The Dead Sea needs salt water… massively bleeding patients need whole blood: The evolution of blood product resuscitation

A national database review of whole blood use among females of childbearing potential experiencing traumatic hemorrhage

INTRODUCTION

The use of low-titer O whole blood (LTOWB) for traumatic hemorrhage is growing. Most LTOWB for use in adults is RhD-positive, which presents potential risks to females of childbearing potential (FCP); however, data on practice patterns are lacking. We sought to assess the use of LTOWB among FCPs compared to similarly aged males in facilities with documented LTOWB capabilities.

METHODS

We compared FCP (females 15-50 years of age) to similarly aged males (or sex unclassified/undocumented) who were included in the Trauma Quality Improvement Program database from 2020 to 2022. This database records transfusion volumes administered within the first 4 h after admission and patient demographics. We compared LTOWB use among FCPs versus similarly aged males using descriptive, inferential, and multivariable statistics.

RESULTS

There were 79,298 that met inclusion for this analysis. There were 16,823 (21%) FCPs, of whom, 2759/16,823 (16%) received any volume of LTOWB compared to 16,310/62,475 (26%) of the males. Furthermore, among LTOWB recipients, the median (interquartile range) volume administered to FCPs was 1162 mL (500-1000) compared to 1352 mL (500-1000, p = .003) for males. In our multivariable logistic regression analysis, males had a higher odds for the receipt of LTOWB compared to FCPs (odds ratio 1.76, 95% confidence interval 1.68-1.84) after adjusting for age, mechanism of injury, and composite injury severity score. These findings persisted on sensitivity testing.

CONCLUSIONS

Males were more likely than FCPs to receive LTOWB during trauma resuscitation in unadjusted and adjusted analyses. The reasons for such differences require elucidation in future prospective studies.

Prehospital whole blood use in civilian trauma care: A review of current evidence and practices

ABSTRACT

The use of whole blood (WB) as an adjunct to component therapy has gained popularity for the resuscitation of civilian trauma patients in the last decade. Additionally, it has been shown that earlier transfusion of WB is associated with improved early and late mortality. Despite the proven association of improved outcomes with the emergency transfusion of WB, the role of prehospital whole blood in the resuscitation of hemorrhaging trauma patients remains uncertain because of conflicting results in previous studies. This article will review the existing literature on the use of WB in prehospital settings and the rationale behind its potential advantages among hemorrhaging trauma patients.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level V.

Multicenter analysis of massive transfusion practices demonstrates variabilities across trauma centers in the Southwestern Surgical Congress

BACKGROUND

This study's purpose is to investigate emergent blood (EB) usage, massive transfusion protocols (MTP), and the use of pharmacologic adjuncts to resuscitation across trauma centers in the Southwestern Surgical Congress (SWSC).

METHODS

Anonymous, voluntary 26-question survey conducted by the SWSC multicenter trials group. Descriptive statistical analysis was performed.

RESULTS

36 institutions across 14 states responded. EB is immediately available at 27 institutions. 53 ​% have LTOWB available. LTOWB is incorporated into MTP at 39 ​% of institutions and is the primary MTP product used at 4 centers. 65 ​% of institutions use thromboelastography to guide resuscitation. 70 ​% of institutions reported using TXA and 11 ​% used fibrinogen concentrate. 36 ​% of responding institutions routinely draw ionized calcium values. Four institutions have a calcium replacement protocol. Only 6 centers report redosing antibiotics during MTP.

CONCLUSION

EB availability and MTP practices are evolving with variability across the SWSC. Pharmacologic therapies remain poorly incorporated into the MTP.

Low titer group O whole blood and risk of RhD alloimmunization: Rationale for use in Finland

BACKGROUND

Prehospital low-titer group O whole blood (LTOWB) used for patients with life-threatening hemorrhage is often RhD positive. The most important complication following RhD alloimmunization is hemolytic disease of the fetus and newborn (HDFN). Preceding clinical use of RhD positive LTOWB, we estimated the risk of HDFN due to LTOWB prehospital transfusion in the Finnish population.

STUDY DESIGN AND METHODS

We collected data on prehospital transfusions in Tampere and Helsinki University Hospital areas. Using the mean of reported alloimmunization rates in trauma studies (24%) and a higher reported rate representing trauma patients of 13-50 years old (42.7%), we estimated the risk of HDFN and extrapolated it to the whole of Finland.

RESULTS

We estimated that in Finland, with the current prehospital transfusion rate we would see 1-3 cases of severe HDFN due to prehospital LTOWB transfusions every 10 years, and fetal death due to HDFN caused by LTOWB transfusion less than once in 100 years.

DISCUSSION

The estimated risk of serious HDFN due to prehospital LTOWB transfusion in the Finnish population is similar to previous estimates. As Finland routinely screens expectant mothers for red blood cell antibodies and as the contemporary treatment of HDFN is very effective, we support the prehospital use of RhD positive LTOWB in all patient groups.

Maternal and child life years gained by transfusing low titer group O whole blood in trauma: A computer simulation

BACKGROUND

Using low titer group O whole blood (LTOWB) is increasingly popular for resuscitating trauma patients. LTOWB is often RhD-positive, which might cause D-alloimmunization and hemolytic disease of the fetus and newborn (HDFN) if transfused to RhD-negative females of childbearing potential (FCP). This simulation determined the number of life years gained by the FCP and her future children if she was resuscitated with LTOWB compared with conventional component therapy (CCT).

METHODS

The model simulated 500,000 injured FCPs of each age between 0 and 49 years with LTOWB mortality relative reductions (MRRs) compared with components between 0.1% and 25%. For each surviving FCP, number of life years gained was calculated using her age at injury and average life expectancy for American women. The number of expected future pregnancies for FCPs that did not survive was also based on her age at injury; each future child was assigned the maximum lifespan unless they suffered perinatal mortality or serious neurological events from HDFN.

RESULTS

The LTOWB group with an MRR 25% compared with CCT had the largest total life years gained. The point of equivalence for RhD-positive LTOWB compared to CCT, where life years lost due to severe HDFN was equivalent to life years gained due to FCP survival/future childbearing, occurred at an MRR of approximately 0.1%.

CONCLUSION

In this model, RhD-positive LTOWB resulted in substantial gains in maternal and child life years compared with CCT. A >0.1% relative mortality reduction from LTOWB offset the life years lost to HDFN mortality and severe neurological events.

Low-titer group O whole blood in military ground ambulances: Lessons from the Israel Defense Forces initial experience

BACKGROUND

Cold-stored low-titer group O whole blood (LTOWB) has become increasingly utilised in both prehospital and in-hospital settings for resuscitation of traumatic haemorrhage. However, implementing the use of LTOWB to ground medical teams has been limited due to logistic challenges.

METHODS

In 2022, the Israel Defense Forces (IDF) started using LTOWB in ambulances for the first time in Israel. This report details the initial experience of this rollout and presents a case-series of the first patients treated with LTOWB.

RESULTS

Between January-December 2022, seven trauma patients received LTOWB administered by ground IDF intensive care ambulances after presenting with profound shock. Median time from injury to administration of LTOWB was 35 min. All patients had evidence of severe bleeding upon hospital arrival with six undergoing damage control laparotomy and all but one surviving to discharge.

CONCLUSIONS

The implementation of LTOWB in ground medical units is in its early stages, but continued experience may demonstrate its feasibility, safety, and effectiveness in the prehospital setting. Further research is necessary to fully understand the indications, methodology, and benefits of LTOWB in resuscitating severely injured trauma patients in this setting.

Hypocalcemia in Trauma is Determined by the Number of Units Transfused, Not Whole Blood Versus Component Therapy

INTRODUCTION

Blood component resuscitation is associated with hypocalcemia (HC) (iCal <0.9 mmol/L) that contributes to coagulopathy and death in trauma patients. It is unknown whether or not whole blood (WB) resuscitation helps mitigate the risk of HC in trauma patients. We hypothesized that calcium homeostasis is maintained and mortality improved in patients who only receive WB.

MATERIALS AND METHODS

This is a retrospective review of all adult trauma patients who received WB from July 2018 to December 2020. Variables included transfusions, ionized calcium levels, and calcium replacement. Patients were characterized as follows based on blood products received: WB or WB with other blood components. Groups were compared with respect to HC, correction of HC, 24 h, and inpatient mortality.

RESULTS

Two hundred twenty-three patients received WB and met the inclusion criteria. 107 (48%) received WB only. HC occurred in 13% of patients who received more than one WB unit compared to 29% of WB and other blood component patients (P = 0.02). WB patients received less calcium replacement (median 250 mg versus 2000 mg, P < 0.01). HC and total units transfused within 4 h were associated with mortality in the adjusted model. HC significantly increased after 5 units of blood products were transfused, regardless of product type. WB was not protective against HC.

CONCLUSIONS

HC and failure to correct HC are significant risk factors for mortality in trauma. Resuscitations with WB only and WB in combination with other blood components are associated with HC especially when more than 5 units of any blood product are transfused. Calcium supplementation should be prioritized in any large volume transfusion, regardless of blood product type.

Low titer Group O whole blood utilization in pediatric trauma resuscitation: A National Survey

BACKGROUND

Renewed interest in low titer group O whole blood (LTOWB) transfusion has led to increased utilization in adult trauma centers; little is known regarding LTOWB use in pediatric centers.

STUDY DESIGN AND METHODS

A survey of LTOWB utilization at American pediatric level 1 trauma centers.

RESULTS

Responses were received from 43/72 (60%) centers. These institutions were primarily urban (84%) and pediatric-specific (58%). There were 16% (7/43) centers using LTOWB, 7% (3/43) imminently initiating an LTOWB program, 47% (20/43) with interest but no current plan to develop a LTOWB program, and 30% (13/43) with no immediate interest in an LTOWB program. For the hospitals actively or imminently using LTOWB, 70% (3/10) have a minimum recipient weight criterion, 60% (6/10) have a minimum age criterion, and 70% (7/10) restrict the maximum volume transfused. Before the patient's RhD type becomes known, 30% (3/10) use RhD negative LTOWB for males and females, 40% (4/10) use RhD positive LTOWB for males and RhD negative LTOWB for females, 20% (2/10) use RhD positive LTOWB for males and RhD negative RBCs for females, and 10% (1/10) use RhD positive LTOWB for both males and females. Maximum LTOWB storage duration was 14-35 days and units nearing expiration were used for non-trauma patients (40%), processed to RBC (40%), and/or discarded (40%). The most common barriers to implementation were concerns about inventory management (37%), wastage (35%), infrequent use (33%), cost (21%) and unclear efficacy (14%).

CONCLUSION

LTOWB utilization is increasing in pediatric level 1 trauma centers in the United States.

Receipt of at least 4 units of low titer group O whole blood with titer <100 does not lead to hemolysis in adult trauma patients

BACKGROUND

The serological safety of transfusing low titer group O whole blood (LTOWB) with an anti-A and anti-B titer of <100 was evaluated in group O and non-group O trauma recipients.

METHODS

Civilian adult trauma patients who received ≥4 units of leukoreduced LTOWB during their initial resuscitation and who survived for >24 h after admission at two level 1 trauma centers were included in this retrospective study. Lactate dehydrogenase (LDH), total bilirubin, haptoglobin, potassium, creatinine were evaluated on the day of LTOWB transfusion (day 0) and on the next 3 days.

RESULTS

There were 77 injured recipients evaluated: 39 non-group O and 38 group O. The median (IQR) number of transfused LTOWB units was 4 (4-6) and 4 (4-5), respectively, and the maximum number of units was 8 and 11, respectively. The non-group O patients received a median (IQR) volume of 1710 ml (1368-2070) of ABO-incompatible plasma. Comparing non-group O to group O recipients, there were no significant differences in the median haptoglobin, LDH, or creatinine concentrations at any time point. The median concentration of total bilirubin was significantly higher amongst the non-group O recipients on days 1 and 2, while on day 0 the median potassium concentration was significantly higher amongst the group O recipients. All median elevated values were within the laboratory's normal range. Amongst the non-group O recipients there were no reported transfusion reactions.

CONCLUSION

Receiving at least four LTOWB units (anti-A&B titer <100) was not associated with biochemical/clinical evidence of hemolysis in adult trauma patients.

Estimating the risks of prehospital transfusion of D-positive whole blood to trauma patients who are bleeding in England

Background and Objectives

D‐negative red cells are transfused to D‐negative females of childbearing potential (CBP) to prevent haemolytic disease of the foetus and newborn (HDFN). Transfusion of low‐titre group O whole blood (LTOWB) prehospital is gaining interest, to potentially improve clinical outcomes and for logistical benefits compared to standard of care. Enhanced donor selection requirements and reduced shelf‐life of LTOWB compared to red cells makes the provision of this product challenging.

Materials and Methods

A universal policy change to the use of D‐positive LTOWB across England was modelled in terms of risk of three specific harms occurring: risk of haemolytic transfusion reaction now or in the future, and the risk of HDFN in future pregnancies for all recipients or D‐negative females of CBP.

Results

The risk of any of the three harms occurring for all recipients was 1:14 × 10³ transfusions (credibility interval [CI] 56 × 10²–42 × 10³) while for females of CBP it was 1:520 transfusions (CI 250–1700). The latter was dominated by HDFN risk, which would be expected to occur once every 5.7 years (CI 2.6–22.5). We estimated that a survival benefit of ≥1% using LTOWB would result in more life‐years gained than lost if D‐positive units were transfused exclusively. These risks would be lower, if D‐positive blood were only transfused when D‐negative units are unavailable.

Conclusion

These data suggest that the risk of transfusing RhD‐positive blood is low in the prehospital setting and must be balanced against its potential benefits.

Hemorrhagic Resuscitation Guided by Viscoelastography in Far-Forward Combat and Austere Civilian Environments: Goal-Directed Whole-Blood and Blood-Component Therapy Far from the Trauma Center

Modern approaches to resuscitation seek to bring patient interventions as close as possible to the initial trauma. In recent decades, fresh or cold-stored whole blood has gained widespread support in multiple settings as the best first agent in resuscitation after massive blood loss. However, whole blood is not a panacea, and while current guidelines promote continued resuscitation with fixed ratios of blood products, the debate about the optimal resuscitation strategy-especially in austere or challenging environments-is by no means settled. In this narrative review, we give a brief history of military resuscitation and how whole blood became the mainstay of initial resuscitation. We then outline the principles of viscoelastic hemostatic assays as well as their adoption for providing goal-directed blood-component therapy in trauma centers. After summarizing the nascent research on the strengths and limitations of viscoelastic platforms in challenging environmental conditions, we conclude with our vision of how these platforms can be deployed in far-forward combat and austere civilian environments to maximize survival.

THOR-AABB Working Party Recommendations for a Prehospital Blood Product Transfusion Program

The evidence for the lifesaving benefits of prehospital transfusions is increasing. As such, emergency medical services (EMS) might increasingly become interested in providing this important intervention. While a few EMS and air medical agencies have been providing exclusively red blood cell (RBC) transfusions to their patients for many years, transfusing plasma in addition to the RBCs, or simply using low titer group O whole blood (LTOWB) in place of two separate components, will be a novel experience for many services. The recommendations presented in this document were created by the Trauma, Hemostasis and Oxygenation Research (THOR)-AABB (formerly known as the American Association of Blood Banks) Working Party, and they are intended to provide a framework for implementing prehospital blood transfusion programs in line with the best available evidence. These recommendations cover all aspects of such a program including storing, transporting, and transfusing blood products in the prehospital phase of hemorrhagic resuscitation.

Whole Blood Transfusion: Past, Present, and Future

Transfusion of whole blood largely was replaced by component therapy in the 1970s and 1980s. The recent military operations in Iraq and Afghanistan returned whole blood to military trauma care. Eventually, whole blood use was incorporated into some civilian trauma care. It has been utilized in several other civilian populations as well. Trials to compare whole blood to component therapy are ongoing.

Survey to inform trial of low-titer group O whole-blood compared to conventional blood components for children with severe traumatic bleeding

BACKGROUND

Low-titer group O whole-blood (LTOWB) is being used for children with life-threatening traumatic bleeding. A survey was conducted to determine current LTOWB utilization and interest in participation in a randomized control trial (RCT) of LTOWB versus standard blood component transfusion in this population.

STUDY DESIGN AND METHODS

Transfusion medicine (TM) directors and pediatric trauma directors at 36 US children's hospitals were surveyed by e-mail in June 2020. Hospitals were selected by participation in the Massive Transfusion Epidemiology and Outcomes in Children Study or being among the largest 30 children's hospitals by bed capacity per the Becker Hospital Review.

RESULTS

The response rate was 83.3% (30/36) from TM directors and 88.9% (32/36) from trauma directors. The median of massive transfusion protocol activations for traumatic bleeding was reported as 12 (IQR 5.8-20) per year by TM directors. LTOWB was used by 18.8% (6/32) of trauma directors. Survey responses indicate that 86.7% (26/30) of TM directors and 90.6% (29/32) of trauma directors either moderately or strongly agree that a LTOWB RCT is important to perform. About 83.3% (25/30) of TM directors and 93.8% (30/32) of trauma directors were willing to participate in the proposed trial. About 80% (24/30) of TM directors and 71.9% (23/32) of trauma directors would transfuse RhD+ LTOWB to male children, but fewer would transfuse Rh + LTOWB to females [20% (6/30) TM directors and 37.5% (12/32) of trauma directors].

CONCLUSIONS

A majority of respondents supported an RCT comparing LTOWB to component therapy in children with severe traumatic bleeding.

A whole blood based resuscitation strategy in civilian medical services: Experience from a Norwegian hospital in the period 2017-2020

BACKGROUND

Civilian and military guidelines recommend early balanced transfusion to patients with life-threatening bleeding. Low titer group O whole blood was introduced as the primary blood product for resuscitation of massive hemorrhage at Haukeland University Hospital, Bergen, Norway, in December 2017. In this report, we describe the whole blood program and present results from the first years of routine use.

STUDY DESIGN AND METHODS

Patients who received whole blood from December 2017 to April 2020 were included in our quality registry for massive transfusions. Post-transfusion blood samples were collected to analyze isohemagglutinin (anti-A/-B) and hemolysis markers. Administration of other blood products, transfusion reactions, and patient survival (days 1 and 30) were recorded. User experiences were surveyed for both clinical and laboratory staff.

RESULTS

Two hundred and five patients (64% male and 36% female) received 836 units in 226 transfusion episodes. Patients received a mean of 3.7 units (range 1-35) in each transfusion episode. The main indications for transfusion were trauma (26%), gastrointestinal (22%), cardiothoracic/vascular (18%), surgical (18%), obstetric (11%), and medical (5%) bleeding. There was no difference in survival between patients with blood type O when compared with non-group O. Haptoglobin level was lower in the transfusion episodes for non-O group patients, however no clinical hemolysis was reported. No patients had conclusive transfusion-associated adverse events. Both clinical and laboratory staff preferred whole blood to component therapy for massive transfusion.

DISCUSSION

The experience from Haukeland University Hospital indicates that whole blood is feasible, safe, and effective for in-hospital treatment of bleeding.

Coagulation function of never frozen liquid plasma stored for 40 days

BACKGROUND

Never frozen liquid plasma (LP) has limited shelf life versus fresh frozen plasma (FFP) or plasma frozen within 24 h (PF24). Previous studies showed decreasing factor activities after Day (D)14 in thawed FFP but no differences between LP and FFP until D10. This study examined LP function through D40.

STUDY DESIGN AND METHODS

FFP and PF24 were stored at -20°C until assaying. LP was assayed on D5 then stored (4°C) for testing through D40. A clinical coagulation analyzer measured Factor (F)V, FVIII, fibrinogen, prothrombin time (PT), and activated partial thromboplastin time (aPTT). Thromboelastography (TEG) and thrombogram measured functional coagulation. Ristocetin cofactor assay quantified von Willebrand factor (vWF) activity. Residual platelets were counted.

RESULTS

FV/FVIII showed diminished activity over time in LP, while PT and aPTT both increased over time. LP vWF declined significantly by D7. Fibrinogen remained high through D40. Thrombin lagtime was delayed in LP but consistent to D40, while peak thrombin was significantly lower in LP but did not significantly decline over time. TEG R-time and angle remained constant. LP and PF24 (with residual platelets) had initially higher TEG maximum amplitudes (MA), but by D14 LP was similar to FFP.

CONCLUSION

Despite significant declines in some factors in D40 LP, fibrinogen concentration and TEG MA were stable suggesting stored LP provides fibrinogen similarly to frozen plasmas even at D40. LP is easier to store and prepare for prehospital transfusion, important benefits when the alternative is crystalloid.

Knowledge Level, Motivators and Barriers of Blood Donation among Students at Qatar University

In Qatar, one out of every ten patients admitted to the hospitals is in urgent need of a blood transfusion or blood products. The aims of this study are as follows: (1) to assess the level of awareness and knowledge about blood donation and (2) to identify the factors that contribute to the willingness to donate blood among young adults. A cross-sectional survey using a constructed questionnaire was conducted among students at Qatar University. A total of 590 responses were collected, out of which 423 were suitable for analysis. Only 72 out of 472 (15%) participants were blood donors. The chi-square test and t-test were then used to study the association of blood donation status with different factors. Significant values were considered to be p ≤ 0.5. Gender and age were found to be significantly associated with blood donation status, with a higher frequency of donation among males and adults above the age of 24 years old. On the other hand, the total knowledge score was found to not be significantly associated with blood donation status with a mean score of 60.5% for both groups (blood donors, non-blood donors). The most common motivators that encouraged blood donors were donating to help people, followed by having a blood mobile unit come to your place, whereas the most common barriers reported by non-blood donors were failing to meet the requirements, followed by "never having been asked to give blood". This is the first study in Qatar to assess blood donation status. It provides insights that would help in developing effective strategies for the recruitment and retention of young adult blood donors in Qatar and countries with similar cultures. Raising awareness about blood donation, along with providing more mobile blood donation units at public places, will aid in increasing the frequency of blood donation among young adults.

Whole Blood, Fixed Ratio, or Goal-Directed Blood Component Therapy for the Initial Resuscitation of Severely Hemorrhaging Trauma Patients: A Narrative Review

This narrative review explores the pathophysiology, geographic variation, and historical developments underlying the selection of fixed ratio versus whole blood resuscitation for hemorrhaging trauma patients. We also detail a physiologically driven and goal-directed alternative to fixed ratio and whole blood, whereby viscoelastic testing guides the administration of blood components and factor concentrates to the severely bleeding trauma patient. The major studies of each resuscitation method are highlighted, and upcoming comparative trials are detailed.

The Role of α1-Microglobulin (A1M) in Erythropoiesis and Erythrocyte Homeostasis-Therapeutic Opportunities in Hemolytic Conditions

α₁-microglobulin (A1M) is a small protein present in vertebrates including humans. It has several physiologically relevant properties, including binding of heme and radicals as well as enzymatic reduction, that are used in the protection of cells and tissue. Research has revealed that A1M can ameliorate heme and ROS-induced injuries in cell cultures, organs, explants and animal models. Recently, it was shown that A1M could reduce hemolysis in vitro, observed with several different types of insults and sources of RBCs. In addition, in a recently published study, it was observed that mice lacking A1M (A1M-KO) developed a macrocytic anemia phenotype. Altogether, this suggests that A1M may have a role in RBC development, stability and turnover. This opens up the possibility of utilizing A1M for therapeutic purposes in pathological conditions involving erythropoietic and hemolytic abnormalities. Here, we provide an overview of A1M and its potential therapeutic effect in the context of the following erythropoietic and hemolytic conditions: Diamond-Blackfan anemia (DBA), 5q-minus myelodysplastic syndrome (5q-MDS), blood transfusions (including storage), intraventricular hemorrhage (IVH), preeclampsia (PE) and atherosclerosis.