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1 ISSN J Korean Assoc Pediatr Surg Vol. 20, No. 1, June Original Article 소아에서서혜부탈장수술후장골서혜신경및장골하복신경차단술과창상국소주사의진통효과비교 박대근, 이남혁 영남대학교의과대학외과학교실 A Comparison between Ilioinguinal and Iliohypogastric Nerve Block and Infiltration of Local Anesthetics for Postoperative Pain after Inguinal Herniorrhaphy in Children Dae-Geun Park, Nam-Hyuk Lee Department of Surgery, Yeungman University Collage of Medicine, Daegu, Korea The present study compared the postoperative analgesic effects of ilioinguinal and iliohypogastric nerve block with infiltration of local anesthetics (bupivacaine) into the wound in children after inguinal hernia repair. Ninety children below 7 years old who were scheduled elective inguinal hernia repair were randomly allocated into one of three groups. The patients in nerve block (NB) group, ilioinguinal and iliohypogastric nerve block was done with 0.5 ml/kg of 0.25% bupivacaine. The patients in infiltration of local anesthetics (LI) group, 0.5 ml/kg of 0.25% bupivacaine was infiltrated into the wound after surgery. The patients in control group were allocated as a Control group. Postoperative pain was assessed at 1, 3, 5, and 24 hours after operation with FLACC scale and additional analgesic consumption were counted. The three groups were not significantly different in age, sex, body weight, and duration of operation. Pain scores at 1 hour and 3 hours after operation were significantly higher in Control group than in NB group and LI group (p<0.01), whereas there were no difference between NB group and LI group. The rescue analgesics administration was significantly higher in Control group (n=11) than in NB group (n=6) and LI group (n=7) (p<0.05). There were 2 cases of transient femoral nerve palsy in NB group. Both of ilioinguinal and iliohypogastric nerve block and infiltration of local anesthetics into the wound provided effective postoperative analgesia in early postoperative period following inguinal hernia repair in children. But no difference between the two methods. Technically, infiltration of local anesthetics into the wound was easier and safer than ilioinguinal and iliohypogastric nerve block. Index Word: Inguinal hernia, Postoperative pain, Ilioinguinal and iliohypogastric nerve block, Infiltration, Children 서론서혜부탈장수술은소아에서가장흔하게시행되고있는수술중하나로, 수술시간이비교적짧고수기도간단하지만대부분의환자는술후통증을경험하게된다. 소아에서수술후에발생하는통증은오심과구토를유발할수있으며정상적인활동과생활로의복귀를지연시키고, 창상치유과정에도나쁜영향을미칠뿐아니라정서적불안감의원인이되기도한다. 따라서수술후스트레스를줄이고빠른회복을위 해서는적극적인통증관리가필요하다 1-3. 소아에서진통제의경구혹은정맥주사에의한전신투여는통증조절의효과는우수하지만오심, 구토, 졸음, 그리고호흡억제와같은부작용의우려가있어 4 가능하면국소마취제를이용한수술부위의국소마취나수술부위의통증을담당하는국소신경의차단이바람직하다. 5 서혜부탈장에서는미추차단 (Caudal block), 요추경막외차단 (Lumbar epidural block), 장골서혜신경및장골하복신경차단 (Ilioinguinal and Iliohypogastric nerve block), 창상국소주사등 Received: March 15, 2014, Accepted: June 1, 2014 Correspondence: Nam-Hyuk Lee, Department of Surgery, Yeungnam University College of Medicine, 170, Hyeonchung-ro, Nam-gu, Daegu , Korea. Tel: , Fax: , nhlee@med.yu.ac.kr Copyright 2014 Korean Association of Pediatric Surgeons. All right reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Journal of the Korean Association of Pediatric Surgeons 7

2 J Korean Assoc Pediatr Surg 2014;20(1):7-11 이시행되고있다 6. 이중미추차단은술기가어렵고합병증의위험성이가장높아 2 특별한수련이없이시행하기에는무리가있으나, 장골서혜신경및장골하복신경차단이나창상국소주사는별다른수련없이외과의사가탈장수술과동시에시행할수있다. 그러나아직은이들의효과나장단점을비교한연구들이많지않다. 이에저자들은소아서혜부탈장수술후장골서혜신경및장골하복신경차단과창상국소주사가통증관리에어느정도효과가있는지, 또한이두방법중어떤방법이더효과적인지알아보기위해본연구를시행하였다. 대상및방법 2010년 7월부터 2011년 12월까지 18개월동안영남대학교병원에서전신마취하에편측서혜부탈장수술을받은 6개월에서 7세사이의소아환자 90명을무작위로 30명씩세군으로나누어연구를진행하였다. 장골서혜신경및장골하복신경차단 (ilioinguinal and iliohypogastric nerve block, II/IH NB) 을시행한 30명을신경차단군 (Nerve block group, NB group), 수술절개부위에국소마취제를투여한 30 명을국소마취군 (Local infiltration group, LI group), 그리고둘중어느것도시행하지않은 30명을대조군 (Control group) 으로나누었다. 신경학적이상, 수술부위의피부질환, 혈액응고장애, 국소마취제과민반응이있는환자는대상에서제외하였다. 수술동의서를작성할때국소마취제를이용한신경차단과국소주사의장점과단점그리고합병증을설명하고이에대한동의를구하였다. 모든환자는전신마취하에한명의소아외과의사에의해수술이진행되었다. 장골서혜신경및장골하복신경차단은탈장수술창을봉합한다음 23 gauge 바늘로수술편측의전상장골극 (anterior superior iliac spine, ASIS) 에서대상환자의검지한마디만큼안쪽그리고아래쪽에서피부를직각 으로천자한다음피하층을서서히내려가다가외사복근의건막이뚫리면서저항이없어지는느낌이오면바늘을멈추고국소마취제를주사하였다 7. 국소주사는외사복근건막을닫은후피부를봉합하기전에 25 gauge 바늘을이용하여국소마취제를피하조직에주사하였다. 국소마취제는두군모두 0.25% Bupivacaine 을 0.5 ml/kg 의용량으로사용하였다. 술후통증을비교하기위해술후 1시간, 3시간, 5시간, 그리고 24시간에 FLACC scale ( 표 1) 을이용하여소아외과전담간호사가술후통증평가를하였다. 통증평가시통증점수가 6점이넘으면 Pethidine hydrochloride 를 1 mg/kg 투여하였으며, 각군에서추가적인진통제의요구횟수를비교하였다. 통계학적분석을위해세군의나이, 성별, 체중, 수술시간의비교는 ANOVA 를이용하였다. 또한세군의통증점수와추가적인진통제의요구횟수, 그리고합병증의빈도에대해서는 Kruskal-Wallis test 를이용하여비교한다음각군과의비교는 Mann-Whitney U test 를이용하였다. p값이 0.05 미만인경우를유의한것으로판정하였다. 결과 대상환자의연령은신경차단군이 3.0±2.9 세, 국소마취군이 3.0±2.7 세, 그리고대조군이 2.6±2.9 세였으며, 체중 Table 2. Patients and Clinical Data Age (yr) Sex (M/F) Weight (kg) Duration of surgery (min) NB LI Control 3.0±2.9 23/7 15.8± ± ±2.7 22/8 14.6± ± ±2.9 20/ ± ±8.3 Table 1. FLACC Pain Assessment Tool Categories Scoring Face Legs Activity Cry Consolability No particular expression or smile Normal position or relaxed Lying quietly, normal position, moves easily No cry (awake or sleep) Content, relaxed Occasional grimace or frown, withdrawn, disinterested Uneasy, restless, tense Squirming, shifting back and forth, tense Moans or whimpers, occasional complaint Reassured by occasional touching, hugging, or talking; distractable Frequent to constant frown, clenched jaw, quivering ching Kicking or legs drawn up Arched, rigid, or jerking Crying steadily, screams or sobs, frequent complaints Difficult to console or comfort 8 Journal of the Korean Association of Pediatric Surgeons

3 Park DG, et al: Nerve Block vs Infiltration after Inguinal Herniorrhaphy in Children Table 3. Postoperative Pain Scores 1 hour 3 hour 5 hour 24 hour NB LI Control 3.8±2.2* 2.2±1.5* 1.7± ±0.9 *p<0.05 vs control group. 5.0±1.8* 2.7±1.9* 2.1± ± ± ± ± ±1.3 은각각 15.8±9.5 kg, 14.6±7.3 kg, 14.7±9.3 kg으로각군간에차이가없었고, 성별에도차이가없었다. 수술시간은신경차단군이 18.7±5.9 분, 국소마취군이 20.7±6.1 분그리고대조군이 20.1±8.3 분으로각군간에유의한차이가없었다 ( 표 2). 통증점수는술후 1시간에대조군이 6.9±1.4 점으로신경차단군의 3.8±2.2 점과국소마취군의 5.0±1.8 점에비해유의하게높았으며 (p<0.01), 술후 3시간에도대조군은 4.4±1.5 점으로신경차단군과국소마취군의 2.2±1.5 점과 2.7±1.9 점에비해유의하게높게나타났다 (p<0.01). 그러나술후 5시간과 24시간에는유의한차이가없었다 ( 표 3). 그리고신경차단군과국소마취군간의비교에서는통계적으로유의한차이가없었다. 추가적인진통제의투여는대조군에서 11회로신경차단군의 6회와국소마취군의 7회보다통계적으로유의하게많았던것으로조사되었다 (p=0.03). 그러나신경차단군과국소마취군사이에는통계적으로유의한차이가없었다. 합병증은신경차단군의 2예에서일시적대퇴신경마비로인한보행장애가있었으나통계적유의성은없었으며, 국소마취군에서는발생이없었다. 일시적대퇴신경마비가있었던두환자는마비가발생한지각각 2시간 30분과 3시간 30 분후에다른합병증없이회복되었다 ( 표 4). 고찰 소아에서수술후통증은제대로관리되지못하는경우가많다 1. 그이유는소아들은인지능력이떨어지고정확한의사표현이안된다는점도있지만, 소아들은통증을잘느끼지못한다는그릇된인식이나진통제의부작용에대한우려등으로통증조절에소극적인점도크게작용한다 8. 실제로모든연령의소아들은수술후에통증을느끼며이는육체적고통일뿐아니라정서적충격과불안감을유발한다. 따라서소아에서수술후통증에대한적절한평가와이에따른적극적인치료가필요하다 8. 통증은지극히주관적인증상이라의사표현능력이떨어 Table 4. Requirement of Rescue Analgesics and Complications Number of rescue analgesics Complication NB LI Control p-value 지는소아에서그정도를평가하고객관화하기는쉽지않다. 통증평가에가장흔히이용되는 Visual analogue scale (VAS) 은 0에서 10까지숫자가적힌선으로표시된그래프에환자가자신의통증정도를평가하는방법으로, 이해력이부족한소아에서적용하는데는어려움이있다 9. Wrong- Baker scale 은여섯가지의표정을가진얼굴그림과그에대한설명으로이루어져있어, VAS 보다는이해하기쉬워소아에서좀더많이이용되고있다 1. 그러나이러한자가평가도구는어느정도이러한평가에대한이해와스스로의표현이가능해야함으로대체로 3세정도까지는적용이가능하다고보고있으나, 그보다어린소아에서는관찰자가환자의행동이나자세혹은활력징후등을보고평가하는도구를이용한다 1. 본연구에서이용한 FLACC scale 도그중하나로관찰자가환자의얼굴표정 (Facial expression), 다리의자세 (Position of legs), 활동력 (Activity), 울음 (Presence of crying), 그리고안정성 (Ability to console), 이렇게 5가지를보고판정하는방법으로 2개월에서 7세까지의소아에게적용할수있는통증평가도구이다 10. 수술로조직에기계적손상이가해지면이에대한신체반응으로염증반응이일어나고 TNF-α, Interleukin-6, Interleukin-8 등의전염증성사이토카인 (Proinflammatory cytokine) 이증가하게된다. 이들사이토카인이 COX- 2 의존경로 (cyclo-oxygenase-2 dependent pathway) 를통해말초신경과중추신경계를민감하게만들어통각과민 (hyperalgesia) 상태가된다 11. 따라서수술로인한통증을조절하는데는통증이발생한후에치료하는것보다는이러한염증반응이일어나기전에차단하는것이효과적이라고생각할수있다 5. Bao 등 11 (2012) 은성인환자에서비스테로이드성항염증제를피부절개를하기전에투여하는것이절개후에투여하는것보다진통제의요구량이적었고술후진통제를요구하는시기도늦출수있었으며혈중사이토카인레벨도낮았다고하였다 11,12. Sajedi 등 13 (2011) 은소아서혜부탈장환자에서미추차단을피부절개전에하는것이절개후에하는것보다술후통증이적고진통제의요구량도적었다고하였다. 그러나 Cnar 등 14 (2009) 과 Sakellaris 등 2 (2004) 은국소마취제의창상국소주사를절개하기전과후에시행한것을비교한연구에서술후통증과수술후혈중스트레스호르몬농도의차이가없다고하였으며, 실제국소마취제를주사한 Journal of the Korean Association of Pediatric Surgeons 9

4 J Korean Assoc Pediatr Surg 2014;20(1):7-11 조직은부종때문에전기소작기를이용한조직의절개가불편하기도하여본연구에서는국소마취제의창상국소주사는모두수술을마치고피부를봉합하기전에시행하였다. 소아에서진통제, 특히마약성진통제의전신투여에따른부작용을피하면서서혜부탈장수술후통증조절을위한방법에는미추차단, 장골서혜신경및장골하복신경차단, 그리고마취제의창상국소주사와피부도포크림등이있다. 이들은서로술기의난이도가다르고장단점이있으며아직은어느한가지가다른방법들에비해통증조절효과가우월하다고밝혀지지않고있다 15. 장골서혜신경과장골하복신경은해부학적으로복횡근과내사복근사이를주행하여뒤에서앞쪽으로돌아나오는데전상장골극근처에와서내사복근을관통하여외사복근건막아래에위치하게된다 16. 따라서장골서혜신경및장골하복신경차단을위해서는전상장골극내측에서외사복근건막과내사복근사이의공간에국소마취제를주입해야한다 16. 따라서신경차단을효과적으로시행하기위해서는바늘끝의위치가대단히중요한데육안적으로해부학적위치를정해서시행할때실패율이약 30% 정도에이른다는보고도있으며 17, 일시적대퇴신경마비나장천공같은합병증이발생할위험이있다 18,19. 일시적대퇴신경마비는국소마취제의약효가소실되면서자연회복되므로 3시간에서 6시간정도침상안정을취하면서경과를관찰하면별다른후유증없이회복되는일시적합병증이다 20. 그러나하지가마비된상태를인지하지못하고조기에보행을하다가넘어지면골절상이나뇌손상같은심각한손상을초래할수있으므로주의를요한다 20. 발생빈도는장골서혜신경차단의약 0.25% 에서 10% 까지아주다양하게보고되고있다 19,20. 원인은바늘이너무깊게들어가거나 21, 성공률을높이기위해고농도혹은과량의국소마취제를사용하여약제가복횡근보다아래층으로들어가서발생한다고알려져있다 19,22. 예방을위해서바늘의위치를정확히, 특히너무깊이들어가지않도록하고, 국소마취제의농도는 0.5% 이하그리고용량을 0.5 ml/kg 이하로투여하는것을권장한다 20. 장골서혜신경차단을초음파유도하에시행하면신경과바늘끝의위치, 그리고국소마취제의주입을실시간으로관찰할수있으므로신경차단의성공률을높이고합병증의발생을줄일수있지만 23, 의료비가상승되는부담이있다. Matsota 등 17 (2007) 은국소마취제의창상국소주사는아세트아미노펜의직장 (rectum) 을통한투여에비해조기에그리고좀더긴진통효과를보인다고하였고, Fell 등 4 (1988) 은미추차단과비교해서통증을줄이는효과는비슷하지만상대적으로시술하기가쉽다고하였다. Casey 등 24 (1990) 과 Reid 등 25 (1987) 은창상국소주사와장골서혜신경및장골하복신경차단이비슷한수술후통증조절의효과를보인다고하였다. 본연구에서도창상국소주사와장골서혜신경및장골하복신경차단술은모두술후 1시간과 3시간에유의하게통증을줄였으며추가진통제의요구도유의하게적어, 수술후초기의통증조절에효과적인방법임을알수있었지만두방법사이에는통계적으로유의한차이는발견할수없었다. 본연구에서장골서혜신경및장골하복신경차단술과창상국소주사는외과의사들이수술시시행하기에큰문제는없었다. 그러나신경차단군에서는비록특별한후유증없이완전히회복되었고통계적으로도의미는없었지만 (p=0.13) 일시적대퇴신경마비가 2예 (6.7%) 발생하였다. 그리고신경차단술은필요한위치에바늘의끝을고정하고약제를주사해야함으로혈관내로약제가투여될수있는위험이있지만창상국소주사는지속적으로바늘의끝을움직이면서시행함으로약제의혈관내주사로인한합병증의위험성은거의없다고볼수있을것이다. 결론 서혜부탈장으로수술한소아에서장골서혜신경및장골하복신경차단술과국소마취제의창상국소주사는수술후초기의통증조절에효과적이었다. 두방법사이에통증조절효과의차이는발견할수없었으나창상국소주사가상대적으로안전하고쉬운방법이라사료된다. 그러나본연구의대상자수가적으므로좀더명확한결론을위해서는더많은환자를대상으로한연구가필요할것이다. REFERENCES 1. Hirschl RB, Coran AG: Special considerations in pediatric anesthesia, in O'Neill JA Jr, Grosfeld JL, Fonkkalsrud EW, Coran AG, Caldamone AA(eds): Principles of Pediatric Surgery(ed 2), chap 10. St. Louis, MO, Mosby, 2003, Pp Sakellaris G, Petrakis I, Makatounaki K, Arbiros I, Karkavitsas N, Charissis G: Effects of ropivacaine infiltration on cortisol and prolactin responses to postoperative pain after inguinal hernioraphy in children. J Pediatr Surg 39: , Usmani H, Pal Singh S, Quadir A, Chana RS: A comparison between EMLA cream application versus lidocaine infiltration for postoperative analgesia after inguinal herniotomy in children. Reg Anesth Pain Med 34: , Fell D, Derrington MC, Taylor E, Wandless JG: Paediatric postoperative analgesia. A comparison between caudal block and wound infiltration of local anaesthetic. Anaesthesia 43: , Okur H, Küçükaydin M, Muhtaroğlu S, Kazez A: Effects of bupivacaine infiltration on beta-endorphin and cortisol release and postoperative pain following inguinal herniorrhaphy in children. Pediatr Surg Int 11:41-44, Journal of the Korean Association of Pediatric Surgeons

5 Park DG, et al: Nerve Block vs Infiltration after Inguinal Herniorrhaphy in Children 6. Anatol TI, Pitt-Miller P, Holder Y: Trial of three methods of intraoperative bupivacaine analgesia for pain after paediatric groin surgery. Can J Anaesth 44: , van Schoor AN, Boon JM, Bosenberg AT, Abrahams PH, Meiring JH: Anatomical considerations of the pediatric ilioinguinal/iliohypogastric nerve block. Paediatr Anaesth 15: , Landsman IS, Hay SR, Karsanac CJ, Franklin A: Pediatric anesthesia, in Coran AG, Adzick NS, Krummel T, Laberge JM, Shamberger R, Caldmone A(eds): Pediatric Surgery(ed 7), chap 13. Philadelphia, PA, Mosby Inc., 2012, Pp Beyer JE, Wells N: The assessment of pain in children. Pediatr Clin North Am 36: , Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S: The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs 23: , Bao Y, Fang J, Peng L, Yi Y, Liu K, Li W, Luo H: Comparison of preincisional and postincisional parecoxib administration on postoperative pain control and cytokine response after total hip replacement. J Int Med Res 40: , Ong CK, Lirk P, Seymour RA, Jenkins BJ: The efficacy of preemptive analgesia for acute postoperative pain management: a meta-analysis. Anesth Analg 100: , Sajedi P, Yaraghi A, Zadeh MT: Comparison of pre- vs. post-incisional caudal bupivacaine for postoperative analgesia in unilateral pediatric herniorrhaphy: A double-blind randomized clinical trial. Saudi J Anaesth 5: , Cnar SO, Kum U, Cevizci N, Kayaoglu S, Oba S: Effects of levobupivacaine infiltration on postoperative analgesia and stress response in children following inguinal hernia repair. Eur J Anaesthesiol 26: , Matsota P, Papageorgiou-Brousta M, Kostopanagiotou G: Wound infiltration with levobupivacaine: an alternative method of postoperative pain relief after inguinal hernia repair in children. Eur J Pediatr Surg 17: , Weintraud M, Lundblad M, Kettner SC, Willschke H, Kapral S, Lönnqvist PA, Koppatz K, Turnheim K, Bsenberg A, Marhofer P: Ultrasound versus landmark-based technique for ilioinguinal-iliohypogastric nerve blockade in children: the implications on plasma levels of ropivacaine. Anesth Analg 108: , Weintraud M, Marhofer P, Bösenberg A, Kapral S, Willschke H, Felfernig M, Kettner S: Ilioinguinal/iliohypogastric blocks in children: where do we administer the local anesthetic without direct visualization? Anesth Analg 106:89-93, Amory C, Mariscal A, Guyot E, Chauvet P, Leon A, Poli-Merol ML: Is ilioinguinal/iliohypogastric nerve block always totally safe in children? Paediatr Anaesth 13: , Erez I, Buchumensky V, Shenkman Z, Lazar L, Freud E: Quadriceps paresis in pediatric groin surgery. Pediatr Surg Int 18: , Lim SL, Ng Sb A, Tan GM: Ilioinguinal and iliohypogastric nerve block revisited: single shot versus double shot technique for hernia repair in children. Paediatr Anaesth 12: , Rosario DJ, Jacob S, Luntley J, Skinner PP, Raftery AT: Mechanism of femoral nerve palsy complicating percutaneous ilioinguinal field block. Br J Anaesth 78: , Selway RP: Transient femoral nerve block following groin surgery in children. Pediatr Surg Int 9: , Willschke H, Marhofer P, Bösenberg A, Johnston S, Wanzel O, Cox SG, Sitzwohl C, Kapral S: Ultrasonography for ilioinguinal/iliohypogastric nerve blocks in children. Br J Anaesth 95: , Casey WF, Rice LJ, Hannallah RS, Broadman L, Norden JM, Guzzetta P: A comparison between bupivacaine instillation versus ilioinguinal/iliohypogastric nerve block for postoperative analgesia following inguinal herniorrhaphy in children. Anesthesiology 72: , Reid MF, Harris R, Phillips PD, Barker I, Pereira NH, Bennett NR: Day-case herniotomy in children. A comparison of ilio-inguinal nerve block and wound infiltration for postoperative analgesia. Anaesthesia 42: , 1987 Journal of the Korean Association of Pediatric Surgeons 11

제5회 가톨릭대학교 의과대학 마취통증의학교실 심포지엄 Program 1 ANESTHESIA (Room 2층 대강당) >> Session 4 Updates on PNB Techniques PNB Techniques for shoulder surgery: continuou

제5회 가톨릭대학교 의과대학 마취통증의학교실 심포지엄 (Room 2층 대강당) >> Session 4 Updates on PNB Techniques PNB Techniques for shoulder surgery: continuous vs single injection, interscalene vs supraclavicular approach 의정부성모병원