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Civilian and military guidelines recommend balanced transfusion to patients with life-threatening bleeding. Early start of transfusion has shown improved survival. Thus, a balanced blood inventory must be available in all levels of health care to ensure early stabilization and damage control resuscitation of patients with bleeding. Whole blood has been reintroduced as a blood product for massive bleeding situations because it affords plasma, red blood cells, and platelets in a balanced ratio in a logistically advantageous way. In this article, we describe how to establish a whole blood-based blood preparedness program in a small rural hospital with limited resources. We present an implementation tool kit, which includes discussions on whole blood program strategies and the process of developing detailed procedures on donor selection, collection, storage, and transfusion management of whole blood. The importance of training and audit of the routines is highlighted, and establishment of an emergency walking blood bank is discussed. We conclude that implementation of a whole blood program is achievable in small rural hospitals and recommend that rural health care facilities at all treatment levels enable early balanced transfusion for patients with life-threatening bleeding by establishing protocols for whole blood-based preparedness.

Background Some jurisdictions require leukoreduction of cellular blood components. The only whole blood collection set with a platelet-saving filter uses citrate-phosphate-dextrose (CPD) as storage solution. Substituting CPD with citrate-phosphate-dextrose-adenine (CPDA-1) increases shelf life from 21 to 35 days. This would simplify prehospital and rural resupply and reduce wastage. We investigated in vitro quality and hemostatic properties of CPDA-1 whole blood leukoreduced with a platelet-saving filter. Study design and methods CPDA-1 whole blood was leukoreduced using a platelet-saving filter and stored 35 days. EDQM requirements, hematology, metabolic parameters, thromboelastography, light transmission aggregometry, fibrinogen, factor VIII, and interleukin-6 were measured on Days 0, 1, 14, 21, and 35 and compared to non-leukoreduced blood. Results All units met EDQM requirements. Leukoreduction yielded residual white blood cell count 0.8% was observed. Factor VIII was higher on Day 35 in the leukoreduced group, 37.9 (95% CI: 26.0, 49.8) versus 13.8 (9.4, 18.2) IU/dL. In both groups, aggregation was significantly reduced by Day 14. Thromboelastography showed remaining platelet activity on Day 35, MA 46.9 (42.1, 51.7) in the leukoreduced and 44.3 (39.6, 49.0) mm in the non-leukoreduced group. Fibrinogen was within reference ranges at Day 35 (>2 g/dL). Interleukin-6 was not detectable. Conclusion Leukoreducing CPDA-1 whole blood with a platelet-saving filter did not compromise hemostatic properties. We encourage development of a single bag CPDA-1 whole blood collection set with in-line platelet-saving filter.

Background Blood products are frequently exposed to room temperature or higher for longer periods than permitted by policy. We aimed to investigate if this resulted in a measurable effect on common quality parameters and viscoelastic hemostatic function of cold stored CPDA-1 whole blood. Study Design and Methods 450 ml of whole blood from 16 O Rh(D) positive donors was collected in 63 ml of CPDA-1 and stored cold. Eights bags were exposed to five weekly 4-h long transient temperature changes to 28°C. Eight bags were stored continuously at 4°C as a control. Samples were collected at baseline on day 1, after the first cycle on day 1 and weekly before each subsequent cycle (day 7, 14, 21, 28 and 35). Hemolysis, hematological parameters, pH, glucose, lactate, potassium, thromboelastography, INR, APTT, fibrinogen, and factor VIII were measured. Results CPDA-1 whole blood repeatedly exposed to 28°C did not show reduced quality compared to the control group on day 35. Two units in the test group had hemolysis of 1.1% and 1.2%, and two in the control group hemolysis of 0.8%. Remaining thromboelastography clot strength (MA) on day 35 was 51.7 mm (44.8, 58.6) in the test group and 46.1 (41.6, 50.6) in the control group (p = .023). Platelet count was better preserved in the test group (166.7 [137.8, 195.6] vs. 117.8 [90.3, 145.2], p = .018). One sample in the test group was positive for Cutibacterium acnes on day 35 + 6. Conclusion Hemolysis findings warrant further investigation. Other indicators of quality were not negatively affected. publishedVersion

Background Cold storage of platelets may extend shelf life compared to room temperature storage. This study aimed to investigate in vitro platelet quality and function in cold-stored and delayed-cold-stored nonagitated apheresis platelets in platelet additive solution during storage for 21 days. Study design and methods Ten double apheresis platelet concentrates in 37% plasma/63% PAS-IIIM were split into two groups; nonagitated 2 to 6°C storage (CSPs) and delayed cold storage (DCSPs) with 7 days agitated storage at 20-24°C followed by nonagitated cold storage for 14 additional days. Platelet count, metabolism, viscoelastic properties, and aggregation ability were measured on Days 1, 7, 14, and 21. Results All platelet units, both CSPs and DCSPs, complied with the EU guidelines throughout storage for 21 days. Swirling was not detectable after cold storage. Cold storage improved platelet function; however, DCSP on Day 7 showed poorer results compared to CSP. Cold storage slowed down metabolism, with lower lactate and higher glucose concentrations in the CSP compared to the DCSP throughout storage for 21 days. Conclusion Cold storage of platelets improved platelet function in in vitro assays, even though delayed cold storage on Day 7 showed poorer results compared to continuous cold storage. This difference could be explained by accelerated metabolism and higher glucose consumption during the period of room temperature storage. Cold storage and delayed cold storage could ease inventory management. Further studies investigating the in vitro and clinical effects of cold-stored and delayed-cold-stored platelets are encouraged.

Transfusion support is a key enabler to the response to mass casualty events (MCEs). Transfusion demand and capability planning should be an integrated part of the medical planning process for emergency system preparedness. Historical reviews have recently supported demand planning for MCEs and mass gatherings; however, computer modeling offers greater insights for resource management. The challenge remains balancing demand and supply especially the demand for universal components such as group O red blood cells. The current prehospital and hospital capability has benefited from investment in the management of massive hemorrhage. The management of massive hemorrhage should address both hemorrhage control and hemostatic support. Labile blood components cannot be stockpiled and a large surge in demand is a challenge for transfusion providers. The use of blood components may need to be triaged and demand managed. Two contrasting models of transfusion planning for MCEs are described. Both illustrate an integrated approach to preparedness where blood transfusion services work closely with health care providers and the donor community. Preparedness includes appropriate stock management and resupply from other centers. However, the introduction of alternative transfusion products, transfusion triage, and the greater use of an emergency donor panel to provide whole blood may permit greater resilience.

BACKGROUND Allergic transfusion reactions (ATRs) present with a broad range of symptoms probably caused by mediators released from mast cells and basophil granulocytes upon activation. Passive immunoglobulin (Ig)E sensitization may yield clinical symptoms and positive allergy tests. Unexpected findings of IgE antibodies in pooled solvent/detergent (S/D)-treated plasma (Octaplas, Octapharma) during routine analysis initiated an investigation of serum proteins. STUDY DESIGN AND METHODS Consecutive batches of S/D-plasma transfused during September 2014 through March 2015 were investigated for IgE, IgG, IgA IgM, C3, C4, haptoglobin, anti-nuclear antibodies (ANAs), and red blood cell (RBC) antibodies. RESULTS During the study period, 4203 S/D-plasma units were transfused. Nineteen (14 Octaplas A and five Octaplas AB) of 20 batches of S/D-plasma were included, representing 99.9% of total number of plasma units. A total of 0.4% of units and five batches reported ATRs. Concentrations of total IgE higher than expected values in adults (

Allergic transfusion reactions (ATRs) present with a broad range of symptoms probably caused by mediators released from mast cells and basophil granulocytes upon activation. Passive immunoglobulin (Ig)E sensitization may yield clinical symptoms and positive allergy tests. Unexpected findings of IgE antibodies in pooled solvent/detergent (S/D)-treated plasma (Octaplas, Octapharma) during routine analysis initiated an investigation of serum proteins.Consecutive batches of S/D-plasma transfused during September 2014 through March 2015 were investigated for IgE, IgG, IgA IgM, C3, C4, haptoglobin, anti-nuclear antibodies (ANAs), and red blood cell (RBC) antibodies.During the study period, 4203 S/D-plasma units were transfused. Nineteen (14 Octaplas A and five Octaplas AB) of 20 batches of S/D-plasma were included, representing 99.9% of total number of plasma units. A total of 0.4% of units and five batches reported ATRs. Concentrations of total IgE higher than expected values in adults (120 kU/L) were observed in 18 of the 19 (95%) batches investigated (median concentration [quartiles], 161 [133-183]). Specific IgE antibodies (expected 0.35 kilounits antigen [kUA]/L) against house dust mite (2.52 [1.01-5.09]), timothy (2.83 [2.48-3.24]), cat (1.13 [0.58-1.52]), dog (0.83 [0.50-1.05]), mugwort (0.69 [0.53-0.97]), birch (0.62 [0.28-0.92]), peanut (0.52 [0.29-075]), wheat (0.46 [0.33-0.69]), and latex (0.32 [0.21-0.53]) were also detected. IgG, IgA, IgM, C3, C4, and haptoglobin were within or below normal ranges. No RBC antibodies were observed, but 18% of batches showed low levels of ANA (anti-RNP).Specific IgE antibodies against airborne allergens, food allergens, and latex were detected in S/D-treated pooled plasma.