Anesth Pain Med 2018;13: pissn ㆍ eissn 종설 수술후회복향상프로그램 : 마취통증의학과의사의관점 채민석ㆍ이형묵ㆍ박찬오

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1 Anesth Pain Med 2018;13: pissn ㆍ eissn 종설 수술후회복향상프로그램 : 마취통증의학과의사의관점 채민석ㆍ이형묵ㆍ박찬오ㆍ홍상현 가톨릭대학교의과대학서울성모병원마취통증의학교실 Received September 10, 2018 Accepted September 17, 2018 Enhanced recovery after surgery: an anesthesiologist s perspective Minsuk Chae, Hyungmook Lee, Chan-oh Park, and Sang Hyun Hong Department of Anesthesiology and Pain Medicine, Seoul St. Mary s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea Corresponding author Sang Hyun Hong, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Seoul St. Mary s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea Tel: Fax: shhong7272@gmail.com ORCID Enhanced recovery after surgery (ERAS) is a multimodal and multidisciplinary approach to maintaining physiologic function and improving recovery for surgical patients. The ERAS protocol is based on a range of empirical evidence, and consensus ERAS guidelines for various surgical procedures have been published. The elements of the ERAS protocol include minimal preoperative fasting and carbohydrate treatment instead of overnight fasting; no routine use of preoperative bowel preparation; minimally invasive surgical techniques; standard anesthetic protocol; optimal fluid management rather than generous intravenous fluid administration; prevention and treatment of postoperative nausea and vomiting; active prevention of perioperative hypothermia; multimodal approaches to controlling postoperative pain; and early oral intake and mobilization. Implementation of ERAS shortened hospital stays by 30% to 50% and reduced postoperative complications by 50%. A recent study reported that, when patient compliance with the colorectal ERAS protocol was over 70%, 5-year mortality fell by 42% compared with when compliance was below 70%. Auditing process compliance and patient outcomes are key measures for assisting clinicians implementing the ERAS program. As a perioperativist, an anesthesiologist can play a crucial role in implementing the ERAS program and contribute to protocol establishment, auditing, team education and team leadership. While the ERAS protocol was first implemented for colorectal surgery, as a result of its efficacy, it is now being used in nearly all major surgical specialties. Keywords: Enhanced recovery after surgery; Fast-track surgery. 서론 수술및마취기법의비약적인발전에도불구하고수술자극에대한신체의스트레스반응 (stress response), 이로인한대사적항상성 (metabolic homeostasis) 의교란및면역기능의저하 는여전히수술과관련된합병증을야기한다. 따라서수술환자가수술자체에의해수술중이나직후에사망하는경우는현저하게줄었으나수술과관련된합병증으로수술후치료중사망하는경우는여전히드물지않다 [1]. Enhanced recovery after surgery (ERAS) 프로그램은수술에의한기능의감소를최소화 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright c the Korean Society of Anesthesiologists,

2 수술후회복향상프로그램 : 마취통증의학과의사의관점하고회복과정을촉진시켜주술기환자관리의질을향상시키 ERAS 가이드라인이개발중에있다 [11 23]. Table 1은대장절기위하여 1990년대유럽에서시작되었고, ERAS 프로그램의시제술에대한 ERAS 컨센서스가이드라인이다 [11]. 행이입원기간을단축시켜의료비절감의효과가있을뿐만아 ERAS 프로그램하에서는위와같은근거중심의프로토콜이니라수술과관련된합병증을감소시키고수술사망률을감소다학제의료진에의해서다중적으로시행된다. 수술환자관리시키는것이밝혀지면서근래에는전세계적으로확산되고있다및치료의어려운점은환자가수술전, 중, 후에외래, 입원병동, [2 6]. 수술실, 회복실, 경우에따라중환자실등을거치는동안각파트이논문에서는 ERAS의개념과역사에대해알아보고 ERAS 의의료진으로부터치료및관리를받게되므로앞선파트에서프로그램을구성하는구성항목을대장절제술을중심으로기술행하여진의료행위는그뒤에행하여질의료행위에영향을미하며, 실제 ERAS 프로그램을시행할경우에임상적으로고려할칠수있음에도불구하고통합적인치료및관리가어렵다는데점들과 ERAS 프로그램시행의결과에대해서술하고, ERAS 프있다. 예를들어, 외과의사가수술전에창자세척 (mechanical 로그램시행에있어마취통증의학과의사의역할에대해알아보 bowel preparation) 을철저히하고하루전부터금식을시켰다고자한다. 면마취통증의학과의사는수술실에서마취유도직후탈수된환자상태로인해심한저혈압을경험할가능성이높아진다. 전통 ERAS 의개념 ERAS 프로그램은수술자극에대한신체의스트레스반응을줄여수술후회복을향상시키기위한 근거중심 의개별의료행위들을환자의수술전, 중, 후의치료및관리에참여하는여러의료진으로구성된 다학제팀 (multidisciplinary team) 이 다중적 (multimodal) 으로제공한다는수술환자치료및관리의새로운개념이다. ERAS 프로그램이태동할당시는 fast-track surgery 라는용어를혼용하였지만핵심적목표는회복의속도가아니라질이다. ERAS 프로그램의시행은수술중, 후카테콜아민 (catecholamine) 분비및염증반응으로증가하는인슐린저항성 (insulin resistance) 을감소시킴으로써세포기능저하를막고근육량및근력의손실을완화시키는한편주술기대사적항상성의교란을완화한다 [7]. 초기의 ERAS 컨센서스가이드라인 (consensus guideline) 은 ERAS에관심이있던유럽외과의사들이 2001년결성한 ERAS Study group 에의해대장절제술에대한주술기관리프로토콜이 2005년발표되었고, 이어서대장직장절제술에대한주술기관리프로토콜이 2009년발표되었다 [8,9]. 이후 ERAS Study group 의사들에의해이들프로토콜의효용성을검증하는결과도발표되었다 [10]. ERAS Society가설립된 2010년이후에는대장절제술, 직장절제술에대한 ERAS 프로토콜이 2012년발표되었고, 췌십이지장절제술 (pancreaticoduodenectomy), 방광절제술 (cystectomy), 위절제술 (gastrectomy), 부인과암수술 (gynecologic oncology surgery), 위장관수술에대한마취 (anesthesia for gastrointestinal surgery), 비만수술 (bariatric surgery), 간절제 (liver resection), 두경부암수술 (head and neck cancer surgery) 및유방재건술 (breast reconstruction) 에대한 ERAS 가이드라인이이어서발표되었으며, 고관절및슬관절치환술 (hip and knee replacement), 폐절제술 (lung resection), 식도절제술 (esophageal resection) 등수술에대한 적인방식은이러한수술적치료과정에서생기는합병증이나다른문제점들을각파트의의료진들이개별적으로해결했다면 ERAS 프로그램에서는각파트의다양한의료진들에의해서제공되는각각의의료행위가유기적으로결과에영향을미친다는생각하에환자치료및관리에동원되는모든의료진들이정기적인회의와같은활발한의사소통을통해통합적으로해결하고자노력한다. ERAS 프로그램전체의운영 (ERAS clinical leader) 은외과의사혹은외과의사와마취통증의학과의사가관장하는것이일반적이다 [24]. ERAS 코디네이터 (coordinator) 는전체 ERAS 팀의실질적인운영자로 ERAS 프로토콜을각파트의의료진이실제적으로따를수있도록도와주고각파트로부터의피드백을운영진에전달하며각의료진간의의사소통이원활하도록노력할뿐아니라프로토콜의개별항목들이얼마나잘준수되고있는지를감시 (audit) 하게되는데대부분의경우간호사혹은의사보조자 (physician assistant) 가맡게된다. ERAS 팀의료진은의사, 간호사등의료인뿐만아니라영양사, 물리치료사, 직업치료사등다양한직종의의료진을포함한다. ERAS 의역사 1994년 Engelman 등 [25] 은관상동맥우회술 (coronary artery bypass surgery) 환자의입원기간을단축하기위해당시까지의근거중심주술기관리행위들을묶어이른바 Fast Track 을실시하여수술후중환자실입원기간을 20% 감소시켰다는보고를하였다. 다음해에덴마크의외과의사인 Kehlet 그룹은 8명의 S자결장절제술 (sigmoid resection) 환자들을경막외진통 (epidural analgesia) 과수술후조기경구영양및거동 (early oral nutrition and mobilization) 으로수술후 2일만에퇴원시킨예를보고하였고이후이를확대시킨임상결과를보고하였는데, 경막외진통은수술후통증을조절하고운동성 KSNACC 373

3 Anesth Pain Med Vol. 13 No. 4 Table 1. Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery after Surgery (ERAS ) Society Recommendations Element Preadmission Preoperative information, education and counselling Preoperative optimization Preoperative Preoperative fasting and carbohydrate treatment Preoperative bowel preparation Pre-anesthetic medication Prophylaxis against thromboembolism Antimicrobial prophylaxis and skin preparation Intraoperative Laparoscopy and modifications of surgical access Standard anesthetic protocol Perioperative fluid management PONV Preventing intraoperative hypothermia Drainage of peritoneal cavity after colonic anastomosis Nasogastric intubation Postoperative Postoperative analgesia Prevention of postoperative ileus Perioperative nutritional care Recommendation Patients should routinely receive dedicated preoperative counselling. Preoperative medical optimization is necessary before surgery. Smoking and alcohol consumption (alcohol abusers) should be stopped four weeks before surgery. Clear fluids should be allowed up to 2 h and solids up to 6 h prior to induction of anesthesia. Preoperative oral carbohydrate treatment should be used routinely. In diabetic patients carbohydrate treatment can be given along with the diabetic medication. Mechanical bowel preparation should not be used routinely in colonic surgery. Patients should not routinely receive long- or short-acting sedative medication before surgery because it delays immediate postoperative recovery. Patients should wear well-fitting compression stockings, have intermittent pneumatic compression, and receive pharmacological prophylaxis with LMWH. Extended prophylaxis for 28 days should be given to patients with colorectal cancer. Routine prophylaxis using intravenous antibiotics should be given min before initiating surgery. Additional doses should be given during prolonged operations according to half-life of the drug used. Preparation with chlorhexidine-alcohol should be used. Laparoscopic surgery for colonic resections is recommended if the expertise is available. A standard anesthetic protocol allowing rapid awakening should be given. The anesthetist should control fluid therapy, analgesia and hemodynamic changes to reduce the metabolic stress response. Open surgery: mid-thoracic epidural blocks using local anesthetics and low-dose opioids. Laparoscopic surgery: spinal analgesia or morphine PCA is an alternative to epidural anesthesia. Patients should receive intraoperative fluids (colloids and crystalloids) guided by flow measurements to optimize cardiac output. Vasopressors should be considered for intra- and postoperative management of epidural-induced hypotension provided the patient is normovolemic. The enteral route for fluid postoperatively should be used as early as possible and intravenous fluids should be discontinued as soon as is practicable. A multimodal approach to PONV prophylaxis should be adopted in all patients with 2 risk factors undergoing major colorectal surgery. If PONV is present, treatment should be given using a multimodal approach. Intraoperative maintenance of normothermia with a suitable warming device and warmed intravenous fluids should be used routinely to keep body temperature > 36 C. Routine drainage is discouraged because it is an unsupported intervention that is likely to impair mobilization. Postoperative nasogastric tubes should not be used routinely. Nasogastric tubes inserted during surgery should be removed before reversal of anesthesia. Open surgery: TEA using low-dose local anesthetic and opioids. Laparoscopic surgery: an alternative to TEA is a carefully administered spinal analgesia with a low-dose, long-acting opioid. Mid-thoracic epidural analgesia and laparoscopic surgery should be utilized in colonic surgery if possible. Fluid overload and nasogastric decompression should be avoided. Chewing gum can be recommended, whereas oral magnesium and alvimopan may be included. Patients should be screened for nutritional status and if at risk of under-nutrition given active nutritional support. Perioperative fasting should be minimized. Postoperatively patients should be encouraged to take normal food as soon as lucid after surgery. ONS may be used to supplement total intake

4 Table 1. Continued Element 수술후회복향상프로그램 : 마취통증의학과의사의관점 Recommendation KSNACC Urinary drainage Postoperative glucose control Early mobilization Routine transurethral bladder drainage for 1 2 days is recommended. The bladder catheter can be removed regardless of the usage or duration of thoracic epidural analgesia. Hyperglycemia is a risk factor for complications and should therefore be avoided. Several interventions in the ERAS protocol affect insulin action/resistance, thereby improving glycemic control with no risk of causing hypoglycemia. For ward-based patients, insulin should be used judiciously to maintain blood glucose as low as is feasible with the available resources. Prolonged immobilization increases the risk of pneumonia, insulin resistance and muscle weakness. Patients should therefore be mobilized. Modified from the guideline at LMWH: low molecular weight heparin, PCA: patient-controlled analgesia, PONV: postoperative nausea and vomiting, TEA: thoracic epidural analgesia, ONS: oral nutritional support. 을향상시키는한편장폐색을줄여주는데효과적인방법으로이용되었다 [26,27]. 이시기에는위와같이수술환자의수술후입원기간을줄이려는시도뿐아니라대사적관점에서수술자극에대한신체의스트레스반응을줄이고대사적항상성을유지하려는연구도진행되었는데글루타민 (glutamine) 과같은특정아미노산이주술기영양에미치는영향이라던가탄수화물음료의수술전섭취에대한연구결과가발표되었다 [28,29]. 1990년대에유럽에서 ERAS 임상연구를이끈의사들이모여 2001년 ERAS Study group이결성되었다. 이들은근거중심의프로토콜을개발하는한편, 수술결과를지배하는것은수술자체가아닌주술기치료및관리라는개념을임상결과를바탕으로주장하였고유럽에서주술기관리는근거중심이아닌관행적으로시행되어기관마다큰편차가있음을밝혀내었다 [8,9,30,31]. ERAS Study group의활발한활동에더불어 ERAS 의개념은전세계적으로확산되었으나실제로 ERAS 프로그램을도입하는경우는매우제한적이었다. 이에따라연구, 교육뿐아니라 ERAS 프로그램의도입을전세계적으로확산시키기위하여 ERAS Society ( 가설립되었다. 이후 ERAS Society는여러수술분야에서주술기관리의컨센서스가이드라인을발표하였고전세계병원에서 ERAS 프로그램의도입을돕는활동을하고있다. ERAS 의구성항목 ERAS 프로그램은근거중심주술기의료행위의집합체이다. 따라서하나하나의의료행위로구성되는데본장에서는최초의 ERAS 컨센서스가이드라인인대장절제술의 ERAS 프로토콜을중심으로특히, 마취통증의학과의사의입장에서잘이해해야할주요한구성항목에대해논의하고자한다. 최소수술전금식및탄수화물치료 (Minimal preoperative fasting and carbohydrate treatment) 정규수술 (elective surgery) 에서폐흡인 (pulmonary aspiration) 을예방하기위해수술전일자정이후부터금식하는관행은표준적인주술기관리지침으로자리잡아왔으나이는근거에뒷받침한진료가아니다 [32]. 22개의무작위대조시험 (randomized controlled trial) 을메타분석한결과, 자정이후금식한환자에서수술전 2시간까지맑은음료 (clear fluid) 를섭취한환자보다위내용물이적거나위액의산도 (acidity) 가낮지않았다 [33]. 오히려 2.5% 의탄수화물음료를수술전 2시간까지섭취하는것은수술전갈증, 배고픔, 불안등을줄여줄뿐아니라수술후인슐린저항성의증가를줄여주고수술후단백질분해및근력의소실을완화시켜준다 [33 36]. 일상적인수술전창자세척의불필요성 (No routine preoperative bowel preparation) 수술전창자세척의시행은환자를탈수상태로만들뿐아니라대장수술후장폐색의위험을높일수있다 [37]. 18개의무작위대조시험 (randomized controlled trial, RCT) 을메타분석한결과에의하면창자세척을시행한환자나안한환자에서대장결장수술후문합부위누출 (anastomotic leakage), 사망률, 재수술률, 감염률등이차이가없었다 [38]. 따라서과거처럼무조건적인창자세척의시행은근거가없다. 다만복강경수술에있어서는수술적편이의이유로창자세척이선호되기도하고, 장루 (stoma) 를만드는경우창자세척이필요할수있다 [11,12]. 최소침습수술기법 (Minimally invasive surgical techniques) 대장절제술에있어복강경하수술은수술후합병증, 통증 375

5 Anesth Pain Med Vol. 13 No. 4 및입원기간을감소시키는한편, 종양학적결과 (oncologic outcome) 는개복수술과비슷하다 [3,39,40]. 네덜란드의 9개병원에서시행된다기관임상연구에서복강경하대장절제술을받은환자는개복하대장절제술을받은환자에비해입원기간이 2일짧았는데다변량회귀분석 (multivariate regression analysis) 결과입원기간및수술후합병증을감소시킨유일한독립인자는복강경하수술이었다 [3]. 표준마취프로토콜 (Standard anesthetic protocol) 마취중사용하는마취유도제, 근이완제, 아편양제제등은작용시간이짧은것을사용해야한다. Bispectral index (BIS) 는 40에서 60 사이로유지하는것이바람직하고특히노인환자에서깊은 BIS 45 이하의깊은마취는바람직하지않다 [41,42]. 복강경하수술에서깊은근이완이수술에도움이되는지에대해서는논란의여지가있다 [19]. 적절한수액요법 (Optimal fluid management) 적절한수액관리는 ERAS 프로토콜중매우중요한부분이다. 수액관리는반드시수술전, 중, 후를연계해서고려해야하는데전단계에서의적절하지못한관리는다음단계에영향을미치고이는수술결과에영향을미칠수있기때문이다. 수술전수액관리에서중점을두어야할것은환자가수술실에가능한적절한수분균형상태 (euvolemia) 로도착하게하는것이다. 이를위해앞서언급했듯이금식시간을최대한줄이고무조건적인창자세척시행을지양해야하는한편탄수화물음료를수술 2시간전까지섭취하게해야한다. 수술중수액관리의중점은과다한체액과염분의축적을방지하는것이다. 이를위해개별화된수액관리가필요하다. 환자의동반질환이경미하고수술위험도가낮은경위에는 zero-balance 의수액관리를하고환자의동반질환이심하고수술위험도가높은경우에는 goal-directed fluid therapy 가추천된다 [43,44]. 수액의종류로는생리식염수 (normal saline) 의과도한사용을피하고생리적평형용액 (balanced solution) 을사용하는것이바람직하다 [19]. 경막외진통으로인한저혈압은적절한수분균형상태라면승압제 (vasopressor) 로써치료한다 [45]. 수술후에는가능하면일찍경구로수액을섭취시키고정맥투여는중단한다 [46,47]. ERAS 프로토콜을따르는환자에서흔히있을수있는소변량의감소는임상적으로유의한신장손상 (acute kidney injury) 을유발하지않는것으로보고되었다 [48]. 수술후오심및구토예방및치료 (Preventing and treating postoperative nausea and vomiting) ERAS 프로토콜은적극적인수술후오심및구토 (postoperative nausea and vomiting, PONV) 예방을포함한다. PONV 발생위험인자인여성, 멀미나 PONV의과거력, 비흡연자, 수술후아편양제제의사용중 1, 2개의위험인자가있는경우는두가지의항구토제 (antiemetic) 을사용하고 3, 4개의위험인자가있는경우에는두세가지의항구토제를사용하고전정맥마취 (total intravenous anesthesia) 를하는것이추천된다 [19,49]. 또한, 부위마취와비스테로이드성항염증제 (nonsteroidal anti-inflammatory drug, NSAID) 를포함하여아편양제제의사용을줄임으로써다중적으로 PONV를예방하는것이바람직하다. 수술중저체온발생에대한적극적인예방 (Active prevention of intraoperative hypothermia) 중심체온 (core temperature) 이 36 C 이하인주술기저체온은수술및마취중후흔히일어난다. 의도하지않은저체온을예방하는것은창상감염 (wound infection), 심혈관계합병증, 출혈량및수혈량을줄이고면역기능을향상시킬수있다 [50,51]. 따라서, 공기예열시스템 (forced air warming system), 온수매트 (circulating water mattress), 혹은가온된수액 (warmed intravenous fluid) 등으로적극적인가온 (active warming) 을하는것이중요하다 [19]. 수술후통증조절을위한다중접근방식 (Multimodal approach to control postoperative pain) 수술후통증은심근허혈 (myocardial ischemia) 및정맥혈전색전증 (venous thromboembolism) 의위험성을높이고무기폐 (atelectasis), 폐렴의발생률을증가시키며수술후장운동의회복을지연시키고인슐린저항성를증가시키는한편, 수술후감염의위험성을높인다 [18]. 수술후통증은다양한원인에기인하므로그치료도다중적으로접근해야하는데이때적절한통증조절만이치료의목표가아니라수술에의한스트레스반응을줄여인슐린저항성을낮추고장운동의이른회복을촉진시켜이른경구섭취 (oral intake) 가가능하게하며또한이른거동 (mobilization) 이가능하게하는데까지중점을두어야한다 [52,53]. 개복대장결장절제술을주로대상으로하였던초기의 ERAS 프로그램에서흉추경막외진통은적절한통증조절을가능케할뿐아니라인슐린저항성을낮추고장운동의회복을촉진시 376

6 키는핵심적인진통방법이었다 [54,55]. 하지만최근복부수술은복강경하수술이주가되었고복강경하수술에있어서경막외진통의유용성은논란의여지가있다 [56]. 따라서척수강내진통 (spinal analgesia), 배가로근판신경차단술 (transversus abdominis plane block) 등과같은안전하고유용한부위마취기법을다양하게활용함과동시에아편양제제의사용을줄이기위해아세트아미노펜 (acetaminophen), NSAID, 가바펜틴유사체 (gabapentinoid), 트라마돌 (tramadol), 정맥투여용리도카인 (intravenous lidocaine) 등과같은약제를수술전, 중, 후에다중적으로배치하여투여하는것이추천된다 [52]. 주술기 NSAID의투여가수술후출혈위험을높이고문합부위누출 (anastomotic leakage) 의위험을증가시킨다는우려가있었으나메타분석결과 NSAID의투여에의해수술후출혈위험이높아지지않는다는것이밝혀졌고, 문합부위누출위험에대해서는연구가필요하다 [57,58]. 수술후장기능장애를조절하기위한다중접근방식 (Multimodal approach to control postoperative bowel dysfunction) 수술후장기능의저하는장수술후필연적인결과이며장기능의회복이늦어지면경구섭취와회복이지연된다. 흉추경막외진통과복강경수술은장운동의회복을촉진시키는것으로알려져있으며과도한수액의투여는수술후장운동의회복을지연시킨다 [3,55,59]. 환자에게검을씹도록하는것 (chewing gum) 은장운동회복을촉진시키고마그네슘경구섭취와뮤아편양수용체의길항제 (m-opioid receptor antagonist) 인알비모판 (alvimopan) 은장운동회복에도움이될수있다 [60 62]. 혈당조절 (Control of glucose level) 수술중후에는수술자극에의한시상하부-뇌하수체-부신피질축 (hypothalamic-pituitary-adrenal axis), 교감신경흥분, 염증성사이토카인 (proinflammatory cytokine) 의분비등에의해인슐린저항성이증가되고이로인해수술중후고혈당 (hyperglycemia) 이흔하다 [18]. 수술중후고혈당은합병증및사망률의증가와연관이있음이밝혀져있고고혈당에대한치료가환자예후를향상시키지만수술환자의혈당을어느정도로조절하여야적절한지에대해선컨센서스가정립되어있지않다 [63 66]. ERAS 프로그램에서는인슐린저항성을완화시켜고혈당유발의위험성을낮추는항목들이있는데, 수술전금식의최소화와탄수화물음료의섭취, 흉추경막외진통, 이른경구섭취와거동및적절한통증조절이포함된다 [7]. 수술후회복향상프로그램 : 마취통증의학과의사의관점 조기거동 (Early mobilization) 수술후조기거동은폐합병증을감소시키고인슐린저항성을완화시킴과동시에수술직후근력을향상시키지만장기적으로긍정적인효과는밝혀지지않았다 [67,68]. 하지만수술후오랜침상안정 (prolonged bed rest) 은기능적회복을지연시킨다 [69]. 수술후이른거동이힘들게하는요인으로는부적절한통증조절, 지속적인수액투여및도뇨관거치, 및수술전합병여부가있다 [3]. ERAS 의시행 진료의관행을바꾸는것은쉽지않다. 일반적으로특정의료행위에대한임상적인근거가발표된후임상현장에서실제로시행되기까지는상당한시간이필요하다. 대장절제술에대한 ERAS 프로토콜은 2005년부터발표되어 2009년, 2012년에걸쳐개정되었지만아직까지도 ERAS 프로토콜이전세계적으로널리시행된다고말할수없다 [8,9,11]. ERAS Society는전세계적으로 ERAS 프로토콜이시행될수있도록돕고있다. 이를위해 ERAS Interactive Audit System 을개발하였고이는 ERAS Society가운영하는 ERAS Implementation Programs 의일부이다 ( 이감시시스템 (audit system) 은현재프랑스, 독일, 노르웨이, 포르투갈, 스페인, 네덜란드, 영국, 스웨덴, 캐나다, 미국, 멕시코, 브라질, 콜롬비아, 아르헨티나, 싱가폴, 필리핀, 뉴질랜드, 이스라엘, 우루과이, 칠레, 남아프리카공화국의병원에서사용되고있다. ERAS 프로그램을시행하는데있어서지속적인수행율의감시 (audit) 는필수적이다. 네덜란드의 33개병원에서 10개월간대장수술환자에대해 ERAS 시행프로그램을실시한후평균입원기간은 9 10일에서 6일로줄어들었다 [70]. 이후계속적으로 ERAS 프로그램을시행한결과대부분의병원에서입원기간은다시늘어났는데그원인은지속적인교육과수행율의감시가없는상태에서 ERAS 프로토콜에대한순응도 (compliance) 가떨어졌기때문이었다 [71]. 연구결과에의하면 ERAS 프로토콜에대한순응도에따라수술후합병증, 재입원율, 입원기간뿐아니라사망률까지유의하게차이가생기므로프로토콜수행율의지속적인감시는 ERAS 프로그램시행의핵심도구라할수있겠다 [5,6,10]. 성공적인 ERAS 프로토콜시행을위한요소로는의료진의진료관행변화에대한긍적적자세, 다학제팀의구성및팀원간의효율적인소통과협업, 병원경영진의지원, 처방및환자관리의표준화, 그리고프로토콜수행율의지속적감시등이있다 [72,73]. 반면, 성공적인 ERAS 프로토콜시행의장애물로서는의료진의진료관행변화에대한부정적인자세, 의료진의부족, KSNACC 377

7 Anesth Pain Med Vol. 13 No. 4 의료진간소통및협업의어려움등이있다. ERAS 시행의결과 ERAS 프로그램의시행은수술후합병증, 입원기간, 의료비용등단기적인결과에영향을끼칠뿐아니라사망률과같은장기적인결과에도영향을미친다. ERAS 프로그램하에서대장항문절제술을받는환자를대상으로한 RCT들을메타분석한결과에의하면 ERAS 프로토콜의적용은수술후합병증의발생률을 50% 까지낮췄다 [4]. 한기관에서대장직장절제술을받는 900명이상의연속된환자에서 ERAS 프로토콜의순응도가높을수록합병증이줄어들고입원기간이짧아지며재입원율이감소하였다 [10]. 또한, 7개국 13개의병원에서 2,300명의연속된환자에서프로토콜을적용한경우도같은결과를얻었다 [5]. 입원기간에대해서는앞서언급했듯이 Kehlet 그룹이이미 1990년대에 S자결장절제술을받는환자들을경막외진통과수술후조기경구영양및거동으로수술후 2일만에퇴원시킨예를보고하였는데당시에는이것이환자선택의결과로여겨졌다 [26,27]. 하지만여러그룹이 ERAS 프로토콜의시행으로이와비슷한입원기간후퇴원하는것이가능하다는결과를보고하였고, 수술전내과적동반질환이심한환자에서도 ERAS 프로토콜의시행으로입원기간을단축시킬수있다는결과가보고되었다 [74,75]. 건강한환자에서는대장절제술후 24시간안에퇴원하는것이가능하다는결과도보고되었다 [76]. ERAS의경제적인측면의평가는그결과가엇갈린다. 네덜란드의 9개병원에서시행된다기관임상연구에서는 ERAS 프로토콜의시행이입원비용을감소시키지못한반면, 캐나다알버타지역의 6개병원에서시행된임상연구의최근결과에서는한환자당입원비용이 2,800에서 5,900 USD 감소되었다 [3,77]. 종합적으로볼때수술을포함한입원비용의감소효과는연구마다다르지만수술과관련된합병증및입원기간은대부분의연구에서감소되므로간접적인의료비용감소효과는있을것으로보인다. ERAS 프로그램시행의장기적효과 (long-term effect) 에대해서는최근보고되기시작하였다. ERAS 프로토콜하에서대장결장절제를받은 900명이상의환자에서 70% 이상프로토콜순응도를보인환자는 70% 미만프로토콜순응도를보인환자에비해 5년사망률이 42% 나낮았다 [6]. 결과에영향을미치는 ERAS 프로토콜의항목은연구에따라다양하다. Gustafsson 등 [10] 이 2011년발표한연구에서는거의모든 ERAS 프로토콜의항목들이결과에영향을미치지만결과에대한독립적인예측인자는제한적수액투여와수술전탄수화물음료의섭취였다. 반면, 네덜란드의 9개병원에서시행된다기관임상연구에서는결과에영향을미치는항목은수술후 이른경구섭취와이른거동, 복강경을이용한수술, 그리고여성이었다 [3]. Gustafsson 등 [6] 에의해 2016년발표된 ERAS 프로그램시행의장기결과에대한보고에서 5년생존율에영향을미친독립적인자는제한적수액투여, 수술후당일경구섭취및수술 1일후 C-반응단백질 (C-reactive protein) 의혈중농도였다. ERAS 시행에서마취통증의학과의사의역할 ERAS 프로그램의성공적인시행을위해마취통증의학과의사의역할은매우중요하다. 마취통증의학과의사는 ERAS 팀의핵심구성원으로서외과의사와함께프로토콜을만들고프로토콜순응도를감시하며, 프로토콜순응도가떨어지거나결과가안좋아지면팀과함께문제점을찾아내고교정하여야하는한편, ERAS 팀을이끌고다학제로구성된팀원의교육에힘써야한다. 환자진료에있어마취통증의학과의사는주술기관리의사 (perioperativist) 로서의역할을해야한다. 수술전에는수술전혹은마취전클릭닉을운영하던지마취에대한컨설테이션 (consultation) 을받아수술이결정된환자의전반적인건강상태를평가하고동반질환에의한수술위험성감소가필요하거나가능한경우이를위한조치를취해야한다. 수술중후마취통증의학과의사의주된업무는마취중적절한수액을투여하고다중적방법으로수술중후통증조절을하는것이지만단지혈압유지만을위해수액을투여하고수술후환자가통증을덜느끼게하기위해통증조절을하는것이아니라, 수술후장기능이빨리돌아오게하여이른경구섭취가가능하게하고, 이른거동이가능케하여기능적회복을촉진시키게하여결국수술후입원기간을단축시키고합병증을줄이는데까지목표를두어야한다. 이를위해수술전금식의최소화, 탄수화물음료의섭취를점검하고수술후통증조절의적절성, 이른경구섭취및거동여부등을추적관찰해야한다. 수술후적절한통증조절은 ERAS 프로그램이가능하게하는핵심적인요소인데, 이를위해마취통증의학과에서급성통증조절팀 (acute pain service team) 을운영하는것이도움이된다 [78]. ERAS 의미래 ERAS 프로그램은대장결장절제술에서시작하였고대장결장절제술을중심으로발전되어왔다. 하지만위에서언급했듯이췌십이지장절제술, 방광절제술, 위절제술, 부인과암수술, 비만수술, 간절제, 두경부암수술및유방재건술에대한 ERAS 컨센서스프로토콜은이미발표되었고, 고관절및슬관절치환술, 폐절 378

8 1. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008; 372: Basse L, Raskov HH, Hjort Jakobsen D, Sonne E, Billesbølle P, Hendel HW, et al. Accelerated postoperative recovery pro- 수술후회복향상프로그램 : 마취통증의학과의사의관점제술, 식도절제술등수술에대한 ERAS 컨센서스프로토콜은개 gramme after colonic resection improves physical performance, 발중이며, 방광절제술, 위절제술, 부인과암수술, 간절제, 슬관 pulmonary function and body composition. Br J Surg 2002; 89: 절및고관절치환술, 폐절제술, 식도절제술등수술의 ERAS 프 로그램시행결과는보고되었다 [79 85]. ERAS 프로그램의적용 3. Vlug MS, Wind J, Hollmann MW, Ubbink DT, Cense HA, Engel AF, et al. Laparoscopy in combination with fast track multimodal 이다양한수술분야에서결과를향상시키는것으로보고됨에 management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). 따라향후에는더욱많은수술분야에서 ERAS 가이드라인이만들어질것이고, 컨센서스가이드라인이발표될것이며시행결 Ann Surg 2011; 254: 과가보고될것이다. 수술에따라다양한 ERAS 가이드라인은 4. Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga 수술전전신상태의최적화, 금식의최소화및탄수화물음료의 M. Enhanced recovery program in colorectal surgery: a metaanalysis of randomized controlled trials. World J Surg 2014; 38: 섭취, 최소침습수술 (minimally invasive surgery), 수술중후적절한수액투여, 다중적이고적극적인통증조절, 이른경구섭 취와거동등많은부분을공유하기때문에새로운수술에있어 5. ERAS Compliance Group. The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: results 서가이드라인의수립및실행의확산속도는매우빨라질것으로예상된다. from an international registry. Ann Surg 2015; 261: Gustafsson UO, Oppelstrup H, Thorell A, Nygren J, Ljungqvist O. 결론 ERAS 프로그램의시행은수술환자의주술기치료및관리에대한패러다임의변화를요구한다. 관행적으로시행되어왔던수술환자관리의개별의료행위들을근거중심의행위로바꾸는것뿐만아니라다학제적인접근, 치료및관리의연속성, ERAS 항목수행도의지속적감시, 데이터에기반한결과의평가및프로토콜개선등이필요하다. 결과적으로 ERAS 프로그램의시행은수술환자의회복을빠르게하고회복의질을높여입원기간및수술과관련된의료비를줄이는한편수술합병증을줄이고사망률을낮춘다. 의료기술이발전하고고령인구가증가함에따라어느나라를막론하고의료비는해마다상승하는반면이에대한사회적재원은한정적이다. 이에따라최근여러나라에서의료비지불방식은 의료행위양에대한보상 뿐만아니라 의료행위질에대한보상 을중요시여기는방향으로변화하고있다 [86]. 우리나라도 2005년부터각종의료행위에대해적정성평가를시행해오고있고평가결과에따라의료질평가지원금이차등지급되고있다. ERAS 프로그램의시행은의료비는증가시키지않거나줄이면서수술환자의치료결과를향상시켜줄방안으로기대된다. REFERENCES Adherence to the ERAS protocol is associated with 5-year survival after colorectal cancer surgery: a retrospective cohort study. World J Surg 2016; 40: Ljungqvist O. Jonathan E. Rhoads lecture 2011: insulin resistance and enhanced recovery after surgery. JPEN J Parenter Enteral Nutr 2012; 36: Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 2005; 24: Lassen K, Soop M, Nygren J, Cox PB, Hendry PO, Spies C, et al. Consensus review of optimal perioperative care in colorectal surgery: enhanced recovery after surgery (ERAS) group recommendations. Arch Surg 2009; 144: Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 2011; 146: Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, et al. Guidelines for perioperative care in elective colonic surgery: enhanced recovery after surgery (ERAS ) society recommendations. Clin Nutr 2012; 31: Nygren J, Thacker J, Carli F, Fearon KC, Norderval S, Lobo DN, et al. Guidelines for perioperative care in elective rectal/pelvic surgery: enhanced recovery after surgery (ERAS ) society recommendations. Clin Nutr 2012; 31: Lassen K, Coolsen MM, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, et al. Guidelines for perioperative care for pancreaticoduodenectomy: enhanced recovery after surgery (ERAS ) society recommendations. Clin Nutr 2012; 31: Cerantola Y, Valerio M, Persson B, Jichlinski P, Ljungqvist O, KSNACC 379

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