√–¬–‡«≈“„π°“√√–ß—∫ª«¥À≈—ßºà“µ—¥¢âÕ–‚æ°À√◊Õ¢âÕ‡¢à“„π
ºŸâ ªÉ « ¬Ÿ ß Õ“¬ÿ : ‡ª√’ ¬ ∫‡∑’ ¬ ∫√–À«à “ ß°“√º¡·≈–‰¡à º ¡
Adrenaline ©’¥‡¢â“™àÕßπÈ”‰¢—πÀ≈—ß
π“«“Ã ·≈π‘ æ.∫.,*
«‘∑¬“ ‡≈‘»«‘√‘¬–°ÿ≈ æ.∫., ««. «‘—≠≠’«‘∑¬“*
®‘√“¿“ ‰™¬∫—≠¥‘…∞å æ.∫., ««. «‘—≠≠’«‘∑¬“*
√ß√Õß ‡√◊Õß®‘√–Õÿ‰√ æ¬.∫.,*
æ√√≥π‘¿“ º“§” æ¬.∫.*
Abstract : Duration of Postoperative Analgesia for Hip or Knee Surgery in Elderly Patients : A Comparison
between Patients with and without Intrathecal Adrenaline
Laeni N, M.D.,* Loetwiriyakul W, M.D.,* Chaibandit C, M.D.,* Ruengjira-urai R, B.N.,* Phakam
P, B.N.*
*Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkla, 90110
of adrenaline in addition to intrathecal isobaric
bupivacaine. The time of first morphine request, total
morphine requirements in the first 48 h and side effects
were evaluated. Postoperative pain was assessed by
using a verbal numerical pain score (VNS). Results :
The demographic data of both groups were comparable. There was no significant difference in time
of first morphine request between the M group [505
(375-1025) min] and the MA group [520 (385-1165)
min] (p = 0.98). The total morphine requirements in
the first 48 h were also comparable between the M
group [3 (0-15) mg] and the MA group [3 (0-12) mg]
(p = 0.06). However, patients who had not required
morphine during the postoperative period were 5.9%
and 37.5% in the M and MA groups, respectively (p =
0.02). Patients who required morphine ≥ 12 mg during
the postoperative period were 41.1% and 6.2% in the
M and MA groups, respectively (p = 0.03). Although
there was no significant difference in the sedation
score, pruritus and nausea/vomiting within 48 hours
postoperatively. No patient exhibited respiratory de-
Background : Hip and knee surgery is frequently
performed under intrathecal bupivacaine with a
morphine solution. An intrathecal addition of
adrenaline has been shown to enhance and prolong the
duration of postoperative analgesia without any added
risks. Objective : To evaluate the effects of adrenaline to
intrathecal isobaric bupivacaine with morphine in
elderly patients undergoing hip or knee surgery ; to
compare the time of first morphine request, total
morphine requirements in the first 48 h and side effects.
Method : In this prospective double-blind study, 40
patients, age ≥ 60 yr., ASA I-III, and undergoing hip
or knee surgery were randomly assigned to two groups
of 20 patients. Each patient in the M group received
a morphine dose of 0.1 mg and patients in the MA
group received a morphine dose of 0.1 mg with 0.2 mg
*¿“§«‘™“«‘≠
— ≠’«∑‘ ¬“
®.ߢ≈“ 90110
§≥–·æ∑¬»“µ√å ¡À“«‘∑¬“≈—¬ߢ≈“π§√‘π∑√å Õ.À“¥„À≠à
63
pression, postdural puncture headache (PDPH) or transient neurological symptoms (TNS). Conclusion : These
results suggest that the addition of 0.2 mg of adrenaline
to 0.5% intrathecal isobaric bupivacaine with 0.1 mg of
morphine does not prolong the duration of analgesia
and does not reduce total morphine requirements in
the first 48 hours postoperatively for hip or knee sur-
gery in elderly patients.
°“√ºà “ µ— ¥ √— ° …“¢â Õ –‚æ°À√◊ Õ ¢â Õ ‡¢à “ ∑’Ë ‡ °‘ ¥ ®“°°“√
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°“√‡æ‘Ë¡‚Õ°“‡’ˬߵàÕ°≈â“¡‡π◊ÈÕÀ—«„®¢“¥‡≈◊Õ¥À√◊Õµ“¬3 ·≈–
‡π◊ËÕß®“°§«“¡ª«¥∑”„À≡àÕ¬“°‡§≈◊ËÕπ‰À« ºŸâŸßÕ“¬ÿ®÷߇’ˬß
µàÕ°“√‡°‘¥·º≈°¥∑—∫ ªÕ¥Õ—°‡∫ ·≈– deep vein thrombosis ´÷Ëߺ≈‡’¬‡À≈à“π’È≈¥≈߉¥â‚¥¬„Àâ°“√√–ß—∫ª«¥À≈—ßºà“µ—¥
Õ¬à“߇撬ßæÕ4,5
ªí®®ÿ∫—π«‘∑¬“°“√√–ß—∫ª«¥¡’§«“¡°â“«ÀπⓇªìπÕ¬à“ß¡“°
À≈—°°“√¢Õß multimodal therapy ·≈– pre-emptive analgesia ™à«¬„Àâ°“√√–ß—∫ª«¥∑—Èß„π√–À«à“ß·≈–À≈—ßºà“µ—¥¡’ª√–‘∑∏‘¿“楒¬‘Ëߢ÷Èπ ‚¥¬‡©æ“–°“√√–ß—∫ª«¥‡©æ“–à«π ‡™àπ
°“√©’¥¬“‡¢â“™àÕßπÈ”‰¢—πÀ≈—ß (intrathecal injection) ´÷Ëß®–
™à«¬≈¥°“√„™â systemic opioid ®÷ß≈¥º≈¢â“߇§’¬ß≈߉¥â1,2 °“√
»÷°…“∑’˺à“π¡“æ∫«à“°“√º¡ morphine 0.1 ¡°. „𬓙“∑’Ë
©’¥‡¢â“™àÕßπÈ”‰¢—πÀ≈—ß„π°“√ºà“µ—¥¢âÕ–‚æ° “¡“√∂√–ß—∫
ª«¥À≈—ßºà“µ—¥‰¥â¥6-9
’ ®÷߇ªìπ∑’Ëπ‘¬¡„™â°—πÕ¬à“ß·æ√àÀ≈“¬ πÕ°
®“°π’È¡’°“√»÷°…“∂÷ß°“√º¡ adrenaline „𬓙“∑’Ë©’¥‡¢â“™àÕß
πÈ”‰¢—πÀ≈—ß ∑—Èß„π°“√ºà“µ—¥π√’‡«™10 ºà“µ—¥µàÕ¡≈Ÿ°À¡“°‚¥¬
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‰¢—πÀ≈—ß„π¡πÿ…¬å14-15 ¡’‡æ’¬ß√“¬ß“π°“√»÷°…“„π°√–µà“¬
´÷Ëßæ∫«à“Õ“®∑”„Àâ¡’°“√‡æ‘Ë¡¢÷Èπ¢Õß√–¥—∫ glutamate „ππÈ”
‰¢—πÀ≈—ß´÷Ëß—¡æ—π∏å°—∫°“√‡°‘¥ neuronal injury ‰¥â16
ªí®®ÿ∫—π¬—߉¡à¡’°“√»÷°…“∑’Ë°≈à“«∂÷ߺ≈°“√º¡ adrenaline „𬓙“∑’Ë©’¥‡¢â“™àÕßπÈ”‰¢—πÀ≈—ßµàÕ°“√√–ß—∫ª«¥„π
°“√ºà“µ—¥¢âÕ–‚æ°À√◊Õ¢âÕ‡¢à“„πºŸâªÉ«¬ŸßÕ“¬ÿ °“√»÷°…“π’È®÷ß
¡’«—µ∂ÿª√–ߧå‡æ◊ËÕ‡ª√’¬∫‡∑’¬∫√–¬–‡«≈“·≈–º≈°“√√–ß—∫ª«¥
À≈—ßºà“µ—¥¢âÕ–‚æ°À√◊Õ¢âÕ‡¢à“„πºŸâªÉ«¬ŸßÕ“¬ÿ √–À«à“ß°“√
º¡·≈–‰¡àº¡ adrenaline ©’¥‡¢â“™àÕßπÈ”‰¢—πÀ≈—ß
64
«‘—≠≠’“√
Keywords : adrenaline, elderly, hip surgery, intrathecal
morphine, knee surgery, postoperative analgesia
Thai J Anesthesiology 2006 ; 32(2): 63-9.
«‘∏’°“√»÷°…“
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„Àâ chlorpheniramine 10 ¡°. ‡¢â“À≈Õ¥‡≈◊Õ¥¥” ´È”‰¥â∑ÿ° 6
™¡. ·≈–√—°…“Õ“°“√§≈◊Ëπ‰âÕ“‡®’¬π‚¥¬„Àâ ondansetron 4
Vol. 32, No. 2, April-June 2006
¡°. ‡¢â“À≈Õ¥‡≈◊Õ¥¥” ´È”‰¥â∑ÿ° 6 ™¡.
∫— π ∑÷ ° ¢â Õ ¡Ÿ ≈ ‡æ» Õ“¬ÿ πÈ ” Àπ— ° à « πŸ ß ASA
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µâÕß°“√„π 48 ™¡. (total morphine requirements in the first
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¢π“¥°≈ÿࡵ—«Õ¬à“ß°≈ÿà¡≈– 20 §π À≈—ß®“°‰¥â∑”°“√∑¥Õ∫
≈—°…≥–°“√°√–®“¬¢ÕߢâÕ¡Ÿ≈·≈â« ®÷߉¥âπ”‡πÕ¢âÕ¡Ÿ≈∑’Ë¡’
°“√°√–®“¬ª°µ‘‡ªìπ mean (SD) ·≈–«‘‡§√“–Àå‚¥¬ t-test
°√≥’ ¢â Õ ¡Ÿ ≈ ¡’ ° “√°√–®“¬‰¡à ª °µ‘ ®–π”‡πÕ‡ªì π median
(range) ·≈–«‘ ‡ §√“–Àå ‚ ¥¬ Mann-Whitney U-test ”À√— ∫
¢âÕ¡Ÿ≈™π‘¥ categorical ‡π◊ËÕß®“° expected value πâÕ¬°«à“
5 ®÷ß«‘‡§√“–Àå‚¥¬ Fisher’s exact test ∑—Èßπ’Èæ‘®“√≥“§«“¡
·µ°µà“ßÕ¬à“ß¡’π—¬”§—≠∑“ß∂‘µ‘∑’Ë p-value πâÕ¬°«à“ 0.5
(p < 0.05)
º≈°“√»÷°…“
ºŸâªÉ«¬∑’Ë»÷°…“¡’∑—ÈßÀ¡¥ 40 §π „π®”π«ππ’È ¡’ºŸâªÉ«¬
2 §π ∑’ˉ¡à“¡“√∂©’¥¬“™“‡¢â“™àÕßπÈ”‰¢—πÀ≈—߉¥â”‡√Á® ·≈–
5 §π ∑’Ë√–¥—∫°“√™“‰¡à‡æ’¬ßæÕ∑’Ë®–ºà“µ—¥·≈–µâÕß„Àâ°“√√–ß—∫
§«“¡√Ÿâ÷°·∫∫∑—Ë«‰ª ®÷ß«‘‡§√“–Àå¢âÕ¡Ÿ≈®“°ºŸâªÉ«¬ 33 §π
·∫à߇ªìπ°≈ÿà¡ M 17 §π °≈ÿà¡ MA 16 §π ´÷Ëß¡’¢π“¥∑’ˇ撬ß
æÕÀ≈—ß®“°‰¥âæ‘®“√≥“®”π«πºŸâªÉ«¬ drop out ·≈â«
¢âÕ¡Ÿ≈æ◊Èπ∞“π ‡æ» Õ“¬ÿ πÈ”Àπ—° à«πŸß ASA
classification ™π‘¥¢Õß°“√ºà“µ—¥ √–¥—∫°“√™“ ·≈–√–¬–‡«≈“
„π°“√ºà“µ—¥ „π∑—ÈßÕß°≈ÿà¡ ‰¡à·µ°µà“ß°—πÕ¬à“ß¡’π—¬”§—≠
∑“ß∂‘µ‘ (Table 1)
Thai Journal of Anesthesiology
65
Table 1 Demographic characteristics of the patients
Sex (n, M : F)
Age (yr.)*
Group M (n = 17)
Group MA (n = 16)
5 : 12
3 : 13
71.6 ±10
Weight (Kg)*
59.7 ± 10.1
Height (cm)*
ASA classification I/II/III (n)
58.7 ± 11.7
157.0 ± 8.7
158.1 ± 8.1
15
12
0/17/0
Hip surgery (n)
Knee surgery (n)
71.9 ± 8.7
1/11/4
2
#
Level of anesthesia (dermatome)
4
T10 (T10-T6)
Duration of surgery (min)*
T10 (T10-T5)
138.2 ± 32.0
151.4 ± 57.7
* Data are mean ± SD,# Data are median (range)
Group M : intrathecal morphine without adrenaline
Group MA : intrathecal morphine with adrenaline
Table 2 Postoperative analgesic characteristics between two groups
Time of first morphine request (min)#
Total morphine requirements in first 48 h (mg)
#
Patients not requiring morphine (n, %)
Patients required morphine in 48 h ≥ 12 mg (n, %)
Group M (n = 17)
Group MA ( n= 16)
p-value
505 (375-1025)
520 (385-1165)
0.98
1 (5.9%)
6 (37.5%)
3 (0-15)
7 (41.1%)
3 (0-12)
0.06
1 (6.2%)
0.03
0 . 0 2
#
Data are median (range)
Group M : intrathecal morphine without adrenaline
Group MA : intrathecal morphine with adrenaline
√–¬–‡«≈“µ—Èß·µà©’¥¬“™“‡¢â“™àÕßπÈ”‰¢—πÀ≈—ß®π°√–∑—Ëß
ºŸâªÉ«¬µâÕß°“√ morphine §√—Èß·√° (time of first morphine
request) ·≈–ª√‘¡“≥ morphine ∑—ÈßÀ¡¥∑’˺ŸâªÉ«¬µâÕß°“√„π 48
™¡. (total morphine requirements in the first 48 hours) „π
∑—ÈßÕß°≈ÿà¡ ‰¡à·µ°µà“ß°—πÕ¬à“ß¡’π—¬”§—≠∑“ß∂‘µ‘ (Table 2)
66
«‘—≠≠’“√
Õ¬à“߉√°Áµ“¡æ∫«à“ºŸâªÉ«¬∑’ˉ¡àµâÕß°“√ morphine ‡≈¬„π°≈ÿà¡
M ( 1 §π, √â Õ ¬≈– 5.9 ) ¡’ ® ”π«ππâ Õ ¬°«à “ „π°≈ÿà ¡ MA
(6 §π, √âÕ¬≈– 37.5) Õ¬à“ß¡’π—¬”§—≠∑“ß∂‘µ‘ (p = 0.02)
·≈–ºŸâªÉ«¬∑’˵âÕß°“√ morphine ¡“°°«à“À√◊Õ‡∑à“°—∫ 12 ¡°.
„π°≈ÿà¡ M (7 §π, √âÕ¬≈– 41.1) ¡’®”π«π¡“°°«à“„π°≈ÿà¡
ªï∑’Ë 32 ©∫—∫∑’Ë 2 ‡¡…“¬π-¡‘∂ÿπ“¬π 2549
Figure 2 Verbal numerical pain score (VNS) in the first 48
hour after intrathecal administration (p = 0.09)
Figure 1 Total morphine requirement in the first 48 hour
systemic opioid
MA
(1 §π, √âÕ¬≈– 6.2) Õ¬à“ß¡’π—¬”§—≠∑“ß∂‘µ‘ (p =
0.03) (Table 2 ·≈– Figure 1)
§–·π𧫓¡ª«¥ (VNS) ¢ÕߺŸâªÉ«¬ ≥. ‡«≈“µà“ßÊ
„π 48 ™¡. À≈—ßºà“µ—¥ „π∑—ÈßÕß°≈ÿà¡ ‰¡à·µ°µà“ß°—πÕ¬à“ß
¡’π—¬”§—≠∑“ß∂‘µ‘ (p = 0.09) (Figure 2)
‰¡àæ∫Õÿ∫—µ‘°“√≥å¢Õß°“√°¥°“√À“¬„® §«“¡ßà«ß´÷¡
√–¥—∫ 3, PDPH ·≈– TNS „πºŸâªÉ«¬∑—ÈßÕß°≈ÿà¡ ¿“¬„π 48
™¡.·√°À≈— ß ºà “ µ— ¥ ®”π«πºŸâ ªÉ « ¬∑’Ë ¡’ Õ “°“√§— π À√◊ Õ §≈◊Ë π ‰â
Õ“‡®’¬π ‰¡à·µ°µà“ß°—πÕ¬à“ß¡’π—¬”§—≠∑“ß∂‘µ‘ ‚¥¬ºŸâªÉ«¬
¡’Õ“°“√§—π 2 §π „π°≈ÿà¡ M ·≈– 1 §π „π°≈ÿà¡ MA
(p = 0.16 ) ºŸâ ªÉ « ¬¡’ Õ “°“√§≈◊Ë π ‰â Õ “‡®’ ¬ π°≈ÿà ¡ ≈– 2 §π
(p = 0.43) ºŸâªÉ«¬∑ÿ°§π¡’Õ“°“√≈¥≈߇¡◊ËÕ‰¥â√—∫°“√√—°…“
«‘®“√≥å
ºŸâªÉ«¬ŸßÕ“¬ÿ¡’§«“¡‰«µàÕ systemic opioid ®÷ß∑”„Àâ¡’
‚Õ°“‡’ˬߵàÕ¿“«–°¥°“√À“¬„®‰¥âßà“¬ Õ—π‡π◊ËÕß¡“®“°¬“
ÕÕ°ƒ∑∏‘Ïπ“π¢÷Èπ·≈–¢—∫ÕÕ°®“°√à“ß°“¬≈¥≈ß1 ·æ∑¬å∑—Ë«‰ª
®÷ß¡’·π«‚πâ¡®–„Àâ systemic opioid ‡æ’¬ß®”π«ππâÕ¬ À√◊Õ
µ“¡§«“¡µâÕß°“√ ºŸâªÉ«¬®”π«π¡“°®÷߉¥â√—∫°“√√–ß—∫ª«¥‰¡à
‡æ’¬ßæÕ °“√„Àâ opioid ‡¢â“™àÕßπÈ”‰¢—πÀ≈—߇ªìπ«‘∏’Àπ÷Ëß∑’Ë
π‘¬¡„™â ∑”‰¥âßà“¬ ·≈–„™â opioid ¢π“¥πâÕ¬¡“°‡¡◊ËÕ‡∑’¬∫°—∫
Vol. 32, No. 2, April-June 2006
‚¥¬°“√º¡√à«¡°—∫¬“™“∑’Ë©’¥‡¢â“™àÕßπÈ”
‰¢—πÀ≈—ß ¡’ƒ∑∏‘Ï√–ß—∫ª«¥π“π 18-24 ™¡. ·≈–°“√»÷°…“
∑’˺à“π¡“æ∫«à“°“√º¡ adrenaline √à«¡¥â«¬10-13 ®–™à«¬¬◊¥
√–¬–‡«≈“„π°“√√–ß—∫ª«¥À≈—ßºà“µ—¥„Àâπ“π¢÷Èπ
°“√»÷°…“π’È·¥ß„Àâ‡ÀÁπ«à“°“√º¡ adrenaline 0.2 ¡°.
„π 0.5% isobaric bupivacaine 17.5 ¡°. ·≈– morphine 0.1
¡°. ‡æ◊ËÕ©’¥‡¢â“™àÕßπÈ”‰¢—πÀ≈—ß„π°“√√–ß—∫ª«¥À≈—ßºà“µ—¥¢âÕ
–‚æ°À√◊Õ¢âÕ‡¢à“„πºŸâªÉ«¬ŸßÕ“¬ÿ ‰¡à™à«¬¬◊¥√–¬–‡«≈“∑’˺ŸâªÉ«¬
µâ Õ ß°“√ morphine §√—È ß ·√°À≈— ß ºà “ µ— ¥ ·≈–‰¡à ≈ ¥ª√‘ ¡ “≥
morphine ∑—ÈßÀ¡¥∑’˺ŸâªÉ«¬µâÕß°“√„π 48 ™¡. ·√°À≈—ßºà“µ—¥
·µàÕ¬à“߉√°Áµ“¡¡’·π«‚πâ¡≈¥®”π«πºŸâªÉ«¬∑’˵âÕß°“√ morphine À≈—ßºà“µ—¥‰¥â ‚¥¬®–‡ÀÁπ«à“√âÕ¬≈–¢ÕߺŸâªÉ«¬∑’ˉ¡àµâÕß
°“√ morphine ‡≈¬ „π°≈ÿà¡∑’ˉ¥â√—∫ adrenaline ¡’¡“°°«à“
°≈ÿà¡∑’ˉ¡à‰¥â√—∫ adrenaline Õ¬à“ß¡’π—¬”§—≠∑“ß∂‘µ‘ (√âÕ¬≈–
37.5 ·≈–√âÕ¬≈– 5.9, p = 0.02) ‚¥¬‰¡à∑”„Àâº≈¢â“߇§’¬ß‡æ‘Ë¡
¢÷Èπ ´÷ËßÕ“®‡°‘¥®“°¢π“¥°≈ÿࡵ—«Õ¬à“ß„π°“√»÷°…“π’È ´÷ËßÕâ“ßÕ‘ß
®“°°“√»÷°…“¢Õßµà“ߪ√–‡∑»„π°“√ºà“µ—¥π√’‡«™ Õ“®πâÕ¬‡°‘π
‰ª∑’Ë ® –∑”„Àâ ‡ ÀÁ 𠧫“¡·µ°µà “ ßÕ¬à “ ß¡’ π— ¬ ”§— ≠ ∑“ß∂‘ µ‘
√–À«à“ßÕß°≈ÿࡇ¡◊ËÕπ”¡“»÷°…“°—∫°≈ÿࡺŸâŸßÕ“¬ÿ§π‰∑¬
°√≥’∑’Ë°“√º¡ adrenaline ‰¡à™à«¬¬◊¥√–¬–‡«≈“∑’˺ŸâªÉ«¬
µâ Õ ß°“√ morphine §√—È ß ·√°À≈— ß ºà “ µ— ¥ à « πÀπ÷Ë ß Õ“®‡ªì π
‡æ√“–«à“°“√»÷°…“π’È„™â isobaric bupivacaine ´÷Ëß¡’º≈°“√√–ß—∫
ª«¥¬“«π“πÕ¬Ÿà·≈â« ‡¡◊ËÕº¡°—∫ morphine 0.1 ¡°. ®÷ßÕ“®
Thai Journal of Anesthesiology
67
∫¥∫—ߺ≈¢Õß adrenaline ·µ°µà“ß®“°°“√»÷°…“∑’˺à“π¡“´÷Ëß„™â
hyperbaric bupivacaine 11,13 À√◊ Õ lidocaine 12 ´÷Ë ß ¡’
ƒ∑∏‘Ï√–ß—∫ª«¥—Èπ°«à“ ®÷ß∑”„Àâ‡ÀÁπº≈¢Õß adrenaline µàÕ
√–¬–‡«≈“„π°“√√–ß—∫ª«¥À≈—ßºà“µ—¥™—¥‡®π°«à“
·¡â«à“°“√»÷°…“π’È®–æ∫«à“°“√º¡ adrenaline ‰¡à™à«¬
≈¥ª√‘¡“≥ morphine ∑—ÈßÀ¡¥∑’˺ŸâªÉ«¬µâÕß°“√„π 48 ™¡.·√°
À≈—ßºà“µ—¥ ·≈–‰¡à≈¥§–·π𧫓¡ª«¥Õ¬à“ß¡’π—¬”§—≠∑“ß
∂‘µ‘ ·µà‡¡◊ËÕæ‘®“√≥“®“° Figure 1 ®–æ∫«à“√âÕ¬≈– 93.8
¢ÕߺŸâªÉ«¬„π°≈ÿà¡∑’ˉ¥â√—∫ adrenaline ¡’§«“¡µâÕß°“√ morphine πâÕ¬°«à“ 12 ¡°. ´÷Ëß·¥ß„Àâ‡ÀÁπ«à“°“√º¡ adrenaline ¡’ · π«‚πâ ¡ ∑’Ë ® –≈¥§«“¡√ÿ π ·√ߢÕߧ«“¡ª«¥‰¥â ·¡â «à “
„π∑“ߪؑ∫—µ‘Õ“®‰¡à·µ°µà“ß°—π
Goyagi T ·≈–§≥–10 »÷°…“º≈¢Õß°“√º¡ adrenaline ·≈– morphine „𬓠tetracaine ∑’Ë©’¥‡¢â“∑“ß™àÕßπÈ”
‰¢—πÀ≈—ß„πºŸâªÉ«¬ 36 §π ∑’Ë¡“ºà“µ—¥∑“ßπ√’‡«™ æ∫«à“°“√
º¡ adrenaline ®–™à«¬¬◊¥√–¬–‡«≈“∑’˺ŸâªÉ«¬µâÕß°“√ morphine §√—Èß·√°„Àâπ“π¢÷Èπ ·≈–“¡“√∂≈¥§«“¡µâÕß°“√ morphine ¢ÕߺŸâªÉ«¬À≈—ßºà“µ—¥‰¥â ´÷Ëß·µ°µà“ß®“°º≈°“√»÷°…“π’È
Õ“®‡°‘¥®“°≈—°…≥–¢ÕߺŸâªÉ«¬°≈ÿࡵ—«Õ¬à“ß ™π‘¥·≈–µ”·Àπàß
¢Õß°“√ºà“µ—¥ ™π‘¥¢Õ߬“™“∑’Ë„™â √«¡∂÷ߪ√‘¡“≥¢Õß morphine ∑’Ë„™â·µ°µà“ß°—π ·≈–¥â«¬‡Àµÿº≈¥—ß°≈à“«∫“ß°“√»÷°…“
®÷ß·¥ß«à“°“√º¡ adrenaline ‰¡à¡’º≈µàÕ√–¬–‡«≈“„π°“√
√–ß—∫ª«¥À≈—ßºà“µ—¥17,18 ‡™àπ°—π
°“√„Àâ morphine ‡¢â“™àÕßπÈ”‰¢—πÀ≈—ß “¡“√∂√–ß—∫ª«¥
À≈—ßºà“µ—¥‰¥âπ“πª√–¡“≥ 24 ™¡. „π°“√ºà“µ—¥°√–¥Ÿ°19 ∑—Èßπ’È
¢÷Èπ°—∫¢π“¥¢Õß morphine ·≈–°“√µÕ∫πÕßµàÕ¬“∑’Ë·µ°
µà “ ß°— π ¢ÕߺŸâ ªÉ « ¬·µà≈–§π °“√»÷°…“π’ȇ≈◊Õ°„™â morphine
¢π“¥ 0.1 ¡°. ‡π◊ËÕß®“° Murphy PM ·≈–§≥–6 »÷°…“æ∫
«à“ morphine ¢π“¥¥—ß°≈à“«‡À¡“–¡„πºŸâªÉ«¬ŸßÕ“¬ÿ∑’Ë¡“√—∫
°“√ºà“µ—¥¢âÕ–‚æ° ‡π◊ÕË ß®“°“¡“√∂√–ß—∫ª«¥À≈—ßºà“µ—¥‰¥â¥’
æÕ°—∫ morphine ¢π“¥ 0.2 ¡°. ·µàº≈¢â“߇§’¬ßπâÕ¬°«à“
‚¥¬∑—Ë«‰ª°“√ª√–‡¡‘𧫓¡ª«¥ (VNS) ®–‰¥â¢âÕ¡Ÿ≈∑’Ë¢÷Èπ°—∫
ºŸâªÉ«¬‡ªìπÕ¬à“ß¡“° (subjective) ”À√—∫ºŸâªÉ«¬ŸßÕ“¬ÿ ¡’√“¬
ß“π«à“Õ“®µÕ∫πÕßµàÕ§«“¡ª«¥≈¥≈ß ·≈–∑πµàÕ§«“¡ª«¥
‡æ‘Ë¡¢÷Èπ20 ®÷ßÕ“®∑”„Àâ VNS ∑’ˉ¥âπâÕ¬°«à“∑’˧«√‡ªìπ Õ¬à“߉√
°Áµ“¡°“√»÷°…“π’ȉ¥â‡°Á∫¢âÕ¡Ÿ≈∑’ˇªìπ subjective πâÕ¬°«à“ §◊Õ
√–¬–‡«≈“µ—Èß·µà©’¥¬“™“‡¢â“™àÕßπÈ”‰¢—πÀ≈—ß®πºŸâªÉ«¬µâÕß°“√
morphine §√—Èß·√° ·≈–ª√‘¡“≥ morphine ∑—ÈßÀ¡¥∑’˺ŸâªÉ«¬
µâÕß°“√∑—ÈßÀ¡¥„π 48 ™¡.·√°À≈—ßºà“µ—¥
68
«‘—≠≠’“√
„π∑“ß∑ƒ…Æ’ °“√√–ß—∫ª«¥‚¥¬«‘∏’ patient controlled
analgesia (PCA) ‡À¡“–¡°—∫°“√√–ß—∫ª«¥À≈—ßºà“µ—¥¡“°
°«à“°“√„Àâ systemic opioid ‡¡◊ËÕºŸâªÉ«¬√âÕߢծ“°æ¬“∫“≈
‡π◊ËÕß®“°ºŸâªÉ«¬“¡“√∂§«∫§ÿ¡°“√√–ß—∫ª«¥‰¥â¥â«¬µ—«‡Õß ·µà
„π∑“ߪؑ∫—µ‘Õ“®¡’§«“¡®”‡ªìππâÕ¬ „π°√≥’∑’˧«“¡ª«¥À≈—ß
ºà“µ—¥¡’§«“¡√ÿπ·√ßπâÕ¬ ´÷Ëß∑”„Àâ¡’§«“¡µâÕß°“√ systemic
opioid πâÕ¬ ‡™àπ„π°“√»÷°…“π’È´÷ËߺŸâªÉ«¬¡’ VNS πâÕ¬°«à“ 4
Õ¬Ÿà„π√–¥—∫∑’ˬա√—∫‰¥â«à“ª«¥πâÕ¬ ª√–°Õ∫°—∫ºŸâªÉ«¬“¡“√∂
°‘π¬“√–ß—∫ª«¥‰¥â∑—π∑’À≈—ßºà“µ—¥·≈–º≈°“√√–ß—∫ª«¥®“°°“√
©’¥¬“‡¢à“™àÕßπÈ”‰¢—πÀ≈—߬“«π“πæÕ ´÷ËßÕ“®™à«¬≈¥§à“„™â®à“¬
®“°°“√„™â‡§√◊ËÕß PCA „π¢≥–∑’ˉ¥âª√–‘∑∏‘¿“æ„π°“√√–ß—∫
ª«¥¥’æÕ°—π
”À√—∫º≈¢â“߇§’¬ß®“°°“√º¡ adrenaline „𬓙“∑’Ë
©’¥‡¢â“™àÕßπÈ”‰¢—πÀ≈—ß °“√»÷°…“∑’˺à“π¡“ æ∫«à“‰¡à≈¥°“√
‰À≈‡«’¬π‡≈◊Õ¥‰ª‡≈’Ȭ߉¢—πÀ≈—ß„π¡πÿ…¬å 14-15 ´÷Ëß°“√»÷°…“π’È
‰¡àæ∫ºŸâªÉ«¬√“¬„¥¡’¿“«–·∑√°´âÕπ¥—ß°≈à“«‡°‘¥¢÷Èπ
√ÿª
0.2 ¡°. „π 0.5% isobaric
bupivacaine 17.5 ¡°. ·≈– morphine 0.1 ¡°. ‡æ◊Õ
Ë ©’¥‡¢â“
°“√º¡
adrenaline
™à Õ ßπÈ ” ‰¢— π À≈— ß „π°“√√–ß— ∫ ª«¥À≈— ß ºà “ µ— ¥ ¢â Õ –‚æ°À√◊ Õ
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