“When patients are bleeding, they're bleeding whole blood. We need to give them back what they're bleeding.” It's a simple concept, but one that hasn't been widely used since blood component therapy became the norm during the Vietnam War. For Justin Richards, MD, and a growing number of whole blood resuscitation advocates around the country, giving patients whole blood during trauma could be the key to better outcomes. Dr. Richards is Associate Professor of Anesthesiology and Critical Care Medicine at the University of Maryland School of Medicine Division of Trauma Anesthesiology, and Associate Medical Director of the Trauma Resuscitation Unit at the R Adams Cowley Shock Trauma Center.
History of blood resuscitation
Blood resuscitation practices are often influenced by the military, according to Dr. Richards. Wars are at the center of trauma and can act as an informant for the best and most efficient care practices for the general population. Physicians have long known the potential of whole blood, which was in use for 100 years and largely used during WWI and WWII, with component therapy only becoming a more common practice around the Vietnam War, when blood banks had the technical capability to partition blood to give patients specifically the portion of blood they needed. Dr. Richards explained: “In the early 2000s with the conflict in the Middle East, we found that we were going in the wrong direction with certain component therapy resuscitation,” he said. “The disadvantages became more apparent, and a specific focus on giving a 1:1:1 resuscitation ratio that was a closer blood product to whole blood – what's in our vessels already – emerged.” Whole blood resuscitation became feasible in the military with good anecdotal outcomes, and as the treatment was used more since patients who received the treatment responded better. With this knowledge, the pendulum has swung back to using whole blood.
Benefits of whole blood
The justification of whole blood resuscitation is quite simple: giving back what we're bleeding. Component therapy consists of three separate units: red blood cells, plasma, and platelets, all of which serve specific functions in the body, including carrying oxygen, helping to form blood clots, and providing proteins that help heal blood vessels and can be administered for specific reasons. But when providing these elements separately through component therapy, patients are also receiving preservatives that don't carry oxygen and dilute the blood product, proteins that differ from natural proteins in whole blood, and an overall higher volume than compared to a single unit of whole blood. Patients may also receive three separate components from three different donors, exposing the patient to added risk.
With whole blood, patients are receiving blood more similar to that running through their vessels every day, at a lower volume, from one donor. In addition, whole blood has a better clotting profile, is easier to use, and is just as safe as component therapy. So why isn't it being more commonly used? Dr. Richards explained that there have been no prospective, randomized, high-quality studies to identify which patients may most benefit or what clinical scenarios are best for whole blood resuscitation. “Like most things with medicine, we need to figure out the right treatment for the right patient at the right time. But at Shock Trauma, our use of whole blood for acutely bleeding trauma patients has been successful, and other hospitals have used whole blood for postpartum hemorrhage, pediatric trauma, bleeding from cardiac surgery, and gastrointestinal bleeding with success.”
The anesthesiologist's role
As the use of whole blood resuscitation continues to evolve, one thing is certain: anesthesiologists will continue their valuable role as clinical experts in the administration of blood products. “Anesthesiologists are responsible for recognizing which patients are acutely bleeding, those who are at risk for acute blood loss, and those at risk for needing massive resuscitation requiring multiple units of blood within an hour,” Dr. Richards noted. “We are critical to determining which patients will benefit from whole blood resuscitation, and we are the providers who administer blood products. We are the experts who are responsible for continuing resuscitation in the OR, recognizing coagulopathy, and determining what patients need when they lose intravascular blood, and what other organs may be dysfunctional. By the nature of our training and clinical practice, anesthesiologists are experts in the clinical area of blood resuscitation.”
Kelly Wolfgang is a freelance writer with over 10 years of experience in medical journalism. She holds a master's degree in organizational psychology from Pennsylvania State University.