Whole Blood in Resuscitating Trauma Patients Is Making a Comeback

In modern medicine, sometimes it turns out that the old way is better than the new. This could be the case in how healthcare providers resuscitate trauma victims who need blood transfusions.

Research is emerging that shows whole blood works better for these patients than fractionated components of blood—a discovery that is catching attention in the worlds of trauma and surgery.

In fact, the most downloaded article from the Journal of the American College of Surgeons (JACS) in 2022 was “Impact of Incorporating Whole Blood into Hemorrhagic Shock Resuscitation.”¹

The study showed that compared to using blood component therapy in patients experiencing hemorrhagic shock, whole blood transfusion improved 30-day survival by 60% and reduced the need for 24-hour blood products by 7%. The retrospective study analyzed a diverse group of 1,377 trauma patients from the Red Duke Trauma Institute (RDTI) at Memorial Hermann Hospital in Houston, TX.

Practice today should return to “the resuscitation practices of World War II,” although with more transmissible disease testing, said JACS study first author Jason B. Brill, MD, a critical care surgery specialist. Dr. Brill recently joined the staff at the Tripler Army Medical Center in Honolulu, HI, after previously working at The University of Texas Health Science Center at Houston (UTHealth Houston).

“They say, ‘what is old is new again,’” said JACS study coauthor Lillian S. Kao, MD, MS, FACS, director of the Division of Acute Care Surgery and professor at UTHealth Houston. “It’s never a bad idea to reassess if something else might be working better. You may just get a completely different perspective on it.”

The study indicated that using whole blood benefits a diverse patient population, especially moderate-to-severely injured patients. It also revealed that the earlier patients received whole blood, the better their resuscitation was likely to be.

“Although this study was not a surprise to the trauma community, it was to the broad readership of the JACS community, and that may be why it is so popular,” said the study’s senior author Bryan A. Cotton, MD, MPH, FACS, professor in the Department of Surgery at the McGovern Medical School at UTHealth Houston and codirector of the Shock–Trauma ICU at Memorial Hermann Hospital.

One finding of the study that may have taken aback the trauma community was the fact that whole blood is beneficial for patients with head injuries, Dr. Cotton said. Like many others, he did not expect this outcome.

A strength of the study was that it was conducted at the RDTI at Memorial Hermann Hospital, one of the largest trauma centers in the country with a large prospective data collection. The RDTI is an ACS–verified Level I trauma center—one of only two Level I trauma centers in Houston—that annually evaluates more than 10,000 trauma patients, admitting more than 8,000.

The advanced trauma center coordinated with prehospital aeromedical providers to start whole blood transfusion at the scene of injury, which may have strengthened the effects seen in the most critically injured patients, the authors concluded.

“This large, diverse patient population, including prehospital data, allowed us to show how effective whole blood is in treating hemorrhagic shock,” Dr. Kao said.

Brief History of Blood Transfusion

Whole blood transfusions have been around for centuries. The technique was hazardous and uncertain until the discovery of the ABO blood group system in the early 20th century. Not until World War II was blood transfusion more widely used and standardized, and its use was common through the conflicts in Korea and Vietnam.

But after the Vietnam War, for a variety of reasons, component products such as red blood cells, white blood cells, plasma, and platelets became the only available products. One key reason was that blood banks realized that by fractionalizing blood they could serve more patients, with each patient getting the particular component they required. The component blood also was easier to preserve for longer periods of time.

“Using component blood can be more efficient because individual patients get what they need,” Dr. Brill said. “You can turn one unit of whole blood into three or four products that various patients can receive.”

Dr. Cotton agreed, explaining that from a logistics and efficiency standpoint, this approach made a lot of sense. Yet even if the logistics and economics worked well, there were never any studies showing that it was safe to substitute component therapy for whole blood in hemorrhagic shock patients.

“They didn’t test against actual bleeding-to-death patients, and so that’s where I think a lot of things went sideways,” he said.

The Reemerging Role of Whole Blood

Fast-forward to the conflicts in Afghanistan and Iraq, and component blood therapy was not always available. As a result, military doctors increasingly used fresh, warm whole blood from nurses, soldiers, and other “walking blood banks,” Dr. Brill said. It turned out that trauma patients lived longer and recovered faster when they received whole blood.

“I think it pushed military planners to be more focused on whole blood as the product of resuscitation, not glycerolized red blood cells and frozen plasma. Yes, those last longer, but they’re just not as good for our patients,” he added.

But medical advances discovered by the military don’t always easily translate into civilian medical practice.

“Sometimes, we have to convince civilians that what we are doing in the military is the right thing,” said J. R. Taylor III, MD, a military veteran and critical care surgery specialist at Jefferson Regional Medical Center in Pine Bluff, AR.

In the military, walking blood banks were tapped when whole blood was needed. Since service personnel already were screened for transfusion risks and classified by blood type, whole blood would come from uninjured soldiers with the appropriate blood types.

However, in civilian life, lining up donors in the hallways of trauma centers would be impracticable and unlikely to pass scrutiny from the agencies, including the US Food and Drug Administration (FDA), that oversee and regulate the blood supply. There would be obvious safety concerns, no matter how effective its use in combat settings, the study authors wrote.

Now, as an alternative to walking blood banks, many major trauma centers are returning to whole blood-based resuscitation by using cold-stored, low-titer group O units—a fully screened, appropriately collected, and FDA-approved product.

This increased use of, and enthusiasm for, whole blood has raised questions about its benefits in transfusion, according to Dr. Brill and his colleagues. These doubts helped shape the purpose of the study, which was to investigate survival benefit of whole blood across a diverse population of bleeding trauma patients.

The study authors were able to prove their hypothesis that for injured patients presenting in hemorrhagic shock, whole blood would demonstrate increased survival and require fewer units transfused compared to those only receiving fractionated component products.

Additional Research: Addressing the Fears One by One

The 2022 JACS study is just one of several research projects dealing with possible objections to increased use of whole blood, especially for heavily bleeding trauma patients.

“We’re trying to address people’s fears about making this change by knocking off the preconceptions about whole blood one by one,” Dr. Cotton said.

Universal versus type-specific blood

One concern is whether or not it is safe to use a universal, low-titer group O whole blood, rather than type-specific blood, which is how whole blood historically has been transfused. There are logistical issues with using type-specific blood for emergency patients, since it can take time to test the patient’s blood and then retrieve the right blood product. In an emergency situation, the challenging logistics can lead to mistakes that potentially could harm the patient, said Dr. Cotton.

Drs. Cotton and Brill were among the authors who published a study in the March 2023 issue of JACS that shows universal blood product is safe for use across all blood types.²

“By and large, there are no differences and low-titer group O whole blood should be used as a universal product,” Dr. Brill said. “We should get away from the thinking that it should be used as a type-specific product.”

Rh+ whole blood versus Rh- whole blood

Another worry has been that Rh+ low-titer group O whole blood could cause harmful reactions in some patients, particularly women of childbearing age, Dr. Cotton said. As a result, he participated in a study to determine if Rh+ whole blood could be safely used as an alternative to Rh- whole blood.³

“What we’ve shown is that it doesn’t look like it’s a problem,” Dr. Cotton explained. “We’re just slowly chipping away at some of the issues about using low-titer whole blood as an emergency release product.”

Using whole blood in children

Another recent study addressed whether whole blood is safe for pediatric trauma patients. The researchers concluded that whole blood in children is safe compared to blood component therapy.⁴

“In one case, I gave whole blood to an 8-year-old with a gunshot wound to the abdomen from a drive-by shooting,” said Dr. Taylor, who recently convinced his hospital and regional blood bank to use whole blood. “He’s the youngest kid ever to get whole blood for trauma in the state of Arkansas.”

Medical advances discovered by the military don’t always easily translate into civilian medical practice.

Obstacles to Using Whole Blood: The Blood Supply

Even as studies continue to show the safety and effectiveness of using whole blood in trauma patients, obstacles remain for trauma surgeons.

For example, once whole blood is kept past a certain date, it can’t be broken into components—so there is the fear among blood suppliers that the blood will be wasted, Dr. Cotton said. Another challenge is that some hospitals have concerns about potential complications or adverse effects of whole blood, added Dr. Kao.

As more and more trauma surgeons want to use whole blood, access has become an issue. In fact, the biggest problem with whole blood is the blood supply system. “You have to convince your blood bank or blood supplier that you need this because it’s better for patients and actually will use less blood product. All other barriers are secondary,” said Dr. Brill.

The fact that using whole blood appears to decrease the need for transfusion may be a convincing factor for blood banks in favor of using more of it. “If you believe our data which show that by giving whole blood, you use less blood overall, then that’s a win for the blood bankers,” Dr. Cotton said.

Ultimately, more whole blood will become available as blood suppliers understand the need for it, according to Dr. Brill, who added that the logistical, financial, and strategic reserve challenges that blood banks face can be overcome.

Using Whole Blood in Community Trauma Centers

The 2022 whole blood study in JACS helped Dr. Taylor—who was well aware of the benefits of whole blood from his military service and his work with Dr. Cotton at UTHealth Houston—convince his hospital and the area blood banks to allow him to use whole blood for his trauma patients.

In Pine Bluff, AR, where Dr. Taylor works, there is a high volume of penetrating trauma, creating a war-zone type of environment, in addition to the standard emergent and elective general surgery cases treated at the center. Knowing the challenges of using component blood therapy, he went to his administration and asked to use whole blood for more of these cases.

“I was very lucky that our administration supported it,” he said. “I think culture change in a healthcare environment is the most difficult thing that you can do, but we were able to make major changes in how we treat trauma patients due to the support of blood bank personnel and the administration.”

Another advantage of whole blood in a community trauma center is that it’s much easier to use and has many advantages compared to the traditional component therapy, Dr. Taylor said.

Other similar trauma centers, with high volumes of trauma patients requiring transfusion, could benefit from having whole blood, he explained, adding that while the use of whole blood should not be restricted to academic medical centers, not every trauma center needs whole blood.

Although he’s only been using whole blood for a year or so, Dr. Taylor thinks he has proved the case for continued use. A review appears to show that his hospital is actually saving money using whole blood when massively transfusing patients.

Beyond Trauma: Additional Uses of Whole Blood

Beyond treating patients in profound hemorrhagic shock, there also could be other uses for whole blood, Dr. Cotton shared.

Dr. Taylor agreed, as research supports that any time there is a need for a massive blood transfusion, whole blood could be advantageous to the patient’s outcome. Examples include patients who have major trauma, ruptured aortas, massive gastrointestinal bleeds or severe liver disease, and are undergoing major cancer surgery.

Looking ahead, according to Dr. Cotton, a large, multicenter study is in progress to further investigate the impact of using whole blood in trauma patients.

Jim McCartney is a freelance writer.

References

1. Brill JB, Tang B, Hatton G, Mueck KM, et al. Impact of incorporating whole blood into hemorrhagic shock resuscitation: Analysis of 1,377 consecutive trauma patients receiving emergency-release uncrossmatched blood products. J Am Coll Surg. 2022;234(4):408-418.
2. Brill JB, Mueck KM, Tang B, Sandoval M, et al. Is low-titer group O whole blood truly a universal blood product? J Am Coll Surg. 2023;236(3):506-513.
3. McCoy CC, Montgomery K, Cotton ME, Meyer DE, et al. Can RH+ whole blood be safely used as an alternative to RH- product? An analysis of efforts to improve the sustainability of a hospital’s low titer group O whole blood program. J Trauma Acute Care Surg. 2021;91(4):627-633.
4. Perea LL, Moore K, Hazelton JP. Whole blood resuscitation is safe in pediatric trauma patients: A multicenter study. The American Surgeon. February 13, 2023. [Epub ahead of print]. https://doi.org/10.1177/00031348231157864.