Effectiveness and safety of whole blood compared to balanced blood components in resuscitation of hemorrhaging trauma patients - A systematic review

Introduction: Hemorrhage is a leading cause of death among trauma patients, and is the most common cause of preventable death after trauma. Since the advent of blood component fractioning, most patients receive blood components rather than whole blood (WB). WB contains all of the individual blood components and has the advantages of simplifying resuscitation logistics, providing physiological ratios of components, reducing preservative volumes and allowing transfusion of younger red blood cells (RBC). Successful experience with fresh whole blood (FWB) by the US military is well documented. In the civilian setting, transfusion of cold-stored low titer type O whole blood (LTOWB) was shown to be safe. Reports of WB are limited by small numbers and low transfusion volumes. Study design: We conducted a systematic review of the available published studies, comparing efficacy and safety of resuscitation with WB to resuscitation with blood components, in hemorrhaging trauma patients, using MEDLINE, EMBASE and ISI Web of Science. The main outcomes of interest were 24 hour and 30-day survival, blood product utilization and adverse events. Two reviewers independently abstracted the studies and assessed for bias. Sub-group analyses were pre-planned on the FWB and LTOWB groups separately. Results: Out of 126 references identified through our search strategy, five studies met the inclusion criteria. Only one study of FWB showed a significant benefit on 24 hour and 30-day survival. Other studies of both FWB and LTOWB showed no statistically significant difference in survival. There is an apparent benefit in blood product utilization with the use of WB across most studies. There were no reports of transfusion related reactions, however there was an increase in the organ failure rates in the FWB groups. Conclusions: WB was not associated with a significant survival benefit or reduced blood product utilization. Nonetheless, it seems that the use of LTOWB is safe and might carry a significant logistic benefit. The quality of the existing data is poor and further high quality studies are required.