ORIINAL ARTICLE Korean J Clin Lab ci., 48(2):09-3 http://dx.doi.org/324/kjcls..48.2.09 pin 738-3544 ein 2288-662 Korean J Clin Lab ci. Vol. 48, No. 2, June 09 Evaluation of Vacutainer Distribution Conditions Chang-Eun Park Department of iomedical Laboratory cience, Namseoul University, Cheonan 3020, Korea 진공채혈관의상태에따른평가 박창은 남서울대학교임상병리학과 Pre-analytical variables account for most laboratory errors and many factors affect the results from a patient. Type of tubes facilitated rapid separation and prevented hemolysis upon prolonged storage. However, there were some limitations associated with vacutainer conditions. To circumvent the problems, the comparability of complete blood cell count values was examined using various vacutainers. The results of the analysis showed a large coefficient variation of 0.24, in the value of white blood cells and platelets, and significant correlation was observed between white blood cells, platelets, and the value of red blood cells (p<0.0). In each of the three tubes, compared to the value of platelets, white blood cells, the greatest coefficient variation was,. In correlation of the three companies, significant difference was observed in values of white blood cells, platelets, and platelet distribution width (p<0.0), however and, the value of platelets, and platelet distribution width were significantly lower (p<0.05). In conclusion, analysis of vacutainers showed that they were suitable for stability of these analytes under vacutainer conditions. Keywords: Evaluation, Vacutainer Corresponding author: Chang-Eun Park Department of iomedical Laboratory cience, Namseoul University, 9 Daehak-ro, eonghwan-eup, eobuk-gu, Cheonan 3020, Korea Tel: 82-4-580-2722 Fax: 82-4-580-2932 E-mail: eun2777@hanmail.net This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright The Korean ociety for Clinical Laboratory cience. All rights reserved. Received: April 28, Revised st : May 9, Revised 2 nd : May 6, Accepted: May 6, 서론신뢰성있는검사결과를얻기위해서는선행되어져야할것이분석전변수들을올바로인식하고해석하는것이요구된다. 이를바탕으로혈장및혈청검체의분석에서는채혈후 2시간이내에서분리가이루어져야하며장기간보관시에는검체의용혈등이심각한문제를일으킨다 []. 진단검사의학과에서유용하게사용되는혈액검사를위한진공채혈관은적절한평가가선행되어야한다. 이를통해적절한검체를채취할수있는용기의선택은필수적으로요구된다 [2,3]. 혈청을분리하기위한진공채혈관의원심분리과정을용이하고신속하게분리하기위한겔의사용으로인한측정물질의안정성분석등이요구되는제한점이발생하여이러한문제점 을해결하기위한시도가이루어졌다 [4]. 현재국내에서는다양한진공채혈관을사용하고있으나, 진공채혈관의평가를실시한보고는부족한실정이다. 특히최근에는국내에서도진공채혈관이개발되고있으므로그성능을평가하는시스템도입이절실한실정이다 [5,6]. 그동안국내에서보고된진공채혈관성능평가는단회측정에의한쌍체비교법 (paired t-test) 이고유효기간에따른선별적인결과의영향에대한평가는부족한점이많다. 이에본연구는최근다양한진공채혈관의유통상태에따른유효기간별진공채혈관의성능및유효성을평가하고자하며혈구산정값을비교평가하여임상적사용적합성을검증하고자한다. 따라서진공채혈관의유효기간별, 생산자별보관및보존, 성능을입증평가하여그유용성을알리고분석전오차의한요인으로서필요성을대두시키고자한다.
0 Chang-Eun Park. Evaluation of Vacutainer 재료및방법. 대상 본연구는남서울대학교임상병리학과재학생을대상으로시행되었다. 연구참여에동의한건강한지원자 5명을대상으로연구를시행하였으며, 채혈및검사를진행하였다. 피험자들은 2시간이상의금식후아침에정맥천자로채혈하였다. 본연구는남서울대학교생명윤리심의위원회 (IR) 의승인 (NU-428-) 을받았으며모든피험자에게연구에대한서면동의서 (informed consent) 를받았다. 2. 채혈및평가분석 모든검체는한종류의바늘고정기 (needle holder, D) 를사용하여동일한피검자로부터 3개사의진공채혈관에순서대로혈액을채취하여분석하였다. 평가를실시한진공채혈관의종류는 ethylenediaminetetraacetic acid (EDTA) 진공채혈관으로성능을검증하기위해 사, 사, 사의 3개제품을평가하였다. 정밀도평가 (precision test) 는 정맥혈및말초혈채취용기의검증에관한지침 인 CLI P34-A [2] 에따라 3개사의각 3개로트번호별로차이를분석하였으며또한유효기간의차이에따른비교를평가하였다 (Table ). 채혈순서에따른검사결과의차이를최소화하기위하여 5명은 사먼저, 5명은 사를먼저, 사를먼저채혈하였다. 채혈직후정밀도및정확도평가를위해즉시검사를시행하였다. 검사종목은백혈구수 (WC), 적혈구수 (RC), 혈색소농도 (Hb), 평균적혈구용적률 (HCT), 평균적혈구용적 (MCV), 평균적혈구혈색소농도 (MCHC), 평균적혈구혈색소 (MCH), 적혈구분포지수 (RDW), 혈소판수 (PLT), 혈소판분포폭 () 의혈구산정검사 0종을측정하였다. 혈구산정검사를위해서자동혈구분석기인 Heco5 (Dae Kwang Co., Korea) 를이용하여수행하였다. 정확도 Table. Information of K 2EDTA tubes and analysis items Manufacture Co. Co. Co. Lot Number (expiration date) 3040287 (5/) 304029 (5/) 3040597 (6/) 455545 (5/0) 49554 (5/) 49579 (5/2) D306004 (4/2) D3200V (5/6) D400I (6/4) Analytes WC, RC, Hb, HCT, MCV, MCH, MCHC, RDW, PLT, Abbreviation: WC, white blood cell; RC, red blood cell; Hb, hemoglobin; HCT, hematocrit; MCV, mean corpuscular volume; MCH, mean corpuscular hemoglobin; MCHC, mean corpuscular hemoglobin concentration; RDW, red cell distribution width; PLT, platelet;, platelet distribution width. 평가를위해각진공채혈관별채혈직후각진공채혈관에서 3회씩반복측정 (triplication) 하였다. 진공채혈관의총정밀도 (total precision) 는지침에따라총변이계수 (total coefficient of variation, CV total) 를계산하였다. 일반통계분석은 Microsoft Excel (Microsoft Corp., Redmond, WA, UA) 을이용하고수집된자료의분석은 P 8.0 (P Inc., Chicago, UA) 를이용하여분석하였다. 각그룹에대한평균과표준편차로분석하였다. 결과 정밀도를위한평가에서는동일검체를이용해진공채혈관의유효기간차이에따른혈구산정검사결과를분석하였다. 또한각 3사의진공채혈관을이용해혈구산정검사 0종의변이계수 (coefficient variation, CV) 값으로비교평가하였다 (Table 2, 3). 유효기한이 년간격이되는다른로트번호의진공채혈관에동일대상자로부터얻은혈액검체를측정한결과, WC와 PLT 의결과값에서 0.24, 순으로다른항목에비해가장큰변이계수를보였다. 한편가장적은변이계수값을보이는것으로는 RDW와 Table 2. Precision measured by CV of tubes for expiration date (as followed by,, year) WC (0 3 / L) RC (0 6 / L) H (g/dl) HCT (%) PLT (0 3 / L) MCV (fl) MCH (pg) MCHC (g/dl) RDW (%) (fl) Years Mean D Variance CV 6.3 6.37 6.59 4.52 4.57 4.60 2.80 2.66 2.77 38.83 39.23 39.50 260.50 265.78 276.88 85.95 86.6 85.66 27.90 27.95 29.34 3.64 32.43 34.22 2.28 2.27 2.2 0.42 0.7 0.60 Abbreviation: ee Table..45.57.54 0.48 0.4.20.7.47 4.68 5.07 4.34 5.47 58.88 6.68 4.73 5.62 5.68.98 2.24 8.02 4.63 0.93 9.22 0.69 0.77.6 0.6 0.60 2.0 2.48 2.36 0.7.43 2.92 2.7 2.90 25.68 8.86 2649.5 3466.33 3803.9 22.40 3.57 32.30 3.93 5.03 64.33 2.48 0.86 84.99 0.65 0.59 2.6 0.37 0.35 0.25 0.20 CV mean 0.24 0.4
Korean J Clin Lab ci. Vol. 48, No. 2, June Table 3. Precision measured by CV of individual,, manufacture tubes as followed Manufacture Mean D Variance CV WC (0 3 / L) RC (0 6 / L) H (g/dl) HCT (%) PLT (0 3 / L) MCV (fl) MCH (pg) MCHC (g/dl) RDW (%) (fl) 6.37 6.5 6.44 4.57 4.73 4.63 2.66 3.00 2.62 39.23 40.68 40.5 265.78 28.59 279.69 86.6 86.63 87.22 27.95 27.82 27.35 32.43 32.06 3.32 2.27 2.29 2.30 0.7 0.57.0.57.82.88 0.44 0.45.7.5.62 5.07 4.5 4.7 58.88 58.65 59.9 5.62 5.56 5.63 2.24 2.23 2.40 0.93 0.95.54 0.7 0.6 0.62.03 2.48 3.32 3.52 0.9 2.92 2.27 2.63 25.68 7.8 22.22 3466.33 3439.24 3589.50 3.57 30.87 3.65 5.03 4.98 5.75 0.86 0.9 2.37 0.65 0.50 0.64 0.37 0.38.05 0.25 0.28 0.29 0.05 CV mean 0.04 MCV로모두 으로나타났다. 특히유효기간지난진공채혈관에서는 RC, 가, 로유효기간내, 유효기간이 년남은진공채혈관에서비해가장큰변이계수를보였다 (Table 2). 이들에대한검사항목간에상관성을조사한결과에서는 WC, PLT, RC의값이의미있는차이를보였다 (p<0.0)(table 4). 이외의검사항목들의상관성조사에서는유의한차이를나타내지않았다 (data not shown). 또한각 3개사의유효기간내진공채혈관을동일검체로부터비교평가한결과, WC, PLT 가, 로가장큰변이계수를보였다. 한편 MCHC, MCV, RDW가 0.04,, 으로가장낮은변이계수를보였다. 특히 3사제품중 사의제품이다른타사제품들에비해변이계수가상대적으로높았다. 그중 WC, 가 0.29, 로가장높은변이계수를보였다 (Table 3). 또한이들에대한해당하는검사항목간에상관성에대해조사한결과 WC, PLT, 의값에서높은유의확률로의미있는차이를보였다 (p< 0.0) 그러나 사와 사는 PLT, 의값에서는비교적낮은유의확률로유의한차이를보였다 (p<0.05) (Table 5). 이들외의검사항목들의상관성조사에서는유의한차이를나타내지않았다 (data not shown). Abbreviation: ee Table. Table 4. Correlation of -tubes for expiration date (as followed by,, year) WC PLT RC WC PLT RC.745**.73.225.50**.33*.64.252.7.43 -.57.270 -.02.477 -.03.829.029.839.859.366**.008.33*.336*.06.242.087 -.039.786.087.543.030.836 -.44.33 -.005.97 -.02.477.46.305.63.254.35* -.099.490 -.06.90.39.329 -.08.452.009.952.057.692.638**.30.364.40**.004.046.75.965 -.07.68 -.275.05 -.056.696.464**.00.03.473.06.459 -.049.734 -.046.747 -.378** -.279*.047 -.73.225 -.230.04.32.357 -.009.950 -.297*.035 -.38**.563**.80.206.095.506.98.64.23.33.449**.00 -.27.374.47.305.4.325 -.8.409.09.446.0.44.03.927 -.233.00.377** Abbreviation: ee Table, **p<0.0, *p<0.05, r(p).
2 Chang-Eun Park. Evaluation of Vacutainer Table 5. Correlation of -, -, -tubes as followed WC PLT WC PLT.454**.00.808**.336*.06.69.235.273.053 -.005.97.0.48 -.096.50.38**.72.229.303*.03.3*.026 -.256.070.08.573 -.264.06.5.29.255.07.206.48 -.066.647.023.872 -.5.289.277*.049.795** -.378** -.6.258 -.350*.02.450**.00 -.294*.036 -.39*.023 -.445**.00 -.569** -.24.385 -.460**.00.299*.033.739**.40**.004 Abbreviation: ee Table, **p<0.0, *p<0.05, r(p). 고찰인체의혈액은질병및예방에대한정보를제공하는중요한체액이다. 이정맥혈을채혈하는진공채혈관의상태및유통기한, 보관상태, 유통상태, 제조상태, 장비의분석방법등에따라검사결과에영향을미칠수있으며 [7-9], 정밀도와정확도를객관적으로평가하고오류를최소화하여신뢰할수있는검사결과를얻기위해서는유통되는제품에대한기초평가가이루어진진공채혈관을이용해야할것이다 [0]. 최근에병원들의소모성원가를줄이기위해다양한저가형진공채혈관들이수입되어국내의료시장에들어와사용하는데있어서기초적이며객관적인평가수행여부를알아볼수없는현실이며묵시적으로의료기관현장에서는사용되고있다. 따라서여러제품들의도입으로부터검사실수준에서검사결과에미치는영향을평가하여이러한기초정보를통해분석전의오차를줄이기위한정도관리차원의분석평가가선행되어져야할것으로사료된다. 최근국내여러연구자들이정맥혈채혈을위한진공채혈관의성능에대해평가해왔으나평가방법에있어서여러한계를제시하고있다 [5,6]. 기존의연구에서는규격화된진공채혈관의평가가일회성측정결과로평가했기때문에신뢰할만한정확도, 정밀도를평가할수없었다는점을제한하고있다. 본연구에서는분석장비별평가, 진공성능의평가, 안정성평가, 무균성평가, 다양한검사항목에대한평가가배제된제한점을가지고있다. Lee 등은정밀도평가결과에서 사는 MCHC,, basophil, reticulocyte 등 4종목에서 6건의 Not allowable 판정을받았고, 사의경우 MCHC,, basophil, reticulocyte, HbAc 등 5종 목에서 7건의 Not allowable 판정을받은것을참조했을때 [6] 본연구에서도 의결과에서유의적인차이를보이는것으로보아항응고제의영향으로인한 의결과에는제조사별차이가있을것으로사료되나검사의임상적의의측면에서는큰영향을미치지않을것으로보인다. 최근연구에서는동일회사의진공채혈관제품중에서유리재질과플라스틱재질간의비교평가에서특이한차이가없는동일한검사결과를나타냈으며단지 72시간이상의혈액검체의보관에서는보체인자들이증가하기때문에 48시간이내사용을권고하였으며 48시간이상보관후검사수행의경우는 20 o C 보관을추천하는것으로보고하였다 []. 또한혈청의수집을위한진공채혈관에서는응고반응속도또는종말점에는영향을주지않기때문에더일관성이있으나혈장의수집을위한진공채혈관은고분자의추가로인해공격적인혈액시료의활성을감소시켜 EDTA 와같은첨가제로응고과정에서요구되는혈소판의방출물질로인해작은펩티드및킬레이트물질이용출되어영향을미치게되는것으로알려져있다 [2]. 이와관련하여본연구에서는혈액응고와관련된인자를측정하지못했지만추후에는보고된지침 [3] 에맞는혈액응고인자의검사를수행하여분석평가를해야할것으로사료된다. 분석평가의통계적관점에서는 RT (rapid separate tube) 와 T (serum separate tube) 를비교평가한이전의보고 [4] 에서결과분석처럼개체내변이계수 (within-subject coefficients of variation, CVw) 와개체간변이계수 (between-subject coefficients of variation, CVg) 를조사하는개념을기반으로 [5]. 각진공채혈관별바이어스의산출을위한평균차 (mean difference (%))
Korean J Clin Lab ci. Vol. 48, No. 2, June 3 는 [( 시험채혈관의평균-대조시험관의평균 / 대조시험관평균 ) 00] 을활용하여평가하는방식이정밀성과정확성을높이는기법으로사료된다. 결론적으로본연구에서평가한 사의진공채혈관은정밀도평가에서객관화된표준기법을통해조사를수행해야할것이며, 사의진공채혈관과비교하여변이계수가높게나타난수준의성능을보이므로실제임상검사에사용하는데있어서유효기간의선택과검사항목별변이계수가다르다는것을참고하여사용하여야할것으로사료된다. 이는변이계수가높은수준으로차이를보이는부분은통계학적인분석을통해검증해야할것으로보이며, 진공채혈관의유용성을판단하기위해서는본연구의수정보완이필요할것이며이는향후평가지침의표준화과정을위한기초정보를제공할것으로보인다. 요약분석전변이로인하여검사실은오류에직면하게되고많은요인들은환자의검사결과에영향을미치게된다. 다양한진공채혈관은신속하게분리하고방치된검체의용혈을방지한다. 그러나진공채혈관의상태에따라몇가지제한점들이발생하는데이러한문제점을알아보기위해다양한진공채혈관을이용해혈구산정검사로비교평가하였다. 유통기한별검사결과에서는백혈구 (WC) 와혈소판 (PLT) 의값에서 0.24, 로큰변이계수를나타냈고상관성에서는백혈구 (WC), 혈소판 (PLT), 적혈구 (RC) 의값이유의성을보였다 (p<0.0). 한편각 3사의비교평가에서는백혈구 (WC), 혈소판 (PLT) 의값에서, 로가장큰변이계수를나타냈고. 상관성에서는각 3사가모두백혈구 (WC), 혈소판 (PLT), 혈소판분포폭 () 의값에서높은유의한차이를보였다 (p< 0.0) 그러나 사와 사는혈소판 (PLT), 혈소판분포폭 () 의값에서는낮은유의한차이를보였다 (p<0.05). 결론적으로진공채혈관의상태에따른분석의안정성을위해적절한진공채혈관의분석평가가이루어져야한다. Acknowledgements: 이논문은 년도남서울대학교학술연구비지원에의해연구되었음. Funding: None Conflict of interest: None References specimens; Approved guideline-second editions. NCCL document H8-A2. Wayne, Pennsylvania: National Committee for Clinical Laboratory tandards; 999. 2. CLI. Validation and verification of tubes for venous and capillary blood specimen collection; Approved guideline. CLI document P34-A. Wayne, Pennsylvania: Clinical and Laboratory tandards Institute; 200. 3. CLI. Method comparison and bias estimation using patient samples; Approved guideline-second edition (interim revision). CLI document EP09-A2-IR. Wayne, Pennsylvania: Clinical and Laboratory tandards Institute; 200. 4. Li Z, Feng Z, Yan C, Yan R. Evaluation of D Vacutainer T TM II plus tubes for common tumor marker tests by Roche Diagnostics Modular E 70 analyzer. J Clin Lab Anal. 200;24(6):48-42. 5. Won EJ, hin M, Jang MJ, Cho D, Kee J, Kim H. et al. Comparison between V-Tubes and D Vacutainer tubes for use in laboratory tests. Lab Med Online. 202:3(3):45-54. 6. Lee JH, Cha YJ, Lee D, Kim Y. A comparison of the performance of oyagreentec Ampulab EDTA and sodium citrate tubes with that of D vacutainer tubes. Lab Med Online. :5(2): 92-00. 7. Hong, Kim J, hin K. The effect of the storage duration and temperature of EDTA pecimen for CC and WC differential count in E-9000 automated cell counter. Korean J Clin Lab ci. 2006;38:47-5. 8. Lim YK, Kim CH, Kang YH, Park CJ, Chi H. IMI channel and HPC mode evaluation in CC autoanalyzer E-9000. Korean J Clin Lab ci. 2000;32:48-52. 9. owen RA, Hortin L, Csako, Otanez OH, Remaley AT. Impact of blood collection devices on clinical chemistry assays. Clin iochem. 200;43:4-25. 0. CLI. Tubes and additives for venous blood specimen collection; Approved standard-fifth edition. CLI document H-A5. Wayne, Pennsylvania: Clinical and Laboratory tandards Institute; 2003.. Li Z, Yan C, Yan R, Zheng X, Feng Z. Evaluation of D Vacutainer TTM II plus tubes for special protein testing. J Clin Lab Anal. 20;25(3):203-206. 2. Drake K, owen RA, Remaley AT, Hortin L. Potential interferences from blood collection tubes in mass spectrometric analyses of serum polypeptides. Clin Chem. 2004;50(2):2398-40. 3. CLI. Collection, transport, and processing of blood specimens for testing plasma-based coagulation assays and molecular hemostasis assays; Approved guideline-fifth edition. CLI Document H2-A5. Wayne, Pennsylvania: Clinical and Laboratory tandards Institute; 2008. 4. Kocijancic M, Cargonja J, Delic-Knezevic A. Evaluation of the D Vacutainer( ) RT blood collection tube for routine chemistry analytes: clinical significance of differences and stability study. iochem Med (Zagreb). ;24(3):368-375. 5. Ricos C, Alvarez V, Cava F, arcia-lario JV, Hernandez A, Jimenez CV. et al. Current databases on biologic variation: pros, cons and progress. cand J Clin Lab Invest. 999;59(7): 49-500.. NCCL. Procedures for the handling and processing of blood