Re-introducing whole blood for transfusion: considerations for blood providers.

Whole blood is the original blood preparation but disappeared from the blood bank inventories in the 1980s following the advent of component therapy. In the early 2000s, both military and civilian practice called for changes in the transfusion support for massive haemorrhage. The 'clear fluid' policy was abandoned and replaced by early balanced transfusion of platelets, plasma and red cells. Whole blood is an attractive alternative to multi-component therapy, which offers reduced hemodilution, lower donor exposure and simplified logistics. However, the potential for wider re-introduction of whole blood requires re-evaluation of haemolysins, storage conditions and shelf-life, the need for leucocyte depletion/ pathogen reduction and inventory management for blood providers. This review addresses these questions and calls for research to define the optimal whole blood product and the indications for its use.

Preparation of leukoreduced whole blood for transfusion in austere environments; effects of forced filtration, storage agitation, and high temperatures on hemostatic function.

BACKGROUND: Damage control resuscitation principles advocate the use of blood to treat traumatic hemorrhage. Hemorrhage is a leading cause of preventable death on the battlefield, but making blood components available far forward presents logistical challenges due to shelf life and storage requirements. Whole blood simplifies logistics and enables collection in the field but can cause leukocyte-related transfusion reactions. A field-adapted leukoreduction system must be fast and safe, and storage of whole blood should preserve hemostatic function. METHODS: Blood was collected using Imuflex WB-SP and leukoreduced at 0, 150, or 300 mm Hg. Additional bags were stored at 4°C for 21 days unagitated, mixed daily, agitated or head-over-heel rotated, at 22°C for 3 days, or 32°C for 2 hours. Hematology, coagulation, CD62P/CD42b, thromboelastography (TEG)/thromboelastometry (ROTEM), and Multiplate was performed. RESULTS: Filtration time was 35 ± 1, 14 ± 0, and 9 ± 0 minutes at 0, 150, and 300 mm Hg, respectively. One of 10 units at 150 mm Hg and 4 of 11 at 300 mm Hg had residual whole blood cells greater than 5.0 × 10 per unit. One of 11 at 300 mm Hg had platelet recovery of less than 80%. Hemolysis was less than 0.2%. Filtration decreased thromboelastography/thromboelastometry and Multiplate aggregation response. Stored at 4°C, α and MA/MCF moderately decreased regardless of mixing. Significant loss of aggregation response and increased CD62P expression was seen by Day 10. By Day 3, storage at 22°C caused loss of most aggregation. Two-hour storage at 32°C did not significantly affect hemostatic capacity. CONCLUSION: Forced filtration reduced leukoreduction time, but increased residual whole blood cells reduced hemostatic function. Aggregation response deteriorated early in storage, while viscoelastic assays decreased more gradually. Mixing showed no benefits. LEVEL OF EVIDENCE: Diagnostic study, level IV.

Staff officers as blood suppliers: Effects of repeated donations and autologous reinfusions of untransfused units.

BACKGROUND: Limited blood inventory and resupply chains in combat settings can result in preventable deaths from traumatic hemorrhage. One way of mitigating this could be to establish donor pools where blood is collected in advance of high-risk missions and then reinfused back to the donor if not needed to treat casualties. METHODS: Four hundred fifty milliliters plus 56 mL of blood was collected, rested for 2 hours in room temperature, and stored at 4°C. The blood was reinfused 22 to 24 hours after donation and the donor observed for adverse reactions. Samples were collected before and 20 minutes after each donation for hematology, immunoglobulin G, ferritin, C-reactive protein, total protein, lactate dehydrogenase, bilirubin, haptoglobin, and activated partial thromboplastin time. RESULTS: Nine participants went through a total of 36 donation and reinfusion procedures. Four donors participated in five rounds, two in four rounds, two in three rounds, and one in two rounds. A significant drop was seen in hemoglobin (14.6 ± 0.9 to 13.9 ± 0.9) and ferritin (179 ± 70 to 149 ± 78) from before the first donation to after the last reinfusion (p < 0.05). Other parameters were unaffected. CONCLUSION: This small pilot study suggests that repeated donations and reinfusions may be both feasible and safe. Blood collected in this way should be labeled with the donor's full name and social security number (or similar) and the identity visually verified by the donor immediately before both donation and reinfusion. To further reduce risk, this form of donation should be restricted to scenarios where there is no other option for making blood available. LEVEL OF EVIDENCE: Therapeutic/Care management study, level V.

Freeze dried plasma and fresh red blood cells for civilian prehospital hemorrhagic shock resuscitation.

BACKGROUND: The last decade of military trauma care has emphasized the role of blood products in the resuscitation of hemorrhaging patients. Damage-control resuscitation advocates decreased crystalloid use and reintroduces blood components as primary resuscitative fluids. The systematic use of blood products have been described in military settings, but reports describing the use of freeze dried plasma (FDP) or red blood cells (RBCs) in civilian prehospital care are few. We describe our preliminary results after implementing RBCs and FDP into our Helicopter Emergency Medical Service (HEMS). METHODS: We collected data on the use of FDP (LyoPlas N-w (AB)) during a 12-month period from May 31, 2013, to May 30, 2014, before RBC (0Rh (D) negative) introduction in June 2014. FDP and RBCs were indicated in trauma and medical patients presenting with clinical significant hemorrhage on scene. Data were obtained from HEMS registry and patient records. RESULTS: Our preliminary results show that FDP was used in 16 patients (88% males) during the first year. Main patient categories were blunt trauma (n = 5), penetrating trauma (n = 4), and nontrauma (n = 7). Ten patients (62%) were hypotensive with systolic blood pressures less than 90 mm Hg on scene. The majority (75%) received tranexamic acid. Of 14 patients admitted to the hospital, 11 received emergency surgery and 8 needed additional transfusions within the first 24 hours. No transfusion-related complications were recorded. Two of the FDP patients died on scene, and the remaining 14 patients were alive after 30 days. Early results from the recent introduction of RBC show that RBCs were given to four patients. Two patients (one penetrating trauma and one blunt trauma patient) died on scene because of exsanguination, while additional two patients (one blunt trauma patient and one with ruptured aortic aneurism) survived to hospital discharge. CONCLUSION: Our small study indicates that introduction of FDP into civilian HEMS seems feasible and may be safe and that logistical and safety issues for the implementation of RBCs are solvable. FDP ensures both coagulation factors and volume replacement, has a potentially favorable safety profile, and may be superior to other types of plasma for prehospital use. Further prospective studies are needed to clarify the role of FDP (and RBCs) in civilian prehospital hemorrhagic shock resuscitation and to aid the development of standardized protocols for prehospital use of blood products. LEVEL OF EVIDENCE: Therapeutic study, level V.

Coagulation function of stored whole blood is preserved for 14 days in austere conditions: A ROTEM feasibility study during a Norwegian antipiracy mission and comparison to equal ratio reconstituted blood.

BACKGROUND: Formulation of a medical preparedness plan for treating severely bleeding casualties during naval deployment is a significant challenge because of territory covered during most missions. The aim of this study was to evaluate the concept of "walking blood bank" as a supportable plan for supplying safe blood and blood products. METHODS: In 2013, the Royal Norwegian Navy conducted antipiracy operations from a frigate, beginning in the Gulf of Aden and ending in the Indian Ocean. Crews were on 24-hour emergency alert in preparation for an enemy assault on the frigate. Under an approved command protocol, a "walking blood bank," using crew blood donations, was established for use on board and on missions conducted in rigid-hulled inflatable boats, during which freeze-dried plasma and leukoreduced, group O low anti-A/anti-B titer, cold-stored whole blood were stored in Golden Hour Boxes. Data demonstrating the ability to collect, store, and provide whole blood were collected to establish feasibility of implementing a whole blood-focused remote damage-control resuscitation program aboard a naval vessel. In addition, ROTEM data were collected to demonstrate feasibility of performing this analysis on a large naval vessel and to also measure hemostatic efficacy of cold-stored leukoreduced whole blood (CWB) stored during a period of 14 days. ROTEM data on CWB was compared with reconstituted whole blood. RESULTS: Drills simulating massive transfusion activation were conducted, in which 2 U of warm fresh whole blood with platelet sparing leukoreduction were produced in 40 minutes, followed by collection of two additional units at 15-minute increments. The ROTEM machine performed well during ship-rolling, as shown by the overlapping calculated and measured mechanical piston movements measured by the ROTEM device. Error messages were recorded in 4 (1.5%) of 267 tests. CWB yielded reproducible ROTEM results demonstrating preserved fibrinogen function and platelet function for at least 3.5 weeks and 2 weeks, respectively. The frequency of ROTEM tests were as follows: EXTEM (n = 88), INTEM (n = 85), FIBTEM (n = 82), and APTEM (n = 12). CWB results were grouped. Compared with Days 0 to 2, EXTEM maximum clot firmness was significantly reduced, beginning on Days 10 to 14; however, results through that date remained within reference ranges and were comparable with the EXTEM maximum clot firmness for the reconstituted whole blood samples containing Day 5 room temperature-stored platelets. CONCLUSION: A "walking blood bank" can provide a balanced transfusion product to support damage-control resuscitation/remote damage-control resuscitation aboard a frigate in the absence of conventional blood bank products. ROTEM analysis is feasible to monitor damage-control resuscitation and blood product quality. ROTEM analysis was possible in challenging operational conditions. LEVEL OF EVIDENCE: Therapeutic study, level V.

The lost art of whole blood transfusion in austere environments.

The optimal resuscitation fluid for uncontrolled bleeding and hemorrhagic shock in both pre- and in-hospital settings has been an ongoing controversy for decades. Hemorrhage continues to be a major cause of death in both the civilian and military trauma population, and survival depends on adequacy of hemorrhage control and resuscitation between onset of bleeding and arrival at a medical treatment facility. The terms far-forward and austere are defined, respectively, as the environment where professional health care providers normally do not operate and a setting in which basic equipment and capabilities necessary for resuscitation are often not available. The relative austerity of a treatment setting may be a function of timing rather than just location, as life-saving interventions must be performed quickly before hemorrhagic shock becomes irreversible. Fresh whole blood transfusions in the field may be a feasible life-saving procedure when facing significant hemorrhage.

Low frequency of anti-D alloimmunization following D+ platelet transfusion: the Anti-D Alloimmunization after D-incompatible Platelet Transfusions (ADAPT) study.

The reported frequency of D alloimmunization in D- recipients after transfusion of D+ platelets varies. This study was designed to determine the frequency of D alloimmunization, previously reported to be an average of 5 ± 2%. A primary anti-D immune response was defined as the detection of anti-D ≥ 28 d following the first D+ platelet transfusion. Data were collected on 485 D- recipients of D+ platelets in 11 centres between 2010 and 2012. Their median age was 60 (range 2-100) years. Diagnoses included: haematological (203/485, 42%), oncological (64/485, 13%) and other diseases (218/485, 45%). Only 7/485 (1·44%; 95% CI 0·58-2·97%) recipients had a primary anti-D response after a median serological follow-up of 77 d (range: 28-2111). There were no statistically significant differences between the primary anti-D formers and the other patients, in terms of gender, age, receipt of immunosuppressive therapy, proportion of patients with haematological/oncological diseases, transfusion of whole blood-derived or apheresis platelets or both, and total number of transfused platelet products. This is the largest study with the longest follow-up of D alloimmunization following D+ platelet transfusion. The low frequency of D alloimmunization should be considered when deciding whether to administer Rh Immune Globulin to D- males and D- females without childbearing potential after transfusion of D+ platelets.

Emergency whole-blood use in the field: a simplified protocol for collection and transfusion.

Military experience and recent in vitro laboratory data provide a biological rationale for whole-blood use in the treatment of exsanguinating hemorrhage and have renewed interest in the reintroduction of fresh whole blood and cold-stored whole blood to patient care in austere environments. There is scant evidence to support, in a field environment, that a whole blood-based resuscitation strategy is superior to a crystalloid/colloid approach even when augmented by a limited number of red blood cell (RBC) and plasma units. Recent retrospective evidence suggests that, in this setting, resuscitation with a full compliment of RBCs, plasma, and platelets may offer an advantage, especially under conditions where evacuation is delayed. No current evacuation system, military or civilian, is capable of providing RBC, plasma, and platelet units in a prehospital environment, especially in austere settings. As a result, for the vast minority of casualties, in austere settings, with life-threatening hemorrhage, it is appropriate to consider a whole blood-based resuscitation approach to provide a balanced response to altered hemostasis and oxygen debt, with the goal of reducing the risk of death from hemorrhagic shock. To optimize the successful use of fresh whole blood/cold-stored whole blood in combat field environments, proper planning and frequent training to maximize efficiency and safety will be required. Combat medics will need proper protocol-based guidance and education if whole-blood collection and transfusion are to be successfully and safely performed in austere environments. In this article, we present the Norwegian Naval Special Operation Commando unit-specific remote damage control resuscitation protocol, which includes field collection and transfusion of whole blood. This protocol can serve as a template for others to use and adjust for their own military or civilian unit-specific needs and capabilities for care in austere environments.

Comparison of in vitro responses to fresh whole blood and reconstituted whole blood after collagen stimulation.

BACKGROUND: In patients who have large bleeds, there is a tendency to transfuse more plasma and platelets than recommended in earlier guidelines, and accordingly many hospitals now provide "transfusion packages" with an intended red cell:platelet:plasma ratio of 1:1:1. The purpose of this study was to investigate in vitro functions of transfusion packs compared with fresh whole blood. MATERIAL AND METHODS: "Reconstituted whole blood" was prepared with the same ratio of red cells, platelets and plasma as used in local transfusion packages. The aggregation and thrombin-antithrombin complex formation responses to collagen stimulation of this reconstituted whole blood were compared with those of fresh whole blood. The storage time of red cells and platelets was varied in a systematic manner, giving nine different compositions of reconstituted whole blood that simulated transfusion packs. RESULTS: The responses varied significantly between whole blood and reconstituted whole blood -and between the reconstituted whole blood of different compositions. A significant decrease (p<0.005) in collagen-induced platelet count reduction was seen with increasing platelet and red blood cell age. Thrombin-antithrombin complex formation peaked in studies with platelets stored for 5 days. The red cells stored for the longest time induced the greatest thrombin-antithrombin complex formation. Fresh whole blood gives more consistent responses, and the aggregation response to collagen is stronger than in reconstituted whole blood. DISCUSSION: Our results indicate that in vitro responses of reconstituted whole blood vary substantially according to how long the red cells and platelets are stored for. As the responses obtained by testing whole blood are more consistent and usually stronger, the alternative use fresh whole blood in special conditions should not be excluded without further consideration.

Cytokine accumulation in photochemically treated and gamma-irradiated platelet concentrates during storage.

BACKGROUND: Photochemical treatment (PCT) for pathogen reduction of platelet concentrates (PCs) affects all cells containing DNA and/or RNA. Soluble mediators, which may cause transfusion reactions, are determined by the balance between secretion and/or cell destruction and binding and/or degradation. STUDY DESIGN AND METHODS: Ten double-dose single-donor leukoreduced PCs were split in two identical units. Two study arms were created: Study Arm A consisting of five PCT PCs with corresponding untreated control PCs and Study Arm B consisting of five PCT PCs with corresponding gamma-irradiated control PCs. PCs that had added PAS-III (Intersol) were treated with amotosalen and ultraviolet A light. Corresponding controls PCs, to which PAS-II (T-sol) were added, received no treatment or were gamma-irradiated before storage. Platelet (PLT)-derived (CCL5/RANTES, CXCL4/PF4, CCL3/MIP-1alpha, transforming growth factor [TGF]-beta, CXCL8/interleukin [IL]-8, IL-1beta) as well as white blood cell (WBC)-associated (IL-6, IL-10, IL-11, IL-12, tumor necrosis factor, interferon-gamma) cytokines were investigated by enzyme-linked immunosorbent assay and cytometric bead array during storage for up to 12 days. RESULTS: Independent of previous treatment we observed that all concentrates showed low levels of WBC-associated cytokines. PLT-derived cytokines were detected at higher levels and showed significant increase during storage. Statistical analysis showed lower PLT content per unit in PCT PCs, higher levels of activation variables in PCT PCs, and higher levels and accumulation rate of CCL5, CXCL4, TGF-beta, and CXCL8 in PCT PCs. CONCLUSION: PLTs are the main source of released cytokines during storage of untreated, gamma-irradiated, and PCT PCs. PCT may affect the level of PLT-derived cytokines in PCs. No additional reduction of WBC-associated cytokines were observed after PCT in prestorage leukoreduced PCs.