05-04신태건

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1 대한응급의학회지제 19 권제 6 호 Volume 19, Number 6, December, 2008 원 저 심폐소생술을시행받은심정지환자에서경피적체외심폐보조장치의임상경험 성균관대학교의과대학삼성서울병원응급의학과 신태건 최진호 송형곤 정연권 조익준 Experience with Percutaneous Cardiopulmonary Support in Cardiopulmonary Arrest and Postresuscitation Care Tae Gun Shin, M.D, Jin-ho Choi, M.D, Hyoung Gon Song, M.D, Yeon Kwon Jeong, M.D, Ik Joon Jo, M.D. Purpose: Percutaneous cardiopulmonary support (PCPS) provides hemodynamic stability under various clinical settings, including cardiopulmonary arrest. We compared a single center's experience with performing PCPS during cardiopulmonary resuscitation (CPR) and post-resuscitation care to evaluate the prognostic factors for survival. Methods: We retrospectively reviewed 83 patients with cardiopulmonary arrest who received PCPS during or within 6 hours of CPR from January, 2004, to December, Venoarterial bypass systems were used in all cases with femoral cannulation. Results: The mean duration of CPR was 37.2±26.4 min and the mean time interval from CPR to PCPS insertion was 73.1±107.9 min. The mean duration of PCPS was 73.4±110.6 h. Of the 83 patients, 48 underwent PCPS during CPR before recovery of spontaneous circulation and 35 received PCPS during post-resuscitation care for hemodynamic support. Forty-eight patients (57.8%) were successfully weaned off of the PCPS and 34 patients (41.0%) were discharged from the hospital. Among the survivors, 29 patients (34.9%) had no neurological deficits. In multivariate regression analysis, the duration of CPR and defibrillation of pulseless ventricular tachycardia or fibrillation before PCPS were significant prognostic factors for survival (p=0.007 and 책임저자 : 조익준서울특별시강남구일원동 50 성균관대학교의과대학삼성서울병원응급의학과 Tel: 02) , Fax: 02) drjij@skku.edu 접수일 : 2008년 7월 4일, 1차교정일 : 2008년 7월 28일게재승인일 : 2008년 10월 2일 632 p=0.015, respectively). In subgroup analysis of the 48 patients who received PCPS before resuscitation with conventional CPR, the duration of CPR that was equal to the time interval from CPR to PCPS insertion was also a significant factor for survival (p=0.011) with a survival rate of 27.1%. Conclusion: The duration of CPR is very important for survival. Application of PCPS in CPR can shorten the duration of CPR and maintain hemodynamic stability. Therefore, PCPS is a good resuscitative tool in CPR and post-resuscitation care with an acceptable survival rate and outcome when conventional measures fail. Key Words: Cardiopulmonary resuscitation, Cardiopulmonary bypass, Heart arrest, Advanced cardiac life support Department of Emergency Medicine, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea 서 심폐소생술을시행받은심정지환자의경우최초반응자인일반인의적절한기본인명구조술과조기제세동및전문적심폐소생술을통해예후를향상시킬수있다는것은잘알려져있다 1,2). 그러나병원내심정지환자의경우생존율이 13.4~17%, 병원전심정지의경우는 6.4% 정도로매우낮게보고되고있다 3-5). 또한실제로는심정지환자가자발적순환상태로회복되었을지라도혈역학적으로불안정해지면서다발성장기부전으로사망하거나치명적인신경학적손상으로인해더이상의회복가능성이없는경우가적지않다. 이러한심정지환자의치료에서일반적인심폐소생술과더불어체외심폐보조기 (Percutaneous Cardio-Pulmonary Support, PCPS 또는 Extra- Corporeal Life Support system, ECLS) 가사용될수있으며, 2005년심폐소생술과응급심혈관처치에관한미국 론

2 신태건외 : 심폐소생술을시행받은심정지환자에서경피적체외심폐보조장치의임상경험 / 633 심장학회가이드라인에따르면병원내심정지환자중에서심정지시간이짧고저체온증, 약물중독과같은가역적인원인을가진환자이거나심장이식수술이나혈관의재개통 (revascularization) 이가능한환자에서체외심폐보조기를고려하도록권고하고있다 6). 체외심폐보조기는주로혈액펌프와막형인공폐 (membranous artificial lung) 로구성되며, 대퇴동맥과정맥을통해산소화된혈액을공급하고혈역학적안정을도모할수있는인공심폐장치로서크게비박동성펌프 (nonpulsatile pump) 와박동성펌프 (pulsatile pump) 를사용하는것으로나누어지며 7,8), 본연구에서는비박동성펌프가사용되었다. 최근에는그사용범위가점차확대되고있을뿐만아니라장비가점차단순화되고소형화되어이동이간편하고응급상황에서빠르게사용할수있게되었다. 체외심폐보조기를심정지환자에서사용하여보고한국내연구는아직많지않다. 저자들은삼성서울병원에서심폐소생술시와소생술후환자관리에서체외심폐보조기를사용한임상경험을바탕으로이들의임상양상, 생존율과신경학적예후및생존에영향을미치는인자등을분석해보고자하였다. 대상과방법 2004년 1월 1일부터 2007년 12월 31일까지 4년간삼성서울병원에서체외심폐보조기를사용한심정지환자를대상으로의무기록을이용한후향적연구를시행하였다. 심폐소생술을시행하는동안체외심폐보조기를적용하였거나 (Extracorporeal cardiopulmonary resuscitation group, ECPR group, 이하 A군 ) 또는심폐소생술에의해자발적순환상태가회복된후 6시간이내에혈역학적으로불안정하여사용한환자군 (postresuscitation group, 이하 B군 ) 을연구대상으로하였다. 심장수술등을시행하면서이미체외심폐보조기를시행중이었던환자, 15세이하의소아환자, 심인성쇽 (cardiogenic shock) 등으로체외심폐보조기를적용하였더라도심폐소생술을시행하지않았던환자는연구대상에서제외하였다. ECPR은심정지부터심폐소생술시작까지시간이짧고, 적어도 10분이상일반적인심폐소생술시행후에도자발적순환이회복되지않은환자를대상으로심폐소생술팀의임상적판단에의해시행되었다. 총 83례의환자가포함되었으며환자의나이, 성별, 기저질환, 심정지의발생장소와원인, 목격자유무, 감시장치의사용유무, 초기심정지리듬, 심정지전 1 주이내수술이나시술의시행여부와심정지후원인교정을위한수술등의시행여부, 심폐소생술시간, 심정지발생에서체외심폐보조기를사용하기까지소요시간, 체외심폐보조기사용시간등을조사하였다. 심정지발생당시의 동맥혈가스분석결과와젖산농도를포함한혈액검사결과를조사하였고, 심정지발생당일부터중환자실에서퇴실하기까지 SOFA score (Sequential Organ Failure Assessment score) 를매 48시간마다조사하였으며환자의생존퇴원여부, 신경학적손상여부및최종추적관찰일을조사하였다. 체외심폐보조기는경피적방법으로대퇴동맥과대퇴정맥에카테터를삽입하거나일부의경우직접절개를시행하여대퇴혈관을찾은후카테터를삽입하여시행하였으며, Emergency Bypass System (EBS : Terumo, Inc., Tokyo, Japan) 을사용하였다. 또한헤파린을주사하여활성화응고시간 (activated clotting time) 을 180~200초로유지하였다. 체외심폐보조기를통해산소를 3~4 L/min으로공급하면서체외순환은분당 2.2 L/m 2 이상의속도로하되일반적으로분당 3.4~3.8 L/m 2 으로유지되었으며, 우측요골동맥에서측정한산소분압을 100 mmhg 이상이되도록하였다. 필요에따라원위부의허혈성괴사를예방하기위해브릿지 (bridge) 카테터를삽입하였다. 체외심폐보조기제거 (weaning) 는기본적으로혈역학적으로안정된환자를대상으로체외순환혈류를단계적으로감량하여생체징후가유지되고, FiO 2 0.5~0.6 L/ min 이하에서적절한동맥혈산소포화도가유지될때시도하였다. 조사한자료는 SPSS 13.0 for Windows (SPSS Inc., USA) 를사용하여통계분석을하였다. 연속변수는평균 ± 표준편차로표시하였고, 연속변수에대해서는 independent-samples T test를이용하였고, 명목변수에대해서는 chi-square test와 Fisher s Exact test를이용하여비교하였다. 표본수가작은하위그룹분석 (subgroup analysis) 에서연속변수의비교는 Mann-Whitney U test를부가적으로사용하였으며, Kaplan-Meier 방법을통하여생존곡선을구하였다. 또한다변량로지스틱회귀분석을시행하여생존율에영향을주는인자를분석하였으며, 통계학적유의수준은 p-value<0.05로하였다. 본연구는삼성서울병원임상시험심사위원회 (Institutional review board) 의심사를통과하였다 ( 심의번호 ). 결과 1. 대상환자군의특성연구기간중전체대상환자는 83명으로평균연령은 58.1±17.3세였으며남자가 53명 (63.9%), 여자가 30명 (36.1%) 이었다. 대상환자들은생존군과사망군으로분류하였으며, 나이, 성별, 기저질환유무에서두군간에유의한차이는없었다 (Table 1). 79명의환자는목격된심정

3 634 / 대한응급의학회지 : 제 19 권제 6 호 2008 지환자였으며, 초기심정지리듬은심실세동및심실빈맥이 39례, 무맥성전기박동이 33례, 무수축이 11례이었 고, 심폐소생술중에제세동을시행한환자는 41명으로초기심정지리듬 (p=0.006) 과제세동시행여부 (p=0.006) Table 1. Baseline characteristics Overall Survivors Nonsurvivors n=83 n=34 n=49 p-value Age, yrs, mean±sd 58.1± ± ± Male/female 53/30 21/13 32/ DM Hypertension Renal failure Previous CVA Previous operation or procedure (within one week) CABG Other heart surgery Other surgery* PCI SD: standard deviation, DM: diabetes mellitus, CVA: cerebral vascular accident, CABG: coronary artery bypass grafting, PCI: percutaneous coronary intervention * Other surgery include abdominal aortic aneurysm repair, lung lobectomy, hepatic lobectomy, cholecystectomy, esophagectomy, etc. Table 2. Variables associated with cardiopulmonary resuscitation Overall Survivors Nonsurvivors n=83 n=34 n=49 p-value Witnessed Monitored Initial rhythm VF or VT PEA Asystole Defibrillation during CPR CPR location Out-of-hospital ER ICU OR/recovery room Ward Catheterization laboratory Suspected cause of arrest Cardiogenic Myocardial infarction Arrhythmia Chronic heart failure Acute myocarditis Others Pulmonary embolism Respiratory failure Hemorrhagic shock Septic shock Unknown VF: ventricular fibrillation, VT: ventricular tachycardia, PEA: pulseless electrical activity, CPR: cardiopulmonary resuscitation, ER: emergency room, ICU: intensive care unit, OR: operating room

4 신태건외 : 심폐소생술을시행받은심정지환자에서경피적체외심폐보조장치의임상경험 / 635 는생존군과사망군간의유의한차이가있었다 (Table 2). 2. 생존군과사망군의분석평균심폐소생술시간은전체환자는 37.2±26.4분, 생존군은 24.0±17.9분, 사망군은 46.4±27.6분으로생존군에서유의하게심폐소생술시간이짧았다 (p<0.001). 전체환자군에서심폐소생술시작부터체외심폐보조기를사용하기까지시간, 체외심폐보조기사용시간, 중환자실체류시간및최대 SOFA score는두군간에유의한차이가없었다 (Table 3). 심정지시시행한혈액검사중젖산수치는전체환자군에서 9.5±4.7 mmol/l, 생존군에서 7.6±3.9 mmol/l, 사망군에서 10.9±4.8 mmol/l로사망군에서유의하게높게측정되었으며 (p=0.001)(table 3), 그외에동맥혈가스검사, 혈중백혈구치, 혈중혈소판치, 총빌리루빈, 간기능수치, 혈액요소질소, 크레아티닌, 나트륨, 칼륨의혈청농도는유의한차이가없었다. 전체환자중 48명에서체외심폐보조기를심폐소생술을시행하는가운데자발순환의회복전에사용하여흉부압박을중단하였고 (A군), 35명의환자에서는자발순환이회복된후에환자를혈역학적으로안정화시키기위해사용하였다 (B군). 대동맥내풍선펌프 (Intra-Aortic Balloon Pump, IABP) 는총 35례에서부가적으로사용되었고두 군간의유의한차이는없었으나 (p=0.452), 급성신부전으로인한지속적신대체요법 (Continuous Renal Replacement Therapy, CRRT) 의경우는생존군에서 6 례, 사망군에서 20례로사망군에서유의하게많았다 (p=0.025) 심폐소생술후에원인교정을위한추가적인치료적시술이나수술을시행한경우는생존군에서 23명으로유의하게많았다 (p=0.016) (Table 3). 3. 생존율과신경학적예후총 83명의심정지환자중에서 65명 (78.3%) 에서자발적순환이회복되었으며 20명이심폐소생술후 24시간이내에사망하였다. 이후 48명 (57.8%) 에서체외심폐보조기를성공적으로제거할수있었다. 이중에서 34명이생존퇴원하였고 (41.0%), 생존환자중에서 29명은신경학적손상없이회복되어퇴원하였다 (34.9%)(Fig. 1). 생존곡선을보면대부분의환자는초기 1개월이내에사망하고일단생존하면장기생존하는경향을보였으며 (Fig. 2), 평균추적관찰기간은사망군 17.4±48.6일, 생존군에서 ±384.2일이었다. 사망환자중대부분은심인성또는다발성장기부전으로사망하였으며, 뇌사판정으로인해체외심폐보조기를중단하고사망한경우가 1례있었다. Table 3. Comparisons between survivors and nonsurvivors Overall Survivors Nonsurvivors n=83 n=34 n=49 p-value CPR duration, min 37.2± ± ±27.6 <0.001 Time interval, CPR to PCPS, min 073.1± ± ±48.5 <0.785 PCPS duration, hrs 073.4± ± ±87.2 <0.561 ICU stay, days 17.8± ± ±23.1 <0.112 Maximal SOFA score 14.1± ± ±3.30 <0.214 Plasma lactate, mmol/l 9.5± ± ±4.80 <0.001 PCPS during CPR (ECPR) <0.003 Use of IABP <0.452 Use of CRRT <0.025 Subsequent procedures <0.016 CABG <0.117 Other heart surgery <1.000 Heart transplantation <0.117 Other surgery* <1.000 PCI <0.218 CPR: cardiopulmonary resuscitation, PCPS: percutaneous cardiopulmonary support, ICU: intensive care unit, SOFA score: Sequential Organ Failure Assessment score, ECPR: Extracorporeal cardiopulmonary resuscitation, IABP: intra-aortic balloon pump, CRRT: continuous renal replacement therapy, CABG: coronary artery bypass grafting, PCI: percutaneous coronary intervention * Other surgery include pulmonary thromboembolectomy, repair of left ventricular wall rupture, explore laparotomy, various bleeding control operations, etc.

5 636 / 대한응급의학회지 : 제 19 권제 6 호 patients with cardiac arrest 48 patients with successful PCPS* during CPR 35 patients with PCPS immediately after CPR 65 patients with ROSC 20 dead within 24 hours 48 patients weaned off PCPS (57.8%) 34 survivors (41.0%) 29 patients without neurologic damage: CPC scale 1 (34.9%) Fig. 1. Outcome results. * PCPS: percutaneous cardiopulmonary support CPR: cardiopulmonary resuscitation ROSC: return of spontaneous circulation CPC: Cerebral Performance Categories Fig. 2. Kaplan-Meier survival curve of all arrest patients with percutaneous cardiopulmonary support. Table 4. Subgroup analysis Group A (ECPR group) Group B (Postresuscitation group) Overall Survivors Nonsurvivors Overall Survivors Nonsurvivors n=48 n=13 n=35 n=35 n=21 n=14 CPR duration, min* 46.2± ± ± ± ± ± min min > 60 min Time interval, CPR to PCPS, min* 46.2± ± ± ± ± ±73.7 PCPS duration, hrs 56.8± ± ± ± ± ±101.0 ICU stay, days* 14.0± ± ± ± ± ±27.7 Maximal SOFA score 14.2± ± ± ± ± ±3.40 Plasma lactate, mmol/l 10.7± ± ± ± ± ±5.50 Use of IABP Use of CRRT Previous heart surgery* (early period) Defibrillation during CPR Subsequent procedures* CABG Other heart surgery Heart transplantation Other surgery PCI ECPR: Extracorporeal cardiopulmonary resuscitation, CPR: cardiopulmonary resuscitation, PCPS: percutaneous cardiopulmonary support, ICU: intensive care unit, SOFA score: Sequential Organ Failure Assessment score, IABP: intra-aortic balloon pump, CRRT: continuous renal replacement therapy, CABG: coronary artery bypass grafting, PCI: percutaneous coronary intervention * p<0.05 in analysis for group A p<0.05 in analysis for group B

6 신태건외 : 심폐소생술을시행받은심정지환자에서경피적체외심폐보조장치의임상경험 / 하위그룹분석 (subgroup analysis) 체외심폐보조기를적용한시기에따라서심폐소생술중에시행한 A군은 48명중 13명, 소생술후에적용한 B군은 35명중 21명이생존하여생존율은각각 27.1%, 60.0% 로나타났다. A군에서심폐소생술시작부터체외심폐보조기를사용하기까지시간, 즉심폐소생술지속시간은생존군에서 31.6±14.7분, 사망군에서 51.6±25.1분으로나타나생존군에서유의하게심폐소생술지속시간이짧았다 (p=0.011). 반면에 B군에서심폐소생술시간은생존군과사망군에서각각 19.3±18.4분, 33.1±30.0분이었으나통계적으로는유의한차이를보이지않았으며, 체외심폐보조기의사용시점도뚜렷한차이가없었다. 심정지전심장수술여부 (p=0.009) 와심폐소생술후추가적인수술시행여부 (p=0.047) 는 A군에서유의한차이를보여, 생존군에서심정지전에심장수술을받았던환자와심폐소생술후에원인교정을위한수술이나시술을받았던환자가더많았다. 혈중젖산농도 (p=0.016) 와지속적신대체요법여부 (p=0.007), 제세동여부 (p=0.013) 는 B 군에서생존군과사망군간에유의한차이를보였다 (Table 4). 5. 생존에영향을미치는요인분석단변량분석에서통계적으로유의한인자를대상으로다변량로지스틱회귀분석을시행하였고, 생존율에영향을미치는인자를분석한결과심폐소생술시간 (p=0.007) 과심폐소생술동안제세동시행여부 (p=0.015) 가유의하게관련이있는것으로나타났다 (Table 5). 6. 합병증체외심폐보조기를사용하면서창상출혈이나혈종, 위장관및폐출혈등의출혈성부작용이주로발생하였다. 이외에창상및카테터감염, 혈관손상, 뇌경색, 용혈등의합병증이발생하였다 (Table 6). 고찰심정지환자의예후는여러노력에도불구하고과거에비해많은향상을보이지못하고있다 9). 그러나여러가지새로운방법들이심정지환자의예후를좀더향상시킬수있는방법들로제시되고있고그중에, 하나의대안으로서 Table 5. Results of multivariate regression analysis for survival Odds ratio 95% confidence interval p-value CPR duration ~ Defibrillation during CPR ~ Subsequent procedures ~ CRRT ~ Plasma lactate ~ CPR: cardiopulmonary resuscitation CRRT: continuous renal replacement therapy Table 6. Complications of percutaneous cardiopulmonary support Complications Number of patients (n=83) Cannulation site complications Bleeding or hematoma 16 Wound or catheter infection 3 Significant vessel injury 1 Wound dehiscence 2 Limb ischemia 7 Gastrointestinal bleeding 9 Pulmonary hemorrhage 4 Ischemic stroke 3 Hemorrhagic stroke 1 Massive hemolysis 1

7 638 / 대한응급의학회지 : 제 19 권제 6 호 2008 체외심폐보조기를사용할수있을것이라고보고되고있다 10). 특히최근논문들에서일반적인심폐소생술에반응이없는심정지환자의경우체외심폐보조기를이용한소생술 (Extracorporeal cardiopulmonary resuscitation, ECPR) 은생존율과신경학적예후를향상시킬수있는것으로보고하고있다 11-13). 심정지환자에게체외심폐보조기를적용한연구에서생존율은연구기관에따라차이가많으나평균적으로약 40% 정도로보고되고있으며 10) 본연구에서의생존율도 41.0% 로이와유사한정도를보여주었다. A군과 B군의생존율이각각 27.1% 와 60.0% 로유의한차이 (p=0.003) 를보이는것은적용시기에따른영향이라기보다는심폐소생술지속시간의차이일가능성이많다고생각된다. 실제로심폐소생술지속시간이길어질수록사망률은급격히증가하는것으로잘알려져있는데 14), 본연구의결과도심폐소생술시간이생존율과유의한관계가있었을뿐만아니라두군간의비교에서심폐소생술지속시간은 A군과 B군이각각 46.2±24.3분, 24.8±24.3분으로유의한차이가있었다 (p<0.001). B군에는심폐소생술시간이비교적짧은심정지환자가포함되어있는반면에, A군의경우는일반적인심폐소생술에반응하지않았던경우로체외심폐보조기를사용하지않았다면생존가능성이희박했을뿐만아니라심폐소생술시행중에체외심폐보조기를결정하여적용한경우이므로상대적으로심폐소생술지속시간은길어질수밖에없었다고생각된다. Chen 등 11) 은일반적인심폐소생술에반응이없었던 57명의환자에게체외심폐보조기를적용하여 31.6% 의생존율과예후인자의하나로서심폐소생술지속시간을제시하였는데, 이와같은점을미루어보면심정지환자에서가능한빠르게체외심폐보조기를사용하여환자의순환및호흡의보조를조기에시작함으로써생존율을향상시킬수있을것이라고생각된다. 한편 B군에서체외심폐보조기를얼마나빨리시작하였는지는생존군과사망군에서차이가없어서, 일단자발순환이회복된후에환자치료 (postresuscitation care) 에서는일반적인치료를시행함과동시에혈역학적안정성을유지하기위해임상적필요에따라체외심폐보조기의적용시점을정하는것을고려해야한다고생각된다. 체외심폐보조기는심인성쇼크나심정지, 급성호흡부전, 심장및혈관수술전후등에서다양하게사용될수있다 8,15,16). 이외에도심한약물중독으로인한쇼크나심정지, 저체온증또는익수에의한심정지등에서사용한연구에서도좋은결과가보고되었다 17-19). 본연구에서대상환자군의심정지추정원인은주로심인성이었으며앞으로좀더다양한환자군을대상으로연구가진행되어야할것이다. 체외심폐보조기를적용한후에원인교정을위한추가적인시술이나수술이생존군에서유의하게많이시행된점은체외심폐보조기가원인질환의근본적치료를위한교 량역할로서이용이가능하다는것을시사한다고생각된다. 예를들어출혈성쇼크는일반적으로체외심폐보조기를흔히사용하는적응증은아니지만, 본연구에서출혈성쇼크로인한심정지 11례중에서생존한총 6례의환자들을살펴보면심장수술후과다출혈이 3례, 다량의객혈과질출혈로인한쇼크가각 1례, 심장의자상 (stab wound) 으로인한경우가 1례있었는데, 이들의생존요인을추론해보면체외심폐보조기를통해매우빠르게다량의수혈이가능했고, 모든환자에서체외심폐보조기를통해순환을보조하면서즉각적으로원인을교정하는수술을시행할수있었다는점을들수있겠다. 본연구의 A군 48명에서심폐소생술지속시간, 즉체외심폐보조기를시작하기까지시간은생존군에서유의하게짧았는데, 예를들어심정지 30분내에체외심폐보조기를시작하였던환자군은 18명으로그리많은수는아니지만, 이들중 9명이생존한반면 60분이상소요된 10명은모두사망하였다 (Table 4). 이를볼때심정지환자에서체외심폐보조기의시술시간이약 20분정도소요될수있는점을감안하면심폐소생술중에빠른임상적결정과시술의시행이중요하다고생각된다. 심정지환자에서체외심폐보조기를사용할때에는즉각적으로시술할수있는숙련된시술자, 체외순환기사등의체외심폐보조기운영팀및장비가필요하다. 본원의체외심폐보조기운영은주로흉부외과와순환기내과의시술팀에의해이루어지며, 장비는흉부외과중환자실과수술실, 심혈관조영실에준비되어있다. 심정지환자의경우는심폐소생술팀의호출에의해체외심폐보조기운영팀이도착하여시행되고있다. 본연구에서심폐소생술지속시간 30분내에체외심폐보조기를시작하였던환자군중대부분이심혈관조영실이나흉부외과또는심장내과중환자실에서심정지가발생하여즉각적으로체외심폐보조기를시작할수있었던경우였다. 이를볼때체외심폐보조기운영팀과심폐소생술팀이긴밀하고빠르게협조하여체외심폐보조기를시행하거나심폐소생술팀이심정지상황에서즉각시행하는것이이상적이라생각된다. 본연구에서생존군 34명중 29명 (85.3%) 에서신경학적손상없이퇴원하여비교적양호한결과를보였는데이는빠른자발순환의회복이나체외심폐보조기를통해충분한양의산소가포함된혈액을뇌로공급할수있었기때문으로추정된다. 반면식물상태 (vegetative state) 의심한신경학적손상을받은환자가 1례, 중등도의신경학적손상의경우가 4례있었으며, 사망군중뇌사판정환자가 1례있었는데특히이러한경우는경제적, 윤리적문제뿐만아니라보호자와의료진에게도큰부담을줄수있다는점에서중요하며, 앞으로체외심폐보조기적용시점, 제거시기등에대해서도신경학적예후와관련하여적절한지침과연구가필요하다고생각된다.

8 신태건외 : 심폐소생술을시행받은심정지환자에서경피적체외심폐보조장치의임상경험 / 639 본연구에서사용된체외심폐보조기는비박동성펌프로서일반적으로 centrifugal pump, roller pump가널리사용되며막형인공폐가연결된순환회로내의압력이높지않고혈구손상이적은장점이있다. 반면박동성펌프는비박동성펌프에비해약 20% 적은혈류량으로조직의관류를유지할수있는장점이있으나혈구손상이많을수있으며, 이러한단점을개선한 (T-PLS, New Heart Bio, Korea) 와 Hemopulsa (Biomedlab Co., Seoul, Korea) 가국내에서개발되어사용되고있다 7). 일반적으로혈구손상은 plasma hemoglobin을측정하여진단할수있으나, 최근장비의발달로혈구손상정도가감소되고있어본연구의대상환자에서는일반혈액검사를통해간접적으로추적관찰을시행하였다. 체외심폐보조기의합병증으로는출혈, 혈전, 감염, 혈관의손상, 하지허혈, 용혈및기술적문제등이있다 8,20). 특히출혈성부작용의경우, 이를예방하기위해서적절한수혈을통해출혈소인을미리교정하고활성화응고시간을더욱적절히조절해야할것으로생각된다. 본연구에서는자료부족으로인해특히용혈성부작용과기술적문제에대해서는그발생을충분히관찰하지못하였다. 본연구의제한점으로는먼저대조군이없는후향적연구로의무기록에의존하여자료를수집했다는점을들수있겠다. 따라서체외심폐보조기는심정지환자에게명확한지침보다는의료진의임상적판단에의존하여시행되었으며, 심폐소생술후체외심폐보조기를사용할때에도일관된지침이부족했다는제한점이있어, 향후좀더많은환자군을대상으로한전향적연구가필요하다고생각된다. 특히앞으로대조비교연구를통해체외심폐보조기사용의임상적유용성을검증해야할것으로생각된다. 둘째. 대상환자의대부분이병원내심정지환자라는점으로, 병원전심정지환자에대한생존율과신경학적예후를판단하기에는자료가부족하였다. 마지막으로응급실에서체외심폐보조기를시술한경우가 8례로비교적적어앞으로응급실영역에서좀더많은사례가필요하다고생각된다. 결론체외심폐보조기를사용한심폐소생술에서전체심폐소생술시간이긴경우환자의생존율이떨어졌으며, 제세동을한경우는환자의생존율이증가하였다. 체외심폐보조기는심폐소생술시간이짧은경우와심실세동같은제세동이필요한환자에서보조적인심폐소생술기구로사용할수있다. 참고문헌 01. Gallagher EJ, Lombardi G, Gennis P. Effectiveness of bystander cardiopulmonary resuscitation and survival following out-of-hospital cardiac arrest. JAMA 1995;274: Eftestol T, Wik L, Sunde K, Steen PA. Effects of cardiopulmonary resuscitation on predictors of ventricular fibrillation defibrillation success during out-of-hospital cardiac arrest. Circulation 2004;110: Ebell MH, Becker LA, Barry HC, Hagen M. Survival after in-hospital cardiopulmonary resuscitation: a meta-analysis. J Gen Intern Med 1998;13: Nichol G, Stiell IG, Laupacis A, Pham B, De Maio VJ, Wells GA. A cumulative meta-analysis of the effectiveness of defibrillator-capable emergency medical services for victims of out-of-hospital cardiac arrest. Ann Emerg Med 1999;34: Peberdy MA, Kaye W, Ornato JP, Larkin GL, Nadkarni V, Mancini ME, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 2003;58: The American Heart Association American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005; 112: Rho YR, Choi H, Lee JC, Choi SW, Chung YM, Lee HS, et al. Applications of the pulsatile flow versatile ECLS: in vivo studies. Int J Artif Organs 2003;26: Sawa Y. Percutaneous extracorporeal cardiopulmonary support: current practice and its role. J Artif Organs 2005;8: Herlitz J, Bang A, Gunnarsson J, Engdahl J, Karlson BW, Lindqvist J, et al. Factors associated with survival to hospital discharge among patients hospitalised alive after out of hospital cardiac arrest: change in outcome over 20 years in the community of Goteborg, Sweden. Heart 2003;89: Nichol G, Karmy-Jones R, Salerno C, Cantore L, Becker L. Systematic review of percutaneous cardiopulmonary bypass for cardiac arrest or cardiogenic shock states. Resuscitation 2006;70: Chen YS, Chao A, Yu HY, Ko WJ, Wu IH, Chen RJ, et al. Analysis and results of prolonged resuscitation in cardiac arrest patients rescued by extracorporeal membrane oxygenation. J Am Coll Cardiol 2003;41: Massetti M, Tasle M, Le Page O, Deredec R, Babatasi G, Buklas D, et al. Back from irreversibility: extracorporeal life support for prolonged cardiac arrest. Ann Thorac Surg

9 640 / 대한응급의학회지 : 제 19 권제 6 호 ;79:178-83, discussion Megarbane B, Leprince P, Deye N, Resiere D, Guerrier G, Rettab S, et al. Emergency feasibility in medical intensive care unit of extracorporeal life support for refractory cardiac arrest. Intensive Care Med 2007;33: Beuret P, Feihl F, Vogt P, Perret A, Romand JA, Perret C. Cardiac arrest: prognostic factors and outcome at one year. Resuscitation 1993;25: Bartlett RH, Roloff DW, Custer JR, Younger JG, Hirschl RB. Extracorporeal life support: the University of Michigan experience. JAMA 2000;283: Chen JS, Ko WJ, Yu HY, Lai LP, Huang SC, Chi NH, et al. Analysis of the outcome for patients experiencing myocardial infarction and cardiopulmonary resuscitation refractory to conventional therapies necessitating extracorporeal life support rescue. Crit Care Med 2006;34: Scaife ER, Connors RC, Morris SE, Nichol PF, Black RE, Matlak ME, et al. An established extracorporeal membrane oxygenation protocol promotes survival in extreme hypothermia. J Pediatr Surg 2007;42: Eich C, Brauer A, Kettler D. Recovery of a hypothermic drowned child after resuscitation with cardiopulmonary bypass followed by prolonged extracorporeal membrane oxygenation. Resuscitation 2005;67: Purkayastha S, Bhangoo P, Athanasiou T, Casula R, Glenville B, Darzi AW, et al. Treatment of poisoning induced cardiac impairment using cardiopulmonary bypass: a review. Emerg Med J 2006;23: Conrad SA, Rycus PT, Dalton H. Extracorporeal life support registry report ASAIO J 2005;51:4-10.

05-10양지아

05-10양지아 대한응급의학회지제 18 권제 3 호 Volume 18, Number 3, June, 2007 원 저 응급센터에서체외심폐보조기를이용한심폐소생술의경험 고려대학교의과대학응급의학과, 고려대학교의과대학흉부외과 1 양지아 이성우 신재승 1 조영덕 한 @ 철 이선범 김낙훈 최성혁 홍윤식 Experiences of Using Extracorporeal Life Support