Is whole blood superior to component therapy for trauma resuscitation?

From the Guidelines

Whole blood is generally considered superior to component therapy for trauma resuscitation in severe hemorrhagic shock, as it provides all blood components in a single product, closely resembling what patients lose during massive bleeding. The recommended approach for severe trauma with significant blood loss is to use whole blood when available, typically given in units of approximately 500 mL per unit 1. Whole blood maintains physiologic ratios of components, preserves clotting factors, and reduces the total volume needed compared to separate component administration. This approach helps restore oxygen-carrying capacity while simultaneously addressing coagulopathy.

Key Benefits of Whole Blood

• Decreased mortality
• Reduced total blood product usage
• Faster hemorrhage control in severely injured trauma patients However, availability remains a challenge in many hospitals, and component therapy (using packed red blood cells, plasma, and platelets in a 1:1:1 ratio) remains an acceptable alternative when whole blood isn't available 1.

Component Therapy as an Alternative

• May be used when whole blood is not available
• Should be administered in a 1:1:1 ratio of FFP:platelet:RBC
• Has been shown to improve survival and haemostasis, but data are equivocal 1 Some studies suggest that the use of coagulation factor concentrates, such as fibrinogen concentrate, may be beneficial in patients with significant bleeding and coagulopathy 1. However, the evidence is not yet conclusive, and further research is needed to determine the optimal approach for trauma resuscitation.

Future Research Directions

• Laboratory-guided resuscitation with whole blood and component therapy
• Comparison of different ratios of FFP:platelet:RBC in component therapy
• Evaluation of the use of coagulation factor concentrates in trauma resuscitation 1

From the FDA Drug Label

A total of 195 patients 17–65 years of age were included in the FIBRYGA group and 203 in the cryoprecipitate group. The fibrinogen level increased from 1.7 ± 0.6 g/L to 2.5 ± 0.6 g/L in the FIBRYGA group and from 1.7 ± 0.6 g/L to 2.3 ± 0.6 g/L for the cryoprecipitate group, FIBRYGA was demonstrated to be non-inferior to cryoprecipitate based on the total number of units of allogeneic blood products (ABPs) administered during the first 24 hours after termination of cardiopulmonary bypass (CPB)

The FDA drug label does not answer the question.

From the Research

Advantages of Whole Blood in Trauma Resuscitation

• Whole blood confers many advantages over component therapy, including the transfusion of blood with a physiologic ratio of components, ease of transport and transfusion, less volume of anticoagulants and additives transfused to the patient, and exposure to fewer donors 2
• The use of whole blood is associated with improved mortality in hemostatic resuscitation of major bleeding, with a 48% reduction in mortality compared to component therapy 3
• Whole blood administration initiated in the prehospital setting may improve early shock severity, coagulopathy, and survival when used over traditional resuscitation fluids such as crystalloid administration or component therapy 4

Comparison to Component Therapy

• Component therapy with a targeted ratio of packed red blood cells, platelets, and plasma has previously been utilized, but whole blood has been shown to be a potent tool in the treatment of massive hemorrhagic shock 5
• The current standard for resuscitating trauma patients is blood component therapy, but whole blood is emerging as the blood product of choice 3
• Hemostatic resuscitation using defined blood component ratios modified by early laboratory results can lead to more efficient blood product usage and improved patient outcomes, but whole blood may be a more effective option 6

Outcomes and Safety

• Resuscitation with cold fresh whole blood has similar outcomes and a similar safety profile compared to resuscitation with hemocomponents 2
• Whole blood patients were 9% less likely to experience bleeding complications and were 48% less likely to die than component therapy patients 3
• The use of whole blood is not without its challenges, including logistical issues, but programs are underway to demonstrate its feasibility in metropolitan areas 5