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whole-blood transfusion


LabLion

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The only previous listing on this topic was by SMILLER in 2017.

I wonder NOW has anyone moved to using STORED whole blood in a tertiary care urban hospital. 

The Story so far: Our supplier has an inventory of whole blood (some of which is used by the Fire dept or first responders at site of trauma). They would like the hospitals to use whole blood for massive transfusions and are trying to convince the surgeons about the advantages.

Question is: What are the advantages (if any). What are the disadvantages.

What would be the indication to use whole blood (instead of the massive transfusion protocol that we currently use). 

What about the logistics of matching blood types? (also I know most whole blood are obviously not leuko reduced).

I realize there are many questions, but  I appreciate your time and any response.

 

Thanks,

P.S. I just saw Jayinsat write updates about the conference in san antonio in 2019. I read the online presentions, but still didn't get convince about in hospital use of the product.

Lablion

 

Edited by LabLion
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A quick disadvantage is the need to ABO match, so just from an inventory standpoint, you're going to have to manage the fine balance in stock without wasting products by the end of the expiration date. How long do you keep the WB before storage and preservation becomes more difficult? Towards the end, would you end up separating it into components? Would you just be ordering low titer group Os?

Advantage that I've read is that the platelets contained in WB are kind of a "bonus" product compared to just issuing 1:1. Furthermore, one WB containing 3 different types of products essentially reduces donor exposure because the WB is only from one source. Whether that can therefore reduce immunological responses and antibody formation is another question.

There was a review published in December of 2018 that outlines some of your bullet points: Massive transfusion of low-titer cold-stored O-positive whole blood in a civilian trauma setting. Transfusion, Epub Dec 27, 2018.

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21 hours ago, LabLion said:

 

Thanks,

P.S. I just saw Jayinsat write updates about the conference in san antonio in 2019. I read the online presentions, but still didn't get convince about in hospital use of the product.

Lablion

 

That particular recent thread has a lot of information on it.  Interesting points of view and references to several papers.  Notably, Dr.Neil Blumberg has some pretty persuasive rhetoric for whole blood use in trauma situations.  However, like you, I wonder at the practicality of such a system compared with our current practices.

Scott

Edited by SMILLER
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As long as the low titer whole blood is really low titer (say <50 or so; not 200), I don't see any major disadvantage in using low titer group O whole blood for trauma patients of unknown ABO type.  For those of known ABO type, ABO identical is no doubt preferable, whether whole blood or components.  We really don't have any comparative data except in trauma patients of unknown ABO type.  Comparisons of ABO identical components versus low titer group O whole blood for everyone are simply not available in any form, to my knowledge.  Would make a very important and useful randomized trial, but no one seems particularly interested in doing the work and incurring the expense, including the military who have sponsored most of this work.  Lots of assumptions being made, but not much data at present.  We know AB plasma given to group O recipients (about 45% of trauma transfusions) is associated with a significant increase in mortality from Swedish national data, so perhaps group O whole blood, if low titer, may actually be safer than traditional component resuscitation in patients of unknown ABO type.  At least the 45% of patients are group O will be getting ABO identical instead of the 5% now occurring (thanks to our giving AB plasma to everyone).

Edited by Neil Blumberg
fix inaccuracy
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Thank you Ward_X, SMiller and Dr. Blumberg for your time and reply.

I Agree with the above: There is so much extrapolation and assumptions involved in the decision to use Low titer O group in Hospital settings.  Like for e.g. the proponents are showing military data as evidence, but the military uses WARM Fresh whole blood.  Secondly, data is about penetrative trauma and whole blood is giving at site or within the golden hour.  Urban hospital settings are so much different.  Third, the proponents claim success of programs at Utah, Pittsburg, Mayo etc. However, so many questions (see below) are unexplored or unanswered. 

 

I agree with SMILLER about practicality of use. If one were to set up Low titer whole blood: 

1). In which scenarios or patients would you use? (trauma or other massive bleed?, penetrative trauma vs blunt trauma, is there a time limit within which it has the best beneficial effect? What sex and age group to use for?

2) What titer is acceptable? IgM and IgG, whether the titers are done in viv from Patients draw or from the unit, whether the titer is historical or done every time the donor donates?

3) what anticoagulant is used for storage....whether titers should be different for different volumes of anticoagulant (dilutional effects?)

4). Leukoreduction?

5). Is old whole blood (>14 days) as beneficial as fresh cold whole blood (1-14 days) or as WARM whole blood?

Too many questions :(

But the most significant if wish to explore is, How to set up hospital criteria to issue whole blood?

 

Thanks again for you insights and time.

Lablion

 

 

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If there is anyone who has implemented the use of Group O LTWB for trauma that would be willing to share SOP?  How are you monitoring recipients for adverse reactions to incompatible plasma? What types of patients are approved to get stored WB transfusions?  What happens to the unit if not used - do you manufacture RBC or waste the units?  Do you use O+ or O Neg (or both)?  Do you have a set limit on the number of units a patient can receive while the ABO/Rh type is unknown?

My trauma surgeons are pushing hard to move forward with the plan to implement, blood supplier is willing to provide product but I have lots of questions and not a lot of resources and don't want to reinvent the wheel.

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In response to LabIon:

1) Currently, the most experience with Low titer group O whole blood is in massively bleeding trauma patients.  There is ongoing investigation to see if this product can be used in massive obstetric bleeding, cardiac surgery or other. It is important to remember that the utilization of this whole blood came  from military experience.  In addition much of the Whole blood used was group specific and warm.  This is because refrigeration in some theaters is non-existent.  the military does HIV, HCV and HBV testing on all service people periodically (every 3-4 months) in order to prevent transmission of these bugs for "walking donors".

Hospitals are providing cold stored whole blood.

1.a. Adults at this time.  experience is limited.

2) Titers are for anti-A and anti-B. The titer should be decided with the imput from the traua team, pathologists and the transfusion committee.  1:100 seems fairly common. The actual procedure for titration has not been standardized though.   In addition some use 1:256.  If you like history and references try : Tisdall LH, Garlane DM, Szanto PB et al. The effects of the transfusion of group O blood of high iso-agglutinin titer into recipients of other blood groups. Medial Corps, Army of the United States, from The army Whole Blood Procurement Service, New York, NY.  https://academic.oup.com/ajcp/article-abstract/16/3/193/1761149

3) Whole blood can only be collected in bags with CPD (21 day expiration) or CPDA-1 (35 day shelf life).  If interested in getting the biggest platelet response, it seems that platelet function drops significantly after day 14 of storage.

4) There is only one FDA approved leukocyte reduction filter that "spares" platelets.  One of my colleagues has looked at platelet function following filtration with these bags and thinks that they are damaged by the filtration process, thus uses unfiltered units.  Others do leukocyte reduce. Your mileage may vary.

5) Because you are not releasing the WB for transfusion until infectious disease testing is complete the unit needs to be stored at 1-6C.

Use of this product is in its infancy.  Stay tuned for new developments.

Hope this helps.

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On 7/18/2019 at 8:53 AM, LabLion said:

Thank you Ward_X, SMiller and Dr. Blumberg for your time and reply.

I Agree with the above: There is so much extrapolation and assumptions involved in the decision to use Low titer O group in Hospital settings.  Like for e.g. the proponents are showing military data as evidence, but the military uses WARM Fresh whole blood.  Secondly, data is about penetrative trauma and whole blood is giving at site or within the golden hour.  Urban hospital settings are so much different.  Third, the proponents claim success of programs at Utah, Pittsburg, Mayo etc. However, so many questions (see below) are unexplored or unanswered. 

 

I agree with SMILLER about practicality of use. If one were to set up Low titer whole blood: 

1). In which scenarios or patients would you use? (trauma or other massive bleed?, penetrative trauma vs blunt trauma, is there a time limit within which it has the best beneficial effect? What sex and age group to use for?

2) What titer is acceptable? IgM and IgG, whether the titers are done in viv from Patients draw or from the unit, whether the titer is historical or done every time the donor donates?

3) what anticoagulant is used for storage....whether titers should be different for different volumes of anticoagulant (dilutional effects?)

4). Leukoreduction?

5). Is old whole blood (>14 days) as beneficial as fresh cold whole blood (1-14 days) or as WARM whole blood?

Too many questions :(

But the most significant if wish to explore is, How to set up hospital criteria to issue whole blood?

 

Thanks again for you insights and time.

Lablion

 

 

South Texas seems to be the vanguard on this issue.  It is worth time reading through their information at www.strac.org/blood.  In response to Lablion's points:

Leukoreduction reduces platelet function drastically on whole blood therefore it is not leuko reduced.

Some data suggests that platelet function rapidly deteriorates after 21 days in CPD.  However, STRAC's data shows the units are adequate up to 28 days with CPD-A1

Titers on our donors are < 1:250.

All of these questions were addressed in depth at the National Whole Blood Summit.  I think we will all be feeling the push.  I can tell you from personal experience, its use pre-hospital (ambulances, air life helicopters) have been very successful.  By the time patients arrive, the transfusion need is minimal if at all!  Use in hospital is pretty much for to continue care and rotate out expiring units.  Wastage has been > 30% when used pre-hospital alone.

 

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"Leukoreduction reduces platelet function drastically on whole blood therefore it is not leuko reduced."

I don't believe the word drastically is correct.  The differences are slight and, as I recall, only in platelet aggregation, which has no known relationship to clinical efficacy of platelet transfusions.  Absence of leukoreduction will almost certainly increase the risk of nosocomial infection, multi-organ failure and mortality for the patients who survive the hemorrhagic emergency.  In addition, non-leukoreduced whole blood will have higher levels of hemolysis in vitro and likely in the patient due to damage to the red cells. Free hemoglobin, heme and iron levels in the patient are associated with increased mortality in recipients of transfusions. I would suggest the choice not to leukoreduce will cause net harm to patients.  The minimal changes, if any are of clinical relevance, in platelet efficacy are not worth the risk, in my opinion, of well documented complications of allogeneic leukocyte infusion.

Edited by Neil Blumberg
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On 7/25/2019 at 7:23 AM, Neil Blumberg said:

I don't believe the word drastically is correct. 

True for the first 14 days in CPD or CPD A-1 according to STRAC's literature.  Our supplier go with a 28 day expiration and, with leukoreduction, even with at platelet-sparing filter, the platelet function (as measured by thromboelastography) is significantly diminished.  

Keep in mind, these are the conclusions of STRAC and our blood supplier.  We are not using it yet because of many of the concerns you and others have mentioned.  What is being pushed is non-leukoreduced for longer shelf life and platelet activity.

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Thanks all for the good discussion.

I would like to point that STRAC is NOT a transfusion related service, and their data is primarily based on outcomes of ambulance and air care patients. How many of such patients have hemolysis, and morbidity related to all things Dr. Blumberg points out, is neither studied OR reported properly. 

Secondly, I believe (I may be wrong ;) that STRAC is involved in and researches whole blood transfusion in trauma settings.  Whereas we are talking about using whole blood in in-hospital and L&D settings which it totally different and uninvestigated. 

Hence, I used the words "extrapolation" and "assumptions" at the begining of this thread. What I meant is, STRAC is extrapolation data from Military, and Hospitals are trying to extrapolate from data from Ambulances and fire fighters. 

Lablion

Edited by Cliff
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On 7/26/2019 at 5:13 PM, LabLion said:

Thanks all for the good discussion.

I would like to point that STRAC is NOT a transfusion related service, and their data is primarily based on outcomes of ambulance and air care patients. How many of such patients have hemolysis, and morbidity related to all things Dr. Blumberg points out, is neither studied OR reported properly. 

Secondly, I believe (I may be wrong ;) that STRAC is involved in and researches whole blood transfusion in trauma settings.  Whereas we are talking about using whole blood in in-hospital and L&D settings which it totally different and uninvestigated. 

Hence, I used the words "extrapolation" and "assumptions" at the begining of this thread. What I meant is, STRAC is extrapolation data from Military, and Hospitals are trying to extrapolate from data from Ambulances and fire fighters. 

Lablion

You are absolutely correct Lablion, which is why our transfusion services medical director put the brakes on our implementation just last week.  

From our perspective, it seems that the push to use whole blood after arrival at the hospital is to decrease waste and continue treatment with like product. 

I want to underscore that pre-hospital whole blood use has been a positive change.  We had a patient arrive by helicopter last night from a rural area that received 2 units of LTOWB en route.  The patient would not have survived the trip without it and it turned what would have been a massive transfusion activation into a semi-routine (but emergent) transfusion.

Edited by jayinsat
grammar and spelling
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