대한임상독성학회지 2013:11(1):01~08 Volume 11, Number 1, June, 2013 Journal of The Korean Society of Clinical Toxicology 종 설 위세척의올바른이해와적용 울산대학교서울아산병원응급의학과, 가천대

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1 대한임상독성학회지 2013:11(1):01~08 Volume 11, Number 1, June, 2013 Journal of The Korean Society of Clinical Toxicology 종 설 위세척의올바른이해와적용 울산대학교서울아산병원응급의학과, 가천대학교의학전문대학원내과 / 임상약리 오범진 노형근 Proper Understanding and Application of Gastric Lavage Bum Jin Oh, M.D., Ph.D., Hyung-Keun Roh, M.D., Ph.D. 1 Department of Emergency Medicine, Ulsan College of Medicine, Asan Medical Center, Seoul, Korea, Department of Internal Medicine, Gachon University School of Medicine, Incheon, Korea 1 Gastric lavage is one of gastrointestinal decontamination methods which have been controversial in the clinical toxicology field for a long time. Expert groups of American and European clinical toxicologists have published the position papers regarding gastric lavage three times since They recommended that gastric lavage should not be used as a routine procedure in the management of acute intoxication, because they thought that there is no certain evidence of improving clinical outcome by its use. However, the studies they reviewed were not well-controlled randomized trials, which cannot be conducted in the clinical toxicology field due to variability of patients and ethical problems. Therefore, the results from these studies should be interpreted with caution. They also insisted that gastric lavage can be undertaken within 60 minutes of ingestion. The limitation of one hour after ingestion is too arbitrary and may cause a lot of misunderstanding. Formation of pharmacobezoar or gastric hypomotility after ingestion may significantly delay the gastric emptying time so that gastric lavage can be useful even after several hours or more in case of highly toxic substances or severe intoxication. Furthermore, as there are a number of serious intoxication by toxic pesticides with large amount in suicidal attempts in Korea, it seems that gastric lavage may be used more frequently in Korea than in Western countries. When deciding whether or not to use gastric lavage, all the indications, contraindications, and possible adverse effects should be taken into account on the basis of risk-benefit analysis. If the procedure is decided to be done, it should only be performed by well-trained experts. Key Words: Gastrointestinal decontamination, Poisoning, Gastric lavage 서론사회의변화와함께생활환경이복잡해지면서매년독성물질에의한급성중독발생이증가하고있다. 또한 20 세기에들어와산업과기술의발달로의약품뿐아니라농 투고일 : 2013년 6월 8일게재승인일 : 2013년 6월 10일책임저자 : 노형근인천광역시남동구구월동 1198번지가천대학교의과대학길병원내과 / 임상약리 Tel: 032) , Fax: 032) keunroh@gachon.ac.kr 약, 세제등의다양한물질에의한중독이증가하고, 중독은손상과관련된사망의주요원인이되고있다 1). 미국의경우해마다 300만에서 400만명의독성물질노출사례가보고되고있으며, 2011년도에는 230만명의노출사례가 American Association of Poison Control Center (AAPCC) 에의해보고되었고, 이들중 75% 이상이경구노출이었다 2). 국내에서는독성물질에대한국가적노출빈도를집계하는체계와전수조사가이루어진바는없지만, 건강보험통계연보의중독관련보험청구진료인원을근거로산출한자료에서국내중독사고는연간 94,200명정도이며, 중독은손상에의한사망중 3번째로많은원인으로 J KOREAN SOC CLIN TOXICOL / 1

2 대한임상독성학회지제 11 권제 1 호 년부터 2010년사이매년 3,000명이상이독성물질에노출되어사망했다 3). 미국의사례와다르게노출보다는급성중독으로병원에내원한환자들에대한자료를기반으로하므로, 정확한비율을확인할수는없으나, 급성중독으로사망한환자의 90% 이상이농약에의한자살이었다 3). 최근국내급성중독에대한조사에서 76% 가음독에의한중독사고였고, 중증독성을보인환자의 99% 가음독이라고보고하였다 4). 음독으로인한급성중독의경우시행하는위장관오염제거는급성중독환자들을다루는임상독성학의핵심논란중의하나이다. 환자를치료할때충분한과학적근거에의하기위해많은임상연구들이무작위대조시험형태로이루어지고있으나, 이런급성중독상황에서는임상적으로유용한결과변수를찾기힘들어이런연구를수행하는데한계가있다. 더구나임상독성학분야의많은연구들이신뢰하기어려운급성중독환자의병력청취에의존하거나독성이낮은물질에노출된환자들을많이포함하는등여건이너무다양하기때문에잘관리된무작위대조연구가수행되기를기대하기어렵다. 따라서위세척, 활성탄투여, 구토유발, 전장관세척등의위장관오염제거시행에대한근거에논란이있어왔고, 통일되지않은여러의견들이많아, 실제로급성중독환자를응급으로처치해야하는일선에서는적용에혼란이있는것이사실이다. 이에여기서는위장관오염제거중위세척의의의와올바른적용에대해그이론적근거와최신경향을정리해보고자한다. 1. 위장관흡수과정의병태생리독성물질의인체내흡수는노출경로에따라큰차이를보이며, 접촉부위의물질농도와화학적및물리적성질에따라세포막과세포간을통과해체내로들어오는과정에다양한차이를보인다. 음독시장관을통해체내로흡수되는경우에는장관내다양한요소와독성물질전달체계의여러물리화학적성상의동력학적상호작용에따라체내흡수의속도와양이결정된다. 주요물리학적요소는산염기상태, 위내용물배출시간, 장관내체류시간등이다. 물리화학적특성은용해도, 입자크기, 화학적형태, 제조의특징으로지속형제제, 산염기민감성, 크기, 모양, 제품의밀도등이흡수에영향을끼칠수있다. 장관내음식이같이있는경우에도흡수에영향을줄수있으나일부지속형제제는영향을받지않는다고한다 5). 산염기도에따른영향으로약염기소수성약제들은위의산성환경보다소장에서빠르게흡수된다 6). 하지만, barbiturate와 aspirin 같은산성약제들도위보다소장에서더빠르게 흡수된다 7,8). 입으로들어간물질은식도를빠르게지나서위에도착하고위내의산성환경에영향을받고일부흡수되지만소장의표면적이위에비해매우크므로대부분의물질들이소장에서빠르게흡수된다 7). 동물실험에서경구투여된약의체내흡수정도는위내용물의십이지장이동속도, 장관운동, 장관계혈류량과속도, 위장관내산염기도, 음식물의존재등조성에따라같은종에서도개체별다양한차이를보인다 9-11). 특정물질이산성환경에서안정성이낮다면, 음식물이없는위에서체류시간이길어질때소장으로이동되기전에활성도가감소되어활성형태로체내로흡수되는양이감소하는생리적인현상이발생할수있다. 하지만, 사람에서는이러한차이가임상적으로어떤영향을주는지확실히밝혀지지않았고, 다량음독시더많은영향요소가더해져또다른양상을보일것으로예상되지만정확한기전에대한연구는아직부족하다. 많은약제들은흡수가많이이루어지는소장에도달하는시간과장관점막의상태가체내흡수에많은영향을주는요소이고, 그중위를통과하여소장에도착하는시간인위내용물배출속도가매우중요하다 12). 결론적으로음독시독성물질의체내흡수는주로소장에서많이일어나므로, 위를통과하여소장에도착하는시간이빠를수록신속하게체내로흡수된다. 2. 위내용물의이동위내용물이소장으로배출되는속도는위장관운동정도와관련된다. 일반적으로액제나부유액이고형제나분해되지않는형태의물질보다위로부터소장으로의배출이빠르게일어난다. 음식물을삼켰을때, 식도에서고형물은 6~9초, 액체는 4~5초만에지나가며, 소장에서는탄수화물 2시간, 단백질 4시간, 지방 6시간으로단순하게나열하지만음식물의상태와조성에따라매우다르게이동한다. 위장관내물질은들어오는속도와다르게배출되는양상을보이기때문에체류시간은매우다양할수있다 13). 위배출속도는위근육의수축을통한경우콜린성운동신경과세로토인수용체활성화로증가되지만, 도파민수용체활성화와아편제제등에의해서는억제된다. 또한, 호르몬, 자세, 복막자극, 심한통증, 위궤양, 당뇨를포함한대사성질환, 술, 항콜린성약제, 수면진통제, 신경절차단제, 제산제, metoclopramide를포함한많은약제들이위내용물의이동속도에영향을끼친다. 그밖에섭취한물질의온도, 심리적상태도위배출시간에영향을준다고알려져있다 14-16). 액체는양이많고지방과아미노산이적으며저장액에염기성일경우위내용물이기하급수적으로 2/ J KOREAN SOC CLIN TOXICOL

3 오범진외 : 위세척의올바른이해와적용 빠르게배출된다. 그러나이런조건과반대되는액체나고체의경우에는비교적직선적으로위내용물배출이이루어진다. 환자의나이에따라신생아에서는위산염기상태가성인보다염기성이고장관으로혈류공급이낮으며, 노인에서는위내용물의배출시간이늦고장관으로혈류공급도감소되어일반성인과흡수에차이를보인다. 위장관운동성을증가시키는약제들은대부분약제의체내흡수속도를빠르게하는데, digoxin과같은약제는위장관운동성을증가시키지만흡수속도는감소시키는것으로알려져있다 17). 울혈성심부전환자에서는위장관의혈류가감소하고장관벽의부종과장운동감소로인해약제의흡수속도가감소한다 18). 따라서, 임상적으로음독환자에서독성물질이위에서배출되어소장으로도달하는시간이중요하지만, 체내로흡수되는정도는어느한가지요소로예측하기어렵다. 3. 위세척의유용성과시간관계위세척은생명을위협하는많은양의독성물질을음독한급성중독환자가내원시위내에아직독성물질이남아있다고판단되며, 심각한독성증상을나타낸다면효과적으로적용될수있다. 독성물질이활성탄에흡착되지않는것이거나활성탄적용이불가능한상황이라면위세척이고려될수있다. 또한자발적구토가전혀없고, 특정해독제가존재하지않거나, 혈액관류나혈액투석등의제독방법이적용될수없는때라면역시위세척이가능한대안이될수있다. 위장관연동운동, 음독시위내음식물의존재, 먹은독성물질이다량인지여부등이위세척의효과에영향을줄수있다. 급성중독으로인해의식이나빠진환자에서음독후 1시간이내에위세척을하였을때하지않은환자들보다임상적예후가호전되었다는보고가있으나, 대개임상적으로는다량을음독한상태로병원에내원하며, 음독후내원시간은다양하나평균 2~3시간을지나서내원한다고보고되었다 19,20). 이러한경우에는위내용물이소장으로일부배출된상태로내원한것으로추정된다. 한편최근연구에의하면대도시에서는오히려좀더신속하여위장관오염제거까지시간이 70~75분소요되었고, 구급차를이용한경우에는중위값이 40분이었다 21). 시간에따른위세척의유용성을확인하기위하여그동안많은연구들이있었다. 많은연구자들이환자가생명을위협하는다량의독성물질을먹거나음독후 60분이내에내원한경우가아니면위세척은시행하지말아야한다는데에동의하여왔다 22). 자원자에게 4 g의 acetaminophen 용액을투여하고 30분후에위세척을시행한교차시험에서투여군은대조군보다 20% AUC 감소를보였으나, 개인차가많고위세척과정의신뢰성문제로임상적의미를강조하기는어렵다 23). 성인자원자에게약제캡슐을투여하고 10분, 60분뒤위세척을한연구에서는각각 45% 와 32% 흡수감소를보고하였다 24,25). 액제를다량섭취한환자에서는 5분뒤위세척으로 90% 흡수감소를보인반면 26), 아스피린을과량경구로투약한자원자들에서 60분뒤에위세척으로 8% 의흡수감소만보고되었다 27). 또한금속표지자를투여하고즉시위세척을하였을때는알약의 48% 가제거되었고 28), 동위원소가포함된액제를투여하고 3분후위세척으로 80~84% 를제거할수있었다 29). 이와같이일반적으로는음독후빠른시간내에위세척을시행하는경우에어느정도흡수의감소를기대할수있으나, 음독후 60분내에내원한환자에게만적용해야한다는것은대단히인위적인설정이므로적절하지않다. Acetaminophen 과용량의가상연구에서 diphenhydramine과 oxycodone의약동학효과를확인한결과 diphenhydramine은위배출을연장시키지않았으나, oxycodone은 acetaminophen의 Tmax를약 1 시간연장시켰다 30). 이연구는 acetaminophen과같은흡수가빠른약물도경우에따라위세척가능한시간이그만큼연장될수있음을의미한다. 또한음독후 5시간이지난후에도많은양의정제가위에남아있었다는증례보고가있으며 31), 약물이위내에서위석 (bezoar) 을형성하는경우며칠간지속적으로위에남을수있다는보고도있다 32). 위세척을 2.5~5.5 L 시행한후내시경으로확인하였을때 88% 의환자에서위내약제가완전히제거되지못하고약제조각이내시경으로확인된보고가있다 28). 또한, 약제가위내에서덩어리를형성하고지속적으로체내에흡수되어, 초기독성이심하지않았던환자가응급실에서위장관오염제거와일반적인초기처치후퇴원한뒤수시간만에사망한 theophylline 중독사례와, 지속적인임상소견악화와반복적인혈중농도상승에이은사망이보고된삼환계항우울제중독사례가있었다 33,34). 두사례모두지속성약제가위내에서덩어리가되어위세척을통해배출되지않아위세척이더이상필요하지않다고판단되었던경우로, 위세척이적절하게위내독성물질을제거하였는지와약제덩어리가남아있는지에대한확인이적절하게이루어지지못했다. 이러한약제위석에대해위세척이후수술적혹은내시경으로제거한사례들도보도되었다 35-37). 다수의약제를내원 10시간전음독한중증환자에서전산화단층촬영으로위장관내음독물질이남아있는것을확인하고, 입위관을이용하지않고코위관을이용한흡입으로만위장관오염제거를시도한뒤합병증없이호전된 J KOREAN SOC CLIN TOXICOL / 3

4 대한임상독성학회지제 11 권제 1 호 2013 사례보고도있다 38). 위내용물배출이늦어지는특수한상황인저체온상태로발견된환자에서우연히발견된위내약제를위세척을이용하여성공적으로제거하였다는보고도있다 39). 항우울제, 진통제, 항간질제등의과용량에의한음독시위배출시간의현저한증가와위운동저하에관한연구에서저자들은이런위운동저하가음독한약물에의한직접효과이기보다는음독으로인한스트레스가한원인이될수있음을시사하였다 40). 따라서음독환자에서위세척을시행할때위장관운동이정상이아닐수있음을염두에두고상황을판단하여야할것이다. 위세척을활성탄투여와함께적용하는경우는위세척만시행한경우와비교할때흡수저하에통계적차이가없었다 41,42). 자원자를대상으로한임상연구는윤리적문제로인해소량의경구투약을적용하였기때문에이러한경우는다량의음독환자와다른양상의위내용물배출과위세척에따른다양한제거양상을보일수있어해석에주의가필요하다. 임상독성학분야의임상적연구도통제된조건에서연구되기어렵다. 유기인계농약을음독한환자에게위세척을시행한 56개의중국인연구들을분석한결과의미있는양의위장관제거가이루어지거나임상적효과가입증된연구는없었다고하였다 43). 그러나이분석의대상이된연구들중그연구의질평가를위한적절한방법을기술한것은하나도없었으므로그결과를참고하여위세척의효과가없다고말할수는없다. 독성물질에의노출은소아에서많이볼수있는데, 소아에서의노출사고는대부분노출량이소량이거나물질의독성이낮으며증상이경증인사례가 90% 를차지한다 44). 독성이낮은물질의소량음독에서의위세척은도움보다해가될가능성이높고, 의식이저하된경우에는흡인등의합병증이발생하기쉽다. 따라서, 독성물질을다량음독후조기에병원으로내원하여위내에독성물질이다량머물러있을경우에흡인의위험성이없도록시행된다면도움이될수있을것이다. 4. 위세척의금기환자의구역반응이소실되어기도를보호할수없는상황, 즉기관내삽관을하지않은의식저하된환자가절대적금기증이다. 또한, 부식성제제를음독한경우, 밀도가낮은탄화수소의음독으로위세척시이차적식도손상과흡인의위험이매우높은경우, 최근의위장관수술이나처치를받아위장관의출혈이나천공의위험이큰경우는금기증에해당한다 45,46). 입위관의크기보다큰정제를먹었 을경우와독성이낮고음독한양과증상이경미할경우에는위세척의적응증이되지않는다. 또한활성탄에잘흡착하는독성물질로음독량이활성탄의흡착한계를벗어나지않는경우나, 이미상당한자발적구토가일어난경우에도위세척의생략이가능하다. 적응증이된다하더라도급성중독환자에서위세척의이득보다위험성이더크다면상대적금기라고생각할수있다. 환자가시술에협조하기를거부하는경우에도상대적금기로받아들여지고있지만, 국내에서유기인계농약용액을마시고 30분만에중소병원응급실로내원한환자에게위세척을적용하고자하였으나, 환자가강력히거부하여위세척을제외한치료만시행한뒤타병원으로전원한다음사망한사례에서병원의일부책임을인정한판결이있었다. 이사례에대해환자가치료에협조하지않고거부하는경우에도생명을구하기위한처치의필요성은환자의의지보다우선된다는해석이있다 47). 위세척시행에상대적금기증인협조하지않아시행하기어려운환자에게강제로위세척을시행해야할지판단해야하는것도국내급성중독의응급처치시고민해야할문제로남아있다. 5. 위세척의시행위장관오염제거를위한위세척에대한경험이풍부한의료진에의해수행되어야하며, 의료기관내에서만시행할것이추천된다. 의식이명료한환자에게는시술의필요성과목적에대해충분한이해를시키고구두동의를얻도록한다. 의식이저하되고구역반사가없는경우에는기관내삽관을적용하고시행하도록한다. 위세척을위한도관의길이는 150 cm이고직경은성인 French ( 외경 12~13.3 mm), 소아 French ( 외경 7.8~9.3 mm) 를사용한다. 위세척을위한도관은삽관전에최소한하부위식도경계부를지나도록삽관할도관의길이를환자의신체에맞추어측정한뒤삽관하도록한다. 위세척도관을삽관하기전흡입기를준비하고, 도관표면에윤활제젤리를충분히바르고구강기도유지기를적용한뒤삽관한다. 도관을삽입하는중과도한힘을가하지않도록하며, 위내에위치하였는지여부는관에서위내용물이나오는것으로확인하도록한다. 위내용물이나오지않을경우에는청진기를상복부에대고위세척관으로주사기를이용해공기를주입하여공기잡음을듣는것으로위치를확인할수있다. 또한위세척관으로뽑은내용물의산염기도를측정하여평가할수도있으나, 최종적으로는방사선검사를통해위치의적절성을평가한다. 위내용물을독성물질검사를위해보관할수있지만대부분의검사실에서는혈액 4/ J KOREAN SOC CLIN TOXICOL

5 오범진외 : 위세척의올바른이해와적용 과소변을이용한검사가선호된다. 삽관후환자의머리를수평면에서 20도가량아래로낮추고환자몸의좌측면이바닥으로향하도록돌아눕게한다. 이자세에서는위유문부가위쪽을향하여이론적으로십이지장으로넘어가는위내용물의양이줄어들것으로기대된다. 위세척은소량의용액을이용해시행하는데, 성인에서는한번에 200~300 ml 양으로섭씨 38도정도의따뜻한수돗물혹은생리식염수를이용하고, 소아에서는체중 1 kg 당 10 ml의따뜻한생리식염수를이용한다. 소량의물을이용한세척을시행하는것은위내용물이위세척으로인해소장으로넘어가는것을줄이려는의도이다 48). 과거문헌에대한체계적고찰연구에서는급성음독환자에서치료적위세척으로인해위내용물을소장으로빠르게배출시키지는않는다고하였지만 49), 독성물질의성질과형태에따라다를수있음은염두에두어야한다. 따뜻한세척액은다량으로위세척을시행할경우발생할수있는저체온증을예방하기위해서이다. 소아에서식염수가아닌수돗물이나증류수를이용할경우저나트륨혈증과물중독을유발할위험이있다. 세척을위해도관으로넣은용액과세척후배출되는용액의양이비슷해야하며, 세척과정은배출되는용액이깨끗해지거나약제조각이보이지않을때까지반복한다. 6. 위세척의합병증위세척의합병증으로흡인성폐렴 50,51), 성문연축 52,53), 부정맥 53), 식도혹은위천공 19,50,54-56), 수분및전해질불균형 57) 등이보고되었다. 고장성식염수 12 L로위세척을시행한후심한고나트륨혈증이발생하기도하였다 58). 개발도상국에서위세척을적용함에있어환자가협조하지않거나안전수칙이잘지켜지지않을경우사망을포함한합병증이발생할수있음과, 위세척에활성탄을함께투여할경우흡인성폐렴에의한호흡부전이더많았다는보고가있다 59,60). 선진국에서도위세척시술과관련된식도천공은여전히보고되고있다 61). 의사가위세척을결정할경우활성탄만투여한환자보다 4배기관내삽관이많았고, 2배더중환자실입원률이높았는데 51), 이는위세척시행으로인해합병증의발생위험과추가적의료비용이증가할수있음을시사한다. 7. 위세척시행의추이와올바른적용지난수십년간의위세척과관련된합병증이보고된반면에임상적효과에대해서는충분한근거가될만한연구 가이루어지지못했다. 위장관오염제거와관련하여과학적인연구를위해환자를무작위로처치군과무처치군으로나누어시행하는비교시험이오래전에는가능하였으나 19), 최근으로오면서는윤리적으로용납되기어려워시행할수없다. 만일독성이높지않은아주소량의물질에노출되었거나, 효과가있으면서안전하고비용이저렴하며바로구할수있는해독제가있다면, 위장관오염제거를생략하는것이가능하다고본다. Acetaminophen 중독의경우가이러한조건에잘맞는것으로보여과용량자원자연구가이루어졌으나 62), 이결과를모든독성물질의중독에적용하기는어렵다. 위세척에대한오랫동안의논란에대해 1997년과 2004 년국제임상독성학계의양대학회인American Academy of Clinical Toxicology (AACT) 와 European Association of Poisons Centres and Clinical Toxicologists (EAPC- CT) 는위세척이임상적으로좋은결과를보인다는확실한증거가없다고입장을표명하였다 22,63). 그렇지만그동안의논란을정리하리라는모두의기대와달리오히려단점과그모호함이부각되는계기가되고말았다. 실제로미국과유럽에서급성중독치료에관계하는전문가들을조사한결과, 위장관오염제거에관한한상당한견해차이를보이며각기다른기준을적용하고있었다 64,65). 이런차이는이제까지음독환자의위세척에대한결정에기여할수있는적절한증거를보이는연구가없다는것을의미한다고볼수있다. 1990년대에서 2000년대로들어서면서위장관오염제거의적용빈도가전체적으로감소하는경향을보이고있다 35,61). 미국에서 1993~2003년사이 1,168만명의응급실내원급성중독환자에서위세척을받은비율이 1993~1997 년 18.7% 에서 1998~2003년 10.3% 로줄었다는보고가있었다 35). 국제학회에서의위세척에대한입장표명후의이런감소는서구에서아마도과거의 barbiturate나삼환계항우울제와같은독성이높은약물들로부터 benzodiazepine이나선택적 serotonin 재흡수억제제 (SSRI) 등의비교적독성이낮은약물들로바뀌어가는과정에어느정도기인한것으로보인다. 물론위세척에대한긍정적연구로, 쥐약급성중독으로내원한 409명의환자에서위세척이사망률을낮추었다고보고도있다 66). 위세척의올바른적용이실제로힘든또다른이유는아무리음독후빠른시간내에, 경험이많은임상독성전문가들이비교적잘조절된조건에서시행하였다하더라도, 개인간의차이가너무커서그효과를신뢰하기어려운경우가매우많다는점이다 67). 가장최근에보고된국제학회의입장표명에서도아직까지위세척이 J KOREAN SOC CLIN TOXICOL / 5

6 대한임상독성학회지제 11 권제 1 호 2013 모든급성중독에적용되어야한다는증거는없고, 드물게적용되더라도잘훈련된전문가가시행하여야함을권하고있다 68). 그러나이러한의견들은급성중독을야기하는독성물질의종류와그빈도가우리와많이다른서구국가들의자료를바탕으로하고있어, 이를우리나라의환경에적용할때에는조심하여야한다. 농약과같이사망률이높고독성이강한물질에의한급성중독이많으며, 자살기도에의한다량음독이대부분을차지하는우리나라의경우는중한중독이흔하므로, 서구와같은개념으로보더라도그적응증의대상은더많을것으로예상된다. 결 론 위세척은위험성이없는과정이아니므로음독한급성중독환자에서관례적으로모두적용하지는말아야한다. 많은연구들이급성중독환자에서음독후시행한위세척이임상적으로유용하다는확실한증거가없다는이유로그적용을부정적으로보고있으나, 이런의견또한신중히검토할필요가있다. 이분야의많은임상연구들은그특성상변수가많고윤리적문제때문에잘관리된무작위대조연구수행이불가능하므로, 연구의결과는실제임상상황의다양함과그한계를염두에두고해석하여야한다. 일반적으로위세척은음독후 1시간이내에시행하여야한다는견해는매우인위적인설정에의한것으로상황에따른판단이필요하다. 위세척은음독후빠른시간내에시행하는것이유리하나, 음독물질이위내에서위석을형성하거나, 위장관운동저하가동반된경우에는상당한시간이지나서도도움이될수있다. 또한농약과같은독성이강한독성물질의다량음독으로인한급성중독이많은우리나라상황에서는서구의국가들에서보는위세척의입장보다그유용성이더높을가능성을인지하여야한다. 그리고위세척을적용할때는그적응증, 금기증, 합병증등을잘검토하고위험-편익관계를판단하여결정하여야하며, 숙련된전문가에의해시행되어야한다. 참고문헌 01. Bohnert AS, Fudalej S, Ilgen MA. Increasing poisoning mortality rates in the United States, Public Health Rep 2010;125: Bronstein AC, Spyker DA, Cantilena LR, Jr., Rumack BH, Dart RC Annual report of the American Association of Poison Control Centers National Poison Data System (NPDS): 29th Annual Report. Clin Toxicol (Phila) 2012; 50: Office KNS, Annual Report on the Cause of Death Statistics (Based on Vital Registration in Year 2011), 2012, Korea National Statistical Office: Daejeon. 04. Sung AJL, K.W., So, B.H., Lee, M.J., Kim, H., Park, K.H., Park, J.B. Multicenter Survey of Intoxication Cases in Korean Emergency Departments: 2nd Annual Report, J Korean Soc Clin Toxicol 2012;10: Golub AL, Frost RW, Betlach CJ, Gonzalez MA. Physiologic considerations in drug absorption from the gastrointestinal tract. J Allergy Clin Immunol 1986;78: Jollow DJ, Brodie BB. Mechanisms of drug absorption and of drug solution. Pharmacology 1972;8: Siurala M, Mustala O, Pyorala K, Kekki M, Airaksinen M, Jussila J, et al. Studies on gastrointestinal absorption of drugs. Acta Hepatogastroenterol (Stuttg) 1972;19: Kojima S, Smith RB, Doluisio JT. Drug absorption. V. Influence of food on oral absorption of phenobarbital in rats. J Pharm Sci 1971;60: Levine RR. Factors affecting gastrointestinal absorption of drugs. Am J Dig Dis 1970;15: Diamond L, Doluisio JT, Crouthamel WG. Physiological factors affecting intestinal drug absorption. Eur J Pharmacol 1970;11: Crouthamel W, Doluisio JT, Johnson RE, Diamond L. Effect of mesenteric blood flow on intestinal drug absorption. J Pharm Sci 1970;59: Kimura T, Higaki K. Gastrointestinal transit and drug absorption. Biol Pharm Bull 2002;25: Camilleri M, Colemont LJ, Phillips SF, Brown ML, Thomforde GM, Chapman N, et al. Human gastric emptying and colonic filling of solids characterized by a new method. Am J Physiol 1989;257:G Holt S. Observations on the relation between alcohol absorption and the rate of gastric emptying. Can Med Assoc J 1981;124:267-77, Wheeler-Usher DH, Wanke LA, Bayer MJ. Gastric emptying. Risk versus benefit in the treatment of acute poisoning. Med Toxicol 1986;1: Fleisher D, Li C, Zhou Y, Pao LH, Karim A. Drug, meal and formulation interactions influencing drug absorption after oral administration. Clinical implications. Clin Pharmacokinet 1999;36: Nimmo WS. Drugs, diseases and altered gastric emptying. Clin Pharmacokinet 1976;1: Lennernas H. Does fluid flow across the intestinal mucosa affect quantitative oral drug absorption? Is it time for a reevaluation? Pharm Res 1995;12: Kulig K, Bar-Or D, Cantrill SV, Rosen P, Rumack BH. Management of acutely poisoned patients without gastric emptying. Ann Emerg Med 1985;14: / J KOREAN SOC CLIN TOXICOL

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8 대한임상독성학회지제 11 권제 1 호 ;1: Merigian KS, Woodard M, Hedges JR, Roberts JR, Stuebing R, Rashkin MC. Prospective evaluation of gastric emptying in the self-poisoned patient. Am J Emerg Med 1990;8: Allan BC. The role of gastric lavage in the treatment of patients suffering from barbiturate overdose. Med J Aust 1961;48: Thompson AM, Robins JB, Prescott LF. Changes in cardiorespiratory function during gastric lavage for drug overdose. Hum Toxicol 1987;6: Caravati EM, Knight HH, Linscott MS, Jr., Stringham JC. Esophageal laceration and charcoal mediastinum complicating gastric lavage. J Emerg Med 2001;20: Mariani PJ, Pook N. Gastrointestinal tract perforation with charcoal peritoneum complicating orogastric intubation and lavage. Ann Emerg Med 1993;22: Wald P, Stern J, Weiner B, Goldfrank L. Esophageal tear following forceful removal of an impacted oral-gastric lavage tube. Ann Emerg Med 1986;15: Mofredj A, Rakotondreantoanina JR, Farouj N. [Severe hypernatremia secondary to gastric lavage]. Ann Fr Anesth Reanim 2000;19: Eddleston M, Haggalla S, Reginald K, Sudarshan K, Senthilkumaran M, Karalliedde L, et al. The hazards of gastric lavage for intentional self-poisoning in a resource poor location. Clin Toxicol (Phila) 2007;45: Wang CY, Wu CL, Tsan YT, Hsu JY, Hung DZ, Wang CH. Early onset pneumonia in patients with cholinesterase inhibitor poisoning. Respirology 2010;15: Griffiths EA, Yap N, Poulter J, Hendrickse MT, Khurshid M. Thirty-four cases of esophageal perforation: the experience of a district general hospital in the UK. Dis Esophagus 2009;22: Christophersen AB, Levin D, Hoegberg LC, Angelo HR, Kampmann JP. Activated charcoal alone or after gastric lavage: a simulated large paracetamol intoxication. Br J Clin Pharmacol 2002;53: Vale JA, Kulig K, American Academy of Clinical T, European Association of Poisons C, Clinical T. Position paper: gastric lavage. J Toxicol Clin Toxicol 2004;42: Juurlink DN, McGuigan MA. Gastrointestinal decontamination for enteric-coated aspirin overdose: what to do depends on who you ask. J Toxicol Clin Toxicol 2000;38: Good AM, Kelly CA, Bateman DN. Differences in treatment advice for common poisons by poisons centres--an international comparison. Clin Toxicol (Phila) 2007;45: Wang LH, Xian MP, Geng WQ, Qin ZL, Li YX. [Logistic regression analysis of factors influencing clinical therapeutic effect on acute tetramine poisoning]. Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi 2004;22: Lapatto-Reiniluoto O, Kivisto KT, Neuvonen PJ. Efficacy of activated charcoal versus gastric lavage half an hour after ingestion of moclobemide, temazepam, and verapamil. Eur J Clin Pharmacol 2000;56: Benson BE, Hoppu K, Troutman WG, Bedry R, Erdman A, Höjer J, et al. Position paper update: gastric lavage for gastrointestinal decontamination. Clin Toxicol (phila) 2013;51: / J KOREAN SOC CLIN TOXICOL

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A 617 Special Issue Diabetic Retinopathy Won Ki Lee, M.D. Department of Ophthalmology The Catholic University of Korea College of Medicine Kangnam St. Mary s Hospital E mail : wklee@catholic.ac.kr Abstract R