A pathology group in Indiana wants to know if others "reconstitute" whole blood from leukoreduced red blood cells plus fresh frozen plasma for use in cranio-facial reconstructive pediatric surgery (or any surgery for that matter). Presently, their hospital is issuing leukoreduced RBCs and thawed FFP as separate products, without reconstituting them into whole blood. However, they have been asked by a pediatric anesthesiologist to begin providing whole blood by combining those components for future surgeries. If they were to comply, they would combine thawed FFP with leukoreduced RBCs that are less than two weeks old. The reconstituted whole blood would be prepared at the start of the surgery, and any product returned at the completion of surgery would be discarded after 24 hours of preparation. They currently have two or three children per year that would require this surgery. They have been told (by the pediatric anesthesiologist) that the reason for requiring reconstituted whole blood is to be prepared for the risk of sudden uncontrolled bleeding. However, sudden bleeding with this surgery has not occurred, so that they are concerned over a potentially high wastage for these reconstituted units.

Editor's Note: Colleagues might find the discussions:

• Reconstituting blood for exchange transfusion in neonates
  and
  
• Fresh Whole Blood - When is it warranted?

to be germane to the present topic.

The following responses have been received.

ADDENDA July 26, 2005

1. A transfusion medicine physician in the state of New York reports that his hospital does NOT reconstitute whole blood from FFP and RBCs, although he understands the natural desire of an anesthesiologist to have a 'drug' of his choice immediately available in case of a hemorrhagic disaster. However, unlike many pharmaceuticals, blood is not a drug that can always be returned to the blood bank and reissued later, and the supply of blood is a limited resource. In addition, if he was to make reconstituted whole blood available for one kind of surgery, he might be pressured to make it available for other surgeries, because hemorrhagic emergencies can occur with many kinds of surgery. The New Yorker also thinks that magical thinking is at play, as he has observed clinicians who are of the opinion that FFP, platelets and Cryoprecipitate have special properties, such that sudden unexpected bleeding will be modified or 'fixed' by blood component infusion. He ventures to say that many episodes of sudden operative bleeding are due to an anatomic lesion that requires surgical repair, and for which the primary treatment has nothing to do with replacement of coagulation factors or platelets. He adds that it takes one to two blood volumes of bleeding for almost any patient with pre-existing normal coagulation status to develop meaningful deficits in coagulation factors or platelets, by which time the blood bank should have FFP thawed and platelets ready to go.

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator