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1 Propofol 을이용한수면방광경검사의효과와안정성연구 Study on the Effects and Safety of Propofol Anesthesia during Cystoscopy 대한비뇨기과학회지제 47 권제 11 호 2006 Ki Seung Kim, Ju Sung Kim, Seong Woon Park From the Department of Urology, Kwangju Christian Hospital, Gwangju, Korea Purpose: Cystoscopy, as with other endoscopic procedures, is a fearful and painful for the majority of patients. To this reduce fear, pain and discomfort, the routine administration of sedative drugs, such as midazolam and propofol, is widely accepted for a gastrointestinal endoscopy. There have also been some studies on midazolam anesthesia during cystoscopy. However, the effects and safety of propofol anesthesia during cystoscopy have not been established. Therefore, the effects and safety of propofol anesthesia during cystoscopy were investigated in this study. Materials and Methods: 200 male patients were divided into 2 groups: Group A consisted of 80 patients sedated using 1mg/kg propofol IV, and group B consisted of 120 patients who received normal saline IV instead of propofol. All patients received 90mg diclofenac IM for pain control. There were no significant differences in the ages and weights between the two groups. The vital signs and oxygen saturation were monitored before, during and after the cystoscopy. The degree of pain and satisfaction of the patients and urologist were measured. Results: The pain scales were significantly reduced in group A compared to group B. Group A patients and the operator were also significantly more satisfied than those in group B. Although the blood pressure, pulse rate or respiratory rate changed during the cystoscopy, they were not clinically significant and there was no need for additional treatment. 12 patients in group A showed temporary hypoxia; however, they were treated with oxygen administration and recovered within several minutes. Conclusions: Propofol anesthesia during cystoscopy can be performed safely and effectively as an outpatient procedure, as long as there is adequate preparation and monitoring. (Korean J Urol 2006;47: ) Key Words: Cystoscopy, Propofol, Anesthesia 광주기독병원비뇨기과 김기승 김주성 박성운 접수일자 :2006년 6월 5일채택일자 :2006년 8월 11일 교신저자 : 박성운광주기독병원비뇨기과광주광역시남구양림동 TEL: FAX: uropark@ shinbiro.com 서론방광경검사는비뇨기과에서가장흔하게시행되는검사및시술의하나이나, 아직많은환자들은검사에대한불안감과통증으로인해두려워하는경향이있고힘든검사로인식하고있으며이로인해방광질환의추적관찰등반복적인검사가힘든경우가많았다. 이에환자의불편감과통증을덜어주면서검사의가원하는부위를정확하고충분히관찰할수있도록진정제를전처치로사용하는수면방광경검사 (sedation cystoscopy) 가사용되고있다. 1,2 현재진정유도약물로가장널리사용되고있는것은 midazolam과아편제제 (opiate) 의병합요법이다. Benzodiazepine 계열의 midazolam은강력한선행성건망증의유발과불안감해소, 진정효과를가지고있으며, 아편제제의병합은진통효과를제공하고진정효과와건망효과 (amnesic effect) 를증가시키며환자의만족도를증가시킨다. 3 그러나호흡억제작용과수면유도에시간이오래걸린다는점, 비교적긴반감기로환자회복이늦다는단점이있다. 마취과와소화기내시경영역에서널리사용되고있는 propofol (2, 6-diisopropylphenol) 은지방친화성이매우높은약제로빠른의식소실효과와짧은반감기를가지고있으 1230

2 김기승외 :Propofol 을이용한수면방광경검사의효과와안정성연구 1231 며환자만족도또한높다고알려져있으나좁은 therapeutic window, 길항제가없다는점, 호흡억제등의부작용이단점이다. 저자들은방광경검사에있어 propofol을이용한수면유도후의혈역학적변화, 산소포화도의변화, 환자와검사의의만족도등을대조군과비교하여그효과와안정성에대하여연구하였다. 대상및방법 본연구는 2003년 10월부터 2005년 9월까지본원에내원하여진단목적으로방광경검사를시행한남자환자 200명을대상으로하였다. 검사전환자들에게검사방법에대해자세한설명을하고연구에동의를구하였으며, 검사방법에따라환자들을두군으로구분하였다. 대상환자의연령과체중은두군간유의한차이는없었으며진정목적의전처치약물에부작용이있는환자, 심폐질환자, 신기능및간기능이상환자는대상에서제외하였다. 환자들을두군으로나누어, A군에서는 propofol을정주하여수면방광경검사를시행하였고, B군에서는 propofol 대신생리식염수를정주하였으며, 두군모두에서통증관리를위하여 diclofenac (Newfenac R ) 90mg을근주하였다. 검사시작 30여분전에 diclofenac을근주하였고 A군에서는검사전 propofol 1mg/kg을천천히정주하여수면유도하였고 B군에서는생리식염수 0.1cc/kg을정주하였다. 진정정도 (sedation scale) 1,4 는검사중환자에게대화를하거나몸을흔드는등의자극을주어이에대한반응을관찰하여 5단계로나누어측정하였고 (Table 1), 3단계이상일때검사를시행하였으며, 이후환자의진정정도와반응정도에따라서진정정도가 3단계이상이되도록 10-20mg을추가정주하여진정상태를유지하였다. 모든환자는검사시행전, 방광경이요도입구를통과하는시점에서 5분이경과한 Table 1. Sedation scale used in the for evaluation of the sedation response in patients undergoing propofol induced anesthetic cystoscopy Sedation scale Alert 0 Drowsy, partial lid closure 1 Eye closed, responding to verbal command 2 No response to verbal command, responding 3 to pain Unresponse 4 시점 ( 시행도중 ), 방광경제거 5분후 ( 시행후 ) 에활력징후와말초혈액산소포화도를 Hewlett Packard사의 vital sign monitor를이용하여관찰, 기록하였다. 검사는 propofol 주입후안검하수가나타나거나속눈썹반사가소실되는시점에시작하였고, 방광경을제거하는과정까지를방광경조작시간으로기록하고, 명령에반응하는시간까지를반응시간으로하였으며검사종료후환자의이름, 연월일등의간단한질문에양호한의식상태를보이고자발적인보행이가능한시점까지를회복시간으로기록하였다. 검사는두군모두에서 Wolf사의 17.5Fr 경성방광경을이용하였으며모든검사는한명의비뇨기과전문의가시행하였다. 두군모두에서환자가느꼈던통증및불편감과검사의의검사시어려움을고려한만족도를 visual analogue scale (VAS) 로표시하였다. 환자의통증및불편감의정도는요도부및하복부의불쾌감및통증정도등에따라 VAS 0= 어려움이없음, 10= 가장힘든정도로환산하였으며, 검사의의만족도는환자의협조상태에따라 VAS 0= 매우불만족, 10= 매우만족으로환산하였다. 추가로환자의만족도를 추후방광경검사시동일방법을통한검사를원하십니까? 라고설문하여 ( 예, 아니오 ) 그비율을비교하였다. 환자의퇴원여부는개선된퇴원점수표 (modified postanesthesia discharge scoring system) 에의거하여활력징후가모두술전에비해 20% 이하의변화를보이고, 어지러움없이안정되게걸으며, 오심과구토가거의없는상태인지 Table 2. Modified postanesthesia discharge scoring system Vital signs 2=within 20% of preoperative value 1=20-40% of preoperative value 0=40% of preoperative value Ambulation Nausea and vomiting Pain 2=steady gait/no dizziness 1=with assistance 0=none/dizziness 2=minimal 1=moderate 0=severe 2=minimal 1=moderate 0=severe Surgical bleeding 2=minimal 1=moderate 0=severe

3 1232 대한비뇨기과학회지 : 제 47 권제 11 호 2006 를확인하여결정하였다 (Table 2). 5 통계적검증은연령, 체중등의일반적인특성과 VAS score는 Student's t-test, 환자의만족도는 chi-square test를이용하였고, 두군간의활력징후와산소포화도의변화는 general linear model로비교하여 p값이 0.05 미만인경우를통계적의의가있는것으로하였다. 통계분석은 SPSS 12.0 for Windows (SPSS, Chicago, USA) 을이용하였다. 결 대상환자의평균연령과체중은두군에서유의한차이가없었다 (Table 3). 두군의검사시간은 propofol군에서의검사시간이의의있게짧았다. Propofol군에서걸린수면유도시간은 0.9±0.1 분, 명령에반응하기까지의반응시간은 10.1±0.9분이었으며의식이회복되고자발적인보행까지가능한회복시간은 Table 3. Patient characteristics Group A Group B Pain control Diclofenac Diclofenac (Newfenac R ) 90mg (Newfenac R ) 90mg Sedation by propofol Normal saline 1mg/kg* 0.1cc/kg No. of patients Age (years) 51.93± ±7.21 Weight (kg) 61.96± ±5.56 *additive dose was injected according to the degree of sedation and response of patient, no significant difference between two group; p>0.05 과 27.8±5.2분이었다. Propofol 군에서사용한진정유도및유지용량은 62.12±0.42mg이었다 (Table 4). Propofol군과대조군의검사시행전, 시행도중, 시행후에측정한수축기혈압과이완기혈압은시행도중 propofol 군에서감소한반면대조군에서는증가하였고이차이는통계적으로유의하였다. 맥박수는검사시행도중두군모두에서증가하였으나대조군에서 propofol군에비해통계적으로유의하게증가폭이컸다. 두군모두에서검사시행도중과시행후에호흡수의증가를보였으며, propofol 주입후호흡정지를보인경우는없었다 (Table 5). 모든활력징후의변화는임상적으로추가적인치료가필요하지는않았다. 두군모두에서검사시행전부터 2L/min로산소를투여하였고 propofol군에서대조군에비해검사시행도중과시행후산소포화도가통계적으로유의하게감소하는양상을보였다. 검사시행도중 3례, 시행후 9례에서산소포화도가 90% 이하로감소하는일시적저산소증을보였으나산소포화도가 85% 이하로감소한예는없었으며, 모든예에서수분간산소투여량을증가시키고 (3-4L/min) 환자를흔들어깨우는등의조치로회복되었고추가적인치료는필요하지 Table 4. Results of cystoscopy in the two groups Group A Group B Duration of induction (min) 0.9±0.1 Mean propofol dose (mg) 62.12±0.42 Duration of cystoscopy (min)* 8.7± ±1.6 Duration of response (min) 10.1±0.9 Duration of recovery (min) 27.8±5.2 *p Table 5. Changes in the vital signs and oxygen saturation in the two groups Before During 5 min after p-value Systolic arterial pressure (mmhg)* Group A 123.3± ± ±11.2 Group B 127.0± ± ±7.5 Diastolic arterial pressure (mmhg)* Group A 81.8± ± ±5.0 Group B 87.5± ± ±6.1 Pulse rate (time/min)* Group A 79.9± ± ±6.7 Group B 83.0± ± ±7.0 Respiratory rate (time/min)* Group A 20.0± ± ±2.1 Group B 21.0± ± ±1.7 Oxygen saturation(%)* Group A 95.6± ± ±3.0 Group B 96.0±1.1 0±1.3 0± *statistically analyzed with general linear model.

4 김기승외 :Propofol 을이용한수면방광경검사의효과와안정성연구 1233 Table 6. Degree of pain and discomfort of patients and the degree of patient and urologist satisfaction Group A Group B p-value Degree of pain and dis- 2.2± ±0.7 comfort, patient (cm)* Degree of satisfaction, 81.3 (65/80) 22.5 (27/120) patient(%) Degree of satisfaction, 6.9± ±1.5 urologist(cm)* *cm: visual analogue scale (VAS), No. of patients satisfied/total No. of patients 않았다 (Table 5). 검사시행후요도부및하복부의불편감이나통증, 기억정도, 어지러움증등을환산한 10cm VAS scale은 propofol 군에서유의하게낮은점수를보였으며, 향후동일방법을통한검사를원하는지에대한설문에 propofol군은 65례 (81.3%) 에서 예 라고답한반면대조군에서는 27례 (22.5 %) 에서만이 예 라고답해통증정도및불편감의차이가만족도및향후방광경검사방법의선택에많은영향을보임을알수있었다. 검사의가검사를하는동안의만족도는 10cm VAS scale에서 propofol군이대조군에비해유의하게높았다 (Table 6). Propofol 군에서검사시작전부터완전히각성될때까지검사시행도중 3례, 시행후 9례에서일시적저산소증 (SaO 2<90%) 을보였으나경비케눌라를통한산소투여량을증가시키고환자를흔들어깨우는정도로모두회복되었고무호흡은없었다. 13례에서불수의적움직임을보여검사가지체되었으나대부분곧사라졌으며완전히사라지지않은경우도방광경검사시행에크게어려움을줄정도는아니었다. 3례에서 propofol 주입후완전한수면유도가될때까지매우수다스러워졌으나이후완전한진정상태에도달하였다. Propofol 군에서검사후에어지러움증 14례 (17.5%), 두통 6례 (7.5%), 오심 3례 (3.75%) 등을호소하였으나모두 1시간가량의수액공급과안정만으로소실되어검사당일퇴원하였다 (Table 7). 고 방광경검사의기본적인적응증은하부요로의병변과증상에관련된해부학적형태와육안적소견을관찰하는것이고, 특히현미경적또는맨눈혈뇨의원인을밝히는데유용하며방광종양수술후재발여부의검사에도많이사 찰 Table 7. Side effects of the propofol group No. of patients (%) Hypoxia 12 (15.0) Involuntary movement 13 (16.3) Talkative 3 (3.8) Dizziness 14 (17.5) Headache 6 (7.5) Nausea 3 (3.8) Total 80 용된다. 또한요관카테터를요관구에삽입하여양측신장의소변을분리채취하거나요세포검사, 조직학적검사, 역행성신우조영술등에이용하는등상부요로의병변에대한검사및처치시에도시행된다. 6 그러나방광경검사시의통증과그에대한불안감은환자가검사를기피하는요인이되고이에의해검사시환자의협조가제대로이루어지지않을경우검사의가적절한검사를충분히시행하기어려우며요도나방광의손상등합병증을유발할수있다. 따라서방광경검사에있어서환자의통증을줄이고, 불안감을없애주는것이무엇보다중요하다. 다양한약제가개발되어기존약제의단점을보완하게되고, 피검사자나검사자모두보다편안하고쉽게검사하는방법을선호하게되면서수면유도하에소화기내시경검사를비롯한각종내시경검사를시행하는경우가많아지고있으며방광경검사에있어서도 benzodiazepine 제제인 midazolam을전처치로사용한경우의효과와안정성에대해보고된바있다. 1,2 Propofol은 phenol계화합물로내시경검사, 수술등에서진정, 마취유도및유지를위해사용되며 midazolam에비해비슷한진정작용과기억상실효과를가지면서도짧은반감기로인한빠른의식회복으로외래방문환자를대상으로사용하기에적절한약제로알려져있다. 7 Patterson 등 7 은 propofol과 midazolam 사용군에서두군모두약제투여후산소포화도의유의한감소를관찰하였고내시경검사도중의유의한맥박수증가와혈압감소를보고하였는데 propofol을사용한군에서빠른회복과제한적기억상실효과로향후에다시내시경검사를시행할환자에게외래에서시행할수있는장점이있다고보고하였다. Propofol은일회유도용량정주후혈액으로부터뇌및체내조직으로신속히분포되어 1분이내에의식소실이발생하며, 8 propofol을지속정주한후투여를중단하였을때에도대부분의환자들에서 10분이내에의식을회복하여명령에

5 1234 대한비뇨기과학회지 : 제 47 권제 11 호 2006 반응하였다고한다. 9 Propofol의적절한수면유도용량은성인에서 mg/kg 이추천되고있으며 60세이상노인에서는 mg/kg이추천되고있고, 10,11 Bell 12 은의식진정목적으로단독사용시 mg/kg의투여를추천하였다. 그러나 Park 등 8 은 1mg/kg의용량은심혈관계에미치는영향은크지않으나마취유도성공률이 30% 밖에되지않고 2mg/kg이평균동맥압의감소가심하지않으며마취유도성공률이 100% 로적절한용량으로판단했다. 본연구에서는방광경검사전 propofol 1mg/kg을일회투여하여수면유도하였으며, 이후환자의진정정도와반응정도에따라서 10-20mg을추가정주하여진정상태를유지하였다. Propofol은통증의역치를올릴수는있으나진통효과는없으므로, 13 아편제제등다른진통제와병합요법이가능하며, 이러한병합요법은상승작용을보인다 본연구에서는 propofol 투여군도대조군과마찬가지로 diclofenac을진통제로병용하였다. 비마취과의사가 propofol을다루는것에대해서는논란의여지가있으나최근의연구들에서심폐소생술을시행할수있는숙련된의사와간호사들이팀을이루어환자들을감시한다면 propofol을사용한수면내시경검사를안전하게시행할수있다고하였다. 16 2,000명을대상으로한 nonanesthesiologist administered propofol (NAP) 연구에서는 85% 이하로저산소증이발생한환자는총 4례있었으며, 모두상부위장관내시경검사중에발생하였고, 마스크환기로곧회복되었으며, 내시경의의감독아래숙련된간호사에의해 propofol은안전하게투여될수있다고하였다. 17 본연구에서는연구단계에서의안전성을확보하기위하여유사시마취과의사의협조를전제하에본원수술장에서환자의활력징후와산소포화도, 심전도등을실시간으로감시하며방광경검사를시행하였고, 검사를시행하기전부터모든환자들에게경비케눌라를통한산소투여를 2L/min 로시행하였으며이러한산소투여는시술중의저산소증을예방하는데도움이된다고하였다. 18 본연구에서는방광경검사중 3례, 검사후 9례에서일시적저산소증 (SaO 2< 90 %) 을보였으나산소포화도가 85% 이하로감소한예는없었고, 경비적산소투여량을수분간증가시키고 (3-4 L/min) 환자를흔들어깨움으로써모두회복되었으며무호흡을보인예는없었다. 일반적으로 propofol은 midazolam에비하여혈압의저하, 호흡억제, 무호흡등의심폐기능저하가더심하게나타나는것으로알려져있으나 Oei-Lim 등 19 은저산소증의위험은 propofol과 midazolam 사이에차이가없다고보고하였고, Patterson 등 20 은 propofol과 midazolam으로진정의질을같게 한후시행한상부위장관내시경검사에서혈압의감소와심박수의변화, 혈중산소포화도는양군에서차이가없었다고보고하였다. 결 Propofol을이용한수면방광경검사는적절한환자선정과체중, 연령에따른 propofol의용량, 주입속도의조절을통해무호흡이나저산소증의빈도를줄일수있을것이며, 검사시행전부터산소및수액공급, 혈역학적변화에대한감시체계, 만일의경우를대비한기도삽관과승압제를갖추고시행한다면마취과의사의도움없이도비교적안전하게시행할수있다고판단된다. 또한환자의통증과불안감을경감시켜검사에매우효과적이었고, 검사의또한방광경의시야확보, 조작의용이성등으로높은만족도를보였다. 특히불안감이매우심하여방광경검사자체를기피하거나반복적으로검사가필요한환자, 통증의역치가낮아진통제만으로검사의진행이힘든환자에서더욱도움이될것이며, 요관부목삽관술및교환술, 방광경하조직검사등단순한진단적방광경검사에비해더오랜시간이걸리고그에따른통증또한큰시술에도그사용범위를넓힐수있을것으로기대한다. 론 REFERENCES 1. Lee SH, Song YS, Park YH. Utility and safety of midazolam anesthesia during cystoscopy. Korean J Urol 2002;43: Jeong HJ, Chung WS, Yoon HN. The efficacy and safety of midazolam induced sedative cystoscopy. Korean J Urol 2004; 45: Chokhavatia S, Nguyen L, Willians R, Kao J, Heavner JE. Sedation and analgesia for gastrointestinal endoscopy. Am J Gastroenterol 1993;88: Forrest P, Galletly DC. Comparison of propofol and antagonised midazolam anesthesia for day case surgery. Anaesth Intensive Care 1987;15: Janet MV, Paul FW. Outpatient anesthesia. In: Ronald DM, editor. Anesthesia. 5th ed. Philadelphia: Churchill Livingstone; 2000; Ballentine CH. Basic instrumentation and cystoscopy. In: Walsh PC, Retik AB, Vaughan ED Jr, Wein AJ, editors. Campbell's urology. 8th ed. Philadelphia: Saunders; 2002; Patterson KW, Casey PB, Murray JP, O'Boyle CA, Cunningham AJ. Propofol sedation for outpatient upper gastrointestinal endoscopy: issues and guidelines. Gastrointest Endosc 1989;35: Park CH, Kim HB, Song PO, Lee SH, Shin MK, Kim IK.

6 김기승외 :Propofol 을이용한수면방광경검사의효과와안정성연구 1235 Adequate dose requirements of propofol by injection during anesthesia induction. Korean J Anesthesiol 1997;32: Beller JP, Pottecher T, Lugnier A, Mangin P, Otteni JC. Prolonged sedation with propofol in ICU patient: recovery and blood concentration changes during periodic interruptions in infusion. Br J Anaesth 1988;61: Sterib A, Freys G, Beller JP, Curzola U, Otteni JC. Propofol in elderly high risk patients. A comparison of haemodynamic effects with thiopentone during induction of anaesthesia. Anaesthesia 1988;43(Suppl): Cummings GC, Dixon J, Kay NH, Windsor JP, Major E, Morgan M, et al. Dose requirements of ICI (propofol, Diprivan ) in a new formulation for induction of anaesthesia. Anaesthesia 1984;39: Bell GD. Premedication, preparation, and surveillance. Endoscopy 2000;32: Carrasco G, Cabre L, Sobrepere G, Costa J, Molina R, Cruspinera A, et al. Synergistic sedation with propofol and midazolam for intensive care patients after coronary artery bypass grafting. Crit Care Med 1998;26: Reimann FM, Samson U, Derad I, Fuchs M, Schiefer B, Stange EF. Synergistic sedation with low-dose midazolm and propofol for colonoscopies. Endoscopy 2000;32: Bhardwaj G, Conlon S, Bowles J, Baralt J. Use of midazolam and propofol during colonoscopy: 7 years of experience. Am J Gastroenterol 2002;97: Hamsen JJ, Ulmer BJ, Rex DK. Technical performance of colonoscopy in patients sedated with nurse-administered propofol. Am J Gastroenterol 2004;99: Rex DK, Overley C, Kinser K, Coates M, Lee A, Goodwine BW, et al. Safety of propofol administered by registered nurse with gastroenterologist supervision in 2000 endoscopic cases. Am J Gastroenterol 2002;97: Oh IH, Han SY, Moon SH, Lee JH, Choi DH, Roh MH, et al. Study on the degree of oxygen saturation during upper gastrointestinal endoscopy using propofol/fentanyl with oxygenation. Korean J Gastrointest Endosc 2001;22: Oei-Lim VL, Kalkman CJ, Bartelsman JF, Res JC, van Wezel HB. Cardiovascular responses, arterial oxygen saturation and plasma catecholamine concentration during upper gastrointestinal endoscopy using conscious sedation with midazolam of propofol. Eur J Anaesthesiol 1998;15: Patterson KW, Casey PB, Murray JP, O'Boyle CA, Cunningham AJ. Propofol sedation for outpatient upper gastrointestinal endoscopy: comparison with midazolam. Br J Anaesth 1991; 67:108-11

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012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar