Fresh whole blood in massive transfusion

In some surgical patients or following major trauma, uncontrolled life-threatening bleeding persists despite transfusions with blood and blood products. In this situation, the haemostatic failure may be due to the underlying disorder, thrombocytopaenia, depletion of coagulation factors or a combination of these. The haemostatic disturbance may be further exacerbated by Heparin (cardiac surgery), the adverse effect of cardiopulmonary bypass on platelet function or hypothermia. Blood product replacement with packed cells, platelet concentrates and plasma is the standard form of transfusion management but does not always control the ongoing bleeding. Fresh unrefrigerated whole blood has been used in this clinical situation but reports of its success are anecdotal. The definition of fresh whole blood varies; blood less than 72 hours old versus unrefrigerated whole blood less than 6 hours old. A recent study demonstrated the value of unrefrigerated fresh whole blood transfused immediately after collection to 11 patients with uncontrollable haemorrhage who were deemed likely to die as a result of the ongoing bleeding. Seven of the 11 patients had a successful outcome with immediate slowing of the bleeding and reduced transfusion requirements. The fresh whole blood had been collected from hospital staff; the majority of whom were regular ARCBS donors, and was transfused without viral testing. The transfusion of blood untested for viruses carries a significant risk to the recipients. Where the donors are regular ARCBS blood donors there is a lower risk of infectivity. In the situation of uncontrollable life-threatening haemorrhage and without an alternative therapy being available, the benefit of the transfusion of fresh unscreened blood may outweigh this small risk of viral transmission. The mechanism of control of haemorrhage with fresh whole blood is not known. It is hypothesised that the platelets within the fresh blood do not have the storage lesion and functional defect of stored platelet concentrates and provide the haemostatic advantage over stored blood components. Unanswered questions regarding fresh whole blood are: how fresh must the blood be to provide the haemostatic benefit; can the ARCBS provide fresh screened blood when required; and, can fresh platelet concentrates provide the haemostatic benefit? Further, what volume of fresh blood or platelets is required and what clinical and/or laboratory criteria should be used to determine the indications for transfusion of fresh whole blood?