Page 55 - JSOM Spring 2024

When Minutes Matter

A Comparison of Whole Blood Collection Techniques

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Russell Wier, DO *; Samuel Walther, DO ; Cat Woodard, MD ;
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Cole Jordan ; Kevin Matthews ; Travis Deaton, MD ;
Brendon Drew, DO ; Terence Byrne ; Gregory J. Zarow, PhD 9
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ABSTRACT
Background: Fast and reliable blood collection is critical to CS-LTOWB is unavailable, fresh whole blood (FWB) from an
emergency walking blood banks (WBB) because mortality on-site prescreened walking blood bank (WBB) or emergency
significantly declines when blood is quickly administered to a donor panel should be used. 5
warfighter with hemorrhagic shock. Phlebotomy for WBB is ac-
complished via either the “straight stick” (SS) or “ruggedized Time is paramount in the collection of FWB because delayed
lock” (RL) method. SS comprises a 16-gauge phlebotomy needle treatment of hemorrhagic shock leads to acute coagulopathy
connected to a blood collection bag via tubing. The RL device that worsens over time. A study of 12 North American level
collects blood through the same apparatus, but has a capped, 1 trauma centers found that each minute of transfusion de-
intravenous (IV) catheter between the needle and the donor’s lay during the early phase of hemorrhagic shock increased
arm. This is the first study to compare these two methods in bat- 24-hour mortality rates by 5%, and MEDEVAC data from
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tlefield-relevant metrics. Methods: Military first responders and Operation Enduring Freedom in Afghanistan revealed a four-
licensed medical providers (N=86) were trained in SS and RL as fold reduction in 24-hour mortality rates when blood prod-
part of fresh whole blood training exercises. Outcomes included ucts were delivered within 36 minutes from the time of injury.
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venipuncture success rates, time to IV access, blood collection Therefore, determining the optimal method for rapidly draw-
times, total time, and user preferences, using a within-subjects ing donor blood is vital for forward-deployed medical person-
crossover design. Data were analyzed using ANOVA and non- nel. The straight stick (SS) and the ruggedized lock (or Ranger
parametric statistics at p<.05. Results: SS outperformed RL in lock [RL]) are the two common devices for collecting donor
first venipuncture success rates (76% vs. 64%, p=.07), IV access blood in austere environments.
times (448 [standard error of the mean; SE 23] vs. 558 [SE 31] s,
p<.01), and blood collection bag fill times (573 [SE 48] vs. 703 The SS device consists of three integrated components: a
[SE 44] s, p<.05), resulting in an approximate 3.5-minute faster 16-gauge phlebotomy needle connected to a blood collection
time overall. Survey data were mixed, with users perceiving SS bag via a length of tubing (Figure 1, Figure 2). SS has the ad-
as simpler and faster, but RL as more reliable and secure. Con- vantage of being a simple, single-use device. A key disadvan-
clusion: SS is optimal when timely collection is imperative, while tage of the SS is that the collection bag cannot be swapped
RL may be preferable when device stability or replacing the col- out without abandoning the venipuncture site, which may be
lection bag is a consideration. required with suboptimal venous access, a slow flow rate, or
clots blocking the tubing. Additionally, SS does not provide a
Keywords: phlebotomy; intravenous access; hemorrhagic reliable visual confirmation of venous access until blood flows
shock; blood donation; walking blood bank; emergency do- through the tubing.
nor panel; buddy transfusion; tactical combat casualty care
The RL technique utilizes the same SS device, but differs by
initially placing a 16-guage intravenous catheter, which is
capped with an injectable saline lock. The site is protected and
Introduction
secured with a transparent occlusive dressing (Figure 3). The
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Hemorrhage is the leading cause of preventable battlefield needle of the RL device is pushed through the injectable saline
death. Rapid resuscitation with blood products reduces mor- lock so that FWB flows through the assembled device to the
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tality. Whole blood demonstrates outcomes equal to or bet- collection bag. The RL technique requires more components
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ter than component therapy for treatment of exsanguinating and steps than the SS technique, but the user can swap out col-
patients. Tactical Combat Casualty Care (TCCC) guidelines lection bags, if necessary, while maintaining the venous access.
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recommend U.S. Food and Drug Administration–approved, Also, the RL technique has a flash chamber on the catheter
cold-stored, low-titer type O whole blood (CS-LTOWB). When that confirms venous access.
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*Correspondence to Russell.P.Wier.mil@health.mil
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1 Dr. Russell Wier, Dr. Samuel Walther, Dr. Cat Woodard, HM2 Cole Jordan, HM1 Kevin Matthews, and Dr. Travis Deaton are affili-
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ated with the First Marine Division, Marine Corps Base Camp Pendleton, CA. Dr. Russell Wier, Dr. Samuel Walther, Dr. Cat Woodard,
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4 HM2 Cole Jordan, CAPT Travis Deaton, CAPT Brendon Drew, and Dr. Gregory J. Zarow are affiliated with the Combat Trauma Research
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Group – West, Naval Medical Center San Diego, San Diego, CA. Dr. Brendon Drew is Force Surgeon at the First Marine Expeditionary Force,
Marine Corps Base Camp Pendleton, CA. ENS Terence Byrne is a medical student at the Tulane School of Medicine, New Orleans, LA, and
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previously positioned as leading petty officer for the medical detachment for the Special Operations Tactical Medic course, Navy Special Warfare
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Advanced Training Command at Coronado, CA. Dr. Gregory J. Zarow is senior scientist at The Emergency Statistician, Idyllwild, CA.
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