Why transfuse whole blood

In addition, WB delivers all needed elements of blood in only one product, which only requires refrigeration for storage i. In contrast, component therapy requires multiple products and storage modalities refrigeration, freezing and generally room temperature storage with agitation for PLTs — though PLTs can also be refrigerated , greatly increasing workload and complexity for clinical teams.

SWB collected in licensed blood centers offers the same level of TTD safety as component therapy collected in licensed centers. It should be noted that due to the extremely short shelf life of standard room temperature-stored PLTs 5 days , all platelet products transfused in the deployed setting are collected in theater and do not undergo TTD testing prior to transfusion, making them a non-approved FDA product.

Recent studies show that apheresis platelet products can be stored under refrigeration for longer than 5 days. Indeed, available evidence suggests that considerable hemostatic function is retained for at least 21 days during cold storage 25 and that refrigerated PLTs are superior to room temperature-stored PLTs for acute hemostasis. For U. The effect of red cell storage, whether in component therapy or SWB has not been rigorously evaluated in certain vulnerable populations, requiring high volume transfusions, such as trauma patients 34 where confounding by indication would also be present and its effect difficult to tease out from the possible effect of the age of the transfused RBCs.

Overall, both SWB and FWB offer at least comparable performance and safety compared with components, as well as very compelling logistical advantages that are particularly important in pre-hospital resuscitation and indeed, in most deployment settings, but also in severely bleeding patients requiring emergency blood release during hospital-based resuscitations. The use of SWB presents a major advantage compared to balanced, platelet-containing component therapy bundles due its increased storage duration and resulting availability of platelet-containing resuscitation.

With storage of SWB for up to 35 days in CPDA-1, the effective platelet storage duration is increased 7-fold compared with standard room temperature apheresis platelet unit storage the current standard , 35 although further study is required to determine the hemostatic efficacy of cold stored PLTs at 35 days. This permits maintenance of an inventory of a platelet-containing product SWB in austere environments where apheresis PLTs are unavailable.

Also, it should be recognized that platelet units are often in short supply even in major medical centers, so use of SWB will alleviate platelet shortages across the spectrum of healthcare delivery platforms.

In view of this and since the vast majority of preventable hemorrhage deaths occur pre-hospital, the logistical benefit of SWB is compelling and makes SWB preferable to blood components for both in- and pre-hospital resuscitation.

Based on the above efficacy, safety, and logistical considerations, the JTS Committee on Tactical Combat Casualty Care and international trauma organizations such as THOR have recommended WB as the preferred resuscitation product for patients with traumatic hemorrhagic shock.

There are risks associated with the use of FWB, including but not limited to increased risk of transfusion-transmitted infections e. Additionally, field conditions are inherently unsanitary and might increase the risk of bacterial contamination of the FWB. Recent history with approximately 10, FWB transfusions to U. It is NOT appropriate, as a matter of convenience, to use FWB as an alternative to more stringently controlled blood products for patients who do not have severe, immediately life-threatening injuries.

FWB is to be used only when other blood products cannot be delivered at an acceptable rate to sustain the resuscitation of an actively bleeding patient, when specific stored products are not available e. It should be noted that studies of FWB donors have not documented significant decrements in military-relevant task performance following donation.

Thus, concerns that FWB collections will adversely affect mission outcomes have not been substantiated and should not preclude WBB activation when conditions for FWB use are met. The potential reduced efficacy, safety, and logistical aspects of blood component therapy should be taken into consideration when choosing between resuscitation strategies Table I.

Raising the Standards on Whole Blood. J Trauma Acute Care Surg. The decision to use FWB is a medical decision that must be made by a physician who has full knowledge of both the clinical situation and the availability of compatible blood products.

A WBB Program should be established based on a risk assessment and the potential for massively bleeding casualties. The calculation of risk should include a medical intelligence assessment which includes infection prevalence and the need for preventative force protection measures.

In general, the use of FWB should be limited to casualties who are anticipated to require a transfusion when the physician determines that SWB or optimal component therapy is unavailable or in limited supply, or in patients that are not responding to SWB or component therapy.

Pre-screened donors registered into the WBB Program are preferably composed of active duty, active reserve, active National Guard, and other DoD beneficiaries. The preferred donors for FWB are fully pre-screened, low titer O donors. The question of whether previously low titer donors need to have their anti-A and -B verified as low titer again before their subsequent donated WB units are issued as LTOWB is controversial but is likely to become the standard of care in the civilian setting.

Donors who have not been pre-screened for TTDs should be considered only when no other donors are available; careful history-taking can improve donor risk stratification.

Indeed, this strategy was successfully employed by a Forward Surgical Team in Afghanistan. FDA standards. Coalition Forces should be screened to relevant mandated international or national standards e.

Coalition Forces will not be utilized routinely as donors, due to national variances in screening for blood borne diseases and differences in disease prevalence. Planned coalition activity should address the interoperability of donor panels.

Non-Coalition Force foreign nationals should be used as a last resort. The decision to use FWB that has not been completely screened for infectious agents is a medical decision that must be made after thorough consideration of risks and benefits. Decision-making should be adequately documented in the casualty record. ASBP-approved rapid infectious disease tests e. If unable to perform prior to transfusion, rapid infectious disease testing should still be performed on donor samples post transfusion.

Frequency of FWB donation must be tracked. In general, WB units should not be collected from donors more frequently than every 8 weeks 56 days. This interval between donations is important to allow the donor to recover RBC mass and iron stores and should not be shortened except under the most extreme circumstances. Donors who give blood frequently may develop iron deficiency even in the absence of anemia. Iron deficiency can cause fatigue, difficulty concentrating, pica, restless leg syndrome RLS , and eventually anemia if untreated.

Consideration should be given to screening ferritin prior to deployment in high-risk donors, particularly low titer O donors who may be called upon to donate more frequently. Consideration should be given to empiric iron supplementation in high-risk donors or donors with symptoms of iron deficiency available as ferrous sulfate mg 65 mg elemental iron , ferrous gluconate mg 38 mg elemental iron , or multivitamins with iron 18—19 mg elemental iron ; 46 , 47 one tablet per day for 60— days may be adequate to replete iron stores.

Patients with documented iron deficiency low ferritin levels as above should be offered iron supplementation and monitored for response. Due to the limited number of laboratory personnel and requirement for those same personnel to complete other laboratory testing requirements, the plan must include other personnel to assist in the donor screening and collection processes. The plan should be reviewed and rehearsed regularly. Equipment and consumables should be inspected with due attention paid to storage conditions and expiry dates.

The key elements for planning and readiness to administer FWB are knowledge and rehearsal of blood donor pre-screening and emergency whole blood collection. This is especially important in emergency situations involving more than one casualty. FDA-approved blood products. All donors must be rescreened at the time of donation. Titers for LTOWB donors should be obtained pre-deployment, which should be no more than 12 months prior to donation.

Before any FWB is transfused, rapid infectious disease testing i. Donors and unit commanders must understand the importance of donor tracing. Food and Drug Administration, recipients of FWB shall receive follow-up advice and infectious disease testing as soon as possible, and at 3-, 6-, and months post-transfusion.

In situations where there are a limited number of donors and a dire need for blood, no more than two units may be taken from a donor. When selecting a donor from which to collect two units, those with larger body masses are probably less at risk of developing iron deficiency than those with smaller body masses. Performance decrements may occur after two-unit collections and volume resuscitation of the donor may be necessary.

Collection of more than one unit per donor should only be considered under extreme circumstances and these should be thoroughly documented. WB has not been rigorously studied in pediatric trauma resuscitation, but both FWB and SWB have been shown to reduce blood loss, and improve platelet function in pediatric cardiac surgery compared to blood components. It should be titrated to clinical response similar to the resuscitation of an adult patient. Circular of Information for the use of human blood and blood components.

October Transfusion ; 53 Suppl 1 : S — 49S. Google Scholar. Indications for transfusion include symptomatic anemia causing shortness of breath, dizziness, congestive heart failure, and decreased exercise tolerance , acute sickle cell crisis, and acute blood loss of more than 30 percent of blood volume.

Fresh frozen plasma infusion can be used for reversal of anticoagulant effects. Platelet transfusion is indicated to prevent hemorrhage in patients with thrombocytopenia or platelet function defects. Cryoprecipitate is used in cases of hypofibrinogenemia, which most often occurs in the setting of massive hemorrhage or consumptive coagulopathy. Transfusion-related infections are less common than noninfectious complications. All noninfectious complications of transfusion are classified as noninfectious serious hazards of transfusion.

Acute complications occur within minutes to 24 hours of the transfusion, whereas delayed complications may develop days, months, or even years later. Blood transfusion can be a lifesaving procedure, but it has risks, including infectious and noninfectious complications.

There is debate in the medical literature concerning the appropriate use of blood and blood products. Clinical trials investigating their use suggest that waiting to transfuse at lower hemoglobin levels is beneficial. Enlarge Print. The threshold for transfusion of red blood cells should be a hemoglobin level of 7 g per dL 70 g per L in adults and most children. A restrictive transfusion strategy hemoglobin level of 7 to 9 g per dL [70 to 90 g per L] should not be used in preterm infants or children with cyanotic heart disease, severe hypoxemia, active blood loss, or hemodynamic instability.

Transfusion of plasma should be considered in a patient who has an International Normalized Ratio greater than 1. Platelets should not be transfused in patients with thrombotic thrombocytopenic purpura or heparin-induced thrombocytopenia unless a life-threatening hemorrhage has occurred. Packed red blood cells RBCs are prepared from whole blood by removing approximately mL of plasma. One unit of packed RBCs should increase levels of hemoglobin by 1 g per dL 10 g per L and hematocrit by 3 percent.

In most areas, packed RBC units are filtered to reduce leukocytes before storage, which limits febrile nonhemolytic transfusion reactions FNHTRs , and are considered cytomegalovirus safe. RBC transfusions are used to treat hemorrhage and to improve oxygen delivery to tissues.

Transfusion of RBCs should be based on the patient's clinical condition. In , a randomized, multicenter, controlled clinical trial evaluated a restrictive transfusion trigger hemoglobin level of 7 to 9 g per dL [70 to 90 g per L] versus a liberal transfusion trigger hemoglobin level of 10 to 12 g per dL [ to g per L] in patients who were critically ill.

The authors recommended transfusion when hemoglobin is less than 7 g per dL, and maintenance of a hemoglobin level between 7 to 9 g per dL. A similar study was carried out in critically ill children. The liberal transfusion trigger was a hemoglobin level of 9. Patients in the restrictive group received 44 percent fewer blood transfusions, with no difference in rates of multiple organ dysfunction syndrome or death.

The restrictive transfusion strategy is useful for children who are stable patients in intensive care. It should not be used in preterm neonates or in children with severe hypoxemia, active blood loss, hemodynamic instability, or cyanotic heart disease.

Plasma products available in the United States include fresh frozen plasma and thawed plasma that may be stored at Plasma contains all of the coagulation factors. Thawed plasma has lower levels of factors V and VIII and is not indicated in patients with consumption coagulopathy diffuse intravascular coagulation.

Plasma transfusion is recommended in patients with active bleeding and an International Normalized Ratio INR greater than 1. Supportive care can decrease high-normal to slightly elevated INRs 1. Table 1 gives indications for plasma transfusion. Inherited deficiency of single clotting factors with no virus-safe or recombinant factor available—anticoagulant factors II, V, X, or XI.

When C1 esterase inhibitor is unavailable 9. Information from references 7 through 9. Platelet transfusion may be indicated to prevent hemorrhage in patients with thrombocytopenia or platelet function defects. Contraindications to platelet transfusion include thrombotic thrombocytopenic purpura and heparin-induced thrombocytopenia. Transfusion of platelets in these conditions can result in further thrombosis. Patients in the lower trigger group received Gastrointestinal bleeding was more common in the lower trigger group; however, there was no difference in blood transfusions between groups.

Tables 2 9 and 3 9 — 12 give indications for platelet transfusion in adults and neonates, respectively. Information from reference 9. Consider transfusion; transfuse for clinical reasons e. Transfuse if any of the following indications exist:. Intraventricular or intraparenchymal cerebral hemorrhage. Coagulation disorder. Sepsis or fluctuating arterial venous pressures. Invasive procedure. If the mother's platelets are used, unit must be washed, irradiated, and resuspended in plasma that is ABO compatible with the neonate.

Information from references 9 through Cryoprecipitate is prepared by thawing fresh frozen plasma and collecting the precipitate. Cryoprecipitate contains high concentrations of factor VIII and fibrinogen. Indications for cryoprecipitate transfusion are listed in Table 4. Congenital dysfibrinogenemia Information from references 12 and Transfusion-related complications can be categorized as acute or delayed, which can be divided further into the categories of noninfectious Table 5 16 and infectious Table 6 16 , Therefore, patients are far more likely to experience a noninfectious serious hazard of transfusion than an infectious complication.

Mistransfusion transfusion of the incorrect product to the incorrect recipient. Noninfectious serious hazards of transfusion. Anesth Analg. I nformation from references 16 and Hemolytic transfusion reactions are caused by immune destruction of transfused RBCs, which are attacked by the recipient's antibodies. The antibodies to the antigens of the ABO blood group or alloantibodies to other RBC antigens are produced after immunization through a previous transfusion or pregnancy.

There are two categories of hemolytic transfusion reactions: acute and delayed. Nonimmune causes of acute reactions include bacterial overgrowth, improper storing, infusion with incompatible medications, and infusion of blood through lines containing hypotonic solutions or small-bore intravenous tubes. In acute hemolytic transfusion reactions, there is a destruction of the donor's RBCs within 24 hours of transfusion.

Hemolysis may be intravascular or extravascular. The most common type is extravascular hemolysis, which occurs when donor RBCs coated with immunoglobulin G IgG or complement are attacked in the liver or spleen.

Symptoms of acute hemolytic transfusion reactions include fever, chills, rigors, nausea, vomiting, dyspnea, hypotension, diffuse bleeding, hemoglobinuria, oliguria, anuria, pain at the infusion site; and chest, back, and abdominal pain. The incidence of acute hemolytic reactions is approximately one to five per 50, transfusions. Allergic reactions range from mild urticarial to life threatening anaphylactic.

Urticarial allergic reactions are defined by hives or pruritus. These antigens are soluble, and the associated reaction is dose-dependent. Allergic transfusion reactions occur in 1 to 3 percent of transfusions. Transfused within minutes to 24 hours of collection, it most closely resembles the blood patients are losing. Data support this idea. From to in Iraq and Afghanistan, more than soliders with life-threatening injuries were transfused with WFWB.

Those patients showed better hour and day survival compared with massively hemorrhaging patients who received stored red blood cells. Zielinski's long-term goal is to have the nation's first WFWB transfusion program for hemorrhaging patients — something that may become critically important when large-scale disasters such as Hurricane Katrina disrupt normal blood product distribution.

But implementing such a program presents huge logistical challenges. Fresh blood is more likely to transmit infections such as HIV and hepatitis C because it can't be tested before transfusion. The only military indications are a short supply of whole-blood components or the failure of a transfusion ratio resuscitation. Zielinski and colleagues at Mayo Clinic say there is overwhelming evidence — and fewer challenges — supporting the use of group O stored whole blood for massively hemorrhaging patients.

Thus, the intermediate step has been to establish a stored whole-blood transfusion program at Mayo Clinic's campus in Minnesota, which currently stores up to four units of whole blood for about 10 days.

Since the program's implementation in February , several patients have been transfused, all very successfully, Dr.