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1 대한화상학회지제 19 권제 1 호 1 Journal of Korean Burn Society Vol. 19, No. 1, 1-5, 2016 화상센터에서음압상처치료 (Negative Pressure Wound Therapy; NPWT) 의유용성 안성백ㆍ김영민 1 ㆍ윤재철 1 ㆍ양형태 1 ㆍ임해준 1 ㆍ조용석 1 ㆍ김도헌 1 ㆍ허준 1 ㆍ전욱 1 한림대학교동탄성심병원외과, 1 한림대학교한강성심병원화상외과 Usefulness of Negative Pressure Wound Therapy (NPWT) in Burn Center Sung Bak An, M.D., Young Min Kim, M.D. 1, Jae Chul Yoon, M.D. 1, Hyeong Tae Yang, M.D. 1, Hae Jun Yim, M.D. 1, Yong-Suk Cho, M.D. 1, Dohern Kim, M.D. 1, Jun Hur, M.D. 1 and Wook Chun, M.D. 1 Department of Surgery, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, 1 Department of Burn Surgery, Hallym University Hangang Sacred Heart Hospital, Seoul, Korea Purpose: Negative pressure wound therapy (NPWT) is an adjunct therapy using negative pressure to remove fluid from open wounds through a sealed dressing and a specialized tubing that is connected to a collection container. NPWT is suitable for acute and chronic wound condition because it was designed to accelerate granulation formation on deep wound. Therefore, we performed this study to assess the effectiveness of NPWT for various wound condition in burn center. Methods: We enrolled 17 patients who were treated with NPWT from January 2014 to April We analyzed the characteristics and outcomes of the patients through retrospectively. Results: Among 17 patients, there were 13 patients for contact burn, 2 patients for electrical injury, 1 patient for diabetic foot ulcer and 1 patient for Flame burn. Most of the contact burn victims were injured by the exposure of relatively low temperature for a long time and some of them were injured under the condition of sensory deterioration including spinal cord injury, diabetes or sedatives. Wound coverage was accomplished by split thickness skin graft (STSG) in 12 patients. Local flap was done in 1 patient. STSG with local flap was done in 3 patients. And there were 1 patient who got a conservative management. The duration of NPWT application was from 8 days to 101 days (average 36.2 days). 책임저자 : 전욱, 서울시영등포구버드나루로 7 길 , 한림대학교한강성심병원화상외과 Tel: , Fax: chun0414@hallym.or.kr Conclusion: NPWT showed good clinical outcomes under various wound condition. Therefore, we think that it can be a new treatment paradigm for difficult wound management in burn center. (J Korean Burn Soc 2016;19:1-5) Key Words: Negative-pressure wound therapy, Burn, Wound healing 서 화상은원인별로화염화상, 열탕화상, 전기화상, 접촉화상, 화학화상등으로분류한다. 화상센터로전원되는환자중에는이런화상이외에도당뇨병성족부궤양, 욕창, 괴저성근막염, 복벽결손, 외상성벗겨진손상등의질환을앓고있는환자들도있다. 이중접촉화상, 전기화상, 당뇨병성족부궤양, 욕창, 괴저성근막염, 큰복부결손, 외상성벗겨진손상같은창상에는창상감염관리및빠른육아조직형성이치료의핵심포인트라고말할수있다. 음압상처치료 (Negative pressure wound therapy; NPWT) 는창상에음압을적용함으로창상치유를촉진시키는방법이다 1-7). 저자는화상센터에서 NPWT의유용성을알아보고자본연구를진행하였다. 론 대상및방법 2014년 1월부터 2016년 4월까지한강성심병원화상센터에입원한환자중에서 NPWT가주된치료방법으로사용된환자 17명을대상으로하였다. 본연구에서 NPWT를위해사용된제품은 V.A.C. TM system (KCI inc., San Antonio, USA) 와 Curavec system (CGBio, Sungnam, Korea) 이다. 결 17명의환자에서주된치료방법으로 NPWT를사용하였다. 원인질환으로는접촉화상이 13명, 전기화상 2명, 당뇨 과

2 2 대한화상학회지 Vol. 19, No. 1, 2016 병성족부궤양 1명, 화염화상 1명이었다. 기저질환으로는당뇨 4명, 고혈압 4명, 하지마비 2명, 진정제과복용 2명, 알코올성간염 1명, 뇌출혈 1명, 파킨슨병 1명, 고관절치환술 1 명등이동반되었다 (Table 1). 접촉화상환자들은대부분상대적으로높지않은온도에오랜시간접촉되어화상을수상하였으며, 하지마비나진정제복용등으로감각이저하 Table 1. Demographics of All Patients Age Underlying disease Mode of injury Site (NPWT applied) Size of wounds (cm 2 ) 1 M/47 Paraplegia, CVA*, HTN, DM Contact burn Buttock M/41 Alcoholic hepatitis Electric burn Left foot M/67 HTN, DM Contact burn Left foot 50 4 F/24 Sedative surgiholic Contact burn Right shoulder, right hip F/74 HTN Contact burn Coccyx M/43 Electric burn Both arm, both wrist F/51 Depression, Hypothyroidism Contact burn Right chest, right hip M/30 Contact burn Right foot 25 9 M/46 Paraplegia Contact burn Right buttock M/32 Flame burn Both feet M/61 DM DM foot gangrene Left foot, left ankle F/33 Sedative surgiholic Contact burn Right buttock M/41 Contact burn Left popliteal F/67 Contact burn Left hip M/29 Contact burn Right buttock M/82 DM, Right THR Contact burn Left foot M/72 HTN, CVA, Parkinson s disease Contact burn Left forearm *CVA = cerebrovascular accident, HTN = hypertension, DM = diabetes mellitus, THR = total hip replacement, pressure wound therapy. = negative Table 2. Progress of All Patients Duration of NPWT* (days) Length of hospital stay (days) Number of operation (relative operation) Final wound coverage STSG with Local flap STSG STSG STSG STSG with local flap STSG STSG STSG STSG STSG Local flap STSG STSG STSG with local flap STSG STSG *NPWT = negative pressure wound therapy, STSG = split thickness skin graft.

3 안성백등 : 화상센터에서음압상처치료 (Negative Pressure Wound Therapy; NPWT) 의유용성 3 된상태혹은열감을인지하기어려운상황에서수상하였다. 모든예에서창상의입구가좁고깊은상처였다. 창상의평균크기는 cm 2 였다. 창상의해결을위해부분층식피술 12명, 국소피판술 1명, 부분층식피술과국소피판술 3 명을시행하였고, 자연적으로치유된환자가 1명이었다. NPWT 적용기간은평균 36.2일이였고, 8일에서 101일까지다양하였다. 입원기간은평균 75.7일이었으며, 25일에서 142일까지였다 (Table 2). 환자들은모두별다른합병증없이회복되었다. 고찰본연구는화상센터에서도그치료가복잡한환자들에서 NPWT를사용하여치료한결과를보고하였다. 본연구는후향적연구로추후 NPWT를사용한환자들과사용하지않은환자들에대한전향적인비교연구가필요할것으로사료된다. 본연구에서사용한 NPWT system 은 V.A.C. TM system과 Curavec system이다. 두제품에서모두 Canister 가삼출물을효과적으로저장하였고, 육안으로관찰시에도육아조직이빠르게생성되어별도로 2개의제품사용에따른환자군을별도로비교하지않았다. 또한환자들모두에서 NPWT 적용기간동안상처에별다른합병증이발생하지않아 Wound culture 등을시행하지않았다. Afshin 등 11) 은 20명의환자에서창상의평균크기가 58.3 cm 2 일때 NPWT 적용기간이 13.5 (7 22) 일, 완전치유까지평균 37.2 (22 64) 일이소요되었다고보고하였는데, 본연구에서는 NPWT 적용기간이 36.2일로더길었으나창상의평균크기가 cm 2 으로더크기때문에 NPWT 적용기간, 치유기간 ( 재원기간 ) 이 Afshin 등의보고와거의비슷하다고할수있다. 본연구에서 1예만 NPWT만으로창상치유가종료되었으며, 나머지 16예에서는피부이식과국소피판술로창상을 해결하였다. NPWT 적용으로인한상처악화같은부작용은단 1예도없었으며, 사망한예도없었다. 1. NPWT의치료기전깊은화상이나창상은치유를위해서가피절제술이나변연절제술을시행한다 7). 상처를제거하게되면살아있는조직이노출되게되는데, 이후혈소판이작용하여출혈을멈추고호중구나대식세포가노출면으로이동하게된다. 이후대식세포는성장인자를분비하고결국섬유아세포 (Fibroblast) 가노출면에모이게된다 (Inflammatory phase). 응집된섬유아세포는콜라겐을합성하게되며, 더많은콜라겐을만들기위해서는산소와영양분이필요하게되어새로운혈관형성이발생한다. 새로운혈관형성을위해 Matrix metalloproteinases (MMP) 가분비되어혈관기저막을분해하고혈관내피세포가노출면으로이동하게된다. 이렇게새로생긴신생혈관이풍부한콜라겐덩어리를육아조직이라부르게된다 (Proliferative phase). 창상치유과정에서콜라겐이만들어지는이유는콜라겐이섬유화를진행하여창상수축을일으키고, 특히 1형콜라겐은창상경계에서상피세포가쉽게이동하게하여반흔을발생시켜창상치유를하기위함이다 (Maturation phase) 8). 이런과정을통해자연적으로회복이되면흉터가생기기때문에, 보다좋은회복을위해육아조직이발생하게되면, 콜라겐은제거하고새로생긴혈관위에피부이식을시행하게된다. NPWT는 Proliferative phase에적용시에강력한음압을통해아주빠른속도로육아조직을형성하게되며혈관내피세포가창상경계로이동하게되고, 이는훨씬빠른속도로신생혈관을만들게한다 1,2). 2. NPWT 기계의구성 NPWT는음압을발생하는본체, 창상에서흘러나오는삼출물을저장하는통 (Canister), 창상에음압을전달하고 Fig. 1. Composition of NPWT.

4 4 대한화상학회지 Vol. 19, No. 1, 2016 밀봉하는 역할을 하는 드레싱 키트 3부분으로 구성된다 장하는 역할을 한다. 또한 삼출물은 나쁜 냄새를 발생시키 (Fig. 1). 기 때문에, 통안에 항생성분의 주머니가 있거나, 통안의 냄 음압을 발생시키는 본체는 최근 발전을 거듭하여 크기가 매우 적고 소음이 적으며, 다양한 음압모드를 적용할 수 있 새가 밖으로 빠져나오지 않도록 하는 공기필터가 통에 장 착되기도 한다. 다. 본 연구에서도 NPWT의 평균 적용 기간이 36일이며 최 드레싱 키트는 창상적용 스펀지, 음압 연결 호스 그리고 대 101일에 달할 정도로 장기간이고, 또한 밤에도 적용되기 접착투명 테이프로 구성된다. 창상의 모양에 스펀지를 모 때문에 본체는 최대한 크기가 적고 조용히 작동하여야 한다. 양에 맞추어 오려낸 다음 창상에 올려놓고 연결호스를 위 일반적으로 육아조직 형성을 빠르게 할 목적으로는 125 치하고 창상과 스펀지 전체를 접착 투명테이프로 덮는다. 3,4) mmhg를 걸어주며, 창상치유를 최대한 촉진시키기 위해 음압을 발생시키게 되면 스펀지의 공기가 빠져 납작해지 서는 음압을 걸었다 풀어줬다를 반복하는 것(Intermittent 며, 삼출물도 조금씩 빠지게 된다. 3) mode)이 도움이 된다는 주장이 있었으며, 통증을 줄이기 위해서는 intermittent mode보다는 Cyclic mode가 더 효과 3. NPWT 적용방법 적이라는 주장이 있다3,9). 적용방법은 의외로 간단하다. 우선 괴사된 조직은 순차 삼출물을 저장하는 통은 삼출물이 음압을 발생시키는 본 적으로 제거한다. 그래서 되도록 창상에 죽은 조직이 남아 체 안으로 빨려 들어가는 것을 방지하며, 많은 삼출물을 저 있지 않거나 소량만이 남아있어야 한다2-4). 그 이후 상처부 Fig. 2. Progress of wound.

5 안성백등 : 화상센터에서음압상처치료 (Negative Pressure Wound Therapy; NPWT) 의유용성 5 위에 NPWT를적용한다. 만일수술실에서변연절제를시행했다면 1 2일경과후에 NPWT를적용해야한다. 수술직후에 NPWT를적용시심각한출혈이발생할수있기때문이다. 육아조직형성을촉진시키는목적이라면 125 mmhg의음압을사용한다 3,4). 간혹창상에적용한스펀지교체시에육아조직이스펀지안에박히기때문에경우에따라 Wound bed에구멍이있는 Mepitel 1 (Mölnlycke Health Care, Sweden) 이나바셀린거즈를적용하고그위에스펀지를적용하기도한다. 육아조직이충분히발생했다면국소피판술이나피부이식술을시행하여창상을상피세포로덮어준다 (Fig. 2) 3). 결 NPWT는사용하기가간편하며, 화상센터에서어려운창상을치료하기위한치료방법으로유용성이매우높다고할수있다. 론 REFERENCES 1) Schintler MV. Negative pressure therapy: theory and practice. Diabetes Metab Res Rev. 2012;28Suppl1: ) Orgill DP, Bayer LR. Negative pressure wound therapy: past, present and future. Int Wound J. 2013;10Suppl1: ) Kim PJ, Attinger CE, Olawoye O, Crist BD, Gabriel A, Galiano RD, et al. Negative Pressure Wound Therapy With Instillation: Review of Evidence and Recommendations. Wounds. 2015;27:S2-S19. 4) Hasan MY, Teo R, Nather A. Negative-pressure wound therapy for management of diabetic foot wounds: a review of the mechanism of action, clinical applications, and recent developments. Diabet Foot Ankle. 2015;6: ) Ma Z, Shou K, Li Z, Jian C, Qi B, Yu A. Negative pressure wound therapy promotes vessel destabilization and maturation at various stages of wound healing and thus influences wound prognosis. Exp Ther Med. 2016;11: ) Webster J, Scuffham P, Stankiewicz M, Chaboyer WP. Negative pressure wound therapy for skin grafts and surgical wounds healing by primary intention. Cochrane Database Syst Rev. 2014;10:CD ) Zhou M, Yu A, Wu G, Xia C, Hu X, Qi B. Role of different negative pressure values in the process of infected wounds treated by vacuum-assisted closure: an experimental study. Int Wound J. 2013;10: ) Young-Joo Lee, Jaechul Yoon, Hyeong-Tae Yang, Yong-Suk Cho, Dohern Kym, Haejun Yim, et al. Effect of Plant Extracts Contained Dressing Material Which Is Rich in Procyanidins for Treatment of Deep Second Degree Burn. J Korean Burn Soc. 2014;17: ) S. Guo, L.A. DiPietro. Factors Affecting Wound Healing. J Dent Res. 2010;89: ) Lee KN, Ben-Nakhi M, Park EJ, Hong JP. Cyclic negative pressure wound therapy: an alternative mode to intermittent system. Int Wound J. 2015;12: ) Rahmanian-Schwarz A, Willkomm LM, Gonser P, Hirt B, Schaller HE. A novel option in negative pressure wound therapy (NPWT) for chronic and acute wound care. Burns. 2012;38:

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