Whole blood

Background

• Fresh Whole Blood (FWB) has been used extensively to resuscitate casualties in military conflicts since World War I.
• FWB has been shown via retrospective studies to improve early and late survival as compared to stored component therapy.
• FWB remains an important tool used in modern military medicine although military physicians often do not have extensive training in its proper use.
• FWB is not extensively used in civilian settings due to the availability of fractionated products which were developed to meet demand for large-scale system needed to collect and distribute blood. Using fractionated products allows for prolonged storage and improved resource utilization of donated blood.

Clinical Features

• Advantages of FWB
  • FWB provides 1:1:1 PRBC:FFP:platelet therapy
  • FWB is more concentrated than component therapy (higher hematocrit)
  • FWB does not contain the high volume of anticoagulant and additives as compared to component therapy
  • FWB is more readily available in austere locations as it can often be 'stored' in walking pre-screen donors
  • FWB has no loss of clotting factor or platelet activity often associated with cold storage of component blood products
  • FWB has no red blood cell "storage lesion"
• Disadvantages of FWB
  • Must be ABO-type specific as it contains both RBCs and plasma
  • Increased risk of blood-borne diseases
  • Increased risk of bacterial contamination due to the field conditions
  • Decreased exercise or operational performance in donors
  • Increased risk of clerical errors (ABO typing) due to chaotic nature during which FWB may be used
  • FWB is not FDA-approved

Indications

• Not use for convenience or as an alternative to component therapy if said blood products are readily available
• Use in trauma casualties who are anticipated to require massive transfusions based on retrospective studies showing benefit to FWB over component therapy
• Use in patients with clinically significant shock or coagulopathy when optimal component therapy is unavailable or stored component therapy is not adequately resuscitating patient with immediate life-threatening injuries
• Use when component therapy inventories are depleted or excepted to be depleted as in mass casualty situation

Management

• Decision to Use
  • Made by physician who has knowledge of the clinical situation and availability of compatible blood components
  • Limit use of FWB to indications noted above
  • Made in consultation with appropriate ancillary stakeholders to include blood bank officer in charge, trauma director, chief of staff of the military treatment facility
  • Ensure FWB is type-specific matched to casualty
  • Annotate decision to use FWB in medical record
• Precautions
  • No universal donor
  • Female casualties of child bearing potential must be Rh match
  • Blood types on identification tags are known to be incorrect on occasion
  • Non-standard equipment may lead to coagulation during transfusion process
• Planning Factors for FWB Donation Program
  • Establish robust pre-screen donor pool if possible
  • Rapidly establish ABO/Rh status of donors and casualties
  • Adhere to same screening, drawing, labeling, and issuing standards as for approved component products
  • Perform on-site testing of potential donors using rapid screening immunoassays then retrospective testing should be performed and documented in medical chart as well

Procedure

• Reference joint clinical practice guidelines for detailed FWB transfusion protocol
• After 24 hours destroy all room temperature-stored units
• If refrigerated within 8 hours of collection, store up to 5 days. Note that FWB product only will have RBCs and plasma if transfused after refrigeration as platelets will be non-viable once they are cooled to 4 degrees C

Disposition

• FWB will continue to be a lifesaving addition to the military physician taking care of seriously injured on the battlefield despite not being FDA-approved therapy.

See Also

Massive transfusion Blood products

References

1 Joint Theater Trauma System Clinical Practice Guideline, Fresh Whole Blood Transfusion, October 2012. 2 Emergency War Surgery, 2013, Fourth US Revision, Chapter 36: Emergency Whole Blood Collection. 3 Makley, A, Goodman, M, Friend, L, et al. Resuscitation with Fresh Whole Blood Ameliorates the Inflammatory Response after Hemorrhagic Shock. J. Trauma. 2010; 68: 305-311. 4 Bowling, F, Pennardt, A. The Use of Fresh Whole Blood Transfusions by the SOF Medic for Hemostatic Resuscitation in the Austere Environment. J Spec Oper Med. 2010 Summer; 10(3):25-35. 5 Cahill, BP, Stinar, TR. Improving the Emergency Whole Blood Program. Mil Med. 2011 Nov; 176(11):1287-91.