08-김창엽

대한응급의학회지제 25 권제 2 호 Volume 25, Number 2, April, 2014 원 저 Pediatrics 응급의료센터를내원한소아환자에서전통적요추천자와초음파를이용한요추천자의유용성비교 을지대학교병원응급의학과, 동아대학교병원응급의학과 1, 충남대학교병원응급의학과 2 김창엽 1 정원준 2 이원석 Comparison between Classical Lumbar Puncture and Ultrasonography-Assisted Lumbar Puncture in the Pediatric Patients Chang Yob Kim, M.D. 1, Won Joon Jeong, M.D. 2, Won Suk Lee, M.D. Purpose: We would like to study the effectiveness and safety during lumbar puncture by classic lumbar puncture and ultrasonography-assisted lumbar puncture in pediatric patients. Methods: This was a prospective randomized controlled trial. We included under 14-year-old pediatric patients who needed to undergo lumbar puncture from May 2010 to August 2011. Patients were divided according to classic lumbar puncture (group A) and ultrasonography-assisted lumbar puncture (group B). Data were collected, including the patient s age, sex, height, underlying disease of vertebrate, weight, frequency of attempting procedure, procedure time, and failure of lumbar puncture. Results: Group A and group B included 31 patients and 33 patients each, with average ages of 9.65±8.53 and 7.38± 4.45(p=0.19), average heights of 126.65±29.81 cm and 122.39±30.01 cm (p=0.57), and average weights of 32.84 ±20.68 kg and 29.17±16.96 kg (p=0.44), without statistically significant differences. Of the distribution of residencies who underwent lumbar puncture between the two groups, no statistically significant differences were observed (p=0.30). Lumbar puncture time in group A was 6.72±9.16 minutes and 3.88±1.51 minutes in group B, but without significant differences (p=0.098). The number of lumbar puncture attempts was 1.68±0.95 in group A and 1.45± 0.56 in group B, without significant statistical difference (p=0.253). The number of patients who failed lumbar puncture was 11 in group A and 3 in group B, showing a statistically significant difference (p=0.015). Conclusion: Compared to the classic lumbar puncture, lumbar puncture using ultrasonography in pediatric patients did not reduce the number of proceduresand the time for the procedure, but reduced the failure rate. Therefore, we recommend the methods of lumbar puncture assisted by ultrasonography in pediatric patients as an effective method for use in the emergency department. Key Words: Ultrasonography, Spinal puncture, Pediatrics Department of Emergency, Eulji University Hospital, Daejeon, Korea, Dong-A University Medical Center, Busan, Korea 1, Chungnam national University Hospital, Daejeon, Korea 2 Article Summary What is already known in the previous study Use of ultrasonography provides useful information for identification of pertinent landmarks for lumbar puncture in pediatric patients. What is new in the current study Lumbar puncture using ultrasonography in pediatric patients, compared to the classic lumbar puncture, reduces the failure rate of the procedure. 책임저자 : 이원석대전광역시서구둔산서로 95 을지대학교병원응급의학과 Tel: 042) 611-3255, Fax: 042) 611-3889 E-mail: medulla@hanmail.net 접수일 : 2013년 9월 13일, 1차교정일 : 2013년 9월 14일게재승인일 : 2014년 1월 6일 189 서론응급의료센터에내원한소아환자에서진단적인요추천자는뇌수막염의진단과치료방침결정에큰도움을주는유용한검사이지만소아환자의특성상협조가어렵고성

190 / 대한응급의학회지 : 제 25 권제 2 호 2014 인보다구조물의크기가작아실패할확률이높다 1). 최근에는초음파를이용한요추천자방법이몇몇연구에서소개되고있는데이연구들에따르면초음파는요추천자를시행하는데있어바늘의도입지점, 지주막하공간까지도달하기위한바늘의각도및바늘이통과해야하는거리에대한유용한정보를제공한다고보고하고있다 2). 특히초음파는방사선조사의위험이없어서소아에게안전한방법이며, 1분여의짧은시간에 96.1% 이상에서요추천자부위의구조물인지주막과경막외공간, 경막, 척추판, 황색인대중 4개이상의구조물을확인할수있는것으로알려졌다 3). 이렇듯초음파를이용한요추천자에대한여러연구가이루어지고있으나, 요추천자시행부위의해부학적구조를초음파를통해알수있는가에대한연구가대부분이며실제응급의료센터에서소아를대상으로한국내연구는없었다. 이에저자들은응급의료센터에내원한소아환자들에게초음파를이용하여요추천자를시행하는방법과전통적인방법으로요추천자를시행하는방법을비교하여요추천자의성공률을포함한유용성에대한연구를기획하였다. 대상과방법 1. 조사대상및기간본연구는 2010년 5월부터 2011년 8월까지 16개월동안동아대학교병원응급의료센터에내원한 14세이하소아환자중, 뇌척수액검사를위해요추천자가필요한환자를대상으로하였다. 표본수의산정은노인을대상으로하였던본저자의논문을기초로하였다 4). 본연구는본원임상연구심의위원회를통과하였다 (IRB 번호 : 10-10- 77). 환자와보호자에게연구의내용과목적을충분히설 명하여동의를얻었으며동의하지않는환자는연구에서제외하였다. 요추천자부위에피부감염이있거나, 협조가잘되지않거나, 유두부종이있는경우및혈소판수치가 50,000/μL 이하로감소하여있는경우에는역시연구대상에서제외하였다 (Fig. 1). 2. 조사방법및내용연구에는응급실에비치된휴대용초음파기기인 SonoSite MicroMaxx (Sonosite Inc., Bothell, WA, USA) 의 2~5 MHz 곡면탐촉자를이용하였다. 검사시행자는응급의학과전공의 4명이며, 요추천자시행부위의해부학적구조물에대한초음파소견을응급의학과전문의가 30분간교육하고요추천자시행부위의해부학적구조물을 30분간 10회이상관찰하여초음파사용이숙달된후연구를시행하였다. 연구자들은환자에대해전통적인방법으로요추천자를시행하는군 (A군) 과초음파를이용하여요추천자를시행하는군 (B군) 으로무작위구분을하기위하여 A군과 B군에대한점검표를봉투에넣은후무작위뽑기를시행하였다. 전통적요추천자는초음파를사용하지않고양측장골능의가장높은부분을연결한선상에있는척추사이, 또는하나아래의척추사이에서가시돌기를촉지하여시행한경우로정의하였고, 초음파를이용한요추천자는양측장골능의가장높은부분을연결한선상에척추와수직인방향으로초음파를보고구조물을확인한후, 그위치나하나아래의척추사이에서초음파방향을수직으로돌려요추천자를시행할위치와수평각도를결정하여표시한후초음파없이요추천자를시행하는것으로정의하였다 (Fig. 2, 3). 요추천자시술시간은바늘이피부를뚫는순간부터뇌척수액을얻거나요추천자에실패할때까지걸린시간으로 Fig. 1. Study flow diagram.

김창엽외 : 응급의료센터를내원한소아환자에서전통적요추천자와초음파를이용한요추천자의유용성비교 / 191 정의하였고, 초음파검사시간은구조물파악을위해초음파를피부에접촉한순간부터구조물파악이종료되어초음파를피부에서떼어내는순간까지로정의하였다. 요추천자시술횟수는바늘이피부를뚫고들어간후다시피부밖으로바늘을뺀것을 1회로정의하였다. 요추천자실패는요추천자를통해뇌척수액을얻지못하는경우로정의하였다. 또한, 환자에대한변수로나이, 성별, 키, 체중, 기저질환여부를파악하였고, 검사시행자의근무연수, 초음파시간, 시술시간, 시술횟수, 천자실패여부를기록하였고, 시간측정은연구의목적을알지못하며, 저자로참여하지않은응급구조사가초시계로측정하였다. 3. 분석방법연속변수는정규성을만족하는경우평균과표준편차, 정규성을만족하지않는경우에는중앙값과사분위수로나타내었고명목변수나구간변수의경우숫자와빈도수로 나타내었다. 전통적방법으로시행한요추천자그룹 (A군) 과초음파를이용한요추천자그룹 (B군) 의비교에서명목변수는카이제곱검정, 혹은 Fisher s exact test를시행하였고연속변수는 independent t test를시행하였으며정규성을만족하지않는경우에는 Mann Whitney U test 를시행하였다. p<0.05인경우통계학적으로유의한것으로판단하였다. 통계분석에는 SPSS 15.0 for Win (SPSS Inc, Chicago, USA) 를사용하였다. 결과 1. 대상소아환자의일반적인특징 2010년 5월부터 2011년 8월까지 16개월동안본원응급의료센터에내원한만 14세이하소아환자중뇌수막염의진단을위해요추천자에동의한 64명의환자가연구의대상이되었다. 전통적인방법으로요추천자를시행하는 Fig. 2. Ultrasonographic landmarks during lumbar puncture. Fig. 3. Ultrasonography-assisted lumbar puncture. Table 1. Overall characteristics of patients with lumbar puncture. Group A* Group B p value Numbers 31 33 Sex Male 20 23 Female 11 10 Age (years) 9.65±8.53 7.38±4.45 0.19 Height (cm) 126.65±29.81 0 122.39±30.01 0 0.57 Body weight (kg) 32.84±20.68 29.17±16.96 0.44 BMI 18.30±5.24 0 17.77±3.23 0 0.49 Use of Sedatives 14 13 0.80 * Classical lumbar puncture group Ultrasonography-assisted lumbar puncture group Mean±Standard deviation BMI: body mass index

192 / 대한응급의학회지 : 제 25 권제 2 호 2014 군과초음파를이용하여요추천자를시행하는군에포함된환자는각각 31명과 33명이었다. 두군의성별, 진정제사용여부, 평균나이, 평균키, 평균체중, 체질량지수모두통계학적으로유의한차이는없었다 (Table 1). 64명의소아환자중이전에척추수술을시행받은환자나기저질환으로척추질환을가진환자는없었다. 2. 검사시행자의일반적특징요추천자를시행한전공의는각년차별로 1명씩총 4명이며, 전통적인방법으로요추천자를시행한대상수는 1 년차 10명, 2년차 12명, 3년차 7명, 4년차 2명으로분포하였으며, 초음파를이용하여요추천자를시행한대상수는1년차7명, 2년차14명, 3년차8명, 4년차4명으로분포하여두군간에통계학적으로유의한차이가없었다 (p=0.72)(table 2). 3. 소아환자에서전통적요추천자법에대한초음파를이용한요추천자법의유용성비교 요추천자시술시간은전통적인방법으로요추천자를시행한군 (A군) 에서 6.73±9.16분, 초음파를이용하여요추천자를시행한군 (B군) 에서는 3.88±1.51분으로나타났으며둘사이에통계적으로유의한차이는없었다 (p=0.098). 요추천자시행횟수는전통적인방법으로요추천자를시행한군에서 1.68±0.95회, 초음파를이용하여요추천자를시행한군에서는 1.45±0.56회로나타나통계적으로유의한차이가보이지않았다 (p=0.25). 요추천자를실패한환자수는전통적인방법으로요추천자를시행한군에서 11 명, 초음파를이용하여요추천자를시행한군에서 3명으로 Table 2. Classification of performed doctors by grade. Group A* Group B p value Grade of residency First year 10 07 Second year 12 14 Third year 07 08 Forth year 02 04 * Classical lumbar puncture group Ultrasonography-assisted lumbar puncture group 0.30 Table 3. Comparison of puncture time, numbers of attempt and failure in lumbar puncture. Group A* Group B p value Procedure time (min) 6.73±9.16** 3.88±1.52** 0.10 Ultrasonography time (min) 2.62±1.50** Numbers of attempt 1.68±0.95** 1.45±0.56** 0.25 Numbers of failure Yes 11 (35.5%) 03 (09.1%) 0.02 No 20 (74.5%) 30 (90.9%) * Classical lumbar puncture group Ultrasonography-assisted lumbar puncture group Median (25th to 75th percentile) ** Mean±Standard deviation Number (percentage) Table 4. Comparison of lumbar puncture failure according to the residents grade. Success Failure p value Grade of residency BMI First year 12 05 Second year 20 06 Third year 12 03 Forth year 06 00 <25 50 12 25 00 02 0.170 0.045

김창엽외 : 응급의료센터를내원한소아환자에서전통적요추천자와초음파를이용한요추천자의유용성비교 / 193 관찰되어통계적으로유의한차이를보였다 (p=0.02) (Table 3). 천자실패와전공의연차와의통계적연관성은보이지않았으며 (p=0.17), BMI 25를기준으로비만과정상으로구분하여양군을비교하였을때비만한그룹에서천자실패가통계적으로유의하게증가하였다 (p=0.045)(table 4). 고찰 1891년 Quinke에의해처음시행된요추천자는응급의료센터에서중추신경계감염과지주막하출혈을진단하는데필수적인검사방법이며응급의학과의사에게중요하고흔하게시행되는시술이다 5). 하지만환자의해부학적구조물의특징과자세유지의어려움, 시술자의미숙등으로인해실패할가능성이적지않다 6,7). 또한표면구조물을이용한천자방법은검사자의숙련도나환자의자세, 척추사이공간, 환자의나이및척추질환에따라실패하는경우가있으며, 구조확인의정확도가 30% 정도밖에되지않아서, 정확한구조물이확인되지않을경우의사들은시술을꺼리게되고, 뇌척수액을얻기힘들어지며, 합병증의빈도를높이게한다는보고도있다 8). 최근들어구조물촉지를통한요추천자방법외에도형광투시유도에의한요추천자방법이소개되었지만, 이는응급실내부에서시행할수없고척수관을볼수없으며방사선조사의위험성을안고있다는단점이있다 9). 그래서 1971년 Bogin과 Stulin 10) 에의해처음으로표면구조물확인에초음파를이용하는방법이소개되었고, Ferre와 Sweeney 11,12) 의연구에서는초음파를이용하는경우요추천자를시행할때바늘의도입지점, 지주막하까지도달하는바늘의각도및바늘이통과해야하는거리에대한정보를제공한다고보고하였고, 초음파를이용하면비만환자에서시술을쉽게할수있다고보고한 Nomura 등 13) 은18 세이상을대상으로전통적인요추천자방법을사용한환자와초음파를이용한요추천자방법을사용한환자사이에요추천자시술시간과요추천자시술횟수및요추천자실패빈도를비교하였는데, 전통적인요추천자방법을사용한환자와초음파를이용한요추천자방법을사용한환자사이에요추천자시술횟수와시술시간은차이가없었으나요추천자실패는초음파를이용한요추천자방법을사용한환자에서전통적인요추천자방법을사용한환자보다드물게발생하였다고보고하고있다. 본연구는 14세이하소아를대상으로하였지만, 똑같이초음파를이용한요추천자방법이요추천자실패를줄이는것으로나타났다. 또한, BMI가 25 이상인환자에서요추천자의실패가유의하게증가하는것으로나타난것으로보아소아비만환아에서초음파를사용한요추천자가유용할것으로사료 된다. 또한, 응급의학과의사들이진단방법으로초음파를이용하는경향이많아지고있고, 요추천자에서도빠른시간내에고화질의영상을얻을수있다는연구결과가발표되고있으며, 본연구에서도실제요추천자를시행하기위하여시행한초음파검사가요추천자시간을지연시키지는않는것으로나타났다 14). 이번연구의제한점으로는첫째, 16개월동안일개대학병원응급실에내원한소아환자를대상으로연구를진행하였기때문에대상자의수가적었다는것인데이는향후다기관연구와장기간연구를통해보완할수있을것이다. 둘째, 검사시행자의분포는차이가없었으나, 개개인의술기능력을표준화하지못했다는점이다. 이또한다기관연구를통해보완할수있을것으로사료된다. 셋째, 소아환자의요추천자실시여부를응급의학과의사가결정하였고, 연구자체의특성상이중맹검이이루어질수없었으며, 또한소아환자의특성및응급실이라는제한적상황으로인해시술후부작용, 합병증, 외상에대한평가및추적관찰이되지않았으며, 소아환자의경우시술을위해진정작용이필요한경우가많았으나진정과시술결과와의상관관계에대해서분석하지못한점등이제한점으로남는다. 결 14세이하소아환자에서초음파를이용한요추천자방법이전통적인요추천자방법과비교하면전체시술시간과시술횟수는줄이지못했지만, 시술실패율을줄일수있는것으로나타났다. 따라서소아환자에게초음파를이용하여요추천자를시행하게되면요추천자의성공률을높일수있어, 소아뇌수막염환자의진단과치료방침결정에도움을주는유용한검사로이용될것으로기대한다. 론 참고문헌 01. Öncel S, Günlemez A, Anik Y, Alvur M. Positioning of infants in the neonatal intensive care unit for lumbar puncture as determined by bedside ultrasonography. Arch Dis Child Fetal Neonatal Ed. 2013;98:F133-5. 02. Stiffler KA, Jwayyed S, Wilber ST, Robinson A. The use of ultrasound to identify pertinent landmarks for lumbar puncture. Am J Emerg Med. 2007;25:331-4. 03. Ferre RM, Sweeney TW. Emergency physicians can easily obtain ultrasound images of anatomical landmarks relevant to lumbar puncture. Am J Emerg Med. 2007;25:291-6. 04. Cho YC, Koo DH, Oh SK, Jeong WJ, Lee WS, Ryu S, et al. Comparison of Ultrasound-assisted Lumbar Puncture with Lumbar Puncture using Palpation of Landmarks in

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