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The whole is greater than the sum of its parts: Hemostatic profiles of whole blood variants

Kornblith, Lucy Z. MD; Howard, Benjamin M. MD, MPH; Cheung, Christopher K.; Dayter, Yelena MD; Pandey, Suchitra MD; Busch, Michael P. MD, PhD; Pati, Shibani MD, PhD; Callcut, Rachael A. MD; Vilardi, Ryan F.; Redick, Brittney J.; Nelson, Mary F. RN; Cohen, Mitchell Jay MD

Journal of Trauma and Acute Care Surgery: December 2014 - Volume 77 - Issue 6 - p 818–827
doi: 10.1097/TA.0000000000000354
WTA 2014 Plenary Papers
Editor's Choice

BACKGROUND: Mounting evidence highlighting the benefits of hemostatic resuscitation has led to a renewed interest in whole blood (WB) and reconstituted WB (RWB). However, few data exist to characterize the clotting profiles of these variants. This study characterizes banked WB variants and RWB in standard 1:1:1 and 2:1:1 transfusion ratios of packed red blood cells, fresh frozen plasma, and platelets (PLTs). We hypothesized that the global hemostatic profile of 1:1:1 RWB is superior to 2:1:1 RWB and that PLT-modified WB (MWB) is superior to 1:1:1 RWB.

METHODS: Twenty-three units of packed red blood cells, fresh frozen plasma, and PLTs were obtained from the regional blood collection center and mixed to create 23 1:1:1 and 23 2:1:1 RWB units. Freshly donated WB units were obtained and used to create 11 of each nonmodified WB (NMWB) (room temperature and cooled) and MWB (room temperature and cooled) variants. International normalized ratio (INR)/partial thromboplastin time (PTT), complete blood cell count, functional studies, and an extensive panel of procoagulant and anticoagulant factor assays were performed on all products.

RESULTS: The 1:1:1 RWB had significantly lower INR and PTT (1.31 vs. 1.55, p = 0.0029; 42 seconds vs. 50 seconds, p = 0.0008) and higher activity of factors II, V, VII, VIII, IX, and X; antithrombin III, as well as protein C and higher fibrinogen levels than did 2:1:1 RWB (factor IX, 86% vs. 70%, p = 0.0313; fibrinogen, 242 mg/dL vs. 202 mg/dL, p = 0.0385). There were no differences in INR/PTT or factor activity between MWB and NMWB. However, MWB had greater maximum clot firmness (MCF) by rotational thromboelastometry tissue factor–activated extrinsic clotting cascade measures than did NMWB (MCF, 61 mm vs. 50 mm, p = 0.0031). MWB also had greater MCF by rotational thromboelastometry tissue factor–activated extrinsic clotting cascade measures than did 1:1:1 RWB (MCF, 61 mm vs. 45 mm, p = 0.0005).

CONCLUSION: Although 1:1:1 RWB had a superior clotting profile relative to 2:1:1 RWB, MWB exhibited even better global hemostasis than did 1:1:1 RWB. Characterization of factor-level and functional clotting differences between WB variants is imperative for understanding the clinical benefits of hemostatic resuscitation.

From the Department of Surgery (L.Z.K., B.M.H., C.K.C., R.A.C., R.F.V., B.J.R., M.F.N., M.J.C.), San Francisco General Hospital and the University of California, San Francisco; Department of Laboratory Medicine (Y.D., S.P., M.P.B., S.P.), University of California, San Francisco; and Blood Systems Research Institute (Y.D., S.P., M.P.B., S.P.), San Francisco, California.

Submitted: January 14, 2014, Revised: April 22, 2014, Accepted: April 28, 2014, Published online: July 21, 2014.

This study, winner of the Earl Young Competition, was presented at the 44th Annual Meeting of the Western Trauma Association, March 2–7 2014, in Steamboat Springs, Colorado.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (

Address for reprints: Lucy Z. Kornblith, MD, Department of Surgery, Ward 3A, San Francisco General Hospital, 1001 Potrero Ave, Room 3C-38, San Francisco, CA 94110; email:

© 2014 Lippincott Williams & Wilkins, Inc.