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1 한국정맥경장영양학회지제 3 권제 1 호 2010 KJPEN Vol. 3, No. 1, 2010 원저 위장관수술후발생한장관누공환자에서영양집중지원팀에의뢰된내용분석 전북대학교병원영양집중지원팀, 1 전북대학교의학전문대학원외과학교실 정미진ㆍ유희철 1 ㆍ황시은 1 ㆍ김찬영 1 ㆍ이민로 1 ㆍ김선형ㆍ김행순ㆍ김주신ㆍ문미경ㆍ윤완기안경숙ㆍ조백환 1 Analysis of Referrals to the Nutrition Support Team for Patients with Postoperative Enterocutaneous Fistula Mi Jin Jeong, Hee Chul Yu, M.D. 1, Si Eun Hwang, M.D. 1, Chan Young Kim, M.D. 1, Min Ro Lee, M.D. 1, Sun Haeng Kim, Hyeong Seon Kim, Ph.D., Ju Sin Kim, Ph.D., Mi Kyung Moon, Ph.D. Wan Ki Yoon, Kyung Sook An, Baik Hwan Cho, M.D. 1 Nutrition Support Team, Chonbuk National University Hospital, 1 Department of Surgery, Chonbuk National University, Medical School, Jeonju, Korea Purpose: The role of nutrition support for the management of enterocutaneous fistula is primarily one of supportive care to prevent malnutrition and thereby halt further deterioration of an already debilitated patient. This therapy is best managed by a nutritional support team (NST). For activation of the NST, physicians must become more aware of the need for nutrition support in patients, and so referrals are required from physicians. This study examined the referrals to the nutritional support team for patients with postoperative enterocutaneous fistula. Methods: Between March 2007 and May 2009, we reviewed 34 patients with postoperative enterocutaneous fistula and who was referred to the NST. Results: The mean age of the patients was 61.1±11.5 years. Twenty seven cases were males and 7 were females. The routes of nutrition support were EN+PN: 32 (55.2%), PN: 16 (27.6%), EN: 8 (13.0%) and oral intake +PN: 2 (3.4%). The direct referrals were 45 (77.6%) and the indirect referrals though the nutritional screening system were 13 (22.4%). The referrals for EN were 40 (69%) and those for PN were 18 (31.0%). The recommendations by the NST were accepted in 48 (82.8%) of the cases. The EN recommendations were accepted in all 40 (100.0%) 책임저자 : 유희철, 전북전주시덕진구금암동 , 전북대학교의학전문대학원외과 Tel: , Fax: hcyu@jbnu.ac.kr4 접수일 :2009 년 11 월 20 일, 게재승인일 :2010 년 6 월 15 일 of the cases. The PN recommendations by direct referral were accepted in 6 of 7 cases, but only 2 of 11 cases were accepted according to indirect referral. Conclusion: More aggressive and thorough follow-up on whether or not to accept the NST recommendation is required. This study shows that regular scheduled nutrition support service orientations for the different staff and departments of the hospital should be held each year. (KJPEN 2010;3(1):45-49) Key Words: Gastrointestinal surgery, Enterocutaneous Fistula, Nutrition Support Team 중심단어 : 위장관수술, 장관누공, 영양집중지원팀 서 영양지원은재원환자에있어서영양결핍이있거나, 정상적인영양섭취가곤란한환자들에게적절한영양평가와영양공급을수행하는과정으로서환자치료에있어필수적인요소로영양지원을적절하게수행하지못하는경우감염, 수분및전해질불균형, 부적절한혈당조절, 산-염기불균형등의잠재적인위험을가지고있다. 1 이러한문제를해결하기위해서영양지원을목적으로하는여러전문인들로구성된의료팀에의한관리가요구된다. 영양집중지원팀 (Nutrition support team, NST) 은환자들에게안전하고효과적인영양지원을제공하기위해영양관련각전문가들이참여하여운영하는조직으로서병원내영양부족위험성이높은환자의선별, 영양치료, 모니터링및교육등의업무를담당하고있으며의사, 간호사, 약사, 영양사및기타직종으로구성된다. 2 수술후영양집중지원을필요로하는여러상황중문합부누출에의한장관누공은재원기간과사망률을높이는중대한합병증으로정맥이나누출부원위부를통한영양공급등의보존적치료를통해서치료가될수있다. 3-5 장관누 론 45

2 46 한국정맥경장영양학회지제 3 권제 1 호 2010 공환자에게적절한영양공급을하기위해서는 NST의적극적인역할이필요하다. 또한 NST의활동을위해서는담당의료진의영양지원의뢰의필요성인식이중요하다. 이에위장관수술후장관누공합병증이발생한환자에서경장 (enteral nutrition, EN)/ 경정맥 (parenteral nutrition, PN) 영양집중지원을위한 NST의자문현황을알아보기위해의뢰된내용을분석하였다. 대상및방법 원에서는환자가입원할때작성되는간호정보조사지항목중영양상태에영향을미치는지표들을선별하여각항목을수치화하고수치의합계를 nutrition score (NS) 라하였고 6 10점은영양불량또는영양불량이의심됨, 11점이상은심한영양불량으로정의하였다 (Table 1). 영양불량환자선별은 NS값이 6 이상이거나식이, % 표준체중, albumin, total lymphocyte count (TLC) 4가지항목중 2가지이상이영양불량범위에있으면위험군으로분류하였다 (Table 2). 조사값은평균, 표준편차, 빈도와백분율로표시하였다. 2007년 3월부터 2009년 5월까지위장관수술후장관누공합병증이발생하여영양집중지원이의뢰된 34명의환자에서 EN/PN 의뢰현황을분석하였다. 조사대상자의일반사항으로연령, 성, 진단명, 누출부위등을환자의무기록을참고하여조사하였다. 영양집중지원에대한자문요청은직접의뢰와영양선별에의한의뢰로나누어조사하였다. 본 결과대상환자는 34명으로남 : 여비는 27:7, 평균연령은 61.1±11.5세였다. 질환별로는위암 22명, 대장암 4명, 궤양성위십이지장천공 3명, 대장천공 2명, 위암및대장암 1명, 크론씨병 1명, 외상성장관손상 1명이었다 (Table 3). Variable Table 1. Nutrition scoresheet based on the adult nursing questionnarie Route of hospital admission Exotic (0) Emergency (1) Etc (0) How to hospitalize Afoot (0) Wheelchair (1) Stretcher cart (1) Etc (1) Patient history None (0) Hypertension (1) Diabetes (1) Tuberculosis (1) Hepatitis (1) Tumor (1) Genetic disease (1) Appetite Good (0) Normal (0) Bad (2) Weight change No (0) Yes (2) Defecation disorder None (0) Diarrhea (2) Constipation (1) Melena (1) Activity Free (0) Not free (2) Bowel dysfunction None (0) Dysphagia (2) Nausea (1) Vomiting (3) Hematemesis (1) Bowel dysfunction (2) Abdominal distention (1) Abdominal pain (3) Mucous stool (1) Edema No (0) Yes (1) Age <60 (0) 60 (1) Total score* *Score of 0 5 = adequate; 6 10 = moderate or suspected malnutrition; 11 or more = severe malnutrition. Score Table 2. Nutrition screening based on the objective parameters At risk of malnutrition Reference value* At high risk of malnutrition Diet (day) NPO, tube feeding, liquid diet >5day %IBW <75 Serum albumin (g/dl) <2.8 TLC 1,200 1,500 <1,200 *Malnutrition was defined as two items out of four being abnormal. Table 3. General characteristics of subjects Age (yrs) 61.1±11.5 Sex (M:F) 27/7 Diagnosis Number (%) Gastric cancer 22 (64.7) Colon cancer 4 (11.8) Gastric or duodenal ulcer perforation 3 (8.8) Colon perforation 2 (5.9) Gastric cancer and colon cancer 1 (2.9) Crohn's disease 1 (2.9) Hemoperitoneum 1 (2.9)

3 정미진외 : 위장관수술후발생한장관누공환자에서영양집중지원팀에의뢰된내용분석 47 영양집중지원의뢰총상담건수는 58건으로 1인당평균 1.7회 (1인당 1 5회 ) 이었다. 영양집중지원상담의뢰는의사가직접한경우가 45건 (77.6%), 선별후의뢰가 13건 (22.4%) 으로의사직접의뢰가약 3배이상많았다. 영양지원경로는 EN+PN 동시지원이 32건 (55.2%), PN만의지원이 16건 (27.6%), EN만의지원이 8건 (13.%), 경구 +PN 동시지원이 2 건 (3.4%) 순으로나타났다. 영양집중지원자문의뢰는 EN 의뢰가 40건 (69%), PN 의뢰가 18건 (31%) 이었다 (Table 4). NST 의자문내용을의뢰의사가수락한경우가 48건 (82.8%), 수락하지않은경우가 10건 (17.2%) 이었는데, EN에대한자문은 40건모두수락하였고 PN은직접의뢰한경우 7건중 6건을수락하였으나선별후의뢰한경우는 11건중 2건만을수락하여수락률이현저히낮았다 (Table 5). Table 4. The present status of nutrition support Number of referral (%) The number of referral per person 1 19 (55.9) 2 9 (26.5) 3 5 (14.7) 5 1 (2.9) Route of nutritional support EN 8 (13.8) PN 16 (27.6) Oral intake+pn 2 (3.4) EN+PN 32 (55.2) Classification of referral Direct referral 45 (77.6) Referral after a nutritional screening 13 (22.4) Referral EN 40 (69.0) PN 18 (31.0) EN = enteral nutrition; PN = parenteral nutrition. Table 5. The acceptance and rejection of nutritional support team recommendation Number of referral (%) Acceptance Direct referral EN 38 (65.5) PN 6 (10.3) Referral affer a nutritional EN 2 (3.4) screening PN 2 (3.4) Rejection Direct referral EN 0 (0.0) PN 1 (1.7) Referral affer a nutritional EN 0 (0.0) screening PN 9 (15.5) EN = enteral nutrition; PN = parenteral nutrition. 고찰영양집중지원이란영양상태회복및질병치료를목적으로경구, 경장혹은정맥으로대량영양소 ( 혹은열량영양소 ) 및미량영양소의전부혹은일부를제공하는것으로환자의병적상태를고려하여가장알맞은영양처방과공급경로를결정하는영양집중지원과정은다직종간협력체계를통해영양관리서비스가제공되어진다. 6 정맥영양공급은심각한대사성, 감염성, 카테터관련합병증이나타날수있고경장영양도흡인, 설사, 감염등잠재적합병증이가능하므로안전하고효과적으로공급하는것이중요하다. 이처럼영양치료가필요한환자에게적절한영양집중지원을제공하기위해서는관련전문가 ( 의사, 영양사, 약사, 간호사 ) 로구성된팀이필요하다. 따라서 NST은영양집중지원이요구되는환자의주치의에게자문을제공하고적절한영양치료를위한활동을한다. 7 위장관수술후발생한문합부누출환자에있어장관영양은환자의회복에있어매우중요하고독립적인변수라고하였다. 8 Power 등의연구에의하면장관영양환자를대상으로 NST 관리시비NST 관리군에비해영양공급을더많이받았고양의질소평형을유지하는환자수가유의적으로많은반면환자의이상소견 ( 폐, 위장관, 대사 ) 은유의하게낮게나타났다. 9 김과김의연구에의하면수술후문합부누출이나장피부누공이합병되었을때단백질의분해및소실을역전시킬적당한열량과단백질을비경구적으로공급함으로써단순한체내영양상태유지만이아니라누공폐쇄의치료적효과도가져올수있다고보고하였다. 10 이처럼여러연구결과에서 NST에의한관리시합병증및사망률감소, 재원기간단축, 비용절감등의이점을보고하였다. 최근정부에서보건의료서비스의향상을도모하고의료서비스의질적수준제고를위한방안의일환으로실시하고있는의료기관서비스평가제도의항목에영양집중지원관리항목이포함되어있음에도불구하고실제임상에서는영양평가나영양집중지원이제대로이루어지지않는경우가많은것으로보고되었다. 본원에서도한정된인력으로개인면담이나의무기록검토를통해전체입원환자를대상으로영양관리가필요한환자를빠른시간내에선별하는것은여러의료인의업무중복및업무의부담이증가되어실제로실행하기는어려운실정이었고, 영양집중지원자문이의뢰된환자에한해자문이이루어졌지만팀차원의효율적인관리가시행되지못하고있는실정이었다. 또한본원에서실시한영양집중지원에대한전공의인식도설문조사결과전공의들은영양집중지원자문업무에대한

4 48 한국정맥경장영양학회지제 3 권제 1 호 2010 필요성을인식하고있고자문결과에대한신뢰도도높은것으로나타났다. 그러나자문업무를하고있다는걸몰라서, 절차등이번거로워서, 자문후회신시간이길어서등의이유로영양집중지원자문없이처방을하는경우도적지않음을알수있었다. 따라서의료진의자문요청외에능동적으로영양집중지원대상환자를찾아내고팀차원의효율적이고체계적인영양집중지원관리서비스를환자에게제공하기위해영양선별, 평가, 모니터링과정을포함한영양집중지원프로그램을개발하여시행하였다. 위장관수술후장관누공합병증이발생한환자에서영양집중지원팀자문요청대상환자는 34명으로이중 22명이위암수술환자였고 50% 이상이한번의자문을요청하였다. 자문요청중직접의뢰가선별후의뢰에비해 3배이상이많았다. 자문요청외에능동적으로영양집중지원대상환자를찾아내어의뢰를유도하고자했으나여전히대부분의경우담당의료진의요청에의해 NST가활동한다는것을알수있었다. 또한대상환자가대부분외과환자로담당의뢰진의영양집중지원의뢰가적극적으로이루어진것으로보아이는외과계의료진의영양집중지원의중요성에대한인식이타과의료진에비해비교적잘되어있는것으로생각한다. 전체자문수락률은 82.8% 로직접의뢰시 97.8%, 영양선별에의한의뢰시 30.8% 로직접의뢰에의한자문수락률에비해영양선별에의한의뢰시매우낮은수락률을보였다. Lido 11 의연구에서영양지원프로그램실행직후영양선별에의한의뢰시자문수락률은 11.3% 로다소낮았으나프로그램실행 2 3년후에는다소증가한 20 30% 의수락률을보였다. 본연구에서도영양지원프로그램실행후조사된내용으로다소낮은수락률을보인것으로생각한다. 또한자문을직접요청한사항에대하여는 NST의권고를대부분따르지만영양검색을통해영양불량으로의심되는환자의적극적영양집중지원이필요한것에대하여관심이없는의료진들은아직도 NST의필요성에대한인지가부족하다는사실을보여주는것이라생각한다. 영양집중지원자문의뢰는 EN이 PN에비해 2배이상자문요청이많아 PN보다는 EN에서의료진들이 NST의도움을필요로한다는것을알수있었다. 특히 EN에대한자문은 40건모두수락하였고 PN은직접의뢰한경우 7건중 6건을수락하였으나, 선별후의뢰한경우는 11건중 2건만을수락하여수락률이현저히낮았다. EN의경우처방에필요한정보및경험이부족하고처방계획안 (protocol) 이없는경우가많아자문의뢰및수락률이높은반면 PN의경우전공서적이나의약품집을통해처방에필요한정보를얻거나경험이나기존에정해져있는처방양식을따르는경우 가많아자문수락률이낮은것으로생각한다. 영양공급을통한치료가필요한환자에게적절한영양공급을하기위해서는영양집중지원팀의적극적인역할이필요하다. 이에의료진의자문요청외에적극적으로영양집중지원대상환자관리를위해프로그램을개발하여영양선별결과에대한메세지를팝업창을통해고지하고자문의뢰를유도하였지만자문수락률이낮아영양집중지원팀의활동을위해서는담당의료진의영양지원의뢰의필요성인식과더불어그자문내용에대한수락여부가중요하다할수있겠다. 이를위해 NST 자문내용수락여부에대한보다적극적인관찰이필요하다고사료된다. 또한향후에는 NST 활동을통한 follow up 등이보다체계적이며지속적으로이루어져야하며, 전공의대상으로하는영양집중지원에대한홍보및체계적인교육이필요함을알수있었다. 또한 NST 권고사항이영양관리의기준으로받아들여질수있는고도의표준화된지침과제도가마련되어야한다고생각한다. REFERENCES 1. Matarese LE, Gottschlich MM. Contemporary nutrition support practice: a clinical guide. 2nd ed. Philadelphia:Saunders Co.; Yang HR, Choi CW, Kim BI, Seo JK, Choi SA, Kim SY. Clinical significance of the nutritional support team for preterm infants in a neonatal intensive care unit. Korean J Pediatr Gastroenterol Nutr 2009;12(1): Urschel JD. Esophagogastrostomy anastomotic leaks complicating esophagectomy: a review. Am J Surg 1995;169(6): Patil PK, Patel SG, Mistry RC, Deshpande RK, Desai PB. Cancer of the esophagus: esophagogastric anastomotic leak--a retrospective study of predisposing factors. J Surg Oncol 1992; 49(3): Poobalan AS, Bruce J, King PM, Chambers WA, Krukowski ZH, Smith WC. Chronic pain and quality of life following open inguinal hernia repair. Br J Surg 2001;88(8): Lochs H, Pichard C, Allison SP. Evidence supports nutritional support. Clin Nutr 2006;25(2): NST Committee, Standardization Committee: Nutrition Support Guideline. KSPEN; Shim YS, Kim CY, Yang DH. The result of treatment of anastomotic leakage after an elective gastrectomy for an adenocarcinoma. J Korean Gastric Cancer Assoc 2004;4(3): Powers DA, Brown RO, Cowan GS Jr, Luther RW, Sutherland DA, Drexler PG. Nutritional support team vs nonteam management of enteral nutritional support in a Veterans Administration Medical Center teaching hospital. JPEN J Parenter Enteral Nutr 1986;10(6): Kim SH, Kim SM. Total parenteral nutrition in patients of

5 정미진외 : 위장관수술후발생한장관누공환자에서영양집중지원팀에의뢰된내용분석 49 postoparative anastomotic leakage and enterocutaneous fistula. J Korean Surg Soc 1987;33(4): Llido LO. The impact of computerization of the nutrition support process on the nutrition support program in a tertiary care hospital in the Philippines: report for the years Clin Nutr 2006;25(1):

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1.. Volume 12, Number 1, 6~16, Factors influencing consultation time and waiting time of ambulatory patients in a tertiary teaching hospital Jee-In Hwang College of Nursing Science, Kyung Hee University :