02-03 정재윤

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1 Review Article 대한소아응급의학회지 2016 제 3 권제 1 호 Pediatric Emergency Medicine Journal Volume 3, Number 1, June, 2016 소아소생술을위한체중추정방법 정재윤 권혁술 최유진 서울대학교의과대학응급의학교실 Methods of weight estimation in pediatric resuscitation Jae Yun Jung, M.D., Hyuksool Kwon, M.D., Yoo Jin Choi, M.D. Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea Knowing a pediatric patient s weight is crucial in resuscitation since the decision on the dose of resuscitation drug and the size of the instrument is made mostly based on a patient s weight. However, using a scale may not always be practical in resuscitation. Therefore, it is important to know the methods of weight estimation in resuscitation. The weight estimation can be performed based on various factors: visual assessment, age, height, and body habitus. One of the most common problems of these methods is that the weight tends to be underestimated as a patient s age increases. This is due to an inappropriate reflection of body habitus. Further research is needed to overcome this problem. Key Words: Body Weight; Child; Emergency Service, Hospital; Infant; Resuscitation 서 론 소아에서병원외심정지의빈도는성인에비해낮은편으로, 미국의자료에의하면연간 10만명중 8 20명의빈도로발생한다고알려져있다 1). 한편, 소아의병원내심정지는병원외심정지의약 100배의빈도로발생하며, 그중 1세이하가약 60% 를차지한다. 성공적인소생술에있어서, 심정지의빠른인지이후가장중요한것은효과적인전문소아소생술 (pediatric advanced life support, 소생술 ) 이다. Received: May 17, 2016 Revised: Jun 6, 2016 Accepted: Jun 8, 2016 Corresponding Author Jae Yun Jung Department of Emergency Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea Tel: Fax: matewoos@gmail.com 소생술은심장압박이나호흡보조등기본적인요소외에도빠른약물투여, 기관내삽관및제세동이중요한요소이다. 성인의전문심장소생술과정에서는약물용량및기구크기의선택이정형화되어있지만소아의경우에는체중을기반으로결정되므로, 소아에서체중을아는것은성공적인소생술을위해매우중요하다. 하지만소생술상황에서소아의체중을정확히알기는힘들다. 이는성장에따라체중이늘뿐아니라, 소생술상황에서는보호자및의료진이심한스트레스로인하여체중을추정하거나기억해내기가매우어렵기때문이다. 따라서소생술시에체중추정은, 곧성공적인소생술과직결된다고할수있겠다. 또한체중추정이후진행되는약물용량및기구크기의선택과정또한지체되어서는안되므로, 체중추정이후정보가전달되는과정의간결함과정확함또한중요한요소이다. 따라서본종설에서는소아환자의소생술에필요한체중추정방법에대한최신지견과각체중추정방법의문제점, 향후필요한연구방향등에대해다루고자한다. 9

2 대한소아응급의학회지제 3 권제 1 호 2016 본 론 1. 눈대중을기반으로하는체중추정방법 가장고전적인방법으로보호자혹은의료진이눈대중으로체중을추정하는방법이며, 별다른장비가필요없다는장점이있다. 의사의눈으로체중을추정하는방법의정확도는 43% 로보고되었다 2). 또한, 보호자및간호사가같은방법으로시행한체중추정의정확도는, 각각 78% 80% 및 55% 로보고되었다 4,5). 즉보호자의체중추정이비교적정확해보이지만, 상기연구는모두소아가건강한상태에서시행되었으므로, 그결과를소생술상황에반영하기는어렵다. 결국소생술시에당황한보호자로부터높은정확도를기대할수없기때문에, 의료진의눈으로체중을추정해야하는경우가대부분이다. 따라서이방법은임상적효용성이높지않을것으로판단된다. 2. 연령을기반으로하는체중추정방법 현재까지가장많이사용됐던방법이다. 환자의연령만을가지고체중을추정할수있고보호자는대부분환자의연령을알고있기때문에간편하게사용될수있는방법으로, 현재까지다양한방법이개발되어있다. 1) Advanced Pediatric Life Support (APLS) 공식 APLS의일환으로개발된공식이다. 1세부터 10세까지의소아를대상으로적용가능하게개발되었으며, 추정체중은연령에 4를더한값에 2를곱한것으로정의되었고가장많이사용되었던공식중하나였다. 하지만이공식의문제는연령이증가할수록실측체중보다추정체중이낮게나타나는것이다 6,7). 따라서이문제를보정하기위해서새로운 APLS 공식이유도되었고, 이는 0세부터 12세까지적용가능하다 8). APLS 공식 : (1 10세) 체중 (kg) = [ 연령 ( 세 ) + 4] 2 새로운 APLS 공식 : 영아 (0 12개월) 체중 (kg) = [ 연령 ( 개월 ) 0.5] + 4 소아 (1 5세) 체중 (kg) = [ 연령 ( 세 ) 2] + 8 소아 (6 12세) 체중 (kg) = [ 연령 ( 세 ) 3] + 7 2) Luscombe and Owens 공식 APLS 공식이연령이증가할수록실제체중보다과소평가되는결과를보이면서개발되었다. 이공식은원래 Nottingham Pediatric Weight Study에의해서제안된공식을기반으로, Luscombe가약 95,000명의소아를대상으로대규모확인연구를통해 1세부터사춘기연령까지적용가능하도록개발한공식이다 9). 체중 (kg) = [ 연령 ( 세 ) 3] + 7 APLS 공식에비해소아의체중을과소평가하는비율이줄어들었으며 1세부터 16세까지골고루사용할수있다는점에서 APLS 공식에비해장점이있으나, 이공식역시연령이아주적거나많은경우에실측체중에비해과소평가되는문제점이있다. 하지만 APLS 공식에비해 6세이상의연령에서는보다높은정확도를보여새로개정된 APLS 지침에서는 6세부터 12세까지이공식을채택하고있다 9). 3) Best guess 공식호주에서개발된공식이다. 이역시널리사용되던 APLS 공식이호주소아환자에게적합하지않다는것을기반으로개발되었다. 지난 20년간대부분의선진국에서는소아의키보다는체중증가가현저하게이루어졌다. 즉, 과체중소아가늘었다는의미로이전에개발된 APLS 공식이호주소아의과체중환자에게는적용하기힘들다는이유로시작되었다 10). 이공식은 70,000명의소아환자로부터유도하였다. 영아 (0 12개월) 체중 (kg) = [ 연령 ( 개월 ) + 9] / 2 소아 (1 4세) 체중 (kg) = [ 연령 ( 세 ) + 5] 2 소아 (5 14세) 체중 (kg) = [ 연령 ( 세 ) 4] 이공식역시연령이증가할수록실제체중보다과소평가되는경향을보였다는아쉬운점은있으나, APLS 공식에비해그정도가개선되었다 11). 4) Leffler 공식 1997년 Leffler에의해개발된공식으로 APLS 공식과유사하게대규모환자의실측체중데이터를통해공식을유도하였다. 0세부터 10세까지적용가능한공식으로다음과같다 5). 영아 (0 12개월) 체중 (kg) = [ 연령 ( 개월 ) / 2] + 4 소아 (1 10세) 체중 (kg) = [ 연령 ( 세 ) 2] + 10 오래전에개발된공식으로 APLS보다정확도가떨어지는경향이있어현재는많이사용되고있지않다. 10 Pediatric Emergency Medicine Journal

3 소아체중추정방법 5) Theron 공식뉴질랜드소아를위한체중추정공식이다. Pacific island와 Maori족소아환자 800명을대상으로개발되었다. 공식은아래와같다. Log( 체중, kg) = 연령 ( 세 ) 또는체중 (kg) = exp [ 연령 ( 세 )] 기존의방식중에서 APLS, Leffler 공식등을실제뉴질랜드소아에게적용하였으나연령이증가할수록실제체중보다과소평가되는경향이있어서새로운공식을만들었다. 이공식은연령이증가할수록과체중이많은것을기반으로만들었으나, 실제공식이로그함수를사용하는등복잡하여암기해서사용하기는힘들다. 따라서, 스마트폰등첨단기기를통해사용하면좋을것으로판단한다 12). 6) Park s 공식여러체중추정공식중에서유일하게한국소아의특성을반영한공식이다. 0세부터 14세소아의전국적인신체계측자료를이용하였고전체약 12만명의자료를이용하였다. 연령별로각구간의평균체중을구하였고이에따른공식을도출하였다. 체중추정공식은아래와같다. 3. 키를기반으로하는체중추정방법 1) Length based weight estimation tape (Broselow tape) 키를기반으로소아의체중을추정하려는시도는 1980 년부터있었고 16,17), 1986년에 James Broselow가단순화된키를기반으로하는체중추정방법을개발하였다 년에미국 National Center for Health Statistics에서 1963년부터 1975년까지미국 18세이하소아 20,000여명의표준샘플을통해백분위가나오는신체계측곡선을발표하였다. Broselow가이곡선에근거를둔키와체중의 50백분위수를이용하여현재의 Broselow tape을개발하였다. 이테이프에는해당키구간의추정체중이표시되어있으며체중과함께약물용량및기구크기가표시되어있어, 소생술을담당하는의료진이계산할필요없이약물용량및기구크기를선택할수있는방법이다. Broselow tape의유용성에관해다양한연구가시행되 영아 (0 12개월) 체중 (kg) = [ 연령 ( 개월 ) + 9] / 2 소아 (1 4세) 체중 (kg) = [ 연령 ( 세 ) 2] + 9 소아 (5 14세) 체중 (kg) = [ 연령 ( 세 ) 4] 1 위공식은한국소아의표준체중추정장비를이용하여한국소아에맞게제작한것에의미가있으나, 기존의공식과마찬가지로소아의연령이증가할수록실측체중보다추정체중이과소평가되는한계가있다 13). 7) 연령을기반으로하는체중추정방법의문제점소아에서일반적으로백분위수를사용하여성장정도를기술한다. 일반적으로연령을이용하는공식은체중의 50 백분위수를사용하며이는해당연령의평균체중을의미한다 14,15). 그리고현재까지의연령을기반으로한체중추정공식은모두해당연령체중의 50백분위수, 즉정상체중소아를참고로하여유도되었다. 그러므로저체중혹은과체중인소아에대한대비가부족한실정이다. 또한, 연령이증가할수록실제체중보다과소평가되는것은비만도를고려하지않았기때문이라고할수있겠다. Fig. 1. The Broselow tape and spaces are labeled with the estimated weight corresponding to the measured length. Reproduced from File:BTape3.jpg [cited 2016 May 10]. Pediatric Emergency Medicine Journal 11

4 대한소아응급의학회지제 3 권제 1 호 2016 었고, 현재가장보편적으로사용되는방법이다 18-21). 지속적인개정을통해현재 2013년판까지개발되었다 (Fig. 1). 2) Broselow tape의문제점키를기반으로하는체중추정방법의문제점은, 앞서연령을기반으로한공식의문제점과동일하다. 비교적대규모의데이터를이용하여보편적으로적용하는부분에대해서는어려움이없지만, 연령을기반으로하는공식과유사하게 50백분위수에해당되는수치를기준으로사용하고있다. 따라서저체중혹은과체중인소아에게적용하였을경우오차가심한것이문제이다. 여러연구에서도 Broselow tape으로연령이증가할수록실제체중보다과소평가되는결과가있어서향후보완해야할문제로판단된다 18,20). 4. 체형을기반으로하는체중추정방법앞서언급된방법들의일관적인단점은저체중혹은과체중인소아에게적용하였을경우오차가매우심하다는점이다. 이단점을극복하고보다정확하게체중을추정하기위한여러가지방법이개발되었다. 대부분소아의체형은위팔중간둘레 (mid-arm circumference) 에비례한다는것에착안하여체중을추정하는방법이개발되었고, 키로체중을추정한이후에의사가소아의체형을판단한후체중을가감하는장비 (pediatric advanced weight prediction in the emergency room tape, PAWPER tape), 소아체형에따라 5백분위수와 95백분위수를구분하여각각의공식을유도한후적용하는방식등이개발되었다. 이외에도 Devised weight estimation method 와 Yamamoto obesity icon system 등이있다. 2) PAWPER tape 원리는비교적간단하다. Broselow tape과동일하게 50백분위수를기준으로신장기반체중추정테이프를만들고각체중구간에체형에따라체중을가감하는방법이다 (Fig. 2). 이방법의장점은실측체중과의오차가거의없다는것이다 23). 하지만이방법의정확도가약 50% 로보고되어, 아직까지임상적유용성은판단하기어렵다 24). 3) Devised weight estimation method 미국에서개발된방법으로비교적적은수인 258명의소아를대상으로개발되었다. 키를 5 cm 구간으로나누고 50 cm부터 175 cm까지소아의 5, 50, 95백분위수를나누어 5백분위수는 slim 으로, 50백분위수는 average 로, 95백분위수는 heavy 로각각표시하여각구간의체중을표로나타내었다. 저체중혹은과체중인소아를잘반영하고비교적실측체중과연관성이높다고제시되고있으나, 전체소아를반영하기에는연구참여자수가적은단점이있고, 이방법또한과체중인경우에실측체중과의오차가커지는경향성이있다 17). 4) Yamamoto obesity icon system 일본에서개발된체형을반영하는방법이다. 다른방법과구분되는것은소아의앉은자세의모양을아이콘모양으로 1) 위팔중간둘레로체중을추정하는방법홍콩에서진행된연구에의해도출된방법으로 1-11세소아를대상으로개발된방법이다. 연령및키로추정하는방법과비교했을때매우우수한결과를보여주목받고있는방법이다. 여기서도출된공식은다음과같다 22). 체중 (kg) = [ 위팔중간둘레 (cm) 10] 3 실제 APLS 공식및 Broselow tape과비교를했을경우에연령이 6세이상인소아에서는매우좋은방법이나 6세이하의소아에서는좋지않은결과를보여주고있다. 따라서, 이방법으로체중을추정할시에는연령이낮은소아에대한고민이필요하다. Fig. 2. A segment of the PAWPER tape with the weight estimations for each habitus score for a child of that length. The habitus score is assigned dependent on the morphological characteristics of the child. Reproduced from Wells et al. Resuscitation 2013;84:227-32, with permission of Elsevier 23). 12 Pediatric Emergency Medicine Journal

5 소아체중추정방법 만들어서기저귀착용을기준으로 3세미만과이상으로아이콘을구분하였고, 의료진의눈대중이아닌아이콘에맞는엉덩이와넓적다리를비교하여참고로삼는다는것이다. 기존의방법에비하여약물용량등에서정확도가높아졌다는결과를보였으나, 아직임상적으로널리사용되고있지않으며다른연구에서유용성이확인되지않았다 25). 손가락까지한손가락이동할때마다체중이 5 kg 증가하는방법이다 (Fig. 3). 매우간단한방법이지만, 다른방법에비해정확도가떨어지지않는다고제시되고있다. 단 1 세부터 9세소아에만적용할수있다는점과다른방법과마찬가지로체형을반영할수없다는점으로인해, 연령이증가할수록실제체중보다과소평가되는단점이있다 26). 5. Finger counting method 6. 기존체중추정방법의문제점 양손가락을이용하여체중을추정하는방법이다. 약 300명의소아를대상으로개발되었다. 왼손및오른손으로나누어, 왼손은엄지부터새끼손가락까지한손가락이동할때마다연령이 2세증가하고, 오른손은엄지부터새끼 기존의체중추정방법은소생술에유용하게사용할수있다. 하지만앞서언급하였듯이여러가지문제점을고려하여사용해야한다. 대부분의방법은연령이증가할수록실제체중보다과소평가되는단점이있다. 이는청소년환자의소생술에서실제로필요한약물용량및기구크기보다적은용량또는작은크기가선택됨으로써효과적인소생술을방해할수있음을시사한다. 이를극복하기위해체형을반영하는방법이개발되었으나, 이또한다른집단에적용하였을경우오차가커질수있고아직유용성이입증되지않았다. 아직완벽하게적용할수있는체중추정방법은없는것으로판단된다. 결 론 Fig. 3. The finger counting weight estimation method. *For even ages, average the adjacent weights (e.g., Four years of age yields 17.5 kg). Reproduced from Young et al. Am J Emerg Med 2014;32:243-7, with permission of Elsevier 26). 소아소생술시에체중을추정하는것은매우중요하다. 이것은소아의약물용량및기구크기선택이체중에근거하고, 소생술상황에서보호자가소아의체중을기억해내기어렵기때문이다. 고전적으로눈대중, 연령, 키를기반으로추정하는방법이사용되었지만, 연령이증가할수록체중이과소평가되는경향이있다. 이후체형을반영하는방법이개발되고있지만, 소생술시효과를확인하는연구가미흡하기때문에아직은실제로적용하기어렵다. 향후더욱정확하고간편한소생술을위한체중추정방법이개발되어야할것으로생각한다. REFERENCES 01. Young KD, Seidel JS. Pediatric cardiopulmonary resuscitation: a collective review. Ann Emerg Med 1999; 33: Rosenberg M, Greenberger S, Rawal A, Latimer-Pierson J, Thundiyil J. Comparison of Broselow tape measurements versus physician estimations of pediatric weights. Am J Emerg Med 2011;29: Partridge RL, Abramo TJ, Haggarty KA, Hearn R, Sutton KL, An AQ, et al. Analysis of parental and nurse weight estimates of children in the pediatric emergency department. Pediatr Emerg Care 2009;25: Krieser D, Nguyen K, Kerr D, Jolley D, Clooney M, Kelly AM. Parental weight estimation of their child s weight is more accurate than other weight estimation methods for Pediatric Emergency Medicine Journal 13

6 대한소아응급의학회지제 3 권제 1 호 2016 determining children s weight in an emergency department? Emerg Med J 2007;24: Leffler S, Hayes M. Analysis of parental estimates of children s weights in the ED. Ann Emerg Med 1997;30: Luscombe M, Owens B. Weight estimation in resuscitation: is the current formula still valid? Arch Dis Child 2007;92: Argall JA, Wright N, Mackway-Jones K, Jackson R. A comparison of two commonly used methods of weight estimation. Arch Dis Child 2003;88: Advanced Life Support Group. Advanced paediatric life support: the practical approach. 5th ed. Samuels M, Wieteska S, editors. Chichester (UK): John Wiley & Sons Ltd; Luscombe MD, Owens BD, Burke D. Weight estimation in paediatrics: a comparison of the APLS formula and the formula Weight=3(age)+7. Emerg Med J 2011;28: Booth ML, Wake M, Armstrong T, Chey T, Hesketh K, Mathur S. The epidemiology of overweight and obesity among Australian children and adolescents, Aust N Z J Public Health 2001;25: Tinning K, Acworth J. Make your best guess: an updated method for paediatric weight estimation in emergencies. Emerg Med Australas 2007;19: Theron L, Adams A, Jansen K, Robinson E. Emergency weight estimation in Pacific island and Maori children who are large-for-age. Emerg Med Australas 2005;17: Park J, Kwak YH, Kim DK, Jung JY, Lee JH, Jang HY, et al. A new age-based formula for estimating weight of Korean children. Resuscitation 2012;83: de Onis M, Garza C, Onyango AW, Borghi E. Comparison of the WHO child growth standards and the CDC 2000 growth charts. J Nutr 2007;137: de Onis M, Onyango AW. The Centers for Disease Control and Prevention 2000 growth charts and the growth of breastfed infants. Acta Paediatr 2003;92: Garland JS, Kishaba RG, Nelson DB, Losek JD, Sobocinski KA. A rapid and accurate method of estimating body weight. Am J Emerg Med 1986;4: Traub SL, Kichen L. Estimating ideal body mass in children. Am J Hosp Pharm 1983;40: Oakley PA. Inaccuracy and delay in decision making in paediatric resuscitation, and a proposed reference chart to reduce error. BMJ 1988;297: Lubitz DS, Seidel JS, Chameides L, Luten RC, Zaritsky AL, Campbell FW. A rapid method for estimating weight and resuscitation drug dosages from length in the pediatric age group. Ann Emerg Med 1988;17: Ramarajan N, Krishnamoorthi R, Strehlow M, Quinn J, Mahadevan SV. Internationalizing the Broselow tape: how reliable is weight estimation in Indian children. Acad Emerg Med 2008;15: Jang HY, Shin SD, Kwak YH. Can the Broselow tape be used to estimate weight and endotracheal tube size in Korean children? Acad Emerg Med 2007;14: Cattermole GN, Leung PY, Mak PS, Graham CA, Rainer TH. Mid-arm circumference can be used to estimate children s weights. Resuscitation 2010;81: Wells M, Coovadia A, Kramer E, Goldstein L. The PAWPER tape: a new concept tape-based device that increases the accuracy of weight estimation in children through the inclusion of a modifier based on body habitus. Resuscitation 2013;84: Garcia CM, Meltzer JA, Chan KN, Cunningham SJ. A validation study of the PAWPER (pediatric advanced weight prediction in the emergency room) tape: a new weight estimation tool. J Pediatr 2015;167: Yamamoto LG, Inaba AS, Young LL, Anderson KM. Improving length-based weight estimates by adding a body habitus (obesity) icon. Am J Emerg Med 2009;27: Young TP, Chen BG, Kim TY, Thorp AW, Brown L. Finger counting: an alternative method for estimating pediatric weights. Am J Emerg Med 2014;32: Pediatric Emergency Medicine Journal

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