Whole Blood

Note: Dr Vuong’s work as the author of this chapter is performed outside of his service in the Canadian Armed Forces. The views expressed herein are those of the author and do not constitute the views or policies of the Canadian Armed Forces.

Whole blood contains red blood cells (RBCs), plasma, and platelets. Once collected from donors, it is leukocyte reduced and not separated into components. It is primarily used in trauma settings involving large-volume hemorrhage. In Canada its use is restricted to military settings, but future application in civilian prehospital care is under assessment. The Canadian Blood Services is the manufacturer and supplier of leukocyte-reduced whole blood for the Canadian Armed Forces.

A whole blood donation of ~500 mL from a single donor is collected and processed with a platelet-sparing leukocyte-reducing filter. A citrate-phosphate-dextrose (CPD) anticoagulant is added and the product is stored at 1 to 6 degrees Celsius with an expiry of 21 days.

In clinical and environmental circumstances where whole blood would be used, timely ABO typing of the patient is often not feasible. To simplify compatibility, whole blood is manufactured primarily from group O RhD-positive and O RhD-negative donors. Unlike single-component RBC concentrates, where RBC antigens are considered, whole blood additionally includes donor plasma, which contains antibodies requiring consideration for recipient compatibility. To mitigate the risk of a hemolytic transfusion reaction, donors with low-titer anti-A and anti-B antibodies are selected. Transfusion of low-titer anti-A and anti-B whole blood has not been associated with increased hemolysis, hemolytic reactions, or mortality when compared with ABO-compatible components in bleeding patients. Only male donors are selected to mitigate the risk of transfusion-related acute lung injury (TRALI) from anti–human leukocyte antigen (HLA) antibodies that can develop as a result of previous pregnancy.

In many countries whole blood is being increasingly introduced into prehospital settings. Parallel to this is some low-quality evidence that incorporating whole blood in addition to component therapy in civilian trauma patients may be associated with reduced mortality and reduced total transfusion of products in comparison to individual component therapy alone.Evidence 1Low Quality of Evidence (low confidence that we know true effects of the intervention). Quality of Evidence lowered due to observational nature of studies and indirectness. Torres CM, Kent A, Scantling D, Joseph B, Haut ER, Sakran JV. Association of Whole Blood With Survival Among Patients Presenting With Severe Hemorrhage in US and Canadian Adult Civilian Trauma Centers. JAMA Surg. 2023 May 1;158(5):532-540. doi: 10.1001/jamasurg.2022.6978. Erratum in: JAMA Surg. 2023 Apr 5. PMID: 36652255; PMCID: PMC9857728. Shea SM, Mihalko EP, Lu L, et al. Doing more with less: low-titer group O whole blood resulted in less total transfusions and an independent association with survival in adults with severe traumatic hemorrhage. J Thromb Haemost. 2023 Oct 4:S1538-7836(23)00727-4. doi: 10.1016/j.jtha.2023.09.025. Epub ahead of print. PMID: 37797692. Large randomized controlled trials are ongoing to assess the efficacy and safety of whole blood transfusion in the prehospital setting and should be completed in the years 2025 to 2028.