Cold-stored whole blood: A better method of trauma resuscitation?

Abstract

BACKGROUND Cold-stored whole blood (CWB) provides a balance of red blood cells, plasma, and platelets in less anticoagulant volume than standard blood component therapy (BCT). We hypothesize that patients receiving CWB along with BCT have improved survival compared with patients receiving only BCT. METHODS We performed a dual-center case-match study of trauma patients who received CWB and BCT at two urban, Level-I Trauma Centers. Criteria to receive CWB included boys 16 years of older, women older than 50 years, SBP less than 90 mm Hg, and identifiable source of hemorrhage. We performed a 2:1 propensity match against any trauma patient who received 1 unit or greater of packed red cells during their initial trauma bay resuscitation. Endpoints included trauma bay mortality, 30-day mortality, laboratory values at 4 hours and 24 hours, and overall blood product utilization. Comparisons were made with Wilcoxon-ranked sum and Fisher's exact test, p less than 0.05 was significant. RESULTS Between both institutions, a total of 107 patients received CWB during the study period with 91 being matched to 182 BCT patients for analysis. Hemodynamic parameters of the patients in both groups at the time of presentation were similar. The CWB patients had higher mean hemoglobin (10 ± 2 g/dL vs. 11 ± 2 g/dL; p < 0.001) and hematocrit (29.2 ± 6.1% vs. 32.1 ± 5.8%; p < 0.001) at 24 hours. Importantly, trauma bay mortality was less in CWB patients (8.8% vs. 2.2%;p = 0.039). Thirty-day mortality was not different in CWB patients, and there were no differences in the total amount of blood products transfused at the 4-hour and 24-hour periods. CONCLUSION Cold-stored whole blood offers the benefit of a balanced resuscitation with improved trauma bay survival and higher mean hemoglobin at 24 hours. A larger, prospective study is needed to determine whether it has a longer-term survival benefit for severely injured patients. LEVEL OF EVIDENCE Therapeutic, level III.

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“…Nessen et al showed that, in the experience with Forward Surgical Teams (FSTs) in Afghanistan, use of FWB in addition to RBCs and FFP was associated with improved inhospital survival compared to RBCs and FFP alone 19 . Within the civilian sector, retrospective analyses suggest superiority or equivalence of WB with regards to mortality and overall blood product use [20][21][22][23] .…”

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“…Another recent study in two civilian level 1 trauma centers showed that injured patients resuscitated with CWB had higher hematocrits and decreased trauma bay mortality compared to those resuscitated with component therapy. However; there was no difference in total amounts of blood products transfused and no difference in 30-day mortality between these two groups (43). Chilled whole blood has been used to treat US combat casualties at the point of injury since 2016 and, according to US military clinical practice guidelines, is the preferred resuscitation product for pre-hospital transfusion (44).…”

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“…Historically, prehospital resuscitation by first responders for point‐of‐injury or en route care was restricted to crystalloid or colloid saline‐based solutions with the occasional adjunct such as tranexamic acid administered. Recently, much evidence has been put forth demonstrating the superiority of using blood and blood products for hemostatic resuscitation, especially in traumatic hemorrhage cases 5–9 . The military has made great strides in providing early resuscitation through programs such as the low titer group O whole blood (LTOWB) effort 10, 11 which is now propagating into the civilian realm 12, 13 …”

“…Recently, much evidence has been put forth demonstrating the superiority of using blood and blood products for hemostatic resuscitation, especially in traumatic hemorrhage cases. [5][6][7][8][9] The military has made great strides in providing early resuscitation through programs such as the low titer group O whole blood (LTOWB) effort 10,11 which is now propagating into the civilian realm. 12,13 With the exception of the recent wars in the Middle East, blood rarely has been available pre-hospital in both civilian and military realms.…”