I work at a trauma center that uses Low Titer Group O Whole Blood.

This year we have basically been forced to copy another facility's protocol where they transfuse up to 10 units of whole blood during MTP.

From a logistics perspective, it's great for the blood bank and the trauma team since there are fewer bags to manage.

However, is there any guidance about how/when you can safely switch back to type specific products for non Group O patients? It's "low titer" but it's not zero.

If a patient gets more than 4 LTOWBs we add a Use Group O RBC's instruction.

We do this because the only articles that I can find about evaluating LTOWB show that it's probably ok if non group O patients get up to 4 LTOWB.

So far, it hasn't been a huge deal to do this. We're not transfusing a ton more O RBC's since the bulk of the transfusion already happened during the MTP.

I'm new to trauma and have kind of been blindsided about how people aren't more concerned about going off on a limb with 10 units like this.

I've seen some older accounts from the military where they tested the patient's reverse at IAT to evaluate safety of switching back, but I don't know if that's clinically relevant. 

It feels like the wild west.

Thank you in advance!

 

We are a Level 1 adult and Peds trauma center.....we don't have a limit............

We will give any MTP patient O POS (leuko reduced) LTWB until our supply runs out.  We will give Oneg to peds - but if we run out of Oneg - they will get Opos.  Our facility is currently involved in several studies using WB in the trauma setting.

In the words of our Medical Director and manager..........."They have to live to have a problem"  Might sound crass to many - but, it's true.  For all the patient's we have transfused out of group WB to - we have had VERY FEW delayed reactions - maybe 2 anti-A's in the eluate and a few anti-D's - but all were males.

Our 1st concern is saving the patient.........

Switch back to the patient's own ABO type as soon as possible is my advice.  For everything.  RBC, platelets, cryo, plasma.  Worrying about the anti-A and anti-B in low titer whole blood is relevant, but so is the smaller amount of incompatible plasma in group O red cells, which are not low titer. There are rare reports of severe hemolytic reactions to group O red cells in non-O patients. Furthermore, the patient is continually making their own group A, B or AB red cells, so hesitancy about transfusing their own ABO type is not helping things get better.  By giving additional group O products we are making the problem worse, not adding safety in any way.

Furthermore, the non-O patient's endothelial cells, platelets, von Willebrand factor, hepatocytes, etc. are all incompatible with the transfused group O plasma, and their function is impaired when modeled in vitro, and leads to increased bleeding. 

Thus there is no benefit whatever in giving group O red cells (or whole blood for that matter) to non-O patients once the hemorrhagic problem is largely under control. And there is likely added risk.   It is only adding harm and reducing the inventory of group O blood for group O recipients.  A total mistake of the last few decades in my opinion. Giving group O plasma containing products to non-Os is only reasonable when you don't know the patient's blood group, or don't have their blood group in stock, or it's an emergency with no time for giving type specific.

No one ever went broke overestimating the importance of the ABO blood group in transfusion.  See attached for the literature references.

ABO trauma commentary Frontiers bioengineering.pdf Reconsider ABO compatible:universal donor.pdf ABO ARC MAC copy.ppt

Edited November 4, 2024Nov 4 by Neil Blumberg

I'm with Dr. Blumberg, we cap our LTOWB for trauma MTP at 4 units. This is due to inventory as well as not wanting to give non-ABO identical as little as possible. We have had zero adverse events thus far. The more O you give a non-O patient, the harder it is to determine their true type as well, especially if you don't get a sample drawn ASAP. Switch to patient's ABO type as soon as you can, and only fall back to type O red cells if inventory is in trouble. 

Also agree with Bet'na - the patient has to live to have a problem, but we can mitigate the problems by capping how much potentially incompatible plasma we give. 

There is an AABB standard 5.27.2 that states that your SOPs must indicate the maximum volume/units allowed per event. You can define that yourself, there isn't really a guide as to how much is too much. There are facilities out there that have no limit and some that have a limit, as evidenced by the responses in this thread. Standard 5.15.4 applies to this as well, which states that you have to have a policy concerning transfusion of significant volumes of plasma containing incompatible ABO antibodies, ie type O plasma to non-O patients. 

I've been doing level 1 trauma for almost 20 years, and it can feel like the wild west, reach out if you need clarification or real-life examples of things. Happy to help.

Thank you everyone for the replies! I definitely have a lot of reading to do.

@Bet'naSBB I definitely agree that the patients have to live to have a problem. I appreciate the info about your facility. I hope to read more research about the WB that's being done at hospitals like yours! I am also curious about studies going on that involve obstetrics and cardiac LTOWB MTPs.

@Neil Blumberg Thank you very much for the articles. I am also worried about the incompatible plasma in the regular red cells for sure. I feel like I'm in between a rock and a hard place.

Just to make sure I've understood, even if a patient just got their total plasma volume replaced with Group O albeit Low titer plasma, we should switch all products to their blood type the second we get a result? 

(I am also curious what you think of blood centers labeling red cells from antibody positive units as regular red cells and don't treat them as antibody positive units needing a minor crossmatch. The blood center claims that the Additive Solutions dilute the titer "enough." I admit I haven't looked for any research on this yet. I don't know if they titer the supernatant or what to prove this.

Maybe this also needs to be brought up in paradigm shifts alongside rethinking out of group ABO compatible red cell transfusions.)

@jshepherd Right now, I would like to limit it to 4 LTOWB and then switch to components until more research is done, but my hands are tied. No amount of articles or concerns has changed our Trauma department's mind. They want unlimited LTOWB in their perfect world, but we were able to limit it to 10 to match the "model" facility's protocol. Maybe a retroactive study can be done here at some point. To be clear, thankfully I have no evidence that any of our patients have experienced harm because of the LTOWB specifically. This is more of a proactive worry.

We are unfortunately not accredited by AABB, but CAP has a similar standard and I outlined our policy as no limit for LTOWB, but if more than 4 transfused, give Group O red cells. After getting Dr. Blumberg's insight, I may be editing it again!

"Just to make sure I've understood, even if a patient just got their total plasma volume replaced with Group O albeit Low titer plasma, we should switch all products to their blood type the second we get a result?"

Yes. Even after a one volume blood exchange 30-40% or more of the original red cells (recipient type) are still there, and more will be made during the recovery from anemia.  So giving the patient's own red cell type is almost certainly better than infusing more anti-A and anti-B antibody via O red cells to A, B and AB patients.

(I am also curious what you think of blood centers labeling red cells from antibody positive units as regular red cells and don't treat them as antibody positive units needing a minor crossmatch. The blood center claims that the Additive Solutions dilute the titer "enough." I admit I haven't looked for any research on this yet. I don't know if they titer the supernatant or what to prove this.

I think this is irresponsible and scientifically indefensible, if I understand you.  Also against FDA regs as the product is misbranded if the known antibody present is not identified on the label.  The remark about additive solutions is totally without merit and once again, irresponsible.  There are no data to support this approach. I don't want to be infusing anti-X antibody (that I don't know about) to a patient who might be X positive. Makes no sense and one would be crucified in a court of law.

 

Thank you very much for your thoughtful response! 

As for my other question, I asked it because at the blood center I worked at, they did start testing the RBC supernatant on antibody positive donors and labeling them as regular unrestricted RBC units.

I figured this was sort of related since the argument they made to the FDA was that the additive solution dilutes antibodies to an undetectable level. 

I've attached a document of exceptions to the CFR from 2018. In section 7d of this document they say as long as they test the supernatant by an "approved method" and it's negative they are allowed to do it. I don't know what studies the blood center did to get this exception granted, but it's been the way this blood center has been doing it for at least 6 years now.

Exceptions-and-Alternative-Procedures----Approved-Under-21-CFR-640.120 (1).pdf

Edited November 5, 2024Nov 5 by BB Gal
revised section in document referenced

If the donor antibody screen is negative then the unit does not need to be labeled. Otherwise it does.