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1 대한수혈학회지 : 제 19 권제 1 호, 2008 국제의료행위분류의수술명에따른최대혈액신청량설정 이승옥 1,3 ㆍ한인수 2 ㆍ강지민 1 ㆍ김용구 1 ㆍ신동섭 3 ㆍ한은경 4 가톨릭대학교의과대학진단검사의학교실 1, 마취통증의학교실 2, 가톨릭대학교성가병원혈액은행 3, 의료정보팀 4 = Abstract = Organization of Maximum Surgical Blood Order Schedule (MSBOS) according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Seungok Lee 1,3, Insoo Han 2, Jimin Kahng 1, Yonggoo Kim 1, Dong-Sub Shin 3, Eun-Kyung Han 4 Departments of Laboratory Medicine 1, Anesthesia 2, College of Medicine, The Catholic University of Korea, Seoul, Unit of Blood Bank 3, Unit of Medical Information 4, Holy Family Hospital, Bucheon, Korea Background: The aim of this study is to organize the maximum surgical blood order schedule (MSBOS) of red blood cells (RBCs) for elective surgeries according to the International Classification of Diseases, Ninth Revision, Clinical Modification guidelines (ICD-9-CM) and we compared the results with the previously reported MSBOSs. Methods: From 1 March to 31 August 2007, the data of the transfused RBCs for elective surgeries in our hospital were analyzed. The MSBOS was organized as the average number of units of transfused RBCs for the type of surgery, according to the ICD-9-CM. The results were compared with the MSBOSs that were previously reportedfrom 1982 to 2004 in Korea. Results: A total of 121 types of 3,375 surgeries were performed. Type & screen for 91 types (81.3%), 1 unit for 20 types (13.8%), 2 units for 7 types (3.8%), 3 units for 1 type (0.4%) and 4 units for 2 types (1.8%) were recommended. There was a minimal difference between these results and the range for the previously reported MSBOSs. Conclusion: It seems that the MSBOS showed minimal change since We organized the MSBOS according to the guidelines of the ICD-9-CM. Standardization of the surgery name should be considered to achieve more useful utilization of MSBOS. (Korean J Blood Transfus 2008;19:15-24) Key words: MSBOS, Elective surgery, ICD-9-CM 서론 획용혈액모두를포함하여매년평균 506만단대한적십자사혈액사업통계연보에따르면혈액위수준에머무르고있다. 1) 국민헌혈률은 4.3 접수일 :2008년 4월 11일, 승인일 :2008년 4월 18일책임저자 : 김용구 서울시영등포구여의도동 62번지가톨릭대학교성모병원진단검사의학과 TEL: 02) , FAX: 02) , yonggoo@catholic.ac.kr 공급실적은 2001 년이후부터수혈용혈액및분

2 대한수혈학회지 : 제 19 권제 1 호 5.0% 로증가율이미미하나혈액의안정성을높이기위한기준의강화로인해혈액공급은한계에있으며 1) 전체수요량의증가로인해혈액공급부족현상이갈수록심화되어국가적혈액관리체계의필요성이대두되고있다. 또한건강보험심사평가원의수혈적정성평가추구관리및보건복지부의료기관평가항목으로서혈액관리의효율성평가등공공기관의평가결과로부터결코자유로울수없다. 이러한이유들로인해의료기관에서의혈액사용이점차까다로워짐에따라공급된혈액을가장적절하고효율적으로환자에게수혈되도록하기위한노력과방안이절실하다. MSBOS (maximum Surgical Blood Order Schedule) 란예정된각종수술에대한적혈구제제의최대혈액신청량제한지침으로과도한혈액사전예약으로인한혈액량확보의어려움을줄이고교차시험검사비용, 혈액의출고및반환과정에따른혈액은행업무부담을줄여주는등여러이점을가지고있다. 2,3) 구미에서이미 1970 년대부터연구되기시작하였고, 4) 국내에서도 1980년대부터최근까지최대혈액신청량에대한개념을가지고이를각병원실정에맞게정착시키려는노력이있어왔다. 5-10) 성공적인시행을위해서는각병원에적합한최대혈액신청량을산정하고, 이를수혈위원회등을통하여진료부서에적극적으로권장하여외과의가수술을위한혈액을미리신청할때이지침을참고하여혈액을신청할수있도록하여야하며, 일정기간이지나면수술방법등의학지식이바뀌기때문에최대혈액신청량의재설정이필요하다. 그러나국내에서는 2004년이후보고가없고또한의무기록이국제의료행위분류 (the International Classification of Diseases, Ninth Revision, Clinical Modification, ICD-9-CM) 11,12) 에의한수술명으로 표준화되고있어이에따른수술명으로설정하여본원의특성에맞는최대혈액신청량지침을마련하고이를기존의보고와비교해봄으로써, 그간의변화양상이나수술명표준화에따른특성에대하여알아보고자하였다. 대상및방법 병원질향상프로그램활동으로서 1, 2차수혈위원회및소회의를통하여마취통증의학과및외과계의료진, 수술실, 전산정보팀등협조부서에대한홍보및의견을수렴하여 2007년 3월 1일부터 8월 31일까지본원에서시행된수술을대상으로수술명별수혈량에관한자료를수집하였고 5회이상시행된수술에대해서최대혈액신청량분석을시행하였다. 특히수술명의정확성을위해병원전산프로그램을통하여수술후마취대장에기록된수술명을사용하였고, 이를국제의료행위분류 (ICD-9-CM) 에따른표준화된수술명으로바꾸어표기하였다. 11,12) 분석방법으로적정수혈량산정은 standard blood order (SBO) 라고하는실제수혈량의평균값을최대혈액신청량으로정하였으며, 2) 수술당평균혈액사용량이 0.5단위이하인수술의경우를 type and screen법 (T&S) 로하였다. 수술당환자수, 실제수혈받은환자수비율 (%), 평균혈액사용량을진료과별로정리하였다. 또한, 환자의수술후처음측정한혈색소치를참고자료로하여분석된자료의적정성여부를검토하였다. 급성수혈의경우혈색소치 10 g/dl이상이면통상적으로적혈구제제의수혈이불필요함을감안하여수혈후 11 g/dl 이상인경우를초과사용으로판단하였다. 3) 또한산정결과를이미국내타병원연구자들에의하여보고된최대혈액신청량연도별자료와비교분석하였다

3 국제의료행위분류의수술명에따른최대혈액신청량설정 결과 1. MSBOS 산정결과기간중총 4,148건으로월평균 691건의수술이시행되었으며, 5회이상시행된수술은 121종 3,357건이었다. 5회이상시행된수술중수혈이전혀이루어지지않은수술이 69종 1,469건 (43.8%), 수혈이 1회이상이루어졌으나평균 0.5 단위이하 22종 1,257건 (37.5%) 으로 type and screen법권고수술이전체의 81.3% 를차지하였다. 1단위권고수술은 20종 462건 (13.8%), 2단위 7종 126건 (3.8%), 3단위 1종 15건 (0.4%), 4단위 2 종 28건 (0.8%) 이었다 (Table 1). 수혈이이루어진경우에수술후평균혈색소수치는 10.4±1.1 g/dl ( 최대 12.7 g/dl, 최소 7.3 g/dl) 이었다. 평균혈색소 11.0 g/dl 이상이었던수술은 15/52종 (28.8%) 이었다. 2. 연도별 MSBOS 보고자료와의비교 1982년부터 2004년도까지국내에보고된최대혈액신청량자료를비교해보면, 수술명불일치로인해 100% 비교는불가능하였지만, 동일수술명에대하여 1983년도보다 1993년이후에권고단위가현저히줄어들었다. 그러나 1993년부터 2007년사이에는권고단위에큰변화가없었다 (Table 2). 본원에서산정한수술별최대혈액신청량결과와타연구자들의보고와비교한결과본원의권고기준은이전보고된권고기준들을취합한권고범위 (range) 에대부분포함되었으나, 특히 2004년신등이다기관연구에서보고한자료와가장근접한결과를보였다. 그러나, 수혈후평균혈색소치 11.0 g/dl 이상이었던수술중, 신경외과수술인 laminectomy (decompression), other cervical fusion, anterior technique 및 intracerebral vascular anastomosis, direct 법은권고단위가 1단위, 성형외과수술인 flap graft-distant flap, except hand 법이 2단위, 치과수술인 radical operation of mandible malformation 법이 1단위로서본원의권고기준이타기관의권고기준인 T&S 보다높았다. 고찰 최대혈액신청량산정방법은수혈된혈액단위의누적비율에따른방법, 4) 수혈량의 3SD를벗어난경우를제외한후다시산정한평균값의 2SD 이내 5) 또는실제수혈량의평균값 (standard blood order, SBO) 으로산정하는방법 2) 등이있으며, 1990년대이후는대부분의보고에서실제수혈량의평균값으로산정하고있다. 6-10) 최대혈액신청량은동일한수술명이라하더라도병원특성에따라내원환자의분포도, 연령, 질환의중증도가달라획일적으로정해질수없으므로시행하고자하는병원실정에맞도록일정기간수술별수혈건수에대한정확한자료분석이필요하고또이를일정한주기로새롭게해주어야한다. 3) 이미정해진최대혈액신청량에따라혈액을신청하더라도수술전혈색소수치, 수술중및직후예상치못한과도출혈등의환자개별적변수와담당의사의판단에의해서혈액사용량이달라질수있다. 그러므로최대혈액신청량제도가원활하게시행되기위해서는무엇보다도추가적으로혈액사용이필요한경우에대비한혈액은행에서의빠른출고시스템이필요하다. Type and screen법은수술당평균혈액사용량이 0.5단위이하인수술의경우에추천되는방법으로, 혈액은행에서교차시험대신환자의 ABO

4 대한수혈학회지 : 제 19 권제 1 호 Table 1. The results of maximum surgical blood order schedule (MSBOS) for elective surgery in this study Type of surgery No. of patients No. of transfused patients (%) Mean units transfused Mean Hb level after surgery (g/dl) MSBOS General surgery Exploratory laparotomy (37.9) Anterior resection/low anterior resection of rectum 25 8 (32.0) Hemicolectomy 9 4 (44.4) Laparoscopic cholecystectomy (3.6) T&S Appendectomy (1.7) T&S Subtotal gastrectomy 43 5 (11.6) T&S Total gastrectomy 15 1 (6.7) T&S Neurosurgery Craniectomy for decompression (75.0) Craniotomy for evacuation of hematoma-subdural or extradural 12 9 (75.0) Craniotomy for excisional brain tumor-superatentorial 23 8 (34.8) Lumbar and lumbosacral fusion, posterior technique 18 5 (27.8) Clipping of Aneurysm (33.8) Laminectomy (decompression) 19 6 (31.6) Cranioplasty 18 4 (22.2) Burr hole or trephination-subdural or epidural 14 3 (21.4) Other cervical fusion, anterior technique 26 5 (19.2) Intracerebral vascular anastomosis, direct 22 8 (36.4) Burr hole or trephination-intracerebral 13 1 (7.7) T&S Shunt operation or bypass operation-ventriculo~other 11 1 (9.1) T&S Craniotomy for evacuation of hematoma-intracranial 11 1 (9.1) T&S Closed reduction of fracture &/or dislocated spine-lumbar 10 1 (10.0) T&S Orthopedic surgery Osteotomy & internal fixation-femur 15 7 (46.7) Lumbar and lumbosacral fusion, posterior technique 8 4 (50.0) Revision total replacement arthroplasty-hip 6 3 (50.0) Partial replacement arthroplasty-hip (46.9) Replacement total arthroplasty-hip (50.0) Replacement total arthroplasty-shoulder/knee 15 5 (35.7) Open reduction of fractured extremity-hand/finger/toe (15.2) T&S Osteotomy & internal fixation-hand/foot/finger/toe 49 5 (10.2) T&S

5 국제의료행위분류의수술명에따른최대혈액신청량설정 Table 1. Continued Type of surgery No. of patients No. of transfused patients (%) Mean units transfused Mean Hb level after surgery (g/dl) MSBOS Osteotomy & internal fixation-humerus 17 4 (23.5) T&S Drainage of intramuscular abscess 9 1 (11.1) T&S Removal of implanted devices from bone 98 3 (3.1) T&S Curettage or excision of benign bone tumor 78 2 (2.6) T&S Menisectomy 44 1 (2.3) T&S Obstetrics & Gynecology Partial oophorectomy 15 2 (13.3) Hysteoscopic myomectomy ( 3 cm) (multiple) 5 1 (20.0) Simple total hysterectomy (22.5) Extirpation of benign adnex tumor, both 25 3 (12.0) Abdominal or vaginal myomectomy, simple subserosal 12 3 (25.0) Exploratory laparotomy 15 4 (26.7) Cesarean section (11.8) T&S Pelviscopic cauterization 56 8 (14.3) T&S Urology Radical nephrectomy 12 3 (25.0) Prostatovesiculectomy (lymphnode removal) 6 2 (33.3) Ureteroneocystostomy 8 1 (12.5) Transuretral tumor excision 30 1 (3.3) T&S Ureteroscopic ureterolihotomy 28 1 (3.6) T&S Plastic surgery Flap graft-distant flap, except hand 6 4 (66.7) Infectious wound dressing 72 4 (5.6) T&S Suture of the wound-face/neck ( 3 cm) 18 4 (5.6) T&S Open reduction of mandible fracture 7 1 (14.3) T&S Dental surgery Radical operation of mandible malformation 6 2 (33.3) Total 1, (15.5) 10.4±

6 대한수혈학회지 : 제 19 권제 1 호 Table 2. Comparison of previous maximum surgical blood order schedule (MSBOS) studies in Korea and this study Reference No. Year of MSBOS organization 5) ) ) ) ) ) 2004 This study Range General surgery Exploratory laparotomy 3 4 T&S* T&S-1 2 T&S-4 Anterior resection/low anterior resection of rectum T&S T&S 2 2 T&S-2 1 T&S-2 Hemicolectomy 3 4 T&S 2 T&S T&S-4 Laparoscopic cholecystectomy T&S T&S T&S T&S T&S T&S Appendectomy T&S T&S T&S T&S T&S T&S Subtotal gastrectomy 3 T&S T&S T&S T&S-1 T&S T&S-3 Total gastrectomy 3 5 T&S T&S 6 T&S T&S T&S-6 Neurosurgery Craniectomy for decompression Craniotomy for evacuation of hematoma-subdural or extradural T&S-2 4 T&S-6 Craniotomy for excisional brain tumor-superatentorial T&S-2 2 T&S-7 Lumbar and lumbosacral fusion, posterior technique 2 3 T&S 1 T&S-3 Clipping of Aneurysm 2 T&S T&S 3 T&S-1 1 T&S-3 Laminectomy (decompression) T&S T&S T&S T&S T&S 1 T&S-1 Cranioplasty T&S T&S-1 1 T&S-1 Burr hole or trephination-subdural or epidural T&S 1 T&S-1 Other cervical fusion, anterior technique 1 T&S T&S 1 T&S-1 Intracerebral vascular anastomosis, direct T&S 1 T&S-1 Burr hole or trephination-intracerebral T&S T&S Shunt operation or bypass operation-ventriculo other T&S 2 T&S T&S-2 Craniotomy for evacuation of hematoma-intracranial T&S-2 4 T&S-2 T&S T&S-6 Closed reduction of fracture &/or dislocated spine-lumbar T&S T&S Orthopedic surgery Osteotomy & internal fixation-femur Lumbar and lumbosacral fusion, posterior technique T&S T&S-6 Revision total replacement arthroplasty-hip Partial replacement arthroplasty-hip T&S 3 T&S-1 2 T&S-3 Replacement total arthroplasty-hip 5 2 T&S T&S 3 T&S-2 1 T&S-5 Replacement total arthroplasty-shoulder/knee 1 T&S T&S 2 T&S-1 1 T&S-2 Open reduction of fractured extremity-hand/finger/toe T&S T&S T&S T&S Osteotomy & internal fixation-humerus T&S T&S

7 국제의료행위분류의수술명에따른최대혈액신청량설정 Table 2. Continued Reference No. Year of MSBOS organization 5) 1982 Drainage of intramuscular abscess T&S T&S T&S Removal of implanted devices from bone T&S T&S T&S T&S Curettage or excision of benign bone tumor T&S T&S T&S T&S T&S Menisectomy T&S T&S T&S Obstetrics & Gynecology Partial oophorectomy T&S T&S 1 T&S-1 Hysteoscopic myomectomy ( 3 cm) (multiple) T&S-1 1 T&S-1 Simple total hysterectomy 3 4 T&S T&S T&S T&S-3 T&S 1 T&S-4 Extirpation of benign adnex tumor, both T&S T&S 1 T&S-1 Abdominal or vaginal myomectomy, simple subserosal T&S T&S-1 1 T&S-1 Exploratory laparotomy 3 T&S T&S T&S 1 T&S-3 Cesarean section 4 T&S T&S T&S T&S T&S T&S-4 Pelviscopic cauterization T&S T&S T&S T&S Urology Radical nephrectomy T&S 3 T&S 2 T&S-3 Prostatovesiculectomy (lymphnode removal) 1 1 Ureteroneocystostomy 1 1 Transuretral tumor excision 2 T&S T&S T&S T&S-2 Ureteroscopic ureterolihotomy T&S T&S Plastic surgery Flap graft-distant flap, except hand T&S T&S 2 T&S-2 Infectious wound dressing T&S T&S T&S T&S Suture of the wound-face/neck ( 3 cm) T&S T&S T&S Open reduction of mandible fracture 2 T&S T&S T&S T&S T&S-2 Dental surgery Radical operation of mandible malformation 3 6 T&S 1 T&S-6 6) ) ) ) ) 2004 This study Range *Type and screen

8 대한수혈학회지 : 제 19 권제 1 호 및 RhD 혈액형을판정하고항체선별검사 (antibody screening test) 를실시해두었다가, 혈액요청후교차시험을실시하여최단시간에적합혈액을공급할수있도록하는것이다. 3) MSBOS를선정함에있어특히어려운점의하나는정확한수술명기재와표준수술명용어의선택이다. 수술전에작성된예비수술명은수술후달라질수있으므로반드시최종수술명을사용하여야정확한결과를얻을수있다. 수술명은과거의세계보건기구 (World Health Organization, WHO) 분류 13) 체계를따라일부연구자들에의해보고되고는있었으나, 9,10) 다수보고들간에수술명이통일되지않아기관간 100% 정확한비교가어렵다. 최근의료행위의발전에따라국제의료행위분류는 ICD-9-CM 11,12) 을기준으로하여의무기록되고있다. ICD-9-CM에기준한수술명은퇴원후의무기록되며이는코드로관리되어전세계적으로동일하게적용되므로장점은무엇보다도병원간의사용량비교가매우용이하여수혈적정성을보다객관적으로평가할수있다는점이라할수있겠다. 또한본연구에서는기존보고에서부족하였던신경외과, 정형외과및비뇨기과계수술명을국제의료행위분류에의한수술명을사용함으로써실제상황에맞도록세분화할수있었다. 따라서학회차원에서표준화된수술명으로최대혈액신청량을설정하고보고한다면보다객관적인통계자료로써부득이혈액사용이많지않거나전산시스템부재로최대혈액신청량산정이어려운의료기관의경우참고자료로써보다실제적이고유용하게활용될수있을것으로기대된다. 또한, 임상에이용될경우표준화된수술명이익숙해질수있도록의료인및혈액은행직원에대한공지또는교육이필요할수있고동일 수술명이라도수술부위별로실혈량이달라질수있으므로점점다양하고세분화되는수술명을어느수준까지표기할것인지에대한연구도향후해결해야할과제로사료된다. 최대혈액신청량변화추이를보면 1980년대보다 1992년도에현저히줄어든이후로큰변화가없었다. 1982년자료이후부터 1992년도까지의수혈량감소요인으로는전혈사용의감소와외과수술시의수혈량감소에원인이있다고생각된다. 6) 본원의분석결과는 2004년신등이분석한다기관연구 ( 월평균수술건수가 470건부터 1200 건에이르는 4개대학병원을대상 ) 와가장근접한결과를보였다. 이는의료기술이점차발달됨에따라혈액사용이감소되고보편화되면서각병원에서의의료수준차이가점차줄어든것으로추측된다. 또한, 수술후혈색소치가 11.0 g/dl 이상으로타기관보고에비해권고기준이높았던몇몇수술명에대해서는향후추가적인분석을통한재설정이필요할것으로생각되었다. 최대혈액신청량설정과 type and screen법을성공적으로적용한타병원예를보면, 서울아산병원의경우최대혈액신청량지침에따라수술중혈액이필요없는경우, 수술중수혈이반드시필요한경우 (type and crossmatch, T&C) 및수술시수혈가능성이 10% 미만으로적은경우 (T&S) 로나누어혈액을요청하도록하고있었다. 14,15) 아주대학교병원에서는수술전정확한수술명을모르거나기입하지않는경우가많고, 수술명이통일되지않거나많으므로최대혈액신청량산정이어렵고주기적으로수정보완해야하며동일한수술에대해서도환자의상황에따라필요한혈액수가다를수있는등최대혈액신청량사용의현실적인문제점과대다수의수술이 type and screen법에해당되는수술임을고려하여모든수술예정환자에서 type and screen법을적용하여성

9 국제의료행위분류의수술명에따른최대혈액신청량설정 공적인결과를얻었음을보고하였다. 7) 그러나아직까지보편화되지는않고있는데, 선택적수술에대해최대혈액신청량과 type and screen법의성공적인사용을위해서는혈액은행과임상과및수술실사이에긴밀한업무협조가이루어지도록적극적으로홍보하고교육하는진단검사의학과전문의와혈액은행담당자의노력과의지가가장중요하다고할수있겠다. 요약배경 : 국제의료행위분류 (ICD-9-CM) 의수술명에따른선택적수술용적혈구최대혈액신청량 (MSBOS) 을설정하고기존보고들과비교해보고자하였다. 방법 : 2007년 3월 1일부터 8월 31일까지본원에서 5회이상시행된수술에대해서적혈구수혈자료를수집하였다. 최대혈액신청량은국제의료행위분류 (ICD-9-CM) 에의한수술명에대하여실제수혈량의평균값으로설정되었다. 결과는 1982년부터 2004년까지국내보고된 MSBOS 자료와비교분석하였다. 결과 : 총 121종 3,357건의수술이시행되었다. type and screen법 91종 (81.3%), 1단위 20종 (13.8%), 2단위 7종 (3.8%), 3단위 1종 (0.4%), 4단위 2종 (0.8%) 이었다. 산정된결과는이전보고된권고기준범위와큰차이가없었다. 결론 : 최대혈액신청량은 2004년이후현재까지큰변화가없었던것으로생각된다. 저자들은국제의료행위분류 (ICD-9-CM) 에의한수술명에대하여최대혈액신청량을설정해보았다. 최대혈액신청량의더욱효과적인활용을위해서수술명의표준화가필요할것으로사료된다. 참고문헌 1.Blood services statistics. Korean Red Cross Vengelen-Tyler V. Technical manual. 13th ed. Bethesda, Maryland: American Association of Blood Banks, 1999: Han KS, Park MH, Kim SI. Transfusion medicine. 3rd ed. Seoul: Korea Medical Book Publisher, 2006: Friedman BA, Oberman HA, Chadwick AR, Kingdon KI. The maximum surgical blood order schedule and surgical blood use in the United States. Transfusion 1976;16: Cho HI, Kim KD, Kim JQ, Moon HR, Park MH, Kim SI. Expected blood unit for elective surgeries. J Korean Med Assoc 1983;26: Lee NY, Um TH, Kwon SW, Han KS, Cho HI. Analysis of the use of red blood cell products for elective surgery: a guide for maximum surgical blood order schedule (MSBOS). Korean J Blood Transfus 1993;4: Lim YA. Surgical blood ordering. Korean J Blood Transfus 2001;12: Park RJ, Kim HO, Nam YT. Reorganization of blood ordering practice for elective surgery. Korean J Lab Med 2000;20: Rheem I, Seo SW, Park JK. Analysis of surgical blood use and determination of maximum surgical blood order schedule at Dankook University Hospital. Korean J Blood Transfus 2003;14: Shin JW, Chun BR, Park R, Choi TY, Shin HB, Lee YK, et al. Suggestion of maximum surgical blood order schedule for major elective surgeries in Korea. Korean J Blood Transfus 2004;15: The National Center for Health Statistics (NCHS) and the Centers for Medicare and

10 대한수혈학회지 : 제 19 권제 1 호 Medicaid Services. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). otheract/icd9/abticd9.htm [online] (last visited on 11 April 2008) 12. Korean Medical Record Association. International classification of disease 9th revision clinical modification volume III. Korea: Korean Medical Record Association, World Health Organization. International classification of procedures in medicine. Geneva: World Health Organization, Kang YH, Ihm CH, Kwon SW. Analysis of effectiveness of the maximum surgical blood order schedule. Korean J Blood Transfus 2002;13: Asan Medical Center. Blood Bank. Transfusion guideline. [online] (last visited on 11 April 2008)

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untitled 대한수혈학회지 : 제 26 권제 1 호, 2015 The Korean Journal of Blood Transfusion Vol. 26, No. 1, 38-46, April 2015 http://dx.doi.org/10.17945/kjbt.2015.26.1.38 pissn 1226-9336 eissn 2383-6881 Original Article 예정수술에서의수술별적혈구제제최대혈액신청량재설정