500 ¡≈./π“∑’ ‡ªî¥Õ—μ√“°“√ ‰À≈¢Õ߇≈◊Õ¥‰¡à‡°‘π 200 ¡≈./π“∑’ «—μ∂ÿª√– ß§å‡æ◊ËÕ‰¡à„Àâ√–¥—∫ BUN À≈—ß°“√øÕ°‡≈◊Õ¥≈¥≈ß¡“°°«à“ √âÕ¬≈– 30-40 ¢Õß§à“°àÕπøÕ°‡≈◊Õ¥ „π°√≥’∑’Ë®”‡ªìπμâÕߥ÷ßπÈ”¡“°§«√„™â«‘∏’øÕ°‡≈◊Õ¥ ≈—∫°“√¥÷ßπÈ” °àÕπÀ√◊ÕÀ≈—ß°“√øÕ°‡≈◊Õ¥ (isolate ultrafiltration)  ”À√—∫√–¬–‡«≈“øÕ°‡≈◊Õ¥·≈–Õ—μ√“°“√‰À≈¢Õß ‡≈◊Õ¥ “¡“√∂‡æ‘Ë¡‰¥â„π§√—ÈßμàÕÊ ‰ª ‚¥¬∑—Ë«‰ª„πºŸâªÉ«¬∑’ˬ—ß¡’ªí  “«–Õ¬Ÿà „π√–¬–·√°¡—°øÕ°‡≈◊Õ¥ 2 §√—ÈßμàÕ —ª¥“Àå√–¬–‡«≈“ 4 ™—Ë«‚¡ßμàÕ§√—Èß  à«π„πºŸâªÉ«¬∑’Ëªí  “«–‡À≈◊ÕπâÕ¬À√◊Õ¡’πÈ”Àπ—°μ—«¡“° À√◊Õ ¡’¿“«–·∑√°´âÕπÀ√◊Õ‚√§Õ◊Ëπ√à«¡‡™àπ ‚√§À—«„®·≈–À≈Õ¥‡≈◊Õ¥ ¡’¿“«– “√πÈ”‡°‘π ‚√§‡∫“À«“π Õ“® ®”‡ªìπμâÕ߇æ‘Ë¡°“√øÕ°‡≈◊Õ¥‡ªìπ 3 §√—ÈßμàÕ —ª¥“Àå ´÷ËßπÕ°®“°∑”„À≥â spKt/V μ“¡‡ªÑ“À¡“¬ ¬—ß ∑”„Àâ¥÷ßπÈ”„Àâ∂÷ß dry weight ‰¥âßà“¬¢÷Èπ „π√“¬∑’Ë·¡â«à“øÕ°‡≈◊Õ¥‰¥âμ“¡‡ªÑ“À¡“¬ spKt/V ·μଗߡ’Õ“°“√ ∑“ߧ≈‘π‘°∑’Ë∫àß™’È«à“°“√øÕ°‡≈◊Õ¥Õ“®¬—߉¡à‡æ’¬ßæÕ ‡™àπ ¬—ß‡∫◊ËÕÕ“À“√ ¡’¿“«–∑ÿæ‚¿™π“°“√ ‰¡à  “¡“√∂§¡ÿ §«“¡¥π— ‚≈Àμ‘ ‰¥â Õ“®æ®‘ “√≥“‡ª≈¬Ë’ π™π¥‘ ¢Õß°“√øÕ°‡≈Õ◊ ¥ (‡™πà ‡ª≈¬Ë’ π®“° low efficiency ‡ªìπ high-efficiency, high-flux À√◊Õ HDF) À√◊Õ‡æ‘Ë¡®”π«π™—Ë«‚¡ß„π·μà≈–§√—ÈߢÕß°“√øÕ°‡≈◊Õ¥ À√◊Õ‡æ‘Ë¡ §«“¡∂’Ë¢Õß°“√øÕ°‡≈◊Õ¥ μ“√“ß∑Ë’ 3 ¢âÕ·μ°μà“ß√–À«à“ß Low-efficiency HD ·≈– High-efficiency HD Low-efficiency HD High-efficiency HD* Dialyzer KoA (¡≈./π“∑’) <500 ≥ 600 ≥ 350 Blood flow rate (¡≈./π“∑’) <350 ≥ 500 Dialysate flow rate (¡≈./π“∑’) ≤ 500 necessary Bicarbonate dialysate optimal * „π high-efficiency hemodialysis (HD) ¡—°¡’ urea clearance > 200 ¡≈./π“∑’ 41

Practical Dialysis in the Year 2009 4.2 Dialyzer °“√‡≈◊Õ°™π‘¥¢Õß dialyzer „π°“√øÕ°‡≈◊Õ¥ æ‘®“√≥“®“°ªí®®—¬μàÕ‰ªπ’È 4.2.1 Material membrane13 ‡¡◊ËÕ‡≈◊Õ¥ —¡º— °—∫ºπ—ߢÕß dialyzer ´÷Ë߇ ¡◊Õπ ‘Ëß·ª≈°ª≈Õ¡„π√à“ß°“¬ ®–‡°‘¥ªØ‘°√‘¬“∑’Ë ‡√’¬°«à“ blood-membrane reaction ‚¥¬ªØ‘°√‘¬“π’È®–ºà“π∑“ß alternative complement pathway ´÷Ëß®– ∑”„Àâ¡’°“√°√–μÿâπ‡¡Á¥‡≈◊Õ¥¢“« ‡°≈Á¥‡≈◊Õ¥ ·≈– coagulation factor ∑”„À⇰‘¥‡¡Á¥‡≈◊Õ¥¢“«‡°“–°≈ÿà¡ (leukoagglutination) ‡°¥‘ blood clot ·≈–¡°’ “√À≈ßË— mediator μ“à ßÊ ‡™πà chemotactic factor, tumor necrosis factor (TNF), interleukin (IL) ¥—ßπ—Èπ membrane ∑’Ë°àÕ„À⇰‘¥ªØ‘°√‘¬“π’ÈπâÕ¬ ®–®—¥‡ªìπ membrane ™π‘¥∑’Ë¡’ biocompatibility ªí®®ÿ∫—π·∫àß™π‘¥¢Õß dialyzer membrane ‰¥â‡ªìπ 3 °≈ÿà¡„À≠ॗßπ’È 1) Unmodified cellulose membrane À√◊Õ regenerated cellulose membrane ‡ªìπ membrane ∑’Ë∑”®“° cellulose membrane ´÷Ë߉¥â®“°∏√√¡™“μ‘ ¡’ºπ—ß∫“ß·≈–ºπ—ß∑π·√ßμ÷ßμ—«‰¥â ßŸ ¡’§ÿ≥ ¡∫—쑇ªìπ hydrophilic ´÷Ëß∑”„Àâ√«¡‰¥â¥’°—∫πÈ”„π√–¥—∫‚¡‡≈°ÿ≈ ∑”„Àâ membrane ™π‘¥π’È¡’ diffusion ‰¥¥â ’ ´ß÷Ë ∑”„À¢â ®¥— small water-soluble uremic solute ‰¥¥â ’ ·μ¢à Õâ ‡ ¬’ §Õ◊ ¢π“¥√°Ÿ √Õ߇≈°Á ·≈–¡§’ ≥ÿ  ¡∫μ— ‡‘ ªπì hydrophilic ∑”„À≡ࠓ¡“√∂¢®—¥¢Õ߇ ’¬∑’Ë¡’¢π“¥„À≠à (middle and large sized uremic toxins) ‰¥â‡æ’¬ß æÕ πÕ°®“°π’È„π unmodified cellulose membrane ®–¡’ free hydroxyl group ¡“°´÷Ëß®–‡ªìπμ—« à߇ √‘¡ ∑”„À⇰‘¥ªØ‘°√‘¬“ blood-membrane reaction ¡“°¢÷Èπ 2) Modified cellulose membrane ¡º’ πß— ∫“ß¢π“¥‚¥¬‡©≈¬’Ë 6-15 ‰¡§√Õπ ·≈–¡‚’ §√ß √“â ß ¡¡“μ√‡À¡Õ◊ π unmodified cellulose membrane ·μ¡à °’ “√ª√∫— ª√ßÿ §≥ÿ  ¡∫μ— „‘ À‡â °¥‘ ªÆ°‘ √¬‘ “μÕà √“à ß°“¬≈¥≈ß membrane °≈ÿ¡à π¡È’ ∑’ ßÈ— ™π¥‘ ∑‡Ë’ ªπì low-flux ·≈– high-flux ·∫à߉¥â‡ªìπ 2 °≈ÿà¡ - cellulose acetate ‡ªìπ membrane ∑’Ë„™â acetate ¡“·∑π∑’Ë hydroxyl group ∑”„Àâ¡’°“√°√–μÿâπ complement ≈¥≈ß ‡™àπ cellulose diacetate ®–¡’°“√·∑π∑’Ë hydroxyl group ª√–¡“≥√âÕ¬≈– 75 ∑”„Àâ ‡°‘¥ªØ‘°‘√‘¬“ blood-membrane reaction ≈¥≈ß  à«π cellulose triacetate ®–¡’°“√·∑π∑’Ë hydroxyl group ¥«â ¬ acetate ‡°Õ◊ ∫∑ßÈ— À¡¥ ∑”„À‡â ªπì biocompatible membrane ¡“°¬ßË‘ ¢πÈ÷ πÕ°®“°π¬È’ ß— ∑”„Àâ membrane ¡’¢π“¥√Ÿ°√Õß„À≠à¢÷Èπ ∑”„À⧫“¡ “¡“√∂„π°“√°√Õߥ’¢÷Èπ‡¡◊ËÕ‡∑’¬∫°—∫ unmodified cellulose - modified cellulose ∑„Ë’ ™â tertiary amino group ·∑π∑Ë’ hydroxyl group Õ¬“à ߉√°μÁ “¡ membrane „π°≈ÿà¡π’Èμà“ß°—∫ cellulose acetate ∑’Ë®”π«π hydroxyl group ∑’Ë∂Ÿ°∑¥·∑ππâÕ¬°«à“¡“° μ—«Õ¬à“߇™àπ hemophan ¡’‡æ’¬ß√âÕ¬≈– 5 ¢Õß hydroxyl group ∑’Ë∂Ÿ°·∑π∑’˥⫬ tertiary amino group ·μà‡π◊ËÕß®“° ‚§√ß √“â ߢÕß tertiary amine group ¡ ’ «à πμÕà ¢¬“¬∑¬Ë’ πË◊ ¡“ªÕÑ ß°π— ‰¡„à À‡â ≈Õ◊ ¥¡“ ¡— º — °∫— hydroxyl group ∑”„Àâ membrane „π°≈ÿà¡π’È¡’ biocompatibility æÕÊ °—∫°≈ÿà¡ cellulose acetate „πªí®®ÿ∫—π¡’°“√„™âÀ≈—° °“√π’Ⱥ≈‘μ membrane ‚¥¬„™â benzyl moiety ‡ªìπμ—«®—∫°—∫ hydroxyl group 3) Synthetic membrane ‡ªπì membrane ∑ Ë’ ß— ‡§√“–À¢å πÈ÷ ‰¡¡à  ’ «à πª√–°Õ∫¢Õß cellulose ‡≈¬ μ«— Õ¬“à ߇™πà AN69 (‡ªπì copolymer acrylonitrile ·≈– anionic sulfonate), polysulfone, polyamide, polymethylmethacrylate (PMMA), 42

Know How! Know Why!! in Chronic Hemodialysis Prescription polyarylethersulfone/polyamide ·≈– polyethersulfone ‡ªìπμâπ membrane °≈ÿà¡π’È¡’ºπ—ßÀπ“ ¡’∑—Èß™π‘¥∑’Ë ‡ªìπ low-flux ·≈– high-flux ·≈–¡’ biocompatibility ¥’°«à“°≈ÿà¡ unmodified cellulose membrane ¢âÕ§«√ √–«—ߧ◊Õ À≈’°‡≈’ˬ߰“√„™â AN69 „πºâŸªÉ«¬∑’ˉ¥â√—∫¬“ ACEi ‡æ√“–Õ“®‡°‘¥ªØ‘°‘√‘¬“™π‘¥ anaphylactoid ‰¥â ‡π◊ËÕß®“°∫πº‘«¢Õß AN69 ®–¡’ª√–®ÿ≈∫ ´÷Ëß “¡“√∂°√–μÿâπ„Àâ‡≈◊Õ¥∑’˺à“πμ—«°√Õß  √â“ß “√ bradykinin ´÷ËߺŸâªÉ«¬∑’ˉ¥â√—∫¬“ ACEi ®–‰¡à “¡“√∂∑”≈“¬ bradykinin ‰¥â ∑”„À⇰‘¥°“√§—ËߢÕß “√¥—ß°≈à“«·≈–‡°‘¥ ªØ‘°‘√‘¬“°“√·æâ√ÿπ·√߉¥â „πª®í ®∫ÿ π— ¬ß— ‰¡¡à À’ ≈°— ∞“π‡æ¬’ ßæÕ«“à synthetic membrane ®–‰¥ªâ √–‚¬™π¡å “°°«“à modified cellulose membrane „π·ßà≈¥Õ—μ√“°“√‡ ’¬™’«‘μ„πºŸâªÉ«¬‰μ«“¬‡√◊ÈÕ√—ß °“√‡≈◊Õ° dialyzer ®÷߇≈◊Õ°μ“¡ §ÿ≥ ¡∫—μ‘¢Õß urea clearance À√◊Õ KoA ‡ªì𠔧—≠°àÕπªí®®—¬Õ◊Ëπ 4.2.2 Sterilization ‡∑§π‘§∑’Ë∑”„Àâ dialyzer ª≈Õ¥‡™◊ÈÕ„πªí®®ÿ∫—π¡’ 3 «‘∏’ 1) Ethylene dioxide (ETO)  “√ ETO Õ“®μ°§â“ß„π dialyzer ∑”„À⇰‘¥Õ“°“√·æâÕ¬à“ß √ÿπ·√ߢ≥–øÕ°‡≈◊Õ¥ ∫“ß√“¬Õ“®¡’Õ“°“√√ÿπ·√ß·∫∫ anaphylactic shock ∑’ˇ√’¬°«à“ first use reaction À√◊Õ dialyzer reaction type A ´÷Ëß¡—°æ∫‡¡◊ËÕπ” dialyzer ∑’Ë∑”„Àâª≈Õ¥‡™◊Èե⫬ ETO ¡“„™â‡ªìπ§√—Èß·√° 2) Gamma irradiation „™â gamma ray „π°“√∑”„Àâ dialyzer ª≈Õ¥‡™◊ÈÕ 3) Stream autoclaving „™â§«“¡√âÕπ®“°‰ÕπÈ”∑’Ë·√ߥ—π ßŸ ∑”„Àâ dialyzer ª≈Õ¥‡™◊ÈÕ „π°√≥’∑’˺ŸâªÉ«¬∑’Ë¡’ªí≠À“ first use reaction À√◊Õ ß —¬«à“·æâ ETO „Àâæ‘®“√≥“„™â dialyzer ∑’Ë∑”„Àâª≈Õ¥ ‡™◊Èե⫬ gamma ray À√◊Õ stream autoclaving 4.2.3 Solute clearance „π¢∫«π°“√øÕ°‡≈Õ◊ ¥ °“√¢®¥— ¢Õ߇ ¬’ ‚¥¬¢∫«π°“√ diffusion ·≈– convection ‡°¥‘ ∑’Ë dialyzer ¥—ßπ—Èπ°“√‡≈◊Õ°„™â dialyzer ®÷ß¡’§«“¡ ”§—≠ §ÿ≥ ¡∫—μ‘¢Õß dialyzer ∑’Ë„™âª√–°Õ∫°“√æ‘®“√≥“√—°…“¡’ ¥—ßπ’È 1) Diffusive clearance ´÷Ë߇ªìπ°“√«—¥Õ—μ√“°“√¢®—¥ urea ·≈– mass transfer area coefficient (KoA) ´÷Ë߇ªìπ§à“∫Õ° dialyzer efficiency 2) Water permeability (Kuf) À√◊Õ water flux 3) Sieving coefficient À√◊Õ Permeability ´÷Ëß∫àß∂÷ß°“√¢®—¥ middle molecule π‘¬¡„™â β2 microglobulin clearance ‡ªìπμ—«·∑π°“√¢®—¥ “√„π°≈ÿà¡ middle molecule  ”À√—∫§”®”°—¥§«“¡¢Õߧÿ≥ ¡∫—쑇À≈à“π’È· ¥ß¥—ßμ“√“ß∑’Ë 4 4.2.3.1 Diffusive clearance ·≈– KoA ë Diffusive clearance „π∑“ߧ≈‘π‘°°“√«—¥Õ—μ√“°“√¢®—¥ solute ¡—°«—¥‚¥¬„™â§à“ clearance ¢Õß “√ (solute) π—ÈπÊ ‚¥¬∑’˧”®”°—¥§«“¡¢Õß clearance §◊Õ ª√‘¡“μ√¢Õ߇≈◊Õ¥À√◊Õæ≈“ ¡“∑’Ë “√π—Èπ∂Ÿ°¢®—¥ÕÕ°À¡¥„π Àπ÷ËßÀπ૬‡«≈“ §à“ clearance ‡ªìπ°“√«—¥ª√‘¡“≥¢Õß blood cleaning ´÷Ë߇ªìπ§à“∑’ˉ¡à¢÷Èπ°—∫§«“¡‡¢â¡¢âπ ¢Õß solute ∑’ˇ¢â“¡“„π dialyzer ·μà§à“ diffusive clearance ®–‡ª≈’ˬπμ“¡ blood flow ‚¥¬ blood flow 43

Practical Dialysis in the Year 2009 μ“√“ß∑Ë’ 4 §”®”°—¥§«“¡¢Õß efficiency, flux ·≈– permeability Efficiency ë measure urea clearance ë low and high efficiency are based on the urea KoA value ë Low efficiency : KoA < 500 ml/min ë High efficiency: KoA > 600 ml/min Flux ë Measure of ultrafiltration capacity ë Low and high flux are based on Kuf ë Low flux: Kuf < 10 ml/h/mmHg ë High flux: Kuf > 20 ml/h/mmHg Permeability ë Measure of the clearance of the middle molecule (e.g. β2 MG) ë General correlation between flux and permeability ë Low permeability: β2 MG < 10 ml/min ë High permeability: β2 MG > 20 ml/min √Ÿª∑Ë’ 3 · ¥ß«‘∏’§”π«≥À“ diffusive clearance ¢Õß dialyzer („π°√≥’∑’Ë ultrafiltration = 0) ∑’Ë Ÿß¢÷Èπ §à“ clearance ®–‡æ‘Ë¡¢÷Èπ ‚¥¬∑—Ë«‰ªπ‘¬¡À“§à“ clearance ¢Õß urea, vitamin B12 ‡ªìπμ—« ‡ª√’¬∫‡∑’¬∫√–À«à“ß dialyzer ™π‘¥μà“ßÊ ¥—ßπ—Èπ§à“ clearance ‡ªìπ§à“∑’Ë· ¥ßª√– ‘∑∏‘¿“æ¢Õß dialyzer „π°“√∑”„Àâ‡≈◊Õ¥ª√“»®“°¢Õ߇ ’¬  “¡“√∂À“§à“ diffusive clearance ‰¥â®“° Ÿμ√¥—ß√ªŸ ∑’Ë 3 μ«— Õ¬à“ß √Ÿª∑’Ë 3 °√≥’∑’˧‘¥ diffusive clearance ‚¥¬„Àâ ultrafiltration rate =0 (QBi = QBo) ‚¥¬ Blood urea nitrogen (BUN) °àÕπ‡¢â“ dialyzer (CBi) 100 mg/dL ·≈– BUN À≈—ß®“°ºà“π dialyzer (CBo) ≈¥≈߇À≈◊Õ 10 44

Know How! Know Why!! in Chronic Hemodialysis Prescription ¡°./¥≈. §‘¥‡ªìπ BUN ≈¥≈ß√âÕ¬≈– 90 ∂Ⓡªî¥ blood flow 100 ¡≈./π“∑’ À¡“¬§«“¡«à“ „π 1 π“∑’ ¡’ ‡≈◊Õ¥‰À≈ºà“π dialyzer 100 ¡‘≈≈‘≈‘μ√ ´÷Ëß®–¡’ª√‘¡“≥‡≈◊Õ¥ 90 ¡‘≈≈‘≈‘μ√ ∂°Ÿ ¢®—¥ urea ÕÕ°®πÀ¡¥μàÕ π“∑’ §à“ difussive clearance π’ÈÀ“‰¥â®“° Clearance = Qb × (CBi - CBo) / CBi = 100 × (100 - 10) / 100 = 100 × 0.90 = 90 ¡≈./π“∑’ „π°√≥’∑’Ë§à“ CBi BUN = 50 ¡°./¥≈. ·≈– CBo BUN ≈¥≈߇À≈◊Õ 5 ¡°./¥≈. §‘¥‡ªìπ BUN ≈¥ ≈ß√âÕ¬≈– 90 §à“ diffusive clearance ®–‰¥â‡∑à“‡¥‘¡ ´÷Ëߧ”π«≥‰¥â®“° Clearance = Qb x (CBi - CBo) / CBi = 100 × (50 - 5) / 50 = 100 × 0.90 = 90 ¡≈./π“∑’ °√≥’∑’ˇªî¥ blood flow ‡æ‘Ë¡‡ªìπ 200 ¡≈./π“∑’ §à“ diffusive clearance = 200 (50-5) / 50 = 180 ¡≈./π“∑’ ë Mass transfer area coefficient (KoA) „π¢∫«π°“√ diffusion º“à π dialyzer membrane ®–‡ªπì ‰ªμ“¡ Fickûs law ´ß÷Ë ‡¢¬’ π‡ªπì  ¡°“√‰¥â ¥—ßπ’È14 J/A= -D (dc/dx) J/A = flux §◊Õª√‘¡“≥¢Õß solute ∑’˺à“π membrane (J) μàÕÀπ૬¢Õßæ◊Èπ∑’˺‘«¢Õß membrane (A) D (diffusivity) §◊Õ §ÿ≥ ¡∫—μ‘¢Õß membrane ∑’ˬա„Àâ solute ·æ√àºà“π ´÷Ëß®–¢÷Èπ°—∫™π‘¥¢Õß solute, ™π‘¥¢Õß membrane ·≈– porosity ´÷Ëß§à“ diffusivity ®–¡’§à“§ß∑’Ë¿“¬„μâÕÿ≥À¿¡Ÿ ‘Àπ÷ËßÊ Àπ૬‡ªìπ ´¡.2 / π“∑’ Porosity (P) À¡“¬∂÷ß æ◊Èπ∑’Ë¢Õß membrane  à«π∑’ˇªìπ™àÕß∑“ߺà“π¢Õß solute μàÕÀπ૬¢Õß æ◊Èπº‘«¢Õß membrane ´÷Ëß porosity π’ȇªìπº≈√«¡¢Õß¢π“¥¢Õß pore ·≈–®”π«π pore „πÀπ÷ËßÀπ૬æ◊Èπ∑’Ë ™π‘¥¢Õß membrane ∑’Ë¡’ porosity  ßŸ ®–¡’ diffusion ∑’Ë¥’°«à“ P = N × pr2 ‡¡◊ËÕ N = ®”π«π pore „πÀπ÷ËßÀπ૬æ◊Èπ∑’Ë¢Õß membrane, P = porosity, r = √—»¡’¢Õß pore A §◊Õ æ◊Èπ∑’˺‘«¢Õß membrane ∑’ˇ°‘¥°“√·≈°‡ª≈’ˬπ¢Õß solute Àπ૬‡ªìπ ´¡.2 Dc §◊Õ §«“¡·μ°μà“ß√–À«à“ߧ«“¡‡¢â¡¢âπ¢Õß solute „π blood compartment ·≈– dialysate compartment Àπ૬‡ªìπ ¡°./¥≈. dx §◊Õ √–¬–Àà“ß∑’ËμâÕ߇§≈◊ËÕπ∑’˺à“π ´÷Ëߧ◊Õ §«“¡Àπ“¢Õß membrane §à“ D/dx ‡ªìπ§ÿ≥ ¡∫—μ‘¢Õß membrane ´÷Ëß√«¡‡√’¬°«à“ mass transfer coefficient (Ko) À√◊Õ  —¡ª√– ‘∑∏‘Ï°“√°√Õß Àπ૬‡ªìπ ´¡. / π“∑’ ¥—ßπ—Èπ J/A = Ko × dc J = KoA × dc (√«¡‡√’¬°§à“ KoA π’È«à“ mass transfer area coefficient Àπ૬‡ªìπ ¡≈./π“∑’) 45

Practical Dialysis in the Year 2009  ”À√—∫ dialyzer ·μà≈–μ—«®–¡’§à“ surface area §ß∑’Ë ¥—ßπ—Èπ®–¡’§à“ KoA ®”‡æ“– ´÷Ë߇ªìπ §ÿ≥ ¡∫—μ‘¢Õß dialyzer μ—«π—ÈπÊ §à“ KoA ®–‡ªìπμ—«∫Õ°ª√– ‘∑∏‘¿“æ„π°“√¢®—¥ solute ‡™àπ KoAurea · ¥ß∂÷ߪ√– ‘∑∏‘¿“æ„π°“√¢®—¥ urea ¢Õß dialyzer §à“ KoA ‡ªìπ§à“ clearance  ßŸ  ÿ¥„π∑“ß∑ƒ…Æ’¢Õß dialyzer μàÕ solute ™π‘¥π—ÈπÊ ‡¡◊ËÕ„™â blood flow  Ÿß ÿ¥ (= ∞) ·≈– dialysate flow  Ÿß ÿ¥ (= ∞) ‚¥¬∑—Ë«‰ª∫√‘…—∑ºŸâº≈‘μ¡—°‰¡à‰¥â„Àâ§à“ KoAurea ¢Õß dialyzer ¡“„Àâ ·μà®–„Àâ§à“ urea clearance (Ku) ∑’Ë blood flow rate (Qb) ·≈– dialysate flow rate (Qd) ∑’Ë§à“„¥§à“Àπ÷Ëß¡“„Àâ ‡™àπ Ku ∑’Ë Qb 200 ¡≈./π“∑’ ·≈– Qd 500 ¡≈./π“∑’ ´÷Ëß “¡“√∂π”§à“ in vitro Kurea, blood flow rate ·≈– dialysate flow ∑’Ë„Àâ¡“π’È §”π«≥À“§à“ KoA ‰¥â®“° μŸ √¥—ß ¡°“√∑’Ë 3 ¢â“ß≈à“ß KoA = QbQd / (Qb - Qd) In [(1 - kd/Qb) / (1 - Kd/Qd)] ......................................................(3) Kd = in vitro dialyzer urea clearance Qb = blood flow rate Qd = Dialysate flow rate ‡¡◊ËÕ‰¥â§à“ KoA ¢Õß dialyzer ¡“·≈â«  “¡“√∂∑’Ë®–𔉪„™â§”π«≥À“§à“ Kurea ∑’Ë blood flow rate ·≈– dialysate flow rate §à“μà“ßÊ ‰¥â ‚¥¬„™â ¡°“√∑’Ë 4 Ku = Qb (eZ - 1) / (eZ - Qb/Qd) ...........................................................................................(4) ‚¥¬ Z = (KoA / Qb) (1 - Qb/Qd) ·≈– e = 2.71828 §«“¡ —¡æ—π∏å¢Õß in vitro urea clearance (Ku), KoA, blood flow rate ·≈– dialysate flow rate πÕ°®“°®–„™â«‘∏’§”π«≥À“¥—ß ¡°“√∑’Ë 3 ¬—ßÕ“®„™â«‘∏’∑’Ëßà“¬·≈– –¥«°°«à“ ‚¥¬„™â°√“ø∑’Ë· ¥ß§«“¡  —¡æ—π∏å KoA, Ku, Qb ·≈– Qd ¥—ß√ªŸ ∑’Ë 4 √Ÿª∑’Ë 4 °√“ø· ¥ß§«“¡ ¡— æπ— ∏√å –À«“à ß KoAurea °∫— in vitro urea clearance ·≈– blood flow (Qb) ∑Ë’ dialysate flow (Qd) 500 ¡≈./π“∑’ 46

Know How! Know Why!! in Chronic Hemodialysis Prescription μ—«Õ¬“à ß dialyzer ¡’§à“ in vitro Ku 180 ¡≈./π“∑’ ∑’Ë Qb 200 ¡≈./π“∑’ ·≈– Qd 500 ¡≈./π“∑’ μâÕß°“√∑√“∫«à“¡’§à“ KoA ‡∑à“‰√ ®“°‡ âπ°√“ø„π√Ÿª∑’Ë 4 „Àâ≈“°‡ âπ®“° Ku (·°π X) ∑’Ë§à“ 180 ¡≈./π“∑’ μ—Èß©“°¢÷Èπ‰ª™π °—∫‡ âπ Qb=200 ·≈â«≈“°‡ âπ¢π“π‰ª∑“ߴ⓬®πμ—¥°—∫·°π Y ®–æ∫«à“ dialyzer μ—«π’È¡’§à“ KoA = 600 ‡¡◊ËÕμâÕß°“√∑√“∫«à“ dialyzer μ—«π’È ‡ªî¥ blood flow ∑’Ë 300 ¡≈./π“∑’ ∑’Ë Qd 500 ¡≈./π“∑’ ®–¡’§à“ in vitro Ku ‡ªπì ‡∑“à ‰√ „™°â √“ø„π√ªŸ ∑Ë’ 4 ≈“°‡ πâ ®“°§“à KoA 600 „π·π«¢π“π‰ª∑“ߢ«“®π™π°∫— ·π«‡ πâ °√“ø Qb 300 ®“°π—Èπ≈“°‡ âπμ—Èß©“°≈߉ª®πμ—¥°—∫·°π X æ∫«à“ Ku = 225 ¡≈./π“∑’ ë Whole blood clearance ·≈– blood water urea clearance ‡π◊ËÕß®“° urea ≈–≈“¬Õ¬Ÿà‡©æ“– à«π∑’ˇªìππÈ” ‚¥¬∑—Ë«‰ª∂Ⓣ¡à‰¥â§‘¥ªí®®—¬ blood water ®– ∑”„À≥â§à“ dialyzer urea clearance ‡°‘π®√‘ߪ√–¡“≥√âÕ¬≈– 10-12 «‘∏’§”π«≥À“ blood water urea clearance (Kw) ¢Õß dialyzer ∑”‰¥â¥—ßπ’È  ¡¡ÿμ‘ Whole blood flow rate = 200 ¡≈./π“∑’, hematocrit = 30 % Plasma flow rate = 200 x (1 - 0.30) = 140 ¡≈./π“∑’ Plasma water flow rate = 0.93 x 140 = 130 ¡≈./π“∑’ (plasma ¡’πÈ”‡ªìπÕߧåª√–°Õ∫√âÕ¬≈– 93) Erythrocyte flow rate = 200 x 0.30 = 60 ¡≈./π“∑’ Erythrocyte water flow rate = 0.80 x 60 = 48 ¡≈./π“∑’ (‡¡Á¥‡≈◊Õ¥·¥ß¡’πÈ”‡ªìπÕß§å ª√–°Õ∫√âÕ¬≈– 80) Blood water flow rate = plasma water flow rate + erythrocyte water flow rate = 130 + 48 = 178 ¡≈./π“∑’ ‚¥¬∑—Ë«‰ªÕ“®„™â §à“§ß∑’Ë 0.894 ‡ªìπ§à“ª√—∫™¥‡™¬ ”À√—∫°“√§”π«≥§à“ clearance „π blood water ‡™àπ ‡ªî¥ whole blood flow 200 ¡≈./π“∑’ ®–‰¥â blood water flow = 0.894 x 200 = 176.8 ¡≈./π“∑’ π”§à“ blood water flow rate, §à“ KoA, dialysate flow ‰ª§”π«≥§à“ blood water urea clearance15μ“¡ μ“√“ß∑’Ë 5 Õ’°«‘∏’∑’Ëßà“¬°«à“§◊Õ„™â normogram √ªŸ ∑’Ë 5 ‡¡◊ËÕ∑√“∫§à“ KoA ¢Õß dilayzer, whole blood flow rate ·≈– dialysate flow  “¡“√∂À“§à“ blood water urea clearance ®“°°√“ø16 · ¥ß¥—ß√Ÿª∑’Ë 5 §à“ KoAurea „™â‡ªìπμ—«∫Õ°ª√– ‘∑∏‘¿“æ¢Õß dialyzer (dialyzer efficiency) „π°“√¢®—¥ urea ‚¥¬§à“ KoA urea < 500 ¡≈./π“∑’ ∂◊Õ«à“‡ªìπ low efficiency dialyzer ·≈– KoA > 600 ¡≈./π“∑’ ∂◊Õ«à“‡ªìπ high efficiency dialyzer (∫“ßμ”√“Õ“®„™â§à“ KoA > 700 ¡≈./π“∑’) ·μà„π°“√√—°…“ºŸâªÉ«¬°“√∑” high- efficiency hemodialysis À¡“¬∂÷ß ¢∫«π°“√øÕ°‡≈◊Õ¥π—Èπ®–μâÕß¡’ urea clearance > 200 ¡≈./π“∑’ „π °√≥’∑’Ë„™â high efficiency dialyzer ·μà‰¡à “¡“√∂‡ªî¥ blood flow  Ÿß‰¥â Õ“®‰¥â§à“ urea clearance μË”°«à“ 200 ¡≈./π“∑’ ´÷Ëß∂◊Õ«à“°“√√—°…“π—Èπ ‰¡à„™à high efficiency HD ¥—ßπ—Èπ„π¢∫«π°“√∑” high efficiency HD ºâŸªÉ«¬®”‡ªìπ∑’Ë®–μâÕß¡’ vascular access ∑’Ë¥’¥â«¬ 47

Practical Dialysis in the Year 2009 μ“√“ß∑’Ë 5 «‘∏’ª√–‡¡‘π dialyzer blood water clearance ®“° §à“ KoA, Qb ·≈– Qd ¢—Èπ∑’Ë 1: π”§à“ KoA ∑’Ë√“¬ß“π‚¥¬∫√‘…—∑ ·≈⫪√—∫≈¥≈ß√âÕ¬≈– 10 ¢—Èπ∑’Ë 2: ª√—∫§à“ KoA ∑’˧”π«≥‰¥â (®“°¢—Èπ∑’Ë 1) ¢÷Èπ√âÕ¬≈– 3.3 „π∑ÿ°Ê 100 ¡≈./π“∑’ ¢Õß dialysate flow ∑’Ë¡“°°«à“ 500 ¡≈./π“∑’ (μ—«Õ¬à“߇™àπ Qd 600 ¡≈./π“∑’ „Àâ§≥Ÿ §à“ KoA ¥â«¬ 1.033, ∂â“ Qd 800 ¡≈./π“∑’ „À⧟≥§à“ KoA ¥â«¬ 1.1) ¢—Èπ∑’Ë 3: ª√—∫§à“ blood flow rate ‡æ◊ËÕ™¥‡™¬ prepump negative pressure (‡π◊ËÕß®“°∂â“ prepump pressure §à“‡ªìπ≈∫¡“° §à“ Qb ∑’ˉ¥â®√‘ß ®–πâÕ¬°«à“§à“∑’ˉ«âÀπâ“ªí¥¢Õ߇§√◊ËÕß) ¥—ßπ’È Adjustment factor (F) = 1.0 - [(Qb - 200) / 2000] Adjusted Qb (Qbadj) = Qb x F (°√≥’∑’Ë Qb < 200 ¡≈./π“∑’ ‰¡àμâÕߪ√—∫§à“ Qb) μ—«Õ¬à“߇™àπ Qb = 400 ¡≈./π“∑’ F = 1 - (400 - 200) / 2000 = 0.9 Qbadj = 400 x 0.9 = 360 ¡≈./π“∑’ ¢—Èπ∑’Ë 4: §”π«≥§à“ diffusion blood water clearance (Kdifw) ®“°§à“ KoA ·≈– Qb ∑’˪√—∫§à“·≈â« (KoAadj ·≈– Qbadj) ¥—ß ¡°“√ Z = exp [KoAadj / Qbadj x (1 - Qbadj/Qd)] Kdifw = 0.894 x Qbadj x (Z - 1) / (Z - Qbadj/Qd) §à“§ß∑’Ë 0.894 ‡ªìπ§à“ª√—∫™¥‡™¬ ”À√—∫°“√§”π«≥§à“ clearance „π blood water ¢—Èπ∑’Ë 5: ∫«°§à“ convective clearance ‡¢â“°—∫§à“ diffusive clearance ‚¥¬‡√‘Ë¡®“°§”π«≥À“ Qf (Àπ૬‡ªìπ ¡≈./π“∑’) ·≈– §”π«≥ total blood water clearance (Ktotw) ®“°§à“ Qbadj, Kdifw ·≈– Qf ¥—ßπ’È ultrafiltraion rate (Qf) = W x 1000 / tmin (W = weight loss (Kg), tmin = dialysis time, min) Ktotw = [1 - Qf / (0.894 x Qbadj)] x Kdifw + Qf exp(X) = eX 4.2.3.2 Ultrafiltration coefficient (Kuf) §à“ Kuf ‡ªìπ°“√«—¥ water permeability À√◊Õ water flux ¢Õß dialyzer „π¢∫«π°“√øÕ°‡≈◊Õ¥ ®–¡’°“√‡§≈◊ËÕπºà“π¢ÕßπÈ”®“° blood compartment ‰ª¬—ß dialysate compartment ‚¥¬Õ“»—¬ Transmembrane pressure (TMP) gradient ª√‘¡“≥ ultrafiltration (UF) π’È¢÷Èπ°—∫§à“ TMP ·≈– Kuf ‚¥¬ Kuf §◊Õ ª√‘¡“≥¢ÕßπÈ”∑’Ë¡’Àπ૬‡ªìπ¡‘≈≈‘≈‘μ√∑’Ë°√Õߺà“π membrane „πÀπ÷Ëß™—Ë«‚¡ß‡¡◊ËÕ¡’§à“ TMP ‡∑à“°—∫ 1 ¡¡.ª√Õ∑ (√ªŸ ∑’Ë 6) μ—«Õ¬à“ß ‡™àπ Kuf = 6 ¡≈./™¡./¡¡.ª√Õ∑ À¡“¬§«“¡«à“ ∂â“μâÕß°“√„Àâ¡’ UF ‡∑à“°—∫ 600 ¡≈./™¡. ®–μâÕß„™â TMP 100 ¡¡.ª√Õ∑ ·μà∂â“„™â dialyzer ∑’Ë¡’ Kuf 60 ¡≈./™¡./¡¡.ª√Õ∑ „™â TMP ‡æ’¬ß 10 ¡¡.ª√Õ∑ ®–‰¥â UF 600 ¡≈./™¡. §«“¡ —¡æ—π∏å¢Õß§à“ Kuf, TMP ·≈– ultrafiltration ‡¢’¬π‡ªìπ  ¡°“√‰¥â¥—ßπ’È Kuf x TMP = Utrafiltration rate 48

Know How! Know Why!! in Chronic Hemodialysis Prescription √Ÿª∑’Ë 5 · ¥ß§«“¡ ¡— æ—π∏¢å Õß blood flow ∑ˇ’ ªî¥ (nominal blood flow rate) ·≈– blood water urea clearance (Ktotw) ·≈– dialyzer efficiency (KoA) ∑Ë’ dialysate flow 500 ¡≈./π“∑’ «‘∏’„™â‡√‘¡Ë ®“°≈“°‡ âπ®“° Qb ∑’Ë „™â (·°π X) μßÈ— ©“°¢÷Èπ‰ª™π°—∫·π«°√“ø¢Õߧ“à KoA ¢Õß dialyzer ∑Ë’„™â ®“°π—πÈ ≈“°„π·π«¢π“π‰ª∑“ߴ⓬ ™π·π«·°π Y ®–‰¥â§“à blood water urea clearance √ªŸ ∑’Ë 6 · ¥ß§«“¡ —¡æ—π∏¢å Õß ultrafiltration rate (¡≈./π“∑’) ·≈– §à“ TMP (¡¡.ª√Õ∑) §à“ slope ¢Õߧ«“¡  —¡æ—π∏πå §È’ ◊Õ §à“ ultrafiltration coefficient (Kuf) Àπ«à ¬‡ªìπ ¡≈./™¡./¡¡.ª√Õ∑ 49

Practical Dialysis in the Year 2009 Dialyzer ∑’Ë¡’§à“ Kuf < 10 ¡≈./™¡./¡¡.ª√Õ∑ ∂◊Õ‡ªìπ low-flux membrane ·≈– §à“ Kuf > 20 ¡≈./™¡./¡¡.ª√Õ∑ ‡ªìπ high-flux membrane °“√„™â dialyzer ∑’Ë¡’§à“ Kuf  Ÿß ‚¥¬‡©æ“–∂â“¡“°°«à“ 10 ®”‡ªìπμâÕß„™â‡§√◊ËÕß hemodialysis ∑’Ë¡’°“√§«∫§ÿ¡ ultrafiltration ‰¥âÕ¬à“߇∑’ˬßμ√ß (volumetric control) ‡æ√“–§«“¡º‘¥æ≈“¥¢Õß TMP ‡æ’¬ß‡≈Á°πâÕ¬ ®–∑”„ÀâºâŸªÉ«¬ Ÿ≠‡ ’¬πÈ”‰¥â‡ªìπ®”π«π¡“°„π‡«≈“Õ—π √«¥‡√«Á ´ß÷Ë °Õà „À‡â °¥‘ Õπ— μ√“¬μÕà ºªŸâ «É ¬ πÕ°®“°π°’È “√„™â dialyzer ∑¡’Ë §’ “à Kuf  ßŸ Ê ®–¡Õ’ μ— √“‡ ¬’Ë ßμÕà °“√‡°¥‘ backfiltration ¢ÕßπÈ”¬“ dialysate ´÷ËßÕ“®¡’ endotoxin ªπ‡ªóôÕπ‡¢â“¡“ blood compartment ¥—ßπ—Èπ®–μâÕß ¡’√–∫∫πÈ”∑’Ë¡’§ÿ≥¿“楒 4.2.3.3 Sieving Coefficient À√◊Õ permeability Sieving coefficient (S) §◊Õ Õ—μ√“ à«π¢Õߧ«“¡‡¢â¡¢âπ¢Õß “√„π filtrate ‡∑’¬∫°—∫ §«“¡‡¢â¡ ¢âπ¢Õß “√π—Èπ„π plasma „π∑“ߧ≈‘π‘°„™â§à“ sieving coefficient ‡ªìπμ—«∫Õ° permeability ¢Õß dialyzer ´÷Ëß„™â‡ªìπμ—«∫Õ°§«“¡ “¡“√∂„π°“√¢®—¥¢Õß middle molecule ¢π“¥ pore ¢Õß dialyzer membrane ∑’Ë „À≠à¢÷Èπ ®–¡’§à“ S μàÕ β2 MG  Ÿß¢÷Èπ ‚¥¬ dialyzer ∑’Ë¡’§à“ S ¢Õß β2 MG ¡“°°«à“ 0.5 ∂◊Õ«à“¡’§à“ sieving coefficient μàÕ β2 MG  Ÿß À√◊Õ «—¥ β2 MG clearance > 20 ¡≈./π“∑’ ∂◊Õ«à“ dialyzer μ—«π—Èπ¡’ high permeability 4.2.3.4 Reused dialyzer °“√π” dialyzer ∑’Ë„™â·≈â«¡“∑”§«“¡ –Õ“¥·≈–¶à“‡™◊ÈÕ·≈â«π”¡“„™â„À¡à ®–™à«¬ª√–À¬—¥§à“ √—°…“ ·≈–Õ“®¡’ª√–‚¬™πå„π·ßà∑’Ë∑”„Àâ≈¥ªØ‘°‘√‘¬“ blood-membrane reaction ‰¥â ‡π◊ËÕß®“°¡’‚ª√μ’π ®“°„π‡≈◊Õ¥‰ª©“∫∑’˺‘«¢Õß membrane Õ¬à“߉√°Áμ“¡°àÕππ”¡“„™â´È”§«√¡’°“√«—¥ total cell volume μâÕ߉¡àμË”°«à“√âÕ¬≈– 80 ¢Õߧà“μ—Èßμâπ ´÷Ëß®–∑”„À≥â urea clearance ª√–¡“≥√âÕ¬≈– 90 ¢Õߧà“μ—Èßμâπ 4.3 Õμ— √“°“√‰À≈¢Õ߇≈◊Õ¥·≈–Õμ— √“°“√‰À≈¢Õßπ”È ¬“øÕ°‡≈◊Õ¥ ªí®®—¬∑“ߧ≈‘π‘°∑’Ë¡’º≈μàÕ urea clearance ∑’Ë ”§—≠§◊Õ blood flow rate (Qb), dialysate flow rate ·≈– dialyzer efficiency (KoAurea) „π°“√øÕ°‡≈◊Õ¥‡¡◊ËÕ —Ëß°“√√—°…“ §«√§”π÷ß∂÷ß™π‘¥ dialyzer ·≈– Qb ∑’Ë„™â √«¡∂÷ß clearance ¢Õß solute ∑’ËμâÕß°“√  ”À√—∫ small solute ‡™àπ urea clearance ®–¡’≈—°…≥– ‡ªìπ flow-dependent °≈à“«§◊Õ ‡¡◊ËÕ‡æ‘Ë¡ Qb ¡“°¢÷Èπ ®–‰¥â clearance ‡æ‘Ë¡¢÷Èπ‡ªìπ —¥ à«πμ“¡ Qb ∑’ˇæ‘Ë¡ ¢÷Èπ (‚¥¬‡©æ“–„π™à«ß Qb = 0-200 ¡≈./π“∑’ urea clearance ‡ªìπ flow-limited) ·μà‡¡◊ËÕ‡æ‘Ë¡ Qb  Ÿß¢÷Èπ ‡√◊ËÕ¬Ê §à“ diffusive urea clearance ®–‰¡à¢÷Èπ‡æ‘Ë¡¢÷Èπ‡ªìπ —¥ à«π°—∫ blood flow rate Õ’°μàÕ‰ª ≈—°…≥– °√“ø®–‡ªìπ plateau ∑’Ë®ÿ¥π’È diffusive urea clearance ®–¢÷Èπ°—∫ efficiency ¢Õß dialyzer (√Ÿª∑’Ë 7) ¥—ßπ—Èπ∑’Ë Qb ∑’Ë Ÿß¢÷Èππ’È  “¡“√∂‡æ‘Ë¡ urea clearance ‰¥â‚¥¬„™â dialyzer ∑’Ë¡’§à“ KoA  ßŸ ¢÷Èπ μ—«Õ¬à“߇™àπ„™â dialyzer ∑’Ë¡’§à“ KoA μË” (KoA=400) ‡¡◊ËÕ‡æ‘Ë¡ blood flow ¢÷Èπ‡ªìπ 2 ‡∑à“®“° 200 ¡≈./π“∑’ ‡ªìπ 400 ¡≈./π“∑’ æ∫«à“ blood water urea clearance ‡æ‘Ë¡¢÷Èπ‡æ’¬ß√âÕ¬≈– 26 ·μà„π°√≥’ ∑’Ë„™â high-efficiency dialyzer ∑’Ë¡’§à“ KoA  Ÿß (‡™àπ KoA=800) æ∫«à“ blood water urea clearance ®–‡æ‘Ë¡ ¢÷Èπ√âÕ¬≈– 42 „π°√≥’∑’ˇªî¥ blood flow < 200-250 ¡≈./π“∑’ §à“ urea clearance ¢Õß low efficiency °—∫ high efficiency dialyzer ®–μà“ß°—π‰¡à¡“°  ”À√—∫°“√‡æ‘Ë¡ dialysate flow ®“° 500 ¡≈./π“∑’ ‡ªìπ 800 50

Know How! Know Why!! in Chronic Hemodialysis Prescription √Ÿª∑’Ë 7 urea clearance ®–‡æ¡Ë‘ ¢π÷È μ“¡ blood flow rate (Qb) ∑’Ë‡æ¡‘Ë ‡¡ËÕ◊ ‡æ‘¡Ë Qb  ßŸ ¢÷πÈ ‡√◊ÕË ¬Ê ®–∂ß÷ ¢¥’ ®”°¥— ¢Õß membrane ∑Ë’§à“ diffusive clearance ®–‰¡à‡æ¡Ë‘ μ“¡ Qb Õ°’ μàÕ‰ª ≈°— …≥–°√“ø®–‡ªìπ plateau °“√¢®¥— ∑’®Ë ÿ¥π’È®–¢π÷È °∫— ™π¥‘ ¢Õß membrane ‡ªπì À≈—° ∑Ë’®¥ÿ π’È “¡“√∂‡æ‘Ë¡ urea clearance ¢÷πÈ ‰¥Õâ °’ ‚¥¬„™â dialyzer ∑’Ë¡§’ à“ KoA  Ÿß¢π÷È ´Ëß÷ Õ“®„™â dialyzer ∑’¡Ë §’ à“ Ko (mass transfer coefficient)  ßŸ ¢π÷È À√◊Õ A (surface area) ¢Õß dialyzer  ßŸ ¢πÈ÷ √ªŸ ∑Ë’ 8 º≈¢Õß blood flow ·≈– dialysate flow μÕà urea clearance ¡≈./π“∑’ ®–¡’º≈μàÕ°“√‡æ‘Ë¡ urea clearance πâÕ¬¡“°„π°√≥’∑’Ë„™âÕ—μ√“°“√‰À≈¢Õ߇≈◊Õ¥πâÕ¬°«à“ 250 ¡≈./π“∑’ ·μà∑’ËÕ—μ√“°“√‰À≈¢Õ߇≈◊Õ¥ ßŸ Ê °“√‡æ‘Ë¡ dialysate flow ®–‰¥â urea clearance ‡æ‘Ë¡¢÷Èπ™—¥‡®π ‚¥¬‡©æ“–‡¡◊ËÕ„™â dialyzer ∑’Ë¡’ KoA  Ÿß17 (√Ÿª∑’Ë 8) °“√ª√–¬ÿ°μå„™â„π∑“ߧ≈‘π‘°§◊Õ ‡¡◊ËÕ„™â high-efficiency dialyzer ®”‡ªìπμâÕß„™â blood flow ∑’Ë Ÿß (> 350-500 ¡≈./π“∑’) ®÷ß®–‰¥âª√–‚¬™π宓° urea clearance ∑’Ë ‡æ‘Ë¡¢÷Èπ®“°°“√„™â high-efficiency dialyzer ·≈–°“√‡æ‘Ë¡ dialysate flow ∑’Ë¡“°°«à“ 500 ¡≈./π“∑’ ®–‰¥â ª√–‚¬™πå°ÁμàÕ‡¡◊ËÕ„™â blood flow ≥ 350 ¡≈./π“∑’ 51

Practical Dialysis in the Year 2009 πÕ°®“°π’È°“√‡≈◊Õ°¢π“¥‡¢Á¡„Àâ‡À¡“– ¡°—∫°“√‡ªî¥Õ—μ√“°“√‰À≈¢Õ߇≈◊Õ¥ ®–™à«¬‡æ‘Ë¡ ª√– ∑‘ ∏¿‘ “æ°“√øÕ°‡≈Õ◊ ¥18 §«√‡≈Õ◊ °„™‡â ¢¡Á AVF ™π¥‘ back eye μ“¡Õμ— √“°“√‰À≈¢Õ߇≈Õ◊ ¥ (BFR) ¥ß— π’È - BFR < 300 ¡≈./π“∑’ „™â‡¢Á¡ AVF No. 17 - BFR 300-350 ¡≈./π“∑’ „™â‡¢Á¡ AVF No. 16 - BFR 350-450 ¡≈./π“∑’ „™â‡¢Á¡ AVF No. 15 - BFR > 450 ¡≈./π“∑’ „™â‡¢Á¡ AVF No. 14 4.4  à«πª√–°Õ∫¢ÕßπÈ”¬“øÕ°‡≈Õ◊ ¥16 4.4.1 ‰∫§“√∫å Õ‡πμ §«“¡‡¢â¡¢âπ¢Õ߉∫§“√å∫Õ‡πμ„ππÈ”¬“øÕ°‡≈◊Õ¥Õ¬àŸª√–¡“≥ 33-35 ¡‘≈≈‘‚¡≈/≈‘μ√ „π¢≥– øÕ°‡≈◊Õ¥ºŸâªÉ«¬®–‰¥â√—∫‰∫§“√å∫Õ‡πμ®“°πÈ”¬“øÕ°‡≈◊Õ¥∑’Ë´÷¡ºà“π‡¢â“√à“ß°“¬ ‡æ◊Ëՙ૬·°â‰¢¿“«– °√¥‡°‘π„π√à“ß°“¬ °“√°”À𥧫“¡‡¢â¡¢âπ¢Õ߉∫§“√å∫Õ‡πμ∑’Ë Ÿß‡°‘π‰ª Õ“®∑”„Àâ‡≈◊Õ¥¡’¿“«–‡ªìπ ¥à“ß´÷Ëß®–‡√àß„À⇰‘¥¿“«– vascular calcification ·≈– tissue calcification ßà“¬¢÷Èπ ‡π◊ËÕß®“°¿“«–‡ªìπ¥à“ß ∑”„À·â §≈‡´¬’ ¡·≈–øÕ ‡øμ®∫— μ«— °π— μ°μ–°Õπß“à ¬¢πÈ÷ ‚¥¬∑«Ë— ‰ªπ¬‘ ¡„™â sodamint √∫— ª√–∑“π√«à ¡¥«â ¬ ‡æ◊ËÕª√—∫„Àâ√–¥—∫‰∫§“√å∫Õ‡πμ„π‡≈◊Õ¥°àÕπøÕ°‡≈◊Õ¥Õ¬Ÿàª√–¡“≥ 20-22 ¡‘≈≈‘‚¡≈/≈‘μ√ ¢âÕ§«√√–«—ß„π °“√„™âπÈ”¬“øÕ°‡≈◊Õ¥∑’Ë¡’‰∫§“√å∫Õ‡π쇪ìπ buffer §◊Õ‰∫§“√å∫Õ‡πμ‰¡à¡’ƒ∑∏‘Ϭ—∫¬—Èß·∫§∑’‡√’¬ ∂â“¡’‡™◊ÈÕ ·∫§∑’‡√’¬ªπ‡ªóôÕπ®–‡®√‘≠‡μ‘∫‚μ‰¥â¥’ ¥—ßπ—ÈπÀ≈—߇ªî¥„™â·≈⫉¡à§«√∑‘È߉«â‡°‘π 24 ™—Ë«‚¡ß 4.4.2 ‚´‡¥’¬¡ ª®í ®∫ÿ π— √–¥∫— §«“¡‡¢¡â ¢πâ ¢Õß‚´‡¥¬’ ¡„ππ”È ¬“øÕ°‡≈Õ◊ ¥∑πË’ ¬‘ ¡„™Õâ ¬ªŸà √–¡“≥ 135-140 ¡≈‘ ≈‘ ‚¡≈/≈‘μ√ ‡π◊ËÕß®“°√–¥—∫§«“¡‡¢â¡¢âπ¢Õß‚´‡¥’¬¡∑’Ë Ÿß 140 ¡‘≈≈‘‚¡≈/≈‘μ√ ¡’¢âÕ‡ ’¬∑”„ÀâºâŸªÉ«¬¡’Õ“°“√ °√–À“¬πÈ”¡“°À≈—ßøÕ°‡≈◊Õ¥ ‡π◊ËÕß®“°∑”„Àâ√–¥—∫§«“¡‡¢â¡¢Õß‚´‡¥’¬¡„π‡≈◊Õ¥ Ÿß ®–°√–μÿâπ»Ÿπ¬å °√–À“¬πÈ”„π ¡Õß ∑”„Àâ°‘ππÈ”¡“° ∑”„Àâinterdialytic weight gain ¡“°μ“¡‰ª¥â«¬ πÕ°®“°π’Ȭ—ß ∑”„Àâ√–¥—∫§«“¡¥—π‚≈À‘μ Ÿß¢÷Èπ¥â«¬ √–¥—∫§«“¡‡¢â¡¢âπ¢Õß‚´‡¥’¬¡„ππÈ”¬“øÕ°‡≈◊Õ¥∑’ËμË”°«à“ 135 ¡‘≈≈‘‚¡≈/≈‘μ√ ®–∑”„ÀâÕÿ∫—μ‘°“√≥å¢Õߧ«“¡¥—π‚≈À‘μμË”√–À«à“ß°“√øÕ°‡≈◊Õ¥ Ÿß¢÷Èπ ¡’°“√»÷°…“„π ºâŸªÉ«¬øÕ°‡≈◊Õ¥ æ∫«à“ºâŸªÉ«¬·μà≈–§πÕ“®¡’ çset pointé ¢Õß√–¥—∫‚´‡¥’¬¡„π‡≈◊Õ¥∑’Ë·μ°μà“ß°—π19 ¥—ß π—ÈπÕ“®‡≈◊Õ°ª√—∫√–¥—∫‚´‡¥’¬¡„ππÈ”¬“„ÀâμË”≈߉¥âμ“¡ çset pointé ¢ÕߺŸâªÉ«¬·μà≈–√“¬ ´÷Ëß®–™à«¬≈¥ Õ“°“√°√–À“¬πÈ”À≈—ßøÕ°‡≈◊Õ¥·≈–Õ“®™à«¬≈¥ interdialytic weight gain ‰¥â πÕ°®“°π’È„π∫“ß°“√ »÷°…“¬—ßæ∫«à“™à«¬„Àâ°“√§«∫§ÿ¡§«“¡¥—π‚≈À‘μ¥’¢÷Èπ¥â«¬20 ‡§√Õ◊Ë ß‰μ‡∑¬’ ¡√πÿà „À¡Êà ®– “¡“√∂ª√∫— √–¥∫— ‚´‡¥¬’ ¡¢ÕßπÈ”¬“øÕ°‡≈Õ◊ ¥„π√–À«“à ßøÕ°‡≈Õ◊ ¥ ‰¥â ‡√’¬°«à“ sodium profiling ´÷Ëß¡’„Àâ‡≈◊Õ°„™â‰¥âÀ≈“¬√ªŸ ·∫∫ ‡™àπ constant Na (√–¥—∫‚´‡¥’¬¡ Ÿß‡ªìπ§à“ §ß∑’Ë), linear decreasing Na (√–¥—∫‚´‡¥’¬¡ ßŸ μÕπμâπ·≈⫧àÕ¬Ê ≈¥μË”≈߇ªìπ·∫∫‡ âπμ√ß), exponentially decreasing Na, step Na À√◊Õ Na  ßŸ  ≈—∫μË” √Ÿª·∫∫∑’Ëπ‘¬¡„™â§◊Õ ·∫∫ linear decreasing Na ·≈– step Na «—μ∂ÿª√– ß§å¢Õß sodium profiling ‡æ◊ËÕ≈¥Õÿ∫—μ‘°“√≥姫“¡¥—π‚≈À‘μμË”√–À«à“ßøÕ°‡≈◊Õ¥ ·≈–™à«¬≈¥ °“√‡°‘¥ dialysis disequilibrium syndrome ·μà¡’¢âÕ§«√√–«—ߧ◊Õ ‰¡à§«√„™â sodium profile „πºŸâªÉ«¬ acute heart failure À√◊Õ¡’§«“¡¥—π‚≈À‘μ ßŸ ∑’ˬ—ߧ«∫§ÿ¡‰¡à‰¥â 52

Know How! Know Why!! in Chronic Hemodialysis Prescription 4.4.3 ‚ª·μ ‡´¬’ ¡ ‚¥¬∑—Ë«‰ª√–¥—∫‚ª·μ ‡´’¬¡„ππÈ”¬“øÕ°‡≈◊Õ¥∑’ˇÀ¡“– ¡§◊Õ 2.0 ¡‘≈≈‘‚¡≈/≈‘μ√ ºŸâªÉ«¬ à«π „À≠à¡—°μâÕß®”°—¥Õ“À“√∑’Ë¡’‚ª·μ ‡´’¬¡ Ÿß√à«¡¥â«¬ °“√„™âπÈ”¬“øÕ°‡≈◊Õ¥∑’Ë¡’√–¥—∫‚ª·μ ‡´’¬¡ ≤1.0 ¡‘≈≈‘‚¡≈/≈‘μ√ „π√–¬–¬“« ‡æ◊ËÕ§«∫§ÿ¡ªí≠À“ hyperkalemia æ∫«à“¡’Õ—μ√“°“√‡°‘¥ cardiac arrest  ßŸ ¢÷Èπ21 ∫“ß°√≥’Õ“®‡≈◊Õ°„™âπÈ”¬“øÕ°‡≈◊Õ¥∑’Ë¡’√–¥—∫‚ª·μ ‡´’¬¡ 3.0 ¡‘≈≈‘‚¡≈/≈‘μ√16 ‡™àπ - „π√“¬∑’Ë¡’√–¥—∫‚ª·μ ‡´’¬¡„π‡≈◊Õ¥°àÕπ°“√øÕ°‡≈◊Õ¥ < 4.5 ¡‘≈≈‘‚¡≈/≈‘μ√ ‡™àπ ºâŸªÉ«¬∑’Ë ¬—ß¡’ª√‘¡“≥ªí  “«–¡“°Õ¬àŸ À√◊պ⟪ɫ¬∑’Ë¡’¿“«–∑ÿæ‚¿™π°“√ ¡’ªí≠À“√—∫ª√–∑“πÕ“À“√‰¥âπâÕ¬ - „πºâŸªÉ«¬∑’ˉ¥â√—∫¬“ digitalis ‡æ√“–∂Ⓡ°‘¥ hypokalemia ®–∑”„À⇰‘¥ digitalis intoxication À√◊Õ„πºâŸªÉ«¬‚√§À—«„®´÷ËßÕ“®‡°‘¥ cardiac arrhythmia ‰¥âßà“¬∂Ⓡ°‘¥ hypokalemia „πºŸâªÉ«¬°≈ÿà¡π’È Õ“® ®”‡ªìπμâÕß„Àâ kayexalate À√◊Õ sodium polystyrene sulfonate resin √à«¡¥â«¬ ‡æ◊Ëՙ૬§«∫§ÿ¡√–¥—∫ ‚ª·μ ‡´’¬¡ 4.4.4 ·§≈‡´¬’ ¡ §«“¡‡¢¡â ¢πâ ¢Õß·§≈‡´¬’ ¡„ππÈ”¬“øÕ°‡≈Õ◊ ¥ ‚¥¬∑«—Ë ‰ªÕ¬„àŸ π√–¥∫— 2.5-3.5 mEq/≈μ‘ √ (‡∑“à °∫— 1.25-1.75 ¡‘≈≈‘‚¡≈/≈‘μ√ À√◊Õ 5.0-7.0 ¡°./¥≈.) §à“ª°μ‘¢Õß√–¥—∫ ionized calcium „π‡≈◊Õ¥‡∑à“°—∫ 4-4.5 ¡°./¥≈. (2.0-2.25 mEq/≈‘μ√) ¥—ßπ—Èπ¢≥–øÕ°‡≈◊Õ¥∂â“„™âπÈ”¬“∑’Ë¡’√–¥—∫·§≈‡´’¬¡¡“°°«à“ 2.5 mEq/≈‘μ√ ®–¡·’ §≈‡´¬’ ¡®“°π”È ¬“øÕ°‡≈Õ◊ ¥´¡÷ º“à π‡¢“â  ‡Ÿà ≈Õ◊ ¥ºªâŸ «É ¬ ‡πÕË◊ ß®“°„πª®í ®∫ÿ π— 𬑠¡„™â phosphate binder ∑’Ë¡’·§≈‡´’¬¡‡ªìπ à«πª√–°Õ∫‡™àπ calcium carbonate, calcium acetate ·≈–¡—°„™â„π¢π“¥∑’Ë Ÿß ∑”„Àâ ·§≈‡´’¬¡¥Ÿ¥´÷¡‡¢â“ àŸ√à“ß°“¬„π√–¥—∫∑’Ë Ÿß πÕ°®“°π’Ȭ—ß¡’°“√„™â¬“°≈ÿà¡«‘μ“¡‘π¥’‡æ◊Ëՙ૬≈¥°“√À≈—Ëß parathyroid hormone „πºªŸâ «É ¬∑¡Ë’ ª’ ≠í À“ secondary hyperparathyroidism ´ßË÷ ‡ªπì Õ°’ ª®í ®¬— ∑ Ë’ ßà ‡ √¡‘ „À‡â °¥‘ hypercalcemia ‰¥â „π°√≥’∑’ˉ¥â√—∫ calcium-based phosphate binder ªí®®ÿ∫—π·π–π”«à“„πºŸâªÉ«¬∑’ˉ¥â√—∫ calcium-based phosphate binder „Àâ„™âπÈ”¬“øÕ°‡≈◊Õ¥∑’Ë¡’√–¥—∫·§≈‡´’¬¡ 2.5 mEq/≈‘μ√ ‡æ◊ËÕÀ≈’°‡≈’Ë¬ß ªí≠À“ hypercalcemia ·≈–¿“«– vascular calcification À√◊Õ tissue calcification ‚¥¬‡©æ“–„π√“¬∑’Ë¡’ Ca x P product  Ÿß „π√“¬∑’Ë¡’ªí≠À“ hypocalcemia Õ“®æ‘®“√≥“„™âπÈ”¬“øÕ°‡≈◊Õ¥∑’Ë¡’√–¥—∫·§≈‡´’¬¡ 3.0-3.5 mEq/≈‘μ√ „π√“¬∑’Ë¡’ªí≠À“ hypercalcemia Õ“®æ‘®“√≥“„™âπÈ”¬“øÕ°‡≈◊Õ¥∑’Ë¡’√–¥—∫·§≈‡´’¬¡ 2.0 mEq/≈‘μ√ ¢âÕ§«√√–«—ߧ◊Õ°“√„™âπÈ”¬“øÕ°‡≈◊Õ¥∑’Ë¡’√–¥—∫·§≈‡´’¬¡μË”°«à“ 2.5 mEq/≈‘μ√ ¡’‚Õ°“  ‡°‘¥§«“¡¥—π‚≈À‘μμË”√–À«à“ßøÕ°‡≈◊Õ¥ ßŸ ¢÷Èπ 4.4.5 ·¡°π’‡´¬’ ¡ √–¥—∫·¡°π’‡´’¬¡„ππÈ”¬“øÕ°‡≈◊Õ¥ ª√–¡“≥ 0.2-0.5 ¡‘≈≈‘‚¡≈/≈‘μ√ À√◊Õ 0.5-1.0 mEq/≈‘μ√ 4.4.6 Dextrose §«“¡‡¢â¡¢âπ¢Õß dextrose „ππÈ”¬“øÕ°‡≈◊Õ¥∑’ˇÀ¡“– ¡Õ¬àŸ√–À«à“ß 100-200 ¡°./¥≈. ∂â“ ‰¡à¡’ dextrose „ππÈ”¬“øÕ°‡≈◊Õ¥ ºŸâªÉ«¬®–¡’°“√ Ÿ≠‡ ’¬ glucose ÕÕ°®“°√à“ß°“¬„π√–À«à“ß°“√øÕ° ‡≈◊Õ¥ Õ“®∑”„À⇰‘¥πÈ”μ“≈„π‡≈◊Õ¥μË”‰¥â‚¥¬‡©æ“–„πºâŸªÉ«¬‡∫“À«“π ¢âÕ‡ ’¬¢ÕßπÈ”¬“øÕ°‡≈◊Õ¥∑’Ë¡’ dextrose §◊Õ∂â“¡’°“√ªπ‡ªóôÕπ¢Õß·∫§∑’‡√’¬„ππÈ”¬“ Õ“®∑”„Àâ·∫§∑’‡√’¬·∫àßμ—«·≈–‡®√‘≠‡μ‘∫‚μ‰¥â¥’ ‡π◊ËÕß®“°¡’ dextrose ‡ªìπÕ“À“√ ·∫§∑’‡√’¬®– √â“ß endotoxin ·≈– pyrogen ´÷Ëß®–ºà“π‰ª∑“ßπÈ”¬“ øÕ°‡≈◊Õ¥ ∑”„À⇰‘¥Õ“°“√‰¢âÀπ“« —Ëπ√–À«à“ßøÕ°‡≈◊Õ¥‰¥â 53

Practical Dialysis in the Year 2009 4.5 °“√°”Àπ¥Õÿ≥À¿Ÿ¡π‘ ”È ¬“øÕ°‡≈◊Õ¥ (dialysate temperature)22 ‚¥¬∑—Ë«‰ªÕÿ≥À¿Ÿ¡‘πÈ”¬“øÕ°‡≈◊Õ¥®–Õ¬Ÿàª√–¡“≥ 36.5-37°C ·μà√–À«à“ß°“√øÕ°‡≈◊Õ¥ ‡¡◊ËÕ ¡’°“√¥÷ßπÈ”ÕÕ°®“°√à“ß°“¬®–¡’°“√≈¥≈ߢÕß “√πÈ”„πÀ≈Õ¥‡≈◊Õ¥ √à“ß°“¬®–¡’°≈‰°ª√—∫μ—«™¥‡™¬ ‡æ◊ËÕ‰¡à„À⧫“¡¥—π‚≈À‘μμË”‚¥¬‡æ‘Ë¡ peripheral vascular resistance ´÷Ëß®–∑”„Àâª√‘¡“≥‡≈◊Õ¥∑’ˉªº‘«Àπ—ß ≈¥≈ß  àߺ≈„Àâ√à“ß°“¬√–∫“¬§«“¡√âÕπ‰¥â≈¥≈ß πÕ°®“°π’È„π¢≥–∑’ËøÕ°‡≈◊Õ¥ √à“ß°“¬®–¡’ metabolic rate ‡æ‘Ë¡¢÷Èπ ∑—Èß Õß “‡Àμÿπ’È∑”„Àâ√à“ß°“¬¡’Õÿ≥À¿Ÿ¡‘ Ÿß¢÷Èπ√–À«à“ßøÕ°‡≈◊Õ¥ ®“°°“√»÷°…“æ∫„π°“√ „™âπÈ”¬“øÕ°‡≈◊Õ¥∑’ËÕÿ≥À¿Ÿ¡‘ 36.5- 37°C æ∫«à“ª√‘¡“≥§«“¡√âÕπ∑’Ë Ÿ≠‡ ’¬ºà“πμ—«°√Õß®–πâÕ¬°«à“ §«“¡√âÕπ∑’ˇ°‘¥¢÷Èπ„π√à“ß°“¬∑”„ÀâÕÿ≥À¿Ÿ¡‘„π√à“ß°“¬‡æ‘Ë¡¢÷Èπ®“°‡¥‘¡ ¥—ßπ—Èπ∂â“„™âπÈ”¬“øÕ°‡≈◊Õ¥∑’Ë¡’ Õÿ≥À¿Ÿ¡‘‡∑à“°—∫À√◊ՠߟ °«à“Õÿ≥À¿Ÿ¡‘¢Õß√à“ß°“¬¢ÕߺŸâªÉ«¬ ®–∑”„À⇰‘¥§«“¡√âÕπ – ¡„π√à“ß°“¬¢≥– øÕ°‡≈◊Õ¥ ‡¡◊ËÕÕÿ≥À¿Ÿ¡‘„π√à“ß°“¬ Ÿß¢÷Èπ∂÷ß®ÿ¥Ê Àπ÷Ëß (threshold) ®–°√–μÿâπ„À⇰‘¥°“√¢¬“¬μ—«¢Õß ‡ âπ‡≈◊Õ¥ à«πª≈“¬‡æ◊ËÕ√–∫“¬§«“¡√âÕπÕÕ°®“°·°π°≈“ß√à“ß°“¬ (core temperature) ∑”„À⇰‘¥ §«“¡¥—π‚≈À‘μμË”√–À«à“ßøÕ°‡≈◊Õ¥‰¥â ¥—ßπ—Èπ°“√°”Àπ¥Õÿ≥À¿Ÿ¡‘¢ÕßπÈ”¬“øÕ°‡≈◊Õ¥®÷ß¡’§«“¡ ”§—≠ „π°“√™à«¬√–∫“¬§«“¡√âÕπ∑’ˇ°‘¥¢÷Èπ„π√à“ß°“¬ ºà“πÕÕ°∑“ßμ—«°√Õß·≈–πÈ”¬“øÕ°‡≈◊Õ¥ ‡§√◊ËÕß‰μ ‡∑’¬¡∑—Ë«‰ª “¡“√∂μ—Èߧà“Õÿ≥À¿Ÿ¡‘πÈ”¬“øÕ°‡≈◊Õ¥μË”≈ß·∫∫§ß∑’ˉ¥â (fixed dialysate temperature) π‘¬¡ μ—ÈßÕ¬Ÿà„π™à«ß 35.5-36°C Õ¬à“߉√°Áμ“¡°“√°”Àπ¥Õÿ≥À¿¡Ÿ ‘πÈ”¬“øÕ°‡≈◊Õ¥∑’ËμË”≈ß¡“°‡°‘π‰ª Õ“®∑”„Àâ ºŸâªÉ«¬√⟠÷°‰¡à ∫“¬·≈–¡’Õ“°“√Àπ“« —Ëπ‰¥â ªí®®ÿ∫—π¡’‡§√◊ËÕ߉μ‡∑’¬¡∑’Ë¡’ online temperature sensor ´÷Ëß μ√«®«¥— Õ≥ÿ À¿¡Ÿ ‡‘ ≈Õ◊ ¥∑Õ’Ë Õ°®“°μ«— ºªâŸ «É ¬∑“ß arterial line ·≈– Õ≥ÿ À¿¡Ÿ ‡‘ ≈Õ◊ ¥∑°’Ë ≈∫— ‡¢“â  ºàŸ ªŸâ «É ¬∑“ß venous line ·≈–¡’√–∫∫™à«¬„π°“√ª√—∫Õÿ≥À¿¡Ÿ ‘„ππÈ”¬“øÕ°‡≈◊Õ¥·∫∫Õ—μ‚π¡—μ‘ ´÷Ëß√–∫∫°“√∑”ß“π¢Õß online temperature monitoring ¡’ 2 ·∫∫ 1) ·∫∫§«∫§ÿ¡ª√‘¡“≥æ≈—ßß“π§«“¡√âÕπ®“°«ß®√‡≈◊Õ¥πÕ°√à“ß°“¬∑’Ë®–‡¢â“·≈–ÕÕ°®“° ºªŸâ «É ¬¡À’ π«à ¬«¥— ‡ªπì °‚‘ ≈®≈Ÿ μÕà ™«—Ë ‚¡ß´ß÷Ë √–∫∫π ’È “¡“√∂ª√∫—  ¡¥≈ÿ ¢Õßæ≈ß— ß“π§«“¡√Õâ π‰¥μâ “¡μÕâ ß°“√ ‚¥¬μßÈ— ‡ªπì μ«— ‡≈¢∫«°À√Õ◊ ≈∫ À√Õ◊ ‡ªπì »πŸ ¬‰å ¥μâ “¡μÕâ ß°“√ „π°√≥∑’ ‰Ë’ ¡μà Õâ ß°“√„À¡â °’ “√∂“à ¬‡∑§«“¡√Õâ π μ—Èß§à“‡ªìπ 0 °‘‚≈®≈Ÿ μàÕ™—Ë«‚¡ß®–‡√’¬°«à“ thermoneutral23 2) ·∫∫§«∫§¡ÿ Õ≥ÿ À¿¡Ÿ √‘ “à ß°“¬¢ÕߺªâŸ «É ¬‚¥¬«¥— Õ≥ÿ À¿¡Ÿ ‡‘ ≈Õ◊ ¥∑Õ’Ë Õ°®“°μ«— ºªâŸ «É ¬∑“ßarterial line ·≈–ª√—∫„Àâ§ß∑’Ëμ≈Õ¥‡«≈“∑’ËøÕ°‡≈◊Õ¥ ‚¥¬√–∫∫π’È®–ª√—∫‡ª≈’ˬπÕÿ≥À¿Ÿ¡‘‡≈◊Õ¥πÈ”¬“øÕ°‡≈◊Õ¥ ‡æ¡‘Ë ¢π÷È À√Õ◊ ≈¥≈߇æÕ◊Ë „ÀÕâ ≥ÿ À¿¡Ÿ √‘ “à ß°“¬¢ÕߺªâŸ «É ¬∑«’Ë ¥— ®“° arterial line §ß∑’Ë ‡√¬’ °«∏‘ °’ “√π«’È “à isothermic23 √–∫∫π’È®–‰¡à π„®°“√‡ª≈’ˬπ·ª≈ߢÕßæ≈—ßß“π§«“¡√âÕπ∑’Ë∂à“¬‡∑ÕÕ°®“°ºŸâªÉ«¬ ‚¥¬∑—Ë«‰ª‡¡◊ËÕμ—È߇ªìπ isothermic ¡—°¡’°“√∂à“¬‡∑§«“¡√âÕπÕÕ°®“°μ—«ºŸâªÉ«¬ √–∫∫ online temperature monitoring π’È¡’¢âÕ¥’§◊Õ ™à«¬§«∫§ÿ¡‰¡à„Àâ√à“ß°“¬¡’ªí≠À“‡√◊ËÕß °“√√–∫“¬§«“¡√âÕπÕÕ°®“°√à“ß°“¬√–À«à“ßøÕ°‡≈◊Õ¥ ™à«¬≈¥‚Õ°“ ‡°‘¥§«“¡¥—π‚≈À‘μμË”®“°°“√∑’Ë ¡’§«“¡√âÕπ – ¡„π√à“ß°“¬ ‚¥¬∑’ˉ¡à∑”„À⇰‘¥Õ“°“√‰¡à ∫“¬·≈–Àπ“« —Ëπ®“°Õÿ≥À¿Ÿ¡‘πÈ”¬“øÕ° ‡≈◊Õ¥∑’ËμË”‡°‘π‰ª ‡À¡◊Õπ„π°√≥’∑’Ë„™â fixed dialysate temperature 54

Know How! Know Why!! in Chronic Hemodialysis Prescription 4.6 °“√°”Àπ¥Õ—μ√“°“√¥ß÷ π”È ·≈– dry weight πÈ”Àπ°— μ«— ·Àßâ À√Õ◊ çdry weighté §Õ◊ πÈ”Àπ°— μ«— À≈ß— øÕ°‡≈Õ◊ ¥¢ÕߺªŸâ «É ¬∑‰’Ë ¡¡à  ’ “√πÈ” «à π‡°π‘ °“√ª√–‡¡‘π∑“ߧ≈‘π‘°‚¥¬∑—Ë«‰ªÀ¡“¬∂÷ß πÈ”Àπ—°μ—«À≈—ßøÕ°‡≈◊Õ¥∑’Ë¥÷ß “√πÈ” à«π‡°‘πÕÕ°À¡¥ ‚¥¬∑’Ë ºâŸªÉ«¬‰¡à¡’Õ“°“√∫«¡ ‰¡à¡’§«“¡¥—π‚≈À‘μ Ÿß ·≈–‰¡à‡°‘¥§«“¡¥—π‚≈À‘μμË”¢≥–øÕ°‡≈◊Õ¥ Õ¬à“߉√ °Áμ“¡‰¡à¡’ Ÿμ√„π°“√§”π«≥À“ dry weight ∑’Ë·¡à𬔠 à«π¡“°„™â«‘∏’ trial and error §◊Õ∑¥≈Õߪ√—∫ ‡ª≈’ˬπ‡ª≈’ˬππÈ”Àπ—°μ—«À≈—ßøÕ°‡≈◊Õ¥‚¥¬¥ŸÕ“°“√∑“ߧ≈‘π‘°ª√–°Õ∫ ‚¥¬∑—Ë«‰ª‡¡◊Ëպ⟪ɫ¬¡’πÈ”„π √à“ß°“¬§—Ë߇°‘π 3 °‘‚≈°√—¡¢÷Èπ‰ª¡—°μ√«®æ∫Õ“°“√∫«¡ ¥—ßπ—Èπ∂⓺ŸâªÉ«¬¬—ß¡’Õ“°“√∫«¡·≈–¡’§«“¡¥—π ‚≈À‘μ ßŸ Õ“®≈Õߪ√—∫ dry weight ≈¥≈߉¥âÕ’° ∂â“ dry weight ∑’Ëμ—È߉«âμË”‡°‘π‰ª ∑”„Àâ¥÷ßπÈ”ÕÕ°¡“°‡°‘𠉪ºŸâªÉ«¬Õ“®¡’§«“¡¥—π‚≈À‘μμË”¢≥–øÕ°‡≈◊Õ¥‰¥â ‚¥¬‡©æ“–„π™—Ë«‚¡ß∑â“¬Ê ∫“ß√“¬Õ“®¡’Õ“°“√ ÕàÕπ‡æ≈’¬ «‘߇«’¬π À√◊Õμ–§√‘«°≈â“¡‡π◊ÈÕÀ≈—ßøÕ°‡≈◊Õ¥ „π°√≥’π’ȧ«√μ—Èß dry weight „Àâ ßŸ ¢÷Èπ dry weight ‰¡à„™à§à“§ß∑’Ë §«√¡’°“√ª√–‡¡‘πºâŸªÉ«¬‡ªìπ√–¬–Ê ·≈–ª√—∫‡ª≈’ˬπ dry weight ‰ªμ“¡Õ“°“√∑“ߧ≈‘π‘°∑’ˇª≈’ˬπ·ª≈߉ª ºâŸªÉ«¬∑’Ë√—∫ª√–∑“πÕ“À“√‰¥â¥’ Õ“®¡’πÈ”Àπ—°μ—«‡æ‘Ë¡¢÷Èπ®“° ¡«≈°≈â“¡‡π◊ÈÕ∑’ˇæ‘Ë¡¢÷Èπ °ÁμâÕߪ√—∫ dry weight ¢÷Èπμ“¡ „π∑“ß°≈—∫°—π°√≥’∑’˺⟪ɫ¬‰¡à ∫“¬ √—∫ ª√–∑“πÕ“À“√‰¥âπâÕ¬≈ß®“°¿“«–μ‘¥‡™◊ÈÕÀ√◊Õ®“° “‡ÀμÿÕ◊ËπÊ Õ“®∑”„Àâ¡«≈°≈â“¡‡π◊ÈÕ≈¥≈ß °ÁμâÕß ª√—∫≈¥ dry weight ≈ßμ“¡ ‰¡à‡™àππ—ÈπºâŸªÉ«¬Õ“®‡°‘¥¿“«–πÈ”‡°‘π ®π‡°‘¥ pulmonary edema ‰¥â ´÷Ëß¡—° ®–¡’Õ“°“√ÀÕ∫‡Àπ◊ËÕ¬πÕπ√“∫‰¡à‰¥â μâÕßμ◊Ëπ¡“π—Ë߇Àπ◊ËÕ¬À√◊Õ‰ÕμÕπ°≈“ߧ◊π ‚¥¬‡©æ“–§◊π«—π°àÕπ∑’Ë ®–¡“øÕ°‡≈◊Õ¥ °“√°”Àπ¥§à“ dry weight ∑”„Àâ –¥«°„π°“√§”π«≥ª√‘¡“≥πÈ”∑’ËμâÕߥ÷ßÕÕ°®“°√à“ß°“¬ ‚¥¬„™âπÈ”Àπ—°°àÕπ°“√øÕ°‡≈◊Õ¥√«¡°—∫ª√‘¡“≥ “√πÈ”∑’ˉ¥â√—∫√–À«à“ßøÕ°‡≈◊Õ¥ (‡™àπ πÈ”‡°≈◊Õ∑’Ë„™â ¢≥–§◊π‡≈◊Õ¥„ÀâºâŸªÉ«¬ √«¡∂÷ߪ√‘¡“≥ “√πÈ”Õ◊ËπÊ ∑’˺ŸâªÉ«¬‰¥â√—∫À√◊Õ√—∫ª√–∑“π√–À«à“ßøÕ°‡≈◊Õ¥) ≈∫ ¥â«¬πÈ”Àπ—° dry weight º≈μà“ß∑’ˉ¥â®–‡∑à“°—∫®”π«π≈‘μ√¢ÕßπÈ”∑’ËμâÕߥ÷ßÕÕ°®“°√à“ß°“¬ „πºŸâªÉ«¬∑’Ë¡’ªí≠À“§«“¡¥—π‚≈À‘μμË”√–À«à“ßøÕ°‡≈◊Õ¥ πÕ°®“°„™â sodium profiling Õ“®„™â ultrafiltration profiling √à«¡¥â«¬ ´÷Ëß¡’„π‡§√◊ËÕ߉μ‡∑’¬¡∫“ß√ÿàπ ∑”„Àâ “¡“√∂°”Àπ¥Õ—μ√“°“√¥÷ßπÈ”∑’Ë ·μ°μ“à ß°π— „π·μ≈à –™«à ߢÕß°“√øÕ°‡≈Õ◊ ¥ ´ßË÷ ¡°— μßÈ— „À¥â ß÷ π”È ¡“°„πμÕπμπâ ¢Õß°“√øÕ°‡≈Õ◊ ¥·≈–§Õà ¬Ê ≈¥≈ß„π™à«ß∑⓬ ¡’À≈“¬√ªŸ ·∫∫„Àâ‡≈◊Õ°‡À¡◊Õπ sodium profiling πÕ°®“°π’È∫“ß√ÿàπ¢Õ߇§√◊ËÕ߉μ‡∑’¬¡ ¬—ßÕÿª°√≥å blood volume monitoring ´÷Ëß™à«¬μ‘¥μ“¡°“√‡ª≈’ˬπ·ª≈ߢÕß “√πÈ”„πÀ≈Õ¥‡≈◊Õ¥ ·≈–  “¡“√∂ª√—∫‡ª≈’ˬπ°“√¥÷ßπÈ” ∑”„Àâ “¡“√∂¥÷ßπÈ”∂÷ß dry weight ‰¥â·≈–ªÑÕß°—π‰¡à„Àâ “√πÈ”„πÀ≈Õ¥ ‡≈◊Õ¥≈¥μË”‡°‘π‰ª®π‡°‘¥§«“¡¥—π‚≈À‘μμË” 4.7 Anticoagulant Õà“π‡æ‘Ë¡‡μ‘¡„π∫∑§«“¡ anticoagulant 4.8 °“√§«“¡¥—π‚≈Àμ‘ „πºªâŸ É«¬øÕ°‡≈Õ◊ ¥ °“√§«∫§¡ÿ ª√¡‘ “≥ “√πÈ”„π√“à ß°“¬‚¥¬∑”„Àºâ ªŸâ «É ¬¡π’ È”Àπ°— μ«— „°≈‡â §¬’ ßπÈ”Àπ°— ·Àßâ „À¡â “° ∑’Ë ÿ¥ ‡ªìπªí®®—¬ ”§—≠¡“°„π°“√§«∫§ÿ¡§«“¡¥—π‚≈À‘μ ¥—ßπ—Èπ®÷ß®”‡ªìπμâÕß„À⧫“¡√Ÿâ·≈–§”·π–π” 55

Practical Dialysis in the Year 2009 „π°“√ªØ‘∫—μ‘μ—«·°àºâŸªÉ«¬„π°“√§«∫§ÿ¡°“√¥◊Ë¡πÈ”·≈–‡°≈◊Õ·√à ‚¥¬Õ“À“√∑’Ë√—∫ª√–∑“π§«√¡’ª√‘¡“≥ ‡°≈◊Õ‚´‡¥’¬¡ª√–¡“≥ 2 °√—¡μàÕ«—π 欓¬“¡‰¡à„ÀâπÈ”Àπ—°μ—«√–À«à“ß∑’ˉ¡à‰¥âøÕ°‡≈◊Õ¥‡æ‘Ë¡¢÷Èπ¡“°‡°‘𠉪 (< 0.5-1 °°./«—π) °“√»÷°…“„πºŸâªÉ«¬∑’ËøÕ°‡≈◊Õ¥§√—Èß≈– 8 ™—Ë«‚¡ß 3 §√—ÈßμàÕ —ª¥“Àå √à«¡°—∫°“√ ®”°—¥Õ“À“√∑’Ë¡’‚´‡¥’¬¡μË” À√◊Õ „πºâŸªÉ«¬∑’ËøÕ°‡≈◊Õ¥μÕπ°≈“ߧ◊π —ª¥“Àå≈– 6-7 §√—Èß (nocturnal daily hemodialysis) æ∫«à“√âÕ¬≈– 90 ¢Õߺ⟪ɫ¬‡À≈à“π’È¡’§«“¡¥—π‚≈À‘μª°μ‘‚¥¬‰¡à®”‡ªìπμâÕ߉¥â√—∫¬“≈¥ §«“¡¥—π‚≈À‘μ Õ¬à“߉√°Áμ“¡ à«π„À≠à¢ÕߺŸâªÉ«¬∑’ËøÕ°‡≈◊Õ¥ 2-3 §√—ÈßμàÕ —ª¥“Àå §√—Èß≈– 4 ™—Ë«‚¡ß¡—°‰¡à  “¡“√∂¥÷ß “√πÈ”„Àâ∂÷ßπÈ”Àπ—°·Àâ߉¥â ¡—°μâÕ߉¥â√—∫¬“≈¥§«“¡¥—π‚≈À‘μ√à«¡¥â«¬∂÷ß®–§«∫§ÿ¡§«“¡ ¥—π‚≈À‘μ‰¥â §”·π–π”¢Õß K/DOQI „πªï 2005 ´÷Ë߇ªì𧔷π–π”√–¥—∫ C §◊Õ‡ªì𧫓¡‡ÀÁπ·≈–°“√ »÷°…“¬âÕπÀ≈—ß ·π–π”„Àâ§ÿ¡§«“¡¥—π‚≈À‘μ°àÕπøÕ°‡≈◊Õ¥ 140/90 ¡¡.ª√Õ∑·≈–À≈—ßøÕ°‡≈◊Õ¥ 130/80 ¡¡.ª√Õ∑24 4.9 Nutrition prescription ºŸâªÉ«¬øÕ°‡≈◊Õ¥§«√‰¥â√—∫‚ª√μ’π 1.2 °√—¡/°.°./«—π ‡æ◊ËÕ„Àâ·πà„®«à“‰¥â√—∫‚ª√μ’π‡æ’¬ßæÕμàÕ §«“¡μâÕß°“√¢Õß√à“ß°“¬ ‚¥¬¡“°°«à“√âÕ¬≈– 50 ¢Õß‚ª√μ’π∑’˧«√‰¥â√—∫ ‡ªìπ‚ª√μ’π™π‘¥∑’Ë¡’§ÿ≥¿“æ ßŸ (high biological value) §◊Õ ‚ª√μ’π∑’Ë¡’°√¥Õ–¡‘‚𮔇ªìπ§√∫∂â«π„π —¥ à«π∑’ˇÀ¡“– ¡ (‡™àπ ‰¢à ‡π◊ÈÕ —μ«å)  à«π„À≠à¢ÕߺŸâªÉ«¬∑’Ë√—∫ª√–∑“π‚ª√μ’πμË”°«à“ 0.75°√—¡/°.°./«—π ∂◊Õ«à“‰¡à‡æ’¬ßæÕ „πºâŸªÉ«¬øÕ°‡≈◊Õ¥ ∑’ËÕ¬àŸ„π ¿“«–§ß∑’Ë (‡™àπ ‰¡àÕ¬Ÿà„π¿“«–‡®Á∫ªÉ«¬À√◊Õ‰¡à¡’¿“«–μ‘¥‡™◊ÈÕ)  “¡“√∂ª√–‡¡‘πª√‘¡“≥‚ª√μ’π ∑’ˉ¥â√—∫‚¥¬°“√§”π«≥§à“ nPNA À√◊Õ nPCR °“√®”°—¥‚ª·μ ‡´’¬¡¡“°πâÕ¬‡∑à“‰√ ¢÷Èπ°—∫ ¿“«–ºŸâªÉ«¬·μà≈–√“¬ ·≈–ª√‘¡“≥ªí  “«– „π·μà≈–«—π ‚¥¬∑—Ë«‰ª∂â“ªí  “«–¬—ß¡“°°«à“ 1 ≈‘μ√·≈–√–¥—∫‚ª·μ ‡´’¬¡„π‡≈◊Õ¥ª°μ‘ ¬—߉¡à®”‡ªìπ μâÕß®”°—¥ª√‘¡“≥‚ª·μ ‡´’¬¡„πÕ“À“√ ºŸâªÉ«¬øÕ°‡≈◊Õ¥∑’Ë¡’ªí  “«–πâÕ¬„Àâ®”°—¥Õ“À“√∑’Ë¡’ ‚ª·μ ‡´’¬¡‰¡à‡°‘π 2-3 °√—¡/«—π ª√‘¡“≥·§≈‡´’¬¡ (elemental calcium) „πÕ“À“√·≈–·§≈‡´’¬¡∑’ˉ¥â√—∫ ®“° phosphate binder √«¡°—π‰¡à§«√‡°‘π 2,500 ¡°./«—π  ”À√—∫ª√‘¡“≥‡°≈◊Õ·√àÕ◊ËπÊ ∑’˧«√‰¥â√—∫· ¥ß ¥—ßμ“√“ß∑’Ë 6 μ“√“ß∑’Ë 6 ª√‘¡“≥∑Ë’§«√‰¥â√—∫ 30-35 °‘‚≈·§≈Õ√’Ë/°.°./«—π ‚¿™π∫”∫—¥„πºâŸªÉ«¬∑’ˉ¥â√—∫øÕ°‡≈◊Õ¥ 1.2 °√—¡/°.°./«—π  “√Õ“À“√ 2-3 °√—¡/«—π æ≈—ßß“π 2-3 °√—¡/«—𠂪√μ’π 800-1,200 ¡°./«—π À√◊Õ < 17 ¡°./°.°. ‚´‡¥’¬¡ 1,000-1,800 ¡°./«—𠂪·μ ‡´’¬¡ øÕ øÕ√—  ·§≈‡´’¬¡ 56

Know How! Know Why!! in Chronic Hemodialysis Prescription 5. °“√ª√–‡¡‘πº≈°“√μ√«®∑“ßÀâÕߪؑ∫—μ‘°“√ 1) Serum albumin §«√μ√«®Õ¬à“ßπâÕ¬∑ÿ° 3 ‡¥◊Õπ æ∫«à“√–¥—∫ serum albumin ∑’ËπâÕ¬ °«à“ 4 °./¥≈.  —¡æ—π∏å°—∫Õ—μ√“°“√‡®Á∫ªÉ«¬·≈–Õ—μ√“‡ ’¬™’«‘μ∑’ˇæ‘Ë¡¢÷Èπ ‚¥¬‡©æ“–∂â“μË”¡“°°«à“ 3 ¡°./ ¥≈. §“à ∑μË’ ”Ë Õ“®‡°¥‘ ®“°¿“«–∑æÿ ‚¿™π“°“√ À√Õ◊ Õ“®‡°¥‘ ®“°¿“«–Õ°— ‡ ∫·∫∫‡©¬’ ∫æ≈π— À√Õ◊ ·∫∫‡√ÕÈ◊ √ß— (acute or chronic inflammation) 2) Blood urea nitrogen (BUN) §«√ àßμ√«® §à“ BUN °àÕπøÕ°‡≈◊Õ¥·≈–À≈—ßøÕ°‡≈◊Õ¥ Õ¬à“ßπâÕ¬ 1 §√—Èß/‡¥◊Õπ ‡æ◊ËÕ„™â„π°“√§”π«≥À“§à“ spKt/V ·≈– nPNA 3) Serum creatinine §à“‡©≈’ˬª√–¡“≥ 12-15 ¡°./¥≈. (range 8-20 ¡°./¥≈.) æ∫«à“ serum creatinine ∑’Ë Ÿß¡’Õ—μ√“°“√쓬∑’ËμË”°«à“ ‡π◊ËÕß®“° serum creatinine ‡ªìπμ—«∫àß™’È¡«≈°≈â“¡‡π◊ÈÕ·≈– ¿“«–‚¿™π“°“√ ∂â“æ∫«à“ serum creatinine μË”°«à“ 10 ¡°./¥≈. §«√μ√«® Õ∫·≈–·°â‰¢¿“«– ‚¿™π“°“√¢ÕߺŸâªÉ«¬ °“√·ª≈º≈ serum creatinine §«√æ‘®“√≥“√à«¡°—∫§à“ BUN ∂â“°“√‡ª≈’ˬπ·ª≈ß ∑—Èß Õ߉ª¥â«¬°—π Õ“®‡°‘¥®“°°“√‡ª≈’ˬπ·ª≈ß dialysis prescription À√◊Õ residual renal function ·μà∂â“ serum creatinine §ß∑Ë’ ·μ¡à °’ “√‡ª≈¬Ë’ π·ª≈ߢÕߧ“à BUN Õ“®‡°¥‘ ®“°°“√‡ª≈¬Ë’ π·ª≈ߢÕß protein intake À√◊Õ‡°‘¥®“° catabolic rate ∑’ˇª≈’ˬπ·ª≈ß 4) Serum total cholesterol §«√μ√«®∑ÿ° 3-6 ‡¥◊Õπ §à“∑’ˇÀ¡“– ¡ 200-250 ¡°./¥≈. √–¥—∫ cholesterol ∑’ËμË”°«à“ 150-180 ¡°./¥≈.  —¡æ—π∏å°—∫Õ—μ√“°“√‡ ’¬™’«‘μ∑’Ë Ÿß¢÷Èπ (KDOQI 2000) 5) √–¥∫— ‚ª·μ ‡´¬’ ¡„π‡≈◊Õ¥ §«√μ√«®∑ÿ° 1 ‡¥◊Õπ §à“∑’ˇÀ¡“– ¡Õ¬Ÿà„π™à«ß 5.0-5.5 ¡‘≈≈‘ ‚¡≈/≈‘μ√ √–¥—∫∑’Ë Ÿß°«à“ 6.5 À√◊Õ μË”°«à“ 3.5 ¡‘≈≈‘‚¡≈/≈‘μ√  —¡æ—π∏å°—∫Õ—μ√“°“√‡ ’¬™’«‘μ∑’Ë Ÿß¢÷Èπ 6) √–¥—∫·§≈‡´’¬¡·≈–øÕ ‡øμ„π‡≈◊Õ¥ §«√μ√«®∑ÿ° 1 ‡¥◊Õπ √–¥—∫∑’ˇÀ¡“– ¡¢Õß ·§≈‡´’¬¡„π‡≈◊Õ¥Õ¬àŸ„π™à«ß 8.8-9.5 ¡°./¥≈. æ∫«à“√–¥—∫¢Õß·§≈‡´’¬¡„π‡≈◊Õ¥∑’Ë Ÿß°«à“ 12 ¡°./¥≈.À√◊Õ μË”°«à“ 7 ¡°./¥≈.  —¡æ—π∏å°—∫Õ—μ√“°“√‡ ’¬™’«‘μ∑’ˇæ‘Ë¡¢÷Èπ ∂â“√–¥—∫·§≈‡´’¬¡„π‡≈◊Õ¥ (corrected serum calcium)  ßŸ °«à“ 10.2 ¡°./¥≈. §«√æ‘®“√≥“ª√—∫‡ª≈’ˬπ°“√√—°…“∑’ËÕ“®¡’º≈μàÕ√–¥—∫·§≈‡´’¬¡„π‡≈◊Õ¥ ¥—ßπ’È - À¬ÿ¥„™â«‘μ“¡‘π¥’™—Ë«§√“« - ª√∫— ‡ª≈¬Ë’ π¢π“¥¢Õß calcium-based phosphate binder À√Õ◊ ‡ª≈¬Ë’ π‰ª„™â non-calcium-based phosphate binder - ∂“â √–¥∫— ·§≈‡´¬’ ¡„π‡≈Õ◊ ¥¬ß—  ßŸ Õ¬Ÿà (>10.2 ¡°./¥≈.) À≈ß— À¬¥ÿ «μ‘ “¡π‘ ¥·’ ≈–ª√∫— ‡ª≈¬’Ë π¢π“¥ calcium-based phosphate binder ·≈â« Õ“®æ‘®“√≥“„™âπÈ”¬“øÕ°‡≈◊Õ¥∑’Ë¡’§«“¡‡¢â¡¢âπ¢Õß·§≈‡´’¬¡μË” ≈ß „π°√≥’∑’Ë„™â√–¥—∫§«“¡‡¢â¡¢âπ¢Õß·§≈‡´’¬¡ 2.5 mEq/≈‘μ√ Õ¬àŸ·≈â« Õ“®≈¥‡À≈◊Õ 2.0 mEq/≈‘μ√ ™—Ë«§√“«‡ªìπ‡«≈“ 3-4  —ª¥“Àå ·≈⫪√–‡¡‘πÕ’°§√—Èß √–¥∫— ∑‡’Ë À¡“– ¡¢ÕßøÕ ‡øμ„π‡≈Õ◊ ¥§«√μË”°«“à 5.5 ¡°./¥≈. ·≈–º≈§≥Ÿ ¢Õß√–¥∫— ·§≈‡´¬’ ¡ ·≈–¢Õß√–¥—∫¢ÕßøÕ ‡øμ (Ca X P product) ‰¡à§«√‡°‘π 55 ¡°.2/¥≈.2 7) Serum alkaline phosphatase §«√«—¥∑ÿ° 3 ‡¥◊Õπ §à“ª°μ‘ (30-115 ¬πŸ ‘μ/≈‘μ√) √–¥—∫∑’Ë πâÕ¬°«à“ 100 ¬πŸ ‘μ/≈‘μ√æ∫«à“Õ—μ√“°“√‡ ’¬™’«‘μμË” ÿ¥ √–¥—∫∑’ˠߟ °«à“ 150 ¬Ÿπ‘μ/≈‘μ√  —¡æ—π∏å°—∫Õ—μ√“ 57

Practical Dialysis in the Year 2009 °“√‡ ’¬™’«‘μ∑’ˇæ‘Ë¡¢÷Èπ 8) √–¥—∫‰∫§“√å∫Õ‡πμ„π‡≈◊Õ¥ §«√«—¥∑ÿ° 1 ‡¥◊Õπ √–¥—∫∑’ˇÀ¡“– ¡Õ¬Ÿà„π™à«ß 20-22.5 ¡‘≈≈‘‚¡≈/≈‘μ√ §à“∑’Ë Ÿß°«à“π’È®–‡ ’ˬßμàÕ°“√‡°‘¥ vascular calcification ‡æ‘Ë¡¢÷Èπ „π¢≥–∑’˧à“∑’ËμË”°«à“§à“ ¥—ß°≈à“« ®–°√–μÿâπ°“√ ≈“¬‚ª√μ’π®“°°≈â“¡‡π◊ÈÕ ·≈–¡’º≈μàÕ°√–¥Ÿ° ‡π◊ËÕß®“°„™â buffer „π°√–¥Ÿ° §à“∑’ËμË”°«à“ 15 ¡‘≈≈‘‚¡≈/≈‘μ√ æ∫«à“ —¡æ—π∏å°—∫Õ—μ√“°“√‡ ’¬™’«‘μ∑’ˇæ‘Ë¡¢÷Èπ 9) Hemoglobin (Hb), hematocrit (Hct), serum ferritin ·≈– transferrin saturation [serum iron/ total iron binding capacity (TIBC)] §à“ Hb ·≈– Hct §«√μ√«®Õ¬à“ßπâÕ¬∑ÿ° 1 ‡¥◊Õπ √–¥—∫∑’ˇÀ¡“– ¡§«√Õ¬Ÿà√–À«à“ß 11-12 °√—¡ ·≈– 33-36% μ“¡≈”¥—∫  à«π ferritin, transferrin saturation §«√μ√«®∑ÿ° 3 ‡¥◊Õπ √–¥—∫ ferritin §«√ ßŸ °«à“ 200 π“‚π°√—¡/¡≈. ·≈– transferrin saturation §«√¡“° °«à“√âÕ¬≈– 20 10) Hepatitis profile screening ·≈– HIV serology §«√μ√«®∑ÿ° 6-12 ‡¥◊Õπ 11) Serum parathyroid hormone §«√μ√«®∑ÿ° 6 ‡¥◊Õπ §à“∑’ˇÀ¡“– ¡Õ¬Ÿà„π™à«ß 100-300 æ‘‚§°√—¡/¡≈. 6. °“√ª√–‡¡‘πºªŸâ É«¬°àÕπ°“√øÕ°‡≈Õ◊ ¥ °àÕπ°“√øÕ°‡≈◊Õ¥§«√ª√–‡¡‘π·≈–∫—π∑÷°¢âÕ¡Ÿ≈μàÕ‰ªπ’È 1) πÈ”Àπ°— μ«— °Õà π°“√øÕ°‡≈Õ◊ ¥ ‡ªìπ¥—™π’∑’Ë¥’„π°“√ª√–‡¡‘π«à“ ºâŸªÉ«¬§«∫§ÿ¡°“√¥◊Ë¡πÈ” ¡“°πâÕ¬‡æ’¬ß„¥ ‚¥¬‡ª√’¬∫‡∑’¬∫°—∫πÈ”Àπ—°μ—«À≈—ß®“°°“√øÕ°‡≈◊Õ¥§√—Èß∑’Ë·≈â« ·≈–ª√–‡¡‘ππÈ”Àπ—° μ—«∑’ˇæ‘Ë¡¢÷Èπ®“° dry weight ∑’Ë°”Àπ¥‰«â ®–∑”„Àâ∑√“∫ª√‘¡“≥πÈ”∑’ËμâÕߥ÷ßÕÕ°®“°μ—«ºâŸªÉ«¬ °“√μ—Èß ª√‘¡“≥πÈ”∑’ËμâÕߥ÷ßÕÕ°‰¡à„™à§‘¥‡∑’¬∫°—∫πÈ”Àπ—°μ—«À≈—ßøÕ°‡≈◊Õ¥§√—Èß°àÕπ ‡æ√“–πÈ”Àπ—°μ—«À≈—ßøÕ° ‡≈◊Õ¥§√—Èß°àÕπÕ“®¡“°°«à“À√◊ÕπâÕ¬°«à“dry weight ‰¥â Õ“®∑”„Àâª√‘¡“≥πÈ”∑’Ë¥÷ßÕÕ°®“°ºâŸªÉ«¬‰¡à∂Ÿ° μâÕß∑”„À⇰‘¥ªí≠À“ ∂â“¥÷ßπÈ”ÕÕ°‰¡àÀ¡¥®–∑”„À⇰‘¥¿“«– volume overload ÀÕ∫‡Àπ◊ËÕ¬ À√◊Õ„π°√≥’ ∑’Ë¥÷ßπÈ”ÕÕ°¡“°‰ªÕ“®∑”„À⇰‘¥μ–§√‘«À√◊Õ§«“¡¥—π‚≈À‘μμË”‰¥â 2) §«“¡¥π— ‚≈Àμ‘  «à π„À≠§à «“¡¥π— ‚≈Àμ‘ ∑ ’Ë ßŸ ¢π÷È °Õà π°“√∑”°“√øÕ°‡≈Õ◊ ¥‡°¥‘ ®“°ª√¡‘ “≥ πÈ”·≈–‚´‡¥’¬¡∑’Ë√—∫ª√–∑“π‡¢â“‰ª·≈– – ¡„π√à“ß°“¬„π™à«ß√–À«à“ß∑’ˉ¡à‰¥â∑”°“√øÕ°‡≈◊Õ¥ ‡¡◊ËÕ ª√‘¡“≥πÈ” à«π‡°‘π∂Ÿ°¢®—¥ÕÕ°®“°√à“ß°“¬„π√–À«à“ß°“√∑”°“√øÕ°‡≈◊Õ¥ §«“¡¥—π‚≈À‘μ®–§àÕ¬Ê ≈¥≈ß√–À«à“ß°“√øÕ°‡≈◊Õ¥ ·≈–≈¥≈ßμË” ÿ¥À≈—ß°“√øÕ°‡≈◊Õ¥ ‚¥¬∑—Ë«‰ª∂⓺ŸâªÉ«¬‰¡à¡’ªí≠À“§«“¡¥—π ‚≈À‘μμË”√–À«à“ßøÕ°‡≈◊Õ¥ ‰¡à®”‡ªìπμâÕßÀ¬ÿ¥¬“§«“¡¥—π‚≈À‘μ«—π∑’Ë¡“øÕ°‡≈◊Õ¥ „π√“¬∑’ËÕ¬Ÿà„π™à«ß∑’Ë °”≈—ߪ√—∫≈¥ dry weight ¡—°®”‡ªìπμâÕߪ√—∫≈¥¬“§«“¡¥—π‚≈À‘μμ“¡ ‰¡à‡™àππ—ÈπÕ“®‡°‘¥§«“¡¥—π‚≈À‘μ μË”√–À«à“ßøÕ°‡≈◊Õ¥ ·≈–Õ“®‡ªì𠓇Àμÿ∑’ˉ¡à “¡“√∂¥÷ßπÈ”ÕÕ°À√◊Õª√—∫≈¥„À≥â dry weight ∑’ËμâÕß°“√ 3) Õ≥ÿ À¿¡Ÿ ‘ ∂“â ºªâŸ «É ¬¡‰’ ¢°â Õà π∑”°“√øÕ°‡≈Õ◊ ¥ ®”‡ªπì μÕâ ßÀ“ “‡Àμ¢ÿ Õ߉¢â ‚¥¬¥«Ÿ “à ¡ª’ ≠í À“ ‡√◊ËÕß°“√μ‘¥‡™◊ÈÕ ‚¥¬‡©æ“–°“√μ‘¥‡™◊ÈÕ∑’Ë vascular access Õ¬à“߉√°Áμ“¡æ∫«à“√–À«à“ßøÕ°‡≈◊Õ¥Õ“®¡’ Õÿ≥À¿¡Ÿ ‘ ßŸ ¢÷Èπ‰¥âª√–¡“≥ 0.5oC ´÷Ëß∂◊Õ«à“ª°μ‘ ‰¡à„™à«à“®–‡°‘¥®“°¿“«–μ‘¥‡™◊ÈÕ·≈– pyrogen ‡ ¡Õ‰ª 58

Know How! Know Why!! in Chronic Hemodialysis Prescription 4) ™’æ®√ §«√∫—π∑÷°∑—Èß®”π«π§√—ÈßμàÕπ“∑’ ·≈–®—ßÀ«–°“√‡μâπ ‡æ◊ËÕ‡ªìπ¢âÕ¡Ÿ≈‡ª√’¬∫‡∑’¬∫ ¢≥–∑”°“√øÕ°‡≈◊Õ¥ 5) Õ“°“√∫«¡ ∫àß™’È«à“¡’πÈ”‡°‘π„π√à“ß°“¬ Õ“°“√∫«¡¡—°æ∫∑’ËÀ≈—߇∑â“ ¢âÕ‡∑â“ Àπâ“·¢âßÀ√◊Õ ∫√‘‡«≥‡ª≈◊Õ°μ“ μ√«®√à“ß°“¬æ∫‡ âπ‡≈◊Õ¥¥”∑’˧ՂªÉßæÕß (jugular vein distension) °“√ª√–‡¡‘π Õ“°“√∫«¡®–™«à ¬„π°“√«“ß·ºπ°“√¥ß÷ πÈ”ÕÕ°®“°√“à ß°“¬·≈–™«à ¬ª√–°Õ∫°“√ª√–‡¡π‘ dry weight „À¡à ‚¥¬‡©æ“–∂⓺ŸâªÉ«¬¡’§«“¡¥—π‚≈À‘μ Ÿß√à«¡¥â«¬ 6) vascular access §«√ª√–‡¡‘π vascular access ∑ÿ°§√—Èß°àÕπ°“√øÕ°‡≈◊Õ¥ ‚¥¬¥«Ÿ à“¡’°“√ μ‘¥‡™◊ÈÕ À√◊Õ¡’ªí≠À“μ’∫μ—πÀ√◊Õ‰¡à 7. °“√ª√–‡¡π‘ ºªŸâ É«¬√–À«à“ß°“√∑”°“√øÕ°‡≈Õ◊ ¥ §«√μ√«®«—¥§«“¡¥—π‚≈À‘μ·≈–™’æ®√∑ÿ° 30-60 π“∑’ ‡π◊ËÕß®“°√–À«à“ß∑”°“√øÕ°‡≈◊Õ¥ ºŸâªÉ«¬Õ“®¡’§«“¡¥—π‚≈À‘μμË”À√◊Õ Ÿß¢÷Èπ¡“°Õ¬à“ß©—∫æ≈—π‰¥â ‡¡◊ËÕ¡’§«“¡¥—π‚≈À‘μμË” §«√μ√«®™’æ®√ ¥â«¬«à“¡’°“√‡μâπ‡√Á«À√◊ՙ⓺‘¥ª°μ‘ À√◊Õº‘¥®—ßÀ«–√à«¡¥â«¬À√◊Õ‰¡à  ”À√—∫ªí≠À“À√◊Õ¿“«–·∑√°´âÕπ √–À«à“ßøÕ°‡≈◊Õ¥ ·≈–·π«∑“ߥ·Ÿ ≈·°â‰¢ „À⥄Ÿ π∫∑§«“¡¿“«–·∑√°´âÕπ√–À«à“ßøÕ°‡≈◊Õ¥ 8. °“√ª√–‡¡π‘ ·≈–·°‰â ¢„π°√≥∑’ ª’Ë √¡‘ “≥°“√øÕ°‡≈Õ◊ ¥∑ºË’ ªŸâ «É ¬‰¥√â ∫— ‰¡‰à ¥μâ “¡ °”Àπ¥ °“√·°â‰¢ª√‘¡“≥øÕ°‡≈◊Õ¥∑’˺⟪ɫ¬‰¥â√—∫‰¡à‰¥âμ“¡∑’Ë°”Àπ¥ Õ“®«‘‡§√“–Àåªí≠À“‚¥¬Õ“»—¬ ·π«∑“ߥ—ß·ºπ¿Ÿ¡‘„π√Ÿª∑’Ë 9 ªí≠À“∑’Ëæ∫∫àÕ¬‡°‘¥®“° °“√ —Ëß°“√√—°…“∑’ˉ¡à∂Ÿ°μâÕß ªí≠À“ access recirculation ºŸâªÉ«¬ noncompliance ´÷ËßÕ“®‡°‘¥®“°μ—«ºŸâªÉ«¬‡ÕßÀ√◊Õªí≠À“∑“߇»√…∞°‘®´÷Ë߇ªìπªí≠À“ „À≠à„πª√–‡∑»‰∑¬ πÕ°®“°π’È„πºŸâªÉ«¬∑’Ë¡’ªí≠À“§«“¡¥—π‚≈À‘μμË”∫àÕ¬Ê √–À«à“ß°“√øÕ°‡≈◊Õ¥ ®”‡ªìπμâÕ߉¥â√—∫°“√·°â‰¢ ‡π◊ËÕß®“°∑”„Àâ°“√øÕ°‡≈◊Õ¥‰¡à‰¥âª√– ‘∑∏‘¿“æ‡∑à“∑’˧«√ (°≈‰°¥—ß√ªŸ ∑’Ë 10) ·π«∑“ߪ√–‡¡‘π·≈–·°â‰¢¡’¥—ßπ’È 8.1 °“√ —Ëß°“√√—°…“∑’ˉ¡à∂Ÿ°μâÕß ‡™àπ „πºŸâªÉ«¬∑’Ë¡’πÈ”Àπ—°μ—«¡“°·μà„™âμ—«°√Õß¢π“¥‡≈Á° À√◊Õ„π√“¬∑’Ë„™âμ—«°√Õß™π‘¥ high-flux À√◊Õ high-efficiency ·μà‰¡à‰¥â„™âÕ—μ√“°“√‰À≈¢Õ߇≈◊Õ¥∑’Ë Ÿß¢÷Èπ ∑”„Àâ‰¡à‰¥â„™âª√– ‘∑∏‘¿“æ¢Õßμ—«°√Õ߇μÁ¡∑’ËÀ√◊Õ‰¡à‰¥â urea clearance ‡æ‘Ë¡¢÷Èπ‡¡◊ËÕ‡∑’¬∫°—∫μ—«°√Õß™π‘¥ low-efficiency °“√‡ªî¥Õ—μ√“°“√‰À≈¢ÕßπÈ”¬“øÕ°‡≈◊Õ¥∑’Ë¡“°°«à“ 500 ¡≈./π“∑’ ®–‡æ‘Ë¡ urea clearance ‡©æ“–„π°√≥∑’ „Ë’ ™â high-efficiency dialyzer ·≈– “¡“√∂‡ª¥î Õμ— √“°“√‰À≈¢Õ߇≈Õ◊ ¥‰¥ â ߟ (> 300-350 ¡≈./ π“∑’) 8.2 °√≥’∑’ËÕ—μ√“°“√¢®—¥¬Ÿ‡√’¬‰¥âπâÕ¬°«à“∑’Ë —Ëß°“√√—°…“ „Àâæ‘®“√≥“Õߧåª√–°Õ∫ ”§—≠∑’Ë ¡’º≈μàÕÕ—μ√“°“√¢®—¥¬‡Ÿ √’¬¢Õß dialyzer ¥—ßμàÕ‰ªπ’È 1) dialyzer permeability (KoA), 2) effective dialyzer surface area, 3) blood flow rate, 4) dialysate flow 59

Practical Dialysis in the Year 2009 √Ÿª∑’Ë 9 ·π«∑“ß°“√·°â ‰¢°√≥∑’ ˪’ √¡‘ “≥øÕ°‡≈Õ◊ ¥∑’˺ŸâªÉ«¬‰¥√â ∫— ‰¡à‰¥âμ“¡∑Ë’°”Àπ¥ √Ÿª∑Ë’ 10 ª®í ®¬— μ“à ßÊ ·≈–°≈‰°∑∑’Ë ”„Àªâ √– ∑‘ ∏¿‘ “æ°“√øÕ°‡≈Õ◊ ¥≈ß≈ß„πºªâŸ «É ¬∑¡Ë’ §’ «“¡¥π— ‚≈Àμ‘ μ”Ë √–À«“à ß°“√øÕ°‡≈Õ◊ ¥ 60

Know How! Know Why!! in Chronic Hemodialysis Prescription ¢π—È μÕπ°“√ª√–‡¡π‘ ·≈–«‡‘ §√“–Àªå í≠À“ 1) μ√«® Õ∫∫—π∑÷°°“√øÕ°‡≈◊Õ¥¢ÕߺŸâªÉ«¬ ‡æ◊ËÕ¥Ÿ«à“°“√√—°…“∑’˺ŸâªÉ«¬‰¥â√—∫®√‘ßμ√ß°—∫∑’Ë —Ëß °“√√—°…“À√◊Õ‰¡à „πª√–‡¥ÁπμàÕ‰ªπ’È Õ—μ√“°“√‰À≈¢Õ߇≈◊Õ¥, Õ—μ√“°“√‰À≈¢ÕßπÈ”¬“øÕ°‡≈◊Õ¥, ™π‘¥ ¢Õßμ—«°√Õß∑’Ë„™â πÕ°®“°π’ȧ«√μ√«®¥Ÿ pre-pump arterial pressure („π°√≥’∑’Ë¡’°“√μ√«®«—¥) ´÷Ëߧà“π’È∂â“ ¡“°°«à“ -200 mmHg ®–∑”„ÀâÕ—μ√“°“√‰À≈¢Õ߇≈◊Õ¥∑’˺à“πμ—«°√Õ߉¡à‰¥â®√‘ßμ“¡∑’Ëμ—È߉«â∑’ËÀπâ“ªí¥¢Õß ‡§√◊ËÕß 2) ª√–‡¡‘π vacular access «à“¡’ªí≠À“ recirculation À√◊Õ‰¡à - μ√«® Õ∫«à“‡°‘¥®“°μ”·Àπàߪ≈“¬‡¢Á¡ (arteriovenous needle) „°≈â°—π¡“°‡°‘π‰ªÀ√◊Õ‰¡à - μ√«® Õ∫∑‘»∑“ß°“√‰À≈¢Õ߇≈◊Õ¥¢Õß vascular access ‡æ◊ËÕ¥Ÿ«à“·∑߇¢Á¡ ≈—∫μ”·Àπàß √–À«“à ß arterial °∫— venous needle À√Õ◊ ‰¡à ª≠í À“π¡È’ °— ‡°¥‘ „π°√≥∑’ „Ë’ ™‡â  πâ ‡≈Õ◊ ¥‡∑¬’ ¡∑‡Ë’ ªπì «ß‚§ßâ (looped AV graft) - μ√«® Õ∫ vascular access «à“¡’ªí≠À“‡√◊ËÕß arterial stenosis ´÷Ëß¡—°¡’ªí≠À“‡ªî¥ blood flow rate ‰¡à‰¥âμ“¡∑’ËμâÕß°“√ À√◊Õ‡°‘¥®“° venous stenosis ´÷Ëß¡—°¡’ venous pressure ∑’Ë Ÿß¡“°·≈–¡’ ªí≠À“°¥‡≈◊Õ¥À¬ÿ¥¬“°À≈—ßøÕ°‡≈◊Õ¥ 3) μ√«® Õ∫ dialyzer ∑’Ë„™â´È” ‚¥¬«—¥ total cell volume (TCV) «à“‰¥âÕ¬à“ßπâÕ¬√âÕ¬≈– 80 ¢Õߧà“μ—ÈßμâπÀ√◊Õ‰¡à 4) μ√«® Õ∫«“à √–À«“à ß°“√øÕ°‡≈Õ◊ ¥¡ª’ ≠í À“≈¡Ë‘ ‡≈Õ◊ ¥Õ¥ÿ „π dialyzer À√Õ◊ ‰¡à ‡πÕË◊ ß®“°∑”„Àâ effective dialyzer surface area ≈¥≈ß „π°√≥’π’ÈμâÕßæ‘®“√≥“«à“ “√°—π‡≈◊Õ¥·¢Áßμ—«∑’Ë„Àâ‡æ’¬ßæÕÀ√◊Õ‰¡à 8.3 ‡«≈“„π°“√øÕ°‡≈◊Õ¥®√‘ß (effective dialysis time) - μ√«® Õ∫«“à «π— ∑μË’ √«® Kt/Vurea ¡ª’ ≠í À“∑∑Ë’ ”„À‡â «≈“„π°“√øÕ°‡≈Õ◊ ¥∑ºË’ ªŸâ «É ¬‰¥√â ∫— ®√ß‘ πÕâ ¬ °«à“‡«≈“∑’Ë —Ëß°“√√—°…“À√◊Õ‰¡à 8.4 °“√‡°Á∫‡≈◊Õ¥‡æ◊ËÕ àßμ√«® BUN ∂°Ÿ «‘∏’À√◊Õ‰¡à °) pre-dialysis BUN μË”°«à“§«“¡‡ªìπ®√‘ß Õ“®æ∫‰¥â„π°√≥’μàÕ‰ªπ’È - ‡°Á∫‡≈◊Õ¥À≈—ß®“°∑’ˉ¥â‡√‘Ë¡∑”°“√øÕ°‡≈◊Õ¥‰ª·≈â« - ‡≈◊Õ¥∂°Ÿ ‡®◊Õ®“ߥ⫬πÈ”‡°≈◊Õ∑’ËÕ¬àŸ„π blood tubing ¢) post-dialysis BUN ∂Ⓡ°Á∫‡≈◊Õ¥À≈—ß ‘Èπ ÿ¥°“√øÕ°‡≈◊Õ¥™â“‡°‘π‰ª ®–‰¥â§à“ post-dialysis BUN  ßŸ °«à“§«“¡‡ªìπ®√‘ß ‡¡◊ËÕ𔉪§”π«≥§à“ spKt/Vurea ®–‰¥âμË”°«à“§«“¡‡ªìπ®√‘ß 9. °“√®¥— ∑”·ø¡Ñ ª√–«μ— º‘ ªâŸ «É ¬ Chronic hemodialysis ºŸâªÉ«¬øÕ°‡≈◊Õ¥∑ÿ°√“¬§«√¡’°“√∫—π∑÷°¢âÕ¡Ÿ≈μàÕ‰ªπ’È 1) ¢âÕ¡Ÿ≈‡°’ˬ«°—∫μ—«ºâŸªÉ«¬ ‡™àπ ™◊ËÕ-π“¡ ÿ°≈ Õ“¬ÿ ‡æ» ∑’ËÕ¬Ÿà ‡∫Õ√å‚∑√»—æ∑å∑’Ë„™â„π°“√μ‘¥μàÕ ºâŸªÉ«¬ √«¡∂÷߇∫Õ√å ‚∑√»—æ∑å¢Õß≠“μ‘À√◊Õ∫ÿ§§≈ ·≈– ∂“π∑’Ëμ‘¥μàÕ„π°√≥’©ÿ°‡©‘π 61

Practical Dialysis in the Year 2009 2) ¢âÕ¡Ÿ≈‡°’ˬ«°—∫‚√§¢ÕߺŸâªÉ«¬ ¢âÕ¡≈Ÿ ‡°’ˬ«°—∫ª√–«—μ‘∑“ß°“√·æ∑¬å¢Õߺ⟪ɫ¬ 3) ∫—π∑÷°°“√„Àâ Hepatitis B virus immunization / ∫—π∑÷°°“√μ√«®ª√–®”ªï HBsAg, anti-HBc, anti-HBs Ab titer, Anti-HCV, Anti-HIV 4) Standing order / specific order 5) Dialysis chart ∑’Ë∑”„π·μà≈–§√—Èß 6) ¢âÕ¡Ÿ≈‡°’ˬ«°—∫°“√√—°…“ ¬“∑’Ë√—∫ª√–∑“π ·≈–º≈°“√μ√«®∑“ßÀâÕߪؑ∫—μ‘°“√ 7) °“√ª√–‡¡‘πºâŸªÉ«¬ª√–®”ªï ·≈–ª√–‡¡‘𧫓¡æ√âÕ¡„πºŸâªÉ«¬∑’Ë√Õ°“√ª≈°Ÿ ∂à“¬‰μ 10.  √ÿª °“√ ßË— °“√√°— …“øÕ°‡≈Õ◊ ¥·æ∑¬μå Õâ ߧ”πß÷ ∂ß÷ ª√¡‘ “≥°“√øÕ°‡≈Õ◊ ¥∑‡Ë’ 欒 ßæÕ§«∫§¡ÿ ¥≈ÿ π”È ‡°≈◊Õ·√àμà“ßÊ ·≈–°√¥¥à“ß„ÀâÕ¬Ÿà„π‡°≥±å∑’ˇÀ¡“– ¡ §«∫§ÿ¡§«“¡¥—π‚≈À‘μ ·°â‰¢¿“«–´’¥·≈– §«∫§ÿ¡√–¥—∫‰¢¡—π„ÀâÕ¬Ÿà„π√–¥—∫∑’ˇÀ¡“– ¡ √—°…“¿“«–·∑√°´âÕπ∑’Ëæ∫√à«¡ πÕ°®“°π’ȧ«√„À⧫“¡√Ÿâ ∑“ß‚¿™π“°“√·≈–μ√«®ª√–‡¡‘π¿“«–‚¿™π“°“√ √«¡∂÷ߪ√–‡¡‘π ¿“«–®‘μ„®  ¿“«–∑“ß —ߧ¡·≈– ‡»√…∞“π– ´÷Ëß°“√¥Ÿ·≈‡À≈à“π’È®”‡ªìπ∑’Ë®–μâÕß¡’∑’¡·æ∑¬å ·≈–∫ÿ§§≈“°√∑“ß°“√·æ∑¬åÀ≈“¬ “¢“ ∑”ß“π√«à ¡°π— ‡æÕ◊Ë ∑º’Ë ªâŸ «É ¬®–‰¥√â ∫— °“√¥·Ÿ ≈·∫∫Õߧ√å «¡∑”„À°â “√ ß—Ë °“√√°— …“‰¥μâ “¡‡ª“Ñ À¡“¬∑μ’Ë Õâ ß°“√ ‡Õ° “√Õ“â ßÕß‘ 1. Corea AL. Hemodialysis orders. In: Nissenson AR, Fine RN, eds. Dialysis therapy 3th ed Hanley & Belfus, Inc 2002:145-148. 2. Clinical practice guidelines for hemodialysis adequacy, KDOQI Update 2006. Am J Kidney Dis 2006; 48(1) Suppl 1:pp S17-S23. 3. Daugirdas JT. Second generation logarithmic estimates of single-pool variable volume Kt/V: An analysis of error. J Am Soc Nephrol 1993;4:1205-1213. 4. Clinical practice guidelines for hemodialysis adequacy, KDOQI Update 2006. Am J Kidney Dis 2006; 48(1) Suppl 1:pp S28-S62. 5. Held PJ, Port FK, Wolfe RA, Stannard DC, et al. The dose of hemodialysis and patient mortality. Kidney Int 1996;50:550-6. 6. Parker TF III, Husni I, Huang W, et al. Survival of hemodialysis patients in the United states is improved with a greater quantity of dialysis. Am J Kidney Dis 1994;23:670-80. 7. Collins Aj, Ma JZ, Umen A, Keshaviah P. Urea index and other predictors of hemodialysis patient survival. Am J Kidney Dis 1994;305:1776-80. 8. Hakim RM, Breyer J, Ismail N, Schulman G. Effects of dose of dialysis on morbidity and mortality. Am J Kidney Dis 1994;23:661-9. 9. NFK-DOQI Clinical Practice Guidelines for Hemodialysis Adequacy. Am J Kidney Dis 1997;30:S111. 10. Wish JB, Webb RL, Levin AS, Port FK, Held PJ. Medical appropriateness of initiating chronic dialysis in the U.S.: Results of the revised medical evidence report pilot study. J Am Soc Nephrol 1994;5:345 (abst). 62

Know How! Know Why!! in Chronic Hemodialysis Prescription 11. Thailand Registry Patient Survival Report on Chronic Hemodialysis. Udom Krairrittichai, Thanom Supaporn, Pote Aimpun, Valai Paasawatdhi. J Am Soc Nephrol 2005:16; 292A. 12. Depner TA. Estimation of Kt/V from the URR for varying levels of dialytic weight loss: A bedside graphic aid. Semin Dial 1993; 6:642. 13. Ronco C, Clark WR. Hollow-fiver dialyzers: Technical and clinical considerations. In: Nissenson AR, Fine RN, eds. Dialysis therapy 4th ed The McGraw-Hill Companies, Inc. 2005:85-100. 14. Ronco C, Clark W. Factors affecting hemodialysis and peritoneal dialysis efficiency. Semin Dialy 2001;14:257-62. 15. Daugirdas JT. Physiologic principle and urea kinetic modeling. In: Daugirdas JT, Blake PG, Ing TS, eds. Handbook of Dialysis 4th ed. Lippincott Williams & Wilkins 2007: 25-58. 16. Daugirdas JT. Chronic hemodialysis prescription: A urea kinetic approach. In: Daugirdas JT, Blake PG, Ing TS, eds. Handbook of Dialysis 4th ed. Lippincott Williams & Wilkins 2007: 146-169. 17. Leypold Jk, Ward RA. What clinically important advances in understanding and improving dialyzer function have occurred recently? Semin Dialy 2001;14(3):160-2. 18. Mehta HK, Deabreu D, McDougall JG, Goldstein MB. Correction of discrepancy between prescribed and actual blood flow rates in chronic hemodialysis patients with use of larger gauge needles. Am J Kidney Dis 2002;39:1231- 1235. 19. Keen M, Janson S, Gotch F. Plasma sodium (CpNa) ùsetpointû: relationship to interdialytic weight gain and mean arterial pressure in hemodialysis patients. J Am Soc Nephrol 1997; 8:241A. 20. Flanigan MJ. How should dialysis fluid be individualized for the chronic hemodialysis patient:? : Sodium. Semin Dialy 2008;21(3):226-9. 21. Lanfrance JP, Nolin L, Senecal L, Leblanc M. Predictors and outcome of cardiopulmonary resuscitation (CPR) calls in a large haemodialysis unit over a seven-year period. Nephrol Dial Transplant 2006; 21:1006-12. 22. Selby NM, Mclntyre CW. How should dialysis fluid be individualized for the chronic hemodialysis patient? Semin Dialy 2008;21(3):229-31. 23. Swartz R, Fitzgerald F, Kalousdian S, Budd M. Hypothermiaa in uremic patients. Nephrol Dial Transplant 1983;12:584- 90. 24. K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am J Kidney Dis 2005;45(Suppl 3): S1-S53. 63



Practical Points of Continuous Renal Replacement Therapy 5 Practical Points of Continuous Renal Replacement Therapy æß»∏√ §™‡ π’ 1. ∫∑π” 2. °≈‰°°“√¢®¥— ¢Õ߇ ¬’ „π CRRT 3. °“√®”·π°™π¥‘ ¢Õß CRRT 4. Õ—μ√“°“√¢®—¥¢Õ߇ ’¬„π°“√∑” CRRT 5. Vascular access 6. Hemofilter / Dialyzer 7.  “√π”È ∑¥·∑π / Dialysate 8. °“√μàÕμâ“π°“√·¢Áßμ—«¢Õ߇≈Õ◊ ¥ (Anticoagulation) „π°“√∑” CRRT 9. ‡§√◊ÕË ß∑” CRRT 10. ¢Õâ ∫àß™’È„π°“√∑” CRRT 11. °“√ ßË— °“√√°— …“ (Prescription) 12.  √ÿª 65

Practical Dialysis in the Year 2009 1. ∫∑π” ¿“«–‰μ∫“¥‡®∫Á ‡©¬’ ∫æ≈π— (acute kidney injury, AKI) ‡ªπì ¿“«–∑æ’Ë ∫‰¥∫â Õà ¬„πºªŸâ «É ¬‡«™∫”∫¥— «‘°ƒμ„πÀÕÕ¿‘∫“≈ºâŸªÉ«¬Àπ—° (Intensive Care Unit, ICU) ºŸâªÉ«¬‡À≈à“π’È à«π„À≠à¡’¿“«–·∑√°´âÕπ À≈“¬Õ¬à“ß√à«¡¥â«¬ ‡™àπ sepsis ¡’¿“«–≈⡇À≈«¢ÕßÕ«—¬«–À≈“¬™π‘¥√à«¡°—π (Multi Organ Dysfunction Syndrome, MODS) ·≈–¡—°μâÕß„™â‡§√◊ËÕߙ૬À“¬„®μ≈Õ¥®π‰¥â√—∫¬“°≈ÿà¡ (vasopressors)1 „πªí®®ÿ∫—π continuous renal replacement therapy (CRRT) ‡ªìπ°“√∫”∫—¥∑¥·∑π‰μ∑’Ëæ—≤π“¢÷Èπ¡“ ”À√—∫ºŸâªÉ«¬ AKI ∑ÕË’ ¬„àŸ π¿“«–«°‘ ƒμ ‡πÕË◊ ß®“°°“√∑” CRRT ¡¢’ Õâ ‰¥‡â ª√¬’ ∫‡ÀπÕ◊ °«“à °“√∑” intermittent hemodialysis (IHD) „πÀ≈“¬¥â“𠇙àπ  “¡“√∂¢®—¥ “√πÈ” à«π‡°‘π¢Õß√à“ß°“¬ÕÕ°‰¥â‚¥¬¡’º≈°√–∑∫μàÕ√–∫∫‰À≈‡«’¬π ‚≈À‘μπâÕ¬°«à“ ∑”„Àâ “¡“√∂„Àâ°“√√—°…“ºâŸªÉ«¬ AKI ∑’Ë¡’¿“«–§«“¡¥—π‚≈À‘μμË”À√◊Õ¡’ —≠≠“≥™’æ‰¡à §ß∑’ˉ¥â ·≈–°“√∑” CRRT  “¡“√∂¢®—¥¢Õ߇ ’¬ÕÕ°®“°√à“ß°“¬‰¥âÕ¬à“ß™â“Ê §àÕ¬‡ªìπ§àÕ¬‰ª ∑”„Àâ ¿“«–·∑√°´âÕπ∑’ˇ°‘¥®“°°“√‡ª≈’ˬπ·ª≈ßÕ¬à“ß√«¥‡√Á«¢Õß osmolality æ∫‰¥âπâÕ¬≈ß ‡™àπ°“√‡°‘¥¿“«– dialysis disequilibrium syndrome ·≈–°“√‡æ‘Ë¡¢÷Èπ¢Õߧ«“¡¥—π„π°–‚À≈°»’√…– (increase intracranial pressure) „πª®í ®∫ÿ π— ‰¥‡â √¡‘Ë ¡°’ “√°≈“à «∂ß÷ ∫∑∫“∑¢Õß CRRT „π¢Õâ ∫ßà ™¥’È “â πÕπ◊Ë πÕ°‡ÀπÕ◊ ®“°¢Õâ ∫ßà ™∑’È “ß‰μ ‡™àπ „™â™à«¬„π°“√¢®—¥ cytokine „π°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ sepsis ‡ªìπμâπ „π™à«ßªï§√‘ μ廫√√… 70 §«“¡√Ÿâ¥â“π dialysis membrane ‰¥â√—∫°“√æ—≤π“¢÷Èπ‚¥¬ “¡“√∂ º≈‘μμ—«°√Õß∑’Ë¡’ high filtration rate ‚¥¬ “¡“√∂¢®—¥¢Õ߇ ’¬∑’Ë¡’‚¡‡≈°ÿ≈¢π“¥°≈“ß (middle molecule) ‚¥¬«‘∏’°“√æ“ (convection) ‰¥â „πªï §.». 1976 ‡∫Õ√åμ—π·≈–§≥–‰¥â‡≈◊Õ°„™â§”«à“ hemofiltration  ”À√—∫‡∑§π‘§„À¡àπ’È2 „πªïμàÕ¡“ Kramer ·≈–§≥–®“°ª√–‡∑»‡¬Õ√¡—π‰¥âπ”‡∑§π‘§ hemofiltration π’ȉª „™â„π°“√√—°…“ºŸâªÉ«¬‚√§À—«„®∑’Ë¡’¿“«–πÈ”‡°‘π·≈–‰¡àμÕ∫ πÕßμàÕ¬“¢—∫ªí  “«– ‚¥¬‰¥â§‘¥§âπ‡∑§π‘§ °“√∑”∑’ˇ√’¬°«à“ continuous arteriovenous hemofiltration (CAVH) ‚¥¬‰¡àμâÕß„™â blood pump „π°“√∑”3 Õ¬à“߉√°Áμ“¡ ‡∑§π‘§¥—ß°≈à“«°Á¬—߉¡à‰¥â√—∫§«“¡π‘¬¡¡“°π—°‡π◊ËÕß®“°¡’¢âÕ®”°—¥ §◊Õ “¡“√∂‡°‘¥º≈ ¢â“߇§’¬ß®“°°“√·∑ß artery ·≈–°“√∑’Ë¡’Õ—μ√“°“√¢®—¥¢Õ߇ ’¬§àÕπ¢â“ßμË”‡π◊ËÕß®“° blood flow rate ®– μâÕߢ÷ÈπÕ¬Ÿà°—∫§«“¡¥—π‚≈À‘μ¢ÕߺŸâªÉ«¬ ®÷߉¥â¡’ºâŸ§‘¥‡∑§π‘§ venovenous pump-driven ¢÷Èπ¡“‚¥¬°“√„™â peristaltic blood pump ‡æ◊ËÕ∑’Ë®–≈¥ªí≠À“¥—ß°≈à“« ∑”„Àâ “¡“√∂∑” CRRT ¥â«¬«‘∏’π’ȉ¥â„π ICU ‚¥¬°“√ „ à “¬ double lumen catheter ·≈â«„™â peristaltic blood pump π”‡≈◊Õ¥‰ªøÕ°∑’Ë high flux dialyzer ‚¥¬  “¡“√∂„™â infusion pump ∑’Ë¡’Õ¬àŸ·≈â«„π ICU ‡ªìπμ—«§«∫§ÿ¡ ultrafiltration ·≈– replacement fluid flow rate4 „πªí®®ÿ∫—π¡’‡§√◊ËÕß CRRT ·∫∫ integrated system ∑’Ë¡’ pump control μ‘¥μ—È߇¢â“‰ª„πμ—«‡§√◊ËÕß ´÷Ëß  “¡“√∂∑’Ë®–§«∫§ÿ¡Õ—μ√“°“√‰À≈‰¥â‡∑’ˬßμ√ß°«à“ ·≈–‰¥â¡’°“√‡æ‘Ë¡°≈‰°°“√·æ√à (diffusion) √«¡‡¢â“ °—∫°“√æ“ (convection) ‚¥¬°“√‡ªî¥πÈ”¬“ dialysate ºà“πμ—«°√Õß‚¥¬„™â dialysate pump §≈⓬°—π°—∫„𠇧√◊ËÕß hemodialysis ‡æ◊ËÕ∑’Ë®–‡æ‘Ë¡ª√– ‘∑∏‘¿“æ„π°“√¢®—¥¢Õ߇ ’¬„Àâ¡“°∑’Ë ÿ¥5 2. °≈‰°°“√¢®—¥¢Õ߇ ’¬„π CRRT °Õà π∑®’Ë –°≈“à «∂ß÷ √ªŸ ·∫∫°“√∑” CRRT ·∫∫μ“à ßÊ ®–¢Õ°≈“à «∂ß÷ §«“¡√æ⟠π◊È ∞“π‡°¬’Ë «°∫— °≈‰° 66

Practical Points of Continuous Renal Replacement Therapy °“√¢®—¥¢Õ߇ ’¬ (solute removal) ‡ ’¬°àÕπ ‡æ◊ËÕ®–‰¥â‡¢â“„®∂÷ßÀ≈—°°“√∑”ß“π¢Õß CRRT ‰¥â¥’¬‘Ëߢ÷Èπ ‚¥¬ “¡“√∂·∫àß°≈‰°°“√¢®—¥¢Õ߇ ’¬ÕÕ°‰¥â‡ªìπ 2 ™π‘¥§◊Õ6 2.1 °“√·æ√à (Diffusion) ‡ªπì °≈‰°∑ÕË’ “»¬— §«“¡·μ°μ“à ß°π— ¢Õߧ«“¡‡¢¡â ¢πâ ¢Õß “√º“à π semipermeable membrane  “√®–‡§≈◊ËÕπ∑’Ë®“°¥â“π∑’Ë¡’§«“¡‡¢â¡¢âπ Ÿß ‰ª¬—ߥâ“π∑’Ë¡’§«“¡‡¢â¡¢âπμË”°«à“ ‡ªìπ°≈‰°∑’Ë°“√∑” hemodialysis „™â‡ªìπÀ≈—° ‚¥¬ªí®®—¬∑’Ë¡’º≈μàÕÕ—μ√“°“√·æ√à‰¥â·°à T ¢π“¥¢Õß‚¡‡≈°ÿ≈ ∂⓬‘Ë߇≈Á°®–‡§≈◊ËÕπ∑’ˇ√Á« T Concentration gradient ‚¥¬®–¢÷Èπ°—∫Õ—μ√“°“√‰À≈¢Õ߇≈◊Õ¥·≈–πÈ”¬“ dialysate T ¢π“¥¢Õßμ—«°√Õß ∂â“¡’æ◊Èπ∑’Ë¡“°®–·æ√àÕÕ°‰¥â‡√Á«°«à“ 2.2 °“√æ“ (Convection) «∏‘ π’ ¢È’ Õ߇ ¬’ ®–‡§≈ÕË◊ π∑μË’ “¡ “√≈–≈“¬∑‡Ë’ §≈ÕË◊ πº“à π membrane ¥ß— ππÈ— Õμ— √“°“√¢®¥— ¢Õ߇ ¬’ ®–¢÷Èπ°—∫ ultrafiltration rate ¡’§«“¡ “¡“√∂„π°“√¢®—¥¢Õ߇ ’¬∑’ˇªìπ “√‚¡‡≈°ÿ≈„À≠à°«à“∑’Ë°“√·æ√à  “¡“√∂¢®—¥ ‡ªìπ°≈‰°∑’Ë°“√∑” hemofiltration „™â‡ªìπÀ≈—° ‚¥¬ªí®®—¬∑’Ë¡’º≈μàÕÕ—μ√“°“√擉¥â·°à T Ultrafiltration coefficient (Kuf) ´÷Ë߇ªìπ§ÿ≥ ¡∫—μ‘¢Õßμ—«°√Õß·μà≈–™π‘¥ T §«“¡·μ°μà“ߢÕߧ«“¡¥—π√–À«à“ßμ—«°√Õß (transmembrane pressure) 3. °“√®”·π°™π¥‘ ¢Õß CRRT ‡æ◊ËÕ∑’Ë®–‰¥â¡’§«“¡‡¢â“„®μ√ß°—π ®÷߉¥â¡’°“√μ°≈ß∑’Ë®–‡√’¬°™◊ËÕ·≈–·∫àß™π‘¥μà“ßÊ ¢Õß CRRT ÕÕ°‡ªìπ¥—ßπ’È7 (√ªŸ ∑’Ë 1) ‡ª√’¬∫‡∑’¬∫‡∑§π‘§°“√∑” CRRT ·∫∫μà“ßÊ ¥—ßμ“√“ß∑’Ë 1 1. Slow Continuous Ultrafiltration (SCUF) ‡ªπì √ªŸ ·∫∫°“√∑” CRRT ∑¡’Ë ßÿà ‡ππâ „π°“√¢®¥— πÈ” «à π‡°π‘ ‡ªπì À≈°— ‚¥¬‰¡‡à ππâ °“√¢®¥— ¢Õ߇ ¬’ «‘∏’°“√§◊Õ®–„™â°√–∫«π°“√ hemofiltration ¥÷ßπÈ” à«π∑’ˇ°‘π„π√à“ß°“¬ÕÕ°‚¥¬‰¡àμâÕß„Àâ “√πÈ”∑¥·∑π Õ—μ√“°“√¥÷ß UF (QUF) ®–‰¡à ßŸ ¡“° ‚¥¬®–Õ¬Ÿà„π™à«ß 100-300 ¡≈./™—Ë«‚¡ß SCUF ‡À¡“– ”À√—∫ºŸâªÉ«¬‚√§ À—«„®∑’Ë¡’¿“«–πÈ”‡°‘π´÷Ë߉¡àμÕ∫ πÕßμàÕ°“√√—°…“¥â«¬¬“¢—∫ªí  “«–À√◊ÕºŸâªÉ«¬‰μ«“¬∑’ˬ—ß¡’√–¥—∫¢Õß ‡ ’¬‰¡à Ÿß¡“°·μà¡’¿“«–πÈ”‡°‘𠇪ìπ‡∑§π‘§∑’˧≈⓬°—∫∑’Ë Kramer ‰¥âπ”¡“„™â„πªï 1977 2. Continuous Hemofiltration (CH) CH ‡ªìπ‡∑§π‘§°“√∑”∑’Ë¡’«ß®√§≈⓬°—∫ SCUF ·μà¡’‡ªÑ“À¡“¬°“√¥÷ß UF ¡“°°«à“ª√‘¡“≥ π”È ∑‡Ë’ °π‘ „π√“à ß°“¬‡æÕË◊ ∑®Ë’ –‡æ¡Ë‘ ª√¡‘ “≥°“√¢®¥— ¢Õ߇ ¬’ ‚¥¬°≈‰° convection ‚¥¬∑®Ë’ –μÕâ ß¡Õ’ μ— √“°“√¥ß÷ UF (QUF)  Ÿß∂÷ß 500-3,000 ¡≈./™—Ë«‚¡ß À√◊ՠߟ °«à“π’È ´÷Ëßπ—∫‡ªìπª√‘¡“≥∑’Ë Ÿß¡“°‡¡◊ËÕ‡∑’¬∫°—∫ª√‘¡“≥¢Õß æ≈“ ¡“„π√à“ß°“¬ (2.5-3.0 ≈‘μ√) ¥—ßπ—Èπ®÷ßμâÕß¡’°“√„Àâ “√πÈ”∑¥·∑π (replacement fluid) ‡æ◊ËÕªÑÕß°—π 67

Practical Dialysis in the Year 2009 ¿“«–¢“¥πÈ”·≈–§«“¡¥—π‚≈À‘μμË” °“√„Àâ “√πÈ”∑¥·∑π∑”‰¥â 3 «‘∏’§◊Õ 2.1 Pre-dilution: „Àâ “√πÈ”∑¥·∑π°àÕπ‡≈◊Õ¥‡¢â“ àŸμ—«°√Õß 2.2 Post-dilution: „Àâ “√πÈ”∑¥·∑πÀ≈—ß®“°‡≈◊Õ¥ºà“πμ—«°√Õß 2.3 Pre-dilution ·≈– post-dilution: ·∫ßà  “√π”È ∑¥·∑π∑„Ë’ À∫â “ß «à π∑“ß pre-dilution ·≈– «à π ∑’ˇÀ≈◊Õ„Àâ∑“ß post-dilution °“√„Àâ “√πÈ”∑¥·∑π«‘∏’ post-dilution ¡’¢âÕ¥’§◊Õ¡’Õ—μ√“°“√¢®—¥¢Õ߇ ’¬¥’°«à“«‘∏’ pre-dilution ‡π◊ËÕß®“°§«“¡‡¢â¡¢âπ¢Õß urea À√◊Õ¢Õ߇ ’¬‰¡à∂Ÿ°‡®◊Õ®“ß≈ß°àÕπ‡¢â“μ—«°√Õß ·μà¡’¢âÕ‡ ’¬§◊Õ ∂â“μ—Èß ultrafiltration rate ¡“°‡°π‘ ‰ª®–∑”„À‚â Õ°“ μ«— °√ÕßÕ¥ÿ μπ— ‡æ¡Ë‘ ¢πÈ÷ (¥√Ÿ “¬≈–‡Õ¬’ ¥„πÀ«— ¢Õâ §” ßË— °“√√°— …“) 3. Continuous hemodialysis (CHD) CHD ¡’≈—°…≥–«ß®√·∫∫‡¥’¬«°—∫‡§√◊ËÕß intermittent hemodialysis ∑—Ë«‰ª ‚¥¬®–¡’°“√‡ªî¥ πÈ”¬“ dialysate ‚¥¬„™â dialysate pump ºà“πμ—«°√Õß„π∑‘»∑’Ë «π∑“ß°—∫‡≈◊Õ¥ ·μàμà“ß°—πμ√ß∑’ËÕ—μ√“°“√ ‰À≈‡¢â“¢ÕßπÈ”¬“ dialysate (QDi) ®–§àÕπ¢â“ߙⓧ◊Õª√–¡“≥ 1-2 ≈‘μ√/™—Ë«‚¡ß (16-32 ¡≈./π“∑’) ·≈–®– ‰À≈Õ¬àŸμ≈Õ¥‡«≈“ Õ—μ√“°“√¥÷ß UF (QUF) „π°√≥’¢Õß CHD π’È®–‡∑à“°—∫ª√‘¡“≥πÈ”∑’ˇ°‘πÕ¬àŸ„π√à“ß°“¬ ‚¥¬®–Õ¬Ÿà∑’˪√–¡“≥ 100-300 ¡≈./™—Ë«‚¡ß «‘∏’π’È„™â°≈‰° diffusion ‡ªìπÀ≈—°„π°“√¢®—¥¢Õ߇ ’¬ ®÷ߢ®—¥  “√‚¡‡≈°ÿ≈¢π“¥°≈“߉¥âπâÕ¬°«à“‡¡◊ËÕ‡∑’¬∫°—∫ CH √ªŸ ∑Ë’ 1 «ß®√°“√∑” CRRT √Ÿª·∫∫μà“ßÊ 68

Practical Points of Continuous Renal Replacement Therapy 4. Continuous Hemodiafiltration (CHDF) CHDF ‡ªìπ°“√æ—≤π“μàÕ¡“‡æ◊ËÕ∑’Ë®–‡æ‘Ë¡Õ—μ√“°“√¢®—¥¢Õ߇ ’¬‚¥¬°“√„™â‡∑§π‘§¢Õß°“√ convection √«¡‡¢â“°—∫ diffusion ‚¥¬®–¡’°“√‡ªî¥πÈ”¬“ dialysate √à«¡°—∫¡’Õ—μ√“°“√¥÷ß UF ∑’Ë Ÿß ·≈–¡’ °“√„Àâ “√πÈ”∑¥·∑π√à«¡¥â«¬ ‡æ◊ËÕ∑’Ë®–„Àâ¡’°“√¢®—¥¢Õ߇ ’¬ÕÕ°¡“°∑’Ë ÿ¥∑—Èß “√‚¡‡≈°ÿ≈¢π“¥‡≈Á°·≈– ¢π“¥°≈“ß °“√‡√’¬°™◊ËÕ«ß®√ CRRT ÕÕ°‡ªìπ™π‘¥μà“ßÊ π—È𠇪ìπ°“√º ¡°—π√–À«à“ß mode °“√√—°…“ °—∫™π‘¥¢Õß vascular access μ—«Õ¬à“߇™àπ CVVHDF ¡“®“° continuous venovenous hemodiafiltration À√◊Õ CAVH ¡“®“° continuous arteriovenous hemofiltration ‡ªìπμâπ μ“√“ß∑Ë’ 1 ‡ª√’¬∫‡∑’¬∫‡∑§π‘§°“√∑” CRRT ·∫∫μà“ßÊ (¥—¥·ª≈ß®“°‡Õ° “√À¡“¬‡≈¢ 8) 8 IHD SLED SCUF CH CHD CHDF Access VV VV AV or VV AV or VV AV or VV AV or VV Membrane Variable Variable High High High High permeability Anticoagulation Short Long Prolonged Prolonged Prolonged Prolonged Blood flow rate 250-400 100-150 < 100 100-200 100-200 100-200 (mL/min) Dialysate flow 500-800 100-300 0 0 16.7-33.4 16.7-33.4 (mL/min) Effluent rate (L/hr) - - 0.1-0.3 1-4 0.1-0.3 1-2 Replacement fluid - - No Yes No Yes Dialysate base Acetate + Acetate + - - Lactate, Lactate, bicarbonate bicarbonate bicarbonate bicarbonate Replacement fluid - - - Lactate, - Lactate, base bicarbonate bicarbonate Solute clearance Diffusion Diffusion Convection Convection Diffusion Both mechanism Urea clearance 180-240 75-90 1.7 16.7-67 21.7 30-60 (mL/min) Duration (hours) 3-4 8-18 Variable >24 >24 >24 IHD: Intermittent Hemodialysis, SLED: Sustained Low-Efficiency Dialysis, SCUF: Slow Continuous Ultrafiltration, CH: Continuous Hemofiltration, CHD: Continuous Hemodialysis, CHDF: Continuous Hemodiafiltration, AV: Arteriovenous, VV: Venovenous 69

Practical Dialysis in the Year 2009 4. Õ—μ√“°“√¢®¥— ¢Õ߇ ’¬„π°“√∑” CRRT Õ—μ√“°“√¢®—¥¢Õ߇ ’¬ (clearance) „π°“√∑” CRRT  “¡“√∂§”π«≥‰¥â®“° Clearance (K) = Removal rate / Concentration K = (ª√‘¡“≥ solute ∑’ËÕÕ°®“°μ—«°√Õß - ª√‘¡“≥ solute ∑’ˇ¢â“μ—«°√Õß) / concentration K = (QDo × CDo › QDi × CDi) / CB ‚¥¬∑’Ë QDi ·≈– QDo §◊ÕÕ—μ√“°“√‰À≈‡¢â“·≈–ÕÕ°¢Õß dialysate μ“¡≈”¥—∫ CDi ·≈– CDo §◊Õ§«“¡‡¢â¡¢âπ¢Õß “√„π dialysate ∑’ˉÀ≈‡¢â“·≈–ÕÕ°®“°μ—«°√Õß CB §◊Õ§«“¡‡¢â¡¢âπ¢Õß “√„π‡≈◊Õ¥∑’ˉÀ≈‡¢â“μ—«°√Õß ‡π◊ËÕß®“°‡√“„™â Urea ‡ªìπ “√∑’Ë„™â§”π«≥ Clearance CDi ®÷߇∑à“°—∫ 0 ·≈–‡¡◊ËÕÕ—μ√“°“√ ultrafiltrate (QUF) = QDo - QDi ‡√“®÷ß “¡“√∂·ª≈ß μŸ √ Clearance ‰¥â¥—ßπ’È K = (QDi × CDo) / CB + (QUF × CDo) / CB ‚¥¬∑’Ë ¡°“√π’È®–·∫à߇ªìπ 2  à«π‰¥â·°à  à«π·√° (QDi × CDo) / CB ‡ªìπÕ—μ√“°“√¢®—¥¢Õ߇ ’¬ ‚¥¬«‘∏’°“√·æ√à (diffusion) ·≈– à«π∑’Ë 2 (QUF × CDo) / CB ‡ªìπÕ—μ√“°“√¢®—¥¢Õ߇ ’¬‚¥¬«‘∏’°“√æ“ (convection) Clearance „π continuous hemodialysis (QUF = 0) ®“° ¡°“√ K = (QDi × CDo) / CB ‡π◊ËÕß®“° QUF = 0 ¥—ßπ—Èπ QDi = QDo ·≈–‡π◊ËÕß®“°°“√∑” CHD ¡’Õ—μ√“°“√‰À≈¢Õß dialysate ™â“ ®÷ß∑”„À⇰‘¥ complete saturation9 §«“¡‡¢â¡¢âπ¢Õß “√„π‡≈◊Õ¥¡’ §à“„°≈⇧’¬ß°—∫„π Dialysate À√◊Õ CDo/ CB ≈ 1 ¥—ßπ—Èπ clearance ¢Õß°“√∑” CHD ®–¡’§à“‡∑à“°—∫Õ—μ√“°“√ ‰À≈ÕÕ°¢Õß Dialysate À√◊Õ K ≈ QDo Clearance „π continuous hemofiltration (QDi = 0) ®“° ¡°“√ K = (QUF × CDo) / CB ‡π◊ËÕß®“° QDi = 0 ¥—ßπ—Èπ CDo = CUF ‡√“®÷ß “¡“√∂‡¢’¬π  ¡°“√π’È„À¡à‡ªìπ K = (QUF × CUF) / CB ‚¥¬∑’Ë CUF / CB §◊Õ§à“ sieving coefficient (S) ´÷Ëß “√‚¡‡≈°ÿ≈‡≈Á°Ê ‡™àπ urea ®–¡’§à“ S ª√–¡“≥ 1 ¥—ßπ—Èπ clearance ¢Õß°“√∑” CH ®–¡’§à“‡∑à“°—∫Õ—μ√“°“√¥÷ß UF À√◊Õ K ≈ QUF ´÷Ëß∂Ⓡªìπ clearance ¢Õß “√Õ◊Ëπ∑’Ë¡’¢π“¥„À≠à°«à“ urea °Á®–¡’§à“≈¥≈ßμ“¡§à“ sieving coefficient ¢Õß “√π—ÈπÊ (μ“√“ß∑’Ë 2) Õ¬à“߉√°Áμ“¡§à“ clearance ∑’˧”π«≥‰¥âπ’È ‡ªìπ§à“ clearance ¢Õß°“√∑” CH ™π‘¥ post-dilution ‡∑à“π—Èπ ∂Ⓡªìπ™π‘¥ pre-dilution ®–¡’§à“∑’ËμË”°«à“π’È ‡π◊ËÕß®“°§«“¡‡¢â¡¢âπ¢Õß “√„π ‡≈◊Õ¥®–∂°Ÿ ∑”„À⇮◊Õ®“ß≈ß®“° “√πÈ”∑¥·∑π 70

Practical Points of Continuous Renal Replacement Therapy μ“√“ß∑’Ë 2 · ¥ß§à“ S (sieving coefficient) ¢Õß solute ·≈– electrolyte ∑’˺à“πμ—«°√Õß Solute S Solute S Na+ 0.99 1.04 K+ 0.99 Glucose 0.64 Cl- 1.05 Ca2+ 0.90 HCO3- 1.12 Mg2+ 1.04 Urea 1.05 Phosphate 0.01 1.02 Albumin 0.02 Creatinine Total protein 5. Vascular access ¥—ß∑’ˉ¥â°≈à“«¡“·≈â««à“ °“√∑” CRRT  “¡“√∂‡≈◊Õ° vascular access ‰¥â 2 ∑“ߧ◊Õ arteriovenous (AV) ·≈– venovenous (VV) ∑—Èß 2 ·∫∫¡’¢âÕ¥’¢âÕ‡ ’¬·μ°μà“ß°—π¥—ßμàÕ‰ªπ’È 5.1 Arteriovenous (AV) °“√„™â vascular access ™π‘¥π’È ®–μâÕß·∑߇¢Á¡∑—Èß∑“ߥâ“π artery ·≈– vein „™â§«“¡¥—π ‚≈À‘μ¢Õߺ⟪ɫ¬‡Õ߇ªìπ·√ߥ—π„À⇰‘¥ blood flow ‚¥¬‰¡àμâÕß¡’ blood pump °“√„™â AV access ·∫∫π’È¡’ ¢âÕ‡ ’¬§◊Õ ®–‰¡à “¡“√∂°”Àπ¥ blood flow ‰¥â ∑”„ÀâÕ—μ√“°“√¢®—¥¢Õ߇ ’¬‰¡à·πàπÕπ ·≈–¡—°®–‰¥âμË” °«à“∑’ËμâÕß°“√ „π¢≥–‡¥’¬«°—π°Á¡’‚Õ°“ ∑’Ë®–‡°‘¥¿“«–·∑√°´âÕπ®“°°“√·∑߇¢Á¡‡¢â“ artery ‰¥â 5.2 Venovenous (VV) „™â°“√·∑ß double lumen catheter ‡¢â“‰ª„π vein ·≈–„™â blood pump π”‡≈◊Õ¥‡¢â“ àŸμ—«°√Õß „π≈—°…≥–‡¥’¬«°—∫°“√∑” acute hemodialysis ∑—Ë«‰ª «‘∏’π’È¡’¢âÕ¥’§◊Õ “¡“√∂°”Àπ¥ blood flow ‰¥â Õ¬à“ß·πàπÕπ ·≈–‰¡àμâÕß·∑߇¢Á¡‡¢â“ artery ·μà¡’¢âÕ‡ ’¬§◊ÕÕ“®‡°‘¥¡’øÕßÕ“°“»Õ¬Ÿà„π arterial line ‰¥â ‡π◊ËÕß®“°∫√‘‡«≥π’ȇªìπ negative pressure μ”·ÀπàߢÕß catheter ∑’Ë¥’∑’Ë ÿ¥§◊Õ right internal jugular vein ·μà„π∑“ߪؑ∫—μ‘°“√„™â femoral vein ®–¡§’ «“¡ –¥«° ”À√∫— ºªâŸ «É ¬¿“«–«°‘ ƒμ¡“°°«“à  «à πμ”·Àπßà left internal jugular ·≈– subclavian vein ∑—Èß 2 ¢â“ßπ—Èπ‰¡à·π–π”„Àâ„™â  ”À√—∫≈—°…≥–¢Õß catheter π—Èπ§«√¡’‡ âπºà“π»πŸ ¬å°≈“ß 14 french ·≈–¡’§«“¡¬“«‡æ’¬ßæÕ‡æ◊ËÕ∑’Ë®–ªÑÕß°—π°“√‡°‘¥¿“«– recirculation ‚¥¬∑’Ëμ”·Àπàß right internal jugular vein §«√¡’§«“¡¬“« 15 ´¡. ·≈–μ”·Àπàß femoral vein §«√¡’§«“¡¬“«Õ¬à“ßπâÕ¬ 20 ´¡. „πªí®®ÿ∫—π°“√∑” CRRT „π ICU ·æ∑¬å®–‡≈◊Õ°„™â vascular access ·∫∫ venovenous ‡°◊Õ∫ ∑—ÈßÀ¡¥ ‡π◊ËÕß®“°μâÕß°“√À≈’°‡≈’ˬ߰“√·∑߇¢â“ artery ·≈– blood pump ‡ªìπÕÿª°√≥å∑’ËÀ“‰¥â‰¡à¬“°„π ICU ·≈–√“§“‰¡à·æß  ”À√—∫„π∫∑π’È®–°≈à“«∂÷߇©æ“–«ß®√ CRRT circuit ∑’Ë„™â vascular access ·∫∫ 71

Practical Dialysis in the Year 2009 venovenous ∑—ÈßÀ¡¥ ´÷Ëß®–ª√–°Õ∫‰ª¥â«¬ continuous venovenous hemofiltration (CVVH), continuous venovenous hemodialysis (CVVHD), continuous venovenous hemodiafiltration (CVVHDF) 6. Hemofilter / Dialyzer μ—«°√ÕߢÕß√–∫∫ CRRT  “¡“√∂‡√’¬°«à“ Hemofilter À√◊Õ Dialyzer °Á‰¥â ¢÷ÈπÕ¬àŸ°—∫«à“√–∫∫ CRRT π—Èπ„™â°≈‰°°“√¢®—¥¢Õ߇ ’¬·∫∫„¥‡ªìπÀ≈—°  ”À√—∫§ÿ≥ ¡∫—μ‘∑’ˇÀ¡“– ¡¢Õßμ—«°√Õß∑’Ë„™âπ—Èπ∂â“ μâÕß°“√®–∑” CH ‡æ’¬ßÕ¬à“߇¥’¬«§«√¡’§à“ water permeability coefficient (KUF) §àÕπ¢â“ß Ÿß§◊Õ ¡“°°«à“ 12 ¡≈./™—Ë«‚¡ß/¡¡.ª√Õ∑ ‡æ◊ËÕ„À≥âÕ—μ√“°“√¥÷ß UF ∑’ˇ撬ßæÕ∑’Ë®–™à«¬„π°“√¢®—¥ uremic toxin ∑’ËμâÕß ¢÷ÈπÕ¬àŸ°—∫ QUF ‰¥â¡“°¢÷Èπ  ”À√—∫„π°√≥’∑’ËμâÕß°“√∑” CHD À√◊Õ CHDF ∑’ËμâÕß„™â°≈‰° diffusion √à«¡¥â«¬ π—Èπ®–μâÕß¡’°“√ÕÕ°·∫∫„Àâ dialysate  —¡º— °—∫º‘«μ—«°√ÕßÕ¬à“ß∑—Ë«∂÷ß ·≈–‰¡à§«√„™âμ—«°√Õß∑’Ë¡’¢π“¥ „À≠à‡°‘π‰ª ‡π◊ËÕß®“°°“√∑” CRRT π—Èπ®–¡’Õ—μ√“°“√‰À≈¢Õ߇≈◊Õ¥μË”°«à“°“√∑” IHD °“√„™âμ—«°√Õß ¢π“¥„À≠à‡°‘π‰ªπ—Èπ‰¡à™à«¬∑”„ÀâÕ—μ√“°“√¢®—¥¢Õ߇ ’¬‡æ‘Ë¡¢÷Èπ ·μàÕ“®∑”„À⇰‘¥°“√·¢Áßμ—«¢Õ߇≈◊Õ¥„π μ—«°√Õß¡“°¢÷Èπ „πªí®®ÿ∫—π°“√„™â‡§√◊ËÕß CRRT ¢Õß∫√‘…—∑μà“ßÊ ®–¡’°“√º≈‘μ Hemofilter / Dialyzer ∑’Ë ÕÕ°·∫∫¡“„™â°—∫‡§√◊ËÕ߇À≈à“π’È‚¥¬‡©æ“– Õ¬à“߉√°Áμ“¡„π°“√∑” CRRT ·∫∫ separated system ‰¥â¡’ °“√»÷°…“«à“ “¡“√∂„™âμ—«°√Õß∑’Ë„™â„π°“√∑” conventional hemodialysis ´÷Ëß¡’√“§“∂Ÿ°°«à“¡“„™â‰¥â Õ¬à“ß¡’ª√– ‘∑∏‘¿“æ∑—Èߥâ“π°“√¢®—¥¢Õ߇ ’¬‚¡‡≈°ÿ≈¢π“¥‡≈Á°·≈–Õ—μ√“°“√¥÷ß UF9 7.  “√πÈ”∑¥·∑π / Dialysate  “√π”È ∑„’Ë ™‡â ªπì  “√π”È ∑¥·∑πÀ√◊Õ Dialysate §«√¡§’ ≥ÿ  ¡∫—μ·‘ ≈– à«πª√–°Õ∫§≈⓬°∫—  “√ πÈ”„π√à“ß°“¬¡“°∑’Ë ÿ¥ ‚¥¬®–ª√–°Õ∫¥â«¬ 3  à«πÀ≈—°§◊Õ T ‡°≈◊Õ·√à ‰¥â·°à sodium, potassium, chloride, calcium ·≈– magnesium T Glucose T ¥à“ß (Buffer) ‰¥â·°à lactate, acetate, citrate ·≈– bicarbonate  «à πª√–°Õ∫¢Õß “√π”È ∑¥·∑πÀ√Õ◊ dialysate ππÈ— ‰¡·à ππà Õπ °“√‡≈Õ◊ °„™®â –¢πÈ÷ Õ¬°Ÿà ∫—  ¿“«– ¢ÕߺŸâªÉ«¬·μà≈–√“¬ √«¡‰ª∂÷ߧà“√–¥—∫§«“¡‡¢â¡¢âπ¢Õ߇°≈◊Õ·√àμà“ßÊ ·≈–§«“¡√ÿπ·√ߢÕß¿“«–‡≈◊Õ¥ ‡ªìπ°√¥ ·≈–∑’Ë ”§—≠®–μâÕß¡’°“√ª√—∫‡ª≈’ˬπ„Àâ¡’§«“¡‡À¡“– ¡Õ¬àŸμ≈Õ¥‡«≈“ ¡’¢âÕ§«√æ‘®“√≥“„π°“√‡≈◊Õ° à«πª√–°Õ∫¢Õß “√πÈ”∑¥·∑π·≈– dialysate ¥—ßμàÕ‰ªπ’È 7.1 §«“¡‡¢â¡¢πâ ¢Õß Sodium ‚¥¬∑—Ë«‰ª‡√“®–°”Àπ¥„À⧫“¡‡¢â¡¢âπ¢Õß sodium „°≈⇧’¬ß°—∫æ≈“ ¡“§◊Õª√–¡“≥ 140 mEq/≈‘μ√ ·μà “¡“√∂ª√—∫¢÷ÈπÀ√◊Õ≈ß„π°√≥’∑’Ë¡’¿“«– hyponatremia À√◊Õ hypernatremia ‰¥âμ“¡§«“¡ ‡À¡“– ¡  “√≈–≈“¬ ”‡√Á®√Ÿª∫“ß™π‘¥¡’√–¥—∫§«“¡‡¢â¡¢âπ¢Õß sodium ‡æ’¬ß 130-132 mEq/≈‘μ√ „π °√≥’π’È®–μâÕß‡μ‘¡ 3% NaCl ‡¢â“‰ªª√–¡“≥ 20-25 ¡≈.  à«π„π°√≥’∑’Ë„™â citrate ‡ªìπ “√μâ“π°“√·¢Áß 72

Practical Points of Continuous Renal Replacement Therapy μ—«¢Õ߇≈◊Õ¥®–μâÕß≈¥§«“¡‡¢â¡¢âπ¢Õß sodium ≈ß¡“∑’Ë 117 mEq/≈‘μ√ 7.2 §«“¡‡¢â¡¢âπ¢Õß Glucose ‚¥¬∑—Ë«‰ª‡√“®–°”À𥧫“¡‡¢â¡¢âπ¢Õß glucose Õ¬Ÿà∑’Ë 100-200 mg/dL ‚¥¬®–º ¡ 50% glucose ≈߉ª 5-10 ¡≈. „π°√≥’∑’Ëπ” 1.5% peritoneal dialysis ¡“„™â‡ªìπ dialysate ®–∑”„À⺟âªÉ«¬‰¥â√—∫ glucose ‡¢â“ Ÿà√à“ß°“¬®”π«π¡“° §«√ª√—∫≈¥ª√‘¡“≥ carbohydrate „πÕ“À“√≈߇æ◊ËÕ≈¥ª√‘¡“≥ æ≈ß— ß“π∑‰’Ë ¥∑â ß—È À¡¥·≈–„π∫“ߧ√ß—È Õ“®μÕâ ß„Àâ insulin∑“ßÀ≈Õ¥‡≈Õ◊ ¥¥”‡æÕ◊Ë §«∫§¡ÿ √–¥∫— πÈ”μ“≈„π‡≈Õ◊ ¥ 7.3 ™π¥‘ ¢Õß Buffer 7.3.1 Lactate  “√πÈ”∑¥·∑πÀ√◊Õ dialysate ·∫∫ ”‡√Á®√Ÿª∑’Ë¡’„π∑âÕßμ≈“¥π—Èπ à«π„À≠à®–„™â lactate ‡ªìπ buffer ´ß÷Ë  “¡“√∂„™‰â ¥„â πºªŸâ «É ¬∑«—Ë ‰ª ‡πÕ◊Ë ß®“°μ∫— ¡§’ «“¡ “¡“√∂„π°“√‡ª≈¬’Ë π lactate ‰ª‡ªπì bicarbonate „πÕ—μ√“ à«π 1:1 ·μà„πºŸâªÉ«¬∑’Ë¡’°“√∑”ß“π¢Õßμ—∫º‘¥ª°μ‘ À√◊Õ‡°‘¥¿“«– lactic acidosis §«“¡ “¡“√∂ ¥—ß°≈à“«Õ“®≈¥≈ß Õ“®∑”„Àâ¡’ lactate §—Ëß¡“°¢÷Èπ·≈–‡°‘¥¿“«– hemodynamic instability ‡°‘¥¢÷Èπ‰¥â „π °√≥’π—Èπ§«√‡≈◊Õ°„™â‡ªìπ bicarbonate-buffered solution ·∑π 7.3.2 Bicarbonate °“√‡≈◊Õ°„™â bicarbonate ‡ªìπ buffer ¡’¢âÕ¥’§◊Õ ¡’§«“¡‡ªìπ¥à“ß„πμ—«¢Õß¡—π‡Õß‚¥¬∑’ˉ¡àμâÕß ‰ª‡ª≈’ˬπ∑’Ëμ—∫ ¡’§«“¡‡À¡“– ¡„π∑“ß √’√«‘∑¬“¡“°∑’Ë ÿ¥ ·μà bicarbonate ‰¡à “¡“√∂º ¡≈߉ª„π  “√≈–≈“¬ ”‡√Á®√Ÿª‰¥â ‡π◊ËÕß®“°‰¡à‡ ∂’¬√ ®–·μ°μ—«‰¥â‡ªìπ H2O + CO2 ·≈–‡°‘¥μ°μ–°Õπ°—∫ ·§≈‡´’¬¡·≈–·¡°π’‡´’¬¡ ‰¥â‡ªìπ‡°≈◊Õ∑’ˉ¡à≈–≈“¬πÈ”‡¡◊ËÕ∑‘È߉«âπ“πÀ≈—߇μ√’¬¡πÈ”¬“ Õ¬à“߉√°Áμ“¡ ‡√“  “¡“√∂·°â‰¢ªí≠À“¥—ß°≈à“«‰¥â‚¥¬°“√‡μ√’¬¡ bicarbonate-buffered solution ‚¥¬‰¡àº ¡·§≈‡´’¬¡·≈– ·¡°π’‡´’¬¡ ≈߉ª¥â«¬ ·≈â«π”·§≈‡´’¬¡°—∫·¡°π’‡´’¬¡‰ª„Àâμà“ßÀ“°∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ®“°ª√– ∫ °“√≥å„π√æ.¿Ÿ¡‘æ≈Õ¥ÿ≈¬‡¥™æ∫«à“ “¡“√∂º ¡·¡°π’‡´’¬¡≈߉ª„π “√πÈ”∑¥·∑π‰¥â‚¥¬‰¡à∑”„À⇰‘¥ °“√μ°μ–°Õπ ·≈–‰¡à‡°‘¥ hypomagnesemia ‚¥¬∑’Ë®–μâÕߺ ¡„π∂ÿß∑’ˉ¡à¡’ bicarbonate „π·∫∫ two-bag formula „πÕ¥μ’ °“√∑” CRRT ‰¥¡â °’ “√π” “√≈–≈“¬ ”‡√®Á √ªŸ À≈“¬™π¥‘ ¡“„™‡â ªπì  “√π”È ∑¥·∑πÀ√Õ◊ dialysate ‡™àπ Lactate Ringerûs solution, Acetate Ringerûs solution, 1.5% peritoneal dialysis fluid, hemodiafiltration fluid ·μà„π∑“ߪؑ∫—쑇π◊ËÕß®“°°“√„™â “√≈–≈“¬ ”‡√Á®√Ÿª‡À≈à“π’È ¢“¥§«“¡¬◊¥À¬ÿàπ „π°“√‡ª≈’ˬπ·ª≈ß à«πª√–°Õ∫„Àâ‡À¡“–°—∫ºâŸªÉ«¬ ª√–°Õ∫°—∫°“√∑’Ë¡’√“§“§àÕπ¢â“ß·æß ICU  à«π „À≠à®÷߉¥â‡≈◊Õ°„™â “√πÈ”∑¥·∑π·∫∫º ¡‡Õß ´÷ËßπÕ°®“°®– “¡“√∂‡ª≈’ˬπ·ª≈ß à«πº ¡‰¥âÕ¬à“ß Õ ‘ √–·≈«â ¬ß—  “¡“√∂„™â bicarbonate ‡ªπì buffer ‰¥¥â «â ¬ ª®í ®∫ÿ π— ¡ ’ “√π”È ∑¥·∑𠔇√®Á √ªŸ ∑¡Ë’ ’ bicarbonate ‡ªìπ à«πª√–°Õ∫ ”À√—∫„™â„π°“√∑” CRRT ‚¥¬∂ÿßπÈ”¬“®–·∫àßÕÕ°‰¥â‡ªìπ 2  à«π  à«π·√°‡ªìππÈ”¬“ bicarbonate  à«π∑’Ë Õ߇ªìπ “√≈–≈“¬‡°≈◊Õ·√à∑’˪√–°Õ∫¥â«¬·§≈‡´’¬¡ ·¡°π’‡´’¬¡ ‚ª·μ ‡´’¬¡ ‡¡◊ËÕ ®–„™âß“π§àÕ¬º ¡πÈ”¬“∑—Èß 2 ∂ÿ߇¢â“¥â«¬°—π ‰¥â· ¥ßμ—«Õ¬à“ß°“√‡μ√’¬¡ “√πÈ”∑¥·∑π∑’Ë„™â bicarbonate 73

Practical Dialysis in the Year 2009 ‡ªìπ buffer ∑’Ë„™âÕ¬àŸ„πªí®®ÿ∫—π„π√æ.¿Ÿ¡‘æ≈Õ¥ÿ≈¬‡¥™™π‘¥ two-bag formula ‡ª√’¬∫‡∑’¬∫°—∫ “√≈–≈“¬  ”‡√Á®√Ÿª™π‘¥μà“ßÊ „πμ“√“ß∑’Ë 3 8. °“√μÕà μ“â π°“√·¢ßÁ μ«— ¢Õ߇≈◊Õ¥ (Anticoagulation) „π°“√∑” CRRT ®ÿ¥ª√– ß§å¢Õß°“√„Àâ “√μâ“π°“√·¢Áßμ—«¢Õ߇≈◊Õ¥„π«ß®√πÕ°√à“ß°“¬ (Anticoagulation) °Á ‡æ◊ËÕ∑’Ë®–¬◊¥Õ“¬ÿ°“√„™âß“π¢Õß«ß®√ CRRT ·≈–∑”„Àâ¡’ª√– ‘∑∏‘¿“æ„π°“√¢®—¥¢Õ߇ ’¬μà“ßÊ ‰¥â Ÿß∑’Ë ÿ¥ Õ¬à“߉√°Áμ“¡ °“√„Àâ “√μâ“π°“√·¢Áßμ—«¢Õ߇≈◊Õ¥®–∑”„Àâ‡æ‘Ë¡§«“¡‡ ’ˬß∑’Ë®–¡’‡≈◊Õ¥ÕÕ°√«¡∂÷ß¡’ ‚Õ°“ ‡°‘¥¿“«–·∑√°´âÕπμà“ßÊ ‰¥â °“√æ‘®“√≥“‡≈◊Õ°«‘∏’°“√μàÕμâ“π°“√·¢Áßμ—«¢Õ߇≈◊Õ¥®÷ß®–μâÕß ‡ª√’¬∫‡∑’¬∫§«“¡‡ ’ˬ߷≈–ª√–‚¬™πå∑’Ë®–‰¥â√—∫Õ¬à“ß√Õ∫§Õ∫ „πªí®®ÿ∫—π¡’«‘∏’°“√μàÕμâ“π°“√·¢Áßμ—« μ“√“ß∑’Ë 3  —¥ à«π¢Õß à«πª√–°Õ∫„π “√πÈ”∑¥·∑π·≈– Dialysate „π√ªŸ ·∫∫μà“ßÊ  à«πª√–°Õ∫  “√≈–≈“¬ ”‡√®Á √ªŸ ·∫∫º ¡‡Õß Two-bag formula d (ª√‘¡“≥ 2,248 ¡≈.) Lactate 1.5% Hemosol BO c ∂ÿß∑Ë’ 1: 0.45% NSS 1000 cc + 7.5% Ringerûs Peritoneal NaHCO3 90 cc + 50% glucose 8 cc. Solution a Dialysis ∂ÿß∑’Ë 2: 0.45% NSS 1000 cc + 3% Fluid b NSS 150 cc + 50% MgSO4 0.5 cc + KCl 8 meq : 10% Calcium gluconate 60 cc + 5% D/W 40 cc drip 20 cc/hr peripheral line Glucose (mg/dL) - 1,360 - 190 Na+ (mEq/L) 130 132 140 138 K+ (mEq/L) 4 - 0 4.0 Cl- (mEq/L) 109 96 109.5 108 Ca2+ (mEq/L) 2.7 3.5 3.5 - Mg2+ (mEq/L) - 0.5 1.0 1.0 Lactate (mEq/L) 28 40 3 - HCO3 - (mEq/L) - - 32 35 a: „™â‡ªìπ‰¥â∑—Èß dialysate ·≈– “√πÈ”∑¥·∑π b: Baxter Healthcare Corp., Renal Division, MacGaw Park, IL („™â ”À√—∫‡ªìπ dialysate ‡∑à“π—Èπ ‰¡à„™â‡ªìπ “√πÈ”∑¥·∑π ‡π◊ËÕß®“°¡’ª√‘¡“≥ glucose  ßŸ ¡“°) c: Gambro Lundia AB, Sweden („™â‡ªìπ‰¥â∑—Èß Dialysate ·≈– “√πÈ”∑¥·∑π) d: „™â ”À√—∫‡ªìπ “√πÈ”∑¥·∑π 74

Practical Points of Continuous Renal Replacement Therapy ¢Õ߇≈◊Õ¥Õ¬ŸàÀ≈“¬«‘∏’ ·μଗ߉¡à¡’¢âÕ¡≈Ÿ ∑’Ë· ¥ßÕ¬à“ß™—¥‡®π«à“«‘∏’„¥®–‡ªìπ«‘∏’∑’Ë¥’∑’Ë ÿ¥10 „πªí®®ÿ∫—π «‘∏’°“√ „™â citrate ‡ªìπ “√μâ“π°“√·¢Áßμ—«¢Õ߇≈◊Õ¥‡√‘Ë¡‡ªìπ∑’Ëπ‘¬¡¡“°¢÷Èπ ‡π◊ËÕß®“°¡’ª√– ‘∑∏‘¿“楒·≈–‰¡à‡æ‘Ë¡ §«“¡‡ ’ˬ߄π°“√∑’Ë®–‡°‘¥‡≈◊Õ¥ÕÕ° ·μà°Á¡’§«“¡¬ÿà߬“°„π°“√‡μ√’¬¡ ·≈–®”‡ªìπ∑’Ë®–μâÕß àßμ√«®À“ ionized calcium ´÷Ë߬—߉¡à “¡“√∂∑”‰¥â∑—Ë«‰ª„πª√–‡∑»‰∑¬ „πÀ—«¢âÕπ’È®–¢Õ楟 ∂÷ß«‘∏’°“√μàÕμâ“π°“√·¢Áß μ—«¢Õ߇≈◊Õ¥∑’Ë„™â§àÕπ¢â“ß∫àÕ¬∑—ÈßÀ¡¥ 4 «‘∏’ §◊Õ 1. Low dose heparin 2. Low molecular weight heparin 3. Regional citrate ·≈– 4. Saline flush ·≈–‰¥â‡ª√’¬∫‡∑’¬∫¢âÕ¥’¢âÕ‡ ’¬¢Õß·μà≈–«‘∏’ √«¡‰ª∂÷ß·π«∑“ß„π °“√‡≈◊Õ°„™â«‘∏’∑’ˇÀ¡“– ¡„πμ“√“ß∑’Ë 4 8.1 Low dose heparin °“√„™â heparin ‡ªìπ “√μâ“π°“√·¢Áßμ—«¢Õ߇≈◊Õ¥„π°“√∑” CRRT ‡ªìπ«‘∏’∑’Ëπ‘¬¡∑’Ë ÿ¥ ‡π◊ËÕß®“°‡ªìπ«‘∏’∑’Ë·æ∑¬å§ÿâπ‡§¬  “¡“√∂μ‘¥μ“¡º≈‰¥â‰¡à¬“° ·≈–√“§“‰¡à·æß ¡’À≈—°°“√¥—ßπ’È • Prime Hemofilter / Dialyzer ¥â«¬ 0.9% NSS 1,000-2,000 cc + heparin 5,000 U/L • ¢≥–‡√‘Ë¡∑” CRRT „Àâ loading heparin 5-10 u/kg ∑“ß arterial blood line ∂â“ baseline PTT ¡“°°«à“ 35 «‘π“∑’ ‰¡àμâÕß„Àâ loading dose ·≈â«„Àâμàե⫬¢π“¥ 3-12 u/kg ‡ªìπ maintenance dose μ“√“ß∑’Ë 4 ‡ª√’¬∫‡∑’¬∫°“√μàÕμâ“π°“√·¢Áßμ—«¢Õ߇≈◊Õ¥«‘∏’μà“ßÊ (¥—¥·ª≈ß®“°‡Õ° “√Õâ“ßÕ‘ßÀ¡“¬‡≈¢ 13) 13 «‘∏’°“√ ¢âÕ‰¥â‡ª√’¬∫ ª≠í À“/¿“«–·∑√°´Õâ π °“√μ‘¥μ“¡º≈ ¢Õâ ∫ßà ™’È Heparin - „™âßà“¬·≈–§ÿâπ‡§¬ - ‡°‘¥¿“«–‡≈◊Õ¥ÕÕ°‰¥â - °“√μ‘¥μ“¡º≈ §àÕπ¢â“ß∫àÕ¬ PTT/ACT ‰¡à¡’¿“«– LMWH ßà“¬ - ‡°‘¥¿“«– HIT ‡≈◊Õ¥ÕÕ° °“√ Citrate - ‡°‘¥¿“«– - °“√μ‘¥μ“¡º≈‰¡à “¡“√∂ ‡≈◊Õ¥ÕÕ°·≈–‡°√Á¥ ∑”‰¥â∑ÿ°·Ààß ·¢Áßμ—«¢Õ߇≈◊Õ¥ Saline flush ‡≈◊Õ¥μË”πâÕ¬°«à“ - √“§“·æß Heparin ª°μ‘ - ¡’§«“¡‡ ’ˬßπâÕ¬ - ‡°‘¥ Hypernatremia, ∑’Ë ÿ¥μàÕ°“√‡°‘¥ metabolic alkalosis Anti-Xa activity ‰¡à¡’¿“«– ¿“«–‡≈◊Õ¥ÕÕ° - μâÕß„™â dialysate À√◊Õ “√ - ¡’ª√– ‘∑∏‘¿“æ Ÿß πÈ”∑¥·∑π摇»… ‡≈◊Õ¥ÕÕ° °“√ - ‰¡à¡’§«“¡‡ ’ˬßμàÕ - ¡’‚Õ°“ ‡°‘¥ air embolism °“√‡°‘¥¿“«– - ª√– ‘∑∏‘¿“æμË” ·¢Áßμ—«¢Õ߇≈◊Õ¥ ‡≈◊Õ¥ÕÕ° ª°μ‘ - PTT/ACT 1.¡’¿“«–‡≈◊Õ¥ - Serum ionized ÕÕ° °“√·¢Áßμ—« calcium ¢Õ߇≈◊Õ¥ª°μ‘ 2. ¡’¿“«– HIT  —߇°μ¥â«¬μ“ 1.°“√·¢Áßμ—«¢Õß ‡ª≈à“ ‡≈◊Õ¥º‘¥ª°μ‘ 2.‡°√Á¥‡≈◊Õ¥μË” PTT: Activated partial thromboplastin time, ACT: Activated clotting time, LMWH: low molecular weight heparin, HIT: Heparin induced thrombocytopenia 75

Practical Dialysis in the Year 2009 • μ‘¥μ“¡º≈‚¥¬°“√«—¥§à“ PTT ¢Õ߇≈◊Õ¥„π arterial ·≈– venous blood line ‚¥¬æ¬“¬“¡ „Àâ arterial PTT = 40-45 «‘π“∑’·≈– venous PTT > 65 «‘π“∑’ ªí≠À“ ”§—≠¢Õß°“√‡≈◊Õ°„™â heparin ‡ªìπ “√μâ“π°“√·¢Áßμ—«¢Õ߇≈◊Õ¥§◊Õ Õÿ∫—μ‘°“√≥å°“√ ‡°¥‘ ¿“«–‡≈Õ◊ ¥ÕÕ°∑§’Ë Õà π¢“â ߠߟ (√Õâ ¬≈–10-50)·≈–¬ß— Õ“®‡°¥‘ ¿“«–·∑√°´Õâ π∑æ’Ë ∫‰¥‰â ¡∫à Õà ¬·μ à ”§≠— §Õ◊ heparin-induced thrombocytopenia (HIT) ´ß÷Ë ‡ªπì ¿“«–∑‡’Ë °¥‘ ®“°°“√∑¡’Ë °’ “√ √“â ß antibody μÕà platelet factor 4 ‡¡ÕË◊ ‡°¥‘ ¿“«–π¢È’ πÈ÷ §«√À¬¥ÿ °“√„Àâ heparin √«¡‰ª∂ß÷ heparin derivative ÕπË◊ Ê ‡πÕË◊ ß®“°æ∫«“à ¡°’ “√ cross- reactivity ‰¥â∂÷ß√âÕ¬≈– 80 ·≈–§«√‡≈◊Õ°„™â«‘∏’Õ◊Ëπ„π°“√μâ“π°“√·¢Áßμ—«¢Õ߇≈◊Õ¥ 8.2 Low molecular weight heparin °“√‡≈◊Õ°„™â Low molecular weight heparin ‡ªìπ “√μâ“π°“√·¢Áßμ—«¢Õ߇≈◊Õ¥ ¡’¢âÕ¥’„π·ßà∑’Ë «à“¡’‚Õ°“ ‡°‘¥¿“«–‡≈◊Õ¥ÕÕ°·≈–‡°√Á¥‡≈◊Õ¥μË”πâÕ¬°«à“ unfractionated heparin ·μà¡’¢âÕ‡ ’¬§◊Õ¢—∫ÕÕ° ∑“ß‰μ ¥—ßπ—Èπ°“√π”¡“„™â„πºâŸªÉ«¬‰μ«“¬®–¡’ªí≠À“«à“‰¡à “¡“√∂§“¥§–‡π¢π“¥¢Õ߬“∑’ˇÀ¡“– ¡‰¥â √«¡∑—Èß°“√μ‘¥μ“¡º≈®–μâÕß„™â°“√«—¥ anti-Xa activity ´÷Ë߇ªìπ°“√μ√«®∑’ˉ¡à “¡“√∂∑”‰¥â∑—Ë«‰ª «‘∏’ °“√π’È®÷߉¡à‡ªìπ∑’Ëπ‘¬¡¡“°‡∑à“ unfractionated heparin „π∫∑π’È®–¬°μ—«Õ¬à“ß«‘∏’°“√„™â enoxaparin ‡ªìπ  “√μâ“π°“√·¢Áßμ—«¢Õ߇≈◊Õ¥Õ¬à“ߧ√à“«Ê ¥—ßπ1’È 1 • Prime Hemofilter / Dialyzer ¥â«¬ 0.9% NSS 2,000 cc • ¢≥–‡√¡‘Ë ∑” CRRT „Àâ loading enoxaparin 40 mg ∑“ß arterial blood line ·≈«â „Àâ maintenance μàե⫬¢π“¥ 10-40 ¡°. ∑ÿ° 4-6 ™—Ë«‚¡ß • μ‘¥μ“¡º≈‚¥¬°“√«—¥§à“ anti-Xa activity ‚¥¬¡’‡ªÑ“À¡“¬Õ¬Ÿà„π™à«ß 0.1-0.4 IU/ml 8.3 Regional citrate °“√„™â citrate ‡ªìπ “√μâ“π°“√·¢Áßμ—«¢Õ߇≈◊Õ¥„π«ß®√πÕ°√à“ß°“¬®—¥«à“‡ªìπ«‘∏’∑’Ë¡’ ª√– ‘∑∏‘¿“æ¡“°∑’Ë ÿ¥ ‚¥¬∑’Ë citrate ®–®—∫°—∫ ionized calcium ´÷Ë߇ªìπ cofactor  ”§—≠„π coagulation cascadeÀ≈“¬¢π—È μÕπƒ∑∏μ‘Ï “â π°“√·¢ßÁ μ«— ¢Õ߇≈Õ◊ ¥π®’È –¡Õ’ ¬‡àŸ ©æ“–„π«ß®√πÕ°√“à ß°“¬‡∑“à ππ—È ‡æ√“–‡¡Õ◊Ë citrate °≈—∫‡¢â“ Ÿà√à“ß°“¬®–∂°Ÿ μ—∫‡ª≈’ˬπ‡ªìπ bicarbonate Õ¬à“ß√«¥‡√Á«μ“¡ ¡°“√ Trisodium Citrate + [O] → 3Na+ + 3HCO3- + 3CO2 + H2O ∑”„Àâƒ∑∏‘Ï¥—ß°≈à“«À¡¥‰ª °“√„™â citrate ‡ªìπ “√μâ“π°“√·¢Áßμ—« ¢Õ߇≈◊Õ¥®÷ß®—¥‡ªìπ regional anticoagulation Õ¬à“߉√°Áμ“¡°“√„™â citrate ¡’¢âÕ§«√√–«—ß„πºâŸªÉ«¬μ—∫«“¬ ¢—Èπ√ÿπ·√߇æ√“–μ—∫®–‰¡à “¡“√∂‡ª≈’ˬπ citrate ‰ª‡ªìπ bicarbonate ‰¥â∑—π ®÷ßÕ“®∑”„À⇰‘¥¿“«– hypocalcemia ·≈–‡≈◊Õ¥ÕÕ°μ“¡¡“‰¥â πÕ°®“°π’È°“√„™â citrate ‡ªìπ “√μâ“π°“√·¢Áßμ—«¢Õ߇≈◊Õ¥Õ“® ∑”„À⇰‘¥º≈¢â“߇§’¬ß ”§—≠§◊Õ ¿“«– metabolic alkalosis ‡π◊ËÕß®“°√à“ß°“¬‰¥â√—∫ citrate ‡¢â“‰ªÕ¬à“ß μàÕ‡π◊ËÕß∑”„Àâ¡’°“√‡°‘¥¢Õß bicarbonate ‡ªìπ®”π«π¡“° ·≈– “√≈–≈“¬ citrate ∑’Ë„™â®–Õ¬àŸ„π√Ÿª¢Õß 4% Trisodium Citrate ´÷Ëß¡’ª√‘¡“≥‚´‡¥’¬¡ ßŸ ∂÷ß 420 mEq/≈‘μ√ ∑”„Àâ√à“ß°“¬‰¥â√—∫‚´‡¥’¬¡‡ªìπª√‘¡“≥¡“° ·≈–Õ“®∑”„À⇰‘¥¿“«– hypernatremia ‰¥â ¥—ßπ—Èπ°“√„™â citrate ‡ªìπ “√μâ“π°“√·¢Áßμ—«¢Õ߇≈◊Õ¥®÷ߧ«√ „™â‚¥¬∫ÿ§≈“°√∑’Ë¡’ª√– ∫°“√≥å·≈–§«√„™âÕ¬à“ß√–¡—¥√–«—ß  ”À√—∫«ß®√ CRRT ∑’Ë„™â®–μâÕß¡’√ªŸ ·∫∫∑’Ë ·μ°μà“߉ª®“° CRRT ∑—Ë«‰ª¥—ßπ8’È (√Ÿª∑’Ë 2) 76

Practical Points of Continuous Renal Replacement Therapy √ªŸ ∑Ë’ 2 μ—«Õ¬à“ß√Ÿª·∫∫°“√„™â Regional citrate anticoagulation „π°“√∑” CVVHDF8 1. ‡æ◊ËÕªÑÕß°—π¿“«– metabolic alkalosis „π°√≥’ CVVH  “√πÈ”∑¥·∑π∑’Ë„Àâ®–„™â citrate ‡ªìπ buffer À≈—° ‚¥¬‰¡à„ à bicarbonate ≈߉ª ·≈–∂â“„™â “√πÈ” dialysate √à«¡¥â«¬„π°“√∑” CVVHDF ®– μâÕß≈¥ª√‘¡“≥¢Õß bicarbonate ≈ß 2. ‡æ◊ËÕªÑÕß°—π¿“«– hypernatremia §«√º ¡ 4% Trisodium Citrate ‡¢â“‰ª‡ªìπ à«πÀπ÷ËߢÕß  “√πÈ”∑¥·∑π ·≈⫪√—∫ —¥ à«π¢Õß sodium „π “√πÈ”∑¥·∑π„Àâ¡’ª√‘¡“≥∑’ˇÀ¡“– ¡  à«π„π°√≥’ CVVHDF ®–μâÕß≈¥ª√‘¡“≥ sodium „π dialysate ≈ߥ⫬ 3. ‡æ◊ËÕ„ÀâÕ—μ√“ à«π¢Õß citrate μàÕ calcium „π«ß®√πÕ°√à“ß°“¬ ŸßæÕ‡æ’¬ß ‰¡à§«√º ¡ calcium ‡¢“â ‰ª„π dialysate À√Õ◊  “√π”È ∑¥·∑π ·≈«â 𔉪„À∑â “ßÀ≈Õ¥‡≈Õ◊ ¥¥” «à π peripheral ·∑π (√°— …“ √–¥—∫ peripheral ionized calcium „ÀâÕ¬Ÿà„π™à«ß 1-1.3 mmol/≈‘μ√) 8.4 Frequent saline flush „πºŸâªÉ«¬∑’Ë¡’‡≈◊Õ¥ÕÕ°À√◊Õ¡’§«“¡‡ ’ˬߠŸß∑’Ë®–‡°‘¥‡≈◊Õ¥ÕÕ° ‡™àπ¡’¿“«–‡°√Á¥‡≈◊Õ¥μË” °“√ „À â “√μ“â π°“√·¢ßÁ μ«— ¢Õ߇≈Õ◊ ¥ππÈ— ¡§’ «“¡‡ ¬Ë’ ß∑®Ë’ –∑”„À‡â ≈Õ◊ ¥ÕÕ°¡“°¬‘ËߢπÈ÷ «‘∏À’ πË÷ß∑πË’ ‘¬¡„™â§Õ◊ °“√„™â saline flush ‚¥¬°≈‰°∑’˙૬§◊Õ °“√≈¥ hemoconcentration ·≈–™–≈â“ß fibrin ÕÕ°®“°μ—«°√Õß πÕ°®“°π’È„π™à«ß∑’Ë∑” saline flush ¬—ß∑”„Àâ “¡“√∂ª√–‡¡‘π°“√·¢Áßμ—«¢Õ߇≈◊Õ¥‰¥â¥â«¬μ“‡ª≈à“Õ’°¥â«¬ Õ¬à“߉√°Áμ“¡¡’°“√»÷°…“æ∫«à“°“√∑” saline flush ‰¡à‰¥â™à«¬¬◊¥Õ“¬ÿ¢Õß«ß®√ CRRT ‡¡◊ËÕ‡∑’¬∫°—∫°“√ ‰¡à„Àâ„πºâŸªÉ«¬∑’Ë¡’ªí®®—¬‡ ’ˬߢÕß°“√¡’‡≈◊Õ¥ÕÕ° ßŸ 12  ”À√—∫À≈—°°“√∑” saline flush „π«ß®√ CRRT ¡’ ¥—ßπ’È • Prime Hemofilter / Dialyzer ¥â«¬ 0.9% NSS 1,000 cc + heparin 2,500-5,000 U/L À≈—ß®“° π—Èπ„Àâ≈â“ß heparin ÕÕ°¥â«¬ 0.9% NSS 1,000 cc 77

Practical Dialysis in the Year 2009 • ¢≥–∑” CRRT „Àâπ” 0.9% NSS ¡“„Àâ∑“ß arterial blood line °àÕπ‡¢â“ blood pump „π ª√‘¡“≥ 100-200 cc ∑ÿ° 30 π“∑’ ·≈–μâÕß∫—π∑÷°®”π«π 0.9% NSS ∑’Ë„™â‡æ◊ËÕ𔉪§”π«≥Õ—μ√“°“√¥÷ß UF  ÿ∑∏‘ 9. ‡§√Ë◊Õß∑” CRRT  “¡“√∂·∫à߇§√◊ËÕß∑” CRRT ‡ªìπ 2 √ªŸ ·∫∫‰¥â·°à 9.1 Separated system ‡ªìπ√–∫∫∑’Ë¡’ blood pump, fluid pump μà“ßÊ ‡™àπ filtrate pump, dialysate pump, replacement fluid pump ·¬°∑”ß“πÕ‘ √–®“°°—π ´÷Ëß¡’¢âÕ‡ ’¬§◊Õ ∂â“ pump „¥À¬ÿ¥∑”ß“π‡π◊ËÕß®“°¢—¥¢âÕß pump Õ◊ËπÊ ®–¬—ß∑”ß“πÕ¬àŸ ´÷Ëß®–∑”„À⧫“¡ ¡¥ÿ≈¢Õß “√πÈ”º‘¥æ≈“¥®“°∑’Ë —Ëß°“√√—°…“‰«â πÕ°®“°π—Èπ°“√ §«∫§ÿ¡ ¡¥ÿ≈¢Õß “√πÈ”®”‡ªìπμâÕß„™â∫ÿ§≈“°√„π°“√μ«ß«—¥ “√πÈ”¢“‡¢â“·≈–¢“ÕÕ°®“°«ß®√ ·≈– ∫π— ∑°÷ „π flow sheet ∑°ÿ ™«—Ë ‚¡ß ‡æÕ◊Ë ªÕÑ ß°π— §«“¡º¥‘ æ≈“¥ ∑ß—È π‡’È πÕ◊Ë ß®“° fluid pump  «à π„À≠‡à ªπì infusion pump ´÷Ë߉¡à‰¥â∂Ÿ°ÕÕ°·∫∫¡“„™â„π√–∫∫∑’Ë¡’§«“¡¥—π Ÿß·≈–‡ª≈’ˬπ·ª≈߉¥âμ≈Õ¥‡«≈“Õ¬à“ß CRRT Õ—μ√“°“√‰À≈¢Õß “√πÈ”®÷ßÕ“®‰¡àμ√ß°—∫∑’Ëμ—È߉«â 9.2 Integrated system ‡ªπì ‡§√ÕË◊ ß¡Õ◊ ∑¡Ë’ °’ “√ÕÕ°·∫∫¡“‡æÕË◊ «μ— ∂ªÿ √– ß§„å π°“√∑” CRRT ‚¥¬‡©æ“– ´ßË÷ √–∫∫ blood pump, fluid pump μà“ßÊ (filtrate pump, dialysate pump, replacement fluid pump) ®–∑”ß“π‡ªìπ√–∫∫ ‡¥’¬«°—π „π«ß®√®–ª√–°Õ∫¥â«¬ pressure-sensing pods ‡æ◊ËÕ«—¥§«“¡¥—π„π®ÿ¥ ”§—≠ 4 ®ÿ¥·∫∫ non- invasive ª√–°Õ∫¥â«¬∫√‘‡«≥ access, pre-filter, filtrate ·≈– return line ¡’√–∫∫ fluid balancing system ‡æ◊ËÕ§«∫§ÿ¡¥ÿ≈ “√πÈ”‡¢â“·≈–ÕÕ°®“°«ß®√ ¡’ fluid warmer set ª√–°Õ∫Õ¬àŸ„πμ—«‡§√◊ËÕß πÕ°®“°π’Ȭ—ß ¡’√–∫∫°“√μ√«® Õ∫¿“«– filter clotting, fluid balance errors, air detection, blood leaks, °“√ ‡ª≈¬Ë’ π·ª≈ߧ«“¡¥π— ·≈–¡°’ “√‡μÕ◊ πÕ¬“à ߇À¡“– ¡ ‚¥¬∑°Ë’ “√∑”ß“π¢Õß·μ≈à – «à π‡ªπì ·∫∫ integrated system ¬°μ—«Õ¬à“߇™àπ „π°√≥’∑’Ë¡’ —≠≠“≥‡μ◊Õπ pressure alarm ·≈â« blood pump À¬ÿ¥∑”ß“π pump Õ◊ËπÊ ®–À¬ÿ¥∑”ß“π‰ª¥â«¬ πÕ°®“°π’È pump ·μà≈–™π‘¥¬—ß∑”ß“π√à«¡°—π„π°“√§«∫§ÿ¡ fluid balance μ“¡∑’Ë —Ëß∑“ß touch screen ‰¥âÕ¬à“ß·¡à𬔠ªí®®ÿ∫—π¡’‡§√◊ËÕß integrated system (machine CRRT) ∑’Ë„™â„π ª√–‡∑»‰∑¬Õ¬àŸÀ≈“¬™π‘¥ (√Ÿª∑’Ë 3) ‚¥¬∑’Ë√“¬≈–‡Õ’¬¥°“√„™â‡§√◊ËÕß machine CRRT ™π‘¥μà“ßÊ μ—Èß·μà ‡√‘Ë¡μâπ‰ª®π∂÷ß°“√·°â‰¢ªí≠À“∑’Ëæ∫∫àÕ¬®–Õ¬Ÿà„π∫∑ machine CRRT work instruction 78

Practical Points of Continuous Renal Replacement Therapy √Ÿª∑Ë’ 3 ‡§√Õ◊Ë ß∑” CRRT ™π‘¥μ“à ßÊ 10. ¢âÕ∫àß™’„È π°“√∑” CRRT CRRT ‡ªìπ dialysis modality ∑’ËμâÕß≈ß∑ÿπ Ÿß ‚¥¬‡©æ“–„π¥â“π·√ßß“π¢Õß∫ÿ§≈“°√ ¥—ßπ—Èπ °“√æ‘®“√≥“‡≈◊Õ° CRRT ‡ªìπ mode of dialysis  ”À√—∫ºâŸªÉ«¬ AKI ·μà≈–√“¬ ®÷ߧ«√æ‘®“√≥“∂÷ß ª√–‚¬™π·å ≈–§«“¡§¡ÿâ §“à ∑º’Ë ªâŸ «É ¬¢Õ߇√“®–‰¥√â ∫— „À¥â ‡’  ¬’ °Õà π ‚¥¬∑¡’Ë À’ ≈°— ‡°≥±™å «à ¬æ®‘ “√≥“¥ß— μÕà ‰ªπ’È 10.1 °“√§«∫§¡ÿ ¥ÿ≈ “√π”È (Fluid balance) CRRT¡°’ “√§«∫§¡ÿ ª√¡‘ “≥πÈ”„π√“à ß°“¬Õ¬“à ßμÕà ‡πÕ◊Ë ßμ≈Õ¥‡«≈“·≈– “¡“√∂ª√∫— „À‡â À¡“– 79

Practical Dialysis in the Year 2009  ¡°—∫°“√‡ª≈’ˬπ·ª≈߉¥âÕ¬à“ß∑—π∑’ ®÷߇À¡“–°—∫ºâŸªÉ«¬ ICU ∑’Ë¡’ —≠≠“≥™’扡à§ß∑’Ë ¢âÕ¡Ÿ≈ à«π„À≠à · ¥ß„Àâ‡ÀÁπ«à“ °“√∑” CRRT ¡’‚Õ°“ ‡°‘¥§«“¡¥—π‚≈À‘μμË”πâÕ¬°«à“‡¡◊ËÕ‡∑’¬∫°—∫ IHD ¿“«–§«“¡¥—π ‚≈À‘μμË”π’ȇªì𠓇Àμÿ ”§—≠∑’Ë∑”„Àâ°“√øóôπ°“√∑”ß“π¢Õ߉μ·≈–Õ«—¬«–Õ◊Ëπ™â“ ´÷Ëß¡—°æ∫„π°“√∑” IHD14 πÕ°®“°π—Èπ CRRT ¬—߇À¡“–°—∫ºâŸªÉ«¬∑’ËμâÕ߉¥â√—∫ “√Õ“À“√∑“ßÀ≈Õ¥‡≈◊Õ¥¥” (parenteral nutrition) À√◊Õ à«πª√–°Õ∫¢Õ߇≈◊Õ¥„πª√‘¡“≥¡“° °“√‡≈◊Õ°°“√∫”∫—¥∑¥·∑π‰μ‡ªìπ CRRT ®–™à«¬„Àâ°“√¥·Ÿ ≈ √—°…“‰¥â –¥«°·≈–¡’§«“¡¬◊¥À¬ÿàπ‰¥â¥’°«à“°“√∑” IHD ·≈– peritoneal dialysis ¬°μ—«Õ¬à“߇™àπ ºâŸªÉ«¬ oliguric AKI ∑’Ë¡’¿“«–πÈ”‡°‘π·≈–®”‡ªìπμâÕ߉¥â√—∫ fresh frozen plasma (FFP) °“√‡≈◊Õ°∑” CRRT ®– ∑”„À⺟âªÉ«¬‰¥â√—∫ FFP ‰¥â‡æ’¬ßæÕμ“¡∑’ËμâÕß°“√ ‚¥¬‰¡àμâÕß°≈—«¿“«–πÈ”‡°‘π‡π◊ËÕß®“°·æ∑¬å “¡“√∂ ª√—∫Õ—μ√“°“√¥÷ß “√πÈ”‡æ‘Ë¡¢÷Èπ‰¥â∑—π∑’ 10.2 §«“¡ “¡“√∂„π°“√¢®—¥¢Õ߇ ’¬ (uremic toxin clearance) „πºŸâªÉ«¬¿“«–«‘°ƒμ¡—°æ∫¿“«– hypercatabolic √à«¡¥â«¬‰¥â∫àÕ¬ ´÷Ëߺ⟪ɫ¬°≈ÿà¡π’È à«π„À≠à ®”‡ªìπ∑’Ë®–μâÕ߉¥â√—∫Õ—μ√“°“√¢®—¥¢Õ߇ ’¬∑’Ë Ÿß‡æ’¬ßæÕ ¡’°“√»÷°…“æ∫«à“ CRRT  “¡“√∂§«∫§ÿ¡„Àâ √–¥—∫§à“‡©≈’ˬ (time average concentration, TAC) ¢Õß urea ‰¥âμË”°«à“°“√∑” IHD √«¡∑—Èß¡’§à“ EKR (equivalent renal clearance) ∑’ˠߟ °«à“¥â«¬15 ´÷Ëß¡’¢âÕ¡Ÿ≈°“√»÷°…“„πºâŸªÉ«¬∑’Ë∑” IHD æ∫«à“§à“ TAC ¢Õß urea ∑’ËμË”°«à“Õ“®¡’º≈∑”„ÀâÕ—μ√“°“√√Õ¥™’«‘μ¢Õߺ⟪ɫ¬ Ÿß¢÷Èπ16  ”À√—∫°“√‡ª√’¬∫‡∑’¬∫Õ—μ√“°“√¢®—¥ ¢Õ߇ ’¬√–À«à“ß CRRT °—∫ SLED (sustain low efficiency dialysis) π—Èπæ∫«à“Õ—μ√“°“√¢®—¥¢Õ߇ ’¬∑’Ë ‚¡‡≈°ÿ≈¢π“¥‡≈Á°§àÕπ¢â“ß„°≈⇧’¬ß°—π ·μà CRRT ®–¡’Õ—μ√“°“√¢®—¥ “√∑’Ë¡’‚¡‡≈°ÿ≈¢π“¥°≈“߉¥â¥’°«à“ 10.3 ¢âÕ∫àߙȒ∑’ËÕ“®‰¥ªâ √–‚¬™πå„πºªŸâ «É ¬∫“ß°≈¡àÿ ¡’°“√»÷°…“æ∫«à“°“√∑” CRRT ®–™à«¬ªÑÕß°—π°“√‡æ‘Ë¡¢÷Èπ¢Õߧ«“¡¥—π„π°–‚À≈°»’√…–„π ºŸâªÉ«¬∑’Ë¡’¿“«– ¡Õß∫«¡ ‡™àπºŸâªÉ«¬À≈—ߺà“μ—¥ ¡Õß ºŸâªÉ«¬μ‘¥‡™◊ÈÕ„π ¡Õß (encephalopathy) ·≈–ºŸâ ªÉ«¬∑’Ë¡’¿“«–μ—∫«“¬‡©’¬∫æ≈—π (acute hepatic failure) ´÷Ëß„πºŸâªÉ«¬‡À≈à“π’È °“√∑” IHD ¡—°®–∑”„Àâ ¿“«– ¡Õß∫«¡·¬à≈ß17 πÕ°®“°π’Ȭ—ß¡’·π«§‘¥∑’Ë«à“ CRRT ‡À¡“– ¡∑’Ë®–‡ªìπ«‘∏’°“√√—°…“¿“«– AKI ∑’Ë ‡°¥‘ √«à ¡°∫— sepsis / SIRS ‡πÕ◊Ë ß®“°§≥ÿ  ¡∫μ— ∑‘  ’Ë “¡“√∂¢®¥—  “√‚¡‡≈°≈ÿ ¢π“¥°≈“ß´ß÷Ë √«¡∂ß÷ inflammatory mediators μà“ßÊ ÕÕ°‰¥â ¡’°“√∑¥≈Õß∑—Èß„π —μ«å·≈–§πæ∫«à“ CRRT  “¡“√∂¢®—¥ “√‚¡‡≈°ÿ≈∑’ˇªìπ mediators À≈—°„π°≈‰°°“√‡°‘¥ sepsis ∑—Èß«‘∏’ convection ·≈– adsorption18 Õ¬à“߉√°Áμ“¡ „πªí®®ÿ∫—π¬—ß ‰¡à¡’¢âÕ¡≈Ÿ ∑“ߧ≈‘π‘°¬◊π¬—π∂÷ߪ√–‚¬™πå∑’Ë®–‰¥â√—∫„π°“√„™â CRRT ‡ªìπ°“√√—°…“ºâŸªÉ«¬ sepsis ∑’ˉ¡à¡’¢âÕ ∫àß™’È∑“ߥâ“π‰μ19 ‡π◊ËÕß®“°¬—ß¡’§”∂“¡∑’Ë√Õ°“√»÷°…“Õ’°¡“°¡“¬ Õ“∑‘‡™àπ mediators ‡À≈à“π’È∫“ß™π‘¥ ‡ªìπª√–‚¬™πåμàÕ√à“ß°“¬ ·μà°“√∑” CRRT ®–¢®—¥ÕÕ°‰ª¥â«¬ ‚¥¬‡©æ“–∂Ⓣ¡à‰¥â∑” CRRT ∑—π∑’μ—Èß·μà ‡√‘Ë¡‡ªìπ20 Õ¬à“߉√°Áμ“¡„πºŸâªÉ«¬ sepsis ∑’Ë¡’¿“«– hemodynamic instability ´÷Ëßæ∫‰¥â∫àÕ¬ °“√∑” CRRT ‡ªìπ«‘∏’°“√∫”∫—¥∑¥·∑π‰μ∑’ˇÀ¡“– ¡°«à“ IHD ‡¡◊ËÕæ‘®“√≥“„π·ßà¢Õß°“√§«∫§ÿ¡¥ÿ≈ “√πÈ”21 πÕ°®“°π¬È’ ß— √“¬ß“π∂ß÷ ¢Õâ ‰¥‡â ª√¬’ ∫¢Õß°“√∑” CRRT ‡ÀπÕ◊ °«“à IHD „πºªâŸ «É ¬°≈¡àÿ ÕπË◊ Ê ‡™πà ºŸâªÉ«¬¿“«–À—«„®≈⡇À≈«∑’ˉ¡àμÕ∫ πÕßμàÕ¬“¢—∫ªí  “«–22 ·≈–ºâŸªÉ«¬À≈—ߺà“μ—¥À—«„®23 ‡ªìπμâπ 80

Practical Points of Continuous Renal Replacement Therapy 10.4 Evident base ∑“ߥ“â πÕ—μ√“°“√√Õ¥™«’ μ‘ „πªí®®ÿ∫—π¬—߉¡à¡’°“√»÷°…“∑’Ë· ¥ß«à“°“√∑” CRRT ∑”„À⺟âªÉ«¬¡’Õ—μ√“√Õ¥™’«‘μ ßŸ °«à“ IHD ‚¥¬∑’Ë randomized trial ∑’Ë®–μÕ∫§”∂“¡¥—ß°≈à“«‰¥â®–μâÕß¡’®”π«πºâŸªÉ«¬ ßŸ æÕ ·≈– “¡“√∂∑’Ë®–·∫àߺ⟠ªÉ«¬‡ªìπ 2 °≈ÿà¡ ‰¥âÕ¬à“߇∑à“‡∑’¬¡°—π„π¥â“𧫓¡√ÿπ·√ߢÕߺ⟪ɫ¬·≈– “‡Àμÿ¢Õß AKI °“√»÷°…“∑’Ë „À≠à∑’Ë ÿ¥§◊Õ°“√»÷°…“¢Õß Vinsonneau ·≈–§≥–24 ∑’Ë∑”„πºâŸªÉ«¬®”π«π∑—Èß ‘Èπ 360 §π æ∫«à“°“√∑” CVVHDF ·≈– IHD ¡’Õ—μ√“°“√√Õ¥™’«‘μ·≈–√–¬–‡«≈“„π°“√Õ¬àŸ‚√ß欓∫“≈‰¡à·μ°μà“ß°—π °“√»÷°…“π’È ¡’®ÿ¥∑’Ëπà“ π„®§◊Õ  “¡“√∂·∫àߺ⟪ɫ¬μ“¡§«“¡√ÿπ·√ߢÕß‚√§‰¥â„°≈⇧’¬ß°—π¡“°∑—Èß 2 °≈ÿà¡ ·≈–¡’°“√ cross over √–À«à“ß 2 °≈ÿà¡πâÕ¬¡“° ºâŸ«‘®—¬‰¥â √ÿª«à“‡¡◊Ëպ⟥·Ÿ ≈¡’ª√– ∫°“√≥å‡æ’¬ßæÕ ·≈–ªØ‘∫—μ‘μ“¡ ·π«∑“ß°“√ªÑÕß°—π¿“«– hemodynamic instability ‡ªìπÕ¬à“ߥ’·≈â« ºŸâªÉ«¬ AKI ∑’Ë¡’¿“«– MODS  à«π „À≠à “¡“√∂√—°…“‰¥â‚¥¬«‘∏’ IHD ·≈–‰¥âº≈„°≈⇧’¬ß°—∫°“√∑” CRRT ¡’°“√»÷°…“·∫∫ meta-analysis 2 ™‘Èπ∑’ˇª√’¬∫‡∑’¬∫ IHD °—∫ CRRT ™‘Èπ·√°∑”‚¥¬ Kellum ·≈–§≥–25 ‰¥â∑”°“√√«∫√«¡ 13 °“√»÷°…“ (¡’ ‡æ’¬ß 3 °“√»÷°…“∑’ˇªìπ randomized trial) æ∫«à“ºŸâªÉ«¬∑’Ë∑” CRRT ¡’§«“¡‡ ’ˬßμàÕ°“√°“√‡ ’¬™’«‘μ‰¡à ·μ°μà“ß®“° IHD (relative risk 0.93; 95% CI 0.79-1.09; p <0.01) Õ¬à“߉√°Áμ“¡‡¡◊ËÕ°”®—¥ªí®®—¬∑“ß ¥â“π§ÿ≥¿“æ¢Õß°“√»÷°…“·≈–§«“¡√ÿπ·√ߢÕß°“√‡®Á∫ªÉ«¬ÕÕ°‰ª ®–æ∫«à“ºâŸªÉ«¬∑’Ë∑” CRRT ¡’§«“¡ ‡ ’ˬßμàÕ°“√°“√‡ ’¬™’«‘μμË”°«à“ (relative risk 0.72; 95% CI 0.60-0.87; p <0.01)  à«π Tonelli ·≈–§≥–26 ‰¥â∑” meta-analysis ®“° 18 °“√»÷°…“ (‡ªìπ RCT 6 °“√»÷°…“) ‰¡àæ∫§«“¡·μ°μà“ß∑“ߥâ“πÕ—μ√“°“√ √Õ¥™’«‘μ·≈– renal recovery ·¡«â “à ®–¬ß— ‰¡¡à ¢’ Õâ ¡≈Ÿ «“à CRRT  “¡“√∂‡æ¡‘Ë Õμ— √“°“√√Õ¥™«’ μ‘ ‰¥¡â “°°«“à IHD ·μ¡à °’ “√»°÷ …“ „πºâŸªÉ«¬ sepsis ·≈–¡“≈“‡√’¬∑’ˇ°‘¥¿“«– AKI æ∫«à“ CRRT „Àâº≈¥’°«à“°“√∑” intermittent peritoneal dialysis (IPD) ∑—Èß„π¥â“πÕ—μ√“°“√√Õ¥™’«‘μ·≈–√–¬–‡«≈“°“√∑” dialysis27 ´÷ËßÕ∏‘∫“¬‰¥â®“°°“√∑’˺⟪ɫ¬  à«π„À≠à„π°“√»÷°…“π’ȇªìπ°≈ÿà¡ hypercatabolism ´÷Ëß°“√∑” IPD Õ“®‰¡à‡æ’¬ßæÕ„π°“√¢®—¥¢Õ߇ ’¬ ¥—ßπ—Èπ®÷߉¥â¡’¢âÕ·π–π”«à“„πºâŸªÉ«¬ sepsis À√◊Õ¡’¿“«– hypercatabolism °“√∑” CRRT ®÷ß¡’§«“¡‡À¡“–  ¡¡“°°«à“ IPD 10.5 Evident base ¥“â π°“√øπóô °“√∑”ß“π¢Õß‰μ ¡’¢âÕ¡≈Ÿ ∑’Ë π—∫ πÿπ«à“°“√∑” CRRT Õ“®∑”„Àâ°“√øóôπ¢Õß‰μ¥’°«à“‡¡◊ËÕ‡∑’¬∫°—∫ IHD ¡’°“√ »÷°…“·∫∫¬âÕπÀ≈—ß 2 °“√»÷°…“28,29 ·≈–°“√»÷°…“·∫∫‰ª¢â“ßÀπâ“ 1 °“√»÷°…“30 æ∫«à“„πºâŸªÉ«¬∑’Ë √Õ¥™’«‘μ ºŸâªÉ«¬∑’ˉ¥â√—∫°“√∑” CRRT ®–¡’Õ—μ√“°“√øóôπ¢Õß°“√∑”ß“π¢Õß‰μ Ÿß°«à“ºâŸªÉ«¬ IHD ‡¡◊ËÕ√«¡ ∑—Èß “¡°“√»÷°…“‡¢â“¥â«¬°—π Õ—μ√“°“√øóôπ¢Õß°“√∑”ß“π¢Õ߉μ„πºŸâªÉ«¬∑’Ë∑” CRRT ·≈–√Õ¥™’«‘μ ‡∑à“°—∫√âÕ¬≈– 80 ‡∑’¬∫°—∫√âÕ¬≈– 58 „πºŸâªÉ«¬∑’Ë∑” IHD (p<0.001) Õ¬à“߉√°Áμ“¡ °“√«‘‡§√“–Àå¢âÕ¡Ÿ≈ ≈—°…≥–π’ÈÕ“®‰¡à∂Ÿ°μâÕß ‡π◊ËÕß®“°‡¡◊ËÕ‡√“æ‘®“√≥“∂÷ߺ≈≈—æ∏å ÿ¥∑⓬§◊Õ ºâŸªÉ«¬∑’Ë√Õ¥™’«‘μ·≈–°“√ ∑”ß“π¢Õ߉μøóôπ‡ªìπª°μ‘ æ∫«à“∑—Èß 2 °≈ÿࡉ¡à¡’§«“¡·μ°μà“ß°—π ®÷߬—߉¡à “¡“√∂ √ÿª‰¥âÕ¬à“ß™—¥‡®π «à“°“√∑” CRRT ∑”„ÀâÕ—μ√“°“√øóôπ°“√∑”ß“π ¢Õß‰μ Ÿß°«à“ IHD  ”À√∫— °“√‡ª√¬’ ∫‡∑¬’ ∫¢Õâ ¥¢’ Õâ ‡ ¬’ ¢Õß«∏‘ °’ “√∫”∫¥— ∑¥·∑π‰μ™π¥‘ μ“à ßʉ¥·â  ¥ß‰«„â πμ“√“ß ∑’Ë 5  à«π¢âÕ∫àß™’È¢Õß°“√‡√‘Ë¡∑” CRRT ‰¥â· ¥ß‰«â„πμ“√“ß∑’Ë 6 81

Practical Dialysis in the Year 2009 μ“√“ß∑’Ë 5 ‡ª√’¬∫‡∑’¬∫¢âÕ¥’¢âÕ‡ ’¬¢Õß«‘∏’°“√∫”∫—¥∑¥·∑π‰μ™π‘¥μà“ßÊ PD (24 hrs) IHD (4 hrs) SLED CRRT (8-18 hrs) (24 hrs) Õ—μ√“°“√¢®—¥¢Õ߇ ’¬ + +++ +++ +++ μàÕ«—π Hemodynamic ++++ + ++ +++ stability °“√§«∫§ÿ¡¥ÿ≈ “√πÈ” + +/- ++ +++ §«“¡√«¥‡√Á«„π°“√ +/- ++++ ++ ++ ·°â‰¢§«“¡º‘¥ª°μ‘ ¢Õ߇°≈◊Õ·√à +++ √“§“·≈–§«“¡  ‘Èπ‡ª≈◊Õߥâ“π ++ + +++ ∫ÿ§≈“°√ Infection, Hypotension Hypotension Air embolism, ¿“«–·∑√°´âÕπ High blood sugar, Hypotension Visceral trauma PD: Peritoneal dialysis, IHD: Intermittent hemodialysis, SLED: Sustained low efficiency dialysis, CRRT: Continuous renal replacement therapy μ“√“ß∑Ë’ 6 ¢âÕ∫àß™’È„π°“√‡√‘Ë¡∑” CRRT 5 Potential indications for CRRT in Intensive Care Units T Non-obstructive oliguria (urine output <200 ml/12hr) or anuria T Severe acidemia (pH <7.1) due to metabolic acidosis T Azotemia (BUN >80 mg/dL) T Hyperkalemia ([K+] >6.5 mmol/L or rapid rising [K+]) T Suspected uremic organ involvement (pericarditis/encephalopathy/neuropathy/myopathy) T Progressive severe dysnatremia ([Na+]>160 or < 115 mmol/L) T Hyperthermia (core temperature > 39.5oC) T Clinical significant organ edema (especially lung) T Drug overdose with dialyzable toxin T Coagulopathy requiring large amounts of blood products in patients with pulmonary edema or ARDS 82

Practical Points of Continuous Renal Replacement Therapy 11. °“√ —ßË °“√√—°…“ (Prescription) „π°“√ —Ëß°“√√—°…“ CRRT ·æ∑¬åºŸâ¥Ÿ·≈§«√¡’ ‘Ëß∑’ËμâÕßæ‘®“√≥“‰¥â·°à ë Dose ¢Õß°“√∑” CRRT ë Blood flow rate ·≈– filtration fraction ë °“√§«∫§ÿ¡¥ÿ≈ “√πÈ” ë °“√§«∫§ÿ¡¥ÿ≈¢Õ߇°≈◊Õ·√à ·≈–°√¥¥à“ß 11.1 Dose ¢Õß°“√∑” CRRT  ‘Ëß·√°∑’˧«√®–§”π÷ß∂÷ß„π°“√ —Ëß°“√√—°…“ CRRT §◊ÕÕ—μ√“°“√¢®—¥¢Õ߇ ’¬‡ªÑ“À¡“¬À√◊Õ∑’Ë ‡√’¬°«à“ dose ¢Õß CRRT ¥—ß∑’ˉ¥â°≈à“«¡“·≈â««à“§à“ clearance ¢Õß “√∑’Ë¡’‚¡‡≈°ÿ≈¢π“¥‡≈Á° ‡™àπ urea ®–¡’§à“„°≈⇧’¬ß°—∫ ultrafiltration rate (QUF) „π«ß®√ CRRT ∑ÿ°™π‘¥ °“√»÷°…“ à«π„À≠à®÷ß„™â§à“ QUF π’È ‡ªìπ«‘∏’∫Õ°¢π“¥¢Õß°“√∑” CRRT, Ronco ·≈–§≥– ‰¥â∑”°“√»÷°…“„πºâŸªÉ«¬∑’Ë∑” CVVH ·∫∫ post- dilution ‚¥¬ºâŸªÉ«¬‰¥â∂Ÿ° ÿà¡μ—«Õ¬à“ßÕÕ°‡ªìπ 3 °≈ÿà¡μ“¡Õ—μ√“¢Õß QUF §◊Õ 20, 35, 45 ¡≈./°°./™—Ë«‚¡ß æ∫«à“°≈ÿà¡∑’ˉ¥â√—∫ QUF 20 ¡≈./°°./™—Ë«‚¡ß ¡’Õ—μ√“°“√√Õ¥™’«‘μμË”∑’Ë ÿ¥  à«πÕ—μ√“°“√√Õ¥™’«‘μ¢ÕßÕ’° 2 °≈ÿà¡ ‰¡à·μ°μà“ß°—πÕ¬à“ß¡’π—¬ ”§—≠31 Õ¬à“߉√°Áμ“¡°“√»÷°…“¢π“¥„À≠à¢Õß The VA/NIH Acute Renal Failure Trial Network ´÷Ëß¡’ºâŸªÉ«¬‡«™∫”∫—¥«‘°ƒμ∑’Ë¡’¿“«– AKI ‡¢â“√à«¡„π°“√»÷°…“¡“°°«à“ 1,000 §π („π®”π«ππ’È¡’ 5,967 §π ‰¥â√—∫°“√∑” CVVHDF) ‰¡àæ∫«à“°“√∑” high dose CVVHDF (35 ¡≈./°°./™—Ë«‚¡ß)  “¡“√∂‡æ‘Ë¡Õ—μ√“°“√√Õ¥™’«‘μ32 ‡¡◊ËÕ‡∑’¬∫°—∫ standard dose (20 ¡≈./°°./™—Ë«‚¡ß) ®“°¢âÕ¡≈Ÿ ªí®®ÿ∫—π®÷ßÕ“® √ÿª‰¥â«à“°“√∑” CRRT §«√¡’ dose Õ¬à“ßπâÕ¬ 20 ¡≈./°°./™—Ë«‚¡ß  à«πºâŸªÉ«¬ sepsis À√◊Õ¡’¿“«– hypercatabolism °“√‡≈◊Õ° —Ëß dose 35 ¡≈./°°./™—Ë«‚¡ß Õ“®‰¥âª√–‚¬™πå ‚¥¬‡©æ“–∂Ⓡ≈◊Õ°«‘∏’ CVVH post-dilution „π≈—°…≥–‡¥’¬«°—∫°“√»÷°…“¢Õß Ronco  ”À√—∫μ—«Õ¬à“ߧ”  —Ëß°“√√—°…“∑’ˉ¥â· ¥ß‰«â„πμ“√“ß∑’Ë 7 ‰¥â‡≈◊Õ°„π√Ÿª·∫∫¢Õß high dose CVVH 11.2 Blood flow rate ·≈– filtration fraction À≈—ß®“°∑’Ë°”Àπ¥ dose „π°“√∑” CRRT ·≈â«  ‘Ëß∑’Ë ”§—≠μàÕ‰ª§◊Õ °“√°”Àπ¥ blood flow rate ´÷Ëß¡’À≈—°°“√«à“ §«√®– ŸßæÕ∑’Ë∑”„ÀâÕ—μ√“ à«π√–À«à“ß ultrafiltration rate °—∫ plasma flow rate (filtration fraction, FF) ‰¡à¡“°°«à“ 20% ´÷Ëß°“√∑’Ë¡’§à“ FF  Ÿß¡“°°«à“π’È ®–∑”„Àâ‡≈◊Õ¥∑’ËÕ¬àŸ„πμ—«°√Õß ¢âπ‡°‘π‰ª ®–∑”„ÀâÕ—μ√“°“√‰À≈¢Õ߇≈◊Õ¥™â“·≈–¡’‚Õ°“ μ—«°√ÕßÕÿ¥μ—π‡æ‘Ë¡¢÷Èπ ‚¥¬¡’«‘∏’°“√§”π«≥§à“ plasma flow rate ¥—ßπ’È Plasma flow rate = (1-Hct) x Blood flow x 0.94 ‡¡◊ËÕ‡√“∑√“∫ ultrafiltration rate ∑’ËμâÕß°“√·≈â«  “¡“√∂𔉪§”π«≥À“ blood flow rate μË”  ÿ¥∑’Ë®–∑”„Àâ§à“ filtration fraction ‰¡à‡°‘π 20% ‚¥¬‰¥â· ¥ß«‘∏’°“√§”π«≥„πºâŸªÉ«¬∑’Ë¡’√–¥—∫ hematocrit 30% ‰«â„πμ“√“ß∑’Ë 8 83

Practical Dialysis in the Year 2009 μ“√“ß∑Ë’ 7 · ¥ßμ—«Õ¬à“ß CRRT prescription: Mode CVVH „πºŸâªÉ«¬ sepsis „π ICU ∑’Ë¡’¿“«– MODS with severe acidosis πÈ”Àπ—° 50 kg Setting ‡Àμºÿ ≈ Modality CVVH ¡’ª√– ‘∑∏‘¿“æ„π°“√¢®—¥¢Õ߇ ’¬ ßŸ ∑—Èß Membrane small ·≈– middle molecule ∂â“„™â utrafiltration rate ∑’Ë ŸßæÕ Aquamax HF12 / Prisma M100  “¡“√∂„™â 0.9 m2 AN69 polyacrylonitrile membrane ‰¥â‚¥¬¡’ clearance „°≈⇧’¬ß°—π Vascular access Rt. Internal jugular vein 15 cm ‡æ◊ËÕ¡’ Blood flow ∑’ˠߟ æÕ ·≈–¡’ recirculation À√◊Õ Femoral vein 24 cm πâÕ¬∑’Ë ÿ¥ Blood flow rate 150 ¡≈./π“∑’ Blood flow μâÕߠߟ ‡æ’¬ßæÕ‡æ◊ËÕ¡’ filtration fraction < 20% ≈¥‚Õ°“ ∑’ˇ°‘¥ Filter clotting Anticoagulation Heparin loading 5-10 u/kg, ¡’Õÿ∫—μ‘°“√≥å°“√‡°‘¥¿“«–‡≈◊Õ¥ÕÕ° 10-50% maintenance 3-12 u/kg keep §«√æ‘®“√≥“§«“¡‡ ’ˬߢÕߺ⟪ɫ¬°àÕπ arterial PTT 40-45 «‘π“∑’, venous PTT >65 «‘π“∑’ Ultrafiltration rate 2 ≈‘μ√/™—Ë«‚¡ß ‡≈◊Õ°„™â high dose (35 ¡≈./°°./™—Ë«‚¡ß) (QUF) ‡π◊ËÕß®“°¡’¿“«– hypercatabolism Replacement fluid Pre-dilution 0.8 ≈‘μ√/™—Ë«‚¡ß ‡æ‘Ë¡ à«π¢Õß Pre-dilution ‡æ◊ËÕ≈¥‚Õ°“ ∑’Ë®– Post-dilution 1.2 ≈‘μ√/™—Ë«‚¡ß ‡°‘¥ Filter clotting ·μà∑”„Àâª√– ‘∑∏‘¿“æ „π°“√¢®—¥¢Õ߇ ’¬≈¥≈ß  “¡“√∂ª√—∫‡ª≈’Ë¬π ‰¥âμ“¡ fluid balance ∑’ˇª≈’ˬπ·ª≈ß Replacement fluid ∂ÿß∑’Ë 1: 0.45% NSS 1000 cc §«“¡‡¢â¡¢âπ sodium ·≈– potassium composition + 7.5% NaHCO3 90 cc + 50% „°≈⇧’¬ß°—∫„πæ≈“ ¡“ §«“¡‡¢â¡¢âπ¢Õß glucose 8 cc. bicarbonate  “¡“√∂ª√—∫‰¥âμ“¡§«“¡√ÿπ·√ß ∂ßÿ ∑Ë’ 2: 0.45% NSS 1000 ml ¢Õß acidosis + 3% NSS 150 cc + 50% MgSO4 0.5 cc + KCl 8 meq Replacement calcium 10% Calcium gluconate 60 cc ‰¡àº ¡ calcium ‡æ◊ËÕªÑÕß°—π°“√μ°μ–°Õπ + 5% D/W 40 cc drip 20 cc/hr ¢Õ߇°≈◊Õ calcium „𠓬 peripheral line Fluid removal rate 120 ¡≈./™—Ë«‚¡ß μ—È߇ªÑ“ UF ∑’Ë®–¥÷ß„π 24 ™—Ë«‚¡ß ·≈– check (net UF) fluid balance ∑ÿ°™—Ë«‚¡ß Monitoring Serum Electrolyte, Ca2+, ∑ÿ° 8 ™—Ë«‚¡ß Glucose BUN, Cr, PO43-, Mg2+, ∑ÿ°«—π CBC, PT, PTT, LFT 84

Practical Points of Continuous Renal Replacement Therapy μ“√“ß∑’Ë 8 Õ—μ√“°“√¥÷ß ultrafiltration rate  Ÿß ÿ¥μàÕ§à“ Blood flow rate μà“ßÊ „πºŸâªÉ«¬∑’Ë¡’§à“ hematocrit 30% Blood Flow Plasma Flow Limit of UF Limit of UF Limit of UF (cc/min) (cc/min) rate (cc/min) rate (L/Hr) rate (L/D) 120 75.6 15 0.9 21.6 150 98.7 19.7 1.18 28 200 131.6 26.3 1.6 37 250 164.5 32.9 1.97 47.4 UF: Ultrafiltration rate ®–‡ÀÁπ‰¥â«à“‡¡◊ËÕ‡√“ —Ëß°“√√—°…“ high dose CVVH ∂â“„™â«‘∏’ post-dilution ·μà‡æ’¬ßÕ¬à“߇¥’π« ®”‡ªìπμâÕßμ—Èß blood flow rate Õ¬à“ßπâÕ¬ 250 ¡≈./π“∑’ ´÷ËßÕ“®∑”‰¥â¬“°„πºâŸªÉ«¬¿“«–«‘°ƒμ ¡’Õ’°«‘∏’∑’Ë ®–™à«¬≈¥ FF ≈߉¥â§◊Õ πÈ”∑¥·∑π¡“„Àâ∑“ß pre-dilution ·μà¡’¢âÕ‡ ’¬§◊ÕÕ—μ√“°“√¢®—¥¢Õ߇ ’¬®–≈¥≈ß °«à“«‘∏’ post-dilution ¥—ß∑’ˉ¥â°≈à“«¡“·≈â« «‘∏’∑’Ë¥’∑’Ë ÿ¥§◊Õ°“√·∫àß„Àâ “√πÈ”∑¥·∑π∑—Èß 2 ∑“ß ¥—ß∑’Ë· ¥ß ‰«â„πμ“√“ß∑’Ë 7 11.3 °“√§«∫§¡ÿ ¥ÿ≈ “√πÈ”  ”À√—∫À≈—°°“√¢Õß°“√§«∫§ÿ¡ ¡¥ÿ≈ “√πÈ”¢Õ߇§√◊ËÕß CRRT ¡—°π‘¬¡μ—È߇§√◊ËÕß„ÀâÕ—μ√“ °“√„Àâ “√πÈ”∑¥·∑π§ß∑’Ë  à«π ultrafiltration rate (QUF) ®–¡’°“√ª√—∫μ“¡§à“ net ultrafiltration rate (net UF) ∑‰Ë’ ¥μâ ßÈ— ‰«â ¥ß— ππÈ— §“à urea clearance „π·μ≈à –™«Ë— ‚¡ß®–·ª√‡ª≈¬Ë’ π‰ªμ“¡§“à net UF ‚¥¬∑‡Ë’ §√ÕË◊ ß CRRT ®–∫—π∑÷° total effluent rate (QEFF) „π·μà≈–™—Ë«‚¡ß‰«â ´÷Ëß “¡“√∂‡√’¬°¥Ÿ‡æ◊ËÕ𔉪§”π«≥ urea clearance ®√‘߉¥â (QEFF = replacement fluid rate + dialysate rate + net UF) °“√ª√–‡¡‘πª√‘¡“≥ “√πÈ”∑’ËμâÕߥ÷ßÕÕ°‚¥¬‡§√◊ËÕß CRRT Õ“»—¬ª√–«—μ‘ μ√«®√à“ß°“¬ §«“¡ ¥—π‚≈À‘μ √«¡‰ª∂÷ß°“√„™â hemodynamic monitoring ‡™àπ central venous pressure (CVP) À√◊Õ pulmonary capillary wedge pressure (PCWP) ™à«¬„π°“√ª√–‡¡‘π ·≈–μâÕß∑”°“√μ‘¥μ“¡°“√‡ª≈’ˬπ·ª≈ßÕ“°“√ ∑“ߧ≈‘π‘°Õ¬à“ß„°≈♑¥ ‡æ◊ËÕ∑’Ë®– —Ëß°“√‡ª≈’ˬπ·ª≈ßÕ—μ√“°“√¢®—¥πÈ” à«π‡°‘π‰¥âÕ¬à“߇À¡“– ¡ ‚¥¬®– ∑”°“√§”π«≥∑ÿ°™—Ë«‚¡ß ¥—ßπ’È Fluid balance = All intake (IV, NG, saline flush) - all output (Urine, NG, chest tube) Fluid removal rate = desired UF (ª√‘¡“≥πÈ” à«π‡°‘π) - Fluid balance 11.4 °“√§«∫§ÿ¡¥ÿ≈¢Õ߇°≈◊Õ·√à ·≈–°√¥¥“à ß °“√·°â‰¢§«“¡º‘¥ª°μ‘¢Õߥÿ≈‡°≈◊Õ·√à (Na+, K+, PO43-, Mg2+, Ca2+) ·≈–°√¥¥à“ß ∑”‰¥â‚¥¬ °“√ª√—∫ à«πª√–°Õ∫¢Õß “√πÈ”∑¥·∑π·≈– dialysate „Àâ¡’§«“¡‡À¡“– ¡ (¥Ÿ√“¬≈–‡Õ’¬¥„πÀ—«¢âÕ  “√πÈ”∑¥·∑π·≈– dialysate) ‚¥¬¡’À≈—° ”§—≠‡æ‘Ë¡‡μ‘¡¥—ßπ’È 85

Practical Dialysis in the Year 2009 11.4.1 Potassium ‚¥¬∑«Ë— ‰ª°“√∑” CRRT ®–¢®¥— ‚ª·μ ‡´¬’ ¡ÕÕ°‰¥™â “â °«“à °“√∑” IHD ®ß÷ ‰¡§à «√∑®Ë’ –‡≈Õ◊ °‡ªπì mode °“√√—°…“„πºŸâªÉ«¬ severe hyperkalemia ·μà∂â“μâÕß„™â CRRT „πºâŸªÉ«¬°≈ÿà¡π’ÈÕ“®„™â‡ªìπ potassium free replacement fluid/dialysate „π™à«ß·√°‡æ◊ËÕ‡æ‘Ë¡Õ—μ√“°“√¢®—¥‚ª·μ ‡´’¬¡ ·μàμâÕßμ√«®μ‘¥μ“¡ √–¥—∫‚ª·μ ‡´’¬¡Õ¬à“ß„°≈♑¥  ”À√—∫ºŸâªÉ«¬‚√§À—«„®À—«„®∑’Ë¡’§«“¡‡ ’ˬßμàÕ°“√‡°‘¥ cardiac arrhythmia §«√μ—Èß§à“‚ª·μ ‡´’¬¡„π replacement fluid/dialysate ‰«â‡∑à“°—∫ 4 meq/≈‘μ√ À√◊ÕÕ“® Ÿß°«à“π’È ∂⓺⟪ɫ¬ ¡’¿“«– hypokalemia 11.4.2 Phosphate °“√∑” CRRT  “¡“√∂√°— …“¿“«– hyperphosphatemia ‰¥¥â ’ Õ¬“à ߉√°μÁ “¡μÕâ ß‡Ω“Ñ √–«ß— ¿“«– øÕ ‡øμ„π‡≈◊Õ¥μË” ´÷ËßÕ“®‡°‘¥μ“¡¡“À≈—ß∑” CRRT ‰ªÀ≈“¬«—π „π°√≥’π’È®–μâÕß‡μ‘¡øÕ ‡øμ≈߉ª „π “√πÈ”∑¥·∑π ‡æ◊ËÕ‡ªìπ∑’ˇ¢â“„®À≈—°°“√„À⧔ —Ëß°“√√—°…“ μ“√“ß∑’Ë 7 ‰¥â· ¥ßμ—«Õ¬à“ß CRRT prescription æ√âÕ¡‡Àμÿº≈„π·μà≈–®ÿ¥„πºâŸªÉ«¬ sepsis ∑’Ë¡’¿“«– AKI ·≈– MODS πÈ”Àπ—° 50 °°. 12.  √ÿª „πªí®®ÿ∫—π CRRT ‰¥â°≈“¬‡ªìπ°“√∫”∫—¥∑¥·∑π‰μÀ≈—°¢Õß°“√¥Ÿ·≈ºŸâªÉ«¬„π ICU ·≈–‰¥â ‡ªìπ∑’Ë π„®¢Õß·æ∑¬å·≈–∫ÿ§≈“°√∑’ˇ°’ˬ«¢âÕß°—∫°“√¥Ÿ·≈ºâŸªÉ«¬‡«™∫”∫—¥«‘°ƒμ¡“°¬‘Ëߢ÷Èπ ¢âÕ¡Ÿ≈ ªí®®ÿ∫—πæ∫«à“ CRRT ‡ªìπ«‘∏’∑’ˉ¥âº≈¥’„πºŸâªÉ«¬∑’Ë¡’ —≠≠“≥™’扡à§ß∑’Ë ºâŸªÉ«¬¿“«– ¡Õß∫«¡ ·≈– ºŸâªÉ«¬∑’Ë¡’¿“«–≈⡇À≈«¢ÕßÕ«—¬«–À≈“¬™π‘¥√à«¡°—π °“√¥Ÿ·≈√—°…“®”‡ªìπ∑’Ë®–μâÕß„™âºŸâ¡’ª√– ∫°“√≥å ‡æ’¬ßæÕ ·≈– “¡“√∂∑”ß“π√à«¡°—π‰¥âÕ¬à“߇ªìπ∑’¡ ‡æ◊Ëՙ૬„Àâ°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬∑’ËÕ¬Ÿà„π¿“«–«‘°ƒμ ‡À≈à“π’È¡’ª√– ‘∑∏‘¿“楒∑’Ë ÿ¥ ‡Õ° “√Õ“â ßÕß‘ 1. Uchino S, Kellum JA, Bellomo R, et al. Acute renal failure in critically ill patients: a multinational, multicenter study. Jama 2005; 294:813-8. 2. Burchardi H. History and development of continuous renal replacement techniques. Kidney Int Suppl 1998; 66:S120- 4. 3. Kramer P, Wigger W, RiegerJ, Matthaei D, Scheler F. Arteriovenous haemofiltration: a new and simple method for treatment of over-hydrated patients resistant to diuretics. KlinWochenschr 1977; 55:1121-2. 4. Bellomo R, Parkin G, Love J, Boyce N. A prospective comparative study of continuous arteriovenous hemodiafiltration and continuous venovenous hemodiafiltration in critically ill patients. Am J Kidney Dis 1993; 21:400-4. 5. Bellomo R, Ronco C. Continuous haemofiltration in the intensive care unit. Crit Care 2000; 4:339-45. 6. Daugirdas JT, Van Stone JC. Physiologic Principles and Urea Kinetic Modeling. In: Daugirdas JT, Blake PG, Ing TS, editors. Handbook of dialysis, 3rd edition. Philadelphia: Lippincott Williams & Wilkins, 2001: 15-45. 7. Ronco C, Bellomo R. Continuous renal replacement therapy: evolution in technology and current nomenclature. Kidney Int Suppl 1998; 66:S160-4. 86

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