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1 대한수혈학회지 : 제 26 권제 1 호, 2015 The Korean Journal of Blood Transfusion Vol. 26, No. 1, 38-46, April pissn eissn Original Article 예정수술에서의수술별적혈구제제최대혈액신청량재설정 박정래ㆍ Essam Alghamdi ㆍ김신영ㆍ김현옥 연세대학교의과대학진단검사의학교실 An Update of Maximum Surgical Blood Order Schedule in Elective Surgery Jeong Rae Park, Essam Alghamdi, Sinyoung Kim, Hyun Ok Kim Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea Background: Recently, operation technology and health care environment are continuously improving and changing. An updated MSBOS using current blood usage data is necessary for efficient blood management in the hospital blood bank. Methods: This study was a retrospective analysis based on operation names according to the ICD-9-CM at Severance hospital in We calculated the average units of red blood cells according to each operation, as well as the total units of RBCs used per each operation and patient. Finally an average unit of RBCs was set for the MSBOS, which were ordered before surgical operation. These analyzed results were compared with the previous reports of our hospital and other hospitals. Results: Transfusion episodes occurred in 3,092 cases, which is only 8.6% of all patients. Total units were 8,230 units, 27% of total RBCs (2,270 units) were used in cardiovascular surgery. Compared with the previous data, the usage of RBCs during surgery was decreased. Conclusion: The MSBOS investigated in this study showed some differences in the indicators in Therefore, regular update of the MSBOS is necessary in each hospital to reflect the advancement of surgical technology. (Korean J Blood Transfus 2015;26:38-46) Key words: Maximal surgical blood order schedule, Elective surgery, Type and screen 서론 수혈을위해혈액이환자에게출고되기위해서는환자의혈액과혈액제공자의혈액을반응 시키는교차시험이필요하다. 1) 교차시험이완료되어출고된혈액은특정환자를위해서만사용되며해당환자에게불필요해질경우에는폐기될수있다. 혈액을대체할수있는인공혈액은아직 Received on March 3, Revised on March 16, Accepted on March 16, 2015 Correspondence to: Hyun Ok Kim Department of Laboratory Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul , Korea Tel: , Fax: , hyunok1019@yuhs.ac This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright C 2015 The Korean Society of Blood Transfusion
2 박정래외 : 예정수술에서의수술별적혈구제제최대혈액신청량재설정 까지개발되지않았으며, 혈액은오직헌혈을통해서만확보가가능하다. 혈액은한정된자원으로서귀중한가치를지니고있기때문에효율적으로사용해야한다. 외과적수술은예상하지못하는상황으로인해환자에게과량의출혈이발생하는경우가있다. 따라서외과의사는수술전이런상황을대비하고자최대한많은양의혈액을준비하고자하지만혈액은행입장에서는수술시적정량의혈액을공급함으로써최대한효율적인혈액사용을유도해야할의무가있다. 외과의사의필요성과효율적혈액사용의접점을찾기위하여국외에서는 1970년도부터수술에따른혈액사용량에관한연구를시작하였고, 이중적혈구제제에있어서는수술시최대혈액신청량 (maximal surgical blood order schedule, MSBOS) 를설정하게되었다. 2) 국내에서는 1980 년대부터최대혈액신청량을도입하여이를수술시혈액출고에지침으로활용하고있다. 그러나혈액사용에대한지침이각의료기관의특성에따라조금씩다를수있어각병원마다자체내의최대혈액신청량의기준을사용하게된다. 3-6) 즉최대혈액신청량에따른혈액제제의뢰지침설정은각병원의특성에맞게진행되는데해당병원에서수술시사용된혈액량을조사하고이를통계내는방식이다. 시간이지남에따라수술의술식이발전하고, 임상의의혈액사용에대한인식도개선되면서동일수술이라하더라도과거와현재의수술시사용되는혈액량이변화되고있다. 이에따라최대혈액신청량역시시기별로수술별사용되는혈액량을재조사하여재설정할필요가있다. Song 등은대학병원에서는 1986년처음혈액의뢰지침을제정한바있으며, 3) 1991년 4) 과 2000 년 5), 2008년 6) 에각각개정하여보고한바가있다. 또한과거수술명이표준화되기전에는집도의별로같은수술을진행하더라도다른수술명이사용되기도하였다. 이로인해수술에따른최대혈액신청량역시수술명의표준화부재로과거자료와현재자료의비교, 타병원과의비교, 국내와국외의비교가어렵게진행되어왔다. 하지만현재는국제의료행위분류 (the international classification of diseases, ninth revision, clinical modification, ICD-9-CM) 에의하여수술명이표준화되었고, 7) 2008년에는국제행위분류의수술명에따른최대혈액신청량이조사된바가있다. 8) 이에최근 5년간수술기법의발달과로봇수술등의도입등으로 2007년자료를바탕으로 2008 년도에설정하였던최대혈액신청량의재산정이필요하게되었다. 따라서본연구에서는최근 1 년간세브란스병원에서진행된수술을국제행위분류에따라수술명을분류하고, 수술시혈액사용량을조사하여 2008년도의기준과비교함과동시에현재상황에적합한혈액제제의뢰지침을재설정하고자하였다. 대상및방법 2013년 1월 1일부터 2013년 12월 31일까지세브란스병원에서시행된수술을대상으로조사하였다. 조사자료는병원자동전산시스템을통해확보하였다. 수술은전신마취하에시행된수술에일부과 ( 산부인과, 정형외과, 비뇨기과 ) 의하반신마취수술도포함하였다. 응급수술은제외하였다. 수술명은의무기록에표기된국제의료행위분류 (ICM-9-CM) 코드를기준으로분류하였다. 분류된수술에따라수술당일실제환자에게수혈된적혈구제제의양을조사하여최대혈액신청량을설정하였다. 최대혈액신청량설정은수혈량의평균값의소수점한자리이하를반올림하여
3 Korean J Blood Transfus Vol. 26, No. 1, 38-46, Apr 적용하였다. 4,5) 수술받은환자수와그중수혈을받은환자수및비율 (%), 수술별전체수혈량및평균수혈량을조사하였다. 수술별평균수혈량이 0.5 미만인경우 Type and Screen법 (T&S) 으로분류하였다. 2) 분석된결과를동일병원의과거자료와비교하는동시에과거국내타병원에서조사된국제의료행위분류의수술명에따른최대혈액신청량과도비교하였다. 결과대상기간동안조사에포함된수술은총 35,885 건이었으며, 그중일반외과 8,520건, 이비인후과 4,075건, 정형외과 4,009건이었다. 이중적혈구제 제를환자에게수혈한건수는 3,092건으로총수술대비 8.6% 를차지하였다. 과별로는이식외과에서수술대비 64.5% 의적혈구제제를수혈하여수술대비수혈비율이높았으며다음으로는심장혈관외과가 54.5%, 소아신경외과에서 30.4% 순으로높았다. 수술시사용한적혈구제제는총 8,230단위였으며, 이중심장혈관수술에서 2,270 단위로가장많은적혈구제제가사용되었고다음으로는정형외과 1,346단위, 신경외과 1,000단위순이었다. 수혈받은환자중평균수혈량이높았던과는흉부외과로평균 4.27단위의적혈구제제를환자가수혈받았고, 심장혈관외과 (4단위), 이식외과 (3.3단위) 순이었다 (Table 1). 주요수술별적혈구제제사용량과최대혈액 Table 1. Blood usage for surgery Department No. of procedures Total RBC units Transfused patients No. (%) Mean transfusion units per patient Mean units per patient General surgery ENT Orthopedics Urology Neurosurgery OB&GYN Ophthalmology Pediatric Urology Plastic surgery Pediatric Orthopedics Chest surgery Cardiovascular surgery Pediatric Neurosurgery Pediatric Surgery Oromaxillofacial surgery Transplantation surgery ETC Total Abbreviations: ENT, ear nose and throat; OB&GYN, obstetric and gynecology; ETC, et cetera
4 박정래외 : 예정수술에서의수술별적혈구제제최대혈액신청량재설정 Table 2. Established guideline for maximum surgical blood order schedule (MSBOS) in this study (continued) Operation No. of patients Transfused patients No. % Total units Mean units MSBOS General surgery Laparoscopic cholecystectomy T&S Total gastrectomy T&S Subtotal gastrectomy T&S Exploratory laparotomy T&S Low anterior resection T&S Hemicolectomy T&S Lobectomy of liver Wedge resection of liver T&S Mastectomy T&S Pylous preserving pancreaticoduodenectomy T&S Bilateral thyroidectomy T&S Hemithyroidectomy T&S Excision of retroperitoneal mass Transplantation surgery Renal allograft Liver transplantation Neurosurgery Laminectomy T&S Posterior spinal fusion Excision of lesion of spinal cord T&S Laminoplasty, cervical T&S Removal of spinal body tumor Craniotomy and Removal of brain tumor Cranioplasty Discectomy T&S Transsphenoidal approach, removal of tumor T&S Removal of ICH C/O & clipping of aneurysm T&S C/O & Grid insertion OB&GYN Total abdominal hysterectomy T&S Low cervical cesarean section T&S Myomectomy, uterus T&S Operative laparoscope ovarian cystectomy T&S Cardiovascular surgery Graft replacement of aorta Aortic valve replacement Mitral valve replacement PDA ligation (Continued)
5 Korean J Blood Transfus Vol. 26, No. 1, 38-46, Apr Table 2. Continued Operation No. of patients Transfused patients No. % Total units Mean units MSBOS Chest surgery Lobectomy of lung T&S Lung transplantation Orthopedics Total knee replacement Total hip replacement Urology Partial Nephrectomy T&S Nephrectomy T&S Radical cystectomy Transurethral resection of prostate T&S Prostatectomy T&S Transurethral resection of bladder tumor T&S Head & Neck surgery Mastoidectomy T&S Mn: B-IVRO setback T&S Abbreviations: T&S, Type and Screen; ICH, intracranial hemorrhage; C/O, craniectomy; PDA, patent ductus arteriosus; Mn: B-IVRO, mandible bilateral intraoral vertical ramus osteotomy. 신청량은 Table 2에정리하였다. 이번연구대상과동일한의료기관에서조사한과거최대혈액신청량자료와도비교하였다. 과거자료와현자료연구대상이된수술중연간시행건수가높은수술을대상으로비교하였다. 과거자료는각각 1989년, 1999년, 2007년을기준으로조사가이루어졌다. 1989년부터 2013년까지 25년간의최대혈액신청량자료를비교해보았을때지속적으로혈액사용량은감소하는양상을보였다. 마지막으로조사가진행된 2007년이후의혈액사용량의변화는크게눈에띄지는않은편이나고관절치환술, 승모판막치환술그리고난소낭종절제술에서최대혈액신청량 1단위씩감소가확인되었다. 근치적신장절제술의경우적혈구제제사용량이크게줄어들어 T&S법적용대상수술이가능하 게되었다 (Table 3). 또한 2007년국내타의료기관에서 ICD-9-CM을기준으로수술명을분류하여설정한최대혈액신청량과도비교하였다 (Table 4). 이번연구대상과겹치는몇몇수술에대한비교를진행하였으며대부분의최대혈액신청량은본연구의자료가낮은결과를나타내었다. 고찰최대혈액량신청량이용시수술당평균혈액사용량이 0.5단위이하인수술의경우에는 Type and Screen법 (T&S) 을사용한다. 즉수혈이거의이루어지지않는수술이므로환자의 ABO, D 혈액형검사와비예기항체선별검사인수혈전검사만을실시한다. 만일응급수혈요청이발생하는
6 박정래외 : 예정수술에서의수술별적혈구제제최대혈액신청량재설정 Table 3. The comparison of MSBOS data in Severance hospital through 1989 to 2013 Operation MSBOS 1989 MSBOS 1999 MSBOS 2007 MSBOS 2013 Anterior resection 2 2 T&S T&S Cholecystectomy 1 T&S T&S T&S Hemicolectomy 2 T&S T&S T&S Mile's operation Radical mastectomy 2 T&S T&S T&S Renal allograft Segmentectomy, liver T&S Thyroidectomy 1 T&S T&S T&S Coronary artery bypass graft Mitral valve replacement Aneurysm clipping 2 T&S T&S T&S Brain tumor removal Total hip replacement 3 T&S 3 2 Cesarean section 1 T&S T&S T&S Transurethral resection of bladder 2 T&S T&S T&S Cystectomy, radical Nephrectomy, radical 3 2 T&S Abbreviation: T&S, Type and Screen. 경우항체선별검사에서음성임을확인한상태이므로생리식염수단계의교차시험을시행하여 5 분안에혈액출고가가능하도록한다는보장을함으로서혈액은행에서불필요한교차시험의업무를줄이는방법이다. 9) 최대혈액신청량은병원마다의특성에따라, 각시기에따라변동한다. 병원마다내원하는환자의연령, 질병분포가다르며, 수술술기의발전에따라수술중혈액손실이변동된다. 본연구에서도 2007년자료와일부차이를보이는것으로보아각병원은일정시기마다최대혈액신청량을개정할필요성이있다. 과거최대혈액신청량을선정하는데있어가장어려운점은체계화되지않은수술명을통합해서분석하는것이었다. 수술명의사용은동일수술임에도불구하고임상과, 주치의, 병원, 국가별로 다르게사용될수있다. 하지만현재는국제의료행위분류표준화작업으로의무기록수술기록에는 ICD-9-CM 코드가사용되고있다. 이코드는전세계적으로동일하게적용되고있어이코드를통한최대혈액신청량선정시각국가, 병원, 그리고과거현재시기별로비교가용이하다. 그래서본연구에서는 ICD-9-CM 코드를최대혈액신청량자료에포함시켰다. 이번연구를통해선정된최대혈액신청량에서대부분의일반외과수술은 T&S법적용이가능하다는결과가나왔다. 다만간이식에최대혈액신청량이 4단위로다른수술에비해높은편이었다. 이식수술의경우공여자와이식자간의혈액형이다른경우가있고이경우제한된혈액형의혈액제제를사용해야하기때문에사전에혈액준비가필요하지만그만큼불필요한혈액사용이있
7 Korean J Blood Transfus Vol. 26, No. 1, 38-46, Apr Table 4. Comparisons of another maximum surgical blood order schedule (MSBOS) studies from this study and other study Operation MSBOS This study MSBOS ) ICD-9-CM code number General surgery Laparoscopic cholecystectomy T&S T&S 5123 Total gastrectomy T&S T&S 4399 Subtotal gastrectomy T&S T&S 4389 Exploratory laparotomy T&S Low anterior resection T&S Hemicolectomy T&S Appendecomty Neurosurgery Laminectomy T&S Craniotomy and Removal of brain tumor Cranioplasty C/O & clipping of aneurysm T&S Craniectomy for decompression Craniotomy of hematoma-subdural OB&GYN Total abdominal hysterectomy T&S Low cervical cesarean section T&S T&S 741 Myomectomy, uterus T&S Orthopedics Total hip replacement Urology Nephrectomy T&S Abbreviations: T&S, Type and Screen; ICD-9-CM, International classification of diseases, clinical modification; C/O, craniectomy. 을수있으므로효율적혈액출고관리가필요하다. 해당의료기관의경우연구대상기간동안 2 건의폐이식수술이진행되었고총 22단위의적혈구제제가사용되어 11단위의최대혈액신청량이설정되었다. 수술수가적어정확한결과를도출하기위해서는축적된통계자료가필요하므로향후몇년간의자료를취합하여개정해야할필요성이있다. 수술시적절한적혈구제제의사용유도는수술기법향상과더불어최대혈액량자료를가지 고혈액은행의임상의를대상으로한교육도중요하다. 최근외국의연구에서도혈액은행이주도로시행한임상의상대교육으로교차시험량대비수혈량 (C/T ratio) 의비율이 1.95에서 1.60까지떨어졌다는보고가있었다. 10) 처음최대혈액신청량제도가도입된후국내외의많은의료기관에서여러차례최대혈액신청량을설정하고개선해왔다. 최대혈액신청량은의료기관별로수술에사용된혈액량을기준으로설정된다. 이러한방식은각의료기관의규모와
8 박정래외 : 예정수술에서의수술별적혈구제제최대혈액신청량재설정 종류에따라입원하는환자의연령, 성별, 질환의중증도가달라지고이는수술시혈액사용량에도영향을미쳐표준화되기어렵다. 게다가임상의가사용하는수술명이다양하여동일한수술에도다른수술명을기록하여수술에따른최대혈액신청량분류가어렵다. 하지만각각의의료기관에서설정한최대혈액신청량이다른의료기관에비해많고적음을비교하여개선의여지를알수있을만한표준지침의필요성은있다. 외국의경우규모가큰의료기관 3개가연합하여최대혈액신청량을통계낸자료도있다. 11) 우리나라역시학회차원이나대형의료기관이연합하여표준이될수있는최대혈액신청량을설정하여국내의료기관에지침으로활용할수있게하는것이수술시효율적인혈액사용에도움이될것이라본다. 이를위해의무기록에사용되고있는 ICD-9-CM 코드를적극활용하여표준화된수술명을이용하는것도중요하다. 그동안의최대혈액신청량개정상황을보면재설정까지걸리는시간이최소 5년이상의긴간극을두고진행되어왔다. 과거와달리의무기록의전산화로수술시사용된혈액량을조사하는것이과거에비해수월해졌기에보다짧은간격으로최대혈액신청량을개정하는것이가능할것이라본다. 1년이나 2년단위로개정되는최대혈액신청량을바탕으로임상의에대한적극적인최대혈액신청량을홍보, 교육한다면임상의의효율적혈액사용을보다개선할수있는기회가될것이다. 최대혈액신청량의최종목표는최대한많은수술에서 T&S법을사용하여불필요한교차시험과혈액출고로폐기되는혈액을줄이는것에있다. 이를위해서는최대혈액신청량이확립되었다면혈액은행은원활한시행을위해혈액을응급상황에서도차질없이공급할수있는능력을갖 추어임상의로부터최대혈액신청량을지켜도된다는확신을얻게해주는것이중요하다. 또한한정되고소중한혈액이불필요하게폐기되지않고효율적으로사용되도록혈액준비량과혈액사용량등의정기적인분석과임상에대한이런정보의제공등진단검사의학전문의와혈액은행담당자의지속적이고꾸준한노력이필요하다. 요약배경 : 발전하는수술기법과변화하는의료환경에맞는혈액제제의뢰지침을설정하기위해최근 1년간세브란스병원에서진행된수술시혈액사용량을조사하여최대혈액신청량 (MSBOS) 를재설정하고자하였다. 방법 : 2013년에세브란스병원에서시행된수술을 ICD-9-CM 기준에따라분류하여조사하였다. 수술시환자가받은적혈구제제의수혈량의평균값을적용하여최대혈액신청량을설정하였다. 분석된결과를동일병원의과거결과및국내타병원의결과와비교하였다. 결과 : 총수술중, 적혈구제제를환자에게수혈한비율은 8.6% (3,092/35,885) 이었다. 수술시사용한적혈구제제는총 8,230단위였다. 심장혈관수술에서 2,270단위로가장많은적혈구제제가사용되었다. 평균수혈량이높은수술은흉부외과로수술환자당평균 4.27단위의적혈구제제를수혈하였다. 과거에비해수술시사용된적혈구제제는감소하였다. 결론 : 본연구에서조사한최대혈액신청량은 2007년지표와일부차이를보였다. 최대혈액신청량은병원마다의특성이나, 각시기에따라변동하므로, 각병원은일정시기마다최대혈액신청량을개정할필요성이있겠다
9 Korean J Blood Transfus Vol. 26, No. 1, 38-46, Apr References 1. Han KS, Park KU, Song EY. Transfusion medicine. 4th ed. Seoul: Korea Medical Book Publishing Co., 2014: 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: Song KS, Kim TS, Rhim CH, Lee SY. A study on a type & screen order in elective surgery. Korean J Hematol 1985;20: Seon YK, Kim HO, Kwon OH, Jeon JW. The maximal surgical blood order schedule and surgical blood use in Severance hospital. Korean J Blood Transfus 1991;2: Park R, Kim HO, Nam YT. Reorganizatin of blood ordering practice for elective surgery. Korean J Clin Pathol 2000;20: Park Y, Kim MJ, Kim JJ, Kim S, Kim J, Kim HO. Re-establishment of blood ordering practice for elective surgery. Korean J Blood Transfus 2008;19: The National center for health statistics (NCHS) and the centers for medicare and medicaid services. International classification of diseases, ninth Revision, clinical modification (ICD-9-CM). [Online] (last visited on 15 March 2015). 8. Lee S, Han I, Kahng J, Kim Y, Shin DS, Han EK. Organization of maximum surgical blood order schedule (MSBOS) according to the international classification of diseases, ninth revision, clinical modification (ICD-9-CM). Korean J Blood Transfus 2008;19: Han KS, Park KU, Song EY. Transfusion medicine. 4th ed. Seoul: Korea Medical Book Publishing Co., 2014: Sajwani FH. Improving blood transfusion practice by regular education in the United Arab Emirates. Transfusion 2012;52: McPherson RA, Pincus MR. Henry s clinical diagnosis and management by laboratory medicine. Guidelines for ordering blood for elective surgery. 22nd ed. Philadelphia, PA: Elsevier Saunders, 2011:
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