Page 25 - JSOM Winter 2024

Does Technique Matter? A Comparison of Fresh Whole Blood Donation
Venous Access Techniques for Time and Success

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David K. Rodgers, DSc, PA-C ; Cecil J. Simmons, DSc, PA-C ;
Philip Castañeda, DSc, PA-C ; Brandon M. Carius, DSc, PA-C *
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ABSTRACT
Background: Fresh whole blood (FWB) is essential for hem- blood banks, is well documented and demonstrates improved
orrhagic shock resuscitation, but little literature evaluates outcomes. 8–10 FWB transfusion training via autologous trans-
medics’ ability to obtain intravenous (IV) access. Options for fusion is now described by the CoTCCC, JTS, and U.S. Army
IV access include a 16-gauge hypodermic needle attached to Medical Center of Excellence for U.S. Army medic initial entry
the FWB collection bag (straight stick technique [SST]) and training, whereby participants ‘donate’ blood to be immedi-
an 18-gauge angiocatheter with a saline lock (saline lock tech- ately returned. With nearly 15,000 serving on active duty as
nique [SLT]), which may improve access given its confirmatory of 2019, medics constitute the largest far forward medical ele-
flash chamber and medic familiarity. Methods: In a prospec- ment across the U.S. Army and are the personnel most likely to
tive, randomized, crossover study, a convenience sample of perform FWB collection in austere environments.
U.S. Army medics performing FWB transfusion training initi-
ated IV access with SST or SLT for FWB collection to achieve Despite strong evidence for FWB transfusions in prehospital
the minimum transfusable volume of 527g. The primary out- hemorrhagic shock resuscitation and for training medics to per-
come was seconds to achieve minimum transfusable volume. form donation procedures, relatively little research addresses
Secondary outcomes included first-attempt IV access success optimal collection technique. Generally, medics are instructed
and end-user feedback. Results: Eighteen medics demonstrated on peripheral intravenous (IV) access with an 18-gauge an-
a shorter median time to reach the minimum transfusable vol- giocatheter, which provides a confirmatory “flash” of blood
ume with SST (819.36 [IQR 594.40–952.30] sec) compared in the device chamber prior to sliding the angio catheter over
with SLT (1148.43 [IQR 890.90–1643.70] sec, P=.002). No the hypodermic needle and into the vein. The IV access subse-
sequence or period effects occurred. Compared with SLT, SST quently allows for the attachment of a saline lock diaphragm
demonstrated higher first-attempt IV access success (18, 78% for another hypodermic needle to access, known as a “saline
versus 11, 48%; P=.037). Accordingly, most medics reported lock technique” (SLT). Recent literature shows that medics
SLT would perform worse than SST for FWB collection and IV demonstrate 66% first-time access success using the 18-gauge
access in tactical environments. Conclusions: Medics achieved IV angiocatheter compared with 44% when using an “unfamil-
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minimum transfusable volume faster and higher first-attempt iar” 18-gauge IV angiocatheter device. However, a standard
IV access success with SST than SLT. Future studies should FWB collection procedure uses a 16-gauge steel hypodermic
compare a 16-gauge SLT and SST, and further evaluate IV ac- needle for IV access, known as the “straight stick technique”
cess techniques for improved evaluation of medic skills. (SST). This hypodermic needle does not provide the familiar
confirmatory flash medics acquire with an 18-gauge IV angio-
Keywords: phlebotomy; military; performance; saline lock; catheter, but instead requires release of the in-line clamp after
straight stick; intravenous access IV access is attempted, risking access failure. Medics recently
demonstrated 100% success in IV access using the SST for
FWB collection; however, with a sample taken from an ad-
vanced training population that may lack generalizability. 12
Introduction
Noncompressible truncal hemorrhage remains the leading Success and device familiarity must be balanced with Poi-
concern with respect to preventable battlefield deaths, and lit- seuille’s Law, which finds improved flow velocity with larger
erature demonstrates the survivability benefits of far forward internal lumen diameter, thereby favoring the larger gauge ve-
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blood product administration. Whole blood continues to be nipuncture associated with the SST. Establishing IV access, first
recommended by the Committee on Tactical Combat Casualty using an angiocatheter with saline lock, and then inserting a
Care (CoTCCC) and the Joint Trauma Systems (JTS) as the 16-gauge hypodermic needle for the SLT, may provide medics
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resuscitative fluid of choice in hemorrhagic shock. However, with benefits of the confirmatory flash and device familiarity
small quantities of prescreened, cold-stored whole blood in for improved success; however, this must be balanced against
forward locations can quickly become exhausted, especially slower flow and increased time to minimum transfusable vol-
in prolonged casualty care and large-scale combat operations. ume collection. Prior narrative literature recommends SST
Prehospital fresh whole blood (FWB), drawn from walking for FWB donation; however, there is no significant published

*Correspondence to Brandon M. Carius, 9430A Jackson Ave., JBLM – Lewis, WA 98431 or brandon.m.carius.mil@mail.mil
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1 CPT David K. Rodgers, MAJ Cecil J. Simmons, MAJ Philip Castañeda, and MAJ Brandon M. Carius are affiliated with Madigan Army Med-
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ical Center, Joint Base Lewis-McChord, Lewis, WA.
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