Should warm fresh whole blood be first choice in acute massive hemorrhage in emergency conditions?

Abstract

Early management of rapid massive hemorrhage requires early administration of blood products and rapid surgical control of bleeding. Professionals in peripheral hospitals with limited resources often work under conditions similar to those in the military. Described in the present report are 3 cases in which warm fresh whole blood (WFWB) was used in patients with massive bleeding who presented to a peripheral hospital that had no blood products suitable for emergency conditions. Described first is the case of a 16-year-old female patient who underwent emergency cesarean section. The patient had massive bleeding from the uterus due to atony. Her hemoglobin (Hb) dropped to 3.5 g/dL. Six units of WFWB were transfused during surgery. Hemodynamic parameters and complete blood count (CBC) stabilized. She was transferred from the intensive care unit (ICU) to obstetrics on day 2 and was discharged on day 7. Described second is the case of a 35-year-old female patient who also underwent emergency cesarean section, and for whom massive bleeding was due to uterine atony. Hb dropped to 2 g/dL and hematocrit (HCT) to 5.4%. Nine units of WFWB were transfused, after which hemodynamic and laboratory parameters stabilized. The patient was extubated the following day, transferred from the ICU to obstetrics on day 3, and was discharged on day 8. Described third is the case of a 36-year-old male patient with stab injuries and hemorrhagic shock who underwent emergency surgery. The patient had injuries to the right renal artery and kidney. Nine units of WFWB were transfused due to continued hemorrhage during surgery. Following surgical control of bleeding and transfusion, hemodynamic parameters improved. The patient was transferred from the ICU on day 5 and discharged on day 10. WFWB transfusion nearly disappeared from civilian medicine after blood was separated into components, and whole blood is not usually available at blood banks. In massive transfusions, WFWB effectively replaces red blood cells (RBCs), platelets, plasma volume, and coagulation factors, while preventing hypothermia and dilutional coagulopathy. Blood components go through biochemical, biomechanical, and immunological changes during long storage, the duration of which affects both transfusion efficacy and associated risks. In the future, with the use of fast donor tests, fast ABO compatibility tests, platelet-sparing leukocyte filters, and developments in pathogen-decreasing technology, fresh whole blood (FWB) may be the first choice for massive transfusion. Future studies will reveal new procedures.

Application of pulsed arterial resuscitation in a rabbit model of hemorrhagic shock

“…[15,24] The direct supply of blood to the brain through the carotid tissues is beneficial to the recovery of vital medullary life functions, consequently improving the functioning of the central nervous system, especially that of the cortex and subcortical regions and thereby restoring the regulatory functions that were initially interfered with. [27,30] As the blood is infused under added arterial pressure, which does not rely on the function of the heart that is already fragile, the burden placed on the heart is relieved. Furthermore, because the infused arterial blood can directly flow into the coronary arteries, this also alleviates the myocardial ischemia and facilitates the recovery of cardiac function.…”

“…Furthermore, because the infused arterial blood can directly flow into the coronary arteries, this also alleviates the myocardial ischemia and facilitates the recovery of cardiac function. [27,30] The blood that flows through the aorta quickly enters the kidneys, gastrointestinal tract, and other organs, thus increasing the blood perfusion, protecting the function of the internal organs, and slowing down the systemic inflammatory response syndrome, as well as reducing the risks of intestinal bacterial translocation and intestinal endotoxemia. Because the transfused blood in the artery flows retrogradely, it forms turbulences in the large vessels (similar to ventricle turbulence), which helps to mix the blood thoroughly.…”

“…This helps reduce ischemia and reperfusion injury and can hence help reduce the risks of visceral and pulmonary edemas. [13,27,30] Moreover, the pressurized transfusion of arterial blood constantly stimulates the vessel walls, including the chemical receptors and baroreceptors of the aortic arch and carotid sinus. The reflex protection system of the body and the vagal reflex from the direct stimulation of blood on the arterial wall can result in a significant elevation of arterial pressure [29,31] and lead to high blood pressure at the arterial end of the capillaries, which helps reduce capillary congestion.…”

An analysis of outcomes for pediatric trauma warm fresh whole blood recipients in Iraq and Afghanistan

“…WFWB is typically used in emergency situations when blood products suitable for emergency conditions are not available, mostly in the austere setting. For massive transfusions, WFWB effectively replaces RBCs, platelets, plasma volume, and coagulation factors while preventing hypothermia and dilutional coagulopathy 11 . There is an increased risk of transmitting infectious agents when using WFWB over component blood.…”

“…For massive transfusions, WFWB effectively replaces RBCs, platelets, plasma volume, and coagulation factors while preventing hypothermia and dilutional coagulopathy. 11 There is an increased risk of transmitting infectious agents when using WFWB over component blood. However, for patients with life-threatening hemorrhage when component therapy is not available, the riskbenefit ratio for WFWB favors its use.…”