New Frontiers in Dialysis

New Frontiers in Dialysis 38 ∏π‘µ ®√‘ ππ— ∑∏å «™—  √‘ ‘¿“ ™â“ß»√‘ ‘°ÿ≈™—¬ ∏ππ— ¥“ µ√–°“√«π™‘ « π— µå  ÿ‡¡∏°≈ÿ ผนวก ง สมาคมโรคไตแหง ประเทศไทย ตารางตรวจสอบระบบน้ําบรสิ ุทธ์ิของศูนยไตเทยี ม เดอื น....................... พ.ศ. ................. (ดูภาพประกอบทายผนวก) รายการ การตรวจ คาปกติ หนว ย จ อ พ พฤ ศ ส อา Raw water Filter แรงดนั น้ํา (เขา /ออก) psi / / / / / / / Pressure (1) แรงดนั ลด <10 psi Chlorination unit (2) ปม จาย 1 หรอื 2 /////// ORP meter MV Chlorine level liter ปริมาณคลอรนี .ในน้ํา >0.3 mg/L Raw water pump (3) ปมจายนาํ้ 1 หรือ 2 psi / / / / / / / Multimedia / Sand / แรงดันนาํ้ (เขา/ออก) psi / / / / / / / Depth filter / Particle แรงดนั ลด (เขา -ออก) <10 psi filter (4) นาฬิกาตัง้ เวลา ตรง / ไมตรง Y/N Y/N Y/N Y/N Y/N Y/N Y/N Water softener (5) แรงดนั น้ํา (เขา/ออก) psi / / / / / / / แรงดนั ลด <10 psi นาฬิกาต้งั เวลา ตรง / ไมตรง Y/N Y/N Y/N Y/N Y/N Y/N Y/N ระดบั เกลือในถัง Y/N Y/N Y/N Y/N Y/N Y/N Y/N ความกระดางของนาํ้ <17.1 mg/L Activated carbon (6) แรงดนั นาํ้ (เขา/ออก) psi / / / / / / / แรงดันลด psi นาฬิกาตง้ั เวลา ตรง / ไมตรง ปริมาณคลอรีน <0.1 mg/L Cartridge filter (5µ) แรงดันนาํ้ (เขา /ออก) psi / / / / / / / (7) แรงดนั ลด <10 psi Pre-RO UV (8) หลอดไฟ, UV ติด / ดับ Y/N Y/N Y/N Y/N Y/N Y/N Y/N ระบบ RO (9) แรงดนั นา้ํ เขา <200 psi อตั ราการผลิตน้ํา (QP) ……… L/h อตั ราการท้งิ นา้ํ (QC) ……... L/h คา conductivity <10 mS/cm %Recovery(QP/QP+QC) >50 % ถังเกบ็ น้าํ RO ระบบควบคมุ ปกติ / ไมปกติ psi Y/N Y/N Y/N Y/N Y/N Y/N Y/N Transfer Pump (10) เคร่ืองสบู จา ยน้ํา 1 หรอื 2 30-50 ////// / Supply-RO UV (11) หลอดไฟ UV ติด / ดับ psi Supply-RO Filter แรงดนั น้าํ (เขา /ออก) psi Y/N Y/N Y/N Y/N Y/N Y/N Y/N Pressure (12) แรงดนั ลด <10 ////// / Return-RO UV (13) หลอดไฟ UV ตดิ / ดับ psi Return-RO Filter แรงดันนํ้า (เขา/ออก) psi Y/N Y/N Y/N Y/N Y/N Y/N Y/N Pressure (14) แรงดันลด <10 ////// / ผตู รวจสอบ

New Thailandûs Guideline of Water Treatment for Hemodialysis °≈»√ ¿—§‚™µ“ππ∑å 39 สมาคมโรคไตแหง ประเทศไทย ตารางบันทกึ การตรวจคุณภาพระบบน้าํ ประจาํ เดือน .................. พ.ศ........... (ดูภาพประกอบทายผนวก) ม.ค. ก.พ. มี.ค. รายการ bacteria endotoxin bacteria endotoxin bacteria endotoxin (CFU /mL) (EU/mL) (CFU/mL) (EU/mL) (CFU/mL) (EU/mL) Pre RO S 1 Post RO S 2 Storage tank S 3 Distribution loop*** จุดแรก (frist outlet) S 4 จุดสดุ ทา ย S 6 จุดลางตวั กรอง S 5 Dialysate in machine S 7 HD machine No.01 HD machine No.02 HD machine No.03 HD machine No.04 HD machine No.05 HD machine No.06 HD machine No.07 ผูรบั ผิดชอบ การตรวจวเิ คราะหค ณุ ภาพน้ํา RO ตามมาตรฐาน AAMI เมื่อ ……………………………………………….. หมายเหตุ 1. *** ตาํ แหนงน้ตี องตรวจใหครบทกุ ตาํ แหนง 2. ผลการเพาะเชอื้ ของน้ําตวั อยางในระบบจา ยนา้ํ บรสิ ุทธิ์ ตองมีแบคทีเรยี นอยกวา 200 CFU/mL และ endotoxin นอยกวา 2 EU/mL 3. Action level ของแบคทีเรยี และ endotoxin กาํ หนดไวที่ 50 CFU/mL และ 1 EU/mL ตามลําดับ 4. การตรวจคุณภาพของ dialysate ของเครื่องฟอกเลอื ด ใหท าํ การสมุ เก็บตวั อยา งสงตรวจอยา งนอย 2 เครือ่ งตอเดอื น และหมุนเวยี นใหค รบทกุ เครือ่ งภายใน 1 ป

สมาคมโรคไตแหง ประเทศไทย New Frontiers in Dialysis ตารางบันทกึ การเปลยี่ นอปุ กรณในระบบนา้ํ RO และ การอบฆา เชื้อระบบนา้ํ 40 ∏𵑠®√‘ π—π∑∏å «—™  √‘ ‘¿“ ™â“ß»√‘ °‘ ≈ÿ ™—¬ ∏ππ— ¥“ µ√–°“√«π™‘ « π— µå  ÿ‡¡∏°≈ÿ รายการ อปุ กรณท เ่ี ปลย่ี น ระยะเวลา ม.ค. ก.พ. ม.ี ค. เม.ย. พ.ค. มิ.ย. ก.ค. ส.ค. ก.ย. ต.ค. พ.ย. ธ.ค. หมายเหตุ Water Filter 20 µ 1 เดือน Multi Filter Filter 1 ป Softener Resin 1 ป Carbon Carbon 1 ป Carbon 1 ป Pre RO Filter Filter 5 µ 1 เดือน Membrane 01 RO Membrane 02 UV in line 8,000 ชั่วโมง UV Bacteria Air-vent filter 1 ป Filter Filter 0.2 µ 6 เดือน * Filter 0.2 µ 6 เดอื น * Disinfection ระบบจา ยน้ําบริสุทธ์ิ 6 เดอื น ** ผูตรวจสอบ * และเปลีย่ นทกุ ครั้งทม่ี กี ารอบฆา เช้อื ระบบนํ้าบรสิ ทุ ธิ์ หรอื เมือ่ เหน็ วา filter สกปรกหรืออุดตัน ** ตองทาํ กอนกาํ หนด ถา ผลการเพาะเช้อื ของนํ้าตัวอยางในระบบจา ยนาํ้ บริสทุ ธ์พิ บแบคทีเรียมากกวา 200 CFU/mL หรอื ตรวจพบ endotoxin มากกวา 2 EU/mL

แผนผงั แสดงตัวอยางการจดั วางอุปกรณตางๆ ในระบบน้าํ บรสิ ุทธิ์ทใ่ี ชในศูนยไ ตเทียมและตําแหนง ทเ่ี กบ็ ตวั อยา งน้าํ เพื่อตรวจสอบคณุ ภาพ Raw Water Filter RO Primary (9) Permeate Conductivity Pressure Pressure RO Unit Meter In out ORP S1 S2 Cartridge Raw Water P1 Sand Softener Dual Column Cartridge High RO Final Sample Filter Tank Filter Activated Carbon Filter Pressure Pressure Port P2 Pump Permeate 25 Micron Raw Water (5) (6) 5 Micron Concentrate Flow Meter Booster Pump (4) + Flow Meter (1) Chlorine Ventilating Filter Injection (3) Pre-RO Concentrate 0.2 Micron UV to Drain (2) RO Storage (7,8) Tank Return RO Filter Pressure New Thailandûs Guideline of Water Treatment for Hemodialysis in out °≈»√ ¿§— ‚™µ“ππ∑å 41 UV Light Re-circulating Loop Pressure (13) Loop Pressure Regulating Valve Dialyzer Cleaning Technician Stations Sample Port S5 0.2 Micron Filter (14) S6 Supply RO Filter Pressure P1 out in S3 UV Light Sample Sample (11) P2 Hemodialysis Machines Port Port Transfer Pump (10) S7 0.2 Micron Filter S4 (12) §”Õ∏‘∫“¬ª√–°Õ∫¿“æ 1. µ”·Àπàß„π®ÿ¥‰¢àª≈“„π¿“æ ‰¡à„™à¢âÕ∫—ߧ—∫ ∑—Èßπ’È¢÷ÈπÕ¬Ÿà°—∫π‚¬∫“¬»Ÿπ¬å‰µ‡∑’¬¡¢Õß·µà≈– ∂“∫—π 2. °“√µ√«® Õ∫ªíö¡πÈ” ¡’®ÿ¥ª√– ß§å„Àâ∑”°“√µ√«® Õ∫°“√∑”ß“π·≈–°“√√—Ë«´÷¡¢Õߪíö¡πÈ”„Àâ§ß ¿“懪ìπª°µ‘ æ√âÕ¡„™âß“πÕ¬Ÿàµ≈Õ¥‡«≈“

New Frontiers in Dialysis 42 ∏𵑠®‘√ππ— ∑å∏«™—  √‘ ‘¿“ ™“â ß»√‘ °‘ ≈ÿ ™—¬ ∏ππ— ¥“ µ√–°“√«π™‘ « —πµå  ‡ÿ ¡∏°ÿ≈ ‡Õ° “√Õ“â ßÕß‘ Association for the Advancement of Medical Instrumentation. American National Standard, ANSI/AAMI RD52:2004: Dialysate for hemodialysis. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2004. Association for the Advancement of Medical Instrumentation. American National Standard, ANSI/AAMI RD62:2006: Water treatment equipment for hemodialysis applications. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2007. European Renal Association-European Dialysis and Transplant Association. European Best Practice Guidelines for Haemodialysis (Part 1), Section IV: Dialysis fluid purity. Nephrol Dial Transplant 2002;17[suppl 7]:45-62.

3 General Care of Vascular Access ªπòî ·°«â °≈“â ¬ª√–¬ß§å 1. ∫∑π” 2. ≈°— …≥–¢Õß Vascular access ∑¥’Ë ’ 3. ™π¥‘ ¢Õß Vascular access 4. ·π«∑“ߪØ∫‘ µ— °‘ “√¥·Ÿ ≈ºªâŸ «É ¬∑¡Ë’  ’ “¬ «π§“À≈Õ¥‡≈Õ◊ ¥¥” 5. ·π«∑“ߪØ∫‘ µ— °‘ “√¥·Ÿ ≈ Permanent Vascular Access 6.  √ªÿ

New Frontiers in Dialysis 44 ∏π‘µ ®√‘ ππ— ∑∏å «—™  √‘ ‘¿“ ™â“ß»√‘ ‘°≈ÿ ™¬— ∏π—𥓠µ√–°“√«π‘™ « π— µå  ‡ÿ ¡∏°ÿ≈ 1. ∫∑π” °“√øÕ°‡≈Õ◊ ¥¥«â ¬‡§√ÕË◊ ߉µ‡∑¬’ ¡ (Hemodialysis) µÕâ ßÕ“»¬— °√–∫«π°“√„π°“√π”‡≈Õ◊ ¥ ´ßË÷ ¡’ ¢Õ߇ ’¬¢ÕߺŸâªÉ«¬ÕÕ° Ÿà«ß®√¿“¬πÕ°√à“ß°“¬ºà“π∑“߇¢â“ÕÕ°∑’ËÀ≈Õ¥‡≈◊Õ¥ (vascular access) °“√ ¥Ÿ·≈√—°…“ vascular access „À≥⥒¡’ª√– ‘∑∏‘¿“æ  àߺ≈∂÷ߧÿ≥¿“æ™’«‘µ∑’Ë¥’¢ÕߺŸâªÉ«¬ µâÕߪ√– “π ß“π√à«¡°—π°—∫∑’¡ß“π∑—Èߥâ“πÕ“¬ÿ√·æ∑¬å »—≈¬·æ∑¬å √—ß ’·æ∑¬å·≈–欓∫“≈‰µ‡∑’¬¡ ªí®®ÿ∫—πæ∫«à“ √âÕ¬≈– 15-20 ¢ÕßÕ—µ√“°“√πÕπ‚√ß欓∫“≈¢ÕߺŸâªÉ«¬∑’Ë∑”°“√øÕ°‡≈◊Õ¥ ‡°‘¥®“°ªí≠À“¿“«– ·∑√°´Õâ π¢Õß vascular access1 欓∫“≈‡ªπì ∫§ÿ §≈∑ªË’ Ø∫‘ µ— °‘ √–∫«π°“√øÕ°‡≈Õ◊ ¥·≈–¡∫’ ∑∫“∑„π°“√ „™â vascular access ‚¥¬µ√ß ¥â«¬‡Àµÿπ’È®÷ߧ«√æ‘®“√≥“æ—≤π“ª√—∫ª√ÿß ∑∫∑«π°“√欓∫“≈Õ¬à“ßµàÕ ‡πÕË◊ ß·≈–‡À¡“– ¡ ‡æÕË◊ ¬¥◊ Õ“¬°ÿ “√„™ßâ “π¢Õß vascular access 2. ≈°— …≥–¢Õß Vascular access ∑¥Ë’ ’ 2.1 „™ßâ “πß“à ¬ 2.2 ¡§’ «“¡∑π∑“π ¡Õ’ “¬°ÿ “√„™ßâ “π‰¥πâ “π ¡¿’ “«–·∑√°´Õâ πµ”Ë 2.3 ‡ª¥î Õµ— √“‰À≈¢Õ߇≈Õ◊ ¥ blood flow rate (BFR) ‰¥ â ߟ ∑”„À°â “√øÕ°‡≈Õ◊ ¥¡ª’ √– ∑‘ ∏¿‘ “æ 2.4 §“à „™®â “à ¬„π°“√¥·Ÿ ≈√°— …“µË” 3. ™π¥‘ ¢Õß Vascular access 2, 3, 4 3.1 ™π¥‘ ™«—Ë §√“« (Temporary vascular access) 5, 6 3.1.1 Non-cuffed double lumen catheter «— ¥ÿ∑’Ë„™â∑” ‰¥â·°à polyurethane À√◊Õ polyvinyl  à«π„À≠àÀπ⓵—¥¢Õß lumens ‡ªìπ·∫∫ double çDé ª≈“¬ “¬¥â“π artery ·≈– vein §«√Õ¬ŸàÀà“ß°—π Õ¬à“ßπâÕ¬ 1-2 ‡´πµ‘‡¡µ√ À√◊Õ·¬°®“°°—π (split) ‡æ◊ËÕ≈¥°“√‡°‘¥ blood recirculation §«√„™â‡©æ“– ºªŸâ «É ¬∑π’Ë Õπ√°— …“„π‚√ß欓∫“≈‡∑“à ππ—È µÕâ ßÀ≈°’ ‡≈¬’Ë ß°“√„ ∑à ’Ë subclavian vein °“√„ à catheter ∑’Ë jugular vein §«√„™â ultrasound guide ·≈–§“ “¬‰«‰â ¡‡à °π‘ 1  ª— ¥“Àå 1 ∂“â ®–„™µâ Õà ‡πÕË◊ ߇°π‘ 1  ª— ¥“Àå ·æ∑¬§å «√ 殑 “√≥“„™™â 𥑠long-term catheter °√≥„’   à “¬ double lumen catheter ∑Ë’ femoral vein §«√„™ â “¬¬“« 20-24 ‡´πµ‡‘ ¡µ√ ·≈–∂“â  “¬¬“«‰¡∂à ß÷ inferior vena cava À√Õ◊ ‰¡ à “¡“√∂‡ª¥î BFR 300 ´´’ µ’ Õà π“∑’ §«√„™ â “¬¬“« 24-31 ‡´πµ‡‘ ¡µ√ ‰¡§à «√§“ “¬‰«„â ™ßâ “π‡°π‘ 5 «π— ‡æ√“–¡‚’ Õ°“ ‡°¥‘ °“√µ¥‘ ‡™ÕÈ◊ ‡æ¡Ë‘ ¢πÈ÷ 1, 7 3.1.2 Long-term catheter ‰¡§à «√„™‡â ªπì permanent vascular access °. Tunneled cuffed venous catheter æ≤— π“¢πÈ÷ §√ßÈ— ·√°„πªï §.».1987 « — ¥∑ÿ „Ë’ ™ºâ ≈µ‘ ‰¥·â °à silicone, carbothane À√Õ◊ polymers ∑ÕË’ Õà ππ¡àÿ ‡ πâ º“à »πŸ ¬°å ≈“ß¿“¬„𠓬 11-14 french  “¡“√∂‡ª¥î

General Care of Vascular Access ªîòπ·°â« °≈“â ¬ª√–¬ß§å 45 BFR ‰¥¡â “°°«“à 350 ´´’ µ’ Õà π“∑’ Àπ“â µ¥— ¢Õß lumen ‡ªπì ·∫∫ double D, circle C, coaxial, shotgun, Duo- split ·≈–Õπ◊Ë Ê ·µ‡à ¡Õ◊Ë „™ßâ “π¬“«π“πæ∫«“à ‡ª¥î BFR ‰¥µâ Ë”≈ß (‚¥¬°“√µ√«®«¥— negative pre-pump arterial pressure) ·≈–¡‚’ Õ°“ ‡ ¬Ë’ ßµÕà °“√µ∫’ µπ— ¢Õß central vein °“√ ß—Ë °“√√°— …“‚¥¬∑”°“√øÕ°‡≈Õ◊ ¥Õ¬“à ߇√ßà ¥«à π¿“¬À≈ß— °“√„  à “¬∑π— ∑’·≈–„™âheparinfree technique À√Õ◊ no heparin ‡ªπì  “‡Àµ¢ÿ Õß°“√Õ¥ÿ µπ— ¿“¬„𠓬 ∑”„À‰â ¡ à “¡“√∂‡ª¥î BFR ‰¥¥â ’ Õ“¬ÿ °“√„™ßâ “π π—È ≈ß §«√µ¥— ‰À¡·º≈º“à µ¥— 2  ª— ¥“Àå  «à π‰À¡‡¬∫Á ∑∫’Ë √‡‘ «≥ª°ï ·≈– ™Õà ß∑“ßÕÕ° (exit site) 2 ‡¥Õ◊ π ¢. Port catheter systems ‡ªπì ™π¥‘ ∑Õà (tubing) µÕà „µºâ «‘ Àπß— (subcutaneous) ‰¡§à «√„ ¢à “â ß ‡¥¬’ «°∫— AV fistula ‡«≈“„™ßâ “π „™«â ∏‘ ’ buttonhole technique ·µ¬à ß— ‰¡¡à °’ “√„™„â πª√–‡∑»‰∑¬ ·≈–√“§“ ¬ß— ‰¡√à –∫·ÿ π™à ¥— (ª√–¡“≥ 5 À¡πË◊ ∫“∑) 3.2 ™π¥‘ permanent vascular access ¥¢Ÿ Õâ ∑’Ë 5 4. ·π«∑“ߪØ∫‘ µ— °‘ “√¥·Ÿ ≈ºªŸâ «É ¬∑¡’Ë  ’ “¬ «π§“À≈Õ¥‡≈Õ◊ ¥¥” 4.1 °“√„À§â ”·π–π”ºªŸâ «É ¬„π°“√¥·Ÿ ≈ “¬ «π§“À≈Õ¥‡≈Õ◊ ¥¥” 4.1.1 √°— …“§«“¡ –Õ“¥ ‰¡·à °–‡°“∫√‡‘ «≥√Õ∫·º≈∑ªË’ ¥î ‰«â 4.1.2 ‰¡„à  ‡à  ÕÈ◊  «¡»√’ …– §«√„ ‡à  ÕÈ◊ º“à Àπ“â ‡æÕË◊ ‰¡„à À â “¬À°— æ∫— ßÕ ¥ß÷ √ßÈ— 4.1.3 √–«ß— ‰¡„à Àπâ ”È ‡ª¬ï °·º≈ À“°‡°¥‘ °“√‡ª¬ï °π”È „À‰â ª‡ª≈¬Ë’ π·º≈¿“¬πÕ°∑§Ë’ ≈π‘ °‘ À√Õ◊ ‚√ß欓∫“≈∑Õ’Ë ¬„Ÿà °≈∫â “â π∑π— ∑’ 4.1.4 À“°¡Õ’ “°“√ª«¥∫√‡‘ «≥ “¬·≈–¡‰’ ¢â µÕâ ß√∫’ ‰ªæ∫·æ∑¬∑å π— ∑’ 4.1.5 ∂â“ “¬‡≈◊ËÕπÀ≈ÿ¥À√◊Õ∂Õ¬ÕÕ°¡“®“°µ”·Àπà߇¥‘¡ Õ¬à“¥—πÀ≈Õ¥‡≈◊Õ¥‡¢â“‰ª‡Õß „™æâ ≈“ ‡µÕ√¬å ¥÷ µ¥‘ ·≈–‰ªæ∫·æ∑¬∑å π— ∑’ 4.1.6  “¬∑¢Ë’ “Àπ∫’ ™π¥‘ non-cuffed double lumen catheter À“â ¡ºªâŸ «É ¬ßÕ¢“ πßË— ¬π◊ ‡¥π‘ 4.2 °“√„À°â “√欓∫“≈„π°“√„™ â “¬ «π§“À≈Õ¥‡≈Õ◊ ¥¥”√–À«“à ß°“√øÕ°‡≈Õ◊ ¥ Õªÿ °√≥å 4.2.1 ™¥ÿ ∑”·º≈ª√“»®“°‡™ÕÈ◊ 1 ™¥ÿ (À√Õ◊ hemodialysis set) 4.2.2 º“â  ‡’Ë À≈¬’Ë ¡‡®“–°≈“ߪ√“»®“°‡™Õ◊È 4.2.3 ∂ßÿ ¡Õ◊ ª√“»®“°‡™ÕÈ◊ , mask 4.2.4 Heparin 4.2.5 Fixomull ¢π“¥ 10 × 25 ‡´πµ‡‘ ¡µ√ 4.2.6 °√–∫Õ°©¥’ ¬“ (syringe) 20 ´´’ ’ = 1 Õπ— : 5 ´´’ ’ = 1 Õπ— : 3 ´´’ ’ = 2 Õπ— 4.2.7 ‡¢¡Á ‡∫Õ√å 21= 3 Õπ—

New Frontiers in Dialysis 46 ∏π‘µ ®√‘ π—π∑∏å «—™  √‘ ¿‘ “ ™â“ß»‘√°‘ ≈ÿ ™¬— ∏ππ— ¥“ µ√–°“√«π‘™ « —πµå  ÿ‡¡∏°≈ÿ 4.2.8 ®°ÿ ª¥î (cap) ª√“»®“°‡™ÕÈ◊  ”À√∫— ª¥î ª≈“¬ catheter 2 Õπ— 4.2.9 πÈ”¬“¶“à ‡™Õ◊È (antiseptic solution) ∑ß—È π§’È «√µ√«® Õ∫§¡àŸ Õ◊ §”·π–π”°“√„™â catheter ·µ≈à – ™π¥‘ ¢Õß∫√…‘ ∑— ººŸâ ≈µ‘ ‡πÕ◊Ë ß®“°πÈ”¬“¶“à ‡™Õ◊È ¡ª’ Ø°‘ √‘ ¬‘ “∑‡’Ë °¥‘ º≈‡ ¬’ µÕà « — ¥∑ÿ „’Ë ™ºâ ≈µ‘ ·µ≈à –™π¥‘ ·µ°µ“à ß°π— ‡™πà « — ¥∑ÿ ∑Ë’ ” “¬‡ªπì ™π¥‘ polyurethane À“â ¡„™â alcohol « — ¥∑ÿ ∑Ë’ ” “¬‡ªπì ™π¥‘ silicone À“â ¡„™â tincture of iodine ·≈– povidone iodine ‡æ√“–®–∑”„À â “¬°√Õ∫À°—  «à 𠓬∑∑Ë’ ”®“° carbothane „™πâ ”È ¬“¶“à ‡™ÕÈ◊ ‰¥∑â °ÿ ™π¥‘ 8 °“√∑”§«“¡ –Õ“¥ exit site ¢Õß catheter §Õ◊ 1, 9 °. 2% chlorhexidine with 70% alcohol  ”À√∫— exit site ¢Õß long-term catheter ¢. „™â chlorhexidine aqueous „π°√≥∑’ ºË’ ªâŸ «É ¬‰«µÕà ªØ°‘ √‘ ¬‘ “ (sensitive) µÕà π”È ¬“¢Õâ °. §. „™â povidone solution „π°√≥∑’ ºË’ ªŸâ «É ¬‰«µÕà ªØ°‘ √‘ ¬‘ “µÕà π”È ¬“¢Õâ °. ·≈– ¢. ß. ¡°’ “√»°÷ …“°“√„™â povidone ointment ∑Ë’ exit site ¢Õß non-cuffed double lumen catheter æ∫«à“Õ—µ√“°“√µ‘¥‡™◊ÈÕ≈¥≈ß 10  ”À√—∫ mupirocin ointment ¡’°“√»÷°…“æ∫«à“∑”„À⇙◊ÈÕ‚√§¥◊ÈÕµàÕ ¬“‰¥â 11 4.3 ¢πÈ— µÕπ°“√µÕà  “¬ ßà ‡≈Õ◊ ¥°∫— Catheter 1, 4 «∏‘ ª’ Ø∫‘ µ— ‘ 4.3.1 º°Ÿ mask „Àºâ ªâŸ «É ¬ ·≈–®¥— ∑“à ºªŸâ «É ¬„ÀÀâ π— Àπ“â ‰ª„π∑“ßµ√ß°π— ¢“â ¡°∫— catheter 4.3.2 欓∫“≈≈“â ß¡Õ◊ „À â –Õ“¥ º°Ÿ mask ·≈– «¡∂ßÿ ¡Õ◊ ª√“»®“°‡™ÕÈ◊ 4.3.3 ‡ª¥î dressing ∑·Ë’ º≈¢ÕߺªŸâ «É ¬ÕÕ°„ÀÀâ ¡¥  ß— ‡°µ¥Ÿ exit site «“à º¥‘ ª°µÀ‘ √Õ◊ ‰¡à ‡™πà °“√Õ°— ‡ ∫ ∫«¡·¥ß ‡≈Õ◊ ¥ÕÕ°¡“° ‰À¡‡¬∫Á À≈¥ÿ ‡ªπì µπâ 4.3.4 ‡ª≈¬’Ë π∂ßÿ ¡Õ◊ ª√“»®“°‡™Õ◊È §„Ÿà À¡à 4.3.5 ∑”§«“¡ –Õ“¥·º≈√Õ∫ catheter ¥â«¬πÈ”¬“¶à“‡™◊ÈÕ ‡™Á¥„π≈—°…≥–‡ªìπ«ß°≈¡«π ÕÕ°‰ª®“° exit site 10 ‡´πµ‡‘ ¡µ√·≈–√Õ·Àßâ 2 §√ßÈ— 4.3.6 Scrub ¢Õâ µÕà ¢Õß catheter ∑ßÈ— 2 ∑Õà ¥«â ¬π”È ¬“¶“à ‡™ÕÈ◊ 4.3.7 ∑”§«“¡ –Õ“¥ catheter ®“°¢Õâ µÕà ‡ÀπÕ◊ ¢πÈ÷ ‰ª 10 ‡´πµ‡‘ ¡µ√¥«â ¬π”È ¬“¶“à ‡™ÕÈ◊ 4.3.8 ª¥î exit site ¢Õß catheter ¥«â ¬º“â °ÕÁ  ª√“»®“°‡™ÕÈ◊ 4.3.9 ªºŸ “â  ‡Ë’ À≈¬Ë’ ¡‡®“–°≈“ß≈ß∫π catheter 4.3.10 ‡ª¥î ®°ÿ ∑ªË’ ≈“¬ “¬·≈–∑”§«“¡ –Õ“¥ª≈“¬ catheter ∑ßÈ— 2 ¢“â ߥ«â ¬π”È ¬“¶“à ‡™ÕÈ◊ Õ°’ §√ßÈ— ®“°ππÈ— „™°â √–∫Õ°©¥’ ¬“ 5 ´´’ ’ ¥¥Ÿ heparin ∑ÀË’ ≈Õà ∑ Ë’ “¬∑ß—È 2 ¢“â ßÕÕ°¢“â ß≈–ª√–¡“≥ 2.5 ´´’ ’ ·≈–∑”°“√¥¥Ÿ ‡≈Õ◊ ¥‡¢“â -ÕÕ° ¢“â ß≈– 2-3 §√ßÈ— ‡æÕË◊ ∑¥ Õ∫°“√∑”ß“π¢Õß catheter À“°‰¡¡à °’ “√µ¥‘ ¢¥— · ¥ß«“à catheter „™°â “√‰¥¥â ’ 4.3.11 ∑”§«“¡ –Õ“¥ª≈“¬ “¬ ßà ‡≈Õ◊ ¥¥“â πartery¥«â ¬πÈ”¬“¶“à ‡™Õ◊È √Õ„À·â Àßâ ·≈–µÕà ‡¢“â °∫— catheter ¥“â π artery ≈ÕÁ §„À·â ππà 4.3.12 ‡ª¥î ª¡íö ‡≈Õ◊ ¥‡æÕ◊Ë  ßà ‡≈Õ◊ ¥‡¢“â ‰ª„π«ß®√‰µ‡∑¬’ ¡ ·≈–‰≈àNSS∑ß‘È ∑ª’Ë ≈“¬ “¬ ßà ‡≈Õ◊ ¥¥“â π vein

General Care of Vascular Access ªòπî ·°«â °≈⓬ª√–¬ß§å 47 4.3.13 ‡¡ÕË◊ ‡≈Õ◊ ¥¡“∂ß÷ venous chamber ∑”§«“¡ –Õ“¥ª≈“¬ “¬ ßà ‡≈Õ◊ ¥‡¢“â °∫— ¥“â π vein ¥«â ¬π”È ¬“¶“à ‡™ÕÈ◊ √Õ·Àßâ ·≈–µÕà ‡¢“â °∫— catheter ¥“â π vein ≈ÕÁ §„À·â ππà 4.3.14 À¡âÿ ¢Õâ µÕà ¢Õß catheter °∫—  “¬ ßà ‡≈Õ◊ ¥¥«â ¬º“â °ÕÁ  ·Àßâ ª√“»®“°‡™ÕÈ◊ 4.3.15 ‡√¡‘Ë ∑”°“√øÕ°‡≈Õ◊ ¥ 4.3.16 ªî¥·º≈„Àâ‡√’¬∫√âÕ¬ (‰¡à§«√„™â·ºàπ tegaderm ‡æ√“–∑”„À⇰‘¥µÿà¡„ ·≈–º‘«Àπ—ß Õ°— ‡ ∫µ¥‘ ‡™ÕÈ◊ „π¿“¬À≈ß— 12 ) 4.4 ¢π—È µÕπ°“√ª≈¥ “¬ ßà ‡≈Õ◊ ¥®“° Catheter «∏‘ ª’ Ø∫‘ µ— ‘ 4.4.1 º°Ÿ mask „Àºâ ªâŸ «É ¬ ·≈–®¥— ∑“à ºªâŸ «É ¬„ÀÀâ π— Àπ“â ‰ª„π∑“ßµ√ß°π— ¢“â ¡°∫— catheter 4.4.2 欓∫“≈≈“â ß¡Õ◊ „À â –Õ“¥ º°Ÿ mask ·≈– «¡∂ßÿ ¡Õ◊ ª√“»®“°‡™ÕÈ◊ 4.4.3 ‡µ√¬’ ¡ heparin lock ¥ß— πÈ’ °. °√–∫Õ°©¥’ ¬“ 20 ´´’ ’ „ à NSS ‡µ¡Á ª¥î ª≈“¬¥«â ¬‡¢¡Á ‡∫Õ√å 21 ¢. °√–∫Õ°©¥’ ¬“ 3 ´´’ ’ ª¥î ª≈“¬¥«â ¬‡¢¡Á ‡∫Õ√å 21 = 2 ™¥ÿ ·∫ßà „ à heparin + NSS - ª√¡‘ “µ√√«¡¢Õß heparin 2  “¬‡∑“à °∫— 5,000-7,000 ¬πŸ µ‘  ”À√∫— „™°â ∫— non-cuffed catheter - ª√¡‘ “µ√√«¡¢Õß heparin 2  “¬‡∑“à °∫— 8,000-15,000 ¬πŸ µ‘  ”À√∫— „™°â ∫— tunneled-cuffed catheter §. ‡æ¡Ë‘ ¢π“¥¢Õß heparin À“°æ∫«“à ¡≈’ ¡Ë‘ ‡≈Õ◊ ¥Õ¥ÿ µπ— „π catheter ‡¡ÕË◊ ¥¥Ÿ heparin lock ÕÕ° „π°“√∑”øÕ°‡≈◊Õ¥§√—ÈßµàÕ‰ª (ª√‘¡“≥¢π“¥¬“ Ÿß ÿ¥πâÕ¬°«à“ 5,000 ¬Ÿπ‘µµàÕ´’´’ ‡æ√“–∑”„À⇰‘¥ ¿“«–‡≈Õ◊ ¥ÕÕ°‰¥â 13) ß. ª√¡‘ “µ√∑„Ë’  à heparin lock „𠓬 catheter µÕâ ß„™°â √–∫Õ°©¥’ ¬“·¬°®“°°π— ‡æÕË◊ „À‰â ¥â ª√¡‘ “µ√µ√ß·≈– fill heparin lock „𠓬 catheter ‰¥‡â √«Á ·µ≈à –¢“â ß„ ¡à “°°«“à §«“¡¬“«¢Õß “¬ 0.1-0.2 ´´’ ’ 14°“√„ ¡à “°‡°π‘ ‰ª®–∑”„Àâheparin‡¢“â  °Ÿà √–· ‚≈Àµ‘ ºªâŸ «É ¬·≈–‡°¥‘ Õπ— µ√“¬‰¥â·µ∂à “â „ ‡à ∑“à °∫— ª√¡‘ “µ√ ¢Õß “¬æÕ¥’®–‡°‘¥≈‘Ë¡‡≈◊Õ¥Õÿ¥ª≈“¬ “¬ À√◊Õ¡’·ºàπ‰ø∫√‘π (fibrin sheath) ¬◊Ëπªî¥√Ÿ¢Õߪ≈“¬ “¬ ∑”„À‡â ≈Õ◊ ¥‰À≈‡¢“â ‰¥·â µ¥à ¥Ÿ ÕÕ°¡“‰¡‰à ¥·â ≈–Õ“¬°ÿ “√„™ßâ “π π—È ≈ß 4.4.4 Scrub ¢Õâ µÕà  “¬ ßà ‡≈Õ◊ ¥ ·≈–ª≈“¬ catheter ∑ßÈ— 2 ¢“â ߥ«â ¬π”È ¬“¶“à ‡™ÕÈ◊ 4.4.5 Clamp ∑¥Ë’ “â π artery ¢Õß catheter ·≈–∑ Ë’ “¬ ßà ‡≈Õ◊ ¥ ª≈¥ “¬ ßà ‡≈Õ◊ ¥ÕÕ° ∑”°“√ §π◊ ‡≈Õ◊ ¥°≈∫— ‡¢“â µ«— ºªâŸ «É ¬ µ“¡·π«∑“ߪØ∫‘ µ— °‘ “√¥·Ÿ ≈ºªâŸ «É ¬À≈ß— °“√øÕ°‡≈Õ◊ ¥ 4.4.6 Clamp ∑¥Ë’ “â π vein ¢Õß catheter ·≈–∑ Ë’ “¬ ßà ‡≈Õ◊ ¥ ª≈¥ “¬ ßà ‡≈Õ◊ ¥ÕÕ° 4.4.7 ∑”§«“¡ –Õ“¥ª≈“¬ catheter ∑ßÈ— 2 ¢“â ߥ«â ¬π”È ¬“¶“à ‡™ÕÈ◊ ´”È Õ°’ §√ßÈ— 4.4.8 Flush ·µ≈à –¢“â ߢÕß catheter ¥«â ¬ NSS ¢“â ß≈– 10 ´´’ ’ 4.4.9 Fill µ“¡¥«â ¬ heparin solution ∑ºË’  ¡‡Õ“‰«â µ“¡ª√¡‘ “µ√¢Õß “¬·µ≈à –¢“â ß + 0.1 ´´’ ’ ¢≥–„ à heparin solution §«√∑”Õ¬à“ß√«¥‡√Á«  àߺ≈„Àâ heparin ‰ª∂÷ß à«πª≈“¬¢Õß∑àÕ·≈– clamp ∑π— ∑‡’ æÕË◊ ªÕÑ ß°π— ‡≈Õ◊ ¥‰À≈¬Õâ π°≈∫— ‡¢“â ‰ª„π catheter ·≈–ª¥î ª≈“¬ catheter ¥«â ¬®°ÿ ª¥î ª√“»®“°‡™ÕÈ◊

New Frontiers in Dialysis 48 ∏π‘µ ®‘√π—π∑å∏«™—  ‘√‘¿“ ™â“ß»√‘ ‘°≈ÿ ™¬— ∏π—𥓠µ√–°“√«π‘™ « π— µå  ‡ÿ ¡∏°≈ÿ 4.4.10 ªî¥·º≈¥â«¬æ≈“ ‡µÕ√å„  ·≈– fixomull ‚¥¬®—¥∑‘»∑“ߢÕß catheter „Àâ∂Ÿ°µâÕß ‡æÕË◊ ªÕÑ ß°π— °“√À°— ßÕ¢Õß catheter 4.4.11 ≈ß∫π— ∑°÷ ª≠í À“∑æË’ ∫·≈–°“√·°‰â ¢ª≠í À“‡°¬Ë’ «°∫— catheter ∑°ÿ §√ßÈ— 4.5 ¢Õâ §«√√–«ß— 1, 4 4.5.1 ¬¥÷ À≈°— aseptic technique ∑°ÿ §√ßÈ— ∑„Ë’ À°â “√欓∫“≈ºªŸâ «É ¬ 4.5.2 °“√„™·â ≈–‡ª≈¬Ë’ π dressing ∑”‚¥¬æ¬“∫“≈‰µ‡∑¬’ ¡‡∑“à ππÈ— 4.5.3 µ√«®¥∫Ÿ √‡‘ «≥ exit site ∑°ÿ §√ßÈ— ∑∑Ë’ ”°“√‡ª¥î ·º≈«“à ¡°’ “√µ¥‘ ‡™ÕÈ◊ À√Õ◊ §«“¡º¥‘ ª°µ‘ À√Õ◊ ‰¡à ∂“â æ∫«“à ¡§’ «“¡º¥‘ ª°µ„‘ À√â “¬ß“π·æ∑¬∑å √“∫°Õà π°“√øÕ°‡≈Õ◊ ¥ 4.5.4 µ√«®¥Ÿ‰À¡‡¬Á∫∑’Ë∫√‘‡«≥ªï° ‰¡à„Àâ‡≈◊ËÕπÀ≈ÿ¥À√◊Õ¢“¥ ‡æ◊ËÕªÑÕß°—π catheter ‡≈◊ËÕπ À≈¥ÿ ÕÕ°¡“®“°ª“°·º≈ 4.5.5 ª≈“¬ catheter µâÕߪÿ° À√◊ժ⫬°√–∫Õ°©’¥¬“ª√“»®“°‡™◊ÈÕ √–À«à“ß°“√ ∑”§«“¡ –Õ“¥ 4.5.6 ‡¡ÕË◊ ‡°¥‘ one-wayobstruction( “¡“√∂¥π— πÈ”‡°≈Õ◊ À√Õ◊ ‡≈Õ◊ ¥‡¢“â ‰¥·â µ‰à ¡ à “¡“√∂¥¥Ÿ ÕÕ°‰¥â ‡πÕË◊ ß®“°¡≈’ ¡Ë‘ ‡≈Õ◊ ¥Õ¥ÿ µπ— À√Õ◊ ª≈“¬¢Õß catheter Õ¬„Ÿà πµ”·Àπßà ∑‰Ë’ ¡¥à )’ ∑”°“√·°‰â ¢‰¥¥â ß— πÈ’ °. ®¥— ∑“à ºªŸâ «É ¬„À¡à ¢. À¡ÿπ catheter „Àâ¥â“π arterial À—πÕÕ°®“°ºπ—ߢÕßÀ≈Õ¥‡≈◊Õ¥ ‡æ◊ËÕ„Àâ¡’°“√‰À≈¢Õß ‡≈Õ◊ ¥‰¥ â –¥«°¡“°¢π÷È §. À“°ªØ∫‘ µ— µ‘ “¡¢Õâ °. ·≈– ¢. ·≈«â °“√‰À≈¢Õ߇≈Õ◊ ¥¬ß— ‰¡‡à 欒 ßæÕ ”À√∫— °“√øÕ°‡≈Õ◊ ¥ À√Õ◊ ¡°’ “√ ≈∫—  “¬ µÕâ ß√“¬ß“π·æ∑¬∑å √“∫ ‡æ√“–‡°¥‘ access recirculation ¡“°¢πÈ÷ (√ªŸ ∑Ë’ 1) 4.5.7 À“â ¡¢¬∫— catheter „À≈â °÷ ‡¢“â ‰ª„πÀ≈Õ¥‡≈Õ◊ ¥¡“°¢πÈ÷ 4.5.8 À“â ¡ flush catheter ∑ÕË’ ¥ÿ µπ— ‚¥¬‡¥¥Á ¢“¥ 4.5.9 „π°√≥∑’ ‰Ë’ ¡‰à ¥∑â ”°“√øÕ°‡≈Õ◊ ¥µÕâ ß clamp catheter ‰«âµ≈Õ¥‡«≈“ ªÑÕß°—π‡≈◊Õ¥‰À≈¬âÕπ°≈—∫„π à«π ª≈“¬¢Õß “¬ ‡ªì𠓇Àµÿ¢Õß°“√Õÿ¥µ—π„π‡«≈“µàÕ¡“ ·≈–§«√‡≈◊ËÕπµ”·ÀπàߢÕß clamp ∑ÿ°§√—È߇æ◊ËÕªÑÕß°—π°“√ µ∫’ ¢Õß “¬®“°°“√°¥∑∫— ‡ªπì ‡«≈“π“π 5. ·π«∑“ߪØ∫‘ µ— °‘ “√¥·Ÿ ≈ Permanent Vascular √ªŸ ∑’Ë 1 Access15 · ¥ß access recirculation µ“¡ ≈°— …≥–¢Õß catheter (A) ·≈–°“√ 5.1 ™π¥‘ ¢Õß permanent vascular access 1  ≈∫—  “¬ (B) 14 5.1.1 Native Arteriovenous Fistula (AV fistula) 5.1.2 Synthetic Arteriovenous Graft (AV graft)

General Care of Vascular Access ªπòî ·°â« °≈⓬ª√–¬ß§å 49 5.2 °“√„À§â ”·π–π”ºªâŸ «É ¬„π°“√¥·Ÿ ≈ Permanent vascular access 16 5.2.1 °“√„À§â ”·π–π”°“√ªØ∫‘ µ— µ‘ «— À≈ß— °“√∑”º“à µ¥— ‡ πâ ‡≈Õ◊ ¥ ·¢π¢“â ß∑∑’Ë ”º“à µ¥— °. √–«ß— ‰¡„à Àπâ È”‡ª¬ï °·º≈ ¢. ¬°·¢π ßŸ °«“à √–¥∫— À«— „® ‡æÕË◊ ≈¥Õ“°“√∫«¡ §. ·π–π” fistula hand-arm exercise (hand grip exercise) „Àºâ ªŸâ «É ¬∫√À‘ “√∑π— ∑‡’ ¡ÕË◊ ‰¡¡à Õ’ “°“√ ª«¥·º≈ ‚¥¬°“√„™â¡◊Õ∫’∫≈Ÿ°∫Õ≈¬“ß√à«¡°—∫°“√„™â¡◊ÕÕ’°¢â“ß°”µâπ·¢π¢â“ß∑’Ë∑”ºà“µ—¥‚¥¬∑”‰ª æ√Õâ ¡°π— π∫— 1 ∂ß÷ 5 ·≈–§≈“¬¡Õ◊ ÕÕ°æ√Õâ ¡ Ê °π— ‡ªπì ®ß— À«–µÕà ‡πÕË◊ ß°π— ‰ª‚¥¬ ¡”Ë ‡ ¡Õ §√ßÈ— ≈– 15 π“∑’ Õ¬“à ßπÕâ ¬«π— ≈– 4-6 §√ßÈ— Õ∏∫‘ “¬„Àºâ ªŸâ «É ¬‡¢“â „®«“à µÕâ ߪØ∫‘ µ— Õ‘ ¬“à ßµÕà ‡πÕË◊ ß„π√–¬– 2-3 ‡¥Õ◊ π·√°°Õà π°“√·∑߇¢¡Á ‡æÕË◊ ‡æ‘Ë¡°“√‰À≈ºà“π¢Õ߇≈◊Õ¥¿“¬„πÀ≈Õ¥‡≈◊Õ¥·≈–∑”„ÀâÀ≈Õ¥‡≈◊Õ¥·¢Áß·√ß (mature) ‡æ√“–À“°ªØ‘∫—µ‘ ¿“¬À≈ß— ®“°°“√„™â AV fistula ‰ª·≈«â ®–‡°¥‘ ª√–‚¬™ππå Õâ ¬¡“° ß. À“â ¡πÕπ∑∫— ·¢π ·≈–„À¬â °·¢π ßŸ °«“à ≈”µ«— ®. À“â ¡¬°¢ÕßÀπ°— „ ‡à §√ÕË◊ ߪ√–¥∫— À√Õ◊ ‡ ÕÈ◊ √¥— ·¢π ©. À“â ¡«¥— §«“¡¥π— ‚≈Àµ‘ À“â ¡‡®“–‡≈Õ◊ ¥ ·≈–„À â “√π”È ∑“ßÀ≈Õ¥‡≈Õ◊ ¥ ™. √–«ß— ‰¡„à À·â ¢π¢“â ß∑µË’ Õà ‡ πâ ‡≈Õ◊ ¥°√–·∑° ∂°Ÿ ¢Õß¡§’ ¡ ´. À“â ¡·°–‡°“º«‘ Àπß— ·¢π¢“â ß∑µ’Ë Õà ‡ πâ ‡≈Õ◊ ¥ ¨. „À√â ∂Ÿâ ß÷ Õ“°“√· ¥ß¢Õß°“√µ¥‘ ‡™ÕÈ◊ ∫√‡‘ «≥∑µË’ Õà ‡ πâ ‡≈Õ◊ ¥ ´ßË÷ µÕâ ߉ªæ∫·æ∑¬∑å π— ∑’ ≠. ·π–π”„Àºâ ªŸâ «É ¬§≈” thrill ·≈–„™·â ¢π·π∫À‡Ÿ æÕË◊ øßí ‡ ¬’ ß bruit Õ¬“à ß ¡”Ë ‡ ¡Õ ·≈–∑°ÿ §√ßÈ— ∑√’Ë  âŸ °÷ ¡Õ’ “°“√«ß‘ ‡«¬’ π»√’ …–§«“¡¥π— ‚≈Àµ‘ µË”À“°æ∫«“à º¥‘ ª°µÀ‘ √Õ◊ §≈”thrill‰¡‰à ¥â„À√â ∫’ ‰ªæ∫·æ∑¬∑å π— ∑’ Æ.  ß— ‡°µÕ“°“√º¥‘ ª°µ‘ ‡™πà ¡‡’ ≈Õ◊ ¥´¡÷ ·¢πª«¥ ∫«¡¡“°¢πÈ÷ À√Õ◊ ¡Õ’ “°“√™“ª≈“¬π«È‘ ¡Õ◊ ¢“â ß∑∑Ë’ ”º“à µ¥— „À√â ∫’ ‰ªæ∫·æ∑¬å 5.2.2 °“√„À§â ”·π–π”°“√ªØ∫‘ µ— µ‘ «— °Õà π·≈–À≈ß— °“√øÕ°‡≈Õ◊ ¥ °. ∑”§«“¡ –Õ“¥·¢π∑°ÿ «π— ·≈–∑°ÿ §√ßÈ— °Õà π°“√øÕ°‡≈Õ◊ ¥ ¢. ¢≥–∑”°“√øÕ°‡≈Õ◊ ¥ ∂“â ®”‡ªπì µÕâ ߢ¬∫— ·¢π¢“â ß∑·Ë’ ∑߇¢¡Á µÕâ ß„™§â «“¡√–¡¥— √–«ß— ‡æ√“–Õ“®∑”„À‡â  πâ ·µ°‰¥â ‰¡·à °–‡°“ ‰¡‰à Õ®“¡√¥∫√‡‘ «≥·¢π„πº“â √Õß·¢π §. ∂“â ¡Õ’ “°“√ª«¥º¥‘ ª°µ¢‘ ≥–∑”°“√øÕ°‡≈Õ◊ ¥ „À√â ∫’ ·®ßâ 欓∫“≈∑√“∫∑π— ∑’ ß. ºªâŸ «É ¬§«√¡º’ “â °ÕÁ   –Õ“¥·≈–æ≈“ ‡µÕ√¬å “µ¥‘ µ«— ‡æÕ◊Ë æ√Õâ ¡„™Àâ “°æ∫«“à ¡‡’ ≈Õ◊ ¥´¡÷ ∑√’Ë ‡Ÿ ¢¡Á √–À«“à ß°“√‡¥π‘ ∑“ß°≈∫— ∫“â π ®. ‡¡ÕË◊ °≈∫— ∂ß÷ ∫“â π ·≈–æ∫§«“¡º¥‘ ª°µ‘ ‡™πà §≈” thrill øßí ‡ ¬’ ß bruit ‰¥‡â ∫“≈ß ·¢π∫«¡ ª«¥¡“°¢πÈ÷ À√Õ◊ ¡°’ “√Õ°— ‡ ∫ ·¥ß ∫√‡‘ «≥‡ πâ „À√â ∫’ ¡“æ∫·æ∑¬∑å π— ∑’ ©. ºŸâªÉ«¬·≈–≠“µ‘µâÕß¡’‡∫Õ√å‚∑√»—æ∑嵑¥µàÕÀâÕ߉µ‡∑’¬¡ ‡æ◊ËÕ·®âß·≈–¢Õ§”·π–π” ‡¡Õ◊Ë ¡Õ’ “°“√º¥‘ ª°µ∑‘ ∫’Ë “â π

New Frontiers in Dialysis 50 ∏π‘µ ®√‘ ππ— ∑∏å «™—  √‘ ¿‘ “ ™â“ß»√‘ ‘°≈ÿ ™—¬ ∏π—𥓠µ√–°“√«π™‘ « π— µå  ‡ÿ ¡∏°ÿ≈ 5.3 °“√„™â AV fistula ·≈– AV graft 1, 4, 17 5.3.1 °“√‡√¡‘Ë „™â permanent vascular access §«√‡√¡‘Ë „™‡â ¡Õ◊Ë ‡ πâ ππ—È ¡§’ «“¡ ¡∫√Ÿ ≥‡å µ¡Á ∑’Ë ‡æ√“– ∂â“„™âß“π¢≥–∑’ˇ âπ¬—߉¡à ¡∫Ÿ√≥凵Á¡∑’Ë¡’‚Õ°“ ‡ ’ˬߵàÕ°“√‡°‘¥ hematoma ‡ªì𠓇Àµÿ¢Õß °“√ Ÿ≠‡ ’¬ vascular access Õ¬à“ß∂“«√ ‚¥¬√–¬–‡«≈“∑’˧«√√ÕÀ≈—ß®“°°“√ºà“µ—¥‡ âπ‡≈◊Õ¥‡æ◊ËÕ„Àâ ‡ πâ ‡≈Õ◊ ¥¡§’ «“¡ ¡∫√Ÿ ≥‡å 欒 ßæÕ¡¥’ ß— π’È °. AV fistula §«√∑”°“√º“à µ¥— °Õà π°“√„™ßâ “π 6 ‡¥Õ◊ π (‰¡§à «√„™ßâ “π°Õà π 4-6  ª— ¥“À)å §«√‡√¡‘Ë „™â AV fistula §√ßÈ— ·√°‡¡ÕË◊ §≈” thrill ‰¥‰â °≈°«“à anastomosis 8-10 ‡´πµ‡‘ ¡µ√·≈–„™°â Æ 6s ¥ß— πÈ’ - access flow ¡“°°«“à 600 ´´’ µ’ Õà π“∑’ - ‡ πâ º“à »πŸ ¬°å ≈“ߢÕßÀ≈Õ¥‡≈Õ◊ ¥∑¡Ë’ Õ߇ÀπÁ ¢π“¥ 0.6 ‡´πµ‡‘ ¡µ√ - ‰¡·à ∑߇ πâ ∑≈Ë’ °÷ °«“à ∑¡Ë’ Õ߇ÀπÁ 0.6 ‡´πµ‡‘ ¡µ√ - À“°æ∫«“à AV fistula ‰¡à mature ¿“¬À≈ß— ®“°°“√º“à µ¥— 6  ª— ¥“Àå „À â ßà æ∫»≈— ¬·æ∑¬å ¢. AV graft §«√√Õ 3-6  ª— ¥“Àå (‰¡§à «√„™ßâ “π°Õà π 2  ª— ¥“Àå ‡æ√“–‡πÕÈ◊ ‡¬ÕË◊ √Õ∫ Ê ¬ß— ‰¡à ¬¥÷ µ¥‘ °∫— À≈Õ¥‡≈Õ◊ ¥‡∑¬’ ¡·ππà ‡æ¬’ ßæÕ Õ“®‡°¥‘ ‡≈Õ◊ ¥‡´“–√Õ∫ tunnel ‡ªπì ≈¡‘Ë ‡≈Õ◊ ¥¢π“¥„À≠„à µºâ «‘ Àπß— ) 5.3.2 ¡°’ “√ª√–‡¡π‘  ¿“懠πâ ‡≈Õ◊ ¥°Õà π°“√„™ßâ “π∑°ÿ §√ß—È °. §≈” thrill øßí ‡ ¬’ ß bruit ‰¥§â ߇¥¡‘ ¢. ‰¡¡à ≈’ °— …≥–™È”∫«¡ §. ‰¡¡à °’ “√Õ°— ‡ ∫µ¥‘ ‡™Õ◊È ß. »°÷ …“ direction flow ¢Õß vascular access °Õà π°“√·∑߇¢¡Á ∑°ÿ §√ßÈ— Loop graft §«√µ√«® Õ∫‡¡ÕË◊ ‡√¡Ë‘ „™ßâ “π§√ß—È ·√° ≈ß∫π— ∑°÷ ·≈–∫Õ°„Àºâ ªâŸ «É ¬√∑⟠»‘ ∑“ß°“√ «ß‘Ë ¢Õ߇≈Õ◊ ¥‡æÕ◊Ë ‡ªπì ·π«∑“ß°“√ªØ∫‘ µ— ‚‘ ¥¬„™∑â »‘ ∑“ß∂°Ÿ µÕâ ߇¡Õ◊Ë ºªŸâ «É ¬‰ª∑”°“√øÕ°‡≈Õ◊ ¥∑‚’Ë √ß欓∫“≈Õπ◊Ë °“√µ√«® Õ∫∑»‘ ∑“ß°“√‰À≈¢Õ߇≈Õ◊ ¥∑”‰¥â ¥ß— πÈ’ - ¥®Ÿ “° operative note ¢Õß»≈— ¬·æ∑¬å ¥ß— √ªŸ ∑Ë’ 2 -∂“â ‰¡¡à °’ “√∫π— ∑°÷ °“√º“à µ¥— §«√µ√«® Õ∫‡¡Õ◊Ë ‡√¡‘Ë „™ßâ “π§√ß—È ·√°·≈–∫π— ∑°÷ ‰«â ‡æ√“–°“√µ√«®  Õ∫¿“¬À≈—ß°“√„™âß“π‰ª·≈â« Õ“®®–‰¥âº≈º‘¥æ≈“¥ ´÷Ë߇°‘¥ ®“°ª≠í À“°“√µ∫’ µπ— (stenosis) ¢Õß vascular access ππÈ— ‰¥â „Àâ µ√«® Õ∫¥«â ¬«∏‘ ’ : Compression test ‚¥¬„™¡â Õ◊ ¢“â ßÀπß◊Ë °¥µ√ß «à π°≈“ß ¢Õß loop graft ·≈–π” stethoscope øßí ∑Ë’ loop graft ∑ßÈ— 2 ¢“â ß øí߇ ’¬ß bruit ¥â“π„¥¥—ß°«à“· ¥ß«à“¥â“ππ—Èπ‡ªìπ artery ·µà∂â“ ·¬°§«“¡·µ°µ“à ߉¡™à ¥— ‡®π „Àªâ Ø∫‘ µ— µ‘ “¡ ¥ß— µÕà ‰ªπÈ’ : T-way connection ·∑߇¢¡Á ∑Ë’ loop graft ∑ßÈ— 2  “¬ √ªŸ ∑Ë’ 2 ‡™ÕË◊ ¡ª≈“¬ AVF ¥«â ¬ T-way π”°√–∫Õ°©¥’ ¬“ 20 ´´’ ’ + NSS 20 · ¥ß∑»‘ ∑“ß°“√‰À≈¢Õ߇≈Õ◊ ¥ ´´’ ’ „ à NSS „π AVF ∑≈’ – “¬ clamp ‰«â ·≈–‡ª¥î clamp æ√Õâ ¡°π— ®“° operative note  ß— ‡°µ«“à ‡≈Õ◊ ¥«ßË‘ ®“°¥“â π„¥ ¥“â π∑·Ë’ √ß°«“à ‡ªπì artery

General Care of Vascular Access ªîòπ·°«â °≈“â ¬ª√–¬ß§å 51 5.3.3 °“√„™Àâ ≈°— aseptic technique „π°“√·∑߇¢¡Á °. §«√¡’°“√®—¥ Õπ·≈–∑∫∑«πÀ≈—° aseptic technique ·≈– standard precaution ·°æà ¬“∫“≈ ·≈–∫§ÿ ≈“°√„πÀÕâ ߉µ‡∑¬’ ¡‡ªπì √–¬–‚¥¬ ¡”Ë ‡ ¡Õ ¢. 欓∫“≈≈â“ß¡◊Õ„Àâ –Õ“¥  «¡∂ÿß¡◊Õ –Õ“¥°àÕπ°“√·∑߇¢Á¡ ‡ª≈’ˬπ∂ÿß¡◊Õ‡¡◊ËÕ‡°‘¥°“√ contamination ·≈–‡ª≈¬Ë’ π∂ßÿ ¡Õ◊ ∑°ÿ §√ßÈ—  ”À√∫— °“√·∑߇¢¡Á ºªâŸ «É ¬·µ≈à –√“¬ §.  «¡ mask ¢≥–„À°â “√欓∫“≈ºªŸâ «É ¬ ß. µ√«® Õ∫≈°— …≥–º«‘ Àπß— «“à ¡°’ “√Õ°— ‡ ∫∫√‡‘ «≥ vascular access À√Õ◊ ‰¡à À“°µ√«®æ∫ «“à ¡°’ “√Õ°— ‡ ∫ À“â ¡„™â vascular access ππÈ— ·≈–√“¬ß“π·æ∑¬‡å æÕË◊ °“√·°‰â ¢µÕà ‰ª 5.3.4 µ”·Àπßà ∑·Ë’ ∑߇¢¡Á ·≈–«∏‘ °’ “√·∑߇¢¡Á 18 °. ‡≈◊Õ°„™â‡¢Á¡ AVF ™π‘¥ back eye ‡≈◊Õ°¢π“¥¢Õ߇¢Á¡„Àâ‡À¡“– ¡°—∫°“√‡ªî¥ BFR ¡°’ “√»°÷ …“æ∫«“à °“√‡æ¡Ë‘ ¢π“¥¢Õ߇¢¡Á „À≠¢à πÈ÷ ™«à ¬„À‡â ª¥î BFR ‰¥¡â “°¢πÈ÷ ·≈–‡æ¡Ë‘ ª√– ∑‘ ∏¿‘ “æ°“√ øÕ°‡≈Õ◊ ¥ 19 - BFR < 300 ¡≈‘ ≈≈‘ µ‘ √µÕà π“∑’ „™‡â ¢¡Á AVF No.17 - BFR 300-350 ¡≈‘ ≈≈‘ µ‘ √µÕà π“∑’ „™‡â ¢¡Á AVF No.16 - BFR 350-450 ¡≈‘ ≈≈‘ µ‘ √µÕà π“∑’ „™‡â ¢¡Á AVF No.15 - BFR > 450 ¡≈‘ ≈≈‘ µ‘ √µÕà π“∑’ „™‡â ¢¡Á AVF No.14 ¢. °“√·∑߇¢¡Á vascular access ∑‡Ë’ √¡Ë‘ „™ßâ “π „À·â ∑߇¢¡Á ‚¥¬æ¬“∫“≈∑‡Ë’ ™¬Ë’ «™“≠∑ Ë’ ¥ÿ „πÀÕâ ß ‰µ‡∑¬’ ¡ ‰¡§à «√‡ª≈¬Ë’ π§π·∑ß®π°«“à ®–„™ßâ “π‰¥¥â ·’ ≈–‰¡æà ∫ª≠í À“„π√–¬– 3  ª— ¥“À·å √° 20 - ∂“⠬ߗ ¡’ temporary vascular access §«√π” “¬ «πÕÕ°¿“¬À≈ß— ·∑߇¢¡Á ª√– ∫º≈ ”‡√®Á 6 §√ßÈ— - °“√·∑߇¢¡Á 2 §√ßÈ— ·√° „À≈â ߇¢¡Á ∑Ë’ permanent vascular access 1 ‡¢¡Á „™‡â ¢¡Á AVF No.17 ·≈–‡ªî¥ BFR 200-250 ¡‘≈≈‘≈‘µ√µàÕπ“∑’ ‡æ◊ËÕªÑÕß°—π°“√™Õ°™È”¢ÕßÀ≈Õ¥‡≈◊Õ¥®“°∫“°µ—¥¢Õ߇¢Á¡ ·≈–≈¥·√ߥ—π‡≈◊Õ¥ §«√„™â‡ªìπ¥â“π artery ∑‘»∑“ߢÕ߇¢Á¡À—π‰ª∑“߇¥’¬«°—∫°“√‰À≈¢Õ߇≈◊Õ¥ (‡ªìπ °“√ªÑÕß°—πªí≠À“°“√∫«¡™È”¿“¬À≈—ß®“°°“√ª≈¥‡¢Á¡ ‡æ√“– flap ∑’˪ªìπ∑‘»∑“߇¥’¬«°—∫°“√‰À≈ ¢Õ߇≈Õ◊ ¥) ·≈–„™â catheter √«à ¡¥«â ¬‡ªπì ¥“â π venous - ∂Ⓡ°‘¥°“√∫«¡™È”∫√‘‡«≥∑’Ë·∑߇¢Á¡„Àâæ—° °“√„™ßâ “πÕ¬“à ßπÕâ ¬ 1 §√ßÈ— ®π°«“à ®–À“¬®“°°“√∫«¡™”È ·≈–°≈—∫‰ª„™â catheter §«√·∑߇¢Á¡‡Àπ◊Õ∫√‘‡«≥∑’Ë∫«¡™È” „π§√ßÈ— ∂¥— ‰ª 21 §. µ”·Àπàß∑’Ë·∑߇¢Á¡µâÕßÀà“ß®“° anastomosis Õ¬“à ßπÕâ ¬ 3 ‡´πµ‡‘ ¡µ√ √ªŸ ∑Ë’ 3 ß. °√≥∑’ ·Ë’ ∑߇¢¡Á „π‡ πâ ‡¥¬’ «°π— ª≈“¬‡¢¡Á ∑ßÈ— 2 · ¥ß∑‘»∑“ߢÕ߇¢Á¡ retrograde ·≈– antegrade cannulation µÕâ ßÀ“à ß°π— Õ¬“à ßπÕâ ¬ 5 ‡´πµ‡‘ ¡µ√ ª≈“¬‡¢¡Á ¥“â π venous ™‰’È ª∑“߇¥¬’ «°∫— °“√‰À≈¢Õ߇≈Õ◊ ¥°≈∫—  ÀŸà «— „®

New Frontiers in Dialysis 52 ∏π‘µ ®√‘ ππ— ∑å∏«—™  √‘ ‘¿“ ™“â ß»√‘ ‘°≈ÿ ™¬— ∏π—𥓠µ√–°“√«π‘™ « —πµå  ÿ‡¡∏°≈ÿ - °“√·∑߇¢¡Á ¥“â π artery √∫— flow ‡√¬’ °«“à retrograde cannulation - °“√·∑߇¢¡Á ¥“â π artery ∑»‘ ∑“߇¥¬’ «°∫— °“√‰À≈¢Õ߇≈Õ◊ ¥ ‡√¬’ °«“à antegrade cannulation - Buttonhole technique 22, 23 ‡√¡Ë‘ „π∑«ª’ ¬‚ÿ √ª¡“¡“°°«“à 25 ªï ‡√¡Ë‘ „™§â √ßÈ— ·√°„πª√–‡∑» ‚ª·≈π¥å ª§ï .».1977 „πºªŸâ «É ¬∑”°“√øÕ°‡≈Õ◊ ¥∑∫Ë’ “â π∑·Ë’ ∑߇¢¡Á ¥«â ¬µπ‡Õß K/DOQI guideline1 ‰¥‡â æ¡‘Ë ·π«∑“ߪؑ∫—µ‘„π°“√·∑߇¢Á¡ AV fistula ‡π◊ËÕß®“°°√≥’∑’Ë¡’‡π◊ÈÕ∑’Ë„π°“√·∑߇¢Á¡πâÕ¬ ‰¡à “¡“√∂ ‡ª≈’ˬπ∫√‘‡«≥∑’Ë·∑߇¢Á¡‰¥â °“√„™â‡¢Á¡ª≈“¬·À≈¡ (sharp) ´È”∫√‘‡«≥‡¥‘¡∑”„À⇰‘¥ aneurysm ®÷ß¡’¢âÕ ·π–π”„Àℙ⫑∏’ buttonhole technique °—∫ºâŸªÉ«¬∑’Ë¡’æ◊Èπ∑’Ë®”°—¥„π°“√·∑߇¢Á¡ ‡™àπ AV fistula „π µ”·Àπßà µπâ ·¢π (upper arm) ®. °√≥’ AV graft „À·â ∑߇¢¡Á ∑Ë’ AV graft ∑—ßÈ 2 ‡¢¡Á ‡æÕË◊ √°— …“ proximal vein ‰«â ©. ‡ª≈¬Ë’ πµ”·Àπßà °“√·∑߇¢¡Á ∑°ÿ §√ßÈ— (rope cannulation) - AV fistula §«√·∑߇¢¡Á À“à ß®“°®¥ÿ ‡¥¡‘ Õ¬“à ßπÕâ ¬ 2-3 ‡´πµ‡‘ ¡µ√ - AV graft §«√¡µ’ “√“ß°“√·∑߇¢¡Á À“à ß®“°®¥ÿ ‡¥¡‘ 1 ‡´πµ‡‘ ¡µ√ ·≈–§«√·∑ßÀ“à ß®“°  à«π‚§âߢÕß loop graft Õ¬à“ßπâÕ¬ 2.5 ‡´πµ‘‡¡µ√ °“√·∑߇¢Á¡„πµ”·Àπà߇¥‘¡®–¡’‰ø∫√‘π·≈–‡°√Á¥ ‡≈Õ◊ ¥¡“‡°“–‡ªπì ®”π«π¡“° ¿“¬„πÀ≈Õ¥‡≈Õ◊ ¥‡°¥‘ °“√µ∫’ ·§∫·≈–Õ¥ÿ µπ— „π∑ Ë’ ¥ÿ ™. ‰¡·à ∑߇¢¡Á ∫√‡‘ «≥∑æ’Ë ∫«“à ¡’ aneurysm ·≈– pseudo aneurysm ‡æ√“–®–∑”„À‡â ≈Õ◊ ¥À¬¥ÿ ¬“° ¡‚’ Õ°“ ‡ ¬Ë’ ßµÕà °“√·µ° °“√Õ°— ‡ ∫µ¥‘ ‡™ÕÈ◊ ¡º’ ≈„À‡â °¥‘ °“√ ≠Ÿ ‡ ¬’ vascular access ´. ºªŸâ «É ¬µÕâ ß≈“â ß·¢π¥«â ¬π”È  ∫¶Ÿà “à ‡™ÕÈ◊ ‚√§ (antibacterial soap) ·≈–≈“â ßÕÕ°¥«â ¬π”È  –Õ“¥ ‡™¥Á ·¢π„À·â Àßâ °Õà π∑”°“√øÕ°‡≈Õ◊ ¥ ¨. ‡µ√’¬¡º‘«Àπ—ß°àÕπ°“√·∑߇¢Á¡ ‚¥¬„™âπÈ”¬“¶à“‡™◊ÈÕ‡™Á¥«π‡ªìπ«ß°≈¡®“°µ”·Àπàß∑’Ë®– ·∑߇¢Á¡ÕÕ°√Õ∫πÕ° (À“°¡’°“√ —¡º— ∫√‘‡«≥∑’Ë¡’°“√¶à“‡™◊ÈÕ·≈⫵âÕß∑”§«“¡ –Õ“¥´È”Õ’° 1 §√—Èß) ¥ß— πÈ’ 1 - 2% chlorhexidine gluconate with 70% isopropyl alcohol √Õ·Àßâ 30 «π‘ “∑’ À√Õ◊ - 70% alcohol √Õ·Àßâ 1 π“∑’ ·≈–/À√Õ◊ 10% povidone iodine √Õ·Àßâ 2-3 π“∑’ 5.3.5 ¢≥–·∑߇¢¡Á „Àªâ Ø∫‘ µ— ‘ ¥ß— πÈ’ 1, 14 °. AV fistula - „™°â √–∫Õ°©¥’ ¬“ 10 ´´’ ’ „ à π”È ‡°≈Õ◊ 8 ´´’ ’ ·≈– prime ‡¢¡Á AVF ·≈–ª¥î clamp ¢Õß “¬ AVF (wet cannulation technique) À“â ¡∑”∑ßÈ‘ ‰«°â Õà π°“√≈߇¢¡Á - √¥— tourniquet ‡ÀπÕ◊ ∫√‡‘ «≥∑®Ë’ –·∑߇¢¡Á (À“â ¡√¥— ·ππà ) - µ√÷ߺ‘«Àπ—ß„Àâµ÷ß„π∑‘»∑“ßµ√ß°—π¢â“¡°—∫∑‘»∑“ߢÕ߇¢Á¡ ‡æ◊ËÕ°¥ª√– “∑√–À«à“ß Àπß— °”æ√“â °∫— Àπß— ·∑â - ·∑߇¢Á¡¥â«¬§«“¡πÿà¡π«≈ ·≈–√–¡—¥√–«—ß ‰¡à„À⇰‘¥°“√∑–≈ÿÕÕ°πÕ°‡ âπ ‚¥¬À—π Àπ“â µ¥— ¢Õ߇¢¡Á ¢π÷È - ·∑߇¢¡Á ∑”¡¡ÿ °∫— º«‘ Àπß— 25 Õß»“ ‡¡ÕË◊ ‡¢¡Á ‡¢“â  ÀŸà ≈Õ¥‡≈Õ◊ ¥ „™æâ ≈“ ‡µÕ√¢å π“¥ 1 π«È‘ ¬“« 6 π«È‘ µ√ß÷ ‡¢¡Á °∫— º«‘ Àπß—

General Care of Vascular Access ªπòî ·°«â °≈⓬ª√–¬ß§å 53 - ª≈¥ tourniquet - ‡ªî¥ clamp ¢Õß “¬ AVF ‡¡◊ËÕ‡ÀÁπ‡≈◊Õ¥ ‡¢“â ¡“„𠓬 „À∑â ¥ Õ∫¥«â ¬ NSS „π °√–∫Õ°©¥’ ¬“ 1-5 ´´’ ’ ·≈–ª¥î clamp -  —߇°µ≈—°…≥–«à“¡’ °“√√—Ë«ÕÕ°πÕ° ‡ πâ ‡≈Õ◊ ¥À√Õ◊ ‰¡à - ·∑߇¢¡Á Õ°’ 1 ‡¢¡Á µ“¡¢πÈ— µÕπ‡¥¡‘ ¢. AV graft √ªŸ ∑’Ë 4 - À“â ¡√¥— tourniquet · ¥ß°“√·∑߇¢Á¡∑”¡ÿ¡°—∫º‘«Àπ—ß - „™¡â Õ◊ ¢“â ß∑‰Ë’ ¡‰à ¥·â ∑߇¢¡Á ¥ß÷ º«‘ Àπß— ·≈–„™â ¡“°°«à“ 25 Õß»“ ∑”„À⇢Á¡∑–≈ÿ π«‘È ¡Õ◊ µ√ß÷ À≈Õ¥‡≈Õ◊ ¥‡∑¬’ ¡„ÀÕâ ¬°Ÿà ∫— ∑’Ë À≈Õ¥‡≈Õ◊ ¥¥“â π≈“à ß - ·∑߇¢¡Á ‚¥¬«“ߪ≈“¬‡¢¡Á ∑”¡¡ÿ °∫— º«‘ Àπß— 45 Õß»“ ‚¥¬À—πÀπ⓵—¥¢Õ߇¢Á¡¢÷Èπ °“√·∑߇¢Á¡„π·π«‡©’¬ß∑”¡ÿ¡πâÕ¬°«à“ 45 Õß»“ ª≈“¬‡¢Á¡®– ∫“°À≈Õ¥‡≈◊Õ¥‡∑’¬¡„Àâ©’°¢“¥ ¡’√Ÿ‚µ°«à“√Ÿ‡¢Á¡‡¥‘¡ ∑”„Àâ‡≈◊Õ¥‰À≈‰¡àÀ¬ÿ¥À≈—ß®“°ª≈¥‡¢Á¡ ·≈–µâÕß º“à µ¥— ´Õà ¡√√Ÿ «—Ë - °√≥∑’ À’Ë ≈Õ¥‡≈Õ◊ ¥‡∑¬’ ¡µπ◊È ·≈–‡ÀπÁ ™¥— ‰¡Àà ¡πÿ ‡¢¡Á ·∑߇¢¡Á „Àºâ “à πºπß— ¢ÕßÀ≈Õ¥‡≈Õ◊ ¥ ‡∑¬’ ¡¥“â π∫π √–«ß— Õ¬“à „À∑â –≈ºÿ πß— ¢ÕßÀ≈Õ¥‡∑¬’ ¡¥“â π≈“à ß - °√≥∑’ ÀË’ ≈Õ¥‡≈Õ◊ ¥‡∑¬’ ¡≈°÷ ‡¡ÕË◊ ·∑߇¢¡Á ‡¢“â ‰ª 1/8 ¢Õ߇¢¡Á ‡ÀπÁ ‡≈Õ◊ ¥¬Õâ π‡¢“â ¡“„𠓬 AVF „ÀÀâ ¡πÿ ‡¢¡Á 180 Õß»“ „Àªâ ≈“¬µ¥— ¢Õ߇¢¡Á Àπ— ≈ß (‡æÕ◊Ë ‰¡„à Àªâ ≈“¬µ¥— ¢Õ߇¢¡Á ∑”Õπ— µ√“¬µÕà ™π—È intima ¥â“π∫π¢ÕßÀ≈Õ¥‡≈◊Õ¥‡∑’¬¡) ·≈– Õ¥‡¢Á¡‡¢â“‰ªÕ¬à“ß™â“ Ê À≈—ß®“°π—Èπ À¡ÿπ‡¢Á¡°≈—∫ 180 Õß»“ (‡æÕË◊ ‰¡„à Àªâ ≈“¬µ¥— ¢Õ߇¢¡Á ∑”Õπ— µ√“¬µÕà ™πÈ— intima ¥“â π≈“à ߢÕßÀ≈Õ¥‡≈Õ◊ ¥‡∑¬’ ¡) - „™æâ ≈“ ‡µÕ√¢å π“¥ 1 π«È‘ ¬“« 6 π«È‘ µ√ß÷ ‡¢¡Á °∫— º«‘ Àπß— 5.3.6 °“√·∑߇¢¡Á ∂“â ¡’ leakage À≈ß— ®“°„Àâ heparin µÕâ ßÀ“â ¡‡≈Õ◊ ¥„Àπâ “πæÕ ·≈–ª√–§∫ ‡¬πÁ ∑π— ∑’ ‡æÕË◊ ≈¥Õ“°“√ª«¥·≈–∫«¡ §«√ª√∫— ≈¥ª√¡‘ “≥ heparin „À‡â À¡“– ¡ 5.3.7 „™ºâ “â °ÕÁ  ª√“»®“°‡™Õ◊È ª¥î ∫√‡‘ «≥√Õ¬µÕà ¢Õ߇¢¡Á °∫— º«‘ Àπß— °Õà πª¥î ∑∫— ¥«â ¬æ≈“ ‡µÕ√å ‡æÕ◊Ë ªÕÑ ß°π— °“√µ¥‘ ‡™Õ◊È ®“°º«‘ Àπß— ‡¢“â  °Ÿà √–· ‚≈Àµ‘ √ªŸ ∑Ë’ 5 · ¥ß°“√·∑߇¢¡Á AV graft ∑≈Ë’ °÷

New Frontiers in Dialysis 54 ∏π‘µ ®√‘ π—π∑å∏«—™  √‘ ‘¿“ ™â“ß»√‘ ‘°ÿ≈™¬— ∏ππ— ¥“ µ√–°“√«π™‘ « π— µå  ‡ÿ ¡∏°ÿ≈ 5.3.8 √–À«à“ß°“√øÕ°‡≈◊Õ¥ 欓∫“≈µâÕß„Àâ°“√欓∫“≈‡æ◊ËÕªÑÕß°—π‰¡à„À⺟âªÉ«¬‡°‘¥ ª≠í À“§«“¡¥π— ‚≈Àµ‘ µË” 5.3.9  π‘È  ¥ÿ °“√øÕ°‡≈Õ◊ ¥ °. ¥ß÷ ‡¢¡Á ÕÕ°„π¡¡ÿ ‡¥¬’ «°∫— ∑·’Ë ∑߇¢¡Á - Àâ“¡ÕÕ°·√ß°¥º‘«Àπ—ß°àÕπ¥÷߇¢Á¡ÕÕ°À¡¥ ‡æ√“–®–∑”„Àâª≈“¬µ—¥¢Õ߇¢Á¡∑”≈“¬ ™π—È ¢ÕßÀ≈Õ¥‡≈Õ◊ ¥®π©°’ ¢“¥‰¥â - „™ºâ “â °ÕÁ  ª√“»®“°‡™Õ◊È °¥À“â ¡‡≈Õ◊ ¥¥«â ¬πÈ”Àπ°— ∑æ’Ë Õ‡À¡“–√–«ß— Õ¬“à °¥·√߇°π‘ ‰ª·≈– À“â ¡„™ â “¬√¥— ‡æ√“–®–∑”„À‡â ≈Õ◊ ¥‰À≈º“à πÀ≈Õ¥‡≈Õ◊ ¥‰¥πâ Õâ ¬·≈–‡°¥‘ °“√Õ¥ÿ µπ— (thrombosis)µ“¡¡“ ¢. °¥À“â ¡‡≈Õ◊ ¥„Àπâ “πæÕ‡À¡“– AV fistula §«√°¥À“â ¡‡≈Õ◊ ¥π“π 10-15 π“∑’ °√≥’ AV graft „™‡â «≈“¡“°°«“à 15 π“∑’ (°“√°¥À“â ¡‡≈Õ◊ ¥‰¡πà “πæÕ∑”„À‡â °¥‘ ≈¡Ë‘ ‡≈Õ◊ ¥„µºâ «‘ Àπß— ) §. ¡°’ “√ª√–‡¡π‘  ¿“懠πâ ‡≈Õ◊ ¥À≈ß— ®“° π‘È  ¥ÿ °“√øÕ°‡≈Õ◊ ¥‡≈Õ◊ ¥À¬¥ÿ ‰À≈„π‡«≈“∑‡’Ë À¡“– ¡ - §≈” thrill ·≈– øßí ‡ ¬’ ß bruit ‰¥§â ߇¥¡‘ -  ß— ‡°µ§«“¡º¥‘ ª°µ‘ ≈¡Ë‘ ‡≈Õ◊ ¥„µºâ «‘ Àπß— - „À§â ”·π–π”ºªâŸ «É ¬°Õà π°≈∫— ∫“â π - ≈ß∫π— ∑°÷  ßË‘ º¥‘ ª°µ¢‘ Õß vascular access ¿“¬À≈ß— °“√øÕ°‡≈Õ◊ ¥ 5.4 °“√‡ΩÑ“√–«—ߪí≠À“¿“«–µ’∫µ—π·≈–°“√ª√–‡¡‘𧫓¡º‘¥ª°µ‘‡∫◊ÈÕßµâπ¢Õß AV fistula ·≈– AV graft 1, 4 5.4.1 °“√ ß— ‡°µ·≈–°“√µ√«®√“à ß°“¬ °“√µ√«®æ∫∑∫Ë’ ßà ∫Õ°∂ß÷ §«“¡º¥‘ ª°µ‘ ‰¥·â °à °. §≈” thrill À√Õ◊ øßí ‡ ¬’ ßæ∫«“à bruit ≈¥≈ß À√Õ◊ °√≥’ AV graft ‰¡‡à ªπì continuous thrill ¢. ·¢π¢“â ß∑¡Ë’ ’ vascular access ∫«¡ §. °“√·∑߇¢¡Á ≈”∫“° ß. ¡°’ “√Õ°— ‡ ∫ ·≈–µ¥‘ ‡™ÕÈ◊ ∫√‡‘ «≥º«‘ Àπß— ®. ª≈“¬¡Õ◊ ª≈“¬·¢πª«¥ ‡¬πÁ ™“ ©. ‡≈Õ◊ ¥À¬¥ÿ ¬“°¿“¬À≈ß— °“√∂Õπ‡¢¡Á π“π¡“°°«“à 30 π“∑’ ™. ¢π“¥¢Õß pseudo aneurysm ‚µ¢πÈ÷ ‡ªπì 2 ‡∑“à ¢Õß¢π“¥ graft 5.4.2 °“√µ√«®«¥— ¥«â ¬‡§√Õ◊Ë ß‰µ‡∑¬’ ¡ °. ‚¥¬¥∑Ÿ ’Ë pre-pump arterial pressure ¡§’ “à ‡ªπì ‡ªπì ≈∫ (negative)‡æ¡‘Ë ¢π÷È §«√‡æ¡‘Ë ¢π“¥¢Õ߇¢¡Á AVF ‡¡ÕË◊ æ∫«“à negative pre-pump arterial pressure ¡“°°«“à -250 ¡≈‘ ≈‡‘ ¡µ√ª√Õ∑ À√Õ◊ ª√∫— BFR „Àâ ‡À¡“– ¡‡æ√“–∑”„À‡â °¥‘ access recirculation  ßŸ ·≈–Õ“®‡ªπì  “‡Àµ„ÿ À‡â ¡¥Á ‡≈Õ◊ ¥·¥ß·µ° (hemolysis) 19 ¢. °“√¥§Ÿ “à dynamic venous pressure (DVP) ‡¡ÕË◊ ‡ª¥î BFR 200 ´´’ µ’ Õà π“∑’ À≈ß— ®“°µÕà «ß®√‰µ ‡∑¬’ ¡¿“¬„π 2-5 π“∑·’ √° ·π«∑“ߪØ∫‘ µ— ‘ K/DOQI ª®í ®∫ÿ π— ‰¡‡à ªπì ¡“µ√∞“π°“√µ√«® Õ∫¿“«–µ∫’ µπ— ¢Õß vascular access 1 §. °“√¥§Ÿ “à static intra-access pressure ratio (SIAPR) ®“°°“√«¥— SIAP §«√«¥— ‡¡ÕË◊ °“√„™â

General Care of Vascular Access ªòπî ·°«â °≈“â ¬ª√–¬ß§å 55 §√ß—È ·√°·≈–∫π— ∑°÷ ‰«‡â ªπì æπ◊È ∞“π‡ª√¬’ ∫‡∑¬’ ∫‡ªπì °“√«¥— ·√ß¥π— ¿“¬„πvascularaccess¢≥–À¬¥ÿ ª¡íö ‡≈Õ◊ ¥ §«√«¥— ∑°ÿ 2  ª— ¥“Àå «∏‘ °’ “√«¥— - „™«â ∏‘ °’ “√«¥— ‚¥¬µ√ß À≈ß— ®“°·∑߇¢¡Á 2 ‡¢¡Á π” pressure gauge µÕà °∫— ª≈“¬¢Õ߇¢¡Á AVF ¥â«¬¢âÕµàÕ‡™◊ËÕ¡∑’˪√“»®“°‡™◊ÈÕ ·≈–Õà“π§à“·√ߥ—π (¡‘≈≈‘‡¡µ√ª√Õ∑) ·≈–π”¡“À“√¥â«¬ MAP ∑’Ë«—¥ ®“°·¢πÕ°’ ¢“â ßÀπßË÷ ¢ÕߺªâŸ «É ¬„π‡«≈“‡¥¬’ «°π— §“à ∑‰Ë’ ¥‡â ªπì normalized arterial ·≈– venous static IAP µ“¡≈”¥∫— À√Õ◊ - „™â«‘∏’°“√«—¥¢≥–∑”°“√øÕ°‡≈◊Õ¥ §«√«—¥¿“¬„π‡«≈“ 1.5 ™—Ë«‚¡ß·√°¢Õß°“√øÕ°‡≈◊Õ¥ ‡æ√“–·√ß¥π— „πÀ≈Õ¥‡≈Õ◊ ¥®–≈¥≈ß®“°º≈¢Õß°“√¥ß÷ πÈ” : «¥— §“à ·√ߥπ— 0 (P0) ¢Õß arterial pressure ·≈– venous pressure ∑®’Ë Õ‡§√Õ◊Ë ß‰µ‡∑¬’ ¡ ‡æÕ◊Ë ∫«° ≈∫§“à º¥‘ æ≈“¥∑‡Ë’ °¥‘ ®“°‡§√ÕË◊ ߉µ‡∑¬’ ¡‰¡‰à ¥∑â ”°“√ calibrate : ‡¡ÕË◊ ∑”°“√«¥— „ÀÀâ ¬¥ÿ ª¡öí ‡≈Õ◊ ¥·≈–Àπ∫’ clamp ‡ÀπÕ◊ venous chamber : À≈—ß®“°π—Èπ 30 «‘π“∑’ Õà“π§à“·√ߥ—π‡≈◊Õ¥∑’˵àÕ®“°µ—«¥—°‡≈◊Õ¥¥â“π pre-pump arterial pressure ‡√¬’ °«“à §“à arterial drip chamber IAP ·≈– venous pressure ‡√¬’ °«“à §“à venous drip chamber IAP : ª≈¥ clamp ·≈–∑”°“√øÕ°‡≈Õ◊ ¥µÕà : «¥— §«“¡ ßŸ √–À«“à ߇¢¡Á ·∑ß°∫— °∫—  «à π∫π¢Õß√–¥∫— ‡≈Õ◊ ¥„π arterial chamber ·≈– venous chamber (‡´πµ‡‘ ¡µ√) §“à height correction (¡≈‘ ≈‡‘ ¡µ√ª√Õ∑) ‰¥®â “° °“√«¥— ‚¥¬µ√ß = §«“¡ ßŸ (∆) × 0.76 À√Õ◊ „™ â µŸ √§”π«≥ = 3.6 + 0.35 × ∆ : «¥— §«“¡¥π— ‚≈Àµ‘ ∑«Ë’ ¥— ®“°·¢πÕ°’ ¢“â ßÀπßË÷ ¢ÕߺªâŸ «É ¬„π‡«≈“‡¥¬’ «°π— À“§“à MAP §”π«≥®“° µŸ √ : Arterial static IAP = arterial drip chamber IAP +/- arterial P0 : Venous static IAP = venous drip chamber IAP +/- venous P0 √ªŸ ∑’Ë 6 · ¥ß°“√«¥— static IAP ‚¥¬‡§√ÕË◊ ߉µ‡∑¬’ ¡1, 4

New Frontiers in Dialysis 56 ∏𵑠®√‘ π—π∑∏å «—™  √‘ ‘¿“ ™“â ß»√‘ ‘°ÿ≈™—¬ ∏ππ— ¥“ µ√–°“√«π‘™ « π— µå  ‡ÿ ¡∏°ÿ≈ : §”π«≥À“§“à normalized arterial ·≈– venous static IAP ratio(s) ¥ß— πÈ’ Arterial ratio = (arterial static IAP + arterial height correction) / MAP Venous ratio = (venous static IAP + venous height correction) / MAP °“√·ª√º≈ µ“√“ß∑’Ë 1 · ¥ß°“√·ª≈º≈§“à SIAPR 1 Access type AV Graft AV Graft Native AVF Native AVF (Venous ratio) (Arterial ratio) (Venous ratio) (Arterial ratio) 0.15-0.49 0.13-0.43 0.08-0.34 §“à ·√ß¥π— ª°µ‘ 0.35-0.74 >0.5 <0.5 §“à ·√ߥπ— ∑µ’Ë ∫’ µπ— °“√µ√«®æ∫ ∑“ߧ≈π‘ °‘ : °“√Õ¥ÿ µπ— ∑∑Ë’ “߇¢“â >0.75 >0.43 >0.35 >0.43 ≤0.35 : °“√Õ¥ÿ µπ— √–À«“à ߇¢¡Á ≥0.65 <0.13 + °“√µ√«®æ∫ °“√µ√«®æ∫ ∑“ߧ≈π‘ °‘ : °“√Õ¥ÿ µπ— ∑∑Ë’ “ßÕÕ° <0.3 ∑“ߧ≈π‘ °‘ 5.4.3 °“√«¥— Intra › access flow (Qa) §«√«¥— ∑°ÿ 1 ‡¥Õ◊ 𠧫√∑”°“√µ√«®«¥— ¿“¬„π‡«≈“ 1.5 ™«—Ë ‚¡ß·√°¢Õß°“√øÕ°‡≈Õ◊ ¥ °. ‡§√ÕË◊ ß Transonics ‡ªπì °“√«¥— ∑‡Ë’ ∑¬Ë’ ßµ√ß·µ‡à §√ÕË◊ ß¡Õ◊ ¡√’ “§“·æß °“√«¥— ∑”‚¥¬π”‡§√ÕË◊ ß ¡Õ◊ ππÈ— ¡“«¥— ‚¥¬µ√ß∑ Ë’ “¬ ßà ‡≈Õ◊ ¥¢≥–∑”°“√øÕ°‡≈Õ◊ ¥ Õ“à πº≈‡ªπì µ«— ‡≈¢§«“¡‡√«Á ¢Õ߇≈Õ◊ ¥∑«Ë’ ßË‘ Õ¬„àŸ π vascular access ¡º’ »Ÿâ °÷ …“æ∫«“à 1 ‡¡ÕË◊ «¥— AV graft ∑¡Ë’ §’ “à vascular access blood flow πÕâ ¬°«“à 600 ´´’ µ’ Õà π“∑’ ¡’ ‚Õ°“ ‡°¥‘ ≈¡Ë‘ ‡≈Õ◊ ¥Õ¥ÿ µπ— „π vascular access ¿“¬„π 6 ‡¥Õ◊ π ßŸ °«“à AV graft ¡§’ “à vascular access blood flow ¡“°°«“à 600 ´´’ µ’ Õà π“∑’ ‡¡ÕË◊ µ√«®æ∫«“à AV fistula §“à Qa πÕâ ¬°«“à 400 ´´’ µ’ Õà π“∑’ ·≈– AV graft §“à Qa πÕâ ¬°«“à 600 ´´’ µ’ Õà π“∑À’ √Õ◊ §“à ≈¥≈ß 25% ®“°§“à µßÈ— µπâ ∑«Ë’ ¥— ‰¥â 1,000 ´´’ µ’ Õà π“∑¿’ “¬„π√–¬–‡«≈“ 4 ‡¥Õ◊ 𠧫√ ßà angiogram ‡æÕË◊ µ√«®À“°“√µ∫’ µπ— ¢Õß vascular access ¢. Crit-line III (optiodilution by ultrafiltration) §. Glucose pump infusion technique (GPT) 5.4.4 °“√µ√«®À“ access recirculation 1, 3, 4 ‰¡§à «√„™°â ∫— AV graft ¢Õâ ‡ ¬’ §Õ◊ µ√«®æ∫‡¡ÕË◊ §“à BFR  ßŸ °«“à §“à vascular access blood flow ‡∑“à ππÈ— ·≈–‡¡ÕË◊ æ∫«“à ª≠í À“°“√µ∫’ µπ— √πÿ ·√ß  «à π°“√µ∫’ µπ— ∑’Ë central ·≈– collateral veins ‰°≈ÕÕ°‰ª ®–„Àºâ ≈°“√µ√«® ‡ªπì ≈∫ °. ‚¥¬«∏‘ °’ “√‡®“–‡≈Õ◊ ¥§”π«≥ (urea›based measurement) „À∑â ”°“√∑¥ Õ∫¿“¬À≈ß— °“√

General Care of Vascular Access ªòîπ·°«â °≈⓬ª√–¬ß§å 57 øÕ°‡≈Õ◊ ¥µ“¡ª°µ‰‘ ª·≈«â 30 π“∑’ «∏‘ °’ “√«¥— - ª¥î UF ‡®“–µ«— Õ¬“à ߇≈Õ◊ ¥ ( ßà µ√«® BUN) ∑’Ë arterial port ·≈– venous port æ√âÕ¡°—π∑’Ë BFR ∑’˺ŸâªÉ«¬„™â µ“¡ª°µ‘ ®–‰¥§â “à A ·≈– V µ“¡≈”¥∫— - ≈¥ BFR ∑π— ∑‡’ À≈Õ◊ 120 ¡≈‘ ≈≈‘ µ‘ √µÕà π“∑’ √Õ 10 «π‘ “∑®’ ß÷ ª¥î ª¡öí ‡≈Õ◊ ¥ - clamp arterial blood line µ√ß «à π√Õ¬µÕà √ªŸ ∑’Ë 7 sampling port ÕÕ°‰ª‚¥¬™¥‘ °∫— sampling port ¡“° · ¥ß°“√‡°¥‘ access recirculation (≈“à ß) ∑ ’Ë ¥ÿ - ‡®“–µ«— Õ¬“à ߇≈Õ◊ ¥∑Ë’ arterial port ( ßà µ√«® BUN) „™·â ∑π§“à S „π µŸ √ - ‡ª¥î clamp ÕÕ° ·≈«â ∑”°“√øÕ°‡≈Õ◊ ¥µÕà ‰ªµ“¡ª°µ‘ -  «à 𵫗 Õ¬“à ߇≈Õ◊ ¥ A, V ·≈– S 𔉪À“§“à BUN - §”π«≥ % recirculation ®“° µŸ √ R = S − A × 100 S−V °“√·ª≈º≈ ∂Õ◊ «“à §“à πÕâ ¬°«“à √Õâ ¬≈–10 ‰¡¡à §’ «“¡ ”§≠— ∑“ߧ≈π‘ °‘ ∂“â §“à ¡“°°«“à √Õâ ¬≈–10 °√≥’ BFR πÕâ ¬ °«“à 350 ´´’ µ’ Õà π“∑’ ·≈–¡“°°«“à √Õâ ¬≈– 15 °√≥’ BFR ¡“°°«“à 400 ´´’ µ’ Õà π“∑’ §«√µ√«®«π‘ ®‘ ©¬— ‡æ¡Ë‘ 24 §“à ¡“°°«“à 20 % µÕâ ßµ√«®µ”·Àπßà ¢Õ߇¢¡Á (·∑߇¢¡Á º¥‘ ∑»‘ ∑“ß) ¢. °“√µ√«®À“ access recirculation ‚¥¬«∏‘ ’ dilution technique (non-urea based measurement) µÕâ ß„™‡â §√ÕË◊ ß¡Õ◊ 懑 »… ‰¥·â °à Transonics (ultrasound dilution), Crit-line III (optiodilution), blood temperature monitor (BTM; thermo-dilution) ‡ªπì µπâ ∂Õ◊ «“à §“à ∑π’Ë Õâ ¬°«“à 5% ‰¡¡à §’ «“¡ ”§≠— ∑“ߧ≈π‘ °‘ ∂“â §“à ∑¡’Ë “°°«“à 5% §«√µ√«®«π‘ ®‘ ©¬— ‡æ¡‘Ë ‡™πà angiogram 5.4.5 ¥§Ÿ «“¡·µ°µ“à ߢÕß URR ·≈– Kt/V ‰¡ à “¡“√∂Õ∏∫‘ “¬ Kt/V ∑≈Ë’ ¥≈ß¡“°°«“à 0.2 „π ·µà≈–‡¥◊Õπ ¡—°æ∫‡¡◊ËÕ “¬‡°‘π‰ª‡æ√“–Àπ૬‰µ‡∑’¬¡∫“ß·Ààßµ√«®«—¥ URR ·≈– Kt/V π“π‡°‘π‰ª ·≈– “‡Àµ¢ÿ Õß Kt/V ∑≈’Ë ¥≈ß¡ª’ ®í ®¬— À≈“¬ª√–°“√  ”À√∫— ‡§√Õ◊Ë ß‰µ‡∑¬’ ¡∑¡’Ë ’ online urea clearance monitoring (OCM)  “¡“√∂µ√«®æ∫·π«‚π¡â §«“¡·µ°µ“à ߢÕß Kt/V ¥°’ «“à °“√‡®“–‡≈Õ◊ ¥ ‡æ√“– “¡“√∂µ√«®‰¥â ∑°ÿ §√ß—È ∑∑’Ë ”°“√øÕ°‡≈Õ◊ ¥ 5.4.6 Duplex doppler ultrasound (DDU) ‡æ◊ËÕµ√«®¥Ÿ°“√‰À≈À√◊Õ°“√Õÿ¥µ—π¢Õ߇ âπ‡≈◊Õ¥ ∑”‰¥‡â ©æ“–„π‚√ß欓∫“≈∫“ß·Àßà ·≈–µÕâ ßÕ“»¬— ·æ∑¬∑å ¡’Ë ª’ √– ∫°“√≥å 5.4.7 °“√∑” angiogram (fistulogram) ·≈– MRA (magnetic resonancce angiography)

New Frontiers in Dialysis 58 ∏π‘µ ®√‘ π—π∑å∏«™—  √‘ ¿‘ “ ™“â ß»‘√°‘ ÿ≈™—¬ ∏π—𥓠µ√–°“√«π™‘ « π— µå  ‡ÿ ¡∏°≈ÿ ‡ªπì «∏‘ «’ π‘ ®‘ ©¬— ¿“«–µ∫’ µπ— ¢Õß vascular access ‰¥¥â ∑’  Ë’ ¥ÿ °“√∑” angiogram ·≈– MRA ¡’ §«“¡¬ßàÿ ¬“°·≈–µÕâ ßÕ“»¬— √ß—  ·’ æ∑¬å §«√∑”‡¡ÕË◊ ¡¢’ Õâ ∫ßà ™È’ ‡™πà º≈°“√µ√«®∑“ߧ≈π‘ °‘ °“√«¥— SIAPR À√◊Õº≈°“√µ√«®¥â«¬ DDU º‘¥ª°µ‘ ªí®®ÿ∫—π¡’·π«‚πâ¡„™â°“√√—°…“„π°“√·°âªí≠À“°“√µ’∫µ—π¥â«¬«‘∏’ percutaneous transluminal angioplasty (PTA) ‡æ¡Ë‘ ¢πÈ÷ ¢Õâ ‡ ¬’ §Õ◊ √“§“·æß ·≈–µÕâ ß„™ â “√∑∫÷ √ß—  ´’ ßË÷ ‡ªπì æ…‘ µÕà ‰µ Õ“®‡°¥‘ °“√·æ â “√π‰È’ ¥â 6.  √ªÿ À«— „® ”§≠— ¢Õß°“√欓∫“≈ vascular access „πºªŸâ «É ¬∑”°“√øÕ°‡≈Õ◊ ¥¥«â ¬‡§√Õ◊Ë ß‰µ‡∑¬’ ¡§Õ◊ °“√ªÑÕß°—π¿“«–·∑√°´âÕπ·≈–¥Ÿ·≈∑–πÿ∂πÕ¡ vascular access „Àâ¡’Õ“¬ÿ°“√„™âß“ππ“π∑’Ë ÿ¥ 欓∫“≈µâÕß¡’§«“¡ π„®¥Ÿ·≈‡ªìπ摇»… „™â‡∑§π‘§∑’Ë∂Ÿ°µâÕß·≈–µ√«®À“§«“¡º‘¥ª°µ‘‡ªìπª√–®” ‡π◊ËÕß®“°°“√«—¥ intra access flow ·≈– DDU ¡’¢âÕ®”°—¥‡©æ“–‚√ß欓∫“≈∫“ß·Ààß °“√µ√«®æ∫ §«“¡ª°µ‘®“°°“√ —߇°µ °“√µ√«®√à“ß°“¬·≈–°“√«—¥ SIAPR ‰¡à‡ ’¬§à“„™â®à“¬·≈–µ√«®‰¥âßà“¬  “¡“√∂∫àß∫Õ°·π«‚π⡧«“¡º‘¥ª°µ‘¢Õß vascular access ‰¥â 欓∫“≈µâÕßµ√–Àπ—°∂÷ߧ«“¡ ”§—≠ ·≈–ª√– “πß“π°—∫∑’¡·æ∑¬åÕ¬à“߇√àߥà«π‡¡◊ËÕ‡√‘Ë¡æ∫ªí≠À“ ‡æ◊ËÕ “¡“√∂·°â‰¢ªí≠À“·≈–¿“«–µ’∫ µ—π¢ÕßÀ≈Õ¥‡≈◊Õ¥°àÕπ∑’Ë®–‡°‘¥°“√Õÿ¥µ—π πÕ°®“°π’ȧ«√®–¡’°“√ª√–‡¡‘π‡ªìπ√–¬– §«√¡’°“√‡°Á∫ ¢âÕ¡Ÿ≈‡°’ˬ«°—∫Õ—µ√“°“√‡°‘¥¿“«–·∑√°´âÕπ¢Õß vascular access ·µà≈–™π‘¥·≈–ª√—∫ª√ÿßæ—≤π“ §≥ÿ ¿“æÕ¬“à ßµÕà ‡πÕ◊Ë ß ‡Õ° “√Õ“â ßÕß‘ 1. National Kidney Foundation: K/DOQI Clinical Practice Guidelines and clinical practice recommendations for 2006 updates: Hemodialysis adequacy, peritoneal dialysis adequacy and vascular access. Am J Kidney Dis 2006; 48(Suppl 1): s188-s284. 2. Besarab A, Roja RM. Vascular access for hemodialysis In: Daugirdas JT, Blake PG, Ing TS, 3rd ed. Handbook of Dialysis. Philadelphia: Lippincott Williams & Wilkins, 2001: 67-101. 3. Levy J, Morgan J, brown E. Vascular access: overview. Oxford Handbook of Dialysis. Grestbritain: The Bath Press Ltd, 2001: 101-131. 4. National Kidney Foundation: K/DOQI Clinical Practice Guidelines for Hemodialysis Adequacy. Am J Kidney Dis 2001; 37(Suppl 1): s137-s181. 5. ¥‡‘ √° ∫√√≥®°— √.å Vascular access : Overview „π  ¡™“¬ ‡Õ¬Ë’ ¡ÕÕà ß, ‡°ÕÈ◊ ‡°¬’ √µ‘ ª√–¥…‘ ∞æå √»≈‘ ª,á ∏ππ— ¥“ µ√–°“√«π™‘ . ∫√√≥“∏°‘ “√. Practical Hemodialysis. °√ßÿ ‡∑æœ : Text and Journal Publication Co.,Ltd. 2548: 149-158. 6. Butterly DW, Schwab SJ. Catheter access for hemodialysis : An overview. Semin in Dial 2001; 14: 411-415. 7. Oliver MJ. Acute dialysis catheters. Simin in Dial 2001; 14: 432-435.

General Care of Vascular Access ªπòî ·°«â °≈“â ¬ª√–¬ß§å 59 8. Ash SR. The evolution and function of central venous catheters for dialysis. Semin in Dial 2001; 14: 416- 424. 9. Camp-Sorrell D. Access device guildline: recommendations for nursing practice and education. 2 nd ed. USA: Oncology Nursing Society, 2004. 10. Hawkins CT. Nursing international related to vascular access infections. Adv Renal Repl Ther 1996; 3: 218- 221. 11. Kian K, vassalotti JA. The new arteriovenous fistula: the need for earlier evaluation and intervention. Simin in Dial 2005; 18: 3. 12. ¬«ÿ ¥’ ‡°µ ¡— æπ— ∏,å »√‡’ ∫≠Á ®“ ‰«∑¬æ‡‘ ™…∞,å  √Õâ ¬ –Õ“ß  √“â ß ¡— «ß….å °“√ Dressing exit site. ∫∑∫“∑·≈– ∑»‘ ∑“ß°“√æ≤— π“°“√欓∫“≈‚√§‰µ. °“√ª√–™¡ÿ «™‘ “°“√ª√–®”ªï ™¡√¡æ¬“∫“≈‚√§‰µ ·Àßà ª√–‡∑»‰∑¬. 2547. 13. Yevzlin AS, Sanchez RJ, Hiatt JG, et al. Concentrated heparin lock is associated with major bleeding complications after tunneled hemodialysis catheter placement. Semin in Dial 2007; 20(5): 351-354. 14. Beathard GA. Catheter thrombosis : The use and complications for hemodialysis vascular access. Semin in Dial 2001; 14: 441-445. 15. ªπîò ·°«â °≈“â ¬ª√–¬ß§.å ·π«∑“ߪØ∫‘ µ— °‘ “√¥·Ÿ ≈ Vascular access „π  ¡™“¬ ‡Õ¬’Ë ¡ÕÕà ß, ‡°Õ◊È ‡°¬’ √µ‘ ª√–¥…‘ ∞å æ√»≈‘ ª,á ∏ππ— ¥“ µ√–°“√«π™‘ . ∫√√≥“∏°‘ “√. Practical Hemodialysis. °√ßÿ ‡∑æœ : Text and Journal Publication Co.,Ltd. 2548: 159-166. 16. °”æ≈ ‡≈“À‡æ≠Á · ß. Vascular access for hemodialysis. ‡™¬’ ß„À¡:à ¿“§«™‘ “»≈— ¬»“ µ√å §≥–·æ∑¬»“ µ√å ¡À“«∑‘ ¬“≈¬— ‡™¬’ ß„À¡,à 2537. 17. Hartigan MF. Vascular access and nephrology nursing practice: Existing views and nationales for charge. Adv Renal Repl Ther 1994; 1: 156-162. 18. Brouwer DJ. Cannulation camp: basic needle cannulation training for dialysis staff. Dial & Transpl 1995; 24: 606-612. 19. 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. 20. Besarab A, Brouwer D. Improving arteriovenous fistula construction: fistula first initiative. Hemodial Int 2004; 8: 199-206. 21. Zakrzewska-Bode A, Muytjens HL, Liem KD, Hoogkamp-Korstanje JA. Mupirocin resistance in coagulase- negative staphylococci, after topical prophylaxis for the reduction of colonization of central venous catheters. J Hosp Infect 1995; 31: 189-193. 22. Medisystem. ButtonHole needle sets with anti-stick dull bevel. 2004. 23. Jaber BL, Pereira BJG. Complications associated with hemodialysis In: Brenner BM, Rector FC, eds. The Kidney. Philadelphia: WB Saunders, 1999: 558-559. 24. Windus DW. Permanent vascular access: A Nephrologistûs view. Am J Kidney Dis 1993; 21(5): 436.



4 Antimicrobial Locked Catheter °”∏√ ≈≈’ “¡–≈‘ 1. Hemodialysis catheter related infection 2. °“√√°— …“ Catheter related infection 3. °“√√°— …“ Catheter related infection ¥«â ¬ Antibiotic lock solution 4. °“√ªÕÑ ß°π— Catheter related bacteremia ¥«â ¬ Catheter lock solution 5. °√–∫«π°“√°“√ªÕÑ ß°π— °“√‡°¥‘ Catheter related bacteremia 6. ¬“∑Ë’„™‡â ªπì Catheter lock solution ‡æÕË◊ ªÕÑ ß°π— °“√‡°¥‘ Catheter related infection

New Frontiers in Dialysis 62 ∏π‘µ ®‘√ππ— ∑∏å «—™  √‘ ¿‘ “ ™“â ß»√‘ °‘ ≈ÿ ™¬— ∏π—𥓠µ√–°“√«π™‘ « —πµå  ‡ÿ ¡∏°ÿ≈ 1. Hemodialysis catheter related infection ºªâŸ «É ¬‰µ«“¬‡√Õ◊È √ß— ∑µ’Ë Õâ ßøÕ°‡≈Õ◊ ¥¥«â ¬‡§√Õ◊Ë ß‰µ‡∑¬’ ¡·≈–¬ß— ‰¡¡à ‡’  πâ øÕ°‡≈Õ◊ ¥∂“«√∑·’Ë ¢πÀ√Õ◊ ¢“ À√◊Õ¡’·≈â«·µà¬—߉¡à “¡“√∂„™â‡ âπøÕ°‡≈◊Õ¥‰¥â À√◊Õ‰¡à¡’‡ âπ‡≈◊Õ¥∑’Ë®–∑”‡ âπøÕ°‡≈◊Õ¥∂“«√ „π °√≥‡’ À≈“à πº’È ªŸâ «É ¬µÕâ ߉¥√â ∫— °“√øÕ°‡≈Õ◊ ¥¥«â ¬ “¬ Catheter („π∑π’Ë ®’È –‡√¬’ °«“à Hemodialysis catheter À√Õ◊ HD catheter) ∑’Ë„ à∑“߇ âπ‡≈◊Õ¥¥”„À≠à ´÷Ëß à«π„À≠à®–„ à∑’˧Õ∫√‘‡«≥‡ âπ‡≈◊Õ¥¥” Internal jugular ºâŸ ª«É ¬‡À≈“à π¡È’ §’ «“¡‡ ¬Ë’ ß∑®Ë’ –‡°¥‘ °“√µ¥‘ ‡™ÕÈ◊ Õπ— ‡πÕË◊ ß®“° “¬ HD catheter °“√µ¥‘ ‡™ÕÈ◊ ∑¡Ë’  ’ “‡Àµ®ÿ “° “¬ HD catheter À√Õ◊ HD catheter related infection (CRI) ‡ªπì ª≠í À“∑æË’ ∫‰¥∫â Õà ¬ ¡√’ “¬ß“πµßÈ— ·µà 14 ∂ß÷ 54% ¡’∑—Èß°“√µ‘¥‡™◊ÈÕ∑’˺‘«Àπ—ß∫√‘‡«≥∑“߇¢â“¢Õß “¬ HD catheter À√◊Õ‡√’¬°«à“ Exit site infection À√◊Õ ∫√‡‘ «≥º«‘ Àπß— √–À«“à ßµ«— Cuff ·≈–∑“߇¢“â ‡ πâ ‡≈Õ◊ ¥¥”¢Õß “¬ HD catheter À√Õ◊ ‡√¬’ °«“à Tunnel infection ´ßË÷ „π°√≥π’ æÈ’ ∫‰¥‡â ©æ“–„𠓬 HD catheter ∑¡Ë’ ’ Cuff ´ßË÷ ¡°— ®–„™‡â ªπì Long-term hemodialysis catheter ·≈– ÿ¥∑⓬§◊Õ°“√µ‘¥‡™◊ÈÕ„π°√–· ‡≈◊Õ¥ À√◊Õ‡√’¬°«à“ Catheter related bacteremia (CRB) ´÷Ëß CRB Õ“®®–∑”„Àºâ ªŸâ «É ¬¡Õ’ “°“√ Shock ·≈–‡ ¬’ ™«’ µ‘ ‰¥â À√Õ◊ ∑”„À‡â °¥‘ ¿“«–·∑√°´Õâ πÀ≈“¬Õ¬“à ß ‡™πà °“√ µ¥‘ ‡™Õ◊È ∑≈’Ë π‘È À«— „® (Endocarditis), °“√µ¥‘ ‡™Õ◊È ‡¢“â ¢Õâ (Septic arthritis), °“√µ¥‘ ‡™Õ◊È ∑‡’Ë ¬Õ◊Ë À¡ÿâ ‰¢ π— À≈ß— (Epidural abscess) ´ßË÷ ∑”„À‡â ªπì ª≠í À“„π°“√√°— …“·≈–Õ“®∑”„À∂â ß÷ ·°™à «’ µ‘ ‰¥„â π∑ Ë’ ¥ÿ Àπ૬‰µ‡∑’¬¡§«√¡’°“√∫—π∑÷°°“√µ‘¥‡™◊ÈÕ¢Õß “¬ HD Catheter Õ¬à“ß ¡Ë”‡ ¡Õ ·≈– √“¬ß“π§“à ‡ªπì ®”π«π§√ßÈ— ¢Õß°“√µ¥‘ ‡™ÕÈ◊ µÕà 1000 Catheter days ‚¥¬∑«Ë— ‰ª§«√¡‰’ ¡‡à °π‘ 1 ∂ß÷ 2 §√ßÈ— µÕà 1000 Catheter days ∂“â ¡§’ “à µ«— ‡≈¢Õ¬„àŸ π™«à ß 4 ∂ß÷ 5 ®¥— ‰¥«â “à çæÕ„™éâ ·≈–∂“â µ«— ‡≈¢Õ¬„àŸ π™«à ß 6 ∂ß÷ 7 ®¥— «“à 牡¥à é’ πÕ°®“°ππ—È ¬ß— µÕâ ß欓¬“¡À“‡™Õ◊È ∑‡’Ë ªπì  “‡Àµ¥ÿ «â ¬‡™Õ◊È  «à π„À≠‰à ¥·â °àStaphylococcusaureus, Staphylococcus epidermidis πÕ°®“°ππÈ— ¬ß— æ∫«“à ¡‡’ ™ÕÈ◊ ™π¥‘ Gram-negative Õ°’ ∂ß÷ 30% „π∫“ߧ√ßÈ— æ∫ «“à ¡°’ “√µ¥‘ ‡™ÕÈ◊ À≈“¬µ«— æ√Õâ ¡Ê °π— ¡’ªí®®—¬‡ ’ˬßÀ≈“¬Õ¬à“ß∑’Ë¡’º≈µàÕ°“√µ‘¥‡™◊ÈÕ ‰¥â·°à √–¬–‡«≈“„π°“√„ à “¬ HD catheter °“√‡°¥‘ °“√Õ¥ÿ µπ— ¿“¬„𠓬 HD catheter §«“¡∫Õà ¬„π°“√∑µË’ Õâ ߉ª∑” Intervention „¥Ê °∫—  “¬ HD catheter °“√¡‡’ ™ÕÈ◊ Staphylococcus  – ¡∫√‡‘ «≥º«‘ Àπß— ·≈–‡¬ÕË◊ ∫‚ÿ æ√ß®¡°Ÿ °“√¡‡’ ™ÕÈ◊  – ¡∑Ë’ Catheter hub °“√ªî¥ “¬ Catheter ¥â«¬«‘∏’ Transparent dressing (ªí®®ÿ∫—π‰¡à‡™◊ËÕ«à“‡æ‘Ë¡Õÿ∫—µ‘°“√≥å°“√µ‘¥‡™◊ÈÕ) °“√∑’˺ŸâªÉ«¬‡ªìπ‚√§‡∫“À«“π °“√¡’ª√‘¡“≥∏“µÿ‡À≈Á°¿“¬„π√à“ß°“¬¡“° ·≈–°“√¡’√–∫∫ Immune ∑”ß“π∫°æ√Õà ß (Immunoincompetency)(1) 2. °“√√°— …“ Catheter related infection °“√√°— …“°“√µ¥‘ ‡™Õ◊È ¢Õß HD Catheter „À·â ¬°ª√–‡¿∑µ“¡µ”·Àπßà °“√µ¥‘ ‡™Õ◊È ‡ªπì ∫√‡‘ «≥ Exit site, Tunnel ·≈– CRB ¥ß— πÈ’

Antimicrobial Locked Catheter °”∏√ ≈’≈“¡–≈‘ 63 2.1 Exit site infection ∂“â ‰¡¡à °’ “√µ¥‘ ‡™ÕÈ◊ ∑Ë’ Tunnel À√Õ◊ CRB √«à ¡¥«â ¬ „À‡â √¡Ë‘ °“√√°— …“·∫∫ local antibiotic °Õà 𠇙πà °“√„™¬â “ Mupirocin ointment ·µ∂à “â ‰¡¥à ¢’ πÈ÷ À√Õ◊ ¡°’ “√Õ°— ‡ ∫¡“°À√Õ◊ ¡ª’ √¡‘ “≥¢Õß discharge ¡“° Õ“®„À¬â “ antibiotic ∑“ß√∫— ª√–∑“πÀ√Õ◊ „À∑⠓߇ πâ ‡≈Õ◊ ¥√«à ¡¥«â ¬ ®–µÕâ ßµ¥‘ µ“¡°“√¥·Ÿ ≈Õ¬“à ß„°≈™â ¥‘ ·≈–∑”·º≈∑ÿ°«—π ‰¡à§«√ªî¥·º≈‰«â·≈–√Õ¡“¥Ÿ·º≈Õ’°§√—Èß„π°“√∑”°“√øÕ°‡≈◊Õ¥√Õ∫∂—¥‰ª ·≈–µâÕß µ¥‘ µ“¡«“à ¡°’ “√≈°ÿ ≈“¡‡ªπì Tunnel infection À√Õ◊ CRB À√Õ◊ ‰¡à 2.2 Tunnel infection ‡πÕ◊Ë ß®“°‡ªπì °“√µ¥‘ ‡™Õ◊È ‡ÀπÕ◊ µÕà Dacron cuff ·≈–∫√‡‘ «≥π¡’È ∑’ “ßµ¥‘ µÕà ‚¥¬µ√ß°∫— °√–· ‚≈Àµ‘ ¥ß— ππÈ— µÕâ ß√∫’ „À°â “√√°— …“Õ¬“à ߇√ßà ¥«à π¥«â ¬°“√„À¬â “ antibiotic ∑“߇ πâ ‡≈Õ◊ ¥ ·≈–µÕâ ß∂Õ¥ “¬ Catheter ÕÕ° ·≈–‡ª≈¬Ë’ π·π« exit site ·≈– venotomy site „À¡à 2.3 Catheter related bacteremia (CRB) °“√√°— …“‚¥¬√«¡§Õ◊ µÕâ ß„À¬â “ antibiotic ∑ ’Ë “¡“√∂¶“à ‡™ÕÈ◊ ·≈–∑ Ë’ ”§≠— §Õ◊ ‰¢·â ≈–Õ“°“√ÕπË◊ Ê ®–µÕâ ßÀ“¬‰ªÕ¬“à ߇√«Á ·≈–µÕâ ß„À¬â “π“π3 ª— ¥“Àå·≈–µÕâ ßµ¥‘ µ“¡°“√‡æ“–‡™Õ◊È À≈ß— À¬¥ÿ ¬“Õ°’ 1 ª— ¥“Àå ‡æ◊ËÕ„Àâ·πà„®«à“‡™◊ÈÕ∂Ÿ°¶à“À¡¥‰ª®√‘ß ∂Ⓣ¢â‰¡à≈ß∑—ÈßÊ ∑’Ë„À⬓¶à“‡™◊ÈÕ∑’ˇÀ¡“– ¡·≈â« Õ“®‡°‘¥‡π◊ËÕß®“° ¬ß— ¡·’ À≈ßà ‡™ÕÈ◊ ‚√§‡À≈Õ◊ Õ¬àŸ ‚¥¬‡©æ“–∑µË’ «—  “¬ HD catheter ‚¥¬‡™ÕÈ◊ ·∫§∑‡’ √¬’ ®–Õ¬„Ÿà π√ªŸ ¢Õß Biofilm ¢Õß “¬ HD catheter À√Õ◊ ¡°’ “√µ¥‘ ‡™ÕÈ◊ ∑µË’ ”·Àπßà ÕπË◊ √«à ¡¥«â ¬ µ”·Àπßà ∑µË’ Õâ ß¡ÕßÀ“§Õ◊ ∫√‡‘ «≥≈πÈ‘ À«— „® (Endocarditis), ∫√‡‘ «≥‡¬ÕË◊ À¡âÿ ‰¢°√–¥°Ÿ (Epidural abscess) ·≈–∫√‡‘ «≥¢Õâ (Septic arthritis) ‡π◊ËÕß®“° “¬ HD catheter ‡ªìπ·À≈àߢÕß°“√µ‘¥‡™◊ÈÕ ∑“߇≈◊Õ°¡’Õ¬ŸàÀ≈“¬«‘∏’ ·¡â«à“«‘∏’∑’Ë ·æ∑¬å‚√§‰µ·≈–欓∫“≈‰µ‡∑’¬¡µâÕß°“√ §◊Õ‰¡à∂Õ¥ “¬ HD catheter ∑‘Èß ·µà«‘∏’π’ÈÕ“®®–∑”„Àâ‰¡à  “¡“√∂√—°…“ CRB ‰¥â ·≈–∂â“¡’‰¢âÕ¬àŸπ“πÕ“®‡°‘¥‚√§·∑√°´âÕπ‡™àπ Metastatic infection ·≈–∑”„Àâ °“√√—°…“¬“° ·≈–‡ ’¬™’«‘µ‰¥â ®–‡≈◊Õ°«‘∏’π’ȵâÕß·πà„®«à“ À≈—ß„Àâ°“√√—°…“·≈⫉¢â≈¥≈ßÕ¬à“ß√«¥‡√Á« ·≈–‰¡à¡’°“√‰¢â —Ëπ„π√–À«à“ß°“√∑” HD ·≈–µ√«®‰¡àæ∫‡™◊ÈÕ„π°√–· ‡≈◊Õ¥®“°°“√‡æ“–‡™◊ÈÕ„π √–À«à“ß°“√√—°…“·≈–À≈—ß®“°®∫°“√√—°…“·≈â« æ∫«à“´÷Ëß«‘∏’π’È¡’Õ—µ√“§«“¡ ”‡√Á®µË”ª√–¡“≥ 30-40% ·≈–‡ ¬Ë’ ßµÕà °“√‡°¥‘ ‚√§·∑√°´Õâ πµ“à ßÊ  ßŸ ¥ß— ®–‰¥°â ≈“à «µÕà ‰ª «∏‘ ∑’ ‰Ë’ ¥ºâ ≈¥∑’  Ë’ ¥ÿ §Õ◊ ∂Õ¥ “¬ HD catheter ÕÕ° ·≈–√Õ„ „à À¡‡à ¡ÕË◊ °“√µ¥‘ ‡™ÕÈ◊ À“¬ π∑‘ „π √–À«“à ßπ„’È Àøâ Õ°‡≈Õ◊ ¥∑“ß “¬ Non-cuff HD catheter ™«—Ë §√“«∑µ’Ë ”·Àπßà Õπ◊Ë ‰ª°Õà π «∏‘ π’ µ’È Õâ ß∑”Àµ— ∂°“√∂ß÷ 2-4 ¢πÈ— µÕπ‚¥¬‡©æ“–∂“â ‡ªπì  “¬ Tunnel-cuff HD catheter §Õ◊ µÕâ ß∂Õ¥ “¬‡¥¡‘ ÕÕ°, „  à “¬ Non-cuff HD catheter ∑„Ë’ À¡,à ‡¡Õ◊Ë °“√√°— …“‰¥ºâ ≈·≈–„À¬â “§√∫ „À∂â Õ¥ “¬ Non-cuff HD catheter ÕÕ° ·≈–„ à  “¬ Tunnel-cuff HD catheter „À¡à ¢Õâ ‡ ¬’ ∑ Ë’ ”§≠— §Õ◊ Õ“®®–À“∑„Ë’ À¡„à  ‰à ¡‰à ¥â À√Õ◊ Õ“®®–‡ªπì µ”·Àπßà ∑‰Ë’ ¡¥à ‡’ ¡ÕË◊ ‡ª√¬’ ∫‡∑¬’ ∫°∫— µ”·Àπßà ‡¥¡‘ µ”·Àπßà ∑¥Ë’ ∑’  Ë’ ¥ÿ §Õ◊ ‡ πâ ‡≈Õ◊ ¥¥” Internal jugular ¢“â ߢ«“ ´ßË÷ ∂“â ∂Õ¥ “¬ÕÕ° ·≈–®–„ à„À¡à„π§√—ÈßµàÕ‰ª Õ“®®–¡’°“√µ’∫µ—π¢Õß “¬∑”„À≡ࠓ¡“√∂„ à “¬„π µ”·Àπßà π‰È’ ¥â ∑”„Àµâ Õâ ß„  à “¬∑µË’ ”·Àπßà ÕπË◊ ∑‰Ë’ ¡„à ™µà ”·Àπßà ∑¥Ë’ ∑’  Ë’ ¥ÿ (2)

New Frontiers in Dialysis 64 ∏π‘µ ®‘√π—π∑∏å «™—  √‘ ¿‘ “ ™“â ß»√‘ °‘ ÿ≈™—¬ ∏π—𥓠µ√–°“√«π‘™ « π— µå  ÿ‡¡∏°≈ÿ ∑“߇≈Õ◊ °ÕπË◊ ‰¥·â °°à “√‡ª≈¬Ë’ 𠓬 Catheter º“à π∑“ß Guidewire ´ßË÷ πÕ°®“°®–¬ß— ‰¡µà Õâ ßÀ“ Venotomy site „À¡à ¬ß— ‡ªπì °“√∑”Àµ— ∂°“√¢πÈ— µÕπ‡¥¬’ « Õ¬“à ߉√°µÁ “¡µÕâ ßÀ“ Exit site ·≈– Tunnel „À¡à ∂“â ¡°’ “√µ¥‘ ‡™ÕÈ◊ ∑∫Ë’ √‡‘ «≥ Exit site √«à ¡¥«â ¬ ¡°— ®–∑”À≈ß— ®“°„À¬â “ antibiotic ‰ª·≈«â 1-3 «π— ‰¡µà Õâ ß√Õ ®π‰¢â≈¥≈ß°àÕπ∑”À—µ∂°“√π’È ·µà„π°√≥’∂â“¡’Õ“°“√√ÿπ·√ß¡“°‚¥¬‡©æ“– Septic shock ·π–π”„Àâ√’∫ ‡Õ“ “¬ÕÕ°∑π— ∑’ ·≈–√Õ„  à “¬„À¡®à π°«“à ‰¢®â –À“¬ æ∫«“à «∏‘ π’ ‰È’ ¥ºâ ≈¡“°°«“à 80% (3-5) ª®í ®∫ÿ π— ‡™ÕË◊ «“à Biofilm ∑ªË’ √“°ØÕ¬∑àŸ ºË’ «‘ ¢Õß HD catheter ‡ªπì  “‡ÀµÀÿ ≈°— ¢Õß°“√‡°¥‘ CRB ‡™ÕÈ◊ ·∫§∑‡’ √¬’ ®–¡“‡°“–Õ¬∑Ÿà ºË’ «‘ ¢Õß HD catheter ·≈– √“â ß “√∫“ßÕ¬“à ߇™πà Glycocalyx ÕÕ°¡“‡§≈Õ◊ ∫‰«â ‡√’¬° “√π’È·≈–µ—«·∫§∑’‡√’¬«à“ Biofilm ´÷Ëß®–∑”„À⬓ªØ‘™’«π–À√◊Õ antibiotic ‰¡à “¡“√∂‡¢â“‰ª¶à“‡™◊ÈÕ ‰¥Õâ ¬“à ßß“à ¬À√Õ◊ °≈“à «Õ°’ Õ¬“à ß«“à ‡™Õ◊È ·∫§∑‡’ √¬’ ∑µ’Ë ”·Àπßà π®’È –¥Õ◊È ¬“¡“°°«“à ·∫§∑‡’ √¬’ ∑Õ’Ë ¬„Ÿà π°√–· ‡≈Õ◊ ¥ ¡º’ √Ÿâ “¬ß“π«“à æ∫ Biofilm „𠓬 Central venous catheter ∑Ë’ ICU ®”π«π 100%  “¬ Catheter ∫“ß  “¬„ ‰à ¥πâ “π‡æ¬’ ß 1 «π— ·≈–æ∫‡™ÕÈ◊ ·∫§∑‡’ √¬’ „π Biofilm 88% ‡¡ÕË◊ ¡ª’ √¡‘ “≥‡™ÕÈ◊ „π Biofilm ¡“°∂ß÷ ®¥ÿ ÀπßË÷ °®Á –°√–®“¬µ«— ‡¢“â  °àŸ √–· ‡≈Õ◊ ¥·≈–∑”„À‡â °¥‘ CRB ¢πÈ÷ ´ßË÷ °“√„À¬â “ antibiotic „π¢π“¥ª°µ∑‘ Ë’  “¡“√∂¶“à ‡™ÕÈ◊ ·∫§∑‡’ √¬’ „π°√–· ‡≈Õ◊ ¥‰¥â ·µ‰à ¡ à “¡“√∂¶“à ‡™ÕÈ◊ „π Biofilm ‰¥â ¥ß— ππÈ— °”®¥—  “¬ Catheter ®ß÷ ¡§’ «“¡®”‡ªπì „π°“√√°— …“ CRB Õ¬“à ߉√°µÁ “¡„πª®í ®∫ÿ π— ‰¥¡â °’ “√„™â antibiotic „𧫓¡‡¢¡â ¢πâ ¢π“¥  ßŸ „ ‡à ¢“â ‰ª„𠓬 Catheter (antibiotic lock) §«“¡‡¢¡â ¢πâ ¢Õ߬“∑ Ë’ ߟ πÈ’ ®–¶“à ‡™ÕÈ◊ ·∫§∑‡’ √¬’ „π Biofilm ‰¥â ®ß÷ ¡§’ «“¡æ¬“¬“¡∑®’Ë –√°— …“ “¬ HD Catheter ‰«¥â «â ¬°“√„À¬â “ antibiotic ∑“߇ πâ ‡≈Õ◊ ¥ √«à ¡°∫— antibiotic lock ‡æÕË◊ ®–‰¥‰â ¡µà Õâ ß∂Õ¥ “¬ Catheter ÕÕ°®“°√“à ß°“¬ æ∫«“à ‰¥ºâ ≈¥’ (6) 3. °“√√°— …“ Catheter related infection ¥«â ¬ Antibiotic lock solution ‡¡ÕË◊ ºªâŸ «É ¬∑øË’ Õ°‡≈Õ◊ ¥¥«â ¬‡§√ÕË◊ ߉µ‡∑¬’ ¡∑“ß Tunnel-cuff HD catherter ¡‰’ ¢â ·≈–µ√«®‰¡æà ∫ °“√µ¥‘ ‡™ÕÈ◊ ∑ÕË’ πË◊ „À â ß ¬— «“à  “‡Àµ¢ÿ Õ߉¢‡â °¥‘ ®“° HD catheter ‡ªπì Õπ— ¥∫— ·√° ·≈–„À°â “√√°— …“¥«â ¬¬“ ªØ™‘ «’ π–∑“߇ πâ ‡≈Õ◊ ¥¥«â ¬«∏‘ ¡’ “µ√∞“π·≈–°“√„À¬â “ªØ™‘ «’ 𖧓â ß¿“¬„𠓬 HD catheter À√Õ◊ antibiotic lock ¥ß— πÈ’ 3.1 °“√„À¬â “ªØ™‘ «’ π–∑“߇ πâ ‡≈Õ◊ ¥ (Systemic antibiotics) ·π–π”„À¬â “ªØ™‘ «’ π–§√Õ∫§≈¡ÿ ‡™ÕÈ◊ Gram positive ·≈– Gram negative ∑°ÿ √“¬∑ Ë’ ß ¬— «“à ¡’ CRB ¥«â ¬°“√„À¬â “ Vancomycin „π¢π“¥ 20mg/kg  ”À√∫— ‡™ÕÈ◊ Gram positive ·≈–¬“ Ceftazidime ¢π“¥ 1gm  ”À√∫— ‡™Õ◊È Gram negative ‚¥¬„À∑⠓߇ πâ ‡≈Õ◊ ¥∑π— ∑À’ ≈ß— ®“°¥¥Ÿ ‡≈Õ◊ ¥‡æÕ◊Ë °“√‡æ“–‡™Õ◊È ·≈«â ®“°ππ—È „Àâ Vancomycin „π¢π“¥ 500mg À¬¥∑“߇ πâ ‡≈Õ◊ ¥„π™«—Ë ‚¡ß ¥ÿ ∑“â ¬¢Õß°“√øÕ°‡≈Õ◊ ¥ ·≈– Ceftazidime ¢π“¥ 1gm À≈ß— ®“° πÈ‘  ¥ÿ °“√øÕ°‡≈Õ◊ ¥∑°ÿ §√ßÈ— √«¡‡ªπì ‡«≈“ 3  ª— ¥“Àå °√≥∂’ “â º≈°“√‡æ“–‡™ÕÈ◊ æ∫‡©æ“–‡™ÕÈ◊ Gram positive À√◊Õ Gram negative „ÀâÀ¬ÿ¥¬“ Ceftazidime À√◊Õ Vancomycin µ“¡≈”¥—∫ ∂⓺≈°“√ ‡æ“–‡™ÕÈ◊ æ∫‡ªπì ‡™ÕÈ◊ Gram positive ∑‰Ë’ ¡‰à ¥¥â ÕÈ◊ µÕà ¬“ Methicillin (Methicillin sensitive) À√Õ◊ ‡ªπì ‡™ÕÈ◊ Gram negative ∑‰Ë’ ¡¥à ÕÈ◊ µÕà ¬“ Cefazolin „À‡â ª≈¬Ë’ π‡ªπì ¬“ Cefazolin ¢π“¥ 1gm ·∑π À√Õ◊ ¬“ÕπË◊ Ê ∑ Ë’ “¡“√∂

Antimicrobial Locked Catheter °”∏√ ≈’≈“¡–≈‘ 65 ¶“à ‡™Õ◊È ‰¥â  ”À√∫— ¬“ Gentamycin „À„â π¢π“¥ 1.5mg/kg „π§√ß—È ·√° À≈ß— ®“°ππ—È „ÀÀâ ≈ß—  π‘È  ¥ÿ °“√øÕ°‡≈Õ◊ ¥ 1mg/kg ·µ‰à ¡‡à °π‘ 100mg µÕà §√ßÈ— (7-8) 3.2 °“√„À¬â “ªØ™‘ «’ 𖧓â ß¿“¬„𠓬 HD catheter (antibiotic lock) „À„â ™¬â “ µŸ √‡¥¬’ «°∫— ∑‡’Ë ≈Õ◊ °„™„â π°“√©¥’ ‡¢“â ‡ πâ ‡≈Õ◊ ¥ ¥«â ¬°“√º ¡°∫— Heparin ·≈–À√Õ◊ Normal saline „À‰â ¥§â «“¡‡¢¡â ¢πâ µ“¡µ“√“ß∑Ë’ 1 ·≈–„ ¿à “¬„𠓬 HD catheter ·µ≈à –¢“â ßÀ≈ß— ®“° πÈ‘  ¥ÿ °“√ øÕ°‡≈Õ◊ ¥∑°ÿ §√ßÈ— ∑”π“π 3  ª— ¥“Àå À≈ß— ®“°ππÈ— „Àâ Lock ¥«â ¬ Heparin µ“¡ª°µ‘ ‚¥¬∑«Ë— ‰ª®–·∫ßà ¬“ ®“°¬“∑’Ë®–©’¥‡¢â“‡ âπ‡≈◊Õ¥ ‡π◊ËÕß®“°¬“∑’Ë®–∑”°“√©’¥‡¢â“ à°Ÿ √–· ‡≈◊Õ¥®–µâÕß∂°Ÿ ≈–≈“¬¥â«¬πÈ”‡°≈◊Õ Normal saline °àÕπ∑’Ë®–©’¥‡¢â“ àŸ‡ âπ‡≈◊Õ¥‚¥¬µ√ß ¬“∑’Ë∂Ÿ°≈–≈“¬„ππÈ”‡°≈◊Õ„π¢—ÈπµÕππ’È¡—°®–¡’§«“¡ ‡¢Á¡¢âπ‡¢â“‰¥â°—∫∑’Ë√–∫ÿ‰«â„πµ“√“ß ∂Ⓣ¡à‰¥â§«“¡‡¢â¡¢âπ¥—ß°≈à“«„Àâª√—∫ª√‘¡“≥πÈ”‡°≈◊Õ‡æ◊ËÕ„À≥⧫“¡ ‡¢¡â ¢πâ µ“¡µÕâ ß°“√ ®“°ππÈ— °πÁ ”¡“º ¡°∫— Heparin ·≈–À√Õ◊ Normal saline µ“¡µ“√“ß  «à πº ¡∑‰Ë’ ¥â ®–‰¡∑à ”„À‡â °¥‘ °“√µ°µ–°Õπ‡°¥‘ ¢π÷È ·≈–‰¥√â ∫— °“√æ ‘ ®Ÿ π«å “à ¡§’ «“¡§ßµ«— Õ¬¿Ÿà “¬ “¬HDcatheterÕ¬“à ßπÕâ ¬ 72 ™«Ë— ‚¡ß∑ÕË’ ≥ÿ À¿¡Ÿ ‘ 37°C §«“¡‡¢¡â ¢πâ ¢Õ߬“∑Ë’ Lock ¿“¬„𠓬 HD catheter ®–¡“°°«“à √–¥∫— ¬“„π °√–· ‡≈Õ◊ ¥¡“°°«“à 100 ‡∑“à ´ßË÷ ‡™Õ◊Ë «“à ®– “¡“√∂¶“à ‡™ÕÈ◊ ·∫§∑‡’ √¬’ ∑ÕË’ ¬¿Ÿà “¬„π Biofilm ‰¥â  ”À√—∫¬“ Gentamicin æ∫«à“ à«πº ¡¢Õ߬“„π¢π“¥ª°µ‘§◊Õ 40mg/ml ®–µ°µ–°Õπ‡¡◊ËÕ „ √à «¡°∫— Heparin ·µ‰à ¡µà °µ–°Õπ‡¡Õ◊Ë º ¡°∫— Citrate ¥ß— ππ—È ®”‡ªπì µÕâ ß≈¥§«“¡‡¢¡â ¢πâ ¢Õ߬“‡À≈Õ◊ 4mg/ ml ´÷Ëß®–‰¡àµ°µ–°Õπ‡¡◊ËÕº ¡°—∫ Heparin ·≈–¬—ß “¡“√∂¶à“‡™◊ÈÕ‰¥â¿“¬„𠓬 HD catheter ‰¥â¥’ πÕ°®“°πæÈ’ ∫«“à °“√„™¬â “ Gentamycin ∑“߇ πâ ‡≈Õ◊ ¥„πºªŸâ «É ¬‰µ«“¬ ¡Õ’ ∫ÿ µ— °‘ “√≥„å π°“√‡°¥‘ Ototoxicity ®“°¬“ aminoglycoside ®ß÷ ‰¡‡à ªπì ∑πË’ ¬‘ ¡„π°“√π”¡“„™â (7-8) µ“√“ß∑’Ë 1 · ¥ß «à πº ¡·≈–§«“¡‡¢¡â ¢πâ ¢Õ߬“ªØ™‘ «’ π–∑®’Ë –„™â Lock ¿“¬„𠓬 HD catheter ‡æÕ◊Ë √°— …“ Catheter related infection ª√¡‘ “≥¢Õ߬“ªØ™‘ «’ π– (ml) ™π¥‘ ¢Õß Lock solution Vanco Ceftaz Cefaz Genta Heparin NSS Vancomycin 1.0 ---- ---- ---- 1.0 ---- Ceftazidime ---- 1.0 ---- ---- 1.0 ---- Cefazolin ---- ---- 1.0 ---- 1.0 ---- Gentamycin ---- ---- ---- 0.5 1.0 0.5 Vancomycin/Ceftazidime 1.0 0.5 ---- ---- 0.5 ---- Vancomycin/Gentamycin 1.0 ---- ---- 0.5 0.5 ---- Cefazolin/Gentamycin ---- ---- 1.0 0.5 0.5 ---- Initial concentration 5.0mg/ml 10mg/ml 10mg/ml 4mg/ml 5000u/ml Final concentration 2.5mg/ml 2.5-5.0 5.0mg/ml 1mg/ml 1250-2500 mg/ml u/ml

New Frontiers in Dialysis 66 ∏π‘µ ®√‘ π—π∑∏å «—™  ‘√¿‘ “ ™â“ß»‘√‘°≈ÿ ™—¬ ∏ππ— ¥“ µ√–°“√«π‘™ « π— µå  ‡ÿ ¡∏°≈ÿ 3.3 ¢π—È µÕπ°“√¥·Ÿ ≈√°— …“ºªŸâ «É ¬∑¡’Ë ’ CRB ∂“â ºªŸâ «É ¬¡Õ’ “°“√Àπ°— ‡™πà ¡‰’ ¢ â ߟ ¡“° ¡Õ’ “°“√Àπ“« πË— ¡“° ¡§’ «“¡¥π— ‚≈Àµ‘ µ”Ë À√Õ◊ ´¡÷ ≈ß „Àâ∑”°“√√—°…“·∫∫ºâŸªÉ«¬„π ¿“¬„π‚√ß欓∫“≈ ∂⓺⟪ɫ¬¡’Õ“°“√‰¡à¡“° „Àâ√—°…“·∫∫ºŸâªÉ«¬πÕ° æ∫«à“ à«π„À≠à¢Õߺ⟪ɫ¬¡—°®–ª√“°ØÕ“°“√‰¢â„π√–À«à“ß∑”°“√øÕ°‡≈◊Õ¥ ´÷ËßµâÕß·¬°®“°°“√µ‘¥ ‡™ÕÈ◊ Õπ— ‡πÕË◊ ß®“°√–∫∫π”È ´ßË÷ „π°√≥°’ “√µ¥‘ ‡™ÕÈ◊ CRB ¡°— ‡°¥‘ 30-90 π“∑À’ ≈ß— ®“°‡√¡Ë‘ øÕ°‡≈Õ◊ ¥ ·µ°à “√ µ‘¥‡™◊ÈÕ®“°√–∫∫πÈ”¡—°‡°‘¥¿“¬„π 30 π“∑’ À≈—ß®“°‡√‘Ë¡øÕ°‡≈◊Õ¥ ·≈–∫“ߧ√—ÈߺŸâªÉ«¬®–¡’Õ“°“√‰¢â ·≈–Àπ“« —Ëπ¡“° À√◊Õ¡’§«“¡¥—π‚≈À‘µ∑’˵˔ ‡ªìπÕÿª √√§µàÕ°“√øÕ°‡≈◊Õ¥ ·≈–°“√øÕ°‡≈◊Õ¥¡—°®– ∑”„ÀâÕ“°“√‡À≈à“π’ȇæ‘Ë¡¡“°¢÷Èπ ¥—ßπ—Èπ∂Ⓣ¡à¡’§«“¡®”‡ªìπ‡√àߥà«π Õ“®®–À¬ÿ¥·≈–‡≈◊ËÕπ°“√øÕ°‡≈◊Õ¥ ÕÕ°‰ª ‡¡Õ◊Ë „À°â “√√°— …“¥«â ¬¬“ªØ™‘ «’ π–∑“߇ πâ ‡≈Õ◊ ¥·≈–°“√ Lock ¿“¬„𠓬 HD catheter ∂“â ¿“¬„π 48 ™—Ë«‚¡ß À√◊Õ„π√Õ∫°“√øÕ°‡≈◊Õ¥∂—¥‰ª ºâŸªÉ«¬¬—ß¡’‰¢â ¡’Õ“°“√‰¡à¥’¢÷Èπ À√◊Õ¬—ß¡’§«“¡¥—π‚≈À‘µµË” §«√√∫’ 殑 “√≥“∂Õ¥ “¬ HD catheter ∑ß‘È Õ¬“à ߇√ßà ¥«à π¿“¬„π 24 ™«—Ë ‚¡ß‡æÕ◊Ë ‡ªπì °“√°”®¥— ·À≈ßà ‡æ“–‡™Õ◊È ·≈–„π√–À«“à ßπ∂’È “â ®”‡ªπì „Àøâ Õ°‡≈Õ◊ ¥∑“ß “¬ Non-cuff HD catheter ∑∫’Ë √‡‘ «≥Õπ◊Ë °Õà 𠇙πà ∫√‡‘ «≥ Femoral vein ‡¡ÕË◊ ‰¢≈â ¥≈ß„À„â   à “¬ Tunnel-cuff HD catheter ∑µË’ ”·Àπßà ‡¥¡‘ À√Õ◊ µ”·Àπßà „À¡à ‰¡§à «√Ωπó ‡°∫Á √°— …“ HD catheter ‰«‡â πÕË◊ ß®“°¡√’ “¬ß“π«“à ¬ßË‘ ¡’ Bacteremia π“π ¬ßË‘ æ∫‚√§·∑√°´Õâ πµ“à ßÊ ¡“°¢πÈ÷ ·≈–‰¡à §«√„  à “¬ HD catheter ‡ πâ „À¡∑à µË’ ”·Àπßà ‡¥¡‘ „π¢≥–∑¬Ë’ ß— ¡‰’ ¢â °√≥’∂â“Õ“°“√‰¢âÀ“¬‰ª·≈–Õ“°“√∑—Ë«‰ª¥’¢÷Èπ „Àâ°“√√—°…“µàÕ‡π◊ËÕßπ“π 3  —ª¥“Àå „Àâª√—∫ ‡ª≈’Ë¬π¬“µ“¡º≈°“√‡æ“–‡™◊ÈÕ·≈–§«“¡‰«¢Õ߬“ªØ‘™’«π–µàÕ‡™◊ÈÕπ—ÈπÊ °√≥’∂Ⓣ¡àæ∫«à“¡’°“√µ‘¥‡™◊ÈÕ „Àâæ‘®“√≥“À“ “‡ÀµÿÕ◊Ëπ¢Õ߉¢â·≈–Õ“®æ‘®“√≥“À¬ÿ¥°“√„À⬓ªØ‘™’«π– „π√–À«à“ß°“√√—°…“π’ÈÕ“® ®–∑”°“√‡æ“–‡™◊ÈÕ„π°√–· ‡≈◊Õ¥‡æ◊ËÕ ”√«®«à“¡’‡™◊ÈÕ·∫§∑’‡√’¬‡À≈◊ÕÕ¬Ÿà¿“¬„π°√–· ‡≈◊Õ¥À√◊Õ‰¡à ¢—Èπ µÕππÕÈ’ “®®–‰¡®à ”‡ªπì ∂“â ºªŸâ «É ¬‰¡¡à Õ’ “°“√„¥Ê ·µ‡à ¡ÕË◊ „À¬â “§√∫ 3  ª— ¥“Àå §«√∑”°“√‡æ“–‡™ÕÈ◊ ´”È Õ°’ §√—ÈßÕ¬à“ßπâÕ¬∑’Ë√–¬–‡«≈“ 1  —ª¥“ÀåÀ≈—ß®“° ‘Èπ ÿ¥°“√√—°…“ ‡π◊ËÕß®“°¡’‚Õ°“ æ∫«à“‡™◊ÈÕ°”‡√‘∫‚¥¬ Õ“®®–‡ªπì ‡™Õ◊È µ«— ‡¥¡‘ ´ß÷Ë À¡“¬§«“¡«“à °“√√°— …“‰¡‰à ¥ºâ ≈À√Õ◊ ‡™Õ◊È µ«— „À¡´à ß÷Ë ‡ªπì ¿“«–·∑√°´Õâ π‡°¥‘ ¢π÷È (3- 5, 7-8) 3.4 º≈°“√√°— …“ CRB ¥«â ¬ antibiotic lock æ∫«“à §«“¡æ¬“¬“¡√°— …“ HD catheter ‰«¥â «â ¬°“√„À¬â “ªØ™‘ «’ π–∑“߇ πâ ‡≈Õ◊ ¥‡æ¬’ ßÕ¬“à ߇¥¬’ « ®–√°— …“ CRB ·≈–‡°∫Á √°— …“ HD catheter ‰«‰â ¥‡â 欒 ß 22% ∂ß÷ 37% ‡¡ÕË◊ ‡ª√¬’ ∫‡∑¬’ ∫°∫— °“√∂Õ¥ “¬ HD catheter ∑ßÈ‘ ‰¡«à “à ®–‡ªπì «∏‘ °’ “√∂Õ¥∑ß‘È ·≈–√Õ„ „à À¡¿à “¬À≈ß— (Removal and delay replacement) À√Õ◊ °“√∂Õ¥∑ßÈ‘ ·≈–‡ª≈¬Ë’ π„ à HD catheter „À¡ºà “à π∑“ß·π«‡ πâ ‡¥¡‘ ∑π— ∑’ (Exchange over guidewire) ´ßË÷ æ∫«“à ®–√°— …“ CRB ‰¥â 66% ∂ß÷ 83% ·µ∂à “â ‡æ¡Ë‘ °“√√°— …“¥«â ¬«∏‘ ’ antibiotic lock ®–∑”„À â “¡“√∂√°— …“ CRB ·≈–‡°∫Á √°— …“ HD catheter ‰¥â 68% ∂ß÷ 75% ´ßË÷ ‡∑¬’ ∫‡∑“à °∫— «∏‘ ∂’ Õ¥ “¬ HD catheter ∑ßÈ‘ (9-11) æ∫«“à °“√„À¬â “ antibiotic lock ‰¡‡à æ¡‘Ë Õ∫ÿ µ— °‘ “√≥°å “√‡°¥‘ metastatic infection æ∫«“à  «à π„À≠¢à Õß metastatic infection æ∫µßÈ— ·µ‡à √¡Ë‘ °“√√°— …“ ¡√’ “¬ß“πµßÈ— ·µà 3.5% ∂ß÷ 22% ‚¥¬æ∫¡“°®“°‡™ÕÈ◊ Gram

Antimicrobial Locked Catheter °”∏√ ≈≈’ “¡–≈‘ 67 positive ¡“°°«“à Gram negative ‚¥¬‡©æ“–„πºªŸâ «É ¬∑¡Ë’ ‰’ ¢πâ “π¡“°°«“à 48-72 ™«Ë— ‚¡ß ´ßË÷ °≈¡àÿ ¥ß— °≈“à « π∂È’ Õ◊ «“à ¡°’ “√√°— …“∑≈Ë’ ¡â ‡À≈«·≈–µÕâ ß∑”°“√∂Õ¥ “¬ HD catheter ∑ßÈ‘ (7-11) 3.5 ™π¥‘ ¢Õ߇™Õ◊È ·≈–º≈µÕà °“√√°— …“ CRB (7-11) ‡™ÕÈ◊ ∑µË’ √«®æ∫‡ªπì ‡™ÕÈ◊ ™π¥‘ ‡¥¬’ «ª√–¡“≥ 79% ∂ß÷ 89% ·≈–¡‡’ ™ÕÈ◊ ¡“°°«“à 1 ™π¥‘ ª√–¡“≥ 4% ∂ß÷ 21% ·≈–æ∫«“à ‡ªπì ‡™Õ◊È Gram positive 61% ∂ß÷ 95% ‡ªπì ‡™Õ◊È Gram negative 5% ∂ß÷ 39%  ”À√∫— ‡™Õ◊È Gram positive æ∫«“à ‡ªπì ‡™ÕÈ◊ Staphylococus aureus 3% ∂ß÷ 74% ‡ªπì ‡™ÕÈ◊ Staphylococcus epidermidis 7% ∂ß÷ 42% ·≈–‡ªπì ‡™ÕÈ◊ Enterococcus 2% ∂ß÷ 20% ∂“â „À¬â “∑“߇ πâ ‡≈Õ◊ ¥‡æ¬’ ßÕ¬“à ߇¥¬’ « æ∫«“à ∂“â ‡ªπì ‡™ÕÈ◊ Gram negative ®–‰¥ºâ ≈„π°“√√°— …“ 50% ·≈–∂“â ‡ªπì Gram positive ´ß÷Ë ‰¡‰à ¥·â ¬°ª√–‡¿∑¢Õ߇™Õ◊È ®–‰¥ºâ ≈„π°“√√°— …“ 23% °“√„™¬â “ antibiotic lock √«à ¡¥«â ¬∑”„Àºâ ≈°“√√°— …“¥¢’ πÈ÷  ”À√∫— ‡™ÕÈ◊ Gram negative ®–‰¥ºâ ≈„π°“√√°— …“ 87% ∂ß÷ 100% ∂“â ‡ªπì ‡™ÕÈ◊ Staphylococus aures ®–‰¥ºâ ≈‡æ¬’ ß 40% ∂ß÷ 54% ·≈–∂“â ‡ªπì ‡™ÕÈ◊ Staphylococus epidermidis ®–‰¥ºâ ≈ 75% æ∫«“à  “‡Àµ∑ÿ ∑Ë’ ”„À°â “√√°— …“≈¡â ‡À≈«¡’ 2  “‡Àµÿ §Õ◊ ¡‰’ ¢πâ “π°«“à 48-72 ™«—Ë ‚¡ß À√Õ◊ ¡‡’ ™ÕÈ◊ °≈∫— „À¡Õà °’ §√ßÈ— À≈ß— ®“°À¬¥ÿ °“√√°— …“ æ∫«“à ∂“â ‡ªπì ‡™ÕÈ◊ Staphylococus aureus ®–æ∫«“à ¡ ’ ¥—  «à π¢Õß §«“¡≈“â ‡À≈«‡πÕË◊ ß®“°°“√¡‰’ ¢πâ “π¡“°°«“à 48-72 ™—«Ë ‚¡ß ·µ∂à “â ‡ªπì ‡™ÕÈ◊ Staphylococcus epidermidis æ∫«à“ —¥ à«π¢Õߧ«“¡≈⡇À≈«‡°‘¥®“°°“√°”‡√‘∫¢Õ߇™◊ÈÕÀ≈—ß®“°À¬ÿ¥°“√√—°…“ ∑—Èßπ’ȉ¡à¢÷Èπ°—∫§«“¡ ‰«¢Õ߇™ÕÈ◊ µÕà Methicillin  ”À√—∫°“√√—°…“‡™◊ÈÕ Staphylococus aureus πÕ°®“°®–‰¥âº≈‰¡à¥’·≈â« ¬—ßæ∫«à“¡’‚√§ ·∑√°´Õâ π∑‡Ë’ °¥‘ ®“°°“√µ¥‘ ‡™ÕÈ◊ ‡™πà Endocarditis, Osteomyelitis, Epidural abscess, Septic arthritis, Septic shock ´÷Ëßæ∫‰¥â∫àÕ¬„πºâŸªÉ«¬∑’Ë¡’‰¢â ŸßÕ¬Ÿàπ“π‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫°≈ÿà¡∑’ˉ¢âÀ“¬‡√Á« ¥—ßπ—Èπ®÷ߧ«√√—°…“ ‡™ÕÈ◊ π¥È’ «â ¬°“√∂Õ¥ “¬ HD catheter ∑ßÈ‘  ”À√∫— ‡™Õ◊È Õ°’ µ«— §Õ◊ Enterococus ¡√’ “¬ß“π«“à „À°â “√µÕ∫ πÕߥµ’ Õà °“√√°— …“¥«â ¬«∏‘ ’ antibiotic lock ·µ‡à πÕË◊ ß®“°µÕâ ß„À¬â “ Vancomycin §°Ÿà ∫— Gentamycin π“πª√–¡“≥ 3  ª— ¥“Àå ·≈–æ∫«“à ‡¡ÕË◊ „Àâ ¬“§√∫ 3  ª— ¥“Àå ®–µ√«®æ∫‡™ÕÈ◊ Candida „π°√–· ‡≈Õ◊ ¥‰¥∂â ß÷ 42% ´ßË÷ µÕâ ß∂Õ¥ “¬ HD catheter ∑ßÈ‘ ·≈–„À¬â “¶“à ‡™ÕÈ◊ √“π“π 2  ª— ¥“Àå ®ß÷ ‰¡·à π–π”„À°â “√√°— …“¥«â ¬«∏‘ ’ antibiotic lock 4. °“√ªÕÑ ß°π— Catheter related bacteremia ¥«â ¬ Catheter lock solution æ∫«“à  “¬ Tunnel-cuff HD catheter ¡Õ’ ∫ÿ µ— °‘ “√≥¢å Õß°“√‡°¥‘ Catheter related bacteremia (CRB) µßÈ— ·µà 2.5 ∂ß÷ 5.5 §√ßÈ— µÕà 1000 catheter-days ®ß÷ ¡§’ «“¡æ¬“¬“¡À“Àπ∑“ߪÕÑ ß°π— °“√‡°¥‘ CRB ¥«â ¬ «∏‘ °’ “√µ“à ßÊ °≈‰°°“√‡°¥‘ CRB Õ“®‡°¥‘ ®“°‡™ÕÈ◊ ·∫§∑‡’ √¬’ ∑ÕË’ ¬√àŸ Õ∫Ê ·º≈ Exit site ≈°ÿ ≈“¡º“à π‡¢“â  àŸ °√–· ‡≈Õ◊ ¥‚¥¬µ√ß ¥ß— ‡™πà „π°√≥¢’ Õß Non-cuff HD catheter Õ¬“à ߉√°µÁ “¡ Tunnel-cuff HD catheter ¡’ Dacron cuff ´ßË÷ ®–∑”ªØ°‘ √‘ ¬‘ “°∫— ‡πÕÈ◊ ‡¬ÕË◊ ‚¥¬√Õ∫·≈–‡°¥‘ Fibrosis √Õ∫µ«— Cuff ∑”„À‡â ™ÕÈ◊ ·∫§∑‡’ √¬’ ®“°

New Frontiers in Dialysis 68 ∏𵑠®√‘ π—π∑∏å «™—  ‘√‘¿“ ™“â ß»‘√°‘ ≈ÿ ™—¬ ∏π—𥓠µ√–°“√«π‘™ « π— µå  ÿ‡¡∏°ÿ≈ Exit site ‰¡à “¡“√∂≈ÿ°≈“¡‡¢â“‰ª¬—ß°√–· ‡≈◊Õ¥‰¥â‚¥¬µ√ß æ∫«à“ “¬ Tunnel-cuff HD catheter ¡’ Õ∫ÿ µ— °‘ “√≥°å “√‡°¥‘ CRB πÕâ ¬°«“à Non-cuff HD catheter 2 ∂ß÷ 3 ‡∑“à (12-13) Õ¬“à ߉√°µÁ “¡‡™ÕÈ◊ ·∫§∑‡’ √¬’ ¬ß—  “¡“√∂‡¢â“‰ª‰¥â∑“ß√Ÿ¢Õß “¬ HD catheter ‚¥¬µ√ß„π√–À«à“ß°“√‡ªî¥À√◊Õªî¥Ω“À√◊Õ®ÿ°∑’˪≈“¬ “¬ ‚¥¬‡©æ“–∂â“¡’°“√ªπ‡ªóôÕπ¢Õ߇™◊ÈÕ·∫§∑’‡√’¬√Õ∫Ω“À√◊Õ®ÿ°∑’˪≈“¬ “¬ À√◊Õ¡’‡™◊ÈÕ·∫§∑’‡√’¬ – ¡Õ¬Ÿà „π∫√‘‡«≥„°≈⇧’¬ßπ—Èπ®”π«π¡“° °Á®–∑”„À⇙◊ÈÕ·∫§∑’‡√’¬ºà“π‡¢â“ àŸ°√–· ‡≈◊Õ¥‰¥â‡¡◊ËÕ¡’°“√‡ªî¥®ÿ° ÕÕ°‡æÕË◊ µÕà ‡¢“â °∫—  “¬øÕ°‡≈Õ◊ ¥ ‡¡ÕË◊ ‡™ÕÈ◊ ·∫§∑‡’ √¬’ ‡¢“â ‰ª¿“¬„𠓬 HD catheter ®–‰ª √“â ß Biofilm ¿“¬„𠓬 HD catheter ·≈–‡ªπì  “‡Àµ¢ÿ Õß CRB „π‡«≈“µÕà ¡“ 5. °√–∫«π°“√°“√ªÕÑ ß°π— °“√‡°¥‘ Catheter related bacteremia 5.1 °“√≈¥ª√¡‘ “≥¢Õ߇™ÕÈ◊ ·∫§∑‡’ √¬’ ∫√‡‘ «≥ Exit site ·≈– Hub ¢Õß “¬ HD catheter ‰¥·â °°à “√¥·Ÿ ≈‰¡„à À¡â °’ “√µ¥‘ ‡™Õ◊È ∑∫’Ë √‡‘ «≥ Exit site ‡πÕ◊Ë ß®“°∂“â ¡ª’ √¡‘ “≥¢Õ߇™Õ◊È ·∫§∑‡’ √¬’ ¡“° ®–∑”„Àâ¡’‚Õ°“ ‡°‘¥ CRB ‡æ‘Ë¡¡“°¢÷Èπ «‘∏’∑’Ë ”§—≠§◊Õ°“√ Dressing ·º≈ ·≈–°“√ªÑÕß°—π‰¡à„Àâ¡’πÈ” ‡¢â“‰ª„π∫√‘‡«≥·º≈ Exit site πÕ°®“°π’Ȭ—ß¡’°“√≈¥ª√‘¡“≥·∫§∑’‡√’¬∑’Ë∫√‘‡«≥ Exit site ¥â«¬°“√„™â ¬“¶“à ‡™ÕÈ◊ ∑“∫√‡‘ «≥ Exit site ¬“‡À≈“à π‰È’ ¥·â °à Povidine, Mupironcin À√Õ◊ Polysporin ointment æ∫«“à °“√„™â Mupirocin ointment ´ßË÷ ¡ƒ’ ∑∏¶Ï‘ “à ‡™ÕÈ◊ Gram positive ®–≈¥Õ∫ÿ µ— °‘ “√≥°å “√‡°¥‘ CRB ‚¥¬‡©æ“–®“°‡™ÕÈ◊ Staphylococcus ≈߉¥Õâ ¬“à ß¡“° (14)  ”À√∫— Polysporin ´ß÷Ë ª√–°Õ∫¥«â ¬ Bacitracin, Gramicidin ·≈– Polymyxin B ´ßË÷ ¡§’ «“¡ “¡“√∂¶“à ‡™ÕÈ◊ Gram positive ·≈– Gram negative ‰¥â ° Á “¡“√∂≈¥°“√‡°¥‘ CRB ‰¥â (15) ‡πÕ◊Ë ß®“°‡™Õ◊È  «à π„À≠∑à Õ’Ë ¬„Ÿà π∫√‡‘ «≥ππ—È §Õ◊ ‡™Õ◊È Staphylococcus·≈–‡™Õ◊È µ«— π¡’È °—  – ¡Õ¬¿Ÿà “¬„π ‚æ√ß®¡Ÿ° ¥—ßπ—Èπ°“√≈¥ª√‘¡“≥¢Õ߇™◊ÈÕ Staphylococcus ¿“¬„π‚æ√ß®¡Ÿ°®–∑”„Àâ≈¥ª√‘¡“≥¢Õ߇™◊ÈÕ Staphylococcus ∑’Ë∫√‘‡«≥ Exit site ·≈–≈¥°“√‡°‘¥ CRB ®“°‡™◊ÈÕ Staphylococcus ≈߉¥â‡™àπ‡¥’¬«°—π ¥«â ¬°“√„™¬â “ Mupirocin ª“Ñ ¬∑‚’Ë æ√ß®¡°Ÿ ‡¥Õ◊ π≈– 5 «π— À√Õ◊  ª— ¥“À≈å – 1 §√ß—È À√Õ◊ °“√„À°â π‘ ¬“ Rifampicin 5 «π— ´ßË÷  “¡“√∂≈¥ª√¡‘ “≥¢Õ߇™ÕÈ◊ ∑‚Ë’ æ√ß®¡°Ÿ ‰¥∂â ß÷ 3 ‡¥Õ◊ π Õ¬“à ߉√°µÁ “¡¡√’ “¬ß“π°“√¥ÕÈ◊ ¬“ ¢Õ߇™ÕÈ◊ Staphylococus µÕà ¬“ Rifampicin ‡°¥‘ ¢πÈ÷ „π√–À«“à ß°“√„™¬â “¥ß— °≈“à « (16-17) 5.2 °“√≈¥°“√µ¥‘ ‡™Õ◊È º“à π‡¢“â √¢Ÿ Õß “¬ HD catheter (Transluminal route) ¡“µ√°“√„π°“√≈¥‚Õ°“ ∑‡’Ë ™Õ◊È ·∫§∑‡’ √¬’ ®–‡¢“â ‰ª¿“¬„𠓬 HD catheter ‰¥·â °à °“√„À§â «“¡ √–«—߇ªìπ°√≥’摇»…„π¢≥–‡ªî¥®ÿ°À√◊ÕΩ“∑’˪≈“¬ “¬ HD catheter ‡æ◊ËÕµàÕ‡¢â“°—∫ “¬øÕ°‡≈◊Õ¥‡æ◊ËÕ ‡√¡Ë‘ °“√∑”°“√øÕ°‡≈Õ◊ ¥ À√Õ◊ ‡¡ÕË◊  πÈ‘  ¥ÿ °“√øÕ°‡≈Õ◊ ¥·≈–µÕâ ß∂Õ¥ “¬øÕ°‡≈Õ◊ ¥ÕÕ°®“° HD catheter ·≈–ª¥î Ω“§√Õ∫∑ªË’ ≈“¬ “¬ HD catheter „π¢πÈ— µÕπ‡À≈“à π®È’ –µÕâ ß∑”„À‡â √«Á ‰¡§à «√„À â “¬ HD catheter ∂°Ÿ ‡ª¥î ·≈– ¡— º — °∫— Õ“°“»π“π‡°π‘ ‰ª§«√ «¡Mask∑ß—È æ¬“∫“≈·≈–ºªâŸ «É ¬§«√ «¡∂ßÿ ¡Õ◊ ∑ª’Ë √“»®“°‡™Õ◊È ·≈–§«√„Àâ欓∫“≈ºâŸ‡™’ˬ«™“≠∑’˺à“π°“√Õ∫√¡‡ªìπÕ¬à“ߥ’‡∑à“π—Èπ„π°“√∑”À—µ∂°“√‡À≈à“π’È °“√„™âºâ“ °Õ´™∫ÿ Iodine À¡âÿ √Õ∫Ω“À√Õ◊ ®°ÿ §√Õ∫π“π 5 π“∑°’ Õà π‡ª¥î Ω“§√Õ∫

Antimicrobial Locked Catheter °”∏√ ≈≈’ “¡–≈‘ 69 5.3 °“√ªÕÑ ß°π— À√Õ◊ °”®¥— Biofilm ¿“¬„𠓬 HD catheter °“√ªÑÕß°—π¥â«¬«‘∏’¥—ß°≈à“«¢â“ßµâπ„™â‰¥â¥’ ‚¥¬‡©æ“–„π°√≥’∂â“∑”À≈—ß®“°‡√‘Ë¡„ à “¬ HD catheter ‡ πâ „À¡à ‡πÕË◊ ß®“°¬ß— ‰¡¡à ’ Biofilm ¿“¬„𠓬 ¬ß— ‰¡∑à √“∫·π™à ¥— «“à ∂“â ¡’ Biofilm ‡°¥‘ ·≈«â «∏‘ ’ ¥—ß°≈à“«¢â“ßµâπ®–‰¥âº≈‡ªìπÕ¬à“߉√ ·≈–∂Ⓡ≈◊Õ°°”®—¥‡™◊ÈÕ Staphylococcus ®“°«‘∏’∫“ßÕ¬à“ߢâ“ßµâπ Õ“®®–∑”„À‡â æ¡Ë‘ Õ∫ÿ µ— °‘ “√≥¢å Õ߇™ÕÈ◊ ÕπË◊ ‡°¥‘ ¢πÈ÷ «∏‘ µ’ Õà ‰ªπ‡È’ ªπì «∏‘ °’ “√ªÕÑ ß°π— ‰¡„à À‡â °¥‘ Biofilm ¿“¬„𠓬 HD catheter °“√ªÕÑ ß°π— °“√‡°¥‘ Biofilm ´ß÷Ë ¡Õ’ ¬àŸ 2 «∏‘ ’ «∏‘ ·’ √°§Õ◊ °“√„™ â “¬ Catheter ∑ª’Ë ÕÑ ß°π— °“√‡°¥‘ Biofilm æ∫«“à  “¬ HD catheter ∑‡Ë’ §≈Õ◊ ∫¥«â ¬ Silver  “¡“√∂≈¥°“√‡°¥‘ Biofilm ‰¥„â πÀÕâ ß∑¥≈Õß ‡πÕË◊ ß®“°µ«— Silver¡ƒ’ ∑∏¬‘Ï ∫— ¬ß—È °“√∑”ß“π¢Õ߇™Õ◊È ·∫§∑‡’ √¬’ Õ¬“à ߉√°µÁ “¡º≈°“√«®‘ ¬— ‡ª√¬’ ∫‡∑¬’ ∫°“√„™ â “¬HDcatheter ∑¡Ë’ ’ Silver ‡§≈Õ◊ ∫‡ª√¬’ ∫‡∑¬’ ∫°∫—  “¬ª°µ‘ æ∫«“à º≈„π°“√≈¥ CRB ‰¡·à µ°µ“à ß°π— ®“°°≈¡àÿ §«∫§¡ÿ (18) «∏‘ ∑’  Ë’ ÕߧÕ◊ °“√„™¬â “¶“à ‡™ÕÈ◊ ‰¡«à “à ®–‡ªπì ¬“ antibiotic À√Õ◊ antiseptic „ ·à ≈–§“â ߉«¿â “¬„𠓬 HD catheter À≈—ß®“°øÕ°‡≈◊Õ¥·≈â« ‡æ◊ËÕªÑÕß°—πÀ√◊Õ¶à“‡™◊ÈÕ·∫§∑’‡√’¬¿“¬„π Biofilm ´÷Ëß¡’√“¬ß“π«à“  “¡“√∂≈¥Õ∫ÿ µ— °‘ “√≥°å “√‡°¥‘ CRB ®“° 21. ∂ß÷ 5.6 §√ßÈ— µÕà 1000 catheter-days ‡À≈Õ◊ 0 ∂ß÷ 1.56 §√ßÈ— µÕà 1000 catheter-days ¡’√“¬ß“π°“√„™â¬“ Trisodium Citrate, Taurolidine+Citrate, Gentamycin+Citrate, Gentamycin+Heparin, Minocycline+EDTA, Cefazolin+Heparin ·≈– Cefotaxime+Heparin ‡ªπì Catheter lock solution 5.4 °“√„™â Catheter Lock Solution À≈°— °“√ ”§≠— §Õ◊ ¬“∑„’Ë ™â Lock §«√¡ƒ’ ∑∏„‘Ï π°“√¶“à ‡™Õ◊È ·∫§∑‡’ √¬’ ‰¥∑â ß—È Gram positive ·≈– Gram negative ·≈–¬“®–µâÕߺ ¡Õ¬àŸ√«¡¬“∑’Ë„™âªÑÕß°—π°“√‡°‘¥≈‘Ë¡‡≈◊Õ¥¿“¬„𠓬 HD catheter ´÷Ë߬“¥—ß °≈“à «¡°— ‡ªπì Heparin ¥ß— ππ—È ®–µÕâ ߉¡µà °µ–°Õπ‡¡Õ◊Ë √«¡µ«— °∫— Heparin ·≈–‰¡√à ∫°«πª√– ∑‘ ∏¿‘ “æ¢Õ߬“ Heparin „π∑“ß°≈∫— °π— Heparin ®–µÕâ ߉¡∑à ”„Àªâ √– ∑‘ ∏¿‘ “æ¢Õ߬“∑„’Ë ™â lock ≈¥≈߇™πà °π— ¬“∫“ßÕ¬“à ߇™πà Gentamicin „𧫓¡‡¢¡â ¢πâ ∑ Ë’ ߟ ®–µ°µ–°Õπ‡¡ÕË◊ „ √à «¡°∫— Heparin ¥ß— ππÈ— µÕâ ß„™â anticoagulant µ«— ÕπË◊ ‡™πà Trisodium citrate ®ß÷ ‰¡µà °µ–°Õπ ‡πÕË◊ ß®“°µÕâ ß„ ¬à “ Lock Õ¬πàŸ “𠬓∑„Ë’ ™®â –µÕâ ߉¡∑à ”≈“¬ «à π ª√–°Õ∫¢Õß “¬ HD catheter ·≈– ·≈–‰¡§à «√¡ƒ’ ∑∏¢Ï‘ “â ߇§¬’ ߢÕ߬“‡¡ÕË◊ „™„â π√–¬–¬“« ·≈–‰¡∑à ”„Àâ ‡™Õ◊È ·∫§∑‡’ √¬’ ¥Õ◊È ¬“ ‡πÕË◊ ß®“°¬“∑„Ë’ ™â Lock ¿“¬„𠓬 HD catheter ¡°— ®–¡°’ “√√«Ë— ´¡÷ ‡¢“â  °Ÿà √–· ‡≈Õ◊ ¥µßÈ— ·µ„à π √–¬–·√°∑Ë’ Lock ¿“¬„𠓬 ´ßË÷ Õ“®‡°¥‘ ®“°°“√„™ªâ √¡‘ “≥∑¡Ë’ “°°«“à ∑√Ë’ –∫‰ÿ «¿â “¬„𠓬‡æÕË◊ ªÕÑ ß°π— Tip thrombosisÀ√Õ◊ ·¡«â “à ®–„™„â π¢π“¥∑æ’Ë Õ¥°’ ¡Á °— ®–√«—Ë ‡¢“â  °àŸ √–· ‡≈Õ◊ ¥‡πÕ◊Ë ß®“°∑ƒ…Æ°’ “√‰À≈·∫∫Laminar flow·≈–„π√–À«“à ß∑‰’Ë ¡‰à ¥øâ Õ°‡≈Õ◊ ¥¬“°¡Á °’ “√Diffusion‡¢“â  °Ÿà √–· ‡≈Õ◊ ¥‰¥â¬ß‘Ë °«“à ππ—È ∂“â  “¬HDcatheter ¡ª’ ≠í À“‰¡ à “¡“√∂¥¥Ÿ π”È ¬“∑Ë’ Lock ÕÕ°‰¥Àâ ¡¥ ·µ¬à ß—  “¡“√∂¥π— π”È ‡°≈Õ◊ º“à π‰ª‰¥â °®Á –∑”„Àºâ ªŸâ «É ¬ ‰¥â√—∫¬“‡¢â“ Ÿà√à“ß°“¬‚¥¬µ√ß ¥—ßπ—Èπ®–µâÕßæ‘ Ÿ®πå«à“‡¡◊ËÕ¡’ª√‘¡“≥¬“Õ¬Ÿà„π°√–· ‡≈◊Õ¥¢π“¥πâÕ¬Ê ‡ªπì √–¬–‡«≈“π“π À√Õ◊ ‡¡ÕË◊ ª√¡‘ “≥¬“∑Ë’ Lock ‰«∂â °Ÿ ¥π— ‡¢“â  °Ÿà √–· ‡≈Õ◊ ¥‚¥¬µ√ß‚¥¬Õ∫ÿ µ— ‡‘ Àµÿ ®–‰¡¡à ’ ƒ∑∏¢Ï‘ “â ߇§¬’ ß„¥Ê ‡°¥‘ ¢πÈ÷

New Frontiers in Dialysis 70 ∏π‘µ ®√‘ π—π∑å∏«™—  √‘ ‘¿“ ™â“ß»‘√°‘ ÿ≈™¬— ∏ππ— ¥“ µ√–°“√«π‘™ « —πµå  ÿ‡¡∏°≈ÿ 6. ¬“∑’Ë„™‡â ªπì Catheter lock solution ‡æÕ◊Ë ªÕÑ ß°π— °“√‡°¥‘ Catheter related infection (µ“√“ß∑Ë’ 2) 6.1 Trisodium Citrate ¬“ Trisodium citrate (TSC) ‡ªπì ¬“∑¡Ë’ ƒ’ ∑∏‡Ï‘ ªπì anticoagulant ·≈– antimicrobial °≈‰°¢Õß anticoagulant ‡°¥‘ ®“°°“√≈¥ª√¡‘ “≥¢Õß∏“µÿ Calcium ·≈– Magnesium ´ßË÷ ‡ªπì  «à πª√–°Õ∫∑ Ë’ ”§≠— „π°“√‡°‘¥≈‘Ë¡‡≈◊Õ¥ §«“¡ “¡“√∂„π°“√‡ªìπ antimicrobial ¢÷ÈπÕ¬Ÿà°—∫§«“¡‡¢â¡¢âπ¢Õß Citrate æ∫«à“ §«“¡‡¢¡â ¢πâ ¢Õß Citrate ∑πË’ Õâ ¬°«“à 2% ®–‰¡¡à ƒ’ ∑∏„Ï‘ π°“√¶“à ‡™ÕÈ◊ ·∫§∑‡’ √¬’ ·µ∂à “â §«“¡‡¢¡â ¢πâ ¡“°°«“à 30% ®–¡ƒ’ ∑∏„Ï‘ π°“√¶“à ‡™ÕÈ◊ ·∫§∑‡’ √¬’ ∑ßÈ— Gram positive ·≈– Gram negative √«¡∑ßÈ— ‡™ÕÈ◊ √“ ·≈–§«“¡ ‡¢â¡¢âπ„π√–À«à“ß 2% ∂÷ß 30% ®–¡’ƒ∑∏‘Ï¶à“‡™◊ÈÕ∫“ßÕ¬à“߇™àπ Gram positive °≈‰°Õ“®®–‡°‘¥®“° Hyperosmolarity ¢Õ߬“À√◊Õ°“√≈¥ª√‘¡“≥ Calcium À√◊Õ Magnesium ∑”„À⇙◊ÈÕ·∫§∑’‡√’¬‰¡à “¡“√∂ Õ¬√àŸ Õ¥‰¥â ‰¥¡â °’ “√∑¥≈Õß„™â TSC 30% ‡ªπì Locking solution ‡ª√¬’ ∫‡∑¬’ ∫°∫— Unfractionated heparin 5000 unit/ml ·∫∫ Double-blind randomized control trial „πºªâŸ «É ¬ 291 √“¬ ∑¡Ë’  ’ “¬ Non-cuff ·≈– Tunnel- cuff HD catheter ®”π«π 98 ·≈– 193 √“¬µ“¡≈”¥∫— ºªâŸ «É ¬∑°ÿ √“¬‡ªπì ºªâŸ «É ¬„À¡∑à ‡Ë’ æßË‘ ‰¥√â ∫— °“√„  à “¬ HD catheter √–¬–‡«≈“°“√µ¥‘ µ“¡π“π ßŸ  ¥ÿ 400 «π— æ∫«“à  “¡“√∂≈¥°“√‡°¥‘ CRB ®“° 4.1 §√ßÈ— µÕà 1000 catheter-days ‡À≈Õ◊ 1.1 §√ßÈ— µÕà 1000 catheter-days ‚¥¬≈¥‚Õ°“ ‡°¥‘ CRB ≈ß 87%  ”À√∫— Non- cuff HD catheter ·≈– 64%  ”À√—∫ Tunnel-cuff HD catheter ·≈–æ∫«à“¡’Õÿ∫µ‘°“√≥å°“√‡°‘¥¿“«– ‡≈Õ◊ ¥ÕÕ°„πª√¡‘ “≥¡“°≈¥πÕâ ¬≈ß ‰¥·â °°à “√∑”„À§â “à Hb ≈¥≈ß¡“°°«“à 3.6 g/dL À√Õ◊ µÕâ ß„À‡â ≈Õ◊ ¥∑¥·∑π (16 √“¬„π°≈¡ÿà Citrate °∫— 5 √“¬„π°≈¡ÿà Heparin) ‚¥¬‰¡∑à ”„À¡â ª’ ≠í À“µÕà °“√ ßà ‡≈Õ◊ ¥¢Õß “¬ HD catheter ºªŸâ «É ¬ 4 §π∑„’Ë ™â Heparin ·≈–ºªŸâ «É ¬ 9 §π∑„’Ë ™â TSC ¡Õ’ “°“√™“√Õ∫ª“° (Perioral paresthesia) ·≈–√Õ∫π«‘È ¡Õ◊ (Peripheral paresthesia) √«¡∑ßÈ— ¡’ metallic taste À≈ß— ®“°„ ¬à “¿“¬„𠓬∑π— ∑’ ·≈–Õ“°“√À“¬¿“¬„π 1 µ“√“ß∑Ë’ 2 · ¥ß «à πª√–°Õ∫¢Õ߬“™π¥‘ µ“à ßÊ ∑∂Ë’ °Ÿ „™‡â ªπì Catheter lock solution ‡æÕË◊ ªÕÑ ß°π— °“√‡°¥‘ CRB ¬“ ¢Õâ §«√√–«ß— Citrate 30% Cardiac dysfunction Gentamicin 40mg/ml + Citrate 3.13% (Ratio 2:1) Ototoxicity Gentamicin 5mg/ml + Heparin 5000U/ml No Taurolidine 1.35% + Citrate 4% No Minocycline 3mg/ml + EDTA 30mg/ml No Cefotaxime final of 10mg/ml + Heparin 5000U/ml ‡™Õ◊È ¥Õ◊È ¬“ Cefazolin 10mg/ml + Gentamicin 5mg/ml + Heparin 1000U/ml ‡™Õ◊È ¥Õ◊È ¬“

Antimicrobial Locked Catheter °”∏√ ≈’≈“¡–≈‘ 71 π“∑’ ´÷Ëßπà“®–‡ªìπÕ“°“√∑’ˇ°‘¥®“°°“√∑’ˬ“∫“ß à«π°√–®“¬‡¢â“ àŸ°√–· ‡≈◊Õ¥ „πªí®®ÿ∫—πª√–‡∑» §“𓥓·≈–ª√–‡∑»∑“ß·∂∫¬‚ÿ √ª‰¥„â ™â TSC ·∑π Heparin Õ¬“à ߉√°µÁ “¡¡√’ “¬ß“π°“√„™â TSC ¢π“¥ 46.7% Lock „πª√¡‘ “≥∑¡Ë’ “°°«“à ∑√Ë’ –∫‰ÿ «¿â “¬„𠓬 HD catheter ∑”„À¡â ¬’ “‡¢“â  °àŸ √–· ‡≈Õ◊ ¥∑”„À‡â °¥‘ Hypocalcemia Õ¬“à ß√πÿ ·√ß ·≈–°√–µπâÿ „À‡â °¥‘ Ventricular arrhythmias ·≈–ºªŸâ «É ¬‡ ¬’ ™«’ µ‘ „π∑ Ë’ ¥ÿ FDA „πª√–‡∑» “∏“√≥√—∞Õ‡¡√‘°“‰¥â‡µ◊Õπ°“√„™â¬“ Citrate ∑’ˇ¢â¡¢âπ¡“°°«à“ 4% Õ¬à“߉√°Áµ“¡‰¡àæ∫ Õÿ∫—µ‘°“√≥åπ’È„π°“√„™â TSC 30% „πß“π«‘®—¬¢â“ßµâπ ´÷Ëß„™â TSC ·∫∫ Prefilled syringes ·≈–„™â¬“„𠧫“¡‡¢â¡¢âπ∑’ËπâÕ¬°«à“ ¢âÕ¥’Õ’°¢âÕ§◊Õ TSC ‰¡à∑”„À⇙◊ÈÕ‡°‘¥°“√¥◊ÈÕ¬“¡“°¢÷Èπ ·≈–¬“ “¡“√∂∂Ÿ° ‡µ√¬’ ¡‰¥‡â Õß´ßË÷ ¡√’ “§“∂°Ÿ °«“à Heparin (19) 6.2 Taurolidine ¬“ Taurolidine ´ßË÷ æ≤— π“¡“®“° Taurine ´ßË÷ ‡ªπì amino acid µ«— ÀπßË÷ æ∫«“à Taurolidine ¡ƒ’ ∑∏Ï‘ ‡ªπì antimicrobial µÕà ‡™ÕÈ◊ À≈“¬™π¥‘ ‰¥πâ ”¬“ Taurolidine 1.35% º ¡°∫— Citrate 4% ‡ªπì Catheter lock solution ‡ª√¬’ ∫‡∑¬’ ∫°∫— ¬“ Heparin ·∫∫ Open-label randomized control trial „πºªŸâ «É ¬„À¡∑à ‰Ë’ ¥√â ∫— °“√„ à HD catheter ®”π«π 58 √“¬ ‡ªπì Tunnel-cuff HD catheter ®”π«π 18 √“¬ ∑‡Ë’ À≈Õ◊ ‡ªπì Non-cuff HD catheter ¡√’ –¬–‡«≈“µ¥‘ µ“¡π“π 90 «π— æ∫«“à ≈¥°“√‡°¥‘ CRB ®“° 2.1 §√ßÈ— µÕà 1000 catheter-days ‡À≈Õ◊ 0 §√ßÈ— µÕà 1000 catheter-days ‚¥¬‰¡æà ∫‚√§·∑√°´Õâ π„¥Ê ·≈–‰¡æà ∫ª≠í À“„π°“√ ßà ‡≈Õ◊ ¥¢Õß “¬ HD catheter (20) Õ¬“à ߉√°µÁ “¡¡√’ “¬ß“πÕπ◊Ë ∑‰’Ë ¥„â ™â Taurolidine  µŸ √‡¥¬’ «°π— „π Tunnel-cuff HD catheter ®”π«π 20 √“¬ ‡ª√¬’ ∫‡∑¬’ ∫°∫— Heparin ´ßË÷ ‡ªπì Non randomized control ®”π«π 30 √“¬ ‡ªπì ‡«≈“ 90 «π— æ∫ «“à ≈¥ CRB ®“° 5.6 §√ßÈ— µÕà 1000 catheter-days ‡À≈Õ◊ 0.6 §√ßÈ— µÕà 1000 catheter-days Õ¬“à ߉√°µÁ “¡ æ∫«à“¡’°“√ “¬ HD catheter ∑’Ë Lock ¥â«¬ Taurolidine ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫ Heparin  à߇≈◊Õ¥‰¥âπâÕ¬ °«“à ·≈–µÕâ ß„™¬â “ Thrombolytic ¡“°°«“à ∂ß÷ 4 ‡∑“à (21) ¬“ Taurolidine ‰¡∑à ”„À‡â °¥‘ ‡™Õ◊È ¥Õ◊È ¬“„πÀÕâ ß∑¥≈Õß ¬“π¡È’ ¢’ Õâ ‡ ¬’ §Õ◊ À“‰¥¬â “° ·≈–¡√’ “§“·æß 6.3 Gentamicin ¬“ Gentamicin ´ßË÷ ‡ªπì ¬“∑¶Ë’ “à ‡™ÕÈ◊ Gram negative ·µ∂à “â ¡§’ «“¡‡¢¡â ¢πâ  ßŸ  “¡“√∂¶“à ‡™ÕÈ◊ Gram positive ‰¥â ‰¥¡â °’ “√π” Gentamicin ¡“„™‡â ªπì Catheter lock solution ·µ‡à πÕË◊ ß®“°¬“ Gentamicin ®– µ°µ–°Õπ‡¡ÕË◊ „ √à «¡°∫— Heparin ¥ß— ππÈ— µÕâ ß„ √à «¡°∫— Citrate ´ßË÷ ®–∑”Àπ“â ∑‡Ë’ ªπì anticoagulant ·µ∂à “â Gentamicin ¡’§«“¡‡¢â¡¢âπµË” “¡“√∂„ à√«¡°—∫ Heparin ‰¥â ¡’ Ÿµ√¬“∑’Ëπ”¡“„™â 3  Ÿµ√ ‰¥â·°à°“√„™â Gentamicin ¢π“¥ 40mg/ml º ¡°∫— Citrate 3.13% (Gentamicin40mg/ml-Citrate) „π ¥—  «à π 2:1 °“√„™â Gentamicin ¢π“¥ 4mg/ml º ¡°∫— Citrate 3.13% (Gentamicin 4mg/ml-Citrate) ·≈–°“√„™â Gentamicin ¢π“¥ 5mg/ml º ¡°∫— Heparin 5000unit/ml (Gentamicin 5mg/ml-Heparin) µ“¡≈”¥∫—  ”À√∫—  µŸ √¬“Gentamicin40mg/ml-Citrate‰¥¡â °’ “√π”¡“„™‡â ª√¬’ ∫‡∑¬’ ∫°∫— Haparin„πºªŸâ «É ¬∑„’Ë  à Tunnel-cuff HD catheter „À¡®à ”π«π 112 √“¬ ·∫∫ Double-blind randomized control trial µ¥‘ µ“¡π“π 288 «π— æ∫«“à ≈¥Õµ— √“°“√‡°¥‘ CRB ®“° 4.2 §√ßÈ— µÕà 1000 catheter-days ‡À≈Õ◊ 0.03 §√ßÈ— µÕà 1000 catheter-

New Frontiers in Dialysis 72 ∏π‘µ ®√‘ ππ— ∑∏å «—™  ‘√‘¿“ ™“â ß»‘√°‘ ÿ≈™¬— ∏ππ— ¥“ µ√–°“√«π‘™ « —πµå  ÿ‡¡∏°≈ÿ days ‚¥¬‰¡‡à ª≈¬Ë’ π·ª≈ß°“√ ßà ‡≈Õ◊ ¥¢Õß HD catheter Õ¬“à ߉√°µÁ “¡ ¡º’ ªâŸ «É ¬ 10% „π°≈¡àÿ Gentamicin ¡’Õ“°“√§≈⓬ Ototoxicity ®“° Gentamicin ·≈– à«πÀπ÷ËßÕ“°“√À“¬‰ª‡Õß Õ’° à«πÀπ÷ËßÕ“°“√¥’¢÷Èπ ‡¡Õ◊Ë À¬¥ÿ °“√«®‘ ¬— æ∫«“à √–¥∫— ¬“ Gentamicin °Õà π∑” Hemodialysis ∑‡’Ë ®“– ¡ÿà ®“°ºªâŸ «É ¬ 5 √“¬ ¡§’ “à 2.8mg/ L (0.6 ∂ß÷ 3.5 mg/L) ´ßË÷ Õ“®®–‡ ¬Ë’ ßµÕà °“√‡°¥‘ Ototoxicity ¢Õ߬“ Gentamicin ·≈–Õ“®∑”„À¡â ¿’ “«– ‡™ÕÈ◊ ¥ÕÈ◊ ¬“‡°¥‘ ¢πÈ÷ (22) µÕà ¡“‰¥¡â °’ “√π” µŸ √¬“ Gentamicin 5mg/ml-Heparin ¡“‡ª√¬’ ∫‡∑¬’ ∫°∫— Heparin „πºªâŸ «É ¬∑Ë’ „ à Tunnel-cuff HD catheter „À¡®à ”π«π 50 §√ßÈ— ·∫∫ Double-blind randomized control trial µ¥‘ µ“¡π“π 365 «π— æ∫«“à ≈¥Õµ— √“°“√‡°¥‘ CRB ®“° 4 §√ßÈ— µÕà 1000 catheter-days ‡À≈Õ◊ 0.03 §√ßÈ— µÕà 1000 catheter- days ‚¥¬‰¡‡à ª≈¬’Ë π·ª≈ß°“√ ßà ‡≈Õ◊ ¥¢Õß HD catheter ·≈–æ∫«“à ºªâŸ «É ¬∑‰’Ë ¥√â ∫— °“√ ¡ÿà µ√«®§“à Gentamicin °àÕπøÕ°‡≈◊Õ¥¡’√–¥—∫ <0.2mg/L ∑ÿ°√“¬  ”À√—∫ß“π«‘®—¬π’Ȭ—ßæ∫«à“°≈ÿà¡∑’ˉ¥â Gentamicin ‡¡◊ËÕ‡ª√’¬∫ ‡∑¬’ ∫°∫— °≈¡àÿ Heparin ¡√’ –¥∫— Hb  ßŸ °«“à ª√–¡“≥ 0.9g/dL ·≈–„™â EPO πÕâ ¬°«“à ª√–¡“≥ 1000IU µÕà  ª— ¥“Àå ‚¥¬‰¡√à «¡ºªâŸ «É ¬∑‡Ë’ °¥‘ CRB (23)  ”À√∫—  µŸ √¬“ Gentamicin 4mg/ml-Citrate ‰¥∂â °Ÿ π”¡“‡ª√¬’ ∫‡∑¬’ ∫°∫— Minocycline/EDTA (®– ‰¥â°≈à“«µàÕ‰ª) ·≈– Heparin „πºŸâªÉ«¬∑’Ë„ à Tunnel-cuff HD catheter ∑—ÈߺŸâªÉ«¬„À¡à·≈–ºâŸªÉ«¬‡°à“ ´÷Ëß  «à π„À≠‡à ªπì ºªâŸ «É ¬‡°“à ®”π«π 62 √“¬ ·∫∫ Open-label randomized control trial µ¥‘ µ“¡π“π 160 «π— æ∫«“à ¬“ Gentamicin 4mg/ml-Citrate  “¡“√∂≈¥°“√‡°¥‘ CRB ®“° 4 §√ßÈ— µÕà 1000 catheter-days ‡À≈Õ◊ 0 §√ßÈ— µÕà 1000 catheter-days ·≈–¬“ Minocycline/EDTA ≈¥ CRB ‡À≈Õ◊ 0.3 §√ßÈ— µÕà 1000 catheter-days „π√“¬ß“π©∫—∫π’ȉ¡à‰¥â«—¥ª√‘¡“≥¢Õ߬“ Gentamicin ·µàºâŸ∑”«‘®—¬§“¥‡¥“®“°§à“°“√°√–®“¬µ—«¢Õß ¬“„π√“à ß°“¬ºªŸâ «É ¬ æ∫«“à ·¡®â –‰¥¬â “∑’Ë Lock ‡¢“â  √àŸ “à ß°“¬∑ß—È À¡¥ √–¥∫— ¬“∑«’Ë ¥— ‰¥πâ “à ®–¡ª’ √¡‘ “≥‰¡¡à “° º«âŸ ®‘ ¬— „À§â «“¡‡ÀπÁ «“à Gentamicin ‡¡Õ◊Ë √«¡°∫— Citrate ¡§’ «“¡‡ ∂¬’ √¿“æ¡“°°«“à °“√„™â Gentamicin √«¡°∫— Heparin ·≈–‡πÕË◊ ß®“°ß“π«®‘ ¬— π∑È’ ”„πºªŸâ «É ¬∑ßÈ— ∑„Ë’  à HD catheter „À¡·à ≈–‡°“à ∑”„À â √ªÿ ‰¥«â “à Catheter lock solution ‰¥ªâ √–‚¬™π·å ¡«â “à ®–‡ªπì ºªŸâ «É ¬∑‰Ë’ ¥√â ∫— °“√„ à HD catheter ¡“√–¬–ÀπßË÷ ·≈«â (24) 6.4 Minocycline  ”À√∫— ¬“ Minocycline ¢π“¥ 3mg/ml ´ßË÷ ‡ªπì Derivative ¢Õ߬“ Tetracycline ‰¥∂â °Ÿ π”¡“º ¡ °∫— EDTA ¢π“¥ 30mg/dL ‡¡ÕË◊ º ¡°π— ·≈«â ®–¡ ’ ‡’ À≈Õ◊ ß ·≈– π’ ®È’ –®“ß≈߇√ÕË◊ ¬Ê ¿“¬„π 24 ™«Ë— ‚¡ß∑Ë’ Õÿ≥À¿¡Ÿ ‘ÀâÕß ¬“ EDTA ∑’Ë„™â‡ªìπ anticoagulant ¡’ƒ∑∏‘Ï¶à“‡™◊ÈÕ·∫§∑’‡√’¬§≈⓬ Citrate ·µà¡’ƒ∑∏‘ϵàÕ‡™◊ÈÕ Staphylococcus ·≈–‡™ÕÈ◊ √“πÕâ ¬°«“à ‰¥¡â °’ “√π”¡“„™‡â ª√¬’ ∫‡∑¬’ ∫°∫— Heparin „πºªâŸ «É ¬∑‰Ë’ ¥√â ∫— °“√„  à “¬ HD catheter ∑ßÈ— ™π¥‘ Tunnel-cuff ·≈– Non-cuff (17.5%:82.5%) ¿“¬„π 72 ™«Ë— ‚¡ß ®”π«π 57 √“¬ ·∫∫ Double-blind randomized control trial µ¥‘ µ“¡Õ¬“à ßπÕâ ¬ 90 «π— ·≈– ßŸ  ¥ÿ 360 «π— æ∫«“à ≈¥°“√‡°¥‘ CRB ®“° 2.2 §√ßÈ— µÕà 1000 catheter-days ‡À≈Õ◊ 0 §√ßÈ— µÕà 1000 catheter-days Õ¬“à ߉√°µÁ “¡æ∫«“à ¡®’ ”π«π “¬ HD catheter ‡À≈Õ◊ „Àµâ ¥‘ µ“¡∑‡Ë’ «≈“ 90 «π— §Õà π¢“â ßπÕâ ¬ ‡À≈Õ◊ 10 √“¬®“°°≈¡àÿ Minocycline ·≈– 6 √“¬®“°°≈¡àÿ Heparin ‡πÕË◊ ß®“°¡°’ “√∂Õ¥ “¬ÕÕ°‡ªπì ®”π«π¡“° (25) Õ¬“à ߉√°µÁ “¡‰¥¡â √’ “¬ß“π¬π◊ ¬π— ª√– ∑‘ ∏¿‘ “æÕ°’ √“¬ß“π®“°°“√„™â Minocycline/EDTA, Gentamicin/Citrate ·≈– Heparin „πÀ«— ¢Õâ Gentamicin

Antimicrobial Locked Catheter °”∏√ ≈’≈“¡–≈‘ 73 ¢“â ßµπâ æ∫«“à °≈¡àÿ Minocycline/EDTA ≈¥ CRB ®“° 4 §√ßÈ— µÕà 1000 catheter-days ‡À≈Õ◊ 0.4 §√ßÈ— µÕà 1000 catheter-days (24) 6.5 Cefotaxime ·≈– Cefazolin  ”À√∫— ¬“ Cefotaxime º ¡°∫— Heparin 5000 unit/ml „À‰â ¥§â «“¡‡¢¡â ¢πâ 10mg/ml ‡ªπì Catheter lock solution ·≈–π”¡“„™â‡ª√’¬∫‡∑’¬∫°—∫ Heparin „πºâŸªÉ«¬‡∫“À«“π∑’Ë„ à Tunnel-cuff HD catheter „À¡®à ”π«π 109 √“¬ ·∫∫ Double-blind randomized control trial µ¥‘ µ“¡π“π ßŸ  ¥ÿ 547 «π— æ∫«“à ≈¥ Õµ— √“°“√‡°¥‘ CRB ®“° 3.68 §√ßÈ— µÕà 1000 catheter-days ‡À≈Õ◊ 1.56 §√ßÈ— µÕà 1000 catheter-days ·≈– æ∫«“à ≈¥Õ∫ÿ µ— °‘ “√≥°å “√µ¥‘ ‡™ÕÈ◊ ®“° Gram negative ¡“°°«“à Gram positive ·≈–‡™ÕÈ◊ Gram negative ∑Ë’ ‡ªπì  “‡Àµ¢ÿ Õß CRB ∑µË’ √«®æ∫‰¡¥à ÕÈ◊ µÕà ¬“ Cefotaxime „π™«à ß√–¬–‡«≈“ 1 ªï ¢Õßß“π«®‘ ¬— (26) Õ°’ ß“π«®‘ ¬— „™¬â “ Cefazolin 10mg/ml º ¡°∫— Gentamicin 5mg/ml º ¡°∫— Heparin 1000U/ml ‡ª√¬’ ∫‡∑¬’ ∫°∫— Heparin „πºªŸâ «É ¬ 120 √“¬∑„Ë’  à Non-cuff HD catheter „À¡‡à æÕË◊ √Õ maturation ¢Õß vascular access ·∫∫ Double-blind randomized control trial µ¥‘ µ“¡π“π ßŸ  ¥ÿ 60 «π— æ∫«“à ≈¥ CRB ®“° 3.12 §√ßÈ— µÕà 1000 catheter-days ‡À≈Õ◊ 0.44 §√ßÈ— µÕà 1000 catheter-days (27) º‡Ÿâ ¢¬’ π¡§’ «“¡‡ÀπÁ «“à ‰¡§à «√„™â antibiotic ‡™πà Cefazolin À√Õ◊ Cefotaxime À√Õ◊ µ«— ÕπË◊ Ê ∑¬Ë’ ß— ‡ªπì ∑’Ëπ‘¬¡„™â„π°“√√—°…“ ¿“«°“√≥嵑¥‡™◊ÈÕ¡“„™â‡ªìπ catheter lock solution ‡π◊ËÕß®“°¡’‚Õ°“ ∑’Ë®–∑”„Àâ ‡™◊ÈÕ¥◊ÈÕ¬“‰¥â„πÕ𓧵 ¬°‡«â𬓠Gentamicin À√◊Õ Minocycline ´÷Ë߉¡à‰¥â‡ªìπ¬“À≈—°„π°“√√—°…“„π ª®í ®∫ÿ π— ·≈«â  ”À√∫— ¬“∑‰Ë’ ¡‰à ¥‡â ªπì antibiotic ‰¥·â °à Citrate ·≈– Taurolidine ‰¡∑à ”„À‡â °¥‘ ¿“«–‡™ÕÈ◊ ¥ÕÈ◊ ¬“ ®ß÷  “¡“√∂π”¡“„™‰â ¥¥â ’ ·µµà Õâ ß√–«ß— ‚√§·∑√°´Õâ π∑ÕË’ “®®–‡°¥‘ ®“° Citrate √«Ë— ‡¢“â  °Ÿà √–· ‡≈Õ◊ ¥ ·≈–¬“ Taurolidine ∑¡Ë’ √’ “§“·æß ‡Õ° “√Õ“â ßÕß‘ 1. Howell PB, Walters PE, Donowitz GR, Farr BM. Risk factors for infection of adult patients with cancer who have tunneled central venous catheters. Cancer 1995; 75:1367-1375. 2. Schwab SJ, Quarles LD, Middleton JP, Cohan RH, Saeed M, Dennis VW. Hemodialysis associated subclavian vein stenosis. Kidney Int 1988; 33: 1156-1159. 3. Beathard GA. Management of bacteremia associated with tunneled-cuffed hemodialysis catheters. J Am Soc Neph 1999; 10:1045-1049. 4. Robinson D, Suhocki P, Schwab SJ. Treatment of infected tunneled venous access hemodialysis catheters with guidewire exchange. Kidney Int 1998; 53: 1792-1794. 5. Beathard GA. Catheter management protocol for catheter-related bacteraemia prophylaxis. Semin Dial 2003; 16:403-405. 6. Costerton JW, Stewart PS, Greenberg EP. Bacterial biofilms (A common cause of persistent infections). Science. 1999;284:1318-1322. 7. Krishnasami Z, Carlton D, Bimbo L, et al. Management of hemodialysis catheter-related bacteraemia with

New Frontiers in Dialysis 74 ∏π‘µ ®‘√ππ— ∑∏å «™—  ‘√¿‘ “ ™“â ß»‘√‘°ÿ≈™¬— ∏π—𥓠µ√–°“√«π™‘ « π— µå  ‡ÿ ¡∏°ÿ≈ an adjunctive antibiotic lock solution. Kidney Int 2002; 61:1136-1142. 8. Poole CV, Carlton D, Bimbo L, et al. Treatment of catheter-related bacteraemia with an antibiotic lock protocol: effect of bacterial pathogen. Nephrol Dial Transplant 2004; 19:1237-1244. 9. Marr KA, Sexton DJ, Conlon PJ, et al. Catheter-related bacteriemia and outcome of attempted catheter salvage in patients undergoing hemodialysis. Ann Intern Med 1997; 127:275-280. 10. Saad TF. Bacteraemia associated with tunnelled, cuffed hemodialysis catheters. Am J Kidney Dis 1999; 34:1114-1124. 11. Tanriover B, Carlton D, Saddekni S, et al. Bacteremia associated with tunneled dialysis catheters (Comparison of two treatment strategies). Kidney Int. 2000; 57:2151-2155. 12. Stevenson KB, Hannah EL, Lowder CA, et al. Epidemiology of hemodialysis vascular access infections from longitudinal infection surveillance data (Predicting the impact of NKF-DOQI clinical practice guidelines for vascular access). Am J Kidney Dis. 2002;39:549-555. 13. Weijmer MC, Vervloet MG, ter Wee PM. Compared to tunnelled cuffed haemodialysis catheters, temporary untunnelled catheters are associated with more complications already within 2 weeks of use. Nephrol Dial Transplant. 2004;19:670-677. 14. Johnson DW, MacGinley R, Kay TD, et al. A randomized controlled trial of topical exit site mupirocin application in patients with tunnelled, cuffed hemodialysis catheters. Nephrol Dial Transplant 2002; 17:1802- 1807. 15. Lok CE, Stanley KE, Hux JE, Richardson R, Tobe SW, Conly J. Hemodialysis infection prevention with polysporin ointment. J Am Soc Nephrol. 2003; 13:169-179. 16. Yu VL, Goetz A, Wagener M, et al. Staphylococcus aureus nasal carriage and infection in patients on hemodialysis (Efficacy of antibiotic prophylaxis). N Engl J Med. 1986; 315:91-96. 17. Boelaert JR, Van Landuyt HW, Godard CA, et al. Nasal mupirocin ointment decreases the incidence of Staphylococcus aureus bacteraemias in haemodialysis patients. Nephrol Dial Transplant. 1993; 8:235-239. 18. Trerotola SO, Johnson MS, Shah H, et al. Tunneled hemodialysis catheters (Use of a silver-coated catheter for prevention of infection. A randomized study). Radiology. 1998; 207:491-496. 19. Weijmer MC, Van Den Dorpel MA, Van de Ven PJ, et al. Randomized, clinical trial comparison of trisodium citrate 30% and heparin as catheter-locking solution in hemodialysis patients. J Am Soc Nephrol 2005; 16:2769-2777. 20. Betjes MG, van Agteren M. Prevention of dialysis catheter-related sepsis with a citrate-taurolidine-containing lock solution. Nephrol Dial Transplant 2004; 19:1546-1551. 21. Allon M. Prophylaxis against dialysis catheter-related bacteremia with a novel antimicrobial lock solution. Clin Infect Dis. 2003; 36:1539-1544. 22. Dogra GK, Herson H, Hutchison B, et al. Prevention of tunnelled hemodialysis catheter-related infections using catheter-restricted filling with gentamicin and citrate: a randomized controlled study. J Am Soc

Antimicrobial Locked Catheter °”∏√ ≈≈’ “¡–≈‘ 75 Nephrol 2002; 13:2133-2139. 23. McIntyre CW, Hulme LJ, Taal M, et al. Locking of tunnelled hemodialysis catheters with gentamicin and heparin. Kidney Int 2004; 66:801-805. 24. Nori US, Manoharan A, Yee J, et al. Comparison of a low-dose gentamicin with minocycline as catheter lock solutions in the prevention of catheter-related bacteraemia. Am J Kidney Dis 2006; 48:596-605. 25. Bleyer AJ, Mason L, Russell G, et al. A randomized, controlled trial of a new vascular catheter flush solution (minocycline-EDTA) in temporary hemodialysis access. Infect Control Hosp Epidemiol 2005; 26:520-524. 26. Saxena AK, Panhotra BR, Sundaram DS, et al. Tunneled cathetersû outcome optimization among diabetics on dialysis through antibiotic-lock placement. Kidney Int 2006; 70:1629-1635. 27. Kim SH, Song KI, Chang JW, et al. Prevention of uncuffed hemodialysis catheter-related bacteraemia using an antibiotic lock technique: a prospective, randomized clinical trial. Kidney Int 2006; 69:161-164.



5 Optimum and Adequacy of Hemodialysis ∏𵑠®√‘ ππ— ∑∏å «™— 1. ∫∑π” 2. §«“¡À¡“¬¢Õߧ«“¡‡æ¬’ ßæÕ¢Õß°“√øÕ°‡≈Õ◊ ¥ 3. µ«— «¥— §«“¡‡æ¬’ ßæÕ¢Õß°“√øÕ°‡≈Õ◊ ¥ 4. «∏‘ ª’ √–‡¡π‘ urea-based hemodialysis adequacy 5. «∏‘ °’ “√ª√–‡¡π‘ §“à Kt/V 6. Urea rebound 7. Rate equation 8. ¢Õâ ·π–𔇰¬Ë’ «°∫— «∏‘ °’ “√«¥— §«“¡‡æ¬’ ßæÕ¢Õß°“√øÕ°‡≈Õ◊ ¥ 9. ¢Õâ ·π–𔇰¬’Ë «°∫— ª√¡‘ “≥°“√øÕ°‡≈Õ◊ ¥ 10.  √ªÿ

New Frontiers in Dialysis 78 ∏π‘µ ®√‘ π—π∑∏å «—™  √‘ ¿‘ “ ™â“ß»‘√°‘ ÿ≈™¬— ∏ππ— ¥“ µ√–°“√«π‘™ « —πµå  ‡ÿ ¡∏°≈ÿ 1. ∫∑π” ‚√§‰µ«“¬‡√Õ◊È √ß— ¢π—È  ¥ÿ ∑“â ¬ (End stage kidney disease) ‡ªπì ª≠í À“ ¢ÿ ¿“æ∑ ’Ë ”§≠— ¢Õߪ√–‡∑» ‰∑¬ ·¡â«à“°“√ªÑÕß°—π·≈–√—°…“‚√§‰µ®–°â“«ÀπⓉª¡“° ·µàºâŸªÉ«¬‚√§‰µ«“¬‡√◊ÈÕ√—߬—ߧߡ’®”π«π‡æ‘Ë¡ ¡“°¢÷Èπ‡√◊ËÕ¬Ê °“√√—°…“ºŸâªÉ«¬‚√§‰µ«“¬‡√◊ÈÕ√—߇¡◊ËÕ¡“∂÷ß√–¬– ÿ¥∑⓬®”‡ªìπµâÕß√—°…“∑¥·∑πÀπâ“∑’Ë ‰µ∑’ˇ ’¬‰ª (Renal replacement therapy) ¢âÕ¡Ÿ≈®π∂÷ߪ≈“¬ªï æ.».2549 æ∫«à“¡’ºâŸªÉ«¬µâÕ߉¥â√—∫°“√ øÕ°‡≈◊Õ¥®”π«π 15,069 √“¬ µâÕ߉¥â√—∫°“√≈â“߉µ∑“ß™àÕß∑âÕß 691 √“¬ ·≈–¡’ºâŸªÉ«¬∑’ˉ¥â√—∫°“√ º“à µ¥— ª≈°Ÿ ∂“à ¬‰µ·≈«â 1,287√“¬Õ°’ ∑ß—È ¬ß— ¡º’ ªâŸ «É ¬√“¬„À¡‡à ¢“â ¡“ √àŸ –∫∫°“√√°— …“∑¥·∑π‰µ„πªïæ.».2549 ‡ªπì Õµ— √“ 258, 12 ·≈– 21 √“¬µÕà ª√–™“°√Àπß÷Ë ≈“â π§πµ“¡≈”¥∫— 1 ®–‡ÀπÁ ‰¥«â “à „πª√–‡∑»‰∑¬π¬‘ ¡‡≈Õ◊ ° √°— …“¥«â ¬«∏‘ °’ “√øÕ°‡≈Õ◊ ¥ (Hemodialysis, HD) ¡“°°«“à «∏‘ °’ “√≈“â ߉µº“à π™Õà ß∑Õâ ß (Peritoneal dialysis) 21 ‡∑“à ‡æ¡Ë‘ ¢π÷È ¡“°‡¡ÕË◊ ‡∑¬’ ∫°∫— ¢Õâ ¡≈Ÿ ªï æ.».2536 ´ßË÷ ¡ ’ ¥—  «à π‡æ¬’ ß 1.5 ‡∑“à 2 ¥ß— ππ—È §«“¡√‡âŸ °¬’Ë «°∫— °“√øÕ°‡≈Õ◊ ¥®ß÷ ¡§’ «“¡ ”§≠— Õ¬“à ß¬ß‘Ë  ”À√∫— ∫§ÿ ≈“°√∑∑’Ë ”ß“π„À∫â √°‘ “√ ºŸâªÉ«¬∑’ËÀâÕ߉µ‡∑’¬¡ ‡æ◊ËÕ∑’Ë®–¥Ÿ·≈ºâŸªÉ«¬„Àâ¡’§ÿ≥¿“æ™’«‘µ∑’Ë¥’·≈– “¡“√∂¡’Õ“¬ÿ¬◊𬓫„°≈⇧’¬ßª°µ‘ ¡“°∑’Ë ÿ¥ ®”‡ªìπµâÕß¡’°“√µ√«®ª√–‡¡‘πº≈°“√√—°…“‡æ◊ËÕ„Àâ·πà„®«à“°“√øÕ°‡≈◊Õ¥∑’Ë∑”„À⺟âªÉ«¬π—Èπ ‡À¡“– ¡·≈–‡æ¬’ ßæÕ (Optimum and adequacy of hemodialysis) „π∫∑π®È’ –°≈“à «∂ß÷ ∑¡Ë’ “ §«“¡ ”§≠— ·≈–«∏‘ °’ “√ª√–‡¡π‘ §«“¡‡æ¬’ ßæÕ¢Õß°“√øÕ°‡≈Õ◊ ¥ ·≈–¢Õâ ·π–π”„π°“√𔉪ªØ∫‘ µ— ·‘ °ºà ªâŸ «É ¬ 2. §«“¡À¡“¬¢Õߧ«“¡‡æ¬’ ßæÕ¢Õß°“√øÕ°‡≈Õ◊ ¥ (Adequacy of hemodialysis) 3 °“√√°— …“¥«â ¬«∏‘ °’ “√øÕ°‡≈Õ◊ ¥‡À¡Õ◊ π°∫— °“√„À¬â “ºªŸâ «É ¬ À≈ß— °“√øÕ°‡≈Õ◊ ¥ºªŸâ «É ¬ «à π„À≠à ®–¡Õ’ “°“√¥¢’ π÷È Õ¬“à ß™¥— ‡®π·µºà ªâŸ «É ¬∫“ß√“¬¬ß— ¡Õ’ “°“√µ“à ßÊÕ¬Ÿà´ß÷Ë À“°‰¡¡à °’ “√ª√–‡¡π‘ ¢π“¥°“√øÕ° ‡≈◊Õ¥ (dialysis dose) «à“‡æ’¬ßæÕ ”À√—∫ºŸâªÉ«¬√“¬π—ÈπÀ√◊Õ‰¡à ®–‰¡à∑√“∫·πà™—¥«à“Õ“°“√µà“ßÊ ¢Õߺ⟠ªÉ«¬‡°‘¥®“°°“√øÕ°‡≈◊Õ¥∑’ˉ¡à‡æ’¬ßæÕÀ√◊Õ‡°‘¥®“° “‡ÀµÿÕ◊ËπÊ ‡™àπ‡¥’¬«°—∫°“√ª√–‡¡‘π¢π“¥¬“  ”§—≠∑’Ë„Àâ·°àºâŸªÉ«¬ ‚¥¬‡©æ“–Õ¬à“߬‘Ëß„πªí®®ÿ∫—π∑’˺⟪ɫ¬‰¥â√—∫°“√øÕ°‡≈◊Õ¥Õ¬à“ß ¡Ë”‡ ¡Õ À“° Õ“»—¬‡æ’¬ß°“√ª√–‡¡‘π®“°Õ“°“√·≈–Õ“°“√· ¥ß ®–‡ªìπ°“√¬“°∑’Ë®–ª√–‡¡‘π«à“¢π“¥¢Õß°“√øÕ° ‡≈◊Õ¥π—Èπ‡À¡“– ¡·≈–‡æ’¬ßæÕ ”À√—∫ºŸâªÉ«¬·µà≈–√“¬À√◊Õ‰¡à ®÷ß®”‡ªìπµâÕß¡’«‘∏’°“√ª√–‡¡‘π∑’Ë  “¡“√∂𔉪ªØ∫‘ µ— „‘ π°“√¥·Ÿ ≈ºªŸâ «É ¬øÕ°‡≈Õ◊ ¥∑∑’Ë ”‰¥‰â ¡¬à “°·≈–∑”‰¥„â π‡«™ªØ∫‘ µ— ∑‘ «—Ë ‰ª ¥ß— ππ—È §«“¡‡æ¬’ ßæÕ¢Õß°“√øÕ°‡≈Õ◊ ¥®ß÷ ∂°Ÿ π”¡“„™‡â æÕ◊Ë ‡ªπì ·π«∑“ß„π°“√ ß—Ë °“√√°— …“¥«â ¬«∏‘ ’ °“√øÕ°‡≈Õ◊ ¥‰¡„à À¡â “°À√Õ◊ πÕâ ¬‡°π‘ ‰ª‚¥¬¡‰‘ ¥¡â «’ µ— ∂ªÿ √– ß§‡å 欒 ß·§„à Àºâ ªâŸ «É ¬ª√“»®“°uremicsymptom ‡∑“à ππÈ— ·µ§à «√¡«’ µ— ∂ªÿ √– ß§§å √Õ∫§≈¡ÿ ¥ß— πÈ’ 1. ¡Õ’ µ— √“°“√‡®∫Á ª«É ¬·≈–Õµ— √“°“√µ“¬„°≈‡â §¬’ ߪ°µ¡‘ “°∑ ’Ë ¥ÿ ·≈–¡§’ ≥ÿ ¿“晫’ µ‘ ∑¥’Ë ’´ß÷Ë ‡ªπì ‡ª“Ñ À¡“¬ ßŸ  ¥ÿ 2. ª√“»®“° uremic symptom „π∑°ÿ √–∫∫ 3. º≈∑“ßÀÕâ ߪØ∫‘ µ— °‘ “√µ“à ßÊ ‡™πà BUN, Cr, Ca, PO4, uric acid, albumin, electrolyte Õ¬„Ÿà π

Optimum and Adequacy of Hemodialysis ∏𵑠®√‘ π—π∑å∏«™— 79 ‡°≥±‡å À¡“– ¡ 4. ‰¡‡à °¥‘ ¿“«–∑æÿ ‚¿™π“°“√®“°°“√¢“¥æ≈ß— ß“π·≈–‚ª√µπ’ 5.  “¡“√∂§«∫§¡ÿ πÈ”Àπ°— „À§â ß∑„’Ë °≈‡â §¬’ ßπÈ”Àπ°— ª°µ‘‰¡‡à °¥‘ ¿“«–∫«¡‰¡¡à °’ “√‡æ¡‘Ë ¢ÕßπÈ” Àπ°— √–À«“à ß°“√∑” HD ·µ≈à –§√ßÈ— ¡“°‡°π‘ ‰ª 6. ª√“»®“°º≈·∑√°´Õâ π¢Õß¿“«–‰µ«“¬‡√ÕÈ◊ √ß— ‡™πà Õ“°“√®“°¿“«–´¥’ §«“¡º¥‘ ª°µ¢‘ Õß °√–¥Ÿ° (renal osteodystrophy) ·≈– “¡“√∂§«∫§ÿ¡¿“«– secondary hyperparathyroidism „ÀâÕ¬Ÿà„π ‡°≥±‡å À¡“– ¡ °“√ ß—Ë °“√√°— …“¥«â ¬«∏‘ °’ “√øÕ°‡≈Õ◊ ¥§«√®–¡“°À√Õ◊ πÕâ ¬Õ¬“à ߉√¢π÷È Õ¬°Ÿà ∫— ª®í ®¬— ∑“ߥ“â 𵫗 ºŸâ ª«É ¬«“à ¡¢’ Õ߇ ¬’ §ßË— §“â ß¡“À√Õ◊ πÕâ ¬‡æ¬’ ߉√ ´ßË÷ ‡ªπì º≈®“°¢π“¥√“à ß°“¬¢ÕߺªâŸ «É ¬ ¿“«–‡¡µ“∫Õ≈ ‘ ´¡÷ °“√√—∫ª√–∑“πÕ“À“√ °“√∑”ß“π¢Õ߉µ∑’ˇÀ≈◊Õ ·≈–°“√ Ÿ≠‡ ’¬ÕÕ°®“°√à“ß°“¬ ‡¡◊ËÕ¡’°“√ª√–‡¡‘𠧫“¡‡æ’¬ßæÕ¢Õß°“√øÕ°‡≈◊Õ¥·≈â«®–𔉪 àŸ°“√ª√—∫‡ª≈’ˬπ°“√ —Ëß°“√øÕ°‡≈◊Õ¥„Àâ‡À¡“– ¡°—∫ºŸâ ª«É ¬µÕà ‰ª ¥ß— √ªŸ ∑Ë’ 1 3. µ«— «¥— §«“¡‡æ¬’ ßæÕ¢Õß°“√øÕ°‡≈Õ◊ ¥ (Marker of adequacy of hemodialysis) µ«— «¥— §«“¡‡æ¬’ ßæÕ¢Õß°“√øÕ°‡≈Õ◊ ¥¡‰’ ¥Àâ ≈“¬ª√–‡¿∑ ‰¥·â °à 3.1 Õµ— √“°“√‡®∫Á ª«É ¬·≈–Õµ— √“°“√µ“¬π“à ®–‡ªπì  ß‘Ë ∑‡’Ë ™Õ◊Ë ∂Õ◊ ‰¥¥â ∑’  ’Ë ¥ÿ ·µ∑à ”‰¥¬â “°‡πÕ◊Ë ß®“° ¡’§«“¡·µ°µà“ß„π°“√°”À𥫑∏’√—°…“¥â«¬°“√øÕ°‡≈◊Õ¥„π·µà≈– ∂“π∑’Ë ‡™àπ √–¥—∫¢Õß creatinine √ªŸ ∑Ë’ 1 ªí®®—¬∑“ߥâ“πµ—«ºâŸªÉ«¬·≈–«‘∏’°“√ —Ëß°“√√—°…“¥â«¬«‘∏’°“√øÕ°‡≈◊Õ¥ ´÷Ëß¡’º≈µàÕ§«“¡‡æ’¬ßæÕ¢Õß °“√øÕ°‡≈Õ◊ ¥

New Frontiers in Dialysis 80 ∏𵑠®‘√π—π∑å∏«™—  √‘ ‘¿“ ™“â ß»‘√°‘ ≈ÿ ™¬— ∏π—𥓠µ√–°“√«π™‘ « —πµå  ÿ‡¡∏°≈ÿ clearance ∑’ˇ√‘Ë¡∑” dialysis ®”π«π§√—ÈßµàÕ —ª¥“Àå √–¬–‡«≈“„π°“√∑”øÕ°‡≈◊Õ¥ √«¡∑—Èßªí®®—¬¥â“πºŸâ ª«É ¬´ßË÷ ¡§’ «“¡·µ°µ“à ß°π— ¡“° Õ¬“à ߉√°µÁ “¡«∏‘ π’  È’ “¡“√∂π”¡“„™Õâ “â ßÕß‘  ”À√∫— «∏‘ Õ’ πË◊ ∑πË’ ”¡“»°÷ …“ 3.2 Õ“°“√∑“ߧ≈π‘ °‘ 4,5 ∑‡’Ë °¥‘ ®“°°“√§ß—Ë ¢ÕߢÕ߇ ¬’ „π√“à ß°“¬‡™πà Õ“°“√ uremia µ“à ßÊ À√Õ◊ „™°â “√µ√«®«¥— º≈°“√∑”ß“π¢ÕßÕ«¬— «–∑º’Ë ¥‘ ª°µ‰‘ ª®“°¿“«–uremia‡™πà °“√«¥— §≈π◊Ë ‰øø“Ñ ¢Õß°≈“â ¡‡πÕ◊È (electromyography, EMG) °“√«¥— §≈πË◊  ¡Õ߉øø“Ñ (electroencephalography, EEG) °“√«¥— °“√π”‰øø“Ñ ¢Õ߇ âπª√– “∑ à«πª≈“¬ (nerve conduction velocity, NCV) °“√µ√«®¥â«¬ neuropsychologic test ·≈–°“√∑”ß“π¢Õ߇°≈¥Á ‡≈Õ◊ ¥ (in vitro platelet function) Õ¬“à ߉√°µÁ “¡Õ“°“√µ“à ßÊ ®–ª√“°Æ™¥— ‡¡ÕË◊ ºŸâ ªÉ«¬¡’√–¥—∫¢Õ߇ ’¬§—Ëß„π‡≈◊Õ¥¡“° √«¡∑—ÈßÕ“°“√µà“ßÊ ¡—°‰¡à‡©æ“–‡®“–®ß  “¡“√∂‡°‘¥‰¥â®“°  “‡ÀµÿÕ◊ËπÕ’°¡“° √«¡∑—Èß°“√«—¥¥—ß°≈à“«‡ªìπ°“√«—¥º≈°“√∑”ß“π¢ÕßÕ«—¬«–∑’˺‘¥ª°µ‘‡æ’¬ß√–∫∫„¥ √–∫∫Àπß÷Ë ¡‰‘ ¥Àâ ¡“¬§«“¡«“à √–∫∫Õπ◊Ë ®–‡ªπì ‡™πà ππ—È ¥«â ¬·≈–Õ“®‡°¥‘ ®“° “‡ÀµÕÿ π◊Ë ÊÀ√Õ◊ ®“°°“√√°— …“‰¥â 3.3 °“√«¥— uremic toxin ·∫ßà ÕÕ°‰¥‡â ªπì 3 °≈¡àÿ 6 µ“¡≈°— …≥–°“√∂°Ÿ ¢®¥— ÕÕ°®“°√“à ß°“¬ º“à π small pore, low flux dialyzer §Õ◊ 1. Small molecules (µ“√“ß∑Ë’ 1) ¡π’ ”È Àπ°— ‚¡‡≈°≈ÿ πÕâ ¬°«“à 500 ¥“≈µπ— ∑ Ë’ ”§≠— ‰¥·â °à urea ·≈– creatinine  ”À√∫— urea ‡ªπì  “√∑‰Ë’ ¥®â “° metabolism ¢Õß‚ª√µπ’ ´ßË÷  “¡“√∂∂°Ÿ ¢®¥— º“à π small pore, low flux dialyzer ‰¥ßâ “à ¬ ‚¥¬¢∫«π°“√ diffusion  «à π creatinine ¡π’ ”È Àπ°— ‚¡‡≈°≈ÿ „À≠°à «“à ∑”„À∂â °Ÿ ¢®¥— ‰¥πâ Õâ ¬°«“à 2. Protein-bound molecules (µ“√“ß∑Ë’ 2) ‡ªπì  “√∑¡Ë’ ‚’ ¡‡≈°≈ÿ ®∫— Õ¬°Ÿà ∫—  “√‚ª√µπ’  «à π„À≠¡à ’ ¢π“¥‚¡‡≈°≈ÿ πÕâ ¬°«“à 500 ¥“≈µπ— ¬°‡«πâ leptin ·≈– retinol binding protein ·¡«â “à ®–¡¢’ 𓥂¡‡≈°≈ÿ ‰¡„à À≠à ·µ¢à ®¥— ÕÕ°‚¥¬«∏‘ ø’ Õ°‡≈Õ◊ ¥‰¥¬â “°‡πÕË◊ ß®“°®∫— Õ¬°àŸ ∫—  “√‚ª√µπ’ 3. Middle molecules (µ“√“ß∑Ë’ 3) ¡π’ ”È Àπ°— ‚¡‡≈°≈ÿ ¡“°°«“à 500 ¥“≈µπ— §«“¡ “¡“√∂„π °“√∂°Ÿ ¢®¥— ÕÕ°®“°√“à ß°“¬¡®’ ”°¥— ‡πÕË◊ ß®“°¡¢’ 𓥄À≠à ‡π◊ËÕß®“°°“√«—¥ uremic toxin  à«π„À≠à∑”‰¥â¬“°·≈–‰¡à‡À¡“– ¡„π∑“ߪؑ∫—µ‘ ®÷ß®”‡ªìπ µâÕßÀ“ “√µ—«Àπ÷Ëß„π®”π«ππ’ȇªìπµ—«·∑π¢Õß “√∑’ˇÀ≈◊Õ ´÷Ëßæ∫«à“ urea ¡’§«“¡‡À¡“– ¡„π°“√‡ªì𠵫— ·∑πÀ≈“¬ª√–°“√ Urea ‡ªπì ¢Õ߇ ¬’ ∑‡Ë’ °¥‘ ®“°°“√ ≈“¬¢Õß‚ª√µπ’ „π‡πÕÈ◊ ‡¬ÕË◊ ‰¥‡â ªπì amino group ´ßË÷ ∂°Ÿ ‡ª≈¬Ë’ π∑Ë’ µ∫— ‡ªπì urea®“°ππ—È urea®–‡¢“â °√–· ‡≈Õ◊ ¥·≈–∂°Ÿ ¢∫— ÕÕ°∑“ߪ í  “«–urea¡§’ «“¡ ¡— æπ— ∏°å ∫— ª®í ®¬— µ“à ßÊ ‡™àπ Õ—µ√“°“√‡º“º≈“≠‚ª√µ’π¢Õß√à“ß°“¬ ª√‘¡“≥‚ª√µ’π∑’Ë√—∫ª√–∑“π‡¢â“‰ª ¡’°“√»÷°…“≈—°…≥– °“√°√–®“¬¢Õß urea ·≈–§«“¡ —¡æ—π∏å¢Õß√–¥—∫ urea „π‡≈◊Õ¥°—∫Õ—µ√“°“√µ“¬¢Õߺ⟪ɫ¬∑’Ë√—°…“ ¥«â ¬°“√øÕ°‡≈Õ◊ ¥Õ¬“à ß°«“â ߢ«“ß Õ°’ ∑ß—È  “¡“√∂µ√«®À“√–¥∫— urea „π‡≈Õ◊ ¥‰¥ßâ “à ¬·≈–·¡πà ¬” ®ß÷ ∑”„Àâ urea∂°Ÿ π”¡“„™‡â æÕ◊Ë »°÷ …“°“√‡ª≈¬’Ë π·ª≈ß·≈–®≈»“ µ√å‡æÕ◊Ë ª√–‡¡π‘ À“§«“¡‡æ¬’ ßæÕ¢Õß°“√øÕ°‡≈Õ◊ ¥  √ªÿ ¢Õâ ¥¢’ Õß°“√„™â Urea ‡ªπì µ«— ·∑π¢Õß uremic toxin 7 1. urea ¡ª’ √¡‘ “≥¡“°„π‡≈Õ◊ ¥ ·≈–∂°Ÿ ¢∫— ∑‰Ë’ µ‡ªπì  ”§≠— 2. «¥— √–¥∫— urea „π‡≈Õ◊ ¥‰¥ßâ “à ¬ µ“à ß®“°°“√«¥—  “√ÕπË◊ À√Õ◊ middle molecules ´ßË÷ ∑”‰¥¬â “° °«“à

Optimum and Adequacy of Hemodialysis ∏π‘µ ®‘√π—π∑∏å «—™ 81 3. urea‡ªπì ¢Õ߇ ¬’ ∑‡’Ë °Õ◊ ∫∑ß—È À¡¥‡°¥‘ ¢π÷È ®“°°“√‡º“º≈“≠ “√Õ“À“√∑¡’Ë ‰’ π‚µ√‡®π‡ªπì  «à π ª√–°Õ∫ 4. ¡§’ «“¡ ¡— æπ— ∏¢å Õßuremicsymptoms¢ÕߺªŸâ «É ¬‰µ«“¬‡√Õ◊È √ß— ¢π—È  ¥ÿ ∑“â ¬·≈–ª√¡‘ “≥‚ª√µπ’ ∑√Ë’ ∫— ª√–∑“π„π·µ≈à –«π— ´ßË÷ ‡ªπì  “√µßÈ— µπâ ¢Õß urea 5. urea ¡¢’ 𓥂¡‡≈°≈ÿ ‡≈°Á °√–®“¬‰ª∑«—Ë  «à πµ“à ßÊ ¢ÕßπÈ”„π√“à ß°“¬ ·≈–‡°¥‘ °“√‡§≈Õ◊Ë π¬“â ¬ µ“√“ß∑Ë’ 1 Small free water-soluble molecules ™π¥‘ µ“à ßÊ (N = 45) (CN normal concentration, Cu mean uremic concentration, Cmax maximal uremic concentration, MW molecular weight)

New Frontiers in Dialysis 82 ∏𵑠®√‘ π—π∑å∏«—™  ‘√‘¿“ ™“â ß»√‘ °‘ ÿ≈™¬— ∏π—𥓠µ√–°“√«π™‘ « —πµå  ‡ÿ ¡∏°≈ÿ µ“√“ß∑’Ë 2 Protein-bound solutes ™π¥‘ µ“à ßÊ (N = 25) µ“√“ß∑Ë’ 3 Middle Molecules ™π¥‘ µ“à ßÊ (N = 22)

Optimum and Adequacy of Hemodialysis ∏𵑠®√‘ ππ— ∑å∏«™— 83 ‰¥√â «¥‡√«Á ·≈–¬ß— ‡§≈Õ◊Ë π∑º’Ë “à π‡¬Õ◊Ë À¡ÿâ ‡´≈≈‡å ¡¥Á ‡≈Õ◊ ¥·¥ß‰¥ßâ “à ¬ ∑”„À„â °≈‡â §¬’ ß°∫— single pool urea kinetic model ¡“°°«“à  “√ÕπË◊ 6. ¡°’ “√„™â urea „π·∫∫®”≈Õß∑“ß°≈»“ µ√å (urea kinetic model) ∑”„À â “¡“√∂«¥— §«“¡ ‡æ¬’ ßæÕ¢Õß°“√øÕ°‡≈Õ◊ ¥‰¥ßâ “à ¬·≈–‡ªπì ¡“µ√∞“π‡¥¬’ «°π— 7. urea ‡ªπì uremic toxin ™π¥‘ ‡¥¬’ « ∑¡Ë’ °’ “√»°÷ …“∑“ߧ≈π‘ °‘ Õ¬“à ß°«“â ߢ«“ß ∑ßÈ— „π·ßºà ≈¢Õß °“√√°— …“ morbidity ·≈– mortality ·¡«â “à urea ®–¡§’ ≥ÿ  ¡∫µ— „‘ °≈‡â §¬’ ß°∫— µ«— ·∑π uremic toxin „πÕ¥ÿ ¡§µ‘ (µ“√“ß∑Ë’ 4) ·µ§à «“¡ ‡ªπì æ…‘ ‚¥¬µ√ߢÕß urea ‡Õ߉¡√à πÿ ·√ßπ°— ·≈–ºªâŸ «É ¬∑¡Ë’ §’ “à BUN µ”Ë ‡°π‘ ‰ª Õ“®‡ªπì ºªŸâ «É ¬∑¡Ë’  ’ ¢ÿ ¿“扡¥à ’ ‡πÕË◊ ß®“°∑“πÕ“À“√‚ª√µπ’ µ”Ë ‡°π‘ ‰ª ·≈– urea ®¥— ‡ªπì small molecules ∑¡Ë’ ¢’ 𓥇≈°Á ¡“° ®ß÷ ‰¡‡à ªπì µ«— ·∑π¢Õß “√„π°≈¡àÿ middle molecules ´ßË÷ ¡°’ “√¢®¥— º“à π∑“ß cellulose membrane ‰¥πâ Õâ ¬ ‡™πà beta-2 microglobulin, PTH ´ß÷Ë  “√„π°≈¡ÿà middle molecules ¡∫’ ∑∫“∑ ”§≠— ¡“°¢π÷È „πª®í ®∫ÿ π— ‡πÕ◊Ë ß®“°¡°’ “√„™â dialyzer membrane ∑¡Ë’ °’ “√¢®¥— middle molecules ‰¥¡â “°¢π÷È ∑”„Àµâ Õâ ß¡°’ “√殑 “√≥“«¥— °“√¢®¥— middle molecules √«à ¡¥«â ¬ ‚¥¬∑«Ë— ‰ª¡°— „™â beta-2 microglobulin ‡ªπì µ«— ·∑π “√„π°≈¡àÿ middle molecules 4. «∏‘ ª’ √–‡¡π‘ urea-based hemodialysis adequacy °“√ª√–‡¡π‘ §«“¡‡æ¬’ ßæÕ¢Õß°“√øÕ°‡≈Õ◊ ¥ ‚¥¬¥®Ÿ “°°“√¢®¥— urea ÕÕ°®“°√“à ß°“¬  “¡“√∂ ∑”‰¥Àâ ≈“¬«∏‘ ’ 4.1 §“à Õµ— √“ «à π (R) ¢Õß postdialysis BUN (Cpost) µÕà predialysis BUN (Cpre) ·≈–§“à urea reduction ratio (URR) ‡ªπì °“√ª√–‡¡π‘ urea removal ∑ßË’ “à ¬∑ Ë’ ¥ÿ ‚¥¬ R = C post / C pre ·≈– (URR) = 1 - R µ“√“ß∑’Ë 4 §≥ÿ  ¡∫µ— ¢‘ Õßµ«— ·∑π uremic toxin „πÕ¥ÿ ¡§µ‘ („πª®í ®∫ÿ π— ¬ß— ‰¡¡à µ’ «— ·∑π„¥∑¡’Ë §’ ≥ÿ  ¡∫µ—  ‘ ¡∫√Ÿ ≥·å ∫∫)

New Frontiers in Dialysis 84 ∏𵑠®√‘ π—π∑∏å «—™  √‘ ¿‘ “ ™“â ß»√‘ ‘°≈ÿ ™—¬ ∏π—𥓠µ√–°“√«π‘™ « —πµå  ‡ÿ ¡∏°≈ÿ À√Õ◊ Õ“®¥„Ÿ π·ßà percent reduction in urea concentration (PRC) = URR x 100 % ®“°°“√»°÷ …“¢Õß Owen8 æ∫«“à URR  ¡— æπ— ∏°å ∫— Õµ— √“°“√µ“¬„πºªâŸ «É ¬øÕ°‡≈Õ◊ ¥ ‚¥¬Õµ— √“ °“√µ“¬®–≈¥≈ßÕ¬à“ß™—¥‡®π‡¡◊ËÕ URR > 0.65 Õ¬à“߉√°Áµ“¡§à“ R ·≈– URR ‰¡à‰¥âπ”ªí®®—¬Õ◊Ëπ¡“ æ‘®“√≥“¥â«¬ ‡™àπ ª√‘¡“≥Õ“À“√‚ª√µ’π∑’Ë√—∫ª√–∑“π„π·µà≈–«—π Õ—µ√“°“√ ≈“¬‚ª√µ’π„π√à“ß°“¬ ¥ß— ππÈ— °“√„™§â “à ¥ß— °≈“à «¡“‡ªπì µ«— ·∑π¢Õߧ«“¡‡æ¬’ ßæÕ¢Õß°“√øÕ°‡≈Õ◊ ¥ Õ“®‰¡∂à °Ÿ µÕâ ß 4.2 Mid-week predialysis BUN „™„â π°√≥∑’ ”øÕ°‡≈Õ◊ ¥ ª— ¥“À≈å – 3 §√ßÈ— ‚¥¬«¥— predialysis BUN µ√ß°≈“ß ª— ¥“Àå §“à mid- week predialysis BUN  “¡“√∂‡ªìπµ—«∫Õ°§√à“«Ê ∂÷ߧ«“¡ ¡¥ÿ≈√–À«à“ß°“√º≈‘µ urea °—∫§«“¡  “¡“√∂„π°“√¢∫— urea ÕÕ°®“°√“à ß°“¬ §“à mid-week predialysis BUN §«√¡§’ “à ‰¡‡à °π‘ 80 mg/dl 9 4.3 Time average concentration of urea (TAC urea) ‡ªπì °“√À“§“à ‡©≈¬Ë’ √–¥∫— BUN ¢ÕߺªâŸ «É ¬µ≈Õ¥ ª— ¥“Àå (√ªŸ ∑Ë’ 2) §”π«≥‰¥®â “° µŸ √¥ß— πÈ’ 10 TAC urea = [ (C1 + C2) td + (C2 + C3) tid ] / 2 (td + tid) ‚¥¬ td = √–¬–‡«≈“∑”øÕ°‡≈Õ◊ ¥ tid = √–¬–‡«≈“√–À«“à ß°“√∑”øÕ°‡≈Õ◊ ¥·µ≈à –§√ß—È C1 = predialysis BUN C2 = postdialysis BUN C3 = predialysis BUN §√ßÈ— µÕà ‰ª §“à TACurea  “¡“√∂„™·â  ¥ß ¡¥≈ÿ √–À«“à ß urea ∑√Ë’ “à ß°“¬ √“â ߢπÈ÷ ·≈–°“√¢®¥— urea ÕÕ° ®“°√“à ß°“¬ ‰¥¥â °’ «“à °“√„™â URR ‡æ√“–ºªŸâ «É ¬∑∑Ë’ ” hemodialysis ®–¡°’ “√‡ª≈¬Ë’ π·ª≈ߢÕß√–¥∫— BUN √ªŸ ∑’Ë 2 Time average concentration of urea ‡ªπì §“à ‡©≈¬Ë’ √–¥∫— BUN ¢ÕߺªâŸ «É ¬µ≈Õ¥ ª— ¥“Àå

Optimum and Adequacy of Hemodialysis ∏𵑠®√‘ ππ— ∑å∏«—™ 85 ‡ªìπ‡ âπ°√“ø¢“≈ß√–À«à“ß∑” hemodialysis ·≈–‡ªìπ‡ âπ°√“ø¢“¢÷Èπ„π™à«ß∑’ˉ¡à‰¥â∑” hemodialysis ∑”„À‡â ªπì ‡ πâ °√“ø§≈“â ¬øπí ª≈“11 §“à TACurea ™«à ¬‡ª≈¬’Ë π‡ πâ °√“øøπí ª≈“„À‡â ªπì ‡ πâ µ√ß∑”„Àßâ “à ¬µÕà °“√·ª≈º≈ ®“°√“¬ß“π¢Õß National cooperative dialysis study (NCDS) ´÷Ë߉¥â»÷°…“§«“¡ —¡æ—π∏å √–À«à“ßÕ—µ√“°“√µ“¬¢ÕߺŸâªÉ«¬øÕ°‡≈◊Õ¥°—∫§à“ TACurea æ∫«à“ºŸâªÉ«¬¡’Õ—µ√“°“√µ“¬πâÕ¬≈ß ∂â“§à“ TACurea ‰¡‡à °π‘ 50 mg/dl Õ¬“à ߉√°µÁ “¡§“à TAC urea ¬ß— ‰¡„à ™µà «— «¥— §«“¡‡æ¬’ ßæÕ¢Õß°“√øÕ°‡≈Õ◊ ¥∑Ë’ ¥∑’  Ë’ ¥ÿ ‡æ√“–‰¡‰à ¥πâ ”ª√¡‘ “≥‚ª√µπ’ ∑√Ë’ ∫— ª√–∑“π„π·µ≈à –«π— ¡“殑 “√≥“√«à ¡¥«â ¬ 4.4 §“à Kt/V „πªï æ.».1985 Gotch ·≈– Sargent 11 µÕâ ß°“√§πâ À“«“à ¡¥’ √√™πÕ’ πË◊ ∑ÕË’ “®„™·â  ¥ß§«“¡‡æ¬’ ß æÕ¢Õß°“√øÕ°‡≈◊Õ¥ ‰¥â¥’°«à“§à“ TACurea À√◊Õ‰¡à ‚¥¬‰¥â¥—¥·ª≈ߢâÕ¡Ÿ≈®“°°“√»÷°…“¢Õß NCDS ·≈–‡ πÕ«“à  “¡“√∂„™§â “à ¥√√™π„’ À¡∑à ‡Ë’ √¬’ °«“à Kt/V ´÷ßË ¡§’ “à ‡∑“à °∫— -ln(Cpost/Cpre) ‡ªπì ‡§√ÕË◊ ߪ√–‡¡π‘ §«“¡‡æ¬’ ßæÕ¢Õß°“√øÕ°‡≈Õ◊ ¥‰¥¥â °’ «“à §“à TACurea ‡æ√“–§“à Kt/V ¡§’ «“¡ ¡— æπ— ∏°å ∫— Õµ— √“µ“¬·≈– Õµ— √“‡®∫Á ª«É ¬¢ÕߺªŸâ «É ¬ §“à Kt/V ‡ªπì µ«— ∫Õ°ª√¡‘ “µ√¢Õßæ≈“ ¡“∑¡’Ë °’ “√¢®¥— urea ÕÕ° (K x t) µÕà ª√¡‘ “µ√°“√°√–®“¬ ¢Õß urea (V) ´ßË÷ À¡“¬∂ß÷  ¥—  «à π°“√¢®¥— urea ÕÕ°®“°√“à ß°“¬ ‡¡ÕË◊ ‡∑¬’ ∫°∫— ª√¡‘ “µ√°“√°√–®“¬¢Õß urea ‰¥‡â ªπì §“à Kt/V ‚¥¬ K = dialyzer urea clearance Àπ«à ¬‡ªπì ml/min t = √–¬–‡«≈“∑” hemodialysis Àπ«à ¬‡ªπì minute V = volume of distribution of urea Àπ«à ¬‡ªπì ml §“à Kt/V ®ß÷ ‡ªπì µ«— «¥— dialysis dose „π°“√∑”øÕ°‡≈Õ◊ ¥ 1 §√ßÈ— §“à Kt/V πÕ°®“°®–¡§’ «“¡  —¡æ—π∏å°—∫Õ—µ√“µ“¬·≈–Õ—µ√“‡®Á∫ªÉ«¬·≈â« ¬—ߧ”π÷ß∂÷ߺ≈ª√‘¡“≥‚ª√µ’π∑’Ë√—∫ª√–∑“π„π·µà≈–«—π ·≈–º≈¢Õß ultrafiltrate µÕà §“à Cpost °“√«‡‘ §√“–À§å “à Kt/V  “¡“√∂𔉪„™ªâ √∫— «∏‘ °’ “√∑”øÕ°‡≈Õ◊ ¥„π ºªŸâ «É ¬·µ≈à –√“¬¥«â ¬ 5. «∏‘ °’ “√ª√–‡¡π‘ §“à Kt/V  “¡“√∂§”π«≥§“à Kt/V ‰¥Àâ ≈“¬«∏‘ ’ 5.1 Urea kinetic model (UKM) 12,13 °“√»°÷ …“ Modeling ‡ªπì °“√»°÷ …“·∫∫®”≈Õß∑“ß°≈»“ µ√∑å ∂Ë’ °Ÿ π”¡“„™‡â æÕË◊ «‡‘ §√“–À√å –∫∫ ∑’Ë¡’ “√‡§≈◊ËÕπ∑’ˇ¢â“·≈–ÕÕ°®“°√–∫∫‚¥¬„™â ¡°“√§≥‘µ»“ µ√å ∑”„Àâ°“√ª√–‡¡‘π„π·ßàª√‘¡“≥¢Õß  “√„π√–∫∫¡§’ «“¡∂°Ÿ µÕâ ߠߟ  ”À√∫— °“√∑” hemodialysis ·∫∫®”≈Õß urea kinetic model ∂°Ÿ π”¡“ „™‡â æÕË◊ »°÷ …“ ¡°“√°“√¢®¥— urea ÕÕ°®“°√“à ß°“¬‚¥¬º“à 𵫗 °√Õ߉µ‡∑¬’ ¡ (√ªŸ ∑Ë’ 3) UKM ¡∑’ ßÈ— ·∫∫ ®”≈Õß∑¡Ë’  ’ ¡°“√ß“à ¬Ê ·≈–·∫∫®”≈Õß∑¡Ë’  ’ ¡°“√¬ßàÿ ¬“°´∫— ´Õâ π UKM ·∫∫µ“à ßÊ ‰¥·â °à

New Frontiers in Dialysis 86 ∏𵑠®‘√π—π∑å∏«™—  ‘√¿‘ “ ™“â ß»‘√°‘ ≈ÿ ™—¬ ∏ππ— ¥“ µ√–°“√«π™‘ « π— µå  ‡ÿ ¡∏°ÿ≈ √ªŸ ∑’Ë 3 ·∫∫®”≈Õß∑«Ë— ‰ª¢Õß Urea kinetic model  ”À√∫— °“√øÕ°‡≈Õ◊ ¥ (G urea generation rate, K dialyzer urea clearance, Kr residual renal urea clearance, UF ultrafiltration, ICF intracellular fluid, ECF extracellular fluid) 5.1.1 Fixed volume, single pool (FVSP) UKM ·∫∫®”≈Õß™π¥‘ π¡È’  ’ ¡°“√∑ßË’ “à ¬°«“à ™π¥‘ ÕπË◊ ‚¥¬°”Àπ¥„Àâ urea distribution volume (V) ´ßË÷ ¡’ §“à ‡∑“à °∫— total body water ‡ªπì  ¿“æ compartment ‡¥¬Ë’ « ¡’ urea °√–®“¬Õ¬ Ÿà ¡”Ë ‡ ¡Õ ·≈–¡¢’ π“¥ §ß∑‰Ë’ ¡‡à ª≈¬Ë’ π·ª≈ßµ≈Õ¥°“√∑”øÕ°‡≈Õ◊ ¥ °”Àπ¥„ÀÕâ µ— √“°“√ √“â ß urea „π√“à ß°“¬ (urea generation rate, G) ¡’§à“§ß∑’Ë Õ—µ√“°“√¢®—¥ urea ÕÕ°®“°√à“ß°“¬·ª√‚¥¬µ√ß°—∫§à“§«“¡‡¢â¡¢âπ¢Õß urea „π ‡≈Õ◊ ¥∑ºË’ “à π dialyzer „π≈°— …≥–¢Õß first order kinetic ´ßË÷ À¡“¬§«“¡«“à ∂“â §“à §«“¡‡¢¡â ¢πâ ¢Õß urea „π‡≈◊Õ¥¡“° Õ—µ√“°“√¢®—¥ urea ÕÕ°®“°√à“ß°“¬°Á®–¡“°µ“¡ ∂â“«“¥°√“ø· ¥ß§«“¡ —¡æ—π∏å¢Õß §“à §«“¡‡¢¡â ¢πâ ¢Õß urea„π‡≈Õ◊ ¥ (C) °∫— ‡«≈“∑ºË’ “à π‰ª (t) À≈ß— ‡√¡Ë‘ ∑”°“√øÕ°‡≈Õ◊ ¥ HD ®–‡ªπì ‡ πâ ‚§ßâ exponential ¥ß— √ªŸ ∑Ë’ 4 ‡¡ÕË◊ §”πß÷ ∂ß÷ Mass balance equation µ“¡·∫∫¢Õß FVSP UKM (√ªŸ ∑Ë’ 5) ®–‰¥ â ¡°“√ Õµ— √“°“√‡ª≈¬Ë’ π·ª≈ß urea compartment „π√“à ß°“¬ = urea generation rate - urea removal rate V dC/dt = G - (K + Kr) C  ¡°“√ 1 K = Dialyzer urea clearance Kr = residual renal urea clearance V = distribution volume ¢Õß urea C = §«“¡‡¢¡â ¢πâ ¢Õß urea „π‡≈Õ◊ ¥ G = urea generation rate À“°°”Àπ¥„À√â –À«“à ß°“√øÕ°‡≈Õ◊ ¥ °“√‡ª≈¬Ë’ π·ª≈ߧ«“¡‡¢¡â ¢πâ ¢Õß urea „π‡≈Õ◊ ¥ ®“°§“à G ·≈– ®“°°“√∑” ultrafiltration (UF) πÕâ ¬¡“°  “¡“√∂µ¥— ∑ßÈ‘ ‰¥â ¥ß— ππÈ— ‡¡ÕË◊ integrate  ¡°“√∑Ë’ 1 ∑‡Ë’ «≈“ t ®–‰¥§â “à Ct ¥ß— √ªŸ ∑Ë’ 5

Optimum and Adequacy of Hemodialysis ∏π‘µ ®√‘ π—π∑å∏«™— 87 C (mg/dl) C0 t (min) √ªŸ ∑’Ë 4 °√“ø· ¥ß§«“¡ ¡— æπ— ∏¢å Õß C ·≈– t (C0 §«“¡‡¢¡â ¢πâ ¢Õß urea „π‡≈Õ◊ ¥¢≥–‡«≈“‡√¡Ë‘ µπâ ) √ªŸ ∑Ë’ 5 ·∫∫®”≈ÕߢÕß Fixed volume, single pool urea kinetic model ∑µË’ ¥— º≈¢Õߧ“à G ·≈– UF ·≈–°“√ §”π«≥‡æÕË◊ À“§“à Ct (Ct §«“¡‡¢¡â ¢πâ ¢Õß urea „π‡≈Õ◊ ¥∑‡Ë’ «≈“ πÈ‘  ¥ÿ °“√∑” HD, t ‡«≈“ πÈ‘  ¥ÿ °“√∑” HD, tid ‡«≈“√–À«“à ß°“√∑” HD ·µ≈à –§√ßÈ— , C0 §«“¡‡¢¡â ¢πâ ¢Õß urea „π‡≈Õ◊ ¥∑‡Ë’ «≈“‡√¡Ë‘ °“√∑” HD) ‡æ◊ËÕ„À≥â√Ÿª·∫∫·≈– ¡°“√∑’Ëßà“¬¬‘Ëߢ÷Èπ À“°°”Àπ¥‡æ‘Ë¡‡µ‘¡„Àâ√–À«à“ß°“√øÕ°‡≈◊Õ¥ πÕ°®“°®–µ—¥°“√‡ª≈’ˬπ·ª≈ߧ«“¡‡¢â¡¢âπ¢Õß urea „π‡≈◊Õ¥ ∑’ˇªìπº≈®“°§à“ G ·≈– ®“°°“√∑” ultrafiltration (UF) ·≈â« ¬—ßµ—¥º≈¢Õß°“√∑”ß“π¢Õ߉µ∑’ˇÀ≈◊ÕÕ¬Ÿà (Kr) „π√–À«à“ß°“√øÕ°‡≈◊Õ¥¥â«¬ ∑”„À‰â ¥ â ¡°“√∑ßË’ “à ¬¢πÈ÷ ·≈–‡ªπì ∑¡Ë’ “¢ÕßÀ≈°— °“√¢Õߧ“à Kt/V Õ°’ ¥«â ¬ ¥ß— √ªŸ ∑Ë’ 6