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1 대한화상학회지제 19 권제 2 호 73 Journal of Korean Burn Society Vol. 19, No. 2, 73-81, 2016 ORIGINAL ARTICLE 돼지모델에서상처및화상치유과정의표면온도변화 김승환ㆍ이대로 1 ㆍ송근정 2 ㆍ이성준 3 ㆍ신명하 4 ㆍ오성범 5 ㆍ권인선 6 ㆍ황태식 1 충남대학교의과대학응급의학과, 1 대구파티마병원응급의학과, 2 성균관대학교의과대학삼성서울병원응급의학과, 3 베스티안중앙연구소, 4 베스티안부산병원, 5 단국대학교의과대학응급의학과, 6 충남대학교병원임상시험센터 The Change of Surface Temperature in Healing Process of Wound and Burn in Porcine Model Seung Hwan Kim, M.D., Dae Ro Lee, M.D. 1, Keun Jeong Song, M.D. 2, Sung-jun Lee, M.S. 3, Myung Ha Shin, M.D. 4, Seong Beom Oh, M.D. 5, In Sun Kwon, Ph.D. 6 and Tae Sik Hwang, M.D. 1 Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, 1 Department of Emergency Medicine, Daegu Fatima Hospital, Daegu, 2 Department Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 3 Bestian Research Center, Daejeon, 4 Burn Center, Bestian Busan Hospital, Busan, 5 Department of Emergency Medicine, Dankook University College of Medicine, Cheonan, 6 Chungnam National University Hospital Clinical Trial Center, Daejeon, Korea Purpose: The goal of wound managements are to prevent further tissue injury during dressing changes, and absorb the excessive exudates, provide moist condition, reduce the infection. But the usual dressing methods have several limitations to serve the information about wound surface environment. Moist, pressure, temperature, ph are the important factors that give us the information about the healing process phase, speed of healing, & the risk of infection. Methods: We made full thickness wounds & burn on porcine model, then assessed the surface temperature intermittently until repithelialization were completed, and size measurement were done with Image Pro Plus 6.0. Results: In wound areas, the surface temperature was lowest at post operation #1 day, then slightly increased till POD #21 days, and again down slope curvature. In burn area, the surface temperature was highest at POD #1 day, then slightly decreased till POD # 21 days, and more fall curvature. Modern sensing technology along with wireless radio frequency communication technology is posed to make significant advances in wound management. Our result will be a basic data for the future researches about the surface temperature monitor to detect the early infection and the intervention to modulate the surface temperature to increase the rate of epithelialization. Conclusion: The result of the correlation between the surface temperature and area reduction have weak or moderate negative Pearson correlation coefficient. (J Korean Burn Soc 2016;19:73-81) Key Words: Wound-surface interface, Wound surface temperature, Wound area reduction, Dressing, Capillary perfusion 서 치료에사용되는드레싱은연고, 크림, 용액등다양한형태로발전되었고, 이러한드레싱재료는상처주변환경에영향을준다. 상처주변환경에대한명확한정의가없는데, external microenvironment는상처바깥쪽으로상처표면과인접한부위이고, internal microenvironment는상처표 접수일 : , 수정일 : , 승인일 : 책임저자 : 황태식, 대구시동구아양로 , 대구파티마병원응급의학과 Tel: , Fax: emhwang1@hanmail.net 론 면아래에인접한부위로다양한세포와세포외기질 (extracellular matrix) 로이루어진다 1). 상처치료는드레싱과정에추가적인손상이발생하는것을방지하고, 과도한삼출액은흡수하고상처표면이건조되는것을막고, 감염발생위험을줄이는등상처주변환경개선을통해상처치유를가속화하는데초점을맞춰왔다 2). 상처표면온도는기본적으로외부온도와상처부위로의혈류량에의해결정되는데, 표면온도변화를측정하는것은상처관리에도움을줄수있다. 급성기상처에서상처표면온도는국소적인혈관확장에의해상승하게되는데, 이는손상된부위로추가적인산소와영양분을전달하기위한정상적인신체반응이다 3). 기존에보고된상처-표면접점 (interface) 온도에있어임상적으로중요한 2가지내용

2 74 대한화상학회지 Vol. 19, No. 2, 2016 은자발적으로치유되는급성기상처는상처주변정상피부조직보다높지않다는것과만성상처에서상처표면온도가갑자기상승하면감염의증거로생각해야한다는것이다 4-6). 표면온도측정방법중하나인 thermography는화상깊이측정에사용되었는데, 화상깊이가깊으면표면혈관손상이심해혈액관류 (perfusion) 가감소하기때문에얕은화상에비해표면온도가낮다고보고되었다 7). 부분층화상과전층화상간에는약 2 o C 정도의온도차이가있었고 8), 화상환자를대상으로한실험에서는정상피부와화상피부사이에 1 o C 온도차이가있다고한다 9). 한편슬관절전치환술 (total knee replacement) 시행후 C-reactive protein과수술부위피부표면온도를측정해서감염발생여부를확인한연구에서는감염이발생하지않더라도수술부위는상처치유과정에일어나는염증반응으로수술하지않은부위에비해표면온도가 6주까지평균 1 2 o C높게유지되었는데, 수술한부위피부표면온도는 o C, 수술하지않는부위피부표면온도는 o C였다 10). 저자는상처치유과정에서역동적으로변화하는상처표면상태를반영하는다양한인자들중표면온도의역할을알아보고자본연구를진행하였는데, 돼지모델에서동일한돼지에각각상처와화상을만들고, 감염이나다른합병증없이치유되는과정에표면온도를일정한간격으로측정해서상처와화상에서의온도변화과정을알아보고, 더불어표면온도변화와상처및화상의치유과정에서면적감소와의관련성을알아보고자한다. 1. 동물 (animal) 대상및방법 본연구의실험은 AAALAC International (Association for Assessment and Accreditation of Laboratory Animal Care International) 인증기관인삼성생명과학연구소동물실험윤리위원회의검토와승인을거쳤으며, 위원회의실험동물관리와사용에관한지침을준수하며시행하였다 11). 2 3개월수령의암컷돼지 (25 kg) 2마리를실험에사용하였다. 환경은 18 o C 기온과 60% 의습도를유지하면서규칙적으로사료를먹이고, 물은자유롭게섭취할수있도록하였다. 12시간주기로점등과소등을반복하였다. 피부및상처부위에추가적인손상을주지않도록모서리가둥근스테인레스울타리로만든우리에격리해서사육하였다. 2. 마취및진통 (anesthesia & analgesic) Zoletil R (Virbac Korea, 대한민국 ) 5 mg/kg와 Rompun R (Xylazine, 바이엘코리아, 한국 ) 1 mg/kg을섞어귀뒤쪽 목근육에근주하여마취를유도하였고, 돼지가마취되면체중을측정하고, 수술실로옮겨흡입마취제 Furane R ) 을사용해서마취를유지하였는데, 흡입마취기를통해마취제와함께 2 3 L/min의산소를함께공급하였고, 흡입마취기연결관사이에 end tidal CO 2 sensor를부착해서값을측정하였다. 수술실침대에는온열기가장착되어있어실험진행과정에섭씨 o C를유지했다. 심전도유도 (electrode) 를왼쪽앞발, 오른쪽앞발, 왼쪽뒷발에붙여심전도를모니터링하였고, 중심체온 (core temperature) 측정으로위해입을통해식도위치까지체온측정 probe를삽입하였고, 맥박산소측정기 (pulse oxymeter) 를귀에부착해서산소포화도 (oxygen saturation) 를측정하였고, 귀에정맥로를확보하고, 생리식염수 (0.9% normal saline R, 중외제약, 대한민국 ) 를연결하였다. 수술후통증조절을위해서는 Metacam (Boehringer Ingelheim, Germany) 0.2 mg/kg를마취회복중근주하였다. 3. 상처및화상 (wound & thermal burn) 마취된돼지를엎드린자세로눕히고, 등쪽부위의털을깎은다음베타딘용액 (Povidone R ) 과알코올 (ethyl alcohol) 로소독하였다. 등부위를제외한다른부위는소독포로덮어주변부위로부터의오염을차단하였다. blade #15을사용해서 4군데에 4 4 cm 크기로 panniculus carnosus까지피부전층 ( 두께약 0.8 cm) 을제거하여상처를만들었다. 화상은직경 2 cm 크기의원형인두를섭씨 o C로 30초간접촉하여유발하였는데, 각각의부위에 3번씩원형화상이겹쳐지도록하였다. 상처와화상배열은위치에따른변수를줄이기위해서로마주보도록하고, 머리쪽에서엉덩이쪽을향해왼쪽, 오른쪽에각각한부위씩 4쌍을만들었으며, 드레싱과정에삼출액이번지는것을방지하고자같은쪽상처끼리도 4 cm 이상간격을유지하였다. 1번, 4번, 5번, 8번은상처이고, 2번, 3번, 6번, 7번은화상이다 (Fig. 1). 4. 온도측정열화상카메라 (FLIR P620, infrared camera Hongkong) 촬영은첫째날은상처와화상을유발하고 30분경과한다음촬영하였고, 이후에는드레싱교체를하면서이전드레싱재료를제거한직후촬영하였다. 온도는열화상카메라촬영으로측정하였는데, 상처, 가장자리, 치유부위등 3군데값을비교하였다. 상처및화상은상처및화상의중심부위, 가장자리는상처및화상과정상피부경계에서상처부위쪽, 치유부위는상처및화상과정상피부경계에서상피화가이루어진부위값을선택하였는데, 상처와화상부위를 9등분해서상처및화상, 가장자리, 치유부위등에가장

3 김승환등 : 돼지모델에서상처및화상치유과정의표면온도변화 75 근접한부분의온도를선택하였다. Fig. 2는열화상카메라로 A 돼지 1번상처를 11일째촬영한사진이고, Fig. 3은동일한화면에서상처부위를 9등분해서각각의온도를구한사진이다. 5. 드레싱 (dressing) 상처와화상은멸균생리식염수를적신거즈를사용해서삼출액이나이물질을닦아내고, 상처부위에는첫째날부터마지막날까지 Mupirocin ( 뉴젠팜, 한국 ) 을도포하고, 그위에드레싱재료를선택해서사용하였고, 화상부위에는 첫째날은 mupirocin, 둘째날부터가피가형성되어있는동안에는 mafede (mafenamic acetate, 한국유니팜, 한국 ), 가피절제술을시행한후에는다시 mupirocin을도포하고, 선택한드레싱재료를사용하였다. 상처와화상을유발하고삼출액양이많은 1주차에는 4번 / 주드레싱을하였고, 2주차부터는삼출액이줄어들어평균 2번 / 주드레싱하였다. 드레싱을하는과정에도위에설명한마취와진통방법을동일하게시행하였다. 드레싱재료는 nylon #3.0으로일차봉합을해서고정하고, 주변에 Op-site (Smith & Nephew, Hull, UK) 를붙여삼출액의누출을방지했고, 전체적으로다시 hypafix (BSN medical, Hamburg, Germany) 를붙였고, 마지막은 Peha- Fig. 1. The experimental pig photography and the number of wound & burn. Fig. 2. The photography of infrared camera. Pig A number 1 wound, POD 11 day. Fig. 3. The photography of infrared camera, 9 division. Pig A number 1 wound, POD 11 day.

4 76 대한화상학회지 Vol. 19, No. 2, 2016 haft (Paul Hartman, Heidenheim, Germany) 로마무리하였다. 일차드레싱 (primary dressing) 재료로는 Mepitel One (Moelnlycke Healthcare, Goeteborg, Sweden), Aquacel Ag (Convatec, London, UK), Aquacel (Convatec, London, UK), Acticoat (Smith & Nephew, Hull, UK) 중에서선택하였고, 이차드레싱 (second dressing) 재료로는 Mepilex (Moelnlycke Healthcare, Goeteborg, Sweden), Mepilex Ag (Moelnlycke Healthcare, Goeteborg, Sweden), Versivas XC (Convatec, London, UK), DuoDerm CGF (Convatec, London, UK) 중에서선택하였는데, 상처바닥의상태와삼출액양을근거로선택하였다. 3번, 6번화상부위는화상후 2일째 blade #15를사용해서가피절제술을시행하였고, 2번, 7번화상부위는화상후 8일째동일한방법으로가피절제술을시행하였다. 상처의치료및관찰은수상후 30일간시행하였다. 6. 면적측정, 균배양검사및분석상처및화상부위면적측정은카메라로촬영을하는데, 6*6 cm 크기의기준틀을대고촬영하였고, 기준틀안의전체면적에서상처부위 pixel 수를 Image Pro Plus 6.0 (Media Cybemetics, Inc., Silver Spring, MD) 으로계산해서피부재상피화에따른크기감소정도를측정하였다. 수술 14일째 cotton swab 방법으로균배양검사를실시했는데, Trypticase soy agar (TSA), Sabouraud dextrose agar (SDA) 배지를사용하여 colony count를구했는데, TSA는섭씨 37 o C에서 2일, SDA는 25 o C에서 7일배양하였다. 상처및화상부위의표면온도변화값과화상에서가피절제술을 2 일째시행한 3번, 6번과 8일째시행한 2번, 7번간에표면온도변화값을 t-test와 Mann-Whitney U test로비교하였고, P값이 0.05 미만인경우에통계적으로유의성이있다고해석하였으며, 상처및화상부위의표면온도변화와면적변화관계에서 Pearson correlation coefficient를구하였다. 결과실험기간동안돼지의체중변화와수술및드레싱교체과정에서의심박동수, 중심체온, 맥박산소포화도, 호기말이산화탄소분압, 수술대온도등을측정하였는데, 체중은실험기간동안꾸준히증가하였고, 마취과정동안심박동수, 중심체온, 맥박산소포화도, 호기말이산화탄소분압, 수술대온도등에서특이사항은관찰되지않았다 (Table 1). 돼지가와돼지나의 1번, 4번, 5번, 8번상처부위평균온도변화는상처를만들었을때표면온도가가장낮았고, 상처가치유되는과정에서표면온도는상승하다가피부상피화가마무리되는 POD 21일째급격히감소되는결과를보였고, 상처중심, 가장자리, 치유부위모두유사한변화과정을나타냈다 (Fig. 4, 5). 돼지가와돼지나의 2번, 3번, 6번, 7번화상부위평균온도변화는화상을만들었을때표면온도가가장높았고, 화상이치유되는과정에서표면온도는감소하다가피부상피화가마무리되는 POD 24일째감소폭이커지는결과를보였고, 화상중심, 가장자리, 치유부위모두유사한변화과정을나타냈는데, 상처에비해변화폭이큰모습을보였다 (Fig. 6, 7). 돼지가와돼지나의 1번, 4번, 5번, 8번상처부위면적변화는 POD 8일째까지변화가없다가 POD 11일째부터급격히감소하는결과를보였다 (Fig. 8, 9). 돼지가와돼지나의 2번, 3번, 6번, 7번화상부위면적변 Table 1. The Basic Physiologic Data of Experimental Pig Op day Average Pig A Weight (kg) Heart rate (/min) Core temperature ( o C) O2 saturation (%) EtCO2 (mmhg) Bed temperature ( o C) Pig B Weight (kg) Heart rate (/min) Core temperature ( o C) O2 saturation (%) EtCO Bed temperature ( o C)

5 김승환등 : 돼지모델에서상처및화상치유과정의표면온도변화 77 Fig. 4. The average temperature change of wound, Pig A. Fig. 7. The average temperature change of burn, Pig B. Fig. 5. The average temperature change of wound, Pig B. Fig. 8. The wound area change, Pig A. #1, 4, 5, 8: the number of wound. Fig. 6. The average temperature change of burn, Pig A. Fig. 9. The wound area change, Pig B. #1, 4, 5, 8: the number of wound. 화는 POD 11일째까지변화없다가돼지가는 POD 18일째부터, 돼지나는 POD 15일째부터급격히감소하는결과를보였다 (Fig. 10, 11). 상처및화상부위의조직학적변화는 Table 2에정리하였다. POD 18일째시행한균배양검사에서 TSA 배지에서는돼지나의 2번과 5번, SDA 배지에서는돼지나의 2번에서

6 78 대한화상학회지 Vol. 19, No. 2, 2016 Fig. 10. The burn area change, Pig A. #2, 7, 3, 6: the number of burn. Fig. 11. The burn area change, Pig B. #2, 7, 3, 6: the number of burn. Table 2. The Histopathologic Finding of Wound & Burn Op day Identify the depth of wound & burn POD 3 Not found any interval change POD 8 Frequently identify the infiltration of inflammatory cells, mainly neutrophil POD 15 A lot of cell infiltration, especially mononuclear cell & macrophage Active differentiation of fibroblast (swollen appearance, found nucleoli & division of nucleus, irregular array) Active angiogenesis (perpendicular growth of capillary toward skin surface.) Maturation of granulation tissue POD 21 Maintained cell infiltration but less than POD 15. Maintained differentiation of fibroblast, and found a few regular array. Maintained angiogenesis (the capillary made a lumen, & parallel direction). POD 28 Marked decreased cell infiltration Rarely found differentiation of fibroblast, but mature appearance & regular array. Found clear lumen of capillary Found epidermis, & indentation of basal layer Table 3. The Result of Wound Culture, #POD 18 Sample TSA* (Colony number) SDA (Colony number) Pig A Pig B Pig A Pig B 1-18 TNTC TNTC TNTC TNTC 2-18 TNTC No bacteria TNTC No bacteria 3-18 TNTC 583 TNTC TNTC TNTC TNTC TNTC No bacteria TNTC TNTC TNTC TNTC TNTC 179 TNTC TNTC TNTC TNTC 1 *TSA = Trypcase Soy Agar, SDA = Sabouraud Dextrose Agar, TNTC = Too Numerous To Count. no bacteria가나왔고, 다른상처와화상에서는 TNTC 혹은 bacteria colony number를확인하였다 (Table 3). 상처와화상부위에대한표면온도변화값을비교하면 t-test에서 P값 0.052로통계학적차이가없었고, Mann- Whitney U test로중앙값을비교해도 P값 0.152로차이가없었다. 한편표면온도와면적변화를 Pearson 상관관계로

7 김승환등 : 돼지모델에서상처및화상치유과정의표면온도변화 79 Table 4. Pearson s Correlation Coefficient between Surface Temperature and Area Change Wound & burn area Pig A Pig B Center temperature change (0.354) (0.006) Margin temperature change (0.008) (0.123) Healed area temperature (0.0001) (0.0001) change 분석해보면모두음의상관관계를보였는데, 돼지가의가장자리온도변화와치유부위온도변화, 돼지나의가장자리온도변화는 사이의중등도음의선형관계를보였고, 돼지가의중심온도변화와돼지나의가장자리온도변화는 사이의약한음의선형관계를보였다 (Table 4). 고 상처표면의미세환경 (microenvironment) 은주변환경 (atmosphere), 드레싱, 전신순환에의해영향을받는모세혈관, 상처부위의다양한세포등의상호작용에의해변하게되고, 온도, 압력, 습도, 산소및이산화탄소농도, ph, 등의인자들이상처상태를반영하는지표가될수있는데, 이들에대한비침습적모니터링의방법은정상적인상처치유과정의진행정도와치유지연여부, 감염발생여부등을확인할수있는수단으로사용할수있다 1). Dehennis 등은상처표면에서온도, 압력, 습도를, Schielierf 등은온도와압력을측정하는방법을고안했지만충분한임상실험의결과는보고되지않았다. 상처표면의외부환경을모니터하고, 교정할수있는적절한기술과기구를적용한다면상처치유과정에서상처상태에대한객관적인데이터와치료결과를얻을수있고, 궁극적으로는상처상황에따라보다개별적인치료적접근을할수있게된다 12,13). 상처표면온도에영향을줄수있는내용을단계별상처치유과정으로나누어살펴보면첫번째단계인 vascular response에서는지혈과응고과정에서일시적인혈관수축이발생하여국소적인관류감소로인한산소공급부족과 glcolysis 증가, ph 변화가발생한다 14). 일시적혈관수축은연이은혈관이완으로연결되고, 두번째단계인 cellular response 과정의염증반응이일어난다. 2 5일정도지속되는염증반응단계에서는다양한면역관련세포들의작용이이루어지면서 pathogen과 cell debris에대한 phagocytosis 가진행되고, growth factor, cytokine, chemokine들이분비된다 15). 세번째증식단계에서는육아조직생성이중심인 찰 데, 3일 10일에걸쳐신생혈관증식과각질세포재생이이루어지고, 평균적으로 21일정도가지나면서네번째단계인상처부위의 remodeling이시작된다. 상처부위표면온도를보다섬세하게측정한다면 vascular response에서는일시적표면온도저하후상승이이어질것이고, cellular response에서도염증반응의진행에따른온도상승이유지되고, 증식단계에서는혈관재생에따른온도상승이있다가각질세포가재생되면서표면과혈관사이의간격이커져온도저하가이어질것이다 16). Fig. 4와 Fig. 5의상처부위표면온도변화는상처발생 1일째온도가가장낮았고, 시간이경과하면서온도가상승하다가상처가마무리되는시기에온도가감소하는경향을보였고, Fig. 6과 Fig. 7의화상부위표면온도변화는화상발생 1일째온도가상대적으로높았고, 시간이경과하면서온도가감소하다가화상이마무리되는시기에온도감소폭이증가하는경향을보였다. 상처에서는표피와진피를모두제거하였기에표면온도에영향을주는혈액순환량이절대적으로감소하여온도저하가발생하였다고판단되고, 반면화상부위의경우화상깊이에따라피부로공급되는혈액순환감소에차이가있는데, 조직학적표본을통해화상깊이를검증하였을때부분층화상과전층화상이혼재되어있었다. 따라서가피절제술을시행하기전까지는부분적으로혈액순환이유지되는부위가있어표면온도도전층손상을유발한상처에비해상대적으로높게유지되었다고추정된다. 가피제거술을 2일째시행한 3번과 6번화상부위가 7일째시행한 2번과 7번화상부위보다돼지나에서는그룹간차이가있게온도가낮았다. 하지만돼지가와돼지나를비교했을때도차이가있었기때문에이를일반화하기에는무리가있을것으로판단된다. 동물모델에서화상표면온도는증발에따른열손실혹은증발에따른냉각효과등에의해부분층화상도전층화상으로잘못판단할수있다고하고, 전층화상에서도수포가유지되는상태라면열손실을막아주기때문에부분층화상으로판단할수있다고한다. 이러한변수는화상후 4일이내에특히두드러진다고한다 17). 삼출액정도를비교하면상처부위와화상부위가삼출액이가장많은부위이고, 치유부위는삼출액이없고, 가장자리는삼출액이상대적으로적었는데, 온도변화를측정한대부분의시기에치유부위와가장자리가상처및화상부위에비해온도가높게나왔다. 각각의상처및화상부위는동일한드레싱을시행한상태이기에표면온도측정후 9등분을통해각각의상처및화상에서지역적인표면온도를비교했을때차이가있다는것은혈액순환의차이와함께삼출액정도도영향을미쳤을것으로판단된다.

8 80 대한화상학회지 Vol. 19, No. 2, 2016 상처및화상부위온도변화와넓이변화와의관계에서음의상관관계를보였는데, 피어슨상관계수는 0.137과 0.226과같은약한음적선형관계를보인경우도있고, 0.384에서 0.533까지의뚜렷한음적선형관계를보인경우가있었다. 본연구결과를근거로온도가높을수록면적감소가빨리이루어졌다라고확대해석할수는없지만, 온도가높으면혈액순환이증가된상태로상피화진행이빠를것으로예상되며, 반면상피화진행이빨리이루어지면상대적으로혈관으로부터표면까지의거리가늘어나기때문에표면온도는오히려감소될수도있다. 치료목적으로 pressure ulcer에 heat radiating dressing을사용하게되면모세혈관순환및산소분압증가로상처치유가향상된다고하는데 18-20), Khan 등은부분층피부이식공여부위에간헐적으로 1시간동안섭씨 38도까지의열을전달했을때진피층의혈액순환이증가하였고, lymphocyte extravasation이향상되었다고보고하였다 21). Kloth 등은 pressure ulcer에 heating element를사용해서하루에 3번, 1시간씩 12주동안온열치료를하였을때온열치료를하지않은군에비해상처면적이감소하는속도가 0.52 cm 2 vs 0.23 cm 2 /week로빨랐다고한다 22). Pressure ulcer 환자에서 thermography를사용해서 periwound와의온도차이를확인하였는데, peri-wound보다 pressure ulcer부위온도가낮은군에서는 3주동안상처크기감소가 30% 이상이루어진반면, peri-wound보다 pressure ulcer 온도가높은군에서는상처크기감소가지연되었다는보고가있다 23). 임상적으로발적이나부종과같은감염소견이뚜렷하지않은상태에서 thermography를사용해서표면온도를측정했을때염증반응이진행되고있는부위는정상피부부위에비해상대적으로온도가높게나왔다고한다 24,25). 본연구에서균배양결과를보면대부분의상처및화상부위에서 colony count가높게나왔는데, 임상적으로감염으로판단될만한소견은치료과정에발생하지않았고, 상처및화상치유기간의지연을유발하지않았다. 그리고 colony count가높지않았던돼지나의 2번화상과 5번상처가다른화상과상처부위와비교했을때치유과정에서의온도변화와면적변화에뚜렷한차이를보이지않았다. 하지만임상적으로는화상에서 surgical wound infection이유발되면수술적치료빈도가늘어나고, 이식된피부의착상에악영향을주며, 치료기간의지연이유발되고, 더불어요로감염이나폐렴, catheter related infection, 공여부감염등의 nosocomial infection도증가할수있기때문에화상부위의 colonization 발생을줄이는것이중요하다 26). 한편표면온도측정에있어 thermography 사용은변수가많고, 측정방식에따른차이가있기때문에 손상부위와정상피부사이의열전도 (conductivity) 와열확산 (diffusivity) 차이를이용한방식이제시되었는데, 기본적인표면온도측정을하고, 이후할로겐램프로열을가한후시간에따른온도변화를측정하는방식이다 27). 적절한드레싱재료로상처및화상을덮어치료하는것은삼출액을흡수하고, 통증을완화시키며, 상처치유속도를빠르게해주기위함인데, 기존의드레싱방식은상처표면상태에대한정보제공에한계가있다. 상처표면의습도, 압력, 온도, ph 등은치유속도, 감염여부, 치유단계등을반영하기에드레싱재료에이들인자를측정할수있는 sensor를삽입해서정보를얻는다면반복적으로드레싱을떼서확인하지않더라도 wound care decision making 을할수있게된다. 온도를측정하는센서와드레싱재료를결합해서상처표면온도를모니터하는방법이최근연구되고있는데, 드레싱재료에소형화된센서를넣어연속적으로온도를측정하는방법으로 radio frequency identification device (RFID) 혹은 platinum based sensor를사용하여전기적저항을측정해서온도를계산하는방법이다 28). 결론저자는돼지에상처및화상을유발하고, 임상적으로감염소견없이치유되는과정동안표면온도를측정하고, 온도변화와면적변화과정을함께측정하였는데, 상처부위평균온도변화는상처를만들었을때표면온도가가장낮았고, 상처가치유되는과정에서표면온도는상승하다가피부상피화가마무리되는 POD 21일째급격히감소되는결과를보였고, 화상부위평균온도변화는화상을만들었을때표면온도가가장높았고, 화상이치유되는과정에서표면온도는감소하다가피부상피화가마무리되는 POD 24일째감소폭이커지는결과를보였다. 상처부위면적변화는 POD 8일째까지변화가없다가 POD 11일째부터급격히감소하는결과를보였고, 화상부위면적변화는 POD 11일째까지변화없다가돼지가는 POD 18일째부터, 돼지나는 POD 15일째부터급격히감소하는결과를보였다. 그리고표면온도와면적변화를 Pearson 상관관계로분석해보면모두음의상관관계를보였는데, 돼지가의가장자리온도변화와치유부위온도변화, 돼지나의가장자리온도변화는 사이의중등도음의선형관계를보였고, 돼지가의중심온도변화와돼지나의가장자리온도변화는 사이의약한음의선형관계를보였다. 실험동물개체수가적어위에서측정한결과를일반화할수없지만, 이번연구결과가추후상처및화상치료에서표면온도측정을통한감염여부발생을진단하는연구나표면

9 김승환등 : 돼지모델에서상처및화상치유과정의표면온도변화 81 온도변화를유도하여치유속도차이와의관련성을확인하는연구에서기본적인자료로사용할수있을것으로기대한다. REFERENCES 1) Kruse CR, Nuutila K, Cameron CY, Lee BS, Kiwanyka E, Signh M, et al. The external microenvironment of healing skin wounds. Wound Repair Regen 2015;23: ) Junker JP, Kamel RA, Caterson EJ, Eriksson E. Clinical impact upon wound healing and inflammation in moist, wet, and dry environment. Adv Wound Care 2013;2: ) Wilmore DW, Aulick LH, Mason AD, Pruitt BA. Influence of the burn wound on local and systemic responses to injury. Ann Surg 1977;186: ) Martinez-Jimenez MA, Aguilar-Garcia J, Valdes-Rodriguez R, Metlich-Medlich MA, Dietsch LJ, Gaitan-Gaoga FI, et al. Local use of insulin in wounds of diabetic patients: higher temperature, fibrosis, and angiogenesis. Plast Reconstr Surg 2013; 132:1015e-9e. 5) Nakagami G, Sanada H, Iizaka S, Kadono T, Higashino T. Predicting delayed pressure ulcer healing using thermography: a prospective cohort study. J Wound Care 2010; 19:465-6, 8, 70 passim. 6) Kelechi TJ, Haight BK, Herman J, Michel Y, Brothers T, Edlund B. Skin temperature and chronic venous insufficiency. J Wound Ostomy Continence Nurs 2003;30: ) Lawson RN, Gaston JP. Temperature measurements of localized pathological processes. Ann NY Acad Sci 1969;121: ) Watson AC, Vasilescu C Thermography in plastic surgery. J R Coll Surg Edinb 1972;17: ) Hackett ME. The use of thermography in assessment of depth of burn and blood supply of flaps, with preliminary reports on its use in Dupuytren s contracture and treatment of varicose ulcers. Br J Plast Surg 1974;27: ) Mehra A, Langkamer VG, Day A, Harris S, Spencer RR. C reactive protein and skin temperature post total knee replacement. The knee 2005;12: ) Chung SP, Hwang TS, Song KJ, Shin MH, Lee SJ. Comparison of wound healing process between burn and skin defect in a porcine model. J Korean Burn Soc 2013;16: ) DeHennis AD, Wise KD. A wireless microsystem for the remote sensing of pressure, temperature, and relative humidity. J Microelectromech 2005;14: ) Schlierf R, Horst U, Ruhl M, Schmitz-Rode T, Mokwa W, Schnakenberg U. A fast telemetric pressure and temperature sensor system for medical applications. J Microelectromech 2007;17:S98-S ) Woo YC, Park SS, Subieta AR, Brennan TJ. Changes in tissue ph and temperature after incision indicate acidosis may contribute to postoperative pain. Anesthesiology 2004;101: ) Gurtner GC, Werner S, Barrandon Y, Longaker MT. Wound repair and regeneration. Nature 2008;453: ) Reinke JM, Sorg H. Wound repair and regeneration. Eur Surg Res 2012;49: ) Anselmo VJ, Zawacki BE. Effect of evaporative surface cooling on thermographic assessment of burn depth. Radiology 1977;123: ) Price P, Bale S, Crook H, Harding KG. The effect of a radiant heat dressing on pressure ulcer. J Wound Care 2000;9: ) Thomas DR, Diebold MR, Eggemeyer LM. A controlled, randomized, comparative study of a radiant heat bandage on the healing of stage 3-4 pressure ulcer: a pilot study. J Am Med Dir Assoc 2005;6: ) Smith ME, Totten A, Hickam DH, Fu R, Wasson N, Rahman B, et al. Pressure ulcer treatment strategies: a systematic comparative effectiveness review. Ann Int Med 2013;159: ) Khan AA, Banwell PE, Bakker MC, Gillespie PG, McGrouther DA, Robert AH. Topical radiant heating in wound healing: an experimental study in a donor site wound model. Int Wound J 2004;1: ) Kloth LC, Berman JE, Nett M, Papanek PE, Dumit-Minkel S. A randomized controlled clinical trial to evaluate the effect of noncontact normothermic wound therapy on chronic full thickness pressure ulcers. Adv Skin Wound Care 2002;102: ) Nakagami G, Sanada H, Iizaka S, Kadono T, Higashino T, Koyanagi H, et al. Predicting delayed pressure ulcer healing using thermography: a prospective cohort study. J Wound Care 2010;19: )Sayre EK, Kelechi TJ, Neal D. Sudden increase in skin temperature predicts venous ulcer: a case study. J Vasc Nurs 2007;25: ) Nishide K, Nagase T, Oba M. Ultrasonographic screening and thermographic screening for latent inflammation in diabetic foot callus. Diabetes Res Clin Pract 2009;85: ) Posluszny JA, Conrad P, Halerz M, Shanker R, Gamelli RL. Surgical burn wound infection and their clinical implications. J Burn Care Res 2011;32: ) Nowakowski A., Kaczmarck M. Dynamic thermography as a quantitative medical diagnostic tool. Med Biol Eng Comput 1999;37: ) Mehmood N., Hariz A., Fitridge R., Voelcker NH. Application of modern sensors and wireless technology in effective wound management. J Biomed Mater Res B Appl Biomater 2014;102:

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