Journal of Korean Society of Spine Surgery Acute Myocardial Infarction and Postpharyngeal Hematoma after Anterior Cervical Spine Surgery on a Coronary Artery Disease Patient - A Case Report - Jung-Eun Kim, M.D., Young-Jin Kang, M.D., Sung-Wook Park, M.D., Keon-Sik Kim, M.D., Dong-Ki Lee, M.D., Kyung-Soo Suk, M.D. J Korean Soc Spine Surg 2013 Dec;20(4):190-195. Originally published online December 31, 2013; http://dx.doi.org/10.4184/jkss.2013.20.4.190 Korean Society of Spine Surgery Department of Orthopedic Surgery, Inha University School of Medicine #7-206, 3rd ST. Sinheung-Dong, Jung-Gu, Incheon, 400-711, Korea Tel: 82-32-890-3044 Fax: 82-32-890-3467 Copyright 2013 Korean Society of Spine Surgery pissn 2093-4378 eissn 2093-4386 The online version of this article, along with updated information and services, is located on the World Wide Web at: http:///doix.php?id=10.4184/jkss.2013.20.4.190 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Case Report pissn 2093-4378 eissn 2093-4386 J Korean Soc Spine Surg. 2013 Dec;20(4):190-195. http://dx.doi.org/10.4184/jkss.2013.20.4.190 Acute Myocardial Infarction and Postpharyngeal Hematoma after Anterior Cervical Spine Surgery on a Coronary Artery Disease Patient - A Case Report - Jung-Eun Kim, M.D.*,, Young-Jin Kang, M.D., Sung-Wook Park, M.D.*,, Keon-Sik Kim, M.D.*,, Dong-Ki Lee, M.D., Kyung-Soo Suk, M.D. Department of Anesthesiology and Pain Medicine, Graduate School, Kyung Hee Medical University, Seoul, Korea* Department of Anesthesiology and Pain Medicine, Kyung Hee Medical Center, Kyung Hee University of Korea, Korea Department of Orthopedic Surgery, Kyung Hee Medical Center, Kyung Hee University of Korea, Korea, Study Design: Case report. Objectives: To report a case of preventive intubation to coronary artery disease patient who underwent percutaneous coronary intervention following an anterior cervical spine surgery Summary of Literature Review: Postpharyngeal hematoma occurs more to a patient who underwent percutaneous coronary intervention for myocardial infarction following an anterior cervical spine surgery. And postoperative airway obstruction due to it is one of the most serious adverse events associated with anterior cervical spine surgery. Preventive intubation was tried and it was useful for treatment. Materials and Methods: A 61-year-old man suffered from neck pain and radiating pain on left upper extremity was performed an anterior cervical spine surgery. After operation, he complained acute myocardial infarction symptoms and Emergency percutaneous coronary intervention was performed. After that, postpharyngeal hematoma appeared and compressed the airway. Intubation was performed to prevent airway obstruction. Result: Airway obstruction was prevented through early intubation. Hematoma evacuation and insertion of Hemovac performed and the patient discharged without any complications such as neurologic or cardiac problems. Conclusion: Preventive intubation to coronary artery disease patient who underwent percutaneous coronary intervention following an anterior cervical spine surgery is useful for treatment of airway obstruction due to postpharyngeal hematoma. Key Words: Anterior cervical spine surgery, Coronary artery disease, Postpharyngeal hematoma, Airway obstruction 서론 경추부전방수술 (Anterior cervical spine surgery) 은경추부위의정형외과수술에서흔하게시행되는수술이다. 경추부전방수술후합병증중가장심각한것은수술부위혈종 (wound hematoma) 으로인한기도폐쇄로이는 0.2%-1.9% 로그발생률은낮지만발생시적절하게치료하지않으면호흡곤란 (respiratory arrest) 으로환자의생명을위협할수있는가장위험한합병증이다. 1,2) 특히관상동맥질환을가진환자에있어서경피적관상동맥중재술후항혈전제를복용하는환자의경우수술부위에혈종이생길위험은매우높아진다. 저자들은관상동맥질환을기저질환으로가진환자가경추부전방수술후급성 Received: January 17, 2013 Revised: February 18, 2013 Accepted: Sep 27, 2013 Published Online: December 31, 2013 Corresponding author: Keon-Sik Kim, M.D Department of Anesthesiology and Pain Medicine, Kyung Hee Medical Center, Hoegi-dong, Dongdaemun-gu, Seoul, Korea TEL: 82-2-958-8589, FAX: 82-2-958-8580 E-mail: keonsikkim@gmail.com This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 190 Copyright 2013 Korean Society of Spine Surgery
Journal of Korean Society of Spine Surgery Postpharyngeal Hematoma after Anterior Cervical Surgery on a CAD Patient 심근경색증 (myocardial infarction) 이발생, 응급경피적관상동맥중재술및스텐트삽입술을시행후수술부위의후인두혈종 (postpharyngeal hematoma) 이생겼고예방적기관내삽관을통해환자의안전은물론마취과의사와정형외과의사에게도좋은결과를가져다준사례를경험하였기에증례보고하는바이다. 증례보고 2011 년도 61세남자환자가한달간의경부통증과좌측상지방사통을주소로본원정형외과에내원하였다. 환자는제 5,6,7 경추간추간판탈출증 (herniate cervical disc) 을진단받고약물치료와주사치료등보존적치료를받았으나호전이없고증상이심해져전방경추추간판절제술및유합술 (anterior cervival discetomy and fusion) 을시행하기로결정하였다 (Fig. 1). 환자의키는 169cm, 체중은 83kg 이었다. 환자는과거력상고혈압과당뇨가있었다. 환자는 2008 년협심증이발생하여관상동맥조영술을실시, 그결과우측관상동맥 (Rt. coronary artery, RCA), 좌회선지동맥 (left circumflex artery, LCX), 좌전하행지동맥 (left anterior descending artery, LAD) 에협착이각각 70%, 60%, 85% 가있어서우측관상동맥과좌전하행지동맥에스텐트삽입술을시행한과거력이있었다. 환자는고혈압약으로 b-blocker, Angiotensin II receptor antagonist, Amlodipine, 당뇨약으로 Fig. 1. preoperative serial x-rays Glimepiride, Metformin, 스텐트삽입술후 clopidgrel 75mg 을복용하고있었다. 환자는수술일주일전 clopidogrel 을, 수술하루전당뇨약복용을중단하였다. 환자의심전도검사상에서는전중격의경벽성경색증 (anteroseptal infarct) 소견이있었고경흉부심장초음파상에서는특이사항없었다. 흉부방사선검사와폐기능검사도정상이었으며일반혈액검사, 전해질검사, 혈액응고검사 (PT, aptt) 상에도이상소견은없었다. 환자는수술실에입실하기 30분전 glycopyrrolate 0.2mg 을근주하였고, 수술실도착후환자에게혈압계와심전도, 맥박산소계측기호기말이산화탄소분압계를부착하여감시하였다. 마취유도전환자의혈압은 130/70mmHg, 심박수는 90회 /min, 산소포화도는 100% 였다. 마취유도는 propofol 120mg, Rocuronium 50mg 을정주한뒤기관내삽관을하였고, 마취유지는 N2O 및 O2를분당 2L씩투여하였으며흡입마취제로는 sevoflurane 을사용하였다. 수술중유도저혈압마취및활력징후안정을위해 remifentanyl 을 0.1ug/ kg/min로투여하였고경부조직의부종을막기위해 cortisol 100mg 을투여하였다. 우측전박에있는 18G 카테터정맥로외에좌측전박에 16G 카테터정맥로를추가로확보했으며직접동맥압측정을위해요골동맥을천자하였고, 수술중소변량측정을위해도뇨관을삽입하였다. 환자는특이소견없이제 5,6,7 경추간전방추간판절제술및유합술을끝마쳤고수술후수술부위혈종을예방하기위해 Hemovac 을삽입하였다. 수술직후환자는마취회복실로이송되었으며마취회복실퇴실직전환자의혈압은 130/85 mmhg, 맥박은 100회 /min, 산소포화도는 98% 로안정적양상을보였다. 수술후 1일오전에측정된환자의 Hemovac volume 은 45ml, 수술후 2일오전에측정된환자의 Hemovac volume 은 27ml 로안정된양상을보여환자는수술후 2일오후 16:00 경에 Hemovac 을제거하였다. 수술후 2일째저녁 20:00 경부터환자는갑자기 6~7회의간헐적가슴통증 (chest pain) 을호소하였고, 심전도검사상 ST elevation and Q wave in V2,3,4 소견, 심장질환에서심장표지자검사 (Cardiac marker) 결과 Troponin-I 1.3, CK/CK-MB 151/2.8 로상승된소견을보였다. 환자는급성심근경색으로진단받아심장내과로전과, 응급관상동맥조영술 (coronary angiography, CAG) 을시행하였고관상동맥조영술결과좌전하행지동맥 (mid left anterior descending artery, mid LAD) 에만성폐색병변 (chronic total occlusion), 우측관상동맥 (distal RCA) 에 90% 협착소견 (stenosis) 이관찰되어좌전하행지동맥에풍선확장술을, 우측관상동맥에스텐트삽입술을시행하였다. 시술후환자는스텐트삽입부위의응고를막기위해서 enoxaparin 191
Jung-Eun Kim et al Volume 20 Number 4 December 2013 80mg, aspirin 300mg, plavix 75mg 을투여하였다. 환자수술후 1 일째아침 7 시에시행한경추부측면방사선소견상제 3 경추 체의전방과인두사이의거리는 4.82mm, 제 6 경추제의전방 과기도사이의거리는 17.76mm 로측정이되었으며수술후 2 Fig. 2. postoperative serial x-rays (post op 1day 07:00) Fig. 3. postoperative serial x-rays (post op 2day 07:00) Fig. 4. postoperative serial x-rays (post op 3day 13:00) Fig. 5. postoperative serial x-rays (post op 3day 19:00) 192
Journal of Korean Society of Spine Surgery Postpharyngeal Hematoma after Anterior Cervical Surgery on a CAD Patient 일째아침 7시에시행한경추부측면방사선소견에서는각각 10.53mm, 22.05mm 가측정되었다 (Fig. 2, 3). 급성심근경색발생이후인수술후 3일째오후 1시에시행한경추부측면방사선소견상각각 27.32mm, 31.45mm 로급격하게증가하였으며오후 5시에는 28.67mm, 34.95mm 그리고오후 7시에는 30.46mm, 37.49mm 로증가하였다 (Fig. 4, 5). 환자의심근경색발생이후응고를막기위해항혈전제, 항응고제가투여되면서급격하게기도가좁아지는양상을보여부종보다는혈종이라고생각을하게되었으며 Hemovac 를제거한상태로혈종은점점커질것이라고예상하였다. 정확한원인파악을위해서경추부전산화단층촬영을시행하였다. 경추부전산화단층촬영상환자의기도에후인두혈종이의심되었고기도가우측으로전위되어기도폐색의위험성이높았다. 의료진은더이상의혈종크기증가를막기위해항응고제제인 enoxaparin 을끊었지만스텐트삽입부위의응고를막기위해 aspirin 과 plavix 투여는유지하여야했다. 환자는안절부절하지못하는등의불안감을호소하는상태로환자의활력징후는 SpO2 89%, RR 25회 /min, HR 131 회 /min, BP 160/100mmHg 으로불안정한모습을보였고, 동맥혈가스검사상 PO2 68mmHg, PCO2 54mmHg 로저산소증, 고탄산혈증이나타났다. 본증례의환자는 aspirin 과 plavix 를계속복용하여야했으며항혈전제투여로환자의혈종크기가증가할위험성이있었고주기적으로시행한방사선소견상환자의기도가좁아지는것이확연히관찰되었기에이차적으로발생할환자의기도폐색을우려하여저자들은기관내삽관이필요하다고판단하였다. Aspirin 과 plavix 를지속적으로투여해야했으며수술위험도가높아일단기관내삽관으로기도폐색을방지하고 추후경과를관찰한후에혈종제거술을고려하기로하였다. 일차적으로저자들은후두직접경 (direct laryngoscope) 으로기관내삽관을시도하였다. 그러나환자는병변및수술로인해환자는경부신전이제한적이었으며환자의기도는수술부위의혈종및후두부조직의부종으로협소해진상태였고해부학적구조도정중선편위 (midline deviation) 가되어후두경으로기관내삽관이어려웠다. 이에저자들은의식하굴곡기관지경삽관 (awake bronchoscopic intubation) 을시행하였고시행중환자의구역반사 (gag reflex) 를감소시키기위해 10% lidocaine spray 로구개수부위 (uvula area) 와성대부위 (vocal cord area) 에분무후 reinforced tube 를안전하게거치시켰다 (Fig. 7). 기관내삽관후환자는 midazolam 과 fentanyl 로 sedation 하고 vecuronim 으로근이완을유지하며기계조절환기 ((Controlled mandatory ventilation=cmv) PR 15mmHg, RR 20회 /min, FiO2 0.5, PEEP 5mmHg) 를실시하였고환자의활력징후는 SpO2 97%, RR 15 회 /min, HR 103회 /min, BP 140/80mmHg 로호전되었다. 기관내삽관 14일후환자의후인두혈종은경추부측면방사선소견과경추컴퓨터단층촬영상그크기가유의하게줄어들지않았다. 장기간의기관내삽관및 sedation 으로인한합병증을우려한의료진은기관내삽관을유지한상태로경추부전방수술실시일로부터 16일후혈종제거술및 Hemovac 삽입술을시행하였고혈종은다량제거하였다. 수술 2일째 Hemovac volume 은 5mm 미만으로나와제거한후점차적으로 ventilation 을 weaning 하였으며그후환자는호전되었으며신경학적증상및가슴통증이없는등합병증없이 30일후퇴원하였다. Fig. 6. Serial CT images preoperative CT scan shows patent airway (arrow) Fig. 7. Serial CT images postoperative CT scan shows narrow airway sustained by a reinforced tube (arrow) 193
Jung-Eun Kim et al Volume 20 Number 4 December 2013 고찰 경추부위의수술부위연부조직의부종 (postoperative swelling) 및수술부위의혈종으로인한기도압박 (airway compromise) 은환자의생명을위협할수있는위험한합병증으로발생즉시기도관리및기도폐색의예방적조치를하여야한다. 3,4) 특히경동맥내막절제술 (carotid endarterectomy, CEA), 갑상선절제술 (thyroidectomy), 구순성형술 (repair of cleft palate), 경추부전방수술, 그밖에인두부위의수술 (other procedures in the pharyngeal area) 후수술부위의혈종및수술후연부조직의부종으로인한기도폐색사례및그에대한활발한연구가보고되고있다. 5) 이러한문제가발생했을때빠르고정확하게기도관리 (airway management) 를하지않을경우환자의생명이위험할수있다. 경추부전방수술후혈종이생기는이유는수술중동맥이나정맥, 주로위갑상동맥 (superior thyroid artery) 의적절하지못한지혈 (bleeding control), 환자의이차적인혈액응고장애 (coagulopathy), 기관내삽관후발관시발살바효과 (Valsalva effect) 로인한정맥압의증가, 마취회복시 (emergence) 발생하는혈압상승등이있다. 6,7) 본증례의환자의경우는환자의관상동맥기저질환으로인해발생한급성심근경색, 경피적관상동맥중재술및스텐트삽입술시행과이로인한항혈소판제의복용으로인한이차적인혈액응고장애로환자의수술후수술부위혈종발생의위험인자가있었다. 급성으로기도부위에혈종이발생할경우환자는서맥과함께저혈압이발생할수있다. 이러한혈역학적변화는혈종의종괴효과 (mass effect) 로경동맥동 (carotid sinus) 이눌리고그로인한압수용기반사 (baroreceptor reflex) 가발생함으로서나타나는증상이다. 8) 기도부위혈종이 24-72h 에걸쳐천천히발생하는경우, 환자의기도는부분폐색에서완전폐색이발생할수도있고이처럼폐색의정도에따라증상도생길수있고폐색의정도에따라증상도무증상에서부터호흡정지 (respiratory arrest) 에이르기까지다양하게나타난다. 때문에천천히혈종이커지는경우의료진은혈역학적변화가악화되기전에환자가호소하는증상으로초기에의심하고검사하여발견하는것이중요하다. 기도가혈종에눌렸을경우초기증상으로환자들은말하는것과숨쉬는것이힘들다고호소한다. 시간이지남에따라기도압박 (airway compromise) 이진행되고환자는환기 (ventilation) 가원활하게되지않아고탄산혈증 (hypercarbia) 이초래되어불안함 (restless and agitation) 을보인다. 기도부위의혈종압박이더심해질경우환자는호흡곤란과저산소증, 청색증을보이며호흡정지및심장마비가초래되어사망에까지이를수있다. 9) 경추부전방수술후수술부위의혈종이생긴경우의료진은환자의호소증상과활력증후의변화를보고수술부위의혈종의기도압박발생시기관내삽관이필요성여부를빠르게판단하고처치하는것이중요하다. 기도부위에혈종이생길경우혈종발생후시간이지연되어그크기가커질수록기관내삽관이어려워지기때문이다. 혈종이누름에따라기도는직접적으로기도에가해지는압력으로인해정중선편위 (midline deviation) 가나타난다. 또한혈종의크기가커지면서기도에가해지는압력이증가할수록기도내강 (lumen) 이좁아지기때문에기관내삽관시어려움이많고그성공확률도떨어진다. 10) 이러한이유로기도부위의혈종발생시이로인한압박의정도가심해질경우기관내삽관이추천된다. 경추부전방수술후수술부위의혈종발생으로기관내삽관하는경우후두경 (laryngoscope) 보다는굴곡기관지경으로삽관 (fiberoptic bronchoscope intubation) 하는것이추천된다. 11) 경추부전방수술후환자는경부신전을비롯한경부운동의장애가있으며기도의해부학적변화, 기도내강의좁아짐등으로인해기도삽관의어려움이있기때문이다. 본증례의환자역시그러하였다. 환자는경추부전방수술로인해경부신전이제한되었고수술부위의후인두혈종으로인해기도가압박되어기도의정중선편위및기도내강이좁아짐이관찰되었다. 이는수술전후환자의경추컴퓨터단층촬영상에서도잘보여진다. 수술전에비하여기관내삽관직전환자의기도는혈종및부종으로인해튜브도겨우들어갈만큼좁아져있었고위치역시압력으로인해정중선으로부터편위되어있음을볼수있다 (Fig. 7). 사진에서환자의기도는수술후발생한후인두혈종에눌려삽관된튜브로그모양과크기가유지되어있는모습을볼수있다. 이런경우기관내삽관을하지않았다면후두부혈종이더커지면서기도를압박, 완전기도폐색으로호흡정지가올가능성이있었음을예상할수있다. 본증례의경우관상동맥질환을기저질환으로가지고있었던환자가경추부전방수술후급성심근경색이발생, 응급으로경피적관상동맥중재술및스텐트삽입술을시행하였고시술후환자는복용하고있었던항혈전제로인하여수술부위에후인두혈종이발생하였다. 환자는경피적관상동맥중재술및스텐트삽입술을시행한직후였기에항혈전제복용을중단할수없었고수술부위의후인두혈종의크기가점점커지자혈종으로인해기도가압박되어호흡정지발생을우려하였던의료진은환자에게예방적기관내삽관을하였고결과적으로이는환자의안전은물론, 더나아가의료진에게도좋은결과를가져다주었다. 194
Journal of Korean Society of Spine Surgery Postpharyngeal Hematoma after Anterior Cervical Surgery on a CAD Patient REFERENCES 1. Emery SE, Bohlman HH, Bolesta MJ, Jones PK. Anterior cervical decompression and arthrodesis for the treatment of cervical spondylotic myelopathy -Two to seventeen-year follow-up. J Bone Joint Surg Am. 1998;80:941-51. 2. Marotta N, Landi A, Tarantino R, Mancarella C, Ruggeri A, Delfini R. Five-year outcome of stand-alone fusion using carbon cages in cervical disc arthrosis. Eur Spine J. 2011;20:S8-12. 3. Mcafee PC, Bohlman HH, Riley LH, Robinson RA, Southwick W0, Nachlas NE. The Anterior Retropharyngeal Approach to the Upper Part of the Cervical Spine. J Bone Joint Surg Am. 1987;69:1371-83. 4. Suk KS, KIM KT, Lee SH, Park SW. Prevertebral soft tissue swelling after anterior cervical discectomy and fusion with plate fixation. Int Orthop. 2006;30:290-4. 5. Levelle JP, Martinez OA. Airway obstruction after bilateral carotid endarterectomy. Anesthesiology. 1985;63:220-2 6. Yu NH, Jahng TA, Kim CH, Chung CK. Life-threatening late hemorrhage due to superior thyroid artery dissection after anterior cervical discectomy and fusion. Spine(Phila Pa 1976). 2010;35:E739-42. 7. Sethi R, Tandon M, Ganjoo P. Neck hematoma causing acute airway and hemodynamic compromise after anterior cervical spine surgery. J Neurosurg Anesthesiol. 2008;20:69-70. 8. Boyce JR, Peters GE. Complete vasomotor collapse: an unusual manifestation of the carotid sinus reflex. Anesthesiology. 2003;98:1285-7. 9. Mark A. Palumbo, Jessica Pelow Aidlen, Alan H. Daniels, Nikhil A. Thakur and Joseph Caiati. Airway compromise due to wound hematoma following anterior cervical spine surgery. Open Orthop J. 2012;45:108-13. 10. Bukht D, Langford RM. Airway obstruction after surgery in the neck. Anaesthesia. 1983;38:389-90. 11. Edward T, Crosby MD. Considerations for airway management for cervical spine surgery in adults. Department of Anesthesiology Clinics. 2007;25:511-33 관상동맥질환을가진환자의경추부전방수술후발생한급성심근경색과그치료로인해생긴후인두혈종사례보고 김정은 *, 강영진 박성욱 *, 김건식 *, 이동기 석경수 경희대학교대학원의학과마취통증의학과교실 *, 경희대학교병원마취통증의학과, 경희대학교병원정형외과 연구계획 : 증례보고 목적 : 관상동맥질환을가진환자가경추부전방수술을한후발생한급성심근경색및이로인한후인두혈종이생긴예를보고하고, 지속적인출혈성 위험이있는환자에서예방적으로기관내삽관을하는것이유용함을제시하고자한다. 선행문헌의요약 : 경추부전방수술후후인두혈종으로인한기도폐쇄는수술후발생할수있는합병증중가장위험한합병증으로발생시의료진의빠 르고신속한처치가필요하다. 대상및방법 : 기저질환으로관상동맥질환이있었던 61 세남자가경부통증과죄측상지방사통이유발되어수술을하였다. 수술이틀후환자는급성 심근경색이유발되어응급경피적관상동맥중재술및스텐트삽입술을시행하였고복용하는약물로인해수술부위의후인두혈종이발생, 기도를압 박하여의료진은기도폐쇄를예방하기위해기관내삽관을하였다. 결과 : 환자는기관내삽관을하여기도폐쇄를예방할수있었고수술부위및심장질환모두임상적이상소견없이퇴원하였다. 결론 : 경추부전방수술을한후발생한급성심근경색으로경피적관상동맥중재술및스텐트삽입술을시행한환자에서항혈전제복용으로인한후인 두혈종발생시예방적기관내삽관을시행하는것은환자의안전을높이는데도움이되었다. 색인단어 : 경추부전방수술, 관상동맥질환, 후인두혈종, 기도폐쇄 약칭제목 : 관상동맥질환을가진환자의경추부전방수술후후인두혈종발생사례 195