JOINT TRAUMA SYSTEM CLINICAL PRACTICE GUIDELINE (JTS CPG)
Whole Blood Transfusion (CPG ID: 21)
This CPG provides the rationale and guidelines for WB transfusion, including but
not limited to product definitions, indications, collection, storage, testing,
transfusion, and documentation.
Contributors
COL Andrew P Cap, MC, USA COL Elon Glassberg, MC, IDF LTC Jose Quesada, MSC, USA
LTC Andrew Beckett, MC, CAF COL Jennifer Gurney, MC, USA COL Michael Reade, MC, ADF
MAJ Avi Benov, MC, IDF COL (ret) Richard Gonzales, MSC, USA MG Anne Sailliol, MC, France
LTC Matthew Borgman, MC, USA COL Shawn F. Kane, MC, USA PROF Philip C Spinella, US
PROF Barbara Bryant, MD, USA LTC (ret) Wilbur W Malloy, MSC, USA CAPT Zsolt Stockinger, MC, USN
LTC Jacob Chen, MC, IDF COL Shawn Nessen, MC, USA CDR Geir Strandenes, MC, Norway
LTC Jason B Corley, MSC, USA COL Jeremy G Perkins MC, USA COL Audra Taylor, MSC, USA
COL (ret) Heidi Doughty, MC, UK MAJ Nicolas Prat, MC, France PROF Mark Yazer, MD, USA
MAJ Andrew Fisher, SP, USA
First Publication Date: 01 Oct 2006 Publication Date: 15 May 2018 Supersedes CPG dated 24 Oct 2012
TABLE OF CONTENTS
Definitions ................................................................................................................................................................................... 2
Background.................................................................................................................................................................................. 3
Advantages of Whole Blood over Components .......................................................................................................................... 3
Considerations in Choosing SWB or FWB .................................................................................................................................... 4
Whole Blood Recommendations ................................................................................................................................................. 5
Guidelines for Walking Blood Bank Program for FWB ................................................................................................................ 5
WBB Planning .............................................................................................................................................................................. 6
WB Pediatric Considerations ....................................................................................................................................................... 7
Performance Improvement (PI) Monitoring ............................................................................................................................... 8
Population of Interest ............................................................................................................................................................. 8
Intent (Expected Outcomes) ................................................................................................................................................... 8
Performance/Adherence Metrics ........................................................................................................................................... 8
Data Source ............................................................................................................................................................................. 8
System Reporting & Frequency............................................................................................................................................... 8
References ................................................................................................................................................................................... 8
Appendix A: Walking Blood Bank Process Map ......................................................................................................................... 11
Appendix B: Blood Donor Pre-screening SOP ............................................................................................................................ 12
Appendix C: Emergency Whole Blood Collection SOP............................................................................................................... 21
Appendix D: Additional Information Regarding Off-label Uses in CPGs .................................................................................... 39
Guideline Only/Not a Substitute for Clinical Judgment 1
,Whole Blood Transfusion CPG ID: 21
DEFINITIONS
Whole blood (WB) collected in the anticoagulants CPD or CPDA-1 is an FDA-approved product when it is
appropriately collected, stored and tested for transfusion transmitted disease (TTD) by a licensed blood donor
center. It can be stored for 21 days at 1-6°C in CPD or 35 days at 1-6°C in CPDA-1 and is designated stored whole
blood (SWB) in this CPG. SWB retains in vitro hemostatic parameters to an acceptable level during approved
storage duration.1 However, after the first 2 weeks of storage, the hemostatic function of WB may vary and
supplementation with fresher whole blood units or blood components, especially platelets, may be necessary.
Fresh whole blood (FWB) refers to WB collected on an emergency basis from a “walking blood bank” (WBB).
FWB can either be stored at room temperature and used within 24 hours of collection (and then destroyed if not
used) or it can be refrigerated within 8 hours of collection, after which point it becomes WBB-SWB. FWB is
considered to have full hemostatic function. FWB is collected from pre-screened donors when possible, but does
not undergo TTD testing prior to transfusion; this fact makes it not approvable by the FDA. Because FWB
presents a higher risk of disease transmission, it is reserved for situations in which tested blood products are
unavailable or ineffective (further discussion below).
The most important safety consideration in transfusing WB is that donor red blood cells (RBCs) be compatible
with the recipient to avoid acute hemolytic transfusion reactions (a.k.a., major mismatch). WB from group O
donors contains RBCs that are compatible with all recipients, but the plasma in group O WB may contain anti-A
and anti-B antibodies that could cause hemolysis in a non-group O recipient (a.k.a., minor mismatch). There are
two approaches to mitigating this risk: 1) transfuse only group-specific WB (i.e. A to A, B to B, AB to AB and O to
O), or 2) anti-A and anti-B antibody titers can be measured in group O WB and only units containing a low titer
of antibody (e.g., <1:256 saline dilution, immediate spin method) are designated “low titer O WB” (LTOWB) and
these are used as “universal WB.” LTOWB has been used extensively to resuscitate combat casualties and was a
standard of care in WWII, and the conflicts in Korea and Vietnam.2 Note that LTOWB may be either SWB or may
be collected from pre-screened O donors in a WBB protocol and thus be considered FWB (e.g., the Ranger O Low
titer or ROLO protocol).3 In practice, the only SWB supplied by the Armed Services Blood Program (ASBP) to
OCONUS locations will be LTOWB due to the relatively higher risk of donor-recipient blood group mismatch and
resulting hemolysis during group-specific WB transfusion, compared to the much lower risk of hemolysis with
LTOWB.2 Collecting LTOWB from WBB pre-screened donors is also preferred to group-specific transfusion. In
short, most WB transfused during future contingency operations will be LTOWB, and most of this is likely to be
SWB. Use of LTOWB is recognized under AABB Standard 5.15.1 (31st Edition, AABB Standards, in effect
beginning 01 April 2018).4
It should be noted that anti-A and anti-B titers may vary in group O donors. Ideally, WBB donors should be re-
titered every 90 days in conjunction with TTD testing. However; since availability of titer testing in the deployed
setting is very limited, every effort should be made to ensure that donors are titered at least annually if not prior
to each deployment. ASBP collects WB from male and never-pregnant female donors, or from female donors
testing negative for anti-HLA antibodies (this mitigates risk of transfusion-associated acute lung injury, TRALI).
WB is primarily collected from Rh positive donors and there is a limited supply of Rh negative blood products in
the deployed environment. Every effort should be made to provide Rh negative whole blood or red cells to
females of child-bearing potential (age<50 years) who are Rh negative or of unknown blood type. However;
should transfusions of Rh positive blood products occur in these patients, these must be thoroughly
documented in the patient’s medical record due to the risk of allo-immunization to Rh and potential for
hemolytic disease of the fetus/newborn (HDFN) in future pregnancies.
All WB products (SWB, FWB, and LTOWB) are indicated for the resuscitation of massive blood loss. WB, and in
particular LTOWB, is the preferred resuscitation product for the pre-hospital treatment of patients in
hemorrhagic shock.5,6 This CPG will distinguish between stored whole blood (SWB) and fresh whole blood
(FWB), and discuss uses and limitations of both products.
Guideline Only/Not a Substitute for Clinical Judgment 2
,Whole Blood Transfusion CPG ID: 21
BACKGROUND
The first documented animal-to-animal (dog) blood transfusion was performed at Oxford in 1665 by Richard
Lower, followed by the first animal-to-human blood transfusion in 1667 by Jean Denis. The first human-to-
human blood transfusion was performed by James Blundell in 1818. In the year 1900, the ABO blood grouping
system was classified by Landsteiner and, based on this, the first pre-transfusion cross-match was done by
Ottenberg in 1907. The system of Rh typing was invented by Landsteiner and Wiener in the year 1940.7 In
military settings, whole blood has been used extensively to resuscitate casualties in military conflicts since 1917,
during World War I.8 Whole blood is the starting point for blood donation and continues to be used extensively
worldwide where component production is not available.
Blood safety and sustainability are global issues. Component development supports the sustainability of blood
services where demand can outstrip supply. Component use also permits optimal storage conditions for each
element of the blood, minimizes hemolytic reactions and supports precision treatment. Examples include the
use of red blood cells (RBCs) for anemia, fresh frozen plasma (FFP) to replace lost or consumed clotting factors,
platelets (PLTs) for platelet abnormalities and thrombocytopenia, and cryoprecipitate (Cryo) for
hyperfibrinogenemia. Whole blood contains all of these elements in a smaller volume of anticoagulant and thus
provides a more concentrated product for treating bleeding patients who need all elements of blood replaced.
The widespread use of component therapy is driven by blood product availability. For the reasons outlined
above, blood banks have preferred to stock components over WB.
The clinical data comparing WB to components have recently been reviewed.6 Currently available clinical data
indicate that use of WB to treat hemorrhage results in outcomes that are at least as favorable as those that can
be expected with component therapy that includes RBCs, plasma and platelets.
Severely injured combat casualties requiring transfusion have a significant mortality rate (16%) and have the
greatest potential to benefit from early and appropriate transfusion strategies. A large retrospective cohort
study of casualties requiring transfusions during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF)
suggests a significant survival benefit for transfused casualties when RBCs, fresh frozen plasma, and platelets are
transfused at a 1:1:1 ratio.9 A recent randomized trial in civilian trauma patients demonstrated that a 1:1:1
transfusion ratio resulted in improved early hemostasis, though no statistically significant improvement in
survival.10 Two retrospective analyses in combat casualties comparing FWB to component therapy (which
included platelets) have also been published. One study showed a potential survival benefit to the use of FWB
during resuscitation of severe combat injuries, and the other showed FWB to be equivalent to component
therapy.11,12 These studies underscore the importance of providing all elements of whole blood (RBCs, plasma
and platelets) to severely bleeding patients and suggest that use of either WB or components in a 1:1:1 ratio for
resuscitation of bleeding patients is acceptable; product choices can be guided by practical considerations.
ADVANTAGES OF WHOLE BLOOD OVER COMPONENTS
SWB and FWB provide FFP:RBC:PLTs in a physiologic ratio and return to the bleeding patient what has been lost.
It should be noted that the 1:1:1 ratio of blood components (platelets: plasma:RBC) recommended for damage
control resuscitation does not faithfully reconstitute WB. The 1:1:1 ratio yields a dilute blood mixture with a
hematocrit of 29%,13 a platelet count of approximately 90,000/µL, and coagulation factors diluted to
approximately 62% of WB concentrations due to the presence of anticoagulants and red cell additive solution. In
addition, WB delivers all needed elements of blood in only one product, which only requires refrigeration for
storage. In contrast, component therapy requires multiple products and storage modalities (refrigeration,
freezing and generally room temperature storage with agitation for platelets – though platelets can also be
refrigerated), greatly increasing workload and complexity for clinical teams.
Guideline Only/Not a Substitute for Clinical Judgment 3
, Whole Blood Transfusion CPG ID: 21
SWB collected in licensed blood centers offers the same level of TTD safety as component therapy collected in
licensed centers. It should be noted that due to the extremely short shelf life of standard room temperature
stored platelets (5 days), all platelet products transfused in the deployed setting are collected in theater and do
not undergo TTD testing prior to transfusion. Therefore, SWB collected in licensed centers and fully tested
presents a lower TTD risk than component therapy using in-theater collected platelets or FWB.
For U.S. casualties presenting in hemorrhagic shock, a transfusion strategy that included FWB with RBCs and
plasma was associated with an improved survival compared to the use of stored components only (FFP, RBCs,
and PLTs).11 Compared to SWB or component therapy, FWB is more readily available in austere conditions and
requires only the presence of donors and simple collection equipment, though safe collection and transfusion of
FWB requires appropriate pre-deployment training 14,15 and careful donor evaluation. FWB has no loss of the
labile clotting factors or platelet activity that is often associated with storage, has close to physiological
hematocrit and has no red blood cell “storage lesion.” Storage lesion describes the degradation of the RBC
involving loss of membrane plasticity,11,12 diphosphoglycerate, adenosine triphosphate, nitric oxide, and other
factors leading to potentially reduced delivery of oxygen to tissues and contribution to a variety of
pathophysiologic processes.16 It should be noted that recent randomized trials assessing the effects of red blood
cell storage age have not confirmed a clinically detectable deleterious effect of the red cell storage lesion in the
populations evaluated. The effect of red cell storage age, whether in component therapy or SWB has not been
rigorously evaluated in certain vulnerable populations, such as trauma patients.17
Overall, both SWB and FWB offer at least comparable performance and safety compared with components, as
well as compelling logistical advantages that are particularly important in pre-hospital resuscitation and indeed,
in most deployment settings.
CONSIDERATIONS IN CHOOSING SWB OR FWB
There are risks associated with the use of FWB, including but not limited to increased risk of transfusion-
transmitted infections (e.g., HIV, hepatitis B/C, syphilis), and an increased risk of clerical errors leading to major
mismatch when ABO-identical WB is provided, due to the potentially chaotic conditions during which FWB is
requested. Additionally, field conditions are inherently unsanitary and are presumed to increase the risk of
bacterial contamination of the blood. Recent history with approximately 10,000 FWB transfusions to U.S.
personnel during OIF/OEF have resulted in one Hepatitis C (HCV), one Human T-Lymphocyte Virus (HTLV)
seroconversion, and one fatal case of transfusion-associated graft-versus host disease that was potentially due
to a FWB transfusion.4 FWB is not FDA-approved and is not intended or indicated for routine use. It is NOT
appropriate, as a matter of convenience, to use FWB as an alternative to more stringently controlled blood
products for patients who do not have severe, immediately life-threatening injuries. FWB is to be used only
when other blood products cannot be delivered at an acceptable rate to sustain the resuscitation of an actively
bleeding patient, when specific stored products are not available (e.g., SWB, RBCs, FFP, PLTs, Cryo), or when
stored components are not adequately resuscitating a patient with an immediately life-threatening injury. FWB
should not routinely be collected from pre-screened donors as a way to maintain a routine inventory of WBB-
SWB products. In other words, the use of WBB for collection of FWB is for emergency use only. It should be
noted that studies of FWB donors have not documented significant decrements in military-relevant task
performance following donation. Thus, concerns that FWB collections will adversely affect mission outcomes
have not been substantiated and should not preclude WBB activation when conditions for FWB use are met.18
In patients receiving LTOWB (SWB or FWB), every effort should be made to obtain a pre-transfusion blood
sample in order to establish the original blood group. If blood samples are obtained after transfusion with
LTOWB, it may be impossible to definitively establish a patient’s blood group with the equipment available in
the deployed setting. As a result, patients of unknown blood group receiving LTOWB will continue to receive
LTOWB or group O RBC units for their acute transfusion requirements for up to a month following admission.
This can deplete inventories of LTOWB and group O RBCs.
Guideline Only/Not a Substitute for Clinical Judgment 4
Whole Blood Transfusion (CPG ID: 21)
This CPG provides the rationale and guidelines for WB transfusion, including but
not limited to product definitions, indications, collection, storage, testing,
transfusion, and documentation.
Contributors
COL Andrew P Cap, MC, USA COL Elon Glassberg, MC, IDF LTC Jose Quesada, MSC, USA
LTC Andrew Beckett, MC, CAF COL Jennifer Gurney, MC, USA COL Michael Reade, MC, ADF
MAJ Avi Benov, MC, IDF COL (ret) Richard Gonzales, MSC, USA MG Anne Sailliol, MC, France
LTC Matthew Borgman, MC, USA COL Shawn F. Kane, MC, USA PROF Philip C Spinella, US
PROF Barbara Bryant, MD, USA LTC (ret) Wilbur W Malloy, MSC, USA CAPT Zsolt Stockinger, MC, USN
LTC Jacob Chen, MC, IDF COL Shawn Nessen, MC, USA CDR Geir Strandenes, MC, Norway
LTC Jason B Corley, MSC, USA COL Jeremy G Perkins MC, USA COL Audra Taylor, MSC, USA
COL (ret) Heidi Doughty, MC, UK MAJ Nicolas Prat, MC, France PROF Mark Yazer, MD, USA
MAJ Andrew Fisher, SP, USA
First Publication Date: 01 Oct 2006 Publication Date: 15 May 2018 Supersedes CPG dated 24 Oct 2012
TABLE OF CONTENTS
Definitions ................................................................................................................................................................................... 2
Background.................................................................................................................................................................................. 3
Advantages of Whole Blood over Components .......................................................................................................................... 3
Considerations in Choosing SWB or FWB .................................................................................................................................... 4
Whole Blood Recommendations ................................................................................................................................................. 5
Guidelines for Walking Blood Bank Program for FWB ................................................................................................................ 5
WBB Planning .............................................................................................................................................................................. 6
WB Pediatric Considerations ....................................................................................................................................................... 7
Performance Improvement (PI) Monitoring ............................................................................................................................... 8
Population of Interest ............................................................................................................................................................. 8
Intent (Expected Outcomes) ................................................................................................................................................... 8
Performance/Adherence Metrics ........................................................................................................................................... 8
Data Source ............................................................................................................................................................................. 8
System Reporting & Frequency............................................................................................................................................... 8
References ................................................................................................................................................................................... 8
Appendix A: Walking Blood Bank Process Map ......................................................................................................................... 11
Appendix B: Blood Donor Pre-screening SOP ............................................................................................................................ 12
Appendix C: Emergency Whole Blood Collection SOP............................................................................................................... 21
Appendix D: Additional Information Regarding Off-label Uses in CPGs .................................................................................... 39
Guideline Only/Not a Substitute for Clinical Judgment 1
,Whole Blood Transfusion CPG ID: 21
DEFINITIONS
Whole blood (WB) collected in the anticoagulants CPD or CPDA-1 is an FDA-approved product when it is
appropriately collected, stored and tested for transfusion transmitted disease (TTD) by a licensed blood donor
center. It can be stored for 21 days at 1-6°C in CPD or 35 days at 1-6°C in CPDA-1 and is designated stored whole
blood (SWB) in this CPG. SWB retains in vitro hemostatic parameters to an acceptable level during approved
storage duration.1 However, after the first 2 weeks of storage, the hemostatic function of WB may vary and
supplementation with fresher whole blood units or blood components, especially platelets, may be necessary.
Fresh whole blood (FWB) refers to WB collected on an emergency basis from a “walking blood bank” (WBB).
FWB can either be stored at room temperature and used within 24 hours of collection (and then destroyed if not
used) or it can be refrigerated within 8 hours of collection, after which point it becomes WBB-SWB. FWB is
considered to have full hemostatic function. FWB is collected from pre-screened donors when possible, but does
not undergo TTD testing prior to transfusion; this fact makes it not approvable by the FDA. Because FWB
presents a higher risk of disease transmission, it is reserved for situations in which tested blood products are
unavailable or ineffective (further discussion below).
The most important safety consideration in transfusing WB is that donor red blood cells (RBCs) be compatible
with the recipient to avoid acute hemolytic transfusion reactions (a.k.a., major mismatch). WB from group O
donors contains RBCs that are compatible with all recipients, but the plasma in group O WB may contain anti-A
and anti-B antibodies that could cause hemolysis in a non-group O recipient (a.k.a., minor mismatch). There are
two approaches to mitigating this risk: 1) transfuse only group-specific WB (i.e. A to A, B to B, AB to AB and O to
O), or 2) anti-A and anti-B antibody titers can be measured in group O WB and only units containing a low titer
of antibody (e.g., <1:256 saline dilution, immediate spin method) are designated “low titer O WB” (LTOWB) and
these are used as “universal WB.” LTOWB has been used extensively to resuscitate combat casualties and was a
standard of care in WWII, and the conflicts in Korea and Vietnam.2 Note that LTOWB may be either SWB or may
be collected from pre-screened O donors in a WBB protocol and thus be considered FWB (e.g., the Ranger O Low
titer or ROLO protocol).3 In practice, the only SWB supplied by the Armed Services Blood Program (ASBP) to
OCONUS locations will be LTOWB due to the relatively higher risk of donor-recipient blood group mismatch and
resulting hemolysis during group-specific WB transfusion, compared to the much lower risk of hemolysis with
LTOWB.2 Collecting LTOWB from WBB pre-screened donors is also preferred to group-specific transfusion. In
short, most WB transfused during future contingency operations will be LTOWB, and most of this is likely to be
SWB. Use of LTOWB is recognized under AABB Standard 5.15.1 (31st Edition, AABB Standards, in effect
beginning 01 April 2018).4
It should be noted that anti-A and anti-B titers may vary in group O donors. Ideally, WBB donors should be re-
titered every 90 days in conjunction with TTD testing. However; since availability of titer testing in the deployed
setting is very limited, every effort should be made to ensure that donors are titered at least annually if not prior
to each deployment. ASBP collects WB from male and never-pregnant female donors, or from female donors
testing negative for anti-HLA antibodies (this mitigates risk of transfusion-associated acute lung injury, TRALI).
WB is primarily collected from Rh positive donors and there is a limited supply of Rh negative blood products in
the deployed environment. Every effort should be made to provide Rh negative whole blood or red cells to
females of child-bearing potential (age<50 years) who are Rh negative or of unknown blood type. However;
should transfusions of Rh positive blood products occur in these patients, these must be thoroughly
documented in the patient’s medical record due to the risk of allo-immunization to Rh and potential for
hemolytic disease of the fetus/newborn (HDFN) in future pregnancies.
All WB products (SWB, FWB, and LTOWB) are indicated for the resuscitation of massive blood loss. WB, and in
particular LTOWB, is the preferred resuscitation product for the pre-hospital treatment of patients in
hemorrhagic shock.5,6 This CPG will distinguish between stored whole blood (SWB) and fresh whole blood
(FWB), and discuss uses and limitations of both products.
Guideline Only/Not a Substitute for Clinical Judgment 2
,Whole Blood Transfusion CPG ID: 21
BACKGROUND
The first documented animal-to-animal (dog) blood transfusion was performed at Oxford in 1665 by Richard
Lower, followed by the first animal-to-human blood transfusion in 1667 by Jean Denis. The first human-to-
human blood transfusion was performed by James Blundell in 1818. In the year 1900, the ABO blood grouping
system was classified by Landsteiner and, based on this, the first pre-transfusion cross-match was done by
Ottenberg in 1907. The system of Rh typing was invented by Landsteiner and Wiener in the year 1940.7 In
military settings, whole blood has been used extensively to resuscitate casualties in military conflicts since 1917,
during World War I.8 Whole blood is the starting point for blood donation and continues to be used extensively
worldwide where component production is not available.
Blood safety and sustainability are global issues. Component development supports the sustainability of blood
services where demand can outstrip supply. Component use also permits optimal storage conditions for each
element of the blood, minimizes hemolytic reactions and supports precision treatment. Examples include the
use of red blood cells (RBCs) for anemia, fresh frozen plasma (FFP) to replace lost or consumed clotting factors,
platelets (PLTs) for platelet abnormalities and thrombocytopenia, and cryoprecipitate (Cryo) for
hyperfibrinogenemia. Whole blood contains all of these elements in a smaller volume of anticoagulant and thus
provides a more concentrated product for treating bleeding patients who need all elements of blood replaced.
The widespread use of component therapy is driven by blood product availability. For the reasons outlined
above, blood banks have preferred to stock components over WB.
The clinical data comparing WB to components have recently been reviewed.6 Currently available clinical data
indicate that use of WB to treat hemorrhage results in outcomes that are at least as favorable as those that can
be expected with component therapy that includes RBCs, plasma and platelets.
Severely injured combat casualties requiring transfusion have a significant mortality rate (16%) and have the
greatest potential to benefit from early and appropriate transfusion strategies. A large retrospective cohort
study of casualties requiring transfusions during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF)
suggests a significant survival benefit for transfused casualties when RBCs, fresh frozen plasma, and platelets are
transfused at a 1:1:1 ratio.9 A recent randomized trial in civilian trauma patients demonstrated that a 1:1:1
transfusion ratio resulted in improved early hemostasis, though no statistically significant improvement in
survival.10 Two retrospective analyses in combat casualties comparing FWB to component therapy (which
included platelets) have also been published. One study showed a potential survival benefit to the use of FWB
during resuscitation of severe combat injuries, and the other showed FWB to be equivalent to component
therapy.11,12 These studies underscore the importance of providing all elements of whole blood (RBCs, plasma
and platelets) to severely bleeding patients and suggest that use of either WB or components in a 1:1:1 ratio for
resuscitation of bleeding patients is acceptable; product choices can be guided by practical considerations.
ADVANTAGES OF WHOLE BLOOD OVER COMPONENTS
SWB and FWB provide FFP:RBC:PLTs in a physiologic ratio and return to the bleeding patient what has been lost.
It should be noted that the 1:1:1 ratio of blood components (platelets: plasma:RBC) recommended for damage
control resuscitation does not faithfully reconstitute WB. The 1:1:1 ratio yields a dilute blood mixture with a
hematocrit of 29%,13 a platelet count of approximately 90,000/µL, and coagulation factors diluted to
approximately 62% of WB concentrations due to the presence of anticoagulants and red cell additive solution. In
addition, WB delivers all needed elements of blood in only one product, which only requires refrigeration for
storage. In contrast, component therapy requires multiple products and storage modalities (refrigeration,
freezing and generally room temperature storage with agitation for platelets – though platelets can also be
refrigerated), greatly increasing workload and complexity for clinical teams.
Guideline Only/Not a Substitute for Clinical Judgment 3
, Whole Blood Transfusion CPG ID: 21
SWB collected in licensed blood centers offers the same level of TTD safety as component therapy collected in
licensed centers. It should be noted that due to the extremely short shelf life of standard room temperature
stored platelets (5 days), all platelet products transfused in the deployed setting are collected in theater and do
not undergo TTD testing prior to transfusion. Therefore, SWB collected in licensed centers and fully tested
presents a lower TTD risk than component therapy using in-theater collected platelets or FWB.
For U.S. casualties presenting in hemorrhagic shock, a transfusion strategy that included FWB with RBCs and
plasma was associated with an improved survival compared to the use of stored components only (FFP, RBCs,
and PLTs).11 Compared to SWB or component therapy, FWB is more readily available in austere conditions and
requires only the presence of donors and simple collection equipment, though safe collection and transfusion of
FWB requires appropriate pre-deployment training 14,15 and careful donor evaluation. FWB has no loss of the
labile clotting factors or platelet activity that is often associated with storage, has close to physiological
hematocrit and has no red blood cell “storage lesion.” Storage lesion describes the degradation of the RBC
involving loss of membrane plasticity,11,12 diphosphoglycerate, adenosine triphosphate, nitric oxide, and other
factors leading to potentially reduced delivery of oxygen to tissues and contribution to a variety of
pathophysiologic processes.16 It should be noted that recent randomized trials assessing the effects of red blood
cell storage age have not confirmed a clinically detectable deleterious effect of the red cell storage lesion in the
populations evaluated. The effect of red cell storage age, whether in component therapy or SWB has not been
rigorously evaluated in certain vulnerable populations, such as trauma patients.17
Overall, both SWB and FWB offer at least comparable performance and safety compared with components, as
well as compelling logistical advantages that are particularly important in pre-hospital resuscitation and indeed,
in most deployment settings.
CONSIDERATIONS IN CHOOSING SWB OR FWB
There are risks associated with the use of FWB, including but not limited to increased risk of transfusion-
transmitted infections (e.g., HIV, hepatitis B/C, syphilis), and an increased risk of clerical errors leading to major
mismatch when ABO-identical WB is provided, due to the potentially chaotic conditions during which FWB is
requested. Additionally, field conditions are inherently unsanitary and are presumed to increase the risk of
bacterial contamination of the blood. Recent history with approximately 10,000 FWB transfusions to U.S.
personnel during OIF/OEF have resulted in one Hepatitis C (HCV), one Human T-Lymphocyte Virus (HTLV)
seroconversion, and one fatal case of transfusion-associated graft-versus host disease that was potentially due
to a FWB transfusion.4 FWB is not FDA-approved and is not intended or indicated for routine use. It is NOT
appropriate, as a matter of convenience, to use FWB as an alternative to more stringently controlled blood
products for patients who do not have severe, immediately life-threatening injuries. FWB is to be used only
when other blood products cannot be delivered at an acceptable rate to sustain the resuscitation of an actively
bleeding patient, when specific stored products are not available (e.g., SWB, RBCs, FFP, PLTs, Cryo), or when
stored components are not adequately resuscitating a patient with an immediately life-threatening injury. FWB
should not routinely be collected from pre-screened donors as a way to maintain a routine inventory of WBB-
SWB products. In other words, the use of WBB for collection of FWB is for emergency use only. It should be
noted that studies of FWB donors have not documented significant decrements in military-relevant task
performance following donation. Thus, concerns that FWB collections will adversely affect mission outcomes
have not been substantiated and should not preclude WBB activation when conditions for FWB use are met.18
In patients receiving LTOWB (SWB or FWB), every effort should be made to obtain a pre-transfusion blood
sample in order to establish the original blood group. If blood samples are obtained after transfusion with
LTOWB, it may be impossible to definitively establish a patient’s blood group with the equipment available in
the deployed setting. As a result, patients of unknown blood group receiving LTOWB will continue to receive
LTOWB or group O RBC units for their acute transfusion requirements for up to a month following admission.
This can deplete inventories of LTOWB and group O RBCs.
Guideline Only/Not a Substitute for Clinical Judgment 4
