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1 Anesth Pain Med 2007; 2: 211~218 임상연구 성인자원자에서생리식염수와하트만씨용액의수분공간모형비교 울산대학교의과대학서울아산병원마취통증의학교실 이지용ㆍ전혜영ㆍ최규택 Comparison of Fluid Kinetic Model of Normal Saline with Hartmann's Solution in Adult Volunteers Ji Yong Lee, M.D., Hye Young Jeon, M.D., and Kyu Taek Choi, M.D. Department Anesthesiology and Pain Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea Background: Changes in the volume of fluid space expanded by intravenous infusion of crystalloid solution have been analyzed using mathematical models. Crystalloids with similar osmolality would reveal no significant differences in distribution and elimination from the body. But each solution has different ionic composition, this can affect fluid volume kinetics. Therefore, we evaluated the fluid volume kinetics of normal saline and Hartmann s solution. Methods: After infusion of 15 ml/kg of normal saline (n=5) and Hartmann s solution (n = 4) over 30 min and measured a serial hemoglobin concentration. The changes were expressed as fractional dilution and then plotted against time. The curves were fitted to two-volume model using non linear least square fitting process. Results: Central and peripheral volume space were present. There were no significant differences between the two groups on central volume, peripheral volume and expansion ratio of fluid space per body weight and expansion ratio of peripheral volume. The expansion ratio of central volume was greater in Hartmann s solution than normal saline from 25 min to 60 min after infusion. Hartmann s solution expanded fluid space higher than normal saline on initial period. Conclusions: There were no significant differences in fluid kinetic parameters between normal saline and Hartmann s solution. However, the volume expansion effect of Hartmann s solution was more rapid than normal saline in early infusion period. (Anesth Pain Med 2007; 2: ) Key Words: fluid space; fluid kinetics, mass balance, fluid; Hartmann s solution, normal saline. 논문접수일 :2007 년 8 월 10 일책임저자 : 최규택, 서울시송파구풍납동 서울아산병원마취통증의학과, 우편번호 : Tel: , Fax: qtek@amc.seoul.kr 211 서 혈액량을늘리기위하여정맥내로수액을투여할때정질액의경우, 투여시작 1시간후 20-25% 가혈관내잔류하므로최소한출혈량의 3배를투여해야혈량을유지할수있다고알려져있다. 1) 또한등장성의정질액을투여하였을때투여종료 30분후에약 1/3 정도가혈장내에남으며이후급격히감소한다고한다. 2,3) 정질액은전해질의구성성분이달라도삼투압이같을경우세포외액에분포하는양상은같을것으로기대하지만생리식염수와하트만씨용액은그구성성분이다르고삼투압도다르기때문에등장성의정질액이라도그구성성분에따라체내분포배설되는정도가다를수있다. 생리식염수를투여하면수술후일과성이지만대사성산증이증가하고혈중나트륨, 염소및삼투압이하트만씨용액에비해증가하며그이유는체내저류되는수분의양이생리식염수가더많기때문이라고생각한다. 그러나 Waters 등 4) 은대동맥류수술시사용된수액의양을비교하였을때생리식염수가하트만씨용액보다많았다고보고하였고그이유는혈량증가량이하트만씨용액에비해생리식염수가더작기때문이라고설명할수있다. 이는체내저류되는수분의양과혈량의증가는비례하지않는시기가있는것으로추정되며수분분포를역동적으로관찰하면그시간적인차이를이해할수있을것이다. 한편수분이정맥으로투여되면세포외액전체가아닌일부분에역동적으로분포하며그분포용적을수분역학모형으로해석하여계산하는방법이제안되었다. 5) 즉수액이투여되면수분공간은확장된후다시일정한공간으로환원되며그속도는수분공간모형화에의하여계산할수있다. 6) 최근에 25 ml/kg의정질액을 30분에걸쳐투여한후비교하였을때생리식염수가하트만씨용액에비해혈액내에더오래잔류한다고 7) 보고되었다. 하지만수분역학모형에사용된수액의양은임상에서흔히사용되는용량의범위에서조사되는것이적절하다고본다. 따라서본연구에서는체중당 15 ml의생리식염수혹은하트만씨용액을 30 론

2 212 Anesth Pain Med Vol. 2, No. 4, 2007 분동안에걸쳐주입한후수분공간모형을이용하여수분공간용적을계산하고혈액량의변화와비교한후이를토대로하여혈량증가를위한수액주입방법을모식화하고자하였다. 대상및방법 건강한성인남녀자원자를대상으로윤리위원회의승인과동의서를얻은후생리식염수 ( 중외제약 ; ionic content in meq/l; Na, 154; Cl, 154; ph, 6.0; osmolality, 308 mosm/l) 군 5명 ( 남 3, 여 2), 하트만씨용액 ( 중외제약 ; ionic content in meq/l; Na, 130; K, 4; Ca, 2.7; Cl, 109; lactate, 28; ph, 6.5; osmolality, 273 mosm/l) 군 4명 ( 남 3, 여 1) 으로나누었다. 혈액의희석도를이용한공간모형의계산을위해생리식염수와하트만씨용액 15 ml/kg를 30분간정주한후일정한간격으로혈중혈색소농도를측정하였다. 자원자는실험전날자정부터실험종료까지금식시켰다. 아침 9시에배뇨를시킨후수술실침대에편안히누운상태에서 20분이경과한뒤수액을주입하였다. 양측주와정맥에카테타를거치하고한곳은펌프 (Flo-Gard R Volumetric Infusion Pump; Baxter Health care, Deerfield, IL, USA) 를통해수액을일정한속도로주입하고다른한곳은채혈로로사용하였다. 혈액의혈색소를측정하기위하여 1 ml의혈액을채취하였으며, 채혈전에 1 ml의혈액을뽑아서버린후수액주입전 5분, 주입시작 0, 5, 10, 15, 20, 25, 30, 45, 60, 80, 100, 120 분후채혈하였다. 채혈후 2 ml의동일수액을주입하여카테타를세척하였다. 주입시작후요의가있을때와실험종료에배뇨시켜소변량을측정하였다. 실험중에는 5분간격으로비침습적방법을통해혈압과심박수를기록하였다. 모형의개념은 Hahn의모형을이용하였다. 1) 요약하면, 단일공간모형은일정한속도 (ki) 로수액을투여하면공간 (V) 은확장되어확장용적 (v) 이되고확장용적은수분공간에서기초배설속도 (kb: 발한, 기초소변량 ) 와목표용적 (V) 의확장율 [(v V)/V] 과그상수 (kr) 에비례하는속도로수분이제거됨에따라변화한다고가정하였다. 이가설에서수분공간의시간에대한부피변화속도는주입속도에서기초배설속도와목표용적의확장율에비례하여배설되는속도를감한값으로표시하였다. 6) (dv/dt = ki }kb }kr(v V)/V). 2-공간모형은다음과같이가정하였다. 일정한속도 ki로수액을투여하면공간v1은확장되어 v1이되고 V1과연결된수액공간 V2가따라서확장되어 v2가된다. 이때 v1은 V2로유출되고 V1의수분제거속도로수분이제거됨에따라변화한다. v2는 V1, V2의확장율의상대적차이와그상수 (kt) 에비례한다. 본실험에서는 2 공간모형을규명해보았으며편의상 Fig. 1. Diagramatic representations of the single-fluid space model and the two-volume fluid space model. V 1 and V 2 : sizes of central and peripheral fluid spaces, K i : infusion rate, K b : basal fluid losses, K r : elimination rate constant, K t : distribution rate constant. 1) V 1 은중심공간이고 V 2 는말초공간으로정의하였다 (Fig. 1). 8) 이가설에의해중심공간의시간에대한부피변화속도는기초배설속도와중심공간의목표용적의확장률에비례하여배설되는속도와중심공간과말초공간의확장속도의차이를감한값으로표현하였고말초공간의시간에대한부피변화속도는중심공간과말초공간의확장율의차이에비례한다고표시하였다. dv1/dt = ki }kb }kr(v1 V1)/V1 }kt{(v1 V1)/V1 }(v2 V2)/V2} dv2/dt = kt{(v1 V1)/V1 }(v2 V2)/V2} 공식에서 ki는주입속도이고 kb는기초배설상수로 1.1 ml/min로하였다. 9) (v-v)/v는공간증가율이며혈액의희석도를이용하였고혈액의희석도는혈액의혈색소의농도를측정하여계산하였다. 10) 체중당증가량은중심공간과희석도의곱을체중으로나누어구하였다 {V1 D1/Kg, D1 = (v1 V1)/V1}. 혈색소의희석자료를상기공식에서풀이한함수에대입하고최소자승곡선에적용 (least square curve fitting procedure) 함으로써 V, V1, V2, v1, v2, kr, kt를구하였다. 함수의계산은 MATLAB을이용하여추정치를얻었다. 질량균형법에의한혈액의용적변화는각시점의혈액량 (BVt) 과초기혈액량 (BVo) 의차이를초기혈액량으로나누어계산하였고 {(BVt BVo)/BVo}, 체중당혈액증가량은혈액량의차이를체중으로나누어구하였다 {(BVt BVo)/kg} (Table 1).

3 이지용외 2 인 : 수액별수분공간모형 213 Table 1. Description of the Methods Used to Calculate the Dilution and the Volume Changes According to Mass Principle and Volume Kinetics Mass balance Volume kinetics Dilution (BVt-BVo)/BVo (v-v)/v Target volume Bvo or ECF V ΔCentral volume (PVt-PVo) V1 D1 ΔPeripheral volume Infused volume-urine-central volume increase-basal loss V2 D2 Urine Measured urine Kr * AUC of dilution curve Δ: increase amount, BV: blood volume, PV: plasma volume, ECF: extracellular fluid volume, o: baseline value, t: value at a time, V: target volume of single space model, v: expanded volume of single space model, V1: central volume of two-volume model, V2: peripheral volume of two-volume model, D1: dilution of central volume in twospace model, D2: dilution of peripheral volume of two-volume space model, Kr: elimination rate constant, AUC: area under the curve. Table 2. Fluid Volume Kinetic Data of the Normal Saline Group and the Hartman s Solution Group in Volunteers Who Received 15 ml/kg for 30 min Normal saline Hartmann s solution (n = 5) (n = 4) Age (yr) 31 ± 1 31 ± 1 Sex (M/F) 3/2 3/1 Weight (kg) 72.6 ± ± 13 Height (cm) ± ± 2.6 V1 (ml) 9,124 ± 2,142 7,085 ± 414 V2 (ml) 7,155 ± 2,381 9,396 ± 1,523 Kr (ml/min) ± ± 75.5 Kb (ml/min) Values are mean ± SDM. SDM: standard deviation of mean, V1: target volume of central fluid space in two-volume space model, V2: target volume of peripheral fluid space in two-volume space model, Kr: elimination rate constant for two-volume space model, Kb: basal elimination rate constant for two-volume space model. 모형의검정방법통계프로그램은 Statview (Abacus, USA) 를이용하였으며각개체의 2-공간모형의적합성여부는모형의중심공간희석도와말초공간희석도를구하여유의한차이가있을때 (P < 0.05) 2-공간모형이존재하는것으로판단하였다 (Wilcoxon Signed Rank test). 수분공간모형화에의한공간의희석도와질량균형법에의한 11) 혈액희석도는 Mann-Whitney U test를실시하고 P < 0.05 이하면유의한차이가있다고판정하였다. 결 과 양군모두에서부작용없이 30분동안 15 ml/kg의생리식염수와하트만씨용액을투여할수있었다. 체중은생리식염수군 72.6 ± 9.5 kg, 하트만씨용액군 66.3 ± 13 kg로양군간유의한차이가없었다. 신장도생리식염수군 ± 8.2 cm, 하트만씨용액군 ± 2.6 cm으로양군간유의한차이가없었다 (Table 2). 수분역학모형에의한결과생리식염수군과하트만씨용액군모두시간에따른중심공간용적과말초공간용적의변화는유의한차이를보이는양상으로변하였다. 즉중심공간용적은투여종료까지최대로증가하였다가지수적으로감소한반면말초공간의용적은서서히증가하여약 60분경최대를이루었다가투여후 120분까지완만히감소하였다 (Fig. 2, 3). 공간모형의지표 : 중심공간의용적은생리식염수군 9124 ± 2141 ml과하트만씨용액군 7084 ± 413 ml로생리 Fig. 2. Two-volume space modeling for the normal saline group. Experimental data means actual hemoglobin dilution data measured during the experiment. Two-volume model u1 means curve fitted data of central volume of two-volume fluid kinetic model. Two-volume model u2 means curve fitted data of peripheral volume of two-volume fluid kinetic model. 식염수군이하트만씨용액군보다크지만통계적으로양군간의유의한차이가없었다 (Table 2). 말초공간의용적은생리식염수군 7155 ± 2381 ml, 하트만씨용액군 9396 ± 1523 ml로양군간유의한차이가없었다. 공간확장에따른배설상수 Kr은생리식염수군이 ± 72.4 ml/min, 하트만씨용액군이 ± 75.5 ml/min로양군간에유의한차이가없었다. 공간증가율 : 중심공간의용적증가율은생리식염수군에서최대확장시 6.5 ± 2.3% 이었다가 120분후 1.1 ± 0.4%

4 214 Anesth Pain Med Vol. 2, No. 4, 2007 Fig. 3. Two-volume space modeling for the Hartmann s solution group. Experimental data means actual hemoglobin dilution data measured during the experiment. Two-volume model u1 means curve fitted data of central volume of two-volume fluid kinetic model. Two-volume model u2 means curve fitted data of peripheral volume of two-volume fluid kinetic model. Fig. 5. Volume expansion ratios of peripheral volume in two-volume space model after infusion of normal saline or Hartmann s solution 15 ml/kg for 30 min. There was no statistically significant difference between the groups. Table 3. Comparison of Fluid Kinetic Results with Mass Balance Calculation Normal saline Hartmann s solution (n = 5) (n = 4) Fig. 4. Volume expansion ratios of central volume in two-volume space model after infusion of normal saline or Hartmann s solution 15 ml/kg for 30 min. Significant difference of volume expansion ratio between the groups was noted from 25 min to 60 min after infusion. *P < 로감소하였고하트만씨용액군은 9.2 ± 1.2% 이었다가 120 분후 1.7 ± 1.2% 로감소하였다. 투여 25분부터 60분까지생리식염수군의중심공간의증가율이하트만씨용액군에비해유의하게작았다 (Fig. 4). 말초공간의목표용적증가율은생리식염수군이 45분에 3.2 ± 1.7% 로최대확장되어유지되다가 120분에 1.8 ± 0.6% 로감소하였고하트만씨액군은 45분에 4.3 ± 2.7% 로확장되었다가 120분에 2.7 ± 0.7% 로감소하였다. 양군간에유의한차이는없었다 (Fig. 5). 체중당증가량 : 중심공간의체중당증가량은생리식염수군은 30분후최대 8.9 ± 0.2 ml/kg로증가하였다가 120 Mass Balance Fluid Kinetics Urine (ml) Plasma Volume Expansion (ml/kg) Maximum 4.5 ± ±1.3 After 120 min 1.2 ± ±1.1 Central Volume Expansion (ml/kg) Maximum 8.9 ± ±0.8 After 120 min 1.4 ± ±1 Peripheral Volume Expansion (ml/kg) Maximum 3.2 ± ±2.7 After 120 min 2.4 ± ±1.4 Actual 295 ± ±228 Calculation 329 ± ±116 Values are mean ± SD. There were no significant differences between the normal saline and the Hartmann s solution groups on plasma volume expansion, central volume expansion, peripheral volume expansion and urine output. 분후 1.4 ± 0.1 ml/kg가잔류하였고하트만씨용액군은 8.7 ± 0.8 ml/kg에서 120분에 1.6 ± 1.0 ml/kg가잔류하였다. 양군간유의한차이는없었다 (Table 3). 말초공간의체중당증가량은생리식염수군이 60분에 3.2 ± 0.7 ml/kg로증가하여유지되다가 120분에 2.4 ± 1.0 ml/kg가잔류하였고하트만씨용액군은 4.3 ± 1.7 ml/kg로증가하였다가 120분에 2.9 ± 1.4 ml/kg가잔류하여양군간에유의한차이는없었다.

5 이지용외 2 인 : 수액별수분공간모형 215 질량균형법에의한비교혈액량의증가율 : 생리식염수군은투여후 30분에혈액량이 10.8 ± 4.7% 증가하였다가 120분에 2.7 ± 2.0% 증가되어있었다. 하트만씨용액군의 15.3 ± 2.4%, 3.8 ± 2.7% 에비해낮았으나유의성은없었다 (Fig. 6). 체중당혈액증가량 : 최대혈장량의증가는생리식염수투여후 30분에 4.5 ± 1.7 ml/kg이었고차츰감소하여 120분에 1.2 ± 0.7 ml/kg가혈장내에잔류하였다. 하트만씨용액군은 30분에 6.7 ± 1.3 ml/kg로증가하였다가 120분에 1.9 ± 1.1 ml/kg이었다. 양군간에유의한차이는없었으나투여 25분에하트만씨용액군이생리식염수군에비해증가하였다 (Table 3). 소변량 : 실측소변량은생리식염수군이 295 ± 45 ml, 하트만씨용액군이 403 ± 228 ml로하트만씨용액군이많 았으나양군간유의한차이는없었다. 계산에의한소변량은생리식염수군이 329 ± 107 ml, 하트만씨용액군이 378 ± 116 ml로유의한차이가없었다 (Table 3). 수분역학지표를이용한수액투여방법표에의한비교도표보는법 (Fig. 7, 8): 첫번째도표에서확장하고자할목표용적 % 를정한후곡선에맞추어주입속도와주입시간을정한다. Y축에서초기주입속도를정하고해당곡선의점에서수직으로내려 X축과만나는값이주입시간이되고두번째도표에서 Y축의주입속도와일치하는주입시간선과만나는점에서수직으로내려 X축과만나는점이지속주입속도가된다. 생리식염수로목표용적의 5% 를증가시킨후유지하고자할경우초기속도 28 ml/min로 30분간투여한후 11 ml/ min의속도로주입하면되고 1시간에투여된양은 1170 ml이다. 하트만씨용액으로목표용적의 5% 를증가, 유지하고자할경우초기 20 ml/min속도로 30분간투여한후 7 ml/min 의속도로지속주입하면되고 1시간동안투여된양은 810 ml이다. 생리식염수와하트만씨용액모두중심공간의증가율은혈량의증가율과유의한차이가없었다 (Fig 9, 10). 따라서모델의확장률에의거하여수액투여를하면혈액량의증가율을반영한다고볼수있었다. 고 찰 Fig. 6. Blood volume expansion ratio after infusion of normal saline or Hartmann s solution 15 ml/kg for 30 min. There was no statistically significant difference between groups except 25 min. *: P < 년 Latta가사망직전의콜레라환자들에게생리식염수를투여를하면회복이빠르다는보고를한후 12) 생리식염수는혈액확장의목적으로널리사용되고있다. 하지만 Fig. 7. Infusion strategy nomogram for normal saline.

6 216 Anesth Pain Med Vol. 2, No. 4, 2007 Fig. 8. Infusion strategy nomogram for Hartmann s solution. Fig. 9. Expansion ratios of blood volume and central volume of two-volume fluid kinetic model after infusion of normal saline 15 ml/kg for 30 min. There was no statistically significant difference between the expansion ratios of blood volume and central volume. Fig. 10. Expansion ratios of blood volume and central volume of two-volume kinetic model after infusion of Hartmann s solution 15 ml/kg for 30 min. There was no statistically significant difference between the expansion ratios of blood volume and central volume. 하트만씨용액이소아설사환자들에게서생리식염수군에서보다더좋은치료율을보였다는연구와 13) 심폐소생술시생리식염수보다하트만씨용액에서더높은생존율을보였다는연구를 14) 비교하면어느용액이생리적으로더적절한혈액증량수액이라고말할수없다. 특히수술중사용되는수액은투여후혈액내에잔류하는수액의양을예측하고이에맞는용액을선택, 투여하는것이바람직하다고볼수있다. 이를위해본실험은생리식염수와하트만씨용액의수분분포를비교한후이를토대로각각의수액주입방법을도식화해보고자하였다. 혈액의희석도를이용하여수분역학을규명하고그분포공간을이해하려는노력은 1990년대말부터발전하기시작하였다. 1) 증가하는공간의부피를측정하기위하여그공간내에만존재하는물질의희석도를측정하는것이타당하므로 15) 혈량을측정하기위해서는혈색소가적절하다고 할수있다. 이에혈액의희석도를이용하여수분공간을모형화하였다. 그결과수액의투여량과투여속도에따라시간적으로용적이변화하는수분공간의크기를구할수있다. 약동역학에서는용질이분포하는수분공간을분포용적으로표현하며그것은투여량에상관없이일정하고용질에따라변화하지않는것으로간주한다. 16) 수분공간모형에서도분포용적과비슷한개념인수분공간을사용하고공간크기는수액투여에의해변화하지만원래대로환원되는목표용적이있다고가정한다. 즉기능적으로구분이되면서도견고한공간이며그공간은팽창가능하다고보는것이수분공간의근본개념이다. 투여용량에따라목표용적에서팽창되는부피가달라진다는것이다. 수분공간의역학적모형은약동력학의용어인분포용적대신목표용적을, 청소율대신목표용적의확장률에비례하여배설되

7 이지용외 2 인 : 수액별수분공간모형 217 는속도를사용하므로용어의정의에차이가있는것이외에는자료분석과수학적공식은약동역학의구획모형과비슷하다. 17,18) 본연구에서 2-공간모형을규명할수있었으며중심공간은수액투여종료시점에최대로팽창되었다가지수적으로감소하는특징을보였고말초공간은투여종료 30분에최대팽창되었다가서서히감소하는양상을보였다. 또한중심공간 7-9 L, 말초공간 7-9 L로중심공간의용적은말초공간과비슷하였고양공간을합하면세포외액의용적과비슷하였다. 삼투압은용액내의용질이발생시키고분자나이온의수와전기하전정도에비례하지만용질의분자량과는상관이없다. 수분은반투과성막을통하여삼투압에의해용질이많은쪽으로이동한다. 그러므로용질의분포상태가각구획의수분의양을결정한다. 반투과성막을자유로이이동할수있는용질은삼투압을형성하지못하고용질이자유로이분포할수있는용적을분포용적이라한다. 그러므로수액투여에의한혈량증가효과는수액의분포용적의영향을직접적으로받는다. 16) 삼투압을비교해보면생리식염수가 308 mosm, 하트만씨용액이 273 mosm로생리식염수의삼투압이더높아생리식염수의공간용적이더클것으로예상하였으나두정질액의공간용적은유의한차이가없이비슷하였다. 본실험에서중심공간의목표용적증가율은투여 25분부터 60분까지생리식염수군이하트만씨용액군에서보다유의하게작은결과를보였고체중당혈장량의증가역시투여 25분에생리식염수군이하트만씨용액군에비해유의하게작은결과를보였다. 그이유는생리식염수의중심공간의목표용적이비록유의성은없으나하트만씨용액에비해더크기때문에동일한투여량에의한목표용적증가율은생리식염수군에서낮을것이라고생각된다. 또한중심공간과혈관내용적은동일한것이아니며생리식염수와하트만씨용액이세포외액에역동적으로분포하는양상이서로다르기때문에이와같은결과를얻은것이라고생각되었으며이는더연구되어야할과제로사료되었다. 본연구에서투여종료후생리식염수는투여직후최대 80% {( )/15}, 하트만씨용액은 87% {( )/15} 가체내잔류하고투여 2시간후생리식염수는 25.3% {( )/15}, 하트만씨용액은 30% {( )/15} 가체내잔류하는것으로나타났다. 그리고비록통계적으로유의하지는않았지만하트만씨용액군에서생리식염수군보다소변량이조금은더많았다는결과를얻을수있었다. Reid 등 19) 에의하면 9명의성인을대상으로생리식염수와하트만씨용액 2 L를 1시간동안주입하고비교해보았을때투여후 6시간에생리식염수는 56% 가체내에잔류하고하트만씨용액은 30% 가잔류하며하트만씨용액군에서 1,000 ml의소변량을보인반면생리식염수군에서는 450 ml의소변량을보였다고하였다. 또한하트만씨용액군에서소변의나트륨수치가 122 mmol로생리식염수군 73 mmol보다오히려더높았다고보고하였다. 또한 Williams 등 20) 은 1시간에걸쳐생리식염수와하트만씨용액을 50 ml/ kg로투여한후수분역학모델을비교해보았을때하트만씨용액군에서생리식염수군에서보다유의하게소변이배설되는시간이짧았다고보고하고있다. 이러한결과는하트만씨용액의삼투압이더낮고, 나트륨이더적음에도불구하고소변량의나트륨이많이검출된이유는이해하기힘들지만아마도생리식염수의염소이온양이하트만씨용액의염소이온보다많아서염소이온이사구체여과율에영향을주었을것이며항이뇨호르몬의분비가더낮았기때문이었을것이라고설명하고있다. 본실험에서의배설상수 Kr은생리식염수군과하트만씨용액군간에유의한차이가없었으나 Hahn 5) 등은 25 ml/kg의 Ringer s 용액을 15분, 30분, 45분, 80분에걸쳐주입한후수분공간모형을살펴본결과용액을천천히주입할수록혈장확장량이더높았다는결론을얻었으며배설상수 Kr이각개체간유의한차이가있었음을밝혀낸바있다. 본수분역학모형에의한지표들을이용하여혈량증가를위한수액주입방법을결정하는지표를제작한후투여방법에따른투여용량을서로비교해보았다. Drobin 등 21) 25 ml/kg 의하트만씨용액을 30 분에걸쳐투여한후 이를모식화해본결과, 혈액량 5% 증가를위하여 30분동안 15 ml/min을투여후 12 ml/min의속도를유지, 1시간에투여된양은 810 ml라고보고한바있다. 본실험에서는하트만씨용액으로목표용적의 5% 를증가, 유지하고자할경우수액투여방법표에의하면 1시간에투여될양은하트만씨용액의경우 810 ml이었고생리식염수의경우 1170 ml였다. 이와같이동일한중심공간의증가율을얻기위하여 1시간동안필요한수액의양은하트만씨용액이생리식염수보다더작음을알았으며이러한이유는목표용적증가율은하트만씨용액이생리식염수보다크기때문일것으로판단되었다. 또한중심공간의증가율과혈량의증가율이통계적으로유의성을보이지않았고유사하였으므로수액투여방법표에의거하여혈량을증가시키는것은믿을수있다고사료되었다. 본연구의한계점으로는관찰대상수가너무작고수학적모형화를임상에그대로적용하는것에대한타당성이부족하다는것이다. 또한본실험에서는이전의여러논문에서 25 ml/kg 이상의많은양을주입한후실험한것과는달리 15 ml/kg의용액을 30분에걸쳐주입한후결과를살펴보았다. 앞서살펴본바와같이투여속도에따라수분공간의모형이다양화될수있음을고려해보면투여량과

8 218 Anesth Pain Med Vol. 2, No. 4, 2007 투여속도의변수를다르게설정하였을때결과역시다르게나올수있음을염두해두었어야한다. 하지만임상에서적응을생각한다면 25 ml/kg 보다는 15 ml/kg의용액을 30분에걸쳐주입하는것이더현실적이라할수있다. 이번연구를통하여 2시간의관찰기간중수분공간은생리식염수와하트만씨용액이비슷한용적을가지나수액투여종료직후혈량증가효과는하트만씨용액이생리식염수보다크고, 동일한수분공간의증가를위해서생리식염수가하트만씨용액보다더많은양이투여되어야함을알게되었다. 참고문헌 1. Stahle L, Nilsson A, Hahn RG: Modeling the volume of expandable body fluid spaces during i.v. fluid therapy. Br J Anaesth 1997; 78: Drummond JC, Charise TP: Intraoperative blood salvage: fluid replacement calculation. Anesth Analg 2005; 100: Brauer KI, Svensen C, Hahn RG: Volume kinetics analysis of the distribution of 0.9% saline in conscious versus isofluraneanesthetized sheep. Anesthesiology 2002; 96: Waters JH, Gottlieb A, Schoenwald P, Popovich MJ, Sprung J, Nelson DR: Normal saline versus lactated Ringer s solution for intraoperative fluid management in patients undergoing abdominal aortic aneurysm repair. Anesth Analg 2001; 93: Hahn RG, Drobin D, Stahle L: Volume kinetics of Ringer s solution in female volunteers. Br J Anaesth 1997; 78: Choi KT, Lee EH, Yeo YG, Lee JY: Modeling the expandable body fluid space after I.V. fluid infusion. Korean J Anesthesiol 2006; 51: Drobin D, Hahn RG: Kinetics of isotonic and hypertonic plasma volume expanders. Anesthesiology 2002; 96: Hahn RG: Physiological or functional fluid spaces. Anesth Analg 2002; 95: Nam SH: Intravascular fluid and electrolyte physiology. In: Anesthesia. Editied by The Korean Society of Anesthesiologisits: Seoul, Kunja. 2005, pp Hahn RG: A haemoglobin dilution method for estimation of blood volume variations during tansurethral prostatic surgery. Acta Anaesthsiol Scand 1987; 31: Brauer KI, Svensen C, Hahn RG, Traber LD, Prough DS: Volume kinetic analysis of the distribution of 0.9% saline in conscious versus isoflurane-anesthetized sheep. Anesthesiology 2002; 96: Latta T: Malignant cholera. Documents communicated by Central Board of Health, London: relative to the treatment of cholera by copious injection of aqueous and saline into the veins 1832; Hartmann AF: Theory and practice of parenteral fluid administration. JAMA 1934; 103: Healey MA, Davis RE, Liu FC: Lactated Ringer s is superior to normal saline in a model of massive hemorrhage and resuscitation. J Trauma 1998; 45: Svensen C, Hahn RG: Volume kinetics of Ringer s solution, dextran 70 and hypertonic saline male volunteers. Anesthesiology 1997; 87: Grocott MP, Mythen MG, Gan TJ: Perioperative fluid management and clinical outcomes inj adults. Anesth Analg 2005; 100: Boroujerdi M: Principle and application. In: Pharmacokinetics. edited by KSA: New York, Mc Graw Hill. 2002, pp Lee DI: Basic pharmacology. In: Anesthesia. Seoul, Kunja. 2002, pp Reid F, Lobo DN, Williams RN: Normal saline and physiological Hartmann s solution: a randomized double-blind crossover study. Clinical Science 2003; 104: Williams EL, Hildebrand KL, McCormick SA, Bedel MJ: The solution on serum osmolality in human volunteers. Anesth Analg 1999; 88: Drobin D, Hahn RG. Volume kinetics of Ringer s solution in hypovolemic volunteers. Anesthesiology 1999; 90:

012임수진

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