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

Abstract

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.

Changes in donor antibody titer levels over time in a military group O low‐titer whole blood program

“…It is known that anti‐A and ‐B titers decrease over time, but it was an unexpected finding that this decrease could be observed over only an approximately 18‐month period; a recent Danish study evaluated immunoglobulin (Ig)G and IgM titers of 56 non–group AB subjects over an approximately 1‐year period . In that study, each participant had their titer levels determined four times over a mean period of 43 weeks (range, 38–56 weeks) and it was found that the antibody titers over this period of time were generally stable with the majority of the repeat titers within one dilution of the initial measurement . The Danish study had fewer subjects than in the current study but they included groups A and B individuals, which this study did not evaluate.…”

“…The Armed Services Blood Program (ASBP) has defined a low‐titer donor to be one whose titers of both anti‐A and anti‐B are less than 256 by saline tube testing. Recent data suggest that the mean percentage of low‐titer donors in the US military is between 70% and 75% of the soldiers tested, which compares favorably with the percentage in the general population …”

Get ready: whole blood is back and it's good for patients

“…At last count, 19 leading trauma centers are using this approved product as their first line transfusion, with some starting prehospital (both ground and air ambulance) and continuing into the Emergency Department (ED) and Operating Room. Seheult and colleagues have been leaders in this civilian effort, along with a multinational group of collaborators …”

“…The Pittsburgh group instituted low titer group O WB (LTOWB) transfusion protocols in 2014 and has systematically documented their approach and outcomes in multiple studies over the last 4 years . In this issue of TRANSFUSION , Seheult and colleagues report a retrospective, observational study of their recent experience, performed in a rigorous fashion, with appropriate analysis and without overstating their results .…”

Immunologic risks of whole blood: ABO compatibility, D alloimmunization, and transfusion‐related acute lung injury

“…High‐titer units are processed into RBC units with a 21‐day shelf life . Other published whole blood titer thresholds include < 200, and < 256 …”