Clinical Guidance for Acute Pain Management

46
(Clinical Guidance for Acute Pain Management) ©∫—∫∑’Ë 1 æ.». 2552 (æ‘¡æå§√—Èß∑’Ë 1) ISBN: 978-974-8285-72-6 ®—¥∑”‚¥¬  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ ACUTEPAIN ·π«∑“ßæ—≤π“ °“√√–ß—∫ª«¥‡©’¬∫æ≈—π

Transcript of Clinical Guidance for Acute Pain Management

Page 1: Clinical Guidance for Acute Pain Management

(Clinical Guidance for Acute Pain Management)

©∫—∫∑’Ë 1 æ.». 2552 (æ‘¡æå§√—Èß∑’Ë 1)ISBN: 978-974-8285-72-6

®—¥∑”‚¥¬

 ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬

ACUTEPAIN

·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—π

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Thai Association for the Study of Pain (TASP)

√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬Ï·ÀËߪ√–‡∑»‰∑¬√“™«‘∑¬“≈—¬»—≈¬·æ∑¬Ï·ÀËߪ√–‡∑»‰∑¬

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√“™«‘∑¬“≈—¬‚ μ »Õ π“ ‘°·æ∑¬Ï·ÀËߪ√–‡∑»‰∑¬√“™«‘∑¬“≈—¬®—°…ÿ·æ∑¬Ï·ÀËߪ√–‡∑»‰∑¬

√“™«‘∑¬“≈—¬·æ∑¬Ï‡«™»“ μ√Ïø◊ÈπøŸ·ÀËߪ√–‡∑»‰∑¬™¡√¡‡«™»“ μ√Ï©ÿ°‡©‘π·ÀËߪ√–‡∑»‰∑¬

‚√ß欓∫“≈¡À“√“™π§√√“™ ’¡“‚√ß欓∫“≈À“¥„À≠Ë

‚√ß欓∫“≈æ√–π—Ë߇°≈È“ ∂“∫—π ÿ¢¿“懥Á°·ÀËß™“μ‘¡À“√“™‘π’

©∫—∫∑’Ë 1 æ.». 2552 (æ‘¡æϧ√—Èß∑’Ë 1)ISBN: 978-974-8285-72-6

Page 3: Clinical Guidance for Acute Pain Management

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·¡â«à“„πÀ≈“¬ª√–‡∑»®–¡’°“√®—¥∑”·π«∑“ß°“√√–ß—∫ª«¥¡“‡°◊Õ∫ 20 ªï·≈â«°Áμ“¡ ·μà„πª√–‡∑»‰∑¬¬—߉¡à¡’°“√®—¥∑”·π«∑“ߥ—ß°≈à“«¡“°àÕπ ¥—ßπ—Èπ ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬®÷߉¥â®—¥∑”·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—π¢÷Èπ ‚¥¬¡’«—μ∂ÿª√– ß§å ‡æ◊ËÕ‡ªìπ·π«∑“ß„π°“√¥Ÿ·≈ºŸâªÉ«¬∑’Ë¡’Õ“°“√ª«¥‡©’¬∫æ≈—π·≈– “¡“√∂„™âÕâ“ßՑ߉¥âμàÕ‰ª

Õ¬à“߉√°Áμ“¡·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—π©∫—∫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°—π‰ª ‡ªìπÕߧåª√–°Õ∫∑’Ë ”§—≠¥â«¬

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 ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬À«—ß«à“·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—π©∫—∫π’È®–¡’°“√𔉪ª√–¬ÿ°μå„™â„π‚√ß欓∫“≈μà“ßÊ Õ¬à“ß°«â“ߢ«“ß ÷Ëß®–¡’ à«π™à«¬„Àâ§ÿ≥¿“æ™’«‘μ¢ÕߺŸâªÉ«¬¥’¢÷Èπ ·≈–¢Õ¢Õ∫§ÿ≥ºŸâ‡°’ˬ«¢âÕß∑ÿ°∑à“π∑’Ë¡’ à«π„π°“√®—¥∑”·π«∑“ß©∫—∫π’È®π ”‡√Á®≈ÿ≈à«ß¥â«¬¥’

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1. √».πæ.ª√–¥‘…∞å ª√–∑’ª–«≥‘™π“¬° ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ ∑’˪√÷°…“

2. ».πæ. ¡∫Ÿ√≥å ‡∑’¬π∑ÕßÕÿªπ“¬° ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ ª√–∏“π

3. æ.μ.πæ.™“≠ƒ∑∏‘Ï ≈âÕ∑«’ «— ¥‘χ≈¢“∏‘°“√ ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ ‡≈¢“πÿ°“√

4. √».æ≠.«‘¡≈≈—°…≥å  π—Ëπ»‘≈ªá§≥–·æ∑¬»“ μ√廑√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈ °√√¡°“√

5. √».πæ.«‘™—¬ Õ‘∑∏‘™—¬°ÿ≈±≈§≥–·æ∑¬»“ μ√å‚√ß欓∫“≈√“¡“∏‘∫¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈ °√√¡°“√

6. √».æ≠. ÿª√“≥’ π‘√ÿμμ‘»“ πå§≥–·æ∑¬»“ μ√å ®ÿÓ≈ß°√≥å¡À“«‘∑¬“≈—¬ °√√¡°“√

7. æ.Õ.πæ.πæ¥≈ ™◊Ëπ»‘√‘‡°…¡«‘∑¬“≈—¬·æ∑¬»“ μ√åæ√–¡ß°ÿƇ°≈â“ °√√¡°“√

8. º».æ≠. À—∑¬“ ‰æ∫Ÿ≈¬å«√™“쑧≥–·æ∑¬»“ μ√å ¡À“«‘∑¬“≈—¬‡™’¬ß„À¡à °√√¡°“√

9. º».æ≠.»»‘°“πμå π‘¡¡“π√—™μå§≥–·æ∑¬»“ μ√å ¡À“«‘∑¬“≈—¬ ß¢≈“π§√‘π∑√å °√√¡°“√

10. º».æ≠.≈—°…¡’ ™“≠‡«™™å°√√¡°“√ ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ °√√¡°“√

11. √».¥√.πæ.ª√–«‘∑¬å Õ—§√‡ √’ππ∑å§≥–·æ∑¬»“ μ√廑√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈ °√√¡°“√

√“¬π“¡§≥–ºŸâ®—¥∑”

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√“™«‘∑¬“≈—¬μà“ßÊ ‰¥â·°à √“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬»—≈¬·æ∑¬å·Ààߪ√–‡∑»‰∑¬

√“™«‘∑¬“≈—¬·æ∑¬åÕÕ√å‚∏ªî¥‘° å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬ Ÿμ‘π√’·æ∑¬å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬

‚ μ »Õ π“ ‘°·æ∑¬å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬®—°…ÿ·æ∑¬å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬·æ∑¬å

‡«™»“ μ√åøóôπøŸ·Ààߪ√–‡∑»‰∑¬ ·≈– ™¡√¡‡«™»“ μ√å©ÿ°‡©‘π·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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ë °“√√–ß—∫ª«¥·∫∫º ¡º “π 11

ë «‘∏’°“√√—°…“Õ“°“√·∑√° âÕπ 11

¿“§ºπ«° :

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ë ‡§√◊ËÕß¡◊Õ ”À√—∫ª√–‡¡‘π√–¥—∫§«“¡ª«¥ 14

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*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 1

∫∑𔇪ìπ∑’Ë∑√“∫¥’«à“Õ“°“√ª«¥∑”„À⇰‘¥º≈‡ ’¬μàÕºŸâªÉ«¬À≈“¬Õ¬à“ß ‡™àπ ∑”„Àâ ‰¡à ÿ¢ ∫“¬ ¡’Õ“°“√·∑√° âÕπ

μàÕ√–∫∫μà“ßÊ ¢Õß√à“ß°“¬ ·≈–‡ ’¬§à“„™â®à“¬„π°“√√—°…“¡“°¢÷Èπ ªí®®ÿ∫—πÀπ૬ߓπμà“ßÊ ∑—Ë«‚≈°∑’Ë¡’ à«π„π

°“√√–ß—∫ª«¥‡©’¬∫æ≈—π¡’§«“¡μâÕß°“√∑’Ë®–æ—≤π“°“√∫√‘°“√„Àâ ‰¥â§ÿ≥¿“æÕ¬à“ßμàÕ‡π◊ËÕß ·≈–¡’À≈—°∞“π∑’Ë

 “¡“√∂μ√«® Õ∫‰¥â ¥â«¬‡Àμÿπ’È®÷߉¥â¡’°“√®—¥∑”·π«∑“ßæ—≤π“ (Clinical Guidance: „π∑’Ëπ’È®–¢Õ‡¢’¬π —ÈπÊ

«à“ ç·π«∑“ßé) ¢Õß·μà≈–·Ààß ‡™àπ The American Society of Anesthesiologists (ASA:2004)1, The

American Pain Society (2005)2, Australian and New Zealand College of Anaesthetists (2005)3,

British Pain Society (2007)4, Institute for Clinical Systems Improvement (ICSI:2008)5 ·≈–·π«∑“ß

Õ◊ËπÊ Õ’°À≈“¬·Ààß

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„™âÕâ“ßՑ߉¥âμàÕ‰ª ‚¥¬À«—ß«à“·π«∑“ßπ’È®–™à«¬„Àâ§ÿ≥¿“æ™’«‘μ¢ÕߺŸâªÉ«¬¥’¢÷Èπ  à߇ √‘¡„À⺟âªÉ«¬øóôπμ—«·≈– “¡“√∂

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·μ°μà“ß°—π‰ª ‡™àπ ºŸâªÉ«¬„πÀâÕßæ—°øóôπ∑’Ë¡’Õ“°“√ª«¥¡“°°«à“ 5 §–·ππ æ∫√âÕ¬≈– 246 ºŸâªÉ«¬À≈—ߺà“μ—¥∑“ß

ÕÕ√å‚∏ªî¥‘° å∑’Ë¡’Õ“°“√ª«¥ >7 §–·ππ æ∫√âÕ¬≈– 28.77 ºŸâªÉ«¬ºà“μ—¥§≈Õ¥∑“ßÀπâ“∑âÕß¡’Õ“°“√ª«¥¡“°„π

¢≥–¢¬—∫μ—«√âÕ¬≈– 228 ·μଗ߉¡à¡’√“¬ß“π∑’Ë™—¥‡®π‡°’ˬ«°—∫§«“¡™ÿ°¢Õߧ«“¡ª«¥‡©’¬∫æ≈—π∑’Ëπ”ºŸâªÉ«¬¡“æ∫

·æ∑¬å∑’Ë ‚√ß欓∫“≈

§”®”°—¥§«“¡§«“¡ª«¥·∫àßμ“¡√–¬–‡«≈“ÕÕ°‡ªìπ Õߪ√–‡¿∑ §◊Õ §«“¡ª«¥‡©’¬∫æ≈—π (acute pain) ·≈–§«“¡

ª«¥‡√◊ÈÕ√—ß (chronic pain)

°“√√–ß—∫ª«¥μ“¡·π«∑“ß∑’Ë®—¥∑”π’È ®”°—¥‡©æ“–§«“¡ª«¥™π‘¥‡©’¬∫æ≈—π ´÷ËßÀ¡“¬∂÷ߧ«“¡ª«¥∑’ˇ°‘¥

¢÷Èπ„πªí®®ÿ∫—𠇪ìπ¡“‰¡à‡°‘π 6 ‡¥◊Õ𠇪ì𧫓¡ª«¥∑’Ë¡’ “‡Àμÿ®“°°“√∫“¥‡®Á∫À√◊Õ°“√Õ—°‡ ∫‡ªìπ à«π„À≠à √–¬–

‡«≈“∑’˪«¥®–Õ¬Ÿà‰¡àπ“π ‚¥¬Õ“°“√ª«¥®–∑ÿ‡≈“‡¡◊ËÕ “‡Àμÿ‰¥â√—∫°“√·°â ‰¢À√◊ÕÀ“¬·≈â« μ—«Õ¬à“ߢÕߧ«“¡ª«¥

‡©’¬∫æ≈—𠇙à𠧫“¡ª«¥®“°°“√ºà“μ—¥ Õÿ∫—쑇Àμÿ ‰ø‰À¡â πÈ”√âÕπ≈«° ‰ âμ‘ËßÕ—°‡ ∫ ·≈–Õ◊ËπÊ „π∑ÿ°‡æ»·≈–

∑ÿ°°≈ÿà¡Õ“¬ÿ

«‘∏’°“√√–ß—∫ª«¥‚¥¬„™â¬“μ“¡·π«∑“ßπ’È ®–‡πâπ‡©æ“–«‘∏’°“√∑’Ë¡’„™â°—π∑—Ë«‰ª ‡™àπ °“√©’¥¬“∑“ßÀ≈Õ¥

‡≈◊Õ¥¥” ©’¥„μ⺑«Àπ—ßÀ√◊Õ‡¢â“°≈â“¡ √«¡∑—Èß«‘∏’°“√√—∫ª√–∑“π  ”À√—∫‡∑§π‘§Õ◊ËπÊ ∑’ËμâÕßÕ“»—¬∑—°…–摇»… ‡™àπ

Page 9: Clinical Guidance for Acute Pain Management

 ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***2

°“√∑” epidural block √«¡∑—Èß°“√„™â‡§√◊ËÕß¡◊Õμà“ßÊ „π°“√√–ß—∫ª«¥ ‡™à𠇧√◊ËÕß patient-controlled analge-

sia (PCA) ®–‰¡à‰¥â°≈à“«∂÷ß„π∑’Ëπ’È

°≈ÿࡇªÑ“À¡“¬°≈ÿࡇªÑ“À¡“¬ ”À√—∫ºŸâ„™â·π«∑“ßπ’È ‰¥â·°à ·æ∑¬å ·≈–欓∫“≈ ∑’˪ؑ∫—μ‘ß“π„π‚√ß欓∫“≈∑ÿ°√–¥—∫„π

ª√–‡∑»‰∑¬ ∑’Ë„Àâ°“√¥Ÿ·≈ºŸâªÉ«¬´÷Ëß¡’Õ“°“√ª«¥‡©’¬∫æ≈—π

·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—π

ºŸÈªË«¬¡’Õ“°“√ª«¥‡©’¬∫æ≈—π

ª√–‡¡‘π√–¥—∫§«“¡ª«¥

¡’ “‡Àμÿ∑’Ë∑”„Àȇ°‘¥Õ“°“√ª«¥√Ë«¡¥È«¬

1

2

√—°…“ “‡Àμÿ¢ÕßÕ“°“√ª«¥

Õ“°“√ª«¥μÈÕß°“√°“√√—°…“

°“√√–ß—∫ª«¥‰¥Èº≈¥’

ª√–‡¡‘π È”·≈–∫—π∑÷°

‡°‘¥Õ“°“√·∑√°´ÈÕπ®“°°“√√—°…“À√◊Õ‰¡Ë

‰¡Ë„™Ë

„™Ë

„™Ë

‰¡Ë„™Ë

„™Ë

‰¡Ë„™Ë

√—°…“Õ“°“√·∑√°´ÈÕπ

‡≈◊Õ°«‘∏’°“√√—°…“∑’ˇÀ¡“– ¡À√◊Õª√÷°…“ºŸÈ‡™’ˬ«™“≠ (∂È“¡’)

°“√√–ß—∫ª«¥‡©’¬∫æ≈—π :ë °“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬„™â¬“ ë °“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬‰¡à„™â¬“ë °“√√–ß—∫ª«¥·∫∫º ¡º “π

3

5

8

6 7

4

·ºπ¿Ÿ¡‘∑’Ë 1 ·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—π

Page 10: Clinical Guidance for Acute Pain Management

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 3

 √ÿª§”·π–π” ”À√—∫°“√√–ß—∫ª«¥‡©’¬∫æ≈—πμ“¡·π«∑“ß·ºπ¿Ÿ¡‘∑’Ë 11. °≈àÕß∑’Ë 1: ºŸâªÉ«¬¡’‚√§ª√–®”μ—«∑’ˇ°’ˬ«¢âÕß°—∫Õ“°“√ª«¥À√◊Õ‰¡à

§”·π–π”: §«√ª√–‡¡‘π ¿“æºŸâªÉ«¬‡æ◊ËÕÀ“ “‡Àμÿ∑’ˇ°’ˬ«¢âÕß·≈–„Àâ°“√√—°…“Õ“°“√ª«¥μ“¡ “‡Àμÿ

2. °≈àÕß∑’Ë 2: °“√ª√–‡¡‘π√–¥—∫§«“¡ª«¥¢ÕߺŸâªÉ«¬ (pain assessment)

§”·π–π”: 1) §«√‡≈◊Õ°„™â‡§√◊ËÕß¡◊Õ„π°“√ª√–‡¡‘𧫓¡ª«¥„Àâ‡À¡“– ¡°—∫ºŸâªÉ«¬·μà≈–√“¬

2) ∑”°“√ª√–‡¡‘𧫓¡ª«¥°àÕπ°“√√—°…“·≈–À≈—ß„Àâ°“√√—°…“Õ¬à“ß ¡Ë”‡ ¡Õ

3) §«√∫—π∑÷°§«“¡ª«¥„Àâ‡ÀÁπ™—¥‡®π

3. °≈àÕß∑’Ë 3: Õ“°“√ª«¥μâÕß°“√°“√√—°…“À√◊Õ‰¡à

§”·π–π”: §«√„À⧫“¡√Ÿâ·°àºŸâªÉ«¬‡√◊ËÕß°“√√–ß—∫ª«¥·≈–„À⺟âªÉ«¬‰¥â¡’ à«π√à«¡„π°“√μ—¥ ‘π„®‡≈◊Õ°

«‘∏’°“√√–ß—∫ª«¥¥â«¬μ—«‡Õß

4. °≈àÕß∑’Ë 4: °“√√–ß—∫ª«¥‡©’¬∫æ≈—π (acute pain treatment)

4.1 °“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬„™â¬“ (pharmacological therapy)

§”·π–π”: 1) ºŸâ„Àâ°“√√—°…“§«√¡’§«“¡√Ÿâ‡°’ˬ«°—∫¬“·°âª«¥ª√–‡¿∑μà“ßÊ ∑—Èß°≈‰°°“√ÕÕ°ƒ∑∏‘Ï

¢π“¥¬“ ¢âÕ§«√√–«—ß ¢âÕÀâ“¡ Õ“°“√·∑√°´âÕπ œ≈œ

2) ‡≈◊Õ°„™â¬“·°âª«¥μ“¡√–¥—∫§«“¡√ÿπ·√ߢÕßÕ“°“√ª«¥∑’ˇ°‘¥¢÷Èπ®√‘ßÀ√◊Õ§“¥«à“

®–‡°‘¥¢÷Èπ

3) „™â«‘∏’°“√º ¡º “π„π°“√√–ß—∫ª«¥‡©’¬∫æ≈—π (multimodal pain therapy)

4) §«√¡’·π«∑“ß„π°“√∫√‘À“√¬“·°âª«¥ (opioid) ‰¡à«à“®–∫√‘À“√∑“ß IM À√◊Õ IV

4.2 °“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬‰¡à„™â¬“ (non-pharmacological therapy)

§”·π–π”: 1) °“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬‰¡à„™â¬“¡’®ÿ¥¡ÿàßÀ¡“¬‡æ◊ËÕ π—∫ πÿπ„Àâ°“√√—°…“§«“¡

ª«¥®“°°“√„™â¬“‰¥âº≈¥’¢÷Èπ‚¥¬‰¡à¡’®ÿ¥¡ÿàßÀ¡“¬∑’Ë®–∑¥·∑π°“√„™â¬“·°âª«¥

5. °≈àÕß∑’Ë 5: Õ“°“√ª«¥¥’¢÷ÈπÀ√◊Õ‰¡àÀ≈—߉¥â√—∫°“√√—°…“

§”·π–π”: ∑”°“√ª√–‡¡‘𧫓¡ª«¥À≈—ß„Àâ°“√√—°…“Õ¬à“ß ¡Ë”‡ ¡Õ‡æ◊ËÕª√–‡¡‘πª√– ‘∑∏‘¿“æ¢Õß

°“√√—°…“

6. °≈àÕß∑’Ë 6: °“√ª√–‡¡‘πÕ“°“√·∑√°´âÕπ®“°°“√√–ß—∫ª«¥

§”·π–π”: §«√¡’°“√‡ΩÑ“√–«—ßÕ“°“√·∑√° âÕπ ·≈–¡’§” —Ëß°“√√—°…“ ”À√—∫Õ“°“√·∑√° âÕπ„π

ºŸâªÉ«¬∑ÿ°√“¬Õ¬à“ß™—¥‡®π

7. °≈àÕß∑’Ë 7: «‘∏’°“√√—°…“Õ“°“√·∑√° âÕπ

§”·π–π”: 1)  “¡“√∂„À⬓√—°…“Õ“°“√·∑√° âÕπ‰¥âμ—Èß·μà‡√‘Ë¡¡’Õ“°“√

2) À“°„™â¬“¢π“π‡¥’¬«‰¡à‰¥âº≈ “¡“√∂„™â¬“∑’Ë¡’°≈‰°ÕÕ°ƒ∑∏‘Ïμà“ß°—π¡“„™â‡ √‘¡ƒ∑∏‘Ï°—π‰¥â

8. °≈àÕß∑’Ë 8: °“√ª√–‡¡‘πÕ“°“√ª«¥´È”·≈–°“√∫—π∑÷°º≈°“√ª√–‡¡‘π

§”·π–π”: ∑”°“√ª√–‡¡‘𧫓¡ª«¥À≈—ß„Àâ°“√√—°…“Õ¬à“ß ¡Ë”‡ ¡Õ·≈–∫—π∑÷°§«“¡ª«¥„Àâ‡ÀÁπ™—¥‡®π

(¥Ÿ§”·π–π”∑’Ë 2, 3 „π°≈àÕß∑’Ë 2)

Page 11: Clinical Guidance for Acute Pain Management

 ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***4

§”Õ∏‘∫“¬·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—π

1. °“√√—°…“ “‡Àμÿ∑’ˇ°’ˬ«¢âÕß°—∫Õ“°“√ª«¥ (°≈àÕß∑’Ë 1)§”·π–π”: §«√ª√–‡¡‘π ¿“æºŸâªÉ«¬‡æ◊ËÕÀ“ “‡Àμÿ∑’ˇ°’ˬ«¢âÕß·≈–„Àâ°“√√—°…“Õ“°“√ª«¥μ“¡ “‡Àμÿ

°“√√–ß—∫ª«¥‡©’¬∫æ≈—π„Àâ ‰¥âº≈¥’ μâÕß√—°…“ “‡Àμÿ∑’Ë∑”„À⇰‘¥«“¡ª«¥π—Èπ‚¥¬μ√ß ‡™à𠪫¥∑âÕß®“°

·º≈„π°√–‡æ“–Õ“À“√μâÕß¡’¬“√—°…“·º≈„π°√–‡æ“–Õ“À“√ À√◊Õª«¥·º≈∑’Ëμ‘¥‡™◊ÈÕμâÕß√—°…“°“√μ‘¥‡™◊ÈÕ ‡ªìπμâπ

°√≥’∑’Ë¡’§«“¡ª«¥‡©’¬∫æ≈—π ‚¥¬ºŸâªÉ«¬Õ¬Ÿà„π ¿“æ∑’ˉ¡à¡’¿“«–§ÿ°§“¡μàÕ√–∫∫ ¡ÕßÀ√◊Õ°“√‰À≈‡«’¬π

¢Õ߇≈◊Õ¥ ·≈–Õ¬Ÿà„π√–À«à“ß°“√√—°…“ “‡Àμÿ¢Õߧ«“¡ª«¥ §«√„Àâ°“√√–ß—∫§«“¡ª«¥‡©’¬∫æ≈—π®πÕ“°“√ª«¥

∫√√‡∑“‰ª°àÕπ‡æ◊ËÕ≈¥§«“¡∑ÿ°¢å∑√¡“π¢ÕߺŸâªÉ«¬

2. °“√ª√–‡¡‘π√–¥—∫§«“¡ª«¥ (°≈àÕß∑’Ë 2)9

§”·π–π”: 1) §«√‡≈◊Õ°„™â‡§√◊ËÕß¡◊Õ„π°“√ª√–‡¡‘𧫓¡ª«¥„Àâ‡À¡“– ¡°—∫ºŸâªÉ«¬·μà≈–√“¬

2) ∑”°“√ª√–‡¡‘𧫓¡ª«¥Õ¬à“ß ¡Ë”‡ ¡Õμ“¡·π«ªØ‘∫—μ‘¢Õß·μà≈–·Ààß √«¡∑—Èß°àÕπ·≈–

À≈—ß„Àâ°“√√—°…“

3) §«√∫—π∑÷°§«“¡ª«¥„Àâ‡ÀÁπ™—¥‡®π

°“√√–ß—∫ª«¥„Àâ ‰¥âº≈¥’μâÕ߇√‘Ë¡®“°°“√ª√–‡¡‘𧫓¡ª«¥¢ÕߺŸâªÉ«¬„Àâ∂Ÿ°μâÕß°àÕπ ‚¥¬μâÕߪ√–‡¡‘π

μ—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

‡¥‘¡ ¥—ßπ—Èπ°“√∫Õ°√–¥—∫§«“¡ª«¥¥â«¬μ—«¢ÕߺŸâªÉ«¬®÷߇ªìπ«‘∏’ª√–‡¡‘π∑’ˇÀ¡“– ¡∑’Ë ÿ¥ ‡§√◊ËÕß¡◊Õ ”À√—∫ª√–‡¡‘π

§«“¡√ÿπ·√ߢÕߧ«“¡ª«¥¥Ÿ„π√Ÿª∑’Ë 1

3. Õ“°“√ª«¥μâÕß°“√°“√√—°…“À√◊Õ‰¡à (°≈àÕß∑’Ë 3)§”·π–π”: §«√„À⧫“¡√Ÿâ·°àºŸâªÉ«¬‡√◊ËÕß°“√√—°…“Õ“°“√ª«¥·≈–„À⺟âªÉ«¬‰¥â¡’ à«π√à«¡„π°“√μ—¥ ‘π„®

‡≈◊Õ°«‘∏’°“√√—°…“Õ“°“√ª«¥¥â«¬μ—«‡Õß

ºŸâªÉ«¬∑’Ë¡’§«“¡ª«¥·¡â‡≈Á°πâÕ¬·μà∂â“μâÕß°“√°“√√–ß—∫ª«¥ „Àâæ‘®“√≥“‡≈◊Õ°«‘∏’°“√μ“¡§«“¡‡À¡“– ¡

„π°√≥’∑’˺ŸâªÉ«¬¡’ªí≠À“‡√◊ËÕß°“√ ◊ËÕ “√μâÕ߉¥â√—∫°“√¥Ÿ·≈‡ªìπ摇»…´÷Ëß„π·π«∑“ßπ’Ȭ—߉¡à‰¥â√«∫√«¡‰«â ·æ∑¬åºŸâ

„Àâ°“√√—°…“§«√æ‘®“√≥“°“√¥Ÿ·≈‡ªìπ√“¬Ê ‰ª

°√≥’∑’Ë∑√“∫≈à«ßÀπâ“«à“®–¡’§«“¡ª«¥‡°‘¥¢÷È𠇙à𠧫“¡ª«¥®“°°“√ºà“μ—¥ °“√„À⧫“¡√Ÿâ‡°’ˬ«°—∫§«“¡ª«¥

·°àºŸâªÉ«¬μ—Èß·μà°àÕπºà“μ—¥  “¡“√∂™à«¬„À⧫“¡ª«¥¢ÕߺŸâªÉ«¬≈¥≈ß ºŸâªÉ«¬§≈“¬§«“¡«‘μ°°—ß«≈ ·≈–‡æ‘Ë¡§«“¡

æ÷ßæÕ„®μàÕ°“√√—°…“‰¥â  ”À√—∫°√≥’∑’˺ŸâªÉ«¬¡’Õ“°“√ª«¥‡°‘¥¢÷Èπ·≈â« °“√„À⧔·π–π”¬—ß§ß¡’ª√–‚¬™πå ‚¥¬

™à«¬„À⺟âªÉ«¬‡¢â“„®·≈–„À⧫“¡√à«¡¡◊Õ„π°“√√—°…“¡“°¢÷Èπ ºŸâ„Àâ°“√√—°…“®÷ߧ«√„À⧔·π–π”ºŸâªÉ«¬‡°’ˬ«°—∫°“√

√—°…“Õ“°“√ª«¥¥—ßμàÕ‰ªπ’È

ºŸâªÉ«¬§«√‰¥â√—∫°“√Õ∏‘∫“¬∂÷ߧ«“¡ª«¥À≈—ߺà“μ—¥ «à“§«“¡ª«¥¢Õß·μà≈–§π®–‰¡à‡À¡◊Õπ°—π ¢÷Èπ°—∫™π‘¥

À√◊Õ¢π“¥¢Õß·º≈ºà“μ—¥ ·μà∂÷ß·¡â«à“®–‰¥â√—∫°“√ºà“μ—¥™π‘¥‡¥’¬«°—π°ÁÕ“®®–ª«¥‰¡à‡À¡◊Õπ°—π‰¥â·≈–§«“¡ª«¥

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*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 5

À≈—ߺà“μ—¥®–≈¥≈߇¡◊ËÕ‡«≈“ºà“π‰ª

°“√√–ß—∫ª«¥ “¡“√∂∑”‰¥â∑—Èß°“√„™â¬“·≈–‰¡à„™â¬“ ºŸâªÉ«¬§«√∫Õ°·æ∑¬å∑’Ë¥Ÿ·≈«à“ μπ¡’ª√– ∫°“√≥å

μàÕ°“√∫”∫—¥§«“¡ª«¥À≈—ߺà“μ—¥Õ¬à“߉√∫â“ß ·≈–¡’¿“«–·∑√°´âÕπÕ¬à“߉√ °“√√–ß—∫ª«¥∑’Ë¥’®–∑”„À⺟âªÉ«¬øóôπ

μ—«‰¥â‡√Á«¢÷Èπ

ºŸâªÉ«¬¡’ ‘∑∏‘·≈–§«“¡™Õ∫∏√√¡„π°“√√—∫°“√∫”∫—¥§«“¡ª«¥Õ¬à“߇μÁ¡∑’Ë ·μà∂÷ß·¡â«à“§«“¡ª«¥À≈—ߺà“μ—¥

®–‰¥â√—∫°“√∫”∫—¥Õ¬à“ߥ’·≈â« ºŸâªÉ«¬Õ“®¡’§«“¡ª«¥Õ¬Ÿà∫â“ß´÷Ëߧ«√®–Õ¬Ÿà„π√–¥—∫∑’ˬա√—∫‰¥â

ºŸâªÉ«¬§«√‡ªìπºŸâª√–‡¡‘𧫓¡ª«¥À≈—ߺà“μ—¥¥â«¬μπ‡Õß ¬°‡«âπºŸâ∑’ˉ¡à “¡“√∂ª√–‡¡‘𧫓¡ª«¥‰¥â „Àâ

„™â‡§√◊ËÕß¡◊Õ∑’ˇÀ¡“– ¡°—∫ºŸâªÉ«¬·μà≈–§π ·≈–„À⺟âªÉ«¬∫Õ°√–¥—∫§«“¡ª«¥‡¡◊ËÕ‰¥â√—∫°“√ Õ∫∂“¡®“°‡®â“Àπâ“∑’Ë

ºŸâªÉ«¬‰¡à§«√«‘μ°°—ß«≈‡°’ˬ«°—∫§«“¡‡ ’ˬ߄π°“√μ‘¥¬“·°âª«¥ ‡π◊ËÕß®“°√–¬–‡«≈“„π°“√„À⬓‡ªìπ√–¬–

‡«≈“ —Èπ ·μຟâªÉ«¬Õ“®¡’¿“«–·∑√° âÕπ®“°°“√„™â¬“‰¥â ‡™àπ ∑âÕߺŸ° §≈◊Ëπ‰ âÕ“‡®’¬π ·≈–¿“«–ßà«ß´÷¡

∂⓺ŸâªÉ«¬¡’Õ“°“√ª«¥¡“°¢÷Èπ·≈–‰¡à “¡“√∂∫”∫—¥‰¥â¥â«¬¬“∑’ˉ¥â√—∫À√◊Õ¡’¿“«–·∑√° âÕ𠧫√·®âß„Àâ·æ∑¬å

ºŸâ¥Ÿ·≈∑√“∫∑—π∑’

4. °“√√–ß—∫ª«¥‡©’¬∫æ≈—π (°≈àÕß∑’Ë 4)§«√™’È·®ß„À⺟âªÉ«¬∑√“∫«à“ μ—«ºŸâªÉ«¬¡’§«“¡ ”§—≠¡“°„π°“√√–ß—∫ª«¥„Àâ ‰¥âº≈¥’ ‚¥¬ºŸâªÉ«¬μâÕß„À⧫“¡

√Ÿª∑’Ë 1 °“√‡≈◊Õ°„™â‡§√◊ËÕß¡◊Õª√–‡¡‘π√–¥—∫§«“¡ª«¥μ“¡§«“¡ “¡“√∂„π°“√ ◊ËÕ “√¢ÕߺŸâªÉ«¬(¥—¥·ª≈ß®“° European society of regional anaesthesia and pain therapy ·≈– Newman CJ10)

‰¡àª«¥ ª«¥ª“π°≈“ß

‰¡àª«¥ ª«¥‡≈Á°πâÕ¬

ª«¥ª“π°≈“ß

ª«¥¡“° ª«¥¡“°∑’Ë ÿ¥

‰¡àª«¥ ª«¥¡“°∑’Ë ÿ¥

‰¡àª«¥0

ª«¥¡“°∑’Ë ÿ¥

ª«¥¡“°∑’Ë ÿ¥

Face painassessment

scale

ºŸâªÉ«¬ ◊ËÕ “√

‰¥â®”°—¥

‡§√◊ËÕß¡◊Õ

ª√–‡¡‘π

√–¥—∫

§«“¡ª«¥

2 4 6 8 10

Numericalrating scale

(NRS)

Verbalrating scale

(VRS)

ºŸâªÉ«¬ ◊ËÕ “√

‰¥â¥’

Visualanalog scale

(VAS)

0 1 2 3 4 5 6 7 8 9 10

Page 13: Clinical Guidance for Acute Pain Management

 ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***6

√à«¡¡◊Õ„π°“√„Àâª√–«—쑧«“¡ª«¥·≈–‚√§μà“ßÊ ∑’ˇªìπÕ¬à“ß≈–‡Õ’¬¥ √«¡∑—Èß¡’ à«π√à«¡„π°“√ª√–‡¡‘π√–¥—∫§«“¡

√ÿπ·√ߢÕߧ«“¡ª«¥∑’Ë°”≈—ߪ√– ∫·≈–·®âß„Àâ·æ∑¬åÀ√◊Õ欓∫“≈∑√“∫‡¡◊ËÕ°“√√–ß—∫ª«¥¬—߉¥âº≈‰¡à¥’æÕÀ√◊Õ

¡’¿“«–·∑√° âÕπ‡°‘¥¢÷Èπ ‡æ◊ËÕ„Àâ°“√¥Ÿ·≈√—°…“∑”‰¥â∑—π∑à«ß∑’

°“√«“ß·ºπ°“√√—°…“„À⧔π÷ß∂÷ßªí®®—¬μàÕ‰ªπ’È ¥â«¬ ‡™à𠧫“¡‡™◊ËÕ¢ÕߺŸâªÉ«¬ ·≈–¢π∫∏√√¡‡π’¬¡ª√–‡æ≥’

§«“¡°≈—«¢ÕߺŸâªÉ«¬ (‡™àπ °≈—«μ‘¥¬“) º≈°√–∑∫¢Õߧ«“¡ª«¥ (‡™àπ μàÕ™’«‘짫“¡‡ªìπÕ¬Ÿà ·≈–Õ“√¡≥å)

®ÿ¥¡ÿàßÀ¡“¬¢ÕߺŸâªÉ«¬ (‡™àπ √–¥—∫§«“¡ª«¥∑’˺ŸâªÉ«¬¬Õ¡√—∫‰¥â) °“√„™â«‘∏’°“√√—°…“Õ◊Ëπ∑’ˉ¡à„™â¬“·≈–§«“¡√Ÿâ

¢ÕߺŸâªÉ«¬‡°’ˬ«°—∫‚√§·≈–§«“¡ª«¥ ‡ªìπμâπ

À≈—°°“√√–ß—∫ª«¥‡©’¬∫æ≈—π ª√–°Õ∫¥â«¬

ë √—°…“ “‡Àμÿ∑’Ë∑”„À⪫¥·≈–√–ß—∫Õ“°“√ª«¥‡©’¬∫æ≈—π (°≈àÕß∑’Ë 1)

ë ª√–‡¡‘π√–¥—∫§«“¡√ÿπ·√ߢÕߧ«“¡ª«¥°àÕπ·≈–À≈—ß°“√√—°…“ (°≈àÕß∑’Ë 2)

ë „™â«‘∏’°“√√–ß—∫ª«¥∑—Èß°“√„™â¬“·≈–/À√◊Õ√à«¡°—∫°“√‰¡à„™â¬“ ·≈–/À√◊Õ „™â«‘∏’°“√√–ß—∫ª«¥·∫∫

º ¡º “π (multimodal analgesia) μ“¡·μà‚Õ°“ 

°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬„™â¬“ (Pharmacological therapy)¬“∑’Ë„™â„π°“√√–ß—∫ª«¥ ‰¥â·°à¬“„π°≈ÿà¡ paracetamol, nonsteroidal anti-inflammatory drugs, opioids,

local anesthetic ·≈–¬“„π°≈ÿà¡ adjuvants

æ‘®“√≥“°“√„™â¬“·°âª«¥¥—ßπ’È

1. ‡≈◊Õ°„™â™π‘¥¢Õ߬“·≈–°“√∫√‘À“√¬“μ“¡§«“¡√ÿπ·√ߢÕߧ«“¡ª«¥ (√Ÿª∑’Ë 2)

√Ÿª∑’Ë 2 ∫—π‰¥ 3 ¢—Èπ  ”À√—∫‡≈◊Õ°„™â™π‘¥¢Õ߬“·≈–°“√∫√‘À“√¬“μ“¡§«“¡√ÿπ·√ߢÕߧ«“¡ª«¥  “¡“√∂„™â¬“‡ √‘¡·≈–¬“™“‡©æ“–∑’Ë ‡ √‘¡ƒ∑∏‘Ϭ“·°âª«¥‰¥â

3

1

2

3

1

2

Page 14: Clinical Guidance for Acute Pain Management

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 7

2. ¢π“¥¢Õ߬“∑’ˇÀ¡“– ¡ §◊Õ¢π“¥∑’Ë “¡“√∂·°âª«¥‰¥â¥’‚¥¬¡’º≈¢â“߇§’¬ßπâÕ¬∑’Ë ÿ¥

3. °√≥’∑’Ë∑√“∫«à“¡’°“√∫“¥‡®Á∫≈à«ßÀπâ“ ‡™àπ °“√ºà“μ—¥  “¡“√∂„À⬓·°âª«¥°àÕπ°“√ºà“μ—¥ ‡æ◊Ëՙ૬

≈¥°“√√—∫√Ÿâ§«“¡ª«¥·≈–Õ“® “¡“√∂≈¥ª√‘¡“≥°“√„™â¬“·°âª«¥≈߉¥â

4. §«√„™â¬“·°âª«¥À≈“¬¢π“π∑’Ë¡’°≈‰°°“√ÕÕ°ƒ∑∏‘Ïμà“ß°—πº ¡º “π°—π ‡æ◊ËÕ„Àâº≈√–ß—∫ª«¥¥’¢÷Èπ

≈¥¢π“¥¢Õ߬“·≈–≈¥º≈¢â“߇§’¬ß¢Õ߬“·°âª«¥·μà≈–¢π“π≈ß

°“√∫√‘À“√¬“ Opioid°“√∫√‘À“√¬“ opioid ∑“ßÀ≈Õ¥‡≈◊Õ¥¥” (IV) ·≈–∑“ß°≈â“¡‡π◊ÈÕÀ√◊Õ„μ⺑«Àπ—ß (IM/SC) · ¥ß„π·ºπ¿Ÿ¡‘

∑’Ë 2, 3 ·≈– 4

°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬‰¡à„™â¬“ (Non-pharmacological therapy)°“√√–ß—∫ª«¥‚¥¬‰¡à„™â¬“ Õ“®·∫à߉¥â‡ªìπ psychological therapy ·≈– physical therapy

Psychological therapy 䴉ᡈ

1. °“√„Àâ¢âÕ¡Ÿ≈ (Provision of information)

2. °“√ºàÕπ§≈“¬·≈–°“√¡ÿà߇πâ𧫓¡ π„® (Relaxation and attention strategies)

3. °“√ –°¥®‘μ (Hypnosis)

4. °“√ª√—∫‡ª≈’Ë¬π§«“¡§‘¥·≈–æƒμ‘°√√¡ (Cognitive-behavioral therapy)

‡ªÑ“À¡“¬¢Õß°“√„™â psychological therapy §◊Õ°“√ª√—∫‡ª≈’ˬπ°“√√—∫√Ÿâ§«“¡ª«¥ °“√ª√—∫‡ª≈’ˬπ

§«“¡§‘¥·≈–æƒμ‘°√√¡¢ÕߺŸâªÉ«¬ ÷Ëß®–™à«¬„À⺟âªÉ«¬ “¡“√∂§«∫§ÿ¡§«“¡ª«¥‰¥â¥’¢÷Èπ

Physical therapy 䴉ᡈ

1. °“√ª√–§∫√âÕπ·≈–‡¬Áπ (Applications of heat and cold)

2. °“√°¥®ÿ¥·≈–°“√π«¥ (Manual and massage therapy)

3. Transcutaneous electrical nerve stimulation (TENS)

4. °“√Ωí߇¢Á¡ (Acupuncture)

‡ªÑ“À¡“¬¢Õß°“√„™â physical therapy §◊ՙ૬„À⺟âªÉ«¬ ∫“¬ ·°â ‰¢§«“¡º‘¥ª°μ‘„π°“√∑”ß“π¢Õß√à“ß°“¬

∑“ß°“¬¿“æ ‡™àπ -°≈â“¡‡π◊ÈÕ·≈–‡ª≈’ˬπ·ª≈ß°“√μÕ∫ πÕß∑“ß √’√«‘∑¬“ √«¡∑—Èß≈¥§«“¡°≈—«§«“¡ª«¥

®“°°“√‡§≈◊ËÕπ‰À«‡æ◊ËÕ„À⺟âªÉ«¬‡§≈◊ËÕπ‰À«‰¥â‡√Á«¢÷Èπ

¥—ßπ—Èπ°“√„™â non-pharmacological therapy „π°“√√–ß—∫ª«¥‡©’¬∫æ≈—π®÷ß¡’®ÿ¥¡ÿàßÀ¡“¬‡æ◊ËÕ π—∫ πÿπ

„Àâ°“√√—°…“§«“¡ª«¥®“°°“√„™â¬“‰¥â¥’¢÷Èπ‚¥¬‰¡à¡’®ÿ¥¡ÿàßÀ¡“¬∑’Ë®–∑¥·∑π°“√„™â¬“·°âª«¥

°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬‰¡à„™â¬“‡À¡“–°—∫ºŸâªÉ«¬∑’Ë¡’≈—°…≥–¥—ßμàÕ‰ªπ’ȧ◊Õ

1.  π„®°“√√—°…“«‘∏’π’È

2. °≈—«À√◊Õ°—ß«≈¡“°

3. ¡’Õ“°“√¢â“߇§’¬ß®“°¬“·°âª«¥¡“° ‡æ◊ËÕ®–™à«¬≈¥ª√‘¡“≥°“√„À⬓·°âª«¥

4. §«“¡ª«¥¬—ß¡’Õ¬Ÿà¥â«¬°“√√—°…“μ“¡ª°μ‘

Page 15: Clinical Guidance for Acute Pain Management

 ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***8

·ºπ¿Ÿ¡‘∑’Ë 2 °“√∫√‘À“√¬“ opioid ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”·∫∫§√—Èߧ√“« (IV titration)3

„ÀȬ“ 0.5 ¡≈.

„ÀȬ“ 1 ¡≈.

ºŸÈªË«¬μÈÕß°“√¬“·°Èª«¥

‰¥È¬“ < 3 §√—Èß„π 15 π“∑’

Sedation score < 2RR > 10/min1

‰¡Ë¡’ hypotension

¬—ß¡’Õ“°“√ª«¥

ª√–‡¡‘π´È”լ˓ߠ¡Ë”‡ ¡Õ

ª«¥¡“°pain score ≥ 7

„ÀȬ“ 1 ¡≈.

Õ“¬ÿ < 70 ª’

„ÀȬ“ 2 ¡≈.

À¡“¬‡Àμÿ 1. RR = respiratory rate À“°≈¥≈ßπÈÕ¬°«Ë“ 10 §√—Èß/π“∑’ Õ“®‡ªÁπÕ—πμ√“¬μËÕºŸÈªË«¬‰¥ÈßË“¬Sedation score 0-3 (0 = √ŸÈ ÷°μ—«¥’, 1 = ß˫߇≈Á°πÈÕ¬, 2 = ßË«ß¡“°·μ˪≈ÿ°μ◊ËπßË“¬, 3 = ª≈ÿ°μ◊Ë𬓰, S = πÕπÀ≈—∫ª°μ‘)

°“√‡μ√’¬¡¬“ë Morphine ‡μ√’¬¡‡ªìπ 1 mg/mlë Pethidine ‡μ√’¬¡‡ªìπ 10 mg/ml

ߥ¬“¡◊ÈÕμËÕ‰ª√Õ®π°«Ë“ Sedation score < 2 ·≈– RR > 10/min Õ“®μÈÕß„ÀȬ“ naloxone §√—Èß≈– 0.1 mg IV

√“¬ß“π·æ∑¬Ï

‰¡Ë„™Ë„™Ë

‰¡Ë„™Ë

‰¡Ë„™Ë

ªØ‘∫—μ‘μ“¡·π«∑“ßæ—≤π“ °“√√–ß—∫ª«¥¢Õß TASP(·ºπ¿Ÿ¡‘∑’Ë 1)

√“¬ß“π·æ∑¬Ï

‰¡Ë„™Ë

‰¡Ë„™Ë ‰¡Ë„™Ë

„™Ë

„™Ë

„™Ë

„™Ë

„™Ë§Õ¬ ~ 5 π“∑’

ª«¥¡“°pain score ≥ 7

Page 16: Clinical Guidance for Acute Pain Management

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 9

·ºπ¿Ÿ¡‘∑’Ë 3 °“√∫√‘À“√¬“ opioid ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”·∫∫μ“¡‡«≈“ (IV around the clock)3

∂÷߇«≈“©’¥¬“μ“¡‡«≈“∑’Ë°”Àπ¥

ºŸÈªË«¬μÈÕß°“√¬“·°Èª«¥ª√–‡¡‘π´È”

լ˓ߠ¡Ë”‡ ¡Õ

§” —Ëß°“√√—°…“ Morphine IV(μ“¡‡«≈“∑’Ë°”Àπ¥) (æ‘®“√≥“μ“¡Õ“¬ÿ πÈ”Àπ—°μ—« ·≈–√–¥—∫§«“¡ª«¥)ë 1-2 mg iv 2 hrë 2-3 mg iv 3 hrë 3-4 mg iv 4 hr

Sedation score < 2, RR > 10/min1

‰¡Ë¡’ hypotension

©’¥¬“μ“¡§” —Ëß°“√√—°…“2

ª√–‡¡‘πºŸÈªË«¬ È”À≈—ß©’¥¬“ 5-10 π“∑’

Sedation score < 2 RR > 10/min

√“¬ß“π·æ∑¬Ï

ºŸÈªË«¬¢Õ¬“Õ’°

Sedation score < 2 RR > 10/min

§√∫‡«≈“©’¥¬“μ“¡§” —Ëß°“√√—°…“μ“¡§” —Ëß

„ÀȬ“´È”„π¢π“¥‡¥‘¡

‰¡Ë„™Ë

‰¡Ë„™Ë

‰¡Ë„™Ë

√“¬ß“π·æ∑¬Ï

‰¡Ë„™Ë

‰¡Ë„™Ë

ª√–‡¡‘π´È”լ˓ߠ¡Ë”‡ ¡Õ

√“¬ß“π·æ∑¬Ï ∂È“ºŸÈªË«¬¢Õ¬“‡°‘π2 §√—Èß„π‡«≈“∑’Ë°”Àπ¥

ë §” —Ëß BTP √–À«à“ß¡◊ÈÕ3

ë ‡æ‘Ë¡¢π“¥¬“Õ’° 50%„π§√—ÈßμàÕ‰ª

≈¥¢π“¥¬“≈ß 25%„π§√—ÈßμËÕ‰ª

ߥ¬“¡◊ÈÕμËÕ‰ª √Õ®π°«Ë“Sedation score < 2 ·≈– RR > 10/minÕ“®μÈÕß„ÀȬ“ naloxone §√—Èß≈– 0.1 mg IV

„™Ë

„™Ë

„™Ë

„™Ë

„™Ë

„™Ë

À¡“¬‡Àμÿ 1. RR = respiratory rate À“°≈¥≈ßπâÕ¬°«à“ 10 §√—Èß/π“∑’ Õ“®‡ªìπÕ—πμ√“¬μàÕºŸâªÉ«¬‰¥âßà“¬ 2. ¥Ÿ§” —Ëß°“√√—°…“ ”À√—∫ opioid IV μ“¡‡«≈“∑’Ë°”Àπ¥

3. BTP = breakthrough pain (Õ“°“√ª«¥∑’ˇ°‘¥¢÷Èπ√–À«à“ß¡◊ÈÕ Õ“® —Ë߬“„Àâ„π¢π“¥ 25-50% ¢Õߪ°μ‘)Sedation score 0-3 (0 = √Ÿâ ÷°μ—«¥’, 1 = ßà«ß‡≈Á°πâÕ¬, 2 = ßà«ß¡“°·μàª≈ÿ°μ◊Ëπßà“¬, 3 = ª≈ÿ°μ◊Ë𬓰, S = πÕπÀ≈—∫ª°μ‘)

Page 17: Clinical Guidance for Acute Pain Management

 ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***10

·ºπ¿Ÿ¡‘∑’Ë 4 °“√∫√‘À“√¬“ opioid ∑“ß°≈â“¡‡π◊ÈÕÀ√◊Õ„μ⺑«Àπ—ß (IM/SC PRN)3

ºŸÈªË«¬μÈÕß°“√¬“·°Èª«¥

Sedation score < 2 RR > 10 /min1

§” —Ëß°“√√—°…“ IM prn q 2 hrÕ“¬ÿ (ª’) Morphine (mg) Pethidine (mg)20-59 5.0-10.0 50-10060-85 2.5-5.0 25-50> 85 2.0-3.0 20-30©’¥¬“μ“¡¢π“¥∑’Ë°”Àπ¥2

Sedation score < 2 RR > 10 /min

√“¬ß“π·æ∑¬Ï

√“¬ß“π·æ∑¬Ï

ª√–‡¡‘π´È”լ˓ߠ¡Ë”‡ ¡Õ

ߥ¬“¡◊ÈÕμËÕ‰ª √Õ®π°«Ë“Sedation score < 2 ·≈– RR > 10 /min Õ“®μÈÕß„ÀȬ“ naloxone§√—Èß≈– 0.1 mg IV

ºŸÈªË«¬¢Õ¬“Õ’°

Sedation score < 2 RR > 10 /min

©’¥¬“§√—Èß ÿ¥∑È“¬‡°‘π 2 ™—Ë«‚¡ß·≈È«

ª√–‡¡‘πºŸÈªË«¬ È”À≈—ß©’¥¬“ 30 π“∑’

„ÀȬ“ È”‰¥È„π¢π“¥‡¥‘¡®π∑ÿ‡≈“

√“¬ß“π·æ∑¬Ï∂È“ºŸÈªË«¬¢Õ¬“‡°‘π2 §√—Èß„π 2 ™¡.

„™Ë

„™Ë

„™Ë

„™Ë

„™Ë

‰¡Ë„™Ë

‰¡Ë„™Ë

‰¡Ë„™Ë

‰¡Ë„™Ë

À¡“¬‡Àμÿ 1. RR = respiratory rate À“°≈¥≈ßπÈÕ¬°«Ë“ 10 §√—Èß/π“∑’ Õ“®‡ªÁπÕ—πμ√“¬μËÕºŸÈªË«¬‰¥ÈßË“¬ 2. ¥Ÿ§” —Ëß°“√√—°…“ ”À√—∫ opioid IM prn q 2 hr (¢π“¥¬“μ“¡Õ“¬ÿºŸÈªË«¬)

Sedation score 0-3 (0 = √ŸÈ ÷°μ—«¥’, 1 = ß˫߇≈Á°πÈÕ¬, 2 = ßË«ß¡“°·μ˪≈ÿ°μ◊ËπßË“¬, 3 = ª≈ÿ°μ◊Ë𬓰, S = πÕπÀ≈—∫ª°μ‘)

≈¥¢π“¥¬“≈ß 25%„π§√—ÈßμËÕ‰ª

‡æ‘Ë¡¢π“¥¬“Õ’° 50%„π§√—ÈßμËÕ‰ª

Page 18: Clinical Guidance for Acute Pain Management

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 11

°“√√–ß—∫ª«¥·∫∫º ¡º “π (Multimodal analgesia)°“√„À⬓·°âª«¥‡æ’¬ß¢π“π‡¥’¬«Õ“®√–ß—∫ª«¥‰¥â ‰¡à¥’‡∑à“∑’˧«√ °“√‡æ‘Ë¡¢π“¥¬“·°âª«¥∑’Ë„™â„Àâ¡“°¢÷Èπ

‡æ◊ËÕ欓¬“¡√–ß—∫ª«¥„Àâ ‰¥âº≈‡μÁ¡∑’Ë °ÁÕ“®‡°‘¥Õ“°“√·∑√° âÕπ®“°¬“π—Èπ‰¥â ‡™àπ Õ“°“√§≈◊Ëπ‰ â Õ“‡®’¬π

∑âÕßÕ◊¥ ·≈–°¥°“√À“¬„® ‡ªìπμâπ11 ®÷ß¡’°“√„™â¬“·°âª«¥‚¥¬«‘∏’º ¡º “πÀ√◊Õ„™â¬“À≈“¬¢π“π√à«¡°—π¢÷Èπ12

‚¥¬¡’«—μ∂ÿª√– ß§å‡æ◊ËÕ„Àâ°“√√–ß—∫ª«¥‰¥âº≈¥’¢÷Èπ ‚¥¬°“√‡≈◊Õ°„™â¬“À≈“¬¢π“π∑’ËÕÕ°ƒ∑∏‘ϥ⫬«‘∏’°“√∑’Ëμà“ß°—π

À√◊ÕÕÕ°ƒ∑∏‘Ïμà“ß∑’Ë°—π ‚¥¬∑’ˬ“·μà≈–¢π“π®–‡ √‘¡ƒ∑∏‘Ï°—π ·≈–≈¥¢π“¥¬“¢Õß·μà≈–¢π“π≈ß Õ’°∑—È߬—ߙ૬

≈¥Õ“°“√·∑√° âÕπ∑’ËÕ“®®–‡°‘¥®“°¬“·μà≈–¢π“π≈߉¥â¥â«¬11 μ—«Õ¬à“ß ‡™àπ °“√„™â¬“™“√à«¡°—∫ NSAIDs ·≈–

opioids ‡ªìπμâπ ‚¥¬∑’ˬ“™“ ·≈– opioids ®–¬—∫¬—Èß°“√π” àß —≠≠“≥ª«¥∑—Èß∑’Ë√–¥—∫ peripheral, spinal

·≈– supraspinal  à«π NSAIDs ®–¬—∫¬—Èß —≠≠“≥ª«¥∑’Ë peripheral À√◊Õ∑’Ë∫√‘‡«≥·º≈ºà“μ—¥ ·≈– NSAIDs

∫“ß™π‘¥ “¡“√∂ÕÕ°ƒ∑∏‘Ï∑’Ë√–∫∫ª√– “∑ à«π°≈“ß‚¥¬‡©æ“–∑’Ë√–¥—∫ spinal cord ‰¥â¥â«¬

5. Õ“°“√ª«¥¥’¢÷ÈπÀ√◊Õ‰¡àÀ≈—߉¥â√—∫°“√√—°…“ (°≈àÕß∑’Ë 5)§”·π–π”: ∑”°“√ª√–‡¡‘π√–¥—∫§«“¡ª«¥À≈—ß„Àâ°“√√—°…“Õ¬à“ß ¡Ë”‡ ¡Õ‡æ◊ËÕª√–‡¡‘πº≈°“√√—°…“

º≈°“√√–ß—∫ª«¥Õ“®¡’°“√ª√–‡¡‘π‰¥âÀ≈“¬√Ÿª·∫∫‡™àπ‡¥’¬«°—∫°“√ª√–‡¡‘π√–¥—∫§«“¡√ÿπ·√ߢÕßÕ“°“√

ª«¥ μ—«Õ¬à“ß°“√ª√–‡¡‘πº≈°“√√–ß—∫ª«¥‡ªìπ 5 √–¥—∫ ‰¥â·°à: none (0), slight (1), moderate (2), good or

lots (3) ·≈– complete (4) À√◊Õª√–‡¡‘πº≈°“√√–ß—∫ª«¥¥â«¬ numeric rating scale (0-10): 0 À¡“¬∂÷ß

√–ß—∫ª«¥‰¡à‰¥â‡≈¬ ·≈– 10 À¡“¬∂÷ß√–ß—∫ª«¥‰¥â∑—ÈßÀ¡¥ À√◊Õ®–ª√–‡¡‘π‚¥¬„Àâ∑”‡§√◊ËÕßÀ¡“¬∫π visual

analogue scale ‡™àπ‡¥’¬«°—∫°“√ª√–‡¡‘π√–¥—∫§«“¡ª«¥°Á‰¥â

º≈°“√√–ß—∫ª«¥®–¡’§«“¡ —¡æ—π∏å‚¥¬μ√ß°—∫√–¥—∫§«“¡æ÷ßæÕ„®„π°“√√–ß—∫ª«¥¢ÕߺŸâªÉ«¬ ‚¥¬æ∫«à“

ºŸâªÉ«¬®–¡’§«“¡æ÷ßæÕ„®¡“°À“°°“√√–ß—∫ª«¥‰¥âº≈¥’·≈–¡’√–¥—∫§«“¡ª«¥πâÕ¬°«à“ 4 §–·ππ13

6. Õ“°“√·∑√° âÕπ∑’ˇ°‘¥®“°°“√√–ß—∫ª«¥ (°≈àÕß∑’Ë 6)§”·π–π”: §«√¡’°“√‡ΩÑ“√–«—ßÕ“°“√·∑√° âÕπ ·≈–¡’§” —Ëß°“√√—°…“ ”À√—∫Õ“°“√·∑√° âÕπ„πºŸâªÉ«¬

∑ÿ°√“¬Õ¬à“ß™—¥‡®π (¥Ÿ√“¬≈–‡Õ’¬¥„π°≈àÕß∑’Ë 7)

Õ“°“√·∑√° âÕπ∑’Ëæ∫∫àÕ¬ ‡™àπ §≈◊Ëπ‰ âÕ“‡®’¬π «‘߇«’¬π»’√…– ∑âÕßÕ◊¥ ßà«ß´÷¡ §«“¡¥—π‡≈◊Õ¥≈¥≈ß

·≈–§—π  à«πÕ“°“√·∑√° âÕπ∑’Ëæ∫πâÕ¬·μà√ÿπ·√ß ‡™àπ °¥°“√À“¬„® ‡ªìπμâπ

7. «‘∏’°“√√—°…“Õ“°“√·∑√° âÕπ (°≈àÕß∑’Ë 7)§”·π–π”: 1)  “¡“√∂„À⬓√—°…“Õ“°“√·∑√° âÕπ‰¥âμ—Èß·μà‡√‘Ë¡¡’Õ“°“√

2) À“°„™â¬“¢π“π‡¥’¬«‰¡à‰¥âº≈ “¡“√∂„™â¬“∑’Ë¡’°≈‰°ÕÕ°ƒ∑∏‘Ïμà“ß°—π¡“„™â‡ √‘¡ƒ∑∏‘Ï°—π‰¥â

«‘∏’°“√√—°…“Õ“°“√·∑√° âÕπ „π∑’Ëπ’È®–°≈à“«∂÷߇©æ“–Õ“°“√·∑√° âÕπ®“° opioid ‡∑à“π—Èπ  à«π°“√

√—°…“Õ“°“√·∑√° âÕπÕ◊ËπÊ  “¡“√∂¥Ÿ√“¬≈–‡Õ’¬¥‰¥â„π¿“§ºπ«°

Page 19: Clinical Guidance for Acute Pain Management

 ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***12

º≈‰¡àæ÷ߪ√– ß§å¢Õß opioids ∑’Ë ”§—≠ ¡’¥—ßπ’È

1. Õ“°“√√ÿπ·√ß·μàæ∫‰¡à∫àÕ¬ §◊Õ°“√°¥°“√À“¬„® æ∫‰¥â„π°√≥’„À⬓‡°‘π¢π“¥ À√◊Õ¡’°“√„™â¬“ seda-

tive Õ◊Ëπ√à«¡¥â«¬ √—°…“‚¥¬°“√„À⬓ naloxone 0.001-0.004 mg/kg ‡¢â“À≈Õ¥‡≈◊Õ¥¥” ∑ÿ° 2-3 π“∑’ ®π°«à“

®–¥’¢÷Èπ À√◊Õ„ÀâÀ¬¥μàÕ‡π◊ËÕß„π¢π“¥ 0.003-0.005 mg/kg/hr ®÷ßμâÕß¡’°“√‡ΩÑ“√–«—ß°“√À“¬„®¿“¬À≈—ß°“√‰¥â

√—∫¬“°≈ÿà¡ opioids √à«¡°—∫ª√–‡¡‘π sedation scores (¥ŸÀ—«¢âÕÕ“°“√ßà«ß´÷¡)

2. Õ“°“√‰¡à√ÿπ·√ß·μàæ∫∫àÕ¬

2.1 ßà«ß´÷¡ §«√‡ΩÑ“√–«—ß‚¥¬ª√–‡¡‘π sedation scores (0-3) ¥—ßπ’È 0 = √Ÿâ ÷°μ—«¥’, 1 = ßà«ß‡≈Á°πâÕ¬,

2 = ßà«ß¡“°·μàª≈ÿ°μ◊Ëπßà“¬, 3 = ª≈ÿ°¬“°À√◊Õ‰¡àμ◊Ëπ

2.2 §≈◊Ëπ‰ âÕ“‡®’¬π ºŸâªÉ«¬∑’ˉ¥â opioids ®–‡°‘¥Õ“°“√§≈◊Ëπ‰ âÕ“‡®’¬πßà“¬À“°‡ªìπ ºŸâªÉ«¬À≠‘ß ¡’ª√–«—μ‘

‡¡“√∂ßà“¬ ‰¡à‡§¬ Ÿ∫∫ÿÀ√’Ë ºŸâªÉ«¬‡À≈à“π’È®÷ߧ«√‰¥â√—∫¬“·°âÕ“‡®’¬π„π¢π“¥∑’ˇ撬ßæÕ ‚¥¬„Àâμ“¡‡«≈“ ·≈–Õ“®

μâÕß„™â¬“·°âÕ“‡®’¬π√à«¡°—π¡“°°«à“ 1 ™π‘¥ ‡™àπ ondansetron √à«¡°—∫ metoclopramide ®÷ß®– “¡“√∂

√—°…“·≈–ªÑÕß°—πÕ“°“√§≈◊Ëπ‰ âÕ“‡®’¬π®“° opioids ‰¥âº≈¥’

2.3 Õ“°“√Õ◊ËπÊ ‰¥â·°à ∑âÕßÕ◊¥ Õ“°“√§—π ·≈– ªí  “«–‰¡àÕÕ°  “¡“√∂„Àâ°“√√—°…“μ“¡Õ“°“√‰¥â

8. °“√ª√–‡¡‘π√–¥—∫§«“¡ª«¥À≈—ß„Àâ°“√√—°…“·≈–°“√∫—π∑÷°º≈°“√ª√–‡¡‘π (°≈àÕß∑’Ë 8)§”·π–π”: ∑”°“√ª√–‡¡‘π√–¥—∫§«“¡ª«¥À≈—ß„Àâ°“√√—°…“Õ¬à“ß ¡Ë”‡ ¡Õ·≈–∫—π∑÷°§«“¡ª«¥„Àâ‡ÀÁπ

™—¥‡®π (¥Ÿ§”·π–π”∑’Ë 2, 3 „π°≈àÕß∑’Ë 2)

°“√ª√–‡¡‘π√–¥—∫§«“¡ª«¥ È” ·π–π”„Àâª√–‡¡‘π‡ªìπ√–¬– À≈—ß®“°‰¥â„Àâ°“√√—°…“§«“¡ª«¥ ‡™àπ

°“√∫√‘À“√¬“ opioid ∑“ßÀ≈Õ¥‡≈◊Õ¥¥” (IV) §«√ª√–‡¡‘π´È”¿“¬„π 5-10 π“∑’ °“√∫√‘À“√¬“ opioid ∑“ß

°≈â“¡‡π◊ÈÕÀ√◊Õ„μ⺑«Àπ—ß (IM/SC) §«√ª√–‡¡‘π´È”¿“¬„π 30 π“∑’  ”À√—∫¬“√—∫ª√–∑“π·≈–°“√√–ß—∫ª«¥

∑’ˉ¡à„™â¬“ §«√ª√–‡¡‘π´È”¿“¬„π 60 π“∑’

À“° “¡“√∂∑”‰¥â §«√ª√–‡¡‘π·≈–∫—π∑÷°√–¥—∫§«“¡ª«¥‡ªìπ√–¬– ‡™àπ‡¥’¬«°—∫ —≠≠“≥™’æÕ◊ËπÊ ‚¥¬

°”Àπ¥„Àâ√–¥—∫§«“¡ª«¥‡ªìπ —≠≠“≥™’æ∑’ËÀâ“ ·≈–§«√∫—π∑÷°ªí®®—¬Õ◊ËπÊ ∑’ˇ°’ˬ«¢âÕß°—∫§«“¡ª«¥¢ÕߺŸâªÉ«¬

‰¥â·°à μ”·Àπàß·≈–≈—°…≥–¢Õߧ«“¡ª«¥ Õ–‰√∑”„Àâ√–¥—∫§«“¡ª«¥¡“°¢÷Èπ

∂⓪√–‡¡‘π·≈â«æ∫«à“√–¥—∫§«“¡ª«¥¬—߉¡à¥’¢÷Èπ 欓∫“≈§«√ª√÷°…“·æ∑¬å‡æ◊ËÕª√—∫·ºπ°“√√—°…“μàÕ‰ª

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*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 13

¿“§ºπ«°

 “‡Àμÿ·≈–°“√√—∫√Ÿâ‡√◊ËÕߧ«“¡ª«¥‡©’¬∫æ≈—π14

§«“¡ª«¥‡©’¬∫æ≈—π ‡°‘¥®“°°√–∫«π°“√Õ—°‡ ∫ ¡’ “‡ÀμÿÀ≈“¬Õ¬à“ß ‡™àπ ‡°‘¥®“°§«“¡√âÕπ °“√∫“¥‡®Á∫

·≈– “√‡§¡’ °√–∫«π°“√Õ—°‡ ∫∑”„Àâ√à“ß°“¬À≈—Ëß “√‡§¡’À≈“¬™π‘¥ (‡™àπ prostaglandin, substance-P,

histamine, H+ ‡ªìπμâπ) ÕÕ°¡“  “√‡§¡’‡À≈à“π’È®–°√–μÿâπª≈“¬ª√– “∑√—∫√Ÿâ§«“¡√Ÿâ ÷° ·≈–∂Ÿ°·ª≈߇ªìπ —≠≠“≥

§«“¡ª«¥‡°‘¥¢÷È𠧫“¡ª«¥∑’ˇ°‘¥¢÷Èπ®–∂Ÿ°∂à“¬∑Õ¥‰ªμ“¡‡ âπª√– “∑ C fiber ·≈– Aδ fiber ‡¢â“ Ÿà‰¢ —πÀ≈—ß

∫√‘‡«≥ dorsal horn ·≈–∂à“¬∑Õ¥°√–· ª√– “∑´÷Ë߇ªìπ —≠≠“≥§«“¡ª«¥π’È „Àâ°—∫‡´≈≈åª√– “∑μ—«∑’Ë 2

‡æ◊ËÕ àß —≠≠“≥§«“¡ª«¥ºà“π∑“ß spinothalamic tract ‰ª¬—ß√–∫∫ª√– “∑ à«π°≈“ß·≈– ¡Õß„π√–¥—∫μà“ßÊ

‡™àπ thalamus ·≈– cerebral cortex ‡æ◊ËÕ„Àâ¡’°“√√—∫√Ÿâ·≈–μÕ∫ πÕßμàÕ§«“¡ª«¥∑’ˇ°‘¥¢÷ÈπμàÕ‰ª (√Ÿª∑’Ë 3)

√Ÿª∑’Ë 3 μ”·Àπàß„π°“√ÕÕ°ƒ∑∏‘Ï¢Õ߬“·°âª«¥™π‘¥μà“ßÊ

(NSAIDs = Nonsteroidal anti-inflammatory drugs, COXIBs = COX-II specific inhibitors)

Page 21: Clinical Guidance for Acute Pain Management

 ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***14

°√–∫«π°“√Õ—°‡ ∫∑’ˇ°‘¥¢÷Èπ∑’˪≈“¬‡ âπª√– “∑ À“°¡’°“√À≈—Ëß “√‡§¡’ÕÕ°¡“Õ¬à“ßμàÕ‡π◊ËÕß ®–∑”„Àâ

Õ“°“√ª«¥·≈–∫«¡¢¬“¬«ß‰ª√Õ∫Ê ∫√‘‡«≥∑’ˉ¥â√—∫∫“¥‡®Á∫ ·≈–∑”„Àâ∫√‘‡«≥√Õ∫Ê °“√∫“¥‡®Á∫¡’Õ“°“√ª«¥

¡“°°«à“ª°μ‘ ‡√’¬°°√–∫«π°“√π’È«à“ peripheral sensitization „π¢≥–‡¥’¬«°—π∑’Ë∫√‘‡«≥ dorsal horn ¢Õß

‰¢ —πÀ≈—ß°Á®–‰¥â√—∫ —≠≠“≥§«“¡ª«¥‡¢â“¡“Õ¬à“ßμàÕ‡π◊ËÕß ·≈–‡°‘¥°√–∫«π°“√∂à“¬∑Õ¥ —≠≠“≥§«“¡ª«¥

‰ª¬—ß√–∫∫ª√– “∑ à«π°≈“߇æ‘Ë¡¢÷Èπ ‡√’¬°°√–∫«π°“√π’È«à“ central sensitization ¥—ßπ—Èπ„π°“√√—°…“Õ“°“√

ª«¥‡©’¬∫æ≈—π®÷ßμâÕß欓¬“¡≈¥·≈–ªÑÕß°—π‰¡à„À⇰‘¥°√–∫«π°“√ peripheral ·≈– central sensitization ¢÷Èπ

‡§√◊ËÕß¡◊Õ ”À√—∫ª√–‡¡‘π√–¥—∫§«“¡ª«¥ (√Ÿª∑’Ë 1)

1. Numerical rating scale (NRS) ‡ªìπ‡§√◊ËÕß¡◊Õ∑’Ëπ‘¬¡„™â„π∑“ߧ≈‘π‘°‡æ√“– –¥«° „À⺟âªÉ«¬∫Õ°

§–·π𧫓¡ª«¥‡ªìπμ—«‡≈¢ ‚¥¬ 0 §–·ππ À¡“¬∂÷߉¡àª«¥ 1-9 §–·ππ À¡“¬∂÷ߪ«¥¡“°¢÷Èπμ“¡≈”¥—∫

·≈–10 §–·ππ À¡“¬∂÷ߪ«¥¡“°∑’Ë ÿ¥‡∑à“∑’Ë®–§‘¥‰¥â

2. Verbal rating scale (VRS) „™â ”À√—∫ºŸâªÉ«¬∑’ˉ¡à “¡“√∂∫Õ°√–¥—∫§«“¡ª«¥‡ªìπμ—«‡≈¢‰¥â ‚¥¬ Õ“®

·∫àßÕÕ°‡ªìπ 5 √–¥—∫§◊Õ 0 §–·ππ À¡“¬∂÷߉¡àª«¥, 1-3 §–·ππ À¡“¬∂÷ߪ«¥πâÕ¬, 4-6 §–·ππ À¡“¬

∂÷ߪ«¥ª“π°≈“ß, 7-9 §–·ππ À¡“¬∂÷ߪ«¥¡“° ·≈– 10 §–·ππ À¡“¬∂÷ߪ«¥¡“°∑’Ë ÿ¥‡∑à“∑’Ë®–§‘¥‰¥â

3. Visual analog scale (VAS) „™â ‰¡â∫√√∑—¥À√◊Õ‡ âπμ√ß∑’Ë¡’§«“¡¬“« 10 ‡´π쑇¡μ√ ‚¥¬‡√‘Ë¡®“° 0

‡´π쑇¡μ√ À¡“¬∂÷߉¡àª«¥ ∂÷ß 10 ‡´π쑇¡μ√ À¡“¬∂÷ߪ«¥¡“°∑’Ë ÿ¥‡∑à“∑’Ë®–§‘¥‰¥â ‚¥¬„À⺟âªÉ«¬°“°∫“∑ (X)

∫π‡ âπμ√ß μ“¡√–¥—∫§«“¡ª«¥®√‘ߢÕߺŸâªÉ«¬

4. Face pain scale ‡ªìπ visual pain analogue „™â√Ÿª· ¥ß§«“¡√Ÿâ ÷°∑“ß„∫Àπâ“ ‡À¡“– ”À√—∫

‡¥Á°Õ“¬ÿ 5-8 ªï À√◊ÕºŸâªÉ«¬∑’ˉ¡à “¡“√∂∫Õ°§«“¡ª«¥‡ªìπμ—«‡≈¢‰¥â

¢âÕ·π–π”

* °“√„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“¥—∫

* 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

* „Àâ„™â§Ì“«à“ 燮Á∫é À√◊Õ çª«¥é μ“¡§«“¡‡À¡“– ¡·°àºŸâªÉ«¬‡¥Á°·μà≈–§π

5. ‡§√◊ËÕß¡◊Õª√–‡¡‘π√–¥—∫§«“¡ª«¥Õ◊ËπÊ ‰¥â·°à

5.1 The FLACC behavioral pain scale (μ“√“ß∑’Ë 1) ‡À¡“– ”À√—∫‡¥Á°‡≈Á°À√◊ÕºŸâªÉ«¬∑’ˉ¡à‡¢â“„®

¿“…“ ª√–°Õ∫¥â«¬ 5  à«π ‰¥â·°à °“√ª√–‡¡‘π°“√· ¥ßÕÕ°∑“ß„∫Àπâ“ °“√¢¬—∫¢Õߢ“ °“√‡§≈◊ËÕπ‰À«

(activity) √âÕ߉Àâ ·≈–°“√μÕ∫ πÕßμàÕ°“√ª≈Õ∫‚¬π (consolability) ÷Ëß·μà≈– à«π¡’§–·ππ 0-2 √«¡∑—ÈßÀ¡¥

10 §–·ππ

5.2 The CHEOPS behavioral pain scale15 (μ“√“ß∑’Ë 2) ‡À¡“– ”À√—∫‡¥Á°‡≈Á°À√◊ÕºŸâªÉ«¬∑’ˉ¡à

‡¢â“„®¿“…“ ‡§√◊ËÕß¡◊Õ¡’§–·ππμ—Èß·μà 4-13

Page 22: Clinical Guidance for Acute Pain Management

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 15

6. ‡§√◊ËÕß¡◊Õª√–‡¡‘𧫓¡ª«¥ ”À√—∫ºŸâªÉ«¬∑’ˉ¡à “¡“√∂ ◊ËÕ “√¥â«¬μ—«‡Õ߉¥â „πÀÕ«‘°ƒμ À√◊ÕºŸâªÉ«¬

√–¥—∫§«“¡√Ÿâ ÷°μ—«πâÕ¬≈ß §«√„™â°“√ª√–‡¡‘π®“°°“√ —߇°μæƒμ‘°√√¡·≈–°“√‡ª≈’ˬπ·ª≈ߢÕß —≠≠“≥™’懪ìπ

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μ“√“ß∑’Ë 2 The CHEOPS behavioral pain scale15

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μ“√“ß∑’Ë 1 The FLACC behavioral pain scale15

Page 23: Clinical Guidance for Acute Pain Management

 ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***16

°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬„™â¬“ (Pharmacological therapy)¬“·°âª«¥™π‘¥μà“ßÊ ∑’Ë “¡“√∂‡≈◊Õ°„™â ¡’¥—ßπ’È

1. Paracetamol À√◊Õ Acetaminophen Paracetamol‡ªì𬓷°âª«¥·≈–≈¥‰¢â (·μà‰¡à≈¥°“√Õ—°‡ ∫) ∑’Ë¡’„™â°—πÕ¬à“ß·æ√àÀ≈“¬‡π◊ËÕß®“°¡’§«“¡ª≈Õ¥¿—¬ Ÿß

 “¡“√∂„™â‰¥â∑ÿ°°≈ÿà¡Õ“¬ÿ paracetamol ¡’ƒ∑∏‘Ï√–ß—∫ª«¥∑’ËÕàÕπ ®÷ߧ«√‡≈◊Õ°„™â„π°√≥’∑’Ë¡’Õ“°“√ª«¥‡≈Á°πâÕ¬

À√◊Õª«¥ª“π°≈“ß

Paracetamol ¬—߉¡à∑√“∫°≈‰°°“√ÕÕ°ƒ∑∏‘Ï∑’Ë·πà™—¥ ªí®®ÿ∫—π‡™◊ËÕ«à“ÕÕ°ƒ∑∏‘Ϻà“π∑“ß descending

serotonergic pathways16 ‚¥¬°≈‰°À≈—°§◊Õ¬—∫¬—Èß°“√ √â“ß prostaglandins „π ¡Õß ®“°°“√ √â“ß “√ AM404

(´÷Ëß¡’ƒ∑∏‘Ϭ—߬—È߇Õπ‰´¡å COX ‚¥¬μ√ß) ´÷ËßμâÕß¡’ fatty acid amide hydrolase (FAAH) ‡ªìπμ—«°√–μÿâπ°“√

 √â“ß πÕ°®“°π’Ȭ—ßæ∫«à“ AM404 ¬—߉ª°√–μÿâπ TRPV1 receptor ÷Ëß¡’ ligand √à«¡°—∫ CB1 receptor  àß

º≈„À⇰‘¥°“√¬—∫¬—Èß anadamide (‡ªìπ endogenous canabinoid) ‡¢â“‡´≈≈å ‡°‘¥°“√‡æ‘Ë¡¢÷Èπ¢Õß endoge-

nous canabinoid ÷Ë߇™◊ËÕ«à“‡ªìπ°≈‰°Àπ÷Ëß„π°“√Õ∏‘∫“¬º≈¢â“߇§’¬ß‡√◊ËÕßßà«ßπÕπ„πºŸâ„™â¬“∫“ß√“¬

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§√÷Ëß™—Ë«‚¡ß ®“°π—Èπ®–∂Ÿ°∑”≈“¬∑’Ëμ—∫·≈–¢—∫ÕÕ°∑“ßªí  “«–μàÕ‰ª ‡¡◊ËÕ¡’°“√„™â¬“μ—«π’Èμ‘¥μàÕ°—π‡ªìπ‡«≈“π“π

À√◊Õ‰¥â√—∫¬“π’Ȫ√‘¡“≥¡“° Õ“®∑”„À⇰‘¥μ—∫«“¬‰¥â paracetamol ¡’§à“§√÷Ëß™’«‘μª√–¡“≥ 2 ™—Ë«‚¡ß

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πÈ”Àπ—°μ—« 1 °°. ∑ÿ° 4-6 ™—Ë«‚¡ß À√◊Õμ“¡¢π“¥∑’Ë·π–π”„πμ“√“ß∑’Ë 3 paracetamol  “¡“√∂„™â ‰¥â∑—Èß„Àâ

¬“‡æ’¬ß¢π“π‡¥’¬« À√◊Õ„Àâ„π√Ÿª·∫∫º ¡°—∫¬“™π‘¥Õ◊Ë𠇙àπ codeine, NSAIDs ·≈– tramadol

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Page 24: Clinical Guidance for Acute Pain Management

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 17

º≈¢â“߇§’¬ß¢Õ߬“ ‡°‘¥πâÕ¬¡“° ·μà„Àâ√–«—ß„π§π∑’Ë¡’Õ“°“√·æâ ‚¥¬Õ“®¡’º◊Ëπ·¥ß∑’˺‘«Àπ—ß §—π

À√◊Õ¡’§≈◊Ëπ‰ â Õ“‡®’¬π ¬“π’È®–‰¡à‡°‘¥Õ“°“√¢â“߇§’¬ß„¥Ê À“°√—∫ª√–∑“πÕ¬à“ß∂Ÿ°μâÕß„π√–¬–‡«≈“ —ÈπÊ  ”À√—∫

ºŸâªÉ«¬∑’ˇªìπ‚√§μ—∫§«√≈¥¢π“¥¬“≈ß ‡æ√“–Õ“®∑”„À⇰‘¥æ‘…®“°¬“‰¥âßà“¬

2. Nonsteroidal anti-inflammatory drugs (NSAIDs)°“√„™â¬“ NSAIDs „π°“√√–ß—∫ª«¥À≈—ß°“√ºà“μ—¥ Õ“®„™â‡æ’¬ß¢π“π‡¥’¬«„π°√≥’∑’˧«“¡ª«¥‰¡à√ÿπ·√ß

À√◊Õ„™â√à«¡°—∫¬“·°âª«¥Õ◊ËπÊ ∂ⓧ«“¡ª«¥√ÿπ·√ß¡“°

NSAIDs πÕ°®“°¡’ƒ∑∏‘Ï√–ß—∫ª«¥·≈⫬—ß¡’ƒ∑∏‘Ïμâ“π°“√Õ—°‡ ∫·≈–≈¥‰¢â¥â«¬°“√ÕÕ°ƒ∑∏‘Ï¥—ß°≈à“«

‡°‘¥®“°°“√¬—∫¬—Èß°“√ √â“ß prostaglandins ‚¥¬¬—∫¬—Èß°“√∑”ß“π¢Õ߇Õπ‰´¡å cyclooxygenase ∑’Ë∫√‘‡«≥

‡π◊ÈÕ‡¬◊ËÕ∑’ˉ¥â√—∫°“√∫“¥‡®Á∫ ∑’Ë√–∫∫ª√– “∑∑—Èß∑’Ë à«πª≈“¬·≈– à«π°≈“ß

‡Õπ‰´¡å cyclooxygenase ¡’ 2 isoenzymes §◊Õ cyclooxygenase-1 (COX-1) ·≈– cyclooxy-

genase-2 (COX-2) ‚¥¬‡Õπ‰´¡å COX-1 ®–æ∫„π¿“«–ª°μ‘„π‡π◊ÈÕ‡¬◊ËÕÀ≈“¬™π‘¥ ‡™à𠇬◊ËÕ∫ÿ°√–‡æ“–Õ“À“√

‡¬◊ËÕ∫ÿÀ≈Õ¥‡≈◊Õ¥·≈–‰μ ´÷Ë߇Õπ‰´¡å COX-1 ®–∑”Àπâ“∑’˧«∫§ÿ¡ ¡¥ÿ≈¢Õß√à“ß°“¬  à«π‡Õπ‰´¡å COX-2 ®–

∂Ÿ°°√–μÿâπ„Àâ √â“ߢ÷Èπ‡¡◊ËÕ¡’°√–∫«π°“√Õ—°‡ ∫‡°‘¥¢÷Èπ ®–æ∫‰¥â„π‡¡Á¥‡≈◊Õ¥¢“« À≈Õ¥‡≈◊Õ¥ ·≈–‡π◊ÈÕ‡¬◊ËÕª√– “∑

NSAIDs ·μà≈–™π‘¥¡’§«“¡ “¡“√∂„π°“√¬—∫¬—È߇Õπ‰´¡å COX-1 ·≈– COX-2 ‰¥â ‰¡à‡∑à“°—π Õ—μ√“ à«π

°“√¬—∫¬—È߇Õπ‰´¡å COX-1 μàÕ COX-2 πÕ°®“°®–¡’º≈μàÕ°“√ÕÕ°ƒ∑∏‘Ï·≈â« ¬—ß®–∫Õ°∂÷ß‚Õ°“ ‡°‘¥¿“«–

·∑√° âÕπ¥â«¬ „π∑’Ëπ’È®–·∫àß NSAIDs ÕÕ°‡ªìπ Õß°≈ÿà¡„À≠àÊ §◊Õ°≈ÿà¡ conventional NSAIDs ‡™àπ diclofenac,

aspirin, ibuprofen, ketoprofen, naproxen, mefenamic, piroxicam ·≈– meloxicam ·≈–°≈ÿà¡ COX-2

specific inhibitors18 ‡™àπ celecoxib, valdecoxib, parecoxib, ·≈– etoricoxib ‚¥¬∑’Ë°≈ÿà¡ conventional

NSAIDs π—Èπ„π¢π“¥∑’Ë„™â„π°“√√—°…“ ®–¬—∫¬—Èß°“√∑”ß“π¢Õ߇Õπ‰´¡å COX-1 ·≈– COX-2 ¥â«¬‡ ¡Õ „π

¢≥–∑’Ë°≈ÿà¡ COX-2 specific inhibitors ¢π“¥¢Õ߬“∑’Ë„™â„π°“√√—°…“®–¬—∫¬—Èß°“√∑”ß“π¢Õ߇Õπ‰´¡å

COX-2 ‚¥¬‰¡à¡’º≈¬—∫¬—Èß°“√∑”ß“π¢Õ߇Õπ‰´¡å COX-1 ®“°°≈‰°∑’ËÕÕ°ƒ∑∏‘Ïμà“ß°—π∑”„Àâ conventional NSAIDs

¡’¢âÕ®”°—¥À≈“¬ª√–°“√∑’Ë®–π”¡“„™â‡æ◊ËÕ√–ß—∫ª«¥√–À«à“ß·≈–À≈—ߺà“μ—¥ „π¢≥–∑’Ë°≈ÿà¡ COX-2 specific

inhibitors ¡’¢âÕ¥’°«à“ conventional NSAIDs „π‡√◊ËÕߺ≈¢â“߇§’¬ßμàÕ√–∫∫∑“߇¥‘πÕ“À“√·≈–‰¡à¬—∫¬—Èß°“√∑”ß“π

¢Õ߇°≈Á¥‡≈◊Õ¥ ·μà¡’º≈‰¡àæ÷ߪ√– ß§åÀ≈“¬Õ¬à“ß∑’Ë∑”„À⺟ℙâμâÕß√–¡—¥√–«—߇™àπ‡¥’¬«°—π

°“√‡≈◊Õ°„™â NSAIDs

‡π◊ËÕß®“°°“√„™â NSAIDs ‡æ◊ËÕ≈¥Õ“°“√ª«¥À≈—ß°“√ºà“μ—¥¡—°„Àâ„π√–¬–‡«≈“ —ÈπÊ ∂Ⓡªìπ°“√ºà“μ—¥‡≈Á°

Õ“®„À⬓‡æ’¬ß§√—È߇¥’¬« ·μà∂Ⓡªìπ°“√ºà“μ—¥„À≠àÕ“®„À⬓‰¡à‡°‘π 3-7 «—π °“√‡≈◊Õ°™π‘¥¢Õ߬“®÷ߧ«√‡≈◊Õ°¬“

∑’Ë¡’ª√– ‘∑∏‘¿“æ „™âßà“¬ ÕÕ°ƒ∑∏‘χ√Á« ·≈–¡’¿“«–·∑√° âÕππâÕ¬ §«√‡≈◊Õ°„™â¬“‡æ’¬ß¢π“π‡¥’¬«„π°“√„™â¬“

·μà≈–§√—Èß ·≈–À≈’°‡≈’ˬ߰“√„™â¬“À“°ºŸâªÉ«¬¡’ª√–«—μ‘°“√·æ⬓„π°≈ÿà¡ NSAIDs

¢π“¥·≈–«‘∏’∫√‘À“√¬“ ª√‘¡“≥°“√„™â¬“®”‡ªìπμâÕߪ√—∫„Àâ‡À¡“– ¡°—∫ºŸâªÉ«¬·μà≈–√“¬ ‚¥¬¥Ÿ®“°

°“√μÕ∫ πÕߢÕߺŸâªÉ«¬‡ªìπÀ≈—° °“√„À⬓§«√„Àâμ“¡™à«ß‡«≈“∑’Ë°”Àπ¥®–√–ß—∫ª«¥‰¥â¥’°«à“„À⬓‡¡◊ËÕºŸâªÉ«¬

¡’Õ“°“√ª«¥·≈â« «‘∏’∫√‘À“√¬“¢÷Èπ°—∫™π‘¥°“√ºà“μ—¥ «‘∏’°“√√–ß—∫ª«¥„π°“√ºà“μ—¥ ·≈–√Ÿª·∫∫¢Õ߬“∑’Ë¡’„™â

Page 25: Clinical Guidance for Acute Pain Management

 ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***18

´÷Ëß·∫àßÕÕ°‡ªìπ

°“√©’¥ ‡ªìπ«‘∏’°“√∫√‘À“√¬“∑’ˉ¥âº≈¥’∑’Ë ÿ¥ ¡’∑—Èß©’¥‡¢â“À≈Õ¥‡≈◊Õ¥¥”·≈–©’¥‡¢â“°≈â“¡ °“√©’¥‡¢â“°≈â“¡

‡ªìπ«‘∏’∑’Ë„™â¡“°∑’Ë ÿ¥‡π◊ËÕß®“°¬“ à«π„À≠àº≈‘μ¡“„π√Ÿª¢Õ߬“©’¥‡¢â“°≈â“¡ ·μà¢âÕ‡ ’¬§◊Õª«¥¢≥–©’¥¬“ ®÷߉¡à

‡À¡“– ”À√—∫°“√„™â„π‡¥Á° ¬“∑’Ë “¡“√∂„™â«‘∏’©’¥ ‰¥â·°à diclofenac, ketoprofen, ketorolac, piroxicam,

tenoxicam ·≈– parecoxib

°“√√—∫ª√–∑“𠇪ìπ«‘∏’∑’Ë„™âßà“¬·≈–√∫°«πºŸâªÉ«¬πâÕ¬∑’Ë ÿ¥ NSAIDs  à«π„À≠à “¡“√∂„™â«‘∏’√—∫ª√–∑“π‰¥â

 ”À√—∫ºŸâªÉ«¬À≈—ߺà“μ—¥∑’Ë¡’Õ“°“√§≈◊Ëπ‰ âÕ“‡®’¬π À√◊Õ®”‡ªìπμâÕßߥՓÀ“√·≈–πÈ”®–‰¡à “¡“√∂„™â«‘∏’π’È ‰¥â

°“√‡ÀπÁ∫∑«“√ ‡ªìπ«‘∏’∑’ˇÀ¡“– ”À√—∫‡¥Á° „πºŸâªÉ«¬ºŸâ„À≠àÕ“®‰¡à™Õ∫«‘∏’π’È·≈–Õ“®‡°‘¥ªí≠À“°“√

Õ—°‡ ∫¢Õß∑«“√Àπ—° (‡¡◊Õ߉∑¬‰¡à¡’¬“‡ÀπÁ∫∑«“√)

º≈¢â“߇§’¬ß

º≈¢â“߇§’¬ß¢Õß NSAIDs  à«π„À≠à®–æ∫¡“°„π°√≥’∑’Ë„™âμàÕ‡π◊ËÕß√–¬–¬“« °“√„™â‡æ◊ËÕ√–ß—∫ª«¥À≈—ß

ºà“μ—¥‡ªìπ°“√„™â„π™à«ß —ÈπÊ ·μà°Á¬—ßæ∫º≈¢â“߇§’¬ß‰¥â ‡™àπ √–∫∫∑“߇¥‘πÕ“À“√ Õ“®∑”„À⇰‘¥°“√√–§“¬‡§◊Õß

μàÕ°√–‡æ“–Õ“À“√ ‚¥¬‡©æ“–„πºŸâ ŸßÕ“¬ÿ∑’ˇ§¬¡’·º≈„π°√–‡æ“–Õ“À“√ À√◊Õ‡§¬μ°‡≈◊Õ¥„π°√–‡æ“–Õ“À“√

À√◊Õ°”≈—߉¥â√—∫¬“ ‡μ’¬√Õ¬¥å ®–¡’‚Õ°“ ‡°‘¥º≈¢â“߇§’¬ßπ’È ‰¥â ¬“„π°≈ÿà¡ COX-2 specific inhibitors ∑”„Àâ

‡°‘¥¿“«–·∑√° âÕπμàÕ√–∫∫π’ÈπâÕ¬°«à“°≈ÿà¡ conventional NSAIDs19

º≈μàÕ‰μ º≈¢Õß conventional NSAIDs ·≈– COX-2 specific inhibitors μàÕ°“√∑”ß“π¢Õß‰μ·ª√

μ“¡ª√‘¡“≥·≈–√–¬–‡«≈“¢Õß°“√„™â¬“ ‡¡◊ËÕÀ¬ÿ¥°“√„™â¬“ ƒ∑∏‘Ï¢Õ߬“°Á®–À¡¥‰ª¥â«¬ „πºŸâªÉ«¬∑’Ë°“√∑”ß“π

¢Õß‰μª°μ‘  à«π„À≠à®–‰¡à‡°‘¥º≈¢â“߇§’¬ß®“°°“√„™â¬“20 ·μà∂â“°“√∑”ß“π¢Õ߉μ∫°æ√àÕß ¡’°“√‡ ’¬‡≈◊Õ¥¡“°

À√◊Õ¡’¿“«–¢“¥πÈ” ·≈–„πºŸâªÉ«¬ ŸßÕ“¬ÿÕ“®∑”„Àâ°“√∑”ß“π¢Õ߉μ∫°æ√àÕßÀ√◊Õ‡°‘¥¿“«–‰μ«“¬‡©’¬∫æ≈—π‰¥â

º≈μàÕ√–∫∫°“√·¢Áßμ—«¢Õ߇≈◊Õ¥ ‡π◊ËÕß®“°¬“°≈ÿà¡ conventional NSAIDs ¡’ƒ∑∏‘Ϭ—∫¬—Èß°“√‡°“–μ—«¢Õß

‡°≈Á¥‡≈◊Õ¥´÷ËßÕ“»—¬‡Õπ‰´¡å COX-1 ‡ªìπÀ≈—° ∑”„À⺟âªÉ«¬∫“ß°≈ÿà¡ ‡™àπ ºŸâªÉ«¬ºà“μ—¥°√–¥Ÿ° ºŸâªÉ«¬ºà“μ—¥∑Õπ´‘≈

ºŸâªÉ«¬ºà“μ—¥ ¡Õß ºŸâªÉ«¬∑’ˉ¥â√—∫¬“μâ“π°“√·¢Áßμ—«¢Õ߇≈◊Õ¥¡“°àÕπ ‡¡◊ËÕ‰¥â√—∫¬“·°âª«¥°≈ÿà¡ conventional

NSAIDs ®–¡’‚Õ°“ ‡≈◊Õ¥ÕÕ°‰¥âßà“¬21 „π¢≥–∑’Ë°≈ÿà¡ COX-2 specific inhibitors ¡’‚Õ°“ ∑’Ë®–∑”„À⇰‘¥

thrombosis ¥—ßπ—Èπ§«√‡≈’ˬ߰“√„™â¬“°≈ÿà¡ COX-2 specific inhibitors „πºŸâªÉ«¬∑’˺à“μ—¥‡°’ˬ«°—∫À≈Õ¥‡≈◊Õ¥

¢ÕßÀ—«„®·≈– ¡Õß22

º≈μàÕ√–∫∫°“√À“¬„®·≈–¿Ÿ¡‘·æâ °“√„™â¬“ conventional NSAIDs „πºŸâªÉ«¬∑’Ë¡’ª√–«—μ‘ÀÕ∫À◊¥À√◊Õ

‚√§¿Ÿ¡‘·æâÕ“®∑”„À⇰‘¥Õ“°“√ÀÕ∫À◊¥‰¥â ºŸâªÉ«¬∑’Ë¡’ª√–«—μ‘ aspirin-exacerbated respiratory disease

Àâ“¡„™â¬“ conventional NSAIDs √–ß—∫ª«¥ ·μà„™â°≈ÿà¡ COX-2 specific inhibitors ‰¥â23

NSAIDs ∑—Èß 2 °≈ÿà¡ ¡’ª√– ‘∑∏‘¿“楒„π°“√√–ß—∫ª«¥À≈—ߺà“μ—¥ Õ’°∑—È߇¡◊ËÕ„™â√à«¡°—∫¬“°≈ÿà¡ opioid °Á

®–‡ √‘¡ƒ∑∏‘Ï„π°“√√–ß—∫ª«¥¡“°¢÷Èπ ·≈–≈¥º≈¢â“߇§’¬ß¢Õß opioid ‡æ√“–„™â opioid πâÕ¬≈ß24,25 ·μàº≈¢â“ß

‡§’¬ß¢Õß NSAIDs ∑—Èß 2 °≈ÿà¡°Á‡ªìπ¢âÕ®”°—¥„π°“√„™â¬“ μâÕß„™â¥â«¬§«“¡√–¡—¥√–«—ß·≈–‡≈’ˬ߰“√„™â„π°≈ÿà¡

‡ ’ˬß∑—ÈßÀ≈“¬

Page 26: Clinical Guidance for Acute Pain Management

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 19

3. Opioids ‡ªìπ¬“∑’Ë„™â„π°“√√–ß—∫ª«¥√ÿπ·√ß ·μà¡’º≈‰¡àæ÷ߪ√– ß§å‰¥â (¥Ÿ√“¬≈–‡Õ’¬¥°≈àÕß∑’Ë 7)

opioid ·∫àßÕÕ°‡ªìπ 2 °≈ÿà¡ §◊Õ opioid ∑’Ë¡’ƒ∑∏‘ÏÕàÕπ·≈–∑’Ë¡’ƒ∑∏‘Ï·√ß

A. Opioids ∑’Ë¡’ƒ∑∏‘ÏÕàÕπ

A1. Codeine

Codeine ‡ªìπμâπ·∫∫¢Õß opioid ∑’Ë¡’ƒ∑∏‘ÏÕàÕπ5 ∂Ÿ°¥Ÿ¥´÷¡‰¥â¥’®“°∑“߇¥‘πÕ“À“√ ¡’§«“¡

·√߇ªìπ 1/10 ¢Õß morphine26 ª√–¡“≥√âÕ¬≈– 10 ¢Õß codeine ∂Ÿ°‡ª≈’ˬπ√Ÿª∑’Ëμ—∫ ‰¥â‡ªìπ morphine27

¢π“¥¬“∑’Ë„™â§◊Õ 30-120 ¡°. „Àâ È”‰¥â∑ÿ° 4 ™—Ë«‚¡ß26 °“√„À⬓√à«¡°—π√–À«à“ß codeine 60 ¡°. °—∫ paracetamol

600-1,000 ¡°. „Àâº≈√–ß—∫ª«¥∑’Ë¥’°«à“ paracetamol Õ¬à“߇¥’¬«28

°“√√–ß—∫ª«¥®“° codeine ¢÷Èπ°—∫¢π“¥¬“∑’ˉ¥â√—∫28 ·μà‰¡à§«√„™â¬“‡°‘π°«à“¢π“¥∑’Ë·π–π”

‡π◊ËÕß®“°®–‡°‘¥º≈¢â“߇§’¬ß‡æ‘Ë¡¢÷Èπ ÷Ë߉¥â·°à ∑âÕߺŸ° §≈◊Ëπ‰ âÕ“‡®’¬π ·≈– —∫ π

A2. Tramadol

Tramadol ‡ªì𬓷°âª«¥∑’ËÕÕ°ƒ∑∏‘Ϻà“π 2 °≈‰° °≈‰°·√°§◊Õ ®—∫°—∫ μ-opioid receptor

 à«π°≈‰°∑’Ë 2 §◊Õ ¬—∫¬—Èß°“√π”°≈—∫¢Õß serotonin ·≈– norepinephrine „π√–∫∫ª√– “∑ à«π°≈“ß29,30

ƒ∑∏‘Ï√–ß—∫ª«¥  à«π„À≠à¢Õß tramadol ºà“π¡“∑“ß°≈‰°∑’Ë 2 tramadol ¡’§«“¡·√߇ªìπ 1/20-1/5 ¢Õß mor-

phine º≈¢â“߇§’¬ß∑’Ëæ∫∫àÕ¬¢Õß tramadol §◊Õ §≈◊Ëπ‰ âÕ“‡®’¬π26  à«πº≈¢â“߇§’¬ßÕ◊Ëπæ∫‰¥âπâÕ¬ ‡™àπ °¥°“√

À“¬„®·≈–∑âÕߺŸ°26,31 ¢π“¥¬“∑’Ë·π–π”„Àâ„™â§◊Õ 50-100 ¡°. „Àâ´È”‰¥â∑ÿ° 4 ™—Ë«‚¡ß26 ·μà‰¡à§«√‡°‘π 400 ¡°.

μàÕ«—π ·≈–„πºŸâªÉ«¬∑’Ë¡’ªí≠À“¢Õßμ—∫À√◊Õ‰μ§«√≈¥¢π“¥≈ß ‚¥¬„Àâ ‰¡à‡°‘π 200 ¡°. μàÕ«—π

B. Opioids ∑’Ë¡’ƒ∑∏‘Ï·√ß

Opioids ∑’Ë¡’ƒ∑∏‘Ï·√ß ‰¥â·°à morphine, pethidine ·≈– fentanyl ¬“„π°≈ÿà¡π’È∑ÿ°μ—«„Àâº≈°“√

√–ß—∫ª«¥‡∑à“°—π∂â“„Àâ„π¢π“¥∑’ˇ√’¬°«à“ çequianalgesic doseé (μ“√“ß∑’Ë 4) ®÷ߧ«√ª√—∫¢π“¥¬“ opioids

„Àâ‡À¡“– ¡°—∫ºŸâªÉ«¬·μà≈–√“¬ ‡™àπ ª√—∫μ“¡ Õ“¬ÿ ‚√§μà“ßÊ ∑’˺ŸâªÉ«¬‡ªì𠬓μà“ßÊ ∑’˺ŸâªÉ«¬‰¥â√—∫ ·≈–«‘∏’

°“√„À⬓ ”À√—∫ºŸâªÉ«¬Õ“¬ÿμ—Èß·μà 20 ªï¢÷Èπ‰ª §«√§‘¥¢π“¥¬“ morphine μ“¡Õ“¬ÿ¥’°«à“§‘¥μ“¡πÈ”Àπ—°μ—«3 ‡æ√“–

§«“¡μâÕß°“√ morphine ¡’§«“¡·μ°μà“ß°—π¡“°„π·μà≈–™à«ßÕ“¬ÿ (Õ“® Ÿß∂÷ß 10 ‡∑à“) „πºŸâ ŸßÕ“¬ÿ§«“¡

μâÕß°“√¢π“¥¢Õß morphine ≈¥≈ß·≈–√–¬–‡«≈“°“√ÕÕ°ƒ∑∏‘Ïπ“π¢÷Èπ  à«π„πºŸâªÉ«¬‡¥Á°§«√„™âπÈ”Àπ—°μ—«‡ªìπ

μ—«°”Àπ¥¢π“¥¢Õß morphine

μ“√“ß∑’Ë 4 Equianalgesic doses of opioids5

Opioids

Morphine

Pethidine

Fentanyl

Tramadol

™π‘¥©’¥ (Parenteral)

10 mg

100 mg

100 microgram

100 mg

Page 27: Clinical Guidance for Acute Pain Management

 ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***20

À≈—߉¥â√—∫ opioids §«√¡’°“√μ‘¥μ“¡ª√–‡¡‘πº≈°“√μÕ∫ πÕߢÕߺŸâªÉ«¬ ‡æ◊ËÕª√—∫¢π“¥·≈–

§«“¡∂’ËÀà“ߢÕß°“√∫√‘À“√¬“ opioids „Àâ‡À¡“– ¡°—∫ºŸâªÉ«¬·μà≈–√“¬3 √«¡∑—Èߪ√–‡¡‘πÕ“°“√·∑√°´âÕπ∑’Ë

Õ“®‡°‘¥®“° opioids ¥â«¬ μ“¡§”·π–π”„π·ºπ¿Ÿ¡‘∑’Ë 2, 3 ·≈– 4

B1.Morphine

Morphine ‡ªìπ opioid ¡“μ√∞“π  “¡“√∂∫√‘À“√‰¥âÀ≈“¬∑“ß morphine ∑’Ë∫√‘À“√¥â«¬«‘∏’

©’¥‡¢â“À≈Õ¥‡≈◊Õ¥¥” °≈â“¡‡π◊ÈÕ ·≈–„μ⺑«Àπ—ß ¡’√–¬–‡«≈“°“√‡√‘Ë¡ÕÕ°ƒ∑∏‘Ï ¥—ßπ’È 5-20 π“∑’, 20-60 π“∑’

·≈– 20-60 π“∑’ μ“¡≈”¥—∫ morphine ¡’√–¬–‡«≈“°“√ÕÕ°ƒ∑∏‘Ïπ“π 2-4 ™¡.

Morphine ∂Ÿ°∑”≈“¬∑’Ëμ—∫‰¥â‡ªìπ morphine-3-glucuronide (M3G) ·≈– morphine-6-glu-

curonide (M6G) ÷Ëß M6G ¡’ƒ∑∏‘Ï„π°“√√–ß—∫ª«¥‡™àπ‡¥’¬«°—∫ morphine °“√∑”≈“¬¢Õß morphine ∑’Ëμ—∫

Õ“®¡’°“√‡ª≈’ˬπ·ª≈ß„π°√≥’∑’Ë°“√∑”ß“π¢Õßμ—∫∫°æ√àÕßÕ¬à“ß√ÿπ·√ß  à«π°“√∑”ß“π¢Õ߉μ∑’Ë∫°æ√àÕß®–

∑”„Àâ°”®—¥ morphine ·≈– metabolites (M6G) ÕÕ°®“°√à“ß°“¬‰¡à‰¥â ®÷ßÕ“®¡’º≈°¥°“√À“¬„®‰¥â32

B2. Pethidine

‡ªìπ opioid  —߇§√“–Àå∑’Ë¡’ƒ∑∏‘Ï anticholinergic √à«¡¥â«¬§◊ÕÕ“®∑”„ÀâÀ—«„®‡μâπ‡√Á« ª“°§Õ·Àâß

pethidine ¡’§à“§√÷Ëß™’«‘μ 2-2.5 ™¡. ·≈–√–¬–‡«≈“°“√ÕÕ°ƒ∑∏‘Ï 2-4 ™¡. pethidine ∂Ÿ°∑”≈“¬∑’Ëμ—∫‰¥â meta-

bolite ∑’Ë ”§—≠ §◊Õ norpethidine ´÷ËßÕÕ°ƒ∑∏‘Ï°√–μÿâπ√–∫∫ª√– “∑ à«π°≈“ßÕ¬à“ß¡“° ∑”„À⇰‘¥Õ“°“√

°√– —∫°√– à“¬ ¡◊Õ —Ëπ °≈â“¡‡π◊ÈÕ‡°√Áß °√–μÿ° ·≈–™—°‰¥â ®÷߉¡à§«√„™â pethidine „πºŸâªÉ«¬∑’Ë¡’°“√∑”ß“π¢Õß

‰μÀ√◊Õμ—∫∫°æ√àÕß32

B3. Fentanyl

‡ªìπ opioid  —߇§√“–Àå ÕÕ°ƒ∑∏‘χ√Á«¿“¬„π 2-3 π“∑’À≈—ß©’¥‡¢â“À≈Õ¥‡≈◊Õ¥¥” √–¬–‡«≈“

°“√ÕÕ°ƒ∑∏‘Ï —Èπª√–¡“≥ 30-60 π“∑’ fentanyl ∂Ÿ°∑”≈“¬∑’Ëμ—∫‰¥â‡ªìπ norfentanyl ·≈–∂Ÿ°¢—∫ÕÕ°∑“ßªí  “«–

‚¥¬¡’¬“∫“ß à«π (‰¡à‡°‘π√âÕ¬≈– 7) ∂Ÿ°¢—∫ÕÕ°∑“ßªí  “«–‚¥¬‰¡à‡ª≈’ˬπ√Ÿª32

4. Local anesthetics (¬“™“)

¬“™“ÕÕ°ƒ∑∏‘Ϭ—∫¬—Èß∑’Ë sodium channels ∑’˺π—߇´≈≈å¢Õ߇ âπª√– “∑ ®÷ߢ—¥¢«“ß°“√°√–μÿâπ°“√

‡°‘¥ depolarization ·≈–°“√π”ª√– “∑ ∑”„Àâ≈¥Õ“°“√ª«¥‰¥â

°“√‡≈◊Õ°„™â¬“™“μâÕß∑√“∫¢π“¥ Ÿß ÿ¥∑’Ë„™â ‰¥âª≈Õ¥¿—¬ √–¬–°“√ÕÕ°ƒ∑∏‘Ï «‘∏’°“√„Àâ ‡™àπ °“√æàπ

°“√©’¥¬“™“‡©æ“–∑’Ë ©’¥∑’ˇ âπª√– “∑ ©’¥‡¢â“À≈Õ¥‡≈◊Õ¥¥”∑’Ë·¢πÀ√◊Õ¢“ ©’¥∑“ß spinal ·≈– epidural

¬“™“∑’Ë¡’„™â∫àÕ¬33,34 ·∫àßμ“¡√–¬–‡«≈“°“√ÕÕ°ƒ∑∏‘ϧ◊Õ

1. ¬“™“°≈ÿà¡ÕÕ°ƒ∑∏‘Ï —Èπ

„™â∑—Ë«‰ª„π°“√≈¥ª«¥‡©’¬∫æ≈—π ∑’Ë¡’„™â„πªí®®ÿ∫—π‰¥â·°à lignocaine (lidocaine) ·≈– prilocaine

(prilocaine ¡’„™âπâÕ¬¡“° ‡æ√“–Õ“®∑”„À⇰‘¥ methemoglobinemia ∂â“„™â‡°‘π¢π“¥ §◊Õ 600 ¡°.)

Lidocaine ÕÕ°ƒ∑∏‘ω¥â‡√Á« ®—∫°—∫‚ª√μ’ππâÕ¬®÷ß¡’√–¬–‡«≈“ÕÕ°ƒ∑∏‘Ï —Èπ √–¬–‡«≈“∑’ËÕÕ°ƒ∑∏‘Ï¢÷Èπ

Õ¬Ÿà°—∫«‘∏’°“√„Àâ ∫√‘‡«≥∑’Ë„Àâ·≈–¢π“¥¬“ °“√„Àâ lidocaine ‚¥¬°“√À¬¥μàÕ‡π◊ËÕß (infusion) „πºŸâªÉ«¬∑’Ë¡’§«“¡

ª«¥‡©’¬∫æ≈—πÕ“®æ∫¡’¿“«–¥◊ÈÕ¬“ (tachyphylaxis) ®÷߉¡à§«√„™â

Page 28: Clinical Guidance for Acute Pain Management

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 21

2. ¬“™“°≈ÿà¡ÕÕ°ƒ∑∏‘Ϭ“«

‰¥â·°à bupivacaine, levobupivacaine ·≈– ropivacaine ÷Ëß¡’§«“¡‡°’ˬ«¢âÕß°—π§◊Õ bupivacaine

‡ªìπ¬“∑’Ë¡’ à«πº ¡¢Õß racemic ∑—Èß S-enantiomer ·≈– R-enantiomer  à«π levobupivacaine ·≈–

ropivacaine ‡ªìπ S-enantiomer ¢Õß bupivacaine ‡¡◊ËÕ„Àâ„π¢π“¥∑’Ë∑”„À⇠âπª√– “∑™“∑’ˇ∑à“°—πæ∫«à“

S-enantiomer ¢Õ߬“™“¡’º≈μàÕ√–∫∫ª√– “∑ à«π°≈“ß·≈–‡ªìπæ‘…μàÕÀ—«„®πâÕ¬°«à“¬“™“∑’ˇªìπ R-enantio-

mer À√◊Õ¬“™“∑’Ë¡’ à«πº ¡ racemic

°“√©’¥ bupivacaine „π¢π“¥ Ÿß·∫∫‰¡àμ—Èß„®‡¢â“À≈Õ¥‡≈◊Õ¥¡’º≈°¥°≈â“¡‡π◊ÈÕÀ—«„®Õ¬à“ß√ÿπ·√ß

·≈–¡’ ventricular fibrillation ™π‘¥¬“°μàÕ°“√√—°…“ ÷Ë߇°‘¥‡æ√“–°“√ ≈“¬μ—«¢Õß bupivacaine ®“°

sodium channel ¢Õß°≈â“¡‡π◊ÈÕÀ—«„®‡ªìπ‰ªÕ¬à“ß™â“Ê ∑”„Àâ bupivacaine ¡’æ‘…¡“°°«à“ levobupivacaine

·≈– ropivacaine35

º≈¢â“߇§’¬ß¢Õ߬“™“

1. ªØ‘°‘√‘¬“¿Ÿ¡‘·æâ æ∫„𬓙“°≈ÿà¡ ester ®“° “√ para aminobenzoic acid Õ“°“√º◊Ëπ§—π ∫«¡

À“¬„®≈”∫“° À≈Õ¥≈¡‡°√Áß §«“¡¥—π‡≈◊Õ¥μË” À—«„®À¬ÿ¥‡μâπ

2. æ‘…®“°¬“™“‡°‘¥‡¡◊ËÕ„À⇰‘π¢π“¥À√◊Õ©’¥‡¢â“À≈Õ¥‡≈◊Õ¥‚¥¬‰¡àμ—Èß„® º≈μàÕ√–∫∫ª√– “∑ à«π°≈“ß

‡√‘Ë¡®“°«‘߇«’¬π ÀŸÕ◊ÈÕ ™“√Õ∫ª“°·≈–≈‘Èπ μ“æ√à“ °≈â“¡‡π◊ÈÕ°√–μÿ° ·≈â«´÷¡ À¡¥ μ‘ À¬ÿ¥À“¬„® º≈μàÕ√–∫∫

À—«„®·≈–À≈Õ¥‡≈◊Õ¥ §◊Õ ¢¬“¬À≈Õ¥‡≈◊Õ¥·≈–°¥°≈â“¡‡π◊ÈÕÀ—«„®‡¡◊ËÕ„™â¬“„π¢π“¥ Ÿß

«‘∏’°“√„™â¬“™“„π°“√√–ß—∫ª«¥‡©’¬∫æ≈—π

1. °“√„™â¬“‡©æ“–∑’Ë (topical anesthesia)

EMLA cream (eutectic mixture of local anesthetics) ‡ªì𬓙“¡’≈—°…≥–‡ªìπ§√’¡∑’˺ ¡√–À«à“ß

2.5% lidocaine ·≈– 2.5% prilocaine π‘¬¡∑“„ÀâÀπ“∑’˺‘«Àπ—߇æ◊ËÕ≈¥ª«¥®“°°“√·∑߇¢Á¡‡ªî¥À≈Õ¥‡≈◊Õ¥¥”

·π–π”„Àâ„™â 1-2 °√—¡μàÕæ◊Èπ∑’˺‘« 10 μ√.´¡. ‡√‘Ë¡ÕÕ°ƒ∑∏‘Ï„π 45-60 π“∑’ √–¬–‡«≈“§ßƒ∑∏‘Ïπ“π 1-2 ™¡.

2-4% lidocaine, 4-10% cocaine „™âæàπ À√◊Õ∑“∫√‘‡«≥‡¬◊ËÕ‡¡◊Õ° ‡™àπ „π°“√ºà“μ—¥™àÕß®¡Ÿ°·≈–™àÕߪ“°

‡æ◊ËÕ„À♓ ·≈–≈¥Õ“°“√ª«¥®“°°“√∑”À—μ∂°“√

2. °“√©’¥¬“™“‡©æ“–∑’Ë (local infiltration)

„™â¬“™“ 0.5-1% lidocaine, 0.25% bupivacaine, À√◊Õ 0.2-0.5% ropivacaine ©’¥¬“∑’˺‘«Àπ—ß

∫√‘‡«≥∑’Ë∑”°“√ºà“μ—¥À√◊Õ‡¬Á∫·º≈

3. °“√©’¥¬“™“∑’ˇ âπª√– “∑ (peripheral nerve block)

‡ªìπ°“√©’¥¬“„°≈⇠âπª√– “∑∑’ˉª‡≈’Ȭß∫√‘‡«≥ºà“μ—¥ ‡™àπ brachial plexus block, intercostal nerve

block, femoral nerve block ‚¥¬‡ âπª√– “∑°≈ÿà¡„À≠à®”‡ªìπμâÕß„™â¬“¡“°¢÷Èπ·μàμâÕ߉¡à‡°‘π¢π“¥∑’Ë°”Àπ¥

¬“™“∑’Ë„™â ‰¥â·°à 1-1.5% lidocaine, 0.25-0.5% bupivacaine ·≈– 0.5-1% ropivacaine

4. °“√©’¥¬“™“‡¢â“À≈Õ¥‡≈◊Õ¥¥”∑’Ë·¢πÀ√◊Õ¢“ (intravenous regional anesthesia) °“√©’¥¬“™“∑“ß

spinal ·≈– epidural  à«π„À≠à„™â„π°“√∑”ºà“μ—¥ ¬°‡«âπ epidural analgesia ∑’Ë„™â√–ß—∫ª«¥À≈—ߺà“μ—¥‰¥â

¥â«¬ °“√©’¥¬“™“¥â«¬‡∑§π‘§‡À≈à“π’ȇªìπÀ—μ∂°“√∑’ËμâÕßÕ“»—¬§«“¡™”π“≠ ÷Ëß®–‰¡à°≈à“«∂÷ß„π∑’Ëπ’È

Page 29: Clinical Guidance for Acute Pain Management

 ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***22

5. ¬“Õ◊ËπÊ ∑’Ë¡’ƒ∑∏‘χ √‘¡°“√√–ß—∫ª«¥ (Adjuvants)

‡ªìπ¬“∑’ËÕ“®π”¡“„™â‡ √‘¡ƒ∑∏‘Ï°“√√–ß—∫ª«¥√à«¡°—∫¬“·°âª«¥À≈—°∑’Ë°≈à“«¡“¢â“ßμâπ ‰¡à·π–π”„Àâ„™â

¬“„π°≈ÿà¡π’ȇ撬ß≈”æ—߇æ√“–‰¡à “¡“√∂√–ß—∫ª«¥‰¥â‡æ’¬ßæÕ ¬“„π°≈ÿà¡π’È ‰¥â·°à N-methyl-D-aspartate (NMDA)

receptor antagonists (‰¥â·°à ketamine36,37 ·≈– dextromethorphan37,38), antidepressant, anticonvul-

sant (gabapentin)39, membrane stabilizers (lidocaine), alpha-2 agonists (clonidine ·≈– dexme-

detomidine)38,40 °“√‡≈◊Õ°„™â¬“„π°≈ÿà¡π’ȇæ◊ËÕ„™â√à«¡„π°“√√–ß—∫ª«¥·∫∫‡©’¬∫æ≈—ππ—Èπ μâÕßæ‘®“√≥“∂÷ß

ª√– ‘∑∏‘¿“æ §«“¡‡À¡“– ¡ §«“¡®”‡ªìπ ¢âÕ¥’ ·≈–¢âÕ‡ ’¬¢Õ߬“√à«¡¥â«¬

μ“√“ß √ÿª°“√√–ß—∫ª«¥‡©’¬∫æ≈—π

μ“√“ß∑’Ë 5 · ¥ß√“¬≈–‡Õ’¬¥°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬„™â¬“

μ“√“ß∑’Ë 6 · ¥ß√“¬≈–‡Õ’¬¥°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬‰¡à„™â¬“

Page 30: Clinical Guidance for Acute Pain Management

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 23

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Page 31: Clinical Guidance for Acute Pain Management

 ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***24

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Page 32: Clinical Guidance for Acute Pain Management

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 25

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Page 33: Clinical Guidance for Acute Pain Management

 ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***26

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Page 34: Clinical Guidance for Acute Pain Management

*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 27

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Page 35: Clinical Guidance for Acute Pain Management

 ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬

*** ¢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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Page 36: Clinical Guidance for Acute Pain Management

*** ¢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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Page 38: Clinical Guidance for Acute Pain Management

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*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***36

‡Õ° “√Õâ“ßÕ‘ß

1. American Society of Anesthesiologists Task Force on Acute Pain Management. Clinical Guidances for acute painmanagement in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Forceon Acute Pain Management. Anesthesiology 2004;100(6):1573-81.

2. Gordon DB, Dahl JL, Miaskowski C, McCarberg B, Todd KH, Paice JA, et al. American pain society recommendationsfor improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force.Arch Intern Med. 2005;165(14):1574-80.

3. Australian and New Zealand College of Anaesthetists, Faculty of Pain Medicine. Acute Pain Management: ScientificEvidence. 2nd ed. Melbourne: Australian and New Zealand College of Anaesthetists, 2005. Available from http://www.anzca.edu.au/publications/acutepain.htm. Access 25/7/08.

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·À≈àߢâÕ¡Ÿ≈‡æ‘Ë¡‡μ‘¡∑’Ëπà“ π„® (Evidence-based resources)

1. Bandolier evidence based thinking about health care. Available from http://www.medicine.ox.ac.uk/bandolier/booth/painpag/acute.html

2. Australian and New Zealand College of Anaesthetists, Faculty of Pain Medicine. Acute Pain Management: ScientificEvidence. 2nd ed. Melbourne: Australian and New Zealand College of Anaesthetists, Available from http://www.anzca.edu.au/publications/acutepain.htm.

3. Institute for clinical systems improvement 6th edition; Available from http://www.icsi.org/pain_acute/pain__acute__assessment_and_management_of__3.html

4. Procedure specific postoperative pain management (prospect). European society of regional anaesthesia and paintherapy. Available from http://www.postoppain.org/frameset.htm

5. European society of regional anaesthesia and pain therapy. www.anaesthesia-az.com

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ACUTEPAIN

Thai Association for the Study of PainISBN: 978-974-8285-72-6