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√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬
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·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—πÀ≈—ߺà“μ—¥„π∑’Ëπ’È
‡ªìπ‡æ’¬ß¢âÕ·π–π”„π°“√√–ß—∫ª«¥™π‘¥‡©’¬∫æ≈—πÀ≈—ߺà“μ—¥
‡æ◊ËÕ à߇ √‘¡§ÿ≥¿“æ¢Õß°“√∫√‘°“√¥â“π ÿ¢¿“æ¢Õߧπ‰∑¬ °“√𔉪„™âμâÕß¡’°“√ª√–¬ÿ°μå
„Àâ‡À¡“– ¡°—∫∫√‘∫∑¢Õß·μà≈–·Ààß ºŸâ„™â “¡“√∂ªØ‘∫—μ‘·μ°μà“߉ª®“°¢âÕ·π–π”π’È ‰¥â
¢÷ÈπÕ¬Ÿà°—∫°√≥’À√◊Õ ∂“π°“√≥å∑’Ë·μ°μà“ßÕÕ°‰ª À√◊Õ¡’‡Àμÿº≈∑’Ë ¡§«√
‚¥¬„™â«‘®“√≥≠“≥ ·≈–°“√μ—¥ ‘π„®∑’ˇªìπ∑’ˬա√—∫„π —ߧ¡
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’È ‰¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***
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¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬
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„πªí®®ÿ∫—π‰¥â¡’§«“¡√Ÿâ§«“¡‡¢â“„®„π欓∏‘ √’√«‘∑¬“ ‡¿ —™«‘∑¬“ ·≈–‡∑§π‘§¢Õß°“√∫”∫—¥§«“¡ª«¥
¡“°¢÷Èπ ·μ৫“¡ª«¥À≈—ߺà“μ—¥¬—߇ªìπªí≠À“∑’Ëæ∫‰¥â‡ ¡Õ„πºŸâªÉ«¬À≈—ߺà“μ—¥ √“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààß
ª√–‡∑»‰∑¬ √à«¡°—∫ ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬®÷ß¡’«—μ∂ÿª√– ߧå„Àâ®—¥∑” ç·π«∑“ß
æ—≤π“°“√√–ß—∫ª«¥À≈—ߺà“μ—¥é „À⇪ìπ·π«∑“ß„π°“√æ—≤π“∫”∫—¥§«“¡ª«¥ºŸâªÉ«¬À≈—ߺà“μ—¥ ‡æ◊ËÕ„À⺟âªÉ«¬
¡’§«“¡ ÿ¢ ∫“¬®“°§«“¡ª«¥
„π·π«∑“ßπ’È∫“ß∫∑§«“¡¡’°“√„™â∑—∫»—æ∑å¿“…“Õ—ß°ƒ… ‡æ◊ËÕ§«“¡‡¢â“„®·≈–°√–™—∫¢Õ߇π◊ÈÕÀ“
‰¡à„À⺑¥®“°§«“¡À¡“¬‡¥‘¡ ¢âÕ§«“¡∫“ßμÕπ‰¥â§—¥≈Õ°¡“®“° ç·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—πé
(Clinical Guidance for Acute Pain Management) ∑’Ë®—¥∑”‚¥¬ ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààß
ª√–‡∑»‰∑¬ ¿“§ºπ«°‰¥â√«∫√«¡·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥À≈—ߺà“μ—¥„πºŸâªÉ«¬°≈ÿà¡æ‘‡»… μ—«Õ¬à“ߢÕß
ºŸâªÉ«¬ ·≈–°“√®—¥∑” Acute Pain Service Model
Õ¬à“߉√°Áμ“¡·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥À≈—ߺà“μ—¥©∫—∫π’ȇªìπ‡æ’¬ß§”·π–π”„π°“√ªØ‘∫—쑇∑à“π—Èπ
¡‘‰¥â‡ªìπ¢âÕ∫—ߧ—∫À√◊հƇ°≥±å∑’Ë∫—ߧ—∫„ÀâμâÕߪؑ∫—μ‘μ“¡ ‡π◊ËÕß®“°„π°“√ªØ‘∫—μ‘®√‘ßπ—Èπ®–μâÕßÕ“»—¬∑—°…–
·≈–¥ÿ≈¬æ‘π‘®¢Õß·æ∑¬å∑’Ë„Àâ°“√√—°…“„π‚√ß欓∫“≈·μà≈–·Ààß´÷Ëß·μ°μà“ß°—𠇪ìπÕߧåª√–°Õ∫∑’Ë ”§—≠¥â«¬
„ππ“¡¢Õߧ≥–ºŸâ®—¥∑”œ ¢Õ¢Õ∫æ√–§ÿ≥√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬ ·≈– ¡“§¡°“√
»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬∑’Ë„Àâ°“√ π—∫ πÿπ„π°“√®—¥∑” ç·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥À≈—ߺà“μ—¥é
·≈–¢Õ¢Õ∫§ÿ≥ºŸâ‡°’ˬ«¢âÕß∑ÿ°∑à“π∑’Ë¡’ à«π√à«¡„π°“√®—¥∑”·π«∑“ß©∫—∫π’È®π ”‡√Á®≈ÿ≈à«ß¥â«¬¥’
√Õß»“ μ√“®“√¬å𓬷æ∑¬å «‘™—¬ Õ‘∑∏‘™—¬°ÿ≈±≈
ª√–∏“π§≥–ºŸâ®—¥∑”·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥À≈—ߺà“μ—¥
√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬
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1. √».πæ. ¡√—μπå ®“√ÿ≈—°…≥“π—π∑åª√–∏“π√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬ ∑’˪√÷°…“
2. √».πæ.ª√–¥‘…∞å ª√–∑’ª–«≥‘™π“¬° ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ ∑’˪√÷°…“
3. ».πæ. ¡∫Ÿ√≥å ‡∑’¬π∑Õß°√√¡°“√∫√‘À“√ ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ ∑’˪√÷°…“
4. √».πæ.«‘™—¬ Õ‘∑∏‘™—¬°ÿ≈±≈°√√¡°“√∫√‘À“√√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬ ª√–∏“π
5. æ.μ.πæ.™“≠ƒ∑∏‘Ï ≈âÕ∑«’ «— ¥‘Ï°√√¡°“√∫√‘À“√√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬ ‡≈¢“πÿ°“√
6. æ≠.πÿ™ μ—πμ‘»‘√‘π∑√å§≥–·æ∑¬»“ μ√å‚√ß欓∫“≈√“¡“∏‘∫¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈ √Õ߇≈¢“πÿ°“√
7. √».æ≠.«‘¡≈≈—°…≥å π—Ëπ»‘≈ªá§≥–·æ∑¬»“ μ√廑√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈ °√√¡°“√
8. æ≠. ÿ«‘¡≈ μà“ß«‘«—≤πå§≥–·æ∑¬å»“ μ√廑√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈ °√√¡°“√
9. √».æ≠. ÿª√“≥’ π‘√ÿμμ‘»“ πå§≥–·æ∑¬»“ μ√å ®ÿÓ≈ß°√≥å¡À“«‘∑¬“≈—¬ °√√¡°“√
10. æ.Õ.πæ.πæ¥≈ ™◊Ëπ»‘√‘‡°…¡«‘∑¬“≈—¬·æ∑¬»“ μ√åæ√–¡ß°ÿƇ°≈â“ °√√¡°“√
11. æ≠.Õ—≠™≈’ Õ—μ™Ÿ ∂“∫—π ÿ¢¿“懥Á°·Ààß™“μ‘¡À“√“™‘π’ °√√¡°“√
12. º».æ≠. À—∑¬“ ‰æ∫Ÿ≈¬å«√™“쑧≥–·æ∑¬»“ μ√å ¡À“«‘∑¬“≈—¬‡™’¬ß„À¡à °√√¡°“√
13. √».æ≠.»»‘°“πμå π‘¡¡“π√—™μå§≥–·æ∑¬»“ μ√å ¡À“«‘∑¬“≈—¬ ߢ≈“π§√‘π∑√å °√√¡°“√
14. ¿°.æß»∏√ ¡’ «— ¥‘Ï ¡§≥–‡¿ —™»“ μ√å ¡À“«‘∑¬“≈—¬¡À‘¥≈ °√√¡°“√
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ª√–‡∑»‰∑¬ ¢Õ¢Õ∫§ÿ≥μ—«·∑π®“°√“™«‘∑¬“≈—¬μà“ßÊ ‰¥â·°à √“™«‘∑¬“≈—¬»—≈¬·æ∑¬å·Ààߪ√–‡∑»‰∑¬
√“™«‘∑¬“≈—¬·æ∑¬åÕÕ√å‚∏ªî¥‘° å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬ Ÿμ‘π√’·æ∑¬å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬
‚ μ »Õ π“ ‘°·æ∑¬å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬®—°…ÿ·æ∑¬å·Ààߪ√–‡∑»‰∑¬ √«¡∑—Èßμ—«·∑π®“°
‚√ß欓∫“≈„π°√–∑√«ß “∏“√≥ ÿ¢Õ’° ’Ë·Ààß ‰¥â·°à √æ.¡À“√“™π§√√“™ ’¡“ √æ.À“¥„À≠à √æ.æ√–π—Ë߇°≈â“
·≈– ∂“∫—π ÿ¢¿“懥Á°·Ààß™“μ‘¡À“√“™‘π’ ∑’˙૬μ√«® Õ∫§«“¡∂Ÿ°μâÕß·≈–‡À¡“– ¡¢Õß·π«∑“ß„π§√—Èßπ’È
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∫∑π”/§”®”°—¥§«“¡/°≈ÿࡇªÑ“À¡“¬ 1
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√ÿª§”·π–π” ”À√—∫·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—πÀ≈—ߺà“μ—¥ 3
§”Õ∏‘∫“¬·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—πÀ≈—ߺà“μ—¥ 4
ë °≈àÕß∑’Ë 1: °“√ª√–‡¡‘πºŸâªÉ«¬·≈–‡≈◊Õ°«‘∏’°“√√–ß—∫ª«¥μ“¡ª√–‡¿∑¢Õß°“√ºà“μ—¥
ë °≈àÕß∑’Ë 2: «‘∏’°“√„À⬓√–ß—∫§«“¡√Ÿâ ÷°
ë °≈àÕß∑’Ë 3: ¡’Õ“°“√ª«¥À≈—ߺà“μ—¥
ë °≈àÕß∑’Ë 4: ª√–‡¡‘π√–¥—∫§«“¡ª«¥À≈—ß°“√ºà“μ—¥
ë °≈àÕß∑’Ë 5: °“√√–ß—∫ª«¥À≈—ß°“√ºà“μ—¥: ·∫∫º ¡º “π
ë °≈àÕß∑’Ë 6: °“√√–ß—∫ª«¥‰¥âº≈¥’À√◊Õ‰¡à
ë °≈àÕß∑’Ë 7: ‡°‘¥º≈¢â“߇§’¬ß/Õ“°“√·∑√° âÕπ®“°°“√√–ß—∫ª«¥
ë °≈àÕß∑’Ë 8: √—°…“º≈¢â“߇§’¬ß/Õ“°“√·∑√° âÕπ®“°°“√√–ß—∫ª«¥
ë °≈àÕß∑’Ë 9: ª√–‡¡‘π√–¥—∫§«“¡ª«¥ È”·≈–°“√∫—π∑÷°
¿“§ºπ«° 1: Incidence / Pathophysiology of acute postoperative pain 17
¿“§ºπ«° 2: Pain Pathway 19
¿“§ºπ«° 3: Pain Assessment 20
¿“§ºπ«° 4: Multimodal Analgesia 23
¿“§ºπ«° 5: Patient-Controlled Analgesia 25
¿“§ºπ«° 6: Continuous Peripheral Nerve Blockade 27
¿“§ºπ«° 7: Patient Groups with Special Problems 30
¿“§ºπ«° 8: Acute Pain Service 38
μ“√“ß√“¬≈–‡Õ’¬¥°“√√–ß—∫ª«¥‡©’¬∫æ≈—πÀ≈—ߺà“μ—¥‚¥¬„™â¬“ 42
μ“√“ß√“¬≈–‡Õ’¬¥°“√√–ß—∫ª«¥‡©’¬∫æ≈—πÀ≈—ߺà“μ—¥‚¥¬‰¡à„™â¬“ 52
∫√√≥“πÿ°√¡ 56
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 1
¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬
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§”®”°—¥§«“¡ [Definition of Postoperative Pain]:§«“¡ª«¥À≈—ߺà“μ—¥ ‰¥â·°à §«“¡ª«¥∑’ˇ°‘¥¢÷ÈπÀ≈—ß®“°‰¥â√—∫°“√ºà“μ—¥ ∫“ߧ√—È߇°‘¥√à«¡°—∫ °“√¡’ “¬
√–∫“¬ ‡™à𠓬∑“߇¥‘πÕ“À“√ “¬√–∫“¬®“°Àπâ“Õ° À√◊Õ‡°’ˬ«¢âÕß°—∫°“√‡§≈◊ËÕπ‰À«À≈—ß°“√ºà“μ—¥·≈–
°“√°≈—∫¡“∑”°‘®«—μ√ª√–®”«—π ·≈–/À√◊Õ¿“«–·∑√° âÕπ °“√√–ß—∫§«“¡ª«¥À≈—ߺà“μ—¥∑’Ë¡’ª√– ‘∑∏‘¿“æ
§«√¡’°“√«“ß·ºπ°“√√–ß—∫ª«¥≈à«ßÀπâ“ „π√–¬–°àÕπ √–À«à“ß ·≈–À≈—ß°“√ºà“μ—¥
°≈ÿࡇªÑ“À¡“¬:°≈ÿࡇªÑ“À¡“¬ºŸâ„™â·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—πÀ≈—ߺà“μ—¥§◊Õ ∫ÿ§≈“°√∑“ß°“√·æ∑¬å∑’Ë¥Ÿ·≈
ºŸâªÉ«¬À≈—ߺà“μ—¥ ‰¥â·°à »—≈¬·æ∑¬å∑ÿ° “¢“ ·æ∑¬å∑’Ë¥Ÿ·≈ºŸâªÉ«¬À≈—ߺà“μ—¥ «‘ —≠≠’·æ∑¬å·≈–欓∫“≈ œ≈œ
°“√√–ß—∫§«“¡ª«¥À≈—ߺà“μ—¥°“√√–ß—∫§«“¡ª«¥À≈—ߺà“μ—¥∑’Ë¡’ª√– ‘∑∏‘¿“æ μâÕߧ√Õ∫§≈ÿ¡∂÷ß√–¬–°àÕπ √–À«à“ß ·≈–À≈—ߺà“μ—¥
μâÕ߇√‘Ë¡¥â«¬°“√«“ß·ºπμ—Èß·μà°àÕπºà“μ—¥ §◊Õ °“√ Õπ„À⺟âªÉ«¬ ◊ËÕ “√°—∫∫ÿ§≈“°√‚¥¬„™â§–·π𪫥 °“√„Àâ
§«“¡√Ÿâ«à“ §«“¡ª«¥¡’º≈‡ ’¬ ·≈–„Àâ¢Õ¬“μ—Èß·μà‡√‘Ë¡ª«¥‡æ◊ËÕ„Àâ°“√√–ß—∫ª«¥Õ¬à“ß∑—π∑à«ß∑’ °“√‡≈◊Õ°«‘∏’
√–ß—∫§«“¡√Ÿâ ÷°√–À«à“ߺà“μ—¥ °“√‡≈◊Õ°‡∑§π‘§·≈–¬“·°âª«¥∑’ˇÀ¡“– ¡ √«¡∂÷ß°“√„™â‡∑§π‘§√–ß—∫ª«¥·≈–/
À√◊Õ„À⬓·°âª«¥μà“ßÊ μ—Èß·μà°àÕπ°“√ºà“μ—¥‡æ◊ËÕ≈¥§«“¡√ÿπ·√ß·≈–√–¬–‡«≈“¢Õߧ«“¡ª«¥À≈—ߺà“μ—¥
‡¡◊ËÕºŸâªÉ«¬‰¥â√—∫°“√√–ß—∫§«“¡ª«¥·≈â« ®–μâÕ߉¥â√—∫°“√ª√–‡¡‘πº≈°“√√—°…“·≈–¿“«–·∑√°´âÕπ∑’ˇ°‘¥¢÷Èπ
·≈– ‡ª≈’ˬπ«‘∏’‡¡◊ËÕ°“√√—°…“‰¡à‰¥âº≈ ∑—Èßπ’È ‡æ◊ËÕ„À⺟âªÉ«¬ “¡“√∂øóôπμ—«‰¥â‡√Á«À≈—ß°“√ºà“μ—¥ ¡’§«“¡ ÿ¢ ∫“¬
ª≈Õ¥¿—¬ ·≈–æÕ„®°—∫º≈¢Õß°“√√—°…“ (·ºπ¿Ÿ¡‘∑’Ë 1)
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***2
√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬
·ºπ¿Ÿ¡‘∑’Ë 1 ·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—πÀ≈—ߺà“μ—¥
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 3
¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬
°≈àÕß∑’Ë 1: ª√–‡¡‘πºŸâªÉ«¬·≈–‡≈◊Õ°«‘∏’°“√√–ß—∫ª«¥μ“¡ª√–‡¿∑¢Õß°“√ºà“μ—¥ [Preoperative Period]
§”·π–π”: §«√ª√–‡¡‘π ¿“æºŸâªÉ«¬°àÕπºà“μ—¥ ™π‘¥°“√ºà“μ—¥ «‘∏’°“√√–ß—∫§«“¡√Ÿâ ÷° ·≈–‡≈◊Õ°«‘∏’°“√√–ß—∫§«“¡ª«¥μ“¡√–¥—∫§«“¡ª«¥¢Õߪ√–‡¿∑°“√ºà“μ—¥ ·≈–„™â∫—π‰¥ 3 ¢—Èπ¢Õß°“√√–ß—∫§«“¡ª«¥μ“¡Õߧ尓√Õπ“¡—¬‚≈°
°≈àÕß∑’Ë 2: «‘∏’°“√√–ß—∫§«“¡√Ÿâ ÷° [Intraoperative Period]
§”·π–π”: ¢÷ÈπÕ¬Ÿà°—∫™π‘¥¢Õß°“√ºà“μ—¥, ¿“«–¢ÕߺŸâªÉ«¬, §«“¡∂π—¥¢Õß«‘ —≠≠’·æ∑¬å / »—≈¬·æ∑¬å ·≈–§«“¡æ√âÕ¡¢ÕßÕÿª°√≥凧√◊ËÕß¡◊Õ
°≈àÕß∑’Ë 3: ¡’Õ“°“√ª«¥À≈—ߺà“μ—¥ [Postoperative Period]
§”·π–π”: μâÕßæ‘®“√≥“«à“§«“¡ª«¥∑’ˇ°‘¥¢÷Èπ‡ªì𧫓¡ª«¥®“°°“√ºà“μ—¥À√◊Õ‰¡à ∂Ⓡªì𧫓¡ª«¥®“° “‡ÀμÿÕ◊Ëπ„Àâ√—°…“μ“¡ “‡Àμÿ¢Õß‚√§
°≈àÕß∑’Ë 4: ª√–‡¡‘π√–¥—∫§«“¡ª«¥À≈—ß°“√ºà“μ—¥
§”·π–π”: §«√‡≈◊Õ°„™â‡§√◊ËÕß¡◊Õ„π°“√ª√–‡¡‘π√–¥—∫§«“¡ª«¥„Àâ‡À¡“– ¡°—∫ºŸâªÉ«¬·μà≈–√“¬
°≈àÕß∑’Ë 5 °“√√–ß—∫ª«¥À≈—ß°“√ºà“μ—¥: ·∫∫º ¡º “π
§”·π–π”: „™â«‘∏’°“√º ¡º “π (Multimodal analgesia) À¡“¬∂÷ß °“√„™â¬“À≈“¬¢π“π À√◊Õ‡∑§π‘§°“√√–ß—∫ª«¥À≈“¬™π‘¥√à«¡°—π
5.1 °“√√–ß—∫ª«¥‚¥¬„™â¬“ (Pharmacological Therapy)
§”·π–π”: ‡≈◊Õ°„™â¬“·°âª«¥μ“¡√–¥—∫§«“¡√ÿπ·√ߢÕßÕ“°“√ª«¥∑’ˇ°‘¥¢÷Èπ®√‘ßÀ√◊Õ§“¥«à“®–‡°‘¥¢÷Èπ
5.2 °“√√–ß—∫ª«¥‚¥¬‰¡à„™â¬“ (Nonpharmacological Therapy)
§”·π–π”: °“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬‰¡à„™â¬“ ¡’®ÿ¥¡ÿàßÀ¡“¬‡æ◊ËÕ π—∫ πÿπ„Àâ°“√√–ß—∫ª«¥®“°°“√„™â¬“‰¥âº≈¥’¢÷Èπ‰¡à„™à∑¥·∑π°“√„™â¬“·°âª«¥
°≈àÕß∑’Ë 6: °“√√–ß—∫ª«¥‰¥âº≈¥’À√◊Õ‰¡à
§”·π–π”: ∑”°“√ª√–‡¡‘π√–¥—∫§«“¡ª«¥´È”À≈—ß„Àâ°“√√—°…“Õ¬à“ß ¡Ë”‡ ¡Õ
°≈àÕß∑’Ë 7: ‡°‘¥º≈¢â“߇§’¬ß/Õ“°“√·∑√° âÕπ®“°°“√√–ß—∫ª«¥
§”·π–π”: §«√¡’°“√‡ΩÑ“√–«—ߺ≈¢â“߇§’¬ß·≈–Õ“°“√·∑√° âÕπ®“°°“√√–ß—∫ª«¥
°≈àÕß∑’Ë 8: √—°…“º≈¢â“߇§’¬ß/Õ“°“√·∑√° âÕπ®“°°“√√–ß—∫ª«¥
§”·π–π”: „Àâ√—°…“º≈¢â“߇§’¬ß·≈–Õ“°“√·∑√°´âÕπ®“°°“√√–ß—∫ª«¥μ—Èß·μà‡√‘Ë¡¡’Õ“°“√
°≈àÕß∑’Ë 9: ª√–‡¡‘π√–¥—∫§«“¡ª«¥ È”·≈–∫—π∑÷°
§”·π–π”: ‡¡◊ËÕ¡’§«“¡ª«¥À≈—ß°“√ºà“μ—¥∑’ËμâÕß°“√°“√√—°…“‡°‘¥¢÷ÈπÕ’° „Àâ∑” È”μ“¡·π«∑“ßæ—≤π“œ μàÕ‰ª
√ÿª§”·π–π” ”À√—∫·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—πÀ≈—ߺà“μ—¥
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***4
√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬
§”Õ∏‘∫“¬·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—πÀ≈—ߺà“μ—¥
°≈àÕß∑’Ë 1 ª√–‡¡‘πºŸâªÉ«¬·≈–‡≈◊Õ°«‘∏’°“√√–ß—∫ª«¥μ“¡ª√–‡¿∑¢Õß°“√ºà“μ—¥[Preoperative period]
§”·π–π”: 1) §«√ª√–‡¡‘π ¿“æºŸâªÉ«¬°àÕπºà“μ—¥ ™π‘¥°“√ºà“μ—¥ «‘∏’°“√√–ß—∫ §«“¡√Ÿâ ÷° ·≈–‡≈◊Õ°«‘∏’
°“√√–ß—∫ª«¥μ“¡ª√–‡¿∑¢Õß°“√ºà“μ—¥ Õ“®„À⺟âªÉ«¬¡’ à«π√à«¡„π°“√μ—¥ ‘π„®‡≈◊Õ°«‘∏’
„π°“√√—°…“¥â«¬μπ‡Õß
2) ºŸâªÉ«¬‰¥â√—∫§«“¡√Ÿâ‡°’ˬ«°—∫«‘∏’°“√ª√–‡¡‘π√–¥—∫§«“¡ª«¥ «‘∏’°“√„™â‡§√◊ËÕß¡◊Õ√–ß—∫ª«¥
¬“·°âª«¥ ¿“«–·∑√°´âÕπ ·≈–„À⧫“¡√Ÿâ·°àºŸâªÉ«¬‡√◊ËÕߺ≈¥’·≈–º≈‡ ’¬¢Õß°“√√—°…“
°≈àÕß∑’Ë 1.1: °“√ºà“μ—¥ª√–‡¿∑ª«¥πâÕ¬
À¡“¬∂÷ß°“√ºà“μ—¥∑’Ë∑”„À⇰‘¥Õ“°“√ª«¥πâÕ¬ ‡™àπ °“√ºà“μ—¥ excision ¢π“¥‡≈Á° ‡ âπ‡≈◊Õ¥
¢Õ¥ ‡ªìπμâπ
§”·π–π”: „Àâ¬“μ“¡≈”¥—∫ª«¥πâÕ¬¢Õß∫—π‰¥ 3 ¢—Èπ ¢ÕßÕߧ尓√Õπ“¡—¬‚≈° ‰¥â·°à °“√„Àâ
paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs) √à«¡°—∫
°“√©’¥¬“™“‡©æ“–∑’Ë
°≈àÕß∑’Ë 1.2: °“√ºà“μ—¥ª√–‡¿∑ª«¥ª“π°≈“ß
À¡“¬∂÷ß°“√ºà“μ—¥∑’Ë∑”„À⇰‘¥Õ“°“√ª«¥ª“π°≈“ß ‡™àπ °“√ºà“μ—¥‰ â‡≈◊ËÕπ, wide excision
À√◊Õ°“√ºà“μ—¥„π™àÕß∑âÕß à«π≈à“ß ‡ªìπμâπ
§”·π–π”: „Àâ¬“μ“¡≈”¥—∫ª«¥ª“π°≈“ߢÕß∫—π‰¥ 3 ¢—Èπ ¢ÕßÕߧ尓√Õπ“¡—¬‚≈° ‰¥â·°à °“√„À⬓°≈ÿà¡
weak opioid À√◊Õ strong opioid „πª√‘¡“≥πâÕ¬ √à«¡°—∫°“√©’¥¬“™“‡©æ“–∑’Ë ·≈–°“√„Àâ
paracetamol, NSAIDs
°≈àÕß∑’Ë 1.3: °“√ºà“μ—¥ª√–‡¿∑ª«¥¡“°
À¡“¬∂÷ß°“√ºà“μ—¥∑’Ë∑”„À⇰‘¥Õ“°“√ª«¥¡“° ‡™àπ °“√ºà“μ—¥„π™àÕß∑âÕß à«π∫π ™àÕßÕ°
‡ª≈’ˬπ¢âÕ‡¢à“‡∑’¬¡ ‡ªìπμâπ
§”·π–π”: „Àâ¬“μ“¡≈”¥—∫ª«¥¡“°¢Õß∫—π‰¥ 3 ¢—Èπ¢ÕßÕߧ尓√Õπ“¡—¬‚≈° ‰¥â·°à °“√„Àâ strong
opioid °“√„™â‡∑§π‘§°“√„À⬓·°âª«¥ ‡™àπ patient-controlled analgesia (PCA), epidu-
ral analgesia À√◊Õ°“√©’¥¬“™“‡©æ“– à«π ·≈–°“√„Àâ paracetamol ·≈–/À√◊Õ NSAIDs
°≈àÕß∑’Ë 2 «‘∏’°“√√–ß—∫§«“¡√Ÿâ ÷° [Intraoperative period]§”·π–π”: ¢÷ÈπÕ¬Ÿà°—∫™π‘¥¢Õß°“√ºà“μ—¥, ¿“«–¢ÕߺŸâªÉ«¬, §«“¡∂π—¥¢Õß«‘ —≠≠’·æ∑¬å / »—≈¬·æ∑¬å
·≈–§«“¡æ√âÕ¡¢ÕßÕÿª°√≥凧√◊ËÕß¡◊Õ
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 5
¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬
°≈àÕß∑’Ë 3 ¡’Õ“°“√ª«¥À≈—ߺà“μ—¥ [Postoperative period]§”·π–π”: μâÕßæ‘®“√≥“«à“§«“¡ª«¥∑’ˇ°‘¥¢÷Èπ‡ªì𧫓¡ª«¥®“°°“√ºà“μ—¥À√◊Õ‰¡à ∂Ⓡªì𧫓¡ª«¥®“°
“‡ÀμÿÕ◊Ëπ„Àâ√—°…“μ“¡ “‡Àμÿ¢Õß‚√§ ∂Ⓡªì𧫓¡ª«¥®“°°“√ºà“μ—¥®√‘ß „Àâª√–‡¡‘π√–¥—∫
§«“¡ª«¥ ·≈–„Àâ°“√√—°…“ ·≈–¬È”‡μ◊ÕπºŸâªÉ«¬‡√◊ËÕߢâÕ¥’·≈–¢âÕ‡ ’¬¢Õß«‘∏’√–ß—∫ª«¥∑’Ë„™â ∑—Èßπ’È
§«√„À⺟âªÉ«¬¡’ à«π√à«¡„π°“√‡≈◊Õ°«‘∏’„π°“√√—°…“ ∂⓺ŸâªÉ«¬¡’§«“¡ª«¥·μଗ߉¡àμâÕß°“√°“√
√—°…“ μâÕߪ√–‡¡‘π√–¥—∫§«“¡ª«¥´È”·≈–∫—π∑÷°‡ªìπ√–¬– ∂ⓧ«“¡ª«¥∂÷ß√–¥—∫∑’˧«√√—∫°“√
√—°…“ §«√„Àâ°“√√—°…“æ√âÕ¡°—∫·π–π”ºŸâªÉ«¬„À⇢Ⓞ®·≈–·°â ‰¢§«“¡‡¢â“„®º‘¥∑’Ë∑”„À⬗߉¡à
μâÕß°“√°“√√—°…“
°≈àÕß∑’Ë 4 ª√–‡¡‘π√–¥—∫§«“¡ª«¥À≈—ß°“√ºà“μ—¥§”·π–π”: 1) °“√ª√–‡¡‘𧫓¡ª«¥∑’Ë¥’∑’Ë ÿ¥ §«√„À⺟âªÉ«¬∫Õ°√–¥—∫§«“¡ª«¥¥â«¬μπ‡Õß „π√“¬∑’ˉ¡à
“¡“√∂∫Õ°√–¥—∫§«“¡ª«¥¥â«¬μπ‡Õß §«√‡≈◊Õ°„™â‡§√◊ËÕß¡◊Õ„π°“√ª√–‡¡‘𧫓¡ª«¥
„Àâ‡À¡“– ¡°—∫ºŸâªÉ«¬·μà≈–√“¬ (√Ÿª∑’Ë 1)
2) ∑”°“√ª√–‡¡‘𧫓¡ª«¥Õ¬à“ß ¡Ë”‡ ¡Õμ“¡·π«ªØ‘∫—μ‘¢Õß·μà≈– ∂“π欓∫“≈°àÕπ
·≈–À≈—ß„Àâ°“√√—°…“
3) §«√∫—π∑÷°§«“¡ª«¥„Àâ‡ÀÁπ™—¥‡®π °“√√–ß—∫ª«¥„Àâ ‰¥âº≈¥’μâÕ߇√‘Ë¡®“°°“√ª√–‡¡‘𧫓¡
ª«¥¢ÕߺŸâªÉ«¬„Àâ∂Ÿ°μâÕß°àÕπ ‚¥¬ª√–‡¡‘πμ—Èß·μà‡√‘Ë¡μâπ√—°…“ ·≈–ª√–‡¡‘πÀ≈—ß„Àâ°“√√—°…“
∑—Èߢ≥–ºŸâªÉ«¬æ—°·≈–¢≥–¡’°“√¢¬—∫μ—« ´÷Ëߧ«“¡ª«¥‡ªì𧫓¡√Ÿâ ÷° à«π∫ÿ§§≈ ·≈–‰¡à
‡À¡◊Õπ°—π∑ÿ°§π ·μà≈–∫ÿ§§≈®–¡’ªí®®—¬Õ◊Ëπ‡¢â“¡“‡°’ˬ«¢âÕß ‡™àπ Õ“√¡≥å ª√– ∫°“√≥å
‡¥‘¡ ¡“ª√—∫‡ª≈’Ë¬π§«“¡√Ÿâ ÷°ª«¥
√Ÿª∑’Ë 1 °“√‡≈◊Õ°„™â‡§√◊ËÕß¡◊Õª√–‡¡‘π√–¥—∫§«“¡ª«¥μ“¡§«“¡ “¡“√∂„π°“√ ◊ËÕ “√¢ÕߺŸâªÉ«¬(¥—¥·ª≈ß®“° European society of regional anaesthesia and pain therapy)
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***6
√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬
°≈àÕß∑’Ë 5 °“√√–ß—∫ª«¥À≈—ß°“√ºà“μ—¥: ·∫∫º ¡º “π (Multimodal analgesia)À¡“¬∂÷ß °“√„™â¬“À≈“¬¢π“π À√◊Õ ‡∑§π‘§°“√√–ß—∫ª«¥À≈“¬™π‘¥√à«¡°—π
5.1 °“√√–ß—∫ª«¥‚¥¬„™â¬“ (Pharmacological therapy)
§”·π–π”: 1) ºŸâ „Àâ°“√√—°…“§«√¡’§«“¡√Ÿâ‡°’ˬ«°—∫¬“·°âª«¥ª√–‡¿∑μà“ßÊ ∑—Èß°≈‰°°“√
ÕÕ°ƒ∑∏‘Ï ¢π“¥¬“ ¢âÕ§«√√–«—ß ¢âÕÀâ“¡ º≈¢â“߇§’¬ß·≈–Õ“°“√·∑√° âÕπ
¢Õ߬“
2) ‡≈◊Õ°„™â¬“·°âª«¥μ“¡√–¥—∫§«“¡√ÿπ·√ߢÕߧ«“¡ª«¥∑’ˇ°‘¥¢÷Èπ®√‘ßÀ√◊Õ
§“¥«à“®–‡°‘¥¢÷Èπ
3) §«√¡’·π«∑“ß„π°“√∫√‘À“√¬“·°âª«¥ ‰¡à«à“®–∫√‘À“√∑“ß°“√©’¥¬“‡¢â“
°≈â“¡‡π◊ÈÕ (IM), À≈Õ¥‡≈◊Õ¥¥” (IV), patient-controlled analgesia (PCA),
spinal / epidural analgesia, patient-controlled epidural analgesia
(PCEA), perineural analgesia
À≈—°°“√: 1. ‡≈◊Õ°„™â¬“∑’Ë¡’°≈‰°°“√ÕÕ°ƒ∑∏‘Ï·μ°μà“ß°—π‚¥¬μâÕßæ‘®“√≥“ªí®®—¬Õ◊ËπÊ ¢ÕߺŸâªÉ«¬´÷Ëß¡’º≈
μàÕ°“√ÕÕ°ƒ∑∏‘Ï·≈–°“√¢®—¥¬“ ‡™àπ ‚√§ª√–®”μ—« ¬“∑’Ë„™â„πªí®®ÿ∫—π ª√–«—μ‘°“√·æ⬓
¢âÕÀâ“¡„™â¢Õ߬“μà“ßÊ ·≈–Õ—πμ√°‘√‘¬“√–À«à“߬“∑’ËÕ“®‡°‘¥¢÷Èπ
2. °“√‡≈◊Õ°„™â¬“·°âª«¥μ—Èß·μà 2 ¢π“π¢÷Èπ‰ª (μ“√“ß∑’Ë 1) ‡æ◊ËÕÀ«—ߺ≈„À⇠√‘¡ƒ∑∏‘Ï°—π ‚¥¬
º≈¢â“߇§’¬ß‰¡à¡“°‰ª°«à“°“√„™â¬“¥—ß°≈à“«‡æ’¬ß¢π“π‡¥’¬«
‚¥¬∑—Ë«‰ª §«“¡ª«¥À≈—ߺà“μ—¥¡—°¡’°≈‰°°“√‡°‘¥§«“¡ª«¥‡ªìπ·∫∫ nociceptive ∑’ËμÕ∫ πÕߥ’μàÕ¬“
„π°≈ÿà¡ paracetamol, NSAIDs, coxibs, ·≈– opioids ·π–π”„Àâ„™â paracetamol ‡ªìπ¬“æ◊Èπ∞“π„π°“√
√–ß—∫§«“¡ª«¥∑ÿ°√–¥—∫ª«¥ ‚¥¬¢π“¥¬“∑’Ë·π–π”§◊Õ§√—Èß≈– 500-1,000 ¡°. (‰¡à‡°‘π 4,000 ¡°./«—π) „π
ºŸâªÉ«¬∑—Ë«‰ª ‰¡à§«√„™â√à«¡°—∫¬“∑’Ë¡’º≈‡Àπ’ˬ«π” CYP2E1 (¥Ÿ‡æ‘Ë¡‡μ‘¡„π à«π Õ—πμ√°‘√‘¬“√–À«à“߬“) ·μàÕ“®„Àâ
NSAIDs À√◊Õ coxibs √à«¡‰¥â∂Ⓣ¡à¡’¢âÕÀâ“¡ ∂⓺ŸâªÉ«¬¡’§«“¡ª«¥„π√–¥—∫ª“π°≈“ß∂÷ß√ÿπ·√ß ®÷ßæ‘®“√≥“„™â
opioid √à«¡¥â«¬
Gabapentin ·≈– pregabalin ‡ªìπ adjuvant À√◊Õ ¬“‡ √‘¡ ‰¡à·π–π”„Àâ„™â„π°“√§«∫§ÿ¡§«“¡ª«¥
À≈—ߺà“μ—¥∑—Ë«‰ª ·μàÕ“®æ‘®“√≥“‡≈◊Õ°„™â¿“¬À≈—ß°“√ºà“μ—¥∫“ß™π‘¥ ‡™àπ °“√ºà“μ—¥°√–¥Ÿ° —πÀ≈—ß∑’Ë¡’·π«‚πâ¡
‡°‘¥ nerve root pain À≈—ߺà“μ—¥ ·≈–„πºŸâªÉ«¬¡’‚√§√à«¡∑’Ë∑”„Àâ ‰¡à “¡“√∂„™â NSAIDs, coxibs À√◊Õ opioids
‰¥â ·μàμâÕßæ‘®“√≥“„Àâ¡’ª√–‚¬™πå¡“°°«à“§«“¡‡ ’ˬß∑’Ë®–‰¥â√—∫
πÕ°®“°°“√„™â¬“¥—ß°≈à“«·≈â« °“√„™âÀ≈—°°“√·∫∫º ¡º “π„Àâ ‰¥âº≈¥’μâÕßÕ“»—¬°“√√–ß—∫ª«¥¥â«¬
«‘∏’Õ◊ËπÊ √à«¡¥â«¬ ‡™àπ °“√©’¥¬“™“‡©æ“–∑’Ë∑’Ë·º≈ºà“μ—¥ °“√∑” regional block, peripheral nerve block,
plexus block À√◊Õ epidural analgesia ÷ËßμâÕßÕ“»—¬√–¥—∫§«“¡™”π“≠‡©æ“–∑’Ë·μ°μà“ß°—π Õ¬à“߉√°Áμ“¡
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*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 7
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*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***8
√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬
5.1.1 «‘∏’∫√‘À“√¬“ (Administration Technique)
5.1.1.1 Systemic analgesic administration §◊Õ °“√„À⬓·°âª«¥¥â«¬°“√©’¥À√◊Õ√—∫ª√–∑“π
·μà„π™à«ßÀ≈—ߺà“μ—¥∑’˺ŸâªÉ«¬¬—߉¡àøóôπ®“°¬“√–ß—∫§«“¡√Ÿâ ÷° ‰¡à “¡“√∂√—∫ª√–∑“π¬“À√◊Õ¡’°“√ߥπÈ”·≈–Õ“À“√
®÷ßπ‘¬¡„À⬓·°âª«¥‚¥¬°“√©’¥ ‰¥â·°à °“√©’¥‡¢â“∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ‡¢â“°≈â“¡‡π◊ÈÕ À√◊Õ‡¢â“™—Èπ„μ⺑«Àπ—ß ‚¥¬
¡ÿàßÀ«—ß„Àâ√–¥—∫¬“„π‡≈◊Õ¥Õ¬Ÿà„π™à«ß√—°…“ (therapeutic window) ¥â«¬‡∑§π‘§μà“ßÊ ·∫à߇ªìπ
ë p.r.n. „À⇡◊ËÕºŸâªÉ«¬μâÕß°“√¬“·°âª«¥ ¢âÕ¥’ §◊Õ √–¥—∫¬“„π‡≈◊Õ¥‰¡à Ÿß‡°‘π™à«ß√—°…“¢Õß
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„™â‡«≈“π“π°«à“®–‰¥â√—∫¬“·°âª«¥·≈–°«à“√–¥—∫¬“®–‡æ‘Ë¡¢÷Èπ∂÷ß√–¥—∫√—°…“ ‚¥¬æ∫«à“ √âÕ¬≈– 50 ¢ÕߺŸâªÉ«¬
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‰¡à√Õ„À⪫¥¡“°®÷ß„À⬓
ë Around the clock À√◊Õ continuous infusion „Àâ¬“μ“¡‡«≈“À√◊ÕÕ¬à“ßμàÕ‡π◊ËÕß ¢âÕ¥’ §◊Õ
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ë °“√„™â‡§√◊ËÕß PCA (Patient-controlled analgesia) À¡“¬∂÷ß «‘∏’°“√∑’˺ŸâªÉ«¬ “¡“√∂
„À⬓·°âª«¥¥â«¬μπ‡Õß ‡ªìπ«‘∏’∑’Ë –¥«°·≈–π‘¬¡„™âÀ≈—ߺà“μ—¥ ‚¥¬°“√°¥ªÿÉ¡ª≈àÕ¬¬“„Àâμπ‡Õ߇¡◊ËÕ√Ÿâ ÷°ª«¥
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«‘∏’°“√„™â PCA π‘¬¡„™â 2 «‘∏’ ‰¥â·°à
1. Demand dosing §◊Õ°“√„À⬓·°âª«¥¢π“¥πâÕ¬Ê ‡¡◊ËÕ√Ÿâ ÷°ª«¥ ‚¥¬ºŸâªÉ«¬°¥ªÿÉ¡ª≈àÕ¬¬“„Àâμπ‡Õß
2. Continuous infusion √à«¡°—∫ demand dosing §◊Õ°“√„À⬓·°âª«¥À¬¥‡¢â“À≈Õ¥‡≈◊Õ¥¥”Õ¬à“ß
μàÕ‡π◊ËÕß √à«¡°—∫°“√„À⬓·°âª«¥‡æ‘Ë¡¥â«¬μπ‡Õß∂⓬—ß¡’Õ“°“√ª«¥Õ¬Ÿà
ª√‘¡“≥¬“∑’Ë„™â„π PCA · ¥ß„πμ“√“ß∑’Ë 2 ·≈–μ—«Õ¬à“ß«‘∏’°“√μ—Èß PCA · ¥ß„π·ºπ¿Ÿ¡‘∑’Ë 2
μ“√“ß∑’Ë 2: μ—«Õ¬à“ߢÕß°“√μ—Èß§à“ IV-PCA
Drugs PCA Dose Lockout Interval Continuous Infusion(¡°.) (π“∑’) (¡°./™¡.)
Morphine 0.50-3.0 (1) 5-20 (7) 0-10 (0.5-2)
Fentanyl 0.02-0.05 (0.025) 3-10 (5) 0.02-0.1 (0.025)
Pethidine 5-20 5-15 0-40
Tramadol 10-20 5-10 0-20
( ) · ¥ß§à“∑’Ëπ‘¬¡„™â
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 9
¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬
·ºπ¿Ÿ¡‘∑’Ë 2 μ—«Õ¬à“ß«‘∏’°“√μ—Èß PCA
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***10
√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬
„π∑“ߪؑ∫—쑉¡àπ‘¬¡„™â pethidine ‡π◊ËÕß®“°º≈¢â“߇§’¬ß §◊Õ Õ“°“√ßà«ß´÷¡ ·≈–Õ“®‡°‘¥°“√ – ¡¢Õß
metabolite §◊Õ norpethidine ‚¥¬‡©æ“–„πºŸâªÉ«¬∑’Ë¡’¿“«–°“√∑”ß“π¢Õ߉μ≈¥≈ß
‰¡àπ‘¬¡ tramadol ‡π◊ËÕß®“°¡’ ceiling analgesic effect §◊Õ ƒ∑∏‘Ï√–ß—∫ª«¥‰¡à‡æ‘Ë¡¢÷Èπ‡¡◊ËÕ‡æ‘Ë¡¢π“¥¬“
5.1.1.2 Regional administration À√◊Õ regional analgesia ‰¥â·°à
°. Continuous central neuraxial blockade (CCNB) §◊Õ °“√ °—¥°—Èπ√–∫∫ª√– “∑ à«π
°≈“ß·∫∫μàÕ‡π◊ËÕß ‡ªìπ«‘∏’°“√∑’Ë¡’ª√– ‘∑∏‘¿“æ Ÿß«‘∏’Àπ÷Ëß„π°“√√–ß—∫ª«¥À≈—ߺà“μ—¥ ·≈–¡—°‡ªìπ«‘∏’∑’Ë∂Ÿ°‡≈◊Õ°
‡æ◊ËÕ√–ß—∫ª«¥„π°“√ºà“μ—¥∑’ˇ ’ˬßμàÕ°“√ª«¥√ÿπ·√ß À√◊Õ√–ß—∫¥â«¬«‘∏’¡“μ√∞“π·≈â«¡—°‰¡à‰¥âº≈√–ß—∫ª«¥∑’Ë¥’
‡™àπ °“√ºà“μ—¥∑√«ßÕ° °“√ºà“μ—¥™àÕß∑âÕß °“√‡ª≈’ˬπ¢âÕ‡¢à“ ‡ªìπμâπ
°“√ °—¥°—Èπ√–∫∫ª√– “∑ à«π°≈“ß·∫∫μàÕ‡π◊ËÕß¡’Õ¬Ÿà 2 «‘∏’§◊Õ
1. Continuous spinal analgesia ‰¡à·π–π”„Àℙ₥¬∑—Ë«‰ª
2. Continuous epidural analgesia ·π–𔇪ìπ«‘∏’À≈—° ‚¥¬¬“∑’Ë “¡“√∂„™â ”À√—∫«‘∏’°“√π’È ‰¥â·°à
¬“™“§«“¡‡¢â¡¢âπμË”∑’Ë¡’ƒ∑∏‘Ïπ“𠬓·°âª«¥°≈ÿà¡ opioid ·≈–¬“°≈ÿà¡ adjuvants ‡™àπ ketamine, clonidine,
neostigmine ·μà à«π„À≠ଓ°≈ÿà¡ adjuvants π’ȧ«√„™â‚¥¬ºŸâ‡™’ˬ«™“≠ ‰¡à·π–π”„Àâ„™â„π∑“ߪؑ∫—μ‘∑—Ë«‰ª
‡æ◊ËÕ„Àâ°“√√–ß—∫ª«¥‰¥âº≈¥’ π‘¬¡„™â¬“™“§«“¡‡¢â¡¢âπμË”∑’Ë¡’ƒ∑∏‘Ϭ“«√à«¡°—∫¬“√–ß—∫ª«¥°≈ÿà¡ opioid
¡“°°«à“∑’Ë®–„™â¬“¢π“π„¥¢π“πÀπ÷Ë߇撬ߢπ“π‡¥’¬«
«‘∏’°“√„À⬓∑“ß™àÕ߇Àπ◊Õ‰¢ —πÀ≈—ß (epidural) ‡æ◊ËÕ√–ß—∫ª«¥·∫∫μàÕ‡π◊ËÕß “¡“√∂∑”‰¥âÀ≈“¬«‘∏’
¥—ßπ’È
1. °“√À¬¥Õ¬à“ßμàÕ‡π◊ËÕß (continuous infusion) ‡ªìπ«‘∏’∑’Ëßà“¬ ·μà„π¢≥–‡¥’¬«°—π°Á∑”„Àâ¡’°“√
– ¡¢Õ߬“„πª√‘¡“≥∑’Ë Ÿß·≈–‡°‘¥º≈¢â“߇§’¬ß‰¥âßà“¬
2. °“√‡μ‘¡¬“‡ªìπ§√—Èß (intermittent bolus) «‘∏’°“√π’ȺŸâªÉ«¬®–μâÕß√Õ·æ∑¬å¡“‡μ‘¡¬“„À⇪ìπ√–¬–Ê
μâÕß√Õ¬“ÕÕ°ƒ∑∏‘Ï ∑”„Àâº≈°“√√–ß—∫ª«¥‰¡àμàÕ‡π◊ËÕ߇∑à“«‘∏’·√°
3. Patient-controlled epidural analgesia (PCEA) ‡ªìπ«‘∏’√–ß—∫ª«¥∑’˪√—∫μ“¡§«“¡μâÕß°“√
¢ÕߺŸâªÉ«¬¡“°∑’Ë ÿ¥ °≈à“«§◊ÕºŸâªÉ«¬®–°¥ªÿÉ¡ª≈àÕ¬¬“„Àâμπ‡Õ߉¥â∑—π∑’∑’ˇ√‘Ë¡¡’Õ“°“√ª«¥ ∑”„Àâ≈¥°“√‰¥â¬“‡°‘π
®”‡ªìπ·≈–¡’º≈¢â“߇§’¬ßπâÕ¬°«à“«‘∏’·√° ·μà„π¢≥–‡¥’¬«°—π°Á‡ªìπ«‘∏’°“√∑’Ë¡’§à“„™â®à“¬ Ÿß‡æ√“–μâÕßÕ“»—¬
‡§√◊ËÕß¡◊Õ‡©æ“–„π°“√„À⬓
μ”·ÀπàߢÕß “¬ epidural
¢÷ÈπÕ¬Ÿà°—∫°“√ºà“μ—¥ ·μà¡’À≈—°°“√§◊Õ§«√„Àâª≈“¬ “¬„π™àÕß epidural Õ¬Ÿà°÷Ëß°≈“ߢÕß dermatome
∫√‘‡«≥∑’Ë®–ºà“μ—¥ ‚¥¬‡©æ“–‡¡◊ËÕ„™â¬“™“√à«¡¥â«¬À√◊Õ„™â¬“ opioid „π°≈ÿà¡ lipophilic
¬“™“ ·≈–¬“ opioid ∑’Ë„Àâ∑“ß epidural
¬“™“ Levobupivacaine À√◊Õ bupivacaine ¢π“¥§«“¡‡¢â¡¢âπ∑’Ëπ‘¬¡§◊Õ 0.0625%-0.125% ‚¥¬
º ¡ opioid ‡®◊Õ®“ß ‡™àπ morphine 0.01-0.03 ¡°./¡≈. À√◊Õ fentanyl 1-5 ¡§°./¡≈. √à«¡¥â«¬
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 11
¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬
Opioid ∑’Ë„Àâ∑“ß epidural
Opioid Bolus Onset Peak effect √–¬–‡«≈“ Infusion(¡°.) (π“∑’) (π“∑’) ÕÕ°ƒ∑∏‘Ï (™¡.) (¡°./™¡.)
morphine 1-5 20-30 30-60 6-24 0.1-0.5fentanyl 0.025-0.1 5-10 10-20 1-4 0.025-0.075
ª√‘¡“≥¬“ ”À√—∫°“√À¬¥Õ¬à“ßμàÕ‡π◊ËÕß∑’Ë√–¥—∫ thoracic À√◊Õ lumbar: 3-12 ¡≈./™¡.
”À√—∫ PCEA ∑’Ë√–¥—∫ thoracic À√◊Õ lumbar
background infusion 4-6 ¡≈./™¡.
bolus dose 2-4 ¡≈.
minimum lockout interval 10-30 π“∑’
maximum hourly dose 20 ¡≈.
¢. Continuous peripheral nerve blockade (CPNB) §◊Õ °“√„À⬓™“ºà“π∑“ß “¬§“ ∫√‘‡«≥
‡ âπª√– “∑‡æ◊ËÕ√–ß—∫§«“¡ª«¥ ”À√—∫°“√ºà“μ—¥√–¬“ߧå à«π∫π·≈–≈à“ß ‚¥¬ “¡“√∂§«∫§ÿ¡§«“¡ª«¥‰¥â
π“π°«à“°“√©’¥¬“™“√–ß—∫§«“¡√Ÿâ ÷°‡æ’¬ß§√—È߇¥’¬« (´÷Ëß¡’√–¬–‡«≈“ —Èπª√–¡“≥ 10-24 ™¡.) ∑”„Àâ “¡“√∂
∑”°“¬¿“æ∫”∫—¥‰¥â‡μÁ¡∑’Ë §«∫§ÿ¡§«“¡ª«¥‰¥â¥’°«à“ ¡’º≈¢â“߇§’¬ßπâÕ¬°«à“°“√©’¥¬“·°âª«¥°≈ÿà¡ opioid À√◊Õ
·∫∫ IV PCA ·≈–º≈√–ß—∫ª«¥¡’ª√– ‘∑∏‘¿“æ„°≈⇧’¬ß°—∫«‘∏’ continuous epidural analgesia ‚¥¬∑’Ë¡’
¿“«–·∑√°´âÕππâÕ¬°«à“
5.2 °“√√–ß—∫ª«¥‚¥¬‰¡à„™â¬“ (Nonpharmacological Therapy)
§”·π–π”: °“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬‰¡à„™â¬“¡’®ÿ¥¡ÿàßÀ¡“¬‡æ◊ËÕ π—∫ πÿπ„Àâ°“√√—°…“§«“¡
ª«¥‚¥¬°“√„™â¬“„Àâ ‰¥âº≈¥’¢÷Èπ ‰¡à„™à‡æ◊ËÕ∑¥·∑π°“√„™â¬“·°âª«¥
°≈àÕß∑’Ë 6 °“√√–ß—∫ª«¥‰¥âº≈¥’À√◊Õ‰¡à§”·π–π”: 1) ∑”°“√ª√–‡¡‘π√–¥—∫§«“¡ª«¥À≈—ß„Àâ°“√√—°…“Õ¬à“ß ¡Ë”‡ ¡Õ‡æ◊ËÕª√–‡¡‘πª√– ‘∑∏‘¿“æ
¢Õß°“√√—°…“ §«√„À⺟âªÉ«¬¡’√–¥—∫§«“¡ª«¥ VAS < 4 À√◊Õ¡’§«“¡æ÷ßæÕ„®°—∫°“√
√—°…“§«“¡ª«¥
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3) ª√÷°…“ºŸâ‡™’ˬ«™“≠ Acute Pain Service (APS) ‚¥¬„π·μà≈–‚√ß欓∫“≈§«√¡’°“√
°”Àπ¥π‚¬∫“¬ (Policy) ·≈–«‘∏’°“√ (Procedure) „π°“√¥Ÿ·≈√—°…“§«“¡ª«¥À≈—ß
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APS ‡æ◊ËÕ„Àâ°“√∫√‘°“√·≈–§”ª√÷°…“¥â“π°“√¥Ÿ·≈√—°…“§«“¡ª«¥À≈—ߺà“μ—¥
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***12
√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬
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7.1 º≈¢â“߇§’¬ß/Õ“°“√·∑√° âÕπ®“°°“√„À⬓·°âª«¥·∫∫ systemic º≈¢â“߇§’¬ß®“°¬“ opioids
¥â«¬«‘∏’°“√„À⬓μà“ß Ê ‡™àπ systemic À√◊Õ neuraxial (μ“√“ß∑’Ë 3) ‰¡à·μ°μà“ß°—π º≈¢â“߇§’¬ß¢Õ߬“„π°≈ÿà¡
NSAIDs „À⥟„πμ“√“߬“ (μ“√“ß∑’Ë 17)
μ“√“ß∑’Ë 3: º≈¢â“߇§’¬ß¢Õß epidural opioid ·≈– ¬“™“
Opioid ¬“™“
√–∫∫À“¬„® °¥°“√À“¬„® ¡’º≈πâÕ¬
√–∫∫À—«„®·≈–À≈Õ¥‡≈◊Õ¥ ¡’º≈πâÕ¬ §«“¡¥—π‡≈◊Õ¥μË”, À—«„®‡μâπ™â“
Õ“°“√ßà«ß ÷¡ ¡’ πâÕ¬ À√◊Õ ‰¡à¡’
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Õ“°“√§—π ¡’ ‰¡à¡’
Motor weakness ‰¡à¡’ ¡’
Sensory loss ‰¡à¡’ ¡’
Urinary retention ¡’ ¡’
√–∫∫∑“߇¥‘πÕ“À“√ ≈¥°“√‡§≈◊ËÕπ‰À« ‡æ‘Ë¡°“√‡§≈◊ËÕπ‰À«
7.2 º≈¢â“߇§’¬ß/Õ“°“√·∑√° âÕπ®“°°“√„À⬓·∫∫ regional
7.2.1 · ¥ßº≈¢â“߇§’¬ß¢Õß neuraxial analgesia (μ“√“ß∑’Ë 4)
7.2.2 ¿“«–·∑√° âÕπ∑’Ë√ÿπ·√ß∑’ËÕ“®‡°‘¥‰¥â®“°°“√∑” continuous peripheral nerve blockade
(CPNB)
7.2.2.1 °“√∫“¥‡®Á∫μàÕ‡ âπª√– “∑3 ¡—°‡°‘¥®“°°“√∫“¥‡®Á∫μàÕ‡ âπª√– “∑‚¥¬μ√ß À√◊Õ®“°
°“√∑’Ë·¢πÀ√◊Õ¢“∑’Ë™“ ∑”„À⇰‘¥°“√∫“¥‡®Á∫μàÕ‡ âπª√– “∑Õ◊Ëπ ¢âÕ·π–π”§◊Õ„π°≈ÿà¡∑’Ë ß —¬«à“¡’ªí≠À“‡√◊ËÕß
°“√∫“¥‡®Á∫μàÕ‡ âπª√– “∑¡“°àÕ𠇙àπ ¡’Õ“°“√ paresthesia, dysesthesia ‰¡à§«√∑” continuous peripheral
nerve block À√◊Õ∑”‰¥â·μàμâÕ߇ΩÑ“√–«—߇ªìπ摇»… ¡’°“√»÷°…“√“¬ß“π«à“ ¬“™“Õ“®√∫°«π°“√‡μ‘∫‚μ·≈–
regeneration ¢Õ߇´≈≈åª√– “∑ ¥—ßπ—Èπ§«√æ‘®“√≥“¢âÕ¥’ ·≈–¢âÕ‡ ’¬¢Õß°“√©’¥¬“™“∑’ˇ âπª√– “∑„πºŸâªÉ«¬
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7.2.2.2 °“√μ‘¥‡™◊ÈÕ æ∫ªí®®—¬‡ ’ˬß∑’Ë∑”„À⇰‘¥°“√μ‘¥‡™◊ÈÕ¢Õß CPNB ‰¥â·°à ºŸâªÉ«¬Õ¬Ÿà„πÀÕ
Õ¿‘∫“≈ºŸâªÉ«¬¿“«–«‘°ƒμ, √–¬–‡«≈“∑’Ë„ à “¬π“π°«à“ 48 ™¡., ‰¡à¡’ antibiotic prophylaxis, μ”·Àπàß∑’Ë„ à
“¬ ‡™àπ femoral À√◊Õ axillary ‡π◊ËÕß®“°¡’μàÕ¡‡Àß◊ËÕ¡“° ·≈–¡’·∫§∑’‡√’¬®”π«π¡“° ¢âÕ·π–π”‡æ◊ËÕ≈¥
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 13
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*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***14
√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬¬“
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*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 15
¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬
°“√μ‘¥‡™◊ÈÕ ‰¥â·°à „ à “¬¥â«¬«‘∏’ª√“»®“°‡™◊ÈÕ μ—Èß·μà°“√ «¡‡ ◊ÈÕ§≈ÿ¡ À¡«° Àπâ“°“°ªî¥ª“°·≈–®¡Ÿ° ∂ÿß¡◊Õ
‡≈◊Õ°„™âπÈ”¬“°”®—¥‡™◊ÈÕ™π‘¥ alcoholic antiseptic À√◊Õ chlorhexidine gluconate ‡∑§π‘§·≈–Õÿª°√≥å
°“√„ à “¬∑’ËÕ“®™à«¬‰¥â ‡™àπ Õÿª°√≥å∑’Ë¡’ bacterial filter, À≈’°‡≈’ˬ߰“√‡μ‘¡¬“À≈“¬§√—Èß ·≈–∑” catheter
tunneling ´÷Ëß¡’®ÿ¥ª√– ߧå‡æ◊ËÕ≈¥ catheter movement ·≈–≈¥°“√°√–®“¬¢Õ߇™◊ÈÕ‚√§
7.2.2.3 ¬“™“‡ªìπæ‘… (local anesthetic systemic toxicity, LAST) „π√–À«à“ß∑’ˉ¥â continuous infusion
¢Õ߬“™“ Õ“®‡°‘¥Õ“°“√¢Õ߬“™“‡ªìπæ‘…‰¥â®“°ª≈“¬ “¬Õ¬Ÿà„πÀ≈Õ¥‡≈◊Õ¥ À√◊Õ¬“™“§àÕ¬Ê ∂Ÿ°¥Ÿ¥´÷¡‡¢â“
°√–· ‡≈◊Õ¥ Õ“°“√π’ÈÕ“®‡°‘¥¢÷Èπ∑—π∑’À√◊Õ¡“°°«à“ 1 ™¡. À≈—ß®“°‡√‘Ë¡„À⬓™“ ®÷ߧ«√¡’°“√‡ΩÑ“√–«—ßÕ“°“√
μà“ßÊ ‡À≈à“π’È
ë Õ“°“√∑—Ë«‰ª ‰¥â·°à ª“°¢¡, ™“√Õ∫ª“°, ‡ÀÁπ¿“æ âÕπ (diplopia), ÀŸÕ◊ÈÕ, ¡’‡ ’¬ß„πÀŸ,
¡÷π»’√…–
ë Õ“°“√∑“ß√–∫∫ª√– “∑ ‰¥â·°à ¿“«–√–∫∫ª√– “∑μ◊Ëπμ—« ‰¥â·°à ºŸâªÉ«¬«ÿà𫓬 —∫ π °√–μÿ°
·≈–™—° μ“¡¥â«¬¿“«–√–∫∫ª√– “∑∂Ÿ°°¥ ‰¥â·°à ßà«ß ´÷¡ ‚§¡à“ À√◊Õ À¬ÿ¥À“¬„®
ë √–∫∫À—«„®À≈Õ¥‡≈◊Õ¥ ‰¥â·°à ¿“«–§«“¡¥—π‡≈◊Õ¥μË” À—«„®‡μâπ™â“ ventricular ectopy,
ventricular tachycardia, ventricular fibrillation À√◊Õ asystole
7.2.2.4 °≈â“¡‡π◊ÈÕÕàÕπ·√ß (muscle weakness) ∑”„Àâ ‰¡à “¡“√∂∑”°“¬¿“扥⠧«√√–«—ß°“√À°≈â¡
„πºŸâªÉ«¬∑’ˉ¥â√—∫¬“™“μ≈Õ¥‡«≈“„π à«π¢“ °“√·°â ‰¢§◊Õ≈¥§«“¡‡¢â¡¢âπ¢Õ߬“™“ ∂⓬—߉¡à¥’¢÷Èπ„Àâ≈¥ª√‘¡“≥
¢Õ߬“™“
°≈àÕß∑’Ë 8 √—°…“º≈¢â“߇§’¬ß/Õ“°“√·∑√° âÕπ®“°°“√√–ß—∫ª«¥ (μ“√“ß∑’Ë 4)
§”·π–π”: 1) „À⬓√—°…“Õ“°“√·∑√°´âÕπ®“°°“√√–ß—∫ª«¥μ—Èß·μà‡√‘Ë¡¡’Õ“°“√
2) ∂â“„™â¬“¢π“π‡¥’¬«‰¡à‰¥âº≈ §«√„™â¬“∑’Ë¡’°≈‰°ÕÕ°ƒ∑∏‘Ïμà“ß°—π¡“‡ √‘¡ƒ∑∏‘Ï°—π
°≈àÕß∑’Ë 9 ª√–‡¡‘π√–¥—∫§«“¡ª«¥´È”·≈–∫—π∑÷°§”·π–π”: 1) ∑”°“√ª√–‡¡‘π√–¥—∫§«“¡ª«¥À≈—ß„Àâ°“√√—°…“μ“¡√–¬–‡«≈“Õ¬à“ß ¡Ë”‡ ¡Õ ·≈–
∫—π∑÷°√–¥—∫§«“¡ª«¥„Àâ‡ÀÁπ™—¥‡®π
2) ‡¡◊ËÕ¡’§«“¡ª«¥À≈—ß°“√ºà“μ—¥∑’ËμâÕß°“√°“√√—°…“ ‡°‘¥¢÷ÈπÕ’°„Àâ∑”´È”μ“¡·π«∑“ß
æ—≤π“œ μàÕ‰ª
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***16
√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬
√ÿª§«“¡ª«¥À≈—ߺà“μ—¥‡ªìπÕ“°“√∑’˺ŸâªÉ«¬‰¡à “¡“√∂À≈’°‡≈’ˬ߉¥â ·μà “¡“√∂√–ß—∫‰¥âÕ¬à“ß¡’ª√– ‘∑∏‘¿“æ
‚¥¬«“ß·ºπªÑÕß°—π·≈–§«∫§ÿ¡Õ“°“√ª«¥μ—Èß·μà°àÕπ √–À«à“ß ·≈–À≈—ߺà“μ—¥ §«√„À⧫“¡√Ÿâ·°àºŸâªÉ«¬ „Àâ
ºŸâªÉ«¬‰¥â√—∫¬“μ—Èß·μà‡√‘Ë¡¡’Õ“°“√ª«¥ „À⧫“¡ π„®√à«¡°—∫°“√¥Ÿ·≈∑’Ë∂Ÿ°μâÕ߇À¡“– ¡ ·≈–¡’°“√ª√–‡¡‘𧫓¡
ª«¥Õ¬à“ß ¡Ë”‡ ¡Õ∑—Èß°àÕπ·≈–À≈—ß°“√√—°…“
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 17
¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬
¿“§ºπ«° 1: Incidence / Pathophysiology of
acute postoperative pain
Õÿ∫—μ‘°“√≥å¢Õß°“√√–ß—∫ª«¥‡©’¬∫æ≈—πÀ≈—ߺà“μ—¥ªí®®ÿ∫—𧫓¡ª«¥‰¥â√—∫°“√¬Õ¡√—∫«à“¡’§«“¡ ”§—≠ Õߧ尓√Õπ“¡—¬‚≈°‰¥â∂◊Õ§«“¡ª«¥‡ªìπ —≠≠“≥™’æ
∑’Ë 5 (5th Vital sign) ·μଗßæ∫«à“Àπ÷Ëß„π “¡¢ÕߺŸâªÉ«¬À≈—ߺà“μ—¥μâÕß∑ÿ°¢å∑√¡“π®“°§«“¡ª«¥ „π√–¥—∫
ª“π°≈“ß∂÷ߪ«¥¡“°„π 24 ™¡. À≈—ߺà“μ—¥ ¡’°“√»÷°…“æ∫«à“√âÕ¬≈– 59 ¢ÕߺŸâªÉ«¬∑’Ë√—∫°“√ºà“μ—¥¡’§«“¡
π„®À√◊Õ°—ß«≈‡°’ˬ«°—∫Õ“°“√ª«¥À≈—ߺà“μ—¥2 °“√»÷°…“„πªï æ.». 2545 æ∫«à“√âÕ¬≈– 76 ¢ÕߺŸâªÉ«¬‰¡à∑√“∫
«à“À≈—ߺà“μ—¥®–¡’Õ“°“√ª«¥·º≈¡“°πâÕ¬‡æ’¬ß‰√·≈–π“π‡∑à“„¥ ·≈–¡’‡æ’¬ß√âÕ¬≈– 30 ∑’Ë∑√“∫«à“¡’∑“߇≈◊Õ°
„π°“√√–ß—∫§«“¡ª«¥À≈—ߺà“μ—¥3 °“√√–ß—∫§«“¡ª«¥∂◊Õ‡ªìπ‡√◊ËÕߢÕß¡πÿ…¬∏√√¡ ·≈–¡’º≈¥’„π∑“ߧ≈‘π‘°
ª√– ‘∑∏‘¿“æ¢Õß°“√√–ß—∫§«“¡ª«¥¢÷ÈπÕ¬Ÿà°—∫∑’¡ß“π π‚¬∫“¬ °“√„À⧫“¡√Ÿâ∫ÿ§≈“°√ ºŸâªÉ«¬·≈–≠“μ‘ °“√
ª√–‡¡‘π·≈–°“√√–ß—∫§«“¡ª«¥¥â«¬‡∑§π‘§·≈–¬“∑’Ë∂Ÿ°μâÕß ‚¥¬¡’‡ªÑ“À¡“¬„À⺟âªÉ«¬ ÿ¢ ∫“¬ ‰¡à¡’¿“«–
·∑√° âÕπ·≈–√à“ß°“¬øóôπμ—«‰¥â‡√Á«
欓∏‘°”‡π‘¥¢Õߧ«“¡ª«¥À≈—ߺà“μ—¥ [Pathophysiology of Postoperative Pain]‡¡◊ËÕ‡π◊ÈÕ‡¬◊ËÕ∂Ÿ°∑”≈“¬®“°°“√ºà“μ—¥ ∑”„À⇰‘¥§«“¡ª«¥·∫∫‡©’¬∫æ≈—π æ∫«à“§«“¡√ÿπ·√ߢÕߧ«“¡
ª«¥®– —¡æ—π∏å°—∫§«“¡√ÿπ·√ߢÕß°“√∑”≈“¬‡π◊ÈÕ‡¬◊ËÕÀ√◊Õ™π‘¥¢Õß°“√ºà“μ—¥ °“√ºà“μ—¥∑’Ë —¡æ—π∏å°—∫§«“¡
ª«¥√ÿπ·√ß ‰¥â·°à °“√ºà“μ—¥„π™àÕßÕ° ™àÕß∑âÕß à«π∫π ‰μ ·≈–°“√ºà“μ—¥∑“ßÕÕ√å‚∏ªî¥‘° å §«“¡ª«¥À≈—ß
ºà“μ—¥¡—°≈¥≈ß¿“¬„π 2-3 «—π ∂â“Õ“°“√ª«¥¬—߇ªìπ¡“°Õ¬ŸàÀ√◊Õ¡’§«“¡ª«¥‡°‘¥¢÷Èπ„À¡à μâÕßÀ“ “‡Àμÿ ‡™àπ °“√
Õ—°‡ ∫∑’Ë·º≈ À√◊Õ¡’¿“«–·∑√° âÕπ„π™àÕß∑âÕß ‡ªìπμâπ
°“√√–ß—∫§«“¡ª«¥À≈—ߺà“μ—¥§◊Õ°“√ °—¥°—ÈπÀ√◊Õ¬—∫¬—Èß°“√ àß —≠≠“≥§«“¡ª«¥ ¥â«¬°≈‰°μà“ßÊ ¥—ßπ—Èπ
°“√‡¢â“„®∂÷ß°≈‰°°“√ àß —≠≠“≥§«“¡ª«¥®–∑”„À⇢Ⓞ®∂÷ß°≈‰°°“√ÕÕ°ƒ∑∏‘Ï¢Õ߬“·°âª«¥‰¥â¥’¢÷Èπ
º≈‡ ’¬∑’ˇ°‘¥®“°§«“¡ª«¥‡¡◊ËÕ‡π◊ÈÕ‡¬◊ËÕ‰¥â√—∫Õ—πμ√“¬®“°°“√ºà“μ—¥∑”„À⇰‘¥§«“¡ª«¥¢÷Èπ √–∫∫μà“ßÊ „π√à“ß°“¬®–¡’ªØ‘°‘√‘¬“
μÕ∫ πÕßμàÕ§«“¡ª«¥À≈“¬√–∫∫ ‡™àπ √–∫∫À“¬„® √–∫∫À—«„®·≈–À≈Õ¥‡≈◊Õ¥ √–∫∫μàÕ¡‰√â∑àÕ ·≈–√–∫∫
∑“߇¥‘πÕ“À“√ ‡ªìπμâπ (μ“√“ß∑’Ë 5)
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***18
√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬
μ“√“ß∑’Ë 5: °“√‡ª≈’ˬπ·ª≈ß∑“ß √’√«‘∑¬“∑’ˇ°‘¥®“°§«“¡ª«¥
Õ«—¬«–
√–∫∫∑“߇¥‘πÀ“¬„®:°≈â“¡‡π◊ÈÕμ÷ßμ—« ≈¥°“√¢¬“¬¢Õߪե (compliance)
√–∫∫À—«„®-À≈Õ¥‡≈◊Õ¥:À—«„®∑”ß“π¡“°¢÷Èπ ®“°°“√°√–μÿâπ°“√À≈—Ëßcatecholamine ·≈– angiotensin II
√–∫∫μàÕ¡‰√â∑àÕ:‡æ‘Ë¡°“√À≈—ËߌÕ√å‚¡πë Adrenocorticotropinë Cortisolë Glucagonë Epinephrineë Aldosteroneë Antidiureticë Catecholamine
ë Angiotension II
≈¥°“√À≈—Ëß ŒÕ√å‚¡πë Insulinë Testosterone
√–∫∫¬àÕ¬Õ“À“√
√–∫∫∑“߇¥‘πªí “«–‡æ‘Ë¡ sphincter tone, ≈¥ smooth muscle tone
√–∫∫°“√·¢Áßμ—«¢Õ߇≈◊Õ¥‡°≈Á¥‡≈◊Õ¥∑”ß“π¡“°¢÷Èπ °√–μÿâπ¢∫«π°“√·¢Áßμ—«¢Õ߇≈◊Õ¥≈¥¢∫«π°“√≈–≈“¬≈‘Ë¡‡≈◊Õ¥ (fibrinolysis)
√–∫∫¿Ÿ¡‘§ÿâ¡°—π‡¡Á¥‡≈◊Õ¥¢“«‡æ‘Ë¡¢÷Èπ ·μà lymphocyte ≈¥≈ß≈¥¢∫«π°“√ √â“߇¡Á¥‡≈◊Õ¥ killer T-cell, cytotoxicity ≈¥≈ß
¥â“π®‘μ„®
Õ“°“√∑“ߧ≈‘π‘°
ë ÕÕ°´‘‡®π„π‡≈◊Õ¥μË”ë §“√å∫Õπ‰¥ÕÕ°‰´¥å„π‡≈◊Õ¥ Ÿßë ∂ÿß≈¡·ø∫ë ªÕ¥Õ—°‡ ∫ë Ventilation-perfusion mismatch
ë À—«„®‡μâπ‰¡à‡ªìπ®—ßÀ«–ë ‡®Á∫Àπâ“Õ° ¡’¿“«–À—«„®¢“¥‡≈◊Õ¥ë À—«„®«“¬
ë °“√ ≈“¬‚ª√μ’π (protein catabolism)ë °“√ ≈“¬‰¢¡—π (Lipolysis)ë À—«„®«“¬ (Congestive heart failure)ë πÈ”μ“≈„π‡≈◊Õ¥ Ÿßë πÈ”μ“≈„π‡≈◊Õ¥ Ÿßë Salt-water retentionë À—«„®∫’∫μ—«¡“°¢÷Èπë À—«„®‡μâπ‡√Á«ë Salt-water retentionë À≈Õ¥‡≈◊Õ¥À¥μ—«
ë πÈ”μ“≈„π‡≈◊Õ¥ Ÿßë ≈¥°“√ √â“ß‚ª√μ’π
ë ≈”‰ ⇧≈◊ËÕπ‰À«≈¥≈ß
ë ªí “«–§—Ëß (urinary retention)
ë ‡æ‘Ë¡ thromboembolic phenomena
ë ≈¥¿Ÿ¡‘§ÿâ¡°—π¢Õß√à“ß°“¬
ë °—ß«≈ Àßÿ¥Àß‘¥·≈–‰¡à ∫“¬„®
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 19
¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬
¿“§ºπ«° 2: Pain Pathways
1. °“√·ª≈ß —≠≠“≥§«“¡ª«¥(transduction) ·≈–°“√ àß —≠≠“≥§«“¡ª«¥ (transmission)
§◊Õ ‡¡◊ËÕ¡’°“√∑”≈“¬‡π◊ÈÕ‡¬◊ËÕÀ√◊Õ°“√ºà“μ—¥ ®–°√–μÿâπ
nociceptor ´÷Ë߇ªìπª≈“¬ª√– “∑¢Õ߇´≈≈åª√– “∑√—∫ —≠≠“≥
§«“¡ª«¥μ—«·√° (primary afferent neuron) —≠≠“≥§«“¡ª«¥
®–∂Ÿ° à߉ªμ“¡ small myelinated A-delta fibers ·≈– unmyelinated
C-fibers ‡¢â“ Ÿà primary afferent neuron „π dorsal root ganglion
(DRG) ´÷Ëß®– àß —≠≠“≥§«“¡ª«¥μàÕ‰ª¬—ß secondary neuron ∑’Ë
∫√‘‡«≥ dorsal horn ¢Õߪ√– “∑‰¢ —πÀ≈—ß ‡æ◊ËÕ àߢ÷Èπ‰ª Ÿà√–∫∫
ª√– “∑ à«π∫𠇙àπ thalamus ·≈– cerebral cortex (√Ÿª∑’Ë 2)
°“√ àß°√–· ª√– “∑®–„™â neurotransmitters ∑’Ë ”§—≠
‰¥â·°à prostaglandin E2 (PG E2) ·≈– substance P ∑’Ë peripheral
nociceptor ·≈– glutamate ∑’Ë dorsal horn ¢Õ߉¢ —πÀ≈—ß
2. °“√ª√—∫‡ª≈’ˬπ —≠≠“≥§«“¡ª«¥ (modulation) ∑’Ë
dorsal horn ¢Õ߉¢ —πÀ≈—ߪ√–°Õ∫¥â«¬2.1 °“√§«∫§ÿ¡‚¥¬‡´≈≈åª√– “∑¿“¬„π dorsal horn
¢Õ߉¢ —πÀ≈—ß (endogenous pain modulation) ºà“π
∑“ß neurotransmitters ‡™àπ endogenous opioids
·≈– calcium
2.2 °“√§«∫§ÿ¡®“°ª√– “∑ à«π∫π (descending modu-
latory system) ‡™àπ thalamus ·≈– cerebral cortex
´÷Ë߬—∫¬—Èß°“√∑”ß“π¢Õ߇´≈≈åª√– “∑¿“¬„π dorsal
horn ºà“π∑“ß neurotransmitters ™π‘¥μà“ßÊ ‰¥â·°à
serotonin, dopamine, norepinephrine ·≈– opioids
3. °“√√—∫√Ÿâ§«“¡ª«¥ (perception) ‡ªìπ°√–∫«π°“√ ÿ¥∑⓬∑’ˇ°‘¥¢÷Èπ„π ¡Õß ∑”„Àâ√—∫√Ÿâ∂÷ߧ«“¡ª«¥·≈–√Ÿâ ÷°‰¡àæ÷ßæÕ„®
°“√π” —≠≠“≥§«“¡ª«¥
√Ÿª∑’Ë 2: °“√π” —≠≠“≥§«“¡ª«¥
Cerebral cortex
Thalamus
Spinal tracts
Dorsal horn
Peripheral nerve
Pain source
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***20
√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬
¿“§ºπ«° 3: Pain Assessment
‡§√◊ËÕß¡◊Õ ”À√—∫ª√–‡¡‘π√–¥—∫§«“¡ª«¥ (√Ÿª∑’Ë 3)Numerical Rating Scale (NRS) ‡ªìπ‡§√◊ËÕß¡◊Õ∑’Ëπ‘¬¡„™â„π∑“ߧ≈‘π‘°‡æ√“– –¥«° „À⺟âªÉ«¬∫Õ°
§–·π𧫓¡ª«¥‡ªìπμ—«‡≈¢ ‚¥¬ 0 §–·ππÀ¡“¬∂÷߉¡àª«¥ 1-9 §–·ππÀ¡“¬∂÷ߪ«¥¡“°¢÷Èπμ“¡≈”¥—∫ ·≈–
10 §–·ππÀ¡“¬∂÷ߪ«¥¡“°∑’Ë ÿ¥‡∑à“∑’Ë®–§‘¥‰¥â
Verbal Rating Scale (VRS) „™â ”À√—∫ºŸâªÉ«¬∑’ˉ¡à “¡“√∂∫Õ°√–¥—∫§«“¡ª«¥‡ªìπμ—«‡≈¢‰¥â ‚¥¬
Õ“®·∫àßÕÕ°‡ªìπ 5 √–¥—∫§◊Õ ‰¡àª«¥, ª«¥πâÕ¬, ª«¥ª“π°≈“ß, ª«¥¡“° ·≈– ª«¥¡“°∑’Ë ÿ¥‡∑à“∑’Ë®–§‘¥‰¥â
Visual Analog Scale (VAS) „™â ‰¡â∫√√∑—¥À√◊Õ‡ âπμ√ß∑’Ë¡’§«“¡¬“« 10 ´¡. ‚¥¬‡√‘Ë¡®“° 0 ´¡.
À¡“¬∂÷߉¡àª«¥ ∂÷ß 10 ´¡. À¡“¬∂÷ߪ«¥¡“°∑’Ë ÿ¥‡∑à“∑’Ë®–§‘¥‰¥â ‚¥¬„À⺟âªÉ«¬°“°∫“∑ (X) ∫π‡ âπμ√ß μ“¡
√–¥—∫§«“¡ª«¥®√‘ߢÕߺŸâªÉ«¬ ∑—Èßπ’È ‡ âπμ√ßμâÕ߉¡à¡’μ—«Àπ—ß ◊ÕÀ√◊Õμ—«‡≈¢„¥Ê °”°—∫ ¬°‡«âπ∑’˪≈“¬∑—Èß Õß
¢â“߇∑à“π—Èπ
Face pain scale „™â√Ÿª· ¥ß§«“¡√Ÿâ ÷°∑“ß„∫Àπâ“ ‡À¡“– ”À√—∫‡¥Á°Õ“¬ÿ 5-8 ªï À√◊ÕºŸâªÉ«¬∑’ˉ¡à
“¡“√∂∫Õ°§«“¡ª«¥‡ªìπμ—«‡≈¢ ·μà “¡“√∂™’È∑’Ë„∫ÀπⓇæ◊ËÕ∫Õ°√–¥—∫§«“¡ª«¥¢Õßμπ‡Õ߉¥â
§”·π–π”:
ë „Àâ„™â§Ì“«à“ 燮Á∫é À√◊Õ骫¥é μ“¡§«“¡‡À¡“– ¡·°àºŸâªÉ«¬‡¥Á°·μà≈–§π
ë °“√„À⧖·ππ‰¡à„™à¥Ÿ≈—°…≥– ’Àπâ“¢Õ߇¥Á°‡∑’¬∫°—∫„∫Àπâ“„π√Ÿª ·μà„À⺟âªÉ«¬™’È√ŸªÀπâ“∑’Ë· ¥ß√–¥—∫
§«“¡ª«¥¢Õßμπ‡Õß „À⧖·ππμ“¡√ŸªÀπâ“∑’ˇ≈◊Õ° 0, 2, 4, 6, 8, 10 μ“¡≈Ì“¥—∫
ë μ—«Õ¬à“ß°“√ Õ𠇙àπ ç√ŸªÀπâ“μàÕ‰ªπ’È®–· ¥ß„Àâ‡ÀÁπ«à“¡’§«“¡ª«¥¡“°‡∑à“‰√ √Ÿª´â“¬ ÿ¥· ¥ß«à“
‰¡àª«¥‡≈¬ √ŸªÀπâ“∂—¥¡“· ¥ß«à“ª«¥¡“°¢÷Èπ¡“°¢÷Èπ (™’È√ŸªÀπâ“®“°´â“¬¡“¢«“) ®π∂÷ß√Ÿª¢«“ ÿ¥
· ¥ß«à“ª«¥¡“°Ê „ÀâÀπŸ™’È√ŸªÀπâ“∑’Ë· ¥ß«à“ μÕππ’ÈÀπŸª«¥¡“°·§à‰Àπé
‡§√◊ËÕß¡◊Õª√–‡¡‘π√–¥—∫§«“¡ª«¥Õ◊ËπÊ ‰¥â·°àNewborn & Infant Pain Scale (NIPS) ”À√—∫‡¥Á° 0-1 ªï (μ“√“ß∑’Ë 6) §–·ππ∑’Ë¡“°°«à“ > 4
À¡“¬∂÷ß¡’§«“¡ª«¥ μâÕß„À⬓
The FLACC Behavioral Pain Scale (μ“√“ß∑’Ë 7) “¡“√∂„™â∫Õ°√–¥—∫§«“¡ª«¥¢ÕߺŸâªÉ«¬∑’ˉ¡à
“¡“√∂∫Õ°‡ªìπ§–·π𪫥¥â«¬μπ‡Õ߉¥â ª√–°Õ∫¥â«¬ 5 à«π ‰¥â·°à °“√ª√–‡¡‘π°“√· ¥ßÕÕ°∑“ß„∫Àπâ“
°“√¢¬—∫¢Õߢ“ °“√‡§≈◊ËÕπ‰À« °“√√âÕ߉Àâ ·≈–°“√μÕ∫ πÕßμàÕ°“√ª≈Õ∫‚¬π ÷Ëß·μà≈– à«π ¡’§–·ππ 0-2
√«¡∑—ÈßÀ¡¥ 10 §–·ππ
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 21
¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬
μ“√“ß∑’Ë 7: The FLACC Behavioral Pain Scale
Categories Definition Scoring
’Àπâ“ (Face) ‡©¬ ‰¡à¬‘È¡ 0Àπâ“쓇∫– À√◊Õ¢¡«¥§‘È« ∂Õ¬Àπ’ ‰¡à π„® ‘Ëß·«¥≈âÕ¡‡ªìπ∫“ߧ√—Èß 1§“ß —Ëπ °—¥øíπ·πà𠇪ìπ∫àÕ¬Ê À√◊Õμ≈Õ¥‡«≈“ 2
¢“ (Legs) Õ¬Ÿà„π∑à“ª°μ‘ À√◊Õ∑à“ ∫“¬Ê 0Õ¬Ÿà„π∑à“‰¡à ∫“¬ °√– —∫°√– à“¬ ‡°√Áß 1‡μ–À√◊ÕßÕ¢“¢÷Èπ 2
°“√‡§≈◊ËÕπ‰À« πÕπ‡ß’¬∫Ê ∑à“ª°μ‘ ‡§≈◊ËÕπ‰À« ∫“¬Ê 0(Activity) ∫‘¥μ—«‰ª¡“ ·ÕàπÀπâ“·ÕàπÀ≈—ß ‡°√Áß 1
μ—«ßÕ ‡°√Áß®πμ—«·¢Áß À√◊Õ —Ëπ°√–μÿ° 2
√âÕ߉Àâ (Cry) ‰¡à√âÕß (μ◊ËπÀ√◊ÕÀ≈—∫°Á‰¥â) 0§√“ߌ◊ÕÊ À√◊Õ§√“߇∫“Ê ∫àπ‡ªìπ∫“ߧ√—Èß 1√âÕ߉Àâμ≈Õ¥ À«’¥√âÕß –Õ÷° –Õ◊Èπ ∫àπ∫àÕ¬Ê 2
°“√μÕ∫ πÕßμàÕ ‡™◊ËÕøíߥ’ ∫“¬Ê 0°“√ª≈Õ∫‚¬π “¡“√∂ª≈Õ∫‚¬π¥â«¬°“√ —¡º— ‚Õ∫°Õ¥ 查§ÿ¬¥â«¬ 1(Consolability) ‡æ◊ËÕ¥÷ߥŸ¥§«“¡ π„®‡ªìπ√–¬–Ê
¬“°∑’Ë®–ª≈Õ∫‚¬πÀ√◊Õ∑”„Àâ ∫“¬ 2
μ“√“ß∑’Ë 6: Newborn & Infant Pain Scale (NIPS)
μ—«™’È«—¥ 0 1 2
’Àπâ“ - ‡©¬Ê ∫“¬ - · ¬– ª“°‡∫– ®¡Ÿ°¬àπ §‘È«¬àπ ªî¥μ“·πàπ
√âÕ߉Àâ - ‰¡à√âÕß - √âÕߧ√“ß - °√’¥√âÕß
°“√À“¬„® - À“¬„® ¡Ë”‡ ¡Õ - À“¬„®‡√Á«¢÷ÈπÀ√◊Õ™â“≈ß À√◊Õ°≈—ÈπÀ“¬„®
·¢π - «“ß ∫“¬Ê - ßÕ
¢“ - «“ß ∫“¬Ê - ßÕ / ‡À¬’¬¥
√–¥—∫°“√μ◊Ëπ - À≈—∫ / μ◊Ëπ - °√– —∫°√– à“¬ «ÿà𫓬
The CHEOPS Behavioral Pain Scale (μ“√“ß∑’Ë 8) ‡À¡“– ”À√—∫‡¥Á°Õ“¬ÿ 1-6 ªï∑’ˉ¡à “¡“√∂
∫Õ°√–¥—∫§«“¡ª«¥¥â«¬μπ‡Õ߉¥â ‡§√◊ËÕß¡◊Õ¡’§–·ππ√«¡μ—Èß·μà 4-13
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***22
√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬
μ“√“ß∑’Ë 8: The CHEOPS Behavioral Pain Scale
æƒμ‘°√√¡™’È«—¥ 0 1 2 3
√âÕ߉Àâ - - ‰¡à√âÕß - §√“ß, √âÕ߉Àâ - À«’¥√âÕß
°“√‡ª≈à߇ ’¬ß - 查 πÿ°√à“‡√‘ß - ∫àπÕ◊ËπÊ ‡™àπ À‘« - ∫à𪫥 + ∫àπÕ◊ËπÊ æŸ¥∑“ß∫«° À“·¡à À√◊Õ‰¡à查
’Àπâ“ - ¬‘È¡ - ‡©¬ - ‡∫â -
∑à“∑“ߢÕß≈”μ—« - - ∏√√¡¥“ ∫“¬Ê - ¥‘Èπ‰ª¡“/‡°√Áß/μ—«ßÕ·¢Áß/ - —Ëπ/¬◊π/¥‘Èπ®π∂Ÿ°®—∫μ√÷߉«â
°“√ —¡º— ·º≈ - - ‰¡à —¡º— - ‡Õ◊ÈÕ¡¡◊Õ¡“∑’Ë·º≈/·μ–·º≈ - ‡∫“Ê/μ–ª∫·º≈/ ‡Õ◊ÈÕ¡¡◊Õ¡“ ®πμâÕß®—∫¡◊ÕÀ√◊Õ·¢π‰«â/ ‡°√Áß·¢π‰¡à„Àâ∂Ÿ°·º≈
¢“ - - ∑à“ ∫“¬ - ∫‘¥μ—«‰ª¡“/‡μ–/¥÷ߢ“Àπ’/ - ‡°√Áß/¬◊π/¥‘Èπ®π∂Ÿ°®—∫À√◊Õ μ√÷߉«â/‡°√Á߉¡à‡§≈◊ËÕπ‰À«
μ“√“ß∑’Ë 9: °“√ª√–‡¡‘𧫓¡ª«¥®“°°“√ —߇°μæƒμ‘°√√¡¢ÕߺŸâªÉ«¬ (Behavioral Pain Assessment Scale) ”À√—∫ºŸâªÉ«¬∑’ˉ¡à “¡“√∂∫Õ°√–¥—∫§«“¡ª«¥‰¥â¥â«¬μπ‡Õß „™â°“√ —߇°μ∑“ߧ≈‘π‘° „À⇪ìπ§–·ππ 0-10
Categories 0 1 2
’Àπâ“ ’Àπ⓺àÕπ§≈“¬ Àπâ“π‘Ë«§‘È«¢¡«¥ Àπâ“π‘Ë«§‘È«¢¡«¥μ≈Õ¥‡«≈“(Face) Àπ⓬Ÿà¬’Ë °—¥øíπ·πàπ
§«“¡°√–«π°√–«“¬ ‡ß’¬∫ ºàÕπ§≈“¬ °√–«π°√–«“¬ °√–«π°√–«“¬μ≈Õ¥‡«≈“(Restlessness) ‡§≈◊ËÕπ‰À«ª°μ‘ °√– —∫°√– à“¬‡ªìπ∫“ߧ√—Èß ‡§≈◊ËÕπ‰À«·¢π¢“·≈–»’√…–
§«“¡μ÷ßμ—«¢Õß §«“¡μ÷ßμ—«¢Õß ‡æ‘Ë¡§«“¡μ÷ßμ—«¢Õß°≈â“¡‡π◊ÈÕ ‡°√Áß °≈â“¡‡π◊ÈÕ·¢Áß°≈â“¡‡π◊ÈÕ* °≈â“¡‡π◊ÈÕª°μ‘ ßÕπ‘È«¡◊Õ π‘È«‡∑â“(Muscle tone) ºàÕπ§≈“¬
°“√ à߇ ’¬ß** ‰¡à à߇ ’¬ßº‘¥ª°μ‘ √âÕߧ√«≠§√“߇ªìπ∫“ߧ√—Èß √âÕߧ√«≠§√“ß μ≈Õ¥‡«≈“(Vocalization)
°“√ª≈Õ∫‚¬π ∫“¬„® ºàÕπ§≈“¬‚¥¬°“√ —¡º— ‰¡à “¡“√∂ºàÕπ§≈“¬‡≈¬(Consolability) ºàÕπ§≈“¬ ·≈–查§ÿ¬¥÷ߧ«“¡ π„®‰ª ‚¥¬°“√ —¡º— ·≈–查§ÿ¬
®“°§«“¡ª«¥‰¥â
* °“√ª√–‡¡‘𧫓¡μ÷ßμ—«¢Õß°≈â“¡‡π◊ÈÕ„πºŸâªÉ«¬∑’Ë¡’ªí≠À“‰¢ —πÀ≈—ß „Àâ∑”‡Àπ◊Õ√–¥—∫∑’Ë¡’°“√∫“¥‡®Á∫ ª√–‡¡‘πºŸâªÉ«¬Õ—¡æ“μ§√÷Ëß´’°¥â“π∑’ˉ¡à‡ªìπ‚√§
** ‰¡à “¡“√∂ª√–‡¡‘π°“√ à߇ ’¬ß„πºŸâªÉ«¬∑’Ë¡’°“√™à«¬À“¬„®
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 23
¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬
Behavioral Pain Assessment Scale (μ“√“ß∑’Ë 9) ‡ªìπ‡§√◊ËÕß¡◊Õª√–‡¡‘𧫓¡ª«¥ ”À√—∫ºŸâªÉ«¬
∑’ˉ¡à “¡“√∂ ◊ËÕ “√¥â«¬μ—«‡Õ߉¥â „πÀÕºŸâªÉ«¬«‘°ƒμ À√◊ÕºŸâªÉ«¬∑’Ë√–¥—∫§«“¡√Ÿâ ÷°μ—«πâÕ¬≈ß ‚¥¬„™â°“√ª√–‡¡‘π
®“°°“√ —߇°μæƒμ‘°√√¡·≈–°“√‡ª≈’ˬπ·ª≈ߢÕß —≠≠“≥™’懪ìπ√“¬Ê ‰ª
—߇°μæƒμ‘°√√¡¢ÕߺŸâªÉ«¬·≈â«„À⧖·ππ„π·μà≈–™àÕß √«¡‡ªìπº≈√«¡
0 = ‰¡à¡’À≈—°∞“π«à“ª«¥ 1-3 = ª«¥πâÕ¬ 4-5 = ª«¥ª“π°≈“ß 6 ¢÷Èπ‰ª = ª«¥√ÿπ·√ß
∂â“ “¡“√∂„À⺟âªÉ«¬ª√–‡¡‘𧫓¡ª«¥¥â«¬μπ‡Õ߉¥â®–¥’∑’Ë ÿ¥ °“√ª√–‡¡‘ππ’È„™â°—∫°√≥’∑’˺ŸâªÉ«¬ª√–‡¡‘π
§«“¡ª«¥¥â«¬μπ‡Õ߉¡à‰¥â ‚¥¬¥—¥·ª≈ß®“° FLACC scale “¡“√∂„™â∑—Èß„π‡¥Á°·≈–ºŸâ„À≠à ºŸâ„°≈♑¥∑’Ë
§ÿâπ‡§¬°—∫ºŸâªÉ«¬Õ“®™à«¬„π°“√ª√–‡¡‘π‰¥â¥’ °√≥’∑’Ë ß —¬«à“ª«¥®√‘ßÀ√◊Õ‰¡à °“√„À⬓·°âª«¥Õ“®™à«¬∑—Èß°“√
«‘π‘®©—¬·≈–°“√√—°…“§«“¡ª«¥‰¥â
¿“§ºπ«° 4: Multimodal Analgesia
μ“√“ß∑’Ë 10: ¬“∑’Ë “¡“√∂‡≈◊Õ°„™â„π multimodal analgesia
¬“ °≈‰°°“√ÕÕ°ƒ∑∏‘Ï·°âª«¥
Paracetamol ë °√–μÿâπ CB-1 receptor „π√–∫∫ª√– “∑ à«π°≈“ßë ≈¥°“√ √â“ß prostaglandin E2 ‚¥¬√∫°«π peroxidase activity
¢Õß cyclooxygenase 2 (COX-2) „π√–∫∫ª√– “∑ à«π°≈“ß
NSAIDs ·≈– COX-2 inhibitors ë ≈¥°“√ √â“ß prostaglandin E2 ‚¥¬¬—∫¬—Èß°“√∑”ß“π¢Õß COX-2(coxibs) „π∫√‘‡«≥∑’Ë¡’°“√Õ—°‡ ∫·≈–„π√–∫∫ª√– “∑ à«π°≈“ß
Opioids: ë °√–μÿâπ μ receptor ¡’º≈°¥°“√ àß —≠≠“≥§«“¡ª«¥∑ÿ°√–¥—∫°≈ÿà¡ weak opioids ‡™àπtramadol ·≈– codeine°≈ÿà¡ strong opioids ‡™àπmorphine pethidine(meperidine) ·≈– fentanyl
Gabapentin, Pregabalin* ë ªî¥°—Èπ α2δ1 calcium channel ∑’Ë nociceptive fiber „π spinalcord* ‰¡à·π–π”„Àâ„™â„π acute postoperative pain ∑—Ë«‰ª
Local anesthetics ë ªî¥°—Èπ sodium channel „π«‘∂’ª√– “∑√—∫§«“¡ª«¥ „πμ”·Àπàß∑’Ë∫√‘À“√¬“
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***24
√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬
μ—«Õ¬à“ߢÕß°“√‡≈◊Õ°„™â¬“·°âª«¥√à«¡°—πμ“¡√–¥—∫§«“¡√ÿπ·√ß ‰¥â·°à
ª«¥√–¥—∫πâÕ¬ ‡™àπ breast mass excision ·≈– diagnostic laparoscopy ‡ªìπμâπ
ë Paracetamol 1,000 ¡°. «—π≈– 4 §√—Èß ·∫∫ around the clock 1-3 «—π ®÷߇ª≈’ˬπ‡ªìπ p.r.n.
ë Õ“®æ‘®“√≥“„Àâ NSAIDs À√◊Õ coxib 1 ™π‘¥ (∂Ⓣ¡à¡’¢âÕÀâ“¡) ·∫∫ around the clock √à«¡¥â«¬
1-3 «—π
ë ∂⓺ŸâªÉ«¬„™â NSAIDs À√◊Õ coxib ‰¡à‰¥â æ‘®“√≥“„™â opioid 1 ™π‘¥‡ªìπ¬“À≈—°·∫∫ around the
clock ·≈– „™â opioid ™π‘¥‡¥’¬«°—π‡ªìπ rescue analgesic ‚¥¬Õ“®‡≈◊Õ°„™â weak opioid À√◊Õ low dose
strong opioid
ª«¥√–¥—∫ª“π°≈“ß ‡™àπ hysterectomy ·≈– jaw surgery ‡ªìπμâπ
ë Paracetamol 1,000 ¡°. «—π≈– 4 §√—Èß ·∫∫ around the clock 3 «—π ®÷߇ª≈’ˬπ‡ªìπ p.r.n.
ë „Àâ opioid 1 ™π‘¥ ·∫∫ around the clock ‚¥¬Õ“®‡≈◊Õ° weak À√◊Õ low dose strong opioid
‡ªìπ¬“À≈—° ·≈–„™â strong opioid ™π‘¥‡¥’¬«°—π‡ªìπ rescue analgesic
ë Õ“®æ‘®“√≥“„Àâ NSAIDs À√◊Õ coxib 1 ™π‘¥ (∂Ⓣ¡à¡’¢âÕÀâ“¡) √à«¡¥â«¬ 3 «—π
ª«¥√–¥—∫√ÿπ·√ß ‡™àπ thoracotomy, upper abdominal surgery, aortic surgery, knee replacement
‡ªìπμâπ
ë Paracetamol 1,000 ¡°. «—π≈– 4 §√—Èß ·∫∫ around the clock 3-5 «—π ®÷߇ª≈’ˬπ‡ªìπ p.r.n.
ë Opioid 1 ™π‘¥ ‡ªìπ¬“À≈—°‚¥¬„Àâ strong opioid ·∫∫ around the clock ·≈–„™â opioid ™π‘¥
‡¥’¬«°—π‡ªìπ rescue analgesic
ë Õ“®æ‘®“√≥“„Àâ NSAIDs À√◊Õ coxibs 1 ™π‘¥ (∂Ⓣ¡à¡’¢âÕÀâ“¡) √à«¡¥â«¬ 3-5 «—π
∑—Èßπ’È ‡¡◊ËÕ„¥∑’ˇ√‘Ë¡√—∫ª√–∑“π‰¥â „Àâæ‘®“√≥“‡√‘Ë¡¬“™π‘¥√—∫ª√–∑“π„Àâ‡√Á«∑’Ë ÿ¥ ‡æ◊ËÕ§àÕ¬Ê ≈¥À√◊Õ
‡≈‘°¬“∑’Ë„Àâ∑“ß parenteral
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 25
¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬
¿“§ºπ«° 5: Patient-Controlled Analgesia
°“√μ—Èß§à“ PCA (μ“√“ß∑’Ë 2) ‰¥â·°à °“√μ—Èß§à“™π‘¥¢Õ߬“·°âª«¥ background infusion, bolus dose,
lockout interval
™π‘¥¢Õß opioid24,25
π‘¬¡„™â μ-agonist ÷Ëß¡’ƒ∑∏‘Ï√–ß—∫ª«¥‡∑à“°—π∑’Ë equianalgesic doses ‰¡àπ‘¬¡„™â agonist-antagonists
·≈– partial agonist ‡π◊ËÕß®“°¡’ ceiling effect §◊Õƒ∑∏‘Ï√–ß—∫ª«¥‰¡à‡æ‘Ë¡¢÷Èπ·¡â‡æ‘Ë¡¢π“¥¬“
Morphine ‡ªìπ¬“∑’Ëπ‘¬¡„™â¡“°∑’Ë ÿ¥ ‡π◊ËÕß®“°¡’ƒ∑∏‘Ï√–ß—∫ª«¥π“π ∂Ÿ° ≈“¬‰¥â morphine-6-glucuro-
nide (M6G) ·≈–¢—∫ÕÕ°∑“ß‰μ ´÷Ëß M6G π’È¡’ƒ∑∏‘Ï√–ß—∫ª«¥ ∑”„Àâßà«ß´÷¡·≈–°¥°“√À“¬„®‰¥â ¥—ßπ—Èπ§«√
√–¡—¥√–«—ß °“√„™â morphine „πºŸâªÉ«¬∑’Ë¡’¿“«–‰μ«“¬ (serum creatinine ¡“°°«à“ 2 ¡°./¡≈.)
Fentanyl ‰¡à¡’ active metabolites ‡À¡“–°—∫ºŸâªÉ«¬∑’Ë¡’¿“«–‰μ«“¬ ·≈– histamine release πâÕ¬
‡À¡“–°—∫ºŸâªÉ«¬∑’ˉ«μàÕ histamine ‡™àπ ºŸâªÉ«¬ÀÕ∫À◊¥ À√◊ÕºŸâªÉ«¬∑’Ë¡’º≈¢â“߇§’¬ß®“° morphine ¡“° ·¡â
fentanyl ¡’ƒ∑∏‘Ï√–ß—∫ª«¥ —Èπ·μஓ°º≈°“√»÷°…“æ∫«à“¡’ª√– ‘∑∏‘¿“æ„π°“√√–ß—∫ª«¥À≈—ߺà“μ—¥‰¡àμà“ß®“°
morphine
Pethidine π—Èπ ≈“¬‰¥â norpethidine ÷Ë߉¡à¡’ƒ∑∏‘Ï·°âª«¥ ·μà‡¡◊ËÕ – ¡¡“°®–∑”„À⇰‘¥Õ“°“√°√–«π
°√–«“¬®π∂÷ß™—°‰¥â ®÷߉¡à§«√„Àâ pethidine ¡“°°«à“ 10 ¡°./°°./«—π ·≈–‰¡à§«√„Àâπ“π‡°‘π 3 «—π À√◊Õ‰¡à
§«√‡°‘π 700 ¡°. „π 1 «—π ·≈–‡ªìπ¢âÕÀâ“¡„™â„πºŸâªÉ«¬∑’Ë¡’ª√–«—μ‘™—° ‰μ«“¬ ·≈–ºŸâ∑’ˉ¥â√—∫¬“ monoamine
oxidase inhibitors ‡π◊ËÕß®“°Õ“®∑”„À⇰‘¥ malignant hyperpyrexia syndrome
Tramadol ®—∫°—∫ μ-receptor πâÕ¬°«à“ morphine ª√–¡“≥ 6,000 ‡∑à“ ·μà mono-o-desmethyl ÷Ëß
‡ªìπ metabolite ¢Õß tramadol ®–®—∫°—∫ opiate receptor ‰¥â¥’°«à“ tramadaol ÷Ë߇™◊ËÕ«à“‡ªìπ “√∑’Ë¡’ƒ∑∏‘Ï
√–ß—∫ª«¥¥’°«à“ ¢≥–‡¥’¬«°—π tramadol ¬—ß¡’ƒ∑∏‘Ï√–ß—∫°“√ reuptake ¢Õß norepinephine ·≈– serotonin
∑’Ë√–∫∫ª√– “∑ à«π°≈“ß ÷Ë߇ªìπ°“√ÕÕ°ƒ∑∏‘Ï√–ß—∫ª«¥Õ’°∑“ßÀπ÷Ëߥ⫬ tramadol ¡’ƒ∑∏‘Ϫ√–¡“≥ 1 „π 10
∂÷ß 1 „π 6 ¢Õß morphine
Background (continuous) infusionÀ¡“¬∂÷ß¢π“¥¬“∑’Ë°”Àπ¥„Àâª≈àÕ¬Õ¬à“ßμàÕ‡π◊ËÕß ‚¥¬∑—Ë«‰ª ‰¡à·π–π”„Àâμ—Èß background infusion
μ—Èß·μà·√°„πºŸâªÉ«¬À≈—ߺà“μ—¥ ‡π◊ËÕß®“°º≈°“√»÷°…“ à«π„À≠àæ∫«à“ °“√„Àâ background infusion ‰¡à‰¥â
√–ß—∫ª«¥À√◊Õ∑”„À⺟âªÉ«¬À≈—∫‰¥â¥’¢÷Èπ ‚¥¬ºŸâªÉ«¬¬—ßμâÕß°“√¬“„πª√‘¡“≥∑’ˉ¡àμà“ß®“°∑’ˉ¡à‰¥â„Àâ background
infusion ·μà‡æ‘Ë¡Õ“°“√¢â“߇§’¬ß §◊Õ Õÿ∫—μ‘°“√≥å¢Õß°“√°¥°“√À“¬„®‡æ‘Ë¡¢÷Èπ §◊Õ ®“°√âÕ¬≈– 0.1-0.8 ‡ªìπ
√âÕ¬≈– 1.1-3.9 ‡¡◊ËÕ¡’°“√„™â background infusion √à«¡¥â«¬
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***26
√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬
·μà„πºŸâªÉ«¬∑’ËμâÕß„™â¬“„πª√‘¡“≥¡“° ‡™àπ ºŸâªÉ«¬∑’ˉ¥â√—∫ morphine ¡“π“π°àÕπºà“μ—¥ À√◊Õ„π√“¬∑’Ë
°¥ PCA ∫àÕ¬§√—Èß„π™à«ß 2-4 ™¡. ·√°À≈—ß„™â PCA §«√æ‘®“√≥“μ—Èß background infusion ∑—Èßπ’È ‰¡à§«√
μ—Èߧà“π’È¡“°°«à“√âÕ¬≈– 50 ¢Õߪ√‘¡“≥ opioid ∑’Ë„™â∑—ÈßÀ¡¥ (·ºπ¿Ÿ¡‘∑’Ë 2)
PCA dose (Bolus dose)À¡“¬∂÷ß¢π“¥¬“∑’˪≈àÕ¬ÕÕ°¡“·μà≈–§√—È߇¡◊ËÕºŸâªÉ«¬°¥ªÿÉ¡ª≈àÕ¬¬“ ¢π“¥¢Õß PCA dose ∑’Ë¥’ μâÕß¡’
¢π“¥¬“πâÕ¬∑’Ë ÿ¥∑’Ë∑”„À⺟âªÉ«¬À“¬ª«¥‰¥â ‡æ◊ËÕ„Àâ¡’Õ“°“√¢â“߇§’¬ßπâÕ¬∑’Ë ÿ¥
§«√ª√—∫¢π“¥„Àâ‡À¡“– ¡°—∫ºŸâªÉ«¬·μà≈–√“¬ ‚¥¬§”π÷ß∂÷ßªí®®—¬Õ◊Ëπ√à«¡¥â«¬ ‡™àπ Õ“¬ÿ ‚√§ª√–®”μ—«
‚¥¬≈¥¢π“¥¬“≈ß„πºŸâ ŸßÕ“¬ÿ ‡ªìπμâπ
Lockout intervalÀ¡“¬∂÷ß™à«ß‡«≈“∑’ˇ§√◊ËÕß®–‰¡àª≈àÕ¬¬“·¡â¡’°“√°¥´È” ºŸâªÉ«¬®–‰¥â√—∫Õ’°§√—È߇¡◊ËÕºà“π√–¬–‡«≈“∑’Ë°”Àπ¥π’È
∑”„À⺟âªÉ«¬ª≈Õ¥¿—¬®“°°“√‰¥â√—∫¬“∑’Ë¡“°‡°‘π®π‡ªìπÕ—πμ√“¬
Dose limitsÀ¡“¬∂÷ߪ√‘¡“≥¬“ Ÿß ÿ¥„π√–¬–‡«≈“ 1 ™¡. À√◊Õ 4 ™¡. ∑’Ë°”Àπ¥„Àâ¡’°“√‡μ◊Õπ·æ∑¬å‡æ◊ËÕª√–‡¡‘π
ºŸâªÉ«¬´È”Õ’°§√—Èß ‚¥¬ª°μ‘®–μ—Èߪ√–¡“≥ 10 ¡°. „π‡«≈“ 1 ™¡. À√◊Õ 30 ¡°. „π‡«≈“ 4 ™¡. °“√„À⧫“¡√Ÿâ
‡°’ˬ«°—∫«‘∏’„™â∑’Ë∂Ÿ°μâÕß„Àâ°—∫ºŸâªÉ«¬ ·≈–°“√‡ΩÑ“μ‘¥μ“¡¥Ÿ·≈¢Õ߇®â“Àπâ“∑’ˇªìπ°“√ªÑÕß°—π¿“«–·∑√°´âÕπ‰¥â
¥’°«à“°“√μ—Èߧà“π’È
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 27
¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬
¿“§ºπ«° 6: Continuous Peripheral Nerve Blockade
¢âÕ§«√ªØ‘∫—μ‘ ”À√—∫ peripheral nerve block catheter1. §«√„ à “¬§“ ∑’ˇ âπª√– “∑¥â«¬«‘∏’ª√“»®“°‡™◊ÈÕ ·≈–ªî¥∑—∫¥â«¬·ºàπ„ ª√“»®“°‡™◊ÈÕ‡æ◊ËÕ„Àâ
“¡“√∂μ√«®¥Ÿ§«“¡≈÷° Õ“°“√· ¥ß¢Õß°“√μ‘¥‡™◊ÈÕ‰¥â ·≈–§«√μ√«®¥ŸÕ¬à“ßπâÕ¬«—π≈– 1 §√—Èß
2. §«√∑¥ Õ∫«à“ “¬‰¡à‰¥âÕ¬Ÿà„πÀ≈Õ¥‡≈◊Õ¥ çtest doseé ¥â«¬ 2% lidocaine with epinephrine
1:200,000 ®”π«π 3 ¡≈. (epinephrine = 15 ¡§°.) ·≈â«¥Ÿ°“√μÕ∫ πÕߢÕßÕ—μ√“°“√‡μâπ¢ÕßÀ—«„®
∂â“¡“°¢÷Èπ®“°‡¥‘¡ 10 §√—Èß „π 30-60 «‘π“∑’ ∂◊Õ«à“ “¬Õ¬Ÿà„πÀ≈Õ¥‡≈◊Õ¥
3. ‡Õ“ “¬ÕÕ°‚¥¬„™â«‘∏’ª√“»®“°‡™◊ÈÕ ‡¡◊ËÕ “¡“√∂§«∫§ÿ¡§«“¡ª«¥‰¥â¥â«¬¬“·°âª«¥™π‘¥√—∫ª√–∑“π
4. §«√√–«—ß„π¢≥–∑’ˇՓ “¬ÕÕ° ∂⓺ŸâªÉ«¬¡’Õ“°“√ª«¥μ“¡‡ âπª√– “∑ ·≈–§«√‡ΩÑ“μ‘¥μ“¡Õ’° 24 ™¡.
‡æ◊ËÕ¥ŸÕ“°“√¢Õß nerve injury
5. ¢≥–∑’Ë„À⬓™“‡æ◊ËÕ√–ß—∫ª«¥∑“ß catheter ·¢πÀ√◊Õ¢“π—Èπ®–™“ ¥—ßπ—Èπ§«√‡ΩÑ“√–«—ß°“√∫“¥‡®Á∫μàÕ
‡ âπª√– “∑Õ◊Ëπ®“°∑à“∑“ߢÕߺŸâªÉ«¬ ‡™àπ ulnar nerve ∑’Ë√–¥—∫¢âÕ»Õ°, radial nerve ∑’Ë√–¥—∫ midhumerus
·≈– common peroneal nerve ∑’Ë fibular head §«√¡’À¡ÕπÀ√◊Õºâ“πÿࡪÑÕß°—π°“√°¥‡∫’¬¥À√◊Õ∂Ⓡªìπ·¢π
§«√„ à arm sling √–«—ß„π°√≥’∑’˺ŸâªÉ«¬‰¡à “¡“√∂∫Õ°§«“¡‡®Á∫ª«¥∑’ˇ°‘¥®“° compartment syndrome,
°“√„ à‡ΩóÕ°À√◊Õ‡ΩóÕ°ÕàÕπ∑’Ëæ—π elastic bandage ·πàπ‡°‘π‰ª À√◊Õ‡°‘¥ thermal skin injury ∑’Ë«“ß cold À√◊Õ
warm pad
6. ∂â“„™â stimulating catheter ‰¡à§«√μ—¥ “¬ ‡π◊ËÕß®“°¡’‡ âπ≈«¥¢π“¥‡≈Á°∑’Ëπ”°√–· ‰øøÑ“‰¥âÕ¬Ÿà
¿“¬„πμ≈Õ¥ “¬ °“√μ—¥ “¬Õ“®∑”„À♑Èπ à«π¢Õß≈«¥§â“ßÕ¬Ÿà¿“¬„π√à“ß°“¬‰¥â·≈–∑”„Àâ‡Õ“ “¬ÕÕ°¬“°¢÷Èπ
7. °“√‡ΩÑ“√–«—ß°“√„ à “¬„π°≈ÿࡺŸâªÉ«¬∑’ˉ¥â√—∫¬“ anticoagulant „À⥟·≈‡À¡◊Õπ°—∫ neuraxial catheter
8. ª√‘¡“≥¬“™“·≈–§«“¡‡¢â¡¢âπ¢Õ߬“™“∑’Ë„Àâμ≈Õ¥‡«≈“∑“ß “¬¬—ß¡’§«“¡À≈“°À≈“¬ ‰¡à¡’¢âÕ √ÿª∑’Ë
·πàπÕπ à«π„À≠à¡’√“¬ß“π∑’Ë„™â 0.2% ropivacaine ”À√—∫°“√„À⬓™“μ≈Õ¥‡«≈“ ·μà„πª√–‡∑»‰∑¬¡’
‡©æ“–¬“™“ bupivacaine ·≈– levobupivacaine ÷Ëß¡’ƒ∑∏‘Ï√–ß—∫ª«¥∑’ˇ∑’¬∫‡∑à“°—∫ 0.2% ropivacaine §◊Õ
§«“¡‡¢â¡¢âπ 0.125% levobupivacaine À√◊Õ bupivacaine ¥—ßπ—Èπ ¢âÕ·π–π”¢Õߪ√‘¡“≥·≈–§«“¡
‡¢â¡¢âπμàÕ‰ªπ’ȇªìπ°“√·π–𔇪ìπ™à«ß§à“§«“¡‡¢â¡¢âπ ÷Ëߧ«√ª√—∫‡ª≈’ˬπμ“¡§«“¡μâÕß°“√¢ÕߺŸâªÉ«¬·μà≈–§π
(μ“√“ß∑’Ë 11)
9. «‘∏’¢Õß°“√„À⬓™“μ≈Õ¥‡«≈“∑“ß “¬ perineural catheter ‰¥â·°à «‘∏’ continuous infusion ·≈–
«‘∏’ patient-controlled regional analgesia (PCRA) ™π‘¥ background infusion √à«¡°—∫ bolus mode
®ÿ¥ª√– ߧå‡æ◊ËÕ°“√√–ß—∫§«“¡ª«¥∑’Ë¥’ ·≈– “¡“√∂¢¬—∫·¢πÀ√◊Õ¢“‰¥â ‡æ‘Ë¡§«“¡æ÷ßæÕ„®¢ÕߺŸâªÉ«¬
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***28
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*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 29
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*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***30
√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬
¿“§ºπ«° 7: Patient Groups with Special Problems
°≈ÿࡺŸâªÉ«¬∑’Ë¡’ªí≠À“‡©æ“–
1. °“√√–ß—∫ª«¥À≈—ß°“√ºà“μ—¥„πºŸâªÉ«¬¿“«–«‘°ƒμ (Critically ill patients)À≈—°¢Õß°“√√–ß—∫ª«¥ºŸâªÉ«¬„πÀÕÕ¿‘∫“≈ºŸâªÉ«¬¿“«–«‘°ƒμ ‰¥â·°à
ë «“ß·ºπ°“√√–ß—∫ª«¥„Àâ™—¥‡®π ·≈–·®âß„À⺟⥟·≈ºŸâªÉ«¬√—∫∑√“∫∑—Ë«°—π
ë ª√–‡¡‘𧫓¡ª«¥ ·≈–º≈μÕ∫ πÕßμàÕ°“√√—°…“Õ¬à“ß ¡Ë”‡ ¡Õ
ë °“√ª√–‡¡‘𧫓¡ª«¥¡“μ√∞“π §◊Õ °“√ª√–‡¡‘𧫓¡ª«¥‚¥¬μ—«ºŸâªÉ«¬‡Õß ·μà„π°√≥’∑’˺ŸâªÉ«¬‰¡à
“¡“√∂ ◊ËÕ “√‰¥â μâÕß„™â«‘∏’Õ◊ËπÊ ‡æ◊ËÕª√–‡¡‘𧫓¡ª«¥ ‰¥â·°à °“√ª√–‡¡‘π§–·π𪫥‚¥¬„™â°“√ —߇°μ
æƒμ‘°√√¡ À√◊Õ°“√‡ª≈’ˬπ·ª≈ß∑“ß √’√«‘∑¬“
ë §«√„Àâ°“√√–ß—∫ª«¥Õ¬à“߇撬ßæÕ ·≈–·°â ‰¢ “‡ÀμÿÕ◊ËπÊ ∑’Ë∑”„À⺟âªÉ«¬°√–«π°√–«“¬ °àÕπ∑’Ë®–„Àâ
¬“°≈àÕ¡ª√– “∑„πºŸâªÉ«¬°≈ÿà¡π’È
°“√ª√–‡¡‘𧫓¡ª«¥¢ÕߺŸâªÉ«¬„πÀÕÕ¿‘∫“≈ºŸâªÉ«¬¿“«–«‘°ƒμ‡π◊ËÕß®“°ºŸâªÉ«¬°≈ÿà¡π’ÈÕ“®„ à∑àÕÀ“¬„® À√◊Õ√–¥—∫§«“¡√Ÿâ ÷°μ—«μË”‡π◊ËÕß®“°§«“¡‡®Á∫ªÉ«¬À√◊Õ‰¥â√—∫¬“
∑’Ë°¥√–¥—∫§«“¡√Ÿâ ÷°μ—« ∑”„À⺟âªÉ«¬‰¡à “¡“√∂ ◊ËÕ “√‰¥â °“√ª√–‡¡‘𧫓¡ª«¥®÷ßμâÕßÕ“»—¬°“√ —߇°μ
æƒμ‘°√√¡ À√◊Õ°“√‡ª≈’ˬπ·ª≈ß∑“ß √’√«‘∑¬“
°“√√–ß—∫ª«¥‚¥¬‰¡à„™â¬“
§«“¡‰¡à ÿ¢ ∫“¬¢ÕߺŸâªÉ«¬„πÀÕÕ¿‘∫“≈ºŸâªÉ«¬¿“«–«‘°ƒμ‡°‘¥®“°À≈“¬ªí®®—¬ ®÷ßμâÕß„Àâ°“√¥Ÿ·≈√—°…“
·∫∫ holistic
°“√√–ß—∫ª«¥‚¥¬„™â¬“
°“√√–ß—∫ª«¥∑’ˇªìπÀ≈—° ”À√—∫ºŸâªÉ«¬„πÀÕÕ¿‘∫“≈ºŸâªÉ«¬¿“«–«‘°ƒμ ‰¥â·°à °“√„À⬓·°âª«¥°≈ÿà¡ opioid
∑“ßÀ≈Õ¥‡≈◊Õ¥¥” Àâ“¡„Àâ partial agonist ‡π◊ËÕß®“°Õ“®∑”„À⇰‘¥Õ“°“√∂Õ𬓉¥â„πºŸâªÉ«¬∑’ˉ¥â√—∫ opioid
¡“·≈â«√–¬–Àπ÷Ëß §«√√–¡—¥√–«—ß°“√„™â morphine „πºŸâªÉ«¬∑’Ë¡’°“√∑”ß“π¢Õ߉μ∫°æ√àÕß ‰¡àπ‘¬¡„™â pethidine
‡æ√“–Õ“®∑”„À⇰‘¥°“√ – ¡¢Õß norpethidine ‚¥¬‡©æ“–Õ¬à“߬‘Ëß„πºŸâªÉ«¬∑’Ë¡’°“√∑”ß“π¢Õ߉μ∫°æ√àÕß
À√◊Õ‰¥â√—∫ pethidine ‡ªìπ√–¬–‡«≈“π“π πÕ°®“°π’È pethidine ¬—߇°‘¥ªÆ‘°‘√‘¬“°—∫¬“Õ◊ËπÊ À≈“¬¢π“𠇙àπ
tramadol, MAOI ·≈– selective serotonin reuptake inhibitor ‡ªìπμâπ
fentanyl ∑”„À⇰‘¥°“√‡ª≈’ˬπ·ª≈ߢÕß√–∫∫‰À≈‡«’¬π‡≈◊Õ¥πâÕ¬°«à“ morphine ·¡â«à“ fentanyl
®–À¡¥ƒ∑∏‘χ√Á«®“°¢∫«π°“√ redistribution ·μà°“√„™â¢π“¥ Ÿß‡ªìπ√–¬–‡«≈“π“πÕ“®∑”„À⇰‘¥°“√ – ¡
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 31
¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬
·≈–∑”„Àâ§à“§√÷Ëß™’«‘μ¢Õß°“√¢®—¥¬“¬“«‰¥â ∑—Èß alfentanil ·≈– remifentanil ‡ªìπ¬“∑’Ë¡’§ÿ≥ ¡∫—μ‘∑“ß
pharmacokinetic ∑’Ë¥’ ®÷߇À¡“– ”À√—∫ºŸâªÉ«¬∑’Ë¡’°“√∑”ß“π¢ÕßÕ«—¬«–∫°æ√àÕß °“√°”®—¥ remifentanil ‡ªìπ
‰ªÕ¬à“ß√«¥‡√Á«·≈–‰¡à¢÷Èπ°—∫°“√∑”ß“π¢Õß‰μ ·¡â«à“„πºŸâªÉ«¬∑’Ë¡’°“√∑”ß“π¢Õ߉μ∫°æ√àÕßÕ“®‡°‘¥°“√ – ¡
¢Õß remifentanil acid ÷Ë߇ªìπ active metabolite Õ¬à“ßÕàÕπ‰¥â ·μà°Á‰¡à∑”„À⇰‘¥º≈‡ ’¬„¥Ê μ“¡¡“
dexmedetomidine ‡ªìπ highly selective alpha-2 agonist sedative ∑’Ë¡’ƒ∑∏‘Ï≈¥§«“¡°—ß«≈·≈–
√–ß—∫ª«¥√à«¡¥â«¬ ¢âÕ¥’¢Õß dexmedetomidine §◊Õ “¡“√∂ª√—∫¬“ ‡æ◊ËÕª√—∫√–¥—∫§«“¡§≈“¬°—ß«≈‰¥â¥’„π
¢≥–∑’Ë°¥°“√À“¬„®‡æ’¬ß‡≈Á°πâÕ¬
2. °“√√–ß—∫ª«¥À≈—ß°“√ºà“μ—¥„πºŸâªÉ«¬ ŸßÕ“¬ÿ (Elderly patients)ªí®®—¬∑’Ë¡’º≈„Àâ°“√√–ß—∫ª«¥‡©’¬∫æ≈—π„πºŸâ ŸßÕ“¬ÿ¥âÕ¬ª√– ‘∑∏‘¿“æ ‰¥â·°à
ë ºŸâªÉ«¬¡—°¡’À≈“¬‚√§√à«¡°—π
ë ¡—°„™â¬“À≈“¬¢π“π ∑”„Àâ¡’§«“¡‡ ’Ë¬ß ŸßμàÕ°“√‡°‘¥Õ—πμ√°‘√‘¬“√–À«à“߬“
ë Õ“¬ÿ¡“° ∑”„À⇰‘¥°“√‡ª≈’ˬπ·ª≈ß∑“ß √’√«‘∑¬“ ·≈–‡¿ —™«‘∑¬“
ë ¡’°“√‡ª≈’ˬπ·ª≈ߢÕß°“√μÕ∫ πÕßμàÕ§«“¡ª«¥
ë ª√–‡¡‘𧫓¡ª«¥‰¥â¬“° ÷ËßÕ“®‡°‘¥®“°§«“¡®”∑’Ë≈¥≈ß
°“√ª√–‡¡‘𧫓¡ª«¥„πºŸâªÉ«¬ ŸßÕ“¬ÿ
“¡“√∂ª√–‡¡‘π‚¥¬„™â visual analog scale (VAS), verbal numerical rating scale (VNRS) ·≈–
verbal descriptor scale (VDS) „πºŸâªÉ«¬∑’ˉ¡à¡’ªí≠À“‡√◊ËÕߧ«“¡®”‰¥â °“√ª√–‡¡‘π¥â«¬«‘∏’‡À≈à“π’È®–„™â‡«≈“
π“π¢÷Èπ„π√“¬∑’Ë¡’§«“¡®”∫°æ√àÕßπâÕ¬∂÷ߪ“π°≈“ß ‡π◊ËÕß®“°ºŸâªÉ«¬μâÕß°“√‡«≈“‡æ◊ËÕ∑”§«“¡‡¢â“„®·≈–
μÕ∫ πÕß°“√ª√–‡¡‘𧫓¡ª«¥„πºŸâªÉ«¬∑’Ë¡’§«“¡®”∫°æ√àÕßÕ¬à“ß¡“°‡ªìπ‡√◊ËÕ߬“° Õ“®μâÕß„™â°“√ —߇°μ
æƒμ‘°√√¡ ‡™àπ °“√· ¥ßÕÕ°∑“ß ’Àπâ“ °“√√âÕߧ√«≠§√“ß ‡ªìπμâπ À√◊Õ„™â‡§√◊ËÕß¡◊Õ„À⧖·ππ
¬“∑’Ë„™â‡æ◊ËÕ√–ß—∫ª«¥Nonsteroidal anti-inflammatory drugs ·≈– paracetamol
ºŸâªÉ«¬ ŸßÕ“¬ÿ¡’‚Õ°“ ‡°‘¥º≈¢â“߇§’¬ß¢Õß∑“߇¥‘πÕ“À“√·≈–‰μ®“° NSAIDs ‘Ëß∑’ËμâÕß√–«—ßÕ¬à“ß
¡“° §◊Õ ºŸâªÉ«¬Õ“®‡°‘¥¿“«–‰μ«“¬®“°°“√„™â NSAIDs ‰¥â ‡æ√“–ºŸâªÉ«¬‡À≈à“π’È¡—°¡’°“√∑”ß“π¢Õ߉μ∫°æ√àÕß
Õ¬Ÿà°àÕπ À√◊Õ¡’μ—∫·¢Áß À—«„®«“¬ „™â¬“¢—∫ªí “«–À√◊Õ¬“≈¥§«“¡¥—π‡≈◊Õ¥ ¬“°≈ÿà¡ selective COX-2 inhibitor
∑”„ÀâÕÿ∫—μ‘°“√≥å¢Õß°“√‡°‘¥¿“«–·∑√° âÕπμàÕ∑“߇¥‘πÕ“À“√≈¥≈ßÕ¬à“ß™—¥‡®π ·≈–‰¡à¡’º≈μàÕ°“√∑”ß“π
¢Õ߇°≈Á¥‡≈◊Õ¥ ·μà∑”„À⇰‘¥º≈‡ ’¬μàÕ‰μ‰¡àμà“ß®“° NSAIDs
‡π◊ËÕß®“°¡’À≈—°∞“π∑’Ë·πà™—¥«à“Õ“¬ÿ‰¡à¡’º≈μàÕ°“√¢®—¥¬“ paracetamol ®÷ß “¡“√∂„™â ‰¥â Ÿß ÿ¥∂÷ß
4 °./«—π „πºŸâªÉ«¬ ŸßÕ“¬ÿ ¬°‡«âπ„Àâ≈¥¢π“¥≈ß√âÕ¬≈– 50-75 ‡¡◊ËÕ°“√∑”ß“π¢Õßμ—∫∫°æ√àÕßÀ√◊Õ¡’ª√–«—μ‘
μ‘¥ ÿ√“√à«¡¥â«¬
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***32
√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬
¬“°≈ÿà¡ opioid ·≈– tramadol
ºŸâªÉ«¬ ŸßÕ“¬ÿ¡’§«“¡μâÕß°“√¢π“¥¢Õ߬“°≈ÿà¡ opioid ≈¥≈ß ·μ৫“¡μâÕß°“√¢ÕߺŸâªÉ«¬ ŸßÕ“¬ÿ·μà≈–
§π¡’§«“¡·μ°μà“ß°—π‰¥â¡“° ®÷ßμâÕߪ√—∫¢π“¥¬“∑’Ë„™â„Àâ‡À¡“– ¡„π·μà≈–√“¬
ºŸâªÉ«¬ ŸßÕ“¬ÿÕ“®¡’°“√∑”ß“π¢Õ߉μ∫°æ√àÕß ´÷ËßÕ“®∑”„À⇰‘¥°“√ – ¡¢Õß active metabolite ‡™àπ
morphine-6-glucuronide, norpethidine ·≈– desmethyltramadol ‰¥â
§à“§√÷Ëß™’«‘μ¢Õß°“√¢®—¥ tramadol ‡æ‘Ë¡¢÷Èπ„πºŸâªÉ«¬∑’ËÕ“¬ÿ¡“°°«à“ 75 ªï ®÷ßμâÕß≈¥¢π“¥¬“∑’Ë„™â≈ß
§«“¡«‘μ°°—ß«≈μàÕ°“√‡°‘¥°“√°¥°“√À“¬„®®“°¬“°≈ÿà¡ opioid ∑”„À⺟âªÉ«¬ ŸßÕ“¬ÿ‰¥â√—∫¬“·°âª«¥‰¡à
‡æ’¬ßæÕ ºŸâªÉ«¬ ŸßÕ“¬ÿ°Á‡À¡◊ÕπºŸâªÉ«¬Õ◊ËπÊ ∑’Ë “¡“√∂À≈’°‡≈’ˬ߰“√‡°‘¥°“√°¥°“√À“¬„®‰¥â∂ⓇΩÑ“√–«—ß√–¥—∫
§«“¡√Ÿâ ÷°μ—« (sedation score) Õ¬à“ß„°≈♑¥
Õÿ∫—μ‘°“√≥å¢ÕßÕ“°“√§≈◊Ëπ‰ âÕ“‡®’¬π·≈–§—π≈¥≈߇¡◊ËÕÕ“¬ÿ¡“°¢÷Èπ fentanyl Õ“®∑”„À⇰‘¥°“√ Ÿ≠‡ ’¬
§«“¡®”πâÕ¬°«à“ morphine ¬“μâ“π°“√Õ“‡®’¬π∫“ß™π‘¥ ‚¥¬‡©æ“–¬“∑’Ë¡’§ÿ≥ ¡∫—μ‘ anticholinergic ‡™àπ
orphenadrine, amitriptyline ‡ªìπμâπ ∑”„À⇰‘¥º≈¢â“߇§’¬ß‡æ‘Ë¡¢÷Èπ„πºŸâ ŸßÕ“¬ÿ
¬“™“ºŸâªÉ«¬ ŸßÕ“¬ÿ¡’§«“¡‰«μàÕ¬“™“‡æ‘Ë¡¢÷Èπ ‡π◊ËÕß®“°°“√ àß —≠≠“≥„π‡ âπª√– “∑ à«πª≈“¬™â“≈ß·≈–
®”π«π¢Õ߇´≈≈åª√– “∑„π‰¢ —πÀ≈—ß≈¥≈ß
3. °“√√–ß—∫ª«¥À≈—ß°“√ºà“μ—¥„πºŸâªÉ«¬πÕ° (Outpatient Surgery)°“√√–ß—∫ª«¥‡©’¬∫æ≈—π„πºŸâªÉ«¬∑’Ë¡“√—∫°“√ºà“μ—¥·∫∫ºŸâªÉ«¬πÕ°π—Èπ ¡’À≈—°°“√·≈–·π«∑“ß°“√√—°…“
§«“¡ª«¥§≈⓬§≈÷ß°—∫ºŸâªÉ«¬∑—Ë«‰ª ·μà¡’¢âÕ·μ°μà“߇æ‘Ë¡‡μ‘¡∑’Ë ”§—≠§◊Õ °“√√—°…“§«“¡ª«¥π—Èπ§«√®–‰¥âº≈
„π°“√√—°…“ Ÿß ÿ¥ ·≈–¡’º≈°√–∑∫μàÕ°“√°≈—∫∫â“ππâÕ¬∑’Ë ÿ¥
‘Ëß∑’˧«√§”π÷ß„π°“√√–ß—∫ª«¥„πºŸâªÉ«¬πÕ° ¡’¥—ßμàÕ‰ªπ’È
1. ‡≈◊Õ°„™â¬“·°âª«¥À√◊Õª√—∫¢π“¥¬“„Àâ¡’º≈¢â“߇§’¬ß‚¥¬‡©æ“–μàÕ√–∫∫ª√– “∑ à«π°≈“ßπâÕ¬∑’Ë ÿ¥
À√◊Õ‰¡à¡’‡≈¬ ‰¥â·°à ßà«ßπÕπ §≈◊Ëπ‰ âÕ“‡®’¬π ¡÷πßß ‡«’¬π»’√…– §«“¡¥—π‡≈◊Õ¥·¥ß≈¥≈ß ‡ªìπμâπ
2. ‡≈◊Õ°«‘∏’°“√©’¥¬“™“‡©æ“–∑’Ë À√◊Õ°“√ °—¥°—Èπ‡ âπª√– “∑ (nerve block) ‡æ◊ËÕ≈¥§«“¡ª«¥ ‚¥¬
‰¡à√∫°«π√–∫∫ª√– “∑ à«π°≈“ß
3. ‡≈◊Õ°«‘∏’√–ß—∫ª«¥·∫∫º ¡º “π À√◊Õ∑’ˇ√’¬°«à“ multimodal analgesia
4. ‡≈◊Õ°„™â¬“∑’Ë∫√‘À“√ßà“¬ ‰¥â·°à ¬“√—∫ª√–∑“𠇪ìπμâπ
5. Õ∏‘∫“¬À√◊Õ·π–π”ºŸâªÉ«¬„π°√≥’∑’Ë¡’ªí≠À“¥â“𧫓¡ª«¥‡°‘¥¢÷Èπ∑’Ë∫â“π ‰¥â·°à °“√¥Ÿ·≈®—¥°“√¥â«¬
μπ‡Õ߇∫◊ÈÕßμâπ À√◊Õ°“√μ‘¥μàÕ°—∫·æ∑¬å‡æ◊ËÕ¢Õ§”·π–π”∑“ß‚∑√»—æ∑å
6. °“√ºà“μ—¥·∫∫ºŸâªÉ«¬πÕ° à«π„À≠ຟâªÉ«¬®–¡’§«“¡ª«¥À≈—ߺà“μ—¥ª“π°≈“ß ´÷Ëß “¡“√∂§«∫§ÿ¡
§«“¡ª«¥‰¥â‚¥¬‰¡àμâÕß„À⬓·°âª«¥∑’Ë¡’§«“¡·√ß¡“°
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 33
¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬
°“√√–ß—∫ª«¥‡©’¬∫æ≈—πÀ≈—ߺà“μ—¥¡’·π«∑“ßμàÕ‰ªπ’È (§«√æ‘®“√≥“Õ“¬ÿ·≈–§–·π𪫥√à«¡¥â«¬)1. °“√√—°…“„πÀâÕßæ—°øóôπ (Postanesthesia care unit medication) ‰¥â·°à
1.1 Morphine 0.5-1 ¡°. ‡¢â“À≈Õ¥‡≈◊Õ¥¥” ∑ÿ° 5 π“∑’ ®π°«à“®–§«∫§ÿ¡§«“¡ª«¥‰¥â
1.2 Fentanyl 5-10 ¡§°. ‡¢â“À≈Õ¥‡≈◊Õ¥¥” ∑ÿ° 5 π“∑’ ®π°«à“®–§«∫§ÿ¡§«“¡ª«¥‰¥â
1.3 Pethidine 5-10 ¡°. ‡¢â“À≈Õ¥‡≈◊Õ¥¥” ∑ÿ° 5 π“∑’ ®π°«à“®–§«∫§ÿ¡§«“¡ª«¥‰¥â
1.4 Parecoxib 20-40 ¡°. ‡¢â“À≈Õ¥‡≈◊Õ¥¥”
2. °“√√—°…“‡¡◊ËÕÕÕ°®“°‚√ß欓∫“≈À√◊Õ‡¡◊ËÕÕ¬Ÿà∑’Ë∫â“π (Home analgesic medication)
2.1 Paracetamol 500-1,000 ¡°. √—∫ª√–∑“π∑ÿ° 4-6 ™¡. (‰¡à‡°‘π«—π≈– 4,000 ¡°.)
2.2 Celecoxib 200-400 ¡°. √—∫ª√–∑“π∑ÿ° 24 ™¡.
2.3 Etoricoxib 90-120 ¡°. √—∫ª√–∑“π∑ÿ° 24 ™¡. π“π‰¡à‡°‘π 8 «—π
2.4 Tramadol 50-100 ¡°. √—∫ª√–∑“π∑ÿ° 4-6 ™¡.
3. „™â«‘∏’°“√º ¡º “π (Multimodal analgesia)
À¡“¬∂÷ß°“√√–ß—∫ª«¥‚¥¬„™âÀ≈“¬«‘∏’√à«¡°—π ‡æ◊ËÕ‡æ‘Ë¡ª√– ‘∑∏‘¿“æ„π°“√√—°…“·≈–≈¥º≈¢â“߇§’¬ßμ—«Õ¬à“ß ‰¥â·°à
3.1 °“√ °—¥°—Èπ‡ âπª√– “∑√à«¡°—∫°“√„À⬓·°âª«¥
3.2 °“√„À⬓·°âª«¥À≈“¬™π‘¥√à«¡°—π ‰¥â·°à °“√„Àâ paracetamol √à«¡°—∫ tramadol À√◊Õ¬“°≈ÿà¡NSAIDs ‡™àπ celecoxib ‡ªìπμâπ
Õ¬à“߉√°Áμ“¡ °“√‡≈◊Õ°„™â¬“·°âª«¥ À√◊Õ«‘∏’°“√μà“ßÊ ¢÷Èπ°—∫·æ∑¬åºŸâª√–°Õ∫«‘™“™’懫™°√√¡ ‚¥¬Õ“»—¬ªí®®—¬μà“ßÊ √«¡∑—ÈßÀ≈—°«‘™“°“√‡æ◊ËÕ‡≈◊Õ°¬“·°âª«¥ ‚¥¬§”π÷ߪ√– ‘∑∏‘¿“æ„π°“√√—°…“§«“¡ª«¥ √à«¡
°—∫§«“¡ª≈Õ¥¿—¬¢ÕߺŸâªÉ«¬
4. °“√√–ß—∫ª«¥À≈—ß°“√ºà“μ—¥„πºŸâªÉ«¬‡¥Á° (Postoperative analgesia in Pediatrics):
°“√ª√–‡¡‘𧫓¡ª«¥À≈—ߺà“μ—¥„π‡¥Á°ª√–°Õ∫¥â«¬°“√ª√–‡¡‘π¥â“π§ÿ≥≈—°…≥– (qualitative assessment) ‰¥â·°à°“√ª√–‡¡‘πμ”·Àπàß ≈—°…≥–
¢Õߧ«“¡ª«¥ œ≈œ ·≈–°“√ª√–‡¡‘π¥â“πª√‘¡“≥ (quantitative assessment) ‰¥â·°à°“√ª√–‡¡‘π√–¥—∫À√◊Õ§«“¡√ÿπ·√ߢÕߧ«“¡ª«¥ (pain intensity) ÷Ëß®–™à«¬„π°“√√—°…“·≈–μ‘¥μ“¡º≈°“√√—°…“ °“√ª√–‡¡‘𧫓¡ª«¥„π‡¥Á°¡’§«“¡·μ°μà“ß®“°ºŸâ„À≠à ‡π◊ËÕß®“°°“√æ—≤π“¥â“π°“√μÕ∫ πÕßμàÕ§«“¡ª«¥ √«¡∂÷ß°“√
◊ËÕ “√·≈–°“√· ¥ßÕÕ°‡ªìπ‰ªμ“¡«—¬ ¥—ßπ—Èπ °“√ª√–‡¡‘𧫓¡√ÿπ·√ߢÕߧ«“¡ª«¥À≈—ߺà“μ—¥®÷ß “¡“√∂
∑”‰¥â‚¥¬°“√‡≈◊Õ°„™â‡§√◊ËÕß¡◊Õª√–‡¡‘π∑’ˇÀ¡“– ¡°—∫Õ“¬ÿ (μ“√“ß∑’Ë 12)
πÕ°®“°π’È ¬—ß¡’°“√æ—≤𓇧√◊ËÕß¡◊Õª√–‡¡‘𧫓¡ª«¥ ”À√—∫ºŸâªÉ«¬‡©æ“–°≈ÿà¡ ‰¥â·°à COMFORT scale
”À√—∫ºŸâªÉ«¬¿“«–«‘°ƒμ‘ (critical care patient) à«πºŸâªÉ«¬ cognitive impaired ¡’‡§√◊ËÕß¡◊Õ Revised FLACC(r-FLACC), Non-communicating Childrenûs Pain Checklist-Postoperative version (NCCPC-PV)
·≈– NursesûAssessment of Pain Intensity (NAPI) ‡ªìπμâπ
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***34
√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬
§«√„À⺟⪰§√Õß¡’ à«π√à«¡„π°“√ª√–‡¡‘π ·≈–„™â¢âÕ¡Ÿ≈Õ◊ËπÊ ª√–°Õ∫ πÕ°‡Àπ◊Õ®“°°“√ª√–‡¡‘π
§«“¡√ÿπ·√ߢÕߧ«“¡ª«¥‚¥¬„™â‡§√◊ËÕß¡◊Õ
°“√√–ß—∫ª«¥À≈—ߺà“μ—¥°“√«“ß·ºπ°“√√—°…“§«√‡√‘Ë¡μ—Èß·μà°àÕπºà“μ—¥ ‚¥¬°“√¡’ à«π√à«¡¢Õß«‘ —≠≠’·æ∑¬å ∑’¡ºà“μ—¥ ºŸâª°§√Õß
·≈–ºŸâªÉ«¬ ‚¥¬„™âÀ≈—°°“√¢Õß°“√√–ß—∫ª«¥·∫∫º ¡º “π√à«¡°—∫°“√√–ß—∫ª«¥‚¥¬‰¡à„™â¬“
°“√√—°…“¥â«¬¬“ë §«√‡≈◊Õ°™π‘¥¢Õ߬“·≈–°“√∫√‘À“√¬“μ“¡§«“¡√ÿπ·√ߢÕߧ«“¡ª«¥ ‡™àπ „™â nonopioid analgesic
√à«¡°—∫¬“™“‡©æ“–∑’Ë ”À√—∫ mild pain, „™â weak opioid analgesic ”À√—∫ moderate pain ·≈–„™â strong
opioid À√◊Õ√à«¡°—∫ regional analgesia ”À√—∫ severe pain
ë ‡≈◊Õ°„™â¬“μà“ß°≈ÿà¡√à«¡°—π‡æ◊ËÕ‡æ‘Ë¡ª√– ‘∑∏‘¿“æ¢Õß°“√√—°…“ ·≈–≈¥¿“«–·∑√° âÕπ
ë ∂â“ “¡“√∂∑”‰¥â æ‘®“√≥“„™â‡∑§π‘§ preemptive analgesia §◊Õ„À⬓≈à«ßÀπâ“μ—Èß·μà°àÕπºà“μ—¥
À√◊Õ∑”À—μ∂°“√„¥Ê ·≈–§«√„À⬓π—ÈπÕÕ°ƒ∑∏‘Ï°àÕπ∑’Ë®–∑”À—μ∂°“√À√◊Õºà“μ—¥
ë À≈’°‡≈’ˬ߰“√„À⬓·∫∫ p.r.n. „π«—π·√°À≈—ߺà“μ—¥ ·μ৫√„Àâ¬“μ“¡‡«≈“ (around the clock)
°“√√—°…“¥â«¬¬“ª√–°Õ∫¥â«¬¬“°≈ÿà¡μà“ßÊ ¥—ßπ’È
- Nonopioid analgesic: paracetamol, NSAIDs
- Weak opoid analgesic: codeine, tramadol
- Strong opioid analgesic: morphine, pethidine, fentanyl
- Local and regional anesthesia and analgesia
μ“√“ß∑’Ë 12: ‡§√◊ËÕß¡◊Õª√–‡¡‘𧫓¡√ÿπ·√ߢÕߧ«“¡ª«¥À≈—ߺà“μ—¥∑’ˇÀ¡“– ¡°—∫Õ“¬ÿ
∑“√°·√°‡°‘¥·≈–∑“√° ‡¥Á°°àÕπ«—¬‡√’¬π ‡¥Á°«—¬‡√’¬π·≈–«—¬√ÿàπ„™â Composite pain measures „™â Behavioral measures „™â Self report
PIPP CHEOPS VASNIPS FLACC Wong-Baker Faces ScaleCRIES OPS FPS-R
NRS
PIPP = Premature Infant Pain Profile, NIPS = Neonatal Infant Pain Scale, CRIES = Crying Requires Increased VitalSigns Expression Sleeplessness, CHEOPS = Childrenûs Hospital of Eastern Ontario Pain Scale, FLACC = Face LegsActivity Cry Consolability, OPS = Objective Pain Scale, VAS = Visual Analog Scale, FPS-R = Faces Pain Scale-Revised, NRS = Numeric Rating Scale
À¡“¬‡Àμÿ §«√‡≈◊Õ°„™â self report „π°√≥’∑’ˇ¥Á° “¡“√∂ ◊ËÕ “√‡™◊ËÕ∂◊Õ‰¥â
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 35
¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬
Nonopioid analgesic
ë „™â ”À√—∫ mild ∂÷ß moderate pain À√◊Õ„™â√à«¡°—∫¬“À√◊Õ‡∑§π‘§Õ◊ËπÊ ‡æ◊ËÕ≈¥ª√‘¡“≥°“√„™â¬“
opioid (opioid sparing effect)
ë ¬“∑’Ëπ‘¬¡„™â§◊Õ paracetamol ·≈– NSAIDs (μ“√“ß∑’Ë 13)
μ“√“ß∑’Ë 13: ¬“ nonopioid analgesics ∑’Ë„™â„π‡¥Á°
¬“ ¢π“¥ «‘∏’∫√‘À“√ ¢π“¥ ”À√—∫‡¥Á° √–¬–Àà“ߢÕß ¢π“¥ Ÿß ÿ¥μàÕ«—π*(¡°./°°.) > 60 °°. (¡°.) ·μà≈–¡◊ÈÕ (™¡.) (¡°./°°.)
Paracetamol 10-15 √—∫ª√–∑“π 650-1,000 4 75 (children)15-20 ‡ÀπÁ∫∑«“√† 6-8 60 (newborn/infant)
40 (preterm)
Diclofenac 1 √—∫ª√–∑“π 50 8 3
Naproxen 5-6 √—∫ª√–∑“π 250-375 12 24
Ibuprofen 6-10 √—∫ª√–∑“π 400-600 6-8 40
Ketorolac 0.5 À≈Õ¥‡≈◊Õ¥¥” 30 p.r.n. ∑ÿ° 6-12 ™¡. 2
À¡“¬‡Àμÿ ‰¡à§«√„™â NSAIDs „π‡¥Á°Õ“¬ÿμË”°«à“ 6 ‡¥◊Õπ À√◊Õ∑’Ë¡’¢âÕÀâ“¡„™â* ”À√—∫‡¥Á°πÈ”Àπ—° < 60 °°.† loading dose ‰¥â∂÷ß 40 ¡°./°°.
Weak opioid analgesicë „™â ”À√—∫ mild ∂÷ß moderate pain “¡“√∂„™â√à«¡°—∫ nonopioid analgesic ‰¥â
ë Codeine ™π‘¥√—∫ª√–∑“π‡æ◊ËÕ√–ß—∫ª«¥ ¢π“¥∑’Ë„™â 0.5-1 ¡°./°°. (‰¡à‡°‘π¡◊ÈÕ≈– 65 ¡°.) ∑ÿ° 4-6
™¡. „π°√≥’∑’ˇ≈◊Õ°„™â codeine ∑’˺ ¡°—∫ paracetamol §«√√–¡—¥√–«—ß¢π“¥¢Õ߬“∑—Èß codeine ·≈–
paracetamol ‰¡à„À⇰‘π¢π“¥¬“ Ÿß ÿ¥∑’Ë “¡“√∂„Àâ ‰¥â „πª√–‡∑»‰∑¬¡’μ”√—∫∑’Ë¡’¢π“¥ codeine ·≈–
paracetamol μà“ßÊ °—𠇙àπ paracetamol 500/codeine 15, paracetamol 500/codeine 30, paracetamol
300/codeine 15 ·≈– paracetamol 300/codeine 30
ë ¬“∑’Ë¡’ à«πº ¡¢Õß codeine ‡ªì𬓇 æμ‘¥„Àâ‚∑…„πª√–‡¿∑ 3
ë Tramadol ¢π“¥ 1-2 ¡°./°°. (‰¡à‡°‘π¡◊ÈÕ≈– 100 ¡°.) ∑ÿ° 4-6 ™¡. ∫√‘À“√∑“ßÀ≈Õ¥‡≈◊Õ¥¥”
À√◊Õ√—∫ª√–∑“π¢π“¥ Ÿß ÿ¥ 8 ¡°./°°./«—π
Strong opioid analgesicë „™â ”À√—∫ moderate to severe pain
ë “¡“√∂∫√‘À“√‰¥â‚¥¬ intermittent injection, continuous infusion À√◊Õ patient-controlled
analgesia (PCA) (μ“√“ß∑’Ë 14) ‰¡à§«√∫√‘À“√¬“∑“ß intramuscular
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***36
√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬
ë μâÕ߇ΩÑ“√–«—ߺŸâªÉ«¬„π¥â“π°“√À“¬„® ‚¥¬°“√ª√–‡¡‘π sedation score À√◊Õ„™â pulse oximeter
√à«¡¥â«¬ ·≈–§«√¡’ naloxone ‡μ√’¬¡æ√âÕ¡¥â«¬
ë §«√¡’°“√√—°…“º≈¢â“߇§’¬ß¢Õ߬“‰ªæ√âÕ¡°—𠇙àπ Õ“°“√§≈◊Ëπ‰ âÕ“‡®’¬π À√◊Õ Õ“°“√§—π
ë ¬“∑’Ëπ‘¬¡„™â„πª√–‡∑»‰∑¬ ‰¥â·°à morphine, pethidine ·≈– fentanyl (μ“√“ß∑’Ë 15)
μ“√“ß∑’Ë 14: ™π‘¥·≈–¢π“¥¬“∑’Ë„Àâ¥â«¬«‘∏’ PCA „π‡¥Á°
¬“ PCA dose Lockout interval Basal infusion 1-h/4-hr limit(¡§°./°°.) (π“∑’) (¡§°./°°./™¡.) (¡§°./°°.)
morphine 10-20 5-10 0-20 100/300
fentanyl 0.5 5-8 0-0.5 2.5/4
μ“√“ß∑’Ë 15: ¬“ opioid analgesics ∑’Ë„™â„π‡¥Á°
¬“ IV bolus p.r.n. IV infusion
morphine preterm 10-25 ¡§°./°°. ∑ÿ° 2-3 ™¡. preterm 2-5 ¡§°./°°./™¡.full-term 25-50 ¡§°./°°. ∑ÿ° 2-3 ™¡. full-term 5-10 ¡§°./°°./™¡.Infant & children 30-50 ¡§°./°°. ∑ÿ° 2-3 ™¡. Infant & children 15-30 ¡§°./°°./™¡.
fentanyl 0.5-1 ¡§°./°°. ∑ÿ° 1-2 ™¡. preterm 0.3 ¡§°./°°./™¡.full-term 0.3-0.5 ¡§°./°°./™¡.Infant & children 0.5-1 ¡§°./°°./™¡.
pethidine 0.5-1 ¡°./°°. ∑ÿ° 2-3 ™¡. -
°“√√–ß—∫§«“¡√Ÿâ ÷°·≈–°“√√–ß—∫ª«¥‚¥¬°“√„™â¬“™“‡©æ“–∑’Ë ·≈–‡©æ“– à«πë „™â√à«¡°—∫¬“·°âª«¥™π‘¥Õ◊Ëπμ“¡À≈—°°“√¢Õß multimodal analgesia
ë ¡’À≈“¬‡∑§π‘§ ‰¥â·°à topical anesthesia, wound instillation, wound infiltration, peripheral
nerve block, regional block ‡™àπ °“√∑” caudal block, epidural block À√◊Õ spinal block
ë °“√∑”À—μ∂°“√„À⬓™“‡©æ“–∑’Ë„π‡¥Á° §«√°√–∑”‚¥¬ºŸâ∑’ˉ¥â√—∫°“√Ωñ°Ωπ®π™”π“≠
ë π‘¬¡„™â¬“™“‡©æ“–∑’Ë∑’Ë¡’ƒ∑∏‘Ϭ“« ‡™àπ bupivacaine, levobupivacaine À√◊Õ ropivacaine
ë „π°“√∑”·μà≈–‡∑§π‘§ μâÕß√–«—߉¡à„Àâª√‘¡“≥¬“∑’Ë„™â‡°‘π¢π“¥ Ÿß ÿ¥∑’˺ŸâªÉ«¬§«√‰¥â√—∫ ∑—Èß„π°√≥’
„À⬓§√—È߇¥’¬« (single/bolus dose) ·≈–„À⬓μàÕ‡π◊ËÕß (continuous infusion) (μ“√“ß∑’Ë 16)
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 37
¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬
ë ‡∑§π‘§°“√„À⬓μàÕ‡π◊ËÕß∑“ß epidural (continuous epidural infusion) π—Èπ “¡“√∂∑”‰¥â
„πºŸâªÉ«¬∑ÿ°Õ“¬ÿ π‘¬¡„™â§«“¡‡¢â¡¢âπ¢Õ߬“ bupivacaine, levobupivacaine À√◊Õ ropivacaine √–À«à“ß
0.05-0.1% ·≈–Õ“®º ¡°—∫ opioid ‡æ◊ËÕ‡ √‘¡ƒ∑∏‘Ï√–ß—∫ª«¥ (μ“√“ß∑’Ë 16) ∑—Èßπ’È μâÕßæ‘®“√≥“μ“¡§«“¡
‡À¡“– ¡ ·≈–μâÕß¡’°“√‡ΩÑ“√–«—ß¿“«–·∑√° âÕπ‰¥â·°à °“√°¥°“√À“¬„® ¿“«–ßà«ß ÷¡ ¿“«–°≈â“¡‡π◊ÈÕ
ÕàÕπ·√ß Õ“°“√§≈◊Ëπ‰ âÕ“‡®’¬π ·≈–°“√‡°‘¥ªí “«–§—Ëß
μ“√“ß∑’Ë 16: ¢π“¥¬“∑’Ë„Àâ∑“ß epidural: ¢π“¥∑’Ë·π–π”·≈–¢π“¥ Ÿß ÿ¥ ”À√—∫¬“™“ bupivacaine, levobupivacaine·≈– ropivacaine („™â¢π“¥‡¥’¬«°—π) ·≈–¢π“¥¬“ opioids
¬“™“∑“ß epidural Fentanyl MorphineSingle Continuous ¢π“¥¬“ (1-3 ¡§°./¡≈.) (5-10 ¡§°./¡≈.)bolus infusion Ÿß ÿ¥
‡¥Á°·√°‡°‘¥-6 ‡¥◊Õπ 2 ¡°./°°. 0.1-0.3 0.3 0.3-1 1-5¡°./°°./™¡. ¡°./°°./™¡. ¡§°./°°./™¡. ¡§°./°°./™¡.
‡¥Á°∑“√° (> 6 ‡¥◊Õπ) 2.5 ¡°./°°. 0.2-0.4 0.4¡°./°°./™¡. ¡°./°°./™¡.
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***38
√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬
¿“§ºπ«° 8: Acute Pain Service
·∫∫®”≈Õß™π‘¥·≈–·π«∑“ߢÕßÀπ૬√–ß—∫ª«¥ (Acute Pain Service Model)ë Anesthesiologist-based model
ªï §.». 1986 „πª√–‡∑» À√—∞Õ‡¡√‘°“ Prof. L Brian Ready ‰¥â®—¥∑” acute pain service ‚¥¬
„Àâ«‘ —≠≠’·æ∑¬å‡ªìπÀ≈—°„π°“√¥Ÿ·≈ºŸâªÉ«¬ ‡æ√“–‡ªìπºŸâ‡™’ˬ«™“≠¥â“π‡¿ —™«‘∑¬“¢Õ߬“·°âª«¥´÷Ëß¡’À≈“¬
¢π“π·≈–√Ÿâ§«“¡·μ°μà“ß ¢âÕ¥’-¢âÕ‡ ’¬ ¢Õ߇∑§π‘§°“√√–ß—∫ª«¥·μà≈–«‘∏’ ÷Ëß “¡“√∂ª√—∫«‘∏’°“√„À⬓·°âª«¥
„Àâ‡À¡“– ¡°—∫ºŸâªÉ«¬·μà≈–§π‰¥âÕ¬à“ߥ’ √«¡∂÷ß “¡“√∂Õ∏‘∫“¬„À⺟âªÉ«¬·≈–≠“쑇¢â“„®∂÷ߧ«“¡‡°’ˬ«¢âÕß°—π
¢Õß‚√§·μà≈–™π‘¥°—∫°“√ºà“μ—¥ ·≈–«‘∏’ªØ‘∫—μ‘μ—«À≈—ß°“√ºà“μ—¥ ‚¥¬ Õ¥§≈âÕß°—∫«‘∏’√–ß—∫§«“¡ª«¥∑’ˉ¥â√—∫
‡æ◊ËÕ„Àâøóôπμ—«‰¥â‡√Á«¢÷Èπ πÕ°®“°π’È ‡§√◊ËÕß¡◊Õ∑’Ë∑—π ¡—¬ çhigh-teché ‡™à𠇧√◊ËÕß¡◊Õ§«∫§ÿ¡§«“¡ª«¥‚¥¬μ—«
ºŸâªÉ«¬‡Õß (Patient-Controlled Analgesia, PCA) ÷Ëß¡’§«“¡¬ÿà߬“°„π°“√μ—Èß·≈–ª√—∫§à“‡æ◊ËÕ„À⇰‘¥º≈√–ß—∫
ª«¥¥’∑’Ë ÿ¥ ¡’º≈¢â“߇§’¬ß¢Õ߬“πâÕ¬∑’Ë ÿ¥ ·≈–∑”„À⇰‘¥§«“¡ª√–∑—∫„® Ÿß ÿ¥ §«√®–μâÕߥŸ·≈‚¥¬ºŸâ‡™’ˬ«™“≠
∑’Ë¡’ª√– ∫°“√≥å¡“°æÕ ¥—ßπ—Èπ √Ÿª·∫∫ anesthesiologist-based model ®÷ß„Àâ§ÿ≥¿“æ°“√√–ß—∫§«“¡ª«¥
À≈—ߺà“μ—¥·≈–§«“¡ª√–∑—∫„®∑’Ë¥’¡“° ·μà„πª√–‡∑»‰∑¬¬—ß¡’¢âÕ®”°—¥ ‡æ√“–®”π«π«‘ —≠≠’·æ∑¬å¡’‰¡à¡“°æÕ
·≈– à«π„À≠àμâÕß∑”ß“π„πÀâÕߺà“μ—¥ πÕ°®“°π’È √–∫∫π’Ȭ—ß¡’§à“„™â®à“¬∑’Ë Ÿß
ë Nurse-based, Anesthesiologist-Supervised model‡√‘Ë¡μâπ∑’˪√–‡∑» «’‡¥π „πªï §.». 1994 ‚¥¬ Prof. Narinder Rawal „Àâ欓∫“≈∑’ˉ¥â√—∫°“√Ωñ°
Õ∫√¡‡©æ“–¥â“π°“√¥Ÿ·≈√–ß—∫§«“¡ª«¥ (Pain Nurse) ‡ªìπ°≈‰°À≈—°„π°“√¥Ÿ·≈ºŸâªÉ«¬ ‡æ◊ËÕ‡æ‘Ë¡ª√– ‘∑∏‘¿“æ
°“√√–ß—∫§«“¡ª«¥À≈—ߺà“μ—¥ ‚¥¬¡’«‘ —≠≠’·æ∑¬å‡ªìπºŸâ„À⧔ª√÷°…“ ¢âÕ¥’¢Õß model π’È §◊Õ ¡’§à“„™â®à“¬„π
°“√¥”‡π‘π°“√≈¥≈ß ÷Ë߇À¡“– ¡°—∫ª√–‡∑»‰∑¬ «‘∏’°“√¥”‡π‘π°“√¢Õß model π’È®–‡πâπ°“√‡æ‘Ë¡æŸπ§«“¡√Ÿâ
·≈–°“√ª√–‡¡‘𧫓¡ª«¥Õ¬à“ß ¡Ë”‡ ¡Õ ‚¥¬„™â°“√ª√–‡¡‘𧫓¡ª«¥¥â«¬√–∫∫¡“μ√∞“π ∑”§«“¡ª«¥„Àâ
¡Õ߇ÀÁπ‰¥â (making pain visible) ‡™àπ „™â Visual Analogue Scale [VAS], Verbal Numerical Rating
Scale [VNRS] ‡æ◊ËÕ„Àâ·ª≈º≈‰¥âμ√ß°—π ∑”„Àâ«‘ —≠≠’·æ∑¬å “¡“√∂æ‘®“√≥“‡ª≈’ˬπ°“√√—°…“‰¥âÕ¬à“ß∑—π∑à«ß∑’
∑”„Àâ°“√√–ß—∫ª«¥À≈—ߺà“μ—¥¡’ª√– ‘∑∏‘¿“æ¡“°¢÷Èπ ®“°°“√»÷°…“·≈–®“°§”·π–π”¢ÕߺŸâ‡™’ˬ«™“≠ æ∫«à“
§«“¡ ”‡√Á®¢Õß APS ‡°‘¥®“°°“√ª√– “πß“π°—πÕ¬à“ß„°≈♑¥¢Õß∫ÿ§≈“°√„π∑’¡∑’ˇ°’ˬ«¢âÕß ·≈–‡ªìπº≈®“°
°“√„Àâ¡’§«“¡√Ÿâ‡æ’¬ßæÕ ·≈–¡’‚§√ß √â“ß∑’ˇªìπ√–∫∫„π°“√„Àâ°“√√–ß—∫§«“¡ª«¥ ¡“°°«à“®“°‡∑§π‘§√–ß—∫
ª«¥∑’˺ŸâªÉ«¬‰¥â√—∫
·π«∑“ßæ—≤π“Àπ૬√–ß—∫§«“¡ª«¥‡©’¬∫æ≈—πÀ≈—ߺà“μ—¥ [Acute Pain Service]:
1. °“√«“ß·ºπ°“√√–ß—∫ª«¥≈à«ßÀπâ“ (Proactive planning)
‡ªìπ¢∫«π°“√º ¡º “π°“√¥Ÿ·≈√—°…“§«“¡ª«¥‡¢â“‰«â„π°“√¥Ÿ·≈ºŸâªÉ«¬„π√–¬–°àÕπ √–À«à“ß ·≈–
À≈—ß°“√ºà“μ—¥ «‘ —≠≠’·æ∑¬å§«√¡’°“√∑” proactive planning „πºŸâªÉ«¬∑ÿ°√“¬∑’Ë¡“√—∫°“√ºà“μ—¥
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 39
¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬
1.1 ªí®®—¬∑’Ë¡’Õ‘∑∏‘æ≈μàÕ°“√∑” proactive planning ‰¥â·°à
1.1.1 ™π‘¥¢Õß°“√ºà“μ—¥·≈–°“√§“¥§–‡π§«“¡√ÿπ·√ߢÕߧ«“¡ª«¥À≈—ß°“√ºà“μ—¥
1.1.2 ‚√§ª√–®”μ—« (‡™àπ ‚√§ªÕ¥À√◊Õ‚√§À—«„®), ª√–«—μ‘°“√·æ⬓
1.1.3 Õ—μ√“ à«π¢Õߺ≈¥’º≈‡ ’¬¢Õß«‘∏’√–ß—∫ª«¥·μà≈–«‘∏’
1.1.4 §«“¡™Õ∫ à«πμ—«¢ÕߺŸâªÉ«¬ ·≈–ª√– ∫°“√≥姫“¡ª«¥®“°°“√ºà“μ—¥§√—Èß°àÕπ
1.2 °‘®°√√¡„π proactive planning ‰¥â·°à
1.2.1 °“√∂“¡ª√–«—쑇¥‘¡‡°’ˬ«°—∫ª√– ∫°“√≥姫“¡ª«¥∑’ˇ°’ˬ«°—∫°“√ºà“μ—¥¢ÕߺŸâªÉ«¬
1.2.2 °“√√–ß—∫ª«¥μ—Èß·μà°àÕπºà“μ—¥‡¡◊ËÕ “¡“√∂∑”‰¥â
1.2.3 °“√√–ß—∫ª«¥„π√–À«à“ߺà“μ—¥ ‡™àπ °“√©’¥¬“™“∑’Ë·º≈ºà“μ—¥
1.2.4 °“√‡μ√’¬¡°“√√–ß—∫ª«¥√–À«à“ß·≈–À≈—ߺà“μ—¥ ‡™àπ «‘∏’ epidural analgesia
2. °“√Ωñ°Õ∫√¡∫ÿ§≈“°√„π‚√ß欓∫“≈
§«√®—¥„Àâ¡’°“√ª√– “π°—π√–À«à“ß«‘ —≠≠’·æ∑¬å·≈–∫ÿ§≈“°√Õ◊ËπÊ ∑’ˇ°’ˬ«¢âÕß ∑”°“√Ωñ°Õ∫√¡∑’Ë
μàÕ‡π◊ËÕß·≈–‡À¡“– ¡·°à∫ÿ§≈“°√¢Õß‚√ß欓∫“≈ ‡æ◊ËÕ„Àâ¡’§«“¡√Ÿâ·≈–∑—°…–„π°“√¥Ÿ·≈·≈–√–ß—∫ª«¥Õ¬à“ß
¡’ª√– ‘∑∏‘¿“æ
¢Õ∫‡¢μ¢Õß°“√Ωñ°Ωπ ‰¥â·°à
2.1 °“√∑∫∑«π§«“¡√Ÿâ·≈–∑—°…–„π°“√√—°…“‚¥¬«‘∏’∑’Ë¡’§«“¡´—∫´âÕ𠇙àπ PCA, epidural analgesia
‡ªìπμâπ
2.2 °“√ª√–‡¡‘π§–·π𧫓¡ª«¥ pain score, sedation score, Õ—μ√“°“√À“¬„® ·≈–º≈
¢â“߇§’¬ßÕ◊ËπÊ ‡æ◊ËÕ„Àâ°“√√–ß—∫ª«¥¡’ª√– ‘∑∏‘¿“æ·≈–ª≈Õ¥¿—¬
2.3 °“√„À⧔·π–π”À≈—ß°“√ºà“μ—¥Õ◊ËπÊ ‡æ◊ËÕ„À⺟âªÉ«¬æ◊Èπμ—«‰¥âÕ¬à“ß¡’ª√– ‘∑∏‘¿“æ ‡™àπ deep
breathing exercise & cough, early ambulation
2.4 °“√Ωñ°Õ∫√¡®”‡ªìπμâÕß°√–∑”Õ¬à“ßμàÕ‡π◊ËÕß ‡¡◊ËÕ¡’°“√√—∫∫ÿ§≈“°√„À¡àÀ√◊Õ‡¡◊ËÕ¡’°“√ª√—∫ª√ÿß
‡ª≈’ˬπ·ª≈ß«‘∏’°“√√—°…“„À¡à
3. °“√„À⧫“¡√Ÿâ·≈–°“√¡’ à«π√à«¡¢ÕߺŸâªÉ«¬·≈–§√Õ∫§√—«„π°“√√–ß—∫ª«¥À≈—ߺà“μ—¥§«√®—¥„Àâ¡’°“√„À⧫“¡√Ÿâ·°àºŸâªÉ«¬·≈–§√Õ∫§√—«‡°’ˬ«°—∫∫∑∫“∑¢ÕߺŸâªÉ«¬·≈–§√Õ∫§√—« „π°“√
√“¬ß“𧫓¡ª«¥ ·≈–§«√·°â§«“¡‡¢â“„®∑’Ë¡—°‡™◊ËÕ°—πº‘¥Ê ‡°’ˬ«°—∫Õ“°“√¢â“߇§’¬ß·≈–°“√μ‘¥¬“
«‘∏’μà“ßÊ „π°“√„À⧫“¡√Ÿâ·°àºŸâªÉ«¬·≈–§√Õ∫§√—« „π√“¬∑’Ë„™â«‘∏’°“√√–ß—∫ª«¥∑’Ë´—∫´âÕ𠇙àπ PCA
‰¥â·°à °“√®—¥∑”·ºàπæ—∫‡°’ˬ«°—∫«‘∏’°“√√–ß—∫ª«¥ ”À√—∫ºŸâªÉ«¬ ·≈–Õ∏‘∫“¬μÕ∫¢âÕ´—°∂“¡‡°’ˬ«°—∫«‘∏’√–ß—∫
ª«¥‡¡◊ËÕ‡¬’ˬ¡ºŸâªÉ«¬À≈—ߺà“μ—¥
4. °“√ª√–‡¡‘π·≈–∫—π∑÷°°“√¥Ÿ·≈√—°…“§«“¡ª«¥‡©’¬∫æ≈—πÀ≈—ß°“√ºà“μ—¥§«√®—¥„Àâ¡’°“√ª√–‡¡‘π·≈–∫—π∑÷°§–·π𪫥 ‡æ◊ËÕ®–‰¥â∑√“∫«à“«‘∏’√–ß—∫ª«¥∑’˺ŸâªÉ«¬‰¥â√—∫π—Èπ ¡’
ª√– ‘∑∏‘¿“æ‡æ’¬ßæÕÀ√◊Õ‰¡à à«π°“√ª√–‡¡‘π·≈–∫—π∑÷° sedation score °Á‡æ◊ËÕ‡ΩÑ“√–«—ß«à“«‘∏’√–ß—∫ª«¥∑’Ë
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***40
√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬
ºŸâªÉ«¬‰¥â√—∫Õ¬Ÿàπ—Èπ ¡’·π«‚πâ¡®–‡°‘¥º≈¢â“߇§’¬ß∑’ˇ°’ˬ«°—∫°“√°¥°“√À“¬„®À√◊Õ‰¡àμ—Èß·μà‡π‘ËπÊ „πªí®®ÿ∫—π
·π–π”„ÀℙⰓ√ª√–‡¡‘π sedation score ‡ªìπ 6th Vital sign ‚¥¬‡©æ“–Õ¬à“߬‘Ëß„πºŸâªÉ«¬∑’Ë¡’ªí≠À“‡√◊ËÕß
√–∫∫∑“߇¥‘πÀ“¬„®
5. °“√¡’«‘ —≠≠’·æ∑¬å„À⧔ª√÷°…“μ≈Õ¥ 24 ™¡.‡π◊ËÕß®“°¿“«–μà“ßÊ ¢ÕߺŸâªÉ«¬„π™à«ßÀ≈—ß°“√ºà“μ—¥¡—°¡’°“√‡ª≈’ˬπ·ª≈ßÕ¬Ÿàμ≈Õ¥‡«≈“ «‘∏’°“√
√–ß—∫ª«¥ à«π„À≠à¡’‚Õ°“ ‡ ’ˬßμàÕ¿“«–·∑√°´âÕπ´÷ËßμâÕß°“√°“√ª√–‡¡‘π·≈–√—°…“∑—π∑’ §«“¡μâÕß°“√¬“
·°âª«¥Õ“®‡ª≈’ˬπ·ª≈߇¡◊ËÕ„¥°Á‰¥â ®÷ߧ«√¡’«‘ —≠≠’·æ∑¬å∑’Ë√—∫º‘¥™Õ∫¥Ÿ·≈§«“¡ª«¥À≈—ߺà“μ—¥μ≈Õ¥ 24 ™¡.
‡æ◊ËÕ„Àâ欓∫“≈ »—≈¬·æ∑¬å ·≈–·æ∑¬åÕ◊ËπÊ ∑’ˇ°’ˬ«¢âÕߢէ”ª√÷°…“‰¥âμ≈Õ¥‡«≈“ μ≈Õ¥®π™à«¬ª√–‡¡‘π
ºŸâªÉ«¬∑’Ë¡’ªí≠À“‡°’ˬ«°—∫°“√√–ß—∫ª«¥ ‡æ◊ËÕ§«“¡ª≈Õ¥¿—¬ Ÿß ÿ¥¢ÕߺŸâªÉ«¬
6. °“√¡’π‚¬∫“¬ (Policy) ·≈–«‘∏’°“√ (Procedure) ”À√—∫°“√ —Ëß°“√√—°…“, °“√∫√‘À“√¬“ ·≈–°“√À¬ÿ¥°“√√—°…“ μ≈Õ¥®π°“√ àßμàÕ§«“¡√—∫º‘¥™Õ∫„π°“√¥Ÿ·≈√—°…“§«“¡ª«¥‡©’¬∫æ≈—πÀ≈—ß°“√
ºà“μ—¥∑’ˇªìπ¡“μ√∞“π¢Õß‚√ß欓∫“≈«‘ —≠≠’·æ∑¬åºŸâ„Àâ°“√√–ß—∫ª«¥°àÕπ √–À«à“ß ·≈–À≈—ß°“√ºà“μ—¥ §«√√à«¡¡◊Õ°—∫∫ÿ§≈“°√Õ◊ËπÊ ∑’Ë
‡°’ˬ«¢âÕß „π°“√æ—≤π“π‚¬∫“¬¢Õß‚√ß欓∫“≈„π≈—°…≥– À “¢“«‘™“™’æ ”À√—∫°“√ —Ëß°“√√—°…“, °“√∫√‘À“√
¬“ ·≈–°“√À¬ÿ¥°“√√—°…“ μ≈Õ¥®π°“√ àßμàÕ§«“¡√—∫º‘¥™Õ∫„π°“√√–ß—∫ª«¥À≈—ߺà“μ—¥ °“√æ—≤π“π‚¬∫“¬
·≈–«‘∏’°“√¢Õß‚√ß欓∫“≈™à«¬„Àâ¡’°“√ªØ‘∫—μ‘Õ¬à“߇ªìπ¡“μ√∞“π „π°“√„™â«‘∏’°“√√–ß—∫ª«¥μà“ßÊ ™à«¬„Àâ
‡°‘¥§«“¡ª≈Õ¥¿—¬ ‡™àπ ¡“μ√∞“π¢Õß‚√ß欓∫“≈ ”À√—∫ —Ëß°“√√—°…“ PCA ·≈– epidural analgesia À√◊Õ
nerve block
π‚¬∫“¬·≈–«‘∏’°“√∑’Ëæ—≤π“¢÷Èπ¡“§«√ “¡“√∂𔉪„™â ‰¥â°—∫∑ÿ°Ê Àπ૬ߓπ∑’Ë„Àâ°“√¥Ÿ·≈ºŸâªÉ«¬ ·≈–
§«√ à߇ √‘¡„À⇰‘¥°“√»÷°…“Õ¬à“ßμàÕ‡π◊ËÕß·≈–‡ªìπ¢âÕ¡Ÿ≈∑’ËÕâ“ßՑ߉¥â
7. °“√„™â«‘∏’°“√‡©æ“– 3 «‘∏’ ”À√—∫°“√√–ß—∫ª«¥À≈—ߺà“μ—¥
π—∫ πÿπ„Àâ«‘ —≠≠’·æ∑¬åºŸâ„Àâ°“√√–ß—∫ª«¥°àÕπ √–À«à“ß ·≈–À≈—ߺà“μ—¥ ‡≈◊Õ°„™â«‘∏’°“√√–ß—∫ª«¥
∑’Ë¡’ª√– ‘∑∏‘¿“æ·≈–ª≈Õ¥¿—¬ ‡À¡“– ¡°—∫ºŸâªÉ«¬·μà≈–§π «‘∏’‡À≈à“π’È ‰¥â·°à
7.1 °“√„Àâ opioids ¥â«¬ PCA [Patient-Controlled Analgesia] ∑“ß systemic À√◊Õ epidural
7.2 °“√„Àâ opioid À√◊Õ opioid º ¡°—∫¬“™“‡©æ“–∑’˥⫬«‘∏’ epidural analgesia
7.3 «‘∏’ regional analgesia ‰¥â·°à °“√∑” nerve block μà“ßÊ ·≈–°“√©’¥¬“™“‡©æ“–∑’Ë∫√‘‡«≥
·º≈ºà“μ—¥
8. °“√„™â«‘∏’º ¡º “π (Multimodality Approach) ‚¥¬°“√„™â¬“À≈“¬¢π“π·≈–À≈“¬«‘∏’„π°“√√–ß—∫ª«¥À≈—ߺà“μ—¥
°“√„À⬓√–ß—∫§«“¡√Ÿâ ÷°√–À«à“ß°“√ºà“μ—¥π‘¬¡„™â¬“À≈“¬™π‘¥√à«¡°—π‡æ◊ËÕ„À⇰‘¥ª√–‚¬™πå Ÿß ÿ¥
„π∑”πÕ߇¥’¬«°—π °“√√–ß—∫ª«¥À≈—ߺà“μ—¥°Á‰¥â√—∫ª√–‚¬™π宓°°“√„™â¬“À√◊Õ«‘∏’°“√√–ß—∫ª«¥¡“°°«à“Àπ÷Ëß
™π‘¥ ¡“°°«à“°“√„™â¬“À√◊Õ„™â«‘∏’°“√√–ß—∫ª«¥‡æ’¬ßÕ¬à“ß„¥Õ¬à“ßÀπ÷Ëß
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 41
¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬
Multimodal À√◊Õ balanced analgesia ‡ªìπ·π«§‘¥¢Õß°“√„™â¬“·°âª«¥À≈“¬°≈ÿà¡∑’Ë¡’°≈‰°°“√
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Definition of postoperative pain:1. Liossi C, Franck L. Psychological interventions for acute pediatric pain. In: Macintyre P, Walker SM, Rowbotham DJ,
editors. Clinical Pain Management. 2nd ed. Acute pain. London: Hodder Arnold; 2008. p. 308-23.
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postoperative pain continues to be under managed. Anesth Analg 2003;97(2):534-40.
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