4 Single femoral

º≈°“√∑” Single femoral nerve block μàÕ°“√øóôπμ—«À≈—ß
ºà“μ—¥‡ª≈’ˬπ¢âÕ‡¢à“
∞‘μ‘¡“ ™‘π–‚™μ‘ æ.∫.,*
ªí∑¡«√√≥ æß»åæ‘» æ.∫.,*
ÿ∑∏‘√—° §ÿ√ÿÀß…“ æ.∫.*
Abstract
Effect of femoral nerve block in ambulatory process after total knee replacement
Chinachoti T, M.D.,* Pongpit P, M.D.,* Kuruhongsa S, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700
were completely interviewed. Spinal block with morphine was used in 160 patients and general anesthesia
was chosen in 20 patients. Seventy six patients or
42.2% received FNB. Patients who received FNB combined with spinal morphine were given lower dose of
spinal morphine than patient who did not. There was
no any difference between groups in demographic
data, side effects and post operative pain medications.
There was no any difference in ambulatory process
between the two groups. Conclusion : FNB did not
interfere with ambulatory process after total knee
replacement. From this study, we could not demonstrate the value of FNB in the reduction of opioid consumption and its side effects due to the limitation of
the study design. We did not find any complication
caused by FMB from this study
Background : Total knee replacement (TKR) is
a most common operation in orthopedic surgery. Post
operative pain from TKR is considered moderate to
severe. There are numerous methods to use for postoperative pain control after TKR. Femoral nerve block
(FNB) have been suggested as a useful method in relieving pain after TKR but prolonged motor blockage
may cause delayed ambulatory process. Material and
Methods : This is prospective observational study. Every
consecutive patients who underwent TKR during
January to April 2007 at Siriraj hospital were included
in this study. They were postoperatively interviewed by
the study team daily for three days about ambulation
time, ability of mobilization (sit in bed, walk) and readiness to be discharged from hospital. Demographic
data, anesthetic technique, postoperative pain medications, side effects and ambulatory process were
recorded. The data were analyzed by SPSS version 11.5
compared between the patients who did or did not
receive FNB (FNB or NFNB group). P-value ≤ 0.01 was
considered statistically significant. Results : A total of
180 patients who underwent TKR during study period
Keywords :
Femoral nerve block, ambulatory process,
total knee replacement.
Thai J Anesthesiology 2008 ; 34(4) : 250-7.
*¿“§«‘™“«‘ —≠≠’«‘∑¬“ §≥–·æ∑¬»“ μ√廑√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈ °√ÿ߇∑æœ 10700
250
°“√§«∫§ÿ¡Õ“°“√ª«¥¿“¬À≈—ß°“√ºà“μ—¥‡ª≈’ˬπ
¢âÕ‡¢à“ “¡“√∂°√–∑”‰¥âÀ≈“¬«‘∏’ ‰¡à«à“®–‡ªìπ°“√„Àâ intravenous patient control analgesia (PCA) °“√„Àâ epidural
patient control analgesia (PCEA) °“√„™â epidural À√◊Õ
spinal morphine1-4 °“√∑” nerve block ‰¡à«à“®–‡ªìπ femoral, sciatic ·≈– obturator nerve block ®–™à«¬‡ √‘¡°“√√–ß—∫
ª«¥‰¥â¥’‚¥¬‡©æ“–„π 24 ™—Ë«‚¡ß·√°À≈—ß°“√ºà“μ—¥5-7 ´÷Ëß
‚¥¬∑—Ë«‰ª·≈â«¿“¬„π 12-24 ™—Ë«‚¡ßÀ≈—ߺà“μ—¥ ºŸâªÉ«¬®– “¡“√∂
√—∫ª√–∑“πÕ“À“√·≈–¬“‰¥â¥’ ¥—ßπ—Èπ®÷ß “¡“√∂„™â¬“·°âª«¥
°≈ÿà¡μà“ß Ê ∑’Ë„Àâ‚¥¬°“√√—∫ª√–∑“π‰¥â ‰¡à«à“®–‡ªì𬓰≈ÿà¡
COX 1 À√◊Õ COX 2, paracetamol ·≈–¬“Õ◊Ëπ Ê1,2,8,9 ¥—ßπ—Èπ
·¡â«à“°“√»÷°…“μà“ß Ê ®–¬◊π¬—π«à“°“√∑” femoral nerve
block ®–™à«¬‡ √‘¡§«“¡ “¡“√∂„π°“√√–ß—∫ª«¥¢ÕߺŸâªÉ«¬
∑’Ë¡“√—∫°“√ºà“μ—¥‡ª≈’ˬπ¢âÕ‡¢à“„π 24 ™—Ë«‚¡ß·√° ≈¥§«“¡
μâÕß°“√¬“ opioid ‡æ◊ËÕ°“√√–ß—∫ª«¥ ·≈–≈¥º≈¢â“߇§’¬ß∑’Ë
‡°‘¥®“°°“√„™â¬“√–ß—∫ª«¥1,2,7,10 ·μà°“√∑” femoral nerve
block (FNB) °Á ‡ ªì π À— μ ∂°“√∑’Ë Õ “®∑”„Àâ ‡ °‘ ¥ Õ— π μ√“¬°— ∫
‡ âπª√– “∑‚¥¬μ√ß ¡’‚Õ°“ ∑’Ë®–∑”„À⇰‘¥°“√ÕàÕπ·√ߢÕß
°≈â“¡‡π◊ÈÕμâπ¢“ ´÷ËßÕ“®®–√ÿπ·√ß·≈–π“π®π‡ªìπº≈∑”„Àâ°“√
øóôπμ—«¢ÕߺŸâªÉ«¬ °“√∫√‘À“√¢âÕ‡¢à“‰¡à«à“®–‡ªìπ°“√ßÕ‡¢à“ ¬—π
‡¢à“ ¬°¢“μ√ß √«¡‰ª∂÷ߧ«“¡ “¡“√∂„π°“√≈ÿ°‡¥‘π ™à«¬
μ—«‡Õß ·≈–§«“¡æ√âÕ¡„π°“√ÕÕ°®“°‚√ß欓∫“≈™â“°«à“°≈ÿ¡à
∑’ˉ¡à‰¥â√—∫°“√∑” FNB
μ—Èß·μàªï æ.». 2547 „π‚√ß欓∫“≈»‘√‘√“™‰¥â‡√‘Ë¡π”
«‘∏’°“√∑” FNB √à«¡°—∫ spinal block √à«¡°—∫ spinal morphine ¡“„™â„π°“√ºà“μ—¥·≈–°“√√–ß—∫ª«¥¿“¬À≈—ß°“√ºà“μ—¥
‡ª≈’ˬπ¢âÕ‡¢à“ ·≈–‡√‘Ë¡ Õπ„Àâ·æ∑¬åª√–®”∫â“π‰¥âÀ—¥∑” FNB
®π„πªï æ.». 2549 ·æ∑¬åª√–®”∫â“π∑ÿ°§π∑’Ë®∫°“√»÷°…“®–
¡’§«“¡ “¡“√∂‡æ’¬ßæÕ∑’Ë®–∑” FNB ‰¥â¥â«¬μ—«‡Õß ‡¡◊ËÕ°“√
∑” FNB ·æ√àÀ≈“¬¡“°¢÷Èπ ·≈–·¡â«à“ºŸâªÉ«¬®–‰¥â√—∫°“√
ª√–‡¡‘ π ‚¥¬·æ∑¬å ºŸâ ∑”À√◊ Õ ∑’ ¡ «‘ — ≠ ≠’ æ ¬“∫“≈∑’Ë μ‘ ¥ μ“¡
ª√–‡¡‘πºŸâªÉ«¬À≈—ߺà“μ—¥®–æ∫º≈¢â“߇§’¬ß®“°°“√∑” FNB
πâÕ¬¡“° ·μà°“√ª√–‡¡‘πº≈‡æ’¬ß§√—È߇¥’¬«À≈—ß°“√ºà“μ—¥Õ“®
‰¡à‡æ’¬ßæÕ ∑’®Ë –μ√«®æ∫º≈°√–∑∫∑’‰Ë ¡àæß÷ ª√– ߧ宓°°“√∑”
FNB ºŸâ«‘®—¬®÷ß∑”°“√»÷°…“‡æ◊ËÕª√–‡¡‘πº≈°√–∑∫∑’ˇ°‘¥®“°
°“√∑” FNB μàÕ°“√øóôπμ—« ·≈–§«“¡ “¡“√∂„π°“√™à«¬μ—«
‡ÕߢÕߺŸâªÉ«¬¿“¬À≈—ß°“√ºà“μ—¥‡ª≈’ˬπ¢âÕ‡¢à“
Vol. 34, No. 4, October-December 2008
«‘∏’°“√»÷°…“
∑”°“√»÷°…“·∫∫‰ª¢â“ßÀπⓇ™‘ß —߇°μ ‚¥¬°“√
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¢âÕ¡Ÿ≈æ◊Èπ∞“π¢ÕߺŸâªÉ«¬ ‰¥â·°à Õ“¬ÿ ‡æ» à«π Ÿß
πÈ”Àπ—°μ—« ASA ‚√§ª√–®”μ—« §«“¡ “¡“√∂„π°“√ªØ‘∫—μ‘
°‘®«—μ√ª√–®”«—π°àÕπ°“√ºà“μ—¥ ·≈–º≈°“√μ√«®∑“ßÀâÕß
ªØ‘∫—μ‘°“√ ‰¥â·°à hematocrit, blood sugar, BUN ·≈– creatinine
¢âÕ¡Ÿ≈‡°’ˬ«°—∫°“√√–ß—∫§«“¡√Ÿâ ÷° ‰¥â·°à «‘∏’∑’Ë„™â„π
°“√„Àâ°“√√–ß—∫§«“¡√Ÿâ ÷° ¢π“¥¢Õ߬“∑’Ë„™â„π°“√√–ß—∫§«“¡
√Ÿâ ÷° √–¬–‡«≈“∑’Ë„™â„π°“√√–ß—∫§«“¡√Ÿâ ÷° ™π‘¥·≈–¢π“¥¬“™“
‡©æ“–∑’Ë∑’Ë„™â °“√º ¡ morphine ·≈–®”π«π∑’Ë„Àâ√à«¡ °“√∑”
femoral nerve block √«¡∑—Èß∫—π∑÷°«à“ºŸâ∑”‡ªìπ„§√ Õ“®“√¬å
À√◊Õ·æ∑¬åª√–®”∫â“π «‘∏’·≈–™π‘¥·≈–®”π«π¬“™“‡©æ“–∑’Ë∑’Ë
„™â„π°“√∑” femoral nerve block √–¥—∫°“√™“ √–¥—∫·≈–°“√
‡ª≈’¬Ë π·ª≈ߢÕߧ«“¡¥—π‡≈◊Õ¥ ™’æ®√ Õ—μ√“°“√À“¬„® ª√‘¡“≥
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„À⬓√–ß—∫§«“¡√Ÿâ ÷°„π√–À«à“ß·≈–À≈—ß°“√ºà“μ—¥
¢âÕ¡Ÿ≈À≈—ß°“√ºà“μ—¥‰¥â·°à «‘∏’°“√√–ß—∫°“√ª«¥À≈—ß
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À≈—ߺà“μ—¥ √–¬–‡«≈“∑’˺ŸâªÉ«¬μâÕß°“√¬“·°âª«¥§√—Èß·√° §√—Èß∑’Ë
2 §√—Èß∑’Ë 3 (∂â“¡’) º≈¢â“߇§’¬ß®“°°“√„Àâ°“√√–ß—∫ª«¥∑’ˉ¥â√—∫
§«“¡ “¡“√∂„π°“√∑”°‘®°√√¡μà“ß Ê ‰¥â ‡™àπ °“√π—ßË ∫π‡μ’¬ß
°“√≈߇¥‘π¢â“ß‡μ’¬ß ·≈–§«“¡ “¡“√∂„π°“√™à«¬‡À≈◊Õμ—«‡Õß
√«¡∑—Èߧ«“¡æ√âÕ¡„π°“√°≈—∫∫â“π „π 24, 48 ·≈– 72 ™—Ë«‚¡ß
À≈—ß°“√ºà“μ—¥
∫—π∑÷°¢âÕ¡Ÿ≈‚¥¬„™â‚ª√·°√¡ SPSS version 11.5
‡ª√’¬∫‡∑’¬∫√–À«à“ߺŸâªÉ«¬∑’ˉ¥â√—∫·≈–‰¡à‰¥â√—∫°“√∑” femoral
Thai Journal of Anesthesiology
251
Table 1
Patients’ characteristics compared between femoral nerve block group (FNB) and non femoral nerve block
group (NFNB). Data were displayed in mean, SD or percentage of each group.
p-value
FNB (n = 76)
NFNB (n = 104)
Age (yr)
70.4 ± 10.4
68.9 ± 8.0
0.29
Weight (kg)
64.3 ± 10.2
63.1 ± 11.8
0.45
Patient’ characteristics
154.7 ± 7.5
152.6 ± 6.5
0.53
15.8 / 84.2
13.5 / 86.5
0.72
Class 1
2.6%
7.7%
0.14
Class 2
78.9%
79.8%
Class 3
18.4%
12.5%
Functional class Class 1
11.8%
21.2%
Class 2
84.2%
77.9%
Class 3
4%
0.9%
Smoking (No)
98.7%
98.7%
0.17
Drinking (No)
100%
100%
1.00
Hypertension
67.1%
60.6%
0.26
Diabetes Mellitus
18.4%
11.5%
0.17
Coronary artery disease
6.6%
3.8%
0.38
Old myocardial infarction
1.3%
1.9%
0.79
77.4 ± 9.0
75.7 ± 9.0
0.19
BP systolic (mmHg.)
135.6 ± 15.8
134.3 ± 23.0
0.65
BP diastolic (mmHg.)
81.3 ± 8.9
80.3 ± 9.9
0.49
Hematocrit (%)
37.3 ± 3.5
37.3 ± 3.8
1.00
BUN (mg/dl)
16.4 ± 5.6
16.2 ± 5.7
0.80
0.9 ± 0.2
0.8 ± 0.3
0.29
115.3 ± 37.5
99.9 ± 15.8
0.05
Height (cm)
Sex (M/F) %
ASA
Heart rate (bpm)
Creatinine (mg/dl)
Glucose (mg%)
nerve block
‚¥¬∑¥ Õ∫°“√°√–®“¬¢ÕߢâÕ¡Ÿ≈ ·≈–«‘‡§√“–Àå
¢âÕ¡Ÿ≈‚¥¬∑“ß ∂‘μ‘‚¥¬„™â t-test ”À√—∫¢âÕ¡Ÿ≈‡™‘ߪ√‘¡“≥∑’Ë¡’
°“√°√–®“¬μ—«·∫∫ª°μ‘ ·≈– chi-square ”À√—∫¢âÕ¡Ÿ≈‡™‘ß
§ÿ≥¿“æ ‚¥¬°”Àπ¥„Àâ p-value ∑’ËπâÕ¬°«à“À√◊Õ‡∑à“°—∫ 0.01
®÷ß¡’§«“¡ ”§—≠∑“ß ∂‘μ‘
º≈°“√»÷°…“
®“°ºŸâªÉ«¬∑’ˉ¥â√—∫°“√ºà“μ—¥‡ª≈’ˬπ¢âÕ‡¢à“„π√–À«à“ß
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ºŸâ«‘®—¬ “¡“√∂μ‘¥μ“¡ª√–‡¡‘πºŸâªÉ«¬‰¥â§√∫∑—Èß 3 «—π®”π«π
252
«‘ —≠≠’ “√
0.05
180 √“¬ À√◊Õ√âÕ¬≈– 72 ‡ªìπºŸâªÉ«¬‡æ»À≠‘ß√âÕ¬≈– 85.6 ¡’
πÈ”Àπ—°μ—«‡©≈’ˬ 63.6 ± 11.1 °‘‚≈°√—¡ à«π Ÿß‡©≈’ˬ 153.5 ±
7.0 ‡´π쑇¡μ√ ®—¥Õ¬Ÿà„π ASA √–¥—∫ 2 √âÕ¬≈– 79.4 ‚¥¬¡’
ª√–«—쑇ªìπ‚√§‡∫“À«“π√âÕ¬≈– 14.4 §«“¡¥—π‚≈À‘μ Ÿß√âÕ¬≈–
73.3 æ∫«à“·¡âºŸâªÉ«¬®–¡’Õ“¬ÿ§àÕπ¢â“ß Ÿß·μà®—¥‡ªìπºŸâªÉ«¬∑’Ë¡’
ÿ¢¿“æÕ¬Ÿà„π‡°≥±å∑’Ë¥’ ‚¥¬ºŸâªÉ«¬ 160 √“¬ ‰¥â√—∫°“√∑”
spinal block ¥â«¬ 0.5% bupivacaine „π®”π«ππ’È 65 √“¬
‰¥â√—∫°“√∑” FNB √à«¡¥â«¬ ºŸâªÉ«¬Õ’° 20 √“¬ ‰¥â√—∫°“√„À⬓
√–ß—∫§«“¡√Ÿâ ÷°∑—Èßμ—«‚¥¬«‘∏’„ à∑àՙ૬À“¬„® ·≈–„π®”π«ππ’È
11 √“¬ ‰¥â√—∫°“√∑” FNB √«¡‡ªìπºŸâªÉ«¬∑’ˉ¥â√—∫°“√∑” FNB
ªï∑’Ë 34 ©∫—∫∑’Ë 4 μÿ≈“§¡-∏—𫓧¡ 2551
Table 2
Anesthetic techniques, duration of anesthesia, post operative pain medications and rescue opioids requirements
compared between femoral nerve block group (FNB) and non femoral nerve block group (NFNB). Data were
displayed in percentage of each group or mean ± SD.
p-value
FNB (n = 76)
NFNB (n = 104)
85.5%
91.3%
0.20
100%
98.9%
0.87
2.7 ± 0.3
2.6 ± 0.3
0.23
96.9%
98.9%
0.42
0.15 ± 0.09
0.18 ± 0.09
0.01
14.5%
8.7%
175.3 ± 46.5
152.4 ± 40.7
0.30
65.8%
67.3%
0.68
75%
67.3%
0.28
Ultracet
69.7%
73.1%
0.56
Paracetamol
90.8%
91.3%
0.86
within 12 hr.
19.7%
18.3%
0.83
within 24 hr.
35.5%
35.6%
0.94
Anesthetic technique
Spinal block
0.5% heavy bupivacaine
Dose of 0.5% heavy bupivacaine (ml)
Spinal morphine
Dose of spinal morphine (mg)
General anesthesia
Duration of anesthesia (min)
Post operative pain treatment
Arcoxia®
Dynastat
®
®
Needed rescue opioids
Table 3
Percentage of patient who reported of nausea, vomiting and dizziness in postoperative day one, two and three
compared between femoral nerve block group (FNB) and non femoral nerve block group (NFNB)
FNB (n = 76)
Nausea
Vomiting
Dizziness
NFNB (n = 104)
P-value
Day 1
46
50.4
0.56
Day 2
14.5
19.4
0.09
Day 3
1.3
5.9
0.29
Day 1
35.5
45.2
0.43
Day 2
9.2
16.3
0.19
Day 3
0
4.8
0.15
Day 1
49.4
39.4
0.43
Day 2
9.2
15.4
0.33
Day 3
1.3
7.7
0.15
Vol. 34, No. 4, October-December 2008
Thai Journal of Anesthesiology
253
Table 4
Ambulatory profiles that were reported by patients compared between femoral nerve block group (FNB) and
non femoral nerve block group (NFNB) on postoperative day one, two and three. Data were displayed in percentage of each group.
FNB (n = 76)
Ambulatory profile
NFNB (n = 104)
P-value
Day 1
13.2
20.2
0.43
Day 2
67.1
67.3
0.77
Day 3
90.8
93.3
0.54
Day 1
64.5
78.8
0.03
Day 2
94.7
97.1
0.42
Day 3
97.4
97.1
0.92
Ability to walk around bed Day 1
3.9
7.7
0.30
Day 2
38.2
50.0
0.12
Day 3
86.8
86.5
0.95
Day 1
98.7
98.0
0.75
Day 2
98.7
99.0
0.82
Day 3
94.7
97.1
0.41
Day 1
18.4
28.9
0.22
Day 2
76.3
78.8
0.45
Day 3
98.7
98.1
0.91
14.5
22.1
0.19
Ability to eat well
Ability to sit
Need assistant to ambulate
Self ambulate
Ready to be discharged in day 3
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FNB 76 √“¬ ·≈–°≈ÿà¡∑’ˉ¡à‰¥â∑” FNB (NFNB) 104 √“¬
æ∫«à“¢âÕ¡Ÿ≈æ◊Èπ∞“π¢ÕߺŸâªÉ«¬∑—Èß 2 °≈ÿà¡ (μ“√“ß∑’Ë 1) ‰¥â·°à
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μà“ß°—πÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘μ‘
ºŸâªÉ«¬√âÕ¬≈– 88.8 ‰¥â√—∫°“√∑” spinal block ‡æ◊ËÕ
°“√√–ß—∫ª«¥√–À«à“ß°“√ºà“μ—¥ ‚¥¬æ∫«à“ºŸâªÉ«¬∑ÿ°√“¬∑’ˉ¥â
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254
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spinal morphine „π®”π«π∑’ËπâÕ¬°«à“ºŸâªÉ«¬∑’ˉ¡à‰¥â√—∫°“√∑”
FNB ‚¥¬®”π«π morphine ≈¥≈ß®“° 0.18 ± 0.09 ¡°. ‡ªìπ
0.15 ± 0.09 ¡°. (p = 0.01) ´÷Ëß¡’§«“¡·μ°μà“ß∑’Ë¡’π—¬ ”§—≠
∑“ß ∂‘μ‘
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â «É ¬·μà≈–√“¬®–‰¥â√∫— ¬“√–ß—∫ª«¥‡ √‘¡Õ¬à“ß
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√—∫°“√∑” FNB ‰¥â√—∫¬“√–ß—∫ª«¥‡ √‘¡ ‰¡à·μ°μà“ß°—π ·≈–
¡’§«“¡μâÕß°“√¬“√–ß—∫ª«¥°≈ÿà¡ opioids ‡æ‘Ë¡‡μ‘¡„π 12 ·≈–
24 ™—Ë«‚¡ßÀ≈—ߺà“μ—¥‰¡à·μ°μà“ß°—πÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘μ‘
ªï∑’Ë 34 ©∫—∫∑’Ë 4 μÿ≈“§¡-∏—𫓧¡ 2551
‚¥¬ª√–¡“≥√âÕ¬≈– 20 ·≈–√âÕ¬≈– 35 ¢ÕߺŸâªÉ«¬∑—Èß Õß°≈ÿà¡
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μà“ß„πºŸâªÉ«¬∑—Èß 2 °≈ÿà¡Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘μ‘ (μ“√“ß∑’Ë 3)
‚¥¬ºŸâªÉ«¬∑—Èß Õß°≈ÿà¡®–æ∫¡’Õ“°“√¢â“߇§’¬ß¡“°∑’Ë ÿ¥„π 24
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π—¬ ”§—≠∑“ß ∂‘μ‘ Õ“®‡π◊ËÕß®“°ª√–™“°√∑’ËπâÕ¬‰ª‡π◊ËÕß®“°
‰¡à ‰ ¥â ¡’ ° “√§”π«≥®”π«πª√–™“°√∑’Ë ∑”°“√»÷ ° …“´’Ë ß Õ“®
μâÕß°“√¢π“¥∑’Ë„À≠à°«à“π’È®÷ß®–æ∫§«“¡·μ°μà“ß ·≈–æ∫«à“
ºŸâªÉ«¬®”π«ππâÕ¬¡“°®“°∑—Èß 2 °≈ÿà¡∑’Ë¡’§«“¡æ√âÕ¡∑’Ë®–ÕÕ°
®“°‚√ß欓∫“≈„π«—π∑’Ë 3 À≈—ߺà“μ—¥
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ºŸâªÉ«¬ª√–¡“≥√âÕ¬≈– 42.2 ∑’Ë√—∫°“√ºà“μ—¥‡ª≈’ˬπ
¢âÕ‡¢à“‚¥¬‰¥â√—∫°“√∑” FNB √à«¡¥â«¬ ®“°°“√»÷°…“‰¡àæ∫
«à“ºŸâªÉ«¬∑’ˉ¥â√—∫°“√∑” FNB „™â‡«≈“„π°“√øóôπμ—«À≈—ß®“°
°“√ºà“μ—¥·μ°μà“ß®“°°≈ÿࡺŸâªÉ«¬∑’ˉ¡à‰¥â√—∫°“√∑” FNB ∑—Èß
„π¥â“𧫓¡ “¡“√∂„π°“√≈ÿ°®“°‡μ’¬ß ‡¥‘π√Õ∫‡μ’¬ß °“√
™à«¬‡À≈◊Õμπ‡Õß ·≈–Õ◊Ëπ Ê ‰¡àæ∫ºŸâªÉ«¬∑’Ë¡’Õ“°“√ÕàÕπ·√ß
¢Õß°≈â“¡‡π◊ÈÕÀπâ“¢“ ·≈–ºŸâªÉ«¬∑ÿ°√“¬ “¡“√∂∂Õ¥ “¬ «π
ªí “«–ÕÕ°‰¥â„π«—π∑’Ë 2 ‚¥¬‰¡à¡’ªí≠À“„π°“√ªí “«– ‚¥¬
æ∫«à “ ‡¡◊Ë Õ «‘ — ≠ ≠’ · æ∑¬å ‡ ≈◊ Õ °∑’Ë ® –„™â FNB √à«¡°—∫°“√„™â
spinal morphine ‡æ◊ËÕ§«∫§ÿ¡Õ“°“√ª«¥À≈—ß°“√ºà“μ—¥ ®–≈¥
®”π«π morphine ≈ß ´÷Ëß· ¥ß„Àâ‡ÀÁπÕ¬à“ß™—¥‡®π®“°º≈°“√
»÷°…“π’È ∑’Ëæ∫«à“ºŸâªÉ«¬°≈ÿà¡∑’ˉ¥â√—∫°“√∑” FNB ®–‰¥â√—∫ spinal morphine „π®”π«π∑’ËπâÕ¬°«à“ºŸâªÉ«¬°≈ÿà¡∑’ˉ¡à‰¥â√—∫°“√
∑” FNB Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘μ‘ ·≈–¡’¢π“¥ spinal morphine ·μ°μà“ß°—π 0.03 ¡°. ´÷Ë߇ªì𧫓¡·μ°μà“ß°—π∑’Ë¡’
§«“¡À¡“¬∑“ߧ≈‘π‘° ·≈–Õ“® àߺ≈„Àâ≈¥Õ“°“√¢â“߇§’¬ß∑’Ë
Vol. 34, No. 4, October-December 2008
‡°‘¥®“°°“√„™â spinal morphine ‚¥¬‡©æ“–Õ“°“√§≈◊Ëπ‰ â
Õ“‡®’¬π ·≈–Õ“°“√§—π
‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫º≈°“√∑” FNB μàÕ°“√‡ √‘¡§«“¡
“¡“√∂„π°“√√–ß—∫ª«¥„π√–¬–À≈—ß°“√ºà“μ—¥ ‚¥¬‡©æ“–„π
24 ™—Ë«‚¡ß·√°À≈—ß°“√ºà“μ—¥ ®“°°“√»÷°…“π’ȉ¡àæ∫«à“ºŸâªÉ«¬
∑—Èß 2 °≈ÿà¡ μâÕß°“√¬“°≈ÿà¡ opioids ‡æ‘Ë¡‡μ‘¡„π 12 ·≈– 24
™—«Ë ‚¡ßÀ≈—ߺà“μ—¥·μ°μà“ß°—π ´÷ßË ª√–¡“≥√âÕ¬≈– 35 ¢ÕߺŸªâ «É ¬
∑—ßÈ Õß°≈ÿ¡à ¢Õ¬“√–ß—∫ª«¥‡æ‘¡Ë ·≈– à«π¡“°¢Õ‡æ’¬ß§√—ßÈ ‡¥’¬«
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„π°“√§«∫§ÿ¡Õ“°“√ª«¥À≈—ß°“√ºà“μ—¥ ‡π◊ÕË ß®“°‰¡à‰¥â欓¬“¡
§«∫§ÿ¡μ—«·ª√ ∑—ßÈ §«“¡ “¡“√∂¢ÕߺŸ∑â ” FNB ·≈–‰¡à “¡“√∂
ª√–‡¡‘π‰¥â«à“°“√∑” FNB „π·μà≈–§√—Èßπ—Èπ “¡“√∂¢—¥¢«“ß
°“√∑”ß“π¢Õß femoral nerve ‰¥â„π·¢πß∑’Ë∂Ÿ°μâÕßÀ√◊Õ‰¡à
´÷Ë ß °“√»÷ ° …“∑’Ë ® –· ¥ß‰¥â π—È π ®–μâ Õ ß¡’ ° √–∫«π°“√§«∫§ÿ ¡
μ—«·ª√∑’Ë√—¥°ÿ¡ ¥—߇™àπ°“√»÷°…“¢Õß Allen HW ·≈–§≥–6
´÷Ëßæ∫«à“°“√∑” FNB ‡æ‘Ë¡§«“¡ “¡“√∂„π°“√√–ß—∫ª«¥ ·≈–
≈¥§«“¡μâÕß°“√¬“ opioids À≈—ߺà“μ—¥‡ª≈’ˬπ¢âÕ‡¢à“·≈–≈¥
º≈¢â“߇§’¬ß®“°°“√„™â¬“ opioids
®“°°“√»÷°…“§√—Èßπ’È æ∫«à“ºŸâªÉ«¬∑’ˉ¥â√—∫°“√ºà“μ—¥
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®–‰¥â√—∫¬“‡ √‘¡‡ªìπ paracetamol, dynastat ·≈– arcoxia
À√◊Õ ultracet ´÷Ë߬“‡ √‘¡∑ÿ°™π‘¥ “¡“√∂„À≥â„π 24 ™—Ë«‚¡ß
·√°À≈—ߺà“μ—¥ ‚¥¬ºŸâªÉ«¬·μà≈–√“¬®–‰¥â¬“‡ √‘¡Õ¬à“ßπâÕ¬ 3
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2 ‡ªìπμâπ‰ª ‚¥¬· ¥ßºà“𧫓¡ “¡“√∂„π°“√™à«¬‡À≈◊Õ
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3 À≈—ߺà“μ—¥ ´÷Ë߇ªìπ√–¬–‡«≈“∑’˧«“¡ª«¥À≈—ߺà“μ—¥≈¥≈ß¡“°
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ª√–‡¡‘π√–¥—∫§«“¡ª«¥ (VAS) „π‡«≈“∑’Ë Õ∫∂“¡¢âÕ¡Ÿ≈®“°
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π—Èπ‡ªìπº≈®“°«‘∏’°“√„¥‡ªì𠔧—≠ ´÷Ë߉¡àÕ“® √ÿª‰¥â«à“‡ªìπº≈
‚¥¬μ√ß®“°°“√∑” FNB
Thai Journal of Anesthesiology
255
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„Àâ°“√√–ß—∫ª«¥πâÕ¬∑’Ë ÿ¥´÷ËßπÕ°‡Àπ◊Õ®“°°“√∑” regional
block ·≈– peripheral nerve block ·≈â« °“√©’¥¬“™“‡©æ“–
∑’„Ë π¢âÕ‡¢à“‚¥¬»—≈¬·æ∑¬å¢≥–∑”°“√ºà“μ—¥®–‡æ‘¡Ë §«“¡ “¡“√∂
„π°“√√–ß—∫ª«¥ ·≈–≈¥§«“¡μâÕß°“√¬“ opioids À≈—ߺà“μ—¥
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π“π¢÷Èπ ‚¥¬‰¡à√∫°«π°”≈—ߢÕß°≈â“¡‡π◊ÈÕ ‡™àπ °“√„ à catheter „π femoral sheath ‡æ◊ËÕ„™â‡ªìπ continuous femoral nerve
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Femoral nerve block,
°“√øóôπμ—«À≈—ß°“√ºà“μ—¥‡ª≈’ˬπ¢âÕ‡¢à“
Vol. 34, No. 4, October-December 2008
Thai Journal of Anesthesiology
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