title: 최근 마취과 영역의 흥미로운 발견과 IF>5 저널 최신 논문 업데이트
date: 2026-03-30
category:

• Anesthesiology
• Perioperative Medicine
• Evidence-Based Medicine
  tags:
• PEEP
• GLP-1
• remimazolam
• ACEi/ARB
• EVT
• 폐보호환기
• 주술기
• Anesthsiology
  keywords:
• DESIGNATION trial
• PROTHOR
• Stop-or-Not
• SEGA
• GLP-1RA
• remimazolam
• JAMA
• Lancet
  author: AI Research Report
  IF_threshold: ">5"

최근 마취과 영역의 흥미로운 발견과 IF>5 저널 최신 논문

📋 개요

본 보고서는 2024–2026 초에 발표된 고임팩트 저널(IF 5 이상) 중심의 마취·주술기 의학 관련
최신 근거를 정리하고, 임상 마취과 전문의 관점에서 실질적인 practice implication을 제시한다.

다루는 주제 영역:

• 호흡기 전략(PEEP 세팅)
• 항고혈압제(ACEi/ARB) 수술 전 관리
• 급성 허혈뇌졸중 혈전제거술(EVT)의 마취 방식
• GLP-1 수용체 작용제의 주술기 관리
• 신형 정맥마취제 remimazolam

1. 폐 보호 환기 전략 (Protective Ventilation)

1-1. DESIGNATION Trial — 개별화 고 PEEP 전략의 한계

저널: JAMA (2026) | 설계: 다국가 무작위 임상시험 | 대상: 개복 복부수술 고위험 성인 1,435명

연구 내용

Driving pressure를 최소화하도록 PEEP를 개별 titration(최대 20 cmH₂O까지 올렸다가 내리는 방식)
한 군과, 표준 low PEEP(5 cmH₂O) 전략을 비교하였다.

주요 결과

✅ 임상적 함의

• Driving pressure-guided high PEEP + recruitment가 표준 low PEEP 전략보다
  명확한 임상적 이득을 입증하지 못했다.
• 고 PEEP 전략의 hemodynamic cost(저혈압, 혈관작용제 필요 증가)를 고려할 때,
  복잡한 PEEP titration을 일괄 적용할 동기가 약하다.

1-2. PROTHOR Trial — 일폐환기에서 고 vs 저 PEEP

저널: Lancet Respiratory Medicine (2025) | 설계: 다국가 무작위 임상시험 | 대상: 흉부수술(BMI <35 kg/m²) 2,200명

연구 내용

일폐환기 시 고 PEEP(10 cmH₂O + 정기적 recruitment) vs 저 PEEP(5 cmH₂O, routine recruitment 없음)을 비교하였다.

주요 결과

✅ 임상적 함의

• 일폐환기에서도 고 PEEP + recruitment가 폐합병증을 일관되게 줄이지 못함.
• Fixed high PEEP routine 적용보다 환자 특성·혈역학에 따른 보수적 설정이 타당.

2. 주술기 약제 관리

2-1. Stop-or-Not Trial — ACEi/ARB 지속 vs 중단

저널: JAMA (2024) | 설계: 무작위 임상시험 | 대상: RASI 장기 복용 비심장수술 환자 2,222명

연구 내용

수술 48시간 전 ACEi/ARB 중단 vs 수술 당일까지 지속 전략을 비교, 28일 사망 및 주요 수술 후 합병증 복합 지표를 평가하였다.

주요 결과

✅ 임상적 함의

• 전체 예후 측면에서 두 전략 간 차이 없음 → 개별화 전략의 여지 확보.
• 중단 선호: 대동맥·장시간 수술, vasoplegia 고위험 환자.
• 유지 선호: 심부전 조절 중요, rebound hypertension 우려 환자.

2-2. GLP-1 수용체 작용제와 흡인 위험

저널: Journal of the Endocrine Society (2025) | 설계: 체계적 문헌고찰·메타분석

연구 내용

38만여 명(수술 코호트 3개) + 15만여 명(EGD 코호트 4개)에서 GLP-1RA 사용 vs 비사용 환자의
흡인·폐렴 위험을 메타 분석하였다.

주요 결과

✅ 임상적 함의

• Elective 수술·내시경에서 GLP-1RA가 흡인·폐렴 위험을 유의하게 높인다는 증거 부족.
• ASA 2024 다학회 권고 — 대부분의 환자는 약제 지속 허용.
• 예외적 보수 전략 고려: 고용량·급증 중인 환자, 위장증상(오심·조기포만감), 대관절 치환술 등.

3. 신경마취 (Neuroanesthesia)

3-1. SEGA Trial — 뇌졸중 EVT에서 진정 vs 전신마취

저널: JAMA Neurology (2025) | 설계: 무작위 임상시험 | 대상: 대혈관폐색 급성 허혈뇌졸중 EVT 환자 260명

연구 내용

중등도 진정(moderate sedation) vs 전신마취(general anesthesia)를 1:1 무작위 배정,
90일 mRS 분포를 비교하였다.

주요 결과

✅ 임상적 함의

• 통제된 전신마취 환경이 EVT 성적(재관류율·기능 예후)에 유리할 가능성.
• 혈압·CO₂·산소화 정밀 조절이 가능한 전신마취를 기본으로, 기도 위험·응급도에 따라 개별화.

4. 마취약리 — 신약 및 임상 적용

4-1. Remimazolam — Hemodynamic Stability와 PONV 이점

주요 근거 저널: Scientific Reports, Journal of Clinical Anesthesia (2025) | 설계: RCT, 메타분석

약물 특성 요약

주요 결과 (vs propofol RCT)

• 유도·유지 모두 100% 목표 마취 달성 (비열등성 입증)
• 혈압·심박수 저하 감소, 혈관작용제 필요 감소
• PONV 유의한 감소 (메타분석, vs 흡입마취제)

✅ 임상적 함의

• 심혈관 reserve 부족한 고령·심질환 환자 TIVA에 유리.
• PONV 고위험 환자 — 흡입마취제 대체재로 고려.
• 빠른 신경학적 평가가 필요한 수술(예: 뇌신경외과) — 짧은 context-sensitive half-time 활용.

5. 실무 요약 및 Practice Recommendation

6. 추적 권고 저널 목록 (IF > 5, 마취·주술기 관련)

전문 마취 저널

• Anesthesiology (ASA 공식 저널)
• British Journal of Anaesthesia (BJA)
• Anaesthesia
• Anesthesia & Analgesia
• Regional Anesthesia and Pain Medicine

고임팩트 종합 저널 (주술기 논문 게재 빈도 높음)

• JAMA / JAMA Surgery / JAMA Neurology
• Lancet / Lancet Respiratory Medicine
• NEJM
• Critical Care Medicine
• Intensive Care Medicine

💡 PubMed My NCBI alert 팁: 관심 키워드(예: perioperative, intraoperative ventilation, remimazolam)와 위 저널명을 조합하여 자동 알림 설정 권장.

보고서 생성일: 2026-03-30 | 근거 검색 기간: 2024–2026

CABG indications

source, harrisons’ internal medicine 21e8

1.Alexander JH, Smith PK. Coronary-Artery Bypass Grafting. Jarcho JA, ed. N Engl J Med. 2016;374(20):1954-1964. doi:10.1056/NEJMra1406944

Syntax scoring links

Syntax scoring links

Lawton Jennifer S., Tamis-Holland Jacqueline E., Bangalore Sripal, Bates Eric R., Beckie Theresa M., Bischoff James M., et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Journal of the American College of Cardiology 2022;79:e21–129.

1. Patients with complex disease
   1. In patients who require revascularization for significant left main CAD with high-complexity CAD, it is recommended to choose CABG over PCI to improve survival (1,2).
   2. In patients who require revascularization for multivessel CAD with complex or diffuse CAD (e.g., SYNTAX score >33), it is reasonable to choose CABG over PCI to confer a survival advantage (2-5).
2. Patients with Diabetes
   1. In patients with diabetes and multivessel CAD with the involvement of the LAD, who are appropriate candidates for CABG, CABG (with a LIMA to the LAD) is recommended in preference to PCI to reduce mortality and repeat revascularizations (1-8).
   2. In patients with diabetes who have multivessel CAD amenable to PCI and an indication for revascularization and are poor candidates for surgery, PCI can be useful to reduce long-term ischemic outcomes(9,10).
   3. In patients with diabetes who have left main stenosis and low- or intermediate-complexity CAD in the rest of the coronary anatomy, PCI may be considered an alternative to CABG to reduce major adverse cardiovascular outcomes (5,11).
3. Patients with CKD
   1. In patients with STEMI and CKD, coronary angiography and revascularization are recommended, with adequate measures to reduce the risk of AKI.
   2. In high-risk patients with NSTE-ACS and CKD, it is reasonable to perform coronary angiography and revascularization, with adequate measures to reduce the risk of AKI (4,5).

1.Bachar BJ, Manna B. Coronary Artery Bypass Graft. StatPearls Publishing, Treasure Island (FL); 2022. http://europepmc.org/abstract/MED/29939613

CABG indication

1. Left main disease greater than 50%
2. Three-vessel coronary artery disease of greater than 70% with or without proximal LAD involvement
3. Two-vessel disease: LAD plus one other major artery
4. One or more significant stenosis greater than 70% in a patient with significant anginal symptoms despite maximal medical therapy
5. One vessel disease greater than 70% in a survivor of sudden cardiac death with ischemia-related ventricular tachycardia

Contraindication

1. Contraindications to CABG include patient refusal, coronary arteries incompatible with grafting, and the absence of viable myocardium to graft.

1.Gersh BJ, Frye RL. Methods of Coronary Revascularization — Things May Not Be as They Seem. N Engl J Med. 2005;352(21):2235-2237. doi:10.1056/NEJMe058053

→ Survival benefit for surgery

1. Three-vessel disease
2. Two-vessel with LAD involve
3. Two-vessel but without proximal LAD

4th UDMI(Universial definition of MI)

1. Landesberg G, Beattie WS, Mosseri M, Jaffe AS, Alpert JS. Perioperative Myocardial Infarction. Circulation 2009;119:2936–44.

1. Redifinition of PMI
   1. most PMIs occur without symptoms in anesthetized or sedated patients, ECG changes are subtle and/or transient, and the creatine kinase-MB isoenzyme has limited sensitivity and specificity because of coexisting skeletal muscle injury. 8
   2. Yet, 90% of troponin elevations began within _24 hours.
2. Pathophysiology
   1. Universial definition of MI
   2. Type 1 PMI (Acute Coronary syndrome)
      1. Physical and emotional streesses, | sympathetic induced hemodynamic, coronary vasoconstrictive, and prothrombotic forces thought to promote plaque disruption.
      2. Tachycardia and hypertension, common in the perioperative period, may exert shear stress,
      3. Increased postoperative procoagulants (fibrinogen, factor VIII coagulant, von Willebrand factor, _1-antitrypsin), increased platelet reactivity, 23decreased endogenous anticoagulants (protein C, antithrombin III, _2-macroglobulin), 24and decreased fibrinolysis 25have been reported
   3. Type 2 PMI (Myocardial Oxygen Supply-Demand Imbalance)
      1. Postoperative cardiac complications, including sudden death, 33,34occurred after prolonged (_30 minutes, (35,36)_2 hours, (37,38)or _5 hours(39,40)) silent ST-segment depression
      2. ST elevation occurred in _2% of postoperative ischemic events and was a rare cause of PMI. (12,30,41)Hence, prolonged, ST-depression–type ischemia is the most common cause of PMI.
      3. Although troponin elevation is common mainly among patients with history of CAD 41–44or moderate to severe ischemia on preoperative stress thallium scanning, 45troponin elevations occur also in the setting of septic shock, renal failure, or pulmonary embolism. (46)These causes, however, are less frequent and occur later after surgery than PMI.
      4. Tachycardia is the most common cause of postoperative oxygen supply-demand imbalance(12,47)
3. Prognosis
   1. Early mortality after PMI ranges from 3.5% to 25%13,15,31,41,42,55 and is higher among patients with marked troponin elevation compared with patients with minor troponin elevation (0% to 7%). 15,41,42
4. Prevention and Treatment
   1. Prophylatic theraphy 
      1. Beta-blockers - POISE-I trial
         1. The large Perioperative Ischemic Evaluation (POISE) trial 6(8351 patients) reported increased mortality (by 31%) and stroke (by 100%), mostly in association with hypotension and bleeding, in patients treated with metoprolol despite a reduction in nonfatal PMI by 26%.
         2. Beta -Blockade may aggravate hypotension (12% of POISE patients) and interfere with the ability to maintain adequate cardiac output during active bleeding, anemia, or infection.
         3. The consensus is that long-term beta-blockade should not be discontinued. Intravenous beta-blockers are often used to treat tachycardia, hypertension, or ischemia with results comparable to or better than those reported with prophylactic beta-blockade.
5. Perioperative management
   1. The importance of preventing even modest increases in heart rate cannot be overemphasized.
   2. All causes of tachycardia, hypertension, hypotension, anemia, and pain should be treated aggressively.
   3. Frequently, vasopressors to maintain blood pressure and _-blockers to slow heart rate while managing blood volume, postoperative pain, and respiratory function are necessary.
   4. Therefore, hematocrit between 25% and 33% is a gray zone in which transfusion must be individualized.
6. Conclusion
   1. Postoperative tachycardia, hypotension, hypertension, anemia, hypoxemia, and systolic and diastolic myocardial dysfunction are common causes of prolonged ST-depression and type 2 infarction in patients with stable CAD undergoing major noncardiac surgery.
   2. PMI is often silent and its ECG changes are frequently transient, yet even minor troponin elevations predict early and late morbidity and mortality.

1. Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, et al. Fourth Universal Definition of Myocardial Infarction (2018). Circulation 2018;138.

4th UDMI

Perioperative MI

1. Perioperative MI is one of the most important complications in major noncardiac surgery and it is associated with a poor prognosis. 77,78

2. Most patients who have a perioperative MI will not experience ischemic symptoms due to anesthesia sedation, or pain relieving medications

3. Nevertheless, asymptomatic perioperative MI is as strongly associated with 30 day mortality as symptomatic MI. 77,78

4. It is recognized that the perioperative period is characterized by increased cardiac metabolic demand that may lead to MI in patients with otherwise stable CAD. 84,85

5. predominant etiology of perioperative MI,84,85 which together with a rise and/or fall of cTn values indicates type 2 MI.

However, other angiographic studies have detected coronary plaque rupture in 50% to 60% of patients with perioperative MI, 86,87which qualifies as type 1 MI.