cpg acute pain
DESCRIPTION
TRANSCRIPT
(Clinical Guidance for Acute Pain Management)
©∫—∫∑’Ë 1 æ.». 2552 (æ‘¡æå§√—Èß∑’Ë 1)ISBN: 978-974-8285-72-6
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ACUTEPAIN
·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—π
Thai Association for the Study of Pain (TASP)
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«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
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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
¡“§¡°“√»÷°…“‡√◊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«¬
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√—°…“ “‡Àμÿ¢ÕßÕ“°“√ª«¥
Õ“°“√ª«¥μÈÕß°“√°“√√—°…“
°“√√–ß—∫ª«¥‰¥Èº≈¥’
ª√–‡¡‘π È”·≈–∫—π∑÷°
‡°‘¥Õ“°“√·∑√°´ÈÕπ®“°°“√√—°…“À√◊Õ‰¡Ë
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√—°…“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
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·ºπ¿Ÿ¡‘∑’Ë 1 ·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—π
*** ¢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)
¡“§¡°“√»÷°…“‡√◊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
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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„®
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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
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„™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¥
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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
¡“§¡°“√»÷°…“‡√◊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
*** ¢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‘
¡“§¡°“√»÷°…“‡√◊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”Õ¬Ë“ß ¡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
*** ¢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”
Õ¬Ë“ß ¡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
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√“¬ß“π·æ∑¬Ï
‰¡Ë„™Ë
‰¡Ë„™Ë
ª√–‡¡‘π´È”Õ¬Ë“ß ¡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‘)
¡“§¡°“√»÷°…“‡√◊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”Õ¬Ë“ß ¡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 ™¡.
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‰¡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
*** ¢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√– ߧå‡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«°
¡“§¡°“√»÷°…“‡√◊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√– ߧå¢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
*** ¢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)
¡“§¡°“√»÷°…“‡√◊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
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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“„®
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(activity) √âÕ߉Àâ ·≈–°“√μÕ∫ πÕßμàÕ°“√ª≈Õ∫‚¬π (consolability) ÷Ëß·μà≈– à«π¡’§–·ππ 0-2 √«¡∑—ÈßÀ¡¥
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5.2 The CHEOPS behavioral pain scale15 (μ“√“ß∑’Ë 2) ‡À¡“– ”À√—∫‡¥Á°‡≈Á°À√◊ÕºŸâªÉ«¬∑’ˉ¡à
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*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 15
6. ‡§√◊ËÕß¡◊Õª√–‡¡‘𧫓¡ª«¥ ”À√—∫ºŸâªÉ«¬∑’ˉ¡à “¡“√∂ ◊ËÕ “√¥â«¬μ—«‡Õ߉¥â „πÀÕ«‘°ƒμ À√◊ÕºŸâªÉ«¬
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Categories Definition Scoring
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Àπâ“쓇∫– À√◊Õ¢¡«¥§‘È« ∂Õ¬Àπ’ 1
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∫‘¥μ—«‰ª¡“ ·ÕàπÀπâ“·ÕàπÀ≈—ß ‡°√Áß 1
μ—«ßÕ ‡°√Áß®πμ—«·¢Áß À√◊Õ —Ëπ°√–μÿ° 2
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√âÕ߉Àâμ≈Õ¥ À«’¥√âÕß –Õ÷° –Õ◊Èπ ∫àπ∫àÕ¬Ê 2
°“√μÕ∫ πÕßμàÕ°“√ª≈Õ∫‚¬π ‡™◊ËÕøíߥ’ ∫“¬Ê 0
“¡“√∂ª≈Õ∫‚¬π¥â«¬°“√ —¡º— ‚Õ∫°Õ¥ 查§ÿ¬¥â«¬ 1
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¬“°∑’Ë®–ª≈Õ∫‚¬πÀ√◊Õ∑”„Àâ ∫“¬ 2
μ“√“ß∑’Ë 1 The FLACC behavioral pain scale15
¡“§¡°“√»÷°…“‡√◊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√“¬
Paracetamol ¥Ÿ¥ ÷¡∑“ß√–∫∫∑“߇¥‘πÕ“À“√‰¥â¥’·≈–‡√Á« ‚¥¬√–¥—∫¬“„π‡≈◊Õ¥ Ÿß ÿ¥®–‡°‘¥¢÷Èπ¿“¬„π
§√÷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
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μ“√“ß∑’Ë 3 ¢π“¥¬“ paracetamol „π‡¥Á°·μà≈–™à«ßÕ“¬ÿ17
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*** ¢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√– ߧåÀ≈“¬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
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°“√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
¡“§¡°“√»÷°…“‡√◊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≈“¬
*** ¢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√– ߧ剥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
¡“§¡°“√»÷°…“‡√◊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
*** ¢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
¡“§¡°“√»÷°…“‡√◊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¬“
*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 23
μ“√“
ß∑’Ë 5
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e,
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l inf
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tion,
epid
ural b
lock
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nest
hesia
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200-
400
π“∑’
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¢π“¥
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tion/
Epid
ural:
¢π“¥
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”
2 m
g/kg
, 4-h
ourly
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ax d
ose
¢÷Èπ°—∫
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: 1 m
g/kg
,
6-ho
urly
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ax d
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3 m
g/kg
/
day
-
¢π“¥
¬“„π
ºŸâ„À≠
à
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filtra
tion/
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ural:
2 m
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, 4-h
ourly
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ax d
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¢÷Èπ°—∫
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g, 4
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rly
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240
mg/
day
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*** ¢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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*** ¢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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chos
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/IM/S
C:
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1 m
g/kg
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fusion
:
5 m
g/kg
in
50 m
l
NSS
rate
1-3
ml/h
r
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¢π“¥
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à
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0 m
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en
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g, 1
2-ho
urly
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ax d
ose
80 m
g/da
y
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50 m
g p.
r.n.
q 2
hr
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g
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*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 37
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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
ACUTEPAIN
Thai Association for the Study of PainISBN: 978-974-8285-72-6