Tag Archives: transfusion

Blood Transfusion With Component Therapy vs Whole Blood

About 40 years ago, blood banks started moving away from keeping whole blood and began separating it into components (packed cells, platelets, plasma, etc.) for more targeted use. For most uses, this is just fine. But what about trauma?

Trauma patients bleed whole blood. Doesn’t it make sense to give whole blood back? Much of our experience with massive transfusion is derived from our colleagues in the military. Two decades ago, the norm was to give 4 units of packed red cells or so, then give two units of plasma, and every once in a while slip in a bag of platelets. Our military experience seems to indicate that this 4:2:1 ratio is not optimal, and that something like 1:1:1 is better.

If you think about it, whole blood is already 1:1:1. Splitting it into components and then giving each one of them back separately seems to be a lot of extra work (and expense) to accomplish the same thing as just giving a unit of whole blood. And if you look at the purple table above, rebuilding a unit of whole blood from components isn’t nearly as good as whole blood. Plus it triples the exposure to infectious agents and antigens, since the components will usually come from (at least) three separate donors. Note that the data in the table above is true for fresh whole blood (not practical in civilian life); banked whole blood will still lose some coagulation activity. 

Is it time to think about supplying whole blood to trauma centers? And actually looking at whether the outcomes are better or not?

Jehovah’s Witnesses And Blood Transfusion Demystified

Injury can be a bloody business, and trauma professionals take replacement of blood products for granted. Some patients object to this practice on religious grounds, and their health care providers often have a hard time understanding this. So why would someone refuse blood when the trauma team is convinced that it is the only thing that may save their life?

Jehovah’s Witnesses are the most common group encountered in the US that refuse transfusion. There are more than 20 million Witnesses worldwide, with over 7 million actively preaching. It is a Christian denomination that originated in Pennsylvania during the 1870s.

Witnesses believe that the bible prohibits taking any blood products, including red cells, white cells, platelets or plasma. It also includes the use of any dialysis or pump equipment that must be primed with blood. This is based on the belief that life is a gift from God and that it should not be sustained by receiving blood products. The status of certain prepared fractions such as albumin, factor concentrates, blood substitutes derived from hemoglobin, and albumin is not clear, and the majority of Witnesses will accept these products. Cell saver techniques may be acceptable if the shed blood is not stored but is immediately reinfused.

Why are Witnesses so adamant about refusing blood products? If a transfusion is accepted, that person has abandoned the basic doctrines of the religion, and essentially separates themselves from it. They may then be shunned by other believers.

So what can trauma professionals do to provide best care while abiding by our patient’s religious belief? In trauma care it gets tricky, because time is not on our side and non-blood products are not necessarily effective or available. Here are some tips:

  • Your first duty is to your patient. Provide the best, state of the art care you can until it is absolutely confirmed that they do not wish to receive blood products. In they are comatose, you must use blood if indicated until the patient has been definitively identified by a relative who can confirm their wishes with regard to blood. Mistaken identity does occur on occasion when there are multiple casualties, and withholding blood by mistake is a catastrophe.
  • Talk with the patient or their family. Find out exactly what they believe and what they will allow. And stick to it.
  • Aggressively reduce blood loss in the ED. We are not always as fastidious as we should be because of the universal availability of blood products. Use direct pressure or direct suture ligation for external bleeding. Splint to reduce fracture bleeding.
  • Aggressively use damage control surgery. Don’t go for a definitive laparotomy which may take hours. Pack well, close and re-establish normal physiology before doing all the final repairs.
  • Always watch the temperature. Pull out all the stops in terms of warming equipment. Keep the OR hot. Cover every bit of the patient possible with warming blankets. All fluids should be hot. Even the ventilator gases can be heated.
  • Think about inorganic and recombinant products such as Factor VIIa, tranexamic acid and Vitamin K. These are generally acceptable.
  • Consider angiography if appropriate, and call them early so their are no delays between ED and angio suite or OR and angio suite.

Bottom line: Do what is right for your patient. Once you are aware of their beliefs, avoid the use of any prohibited products. Speak with them and their family to clarify exactly what you can and cannot do. This is essentially an informed consent discussion, so make sure they understand the consequences. Follow their wishes to the letter, and don’t let your own beliefs interfere with what they want.

Jehovah’s Witnesses And Blood Transfusion Demystified

Injury can be a bloody business, and trauma professionals take replacement of blood products for granted. Some patients object to this practice on religious grounds, and their health care providers often have a hard time understanding this. So why would someone refuse blood when the trauma team is convinced that it is the only thing that may save their life?

Jehovah’s Witnesses are the most common group encounted in the US that refuse transfusion. There are more than 20 million Witnesses worldwide, with over 7 million actively preaching. It is a Christian denomination that originated in Pennsylvania during the 1870s.

Witnesses beleive that the bible prohibits taking any blood products, including red cells, white cells, platelets or plasma. It also includes the use of any dialysis or pump equipment that must be primed with blood. This is based on the belief that life is a gift from God and that it should not be sustained by receiving blood products. The status of certain prepared fractions such as albumin, factor concentrates, blood substitutes derived from hemoglobin, and albumin is not clear, and the majority of Witnesses will accept these products. Cell saver techniques may be acceptable if the shed blood is not stored but is immediately reinfused.

Why are Witnesses so adamant about refusing blood products? If a transfusion is accepted, that person has abandoned the basic doctrines of the religion, and essentially separates themselves from it. They may then be shunned by other believers.

So what can trauma professionals do to provide best care while abiding by our patient’s religious belief? In trauma care it gets tricky, because time is not on our side and non-blood products are not necessarily effective or available. Here are some tips:

  • Your first duty is to your patient. Provide the best, state of the art care you can until it is absolutely confirmed that they do not wish to receive blood products. In they are comatose, you must use blood if indicated until the patient has been definitively identified by a relative who can confirm their wishes with regard to blood. Mistaken identity does occur on occasion when there are multiple casualties, and withholding blood by mistake is a catastrophe.
  • Talk with the patient or their family. Find out exactly what they believe and what they will allow. And stick to it.
  • Aggressively reduce blood loss in the ED. We are not always as fastidious as we should be because of the universal availabilty of blood products. Use direct pressure or direct suture ligation for external bleeding. Splint to reduce fracture bleeding.
  • Aggressively use damage control surgery. Don’t go for a definitive laparotomy which may take hours. Pack well, close and re-establish normal physiology before doing all the final repairs.
  • Always watch the temperature. Pull out all the stops in terms of warming equipment. Keep the OR hot. Cover every bit of the patient possible with warming blankets. All fluids should be hot. Even the ventilator gases can be heated.
  • Think about inorganic and recombinant products such as Factor VIIa, tranexamic acid and Vitamin K. These are generally acceptable.
  • Consider angiography if appropriate, and call them early so their are no delays between ED and angio suite or OR and angio suite.

Bottom line: Do what is right for your patient. Once you are aware of their beliefs, avoid the use of any prohibited products. Speak with them and their family to clarify exactly what you can and cannot do. This is essentially an informed consent discussion, so make sure they understand the consequences. Follow their wishes to the letter, and don’t let your own beliefs interfere with what they want.

Jehovah’s Witnesses And Blood Transfusion Demystified

Injury can be a bloody business, and trauma professionals take replacement of blood products for granted. Some patients object to this practice on religious grounds, and their health care providers often have a hard time understanding this. So why would someone refuse blood when the trauma team is convinced that it is the only thing that may save their life?

Jehovah’s Witnesses are the most common group encountered in the US that refuse transfusion. There are more than 20 million Witnesses worldwide, with over 7 million actively preaching. It is a Christian denomination that originated in Pennsylvania during the 1870s.

Witnesses believe that the bible prohibits taking any blood products, including red cells, white cells, platelets or plasma. It also includes the use of any dialysis or pump equipment that must be primed with blood. This is based on the belief that life is a gift from God and that it should not be sustained by receiving blood products. The status of certain prepared fractions such as albumin, factor concentrates, blood substitutes derived from hemoglobin, and albumin is not clear, and the majority of Witnesses will accept these products. Cell saver techniques may be acceptable if the shed blood is not stored but is immediately reinfused.

Why are Witnesses so adamant about refusing blood products? If a transfusion is accepted, that person has abandoned the basic doctrines of the religion, and essentially separates themselves from it. They may then be shunned by other believers.

So what can trauma professionals do to provide best care while abiding by our patient’s religious belief? In trauma care it gets tricky, because time is not on our side and non-blood products are not necessarily effective or available. Here are some tips:

  • Your first duty is to your patient. Provide the best, state of the art care you can until it is absolutely confirmed that they do not wish to receive blood products. In they are comatose, you must use blood if indicated until the patient has been definitively identified by a relative who can confirm their wishes with regard to blood. Mistaken identity does occur on occasion when there are multiple casualties, and withholding blood by mistake is a catastrophe.
  • Talk with the patient or their family. Find out exactly what they believe and what they will allow. And stick to it.
  • Aggressively reduce blood loss in the ED. We are not always as fastidious as we should be because of the universal availability of blood products. Use direct pressure or direct suture ligation for external bleeding. Splint to reduce fracture bleeding.
  • Aggressively use damage control surgery. Don’t go for a definitive laparotomy which may take hours. Pack well, close and re-establish normal physiology before doing all the final repairs.
  • Always watch the temperature. Pull out all the stops in terms of warming equipment. Keep the OR hot. Cover every bit of the patient possible with warming blankets. All fluids should be hot. Even the ventilator gases can be heated.
  • Think about inorganic and recombinant products such as Factor VIIa, tranexamic acid and Vitamin K. These are generally acceptable.
  • Consider angiography if appropriate, and call them early so their are no delays between ED and angio suite or OR and angio suite.

Bottom line: Do what is right for your patient. Once you are aware of their beliefs, avoid the use of any prohibited products. Speak with them and their family to clarify exactly what you can and cannot do. This is essentially an informed consent discussion, so make sure they understand the consequences. Follow their wishes to the letter, and don’t let your own beliefs interfere with what they want.

Giving Rhogam (Rh Immunoglobulin) To A Man?

Rhogam is for women, right? The ATLS course points out that pregnant women who are Rh- and sustain significant blunt torso trauma should empirically receive Rhogam in case the fetus turns out to be Rh+.

But there is one situation where men might receive it. Most trauma centers use O- blood as their universal donor units because it does not contain any major antigens. However, O- blood is uncommon. Worldwide, only 4-9% of the population have this blood type. In China, the incidence of O- blood is nearly zero! So busy centers that don’t have much O- may substitute O+ blood for men. They then switch to the proper blood type when the crossmatch is complete

This makes sense, since men don’t ever have to worry about a Rh+ fetus. However, since this typically occurs at very busy (read: high penetrating injury) centers, there is a significant number of repeat offenders. And if they receive it again, the antibodies to the Rh factor they developed the first time can cause a significant hemolytic reaction. So men who receive O+ blood must be typed and given Rhogam if they are Rh-.

Reference: Emergency uncrossmatched transfusion effect on blood type alloantibodies. J Trauma 72(1):48-53, 2012.