병원 밖 심정지 생존환자에게 시행된 목표체온조절치료법과 생존 여부의 관련성

Abstract

Background Each year the incidence of patients with out-of-hospital cardiac arrest is increasing. As a method to reduce brain damage in patients with cardiac arrest, targeted temperature management is being applied in clinical practice. There are many overseas studies on the relationship between targeted temperature management and neurological prognosis. However, there are insufficient studies on the relationship between factors of survival and targeted temperature management for Korean patients with out-of-hospital cardiac arrest. The purpose of this study was to analyze the relationship between factors of survival and targeted temperature management applied to patients with spontaneous circulation among patients with out-of-hospital cardiac arrest. This study also performed multiple logistic regression with three types of models including unadjusted model 1, model 2 with general characteristics, gender, age, and insurance type as control variables, and model 3 with additional adjustments for health characteristics, hypertension and diabetes to analyze the relationship between targeted temperature management applied to patients with spontaneous circulation and factors of survival. Method This study analyzed the data of a total of 46,195 cardiac arrest patients, using data from cardiac arrest surveys (2015-2019) containing medical records of patients with out-of-hospital cardiac arrest who were transported through 119 paramedics according to the control system of the Korea Disease Control and Prevention Agency. This study conducted a frequency analysis in order to identify the general characteristics of all subjects and whether the targeted temperature management is implemented. This study conducted the chi-squared test to analyze the differences in insurance type, region, history, drinking and smoking history between the surviving and deceased patient groups. Results A total of 46,195 subjects was composed of 30,772 males (66.61%) and 15,423 females (33.39%). Among them, 17,716 patients (38.4%) were surviving. The targeted temperature management was applied to 4,290 patients (9.29%). Among the group of patients to whom the targeted temperature management was applied, 2,220 (51.75%) survived, and 36.98% (p<0.0001) of the patients in the non-applied group survived. The targeted temperature management was applied to 18.3% of patients aged 30-39 years, and was applied to 5.66% of patients aged 70 years or older. The multiple logistic regression result shows that when the targeted temperature management is applied, the odds ratio of the unadjusted model to survival recorded 1.83 (95% CI = 1.72-1.95), and models 2 and 3 that controlled for confounding variables recorded a high level (Model 2, OR 1.64, 95% CI=1.53-1.75); Model 3, OR 1.48, 95% CI=1.38-1.58). In Model 3, the following groups had a low odds ratio to belong to the survival group: female (OR 0.81, 95% CI=0.77-0.85), among age groups, age 70 and older (OR 0.36, 95% CI=0.31-0.41), among insurance types, auto insurance (OR 0.48, 95% CI=0.42-0.54) and one type of benefit (OR 0.71, 95% CI=0.57-0.88). Conclusion Results of an analysis of the survey data for cardiac arrest, including cases of 119 paramedics transporting patients with out-of-hospital cardiac arrest showed that results of an analysis of the survey data for cardiac arrest, including cases of 119 paramedics transporting patients with out-of-hospital cardiac arrest Application of the targeted temperature management to cardiac arrest patients with spontaneous circulation increased their chances of survival. However, this result is an analysis result of Real World Data (RWD). Therefore, this result should be interpreted in consideration of the limitations of the study design, such as the possibility that the treatment was applied in patients with high survival potential. Beyond the consideration of factors of survival, treatment effects, including neurological prognosis, should be verified based on well-designed intervention studies in the future.

매년 병원 밖 심정지 발생 환자는 증가하는 추세이다. 심정지 환자에게서 뇌손상을 줄이기 위한 방법으로 목표체온조절치료법이 임상에서 적용되고 있는 가운데 목표체온조절치료법과 신경학적 예후와의 연관성에 대한 해외 연구는 많지만, 우리나라에서 발생한 병원 밖 심정지 환자에게 시행된 목표체온조절치료법과 생존 여부의 관련성에 대한 연구는 부족한 실정이다. 본 연구에서는 병원 밖 심정지 환자 중 자발순환이 된 환자에게 시행된 목표체온조절치료법과 생존 여부와의 관련성을 분석하기 위한 목적으로 수행되었다. 본 연구는 질병관리청 감시체계로서 119 구급대를 통해 이송된 병원 밖 급성 심정지 환자 전수 대상 의무기록을 조사한 급성심장정지조사 자료(2015년-2019년)를 활용하여, 총 46,195명의 심정지 환자 자료를 분석하였다. 전체 대상자의 일반 특성 및 목표체온조절치료법 시행 여부를 파악하기 위해 빈도분석을 실시하였다. 생존환자군과 사망환자군의 보험 유형, 지역, 과거력, 음주·흡연력의 차이를 분석하기 위해 카이제곱 검정을 실시하였다. 자발순환이 된 환자에게 시행된 목표체온조절치료법과 생존 여부의 관련성을 분석하기 위해 무보정 모형 1, 일반 특성 성별, 연령, 보험 유형을 통제변수로 한 모형 2, 그리고 건강 특성 고혈압, 당뇨병을 추가로 보정한 모형 3의 세 개 모형을 구축하여 다중 로지스틱 회귀분석을 시행하였다. 연구대상자 전체 46,195명 중 남자는 30,772명(66.61%), 여자는 15,423명(33.39%)이었으며, 생존 17,716명(38.4%), 목표체온조절치료법 시행은 4,290명(9.29%) 이었다. 목표체온조절치료법 시행군 중 생존자는 2,220명(51.75%), 미시행군의 생존자는 36.98%였으며(p<0.0001), 30-39세에서는 18.3%에서 시행된 반면, 70세 이상에서는 5.66%에서만 시행되었다. 다중 로지스틱 회귀분석 결과, 목표체온조절치료법 미시행에 비해 시행한 경우 생존에 대한 무보정모형의 오즈비는 1.83(95% CI=1.72-1.95)이었고, 혼란변수를 통제한 모형 2, 3에서도 유의하게 높았다(모형 2, OR 1.64, 95% CI=1.53-1.75; 모형 3, OR 1.48, 95% CI=1.38-1.58). 모형 3에서, 여자(OR 0.81, 95% CI=0.77-0.85), 연령군에서는 70세 이상(OR 0.36, 95% CI=0.31-0.41), 보험 유형의 경우 자동차 보험(OR 0.48, 95% CI=0.42-0.54), 급여 1종(OR 0.71, 95% CI=0.57-0.88) 인 경우에는 생존군에 속할 오즈비가 낮았다. 병원 밖 급성 심정지 119 구급대 이송 전수를 포함한 급성심장정지조사 자료 분석 결과, 자발순환된 심정지 환자에게 목표체온조절치료법 시행 시 생존 가능성이 높았다. 그러나 이는 실제임상자료(Real World Data, RWD) 분석 결과로서, 생존가능성이 높은 환자에서 치료법이 시행되었을 가능성과 같은 연구 설계상의 제한점을 고려하여 해석되어야 한다. 생존 여부 외에 신경학적 예후를 포함한 치료 효과는 향후 잘 고안된 개입 연구로 검증되어야 할 것이다.