Whole Blood in the Management of Hypovolemia Due to Obstetrical Hemorrhage
Whole Blood in the Management of Hypovolemia Due to Obstetrical Hemorrhage
Abstract & Commentary
By John C. Hobbins, MD, Professor and Chief of Obstetrics, University of Colorado Health Sciences Center, Denver, is Associate Editor for OB/GYN Clinical Alert.
Dr. Hobbins reports no financial relationship to this field of study.
Synopsis: The concept of abandoning the use of whole blood in favor of packed cells for the treatment of hypovolemia in obstetric hemorrhage should be questioned in view of this study's suggestion of a lower rate of acute tubular necrosis in patients treated with whole blood.
Source: Alexander JM, et al. Whole blood in the management of hypo-volemia due to obstetric hemorrhage. Obstet Gynecol 2009;113:1320-1326.
If I were asked to name the 4 most prominent clinical leaders in obstetrics in the United States during its formative years, they would be Hon, Quilligan, Zuspan (who, sadly, passed away in June), and Pritchard. The latter giant led an incredibly productive group at Parkland Hospital in Dallas for years and developed protocols that are still ingrained in obstetrical practice today. He was a stickler for aggressively treating obstetrical hemorrhage, resulting from abruption or other causes, with whole blood. However, for a variety of reasons, the current tendency is to break down a unit of blood into component parts, with packed cells being utilized for pure hemorrhage, and platelets, fibrinogen, or fresh frozen plasma being used for other specific needs. Since the rationale for this approach was that one could get more uses out of one pint of blood and that the non-red cell products could be pooled, this resulted in a major drop-off in the availability of whole blood.
Rather than to succumb meekly to this trend, the group in Dallas conducted this study to pit whole blood against packed cells, with or without other blood components, in the treatment of maternal hypo-volemia due to obstetrical hemorrhage. Charts were reviewed from 1540 patients who were transfused over a 4-year period (2002-2006). The choice of blood products was based on availability. Many of those receiving whole blood had an immediate need for replacement before typing could be accomplished, and they received O negative blood.
Six hundred and fifty-nine received whole blood only, 593 received packed red cells only, and 208 received red cells with component products. The endpoints evaluated were: acute tubular necrosis (ATN), adult respiratory distress syndrome, pulmonary edema, hypofibrinogenemia, admission to the ICU, and death.
The group receiving combination therapy was in a severity class of its own, requiring on average double the amount of whole blood or packed cells than the other two groups. These patients also had a 2-8 times higher rate of the above complications compared with the other groups. When comparing the whole blood vs packed cell groups, the outcomes were comparable in every category, including average amount of transfused units (2.3 vs 2.2). However, there was a lower incidence of ATN (0.3% vs 2%; P = 0.001) and a higher incidence of pulmonary edema (7% vs 4%; P = 0.001) for those getting whole blood.
Commentary
The conclusion to be reached was that 10 of the 12 cases of ATN (not receiving combination therapy) might have been avoided if whole blood had been used instead of packed cells. This could easily counter the doubling of pulmonary edema in the whole blood group, since all of these cases were successfully treated without consequences, as opposed to the more serious potential aftermath of ATN.
At the end of the paper, the authors lapsed into an interesting discussion on the use of blood products in soldiers in Iraq suffering from acquired coagulopathy from battlefield injuries.1 In 87 seriously injured soldiers, packed cells had a tendency to foster coagulopathy by not correcting platelet abnormalities, while whole blood appeared to correct the coagulopathy. Last, 1 unit of whole blood limits patient exposure to only 1 individual's blood, rather than to the blood of many individuals when combination replacement is required.
For all of the above reasons, the Dallas group made a reasonable argument for bringing back, or certainly not abandoning, the use of whole blood for replacement therapy in obstetrical hemorrhage.
Reference
- Spinella PC, et al; 31st CSH Research Working Group. Fresh whole blood transfusions in coalition military, foreign national, and enemy combatant patients during Operation Iraqi Freedom in a U. S. combat support hospital. World J Surg 2008;32:2-6.
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