Transfusion medicine
Transfusion therapy
Other therapy
Whole blood therapy
Author: Bryon P. Jackson, M.D.
Editorial Board Member: Kyle Annen, D.O.
Deputy Editor-in-Chief: Patricia Tsang, M.D., M.B.A.
Last author update: 13 July 2021
Last staff update: 13 July 2021
Copyright: 2020-2025, PathologyOutlines.com, Inc.
PubMed Search: Whole blood [TI] therapy review [PT]
Table of Contents
Definition / general | Essential features | Terminology | Pathophysiology | Clinical features | Transmission | Screening | Blood donor screening | Blood donor selection | Laboratory | Treatment | Sample assessment & plan | Additional references | Board review style question #1 | Board review style answer #1Cite this page: Jackson B. Whole blood therapy. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/transfusionmedwholeblood.html. Accessed April 1st, 2025.
Definition / general
- Cold, stored whole blood (WB) may be stored at 1 - 6°C for up to 35 days (should be distinguished from fresh, warm whole blood)
- Group O whole blood is used primarily for the resuscitation of trauma patients with massive bleeding
Essential features
- Used primarily in the treatment of trauma patients with massive bleeding
- Group O units can be used emergently across patient ABO types, making it practical as the initial resuscitation product
- Risk of hemolysis can be mitigated by using units that have low anti-A and anti-B titers
- May be effective tool for prehospital transfusion
Terminology
- CSWB: cold, stored whole blood
- LTOWB: low titer group O whole blood
- WFWB: warm, fresh whole blood
Pathophysiology
- Stored for 21 days at 1 - 6°C in CPD and CP2D anticoagulant or for 35 days at 1 - 6°C in CPDA-1 (AABB: Circular of Information for the use of human blood and blood components [Accessed 9 November 2020])
- Cold storage may improve the hemostatic function of platelets due to increased in vivo aggregation and superior correction of bleeding time of cold-stored relative to warm-stored platelets (J Trauma Acute Care Surg 2014;77:S114)
- More concentrated product contains less anticoagulant and additive solutions when compared with equivalent doses of component therapy with red blood cells (RBCs) stored in additive solutions (J Trauma 2009;66:S69)
- American Association of Blood Banks (AABB) standards allow the use of whole blood for non group O patients or patients with unknown ABO group (American Association of Blood Banks: Standards for blood banks and transfusion services, 31st Edition, 2018)
- WB from group O donors contains RBCs that are compatible with all recipients but the plasma in group O whole blood contains anti-A and anti-B antibodies that could potentially cause hemolysis in a non group O recipient (minor mismatch)
Clinical features
- Delivers all components in a single product, providing early inclusion of plasma in trauma patients to address the coagulopathy of trauma (JAMA 2015;313:471)
- Group O units can be used emergently across patient ABO blood types, making it practical as the initial resuscitation product in appropriate patients
- May be effective tool for prehospital transfusion (JAMA Surg 2016;151:15)
- Patients should be monitored for hemolysis after transfusion
- Risk of hemolysis can be mitigated by using units that have low anti-A and anti-B titers (low titer O whole blood)
Transmission
- WB may reduce the number of donor exposures and may reduce risk of transfusion transmitted infections
Screening
- All blood for transfusion is tested for the presence of certain infectious disease pathogens
- Titers are typically performed with each collection
- Low-titer group O whole blood (LTOWB) units are titered for both Anti-A and Anti-B antibodies; each institution is responsible for determining its acceptable titer but most are below 256 (Transfusion 2020;60:S45)
Blood donor screening
- Armed Services Blood Program collects whole blood from male and never pregnant female donors or from female donors testing negative for anti-human leukocyte antigens antibodies (this mitigates risk of transfusion associated acute lung injury, transfusion related acute injury, and is an AABB / FDA requirement)
- WB is collected from both Rh positive and negative donors (Mil Med 2018;183:44)
Blood donor selection
- Donors are TRALI risk mitigated
- Males and females who have never been pregnant
- Rh positive and negative
Laboratory
- Cold, stored whole blood may be stored at 1 - 6°C for up to 35 days (should be distinguished from fresh, warm whole blood)
Treatment
- Used primarily in the treatment of trauma patients with massive bleeding
- Protocols that use whole blood beyond day 21 should consider the need for supplemental platelet transfusion
Sample assessment & plan
- A: 27 year old man presents to a level I trauma center with several injuries after motor vehicle collision. SBP is < 90mmHg and EBL > 150 mL per minute. No labs including CBC and type and screen have been resulted.
- P: Initiate massive transfusion protocol with low titer group O whole blood. Switch to component based goal directed therapy when sufficient hemostasis has been achieved and allows for proper use of visoelastic and traditional coagulation testing. Send labs to monitor for the presence of hemolysis.
Additional references
Board review style question #1
How can the risk of hemolysis associated with the transfusion of group O whole blood to non group O recipients be mitigated?
- Agitating units in storage
- Leukoreduction
- Selecting units with low anti-A and anti-B titers
- Using units less than 7 days old
- Washing
Board review style answer #1
C. Selecting units with low anti-A and anti-B titers. The risk of hemolysis is due to the presence of anti-A and anti-B antibodies binding to recipient red cells. Selecting for low titers should minimize the risk. Washing would remove the plasma that is needed to provide coagulation factors that treat the trauma induced coagulopathy. Whole blood units can be leukoreduced but this does not impact hemolysis. Age of the units does not impact hemolysis. Whole blood is stored without agitation.
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Reference: Whole blood therapy
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