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Cpg acute pain
 

Cpg acute pain

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    Cpg acute pain Cpg acute pain Document Transcript

    • ·π«∑“ßæ—≤π“ °“√√–ß—∫ª«¥‡©’¬∫æ≈—π(Clinical Guidance for Acute Pain Management) ©∫—∫∑’Ë 1 æ.». 2552 (æ‘¡æå§√—Èß∑’Ë 1) ISBN: 978-974-8285-72-6 ®—¥∑”‚¥¬  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ACUTEPAIN
    • Thai Association for the Study of Pain (TASP) √“™«‘∑¬“≈—¬«‘ —≠≠’·æ∑¬Ï·ÀËߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬»—≈¬·æ∑¬Ï·ÀËߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬·æ∑¬ÏÕÕ√Ï‚∏ª‘¥‘° Ï·ÀËߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬ Ÿμ‘π√’·æ∑¬Ï·ÀËߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬‚ μ »Õ π“ ‘°·æ∑¬Ï·ÀËߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬®—°…ÿ·æ∑¬Ï·ÀËߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬·æ∑¬Ï‡«™»“ μ√Ïø◊ÈπøŸ·ÀËߪ√–‡∑»‰∑¬ ™¡√¡‡«™»“ μ√Ï©ÿ°‡©‘π·ÀËߪ√–‡∑»‰∑¬ ‚√ß欓∫“≈¡À“√“™π§√√“™ ’¡“ ‚√ß欓∫“≈À“¥„À≠Ë ‚√ß欓∫“≈æ√–π—Ë߇°≈È“  ∂“∫—π ÿ¢¿“懥Á°·ÀËß™“μ‘¡À“√“™‘π’ ©∫—∫∑’Ë 1 æ.». 2552 (æ‘¡æϧ√—Èß∑’Ë 1) ISBN: 978-974-8285-72-6
    •  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’È ‰¡à „™à¢Õ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** â ·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥„π∑’ËπÈ’‡ªìπ‡æ’¬ß¢âÕ·π–π”„π°“√√–ß—∫ª«¥ ™π‘¥‡©’¬∫æ≈—π ‡æ◊Õ à߇ √‘¡§ÿ≥¿“æ¢Õß°“√∫√‘°“√¥â“π ÿ¢¿“æ¢Õߧπ‰∑¬ °“√π” Ë ‰ª„™âμâÕß¡’°“√ª√–¬ÿ°μå„Àâ‡À¡“– ¡°—∫∫√‘∫∑¢Õß·μà≈–·Ààß ºŸâ „™â “¡“√∂ªØ‘∫—μ‘ ·μ°μà“߉ª®“°¢âÕ·π–π”π’È ‰¥â ¢÷πÕ¬Ÿ°∫°√≥’À√◊Õ ∂“π°“√≥å∑·μ°μà“ßÕÕ°‰ª À√◊Õ È à— Ë’ ¡’‡Àμÿº≈∑’Ë ¡§«√ ‚¥¬„™â«®“√≥≠“≥ ·≈–°“√μ—¥ ‘π„®∑’ˇªìπ∑’ˬա√—∫„π —ߧ¡ ‘ ii
    • §”π” Õ“°“√ª«¥‡©’¬∫æ≈—π À¡“¬∂÷ߧ«“¡ª«¥∑’ˇ°‘¥¢÷Èπ„πªí®®ÿ∫—𠇪ì𧫓¡ª«¥∑’Ë¡’ “‡Àμÿ®“°°“√∫“¥‡®Á∫À√◊Õ°“√Õ—°‡ ∫‡ªìπ à«π„À≠à μ—«Õ¬à“߇™à𠧫“¡ª«¥®“°°“√ºà“μ—¥ Õÿ∫—쑇Àμÿ ‰ø‰À¡â πÈ”√âÕπ≈«° ‰ âμ‘ËßÕ—°‡ ∫ ·≈–Õ◊ËπÊ „π∑ÿ°‡æ»·≈–∑ÿ°°≈ÿà¡Õ“¬ÿ ´÷ËßÕ“°“√ª«¥π’ÈÕ“®∑”„À⇰‘¥º≈‡ ’¬μàÕºŸâªÉ«¬À≈“¬Õ¬à“ß ‡™àπ ∑”„À≡à ÿ¢ ∫“¬ ¡’Õ“°“√·∑√°´âÕπμàÕ√–∫∫μà“ßÊ ¢Õß√à“ß°“¬ ·≈–Õ“®π”‰ª ŸàÕ“°“√ª«¥‡√◊ÈÕ√—߉¥â °“√√—°…“Õ“°“√ª«¥‡©’¬∫æ≈—π¬—߇ªìπªí≠À“ ”À√—∫∑ÿ°ª√–‡∑» ªí®®ÿ∫—πÀπ૬ߓπμà“ßÊ ∑—Ë«‚≈°¡’§«“¡μâÕß°“√∑’Ë®–æ—≤π“°“√∫√‘°“√„Àâ ‰¥â§ÿ≥¿“æÕ¬à“ßμàÕ‡π◊ËÕß ·≈–¡’À≈—°∞“π∑’Ë “¡“√∂μ√«® Õ∫‰¥â ¥â«¬‡Àμÿπ’È®÷߉¥â¡’°“√®—¥∑”·π«∑“ßæ—≤π“ (Clinical Guidance) ¢Õß·μà≈–·Ààߢ÷Èπ ·¡â«à“„πÀ≈“¬ª√–‡∑»®–¡’°“√®—¥∑”·π«∑“ß°“√√–ß—∫ª«¥¡“‡°◊Õ∫ 20 ªï·≈â«°Áμ“¡ ·μà „πª√–‡∑»‰∑¬¬—߉¡à¡’°“√®—¥∑”·π«∑“ߥ—ß°≈à“«¡“°àÕπ ¥—ßπ—Èπ ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬®÷߉¥â®—¥∑”·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—π¢÷Èπ ‚¥¬¡’«—μ∂ÿª√– ß§å ‡æ◊ËÕ‡ªìπ·π«∑“ß„π°“√¥Ÿ·≈ºŸâªÉ«¬∑’Ë¡’Õ“°“√ª«¥‡©’¬∫æ≈—π·≈– “¡“√∂„™âÕ“ßՑ߉¥âμàÕ‰ª â Õ¬à“߉√°Áμ“¡·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—π©∫—∫𒇪ìπ‡æ’¬ß§”·π–π”„π°“√ªØ‘∫μ‡∑à“π—π È —‘ È¡‘‰¥â‡ªìπ¢âÕ∫—ߧ—∫À√◊հƇ°≥±å∑Ë’∫—ߧ—∫„ÀâμâÕߪؑ∫—μ‘μ“¡ ‡π◊ËÕß®“°„π°“√ªØ‘∫—μ‘®√‘ßπ—Èπ®–μâÕßÕ“»—¬∑—°…–·≈–¥ÿ≈¬æ‘π‘®¢Õß·æ∑¬å∑Ë’„Àâ°“√√—°…“„π‚√ß欓∫“≈·μà≈–·Ààß´÷Ëß·μ°μà“ß°—π‰ª ‡ªìπÕߧåª√–°Õ∫∑’Ë ”§—≠¥â«¬ „π·π«∑“ßπ’È Õ“®¡’°“√„™â§”»—æ∑å∑’ˇªìπ¿“…“Õ—ß°ƒ…„πÀ≈“¬∑’Ë ∑—Èßπ’ȇæ◊ËÕ§«“¡ –¥«°·≈–§«“¡°√–™—∫¢Õ߇π◊ÈÕÀ“  ¡“§¡°“√»÷ ° …“‡√◊Ë Õ ß§«“¡ª«¥·Àà ß ª√–‡∑»‰∑¬À«— ß «à “ ·π«∑“ßæ— ≤ π“°“√√–ß— ∫ ª«¥‡©’¬∫æ≈—π©∫—∫π’È®–¡’°“√𔉪ª√–¬ÿ°μ儙⠄π‚√ß欓∫“≈μà“ßÊ Õ¬à“ß°«â“ߢ«“ß ´÷Ëß®–¡’ à«π™à«¬„Àâ§≥¿“æ™’«‘μ ÿ¢ÕߺŸâªÉ«¬¥’¢÷Èπ ·≈–¢Õ¢Õ∫§ÿ≥ºŸâ‡°’ˬ«¢âÕß∑ÿ°∑à“π∑’Ë¡’ à«π„π°“√®—¥∑”·π«∑“ß©∫—∫π’È®π ”‡√Á®≈ÿ≈à«ß¥â«¬¥’ »“ μ√“®“√¬å𓬷æ∑¬å  ¡∫Ÿ√≥å ‡∑’¬π∑Õß ª√–∏“π§≥–ºŸâ®—¥∑”·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—π iii
    •  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ √“¬π“¡§≥–ºŸâ®—¥∑” 1. √».πæ.ª√–¥‘…∞å ª√–∑’ª–«≥‘™ 𓬰 ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ ∑’˪√÷°…“ 2. ».πæ. ¡∫Ÿ√≥å ‡∑’¬π∑Õß Õÿªπ“¬° ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ ª√–∏“π 3. æ.μ.πæ.™“≠ƒ∑∏‘Ï ≈âÕ∑«’ «— ¥‘Ï ‡≈¢“∏‘°“√ ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ ‡≈¢“πÿ°“√ 4. √».æ≠.«‘¡≈≈—°…≥å  π—Ëπ»‘≈ªá §≥–·æ∑¬»“ μ√廑√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈ °√√¡°“√ 5. √».πæ.«‘™—¬ Õ‘∑∏‘™—¬°ÿ≈±≈ §≥–·æ∑¬»“ μ√å‚√ß欓∫“≈√“¡“∏‘∫¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈ °√√¡°“√ 6. √».æ≠. ÿª√“≥’ π‘√ÿμμ‘»“ πå §≥–·æ∑¬»“ μ√å ®ÿÓ≈ß°√≥å¡À“«‘∑¬“≈—¬ °√√¡°“√ 7. æ.Õ.πæ.πæ¥≈ ™◊Ëπ»‘√‘‡°…¡ «‘∑¬“≈—¬·æ∑¬»“ μ√åæ√–¡ß°ÿƇ°≈â“ °√√¡°“√ 8. º».æ≠. À—∑¬“ ‰æ∫Ÿ≈¬å«√™“μ‘ §≥–·æ∑¬»“ μ√å ¡À“«‘∑¬“≈—¬‡™’¬ß„À¡à °√√¡°“√ 9. º».æ≠.»»‘°“πμå π‘¡¡“π√—™μå §≥–·æ∑¬»“ μ√å ¡À“«‘∑¬“≈—¬ ß¢≈“π§√‘π∑√å °√√¡°“√ 10. º».æ≠.≈—°…¡’ ™“≠‡«™™å °√√¡°“√ ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ °√√¡°“√ 11. √».¥√.πæ.ª√–«‘∑¬å Õ—§√‡ √’ππ∑å §≥–·æ∑¬»“ μ√廑√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈ °√√¡°“√ iv
    • °‘μμ‘°√√¡ª√–°“» „ππ“¡¢Õß ¡“§¡°“√»÷ ° …“‡√◊Ë Õ ß§«“¡ª«¥·Àà ß ª√–‡∑»‰∑¬ ¢Õ¢Õ∫§ÿ ≥ μ— « ·∑π®“°√“™«‘∑¬“≈—¬μà“ßÊ ‰¥â·°à √“™«‘∑¬“≈—¬«‘ ≠≠’·æ∑¬å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬»—≈¬·æ∑¬å·Ààߪ√–‡∑»‰∑¬ —√“™«‘∑¬“≈—¬·æ∑¬åÕÕ√å‚∏ªî¥‘° å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬ Ÿμ‘π√’·æ∑¬å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬‚ μ »Õ π“ ‘°·æ∑¬å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬®—°…ÿ·æ∑¬å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬·æ∑¬å‡«™»“ μ√åøóôπøŸ·Ààߪ√–‡∑»‰∑¬ ·≈– ™¡√¡‡«™»“ μ√å©ÿ°‡©‘π·Ààߪ√–‡∑»‰∑¬ √«¡∑—Èßμ—«·∑π®“°‚√ß欓∫“≈„π°√–∑√«ß “∏“√≥ ÿ¢Õ’° ’·Ààß ‰¥â·°à √æ.¡À“√“™π§√√“™ ’¡“ √æ.À“¥„À≠à √æ.æ√–π—߇°≈â“ Ë Ë·≈– ∂“∫—π ÿ¢¿“懥Á°·Ààß™“μ‘¡À“√“™‘π’ ∑’™«¬μ√«® Õ∫§«“¡∂Ÿ°μâÕß·≈–‡À¡“– ¡¢Õß·π«∑“ß„π§√—ßπ’È Ëà È v
    •  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬  “√∫—≠ ∫∑π” 1 Õÿ∫—μ‘°“√≥å¢Õߧ«“¡ª«¥‡©’¬∫æ≈—π 1 §”®”°—¥§«“¡ 1 °≈ÿࡇªÑ“À¡“¬ 2 ·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—π 2 §”Õ∏‘∫“¬·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—π : ë °“√√—°…“ “‡Àμÿ∑’ˇ°’ˬ«¢âÕß°—∫Õ“°“√ª«¥ 4 ë °“√ª√–‡¡‘π√–¥—∫§«“¡ª«¥ 4 ë °“√√–ß—∫ª«¥‡©’¬∫æ≈—π 5 ë °“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬„™â¬“ 6 ë °“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬‰¡à „™â¬“ 7 ë °“√√–ß—∫ª«¥·∫∫º ¡º “π 11 ë «‘∏’°“√√—°…“Õ“°“√·∑√°´âÕπ 11 ¿“§ºπ«° : ë  “‡Àμÿ·≈–°“√√—∫√Ÿâ‡√◊ËÕߧ«“¡ª«¥‡©’¬∫æ≈—π 13 ë ‡§√◊ËÕß¡◊Õ ”À√—∫ª√–‡¡‘π√–¥—∫§«“¡ª«¥ 14 ë μ“√“ß√“¬≈–‡Õ’¬¥°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬„™â¬“ 23 ë μ“√“ß√“¬≈–‡Õ’¬¥°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬‰¡à„™â¬“ 32 ‡Õ° “√Õâ“ßÕ‘ß 36 ·À≈àߢâÕ¡Ÿ≈‡æ‘Ë¡‡μ‘¡∑’Ëπà“ π„® 38 vi
    • ∫∑π” ‡ªìπ∑’∑√“∫¥’«“Õ“°“√ª«¥∑”„À⇰‘¥º≈‡ ’¬μàÕºŸª«¬À≈“¬Õ¬à“ß ‡™àπ ∑”„Àâ ‰¡à ¢ ∫“¬ ¡’Õ“°“√·∑√°´âÕπ Ë à â É ÿμàÕ√–∫∫μà“ßÊ ¢Õß√à“ß°“¬ ·≈–‡ ’¬§à“„™â®à“¬„π°“√√—°…“¡“°¢÷Èπ ªí®®ÿ∫—πÀπ૬ߓπμà“ßÊ ∑—Ë«‚≈°∑’Ë¡’ à«π„π°“√√–ß—∫ª«¥‡©’¬∫æ≈—π¡’§«“¡μâÕß°“√∑’Ë®–æ—≤π“°“√∫√‘°“√„Àâ ‰¥â§ÿ≥¿“æÕ¬à“ßμàÕ‡π◊ËÕß ·≈–¡’À≈—°∞“π∑’Ë “¡“√∂μ√«® Õ∫‰¥â ¥â«¬‡Àμÿπ’È®÷߉¥â¡’°“√®—¥∑”·π«∑“ßæ—≤π“ (Clinical Guidance: „π∑’Ëπ’È®–¢Õ‡¢’¬π —ÈπÊ«à“ ç·π«∑“ßé) ¢Õß·μà≈–·Ààß ‡™àπ The American Society of Anesthesiologists (ASA:2004)1, TheAmerican 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«∑“ßÕ◊ËπÊ Õ’°À≈“¬·Ààß ·¡â«à“„πÀ≈“¬ª√–‡∑»®–¡’°“√®—¥∑”·π«∑“ß°“√√–ß—∫ª«¥¡“‡°◊Õ∫ 20 ªï·≈â«°Áμ“¡ ·μà„πª√–‡∑»‰∑¬¬—߉¡à¡°“√®—¥∑”·π«∑“ߥ—ß°≈à“«¡“°àÕπ ¥—ßπ—Èπ ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ ®÷߉¥â®—¥∑” ’·π«∑“ßæ—≤π“π’¢π ‚¥¬¡’«μ∂ÿª√– ß§å ‡æ◊Õ‡ªìπ·π«∑“ß„π°“√¥Ÿ·≈ºŸª«¬∑’¡§«“¡ª«¥‡©’¬∫æ≈—π·≈– “¡“√∂ È È÷ — Ë â É Ë ’„™âÕ“ßՑ߉¥âμÕ‰ª ‚¥¬À«—ß«à“·π«∑“ßπ’®–™à«¬„Àâ§≥¿“æ™’«μ¢ÕߺŸª«¬¥’¢π  à߇ √‘¡„À⺪«¬øóπμ—«·≈– “¡“√∂ â à È ÿ ‘ â É ÷È Ÿâ É ô°≈—∫¡“∑”Àπâ“∑’Ë ‰¥âμ“¡ª°μ‘‡√Á«¢÷π ≈¥‚Õ°“ ‡°‘¥Õ“°“√·∑√°´âÕπ·≈–Õ“®™à«¬„À⺪«¬ÕÕ°®“°‚√ß欓∫“≈‰¥â È Ÿâ ɇ√Á«¢÷ÈπÕÿ∫—μ°“√≥å¢Õߧ«“¡ª«¥‡©’¬∫æ≈—π ‘ ¡’°“√»÷°…“Õÿ∫—μ‘°“√≥å¢ÕßÕ“°“√ª«¥À≈—ߺà“μ—¥¢Õß ∂“∫—πμà“ßÊ „πª√–‡∑»‰∑¬ æ∫Õÿ∫—μ‘°“√≥å∑’Ë·μ°μà“ß°—π‰ª ‡™àπ ºŸâªÉ«¬„πÀâÕßæ—°øóôπ∑’Ë¡’Õ“°“√ª«¥¡“°°«à“ 5 §–·ππ æ∫√âÕ¬≈– 246 ºŸâªÉ«¬À≈—ߺà“μ—¥∑“ßÕÕ√å‚∏ªî¥‘° å∑’Ë¡Õ“°“√ª«¥ >7 §–·ππ æ∫√âÕ¬≈– 28.77 ºŸâªÉ«¬ºà“μ—¥§≈Õ¥∑“ßÀπâ“∑âÕß¡’Õ“°“√ª«¥¡“°„π ’¢≥–¢¬—∫μ—«√âÕ¬≈– 228 ·μଗ߉¡à¡’√“¬ß“π∑’Ë™—¥‡®π‡°’ˬ«°—∫§«“¡™ÿ°¢Õߧ«“¡ª«¥‡©’¬∫æ≈—π∑’Ëπ”ºŸâªÉ«¬¡“æ∫·æ∑¬å∑’Ë ‚√ß欓∫“≈§”®”°—¥§«“¡ §«“¡ª«¥·∫àßμ“¡√–¬–‡«≈“ÕÕ°‡ªìπ Õߪ√–‡¿∑ §◊Õ §«“¡ª«¥‡©’¬∫æ≈—π (acute pain) ·≈–§«“¡ª«¥‡√◊ÈÕ√—ß (chronic pain) °“√√–ß—∫ª«¥μ“¡·π«∑“ß∑’Ë®¥∑”π’È ®”°—¥‡©æ“–§«“¡ª«¥™π‘¥‡©’¬∫æ≈—π ´÷ËßÀ¡“¬∂÷ߧ«“¡ª«¥∑’ˇ°‘¥ —¢÷π„πªí®®ÿ∫𠇪ìπ¡“‰¡à‡°‘π 6 ‡¥◊Õ𠇪ì𧫓¡ª«¥∑’¡ “‡Àμÿ®“°°“√∫“¥‡®Á∫À√◊Õ°“√Õ—°‡ ∫‡ªìπ à«π„À≠à √–¬– È — Ë ’‡«≈“∑’ª«¥®–Õ¬Ÿà ‰¡àπ“π ‚¥¬Õ“°“√ª«¥®–∑ÿ‡≈“‡¡◊Õ “‡Àμÿ‰¥â√∫°“√·°â ‰¢À√◊ÕÀ“¬·≈â« μ—«Õ¬à“ߢÕߧ«“¡ª«¥ Ë Ë —‡©’¬∫æ≈—𠇙à𠧫“¡ª«¥®“°°“√ºà“μ—¥ Õÿ∫—쑇Àμÿ ‰ø‰À¡â πÈ”√âÕπ≈«° ‰ âμËßÕ—°‡ ∫ ·≈–Õ◊ËπÊ „π∑ÿ°‡æ»·≈– ‘∑ÿ°°≈ÿ¡Õ“¬ÿ à «‘∏’°“√√–ß—∫ª«¥‚¥¬„™â¬“μ“¡·π«∑“ßπ’È ®–‡πâπ‡©æ“–«‘∏’°“√∑’Ë¡’„™â°—π∑—Ë«‰ª ‡™àπ °“√©’¥¬“∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ©’¥„μ⺫Àπ—ßÀ√◊Õ‡¢â“°≈â“¡ √«¡∑—ß«‘∏°“√√—∫ª√–∑“π  ”À√—∫‡∑§π‘§Õ◊πÊ ∑’μÕßÕ“»—¬∑—°…–摇»… ‡™àπ ‘ È ’ Ë Ëâ*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢Õ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** â 1
    •  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬°“√∑” epidural block √«¡∑—ß°“√„™â‡§√◊Õß¡◊Õμà“ßÊ „π°“√√–ß—∫ª«¥ ‡™à𠇧√◊Õß patient-controlled analge- È Ë Ësia (PCA) ®–‰¡à ‰¥â°≈à“«∂÷ß„π∑’Ëπ’È°≈ÿ¡‡ªÑ“À¡“¬ à °≈ÿࡇªÑ“À¡“¬ ”À√—∫ºŸâ „™â·π«∑“ßπ’È ‰¥â·°à ·æ∑¬å ·≈–欓∫“≈ ∑’˪ؑ∫—μ‘ß“π„π‚√ß欓∫“≈∑ÿ°√–¥—∫„πª√–‡∑»‰∑¬ ∑’Ë„Àâ°“√¥Ÿ·≈ºŸâªÉ«¬´÷Ëß¡’Õ“°“√ª«¥‡©’¬∫æ≈—π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—π ·ºπ¿Ÿ¡‘∑Ë’ 1 ·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—π ºŸÈªË«¬¡’Õ“°“√ª«¥‡©’¬∫æ≈—π ¡’ “‡Àμÿ∑’Ë∑”„Àȇ°‘¥ √—°…“ “‡Àμÿ 1 Õ“°“√ª«¥√Ë«¡¥È«¬ ¢ÕßÕ“°“√ª«¥ 2 ª√–‡¡‘π√–¥—∫§«“¡ª«¥ ‰¡Ë„™Ë 3 Õ“°“√ª«¥μÈÕß°“√°“√√—°…“ „™Ë 4 °“√√–ß—∫ª«¥‡©’¬∫æ≈—π : ë °“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬„™â¬“ ë °“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬‰¡à„™â¬“ ë °“√√–ß—∫ª«¥·∫∫º ¡º “π ‰¡Ë„™Ë 5 °“√√–ß—∫ª«¥‰¥Èº≈¥’ ‡≈◊Õ°«‘∏’°“√√—°…“∑’ˇÀ¡“– ¡ À√◊Õª√÷°…“ºŸÈ‡™’ˬ«™“≠ (∂È“¡’) „™Ë ‡°‘¥Õ“°“√·∑√°´ÈÕπ „™Ë 6 ®“°°“√√—°…“À√◊Õ‰¡Ë 7 √—°…“Õ“°“√·∑√°´ÈÕπ ‰¡Ë„™Ë 8 ª√–‡¡‘π´È”·≈–∫—π∑÷°2 *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***
    •  √ÿª§”·π–π” ”À√—∫°“√√–ß—∫ª«¥‡©’¬∫æ≈—πμ“¡·π«∑“ß·ºπ¿Ÿ¡‘∑’Ë 1 1. °≈àÕß∑’Ë 1: ºŸâª«¬¡’ ‚√§ª√–®”μ—«∑’ˇ°’ˬ«¢âÕß°—∫Õ“°“√ª«¥À√◊Õ‰¡à É §”·π–π”: §«√ª√–‡¡‘π ¿“æºŸª«¬‡æ◊ÕÀ“ “‡Àμÿ∑‡°’¬«¢âÕß·≈–„Àâ°“√√—°…“Õ“°“√ª«¥μ“¡ “‡Àμÿ â É Ë Ë’ Ë 2. °≈àÕß∑’Ë 2: °“√ª√–‡¡‘π√–¥—∫§«“¡ª«¥¢ÕߺŸâª«¬ (pain assessment) É §”·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⧫“¡√Ÿ·°àºª«¬‡√◊Õß°“√√–ß—∫ª«¥·≈–„À⺪«¬‰¥â¡ «π√à«¡„π°“√μ—¥ ‘π„®‡≈◊Õ° â Ÿâ É Ë Ÿâ É ’ à «‘∏’°“√√–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°“√√—°…“§«√¡’§«“¡√Ÿ‡°’¬«°—∫¬“·°âª«¥ª√–‡¿∑μà“ßÊ ∑—ß°≈‰°°“√ÕÕ°ƒ∑∏‘Ï â Ë È ¢π“¥¬“ ¢âÕ§«√√–«—ß ¢âÕÀâ“¡ Õ“°“√·∑√°´âÕπ œ≈œ 2) ‡≈◊Õ°„™â¬“·°âª«¥μ“¡√–¥—∫§«“¡√ÿπ·√ߢÕßÕ“°“√ª«¥∑’‡°‘¥¢÷π®√‘ßÀ√◊Õ§“¥«à“ Ë È ®–‡°‘¥¢÷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¬“¡’®¥¡ÿßÀ¡“¬‡æ◊Õ π—∫ πÿπ„Àâ°“√√—°…“§«“¡ ÿ à Ë ª«¥®“°°“√„™â¬“‰¥âº≈¥’¢÷Èπ‚¥¬‰¡à¡’®¥¡ÿàßÀ¡“¬∑’Ë®–∑¥·∑π°“√„™â¬“·°âª«¥ ÿ 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“°“√·∑√°´âÕ𠧔·π–π”: 1)  “¡“√∂„À⬓√—°…“Õ“°“√·∑√°´âÕπ‰¥âμÈß·μà‡√‘Ë¡¡’Õ“°“√ — 2) À“°„™â¬“¢π“π‡¥’¬«‰¡à‰¥âº≈ “¡“√∂„™â¬“∑’¡°≈‰°ÕÕ°ƒ∑∏‘μ“ß°—π¡“„™â‡ √‘¡ƒ∑∏‘°π‰¥â Ë ’ Ïà Ï— 8. °≈àÕß∑’Ë 8: °“√ª√–‡¡‘πÕ“°“√ª«¥´È”·≈–°“√∫—π∑÷°º≈°“√ª√–‡¡‘𠧔·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)*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢Õ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** â 3
    •  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ §”Õ∏‘∫“¬·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥‡©’¬∫æ≈—π1. °“√√—°…“ “‡Àμÿ∑’ˇ°’ˬ«¢âÕß°—∫Õ“°“√ª«¥ (°≈àÕß∑’Ë 1) §”·π–π”: §«√ª√–‡¡‘π ¿“æºŸâª«¬‡æ◊ËÕÀ“ “‡Àμÿ∑’ˇ°’ˬ«¢âÕß·≈–„Àâ°“√√—°…“Õ“°“√ª«¥μ“¡ “‡Àμÿ É °“√√–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≈∑’쥇™◊ÕμâÕß√—°…“°“√μ‘¥‡™◊Õ ‡ªìπμâπ Ë‘ È È °√≥’∑’Ë¡’§«“¡ª«¥‡©’¬∫æ≈—π ‚¥¬ºŸâªÉ«¬Õ¬Ÿà„π ¿“æ∑’Ë ‰¡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√–‡¡‘πμ—ß·μà‡√‘¡μâπ√—°…“ ·≈–ª√–‡¡‘πÀ≈—ß„Àâ°“√√—°…“ ∑—ߢ≥–ºŸª«¬æ—°·≈–¢≥–¡’°“√¢¬—∫μ—« ´÷ߧ«“¡ª«¥‡ªì𧫓¡ È Ë È â É Ë√Ÿâ ÷° à«π∫ÿ§§≈ ·≈–‰¡à‡À¡◊Õπ°—π∑ÿ°§π ·μà≈–∫ÿ§§≈®–¡’ª®®—¬Õ◊Ëπ‡¢â“¡“‡°’ˬ«¢âÕß ‡™àπ Õ“√¡≥å ª√– ∫°“√≥å 퇥‘¡ ¥—ßπ—π°“√∫Õ°√–¥—∫§«“¡ª«¥¥â«¬μ—«¢ÕߺŸª«¬®÷߇ªìπ«‘∏ª√–‡¡‘π∑’‡À¡“– ¡∑’ ¥ ‡§√◊Õß¡◊Õ ”À√—∫ª√–‡¡‘π È â É ’ Ë Ë ÿ ˧«“¡√ÿπ·√ߢÕߧ«“¡ª«¥¥Ÿ„π√Ÿª∑’Ë 13. Õ“°“√ª«¥μâÕß°“√°“√√—°…“À√◊Õ‰¡à (°≈àÕß∑’Ë 3) §”·π–π”: §«√„À⧫“¡√Ÿâ·°àºŸâªÉ«¬‡√◊ËÕß°“√√—°…“Õ“°“√ª«¥·≈–„À⺟âªÉ«¬‰¥â¡’ à«π√à«¡„π°“√μ—¥ ‘π„®‡≈◊Õ°«‘∏’°“√√—°…“Õ“°“√ª«¥¥â«¬μ—«‡Õß ºŸª«¬∑’¡§«“¡ª«¥·¡â‡≈Á°πâÕ¬·μà∂“μâÕß°“√°“√√–ß—∫ª«¥ „Àâ殓√≥“‡≈◊Õ°«‘∏°“√μ“¡§«“¡‡À¡“– ¡ â É Ë ’ â ‘ ’„π°√≥’∑ºª«¬¡’ª≠À“‡√◊Õß°“√ ◊Õ “√μâÕ߉¥â√∫°“√¥Ÿ·≈‡ªìπ摇»…´÷ß„π·π«∑“ßπ’¬ß‰¡à ‰¥â√«∫√«¡‰«â ·æ∑¬åºŸâ ’Ë Ÿâ É í Ë Ë — Ë È—„Àâ°“√√—°…“§«√æ‘®“√≥“°“√¥Ÿ·≈‡ªìπ√“¬Ê ‰ª °√≥’∑∑√“∫≈à«ßÀπâ“«à“®–¡’§«“¡ª«¥‡°‘¥¢÷𠇙à𠧫“¡ª«¥®“°°“√ºà“μ—¥ °“√„À⧫“¡√Ÿ‡°’¬«°—∫§«“¡ª«¥ Ë’ È â Ë·°àºª«¬μ—ß·μà°Õπºà“μ—¥  “¡“√∂™à«¬„À⧫“¡ª«¥¢ÕߺŸª«¬≈¥≈ß ºŸª«¬§≈“¬§«“¡«‘μ°°—ß«≈ ·≈–‡æ‘¡§«“¡ Ÿâ É È à â É â É Ëæ÷ßæÕ„®μàÕ°“√√—°…“‰¥â  ”À√—∫°√≥’∑’˺Ÿâª«¬¡’Õ“°“√ª«¥‡°‘¥¢÷Èπ·≈â« °“√„À⧔·π–π”¬—ß§ß¡’ª√–‚¬™πå ‚¥¬ ə૬„À⺪«¬‡¢â“„®·≈–„À⧫“¡√à«¡¡◊Õ„π°“√√—°…“¡“°¢÷π ºŸâ„Àâ°“√√—°…“®÷ߧ«√„À⧔·π–π”ºŸª«¬‡°’¬«°—∫°“√ Ÿâ É È â É Ë√—°…“Õ“°“√ª«¥¥—ßμàÕ‰ªπ’È ºŸª«¬§«√‰¥â√∫°“√Õ∏‘∫“¬∂÷ߧ«“¡ª«¥À≈—ߺà“μ—¥ «à“§«“¡ª«¥¢Õß·μà≈–§π®–‰¡à‡À¡◊Õπ°—π ¢÷π°—∫™π‘¥ â É — ÈÀ√◊Õ¢π“¥¢Õß·º≈ºà“μ—¥ ·μà∂ß·¡â«“®–‰¥â√∫°“√ºà“μ—¥™π‘¥‡¥’¬«°—π°ÁÕ“®®–ª«¥‰¡à‡À¡◊Õπ°—π‰¥â·≈–§«“¡ª«¥ ÷ à —4 *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***
    • Numerical ‰¡àª«¥ ª«¥ª“π°≈“ß ª«¥¡“°∑’Ë ÿ¥ rating scale (NRS) 0 1 2 3 4 5 6 7 8 9 10 ºŸâªÉ«¬ ◊ËÕ “√ Verbal rating scale ‰¥â¥’ (VRS) ‡§√◊ËÕß¡◊Õ ‰¡àª«¥ ª«¥ ª«¥ ª«¥¡“° ª«¥ ‡≈Á°πâÕ¬ ª“π°≈“ß ¡“°∑’Ë ÿ¥ ª√–‡¡‘π Visual analog scale (VAS) √–¥—∫ ‰¡àª«¥ ª«¥¡“°∑’ ÿ¥ Ë §«“¡ª«¥ ºŸâªÉ«¬ ◊ËÕ “√ Face pain assessment ‰¥â®”°—¥ scale 0 2 4 6 8 10 ‰¡àª«¥ ª«¥¡“°∑’ ÿ¥ Ë√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)À≈—ߺà“μ—¥®–≈¥≈߇¡◊ËÕ‡«≈“ºà“π‰ª °“√√–ß—∫ª«¥ “¡“√∂∑”‰¥â∑—Èß°“√„™â¬“·≈–‰¡à „™â¬“ ºŸâªÉ«¬§«√∫Õ°·æ∑¬å∑Ë¥Ÿ·≈«à“ μπ¡’ª√– ∫°“√≥å ’μàÕ°“√∫”∫—¥§«“¡ª«¥À≈—ߺà“μ—¥Õ¬à“߉√∫â“ß ·≈–¡’¿“«–·∑√°´âÕπÕ¬à“߉√ °“√√–ß—∫ª«¥∑’¥®–∑”„À⺪«¬øóπ Ë’ Ÿâ É ôμ—«‰¥â‡√Á«¢÷Èπ ºŸª«¬¡’ ∑∏‘·≈–§«“¡™Õ∫∏√√¡„π°“√√—∫°“√∫”∫—¥§«“¡ª«¥Õ¬à“߇μÁ¡∑’Ë ·μà∂ß·¡â«“§«“¡ª«¥À≈—ߺà“μ—¥ â É ‘ ÷ à®–‰¥â√—∫°“√∫”∫—¥Õ¬à“ߥ’·≈â« ºŸâªÉ«¬Õ“®¡’§«“¡ª«¥Õ¬Ÿà∫â“ß´÷Ëߧ«√®–Õ¬Ÿà„π√–¥—∫∑’ˬա√—∫‰¥â ºŸâªÉ«¬§«√‡ªìπºŸâª√–‡¡‘𧫓¡ª«¥À≈—ߺà“μ—¥¥â«¬μπ‡Õß ¬°‡«âπºŸâ∑’Ë ‰¡à “¡“√∂ª√–‡¡‘𧫓¡ª«¥‰¥â „Àℙ⇧√◊Õß¡◊Õ∑’‡À¡“– ¡°—∫ºŸª«¬·μà≈–§π ·≈–„À⺪«¬∫Õ°√–¥—∫§«“¡ª«¥‡¡◊Õ‰¥â√∫°“√ Õ∫∂“¡®“°‡®â“Àπâ“∑’Ë Ë Ë â É Ÿâ É Ë — ºŸª«¬‰¡à§«√«‘μ°°—ß«≈‡°’¬«°—∫§«“¡‡ ’¬ß„π°“√μ‘¥¬“·°âª«¥ ‡π◊Õß®“°√–¬–‡«≈“„π°“√„À⬓‡ªìπ√–¬– â É Ë Ë Ë‡«≈“ —Èπ ·μàºâªÉ«¬Õ“®¡’¿“«–·∑√°´âÕπ®“°°“√„™â¬“‰¥â ‡™àπ ∑âÕߺŸ° §≈◊Ëπ‰ âÕ“‡®’¬π ·≈–¿“«–ßà«ß´÷¡ Ÿ ∂⓺Ÿª«¬¡’Õ“°“√ª«¥¡“°¢÷π·≈–‰¡à “¡“√∂∫”∫—¥‰¥â¥«¬¬“∑’ˉ¥â√∫À√◊Õ¡’¿“«–·∑√°´âÕ𠧫√·®âß„Àâ·æ∑¬å â É È â —ºŸ¥·≈∑√“∫∑—π∑’ âŸ4. °“√√–ß—∫ª«¥‡©’¬∫æ≈—π (°≈àÕß∑’Ë 4) §«√™’·®ß„À⺪«¬∑√“∫«à“ μ—«ºŸª«¬¡’§«“¡ ”§—≠¡“°„π°“√√–ß—∫ª«¥„Àâ ‰¥âº≈¥’ ‚¥¬ºŸª«¬μâÕß„À⧫“¡ È Ÿâ É â É â É*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢Õ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** â 5
    •  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬√à«¡¡◊Õ„π°“√„Àâª√–«—짫“¡ª«¥·≈–‚√§μà“ßÊ ∑’‡ªìπÕ¬à“ß≈–‡Õ’¬¥ √«¡∑—ß¡’ «π√à«¡„π°“√ª√–‡¡‘π√–¥—∫§«“¡ ‘ Ë È à√ÿπ·√ߢÕߧ«“¡ª«¥∑’°”≈—ߪ√– ∫·≈–·®âß„Àâ·æ∑¬åÀ√◊Õ欓∫“≈∑√“∫‡¡◊Õ°“√√–ß—∫ª«¥¬—߉¥âº≈‰¡à¥æÕÀ√◊Õ Ë Ë ’¡’¿“«–·∑√°´âÕπ‡°‘¥¢÷Èπ ‡æ◊ËÕ„Àâ°“√¥Ÿ·≈√—°…“∑”‰¥â∑π∑à«ß∑’ — °“√«“ß·ºπ°“√√—°…“„À⧔π÷ß∂÷ßªí®®—¬μàÕ‰ªπ’È ¥â«¬ ‡™à𠧫“¡‡™◊Õ¢ÕߺŸª«¬ ·≈–¢π∫∏√√¡‡π’¬¡ª√–‡æ≥’ Ë â ɧ«“¡°≈—«¢ÕߺŸâªÉ«¬ (‡™àπ °≈—«μ‘¥¬“) º≈°√–∑∫¢Õߧ«“¡ª«¥ (‡™àπ μàÕ™’«‘짫“¡‡ªìπÕ¬Ÿà ·≈–Õ“√¡≥å)®ÿ¥¡ÿàßÀ¡“¬¢ÕߺŸâªÉ«¬ (‡™àπ √–¥—∫§«“¡ª«¥∑’˺ŸâªÉ«¬¬Õ¡√—∫‰¥â) °“√„™â«‘∏’°“√√—°…“Õ◊Ëπ∑’Ë ‰¡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°≈ÿ¡ paracetamol, nonsteroidal anti-inflammatory drugs, opioids, àlocal anesthetic ·≈–¬“„π°≈ÿà¡ adjuvants æ‘®“√≥“°“√„™â¬“·°âª«¥¥—ßπ’È 1. ‡≈◊Õ°„™â™π‘¥¢Õ߬“·≈–°“√∫√‘À“√¬“μ“¡§«“¡√ÿπ·√ߢÕߧ«“¡ª«¥ (√Ÿª∑’Ë 2) 3 2 1√Ÿª∑’Ë 2 ∫—π‰¥ 3 ¢—π  ”À√—∫‡≈◊Õ°„™â™π‘¥¢Õ߬“·≈–°“√∫√‘À“√¬“μ“¡§«“¡√ÿπ·√ߢÕߧ«“¡ª«¥  “¡“√∂„™â¬“‡ √‘¡ È ·≈–¬“™“‡©æ“–∑’Ë ‡ √‘¡ƒ∑∏‘Ϭ“·°âª«¥‰¥â6 *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***
    • 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«¥¥’¢È÷π≈¥¢π“¥¢Õ߬“·≈–≈¥º≈¢â“߇§’¬ß¢Õ߬“·°âª«¥·μà≈–¢π“π≈ß °“√∫√‘À“√¬“ Opioid °“√∫√‘À“√¬“ opioid ∑“ßÀ≈Õ¥‡≈◊Õ¥¥” (IV) ·≈–∑“ß°≈â“¡‡π◊ÕÀ√◊Õ„μ⺫Àπ—ß (IM/SC) · ¥ß„π·ºπ¿Ÿ¡‘ È ‘∑’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 ‰¥â·°à 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≈’Ë¬π§«“¡§‘¥·≈–æƒμ‘°√√¡¢ÕߺŸâªÉ«¬ ´÷Ëß®–™à«¬„À⺟âªÉ«¬ “¡“√∂§«∫§ÿ¡§«“¡ª«¥‰¥â¥’¢÷Èπ Physical therapy ‰¥â·°à 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⺪«¬ ∫“¬ ·°â ‰¢§«“¡º‘¥ª°μ‘„π°“√∑”ß“π¢Õß√à“ß°“¬ Ÿâ É∑“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—π°“√„™â non-pharmacological therapy „π°“√√–ß—∫ª«¥‡©’¬∫æ≈—π®÷ß¡’®¥¡ÿßÀ¡“¬‡æ◊Õ π—∫ πÿπ È ÿ à Ë„Àâ°“√√—°…“§«“¡ª«¥®“°°“√„™â¬“‰¥â¥’¢÷Èπ‚¥¬‰¡à¡’®¥¡ÿàßÀ¡“¬∑’Ë®–∑¥·∑π°“√„™â¬“·°âª«¥ ÿ °“√√–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‘*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢Õ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** â 7
    •  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ ·ºπ¿Ÿ¡‘∑’Ë 2 °“√∫√‘À“√¬“ opioid ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”·∫∫§√—Èߧ√“« (IV titration)3 ºŸÈªË«¬μÈÕß°“√¬“·°Èª«¥ °“√‡μ√’¬¡¬“ ë Morphine ‡μ√’¬¡‡ªìπ 1 mg/ml ª√–‡¡‘π´È” ë Pethidine ‡μ√’¬¡‡ªìπ 10 mg/ml լ˓ߠ¡Ë”‡ ¡Õ ‰¡Ë„™Ë ߥ¬“¡◊ÈÕμËÕ‰ª√Õ®π°«Ë“ Sedation score < 2 „™Ë Sedation score < 2 ‰¡Ë„™Ë √“¬ß“π ·≈– RR > 10/min ¬—ß¡’Õ“°“√ª«¥ RR > 10/min1 Õ“®μÈÕß„ÀȬ“ naloxone ·æ∑¬Ï ‰¡Ë¡’ hypotension §√—Èß≈– 0.1 mg IV „™Ë ‰¡Ë„™Ë ªØ‘∫—μ‘μ“¡·π«∑“ßæ—≤π“ ‰¥È¬“ < 3 §√—Èß √“¬ß“π °“√√–ß—∫ª«¥¢Õß TASP „π 15 π“∑’ ·æ∑¬Ï (·ºπ¿Ÿ¡‘∑’Ë 1) „™Ë ‰¡Ë„™Ë ‰¡Ë„™Ë Õ“¬ÿ < 70 ª’ ª«¥¡“° pain score ≥ 7 §Õ¬ ~ 5 π“∑’ „™Ë „™Ë ‰¡Ë„™Ë ª«¥¡“° „ÀȬ“ 1 ¡≈. „ÀȬ“ 0.5 ¡≈. pain score ≥ 7 „™Ë „ÀȬ“ 1 ¡≈. „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‘)8 *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***
    • ·ºπ¿Ÿ¡‘∑’Ë 3 °“√∫√‘À“√¬“ opioid ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”·∫∫μ“¡‡«≈“ (IV around the clock)3 ∂÷߇«≈“©’¥¬“μ“¡‡«≈“∑’Ë°”Àπ¥ ‰¡Ë„™Ë ª√–‡¡‘π´È” ºŸÈªË«¬μÈÕß°“√¬“·°Èª«¥ լ˓ߠ¡Ë”‡ ¡Õ „™Ë Sedation score < 2, RR > 10/min1 ‰¡Ë¡’ hypotension §” —Ëß°“√√—°…“ Morphine IV (μ“¡‡«≈“∑’Ë°”Àπ¥) „™Ë (æ‘®“√≥“μ“¡Õ“¬ÿ πÈ”Àπ—°μ—« ©’¥¬“μ“¡§” —Ëß°“√√—°…“2 ·≈–√–¥—∫§«“¡ª«¥) ë 1-2 mg iv 2 hr ë 2-3 mg iv 3 hr ª√–‡¡‘πºŸÈªË«¬´È”À≈—ß©’¥¬“ 5-10 π“∑’ ë 3-4 mg iv 4 hr Sedation score < 2 ‰¡Ë„™Ë √“¬ß“π RR > 10/min ·æ∑¬Ï „™Ë ‰¡Ë„™Ë ª√–‡¡‘π´È” ߥ¬“¡◊ÈÕμËÕ‰ª ºŸÈªË«¬¢Õ¬“Õ’° լ˓ߠ¡Ë”‡ ¡Õ √Õ®π°«Ë“ „™Ë Sedation score < 2 ·≈– RR > 10/min Sedation score < 2 ‰¡Ë„™Ë √“¬ß“π Õ“®μÈÕß„ÀȬ“ naloxone RR > 10/min ·æ∑¬Ï §√—Èß≈– 0.1 mg IV „™Ë √“¬ß“π·æ∑¬Ï §√∫‡«≈“©’¥¬“μ“¡§” —Ëß°“√√—°…“ ‰¡Ë„™Ë ∂È“ºŸÈªË«¬¢Õ¬“‡°‘π μ“¡§” —Ëß 2 §√—Èß„π‡«≈“∑’Ë°”Àπ¥ „™Ë ë §” —Ëß BTP ≈¥¢π“¥¬“≈ß 25% „ÀȬ“´È”„π¢π“¥‡¥‘¡ √–À«à“ß¡◊ÈÕ3 „π§√—ÈßμËÕ‰ª ë ‡æ‘Ë¡¢π“¥¬“Õ’° 50% „π§√—ÈßμàÕ‰ª 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‘)*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢Õ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** â 9
    •  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ ·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 §” —Ëß°“√√—°…“ IM prn q 2 hr RR > 10 /min1 Õ“¬ÿ (ª’) Morphine (mg) Pethidine (mg) 20-59 5.0-10.0 50-100 „™Ë 60-85 2.5-5.0 25-50 ©’¥¬“μ“¡¢π“¥∑’Ë°”Àπ¥2 > 85 2.0-3.0 20-30 ª√–‡¡‘πºŸÈªË«¬´È”À≈—ß©’¥¬“ 30 π“∑’ Sedation score < 2 ‰¡Ë „™Ë √“¬ß“π RR > 10 /min ·æ∑¬Ï „™Ë ‰¡Ë „™Ë ª√–‡¡‘π´È” ߥ¬“¡◊ÈÕμËÕ‰ª √Õ®π°«Ë“ ºŸÈªË«¬¢Õ¬“Õ’° լ˓ߠ¡Ë”‡ ¡Õ Sedation score < 2 „™Ë ·≈– RR > 10 /min Sedation score < 2 ‰¡Ë „™Ë √“¬ß“π Õ“®μÈÕß„ÀȬ“ naloxone RR > 10 /min ·æ∑¬Ï §√—Èß≈– 0.1 mg IV „™Ë √“¬ß“π·æ∑¬Ï ©’¥¬“§√—Èß ÿ¥∑È“¬ ‰¡Ë „™Ë ∂È“ºŸÈªË«¬¢Õ¬“‡°‘π ‡°‘π 2 ™—Ë«‚¡ß·≈È« 2 §√—Èß„π 2 ™¡. „™Ë „ÀȬ“´È”‰¥È „π¢π“¥‡¥‘¡®π∑ÿ‡≈“ ‡æ‘Ë¡¢π“¥¬“Õ’° 50% ≈¥¢π“¥¬“≈ß 25% „π§√—ÈßμËÕ‰ª „π§√—ÈßμËÕ‰ª 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“¬ÿºÈªË«¬) Ÿ 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‘)10 *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***
    • °“√√–ß—∫ª«¥·∫∫º ¡º “π (Multimodal analgesia) °“√„À⬓·°âª«¥‡æ’¬ß¢π“π‡¥’¬«Õ“®√–ß—∫ª«¥‰¥â ‰¡à¥‡∑à“∑’§«√ °“√‡æ‘¡¢π“¥¬“·°âª«¥∑’Ë „™â „Àâ¡“°¢÷π ’ Ë Ë È‡æ◊ËÕ欓¬“¡√–ß—∫ª«¥„Àâ ‰¥âº≈‡μÁ¡∑’Ë °ÁÕ“®‡°‘¥Õ“°“√·∑√°´âÕπ®“°¬“π—Èπ‰¥â ‡™àπ Õ“°“√§≈◊Ëπ‰ â Õ“‡®’¬π∑âÕßÕ◊¥ ·≈–°¥°“√À“¬„® ‡ªìπμâπ11 ®÷ß¡’°“√„™â¬“·°âª«¥‚¥¬«‘∏’º ¡º “πÀ√◊Õ„™â¬“À≈“¬¢π“π√à«¡°—π¢÷Èπ12‚¥¬¡’«μ∂ÿª√– ß§å‡æ◊Õ„Àâ°“√√–ß—∫ª«¥‰¥âº≈¥’¢π ‚¥¬°“√‡≈◊Õ°„™â¬“À≈“¬¢π“π∑’ÕÕ°ƒ∑∏‘¥«¬«‘∏°“√∑’μ“ß°—π — Ë ÷È Ë Ïâ ’ ËàÀ√◊ÕÕÕ°ƒ∑∏‘Ïμà“ß∑’Ë°—π ‚¥¬∑’ˬ“·μà≈–¢π“π®–‡ √‘¡ƒ∑∏‘Ï°—π ·≈–≈¥¢π“¥¬“¢Õß·μà≈–¢π“π≈ß Õ’°∑—È߬—ߙ૬≈¥Õ“°“√·∑√°´âÕπ∑’Õ“®®–‡°‘¥®“°¬“·μà≈–¢π“π≈߉¥â¥«¬11 μ—«Õ¬à“ß ‡™àπ °“√„™â¬“™“√à«¡°—∫ NSAIDs ·≈– Ë âopioids ‡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 orlots (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 visualanalogue scale ‡™àπ‡¥’¬«°—∫°“√ª√–‡¡‘π√–¥—∫§«“¡ª«¥°Á ‰¥â º≈°“√√–ß—∫ª«¥®–¡’§«“¡ —¡æ—π∏å‚¥¬μ√ß°—∫√–¥—∫§«“¡æ÷ßæÕ„®„π°“√√–ß—∫ª«¥¢ÕߺŸª«¬ ‚¥¬æ∫«à“ â ɺŸâªÉ«¬®–¡’§«“¡æ÷ßæÕ„®¡“°À“°°“√√–ß—∫ª«¥‰¥âº≈¥’·≈–¡’√–¥—∫§«“¡ª«¥πâÕ¬°«à“ 4 §–·ππ136. 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“¬„® ‡ªìπμâπ7. «‘∏’°“√√—°…“Õ“°“√·∑√°´âÕπ (°≈àÕß∑’Ë 7) §”·π–π”: 1)  “¡“√∂„À⬓√—°…“Õ“°“√·∑√°´âÕπ‰¥âμ—Èß·μà‡√‘Ë¡¡’Õ“°“√ 2) À“°„™â¬“¢π“π‡¥’¬«‰¡à ‰¥âº≈ “¡“√∂„™â¬“∑’¡°≈‰°ÕÕ°ƒ∑∏‘μ“ß°—π¡“„™â‡ √‘¡ƒ∑∏‘°π‰¥â Ë ’ Ïà Ï— «‘∏’°“√√—°…“Õ“°“√·∑√°´âÕπ „π∑’Ëπ’È®–°≈à“«∂÷߇©æ“–Õ“°“√·∑√°´âÕπ®“° opioid ‡∑à“π—Èπ  à«π°“√√—°…“Õ“°“√·∑√°´âÕπÕ◊ËπÊ  “¡“√∂¥Ÿ√“¬≈–‡Õ’¬¥‰¥â „π¿“§ºπ«°*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢Õ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** â 11
    •  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ º≈‰¡àæ÷ߪ√– ß§å¢Õß opioids ∑’Ë ”§—≠ ¡’¥—ßπ’È 1. Õ“°“√√ÿπ·√ß·μàæ∫‰¡à∫Õ¬ §◊Õ°“√°¥°“√À“¬„® æ∫‰¥â „π°√≥’„À⬓‡°‘π¢π“¥ À√◊Õ¡’°“√„™â¬“ seda- àtive 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‰¡àμËπ ◊ 2.2 §≈◊π‰ âÕ“‡®’¬π ºŸª«¬∑’ˉ¥â opioids ®–‡°‘¥Õ“°“√§≈◊π‰ âÕ“‡®’¬πßà“¬À“°‡ªìπ ºŸª«¬À≠‘ß ¡’ª√–«—μ‘ Ë â É Ë â ɇ¡“√∂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“°“√‰¥â8. °“√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«¥∑’Ë ‰¡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«¥¢ÕߺŸâª«¬ ɉ¥â·°à μ”·Àπàß·≈–≈—°…≥–¢Õߧ«“¡ª«¥ Õ–‰√∑”„Àâ√–¥—∫§«“¡ª«¥¡“°¢÷Èπ ∂⓪√–‡¡‘π·≈â«æ∫«à“√–¥—∫§«“¡ª«¥¬—߉¡à¥¢π 欓∫“≈§«√ª√÷°…“·æ∑¬å‡æ◊Õª√—∫·ºπ°“√√—°…“μàÕ‰ª ’ ÷È Ë12 *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***
    • ¿“§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’®–°√–μÿπª≈“¬ª√– “∑√—∫√Ÿ§«“¡√Ÿ ° ·≈–∂Ÿ°·ª≈߇ªìπ —≠≠“≥ È â â â÷§«“¡ª«¥‡°‘¥¢÷𠧫“¡ª«¥∑’‡°‘¥¢÷π®–∂Ÿ°∂à“¬∑Õ¥‰ªμ“¡‡ âπª√– “∑ C fiber ·≈– Aδ fiber ‡¢â“ Ÿà ‰¢ —πÀ≈—ß È Ë È∫√‘‡«≥ dorsal horn ·≈–∂à“¬∑Õ¥°√–· ª√– “∑´÷Ë߇ªìπ —≠≠“≥§«“¡ª«¥π’È „Àâ°—∫‡´≈≈åª√– “∑μ—«∑’Ë 2‡æ◊Õ àß —≠≠“≥§«“¡ª«¥ºà“π∑“ß spinothalamic tract ‰ª¬—ß√–∫∫ª√– “∑ à«π°≈“ß·≈– ¡Õß„π√–¥—∫μà“ßÊ Ë‡™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)*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢Õ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** â 13
    •  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ °√–∫«π°“√Õ—°‡ ∫∑’ˇ°‘¥¢÷Èπ∑’˪≈“¬‡ âπª√– “∑ À“°¡’°“√À≈—Ëß “√‡§¡’ÕÕ°¡“Õ¬à“ßμàÕ‡π◊ËÕß ®–∑”„ÀâÕ“°“√ª«¥·≈–∫«¡¢¬“¬«ß‰ª√Õ∫Ê ∫√‘‡«≥∑’Ë ‰¥â√∫∫“¥‡®Á∫ ·≈–∑”„Àâ∫√‘‡«≥√Õ∫Ê °“√∫“¥‡®Á∫¡’Õ“°“√ª«¥ —¡“°°«à“ª°μ‘ ‡√’¬°°√–∫«π°“√π’È«à“ peripheral sensitization „π¢≥–‡¥’¬«°—π∑’Ë∫√‘‡«≥ dorsal horn ¢Õ߉¢ —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 ¢÷πȇ§√◊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√—∫ºŸª«¬∑’ˉ¡à “¡“√∂∫Õ°√–¥—∫§«“¡ª«¥‡ªìπμ—«‡≈¢‰¥â ‚¥¬ Õ“® â É·∫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«¬∑’Ë ‰¡à “¡“√∂∫Õ°§«“¡ª«¥‡ªìπμ—«‡≈¢‰¥â ¢âÕ·π–π” * °“√„À⧖·ππ‰¡à „™à¥Ÿ≈—°…≥– ’Àπâ“¢Õ߇¥Á°‡∑’¬∫°—∫„∫Àπâ“„π√Ÿª ·μà „À⺟âªÉ«¬™’È√ŸªÀπâ“∑’Ë· ¥ß√–¥—∫§«“¡ª«¥¢Õßμπ‡Õß „À⧖·ππμ“¡√ŸªÀπâ“∑’ˇ≈◊Õ° 0, 2, 4, 6, 8, 10 μ“¡≈Ì“¥—∫ * μ—«Õ¬à“ß°“√ Õ𠇙àπ ç√ŸªÀπâ“μàÕ‰ªπ’È®–· ¥ß„Àâ‡ÀÁπ«à“¡’§«“¡ª«¥¡“°‡∑à“‰√ √Ÿª´â“¬ ÿ¥· ¥ß«à“ ‰¡àª«¥‡≈¬ √ŸªÀπâ“∂—¥¡“· ¥ß«à“ª«¥¡“°¢÷Èπ¡“°¢÷Èπ (™’È√ŸªÀπâ“®“°´â“¬¡“¢«“) ®π∂÷ß√Ÿª¢«“ ÿ¥· ¥ß«à“ª«¥¡“°Ê „ÀâÀπŸ™’È√ŸªÀπâ“∑’Ë· ¥ß«à“ μÕππ’ÈÀπŸª«¥¡“°·§à‰Àπé * „Àâ „™â§Ì“«à“ 燮Á∫é À√◊Õ çª«¥é μ“¡§«“¡‡À¡“– ¡·°àºŸâªÉ«¬‡¥Á°·μà≈–§π 5. ‡§√◊ËÕß¡◊Õª√–‡¡‘π√–¥—∫§«“¡ª«¥Õ◊ËπÊ ‰¥â·°à 5.1 The FLACC behavioral pain scale (μ“√“ß∑’Ë 1) ‡À¡“– ”À√—∫‡¥Á°‡≈Á°À√◊ÕºŸâªÉ«¬∑’ˉ¡à‡¢â“„®¿“…“ ª√–°Õ∫¥â«¬ 5  à«π ‰¥â·°à °“√ª√–‡¡‘π°“√· ¥ßÕÕ°∑“ß„∫Àπâ“ °“√¢¬—∫¢Õߢ“ °“√‡§≈◊ËÕπ‰À«(activity) √âÕ߉Àâ ·≈–°“√μÕ∫ πÕßμàÕ°“√ª≈Õ∫‚¬π (consolability) ´÷ß·μà≈– à«π¡’§–·ππ 0-2 √«¡∑—ßÀ¡¥ Ë È10 §–·ππ 5.2 The CHEOPS behavioral pain scale15 (μ“√“ß∑’Ë 2) ‡À¡“– ”À√—∫‡¥Á°‡≈Á°À√◊ÕºŸâª«¬∑’Ë ‰¡à ɇ¢â“„®¿“…“ ‡§√◊ËÕß¡◊Õ¡’§–·ππμ—Èß·μà 4-1314 *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***
    • μ“√“ß∑’Ë 1 The FLACC behavioral pain scale15 Categories Definition Scoring  ’Àπâ“ ‡©¬ ‰¡à¬‘È¡ 0 Àπâ“쓇∫– À√◊Õ¢¡«¥§‘È« ∂Õ¬Àπ’ 1 ‰¡à π„® ‘Ëß·«¥≈âÕ¡‡ªìπ∫“ߧ√—Èß §“ß —Ëπ °—¥øíπ·πà𠇪ìπ∫àÕ¬Ê À√◊Õμ≈Õ¥‡«≈“ 2 ¢“ Õ¬Ÿà „π∑à“ª°μ‘ À√◊Õ∑à“ ∫“¬Ê 0 Õ¬Ÿà „π∑à“‰¡à ∫“¬ °√– —∫°√– à“¬ ‡°√Áß 1 ‡μ–À√◊ÕßÕ¢“¢÷Èπ 2 °“√‡§≈◊ËÕπ‰À« πÕπ‡ß’¬∫Ê ∑à“ª°μ‘ ‡§≈◊ËÕπ‰À« ∫“¬Ê 0 ∫‘¥μ—«‰ª¡“ ·ÕàπÀπâ“·ÕàπÀ≈—ß ‡°√Áß 1 μ—«ßÕ ‡°√Áß®πμ—«·¢Áß À√◊Õ —Ëπ°√–μÿ° 2 √âÕ߉Àâ ‰¡à√âÕß (μ◊ËπÀ√◊ÕÀ≈—∫°Á ‰¥â) 0 §√“ߌ◊ÕÊ À√◊Õ§√“߇∫“Ê ∫àπ‡ªìπ∫“ߧ√—Èß 1 √âÕ߉Àâμ≈Õ¥ À«’¥√âÕß  –Õ÷° –Õ◊Èπ ∫àπ∫àÕ¬Ê 2 °“√μÕ∫ πÕßμàÕ°“√ª≈Õ∫‚¬π ‡™◊ËÕøíߥ’  ∫“¬Ê 0  “¡“√∂ª≈Õ∫‚¬π¥â«¬°“√ —¡º—  ‚Õ∫°Õ¥ 查§ÿ¬¥â«¬ 1 ‡æ◊ËÕ¥÷ߥŸ¥§«“¡ π„®‡ªìπ√–¬–Ê ¬“°∑’Ë®–ª≈Õ∫‚¬πÀ√◊Õ∑”„Àâ ∫“¬ 2μ“√“ß∑’Ë 2 The CHEOPS behavioral pain scale15‡«≈“ √âÕ߉Àâ  ’Àπâ“ °“√ à߇ ’¬ß ∑à“∑“ß(≈”μ—«)  —¡º— ·º≈ ¢“ §–·ππ 1=‰¡à√Õß â 0=¬‘¡ 0=查  πÿ°√à“‡√‘ß 1=∏√√¡¥“ 1=‰¡à —¡º—  È 1= ∑à“ ∫“¬ √«¡ 2=§√“ß/√âÕ߉Àâ 1=‡©¬ À√◊Õ‰¡à查  ∫“¬Ê 2=‡Õ◊ÈÕ¡¡◊Õ¡“/ 2= ∫‘¥μ—«/‡μ–/¥÷ß 3=À«’¥√âÕß 2=‡∫â 1=∫àπÕ◊ËπÊ ‡™àπ 2=¥‘π/‡°√Áß/ È ·μ–‡∫“Ê/μ–ª∫ ¢“Àπ’/‡°√Áß/ À‘«, À“·¡à  —Ëπ/¬◊π/¥‘Èπ /‡Õ◊ÈÕ¡¡◊Õ¡“®π ¬◊π/¥‘Èπ®π∂Ÿ° 2=∫à 𠪫¥ + ∫à π ®π∂Ÿ°®—∫μ√÷ß μâÕß®—∫¡◊Õ À√◊Õ ®—∫μ√÷߉«â Õ◊ËπÊ ‰«â ·¢π‰«â06.0010.0014.00 6. ‡§√◊ËÕß¡◊Õª√–‡¡‘𧫓¡ª«¥ ”À√—∫ºŸâªÉ«¬∑’Ë ‰¡à “¡“√∂ ◊ËÕ “√¥â«¬μ—«‡Õ߉¥â „πÀÕ«‘°ƒμ À√◊ÕºŸâªÉ«¬√–¥—∫§«“¡√Ÿ °μ—«πâÕ¬≈ß §«√„™â°“√ª√–‡¡‘π®“°°“√ —߇°μæƒμ‘°√√¡·≈–°“√‡ª≈’¬π·ª≈ߢÕß —≠≠“≥™’懪ìπ â ÷ Ë√“¬Ê ‰ª*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢Õ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** â 15
    •  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬°“√√–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—°‡ ∫) ∑’¡’„™â°πÕ¬à“ß·æ√àÀ≈“¬‡π◊Õß®“°¡’§«“¡ª≈Õ¥¿—¬ Ÿß Ë — Ë “¡“√∂„™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 ’ 16serotonergic pathways ‚¥¬°≈‰°À≈—°§◊Õ¬—∫¬—ß°“√ √â“ß prostaglandins „π ¡Õß ®“°°“√ √â“ß “√ AM404 È(´÷Ëß¡’ƒ∑∏‘Ϭ—߬—È߇Õπ‰´¡å COX ‚¥¬μ√ß) ´÷ËßμâÕß¡’ fatty acid amide hydrolase (FAAH) ‡ªìπμ—«°√–μÿâπ°“√ √â“ß πÕ°®“°π’Ȭßæ∫«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¥®–‡°‘¥¢÷π¿“¬„π ’ È§√÷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 «‘∏’„™â¬“: ºŸâ „À≠à √—∫ª√–∑“π§√—Èß≈– 500-1,000 ¡°. ∑ÿ° 4-6 ™—Ë«‚¡ß ‡¡◊ËÕ¡’Õ“°“√ª«¥À√◊Õ¡’ ‰¢â ‰¡à§«√√—∫ª√–∑“π‡°‘π 4 °√—¡/«—π À√◊Õ 8 ‡¡Á¥ (¢π“¥ 500 ¡°.)/«—𠇥Á°„Àâ√—∫ª√–∑“π§√—Èß≈– 10-20 ¡°.μàÕπÈ”Àπ—°μ—« 1 °°. ∑ÿ° 4-6 ™—Ë«‚¡ß À√◊Õμ“¡¢π“¥∑’Ë·π–π”„πμ“√“ß∑’Ë 3 paracetamol  “¡“√∂„™â ‰¥â∑—Èß„À⬓‡æ’¬ß¢π“π‡¥’¬« À√◊Õ„Àâ „π√Ÿª·∫∫º ¡°—∫¬“™π‘¥Õ◊Ë𠇙àπ codeine, NSAIDs ·≈– tramadol √Ÿª·∫∫¬“∑’Ë¡’®”Àπà“¬ ¬“‡¡Á¥ ¢π“¥ 325 ¡°. ·≈– 500 ¡°. ¬“πÈ” ”À√—∫‡¥Á°·≈–∑“√° ™π‘¥πÈ”‡™◊ËÕ¡ ¡’‡π◊ÈÕ¬“ 120 ·≈– 125 ¡°./ 5 ¡≈. ™π‘¥À¬¥ 60 ¡°./0.6 ¡≈. §”‡μ◊Õπ·≈–¢âÕ§«√√–«—ß ‰¡à§«√√—∫ª√–∑“π¬“π’Èμ¥μàÕ°—ππ“π‡°‘π 7 «—π ‰¡à „™â‡°‘πª√‘¡“≥∑’Ë°”Àπ¥ ‰¡à§«√¥◊Ë¡‡À≈â“√–À«à“ß ‘∑’Ë„™â¬“π’È ·≈–‰¡à§«√„™â¬“π’È°—∫ºŸâªÉ«¬‚√§μ—∫  “¡“√∂„™â¬“π’È°—∫ μ√’¡’§√√¿å·≈– μ√’∑’Ë°”≈—ß„Àâπ¡∫ÿμ√‰¥âμ“√“ß∑’Ë 3 ¢π“¥¬“ paracetamol „π‡¥Á°·μà≈–™à«ßÕ“¬ÿ17 ¢π“¥¬“∑’Ë„™â„π‡¥Á° Õ“¬ÿ ¢π“¥ (¡°.) Õ“¬ÿ ¢π“¥ (¡°.) 0 - 3 ‡¥◊Õπ 40 6 - 8 ªï 320 4 - 11 ‡¥◊Õπ 80 9 - 10 ªï 400 1 - 2 ªï 120 11 ªï 480 2 - 3 ªï 160 12 - 14 ªï 640 4 - 5 ªï 240 > 14 ªï 65016 *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***
    • º≈¢â“߇§’¬ß¢Õ߬“ ‡°‘¥πâÕ¬¡“° ·μà „Àâ√–«—ß„π§π∑’Ë¡’Õ“°“√·æâ ‚¥¬Õ“®¡’ºËπ·¥ß∑’˺«Àπ—ß §—π ◊ ‘À√◊Õ¡’§≈◊π‰ â Õ“‡®’¬π ¬“π’®–‰¡à‡°‘¥Õ“°“√¢â“߇§’¬ß„¥Ê À“°√—∫ª√–∑“πÕ¬à“ß∂Ÿ°μâÕß„π√–¬–‡«≈“ —πÊ  ”À√—∫ Ë È ÈºŸâªÉ«¬∑’ˇªìπ‚√§μ—∫§«√≈¥¢π“¥¬“≈ß ‡æ√“–Õ“®∑”„À⇰‘¥æ‘…®“°¬“‰¥âß“¬ à 2. Nonsteroidal anti-inflammatory drugs (NSAIDs) °“√„™â¬“ NSAIDs „π°“√√–ß—∫ª«¥À≈—ß°“√ºà“μ—¥ Õ“®„™â‡æ’¬ß¢π“π‡¥’¬«„π°√≥’∑§«“¡ª«¥‰¡à√π·√ß ’Ë ÿÀ√◊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∑’Ë ‰¥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°°√–μÿπ„Àâ √â“ߢ÷π‡¡◊Õ¡’°√–∫«π°“√Õ—°‡ ∫‡°‘¥¢÷π ®–æ∫‰¥â„π‡¡Á¥‡≈◊Õ¥¢“« À≈Õ¥‡≈◊Õ¥ ·≈–‡π◊Õ‡¬◊Õª√– “∑ â È Ë È È Ë NSAIDs ·μà≈–™π‘¥¡’§«“¡ “¡“√∂„π°“√¬—∫¬—߇Õπ‰´¡å COX-1 ·≈– COX-2 ‰¥â ‰¡à‡∑à“°—π Õ—μ√“ à«π È°“√¬—∫¬—È߇Õπ‰´¡å COX-1 μàÕ COX-2 πÕ°®“°®–¡’º≈μàÕ°“√ÕÕ°ƒ∑∏‘Ï·≈â« ¬—ß®–∫Õ°∂÷ß‚Õ°“ ‡°‘¥¿“«–·∑√°´âÕπ¥â«¬ „π∑’π®–·∫àß NSAIDs ÕÕ°‡ªìπ Õß°≈ÿ¡„À≠àÊ §◊Õ°≈ÿ¡ conventional NSAIDs ‡™àπ diclofenac, Ë ’È à àaspirin, ibuprofen, ketoprofen, naproxen, mefenamic, piroxicam ·≈– meloxicam ·≈–°≈ÿà¡ COX-2specific inhibitors18 ‡™àπ celecoxib, valdecoxib, parecoxib, ·≈– etoricoxib ‚¥¬∑’Ë°≈ÿà¡ conventionalNSAIDs 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‰´¡åCOX-2 ‚¥¬‰¡à¡º≈¬—∫¬—ß°“√∑”ß“π¢Õ߇Õπ‰´¡å COX-1 ®“°°≈‰°∑’ÕÕ°ƒ∑∏‘μ“ß°—π∑”„Àâ conventional NSAIDs ’ È Ë Ïà¡’¢âÕ®”°—¥À≈“¬ª√–°“√∑’Ë®–π”¡“„™â‡æ◊ËÕ√–ß—∫ª«¥√–À«à“ß·≈–À≈—ߺà“μ—¥ „π¢≥–∑’Ë°≈ÿà¡ COX-2 specificinhibitors ¡’¢Õ¥’°«à“ conventional NSAIDs „π‡√◊Õߺ≈¢â“߇§’¬ßμàÕ√–∫∫∑“߇¥‘πÕ“À“√·≈–‰¡à¬∫¬—ß°“√∑”ß“π â Ë — È¢Õ߇°≈Á¥‡≈◊Õ¥ ·μࡺ≈‰¡àæ÷ߪ√– ß§åÀ≈“¬Õ¬à“ß∑’Ë∑”„À⺟⠄™âμÕß√–¡—¥√–«—߇™àπ‡¥’¬«°—π ’ â °“√‡≈◊Õ°„™â NSAIDs ‡π◊Õß®“°°“√„™â NSAIDs ‡æ◊Õ≈¥Õ“°“√ª«¥À≈—ß°“√ºà“μ—¥¡—°„Àâ„π√–¬–‡«≈“ —πÊ ∂Ⓡªìπ°“√ºà“μ—¥‡≈Á° Ë Ë ÈÕ“®„À⬓‡æ’¬ß§√—È߇¥’¬« ·μà∂“‡ªìπ°“√ºà“μ—¥„À≠àÕ“®„À⬓‰¡à‡°‘π 3-7 «—π °“√‡≈◊Õ°™π‘¥¢Õ߬“®÷ߧ«√‡≈◊Õ°¬“ â∑’Ë¡ª√– ‘∑∏‘¿“æ „™âßà“¬ ÕÕ°ƒ∑∏‘χ√Á« ·≈–¡’¿“«–·∑√°´âÕππâÕ¬ §«√‡≈◊Õ°„™â¬“‡æ’¬ß¢π“π‡¥’¬«„π°“√„™â¬“ ’·μà≈–§√—Èß ·≈–À≈’°‡≈’ˬ߰“√„™â¬“À“°ºŸâªÉ«¬¡’ª√–«—μ‘°“√·æ⬓„π°≈ÿà¡ NSAIDs ¢π“¥·≈–«‘∏∫√‘À“√¬“ ª√‘¡“≥°“√„™â¬“®”‡ªìπμâÕߪ√—∫„Àâ‡À¡“– ¡°—∫ºŸâªÉ«¬·μà≈–√“¬ ‚¥¬¥Ÿ®“° ’°“√μÕ∫ πÕߢÕߺŸâªÉ«¬‡ªìπÀ≈—° °“√„À⬓§«√„Àâμ“¡™à«ß‡«≈“∑’Ë°”Àπ¥®–√–ß—∫ª«¥‰¥â¥’°«à“„À⬓‡¡◊ËÕºŸâªÉ«¬¡’Õ“°“√ª«¥·≈â« «‘∏’∫√‘À“√¬“¢÷Èπ°—∫™π‘¥°“√ºà“μ—¥ «‘∏’°“√√–ß—∫ª«¥„π°“√ºà“μ—¥ ·≈–√Ÿª·∫∫¢Õ߬“∑’Ë¡’„™â*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢Õ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** â 17
    •  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬´÷ß·∫àßÕÕ°‡ªìπ Ë °“√©’¥ ‡ªìπ«‘∏’°“√∫√‘À“√¬“∑’Ë ‰¥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„™âß“¬·≈–√∫°«πºŸª«¬πâÕ¬∑’ ¥ NSAIDs  à«π„À≠à “¡“√∂„™â«∏√∫ª√–∑“π‰¥â ’ à â É Ë ÿ ‘’— ”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≈—ߺà“μ—¥‡ªìπ°“√„™â „π™à«ß —πÊ ·μà°¬ßæ∫º≈¢â“߇§’¬ß‰¥â ‡™àπ √–∫∫∑“߇¥‘πÕ“À“√ Õ“®∑”„À⇰‘¥°“√√–§“¬‡§◊Õß È Á—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 ∑”„À⇰‘¥¿“«–·∑√°´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∂“°“√∑”ß“π¢Õ߉μ∫°æ√àÕß ¡’°“√‡ ’¬‡≈◊Õ¥¡“° âÀ√◊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—«¢Õ߇°≈Á¥‡≈◊Õ¥´÷ßÕ“»—¬‡Õπ‰´¡å COX-1 ‡ªìπÀ≈—° ∑”„À⺪«¬∫“ß°≈ÿ¡ ‡™àπ ºŸª«¬ºà“μ—¥°√–¥Ÿ° ºŸª«¬ºà“μ—¥∑Õπ´‘≈ Ë Ÿâ É à â É â ɺŸâªÉ«¬ºà“μ—¥ ¡Õß ºŸâªÉ«¬∑’Ë ‰¥â√—∫¬“μâ“π°“√·¢Áßμ—«¢Õ߇≈◊Õ¥¡“°àÕπ ‡¡◊ËÕ‰¥â√—∫¬“·°âª«¥°≈ÿà¡ conventionalNSAIDs ®–¡’ ‚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 diseaseÀâ“¡„™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“߇§’¬ß¢Õß NSAIDs ∑—Èß 2 °≈ÿà¡°Á‡ªìπ¢âÕ®”°—¥„π°“√„™â¬“ μâÕß„™â¥â«¬§«“¡√–¡—¥√–«—ß·≈–‡≈’ˬ߰“√„™â„π°≈ÿࡇ ’ˬß∑—ÈßÀ≈“¬18 *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***
    • 3. Opioids ‡ªìπ¬“∑’Ë „™â „π°“√√–ß—∫ª«¥√ÿπ·√ß ·μà¡’º≈‰¡àæ÷ߪ√– ß§å ‰¥â (¥Ÿ√“¬≈–‡Õ’¬¥°≈àÕß∑’Ë 7)opioid ·∫àßÕÕ°‡ªìπ 2 °≈ÿà¡ §◊Õ opioid ∑’Ë¡’ƒ∑∏‘ÏÕÕπ·≈–∑’Ë¡’ƒ∑∏‘Ï·√ß à 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∑° 4 ™—«‚¡ß26 °“√„À⬓√à«¡°—π√–À«à“ß codeine 60 ¡°. °—∫ paracetamol ◊ ÿ Ë600-1,000 ¡°. „Àâº≈√–ß—∫ª«¥∑’Ë¥’°«à“ paracetamol Õ¬à“߇¥’¬«28 °“√√–ß—∫ª«¥®“° codeine ¢÷Èπ°—∫¢π“¥¬“∑’Ë ‰¥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°≈“ß29,30ƒ∑∏‘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∑° 4 ™—Ë«‚¡ß26 ·μà ‰¡à§«√‡°‘π 400 ¡°. ÿμàÕ«—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√—∫ºŸª«¬Õ“¬ÿμß·μà 20 ªï¢π‰ª §«√§‘¥¢π“¥¬“ morphine μ“¡Õ“¬ÿ¥°«à“§‘¥μ“¡πÈ”Àπ—°μ—«3 ‡æ√“– â É —È ÷È ’§«“¡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∑∏‘π“π¢÷π  à«π„πºŸª«¬‡¥Á°§«√„™âπÈ”Àπ—°μ—«‡ªìπ Ï È â Éμ—«°”Àπ¥¢π“¥¢Õß morphine μ“√“ß∑’Ë 4 Equianalgesic doses of opioids5 Opioids ™π‘¥©’¥ (Parenteral) Morphine 10 mg Pethidine 100 mg Fentanyl 100 microgram Tramadol 100 mg*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢Õ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** â 19
    •  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ 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∑’ËÕ“®‡°‘¥®“° 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°∑”≈“¬∑’μ∫‰¥â‡ªìπ morphine-3-glucuronide (M3G) ·≈– morphine-6-glu- Ë—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∑¡ƒ∑∏‘Ï anticholinergic √à«¡¥â«¬§◊ÕÕ“®∑”„ÀâÀ«„®‡μâπ‡√Á« ª“°§Õ·Àâß ’Ë ’ —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¢Õ߉μÀ√◊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∑∏‘ πª√–¡“≥ 30-60 π“∑’ fentanyl ∂Ÿ°∑”≈“¬∑’μ∫‰¥â‡ªìπ norfentanyl ·≈–∂Ÿ°¢—∫ÕÕ°∑“ßªí  “«– Ï —È Ë—‚¥¬¡’¬“∫“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. ¬“™“°≈ÿ¡ÕÕ°ƒ∑∏‘ π à Ï —È „™â∑«‰ª„π°“√≈¥ª«¥‡©’¬∫æ≈—π ∑’¡’„™â „πªí®®ÿ∫π‰¥â·°à lignocaine (lidocaine) ·≈– prilocaine —Ë Ë —(prilocaine ¡’„™âπâÕ¬¡“° ‡æ√“–Õ“®∑”„À⇰‘¥ methemoglobinemia ∂â“„™â‡°‘π¢π“¥ §◊Õ 600 ¡°.) Lidocaine ÕÕ°ƒ∑∏‘Ï ‰¥â‡√Á« ®—∫°—∫‚ª√μ’ππâÕ¬®÷ß¡’√–¬–‡«≈“ÕÕ°ƒ∑∏‘ π √–¬–‡«≈“∑’ÕÕ°ƒ∑∏‘¢π Ï —È Ë Ï ÷ÈÕ¬Ÿà°—∫«‘∏’°“√„Àâ ∫√‘‡«≥∑’Ë„Àâ·≈–¢π“¥¬“ °“√„Àâ lidocaine ‚¥¬°“√À¬¥μàÕ‡π◊ËÕß (infusion) „πºŸâªÉ«¬∑’Ë¡§«“¡ ’ª«¥‡©’¬∫æ≈—πÕ“®æ∫¡’¿“«–¥◊ÈÕ¬“ (tachyphylaxis) ®÷߉¡à§«√„™â20 *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***
    • 2. ¬“™“°≈ÿà¡ÕÕ°ƒ∑∏‘Ϭ“« ‰¥â·°à bupivacaine, levobupivacaine ·≈– ropivacaine ´÷ß¡’§«“¡‡°’¬«¢âÕß°—π§◊Õ bupivacaine Ë Ë‡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“¬“™“∑’‡ªìπ R-enantio- Ëmer 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°≈“߇√‘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§√’¡∑’º ¡√–À«à“ß — Ë2.5% lidocaine ·≈– 2.5% prilocaine π‘¬¡∑“„ÀâÀπ“∑’º«Àπ—߇æ◊Õ≈¥ª«¥®“°°“√·∑߇¢Á¡‡ªî¥À≈Õ¥‡≈◊Õ¥¥” Ë‘ Ë·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√– “∑∑’Ë ‰ª‡≈’¬ß∫√‘‡«≥ºà“μ—¥ ‡™àπ brachial plexus block, intercostal nerve Èblock, femoral nerve block ‚¥¬‡ âπª√– “∑°≈ÿà¡„À≠à®”‡ªìπμâÕß„™â¬“¡“°¢÷Èπ·μàμÕ߉¡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) °“√©’¥¬“™“∑“ßspinal ·≈– 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*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢Õ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** â 21
    •  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ 5. ¬“Õ◊ËπÊ ∑’Ë¡’ƒ∑∏‘χ √‘¡°“√√–ß—∫ª«¥ (Adjuvants) ‡ªìπ¬“∑’Õ“®π”¡“„™â‡ √‘¡ƒ∑∏‘°“√√–ß—∫ª«¥√à«¡°—∫¬“·°âª«¥À≈—°∑’°≈à“«¡“¢â“ßμâπ ‰¡à·π–π”„Àâ „™â Ë Ï Ë¬“„π°≈ÿ¡π’‡æ’¬ß≈”æ—߇æ√“–‰¡à “¡“√∂√–ß—∫ª«¥‰¥â‡æ’¬ßæÕ ¬“„π°≈ÿ¡π’È ‰¥â·°à N-methyl-D-aspartate (NMDA) à È àreceptor 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‘®“√≥“∂÷ߪ√– ‘∑∏‘¿“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¬“22 *** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***
    • μ“√“ß∑’Ë 5 √“¬≈–‡Õ’¬¥°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬„™â¬“ (‡√’¬ßμ“¡Õ—°…√) ¬“ √“¬≈–‡Õ’¬¥·≈–¢âÕ∫àß™’È ¢âÕ§«√√–«—ß/¢âÕÀâ“¡ Õ“°“√·∑√°´âÕπ ¢π“¥¬“„π‡¥Á° ¢π“¥¬“„πºŸâ„À≠à Bupivacaine ‡ªì𬓙“°≈ÿà¡ amide, - ¡’ cardiotoxicity §àÕπ¢â“ß Toxicity: ¡’Õ“°“√ - Infiltration/Epidural: - Infiltration/Epidural: „™â ”À√—∫ local infiltration,  Ÿß°«à“¬“™“™π‘¥Õ◊Ëπ ™“≈‘Èπ√Õ∫ª“° ¢π“¥·π–π” 2 mg/kg, 4-hourly epidural block ·≈– - ‰¡à§«√„™â∑” IV regional °√–«π°√–«“¬ 2 mg/kg, 4-hourly - Max dose ¢÷Èπ°—∫ spinal anesthesia analgesia ◊È ÀŸÕÕ ™—° À—«„®À¬ÿ¥‡μâπ - Max dose ¢÷Èπ°—∫ μ”·Àπàß∑’Ë©¥ ’ duration 200-400 π“∑’ - ¡’°“√º ¡ adrenaline μ”·Àπàß∑’Ë©’¥ - „πª√–‡∑»‰∑¬¡’ “√≈–≈“¬ 0.25-0.5% Celecoxib NSAIDs ∑’ˬ—∫¬—Èß®”‡æ“– - ·æâ sulfonamide À√◊Õ - ‰¡à·π–π”„Àâ „™â - PO: 400 mg initially μàÕ Cyclooxygenase-II (COX-II) aspirin ¥â«¬ 200 mg od À√◊Õ bid ≈¥º≈¢â“߇§’¬ßμàÕ√–∫∫∑“ß - ‰μ«“¬Õ¬à“ß√ÿπ·√ß ‡¥‘πÕ“À“√ Õ“°“√À≈Õ¥≈¡ - ·º≈„π°√–‡æ“–Õ“À“√ μ’∫ ·≈–‡°≈Á¥‡≈◊Õ¥ - ‚√§À≈Õ¥‡≈◊Õ¥À—«„®·≈–‚√§ À≈Õ¥‡≈◊Õ¥ ¡Õß â - À≈—ß°“√ºà“μ—¥ CABG/Stent - À≠‘ß¡’§√√¿å „Àâπ¡∫ÿμ√ Codeine Opioid ∑’ËÕÕ°ƒ∑∏‘ÏÕàÕπ Ë §≈◊π‰ âÕ“‡®’¬π - PO: 1 mg/kg, - PO: 30-60 mg, 4-hourly „™â ”À√—∫Õ“°“√ª«¥‡≈Á°πâÕ¬ ßà«ß´÷¡  —∫ π ‡Õ–Õ– 6-hourly - Max dose 240 mg/day ∂÷ߪ«¥ª“π°≈“ß ‚«¬«“¬ - Max dose 3 mg/kg/ ∑âÕߺŸ° day*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢Õ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** Codeine ¥Ÿ paracetamol ·≈– °“√‡æ‘Ë¡¢π“¥‚¥¬°“√‡æ‘Ë¡ ¥Ÿ paracetamol ·≈– - ¥Ÿ paracetamol ·≈– 15/30 mg + codeine ®”π«π‡¡Á¥¬“ Õ“®∑”„Àâ¬“μ—«„¥ codeine codeine Paracetamol μ—«Àπ÷Ë߇°‘π¢π“¥‰¥â 300 mg23
    • 24 μ“√“ß∑’Ë 5 √“¬≈–‡Õ’¬¥°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬„™â¬“ (‡√’¬ßμ“¡Õ—°…√) (μàÕ) ¬“ √“¬≈–‡Õ’¬¥·≈–¢âÕ∫àß™’È ¢âÕ§«√√–«—ß/¢âÕÀâ“¡ Õ“°“√·∑√°´âÕπ ¢π“¥¬“„π‡¥Á° ¢π“¥¬“„πºŸâ„À≠à Diclofenac NSAIDs ∑’Ë¡’ª√– ‘∑∏‘¿“æ Ÿß - ·æâ aspirin - ¬—∫¬—Èß°“√∑”ß“π¢Õß PO: (Õ“¬ÿ > 1 ªï) - PO: 25-50 mg, 8-hourly  ”À√—∫§«“¡ª«¥‡≈Á°πâÕ¬∂÷ß - ÀÕ∫À◊¥ ‡°≈Á¥‡≈◊Õ¥ √∫°«π 1 mg/kg, 8-hourly - deep IM: 75 mg od ª“π°≈“ß - ‰μº‘¥ª°μ‘√ÿπ·√ß À√◊Õ∑”„Àâ‡≈◊Õ¥ÕÕ° Max dose 3 mg/kg/ - IV infusion: - ·º≈„π°√–‡æ“–Õ“À“√ „π√–∫∫∑“߇¥‘π day ë °√≥’ª«¥√ÿπ·√ß: Õ“À“√ „Àâ 75 mg IV infusion - bronchospasm Ë „π 15-30 π“∑’ Õ“®‡æ‘¡Õ’° - ÀŸÕ◊ÈÕ ∫«¡ 75 mg ‚¥¬‡«âπ√–¬–°“√ ©’¥ 2-3 ™—Ë«‚¡ß ë °√≥’ª«¥À≈—ߺà“μ—¥: 25-50 mg IV infusion „π 15-30 π“∑’ μ“¡¥â«¬ 5 mg/hour  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ - Max dose 150 mg/day - IV/IM ‰¡à§«√π“π‡°‘π 2 «—π ∂â“π“π„À⇪≈’ˬπ‡ªìπ PO EMLA §√’¡º ¡ 2.5% lidocaine + - °“√¥Ÿ¥´÷¡¢÷Èπ°—∫∫√‘‡«≥·≈– √–«—ß°“√‡°‘¥ Methe- ‰¡à§«√„™â „π‡¥Á°μË”°«à“ ∑“Àπ“Ê ·≈–ªî¥‰«â 1-2 ™¡. (Eutectic 2.5% prilocaine  ”À√—∫∑“ √–¬–‡«≈“∑’Ë∑“ moglobinemia 1 ªï °àÕπ∑”À—μ∂°“√ Mixture of Àπ“Ê ·≈–ªî¥∑’˺‘«Àπ—ß - ‰¡à§«√„™â „π∫√‘‡«≥º‘«Àπ—ß∑’Ë „πºŸâªÉ«¬∑’Ë¡’¿“«–‡ ’Ë¬ß Local Anes- ¡’·º≈À√◊Õ∑’Ë mucous mem- ‡™àπ G6PD deficiency thetic) brane*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***
    • μ“√“ß∑’Ë 5 √“¬≈–‡Õ’¬¥°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬„™â¬“ (‡√’¬ßμ“¡Õ—°…√) (μàÕ) ¬“ √“¬≈–‡Õ’¬¥·≈–¢âÕ∫àß™’È ¢âÕ§«√√–«—ß/¢âÕÀâ“¡ Õ“°“√·∑√°´âÕπ ¢π“¥¬“„π‡¥Á° ¢π“¥¬“„πºŸâ„À≠à Etoricoxib NSAIDs ∑’ˬ—∫¬—Èß®”‡æ“– - ·æâ aspirin - ‰¡à·π–π”„Àâ „™â - PO: 60-120 mg od cyclooxygenase-II (COX-II) - ‰μ«“¬Õ¬à“ß√ÿπ·√ß (¢π“¥ 120 mg  ”À√—∫ ≈¥º≈¢â“߇§’¬ßμàÕ√–∫∫∑“ß - ·º≈„π°√–‡æ“–Õ“À“√ ª«¥‡©’¬∫æ≈—𠇥‘πÕ“À“√ Õ“°“√À≈Õ¥≈¡ - §«“¡¥—π‚≈À‘μ Ÿß∑’ˬ—ߧ«∫§ÿ¡ ‰¡à§«√„™âπ“π°«à“ 8 «—π) μ’∫ ·≈–‡°≈Á¥‡≈◊Õ¥ ‰¡à¥’ - ‚√§À≈Õ¥‡≈◊Õ¥À—«„®·≈–‚√§ À≈Õ¥‡≈◊Õ¥ ¡Õß - À≈—ß°“√ºà“μ—¥ CABG/Stent - À≠‘ß¡’§√√¿å „Àâπ¡∫ÿμ√ Fentanyl Opioid ™π‘¥ —߇§√“–Àå - ≈¥¢π“¥„πºŸâ ŸßÕ“¬ÿ °¥°“√À“¬„®·≈– - IV bolus:  ”À√—∫‡¥Á° - IV bolus:0.001-0.005 mg/ ≈–≈“¬„π‰¢¡—π‰¥â¥’ - °¥°“√À“¬„® √–∫∫°“√‰À≈‡«’¬π ‰∑¬∑’Ë ‰¡à ‰¥â on venti- kg (up to 0.05 mg/kg) cardiostability Epidural/spinal: §—π ·≈– ‡≈◊Õ¥„π¢π“¥ ŸßÕ“® lator „Àâμ“¡Õ“¬ÿ: - Epidural: 0.025-0.1 mg â duration 30-60 π“∑’ delayed respiratory ‡°‘¥ muscle rigidity ë ∑“√°§≈Õ¥°àÕπ (º ¡°—∫¬“™“À√◊Õ saline) depression °”Àπ¥ „Àâ 0.0003 - Spinal: 0.005-0.02 mg mg/kg p.r.n. q 2 hr ë ∑“√°§≈Õ¥§√∫ °”Àπ¥ „Àâ 0.0003-0.0005 mg/*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢Õ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** kg p.r.n. q 2 hr ë Õ“¬ÿ >1 ‡¥◊Õπ ·≈– ‡¥Á°‚μ „Àâ 0.0005- 0.001 mg/kg p.r.n.25 q 2 hr
    • 26 μ“√“ß∑’Ë 5 √“¬≈–‡Õ’¬¥°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬„™â¬“ (‡√’¬ßμ“¡Õ—°…√) (μàÕ) ¬“ √“¬≈–‡Õ’¬¥·≈–¢âÕ∫àß™’È ¢âÕ§«√√–«—ß/¢âÕÀâ“¡ Õ“°“√·∑√°´âÕπ ¢π“¥¬“„π‡¥Á° ¢π“¥¬“„πºŸâ„À≠à Fentanyl ë ‡¡◊ËÕ on ventilator „Àâª√—∫‡æ‘Ë¡¢π“¥„Àâ ‡À¡“– ¡ - IV Infusion:  ”À√—∫ ‡¥Á ° ‰∑¬∑’Ë ‰ ¡à ‰¥â on ventilator „Àâμ“¡Õ“¬ÿ: ë ∑“√°§≈Õ¥°àÕπ °”Àπ¥ „Àâ 0.0003 mg/kg/hr ë ∑“√°§≈Õ¥§√∫ °”Àπ¥ „Àâ 0.0003-  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ 0.0005 mg/kg/hr ë Õ“¬ÿ >1 ‡¥◊Õπ ·≈– ‡¥Á°‚μ „Àâ 0.0005- 0.001 mg/kg/hr ë ‡¡◊ËÕ on ventilator „Àâª√—∫‡æ‘Ë¡¢π“¥„Àâ ‡À¡“– ¡*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***
    • μ“√“ß∑’Ë 5 √“¬≈–‡Õ’¬¥°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬„™â¬“ (‡√’¬ßμ“¡Õ—°…√) (μàÕ) ¬“ √“¬≈–‡Õ’¬¥·≈–¢âÕ∫àß™’È ¢âÕ§«√√–«—ß/¢âÕÀâ“¡ Õ“°“√·∑√°´âÕπ ¢π“¥¬“„π‡¥Á° ¢π“¥¬“„πºŸâ„À≠à Ibuprofen NSAIDs  ”À√—∫§«“¡ª«¥ - ·æâ aspirin È - ¬—∫¬—ß°“√∑”ß“π¢Õß - PO: 6-10 mg/kg tid - PO: 400 mg qid ‡≈Á°πâÕ¬∂÷ߪ“π°≈“ß - ÀÕ∫À◊¥ ‡°≈Á¥‡≈◊Õ¥ √∫°«π À√◊Õ 5 mg/kg qid º≈¢â“߇§’¬ßπâÕ¬∑’Ë ÿ¥„π - ‰μº‘¥ª°μ‘√ÿπ·√ß À√◊Õ∑”„Àâ‡≈◊Õ¥ÕÕ°„π (BW >7 kg) °≈ÿà¡ NSAIDs - ·º≈„π°√–‡æ“–Õ“À“√ √–∫∫∑“߇¥‘πÕ“À“√ - bronchospasm - ÀŸÕ◊ÈÕ ∫«¡ Indometha- NSAIDs  ”À√—∫§«“¡ª«¥ - ·æâ aspirin È - ¬—∫¬—ß°“√∑”ß“π¢Õß - - PO: 50-100 mg bid cin ª“π°≈“ß Õÿ∫—μ‘°“√≥å¢Õß - ÀÕ∫À◊¥ ‡°≈Á ¥ ‡≈◊ Õ ¥ √∫°«π Õ“°“√·∑√°´âÕπ Ÿß - ‰μº‘¥ª°μ‘√ÿπ·√ß À√◊Õ∑”„Àâ‡≈◊Õ¥ÕÕ°„π - ·º≈„π°√–‡æ“–Õ“À“√ √–∫∫∑“߇¥‘πÕ“À“√ - bronchospasm - ÀŸÕ◊ÈÕ ∫«¡ â Ketamine Phencyclidine derivative - §«“¡¥—π‚≈À‘μ Ÿß - §«“¡¥—π‚≈À‘μ §«“¡ - -  ”À√—∫√–ß—∫ª«¥ ∑”„À⇰‘¥ dissociative - ‡Õ–Õ–‚«¬«“¬ ¥—π„π°–‚À≈°»’√…– 0.05-0.1 mg/kg/hr √à«¡°—∫ anesthesia - πÈ”≈“¬¡“° ·≈–·√ßμ÷ ß μ— « ¢Õß opioid °≈â“¡‡π◊ÈÕ¡¥≈Ÿ°‡æ‘Ë¡ („™â ‚¥¬ºŸâ‡™’ˬ«™“≠) ¢÷π È - πÈ”≈“¬¡“°*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢Õ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** - °¥°“√À“¬„®∂â “ „Àâ Õ¬à“ß√«¥‡√Á« Levobupiva- Levorotatory (S) enan- ‡™àπ‡¥’¬«°—∫ bupivacaine ‡™àπ‡¥’¬«°—∫ ‡™àπ‡¥’¬«°—∫ - ‡™àπ‡¥’¬«°—∫ bupivacaine caine tiomer of bupivacaine bupivacaine bupivacaine Max dose 150 mg,27 Ë ´÷ß¡’ƒ∑∏‘Ï cardiotoxicity ·≈– Max dose 400 mg/day CNS toxicity ≈¥≈ß
    • μ“√“ß∑’Ë 5 √“¬≈–‡Õ’¬¥°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬„™â¬“ (‡√’¬ßμ“¡Õ—°…√) (μàÕ)28 ¬“ √“¬≈–‡Õ’¬¥·≈–¢âÕ∫àß™’È ¢âÕ§«√√–«—ß/¢âÕÀâ“¡ Õ“°“√·∑√°´âÕπ ¢π“¥¬“„π‡¥Á° ¢π“¥¬“„πºŸâ„À≠à Lidocaine ‡ªì𬓙“™π‘¥ amide, ÕÕ°  “√≈–≈“¬∑’˺ ¡ adrenaline Toxicity: ¡’Õ“°“√™“≈‘π -  “√≈–≈“¬ 0.5-2% È -  “√≈–≈“¬ 0.5-2% Ï ƒ∑∏‘‡√Á« duration 30-90 π“∑’ ®–¡’ preservative √Õ∫ª“° °√–«π - Max dose ¢÷È π °— ∫ - È Max dose ¢÷π°—∫μ”·Àπàß °“√º ¡ adrenaline ∑”„Àâ ◊È °√–«“¬ ÀŸÕÕ ™—° À—«„® μ”·Àπàß∑’Ë©’¥ ∑’Ë©’¥ ÕÕ°ƒ∑∏‘Ïπ“π¢÷Èπ À¬ÿ¥‡μâπ - 3 mg/kg, 4-hourly - 3 mg/kg, 4-hourly (with adrenaline: (with adrenaline: 6 mg/ 6 mg/kg, 4-hourly) kg, 4-hourly) Morphine Opioid analgesic 1. °“√„À⬓∑“ß epidural/spi- - À≈—Ëß histamine - PO: 0.3-0.5 mg/kg, - IV: 2-5 mg p.r.n. q 2 hr nal Õ“®¡’ ‚Õ°“ ‡°‘¥°¥°“√ - §«“¡¥—π‡≈◊Õ¥≈¥≈ß 4-hourly ‰¡à·π–π” - IM/SC: 5-10 mg, 4-hourly À“¬„® §—π §≈◊Ëπ‰ â Õ“‡®’¬π - bronchospasm â „Àâ „™â∂“∑âÕßÕ◊¥ À√◊Õ p.r.n. q 2 hr ‰¥âπ“π°«à“ „Àâ«‘∏’Õ◊Ëπ - §—π §≈◊Ëπ‰ â Õ“‡®’¬π - IV bolus:  ”À√— ∫ ¢π“¥¬“„Àâ æ‘ ® “√≥“μ“¡ 2. ‰¡à§«√„™â „π biliary colic -  —∫ π ‡Õ–Õ–‚«¬«“¬ ‡¥Á°Õ“¬ÿ > 1 ªï: 0.03- Õ“¬ÿ §«“¡√ÿπ·√ߢÕß°“√ ‡æ√“– morphine ∑”„À⇰‘¥ 0.05 mg/kg p.r.n. q ∫“¥‡®Á∫·≈– ¿“æ¢Õß spasm ¢Õß sphincter of 2-4 hr â É ºŸª«¬ Oddi §«√„™â pethidine ·∑π - IV infusion  ”À√—∫ - PO: 10-30 mg, 4-hourly 3. ‰¡à§«√„™â „π renal colic pain ‡¥Á°Õ“¬ÿ > 1 ªï: 0.01- ‰¡à·π–π”„Àâ „™â∂â“∑âÕßÕ◊¥  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ ‡æ√“– morphine ∑”„À⇰‘¥ 0.03 mg/kg/hr ª√—∫ - Epidural: 2-4 mg* spasm ¢Õß ureter ‰¥â §«√„™â ‰¥âμ“¡Õ“°“√ºŸâªÉ«¬ - Spinal: 0.1-0.3 mg* NSAIDs À√◊Õ pethidine ·∑π (* preservative free) Naloxone Pure opioid antagonist Duration of action 30 π“∑’ - IV bolus:-0.005-0.01 - IV bolus: 0.1-0.4 mg „™â·°âƒ∑∏‘Ï°¥°“√À“¬„®¢Õß √–«—ß„π°“√·°âƒ∑∏‘Ï opioid ∑’Ë¡’ mg/kg titrated to desired effect opioid Ï ƒ∑∏‘π“π Õ“®‡°‘¥ renarcotisa- - Infusion: 0.005-0.02 - — ·°â§π®“° epidural opioid: „™â „ π¢π“¥μË” ‡æ◊Ë Õ ·°â ƒ ∑∏‘Ï tion Õ“®‡°‘¥ acute withdrawal mg/kg/hr 0.1 mg bolus + 0.3 mg Õ“°“√§— π ®“° epidural „πºŸâ∑’Ëμ‘¥¬“ opioid - IM in Newborn: 0.2 º ¡„π IV fluid opioid ·≈–„Àâ IM „π‡¥Á° mg Ë — ·√°‡°‘¥∑’¡“√¥“‰¥â√∫ opioid - ·°â§—π®“° epidural*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** opioid: 0.005 mg/kg
    • μ“√“ß∑’Ë 5 √“¬≈–‡Õ’¬¥°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬„™â¬“ (μàÕ) ¬“ √“¬≈–‡Õ’¬¥·≈–¢âÕ∫àß™’È ¢âÕ§«√√–«—ß/¢âÕÀâ“¡ Õ“°“√·∑√°´âÕπ ¢π“¥¬“„π‡¥Á° ¢π“¥¬“„πºŸâ„À≠à Naproxen NSAIDs  ”À√—∫ª«¥‡≈Á° - ·æâ aspirin È - ¬—∫¬—ß°“√∑”ß“π¢Õß - PO: 5 mg/kg bid - PO: 500 mg bid πâÕ¬∂÷ߪ“π°≈“ß - ÀÕ∫À◊¥ ‡°≈Á ¥ ‡≈◊ Õ ¥ √∫°«π (>5 yr) - ‰μº‘¥ª°μ‘√ÿπ·√ß À√◊Õ∑”„Àâ‡≈◊Õ¥ÕÕ°„π - ·º≈„π°√–‡æ“–Õ“À“√ √–∫∫∑“߇¥‘πÕ“À“√ - bronchospasm - ÀŸÕ◊ÈÕ ∫«¡ Paracetamol Õ“°“√ª«¥‡≈Á°πâÕ¬∂÷ß ‡¥Á°·√°‡°‘¥ μ—∫∂Ÿ°∑”≈“¬∂â“„™â‡°‘π - PO: 10-20 mg/kg, - PO: 0.5-1 g , 4-6 hourly ª«¥ª“π°≈“ß ºŸâªÉ«¬ G-6-PD deficiency ¢π“¥ 4-6 hourly - Slow IV: 0.5-1 g qid ≈¥‰¢â - PR: loading dose - Max dose 6 gm/day 30-40 mg/kg (>44 wk post â conception) Paracetamol ¥Ÿ paracetamol ·≈– °“√‡æ‘Ë¡¢π“¥‚¥¬°“√‡æ‘Ë¡ ¥Ÿ paracetamol ·≈– ¢π“¥¬“§”π«≥‚¥¬„™â ¥Ÿ paracetamol ·≈– 300 mg codeine ®”π«π‡¡Á¥¬“ Õ“®∑”„Àâ¬“μ—«„¥ codeine dose codeine codeine + codeine μ—«Àπ÷Ë߇°‘π¢π“¥‰¥â 15 /30 mg Paracetamol ¥Ÿ paracetamol °“√‡æ‘Ë¡¢π“¥‚¥¬°“√‡æ‘Ë¡ ¥Ÿ paracetamol ·≈– - ¥Ÿ paracetamol*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢Õ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** 325 mg + ·≈– tramadol ®”π«π‡¡Á¥¬“ Õ“®∑”„Àâ¬“μ—«„¥ tramadol ·≈– tramadol tramadol μ—«Àπ÷Ë߇°‘π¢π“¥‰¥â 37.5 mg29
    • μ“√“ß∑’Ë 5 √“¬≈–‡Õ’¬¥°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬„™â¬“ (‡√’¬ßμ“¡Õ—°…√) (μàÕ)30 ¬“ √“¬≈–‡Õ’¬¥·≈–¢âÕ∫àß™’È ¢âÕ§«√√–«—ß/¢âÕÀâ“¡ Õ“°“√·∑√°´âÕπ ¢π“¥¬“„π‡¥Á° ¢π“¥¬“„πºŸâ„À≠à Parecoxib - Pro-drug ¢Õß valdecoxib - ·æâ sulfonamide À√◊Õ - - - IV/IM: 40 mg, then ‡ªìπ NSAIDs ∑’ˬ—∫¬—Èß aspirin 20-40 mg, 12-hourly ®”‡æ“– Cyclooxygenase- - À≈—ß°“√ºà“μ—¥ CABG/Stent - Max dose 80 mg/day II (COX-II) - ‚√§À≈Õ¥‡≈◊Õ¥À—«„®·≈–‚√§ - ≈¥º≈¢â“߇§’¬ßμàÕ√–∫∫ À≈Õ¥‡≈◊Õ¥ ¡Õß ∑“߇¥‘πÕ“À“√ ·≈– - ‰μ«“¬Õ¬à“ß√ÿπ·√ß ‡°≈Á¥‡≈◊Õ¥ - √–¡—¥√–«—ß„πºŸâªÉ«¬ ŸßÕ“¬ÿ - „™â ”À√—∫√–ß—∫ª«¥À≈—ß - À≠‘ß¡’§√√¿å „Àâπ¡∫ÿμ√ ºà“μ—¥‰¡à‡°‘π 3 «—π - ·º≈„π°√–‡æ“–Õ“À“√ Pethidine Opioid ™π‘¥ —߇§√“–Àå Õ“®™—°®“°¬“¢π“¥ Ÿß - °¥°“√À“¬„® - IV/IM/SC: - IV: 20-50 mg p.r.n. 1. √–ß—∫ª«¥ - Max dose 1g/day (20 mg/ - §«“¡¥—π‡≈◊Õ¥μË” 0.5-1 mg/kg q 2 hr 2. ºŸâªÉ«¬Àπ“« —ËπÀ≈—ߺà“μ—¥ kg/day) -  —∫ π ‡Õ–Õ–‚«¬«“¬ - Infusion: Ë Õ“°“√Àπ“« —π: 10-25 mg 3. Biliary colic ºŸâªÉ«¬‰¥â√—∫ MAOI 5 mg/kg in 50 ml - IM/SC: 25-100 mg,  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ 4. Renal colic NSS 3-hourly À√◊Õ p.r.n. q 2 rate 1-3 ml/hr hr ¢π“¥¬“„Àâ æ‘ ® “√≥“ (0.1-0.3 mg/kg/hr) μ“¡Õ“¬ÿ §«“¡√ÿπ·√ߢÕß °“√∫“¥‡®Á∫·≈– ¿“æ ¢ÕߺŸâªÉ«¬ Piroxicam NSAID  ”À√—∫§«“¡ª«¥ - ·æâ aspirin ¬— ∫ ¬—È ß °“√∑”ß“π¢Õß - - PO: 10-30 mg od ª“π°≈“ß Õÿ∫—μ‘°“√≥å¢Õß - ÀÕ∫À◊¥ ‡°≈Á¥‡≈◊Õ¥ √∫°«πÀ√◊Õ Õ“°“√·∑√°´âÕπ Ÿß - ‰μº‘¥ª°μ‘√ÿπ·√ß ∑”„Àâ‡≈◊Õ¥ÕÕ°„π√–∫∫ - ·º≈„π°√–‡æ“–Õ“À“√ ∑“߇¥‘πÕ“À“√*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** - Ë â É À≈’°‡≈’¬ß„πºŸª«¬ porphyria bronchospasm ÀŸÕ◊ÈÕ ∫«¡
    • μ“√“ß∑’Ë 5 √“¬≈–‡Õ’¬¥°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬„™â¬“ (‡√’¬ßμ“¡Õ—°…√) (μàÕ) ¬“ √“¬≈–‡Õ’¬¥·≈–¢âÕ∫àß™’È ¢âÕ§«√√–«—ß/¢âÕÀâ“¡ Õ“°“√·∑√°´âÕπ ¢π“¥¬“„π‡¥Á° ¢π“¥¬“„πºŸâ„À≠à Tenoxicam NSAIDs  ”À√—∫§«“¡ª«¥ - ·æâ aspirin È - ¬—∫¬—ß°“√∑”ß“π¢Õß ‰¡à·π–π”„Àâ „™â PO: 20 mg od ‡≈Á°πâÕ¬ ∂÷ߪ“π°≈“ß - ÀÕ∫À◊¥ ‡°≈Á¥‡≈◊Õ¥ √∫°«π - ‰μº‘¥ª°μ‘√ÿπ·√ß À√◊Õ∑”„Àâ‡≈◊Õ¥ÕÕ°„π - ·º≈„π°√–‡æ“–Õ“À“√ √–∫∫∑“߇¥‘πÕ“À“√ - bronchospasm - ÀŸÕ◊ÈÕ ∫«¡ Tramadol - Opioid ∑’˧“¥«à“¡’º≈μàÕ - ·°âƒ∑∏‘ϥ⫬ naloxone ‰¥â §≈◊Ëπ‰ â «‘߇«’¬π - PO: 1-2 mg/kg, - PO: 50-100 mg, 4-hourly °“√°¥°“√À“¬„® ∑âÕߺŸ° ‡æ’¬ß 30% ª“°·Àâß 6-hourly - Slow IV/IM: 50-100 mg euphoria À√◊Õμ‘¥¬“πâÕ¬ - √–«—ß„π epilepsy 4-hourly °«à“ opioid ™π‘¥Õ◊Ëπ - ‰¡à·π–π”„Àâ „™â „πºŸâªÉ«¬∑’Ë ‰¥â - Max dose 400 mg/day Ï ’ —È - °“√ÕÕ°ƒ∑∏‘¡∑ß°≈‰°·∫∫ √—∫¬“ MAOI â opioid ·≈– non-opioid Tramadol ¥Ÿ paracetamol °“√‡æ‘Ë¡¢π“¥‚¥¬°“√‡æ‘Ë¡ ¥Ÿ paracetamol ·≈– - ¥Ÿ paracetamol 37.5 mg + ·≈– tramadol ®”π«π‡¡Á¥¬“ Õ“®∑”„Àâ¬“μ—«„¥ tramadol ·≈– tramadol paracetamol μ—«Àπ÷Ë߇°‘π¢π“¥‰¥â 325 mg À¡“¬‡Àμÿ :*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢Õ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** ë od = once daily, bid = twice daily, tid = three times daily, qid = four times daily ë Max = maximum, MAOI = monoamine oxidase inhibitors, NSS = normal saline ë PO = per oral, PR = per rectal, SC = subcutaneous, SL = sublingual, IM = intramuscular, IV = intravenous ë ¬“∑’Ë„Àâ∑“ß PR ∫“ß™π‘¥ªí®®ÿ∫—π„πª√–‡∑»‰∑¬¬—߉¡à¡’„™â31
    • μ“√“ß∑’Ë 6 √“¬≈–‡Õ’¬¥°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬‰¡à„™â¬“532 Non-pharmacological √“¬≈–‡Õ’¬¥ ¢âÕ¡Ÿ≈∑“ß ∂‘μ‘ ª√–‡¥Á𠔧—≠ therapy A: Psychological Procedural information §◊Õ¢âÕ¡Ÿ≈∑’Ë·®âß„À⺟âªÉ«¬ Combined sensory-procedural information â °“√„Àâ¢Õ¡Ÿ≈ therapy Ë ∑√“∫°àÕπ„Àâ°“√√—°…“„¥Ê ´÷ß √ÿª«à“®–‡°‘¥Õ–‰√¢÷π„π È ®–∑”„À⇰‘¥ª√– ‘∑∏‘¿“楒¡“° ‚¥¬≈¥°“√∑∫°√–‡∑◊Õπ (Sensory-proce- â 1. °“√„Àâ¢Õ¡Ÿ≈ √–À«à“ß°“√√—°…“ â É ®‘μ„®„π∑“ß≈∫¢ÕߺŸª«¬·≈–≈¥°“√√“¬ß“π«à“¡’§«“¡ dural informa- (Provision of Ë Sensory information §◊Õ¢âÕ¡Ÿ≈∑’Õ∏‘∫“¬ª√– ∫°“√≥å Ë— — à ª«¥∑’ ¡æ—π∏å°∫À—μ∂°“√„π°“√√—°…“·≈–¬—ß¡’ «π™à«¬ tion) ™à«¬≈¥ information) ‡°’ˬ«°—∫§«“¡√Ÿâ ÷°„π√–À«à“ß°“√√—°…“∑’˺ŸâªÉ«¬§“¥«à“ ≈¥§«“¡«‘μ°°—ß«≈¢ÕߺŸâªÉ«¬μàÕÀ—μ∂°“√À≈“¬Õ¬à“ß ®–‰¥â√—∫ Ë ∑’∑”„À⇰‘¥§«“¡ª«¥ ‡™àπ À—μ∂°“√∑—πμ°√√¡ À—μ∂°“√ Õ“°“√ª«¥·≈– °“√„Àâ¢âÕ¡Ÿ≈·∫∫ procedural ·≈–À√◊Õ sensory „π°“√μ√«®«‘π‘®©—¬·≈–À—μ∂°“√„π°“√∑¥≈Õß∑“ß «‘μ°°—ß«≈‰¥âÕ¬à“ß ®–‰¥âº≈∑’Ë·μ°μà“ß°—π¢÷ÈπÕ¬Ÿà°—∫°≈ÿࡺŸâªÉ«¬·μà≈–°≈ÿà¡ «‘∑¬“»“ μ√åμà“ßÊ ¡’ª√– ‘∑∏‘¿“æ 2. °“√ºàÕπ§≈“¬·≈– Ÿâ É â ÷ °“√Ωñ°ºàÕπ§≈“¬ ‡ªìπ‡∑§π‘§∑’Ë„™â∑”„À⺪«¬√Ÿ ° ß∫ °“√„™â«‘∏’Ωñ°ºàÕπ§≈“¬„πºŸâªÉ«¬¡–‡√Áß∑’Ë¡“√—∫°“√∑” °“√¡ÿà߇πâ𧫓¡ π„® ≈ß®“°§«“¡ª«¥À≈—ߺà“μ—¥‚¥¬„™â«‘∏’°“√øí߇ ’¬ß®“° À—μ∂°“√∑’Ë∑”„À⇰‘¥§«“¡ª«¥®–™à«¬≈¥§«“¡ª«¥‰¥â (Relaxation ‡§√◊ËÕß∫—π∑÷°‡ ’¬ßÀ√◊Õ°“√Ωñ°‡¢’¬πÀ√◊ÕæŸ¥μ“¡·∫∫ Õ¬à“ß¡’ª√– ‘∑∏‘¿“æ ‚¥¬ —߇°μ®“°°“√«—¥™’æ®√ and Attention Ωñ°À—¥ ∫“ß«‘∏’ °“√Ωñ°®–‡πâπ„À⧫“¡ π„®μàÕ°“√μ÷ß â É Ë §«“¡¥—π‚≈À‘μ¢ÕߺŸª«¬·≈– —߇°μ§«“¡‡ª≈’¬π·ª≈ß Strategies) μ—«¢Õß°≈â“¡‡π◊ÈÕμ“¡®—ßÀ«–°“√À“¬„® ¥—ßπ—Èπ‡∑§π‘§ â É ∑“ßÕ“√¡≥å¢ÕߺŸª«¬ ‡™àπ Õ“°“√´÷¡‡»√â“ Õ“°“√«‘μ°  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ — °“√Ωñ°ºàÕπ§≈“¬¡—°®–¡’§«“¡ —¡æ—π∏å°∫°“√∑” ¡“∏‘ °—ß«≈ ‰¡à‡ªìπ¡‘μ√ ·≈–°“√ –°¥®‘μÕ¬à“߉¡à “¡“√∂·¬°§«“¡·μ°μà“߉¥â  π—∫ πÿπ„Àâ „™â‡∑§π‘§°“√‡∫’ˬ߇∫𧫓¡ π„®√à«¡ °“√„™â¥πμ√’™à«¬„π°“√ºàÕπ§≈“¬‡ªìπ«‘∏’∑’Ë ‰¥âº≈ ‚¥¬ Ë °—∫°“√Ωñ°ºàÕπ§≈“¬ ‡æ◊Õ≈¥°“√√“¬ß“π«à“¡’§«“¡ª«¥ â É â ‡ ’¬‡«≈“ ÕπºŸª«¬‡æ’¬ß‡≈Á°πâÕ¬ ·μàμÕß∑”∫àÕ¬Ê ·≈– ·≈–≈¥°“√„™â¬“·°âª«¥‰¥â ≠“μ‘ºŸâªÉ«¬§«√ π—∫ πÿπ°‘®°√√¡‡À≈à“π’ȥ⫬ Ë — „π¢≥–∑’∫“ßß“π«‘®¬æ∫«à“¥πμ√’‰¡à “¡“√∂≈¥§«“¡ Attention techniques ‡ªìπ‡∑§π‘§„π°“√‡∫’ˬ߇∫π «‘μ°°—ß«≈À√◊Õ≈¥§«“¡ª«¥„πºŸâªÉ«¬∑’Ë ‰¥â√—∫°“√ºà“μ—¥ â É Ë ’ Ë §«“¡ π„®¢ÕߺŸª«¬∑’¡§«“¡ª«¥‰ª¬—ß ‘ß°√–μÿπ¿“¬ â À√◊ÕÀ—μ∂°“√‰¥â πÕ° ‡™àπ ‡ ’¬ß¥πμ√’ √Ÿª¿“æ∑’ˇÀÁπÀ√◊Õ°“√‰¥â°≈‘Ëπ μà“ßÊ ‡ªì𧫓¡æ¬“¬“¡∑’Ë®–ª√—∫ ¿“«–Õ“√¡≥å∑’Ë¡’ §«“¡‡§√’¬¥À√◊Õ§«“¡À«“¥°≈—«¡“‡ªìπÕ“√¡≥å∑’Ë√Ÿâ ÷°*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***  ∫“¬ ß∫ ÿ¢
    • μ“√“ß∑’Ë 6 √“¬≈–‡Õ’¬¥°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬‰¡à„™â¬“5 (μàÕ) Non-pharmacological √“¬≈–‡Õ’¬¥ ¢âÕ¡Ÿ≈∑“ß ∂‘μ‘ ª√–‡¥Á𠔧—≠ therapy 3. °“√ –°¥®‘μ  à«πª√–°Õ∫ ”§—≠„π°“√Ωñ° –°¥®‘μ§◊Õ °“√∑”„Àâ °“√ –°¥®‘μ¡’ª√– ‘∑∏‘¿“楒„π°“√≈¥§«“¡ª«¥‡©’¬∫ °“√ –°¥®‘μ ·≈– (Hypnosis) ®ÿ¥ π„®μà“ßÊ ·§∫≈ß °“√≈¥°“√μ√–Àπ—°√—∫√Ÿâ ◊ËÕ æ≈—π∑’ˇ°’ˬ«°—∫À—μ∂°“√∑“ß°“√·æ∑¬åμà“ßÊ ‡™àπ °“√¡ÿà߇πâ𧫓¡ °√–μÿâπ¿“¬πÕ°‚¥¬°“√¥Ÿ¥´—∫·≈–°“√‡æ‘Ë¡°“√μÕ∫ °“√∑”À—μ∂°“√„πºŸâªÉ«¬∑’Ë¡’∫“¥·º≈‰ø‰À¡â À—μ∂°“√  π„® ™à«¬≈¥  πÕßμàÕ°“√™—°π” –°¥®‘μ ‡®“–°√–¥Ÿ° ·≈–°“√∑”§≈Õ¥ Õ“°“√ª«¥®“°  à«π„πºŸâªÉ«¬¡–‡√Áß°“√ –°¥®‘μ¡’ à«π™à«¬≈¥§«“¡ °“√∑”À—μ∂°“√∑’Ë ª«¥„πÀ≈“¬À—μ∂°“√ ‡™àπ °“√‡®“–‡π◊ÈÕßÕ°‡μâ“π¡ ¡’§«“¡ª«¥‰¥â ‡®“–πÈ”‰¢ —πÀ≈—ß °“√‡®“–‰¢°√–¥Ÿ° °“√ –°¥®‘μ„π¡“√¥“∑’˧≈Õ¥∫ÿμ√æ∫«à“™à«¬≈¥§«“¡ Ë μâÕß°“√¬“·°âª«¥·≈–™à«¬‡æ‘¡‚Õ°“ „π°“√§≈Õ¥∫ÿμ√ ‡Õß∑“ß™àÕߧ≈Õ¥‰¥â Ë â É ‡¡◊ÕºŸª«¬¡’§«“¡°≈—«·≈–«‘μ°°—ß«≈ §«√ª√–‡¡‘π¿“«– °“√Ωñ°Ωπ„π°“√®—¥°“√‡º™‘≠Àπâ“°—∫§«“¡ª«¥·≈– °“√Ωñ°Ωπ„π°“√ Ë 4. °“√ª√—∫‡ª≈’¬π§«“¡ ®‘μ„®¢ÕߺŸâªÉ«¬ ·≈– Õπ«‘∏’∑’Ë®–‡º™‘≠Àπâ“°—∫§«“¡ ª√—∫æƒμ‘°√√¡°àÕπ∑’Ë®–¡“√—∫°“√ºà“μ—¥®–™à«¬„Àâ°“√ ®—¥°“√°—∫§«“¡ §‘¥·≈–æƒμ‘°√√¡ ª«¥π—ÈπÊ (coping skills) ‰¥â·°à °“√ Õπ„À⺟âªÉ«¬ ª√–‡¡‘ 𠧫“¡√ÿ π ·√ߢÕߧ«“¡ª«¥À≈— ß ºà “ μ— ¥ ¡’ ª«¥ ·≈–ª√—∫ (Cognitive- ¡Õß‚≈°„π·ß॒ °“√ºàÕπ§≈“¬ °“√ √â“ß®‘πμπ“°“√ ª√– ‘∑∏‘¿“楒¢÷Èπ ≈¥§«“¡°√–∑∫ °√–‡∑◊Õπ®‘μ„® æƒμ‘°√√¡°àÕπ Behavioral therapy) Ë È â É ‡æ◊Õ≈¥§«“¡°≈—«π—πÊ ·μà„πºŸª«¬∫“ß√“¬°“√„Àâ¢Õ¡Ÿ≈ â „π∑“ß≈∫¢ÕߺŸâªÉ«¬·≈–≈¥§«“¡μâÕß°“√¬“·°âª«¥ °“√ºà“μ—¥®–™à«¬ â ¡“°‡°‘π‰ª°Á®–∑”„À⺟âªÉ«¬‡°‘¥§«“¡°≈—«·≈–°—ß«≈®π ‰¥â¥â«¬ ≈¥Õ“°“√ª«¥, ‡°‘π°«à“‡Àμÿ °“√„Àâ¢âÕ¡Ÿ≈°—∫ºŸâªÉ«¬®÷ß¡’§«“¡®”‡ªìπ∑’Ë æ∫«à“ºŸâªÉ«¬∑’Ë¡—°· ¥ß°“√μÕ∫ πÕߧ«“¡ª«¥Õ¬à“ß ≈¥°“√„™â¬“·°â ®–μâÕߪ√–‡¡‘𧫓¡√Ÿâ §«“¡‡¢â“„®·≈–„À⧫“¡√Ÿâ „π ‡°‘𧫓¡‡ªìπ®√‘ߧ≈⓬Փ°“√μ◊ËπμŸ¡À√◊Õ°“√· ¥ß ª«¥ ·≈–≈¥º≈ Ë ª√‘¡“≥æÕ‡À¡“–„π·μà≈–√“¬ ‡æ◊Õ®–‰¥â ‰¡à∑”„À⺪«¬ Ÿâ É ∑— » π§μ‘ ∑’Ë ‰¡à∂Ÿ°μâÕß ¡—°¡’·π«‚πâ¡∑’Ë®–¡’§«“¡«‘μ° °√–∑∫„π∑“ß≈∫ °≈—«À√◊Õ°—ß«≈®π‡°‘π‰ª °“√„À⧫“¡√Ÿâ§«“¡‡¢â“„®·°à °—ß«≈·≈–¡’ª√– ∫°“√≥åμàÕ§«“¡ª«¥∑’Ë¡“°°«à“§π ®“°§«“¡ª«¥μàÕ ºŸâªÉ«¬„π‡√◊ËÕß°“√ºà“μ—¥ °“√„À⬓√–ß—∫§«“¡√Ÿâ ÷° ª°μ‘ â É ºŸª«¬≈߉¥â °“√√—°…“§«“¡ª«¥À≈—ߺà“μ—¥μ“¡ºŸâªÉ«¬μâÕß°“√√à«¡*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢Õ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** °—∫°“√ Õπ«‘∏’°“√À“¬„®≈÷°Ê °“√‰Õ °“√¢¬—∫μ—« Ë °“√‡¥‘π ‡æ◊Õ≈¥Õ“°“√‰¡à ∫“¬μ—«À≈—ߺà“μ—¥  “¡“√∂ ≈¥§«“¡μâÕß°“√„™â¬“·°âª«¥À≈—ߺà“μ—¥≈ß ·≈–ºŸª«¬ â É  “¡“√∂‡§≈◊ËÕπ‰À«‰¥â¥’¢÷Èπ ·π«∑“ß„π°“√ Õπ«‘∏’∑’Ë È ÿ ’ —È ®–‡º™‘≠Àπâ“°—∫§«“¡ª«¥π—πÊ ¡—°„™â∑°«‘∏∑ß°√–∫«π33 °“√§‘¥·≈–æƒμ‘°√√¡
    • 34 μ“√“ß∑’Ë 6 √“¬≈–‡Õ’¬¥°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬‰¡à„™â¬“5 (μàÕ) Non-pharmacological √“¬≈–‡Õ’¬¥ ¢âÕ¡Ÿ≈∑“ß ∂‘μ‘ ª√–‡¥Á𠔧—≠ therapy B: Physical therapy °“√ª√–§∫√âÕπ-‡¬Áπ ®–≈¥§«“¡ª«¥‚¥¬™à«¬„Àâ ª√–‚¬™πå¢Õß°“√ª√–§∫‡¬Áπ∫√‘‡«≥∑’Ë∑”°“√ºà“μ—¥ 1. °“√ª√–§∫√âÕπ-‡¬Áπ °≈â“¡‡π◊ÈÕ§≈“¬μ—« ·≈– ≈¥Õ“°“√∫«¡¢Õß·º≈ºà“μ—¥ ¡’ à«π™à«¬≈¥°“√„™â¬“·°âª«¥‰¥â·≈–≈¥√–¥—∫§«“¡ (Applications of È Ë °“√ª√–§∫‡¬Áπ®–∂Ÿ°„™â „π¢—πμÕπ·√°‡æ◊Õ≈¥°“√μÕ∫ √ÿπ·√ߢÕߧ«“¡ª«¥‰¥â „πÀ≈“¬°“√ºà“μ—¥ ‡™àπ °“√ heat and cold)  πÕߢÕ߇π◊ÈÕ‡¬◊ËÕ  à«π°“√ª√–§∫√âÕππ”¡“„™â „π¢—Èπ ºà“μ—¥°√–¥Ÿ°·≈–¢âÕ ·μà∫“ß°“√«‘®—¬æ∫«à“‰¡à™à«¬≈¥ Ë μÕπÀ≈—ß ‡æ◊ՙ૬¢®—¥ “√æ‘…·≈–°“√¬ÿ∫∫«¡ °“√π«¥ §«“¡ª«¥ ‡™àπ °“√ºà“μ—¥§≈Õ¥∑“ßÀπâ“∑âÕß ·≈– Ë È ·≈–°“√ÕÕ°°”≈—߇æ◊Õ„Àâ°≈â“¡‡π◊Õ§≈“¬μ—«·≈–‡ âπ‡ÕÁπ °“√ºà“μ—¥¡¥≈Ÿ° ¢¬“¬μ—« °“√¥“¡«‘∏’μà“ßÊ ¡—°®–„™âμ“¡À≈—ß°“√ºà“μ—¥ °≈â“¡‡π◊ÈÕ·≈–°√–¥Ÿ° ‡æ◊ËÕ„Àâ√Ÿª∑√ߢÕßÕ«—¬«–§ß∑’Ë ‰¡àº‘¥√Ÿª‰ª °“√„™â physical modalities ‡À≈à“π’È ¡—°®–¡’®ÿ¥À¡“¬„π∑“ß √’√«‘∑¬“¡“°°«à“°“√√—°…“  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ §«“¡ª«¥‚¥¬μ√ß 2. °“√°¥®ÿ¥·≈– ¢âÕ¡Ÿ≈∑’Ë ‰¥â√—∫°“√μ’æ‘¡æå à«π„À≠à‡°’ˬ«°—∫°“√°¥®ÿ¥ °“√π«¥ (Manual ·≈–°“√π«¥ ∑—Èß°“√∑”°“¬¿“æ∫”∫—¥·≈–°“√®—¥ and massage °√–¥Ÿ° (chiropractic)  π—∫ πÿπ«à“¡’ª√–‚¬™πå„π therapy) °“√√—°…“Õ“°“√ª«¥À≈—ß ·≈–ª«¥°≈â“¡‡π◊ÈÕμà“ßÊ ¡’ ¢âÕ¡Ÿ≈ à«ππâÕ¬∑’Ë«‘®—¬‡°’ˬ«°—∫ª√–‚¬™πå¢Õß°“√π«¥ μàÕ§«“¡ª«¥À≈—ß°“√ºà“μ—¥ μ—«Õ¬à“ß∑’Ëæ∫‰¥â§◊Õ °“√ 𫥇∑Ⓣ¡à ‰¥â™à«¬≈¥§«“¡ª«¥À≈—ß°“√ºà“μ—¥À—«„®*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ***
    • μ“√“ß∑’Ë 6 √“¬≈–‡Õ’¬¥°“√√–ß—∫ª«¥‡©’¬∫æ≈—π‚¥¬‰¡à„™â¬“5 (μàÕ) Non-pharmacological √“¬≈–‡Õ’¬¥ ¢âÕ¡Ÿ≈∑“ß ∂‘μ‘ ª√–‡¥Á𠔧—≠ therapy 3. Transcutaneous °“√√—°…“‚¥¬„™â TENS ‡ªìπ«‘∏’ noninvasive ∑’Ëßà“¬ â É â „πºŸª«¬·¢Áß·√ß°“√°√–μÿπ¥â«¬°√–· øÑ“‚¥¬„™â§«“¡ TENS Õ“®®–¡’ electrical nerve ª≈Õ¥¿—¬‰¡à¡’º≈¢â“߇§’¬ß ∑”„À⺟âªÉ«¬‡§≈◊ËÕπ‰À«‰¥â ·√ß (amplitude) ¡“°°«à“ 15 mA  “¡“√∂≈¥§«“¡ ª√– ‘∑∏‘¿“æ„π stimulation (TENS) ‡√Á«¢÷π È μâÕß°“√¬“·°âª«¥À≈—ߺà“μ—¥‰¥âÕ¬à“ß¡’π—¬ ”§—≠ °“√√–ß—∫ª«¥ ∂÷ß·¡âß“π«‘®—¬∑’Ë π—∫ πÿπ«à“ TENS ¡’ª√– ‘∑∏‘¿“楒 ‡¡◊ËÕ„™â TENS ∑’˧«“¡∂’Ë (frequency) 50 Hz ·≈– ‡©’¬∫æ≈—π∫“ß „π°“√√–ß—∫§«“¡ª«¥‡©’¬∫æ≈—π¬—߉¡à¡“° ·μà°Á¡’ 100 Hz ®–™à«¬‡ √‘¡ƒ∑∏‘Ï¢Õ߬“·°âª«¥‰¥â ‡¡◊ËÕ„™â ª√–‡¿∑ ª√–‚¬™πå „π°“√≈¥§«“¡μâÕß°“√¬“·°âª«¥„π°“√ TENS √à«¡°—∫ PCA morphine À≈—ß°“√ºà“μ—¥ ºà“μ—¥‰¥â ‚¥¬‡©æ“–°“√ºà“μ—¥∑’Ë¡’ ‚Õ°“ ‡°‘¥‡ªìπ neu- Àπâ“∑âÕßæ∫«à“™à«¬≈¥§«“¡μâÕß°“√ morphine ‰¥â ropathic pain μ“¡¡“ ≈¥√–¬–‡«≈“„π°“√√—°…“¥â«¬ PCA morphine ·≈– ‚¥¬∑—Ë«‰ª¡—°„™â TENS ‡ªìπ«‘∏’°“√‡ √‘¡√à«¡°—∫«‘∏’ Õÿ∫—μ‘°“√≥凰‘¥Õ“°“√§≈◊Ëπ‰ âÕ“‡®’¬π ‡«’¬π»’√…–·≈– °“√Õ◊ËπÊ „π°“√√—°…“§«“¡ª«¥‡©’¬∫æ≈—π Õ“°“√ §—πμà“ßÊ â ¡’¢âÕÀâ“¡„™â TENS „πºŸâªÉ«¬∑’Ëμ—Èߧ√√¿å„π™à«ß 3 ‡¥◊Õπ TENS §«“¡∂’Ë Ÿß¡’ª√–‚¬™πå „π°“√≈¥§«“¡ª«¥ â É Ë â ·√° ·≈–„πºŸª«¬∑’Ë„ à‡§√◊Õß°√–μÿπ®—ßÀ«–°“√‡μâπ¢Õß ª√–®”‡¥◊Õπ‰¥â À—«„® 4. °“√Ωí߇¢Á¡ °“√Ωí߇¢Á¡„π°“√√–ß—∫ª«¥‡©’¬∫æ≈—π ®–‰¥âº≈¥’ „π °“√Ωí߇¢Á¡Õ“®®– (Acupuncture) °“√§«∫§ÿ¡§«“¡ª«¥„π°“√§≈Õ¥∫ÿμ√ √—°…“Õ“°“√ ¡’ª√– ‘∑∏‘¿“æ„𠪫¥»’√…–∑’Ë ‰¡à∑√“∫ “‡Àμÿ ·≈–√—°…“§«“¡ª«¥øíπ °“√√–ß—∫ª«¥  à«π°“√√–ß—∫ª«¥À≈—ß°“√ºà“μ—¥™àÕß∑âÕß °“√Ωí߇¢Á¡ ‡©’¬∫æ≈—π∫“ß*** ¢âÕ·π–π”μà“ßÊ „π·π«∑“ßæ—≤π“°“√√–ß—∫ª«¥π’ȉ¡à„™à¢Õ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ *** °àÕπ·≈–À≈—ß°“√ºà“μ—¥ ¡’ à«π™à«¬≈¥§«“¡μâÕß°“√ ª√–‡¿∑ ¬“·°âª«¥·≈–≈¥º≈¢â“߇§’¬ß¢Õ߬“·°âª«¥‰¥â35
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    • ACUTEPAIN Thai Association for the Study of Pain ISBN: 978-974-8285-72-6