Use of Whole Blood in Massive Transfusions

[SMILLER]

The idea is that whole blood was always the best way to accommodate massively bleeding patients---plasma, RBCs and platelets all in one shot so to speak.  And that the common use of component therapy over the years is more due to convenience than otherwise. There have been a few retrospective studies out that seem to suggest that the use of whole blood in these patients leads to better outcomes.  On the other hand, maintaining an inventory of WB for the occasional massive transfusion patient seems impractical.   Here's one article:

http://www.mayoclinic.org/medical-professionals/clinical-updates/trauma/whole-blood-transfusions-reduce-mortality-in-massively-hemorrhaging-patients

I am curious if some of our more astute PathLabTalk associates have any opinions on this topic?

Thanks, Scott

[Dansket]

The US military has been a constant practitioner of the use of whole blood in trauma.

[John C. Staley]

I seem to remember a talk on this subject the last year I was able to attend the Blood Bank meeting in Ann Arbor, MI, by someone in the military.  He made a very convincing argument for the use of whole blood in a trauma situation.  This would have been about 10 years ago, give or take a couple.  One of the many problems I see and you alluded to it Scott, is the availability of whole blood at all, let alone in the quantities needed in a massive bleed/trauma situation.  I wonder what the response would be from the major suppliers if a few of you started requesting whole blood on a regular basis.   

[MAGNUM]

What about the testing required for the crossmatch?

[kate murphy]

Univ of Texas, with the military, conducted a study a couple of years ago - PROPPR study - about the proper ratios of plasma/platelets to red cells in massive transfusions.  Most trauma centers have adopted the guidelines.

Generally, ratios of 1:1 plasma:red cells or 1:2 plasma:red cells is now accepted.  Platelets are counted in plasma products.

So when docs notify us they are activating the massive transfusion protocol, we issue 1:1 plasma:red cells.  Kind of a simulated WB.  Patients mostly do better, avoiding the edema and coagulopathies associated with massive transfusions.  And overall mostly use less blood.  Google PROPPR STUDY for more info.

[carolyn swickard]

How does even the military keep a "Fresh" whole blood stock that would be any good for platelet or coagulation factor replacement?  Maybe in the field it comes from live donors (what about testing??), but what about elsewhere? 

There is not a prayer for us to keep useful whole blood on the shelves, so we are doing the 1:1 RBC to FFP ratio for a massive transfusion protocol also. 

 

[Malcolm Needs ☆]

6 minutes ago, cswickard said:

How does even the military keep a "Fresh" whole blood stock that would be any good for platelet or coagulation factor replacement?  Maybe in the field it comes from live donors (what about testing??), but what about elsewhere? 

There is not a prayer for us to keep useful whole blood on the shelves, so we are doing the 1:1 RBC to FFP ratio for a massive transfusion protocol also. 

 

In addition, as I understand it, treatment of blunt trauma is different from treatment of sharp trauma (although I can't remember which way round it is - which doesn't help one iota on the site, I know!), but I do know that tranexamic acid, given at the site of the accident (or whatever) prior to moving the patient to hospital reduces the volume of the transfusion required and is associated with fewer deaths.

[kate murphy]

The military does use "walking" donors - other soldiers who have been tested within a time frame, and are available for donation.  Field hospitals are definitely much more sophisticated now than even 10 yrs ago.  Field hospitals do have plasma and platelets as well as red cells available. 

TXA (tranexamic acid) is being used extensively in urban trauma centers.  Recombinant activated FVIIa  (NovoSeven)is less in vogue at the moment due to many bleeding episodes. 

Many of our trauma surgeons are ex-military - or active army reserve - and they are big advocates for simulated whole blood.  Some of our trauma surgeons will be publishing soon on experience with simulated WB being almost as good as WB.  They know nothing is as good as fresh WB, but understand that's an unrealistic goal.

 

[MaryPDX]

11 hours ago, kate murphy said:

Univ of Texas, with the military, conducted a study a couple of years ago - PROPPR study - about the proper ratios of plasma/platelets to red cells in massive transfusions.  Most trauma centers have adopted the guidelines.

Generally, ratios of 1:1 plasma:red cells or 1:2 plasma:red cells is now accepted.  Platelets are counted in plasma products.

So when docs notify us they are activating the massive transfusion protocol, we issue 1:1 plasma:red cells.  Kind of a simulated WB.  Patients mostly do better, avoiding the edema and coagulopathies associated with massive transfusions.  And overall mostly use less blood.  Google PROPPR STUDY for more info.

Our facility was involved in the that study. As a result, in a massive the first box issued is 4RC and 4FFP (which we always have ready to go) thereafter it's 6RC 6FFP and 1u Platelets. We keep ahead with this until the massive is called off.

 

[AMcCord]

I've been around long enough to remember the days when we stocked both whole blood and packed cells. It was a logistical nightmare! You never had enough of the right type, in the right product to meet demands. We were constantly packing whole blood to give packed red cells and telling surgeons they were going to have to use packed red cells because our whole blood stock was depleted (because we packed some of it to meet demand for packed cells). Fresh whole blood may definitely be a better product for trauma patients, but stored whole blood??? So which is better....stored whole blood vs component therapy?

[kate murphy]

Trauma docs now are looking for simulated WB - component therapy in the ratio of 1:1.  They would LOVE fresh WB, but that ain't happenin'!

[SMILLER]

Military use --right, and that seems to be where most of these retrospective studies come from, with the claim that whole blood transfusions are better for the patient than separate components.  

Scott