LOW TITRE ‘O’
WHOLE BLOOD
TRANSFUSIONS
DR.SAKTHI MUTHALRAJU
1628- William Harvey discovered blood circulation in body
1659- Christopher wren invented syringes for injection
1666- First successful transfusion between animals
1667- First successful blood transfusion by Jean baptiste Denis
- Xenotransfusion – 350ml of sheep’s blood to 15yr old boy
“For some, the risk that science could create monsters—or worse, corrupt the
entire human race with foreign blood—was simply too much to bear,”
- On banning blood transfusions
1900 – Karl Landsteiner discovers 3 blood groups
1940 – Karl Landsteiner discovers Rh typing
o WB has been used on a mass scale for resuscitation of trauma patients since
World War I.3
o Near the end of World War II, the Army Blood Program noted mild transfusion
reactions in WB with IgM anti-A and anti-B titers >512 with one severe
transfusion reaction of an IgM anti-A titer of 8000.
o In response, the Army Blood Program defined low titer group O whole blood
(LTOWB) to help mitigate and eliminate further severe reactions. LTOWB is
defined as with IgM anti-A and anti-B < 250.4
o As blood fractionalization was developed, civilian blood banks shifted away from
WB and toward component-based therapy due to risk of transfusion transmitted
diseases (TTD), requirements for specific component therapy, and logistical
issues.
Shea SM, Mihalko EP, Lu L, Thomas KA, Schuerer D, Brown JB, Bochicchio GV,
Spinella PC. Doing more with less: low-titer group O whole blood resulted in less
total transfusions and an independent association with survival in adults with severe
traumatic hemorrhage. Journal of Thrombosis and Haemostasis. 2024 Jan
1;22(1):140-51.
• In total, 348 patients were included (CT, n = 180; LTOWB, n = 168).
• Unadjusted 24-hour mortality was reduced in LTOWB vs CT: 8% vs 19% (P = .003),
but 6-hour and 28-day mortality were similar.
• In an adjusted analysis with multivariable Cox regression, LTOWB was independently
associated with reduced 24-hour mortality (hazard ratio, 0.21; 95% CI, 0.07-0.67; P =
.004).
• LTOWB patients received significantly less 72-hour total blood products (80.9 [41.6-
139.3] mL/kg vs 48.9 [25.9-106.9] mL/kg; P < .001).
• In stratified 24-hour survival analyses, LTOWB was associated with improved survival
for patients in shock or with coagulopathy. LTOWB use in non–group O patients was
not associated with increased mortality, organ injury, or adverse events.
LTOWB
• LTOWB is unseparated blood, collected from a donor with “low” IgM and/or IgG anti-A
and anti-B and can either be stored or given fresh (within 8-24 hours).
• No universally accepted definition of LTOWB - IgM anti-A and anti-B < 256 to < 50.
• Internationally, in addition to IgM, IgG is often used to define low titer status.
• The presence or absence of the Rhesus (Rh) (D) antigen is much less relevant during
hemorrhagic shock resuscitation; therefore, LTOWB is not defined by its Rh factor
status.
• Rh negative patients do not develop sensitivity to Rh positive blood until weeks after
exposure. Therefore, in the acute trauma setting, Rh positive blood can be
administered to Rh negative patients without significant risk of transfusion reaction.
ADVANTAGES
• SIMPLICITY
• SAVINGS
• AVOIDING EXCESS FLUIDS
SIMPLICITY AND LESS ERROR
• Evidence suggests that early administration of any blood product to severely injured
patients has early survival benefit.
• When using LTOWB, one bag is delivered versus a separate bag for each component
for equivalent resuscitation efforts.
• When compared to ABO group-specific WB in emergent situations, LTOWB may
expedite treatment due to reduction in time necessary for ABO typing and reduce the
under-resuscitation that may happen when specific ABO groups are not available.
• The ease of administering one product - LTOWB use over group-specific WB reduces
the likelihood of human error as well as the probability of severe blood cell and
plasma-related transfusion reactions.
SAVINGS
• When preparing and storing components, whole blood is centrifuged to
separate the red blood cells, plasma and platelets. RBCs are washed to
remove proteins that did not remain with the plasma after centrifugation.
Plasma is frozen but can be also be processed to make cryoprecipitate. This
process can be costly, which is passed onto the patient.
• All blood is pre-tested for TTDs. LTOWB requires minimal interventions, but
does require TTD, titer testing, and leukocyte reduction before use or
storage. LTOWB has the potential to reduce logistical concerns regarding
cost.
AVOIDING EXCESS FLUID
• Additives and anticoagulants are required for any blood
collection. However, when components are used for MTP, they contain
three times the additives and anticoagulants in terms of volume compared
to whole blood.
• This excess anticoagulant and additives may cause a dilutional
coagulopathy in patients receiving components.
• Citrate, an anticoagulant added to blood collection bags, is metabolized by
the liver and can lead to acidosis and hypocalemia.26
DISADVANTAGES
• Shelf life
• Probably the greatest disadvantage of LTOWB is the shelf life. LTOWB is
usually anticoagulated with citrate phosphate dextrose (CPD) and has a
shelf life of 21 days. When citrate phosphate dextrose adenine (CPDA-1) is
used in lieu of CPD, the shelf life is extended to 35 days.
• However, platelet function drops after 14 days and significantly after 21
days.27 This is shorter than the shelf lives of PRBCs and FFP, which are 42
days and a year, respectively.2
TRIALS
• SWIFT TRIAL
• PPOWER TRIAL
