07-11 오동길

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1 대한외상학회지 Vol. 21, No. 2, December, 2008 원 저 외상환자에서알코올금단증후군의발생이예후에미치는영향 연세대학교원주의과대학외과학교실오동길 조민수 배금석 강성준 Abstract Prognosis and Clinical Outcome of Alcohol Withdrawal Syndrome in Trauma Patients Dong Gil Oh, M.D., Min Soo Cho, M.D., Keum Seok Bae, M.D., and Sung Joon Kang, M.D. Department of surgery, Yonsei University Wonju College of Medicine, Wonju, Korea Purpose: Abrupt abstinence from alcohol in cause of chronic alcohol addiction can trigger alcohol withdrawal syndrome. The authors studied the effect of post-operative alcohol withdrawal syndrome in patients who require intensive care due to trauma. Methods: For the study group, we selected 70 patients who had undergone emergency surgery from May 2003 to March 2007 due to trauma and who had been treated with prophylactic thiamine. Data was collected retrospectively. We excluded those who extended their hospital stay for other than traumatic causes, those who died within 3 days of surgery after trauma, those who transferred to other institutions, and those who received a psychiatric diagnosis. Patient groups were determined by the existence or the non-existence of withdrawal syndrome. Age, sex, injury mechanism, mortality, complications, durations of hospital stay and intensive care, use of mechanical ventilator, and sedative use were investigated. A Chi-square test and The Mann-Whitney method were used for statistical analysis in this study. Results: Twenty-four (24) patients from the 58 who had an ISS of 16 or more showed alcohol withdrawal syndrome, and men were shown to be affected with the syndrome significantly more than women. Although ISS was higher in the group with alcohol withdrawal syndrome, statistically, the difference was not significant (P<0.08). The total hospital stay in the patient group with alcohol withdrawal syndrome was on average 10 days longer. However, the difference was not significant (P<0.054). The duration of intensive care in the patient group with alcohol withdrawal syndrome was significantly longer (P<0.029). The patients with alcohol withdrawal syndrome showed no significant difference in the duration of mechanical ventilator use (P<0.783), or in the duration of sedative use (P<0.284). Respiratory distress, pneumonia, upper airway infection, sepsis, acute renal failure, and mortality in the alcohol withdrawal syndrome group were investigated, but no statistically significant difference were noted. Conclusion: We found that the duration of intensive care in chronic alcohol abusers was longer due to the development of alcohol withdrawal syndrome. We also discovered that, when the patients overcame the symptoms of alcohol withdrawal syndrome after intensive care, no difference was found in the frequency of developing complications, the morbidity, and the mortality. Therefore, we conclude that intensive care in trauma patients who are chronic alcohol abusers decreases the incidence of complications found in patients with postoperative alcohol withdrawal syndrome and does not adversely impact the prognoses for those patients. (J Korean Soc Traumatol 2008;21: ) Key Words: Trauma, Alcohol withdrawal syndrome, Injury severity score, Complication, Mortality Address for Correspondence : Keum Seok Bae, M.D. Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea 162 Ilsan-dong, Wonju, Kangwon-do , Korea Tel : , Fax : , bksgs@yonsei.ac.kr 접수일 : 2008 년 10 월 16 일, 심사일 : 2008 년 10 월 20 일, 수정일 : 2008 년 11 월 28 일, 승인일 : 2008 년 12 월 15 일 115

2 대한외상학회지제 21 권제 2 호 I. 서론 우리나라의경우 1997년대한주류공업협회와생산성본부의조사결과에의하면 18세이상성인의 74.5% 가음주경험자인것으로나타났는데, 비슷한시기에조사된캐나다 (1997년) 의경우에는 72.3% 가, 미국 (1996년) 은 64.9% 가음주경험자인것으로보고된것과비교해보면우리나라의음주경험자가좀더많은것을알수있다. 또한1997 년 6월현재우리나라의알코올상습남용자 / 중독자수가약 460만명으로추정되고있는데, 이는미국 1천만명, 일본 250만명인것과비교해볼때우리나라가인구수에비례해음주경험자와알코올상습남용자 / 중독자수가다른나라에비해비교적높은것을알수있다.(1) 이렇게음주자가많고알코올소비량이많음에따라경제적비용의손실도적지않아서 1995년도 GNP의 2.75% 인 9조 5,670억원으로추정된다. 미국에서의알코올과관련된문제는해마다 3천억달러의소용경비를유발하며여기에는사고, 건강문제, 생산성의소실, 범죄, 치료등을포함한다.(2) 해마다알코올과관련된교통사고로인해 22만명이사망했으며 2백만명이부상을당하며 5천만대의차에손상이생긴다. 과량의음주자는작업시간의 5% 를소실하고작업수행에서 25% 의감소를보이는데알코올사용장애의기준을만족하는남자와여자는 15년가량수명이감소된다. 또한알코올남용및의존은외상환자에서밀접하게연관되어있으며외상으로입원이불가피할때얘 Table 1. Demographics Total patients 70 Male 57 (81.42%) Mean age years Blunt injury 50 (71.42%) *AWS 25 (35.71%) ISS > *AWS ; alcohol withdrawal syndrome, ISS ; injury severity score 기치못한알코올의급작스러운중단이발생하게된다. 환자들은알코올금단증후군이발생할위험에처하며임상적으로손의진전, 초조와불안, 빈맥, 호흡수그리고체온의상승등과같은자율신경계의과활성이나타나불면, 악몽과동반하기도하고소화기계의불편감을경험하게된다.(3,4) 알코올중독은간경화, 출혈성질환, 패혈증등과같은다른기저질환과도많은연관되어있으므로다른질병과의감별이매우복잡하다. 이는빠른진단과치료에저해하는요인으로작용하며오랜재원기간과많은비용으로연결된다.(5) 본연구는 injury severity score (ISS) 에따른알코올금단증후군의발생빈도와이에따른병원재원기간, 중환자실집중치료기간, 인공호흡기치료기간, 사망률, 합병증및예후에관하여후향적으로알아보고자하였다. II. 대상및방법 2003년 5월부터 2007년 3월까지강원도원주원주기독병원에서외상으로인해응급실을경유수술을시행받은환자중만성알코올남용의과거력이있어예방적치아민 (thiamine) 을투여받은환자 70명을대상으로후향적으로자료를수집하였다. 여기서만성알코올중독자는 4일에한번이상의음주를하는것으로정의하였다.(6) 상기기간동안외상으로인해응급수술을시행받았으나만성알코올중독, 의존및남용의과거력이없는자, 외상성원인이아닌기초질환으로재원기간이연장되거나, 외상성손상으로인해수술후 3일이내에사망하거나타병원으로전원한환자및다른정신과적인진단을받은환자는제외하였다. 금단증후군발생유무에따라환자를분류하여나이, 성별, 사고기전, 재원기간, 중환자실치료기간, 인공호흡기치료기간, 사망률및합병증을조사하였다. 통계분석은 chi-square test 와 Mann-Whitney method로분석하였다. Table 2. ISS of 16 or more, compared with AWS and no AWS *AWS (n=24) No *AWS (n=34) P-value Age 50.17± ± Male 24 (.100%) 24 (70.6%) P=0.01 Blunt injury 21 (87.5%) 21 (61.8%) ISS 28.13± ± P=0.080 LOS 39.71± ± P=0.054 ICU++ day 10.92± ±7.590 P=0.029 Ventilator care 3.96± ±5.990 P=0.783 Total sedation day 3.25± ±4.281 P=0.284 *AWS ; alcohol withdrawal syndrome, ISS ; injury severity score, LOS ; length of hospital stay, ICU ; intensive care unit, ; not significance 116

3 오동길외 : 외상환자에서알코올금단증후군의발생이예후에미치는영향 III. 결과만성알코올중독및남용의과거력이있는환자 70명의평균나이는 53.36세였으며남성이총 57명 (81.42%) 이였다. 사고기전으로는둔상 (blunt injury) 이 50명 (71.42%) 으로많은수를차지하고있었으며알코올금단증후군이발생한예는총 25명 (35.71%) 이었다 (Table 1). ISS 16 이상인환자 58명중에서 24명 (41.4%) 에서알코올금단증후군이나타났다. 이를비교하였을때알코올금단증후군의발생빈도는남자에서유의하게높게나타났다. 알코올금단증후군이발생한환자군에서 ISS가좀더높게나타났으나유의한차이는보이지않았다. 총재원기간은알코올금단증후군이발생한환자군에서평균 10일가량길었지만통계학적으로유의한차이를보이지 않았으나, 중환자실치료기간은알코올금단증후군에서유의하게길었다. 인공호흡기치료기간은금단증후군발생한군과그렇지않은군을비교하였을때유의한차이를보이지는않았다 (Table 2). ISS 16 이하인환자 12명중 1명 (8.33 %) 에서알코올금단증후군이발생하였으나유의한차이는보이지않았다 ( Table 3). 알코올금단증후군발생한환자군에서호흡부전, 폐렴, 요로감염, 패혈증, 급성신부전, 사망률은알코올금단증후군이발생하지않은환자군보다발생빈도는높았으나통계학적으로유의한차이는보이지않았다 (Table 4, 5). Table 3. below ISS 16, compared with AWS and no AWS *AWS (n=1) No *AWS (n=11) P-value ±18.69 Male 1 (100%) 8 (72.7%) P=1.00. Blunt injury 0 (000%) 8 (72.7%) ISS ±2.580 P=0.667 LOS ± P=0.500 ICU day 0 3.0±3.0 P=0.333 Ventilator care ±1.036 P=0.833 Total sedation day ±0.302 P=1.000 *AWS ; alcohol withdrawal syndrome, ISS; injury severity score, LOS ; length of hospital stay, ICU ; intensive care unit, ; not significance Table 4. ISS of 16 or more, compared with AWS and no AWS in complication *AWS (n=24) No *AWS (n=34) P-value Respiratory failure 3 (12.5%) 2 (05.9%) P=0.682 Pneumonia 8 (33.3%) 5 (14.7%) P=0.175 UTI 4 (16.7%) 2 (05.9%) P=0.373 Sepsis 0 (0.00%) 1 (02.9%) P=1.000 Acute kidney injury 1 (04.2%) 0 (00.0%) P=0.860 Mortality 0 (00.0%) 1 (02.9%) P=1.000 AWS* ; alcohol withdrawal syndrome, UTI ; urinary tract infection Table 5. below ISS 16, compared with AWS and no AWS in complication AWS* (n=1) No AWS* (n=11) P-value Respiratory failure 0 0 Pneumonia 0 0 UTI** 0 1 (9.1%) P=1.0 Sepsis 0 0 Acute kidney injury 0 0 Mortality 0 0 *AWS ; alcohol withdrawal syndrome, UTI ; urinary tract infection, ; not significance 117

4 대한외상학회지제 21 권제 2 호 IV. 고찰알코올금단증후군의조기진단과빠른치료대응을위한발표논문들이있으나명확한치료법에대한논문은그수가적다.(7) 알코올금단증후군의증상에따른적절하고적극적인치료가반드시필요하다.(8) 그러므로조기의대응을위해서는알코올금단증후군의증상에대해명확히인지할필요가있다. 술을갑자기끊거나양을줄이면먼저손, 혀, 눈꺼풀등이떨리고구토, 구역, 전신쇠약, 빈맥, 땀이나고, 혈압상승등의자율신경항진으로인한증상이나타나고불안, 우울, 초조, 불면, 환각, 전신경련등의증상이나타날수있다. 그외심한구갈, 두통, 말초부종을보일수있다. 일반적으로떨림이가장먼저나타나는증상이며환각, 경련, 섬망의순서로증상이나타난다 (Table 6). 알코올금단증후군은술의양이줄거나끊은다음약 6 시간이후부터나타나기시작하여약 5~7일이내에감소한다. 심한경우진전섬망을경험하게되며이는알코올금단증상중가장심한상태로치료를안했을경우에는치사율이 15~20% 에달할정도이며대개감염, 지방색전, 폐렴, 신장질환, 간부전증, 심부전증, 심부정맥등내과적합병증으로사망한다. 이는대개칼슘과다증, 고열, 탈수와연관돼있다. 알코올금단섬망은감염, 경막하혈종, 외상, 간손상과대사성질환을가진사람에서자주나타나며가장위험하다. 의식의혼탁, 착각, 환각, 망상, 떨림, 초조, 수면장애, 자율신경항진, 동공산대, 불안정한혈압등의증상이동반된다 (Table 6). 또한치료를하지않으면폐렴및심부전증등으로사망하는비율이 5~15% 로높고, 알코올성기억장애증후군으로이행되기쉬우며또한식욕부진, 구토와설사가금단현상중에발생할수있다.(9) 그러므로만성알코올중독및남용환자에있어조기예방과치료가중요하다.(10) 수술적치료가불가피한외상환자에있어발생하는알코올금단증상은예방이어렵기때문에알코올금단증후군이예견되는환자의집중감시시에호흡저하, 부정맥또는위험할수있는혈압변화의증거없이생체징후가비교적안정되게하는것 이중요하며적절한응급처치가필요하다. 의사는알코올중독환자에서혼수상태가될수있는여러가지원인들을인지해야만한다. 다른약물의중독가능성도고려되어야하며혈액이나소변의채취로아편양제제나벤조다이아제핀이나바비투레이트와같은다른중추신경계억제제의선별검사가이루어져야한다. 또한동반된간질, 두부손상, 뇌막염, 뇌종양또는신경학적질환을감별하여야하며저혈당, 간손상, 당뇨병성케톤산증역시감별되어야한다.(11) 본연구대상의환자군은내과, 신경과, 신경외과및정신과협진하에내과적질환, 중추신경계질환및약물에의한섬망등을배제할수있었다. 본논문에서외상환자에서알코올금단증후군이발생하지않은환자군과비교하였을때알코올금단증후군이발생한환자군에서통계학적의의는없으나재원기간이길었으며중환자실집중치료기간은통계학적으로유의하게길었다. 또한발생한군에서통계학적의의는없으나수술후폐렴및요로감염과같은합병증이더많이발생하는것을볼수있다. 이러한결과는뇌의과활성에따른의식의저하와연관있다. 기도확보의어려움과흡인폐렴의위험도가증가되어중환자실집중치료기간이길어지며기도삽관및인공호흡기치료기간도길어지게된다.(12,13) V. 결론만성알코올중독환자에서알코올금단증후군발생에따른합병증의발생으로중환자실집중치료기간이연장되었다. 그러나중환자실집중치료후알코올금단증상이극복되면사망률의차이는보이지않으며예후에큰차이가없음을확인할수있었다. 따라서앞으로알코올남용및의존이의심되는환자가응급실에내원하였을때알코올금단증후군의발생위험도를명확히분류할수있는진단법과이에따른집중치료알고리듬의확립을위한체계적인연구가필요할것으로사료된다. REFERENCES Table 6. Symptom of alcohol withdrawal syndrome Symptom Number (patients) Confusion 25 Illusion 23 tremor 19 Irritation 17 Hallucination 14 Insomnia 08 Unstable vital sign 03 01) Jegal Jung. Korean Drinking Behavior. Vol. 1. Seoul: Korea Alcohol and liquor Industry ) Mayo-Smith MF: Pharmacological management of alcohol withdrawal: a metaanalysis and evidence-based practice guidline. JAMA 1997; 278: ) Field CA, Claasen CA, O Keefe G. Association of alcohol use and other high-risk behaviors among trauma patients. J Trauma. 2001; 50: ) Bayard M, Mcintyre J, Hill KR, Woodside J. Alcohol withdrawal syndrome. Am Fam Physician. 2004;69:

5 오동길외 : 외상환자에서알코올금단증후군의발생이예후에미치는영향 05) Foy A, Kay J, Tayler A: The course of alcohol withdrawal in a general hospital. QJM 1997; 90: ) Harrison,s internal medicine 15th edition : ) Saitz R, Mayo-Smith MF, Roberts MS, et al: Indivisualized treatment for alcohol-withdrawal: A randomized, double-blind, controlled trial. JAMA 1994;272: ) Jaeger TM, Lohr RH, Pandratz VS: Symtom-triggered therapy for alcohol withdrawal syndrome in medical inpatients. Mayo Clin Proc 2001; 76: ) Jennifer Repper-DeLisi, Theodore A Stern, Monique Mitchell, Mary Lussier-Cush: Successful Implementation of an alcohol-withdrawal pathway in a general hospital. Psychosomatics 2008; 49: ) Renholm M, Leino-Kilpi H, Suomine T: Critical pathway: a systemic review. J Nurs Adm 2002; 32: ) O Connor PG, Schottenfeld RS: Medical progress: patients with alcohol problem. N Engl J Med 1998;338: ) Grossman RF, Fein A. Evidence-based assessment of diagnostic tests for ventilator-associated pneumonia. Chest. 2000;117:177S-181S. 13) Alcon A, Fabregas N, Torres A. Hospital-acquired pneumonia: etiologic considerations. Infect Dis Clin North Am. 2003;17:

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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