대한수혈학회지 : 제 29 권제 2 호, 2018 The Korean Journal of Blood Transfusion Vol. 29, No. 2, 130-139, August 2018 https://doi.org/10.17945/kjbt.2018.29.2.130 pissn 1226-9336 eissn 2383-6881 Original Article 단일상급종합병원에서여러수혈전검사프로토콜운영경험 최수인 1 ㆍ신성환 1 ㆍ서지영 1 ㆍ유홍비 2 ㆍ천세종 3 ㆍ조덕 1,2 성균관대학교삼성서울병원진단검사의학과 1, 성균관대학교삼성융합의과학원 2, 전남대학교의과대학진단검사의학교실 3 An Experience of Various Pretransfusion Test Protocols in a Tertiary Referral Hospital Sooin Choi 1, Sunghwan Shin 1, Ji Young Seo 1, HongBi Yu 2, Sejong Chun 3, Duck Cho 1,2 Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine 1, Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University 2, Seoul, Department of Laboratory Medicine, Chonnam National University Medical School 3, Gwangju, Korea Background: Pretransfusion tests are essential for safe transfusions, but occasionally, part or all can be omitted when a transfusion is needed urgently in an emergency. The purpose of this study was to share the authors experience of various pretransfusion test protocols in a tertiary referral hospital in Korea. Methods: From July 2016 to June 2017, all transfusion cases at Samsung Medical Center were analyzed retrospectively. For each pretransfusion test protocol, the parameters regarding issue, return and disposal rate of blood products, occurrence of hemolytic transfusion adverse effect, and prescription frequency of each respective department and ordering site were analyzed. Results: A total of 90,539 units of red blood cells, 24,814 units of fresh frozen plasmas, 24,758 units of single donor platelets, and 23,303 units of platelet concentrates were issued during the study period. Among them, 3.6%, 1.8%, 0.3%, and 0.4% of red blood cells, fresh frozen plasmas, single donor platelets, and platelet concentrates were issued according to the emergency transfusion protocols. When various pretransfusion test protocols were applied to issue blood products, there was no case in which an adverse hemolytic transfusion reaction was suspected. When compared with usual pretransfusion test protocol, all emergency transfusion protocols showed significantly higher return and wastage rates in red blood cells and fresh frozen plasmas. Platelets also had a higher return and wastage rate, but the difference was not significant. Conclusion: These results suggests that there is no different risk of adverse hemolytic transfusion reaction regardless the pre-transfusion protocols, but management about of the increased rate of return and wastage of blood products in emergency transfusions should be considered. (Korean J Blood Transfus 2018;29:130-139) Key words: Pretransfusion test, Emergency transfusion, Universal blood, Massive transfusion Received on July 6, 2018. Revised on July 23, 2018. Accepted on July 24, 2018 Correspondence to: Duck Cho Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea Tel: 82-2-3410-2403, Fax: 82-2-3410-2719, E-mail: duck.cho@skku.edu, ORCID: http://orcid.org/0000-0001-6861-3282 This work was supported by the Research Program funded by the Korea Centers for Disease Control and Prevention (fund code 2017-E83001-00). 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 C 2018 The Korean Society of Blood Transfusion - 130 -
최수인외 : 단일상급종합병원에서여러수혈전검사프로토콜운영경험 서론수혈전검사는용혈성수혈이상반응을방지하기위해수혈전에시행하는검사로, 일반적으로 ABO 및 D 혈액형검사, 비예기항체선별및동정검사, 그리고교차적합시험을의미한다 [1]. 이러한수혈전검사는모두시행하는것이원칙이지만, 수혈이늦어지면심각한결과가초래될수있는환자에게는이들검사를충분히실시하지못한채로긴급하게수혈을해야할경우가있다. 이렇게응급수혈이필요한경우교차적합시험을일부단계만시행하거나혹은생략하고혈액형만검사후동형의혈액을출고하기도하고, 환자의혈액형과관계없이 O형적혈구를사용하기도한다 [2]. 다양한임상적상황을고려한여러유형의수혈전검사프로토콜이필요하지만, 국내의료기관에서여러수혈전검사프로토콜운영경험을상세하게소개한보고가그간없었다. 이에저자들은단일상급종합병원에서여러임상적상황에따라다르게운영되고있는수혈전검사프로토콜에대한경험을소개하고자한다. 특히, 간소화되 거나생략된수혈전검사프로토콜이적용된혈액제제의비율, 출고후폐기및반납률, 그리고기관수혈이상반응보고시스템을통하여보고된용혈성수혈이상반응의빈도를조사하였다. 대상및방법본연구는 2016년 7월부터 2017년 6월까지삼성서울병원에서시행된모든수혈사례들을대상으로후향적으로분석되었으며, 환자의의료정보는전자의무기록, 검사결과및혈액제제입출고내역은검사실전자시스템을이용하여파악하였다. 수혈전검사는네종류의프로토콜로운영되었다 (Table 1). 일반적인상황에서는 ABO, D 혈액형검사, 비예기항체선별검사, 그리고 3단계교차적합시험을포함한수혈전검사를모두시행한후혈액제제를출고하였고, 응급상황에서는세가지수혈전검사프로토콜로세분화하여응급 (abbreviated crossmatch), 초응급 (uncrossmatch), 대량수혈프로토콜 (massive transfusion protocol, MTP) 로명명하였다. Table 1. Various pretransfusion test protocols applied at the authors organization and time required to issue Protocol Pretransfusion tests Available blood components Time required to issue Routine ABO/D type All components 40 60 minutes Antibody screen Three phases crossmatch Abbreviated crossmatch ABO/D type RBC only 10 minutes Saline phase crossmatch Uncrossmatch None O+ RBC only Immediate MTP None Issued as a set: 6 O+ RBCs 6 AB+ FFP 6 AB+ PC or 1 AB+ SDP Immediate Abbreviations: RBC, red blood cell; MTP, massive transfusion protocol; FFP, frozen flash plasma; PC, plasma concentrate; SDP, single donor platelet. - 131 -
Korean J Blood Transfus Vol. 29, No. 2, 130-139, Aug. 2018 병원전산시스템에서는임상의필요에따라수혈처방을입력하는시점에응급, 초응급, 또는 MTP로수혈전검사프로토콜을선택하여요청할수있었다. 수혈의긴급성에따라응급수혈프로토콜을처방시에는생리식염수법을이용한 1단계교차적합시험만을완료한동형적혈구가출고되었고, 초응급수혈프로토콜처방시에는환자의혈액형과관계없이모든교차적합시험을생략한 O형 D 양성적혈구가출고되었다. 긴급하게대량의수혈이필요한경우에는 MTP 처방을통하여여섯단위의 O형 D 양성적혈구, 여섯단위의 AB형 D 양성신선동결혈장, 그리고 AB형 D 양성혈소판제제 ( 한단위성분채집혈소판혹은여섯단위농축혈소판 ) 가출고되었다. 응급수혈의처방및출고는유선연락없이전산으로이루어지며, 혈액은행에서 는수혈처방현황표시화면에응급수혈여부및수혈전검사프로토콜의종류가표시되었다. 응급수혈프로토콜들의경우사용자가확인할때까지알림음이반복되었다. 일반수혈에대한화면정보는 1분마다자동으로업데이트되었다 (Fig. 1). 일반수혈처방건과비교하여세가지응급수혈전검사프로토콜로처방된혈액제제의출고, 반납, 폐기현황과용혈성수혈이상반응에대하여후향적으로분석하였다. O형 D 양성적혈구가출고되도록설정되어있는초응급수혈과 MTP를통하여출고된적혈구제제의실제혈액형분포도분석되었다. 또한진료과에따른수혈전검사프로토콜처방건수및수혈처방이발생한장소의분포를분석하였다. 진료과는일반수혈처방건기준으로 Fig. 1. Screen shot of blood bank for computerized prescription transfusion. The first column shows the pretransfusion protocol. *E, U, and M are the abbreviated crossmatch, uncrossmatch (O+ red blood cell), and massive transfusion protocols, respectively. - 132 -
최수인외 : 단일상급종합병원에서여러수혈전검사프로토콜운영경험 연간 1,000건이상이처방되는경우개별과로분류하였으며, 개별과로분류되지못한진료과는기타로분류하였다. 처방장소를기록하는검사실전자시스템이 2016년 9월경개발되었기에연구기간중 2016년 7월부터 8월까지 2개월동안발생한일반수혈처방장소는분석에서제외되었다. 본원에서는수혈시작, 수혈중, 그리고수혈종료시점의환자상태에대하여체온과혈압을비롯한활력증후와환자가호소하는호흡곤란, 발열, 오한, 소양감등의증상과두드러기, 혈뇨등의증후를체크박스형식의전자의무기록으로남기도록되어있다. 입력된전자의무기록은자동분류로직에의하여수혈이상반응에해당되는 경우분류되어집계되었다. 그외에도수혈이상반응이의심되는경우에는진료과에서수혈이상반응보고시스템을사용하여이를보고하고, 진단검사의학과에서해당환자에대해검토한후에수혈이상반응해당여부를확인및분류하고있다. 저자들은전자의무기록및수혈이상반응보고시스템을이용하여수혈전검사프로토콜에따른용혈성수혈이상반응발생율을조사하였다. 통계처리는 IBM SPSS version 18.0 (IBM, New York, NY, USA) 을이용하였다. 프로토콜간의비교를위해 Fisher 정확검정 (Fisher's Exact Test) 을사용하였고, P<0.05를통계학적으로유의한차이가있는것으로간주하였다. Table 2. Status of blood components issued according to each pretransfusion test protocol Total Routine (%) Abbreviatedcrossmatch (%) Uncrossmatch (%) MTP (%) RBC Prepared Unit 90,539 87,299 (96.4) 1,823 (2.0) 910 (1.0) 507 (0.6) Unit of Return 807 685 (84.9) 60 (7.4) 31 (3.8) 31 (3.8) Rate of Return (%) 0.9 0.8 3.3 P<0.05 3.4 P<0.05 6.1 P<0.05 Unit of Waste 119 26 (21.9) 13 (10.9) 21 (17.7) 59 (49.6) Rate of Waste (%) 0.1 0.0 0.7 P<0.05 2.3 P<0.05 11.6 P<0.05 FFP Prepared Unit 24,814 24,365 (98.2) 449 (1.8) Unit of Return 21 21 (100.0) 0 (0) Rate of Return (%) 0.1 0.1 0.0 P<0.05 Unit of Waste 1,616 1,498 (92.7) 118 (7.3) Rate of Waste (%) 6.5 6.2 26.3 P<0.05 SDP Prepared Unit 24,758 24,693 (99.7) 65 (0.3) Unit of Return 313 311 (99.4) 2 (0.6) Rate of Return (%) 1.3 1.3 3.1 P=0.19 Unit of Waste 23 22 (95.7) 1 (4.4) Rate of Waste (%) 0.1 0.1 1.5 P=0.06 PC Prepared Unit 23,303 23,201 (99.6) 102 (0.4) Unit of Return 108 102 (94.4) 6 (5.6) Rate of Return (%) 0.5 0.4 5.9 P<0.05 Unit of Waste 64 64 (100) 0 (0) Rate of Waste (%) 0.3 0.3 0.0 P=0.77 Abbreviation: See Table 1. - 133 -
Korean J Blood Transfus Vol. 29, No. 2, 130-139, Aug. 2018 Table 3. Distribution of the departments and place that the pretransfusion test protocols had been applied Routine (%) Abbreviated crossmatch (%) Uncrossmatch (%) MTP (%) Total 55,767 985 378 85 Gender Female 7,525 (47.5) 298 (43.1) 106 (37.9) 26 (43.3) Male 8,307 (52.5) 394 (56.9) 174 (62.1) 34 (56.7) Department Hematology and Oncology 11,582 (20.8) 81 (8.2) 20 (5.3) 3 (3.5) Pediatrics 7,136 (12.8) 4 (0.4) 19 (5.0) 0 (0.0) General surgery 6,407 (11.5) 151 (15.3) 21 (5.6) 13 (15.3) Thoracic surgery 4,635 (8.34) 116 (11.8) 21 (5.6) 10 (11.8) Critical care medicine 3,285 (5.9) 69 (7.0) 42 (11.1) 13 (15.3) Gynecology and Obstetrics 3,103 (5.6) 44 (4.5) 15 (4.0) 10 (11.8) Emergency medicine 1,899 (3.4) 217 (22.0) 156 (41.3) 16 (18.8) Other 17,720 (31.8) 303 (30.8) 84 (22.2) 20 (23.5) Order site Ward 24,305 (51.0) 598 (60.7) 192 (50.8) 55 (64.7) Operation room 15,847 (33.3) 126 (12.8) 17 (4.5) 10 (11.8) Outpatient 4,276 (9.0) 9 (0.9) 0 (0.0) 0 (0.0) Emergency room 3,049 (6.4) 242 (24.6) 166 (43.9) 19 (22.4) Delivery room 112 (0.2) 7 (0.7) 3 (0.8) 1 (1.2) Other 64 (0.1) 3 (0.3) 0 (0.0) 0 (0.0) Unknown* 8,114 *Laboratory information system that records the location of the transfusion prescription was developed around Sep. 2016. For this reason, the place where the routine transfusion prescription occurred during the period of two months from Jul to Aug 2016 was excluded from the analysis. 결과 1. 혈액제제출고, 반납및폐기분석연구기간동안적혈구 90,539 단위, 신선동결혈장 24,814 단위, 성분채집혈소판 24,758 단위, 그리고농축혈소판 23,303 단위가출고되었다. 그중응급수혈프로토콜로출고된것은적혈구, 신선동결혈장, 성분채집혈소판, 그리고농축혈소판의각각 3.6%, 1.8%, 0.3%, 그리고 0.4% 였다. 적혈구, 신선동결혈장, 성분채집혈소판그리고농축혈소판제제의출고, 반납, 폐기현황은 Table 2와같았다. 응급수혈프로토콜을이용하여출고된적혈구제제와신선동결혈장은일반수혈로시 행된경우에비하여반납및폐기되는비율이유의하게높았다 (P<0.05). 혈소판제제에서는성분채집혈소판과농축혈소판모두응급수혈시에반납률과폐기율이높은경향이있으나유의한차이를보이지는않았다. 하지만, 농축혈소판의반납률은유의하게높았다 (P<0.05). 초응급수혈로출고된적혈구제제는 910 단위였는데, 출고원칙대로 O형 D 양성적혈구를수혈한예가 99.8% (908/910 단위 ) 였고, 진료과요청에의해 ABO, D 항원일치적혈구제제가 0.2% (2/910 단위 ) 였다. 한편, MTP로출고된적혈구제제는 507 단위였는데, O형 D 양성적혈구는 85.8% (435/507 단위 ) 였고, ABO, D 항원일치적혈구제제는 14.2% (72/507 단위 ) 였다. - 134 -
최수인외 : 단일상급종합병원에서여러수혈전검사프로토콜운영경험 2. 수혈전검사유형과출고소요시간및임상과별처방분석 연구기간동안총 16,864명의환자에게적혈구제제를수혈하였고, 일반수혈, 응급수혈, 초응급수혈, 그리고 MTP로각각 93.8%, 4.1%, 1.7%, 0.4% 의환자에게처방되었다. 보고된용혈성수혈이상반응이의심된사례는일반수혈과세가지응급수혈프로토콜모두에서관찰되지않았다. 프로토콜에따라시행되는수혈전검사와출고에소요되는시간은 Table 1과같다. 진료과별수혈처방유형분석에서일반수혈이연간 1,000건이상으로개별과로분류된진료과는소화기내과, 순환기내과, 혈액종양내과, 비뇨의학과, 산부인과, 소아청소년과, 신경외과, 외과, 응급의학과, 정형외과, 중환자의학과그리고흉부외과다. 그외는기타진료과로분류하여과별분석을시행하지않았다. 일반수혈의경우혈액종양내과에서발생한처방이 20.8% 를차지하였고, 소아청소년과와일반외과에서각각 12.8% 와 11.5% 의처방이발생하였다. 응급수혈프로토콜에서는응급의학과 22.0%, 일반외과 15.3%, 그리고흉부외과에서 11.8% 의처방이발생하였다. 초응급수혈프로토콜은응급의학과 41.3%, 중환자의학과 11.1%, 그리고소화기내과 10.3% 순이었다. MTP 처방은응급의학과 (18.8%), 중환자의학과 (15.3%), 일반외과 (15.3%), 산부인과 (11.8%) 및흉부외과 (11.8%) 등에서발생하였다 (Table 3). 일반수혈은병동과수술실에서각각 51.0% 와 33.3% 의처방이발생하였다. 응급수혈프로토콜에서는병동 60.7%, 응급실 24.6%, 그리고수술실에서 12.8% 의처방이발생하였다. 초응급수혈프로토콜의경우병동과응급실이각각 50.8%, 43.9% 를차지하였고 MTP의경우병동 64.7%, 응급실 22.4%, 그리고수술실에서 11.8% 의처방이 발생하였다. 고찰 일반적인상황에서는혈액출고전에 ABO 및 D 혈액형검사, 비예기항체선별과동정검사그리고교차적합시험이필수적이다. 북미지역에서는비예기항체가발견되면대부분젤카드법으로교차시험을한후적합혈을출고하고, 비예기항체가발견되지않으면실온식염수법의교차적합시험만시행후혈액을출고해도임상적으로큰문제가없다고보고하였다 [3,4]. 더나아가미국의한병원에서는혈액제제와환자의 ABO 혈액형이정확히확인될경우는혈청학적교차적합시험을생략하여도안전하다고하였다 [5]. 하지만, Park 등 [6] 은외국에서수입된비예기항체선별시약으로는동양인에서중요한항-Di(a) 를검출할수없음을보고하여서구와는다른상황임을시사하였는데, 11,219명에게 Diego 항원이포함된선별혈구를추가하였을때 8 명에서항-Di(a) 가검출되었다. 이처럼국내에서실시하는비예기항체선별검사가 Di a 등의일부동양인에서중요한비예기항체를놓칠수도있으므로기존시약에 Di a 선별혈구를추가하거나 Di a 선별혈구가미리포함된시약을사용하는방법이제시되기도하였다 [7]. 따라서비예기항체선별검사에서음성인환자들은실온식염수법의교차적합시험만실시해도안전하다는보고는추가적인연구를통해서확인되어야할것이다. 따라서, 본원에서는일반적인상황에서는비예기항체선별검사에서음성일지라도교차적합시험을항글로불린단계까지확인한다. 하지만, 응급상황에는실온식염수단계의교차적합시험을실시하고항글로불린단계는출고후시행하며, 만약교차반응시험을위한검체를채취할시간이 - 135 -
Korean J Blood Transfus Vol. 29, No. 2, 130-139, Aug. 2018 없는상황에서는수혈전검사를모두생략하고범용혈액 ( 적혈구 O+형, 혈장및혈소판 AB+형 ) 을출고한다. 응급상황에서는모든수혈전검사를생략하고환자의혈액형과관계없이범용혈액 (universal blood) 을출고할수있다 [8]. 이러한상황에서대부분교차적합시험을생략한 O형 D 음성적혈구의공급이권장되지만, 헌혈자의 9% 가 O형 D 음성인미국에서도 D 음성혈액의공급에있어가임기의 D 음성여성에게우선순위를둘것을제안한바있다 [9]. 더나아가일부기관에서는모든남성과 50세이상의여성에대한응급수혈시 O 형 D 양성적혈구를공급하는출고정책을운영하고있다 [10]. 따라서, D 음성자가약 0.15% 에불과한우리나라에서는 O형 D 음성적혈구의공급이부족한상황에서는 O형 D 양성혈액을사용하고있는실정이며 [11], 일본의경우도범용혈액으로 O형 D 양성혈액을사용하고있다는보고가있다 [12]. 본원에서도응급상황에서 O형 D 양성적혈구를출고하였다. 또한, 과거검사기록조회로환자의 ABO, D 혈액형을확인할수있는상황에서도실제수혈전검사가실시되지않는경우에는 ABO, D 혈액형일치혈액을출고하기보다는범용혈액인 O형 D 양성적혈구를주로출고하였다. 이는사무적오차로인한 ABO 불일치용혈성수혈이상반응을방지하기위함이다 [13]. O형적혈구는 A 또는 B 항원을표현하지않으므로 ABO 불일치에의한용혈성수혈이상반응을초래하지않지만, ABO 항체외의비예기항체에의한용혈성수혈이상반응의위험은남아있다 [9]. 교차적합시험을시행하지않고적혈구제제를수혈할때환자가가지고있는비예기항체에해당하는항원이양성인부적합혈액을수혈하게되는경우는 0.3% 미만이며 [14], 이러한부적합혈액의수혈에의해지연성용혈성수혈이상 반응이발생하는경우는약 0.1% (4/2,906) 정도인것으로보고된바있다 [9,14]. 따라서, 응급상황에서범용혈액을수혈할경우 ABO 불일치수혈사고는예방할수있으나, 비예기항체에의한지연성용혈성수혈이상반응의위험은일반적인경우와동일한비율로존재하므로출고후비예기항체를확인하여필요시예방조치를취해야할것이다. 본연구에서응급수혈로인한용혈성수혈이상반응이의심되는사례는발생하지않았다. 본연구기간동안초응급수혈과 MTP로처방된적혈구제제의대부분 (94.8%, 1,343/1,417 단위 ) 은교차적합시험없이범용혈액을출고하는원칙에따라출고되었다. 하지만본원수혈력이있는일부환자의경우에는, 임상과의요청에의해기존전산시스템에등록된환자의혈액형과일치하는 74 단위 (5.2%) 의적혈구제제가교차적합시험을시행하지않은상태에서출고되었다. MTP는환자의평가부터대량수혈을마칠때까지의일련의과정을프로토콜화함으로써응급상황에서임상의사는환자의상태에더집중할수있고, 혈액은행은더욱빠르고실수없이혈액제제를준비할수있다. 무엇보다이러한프로토콜은환자의생존율을높이고사용되는혈액제제의양도줄일수있다는장점이있는것으로보고된바있다 [15]. 또한 Riskin 등 [16] 과 O Keeffe 등 [17] 은혈액은행과임상의사의분명한의사소통과보다신속한혈액제제불출을가능하게하기때문에 MTP 자체가생존율을향상시키는것으로분석하였다. 본연구에서는 MTP의사용이생존율에미치는영향에대한분석은시행되지않았다. MTP의적용이혈액의과다사용및폐기량의증가로이어질수있다는일반적인우려와는달리, O'Keefe 등 [17] 은명료한프로토콜의적용이 - 136 -
최수인외 : 단일상급종합병원에서여러수혈전검사프로토콜운영경험 혈액사용량을감소시킬수있다고보고하였다. 하지만본연구에서는응급수혈프로토콜을이용할경우일반수혈에비하여혈액제제의반납률과폐기율이유의하게높았고, 특히 MTP의경우혈액제제폐기율이적혈구제제는 11.6%, 신선동결혈장은 26.3% 였다. McDaniel 등 [18] 은 MTP에서나타나는높은혈액제제폐기율의원인으로비외상환자에대한 MTP 과활성률이높다는점을주목하였다. 본원의응급수혈처방은응급의학과, 일반외과, 흉부외과에서많이발생하였지만, 처방장소는의외로병동이대부분이었다. 따라서본원 MTP에서의높은폐기율이앞선보고와같이비외상환자에대한 MTP의과활성화로인해비롯하였을가능성이있을것으로사료되었다. Patel 등 [19] 은외상환자와비외상환자에서공통적인 MTP를사용하기보다는상황에따라다른 MTP를구성하여사용하는것을제안하였다. 저자들은본연구를통하여국내에서최초로여러종류의수혈전검사프로토콜에따른용혈성수혈부작용의빈도, 혈액폐기율과반납률에대한경험을공유하였다. 응급상황에서수혈전검사가일부생략되거나수혈전검사가모두생략된상태로 O형 D 양성혈액을수혈한 1,032명의환자모두에서비예기항체나 ABO 불일치에의한용혈성수혈이상반응의심사례는보고되지않았다. 또한 O형 D 음성적혈구가아닌 O형 D 양성적혈구를 ABO, D 불일치혈액으로선정하여출고하였으나이에따른 D 항원감작사례또한보고되지않아안전하게수혈된것으로평가할수있었다. 그러나, 응급수혈프로토콜, 특히 MTP의경우혈액제제의폐기율및반납률이일반수혈에비해높아관리가필요함을시사하였다. 하지만비외상환자에대한 MTP의과활성화여부에대한사후리뷰를시행한후이를관리하고, 혈액제제전용냉장고를적절한사용한다면혈액제제폐 기율을개선할있을것으로생각된다. 요약배경 : 수혈전검사는안전한수혈을위해필수적이지만, 응급수혈이필요할경우는수혈전검사의일부또는전부를생략할수도있다. 본연구에서는국내의일개상급기관에서운영하는여러종류의수혈전검사프로토콜의경험을공유하고자한다. 방법 : 2016년 7월부터 2017년 6월까지삼성서울병원에서발생한모든수혈처방을대상으로후향적으로분석하였다. 각각의수혈전검사프로토콜로처방된혈액제제의출고, 반납률, 폐기율의차이를비교하고, 응급수혈에따른용혈성수혈이상반응발생여부및진료과또는처방장소에따른수혈전검사프로토콜처방의경향성이차이를나타내는지분석하였다.. 결과 : 연구기간동안적혈구 90,539 단위, 신선동결혈장 24,814 단위, 성분채집혈소판 24,758 단위, 그리고농축혈소판 23,303 단위가출고되었다. 그중응급수혈프로토콜로출고된것은적혈구, 신선동결혈장, 성분채집혈소판, 그리고농축혈소판의각각 3.6%, 1.8%, 0.3%, 그리고 0.4% 였다. 다양한수혈전검사프로토콜을적용했을때, 수혈로인한용혈성수혈이상반응이의심된사례는없었다. 그러나, 일반수혈처방과비교하였을때, 모든응급수혈프로토콜은적혈구와신선동결혈장제제의반납률과폐기율이유의하게높았고, 혈소판제제도높은경향을보였지만, 통계적으로유의하지는않았다. 결론 : 저자들의경험은용혈성수혈이상반응의위험은수혈전검사프로토콜에따라다르지않았지만, 응급수혈시반납률과폐기율이증가하여이에대한관리가필요함을시사하였다. - 137 -
Korean J Blood Transfus Vol. 29, No. 2, 130-139, Aug. 2018 감사의글 도움을주신질병관리본부혈액안전감시과김준년및최새롬선생님께감사의뜻을표합니다. References 1. Mark KF, Eder A, Spitalnik SL, Westhoff CM, American Association of Blood Banks. Technical manual. 19th ed. Bethesda, Md: American Association of Blood Banks, 2017:457-81 2. Hirani R, Wong J, Diaz P, Mondy P, Hogan C, Dennington PM, et al. A national review of the clinical use of group O D- red blood cell units. Transfusion 2017;57:1254-61 3. Downes KA, Shulman IA. Pretransfusion testing practices in North America, 2005-2010: an analysis of the college of American pathologists interlaboratory comparison program J-survey data, 2005 2010. Arch Pathol Lab Med 2012;136:294-300 4. Kim HR, Kim HH. Applied the "type and screen" method based on antibody screening test including Dia cells and immediate spin crossmatch to all patients who received transfusion for five years. Korean J Blood Transfus 2013;24:258-64 5. Kuriyan M, Fox E. Pretransfusion testing without serologic crossmatch: approaches to ensure patient safety. Vox Sang 2000;78:113-8 6. Park TS, Oh SH, Choi JC, Lee DD, Kim HH, Chang CL, et al. The clinical significance of antibody screening test including Dia+ panel cell in Asian-Mongoloid populations. J Korean Med Sci 2003;18:669-72 7. Lee JM, Kim NH, Shin KH, Lee HJ, Chang CH, Lee EY, et al. Performance evaluation of unexpected antibody screening test including Di a cell using 3% surgiscreen sub-code D in Korean multi-transfused patients. Korean J Blood Transfus 2015;26:47-53 8. Korea Centers for Disease Control and Prevention. National transfusion guideline. 4th ed. Cheongju: Korea Centers for Disease Control and Prevention, 2016 9. Boisen ML, Collins RA, Yazer MH, Waters JH. Pretransfusion testing and transfusion of uncrossmatched erythrocytes. Anesthesiology 2015;122:191-5 10. Meyer E, Uhl L. A case for stocking O D+ red blood cells in emergency room trauma bays. Transfusion 2015;55:791-5 11. Park SJ, Bae IC, Park YH, Park IC, Kim SH, Kim HO. The usage of uncrossmatched group O, rh-negative RBCs for emergency transfusion. Korean J Blood Transfus 2007;18:9-14 12. Moriwaki Y, Suzuki N, Sugiyama M. Uncrossmatched red cell concentrate transfusion for abdominal injury with hemorrhagic shock. Jpn J Gastroenterol Surg 2009;42:147-53 13. Linden JV, Paul B, Dressler KP. A report of 104 transfusion errors in New York state. Transfusion 1992;32:601-6 14. Mulay SB, Jaben EA, Johnson P, Badjie K, Stubbs JR. Risks and adverse outcomes associated with emergency-release red blood cell transfusion. Transfusion 2013;53:1416-20 15. Lee HT, Park PW, Seo YH, Ahn JY, Seo JY, Jeong JH, et al. Massive transfusion protocols for pediatric patients. Lab Med Online 2016;6:60-3. 16. Riskin DJ, Tsai TC, Riskin L, Hernandez- Boussard T, Purtill M, Maggio PM, et al. Massive transfusion protocols: the role of aggressive resuscitation versus product ratio in mortality reduction. J Am Coll Surg 2009; 209:198-205 17. O'Keeffe T, Refaai M, Tchorz K, Forestner JE, Sarode R. A massive transfusion protocol to - 138 -
최수인외 : 단일상급종합병원에서여러수혈전검사프로토콜운영경험 decrease blood component use and costs. Arch Surg 2008;143:686-90; discussion 690-1 18. McDaniel LM, Neal MD, Sperry JL, Alarcon LH, Forsythe RM, Triulzi D, et al. Use of a massive transfusion protocol in nontrauma patients: activate away. J Am Coll Surg 2013; 216:1103-9 19. Patel EU, Ness PM, Marshall CE, Gniadek T, Efron DT, Miller PM, et al. Blood product utilization among trauma and nontrauma massive transfusion protocols at an urban academic medical center. Anesth Analg 2017; 125:967-74 - 139 -