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1 대한마취과학회지 2008; 54: 406~10 Korean J Anesthesiol Vol. 54, No. 4, April, 2008 임상연구 하지관절성형술을받은환자에서전신합병질환의추이 연세대학교의과대학 1 마취통증의학교실및 2 마취통증의학연구소 원영주 1 ㆍ신양식 1,2 ㆍ이기영 1,2 ㆍ윤주선 1 ㆍ전덕희 1 Trends in Systemic Comorbidity Profiles of Patients Undergoing Artificial Joint Replacement on the Lower Extremities Young Ju Won, M.D. 1, Yang-Sik Shin, M.D. 1,2, Ki-Young Lee, M.D. 1,2, Joo-Sun Yun, M.D. 1, and Duk-Hee Chun, M.D. 1 1 Department of Anesthesiology and Pain Medicine, and 2 Anesthesiology and Pain Research Institute, Yonsei Univerisity College of Medicine, Seoul, Korea Background: Geriatric patients undergoing artificial joint replacement have increased not only in numbers but in age over the past years. These patients usually have accompanying comorbidities which may be increased by age itself and these comorbidities increases clinical challenge while undergoing anesthesia. Methods: Raw data from 1992 to 2006 undergoing artificial joint replacement were collected and investigated retrospectively. Five-year periods of interest (POI) were created for analysis. POI I is five-year periods of interest from 1992 to 1996, POI II from 1997 to 2001 and POI III from 2002 to Changes in demographic variables and prevalence of a variety of comorbidities were statistically evaluated. Results: We identified 4,196 patients in whom artificial joint replacement was performed between 1992 and Of those, 805, 1,212 and 2,179 were performed in POI I, POI II and POI III, respectively. The average age and the prevalence of hypertension and diabetes mellitus increased significantly. Conclusions: The prevalence of comorbid diseases among the patients undergoing artificial joint replacement has increased significantly for hypertension and diabetes mellitus. Also increase in average age of patients undergoing surgery as well as accompanying comorbidities pose an increased clinical challenge. A thorough preanesthetic evaluation and optimal anesthetic technique is necessary to decrease the morbidity and mortality in geriatric patients undergoing artificial joint replacement on the lower extremities. (Korean J Anesthesiol 2008; 54: ) Key Words: arthroplasty, comorbidity, diabetes mellitus, hypertension. 서 현대의학의발달및생활수준의향상등으로인하여평균수명이점차연장되어전체인구에서노인인구가차지하는비율이증가되고있고, 이로인해수술을필요로하는노인환자의수도증가하고있으며 1) 65세이상에서는 21% 이상이매년수술을받고있다. 2) 하지관절성형술의대표적적응질환인관절염은통증과기능장애를동반하는질환으로노화과정으로도볼수있다. 논문접수일 :2007 년 11 월 21 일책임저자 : 전덕희, 서울시서대문구신촌동 134 연세대학교의과대학마취통증의학교실, 우편번호 : Tel: , Fax: ysshin@yuhs.ac 론 보존적치료가원칙이나이러한치료로더이상의통증이나기능저하를경감시키지못할때인공관절치환술이통증을완화시키고기능을향상시키는비용효율적인치료방법이라고알려져있다. 3-5) 하지관절성형술은노령환자에게서많이시행되는대표적인수술로, 최근관절치환물들이연구개발되어사용되고있으며, 다양한삽입물의조합과수술수기의발달로이들에대한수술빈도역시증가되고있다. 1,6) 미국에서는해마다 168,000예의고관절치환술 (total hip replacement, THR) 과 267,000예의슬관절치환술 (total knee replacement, TKR) 이시행되고있으며 7) 지속적으로증가하고있는추세이다. 8) 인공관절치환술은중증합병증이적은치료방법이며재원사망률은 1% 미만이다. 9-12) 하지만고령환자들은정상적인생리기능이저하되어있고, 만성질환이동반되어있는경우가많기때문에 13) 젊은환자들에비해정형외과적대수술과관련하여술중이 406

2 원영주외 4 인 : 전신합병질환의추이 나술후에순환계, 호흡기계, 뇌기능및인지기능에대한합병증의발생가능성이매우크다. 6,14) 이에본저자들은 TKR, THR과양극성반관절성형술 (bipolar hemiarthroplasty, HA) 의수술빈도가증가하고있는추세에서마취에대한 clinical challenge의증가유무와질환유병률, 사망률의추이를규명하고자하였다. 대상및방법 1992년 1월부터 2006년 12월까지 15년간본원에서 TKR, THR과 HA를시행받은환자들의의무기록을검토하여후향적연구를하였다. 조사항목은환자의나이, 성별, 재원일, 수술일, 진단명, 원인질환, 전신합병질환및수술명, 치료결과등을조사하였다. 본원의수술도입이나컴퓨터의무기록가용성등을감안하여 five-year periods of interest (POI) 로구분하였으며 ( = POI I, = POI II, = POI III) 인구역동학적차이와합병질환유병률을비교평가하였다. 각 POI에따라 TKR, THR, HA 대상에서의합병질환유병률, 수술후재원일수, 사망률을비교평가하였다. 모든값은평균 ± 표준편차로표시하였고, SPSS 13.0 for windows (SPSS Inc, USA) 를사용하여분석하였다. 각군간의연령차이는 ANOVA 또는 t-test를사용하였으며전신합병질환비교는 Chi-square test와 Fisher s exact 검정을사용하여비교하였다. 각군간재원일수의비교는분산분석과사후분석으로 Bonferroni 검정을이용하였다. P값이 0.05 미만일때통계적으로유의한것으로간주하였다. 결과총연구대상 4,196명의환자중, POI I, II 및 III가각각 805, 1,212 및 2,179명이었다. TKR 및 THR 수술군에서의나이가최근 POI에서유의하게증가하였다 (Table 1). TKR 을받은환자군에서고혈압의유병률은 POI I, II 및 III에 Table 1. Patients Characteristics by Number of Each Operation Total knee replacement Total hip replacement Hemiarthroplasty POI I POI II POI III POI I POI II POI III POI II POI III Sex (M/F) 21/194 58/ /1, / / /256 34/91 66/141 Age (yr) 60.4 ± ± 9.6* 66.9 ± ± ± ± ± ± 14.2 Op. cases , The values are mean ± SD or in number of patients. POI I, II, III are five-year periods of interest from 1992 to 1996, from 1997 to 2001, from 2002 to 2006, respectively. *: P < 0.05 POI II vs I in total knee replacement, : P < 0.05 POI III vs I or II in total knee replacement, : P < 0.05 POI III vs POI I or II in total hip replacement. 407 Fig. 1. Trends in the prevalence of comorbidities in patients undergoing total knee replacement. POI I, II, and III are five-year periods of interest from 1992 to 1996, from 1997 to 2001, and from 2002 to 2006, respectively. *: P < 0.05 POI II vs I in hypertension, : P < 0.05 POI III vs II or I in hypertension, : P < 0.05 POI II vs I in diabetes mellitus, : P < 0.05 POI III vs I in diabetes mellitus.

3 대한마취과학회지 : 제 54 권제 4 호 2008 서각각 0.5, 8.8 및 27.1% 로최근에올수록유의하게증가하였으며, 당뇨병의유병률또한각각 2.3, 7.1 및 9.2% 로, 최근들어통계적으로유의하게증가하였다 (P < 0.05)(Fig. 1). THR을받은환자군에서는고혈압과당뇨뿐만아니라심장질환과신장질환또한최근들어유의하게증가하였다 (Fig. 2). HA의경우고혈압유병률만통계적으로유의하게증가하였다 (Fig. 3). TKR과 THR의수술후재원일수는 POI I보다 II와 III에서유의하게감소되었고, HA의수술후재원일수는 POI III에서 II보다유의하게감소하였다 (Table 2). 수술후사망률은 POI I, II 및 III가각각 2, 1 및 2명이 었다. 고찰본연구는하지의인공관절성형술이증가하는추세에따른대상환자의마취관리에안전을확보하는차원에서 1992년부터 2006년까지본원에서 TKR, THR, HA를시행한환자군총 4,196명의의무기록을바탕으로전신합병질환의종류, 유병률및합병증과사망률등을컴퓨터기록을이용하여후향적연구를시행하였다. 5년단위로나누어분석하 Fig. 2. Trends in the prevalence of comorbidities in patients undergoing total hip replacement. POI I, II, and III are five-year periods of interest from 1992 to 1996, from 1997 to 2001, and from 2002 to 2006, respectively. *: P < 0.05 POI II vs I in hypertension, : P < 0.05 POI III vs II or I in hypertension, : P < 0.05 POI III vs I in diabetes mellitus, : P < 0.05 POI III vs II or I in cardiovascular disease, : P < 0.05 POI II vs I in renal disease, : P < 0.05 POI III vs I in renal disease. Fig. 3. Trends in the prevalence of comorbidities in patients undergoing hemiarthroplasty. POI II and III are five-year periods of interest from 1997 to 2001, and from 2002 to 2006, respectively. *: P < 0.05 POI III vs II in hypertension. 408

4 원영주외 4 인 : 전신합병질환의추이 Table 2. Postoperative Hospital Stay POI I POI II POI III (n = 2,170) (n = 1,694) (n = 332) TKR 7.0 ± ± 0.7* 5.1 ± 0.4 THR 10.9 ± ± ± 3.0 HA 12.0 ± ± 10.0 Values are mean ± SD. POI I, II, III are five-year periods of interest from 1992 to 1996, from 1997 to 2001, from 2002 to 2006, respectively. TKR: total knee replacement, THR: total hip replacement, HA: hemi-arthroplasty. *: P < 0.05 POI II vs I in TKR, : P < 0.05 POI III vs I in TKR, : P < 0.05 POI II vs I in THR, : P < 0.05 POI III vs II or I in THR, : P < 0.05 POI III vs II in HA. 였던바, 최근수술건수나연령이증가하였으며합병질환중고혈압과당뇨병의유병률이점점증가하였다. THR 환자는고혈압과당뇨병뿐만이아니라그밖의심장질환과신장질환도증가하는추세를보였으나술후합병증이나사망률에서는기간별로차이를보이지않았다. 인구의고령화가급속히진행되면서노인마취도증가하고있으며인공관절치환술의빈도도증가하고있는추세이다. 고령에서의높은유병률은골다공증, 정주형생활방식, 내과적동반질환등많은요소가작용한다. 특히노인환자에서내과질환의동반율은 37.3에서 90% 까지다양하며 15,16) 고혈압, 당뇨병, 만성폐쇄성페질환, 죽상경화증, 신질환등이많다. 13,17) Gibson 등에 18) 의하면건강한노인환자에비해동반질환이있을경우사망률이 4배이상높다고하였으며, Farrow 등은 19) 동반질환이없는노인환자의 5% 사망률보다동반질환이있는노인환자의사망률이 10-30배높다고보고하였다. 하지관절성형술의결과와회복률에어떠한원인이영향을미치는가에대한연구는많이이뤄지고있다. 대부분의 연구에서 20-24) 환자의동반질환이있을수록수술결과가좋지않을뿐아니라각각의원인질환에따라낮은회복률을보였다. 또한수술에서퇴원까지의재원기간또한길다고보고되어있다. Gill 등의 20) 연구에서 TKR을받은환자군중주술기사망률을조사한결과 0.46% 였으며, 총 14명의사망자중동반질환을가진환자가 12명으로동반질환이사망률에영향을준다는결과를보여주었다. 또한, 심장질환을가지고있는환자에서수술후사망률이증가하였으며 Jain 등은 21) 당뇨병을가지고있던환자들의 TKR이나 THR 수술후합병증비율이높았으며불만족스런결과를나타냈을뿐아니라창상감염의빈도도높다고하였다. 또한 Tuominen 등은 24) 동반질환이있는환자에서 TKR 수술후건강수준으로본삶의질이떨어진다하였다. 본연구의사망자는, POI I, II 및 III가각각에 1명 (0.12%), 2명 (0.17%), 1명 (0.05%) 으로 Gill 등의 20) 연구보다사망률이낮았을뿐아니라평균연령과동반질환이증가하고있는추세에서도증가하지않는것은추적기간이재원기간에국한되어있기도하지만마취관리의향상을보여주는일면으로도생각된다. 또한 TKR, THR, HA의수술후재원일수는최근들어유의하게감소되었는데, 이는수술후이환율감소를보여주는것이기도하지만외과적인환자관리정책의변화에기인한것으로간주된다 (Table 2). HA는노인환자에서거동이불편한정도의허약한상태에서낙상으로인한외상성질환이므로환자의전신상태가다른수술을받는환자에비해악조건이고동반질환이많을것이라고짐작할수있는데, Bernstein과 Rosenberg는 25) 노인환자에서골절이잘생기는선행질환으로하지기능장애, 시력장애, 파킨손씨병, 골다공증, 치매를들었으며평균수명이연장되어골절의기회가많은것등이기인한다고하였다. 하지만본연구에서는고혈압만유의하게증가하였을뿐, 다른동반질환의증가나사망률의증가를볼수없었다. 이연구의문제점은의무기록을토대로한후향적연구이기때문에일부자료가누락되었을가능성이있으며, 술후합병증및사망률에영향을줄수있는고지혈증, 비만등의요인들을의무기록을바탕으로한제한점으로인해포함시키지못한것이다. 고혈압, 당뇨병에서유병률의급격한증가는고혈압의진단기준이예전 140/90 mmhg 이상에서 2003년부터정상혈압이 120/80 mmhg 미만으로새롭게바뀌었으며 26) 당뇨병도공복혈당의기준이 140 mg/dl 에서 2003년부터 126 mg/dl로 27) 낮추어지면서 POI별로진단에차이가있을수있을것으로생각된다. 또한동반질환이증가한다는이런결과가연령에따른동반질환에대한이환율의증가로인해초래되었는지수술적응질환과무관한것인지는확인할수없었다. 결론적으로, 본연구에서하지관절성형술대상환자의동반질환이증가한것은확실하며이들에대한마취관리에서합병증과관련하여더높은술후합병증발생과사망률이예견된다. 따라서환자의수술전평가나수술방법등을고려하여마취방법선택에서부터마취관리까지최적의환자상태를유지할수있도록적극적인감시장치를통한마취관리가필수적이고, 선행질환을악화시키지않고술후합병증발생을감소시키려는노력이요구된다. 참고문헌 1. Baek SW: Geriatric anesthesia. In: Anesthesiology and Pain Medicine. Edited by the Korean Society of Anesthesiologists: Seoul, Ryomungak. 2003, pp

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386-390.hwp 386 HANYANG MEDICAL REVIEWS Vol. 29 No. 4, 2009 우리나라 미숙아의 통계와 의료비용 Statistics and Medical Cost of Preterm in Korea 윤혜선 을지대학교 노원을지병원 소아청소년과학교실 Hye Sun Yoon, M.D., Ph.D., Department of Pediatrics, Nowon