미숙아 동맥관 개존에서 인도메타신 1차 투여 후 폐쇄 실패의 예측 인자
Predictors of Failed Closure of Patent Ductus Arteriosus with the First Course of Indomethacin in Preterm Infants
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목적:미숙아 동맥관 개존의 일차적인 치료제로 인도메타신이 효과적으로 쓰이지만 일부에서는 폐쇄 실패로 반복 투여나 수술적 치료를 필요로 한다. 동맥관 개존은 미숙아에서 높은 유병률, 사망률의 원인으로 내과적 치료가 실패 했을 경우 단락이 많으면 조기에 외과적 결찰을 고려해야 한다. 본 연구에서는 미숙아에서 동맥관 개존에 대한 인도메타신의 1차 투여 후 치료 효과에 영향을 미치는 요인들을 분석하여 동맥관 개존 폐쇄 실패를 예측 할 수 있는 중요한 예측 인자를 알아보고 약물 재투여 및 외과적 결찰이 필요한 환아를 조기에 선별 하여 대비함으로써 합병증을 최소화 하는데 도움이 되고자 하였다. 방법:1990년 1월부터 2007년 12월 사이 고려 대학교 의료원 신생아 중환자실에 입원 하였던 재태기간 37주 미만의 미숙아 중에서 동맥관 개존으로 진단되어 인도메타신을 투여 받았던 43명의 미숙아를 대상으로 하였다. 1차 투여 후 동맥관이 폐쇄된 27명을 폐쇄군으로, 폐쇄에 실패한 16명을 비폐쇄군으로 하여 두 군 간의 차이를 비교 분석하였으며 인도메타신 치료 효과에 영향을 줄 수 있는 인자들에 관하여 후향적으로 조사하였다. 결과:대상 환아는 총 43명으로 남아 20명(46.5%), 여아 23명(53.5%) 이었다. 평균 아프가 점수는 폐쇄군이 1분에 4.1±2.1점, 5분에 6.1±1.9점이었고, 비폐쇄군은 1분에 5.4±1.7점, 5분에 7.3±1.2점으로 폐쇄군에서 통계적으로 유의하게 점수가 낮았다(P<0.04, P< 0.03). 산전 스테로이드 투여를 받은 경우는 폐쇄군 16명(59.3%), 비폐쇄군 3명(18.8%)으로 폐쇄군에서 통계적으로 유의하게 높았다(P<0.01). 도파민 투여는 폐쇄군 17명(63.0%), 비폐쇄군 3명(18.8%)으로 폐쇄군에서 유의하게 높았다(P<0.01). 진단 시 연령은 폐쇄군 3.6±2.1일, 비폐쇄군 5.0±2.2일로 비폐쇄군에서 유의하게 높았다(P<0.05). 이들 주산기 인자 간의 다중 로지스틱 회귀분석 결과 산전 스테로이드 투여만이(OR 0.092, CI 0.010-0.826, P=0.0331) 동맥관 폐쇄 실패에 영향을 미치는 독립적인 인자로서 관련이 있었다. 결론:본 연구에서는 산전 스테로이드를 투여 받은 산모에게서 출생한 미숙아에서 통계적으로 유의하게 동맥관 폐쇄 실패율이 낮게 나타났다. 그러므로 미숙아에서 동맥관 개존 조기 진단과 함께 적극적인 산전 스테로이드 투여가 동맥관 개존 폐쇄 실패율을 낮추는 중요한 인자라 생각된다.
Abstract
Purpose:This study was performed to determine the predictors of failed closure of a patent ductus arteriosus (PDA) following the first course of indomethacin in symptomatic preterm infants. Methods:Forty three of 43 preterm infants, admitted to the neonatal intensive care unit diagnosed with PDA and treated with indomethacin at Korea University Medical Center between January 1990 and October 2007, ware studied. The perinatal risk factors affecting the failed closure of PDA were retrospectively assessed. Results:The failed PDA closure group indended 16 (37%) out of 43 infants three of whom underwent surgery. The closure group included 27 (63%) infants out of 43. In the failed closure group, the Apgar scores (1 min, 5 min) were significantly higher (P<0.05) and antenatal steroid administration was significantly lower (P<0.05). in addition, dopamine administration was significantly lower (P<0.05) and the mean postnatal age at diagnosis was significantly lower (P<0.05). Multiple logistic regression for the prediction of failed PDA closure found only antenatal steroid administration (OR 0.092, CI 0,010-0.826, P=0.0331) as an associated factor. Conclusion:In patients with antenatal steroid administration the failed PDA closure rate was significantly lower. Therefore, antenatal steroid administration can be considered as an important factor for the closure of PDA in preterm pregnancies.
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