Hemostatic resuscitation for perioperative bleeding

The perioperative resuscitation approach to hemorrhagic shock is changing due to recent military experience in managing traumatic injury. For the past few decades, resuscitation of perioperative hemorrhagic shock has most commonly consisted of crystalloids and colloids, followed by RBCs, after which, if indicated according to laboratory results, plasma and platelets. If used, empiric ratios of RBC to plasma units ranged between 10 and 4 units of RBCs to 1 unit of plasma, without platelets. This approach was the foundation of Advanced Trauma Life Support (ATLS). Recent combat experience re-ignited interest in whole blood for the resuscitation of hemorrhagic shock. US Army data indicates that warm whole blood transfusion is associated with improved or comparable survival compared to blood components. This data compliments that of pediatric cardiac surgery trials which found that cold-stored whole blood reduced blood loss and was associated with improved platelet function compared to blood components in a 1:1:1 ratio using platelets were stored at 22 °C. Whole blood availability is limited in civilian hospitals due to perceived logistical barriers, but recent developments suggest that these barriers are obsolete. Data indicates it is safer to provide group O whole blood than ABO-specific whole blood; whole blood can be leukocyte-reduced with platelet-sparring filters; and whole blood stored at 4 °C retains platelet function during 15 days of storage. This approach will improve the availability of whole blood and facilitate its use for peri-operative hemorrhagic shock. There are also logistic and economical advantages of whole blood based resuscitation compared to components for hemorrhagic shock.