Clinical Practice Guideline for postoperative pain

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(Clinical Guidance for Acute Pain Management) ∑’Ë®—¥∑”‚¥¬ ¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààß

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¿“§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

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°≈àÕß∑’Ë 2: «‘∏’°“√√–ß—∫§«“¡√Ÿâ ÷° [Intraoperative Period]

§”·π–π”: ¢÷ÈπÕ¬Ÿà°—∫™π‘¥¢Õß°“√ºà“μ—¥, ¿“«–¢ÕßºŸâªÉ«¬, §«“¡∂π—¥¢Õß«‘ —≠≠’·æ∑¬å / »—≈¬·æ∑¬å ·≈–§«“¡æ√âÕ¡¢ÕßÕÿª°√≥å‡§√◊ËÕß¡◊Õ

°≈àÕß∑’Ë 3: ¡’Õ“°“√ª«¥À≈—ßºà“μ—¥ [Postoperative Period]

§”·π–π”: μâÕßæ‘®“√≥“«à“§«“¡ª«¥∑’Ë‡°‘¥¢÷Èπ‡ªìπ§«“¡ª«¥®“°°“√ºà“μ—¥À√◊Õ‰¡à ∂â“‡ªìπ§«“¡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·√ß¢ÕßÕ“°“√ª«¥∑’Ë‡°‘¥¢÷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“ß‡§’¬ß/Õ“°“√·∑√° âÕπ®“°°“√√–ß—∫ª«¥

§”·π–π”: §«√¡’°“√‡ΩÑ“√–«—ßº≈¢â“ß‡§’¬ß·≈–Õ“°“√·∑√° âÕπ®“°°“√√–ß—∫ª«¥

°≈àÕß∑’Ë 8: √—°…“º≈¢â“ß‡§’¬ß/Õ“°“√·∑√° âÕπ®“°°“√√–ß—∫ª«¥

§”·π–π”: „Àâ√—°…“º≈¢â“ß‡§’¬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≈—ßºà“μ—¥


√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààßª√–‡∑»‰∑¬

§”Õ∏‘∫“¬·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—πÀ≈—ßºà“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“®„ÀâºŸâªÉ«¬¡’ à«π√à«¡„π°“√μ—¥ ‘π„®‡≈◊Õ°«‘∏’

„π°“√√—°…“¥â«¬μπ‡Õß

2) ºŸâªÉ«¬‰¥â√—∫§«“¡√Ÿâ‡°’Ë¬«°—∫«‘∏’°“√ª√–‡¡‘π√–¥—∫§«“¡ª«¥ «‘∏’°“√„™â‡§√◊ËÕß¡◊Õ√–ß—∫ª«¥

¬“·°âª«¥ ¿“«–·∑√°´âÕπ ·≈–„Àâ§«“¡√Ÿâ·°àºŸâªÉ«¬‡√◊ËÕßº≈¥’·≈–º≈‡ ’¬¢Õß°“√√—°…“

°≈àÕß∑’Ë 1.1: °“√ºà“μ—¥ª√–‡¿∑ª«¥πâÕ¬

À¡“¬∂÷ß°“√ºà“μ—¥∑’Ë∑”„Àâ‡°‘¥Õ“°“√ª«¥πâÕ¬ ‡™àπ °“√ºà“μ—¥ excision ¢π“¥‡≈Á° ‡ âπ‡≈◊Õ¥

¢Õ¥ ‡ªìπμâπ

§”·π–π”: „Àâ¬“μ“¡≈”¥—∫ª«¥πâÕ¬¢Õß∫—π‰¥ 3 ¢—Èπ ¢ÕßÕß§å°“√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∑”„Àâ‡°‘¥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°≈“ß¢Õß∫—π‰¥ 3 ¢—Èπ ¢ÕßÕß§å°“√Õπ“¡—¬‚≈° ‰¥â·°à °“√„Àâ¬“°≈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∑”„Àâ‡°‘¥Õ“°“√ª«¥¡“° ‡™àπ °“√ºà“μ—¥„π™àÕß∑âÕß à«π∫π ™àÕßÕ°

‡ª≈’Ë¬π¢âÕ‡¢à“‡∑’¬¡ ‡ªìπμâπ

§”·π–π”: „Àâ¬“μ“¡≈”¥—∫ª«¥¡“°¢Õß∫—π‰¥ 3 ¢—Èπ¢ÕßÕß§å°“√Õπ“¡—¬‚≈° ‰¥â·°à °“√„Àâ strong

opioid °“√„™â‡∑§π‘§°“√„Àâ¬“·°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—¥, ¿“«–¢ÕßºŸâªÉ«¬, §«“¡∂π—¥¢Õß«‘ —≠≠’·æ∑¬å / »—≈¬·æ∑¬å

·≈–§«“¡æ√âÕ¡¢ÕßÕÿª°√≥å‡§√◊ËÕß¡◊Õ


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

°≈àÕß∑’Ë 3 ¡’Õ“°“√ª«¥À≈—ßºà“μ—¥ [Postoperative period]§”·π–π”: μâÕßæ‘®“√≥“«à“§«“¡ª«¥∑’Ë‡°‘¥¢÷Èπ‡ªìπ§«“¡ª«¥®“°°“√ºà“μ—¥À√◊Õ‰¡à ∂â“‡ªìπ§«“¡ª«¥®“°

“‡ÀμÿÕ◊Ëπ„Àâ√—°…“μ“¡ “‡Àμÿ¢Õß‚√§ ∂â“‡ªìπ§«“¡ª«¥®“°°“√ºà“μ—¥®√‘ß „Àâª√–‡¡‘π√–¥—∫

§«“¡ª«¥ ·≈–„Àâ°“√√—°…“ ·≈–¬È”‡μ◊ÕπºŸâªÉ«¬‡√◊ËÕß¢âÕ¥’·≈–¢âÕ‡ ’¬¢Õß«‘∏’√–ß—∫ª«¥∑’Ë„™â ∑—Èßπ’È

§«√„ÀâºŸâªÉ«¬¡’ à«π√à«¡„π°“√‡≈◊Õ°«‘∏’„π°“√√—°…“ ∂â“ºŸâªÉ«¬¡’§«“¡ª«¥·μà¬—ß‰¡àμâÕß°“√°“√

√—°…“ μâÕßª√–‡¡‘π√–¥—∫§«“¡ª«¥´È”·≈–∫—π∑÷°‡ªìπ√–¬– ∂â“§«“¡ª«¥∂÷ß√–¥—∫∑’Ë§«√√—∫°“√

√—°…“ §«√„Àâ°“√√—°…“æ√âÕ¡°—∫·π–π”ºŸâªÉ«¬„Àâ‡¢â“„®·≈–·°â ‰¢§«“¡‡¢â“„®º‘¥∑’Ë∑”„Àâ¬—ß‰¡à

μâÕß°“√°“√√—°…“

°≈àÕß∑’Ë 4 ª√–‡¡‘π√–¥—∫§«“¡ª«¥À≈—ß°“√ºà“μ—¥§”·π–π”: 1) °“√ª√–‡¡‘π§«“¡ª«¥∑’Ë¥’∑’Ë ÿ¥ §«√„ÀâºŸâªÉ«¬∫Õ°√–¥—∫§«“¡ª«¥¥â«¬μπ‡Õß „π√“¬∑’Ë‰¡à

“¡“√∂∫Õ°√–¥—∫§«“¡ª«¥¥â«¬μπ‡Õß §«√‡≈◊Õ°„™â‡§√◊ËÕß¡◊Õ„π°“√ª√–‡¡‘π§«“¡ª«¥

„Àâ‡À¡“– ¡°—∫ºŸâªÉ«¬·μà≈–√“¬ (√Ÿª∑’Ë 1)

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

·≈–À≈—ß„Àâ°“√√—°…“

3) §«√∫—π∑÷°§«“¡ª«¥„Àâ‡ÀÁπ™—¥‡®π °“√√–ß—∫ª«¥„Àâ ‰¥âº≈¥’μâÕß‡√‘Ë¡®“°°“√ª√–‡¡‘π§«“¡

ª«¥¢ÕßºŸâªÉ«¬„Àâ∂Ÿ°μâÕß°àÕπ ‚¥¬ª√–‡¡‘πμ—Èß·μà‡√‘Ë¡μâπ√—°…“ ·≈–ª√–‡¡‘πÀ≈—ß„Àâ°“√√—°…“

∑—Èß¢≥–ºŸâªÉ«¬æ—°·≈–¢≥–¡’°“√¢¬—∫μ—« ´÷Ëß§«“¡ª«¥‡ªìπ§«“¡√Ÿâ ÷° à«π∫ÿ§§≈ ·≈–‰¡à

‡À¡◊Õπ°—π∑ÿ°§π ·μà≈–∫ÿ§§≈®–¡’ªí®®—¬Õ◊Ëπ‡¢â“¡“‡°’Ë¬«¢âÕß ‡™àπ Õ“√¡≥å ª√– ∫°“√≥å

‡¥‘¡ ¡“ª√—∫‡ª≈’Ë¬π§«“¡√Ÿâ ÷°ª«¥

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


√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààßª√–‡∑»‰∑¬

°≈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‡°’Ë¬«°—∫¬“·°âª«¥ª√–‡¿∑μà“ßÊ ∑—Èß°≈‰°°“√

ÕÕ°ƒ∑∏‘Ï ¢π“¥¬“ ¢âÕ§«√√–«—ß ¢âÕÀâ“¡ º≈¢â“ß‡§’¬ß·≈–Õ“°“√·∑√° âÕπ

¢Õß¬“

2) ‡≈◊Õ°„™â¬“·°âª«¥μ“¡√–¥—∫§«“¡√ÿπ·√ß¢Õß§«“¡ª«¥∑’Ë‡°‘¥¢÷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 ¢ÕßºŸâªÉ«¬´÷Ëß¡’º≈

μàÕ°“√ÕÕ°ƒ∑∏‘Ï·≈–°“√¢®—¥¬“ ‡™àπ ‚√§ª√–®”μ—« ¬“∑’Ë„™â„πªí®®ÿ∫—π ª√–«—μ‘°“√·æâ¬“

¢âÕÀâ“¡„™â¢Õß¬“μà“ßÊ ·≈–Õ—πμ√°‘√‘¬“√–À«à“ß¬“∑’ËÕ“®‡°‘¥¢÷Èπ

2. °“√‡≈◊Õ°„™â¬“·°âª«¥μ—Èß·μà 2 ¢π“π¢÷Èπ‰ª (μ“√“ß∑’Ë 1) ‡æ◊ËÕÀ«—ßº≈„Àâ‡ √‘¡ƒ∑∏‘Ï°—π ‚¥¬

º≈¢â“ß‡§’¬ß‰¡à¡“°‰ª°«à“°“√„™â¬“¥—ß°≈à“«‡æ’¬ß¢π“π‡¥’¬«

‚¥¬∑—Ë«‰ª §«“¡ª«¥À≈—ßºà“μ—¥¡—°¡’°≈‰°°“√‡°‘¥§«“¡ª«¥‡ªìπ·∫∫ nociceptive ∑’ËμÕ∫ πÕß¥’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’Ë¬«π” CYP2E1 (¥Ÿ‡æ‘Ë¡‡μ‘¡„π à«π Õ—πμ√°‘√‘¬“√–À«à“ß¬“) ·μàÕ“®„Àâ

NSAIDs À√◊Õ coxibs √à«¡‰¥â∂â“‰¡à¡’¢âÕÀâ“¡ ∂â“ºŸâªÉ«¬¡’§«“¡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≈—ßºà“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≈—ßºà“μ—¥ ·≈–„πºŸâªÉ«¬¡’‚√§√à«¡∑’Ë∑”„Àâ ‰¡à “¡“√∂„™â NSAIDs, coxibs À√◊Õ opioids

‰¥â ·μàμâÕßæ‘®“√≥“„Àâ¡’ª√–‚¬™πå¡“°°«à“§«“¡‡ ’Ë¬ß∑’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“ß‰√°Áμ“¡

°“√©’¥¬“™“‡©æ“–∑’Ë∑’Ë·º≈ºà“μ—¥ ‡ªìπ«‘∏’°“√√–ß—∫ª«¥æ◊Èπ∞“π∑’Ë “¡“√∂∑”‰¥âßà“¬ ®÷ß‡ªìπ«‘∏’°“√æ◊Èπ∞“π„π

°“√√–ß—∫§«“¡ª«¥‰¥â„π∑ÿ°√–¥—∫§«“¡√ÿπ·√ß √à«¡°—∫°“√„™â¬“Õ◊ËπÊ


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5.1.1 «‘∏’∫√‘À“√¬“ (Administration Technique)

5.1.1.1 Systemic analgesic administration §◊Õ °“√„Àâ¬“·°âª«¥¥â«¬°“√©’¥À√◊Õ√—∫ª√–∑“π

·μà„π™à«ßÀ≈—ßºà“μ—¥∑’ËºŸâªÉ«¬¬—ß‰¡àøóôπ®“°¬“√–ß—∫§«“¡√Ÿâ ÷° ‰¡à “¡“√∂√—∫ª√–∑“π¬“À√◊Õ¡’°“√ß¥πÈ”·≈–Õ“À“√

®÷ßπ‘¬¡„Àâ¬“·°âª«¥‚¥¬°“√©’¥ ‰¥â·°à °“√©’¥‡¢â“∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ‡¢â“°≈â“¡‡π◊ÈÕ À√◊Õ‡¢â“™—Èπ„μâº‘«Àπ—ß ‚¥¬

¡ÿàßÀ«—ß„Àâ√–¥—∫¬“„π‡≈◊Õ¥Õ¬Ÿà„π™à«ß√—°…“ (therapeutic window) ¥â«¬‡∑§π‘§μà“ßÊ ·∫àß‡ªìπ

ë p.r.n. „Àâ‡¡◊ËÕºŸâªÉ«¬μâÕß°“√¬“·°âª«¥ ¢âÕ¥’ §◊Õ √–¥—∫¬“„π‡≈◊Õ¥‰¡à Ÿß‡°‘π™à«ß√—°…“¢Õß

ºŸâªÉ«¬ ·μà¢âÕ‡ ’¬ §◊Õ √–¥—∫¬“Õ“®≈¥μË”°«à“√–¥—∫¬“∑’ËπâÕ¬∑’Ë ÿ¥∑’Ë‰¥âº≈„π°“√√–ß—∫ª«¥ ∑”„Àâ¡’Õ“°“√ª«¥ ·≈–

„™â‡«≈“π“π°«à“®–‰¥â√—∫¬“·°âª«¥·≈–°«à“√–¥—∫¬“®–‡æ‘Ë¡¢÷Èπ∂÷ß√–¥—∫√—°…“ ‚¥¬æ∫«à“ √âÕ¬≈– 50 ¢ÕßºŸâªÉ«¬

∑’Ë‰¥â√—∫°“√√—°…“·∫∫ p.r.n. ¬—ß¡’§«“¡ª«¥Õ¬Ÿà «‘∏’·°â ‰¢ ”À√—∫«‘∏’ p.r.n. §◊Õ ¡’°“√ª√–‡¡‘π§–·ππª«¥À≈—ß

ºà“μ—¥Õ¬à“ß ¡Ë”‡ ¡Õ ‡¡◊ËÕæ∫«à“‡√‘Ë¡¡’§–·ππ Ÿß∂÷ß√–¥—∫∑’Ë§«√„Àâ°“√√—°…“ °Á„Àâ¬“μ“¡·ºπ°“√√—°…“∑—π∑’

‰¡à√Õ„Àâª«¥¡“°®÷ß„Àâ¬“

ë Around the clock À√◊Õ continuous infusion „Àâ¬“μ“¡‡«≈“À√◊ÕÕ¬à“ßμàÕ‡π◊ËÕß ¢âÕ¥’ §◊Õ

ºŸâªÉ«¬®–‰¥â√—∫°“√ª√–‡¡‘πÕ¬à“ß ¡Ë”‡ ¡Õ·≈–‰¥â√—∫¬“Õ¬à“ßμàÕ‡π◊ËÕß ∑”„Àâ√–¥—∫¬“‰¡àμË”°«à“√–¥—∫∑’Ë‰¥âº≈„π

°“√√—°…“ ¢âÕ‡ ’¬§◊Õ ‡ ’Ë¬ßμàÕ°“√„Àâ¬“‡°‘π¢π“¥ ∑—Èßπ’È “¡“√∂ªÑÕß°—π‚¥¬°“√ª√–‡¡‘π§«“¡ßà«ß´÷¡Õ¬à“ß ¡Ë”‡ ¡Õ

ë °“√„™â‡§√◊ËÕß PCA (Patient-controlled analgesia) À¡“¬∂÷ß «‘∏’°“√∑’ËºŸâªÉ«¬ “¡“√∂

„Àâ¬“·°âª«¥¥â«¬μπ‡Õß ‡ªìπ«‘∏’∑’Ë –¥«°·≈–π‘¬¡„™âÀ≈—ßºà“μ—¥ ‚¥¬°“√°¥ªÿÉ¡ª≈àÕ¬¬“„Àâμπ‡Õß‡¡◊ËÕ√Ÿâ ÷°ª«¥

μ—¥ªí≠À“§«“¡≈à“™â“„π°“√‡μ√’¬¡¬“·≈–∫√‘À“√¬“ πÕ°®“°π’È ¬—ß‡æ‘Ë¡§«“¡æ÷ßæÕ„®·°àºŸâªÉ«¬‰¥â

«‘∏’°“√„™â PCA π‘¬¡„™â 2 «‘∏’ ‰¥â·°à

1. Demand dosing §◊Õ°“√„Àâ¬“·°âª«¥¢π“¥πâÕ¬Ê ‡¡◊ËÕ√Ÿâ ÷°ª«¥ ‚¥¬ºŸâªÉ«¬°¥ªÿÉ¡ª≈àÕ¬¬“„Àâμπ‡Õß

2. Continuous infusion √à«¡°—∫ demand dosing §◊Õ°“√„Àâ¬“·°âª«¥À¬¥‡¢â“À≈Õ¥‡≈◊Õ¥¥”Õ¬à“ß

μàÕ‡π◊ËÕß √à«¡°—∫°“√„Àâ¬“·°âª«¥‡æ‘Ë¡¥â«¬μπ‡Õß∂â“¬—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“ß¢Õß°“√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


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

·ºπ¿Ÿ¡‘∑’Ë 2 μ—«Õ¬à“ß«‘∏’°“√μ—Èß PCA


√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààßª√–‡∑»‰∑¬

„π∑“ßªØ‘∫—μ‘‰¡àπ‘¬¡„™â pethidine ‡π◊ËÕß®“°º≈¢â“ß‡§’¬ß §◊Õ Õ“°“√ßà«ß´÷¡ ·≈–Õ“®‡°‘¥°“√ – ¡¢Õß

metabolite §◊Õ norpethidine ‚¥¬‡©æ“–„πºŸâªÉ«¬∑’Ë¡’¿“«–°“√∑”ß“π¢Õß‰μ≈¥≈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≈—ßºà“μ—¥ ·≈–¡—°‡ªìπ«‘∏’∑’Ë∂Ÿ°‡≈◊Õ°

‡æ◊ËÕ√–ß—∫ª«¥„π°“√ºà“μ—¥∑’Ë‡ ’Ë¬ßμàÕ°“√ª«¥√ÿπ·√ß À√◊Õ√–ß—∫¥â«¬«‘∏’¡“μ√∞“π·≈â«¡—°‰¡à‰¥âº≈√–ß—∫ª«¥∑’Ë¥’

‡™àπ °“√ºà“μ—¥∑√«ßÕ° °“√ºà“μ—¥™àÕß∑âÕß °“√‡ª≈’Ë¬π¢âÕ‡¢à“ ‡ªìπμâπ

°“√ °—¥°—Èπ√–∫∫ª√– “∑ à«π°≈“ß·∫∫μàÕ‡π◊ËÕß¡’Õ¬Ÿà 2 «‘∏’§◊Õ

1. Continuous spinal analgesia ‰¡à·π–π”„Àâ„™â‚¥¬∑—Ë«‰ª

2. Continuous epidural analgesia ·π–π”‡ªìπ«‘∏’À≈—° ‚¥¬¬“∑’Ë “¡“√∂„™â ”À√—∫«‘∏’°“√π’È ‰¥â·°à

¬“™“§«“¡‡¢â¡¢âπμË”∑’Ë¡’ƒ∑∏‘Ïπ“π ¬“·°âª«¥°≈ÿà¡ opioid ·≈–¬“°≈ÿà¡ adjuvants ‡™àπ ketamine, clonidine,

neostigmine ·μà à«π„À≠à¬“°≈ÿà¡ adjuvants π’È§«√„™â‚¥¬ºŸâ‡™’Ë¬«™“≠ ‰¡à·π–π”„Àâ„™â„π∑“ßªØ‘∫—μ‘∑—Ë«‰ª

‡æ◊ËÕ„Àâ°“√√–ß—∫ª«¥‰¥âº≈¥’ π‘¬¡„™â¬“™“§«“¡‡¢â¡¢âπμË”∑’Ë¡’ƒ∑∏‘Ï¬“«√à«¡°—∫¬“√–ß—∫ª«¥°≈ÿà¡ opioid

¡“°°«à“∑’Ë®–„™â¬“¢π“π„¥¢π“πÀπ÷Ëß‡æ’¬ß¢π“π‡¥’¬«

«‘∏’°“√„Àâ¬“∑“ß™àÕß‡Àπ◊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¡’°“√

– ¡¢Õß¬“„πª√‘¡“≥∑’Ë Ÿß·≈–‡°‘¥º≈¢â“ß‡§’¬ß‰¥âßà“¬

2. °“√‡μ‘¡¬“‡ªìπ§√—Èß (intermittent bolus) «‘∏’°“√π’ÈºŸâªÉ«¬®–μâÕß√Õ·æ∑¬å¡“‡μ‘¡¬“„Àâ‡ªìπ√–¬–Ê

μâÕß√Õ¬“ÕÕ°ƒ∑∏‘Ï ∑”„Àâº≈°“√√–ß—∫ª«¥‰¡àμàÕ‡π◊ËÕß‡∑à“«‘∏’·√°

3. Patient-controlled epidural analgesia (PCEA) ‡ªìπ«‘∏’√–ß—∫ª«¥∑’Ëª√—∫μ“¡§«“¡μâÕß°“√

¢ÕßºŸâªÉ«¬¡“°∑’Ë ÿ¥ °≈à“«§◊ÕºŸâªÉ«¬®–°¥ªÿÉ¡ª≈àÕ¬¬“„Àâμπ‡Õß‰¥â∑—π∑’∑’Ë‡√‘Ë¡¡’Õ“°“√ª«¥ ∑”„Àâ≈¥°“√‰¥â¬“‡°‘π

®”‡ªìπ·≈–¡’º≈¢â“ß‡§’¬ßπâÕ¬°«à“«‘∏’·√° ·μà„π¢≥–‡¥’¬«°—π°Á‡ªìπ«‘∏’°“√∑’Ë¡’§à“„™â®à“¬ Ÿß‡æ√“–μâÕßÕ“»—¬

‡§√◊ËÕß¡◊Õ‡©æ“–„π°“√„Àâ¬“

μ”·Àπàß¢Õß “¬ epidural

¢÷ÈπÕ¬Ÿà°—∫°“√ºà“μ—¥ ·μà¡’À≈—°°“√§◊Õ§«√„Àâª≈“¬ “¬„π™àÕß epidural Õ¬Ÿà°÷Ëß°≈“ß¢Õß 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«¬


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

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 °“√„Àâ¬“™“ºà“π∑“ß “¬§“ ∫√‘‡«≥

‡ âπª√– “∑‡æ◊ËÕ√–ß—∫§«“¡ª«¥ ”À√—∫°“√ºà“μ—¥√–¬“ß§å à«π∫π·≈–≈à“ß ‚¥¬ “¡“√∂§«∫§ÿ¡§«“¡ª«¥‰¥â

π“π°«à“°“√©’¥¬“™“√–ß—∫§«“¡√Ÿâ ÷°‡æ’¬ß§√—Èß‡¥’¬« (´÷Ëß¡’√–¬–‡«≈“ —Èπª√–¡“≥ 10-24 ™¡.) ∑”„Àâ “¡“√∂

∑”°“¬¿“æ∫”∫—¥‰¥â‡μÁ¡∑’Ë §«∫§ÿ¡§«“¡ª«¥‰¥â¥’°«à“ ¡’º≈¢â“ß‡§’¬ßπâÕ¬°«à“°“√©’¥¬“·°âª«¥°≈ÿà¡ opioid À√◊Õ

·∫∫ IV PCA ·≈–º≈√–ß—∫ª«¥¡’ª√– ‘∑∏‘¿“æ„°≈â‡§’¬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°“√√—°…“ §«√„ÀâºŸâªÉ«¬¡’√–¥—∫§«“¡ª«¥ VAS < 4 À√◊Õ¡’§«“¡æ÷ßæÕ„®°—∫°“√

√—°…“§«“¡ª«¥

2) ª√—∫‡ª≈’Ë¬π«‘∏’°“√√–ß—∫§«“¡ª«¥μ“¡§«“¡‡À¡“– ¡

3) ª√÷°…“ºŸâ‡™’Ë¬«™“≠ Acute Pain Service (APS) ‚¥¬„π·μà≈–‚√ßæ¬“∫“≈§«√¡’°“√

°”Àπ¥π‚¬∫“¬ (Policy) ·≈–«‘∏’°“√ (Procedure) „π°“√¥Ÿ·≈√—°…“§«“¡ª«¥À≈—ß

ºà“μ—¥∑’Ë‡ªìπ¡“μ√∞“π¢Õß‚√ßæ¬“∫“≈ ·≈–§«√®—¥μ—ÈßÀπà«¬√–ß—∫§«“¡ª«¥‡©’¬∫æ≈—π

APS ‡æ◊ËÕ„Àâ°“√∫√‘°“√·≈–§”ª√÷°…“¥â“π°“√¥Ÿ·≈√—°…“§«“¡ª«¥À≈—ßºà“μ—¥


√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààßª√–‡∑»‰∑¬

°≈àÕß∑’Ë 7 ‡°‘¥º≈¢â“ß‡§’¬ß/Õ“°“√·∑√°´âÕπ®“°°“√√–ß—∫ª«¥

§”·π–π”: §«√¡’°“√‡ΩÑ“√–«—ßº≈¢â“ß‡§’¬ß/Õ“°“√·∑√° âÕπ®“°°“√√–ß—∫§«“¡ª«¥ ·≈–

¡’§” —Ëß°“√√—°…“ ”À√—∫º≈¢â“ß‡§’¬ß/Õ“°“√·∑√°´âÕπ„πºŸâªÉ«¬∑ÿ°√“¬Õ¬à“ß™—¥‡®π

7.1 º≈¢â“ß‡§’¬ß/Õ“°“√·∑√° âÕπ®“°°“√„Àâ¬“·°âª«¥·∫∫ systemic º≈¢â“ß‡§’¬ß®“°¬“ opioids

¥â«¬«‘∏’°“√„Àâ¬“μà“ß Ê ‡™àπ systemic À√◊Õ neuraxial (μ“√“ß∑’Ë 3) ‰¡à·μ°μà“ß°—π º≈¢â“ß‡§’¬ß¢Õß¬“„π°≈ÿà¡

NSAIDs „Àâ¥Ÿ„πμ“√“ß¬“ (μ“√“ß∑’Ë 17)

μ“√“ß∑’Ë 3: º≈¢â“ß‡§’¬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¡’

Õ“°“√§≈◊Ëπ‰ â Õ“‡®’¬π ¡’ ‰¡à§àÕ¬æ∫

Õ“°“√§—π ¡’ ‰¡à¡’

Motor weakness ‰¡à¡’ ¡’

Sensory loss ‰¡à¡’ ¡’

Urinary retention ¡’ ¡’

√–∫∫∑“ß‡¥‘πÕ“À“√ ≈¥°“√‡§≈◊ËÕπ‰À« ‡æ‘Ë¡°“√‡§≈◊ËÕπ‰À«

7.2 º≈¢â“ß‡§’¬ß/Õ“°“√·∑√° âÕπ®“°°“√„Àâ¬“·∫∫ regional

7.2.1 · ¥ßº≈¢â“ß‡§’¬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™“ ∑”„Àâ‡°‘¥°“√∫“¥‡®Á∫μàÕ‡ âπª√– “∑Õ◊Ëπ ¢âÕ·π–π”§◊Õ„π°≈ÿà¡∑’Ë ß —¬«à“¡’ªí≠À“‡√◊ËÕß

°“√∫“¥‡®Á∫μàÕ‡ âπª√– “∑¡“°àÕπ ‡™àπ ¡’Õ“°“√ paresthesia, dysesthesia ‰¡à§«√∑” continuous peripheral

nerve block À√◊Õ∑”‰¥â·μàμâÕß‡ΩÑ“√–«—ß‡ªìπæ‘‡»… ¡’°“√»÷°…“√“¬ß“π«à“ ¬“™“Õ“®√∫°«π°“√‡μ‘∫‚μ·≈–

regeneration ¢Õß‡´≈≈åª√– “∑ ¥—ßπ—Èπ§«√æ‘®“√≥“¢âÕ¥’ ·≈–¢âÕ‡ ’¬¢Õß°“√©’¥¬“™“∑’Ë‡ âπª√– “∑„πºŸâªÉ«¬

°≈ÿà¡∑’Ë¡’°“√∫“¥‡®Á∫μàÕ‡ âπª√– “∑¡“°àÕπ

7.2.2.2 °“√μ‘¥‡™◊ÈÕ æ∫ªí®®—¬‡ ’Ë¬ß∑’Ë∑”„Àâ‡°‘¥°“√μ‘¥‡™◊ÈÕ¢Õß CPNB ‰¥â·°à ºŸâªÉ«¬Õ¬Ÿà„πÀÕ

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¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

°“√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≈’°‡≈’Ë¬ß°“√‡μ‘¡¬“À≈“¬§√—Èß ·≈–∑” catheter

tunneling ´÷Ëß¡’®ÿ¥ª√– ß§å‡æ◊ËÕ≈¥ catheter movement ·≈–≈¥°“√°√–®“¬¢Õß‡™◊ÈÕ‚√§

7.2.2.3 ¬“™“‡ªìπæ‘… (local anesthetic systemic toxicity, LAST) „π√–À«à“ß∑’Ë‰¥â continuous infusion

¢Õß¬“™“ Õ“®‡°‘¥Õ“°“√¢Õß¬“™“‡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¡„Àâ¬“™“ ®÷ß§«√¡’°“√‡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«¬«ÿàπ«“¬ —∫ 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 “¡“√∂∑”°“¬¿“æ‰¥â §«√√–«—ß°“√À°≈â¡

„πºŸâªÉ«¬∑’Ë‰¥â√—∫¬“™“μ≈Õ¥‡«≈“„π à«π¢“ °“√·°â ‰¢§◊Õ≈¥§«“¡‡¢â¡¢âπ¢Õß¬“™“ ∂â“¬—ß‰¡à¥’¢÷Èπ„Àâ≈¥ª√‘¡“≥

¢Õß¬“™“

°≈àÕß∑’Ë 8 √—°…“º≈¢â“ß‡§’¬ß/Õ“°“√·∑√° âÕπ®“°°“√√–ß—∫ª«¥ (μ“√“ß∑’Ë 4)

§”·π–π”: 1) „Àâ¬“√—°…“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


√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààßª√–‡∑»‰∑¬

√ÿª§«“¡ª«¥À≈—ßºà“μ—¥‡ªìπÕ“°“√∑’ËºŸâªÉ«¬‰¡à “¡“√∂À≈’°‡≈’Ë¬ß‰¥â ·μà “¡“√∂√–ß—∫‰¥âÕ¬à“ß¡’ª√– ‘∑∏‘¿“æ

‚¥¬«“ß·ºπªÑÕß°—π·≈–§«∫§ÿ¡Õ“°“√ª«¥μ—Èß·μà°àÕπ √–À«à“ß ·≈–À≈—ßºà“μ—¥ §«√„Àâ§«“¡√Ÿâ·°àºŸâªÉ«¬ „Àâ

ºŸâªÉ«¬‰¥â√—∫¬“μ—Èß·μà‡√‘Ë¡¡’Õ“°“√ª«¥ „Àâ§«“¡ π„®√à«¡°—∫°“√¥Ÿ·≈∑’Ë∂Ÿ°μâÕß‡À¡“– ¡ ·≈–¡’°“√ª√–‡¡‘π§«“¡

ª«¥Õ¬à“ß ¡Ë”‡ ¡Õ∑—Èß°àÕπ·≈–À≈—ß°“√√—°…“


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

¿“§ºπ«° 1: Incidence / Pathophysiology of

acute postoperative pain

Õÿ∫—μ‘°“√≥å¢Õß°“√√–ß—∫ª«¥‡©’¬∫æ≈—πÀ≈—ßºà“μ—¥ªí®®ÿ∫—π§«“¡ª«¥‰¥â√—∫°“√¬Õ¡√—∫«à“¡’§«“¡ ”§—≠ Õß§å°“√Õπ“¡—¬‚≈°‰¥â∂◊Õ§«“¡ª«¥‡ªìπ —≠≠“≥™’æ

∑’Ë 5 (5th Vital sign) ·μà¬—ßæ∫«à“Àπ÷Ëß„π “¡¢ÕßºŸâªÉ«¬À≈—ßºà“μ—¥μâÕß∑ÿ°¢å∑√¡“π®“°§«“¡ª«¥ „π√–¥—∫

ª“π°≈“ß∂÷ßª«¥¡“°„π 24 ™¡. À≈—ßºà“μ—¥ ¡’°“√»÷°…“æ∫«à“√âÕ¬≈– 59 ¢ÕßºŸâªÉ«¬∑’Ë√—∫°“√ºà“μ—¥¡’§«“¡

π„®À√◊Õ°—ß«≈‡°’Ë¬«°—∫Õ“°“√ª«¥À≈—ßºà“μ—¥2 °“√»÷°…“„πªï æ.». 2545 æ∫«à“√âÕ¬≈– 76 ¢ÕßºŸâªÉ«¬‰¡à∑√“∫

«à“À≈—ßºà“μ—¥®–¡’Õ“°“√ª«¥·º≈¡“°πâÕ¬‡æ’¬ß‰√·≈–π“π‡∑à“„¥ ·≈–¡’‡æ’¬ß√âÕ¬≈– 30 ∑’Ë∑√“∫«à“¡’∑“ß‡≈◊Õ°

„π°“√√–ß—∫§«“¡ª«¥À≈—ßºà“μ—¥3 °“√√–ß—∫§«“¡ª«¥∂◊Õ‡ªìπ‡√◊ËÕß¢Õß¡πÿ…¬∏√√¡ ·≈–¡’º≈¥’„π∑“ß§≈‘π‘°

ª√– ‘∑∏‘¿“æ¢Õß°“√√–ß—∫§«“¡ª«¥¢÷ÈπÕ¬Ÿà°—∫∑’¡ß“π π‚¬∫“¬ °“√„Àâ§«“¡√Ÿâ∫ÿ§≈“°√ ºŸâªÉ«¬·≈–≠“μ‘ °“√

ª√–‡¡‘π·≈–°“√√–ß—∫§«“¡ª«¥¥â«¬‡∑§π‘§·≈–¬“∑’Ë∂Ÿ°μâÕß ‚¥¬¡’‡ªÑ“À¡“¬„ÀâºŸâªÉ«¬ ÿ¢ ∫“¬ ‰¡à¡’¿“«–

·∑√° âÕπ·≈–√à“ß°“¬øóôπμ—«‰¥â‡√Á«

æ¬“∏‘°”‡π‘¥¢Õß§«“¡ª«¥À≈—ßºà“μ—¥ [Pathophysiology of Postoperative Pain]‡¡◊ËÕ‡π◊ÈÕ‡¬◊ËÕ∂Ÿ°∑”≈“¬®“°°“√ºà“μ—¥ ∑”„Àâ‡°‘¥§«“¡ª«¥·∫∫‡©’¬∫æ≈—π æ∫«à“§«“¡√ÿπ·√ß¢Õß§«“¡

ª«¥®– —¡æ—π∏å°—∫§«“¡√ÿπ·√ß¢Õß°“√∑”≈“¬‡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«¥¬—ß‡ªìπ¡“°Õ¬ŸàÀ√◊Õ¡’§«“¡ª«¥‡°‘¥¢÷Èπ„À¡à μâÕßÀ“ “‡Àμÿ ‡™àπ °“√

Õ—°‡ ∫∑’Ë·º≈ À√◊Õ¡’¿“«–·∑√° âÕπ„π™àÕß∑âÕß ‡ªìπμâπ

°“√√–ß—∫§«“¡ª«¥À≈—ßºà“μ—¥§◊Õ°“√ °—¥°—ÈπÀ√◊Õ¬—∫¬—Èß°“√ àß —≠≠“≥§«“¡ª«¥ ¥â«¬°≈‰°μà“ßÊ ¥—ßπ—Èπ

°“√‡¢â“„®∂÷ß°≈‰°°“√ àß —≠≠“≥§«“¡ª«¥®–∑”„Àâ‡¢â“„®∂÷ß°≈‰°°“√ÕÕ°ƒ∑∏‘Ï¢Õß¬“·°âª«¥‰¥â¥’¢÷Èπ

º≈‡ ’¬∑’Ë‡°‘¥®“°§«“¡ª«¥‡¡◊ËÕ‡π◊ÈÕ‡¬◊ËÕ‰¥â√—∫Õ—πμ√“¬®“°°“√ºà“μ—¥∑”„Àâ‡°‘¥§«“¡ª«¥¢÷Èπ √–∫∫μà“ßÊ „π√à“ß°“¬®–¡’ªØ‘°‘√‘¬“

μÕ∫ πÕßμàÕ§«“¡ª«¥À≈“¬√–∫∫ ‡™àπ √–∫∫À“¬„® √–∫∫À—«„®·≈–À≈Õ¥‡≈◊Õ¥ √–∫∫μàÕ¡‰√â∑àÕ ·≈–√–∫∫

∑“ß‡¥‘πÕ“À“√ ‡ªìπμâπ (μ“√“ß∑’Ë 5)


√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààßª√–‡∑»‰∑¬

μ“√“ß∑’Ë 5: °“√‡ª≈’Ë¬π·ª≈ß∑“ß √’√«‘∑¬“∑’Ë‡°‘¥®“°§«“¡ª«¥

Õ«—¬«–

√–∫∫∑“ß‡¥‘πÀ“¬„®:°≈â“¡‡π◊ÈÕμ÷ßμ—« ≈¥°“√¢¬“¬¢ÕßªÕ¥ (compliance)

√–∫∫À—«„®-À≈Õ¥‡≈◊Õ¥:À—«„®∑”ß“π¡“°¢÷Èπ ®“°°“√°√–μÿâπ°“√À≈—Ëßcatecholamine ·≈– angiotensin II

√–∫∫μàÕ¡‰√â∑àÕ:‡æ‘Ë¡°“√À≈—ËßŒÕ√å‚¡πë Adrenocorticotropinë Cortisolë Glucagonë Epinephrineë Aldosteroneë Antidiureticë Catecholamine

ë Angiotension II

≈¥°“√À≈—Ëß ŒÕ√å‚¡πë Insulinë Testosterone

√–∫∫¬àÕ¬Õ“À“√

√–∫∫∑“ß‡¥‘πªí “«–‡æ‘Ë¡ sphincter tone, ≈¥ smooth muscle tone

√–∫∫°“√·¢Áßμ—«¢Õß‡≈◊Õ¥‡°≈Á¥‡≈◊Õ¥∑”ß“π¡“°¢÷Èπ °√–μÿâπ¢∫«π°“√·¢Áßμ—«¢Õß‡≈◊Õ¥≈¥¢∫«π°“√≈–≈“¬≈‘Ë¡‡≈◊Õ¥ (fibrinolysis)

√–∫∫¿Ÿ¡‘§ÿâ¡°—π‡¡Á¥‡≈◊Õ¥¢“«‡æ‘Ë¡¢÷Èπ ·μà lymphocyte ≈¥≈ß≈¥¢∫«π°“√ √â“ß‡¡Á¥‡≈◊Õ¥ killer T-cell, cytotoxicity ≈¥≈ß

¥â“π®‘μ„®

Õ“°“√∑“ß§≈‘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 ≈”‰ â‡§≈◊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 ∫“¬„®


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

¿“§ºπ«° 2: Pain Pathways

1. °“√·ª≈ß —≠≠“≥§«“¡ª«¥(transduction) ·≈–°“√ àß —≠≠“≥§«“¡ª«¥ (transmission)

§◊Õ ‡¡◊ËÕ¡’°“√∑”≈“¬‡π◊ÈÕ‡¬◊ËÕÀ√◊Õ°“√ºà“μ—¥ ®–°√–μÿâπ

nociceptor ´÷Ëß‡ªìπª≈“¬ª√– “∑¢Õß‡´≈≈åª√– “∑√—∫ —≠≠“≥

§«“¡ª«¥μ—«·√° (primary afferent neuron) —≠≠“≥§«“¡ª«¥

®–∂Ÿ° àß‰ªμ“¡ 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 ¢Õßª√– “∑‰¢ —πÀ≈—ß ‡æ◊ËÕ àß¢÷Èπ‰ª Ÿà√–∫∫

ª√– “∑ à«π∫π ‡™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 ¢Õß‰¢ —πÀ≈—ß

2. °“√ª√—∫‡ª≈’Ë¬π —≠≠“≥§«“¡ª«¥ (modulation) ∑’Ë

dorsal horn ¢Õß‰¢ —πÀ≈—ßª√–°Õ∫¥â«¬2.1 °“√§«∫§ÿ¡‚¥¬‡´≈≈åª√– “∑¿“¬„π dorsal horn

¢Õß‰¢ —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

´÷Ëß¬—∫¬—Èß°“√∑”ß“π¢Õß‡´≈≈åª√– “∑¿“¬„π dorsal

horn ºà“π∑“ß neurotransmitters ™π‘¥μà“ßÊ ‰¥â·°à

serotonin, dopamine, norepinephrine ·≈– opioids

3. °“√√—∫√Ÿâ§«“¡ª«¥ (perception) ‡ªìπ°√–∫«π°“√ ÿ¥∑â“¬∑’Ë‡°‘¥¢÷Èπ„π ¡Õß ∑”„Àâ√—∫√Ÿâ∂÷ß§«“¡ª«¥·≈–√Ÿâ ÷°‰¡àæ÷ßæÕ„®

°“√π” —≠≠“≥§«“¡ª«¥

√Ÿª∑’Ë 2: °“√π” —≠≠“≥§«“¡ª«¥

Cerebral cortex

Thalamus

Spinal tracts

Dorsal horn

Peripheral nerve

Pain source


√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààßª√–‡∑»‰∑¬

¿“§ºπ«° 3: Pain Assessment

‡§√◊ËÕß¡◊Õ ”À√—∫ª√–‡¡‘π√–¥—∫§«“¡ª«¥ (√Ÿª∑’Ë 3)Numerical Rating Scale (NRS) ‡ªìπ‡§√◊ËÕß¡◊Õ∑’Ëπ‘¬¡„™â„π∑“ß§≈‘π‘°‡æ√“– –¥«° „ÀâºŸâªÉ«¬∫Õ°

§–·ππ§«“¡ª«¥‡ªìπμ—«‡≈¢ ‚¥¬ 0 §–·ππÀ¡“¬∂÷ß‰¡àª«¥ 1-9 §–·ππÀ¡“¬∂÷ßª«¥¡“°¢÷Èπμ“¡≈”¥—∫ ·≈–

10 §–·ππÀ¡“¬∂÷ßª«¥¡“°∑’Ë ÿ¥‡∑à“∑’Ë®–§‘¥‰¥â

Verbal Rating Scale (VRS) „™â ”À√—∫ºŸâªÉ«¬∑’Ë‰¡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¡“¬∂÷ß‰¡àª«¥ ∂÷ß 10 ´¡. À¡“¬∂÷ßª«¥¡“°∑’Ë ÿ¥‡∑à“∑’Ë®–§‘¥‰¥â ‚¥¬„ÀâºŸâªÉ«¬°“°∫“∑ (X) ∫π‡ âπμ√ß μ“¡

√–¥—∫§«“¡ª«¥®√‘ß¢ÕßºŸâªÉ«¬ ∑—Èßπ’È ‡ âπμ√ßμâÕß‰¡à¡’μ—«Àπ—ß ◊ÕÀ√◊Õμ—«‡≈¢„¥Ê °”°—∫ ¬°‡«âπ∑’Ëª≈“¬∑—Èß Õß

¢â“ß‡∑à“π—Èπ

Face pain scale „™â√Ÿª· ¥ß§«“¡√Ÿâ ÷°∑“ß„∫Àπâ“ ‡À¡“– ”À√—∫‡¥Á°Õ“¬ÿ 5-8 ªï À√◊ÕºŸâªÉ«¬∑’Ë‰¡à

“¡“√∂∫Õ°§«“¡ª«¥‡ªìπμ—«‡≈¢ ·μà “¡“√∂™’È∑’Ë„∫Àπâ“‡æ◊ËÕ∫Õ°√–¥—∫§«“¡ª«¥¢Õßμπ‡Õß‰¥â

§”·π–π”:

ë „Àâ„™â§Ì“«à“ ç‡®Á∫é À√◊Õéª«¥é μ“¡§«“¡‡À¡“– ¡·°àºŸâªÉ«¬‡¥Á°·μà≈–§π

ë °“√„Àâ§–·ππ‰¡à„™à¥Ÿ≈—°…≥– ’Àπâ“¢Õß‡¥Á°‡∑’¬∫°—∫„∫Àπâ“„π√Ÿª ·μà„ÀâºŸâªÉ«¬™’È√ŸªÀπâ“∑’Ë· ¥ß√–¥—∫

§«“¡ª«¥¢Õßμπ‡Õß „Àâ§–·ππμ“¡√ŸªÀπâ“∑’Ë‡≈◊Õ° 0, 2, 4, 6, 8, 10 μ“¡≈Ì“¥—∫

ë μ—«Õ¬à“ß°“√ Õπ ‡™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„Àâ¬“

The FLACC Behavioral Pain Scale (μ“√“ß∑’Ë 7) “¡“√∂„™â∫Õ°√–¥—∫§«“¡ª«¥¢ÕßºŸâªÉ«¬∑’Ë‰¡à

“¡“√∂∫Õ°‡ªìπ§–·ππª«¥¥â«¬μπ‡Õß‰¥â ª√–°Õ∫¥â«¬ 5 à«π ‰¥â·°à °“√ª√–‡¡‘π°“√· ¥ßÕÕ°∑“ß„∫Àπâ“

°“√¢¬—∫¢Õß¢“ °“√‡§≈◊ËÕπ‰À« °“√√âÕß‰Àâ ·≈–°“√μÕ∫ πÕßμàÕ°“√ª≈Õ∫‚¬π ÷Ëß·μà≈– à«π ¡’§–·ππ 0-2

√«¡∑—ÈßÀ¡¥ 10 §–·ππ


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

μ“√“ß∑’Ë 7: The FLACC Behavioral Pain Scale

Categories Definition Scoring

’Àπâ“ (Face) ‡©¬ ‰¡à¬‘È¡ 0Àπâ“μ“‡∫– À√◊Õ¢¡«¥§‘È« ∂Õ¬Àπ’ ‰¡à π„® ‘Ëß·«¥≈âÕ¡‡ªìπ∫“ß§√—Èß 1§“ß —Ëπ °—¥øíπ·πàπ ‡ªìπ∫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

√âÕß‰Àâ (Cry) ‰¡à√âÕß (μ◊ËπÀ√◊ÕÀ≈—∫°Á‰¥â) 0§√“ßŒ◊ÕÊ À√◊Õ§√“ß‡∫“Ê ∫àπ‡ªìπ∫“ß§√—Èß 1√âÕß‰Àâμ≈Õ¥ À«’¥√âÕß –Õ÷° –Õ◊Èπ ∫àπ∫àÕ¬Ê 2

°“√μÕ∫ πÕßμàÕ ‡™◊ËÕøíß¥’ ∫“¬Ê 0°“√ª≈Õ∫‚¬π “¡“√∂ª≈Õ∫‚¬π¥â«¬°“√ —¡º— ‚Õ∫°Õ¥ æŸ¥§ÿ¬¥â«¬ 1(Consolability) ‡æ◊ËÕ¥÷ß¥Ÿ¥§«“¡ 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

√âÕß‰Àâ - ‰¡à√âÕß - √âÕß§√“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“¬ «ÿàπ«“¬

The CHEOPS Behavioral Pain Scale (μ“√“ß∑’Ë 8) ‡À¡“– ”À√—∫‡¥Á°Õ“¬ÿ 1-6 ªï∑’Ë‰¡à “¡“√∂

∫Õ°√–¥—∫§«“¡ª«¥¥â«¬μπ‡Õß‰¥â ‡§√◊ËÕß¡◊Õ¡’§–·ππ√«¡μ—Èß·μà 4-13


√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààßª√–‡∑»‰∑¬

μ“√“ß∑’Ë 8: The CHEOPS Behavioral Pain Scale

æƒμ‘°√√¡™’È«—¥ 0 1 2 3

√âÕß‰Àâ - - ‰¡à√âÕß - §√“ß, √âÕß‰Àâ - À«’¥√âÕß

°“√‡ª≈àß‡ ’¬ß - æŸ¥ πÿ°√à“‡√‘ß - ∫àπÕ◊ËπÊ ‡™àπ À‘« - ∫àπª«¥ + ∫àπÕ◊ËπÊ æŸ¥∑“ß∫«° À“·¡à À√◊Õ‰¡àæŸ¥

’Àπâ“ - ¬‘È¡ - ‡©¬ - ‡∫â -

∑à“∑“ß¢Õß≈”μ—« - - ∏√√¡¥“ ∫“¬Ê - ¥‘Èπ‰ª¡“/‡°√Áß/μ—«ßÕ·¢Áß/ - —Ëπ/¬◊π/¥‘Èπ®π∂Ÿ°®—∫μ√÷ß‰«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–/¥÷ß¢“Àπ’/ - ‡°√Áß/¬◊π/¥‘Èπ®π∂Ÿ°®—∫À√◊Õ μ√÷ß‰«â/‡°√Áß‰¡à‡§≈◊ËÕπ‰À«

μ“√“ß∑’Ë 9: °“√ª√–‡¡‘π§«“¡ª«¥®“°°“√ —ß‡°μæƒμ‘°√√¡¢ÕßºŸâªÉ«¬ (Behavioral Pain Assessment Scale) ”À√—∫ºŸâªÉ«¬∑’Ë‰¡à “¡“√∂∫Õ°√–¥—∫§«“¡ª«¥‰¥â¥â«¬μπ‡Õß „™â°“√ —ß‡°μ∑“ß§≈‘π‘° „Àâ‡ªìπ§–·ππ 0-10

Categories 0 1 2

’Àπâ“ ’Àπâ“ºàÕπ§≈“¬ Àπâ“π‘Ë«§‘È«¢¡«¥ Àπâ“π‘Ë«§‘È«¢¡«¥μ≈Õ¥‡«≈“(Face) Àπâ“¬Ÿà¬’Ë °—¥øíπ·πàπ

§«“¡°√–«π°√–«“¬ ‡ß’¬∫ ºàÕπ§≈“¬ °√–«π°√–«“¬ °√–«π°√–«“¬μ≈Õ¥‡«≈“(Restlessness) ‡§≈◊ËÕπ‰À«ª°μ‘ °√– —∫°√– à“¬‡ªìπ∫“ß§√—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§≈“¬

°“√ àß‡ ’¬ß** ‰¡à àß‡ ’¬ßº‘¥ª°μ‘ √âÕß§√«≠§√“ß‡ªìπ∫“ß§√—Èß √âÕß§√«≠§√“ß μ≈Õ¥‡«≈“(Vocalization)

°“√ª≈Õ∫‚¬π ∫“¬„® ºàÕπ§≈“¬‚¥¬°“√ —¡º— ‰¡à “¡“√∂ºàÕπ§≈“¬‡≈¬(Consolability) ºàÕπ§≈“¬ ·≈–æŸ¥§ÿ¬¥÷ß§«“¡ π„®‰ª ‚¥¬°“√ —¡º— ·≈–æŸ¥§ÿ¬

®“°§«“¡ª«¥‰¥â

* °“√ª√–‡¡‘π§«“¡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∑’Ë‰¡à‡ªìπ‚√§

** ‰¡à “¡“√∂ª√–‡¡‘π°“√ àß‡ ’¬ß„πºŸâªÉ«¬∑’Ë¡’°“√™à«¬À“¬„®


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

Behavioral Pain Assessment Scale (μ“√“ß∑’Ë 9) ‡ªìπ‡§√◊ËÕß¡◊Õª√–‡¡‘π§«“¡ª«¥ ”À√—∫ºŸâªÉ«¬

∑’Ë‰¡à “¡“√∂ ◊ËÕ “√¥â«¬μ—«‡Õß‰¥â „πÀÕºŸâªÉ«¬«‘°ƒμ À√◊ÕºŸâªÉ«¬∑’Ë√–¥—∫§«“¡√Ÿâ ÷°μ—«πâÕ¬≈ß ‚¥¬„™â°“√ª√–‡¡‘π

®“°°“√ —ß‡°μæƒμ‘°√√¡·≈–°“√‡ª≈’Ë¬π·ª≈ß¢Õß —≠≠“≥™’æ‡ªìπ√“¬Ê ‰ª

—ß‡°μæƒμ‘°√√¡¢ÕßºŸâªÉ«¬·≈â«„Àâ§–·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“ “¡“√∂„ÀâºŸâªÉ«¬ª√–‡¡‘π§«“¡ª«¥¥â«¬μπ‡Õß‰¥â®–¥’∑’Ë ÿ¥ °“√ª√–‡¡‘ππ’È„™â°—∫°√≥’∑’ËºŸâªÉ«¬ª√–‡¡‘π

§«“¡ª«¥¥â«¬μπ‡Õß‰¡à‰¥â ‚¥¬¥—¥·ª≈ß®“° FLACC scale “¡“√∂„™â∑—Èß„π‡¥Á°·≈–ºŸâ„À≠à ºŸâ„°≈â™‘¥∑’Ë

§ÿâπ‡§¬°—∫ºŸâªÉ«¬Õ“®™à«¬„π°“√ª√–‡¡‘π‰¥â¥’ °√≥’∑’Ë ß —¬«à“ª«¥®√‘ßÀ√◊Õ‰¡à °“√„Àâ¬“·°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“√¬“


√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààßª√–‡∑»‰∑¬

μ—«Õ¬à“ß¢Õß°“√‡≈◊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 ®÷ß‡ª≈’Ë¬π‡ªìπ p.r.n.

ë Õ“®æ‘®“√≥“„Àâ NSAIDs À√◊Õ coxib 1 ™π‘¥ (∂â“‰¡à¡’¢âÕÀâ“¡) ·∫∫ around the clock √à«¡¥â«¬

1-3 «—π

ë ∂â“ºŸâªÉ«¬„™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 ®÷ß‡ª≈’Ë¬π‡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‘¥ (∂â“‰¡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 ®÷ß‡ª≈’Ë¬π‡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‘¥ (∂â“‰¡à¡’¢âÕÀâ“¡) √à«¡¥â«¬ 3-5 «—π

∑—Èßπ’È ‡¡◊ËÕ„¥∑’Ë‡√‘Ë¡√—∫ª√–∑“π‰¥â „Àâæ‘®“√≥“‡√‘Ë¡¬“™π‘¥√—∫ª√–∑“π„Àâ‡√Á«∑’Ë ÿ¥ ‡æ◊ËÕ§àÕ¬Ê ≈¥À√◊Õ

‡≈‘°¬“∑’Ë„Àâ∑“ß parenteral


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

¿“§ºπ«° 5: Patient-Controlled Analgesia

°“√μ—Èß§à“ PCA (μ“√“ß∑’Ë 2) ‰¥â·°à °“√μ—Èß§à“™π‘¥¢Õß¬“·°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«¬∑’Ë‰«μàÕ histamine ‡™àπ ºŸâªÉ«¬ÀÕ∫À◊¥ À√◊ÕºŸâªÉ«¬∑’Ë¡’º≈¢â“ß‡§’¬ß®“° morphine ¡“° ·¡â

fentanyl ¡’ƒ∑∏‘Ï√–ß—∫ª«¥ —Èπ·μà®“°º≈°“√»÷°…“æ∫«à“¡’ª√– ‘∑∏‘¿“æ„π°“√√–ß—∫ª«¥À≈—ßºà“μ—¥‰¡àμà“ß®“°

morphine

Pethidine π—Èπ ≈“¬‰¥â norpethidine ÷Ëß‰¡à¡’ƒ∑∏‘Ï·°âª«¥ ·μà‡¡◊ËÕ – ¡¡“°®–∑”„Àâ‡°‘¥Õ“°“√°√–«π

°√–«“¬®π∂÷ß™—°‰¥â ®÷ß‰¡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∑’Ë‰¥â√—∫¬“ monoamine

oxidase inhibitors ‡π◊ËÕß®“°Õ“®∑”„Àâ‡°‘¥ 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 ÷Ëß‡™◊ËÕ«à“‡ªìπ “√∑’Ë¡’ƒ∑∏‘Ï

√–ß—∫ª«¥¥’°«à“ ¢≥–‡¥’¬«°—π tramadol ¬—ß¡’ƒ∑∏‘Ï√–ß—∫°“√ reuptake ¢Õß norepinephine ·≈– serotonin

∑’Ë√–∫∫ª√– “∑ à«π°≈“ß ÷Ëß‡ªìπ°“√ÕÕ°ƒ∑∏‘Ï√–ß—∫ª«¥Õ’°∑“ßÀπ÷Ëß¥â«¬ tramadol ¡’ƒ∑∏‘Ïª√–¡“≥ 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≈—ßºà“μ—¥ ‡π◊ËÕß®“°º≈°“√»÷°…“ à«π„À≠àæ∫«à“ °“√„Àâ background infusion ‰¡à‰¥â

√–ß—∫ª«¥À√◊Õ∑”„ÀâºŸâªÉ«¬À≈—∫‰¥â¥’¢÷Èπ ‚¥¬ºŸâªÉ«¬¬—ßμâÕß°“√¬“„πª√‘¡“≥∑’Ë‰¡àμà“ß®“°∑’Ë‰¡à‰¥â„Àâ background

infusion ·μà‡æ‘Ë¡Õ“°“√¢â“ß‡§’¬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«¬


√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààßª√–‡∑»‰∑¬

·μà„πºŸâªÉ«¬∑’ËμâÕß„™â¬“„πª√‘¡“≥¡“° ‡™àπ ºŸâªÉ«¬∑’Ë‰¥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—Èß§à“π’È¡“°°«à“√âÕ¬≈– 50 ¢Õßª√‘¡“≥ opioid ∑’Ë„™â∑—ÈßÀ¡¥ (·ºπ¿Ÿ¡‘∑’Ë 2)

PCA dose (Bolus dose)À¡“¬∂÷ß¢π“¥¬“∑’Ëª≈àÕ¬ÕÕ°¡“·μà≈–§√—Èß‡¡◊ËÕºŸâªÉ«¬°¥ªÿÉ¡ª≈àÕ¬¬“ ¢π“¥¢Õß PCA dose ∑’Ë¥’ μâÕß¡’

¢π“¥¬“πâÕ¬∑’Ë ÿ¥∑’Ë∑”„ÀâºŸâªÉ«¬À“¬ª«¥‰¥â ‡æ◊ËÕ„Àâ¡’Õ“°“√¢â“ß‡§’¬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‡«≈“∑’Ë‡§√◊ËÕß®–‰¡àª≈àÕ¬¬“·¡â¡’°“√°¥´È” ºŸâªÉ«¬®–‰¥â√—∫Õ’°§√—Èß‡¡◊ËÕºà“π√–¬–‡«≈“∑’Ë°”Àπ¥π’È

∑”„ÀâºŸâªÉ«¬ª≈Õ¥¿—¬®“°°“√‰¥â√—∫¬“∑’Ë¡“°‡°‘π®π‡ªìπÕ—πμ√“¬

Dose limitsÀ¡“¬∂÷ßª√‘¡“≥¬“ Ÿß ÿ¥„π√–¬–‡«≈“ 1 ™¡. À√◊Õ 4 ™¡. ∑’Ë°”Àπ¥„Àâ¡’°“√‡μ◊Õπ·æ∑¬å‡æ◊ËÕª√–‡¡‘π

ºŸâªÉ«¬´È”Õ’°§√—Èß ‚¥¬ª°μ‘®–μ—Èßª√–¡“≥ 10 ¡°. „π‡«≈“ 1 ™¡. À√◊Õ 30 ¡°. „π‡«≈“ 4 ™¡. °“√„Àâ§«“¡√Ÿâ

‡°’Ë¬«°—∫«‘∏’„™â∑’Ë∂Ÿ°μâÕß„Àâ°—∫ºŸâªÉ«¬ ·≈–°“√‡ΩÑ“μ‘¥μ“¡¥Ÿ·≈¢Õß‡®â“Àπâ“∑’Ë‡ªìπ°“√ªÑÕß°—π¿“«–·∑√°´âÕπ‰¥â

¥’°«à“°“√μ—Èß§à“π’È


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

¿“§ºπ«° 6: Continuous Peripheral Nerve Blockade

¢âÕ§«√ªØ‘∫—μ‘ ”À√—∫ peripheral nerve block catheter1. §«√„ à “¬§“ ∑’Ë‡ 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∫ πÕß¢ÕßÕ—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¢≥–∑’Ë‡Õ“ “¬ÕÕ° ∂â“ºŸâªÉ«¬¡’Õ“°“√ª«¥μ“¡‡ âπª√– “∑ ·≈–§«√‡ΩÑ“μ‘¥μ“¡Õ’° 24 ™¡.

‡æ◊ËÕ¥ŸÕ“°“√¢Õß nerve injury

5. ¢≥–∑’Ë„Àâ¬“™“‡æ◊ËÕ√–ß—∫ª«¥∑“ß catheter ·¢πÀ√◊Õ¢“π—Èπ®–™“ ¥—ßπ—Èπ§«√‡ΩÑ“√–«—ß°“√∫“¥‡®Á∫μàÕ

‡ âπª√– “∑Õ◊Ëπ®“°∑à“∑“ß¢ÕßºŸâªÉ«¬ ‡™àπ ulnar nerve ∑’Ë√–¥—∫¢âÕ»Õ°, radial nerve ∑’Ë√–¥—∫ midhumerus

·≈– common peroneal nerve ∑’Ë fibular head §«√¡’À¡ÕπÀ√◊Õºâ“πÿà¡ªÑÕß°—π°“√°¥‡∫’¬¥À√◊Õ∂â“‡ªìπ·¢π

§«√„ à arm sling √–«—ß„π°√≥’∑’ËºŸâªÉ«¬‰¡à “¡“√∂∫Õ°§«“¡‡®Á∫ª«¥∑’Ë‡°‘¥®“° 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“®∑”„Àâ™‘Èπ à«π¢Õß≈«¥§â“ßÕ¬Ÿà¿“¬„π√à“ß°“¬‰¥â·≈–∑”„Àâ‡Õ“ “¬ÕÕ°¬“°¢÷Èπ

7. °“√‡ΩÑ“√–«—ß°“√„ à “¬„π°≈ÿà¡ºŸâªÉ«¬∑’Ë‰¥â√—∫¬“ anticoagulant „Àâ¥Ÿ·≈‡À¡◊Õπ°—∫ neuraxial catheter

8. ª√‘¡“≥¬“™“·≈–§«“¡‡¢â¡¢âπ¢Õß¬“™“∑’Ë„Àâμ≈Õ¥‡«≈“∑“ß “¬¬—ß¡’§«“¡À≈“°À≈“¬ ‰¡à¡’¢âÕ √ÿª∑’Ë

·πàπÕπ à«π„À≠à¡’√“¬ß“π∑’Ë„™â 0.2% ropivacaine ”À√—∫°“√„Àâ¬“™“μ≈Õ¥‡«≈“ ·μà„πª√–‡∑»‰∑¬¡’

‡©æ“–¬“™“ bupivacaine ·≈– levobupivacaine ÷Ëß¡’ƒ∑∏‘Ï√–ß—∫ª«¥∑’Ë‡∑’¬∫‡∑à“°—∫ 0.2% ropivacaine §◊Õ

§«“¡‡¢â¡¢âπ 0.125% levobupivacaine À√◊Õ bupivacaine ¥—ßπ—Èπ ¢âÕ·π–π”¢Õßª√‘¡“≥·≈–§«“¡

‡¢â¡¢âπμàÕ‰ªπ’È‡ªìπ°“√·π–π”‡ªìπ™à«ß§à“§«“¡‡¢â¡¢âπ ÷Ëß§«√ª√—∫‡ª≈’Ë¬πμ“¡§«“¡μâÕß°“√¢ÕßºŸâªÉ«¬·μà≈–§π

(μ“√“ß∑’Ë 11)

9. «‘∏’¢Õß°“√„Àâ¬“™“μ≈Õ¥‡«≈“∑“ß “¬ perineural catheter ‰¥â·°à «‘∏’ continuous infusion ·≈–

«‘∏’ patient-controlled regional analgesia (PCRA) ™π‘¥ background infusion √à«¡°—∫ bolus mode

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¿“§ºπ«° 7: Patient Groups with Special Problems

°≈ÿà¡ºŸâªÉ«¬∑’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„ÀâºŸâ¥Ÿ·≈ºŸâªÉ«¬√—∫∑√“∫∑—Ë«°—π

ë ª√–‡¡‘π§«“¡ª«¥ ·≈–º≈μÕ∫ πÕßμàÕ°“√√—°…“Õ¬à“ß ¡Ë”‡ ¡Õ

ë °“√ª√–‡¡‘π§«“¡ª«¥¡“μ√∞“π §◊Õ °“√ª√–‡¡‘π§«“¡ª«¥‚¥¬μ—«ºŸâªÉ«¬‡Õß ·μà„π°√≥’∑’ËºŸâªÉ«¬‰¡à

“¡“√∂ ◊ËÕ “√‰¥â μâÕß„™â«‘∏’Õ◊ËπÊ ‡æ◊ËÕª√–‡¡‘π§«“¡ª«¥ ‰¥â·°à °“√ª√–‡¡‘π§–·ππª«¥‚¥¬„™â°“√ —ß‡°μ

æƒμ‘°√√¡ À√◊Õ°“√‡ª≈’Ë¬π·ª≈ß∑“ß √’√«‘∑¬“

ë §«√„Àâ°“√√–ß—∫ª«¥Õ¬à“ß‡æ’¬ßæÕ ·≈–·°â ‰¢ “‡ÀμÿÕ◊ËπÊ ∑’Ë∑”„ÀâºŸâªÉ«¬°√–«π°√–«“¬ °àÕπ∑’Ë®–„Àâ

¬“°≈àÕ¡ª√– “∑„πºŸâªÉ«¬°≈ÿà¡π’È

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∑’Ë°¥√–¥—∫§«“¡√Ÿâ ÷°μ—« ∑”„ÀâºŸâªÉ«¬‰¡à “¡“√∂ ◊ËÕ “√‰¥â °“√ª√–‡¡‘π§«“¡ª«¥®÷ßμâÕßÕ“»—¬°“√ —ß‡°μ

æƒμ‘°√√¡ À√◊Õ°“√‡ª≈’Ë¬π·ª≈ß∑“ß √’√«‘∑¬“

°“√√–ß—∫ª«¥‚¥¬‰¡à„™â¬“

§«“¡‰¡à ÿ¢ ∫“¬¢ÕßºŸâªÉ«¬„πÀÕÕ¿‘∫“≈ºŸâªÉ«¬¿“«–«‘°ƒμ‡°‘¥®“°À≈“¬ªí®®—¬ ®÷ßμâÕß„Àâ°“√¥Ÿ·≈√—°…“

·∫∫ holistic

°“√√–ß—∫ª«¥‚¥¬„™â¬“

°“√√–ß—∫ª«¥∑’Ë‡ªìπÀ≈—° ”À√—∫ºŸâªÉ«¬„πÀÕÕ¿‘∫“≈ºŸâªÉ«¬¿“«–«‘°ƒμ ‰¥â·°à °“√„Àâ¬“·°âª«¥°≈ÿà¡ opioid

∑“ßÀ≈Õ¥‡≈◊Õ¥¥” Àâ“¡„Àâ partial agonist ‡π◊ËÕß®“°Õ“®∑”„Àâ‡°‘¥Õ“°“√∂Õπ¬“‰¥â„πºŸâªÉ«¬∑’Ë‰¥â√—∫ opioid

¡“·≈â«√–¬–Àπ÷Ëß §«√√–¡—¥√–«—ß°“√„™â morphine „πºŸâªÉ«¬∑’Ë¡’°“√∑”ß“π¢Õß‰μ∫°æ√àÕß ‰¡àπ‘¬¡„™â pethidine

‡æ√“–Õ“®∑”„Àâ‡°‘¥°“√ – ¡¢Õß norpethidine ‚¥¬‡©æ“–Õ¬à“ß¬‘Ëß„πºŸâªÉ«¬∑’Ë¡’°“√∑”ß“π¢Õß‰μ∫°æ√àÕß

À√◊Õ‰¥â√—∫ pethidine ‡ªìπ√–¬–‡«≈“π“π πÕ°®“°π’È pethidine ¬—ß‡°‘¥ªÆ‘°‘√‘¬“°—∫¬“Õ◊ËπÊ À≈“¬¢π“π ‡™àπ

tramadol, MAOI ·≈– selective serotonin reuptake inhibitor ‡ªìπμâπ

fentanyl ∑”„Àâ‡°‘¥°“√‡ª≈’Ë¬π·ª≈ß¢Õß√–∫∫‰À≈‡«’¬π‡≈◊Õ¥πâÕ¬°«à“ morphine ·¡â«à“ fentanyl

®–À¡¥ƒ∑∏‘Ï‡√Á«®“°¢∫«π°“√ redistribution ·μà°“√„™â¢π“¥ Ÿß‡ªìπ√–¬–‡«≈“π“πÕ“®∑”„Àâ‡°‘¥°“√ – ¡


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

·≈–∑”„Àâ§à“§√÷Ëß™’«‘μ¢Õß°“√¢®—¥¬“¬“«‰¥â ∑—Èß alfentanil ·≈– remifentanil ‡ªìπ¬“∑’Ë¡’§ÿ≥ ¡∫—μ‘∑“ß

pharmacokinetic ∑’Ë¥’ ®÷ß‡À¡“– ”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¢Õß‰μ∫°æ√àÕßÕ“®‡°‘¥°“√ – ¡

¢Õß remifentanil acid ÷Ëß‡ªìπ active metabolite Õ¬à“ßÕàÕπ‰¥â ·μà°Á‰¡à∑”„Àâ‡°‘¥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“ß¬“

ë Õ“¬ÿ¡“° ∑”„Àâ‡°‘¥°“√‡ª≈’Ë¬π·ª≈ß∑“ß √’√«‘∑¬“ ·≈–‡¿ —™«‘∑¬“

ë ¡’°“√‡ª≈’Ë¬π·ª≈ß¢Õß°“√μÕ∫ πÕßμàÕ§«“¡ª«¥

ë ª√–‡¡‘π§«“¡ª«¥‰¥â¬“° ÷ËßÕ“®‡°‘¥®“°§«“¡®”∑’Ë≈¥≈ß

°“√ª√–‡¡‘π§«“¡ª«¥„πºŸâªÉ«¬ ŸßÕ“¬ÿ

“¡“√∂ª√–‡¡‘π‚¥¬„™â visual analog scale (VAS), verbal numerical rating scale (VNRS) ·≈–

verbal descriptor scale (VDS) „πºŸâªÉ«¬∑’Ë‰¡à¡’ªí≠À“‡√◊ËÕß§«“¡®”‰¥â °“√ª√–‡¡‘π¥â«¬«‘∏’‡À≈à“π’È®–„™â‡«≈“

π“π¢÷Èπ„π√“¬∑’Ë¡’§«“¡®”∫°æ√àÕßπâÕ¬∂÷ßª“π°≈“ß ‡π◊ËÕß®“°ºŸâªÉ«¬μâÕß°“√‡«≈“‡æ◊ËÕ∑”§«“¡‡¢â“„®·≈–

μÕ∫ πÕß°“√ª√–‡¡‘π§«“¡ª«¥„πºŸâªÉ«¬∑’Ë¡’§«“¡®”∫°æ√àÕßÕ¬à“ß¡“°‡ªìπ‡√◊ËÕß¬“° Õ“®μâÕß„™â°“√ —ß‡°μ

æƒμ‘°√√¡ ‡™àπ °“√· ¥ßÕÕ°∑“ß ’Àπâ“ °“√√âÕß§√«≠§√“ß ‡ªìπμâπ À√◊Õ„™â‡§√◊ËÕß¡◊Õ„Àâ§–·ππ

¬“∑’Ë„™â‡æ◊ËÕ√–ß—∫ª«¥Nonsteroidal anti-inflammatory drugs ·≈– paracetamol

ºŸâªÉ«¬ ŸßÕ“¬ÿ¡’‚Õ°“ ‡°‘¥º≈¢â“ß‡§’¬ß¢Õß∑“ß‡¥‘πÕ“À“√·≈–‰μ®“° NSAIDs ‘Ëß∑’ËμâÕß√–«—ßÕ¬à“ß

¡“° §◊Õ ºŸâªÉ«¬Õ“®‡°‘¥¿“«–‰μ«“¬®“°°“√„™â NSAIDs ‰¥â ‡æ√“–ºŸâªÉ«¬‡À≈à“π’È¡—°¡’°“√∑”ß“π¢Õß‰μ∫°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∑“ß‡¥‘πÕ“À“√≈¥≈ßÕ¬à“ß™—¥‡®π ·≈–‰¡à¡’º≈μàÕ°“√∑”ß“π

¢Õß‡°≈Á¥‡≈◊Õ¥ ·μà∑”„Àâ‡°‘¥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«¬


√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààßª√–‡∑»‰∑¬

¬“°≈ÿà¡ opioid ·≈– tramadol

ºŸâªÉ«¬ ŸßÕ“¬ÿ¡’§«“¡μâÕß°“√¢π“¥¢Õß¬“°≈ÿà¡ opioid ≈¥≈ß ·μà§«“¡μâÕß°“√¢ÕßºŸâªÉ«¬ ŸßÕ“¬ÿ·μà≈–

§π¡’§«“¡·μ°μà“ß°—π‰¥â¡“° ®÷ßμâÕßª√—∫¢π“¥¬“∑’Ë„™â„Àâ‡À¡“– ¡„π·μà≈–√“¬

ºŸâªÉ«¬ ŸßÕ“¬ÿÕ“®¡’°“√∑”ß“π¢Õß‰μ∫°æ√àÕß ´÷ËßÕ“®∑”„Àâ‡°‘¥°“√ – ¡¢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 ∑”„ÀâºŸâªÉ«¬ ŸßÕ“¬ÿ‰¥â√—∫¬“·°âª«¥‰¡à

‡æ’¬ßæÕ ºŸâªÉ«¬ ŸßÕ“¬ÿ°Á‡À¡◊ÕπºŸâªÉ«¬Õ◊ËπÊ ∑’Ë “¡“√∂À≈’°‡≈’Ë¬ß°“√‡°‘¥°“√°¥°“√À“¬„®‰¥â∂â“‡ΩÑ“√–«—ß√–¥—∫

§«“¡√Ÿâ ÷°μ—« (sedation score) Õ¬à“ß„°≈â™‘¥

Õÿ∫—μ‘°“√≥å¢ÕßÕ“°“√§≈◊Ëπ‰ âÕ“‡®’¬π·≈–§—π≈¥≈ß‡¡◊ËÕÕ“¬ÿ¡“°¢÷Èπ fentanyl Õ“®∑”„Àâ‡°‘¥°“√ Ÿ≠‡ ’¬

§«“¡®”πâÕ¬°«à“ morphine ¬“μâ“π°“√Õ“‡®’¬π∫“ß™π‘¥ ‚¥¬‡©æ“–¬“∑’Ë¡’§ÿ≥ ¡∫—μ‘ anticholinergic ‡™àπ

orphenadrine, amitriptyline ‡ªìπμâπ ∑”„Àâ‡°‘¥º≈¢â“ß‡§’¬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¢Õß‡´≈≈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«¥§≈â“¬§≈÷ß°—∫ºŸâªÉ«¬∑—Ë«‰ª ·μà¡’¢âÕ·μ°μà“ß‡æ‘Ë¡‡μ‘¡∑’Ë ”§—≠§◊Õ °“√√—°…“§«“¡ª«¥π—Èπ§«√®–‰¥âº≈

„π°“√√—°…“ Ÿß ÿ¥ ·≈–¡’º≈°√–∑∫μàÕ°“√°≈—∫∫â“ππâÕ¬∑’Ë ÿ¥

‘Ëß∑’Ë§«√§”π÷ß„π°“√√–ß—∫ª«¥„πºŸâªÉ«¬πÕ° ¡’¥—ßμàÕ‰ªπ’È

1. ‡≈◊Õ°„™â¬“·°âª«¥À√◊Õª√—∫¢π“¥¬“„Àâ¡’º≈¢â“ß‡§’¬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∑’Ë‡√’¬°«à“ multimodal analgesia

4. ‡≈◊Õ°„™â¬“∑’Ë∫√‘À“√ßà“¬ ‰¥â·°à ¬“√—∫ª√–∑“π ‡ªìπμâπ

5. Õ∏‘∫“¬À√◊Õ·π–π”ºŸâªÉ«¬„π°√≥’∑’Ë¡’ªí≠À“¥â“π§«“¡ª«¥‡°‘¥¢÷Èπ∑’Ë∫â“π ‰¥â·°à °“√¥Ÿ·≈®—¥°“√¥â«¬

μπ‡Õß‡∫◊ÈÕßμâπ À√◊Õ°“√μ‘¥μàÕ°—∫·æ∑¬å‡æ◊ËÕ¢Õ§”·π–π”∑“ß‚∑√»—æ∑å

6. °“√ºà“μ—¥·∫∫ºŸâªÉ«¬πÕ° à«π„À≠àºŸâªÉ«¬®–¡’§«“¡ª«¥À≈—ßºà“μ—¥ª“π°≈“ß ´÷Ëß “¡“√∂§«∫§ÿ¡

§«“¡ª«¥‰¥â‚¥¬‰¡àμâÕß„Àâ¬“·°âª«¥∑’Ë¡’§«“¡·√ß¡“°


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

°“√√–ß—∫ª«¥‡©’¬∫æ≈—πÀ≈—ßºà“μ—¥¡’·π«∑“ßμàÕ‰ªπ’È (§«√æ‘®“√≥“Õ“¬ÿ·≈–§–·ππª«¥√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°®“°‚√ßæ¬“∫“≈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“ß‡§’¬ßμ—«Õ¬à“ß ‰¥â·°à

3.1 °“√ °—¥°—Èπ‡ âπª√– “∑√à«¡°—∫°“√„Àâ¬“·°âª«¥

3.2 °“√„Àâ¬“·°âª«¥À≈“¬™π‘¥√à«¡°—π ‰¥â·°à °“√„Àâ paracetamol √à«¡°—∫ tramadol À√◊Õ¬“°≈ÿà¡NSAIDs ‡™àπ celecoxib ‡ªìπμâπ

Õ¬à“ß‰√°Áμ“¡ °“√‡≈◊Õ°„™â¬“·°âª«¥ À√◊Õ«‘∏’°“√μà“ßÊ ¢÷Èπ°—∫·æ∑¬åºŸâª√–°Õ∫«‘™“™’æ‡«™°√√¡ ‚¥¬Õ“»—¬ªí®®—¬μà“ßÊ √«¡∑—ÈßÀ≈—°«‘™“°“√‡æ◊ËÕ‡≈◊Õ°¬“·°âª«¥ ‚¥¬§”π÷ßª√– ‘∑∏‘¿“æ„π°“√√—°…“§«“¡ª«¥ √à«¡

°—∫§«“¡ª≈Õ¥¿—¬¢ÕßºŸâªÉ«¬

4. °“√√–ß—∫ª«¥À≈—ß°“√ºà“μ—¥„πºŸâªÉ«¬‡¥Á° (Postoperative analgesia in Pediatrics):

°“√ª√–‡¡‘π§«“¡ª«¥À≈—ßºà“μ—¥„π‡¥Á°ª√–°Õ∫¥â«¬°“√ª√–‡¡‘π¥â“π§ÿ≥≈—°…≥– (qualitative assessment) ‰¥â·°à°“√ª√–‡¡‘πμ”·Àπàß ≈—°…≥–

¢Õß§«“¡ª«¥ œ≈œ ·≈–°“√ª√–‡¡‘π¥â“πª√‘¡“≥ (quantitative assessment) ‰¥â·°à°“√ª√–‡¡‘π√–¥—∫À√◊Õ§«“¡√ÿπ·√ß¢Õß§«“¡ª«¥ (pain intensity) ÷Ëß®–™à«¬„π°“√√—°…“·≈–μ‘¥μ“¡º≈°“√√—°…“ °“√ª√–‡¡‘π§«“¡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√–‡¡‘π§«“¡√ÿπ·√ß¢Õß§«“¡ª«¥À≈—ßºà“μ—¥®÷ß “¡“√∂

∑”‰¥â‚¥¬°“√‡≈◊Õ°„™â‡§√◊ËÕß¡◊Õª√–‡¡‘π∑’Ë‡À¡“– ¡°—∫Õ“¬ÿ (μ“√“ß∑’Ë 12)

πÕ°®“°π’È ¬—ß¡’°“√æ—≤π“‡§√◊ËÕß¡◊Õª√–‡¡‘π§«“¡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


√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààßª√–‡∑»‰∑¬

§«√„ÀâºŸâª°§√Õß¡’ à«π√à«¡„π°“√ª√–‡¡‘π ·≈–„™â¢âÕ¡Ÿ≈Õ◊ËπÊ ª√–°Õ∫ πÕ°‡Àπ◊Õ®“°°“√ª√–‡¡‘π

§«“¡√ÿπ·√ß¢Õß§«“¡ª«¥‚¥¬„™â‡§√◊ËÕß¡◊Õ

°“√√–ß—∫ª«¥À≈—ßºà“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‘¥¢Õß¬“·≈–°“√∫√‘À“√¬“μ“¡§«“¡√ÿπ·√ß¢Õß§«“¡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„Àâ¬“≈à«ßÀπâ“μ—Èß·μà°àÕπºà“μ—¥

À√◊Õ∑”À—μ∂°“√„¥Ê ·≈–§«√„Àâ¬“π—ÈπÕÕ°ƒ∑∏‘Ï°àÕπ∑’Ë®–∑”À—μ∂°“√À√◊Õºà“μ—¥

ë À≈’°‡≈’Ë¬ß°“√„Àâ¬“·∫∫ p.r.n. „π«—π·√°À≈—ßºà“μ—¥ ·μà§«√„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√–‡¡‘π§«“¡√ÿπ·√ß¢Õß§«“¡ª«¥À≈—ßºà“μ—¥∑’Ë‡À¡“– ¡°—∫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°√≥’∑’Ë‡¥Á° “¡“√∂ ◊ËÕ “√‡™◊ËÕ∂◊Õ‰¥â


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

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“ß¢Õß ¢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°√≥’∑’Ë‡≈◊Õ°„™â codeine ∑’Ëº ¡°—∫ paracetamol §«√√–¡—¥√–«—ß¢π“¥¢Õß¬“∑—Èß codeine ·≈–

paracetamol ‰¡à„Àâ‡°‘π¢π“¥¬“ Ÿß ÿ¥∑’Ë “¡“√∂„Àâ ‰¥â „πª√–‡∑»‰∑¬¡’μ”√—∫∑’Ë¡’¢π“¥ codeine ·≈–

paracetamol μà“ßÊ °—π ‡™àπ paracetamol 500/codeine 15, paracetamol 500/codeine 30, paracetamol

300/codeine 15 ·≈– paracetamol 300/codeine 30

ë ¬“∑’Ë¡’ à«πº ¡¢Õß codeine ‡ªìπ¬“‡ 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


√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààßª√–‡∑»‰∑¬

ë μâÕß‡ΩÑ“√–«—ßºŸâªÉ«¬„π¥â“π°“√À“¬„® ‚¥¬°“√ª√–‡¡‘π sedation score À√◊Õ„™â pulse oximeter

√à«¡¥â«¬ ·≈–§«√¡’ naloxone ‡μ√’¬¡æ√âÕ¡¥â«¬

ë §«√¡’°“√√—°…“º≈¢â“ß‡§’¬ß¢Õß¬“‰ªæ√âÕ¡°—π ‡™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∂°“√„Àâ¬“™“‡©æ“–∑’Ë„π‡¥Á° §«√°√–∑”‚¥¬ºŸâ∑’Ë‰¥â√—∫°“√Ωñ°Ωπ®π™”π“≠

ë π‘¬¡„™â¬“™“‡©æ“–∑’Ë∑’Ë¡’ƒ∑∏‘Ï¬“« ‡™àπ bupivacaine, levobupivacaine À√◊Õ ropivacaine

ë „π°“√∑”·μà≈–‡∑§π‘§ μâÕß√–«—ß‰¡à„Àâª√‘¡“≥¬“∑’Ë„™â‡°‘π¢π“¥ Ÿß ÿ¥∑’ËºŸâªÉ«¬§«√‰¥â√—∫ ∑—Èß„π°√≥’

„Àâ¬“§√—Èß‡¥’¬« (single/bolus dose) ·≈–„Àâ¬“μàÕ‡π◊ËÕß (continuous infusion) (μ“√“ß∑’Ë 16)


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

ë ‡∑§π‘§°“√„Àâ¬“μàÕ‡π◊ËÕß∑“ß epidural (continuous epidural infusion) π—Èπ “¡“√∂∑”‰¥â

„πºŸâªÉ«¬∑ÿ°Õ“¬ÿ π‘¬¡„™â§«“¡‡¢â¡¢âπ¢Õß¬“ 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¡°./°°./™¡. ¡°./°°./™¡.


√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààßª√–‡∑»‰∑¬

¿“§ºπ«° 8: Acute Pain Service

·∫∫®”≈Õß™π‘¥·≈–·π«∑“ß¢ÕßÀπà«¬√–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‡™’Ë¬«™“≠¥â“π‡¿ —™«‘∑¬“¢Õß¬“·°âª«¥´÷Ëß¡’À≈“¬

¢π“π·≈–√Ÿâ§«“¡·μ°μà“ß ¢âÕ¥’-¢âÕ‡ ’¬ ¢Õß‡∑§π‘§°“√√–ß—∫ª«¥·μà≈–«‘∏’ ÷Ëß “¡“√∂ª√—∫«‘∏’°“√„Àâ¬“·°âª«¥

„Àâ‡À¡“– ¡°—∫ºŸâªÉ«¬·μà≈–§π‰¥âÕ¬à“ß¥’ √«¡∂÷ß “¡“√∂Õ∏‘∫“¬„ÀâºŸâªÉ«¬·≈–≠“μ‘‡¢â“„®∂÷ß§«“¡‡°’Ë¬«¢âÕß°—π

¢Õß‚√§·μà≈–™π‘¥°—∫°“√ºà“μ—¥ ·≈–«‘∏’ªØ‘∫—μ‘μ—«À≈—ß°“√ºà“μ—¥ ‚¥¬ Õ¥§≈âÕß°—∫«‘∏’√–ß—∫§«“¡ª«¥∑’Ë‰¥â√—∫

‡æ◊ËÕ„Àâøóôπμ—«‰¥â‡√Á«¢÷Èπ πÕ°®“°π’È ‡§√◊ËÕß¡◊Õ∑’Ë∑—π ¡—¬ çhigh-teché ‡™àπ ‡§√◊ËÕß¡◊Õ§«∫§ÿ¡§«“¡ª«¥‚¥¬μ—«

ºŸâªÉ«¬‡Õß (Patient-Controlled Analgesia, PCA) ÷Ëß¡’§«“¡¬ÿàß¬“°„π°“√μ—Èß·≈–ª√—∫§à“‡æ◊ËÕ„Àâ‡°‘¥º≈√–ß—∫

ª«¥¥’∑’Ë ÿ¥ ¡’º≈¢â“ß‡§’¬ß¢Õß¬“πâÕ¬∑’Ë ÿ¥ ·≈–∑”„Àâ‡°‘¥§«“¡ª√–∑—∫„® Ÿß ÿ¥ §«√®–μâÕß¥Ÿ·≈‚¥¬ºŸâ‡™’Ë¬«™“≠

∑’Ë¡’ª√– ∫°“√≥å¡“°æÕ ¥—ßπ—Èπ √Ÿª·∫∫ anesthesiologist-based model ®÷ß„Àâ§ÿ≥¿“æ°“√√–ß—∫§«“¡ª«¥

À≈—ßºà“μ—¥·≈–§«“¡ª√–∑—∫„®∑’Ë¥’¡“° ·μà„πª√–‡∑»‰∑¬¬—ß¡’¢âÕ®”°—¥ ‡æ√“–®”π«π«‘ —≠≠’·æ∑¬å¡’‰¡à¡“°æÕ

·≈– à«π„À≠àμâÕß∑”ß“π„πÀâÕßºà“μ—¥ πÕ°®“°π’È √–∫∫π’È¬—ß¡’§à“„™â®à“¬∑’Ë Ÿß

ë Nurse-based, Anesthesiologist-Supervised model‡√‘Ë¡μâπ∑’Ëª√–‡∑» «’‡¥π „πªï §.». 1994 ‚¥¬ Prof. Narinder Rawal „Àâæ¬“∫“≈∑’Ë‰¥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≈—ßºà“μ—¥ ‚¥¬¡’«‘ —≠≠’·æ∑¬å‡ªìπºŸâ„Àâ§”ª√÷°…“ ¢âÕ¥’¢Õß model π’È §◊Õ ¡’§à“„™â®à“¬„π

°“√¥”‡π‘π°“√≈¥≈ß ÷Ëß‡À¡“– ¡°—∫ª√–‡∑»‰∑¬ «‘∏’°“√¥”‡π‘π°“√¢Õß model π’È®–‡πâπ°“√‡æ‘Ë¡æŸπ§«“¡√Ÿâ

·≈–°“√ª√–‡¡‘π§«“¡ª«¥Õ¬à“ß ¡Ë”‡ ¡Õ ‚¥¬„™â°“√ª√–‡¡‘π§«“¡ª«¥¥â«¬√–∫∫¡“μ√∞“π ∑”§«“¡ª«¥„Àâ

¡Õß‡ÀÁπ‰¥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≈’Ë¬π°“√√—°…“‰¥âÕ¬à“ß∑—π∑à«ß∑’

∑”„Àâ°“√√–ß—∫ª«¥À≈—ßºà“μ—¥¡’ª√– ‘∑∏‘¿“æ¡“°¢÷Èπ ®“°°“√»÷°…“·≈–®“°§”·π–π”¢ÕßºŸâ‡™’Ë¬«™“≠ æ∫«à“

§«“¡ ”‡√Á®¢Õß APS ‡°‘¥®“°°“√ª√– “πß“π°—πÕ¬à“ß„°≈â™‘¥¢Õß∫ÿ§≈“°√„π∑’¡∑’Ë‡°’Ë¬«¢âÕß ·≈–‡ªìπº≈®“°

°“√„Àâ¡’§«“¡√Ÿâ‡æ’¬ßæÕ ·≈–¡’‚§√ß √â“ß∑’Ë‡ªìπ√–∫∫„π°“√„Àâ°“√√–ß—∫§«“¡ª«¥ ¡“°°«à“®“°‡∑§π‘§√–ß—∫

ª«¥∑’ËºŸâªÉ«¬‰¥â√—∫

·π«∑“ßæ—≤π“Àπà«¬√–ß—∫§«“¡ª«¥‡©’¬∫æ≈—πÀ≈—ßºà“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—¥


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

1.1 ªí®®—¬∑’Ë¡’Õ‘∑∏‘æ≈μàÕ°“√∑” proactive planning ‰¥â·°à

1.1.1 ™π‘¥¢Õß°“√ºà“μ—¥·≈–°“√§“¥§–‡π§«“¡√ÿπ·√ß¢Õß§«“¡ª«¥À≈—ß°“√ºà“μ—¥

1.1.2 ‚√§ª√–®”μ—« (‡™àπ ‚√§ªÕ¥À√◊Õ‚√§À—«„®), ª√–«—μ‘°“√·æâ¬“

1.1.3 Õ—μ√“ à«π¢Õßº≈¥’º≈‡ ’¬¢Õß«‘∏’√–ß—∫ª«¥·μà≈–«‘∏’

1.1.4 §«“¡™Õ∫ à«πμ—«¢ÕßºŸâªÉ«¬ ·≈–ª√– ∫°“√≥å§«“¡ª«¥®“°°“√ºà“μ—¥§√—Èß°àÕπ

1.2 °‘®°√√¡„π proactive planning ‰¥â·°à

1.2.1 °“√∂“¡ª√–«—μ‘‡¥‘¡‡°’Ë¬«°—∫ª√– ∫°“√≥å§«“¡ª«¥∑’Ë‡°’Ë¬«°—∫°“√ºà“μ—¥¢ÕßºŸâªÉ«¬

1.2.2 °“√√–ß—∫ª«¥μ—Èß·μà°àÕπºà“μ—¥‡¡◊ËÕ “¡“√∂∑”‰¥â

1.2.3 °“√√–ß—∫ª«¥„π√–À«à“ßºà“μ—¥ ‡™àπ °“√©’¥¬“™“∑’Ë·º≈ºà“μ—¥

1.2.4 °“√‡μ√’¬¡°“√√–ß—∫ª«¥√–À«à“ß·≈–À≈—ßºà“μ—¥ ‡™àπ «‘∏’ epidural analgesia

2. °“√Ωñ°Õ∫√¡∫ÿ§≈“°√„π‚√ßæ¬“∫“≈

§«√®—¥„Àâ¡’°“√ª√– “π°—π√–À«à“ß«‘ —≠≠’·æ∑¬å·≈–∫ÿ§≈“°√Õ◊ËπÊ ∑’Ë‡°’Ë¬«¢âÕß ∑”°“√Ωñ°Õ∫√¡∑’Ë

μàÕ‡π◊ËÕß·≈–‡À¡“– ¡·°à∫ÿ§≈“°√¢Õß‚√ßæ¬“∫“≈ ‡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¡’§«“¡´—∫´âÕπ ‡™àπ PCA, epidural analgesia

‡ªìπμâπ

2.2 °“√ª√–‡¡‘π§–·ππ§«“¡ª«¥ pain score, sedation score, Õ—μ√“°“√À“¬„® ·≈–º≈

¢â“ß‡§’¬ßÕ◊ËπÊ ‡æ◊ËÕ„Àâ°“√√–ß—∫ª«¥¡’ª√– ‘∑∏‘¿“æ·≈–ª≈Õ¥¿—¬

2.3 °“√„Àâ§”·π–π”À≈—ß°“√ºà“μ—¥Õ◊ËπÊ ‡æ◊ËÕ„ÀâºŸâªÉ«¬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≈’Ë¬π·ª≈ß«‘∏’°“√√—°…“„À¡à

3. °“√„Àâ§«“¡√Ÿâ·≈–°“√¡’ à«π√à«¡¢ÕßºŸâªÉ«¬·≈–§√Õ∫§√—«„π°“√√–ß—∫ª«¥À≈—ßºà“μ—¥§«√®—¥„Àâ¡’°“√„Àâ§«“¡√Ÿâ·°àºŸâªÉ«¬·≈–§√Õ∫§√—«‡°’Ë¬«°—∫∫∑∫“∑¢ÕßºŸâªÉ«¬·≈–§√Õ∫§√—« „π°“√

√“¬ß“π§«“¡ª«¥ ·≈–§«√·°â§«“¡‡¢â“„®∑’Ë¡—°‡™◊ËÕ°—πº‘¥Ê ‡°’Ë¬«°—∫Õ“°“√¢â“ß‡§’¬ß·≈–°“√μ‘¥¬“

«‘∏’μà“ßÊ „π°“√„Àâ§«“¡√Ÿâ·°àºŸâªÉ«¬·≈–§√Õ∫§√—« „π√“¬∑’Ë„™â«‘∏’°“√√–ß—∫ª«¥∑’Ë´—∫´âÕπ ‡™àπ PCA

‰¥â·°à °“√®—¥∑”·ºàπæ—∫‡°’Ë¬«°—∫«‘∏’°“√√–ß—∫ª«¥ ”À√—∫ºŸâªÉ«¬ ·≈–Õ∏‘∫“¬μÕ∫¢âÕ´—°∂“¡‡°’Ë¬«°—∫«‘∏’√–ß—∫

ª«¥‡¡◊ËÕ‡¬’Ë¬¡ºŸâªÉ«¬À≈—ßºà“μ—¥

4. °“√ª√–‡¡‘π·≈–∫—π∑÷°°“√¥Ÿ·≈√—°…“§«“¡ª«¥‡©’¬∫æ≈—πÀ≈—ß°“√ºà“μ—¥§«√®—¥„Àâ¡’°“√ª√–‡¡‘π·≈–∫—π∑÷°§–·ππª«¥ ‡æ◊ËÕ®–‰¥â∑√“∫«à“«‘∏’√–ß—∫ª«¥∑’ËºŸâªÉ«¬‰¥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


√“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬å·Ààßª√–‡∑»‰∑¬

ºŸâªÉ«¬‰¥â√—∫Õ¬Ÿàπ—Èπ ¡’·π«‚πâ¡®–‡°‘¥º≈¢â“ß‡§’¬ß∑’Ë‡°’Ë¬«°—∫°“√°¥°“√À“¬„®À√◊Õ‰¡àμ—Èß·μà‡π‘ËπÊ „πªí®®ÿ∫—π

·π–π”„Àâ„™â°“√ª√–‡¡‘π sedation score ‡ªìπ 6th Vital sign ‚¥¬‡©æ“–Õ¬à“ß¬‘Ëß„πºŸâªÉ«¬∑’Ë¡’ªí≠À“‡√◊ËÕß

√–∫∫∑“ß‡¥‘πÀ“¬„®

5. °“√¡’«‘ —≠≠’·æ∑¬å„Àâ§”ª√÷°…“μ≈Õ¥ 24 ™¡.‡π◊ËÕß®“°¿“«–μà“ßÊ ¢ÕßºŸâªÉ«¬„π™à«ßÀ≈—ß°“√ºà“μ—¥¡—°¡’°“√‡ª≈’Ë¬π·ª≈ßÕ¬Ÿàμ≈Õ¥‡«≈“ «‘∏’°“√

√–ß—∫ª«¥ à«π„À≠à¡’‚Õ°“ ‡ ’Ë¬ßμàÕ¿“«–·∑√°´âÕπ´÷ËßμâÕß°“√°“√ª√–‡¡‘π·≈–√—°…“∑—π∑’ §«“¡μâÕß°“√¬“

·°âª«¥Õ“®‡ª≈’Ë¬π·ª≈ß‡¡◊ËÕ„¥°Á‰¥â ®÷ß§«√¡’«‘ —≠≠’·æ∑¬å∑’Ë√—∫º‘¥™Õ∫¥Ÿ·≈§«“¡ª«¥À≈—ßºà“μ—¥μ≈Õ¥ 24 ™¡.

‡æ◊ËÕ„Àâæ¬“∫“≈ »—≈¬·æ∑¬å ·≈–·æ∑¬åÕ◊ËπÊ ∑’Ë‡°’Ë¬«¢âÕß¢Õ§”ª√÷°…“‰¥âμ≈Õ¥‡«≈“ μ≈Õ¥®π™à«¬ª√–‡¡‘π

ºŸâªÉ«¬∑’Ë¡’ªí≠À“‡°’Ë¬«°—∫°“√√–ß—∫ª«¥ ‡æ◊ËÕ§«“¡ª≈Õ¥¿—¬ Ÿß ÿ¥¢ÕßºŸâªÉ«¬

6. °“√¡’π‚¬∫“¬ (Policy) ·≈–«‘∏’°“√ (Procedure) ”À√—∫°“√ —Ëß°“√√—°…“, °“√∫√‘À“√¬“ ·≈–°“√À¬ÿ¥°“√√—°…“ μ≈Õ¥®π°“√ àßμàÕ§«“¡√—∫º‘¥™Õ∫„π°“√¥Ÿ·≈√—°…“§«“¡ª«¥‡©’¬∫æ≈—πÀ≈—ß°“√

ºà“μ—¥∑’Ë‡ªìπ¡“μ√∞“π¢Õß‚√ßæ¬“∫“≈«‘ —≠≠’·æ∑¬åºŸâ„Àâ°“√√–ß—∫ª«¥°àÕπ √–À«à“ß ·≈–À≈—ß°“√ºà“μ—¥ §«√√à«¡¡◊Õ°—∫∫ÿ§≈“°√Õ◊ËπÊ ∑’Ë

‡°’Ë¬«¢âÕß „π°“√æ—≤π“π‚¬∫“¬¢Õß‚√ßæ¬“∫“≈„π≈—°…≥– À “¢“«‘™“™’æ ”À√—∫°“√ —Ëß°“√√—°…“, °“√∫√‘À“√

¬“ ·≈–°“√À¬ÿ¥°“√√—°…“ μ≈Õ¥®π°“√ àßμàÕ§«“¡√—∫º‘¥™Õ∫„π°“√√–ß—∫ª«¥À≈—ßºà“μ—¥ °“√æ—≤π“π‚¬∫“¬

·≈–«‘∏’°“√¢Õß‚√ßæ¬“∫“≈™à«¬„Àâ¡’°“√ªØ‘∫—μ‘Õ¬à“ß‡ªìπ¡“μ√∞“π „π°“√„™â«‘∏’°“√√–ß—∫ª«¥μà“ßÊ ™à«¬„Àâ

‡°‘¥§«“¡ª≈Õ¥¿—¬ ‡™àπ ¡“μ√∞“π¢Õß‚√ßæ¬“∫“≈ ”À√—∫ —Ëß°“√√—°…“ PCA ·≈– epidural analgesia À√◊Õ

nerve block

π‚¬∫“¬·≈–«‘∏’°“√∑’Ëæ—≤π“¢÷Èπ¡“§«√ “¡“√∂π”‰ª„™â ‰¥â°—∫∑ÿ°Ê Àπà«¬ß“π∑’Ë„Àâ°“√¥Ÿ·≈ºŸâªÉ«¬ ·≈–

§«√ àß‡ √‘¡„Àâ‡°‘¥°“√»÷°…“Õ¬à“ßμàÕ‡π◊ËÕß·≈–‡ªìπ¢âÕ¡Ÿ≈∑’ËÕâ“ßÕ‘ß‰¥â

7. °“√„™â«‘∏’°“√‡©æ“– 3 «‘∏’ ”À√—∫°“√√–ß—∫ª«¥À≈—ßºà“μ—¥

π—∫ πÿπ„Àâ«‘ —≠≠’·æ∑¬åºŸâ„Àâ°“√√–ß—∫ª«¥°àÕπ √–À«à“ß ·≈–À≈—ßºà“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“–∑’Ë¥â«¬«‘∏’ 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≈—ßºà“μ—¥

°“√„Àâ¬“√–ß—∫§«“¡√Ÿâ ÷°√–À«à“ß°“√ºà“μ—¥π‘¬¡„™â¬“À≈“¬™π‘¥√à«¡°—π‡æ◊ËÕ„Àâ‡°‘¥ª√–‚¬™πå Ÿß ÿ¥

„π∑”πÕß‡¥’¬«°—π °“√√–ß—∫ª«¥À≈—ßºà“μ—¥°Á‰¥â√—∫ª√–‚¬™πå®“°°“√„™â¬“À√◊Õ«‘∏’°“√√–ß—∫ª«¥¡“°°«à“Àπ÷Ëß

™π‘¥ ¡“°°«à“°“√„™â¬“À√◊Õ„™â«‘∏’°“√√–ß—∫ª«¥‡æ’¬ßÕ¬à“ß„¥Õ¬à“ßÀπ÷Ëß


¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬

Multimodal À√◊Õ balanced analgesia ‡ªìπ·π«§‘¥¢Õß°“√„™â¬“·°âª«¥À≈“¬°≈ÿà¡∑’Ë¡’°≈‰°°“√

√–ß—∫ª«¥∑’Ëμà“ß°—π´÷Ëß‡ √‘¡ƒ∑∏‘Ï´÷Ëß°—π·≈–°—π„π°“√√–ß—∫ª«¥ ‚¥¬¡’®ÿ¥ª√– ß§å‡æ◊ËÕ≈¥Õÿ∫—μ‘°“√≥å·≈–§«“¡

√ÿπ·√ß¢ÕßÕ“°“√¢â“ß‡§’¬ß·≈–¿“«–·∑√° âÕπ®“°°“√„™â¬“·°âª«¥‡æ’¬ß¢π“π‡¥’¬« ‡™àπ Õ“°“√§≈◊Ëπ‰ âÕ“‡®’¬π

·≈–°“√°¥°“√À“¬„®®“°°“√„™â¬“°≈ÿà¡ opioids ®“°À≈“¬ß“π«‘®—¬æ∫«à“ª√– ‘∑∏‘¿“æ°“√√–ß—∫ª«¥¥’¢÷Èπ

Õ¬à“ß¡“° ·μà°Á¬—ß‰¡à “¡“√∂¬—∫¬—Èß stress response ‰¥â∑—ÈßÀ¡¥ πÕ°®“°π’ÈºŸâªÉ«¬Õ“®‡°‘¥Õ“°“√¢â“ß‡§’¬ß

®“°°“√‡æ‘Ë¡¬“°≈ÿà¡Õ◊Ëπ ®÷ß®”‡ªìπμâÕß™—Ëß¢âÕ¥’¢âÕ‡ ’¬„πºŸâªÉ«¬·μà≈–√“¬


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Clinical Practice Guideline for postoperative pain

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