Anesth Pain Med 2016; 11: 404-409 https://doi.org/10.17085/apm.2016.11.4.404 임상연구 http://crossmark.crossref.org/dialog/?doi=10.17085/apm.2016.11.4.404&domain=pdf&date_stamp=2016-10-25 pissn 1975-5171 ㆍ eissn 2383-7977 전신마취로경요도적방광종양절제술을받는환자에서가온담요를이용한저체온증예방효과 인제대학교의과대학상계백병원마취통증의학교실 홍성수ㆍ유병훈ㆍ김계민ㆍ김문철ㆍ연준흠ㆍ이상석 The efficacy of warming blanket on reducing intraoperative hypothermia in patients undergoing transurethral resection of bladder tumor under general anesthesia Seongsoo Hong, Byung Hoon Yoo, Kye-Min Kim, Mun-Cheol Kim, Jun Heum Yon, and Sangseok Lee Department of Anesthsiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea Background: Perioperative hypothermia, defined as a core temperature under 36 o C, increases the risk of cardiac complication, bleeding and infection. This study aimed to compare the hypothermia-preventing effects of a warming blanket (Ready-heat R ) and one-layer cotton blanket in patients undergoing transurethral resection of the bladder (TURBT) under general anesthesia. Methods: Patients undergoing TURBT under general anesthesia were allocated to the warming blanket (N = 23) or one-layer cotton blanket (N = 23) groups. Ten minutes before induction of anesthesia, warming blanket or one-layer cotton blanket was applied according to the assigned group. Tympanic temperature was measured just before induction of anesthesia. Esophageal temperature and tympanic temperature were measured from 20 min after induction of anesthesia at 10-min intervals. Tympanic temperature was measured at 10-min intervals over a 30-min period in the post-anesthesia care unit (PACU). In addition, the incidence and intensity of shivering and thermal comfort were also measured. Results: The core temperature during general anesthesia showed Received: May 26, 2016. Revised: 1st, July 13, 2016; 2nd, August 22, 2016. Accepted: August 30, 2016. Corresponding author: Byung Hoon Yoo, M.D., Ph.D., Department of Anesthsiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, 1342, Dongil-ro, Nowon-gu, Seoul 01757, Korea. Tel: 82-2-950-1170, Fax: 82-2-950-1323, E-mail: twowind@paik.ac.kr This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. no significant intergroup difference. The warming blanket group showed a lower incidence of hypothermia at 1 h after induction of anesthesia. Tympanic temperature, the incidence and intensity of shivering, and thermal comfort in the PACU showed no significant intergroup differences. Conclusions: Application of the warming blanket or one-layer cotton blanket for 10 min before induction of anesthesia showed no hypothermia-preventing effects. However, at one hour after induction of anesthesia, warming blanket application reduced the incidence of hypothermia to a greater degree than one-layer cotton blanket. (Anesth Pain Med 2016; 11: 404-409) Key Words: Hypothermia, Perioperative period, Prevention, Temperature. 서 경요도적방광종양절제술을받는환자의경우, 수술중지속적인방광세척으로인하여수술중이나종료이후에도저체온증이발생할위험이높다 [1]. 또한, 마취중에는부적절한체온조절과차가운수술실환경의노출로인해수술중저체온증의발생위험이더욱증가한다 [2]. 미국마취과학회에따르면수술중심부체온이 36.0 o C 미만인경우를저체온증으로정의하며, 저체온증을교정하고정상체온을유지하는것을권고하고있다 [3,4]. 수술중발생하는저체온증은수술부위감염의증가 [5], 재원기간과회복실에서의회복기간의연장 [6], 수술중출혈량의증가 [7], 심각한순환기합병증 [8], 수술후떨림 [9] 등여러가지합병증을일으킬수있다. 수술중저체온을예방하기위해서수술전또는수술중환자의피부를가온하거나, 수술중가온된수액을주입하는방법등을이용한다 [10,11]. 강제적공기가온법을이용한피부가온은수술중흔히사용되며, 정상체온유지에효과적이다 [4,12]. 하지만강제적공기가온법은화상, 감염의위험이있고, 사용장비가무겁고, 이동이불편하며, 전기를필요로한다는문제점이있다 [13,14]. 가온담요 (Ready-heat R, TechTrade, USA) 는자연재해나응 론 404
홍성수외 5 인 :Preventing hypothermia with warming blanket 405 급상황에서환자의체온을유지하도록개발되었다. 이기구는 9개의가온패드가부착되어있는담요형태로, 3분이내에온도가상승하여 15 20분이내에최대온도 43 o C에도달하여 9시간동안유지된다 [15]. 본연구는전신마취로경요도적방광종양절제술을받는환자에서, 수술실입실후가온담요 (Ready-heat R ) 를이용한전신마취유도 10분전부터시작한피부가온 (pre-warming) 이마취및회복중저체온증발생에미치는영향을알아보았다. 또한, 회복실에서고막체온을측정하고, 떨림의빈도와강도, 온도만족도도평가하였다. 대상및방법본연구는연구윤리심의위원회승인후전향적으로진행하였다. 수술전모든환자에게서면동의서를받은후, 계획수술중전신마취로경요도적방광종양절제술을받는정상체온환자를대상으로진행하였다. 환자가협조되지않거나거부한경우, 수술시작전고막체온이 36.0 o C 미만또는 37.5 o C 이상인경우는제외하였다. 서면동의를한 51명의환자를대상으로무작위배정을하였으며, 탈락자 5명을제외하고가온담요 (Ready-heat R ) 군 23명, 면반덮개 (one-layer cotton blanket, 110 cm 220 cm) 군 23명을분석하였다. 가온담요 (Ready-heat R ) 군 23명, 면반덮개군 23명으로배정되었다. 모든수액은실온 (25 27 o C) 으로준비하였으며, 수술실온도는 23 25 o C, 회복실온도는 26 27 o C로유지하였다. 모든수술은한수술실에서시행되었다. 환자가수술실에들어온후심전도, 비침습적혈압측정기, 맥박산소계측기를이용하여환자의활력징후를감시하였다. 마취유도 10 분전환자의상체를가온담요 (Ready-heat R ) 또는면반덮개로덮었다. 마취유도직전, 고막체온계 (ThermoScan R, infrared tympanic thermometer IRT 4020; Braun, USA) 를이용하여양쪽고막체온을두번씩측정한평균값을기록하였다. Propofol와 rocuronium을이용하여전신마취를유도하였으며, sevoflurane와 remifentanil을이용하여마취유지를하였다. 마취유도 20분후부터 10분간격으로각성직전까지양쪽고막체온을측정하였다. 마취유도후식도체온계 (DeRoyal R, esophageal stethoscope with temperature sensor; EST-03, ERAE SI Company, Korea) 를이용하여마취유도 20분후부터 10분간격으로각성직전까지식도체온을측정하였다. 식도체온계는앞니로부터 37 cm만큼삽입하여위치시켰다. 수술중식도체온이 36.0 o C 미만일경우, 강제적공기가온기 (forced air warmer; Bair hugger warming unit-model 505, Arizant healcare, USA) 를 43 o C로설정한후체온을관리하였고, 식도체온이 36.0 o C로측정되면강제적공기가온법을중단하였다 [4]. 수술이종료되면근육이완제의역전을위해 sugammadex 200 mg을정주하였다. 회복실도착후 10분간격으로 30분동안환자의양쪽고막체온을측정하고, 떨림의빈도와강도, 온도만족도를평가하였다. 떨림은 4점척도 (4-point scale) (0 = none: no shivering noted on palpation of the masseter, neck, or chest wall; 1 = mild: shivering localized to the neck and/or thorax only; 2 = moderate: shivering involves gross movement of the upper extremities (in addition to neck and thorax); 3 = severe: shivering involves gross movements of the trunk and upper and lower extremities) 로평가하였다 [16]. 온도만족도 (ASHRAE thermal sensation scale) (+3 = hot, +2 = warm, +1 = slightly warm, 0 = neutral, 1 = slightly cool, 2 = cool, 3 = cold) 를평가하였다. 전신마취를받는환자에서수술종류, 수술시간, 수술실환경요인등여러요인에의해서수술중저체온증 (36 o C 미만 ) 발생빈도는다양하지만, 이전연구들에따르면 40 60% 까지발생한다고알려져있다 [17,18]. 저자들의사전시험연구 (pilot test) 에서면반덮개군환자들의 90% 에서저체온증이발생하였다. 따라서, 면반덮개군에비해가온담요군에서저체온증발생률이 90% 에서 50% 로감소될것으로가정하고본연구를설계하였다. 이에따라유의수준 ( -value) 을 0.05, 검정력 (power) 80% 를만족하는각군당개체수는 23명으로계산되었다. 10% 의탈락률을고려한전체목표피험자수는 50명이었다. 피험자수의계산은 G*Power for windows (version 3.1, Germany) 를이용하여계산하였다. 모든자료의통계적분석은모든자료의통계분석은 R version 3.3.0 (R Core Team [2016]. R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL: https://www.r-project.org/.) 을이용하여분석하였다. 특정시점에서의관찰된저체온증발생률의비교는피셔의정확도검정 (Fisher s exact test) 을이용하였으며, 환자의온도만족도및떨림의발생여부비교에도피셔의정확도검정을사용하였다. 모든자료는평균 ± 표준편차또는중간값 ( 최소 최대값 ) 으로표기하였다. 통계적인유의성은 P 값이 0.05 미만인경우로하였다. 결과본연구는총 51명의환자를대상으로진행되었으며, 탈락자 5명을제외하고가온담요 (Ready-heat R ) 군 23명, 면반시트군 23명을분석하였다 (Fig. 1). 성별, 나이, 키, 몸무게, 미국마취과학회신체등급분류, 마취시간, 수술시간, 수액량, 출혈양, 수술실온도, 회복실에서고막체온, 수술후떨림, 온도만족도에서두군간차이가없었다. 그러나회복실온도에서는두군간에차이가있었다 (Table 1). 수술중가온담요 (Ready-heat R ) 군과면반덮개군모두에서
406 Anesth Pain Med Vol. 11, No. 4, 2016 Fig. 1. Consort flow diagram of the paients. Table 1. Patient Demographic Data OLCS group (N = 23) WB group (N = 23) P value Male/female (n) 20/3 20/3 1 ASA classification (I/II) 21/2 21/2 1 Age (yr) 66.4 ± 13.3 70.6 ± 8.7 0.216 Weight (kg) 66.9 ± 10.4 66.8 ± 10.7 0.987 Height (cm) 164.0 ± 8.8 163.4 ± 8.1 0.819 Duration of anesthesia (min) 76.7 ± 34.1 90.2 ± 34.5 0.190 Duration of surgery (min) 36.1 ± 31.4 41.4 ± 29.6 0.559 Volume of crystalloid (ml) 669.6 ± 167.7 672.0 ± 258.4 0.971 Estimated blood loss (ml) 26.3 ± 49.6 20.1 ± 23.9 0.597 Operating room temperature ( o C) 24.1 ± 1.1 23.4 ± 1.4 0.052 PACU temperature ( o C) 26.9 ± 1.1 26.0 ± 1.6 0.036 Thermal comfort in PACU 0.0 ± 0.7 0.4 ± 1.0 0.114 Shivering in PACU (0/1) 23/0 22/1 1 Values are expressed as means ± SD or numbers. Thermal comfort in PACU is expressed as median value (maximum value minimum value). OLCS: one-layer cotton blanket, WB: warming blanket, ASA: American society of anesthesiologists, PACU: post anesthesia care unit. 수술이진행되면서점차식도체온과고막체온이감소하였다 (Fig. 2). 식도체온은마취시간 20분째가온담요 (Ready-heat R ) 군 (36.25 ± 0.37 o C), 면반덮개군 (36.11 ± 0.33 o C), 마취시간 60분째가온담요 (Ready-heat R ) 군 (35.97 ± 0.37 o C), 면반덮개군 (35.7 ± 0.19 o C) 으로마취시간 20분째비해마취시간 60분째가온담요 (Ready-heat R ) 군은 0.28 o C, 0.77%, 면반덮개군은 0.41 o C, 1.13% 감소하였다. 고막체온은마취유도시점가온담요 (Ready-heat R ) 군 (36.7 ± 0.35 o C), 면반덮개군 (36.65 ± 0.33 o C), 마취시간 60분째가온담요 (Ready-heat R ) 군 (36.06 ± 0.32 o C), 면반덮개군 (35.98 ± 0.26 o C) 으로마취 유도시점에비해마취시간 60분째가온담요 (Ready-heat R ) 군은 0.64 o C, 1.74% 면반덮개군은 0.67 o C, 1.82% 감소하였다. 식도체온을기준으로수술중저체온증이발생한빈도는양군간에유의한차이가없었다. 그러나마취시간이 60 분이상인 29명의환자를대상으로분석한결과, 마취시간 60분째저체온증이발생한빈도는양군간에유의한차이가있었다 (P < 0.05) (Table 2).
홍성수외 5 인 :Preventing hypothermia with warming blanket 407 Fig. 2. Mean tympanic temperature and esophageal temperature in patients receiving either warming blanket or one layer cotton blanket decreased during transurethral resection of bladder tumor. There was no significant difference between two groups in mean tympanic temperature and esophageal temperature. *Fisher s exact test was used. Table 2. The Incidence of Hypothermia in OLCS Group and WB Group OLCS group (N = 23) WB group (N = 23) Hypothermia Normothermia Hypothermia Normothermia P value 60 min of anesthesia 10 (90.91) 1 (9.09) 7 (38.88) 11 (61.11) 0.008 End of surgery 17 (73.91) 6 (26.09) 12 (52.17) 11 (47.83) 0.221 Values are expressed as number (%). Hypothermia is defined as a core temperature under 36 o C. *Fisher's exact tesr was used. OLCS: one layer cotton blanket, WB: warming blanket. 고찰전신마취후 1시간동안 1 1.5 o C의급격한심부체온의감소는대사성열생산과열손실기전의불균형보다는체열재분포에의해서발생한다. 심부체온의감소는마취제에의한직접적인말초혈관의이완과체온조절중추에의한혈관수축기전이억제됨에따라심부체온이차가운말초조직쪽으로재분배되어발생한다. 초기체열의재분배정도는심부조직과말초조직의온도차이에의해서결정된다 [19]. 마취전피부가온법은말초조직의열함량을증가시켜수술중저체온증을예방할수있는중요한방법이다 [20]. 강제적공기가온을이용한마취전피부가온법이수술중저체온증을효과적으로예방할수있어흔히이용되고있다 [20,21]. 근거중심의학에따른지침에서는수술중저체온증을예방하기위해마취전 20 60분동안마취전피부가온법을시행하는것을권고하고있다 [10,22]. 하지만현실적으로시행하기에어려움이있고, 응급수술인경우불가능하다. 이에 Horn 등 [23] 은 10, 20, 30분동안강제적공기가온법을이용한마취전피부가온을통해, 수술중저 체온증을예방했다고보고하였다. 그러나흔히마취전피부가온의방법으로이용되는강제적공기가온법은화상, 감염의위험있고, 사용장비가무겁고, 전기를필요로한다는문제점이있다 [13,14]. Ng 등 [24] 은 electric heating pad 를, Taguchi 등 [25] 은 circulating-water mattress를이용한마취전피부가온을통해도수술중심부체온을효과적으로유지했다고보고하였다. 가온담요 (Ready-heat R ) 는전기를필요로하지않고 9개의가온패드가부착되어있어밀봉포장지를개봉하면산소와반응하여 3분이내에따뜻해지기시작한다. 이기구는개봉후 15분이내에최대온도 43 o C에도달하여 9시간동안유지되는장점이있으며, 사용하기편리하고화상의위험이적고응급상황, 회복실, 병실에서도사용할수있다. 저자들은마취유도 10분전부터가온담요 (Ready-heat R ) 를이용한피부가온이수술중저체온증발생에미치는영향을면반덮개와비교하였다. 전신마취유도후 1 3시간동안대사성열생산과열손실기전에의해심부체온은천천히감소한다 [12,26]. 심부체온의감소에영향을주는요인으로수술실온도, 수술범위, 차가운물질과의절연이있으며, 가장중요한요인은
408 Anesth Pain Med Vol. 11, No. 4, 2016 수술실온도이다. 본연구에서수술실온도는가온담요 (Ready-heat R ) 군, 면반덮개군각각 23 o C, 24 o C로유의한차이가없었다. 두군에서모두심부체온이점차감소하였고, 수술종료시점에서저체온증발생빈도에차이가없었다 (Table 2). 본연구에서는다른연구들과 [24,25] 다르게수술전가온담요 (Ready-heat R ) 를이용하여환자의상체만마취전피부가온해주었는데, 가온되지않은환자의하체쪽말초조직의영향으로두군간수술중저체온증발생빈도에차이가없었던것으로생각한다. 그리고근거중심의학에따른지침 [4] 에따라본연구에서는환자의심부체온이 36.0 o C 미만으로감소하면환자의안전을위해추가로강제적공기가온법을이용하여저체온증을교정하였다. 일상적인체온관리를받는환자에서전신마취 3 4시간후심부체온이 33 34 o C로감소하는점 [26] 을미루어볼때, 추가적인강제적공기가온을시행하지않았다면가온담요 (Ready-heat R ) 군보다면반덮개군에서심부체온의감소가더컸을것으로생각한다. 결과 (Table 2) 에서보여준것과같이가온담요 (Ready-heat R ) 군과면반덮개군에서수술종료시점에서발생한저체온증의빈도는차이가없었으나, 전신마취유도후 1 시간째가온담요 (Ready-heat R ) 군에서면반덮개군보다저체온증의발생빈도가유의하게낮았다. 본연구에서시행한수술실입실후, 가온시트 (Ready-heat R ) 를이용한 10분정도의짧은마취전피부가온이전신마취에의해발생할수있는체열의재분포에영향을미친것으로보인다. 본연구에서회복실에서가온담요 (Ready-heat R ) 와면반덮개두군간에고막체온, 온도만족도에차이가없었다. 그리고수술후떨림은가온담요 (Ready-heat R ) 군에서만 1명 (5%) 발생하였다. Eberhart 등 [27] 은수술후회복실에서의떨림의발생률은 11.6% 이며, 나이가어릴수록, 환자의체온이낮을수록수술후떨림이잘발생하는것으로보고하였다. 본연구에서수술후떨림의발생빈도가 5% 로논문 [27] 에비해낮은것은상대적으로회복실에서의고막체온이높았고, 평균나이가많았던것, 수술의종류가다른것등이수술후떨림의발생률을낮춘요인으로생각된다. 전신마취유도시점에이용한가온담요 (Ready-heat R ) 은전신마취중식도체온와고막체온의감소의양상이면반덮개와비교하여차이가없었다. 면반덮개와가온담요 (Ready-heat R ) 두군간에수술중저체온증발생빈도에서는차이가없었으나, 전신마취 1시간후면반덮개군에비해가온담요 (Ready-heat R ) 군에서저체온증의발생빈도가유의하게낮았다. REFERENCES 1. Mirza S, Panesar S, AuYong KJ, French J, Jones D, Akmal S. The effects of irrigation fluid on core temperature in endoscopic urological surgery. J Perioper Pract 2007; 17: 494-7, 499-503. 2. Sessler DI. Mild perioperative hypothermia. N Engl J Med 1997; 336: 1730-7. 3. Vaughan MS, Vaughan RW, Cork RC. Postoperative hypothermia in adults: relationship of age, anesthesia, and shivering to rewarming. Anesth Analg 1981; 60: 746-51. 4. Forbes SS, Eskicioglu C, Nathens AB, Fenech DS, Laflamme C, McLean RF, et al. Evidence-based guidelines for prevention of perioperative hypothermia. J Am Coll Surg 2009; 209: 492-503. 5. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med 1996; 334: 1209-15. 6. Lenhardt R, Marker E, Goll V, Tschernich H, Kurz A, Sessler DI, et al. Mild intraoperative hypothermia prolongs postanesthetic recovery. Anesthesiology 1997; 87: 1318-23. 7. Rajagopalan S, Mascha E, Na J, Sessler DI. The effects of mild perioperative hypothermia on blood loss and transfusion requirement. Anesthesiology 2008; 108: 71-7. 8. Frank SM, Fleisher LA, Breslow MJ, Higgins MS, Olson KF, Kelly S, et al. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial. JAMA 1997; 277: 1127-34. 9. Horn EP, Sessler DI, Standl T, Schroeder F, Bartz HJ, Beyer JC, et al. Non-thermoregulatory shivering in patients recovering from isoflurane or desflurane anesthesia. Anesthesiology 1998; 89: 878-86. 10. Torossian A. Thermal management during anaesthesia and thermoregulation standards for the prevention of inadvertent perioperative hypothermia. Best Pract Res Clin Anaesthesiol 2008; 22: 659-68. 11. Seo H, Kim K, Oh EA, Moon YJ, Kim YK, Hwang JH. Effect of electrically heated humidifier on intraoperative core body temperature decrease in elderly patients: a prospective observational study. Anesth Pain Med 2016; 11: 211-6. 12. Hynson JM, Sessler DI. Intraoperative warming therapies: a comparison of three devices. J Clin Anesth 1992; 4: 194-9. 13. Chung K, Lee S, Oh SC, Choi J, Cho HS. Thermal burn injury associated with a forced-air warming device. Korean J Anesthesiol 2012; 62: 391-2. 14. Baker N, King D, Smith EG. Infection control hazards of intraoperative forced air warming. J Hosp Infect 2002; 51: 153-4. 15. TechTrade LLC. Ready-heat temperature management blankets [updated 2011; cited 2016 Jul 12]. Available from http:// www.techtradellc.com/temperature-management-in-hospital-settings. 16. Badjatia N, Strongilis E, Gordon E, Prescutti M, Fernandez L, Fernandez A, et al. Metabolic impact of shivering during therapeutic temperature modulation: the Bedside Shivering Assessment Scale. Stroke 2008; 39: 3242-7. 17. Torossian A. Survey on intraoperative temperature management in Europe. Eur J Anaesthesiol 2007; 24: 668-75. 18. Andrzejowski J, Hoyle J, Eapen G, Turnbull D. Effect of prewarming on post-induction core temperature and the incidence
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