Oswald robertson serving with British and American expeditionary forces during World War I pioneered the use of stored, type specific whole blood, demonstrating for the first time that hemorrhagic shock could be treated with transfusion. During the world war II whole blood was used for transfusion . By 1980's following vietnam war component therapy started to replace the whole blood due to its storage advantage of various components and same donated bloods can be used for multiple recipients. SInce then for neary 4 decades component therapy was used for resuscitation.
Why whole blood now ?
Recent military conflits in Iraq and Afganistan renewed the interest in use of whole blood transfusion. During war the shortage of components and short life of platelet forced the military hospitals to fresh whole blood from walking blood banks. As evidence evolved the US military implemented a cold stored low titre whole blood program for transfusion in austere settings. This has now lead to recent interest for whole blood transfusion in civilian setting.
Recent Evidences
- Spinella et al. J Trauma. 2009 did a retrospective study from US Military combat patients who received ≥1 Warm Fresh Whole Blood (WFWB) to assess whether WFWB transfusion is associated with improved survival compared with component therapy. Study found that 24 hr and 30 day survival was higher in WFWB group 96 of 100 (96%) v/s 223 0f 254(88%) in component therapy group (p= 0.018). Study concluded that in patients with trauma WFWB transfusion may improve 30 day survival.
- Gurney et al. Transfusion. 2020 did a retrospective analysis of casualities treated by role 2 surgical team in Afghanistan who received 1 or more units Fresh Warm Blood( FWB). The Kaplan-Meier plot demonstrated that survival was similar between FWB (79.1%) and no-FWB (74.5%) groups (p = 0.46); after stratifying patients by the combat mortality index, the risk of mortality (Critical patients) was increased in the no-FWB group (hazard ratio:2.8; 95% confidence interval, 1.2-6.4) compared to the FWB cohort.
- Torres et al. JAMA Surg. 2024 did a retrospective cohort study from American College of Surgeons Trauma Quality Improvement Program databank from January 1, 2019,to December 31, 2020, for adult patients presenting to US and Canadian adult civilian level 1 and 2 trauma centers with systolic blood pressure less than 90 mm Hg, with shock index greater than 1, and requiring MTP who received a WB transfusion within the first 24 hours of emergency department (ED) arrival. In this cohort study, receipt of a WB transfusion earlier at any time point within the first 24 hours of ED arrival (adjusted hazard ratio, 0.40; 95% CI, 0.22-0.73; P = .003) was associated with improved survival in patients presenting with severe hemorrhage.
- SWiFT Trial. NEJM.2026 did a phase III , pragmatic, multicentric, unblinded, radomised superiority trial on patients with major traumatic hemorrhage across 10 air ambulance services in England. Patients were assigned to whole blood was transfused 2 units and to standard groups was transfused upto 2 units of PRBC and plasma each. 48.7% (153/314) patients in whole blood group and 47.7% (144/302) in standard care group died within 24 hours after randomization ( RR 1.02; 95% CI 0.80 to 1.31; P=0.84. Study concluded that whole blood transfusion was not superior to standard care in reducing death or massive transfusion in 24 hours.
- TOWAR. NEJM.2026 is a pragmatic, multicentric (44 air medical bases), cluster randomised trial doen to assess transfusion with whole blood is more beneficial than blood components in prehospital setting. Patients were either received 2 units of whole blood or blood components as indicated. Study found that mortality in whole blood (n=695) was 25.9% compared to component group (n= 298) 20.5%(adjusted odds ratio, 1.24; 95% confidence interval [CI], 0.87 to 1.76; P=0.24).Study concluded that use of whole blood for prehospital transfusion did not result in lower 30 day mortality.
Recommendation
- ATLS 11th Edition recommends to prefer whole blood over component therapy if available.
Conclusion
- Although ATLS recommends to prefer whole blood for resuscitation based on military experience, but recent landmark civilian studies haven't shown any superiority over component therapy. More evidences are required to make a final conclusion, till then both the strategies can be followed based on institutional policies and availability of resources.
Reference
- Torres CM, Jenkins D, Sakran JV. Whole-Blood Transfusion From Empiricism to Evidence: A Narrative Review. JAMA Surg. Published online July 08, 2026. doi:10.1001/jamasurg.2026.2574
- Back to the future: Whole blood resuscitation of the severely injured trauma patient. McCoy et al. SHOCK. 2021.DOI: 10.1097/SHK.0000000000001685
- Gurney J, Staudt A, Cap A, Shackelford S, Mann-Salinas E, Le T, Nessen S, Spinella P. Improved survival in critically injured combat casualties treated with fresh whole blood by forward surgical teams in Afghanistan. Transfusion. 2020 Jun;60 Suppl 3:S180-S188. doi: 10.1111/trf.15767. Epub 2020 Jun 3. PMID: 32491216.
- Spinella PC, Perkins JG, Grathwohl KW, Beekley AC, Holcomb JB. Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries. J Trauma. 2009 Apr;66(4 Suppl):S69-76. doi: 10.1097/TA.0b013e31819d85fb. PMID: 19359973; PMCID: PMC3126655.
