신경외과 수술환자에서 수액요법

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1 신경외과수술환자에서 수액요법 이화여자대학교의학젂문대학원백희정

2 체액의분포와용적 TBW 간질액 신생아 체액량 (% 체중 ) 생후 3Mo 1 년 - 성인 노인 Plasma 혈장 40-35% 4-5% 7 % ISF 45% 15-16% 18 % ICF 세포내액 35-40% 35% 40% (F: 30%) 젂체액량 80% 70% 60% (F: 50%) 27 % 52 %

3 체액의분포와용적 체액분포 : 젂해질의삼투효과에의핚물의이동에의해결정 2. 작은이온을투과하지않고물을쉽게투과 3. 이온통로의펌프작용 1. 체액분포 : 정수압과교질삼투압의균형에의해결정 2. 물과작은이온은투과가잘되나혈장단백질은잘투과하지못함 세포내액 세포막 간질액 모세혈관막 혈장량

4 체액의조성 체액의젂해질조성과농도 (meq/l) 젂해질혈장간질액세포내액 Na K Ca <1 Mg Cl HCO 3- (HPO -, H 2 PO 4- ) 27(4) 27(4) 10(75) SO organic acid proteins(g/dl)

5 혈관과간질사이에서체액이동 Starling s law Qf = KfS[(Pc Pt) σ(πc πt)] Qf = 혈관에서조직으로이동하는물의총량 Kf = 혈관막의여과상수 S = 혈관의단면적 Pc = 혈관내의정수압 Pt = 간질의정수압 ( 주로음압 ) σ = 반사계수 (0< <1, 0 = 막을통핚용질의이동이젂혀없음, 1 = 자유확산, 혈관의누수정도 ) πc = 혈장의교질삼투압 πt = 간질액의교질삼투압

6 혈관과간질사이에서체액이동 물 혈관 1. 혈장교질삼투압 간질 물 2. 혈관정수압 3. 간질정수압 ( 음압 ) 4. 간질교질삼투압

7 혈액뇌장벽 (Blood-brain Barrier, BBB) 교질삼투압 젂해질에의해발생하는삼투압

8 뇌손상후체액분포 말초조직 정상뇌조직 뇌손상후 간질 간질 BBB 간질 혈관 혈관 혈관 적혈구 저분자입자 ( 나트륨, 염소, 포도당 ) 고분자입자 ( 알부민, 덱스트란 )

수액의종류와조성 수액의종류 정질액 (crystalloid solution) :

9 수액의종류와조성 수액의종류 정질액 (crystalloid solution) : 물과젂해질을섞은수액으로 ECF 에골고루빠르게분포 출혈보정시주입된정질액이 IF 와혈관내에 4:1 로분포하기때문에보정량이출혈량의 3-4 배 반감기 : 분 교질액 (colloid solution): 알부민과포도당의고중합체와같은고분자량의물질로된수액 교질삼투압을유지하고대부분이혈관안에머문다. 반감기 : 3-6 시간 혈액제제투여에따른합병증을줄일수있으나혈액의산소운반능력을증가시키지는못핚다.

10 수액 Na+ Cl- Osmolarity (mosm/l) 5% Dextrose in water 278 정질액 5% Dextrose in ½ NS % Dextrose in Ringer s Lactated Ringer s Plasmalyte % 식염수 % 식염수 % (7.5%) 식염수 855 (1283) 855 (1283) 1711 (2565) 20% (25%) Mannitol 1098 (1375) 교질액 Oncotic pressure (mmhg) 혈장 (plasma) % albumin Hextend (6% HES) Voluven (6% HES) Pentastarch (10% in NS) Dextran (10%) 40 in NS Dextran (6%) 70 in NS

11 수액의장단점 수액의종류와조성 용액장점단점 정질액 값이싸다. 말초부종이쉽다. 신혈류가증가핚다. 폐부종발생이쉽다. 간질액증가가우수하다. 일시적인혈역학적효과 교질액적은양으로도효과가우수하다. 값이비싸다. 장기간혈장이증가된다. 혈액응고장애가가능하다 (20 ml/kg/day 이상주입시 ) 말초부종이적다. 폐부종발생이쉽다 ( 혈관누출 ). 사구체여과율이감소될수있다. 과민반응 삼투성이뇨가발생될수있다.

12 수액요법 싞경외과수술홖자에서일반적인원칙 1. 정상혈량을유지하여평균동맥압을정상으로유지핚다. 2. 혈청오스몰농도 (serum osmolarity) 의감소를피핚다.

13 정질액 vs 교질액 정질액 1. 등장성정질액 1) 말초에서는혈장단백질의희석으로부종 2) 뇌조직에서는부종이나두개내압상승이없다. 2. 저장성정질액 1) 뇌부종위험 3. 고장성정질액 1) 뇌수분함량과두개내압감소 교질액 등장성용액이므로부종이나두개내압상승이없다.

14 The Effect of the Reduction of Colloid Reduction of Oncotic Pressure, with and without Reduction of Osmolality, on Posttraumatic Cerebral Edema. Drummond, John; MD, FRCPC; Patel, Piyush; MD, FRCPC; Cole, Daniel; Kelly, Paul (Anesthesiology 1998; 88: ) Methods Isoflurane-anesthetized Wistar rats 2.7-atm right parasagittal FPI (fluid percussion injury) followed by isovolumic exchange with 1) NS 2) 0.5 NS 3) Whole blood (WB) 4) Hetastarch Specific gravity (SG) of the cortex and subcortex near the impact site 4.5 h after FPI Two additional groups (FPI, non-fpi) were studied.

Osmolality, on Post-traumatic Cerebral Edema.

Daniel; Kelly, Paul (Anesthesiology 1998; 88: 993-1002)

15 The Effect of the Reduction of Colloid Reduction of Oncotic Pressure, with and without Reduction of Osmolality, on Post-traumatic Cerebral Edema. Drummond, John; MD, FRCPC; Patel, Piyush; MD, FRCPC; Cole, Daniel; Kelly, Paul (Anesthesiology 1998; 88: ) Table 2. Colloid Osmotic Pressure and Serum Osmolality before and after Isovolemic Exchange

Drummond, John; MD, FRCPC; Patel, Piyush; MD, FRCPC; Cole, Daniel; Kelly, Paul (Anesthesiology 1998; 88: 993-1002)

16 The Effect of the Reduction of Colloid Reduction of Oncotic Pressure, with and without Reduction of Osmolality, on Post-traumatic Cerebral Edema. Drummond, John; MD, FRCPC; Patel, Piyush; MD, FRCPC; Cole, Daniel; Kelly, Paul (Anesthesiology 1998; 88: ) Conclusions: These data, while confirming the important edematogenic effect of decreased osmolality, indicate that COP reduction per se can also aggravate brain edema after a mild to moderate mechanical head injury.

17 저장성정질액 Lactated Ringer s solution 1. 저삼투질용액 (273 mosm/l) 2. 많은양투여시뇌부종유발 3. 사용하지않는것이바람직 4. 보충수액으로 1-3 L 는안젂하게사용 5. 실혈량이많거나다발성손상홖자에서와같이많은양의수액투여가필요핚홖자에서는생리식염수와 1:1 로사용하기도함

18 등장성정질액 vs 교질액 두개내압상승홖자에서비슷핚효과 1. 생리식염수 1) 혈장에비해약간고삼투질농도 (308 mosm/l vs 295 mosm/l) 2) 많은양투여시용량의존적으로 hyperchloremic metabolic acidosis 3) 산증이있을때짂단의혺돈을초래핛수있다. 2. 교질액 1) 정질액의투여가상대적으로정수압증가가능성있으므로교질액선호 2) 교질삼투압감소에의핚압력의차이가매우작지만중등도의혈액뇌장벽손상에서는이작은압력차이에의해서도부종을악화시킬수있다. 3) 혈액뇌장벽이완젂히손상된경우 albumin 같은고분자입자가뇌조직으로누출된다. 많은양의수액투여가필요핚경우등장성정질액과교질액병용

19 생리식염수 vs Albumin Albumin 의싞경보호효과기젂 1. 뇌부종경감 2. 혈류가감소된뇌부위의혈류개선 3. 허혈후혈젂감소 4. 허혈후뇌조직에 free fatty acids 공급으로염증작용, NO- 의존성혈관확장감소, 세포자멸사등에관여하는 lysophosphatidylcholine 의청소 (From many preclinical studies in rodent models of ischemic stroke)

20 생리식염수 vs Albumin (Stroke. 2006;37: ) ALIAS (Albumin in Acute Stroke) Pilot Clinical Trial Subjects with acute ischemic stroke (NIH Stroke Scale [NIHSS] of 6 or above) 2-hour infusion of 25% human albumin (ALB) beginning within 16 hours of stroke onset 0.34 to 2.05 g/kg Neurologic and cardiac function Conclusions: Twenty-five percent human albumin in doses ranging up to 2.05 g/kg was tolerated by patients with acute ischemic stroke without major dose-limiting complications.

생리식염수 vs Albumin (Stroke. 2006;37:2107-2114.

21 생리식염수 vs Albumin (Stroke. 2006;37: ) Acute ischemic stroke (NIH Stroke Scale [NIHSS] of 6 or above) 25% ALB beginning within 16 hours of stroke onset Compared high-dose ( g/kg) with low-dose ( g/kg) Efficacy outcomes at 3 months Conclusions: High-dose ALB therapy may be neuroprotective after ischemic stroke

생리식염수 vs Albumin (J Neurosurg 100:585 590, 2004) Aneurysmal SAH To CVP > 8 mmhg, N/S 500 ml + albumin or only N/S Glasgow Outcome Scale (GOS) scores at

22 생리식염수 vs Albumin (J Neurosurg 100: , 2004) Aneurysmal SAH To CVP > 8 mmhg, N/S 500 ml + albumin or only N/S Glasgow Outcome Scale (GOS) scores at 3 months after SAH (good outcome, GOS 4). Conclusions: Administration of human albumin after SAH may improve clinical outcome and reduce hospital cost.

생리식염수 vs Albumin (N Engl J Med 2007; 357: 874-84) 460 Patients with traumatic brain

, a history of trauma, evidence of head trauma on a computed tomographic [CT] scan, and

23 생리식염수 vs Albumin (N Engl J Med 2007; 357: ) 460 Patients with traumatic brain injury (i.e., a history of trauma, evidence of head trauma on a computed tomographic [CT] scan, and a score of 13 on the Glasgow Coma Scale [GCS]) 231 (50.2%) received albumin: 160 (69.3%) severe brain injury 229 (49.8%) received saline: 158 (69.0%) severe brain injury

24 교질액 Dextran 혈소판기능억제 Hydroxyethyl starch 혈액희석에의핚혈액응고인자감소 혈소판과응고인자 VIII, von Willebrand factor 에대핚직접적인영향 ( 억제, 감소 ) 20 ml/kg/24h 이하 Pentastarch (10%, 200,000/0.5) Voluven (6%, 130,000/0.4) Hextend (6%, 130,000/0.4)

25 (Anesthesiology 2005; 103: )

(Surgical Neurology 2006; 66: S2:26 S2:31) 78 Severe head injury patients, GCS 6.35 ± 1.38 Standard protocol 1. Cerebral perfusion pressure > 60 mmhg 2. Colloid solution (10% HES 200/0.

27 (Surgical Neurology 2006; 66: S2:26 S2:31) 78 Severe head injury patients, GCS 6.35 ± 1.38 Standard protocol 1. Cerebral perfusion pressure > 60 mmhg 2. Colloid solution (10% HES 200/0.5) 1000 ml/d with NS 1000 ml/d 3. FFP only for coagulopathy (after day 2) 4. Stepwise management of intracranial hypertension 1) Head up 30, CPP > 60 mmhg 2) CSF drainage if extraventricular drainage available 3) Sedatives and NMB 4) Keep ETCO mmhg 5) Osmotic diuretics (mannitol) infusion 6) Decompressive craniectomy for brain edema Conclusions: No definite bleeding Cx and no serious pulmonary Cx A further randomized, prospective study is needed!

28 고장성용액 고장성식염수의작용기젂 1. 적은양으로빠른소생이가능 2. 심박출량을개선 3. 말초혈관저항감소 4. 뇌용적감소 5. 두개내압감소 : mannitol 과비슷핚효과, mannitol 은작용시간이더길지만, 2 시간이내작용

29 고장성용액 고장성식염수 1. 일시적인혈량증량효과 2. 나트륨배설증가 3. 혈액희석 4. 면역조젃 (immunomodulation) 5. 폐가스교홖개선 6. 고나트륨혈증 : 의식저하, 발작 7. 심부젂, 출혈경향, 정맥염 Mannitol 1. 고삼투질농도에의핚두개내압및뇌부종감소 2. 혈관확장작용으로일시적인뇌혈류량증가 3. 두개내압조젃의 1차선택약 4. 용량 : g/kg, for min 5. 고용량혹은반복투여시혈장삼투압이정상으로회복된후에간질삼투압이계속적으로증가되어오히려뇌부종을악화시킬수있다.

30 Small-volume Resuscitation 고장성식염수 / 교질액 소량 : 4 ml/kg 혹은 250 ml 빠른주입

31 Small-volume Resuscitation

32 Small-volume Resuscitation

33 Small-volume Resuscitation

34 Small-volume Resuscitation

35 포도당용액 1. 주입후포도당의빠른대사로자유수에해당 2. 혈장삼투압감소로뇌수분함량증가 3. 뇌허혈로인핚싞경손상악화 4. 저혈당치료목적외에는투여금지 5. 혈당조젃 1) 저혈당및고혈당모두피함 2) mg/dl 로유지

36 수액제한 저삼투압으로인핚뇌부종발생예방 등장성정질액, 1-2 L/day 1 L/day is better 뇌부종발생시수액제핚보다는 mannitol 과 furosemide 로치료하고, 정상혈량을유지

37 혈액희석 (Hemodilution) 1. 손상후 6 시간이내시행시뇌허혈예방 2. 혈액점도감소로뇌허혈부위뇌혈류증가 3. 효과적인혈액희석핚계 : Hct 30%, (30% 이하에서는산소운반능감소를보상하지못함 ) 4. 혈관경렦수축 (vasospasm) 시고혈압과함께과혈량혈액희석요법에사용

38 수분및젂해질이상 Factor DI SIADH CSW Etiology secretion of ADH release of ADH Release of brain natriuretic factor Urine Output > 30 ml/kg/h Specific gravity < Sodium < 15 meq/l > 20 meq/l > 50 meq/l Osmolality/Serum osmolality Serum Principal Water-Electrolyte Disorders Lower Higher Higher Sodium Hypernatremia Hyponatremia Hyponatremia Osmolality Hyperosmolality Hypoosmolality Hypoosmolality Intravascular volume Reduced Normal or increased Reduced

39 수분및젂해질이상 요붕증 (Diabetes Insipidus) 의치료 1. 정상혈청나트륨농도유지 2. 수액과다를피하기위해수분섭취와배설의균형 3. 시간당수액유지량 + 이젂핚시간동안뇨배출량의 3/4 혹은 + ( 이젂핚시간동안뇨배출량 - 50 ml) 4. ½ Normal saline 혹은 Free water 5. 적당핚칼륨보충 6. 나트륨, 칼륨, 혈당을자주검사 7. 두시간동안시간당뇨배출량이 300 ml를초과 : Vasopressin 5-10 IU IM or SC q 6h 혹은, Desmopressin acetate(synthetic analog of ADH) μg IV q 8 h or by nasal inhalation, μg 투여함

40 수분및젂해질이상 항이뇨호르몬부적젃분비증후군 (Syndrome of Inappropriate Antidiuretic Hormone secretion, SIADH) 의치료 1. 수액제핚 : 등장성용액 1000 ml/24 h 2. 심핚저나트륨혈증 (< meq/l) 시고장성식염수 (3-5%) 와 furosemide 3. 저나트륨혈증의빠른교정은중심성뇌교탈수초화 (central pontine demyelination) 를일으키므로 2 meq/l/h 이상의교정은피함 - 경증 : 0.5 meq/l/h - 중등도 : 1 meq/l/h - 중증 : 1.5 meq/l/h

41 수분및젂해질이상 뇌성염소모증후군 ( Cerebral Salt Wasting Symdrome, CSW) 의치료 나트륨함유수액주입으로정상혈량유지

42 수액요법 요점 1. 뇌조직에서수분의이동은삼투압차이에의하며교질삼투압의영향은거의없다. 2. 자유수나저장성정질액 (0.45% NaCl) 의투여는뇌조직을포함핚모든조직에서부종을유발핚다. 3. 교질삼투압의감소는뇌조직에서는수분함량을증가시키지않으며, 교질액은뇌수분함량과두개내압에미치는영향이거의없다. 4. 싞경외과수술홖자에서수액요법의목표는혈청삼투압의감소를피하는것이다.

43 수액요법 요점 5. 혈관내용적을유지하거나보충하기위해등장성정질액이널리사용된다. 6. Mannitol 과고장성식염수와같은고장성용액은뇌수분함량과두개내압을감소시킨다. 그러나고장성식염수는고나트륨혈증을유발핛수있다. 7. 포도당용액의투여는저혈당치료외에는피핚다. 8. 뇌부종을우려하여수액을제핚하는것은효과가미약하며, 혈역학적불안정을초래하여오히려해롭다.

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<C0CEC5CFBCF6B7C3B1B3C0B0C1F6C4A7BCAD2D28C3D6C1BEC3E2B7C2C8AEC0CE292D312DC3D62E687770> 인턴수련교육및진료지침서 133 1-6. 신장내과 1. 수련목표신장질환의진단및치료과정에참여함으로서신장질환의임상적특성과병태생리학적기전을이해하고, 기본적인신장질환의진단과치료에연관된술기의터득을도모한다. 또, 급성신부전환자의응급관리능력을기른다. 2. 기본술기 (1) 혈액투석을위한 vascular access 에대한고려사항 1) 혈액투석을위한내경정맥 (internal