John R. Hess

Background: Whole blood (WB) is an easy‐to‐use resuscitation fluid. As more low‐titer group O WB has become available at our hospital, it is being used in an increasingly diverse range of situations, both pre‐hospital and in‐hospital. Study Design and Methods: We conducted a retrospective analysis of all WB units issued by our transfusion service during calendar year 2024. Data were obtained from the transfusion service database and linked to patient medical records to characterize indications, location of transfusion, and patient outcomes. Results are descriptive. Results: A total of 1915 WB units were issued. 1879 units (98.1%) were transfused to 524 patients, of which 237 units (12.6%) were prehospital. Of these, 1817 units (96.7%) were transfused to patients ultimately treated at HMC. Trauma accounted for the majority of in‐hospital utilization (87.6%), with motor vehicle collisions (MVCs) and penetrating trauma the most common indications. Non‐trauma indications accounted for 12.4% of transfused units and included gastrointestinal bleeding, vascular surgery, cardiac emergencies, necrotizing soft tissue infections, and other shock states. Among 477 admitted patients who received WB, in‐hospital mortality was 29.6%. Operational strategies, including extended cooler validation and retention of inventory ownership until use, supported high utilization with minimal waste. Conclusions: Whole blood utilization was primarily driven by traumatic hemorrhage but extended across diverse acute care settings. Utilization patterns were shaped by supply limitations and operational considerations rather than clinical demand alone, underscoring the importance of incorporating logistics and utilization data into future whole blood research and implementation efforts.

Background: Stored red blood cells (RBCs) progressively lose metabolic and structural features that are critical for efficient oxygen release, potentially reducing transfusion efficacy. Compared to the standard storage additive saline‐adenine‐glucose‐mannitol (SAGM), successive refinements such as phosphate‐adenine‐glucose‐guanosine‐saline‐mannitol (PAGGSM) and SOLX (AS‐7) have demonstrated better preservation of metabolic and structural properties. Measuring RBC oxygen release permits further evaluation of such refinements within, and beyond, current storage durations. Study Design and Methods: Leukoreduced whole blood (WB) units from six pools of three ABO/Rh‐matched donors were processed into red cell concentrates and stored in SAGM, PAGGSM, or SOLX under standard blood bank conditions for 56 days. Periodic sampling during storage assessed hemolysis, adenosine 5'‐triphosphate (ATP) content, and oxygen‐unloading kinetics measured by single‐cell oxygen saturation imaging or estimated by FlowScore recorded on a hematology analyzer. Results: Hemolysis remained below the European regulatory threshold of 0.8% to day 49 in all units, with SOLX‐stored units showing less variation and more consistent late‐stage compliance. SOLX‐stored units preserved ATP for longer than SAGM and PAGGSM. Oxygen unloading from SOLX‐ and PAGGSM‐stored RBCs was faster than with SAGM; a similar effect was reported for FlowScore, indicating the utility of this surrogate to benchmark additive solutions. Overall, storage in SOLX halved the rate of attrition in oxygen release kinetics, with a statistically significant benefit emerging by week 3 of storage. Conclusion: Over 56 days, SOLX‐ and PAGGSM‐stored RBCs demonstrated faster oxygen release kinetics than SAGM, as measured directly and by the flow‐cytometric surrogate. Additionally, SOLX‐stored RBCs maintained better ATP levels and hemolysis compliance.

Background: Post‐transfusion purpura (PTP) is a rare and severe transfusion reaction characterized by rapid‐onset thrombocytopenia, typically occurring 1–2 weeks after platelet or RBC transfusion. While PTP is commonly seen in patients with prior pregnancies or transfusions, its occurrence in trauma patients has rarely been reported. We present a case highlighting the challenges of PTP diagnosis and management in the post‐trauma setting.Case Report: A 38‐year‐old female was airlifted to Harborview Medical Center, Seattle, WA, USA, following a motor vehicle accident, requiring administration of blood products via massive transfusion protocol. On hospital Day 8, she developed abrupt and significant thrombocytopenia, with a drop in platelets from 157 × 10³/uL to 3 × 10³/uL by hospital Day 9. Surgical intervention, anticoagulation, and additional platelet transfusions were held for five days while a PTP workup was ordered and intravenous immunoglobulin (IVIG) therapy started. Despite concerns around halting acute surgical care, the platelet count steadily improved after 5 days, allowing for reinitiation of surgical intervention. Additional testing revealed the presence of anti‐HPA‐1a antibodies, confirming the diagnosis of PTP.Discussion: This case emphasizes the complexity of diagnosing PTP in the acute trauma setting following massive transfusion protocol. Effective communication between the transfusion medicine, hematology/oncology, and trauma surgery teams was crucial to successfully manage this patient, highlighting the importance of a supportive multidisciplinary approach in these complex clinical scenarios.

Background: The United States military has transfused room temperature platelets (RTPs) in combat since 2004, but distribution to far‐forward locations is limited. To expand access, cold‐stored platelets (CSPs) were approved for 10‐day storage in 2017, increased to 14 days in 2019, but clinical outcome reporting has been limited. This study assessed whether CSPs were associated with mortality in combat trauma patients when compared with RTPs.Study design and methods: A retrospective analysis of military databases evaluated combat casualty records 2001–2023. The intervention of interest was the transfusion of at least one unit of CSPs under a 10‐day or 14‐day expiration protocol. The outcome of interest was mortality at discharge. Logistic regression compared the treatment groups with a control cohort that only received RTPs.Results: Over the study period, 159 patients received 341 CSP units. Records were located for 124 patients: 57 received 10‐day CSPs and 67 received 14‐day CSPs. Overall mortality was 16.1% in the CSP cohort and 13.9% in the control group. Exposure to 10‐day CSPs (adjOR = 0.39 [0.18–0.86]; p = .02) or 14‐day CSPs (adjOR = 0.41 [0.20–0.83]; p = .01) was associated with decreased mortality. The outdating rate was 75.2% for RTPs and 93.4% for CSPs.Conclusion: CSPs up to 14 days old appear non‐inferior to 5‐day RTPs. CSP age at transfusion trended toward the end of shelf life, indicating demand previously unmet by RTPs. Patients do well when they receive platelets as close to injury as possible; CSPs better facilitate this intervention in remote locations. CSPs should be further evaluated for use in a broader range of emergent transfusion scenarios.

Background: Whole blood (WB) is an efficient product for field medical resuscitation because of its unitary composition, tolerance for storage on ice and in field refrigerators, and simplicity of use. We measured quality parameters of a novel 8‐week WB storage system.Study Design and Methods: Here, 500 mL of WB from healthy donors was collected in 70 mL of CPDA‐1, leukoreduced with a platelet‐sparing filter, pooled into ABO‐compatible two‐unit pools, and split into matched pairs of equal volume designated as Test or Control units. Test units received an additional 50 mL of a novel WB preservative solution (APEX units, Hemerus Medical, St Paul, MN). A total of 15 paired WB units were evaluated at Day 0 (D0) and periodically up to Day 56 (D56) of storage at 1–6°C across two centers. Quality testing included cellularity, ATP concentrations, hemolysis, blood gases, metabolites, coagulation factor levels, thromboelastography (TEG), and bacterial culture.Results: At D56, APEX units displayed higher RBC ATP concentration (3.14 vs. 2.18 μmol/gHb, p = 0.001), pH (6.53 vs. 6.50, p = 0.01), and higher bicarbonate reserve (8 vs. 5.4, p < 0.0001). D56 APEX units had greater platelet contribution to TEG clot strength (p < 0.01) and better preservation of red cell ATP (p < 0.001). Activities of fibrinogen, factor VIII, factor V, and protein S activity in APEX units remained within the reference levels on D56. No bacterial contamination was detected at the end of storage.Discussion: These findings suggest that APEX preserves RBCs effectively and maintains platelet and plasma coagulation functions for up to 56 days.

Background: We reviewed trauma blood use at our US regional trauma center 2011–2022—including PROPPR trial participation 2012–2014 and initiation of whole blood availability in 2019—to assess the implementation of early coagulation support in acute trauma care.Study Design/Methods: We identified all acute trauma patients recorded by our Trauma Registry as arriving at our large US regional Level 1 trauma center from April 6, 2011 (Blood Bank opening) through December 2022. Patient cohort data were then linked directly to Blood Bank final‐product‐issue date/time data to identify patients receiving any blood product in the first 24 h of care and then, specifically, at least one unit of Red Blood Cells (RBC), Plasma, or Whole Blood (WB). Results were binned as: “RBC first,” “Plasma first,” “Both at the same time,” or “WB first.”Results: Over the study period, 73,634 acute trauma patients received care, and 12,927 received at least one unit of a blood product. The proportion receiving plasma or a combination of plasma and RBCs as the initial transfusion increased after 2015 from 33% to 66%, while the proportion receiving packed RBCs alone decreased from 57% to about 18%. Since its introduction in 2019, the use of WB as the first product has grown to 20%.Conclusions: This retrospective cohort study documents the increasing use of plasma and now WB as initial products issued in trauma resuscitation, reflecting acceptance of coagulation support as the standard of care and the use of hemostatic resuscitation protocols.