[비즈한국] "Bloodless treatment" is often associated with special medical care for patients who refuse blood transfusions for religious reasons. There is also a perception that it is a way to conserve scarce blood supplies due to the shrinking donor population caused by low birth rates and an aging society.
However, what the medical community refers to as Patient Blood Management (PBM) means more than simply avoiding blood transfusions. Its goal is to correct anemia before surgery, minimize blood loss during procedures, and when a transfusion is necessary, ensure it is administered appropriately by considering the patient's condition and prognosis.
Soonchunhyang University Seoul Hospital opened its Bloodless Center in March 2000, operating this clinical system earlier than most in Korea. According to the hospital, it has performed over 6,000 such surgeries and hosts an annual symposium to share clinical experience and research findings related to minimal and bloodless transfusions.
Park Sun-young, Director of the Bloodless and Patient Blood Management Center at Soonchunhyang University Seoul Hospital (Professor of Anesthesiology and Pain Medicine), explained in an interview with Bizhankook, "We started as a small group of doctors and opened the Bloodless Center over 20 years ago. It has been about 10 years since we changed the name to the Patient Blood Management Center, which we established as one of the first of its kind in the country."
Rather than focusing solely on reducing transfusion volume, Soonchunhyang University Seoul Hospital emphasizes the purpose of PBM as improving patient outcomes by correcting anemia and reducing unnecessary transfusions.
Director Park stated, "While there is a social problem of blood shortages, what is most important is the medical and academic evidence and the patient's prognosis. As we learned that transfusions don't just 'fill up' missing blood but also affect the occurrence of infections, complications, and long-term prognosis, we began a management system that actively reduces bleeding and transfusions."
Beyond Reducing Transfusions to Managing Patient Prognosis: 230,000-Person Analysis Shows 20% Reduction in Complications
The effectiveness of PBM is also reported in international studies. A meta-analysis published in the international journal 'Annals of Surgery' in 2019 analyzed 235,779 surgical patients across 17 studies. By applying pre-operative anemia management, minimizing blood loss, and implementing transfusion strategies based on individual patient conditions, the red blood cell transfusion rate dropped by 39% after the introduction of PBM. Total complications decreased by 20%, mortality by 11%, and the average hospital stay was shortened by 0.45 days.
Transfusion standards are also changing. The 2023 AABB (Association for the Advancement of Blood & Biotherapies) international guidelines, which reviewed 45 randomized controlled trials involving 20,599 adults, recommended a restrictive strategy for hemodynamically stable hospitalized adults, suggesting blood transfusions only when hemoglobin (Hb) levels are below 7g/dL. For cardiac surgery patients, the threshold can be 7.5g/dL, and for orthopedic or cardiovascular patients, 8g/dL may be chosen.
Director Park explained, "In the past, there was a guideline that transfusion was mandatory if Hb was 10g/dL or lower, but the threshold has been lowered following large-scale clinical trials. However, high-risk patients with coronary artery disease or those experiencing acute bleeding need to maintain slightly higher levels."
In other words, the goal is not to avoid transfusions altogether. The paradigm is shifting toward reducing unnecessary transfusions by considering a patient's overall status and bleeding conditions rather than relying solely on a single hemoglobin reading, while still transfusing if the patient requires it.
Reducing Everything from Surgical Bleeding to Blood Sampling
Soonchunhyang University Seoul Hospital does not limit PBM to transfusion decisions in specific departments; instead, it operates as a multidisciplinary clinical system covering the entire pre-, peri-, and post-operative process. Hospital data shows a structure involving various departments, including Emergency Medicine, Cardiology, Gastroenterology, Obstetrics and Gynecology, Thoracic Surgery, Neurosurgery, Orthopedics, Urology, Anesthesiology and Pain Medicine, and Laboratory Medicine.
Advances in surgical techniques have also influenced the spread of PBM. Director Park said, "As minimally invasive surgeries like robot-assisted surgery or endoscopy have become common, the volume of intraoperative bleeding has decreased drastically. In the past, it was common for 10-20% of a patient's blood volume to be lost during cancer or major surgeries, but now, most surgeries result in less than 100-200cc of blood loss."
Actual cases from various departments were introduced at a Bloodless Surgery Innovation Seminar held by Soonchunhyang University Seoul Hospital on the 19th.
In thoracic surgery, Off-Pump Coronary Artery Bypass (OPCAB) is performed on a beating heart without using a cardiopulmonary bypass, lowering the possibility of bleeding and transfusion. In neurosurgery, Biportal Endoscopic Spine Surgery (BESS), which uses two 0.7-1cm incisions, reduces muscle damage and bleeding. In urology, procedures like Rezum, which reduces enlarged prostate tissue using high-temperature water vapor, are being utilized.
Blood sampling is also a target for management. Repeated blood draws to check hemoglobin can cause "iatrogenic anemia," which worsens the condition. Soonchunhyang University Seoul Hospital uses non-invasive continuous hemoglobin monitoring equipment in operating rooms to check hemoglobin changes via a finger sensor.
"Government Support Needed for Dedicated Staff and Hemostatic Agents"
The government is also monitoring the appropriate transfusion status of medical institutions. Although there are no direct financial rewards or penalties yet, Director Park explains that the fact that blood transfusion levels per hospital are being quantified is already changing behaviors in medical settings. Director Park said, "While there aren't many direct additional fees or benefits yet, the mere fact that the government is monitoring and quantifying these figures leads medical staff and hospitals to manage the situation much more actively."
However, she voiced the need for government support, noting the need for personnel to operate PBM. "To properly run PBM, medical staff, in-hospital education, and dedicated monitoring personnel for blood usage are essential," Director Park emphasized. "Medical fee compensation is necessary to sustain these staff and systems."
Accessibility to drugs to reduce bleeding is also required. Internationally, besides fibrinogen concentrates, Prothrombin Complex Concentrates (PCC), which concentrate various clotting factors, are used for emergency reversal of anticoagulants or bleeding. These offer an option to reduce the use of blood products like Fresh Frozen Plasma (FFP) by concentrating and administering necessary clotting factors.
In contrast, options for clotting factor concentrates like PCC are limited in Korea. While Kyungbo Pharmaceutical secured the domestic rights for the 4-factor PCC 'Octaplex' from Switzerland's Octapharma in 2022, it is still in the stage of preparing for domestic approval. The same product is already approved and used in the U.S. under the name 'Balfaxar' and in Europe and Canada as Octaplex.
Director Park pointed out, "We need drugs that can assist with hemostasis without directly giving blood, such as fibrinogen or concentrated hemostatic complexes. However, pharmaceutical companies often don't actively pursue import or approval due to low profitability, so many hemostatic drugs that are widely used overseas cannot be used in domestic clinical settings. We are forced to use blood products like plasma as a result."
While PBM started as bloodless treatment, it has now expanded beyond a treatment concept limited to specific patient groups into a clinical system that manages the entire process of anemia, bleeding, and transfusion for general patients. As the blood supply crisis deepens due to low birth rates and an aging society, the importance of PBM—which minimizes unnecessary transfusions and appropriately uses blood based on patient conditions alongside efforts to increase supply—is expected to continue to grow.