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Group O Whole Blood, Low Titer

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We (blood collection center) are looking into providing Group O Whole Blood, with low anti-A and anti-B titers for treatment of trauma patients.  Is anyone else doing this?  If so, what is your testing protocol on how to identify a donation as "low titer"?  What are your titer cutoffs for anti-A and anti-B?  

Thanks for any assistance!

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March issue of Transfusion has a "How Do I" article on this. 

How do I implement a whole blood program for massively bleeding patients?

Mark H. Yazer,1 Andrew P. Cap,2 Philip C. Spinella,3 Louis Alarcon,4 and Darrell J. Triulzi1

I am working on trying to figure out something for rural hospitals who seldom have massive transfusions but whose patients we would like to save just as much as those who can get to big trauma centers.  Any suggestions would be appreciated.  :)

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Our ARC is starting to offer these products. They are using a titer cut-off of 200.  The whole blood units will cost 3 times the price of a RBC. It's good for 21 days.  Oregon Health Sciences University will be stocking them for traumas. They are the 4th hospital in the country supplied by ARC to use WB in their trauma program. Our ARC is the Pacific Northwest region in Portland.

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Thanks for the info!  Any idea how they are testing the titrations?  I've heard I.S. from some sources and others are taking it through an IAT in gel.

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What little info I have says they are testing 2 tubes, A & B tested separately.  I think IS but I am not sure.  If you contact dragonlady on this site, she should know.

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Stupid question - why is group O whole blood better than group O pack cells and group A thawed plasma? 

 

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From the transfusion article

"WB offers several benefits over component therapy including providing simultaneous treatment for both oxygen debt and the coagulopathy of trauma; it is a more concentrated product compared to reconstituting WB using component therapy; and cold-stored WB contains PLTs that appear to have equivalent or better hemostatic effect in both in vitro tests and in clinical trials, compared to PLTs that have been stored under conventional room temperature conditions. Another benefit of WB that is perhaps harder to quantify is the simplification of the resuscitation effort with its use, especially in the prehospital environment. In such settings, where the clinical staff are task saturated, patient intravenous access is limited, and storage space in helicopters and ambulances is very limited, having the ability to provide a balanced resuscitation fluid in one bag instead of up to four bags is valuable. This is important because any delay in the provision of blood products in hemorrhagic shock can be lethal; mortality is increased by 5% for each minute there is a delay in the delivery of blood products."

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6 minutes ago, BBNC17 said:

From the transfusion article

"WB offers several benefits over component therapy including providing simultaneous treatment for both oxygen debt and the coagulopathy of trauma; it is a more concentrated product compared to reconstituting WB using component therapy; and cold-stored WB contains PLTs that appear to have equivalent or better hemostatic effect in both in vitro tests and in clinical trials, compared to PLTs that have been stored under conventional room temperature conditions. Another benefit of WB that is perhaps harder to quantify is the simplification of the resuscitation effort with its use, especially in the prehospital environment. In such settings, where the clinical staff are task saturated, patient intravenous access is limited, and storage space in helicopters and ambulances is very limited, having the ability to provide a balanced resuscitation fluid in one bag instead of up to four bags is valuable. This is important because any delay in the provision of blood products in hemorrhagic shock can be lethal; mortality is increased by 5% for each minute there is a delay in the delivery of blood products."

THANK YOU FOR THE INFORMATION

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"and cold-stored WB contains PLTs that appear to have equivalent or better hemostatic effect in both in vitro tests and in clinical trials, compared to PLTs that have been stored under conventional room temperature conditions."  (quote)

How long do the platelets in a WB unit last?  Even 7-10 days still leaves half of the unit's lifetime without platelets.

The rest of the benefits sound interesting - especially pre-hospital.  We are not even close to having blood products in the field, but it is an interesting idea to work on.

I wonder how this would change the Massive Transfusion Protocol" 1st response (usually a unit of pheresised platelets in 1st load)- if at all?

 

 

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I think I read that platelet function lasts longer than we would expect--even longer than the accepted 7-10 day life span.  Cold storage slows the platelet metabolism and extends their life???  I'm not sure what you've got on day 21 for platelet function.

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2 hours ago, cswickard said:

"and cold-stored WB contains PLTs that appear to have equivalent or better hemostatic effect in both in vitro tests and in clinical trials, compared to PLTs that have been stored under conventional room temperature conditions."  (quote)

How long do the platelets in a WB unit last?  Even 7-10 days still leaves half of the unit's lifetime without platelets.

The rest of the benefits sound interesting - especially pre-hospital.  We are not even close to having blood products in the field, but it is an interesting idea to work on.

I wonder how this would change the Massive Transfusion Protocol" 1st response (usually a unit of pheresised platelets in 1st load)- if at all?

 

 

I was wondering the same about the platelets in WB.  There article addresses it briefly stating "In Pittsburgh, the decision was made to keep WB for up to 14 days in the refrigerator as it was clear from the literature that cold-stored PLT function was well maintained for at least that length of time. Continuous agitation of WB is not recommended as it does not enhance PLT quality and contributes to increased hemolysis during storage. On Day 15 the unused units of WB are returned to the CTS laboratory where the WB is concentrated into an RBC unit by removing the PLT-rich plasma, and the resulting RBC unit can be stored for an additional 6 days."

 

Not sure what is meant by "the literature", but there are a few cited articles that seem like they may shed some light on this, but I have yet to look at them..

Reddoch KM, Pidcoke HF, Montgomery RK, et al. Hemostatic
function of apheresis platelets stored at 48C and 228C. Shock
2014;41 Suppl 1:54-61.

Nair PM, Pidcoke HF, Cap AP, et al. Effect of cold storage on
shear-induced platelet aggregation and clot strength.
J Trauma Acute Care Surg 2014;77:S88-93.

Becker GA, Tuccelli M, Kunicki T, et al. Studies of platelet concentrates
stored at 22 C and 4 C. Transfusion 1973;13:61-8.

Yazer MH, Glackin EM, Triulzi DJ, et al. The effect of stationary
versus rocked storage of whole blood on red blood cell
damage and platelet function. Transfusion 2016;56:596-
604.

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"Stupid question - why is group O whole blood better than group O pack cells and group A thawed plasma? "

Not stupid at all. There is no clinical evidence that it is superior or inferior. In fact, no clinical evidence whatever.  The main attraction is that it simplifies transfusion in the patients who require red cells, plasma and platelets.  One bag instead of three.  That it provides better hemostasis is a supposition that may or may not prove to be wrong.  It's concerning to me that it's very hard to predict who really needs anything but red cells.  One estimate from London is 25% but that includes everyone with an elevated PT/INR and PTT, which are not good tests for predicting bleeding.  We examined the last half year of our ED uncrossmatched blood cooler release in our Level 1 trauma center in a medium sized American city.  We do not routinely start the massive transfusion protocol with the first cooler (or even the second, unless asked to do so). Of the 230 or so patients, only 2 wound up using more than 8 red cells (0.86%).  I suspect this is typical of many university hospitals and almost all smaller teaching hospitals.  Hence, no whole blood, no massive transfusion protocol routinely started on arrival, unless requested.  I would think that whole blood as the first product to be infused for our patients would harm more patients than help (TRALI, TACO, etc.).

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We know that stored red cells are deficient in G6PD, but that is restored soon after transfusion.

I seem to recall some work done by either Sunny Dzik or George Garraty some years ago now (I lean towards it being Sunny, by I am not certain) that showed that FFP also took time (and volume) to "work", not just in cases where the prolonged PT has been caused by warfarin, but in all cases, so there may be some unknown agent within FFP, analogous to G6PD, that requires a "physiological kick up the backside" to work.  I'm sorry I cannot be more informative.

That having been said, there is growing evidence from London that, in major trauma, it is important to maintain body temperature, blood pressure, oxygen carrying capacity and the avoidance of a trauma induced coagulopathy, and FFP and cryoprecipitate (together with early use of tranexamic acid) seems to be efficacious in this.

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I would not be  in favour of going back to whole blood transfusions (except in countries where they have no choice!).  The point about 'everything being present in the one bag' is fine - if the donor has only just been bled.  But that is not likely to be the case.  How many active clotting factors remain after the blood bag has been stored for a couple of weeks?

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On ‎5‎/‎23‎/‎2018 at 11:55 AM, Mabel Adams said:

I think I read that platelet function lasts longer than we would expect--even longer than the accepted 7-10 day life span.  Cold storage slows the platelet metabolism and extends their life???  I'm not sure what you've got on day 21 for platelet function.

FWIW, we give our Trauma WB products a two week expiration date, because of the declining platelet function.

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Yes to not wanting to worry about WB, but some of this is talking about actual transfusions in the field where fresh (<14 days) WB would be very useful and much easier to deal with for a field team.  I have also heard that some Trauma centers have a procedure where FFP and pRBCs and all get mixed together as they are being transfused(?!!?)  I have no clue how that works, but seems like it would almost be safer to give a WB unit than that procedure?!? 

Fresh FFP with more functioning Coag factors logically seems better, but maybe a fresh WB has enough to keep things going.  I can't see us managing this though - the WB inventory, even with returning it for Packed RBC production, would kill us.  Most of our "traumas" to date have used fewer than 4 units.  It will be interesting to follow this trend. 

 

By the way - does anyone know if the WB is Leukocyte reduced?  If not, still having white cells onboard the unit would cause problems too.  Especially with WC degradation over time before packing and filtering.  Would NOT want to go back to that!

Edited by cswickard
extra question added

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The whole blood being used in Pittsburgh is leukoreduced.  They have chosen a titer of 50, which I would think is much safer than 200, but who knows?  It would nice to have high quality data, or any data whatever, comparing the results with whole blood with similar patients transfused with the usual group O red cells, platelets of whatever group (usually) and AB plasma.  I'd speculate that there is no difference because mixing group O red cells with AB plasma gives patients a substantial dose of iatrogenic ABO immune complexes, which we have demonstrated leads to impaired platelet function (in vitro), endothelial damage (unpublished in vitro data) and increased bleeding (observational clinical data).  Thus low titer group O whole blood might well be safer than our current practices, which have only been validated not to cause acute massive hemolysis, which is only one of many disastrous clinical outcomes that can result from crossing ABO barriers. Focusing on red cells is fine, but there are other cells in the body that carry ABO antigens (endothelial cells for example) and loads of soluble antigen. :)

Edited by Neil Blumberg

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On ‎5‎/‎22‎/‎2018 at 10:26 AM, Mabel Adams said:

Our ARC is starting to offer these products. They are using a titer cut-off of 200.  The whole blood units will cost 3 times the price of a RBC. It's good for 21 days.  Oregon Health Sciences University will be stocking them for traumas. They are the 4th hospital in the country supplied by ARC to use WB in their trauma program. Our ARC is the Pacific Northwest region in Portland.

Correct.  We start the first week of July :) 10 O+ and 10 O=

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On ‎5‎/‎31‎/‎2018 at 10:36 AM, cswickard said:

Yes to not wanting to worry about WB, but some of this is talking about actual transfusions in the field where fresh (<14 days) WB would be very useful and much easier to deal with for a field team.  I have also heard that some Trauma centers have a procedure where FFP and pRBCs and all get mixed together as they are being transfused(?!!?)  I have no clue how that works, but seems like it would almost be safer to give a WB unit than that procedure?!? 

Fresh FFP with more functioning Coag factors logically seems better, but maybe a fresh WB has enough to keep things going.  I can't see us managing this though - the WB inventory, even with returning it for Packed RBC production, would kill us.  Most of our "traumas" to date have used fewer than 4 units.  It will be interesting to follow this trend. 

 

By the way - does anyone know if the WB is Leukocyte reduced?  If not, still having white cells onboard the unit would cause problems too.  Especially with WC degradation over time before packing and filtering.  Would NOT want to go back to that!

The units we will be getting are leukocyte reduced.

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