Guidelines for Tactical Combat Casualty Care has recently focused interest on the benefits of whole blood and blood product for resuscitation in the prehospital setting (13, 21, 22). Indeed, the Norwegian Naval Special Operation Commando protocol calls for collection and transfusion of fresh whole blood on the front lines (23) and recommendations and guidelines are being proposed for use of blood and blood products in austere environments (21, 23, 24). It would be beneficial to the trauma patient if whole blood could be stored, carried, and used at the site of injury. To that end, cold stored whole blood has been proposed (9). The present study shows that cold stored blood has the same beneficial effect as fresh blood in that limited volume that is commonly used prehospital.
This rat model has been shown to be coagulopathic, and the coagulopathy is associated with a rise in plasmin activity, tissue plasminogen activator, and d-dimers. This suggests that elevated fibrinolysis is at least partially involved in the development of the coagulopathy (25). The coagulopathy is also likely due to a decrease in platelet function, which may have multiple etiologies. In this study, the ability of thrombin and collagen to stimulate platelet aggregation was reduced (Fig. 5). Although this reduction was small, it was significant, and may be due in part to the fall in fibrinogen as fibrinogen has been shown to potentiate the effects of natural agonist like ADP and thrombin (26). Because platelets make up 70% to 80% of clot strength (14) (and Table 2), any resuscitation strategy that targets the reversal of this coagulopathy must take into account restoration of platelet function and fibrinogen, as well as the correction of the fibrinolysis.
The present experiments characterize the hemostatic function of rat stored blood. The results presented here are very similar to what was found in human blood stored at 4°C. As shown by Pidcoke et al. (9), human blood stored at 4°C for 21 days exhibited a prolongation in PT and aPTT, and a fall in fibrinogen, and no change in viscoelastic clotting properties (ROTEM) and platelet aggregation over 10 to 14 days (9). Although this is similar to the present study, we observed that rat blood acquires a storage lesion more quickly than human blood, reaching minimal platelet aggregation at 7 days instead of 10 to 14 (human). It should be noted that differences between the studies may be due to a number of factors, such as the blood bag composition and interspecies differences. Irrespective of these differences, both human and rat studies found very little change in clotting time, α angle, and clotting strength during storage, suggesting that rat blood is similar enough to human blood that it can be used in preclinical studies for resuscitation after polytrauma and hemorrhage.
A wealth of clinical studies demonstrates a deficit in clotting function in severely traumatized patients, and includes an elevation in PT, aPTT, and a decrease in clot strength (30–35). Because an elevation in PT or aPTT is associated with an increase in mortality (36, 37), the correct treatment for this condition is essential in terms of survival, morbidity, and treatment costs. Coagulopathy can be attributed to many factors, including inhibition of thrombin generation or an increase in fibrinolysis (38). Inhibitors of thrombin generation include antithrombin, α2-macroglubulin, Tissue Factor Pathway Inhibitor, and activated protein C. The former two bind and neutralize active thrombin, the latter two inhibit thrombin formation. In the present study, the coagulopathy was not corrected after resuscitation with either blood product. It was therefore possible that the amount of transfused FWB and SWB was not sufficient to correct the hemostatic deficits generated in this study or that correction of coagulopathy lags circulatory improvement due to a need to clear activated factors, platelets, etc. in the liver and spleen. It appears that the coagulopathy induced by trauma and hemorrhage may thus be sustained in the first hour after limited whole blood resuscitation despite hemodynamic and metabolic restoration.
1. Nessen SC, Eastridge BJ, Cronk D, Craig RM, Berseus O, Ellison R, Remick K, Seery J, Shah A, Spinella PC. Fresh whole blood use by forward surgical teams in Afghanistan is associated with improved survival compared to component therapy without platelets
2013; 53 (suppl 1):107S–113S.
2. Perkins JG, Cap AP, Spinella PC, Shorr AF, Beekley AC, Grathwohl KW, Rentas FJ, Wade CE, Holcomb JB. G. st Combat Support Hospital Research. Comparison of platelet transfusion as fresh whole blood versus apheresis platelets
for massively transfused combat trauma patients (CME). Transfusion
2011; 51 2:242–252.
3. 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; 66 (4 suppl):S69–S76.
4. Hoehn RS, Jernigan PL, Chang AL, Edwards MJ, Caldwell CC, Gulbins E, Pritts TA. Acid sphingomyelinase inhibition prevents hemolysis during erythrocyte storage. Cell Physiol Biochem
2016; 39 1:331–340.
5. Hoehn RS, Jernigan PL, Japtok L, Chang AL, Midura EF, Caldwell CC, Kleuser B, Lentsch AB, Edwards MJ, Gulbins E, et al. Acid sphingomyelinase inhibition in stored erythrocytes reduces transfusion-associated lung inflammation. Ann Surg
2016; [Epub ahead of print].
6. Grozovsky R, Giannini S, Falet H, Hoffmeister KM. Regulating billions of blood platelets
: glycans and beyond. Blood
2015; 126 16:1877–1884.
7. Kaufman RM. Uncommon cold: could 4 degrees C storage improve platelet function? Transfusion
2005; 45 9:1407–1412.
8. Shrivastava M. The platelet storage lesion. Transfus Apher Sci
2009; 41 2:105–113.
9. Pidcoke HF, McFaul SJ, Ramasubramanian AK, Parida BK, Mora AG, Fedyk CG, Valdez-Delgado KK, Montgomery RK, Reddoch KM, Rodriguez AC, et al. Primary hemostatic capacity of whole blood: a comprehensive analysis of pathogen reduction and refrigeration effects over time. Transfusion
2013; 53 (suppl 1):137S–149S.
10. Jobes D, Wolfe Y, O’Neill D, Calder J, Jones L, Sesok-Pizzini D, Zheng XL. Toward a definition of “fresh” whole blood: an in vitro characterization of coagulation
properties in refrigerated whole blood for transfusion. Transfusion
2011; 51 1:43–51.
11. Strandenes G, Austlid I, Apelseth TO, Hervig TA, Sommerfelt-Pettersen J, Herzig MC, Cap AP, Pidcoke HF, Kristoffersen EK. Coagulation
function of stored whole blood is preserved for 14 days in austere conditions: a ROTEM feasibility study during a Norwegian antipiracy mission and comparison to equal ratio reconstituted blood. J Trauma Acute Care Surg
2015; 78 (6 suppl 1):S31–S38.
12. Yazer MH, Glackin EM, Triulzi DJ, Alarcon LH, Murdock A, Sperry J. The effect of stationary versus rocked storage of whole blood on red blood cell damage and platelet function. Transfusion
13. Cap AP. Platelet storage: a license to chill! Transfusion
2016; 56 1:13–16.
14. Darlington DN, Craig T, Gonzales MD, Schwacha MG, Cap AP, Dubick MA. Acute coagulopathy of trauma in the rat. Shock
2013; 39 5:440–446.
15. Lang T, Bauters A, Braun SL, Potzsch B, von Pape KW, Kolde HJ, Lakner M. Multi-centre investigation on reference ranges for ROTEM thromboelastometry. Blood Coagul Fibrinolysis
2005; 16 4:301–310.
16. Hervig T, Doughty H, Ness P, Badloe JF, Berseus O, Glassberg E, Heier HE. Prehospital use of plasma: the blood bankers’ perspective. Shock
2014; 41 (suppl 1):39–43.
17. O’Reilly DJ, Morrison JJ, Jansen JO, Apodaca AN, Rasmussen TE, Midwinter MJ. Prehospital blood transfusion in the en route management of severe combat trauma: a matched cohort study. J Trauma Acute Care Surg
2014; 77 (3 suppl 2):S114–S120.
18. Sixta SL, Hatch QM, Matijevic N, Wade CE, Holcomb JB, Cotton BA. Mechanistic determinates of the acute coagulopathy of trauma (ACoT) in patients requiring emergency surgery. Int J Burns Trauma
2012; 2 3:158–166.
19. Darlington DN, Jones RO, Magnuson TA, Gann DS. Role of intestinal fluid in restitution of blood volume and plasma protein after hemorrhage
in awake rats. Am J Physiol
1995; 268 (3 Pt
20. Darlington DN, Jones RO, Marzella L, Gann DS. Changes in regional vascular resistance and blood volume after hemorrhage
in fed and fasted awake rats. J Appl Physiol
1995; 78 6:2025–2032.
21. Butler FK, Holcomb JB, Schreiber MA, Kotwal RS, Jenkins DA, Champion HR, Bowling F, Cap AP, Dubose JJ, Dorlac WC, et al. Fluid resuscitation
for hemorrhagic shock in tactical combat casualty care: TCCC guidelines change 14-01-2 June 2014. J Spec Oper Med
2014; 14 3:13–38.
22. Fisher AD, Miles EA, Cap AP, Strandenes G, Kane SF. Tactical damage control resuscitation
. Mil Med
2015; 180 8:869–875.
23. Strandenes G, De Pasquale M, Cap AP, Hervig TA, Kristoffersen EK, Hickey M, Cordova C, Berseus O, Eliassen HS, Fisher L, et al. Emergency whole-blood use in the field: a simplified protocol for collection and transfusion. Shock
2014; 41 (suppl 1):76–83.
24. Cap AP, Pidcoke HF, DePasquale M, Rappold JF, Glassberg E, Eliassen HS, Bjerkvig CK, Fosse TK, Kane S, Thompson P, et al. Blood far forward: time to get moving!. J Trauma Acute Care Surg
2015; 78 (6 suppl 1):S2–6.
25. Wu X, Darlington DN, Cap AP. Procoagulant and fibrinolytic activity after polytrauma
in rat. Am J Physiol Regul Integr Comp Physiol
26. Schneider DJ, Taatjes DJ, Howard DB, Sobel BE. Increased reactivity of platelets
induced by fibrinogen
independent of its binding to the IIb-IIIa surface glycoprotein: a potential contributor to cardiovascular risk. J Am Coll Cardiol
1999; 33 1:261–266.
27. Gerhardt RT, Cap AP, Cestero R, Dubick MA, Heiner J, Koller AR, Lairet J, McClinton AR, Manifold C, Stewart R, et al. The Remote Trauma Outcomes Research Network: rationale and methodology for the study of prolonged out-of-hospital transport intervals on trauma patient outcome. J Trauma Acute Care Surg
2013; 75 (2 suppl 2):S137–S141.
28. Gerhardt RT, Strandenes G, Cap AP, Rentas FJ, Glassberg E, Mott J, Dubick MA, Spinella PC, Network T, Rem TSG. Remote damage control resuscitation
and the Solstrand Conference: defining the need, the language, and a way forward. Transfusion
2013; 53 (suppl 1):9S–16S.
29. Repine TB, Perkins JG, Kauvar DS, Blackborne L. The use of fresh whole blood in massive transfusion. J Trauma
2006; 60 (6 suppl):S59–S69.
30. Cotton BA, Faz G, Hatch QM, Radwan ZA, Podbielski J, Wade C, Kozar RA, Holcomb JB. Rapid thrombelastography delivers real-time results that predict transfusion within 1 hour of admission. J Trauma
2011; 71 2:407–414.
31. Frith D, Goslings JC, Gaarder C, Maegele M, Cohen MJ, Allard S, Johansson PI, Stanworth S, Thiemermann C, Brohi K. Definition and drivers of acute traumatic coagulopathy: clinical and experimental investigations. J Thromb Haemost
2010; 8 9:1919–1925.
32. Johansson PI, Sorensen AM, Perner A, Welling KL, Wanscher M, Larsen CF, Ostrowski SR. Disseminated intravascular coagulation
or acute coagulopathy of trauma shock early after trauma? An observational study. Crit Care
2011; 15 6:R272.
33. Park MS, Martini WZ, Dubick MA, Salinas J, Butenas S, Kheirabadi BS, Pusateri AE, Vos JA, Guymon CH, Wolf SE, et al. Thromboelastography as a better indicator of hypercoagulable state after injury than prothrombin time or activated partial thromboplastin time. J Trauma
2009; 67 2:266–275.
34. Shaz BH, Winkler AM, James AB, Hillyer CD, MacLeod JB. Pathophysiology of early trauma-induced coagulopathy: emerging evidence for hemodilution and coagulation
factor depletion. J Trauma
2011; 70 6:1401–1407.
35. Tauber H, Innerhofer P, Breitkopf R, Westermann I, Beer R, El Attal R, Strasak A, Mittermayr M. Prevalence and impact of abnormal ROTEM(R) assays in severe blunt trauma: results of the ’diagnosis and treatment of trauma-induced coagulopathy (DIA-TRE-TIC) study’. Br J Anaesth
2011; 107 3:378–387.
36. Brohi K, Cohen MJ, Ganter MT, Matthay MA, Mackersie RC, Pittet JF. Acute traumatic coagulopathy: initiated by hypoperfusion: modulated through the protein C pathway? Ann Surg
2007; 245 5:812–818.
37. Frith D, Davenport R, Brohi K. Acute traumatic coagulopathy. Curr Opin Anaesthesiol
2012; 25 2:229–234.
38. Brohi K, Cohen MJ, Ganter MT, Schultz MJ, Levi M, Mackersie RC, Pittet JF. Acute coagulopathy of trauma: hypoperfusion induces systemic anticoagulation and hyperfibrinolysis. J Trauma
2008; 64 5:1211–1217.
39. Raza I, Davenport R, Rourke C, Platton S, Manson J, Spoors C, Khan S, De’Ath HD, Allard S, Hart DP, et al. The incidence and magnitude of fibrinolytic activation in trauma patients. J Thromb Haemost
2013; 11 2:307–314.
40. Schochl H, Voelckel W, Maegele M, Solomon C. Trauma-associated hyperfibrinolysis. Hamostaseologie
2012; 32 1:22–27.
41. Grottke O. Coagulation
management. Curr Opin Crit Care
2012; 18 6:641–646.
42. Lippi G, Favaloro EJ, Cervellin G. Massive posttraumatic bleeding: epidemiology, causes, clinical features, and therapeutic management. Semin Thromb Hemost
2013; 39 1:83–93.
43. Perel P, Prieto-Merino D, Shakur H, Roberts I. Development and validation of a prognostic model to predict death in patients with traumatic bleeding, and evaluation of the effect of tranexamic acid on mortality according to baseline risk: a secondary analysis of a randomised controlled trial. Health Technol Assess
2013; 17 24:1–45.