·π«∑“߇«™ªØ‘∫—μ‘ / Guidelines Public hearing: 23 November 2017

Accepted: 23 March 2019

§”·π–π”°“√¥Ÿ·≈∑“ß‚¿™π“°“√„πºŸªâ «É ¬ºŸ„â À≠à∑πË’ Õπ‚√ß欓∫“≈ æ.». 2560

μÕπ∑’Ë 2: °“√„ÀâÕ“À“√‡¢â“∑“߇¥‘πÕ“À“√ (§”·π–π”∑’Ë 5-10)
¥√ÿ≥’«—≈¬å «‚√¥¡«‘®‘μ√1, ª√’¬“πÿ™ ·¬â¡«ß…2å ,‹ ª√–≥‘∏‘ Àß ª√–¿“ 3, °«’»—°¥‘Ï ®‘μμ«—≤π√—μπå4, ®ß®‘μ√ ՗ߧ∑–«“π‘™5,
«’√–‡¥™ æ‘»ª√–‡ √‘∞3, »“π‘μ «‘™“π»«°ÿ≈6, ‘√°“πμå ‡μ™–«≥‘™7, √«‘‡™…∞å √—μπ™—¬«ß»å3, «‘π—¬ Õ÷ßæ‘π‘®æß»å8,
ª√‘¬ æ√√≥‡™…∞å1, °ÿ≈æß…å ™—¬π“¡9, »‘√‘π∑√å ®‘«“°“ππ∑å10, ª√–æ‘¡æåæ√ ©—μ√πÿ°Ÿ≈™—¬ (©—π∑«»‘π°ÿ≈)1, °√°μ «’√‡∏’¬√11,
¥“√“æ√ √ÿâßæ√“¬12, π≈‘π’ Õ‘Ë¡‡Õ‘∫ ‘π13, àß»√’ ·°â«∂πÕ¡14, Õ√«√√≥ æ‘™‘쉙¬æ‘∑—°…å15, ∫ÿ™™“ æ√“À¡≥ ÿ∑∏‘Ï16,‹
∏—≠«√‘π∑√å μ—È߇ √‘¡«ß»å17, Õÿª∂—¡¿å »ÿ¿ ‘π∏ÿå18
1
“¢“«‘™“‚¿™π«‘∑¬“·≈–™’«‡§¡’∑“ß°“√·æ∑¬å ¿“§«‘™“Õ“¬ÿ√»“ μ√å §≥–·æ∑¬»“ μ√å‚√ß欓∫“≈√“¡“∏‘∫¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈
2
“¢“«‘™“‚¿™π“°“√§≈‘π‘° ¿“§«‘™“Õ“¬ÿ√»“ μ√å §≥–·æ∑¬»“ μ√廑√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈
3
“¢“«‘™“‚¿™π«‘∑¬“§≈‘π‘° ¿“§«‘™“Õ“¬ÿ√»“ μ√å §≥–·æ∑¬»“ μ√å ¡À“«‘∑¬“≈—¬¢Õπ·°àπ
4
¿“§«‘™“»—≈¬»“ μ√å §≥–·æ∑¬»“ μ√å ¡À“«‘∑¬“≈—¬‡™’¬ß„À¡à
5
¿“§«‘™“‚¿™π“°“√·≈–°“√°”Àπ¥Õ“À“√ §≥– À‡«™»“ μ√å ®ÿÓ≈ß°√≥å¡À“«‘∑¬“≈—¬
6
Àπ૬‚¿™π“°“√§≈‘π‘° ¿“§«‘™“Õ“¬ÿ√»“ μ√å §≥–·æ∑¬»“ μ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ μ√å
7
Àπ૬‚¿™π»“ μ√å§≈‘π‘° °ÕßÕ“¬ÿ√°√√¡ ‚√ß欓∫“≈æ√–¡ß°ÿƇ°≈â“
8
°≈ÿà¡ß“π»—≈¬°√√¡ ‚√ß欓∫“≈ ÿ√‘π∑√å
9
∂“∫—π°“√·æ∑¬å®—°√’πƒ∫¥‘π∑√å §≥–·æ∑¬»“ μ√å‚√ß欓∫“≈√“¡“∏‘∫¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈
10
°≈ÿà¡ß“πÕ“¬ÿ√°√√¡ ‚√ß欓∫“≈À“¥„À≠à
11
ß“π‚¿™π“°“√ ‚√ß欓∫“≈æ√–¡ß°ÿƇ°≈â“
12
¿“§«‘™“‡¿ —™°√√¡ §≥–‡¿ —™»“ μ√å ¡À“«‘∑¬“≈—¬»‘≈ª“°√
13
Àπ૬‡¿ —™°√√¡ »Ÿπ¬å°“√·æ∑¬å ‘√‘°‘μ‘Ï §≥–·æ∑¬»“ μ√å‚√ß欓∫“≈√“¡“∏‘∫¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈
14
ß“π‚¿™π»“ μ√å§≈‘π‘° ‚√ß欓∫“≈»‘√‘√“™
15
ß“π°“√欓∫“≈ªÑÕß°—π‚√§·≈– à߇ √‘¡ ÿ¢¿“æ ΩÉ“¬°“√欓∫“≈ ‚√ß欓∫“≈√“¡“∏‘∫¥’
16
°≈ÿà¡ß“π‚¿™π»“ μ√å ∂“∫—π¡–‡√Áß·Ààß™“μ‘ ·≈–Àπ૬‚¿™π“°“√ ‚√ß欓∫“≈®ÿÓ¿√≥å
17
ΩÉ“¬‚¿™π“°“√ §≥–·æ∑¬»“ μ√å‚√ß欓∫“≈√“¡“∏‘∫¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈
18
Àπ૬‚√§‰μ °ÕßÕ“¬ÿ√°√√¡ ‚√ß欓∫“≈æ√–¡ß°ÿƇ°≈â“

Corresponding author: Daruneewan Warodomwichit

Division of Clinical Nutrition and Medical Biochemistry, Department of Medicine, Faculty of Medicine Ramathibodi Hospital,
Mahidol University
Email: daruneewan@yahoo.com
Thai Clinical Practice Recommendations for Nutritional Management in Adult
Hospitalized Patients 2017 Part 2: Enteral Nutrition (Recommendation 5-10) Warodomwichit D. et al

Thai Clinical Practice Recommendations for Nutritional

Management in Adult Hospitalized Patients 2017 Part 2:
Enteral Nutrition (Recommendation 5-10)
Daruneewan Warodomwichit1, Preyanuj Yamwong2, Pranithi Hongsprabhas3, Kaweesak Chittawattanarat4,
Jongjit Angkatavanich5, Veeradej Pisprasert3, Sanit Wichansavakun6, Sirikarn Tejavanija7, Sornwichate Rattanachaiwong3,
Winai Ungpinitpong8, Pariya Phanachet1, Kulapong Jayanama1, Sirin Jiwakanon10, Prapimporn Chattranukulchai Shantavasinkul1,
Korrakot Weratean11, Daraporn Rungprai12, Nalinee Im-erbsin13, Songsri Keawtanom14, Orawan Pichitchaipitak15,
Buchcha Prammanasudh16, Thanwarin Tangsermwong17, Ouppatham Supasyndh18
1
Division of Clinical Nutrition and Medical Biochemistry, Department of Medicine, Faculty of Medicine Ramathibodi Hospital,
Mahidol University
2
Division of Clinical Nutrition, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University
3
Division of Clinical Nutrition, Department of Medicine, Faculty of Medicine, Khon Kaen University
4
Department of Surgery, Faculty of Medicine, Chiang Mai University
5
Department of Nutrition and Dietetics, Faculty of Allied Health Sciences, Chulalongkorn University,
6
Division of Clinical Nutrition, Department of Medicine, Faculty of Medicine, Thammasart University
7
Division of Clinical Nutrition, Department of Internal Medicine, Pharmongkutklao Hospital
8
Department of Surgery, Surin Hospital
9
Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University
10
Department of Internal Medicine, Hat Yai Hospital
11
Department of Nutrition, Pharmongkutklao Hospital
12
Department of Pharmacy, Faculty of Pharmacy, Silpakorn Univesity
13
Department of Pharmacy in Queen Sirikit Medical Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University
14
Research Center for Nutrition Support, Siriraj Hospital
15
Home Health Care Nursing Unit, Division of Ambulatory Care Nursing Service, Department of Nursing, Faculty of Medicine Ramathibodi
Hospital, Mahidol University
16
Department of Nutrition, Nation Cancer Institute and Department of Nutrition, Chulabhorn Hospital
17
Division of Nutrition and Dietetics, Faculty of Medicine Ramathibodi Hospital, Mahidol University
18
Division of Nephrology, Department of Internal Medicine, Phramongkutklao Hospital

Thai JPEN
Volume 27 No. 2 July - December 2019 9
§”·π–π”°“√¥Ÿ·≈∑“ß‚¿™π“°“√„πºŸâªÉ«¬ºŸâ„À≠à∑’ËπÕπ‚√ß欓∫“≈ æ.». 2560
μÕπ∑’Ë 2: °“√„ÀâÕ“À“√‡¢â“∑“߇¥‘πÕ“À“√ (§”·π–π”∑’Ë 5-10) ¥√ÿ≥’«—≈¬å «‚√¥¡«‘®‘μ√ ·≈–§≥–

Thai JPEN 2019;27(2):8-39.

∫∑§—¥¬àÕ
¿“«–∑ÿæ‚¿™π“°“√‡ªìπªí≠À“∑’Ëæ∫∫àÕ¬„πºŸâªÉ«¬ºŸâ„À≠à∑’ËπÕπ‚√ß欓∫“≈·≈–¡—°®–∂Ÿ°≈–‡≈¬ ®“°∫ÿ§≈“°√∑“ß
°“√·æ∑¬å °“√„Àâ°“√¥Ÿ·≈∑“ß‚¿™π“°“√‡√‘Ë¡μ—Èß·μà°“√§—¥°√Õß·≈–°“√ª√–‡¡‘π¿“«–‚¿™π“°“√ °“√„Àâ‚¿™π∫”∫—¥ μ≈Õ¥®π
°“√μ‘¥μ“¡ª√–‡¡‘πº≈Õ¬à“߇À¡“– ¡®–™à«¬∑”„Àâº≈°“√√—°…“¢ÕߺŸâªÉ«¬¥’¢÷Èπ ≈¥¿“«–·∑√°´âÕπ·≈–§à“„™â®à“¬„π
°“√√—°…“ ¡“§¡ºŸâ„ÀâÕ“À“√∑“ßÀ≈Õ¥‡≈◊Õ¥¥”·≈–∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬‰¥â√«∫√«¡¢âÕ¡Ÿ≈°“√»÷°…“∑’ˇ°‘¥¢÷Èπ
„À¡àÕ¬à“߇ªìπ√–∫∫ √«¡∑—Èߧ«“¡‡ÀÁπ®“° À “¢“«‘™“™’æ ®—¥∑”‡ªì𧔷π–π” 10 ¢âÕ„π°“√¥Ÿ·≈∑“ß‚¿™π“°“√„πºŸâªÉ«¬
ºŸâ„À≠à∑’ËπÕπ‚√ß欓∫“≈∑’Ë¡’§«“¡‡À¡“– ¡°—∫∫√‘∫∑¢Õߪ√–‡∑»‰∑¬‡ªìπ§√—Èß·√° ‡æ◊ËÕ‡ªìπ·π«∑“ß ”À√—∫∫ÿ§≈“°√
∑“ß°“√·æ∑¬å„π°“√æ—≤π“°“√¥Ÿ·≈∑“ß‚¿™π“°“√„πª√–‡∑»‰∑¬„À⡪’ √– ∑‘ ∏‘¿“æ §ÿ¡â §à“ ·≈–‡°‘¥ª√–‚¬™πå ߟ ¥ÿ ·°àºªâŸ «É ¬
§”·π–π”°“√¥Ÿ·≈∑“ß‚¿™π“°“√„πºŸâªÉ«¬ºŸâ„À≠à∑’ËπÕπ‚√ß欓∫“≈„πμÕπ∑’Ë 2 π’È ®–ª√–°Õ∫¥â«¬§”·π–π”∑’Ë 5 ∂÷ß
10 ‰¥â·°à §”·π–π”„π°“√„ÀâÕ“À“√‡¢â“∑“߇¥‘πÕ“À“√ °“√‡≈◊Õ° Ÿμ√Õ“À“√ ”À√—∫°“√„ÀâÕ“À“√‡¢â“∑“߇¥‘πÕ“À“√ «‘∏’°“√
„ÀâÕ“À“√‡¢â“∑“߇¥‘πÕ“À“√ °“√∫√‘À“√¬“ºà“𠓬„ÀâÕ“À“√ °“√ª√–‡¡‘π·≈–°“√μ‘¥μ“¡À≈—ß°“√„ÀâÕ“À“√‡¢â“∑“߇¥‘πÕ“À“√
¿“«–·∑√°´âÕπ√«¡∑—Èß·π«∑“ß°“√ªÑÕß°—π·≈–·°â‰¢

ABSTRACT
Malnutrition, a common problem in hospitalized adult patients, is frequently ignored by medics and paramedics. Proper
nutritional management, including nutritional screening and assessment, nutritional intervention, and monitoring can result in
improving clinical outcomes, decreasing complications as well as improve cost effectiveness. The Society of Parenteral and
Enteral Nutrition of Thailand has launched 10 recommendations on nutritional management in hospitalized adult patients
based on updated scientific evidence, adapted to meet the local context with a consensus among a multidisciplinary team,
in order to guide nutritional management, improve quality of patient care in a hospital setting, and maximize benefits from
the provided resources.
The recommendations are separated into 2 parts. Here are the part 2 recommendations, which consists of the latter
6 recommendations; enteral nutrition initiation, titration, formula selection, drug administration in tube feeding, enteral
nutrition complication and monitoring.

§” ”§—≠: §”·π–π”, ‚¿™π“°“√, ∑ÿæ‚¿™π“°“√, ‚¿™π∫”∫—¥, ºŸâªÉ«¬∑’ËπÕπ‚√ß欓∫“≈, ‰∑¬

Keywords: recommendation, nutrition, malnutrition, nutritional management, hospitalized patient, Thai

À≈—°°“√¢Õߧ”·π–π”°“√¥Ÿ·≈∑“ß‚¿™π“°“√„πºŸâªÉ«¬ºŸâ „À≠à∑’ËπÕπ‚√ß欓∫“≈ æ.». 2561

μÕπ∑’Ë 1: °“√„ÀâÕ“À“√‡¢â“∑“߇¥‘πÕ“À“√ (Enteral Nutrition)
§”·π–π”°“√¥Ÿ·≈∑“ß‚¿™π“°“√„πºŸªâ «É ¬∑’πË Õπ‚√ß欓∫“≈‡ªìπ‡§√◊ÕË ß¡◊Õ ßà ‡ √‘¡§ÿ≥¿“æ°“√∫√‘°“√¥â“π‚¿™π“°“√
”À√—∫ºŸâªÉ«¬„π‚√ß欓∫“≈ ´÷Ëß¡’°“√ª√—∫‡ª≈’ˬπ∫√‘∫∑μà“ß Ê „Àâ‡À¡“– ¡°—∫∑√—欓°√¥â“π “∏“√≥ ÿ¢·≈–‡ß◊ËÕπ‰¢¢Õß
—ߧ¡‰∑¬ ‚¥¬¡ÿàßÀ«—߇æ◊ËÕ°“√ à߇ √‘¡·≈–æ—≤π“°“√¥Ÿ·≈ºŸâªÉ«¬∑“ß‚¿™π“°“√„Àâ¡’ª√– ‘∑∏‘¿“æ §ÿâ¡§à“ ·≈–‡°‘¥
ª√–‚¬™πå Ÿß ÿ¥ §”·π–π”μà“ß Ê „π‡Õ° “√©∫—∫π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ºŸâ„™â “¡“√∂ªØ‘∫—μ‘·μ°μà“ß®“°
§”·π–π”π’ȉ¥â„π°√≥’∑’Ë ∂“π°“√≥å·μ°μà“ßÕÕ°‰ª À√◊Õ¡’¢âÕ®”°—¥¢Õß ∂“π∫√‘°“√·≈–∑√—欓°√ À√◊Õ¡’‡Àμÿº≈
Õ—π ¡§«√Õ◊Ëπ Ê ‚¥¬„™â«‘®“√≥≠“≥´÷Ë߇ªìπ∑’ˬա√—∫Õ¬Ÿà„πæ◊Èπ∞“πÀ≈—°«‘™“°“√·≈–®√√¬“∫√√≥

«“√ “√‚¿™π∫”∫—¥
10 ªï∑’Ë 27 ©∫—∫∑’Ë 2 °√°Æ“§¡ - ∏—𫓧¡ 2562
Thai Clinical Practice Recommendations for Nutritional Management in Adult
Hospitalized Patients 2017 Part 2: Enteral Nutrition (Recommendation 5-10) Warodomwichit D. et al

§ÿ≥¿“æÀ≈—°∞“π (Quality of Evidence)

§ÿ≥¿“æ
À≈—°∞“π À≈—°∞“π∑’ˉ¥â®“°
1 1. °“√∑∫∑«π·∫∫¡’√–∫∫ (systematic review) À√◊Õ°“√«‘‡§√“–Àå·ª√∞“π (meta-analysis) ¢Õß°“√»÷°…“·∫∫°≈ÿ¡à ¡àÿ μ—«Õ¬à“ß-
§«∫§ÿ¡ (randomize-controlled clinical trials) À√◊Õ
2. °“√»÷°…“·∫∫°≈ÿ¡à ¡àÿ μ—«Õ¬à“ß-§«∫§ÿ¡∑’¡Ë §’ ≥ÿ ¿“楒‡¬’¬Ë ¡ (well-designed, randomize-controlled, clinical trial) Õ¬à“ßπâÕ¬
1 ©∫—∫
2 1. °“√∑∫∑«π·∫∫¡’√–∫∫¢Õß°“√»÷°…“§«∫§ÿ¡ ·μà‰¡à‰¥â ¡àÿ μ—«Õ¬à“ß (systematic review of non-randomized, controlled,
clinical trials) À√◊Õ
2. °“√»÷°…“§«∫§ÿ¡ ·μà‰¡à ÿà¡μ—«Õ¬à“ß ∑’Ë¡’§ÿ≥¿“楒‡¬’ˬ¡ (well-designed, non-randomized, controlled clinical trial)
À√◊Õ
3. À≈—°∞“π®“°√“¬ß“π°“√»÷°…“μ“¡·ºπμ‘¥μ“¡‡Àμÿ‰ªÀ“º≈ (cohort) À√◊Õ°“√»÷°…“«‘‡§√“–À姫∫§ÿ¡°√≥’¬âÕπÀ≈—ß (case
control analytic studies) ∑’ˉ¥â√—∫°“√ÕÕ°·∫∫«‘®—¬‡ªìπÕ¬à“ߥ’ ¡“®“° ∂“∫—π À√◊Õ°≈ÿà¡«‘®—¬¡“°°«à“Àπ÷Ëß·Ààß/°≈ÿà¡ À√◊Õ
4. À≈—°∞“π®“°æÀÿ°“≈“πÿ°√¡ (multiple time series) ´÷Ëß¡’À√◊Õ‰¡à¡’¡“μ√°“√¥”‡π‘π°“√ À√◊ÕÀ≈—°∞“π∑’ˉ¥â®“°°“√«‘®—¬∑“ß
§≈‘π°‘ √Ÿª·∫∫Õ◊πË À√◊Õ∑¥≈Õß·∫∫‰¡à¡°’ “√§«∫§ÿ¡ ´÷ßË ¡’º≈ª√–®—°…å∂ß÷ ª√–‚¬™πåÀ√◊Õ‚∑…®“°°“√ªØ‘∫μ— ¡‘ “μ√°“√∑’‡Ë ¥àπ™—¥¡“°
3 1. °“√»÷°…“æ√√≥π“ (descriptive studies) À√◊Õ
2. °“√»÷°…“§«∫§ÿ¡∑’Ë¡’§ÿ≥¿“ææÕ„™â (fair-designed, controlled clinical trial)
4 1. √“¬ß“π¢Õߧ≥–°√√¡°“√ºŸ‡â ™’¬Ë «™“≠ ª√–°Õ∫°—∫§«“¡‡ÀÁπæâÕßÀ√◊Õ©—π∑“¡μ‘ (consensus) ¢Õߧ≥–ºŸ‡â ™’¬Ë «™“≠∫πæ◊πÈ ∞“π
ª√– ∫°“√≥å∑“ߧ≈‘π‘° À√◊Õ
2. √“¬ß“πÕπÿ°√¡ºŸâªÉ«¬®“°°“√»÷°…“„πª√–™“°√μà“ß°≈ÿà¡ ·≈–§≥–ºŸâ»÷°…“μà“ߧ≥– Õ¬à“ßπâÕ¬ 2 ©∫—∫

πÈ”Àπ—°§”·π–π” (Strength of Recommendation)

πÈ”Àπ—°§”·π–π” §”Õ∏‘∫“¬
++ §«“¡¡—Ëπ„®¢Õߧ”·π–π”„Àâ∑”Õ¬Ÿà„π√–¥—∫ Ÿß ‡æ√“–¡“μ√°“√¥—ß°≈à“«¡’ª√–‚¬™πåÕ¬à“߬‘ËßμàÕºŸâªÉ«¬·≈–§ÿ⡧à“
(cost effective) 秫√∑”é (strongly recommend)
+ §«“¡¡—πË „®¢Õߧ”·π–π”„Àâ∑”Õ¬Ÿ„à π√–¥—∫ª“π°≈“ß ‡π◊ÕË ß®“°¡“μ√°“√¥—ß°≈à“«Õ“®¡’ª√–‚¬™πåμÕà ºŸªâ «É ¬·≈–Õ“®§ÿ¡â §à“„π
¿“«–®”‡æ“– (Õ“®‰¡à∑”°Á‰¥â¢÷ÈπÕ¬Ÿà°—∫ ∂“π°“√≥å·≈–§«“¡‡À¡“– ¡) çπà“∑”é (recommend)
+/- §«“¡¡—πË „®¬—߉¡à‡æ’¬ßæÕ„π°“√„À⧔·π–π” ‡π◊ÕË ß®“°¡“μ√°“√¥—ß°≈à“«¬—ß¡’À≈—°∞“π‰¡à‡æ’¬ßæÕ„π°“√ π—∫ πÿπÀ√◊Õ§—¥§â“π
«à“ Õ“®¡’À√◊ÕÕ“®‰¡à¡’ª√–‚¬™πåμàÕºŸâªÉ«¬ ·≈–Õ“®‰¡à§ÿâ¡§à“ ·μà‰¡à°àÕ„À⇰‘¥Õ—πμ√“¬μàÕºŸâªÉ«¬‡æ‘Ë¡¢÷Èπ ¥—ßπ—Èπ°“√μ—¥ ‘π
„®°√–∑” ¢÷ÈπÕ¬Ÿà°—∫ªí®®—¬Õ◊ËπÊ çÕ“®∑”À√◊ÕÕ“®‰¡à∑”°Á‰¥âé (neither recommend nor against)
- §«“¡¡—πË „®¢Õߧ”·π–π”Àâ“¡∑”Õ¬Ÿ„à π√–¥—∫ª“π°≈“ß ‡π◊ÕË ß®“°¡“μ√°“√¥—ß°≈à“«‰¡à¡ª’ √–‚¬™πåμÕà ºŸªâ «É ¬·≈–‰¡à§¡âÿ §à“ À“°
‰¡à®”‡ªìπ (Õ“®∑”°Á‰¥â°√≥’¡’§«“¡®”‡ªìπ) 牡àπà“∑”é (against)
-- §«“¡¡—πË „®¢Õߧ”·π–π”‰¡à„Àâ∑”Õ¬Ÿ„à π√–¥—∫ ߟ ‡æ√“–¡“μ√°“√¥—ß°≈à“«Õ“®‡°‘¥‚∑… À√◊Õ°àÕ„À⇰‘¥Õ—πμ√“¬μàÕºŸªâ «É ¬ 牡à
·π–π”„Àâ∑”é (strongly against)

Thai JPEN
Volume 27 No. 2 July - December 2019 11
§”·π–π”°“√¥Ÿ·≈∑“ß‚¿™π“°“√„πºŸâªÉ«¬ºŸâ„À≠à∑’ËπÕπ‚√ß欓∫“≈ æ.». 2560
μÕπ∑’Ë 2: °“√„ÀâÕ“À“√‡¢â“∑“߇¥‘πÕ“À“√ (§”·π–π”∑’Ë 5-10)
§”·π–π”∑’Ë 5: °“√„ÀâÕ“À“√‡¢â“∑“߇¥‘πÕ“À“√
§”·π–π”∑’Ë 5.1
°“√‡√‘ Ë ¡ „Àâ Õ “À“√‡¢â “ ∑“߇¥‘ π Õ“À“√ (Enteral
Nutrition; EN)
5.1.1 ºŸ â ª É « ¬∑’ Ë ¡ ’ § «“¡‡ ’ Ë ¬ ß Ÿ ß μà Õ ¿“«–∑ÿ æ
‚¿™π“°“√·≈–‰¡à “¡“√∂°‘πÕ“À“√‰¥âÕ¬à“߇撬ßæÕ
§«√‡√‘Ë¡„Àâ EN ¿“¬„π 24-48 ™—Ë«‚¡ß
5.1.2 ºŸâªÉ«¬ “¡“√∂√—∫ EN ‰¥â¥’ §«√ª√—∫‡æ‘Ë¡
ª√‘¡“≥Õ“À“√„À≥âμ“¡§«“¡μâÕß°“√æ≈—ßß“π¿“¬„π
72 ™—Ë«‚¡ß
5.1.3 ºŸâªÉ«¬∑’Ë√—∫Õ“À“√∑“ß “¬„ÀâÕ“À“√‰¡à‰¥â
(feeding intolerance) §«√ª√—∫‡æ‘Ë¡ª√‘¡“≥Õ“À“√
Õ¬à“ß√–¡—¥√–«—ß„À≥âμ“¡§«“¡μâÕß°“√æ≈—ßß“π¿“¬„π
5-7 «—π
5.1.4 À“°‰¡à “¡“√∂„Àâæ≈—ßß“π‰¥âμ“¡μâÕß°“√
§«√æ‘ ® “√≥“„Àâ Õ “À“√∑“ßÀ≈Õ¥‡≈◊ Õ ¥¥”‡ √‘ ¡
(Supplemental Parenteral Nutrition; SPN)
§«∫§Ÿà‰ª°—∫ EN
§ÿ≥¿“æÀ≈—°∞“π 4 πÈ”Àπ—°§”·π–π” +
§”Õ∏‘∫“¬
®“°¢âÕ¡Ÿ≈°“√»÷°…“·∫∫ prospective observa-
tional study „πºŸâªÉ«¬«‘°ƒμæ∫«à“ ‡¡◊ËÕºŸâªÉ«¬‰¥â√—∫
æ≈—ßß“π®“°Õ“À“√„π·μà≈–«—π‰¡à‡æ’¬ßæÕ – ¡‰ª‡√◊ÕË ¬ Ê
º≈√«¡¢Õߪ√‘¡“≥æ≈—ßß“π∑’¢Ë “¥‰ª (cumulative energy
deficit) „π·μà≈–«—π¡“°¢÷Èπ¡’§«“¡ —¡æ—π∏å°—∫Õ—μ√“°“√
μ‘¥‡™◊ÕÈ ·∑√°´âÕπ·≈–Õ—μ√“°“√쓬∑’‡Ë æ‘¡Ë ¢÷πÈ 1,2 ·≈–æ∫«à“
„πºŸâªÉ«¬∑’ˉ¥â√—∫æ≈—ßß“π¡“°¢÷Èπ —¡æ—π∏å°—∫Õ—μ√“°“√쓬
∑’Ë≈¥≈ß3 °”Àπ¥™à«ß‡«≈“∑’˧«√‡√‘Ë¡„Àâ EN π—Èπ à«π„À≠à
¡“®“°¢âÕ¡Ÿ≈°“√»÷°…“·∫∫ systematic review ·≈–
12
¥√ÿ≥’«—≈¬å «‚√¥¡«‘®‘μ√ ·≈–§≥–
meta-analysis „π°≈ÿࡺŸâªÉ«¬«‘°ƒμ ‚¥¬æ∫«à“°“√‡√‘Ë¡„Àâ
EN ¿“¬„π 24-48 ™—Ë«‚¡ß (‡©≈’ˬ 36 ™—Ë«‚¡ß) À≈—ß®“°
‡¢â“√—∫°“√√—°…“„π‚√ß欓∫“≈ “¡“√∂≈¥Õ—μ√“°“√°“√
μ‘ ¥ ‡™◊ È Õ ≈¥√–¬–‡«≈“„π°“√πÕπ‚√ß欓∫“≈ ·≈–¡’
·π«‚πâ ¡ ≈¥Õ— μ √“쓬„πºŸ â ª É « ¬À≈“°À≈“¬°≈ÿ à ¡ ‡¡◊ Ë Õ
‡ª√’¬∫‡∑’¬∫°—∫°“√‡√‘¡Ë „Àâ EN ™â“°«à“ 48 ™—«Ë ‚¡ß ∑—ßÈ ºŸªâ «É ¬
«‘°ƒμ∑“ßÕ“¬ÿ√°√√¡·≈–∑“ß»—≈¬°√√¡4,5 ºŸªâ «É ¬À≈—ß°“√
ºà“μ—¥6 ·≈–ºŸâªÉ«¬μ—∫ÕàÕπÕ—°‡ ∫‡©’¬∫æ≈—π7 „π°√≥’∑’Ë
ºŸâªÉ«¬‰¡à¡’§«“¡‡ ’ˬßμàÕ°≈ÿà¡Õ“°“√ refeeding ®÷ß
·π–π”„Àâ·æ∑¬åª√—∫‡æ‘Ë¡ª√‘¡“≥æ≈—ßß“π„À≥âμ“¡§«“¡
μâÕß°“√æ≈—ßß“π¢ÕߺŸâªÉ«¬¿“¬„π‡«≈“ 48-72 ™—Ë«‚¡ß π—∫
®“°∑’ˇ√‘Ë¡„ÀâÕ“À“√∑“ß “¬„ÀâÕ“À“√ °“√„Àâ EN ·°àºŸâªÉ«¬
„π«—π·√°§«√‡√‘Ë¡μâπ∑’Ëæ≈—ßß“π 10 °‘‚≈·§≈Õ√’/°°./«—π
À√◊Õª√–¡“≥√âÕ¬≈– 30 ¢Õߧ«“¡μâÕß°“√æ≈—ßß“π¢Õß
ºŸâªÉ«¬ À“°ºŸâªÉ«¬√—∫Õ“À“√‰¥â¥’«—π∑’Ë Õߧ«√ª√—∫‡æ‘Ë¡
æ≈—ßß“π¢÷Èπ‡ªìπ√âÕ¬≈– 60-70 ¢Õߧ«“¡μâÕß°“√æ≈—ßß“π
·≈–‡æ‘Ë¡‡ªìπ√âÕ¬≈– 90-100 ¢Õߧ«“¡μâÕß°“√æ≈—ßß“π
„π«—π∑’Ë “¡¢Õß°“√„Àâ EN μ“¡≈”¥—∫ °“√ª√—∫‡æ‘Ë¡
Õ“À“√∑“ß “¬„Àâ Õ “À“√„πÕ— μ √“∑’ Ë ‰ ¡à ™ â “ À√◊ Õ ‡√Á « ®π
‡°‘π‰ª®–™à«¬„À⺟âªÉ«¬√—∫Õ“À“√∑“ß “¬„ÀâÕ“À“√‰¥â¥’¢÷Èπ
≈¥§«“¡‡ ’ˬßμàÕ°“√‡°‘¥°≈ÿà¡Õ“°“√ refeeding ‚¥¬‰¡à
∑”„À⺟âªÉ«¬Õ¬Ÿà„π ¿“«–∑’ˉ¥â√—∫Õ“À“√‰¡à‡æ’¬ßæÕπ“π®π
‡°‘π‰ª
„π°√≥’∑ºË’ ªâŸ «É ¬ “¡“√∂√—∫Õ“À“√‰¥â¥§’ «√‡æ‘¡Ë ª√‘¡“≥
Õ“À“√®π‰¥âμ“¡‡ªÑ“À¡“¬„π 48-72 ™—Ë«‚¡ß8 „πºŸâªÉ«¬
∑’√Ë ∫— Õ“À“√∑“ß “¬„ÀâÕ“À“√‰¡à‰¥â (feeding intolerance)
§«√ª√— ∫ ‡æ‘ Ë ¡ ª√‘ ¡ “≥Õ“À“√Õ¬à “ ߙ⠓ Ê ¥â « ¬§«“¡
√–¡—¥√–«—߇æ◊ËÕ„À≥âμ“¡§«“¡μâÕß°“√æ≈—ßß“π¢ÕߺŸâªÉ«¬
¿“¬„π 5-7 «—π8 À“°‰¡à “¡“√∂„Àâæ≈—ßß“π‰¥âμ“¡μâÕß°“√
¿“¬„π√–¬–‡«≈“∑’ Ë · π–π”‰«â §«√æ‘ ® “√≥“„Àâ SPN
§«∫§Ÿ‰à ª°—∫ EN ‡æ◊ÕË „À⺪⟠«É ¬‰¥â√∫— æ≈—ßß“πÕ¬à“߇撬ßæÕ
«“√ “√‚¿™π∫”∫—¥
ªï∑’Ë 27 ©∫—∫∑’Ë 2 °√°Æ“§¡ - ∏—𫓧¡ 2562
Thai Clinical Practice Recommendations for Nutritional Management in Adult
Hospitalized Patients 2017 Part 2: Enteral Nutrition (Recommendation 5-10) Warodomwichit D. et al

§”·π–π”∑’Ë 5.2 2-3 §√—ÈßμàÕ«—π) À√◊Õ„π√Ÿª·∫∫¬“©’¥„π°√≥’∑’ˉ¡à

„π°≈ÿà¡∑’Ë¡’§«“¡‡ ’ˬßμàÕ°≈ÿà¡Õ“°“√ refeeding “¡“√∂„À⬓‡¢â“∑“߇¥‘πÕ“À“√‰¥â ‚¥¬§«√„ÀâÕ¬à“ß
§«√‰¥â√∫— °“√ª√–‡¡‘𧫓¡‡ ¬Ë’ ß°àÕπ‡√‘¡Ë „Àâ‚¿™π∫”∫—¥ πâÕ¬ 30 π“∑’ °àÕπ‡√‘Ë¡„Àâ‚¿™π∫”∫—¥·≈–§«√„ÀâμàÕ
°”Àπ¥·π«∑“ß°“√„Àâ ‚ ¿™π∫”∫— ¥ Õ¬à “ ߇À¡“– ¡ ‡π◊ÕË ß°—πÕ¬à“ßπâÕ¬ 2 «—π (¬“©’¥) À√◊ÕÕ“®„ÀâμÕà ‰ª®π∂÷ß
‚¥¬„Àâ«‘μ“¡‘π∫’ 1 (thiamin) ‡√‘Ë¡„ÀâÕ“À“√·≈– “√ 10 «—π (¬“√—∫ª√–∑“π™π‘¥‡¡Á¥) À√◊Õ®π°«à“ºŸâªÉ«¬‰¥â
πÈ”„πª√‘¡“≥πâÕ¬·≈–ª√—∫‡æ‘Ë¡™â“ Ê ®π‰¥âμ“¡§«“¡ √—∫æ≈—ßß“πμ“¡‡ªÑ“À¡“¬∑’Ëμ—È߉«â πÕ°®“°π’ȧ«√‰¥â√—∫
μâÕß°“√æ≈—ßß“π¿“¬„π 4-10 «—π √«¡∂÷ß°“√‡ΩÑ“μ‘¥μ“¡ «‘μ“¡‘π√«¡·≈–·√à∏“μÿÕ◊ËπÊ Õ¬à“ߧ√∫∂â«π
√–«—ß/·°â‰¢¿“«–‡°≈◊Õ·√ຑ¥ª°μ‘ ·≈–¿“«–°“√„Àâ 5.2.4 „π«—π·√°§«√„Àâæ≈—ßß“πª√–¡“≥ 10 °‘‚≈
“√πÈ”‡°‘πÕ¬à“ß„°≈♑¥ ·§≈Õ√’/°°./«—π ®“°π—Èπ§àÕ¬ Ê ª√—∫‡æ‘Ë¡æ≈—ßß“π
5.2.1 ª√–‡¡‘𧫓¡‡ ’ˬßμàÕ°“√‡°‘¥°≈ÿà¡Õ“°“√ Õ¬à“ß™â“ Ê ‡™àπ ‡æ‘Ë¡§√—Èß≈– 5-10 °‘‚≈·§≈Õ√’/°°./«—π
refeeding ®π∂÷ßæ≈—ßß“π‡ªÑ“À¡“¬¿“¬„π‡«≈“ 4-10 «—𠇪ìπμâπ
5.2.2 ·°â‰¢¿“«–¢“¥πÈ” (dehydration) ·≈– 5.2.5 °“√„Àâ “√πÈ”·≈–‚´‡¥’¬¡ ª√—∫μ“¡ ¡¥ÿ≈
μ√«®√–¥—∫‡°≈◊Õ·√à„π√à“ß°“¬ (‚´‡¥’¬¡ ‚æ·∑ ‡´’¬¡ “√πÈ” °“√‡ª≈’ˬπ·ª≈ßπÈ”Àπ—° ·≈–Õ“°“√∑“ߧ≈‘π‘°
øÕ øÕ√— ·≈–·¡°π’‡´’¬¡) „Àâ°“√·°â‰¢∂â“¡’√–¥—∫ 5.2.6 μ‘¥μ“¡Õ“°“√∑“ߧ≈‘π‘°·≈–°“√‡ª≈’ˬπ
‡°≈◊Õ·√ຑ¥ª°μ‘ ·ª≈ß√–¥— ∫ ¢Õß‚æ·∑ ‡´’ ¬ ¡ ·¡°π’ ‡ ´’ ¬ ¡ ·≈–
5.2.3 „Àâ«‘μ“¡‘π∫’1 ¢π“¥ 200-300 ¡°./«—π Õ“® øÕ øÕ√— „π‡≈◊Õ¥Õ¬à“ß„°≈♑¥„π™à«ß∑’˪√—∫‡æ‘Ë¡
®–„Àâ„π√Ÿª·∫∫¬“√—∫ª√–∑“π™π‘¥‡¡Á¥ (100 ¡°. 1 ‡¡Á¥ æ≈—ßß“π √«¡∂÷ß·°â‰¢√–¥—∫‡°≈◊Õ·√ຑ¥ª°μ‘∑’ˇ°‘¥¢÷Èπ
§ÿ≥¿“æÀ≈—°∞“π 3 πÈ”Àπ—°§”·π–π” +
μ“√“ß∑’Ë 1 °≈ÿࡺŸâªÉ«¬∑’Ë¡’§«“¡‡ ’ˬßμàÕ°“√‡°‘¥°≈ÿà¡Õ“°“√ refeeding10
πÈ”Àπ—°≈¥≈ß‚¥¬‰¡àμ—Èß„® (>5% „π 1 ‡¥◊Õπ À√◊Õ >7.5% „π 3 ‡¥◊Õπ À√◊Õ >10% „π 6 ‡¥◊Õπ) À√◊Õ
ºŸâªÉ«¬∑’Ë¡’¿“«–∑ÿæ‚¿™π“°“√√ÿπ·√ß
°‘πÕ“À“√‰¥â≈¥≈ß
- °‘πÕ“À“√‰¥âπâÕ¬‡ªìπ‡«≈“π“π À√◊Õ Õ¥Õ“À“√ >7 «—π
- Chronic alcoholism
- Eating disorder ‡™àπ anorexia nervosa
- ºŸâ ŸßÕ“¬ÿ∑’¡’ªí≠À“´÷¡‡»√â“
- ºŸâªÉ«¬‚√§∑“ß ¡Õß∑’Ë¡’ªí≠À“‡√◊ËÕß°“√°≈◊π
- ºŸâªÉ«¬¡–‡√Áß À√◊Õ‚√§∑’Ë¡’°“√Õ—°‡ ∫‡√◊ÈÕ√—ßÕ◊ËπÊ ‡™àπ «—≥‚√§ ‡Õ¥ å ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß
- ºŸâªÉ«¬Õâ«π√ÿπ·√ß (morbid obesity) ∑’Ë¡’πÈ”Àπ—°≈¥Õ¬à“ß¡“°
- Diabetic hyperosmolar state
‡æ‘Ë¡°“√ Ÿ≠‡ ’¬ “√Õ“À“√ À√◊Õ ¥Ÿ¥´÷¡ “√Õ“À“√≈¥≈ß
- ≈”‰ â —Èπ ≈”‰ â≈⡇À≈«
- §≈◊Ëπ‰ âÕ“‡®’¬π À√◊Õ ∂à“¬‡À≈«Õ¬à“ß√ÿπ·√ß À√◊Õ¿“«– hyperemesis gravidarum
- À≈—ß°“√ºà“μ—¥≈¥πÈ”Àπ—° (bariatric surgery)
- ºŸâ∑’ˉ¥â√—∫¬“¢—∫ªí “«–¢π“¥ Ÿß À√◊Õ ¬“≈¥°√¥‡ªìπ√–¬–‡«≈“π“π
- ºŸâ∑’Ë¡’°“√¬àÕ¬·≈–°“√¥Ÿ¥´÷¡º‘¥ª°μ‘ ‡™àπ Inflammatory bowel disease μ—∫ÕàÕπÕ—°‡ ∫‡√◊ÈÕ√—ß

Thai JPEN
Volume 27 No. 2 July - December 2019 13
§”·π–π”°“√¥Ÿ·≈∑“ß‚¿™π“°“√„πºŸâªÉ«¬ºŸâ„À≠à∑’ËπÕπ‚√ß欓∫“≈ æ.». 2560
μÕπ∑’Ë 2: °“√„ÀâÕ“À“√‡¢â“∑“߇¥‘πÕ“À“√ (§”·π–π”∑’Ë 5-10) ¥√ÿ≥’«—≈¬å «‚√¥¡«‘®‘μ√ ·≈–§≥–

μ“√“ß∑’Ë 2 °“√ª√–‡¡‘𧫓¡‡ ’ˬߢÕß°≈ÿà¡Õ“°“√ refeeding √«¡∑—Èß·π«∑“ß°“√„Àâ‚¿™π∫”∫—¥9

1. °“√ª√–‡¡‘𧫓¡‡ ’ˬߢÕß°≈ÿà¡Õ“°“√ refeeding ‡∫◊ÈÕßμâπ
§«“¡‡ ’ˬß√Õß (minor risk) §«“¡‡ ’ˬßÀ≈—° (major risk) °≈ÿࡇ ’ˬß
- BMI <18.5 °°./μ√.¡ - BMI <16 °°./μ√.¡. - Õ¥Õ“À“√ª√–∑â«ß Õ¥Õ“À“√√ÿπ·√ß
- πÈ”Àπ—°≈¥≈ß‚¥¬‰¡à‰¥âμ—Èß„® >√âÕ¬≈– 10 - πÈ”Àπ—°≈¥‚¥¬‰¡à‰¥âμ—Èß„® >√âÕ¬≈– 15 „π™à«ß - ºà“μ—¥°√–‡æ“–≈¥πÈ”Àπ—° ≈”‰ â —Èπ
„π™à«ß 3-6 ‡¥◊Õπ 3-6 ‡¥◊Õπ - ºŸâªÉ«¬¡–‡√Áß ºŸâ ŸßÕ“¬ÿ∑’Ë¡’‚√§√à«¡‡√◊ÈÕ√—ß
- °‘π‰¥âπâÕ¬¡“°À√◊Õ‰¡à‰¥â°‘πÕ“À“√ >5 «—π - °‘π‰¥âπâÕ¬¡“°À√◊Õ‰¡à‰¥â°‘πÕ“À“√ >10 «—π
- ¡’ª√–«—μ‘¥◊Ë¡ ÿ√“‡√◊ÈÕ√—ßÀ√◊Õ‰¥â√—∫¬“μàÕ‰ªπ’È - √–¥—∫‚æ·∑ ‡´’¬¡ øÕ øÕ√— À√◊Õ·¡°π’‡´’¬¡
Õ‘π´Ÿ≈‘𠬓‡§¡’∫”∫—¥ ¬“≈¥°√¥ À√◊Õ „π‡≈◊Õ¥μË”°àÕπ‰¥â√—∫Õ“À“√
¬“¢—∫ªí “«–
2. °“√ªÑÕß°—π°≈ÿà¡Õ“°“√ Refeeding √–À«à“ß°“√„Àâ‚¿™π∫”∫—¥
ª√–‡¡‘π ‰¡à¡’ §«“¡‡ ’ˬߪ“π°≈“ß §«“¡‡ ’Ë¬ß Ÿß §«“¡‡ ’Ë¬ß ßŸ ¡“°
§«“¡‡ ’Ë¬ß §«“¡‡ ’Ë¬ß §«“¡‡ ’ˬß√Õß 1 ¢âÕ §«“¡‡ ’ˬßÀ≈—° 1 ¢âÕ - BMI <14 °°./μ√.¡.
À√◊Õ §«“¡‡ ’ˬß√Õß 2 ¢âÕ - πÈ”Àπ—°≈¥‚¥¬‰¡à‰¥âμ—Èß„® >√âÕ¬≈– 20
- ‰¡à‰¥â°‘πÕ“À“√À√◊Õ°‘ππâÕ¬¡“° >15 «—π
°“√ª√–‡¡‘π ·°â‰¢¿“«–¢“¥πÈ”·≈–„Àâ “√πȔլà“ß√–¡—¥√–«—߇æ◊ËÕªÑÕß°—π¿“«–°“√„Àâ “√πÈ”¡“°‡°‘π (fluid overload)
°àÕπ„Àâ ‰¡à¡’ - ·°â‰¢¿“«–‡°≈◊Õ·√à∑’˺‘¥ª°μ‘„πºŸâªÉ«¬∑’Ë¡’√–¥—∫‚æ·∑ ‡´’¬¡ <3.5 ¡‘≈≈‘‚¡≈/≈‘μ√, øÕ øÕ√— <0.8 ¡‘≈≈‘‚¡≈/≈‘μ√,
‚¿™π∫”∫—¥ ·¡°π’‡´’¬¡ <0.7-0.75 ¡‘≈≈‘‚¡≈/≈‘μ√
- „Àâ«‘μ“¡‘π∫’ 1 ¢π“¥ 200-300 ¡°./«—π·≈–«‘μ“¡‘π√«¡„π«—π∑’Ë 1-10
- ∑¥·∑π/·°â‰¢°“√¢“¥·√à∏“μÿª√‘¡“≥πâÕ¬
- ®”°—¥‚´‡¥’¬¡ 1 (¡‘≈≈‘‚¡≈/°°./«—π) „π«—π∑’Ë 1-7
«—π∑’Ë æ≈—ßß“π®“°∑ÿ°™àÕß∑“ß°“√„ÀâÕ“À“√ (°‘‚≈·§≈Õ√’/°°./«—π)
√âÕ¬≈–¢Õߧ“√å‚∫‰Œ‡¥√μ ‚ª√μ’π ·≈–‰¢¡—π §◊Õ 40-60, 15-20 ·≈– 30-40 μ“¡≈”¥—∫
“√πÈ” (¡≈./°°./«—π) ¢÷Èπ°—∫ ¡¥ÿ≈ “√πÈ”‡ªìπ»Ÿπ¬å °“√‡ª≈’ˬπ·ª≈ߢÕßπÈ”Àπ—°
1-3 μ“¡§«“¡μâÕß°“√æ≈—ßß“π æ≈—ßß“π 15-25 æ≈—ßß“π 10-15 æ≈—ßß“π 5-10
30-35 (§”·π–π” 4.1) “√πÈ” 30-35 “√πÈ” 20-25 “√πÈ” 20-25
“√πÈ” 30-35 (‰¡à®”°—¥)
4 æ≈—ßß“π 30 æ≈—ßß“π 15-25 æ≈—ßß“π 10-20
“√πÈ” 30-35 “√πÈ” 30-35 “√πÈ” 20-25
5 μ“¡§«“¡μâÕß°“√æ≈—ßß“π
6 “√πÈ” 30-35 æ≈—ßß“π 30
“√πÈ” 30-35
7-9 μ“¡§«“¡μâÕß°“√æ≈—ßß“π æ≈—ßß“π 20-30
“√πÈ” 30-35 “√πÈ” 25-35
10 ¢÷Èπ‰ª μ“¡§«“¡μâÕß°“√æ≈—ßß“π
“√πÈ” 30-35
‚´‡¥’¬¡ ‰¡à®”°—¥ ‰¡à®”°—¥ ®”°—¥ 1 ¡‘≈≈‘‚¡≈/°°./«—π ®”°—¥ 1 ¡‘≈≈‘‚¡≈/°°./«—π
«—π∑’Ë 1-7 «—π∑’Ë 1-10
°“√μ‘¥μ“¡ - μ‘¥μ“¡√–¥—∫‡°≈◊Õ·√à∑ÿ°«—π„π “¡«—π·√° ·≈–∑ÿ° 2-3 «—πÀ≈—ß®“°π—Èπ
- μ‘¥μ“¡Õ“°“√∑“ߧ≈‘π‘°¢Õß°≈ÿà¡Õ“°“√ refeeding (™’æ®√‡μâπ‡√Á« À“¬„®‡√Á« ∫«¡) √«¡∂÷ß ¡¥ÿ≈ “√πÈ”∑ÿ°«—π
- μ‘¥μ“¡°“√μ√«®§≈◊Ëπ‰øøÑ“À—«„®‚¥¬‡©æ“–„π√“¬∑’Ë¡’§«“¡‡ ’Ë¬ß Ÿß¡“°

«“√ “√‚¿™π∫”∫—¥
14 ªï∑’Ë 27 ©∫—∫∑’Ë 2 °√°Æ“§¡ - ∏—𫓧¡ 2562
Thai Clinical Practice Recommendations for Nutritional Management in Adult
Hospitalized Patients 2017 Part 2: Enteral Nutrition (Recommendation 5-10)
§”Õ∏‘∫“¬
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Ÿ≠‡ ’¬ “√Õ“À“√ °≈ÿà¡∑’Ë¡’§«“¡‡ ’ˬßμàÕ°≈ÿà¡Õ“°“√
refeeding · ¥ß„πμ“√“ß∑’Ë 1 πÕ°®“°π’È The National
Institute for Health and Clinical Excellence (NICE)
°”À𥇰≥±å„π°“√§—¥°√Õß°≈ÿࡇ ’ˬßμàÕ°≈ÿà¡Õ“°“√
refeeding (μ“√“ß∑’Ë 2) °≈ÿà¡Õ“°“√ refeeding §◊Õ¿“«–
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„™â ‡ °≈◊ Õ ·√à · ≈–«‘ μ “¡‘ π ∫“ßμ— « ∑’ Ë ¡ ’ À πâ “ ∑’ Ë ‡ °’ Ë ¬ «¢â Õ ß°— ∫
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Õ“°“√·≈–Õ“°“√· ¥ß¢Õß¿“«–‡°≈◊Õ·√à∑’ËμË”≈ß À√◊Õ
¿“«–¢“¥«‘ μ “¡‘ 𠧫“¡º‘ ¥ ª°μ‘ ∑ ’ Ë æ ∫„π°≈ÿ à ¡ Õ“°“√
refeeding 䴉ᡈ
- ¿“«–‚æ·∑ ‡´’¬¡„π‡≈◊Õ¥μË” (hypokalemia)
‡°‘¥¢÷πÈ À≈—ß®“°∑’¡Ë ‡’ °Á∫‚æ·∑ ‡´’¬¡‡¢â“¡“„π‡´≈≈å (cellular
uptake) „π¢≥–∑’ Ë ¡ ’ ° “√ √â “ ߉°≈‚§‡®π·≈–‚ª√μ’ π
‡π◊ËÕß®“°‚æ·∑ ‡´’¬¡‡ªìπª√–®ÿ∫«°∑’Ë ”§—≠„π‡´≈≈å
(intracellular cation) ‡æ◊ËÕ„Àâ ¡¥ÿ≈°—∫ª√–®ÿ≈∫¢Õß
‚ª√μ’π (negative charges on protein)
- ¿“«–øÕ øÕ√— „π‡≈◊ Õ ¥μË ” (hypo-
phosphatemia) ‡π◊ÕË ß®“°∂Ÿ°„™â‰ª„π°√–∫«π°“√ phos-
phorylation ¢Õß°≈Ÿ‚§ ·≈–°“√ √â“ß ATP ‡æ‘Ë¡¢÷Èπ
πÕ°®“°π’ÈÕ“À“√∑’Ë¡’§“√å‚∫‰Œ‡¥√μ·≈–·§≈‡´’¬¡ Ÿß ®–
∑”„ÀâøÕ øÕ√— ≈¥≈ß ‚¥¬Õ“À“√∑’Ë¡’§“√å‚∫‰Œ‡¥√μ Ÿß
∑”„Àâ¡’°“√‡æ‘Ë¡¢ÕßÕ‘π´Ÿ≈‘π∑”„Àâ¡’°“√‡°Á∫øÕ øÕ√— ‡¢â“
¡“„π‡´≈≈å „π¢≥–∑’ Ë · §≈‡´’ ¬ ¡„πÕ“À“√®–®— ∫ °— ∫
øÕ øÕ√— ∑”„Àâ°“√¥Ÿ¥´÷¡øÕ øÕ√— ≈¥≈ß
Thai JPEN
Volume 27 No. 2 July - December 2019
Warodomwichit D. et al
- ¿“«–·¡°π’ ‡ ´’ ¬ ¡„π‡≈◊ Õ ¥μË ” (hypo-
magnesemia) ‡π◊ËÕß®“°¡’°“√‡°Á∫·¡°π’‡´’¬¡‡¢â“‡´≈≈å
‡æ‘Ë¡¢÷Èπ
- ¿“«–¢“¥«‘μ“¡‘π∫’ 1 À≈—ß®“°„ÀâÕ“À“√®–¡’
°“√„™â«‘μ“¡‘π∫’ 1 ¡“°¢÷Èπ ‡π◊ËÕß®“°«‘μ“¡‘π∫’ 1 ‡ªìπ
‚§·ø°‡μÕ√å (cofactor) „π°√–∫«π°“√ glycolysis
¢Õߧ“√å‚∫‰Œ‡¥√μ ∑”„Àâ¡’‚Õ°“ ‡°‘¥¿“«–¢“¥«‘μ“¡‘π∫’ 1
‡™àπ Wernickeûs encephalopathy ·≈–/À√◊Õ cardic
beriberi ´÷Ëߧ«“¡‡ ’ˬ߮– Ÿß¢÷Èπ„π√“¬∑’Ë¡’°“√Õ¥Õ“À“√
‡ªìπ‡«≈“π“π À√◊Õ„πºŸâªÉ«¬´÷Ëß¡’§«“¡‡ ’ˬßμàÕ°“√¢“¥
«‘μ“¡‘π∫’ 1 Õ¬Ÿà·≈â« ‡™àπ ¥◊Ë¡ ÿ√“‡√◊ÈÕ√—ß ‰¥â√—∫¬“¢—∫
ªí “«–‡ªìπ‡«≈“π“𠇪ìπμâπ
- ¿“«–πÈ”·≈–‡°≈◊Õ§—ßË (salt and water retention)
‡ªìπº≈®“°Õ‘π´Ÿ≈π‘ ߟ ¢÷πÈ À≈—߉¥â√∫— §“√å‚∫‰Œ‡¥√μ (æ≈—ßß“π)
°≈ÿà¡Õ“°“√¥—ß°≈à“« “¡“√∂‡°‘¥μ“¡À≈—ß°“√„Àâ “√
Õ“À“√‰¥â∑—Èß EN ·≈– PN ·æ∑¬å§«√μ√–Àπ—°∂÷ß°≈ÿà¡
Õ“°“√ refeeding ·≈–‡ΩÑ“√–«—ß√«¡∑—Èß·°â‰¢§«“¡º‘¥
ª°μ‘∑’ˇ°‘¥¢÷ÈπÕ¬à“ß∑—π∑à«ß∑’§”·π–π”„π°“√ª√–‡¡‘π
§«“¡‡ ’ˬ߷≈–·π«∑“ß°“√ªØ‘∫—μ‘°àÕπ°“√„Àâ‚¿™π∫”∫—¥
μ“¡√–¥—∫§«“¡‡ ¬Ë’ ß9,10 · ¥ß„πμ“√“ß∑’Ë 2 πÕ°®“°π’¬È ß—
¡’°“√°”Àπ¥·π«∑“ß°“√ª√–‡¡‘π´È” °“√«‘π®‘ ©—¬°≈ÿ¡à Õ“°“√
refeeding ·≈–°“√¥Ÿ·≈À≈—ß®“°„Àâ‚¿™π∫”∫—¥·≈â«μ“¡
√Ÿª∑’Ë 19
§”·π–π”∑’Ë 5.3
°“√„Àâ EN ‚¥¬„Àâæ≈—ßß“πμË”°«à“§«“¡μâÕß°“√¢Õß
ºŸ â ª É « ¬ (permissive underfeeding) “¡“√∂
¬Õ¡√—∫‰¥â„πºŸâªÉ«¬ 2 °≈ÿà¡μàÕ‰ªπ’È
1. ºŸâªÉ«¬¿“«–∑“߇¥‘πÀ“¬„®≈⡇À≈«‡©’¬∫æ≈—π
∑’ˉ¡à‰¥â‡°‘¥®“°¿“«–À—«„®≈⡇À≈« [Acute Lung
Injury (ALI)/Adult Respiratory Distress
Syndrome (ARDS)] ∑’ Ë Õ â « π·≈–‰¡à ¡ ’ ¿ “«–
∑ÿæ‚¿™π“°“√
2. ºŸâªÉ«¬∑’Ë¡’ BMI >30 °°./μ√.¡.
§ÿ≥¿“æÀ≈—°∞“π 4 πÈ”Àπ—°§”·π–π” +
15
§”·π–π”°“√¥Ÿ·≈∑“ß‚¿™π“°“√„πºŸâªÉ«¬ºŸâ„À≠à∑’ËπÕπ‚√ß欓∫“≈ æ.». 2560
μÕπ∑’Ë 2: °“√„ÀâÕ“À“√‡¢â“∑“߇¥‘πÕ“À“√ (§”·π–π”∑’Ë 5-10) ¥√ÿ≥’«—≈¬å «‚√¥¡«‘®‘μ√ ·≈–§≥–

√Ÿª∑’Ë 1 °“√«‘π‘®©—¬°≈ÿà¡Õ“°“√ refeeding ·≈–°“√¥Ÿ·≈À≈—ß®“°„Àâ‚¿™π∫”∫—¥ (¥—¥·ª≈ß®“° 9)

§”Õ∏‘∫“¬ ¢Õߧ«“¡μâÕß°“√æ≈—ßß“π) „π¢≥–∑’Ë°≈ÿà¡ trophic feeding

¢âÕ¡Ÿ≈°“√»÷°…“·∫∫ multi-center randomized
trial „πºŸâªÉ«¬ ALI/ARDS ∑’ˉ¡à¡’¿“«–∑ÿæ‚¿™π“°“√
·≈–Õâ«π (BMI ‡©≈’ˬ 30 °°./μ√.¡.) ‡ª√’¬∫‡∑’¬∫º≈
¢Õß°“√„Àâ EN μ“¡æ≈—ßß“π∑’ËμâÕß°“√ (full feeding)
°—∫°“√„Àâæ≈—ßß“π‡æ’¬ß‡≈Á°πâÕ¬ (trophic feeding)
‚¥¬‡√‘¡Ë „Àâ EN ·∫∫À¬¥μàÕ‡π◊ÕË ß (continuous feeding)
„π∑—ßÈ Õß°≈ÿ¡à ¿“¬„π 6 ™—«Ë ‚¡ßÀ≈—߇¢â“ °àŸ “√»÷°…“ °≈ÿ¡à full
feeding ‡√‘Ë¡„Àâ EN ∑’ËÕ—μ√“ 25 ¡≈./™¡. ·≈–‡æ‘Ë¡¢÷Èπ®π
‰¥âæ≈—ßß“πμ“¡∑’ËμâÕß°“√ 25-30 °‘‚≈·§≈Õ√’/°°./«—π
(‰¥â√—∫‡©≈’ˬ«—π≈– 1,300 °‘‚≈·§≈Õ√’ §‘¥‡ªìπ√âÕ¬≈– 80
‡√‘Ë¡„Àâ EN ∑’ËÕ—μ√“ 20 ¡≈./™¡. „π 6 «—π·√° (‰¥â√—∫
‡©≈’ˬ«—π≈– 400 °‘‚≈·§≈Õ√’ §‘¥‡ªìπ√âÕ¬≈– 25 ¢Õß
§«“¡μâÕß°“√æ≈—ßß“π) ·≈–‡æ‘Ë¡æ≈—ßß“π®π‰¥âμ“¡∑’Ë
μâÕß°“√„π«—π∑’Ë 7 æ∫«à“∑—Èß Õß°≈ÿà¡¡’®”π«π«—π∑’ˉ¡àμâÕß
„™â‡§√◊ËÕߙ૬À“¬„® (ventilator-free days) Õ—μ√“°“√
쓬∑’Ë 60 «—π ·≈–Õ—μ√“°“√μ‘¥‡™◊ÈÕ·∑√°´âÕπ‰¡à·μ°μà“ß
°—π11 Õ¬à“߉√°Áμ“¡ºŸªâ «É ¬°≈ÿ¡à π’ÕÈ “¬ÿ‰¡à¡“° (Õ“¬ÿ‡©≈’¬Ë 52
ªï) ‰¡à¡’¿“«–∑ÿæ‚¿™π“°“√·≈–¡’¿“«–Õâ«π ¡’√–¬–‡«≈“
‡©≈’¬Ë ¢Õß°“√πÕπ„πÀÕºŸªâ «É ¬«‘°ƒμ§àÕπ¢â“ß πÈ— ª√–¡“≥ 5
«—π11 Õ¬à“߉√°Á¥’ trophic feeding Õ“®®–‰¡à‡À¡“–„π

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16 ªï∑’Ë 27 ©∫—∫∑’Ë 2 °√°Æ“§¡ - ∏—𫓧¡ 2562
Thai Clinical Practice Recommendations for Nutritional Management in Adult
Hospitalized Patients 2017 Part 2: Enteral Nutrition (Recommendation 5-10)
ºŸâªÉ«¬ ŸßÕ“¬ÿ Õâ«π¡“°À√◊ÕºÕ¡¡“° À√◊ÕºŸâªÉ«¬∑’Ë¡’‚√§
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≈¥°“√ ≈“¬¡«≈°≈â“¡‡π◊ÈÕ√–À«à“ß∑’Ë¿“«–‡®Á∫ªÉ«¬¬—ߧß
¥”‡π‘πÕ¬Ÿà À≈’°‡≈’ˬ߰“√„Àâæ≈—ßß“π¡“°‡°‘π‰ª´÷Ëß®–∑”„Àâ
¡’√–¥—∫πÈ”μ“≈„π‡≈◊Õ¥ Ÿß¢÷Èπ ‡°‘¥°“√º≈‘짓√å∫Õπ‰¥-
ÕÕ°‰´¥å‡æ‘Ë¡¡“°¢÷Èπ®“°°“√‡º“º≈“≠æ≈—ßß“π à«π‡°‘π
μ≈Õ¥®π‡æ‘Ë¡‰¢¡—π – ¡„π√à“ß°“¬¢ÕߺŸâªÉ«¬ ‡π◊ËÕß®“°
„πªí®®ÿ∫π— ¬—ß¡’¢Õâ ∂°‡∂’¬ß°—π¡“°«à“«‘∏„’ ¥§◊Õ«‘∏∑’ ‡Ë’ À¡“– ¡
∑’Ë ¥ÿ „π°“√§”π«≥§«“¡μâÕß°“√æ≈—ßß“π„πºŸªâ «É ¬‚√§Õâ«π
·≈–°“√«— ¥ æ≈— ß ß“π‚¥¬«‘ ∏ ’ indirect calorimetry
°Á¬—ß¡’¢âÕ®”°—¥„π‡√◊ËÕ߇§√◊ËÕß¡◊Õ·≈–∫ÿ§≈“°√∑’Ë “¡“√∂
∑”°“√«—¥‰¥â §”·π–π”„π°“√°”Àπ¥ª√‘¡“≥æ≈—ßß“π∑’Ë
®–„Àâ„πºŸâªÉ«¬°≈ÿà¡π’È®÷ß¡’·π«‚πâ¡∑’Ë®–„Àâ permissive
underfeeding ∑—Èßπ’ȇæ◊ËÕ≈¥ªí≠À“∑’Ë®–‡°‘¥μ“¡¡“®“°
°“√„Àâæ≈—ßß“π¡“°‡°‘𧫓¡μâÕß°“√¥—ß∑’Ë°≈à“«¢â“ßμâπ
·≈–‡æ◊ËÕ‡Àπ’ˬ«π”„Àâ√à“ß°“¬¡’°“√ ≈“¬‰¢¡—π∑’Ë – ¡‰«â
ÕÕ°¡“„™â‡ªìπæ≈—ßß“πÕ’°¥â«¬13,14 ®“°°“√»÷°…“æ∫«à“ „π
ºŸâªÉ«¬‚√§Õâ«π∑’ËÕ¬Ÿà„π¿“«–«‘°ƒμ‘∑’ˉ¥â√—∫ª√‘¡“≥æ≈—ßß“π
∑’ËμË”°«à“§«“¡μâÕß°“√æ≈—ßß“π¡’®”π«π«—π∑’ËÕ¬Ÿà„πÀÕ
ºŸâªÉ«¬«‘°ƒμ‘πâÕ¬°«à“ ¡’®”π«π«—π∑’ËμâÕß„À⬓ªØ‘™’«π–
πâÕ¬°«à“ ·≈–¡’·π«‚πâ¡∑’Ë®–≈¥®”π«π«—π∑’ËμâÕß„™â‡§√◊ËÕß
™à«¬À“¬„®‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫°≈ÿà¡∑’ˉ¥â√—∫æ≈—ßß“πμ“¡
ª°μ‘ 15 μ“¡§”·π–π”¢Õß American Society of
Parenteral and Enteral Nutrition ·≈– Society of
Critical Care Medicine (A.S.P.E.N./SCCM) 䴉
°”Àπ¥æ≈—ßß“π„πºŸâªÉ«¬«‘°ƒμ∑’ËÕâ«π‚¥¬„Àâ„Àâæ≈—ßß“π
‡æ’¬ß√âÕ¬≈– 65-70 ¢Õßæ≈—ßß“π∑’Ë«—¥‰¥â®“° indirect
calorimetry À√◊Õ„Àâæ≈—ßß“π 11-14 °‘‚≈·§≈Õ√’/°°.
πÈ”Àπ—°ªí®®ÿ∫—π/«—π „πºŸâªÉ«¬∑’Ë¡’ BMI Õ¬Ÿà√–À«à“ß 30-50
°°./μ√.¡. À√◊Õ 22-25 °‘‚≈·§≈Õ√’/°°. πÈ”Àπ—°Õÿ¥¡§μ‘/
«—π„πºŸªâ «É ¬∑’¡Ë ’ BMI ¡“°°«à“ 50 °°./μ√.¡.·≈–„À₪√μ’π
2.0 °√—¡/°°. πÈ”Àπ—°Õÿ¥¡§μ‘/«—π„πºŸâªÉ«¬∑’Ë¡’ BMI
Õ¬Ÿà√–À«à“ß 30-40 °°./μ√.¡.À√◊Õ¡“°∂÷ß 2.5 °√—¡/°°.
πÈ”Àπ—°Õÿ¥¡§μ‘/«—π „πºŸâªÉ«¬∑’Ë¡’ BMI ¡“°°«à“ 40 °°./
μ√.¡. 16
Thai JPEN
Volume 27 No. 2 July - December 2019
Warodomwichit D. et al
§”·π–π”∑’Ë 6: °“√‡≈◊Õ° Ÿμ√Õ“À“√ ”À√—∫°“√„Àâ
Õ“À“√‡¢â“∑“߇¥‘πÕ“À“√ (Enteral
Formulas)
§«√‡≈◊Õ°„™âÕ“À“√∑“ß°“√·æ∑¬å Ÿμ√¡“μ√∞“π
™π‘¥ polymeric (standard polymeric formula)
À√◊ÕÕ“À“√™π‘¥ªíòπº ¡ (blenderized diet) ‡ªìπ
Õ—π¥—∫·√°
§ÿ≥¿“æÀ≈—°∞“π 4 πÈ”Àπ—°§”·π–π” +
§”Õ∏‘∫“¬
Õ“À“√∑“ß°“√·æ∑¬å μŸ √¡“μ√∞“π™π‘¥ polymeric
§◊Õ ∑“ß°“√·æ∑¬å∑¡Ë’ ’ “√Õ“À“√§√∫∂â«π∑—ßÈ §“√å‚∫‰Œ‡¥√μ
‚ª√μ’π ‰¢¡—π «‘μ“¡‘π ‡°≈◊Õ·√à ·≈–·√à∏“μÿ∑’Ë®”‡ªìπμàÕ
√à“ß°“¬ ‚¥¬ “√Õ“À“√À≈—° (macronutrient) Õ¬Ÿà„π√Ÿª
∑’ˬ—߉¡àºà“π°√–∫«π°“√¬àÕ¬ ‚¥¬∑—Ë«‰ª®–¡’§«“¡‡¢â¡¢âπ
1-2 °‘‚≈·§≈Õ√’/¡≈. ‚¥¬ à«π„À≠à¡—°®–„™â§«“¡‡¢â¡¢âπ
1 °‘‚≈·§≈Õ√’/¡≈. ·μà®–‡≈◊Õ°„™â§«“¡‡¢â¡¢âπ∑’Ë Ÿß¢÷Èπ‰¥â
„π°√≥’∑’ËμâÕß®”°—¥πÈ” Õ¬à“߉√°Áμ“¡‰¡à·π–π”„Àâ‡√‘Ë¡μâπ
¥â«¬Õ“À“√∑’Ë¡’§«“¡‡¢â¡¢âπμË”°«à“ 1 °‘‚≈·§≈Õ√’/¡≈.
‡π◊ËÕß®“°®–∑”„À⺟âªÉ«¬‰¥â√—∫Õ“À“√‰¡à‡æ’¬ßæÕ °“√‡≈◊Õ°
„™âÕ“À“√∑“ß°“√·æ∑¬å„πºŸâªÉ«¬∑’Ë√—∫Õ“À“√ºà“𠓬„Àâ
Õ“À“√§«√‡≈◊Õ°Õ“À“√∑“ß°“√·æ∑¬å Ÿμ√¡“μ√∞“π™π‘¥
polymeric ∑—Èß Ÿμ√¡“μ√∞“π∑’Ë¡’À√◊Õ‰¡à¡’‡ âπ„¬Õ“À“√
(fiber) À√◊ÕÕ“À“√ªíòπº ¡°àÕπÕ“À“√∑“ß°“√·æ∑¬å Ÿμ√
‡©æ“–‚√§‡ ¡Õ À“°ºŸ â ª É « ¬¡’ ª í ≠ À“¢≥–∑’ Ë „ ™â Õ “À“√
∑“ß°“√·æ∑¬å Ÿμ√¡“μ√∞“π®÷ߧàլ摮“√≥“„™âÕ“À“√
∑“ß°“√·æ∑¬å Ÿμ√‡©æ“–‚√§‡ªìπ√“¬Ê ‰ª ‚¥¬§«√¬÷¥
μ“¡À≈— ° ∞“π°“√»÷ ° …“«à “ ºŸ â ª É « ¬°≈ÿ à ¡ π— È π Ê ®–‰¥â
ª√–‚¬™π宓°Õ“À“√∑“ß°“√·æ∑¬å Ÿμ√‡©æ“–‚√§ Ÿμ√„¥
”À√—∫„π√“¬∑’˪≈“¬ “¬Õ“À“√Õ¬Ÿà„π≈”‰ â‡≈Á° “¡“√∂„™â
Õ“À“√∑“ß°“√·æ∑¬å Ÿμ√¡“μ√∞“π‰¥â ‰¡à¡’§«“¡®”‡ªìπ
μâÕß„™âÕ“À“√∑’Ë¡’°“√¬àÕ¬∫“ß à«πÀ√◊Õ¡’ oligopeptide
(semielemental formula)17,18
17
§”·π–π”°“√¥Ÿ·≈∑“ß‚¿™π“°“√„πºŸâªÉ«¬ºŸâ„À≠à∑’ËπÕπ‚√ß欓∫“≈ æ.». 2560
μÕπ∑’Ë 2: °“√„ÀâÕ“À“√‡¢â“∑“߇¥‘πÕ“À“√ (§”·π–π”∑’Ë 5-10) ¥√ÿ≥’«—≈¬å «‚√¥¡«‘®‘μ√ ·≈–§≥–

§”·π–π”∑’Ë 7: «‘∏’°“√„ÀâÕ“À“√‡¢â“∑“߇¥‘πÕ“À“√ §”Õ∏‘∫“¬

°“√„Àâ EN ¥â«¬«‘∏’ intermittent feeding ‡ªìπ
§”·π–π” 7.1
«‘∏°’ “√„ÀâÕ“À“√‚¥¬·∫àßÕ“À“√„À⇪ìπ¡◊ÕÈ ºà“𠓬„ÀâÕ“À“√
·π–π”„Àâ„ÀâÕ“À“√¥â«¬«‘∏’°“√„ÀâÕ“À“√·∫∫À¬¥
™â“ Ê ª√–¡“≥ 1-3 ™—Ë«‚¡ßμàÕ¡◊ÈÕ (¢÷Èπ°—∫ºŸâªÉ«¬·μà≈–√“¬)
μàÕ‡π◊ËÕß (continuous feeding) „πºŸâªÉ«¬¥—ßμàÕ‰ªπ’È
·≈–¡’™à«ßæ—°√–À«à“ß„ÀâÕ“À“√·μà≈–¡◊ÈÕ «‘∏’π’ȺŸâªÉ«¬®–√—∫
7.1.1 ºŸâªÉ«¬∑’Ë„ à “¬„ÀâÕ“À“√∑’˪≈“¬ “¬Õ¬Ÿà„π
‰¥â¥’°«à“«‘∏’ bolus feeding ·≈–·μà≈–¡◊ÈÕÕ“®„À≥â
≈”‰ â‡≈Á°
ª√‘¡“≥Õ“À“√‰¥â¡“°°«à“«‘∏’ bolus feeding
7.1.2 ºŸâªÉ«¬∑’ˇ ’ˬßμàÕ°“√ Ÿ¥ ”≈—°
„π°√≥’∑’˪≈“¬ “¬„ÀâÕ“À“√Õ¬Ÿà„π≈”‰ â‡≈Á°‡√‘Ë¡„Àâ
7.1.3 ºŸâªÉ«¬«‘°ƒμ
Õ“À“√‚¥¬«‘∏’ continuous feeding À≈—ß®“°∑’˺ŸâªÉ«¬
7.1.4 ºŸâªÉ«¬∑’ËߥՓÀ“√‡ªìπ‡«≈“π“π
ª√—∫μ—«√—∫Õ“À“√‰¥â¥·’ ≈â« “¡“√∂„™â intermittent feeding
7.1.5 ºŸâªÉ«¬∑’Ë„ÀâÕ“À“√«‘∏’Õ◊Ëπ·≈â«¡’Õ“°“√√—∫
‰¥â‡æ◊ËÕ„À⺟âªÉ«¬¡’™à«ß‡«≈“æ—°√–À«à“ß¡◊ÈÕÕ“À“√·≈–‰¡à
Õ“À“√‰¡à‰¥â (feeding intolerance)
§«√„ÀâÕ“À“√À¡¥‡√Á«°«à“ 3 ™—Ë«‚¡ß19-21
§ÿ≥¿“æÀ≈—°∞“π 4 πÈ”Àπ—°§”·π–π”+/-
§”·π–π”∑’Ë 7.3
§”Õ∏‘∫“¬ ·π–π”„Àâ„ÀâÕ“À“√‡ªìπ¡◊Èե⫬«‘∏’ bolus feeding
°“√„Àâ EN ¥â«¬«‘∏’ continuous feeding μ≈Õ¥ „πºŸâªÉ«¬∑’Ë„ à “¬„ÀâÕ“À“√∑’˪≈“¬ “¬Õ¬Ÿà„π°√–‡æ“–
24 ™—Ë«‚¡ß §«√„™â‡§√◊ËÕߧ«∫§ÿ¡Õ—μ√“°“√À¬¥Õ“À“√ Õ“À“√‡∑à“π—Èπ ·≈–§«√„™â„πºŸâªÉ«¬Õ“°“√§ß∑’Ë´÷Ëß√—∫
(enteral feeding pump) ‡æ◊ËÕ„Àâ “¡“√∂§«∫§ÿ¡Õ—μ√“ Õ“À“√‰¥â¥’·≈â«
°“√À¬¥‰¥â·πàπÕπ‚¥¬‡©æ“–„πºŸâªÉ«¬∑’ˇ√‘Ë¡„ÀâÕ—μ√“°“√
§ÿ≥¿“æÀ≈—°∞“π 4 πÈ”Àπ—°§”·π–π” +/-
À¬¥πâÕ¬ Ê „™â ”À√—∫ºŸâªÉ«¬∑’Ë„ à “¬„ÀâÕ“À“√∑’˪≈“¬
“¬„ÀâÕ“À“√Õ¬Ÿà∑’Ë≈”‰ â‡≈Á° ºŸâªÉ«¬«‘°ƒμ ºŸâªÉ«¬∑’Ëߥ
§”Õ∏‘∫“¬
Õ“À“√‡ªìπ‡«≈“π“π À√◊ÕºŸâªÉ«¬∑’Ë„ÀâÕ“À“√‚¥¬«‘∏’„Àâ
°“√„Àâ EN ¥â«¬«‘∏„’ ÀâÕ“À“√‡ªìπ¡◊ÕÈ (bolus feeding)
Õ“À“√‡ªìπ¡◊ÈÕ (bolus feeding) À√◊Õ „ÀâÕ“À“√·∫∫
‚¥¬ºà“π∑“ß syringe À√◊Õ∂ÿß„ÀâÕ“À“√μ“¡ gravity ®÷ß
À¬¥‡ªìπ¡◊ÈÕ (intermittent feeding) ·≈â«¡’ feeding
∑”„ÀâÕ“À“√À¡¥‡√Á« ‚¥¬‰¡à§«√„ÀâÕ“À“√À¡¥‡√Á«°«à“ 15
intolerance19-21
π“∑’ (Õ—μ√“°“√„À≡৫√‡√Á«°«à“ 60 ¡≈./π“∑’) «‘∏’π’È„™â
°—∫ “¬∑’¡Ë ª’ ≈“¬ “¬„ÀâÕ“À“√Õ¬Ÿ„à π°√–‡æ“–Õ“À“√‡∑à“π—πÈ
§”·π–π”∑’Ë 7.2 §«√„™â„πºŸªâ «É ¬∑’Ë “¡“√∂ª√—∫μ—«„π°“√√—∫Õ“À“√‰¥â¥·’ ≈â«
·π–π”„Àâ„ÀâÕ“À“√¥â«¬«‘∏’À¬¥‡ªìπ¡◊ÈÕ (intermittent À√◊ÕºŸâªÉ«¬∑’Ë«“ß·ºπ°“√„Àâ EN ∑’Ë∫â“π ‰¡à§«√„™â«‘∏’π’È„π
feeding) „πºŸâªÉ«¬¥—ßμàÕ‰ªπ’È ºŸâªÉ«¬«‘°ƒμ·≈–ºŸâªÉ«¬∑’ˇ√‘Ë¡„ÀâÕ“À“√‡ªìπ§√—Èß·√°21
7.2.1 ºŸâªÉ«¬∑’Ë„ à “¬„ÀâÕ“À“√∑’˪≈“¬ “¬Õ¬Ÿà„π
°√–‡æ“–Õ“À“√
7.2.2 ºŸâªÉ«¬‡√‘Ë¡„ÀâÕ“À“√‡ªìπ§√—Èß·√°
7.2.3 ºŸªâ «É ¬∑’ªË √—∫μ—«√—∫Õ“À“√¥â«¬«‘∏’ continuous
feeding ‰¥â¥’·≈â«
§ÿ≥¿“æÀ≈—°∞“π 4 πÈ”Àπ—°§”·π–π” +/-

«“√ “√‚¿™π∫”∫—¥
18 ªï∑’Ë 27 ©∫—∫∑’Ë 2 °√°Æ“§¡ - ∏—𫓧¡ 2562
Thai Clinical Practice Recommendations for Nutritional Management in Adult
Hospitalized Patients 2017 Part 2: Enteral Nutrition (Recommendation 5-10)
§”·π–π”∑’Ë 7.4
EN ∑ÿ°™π‘¥∑’ºË ¡‡ √Á®·≈â«„Àâπ”‡¢â“μŸ‡â ¬Áπ∑—π∑’À“°
¬—߉¡à‰¥â„™â ·≈– “¡“√∂‡°Á∫‰«â„πμŸ‡â ¬Áπ‰¡à‡°‘π 24 ™—«Ë ‚¡ß
‡¡◊ËÕπ”¡“·¢«π„À⺟âªÉ«¬·≈â« ·π–π”„Àâ„™â√–¬–‡«≈“
·¢«πμ“¡™π‘¥Õ“À“√¥—ßπ’È
™π‘¥Õ“À“√
1. Õ“À“√ªíòπº ¡ (blenderized diet)
2. Õ“À“√ ”‡√Á®√Ÿª∑’ËμâÕ߇μ√’¬¡„À¡à°àÕπ𔉪„À⺟âªÉ«¬
(Õ“À“√ºß ”‡√Á®√Ÿª∑’ËμâÕߺ ¡°àÕπ„Àâ
√«¡∂÷ß°“√‡μ‘¡ à«πº ¡Õ◊ËπÊ ≈ß„πÕ“À“√)
3. Õ“À“√ ”‡√Á®√Ÿª∑’ˉ¡àμâÕ߇μ√’¬¡„À¡à°àÕπ𔉪„À⺟âªÉ«¬
(Õ“À“√ ”‡√Á®√Ÿª™π‘¥πÈ”‡ªî¥°√–ªÜÕß·≈–‡∑„ à™ÿ¥„ÀâÕ“À“√)
4. Õ“À“√ ”‡√Á®√Ÿª∑’Ë¡’™ÿ¥„ÀâÕ“À“√¡“μàÕ„À⺟âªÉ«¬‰¥â∑—π∑’
(closed-system EN formulas)
§ÿ≥¿“æÀ≈—°∞“π 4 πÈ”Àπ—°§”·π–π” +
§”Õ∏‘∫“¬
EN “¡“√∂‡°‘¥°“√ªπ‡ªóôÕπ‡™◊ÈÕ‰¥â®“°¢—ÈπμÕπ
°“√‡μ√’¬¡ °“√º ¡°àÕπ𔉪„À⺟âªÉ«¬ °“√‡°Á∫√—°…“
Õ“À“√ ·≈–°“√ªπ‡ªóôÕπ√–À«à“ß°“√„ÀâÕ“À“√ Õÿ≥À¿Ÿ¡‘∑’Ë
Ÿ ß ¢÷ È π ¢Õß ‘ Ë ß ·«¥≈â Õ ¡¡’ º ≈μà Õ °“√‡®√‘ ≠ ‡μ‘ ∫ ‚μ¢Õß
‡™◊ÈÕ22 EN ∑’ˇμ√’¬¡‡ √Á®·≈⫧«√π”¡“„À⺟âªÉ«¬∑—π∑’ À“°
¬—߉¡à„™â “¡“√∂‡°Á∫‰«â„πμŸâ‡¬Áπ‰¥â‰¡à‡°‘π 24 ™—Ë«‚¡ß ·≈–
‡¡◊ËÕπ”Õ“À“√ÕÕ°¡“®“°μŸâ‡¬Á𠧫√Õÿàπ‚¥¬π”Õ“À“√¡“
·™à„ππÈ”Õÿàπ°àÕππ”¡“„À⺟âªÉ«¬
Õ“À“√∑’ˇ ’ˬßμàÕ°“√ªπ‡ªóôÕπ‡™◊ÈÕ¡“°∑’Ë ÿ¥ ‰¥â·°à
Õ“À“√ªíòπº ¡∑’ˇμ√’¬¡‡Õß®“°«—μ∂ÿ¥‘∫∏√√¡™“μ‘ π”¡“
∑”„Àâ °ÿ ·≈–ªíπò º ¡„À⇢⓰—πμ“¡§«“¡μâÕß°“√¢ÕߺŸªâ «É ¬
‡°Á∫‡¢â“μŸâ‡¬Áπ ·≈–·∫àß¡“„ÀâºâªŸ É«¬‡ªìπ¡◊ÈÕ Õ“À“√ªíòπº ¡π’È
Thai JPEN
Volume 27 No. 2 July - December 2019
Warodomwichit D. et al
√–¬–‡«≈“·¢«πÕ“À“√∑’ËÕÿ≥À¿Ÿ¡‘ÀâÕß
‰¡à‡°‘π 2 ™—Ë«‚¡ß (¥Ÿ§”Õ∏‘∫“¬‡æ‘Ë¡‡μ‘¡)
‰¡à‡°‘π 4 ™—Ë«‚¡ß
‰¡à‡°‘π 8 ™—Ë«‚¡ß
“¡“√∂„À≥â 24-48 ™—Ë«‚¡ß
¢÷ÈπÕ¬Ÿà°—∫§”·π–π”¢ÕߺŸâº≈‘μ
·π–π”„Àâ·¢«π„À⺟âªÉ«¬‰¡à‡°‘π 2 ™—Ë«‚¡ß23,24
Õ“À“√ ”‡√Á®√Ÿª™π‘¥ºßÀ√◊Õ™π‘¥πÈ” À“°π”¡“º ¡°—∫
πÈ”À√◊Õ à«πº ¡‡æ‘Ë¡‡μ‘¡∂◊Õ«à“¡’‚Õ°“ ªπ‡ªóôÕπ‡™◊ÈÕ‡™àπ
‡¥’¬«°—π ·μࢗÈπμÕπ°“√‡μ√’¬¡®–‡ ’ˬßπâÕ¬°«à“Õ“À“√
ªíòπº ¡ ®÷ß·π–π”„Àâ·¢«π‰¡à‡°‘π 4 ™—Ë«‚¡ß25
Õ“À“√ ”‡√Á®√Ÿª™π‘¥πÈ”∑’Ëπ”¡“‡∑„ à™ÿ¥„ÀâÕ“À“√
‚¥¬‰¡à¡’°“√‡μ‘¡ à«πº ¡ ¡’§«“¡‡ ’ˬßμàÕ°“√ªπ‡ªóôÕπ
‡™◊ÕÈ „π¢—πÈ μÕπ°“√‡μ√’¬¡πâÕ¬°«à“ ®÷ß·π–π”„Àâ·¢«π‰¡à‡°‘π
8 ™—Ë«‚¡ß25
”À√—∫Õ“À“√ ”‡√Á®√Ÿª∑’¡Ë “æ√âÕ¡™ÿ¥„ÀâÕ“À“√ “¡“√∂
π”¡“μàÕ„À⺟âªÉ«¬‰¥â∑—π∑’„Àâ·¢«π‰¡à‡°‘π 24 ™—Ë«‚¡ß À√◊Õ
μ“¡§”·π–π”¢ÕߺŸâº≈‘μ25
19
§”·π–π”°“√¥Ÿ·≈∑“ß‚¿™π“°“√„πºŸâªÉ«¬ºŸâ„À≠à∑’ËπÕπ‚√ß欓∫“≈ æ.». 2560
μÕπ∑’Ë 2: °“√„ÀâÕ“À“√‡¢â“∑“߇¥‘πÕ“À“√ (§”·π–π”∑’Ë 5-10)
§”·π–π”∑’Ë 8: °“√∫√‘À“√¬“ºà“𠓬„ÀâÕ“À“√
§”·π–π”∑’Ë 8.1
§”·π–π”∑—Ë«‰ª„π°“√∫√‘À“√¬“ºà“𠓬„ÀâÕ“À“√
·°àºŸâªÉ«¬
8.1.1 æ‘®“√≥“‡≈◊Õ°„™â¬“√Ÿª·∫∫√—∫ª√–∑“π™π‘¥
πÈ”‡ªìπ∑“߇≈◊Õ°·√°„π°“√∫√‘À“√¬“ºà“𠓬„ÀâÕ“À“√
8.1.2 ¬“√Ÿª·∫∫√—∫ª√–∑“π™π‘¥πÈ”∑’Ë¡’ “√„Àâ
§«“¡À«“π´Õ√å ∫ ‘ ∑ Õ≈‡ªì π à « πª√–°Õ∫§«√¡’ ° “√
‡®◊Õ®“߬“°àÕπ¥â«¬πÈ” –Õ“¥Õ¬à“ßπâÕ¬ 10-30 ¡≈.
‡æ◊ËÕ≈¥Õ“°“√∂à“¬‡À≈«„πºŸâªÉ«¬
8.1.3 ºŸâªÉ«¬∑’ËμâÕ߉¥â√—∫°“√®”°—¥πÈ” À√◊Õ‰¡à¡’¬“
√Ÿ ª ·∫∫√— ∫ ª√–∑“π™π‘ ¥ πÈ ” “¡“√∂𔬓√Ÿ ª ·∫∫
√—∫ª√–∑“π™π‘¥‡¡Á¥ (tablet) ¡“∫¥≈–≈“¬πÈ” À√◊Õ
·¬°Ω“·§ª´Ÿ≈™π‘¥·¢Áß (hard gelatin capsule)
·≈â«π”ºß¬“ÕÕ°¡“≈–≈“¬πÈ” À“°‡ªì𷧪´Ÿ≈™π‘¥π‘¡Ë
(soft gelatin capsule) Õ“®„™â‡¢Á¡‡®“–·§ª´Ÿ≈ ·≈â«
π”¢Õ߇À≈«¿“¬„πÕÕ°¡“º ¡°—∫πÈ”‰¥â ∑—Èßπ’ȉ¡à§«√
𔬓√Ÿª·∫∫√—∫ª√–∑“π™π‘¥‡¡Á¥∫“ßμ”√—∫ ‡™à𠬓
‡¡Á¥™π‘¥ÕÕ°ƒ∑∏‘χπ‘Ëπ (extended-release tablet)
¬“Õ¡„μâ≈πÈ‘ (sublingual tablet) ¬“‡§¡’∫”∫—¥™π‘¥‡¡Á¥
‡ªìπμâπ ¡“‡μ√’¬¡‡æ◊ÕË „™â„π°“√∫√‘À“√ºà“𠓬„ÀâÕ“À“√
À“°‰¡à∑√“∫À√◊Õ‰¡à·πà„® §«√ª√÷°…“‡¿ —™°√°àÕπ
°“√‡μ√’¬¡¬“‡ ¡Õ
8.1.4 §«√≈â“ß “¬„ÀâÕ“À“√¥â«¬πÈ” –Õ“¥ 15-30
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8.1.5 ‡¡◊ËÕ®”‡ªìπμâÕß∫√‘À“√¬“À≈“¬™π‘¥ §«√
·¬°∫√‘À“√¬“·μà≈–™π‘¥ ·≈–§«√≈â“ß “¬„ÀâÕ“À“√
¥â«¬πÈ” –Õ“¥ 10-15 ¡≈. °àÕπ°“√„À⬓™π‘¥μàÕ‰ª
‰¡à § «√º ¡¬“·μà ≈ –™π‘ ¥ ‡¢â “ ¥â « ¬°— π ‡æ◊ Ë Õ ∫√‘ À “√
æ√âÕ¡°—π„π§√“«‡¥’¬« „πºŸâªÉ«¬∑’ˉ¥â√—∫¬“®”π«π
¡“°·≈–®”‡ªìπμâÕß®”°—¥πÈ” §«√ª√÷°…“‡¿ —™°√
8.1.6 ‰¡à§«√º ¡¬“≈ß„πÕ“À“√∑’Ë∫√‘À“√„Àâ·°à
ºŸâªÉ«¬ ¬°‡«âπ¡’¢âÕ∫àß™’È∑“ß°“√·æ∑¬å ‡™àπ °“√º ¡
ºß°√¥Õ–¡‘‚𮔇ªìπ À√◊Õ«‘μ“¡‘πμà“ß Ê ≈ß„πÕ“À“√
·≈–§«√ª√÷°…“‡¿ —™°√∑ÿ°§√—Èß ‡æ◊ËÕμ√«® Õ∫§«“¡
‡¢â“°—π‰¥â¢ÕßÕ“À“√·≈–¬“∑’ËμâÕß°“√º ¡
§ÿ≥¿“æÀ≈—°∞“π 4 πÈ”Àπ—°§”·π–π” +/-
20
¥√ÿ≥’«—≈¬å «‚√¥¡«‘®‘μ√ ·≈–§≥–
§”Õ∏‘∫“¬
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√Ÿª·∫∫·≈–™π‘¥¢Õ߬“„π°“√∫√‘À“√¬“ºà“𠓬„ÀâÕ“À“√
(· ¥ß„π√Ÿª∑’Ë 2)26-29 §«√æ‘®“√≥“‡≈◊Õ°„™â¬“√Ÿª·∫∫
√—∫ª√–∑“π™π‘¥πÈ”‡ªìπ∑“߇≈◊Õ°·√° ‡π◊ËÕß®“° “¡“√∂
∫√‘À“√‰¥âÕ¬à“ß –¥«° πÕ°®“°π’Ȭ—߇ªìπ°“√À≈’°‡≈’ˬß
°“√Õÿ¥μ—π¢Õß “¬„ÀâÕ“À“√ ‚¥¬‡©æ“–„πºŸâªÉ«¬∑’Ë„™â
“¬„Àâ Õ “À“√∑’ Ë ¡ ’ ¢ 𓥇≈Á ° Õ¬à “ ߉√°Á μ “¡¬“√Ÿ ª ·∫∫
√—∫ª√–∑“π™π‘¥πÈ” ¡—°¡’§à“ÕÕ ‚¡·≈≈‘μ’ (osmolality)
Ÿ ß °«à “ ÕÕ ‚¡·≈≈‘ μ ’ ¢ ÕߢÕ߇À≈«„π∑“߇¥‘ π Õ“À“√
‡π◊ËÕß®“°„πμ”√—∫¬“√Ÿª·∫∫√—∫ª√–∑“π™π‘¥πÈ”¡—°®–¡’
°“√‡μ‘¡ “√„À⧫“¡À«“π ·≈– “√‡æ‘Ë¡§«“¡Àπ◊¥ ®÷ß
∑”„Àâμ”√—∫¬“πÈ”¡’§à“ÕÕ ‚¡·≈≈‘μ’ Ÿß ‚¥¬ª°μ‘¡—° Ÿß°«à“
1,000 ¡‘≈≈‘ÕÕ ‚¡≈/°°. ‡¡◊ËÕ∫√‘À“√¬“ºà“𠓬„ÀâÕ“À“√
≈ß Ÿà≈”‰ â‡≈Á° ´÷Ëß¡’§à“ÕÕ ‚¡·≈≈‘μ’ª√–¡“≥ 300-500
¡‘≈≈‘ÕÕ ‚¡≈/°°. ®÷ß àߺ≈„ÀâπÈ”πÕ°‡´≈≈凧≈◊ËÕπ∑’ˇ¢â“ Ÿà
≈”‰ â ‡ ≈Á ° ‡æ◊ Ë Õ ª√— ∫ ¡¥ÿ ≈ „Àâ § à “ ÕÕ ‚¡≈·≈≈‘ μ ’ ¢ Õß
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Õ“°“√‰¡àæ÷ߪ√– ß§å ‰¥â·°à Õ“°“√∂à“¬‡À≈« ª«¥‡°√Áß
™àÕß∑âÕß ∑âÕßÕ◊¥ (abdominal distention) ·≈–Õ“‡®’¬π‰¥â
à«πª√–°Õ∫Àπ÷Ëß„πμ”√—∫¬“πÈ”∑’Ë¡—°∑”„À⺟âªÉ«¬¡’Õ“°“√
∂à “ ¬Õÿ ® ®“√–‡À≈«‡ªì π πÈ ” (osmotic diarrhea) §◊ Õ
´Õ√å ∫ ‘ ∑ Õ≈ (sorbitol) ´÷ Ë ß ‡ªì π πÈ ” μ“≈·Õ≈°ÕŒÕ≈å ∑ ”
Àπâ“∑’ˇªìπ “√„À⧫“¡À«“π„πμ”√—∫¬“πÈ” ”À√—∫¬“√Ÿª
·∫∫√—∫ª√–∑“π™π‘¥πÈ”∑’Ë¡’®”Àπà“¬„π∑âÕßμ≈“¥ ¡—°¡’
“√„À⧫“¡À«“π´Õ√å∫‘∑Õ≈‡ªìπ à«πª√–°Õ∫„πª√‘¡“≥
∑’Ë·μ°μà“ß°—π‰ª πÕ°®“°π’Ȭ—ß¡’¬“„π√Ÿª·∫∫¬“‡μ√’¬¡
”À√—∫ ºŸªâ «É ¬‡©æ“–√“¬ (extemporaneous preparation)
∑’ Ë ‡ ¿ — ™ °√„π‚√ß欓∫“≈‡ªì π ºŸ â μ — È ß μ”√— ∫ ‡Õß ‚¥¬¡’
«—μ∂ÿª√– ߧå‡æ◊ËÕ∫√‘À“√¬“„π¢π“¥∑’Ë·¡à𬔄ÀⷰຟâªÉ«¬
‡¥Á°‡≈Á°∑’ËμâÕß°“√„™â¬“¢π“¥μË” ·≈–ßà“¬μàÕ°“√∫√‘À“√
ºà“𠓬„ÀâÕ“À“√„πºŸâªÉ«¬∫“ß√“¬∑’Ë¡’ªí≠À“°“√°≈◊π
À√◊Õ‰¡à “¡“√∂°‘𬓇¡Á¥‰¥â ´÷Ëßμ”√—∫¬“‡μ√’¬¡ ”À√—∫
ºŸâªÉ«¬‡©æ“–√“¬π’È ¡—°¡’°“√„™âπÈ”°√– “¬¬“ (solvent)
∑’Ë¡’ à«πº ¡¢Õß´Õ√å∫‘∑Õ≈‡ªìπμ—«∑”≈–≈“¬ ·≈–‡æ‘Ë¡
§«“¡À«“π‡æ◊ Ë Õ „Àâ μ ”√— ∫ ¬“ “¡“√∂°‘ 𠉥â ß à “ ¬ ´÷ Ë ß πÈ ”
°√– “¬¬“™π‘¥π’È¡—°¡’§à“ÕÕ ‚¡·≈≈‘μ’ Ÿß ‡¡◊ËÕ∫√‘À“√ºà“π
«“√ “√‚¿™π∫”∫—¥
ªï∑’Ë 27 ©∫—∫∑’Ë 2 °√°Æ“§¡ - ∏—𫓧¡ 2562
Thai Clinical Practice Recommendations for Nutritional Management in Adult
Hospitalized Patients 2017 Part 2: Enteral Nutrition (Recommendation 5-10)
“¬¬“ß„ÀâÕ“À“√∑’Ë≈ß Ÿà≈”‰ â‡≈Á°‚¥¬μ√ß®÷ߧ«√¡’°“√
‡®◊Õ®“߬“°àÕπ‡ ¡Õ ‡æ◊ÕË ≈¥Õ“°“√∂à“¬‡À≈« ‚¥¬ “¡“√∂
§à“ÕÕ ‚¡·≈≈‘μ’¢Õ߬“πÈ” (mOsm/kg)
ª√‘¡“μ√¬“πÈ”∑’Ë∫√‘À“√ (mL) =
§à“ÕÕ ‚¡·≈≈‘μ’∑’ËμâÕß°“√ (mOsm/kg)
À¡“¬‡Àμÿ: §à“ÕÕ ‚¡·≈≈‘μ’∑’ËμâÕß°“√ §◊Õ §à“ÕÕ ‚¡·≈≈‘μ’∑’ˇ∑à“°—∫¢Õ߇À≈«„π∑“߇¥‘πÕ“À“√ (300-500 mOsm/kg)
mL, ¡‘≈≈‘≈‘μ√; mOsm/kg, ¡‘≈≈‘ÕÕ ‚¡≈μàÕ°‘‚≈°√—¡
Õ¬à“߉√°Áμ“¡„πºŸâªÉ«¬∫“ß√“¬∑’Ë¡’¿“«–∫«¡πÈ”´÷Ëß
μâ Õ ß‰¥â √ — ∫ °“√®”°— ¥ πÈ ” À√◊ Õ „π°√≥’ ∑ ’ Ë ¬ “√Ÿ ª ·∫∫√— ∫
ª√–∑“π∑’ËμâÕß°“√∫√‘À“√„À⺟âªÉ«¬π—Èπ‰¡à¡’™π‘¥πÈ” «‘∏’°“√
·°â ‰ ¢ªí ≠ À“Õ’ ° Àπ÷ Ë ß ∑“߇≈◊ Õ ° §◊ Õ °“√𔬓√Ÿ ª ·∫∫
√—∫ª√–∑“π™π‘¥‡¡Á¥ (tablet) ¡“∫¥≈–≈“¬πÈ” À√◊Õ·¬°
Ω“·§ª´Ÿ≈™π‘¥·¢Áß (hard gelatin capsule) ·≈â«π”ºß
¬“ÕÕ°¡“≈–≈“¬πÈ” À“°‡ªì𷧪´Ÿ≈™π‘¥π‘Ë¡ (soft gelatin
capsule) Õ“®„™â ‡ ¢Á ¡ ‡®“–·§ª´Ÿ ≈ ·≈â « π”¢Õ߇À≈«
¿“¬„πÕÕ°¡“º ¡°—∫πÈ” ·¡â«‘∏’°“√‡μ√’¬¡¬“¥—ß°≈à“«®–
‰¡à‡æ‘Ë¡ÕÕ ‚¡·≈≈‘μ’¢Õß “√≈–≈“¬¬“‡∑à“°—∫°“√∫√‘À“√
¬“√Ÿª·∫∫√—∫ª√–∑“π™π‘¥πÈ” ·μà ‘Ëß∑’ËμâÕßæ÷ß√–«—ßÕ¬à“ß
¬‘Ëß„π°“√∫√‘À“√ “√≈–≈“¬¬“∑’ˇμ√’¬¡®“°¬“™π‘¥‡¡Á¥
À√◊Õ¬“·§ª´Ÿ≈™π‘¥·¢Áß §◊Õ °“√Õÿ¥μ—π¢Õß “¬„ÀâÕ“À“√
‚¥¬‡©æ“–ºŸâªÉ«¬∑’Ë„ à “¬„ÀâÕ“À“√∑’Ë¡’‡ âπºà“π»Ÿπ¬å°≈“ß
< 8 Fr πÕ°®“°π’Ȭ“√Ÿª·∫∫√—∫ª√–∑“π™π‘¥‡¡Á¥∫“ß
μ”√—∫‡ªì𬓉¡à‡À¡“– ¡ ”À√—∫π”¡“‡μ√’¬¡‡æ◊ËÕ∫√‘À“√
ºà“𠓬„ÀâÕ“À“√ ‡™àπ
- ¬“‡¡Á¥™π‘¥ÕÕ°ƒ∑∏‘χπ‘Ëπ (extended-release
tablet) °“√∫¥‡¡Á ¥ ¬“™π‘ ¥ π’ È ® –‡ªì π °“√∑”≈“¬√–∫∫
π” à߬“ ∑”„À⬓∂Ÿ°ª≈¥ª≈àÕ¬ÕÕ°¡“Õ¬à“ß√«¥‡√Á«‡ªìπ
ª√‘¡“≥¡“° àߺ≈„Àâ¡’√–¥—∫¬“ Ÿß ÿ¥∑’Ë°àÕ„À⇰‘¥æ‘…‰¥â
®“°π— È π √–¥— ∫ ¬“∑’ Ë ≈ ¥≈ßÕ¬à “ ß√«¥‡√Á « ®– à ß º≈„Àâ
ª√– ‘∑∏‘¿“æ°“√√—°…“≈¥≈ß Õ“®‡°‘¥§«“¡≈⡇À≈«„π
°“√√—°…“‰¥â
- ¬“‡¡Á¥∑’¡Ë °’ “√‡§≈◊Õ∫·∫∫摇»…‡æ◊ÕË „ÀâÕÕ°ƒ∑∏‘Ï
∑’Ë≈”‰ â‡≈Á° (enteric-coated tablet) ‡ªìπ√Ÿª·∫∫¬“∑’Ë
μâÕß°“√„À⇰‘¥°“√¥Ÿ¥´÷¡∑’Ë≈”‰ â‡≈Á° À√◊ÕªÑÕß°—π°√¥„π
°√–‡æ“–Õ“À“√∑”≈“¬¬“ °“√∫¥‡¡Á ¥ ¬“®–∑”≈“¬
Thai JPEN
Volume 27 No. 2 July - December 2019
Warodomwichit D. et al
§”π«≥ª√‘¡“μ√¢Õ߬“πÈ”∑’˧«√∫√‘À“√„ÀⷰຟâªÉ«¬‰¥â
®“° Ÿμ√ ¥—ßπ’È
× ª√‘¡“μ√¢Õ߬“πÈ”∑’Ë„™âμ“¡¢π“¥¬“ (mL)
§ÿ≥ ¡∫—쑇À≈à“π’È ·≈–Õ“®∑”„À⬓∫“ß™π‘¥∂Ÿ°∑”≈“¬‚¥¬
°√¥„π°√–‡æ“–Õ“À“√ ∑”„Àâª√– ‘∑∏‘¿“æ„π°“√√—°…“
≈¥≈߉¥â Õ¬à“߉√°Áμ“¡„π°√≥’∑’Ë®”‡ªìπ¬“∫“ß™π‘¥Õ“®
‡μ√’ ¬ ¡¬“‡æ◊ Ë Õ ∫√‘ À “√ºà “ 𠓬„Àâ Õ “À“√‰¥â ‚¥¬„™â « ‘ ∏ ’
°“√‡μ√’¬¡æ‘‡»… ¬°μ—«Õ¬à“߇™à𠬓 omeprazole ·≈–
lansoprazole À“°μâÕß°“√∫√‘À“√„À⺟âªÉ«¬∑’Ë¡’ª≈“¬ “¬
„ÀâÕ“À“√Õ¬Ÿà„π°√–‡æ“–Õ“À“√ „Àâ‡μ√’¬¡¬“‚¥¬∂Õ¥
·§ª´Ÿ≈ÕÕ° ·≈â«π”·°√πŸ≈¢â“ß„π (Àâ“¡∫¥·°√πŸ≈) ¡“
º ¡πÈ”º≈‰¡â∑’Ë¡’ƒ∑∏‘χªìπ°√¥ ‡™àπ πÈ” â¡ πÈ”·Õª‡ªîô≈
πÈ” —∫ª–√¥ ‡ªìπμâπ ·μàÀ“°ºŸâªÉ«¬¡’ª≈“¬ “¬„ÀâÕ“À“√
Õ¬Ÿ„à π≈”‰ ‡â ≈Á°„À⺠¡¥â«¬ “√ ≈–≈“¬∑’¡Ë ƒ’ ∑∏‘‡Ï ªìπ¥à“ß ‡™àπ
‚´‡¥’¬¡‰∫§“√å∫Õ‡πμ
- ¬“Õ¡„μâ≈‘Èπ (sublingual tablet) °“√∫¥‡¡Á¥
¬“™π‘¥π’È®–∑”„Àâ°“√¥Ÿ¥´÷¡¬“≈¥≈ß ‡π◊ËÕß®“°¬“™π‘¥π’È
‰¡à‰¥â∂Ÿ°ÕÕ°·∫∫¡“‡æ◊ËÕ¥Ÿ¥´÷¡∫√‘‡«≥∑“߇¥‘πÕ“À“√ ®÷ß
Õ“®∑”„Àâª√– ‘∑∏‘¿“æ„π°“√√—°…“≈¥≈߉¥â
- ¬“‡§¡’∫”∫—¥™π‘¥‡¡Á¥À√◊Õ¬“∑’¡Ë §’ ≥
ÿ ¡∫—쇑 ªìπ
cytotoxic, carcinogenic À√◊Õ teratogenic agents
°“√∫¥‡¡Á¥¬“‡À≈à“π’ȇæ◊ËÕ∫√‘À“√¬“ºà“𠓬„ÀâÕ“À“√‡ªìπ
‘Ëß∑’ˉ¡à§«√ªØ‘∫—μ‘ ‡π◊ËÕß®“°Õ“®∑”„À⇰‘¥°“√øÿÑß°√–®“¬
¢Õ߬“ ·≈–‡ªìπÕ—πμ√“¬μàÕ∫ÿ§≈“°√ºŸâªØ‘∫—μ‘ß“π‰¥â À“°
¡’§«“¡®”‡ªìπ„π°“√∫¥‡¡Á¥¬“Õ¬à“ßÀ≈’°‡≈’ˬ߉¡à‰¥â §«√
π”‡¡Á¥¬“„ à„π∂ÿß æ≈“ μ‘° ªî¥∂ÿß„Àâ π‘∑ ·≈â«„™â™âÕπ
∫¥‚¥¬√–«—߉¡à„Àâ∂ÿßæ≈“ μ‘°∑’ËÀàÕÀÿ⡬“·μ°ÕÕ°
”À√—∫¬“∑’ËÀâ“¡À—°·∫àß ∫¥ ‡§’Ȭ« À√◊Õ∑”„À⇡Á¥¬“
·μ°‚¥¬‡¥Á¥¢“¥ ¡—°®–‡ªìπ¬“∑’Ë∂Ÿ°ÕÕ°·∫∫„Àâ¡’°“√
§«∫§ÿ¡°“√ÕÕ°ƒ∑∏‘Ï„π√Ÿª·∫∫¬“ÕÕ°ƒ∑∏‘Ïπ“π ™◊ËÕ¬“¡—°
≈ß∑⓬¥â«¬ CR, SR, MR, XL À√◊Õ XR ‡ªìπμâπ ∑—Èßπ’È
21
§”·π–π”°“√¥Ÿ·≈∑“ß‚¿™π“°“√„πºŸâªÉ«¬ºŸâ„À≠à∑’ËπÕπ‚√ß欓∫“≈ æ.». 2560
μÕπ∑’Ë 2: °“√„ÀâÕ“À“√‡¢â“∑“߇¥‘πÕ“À“√ (§”·π–π”∑’Ë 5-10)
¢âÕ¡Ÿ≈¬“∑’ËÀâ“¡À—°·∫àß ∫¥ ‡§’Ȭ« À√◊Õ∑”„À⇡Á¥¬“·μ°
·≈–·π«∑“ß°“√∫√‘À“√¬“ºà“𠓬„ÀâÕ“À“√≈ß Ÿà≈”‰ â‡≈Á°
à«πμà“ß Ê ‰¥â√«∫√«¡‰«â„π¿“§ºπ«° 1 ·≈– 2 μ“¡
≈”¥—∫30-32
§”·π–π”∑’Ë 8.2
Õ—πμ√°‘√¬‘ “√–À«à“߬“·≈–Õ“À“√ (Drug-Nutrient
Interaction; DNI) „πºŸâªÉ«¬∑’ˉ¥â√—∫Õ“À“√ ·≈–¬“
‡¢â“∑“߇¥‘πÕ“À“√√à«¡°—π
8.2.1 §«√¡’°“√μ√«® Õ∫¢âÕ¡Ÿ≈‡°’ˬ«°—∫°“√‡°‘¥
DNI ∑ÿ°§√—Èß°àÕπ°“√∫√‘À“√¬“„π√Ÿª·∫∫√—∫ª√–∑“π
„ÀⷰຟâªÉ«¬∑ÿ°√“¬∑’ˉ¥â√—∫ EN ‚¥¬‡©æ“–Õ¬à“߬‘Ëß„π
°≈ÿࡺŸâªÉ«¬∑’Ë¡’§«“¡‡ ’ˬ߄π°“√‡°‘¥ DNI ‰¥â·°à
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‰¡à
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√Ÿª∑’Ë 2 ·π«∑“ß°“√∫√‘À“√¬“ºà“𠓬„ÀâÕ“À“√
22
¥√ÿ≥’«—≈¬å «‚√¥¡«‘®‘μ√ ·≈–§≥–
ºŸªâ «É ¬ ߟ Õ“¬ÿ ºŸªâ «É ¬∑’¡Ë ‚’ √§√à«¡®”π«π¡“° ºŸªâ «É ¬«‘°ƒμ
·≈–ºŸâªÉ«¬∑’ˉ¥â√—∫ continuous feeding
8.2.2 ‰¡à§«√º ¡¬“·≈–Õ“À“√„¥ Ê ‡¢â“¥â«¬°—π
À“°‰¡à¡’¢âÕ¡Ÿ≈À√◊ÕÀ≈—°∞“π∑“ß«‘™“°“√∑’ˬ◊π¬—𧫓¡
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8.2.3 §«√À≈’°‡≈’ˬ߰“√∫√‘À“√Õ“À“√√à«¡°—∫¬“∑’Ë
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¢π“¥¬“„Àâ‡À¡“– ¡ À√◊Õ°“√ª√—∫‡«≈“„π°“√∫√‘À“√
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§«√ª√÷°…“‡¿ —™°√
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ªï∑’Ë 27 ©∫—∫∑’Ë 2 °√°Æ“§¡ - ∏—𫓧¡ 2562
Thai Clinical Practice Recommendations for Nutritional Management in Adult
Hospitalized Patients 2017 Part 2: Enteral Nutrition (Recommendation 5-10)
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ÕÕ°‡ªìπ 4 ª√–‡¿∑33 ‰¥â·°à
1) Type I: ex vivo bioinactivations ‡ªìπ
Õ—πμ√°‘√¬‘ “∑’¡Ë °’ ≈‰°‡°’¬Ë «¢âÕß°—∫°“√‡°‘¥ªØ‘°√‘ ¬‘ “∑“߇§¡’
(chemical reactions) À√◊Õ∑“ß°“¬¿“æ (physical
reactions) ´÷Ë߇°‘¥¢÷Èπ°àÕπ∑’ˬ“À√◊ÕÕ“À“√®–‡¢â“ Ÿà√à“ß°“¬
¢ÕߺŸâªÉ«¬ ‚¥¬Õ—πμ√°‘√‘¬“™π‘¥π’È¡—°‡°‘¥®“°§«“¡‰¡à
‡¢â“°—π¢Õß “√ ´÷Ëß “¡“√∂æ∫‰¥â„π¢—ÈπμÕπ¢Õß°“√‡μ√’¬¡
À√◊Õ°“√∫√‘À“√¬“√à«¡°—∫°√–∫«π°“√„Àâ EN À√◊Õ PN
¥—ßπ—ÈπºŸâªÉ«¬∑’ˉ¥â√—∫Õ“À“√¥â«¬«‘∏’‡À≈à“π’È ®÷߇ªìπºŸâ∑’Ë¡’
§«“¡‡ ¬Ë’ ß„π°“√‡°‘¥Õ—πμ√°‘√¬‘ “√–À«à“߬“·≈–Õ“À“√·∫∫
Type I ‚¥¬Õ—πμ√°‘√‘¬“π’ÈÕ“®‡°‘¥¢÷Èπ®“°°“√º ¡¬“·≈–
Õ“À“√‡¢â“¥â«¬°—π ¥—ßπ—Èπ«‘∏’∑’Ë¥’∑’Ë ÿ¥„π°“√À≈’°‡≈’ˬß
Õ—πμ√°‘√‘¬“™π‘¥π’È §◊Õ ‰¡à§«√º ¡¬“ ·≈–Õ“À“√„¥ Ê
‡¢â“¥â«¬°—π À“°‰¡à¡’¢âÕ¡Ÿ≈ À√◊ÕÀ≈—°∞“π∑“ß«‘™“°“√∑’Ë
¬◊π¬—𧫓¡‡¢â“°—π‰¥â¢Õß “√∑—Èß Õß™π‘¥
2) Type II: absorption phase-associated
interactions ‡ªìπÕ—πμ√°‘√‘¬“∑’Ëæ∫‰¥â∫àÕ¬∑’Ë ÿ¥„π°“√
ªØ‘∫—μ‘ß“π∑“ߧ≈‘π‘° ·≈– “¡“√∂æ∫‰¥â„πºŸâªÉ«¬∑’ˉ¥â√—∫
°“√∫√‘À“√¬“ ·≈–Õ“À“√∑“ߪ“° À√◊Õ∑“߇¥‘πÕ“À“√‡∑à“π—πÈ
Õ—πμ√°‘√‘¬“™π‘¥π’Ȭ—ß∂Ÿ°·∫à߬àÕ¬ÕÕ°‡ªìπ 3 ·∫∫μ“¡
°≈‰°°“√‡°‘¥ ‰¥â·°à
- Type IIA interaction ‡ªìπÕ—πμ√°‘√‘¬“∑’ˇ°‘¥
¢÷πÈ ‡π◊ÕË ß®“°¬“ À√◊ÕÕ“À“√∑’ºË ªâŸ «É ¬‰¥â√∫— ¡’º≈‡ª≈’¬Ë π·ª≈ß
°“√∑”ß“π¢Õ߇Õπ‰´¡å´÷Ëß∑”Àπâ“∑’Ë·ª√ ¿“欓∑’ˉ¥â√—∫
√à«¡°—π
- Type IIB interaction ‡ªìπÕ—πμ√°‘√‘¬“∑’ˇ°‘¥
¢÷Èπ‡π◊ËÕß®“°¬“ À√◊ÕÕ“À“√∑’˺ŸâªÉ«¬‰¥â√—∫¡’º≈‡ª≈’ˬπ
·ª≈ß°“√∑”ß“π¢Õß transport protein ∑’Ëæ∫∫√‘‡«≥
‡¬◊ËÕÀÿ⡇´≈≈å¢Õߺπ—ß≈”‰ â‡≈Á° ´÷Ëß∫“ß™π‘¥‡ªìπ‚ª√μ’π∑’Ë
∑”Àπâ“∑’˧«∫§ÿ¡°“√𔬓 À√◊Õ “√μà“ßÊ ‡¢â“ Ÿà‡´≈≈å¢Õß
√à“ß°“¬ (influx transporters) ‡™àπ Organic Anion
Transport Protein (OATP), Organic Cation
Transporter Type 2 (OCTN2), Oligopeptide
Transporter Type 1 (PEPT1) ·≈–∫“ß™π‘¥∑”Àπâ“∑’Ë
¢—∫¬“ ·≈– “√μà“ßÊ ÕÕ°®“°‡´≈≈å¢Õß√à“ß°“¬ (efflux
Thai JPEN
Volume 27 No. 2 July - December 2019
Warodomwichit D. et al
transporters) ‡™àπ P-glycoprotein (P-gp), Breast
Cancer Resistance Protein (BCRP) ‡ªìπμâπ
- Type IIC interaction ‡ªìπÕ—πμ√°‘√‘¬“∑’ˇ°‘¥
ºà“π°≈‰°°“√√«¡μ—«À√◊Õ®—∫°—π (binding) ¢Õ߬“ ·≈–
Õ“À“√‡°‘¥‡ªìπ “√ª√–°Õ∫‡™‘ß´âÕπ (complexation)
À√◊Õ°√–∫«π°“√„¥ Ê ∑’ˇ°‘¥¢÷Èπ„π∑“߇¥‘πÕ“À“√ ·≈–
∑”„Àâ°“√¥Ÿ¥´÷¡·≈–°“√ÕÕ°ƒ∑∏‘Ï¢Õ߬“≈¥≈ß
°“√®—¥°“√‡∫◊ÈÕßμâπ‡æ◊ËÕ≈¥‚Õ°“ °“√‡°‘¥Õ—πμ√
°‘√¬‘ “√–À«à“߬“·≈–Õ“À“√™π‘¥π’È ”À√—∫Õ—πμ√°‘√¬‘ “ Type
IIA ·≈– IIB “¡“√∂∑”‰¥â‚¥¬À≈’°‡≈’ˬ߰“√∫√‘À“√
Õ“À“√√à«¡°—∫¬“∑’Ë¡’¢âÕ¡Ÿ≈°“√‡°‘¥Õ—πμ√°‘√‘¬“¥—ß°≈à“«
À√◊ÕÀ“°®”‡ªìπμâÕß¡’°“√„™â¬“ °Á§«√ª√—∫¢π“¥¬“„Àâ
‡À¡“– ¡ ‡æ◊ËÕ„À≥âº≈°“√√—°…“∑’Ë¥’∑’Ë ÿ¥ ·≈–≈¥°“√‡°‘¥
Õ“°“√‰¡àæ÷ߪ√– ߧ宓°¬“ à«πÕ—πμ√°‘√‘¬“ Type IIC
“¡“√∂·°â‰¢‰¥â‚¥¬°“√ª√—∫‡«≈“„π°“√∫√‘À“√¬“·≈–
Õ“À“√„ÀâÀà“ß®“°°—π ‚¥¬§«√À¬ÿ¥°“√∫√‘À“√Õ“À“√‡À≈«
Õ¬à“ßπâÕ¬ 15-30 π“∑’ °àÕπ·≈–À≈—ß°“√∫√‘À“√¬“ ∑—Èßπ’È
æ÷ß√–≈÷°∂÷ߧ«“¡‡æ’¬ßæÕ¢ÕßÕ“À“√∑’˺ŸâªÉ«¬‰¥â√—∫·≈–º≈
°√–∑∫∑’ˇ°‘¥®“°Õ—πμ√°‘√‘¬“√–À«à“߬“·≈–Õ“À“√34
3) Type III: physiologic action-associated
interactions °“√‡°‘¥Õ—πμ√°‘√‘¬“√–À«à“߬“·≈–Õ“À“√
™π‘¥π’ȇ°‘¥¢÷Èπ¿“¬À≈—ß®“°¬“À√◊ÕÕ“À“√ ´÷Ë߇ªìπ§ŸàÕ—πμ√
°‘ √ ‘ ¬ “∂Ÿ ° ¥Ÿ ¥ ´÷ ¡ ‡¢â “ Ÿ à ° √–· ‡≈◊ Õ ¥Õ¬à “ ß ¡∫Ÿ √ ≥å · ≈â «
Õ— π μ√°‘ √ ‘ ¬ “™π‘ ¥ π’ È ‡ °‘ ¥ ºà “ π°≈‰°∑’ Ë ° à Õ „Àâ ‡ °‘ ¥ °“√
‡ª≈’ˬπ·ª≈ߧÿ≥ ¡∫—μ‘∑“ß®≈π»“ μ√å∫“ßÕ¬à“ߢÕ߬“
À√◊ÕÕ“À“√∑’ˉ¥â√—∫º≈°√–∑∫®“°Õ—πμ√°‘√‘¬“ ‡™àπ °“√
°√–®“¬μ—«‡¢â“ Ÿà‡´≈≈å À√◊Õ‡π◊ÈÕ‡¬◊ËÕμà“ß Ê ¢Õß√à“ß°“¬
°√–∫«π°“√π” àß “√ À√◊Õ°√–∫«π°“√‡¡·∑∫Õ≈‘´÷¡
πÕ°®“°π’ÈÕ—πμ√°‘√‘¬“™π‘¥π’Ȭ—ß°àÕ„À⇰‘¥°“√‡ª≈’ˬπ
·ª≈ßÀπâ“∑’Ë°“√∑”ß“π¢Õß‚§·ø°‡μÕ√å ‡™àπ clotting
factors À√◊ÕŒÕ√å‚¡π„π√à“ß°“¬∫“ß™π‘¥Õ’°¥â«¬ ´÷Ë߇ªìπ
Õ— π μ√°‘ √ ‘ ¬ “∑’ Ë ‡ °‘ ¥ ¢÷ È π ∫√‘ ‡ «≥μ— « √— ∫ (receptor) ¢Õß
‡π◊ÈÕ‡¬◊ËÕÀ√◊Õ‡´≈≈凪ѓÀ¡“¬ (target cells)
”À√— ∫ °“√®— ¥ °“√ªí ≠ À“Õ— π μ√°‘ √ ‘ ¬ “√–À«à “ ߬“
·≈–Õ“À“√™π‘¥ Type III π—Èπ °“√ª√—∫‡«≈“„π°“√∫√‘À“√
¬“ À√◊ÕÕ“À“√„ÀâÀà“ß®“°°—ππ—Èπ ‰¡à “¡“√∂™à«¬≈¥°“√
‡°‘¥ªí≠À“®“°Õ—πμ√°‘√‘¬“√–À«à“߬“·≈–Õ“À“√™π‘¥π’ȉ¥â
23
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μÕπ∑’Ë 2: °“√„ÀâÕ“À“√‡¢â“∑“߇¥‘πÕ“À“√ (§”·π–π”∑’Ë 5-10)
°“√ªÑ Õ ß°— π ·≈–·°â ‰ ¢ªí ≠ À“®“°Õ— π μ√°‘ √ ‘ ¬ “™π‘ ¥ π’ È
“¡“√∂∑”‰¥â‚¥¬°“√ª√—∫¢π“¥¬“„Àâ‡À¡“– ¡ ‡æ◊ËÕ„À≥â
º≈°“√√— ° …“∑’ Ë ¥ ’ ∑ ’ Ë ÿ ¥ ·≈–≈¥°“√‡°‘ ¥ Õ“°“√‰¡à æ ÷ ß
ª√– ߧ宓°¬“
4) Type IV: elimination phase-associated
interactions ‡°’¬Ë «¢âÕß°—∫§«“¡º‘¥ª°μ‘¢Õß°√–∫«π°“√
°”®—¥ “√ÕÕ°®“°√à“ß°“¬∑“߉μ À√◊Õ∑“ßμ—∫·≈–√–∫∫
∑“߇¥‘ππÈ”¥’ ´÷ËßÕ—πμ√°‘√‘¬“∫“ß™π‘¥Õ“®‡°‘¥®“°°“√∑’ˬ“
À√◊ Õ Õ“À“√¡’ ° “√·¢à ß ¢— π °— π ®— ∫ °— ∫ tissue-specific
transport protein „π°√–∫«π°“√°”®—¥ÕÕ°®“°√à“ß°“¬
‡™àπ °“√®”°—¥Õ“À“√∑’Ë¡’‚´‡¥’¬¡∑”„Àâ√–¥—∫‚´‡¥’¬¡„π
‡≈◊Õ¥≈¥≈ß ´÷Ëß “¡“√∂°√–μÿâπ„À⇰‘¥°“√¥Ÿ¥°≈—∫¢Õ߬“
lithium ∑“ßμàÕÀπ૬‰μ (renal tubular reabsorption)
‰¥â‡æ‘Ë¡¡“°¢÷Èπ
∑—Èßπ’ȺŸâªÉ«¬∑’ˉ¥â√—∫Õ“À“√·≈–¬“∑“ß “¬„ÀâÕ“À“√¡’
·π«‚πâ¡„π°“√‡°‘¥Õ—πμ√°‘√¬‘ “√–À«à“߬“·≈–Õ“À“√™π‘¥∑’Ë
I ·≈– II ‰¥â¡“°∑’Ë ÿ¥
Õ— π μ√°‘ √ ‘ ¬ “√–À«à “ ߬“·≈–Õ“À“√∑’ Ë ”§— ≠ „π°“√
∫√‘À“√¬“ºà“𠓬„ÀâÕ“À“√26-28,35-37
1. ¬“ phenytoin “¡“√∂∂Ÿ°¥Ÿ¥´—∫‚¥¬ “¬„Àâ
Õ“À“√ πÕ°®“°π’Èμ—«¬“ phenytoin ¬—ß√«¡μ—«°—∫‚ª√μ’π
·≈–‡°≈◊Õ·§≈‡´’¬¡„π Ÿμ√Õ“À“√ ‡°‘¥‡ªìπ “√ª√–°Õ∫
‡™‘ß´âÕπ∑”„À⬓∂Ÿ°¥Ÿ¥´÷¡‡¢â“ °àŸ √–· ‡≈◊Õ¥πâÕ¬≈ß „πºŸªâ «É ¬
∑’ Ë ® ”‡ªì π μâ Õ ß‰¥â √ — ∫ ¬“π’ È º à “ 𠓬„Àâ Õ “À“√ §«√¡’ ° “√
μ‘¥μ“¡«—¥√–¥—∫¬“„π‡≈◊Õ¥Õ¬à“ß„°≈♑¥ ‡æ◊ËÕª√—∫¢π“¥
¬“„Àâ‡À¡“– ¡
2. ¬“ carbamazepine “¡“√∂∂Ÿ°¥Ÿ¥´—∫‚¥¬
“¬„ÀâÕ“À“√‰¥â
3. ¬“ warfarin “¡“√∂®—∫°—∫‚ª√μ’π·Õ≈∫Ÿ¡‘π
„π‡≈◊Õ¥‰¥â¡“°∂÷ß√âÕ¬≈– 99 ¥—ßπ—È𠬓 warfarin ®÷ßÕ“®
®—∫√«¡μ—«°—∫‚ª√μ’π„π Ÿμ√Õ“À“√‡À≈«∑’Ë∫√‘À“√∑“ß “¬
„ÀâÕ“À“√ ∑”„À⬓∂Ÿ°¥Ÿ¥´÷¡‡¢â“ Ÿà°√–· ‡≈◊Õ¥πâÕ¬≈ß
·≈– ßà º≈≈¥ƒ∑∏‘¢Ï Õ߬“ warfarin „π°“√μâ“π°“√·¢Áßμ—«
¢Õ߇≈◊Õ¥‰¥â πÕ°®“°π’È°“√„À⬓ warfarin √à«¡°—∫
Õ“À“√∑’Ë¡’ª√‘¡“≥«‘μ“¡‘π‡§ Ÿß ‡™àπ º—°„∫‡¢’¬«™π‘¥μà“ß Ê
24
¥√ÿ≥’«—≈¬å «‚√¥¡«‘®‘μ√ ·≈–§≥–
àߺ≈„Àâ°“√ÕÕ°ƒ∑∏‘Ï¢Õ߬“ warfarin ≈¥≈߉¥â‡™àπ°—π
„π∑“ßμ√ß°—π¢â“¡°“√„À⬓ warfarin √à«¡°—∫Õ“À“√∑’Ë¡’
ª√‘¡“≥«‘μ“¡‘πÕ’ Ÿß ®–∑”„Àâ‡æ‘Ë¡§«“¡‡ ’ˬßμàÕ°“√‡°‘¥
‡≈◊Õ¥ÕÕ°¡“°¢÷Èπ
4. ¬“μâ“π®ÿ≈™’æ„π°≈ÿà¡ fluoroquinolones ®“°
°“√»÷°…“Õ—πμ√°‘√‘¬“¢Õ߬“„π°≈ÿà¡ floroquinolones
À≈“¬°“√»÷°…“æ∫«à“¬“ ciprofloxacin, levofloxacin
·≈– ofloxacin “¡“√∂√«¡μ— « °— ∫ Õß§å ª √–°Õ∫„π
Õ“À“√‡À≈«∑’Ë¡’§ÿ≥ ¡∫—쑇ªìπª√–®ÿ∫«° (cation) ‡™àπ
·§≈‡´’¬¡ ·¡°π’‡´’¬¡ ‡À≈Á° ‡ªìπμâπ ‡°‘¥‡ªìπ “√ª√–°Õ∫
‡™‘ß´âÕππÕ°®“°π’Ȭ—ßÕ“®‡°‘¥°“√√«¡μ—«°—∫‚ª√μ’π„π
Ÿμ√Õ“À“√‡À≈« ∑”„À⬓∂Ÿ°¥Ÿ¥´÷¡‡¢â“ Ÿà°√–· ‡≈◊Õ¥πâÕ¬
≈߉¥â Õ¬à“߉√°Áμ“¡æ∫«à“¬“ moxifloxacin ‰¡à‡°‘¥
Õ—πμ√°‘√‘¬“¥—ß°≈à“«¢â“ßμâπ38
5. ¬“ levothyroxine ≈–≈“¬‰¥â π â Õ ¬ ·≈–
“¡“√∂∂Ÿ°¥Ÿ¥´—∫‚¥¬ “¬„ÀâÕ“À“√‰¥â πÕ°®“°π’Èμ—«¬“
¬— ß “¡“√∂√«¡μ— « °— ∫ Õß§å ª √–°Õ∫„πÕ“À“√‡À≈«∑’ Ë ¡ ’
§ÿ ≥ ¡∫— μ ‘ ‡ ªì π ª√–®ÿ ∫ «° (cation) ‡™à π ·§≈‡´’ ¬ ¡
·¡°π’‡´’¬¡ ‡À≈Á° ‡ªìπμâπ ‡°‘¥‡ªìπ “√ª√–°Õ∫‡™‘ß´âÕπ
∑”„À⬓∂Ÿ°¥Ÿ¥´÷¡‡¢â“ Ÿà°√–· ‡≈◊Õ¥πâÕ¬≈߉¥â
6. ¬“ levodopa/carbidopa ´÷Ëß„™â„π°“√√—°…“
‚√§æ“√å°‘π —π (Parkinsonûs disease) ®–∂Ÿ°¥Ÿ¥´÷¡ºà“π
∑“߇¥‘πÕ“À“√≈¥≈ß ‡¡◊ËÕ∫√‘À“√¬“√à«¡°—∫Õ“À“√‡À≈«∑’Ë¡’
‚ª√μ’π Ÿß ‡π◊ËÕß®“°°√¥Õ–¡‘‚π®–√∫°«π°“√¥Ÿ¥´÷¡¢Õß
¬“ àߺ≈„Àâ√–¥—∫¬“„π°√–· ‡≈◊Õ¥¢ÕߺŸâªÉ«¬≈¥μË”≈ß
·≈–°“√√—°…“‰¡à‡°‘¥ª√– ‘∑∏‘º≈39
§”·π–π”∑’Ë 9: °“√ª√–‡¡‘π·≈–°“√μ‘¥μ“¡À≈—ß°“√
„ÀâÕ“À“√‡¢â“∑“߇¥‘πÕ“À“√
§”·π–π”∑’Ë 9.1
§«√ª√–‡¡‘πºŸâªÉ«¬„π‚√ß欓∫“≈∑’ˉ¥â√—∫ EN ‚¥¬
°“√ Õ∫∂“¡Õ“°“√·≈–μ√«®√à“ß°“¬ºŸâªÉ«¬‡ªìπª√–®”
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Thai Clinical Practice Recommendations for Nutritional Management in Adult
Hospitalized Patients 2017 Part 2: Enteral Nutrition (Recommendation 5-10)
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À√◊Õ·πàπ∑âÕß §≈◊Ëπ‰ â Õ“‡®’¬π ∂à“¬‡À≈« ¬—ß√Ÿâ ÷°À‘«À≈—ß
®“°‰¥â√—∫Õ“À“√∑“ß “¬„ÀâÕ“À“√À√◊Õ‰¡à Õ“°“√‡®Á∫„π
‚æ√ß®¡Ÿ ° À√◊ Õ §Õ„π°√≥’ ∑ ’ Ë „ ™â NG tube °“√μ√«®
√à“ß°“¬§«√μ√«® Õ∫μ”·ÀπàߢÕß “¬„ÀâÕ“À“√ ¡’√Õ¬
·º≈À√◊Õ≈—°…≥–∑’Ë∫àß∫Õ°«à“¡’°“√Õ—°‡ ∫®“°°“√°¥∑—∫
¢Õß “¬„ÀâÕ“À“√„π‚æ√ß®¡Ÿ° ™àÕߪ“°·≈–§ÕÀ√◊Õ‰¡à
μ√«®Õ“°“√· ¥ßμà“ß Ê ∑“ßÀπâ“∑âÕß ·≈–°“√μ√«®
√à“ß°“¬Õ◊Ëπ Ê ‡æ◊ËÕª√–‡¡‘π ¡¥ÿ≈ “√πÈ” (volume status)
∑∫∑«π∫—π∑÷°ª√‘¡“≥ “√πÈ”‡¢â“ÕÕ° μ‘¥μ“¡º≈°“√
μ√«®√–¥—∫πÈ”μ“≈„πºŸâªÉ«¬∑’Ë¡’§«“¡‡ ’ˬßμàÕ°“√‡°‘¥
¿“«–πÈ”μ“≈„π‡≈◊Õ¥ Ÿß (hyperglycemia) √«¡∑—Èß√–¥—∫
Õ‘‡≈Á°‚∑√‰≈∑å„π‡≈◊Õ¥„πºŸâªÉ«¬∑’Ë¡’§«“¡‡ ’ˬßμàÕ°“√‡°‘¥
°≈ÿà¡Õ“°“√ refeeding ´÷Ë߇ªìπ¿“«–·∑√°´âÕπ∑’Ëæ∫‰¥â
∫àÕ¬„π‡«™ªØ‘∫—μ‘
§”·π–π”∑’Ë 9.2
§«√μ‘¥μ“¡«à“ºŸªâ «É ¬‰¥â√∫— æ≈—ßß“π‡æ’¬ßæÕÀ√◊Õ‰¡à
§ÿ≥¿“æÀ≈—°∞“π 4 πÈ”Àπ—°§”·π–π” +/-
§”Õ∏‘∫“¬
®“°°“√»÷°…“·∫∫ observational study „πºŸªâ «É ¬
«‘°ƒμ æ∫«à“ºŸâªÉ«¬∑’ˉ¥â√—∫æ≈—ßß“π‰¡à‡æ’¬ßæÕμàÕ§«“¡
μâÕß°“√„π·μà≈–«—π – ¡‰ª‡√◊ÕË ¬ Ê (cumulative energy
deficit) ¡’§«“¡ —¡æ—π∏å°—∫Õ—μ√“°“√‡°‘¥¿“«–μ‘¥‡™◊ÈÕ
·∑√°´âÕπ∑’ˇæ‘Ë¡¢÷Èπ 2 ·æ∑¬åºŸâ¥Ÿ·≈§«√°”À𥧫“¡
μâÕß°“√æ≈—ßß“π·≈– “√Õ“À“√¢ÕߺŸâªÉ«¬·μà≈–√“¬ ·≈–
μ‘¥μ“¡ª√–‡¡‘π«à“ºŸâªÉ«¬‰¥â√—∫Õ“À“√μ“¡ª√‘¡“≥∑’Ë —Ëß
À√◊Õ‰¡à ‡™àπ ¡’°“√ߥ„ÀâÕ“À“√°àÕπ°“√∑”À—μ∂°“√À√◊Õ
°“√ àßμ√«®∑’ˉ¡à¡’§«“¡®”‡ªìπμâÕßߥՓÀ“√À√◊Õ‰¡à ¡’
°“√ߥՓÀ“√‡π◊ËÕß®“°°“√·ª≈º≈ Gastric Residual
Volume (GRV) ∑’ˉ¡à‡À¡“– ¡À√◊Õ‰¡à ´÷Ëß°“√ ◊ËÕ “√∑’Ë¥’
Thai JPEN
Volume 27 No. 2 July - December 2019
Warodomwichit D. et al
√–À«à“ß∫ÿ§≈“°√„π∑’¡∑’Ë„Àâ°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬®–™à«¬
≈¥ªí≠À“°“√À¬ÿ¥„ÀâÕ“À“√∑“ß “¬„ÀâÕ“À“√∑’ˉ¡à®”‡ªìπ
·≈–™à«¬„À⺟âªÉ«¬‰¥â√—∫æ≈—ßß“πμ“¡‡ªÑ“À¡“¬¡“°¢÷Èπ
ºŸâªÉ«¬‰¥â√—∫æ≈—ßß“π®“°Õ“À“√Õ¬à“߇撬ßæÕ §◊Õ ºŸâªÉ«¬
∑’ Ë ‰ ¥â √ — ∫ æ≈— ß ß“πÕ¬à “ ßπâ Õ ¬√â Õ ¬≈– 70-80 ¢Õߧ«“¡
μâ Õ ß°“√æ≈— ß ß“π„π·μà ≈ –«— π ´÷ Ë ß ‡ªì π ®ÿ ¥ μ— ¥ ∑’ Ë À ≈“¬
°“√»÷°…“æ∫«à“™à«¬≈¥Õ—μ√“°“√‡°‘¥¿“«–μ‘¥‡™◊ÕÈ ·∑√°´âÕπ
·≈–¡’·π«‚πâ¡∑’Ë®–≈¥Õ—μ√“쓬‰¥â40-42
§”·π–π”∑’Ë 9.3
§«√¡’°“√®—¥∑”‡°≥±å«‘∏’„π°“√„ÀâÕ“À“√∑“ß “¬
„ÀâÕ“À“√·°àºŸâªÉ«¬ (EN feeding protocol) „π
‚√ß欓∫“≈‡æ◊ÕË „™â„π°“√¥Ÿ·≈ºŸªâ «É ¬∑’μË Õâ ß°“√‚¿™π∫”∫—¥
§ÿ≥¿“æÀ≈—°∞“π 4 πÈ”Àπ—°§”·π–π” +/-
§”Õ∏‘∫“¬
°“√®—¥∑”‡°≥±å«∏‘ „’ π°“√„ÀâÕ“À“√∑“ß “¬„ÀâÕ“À“√
·°àºŸâªÉ«¬‡ªìπ«‘∏’°“√∑’˙૬„Àâ°“√‡√‘Ë¡„Àâ‚¿™π∫”∫—¥‡√Á«¢÷Èπ
ºŸâªÉ«¬‰¥â√—∫Õ“À“√¡“°¢÷Èπ ·≈–„Àâ EN Õ¬à“ߪ≈Õ¥¿—¬43
‚¥¬§«√‡≈◊ Õ °„™â ‡ °≥±å « ‘ ∏ ’ „ π°“√„Àâ Õ “À“√∑“ß “¬„Àâ
Õ“À“√·°àºŸâªÉ«¬∑’ˉ¥â√—∫°“√μ√«® Õ∫§«“¡ ¡‡Àμÿ ¡º≈
·≈â« ‡™àπ ‡°≥±å«∏‘ ’ volume-based feeding À√◊Õ multi-
strategy top-down ¡“„ à„π à«π¢Õß feeding protocol
Volume-based feeding ∑”‰¥â‚¥¬μ—ßÈ ‡ªÑ“À¡“¬ “√
Õ“À“√∑’ Ë ® –„Àâ º Ÿ â ª É « ¬„π·μà ≈ –«— π ·¡â ® –¡’ ° “√À¬ÿ ¥ „Àâ
Õ“À“√™—Ë«§√“«¥â«¬‡Àμÿº≈„¥ Ê “¡“√∂ª√—∫Õ—μ√“°“√„Àâ
Õ“À“√‡æ‘Ë¡¢÷Èπ‰¥â¿“¬À≈—ß ‡æ◊ËÕ„À⺟âªÉ«¬‰¥â√—∫ “√Õ“À“√
§√∫μ“¡‡ªÑ“À¡“¬44
Multi-strategy top-down ‡ªìπ°“√§“¥°“√≥å«à“
ºŸªâ «É ¬ (‚¥¬‡©æ“–„πºŸªâ «É ¬«‘°ƒμ) ¡’§«“¡‡ ¬Ë’ ß„π°“√‡°‘¥
feeding intolerance ¥—ßπ—Èπ®÷ß¡’°“√π”À≈“¬°≈¬ÿ∑∏å
¡“„™â°—∫ºŸâªÉ«¬μ—Èß·μà‡√‘Ë¡μâπ°“√„ÀâÕ“À“√ ‡™àπ °“√‡≈◊Õ°„™â
volume-based feeding ¬°»’√…– Ÿß¢≥–„ÀâÕ“À“√ „™â
chlorhexidine ∑”§«“¡ –Õ“¥™àÕߪ“° „™â¬“°√–μÿâπ
°“√‡§≈◊ËÕπ‰À«¢Õß≈”‰ â (prokinetics) À√◊Õ°“√„™â
postpyloric feeding ‡æ◊ËÕ„À⺟âªÉ«¬ “¡“√∂√—∫Õ“À“√‰¥â
‡¡◊ËÕºŸâªÉ«¬√—∫Õ“À“√‰¥â¥’®÷ߧàÕ¬ Ê ∂Õπ∫“ß°≈¬ÿ∑∏åÕÕ°8
25
§”·π–π”°“√¥Ÿ·≈∑“ß‚¿™π“°“√„πºŸâªÉ«¬ºŸâ„À≠à∑’ËπÕπ‚√ß欓∫“≈ æ.». 2560
μÕπ∑’Ë 2: °“√„ÀâÕ“À“√‡¢â“∑“߇¥‘πÕ“À“√ (§”·π–π”∑’Ë 5-10)
§”·π–π”∑’Ë 9.4
„πºŸªâ «É ¬∑’‰Ë ¥â√∫— EN ∑ÿ°√“¬§«√ª√–‡¡‘π feeding
intolerance ¥â«¬Õ“°“√∑“ߧ≈‘π‘° Õ“®®–„™â Gastric
Residual Volume (GRV) √à«¡„π°“√æ‘®“√≥“
Õ¬à“߉√°Áμ“¡‰¡à§«√„™â§à“¢Õß GRV ‡æ’¬ßÕ¬à“߇¥’¬«
„π°“√«‘π‘®©—¬¿“«– feeding intolerance À√◊ÕÀ¬ÿ¥
°“√„ÀâÕ“À“√ ¢âÕ·π–π”„π°“√·ª≈º≈ GRV ·≈–
°“√¥Ÿ·≈ºŸâªÉ«¬ ¥—ß√Ÿª∑’Ë 3
§ÿ≥¿“æÀ≈—°∞“π 4 πÈ”Àπ—°§”·π–π” +/-
§”Õ∏‘∫“¬
°“√«—¥ GRV ‡ªìπ à«πÀπ÷ËߢÕß°“√¥Ÿ·≈ºŸâªÉ«¬∑’ˉ¥â
√—∫Õ“À“√∑“ß “¬„ÀâÕ“À“√∑’˪ؑ∫—μ‘ ◊∫μàÕ°—π¡“π“π ¡—°
‡¢â“„®«à“°“√∑’˺ŸâªÉ«¬¡’ GRV Ÿß®–∑”„À⺟âªÉ«¬‡ ’ˬßμàÕ
°“√ Ÿ¥ ”≈—°Õ“À“√ àߺ≈„Àâ∫ÿ§≈“°√∑“ß°“√·æ∑¬å≈—߇≈
∑’Ë®–„Àâ EN μàÕ·≈– —ËßÀ¬ÿ¥ EN ‰«â™—Ë«§√“« ·≈–‡ªìπ
“‡Àμÿ„À⺟âªÉ«¬‰¥â√—∫æ≈—ßß“π‰¡à‡æ’¬ßæÕ45 ®“°À≈—°∞“π
°“√»÷°…“„πªí®®ÿ∫—πæ∫«à“¡’ªí®®—¬À≈“¬Õ¬à“ß∑’Ë¡’º≈μàÕ
°“√«—¥ GRV ·≈–‰¡à¡’°“√°”À𥫑∏’¡“μ√∞“π„π°“√«—¥
∑’™Ë ¥— ‡®π ∑”„À⧓à ∑’«Ë ¥— ‰¥â‰¡à¡§’ «“¡πà“‡™◊ÕË ∂◊Õ„π°“√·ª≈º≈
GRV ∑’Ë«—¥‰¥â‰¡à Õ¥§≈âÕß°—∫ª√‘¡“μ√®√‘ߢÕßÕ“À“√„π
°√–‡æ“–Õ“À“√¢≥–π—Èπ ·≈–‰¡à “¡“√∂„™â«‘π‘®©—¬¿“«–
Õ“À“√μ°§â“ß„π°√–‡æ“–Õ“À“√π“πº‘¥ª°μ‘ (delayed
gastric emptying) ‰¥â46 °“√»÷°…“¢Õß Montejo ·≈–
§≥– ∂÷ߺ≈¢Õß®ÿ¥μ—¥ GRV ∑’Ë 200 ·≈– 500 ¡≈.
„π°“√À¬ÿ¥°“√„ÀâÕ“À“√™—Ë«§√“«„πºŸâªÉ«¬«‘°ƒμæ∫«à“
°“√‡°‘¥∑âÕ߇ ’¬ Õ“‡®’¬π ”√Õ° ·≈–°“√ Ÿ¥ ”≈—°‰¡à
·μ°μà“ß°—π∑—Èß Õß°≈ÿà¡ πÕ°®“°π’Ȭ—߉¡àæ∫§«“¡·μ°
μà“ߢÕß°“√‡°‘¥ªÕ¥Õ—°‡ ∫μ‘¥‡™◊ÈÕ (pneumonia) √–¬–
‡«≈“°“√„™â‡§√◊ËÕߙ૬À“¬„® √–¬–‡«≈“°“√πÕπ„πÀÕ
ºŸâªÉ«¬«‘°ƒμ √–¬–‡«≈“°“√πÕπ‚√ß欓∫“≈ À√◊ÕÕ—μ√“
쓬47 Õ¥§≈âÕß°—∫°“√»÷°…“¢Õß McClave ·≈–§≥––
∑’ˉ¡àæ∫§«“¡ —¡æ—π∏å¢Õß GRV °—∫°“√ ”√Õ° À√◊Õ°“√
Ÿ¥ ”≈—° °“√„™â®ÿ¥μ—¥∑’Ë 200 ¡≈. À√◊Õ 400 ¡≈. ‡°‘¥
26
¥√ÿ≥’«—≈¬å «‚√¥¡«‘®‘μ√ ·≈–§≥–
°“√ ”√Õ°À√◊Õ°“√ Ÿ¥ ”≈—°‰¡à·μ°μà“ß°—π45 „π∑“ß°≈—∫
°—π°“√¬°‡≈‘°°“√«—¥ GRV °≈—∫∑”„À⺟âªÉ«¬‰¥â√—∫Õ“À“√
Õ¬à“߇撬ßæÕ¡“°¢÷Èπ °“√»÷°…“¢Õß Pollard ·≈–§≥–
æ∫«à“°“√‰¡à«—¥ GRV ‡∑’¬∫°—∫°“√„™â®ÿ¥μ—¥ GRV ∑’Ë 250
¡≈. ∑”„À⺟âªÉ«¬«‘°ƒμ‰¥â√—∫Õ“À“√¡“°¢÷Èπ ‚¥¬°“√‡°‘¥
°“√Õ“‡®’ ¬ π·≈–°“√‡°‘ ¥ ªÕ¥Õ— ° ‡ ∫„πºŸ â ª É « ¬∑’ Ë ‰ ¥â √ — ∫
‡§√◊ÕË ß™à«¬À“¬„® (Ventilator Associated Pneumonia;
VAP) ‰¡à · μ°μà “ ß°— π 48 ‡™à 𠇥’ ¬ «°— ∫ °“√»÷ ° …“¢Õß
Reignier ·≈–§≥– „™â®ÿ¥μ—¥ GRV 250 ¡≈.‡∑’¬∫°—∫
°“√‰¡à«—¥ GRV ·≈–„™âÕ“°“√∑“ߧ≈‘π‘° ( ”√Õ° Õ“‡®’¬π
∑âÕßÕ◊¥¡“°) ‡ªìπ¢âÕ∫àß™’È„π°“√À¬ÿ¥„ÀâÕ“À“√™—Ë«§√“«
æ∫«à“°≈ÿà¡∑’ˉ¡à«—¥ GRV ‰¥â√—∫Õ“À“√§√∫μ“¡∑’Ë°”Àπ¥
¡“°°«à“°≈ÿà¡∑’Ë«—¥ GRV „π¢≥–∑’Ë√–¬–‡«≈“°“√„™â‡§√◊ËÕß
™à«¬À“¬„® °“√‡°‘¥ VAP °“√μ‘¥‡™◊ÈÕ„πÀÕºŸâªÉ«¬«‘°ƒμ
√–¬–‡«≈“°“√πÕπ„πÀÕºŸâªÉ«¬«‘°ƒμ ·≈–Õ—μ√“쓬‰¡à
·μ°μà“ß°—π49
®“°¢âÕ¡Ÿ≈°“√»÷°…“∑’ˇæ‘Ë¡¡“°¢÷Èπ∑”„À⇫™ªØ‘∫—μ‘„π
ªí®®ÿ∫—π¡’·π«‚πâ¡∑’Ë®–≈¥§«“¡ ”§—≠¢Õß°“√«—¥ GRV
„π°“√¥Ÿ · ≈ºŸ â ª É « ¬∑’ Ë „ Àâ Õ “À“√∑“ß “¬„Àâ Õ “À“√·≈–
„À⧫“¡ ”§—≠„π°“√«‘π‘®©—¬¿“«– feeding intolerance
¥â«¬Õ“°“√·≈–Õ“°“√· ¥ßÕ◊Ëπ·∑π ‡√‘Ë¡¡’°“√·π–π”„Àâ
¬°‡≈‘°°“√«—¥ GRV „πºŸâªÉ«¬∑’Ë„ÀâÕ“À“√∑“ß “¬„Àâ
Õ“À“√„π∫“ߪ√–‡∑»16 ´÷ßË ¡’¢Õâ ¥’§Õ◊ ®–∑”„Àâ°“√ª√—∫‡æ‘¡Ë
ª√‘¡“≥Õ“À“√∑“ß “¬„ÀâÕ“À“√∑’Ë„ÀⷰຟâªÉ«¬‰¥â∂÷ßμ“¡
‡ªÑ“À¡“¬‡√Á«¢÷Èπ Õ¬à“߉√°Áμ“¡¬—߉¡à¡’¢âÕ¡Ÿ≈°“√»÷°…“∂÷ß
º≈¢Õß°“√„™â GRV ∑’Ë®ÿ¥μ—¥μà“ß Ê °—π„π°“√¥Ÿ·≈ºŸâªÉ«¬
„πª√–‡∑»‰∑¬´÷ËßÕ“®®–¡’§«“¡·μ°μà“ß°—∫ºŸâªÉ«¬„πμà“ß
ª√–‡∑» ®÷ß·π–π”„Àâ„™â GRV „πºŸâªÉ«¬∑’Ë¡’§«“¡‡ ’ˬß
μàÕ°“√ Ÿ¥ ”≈—°Õ“À“√·≈–„™â®ÿ¥μ—¥¢Õß§à“ GRV ∑’Ë 200
·≈– 400 ¡‘≈≈‘≈‘μ√„π°“√°√–μÿâπ„Àâ·æ∑¬åºŸâ¥Ÿ·≈μ◊Ëπμ—«
„π°“√ª√–‡¡‘ π ºŸ â ª É « ¬·≈–§â π À“ “‡Àμÿ ¢ Õß feeding
intolerance ·≈–„Àâ°“√¥Ÿ·≈√—°…“Õ¬à“߇À¡“– ¡ ‰¡à
§«√„™â§à“ GRV ‡æ’¬ßÕ¬à“߇¥’¬«„π°“√À¬ÿ¥„ÀâÕ“À“√∑“ß
“¬„ÀâÕ“À“√ ·μ৫√„™âÕ“°“√∑“ߧ≈‘π°‘ √à«¡æ‘®“√≥“¥â«¬
¢â Õ ·π–π”„π°“√·ª≈º≈ GRV ·≈–°“√¥Ÿ · ≈ºŸ â ª É « ¬
¥—ß√Ÿª∑’Ë 3
«“√ “√‚¿™π∫”∫—¥
ªï∑’Ë 27 ©∫—∫∑’Ë 2 °√°Æ“§¡ - ∏—𫓧¡ 2562
Thai Clinical Practice Recommendations for Nutritional Management in Adult
Hospitalized Patients 2017 Part 2: Enteral Nutrition (Recommendation 5-10) Warodomwichit D. et al

§”·π–π”∑’Ë 9.5 §”·π–π”∑’Ë 9.6

ºŸâªÉ«¬∑’ˉ¥â√—∫ EN ∑ÿ°§π§«√‰¥â√—∫°“√ª√–‡¡‘π
§«“¡‡ ’ˬßμàÕ°“√ Ÿ¥ ”≈—°Õ“À“√
§ÿ≥¿“æÀ≈—°∞“π 4 πÈ”Àπ—°§”·π–π” +/-
§”Õ∏‘∫“¬
ªí®®—¬‡ ’ˬßμàÕ°“√ Ÿ¥ ”≈—°Õ“À“√„πºŸâªÉ«¬∑’ˉ¥â√—∫
Õ“À“√∑“ß “¬„ÀâÕ“À“√‰¥â·°à Õ“¬ÿ¡“°°«à“ 70 ªï ¡’√–¥—∫
§«“¡√Ÿâ ÷°μ—«º‘¥ª°μ‘ (altered mental status) „ à∑àÕ
™à«¬À“¬„®À√◊Õ nasoenteric tube ºŸâªÉ«¬∑’ËπÕπÀß“¬
(supine) ‡ªìπ‡«≈“π“π ·≈–ºŸâªÉ«¬∑’ˉ¥â√—∫ EN ¥â«¬«‘∏’
bolus feeding50
ºŸªâ «É ¬∑’¡Ë §’ «“¡‡ ¬Ë’ ß ßŸ „π°“√ ¥Ÿ ”≈—°Õ“À“√ §«√
æ‘®“√≥“°“√¥Ÿ·≈‡æ◊ËÕ≈¥§«“¡‡ ’Ë¬ß ¥—ßπ’È
● ®—¥„À⺪⟠«É ¬πÕπÕ¬Ÿ„à π∑à“¬°»’√…– ߟ 30-45 Õß»“
● „ÀâÕ“À“√∑“ß “¬„ÀâÕ“À“√‚¥¬«‘∏’ continuous
feeding
● „™â “¬„ÀâÕ“À“√≈÷°≈߉ª„π√–¥—∫≈”‰ â‡≈Á°
● „Àâ prokinetic agent
● ∑”§«“¡ –Õ“¥™à Õ ßª“°¥â « ¬πÈ ” ¬“∫â « 𪓰
chlorhexidine
§ÿ≥¿“æÀ≈—°∞“π 4 πÈ”Àπ—°§”·π–π” +/-

› À¬ÿ¥„ÀâÕ“À“√™—È«§√“«
› ‡æ‘Ë¡ prokinetics ∂â“«—¥´È” GRV >400 ¡≈.
æ‘®“√≥“ postpyrolic feeding

√Ÿª∑’Ë 3 ¢âÕ·π–π”„π°“√·ª≈º≈ Gastric Residual Volume (GRV) ·≈–°“√¥Ÿ·≈ºŸâªÉ«¬

Thai JPEN
Volume 27 No. 2 July - December 2019 27
§”·π–π”°“√¥Ÿ·≈∑“ß‚¿™π“°“√„πºŸâªÉ«¬ºŸâ„À≠à∑’ËπÕπ‚√ß欓∫“≈ æ.». 2560
μÕπ∑’Ë 2: °“√„ÀâÕ“À“√‡¢â“∑“߇¥‘πÕ“À“√ (§”·π–π”∑’Ë 5-10)
§”Õ∏‘∫“¬
ºŸâªÉ«¬∑’Ë¡’ªí®®—¬‡ ’ˬßμàÕ°“√ Ÿ¥ ”≈—°§«√‰¥â√—∫°“√
¥Ÿ·≈‡æ◊ËÕ≈¥§«“¡‡ ’ˬ߂¥¬®—¥„À⺟âªÉ«¬πÕπÕ¬Ÿà„π∑à“¬°
»’√…– Ÿß 30-45 Õß»“ À≈’°‡≈’ˬßÀ√◊Õ„™â¬“ sedation „Àâ
πâ Õ ¬∑’ Ë ÿ ¥ ‡ª≈’ Ë ¬ πμ”·Àπà ß ª≈“¬ “¬„Àâ Õ “À“√®“°
°√–‡æ“–Õ“À“√‡ªìπ≈”‰ â‡≈Á° „ÀâÕ“À“√∑“ß “¬„ÀâÕ“À“√
¥â«¬«‘∏’ continuous feeding ´÷Ëß®–∑”„À⺟âªÉ«¬√—∫
Õ“À“√‰¥â¥’¢÷Èπ24 °“√„™â¬“ prokinetic ‰¥â·°à meto-
clopramide ¢π“¥ 10 ¡‘≈≈‘°√—¡ «—π≈– 4 §√—Èß ´÷Ëß
“¡“√∂„™â‰¥â∑—È߬“√Ÿª·∫∫√—∫ª√–∑“π™π‘¥‡¡Á¥·≈–¬“©’¥
16 À√◊Õ erythromycin ¢π“¥ 200-250 ¡‘≈≈‘°√—¡ «—π≈–
2-4 §√—ßÈ 51,52 („πª√–‡∑»‰∑¬¡’‡©æ“–¬“√Ÿª·∫∫√—∫ª√–∑“π
™π‘¥‡¡Á¥·≈–™π‘¥πÈ”) ¡’°“√»÷°…“«à“ “¡“√∂°√–μÿâπ°“√
‡§≈◊ËÕπ‰À«¢Õß°√–‡æ“–Õ“À“√„À⥒¢÷Èπ ™à«¬≈¥ GRV ‰¥â
®“°°“√»÷°…“æ∫«à“ erythromycin ¡’ª√– ‘∑∏‘¿“æ„π
°“√°√–μÿâπ°“√‡§≈◊ËÕπ‰À«¢Õß°√–‡æ“–Õ“À“√‰¥â¥’°«à“
metoclopramide ·≈–°“√„™â¬“∑—Èß Õßμ—«√à«¡°—π®–
„Àâº≈°“√√—°…“∑’Ë¥’¬‘Ëߢ÷Èπ53 º≈¢â“߇§’¬ß¢Õß meto-
clopramide ∑’˧«√√–«—ß ‰¥â·°à tardive dyskinesia
´÷Ëß¡—°æ∫„πºŸâ ŸßÕ“¬ÿ·≈–ºŸâªÉ«¬∑’Ë¡’°“√∑”ß“π‰μº‘¥ª°μ‘
°“√„™â metoclopramide „πºŸâªÉ«¬°≈ÿà¡π’ȧ«√æ‘®“√≥“
ª√—∫≈¥¢π“¥≈ß à«π erythromycin ¡’º≈¢â“߇§’¬ß§◊Õ
‡ªìπæ‘…μàÕÀ—«„® ·≈–Õ“®∑”„À⇰‘¥‡™◊ÕÈ ¥◊ÕÈ ¬“‰¥â º≈¢â“߇§’¬ß
¢Õ߬“∑—ßÈ Õßμ—«∑’æË ∫√à«¡°—π‰¥â·°à ¿“«– prolonged QT
°“√‡°‘¥ VAP æ∫‰¥â∫àÕ¬„πºŸâªÉ«¬«‘°ƒμ àߺ≈„Àâ
√–¬–‡«≈“°“√πÕπ‚√ß欓∫“≈π“π¢÷Èπ §à“„™â®à“¬ Ÿß¢÷Èπ
‡æ‘Ë¡¿“«– ·∑√°´âÕπ·≈–Õ—μ√“쓬 πÕ°®“°π’Ȭ—ßæ∫«à“
ÿ¢¿“æ„π™àÕߪ“°¡’ à«π„π°“√‡°‘¥ VAP °“√∑”§«“¡
–Õ“¥™àÕߪ“°¢ÕߺŸªâ «É ¬¥â«¬πÈ”¬“≈â“ߪ“° chlorhexidine
™à«¬≈¥®”π«π·∫§∑’‡√’¬ ·≈–≈¥°“√‡°‘¥ VAP °“√
»÷°…“·∫∫ meta-analysis º≈°“√»÷°…“ à«π„À≠à
π—∫ πÿπ°“√∑”§«“¡ –Õ“¥™àÕߪ“°¥â«¬ chlorhexidine
“¡“√∂™à«¬≈¥°“√‡°‘¥ VAP54-56 ·μଗ߉¡à¡’¢âÕ √ÿª«à“
§«“¡‡¢â¡¢âπ„¥¥’∑’Ë ÿ¥ °“√«‘‡§√“–Àå°≈ÿ࡬àÕ¬μ“¡§«“¡
‡¢â¡¢âπ·≈–§«“¡∂’Ë¢Õß chlorhexidine æ∫«à“ §«“¡
‡¢â¡¢âπ 2% ·≈–§«“¡∂’¢Ë Õß°“√∑”§«“¡ –Õ“¥ 4 §√—ßÈ μàÕ«—π
≈¥°“√‡°‘¥ VAP Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘μ56‘ Õ¥§≈âÕß
28
¥√ÿ≥’«—≈¬å «‚√¥¡«‘®‘μ√ ·≈–§≥–
°—∫°“√»÷°…“¢Õß Zand ·≈–§≥– ∑’Ë∑”„πºŸâªÉ«¬«‘°ƒμ∑’Ë
„ à∑àՙ૬À“¬„® ‡ª√’¬∫‡∑’¬∫°“√„™â chlorhexidine 0.2%
·≈– 2% ∑”§«“¡ –Õ“¥™àÕߪ“°«—π≈– 2 §√—Èß æ∫«à“„π
°≈ÿà¡∑’ˉ¥â 2% chlorhexidine ‡°‘¥ VAP μË”°«à“Õ¬à“ß¡’
π—¬ ”§—≠∑“ß ∂‘μ57‘
§”·π–π”∑’Ë 10: ¿“«–·∑√°´âÕπ√«¡∑—Èß·π«∑“ß°“√
ªÑÕß°—π·≈–·°â ‰¢
§”·π–π”∑’Ë 10.1
°“√ªÑÕß°—π·≈–·°â‰¢ “¬„ÀâÕ“À“√Õÿ¥μ—π
10.1.1 °“√ªÑÕß°—𠓬„ÀâÕ“À“√Õÿ¥μ—π‚¥¬°“√
≈â“ß “¬„ÀâÕ“À“√¥â«¬πÈ” –Õ“¥Õ¬à“ßπâÕ¬ 30 ¡≈.
∑ÿ°§√—Èß°àÕπ·≈–À≈—ß„ÀâÕ“À“√·≈–/À√◊Õ¬“ À≈—ߥŸ¥
¢Õ߇À≈«ÕÕ°®“°∑“߇¥‘πÕ“À“√ À√◊Õ∑ÿ° 4 ™¡. ¢Õß
°“√„ÀâÕ“À“√·∫∫ continuous feeding
10.1.2 °√≥’∑’Ë “¬„ÀâÕ“À“√Õÿ¥μ—π·≈–‰¡à “¡“√∂
≈â “ ß “¬¥â « ¬πÈ ” –Õ“¥‰¥â Õ“®®–„™â “√≈–≈“¬
‡Õπ‰´¡å®“°μ—∫ÕàÕπ·≈–‚´‡¥’¬¡‰∫§“√å∫Õ‡πμ (‰¡à
·π–π”„Àℙ⠓√≈–≈“¬∑’¡Ë ƒ’ ∑∏‘‡Ï ªìπ°√¥„π°“√≈â“ß “¬)
À√◊Õª√÷°…“·æ∑¬åºŸâ„ à “¬„ÀâÕ“À“√ °àÕπ®–æ‘®“√≥“
‡ª≈’Ë¬π “¬
§ÿ≥¿“æÀ≈—°∞“π 4 πÈ”Àπ—°§”·π–π” +/-
§”Õ∏‘∫“¬
°“√¥Ÿ·≈·≈–≈â“ß “¬ “¬„ÀâÕ“À“√¥â«¬πÈ” –Õ“¥
“¡“√∂ªÑÕß°—π°“√Õÿ¥μ—π‰¥â ‚¥¬§«√≈â“ß “¬°àÕπ·≈–
À≈—ß°“√„ÀâÕ“À“√·≈–/À√◊Õ¬“ ·≈–À≈—ߥŸ¥¢Õ߇À≈«ÕÕ°
®“°∑“߇¥‘πÕ“À“√ ª√‘¡“μ√πÈ” –Õ“¥∑’Ë„™â„π°“√≈â“ß “¬
„π°“√„ÀâÕ“À“√·∫∫ continuous feeding ¡’§«“¡·μ°
μà“ß°—π„π∑“ߪؑ∫—μ‘μ—Èß·μà 20-100 ¡≈. ·≈–·π–π”„Àâ
≈â“ß “¬∑ÿ° 4-8 ™—Ë«‚¡ß„π¢≥–∑’Ë¡’°“√„™âπÈ” –Õ“¥μ—Èß·μà
15-100 ¡≈. ≈â“ß “¬°àÕπ·≈–À≈—ß°“√„ÀâÕ“À“√·∫∫
bolus À√◊Õ intermittent feeding °“√„™âπÈ” –Õ“¥
¡“°¢÷Èπ®–™à«¬≈¥°“√Õÿ¥μ—π¢Õß “¬„ÀâÕ“À“√ Õ¬à“߉√
°Áμ“¡„πºŸâªÉ«¬∑’Ë®”‡ªìπμâÕß®”°—¥πȔՓ®®–μâÕß„™âπÈ”
–Õ“¥ª√‘¡“≥πâÕ¬≈ß„π°“√≈â“ß “¬24 Õ¬à“߉√°Áμ“¡
«“√ “√‚¿™π∫”∫—¥
ªï∑’Ë 27 ©∫—∫∑’Ë 2 °√°Æ“§¡ - ∏—𫓧¡ 2562
Thai Clinical Practice Recommendations for Nutritional Management in Adult
Hospitalized Patients 2017 Part 2: Enteral Nutrition (Recommendation 5-10)
“¬„ÀâÕ“À“√¡’‚Õ°“ ‡°‘¥°“√Õÿ¥μ—π‰¥â¢÷Èπ°—∫ Ÿμ√Õ“À“√
∑’Ë„™â °“√„À⬓∫“ß™π‘¥„π “¬„ÀâÕ“À“√ °“√‰¡à‡¢â“°—π¢Õß
Õ“À“√·≈–¬“ √«¡∂÷ß°“√¥Ÿ·≈∑’ˉ¡à‡À¡“– ¡ ‚¥¬‡©æ“–
“¬„ÀâÕ“À“√¢π“¥‡≈Á°®–‡°‘¥°“√Õÿ¥μ—π‰¥âßà“¬ ¥—ßπ—Èπ‰¡à
§«√„™â “¬Õ“À“√„π°“√„À⬓ ·μà∂â“®”‡ªìπμâÕß„À⬓∑“ß
“¬„ÀâÕ“À“√§«√∑”μ“¡§”·π–π”¢âÕ 8.1 (√Ÿª∑’Ë 2) °“√
„™âπÈ” –Õ“¥≈â“ß “¬„ÀâÕ“À“√‡ªìπ«‘∏’∑’Ë¡’ª√– ‘∑∏‘¿“æ„π
°“√ªÑÕß°—π°“√Õÿ¥μ—π¢Õß “¬„ÀâÕ“À“√
„π°√≥’∑’Ë “¬„ÀâÕ“À“√Õÿ¥μ—π·≈–‰¡à “¡“√∂≈â“ß
“¬¥â«¬πÈ” –Õ“¥ ¡’°“√„™â‡Õπ‰´¡åμ∫— ÕàÕπ viokase (non-
enteric coated pancreatic enzyme ´÷Ëߪ√–°Õ∫¥â«¬
lipase 8,000 IU, amylase 30,000 IU, protease 30,000
IU) 1‡¡Á¥ ∫¥≈–≈“¬πÈ” 5 ¡≈. ·≈–‡μ‘¡ “√≈–≈“¬
‚´‡¥’ ¬ ¡‰Œ¥√Õ°‰´¥å ® π‰¥â “√≈–≈“¬∑’ Ë ¡ ’ æ ’ ‡ Õ™ 7.9
“¡“√∂·°â‰¢°“√Õÿ¥μ—π¢Õß “¬„ÀâÕ“À“√‰¥â ‚¥¬ “√
≈–≈“¬∑’Ë¡’‡Õπ‰´¡å∑’Ë¡’æ’‡Õ™ 7.9 ¡’ª√– ‘∑∏‘¿“æ¡“°°«à“
πÈ”‡ª≈à“∑’˪√—∫æ’‡Õ™®π‰¥â 7.9 ¥—ßπ—Èπª√– ‘∑∏‘¿“æ∑’ˇ°‘¥
¢÷ È π πà “ ®–¡“®“°‡Õπ‰´¡å ¡ “°°«à “ §«“¡‡ªì π ¥à “ ߢÕß
“√≈–≈“¬58 °“√»÷°…“μàÕ¡“„™â viokase 1 ‡¡Á¥ ∫¥
√«¡°—∫°—∫‚´‡¥’¬¡‰∫§“√å∫Õ‡πμ (324 ¡°.) 1 ‡¡Á¥
≈–≈“¬„ππÈ”Õÿàπ 5 ¡≈. ©’¥‡¢â“‰ª„𠓬„ÀâÕ“À“√¢π“¥ 8 Fr
∑’Ë¡’°“√Õÿ¥μ—π “¡“√∂·°â‰¢°“√Õÿ¥μ—π¢Õß “¬‰¥â∂÷ß
√âÕ¬≈– 9659 ‡π◊ËÕß®“° viokase ‰¡à¡’®”Àπà“¬„πª√–‡∑»
‰∑¬ ‡Õπ‰´¡åμ—∫ÕàÕπ∑’Ë¡’¢âÕ¡Ÿ≈°“√»÷°…“„π°“√·°â‰¢
°“√Õÿ¥μ—π¢Õß “¬„ÀâÕ“À“√∑’Ë¡’®”Àπà“¬„πª√–‡∑»‰∑¬
§◊ Õ creon °“√»÷ ° …“¢Õß Stumpf ·≈–§≥– „™â
‚´‡¥’¬¡§“√å∫Õ‡πμ (650 ¡°.) 1 ‡¡Á¥∫¥·≈–≈–≈“¬„π
πÈ” –Õ“¥ 5-10 ¡≈. À≈—ß®“°≈–≈“¬·≈â«·°– creon 12000
®”π«π 1 ·§ª´Ÿ≈´÷Ëß¡’ lipase 12,000 IU protease
38,000 IU ·≈– amylase 60,000 IU ‡∑·°√πŸ≈≈ß„π
“√≈–≈“¬‚´‡¥’¬¡§“√å∫Õ‡πμ ®–‰¥â “√≈–≈“¬ ’πÈ”μ“≈
ÕàÕπ π” “√≈–≈“¬„ „à 𠓬„ÀâÕ“À“√∑’¡Ë °’ “√Õÿ¥μ—π °¥∫’∫
Thai JPEN
Volume 27 No. 2 July - December 2019
Warodomwichit D. et al
(clamp) “¬∑‘È߉«â 5-15 π“∑’ §≈“¬°“√∫’∫ (unclamp)
“¬„ÀâÕ“À“√·≈â«„™âπ”È Õÿπà ¥—π·≈–¥Ÿ¥‡∫“ Ê „𠓬„ÀâÕ“À“√
„π°“√»÷°…“¥—ß°≈à“« à«π„À≠à„™â Creon „π¢π“¥ lipase
12,000 IU ·μà¡’ à«ππâÕ¬∑’Ë¡’°“√„™â lipase 6,000 IU
(√âÕ¬≈– 5) ·≈– lipase 24,000 IU (√âÕ¬≈– 2.5) æ∫«à“
ª√– ‘∑∏‘¿“æ¢Õß°“√·°â‰¢°“√Õÿ¥μ—π¢Õß “¬„ÀâÕ“À“√
‡æ‘Ë¡¢÷Èπμ“¡¢π“¥¢Õß lipase 6,000 IU, 12,000IU ·≈–
24,000 IU “¡“√∂·°â‰¢°“√Õÿ¥μ—π¢Õß “¬„ÀâÕ“À“√‰¥â
√âÕ¬≈– 20, 46 ·≈– 67 μ“¡≈”¥—∫60 ¥—ßπ—ÈπÀ“°®–π”¡“
ª√—∫„™â„πª√–‡∑»‰∑¬°Áπà“®–„™â creon 10000 (lipase
10,000 IU protease 600 IU amylase 8,000 IU)
1-2 ·§ª´Ÿ≈
‰¡à·π–π”„Àℙ⠓√≈–≈“¬∑’Ë¡’ƒ∑∏‘χªìπ°√¥„π°“√
≈â“ß “¬ ‡™àπ πȔ՗¥≈¡ (carbonated drink) πÈ” â¡ “¬™Ÿ
πÈ”¡–π“« À√◊ÕπÈ”º≈‰¡â ‡æ√“– “√≈–≈“¬∑’ˇªìπ°√¥®–‰ª
∑”ªØ‘°√‘ ¬‘ “°—∫‚ª√μ’π„πÕ“À“√Õ“®®–‡°‘¥°“√Õÿ¥μ—π¡“°¢÷πÈ
·≈–Õ“®®–∑”„ÀâÕ“¬ÿ¢Õß “¬„ÀâÕ“À“√ —Èπ≈ß „π°√≥’∑’ˉ¡à
ª√– ∫§«“¡ ”‡√Á®§«√ª√÷°…“·æ∑¬åºŸâ„ à “¬„ÀâÕ“À“√
°àÕπæ‘®“√≥“‡ª≈’Ë¬π “¬
§”·π–π”∑’Ë 10.2
°√≥’ “¬„ÀâÕ“À“√∑“ß√Ÿ‡ªî¥°√–‡æ“–‡≈◊ÕË πÀ≈ÿ¥À≈—ß
„ à “¬¿“¬„π 7-10 «—π·√° §«√π”ºŸâªÉ«¬¡“‚√ß
欓∫“≈∑—π∑’ ‡æ◊ËÕ„ à “¬„À¡à∑’Ëμ”·Àπà߇¥‘¡‚¥¬«‘∏’
°“√ àÕß°≈âÕßÀ√◊Õ‡∑§‚π‚≈¬’√—ß ’ °√≥’ “¬„ÀâÕ“À“√
∑“ß√Ÿ‡ªî¥°√–‡æ“–‡≈◊ËÕπÀ≈ÿ¥À≈—ß„ à “¬√–¬–‡«≈“
Àπ÷Ëß®π°√–∑—Ëß√Ÿ„ à “¬æ—≤π“¢÷Èπ™—¥‡®π (À≈—ß„ à “¬
‡°‘π°«à“ 7-10 «—π) “¡“√∂„ à “¬¢π“¥‡∑à“‡¥‘¡‚¥¬
‡√Á«∑’Ë ÿ¥‡æ◊ËÕªÑÕß°—π√Ÿªî¥ ‚¥¬§«√∂à“¬¿“æ√—ß ’°àÕπ
„ÀâÕ“À“√„π°√≥’ ß —¬«à“μ”·Àπàß “¬Õ¬Ÿà‰¡à∂Ÿ°μâÕß
§ÿ≥¿“æÀ≈—°∞“π 4 πÈ”Àπ—°§”·π–π” +
29
§”·π–π”°“√¥Ÿ·≈∑“ß‚¿™π“°“√„πºŸâªÉ«¬ºŸâ„À≠à∑’ËπÕπ‚√ß欓∫“≈ æ.». 2560
μÕπ∑’Ë 2: °“√„ÀâÕ“À“√‡¢â“∑“߇¥‘πÕ“À“√ (§”·π–π”∑’Ë 5-10)
§”·π–π”∑’Ë 10.3
„π°√≥’∑’Ë¡’§«“¡º‘¥ª°μ‘¢Õß “¬„ÀâÕ“À“√√Ÿ‡ªî¥
°√–‡æ“–§«√ª√–‡¡‘πÀ“ “‡Àμÿ·≈–À“«‘∏’°“√·°â‰¢∑’Ë
‡À¡“– ¡
● À“°æ∫«à“¡’ granulation tissue √Õ∫√Ÿ‡ªî¥ §«√
√—°…“¥â«¬°“√®’È´‘≈‡«Õ√å‰π‡μ√∑
● À“°æ∫°“√μ‘ ¥ ‡™◊ È Õ √Õ∫ Ê √Ÿ ‡ ªî ¥ §«√„Àâ ¬ “
ªØ‘™’«π–·∫∫°‘πÀ√◊Õºà“π∑“ß “¬„ÀâÕ“À“√ (¡—°‰¡à
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Thai Clinical Practice Recommendations for Nutritional Management in Adult
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diet? Curr Opin Clin Nutr Metab
Care. 2013;16(5):588-94.
62. Chittawatanarat K, Pokawinpudisnun
P, Polbhakdee Y. Mixed fibers diet
in surgical ICU septic patients. Asia
Pac J Clin Nutr. 2010;19(4):458-64.
63. Nakao M, Ogura Y, Satake S, Ito I,
Iguchi A, Takagi K, et al. Useful-
ness of soluble dietary fiber for the
treatment of diarrhea during enteral
nutrition in elderly patients. Nutri-
tion. 2002;18(1):35-9.
64. Rushdi TA, Pichard C, Khater YH.
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¥√ÿ≥’«—≈¬å «‚√¥¡«‘®‘μ√ ·≈–§≥–
Control of diarrhea by fiber-enriched
diet in ICU patients on enteral nu-
trition: a prospective randomized
controlled trial. Clin Nutr. 2004;
23(6):1344-52.
65. Spapen H, Diltoer M, Van Malderen
C, Opdenacker G, Suys E,
Huyghens L. Soluble fiber reduces
the incidence of diarrhea in septic
patients receiving total enteral nu-
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randomized, and controlled trial.
Clin Nutr. 2001;20(4):301-5.
66. Yoon SR, Lee JH, Lee JH, Na GY,
Lee KH, Lee YB, et al. Low-
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67. de Brito-Ashurst I, Preiser JC. Diar-
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Enteral Nutr. 2016;40(7):913-23.
«“√ “√‚¿™π∫”∫—¥
Thai Clinical Practice Recommendations for Nutritional Management in Adult
Hospitalized Patients 2017 Part 2: Enteral Nutrition (Recommendation 5-10) Warodomwichit D. et al

¿“§ºπ«°
¿“§ºπ«° 1 ¢âÕ¡Ÿ≈°“√∫√‘À“√¬“ºà“𠓬„ÀâÕ“À“√≈ß Ÿà≈”‰ â‡≈Á° à«πμà“ßÊ
°“√∫√‘À“√¬“ºà“𠓬„ÀâÕ“À“√≈ß Ÿà≈”‰ â‡≈Á°*
√“¬°“√¬“ ‡¡◊ËÕª≈“¬ “¬„ÀâÕ“À“√ ‡¡◊ËÕª≈“¬ “¬„ÀâÕ“À“√
Õ¬Ÿà∫√‘‡«≥¥Ÿ‚Õ¥‘π—¡ Õ¬Ÿà∫√‘‡«≥‡®®Ÿπ—¡
Abacavir ND ND
Acarbose +a +a
Acetaminophen + +
Acetazolamide ND ND
Acetylcysteine ND ND
Acyclovir ND ND
Alendronate ND ND
Allopurinol + ¬“∂Ÿ°¥Ÿ¥´÷¡‰¥â‡æ’¬ß∫“ß à«π
Amlodipine ND ND
Amoxicillin + +
Ascorbic acid + +
Aspirin -b -b
Atenolol ND ND
Azathioprine +c +c
Baclofen ¬“∂Ÿ°¥Ÿ¥´÷¡‰¥â‡æ’¬ß∫“ß à«π ND
Bupropion NDd NDd
Caffeine + +
Calcium + ¬“∂Ÿ°¥Ÿ¥´÷¡‰¥â‡æ’¬ß∫“ß à«π
Carnitine + +
Carvedilol ND ND
Cefdinir ND ND
Chlorothiazide + +
Ciprofloxacin +c +c
Clarithromycin + +
Clindamycin ND ND
Clonazepam ND ND
Cotrimoxazole ND ND
Cyclosporine -e -e
Dapsone + +
Digoxin + -
Docusate +a +a
Enalapril ND ND
Erythromycin + -

Thai JPEN
Volume 27 No. 2 July - December 2019 35
§”·π–π”°“√¥Ÿ·≈∑“ß‚¿™π“°“√„πºŸâªÉ«¬ºŸâ„À≠à∑’ËπÕπ‚√ß欓∫“≈ æ.». 2560
μÕπ∑’Ë 2: °“√„ÀâÕ“À“√‡¢â“∑“߇¥‘πÕ“À“√ (§”·π–π”∑’Ë 5-10) ¥√ÿ≥’«—≈¬å «‚√¥¡«‘®‘μ√ ·≈–§≥–

°“√∫√‘À“√¬“ºà“𠓬„ÀâÕ“À“√≈ß Ÿà≈”‰ â‡≈Á°*

√“¬°“√¬“ ‡¡◊ËÕª≈“¬ “¬„ÀâÕ“À“√ ‡¡◊ËÕª≈“¬ “¬„ÀâÕ“À“√
Õ¬Ÿà∫√‘‡«≥¥Ÿ‚Õ¥‘π—¡ Õ¬Ÿà∫√‘‡«≥‡®®Ÿπ—¡
Escitalopram ND ND
Ferrous sulfate ¬“∂Ÿ°¥Ÿ¥´÷¡‰¥â‡æ’¬ß∫“ß à«πb -b
Fluconazole +c +c
Fluoxetine ND ND
Folic acid + -
Furosemide + +
Gabapentin + ¬“∂Ÿ°¥Ÿ¥´÷¡‰¥â‡æ’¬ß∫“ß à«π
Griseofulvin + -
Guaifenesin ND ND
Hydrochlorothiazide + +
Hydrocortisone ND ND
Hydroxychloroquine ND ND
Isotretinoin -e -e
Lactobacillus spp. +a +a
Lamivudine ND ND
Lamotrigine ND ND
Lansoprazole ND ND
Levetiracetam + +
Levothyroxine + +
Levofloxacin + +
Linezolid ND ND
Loperamide ND ND
Lopinavir/ritonavir + ¬“∂Ÿ°¥Ÿ¥´÷¡‰¥â‡æ’¬ß∫“ß à«π
Lorazepam + ND
Magnesium + +
Medium-chain triglyceride oil + +
Metformin + -
Methadone ND ND
Metoprolol + +
Metronidazole ND ND
Midazolam +f +f
Morphine ND ND
Mycophenolate + -
Olanzapine ND ND
Oseltamivir + +
Oxcarbazepine + +

«“√ “√‚¿™π∫”∫—¥
36 ªï∑’Ë 27 ©∫—∫∑’Ë 2 °√°Æ“§¡ - ∏—𫓧¡ 2562
Thai Clinical Practice Recommendations for Nutritional Management in Adult
Hospitalized Patients 2017 Part 2: Enteral Nutrition (Recommendation 5-10) Warodomwichit D. et al

°“√∫√‘À“√¬“ºà“𠓬„ÀâÕ“À“√≈ß Ÿà≈”‰ â‡≈Á°*

√“¬°“√¬“ ‡¡◊ËÕª≈“¬ “¬„ÀâÕ“À“√ ‡¡◊ËÕª≈“¬ “¬„ÀâÕ“À“√
Õ¬Ÿà∫√‘‡«≥¥Ÿ‚Õ¥‘π—¡ Õ¬Ÿà∫√‘‡«≥‡®®Ÿπ—¡
Phenobarbital + +
Phenytoin +e -e
Phosphate ND ND
Potassium ND ND
Pravastatin +c -
Pregabalin + +
Propranolol + +
Ramipril +f NDf
Rifampicin + +
Risperidone ND ND
Senna +a +a
Sertraline ND ND
Sevelamer -$,a -$,a
Sidenafil + +
Sirolimus + ¬“∂Ÿ°¥Ÿ¥´÷¡‰¥â‡æ’¬ß∫“ß à«π
Spironolactone + +
Sucralfate -a -a
Tacrolimus + +
Theophylline +f +f
Tocopheral + -
Topiramate + +
Ursodiol + +
Valproic acid - -
Voriconazole ND ND
Warfarin + +
Zidovudine ND ND
Zinc NDC NDC
Zonisamide ND ND
a = ‰¡à∂Ÿ°¥Ÿ¥´÷¡‡¢â“ Ÿà°√–· ‡≈◊Õ¥, b = μâÕßÕ“»—¬ ¿“«–°√¥„π°“√¥Ÿ¥´÷¡, c = Õ“®¡’°“√¥Ÿ¥´÷¡‡æ‘Ë¡¢÷Èπ‡¡◊ËÕ∫√‘À“√≈ß Ÿà≈”‰ â‡≈Á°‚¥¬μ√ß,
d = ¢âÕ¡Ÿ≈°“√¥Ÿ¥´÷¡„π≈”‰ â‡≈Á°, e = ∂Ÿ°¥Ÿ¥´—∫‚¥¬ “¬„ÀâÕ“À“√, f = ¢âÕ¡Ÿ≈®“°°“√∑¥≈Õß‚¥¬„™â√–∫∫§Õ¡æ‘«‡μÕ√å (in silico) ¬—߉¡à¡’
°“√μ√«® Õ∫§«“¡∂Ÿ°μâÕ߇∑’¬∫°—∫º≈≈—æ∏凙‘ߧ≈‘π‘°
*„π°√≥’∑’Ë ND À¡“¬∂÷ß ‰¡à∑√“∫μ”·Àπàß∑’Ë·πà™—¥¢Õß≈”‰ â‡≈Á°∑’ˇ°‘¥°“√¥Ÿ¥´÷¡¬“ ∫ÿ§≈“°√∑“ß°“√·æ∑¬å§«√„™â°“√μ—¥ ‘π„®∑“ߧ≈‘π‘°√à«¡
¥â«¬«à“§«√∫√‘À“√¬“‡À≈à“π—Èπºà“𠓬„ÀâÕ“À“√≈ß Ÿà≈”‰ â‡≈Á°‚¥¬μ√ßÀ√◊Õ‰¡à
$¬“ sevelamer √Ÿª·∫∫√—∫ª√–∑“π∑’Ë¡’®”Àπà“¬„πª√–‡∑»‰∑¬ ¡’‡æ’¬ß™π‘¥¬“‡¡Á¥‡§≈◊Õ∫øî≈å¡´÷Ëߧ«√∫√‘À“√‚¥¬°“√°≈◊π ∑—È߇¡Á¥ ‰¡à§«√∫¥
‡§’Ȭ« À√◊Õ ·∫à߇¡Á¥¬“°àÕπ√—∫ª√–∑“π ·μ°μà“ß®“°„πμà“ߪ√–‡∑»´÷Ëß¡’∑—Èß™π‘¥ºß·≈–™π‘¥‡¡Á¥ ¥—ßπ—Èπ ”À√—∫ºŸâªÉ«¬„πª√–‡∑»‰∑¬®÷ߧ«√
À≈’°‡≈’ˬ߰“√∫√‘À“√¬“π’Ⱥà“𠓬„ÀâÕ“À“√ ·≈–§«√„™â¬“Õ¬à“ß√–¡—¥√–«—ß„πºŸâªÉ«¬∑’Ë¡’§«“¡º‘¥ª|241μ‘¢Õß°“√°≈◊π ≈”‰ ⇧≈◊ËÕπ‰À«º‘¥ª°μ‘
À√◊Õ¡’Õ“°“√∑âÕߺŸ°√ÿπ·√ß ‡π◊ËÕß®“°¬“π’ÈÕ“®°àÕ„À⇰‘¥°“√Õÿ¥μ—π¢Õß∑“߇¥‘πÕ“À“√‰¥â

Thai JPEN
Volume 27 No. 2 July - December 2019 37
§”·π–π”°“√¥Ÿ·≈∑“ß‚¿™π“°“√„πºŸâªÉ«¬ºŸâ„À≠à∑’ËπÕπ‚√ß欓∫“≈ æ.». 2560
μÕπ∑’Ë 2: °“√„ÀâÕ“À“√‡¢â“∑“߇¥‘πÕ“À“√ (§”·π–π”∑’Ë 5-10) ¥√ÿ≥’«—≈¬å «‚√¥¡«‘®‘μ√ ·≈–§≥–

¿“§ºπ«° 2 √“¬°“√¬“∑’Ë¡’√ªŸ ·∫∫°“√ª≈¥ª≈àլ摇»…´÷Ëߧ«√√–¡—¥√–«—ß„π°“√À—°·∫àß ∫¥ ‡§’Ȭ« À√◊Õ∑”„À⇡Á¥

¬“·μ° ‡æ◊ËÕ∫√‘À“√¬“∑“ß “¬„ÀâÕ“À“√ (‡√’¬ßμ“¡≈”¥—∫μ—«Õ—°…√¢Õß™◊ËÕ “¡—≠∑“߬“)
∫¥ ‡§’Ȭ« À√◊Õ À—°·∫àߧ√÷Ëß À√◊Õ
™◊ËÕ “¡—≠∑“߬“ ™◊ËÕ°“√§â“* ∑”„À⇡Á¥¬“·μ° ·°–·§ª´Ÿ≈ÕÕ°
Alfuzosin Xatral XL® tablet ✘ ✘
Ambroxol Mucosolvan PL® capsule ✘ ✓
Bezafibrate Bezalip Retard® tablet ✘ ✘
Bupropion Quomem® tablet ✘ ✘
Carbamazepine Tegretol CR® tablet ✘ ✓
Cefaclor Distaclor MR 375® tablet ✘ ✘
Clarithromycin Klacid MR® tablet ✘ ✘
Co-dergocrine Hydergine FAS® ✘ ✘
Diclofenac Voltaren SR® tablet ✘ ✘
Didanosine Videx EC® capsule ✘ ✓
Diethylpropion Dietil Retard® tablet ✘ ✘
Diltiazem Cardil CR® tablet ✘ ✓
Dilatam SR® tablet
Herbesser SR® capsule
Herbesser 90R® capsule
Esomeprazolea Nexium MUPS® tableta ✘ ✘
Felodipine Plendil® tablet ✘ ✘
Fluvastatin Lescol XL® tablet ✘ ✘
Gliclazide Diamicron MR® tablet ✘ ✘
Indapamide Natrilix SR® tablet ✘ ✘
Indomethacin Indocid R® capsule ✘ ✘
Isosorbide mononitrate Imdur® tablet, Ismo® tablet
Monotrate® tablet ✘ ✓
Monolin SR® capsule
Isradipine Dynacirc SRO® capsule ✘ ✓
Itraconazole Sporal® capsule ✘ ✓
Lansoprazolea Prevacid FDT® capsulea ✘ ✘
Lansoprazoleb Prevacid® capsuleb ✘ ✓
Levodopa/Benserazide Madopa HBS® capsule ✘ ✓
Levodopa/Carbidopa Sinemet CR® tablet ✘ ✓
Loratadine/Pseudoephedrine Clarinase Repetab® ✘ ✘
Clarinase 24 Hour® tablet

«“√ “√‚¿™π∫”∫—¥
38 ªï∑’Ë 27 ©∫—∫∑’Ë 2 °√°Æ“§¡ - ∏—𫓧¡ 2562
Thai Clinical Practice Recommendations for Nutritional Management in Adult
Hospitalized Patients 2017 Part 2: Enteral Nutrition (Recommendation 5-10) Warodomwichit D. et al

∫¥ ‡§’Ȭ« À√◊Õ À—°·∫àߧ√÷Ëß À√◊Õ

™◊ËÕ “¡—≠∑“߬“ ™◊ËÕ°“√§â“* ∑”„À⇡Á¥¬“·μ° ·°–·§ª´Ÿ≈ÕÕ°
Morphine MST® tablet ✘ ✘
Morphinec Kapanol® capsulec ✘ ✓
Nicardipine Cardepine® capsule ✘ ✓
Nifedipine Adalat CR® tablet ✘ ✘
Nifedipinec Nelapine SR® tabletc ✘ ✓
Omeprazolea Losec MUPS® tableta ✘ ✘
Omeprazoleb Losec® capsuleb ✘ ✓
Miracid® capsuleb
Orphenadrine Norflex® slow release tablet ✘ ✘
Pantoprazole Controloc® tablet ✘ ✘
Pentoxifylline Trental® tablet ✘ ✘
Flexital® tablet
Phenytoinc Dilantin (100 mg) Kapseal®c ✘ ✓
Piribedil Trivastal Retard 50® tablet ✘ ✘
Potassium chloride Addi-K® tablet ✘ ✘
Rabeprazole Pariet® tablet ✘ ✘
Salbutamol Volmax® tablet ✘ ✘
Sodium valproate Depakine Chrono® tablet ✘ ✓
Theophylline Nuelin SR® tablet ✘ ✓
Tramadol Tramal Retard® tablet ✘ ✘
Trimetazidine Vastarel MR® tablet ✘ ✘
Venlafaxine Efexor XR® capsule ✘ ✓
Verapamil Isoptin SR® tablet ✘ ✘

✓= “¡“√∂ªØ‘∫—쑉¥â; ✘ = Àâ“¡ªØ‘∫—μ‘‚¥¬‡¥Á¥¢“¥; a = ‡μ√’¬¡¬“∑’ËμâÕß°“√∫√‘À“√∑“ß “¬„ÀâÕ“À“√‚¥¬„ à‡¡Á¥¬“≈ß„π°√–∫Õ°„À⬓∑’ËμàÕ°—∫

“¬„ÀâÕ“À“√ ‡μ‘¡πÈ” ‡¢¬à“‡∫“Ê ®π‡¡Á¥¬“≈–≈“¬°≈“¬‡ªìπ‡¡Á¥‡≈Á°Ê °√–®“¬μ—«„ππÈ” ·≈â«®÷ߥ—π¬“≈߉ªμ“¡ “¬„ÀâÕ“À“√∑—π∑’;
b = À“°μâÕß°“√∫√‘À“√„À⺟âªÉ«¬∑’Ë¡’ª≈“¬ “¬„ÀâÕ“À“√Õ¬Ÿà„π°√–‡æ“–Õ“À“√ „Àâ‡μ√’¬¡¬“‚¥¬∂Õ¥·§ª´Ÿ≈ÕÕ° ·≈â«π”·°√πŸ≈¢â“ß„π
(Àâ“¡∫¥·°√πŸ≈) ¡“º ¡πÈ”º≈‰¡â∑’Ë¡’ƒ∑∏‘χªìπ°√¥ ‡™àπ πÈ” â¡ πÈ”·Õª‡ªîô≈ πÈ” —∫ª–√¥ ‡ªìπμâπ ·μàÀ“°ºŸâªÉ«¬¡’ª≈“¬ “¬„ÀâÕ“À“√Õ¬Ÿà„π
≈”‰ â‡≈Á°„À⺠¡¥â«¬ “√≈–≈“¬∑’Ë¡’ƒ∑∏‘χªìπ¥à“ß ‡™àπ “√≈–≈“¬ sodium bicarbonate 8.4%; c = ·°–·§ª´Ÿ≈ ‡∑ºß¬“∑’ËÕ¬Ÿà¿“¬„π≈ß„π
“¬„ÀâÕ“À“√ ·≈â«≈â“ß “¬∑—π∑’¥â«¬πÈ”
*™◊ËÕ°“√§â“∑’Ë√–∫ÿ„πμ“√“߇ªìπ‡æ’¬ß°“√¬°μ—«Õ¬à“߇∑à“π—È𠬓™π‘¥‡¥’¬«°—π∑’Ë¡’™◊ËÕ°“√§â“μà“ß°—πÕ“®¡’√Ÿª·∫∫°“√ª≈¥ª≈àÕ¬¬“∑’Ë·μ°μà“ß°—π
´÷Ëß¡’º≈μàÕ§«“¡ “¡“√∂„π°“√À—°·∫àß ∫¥ ‡§’Ȭ« À√◊Õ∑”„À⇡Á¥¬“·μ° ·≈–°√–∫«π°“√‡μ√’¬¡¬“‡æ◊ËÕ∫√‘À“√∑“ß “¬„ÀâÕ“À“√
À“°‰¡à∑√“∫¢âÕ¡Ÿ≈¢Õß√Ÿª·∫∫°“√ª≈¥ª≈àÕ¬¬“ À√◊ÕμâÕß°“√‡μ√’¬¡¬“‡æ◊ËÕ∫√‘À“√∑“ß “¬„ÀâÕ“À“√ §«√ª√÷°…“‡¿ —™°√

Thai JPEN
Volume 27 No. 2 July - December 2019 39