영남의대학술지제25권제2호 Yeungnam Univ. J. of Med. Vol.25 No.2 p175-181, Dec. 2008 증례 쇄골하정맥을통하여중심정맥도관삽입실패후나타난혈흉 1 예 김대영 김대우 손희원 박상진 * 이덕희 * 울산대학교의과대학울산대학교병원마취통증의학과, 영남대학교의과대학마취통증의학과교실 * 1) Hemothorax after Central Venous Catherization Failure through the Subclavian Vein Dae-Young Kim, Dae-Woo Kim, Hee-Won Son, Sang-Jin Park*, Deok-Hee Lee* Departments of Anesthesiology and Pain Medicine, Ulsan University Hospital, Ulsan University College of Medicine, Ulsan, Korea *Departments of Anesthesiology and Pain Medicine, College of Medicine, Daegu, Korea -Abstract- Central venous catheterization via an internal jugular vein or subclavian vein has become a common procedure in monitoring CVP and managing severely ill patients. However, there have beennumerous reports of complications associated with central venous catheterization. These include vessel injury, pneumothorax, hemothorax, nerve injury, arrhythmias, arteriovenous thrombosis, pulmonary embolism, and infection at the insertion site. We report a case of hemothorax after subclavian vein catheterization failure, along with successful treatment. Key Words: Central venous catheterization, Complications, Hemothorax, Subclavian vein. 서론중심정맥도관삽입은마취중이나중환자관리시중심정맥압측정, 혈관작용약제및수액, 혈액등의빠른투여, 말초정맥로확보가어려운경우정맥로의제공, 폐동맥카테터의삽입과폐동맥압의측정, 임시심박조율기설치, 일시적인혈액투석로, 고단위영양공급경로등으 책임저자 : 이덕희, 대구광역시남구대명5동 317-1, 영남대학교의과대학마취통증의학과교실 Tel: (053) 620-3368, Fax: (053) 626-5275, E-mail: dhlee415@med.yu.ac.kr 175
- 김대영 김대우 손희원 박상진 이덕희 - 1, 2) 로이용도가점차증가하고있다. 사용되는주요혈관은내경정맥, 쇄골하정맥, 외경정맥, 대퇴정맥, 액와정맥등이있다. 중심정맥도관삽입이많아질수록그에따른합병증도증가하고있고, 그중혈흉, 기흉, 동맥천자등이가장흔하게생기는합병증이다. 가장흔히쓰이는중심정맥도관삽입방법은내경정맥천자와쇄골하정맥천자이며, 두가지방법을비교했을경우쇄골하정맥천자에서기흉과혈흉이더잘생기고, 내경정맥천자에서동맥천자의빈도가더높다고한다. 3) 본증례에서는우측쇄골하정맥도관삽입실패후발생한혈흉의성공적인처치를경험하였기에문헌고찰과함께보고하는바이다. 증 례 26세여자환자는 2006년 7월에 3개월전에전신무력감, 피로, 근육통을주소로본원에내원하였다. 피검사에서 BUN/Cr: 75/8.78 mg/dl, K: 5.5 mm/l, Hb: 6.1 g/dl, Hct: 18.5% 로나와만성신부전진단을받았다. 혈액투석을하면서외래에추적관찰하다가좌측신장이식수술을받기위해본원에다시입원하였다. 과거력상고혈압이있었고, 활력징후는혈압이 150/100 mmhg, 맥박이 82 회 / 분, 호흡수 20 회 / 분이었고, 이학적검사상조금창백한결막외엔특이소견은없었다. 수술전검사에서는 Hb: 12.6 g/dl, Hct: 35.9%, Plt: 161 K/ul, BUN/Cr: 44.1/5.04 mg/dl, glucose: 315 mg/dl, total protein/albumin: 7.6/4.6 g/dl, Na/K: 136/4.4 mm/l, Ca: 9.7 mg/dl에서 glucose 170 mg/dl로조절후수술전처치는하지않고수술장에들어왔다. 수술실도착당시혈압 : Fig. 1. Perm-cath insertion. Chest radiograph shows that 12.5 Fr double lumen perm-catheter insert(arrow) through right jugular vein. 160/100 mmhg, 맥박 : 90회 / 분, 호흡수 20회 / 분이었다. 환자는 153 cm, 43 kg의체격이었고, penthotal sodium 5 mg/kg, atracurium 0.75 mg/kg, Fig. 2. Preoperative chest X-ray. Normal finding in preoperative chest X-ray. 176
- 쇄골하정맥을통하여중심정맥도관삽입실패후나타난혈흉 1 예 - remifentanil 0.05 meq/kg/min 으로마취유도후기관삽관하였다. 환자는 1 년전혈액투석을위해우측내경정맥에초음파를이용하여 12.5 Fr 혈액투석용카테터를삽입하였다가 (Fig. 1) 4일후우측에동정맥루시술후제거한병력이있다. 수술전단순흉부방사선사진은정상이었다 (Fig. 2). 지속적인혈압측정과혈액검사를위해서변형 allen검사후동정맥루가있는우측을피하고좌측요골동맥에 22 gauge 도관을삽입하고, 원활한약제투여와지속적인중심정맥압을측정하기위하여경부신전후두부저하자세에서우측내경정맥천자를시도하였으나, 동맥천자가되어충분히압박하고, 다시오른쪽팔을신전, 내전하여우측쇄골하정맥천자를시도하여정맥혈임을확인하고중심정맥카테터 (Three-lumen central venous catherization set, ARROW R, US) 거치하고나서주사기로혈액이흡인되지않았다. 그래서바로제거하 고, 왼쪽내경정맥에시도하여가까스로성공하여수술준비를시작하고중심정맥카테터가바른위치에거치됐는지를확인하기위해단순흉부방사선사진을촬영하고나서수술을시작하였다. 수술직전동맥혈가스검사상혈색소가 11.6 g/dl, 적혈구용적율이 38% 이었으나, 수술 30분후다시측정한동맥혈가스검사상혈색소가 8.3 g/dl, 적혈구용적률 24% 로떨어지고, 흉부방사선사진상우측전폐엽에혈흉, 또는수흉이라생각되는균질의방사선비투과성음영증가가보여 (Fig. 3) 흉부외과에연락하여수술중응급흉관삽관술을시행하였고 (Fig. 4) 800 1000 ml 정도혈액이배출되어 radiation 된적혈구농축액 2 U수혈하였다. 혈압은수술전잠깐 80/50 mmhg 심박수 70회 / 분떨어진것외엔수술중 120 160/60 90 mmhg정도유지되었고, 중심정맥압은 10 15 mmhg정도유지 Fig. 3. Pleural effusion. Chest radiograph shows large amount of right pleural effusion with diffuse increased right lung shadow(arrow). Fig. 4. Chest tube insertion. Chest radiograph shows evacuating right pleural effusion after chest tube insertion. 177
- 김대영 김대우 손희원 박상진 이덕희 - Fig. 7. Pig tail catheter. insertion. Chest radiograph shows percutaneous drainage with 10.2 Fr pig tail catheter(arrow). Fig. 5. Pulmonary edema. Chest radiograph shows pulmonary edema in right lung(arrow). 하였다. 최대기도내압은 15 20 mmhg정도유지되었고청진상호흡음감소는없었다. 수술은 3 시간 40 분정도걸렸으며, 수액은정질액 1700 ml 교질액 500 ml, radiation 된적혈구농 축액 2 U가들어갔고기관내튜브를발관후회복실에서조금지켜보다가호흡곤란이없음을확인한후일반병실로올라갔다. 다음날오후에더이상흉관으로배액되는혈액이없어흉관을제거하였다 (Fig. 5). 술후 10일째미열 (37.2 ) 과우측흉통을호소하여방사선사진확 Fig. 6. Pleural effusion. Chest radiograph shows moderate amount of right pleural effusion (arrow). Fig. 8. Discharge chest X-ray. Chest radiograph shows neither right pleural fluid nor active lung lesion. 178
- 쇄골하정맥을통하여중심정맥도관삽입실패후나타난혈흉 1 예 - 인후혈흉, 농흉진단하에 (Fig. 6) 돼지꼬리형카테터삽입후 (Fig. 7) 420 cc정도오래된혈액을배액하고나서술후 28일째별다른합병증없이퇴원하였다 (Fig. 8). 고찰신장이식수술의경우, 일반적으로우려할정도의출혈은발생하지않는수술로알려져있으나, 말기신장병으로인하여환자의전신상태가악화되어있고, 고혈압등여러전신질환을동반하고있으므로, 수술중활력징후의변화에유의해야하는수술이다. 4) 그래서본증례에서는중심정맥압의지속적인측정을위해중심정맥도관삽입을시행하고, 지속적인혈압감시를위해동정맥루가없는좌측요골동맥에도관을삽입하였다. 하지만부정확하게거치된중심정맥도관은중심정맥압을제대로반영하지못할뿐만아니라중심정맥도관폐쇄, 혈전형성, 혈전정맥염, 정맥혈관벽의미란, 심장압전, 공기색전증시흡인실패등의위험을증가시킬수있다. 5) 중심정맥도관삽입의방법중어떤것을선택하느냐는환자의체형이나임상상황, 해부학적변이, 예상되는합병증에대한고려와더불어임상의의경험이중요한요소가된다. 6) 본증례에서환자는 1년전내경정맥에혈액투석을위해굵은투과성카테터를삽입하였다가제거한병력이있어오른쪽이다소힘들거라예상은했지만, 주로오른쪽내경정맥천자와쇄골하정맥천자가왼쪽보다는다소경험이많았기때문에오른쪽을먼저시도하였다. 성인에서 J형유도철사를하지방향으로하면서우측쇄골하정맥도관을삽입하는경우머리 자세는중심정맥도관의위치이상이나합병증의빈도와관련이없는것으로생각되나, 7) 중심정맥도관이제위치에삽입되더라도어느정도시간이지나고나서도관이환자의이동이나자세변화에의해이동하거나딱딱한도관이혈관벽에미란성손상을가해중심정맥도관끝이 8, 9) 혈관밖으로이동하여종격동혈종및수종, 그리고수흉 10) 및상대정맥의천공 11) 이발생할수있으므로혈액흡인이잘되는지, 혈액역류가가능한지그리고주기적으로흉부방사선촬영을 8, 9) 하여제위치에있는지확인하여야된다. 흉강내합병증발생시나타나는혈역학적변화로혈압이떨어지고심박수가빨라지며최대기도내압이상승하고, 청진상호흡음의감소와함께동맥혈의산소포화도가감소할수있다. 12) 또확장기에의해서쇄골하동맥열상이생겨혈수흉이생길수있으므로가능한짧은확장기를사용하고그리고 1/3 이상들어가지않도록주의해야한다. 13) 중심정맥도관삽입시유도철사에의한부정맥은그특성상대개자연소실되어치료가필요없으나드물지만심각한부정맥 ( 지속적인심방세동 ) 과 Wolff-Parkinson-White syndrome 증후군환자에서는발작성심실위빠른맥 (paroxysmal supraventricular tachycardia) 이발생할수있 으므로 14) 유도철사삽입시신중을기해야하며, 지속되는심방세동의경우에는치료로약물요법으로심박수를조절하는것이외에도, 신속하게약물학적또는전기적심장율동전환을시도하는것이환자관리에효과적이라고생각된다. 15) 결핵등으로심하게파괴된폐병변을가진환자등에서중심정맥도관을삽입할경우는시술전미리방사선사진을확인하여심장연을 179
- 김대영 김대우 손희원 박상진 이덕희 - 파악한후안전한접근경로로시술하며천자후이유없이저혈압과빈맥을동반하고승압제에반응을하지않을경우에는심장압전을의심하고바로심낭절개를하여빠른치료를시행해야한다. 16) 또쇄골하정맥천자시환자의자세를부적절하게취할경우에는객혈 17) 이나, 기관천자및기관내삽관튜브의기낭파열이 18) 생길수있으므로주의해야한다. 현재까지보고된증례들을요약하자면, 중심정맥도관삽입후부정맥부터, 혈흉, 수흉, 기관천자, 객혈, 심장압전등이발생할수있고이는부적절한자세및미숙한기술로일어날수있으며중심정맥도관삽입후꼭방사선촬영하여적절한위치에있는지확인해야한다. 중심정맥도관삽관의적응증은중심정맥압의측정이필요한경우와말초정맥로확보가불가능할때이며일반적으로단순한정맥로확보를위하여시도함은고려해야한다. 19-21) 본증례의경우신장이식의수술로인하여중심정맥압측정과정맥로확보를위하여중심정맥도관삽입을시도하였는데우측쇄골하정맥천자후중심정맥도관을무리하게밀어넣는과정에서도관이혈관밖으로나와혈흉이생긴걸로사료되고환자는신장이식으로인하여술중, 술후면역억제제투여로면역력이저하되어흉관및배출되지않은혈액이감염원으로작용하여후에농흉이생긴걸로사료된다. 결론적으로중심정맥도관삽입시환자의병력및방사선사진을충분히파악하고가능한합병증을예견한후적절한자세에서조심스럽게시도해야하고중심정맥도관삽입후방사선촬영및혈액의흡인및역류를관찰하여바른위치에있는지반드시확인해야할것으로여겨진다. 그리고합병증이생겼을경우에는 환자의상태가나빠지지않도록신속한조치와적절한치료를시행해야할것으로생각된다. 참고문헌 1. Mark JB, Slaughter TF. Cardiovascular monitoring. In: Miller RD, editors. Miller s anesthesia. 6th ed. New York: Churchil Livingstone; 2005. p.1286-301. 2. Morgan GE, Mikhail MS, Murray MJ. Clinical anesthesiology. 3rd ed. New York: McGraw- Hill Companies; 2002. p.100-2. 3. McGee DC, Gould MK. Preventing complications of central venous catherization. N Engl J Med 2003 Mar 20;348(12):1123-33. 4. Cheong SH, Cho JH, Kim YH, Lim SH, Lee JH, Lee KM, et al. Spontaneous rupture of native kidney in a patient receiving kidney transplantation. Korean J Anesthesiol 2007 Mar;52(3):355-8. 5. Conces DJ Jr, Holden RW. Aberrant locations and complications in initial placement of subclavian vein catheters. Arch Surg 1984 Mar;119(3):293-5. 6. Seo JH, Lee W, Jung CW. Anatomical basis for supraclavicular central venous catheterization assessed by three-dimensional computed tomography. Korean J Anesthesiol 2006 Apr; 50(4):373-8. 7. Ryu HG, Lee SJ, Kwon JE, Choi JY, Yoon SZ, Jeon Y, et al. Influence of the head posture on central venous catheter position during right subclavian catherization. Korean J Anesthesiol 2007 Jun;52(6):627-9. 8. Kwak HJ, Lim ES, Ban SY, Lee JY, Yoon JS, Kil HK, et al. Hydromediastinum following internal jugular vein catherization. Korean J Anesthesiol 2007 Mar;52(3):335-8. 9. Lee KH, Lee KM, Lee YB, Lim HK, Han JW. 180
- 쇄골하정맥을통하여중심정맥도관삽입실패후나타난혈흉 1 예 - Hemomediastinum caused by central venous catheter. Korean J Anesthesiol 1998 Dec;35(6): 1216-20. 10. Kim YO, Lee JR, Kim KT, Choi WJ, Lee SI, Kim JW. Hydrothorax after central vein catheterization for right internal jugular vein and contralateral reexpansion pulmonary edema after right chest tube Insertion. Korean J Anesthesiol 2007 Aug;53(2):234-7. 11. Cho HC, Sohn JT, Choi JY, Shin IW, Lee HK, Chung YK. Perforation of superior vena cava and a right pleural effusion which occurred three days after central venous catherization through the left subclavian vein. Korean J Anesthesiol 2002 Oct;43(4):525-30. 12. Kim SH, Kim YK, Lee BJ, Hwang GS, Hwang JH, Han SM. Acute Hemothorax after percutaneous nephrolithotomy. Korean J Anesthsiol 2007 Apr;52(4):491-4. 13. Oh IY, Kim YI, Kang HS, Lee SK, Yang SY, Choi HY, et al. Hydrohemothorax and subclavian artery laceration during internal jugular vein cannulation. Korean J Anesthesiol 2005 Aug;49(2):269-73. 14. Lee C, O S. Paroxysmal supraventricular tachycardia in a patient with wolff-parkinsonwhite syndrome induced by central venous cannulation and surgical stimuli during operation. Korean J Anesthesiol 2005 Mar;48(3):308-10. 15. Kim SH, Kim D, Lee JS. Newly developed persistent atrial fibrillation during central venous catherization treated with electric cardioversion. Korean J Anesthesiol 2005 Nov; 49(5):684-9. 16. Sim JY, Cho IH, Park SE, Choi IC. Cardiac tamponade occurred during subclavian venous catheterization. Korean J Anesthesiol 2000 Jan;38(1):165-8. 17. Do JY, Kim IS, Hong SJ, Park JH, Shin KM. Hemoptysis after left subclavian central venous catheterization during anesthesia induction for open heart surgery. Korean J Anesthesiol 2007 Jan;52(1):91-4. 18. Roh WS, Joo HC, Kim BI, Cho SK, Lee SH. Tracheal puncture and endotracheal tube cuff perforation as a complication of the subclavian vein catheterization. Korean J Anesthesiol 1998 Oct;35(4):756-60. 19. Park CK, Jung JG, Jeon JK. Massive hydrohemothorax as a complication of C.V.P. catheterization. Korean J Anesthesiol 1978 Mar;11(1):76-8. 20. Chung HK, Jeon JK. Hemothorax resulting from subclavian vein catheterization. Korean J Anesthesiol 1985 Jun;18(2):188-91. 21. Jeoung BY, Cho YL. Hydrohemothorax following subclavian vein catheterization. Korean J Anesthesiol 1979 Sep;12(3):110-3. 181