Anesth Pain Med 2019;14:347-355 https://doi.org/10.17085/apm.2019.14.3.347 pissn 1975-5171 ㆍ eissn 2383-7977 임상연구 김태관ㆍ윤혜진ㆍ고유리ㆍ최유나ㆍ박의진ㆍ윤준로 가톨릭대학교의과대학마취통증의학교실 Received August 2, 2018 Revised 1st, September 21, 2018 2nd, October 11, 2018 3rd, October 18, 2018 4th, October 19, 2018 5th, October 19, 2018 Accepted October 19, 2018 Retrospective investigation of anesthetic management and outcome in patients with deep neck infections Tae Kwane Kim, Hye Jin Yoon, Yuri Ko, Yuna Choi, Ui Jin Park, and Jun Rho Yoon Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea Corresponding author Jun Rho Yoon, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, 327 Sosa-ro, Wonmi-gu, Bucheon 14647, Korea Tel: 82-32-340-7075 Fax: 82-32-340-2255 E-mail: pauly@catholic.ac.kr ORCID https://orcid.org/0000-0001-7457-7433 Background: Although incidence of deep neck infection has decreased after the introduction of antibiotics and improvement of oral hygiene, the disease may remain serious to anesthesiologists and patients, especially relative to postoperative prognosis and airway management. The objective of this study is to clarify clinical characteristics and consider anesthetic implications. Methods: This study reviews the experience of 116 patients that received operations for deep neck infections 1997 2017 in a university hospital. Variables included in data were age, sex, lesion, etiology, underlying disease, result of culture, anesthetic techniques, C-reactive protein level, and a variety of scores including ASA physical status, APACHE II, and SOFA. Scores were analyzed statistically to elucidate prognostic ability, and influences on intubation. Results: The following background variables were associated postoperative complication; age, presence of diabetes, hypertension, and infectious disease, extended space and use of N 2 O. APACHE II 7 and SOFA 3 were revealed to be associated with postoperative complication. The following background variables were associated with difficult intubation: date of surgery 2009, non-otolaryngology department, and submental space. Conclusions: This study revealed the possibility that the preoperative evaluation, including the determination of scoring system, may be useful in predicting outcome and making a clinical decision of airway management in deep neck infections. Keywords: Airway; Infection; Neck; Postoperative complications. 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. Copyright c the Korean Society of Anesthesiologists, 2019 347
Anesth Pain Med Vol. 14 No. 3 서론 심경부공간 (deep neck spaces) 은목의구조물들을둘러싸고있는근막면 (fascial planes) 사이의잠재적공간들이다 [1,2]. 심경부감염은두경부의어떤부위의염증이이근막면을따라퍼지면서발생하는화농성병변이다 [3 5]. 심경부감염은의료기관으로의내원이지체되거나진단과수술을포함한처치가늦어질수록높은이환율과치사율을초래하는질환이다 [1,6]. 따라서심경부농양의조기절개와배농이가장중요한치료방법이며 [1,4,7], 마취시기도의확보를위해다양한술기들이요구된다 [8,9]. 본연구의목적은일개대학병원에서심경부감염으로마취과의사의마취관리를받은수술환자들의임상양상과어려운기도삽관과수술후예후에영향을미친환자와수술의요인들과의관련성의존재유무를분석하여, 향후심경부감염환자들의마취시도움이되고자하였다. 대상및방법 본원의료정보데이터를이용하여 1997년 1월부터 2017년 12월까지두경부감염으로진단되어수술을받은 265명의환자를추출하였으며, 이중전신마취를받은 132명을대상으로하였다. 그중표재성경부감염 2명과편도나편도주위에국한된농양 10명, 구강안에한정되어발생한농양 3명, 경부괴사성근막염으로수술을받은환자 1명, 그리고 15세이하 11명은제외하여 16세이상 105명에대해조사하였다. 연구대상환자들의성별및연령, 원인및원인균, 발생부위, 동반된기저질환, C-반응단백질 (C-reactive protein) 을포함한검사소견, 수술방법및수술시간, 사망을포함한수술후 30일이내합병증여부를수집하였다. 발생부위는예전보고들의 [3 5] 기술에근거하여분류하였고부인강 (parapharyngeal space), 악하강 (submandibular space), 후인두강 (retropharyngeal space), 이하강 (parotid space) 등으로나누었다. 구강저봉와직염 (Ludwig s angina) 은이악하강 (submental space) 으로분류하였다 [3,8]. 발생부위가두개이상인경우는다발성 (extended space) 으로분류하였다 [3,8,10]. 상기자료들을토대로합병증을사전에예측할수있는지표가될수있을것으로가정한 4가지변수인미국마취과학회신체분류 (American Society of Anesthesiologists physical status), acute physiology and chronic health evaluation (APACHE) II 점수, 순차적장기부전평가 (sequential organ failure assessment, SOFA) 점수, C-반응단백질수치를도출및조사하여통계적으로유의한관련성이있는지를비교하였다. 또한, 저자들이어려운기도삽관이었다고가정한조건으로는 Cormack Lehane grade 3 또는 4인경우, 비디오후 두경 (videolaryngoscopy) 이나굴곡성기관지경 (fiberoptic bronchoscopy) 을이용한기도삽관을했던경우, 기관절개술을마취유도전시행한경우, 후두마스크나광봉 (light wand) 을사용한경우일것이라는가설을설정한후환자들과관련이있는요인들이있는지조사하였다. 통계분석은 SAS (version 9.4, SAS Institute, USA) 를이용하였다. 빈도형자료의특성은빈도와백분율 (%) 로, 연속형자료는평균 ± 표준편차로표기하였다. 두그룹비교시연속형변수는 Wilcoxon rank sum test를이용하였고, 명목형변수는 chisquare test 혹은 Fisher s exact test를이용하여비교하였다. 수술연도는데이터의중앙값을이용하여절사점지점을설정하였고, American Society of Anesthesiologists physical status는기능성이상이시작되는 3점, C-반응단백질, APACHE II, 순차적장기부전평가지표들에대해서는수신자조작특성 (receiver operating characteristics) 곡선의 Youden index 를이용하여본데이터의합병증과어려운기도삽관각각의최적의절사점을산출하여적용하였다. 합병증과어려운기도삽관과관련된인자를조사하기위하여단변수와다변수로지스틱회귀분석을수행하여 odds ratio (OR) (95% confidence interval [CI]) 로제시하였으며, 변수를보정하여다변수분석을수행하였다. P값이 0.05 미만일경우, 통계적으로유의한것으로간주하였다. 결과 연구기간동안심경부감염으로전신마취또는감시하마취하에수술한환자는모두 105명으로평균연령은 55.6세 (standard deviation: ± 17.7세, range: 17 101세 ) 였다. 남자는 69명, 여자는 36명으로남녀의비는 1.92:1이었다 (Table 1). 체질량지수 (body mass index) 는 18.5 kg/m 2 이상 23 kg/m 2 미만이 39명 (37.1%) 로가장많았다. 농양이발생한좌우의비율은우측 49예 (46.7%), 좌측 39예 (37.1%), 그리고양측 17예 (16.2%) 에서발생하였다 (Table 1). 집도과로는이비인후과에서 68명, 치과에서 33명, 일반외과에서 3명, 성형외과에서 1명을수술하였다. 74명은경경부절개배농술 (transcervical incision and drainage), 19명은구강내절개배농술을시행받았으며 12명은양측모두에서접근하였다 (Table 1). 심경부감염의원인은 50예 (47.6%) 에서치과치료의병력이있었던치성질환 (odontogenic disease) 들로가장높은빈도를보였고, 급성인두염과정확한원인을확인할수없었던경우들이각각 13예 (12.4%) 있었다. 급성편도선염 6예 (5.7%), 경부임파선염 4예 (3.8%), 둔상 3예 (2.9%) 가있었다. 선천성경부낭종, 이물질, 방사선조사, 폐렴이각각 2예 (1.9%) 씩있었으며그외원인으로침, 급성후두개염, 타석증, 축농증, 이하선염, 중이염이각각 1예 (1.0%) 씩있었다. 348 www.anesth-pain-med.org
Table 1. Patient Characteristics Variable Total of patients (n = 105) Age (yr) Mean ± SD 55.6 ± 17.7 Median (range) 55.0 (17.0 101.0) Sex Male 69 (65.7) Female 36 (34.3) Body mass index (kg/m 2 ) < 18.5 6 (5.7) 18.5 < 23 39 (37.1) 23 < 25 31 (29.5) 25 29 (27.6) Abscesses side Right 49 (46.7) Left 39 (37.1) Both 17 (16.2) Department ENT 68 (64.8) GS, PS 4 (3.8) DT 33 (31.4) Surgery Transcervical 74 (70.5) Intraoral 19 (18.1) Both 12 (11.4) Diabetes No 63 (60.0) Yes 42 (40.0) Hypertension No 75 (71.4) Yes 30 (28.6) Infectious disease No 81 (77.1) Yes 24 (22.9) Anesthetic method MAC 3 (2.9) Inhalational 94 (89.5) TIVA 8 (7.6) N 2 O No 41 (39.1) Yes 64 (61.0) Values are presented as number (%) for categorical variables, unless otherwise indicated. ENT: department of ear, nose and throat, GS: department of general surgery, PS: department of plastic surgery, DT: department of dentistry, MAC: monitoring anesthesia care, Inhalational: inhalational anesthesia, TIVA: total intravenous anesthesia. 동반된기저질환은당뇨가 42 예 (40.0%) 가가장많은빈도를 보였다 (Table 1). 그외에고혈압이 30예 (28.6%), 각종감염성질환이 24건 (22.9%) 그리고알코올의존이 14예 (13.3%) 있었다. 감염성질환에는결핵 (4건), 매독 (4건), B형간염항체양성 (4건) 등이동반되었다. 그외동반된특이기저질환및병력으로원폭피해, 임신, HIV 양성, 둔부농양, 소뇌위축증, 한약복용중, 호르몬대체요법중, 장마비가각 1예씩있었다. www.anesth-pain-med.org Table 2. Spaces of Deep Neck Infections Space Total of patients (n = 105) Parapharyngeal 26 (24.8) Submandibular 24 (22.9) Extended 20 (19.0) Submental 13 (12.4) Retropharyngeal 10 (9.5) Epiglottic 3 (2.9) Pretracheal 3 (2.9) Prevertebral 2 (1.9) Parotid 2 (1.9) Masticatory 1 (1.0) Thyroid 1 (1.0) Values are presented as number (%). Table 3. Methods of Airway Secure Space Total of patients (n = 102) Conventional intubation* 79 (75.2) Awake fiberoptic bronchoscopy 7 (6.9) Flexible blade 4 (3.9) Videolaryngoscope 3 (2.9) Tracheostomy before induction 3 (2.9) Tracheostomy after failure of intubation 2 (2.0) Intubation before induction 2 (2.0) Light wand 1 (1.0) Laryngeal mask airway 1 (1.0) Values are presented as number (%). *One patient received tracheostomy during operation. 심경부감염이의심되는환자들에서염증의정도를파악할수있는표지자중하나인 C-반응단백질수치는 57명에서수술전검사되었는데평균 150.0 ± 120.5 mg/l를보였다. 감염부위는부인강 (parapharyngeal space) 이 26명 (24.8%) 으로가장많았으며, 악하강 (submandibular space) 24예 (22.9%), 다발성 (extended space) 20예 (19.0%), 이악하강 (submental space) 에서 13예 (12.4%), 그리고후인강 (retropharyngeal space) 10예 (9.5%) 의순서였다 (Table 2). 전신마취를 102명에서시행하였으며, 이중흡입마취 94명, 정맥마취 8명이었고, 나머지 3명에서는감시하마취 (monitoring anesthesia care, MAC) 를하였다 (Table 1). 79명은곡형날후두경을이용한고식적기도삽관을받았고, 각성하굴곡성기관지경을 7명, 굴곡성곡날 (flexible blade) 을 4명, 비디오후두경으로 3명, 수술전기관절개술을 3명, 기도삽관실패후기관절개술을 2명, 수술실밖에서수술전기도삽관을 2명, 광봉을 1명, 그리고후두마스크를 1명에서시행하였다 (Table 3). 또한, 금식시간이충분하지못했던 2예에서빠른연속유도 (rapid sequence induction) 를시행하였다. 마취유도중발생했던특이한경우는마취유도중농양이후두경에의해파열되어나온 349
Anesth Pain Med Vol. 14 No. 3 경우, 술전구강으로부터흡입하여위내에체류하던고름이역류되었던경우, 그리고크기가큰후두개낭종이막고있어기도삽관이불가능하여기관절개술을실시한경우가각각 1건씩있었다. 심경부감염환자전체 105명모두에서절개배농술중검체를채취하였으나균이동정된환자는 54명 (51.4%) 이며 72건의미생물이동정되었다. 이중 33예에서 Streptococci 균종이동정되었다. 가장많이동정된균은 Streptococcus viridans 로 17예였으며, 그외에, Staphylococcus aureus 13예, Streptococcus angiosus와 Klebsiella pneumoniae 각각 5예, β- he mo lytic Streptococcus 3예등이동정되었다. 수술후중환자실로 41명 (37.2%) 이이송되었으며, 감시하마취와기관절개술을받은환자들을제외한 95명중 24명 (25.3%) 은발관하지않고이송되었다. 30일이내에발생한합병증은총 45명 (42.9%) 에서발생하였으며, 재발이 15건 (14.3%) 으로가장많았다. 창상감염과세균성폐렴이각각 5건, 패혈증과종격동염이각각 4건, 신경손상 3건, 그리고성인성호흡곤란증후군, 하악골수염, 폐부종, 늑막삼출, 섬망이각각 2건이발생하였다. 그외합병증으로흡인성폐렴, 다장기부전증후군, Ramsay- Hunt 증후군, 정맥동혈전증 (venous sinus thrombosis), 피하기종 (subcutaneous emphysema), 기흉 (pneumothorax), 저용량성쇼크, 간장애, 부신위기 (adrenal crisis), 위장관출혈, 급성신부전, 심근경색, 심막삼출, 저혈당이각 1예씩있었다. 네명 (3.8%) 이사망하였는데, 이중한명은수술중급성심부전으로심정지가발생했으며, 패혈증과성인호흡곤란증후군으로각각 1명이중환자실에서수술후사망하였다. 합병증이발생한군과발생하지않은군사이에나이 (P < 0.001), 당뇨 (P < 0.001), 고혈압 (P = 0.007), 감염성질환유무 (P = 0.002), 아산화질소의사용 (P = 0.028) 에있어유의한차이를보였다 (Table 4). 단변수회귀분석에서합병증과유의한관련이있었던변수들은나이 (P < 0.001), 당뇨 (P < 0.001), 경부양측발생 (P < 0.033), 고혈압 (P = 0.009), 다발성 (P = 0.009), 감염성질환 (P = 0.003), 그리고아산화질소의사용 (P = 0.003) 이있었다 (Table 5). 나이와당뇨를보정한다변수회귀분석에서각각 C- 반응단백질 226.2 mg/l (OR: 17.37, 95% CI: 2.40 125.87; P = 0.005), APACHE II 7 (OR: 3.36, 95% CI: 1.13 9.97; P = 0.029), 순차적장기부전평가 3 (OR: 5.74, 95% CI: 1.53 21.50; P = 0.010) 이통계적으로유의하였다 (Table 6). Table 4. Comparison of Complication and Difficult Intubation according to the Clinical Factors Variable Non-complication (n = 60) Complication (n = 105) Difficult intubation* (n = 102) Complication (n = 45) P value Non-difficult intubation (n = 64) Difficult intubation (n = 38) P value Date of surgery (yr) 2009 28 (46.7) 26 (57.8) 0.260 25 (39.1) 26 (68.4) 0.004 Sex, male 43 (71.7) 26 (57.8) 0.138 45 (70.3) 22 (57.9) 0.202 Age (yr) 49.0 ± 17.2 64.4 ± 14.2 < 0.001 53.2 ± 18.2 60.3 ± 16.6 0.062 Abscesses side Left 26 (43.3) 13 (28.9) 0.093 24 (37.5) 13 (34.2) 0.123 Right 28 (46.7) 21 (46.7) 33 (51.6) 15 (39.5) Both 6 (10.0) 11 (24.4) 7 (10.9) 10 (26.3) Department ENT 39 (65.0) 29 (64.4) 0.953 47 (73.4) 20 (52.6) 0.032 DT, GS, PS 21 (35.0) 16 (35.6) 17 (26.6) 18 (47.4) Surgery Transcervical 40 (66.7) 34 (75.6) 0.264 45 (70.3) 27 (71.1) 0.134 Oral 14 (23.3) 5 (11.1) 14 (21.9) 4 (10.5) Both 6 (10.0) 6 (13.3) 5 (7.8) 7 (18.4) Diabetes 15 (25.0) 27 (60.0) < 0.001 24 (37.5) 16 (42.1) 0.645 Hypertension 11 (18.3) 19 (42.2) 0.007 18 (28.1) 12 (31.6) 0.711 Infectious diseases 0.002 15 (23.4) 9 (23.70) 0.977 Anesthesia Inhalational 7 (11.7) 17 (37.8) > 0.999 MAC, TIVA 6 (10.0) 5 (11.1) N 2 O 42 (70.0) 22 (48.9) 0.028 Values are presented as number (%) or mean ± SD for categorical variable, unless otherwise indicated. ENT: department of ear, nose and throat, DT: department of dentistry, GS: department of general surgery, PS: department of plastic surgery, Inhalational: inhalational anesthesia, MAC: monitoring anesthesia care, TIVA: total intravenous anesthesia. *Three patients for anesthesia with monitoring anesthesia care were excluded from data analysis. P values for difference were determined by using chi-square or Wilcoxon rank sum test. 350 www.anesth-pain-med.org
Table 5. Univariable Logistic Regression Analyses of Clinical Factors Affecting Complication and Difficult Intubation Variable Complication (n = 105) Difficult intubation* (n = 102) Odds ratio (95% CI) P value Odds ratio (95% CI) P value Date of surgery (yr), 2009 1.56 (0.72 3.41) 0.261 3.38 (1.45 7.90) 0.005 Sex, male 1.85 (0.82 4.18) 0.140 1.72 (0.75 3.98) 0.203 Age (yr) 1.06 (1.03 1.09) < 0.001 1.02 (1.00 1.05) 0.055 Abscesses side (reference: left) Right 1.50 (0.63 3.59) 0.363 0.84 (0.34 2.09) 0.706 Both 3.67 (1.11 12.14) 0.033 2.64 (0.81 8.57) 0.107 Department (reference: ENT vs. DT, GS, PS) 1.03 (0.46 2.30) 0.953 2.49 (1.07 5.79) 0.034 Operation (reference: transcervical) Intraoral 0.42 (0.14 1.29) 0.129 0.48 (0.14 1.60) 0.229 Both 1.18 (0.35 3.99) 0.794 2.33 (0.67 8.09) 0.182 Diabetes 4.50 (1.95 10.37) < 0.001 1.21 (0.53 2.75) 0.645 Hypertension 3.26 (1.35 7.86) 0.009 1.18 (0.49 2.83) 0.711 Spaces Parapharyngeal 0.79 (0.32 1.95) 0.602 0.58 (0.22 1.55) 0.274 Submandibular 0.94 (0.37 2.36) 0.894 0.39 (0.13 1.15) 0.087 Extended 4.06 (1.42 11.65) 0.009 1.93 (0.72 5.18) 0.193 Retropharyngeal 0.30 (0.06 1.50) 0.143 0.70 (0.17 2.88) 0.619 Submental 0.55 (0.16 1.93) 0.352 6.31 (1.59 25.07) 0.009 Infectious disease 4.60 (1.70 12.40) 0.003 1.01 (0.39 2.61) 0.977 Anesthesia (reference: inhalational vs. MAC, TIVA) 1.13 (0.32 3.95) 0.854 N 2 O 0.41 (0.18 0.92) 0.030 CRP (n = 64) 226.2 mg/l 11.25 (2.26 56.02) 0.003 ASA 3 5.92 (2.36 14.85) < 0.001 APACHE II 7 8.01 (3.32 19.31) < 0.001 SOFA 3 2.90 (1.29 6.52) 0.010 CI: confidence interval, ENT: department of ear, nose and throat, DT: department of dentistry, GS: department of general surgery, PS: department of plastic surgery, Inhalational: inhalational anesthesia, MAC: monitoring anesthesia care, TIVA: total intravenous anesthesia, CRP: C-reactive protein, ASA: American Society of Anesthesiologists physical status, APACHE II: acute physiology and chronic health evaluation, SOFA: sequential organ failure assessment. *Three patients for anesthesia with monitoring anesthesia care were excluded from data analysis. P values for difference were determined by using chi-square or Wilcoxon rank sum test. Table 6. Multivariable Logistic Regression of CRP, ASA, APACHE II and SOFA with Outcome in Terms of Complications (n = 105) 술 (P = 0.034), 그리고이악하강 (P = 0.009) 이었다 (Table 5). Variable Adjusted odds ratio (95% confidence interval) P value 고 찰 CRP (n = 57) 226.2 17.37 (2.40 125.87) 0.005 ASA 3 2.73 (0.91 8.18) 0.073 APACHE II 7 3.36 (1.13 9.97) 0.029 SOFA 3 5.74 (1.53 21.50) 0.010 Variables are adjusted for age and diabetes mellitus. CRP: C-reactive protein, ASA: American Society of Anesthesiologists physical status, APACHE II: acute physiology and chronic health evaluation, SOFA: sequential organ failure assessment. 기도삽관이쉬었던군과어려웠던군사이에는수술시기가 2009년이전 (P = 0.004) 과집도과가이비인후과가아닌수술의경우 (P = 0.032) 에있어유의한차이를보였다 (Table 4). 단변수회귀분석에서어려운기도삽관과유의한관련이있었던변수들은 2009년이전 (P = 0.005), 집도과가이비인후과가아닌수 www.anesth-pain-med.org 심경부감염은경부공간내에발생하는염증성질환으로모든연령대에서발생가능하고생명을위협하는질환으로알려져있으며 [1,11], 빠른외과적수술처치는기도확보, 항생제처치와함께핵심적위치를갖는다 [1,2]. 연구자에따라수술의적용기준이다양하지만, 수술적응증은비경구적항생제치료시작 24 48시간경과후에도증상의호전이없는경우, 연부조직의종창의확장으로인한질식을포함한치명적합병증의발생이임박한경우, 피하공기가영상에보이는경우, 저산소증을동반한호흡곤란이있는경우등으로, 응급절개배농술을즉시시행하여야한다 [3,4,12,13]. 마취과학적관점에서심경부감염은개구장애와혀를비롯한구강내조직과경부종창의빈번한발생을촉발하므로기도삽 351
Anesth Pain Med Vol. 14 No. 3 관시시야확보가어려운경우가많으며, 수술의시급함때문에수술전금식시간이부족한경우도있으며, 연하통, 연하곤란, 개구장애로인해대부분의환자들은탈진상태인경우가흔하며, 세균혈증으로인해발생할수있는마취중의혈역학적변화에대처해야하는질환이다 [14]. 각종기구의사용으로인하여과거와비교하여심경부감염시어려운기도삽관의발생빈도가감소하고있으나, 신속한대처가늦어졌을경우치명적인합병증들이발생할수있다 [15]. 본연구에서 2009년이후어려운기도삽관군에해당하는항목이유의하게많은것으로나온것은, 이시기이후기도삽관이어려운경우가많았다기보다여러기구들을사용한경우가많아서본연구의가정에이런점이반영된결과라고추측된다. 심경부감염은어느연령에서나발생할수있으나 [13,14], 노인에서합병증이더발생한것은면역기능의연령과연관된감소가감염원에대한감수성을증가시키기때문인것같다. 우리연구와비슷한평균발생연령을보고한타이완의 Huang 등 [3] 은다른저개발국가들에서조사된보고들보다자신들의연구에서발생연령이높았던것은상대적으로우수한자국의위생및의료수준과인구의고령화에기인하는것같다는의견을보고한바있다. 성별에대한비율은남자에서 1.3 1.7배더호발한다는기존보고와같이 [2,6,13] 저자들의연구에서도남자가많았다. 이와관련하여 Lehnerdt 등 [14] 은흡연이급성편도염이나편도주위농양발생의유발요인인점이영향을미친것같다고하였다. 심경부감염의원인의시작점은치아, 편도, 인두, 부비동, 갑상선, 중이및유양돌기, 측두골추체, 설근부, 구강저, 경부림프절등다양하게보고된바있다 [3,6,16]. 항생제가널리사용되기이전에는편도선염이경부심부감염의주원인이었으나, 이번연구결과와같이최근에는일차적치아감염이나발치후이차적감염인치성상태 (ondontogenic condition) 가주원인인것으로보고되고있다 [6,12,14,16,17]. 대부분치과환자들로구성된비이비인후과환자군에서합병증과어려운기도삽관이높았던점은그이유가불분명하다. 의인성요인이작용했을수도있으나, 다음의가능성을생각할수있을것같다. 본연구에서어려운기도삽관과관련성을보였던구강저봉와직염 (Ludwig s angina) 은총 13건중 6건을치과에서집도하였고원인부위중치과환자가차지하는비율이 18.2% 로이비인후과의비율 (10.3%) 보다높았는데, 이질환은이악하강으로부터종격동으로농양이자주진행하여합병증을촉진시키므로, 치과수술에서더합병증이발생하는것에영향을주었을개연성이있다 [3,18]. 심경부감염의가장흔한치성원인으로하악제2, 제3 대구치의치근단감염을들수있는데이치아의뿌리가아래쪽으로는턱목뿔근 (myelohyoid muscle) 의기시부까지뻗어있으며옆으로는개구장애와경부종창이자주관 찰되는악하강과부인강에닿아있어감염전파의경로로자주이용되기때문이다 [2,3,12]. 따라서치성감염인경우, 해부학적관련성때문에치과에서수술을담당하는비율이더높으므로어려운기도삽관이유의하게많았다고추정된다. 본연구에서발생부위는부인강, 악하강과다발성이많았는데이는다른연구자들의보고와일치한다 [4,6,13,14]. 특히발생부위가다발성과후인두강인경우합병증이호발하며, 우리연구에서는다발성인경우에는확인되었지만후인두강인경우는확인하지못했다 [4,13,19]. 편도주위부위의감염은부인강으로직접퍼지기때문에부인강이흔하게침범되므로부인강이가장많았던이유중에하나일것으로생각된다 [4]. Streptococci는심경부감염으로부터가장많이동정되는세균이며, 그다음으로는 Staphylococci인것으로알려져있다 [2,5,6,14]. 이는본조사결과와일치하였다. 심경부감염환자모두에서수술중검체를채취하였지만 51명 (48.6%) 에서는세균이동정되지않았는데이는아마도수술전에정맥주사용고용량의항생제를투여했거나채취기구나채취방법이적절하지못한결과인것같다. 기저질환으로당뇨와고혈압이가장흔했는데이는다른연구와일치한다 [6]. 당뇨가 40.0% 의환자들에서있었는데이는다른연구에서의유병율과유사하다 [12]. 당뇨는심경부감염의위험인자로오래전부터알려져왔다 [2]. 고혈당은단시간에도숙주의면역기능에영향을주어세균들이구인두내에집락을형성하기용이하므로결과적으로다양한종류의감염의위험인자가되고따라서패혈증에빠지기쉽고, 일단패혈증이생기면탄수화물대사를더욱유해 (adverse) 시켜당의상승이일어나는악순환이발생한다 [11,18]. 따라서당뇨가있는심경부감염은사망률과이환율이높아진다 [10,16,17]. 본연구에서도당뇨환자군에서유의하게합병증의발생빈도가높았다. 따라서심경부감염이발생한당뇨환자들에선마취중에도수액상태, 산- 염기균형과혈중전해질과포도당수준에관해신중한조절이필요하다고생각된다 [1,8]. Mallampati 점수의평균값이심경부감염환자에서유의하게높았다는보고가있었으나 [4] 본연구에서상당수는개구장애때문에정확하게측정하지못하였으므로조사에포함시키지않았다. 체질량지수는이환자들에서도어려운기도삽관의예측지표가되지못하였다 [19]. 심경부감염이의심되는전신질환유무를포함한마취전자세한병력파악과더불어마취유도전두경부자기공명이나컴퓨터단층촬영영상을확인하는것이감염부위의정확한해부학적위치및성상, 파급정도를잘알수있으므로, 마취의에게도매우중요하다 [8,20]. 수술전경비굴곡후두경 (transnasal fiberoptic laryngoscopy) 을통하여후인두의구조및전위소견을직접관찰할수있다면마취유도시유익할것으로판단된다 [4]. 352 www.anesth-pain-med.org
내과적치료를받은환자들을포함한 Suehara 등 [5] 의연구에의하면심경부환자들중 25% 가기도삽관시접근이어려웠고, 이중 6% 는내시경, 15% 는윤상감상연골절개 (cricothyroidotomy), 25% 는마취과의사에의해서기도확보가가능하였다고보고한바있다. 따라서심경부감염환자에서기도유지를위해기관내삽관을하는경우, 다양한기구와기술들을이용할수있는수술실에서숙련된마취의의참여하에시행하여야한다는의견을보고한바있다. 본연구의경우고식적인곡형날후두경외에도각종기구를이용하여기관내삽관을통해기도를확보하였다. 기도삽관의무리한반복적시도는구강내출혈이나고름집의파열로인한배출, 이미파열되어위내에체류하던내용물의역류를일으킬수있어, 삽관불가, 환기불가 ( cannot intubate, cannot ventilate situation ) 같은기도재앙 (airway catastrophe) 이나감염원의흡입을일으킬수있다 [2,5]. 의식하굴곡성기관지경유도삽관 (awake fiberoptic intubation) 은삽관과정동안기도개방 (airway patency) 의유지, 가스교환, 흡인방지의장점을제공하므로본연구에서도 6.3% 에서시술되었으나, 굴곡성기관지경이구강및인두에손상을주어출혈을유발시킬가능성도고려하여야한다. 의식하굴곡성기관지경유도삽관이실행되지못하는심각한기도폐쇄를가진환자에서국소마취하에의식하기관절개술이우선적으로고려되어야만한다 [9]. 본연구에서도마취유도실패후각성상태에서응급기관절개술을시행하는경우가 2건 (1.9%) 확인되었다. 따라서심경부감염환자가위중한기도압박상태라고판단될때에는기관절개술에대한준비를한후에마취유도를하는것이안전하다고생각된다. 최근보편화된비디오후두경도어려운기도삽관환자들의후두시야 (glottic view) 를개선시키며기도손상을줄였으나, 기도삽관시도의횟수를감소시킨다든지기도삽관에걸리는시간을줄였다는증거는없다는한계가있다 [21]. 결국기도조작 (airway maneuver) 의선택에있어가장중요한것은마취의의판단과경험에따라각환자별로개별화하는것이다 [3]. 마취방법과수술후합병증사이의관련성은확인못했다. 단아산화질소의사용이합병증발생과상관있는것으로규명되었다. 경부공간내에세균이발생시킨가스가많이형성되어있으면농양의크기와괴사가더심하여예후가안좋다고보고된바있다 [1]. 특히당뇨환자에서높은혈당은혼합산발효 (mixed acid fermentation) 를통해가스가형성되는환경을만들어준다 [22]. 따라서본연구에서 N 2 O의사용은고름이발생한공간의확장과전파경로가되는면을따라스며들며농양의확대에기여하므로중요장기로전파되는길을열어주었을가능성이있다고추측된다. Gidley 등 [12] 은심경부농양의수술후 13.3% 에서발관이실패한보고를하며, 환자들이절개배농술을받은후 24 48시간까 www.anesth-pain-med.org 지종창이증가될수있다고하였고, 발관전후두경이나굴곡성기관지경으로기도의구조가개방을유지하는지파악할것을권장하였다. 이런기도폐쇄의우려때문에마취종료시기도내튜브를제거하지않고중환자실로이송하여호흡상태를감시하며수술부위의종창등상태와의식의회복정도를고려하여기관내튜브를제거하는것이적절한방법이라고생각된다. 이번연구에서마취종료후 22.6% 의환자들에서수술실에서튜브를제거하지않았으며, 이는일반적수술후중환자실로이송된환자들을대상으로보고된다른연구보다높은비율이다 [23]. 본연구에서의합병증발생율은 41.4% 로심경부감염에대한다른연구자들의 11.2% 25.5% 의합병증빈도와비교하여높은데 [3,5] 이는심경부감염에대한많은연구들이국내외에서보고되어있지만, 전신마취를받은환자들만분석한연구는드물고, 기존의연구가마취방법과상관없이집도과별로연구되어있고, 보존적내과적치료를받은사례들이다수포함되어있기때문에, 상대적으로높았다고생각된다 [5]. 저자들의연구에서는심경부감염과관련있다고알려진몇가지점수체계를포함한지표들과 C-반응단백질수치가수술후합병증의발생과관련있는지조사하였다. 염증성질환이나조직의괴사등에서현저하게증가하는급성상반응단백 (acute phase proteins) 의대표적인성분으로여러가지다양한감염성질환의진단이나추후질환의추적관찰, 항생제의반응정도를확인하는등에널리사용되고있는 C-반응단백질수치는심경부감염환자에서사망률을예측하는데유용한혈액검사로보고된바있어 [1,24], 본연구에서다른지표들과비교를시도하였다. 박등 [4] 은심경부감염이있는군에서 C-반응단백질수치가단순경부감염이있는군에서보다통계적으로유의하게높았다고보고한바있다. 본연구에서도수술후예후와의관련성을확인했으나, C-반응단백질검사가 57명 (54.2%) 에서만시행되었기때문에심경부감염수술환자들에서이검사의예후적의미를확정할수는없을것같다. 다변수분석에서미국마취과학회신체분류점수와수술후합병증과의상관관계는발견하지못했다. 그동안의연구들이미국마취과학회신체분류점수가높은경우수술후이환율과사망률의위험의증가와관련을입증한바있지만 [25 27], 심경부감염환자들의전신마취후상황에선확인이되지않았다. APACHE II는수술후합병증과관련이있었다. Huang 등 [3] 은고령과전신질환이심경부감염의예후에가장결정적요인이라고보고한바있는데, 연령은 APACHE II 체계의구성요소로점수에영향을주었고, 질환으로인한생리적변화들도 APACHE II 점수에반영되기때문인것같다. 더불어만성건강부분에각종부전상태가 APACHE II 점수에반영되어영향을줌으로우수한예측능력을보였다고추정된다. 본연구에서평균순차적장기부전평가점수는 1.69 점이었는데이것은응급실에서순차적장기부전평가점수가높 353
Anesth Pain Med Vol. 14 No. 3 을수록환자의생존이낮았다는 Kim 등 [1] 의연구에서평균 1.0 점이었던것보다높다. 따라서본연구에서응급수술을받으러온환자들은장기부전에도달했거나임박한상태의환자들이상대적으로많았음을암시하며, 이로인해순차적장기부전평가가수술후합병증발생과유의한관련성을보인것같다. 본연구의제한점으로는첫째, 일개대학병원수술실을대상으로한연구이므로제한된환자수가통계결과에영향을미쳤을수있다. 둘째, 어려운기도삽관이었다고설정한조건들에서각종기구들을사용한경우실제는어려운기도삽관이아니었으나선재적차원에서이용가능한기구를사용한경우들이포함되었을수있다. 이런경우실제어려운기도삽관은더적었을수있었고결과에영향을주었을수있다. 후향적연구방법으로인하여본연구의가설의타당성에한계가존재한다. 결론적으로, 마취의는심경부감염환자의마취관리시기도확보, 활력징후와당조절을포함한환자감시와처치, 수술후중환자실에서호흡관리와심각한합병증치료에중요한역할을담당한다. 심경부감염은심각한합병증을유발할수있으며그경과가좋지않을수있다는것을늘염두에두고보다적극적이고즉각적인치료를시행해야된다. 이환자들에서 APACHE II 와순차적장기부전평가는수술후예후를예측할수있는수단이될수있을것이다. 또한, 심경부감염환자에있어서마취전영상의학적촬영영상과후두경의소견을확인하는마취과의사의임상적판단과정이제일중요하지만, 심경부감염환자에서기관내삽관의난이도를예측할수있는요인의규명을위한추가적연구가필요하다고생각된다. CONFLICTS OF INTEREST No potential conflict of interest relevant to this article was reported. ORCID Tae Kwane Kim: https://orcid.org/0000-0002-0635-3304 Hye Jin Yoon: https://orcid.org/0000-0002-9558-7865 Yuri Ko: https://orcid.org/0000-0002-9681-3633 Yuna Choi: https://orcid.org/0000-0001-9111-8298 Ui Jin Park: https://orcid.org/0000-0003-2114-0195 REFERENCES 1. Kim JJ, Hyun SY, Kim JK, Lim YS, Shin JH, Cho JS, et al. The clinical features of patients with deep neck infections who were admitted to the intensive care unit in a single emergency center. Korean J Crit Care Med 2008; 23: 96-101. 2. Spitalnic SJ, Sucov A. Ludwig s angina: case report and review. J Emerg Med 1995; 13: 499-503. 3. Huang TT, Liu TC, Chen PR, Tseng FY, Yeh TH, Chen YS. Deep neck infection: analysis of 185 cases. Head Neck 2004; 26: 854-60. 4. Park SJ, Kim SC, Kim MC, Ko YG. Retrospective clinical review of deep neck infections (abscesses). J Korean Soc Emerg Med 2003; 14: 341-5. 5. Suehara AB, Gonçalves AJ, Alcadipani FA, Kavabata NK, Menezes MB. Deep neck infection: analysis of 80 cases. Braz J Otorhinolaryngol 2008; 74: 253-9. 6. Larawin V, Naipao J, Dubey SP. Head and neck space infections. Otolaryngol Head Neck Surg 2006; 135: 889-93. 7. Greenberg SL, Huang J, Chang RS, Ananda SN. Surgical management of Ludwig s angina. ANZ J Surg 2007; 77: 540-3. 8. Lee JK, Lim SC. Deep neck infections in diabetic patients. Korean J Otolaryngol-Head Neck Surg 2006; 49: 323-7. 9. Paik JH, Kim JH, Kim JG. Mediastinitis complicated by peritonsillar abscess. Korean J Otolaryngol-Head Neck Surg 1986; 29: 262-5. 10. Beck HJ, Salassa JR, McCaffrey TV, Hermans PE. Life-threatening soft-tissue infections of the neck. Laryngoscope 1984; 94: 354-62. 11. Do NY, Cho SI, Lee JH, Dong GW, Kim GH. Clinical study of deep neck infection. Korean J Otolaryngol-Head Neck Surg 2007; 50: 240-6. 12. Gidley PW, Ghorayeb BY, Stiernberg CM. Contemporary management of deep neck space infections. Otolaryngol Head Neck Surg 1997; 116: 16-22. 13. Choi KH, Chah SH, Im KL, An DA, Sohn HS. A case of hypoxic encephalopathy following anesthesia for a patient with ludwig s angina. Korean J Anesthesiol 1988; 21: 850-4. 14. Lehnerdt G, Senska K, Fischer M, Jahnke K. Smoking promotes the formation of peritonsillar abscesses. Laryngorhinootologie 2005; 84: 676-9. 15. Song HM, Choi SH, Choi SH, Kim SY, Nam SY. Isolated microorganisms and antimicrobial resistance of the deep neck infection: a retrospective review of 76 cases. Korean J Otolaryngol-Head Neck Surg 2006; 49: 66-71. 16. Lee JK, Kim HD, Lim SC. Predisposing factors of complicated deep neck infection: an analysis of 158 cases. Yonsei Med J 2007; 48: 55-62. 17. Huang TT, Tseng FY, Liu TC, Hsu CJ, Chen YS. Deep neck infection in diabetic patients: comparison of clinical picture and outcomes with nondiabetic patients. Otolaryngol Head Neck Surg 2005; 132: 943-7. 18. Shockley WW. Ludwig angina: a review of current airway management. Arch Otolaryngol Head Neck Surg 1999; 125: 600. 354 www.anesth-pain-med.org
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