Time for an Obituary? Time for an Obituary? Whole blood an entity or Whole blood an entity or

not?not?Dr. Sudipta Sekhar Das Dr. Sudipta Sekhar Das

MD (Transfusion Medicine), SGPGIMS MD (Transfusion Medicine), SGPGIMS

PDCC (Aphaeresis & Component Therapy), PDCC (Aphaeresis & Component Therapy),

SGPGIMSSGPGIMS

Consultant & Head, Transfusion MedicineConsultant & Head, Transfusion Medicine

Associate Professor (AHERF)Associate Professor (AHERF)

Apollo Gleneagles Hospital, KolkataApollo Gleneagles Hospital, KolkataISBTI: 14-16ISBTI: 14-16thth Sept. 2012 Sept. 2012

““If any single medical program can be credited with If any single medical program can be credited with

the saving of countless lives in World War II and the the saving of countless lives in World War II and the

Korean War, it was the prompt and liberal use of Korean War, it was the prompt and liberal use of

whole blood.” – LTG Leonard Heaton, Surgeon whole blood.” – LTG Leonard Heaton, Surgeon

General U.S. Army 1959-1969 General U.S. Army 1959-1969

Whole Whole BloodBlood

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 PRBCWB vs PRBCParameterParameter Whole bloodWhole 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 cellsPacked red cells

200 – 240 ml

≥ 1gm/dl

Same as WB

No

No

+

+

+

+

No

Biochemical changes in stored WBBiochemical changes in stored WB

Whole bloodWhole blood Packed cellsPacked cells

DaysDays 0 35 0 35

Plasma KPlasma K++ 4 27 5 70 (mmol/L)(mmol/L)

2,3DPG2,3DPG 100 10 100 10 % of initial value% of initial value

ATPATP 100 60 100 50 % of initial value% of initial value

Plasma Hb mg/LPlasma Hb mg/L 82 460 78 600

Viability of stored WB over timeViability of stored WB over time

2007

Why Blood ComponentsWhy Blood Components

Why Blood ComponentsWhy 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/ulfresh whole blood 5 units 1750 mlrandom platelets 5 units 250 mlapheresis platelets 1 unit 200 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 count 10,000 /ulHb 9 gm/dl

Transfusion with whole blood

Fresh warm whole blood 3-4 units to raise count up to 30000

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 30000

Advantages of such approach• no volume overload [200 ml]• precious resources spared• decreased complications

Target PLT: 30000 / ul

Advantages to Advantages to FWB 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 Disadvantages to FWB 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 FWB not to be used as a convenience 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 4oC

Recommendations for use of Recommendations for use of FWB 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 The decision to use FWB is a medical Decision

& must be made by a physician who has & must be made by a physician who has

knowledge of clinical situation & availability of knowledge of clinical situation & availability of

compatible blood components compatible blood components

WB in clinical WB in clinical practicepractice

• Paediatric patientsExchange 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 WB in clinical practicepractice

Studies & TrialsStudies & 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 surgeryThus, use of FWB for paediatric cardiac surgery remains controversial till date.remains controversial till date.

Transfusion 2005

Studies & TrialsStudies & 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 hrsFWB < 24 hrs

Studies & TrialsStudies & Trials

Final Final comments………..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

ReferenceReferences s

• 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

www.sudipta.sgpgi@yahoo.co.in+91-9804000473+91-9641949552