The use of warm fresh whole blood transfusion in the austere setting: A civilian trauma experience

Abstract

BACKGROUND Hemostatic resuscitation strategy using blood components with a balanced ratio is adopted in the civilian trauma setting. However, there is usually limited availability of blood components in the austere setting. Warm fresh whole blood (WFWB) has been used for trauma patients with life-threatening hemorrhage necessitating massive transfusions in the Okinawa Islands, Japan. The purpose of this study was to evaluate the safety and feasibility of WFWB use in the austere civilian trauma setting. METHODS We conducted a retrospective cohort study between January 1999 and June 2019, including trauma patients who received WFWB within 24 hours of admission. Immediately after WFWB was collected from blood donors, the sample was typed and screened for transmissible infectious diseases. Approximately half of the study population received irradiated WFWB to prevent graft versus host disease. We evaluated the incidence of transfusion-associated adverse events. Transfusion requirements and patient outcomes were compared between early and late WFWB use. RESULTS A total of 28 patients from three civilian institutions were eligible. Of those, 93% sustained blunt trauma. The median Injury Severity Score was 37 (interquartile range, 32–49). All patients required operative hemostatic intervention, and half of the patients required both operative and endovascular hemostatic interventions. Patients received a median of 1,800 mL WFWB transfusions from seven volunteer blood donors. None of our subjects developed hemolytic reactions, transmissible infectious diseases, or graft versus host disease. Early WFWB use (within 4 hours of admission) was associated with a significant reduction in platelet transfusion requirement compared with the late WFWB group in univariate analysis (16 units vs. 47 units, p = 0.002). CONCLUSION Warm fresh whole blood use is safe and feasible in an austere civilian trauma setting. Prospective studies with larger cohorts are necessary to determine whether early WFWB use will affect patient outcomes, transfusion requirement, and treatment cost. LEVEL OF EVIDENCE Therapeutic, Level IV.

Whole blood transfusion in the treatment of acute hemorrhage, a systematic review and meta-analysis

“…We identified 17 studies reporting about patients with traumatic hemorrhage treated with at least 1 unit WB (without BCT comparison) including 10 retrospective cohort studies, 4 case series, and 3 prospective observational studies 12,14,58–72 . All studies are summarized in Supplementary Digital Content 13, http://links.lww.com/TA/D6.…”

“…We identified 17 studies reporting about patients with traumatic hemorrhage treated with at least 1 unit WB (without BCT comparison) including 10 retrospective cohort studies, 4 case series, and 3 prospective observational studies. 12,14,[58][59][60][61][62][63][64][65][66][67][68][69][70][71][72] All studies are summarized in Supplementary Digital Content 13, http://links.lww.com/TA/D6. In brief, included studies reported that WB transfusion is feasible in both military medicine, 62,68 and civilian medicine, 12,70,71 including in the prehospital setting.…”

“…12,14,[58][59][60][61][62][63][64][65][66][67][68][69][70][71][72] All studies are summarized in Supplementary Digital Content 13, http://links.lww.com/TA/D6. In brief, included studies reported that WB transfusion is feasible in both military medicine, 62,68 and civilian medicine, 12,70,71 including in the prehospital setting. 72 Also, studies indicate WB transfusion is safe, 14,61,65,66,69 even in very large quantities up to 68 units WB.…”

“…5 Possible benefits of WB as compared with blood component therapy (BCT) include, but are not limited to, more balanced transfusion, [5][6][7] logistical advantages, 6,8,9 and when FWB is used, superior characteristics, i.e., higher platelet count, higher hematocrit and higher concentration coagulation factors as compared with reconstituted blood components transfused in a 1:1:1 ratio. 10 Despite these possible benefits and its consistent demonstrated safety, [11][12][13][14] comparative studies and previous systematic reviews show conflicting results in terms of effectiveness. [15][16][17][18][19][20] Since the latest systematic review and meta-analysis was conducted, multiple prospective WB trials have been performed.…”

A Comparative Analysis to Determine the Optimum Histone Deacetylase Inhibitors and Administration Route for Improving Survival and Organ Injury in Rats After Hemorrhagic Shock

“…Hemorrhagic shock after trauma is a much more common cause of death in military personnel and civilians than trauma alone. Particularly in the civilian population, there is higher mortality due to extremity/penetrating injuries (19)(20)(21)(22). Volume expansion for traumatic HS can be achieved via crystalloid resuscitation to restore tissue perfusion and plasma resuscitation to replace the crystalloid (23).…”