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신생아 저산소성 허혈성 뇌증의 저체온 치료

Therapeutic Hypothermia for Newborns with Hypoxic Ischemic Encephalopathy

장미영
대한신생아학회 (THE KOREAN SOCIETY OF NEONATOLOGY)|2013.02|Neonatal medicine|제20권 제1호|pp. 2-11

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키워드

BrainInfantNewbornHypothermiaInducedHypoxia-ischemia

초록

주산기 가사에 의한 저산소성 허혈성 뇌증은 신생아 사망의 주요 원인 중 하나이며, 일반적으로 생존아의 최소 25%에서 뇌성마비, 인지장애, 경련 등과 같은 심각하고 장기적인 신경발달 상의 후유증을 가진다고 알려져 있으나, 현재 저체온 치료 외에 다른 치료법은 정립되지 않았다. 저체온 치료의 신경 보호 기전은 아직 분명히 밝혀지지 않았으나, 저산소성 허혈 손상의 전 과정에 다양하게 작용하며, 특히 1차성 에너지 부전 후, 2차성 에너지 부전이 초래되어 비가역적인 신경 손상의 과정으로 진행되기 전 - latent period - 을 저체온 치료를 시작하는 ‘유효치료시기(therapeutic window)’로 정의하고 있다. 저산소성 허혈성 뇌증의 신생아들에서 시도된 저체온 치료에 대한 무작위 대조군 연구들과 이를 바탕으로 한 체계적 고찰 및 메타 분석의 결과들은 생후 6시간 이내에 선택적 두부 냉각법 또는 전신 냉각법을이용하여 저체온 치료(심부체온 33-35℃)를 유도하고 72시간 동안 유지하는 것이 사망이나 중증의 신경 발달 장애를유의하게 감소시키고 정상 신경 기능을 가지는 생존아의 비율을 유의하게 증가시키며, 부정맥, 혈소판 감소증, 폐동맥고혈압 등은 치료군에서 증가될 수 있으나 그 외의 부작용 발생에는 차이가 없음을 보고하여 저체온 치료의 효과와 안전성을 확인하였다. 이제 저체온 치료는 신생아 저산소성 허혈성 뇌증의 표준 치료법으로 제시되어 있는 만큼 적극적인 도입을 위하여 치료 지침을 잘 정리하고 관련 의료진을 훈련시키는 노력이 필요하다.

Abstract

Brain injury secondary to hypoxia-ischemia (HI) is one of the major causes of neonatal death and severe, long-term neurologic deficits in children. Aside from hypothermia, no established therapies exist. Although the specific mechanisms of hypothermic neuroprotection remain unclear, in part hypothermia suppresses a broad range of injurious factors involved in the both early or primary and late or secondary phases of cell damage and death during the HI injury. In particular, latent (early recovery) phase -a brief period of normal cerebral energetics between resuscitation/reperfusion and the secondary phase of impaired energy metabolism and injury - represents the effective window of opportunity for initiation of therapeutic hypothermia, and ameliorate the later secondary energetic decline, neuronal death and the subsequent neurodevelopmental disability. Randomized controlled studies and systemic reviews have demonstrated that moderate hypothermia (33-35℃ of core body temperature) using systemic or whole body cooling and selective head cooling, started within 6 hours after birth and protracted for 72 hours, significantly improves survival and reduces neurologic impairment in term and near-term infants with moderate and severe HI encephalopathy. Throughout the world, therapeutic hypothermia is increasingly recommended and we should have the protocols, equipment and training to treat the newborns with moderate and severe HI encephalopathy with therapeutic hypothermia.

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