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1 Korean J Anesthesiol 2009 Apr; 56(4): DOI: /kjae Clinical Research Article 갑상선절제술을받은환자에서 P6 의술후오심, 구토에대한예방효과 연세대학교의과대학 1 마취통증의학교실, 2 마취통증의학연구소 라세희 1 ㆍ김나영 1 ㆍ길혜금 1,2 The prophylactic effect of acupressure (P6) on the postoperative nausea and vomiting in patients underwent thyroidectomy Se Hee Na 1, Na Young Kim 1, and Hae Keum Kil 1,2 1 Department of Anesthesiology and Pain Medicine, 2 Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea Background: Postoperative nausea and vomiting (PONV) is a common problem in patients recovering from anesthesia and surgery. P6 point is the acupressure point for prevention of postoperative nausea and vomiting. We evaluated the efficacy of acupressure at the P6 point in 94 patients undergoing thyroidectomy in a randomized, prospective and placebo-controlled study. Methods: Ninety-four female patients, aged 18 to 60, scheduled for elective thyroidectomy, were randomized to have either placebo band or acupressure band (Sea-Band R UK Ltd., Leicestershire, England, UK) applied to the P6 point of both hands before induction of anesthesia. The acupressure bands removed 24 h later. Postoperative nausea and vomiting was evaluated 1, 6 and 24 h following surgery. In addition, the need for rescue antiemetic medication during 24 h was registered. Results: The incidence of postoperative nausea was lower in acupressure group at 0 1 h (16.7% vs. 39.1%; P = 0.015) and at 6 24 h (0% vs. 15.2%; P = 0.05). The need for rescue antiemetic medication was also lower at 0 1 h (4.2% vs. 23.9%; P = 0.006), at 1 6 h (6.2% vs. 20.9%; P = 0.039) and at 6 24 h (0% vs. 13%; P = 0.012). Conclusions: In patients undergoing thyroidectomy, nausea and need of rescue antiemetic medication were reduced by acupressure at the P6 point. (Korean J Anesthesiol 2009; 56: 413~8) Key Words: Antiemetic medication, P6 acupressure, Postoperative nausea and vomiting, Thyroidectomy. 서 전신마취하수술후빈번히발생되는오심이나구토는그정도에따라서는통증보다도더견디기어려운경우가있다. 수술후오심과구토의발생요인은매우복잡하고다양하며크게환자요인, 마취방법적요인, 수술요인으로분류한다. 수술요인중갑상선절제술은수술후오심구토의빈도가 63 84% 로보고될정도로고위험군으로분류된 Received: December 10, Accepted: February 13, Corresponding author: Hae Keum Kil, M.D., Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Sinchon-dong, Seodaemun-gu, Seoul , Korea. Tel: , Fax: , hkkil@yuhs.ac This paper is a master's thesis for Yonsei University Graduate School. Copyright c Korean Society of Anesthesiologists, 2009 론 다 [1,2]. 수술후오심과구토는불쾌감뿐아니라탈수, 전해질이상, 수술봉합부위압력의증가, 혈압증가, 출혈위험성도증가시킬수있을뿐아니라 [3], 전신마취후저하된호흡기의반응성에기인한구토물흡인으로폐렴까지유발시킬수있다. 특히갑상선절제술을받은환자들에서의술후출혈은경부혈종으로인한기도폐쇄는물론재수술의위험성도높인다. 그러므로오심이나구토의고위험환자의구분, 유발자극의회피, 다방면의예방법등술후오심과구토를최소화하는것이중요하다 [4]. 수술후오심과구토의예방및치료는약물적방법과비약물적방법으로나눌수있다. 약물적치료제로는세로토닌길항제, 도파민길항제, droperidol, dexamethasone, 진정제등이있으며이러한약물들은단독투여보다는병용투여가권장된다. 따라서약물각각의부작용은물론세로토닌길항제의경우엔가격적부담까지가지게된다. 비약물적방법으로는한의학에서내관 ( 內關 ) 으로알려지고있는 P6 413

, Leicestershire, England, UK) 적용이간단하고비용적부담도적어임신중의입덧이나뱃멀미혹은차멀미의경감을목적으로시판되기도한다 [10]. 갑상선절제술과같이술후오심과구토의고위험수술에서이와같은간단한비약물적방법으로오심구토의빈도를줄일수있다면약물적치료의부작용감소와함께경제적효과도기대할수있을것이다.

2 Vol. 56, No. 4, April 2009 (Pericardium 6) 점에침을놓거나 (acupuncture), 압박 (acupressure), 전기자극, 혹은레이저자극의효과들이보고된바있다 [5,6]. P6점은요골측수근굴근과손바닥쪽장근의인대사이에있으며손목횡선에서 3 cm 위쪽에위치하는경혈로알려지고있는데 [7], 이곳의자극술이술후오심과구토에매우효과적인것으로추정되고있다 [5-9]. 를위해사용되는간단한기구로는 P6점을자극하도록손목에감는압박대의형태로된것이있다. 이기구는 (Sea-Band R UK Ltd., Leicestershire, England, UK) 적용이간단하고비용적부담도적어임신중의입덧이나뱃멀미혹은차멀미의경감을목적으로시판되기도한다 [10]. 갑상선절제술과같이술후오심과구토의고위험수술에서이와같은간단한비약물적방법으로오심구토의빈도를줄일수있다면약물적치료의부작용감소와함께경제적효과도기대할수있을것이다. 본연구에서는갑상선절제술환자들을대상으로하여 P6점에서의 acupressure Table 1. Demographic Data of Patients Age (yr) Weight (kg) Height (cm 2 ) BMI (kg/m 2 ) Duration of surgery (min) 46.6 ± ± ± ± ± ± ± ± ± ± 60.0 Values are mean ± SD. BMI: bady mass index. There are no significant differences between groups. Korean J Anesthesiol 의효과를검증해보고자하였다. 대상및방법병원의료윤리위원회에서승인을받은후갑상선절제술을받기로계획된 18세이상 60세미만의 100명의성인여자환자를대상으로하여연구에대해설명하고동의서를받았다. 평소멀미를잘하거나술후오심과구토의기왕력이있는환자, BUN, creatinine의혈중농도증가로신장기능이상이의심되는환자, 당뇨병, 비만 (body mass index [BMI] > 30 kg/m 2 ), 수술 72시간전에항구토제를복용한환자는대상에서제외하였다. 환자들은 computerized randomization method에의해군당 50명씩두군으로분류하였고, 대상환자들의나이, 체중, BMI, 수술시간에있어서각군간의유의한차이는없었다 (Table 1). 대상환자중 acupressure군의 2명과 placebo군의 4명은수술후압박대가풀어져연구에서제외되었다. 100명의환자를표본으로추출하였을때연구의 power는 80% 이상, α = 0.05로통계학적의의를가졌다. 본연구는이중맹검법으로전향적으로시행되었으며연구의내용을모르는연구참여자가마취전병실을방문하여 acupressure군에서는압박대 (Sea-Band R UK Ltd., Leicestershire, England) 의압점이손목의 P6점에일치되도록양손목에거치시켰고 placebo군에서는압박대의압점을제거하고느슨하게거치시켰다 (Fig. 1). 압박대는수술후 24시간동안유지하도록하였다. 환자는마취전투약없이수술실로 Fig. 1. Sea-bands (Sea-Band R UK Ltd., Leicestershire, England) placed at the P6 point. The P6 is located approximately 3 cm proximal to the proximal palmar crease between the flexor carpi radialis and the Palmaris longus tendons. 414

3 Na et al: 술후오심, 구토와 P6 옮겼으며비침습적혈압계, 심전도, 맥박산소포화도계측기를부착하고 remifentanil 6 μg/kg와 1% lidocaine 20 mg을섞은 propofol 100 mg으로마취유도를하고 rocuronium 0.6 mg/kg를정주한후기관내삽관하였다. 50% 산소 / 공기와 sevoflurane 및 remifentanil의지속정주로마취를유지하였으며호기말이산화탄소분압이 mmhg이되도록조절환기를시행하였다. 수술이종료되기 10분전수술후제통을위해 ketolorac 1 mg/kg ( 최대용량 60 mg) 을정주하였다. 수술종료시 glycopyrrolate mg/kg와 neostigmine 0.02 mg/kg으로근이완제의잔여효과를역전시키고기관내튜브를발관하였다. 모든환자에서수술후 1시간이내 ( 회복실체류중 ), 수술후 6시간이내, 6시간에서 24시간이내에오심과구토발생유무를관찰하였다. 구토를 1차례이상하거나환자가치료를원할때는 ondansetron 2 mg을정주하였고필요시에는 ondansetron 2 mg 혹은 metoclopramide HCl 10 mg을추가로정주하였다. 항구토제는증상의 50 30% 정도저하를목표로하여투여되었다. 수술후오심구토의관찰은연구내용 을모르는다른연구참여자에의해시행되었다. 오심의정도는시각숫자등급 (Visual Analog Scale, VAS: 1; none, 2 5; mild, 6 7; moderate, 8 10; severe) 에따라분류하였고구토의정도는구토횟수에따라 none, mild (1 2 회 ), moderate (3 4회), severe (5회이상 ) 로분류하여관찰하였다 [11]. 두군간오심의정도와횟수, 구토의횟수, 항구토제의투여정도를비교하여 P6 acupressure의술후오심과구토예방의효과를평가하였다. 모든결과는환자수 ( 백분율 ) 나평균값 ± 표준편차로표시하였다. 통계는 SPSS 15.0 (SPSS Inc., Chicago, IL, USA) 을사용하여 chi-square, Fisher s exact test로분석하였으며 P < 0.05인경우통계적으로유의한것으로판정하였다. 결과갑상선절제술후 1시간이내에서는 placebo군의 39.1%, acupressure군의 16.7% 에서오심을호소하였다 (P = 0.015). 술후 1 6시간사이에서는두군간의유의한차이가없었 Table 2. Incidence of PONV after Thyroidectomy In PACU 1 6 h 6 24 h Incidence [n (%)] Nausea Vomiting Rescue medication [n (%)] In total patients In symptomatic patients 18 (39.1) 11 (23.9) 11/18 (61.1) 8 (16.7) a) 1 (2.1) 2 (4.2) a) 2/8 (25) 15 (32.6) 7 (15.2) 9 (20.9) 9/15 (60) 9 (18.8) 3 (6.3) 3 (6.2) a) 3/9 (33.3) 7 (15.2) 2 (4.3) 6 (13) 6/7 (85.7) a) a) a) Values are number of patients (%). a) P < 0.05 between placebo and acupressure group. PONV: postoperative nausea and vomiting, PACU: postoperative anesthesia care unit. Fig. 2. The incidence of postoperative nausea was lower in acupressure group at 0 1 h (16.7% vs. 39.1%; P = 0.015). Fig. 3. The incidence of postoperative nausea was lower in acupressure group at 6 24 h (0% vs. 15.2%; P = 0.05). 415

4 Vol. 56, No. 4, April 2009 Korean J Anesthesiol Fig. 4. The need for rescue antiemetic medication was also lower in acupressure group at 0 1 h (4.2% vs. 23.9%; P = 0.006). 으나, 6 24시간사이에서는 placebo군의 13.6% 에서, P6 acupressure군의 0% 에서오심을나타내매우유의한차이를보였다 (P = 0.005). 구토의빈도는두군사이에의미있는차이를보이지않았다 (Table 2, Fig. 2, 3). 수술후 1시간이내에 acupressure군의 4.2% 와 placebo군의 23.9% 에서항구토제가투여되었고 (P = 0.006), 1 6시간에는 placebo군의 20.9%, acupressure군의 6.2% (P = 0.039), 6 24 시간사이에는 placebo군에서만 13% 에서항구토제가투여되었다 (P = 0.012) (Table 2, Fig. 4, 5). 오심과구토를호소하는환자에서항구토제의사용의빈도는수술후 6 24시간에 placebo군과 acupressure군이각각 85.7%, 0% 로유의한차이를보였다 (P = 0.005) (Fig. 6). 오심과구토의정도 (severity) 는양군간의유의한차이가없었다 (Table 3). Fig. 5. The need for rescue antiemetic medication was also lower in acupressure group at 1 6 h (6.2% vs. 20.9%; P = 0.039). Fig. 6. The need for rescue antiemetic medication was also lower in acupressure group at 6 24 h (0% vs. 13%; P = 0.012). Table 3. Severity of PONV after Thyroidectomy In PACU 1 6 h 6 24 h Nausea None Mild Moderate Severe Vomiting None Mild Moderate Severe 28 (60.9) 7 (15.2) 8 (17.4) 45 (97.8) 40 (83.3) 5 (10.4) 1 (2.1) 2 (4.2) 47 (97.9) 1 (2.1) 31 (67.4) 6 (13.0) 6 (13.0) 39 (84.8) 39 (81.2) 4 (8.3) 2 (4.2) 3 (6.2) 45 (100) 3 (6.2) 39 (84.8) 44 (95.7) 2 (4.3) 48 (100) 48 (100) Values are number of patients (%). PONV: postoperative nausea and vomiting, PACU: postoperative anesthesia care unit. There are no significant differences between groups. 416

5 Na et al: 술후오심, 구토와 P6 고찰수술후의오심과구토 (postoperative nausea and vomiting, PONV) 는매우불유쾌한경험이며수술로인한통증보다더견디기어려운경우도있다. 1960년대 ether와 cyclopropane을마취제로사용했을당시에는 PONV의빈도가 60% 에달했으며 [12], 항구토제의개발과작용시간이짧은마취제의사용으로그빈도가감소하긴하였으나 [13], 평균발생빈도가 30% 로여전히높으며여성환자, PONV나멀미의기왕력이있는환자, 비흡연자, 술전후마약성진통제를사용한환자에서특히빈발하는것으로보고되어있다 [5]. 또한 30분이상의수술, 복강경술, 이비인후과수술, 신경외과수술, 성형수술, 사시수술, 유방수술, 산부인과수술등에서 PONV의위험도는더욱증가한다 [5]. 갑상선절제술은 PONV를잘일으키는수술로규정되어있으며그빈도는 63 84% 로보고되고있다 [1,2]. 오심중추는수질의외측망상체에위치하고있으며이는화학수용체, 전정기관, 소뇌, 고위뇌중추등에서정보를받는다 [14]. 오심과구토의수용체로는도파민, 무스카린성아세틸콜린, 히스타민, 세로토닌수용체등이있으며마약성수용체도이에관여하는것으로알려져있다. 임상에서사용되는 droperidol, metoclopramide, scopolamine, cyclizine, ondansetron 등이위장관의수용체에작용하여항오심효과를나타내는데약물종류에따라효과정도에차이가있으며 droperidol은오심에더효과적이고 ondansetron은구토에더효과적이다 [15]. 그러나이러한약물치료가오심이나구토를완전히예방하거나치료하지는못하며최근가장각광을받고있는세로토닌수용체길항제의경우에도 number-needed-treatment가 4 5 정도로보고되어있다. 따라서약물의단독투여보다는여러가지약제와수액요법의병용이권장되는데이로인한부작용또한복합적으로발생될수있다. 또한세로토닌수용체길항제 (ondansetron, granisetrone 등 ) 는가격이비싸경제적부담도있다. 최근동양의학에관심이높아지면서 P6 (pericardium 6) 점자극술의 PONV 예방효과에관한연구가증가되고있다. P6점자극술의기전은아직명확히규명되진않았지만피부감각수용체가 A-beta와 A-delta 섬유를활성화시키고 [16], 이섬유가시상하부에시냅스하여엔돌핀을유리하여, 노르에피네프린과세로토닌섬유를활성화시켜항구토효과를일으키는것으로여겨지고있다 [17]. 또한위장관의평활근에직접작용하여식도하부괄약근의이완을 40% 정도줄이고 [18], 쥐실험에서는위장의이완과관련된체성자율신경계에작용한다는보고도있다 [19]. 한편으로는, 부교감신경의조절을통해서 [20], 혹은소뇌의전정센터에영향을 미친다는연구도있다 [21]. 본연구에서는마약성진통제를사용하기전에 acupressure를적용하는것이효과적이라는연구에근거하여마취유도전에압박대를적용하였다 [22,23]. 본연구의결과, 오심의경우엔회복실 ( 수술후 1시간 ) 에서와술후 6 24시간에서 acupressure군이 placebo군에비해유의한효과를나타냈고, 항구토제의사용빈도도감소되었으나오심이나구토의심한정도에는차이가없었다. 최근시행된 meta-analysis에서는 acupressure가술후 6시간까지만효과를나타냈다고하여본연구와는다른결과를나타냈다 [8]. 이는본연구에서마취유도제로 propofol을사용한결과로생각된다. Propofol의항오심효과는이미알려져있으며그효과는술후초기 6시간정도까지지속된다고한다 [24]. 즉, 마취유도제로사용한 propofol이두군모두에서술후초반기에항오심효과를나타냈기때문에 1 6시간사이에서두군간오심의빈도차이가없었던것으로여겨진다. 그러나구토의예방효과가유의하지않은점은전의여러연구들과유사한결과를나타낸부분이다 [10,17,25]. P6점의침술로인한부작용으로침통, 소량의혈종, 정형외과적문제, 침의분실, 피부자극등이보고되어있다 [26]. 이에비해압박대는불편감, 피부자극, 지속적인통증, 손목부종이일어날수있다 [9]. 본연구에서는 6명의환자에서 band의불편감을호소하여 band를제거하였으며그이외의부작용은나타나지않았다. 결론적으로마취유도전부터적용된 P6 acupressure점의지속적인자극은 PONV의고위험수술인갑상선절제술에서수술후오심의예방에효과적인것으로여겨진다. 그러므로약제사용이제한적인환자에서는 P6 acupressure가약물적치료를대체할수있는효과적인방법이라고생각된다. REFERENCES 1. Sonner JM, Hynson JM, Clark O, Katz JA. Nausea and vomiting following thyroid and parathyroid surgery. J Clin Anesth 1997; 9: Fujii Y, Tanaka H. Comparison of granisetron and ramosetron for the prevention of nausea and vomiting after thyroidectomy. Clin Ther 2002; 24: Thompson DP, Ashley FL. Face-lift complications: a study of 922 cases performed in a 6-year period. Plast Reconstr Surg 1978; 61: Gan TJ. Postoperative nausea and vomiting--can it be eliminated? JAMA 2002; 287: Gan TJ, Meyer T, Apfel CC, Chung F, Davis PJ, Eubanks S, et al. Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analg 2003; 97: Gan TJ, Jiao KR, Zenn M, Georgiade G. A randomized controlled 417

6 Vol. 56, No. 4, April 2009 Korean J Anesthesiol comparison of electro-acupoint stimulation or ondansetron versus placebo for the prevention of postoperative nausea and vomiting. Anesth Analg 2004; 99: Streitberger K, Ezzo J, Schneider A. Acupuncture for nausea and vomiting: an update of clinical and experimental studies. Auton Neurosci 2006; 129: Lee A, Done ML. The use of nonpharmacologic techniques to prevent postoperative nausea and vomiting: a meta-analysis. Anesth Analg 1999; 88: Lee A, Done ML. Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev 2004: CD Alkaissi A, Ledin T, Odkvist LM, Kalman S. P6 acupressure increases tolerance to nauseogenic motion stimulation in women at high risk for PONV. Can J Anaesth 2005; 52: Agarwal A, Dhiraaj S, Tandon M, Singh PK, Singh U, Pawar S. Evaluation of capsaicin ointment at the Korean hand acupressure point K-D2 for prevention of postoperative nausea and vomiting. Anaesthesia 2005; 60: Bonica JJ, Crepps W, Monk B, Bennett B. Postanesthetic nausea, retching and vomiting; evaluation of cyclizine (marezine) suppositories for treatment. Anesthesiology 1958; 19: Cohen MM, Duncan PG, DeBoer DP, Tweed WA. The postoperative interview: assessing risk factors for nausea and vomiting. Anesth Analg 1994; 78: Watcha MF, White PF. Postoperative nausea and vomiting. Its etiology, treatment, and prevention. Anesthesiology 1992; 77: Tramer MR. A rational approach to the control of postoperative nausea and vomiting: evidence from systematic reviews. Part I. Efficacy and harm of antiemetic interventions, and methodological issues. Acta Anaesthesiol Scand 2001; 45: Klein AA, Djaiani G, Karski J, Carroll J, Karkouti K. McCluskey S, et al. wristbands for the prevention of postoperative nausea and vomiting in adults undergoing cardiac surgery. J Cardiothorac Vasc Anesth 2004; 18: Stein DJ, Birnbach DJ, Danzer BI, Kuroda MM, Grunebaum A, Thys DM. versus intravenous metoclopramide to prevent nausea and vomiting during spinal anesthesia for cesarean section. Anesth Analg 1997; 84: Zou D, Chen WH, Iwakiri K, Rigda R, Tippett M, Holloway RH. Inhibition of transient lower esophageal sphincter relaxations by electrical acupoint stimulation. Am J Physiol Gastrointest Liver Physiol 2005; 289: G Tada H, Fujita M, Harris M, Tatewaki M, Nakagawa K, Yamamura T, et al. Neural mechanism of acupuncture-induced gastric relaxations in rats. Dig Dis Sci 2003; 48: Huang ST, Chen GY, Lo HM, Lin JG, Lee YS, Kuo CD. Increase in the vagal modulation by acupuncture at neiguan point in the healthy subjects. Am J Chin Med 2005; 33: Yoo SS, Teh EK, Blinder RA, Jolesz FA. Modulation of cerebellar activities by acupuncture stimulation: evidence from fmri study. Neuroimage 2004; 22: Weightman WM, Zacharias M, Herbison P. Traditional Chinese acupuncture as an antiemetic. Br Med J 1987; 295: Alkaissi A, Stalnert M, Kalman S. Effect and placebo effect of acupressure (P6) on nausea and vomiting after outpatient gynaecological surgery. Acta Anaesthesiol Scand 1999; 43: Tramer M, Moore A, McQuay H. Propofol anaesthesia and postoperative nausea and vomiting: quantitative systematic review of randomized controlled studies. Br J Anaesth 1997; 78: Kim SI, Yoo IS, Park HN, Ok SY, Kim SC. Transcutaneous electrical stimulation of the P6 acupoint reduces postoperative nausea after minor breast surgery. Korean J Anesthesiol 2004; 47: MacPherson H, Thomas K, Walters S, Fitter M. The York acupuncture safety study: prospective survey of treatments by traditional acupuncturists. BMJ 2001; 323:

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Microsoft Word doc 갑상선절제술을받은환자에서 P6 Acupressure의술후오심, 구토에대한예방효과 연세대학교대학원 의학과 라세희 갑상선절제술을받은환자에서 P6 Acupressure의술후오심, 구토에대한예방효과 연세대학교대학원 의학과 라세희 갑상선절제술을받은환자에서 P6 Acupressure의술후오심, 구토에대한예방효과 지도교수길혜금 이논문을석사학위논문으로제출함 2008 년 6