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[³»½Ã°æ ÁøÁ¤ - Paradoxical reaction to midazolam]

1. Paradoxical reactionÀÇ Á¤ÀÇ¿Í ´ëó¹ý

Midazolam Åõ¿© ÈÄ ¿ÀÈ÷·Á ÈïºÐ°ú ºÒ¾ÈÀ» º¸À̸ç, ±¸µÎÁö½Ã³ª Àڱؿ¡ ÅëÁ¦µÇÁö ¾Ê´Â ¸ð¼øµÈ ¹ÝÀÀÀ» º¸ÀÌ´Â °ÍÀ» paradoxical reactionÀ̶ó°í ÇÕ´Ï´Ù. º¸Åë ¿ë·®ÀÌ ¸¹À» ¶§ ³ªÅ¸³ª´Â Çö»óÀÔ´Ï´Ù. ¾Æ·¡ Ç¥¿Í °°ÀÌ mild, moderate, severe·Î ºÐ·ùÇϱ⵵ ÇÕ´Ï´Ù.

³»½Ã°æ ¼¼¹Ì³ª °­ÀÇ·Ï (À̹üÀç)

°¡º­¿î °æ¿ì Á¶½É½º·´°Ô ȯÀÚÀÇ ÀÚ¼¼¸¦ À¯ÁöÇϸ鼭 °Ë»çÇÒ ¼ö ÀÖÁö¸¸, ½ÉÇØÁö¸é flumazenilÀ» ¼Ò·® Åõ¿©ÇÏ°í °Ë»çÇϱ⵵ ÇÕ´Ï´Ù. Paradoxical reactionÀÌ ½ÉÇϸé ÀÏ´Ü ³»½Ã°æÀ» »©°í ¸î ºÐ ±â´Ù¸° ´ÙÀ½ ´Ù½Ã »ðÀÔÇÏ¿© °Ë»çÇÏ´Â °Íµµ ÁÁÀº ¹æ¹ýÀÔ´Ï´Ù.

ÃÖ±Ù ¾î¶² ȯÀÚºÐÀÇ °á°úÁö¿¡¼­ paradoxical reactionÀÌ ÀÖ¾ú´Ù´Â ³»¿ëÀ» º¸¾Ò½À´Ï´Ù. Midazolam 5 mg, pethidine 50 mg. ¿ª½Ã ¿ë·®ÀÌ ¸¹¾Ò´ø °Í °°½À´Ï´Ù. ´ÙÀ½ °Ë»ç¿¡¼­´Â º¸´Ù ÀûÀº ¿ë·®À» ¾²µµ·Ï Àǹ«±â·Ï¿¡ Àß ³²°ÜµÎ¾ú½À´Ï´Ù.

Á¤È®ÇÑ ±â·ÏÀº ȯÀÚ¾ÈÀüÀÇ Ãâ¹ßÁ¡ÀÔ´Ï´Ù. ´ÙÇÔ²² ¹Ù¸¥ ³»½Ã°æ!


2. Paradoxical reactionÀÇ °¡Àå ÈçÇÑ ¿øÀÎÀº midazolam ¿ë·® °ú´ÙÀÔ´Ï´Ù.

³»½Ã°æ °á°úÁö¿¡¼­ "paradoxical effect ÀÖ¾î... ÀÌÈķδ ºñ¼ö¸éÀ¸·Î Çϱ⸦ ±ÇÇÕ´Ï´Ù"¶ó´Â ÀÇ°ßÀÌ ºÙÀº °ÍÀ» º¸¾Ò½À´Ï´Ù. Áø´Ü »óºÎ³»½Ã°æÀ̾ú´Âµ¥ Åõ¿©µÈ ¿ë·®Àº midazolam 5mg (3mg + 1mg + 1mg), pethidine 25mgÀ̾ú½À´Ï´Ù.

(2015)

»ç½Ç 60´ë ³²¼º¿¡¼­ ÀÌ Á¤µµ´Â Æò±Õº¸´Ù ÈξÀ ¸¹Àº ¿ë·®ÀÔ´Ï´Ù. ÇâÈÄ ºñÁøÁ¤ ³»½Ã°æÀ» ±ÇÇϱ⺸´Ù´Â ´ÙÀ½ ³»½Ã°æ °Ë»ç¿¡¼­ ¿ë·®À» Á¶±Ý Àû°Ô »ç¿ëÇϵµ·Ï ±ÇÇÏ´Â °ÍÀÌ ´õ ÁÁÀ» °Í °°½À´Ï´Ù.


3. ³»½Ã°æ ¼¼¹Ì³ª ±è¼ºÀº ±³¼ö´Ô °­ÀÇ·Ï ¹ßÃé (¸µÅ©)

"ÃæºÐÇÑ benzodiazepine Åõ¿© ÈÄ È¯ÀÚ°¡ ÁøÁ¤ÀÌ µÇÁö ¾Ê°í ¿ÀÈ÷·Á Ⱦ¼³¼ö¼³ µîÀÇ ºÒ¾ÈÁõ°ú µ¹¹ß ÇൿÀ» º¸ÀÌ´Â °æ¿ì¸¦ ÀÏÄ´´Ù. ¿ª¼³ ¹ÝÀÀÀº ƯÀÌÀûÀÎ(idiosyncratic) ¹ÝÀÀÀ¸·Î ¾Ë·ÁÁ® ÀÖÀ¸³ª, À¯ÀüÀÚ Æ¯¼º°ú ¿¬°üµÇ¾î ÀÖ´Ù´Â ¿¬±¸µµ ÀÖ´Ù. ½ÖµÕÀÌ ¿¬±¸¿¡ ÀÇÇÏ¸é µÎ ¸í¿¡°Ô °¢°¢ ´Ù¾çÇÑ ½Ã±â¿¡ ´Ù¾çÇÑ ¿ë·®ÀÇ midazolamÀ» Åõ¿©Çغ¸¾Ò´Âµ¥, 5 mg Åõ¿©¿¡ ºÒ¾ÈÁõ°ú °úµµÇÑ ¿òÁ÷ÀÓÀ» º¸¿´´ø ¼öÁøÀÚ°¡ Ãß°¡ 5 mg¿¡ Áõ»óÀÌ ´õ¿í ½ÉÇØÁ³°í ÀÌÈÄ ´Ù¸¥ ½Ã±â¿¡ 12 mgÀ» Åõ¿©ÇßÀ» ¶§¿¡´Â ÀǽÄÀÌ ÀúÇϵǾú À¸¸ç ÀÌÈÄ ¶Ç ´Ù¸¥ ½Ã±â¿¡ 10 mgÀ» Åõ¿©ÇÏ¿´À» ¶§¿¡´Â ºñ½ÁÇÏÁö¸¸ ÀÌÀüº¸´Ù´Â ºÎÀÛ¿ëÀÌ ´ú ÇÏ¿´´Ù. ½ÖµÕÀÌ Áß ´Ù¸¥ ÇÑ ¸í¿¡¼­µµ ÀÌ¿Í °°Àº ¹ÝÀÀÀº ºñ½ÁÇÏ°Ô ³ªÅ¸³µ´Ù.

À§ÇèÀÎÀڷδ ¾ËÄÚ¿ÃÀÇ °úµµÇÑ ¼·Ãë·Â, ºÐ³ë Á¶Àý Àå¾Ö, ÆíÁýÁõ°ú °°Àº Á¤½Å°úÀû ¹®Á¦°¡ Àְųª, ¼Ò¾Æ ȤÀº °í·ÉÀÇ È¯ÀÚ·Î ¾Ë·ÁÁ® ÀÖ´Ù. ÁøÁ¤³»½Ã°æÀ» ½ÃÇàÇÑ 1-18¼¼ÀÇ ¼Ò¾Æû¼Ò³âÀ» ´ë»óÀ¸·Î ÇÑ ´ë±Ô¸ð ¿¬±¸µé¿¡ ÀÇÇϸé 1.4-10%ÀÇ ¼Ò¾Æ°¡ ºó¸Æ, ºÒ¾ÈÁõ, ¿ïÀ½, Áö³²·Â ÀúÇÏ µîÀÇ ¿ª¼³ ¹ÝÀÀÀ» º¸¿´´Ù°í ÇÑ´Ù.

¹ÝÀÀÀÌ ¹ß»ýÇÏ´Â ½Ã°£°ú Áö¼Ó ½Ã°£, ȸº¹ ½Ã°£Àº ¼Ò¾ÆÀÇ ¿¬·É°£ Â÷ÀÌ°¡ ¾ø¾ú´Ù. ¼Ò¾ÆÀÇ °æ¿ì ¹Ì´ÙÁ¹¶÷ÀÇ »ç¿ë·®ÀÌ Áõ°¡ÇÒ¼ö·Ï ¿ª¼³ ¹ÝÀÀÀÌ ³ªÅ¸³ª´Â °æ¿ì°¡ ¸¹¾Æ¼­, ¿ë·® Áõ·®°ú ¿¬°üÀÌ ÀÖ´Ù´Â º¸°íµµ ÀÖ´Ù. Benzodiazepine Åõ¿© ÈÄ ³ªÅ¸³ª´Â ȯÀÚÀÇ ºÒ¾ÈÁõ°ú ÀÌ»ó ÇൿµéÀº flumazenilÀ̳ª haloperidol·Î Àß Á¶ÀýµÈ´Ù°í ¾Ë·ÁÁ® ÀÖ´Ù. ½Ã°£À» ¿äÇÏ´Â ½Ã¼úÀ» ÁøÁ¤³»½Ã°æÇÏ¿¡ ÁøÇàÇÒ °æ¿ì, ÃÊ ±â¿¡´Â ¾ÈÁ¤ÀûÀ̾ú´ø ȯÀÚ¶óµµ Ãß°¡ÀÇ ¹Ì´ÙÁ¹¶÷ÀÌ Åõ¿©µÇ¸é¼­ ¿òÁ÷ÀÓÀÌ °úÇØÁö°í ¹°¸®Àû ÈûÀ» °¡ÇØ¾ß ½Ã¼úÀ» ÁøÇàÇÒ ¼ö ÀÖ´Â »óȲÀÌ ¹ß»ýÇÒ ¼ö ÀÖ´Ù. ÀÌ·² °æ¿ì benzodiazepine antagonistÀÎ flumazenil (0.3-0.5 mg)¸¦ Åõ¿©ÇÒ ¼ö Àִµ¥, Åõ¿© ÈÄ¿¡µµ ÁøÁ¤ÀÌ Áö¼ÓµÇ°í ±â¾ï»ó½Ç È¿°úµµ À¯ÁöµÈ´Ù. HaloperidolÀº flumazenilÀÇ 2Â÷ ¾àÁ¦·Î »ç¿ëµÉ ¼ö Àִµ¥, °£À¸·Î ÁÖ·Î ´ë»çµÇ°í, ¹Ý°¨±â°¡ 20½Ã°£ÀÌ´Ù. flumazenilÀÌ ½ÉÇÑ ½ÉÇ÷°üÁúȯÀÌ ÀÖ´Â ÀϺΠȯÀÚ¿¡¼­ ÁÂ½É½Ç ÀÌ¿Ï ¸»±â ¾Ð·ÂÀ» Áõ°¡½ÃÅ°°í, °íÇ÷¾Ð, ºó¸ÆÀ» ÀÏÀ¸ÄÑ ¹®Á¦¸¦ ÀÏÀ¸Å°´Â °æ¿ì°¡ ÀÖÀ¸¹Ç·Î ÀÌ·± °æ¿ì haloperidol »ç¿ëÀÌ ±ÇÀ¯µÈ´Ù. ¿ª¼³ ¹ÝÀÀ ½Ã ±ÇÀåµÇ´Â »ç¿ë·®Àº 10 mgÀ» 2ȸ¿¡ ³ª´©¾î Åõ¿©ÇÏ´Â °ÍÀ̸ç haloperidol¿¡ ÀÇÇÑ °¡Àå ½É°¢ÇÑ ºÎÀÛ¿ëÀº extrapyramidal reactionÀÌ´Ù. ¼Ò¾Æ¿¡¼­ÀÇ ¿ª¼³ ¹ÝÀÀ¿¡µµ ¿ª½Ã flumazenilÀÌ È¿°úÀûÀÎ ¾àÁ¦·Î ¾Ë·ÁÁ® ÀÖ´Ù. ¼Ò¾ÆÀÇ °æ¿ì flumazenil 0.01 mg/kg i.v°¡ Åõ¿©µÈ´Ù."


4. Paradoxical reaction¿¡ ´ëÇÑ »ï¼º¼­¿ïº´¿øÀÇ ³í¹® (Tae CH. Dig Liver Dis 2014)

METHODS: This single center prospective study included 4140 adult patients (2263 males, mean age of 57.7 ¡¾ 12.6) undergoing endoscopy under sedation with midazolam and pethidine between September 2011 and December 2011. The characteristics of patients with and without paradoxical reaction were compared. For patients who experienced paradoxical reaction and received flumazenil, their endoscopic images were reviewed to assess whether European Society of Gastrointestinal Endoscopy guidelines were met as quality indicator of endoscopy.
RESULTS: The incidence of paradoxical reaction was 1.4%. In multivariate analyses, male gender, unsuccessful sedation in previous endoscopy, upper endoscopy, higher dose of midazolam, and lower dose of pethidine were identified as independent risk factors for paradoxical reaction. Despite paradoxical reaction, endoscopic procedures were successfully completed in 93.3% of cases when flumazenil was administered. The rates of meeting quality indicator of endoscopy were 92.3% in patients receiving flumazenil for paradoxical reaction and 97.6% in patients without paradoxical reaction.


CONCLUSIONS: For patients with risk factors for paradoxical reaction, active use of pethidine with a dose reduction of midazolam might be helpful to prevent the occurrence of paradoxical reaction. Administration of flumazenil might be positively considered in cases of paradoxical reaction.


[FAQ]

[2017-1-28. ¾Öµ¶ÀÚ ÆíÁö]

¹Ì´ÙÁ¹¶÷ ÁøÁ¤³»½Ã°æÀ̾ú½À´Ï´Ù. ½ÊÀÌÁöÀå¿¡ µµÂøÇÒ ¹«·Æ ¶§ °©Àڱ⠿ª¼³Àû ¹ÝÀÀÀ¸·Î º¸Á¶ÀÚÀÇ Á¦Áö¿¡µµ ºÒ±¸ÇÏ°í ¼ø½Ä°£¿¡ ¸¶¿ì½ºÇǽº¸¦ ¹ñ°í ³»½Ã°æÀ» ¹°¾î ¹ö·È½À´Ï´Ù.

ÀÏ´Ü flumazenilÀ» Åõ¿©ÇÏ¿´°í ³»½Ã°æÀ» ȸ¼öÇÏ¿´½À´Ï´Ù. ȯÀÚÀÇ Ä¡¾Æ´Â ¾ÈÀüÇß½À´Ï´Ù. MidazolamÀ» ´õ ¸¹ÀÌ ÁÖ¾ú¾î¾ß ÇÏ´Â °Í ¾Æ´Ï¾ú³ª »ý°¢ÇØ º¸¾Ò½À´Ï´Ù. Propofol »ç¿ë À¯È¤ÀÌ ½ºÃÄ°¬À½À» °í¹éÇÕ´Ï´Ù. °ú°Å ¸¶¿ì½ºÇǽº¸¦ ¹°¾î¼­ ÆļսÃŲ ÈÄ Á¶°¢À» »ï²¸¼­ À̹°Á¦°Å¼úÀ» ÇÑ ÀûÀÌ ÀÖÀ¸¸ç, ´ëÀå³»½Ã°æ µµÁß Ä§´ëÀ§·Î ¼­¹ö¸° ȯÀÚµµ ÀÖ¾ú½À´Ï´Ù.

ÇöÀç ÀúÈñ´Â ÁöħÀ» ³ÑÁö ¾Ê´Â ¿ë·®À» »ç¿ëÇÏ°í ÀÖÀ¾´Ï´Ù. ±³¼ö´Ô, ¿ª¼³Àû ¹ÝÀÀÀ» º¸ÀÌ´Â °æ¿ìÀÇ Á¤È®ÇÑ ´ëó ¹æ¹ýÀÌ ¾Ë°í ½Í½À´Ï´Ù.

[2017-1-28. ÀÌÁØÇà ´äº¯]

³»½Ã°æÀÌ ¼Õ»óµÇ¾ú´Ù´Ï »ó´çÈ÷ ½ÉÇÑ °æ¿ì¿´´ø ¸ð¾çÀÔ´Ï´Ù. ¾Æ½Ã°ÚÁö¸¸ paradoxical reactionÀÇ °¡Àå Áß¿äÇÑ À§ÇèÀÎÀÚ´Â midazolam ¿ë·®ÀÔ´Ï´Ù (Tae CH. Dig Liver Dis 2014). MidazolamÀ» Áöħ¿¡ µû¶ó Á¶±Ý¾¿ minimal sedation Á¤µµ±îÁö¸¸ Åõ¾àÇϸé paradoxical reactionÀº °ÅÀÇ ¹ß»ýÇÏÁö ¾Ê½À´Ï´Ù. ¿ÏÀüÈ÷ ±í°Ô Àáµéµµ·Ï Åõ¾àÇÑ´Ù¸é ÀÌ¹Ì overdoseÀÎ ¼ÀÀÔ´Ï´Ù. À̸§À» ºÒ·¶À» ¶§ ´«À» õõÈ÷ ¶ã ¼ö ÀÖ´Â Á¤µµ°¡ ÀÌ»óÀûÀÔ´Ï´Ù¸¸, ¿ì¸®³ª¶ó ÀÇ·á ÇöÀå¿¡¼­´Â À̺¸´Ù´Â Á¶±Ý ´õ ±íÀº ÁøÁ¤À» À¯µµÇÏ´Â °æ¿ì°¡ ¸¹½À´Ï´Ù. ±×·¡µµ Áö³ªÄ¡Áö ¾Êµµ·Ï ÁÖÀÇÇØ¾ß ÇÕ´Ï´Ù.

Á¦°¡ °­Á¶ÇÏ´Â Á¡Àº 'midazolam Åõ¿© 3ºÐ ÈÄ¿¡ ³»½Ã°æ °Ë»ç¸¦ ½ÃÀÛÇÏÀÚ'´Â °ÍÀÔ´Ï´Ù. MidazolamÀÇ ÃÖ´ë È¿°ú°¡ 3-4ºÐ ¹«·Æ¿¡ ³ªÅ¸³ª±â ¶§¹®ÀÔ´Ï´Ù. ³»½Ã°æ °Ë»ç¸¦ midazolam Åõ¿© 3ºÐ À̳»¿¡ ½ÃÀÛÇÏ´Â ½À°üÀÌ µé¸é ¿ë·®ÀÌ ´Ã¾î³¯ ¼ö ¹Û¿¡ ¾ø½À´Ï´Ù. ÃæºÐÈ÷ ±â´Ù¸° ÈÄ ³»½Ã°æ °Ë»ç¸¦ ÇÑ´Ù¸é midazolam ¿ë·®À» »ó´çÈ÷ ÁÙÀÏ ¼ö ÀÖ½À´Ï´Ù. ±×¸®°í Á¶±Ý¾¿ ³ª´©¾î ÁÖ´Â °ÍÀÌ ÁÁ½À´Ï´Ù. ÀÏ´Ü 2mgÀ» Åõ¿©ÇÏ°í 2ºÐ Á¤µµ ±â´Ù¸° ÈÄ 1mgÀ» Åõ¿©ÇÏ´Â °ÍÀÌ ÇѲ¨¹ø¿¡ 3mgÀ» ÁÖ´Â °Íº¸´Ù ÁøÁ¤ÀÇ È¿°ú³ª ¾ÈÀü¼º¿¡¼­ ÈξÀ À¯¸®ÇÕ´Ï´Ù.

PethidineÀº ²À ÇÊ¿äÇÑ °æ¿ì¸¸ ¾²´Â °ÍÀÌ ÁÁ°í, routineÀ¸·Î »ç¿ëÇÏÁö ¸»±â¸¦ ±ÇÇÕ´Ï´Ù. Ȥ½Ã pethidineÀ» ÇÔ²² »ç¿ëÇÒ ¶§¿¡´Â midazolam ¿ë·®À» ´õ¿í ÁÙ¿©¾ß ÇÕ´Ï´Ù. Àú´Â »óºÎÁø´Ü³»½Ã°æ¿¡¼­´Â pethidineÀ» »ç¿ëÇÏÁö ¾Ê½À´Ï´Ù. Ä¡·á³»½Ã°æÀ̳ª ´ëÀå³»½Ã°æ¿¡¼­¸¸ »ç¿ëÇÕ´Ï´Ù.

ÀÏ´Ü paradoxical reactionÀÌ ¹ß»ýÇÏ¸é ±× Á¤µµ¿¡ µû¶ó ´ëó¹ýÀº ´Þ¶óÁý´Ï´Ù. ¾ÆÁÖ °æÇÏ¸é º¸Á¶ÀÚ°¡ ȯÀÚÀÇ ÀÚ¼¼¸¦ Àâµµ·Ï Á¶Ã³ÇÏ°í Àá½Ã ±â´Ù¸° ÈÄ °Ë»ç¸¦ ÇÒ ¼ö ÀÖ½À´Ï´Ù. ±× ÀÌ»óÀÌ¸é ±ÞÈ÷ flumazenilÀ» Åõ¿©ÇÏ°í °Ë»ç¸¦ ÁøÇàÇϱ⵵ ÇÕ´Ï´Ù. ±×·¯³ª Á¶±ÝÀÌ¶óµµ ¿©ÀÇÄ¡ ¾ÊÀ¸¸é ÀÏ´Ü ³»½Ã°æÀ» »©´Â °ÍÀÌ »óÃ¥ÀÔ´Ï´Ù. ³»½Ã°æÀ» »« ÈÄ ¸î ºÐ ±â´Ù·È´Ù°¡ ´Ù½Ã ½ÃµµÇÏ¸é ´ëºÎºÐ °èȹÇÏ¿´´ø ½Ã¼úÀ» ¸¶Ä¥ ¼ö ÀÖ½À´Ï´Ù.

³»½Ã°æ ¼¼¹Ì³ª °­ÀÇ·Ï (À̹üÀç)

ÃÖ±Ù ¾î¶² ȯÀÚºÐÀÇ °á°úÁö¿¡¼­ paradoxical reactionÀÌ ÀÖ¾ú´Ù´Â ³»¿ëÀ» º¸¾Ò½À´Ï´Ù. Midazolam 5 mg, pethidine 50 mg. ¿ª½Ã ¿ë·®ÀÌ ¸¹¾Ò´ø °Í °°½À´Ï´Ù. ´ÙÀ½ °Ë»ç¿¡¼­´Â º¸´Ù ÀûÀº ¿ë·®À» ¾²µµ·Ï Àǹ«±â·Ï¿¡ Àß ³²°ÜµÎ¾ú½À´Ï´Ù.


[2017-9-4. ÀÌÁØÇà]

¾Æ·¡¿Í °°Àº °á°ú¸¦ º¸¾Ò½À´Ï´Ù.

üÁß 51kgÀÎ 60´ë ¿©¼ºÀÇ °ËÁø À§³»½Ã°æ¿¡¼­ midazolam 2mgÀº ÀûÀº ¾çÀÌ ¾Æ´Õ´Ï´Ù. °Ô´Ù°¡ pethidineÀ» »ç¿ëÇÏ¿´À¸´Ï ´õ¿í sedationÀÌ ±í¾î paradoxical reactionÀÌ ³ª¿Â °Í °°½À´Ï´Ù. Áø´Ü¸ñÀûÀÇ »óºÎ³»½Ã°æ¿¡¼­ pethidineÀ» »ç¿ëÇÏÁö ¸» °ÍÀ» ±ÇÇÕ´Ï´Ù.

½Ã°£ Àý¾àÀ» À§ÇÏ¿© Àü °Ë»ç ¿ë·®À» Âü°íÇÏ´Â °ÍÀº ÁÁÀº ÀÏÀÔ´Ï´Ù. ±×·¯³ª Á¦°¡ ±ÇÇÏ´Â ¿ë·®Àº "Àü °Ë»ç ½Ã midzolam - 1 mg"ÀÔ´Ï´Ù. Àü °Ë»ç¿Í °°Àº ¿ë·®ÀÌ ¾Æ´Õ´Ï´Ù. Àü °Ë»çº¸´Ù Á¶±Ý Àû°Ô »ç¿ëÇÑ ÈÄ ¸î ºÐ ±â´Ù¸®½Ã°í Ȥ ºÎÁ·ÇÏ´Ù°í ÆÇ´ÜµÇ¸é ±× ¶§ 1mgÀ» ´õ Åõ¿©ÇϽñ⠹ٶø´Ï´Ù.


[References]

1) EndoTODAY ³»½Ã°æ ÁøÁ¤

2) »ï¼º¼­¿ïº´¿ø ³»½Ã°æ½Ç ÁøÁ¤ °­ÀÇ - À̹ÌÁ¤ °£È£»ç (2015³â)



© ÀÏ¿ø³»½Ã°æ±³½Ç ¹Ù¸¥³»½Ã°æ¿¬±¸¼Ò ÀÌÁØÇà. EndoTODAY Endoscopy Learning Center. Lee Jun Haeng.