The Johns Hopkins Hospital Pasadena, Maryland, United States
Background/Case Studies: Whole blood (WB) for trauma resuscitation has historically been a military practice. In hospitals, massive transfusion protocols (MTP) have guided resuscitation through ratio-based component therapy simulating WB. Early evidence supports the advantages of WB over component therapy in life-threatening bleeds, prompting a resurgence of low titer group O whole blood (LTOWB) use in civilian trauma centers. We review our experience of implementing a LTOWB program at a level 1 trauma center in the US.
Study
Design/Methods: Our hospital implemented a WB program for adult trauma resuscitation. LTOWB RhD positive units are stored remotely in Emergency Department (HaemoBank)(Figure 1) and transfused within 14 days of collection. Up to 4 LTOWB units can be transfused during the initial resuscitation for patients who meet eligibility criteria: 1) Assessment of Blood Consumption (ABC) Score ≥ 2 (heart rate ≥120/min, systolic BP < 90 mmHg, penetrating trauma and/or positive focused assessment with sonography in trauma [FAST]) or 2) MTP activation. Women of childbearing age ( < 50 years), patients undergoing active cardiopulmonary resuscitation, or pulseless patients receiving thoracotomy were excluded. The MTP is activated concurrently to provide a fixed ratio of blood components following LTOWB transfusion. Expiring units (>14 days) are packed into red blood cells (RBC) for the remainder of storage. Patient clinical, demographic, laboratory and transfusion data were compiled via manual chart review of the electronic medical record. LTOWB unit disposition was determined from review of the blood bank laboratory information system.
Results/Findings: From 1/1/23-3/31/23, 102 LTOWB units were received from the blood supplier. 44 (43.1%) were transfused during resuscitation, while disposition of expiring units included 60 (57.7%) modified to RBC, of which 59 were transfused and 1 was discarded due to bag damage during centrifugation. LTOWB units were transfused to 20 male patients with median age of 36.1 (IQR 42.5-26) yrs for diagnoses of gunshot/stab wounds (75%, n=15), motor vehicle accidents (10%, n=2), or other trauma (15%, n=3) with 5 deaths (25%). At the time of LTOWB transfusion, type and screens were available for 9 (45%) patients with ABO/Rh types of group O (60%, n=12, 11 RhD+) and non-O (25%, n=5, RhD+), with 3 unknowns. Ratios of MTP components: LTOWB issued to survivors and non-survivors were 6.3:1 and 50.8:1, respectively. Conclusions: Repurposing WB into RBCs can avoid product expiry and provide wider access to transfusions hospital wide. Overall, launching a new program requires continuous reassessment with multidisciplinary education of appropriate application.
Importance of research: Low titer O whole blood (LTOWB) use, historically a military practice, is gaining traction in civilian trauma centers as a means for early resuscitation. Implementing a LTOWB trauma program requires many moving parts. We describe our experience with additional emphasis on the repurposing of LTOWB into RBC to avoid product expiry while offering hospital wide access to RBC transfusions, a topic frequently omitted in LTOWB discussions throughout the literature.
