Time for an Obituary? Whole blood an entity or not? Dr. Sudipta Sekhar Das MD (Transfusion Medicine), SGPGIMS PDCC (Aphaeresis & Component Therapy), SGPGIMS Consultant & Head, Transfusion Medicine Associate Professor (AHERF) Apollo Gleneagles Hospital, Kolkata ISBTI: th Sept. 2012

“If any single medical program can be credited with the saving of countless lives in World War II and the Korean War, it was the prompt and liberal use of whole blood.” – LTG Leonard Heaton, Surgeon General U.S. Army

Whole Blood  Volume : 350 / 450ml excluding anticoagulant  Shelf life 35 days  HCT : 40 ± 5%  Plasma volume ~ 200 to 240 ml  Plasma contain ABO antibodies  Increment of 1 gm/dl Hb  No viable PLT, labile coagulation factors after 8 hrs storage

WB vs PRBC Parameter Whole blood Volume 350 – 450 ml Increment in Hb ≤ 1 gm/dl Red cell mass /ml Same as PRBC Viable platelets No Labile factors No Plasma citrate ++++ Allergic reactions ++++ FNHTR ++++ Risk of TTI ++++ Waste of components Yes Packed red cells 200 – 240 ml ≥ 1gm/dl Same as WB No

Biochemical changes in stored WB Whole bloodPacked cells Days Days  Plasma K +  Plasma K (mmol/L)  2,3DPG  2,3DPG % of initial value  ATP  ATP % of initial value  Plasma Hb mg/L  Plasma Hb mg/L

Viability of stored WB over time 2007

Why Blood Components Maximize blood resource Whole blood : 1 patient Component therapy :Multiple patients packed red cells: thalassemia plasma: liver disease / burns platelets: thrombocytopenia cryoprecipitate: hemophilia Specific storage requirements of components Whole blood C Components Platelets+ 22 o C Cryo & FFP- 20 o C or less Red cells+ 2 – 8 0 C

Why Blood Components Better patient management concentrated dose of required component avoid circulatory overload minimize adverse reactions Ex.: Requirement of platelets to raise count from 20 to 50,000/ul fresh whole blood5 units1750 ml random platelets5 units250 ml apheresis platelets1 unit200 ml Decreased cost of management except for the cost of bag, other expenses remain same

A 20 yrs old male patient with aplastic anemia admitted with muco-cutaneous bleeding Platelet count10,000 /ul Hb9 gm/dl Transfusion with whole blood Fresh warm whole blood 3-4 units to raise count up to Disadvantages of such approach volume overload [1500 ml] waste of other components increased risk of reactions Transfusion with components Platelet conc. 3-4 RDP to raise count up to Advantages of such approach no volume overload [200 ml] precious resources spared decreased complications Target PLT: / ul

Advantages to FWB FWB provides FFP: RBC: platelets in a 1:1:1 ratio FWB does not contain excess volume of anticoagulant & additives Even today no. of warfare, military/ traffic casualties managed with WB Available in remote locations, very limited storage lesion > 50% patients in & around Kolkata still have to rely on WB Almost all patients in remote NE states of India depends on WB > 80% blood banks in Eastern India have no component separation facility & use rapid cards for TTI screening & issue blood within hours

Disadvantages to FWB Not FDA approved MUST be ABO-type specific (contains both RBCs and plasma) Increased risk of TTI / bacterial contamination from field conditions Increased clerical errors (ABO typing) due to chaotic nature during which FWB is requested Inventory management difficult Components not required are also transfused No universal donor / recipient Female casualties of child bearing potential must be an Rh match

FWB not to be used as a convenience Not appropriate to use FWB as an alternative to blood products Can only be used when components are unable to be delivered at an acceptable rate to sustain resuscitation of actively bleeding pt. Should only be used when specific components are unavailable Or when stored components are not adequately resuscitating a patient with an immediately life-threatening injury If kept at RT then after 24 hours RBCs undergo gradual lysis, labile clotting factors destroy & significant risk of bacterial contamination If refrigerated within 8 hours of collection the product has RBCs and plasma only as platelets become non-viable at 4 o C

Recommendations for use of FWB Trauma casualties who are anticipated to require massive transfusion Patients with clinically significant shock or coagulopathy When component therapy is unavailable or stored component therapy not able to resuscitate patient with immediate life-threatening injuries The risk: benefit ratio does not justify routine use of FWB over blood components except in cases when platelets/FFP inventories are depleted or exhausted The decision to use FWB is a medical Decision & must be made by a physician who has knowledge of clinical situation & availability of compatible blood components

WB in clinical practice Paediatric patients Exchange transfusion Extracorporeal membrane oxygenation Infants undergoing cardiac surgery Major cardiac surgery in adult Acute blood loss > 40% of total blood volume Massive transfusion Trauma

WB in clinical practice

Studies & Trials  In a randomized trial of 61 infants < 1mon age who underwent cardiac surgery and CPB, pts. who received FWB had less postoperative chest tube volume loss, lower need for inotropic support, shorter ventilatory time, and shorter hospital stay, as compared to those who received components.  In another randomized trial of 96 infants requiring CBP, FWB increased perioperative fluid accumulation & length of stay in ICU. Thus, use of FWB for paediatric cardiac surgery remains controversial till date. remains controversial till date. Transfusion 2005

Studies & Trials In a study published in Critical Care med, 2008 authors reviewed current literatures regarding the benefits & risks of FWB For patients with life-threatening hemorrhage at risk for massive transfusion, if complete component therapy is not available or not adequately correcting coagulopathy, the risk : benefit ratio of FWB favors its use There is potential for FWB to be more efficacious than stored component therapy in critically ill patients requiring massive transfusion. FWB < 24 hrs

Studies & Trials

Final comments……….. Component therapy better than whole blood transfusion WB still a lifesaving therapy for seriously injured war fighters Understand the risks : benefit while choosing WB FWB is good when component therapy not available. However, many disadvantages of FWB precludes its indiscriminate use Developing nations face obstacles in achieving the goal of 100% components – where is will, there is way!!! Indiscriminate use of group O WB to non-group O patients should be avoided because of risk of hemolysis and even mortality

References Joint Theater Trauma System Clinical Practice Guideline, Fresh Whole Blood Transfusion, January 2009 Emergency War Surgery, 2004, Third US Revision, Chap 7: Shock and Resuscitation Technical Manual, AABB, Bethesda Maryland, 15th Edition, 2005 Standards for Blood Banks & Transfusion Services, AABB, 25th Ed, February 2008

Thank You