by Heath Alls, MBA, MSM, MLS(ASCP) cm
Blood centers across the country are seeing a renewed interest in whole blood transfusions. The main fuel to this fire appears to be the recent change from AABB and the forthcoming 31st edition of Standards for Blood Banks and Transfusion Services which allows for the use of low titer group O whole blood in emergent situations for recipients of unknown blood type (AABB News, 2017).
Whole blood transfusion needs are limited to a small, and specific, group of situations. Indications include acute hemorrhagic shock and pediatric cardiovascular surgery. For this blog post, the focus will be on acute hemorrhagic whole blood transfusions. In this specific example, the goal is to utilize a product that has a component ratio of 1:1:1; consisting of red blood cells, plasma, and platelets -- or the exact composition of whole blood. In other words, the goal is to replicate whole blood, when and where whole blood is not available due to modern component therapy practices and blood banking economics. The problem faced by blood bankers, is that replicating this recipe via component therapy, falls short in duplicating all aspects of whole blood.
History of Component Therapy
Post World War II, the fractionation of donated blood became the standard practice due to the increased effectiveness of specific component therapy, increasing inventory management, as well as financial and logistical benefits (Murdock, Berséus, Hervig, Strandenes, & Lunde, 2014). Patients were able to receive the exact component of blood they needed, and blood banks were able to provide multiple products from a single whole blood collection. The main issue looking at this transition, retrospectively, is the fact that few studies exist comparing the benefits and risks associated with whole blood vs component therapy (Murdock, Berséus, Hervig, Strandenes, & Lunde, 2014).
Recently, there is a trend in the industry to switch back to whole blood transfusions for the group of patients diagnosed with acute hemorrhagic shock, such as trauma patients. Hospitals are asking blood centers more and more often if they can provide whole blood for transfusion with different requirements. Due to the lack of research around the use of whole blood in the modern world of blood banking, there also appears to be a lack of uniformity in certain requirements concerning whole blood.
One example of a somewhat vague requirement, is the cut off for a “low titer” group O whole blood unit. Some hospitals are asking for a titer cutoff of <100, when blood centers might consider a low titer to be <256. It is also worth mentioning that titer values can vary depending on the sensitivity of the technique used to titer the unit, or even the technique of the technologist performing the titer. The forthcoming 31st edition of Standards for Blood Bank and Transfusion Services will allow for the use of low titer group O whole blood for transfusion, if facilities define what a low titer means to that facility, and describe how they will use the product in their policies and procedures (AABB News, 2017).
Whole Blood Versus Component Therapy
This leads to the real driving question behind the demand for whole blood. Does whole blood transfusion in specific situations improve patient outcomes? The answer is not conclusive based on current research. This is the topic that is currently circulating the blood and transfusion industry, yet there is a lack of adequate studies to address this notion.
There is one conclusion that can be drawn. Component therapy of a 1:1:1 ratio is a more anemic, thrombocytopenic, and coagulopathic product as compared to whole blood based on calculations (Murdock, Berséus, Hervig, Strandenes, & Lunde, 2014). Keep in mind that packed red blood cells have a longer shelf life than whole blood. This difference in shelf life leads to other considerations including the destruction of red cells stored longer than 14 days which may result in products that are high in free hemoglobin, iron, red cell fragments, as well as various acidotic additives leaving component therapy short in terms of overall quality of product (Whole-blood transfusions reduce mortality in massively hemorrhaging patients, n.d.). These are aspects that need to be considered, but it does appear to be unknown if these factors relate to an increase in morbidity and mortality.
Whole Blood Supply and Demand
A slightly different but still important aspect of whole blood transfusion includes the affect the demand for whole blood will have on blood centers. Using the US Military practices for transfusing whole blood, the preferred type of blood is always group O. (James R. Stubbs, 2016). This may increase the demand on group O donors, a population of donors already in high demand. It is hard to predict the overall affect this driver will have on the market until hospital studies have been completed on the civilian population, and a consensus has been made on its effectiveness. There is enough evidence for the AABB to update their standards due to the increased request in variances, which will further drive the demand for group O whole blood, as the previous standards required whole blood to be type specific unless granted an allowance.
In short, there is no conclusive evidence to show that whole blood is a superior or inferior product compared to component therapy for the small population of patients that this product would be transfused. There is evidence to show that whole blood is worth mimicking in certain circumstances, but those attempts to mimic whole blood through component therapy are not an exact match once blood components have been separated and stored.
The effect on the industry moving forward will be a rise in curiosity around whole blood for its use in trials and studies to find new and improved ways to achieve better patient outcomes. In the short term, there will be a higher volume of requests for whole blood as hospitals gather data to draw conclusions on the effectiveness and benefits of whole blood transfusions for specific populations. In the long term, the demand for whole blood will be driven by the data collected and best practices that are established. Our use of whole blood could be a move backwards in history; albeit, a renewed attempt to push better outcomes and move the industry forward. Revisiting whole blood use could also allow the industry to catch up on research needed to support our move forward in component therapy.
The team at Bloodbuy will continue to closely monitor trends related to the therapeutic and clinical use of whole blood. An increased demand for whole blood will bring on its own set of supply and demand challenges; however, together, we can meet the challenge and ensure the efficient flow of these lifesaving products.
AABB News. (2017, November/December). AABB News Vol 19 No. 11.
James R. Stubbs, M. D. (2016, May 26). The state of the science of whole blood: lessons learned at Mayo Clinic. Retrieved from US National Library of Medicine National Institutes of Health: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4882089/
Murdock, A. D., Berséus, O., Hervig, T., Strandenes, G., & Lunde, T. H. (2014, May). Whole Blood: The Future of Traumatic Hemorrhagic Shock Resuscitation. Retrieved from Shock Journal: http://journals.lww.com/shockjournal/Fulltext/2014/05001/Whole_Blood___The_Future_of_Traumatic_Hemorrhagic.13.aspx?trendmd-shared=0
Whole-blood transfusions reduce mortality in massively hemorrhaging patients. (n.d.). Retrieved from Mayo Clinic: https://www.mayoclinic.org/medical-professionals/clinical-updates/trauma/whole-blood-transfusions-reduce-mortality-in-massively-hemorrhaging-patients