<C4A1B0FAB8B6C3EB2D3131B1C732C8A32E687770>

대한치과마취과학회지 :2011; 11: 177~182 증례 항응고제투여중인다발성전신질환자에서과도한발치창출혈부의진정요법과국소마취시행하에창상주위봉합과배농술통한출혈과감염조절 연세대학교치과대학구강악안면외과학교실 ( 원주기독병원 ), * 계명대학교의과대학동산의료원치과학교실 ( 구강악안면외과 ) 유재하 김종배 * Abstract Bleeding & Infection Control by the Circumferential Suture & Drainage on Active Bleeding Extraction Socket under Sedation And Local Anesthesia in a Multiple Medically Compromised Patient with Anticoagulation Drug Jae-Ha Yoo and Jong-Bae Kim* Department of Oral and Maxillofacial Surgery, College of Dentistry, Yonsei University (Wonju Christian Hospital), Wonju, *Department of Dentistry (Oral and Maxillofacial Surgery), Dong San Medical Center, College of Medicine, Keimyung University, Daegu, Korea There are five principal causes for excessive bleeding in the immediate postextraction phase ; (1) Vascular wall alteration (wound infection, scurvy, chemicals, allergy) (2) Disorders of platelet function (genetic defect, drug-aspirin, autoimmune disease) (3) Thrombocytopenic purpuras (radiation, leukemia), (4) Inherited disorders of coagulation (hemophilia, Christmas disease, vitamin deficiency, anticoagulation drug-heparin, coumarin, aspirin, plavix). If the hemorrhage from postextraction wound is unusually aggressive, and then dehydration and airway problem are occurred, the socket must be packed with gelatine sponge(gelfoam) that was moistened with thrombin and wound closure & pressure dressing are applied. The thrombin clots fibrinogen to produce rapid hemostasis. Gelatine sponges moistened with thrombin provide effective coagulation of hemorrhage from small veins and capillaries. But, in dental alveoli, gelatine sponges may absorb oral microorganisms and cause alveolar osteitis (infection). This is a case report of bleeding and infection control by the circumferential suture and iodoform gauze drainage on infected active bleeding extraction socket under sedation and local anesthesia in a 71-years-old male patient with anticoagulation drug. (JKDSA 2011; 11: 177~182) Key Words: Bleeding extraction socket; Circumferential suture; Iodoform gauze drainage; Anticoagulation drug; Multiple medically compromised patient 원고접수일 : 2011 년 12 월 23 일, 최종심사일 : 2011 년 12 월 24 일게재확정일 : 2011 년 12 월 26 일책임저자 : 유재하, 강원도원주시일산동 162 연세대학교원주의과대학치과학교실우편번호 : 220-701 Tel: +82-33-741-1434, Fax: +85-33-742-3245 E-mail: yun8288@hanmail. net 발치나구강내수술시행후발생된출혈이빠르게계속되면우선혈액이입안과인두부위에고이게되어상기도폐쇄의위험이있고, 고인피를뱉어내면주위환경을오염시킴은물론피를본다는것 (sight of blood) 자체로불안과공포가가중되어실신가능성도있으며, 피를삼키는경우위장관 177

178 대한치과마취과학회지 : 제 11 권제 2 호 2011 자극이과도해오심과구토의가능성이높아지는등심각한응급상황에직면할수있다 (Conley, 1979; Laskin, 1985; Falace, 1995). 또한계속되는출혈로인한순환혈류량의감소는완서관류조직 ( 내장, 근육, 피부 ) 의혈액이급서관류조직 ( 심장, 폐, 뇌, 신장 ) 으로이동되는혈역학의변화로심신의약화가초래되며, 과도한출혈은저혈량성쇼크의발생으로생명의위협을가져올수있다 ( 김진복등, 1987). 따라서구강내과다출혈을신속정확하게지혈시키고후처치를제대로시행함은환자의전신건강관리에매우중요하며, 이런점에서치과임상에서발치를시행할때는사전에환자의병력과신체검진을철저히시행해서발치후출혈의원인들에대한파악을하고그에따른적절한관리를신속정확히시행함이매우중요하다. 발치후초기단계에서과도한출혈의주요원인들에는 (1) 창상감염, 괴혈병, 화학물질에의한혈관벽취약 (2) 유전, 아스피린같은약물, 자가면역질환에의한혈소판기능장애, (3) 방사선, 백혈병같은혈소판감소성자반증, (4) 혈우병, 크리스마스질환같은선천성응고장애, (5) 간장질환, 비타민결핍, 쿠마린, 헤파린, 아스피린, 플라빅스 (plavix) 같은항응고약제등에의한후천성응고장애들이있다 (Patton & Ship, 1994; Rodgers, 1999; Little et al, 2002). 만약발치창출혈이매우과도해서전신탈수와기도문제가위협된다면발치창상은통상적으로봉합술을시행하거나트롬빈 (thrombin) 을적신젤라틴스폰지 (gelfoam) 등으로채워서창상봉합과압박지혈을시도하게된다. 트롬빈은신속한지혈을형성하려고피브리노겐을직접응고시킨다. 그러나발치된치조와내부에서젤폼은구강내미생물을흡수해서발치와골염 ( 감염 ) 을야기해창상치유를지연시키는동통과 2차적출혈을더야기할수도있어사용에신중을기해야하며, 2차적후출혈발생시대책도마련되어있어야한다 (Kruger, 1984; Bonoliel et al, 1986; Falace, 1995). 이런면들을종합적으로고려할때치과임상에서는충치나치주염증이과도한경우에발치의적응증이될정도의치성감염치아들도가능한한발치보다는약물요법, 근관치료, 절개배농술같은출혈이적은술식을구사해서치성감염을감소시키고, Fig. 1. Initial panoramic view. 관련의학과의협진과임상병리검사 ( 흔히 CBC, P.T., P.T.T. 등 ) 를통해발치후출혈문제를확인한후에발치를시행하게된다 (Kelly, 1990; Steinberg & Moores, 1995; Sonis et al, 1995). 이원칙에따라서본과에서는고혈압, 협심증, 뇌졸중, 위장관질환등으로항응고제를투여하던환자에서, 관련의학과 ( 심장내과등 ) 의협진으로국소마취하에충치와치주염이과도한상악대구치에서 1차근관치료를계획했다. 그러나근관치료도중치아가발치되면서과도한출혈이계속되어, 응급으로습윤거즈압박지혈하에진정요법과에피네프린함유국소마취보강후에, 발치창상테두리봉합과요오드포름거즈배농술및수액약물 ( 항생제등 ) 요법으로, 창상출혈과감염을힘들게조절한증례를체험해이를보고한다. 증례보고 70세남환이상악좌측제2대구치 ( 치식 : #27) 의심한충치와치주염으로과도한동요도를가진잔존치근의통증해소를위해발치를해달라고본과에내원했다. 구강검사와방사선사진검사결과과도한치성감염상태여서발치의적응증은되었으나 (Fig. 1), 전신병력상다발성내과질환으로발치시출혈위험이크고 2차적감염에따른창상치유도불량할것같아, 관련의학과자문을구한후에발치보다는 1차치근관신경치료 ( 치관제거, 발수및치근관개방통한배농술등 ) 가적절하다고판단되었다. 왜냐하면이환자는약 20년간고혈압관리를받았고, 약 3년전부터협심증과심근경색증, 약 2년전교통사고로지주막하출혈이있어뇌수술을받았으며,

유재하 김종배 : 항응고제투여환자의출혈과감염조절 179 Table 1. Prescribed Drugs 1. Plavix tab [75 mg] 75 mg 2. Acertil 4 mg tab [4 mg] 4 mg 3. Vytorin tab 10/20 1 tab 4. Pletaal 50 mg tab [50 mg] 100 mg 5. Isotril ER tab [60 mg] 120 mg 6. Sigmart tab [5 mg] 10 mg 7. Molsiton tab [4 mg] 8 mg 8. Dilatrend 12.5 mg tab [12.5 mg] 9. Nifedipine tab [10 mg] 30 mg 10. Stilnox 12.5 mg CR tab [12.5 mg] 11. Stilnox 12.5 mg CR tab [12.5 mg] 12. Nitroglycerin tab [0.6 mg] 1 tab Fig. 2. Bleeding control view of extraction socket with circumferential suture and iodoform gauze drainage. 뇌졸중증세도있어아스피린을장기간복용했고, 그로인해위궤양과십이지장궤양이연합되어현재는아스피린대신플라빅스 (Plavix) 복용중이어서발치시출혈가능성이높았기때문이다. 우선출혈과관련된핼액검사 (Complete blood count 에서 Platelet count, Prothrombin time, Partial thromboplastin time) 시행후에심장내과에자문을구한결과 Plavix를 5일간중단하고발치를조심스럽게시행하면괜찮을것같다는자문을받았고, 먼저항생제 (Cephalexin) 와소염진통제 (Tyrenol, Varidase) 및소화제 (Phazyme) 경구투약을했는데, 다음날환자는본인이복용하는약이너무많아 (Table 1) 치과약까지복용하니위장관의불편감이커서주사를맞고치과진료를받기를강렬히원했다. 따라서정맥주사와근육주사를이용한수액약물요법을시행키로하고, 5% D/S 1,000cc IV, Cefazoline 1.0 g IV, Tarasyn 1 ampule IM을투여한다음에발치에앞서서 1차치근관신경치료를시행키로했고, 그후 5 일간 Plavix 중단후발치를계획했다. 통상적인치과용국소마취시행하에 1차근관치료를시행하려고고속드릴 (bur) 로치관삭제를시도하는도중에동요도가과도했던잔존치근이발치가되면서발치창상에서과도한출혈이발생되어부득이습윤거즈 (wet gauze) 압박술을시행했고 30 분후지혈을확인했으나계속출혈이과도했으며혈압도 150/100으로상승되었다. 황급히심장내과주치의에게전화로자문을받은결과, Aspirin이나 Plavix 투여환자는혈액검사상정상이라도과도한출혈이지속될수있으니우선치과적인국소지혈 처치를철저히시행하고서응급실로환자를이송시켜심장내과로입원시킴이적절하다고했다. 그리하여고혈압조절과환자의정서안정을위해서진정요법 (Valium 1 ampule에다가증류수 20cc를혼합한약제를서서히정맥주입함 ) 시행하에추가적인 1: 50,000 epinephrine 함유치과용국소마취제 (2% lidocaine HCL) 로국소마취를다시충분히진행한다음에최대한출혈을감소시키려는의도로발치된창상테두리를철저히봉합했고, 발치창상내부에도출혈방지와 2차적인감염방지를위해서드레인 (iodoform gauze) 삽입술을시행한다음에습윤거즈압박 (gauze biting) 술을시행했다 (Fig. 2). 그런다음 1 시간후에다소지혈이됨을확인했으나, 국소마취효과가사라진다음에후출혈과 2차적인감염예방을위해응급실로환자를이송했고, 계속적인수액약물요법을진행하면서심장내과로입원시켜 3일간가료한결과정상적인발치창상치유경과를보였고, 내과문제 ( 협심증, 뇌졸중, 위십이지장궤양 ) 도개선되어퇴원후치과외래진료 ( 배농재교환창상드렛싱등 ) 도시행받아발치창상이완치되었다. 고찰구강악안면부위는혈행이풍부하며주요혈관분지들이중첩되어측부혈행 (collateral circulation) 도발달되어있다. 이러한풍부한혈행은조직손상시재생력이양호하고감염에대한저항성이큰장점이있는반면, 손상이나출혈성장애를가진내과적질환의병발시과도한출혈에따른위험성이크

180 대한치과마취과학회지 : 제 11 권제 2 호 2011 Table 2. Classification of Bleeding Disorders 1. Nonthrombocytopenic purpuras a. Vascular wall alteration (1) Scurvy (2) infections (3) Chemicals (4) Allergy b. Disorders of platelet function (1) Genetic defects (Bernard-Soulier disease) (2) Drugs (a) Aspirin (b) NSAIDs (c) Alcohol (d) Beta-lactam antibiotics (e) Penicillin (f) Cephalothins (3) Allergy (4) Autoimmune disease (5) von Willebrand's disease (secondary factor VII deficiency) (6) Uremia 2. Thrombocytopenic purpuras a. Primary-idiopathic b. Secondary (1) Chemicals (2) Physical agents(radiation) (3) Systemic disease(leukemia) (4) Metastatic cancer to bone (5) Splenomegaly (6) Drugs (a) Alcohol (b) Thiazide diuretics (c) Estrogens (d) Gold salts (7) Vasculitis (8) Mechanical prosthetic heart valves (9) Viral or bacterial infections 3. Disorders of coagulation a. Inherited (1) Hemophilia A(deficiency of factor VIII (2) Hemophilia B(deficiency of factor IX (3) Others b. Acquired (1) Liver disease (2) Vitamin deficiency (a) Biliary tract obstruction (b) Malabsorption (c) Excessive use of broad - spectrum antibiotics (3) Anticoagulation drugs (a) Heparin and Coumarin (b) Plavix (c) Aspirin and NSAIDs (4) DIC (5) Primary fibrinogenolysis 고동정맥기형발생의우려도있다. 두경부에서대량출혈을야기할수있는혈행부위는익돌부, 이하선부, 인두혈관총, 갑상선부, 후경부의다섯부위가지목되지만, 구강내과다출혈을야기하는부위는상악및하악골특히치조골부, 설하부와구강저부, 구개부, 순협점막하부등의혈관들로알려져있다 (Conley, 1979; Kruger, 1984; Peterson et al, 1988). 구강내과량의출혈은기도폐쇄나삼켜진혈액의구토에의한흡인성폐렴형성의우려이외에도상당한심신의스트레스를야기하며인체는여기에적응을하고자격렬한신경내분비반응을초래하게된다. 그리하여출혈의양이증가되고이로인한면역력의저하로주위조직에염증반응 ( 동통, 종창, 발적, 고열, 기능이상 ) 이형성됨에따라고혈압, 빈맥, 과환기, 과혈당증, 의식장애등이발생된다 (Fonseca & Walker, 1991). 구강내출혈은그자체로도위험하지만치과진료시흔히문제가되는것은치성감염으로구강에는수많은세균들의작용으로충치나치주질환의빈도가높고, 더욱이항응고제를투여받는심장질환 ( 넓 은의미에서는심혈관질환 ), 뇌혈관질환, 간질환, 신장투석환자들은전신의면역성이저하된상태이므로치성감염의관리에어려움이따르게된다 (Topazian & Goldburg, 1981). 즉출혈성장애를가진전신질환자에서는충치나치주염이과도한경우도발치같은출혈을조장하는치료술식을안심하고적용할수없을뿐만아니라치성감염과출혈성질환이연합되어치은이나점막출혈을야기하는경우치과와의과의긴밀한협의진료가이루어져야지혈처치와치성감염의조절이달성되는것이다. 이런관점에서치과의사는출혈성장애와면역성이저하된환자를체계적으로파악해대처함은중요한과제이다. 출혈성질환자는 Table 2와같이혈소판의정상숫자를가진환자 (nonthrombocytopenic purpuras: 비혈소판감소성자반증 ) 와혈소판수의감소에의한환자 (thrombocytopenic purpuras: 혈소판감소성자반증 ), 응고의장애를가진환자로분류할수있다 (Schardt, 2000; Little et al, 2002). 괴혈병이나감염, 화학약품혹은알레르기의일종은출혈문제를초래할정도로혈관벽의구조와

유재하 김종배 : 항응고제투여환자의출혈과감염조절 181 Table 3. Normal control of bleeding 1. Vascular phase a. Vasoconstriction in area of injury b. Begins immediately after injury 2. Platelet phase a. Platelet and vessel wall will become sticky b. Mechanical plug of platelets seals off openings cut vessels c. Begins seconds after injury 3. Coagulation phase a. Blood lost into surrounding area coagulates through extrinsic and common pathways b. Blood in vessel in area of injury coagulates through intrinsic and common pathways c. Takes place more slowly than other phases 4. Metabolic(fibrinolytic) phase a. Release of antithrombotic agents b. Spleen and liver destroy the antithrombotic agents 기능을변화시키며, 혈소판의숫자뿐만아니라기능이상 (disorders) 에서도출혈이일어날수있다. 본증례와연관된항응고약제등에의한후천성응고질환은가장흔하게장시간의출혈을일으키며, 외상이나외과수술후에확실히알수있다. 통상적으로치과임상에서발치와관련된출혈에는 (1) 발치시행중의과도한출혈, (2) 발치시행당일의출혈, (3) 발치시행후 3-5일경과후출혈로구분된다. 우선발치시행도중의과도한출혈의원인에는시술범위내혈관의절단손상, 염증이과도한충혈조직 (hyperemia tissue) 에서발치시행, 발치창상에과도한손상을가함등이있고, 발치시행후당일의출혈원인도유사한데특히전신상태가약화되어출혈의정상조절기전 (Table 3) 에문제가있는환자들에서빈도가높다 (Conley, 1979; Laskin, 1985: Bonoliel et al, 1986). 한편발치등의수술시행후출혈을조절하기위한지혈방법에는습윤거즈를이용한압박지혈, gelfoam 등을이용한전색 (packing), 손상혈관의결찰, 전기응고법, 국소지혈제 (Surgicel, Bone wax, Topical bovine thrombin, Fibrin sealant 등 ) 적용, 전신적약제 (Thrombokinase, Vitamin K 등 ) 투여, 유출재 (rubber strip, iodoform gauze 등 ) 에의한지혈법등이있어각증례에맞는선택을필요로한다 Table 4. Factors in Wound Infection 1. Local factors Number of bacteria Virulence of bacteria Devitalized tissue Decreased blood supply Foreign bodies (traumatic or implants) 2. Systemic factors Generalized sepsis Decreased host defenses diabetes malnutrition cytotoxic-immunosuppressive drugs malignancies Extremes of age 3. Environmental factors Operating room traffic Defective air system Inadequate sterilization techniques The surgeon as source of infection 4. Endogenous factors Patient's skin and hair Presence of infected tissue at time of surgery (cellulitis, abscess, fistula) Presence of resistant or opportunistic organism in the patient's oral cavity or nasopharynx 5. Surgical factors Insufficient hemostasis Presence of dead space Insufficient debridement Tissue necrosis from suture, retractors, or dressings Inappropriate or long-term use of drains Excessive operating time Primary closure of infected wounds (Kruger, 1984; 민병일, 1990; Falace, 1995). 본증례의경우도관련의학과 ( 주로심장내과 ) 에자문을구해 Plavix 투여중단등내과치료를시행했고, 전신상태가협심증, 고혈압, 뇌졸중, 위십이지장궤양등여러질환이연합되어내과관리도시행받으면서치과적으로는창상감염소견이확실하기에 gelfoam이나국소지혈제등을이용한압박지혈대신에창상내혈종이나장액종의제거를통한지혈, 즉유출재 (Nu-gauze 이용 ) 에의한지혈법을시도한셈이다.

182 대한치과마취과학회지 : 제 11 권제 2 호 2011 즉출혈되는발치창주위의염증조직 (granulation tissue) 들을제거해창상내부를확인하고발치창테두리봉합술을시행한다음에발치창내부의비어있는공간 ( 사강 : dead space 역할 ) 에는압박지혈에도움을얻고새로형성되는혈종 (hematoma) 과장액종 (seroma) 의배액로 (drainage route) 로도도움을얻기위해요오드포름거즈 (iodoform gauze: 상품명 Nugauze) 를채워넣는유출재방법을적용한다음습윤압박거즈를다물고있게함 (biting) 으로써확실한지혈을이루게했다. 하지만발치창상치유기전상창상감염에관련된요소들이 Table 4처럼많이있고 (Topazian & Goldburg, 1981), 기존의혈액응고기전에장애가상당했기에통상적으로이용되는국소지혈제 (gelfoam, Surgicel, Fibrin sealant 등 ) 사용은오히려발치창상내부감염만조장할뿐응급지혈에는도움이되지않기에사용치않았다. 또한보트로파제등전신적지혈약제들은약물부작용으로혈전형성의우려가있어 ( 최현림등, 2003) 심장질환이있는환자에서는사용상큰주의가요망되기에, 본환자의경우는사용치않았다. 결론적으로저자등은본증례의치험을통해치과임상에서 Plavix같은항응고제를투여하는환자의진행성치성감염조절에있어서는가능한한출혈이거의없는치근관신경치료가우선적으로고려되어야하지만, 부득이발치가시행되는경우에는관련의학과협진하에진정요법과국소마취로발치창상부테두리봉합술과유출재 (iodoform gauze) 삽입으로압박지혈과감염조절을달성함이바람직하리라사료된다. 참고문헌 김진복, 김춘규, 이용각, 장선택 : 최신외과학, 제 1 판. 서울, 일조각. 1987, pp 21-51. 민병일 : 악안면성형외과학. 서울, 군자출판사. 1990, pp 45-61. 최현림, 김수영, 김철환, 신호철, 이혜리, 조경환등 : 가정의학, 임상편. 서울, 계축문화사. 2003, pp 597-714. Bonoliel R, Leviner E, Katz J: Dental treatment for the patient on anticoagulant therapy. Oral Surg Oral Med Oral Pathol 1986; 62: 149-55. Conley JJ: Complications of head and neck surgery. Philadelphia, WB Saunders. 1979, pp 66-80. Falace DA: Emergency dental care. Baltimore, Williams and Wilkins. 1995, pp 227-53. Fonseca RJ, Walker RV: Oral and Maxillofacial trauma, Vol I. Philadelpha, WB Saunders. 1991, pp 58-73. Kelly MA: Common laboratory tests. their use in the detection and management of patients with bleeding disorders. Gen Dent 1990; 38: 282-5. Kruger GO: Textbook of oral and maxillofacial surgery. Sixth edition. Saint Louis, CV Mosby. 1984, pp 229-54. Laskin DM: Oral and maxillofacial surgery, Vol II. Saint Louis, CV Mosby. 1985, pp 362-98. Little JW, Falace DA: Dental management of the medically compromised patient, Sixth edition. Saint Louis, CV Mosby. 2002, pp 332-64. Patton LL, Ship JA: Treatment of patients with bleeding disorders. Dent Clin Nor Am 1994; 38: 465-82. Peterson LJ, Ellis III E, Hupp JR, Tucker MR: Contemporary oral and maxillofacial surgery. Saint Louis, CV Mosby. 1988, pp 525-76. Rodgers GM: Overview of platelet function. Clin Obstet Gynecol 1999; 42: 349-59. Schardt SD: Update on coagulopathies. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000; 90: 559-63. Sonis ST, Fazio RC, Fang L: Principles and practice of oral medicine. Second edition. Philadelphia, WB Saunders. 1995, pp 242-61. Steinberg MJ, Moores JF: Use of INR to assess degree of anticoagulation in patients who have dental procedures. J Oral Surg Oral Med Oral Path 1995; 80: 175-7. Topazian RG, Goldburg MH: Management of infections of the oral and maxillofacial regions. Philadelphia, WB Saunders. 1981, pp 329-50.