소아 환자에서의 대량수혈 프로토콜

이환태,박필환,서일혜,안정열,서자영,정지훈,김문진,이정남,이길재,김경희 대한진단검사의학회 2016 Laboratory Medicine Online Vol.6 No.2

The number of massive transfusions for pediatric patients has risen owing to the increasing number of complex surgeries and trauma centers. However, as there are only a few studies on pediatric massive transfusion, adult massive transfusion protocols are used for pediatric patients in many hospitals and institutions. Although massive transfusion protocols would improve the outcomes and reduce the received blood products during transfusion, pediatric patients differ from adults in the tolerability to transfusion, incidence of coagulopathy, and mechanisms of injuries. Therefore clinical physicians have requested for a pediatric massive transfusion protocol. Herein, we reviewed pediatric massive transfusion protocols that have been used in various clinical settings. To date, only a few single-center studies with a small number of pediatric patients have been performed. Even though these studies did not show improvement in outcomes such as mortality and side effects, they reported a short preparation time for fresh frozen plasma products and a low coagulopathy rate in pediatric massive transfusion groups. Therefore, large, prospective, multicenter studies are needed to identify the empiric ratio of blood products for improving outcomes of pediatric patients who need massive transfusion. 최근 외상센터의 증가와 이식 수술과 같은 복잡한 수술이 증가하면서 소아에서도 대량수혈을 필요로 하는 경우가 많아지고 있다. 성인에서와 달리 아직 소아 환자에서 대량수혈에 대한 연구는 미흡한 실정이며, 많은 병원과 기관에서는 성인 대량수혈 프로토콜을 소아 환자에도 적용하고 있다. 이러한 프로토콜은 환자의 생존율을 높이고 수혈 시 사용되는 혈액제제의 양도 줄일 수 있다는 장점이 있으나, 소아 환자의 경우 응고병증에 대한 내성이나 수상 기전이 성인과 다르다. 이러한 이유로 임상의사들의 소아 대량수혈 프로토콜에 대한 요구가 있어, 현재 사용되고 있는 프로토콜에 관한 국내외 문헌을 고찰해 보았다. 지금까지 발표된 소아 대량수혈 프로토콜 관련 연구들은 모두 단일 기관에서 적은 수의 환자를 대상으로 진행되었으며, 대조군에 비해 유의하게 높은 생존율 을 보이지는 않았으나 소아 대량수혈 프로토콜에 따라 처치받은 환자군에서 짧은 신선동결혈장 준비 시간과 낮은 응고병증 발생빈도를 보였다. 따라서 국내에서도 여러 기관이 포함된 대규모 연구를 통해서 대량수혈을 필요로 하는 소아 환자의 생존율을 높일 수 있는 최적화된 혈액제제 비율과 대량수혈 프로토콜을 구축할 필요가 있을 것으로 사료된다.

외상성 응고장애와 대량수혈

이대상 대한수혈학회 2020 大韓輸血學會誌 Vol.31 No.2

A massive blood transfusion is a challenging situation that can be encountered in the treatment of trauma patients. Under these circumstances, clinicians should conduct appropriate blood transfusions using the massive transfusion protocol, and make efforts to prepare and apply these protocols to the systems of each hospital in advance. In addition, the effect of massive bleeding on the body highlights the need to understand why fresh frozen plasma and platelets, as well as packed red blood cells (pRBC), are needed during massive transfusion. In hemorrhagic patients, blood pressure maintenance through transfusion is an important part, but above all, efforts to control sustained bleeding by controlling and treating the bleeding itself are more important. This is because patients need to recover their organs after early resuscitation by minimizing the side effects of transfusion. No research has been done to compare the restrictive transfusion and liberal transfusion strategies in patients requiring massive transfusion. On the other hand, various studies suggest that it is more advantageous to apply a liberal blood transfusion strategy in patients with severe or older age. Nevertheless, there has been insufficient research to apply it generally. Therefore, for patients whose resuscitation has been performed by applying a massive transfusion protocol, a reasonable treatment approach would be to shift to a strategy to supplement poor coagulation factors through a goal-directed transfusion. (Korean J Blood Transfus 2020;31:101-108)

Analysis of Massive Transfusion for Trauma Patients and Non-Trauma Patients in a Tertiary Hospital

김혜림,유동원,신경화,이현지,김형회 대한수혈학회 2016 大韓輸血學會誌 Vol.27 No.3

Background: Management of patients with massive hemorrhage often requires the massive blood transfusions. However, few studies have investigated the effects of massive transfusions on non-traumatic patients. Therefore, this study analyzed mortality and descriptive data for patients receiving massive transfusion, including non-trauma patients and trauma patients. Methods: We reviewed a retrospective audit of massive transfusions to investigate the major causes, patient characteristics, ratio of the blood components, and the mortality of massively transfused patients. The analysis was performed using electronic medical records collected from January 2010 to December 2013. Patients who had received a massive transfusion (≥10 units of RBCs within 24-hours) were categorized into trauma and non-trauma patients. We calculated the ratio of blood components and investigated the relationship between ratio and mortality. Descriptive statistics were used to characterize the patients and the indications. Results: A total of 532 massive transfusions were performed, including 187 trauma and 345 non-trauma patients. The overall mortality rate was 32.0%, encompassing 36.4% of the trauma patients and 29.6% of the non-trauma patients. The mortality in trauma patients was significantly reduced (P<0.001) within the first 48-hours compared with that in non-trauma patients, which was due to the high FFP: RBC ratio transfusion. The annual FFP: RBC ratio in trauma patients showed an increasing trend. Non-trauma patients showed no relationship between mortality and procedure indication/blood component ratio. Conclusion: We report clinical data pertaining to massive transfusions. Annual increasing FFP: RBC ratio in trauma patients was associated with a decreasing mortality. Non-trauma patients showed heterogeneous characteristics and a lower FFP: RBC ratio than trauma patients.

Clinical Observation Study of Massive Blood Transfusion in a Tertiary Care Hospital in Korea

Seoyoung Yoon,Ae Ja Park,김현옥 연세대학교의과대학 2011 Yonsei medical journal Vol.52 No.3

Purpose: Massive blood transfusios are uncommon. The goal of this study was to propose an ideal ratio for the blood component of massive hemorrhage treatment after review of five years of massive transfusion practice, in order to have the best possible clinical outcomes. Materials and Methods: We defined a ‘massive transfusionʼ as receiving 10 or more units of red blood cells in one day. A list of patients receiving a massive transfusion from 2004 to 2008 was generated using the electronic medical records. For each case, we calculated the ratio of blood components and examined its relationship to their survival. Results: Three hundred thirty four patients underwent massive transfusion during the five years of the study. The overall seven-day hospital mortality for massive transfusion patients was 26.1%. Factors independently predictive of survival were a fresh-frozen plasma (FFP)/packed red blood cell (pRBC) ratio≥1.1 with an odds ratio (OR) of 1.96 (1.03-3.70), and elective admission with an OR of 2.6 (1.52-4.40). The receiver operation characteristic (ROC) curve suggest that a 1 : 1 : 1 ratio of pRBCs to FFP to platelets is the best ratio for survival. Conclusion: Fixing blood-component ratios during active hemorrhage shows improved outcomes. Thus, the hospital blood bank and physician hypothesized that a fixed blood component ratio would help to reduce mortality and decrease utilization of the overall blood component.

Application of the continuous autotransfusion system (CATS) to prevent transfusion-related hyperkalemia following hyperkalemic cardiac arrest in an infant -A case report-

Hye-Min Sohn,Yong-Hee Park,Hyo-Jin Byon,김진태,Heesoo Kim,Chong Sung Kim 대한마취통증의학회 2012 Korean Journal of Anesthesiology Vol.62 No.3

Transfusion-induced hyperkalemia can lead to cardiac arrest, especially when the patient rapidly receives a large amount of red blood cells (RBCs), previously stored for a long period of time, irradiated or both. We report on a case of application of the Continuous AutoTransfusion System (CATS) to wash RBCs, in order to lower the high potassium (K+) level in the packed RBCs unit, during massive transfusion following transfusion-induced hyperkalemic cardiac arrest. After the washing process using CATS, there was no more electrocardiographic abnormality or cardiac arrest due to hyperkalemia. This case emphasizes the potential risk to develop transfusion-related hyperkalemic cardiac arrest, during massive transfusion of irradiated, pre-stored RBCs. CATS can be effectively used to lower the K+concentration in the packed RBCs unit, especially when the risk of transfusion-induced hyperkalemia is high.

대량수혈 환자의 예후와 관련된 요인 분석

이선민,임영애,곽연식 대한임상병리학회 1999 대한임상병리학회지 Vol.19 No.5

복부대동맥류파열로 인한 심정지 환자에서 대량수혈의 임상적경험

정유남,최윤숙,김수완 대한수혈학회 2015 大韓輸血學會誌 Vol.26 No.1

We report on a case of successful management of a patient with abdominal aortic rupture requiring massive blood transfusion during the peri-operative period. The patient had fully recovered 19 days after the operation, through intra-operative cardiac arrest and massive transfusion. We analyze a process of blood transfusion and related complications resulting from massive transfusion in order to establish a treatment for peri-operative patients with hypovolemic shock. 저자들은 수술 중 대량수혈을 시행하였던 복부 대동맥 파열 환자에 대한 성공적인 수술전후관리의 예를 경험하였다. 환자는 수술 중 심정지가 발생하고 대량 수혈을 받았지만 수술 19일 후에는 완전히 회복하였다. 이에 저혈량성 쇼크를동반하여 대량수혈을 받은 환자의 수혈진행과 수술전후 치료과정과 수혈과 관련된 상황을 분석하여 보고한다.

단일 상급종합병원에서 증례를 중심으로 본 대량수혈 현황

최계령,김현옥,최승준,김신영 대한수혈학회 2014 大韓輸血學會誌 Vol.25 No.2

Background: Massive transfusion (MT) is an unusual event and has been defined as replacement of total bodyfluid volume in less 24 hours or transfusion of 10 or more RBC units in 24 hours. MT is a high priority treatmentfor major blood loss. Methods: We gathered 78 patients receiving MT from 2008 to 2013 at Severance hospital using electronic medicalrecords and performed a retrospective review. For each case, we analyzed patients’ characteristics, including sex,age, major causes of MT, and clinical outcome. We also calculated the ratio of each blood component transfused. Results: Patient sex ratio of male and female was 1.60 and percentage of patients over age 40 was 58.4%. Theindividual diagnostic categories were 28.2% of cardiovascular surgery, 26.9% of liver transplantation, 11.5% of uppergastrointestinal bleeding, and 5.2% of trauma. The overall mortality rate was 47.3%. Mortality rate ranged from thelowest (52.3%) for liver transplantation to the highest (77.8%) for upper gastrointestinal tract bleeding. No correlationwas observed between causes of MT and mortality rate. The average usage of FFP: RBC and platelet: RBC ratiowas 0.83 and 0.68, respectively. However, recently, the ratio of two components transfused is close to 1.0. Conclusion: The highest priority in MT was rapidity and propriety for improvement of patient survival. Byregularly reviewing MT cases, we could provide an improved massive transfusion service.

비 외상 환자에서 대량수혈 필요에 대한 예측 인자 분석

유광열,김정윤,최성혁,윤영훈,임채승,박상민 대한수혈학회 2013 大韓輸血學會誌 Vol.24 No.3

Background:Many patients received transfusion in emergency department because of blood loss. There are few studies on massive transfusion for non-traumatic patients. This study investigated mortality and risk factor for non-traumatic bleeding patients who received transfusion. Methods:Non-trauma patients who received transfusion at the emergency department for 3 years from March 2009 to February 2011 were enrolled. The patients who are younger than 15 years, trauma patients, and transfused FFP or platelet alone are excluded. Medical records was investigated retrospectively. We investigated predictive factors for MT on non-trauma patients and predictive factors for mortality on MT patients. Results:Among 1655 non-trauma patients, 150 patients (9.24%) received MT. The age of MT group was younger than that of non-MT group and systolic bloor pressure, diastolic blood pressure, mean arterial pressure were significantly lower. Base excess, pH, lactate levels were significantly different between MT and non-MT group. Intensive care unit length of stay was longer, mortality of 24 hours was higher and survival discharge was lower than non-MT group. Mortality rate of MT group was 20.7% which was significantly higher than non-MT group’s 9.3%. FFP:RBC ratio was higher in MT group than non-MT group. Among the MT group, non-survival group used higher FFP:RBC ratio product than survival group. On multivariate analysis, sBP, MAP, lactate, pH, BE were significant as predictors of MT. Conclusion:For non-trauma patients in emergency department, if sBP, MAP, lactate, pH, BE are abnormal, massive transfusion could be expected. Like trauma patients, basic scoring system that can predict MT would be necessary and useful. 배경: 많은 환자들이 출혈을 주소로 응급실에내원하며 수혈을 받는다. 대량수혈에 대한 많은연구들은 이에 대한 예측인자 또는 임상적으로적용 가능한 scoring system 등에 관한 연구가 많으며 이들 대부분은 외상 환자만을 대상으로 진행되어 왔고, 비 외상 환자를 대상으로 하는 대량수혈에 관한 연구는 거의 없는 실정이다. 이 연구에서는 수혈환자 중 비 외상 환자를 대상으로 임상적 특성 및 사망률, 대량수혈에 대한 위험인자등을 조사하였다. 방법: 서울지역에 위치한 3차 병원인 고려대학교 부속 구로병원에 2009년 3월부터 2011년 2월까지 3년 동안 내원한 환자 중에서 수혈을 시행받은 비 외상 환자를 대상으로 의무기록을 후향적으로 분석하여 연구를 진행하였다. 15세 미만이거나 외상 환자이거나 신선동결혈장 및 혈소판을 단독으로 투여 받은 환자는 제외하였다. 대량수혈은 응급실 내원 후 6시간 내 5단위 이상을 수혈한 경우로 정의하였다. 비 외상 환자에서 대량수혈을 예측할 수 있는 예측 인자와 대량수혈을받은 환자들에서 사망률에 대한 예측 인자를 조사하였다. 결과: 연구 기간 동안 총 1,655명의 비 외상 환자가 수혈을 받았고, 그 중에서 140명(9.24%)이대량수혈을 받았다. 대량수혈군에서 중환자실 재실 기간은 더 길었고, 사망률은 높았다. 두 군 모두에서 위장관출혈이 가장 많은 원인을 차지했다. FFP:RBC 비는 대량수혈군에서 비 대량수혈군에 비해 더 높았다. 대량수혈군 중에서 비 생존군이 생존군에 비해 FFP:RBC 비가 더 높았다. 대량수혈에 대한 예측인자로는 수축기혈압, 평균동맥압, 젖산, pH, Base excess가 의미 있는 결과를보였다. 결론: 응급실에 내원하는 비외상환자에서 대랑수혈군의 예후는 비 대량수혈군에 비해 좋지않았다. 응급실에 내원하여 수혈을 시행 받은 비외상환자 중 수축기혈압, 평균동맥압, 젖산, Base excess, pH가 비정상일수록 대량수혈을 예상할수 있을 것이다. 이는 외상환자에서와 같이 대량수혈을 예측하는 clinical scoring system 등에 적용하여 조기 치료방침이나 예후를 판정하는데 도움이 될 것이다.

응급/대량 수혈 시 ABO 이형 적합 적혈구제제 선택에 도움을 주기 위한 제안: AB형 환자에게도 O형 적혈구제제가 차선으로 1순위인가?

이혜련 대한수혈학회 2023 大韓輸血學會誌 Vol.34 No.3

According to the transfusion guidelines, type O RBC is the best choice for emergency transfusions if the recipient’s ABO group is unknown. If the recipient’s ABO group is confirmed after pre-transfusion tests, ABO identical and ABO compatible (but non-identical) RBC is the second-best choice in that order. However, non-transfusion medicine physicians have a misconception that type O RBCs are always the second best for patients in all emergency/massive transfusions. The author suggests the use of optimal ABO non-identical but compatible RBC components in emergency/massive transfusions, especially for AB+ recipients.