Page 114 - JSOM Fall 2021

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Over the ensuing year, Robertson would see significant clin- coagulation elements.” It is both interesting, and a tribute to
ical material near the front and became both an adept clini- the clinical acumen of Robertson, that he noted the presence
cian and a scholarly advocate of whole blood transfusion via of coagulopathy in the injured patient. To provide context for
the syringe/cannula technique. He would publish a series of the latter part of this statement, the relationship of trauma-
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papers detailing his experience, the technical aspects of the induced coagulopathy resulting from the loss of coagulation
transfusion process, and several case series detailing the out- factors and platelets secondary to hemorrhage was not iden-
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comes of his patients. The mechanics of the actual transfusion tified until the work of Scott and Crosby in 1954. Robertson
process were still debated, and techniques varied from direct and his colleagues appeared to have understood and appreci-
arterial to venous anastomosis (donor/recipient), temporary ated these benefits in 1916, long before the mechanism was
bedside collection in glass containers lined with paraffin and completely understood.
sodium citrate solution, or the syringe/cannula technique ad-
vocated by Robertson. Whereas Robertson acknowledges that normal saline may be
effective at treating less seriously wounded patients, he ap-
Robertson advocated for the syringe/cannula technique based peals to the reader to recognize a concept that is still not fully
on his previous experience, the relative simplicity of the pro- accepted today, namely that “the broad indications for blood
cess (avoiding a tedious surgical vascular anastomosis), and transfusion are based on the fact that transfused blood is the
the speed with which large volumes of blood could be trans- best substitute for the blood lost in acute haemorrhages.” De-
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ferred. The instruments used included six to eight 20-mL glass spite this statement being published in 1916, the US military
syringes, hollow needle cannulas for venipuncture, and rubber has entered every military conflict of the past century endors-
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tubing to connect the cannulas to the syringe. Blood was as- ing the use of crystalloid solutions. ATLS guidelines previously
pirated from the donor and immediately transfused into the promoted large quantities of crystalloid infusion for patients
recipient and flushed clear with saline. The process required with hemorrhagic shock, and many clinicians continue to use
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an assembly line chain of syringes cycled between aspiration, a crystalloid-based resuscitation strategy throughout the medi-
transfusion, and flushing with saline before repeating the cy- cal community at large.
cle. The typical volume of transfusion advocated by Robert-
son was between 700mL and 1000mL, and a single donor Robertson observes that whole blood acts as “a stimulant
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was typically used. The donor’s blood was not usually typed; to the starved haematopoietic organs.” The relationship of
only occasionally was a crossmatch completed via the Rous hemorrhagic shock as a state of inadequate delivery of oxygen
and Turner technique. Although the concept of distinct blood at the cellular interface was not yet fully understood by the
types had been previously recognized a decade earlier, it is medical community of this era. Nonetheless, it appears that
not clear that the frontline practice emphasized blood typing Robertson and others recognized and appreciated the ability
as fundamental to avoiding hemolytic reactions. Robertson of whole blood to restore perfusion (and oxygen) to the isch-
noted that “tests for haemolysis have been devised which meet emic end organs.
the ordinary requirements for cases of haemorrhage. These
should, if circumstances permit, be performed before transfu- Whole Blood Transfusion for the
sion is carried out. But this may be impossible, or the condi- Injured Is NOT a New Concept
tion of the patient may make it imperative that no time should As detailed in the introduction, the use of blood transfusion
be lost.” 3 before the early 1900s was sporadic at best and lethal at
worst. The unfortunate truism is that the battlefield proves
In October, because of a shortage of surgeons at the Hospital to be a period of rapid advancement in the study of the in-
for Sick Children, the president of the University of Toronto jured patient – and such was particularly the case for the initial
requested that Robertson, now a major in the CAMC, be sent advancement of blood transfusion during World War I. The
home. Following his return in February 1918, he resumed scientific advances of blood typing, blood preservation, and
his work at Sick Children’s and the university and accepted blood cross-matching (see earlier) positioned the physicians
a posting to the CAMC’s Dominion Orthopedic Hospital in caring for the injured of the Great War in an environment
Toronto. At Sick Children’s, he continued his clinical research, of exploration and opportunity to advance concepts of care.
using blood transfusion as a treatment for toxemias in children Robertson appears to have taken full advantage of his pre-
caused, in many instances, by severe burns. In early February liminary experience with blood transfusion in his early medi-
1923, he had an attack of influenza and was hospitalized. Ap- cal training in Canada to fully exploit the advantages of whole
parently recovered, he returned to his home and family, but a blood transfusion at the front. He discussed the risks and inci-
few days later he was stricken with pneumonia. A week later, dence of hemolysis and even discussed “preliminary hemolysis
at age 37, Robertson—soldier and surgeon—died. tests” using techniques published in 1915. He further detailed
his preferred method of transfusion by describing the syringe-
cannula method. This method achieves an immediate result
Why Is This Article Relevant Today?
and requires the physician to remain intimately at the patient’s
Whole Blood Is Superior to Normal Saline for side to observe the effects. Of note is the volume of blood
Resuscitation of the Acutely Injured Patient described and endorsed by Robertson in his articles. The sug-
This manuscript discusses the use of whole blood to treat gested volume of transfusion was 700mL to 1000mL from a
patients in shock secondary to both primary and secondary single donor; this equates to 2 units of whole blood at a sin-
hemorrhage. Robertson discusses the superior effects of whole gle episode, and by Robertson’s observation this methodology
blood compared to normal saline—the standard of care at the was generally well tolerated by the donor. While this technique
time of the writing of this manuscript more than 100 years may appear crude and hazardous by today’s standards (i.e.,
ago. Robertson observed that whole blood “acts as a more lack of anticoagulants, no intermediate cross matching, no fil-
permanent addition to the body tissues [and] carries with it tering to capture small clots or platelet aggregates) it proved

112 | JSOM Volume 21, Edition 3 / Fall 2021