Prehospital low-titer cold-stored whole blood: Philosophy for ubiquitous utilization of O-positive product for emergency use in hemorrhage due to injury

Abstract

The mortality from hemorrhage in trauma patients remains high. Early balanced resuscitation improves survival. These truths, balanced with the availability of local resources and our goals for positive regional impact, were the foundation for the development of our prehospital whole blood initiative-using low-titer cold-stored O RhD-positive whole blood. The main concern with use of RhD-positive blood is the potential development of isoimmunization in RhD-negative patients. We used our retrospective massive transfusion protocol (MTP) data to analyze the anticipated risk of this change in practice. In 30 months, of 124 total MTP patients, only one female of childbearing age that received an MTP was RhD-negative. With the risk of isoimmunization very low and the benefit of increased resources for the early administration of balanced resuscitation high, we determined that the utilization of low-titer cold-stored O RhD-positive whole blood would be safe and best serve our community.

Survey of group A plasma and low‐titer group O whole blood use in trauma resuscitation at adult civilian level 1 trauma centers in the US

“…It is interesting that 51% of the centers that use LTOWB would administer RhD‐positive LTOWB to females of childbearing potential whose RhD‐type is either negative or unknown at the time of the transfusion. Perhaps this reflects the adoption of the findings of studies that demonstrated a survival benefit when blood products were administered early in the resuscitation, 6–9 that there are emerging data showing some benefits of transfusing LTOWB, 21–24 and a recognition that hemolytic disease of the fetus and newborn, while still a stressful and emotionally draining diagnosis, is now largely a manageable condition in many parts of the world 25–28 …”

Civilian walking blood bank emergency preparedness plan

“…LTOWB transfusion is becoming more common, albeit without randomized studies documenting efficacy. 2,16,[24][25][26][27][28][29][30][31][32] However, supply chain issues may complicate timely infectious disease testing. Emergency use of the WBB would not allow for the time (typically requiring 12-24 h after donation) required for complete infectious disease testing.…”

“…Our colleagues in San Antonio, Texas, are finalizing their planning; the Royal Caribbean Cruise liners have long utilized such a policy; and the transfusion authorities in Norway have already instituted such a plan and have activated it for several civilian emergencies. 2,4,[24][25][26][27][28][29][30] It is absolutely critical that the use of fresh EUWB described in this plan will be used only for patients with life-threatening bleeding, severe life-threatening anemia, or potentially profound thrombocytopenia. This is defined as a patient who is rapidly and severely bleeding where RBCs, plasma, and platelets are indicated, or anemia so severe as to cause significant signs of cardiovascular stress, or end-organ hypoxemia, and the patient is at risk of imminent death.…”

Mixed feelings about mixed‐field agglutination: A pathway for managing females of childbearing potential of unknown RhD‐type who are transfused RhD‐positive and RhD‐negative red blood cells during emergency hemorrhage resuscitation

“…The city of San Antonio, Texas, has RhD-positive LTOWB available on many of its emergency medical services' helicopters and ground ambulances. 7,8 Hospitals in other American cities are also implementing LTOWB as their first choice for resuscitating bleeding patients. [9][10][11] One potential logistical concern regarding LTOWB is the quandary of whether to provide RhD-positive or RhD-negative LTOWB to emergency medical services and trauma hospitals.…”

“…13 The patient's HLA type might also have a bearing on her RhD-alloimmunization potential. 14 Given that some emergency medical services and hospitals are using RhD-positive LTOWB to treat massively bleeding females of childbearing potential of unknown RhD type, [7][8][9][10][11] the situation will arise whereby mixed-field agglutination will be detected in RhD typing. Mixed-fieldagglutination is a situation whereby some RBCs are F I G U R E 1 Summary of steps to take when a female of childbearing potential of unknown RhD type has been transfused with both RhD positive and RhD negative red blood cells (RBCs)/low titer group O whole blood (LTOWB) before the type and screen sample is drawn.…”