25 소아외과 : 제 16 권제 1 호 2010 년 Vol. 16, No. 1, June 2010 히크만카테터를삽입한소아환자에서발생한합병증분석 서울아산병원 김태훈 김대연 조민정 김성철 김인구 서 론 대상및방법 히크만카테터 (Hickman catheter) 는카테터의상당부분을피하에심는중심정맥카테터의일종으로반복적인화학항암치료제, 항생제등의정맥주사, 혈액검사를위한혈액채취, 종합비경구영양법의적용등을위해광범위하게사용되고있다 1. 히크만카테터의시술및관리중에발생하는여러가지합병증은환자의치료과정및임상경과에중요한영향을미치기때문에합병증의예방및처치가장기적인환자관리에있어매우중요한과정으로자리매김하고있다 2-5. 저자들은히크만카테터를삽입한소아환자에서발생한합병증을분석하여합병증의발생양상, 합병증의발생에영향을미치는인자들및치료결과를알아보고자하였다. 본논문의요지는 2010 년 6 월대구에서개최된제 26 회소아외과학회춘계학술대회에서구연되었음. 접수일 : 10/7/28 게재승인일 : 10/9/6 교신저자 : 김대연, 138-736 서울송파구아산병원길 86 서울아산병원소아외과 Tel : 02)3010-3964, Fax : 02)3010-6863 E-mail: kimdy@amc.seoul.kr 2004년부터 2009년까지서울아산병원에서히크만카테터삽입술을받고추적관찰이가능하였던 154명의소아환자를대상으로하였다. 의무기록을바탕으로대상환자에서발생한합병증의발생빈도및발생양상을후향적으로분석하였고특히합병증중가장중요한카테터관련감염증의발생에유의한영향을미치는인자들을파악하기위해수술당시환자의나이, 성별, 수술시간, 이전중심정맥수술과거력, C-arm 형광투시법사용여부, 치료받은기저질환의종류, 수술시절대호중구감소증 ( 절대호중구수 0.5 10 9 /L 미만 ) 유무, 수술시혈소판감소증 ( 혈소판수 50,000/mm 3 미만 ) 유무등의다양한인자들을로지스틱회귀분석을사용하여통계적으로분석하여카테터관련감염증에유의한영향을미치는인자들을찾고자하였다. 통계분석은 SPSS 12.0K를사용하였고 P-value가 0.05 이하일때통계적유의성이있다고판단하였다.
26 소아외과제 16 권제 1 호 2010 년 결과총 154명의환자가히크만삽입술을시행받고추적관찰이가능하였다. 수술당시의평균연령은 7.6 ± 5.1 세 (1 개월~18세 ) 였고, 남아가 92명, 여아는 62명이었다. 혈액암을비롯한혈액질환환자가 107명 (69.5 %) 이었고고형종양환자가 39명 (25.3 %), 기타질환환자가 8명 (5.2 %) 이었다. 기존에케모포트삽입술등의중심정맥수술력이있는환자가 121명 (78.6 %) 이었다. 수술시행부위는기존에오른쪽에수술을시행받은환자들이많아서왼쪽속목정맥에삽입한경우가 80례 (51.9 %) 로가장많았고오른쪽속목정맥이 39례 (25.3 %), 오른쪽바깥목정맥과왼쪽바깥목정맥이각각 18 례 (11.7 %), 17례 (11.0 %) 였다. 수술시행시 C-arm 형광투시법을통해카테터의적절한위치를확인한경우가 47례 (30.5 %) 를차지하였다. 평균수술시간은 67.4 ± 21.3 분이었다. 추적관찰기간중에카테터를제거한경우가 143례였는데카테터제거사유를살펴보면특별한문제없이사용종료이후제거한경우가 82례 (57.3 %) 였고, 카테터관련혈류감염증으로제거한경우가 44례 (30.8 %), 기계적기능이상 (mechanical malfunction) 으로제거한경우가 11례 (7.7 %), 자다가환자자신이제거하거나선이발에걸려제거되는등의단순사고로제거된경우가 6례 (4.2 %) 였다 ( 그림 1). 카테터제거를유발한합병증의수를전체카테터유지일로나눈카테터제거를유발한합병증의전체발생률은 2.01/1,000 카테터일 (catheter days) 이었으며이중카테터관련혈류감염증의발생률은 1.45/1,000 카테터일이었다. 합병증없이사용종료이후카테터를제거한 82례의평균카테터유지기간은 214.9 ± 140.2 일이었고카테터관련혈류감염증으로카테터를제거한 44례의평균카테터유지기간은 168.2 ± 116.1 일이었다. 이를수술후 8주를기준으로하여수술후초기감염군 (n = 8) 과수술후후기감염군 (n = 36) 으로나누어보면, 수술후초기감염군의평균카테터유지기간은약한달 (34.1 ± 16.4일 ), 수술후후기감염군의평균카테터유지기간은약 6~7개월 (198.0 ± 116.0 일 ) 이었다. 44례의카테터관련혈류감염증중 24례는 methicillin-resistant Staphylococcus aureus, Streptococcus 등의그람양성균이동정되었으며 20례에서는 Pseudomonas aeruginosa, Acinetobacter 등의그람음성균이동정되었다. 원인균에맞는항생제치료와카테터제거로대부분의경우에서임상적으로호전되었는데카테터제거를한후에도패혈증 Fig. 1. The Causes of Hickman Catheter Removal (n=143)
김태훈외 : 히크만카테터를삽입한소아환자에서발생한합병증분석 27 Table 1. Univariate Analysis for Associated Factors with Catheter Related Bloodstream Infections Variable P value Patient s age ( 6 years old) (n=87) 0.725 Sex (male) (n=92) 0.348 Operation time ( 100 minutes) (n=13) 0.734 Previous central line operation history (n=121) 0.358 Use of C-arm fluoroscopy (n=47) 0.781 Underlying disease (hematologic disease) (n=107) 0.954 Neutropenia(Absolute neutrophil count<0.5 10 9 /L) (n=21) 0.640 Thrombocytopenia (platelet count<50,000/mm 3 ) (n=29) 0.750 Table 2. Univariate Analysis for Associated Factors with Early Post-operative (within 8 weeks) Catheter Related Bloodstream Infections Variable P value Patient s age ( 6 years old) (n=87) 0.718 Sex (male) (n=92) 0.471 Operation time ( 100 minutes) (n=13) 0378 Previous central line operation history (n=121) 0.147 Use of C-arm fluoroscopy (n=47) 0.051 Underlying disease (hematologic disease) (n=107) 0.610 Neutropenia(Absolute neutrophil count<0.5 10 9 /L) (n=21) 0.354 Thrombocytopenia (platelet count<50,000/mm 3 ) (n=29) 0.172 으로인해카테터제거 1개월이내에사망한증례가 2명의환자에서발생하였다. 카테터관련감염증의발생에유의한영향을미치는인자들을파악하기위해수술당시환자의나이, 성별, 수술시간, 이전중심정맥수술과거력, C-arm 형광투시법사용여부, 치료받은기저질환의종류, 수술시절대호중구감소증유무, 수술시혈소판감소증유무등의인자들로단변량분석을실시하였으나어느인자도카테터관련혈류감염증과연관되어통계적으로유의한인자로나타나지않았다 ( 표 1). 같은인자들 을수술후초기감염군에국한하여단변량분석을시행하였을때에도모든인자들이수술후초기카테터관련혈류감염증과연관되어통계적으로유의한인자로나타나지않아 ( 표 2) 카테터관련감염증발생에유의한영향을미치는인자들을찾아낼수없었다. 고찰최근항암화학치료와전반적인환자관리의발전에힘입어치료성적의유의한향상
28 소아외과제 16 권제 1 호 2010 년 이있어왔는데, 히크만카테터는이러한혈액종양환자들의항암화학치료와골수이식의정맥주입치료의효과적인수단으로세계적으로널리활용되고있는중심정맥도관이다 1. 히크만카테터관련합병증들이환자의치료과정과임상경과에영향을미치기때문에이를예방하려는노력과함께합병증의발생과연관된인자들을찾아내려는여러연구들이있었다. 히크만카테터제거를유발한합병증은전체시행된환자들 154례중 61례 (39.6 %) 에서발생하였으며, 특히카테터제거를유발하는가장중요한합병증은감염에의한합병증으로본연구에서도전체카테터제거를유발한합병증 61례중 44례 (72.1 %) 가카테터관련혈류감염증이었다. 카테터관련감염증과연관하여수술시절대호중구감소증 ( 절대호중구수 0.5 10 9 /L 미만 ) 의유무에대해여러연구들이있었는데다수의연구에서호중구감소증이중심정맥도관의감염관련합병증의증가와연관되어있다고보고하고있으며가급적절대호중구수가 0.5 10 9 /L 미만인경우를피하여수술을시행할것을추천하고있다 6-9. 그러나 Press 등 10 (1984) 은성인악성종양환자들의히크만카테터감염합병증에대해 18편의연구들을분석하여수술시호중구감소증이감염합병증과연관되지않았다는결론을내리기도하였다. 본연구에서도호중구감소증이카테터관련혈류감염증의발생과유의한연관이없는것으로나타났으며, 이는수술후 8주이내의초기감염에국한하여살펴보았을때에도동일한결과를보였다. 본원에서수행 되었던다른연구에서 Nam 등 11 (2010) 은케모포트삽입술후후기감염증에유의한인자로혈소판감소증을보고하였는데, 본연구에서는혈소판감소증은카테터관련혈류감염증의발생과유의한연관이없는것으로나타났으며, 이는수술후 8주이내의초기감염및수술후 8주이후의후기감염에서도동일한결과를보였다. 한편환자의나이, 성별및기저질환의종류등이감염합병증과연관되어있다는보고들이있었는데, Fratino 등 12 (2005) 은 418건의소아중심정맥관삽입수술시행후결과분석을통해고형종양질환에비해백혈병등의혈액질환환자에서보다높은감염합병증이발생하였으며, 6세이전의소아에서더많은감염증이발생하였다고보고하였다. Perdikaris 등 1 (2008) 도비슷한결과를보고하였는데어린나이, 혈액질환이보다높은감염증발병과연관되었다는결과와함께남자환자에서더높은감염증발병을보고하였다. 그러나본연구에서는성별, 환자의나이, 기저질환의종류가카테터관련혈류감염증의발생과유의한연관이없는것으로나타났다. 수술시간, 이전중심정맥수술과거력, C-arm 형광투시법사용여부등은수술시행당시수술난이도를반영하는지표들로광범위한조직과혈관의박리및조작이가해졌을가능성을예측할수있어서이들지표를통해환자의특성및전신상태가아닌수술자체의조작이감염에미치는영향을살펴보고자하였다. 앞서언급한 Nam 등 11 (2010) 의보고에서이전중심정맥수술과거력이수술후초기감염증과연관된인자로나타난바있었는데, 이러한
김태훈외 : 히크만카테터를삽입한소아환자에서발생한합병증분석 29 수술과연관된인자들역시본연구에서는카테터관련혈류감염증의발생과통계적으로유의한연관이없는것으로나타났다. 한편카테터관련혈류감염증이발생한환자들은적절한항생제투여와카테터제거로대부분의경우에서임상적으로호전되었는데합병증없이사용종료이후카테터를제거한 82례의평균카테터유지기간이 214.9 일이었고수술후후기감염증으로인해카테터를제거한 36례의평균카테터유지기간은 198.0일로큰차이를보이지않아카테터사용이종료되었을때신속하게카테터를제거하는것이발생할수있는합병증을줄이는매우효과적인예방책이될것으로판단된다. 결 론 히크만카테터제거를유발한합병증은전체시행된환자의 39.6 % 에서발생하였으며, 그중카테터관련혈류감염증의경우가 72.1 % 로가장주요한원인임을알수있었다. 초기감염을제외한수술후후기감염합병증의경우수술후약 6개월에발생하였으므로치료종류후가능한조기에카테터를제거하는것이필요하며, 카테터관련합병증의증상및징후를세심히살펴보아가능한조기에원인규명및처치가이루어지는것이중요하다. 참고문헌 1. Perdikaris P, Petsios K, Vasilatou-Kosmidis H, Matziou V: Complications of Hickman- Broviac catheters in children with malignancies. Pediatr Hematol Oncol 25:375-384, 2008 2. Wickham R, Purl S, Welker D: Long term central venous catheters: issues for care. Semin Oncol Nurs 8:133-147, 1996 3. Bouza E, Burillo A, Munoz P: Catheter related infections: diagnosis and intravascular treatment. Clin Microbiol Infect 8:265-274, 2002 4. Fatkenheuer G, Cornely O, Seifert H: Clinical management of catheter-related infections. Clin Microbiol Infect 8:545-550, 2002 5. Galway R: Central venous access and hand washing: variability in policies and practices. Paediatr Nurs 15:16-18, 2003 6. Nouwen JL, Wielenga JJ, van Overhagen H, Lameris JS, Kluytmans JA, Behrendt MD, Hop WC, Verbrugh HA, de Marie S: Hickman catheter-related infections in neutropenic patients: Insertion in the operating theater versus insertion in the radiology suite. J Clin Oncol 17:1304-1322, 1999 7. Howell PB, Walters PE, Donowitz GR, Farr BM: Risk factors for infection of adult patients with cancer who have tunneled central venous catheters. Cancer 75:1367-1375, 1995 8. McLean TW, Fisher CJ, Snively BM, Chauvenet AR: Central venous lines in children with lesser risk acute lymphoblastic leukemia: Optimal type and timing of placement. J Clin Oncol 23: 3024-3029, 2005 9. Elihu A, Gollin G: Complications of implanted central venous catheters in neutropenic children. Am Surg 73:1079-1082, 2007 10. Press OW, Ramsey PG, Larson EB, Fefer A, Hickman RO: Hickman catheter infections in patients with malignancies.
30 소아외과제 16 권제 1 호 2010 년 Medicine (Baltimore) 63:189-200, 1984 11. Nam SH, Kim DY, Kim SC, Kim IK: Complications and risk factors of infection in pediatric hemato-oncology patients with totally implantable access ports (TIAPs). Pediatr Blood Cancer 54:546-551, 2010 12. Fratino G, Molinari AC, Parodi S, Longo S, Saracco P, Castagnola E, Haupt R: Central venous catheter-related complications in children with oncological/ hematological diseases: an observational study of 418 devices. Ann Oncol 16:648-654, 2005
김태훈외 : 히크만카테터를삽입한소아환자에서발생한합병증분석 31 Analysis of Complication in Pediatric Patients with Hickman Catheters Taehoon Kim, M.D., Dae-Yeon Kim, M.D., Min Jeong Cho, M.D., Seong-Chul Kim, M.D., In-Koo Kim, M.D. Department of Pediatric Surgery, Asan Medical Center, University of Ulsan College of medicine, Seoul, Korea Hickman catheters are tunneled central venous catheters used for long-term venous access in children with malignancies. The appropriate management for various kinds of catheter related complications has become a major issue. We retrospectively analyzed the clinical, demographic, and surgical characteristics in 154 pediatric hemato-oncology patients who underwent Hickman catheter insertion between January 2005 and December 2009. There were 92 boys and 62 girls. The mean age at surgery was 7.6±5.1 years old. The mean operation time was 67.4±21.3 minutes and C-arm fluoroscopy was used in 47(30.5 %). The causes of Hickman catheter removal were termination of use in 82 (57.3 %), catheter related bloodstream infection in 44(30.8 %), mechanical malfunction in 11(7.7 %), and accidents in 6(4.2 %). Univariate and multivariate analysis for associated factors with catheter related bloodstream infection showed that there were no statistically significant associated factors with catheter related infection complications. All cases except two showed clinical improvement with catheter removal and relevant antibiotics treatment. The mean catheter maintenance period in patients of catheter removal without complications was 214.9±140.2 days. And, The mean catheter maintenance period in patients of late catheter related bloodstream infection was 198.0±116.0 days. These data suggest that it is important to remove Hickman catheter as soon as possible after the termination of use. When symptoms and signs of complications were noticed, prompt diagnostic approach and management can lead to clinical improvements. (J Kor Assoc Pediatr Surg 16(1):25~31), 2010. Index Words:Hickman catheter, Children, Complications Correspondence:Dae-Yeon Kim, M.D., Asan Medical Center, Department of Pediatric Surgery, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea Tel : 02)3010-3964, Fax : 02)3010-6863 E-mail: kimdy@amc.seoul.kr