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1 대한수혈학회지 : 제 18 권제 3 호, 2007 박용정ㆍ박윤희ㆍ이양순ㆍ백은정ㆍ김신영ㆍ김현옥 = Abstract = 연세대학교의과대학진단검사의학교실 Evaluating the Appropriateness of a Single Unit Transfusion Yongjung Park, Younhee Park, Yangsoon Lee, Eun Jung Baek, Sinyoung Kim, Hyun Ok Kim Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea Background: The domestic quantity of blood components consumed has been decreasing since 2002, but the rate of a single unit RBC transfusion (SUT) has been on the increase. In the past, a SUT was regarded as an uncesssary procedure, but currently is considered as an effective method to maintain a minimal hemoglobin concentration for physiological needs. We investigated the actual conditions of a SUT. Methods: We analyzed 800 cases of SUTs performed at a tertiary care university hospital between March 2006 March and February The subjects of the study were divided into a surgical group (n=561) and medical group (n=239) for the purpose of RBC unit usage and were analyzed by groups and ordering departments, with an analysis of the pre and post-transfusion hemoglobin concentration and hematocrit values. The distribution according to the pre and post-transfusion hemoglobin ranges were calculated. Results: The mean hemoglobin concentration increment of the surgical group was significantly lower than that of the medical group (P<0.0001) and the mean pre and post-transfusion hemoglobin concentrations of the medical group were lower than that of the surgical group (P<0.0001). Approximately 26% cases of the SUTs performed in the surgical group were appropriate, based on a post-transfusion hemoglobin concentration below 10 g/dl. In the medical group, about 75% of the SUTs were appropriate based on a pre-transfusion hemoglobin concentration below 9 g/dl. Conclusion: Most transfusions are decided based on various clinical situations and opinions of the clinicians. Therefore, continuous evaluation of the appropriateness of transfusion is necessary. In our study, the appropriateness of a SUT was estimated indirectly based on the pre and post-transfusion hemoglobin concentration. Consequently, policies and strategies for performing asingle unit RBC transfusion are required. (Korean J Blood Transfus 2007;18: ) Key words: Single unit, Transfusion, Hemoglobin concentration 접수일 :2007년 9월 5일, 승인일 :2007년 11월 28일책임저자 : 김현옥 서울시서대문구신촌동 134 연세대학교의과대학진단검사의학교실 TEL: 02) , FAX: 02) , hyunok1019@yuhs.ac.kr

2 대한수혈학회지 : 제 18 권제 3 호 서론 보건복지부심사평가원은 2003년부터국내혈액제제사용에대한수혈적정성평가를시행하고있다. 2003년처음시작할때에비해적혈구제제, 신선동결혈장, 혈소판제제는매년그사용량이감소하고있으며, 특히적혈구제제의경우는지속적으로감소되는것으로평가되고있다. 그러나적혈구수혈적정성평가지표중의하나인 1 단위적혈구수혈률은 2002년적혈구제제사용량의 8.8% 에서 2006년에는 10.1% 로증가하였으며, 세브란스병원에서는 2006년상반기 1단위적혈구수혈률이 10.3% 로집계된바있다. 1) 적혈구를 1단위수혈하는경우환자의혈색소수치를 1 g/dl 정도증가시킬수있는데, Reece 등은 1960년대 850병상규모의병원에서적혈구제제사용 2,921건을분석한결과 855건 (29%) 의 1단위수혈중약 2/3가적절하지않았던수혈임을보고한바있어 2) 일반적으로 1단위수혈은불필요한수혈로간주되어왔다. 국내의한연구에서도 1단위적혈구수혈의약 72% 정도가불필요하거나수혈의의미가불분명했다고결론내린바있다. 3) 이러한연구들을근거로현재심사평가원의수혈적정성평가에서 1단위적혈구수혈률은불필요한수혈의지표중하나로사용하고있다. 그러나 2000년대이후수혈로인한감염성질환의전파등수혈로인한부작용 4-6) 빈도가증가하고있으며, 헌혈자감소등혈액제제의수급이어려워지고, 수혈의남용으로인한사회적비용증가등에관심이높아지면서 1단위적혈구수혈은최소한의수혈만으로혈색소 (hemoglobin, Hgb) 농도를유지하기위한방법의하나로인식되고있다. Hebert 등 7) 은 357명의심혈관계중환자를대상으로혈중 Hgb 농도를 7 9 g/dl로유지한군과 g/dl로유지한군을비교한결과 Hgb 농도에따른생존율은통계적으로차이가없다고보고하였으며급성심근경색이나불안정협심증을제외하고는심혈관계중환자라고하더라도혈중 Hgb 농도를 7 9 g/dl 사이로유지하면조직의산소화에지장이없었으며수혈부작용감소로장기부전의발생을줄일수있었다고보고하였다. Gould 등 8) 은대다수의 1단위적혈구수혈이불필요한수혈을방지하는최소한의수혈이라고결론내린바있으며, 수혈이필요한명확한생리적지표가없을경우에는수혈을하지않도록권고하였다. 이러한연구의결과는 1단위수혈이불필요한적혈구수혈을지양하는근거가될수있다. 따라서본연구에서는최근 1단위수혈에대한인식의변화를기반으로종합의료기관에서 1단위적혈구수혈실태를조사하고아울러수혈혈액의적정성추구관리지표로서의 1단위수혈률의의의를평가하고자하였다. 대상및방법세브란스병원에서 2006년 3월부터 2007년 2월까지소아를제외한 16세이상의환자중, 입원기간동안 1단위적혈구수혈을시행받은환자 813 예를대상으로조사하였다. 자료는세브란스병원에서심사평가원에보험청구심사가의뢰되었던전산자료를후향적으로분석하였다. 전체 813 예의환자중자가수혈과동시에타인의적혈구수혈을 1단위더받았던 4예와각기 320 ml 유래적혈구 1단위와 400 ml 유래적혈구 1단위를동시에받아용량별 1단위수혈로잘못집계된 9 예를포함하여총 13예는결과분석에서제외한후 800예에대해분석하였다. 환자의수혈전후의 Hgb과 Hct은적혈구제제의출고시점을전후로가장가까운시기에시행된일반혈액검사로부터산출하였다. 특이질환의

3 과거력이없고수술과관련없는실혈이발생하지않은환자의경우 1개월이내의일반혈액검사중혈액출고시점과가장근접한이전의결과에서수술전 Hgb 농도와 Hct를산출하였으며, 수혈전 1개월이내에일반혈액검사를시행하지않은 5예는수혈전검사결과산출에서제외하였다. 적혈구제제가출고된시점으로부터 3일이내의기간동안일반혈액검사를시행하지않은 41예역시수혈후검사결과산출에서제외하였다. 적혈구제제의사용목적을기준으로수술이나침습적시술과정중에발생하는실혈을보충하기위한것인지또는수술이나침습적시술에관계없는실혈을보정하거나빈혈을개선하기위하여 1단위적혈구수혈을시행한경우인지에따라각각외과계열 (n=561) 과내과계열 (n=239) 로나누어분석을진행하였다. 계열간의나이, 성별, 수혈전후혈중 Hgb 평균농도와 Hct의비교에는 t-test를이용하였다. 또한, 계열별로수혈전후의 Hgb 농도를각각 7 g/dl 이하구간, 7 g/dl부터 15 g/dl까지 1 g/dl 단위구간, 15 g/dl 초과구간으로나누어각각의빈도수를산출하였다. 결과 환자의나이, 성별분포는 Table 1 에요약하였으 Table 1. Characteristics of patients with single unit transfusion Surgical group Medical group Total No. of patients Age* 58.9± ± ±15.5 (year, range) (16 96) (16 95) (16 96) Gender (male/female) 240/ / /435 *The results are shown as mean±standard deviation (min max)'. 며 1단위수혈은외과계에서 561예 (70.1%), 내과계에서 239예 (29.9%) 가시행되었다. 외과계열환자의평균연령이내과계열보다통계적으로유의하게낮았으며 (P=0.012), 외과계열은내과계열에비하여여성의비율이높았다 (P=0.012). 진료과별빈도수와백분율은 Table 2와같다. 수혈전후평균 Hgb 수치는 10.5±2.6 ( ) g/dl에서 10.6±1.7 ( ) g/dl였으며, 통계적 Table 2. Ordering frequencies for single unit transfusion by department Department Frequency, N Frequency, % Anesthesiology Cardiology Cardiovascular surgery Chest surgery Emergency medicine Endocrinology ENT Family medicine Gastroenterology General surgery Hematology Infection medicine Nephrology Neurology Neurosurgery Obstetrics and gynecology Oncology Ophthalmology Oral and maxillofacial surgery Orthopaedics Pediatric neurosurgery Pediatric cardiology Pediatric orthopaedics Pediatrics Plastic surgery Pulmonology Rehabilitation medicine Transplantation Urology Total

4 대한수혈학회지 : 제 18 권제 3 호 으로의의있는상승은관찰되지않았다 (Table 3). 외과계열의수혈전평균 Hgb 농도는 11.4±2.4 ( ) g/dl, 수혈후평균 Hgb은 11.0±1.6 ( ) g/dl였으며, 수혈전후의 Hgb 증가는 0.4±1.8 ( ) g/dl였다 (Table 3). 내과계열의수혈전과후평균 Hgb 농도는각각 8.4±1.7 ( ) g/dl, 9.4±1.4 ( ) g/dl였으며수혈전후의 Hgb 증가는 1.0±1.2 ( ) g/dl Table 3. Pre- and post-transfusion hemoglobin and hematocrit levels in surgical and medical groups Pre-transfusion Pre-transfusion Post-transfusion Post-transfusion ΔHgb ΔHct Hgb (g/dl)* Hct (%)* Hgb (g/dl)* Hct (%)* (g/dl)* (%)* Surgical group, 11.4± ± ± ± ± ±5.4 (n=561) ( ) ( ) ( ) ( ) ( ) ( ) Medical group, 8.4± ± ± ± ± ±3.7 (n=239) ( ) ( ) ( ) ( ) ( ) ( ) Total 10.5± ± ± ± ± ±5.4 (n=800) ( ) ( ) ( ) ( ) ( ) ( ) *The results are shown as mean±standard deviation (min max)'. Abbreviations: Hgb, hemoglobin; Hct, hematocrit; ΔHgb, post transfusion hemoglobin - pre transfusion hemoglobin; ΔHct, post transfusion hematocrit - pre transfusion hematocrit; SUT, single unit RBC transfusion. Table 4. Distribution of single unit RBC transfusion, pre- and post-transfusion hemoglobin levels in surgical groups Department No. of SUT (%) Pre-transfusion Hgb (g/dl)* Post-transfusion Hgb (g/dl)* Anesthesiology 11 (2.0) 12.3±2.3 (9 15.8) 11.7±1.6 ( ) Cardiovascular surgery 46 (8.2) 10.8±2.6 ( ) 9.2±1.4 ( ) Chest surgery 20 (3.6) 10.3±1.9 ( ) 10.4±1.1 ( ) ENT 20 (3.6) 9.6±1.5 ( ) 10.6±1.0 (8.4 13) General surgery 99 (17.7) 10.3±2.2 ( ) 11.1±1.7 ( ) Neurosurgery 116 (20.7) 11.5±2.4 ( ) 11.0±1.4 ( ) Obstetrics and gynecology 37 (6.6) 10.5±1.7 (7.6 14) 10.6±1.1 ( ) Ophthalmology 2 (0.4) 9.1±0.2 ( ) 9.8±0.5 ( ) Oral and maxillofacial surgery 2 (0.4) 13.9±2.4 ( ) 12.2±0.3 ( ) Orthopaedics 129 (23.0) 12.6±2.0 ( ) 11.7±1.3 ( ) Pediatric cardiology 6 (1.1) 14.2±2.7 ( ) 11.9±1.5 ( ) Pediatric neurosurgery 6 (1.1) 13.5±1.4 ( ) 11.9±1.1 ( ) Pediatric orthopaedics 1 (0.2) Plastic surgery 7 (1.3) 8.6±0.9 ( ) 9.7±0.9 (8.2 11) Transplantation 13 (2.3) 8.9±0.9 ( ) 10.2±0.8 ( ) Urology 46 (8.2) 13.0±2.1 ( ) 11.7±1.5 ( ) Total 561 (100.0) 11.4±2.4 ( ) 11.0±1.6 ( ) *The results are shown as mean±standard deviation (min max)'. Abbreviations: See Table

5 였다 (Table 3). 외과계열의진료과별분포와수혈전후의 Hgb 농도는 Table 4와같으며수혈전후 Hgb 농도의구간별빈도를산출하였다 (Table 5). 일반외과, 신경외과, 정형외과의순으로 1단위적혈구수혈의빈도가높은것으로나타났으며, 1단위의적혈구를수혈받았을때약 1 g/dl의 Hgb 농도가증가하는것을고려하여수혈후 Hgb 농도가 8 g/dl 이하인경우를적정수혈이라고가정한다면외과계열에서시행된 1단위적혈구수혈중 1.6% 가적절하였다고평가되며수혈후 Hgb 농도가 10 g/dl 이하일경우를적절한적혈구제제사용으로가정할경우 1단위적혈구수혈의 26.0% 가적절했던것으로판단되었다 (Table 5, Fig. 1). 내과계열에서는신장내과, 소화기내과, 심장내과, 종양학과순으로 1단위적혈구수혈의빈도가높았 Table 5. Distribution and cumulative distribution of hemoglobin levels in surgical groups Pre-transfusion Cumulative Post-transfusion Cumulative No. of SUT (%) No. of SUT (%) Hgb (g/dl) No. of SUT (%) Hgb (g/dl) No. of SUT (%) 7 9 (1.6) 9 (1.6) 7 1 (0.2) 1 (0.2) (5.7) 41 (7.4) (1.5) 9 (1.6) (14.7) 123 (22.1) (7.0) 47 (8.4) (14.4) 203 (36.4) (18.0) 145 (26.0) (8.1) 248 (44.5) (25.7) 285 (51.2) (9.9) 303 (54.4) (21.9) 404 (72.5) (13.5) 378 (67.9) (14.9) 485 (87.1) (16.3) 469 (84.2) (7.0) 523 (93.9) (10.6) 528 (94.8) (2.9) 539 (96.8) >15 29 (5.2) 557 (100.0) >15 5 (0.9) 544 (100.0) Total 557 (100.0) 544 (100.0) Abbreviations: See Table 3. Fig. 1. Distribution of post-transfusion hemoglobin levels in surgical groups and pre-transfusion hemoglobin levels in medical groups

6 대한수혈학회지 : 제 18 권제 3 호 으며 (Table 6), 수혈전혈중 Hgb 농도가 9 g/dl 이하인경우를적절한적혈구제제사용으로간주할때내과계열의 1단위적혈구수혈중약 75% 가이기준에부합하였다 (Table 7, Fig. 1). 외과계열의수혈전후혈중 Hgb 농도는수술중실혈의영향으로약간감소하는양상을보였 Table 6. Distribution of single unit RBC transfusion, pre- and post-transfusion hemoglobin levels in medical groups Department No. of SUT (%) Pre-transfusion Hgb (g/dl)* Post-transfusion Hgb (g/dl)* Cardiology 38 (15.9) 8.7±1.9 ( ) 9.3±1.0 (6.8~11.3) Emergency medicine 16 (6.7) 8.8±2.5 ( ) 9.3±1.6 (6.6~12.4) Endocrinology 4 (1.7) 7.6±1.0 ( ) 8.7±2.4 (5.3~10.9) Family medicine 2 (0.8) 8.7±1.2 ( ) 9.7±0.5 (9.3~10) Gastroenterology 47 (19.7) 9.1±1.6 ( ) 10.2±1.5 (8~14.3) Hematology 3 (1.3) 10.2±1.8 (8.4 12) 10.7±1.9 (8.5~12) Infection medicine 6 (2.5) 7.2±0.7 ( ) 8.8±0.7 (8~9.4) Nephrology 61 (25.5) 7.4±1.2 ( ) 8.7±1.2 (6.3~11.9) Neurology 2 (0.8) 12.0±4.4 ( ) 12.0±3.6 (9.4~14.5) Oncology 36 (15.1) 8.9±0.9 (6.7 11) 10.1±1.1 (6.6~11.7) Pediatrics 9 (3.8) 7.6±0.8 (6 8.8) 9.0±1.6 (5.9~11.1) Pulmonology 13 (5.4) 7.8±1.2 ( ) 9.2±1.3 (7.1~11) Rehabilitation medicine 2 (0.8) 8.1±0.9 ( ) 9.6±0.3 (9.4~9.8) Total 239 (100.0) 8.4±1.7 ( ) 9.4±1.4 ( ) *The results are shown as mean±standard deviation (min max)'. Abbreviations: See Table 3. Table 7. Distribution and cumulative distribution of hemoglobin levels in medical groups Pre-transfusion Cumulative Post-transfusion Cumulative No. of SUT (%) No. of SUT (%) Hgb (g/dl) No. of SUT (%) Hgb (g/dl) No. of SUT (%) 7 41 (17.2) 41 (17.2) 7 11 (5.1) 11 (5.1) (29.0) 110 (46.2) (11.6) 36 (16.7) (28.6) 178 (74.8) (21.9) 83 (38.6) (14.3) 212 (89.1) (29.3) 146 (67.9) (3.4) 220 (92.4) (22.3) 194 (90.2) (3.8) 229 (96.2) (6.5) 208 (96.7) (1.3) 232 (97.5) (1.9) 212 (98.6) (1.7) 236 (99.2) (0.5) 213 (99.1) (0.4) 237 (99.6) (0.9) 215 (100.0) >15 1 (0.4) 238 (100.0) >15 0 (0.0) 215 (100.0) Total 238 (100.0) 215 (100.0) Abbreviations: See Table

7 고, 내과계열은수혈후 1.0±1.23 ( ) g/dl 증가하였다. 수혈전후의혈중 Hgb 농도와 Hct의차이는외과계열이내과계열에비하여유의하게낮은결과를보였다 (P<0.0001). 내과계열의수혈전 후혈중 Hgb 농도와 Hct는외과계열에비하여통계적으로유의하게낮았다 (P<0.0001). 고찰 적혈구수혈의적응증은혈중 Hgb 농도가 7 g/dl 이하로감소되거나전체혈액량의 30 40% 의실혈이발생하였을경우와그외에환자의나이가 65세이상이거나, 심한심혈관계질환, 수술의종류등의임상적상황에따라서혈중 Hgb 농도가 7 g/dl 이상인경우에도수혈이고려될수있다. 그러나만성빈혈환자의경우빈혈의원인을제거하는방법으로치료를시행하고통상적으로혈중 Hgb 농도가 7 g/dl 이하라고하더라도빈혈로인한임상증상이나타나지않을때는수혈을고려하지않을수있다. 9) 하지만대부분의적혈구수혈이다양한임상적상황이나기준에의해이루어지고있기때문에획일된기준을적용하기어려우며다양한관점에서수혈의적정성을지속적으로평가하고조사하는것이필요하다. 수혈의적정성평가에는적정성을규정하는기준과방법에따라다양한결과를얻을수있다. 10) 본연구에서는수혈이필요한상황에대한정확한임상적정보를종합적으로반영하지는못하였으나수혈전후의혈중 Hgb 농도를통해수혈의적정성을간접적으로평가하였다. 수혈을결정하는데에있어혈중 Hgb 농도의적절한기준은논쟁의대상이지만많은연구결과가최소한의적혈구수혈을권장하고있다. 5,7,8,11-14) 본연구에서는적정수혈에대한혈중 Hgb 농도의기준을확정 하지않고다양한기준으로평가가가능하도록혈중 Hgb 농도를구간별로분석하였다. 또한, 본연구는혈중 Hgb 농도가 7 9 g/dl인경우수혈을시작하는것이적절하다는가정하에적정수혈률을분석하였다. 외과계열의경우수술도중의실혈량과환자의활력징후를적정성평가에정확하게반영하는것은정보획득과분석과정에어려움이있다. Audet 등은수술과관련하여수혈을받은경우, 수술당일환자의활력징후변화와실혈량이의학적기록에반영된경우는 68%, 수술다음날의기록에반영된경우는 10% 에지나지않았으며, 수술후수혈과관련된환자의증상이기록된경우는 10% 에지나지않았다고보고하였다. 15) 수혈의적정성분석과추구관리에의학적기록이중요하므로수혈과연관된의학적, 임상적기록에대해임상의에게적절한수혈의기준과수혈관련기록작성의필요성을교육함으로써혈액제제사용의적정성과효율성향상을기대할수있을것이다. 16) Goodnough 등은외과계열환자를대상으로수혈의적정성을평가하기위하여퇴원시점에서의 Hct을적정성평가의지표로사용하였으며, 퇴원시 Hct이 33% 이상인경우에부적절한수혈로평가한바가있다. 14) 또한, 수술후 Hgb 농도 5 6 g/dl 이하인경우급격히사망률과이환율이증가한다는보고가있어 17) 외과계열환자의경우수혈전 Hgb 농도보다는조절목표가되는수혈후 Hgb 농도가임상적으로더중요하다고할수있다. 따라서본연구에서는외과계열환자에대한수혈의적정성평가에있어수혈후혈중 Hgb 농도를분석하여실혈량과적혈구수혈의상쇄효과를간접적으로알아보았다. 본원에서조사대상기간동안시행된 1단위적혈구수혈 800예중 561예 (70.1%) 는수술이나

8 대한수혈학회지 : 제 18 권제 3 호 침습적시술과정에서의실혈을보정하기위하여사용되었다. 적정성판단의기준이명확하지않으므로여러가지의 Hgb 농도를기준으로적정수혈을평가한다면, 결과에서언급한것처럼외과계열의적정수혈률은수혈후 Hgb 농도를 10 g/dl 이하인경우에적절하였다고평가할경우약 26% 정도로낮은양상이었다. 수혈후혈중 Hgb 농도의절대적평가기준이없으므로획일적인기준으로적정성을분석할수없겠으나본연구에서는외과계진료과중 8개과에서수혈후평균 Hgb 농도가 11 g/dl 이상으로나타나외과계열에서시행된 1단위적혈구수혈은적절하지않았다고평가할수있었다. 내과계열에서는주로빈혈상태나자발적실혈의교정을목적으로 1단위적혈구수혈을시행하므로수혈전 Hgb 농도가수혈의적정성을평가하는간접적인지표로유용하다. Hebert 등도 6개기관의중환자실환자를대상으로한수혈경향에관한연구에서수혈을결정하는기준으로수혈전혈중 Hgb 농도를적용하여분석한바있다. 18) 다른연구에서도중환자실에입원중인환자를대상으로수혈전혈중 Hgb 농도를측정하여적정성을평가하였으며, 연구대상기관에서는수혈전혈중 Hgb 농도의기준을 7 9 g/dl 범위로정하고있었다. 13) 본연구결과에서는적정수혈의수혈전 Hgb 농도기준을 8 g/dl로가정할경우내과계열의 1단위수혈중 75% 가적절하였으며기준을 9 g/dl로할경우약 89% 가적절한수혈인것으로판단되었다. 내과계열의수혈전후평균 Hgb 농도의차이는 1.0±1.23 ( ) g/dl로산출되어적혈구제제 1단위는혈중 Hgb 농도를 1 g/dl 정도증가시킨다는일반적인개념에부합하는결과가나타났다. 세브란스병원에서의 1단위적혈구적정수혈률은외과계열에서상대적으로낮았으며 (P< ), 이는 Rubin 등의연구결과와일치하였다. 19) 결과적으로내과계열이외과계열보다 1단위적혈구수혈을더보존적으로시행하고있다고할수있다. 외과계열환자는수술전저장철의양이나수술과정에서의실혈의영향으로빈혈이발생하고, 시간이지나면회복되는양상을보이게된다. 수술후빈혈의정도에따라적혈구 2,3-diphosphoglycerate의증가가보상기전으로나타나기때문에수술후환자의삶의질이저하되는경우는거의없다. 20) 따라서수술후혈중 Hgb 농도를필요이상으로증가시키는것은불필요한수혈이며, 본원에서시행되고있는외과계열의 1단위적혈구수혈중많은부분은개선이필요할것으로사료된다. 적정수혈을유도하기위해서는제도적방법이필요할것이다. Tuckfield 등 21) 은수혈의적정성을관리하는방법의하나로혈액제제요청신청서를적용하여신청서에정해진기준에합당한경우에만혈액을출고하도록한결과적혈구제제의부적정수혈률이 16% 에서 3% 로, 혈소판제제의경우 13% 에서 2.5% 로, 신선동결혈장제제의경우 31% 에서 15% 로감소되었다고보고하였다. 반면, 적정수혈을유도하기위하여수혈적정성평가결과를서면만으로통보하였을때는부적절한혈액제제사용의감소가미미한수준으로, 적정수혈에관한중재의효과는크지않았다고하였다. 19) 1단위적혈구제제수혈에관한한연구에서는같은혈중 Hgb 농도를목표로수혈을고려할때적혈구 2단위를수혈하는것과비교하여 1단위만수혈을하더라도목표혈중 Hgb 농도 (7, 8, 9 g/dl) 에따라각각 98.0%, 79.6%, 42.0% 에서 1단위수혈만으로목표치를달성할수있었으며환자당목표 Hgb 농도에따라각각 0.21, 0.57, 0.82 단위의적혈구제제를절약할수있다고보고하

9 였다. 22) 제한적적혈구수혈을통하여최소한의혈중 Hgb 농도를유지할경우 1단위수혈정책은적혈구제제사용의효율성을증가시킬수있을것으로생각된다. 혈중 Hgb 농도는환자의산소포화능력을간접적으로반영하는대표적인지표이다. 대부분의수혈지침에는수혈전 Hgb 농도에관한기준이포함되어있다. 급격한실혈이있을경우에는실혈량과더불어환자감시장치를이용하여조직의산소포화도를산출함으로써환자의생리적산소요구를반영하여수혈의필요성을판단해야하며, 이러한정보들이명확하게제시되지못할경우심박수, 혈압, 출혈의종류가혈중 Hgb 농도만으로수혈의필요성을판단하는과정을보완할수있다. 23) 수혈은혈압이나산소포화도, 맥박수, 심폐질환의유무등환자의임상적상태를고려하여결정되어야한다. 따라서본연구에서와같이혈중 Hgb 농도만으로 1단위적혈구수혈의적정성을평가하는것은정확한평가가될수없으므로, 수혈전 후환자의종합적인임상적상태를평가하여수혈의적정성을평가하는추가적시도가필요할것으로사료된다. 또한본의료기관이외의의료기관에서도유사한연구를통하여국내 1단위적혈구수혈의경향에대한조사가필요할것으로생각된다. 본연구의의의는 1개대학병원의 1단위적혈구수혈의실태를파악해보고쉽게산출할수있는혈중 Hgb 농도를기준으로간접적으로적정성을평가해보려는시험적시도에서찾을수있을것이다. 요약배경 : 국내의혈액제제사용량은꾸준히감소하고있으나 1단위적혈구수혈률은증가하는추세이다. 과거에는 1단위적혈구수혈이불필요한 혈액제제사용으로간주되어왔으나최근에는최소한의수혈로원하는수준의혈중혈색소 (hemoglobin, Hgb) 농도를유지하기위한방법으로인식되고있다. 이러한인식의변화를기반으로세브란스병원에서시행된 1단위적혈구수혈현황에대한조사를시행하게되었다. 방법 : 2006년 3월부터 2007년 2월까지심사평가원에보험청구한소아를제외한 16세이상의환자중, 입원기간동안 1단위적혈구수혈을시행받은 800예의전산자료를분석하였다. 적혈구제제의사용목적에따라외과계열 (n=561) 과내과계열 (n=239) 로나누어진료과별, 계열별로수혈전후의혈중 Hgb 농도와구간별빈도수를산출하였다. 결과 : 외과계열환자의평균연령은내과계열보다통계적으로유의하게낮았으며 (P=0.012), 외과계열은내과계열에비하여여성의비율이높았다 (P=0.012). 수혈전후의혈중 Hgb 농도와적혈구용적률 (hematocrit, Hct) 의차이는외과계열이내과계열에비하여유의하게낮았고 (P<0.0001) 내과계열의수혈전후혈중 Hgb 농도, Hct은외과계열에비하여유의하게낮았다 (P<0.0001). 수혈후혈중 Hgb 농도가 10 g/dl 이하인경우를적절한적혈구제제사용으로가정하면, 외과계열에서시행된 1단위수혈중 26.0% 가적절한적혈구제제사용이었으며, 내과계열의경우수혈전 Hgb 농도가 9 g/dl 이하일경우를기준으로하였을때 74.8% 가적정수혈로판단되었다. 결론 : 본연구에서수혈전후의혈중 Hgb 농도를기준으로 1단위수혈의적정성을간접적으로평가하였을때외과계열환자의약 74% 에서불필요하다고판단되는 1단위수혈이이루어지고있음을알수있었다. 본연구결과 1단위수혈이아직도불필요한측면에서많이이루어지고있어수혈의적정성에대한지속적인평가가필요하

10 대한수혈학회지 : 제 18 권제 3 호 며, 이부분의개선을위해외과계열의임상의들에대한꾸준한교육과적정수혈을유도하기위한제도적방법이필요할것으로생각되었다. 참고문헌 1. HIRA. Statement of evaluation about appropriateness of transfusion for the first half Review report resources. kr/cms/rg/rgb/pds_09/ _1276.html? MD=02_09 [Online] (last visited on 18 October 2007). 2. Reece RL, Beckett RS. Epidemiology of singleunit transfusion. A one-year experience in a community hospital. JAMA 1966;195: Hahn JS, Park YJ, Yoon JW, Ko YW, Song KS, Lee SY. Clinical study on single unit transfusion-retrospective observation-. Korean J Hematol 1983;18: Kuriyan M, Carson JL. Blood transfusion risks in the intensive care unit. Crit Care Clin 2004; 20: Vincent JL, Piagnerelli M. Transfusion in the intensive care unit. Crit Care Med 2006;34: S Williams AP, Gettinger A. Transfusion therapy in the intensive care unit. Curr Opin Anaesthesiol 2006;19: Hebert PC, Yetisir E, Martin C, Blajchman MA, Wells G, Marshall J, et al. Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases? Crit Care Med 2001; 29: Gould S, Cimino MJ, Gerber DR. Packed red blood cell transfusion in the intensive care unit: limitations and consequences. Am J Crit Care 2007;16: Brecher ME. Technical manual. 15th ed. Bethesda, Maryland: American Association of Blood Banks, 2005: Hasley PB, Lave JR, Kapoor WN. The necessary and the unnecessary transfusion: a critical review of reported appropriateness rates and criteria for red cell transfusions. Transfusion 1994;34: Davenport RD. The red blood cell transfusion threshold: evidence and outcome. Curr Hematol Rep 2002;1: Beale E, Zhu J, Chan L, Shulman I, Harwood R, Demetriades D. Blood transfusion in critically injured patients: a prospective study. Injury 2006;37: Chohan SS, McArdle F, McClelland DB, Mackenzie SJ, Walsh TS. Red cell transfusion practice following the transfusion requirements in critical care (TRICC) study: prospective observational cohort study in a large UK intensive care unit. Vox Sang 2003;84: Goodnough LT, Vizmeg K, Riddell J 4th, Soegiarso RW. Discharge haematocrit as clinical indicator for blood transfusion audit in surgery patients. Transfus Med 1994;4: Audet AM, Goodnough LT, Parvin CA. Evaluating the appropriateness of red blood cell transfusions: the limitations of retrospective medical record reviews. Int J Qual Health Care 1996;8: Friedman MT, Ebrahim A. Adequacy of physician documentation of red blood cell transfusion and correlation with assessment of transfusion appropriateness. Arch Pathol Lab Med 2006;130: Carson JL, Noveck H, Berlin JA, Gould SA. Mortality and morbidity in patients with very low postoperative Hb levels who decline blood transfusion. Transfusion 2002;42: Hebert PC, Wells G, Martin C, Tweeddale M, Marshall J, Blajchman M, et al. Variation in red cell transfusion practice in the intensive

11 care unit: a multicentre cohort study. Crit Care 1999;3: Rubin GL, Schofield WN, Dean MG, Shakeshaft AP. Appropriateness of red blood cell transfusions in major urban hospitals and effectiveness of an intervention. Med J Aust 2001;175: Wallis JP, Wells AW, Whitehead S, Brewster N. Recovery from post-operative anaemia. Transfus Med 2005;15: Tuckfield A, Haeusler MN, Grigg AP, Metz J. Reduction of inappropriate use of blood products by prospective monitoring of transfusion request forms. Med J Aust 1997;167: Ma M, Eckert K, Ralley F, Chin-Yee I. A retrospective study evaluating single-unit red blood cell transfusions in reducing allogeneic blood exposure. Transfus Med 2005;15: Simon TL, Alverson DC, AuBuchon J, Cooper ES, DeChristopher PJ, Glenn GC, et al. Practice parameter for the use of red blood cell transfusions: developed by the Red Blood Cell Administration Practice Guideline Development Task Force of the College of American Pathologists. Arch Pathol Lab Med 1998;122:

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1.. Volume 12, Number 1, 6~16, Factors influencing consultation time and waiting time of ambulatory patients in a tertiary teaching hospital Jee-In Hwang College of Nursing Science, Kyung Hee University :