A reemerging role for whole blood in modern trauma care

May 07, 2022

Whole blood use is increasing in popularity in the trauma field, a discipline in which blood transfusion plays a major role in hemostatic resuscitation. About 15% to 20% of trauma patients receive transfusions, and 3% receive massive transfusions, according to James R. Stubbs, M.D., a transfusion medicine specialist at Mayo Clinic's campus in Rochester, Minnesota.

Blood product evolution in trauma-related transfusion

Military medical personnel used whole blood for transfusion in World War II and in the Korean and Vietnam Wars, according to an article by Dr. Godbey in Clinics in Laboratory Medicine. However, around the Vietnam War, fractionation increased in popularity, says Dr. Stubbs. According to Dr. Godbey's article, the military then transitioned to use of blood components, colloids and crystalloids in transfusion therapy. During the 1970s and 1980s, civilian medicine also began using blood components. The medical community considered the discovery of parsing a whole blood donation into individual components — plasma, platelet and red blood cells — to increase the "mileage" physicians could derive from one donation.

"Division into components allowed donations to benefit three patients rather than one," says Dr. Stubbs. "Each patient would receive only the lacking blood portion, such as platelets. Since individual blood component volumes were lower, patients could get higher doses of the blood constituent needed in lower total volumes."

The medical field has considered blood component usage to produce less waste than the use of whole blood, says Denise B. Klinkner, M.D., M.Ed., a pediatric surgeon and the medical director at Mayo Clinic's Level 1 Pediatric Trauma Center in Rochester, Minnesota, and the chair of the Minnesota Committee on Trauma.

Although physicians today haven't abandoned blood components, especially for hospital patients, physicians have turned away from heavy crystalloid doses.

"As large blood volume replacement with crystalloid has been found to cause more harm than good, it's fallen out of favor," says Dr. Stubbs.

Currently, the 10th edition of Advanced Trauma Life Support (ATLS) recommends administering patients with traumatic injuries one crystalloid bolus followed by blood. With significant blood loss, however, ATLS suggests bypassing crystalloid and giving blood immediately. Previously, ATLS recommended administering two crystalloid boluses to patients with traumatic injury, then moving to blood.

Overall, whole blood is an uncommon transfusion, yet it's proved beneficial in adult patients who've experienced trauma and gastrointestinal disease, says Dr. Klinkner.

Whole blood advantages

Today's standard of care for patients experiencing traumatic injury involves early and balanced resuscitation with equal parts platelets, plasma and red blood cells. Whole blood's advantage is its component balance with a 1-1-1 ratio, which is the goal of massive transfusion. Also, depending on patient needs, whole blood only involves one transfusion, reducing exposure, which Dr. Klinkner notes is especially critical for pediatric, transplant and oncology patients. Dr. Stubbs notes this also means the patient receives less volume and blood factor dilution, benefitting the patient.

"Whole blood is the perfect balanced resuscitation blood product," says Dr. Stubbs. "It allows for balanced resuscitation through one blood access point, which is useful because blood access is sometimes difficult to achieve in severely injured patients, especially in the prehospital setting."

Though most transfusions for patients who've experienced traumatic injury involve component therapy, whole blood can serve a distinct role when a patient is heavily bleeding in the field. Emergency medicine services personnel can transport whole blood in validated, temperature-controlled coolers to use prior to hospital arrival. Prehospital use of whole blood impacts patient survival and arrival at the hospital, according to Dr. Klinkner.

History and availability of whole blood in Southern Minnesota trauma care

Dr. Stubbs, along with Donald H. Jenkins, M.D., vice chair for quality at University of Texas Health in San Antonio, Texas, and former medical director of Mayo Clinic's Level 1 Trauma Center, brought whole blood to Southern Minnesota in 2015, using it in air ambulances. Mayo Clinic began using whole blood in pediatric patients as young as 4 months old in September 2021, according to Dr. Klinkner.

Dr. Stubbs indicates that access to whole blood for any trauma center depends on whether the center's supplier provides it. He notes that though availability varies nationwide, multiple blood centers provide whole blood in the Midwest.

Trauma centers will see increasing use of whole blood in the future, indicates Dr. Klinkner.

Whole blood cannot be stored as long as components, which is notable for Southern Minnesota centers that do not perform a large volume of transfusions. However, if unused within a certain timeframe, whole blood can be separated into components, which can be stored longer, she indicates.

Whole blood in the context of recent blood shortages

Dr. Stubbs explains that episodic blood shortages — impacting whole blood and component supplies — have arisen since the COVID-19 pandemic started. The pandemic led to the following blood supply challenges:

  • Donor and employee illnesses, impacting donation and blood collection
  • Mobile blood donation event hiatus due to exposure risks
  • Employee donors located farther from collection sites while working remotely, complicating donation site visits
  • Patients postponing care or not even appearing at a medical center at all to avoid exposure
  • Higher transfusion needs following disease advancement in the absence of care

"Also, blood banks haven't been able to take walk-ins due the pandemic," says Dr. Klinkner. "Donors who'd normally pop in to donate blood can't do so due to social distancing requirements."

She also says that currently, there isn't a way to manufacture blood, making transfusions dependent on human donors.

Despite concerns about meeting patient transfusion needs, at Mayo Clinic, communication between Transfusion Medicine and the medical practice has allowed transfusion practices to remain conservative yet safe in light of blood shortages throughout the country. The blood shortage nationwide has limited potential supplemental supply options, so Mayo Clinic Donor Center efforts to encourage local donations have been crucial, says Dr. Stubbs.

"Thankfully, we've not reached a compromised blood supply status at Mayo Clinic due to the pandemic to date," he says.

With these factors influencing blood supply during COVID-19 — some of which still exist today — Dr. Stubbs strongly encourages trauma center personnel to donate personally and remind family, friends and community members to donate blood. He suggests hosting blood drives despite the pandemic if such events can be conducted safely to avoid an outbreak.

For more information

Godbey EA. Whole blood transfusion past, present, and future. Clinics in Laboratory Medicine. 2021;41:659.

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