Whole blood and freeze-dried plasma in Canadian trauma care

Summary

This article highlights the crucial role of blood transfusion in trauma care and explores the historical and contemporary use of whole blood and freeze-dried plasma in Canadian health care. Early use of whole blood and freeze-dried plasma during global conflicts led to advancements in transfusion medicine. The transition to blood component therapy improved transfusion safety and precision. However, there is an increasing interest in using whole blood and freeze-dried plasma, supported by recent evidence suggesting potential benefits over blood component therapy, particularly in trauma cases. Canadian initiatives, such as leukoreduced whole blood production for the military, indicate efforts to address logistical challenges in delivering trauma care, especially in remote areas. Challenges remain, including logistical issues and regulatory complexities, requiring coordinated efforts for effective implementation. Overall, there’s growing support for integrating whole blood and freeze-dried plasma into trauma care across Canada.

Early use of whole blood and freeze-dried plasma

Blood transfusions have evolved dramatically over the past 4 centuries, from the earliest experiments in the 17th century to the sophisticated transfusions used today.¹ The early 20th century saw the development of whole blood and freeze-dried plasma for hemorrhagic shock during global conflicts.¹ Innovations in blood typing and storage improved the safety and effectiveness of transfusions. Dr. Lawrence Bruce Robertson, a Canadian surgeon, was instrumental in advancing blood transfusion techniques during World War I, which facilitated the transition of these practices into civilian medical care and led to the establishment of modern transfusion services and national blood banks.¹ These programs supported the war effort and laid the groundwork for the national blood donation and transfusion service, which has become an essential part of the Canadian health care system.¹

During World War II, freeze-dried plasma became essential because of its long shelf-life and portability, making plasma widely accessible for military and medical use.² The development of techniques to process, dry, and vacuum-seal plasma allowed it to be reconstituted with sterile water at the point of care, which enhanced medical logistics and patient treatment, particularly in remote settings.² However, hepatitis transmission from pooled dried plasma was a concern during the Korean War and led to its discontinuation owing to failed irradiation methods.²

Transition to blood component therapy

During the mid-20th century, there was a shift from using whole blood to blood component therapy.¹ This change was motivated by the need to enhance the safety and precision of blood transfusions.¹ Blood component therapy allows for the individualized use of red blood cells, platelets, and plasma to address the specific needs of patients.¹ Canadian regulations in the late 1990s introduced a requirement for pre-storage leukoreduction of cellular blood components. This led to the discontinuation of whole blood as a transfused product in the late 2000s owing to the lack of an adequate leukoreduction technique. This has resulted in improved treatment outcomes and fewer complications related to transfusions.¹ The transition to blood component therapy was made possible by technological advancements, including better refrigeration techniques and the use of plastic bags for blood storage.¹ Additionally, there was a better understanding of blood immunology.¹ These advancements led to better patient care through targeted therapy, increased the efficiency of blood use, and contributed to more effective blood bank management.¹

Concurrently, use of crystalloid fluids in trauma care, particularly for volume resuscitation, became widespread.¹ Initially, crystalloids were adopted as a seemingly simple and efficient way to manage hypovolemia and shock in trauma patients.¹ However, over time, the detrimental effects of excessive crystalloid use became apparent.¹ The historical reliance on crystalloids reflects a period of evolving understanding in trauma care, highlighting the importance of balanced resuscitation strategies that now favour blood product transfusion.

Re-emergence of whole blood and freeze-dried plasma

There is an increasing interest in using whole blood instead of component therapy for hemorrhage resuscitation in trauma patients.³ Studies suggest that whole blood transfusion is safe and may improve outcomes when compared with blood component therapy; however, conclusive evidence is still lacking.³ A recent systematic review comparing whole blood transfusion with blood component therapy in civilian and military patients with acute traumatic hemorrhage found that patients treated with whole blood had a 24-hour survival benefit.³ A subanalysis of civilian studies showed that patients who received whole blood with or without component therapy had lower early and 24-hour mortality than those who received only blood component therapy.³ However, retrospective studies have a major limitation of selection bias. Additionally, the use of whole blood in these studies is heterogeneous, and patients receiving whole blood may have better survival for other reasons.

A recent Canadian study found that freeze-dried plasma that is stored for 4 years possesses a clotting capacity comparable to fresh frozen plasma.² Accordingly, freeze-dried plasma may be a viable alternative to resuscitation fluids when whole blood is unavailable.⁴ Using whole blood and freeze-dried plasma has proven beneficial in resource-limited or remote areas because of their ease of transport, storage, and rapid preparation.^3,4 This could help reduce response times during medical emergencies requiring prompt resuscitation.

In 2022, Canadian Blood Services received Health Canada approval to begin producing leukoreduced whole blood for the Canadian Armed Forces.⁵ This type of blood is derived from single-donor whole blood and is processed with a platelet-sparing filter to reduce leukocytes while maintaining platelet levels.⁵ The purpose of leukoreduced whole blood is to address the challenges of providing trauma care in military and remote environments.⁵ Additionally, it may have potential civilian applications in the future.

Challenges and future directions

The adoption of whole blood and freeze-dried plasma for civilian trauma care represents an important stride forward. However, advancing this agenda is not without its hurdles. Challenges surrounding maintaining an adequate blood supply, meeting regulatory compliance, and standardization across Canada’s diverse health care ecosystem must be addressed.

A shift toward whole blood manufacturing will likely affect the inventory of other blood components in Canada. Each whole blood donation used to manufacture leukoreduced whole blood cannot be used to produce red cells, plasma, or a platelet concentrate. Canada’s expansive geography and variable resource distribution present formidable obstacles to the effective distribution and utilization of blood products. Overcoming these challenges demands innovative solutions. Whereas integrating whole blood and freeze-dried plasma holds promise, establishing a robust logistics framework is imperative to ensure equitable access for all patients.

Furthermore, navigating regulatory complexities adds another layer of intricacy. Harmonizing disparate provincial and territorial health regulations is essential for maintaining consistent standards of trauma care. Thus, a concerted and coordinated effort is indispensable in surmounting these challenges to deliver optimal care to all patients, regardless of their geographic location.

Conclusion

There is growing evidence to support the use of whole blood and freeze-dried plasma in the resuscitation of injured patients in hemorrhagic shock. Although superior clinical outcomes have not yet been demonstrated with these products, they have several logistic advantages. The effectiveness of these treatments in military and remote settings suggests promising directions for enhancing trauma care across Canada.