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คำแนะนำการดูแลทางโภชนาการในผู้ป่วยผู้ใหญ่ที่นอนโรงพยาบาล 2560 ตอนที่ 2 การให้อาหารเข้าทางเดินอาหาร (คำแนะนำที่ 5-10)
คำแนะนำการดูแลทางโภชนาการในผู้ป่วยผู้ใหญ่ที่นอนโรงพยาบาล 2560 ตอนที่ 2 การให้อาหารเข้าทางเดินอาหาร (คำแนะนำที่ 5-10)
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√ ·≈–§≥–
∫∑§—¥¬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∫”∫—¥
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
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) ¥√ÿ≥’«—≈¬å «‚√¥¡«‘®‘μ√ ·≈–§≥–
«“√ “√‚¿™π∫”∫—¥
12 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
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√ ·≈–§≥–
«“√ “√‚¿™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) Warodomwichit D. et al
Thai JPEN
Volume 27 No. 2 July - December 2019 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√ ·≈–§≥–
«“√ “√‚¿™π∫”∫—¥
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) Warodomwichit D. et al
Thai JPEN
Volume 27 No. 2 July - December 2019 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∫”∫—¥
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) Warodomwichit D. et al
§”·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“√ √–¬–‡«≈“·¢«πÕ“À“√∑’ËÕÿ≥À¿Ÿ¡‘ÀâÕß
1. Õ“À“√ªíòπº ¡ (blenderized diet) ‰¡à‡°‘π 2 ™—Ë«‚¡ß (¥Ÿ§”Õ∏‘∫“¬‡æ‘Ë¡‡μ‘¡)
2. Õ“À“√ ”‡√Á®√Ÿª∑’ËμâÕ߇μ√’¬¡„À¡à°àÕπ𔉪„À⺟âªÉ«¬ ‰¡à‡°‘π 4 ™—Ë«‚¡ß
(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«¬ ‰¡à‡°‘π 8 ™—Ë«‚¡ß
(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∑’ “¡“√∂„À≥â 24-48 ™—Ë«‚¡ß
(closed-system EN formulas) ¢÷ÈπÕ¬Ÿà°—∫§”·π–π”¢ÕߺŸâº≈‘μ
§ÿ≥¿“æÀ≈—°∞“π 4 πÈ”Àπ—°§”·π–π” +
Thai JPEN
Volume 27 No. 2 July - December 2019 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) ¥√ÿ≥’«—≈¬å «‚√¥¡«‘®‘μ√ ·≈–§≥–
Thai JPEN
Volume 27 No. 2 July - December 2019 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) ¥√ÿ≥’«—≈¬å «‚√¥¡«‘®‘μ√ ·≈–§≥–
¢âÕ¡Ÿ≈¬“∑’ËÀâ“¡À—°·∫àß ∫¥ ‡§’Ȭ« À√◊Õ∑”„À⇡Á¥¬“·μ° ºŸªâ «É ¬ ߟ Õ“¬ÿ ºŸªâ «É ¬∑’¡Ë ‚’ √§√à«¡®”π«π¡“° ºŸªâ «É ¬«‘°ƒμ
·≈–·π«∑“ß°“√∫√‘À“√¬“ºà“𠓬„ÀâÕ“À“√≈ß Ÿà≈”‰ â‡≈Á° ·≈–ºŸâªÉ«¬∑’ˉ¥â√—∫ continuous feeding
à«πμà“ß Ê ‰¥â√«∫√«¡‰«â„π¿“§ºπ«° 1 ·≈– 2 μ“¡ 8.2.2 ‰¡à§«√º ¡¬“·≈–Õ“À“√„¥ Ê ‡¢â“¥â«¬°—π
≈”¥—∫30-32 À“°‰¡à¡’¢âÕ¡Ÿ≈À√◊ÕÀ≈—°∞“π∑“ß«‘™“°“√∑’ˬ◊π¬—𧫓¡
‡¢â“°—π‰¥â¢Õß “√∑—Èß Õß™π‘¥
§”·π–π”∑’Ë 8.2 8.2.3 §«√À≈’°‡≈’ˬ߰“√∫√‘À“√Õ“À“√√à«¡°—∫¬“∑’Ë
Õ—πμ√°‘√¬‘ “√–À«à“߬“·≈–Õ“À“√ (Drug-Nutrient ¡’¢âÕ¡Ÿ≈™—¥‡®π„π°“√°àÕ„À⇰‘¥ DNI À“°¡’§«“¡
Interaction; DNI) „πºŸâªÉ«¬∑’ˉ¥â√—∫Õ“À“√ ·≈–¬“ ®”‡ªìπ„π°“√„™â¬“¥—ß°≈à“« §«√¡’°“√®—¥°“√ªí≠À“
‡¢â“∑“߇¥‘πÕ“À“√√à«¡°—π Õ¬à“߇À¡“– ¡μ“¡°≈‰°°“√‡°‘¥ DNI ‡™àπ °“√ª√—∫
8.2.1 §«√¡’°“√μ√«® Õ∫¢âÕ¡Ÿ≈‡°’ˬ«°—∫°“√‡°‘¥ ¢π“¥¬“„Àâ‡À¡“– ¡ À√◊Õ°“√ª√—∫‡«≈“„π°“√∫√‘À“√
DNI ∑ÿ°§√—Èß°àÕπ°“√∫√‘À“√¬“„π√Ÿª·∫∫√—∫ª√–∑“𠬓·≈–Õ“À“√ ‡ªìπμâπ À“°‰¡à∑√“∫¢âÕ¡Ÿ≈°“√‡°‘¥ DNI
„ÀⷰຟâªÉ«¬∑ÿ°√“¬∑’ˉ¥â√—∫ EN ‚¥¬‡©æ“–Õ¬à“߬‘Ëß„π §«√ª√÷°…“‡¿ —™°√
°≈ÿࡺŸâªÉ«¬∑’Ë¡’§«“¡‡ ’ˬ߄π°“√‡°‘¥ DNI ‰¥â·°à §ÿ≥¿“æÀ≈—°∞“π 4 πÈ”Àπ—°§”·π–π” +
㪈
‰¡à
㪈
‰¡à
‰¡à
㪈
„™à ‰¡à
«“√ “√‚¿™π∫”∫—¥
22 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
Thai JPEN
Volume 27 No. 2 July - December 2019 23
§”·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√ ·≈–§≥–
°“√ªÑ Õ ß°— π ·≈–·°â ‰ ¢ªí ≠ À“®“°Õ— π μ√°‘ √ ‘ ¬ “™π‘ ¥ π’ È àߺ≈„Àâ°“√ÕÕ°ƒ∑∏‘Ï¢Õ߬“ warfarin ≈¥≈߉¥â‡™àπ°—π
“¡“√∂∑”‰¥â‚¥¬°“√ª√—∫¢π“¥¬“„Àâ‡À¡“– ¡ ‡æ◊ËÕ„À≥⠄π∑“ßμ√ß°—π¢â“¡°“√„À⬓ warfarin √à«¡°—∫Õ“À“√∑’Ë¡’
º≈°“√√— ° …“∑’ Ë ¥ ’ ∑ ’ Ë ÿ ¥ ·≈–≈¥°“√‡°‘ ¥ Õ“°“√‰¡à æ ÷ ß ª√‘¡“≥«‘μ“¡‘πÕ’ Ÿß ®–∑”„Àâ‡æ‘Ë¡§«“¡‡ ’ˬßμàÕ°“√‡°‘¥
ª√– ߧ宓°¬“ ‡≈◊Õ¥ÕÕ°¡“°¢÷Èπ
4) Type IV: elimination phase-associated 4. ¬“μâ“π®ÿ≈™’æ„π°≈ÿà¡ fluoroquinolones ®“°
interactions ‡°’¬Ë «¢âÕß°—∫§«“¡º‘¥ª°μ‘¢Õß°√–∫«π°“√ °“√»÷°…“Õ—πμ√°‘√‘¬“¢Õ߬“„π°≈ÿà¡ floroquinolones
°”®—¥ “√ÕÕ°®“°√à“ß°“¬∑“߉μ À√◊Õ∑“ßμ—∫·≈–√–∫∫ À≈“¬°“√»÷°…“æ∫«à“¬“ ciprofloxacin, levofloxacin
∑“߇¥‘ππÈ”¥’ ´÷ËßÕ—πμ√°‘√‘¬“∫“ß™π‘¥Õ“®‡°‘¥®“°°“√∑’ˬ“ ·≈– ofloxacin “¡“√∂√«¡μ— « °— ∫ Õß§å ª √–°Õ∫„π
À√◊ Õ Õ“À“√¡’ ° “√·¢à ß ¢— π °— π ®— ∫ °— ∫ tissue-specific Õ“À“√‡À≈«∑’Ë¡’§ÿ≥ ¡∫—쑇ªìπª√–®ÿ∫«° (cation) ‡™àπ
transport protein „π°√–∫«π°“√°”®—¥ÕÕ°®“°√à“ß°“¬ ·§≈‡´’¬¡ ·¡°π’‡´’¬¡ ‡À≈Á° ‡ªìπμâπ ‡°‘¥‡ªìπ “√ª√–°Õ∫
‡™àπ °“√®”°—¥Õ“À“√∑’Ë¡’‚´‡¥’¬¡∑”„Àâ√–¥—∫‚´‡¥’¬¡„𠇙‘ß´âÕππÕ°®“°π’Ȭ—ßÕ“®‡°‘¥°“√√«¡μ—«°—∫‚ª√μ’π„π
‡≈◊Õ¥≈¥≈ß ´÷Ëß “¡“√∂°√–μÿâπ„À⇰‘¥°“√¥Ÿ¥°≈—∫¢Õ߬“ Ÿμ√Õ“À“√‡À≈« ∑”„À⬓∂Ÿ°¥Ÿ¥´÷¡‡¢â“ Ÿà°√–· ‡≈◊Õ¥πâÕ¬
lithium ∑“ßμàÕÀπ૬‰μ (renal tubular reabsorption) ≈߉¥â Õ¬à“߉√°Áμ“¡æ∫«à“¬“ moxifloxacin ‰¡à‡°‘¥
‰¥â‡æ‘Ë¡¡“°¢÷Èπ Õ—πμ√°‘√‘¬“¥—ß°≈à“«¢â“ßμâπ38
∑—Èßπ’ȺŸâªÉ«¬∑’ˉ¥â√—∫Õ“À“√·≈–¬“∑“ß “¬„ÀâÕ“À“√¡’ 5. ¬“ levothyroxine ≈–≈“¬‰¥â π â Õ ¬ ·≈–
·π«‚πâ¡„π°“√‡°‘¥Õ—πμ√°‘√¬‘ “√–À«à“߬“·≈–Õ“À“√™π‘¥∑’Ë “¡“√∂∂Ÿ°¥Ÿ¥´—∫‚¥¬ “¬„ÀâÕ“À“√‰¥â πÕ°®“°π’Èμ—«¬“
I ·≈– II ‰¥â¡“°∑’Ë ÿ¥ ¬— ß “¡“√∂√«¡μ— « °— ∫ Õß§å ª √–°Õ∫„πÕ“À“√‡À≈«∑’ Ë ¡ ’
§ÿ ≥ ¡∫— μ ‘ ‡ ªì π ª√–®ÿ ∫ «° (cation) ‡™à π ·§≈‡´’ ¬ ¡
Õ— π μ√°‘ √ ‘ ¬ “√–À«à “ ߬“·≈–Õ“À“√∑’ Ë ”§— ≠ „π°“√ ·¡°π’‡´’¬¡ ‡À≈Á° ‡ªìπμâπ ‡°‘¥‡ªìπ “√ª√–°Õ∫‡™‘ß´âÕπ
∫√‘À“√¬“ºà“𠓬„ÀâÕ“À“√26-28,35-37 ∑”„À⬓∂Ÿ°¥Ÿ¥´÷¡‡¢â“ Ÿà°√–· ‡≈◊Õ¥πâÕ¬≈߉¥â
1. ¬“ phenytoin “¡“√∂∂Ÿ°¥Ÿ¥´—∫‚¥¬ “¬„Àâ 6. ¬“ levodopa/carbidopa ´÷Ëß„™â„π°“√√—°…“
Õ“À“√ πÕ°®“°π’Èμ—«¬“ phenytoin ¬—ß√«¡μ—«°—∫‚ª√μ’π ‚√§æ“√å°‘π —π (Parkinsonûs disease) ®–∂Ÿ°¥Ÿ¥´÷¡ºà“π
·≈–‡°≈◊Õ·§≈‡´’¬¡„π Ÿμ√Õ“À“√ ‡°‘¥‡ªìπ “√ª√–°Õ∫ ∑“߇¥‘πÕ“À“√≈¥≈ß ‡¡◊ËÕ∫√‘À“√¬“√à«¡°—∫Õ“À“√‡À≈«∑’Ë¡’
‡™‘ß´âÕπ∑”„À⬓∂Ÿ°¥Ÿ¥´÷¡‡¢â“ °àŸ √–· ‡≈◊Õ¥πâÕ¬≈ß „πºŸªâ «É ¬ ‚ª√μ’π Ÿß ‡π◊ËÕß®“°°√¥Õ–¡‘‚π®–√∫°«π°“√¥Ÿ¥´÷¡¢Õß
∑’ Ë ® ”‡ªì π μâ Õ ß‰¥â √ — ∫ ¬“π’ È º à “ 𠓬„Àâ Õ “À“√ §«√¡’ ° “√ ¬“ àߺ≈„Àâ√–¥—∫¬“„π°√–· ‡≈◊Õ¥¢ÕߺŸâªÉ«¬≈¥μË”≈ß
μ‘¥μ“¡«—¥√–¥—∫¬“„π‡≈◊Õ¥Õ¬à“ß„°≈♑¥ ‡æ◊ËÕª√—∫¢π“¥ ·≈–°“√√—°…“‰¡à‡°‘¥ª√– ‘∑∏‘º≈39
¬“„Àâ‡À¡“– ¡
2. ¬“ carbamazepine “¡“√∂∂Ÿ°¥Ÿ¥´—∫‚¥¬
“¬„ÀâÕ“À“√‰¥â §”·π–π”∑’Ë 9: °“√ª√–‡¡‘π·≈–°“√μ‘¥μ“¡À≈—ß°“√
3. ¬“ warfarin “¡“√∂®—∫°—∫‚ª√μ’π·Õ≈∫Ÿ¡‘π „ÀâÕ“À“√‡¢â“∑“߇¥‘πÕ“À“√
„π‡≈◊Õ¥‰¥â¡“°∂÷ß√âÕ¬≈– 99 ¥—ßπ—È𠬓 warfarin ®÷ßÕ“® §”·π–π”∑’Ë 9.1
®—∫√«¡μ—«°—∫‚ª√μ’π„π Ÿμ√Õ“À“√‡À≈«∑’Ë∫√‘À“√∑“ß “¬ §«√ª√–‡¡‘πºŸâªÉ«¬„π‚√ß欓∫“≈∑’ˉ¥â√—∫ EN ‚¥¬
„ÀâÕ“À“√ ∑”„À⬓∂Ÿ°¥Ÿ¥´÷¡‡¢â“ Ÿà°√–· ‡≈◊Õ¥πâÕ¬≈ß °“√ Õ∫∂“¡Õ“°“√·≈–μ√«®√à“ß°“¬ºŸâªÉ«¬‡ªìπª√–®”
·≈– ßà º≈≈¥ƒ∑∏‘¢Ï Õ߬“ warfarin „π°“√μâ“π°“√·¢Áßμ—«
¢Õ߇≈◊Õ¥‰¥â πÕ°®“°π’È°“√„À⬓ warfarin √à«¡°—∫ §ÿ≥¿“æÀ≈—°∞“π 4 πÈ”Àπ—°§”·π–π” +/-
Õ“À“√∑’Ë¡’ª√‘¡“≥«‘μ“¡‘π‡§ Ÿß ‡™àπ º—°„∫‡¢’¬«™π‘¥μà“ß Ê
«“√ “√‚¿™π∫”∫—¥
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§”Õ∏‘∫“¬ √–À«à“ß∫ÿ§≈“°√„π∑’¡∑’Ë„Àâ°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬®–™à«¬
§«√´—°∂“¡Õ“°“√·≈–μ√«®√à“ß°“¬ºŸâªÉ«¬∑’ˉ¥â√—∫ ≈¥ªí≠À“°“√À¬ÿ¥„ÀâÕ“À“√∑“ß “¬„ÀâÕ“À“√∑’ˉ¡à®”‡ªìπ
Õ“À“√∑“ß “¬„ÀâÕ“À“√‡ªìπª√–®” ‡æ◊ËÕª√–‡¡‘π«à“ºŸâªÉ«¬ ·≈–™à«¬„À⺟âªÉ«¬‰¥â√—∫æ≈—ßß“πμ“¡‡ªÑ“À¡“¬¡“°¢÷Èπ
“¡“√∂√—∫Õ“À“√‰¥â§√∫μ“¡∑’Ë°”Àπ¥À√◊Õ‰¡à ·≈–¡’ ºŸâªÉ«¬‰¥â√—∫æ≈—ßß“π®“°Õ“À“√Õ¬à“߇撬ßæÕ §◊Õ ºŸâªÉ«¬
¿“«–·∑√°´âÕπ®“°°“√„ÀâÕ“À“√∑“ß “¬„ÀâÕ“À“√À√◊Õ‰¡à ∑’ Ë ‰ ¥â √ — ∫ æ≈— ß ß“πÕ¬à “ ßπâ Õ ¬√â Õ ¬≈– 70-80 ¢Õߧ«“¡
Õ“°“√∑’˧«√ Õ∫∂“¡®“°ºŸâªÉ«¬ ‰¥â·°à ¡’Õ“°“√ª«¥∑âÕß μâ Õ ß°“√æ≈— ß ß“π„π·μà ≈ –«— π ´÷ Ë ß ‡ªì π ®ÿ ¥ μ— ¥ ∑’ Ë À ≈“¬
À√◊Õ·πàπ∑âÕß §≈◊Ëπ‰ â Õ“‡®’¬π ∂à“¬‡À≈« ¬—ß√Ÿâ ÷°À‘«À≈—ß °“√»÷°…“æ∫«à“™à«¬≈¥Õ—μ√“°“√‡°‘¥¿“«–μ‘¥‡™◊ÕÈ ·∑√°´âÕπ
®“°‰¥â√—∫Õ“À“√∑“ß “¬„ÀâÕ“À“√À√◊Õ‰¡à Õ“°“√‡®Á∫„π ·≈–¡’·π«‚πâ¡∑’Ë®–≈¥Õ—μ√“쓬‰¥â40-42
‚æ√ß®¡Ÿ ° À√◊ Õ §Õ„π°√≥’ ∑ ’ Ë „ ™â NG tube °“√μ√«®
√à“ß°“¬§«√μ√«® Õ∫μ”·ÀπàߢÕß “¬„ÀâÕ“À“√ ¡’√Õ¬ §”·π–π”∑’Ë 9.3
·º≈À√◊Õ≈—°…≥–∑’Ë∫àß∫Õ°«à“¡’°“√Õ—°‡ ∫®“°°“√°¥∑—∫ §«√¡’°“√®—¥∑”‡°≥±å«‘∏’„π°“√„ÀâÕ“À“√∑“ß “¬
¢Õß “¬„ÀâÕ“À“√„π‚æ√ß®¡Ÿ° ™àÕߪ“°·≈–§ÕÀ√◊Õ‰¡à „ÀâÕ“À“√·°àºŸâªÉ«¬ (EN feeding protocol) „π
μ√«®Õ“°“√· ¥ßμà“ß Ê ∑“ßÀπâ“∑âÕß ·≈–°“√μ√«® ‚√ß欓∫“≈‡æ◊ÕË „™â„π°“√¥Ÿ·≈ºŸªâ «É ¬∑’μË Õâ ß°“√‚¿™π∫”∫—¥
√à“ß°“¬Õ◊Ëπ Ê ‡æ◊ËÕª√–‡¡‘π ¡¥ÿ≈ “√πÈ” (volume status) §ÿ≥¿“æÀ≈—°∞“π 4 πÈ”Àπ—°§”·π–π” +/-
∑∫∑«π∫—π∑÷°ª√‘¡“≥ “√πÈ”‡¢â“ÕÕ° μ‘¥μ“¡º≈°“√
μ√«®√–¥—∫πÈ”μ“≈„πºŸâªÉ«¬∑’Ë¡’§«“¡‡ ’ˬßμàÕ°“√‡°‘¥ §”Õ∏‘∫“¬
¿“«–πÈ”μ“≈„π‡≈◊Õ¥ Ÿß (hyperglycemia) √«¡∑—Èß√–¥—∫ °“√®—¥∑”‡°≥±å«∏‘ „’ π°“√„ÀâÕ“À“√∑“ß “¬„ÀâÕ“À“√
Õ‘‡≈Á°‚∑√‰≈∑å„π‡≈◊Õ¥„πºŸâªÉ«¬∑’Ë¡’§«“¡‡ ’ˬßμàÕ°“√‡°‘¥ ·°àºŸâªÉ«¬‡ªìπ«‘∏’°“√∑’˙૬„Àâ°“√‡√‘Ë¡„Àâ‚¿™π∫”∫—¥‡√Á«¢÷Èπ
°≈ÿà¡Õ“°“√ refeeding ´÷Ë߇ªìπ¿“«–·∑√°´âÕπ∑’Ëæ∫‰¥â ºŸâªÉ«¬‰¥â√—∫Õ“À“√¡“°¢÷Èπ ·≈–„Àâ EN Õ¬à“ߪ≈Õ¥¿—¬43
∫àÕ¬„π‡«™ªØ‘∫—μ‘ ‚¥¬§«√‡≈◊ Õ °„™â ‡ °≥±å « ‘ ∏ ’ „ π°“√„Àâ Õ “À“√∑“ß “¬„Àâ
Õ“À“√·°àºŸâªÉ«¬∑’ˉ¥â√—∫°“√μ√«® Õ∫§«“¡ ¡‡Àμÿ ¡º≈
§”·π–π”∑’Ë 9.2 ·≈â« ‡™àπ ‡°≥±å«∏‘ ’ volume-based feeding À√◊Õ multi-
§«√μ‘¥μ“¡«à“ºŸªâ «É ¬‰¥â√∫— æ≈—ßß“π‡æ’¬ßæÕÀ√◊Õ‰¡à strategy top-down ¡“„ à„π à«π¢Õß feeding protocol
§ÿ≥¿“æÀ≈—°∞“π 4 πÈ”Àπ—°§”·π–π” +/- 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∏‘∫“¬ Õ“À“√™—Ë«§√“«¥â«¬‡Àμÿº≈„¥ Ê “¡“√∂ª√—∫Õ—μ√“°“√„Àâ
®“°°“√»÷°…“·∫∫ observational study „πºŸªâ «É ¬ Õ“À“√‡æ‘Ë¡¢÷Èπ‰¥â¿“¬À≈—ß ‡æ◊ËÕ„À⺟âªÉ«¬‰¥â√—∫ “√Õ“À“√
«‘°ƒμ æ∫«à“ºŸâªÉ«¬∑’ˉ¥â√—∫æ≈—ßß“π‰¡à‡æ’¬ßæÕμàÕ§«“¡ §√∫μ“¡‡ªÑ“À¡“¬44
μâÕß°“√„π·μà≈–«—π – ¡‰ª‡√◊ÕË ¬ Ê (cumulative energy Multi-strategy top-down ‡ªìπ°“√§“¥°“√≥å«à“
deficit) ¡’§«“¡ —¡æ—π∏å°—∫Õ—μ√“°“√‡°‘¥¿“«–μ‘¥‡™◊ÈÕ ºŸªâ «É ¬ (‚¥¬‡©æ“–„πºŸªâ «É ¬«‘°ƒμ) ¡’§«“¡‡ ¬Ë’ ß„π°“√‡°‘¥
·∑√°´âÕπ∑’ˇæ‘Ë¡¢÷Èπ 2 ·æ∑¬åºŸâ¥Ÿ·≈§«√°”À𥧫“¡ feeding intolerance ¥—ßπ—Èπ®÷ß¡’°“√π”À≈“¬°≈¬ÿ∑∏å
μâÕß°“√æ≈—ßß“π·≈– “√Õ“À“√¢ÕߺŸâªÉ«¬·μà≈–√“¬ ·≈– ¡“„™â°—∫ºŸâªÉ«¬μ—Èß·μà‡√‘Ë¡μâπ°“√„ÀâÕ“À“√ ‡™àπ °“√‡≈◊Õ°„™â
μ‘¥μ“¡ª√–‡¡‘π«à“ºŸâªÉ«¬‰¥â√—∫Õ“À“√μ“¡ª√‘¡“≥∑’Ë —Ëß volume-based feeding ¬°»’√…– Ÿß¢≥–„ÀâÕ“À“√ „™â
À√◊Õ‰¡à ‡™àπ ¡’°“√ߥ„ÀâÕ“À“√°àÕπ°“√∑”À—μ∂°“√À√◊Õ chlorhexidine ∑”§«“¡ –Õ“¥™àÕߪ“° „™â¬“°√–μÿâπ
°“√ àßμ√«®∑’ˉ¡à¡’§«“¡®”‡ªìπμâÕßߥՓÀ“√À√◊Õ‰¡à ¡’ °“√‡§≈◊ËÕπ‰À«¢Õß≈”‰ â (prokinetics) À√◊Õ°“√„™â
°“√ߥՓÀ“√‡π◊ËÕß®“°°“√·ª≈º≈ Gastric Residual postpyloric feeding ‡æ◊ËÕ„À⺟âªÉ«¬ “¡“√∂√—∫Õ“À“√‰¥â
Volume (GRV) ∑’ˉ¡à‡À¡“– ¡À√◊Õ‰¡à ´÷Ëß°“√ ◊ËÕ “√∑’Ë¥’ ‡¡◊ËÕºŸâªÉ«¬√—∫Õ“À“√‰¥â¥’®÷ߧàÕ¬ Ê ∂Õπ∫“ß°≈¬ÿ∑∏åÕÕ°8
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§”·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∫”∫—¥
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› À¬ÿ¥„ÀâÕ“À“√™—È«§√“«
› ‡æ‘Ë¡ prokinetics ∂â“«—¥´È” GRV >400 ¡≈.
æ‘®“√≥“ postpyrolic feeding
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§”·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∫”∫—¥
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§”·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∫”∫—¥
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‡Õ° “√Õâ“ßÕ‘ß
1. Faisy C, Lerolle N, Dachraoui F, nutritional intake and clinical out- 6. Lewis SJ, Andersen HK, Thomas S.
Savard JF, Abboud I, Tadie JM, et comes in critically ill patients: re- Early enteral nutrition within 24 h
al. Impact of energy deficit calcu- sults of an international multicenter of intestinal surgery versus later
lated by a predictive method on out- observational study. Intensive Care commencement of feeding: a sys-
come in medical patients requiring Med. 2009;35(10):1728-37. tematic review and meta-analysis.
prolonged acute mechanical venti- 4. Doig GS, Heighes PT, Simpson F, J Gastrointest Surg. 2009;13(3):569-
lation. Br J Nutr. 2009;101(7):1079- Sweetman EA, Davies AR. Early 75.
87. enteral nutrition, provided within 24 7. McClave SA, Chang WK, Dhaliwal
2. Villet S, Chiolero RL, Bollmann MD, h of injury or intensive care unit R, Heyland DK. Nutrition support
Revelly J-P, Cayeux Rn M-C, admission, significantly reduces in acute pancreatitis: a systematic
Delarue J, et al. Negative impact of mortality in critically ill patients: a review of the literature. JPEN J
hypocaloric feeding and energy bal- meta-analysis of randomised con- Parenter Enteral Nutr.
ance on clinical outcome in ICU trolled trials. Intensive Care Med. 2006;30(2):143-56.
patients. Clinical Nutrition. 2005; 2009;35(12):2018-27. 8. McClave SA, DiBaise JK, Mullin GE,
24(4):502-9. 5. Marik PE, Zaloga GP. Early enteral Martindale RG. ACG Clinical Guide-
3. Alberda C, Gramlich L, Jones N, nutrition in acutely ill patients: a line: Nutrition therapy in the adult
Jeejeebhoy K, Day AG, Dhaliwal R, systematic review. Crit Care Med. hospitalized patient. Am J
et al. The relationship between 2001;29:2264 - 70. Gastroenterol. 2016;111(3):315-34;
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§”·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√ ·≈–§≥–
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§”·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√ ·≈–§≥–
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¿“§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 + -
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Volume 27 No. 2 July - December 2019 35
§”·π–π”°“√¥Ÿ·≈∑“ß‚¿™π“°“√„πºŸâªÉ«¬ºŸâ„À≠à∑’ËπÕπ‚√ß欓∫“≈ æ.». 2560
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Thai Clinical Practice Recommendations for Nutritional Management in Adult
Hospitalized Patients 2017 Part 2: Enteral Nutrition (Recommendation 5-10) Warodomwichit D. et al
Thai JPEN
Volume 27 No. 2 July - December 2019 37
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Thai Clinical Practice Recommendations for Nutritional Management in Adult
Hospitalized Patients 2017 Part 2: Enteral Nutrition (Recommendation 5-10) Warodomwichit D. et al
Thai JPEN
Volume 27 No. 2 July - December 2019 39