Whole Blood for Blood Loss: Hemostatic Resuscitation in Damage Control

Abstract

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.

The Pathophysiology and Management of Hemorrhagic Shock in the Polytrauma Patient

“…Leukoreduction of LTOWB does not appear to afford any distinct clinical benefit over non-leukoreduced units [ 122 ]. Additionally, resuscitation with whole blood may be a better option for exsanguinating hemorrhage in certain parts of the world where there is a lack of well-equipped blood banks and insufficient availability of blood products [ 123 ]. However, the percentage of all donors who are eligible to donate RhD-negative LTOWB (male, group O, RhD-negative, and have low titer anti-A and -B) is only 3% RhD-alloimmunization rate is approximately 21% [ 124 ].…”

Damage control in the emergency department, a bridge to life

“…In the hemodynamically unstable patient, both a common femoral vein and artery lines should be placed for intravenous access and blood pressure monitoring 21 , 22 ( Figure 2 ). Additionally, the institution’s massive transfusion protocol should be activated, which includes four units of red blood cells, four units of plasma, 1 unit of apheresis platelets reserve, 1g of tranexamic acid and 20 ml of 10% calcium gluconate that should be administered according to the coagulation status of the patient 23 . If during the initial resuscitation the systolic blood pressure of the patient reaches 80-90 mm Hg, a whole-body computed tomography (WBCT) should be done.…”

“…Se debe activar el protocolo de transfusión masiva. Este protocolo consta, en nuestros centros de referencia, de 4 unidades de glóbulos rojos, 4 unidades de plasma sin pruebas cruzadas y 1 reserva de aféresis de plaquetas que se administrará con 1 gr de ácido tranexámico en bolo y 20 ml de gluconato de calcio al 10% 23 . Si con la reanimación inicial se alcanzan cifras de presión arterial sistólica entre 80 y 90 mm Hg se podrá trasladar al paciente para la realización de la tomografía axial computarizada corporal total de trauma.…”

Damage control of peripheral vascular trauma - Don’t be afraid of axillary or popliteal fosses

“…Both femoral arterial and venous lines should be placed immediately for blood pressure monitoring and intravenous access. In hemodynamically unstable patients, damage control resuscitation via activation of the institution’s massive transfusion protocol should be initiated 17 .…”

“…Se deben colocar una línea femoral arterial y una venosa para el monitoreo de la presión arterial y el acceso intravenoso. En pacientes con inestabilidad hemodinámica se debe iniciar la resucitación de control de daños activando el protocolo de transfusión masiva 17 .…”