Contents lists available at ScienceDirect Transfusion and Apheresis Science journal homepage: www.elsevier.com/locate/transci Review Implementation of a protocol for prehospital transfusion of low-titer, leukocyte-depleted whole blood for civilian bleeding patients A. Espinosa a, ⁎ , B. Dybvik a , C. Medby b , G. Vangberg c a Dept. of Immunology and Transfusion Medicine, St. Olav University Hospital, Trondheim, Norway b Norwegian Armed Forces Joint Medical Services, Norway c Norwegian Armed Forces Joint Medical Services and Air Ambulance Service, St. Olav University Hospital, Trondheim, Norway ARTICLE INFO Keywords: Whole blood Prehospital Transfusion Bleeding ABSTRACT Blood component therapy is considered the gold standard for the treatment of the massively bleeding patient, but it can be challenging to perform outside the hospital environment. The successful experience from the military shows that whole blood can efficiently provide treatment for massively bleeding patients. Whole blood transfusion has been in use in Norway to some extent in paediatric cardiac surgery, but no major interest has been paid from the blood centres to implement the use of whole blood as an alternative or a supplement to traditional blood component therapy. On the other hand, the increasing number of reports showing a potential benefit of whole blood and the availability of the last generation whole blood leukocyte filters, allowing the platelets to remain in the blood product, has led to the first experiences with prehospital use of whole blood in Norway. Our institution is completing the planning of a program for the use of prehospital whole blood transfusion in the civilian setting, following the same trend at two other hospitals in Norway. 1. Background Haemorrhage is the leading cause of preventable death in both military andcivilian traumatic [1]. Even if blood component therapy is considered the gold standard, we experience an increasing use of whole blood in the civilian setting in Norway. The number of whole blood transfusions is also growing in the US, where at least ten hospitals and air and ground ambulance bases are using whole blood as the initial resuscitation fluid and others are planning to establish a whole blood program in the future [2]. Results from the US military in the Iraq and Afghanistan wars have shown that trauma patients receiving fresh whole blood had improved outcomes compared to those receiving conventional blood component therapies [3]. In a retrospective cohort study of US military combat casualties in Afghanistan between April 1, 2012, and August 7, 2015, blood product transfusion prehospital or within minutes of injury was associated with greater 24-h and 30-day survival than delayed trans- fusion or no transfusion [4]. Massive transfusion is defined as the transfusion of more than ten red blood cell units within 24 h, but other definitions, based on the rate of transfusion, are also in use. The need for massive transfusion may occur during surgery, obstetrics and trauma. In recent years, the treatment of the massively bleeding patient has focused on a balanced transfusion strategy, based on fixed ratios with multiple blood com- ponents, to try to resemble whole blood. In the civilian setting, transfusion of non-leukocyte depleted whole blood has been in use in Norway and other countries for many years, mainly in paediatric cardiac surgery, due to its superior haemostatic effect [5]. Whole blood has otherwise not been available for other pa- tient groups in the civilian setting. Blood centres have been reluctant to implement low titer, group O whole blood, mainly due to the belief that blood component therapy should be the gold standard and that leuko- cytes in whole blood have deleterious effects on the recipient. In ad- dition, concerns about the possible negative effect of cold storage on platelet function have contributed to a negative attitude from blood centres. Contrary to this belief, several studies have now shown that cold-stored platelets aggregate better than platelets stored at 20–24 °C [6–8]. Whole blood has fewer additives and anticoagulant than blood components mixed in a 1:1:1 ratio [9] but, to date, none of these ratios has been validated. These factors, together with the recent availability of platelet-saving leuko-depleting filters have led us to re-evaluate if transfusion of whole blood could also be beneficial in the civilian trauma setting. https://doi.org/10.1016/j.transci.2019.03.012 ⁎ Corresponding author. E-mail address: aurora.espinosa@stolav.no (A. Espinosa). Transfusion and Apheresis Science xxx (xxxx) xxx–xxx 1473-0502/ © 2019 Elsevier Ltd. All rights reserved. Please cite this article as: A. Espinosa, et al., Transfusion and Apheresis Science, https://doi.org/10.1016/j.transci.2019.03.012