Whole blood for the acutely haemorrhaging civilian trauma patient: a novel idea or rediscovery?

A survey of low titer O whole blood use within the trauma quality improvement program registry

INTRODUCTION

The use of low titer O whole blood (LTOWB) has expanded although it remains unclear how many civilian trauma centers are using LTOWB.

METHODS

We analyzed data on civilian LTOWB recipients in the American College of Surgeons Trauma Quality Improvement Program (TQIP) database 2020-2021. Unique facility keys were used to determine the number of centers that used LTOWB in that period.

RESULTS

A total of 16,603 patients received LTOWB in the TQIP database between 2020 and 2021; 6600 in 2020, and 10,003 in 2021. The total number of facilities that reported LTOWB use went from 287/779 (37%) in 2020 to 302/795 (38%) in 2021. Between 2020 and 2021, among all level 1-3 designated trauma facilities that report to TQIP LTOWB use increased at level-1 centers (118 to 129), and level-2 centers (81 to 86), but decreased in level-3 facilities (9 to 4). Among pediatric and dual pediatric-adult designated hospitals there was a decrease in the number of pediatric level-1 centers (29 to 28) capable of administering LTOWB. Among centers with either single or dual level-1 trauma center designation with adult centers, the number that administered LTOWB to injured pediatric patients also decreased from 17 to 10, respectively.

CONCLUSIONS

There was an increase in the number of facilities transfusing LTOWB between 2020 and 2021. The use of LTOWB is underutilized in children at centers that have it available. These findings inform the expansion of LTOWB use in trauma.

Time to Whole Blood Transfusion in Hemorrhaging Civilian Trauma Patients: There Is Always Room for Improvement

BACKGROUND

Whole blood (WB) is becoming the preferred product for the resuscitation of hemorrhaging trauma patients. However, there is a lack of data on the optimum timing of receiving WB. We aimed to assess the effect of time to WB transfusion on the outcomes of trauma patients.

STUDY DESIGN

The American College of Surgeons TQIP 2017 to 2019 database was analyzed. Adult trauma patients who received at least 1 unit of WB within the first 2 hours of admission were included. Patients were stratified by time to first unit of WB transfusion (first 30 minutes, second 30 minutes, and second hour). Primary outcomes were 24-hour and in-hospital mortality, adjusting for potential confounders.

RESULTS

A total of 1,952 patients were identified. Mean age and systolic blood pressure were 42 ± 18 years and 101 ± 35 mmHg, respectively. Median Injury Severity Score was 17 [10 to 26], and all groups had comparable injury severities (p = 0.27). Overall, 24-hour and in-hospital mortality rates were 14% and 19%, respectively. Transfusion of WB after 30 minutes was progressively associated with increased adjusted odds of 24-hour mortality (second 30 minutes: adjusted odds ratio [aOR] 2.07, p = 0.015; second hour: aOR 2.39, p = 0.010) and in-hospital mortality (second 30 minutes: aOR 1.79, p = 0.025; second hour: aOR 1.98, p = 0.018). On subanalysis of patients with an admission shock index >1, every 30-minute delay in WB transfusion was associated with higher odds of 24-hour (aOR 1.23, p = 0.019) and in-hospital (aOR 1.18, p = 0.033) mortality.

CONCLUSIONS

Every minute delay in WB transfusion is associated with a 2% increase in odds of 24-hour and in-hospital mortality among hemorrhaging trauma patients. WB should be readily available and easily accessible in the trauma bay for the early resuscitation of hemorrhaging patients.

In vitro comparison of CPD whole blood with conventional blood components

INTRODUCTION

Resuscitation of severely injured trauma patients is commonly performed using red blood cells in additive solution supplemented with plasma and platelet concentrates. There is an increasing interest in the use of low anti-A titer Group O whole blood (LTOWB) in the early management of the resuscitation. It is unclear whether clinical outcome is improved using this approach.

METHODS

Expired units of CPD-LTOWB were studied on Day 22 and expired units of thawed plasma on Day 6 and Day 7. LTOWB was assessed for hemoglobin content, clotting factor levels and platelet numbers and function using thromboelastography (TEG) and impedance aggregation. Assays of fibrinogen and FV, FVIII, FVII and FX were performed on the expired plasma. The LTOWB hemoglobin was compared to red cells in additive solution (AS-RBCs) and the clotting factor levels to those of expired thawed plasma. Platelet function was compared to fresh whole blood samples from healthy subjects.

RESULTS

LTOWB contained slightly more hemoglobin than the AS-RBCs (Medians, 66 v 59 G), and the plasma content of fibrinogen was similar. Other clotting factors were reduced by approximately 15% except for FVIII which was 30% less. Both TEG and impedance aggregometry showed evidence of residual platelet function despite the prolonged period of refrigerator storage.

CONCLUSION

LTOWB contains higher hemoglobin and adequate clotting factors, and residual platelet function is demonstrated indicating that this product would be expected to be at least equivalent to a single unit of each of the conventional components commonly used in trauma resuscitation.

Whole blood versus component therapy for haemostatic resuscitation of major bleeding: a protocol for a systematic review and meta-analysis

INTRODUCTION

There is a renewed interest in the use of whole blood (WB) to manage patients with life-threatening bleeding. We aimed to estimate mortality and complications risk between WB and blood component therapy for haemostatic resuscitation of major bleeding.

METHODS

We will conduct a systematic review and meta-analysis of studies published between 1 January 1980 and 1 January 2020, identified from PubMed and Scopus databases. Population will be patients who require blood transfusion (traumatic operative, obstetric and gastrointestinal bleeding). Intervention is WB transfusion such as fresh WB (WB unit stored for less than 48 hours), leukoreduced modified WB (with platelets removed during filtration), warm fresh WB (stored warm at 22°C for up to 8 hours and then for a maximum of an additional 24 hours at 4°C). The primary outcomes will be the 24-hour and 30-day survival rates (in-hospital mortality). Comparator is blood component therapy (red blood cells, fresh-frozen plasma and platelets given together in a 1:1:1 unit ratio). The Cochrane risk of bias tool for randomised controlled trials and Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) for observation studies will be used to assess the risk of bias of included studies. We will use random-effects models for the pooling of studies. Interstudy heterogeneity will be assessed by the Cochran Q statistic, where p<0.10 will be considered statistically significant and quantified by I² statistic, where I² ≥50% will indicate substantial heterogeneity. We will perform subgroup and meta-regression analyses to assess geographical differences and other study-level factors explaining variations in the reported mortality risk. Results will be reported as risk ratios and their 95% CIs.

ETHICS AND DISSEMINATION

No ethics clearance is required as no primary data will be collected. The results will be presented at scientific conferences and published in a peer-reviewed journal.

In vitro characteristics and in vivo platelet quality of whole blood treated with riboflavin and UVA/UVB light and stored for 24 hours at room temperature

BACKGROUND

There is a global increase in whole blood usage and at the same time, emerging pathogens give cause for pathogen reduction technology (PRT). The Mirasol PRT has shown promising results for plasma and platelet concentrate products. Treatment of whole blood with subsequent platelet survival and recovery analysis would be of global value.

STUDY DESIGN AND METHODS

A two-arm, open-label laboratory study was performed with 40 whole blood collections in four groups: non-leukoreduced non-PRT-treated, non-leukoreduced PRT-treated, leukoreduced non-PRT-treated, and leukoreduced PRT-treated. Leukoreduction and/or PRT-treatment was performed on the day of collection, then all WB units were stored at room temperature for 24 h. Sampling was performed after hold-time and after 24-h storage in RT. If PRT-treatment or leukoreduction, samples were also taken subsequently after treatment. Thirteen healthy volunteer blood donors completed the in vivo study per protocol. All WB units were non-leukoreduced and PRT-treated. Radioactive labeling of platelets from RT-stored, PRT-treated whole blood, sampling of subjects, recovery, and survival calculations were performed according to the Biomedical Excellence for Safer Transfusion Collaborative protocol.

RESULTS

In vitro characteristics show that PRT-treatment leads to increased levels of hemolysis, potassium, and lactate, while there are decreased levels of glucose, FVIII, and fibrinogen after 24 h of storage. All values are within requirements for WB. In vivo recovery and survival of platelets were 85.4% and 81.3% of untreated fresh control, respectively.

CONCLUSIONS

PRT-treatment moderately reduces whole blood quality but is well within the limits of international guidelines. Recovery and survival of platelets are satisfactory after Mirasol treatment.

Blood product needs and transfusion timelines for the multisite massive Paris 2015 terrorist attack: A retrospective analysis

OBJECTIVE

Hemorrhage is the leading cause of death after terrorist attack, and the immediacy of labile blood product (LBP) administration has a decisive impact on patients' outcome. The main objective of this study was to evaluate the transfusion patterns of the Paris terrorist attack victims, November 13, 2015.

METHODS

We performed a retrospective analysis including all casualties admitted to hospital, aiming to describe the transfusion patterns from admission to the first week after the attack.

RESULTS

Sixty-eight of 337 admitted patients were transfused. More than three quarters of blood products were consumed in the initial phase (until November 14, 11:59 PM), where 282 packed red blood cell (pRBC) units were transfused along with 201 plasma and 25 platelet units, to 55 patients (16% of casualties). Almost 40% of these LBPs (134 pRBC, 73 plasma, 8 platelet units) were transfused within the first 6 hours after the attack. These early transfusions were massive transfusion (MT) for 20 (6%) of 337 patients, and the average plasma/red blood cell ratio was 0.8 for MT patients who received 366 (72%) of 508 LBPs.The median time from admission to pRBC transfusion was 57 (25-108) minutes and 208 (52-430) minutes for MT and non-MT patients, respectively. These same time intervals were 119 (66-202) minutes and 222 (87-381) minutes for plasma and 225 (131-289) minutes and 198 (167-230) minutes for platelets.

CONCLUSION

Our data suggest that improving transfusion procedures in mass casualty setting should rely more on shortening the time to bring LBP to the bedside than in increasing the stockpile.

LEVEL OF EVIDENCE

Epidemiological study, Therapeutic IV.

The use of whole blood in traumatic bleeding: a systematic review

Hemostatic resuscitation is currently considered a standard of care for the management of life-threatening hemorrhage, but in some critical settings the access to high quantities of blood components is problematic. Whole blood (WB) transfusion has been proposed as an alternative modality for hemostatic resuscitation of traumatic major bleeding. To assess the efficacy and safety of WB in trauma-associated massive bleeding, we performed a systematic review of the literature. We selected studies comparing WB transfusions to transfusion of blood components (COMP) in massive trauma bleeding; both randomized clinical trial (RCT) and observational studies were considered. The outcomes were mortality (30-day/in-hospital and 24-h mortality) and adverse events/transfusion reactions. The effect sizes were crude odds ratio (OR), adjusted OR and hazard ratio (HR). The methodological quality of studies was assessed using the Cochrane Risk of Bias tool for RCTs, and the ROBIN-1 tool for observational studies. The overall quality of the available evidence was assessed with the GRADE system. One RCT (2 reports) and 6 cohort studies were included (3642 adult patients; 675 receiving WB, 2967 receiving COMP). Three studies were conducted in military setting, and 4 in civilian setting. In the overall analysis, 30-day/in-hospital and 24-h mortality did not differ significantly between groups (very low quality of the evidence due to high risk of bias, imprecision and inconsistency). After adjustment for baseline covariates in three cohort studies, the OR for mortality was significantly lower in WB recipients compared to COMP (OR 0.22; 95% CIs 0.10/0.45) (moderate grade of evidence). Adverse events and transfusion reactions were overlooked and not consistently reported. The available evidence does not allow to draw definite conclusions on the short-term and long-term efficacy and safety of WB transfusion compared to COMP transfusion. Further well designed research is needed.

Whole blood for blood loss: hemostatic resuscitation in damage control

Hemorrhagic shock and its complications are a major cause of death among trauma patients. The management of hemorrhagic shock using a damage control resuscitation strategy has been shown to decrease mortality and improve patient outcomes. One of the components of damage control resuscitation is hemostatic resuscitation, which involves the replacement of lost blood volume with components such as packed red blood cells, fresh frozen plasma, cryoprecipitate, and platelets in a 1:1:1:1 ratio. However, this is a strategy that is not applicable in many parts of Latin America and other low-and-middle-income countries throughout the world, where there is a lack of well-equipped blood banks and an insufficient availability of blood products. To overcome these barriers, we propose the use of cold fresh whole blood for hemostatic resuscitation in exsanguinating patients. Over 6 years of experience in Ecuador has shown that resuscitation with cold fresh whole blood has similar outcomes and a similar safety profile compared to resuscitation with hemocomponents. Whole blood confers many advantages over component therapy including, but not limited to the transfusion of blood with a physiologic ratio of components, ease of transport and transfusion, less volume of anticoagulants and additives transfused to the patient, and exposure to fewer donors. Whole blood is a tool with reemerging potential that can be implemented in civilian trauma centers with optimal results and less technical demand.

From battlefront to homefront: creation of a civilian walking blood bank

Hemorrhagic shock remains the leading cause of preventable death on the battlefield, despite major advances in trauma care. Early initiation of balanced resuscitation has been shown to decrease mortality in the hemorrhaging patient. To address transfusion limitations in austere environments or in the event of multiple casualties, walking blood banks have been used in the combat setting with great success. Leveraging the success of the region-wide whole blood program in San Antonio, Texas, we report a novel plan that represents a model response to mass casualty incidents.

Elicitation of prior probability distributions for a proposed Bayesian randomized clinical trial of whole blood for trauma resuscitation

BACKGROUND

Whole blood trauma resuscitation is conceptually appealing and increasingly used but lacks evidence. A randomized controlled trial is needed but challenging to design. A Bayesian approach might be more efficient and more interpretable than a conventional frequentist design. We report the results on an elicitation meeting to create prior probability distributions to help develop such a trial.

METHODS

In‐person expert elicitation meeting, based on Sheffield Elicitation Framework methodology. We used an interactive graphical tool to elicit the quantities of interest (24‐hour mortality and certainty required). Two rounds were conducted, with an intervening discussion of deidentified responses. Individual responses were aggregated into probability distributions.

RESULTS

Fifteen experts participated. The pooled belief was that the median 24‐hour mortality of trauma patients with hemorrhagic shock treated with component therapy (the current standard of care) was 19% (95% credible interval [CrI], 6%‐45%), and the median 24‐hour mortality of those treated with whole blood, 16% (95% CrI, 5%‐39%). The pooled prior distribution for the relative risk had a median of 0.84 (95% CrI, 0.26‐3.1), indicating that the expert group had a 64% prior belief that whole blood decreases 24‐hour mortality compared to component therapy.

CONCLUSIONS

Experts had moderately strong beliefs that whole blood reduces the 24‐hour mortality of trauma patients with hemorrhagic shock. These data will assist with the design and planning of a Bayesian trial of whole blood resuscitation, which will help to answer a key question in contemporary transfusion practice.

Whole Blood for Resuscitation in Adult Civilian Trauma in 2017: A Narrative Review

After a hiatus of several decades, the concept of cold whole blood (WB) is being reintroduced into acute clinical trauma care in the United States. Initial implementation experience and data grew from military medical applications, followed by more recent development and data acquisition in civilian institutions. Anesthesiologists, especially those who work in acute trauma facilities, are likely to be presented with patients either receiving WB from the emergency department or may have WB as a therapeutic option in massive transfusion situations. In this focused review, we briefly discuss the historical concept of WB and describe the characteristics of WB, including storage, blood group compatibility, and theoretical hemolytic risks. We summarize relevant recent retrospective military and preliminary civilian efficacy as well as safety data related to WB transfusion, and describe our experience with the initial implementation of WB transfusion at our level 1 trauma hospital. Suggestions and collective published experience from other centers as well as ours may be useful to those investigating such a program. The role of WB as a significant therapeutic option in civilian trauma awaits further prospective validation.

Use of Uncrossmatched Erythrocytes in Emergency Bleeding Situations

Transfusion of uncrossmatched erythrocytes is lifesaving in patients who are severely bleeding when crossmatched erythrocytes are unavailable. The hemolysis risk after uncrossmatched erythrocyte administration to appropriate patients is very low.

Damage Control Resuscitation

Damage control resuscitation (DCR) is a strategy for resuscitating patients from hemorrhagic shock to rapidly restore homeostasis. Efforts are focused on blood product transfusion with whole blood or component therapy closely approximating whole blood, limited use of crystalloid to avoid dilutional coagulopathy, hypotensive resuscitation until bleeding control is achieved, empiric use of tranexamic acid, prevention of acidosis and hypothermia, and rapid definitive surgical control of bleeding. Patients receiving uncrossmatched Type O blood in the emergency department and later receiving cumulative transfusions of 10 or more red blood cell units in the initial 24-hour post-injury (massive transfusion) are widely recognized as being at increased risk of morbidity and mortality due to exsanguination. Ideally, these patients should be rapidly identified, however anticipating transfusion needs is challenging. Useful indicators of massive transfusion reviewed in this guideline include: systolic blood pressure <110 mmHg, heart rate > 105 bpm, hematocrit <32%, pH < 7.25, injury pattern (above-the-knee traumatic amputation especially if pelvic injury is present, multi-amputation, clinically obvious penetrating injury to chest or abdomen), >2 regions positive on Focused Assessment with Sonography for Trauma (FAST) scan, lactate concentration on admission >2.5, admission international normalized ratio ≥1.2-1.4, near infrared spectroscopy-derived StO2 < 75% (in practice, rarely available), BD > 6 meq/L. Unique aspects of out-of-hospital DCR (point of injury, en-route, and remote DCR) and in-hospital (Medical Treatment Facilities: Role 2b/Forward surgical teams - role 3/ combat support hospitals) are reviewed in this guideline, along with pediatric considerations.

Hemostatic properties of cold-stored whole blood leukoreduced using a platelet-sparing versus a non-platelet-sparing filter

BACKGROUND

Whole blood (WB) is an appealing alternative to component-based transfusion in patients with significant bleeding. Historically, WB was transfused less than 48 hours after collection and was not leukoreduced (LR). However, LR components are now standard in many hospitals and LR WB is desirable. We investigated the effect of the type of LR filter used, as well as storage duration, on coagulation laboratory testing of WB.

STUDY DESIGN AND METHODS

Ten units of LR WB-5 units manufactured with a Food and Drug Administration (FDA)-approved platelet (PLT)-sparing filter (WB-PS) and 5 units manufactured with an FDA-approved non-PLT-sparing filter (WB-NPS)-underwent complete blood count, PLT function analyzer (PFA [PFA-100]), thromboelastography (TEG), prothrombin time (PT), partial thromboplastin time (PTT), Factor (F)V activity, chromogenic FVIII, thrombin generation, and microparticle quantification on Storage Days 3, 5, 7, 10, and 14.

RESULTS

WB-PS contains more PLTs than WB-NPS (mean, 71 × 10⁹ /L vs. 1 × 10⁹ /L, p < 0.001). WB-PS yielded essentially normal TEG tracings, while TEG tracings of WB-NPS were grossly abnormal (mean reaction time, 7.0 min for WB-PS vs. 9.7 min for WB-NPS, p < 0.001; mean alpha-angle 54.9° vs. 38.1°, p < 0.001; mean maximum amplitude, 54.9 mm vs. 13.9 mm, p < 0.001). PFA-100 closure was more common among units of WB-PS compared to units of WB-NPS (72% vs. 4%, p < 0.001). PT, PTT, and factor activities were not dramatically affected by the LR filter.

CONCLUSION

The choice LR filter has a major impact on the hemostatic properties of WB. Although storage of WB is associated with a rapid decline in PLT count, hemostasis as assessed by TEG and PFA-100 is not diminished over a 2-week storage period.

Whole Blood Transfusion

Whole blood is the preferred product for resuscitation of severe traumatic hemorrhage. It contains all the elements of blood that are necessary for oxygen delivery and hemostasis, in nearly physiologic ratios and concentrations. Group O whole blood that contains low titers of anti-A and anti-B antibodies (low titer group O whole blood) can be safely transfused as a universal blood product to patients of unknown blood group, facilitating rapid treatment of exsanguinating patients. Whole blood can be stored under refrigeration for up to 35 days, during which it retains acceptable hemostatic function, though supplementation with specific blood components, coagulation factors or other adjuncts may be necessary in some patients. Fresh whole blood can be collected from pre-screened donors in a walking blood bank to provide effective resuscitation when fully tested stored whole blood or blood components are unavailable and the need for transfusion is urgent. Available clinical data suggest that whole blood is at least equivalent if not superior to component therapy in the resuscitation of life-threatening hemorrhage. Low titer group O whole blood can be considered the standard of care in resuscitation of major hemorrhage.

Vox Sanguinis International Forum on the use of prehospital blood products and pharmaceuticals in the treatment of patients with traumatic haemorrhage

While specific practices and transported blood products vary around the world, most of the respondents in this International Forum transported at least one blood product for the transfusion to bleeding patients en route to the hospital. The most commonly carried product was RBCs, while the use of whole blood will likely increase given the recent reports of its successful use in the civilian setting, and because of the change in the AABB's Standards regulating its use. It will be interesting to see if plasma use in the prehospital setting becomes more widely used given today's enhanced appreciated of the coagulopathy of trauma and plasma's beneficial effect in reversing it, and if blood products are transported to the scene of injury by more vehicles, that is, not just predominantly in helicopters. It was not surprising that TXA is being widely administered as close to the time of injury as possible given its potential benefit in these patients. This International Forum highlights the importance of focusing attention on prehospital transfusion management with a need to further high‐quality research in this area to guide optimal resuscitation strategies.

Novel concepts for damage control resuscitation in trauma

PURPOSE OF REVIEW

Traumatic injuries are a major cause of mortality worldwide. Damage control resuscitation or balanced transfusion of plasma, platelets, and red blood cells for the management of exsanguinating hemorrhage after trauma has become the standard of care. We review the literature regarding the use of alternatives to achieve the desired 1 : 1:1 ratio as availability of plasma and platelets can be problematic in some environments.

RECENT FINDINGS

Liquid and freeze dried plasma (FDP) are logistically easier to use and may be superior to fresh frozen plasma. Cold storage platelets (CSPs) have improved hemostatic properties and resistance to bacterial contamination. Low titer type O whole blood can be transfused safely in civilian patients.

SUMMARY

In the face of hemorrhagic shock from traumatic injury, resuscitation should be initiated with 1 : 1 : 1 transfusion of plasma, platelets, and red blood cells with limited to no use of crystalloids. Availability of plasma and platelets is limited in some environments. In these situations, the use of low titer type O whole blood, thawed or liquid plasma, cold stored platelets or reconstituted FDP can be used as substitutes to achieve optimal transfusion ratios. The hemostatic properties of CSPs may be superior to room temperature platelets.

Safety profile of uncrossmatched, cold-stored, low-titer, group O+ whole blood in civilian trauma patients

BACKGROUND

The use of cold-stored low-titer group O whole blood (LTOWB) for civilian trauma patients is gaining popularity. However, hemolysis might occur among non-group O recipients. This study evaluated the serologic safety of transfusing up to 4 units of LTOWB.

STUDY DESIGN AND METHODS

Hypotensive male and at least 50-year-old female trauma patients who received leukoreduced, uncrossmatched, group O+, low-titer (<50 anti-A and anti-B), platelet-replete whole blood during initial resuscitation were included in this prospective, observational study. Biochemical markers of hemolysis were measured on the day of LTOWB receipt (Day 0) and over the next 2 days. Blood product administration in the first 24 hours of admission and reported transfusion-associated adverse events were also reviewed.

RESULTS

There were 102 non-group O and 70 group O recipients of 1 to 4 LTOWB units analyzed. The non-group O recipients received a median volume of 600 mL (range, 300-4100 mL) of ABO-incompatible plasma, including the contribution from the LTOWB units. There were no significant differences in median haptoglobin, lactate dehydrogenase, total bilirubin, creatinine, or potassium levels at any time point between the non-group O and group O recipients. There were also no differences in these markers between the subset of 23 non-group O and 14 group O recipients who received 3 or 4 LTOWB units. No transfusion-associated adverse events were reported.

CONCLUSIONS

Administration of up to 4 units of LTOWB in civilian trauma resuscitation was not associated with clinical or biochemical evidence of hemolysis. Six units per trauma patient are now permitted at these institutions.

How do I implement a whole blood program for massively bleeding patients?

Building on the successful military experience, interest has been rekindled in transfusing whole blood (WB) early in the resuscitation of traumatically injured civilians, often before their ABO group is known. WB efficiently provides treatment for shock and coagulopathy, as well as platelet hemostatic function, to patients losing large volumes of blood. Unlike group O uncrossmatched red blood cells (RBCs), group O WB contains a substantial amount of plasma, which is incompatible with the RBCs of all non-group O recipients. Thus, when implementing a WB program, it is important to decide how to mitigate the risk of immune-mediated hemolysis. Other questions that a hospital needs to answer before implementing a WB program include determining which patients will be eligible for this product, how many units eligible patients can receive, for how long it should be stored and under what conditions, and how to monitor for adverse events. The donor center needs to consider if the WB should be leukoreduced, how to comply with the AABB's transfusion-related acute lung injury risk mitigation standard, and into which storage solution it should be collected. This report describes the multidisciplinary approach taken to implementing a civilian WB program at a multihospital health care system in the United States.

Temperature-dependent haemolytic propensity of CPDA-1 stored red blood cells vs whole blood - Red cell fragility as donor signature on blood units

BACKGROUND

To preserve cellular integrity and avoid bacterial growth, storage and transfer of blood and blood products follow strict guidelines in terms of temperature control. We evaluated the impact of ineligible warming of whole blood donations on the quality of blood components.

MATERIALS AND METHODS

One-hundred and twenty units of whole blood (WB) from eligible blood donors were collected in CPDA-1 and stored at 4±2 °C. During shipment to the blood processing centre, a gradual warming up to 17 °C was recorded within a period of less than eight hours. The warmed units were processed to packed red blood cells (PRBCs) or stored as WB units at 4±2 °C. In-bag haemolysis, osmotic fragility (mean corpuscular fragility, MCF) and bacterial growth were assessed in blood and blood components throughout the storage period.

RESULTS

Normal basal and early storage levels of haemolysis were recorded in both PRBC and WB units. Thereafter, PRBCs exhibited higher average in-bag haemolysis and MCF index compared to the WB units throughout the storage. Moreover, 14.3 and 52.4% of the PRBC units exceeded the upper permissible limit of 0.8% haemolysis at the middle (1.220±0.269%) or late (1.754±0.866%) storage period, respectively. MCF index was similar in all PRBCs at the middle of storage but significantly lower in the non-haemolysed compared to the haemolysed units of PRBCs on the last days. The fragility of stored RBCs was proportional to the donor-related values of day 2 samples (r=0.861, p<10^-32). In the qualified PRBCs, MCF was correlated with haemolysis at every time point of the storage period (r=0.332, p<0.050). Bacterial growth was detected by blood culture in two units of PRBCs.

DISCUSSION

Transient, gradient warming of whole blood from 4 to 17 °C led to increased incidence of in-bag haemolysis in PRBC but not in WB units. Haemolysis is a multi-parametric phenotype of stored blood, and MCF is a donor-related and highly dynamic measure that can, in part, predict the storage lesion.