Rebirth of the cool: the modern renaissance of low titer group O whole blood for treating massively bleeding civilian patients

: The use of whole blood for the resuscitation of trauma patients is not a new concept, but rather it traces its history to the first world war. Whole blood is currently experiencing a renaissance given the modern appreciation for the need for balanced resuscitation and the survival benefits of the early intervention of blood products. According to the AABB Standards, when used in an uncrossmatched manner, the whole blood must be group O and contain low titer anti-A and -B; this product is known as low titer group O whole blood (LTOWB). The serological safety of using LTOWB in the civilian adult and pediatric settings have been demonstrated, and the Standards require each institution to determine the maximum number of units that each patient can receive, the titer threshold, and to set a policy about which patients can receive LTOWB. Unresolved questions surrounding the use of LTOWB include for how long the platelets are active during cold storage, whether leukoreduction affects platelet function, a titer threshold that optimizes patient safety and LTOWB inventory management, and whether LTOWB provides a mortality benefit compared to using conventional components. Another question that needs to be answered is whether RhD-positive red blood cell (RBC) containing products should be administered to females of childbearing potential whose RhD-type is unknown during the pre-hospital phase of the resuscitation.