PRMC using ‘whole blood’ to save lives

Darin Smith checks the quantities of separate blood supply types in the Hospital Blood Bank with LaNeisha Riggan, SBB.

Kerrville’s Peterson Regional Medical Center has initiated a new program using cold-stored whole blood for traumatically injured patients, one of only four hospitals in the STRAC region, along with the emergency helicopter services here.

The next closest participating hospital is in San Antonio. The STRAC region covers 26,000 square miles and 22 counties.

Southwest Texas Regional Advisory Council (STRAC) is the recipient of a $150,000 grant from the SA Med Foundation. This is an inter-institutional collaboration with the University of Texas Health Science Center, University Health Systems, South Texas Blood & Tissue Center, and ISR/SAMMC.

It was formed to study/address the deficit in the care of injured patients in the STRAC region through development of a cold-stored whole blood product; and implement transfusion of cold-stored whole blood in the pre-hospital setting on emergency helicopters.

Local Trauma Coordinator R.N. Darin Smith initiated this process for PRMC, and made this product available to better serve the community in the event it is ever needed in a life-threatening emergency.

Current procedures

Smith said the usual procedure currently when Kerrville-area donors give blood is that they are giving whole blood.

South Texas Blood & Tissue Center personnel take donations to a San Antonio lab where it’s separated into red blood cells, platelets (which have a “shelf life” of three days) and plasma. It’s stored in San Antonio, and when PRMC needs it, it can be delivered here. And PRMC has its own blood bank in the main hospital.

On hand on a “normal day,” Smith said the blood bank staff has two units of whole blood, and units of red blood cells itemized as O+, A+, O-, A-, B+, B-, AB+ and AB-.

Smith said patient demand for whole blood hasn’t decreased during ongoing COVID pandemic; while patients with specific diagnosis still require the individual blood components. For instance, some cancer patients get platelets; and some with chronic anemia need red blood cells.

“When patients bleed whole blood in a trauma or hemorrhage, it makes sense to replace it with whole blood,” Smith said. “We used to transfuse whole blood in the military, even man-to-man, until the 1970s. That’s all there was.”

A limiting factor in the medical process is that only males can donate to whole blood supplies because of the suitable components in their blood.

He said this whole blood is Rh-positive, and there’s still a possibility of the patient reacting if they’re Rh-negative.

“But with whole blood, the ratio of the Rh-factor is smaller, so there’s a very low risk of that.”

Smith said before 2018, if a patient was bleeding, emergency personnel absolutely had to know the patient’s blood type Rh-factor.

Smith was an air-medical flight nurse for almost five years, and based on his experience, whole blood was a tool in his toolbox, but not used in emergency rooms then.

The STRAC website provided this explanation.

Pre-hospital Low Titer Cold Stored Whole Blood

Their goal and philosophy is for “Ubiquitous Utilization of O Positive Product for Emergency Use in Hemorrhage due to Injury.”

The mortality from hemorrhage in trauma patients remains high. Early balanced resuscitation improves survival.

“These truths, balanced with the availability of local resources and our goals for positive regional impact, were the foundation for the development of our pre-hospital whole blood initiative, using low titer cold stored O RhD positive whole blood (LTOWB),” according to Dr. Donald Jenkins, a STRAC physician.

The main concern with use of RhD positive blood is the potential development of iso-immunization in RhD negative patients.

“We used our retrospective massive transfusion protocol data to analyze the anticipated risk of this change in practice. In 30 months, out of 124 total MTP patients, only one female of childbearing age who received an MTP was RhD negative.

“With the risk of isoimmunization very low and the benefit of increased resources for the early administration of balanced resuscitation high, we determined that utilization of ‘whole blood’ would be safe and best serve our community.”

Smith said at PRMC their blood bank now stores and supplies to the staff both whole blood, and the separated components of red blood cells, plasma and platelets. The choice of which to use on any patient is still the doctor’s decision.

But the emergency medical helicopter crews in this area who are first on the scenes of traumatic medical needs also are using whole blood.

Smith said in the human body, it’s already flowing through a person’s veins; and it’s what a blood donor gives at a donation drive. It is what was “transfused” into patients routinely until the 1970s.

Studies now say it provides better oxygen-carrying capacity and coagulation needed in emergencies.

Brothers In Arms

San Antonio is one of the first U.S. communities to transfer military battlefield research to civilian use.

The South Texas Blood and Tissue Center on Jan. 29, 2018 launched the "Brothers In Arms" blood donor program.

The program gave medical helicopter crews a new tool to fight blood loss, and save the lives of critically injured patients by providing them with whole blood for pre-hospital transfusions.

What is whole blood?

Low anti-body titer cold-stored O+ whole blood is an FDA-licensed and AABB-approved blood product for administration in emergency release situations when other blood products are unavailable and/or the patient’s blood type is unknown. It is the unit of blood drawn from the donor, which has been tested like any other blood product, and a preservative is added (like other blood products). So it contains the red cells, plasma, platelets and white cells from the donor, just like it was when circulating in their veins.

Why is it needed?

STRAC’s study of patients indicate waiting until a patient gets to the hospital to give the first transfusion has a very high death rate (more than 70 percent). Cold-stored whole blood can safely provide oxygen-carrying capacity and restore coagulation at the same time.

Are there any concerns?

No. This was the only blood product available from the inception of blood transfusion, into the 1970’s. Patient transfusion risks actually decrease since they are receiving a transfusion from one donor source instead of three.

How much is in a unit of blood?

Each bag contains about 520 cubic centimeters total volume, equivalent to 1 unit of “packed red blood cells,” and one unit each of platelets and plasma.

Why use this, and not “1 to 1 to 1” component therapy?

Logistics. Effective shelf life of platelets, the number one coagulation factor needed by bleeding trauma patients, is three days. Patients bleed whole blood; it’s replaced with whole blood. And it can be warmed.

Do platelets still work?

Yes. Platelet function in cold-stored whole blood on day 35 is the same as platelet function in a regular unit on day 5, when it must be used or discarded.

Is this universal donor blood?

In the traditional sense, no, because it is Rh+, not Rh-.

Can this be given to women of child-bearing age?

Yes. The risk benefit to the patient favors risk of antibody formation versus death due to hemorrhage.

Use in children?

Children under age three probably should not get emergency release whole blood, due to the development of their immune system.

Does this interfere with administering other additional blood products or medications?

No. Administration is the same as with all other blood/blood products.

Can patient receive component therapy after receiving O+ whole blood?

Yes.

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