Is the Whole Greater than the Sum of Its Parts? The Implementation and Outcomes of a Whole Blood Program in Ecuador

Is the Whole Greater than the Sum of Its Parts? 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The Implementation and Outcomes of a Whole Blood Program in Ecuador Amber Nicole Himmler, Monica Eulalia Galarza Armijos, Jeovanni Reinoso Naranjo, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-66244/v2 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Nov, 2021 Read the published version in Trauma Surgery & Acute Care Open → Version 2 posted You are reading this latest preprint version Show more versions Abstract Background : Hemorrhagic shock is a major cause of mortality in low-and-middle-income countries (LMICs). Many institutions in LMICs lack the resources to adequately prescribe balanced resuscitation. This study aims to describe the implementation of a whole blood program in Latin America and to discuss the outcomes of the patients that received whole blood (WB). Methods : We conducted a retrospective review of patients resuscitated with WB from 2013-2019. Five units of O+ WB were made available on a consistent basis for patients presenting in hemorrhagic shock. Variables collected included: gender, age, service treating the patient, units of WB administered, units of components administered, admission vital signs, admission hemoglobin, Shock Index, Revised Trauma Score (RTS) in trauma patients, intraoperative crystalloid (lactated ringers or normal saline) and colloid (5% human albumin) administration, symptoms of transfusion reaction, length-of-stay and in-hospital mortality. Results : The sample includes a total of 101 patients, 57 of whom were trauma and acute care surgery (TACS) patients and 44 of whom were obstetrics and gynecology patients. No patients developed symptoms consistent with a transfusion reaction. Average shock index was 1.16 ( ±0.55). On average, patients received 1.66 ( ±0.80) units of whole blood. Overall mortality was 14/101 (13.86%) in the first 24 hours and 6/101 (5.94%) after 24 hours. Conclusion : Implementing a WB protocol is achievable in LMICs. Whole blood allows for more efficient delivery of hemostatic resuscitation and is ideal for resource-restrained settings. To our knowledge, this is the first description of a whole blood program implemented in a civilian hospital in Latin America. Critical Care & Emergency Medicine trauma global surgery whole blood damage control resuscitation hemorrhage shock Figures Figure 1 Background Hemorrhagic shock kills an estimated 1.9 million people annually worldwide 1 . Prompt management of hemorrhagic shock is essential. Several decades of experience have shown that extensive volume resuscitation with crystalloid can lead to an exacerbation of the “lethal triad,” of trauma-induced coagulopathy, hypothermia and acidosis 2-5 ; this phenomenon has been recently modified to include hypocalcemia, and therefore has been termed the “lethal diamond” 6 . Evidence over the past decade suggest a more balanced resuscitation involving the replacement of lost blood with a 1:1:1 transfusion with red blood cells (RBCs), fresh frozen plasma (FFP) and platelets, mimicking the whole blood (WB) that is lost 7-9 . Adherence to a 1:1:1 ratio, however, remains challenging even in high-resource settings 10 . Many regions of the world do not have the blood bank capabilities to adequately supply and respond to the challenging demands for providing and sustaining a timely and efficient 1:1:1 resuscitation strategy 11 , 12 . As such, there has been renewed interest in WB transfusion programs as an initial approach to damage control resuscitation. Hospital Vicente Corral Moscoso (HVCM) is a public hospital located in Southern Ecuador and serves as a referral center for more than 2 million inhabitants 13 . A WB transfusion program was implemented in 2013 to address the issue of inadequate hemostatic resuscitation for patients in hemorrhagic shock. The aim of this paper is to describe the logistics of the implementation of a WB transfusion protocol at our institution, review the outcomes of exsanguinating trauma and acute care surgery, and obstetrics and gynecology populations who received WB and demonstrate the feasibility of a WB program in a low-and-middle-income country (LMIC). Methods We performed a mixed methods analysis of the WB resuscitation program at the HVCM. In order to document the details of the program, we interviewed of members of the blood bank staff, hospital administration, and clinical leadership of the hospital who were instrumental in establishing the program. In order to characterize the safety profile of WB transfusions in our program, we identified patients who received WB transfusion from 2013-2019. The following datapoints were collected: sex, age, service treating the patient, units of WB administered, units of components administered, admission vital signs, admission hemoglobin, Shock Index, intraoperative crystalloid and colloid administration, length-of-stay and in-hospital mortality. In trauma patients, the revised trauma score (RTS) was calculated. We also collected information suggestive of symptomatic acute transfusion reactions including evidence of anaphylaxis, urticaria, rash, jaundice, hemoglobinuria and respiratory difficulty in the immediate post-transfusion period. No labs were sent post-transfusion to detect subclinical transfusion reactions. Post-transfusion laboratory values were not available on all patients. We used SPSS v 26 for statistical analysis. This study was approved by the ethical committee of our institution, Hospital Vicente Corral Moscoso, and the academic committee of research of the University of Azuay Medicine Faculty. Results Whole Blood Transfusion Protocol at the HVCM Five units of type O+ WB were made available daily and released to patients presenting in hemorrhagic shock, as determined by the attending surgeon taking care of the patient. There is often a delay of only a few minutes in starting a WB transfusion once it is ordered by a physician as five units are always set aside for patients presenting in shock. After the type O+ whole blood is dispensed, the blood bank then proceeds to type and cross the patient using Bio-Rad Saxo ID-Reader. Initial resuscitation was begun in the emergency department and extended into the operating room in most cases, or is begun in the operating room. Given the resource limitations, a warming device was not routinely available. The patient is transfused with WB until vital signs stabilized per the clinical judgment of the attending surgeon, or until the blood bank is depleted of WB, after which type-specific RBCs and FFP are dispensed according to their availability in the blood bank. The decision to transition from WB to component therapy is not based on laboratory parameters at our institution as point-of-care laboratory tests are not available at our institution to allow for rapid decision making. The resuscitation strategy at the HVCM is largely based on clinical exam, as tools such as thrombo-elastography (TEG) used at some institutions to guide blood-based resuscitation are not available. Blood donation and collection: Whole blood is obtained through voluntary unpaid donation or replacement donation. The blood must be collected in no more than 12 minutes with constant manual or mechanical activation so as to prevent the activation of the clotting cascade. The use of aseptic technique is paramount for quality control and prevention of bacterial contamination. The sterile material utilized in this process is disposable. The extraction bags are quadruple bags including CPD+SAG-Mannitol BUFFY-COAT. The filtration system is used only when the blood is fractionated into components. WB processing, storage and administration: After a unit of blood is donated, it is quarantined for 8 hours during which time the ABO type and Rh (D) type are determined. The WB is screened for the following serologic markers according to World Health Organization (WHO) standards 14 : Syphilis, Hepatitis C, Hepatitis B, and HIV. Plasma antibody titers are not measured prior to the transfusion of WB. If the blood tests negative for infectious diseases, it is stored at 4-6°C and available for 48 hours. As such, the product dispensed at the HVCM is considered cold, fresh whole blood. Leukoreduction is not routinely performed on the units of WB due to the inability to preserve platelets. After 48 hours, if the blood is not utilized, it is fractionated into components. The red blood cells and frozen plasma are then made available for up 35-42 days and one year respectively. Platelets are not available to patients at the HVCM after fractionation. Given the relative scarcity of blood products in the region, the platelets obtained through fractionation are primarily sent to the local cancer hospital. The blood bank stock is then replaced by the aforementioned methods. Outcomes of Patients Managed with WB: Variable Trauma and Acute Care Surgery, n (%) Obstetrics and Gynecology, n (%) Age (years) ≤ 18 5 (8.8) 2 (4.5) 19-39 32 (56.1) 39 (88.6) 40-64 15 (26.3) 3 (6.8) ≥ 65 5 (8.8) 0 (0.0) Gender Male 45 (78.9) 0 (0.0) Female 12 (21.1) 44 (100.0) Number of WB units transfused in the first 24 hours 1 26 (45.6) 22 (50.0) 2 23 (40.4) 20 (45.5) 3 6 (10.5) 2 (4.5) 4 1 (1.8) 0 (0) 5 0 (0) 0 (0) 6 1 (1.8) 0 (0) Blood Type A+ 0 (0) 2 (4.5) AB+ 1 (1.8) 0 (0) O+ 56 (98.2) 42 (95.5) Table 1. Demographics of patients receiving whole blood transfusion (n=101) One-hundred-and-one TACS or obstetrics and gynecology patients were identified as receiving resuscitation with WB. Fifty-seven patients presented to the TACS service, and 44 patients presented to the obstetrics and gynecology service with an average shock index of 1.16 (±0.55) (Table 1). Admission vital signs and laboratory values can be found in Table 2. Trauma and Acute Care Surgery (SD) Obstetrics and Gynecology (SD) Systolic blood pressure (mmHg) 96.00 ( ±30.62 ) 99.59 ( ±23.68) Mean arterial pressure (mmHg) 69.11 ( ±22.98) 71.44 ( ±17.63) Heart rate (beats per minute) 100.82 ( ±26.23) 102.50 ( ±23.91) Respiratory rate (breaths per minute) 21.79 ( ±6.47) 20.84 ( ±3.62) Temperature (Celsius) 35.88 ( ±1.72) 35.90 ( ±1.89) Glasgow Coma Score (GCS) 11.32 ( ±4.85) 14.45 ( ±1.98) Shock Index 1.16 ( ±0.53) 1.14 ( ±0.58) Hemoglobin (g/dL) 10.19 ( ±3.13) 8.85 ( ±2.43) Crystalloid administered in the operating room (mL) 2203.13 ( ±1667.03) 1497.94 ( ±778.78) Colloid administered in the operating room (mL) 483.28 ( ±426.88) 400.06 ( ±438.62) Estimated blood loss (mL) 1856.40 ( ±1577.35) 1569.49 ( ±1115.63) Table 2. Admission vital signs and laboratory values of patients resuscitated with WB On average, TACS patients received 1.75 (SD ±0.93) units of WB, and obstetrics and gynecology patients received 1.55 (SD ±0.59) units of WB. An average of 1.91 (SD ± 2.68) and 1.74 (SD ± 1.91) units of pRBCs were administered to TACS and obstetrics and gynecology patients respectively after WB. An average of 1.30 (SD ±2.59) and 0.84 (SD ±1.86) units of FFP were administered to TACS and obstetrics and gynecology patients respectively after WB. Platelets, as previously mentioned, are rarely available at our institution. TACS Patients Of the 57 patients on the TACS service, 47 were trauma patients and 10 were emergency general surgery patients. Average RTS in the trauma population was 6.06 (±1.89) and average shock index was 1.18 (±51). Anatomic injury data was not available in order to calculate an injury severity score. Of the 47 trauma patients, 24 suffered penetrating trauma and 23 suffered blunt trauma. Hemorrhage was localized in the abdomen in twelve (25.53%) patients, thorax in eleven (23.40%) patients, extremities in ten (21.27%) patients, thorax and abdomen in six (12.76%) patients, face in two (4.26%) patients, pelvis in two (4.26%) patients, spine in one (2.13%) patient, and neck in one (2.13%) patient. In the case of two patients (4.26%), the cause of hemorrhage was unknown as these patients expired prior to complete assessment. The remaining 10 patients were emergency general surgery patients. Whole blood transfusion was utilized for intraoperative bleeding in a patient undergoing a repair of a ruptured abdominal aortic aneurysm (n=3, 30.00%), an open necrosectomy for infected pancreatic necrosis (n=1, 10.00%), a bowel resection for ischemic gut (n=1, 10.00%), a repair of an iliac artery aneurysm (n=1, 10.00%), repair of the superficial femoral artery following the excision of a left groin mass (n=1, 10.00%), control of gallbladder fossa hemorrhage following a laparoscopic cholecystectomy (n=1, 10.00%), control of splenic hemorrhage following a splenic biopsy (n=1, 10.00%), and control of hypogastric artery bleeding following a spinal surgery (n=1, 10.00%). Obstetrics and Gynecology Patients Forty-four patients presented to the obstetrics and gynecology service, with an average shock index of 1.15 (±0.58). Thirty-six patients (81.81%) suffered post-partum hemorrhage either after cesarean section or vaginal delivery. Post-partum hemorrhage was found to be due to uterine atony in eighteen (50.00%) patients, placenta accreta spectrum or placenta previa in eight (22.22%) patients, a tear in the vaginal mucosa in four (11.11%) patients, retained products in three (8.33%) patients, and uterine rupture in two (5.56%) patients. One (2.78%) patient had bleeding from an extrauterine vessel following a cesarean section. The remaining eight patients suffered hemorrhage due to a non-pregnancy-related gynecologic emergency (18.18%) including incomplete abortion in three (37.50%) patients, ruptured ectopic pregnancy in two (25.0%) patients, fibroids in one (12.50%) patient, post-operative bleeding after a hysterectomy in one (12.50%) patient, and a hemorrhagic ovarian cyst in one (12.50%) patient. The only mortality in this cohort expired due to complications related to hemorrhage from HELLP syndrome. Length-of-stay in the intensive care unit was 4.79 (SD±5.85) days in TACS patients, and 1.84 (SD±2.77) days in obstetrics and gynecology patients. Length of stay was 13.07 (SD±15.33) days in TACS patients, and 5.86 (SD±4.56) days in obstetrics and gynecology patients (Figure 1). Adverse Outcomes Importantly, none of the patients in our series developed symptomatology consistent with acute transfusion reaction. This includes anaphylaxis, urticaria, rash, jaundice, and hemoglobinuria per the records from both the nurse and the primary surgical team. No patients were diagnosed with TRALI or TACO in the medical record. However, many of these patients were critically ill, and therefore intubated in the perioperative period making the diagnosis challenging. The cause of death in one trauma patient who suffered massive hemorrhagic shock from a penetrating brachial artery injury was noted to be massive pulmonary edema in the setting of multisystem organ failure. This could be consistent with a diagnosis of TRALI. Overall mortality was 13.86% in the first 24 hours and 5.94% after 24 hours. The shock index of patients who expired in the first 24 hours and after 24 hours was 1.42 (SD±0.64) and 1.29 (SD±0.48), respectively. By comparison, patients who survived had an average shock index of 1.09 (SD±00.53). Of those patients that expired in the first 24 hours after transfusion, the cause of death was attributed to hemorrhage in eleven patients, three of whom arrested prior to any operative intervention, six of whom arrested in the operating room, and three of whom arrested shortly after surgery. The two remaining patients expired due to a subarachnoid hemorrhage and irreversible shock postoperatively. One death in the maternal population occurred due to hemorrhage in a patient presenting with HELLP syndrome, severe preeclampsia and intrauterine fetal demise. The patient was found to have evidence of severe coagulopathy and a hepatic hematoma after undergoing a cesarean-section; this patient unfortunately died before to operative intervention could be undertaken. Of the six patients that expired after 24 hours, three suffered sepsis leading to multisystem organ failure. Two patients were declared brain dead and one patient suffered irreversible shock after blunt force trauma to the chest not responsive to treatment. Discussion The HVCM is at the forefront of using WB transfusion in patients with hemorrhagic shock in Latin America. Our experience shows that WB transfusion represents a feasible strategy for achieving hemostatic resuscitation in patients presenting in hemorrhagic shock, especially in LMICs. Through the implementation of a whole blood program, we were able to establish a program wherein patients would receive balanced resuscitation. Prior to the implementation of a WB program, patients were resuscitated with whatever components were available in the blood bank, which included a varying and often scarce number of pRBCs and FFP. Of the patients resuscitated with WB, we do not describe any symptoms consistent with transfusion reactions. The use of WB is not a new concept. Prior to the adoption of component therapy in 1970s, resuscitation of patients in hemorrhagic shock with WB was commonplace 15 . Component therapy was popularized for logistical reasons and was never proven to be as efficacious as WB in hemorrhagic shock 16 . Recent literature from the military suggest that WB may have superior or equivalent outcomes when compared to component therapy. Two retrospective combat casualty analyses compared the use of fresh whole blood to component therapy 17, 18 . One study described a mortality benefit in the WB group at 24-hours and 30-days 18 , while the other found no statistically significant difference in mortality, death due to exsanguination, MSOF or sepsis 17 . Nessen et al. showed that, in the experience with Forward Surgical Teams (FSTs) in Afghanistan, use of FWB in addition to RBCs and FFP was associated with improved in-hospital survival compared to RBCs and FFP alone 19 . Within the civilian sector, retrospective analyses suggest superiority or equivalence of WB with regards to mortality and overall blood product use 20-23 . The only randomized control trial in trauma patients, to our knowledge, compared modified whole blood (leukoreduced whole blood with additional platelet transfusion) with component therapy. After excluding patients with traumatic brain injury, a decrease in the use of component therapy was demonstrated in patients that received modified whole blood 24 . A recent systematic review and metanalysis comparing whole blood to component therapy found no difference in 24-hour or 30-day mortality. Importantly, this study highlighted the heterogeneity in the literature on WB transfusion in trauma. No study in this analysis was from the civilian setting in a LMIC 25 . Whole blood has important implications in LMICs, of which our work is only scratching the surface. Whole blood has both, financial and logistical benefits compared to component therapy 26 . Whole blood has the advantage of being easy to store, transport and administer to patients. Its use is ideal for resource constrained environments and pre-hospital settings 16, 27 , especially those that do not have ready access to all blood components, delivering the product that would otherwise require three bags in one bag 16 . Moreover, when separated components are transfused, each unit contains an increased amount of anticoagulants and additives that contribute to a patient’s overall coagulopathy compared to one unit of whole blood 18, 28 . Spinella et al. found that, in patients receiving massive transfusion, those receiving component therapy received a median of 825ml of additional additives and anticoagulants compared to the group resuscitated with WB 18 . Additionally, it has been asserted that the administration of WB may actually be safer for patients with respect to risk of transmission of blood-borne diseases, exposing them to one donor instead of multiple donors 29 . Access to transfusion therapy and the “blood drought” creates significant barriers to safe surgery in LMICs 30 . The use of WB is a potentially beneficial in countries where keeping up with a 1:1:1 transfusion ratio is not feasible. In resource-limited settings such as our institution in Southern Ecuador, a WB program has allowed us to streamline the prompt and expeditious administration of all blood components at once thus ensuring higher concentrations of all primordial elements thereby securing hemostatic strategy for patients in hemorrhagic shock. Prior to the implementation of this program, there was no way to guarantee the availability of balanced hemostatic resuscitation to patients in hemorrhagic shock. It must be noted that Cuenca, Ecuador provides a favorable setting for implementing a whole blood program as 80% population is type O+ and 2% is type O- per the blood bank records 31 . In our sample, most patients had type O+ blood. Due to the previously mentioned government initiative to reduce maternal mortality, the blood type of the obstetrics and gynecology patients was known prior to transfusion so as to prevent the possibility of Rh incompatibility. The high incidence of type O+ blood in the population makes it easier to identify donors and makes it more likely that a patient receiving a type O+ transfusion will be receiving a transfusion from a donor with the same blood type. While this is an advantage to implementation in our setting, this may make the study less generalizable to other populations. The context for transfusion of patients in our region is distinct from the literature that typically recommends transfusion at a hemoglobin of 7g/dL 32 . Located at 2,560 meters above sea level, the average hemoglobin in this population is higher than at lower altitudes. A study of hemoglobin levels published in Colombia described the average hemoglobin of those living at 2,600 meters to range between 14.6-15.2g/dl in women and 16.8-17.4g/dl in men 33 . As such, patients at our institution are often transfused at a higher threshold, typically 9-10g/dL. The primary concern with the transfusion of group O whole blood to non-group O recipients involves the possibility of minor ABO mismatch. Minor mismatch occurs when the anti-A and anti-B antibodies found in group O WB cause hemolysis in a non-group O recipient. This is typically mitigated by transfusion of only type-specific whole blood or through the transfusion of whole units with lows titer of antibody (most commonly <256 by the saline dilution, immediate spin method), known as low-titer O whole blood (LTOWB) 16 . Numerous studies documented the safety of LTOWB, demonstrating that it does not increase risk of transfusion reaction 15, 16, 20, 21, 29, 34, 35 . However, at the HVCM, anti-A and anti-B titers are not measured prior to administration of blood products. Data supporting the transfusion of untitered whole blood is scarce in the literature. In a safety analysis of the transfusion of stored whole blood, Yazer et. al found that there was no statistically significant difference in the amount of incompatible plasma transfused in a unit of whole blood compared to the amount of incompatible plasma transfused in any unit of platelets (p=0.38) 23 . Additionally, while group AB is considered to be the “universal plasma donor,” the military permits group A plasma to be dispensed in emergencies as group A individuals do not tend to make high anti-B antibodies and B red cells express the B antigen at a low density 36 . Sperry et. al. recently demonstrated a rate of adverse events possibly related to transfusions of 2.2% in a description of AB plasma and A plasma with low-titer B antibodies administered to patients in hemorrhagic shock in the pre-hospital setting 37 . The blood types of the patients in our sample were predominantly type O+, with a smaller percentage of AB+ and A+ individuals. No group B individuals were in our sample. Severe intravascular hemolytic transfusion reactions caused by minor mismatch are a relatively rare phenomenon 19 that may be difficult to detect in an otherwise critically ill patient, and may not have been detected with the n of 93 in our series. While, again, we do not report any patients that developed symptomatology that was recognized as a hemolytic transfusion reaction, hemolysis labs post-transfusion were not routinely ordered. Several studies have documented that whole blood does not have evidence of increased hemolytic reactions with administration of up to 4 units 20, 21, 38 . This study is limited in that it is a single-institution and retrospective study. There are many challenges that come with conducting research in a resource-limited setting, many of which affected this study. While more patients were identified than described, many files were unable to be located in medical records. The documentation at the HVCM continues to be written by hand, and many of the patient charts in medical records are missed pages or written illegibly. It should also be noted that documentation prior to the implementation of the TACS service (2012) was scarce. As such, the ability to compare this sample with patients resuscitated during an earlier time period is limited. The paucity of data in the paper charts also limited our ability to reliably determine the vital signs and labs following transfusion. Conclusion In summary, our experience demonstrates that whole blood administration in patients presenting with hemorrhagic shock can be an achievable alternative therapy to 1:1:1 resuscitation especially in limited resource settings, wherein access to all blood products may not be feasible. Further studies comparing whole blood to component therapy in this population are needed. To our knowledge, this is the first description of a whole blood program implemented in a civilian setting in Latin America. list of Abbreviations WB=Whole Blood LMIC=Low- and middle-income country DCR=Damage control resuscitation HVCM= Hospital Vicente Corral Moscoso RTS=Revised Trauma Score WHO=World Health Organization TACS=Trauma and Acute Care Surgery RBCs=Packed red blood cells FFP=Fresh frozen plasma TEG= Thrombo-elastography Declarations Ethics approval: This study was approved by the ethical committee of our institution, Hospital Vicente Corral Moscoso, and the academic committee of research of the University of Azuay Medicine Faculty. Consent to Participate: This is a retrospective study. Patients cannot be easily identified given the information extracted from the charts. Funding: The authors have no funding to declare. Competing Interests: The authors have no competing interests to declare. Availability of data: The data collection sheet is provided in the electronic supplementary material. All identifying patient information has been removed for privacy. Author contributions Data collection, data analysis, manuscript writing: AH Data collection, manuscript writing: MGA Data collection, data analysis: JRN, DSA, SGPP Critical review of manuscript: NFL, RPA, HAS, LFC, CCA Critical review of manuscript, final approval of manuscript for submission: JCP, JCSM References Cannon JW. Hemorrhagic Shock. N Engl J Med . 01 2018;378(4):370-379. doi:10.1056/NEJMra1705649 Ley EJ, Clond MA, Srour MK, et al. Emergency department crystalloid resuscitation of 1.5 L or more is associated with increased mortality in elderly and nonelderly trauma patients. J Trauma . Feb 2011;70(2):398-400. doi:10.1097/TA.0b013e318208f99b Kasotakis G, Sideris A, Yang Y, et al. 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Comparison of platelet transfusion as fresh whole blood versus apheresis platelets for massively transfused combat trauma patients (CME). Transfusion . Feb 2011;51(2):242-52. doi:10.1111/j.1537-2995.2010.02818.x 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 . Apr 2009;66(4 Suppl):S69-76. doi:10.1097/TA.0b013e31819d85fb Nessen SC, Eastridge BJ, Cronk D, et al. Fresh whole blood use by forward surgical teams in Afghanistan is associated with improved survival compared to component therapy without platelets. Transfusion . Jan 2013;53 Suppl 1:107S-113S. doi:10.1111/trf.12044 Seheult JN, Anto V, Alarcon LH, Sperry JL, Triulzi DJ, Yazer MH. Clinical outcomes among low-titer group O whole blood recipients compared to recipients of conventional components in civilian trauma resuscitation. 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Oct 2013;258(4):527-32; discussion 532-3. doi:10.1097/SLA.0b013e3182a4ffa0 Crowe E, DeSantis SM, Bonnette A, et al. Whole blood transfusion versus component therapy in trauma resuscitation: a systematic review and meta-analysis. J Am Coll Emerg Physicians Open . Aug 2020;1(4):633-641. doi:10.1002/emp2.12089 Holcomb JB. Optimal use of blood products in severely injured trauma patients. Hematology Am Soc Hematol Educ Program . 2010;2010:465-9. doi:10.1182/asheducation-2010.1.465 Sheppard FR, Mitchell TA, Cap AP, Schaub LJ, Macko AR, Glaser JJ. Prehospital whole blood resuscitation prevents coagulopathy and improves acid-base status at hospital arrival in a nonhuman primate hemorrhagic shock model. Transfusion . Jul 2019;59(7):2238-2247. doi:10.1111/trf.15294 Yazer MH, Cap AP, Spinella PC. Raising the standards on whole blood. J Trauma Acute Care Surg . 06 2018;84(6S Suppl 1):S14-S17. doi:10.1097/TA.0000000000001778 Spinella PC, Cap AP. Whole blood: back to the future. Curr Opin Hematol . 11 2016;23(6):536-542. doi:10.1097/MOH.0000000000000284 Raykar NP, Kralievits K, Greenberg SL, Gillies RD, Roy N, Meara JG. The blood drought in context. Lancet Glob Health . Apr 2015;3 Suppl 2:S4-5. doi:10.1016/S2214-109X(14)70351-1 Data from: HVCM Estádisticas del Banco de Sangre. 2019. Carson JL, Guyatt G, Heddle NM, et al. Clinical Practice Guidelines From the AABB: Red Blood Cell Transfusion Thresholds and Storage. JAMA . Nov 2016;316(19):2025-2035. doi:10.1001/jama.2016.9185 Trompetero González A, Cristancho Mejía E, Benavides Pinzón W, Serrato M, Landinéz M, Rojas J. Comportamiento de la concentración de hemoglobina, el hematocrito y la saturación de oxígeno en una población universitaria en Colombia a diferentes alturas. Nutrición Hospitalaria . 2015;32(5):2309-2318. Spinella PC, Pidcoke HF, Strandenes G, et al. Whole blood for hemostatic resuscitation of major bleeding. Transfusion . 04 2016;56 Suppl 2:S190-202. doi:10.1111/trf.13491 Yazer MH, Spinella PC. The use of low-titer group O whole blood for the resuscitation of civilian trauma patients in 2018. Transfusion . 11 2018;58(11):2744-2746. doi:10.1111/trf.14869 Cap AP, Pidcoke HF, Spinella P, et al. Damage Control Resuscitation. Mil Med . 09 2018;183(suppl_2):36-43. doi:10.1093/milmed/usy112 Sperry JL, Guyette FX, Brown JB, et al. Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med . Jul 2018;379(4):315-326. doi:10.1056/NEJMoa1802345 Seheult JN, Triulzi DJ, Alarcon LH, Sperry JL, Murdock A, Yazer MH. Measurement of haemolysis markers following transfusion of uncrossmatched, low-titre, group O+ whole blood in civilian trauma patients: initial experience at a level 1 trauma centre. Transfus Med . Feb 2017;27(1):30-35. doi:10.1111/tme.12372 Supplementary Files DATAWITHOUTIDENTIFIERSFORST26820.xlsx NAKULRAYKARCOI.pdf PUYANACOI.pdf SANDRAPATINOCOI.pdf SALAMEACOI.pdf REINOSOCOI.pdf RAULPINOANDRADECOI.pdf NUBEFLORESCOI.pdf MONICAGALARZACOI.pdf HERNANSACOTOCOI.pdf FDEZCOI.pdf DORISSARMIENTOCOI.pdf CEVALLOSCOI.pdf AMBERHIMMLERCOI.pdf Cite Share Download PDF Status: Published Journal Publication published 01 Nov, 2021 Read the published version in Trauma Surgery & Acute Care Open → Version 2 posted You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-66244","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":7415154,"identity":"905a0dc8-ff49-45df-a10b-5a10aee717d6","order_by":0,"name":"Amber Nicole Himmler","email":"","orcid":"https://orcid.org/0000-0001-7180-5787","institution":"MedStar Georgetown University Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Amber","middleName":"Nicole","lastName":"Himmler","suffix":""},{"id":7415155,"identity":"d838c701-48ee-4f48-9f8c-6c5e4a287c84","order_by":1,"name":"Monica Eulalia Galarza 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13:16:44","currentVersionCode":2,"declarations":"","doi":"10.21203/rs.3.rs-66244/v2","doiUrl":"https://doi.org/10.21203/rs.3.rs-66244/v2","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1136/tsaco-2021-000758","type":"published","date":"2021-11-01T17:23:13+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":4934281,"identity":"f2aa6274-605e-44ac-b70d-8c7763a1c2a4","added_by":"auto","created_at":"2021-01-13 19:00:43","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":84794,"visible":true,"origin":"","legend":"(A) One unit of type O+ whole blood. (B) The three components after whole blood is fractionated. At our institution, whole blood is available for 48 hours, after which it is fractionated into components. 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18:54:44","extension":"pdf","order_by":19,"title":"","display":"","copyAsset":false,"role":"supplement","size":384067,"visible":true,"origin":"","legend":"","description":"","filename":"CEVALLOSCOI.pdf","url":"https://assets-eu.researchsquare.com/files/rs-66244/v2/46a69bf7c85b0dd42b36337b.pdf"},{"id":4934194,"identity":"77f9556a-f82f-4813-8289-2e53c6128a54","added_by":"auto","created_at":"2021-01-13 18:54:44","extension":"pdf","order_by":20,"title":"","display":"","copyAsset":false,"role":"supplement","size":382844,"visible":true,"origin":"","legend":"","description":"","filename":"AMBERHIMMLERCOI.pdf","url":"https://assets-eu.researchsquare.com/files/rs-66244/v2/9890a5d2076f4218ac0dc04c.pdf"}],"financialInterests":"","formattedTitle":"Is the Whole Greater than the Sum of Its Parts? The Implementation and Outcomes of a Whole Blood Program in Ecuador","fulltext":[{"header":"Background","content":"\u003cp\u003eHemorrhagic shock kills an estimated 1.9 million people annually worldwide \u003csup\u003e1\u003c/sup\u003e. Prompt management of hemorrhagic shock is essential. Several decades of experience have shown that extensive volume resuscitation with crystalloid can lead to an exacerbation of the \u0026ldquo;lethal triad,\u0026rdquo; of trauma-induced coagulopathy, hypothermia and acidosis\u003csup\u003e2-5\u003c/sup\u003e; this phenomenon has been recently modified to include hypocalcemia, and therefore has been termed the \u0026ldquo;lethal diamond\u0026rdquo; \u003csup\u003e6\u003c/sup\u003e. Evidence over the past decade suggest a more balanced resuscitation involving the replacement of lost blood with a 1:1:1 transfusion with red blood cells (RBCs), fresh frozen plasma (FFP) and platelets, mimicking the whole blood (WB) that is lost \u003csup\u003e7-9\u003c/sup\u003e. Adherence to a 1:1:1 ratio, however, remains challenging even in high-resource settings \u003csup\u003e10\u003c/sup\u003e. Many regions of the world do not have the blood bank capabilities to adequately supply and respond to the challenging demands for providing and sustaining a timely and efficient 1:1:1 resuscitation strategy \u003csup\u003e11\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e12\u003c/sup\u003e. As such, there has been renewed interest in WB transfusion programs as an initial approach to damage control resuscitation.\u003c/p\u003e\n\u003cp\u003eHospital Vicente Corral Moscoso (HVCM) is a public hospital located in Southern Ecuador and serves as a referral center for more than 2 million inhabitants\u003csup\u003e13\u003c/sup\u003e. A WB transfusion program was implemented in 2013 to address the issue of inadequate hemostatic resuscitation for patients in hemorrhagic shock. The aim of this paper is to describe the logistics of the implementation of a WB transfusion protocol at our institution, review the outcomes of exsanguinating trauma and acute care surgery, and obstetrics and gynecology populations who received WB and demonstrate the feasibility of a WB program in a low-and-middle-income country (LMIC).\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe performed a mixed methods analysis of the WB resuscitation program at the HVCM. In order to document the details of the program, we interviewed of members of the blood bank staff, hospital administration, and clinical leadership of the hospital who were instrumental in establishing the program. In order to characterize the safety profile of WB transfusions in our program, we identified patients who received WB transfusion from 2013-2019. The following datapoints were collected: sex, age, service treating the patient, units of WB administered, units of components administered, admission vital signs, admission hemoglobin, Shock Index, intraoperative crystalloid and colloid administration, length-of-stay and in-hospital mortality. In trauma patients, the revised trauma score (RTS) was calculated. We also collected information suggestive of symptomatic acute transfusion reactions including evidence of anaphylaxis, urticaria, rash, jaundice, hemoglobinuria and respiratory difficulty in the immediate post-transfusion period. No labs were sent post-transfusion to detect subclinical transfusion reactions. Post-transfusion laboratory values were not available on all patients.\u003c/p\u003e\n\u003cp\u003eWe used SPSS v 26 for statistical analysis. This study was approved by the ethical committee of our institution, Hospital Vicente Corral Moscoso, and the academic committee of research of the University of Azuay Medicine Faculty.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eWhole Blood Transfusion Protocol at the HVCM\u003cstrong\u003e\u003cbr /\u003e\u003c/strong\u003e\u003c/em\u003eFive units of type O+ WB were made available daily and released to patients presenting in hemorrhagic shock, as determined by the attending surgeon taking care of the patient. There is often a delay of only a few minutes in starting a WB transfusion once it is ordered by a physician as five units are always set aside for patients presenting in shock. After the type O+ whole blood is dispensed, the blood bank then proceeds to type and cross the patient using Bio-Rad Saxo ID-Reader. Initial resuscitation was begun in the emergency department and extended into the operating room in most cases, or is begun in the operating room. Given the resource limitations, a warming device was not routinely available. The patient is transfused with WB until vital signs stabilized per the clinical judgment of the attending surgeon, or until the blood bank is depleted of WB, after which type-specific RBCs and FFP are dispensed according to their availability in the blood bank. The decision to transition from WB to component therapy is not based on laboratory parameters at our institution as point-of-care laboratory tests are not available at our institution to allow for rapid decision making. The resuscitation strategy at the HVCM is largely based on clinical exam, as tools such as thrombo-elastography (TEG) used at some institutions to guide blood-based resuscitation are not available.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eBlood donation and collection:\u003c/u\u003e Whole blood is obtained through voluntary unpaid donation or replacement donation. The blood must be collected in no more than 12 minutes with constant manual or mechanical activation so as to prevent the activation of the clotting cascade. The use of aseptic technique is paramount for quality control and prevention of bacterial contamination. The sterile material utilized in this process is disposable. The extraction bags are quadruple bags including CPD+SAG-Mannitol BUFFY-COAT. The filtration system is used only when the blood is fractionated into components.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eWB processing, storage and administration:\u003c/u\u003e After a unit of blood is donated, it is quarantined for 8 hours during which time the ABO type and Rh (D) type are determined. The WB is screened for the following serologic markers according to World Health Organization (WHO) standards \u003csup\u003e14\u003c/sup\u003e: Syphilis, Hepatitis C, Hepatitis B, and HIV. Plasma antibody titers are not measured prior to the transfusion\u0026nbsp;of WB. If the blood tests negative for infectious diseases, it is stored at 4-6\u0026deg;C and available for 48 hours. As such, the product dispensed at the HVCM is considered cold, fresh whole blood.\u003c/p\u003e\n\u003cp\u003eLeukoreduction is not routinely performed on the units of WB due to the inability to preserve platelets. After 48 hours, if the blood is not utilized, it is fractionated into components. The red blood cells and frozen plasma are then made available for up 35-42 days and one year respectively. Platelets are not available to patients at the HVCM after fractionation. Given the relative scarcity of blood products in the region, the platelets obtained through fractionation are primarily sent to the local cancer hospital. The blood bank stock is then replaced by the aforementioned methods.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eOutcomes of Patients Managed with WB:\u003c/u\u003e\u003c/p\u003e\n\u003ctable style=\"width: 453.4pt; border-collapse: collapse; border: none;\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 221.1pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 26.7pt; vertical-align: top;\" colspan=\"2\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif;\"\u003e\u003cstrong\u003e\u003cspan style=\"color: #000000; font-size: 11px; font-family: Verdana, Geneva, sans-serif;\"\u003eVariable\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 107.15pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 26.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e\u003cstrong\u003eTrauma and Acute Care Surgery, n (%)\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 125.15pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 26.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e\u003cstrong\u003eObstetrics and Gynecology, n (%)\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 130.25pt; border: none; padding: 0in 5.4pt; height: 12.95pt; vertical-align: top;\" rowspan=\"4\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e\u003cstrong\u003eAge (years)\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; border-top: none; border-right: none; border-left: none; border-image: initial; border-bottom: 1pt solid #7f7f7f; padding: 0in 5.4pt; height: 12.95pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e\u003cspan style=\"background: white;\"\u003e\u0026le;\u003c/span\u003e18\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 107.15pt; border-top: none; border-right: none; border-left: none; border-image: initial; border-bottom: 1pt solid #7f7f7f; padding: 0in 5.4pt; height: 12.95pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e5 (8.8)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 125.15pt; border-top: none; border-right: none; border-left: none; border-image: initial; border-bottom: 1pt solid #7f7f7f; padding: 0in 5.4pt; height: 12.95pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e2 (4.5)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 90.85pt; border: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e19-39\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 107.15pt; border: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e32 (56.1)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 125.15pt; border: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e39 (88.6)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 90.85pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e40-64\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 107.15pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e15 (26.3)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 125.15pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e3 (6.8)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 90.85pt; border: none; padding: 0in 5.4pt; height: 14.5pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e\u003cspan style=\"background: white;\"\u003e\u0026ge;\u003c/span\u003e65\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 107.15pt; border: none; padding: 0in 5.4pt; height: 14.5pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e5 (8.8)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 125.15pt; border: none; padding: 0in 5.4pt; height: 14.5pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e0 (0.0)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 130.25pt; border-right: none; border-bottom: none; border-left: none; border-image: initial; border-top: 1pt solid #7f7f7f; padding: 0in 5.4pt; height: 12.95pt; vertical-align: top;\" rowspan=\"2\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 12.95pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003eMale\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 107.15pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 12.95pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e45 (78.9)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 125.15pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 12.95pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e0 (0.0)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 90.85pt; border: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003eFemale\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 107.15pt; border: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e12 (21.1)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 125.15pt; border: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e44 (100.0)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 130.25pt; border-right: none; border-bottom: none; border-left: none; border-image: initial; border-top: 1pt solid #7f7f7f; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\" rowspan=\"6\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e\u003cstrong\u003eNumber of WB units transfused in the first 24 hours\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e1\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 107.15pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e26 (45.6)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 125.15pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e22 (50.0)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 90.85pt; border: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e2\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 107.15pt; border: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e23 (40.4)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 125.15pt; border: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e20 (45.5)\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 90.85pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e3\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 107.15pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e6 (10.5)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 125.15pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e2 (4.5)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 90.85pt; border: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e4\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 107.15pt; border: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e1 (1.8)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 125.15pt; border: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e0 (0)\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 90.85pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e5\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 107.15pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e0 (0)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 125.15pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e0 (0)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 90.85pt; border: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e6\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 107.15pt; border: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e1 (1.8)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 125.15pt; border: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e0 (0)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 130.25pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\" rowspan=\"3\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e\u003cstrong\u003eBlood Type\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003eA+\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 107.15pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e0 (0)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 125.15pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e2 (4.5)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 90.85pt; border: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003eAB+\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 107.15pt; border: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e1 (1.8)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 125.15pt; border: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e0 (0)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 90.85pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003eO+\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 107.15pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e56 (98.2)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 125.15pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 13.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e42 (95.5)\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cem\u003e\u003cspan style=\"color: #000000; font-size: 11px; font-family: Verdana, Geneva, sans-serif;\"\u003eTable 1. Demographics of patients receiving whole blood transfusion (n=101)\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOne-hundred-and-one TACS or obstetrics and gynecology patients were identified as receiving resuscitation with WB. Fifty-seven patients presented to the TACS service, and 44 patients presented to the obstetrics and gynecology service with an average shock index of 1.16 (\u0026plusmn;0.55) (Table 1). Admission vital signs and laboratory values can be found in Table 2.\u003c/p\u003e\n\u003ctable style=\"width: 458.25pt; border-collapse: collapse; border: none;\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 166.2pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 20.45pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif;\"\u003e\u003cstrong\u003e\u003cspan style=\"color: #000000; font-size: 11px; font-family: Verdana, Geneva, sans-serif;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 137.45pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 20.45pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e\u003cstrong\u003eTrauma and Acute Care Surgery (SD)\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 154.6pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 20.45pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e\u003cstrong\u003eObstetrics and Gynecology (SD)\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 166.2pt; border-top: none; border-right: none; border-left: none; border-image: initial; border-bottom: 1pt solid #7f7f7f; padding: 0in 5.4pt; height: 30.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e\u003cstrong\u003eSystolic blood pressure (mmHg)\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 137.45pt; border-top: none; border-right: none; border-left: none; border-image: initial; border-bottom: 1pt solid #7f7f7f; padding: 0in 5.4pt; height: 30.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e96.00 (\u003cspan style=\"background: white;\"\u003e\u0026plusmn;30.62\u003c/span\u003e)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 154.6pt; border-top: none; border-right: none; border-left: none; border-image: initial; border-bottom: 1pt solid #7f7f7f; padding: 0in 5.4pt; height: 30.7pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e99.59 (\u003cspan style=\"background: white;\"\u003e\u0026plusmn;23.68)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 166.2pt; border: none; padding: 0in 5.4pt; height: 31.3pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e\u003cstrong\u003eMean arterial pressure (mmHg)\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 137.45pt; border: none; padding: 0in 5.4pt; height: 31.3pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e69.11 (\u003cspan style=\"background: white;\"\u003e\u0026plusmn;22.98)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 154.6pt; border: none; padding: 0in 5.4pt; height: 31.3pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e71.44 (\u003cspan style=\"background: white;\"\u003e\u0026plusmn;17.63)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 166.2pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 20.45pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e\u003cstrong\u003eHeart rate (beats per minute)\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 137.45pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 20.45pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e100.82 (\u003cspan style=\"background: white;\"\u003e\u0026plusmn;26.23)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 154.6pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 20.45pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e102.50 (\u003cspan style=\"background: white;\"\u003e\u0026plusmn;23.91)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 166.2pt; border: none; padding: 0in 5.4pt; height: 10.2pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e\u003cstrong\u003eRespiratory rate (breaths per minute)\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 137.45pt; border: none; padding: 0in 5.4pt; height: 10.2pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e21.79 (\u003cspan style=\"background: white;\"\u003e\u0026plusmn;6.47)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 154.6pt; border: none; padding: 0in 5.4pt; height: 10.2pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e20.84 (\u003cspan style=\"background: white;\"\u003e\u0026plusmn;3.62)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 166.2pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 10.2pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e\u003cstrong\u003eTemperature (Celsius)\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 137.45pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 10.2pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e35.88 (\u003cspan style=\"background: white;\"\u003e\u0026plusmn;1.72)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 154.6pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 10.2pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e35.90 (\u003cspan style=\"background: white;\"\u003e\u0026plusmn;1.89)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 166.2pt; border: none; padding: 0in 5.4pt; height: 20.45pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e\u003cstrong\u003eGlasgow Coma Score (GCS)\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 137.45pt; border: none; padding: 0in 5.4pt; height: 20.45pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e11.32 (\u003cspan style=\"background: white;\"\u003e\u0026plusmn;4.85)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 154.6pt; border: none; padding: 0in 5.4pt; height: 20.45pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e14.45 (\u003cspan style=\"background: white;\"\u003e\u0026plusmn;1.98)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 166.2pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 9.6pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e\u003cstrong\u003eShock Index\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 137.45pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 9.6pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e1.16 (\u003cspan style=\"background: white;\"\u003e\u0026plusmn;0.53)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 154.6pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 9.6pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e1.14 (\u003cspan style=\"background: white;\"\u003e\u0026plusmn;0.58)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 166.2pt; border: none; padding: 0in 5.4pt; height: 9.6pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e\u003cstrong\u003eHemoglobin (g/dL)\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 137.45pt; border: none; padding: 0in 5.4pt; height: 9.6pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e10.19 (\u003cspan style=\"background: white;\"\u003e\u0026plusmn;3.13)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 154.6pt; border: none; padding: 0in 5.4pt; height: 9.6pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e8.85 (\u003cspan style=\"background: white;\"\u003e\u0026plusmn;2.43)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 166.2pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 41.6pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e\u003cstrong\u003eCrystalloid administered in the operating room (mL)\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 137.45pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 41.6pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e2203.13 (\u003cspan style=\"background: white;\"\u003e\u0026plusmn;1667.03)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 154.6pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 41.6pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e1497.94 (\u003cspan style=\"background: white;\"\u003e\u0026plusmn;778.78)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 166.2pt; border: none; padding: 0in 5.4pt; height: 41pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e\u003cstrong\u003eColloid administered in the operating room (mL)\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 137.45pt; border: none; padding: 0in 5.4pt; height: 41pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e483.28 (\u003cspan style=\"background: white;\"\u003e\u0026plusmn;426.88)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 154.6pt; border: none; padding: 0in 5.4pt; height: 41pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e400.06 (\u003cspan style=\"background: white;\"\u003e\u0026plusmn;438.62)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 166.2pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 20.45pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e\u003cstrong\u003eEstimated blood loss (mL)\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 137.45pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 20.45pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e1856.40 (\u003cspan style=\"background: white;\"\u003e\u0026plusmn;1577.35)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 154.6pt; border-top: 1pt solid #7f7f7f; border-left: none; border-bottom: 1pt solid #7f7f7f; border-right: none; padding: 0in 5.4pt; height: 20.45pt; vertical-align: top;\"\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cspan style=\"font-family: Verdana, Geneva, sans-serif;\"\u003e\u003cspan style=\"font-size: 11px;\"\u003e1569.49 (\u003cspan style=\"background: white;\"\u003e\u0026plusmn;1115.63)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"margin: 0in; font-size: 16px; font-family: 'Times New Roman',serif; line-height: 200%;\"\u003e\u003cem\u003e\u003cspan style=\"color: #000000; font-size: 11px; font-family: Verdana, Geneva, sans-serif;\"\u003eTable 2. Admission vital signs and laboratory values of patients resuscitated with WB\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOn average, TACS patients received 1.75 (SD \u0026plusmn;0.93) units of WB, and obstetrics and gynecology patients received 1.55 (SD \u0026plusmn;0.59) units of WB. An average of 1.91 (SD \u0026plusmn; 2.68) and 1.74 (SD \u0026plusmn; 1.91) units of pRBCs were administered to TACS and obstetrics and gynecology patients respectively after WB. An average of 1.30 (SD \u0026plusmn;2.59) and 0.84 (SD \u0026plusmn;1.86) units of FFP were administered to TACS and obstetrics and gynecology patients respectively after WB. Platelets, as previously mentioned, are rarely available at our institution.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTACS Patients\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOf the 57 patients on the TACS service, 47 were trauma patients and 10 were emergency general surgery patients. Average RTS in the trauma population was 6.06 (\u0026plusmn;1.89) and average shock index was 1.18 (\u0026plusmn;51). Anatomic injury data was not available in order to calculate an injury severity score. Of the 47 trauma patients, 24 suffered penetrating trauma and 23 suffered blunt trauma. Hemorrhage was localized in the abdomen in twelve (25.53%) patients, thorax in eleven (23.40%) patients, extremities in ten (21.27%) patients, thorax and abdomen in six (12.76%) patients, face in two (4.26%) patients, pelvis in two (4.26%) patients, spine in one (2.13%) patient, and neck in one (2.13%) patient. In the case of two patients (4.26%), the cause of hemorrhage was unknown as these patients expired prior to complete assessment.\u003c/p\u003e\n\u003cp\u003eThe remaining 10 patients were emergency general surgery patients. Whole blood transfusion was utilized for intraoperative bleeding in a patient undergoing a repair of a ruptured abdominal aortic aneurysm (n=3, 30.00%), an open necrosectomy for infected pancreatic necrosis (n=1, 10.00%), a bowel resection for ischemic gut (n=1, 10.00%), a repair of an iliac artery aneurysm (n=1, 10.00%), repair of the superficial femoral artery following the excision of a left groin mass (n=1, 10.00%), control of gallbladder fossa hemorrhage following a laparoscopic cholecystectomy (n=1, 10.00%), control of splenic hemorrhage following a splenic biopsy (n=1, 10.00%), and control of hypogastric artery bleeding following a spinal surgery (n=1, 10.00%).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eObstetrics and Gynecology Patients\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eForty-four patients presented to the obstetrics and gynecology service, with an average shock index of 1.15 (\u0026plusmn;0.58). Thirty-six patients (81.81%) suffered post-partum hemorrhage either after cesarean section or vaginal delivery. Post-partum hemorrhage was found to be due to uterine atony in eighteen (50.00%) patients, placenta accreta spectrum or placenta previa in eight (22.22%) patients, a tear in the vaginal mucosa in four (11.11%) patients, retained products in three (8.33%) patients, and uterine rupture in two (5.56%) patients. One (2.78%) patient had bleeding from an extrauterine vessel following a cesarean section. The remaining eight patients suffered hemorrhage due to a non-pregnancy-related gynecologic emergency (18.18%) including incomplete abortion in three (37.50%) patients, ruptured ectopic pregnancy in two (25.0%) patients, fibroids in one (12.50%) patient, post-operative bleeding after a hysterectomy in one (12.50%) patient, and a hemorrhagic ovarian cyst in one (12.50%) patient. The only mortality in this cohort expired due to complications related to hemorrhage from HELLP syndrome.\u003c/p\u003e\n\u003cp\u003eLength-of-stay in the intensive care unit was 4.79 (SD\u0026plusmn;5.85) days in TACS patients, and 1.84 (SD\u0026plusmn;2.77) days in obstetrics and gynecology patients. Length of stay was 13.07 (SD\u0026plusmn;15.33) days in TACS patients, and 5.86 (SD\u0026plusmn;4.56) days in obstetrics and gynecology patients (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAdverse Outcomes \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eImportantly, none of the patients in our series developed symptomatology consistent with acute transfusion reaction. This includes anaphylaxis, urticaria, rash, jaundice, and hemoglobinuria per the records from both the nurse and the primary surgical team. No patients were diagnosed with TRALI or TACO in the medical record. However, many of these patients were critically ill, and therefore intubated in the perioperative period making the diagnosis challenging. The cause of death in one trauma patient who suffered massive hemorrhagic shock from a penetrating brachial artery injury was noted to be massive pulmonary edema in the setting of multisystem organ failure. This could be consistent with a diagnosis of TRALI.\u003c/p\u003e\n\u003cp\u003eOverall mortality was 13.86% in the first 24 hours and 5.94% after 24 hours. The shock index of patients who expired in the first 24 hours and after 24 hours was 1.42 (SD\u0026plusmn;0.64) and 1.29 (SD\u0026plusmn;0.48), respectively. By comparison, patients who survived had an average shock index of 1.09 (SD\u0026plusmn;00.53). Of those patients that expired in the first 24 hours after transfusion, the cause of death was attributed to hemorrhage in eleven patients, three of whom arrested prior to any operative intervention, six of whom arrested in the operating room, and three of whom arrested shortly after surgery. The two remaining patients expired due to a subarachnoid hemorrhage and irreversible shock postoperatively. One death in the maternal population occurred due to hemorrhage in a patient presenting with HELLP syndrome, severe preeclampsia and intrauterine fetal demise. The patient was found to have evidence of severe coagulopathy and a hepatic hematoma after undergoing a cesarean-section; this patient unfortunately died before to operative intervention could be undertaken.\u003c/p\u003e\n\u003cp\u003eOf the six patients that expired after 24 hours, three suffered sepsis leading to multisystem organ failure. Two patients were declared brain dead and one patient suffered irreversible shock after blunt force trauma to the chest not responsive to treatment.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe HVCM is at the forefront of using WB transfusion in patients with hemorrhagic shock in Latin America. Our experience shows that WB transfusion represents a feasible strategy for achieving hemostatic resuscitation in patients presenting in hemorrhagic shock, especially in LMICs. Through the implementation of a whole blood program, we were able to establish a program wherein patients would receive balanced resuscitation. Prior to the implementation of a WB program, patients were resuscitated with whatever components were available in the blood bank, which included a varying and often scarce number of pRBCs and FFP. Of the patients resuscitated with WB, we do not describe any symptoms consistent with transfusion reactions.\u003c/p\u003e\n\u003cp\u003eThe use of WB is not a new concept. Prior to the adoption of component therapy in 1970s, resuscitation of patients in hemorrhagic shock with WB was commonplace \u003csup\u003e15\u003c/sup\u003e. Component therapy was popularized for logistical reasons and was never proven to be as efficacious as WB in hemorrhagic shock\u003csup\u003e16\u003c/sup\u003e. Recent literature from the military suggest that WB may have superior or equivalent outcomes when compared to component therapy. Two retrospective combat casualty analyses compared the use of fresh whole blood to component therapy \u003csup\u003e17, 18\u003c/sup\u003e. One study described a mortality benefit in the WB group at 24-hours and 30-days\u003csup\u003e18\u003c/sup\u003e, while the other found no statistically significant difference in mortality, death due to exsanguination, MSOF or sepsis \u003csup\u003e17\u003c/sup\u003e. Nessen \u003cem\u003eet al.\u003c/em\u003e showed that, in the experience with Forward Surgical Teams (FSTs) in Afghanistan, use of FWB in addition to RBCs and FFP was associated with improved in-hospital survival compared to RBCs and FFP alone \u003csup\u003e19\u003c/sup\u003e. Within the civilian sector, retrospective analyses suggest superiority or equivalence of WB with regards to mortality and overall blood product use \u003csup\u003e20-23\u003c/sup\u003e. The only randomized control trial in trauma patients, to our knowledge, compared modified whole blood (leukoreduced whole blood with additional platelet transfusion) with component therapy. After excluding patients with traumatic brain injury, a decrease in the use of component therapy was demonstrated in patients that received modified whole blood \u003csup\u003e24\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eA recent systematic review and metanalysis comparing whole blood to component therapy found no difference in 24-hour or 30-day mortality. Importantly, this study highlighted the heterogeneity in the literature on WB transfusion in trauma. No study in this analysis was from the civilian setting in a LMIC\u003csup\u003e25\u003c/sup\u003e. Whole blood has important implications in LMICs, of which our work is only scratching the surface.\u003c/p\u003e\n\u003cp\u003eWhole blood has both, financial and logistical benefits compared to component therapy \u003csup\u003e26\u003c/sup\u003e. Whole blood has the advantage of being easy to store, transport and administer to patients. Its use is ideal for resource constrained environments and pre-hospital settings\u003csup\u003e16, 27\u003c/sup\u003e, especially those that do not have ready access to all blood components, delivering the product that would otherwise require three bags in one bag \u003csup\u003e16\u003c/sup\u003e. Moreover, when separated components are transfused, each unit contains an increased amount of anticoagulants and additives that contribute to a patient\u0026rsquo;s overall coagulopathy compared to one unit of whole blood \u003csup\u003e18, 28\u003c/sup\u003e. Spinella et al. found that, in patients receiving massive transfusion, those receiving component therapy received a median of 825ml of additional additives and anticoagulants compared to the group resuscitated with WB\u003csup\u003e18\u003c/sup\u003e. Additionally, it has been asserted that the administration of WB may actually be safer for patients with respect to risk of transmission of blood-borne diseases, exposing them to one donor instead of multiple donors \u003csup\u003e29\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAccess to transfusion therapy and the \u0026ldquo;blood drought\u0026rdquo; creates significant barriers to safe surgery in LMICs\u003csup\u003e30\u003c/sup\u003e. The use of WB is a potentially beneficial in countries where keeping up with a 1:1:1 transfusion ratio is not feasible. In resource-limited settings such as our institution in Southern Ecuador, a WB program has allowed us to streamline the prompt and expeditious administration of all blood components at once thus ensuring higher concentrations of all primordial elements thereby securing hemostatic strategy for patients in hemorrhagic shock. Prior to the implementation of this program, there was no way to guarantee the availability of balanced hemostatic resuscitation to patients in hemorrhagic shock.\u003c/p\u003e\n\u003cp\u003eIt must be noted that Cuenca, Ecuador provides a favorable setting for implementing a whole blood program as 80% population is type O+ and 2% is type O- per the blood bank records \u003csup\u003e31\u003c/sup\u003e. In our sample, most patients had type O+ blood. Due to the previously mentioned government initiative to reduce maternal mortality, the blood type of the obstetrics and gynecology patients was known prior to transfusion so as to prevent the possibility of Rh incompatibility. The high incidence of type O+ blood in the population makes it easier to identify donors and makes it more likely that a patient receiving a type O+ transfusion will be receiving a transfusion from a donor with the same blood type. While this is an advantage to implementation in our setting, this may make the study less generalizable to other populations.\u003c/p\u003e\n\u003cp\u003eThe context for transfusion of patients in our region is distinct from the literature that typically recommends transfusion at a hemoglobin of 7g/dL \u003csup\u003e32\u003c/sup\u003e. Located at 2,560 meters above sea level, the average hemoglobin in this population is higher than at lower altitudes. A study of hemoglobin levels published in Colombia described the average hemoglobin of those living at 2,600 meters to range between 14.6-15.2g/dl in women and 16.8-17.4g/dl in men \u003csup\u003e33\u003c/sup\u003e. As such, patients at our institution are often transfused at a higher threshold, typically 9-10g/dL.\u003c/p\u003e\n\u003cp\u003eThe primary concern with the transfusion of group O whole blood to non-group O recipients involves the possibility of minor ABO mismatch. Minor mismatch occurs when the anti-A and anti-B antibodies found in group O WB cause hemolysis in a non-group O recipient. This is typically mitigated by transfusion of only type-specific whole blood or through the transfusion of whole units with lows titer of antibody (most commonly \u0026lt;256 by the saline dilution, immediate spin method), known as low-titer O whole blood (LTOWB) \u003csup\u003e16\u003c/sup\u003e. Numerous studies documented the safety of LTOWB, demonstrating that it does not increase risk of transfusion reaction \u003csup\u003e15, 16, 20, 21, 29, 34, 35\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eHowever, at the HVCM, anti-A and anti-B titers are not measured prior to administration of blood products. Data supporting the transfusion of untitered whole blood is scarce in the literature. In a safety analysis of the transfusion of stored whole blood, Yazer et. al found that there was no statistically significant difference in the amount of incompatible plasma transfused in a unit of whole blood compared to the amount of incompatible plasma transfused in any unit of platelets (p=0.38) \u003csup\u003e23\u003c/sup\u003e. Additionally, while group AB is considered to be the \u0026ldquo;universal plasma donor,\u0026rdquo; the military permits group A plasma to be dispensed in emergencies as group A individuals do not tend to make high anti-B antibodies and B red cells express the B antigen at a low density\u003csup\u003e36\u003c/sup\u003e. Sperry et. al. recently demonstrated a rate of adverse events possibly related to transfusions of 2.2% in a description of AB plasma and A plasma with low-titer B antibodies administered to patients in hemorrhagic shock in the pre-hospital setting \u003csup\u003e37\u003c/sup\u003e. The blood types of the patients in our sample were predominantly type O+, with a smaller percentage of AB+ and A+ individuals. No group B individuals were in our sample. Severe intravascular hemolytic transfusion reactions caused by minor mismatch are a relatively rare phenomenon \u003csup\u003e19\u003c/sup\u003e that may be difficult to detect in an otherwise critically ill patient, and may not have been detected with the \u003cem\u003en\u003c/em\u003e of 93 in our series. While, again, we do not report any patients that developed symptomatology that was recognized as a hemolytic transfusion reaction, hemolysis labs post-transfusion were not routinely ordered. Several studies have documented that whole blood does not have evidence of increased hemolytic reactions with administration of up to 4 units \u003csup\u003e20, 21, 38\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThis study is limited in that it is a single-institution and retrospective study. There are many challenges that come with conducting research in a resource-limited setting, many of which affected this study. While more patients were identified than described, many files were unable to be located in medical records. The documentation at the HVCM continues to be written by hand, and many of the patient charts in medical records are missed pages or written illegibly. It should also be noted that documentation prior to the implementation of the TACS service (2012) was scarce. As such, the ability to compare this sample with patients resuscitated during an earlier time period is limited. The paucity of data in the paper charts also limited our ability to reliably determine the vital signs and labs following transfusion.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, our experience demonstrates that whole blood administration in patients presenting with hemorrhagic shock can be an achievable alternative therapy to 1:1:1 resuscitation especially in limited resource settings, wherein access to all blood products may not be feasible. Further studies comparing whole blood to component therapy in this population are needed. To our knowledge, this is the first description of a whole blood program implemented in a civilian setting in Latin America.\u003c/p\u003e"},{"header":"list of Abbreviations","content":"\u003cul\u003e\n\u003cli\u003eWB=Whole Blood\u003c/li\u003e\n\u003cli\u003eLMIC=Low- and middle-income country\u003c/li\u003e\n\u003cli\u003eDCR=Damage control resuscitation\u003c/li\u003e\n\u003cli\u003eHVCM= Hospital Vicente Corral Moscoso\u003c/li\u003e\n\u003cli\u003eRTS=Revised Trauma Score\u003c/li\u003e\n\u003cli\u003eWHO=World Health Organization\u003c/li\u003e\n\u003cli\u003eTACS=Trauma and Acute Care Surgery\u003c/li\u003e\n\u003cli\u003eRBCs=Packed red blood cells\u003c/li\u003e\n\u003cli\u003eFFP=Fresh frozen plasma\u003c/li\u003e\n\u003cli\u003eTEG= Thrombo-elastography\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval: \u003c/strong\u003eThis study was approved by the ethical committee of our institution, Hospital Vicente Corral Moscoso, and the academic committee of research of the University of Azuay Medicine Faculty.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate:\u003c/strong\u003e This is a retrospective study. Patients cannot be easily identified given the information extracted from the charts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The authors have no funding to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e The authors have no competing interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data:\u003c/strong\u003e The data collection sheet is provided in the electronic supplementary material. All identifying patient information has been removed for privacy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eData collection, data analysis, manuscript writing: AH\u003c/li\u003e\n\u003cli\u003eData collection, manuscript writing: MGA\u003c/li\u003e\n\u003cli\u003eData collection, data analysis: JRN, DSA, SGPP\u003c/li\u003e\n\u003cli\u003eCritical review of manuscript: NFL, RPA, HAS, LFC, CCA\u003c/li\u003e\n\u003cli\u003eCritical review of manuscript, final approval of manuscript for submission: JCP, JCSM\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCannon JW. Hemorrhagic Shock. \u003cem\u003eN Engl J Med\u003c/em\u003e. 01 2018;378(4):370-379. doi:10.1056/NEJMra1705649\u003c/li\u003e\n\u003cli\u003eLey EJ, Clond MA, Srour MK, et al. Emergency department crystalloid resuscitation of 1.5 L or more is associated with increased mortality in elderly and nonelderly trauma patients. \u003cem\u003eJ Trauma\u003c/em\u003e. Feb 2011;70(2):398-400. doi:10.1097/TA.0b013e318208f99b\u003c/li\u003e\n\u003cli\u003eKasotakis G, Sideris A, Yang Y, et al. Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients: an analysis of the Glue Grant database. \u003cem\u003eJ Trauma Acute Care Surg\u003c/em\u003e. May 2013;74(5):1215-21; discussion 1221-2. doi:10.1097/TA.0b013e3182826e13\u003c/li\u003e\n\u003cli\u003eRiha GM, Schreiber MA. Update and new developments in the management of the exsanguinating patient. \u003cem\u003eJ Intensive Care Med\u003c/em\u003e. 2013 Jan-Feb 2013;28(1):46-57. doi:10.1177/0885066611403273\u003c/li\u003e\n\u003cli\u003eKushimoto S, Kudo D, Kawazoe Y. Acute traumatic coagulopathy and trauma-induced coagulopathy: an overview. \u003cem\u003eJournal of Intensive Care\u003c/em\u003e. 2017;5(6)doi:10.1186/s40560-016-0196-6\u003c/li\u003e\n\u003cli\u003eDitzel RM, Anderson JL, Eisenhart WJ, et al. A review of transfusion- and trauma-induced hypocalcemia: Is it time to change the lethal triad to the lethal diamond? \u003cem\u003eJ Trauma Acute Care Surg\u003c/em\u003e. Mar 2020;88(3):434-439. doi:10.1097/TA.0000000000002570\u003c/li\u003e\n\u003cli\u003eHolcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. \u003cem\u003eJAMA\u003c/em\u003e. Feb 2015;313(5):471-82. doi:10.1001/jama.2015.12\u003c/li\u003e\n\u003cli\u003eBrown JB, Guyette FX, Neal MD, et al. Taking the Blood Bank to the Field: The Design and Rationale of the Prehospital Air Medical Plasma (PAMPer) Trial. \u003cem\u003ePrehosp Emerg Care\u003c/em\u003e. 2015 Jul-Sep 2015;19(3):343-50. doi:10.3109/10903127.2014.995851\u003c/li\u003e\n\u003cli\u003eHolcomb JB, Fox EE, Wade CE, Group PS. The PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study. \u003cem\u003eJ Trauma Acute Care Surg\u003c/em\u003e. Jul 2013;75(1 Suppl 1):S1-2. doi:10.1097/TA.0b013e3182983876\u003c/li\u003e\n\u003cli\u003eDeLoughery TG. Logistics of massive transfusions. \u003cem\u003eHematology Am Soc Hematol Educ Program\u003c/em\u003e. 2010;2010:470-3. doi:10.1182/asheducation-2010.1.470\u003c/li\u003e\n\u003cli\u003eJenny HE, Saluja S, Sood R, et al. Access to safe blood in low-income and middle-income countries: lessons from India. \u003cem\u003eBMJ Glob Health\u003c/em\u003e. 2017;2(2):e000167. doi:10.1136/bmjgh-2016-000167\u003c/li\u003e\n\u003cli\u003eRaykar NP, Yorlets RR, Liu C, et al. The How Project: understanding contextual challenges to global surgical care provision in low-resource settings. \u003cem\u003eBMJ Glob Health\u003c/em\u003e. 2016;1(4):e000075. doi:10.1136/bmjgh-2016-000075\u003c/li\u003e\n\u003cli\u003eSarmiento Altamirano D, Himmler A, Chango Sig\u0026uuml;enza O, et al. The Successful Implementation of a Trauma and Acute Care Surgery Model in Ecuador. \u003cem\u003eWorld J Surg\u003c/em\u003e. Feb 2020;doi:10.1007/s00268-020-05435-z\u003c/li\u003e\n\u003cli\u003eOrganization WH. Screening for transfusion-transmissible infections. \u003cem\u003eScreening Donated Blood for Transfusion-Transmissible Infections: Recommendations\u003c/em\u003e. WHO Press; 2009:chap 4.\u003c/li\u003e\n\u003cli\u003eStrandenes G, Bers\u0026eacute;us O, Cap AP, et al. Low titer group O whole blood in emergency situations. \u003cem\u003eShock\u003c/em\u003e. May 2014;41 Suppl 1:70-5. doi:10.1097/SHK.0000000000000150\u003c/li\u003e\n\u003cli\u003eCap AP, Beckett A, Benov A, et al. Whole Blood Transfusion. \u003cem\u003eMil Med\u003c/em\u003e. 09 2018;183(suppl_2):44-51. doi:10.1093/milmed/usy120\u003c/li\u003e\n\u003cli\u003ePerkins JG, Cap AP, Spinella PC, et al. Comparison of platelet transfusion as fresh whole blood versus apheresis platelets for massively transfused combat trauma patients (CME). \u003cem\u003eTransfusion\u003c/em\u003e. Feb 2011;51(2):242-52. doi:10.1111/j.1537-2995.2010.02818.x\u003c/li\u003e\n\u003cli\u003eSpinella 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. \u003cem\u003eJ Trauma\u003c/em\u003e. Apr 2009;66(4 Suppl):S69-76. doi:10.1097/TA.0b013e31819d85fb\u003c/li\u003e\n\u003cli\u003eNessen SC, Eastridge BJ, Cronk D, et al. Fresh whole blood use by forward surgical teams in Afghanistan is associated with improved survival compared to component therapy without platelets. \u003cem\u003eTransfusion\u003c/em\u003e. Jan 2013;53 Suppl 1:107S-113S. doi:10.1111/trf.12044\u003c/li\u003e\n\u003cli\u003eSeheult JN, Anto V, Alarcon LH, Sperry JL, Triulzi DJ, Yazer MH. Clinical outcomes among low-titer group O whole blood recipients compared to recipients of conventional components in civilian trauma resuscitation. \u003cem\u003eTransfusion\u003c/em\u003e. 08 2018;58(8):1838-1845. doi:10.1111/trf.14779\u003c/li\u003e\n\u003cli\u003eWilliams J, Merutka N, Meyer D, et al. Safety profile and impact of low-titer group O whole blood for emergency use in trauma. \u003cem\u003eJ Trauma Acute Care Surg\u003c/em\u003e. Jan 2020;88(1):87-93. doi:10.1097/TA.0000000000002498\u003c/li\u003e\n\u003cli\u003eHazelton JP, Cannon JW, Zatorski C, et al. Cold-stored whole blood: A better method of trauma resuscitation? \u003cem\u003eJ Trauma Acute Care Surg\u003c/em\u003e. Nov 2019;87(5):1035-1041. doi:10.1097/TA.0000000000002471\u003c/li\u003e\n\u003cli\u003eYazer MH, Jackson B, Sperry JL, Alarcon L, Triulzi DJ, Murdock AD. Initial safety and feasibility of cold-stored uncrossmatched whole blood transfusion in civilian trauma patients. \u003cem\u003eJ Trauma Acute Care Surg\u003c/em\u003e. 07 2016;81(1):21-6. doi:10.1097/TA.0000000000001100\u003c/li\u003e\n\u003cli\u003eCotton BA, Podbielski J, Camp E, et al. A randomized controlled pilot trial of modified whole blood versus component therapy in severely injured patients requiring large volume transfusions. \u003cem\u003eAnn Surg\u003c/em\u003e. Oct 2013;258(4):527-32; discussion 532-3. doi:10.1097/SLA.0b013e3182a4ffa0\u003c/li\u003e\n\u003cli\u003eCrowe E, DeSantis SM, Bonnette A, et al. Whole blood transfusion versus component therapy in trauma resuscitation: a systematic review and meta-analysis. \u003cem\u003eJ Am Coll Emerg Physicians Open\u003c/em\u003e. Aug 2020;1(4):633-641. doi:10.1002/emp2.12089\u003c/li\u003e\n\u003cli\u003eHolcomb JB. Optimal use of blood products in severely injured trauma patients. \u003cem\u003eHematology Am Soc Hematol Educ Program\u003c/em\u003e. 2010;2010:465-9. doi:10.1182/asheducation-2010.1.465\u003c/li\u003e\n\u003cli\u003eSheppard FR, Mitchell TA, Cap AP, Schaub LJ, Macko AR, Glaser JJ. Prehospital whole blood resuscitation prevents coagulopathy and improves acid-base status at hospital arrival in a nonhuman primate hemorrhagic shock model. \u003cem\u003eTransfusion\u003c/em\u003e. Jul 2019;59(7):2238-2247. doi:10.1111/trf.15294\u003c/li\u003e\n\u003cli\u003eYazer MH, Cap AP, Spinella PC. Raising the standards on whole blood. \u003cem\u003eJ Trauma Acute Care Surg\u003c/em\u003e. 06 2018;84(6S Suppl 1):S14-S17. doi:10.1097/TA.0000000000001778\u003c/li\u003e\n\u003cli\u003eSpinella PC, Cap AP. Whole blood: back to the future. \u003cem\u003eCurr Opin Hematol\u003c/em\u003e. 11 2016;23(6):536-542. doi:10.1097/MOH.0000000000000284\u003c/li\u003e\n\u003cli\u003eRaykar NP, Kralievits K, Greenberg SL, Gillies RD, Roy N, Meara JG. The blood drought in context. \u003cem\u003eLancet Glob Health\u003c/em\u003e. Apr 2015;3 Suppl 2:S4-5. doi:10.1016/S2214-109X(14)70351-1\u003c/li\u003e\n\u003cli\u003eData from: HVCM Est\u0026aacute;disticas del Banco de Sangre. 2019.\u003c/li\u003e\n\u003cli\u003eCarson JL, Guyatt G, Heddle NM, et al. Clinical Practice Guidelines From the AABB: Red Blood Cell Transfusion Thresholds and Storage. \u003cem\u003eJAMA\u003c/em\u003e. Nov 2016;316(19):2025-2035. doi:10.1001/jama.2016.9185\u003c/li\u003e\n\u003cli\u003eTrompetero Gonz\u0026aacute;lez A, Cristancho Mej\u0026iacute;a E, Benavides Pinz\u0026oacute;n W, Serrato M, Landin\u0026eacute;z M, Rojas J. Comportamiento de la concentraci\u0026oacute;n de hemoglobina, el hematocrito y la saturaci\u0026oacute;n de ox\u0026iacute;geno en una poblaci\u0026oacute;n universitaria en Colombia a diferentes alturas. \u003cem\u003eNutrici\u0026oacute;n Hospitalaria\u003c/em\u003e. 2015;32(5):2309-2318.\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"34\"\u003e\n\u003cli\u003eSpinella PC, Pidcoke HF, Strandenes G, et al. Whole blood for hemostatic resuscitation of major bleeding. \u003cem\u003eTransfusion\u003c/em\u003e. 04 2016;56 Suppl 2:S190-202. doi:10.1111/trf.13491\u003c/li\u003e\n\u003cli\u003eYazer MH, Spinella PC. The use of low-titer group O whole blood for the resuscitation of civilian trauma patients in 2018. \u003cem\u003eTransfusion\u003c/em\u003e. 11 2018;58(11):2744-2746. doi:10.1111/trf.14869\u003c/li\u003e\n\u003cli\u003eCap AP, Pidcoke HF, Spinella P, et al. Damage Control Resuscitation. \u003cem\u003eMil Med\u003c/em\u003e. 09 2018;183(suppl_2):36-43. doi:10.1093/milmed/usy112\u003c/li\u003e\n\u003cli\u003eSperry JL, Guyette FX, Brown JB, et al. Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. \u003cem\u003eN Engl J Med\u003c/em\u003e. Jul 2018;379(4):315-326. doi:10.1056/NEJMoa1802345\u003c/li\u003e\n\u003cli\u003eSeheult JN, Triulzi DJ, Alarcon LH, Sperry JL, Murdock A, Yazer MH. Measurement of haemolysis markers following transfusion of uncrossmatched, low-titre, group O+ whole blood in civilian trauma patients: initial experience at a level 1 trauma centre. \u003cem\u003eTransfus Med\u003c/em\u003e. Feb 2017;27(1):30-35. doi:10.1111/tme.12372\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"trauma, global surgery, whole blood, damage control resuscitation, hemorrhage, shock","lastPublishedDoi":"10.21203/rs.3.rs-66244/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-66244/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003eBackground\u003c/em\u003e: Hemorrhagic shock is a major cause of mortality in low-and-middle-income countries (LMICs). Many institutions in LMICs lack the resources to adequately prescribe balanced resuscitation. This study aims to describe the implementation of a whole blood program in Latin America and to discuss the outcomes of the patients that received whole blood (WB).\u003c/p\u003e\u003cp\u003e\u003cem\u003eMethods\u003c/em\u003e: We conducted a retrospective review of patients resuscitated with WB from 2013-2019. Five units of O+ WB were made available on a consistent basis for patients presenting in hemorrhagic shock. Variables collected included: gender, age, service treating the patient, units of WB administered, units of components administered, admission vital signs, admission hemoglobin, Shock Index, Revised Trauma Score (RTS) in trauma patients, intraoperative crystalloid (lactated ringers or normal saline) and colloid (5% human albumin) administration, symptoms of transfusion reaction, length-of-stay and in-hospital mortality.\u003c/p\u003e\u003cp\u003e\u003cem\u003eResults\u003c/em\u003e: The sample includes a total of 101 patients, 57 of whom were trauma and acute care surgery (TACS) patients and 44 of whom were obstetrics and gynecology patients. No patients developed symptoms consistent with a transfusion reaction. Average shock index was 1.16 \u003cstrong\u003e(\u003c/strong\u003e±0.55). On average, patients received 1.66 \u003cstrong\u003e(\u003c/strong\u003e±0.80) units of whole blood.\u0026nbsp;Overall mortality was 14/101 (13.86%) in the first 24 hours and 6/101 (5.94%) after 24 hours.\u003c/p\u003e\u003cp\u003e\u003cem\u003eConclusion\u003c/em\u003e: Implementing a WB protocol is achievable in LMICs. Whole blood allows for more efficient delivery of hemostatic resuscitation and is ideal for resource-restrained settings. To our knowledge, this is the first description of a whole blood program implemented in a civilian hospital in Latin America.\u003c/p\u003e","manuscriptTitle":"Is the Whole Greater than the Sum of Its Parts? The Implementation and Outcomes of a Whole Blood Program in Ecuador","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2021-01-13 18:54:41","doi":"10.21203/rs.3.rs-66244/v2","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2020-09-14 22:42:36","doi":"10.21203/rs.3.rs-66244/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"92ebacae-f9e1-4716-8a84-e782c9285212","owner":[],"postedDate":"January 13th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":513718,"name":"Critical Care \u0026 Emergency Medicine"}],"tags":[],"updatedAt":"2021-11-18T17:23:13+00:00","versionOfRecord":{"articleIdentity":"rs-66244","link":"https://doi.org/10.1136/tsaco-2021-000758","journal":{"identity":"trauma-surgery-and-acute-care-open","isVorOnly":true,"title":"Trauma Surgery \u0026 Acute Care Open"},"publishedOn":"2021-11-01 17:23:13","publishedOnDateReadable":"November 1st, 2021"},"versionCreatedAt":"2021-01-13 18:54:41","video":"","vorDoi":"10.1136/tsaco-2021-000758","vorDoiUrl":"https://doi.org/10.1136/tsaco-2021-000758","workflowStages":[]},"version":"v2","identity":"rs-66244","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-66244","identity":"rs-66244","version":["v2"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}