Page 73 - JSOM Spring 2025

Expired Blood exhausting the in-date supply or to intersperse expired units in
an effort to dilute any storage lesion effects is uncertain and
Situation: Your team is deployed into a contested should be left to provider judgement based on blood supply
battlespace. Resupply is delayed and your blood status and the patient’s clinical picture.
products are now expired. Can you still use them?
Expiration dates for red blood cells (RBCs) and whole blood
(WB) are set by the maximum length of storage during which Storage Temperature Deviation
hemolysis does not exceed 1% and 24-hour post-transfusion Situation: The base power generator is broken and the
recovery remains above 75%. Based on these criteria, RBCs back-up battery on your blood refrigerator is now dead.
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have a 42-day shelf life when stored in additive solutions. WB Can you still use blood that has exceeded the storage
expires after 21 days when stored in citrate-phosphate- dextrose temperature?
(CPD) or 35 days with the addition of adenine (CPDA-1). Regulations require that RBCs, WB, and cold-stored plate-
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However, quality standards are anchored to obsolete storage lets (CSP) be stored at 1–6°C to protect metabolic and he-
systems and measurement techniques. A safety margin may mostatic function while minimizing risk of bacterial growth.
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exist as recent studies suggest modern RBCs and WB usually The power supply needed for refrigeration may be unreliable
out-perform the allowable limits for hemolysis and recovery in a denied combat environment, and providers could find
on the day of expiration. 15–18 themselves managing a blood supply with repeated tempera-
ture deviations. If unit temperatures briefly exceed 6°C due to
Numerous studies have assessed the association between ex- power loss, the most analogous regulation is the transporta-
tended RBC storage duration and clinical outcomes. Four in- tion guideline that allows unit temperatures up 10°C for no
ternational randomized controlled trials found no association more than 24 hours. Beyond this, the decision to hold or
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between extended storage duration and worsened patient out- discard a unit is less clear.
comes. 19–22 Secondary analyses of patients who received RBCs
that were 35–42 days old found increased infection, 23–25 but An in vitro study evaluated fresh WB stored in CPD at 19°C
a concurrent increase in mortality was only found in the crit- and 25°C for up to 72 hours. At the end of day 3, the WB main-
ical care subset of a single study. In general, the studies that tained cellular counts and coagulation activity, although units
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found worsened outcomes included patients with comorbidi- stored at 19°C showed stronger platelet aggregation response.
ties that are rare in the military population. No significant hemolysis or bacterial growth was detected.
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When RBC units were allowed to warm to 25°C for 24 hours
Although fresher blood is likely preferable, official support then returned to refrigeration, they were found to lose 12 days
exists for the use of expired blood under extenuating circum- of shelf life; in other words, the units met storage quality re-
stances. In response to decreased blood donations at the start quirements until day 30. Comparing units stored at 4°C and
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of the COVID-19 pandemic, Canadian Blood Services assessed 22°C for 5 days, minimal differences were found in hemolysis,
49-day-old RBCs and announced, “The data collected here hemoglobin, and hemostatic function. Another study eval-
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supports healthcare professionals and regulatory agencies in uated WB transiently exposed to 28°C for 4 hours per week
making informed decisions about transfusing [RBCs] past ex- throughout its 35-day shelf life. Two out of 8 units had he-
piry for patients in dire need.” Clinical precedent exists for molysis of 1.1% and 1.2%, but quality and hemostatic func-
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the use of expired blood in the U.S. Military. According to the tion were otherwise unaffected. The authors concluded, “In a
U.S. Army Institute of Surgical Research, 0.4% of blood prod- military or contingency setting, the risks related to hemolysis
ucts transfused in U.S. combat theaters from 2002 to 2019 should be weighed against the need for blood availability.” 37
were expired—1,491 expired units transfused to 749 patients.
RBCs were the most common product transfused out of date The current list of FDA-approved variances includes numerous
(899 units, 60% of the total), but the report describes post-date instances of storage temperature deviation, giving precedent
use of all deployed products (RBCs, WB, platelets, fresh frozen for transfusing blood products outside of storage parameters.
plasma, liquid plasma, and cryoprecipitate). Most units (86%) WB units that transiently exceed storage temperature limits or
were only 1–3 days post date at the time of transfusion. 27 are held at room temperature for as long as 5 days may still be
effective. This may also be true for RBC units, although data
In a retrospective review of military databases, 11.6% of ex- is not available. Bacterial growth is a concern in products that
pired RBC recipients were deceased at discharge compared exceed the maximum storage temperature, and the challenge
with 13.4% of the matched control cohort. After adjustment of managing an infection in an austere location should be con-
for injury severity, exposure to expired RBCs was insignifi- sidered accordingly. Although every effort should be made to
cantly protective (OR, 0.40 [95% CI 0.14–1.16]; P=.09). All protect the blood supply with proper refrigeration, providers
11 recipients of expired WB and the 3 recipients of expired should weigh the possible effects of temperature deviation
room-temperature platelets were alive at discharge. Previous against the need for urgent transfusion.
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studies showed that patients do better when transfusion is ini-
tiated early and sustained as long as required. 29–31 Modestly
expired blood may safely and effectively extend an exhausted Walking Blood Bank
blood supply. Situation: Your team is out of blood, and resupply is not
coming. Can you use a walking blood bank to replenish
When patient evacuation and blood resupply are unpredict- your stockpile?
able, providers might consider quarantining expired blood for According to the Pararescue Medical Handbook guidance
possible use in an emergency. Properly refrigerated RBCs and for walking blood banks, fresh WB “can be safely stored in
WB units are likely safe and effective for at least 7 days be- an FDA approved collection bag at room temperature for 24
yond expiration. Whether to transfuse expired units only after hours (this is not recommended because the blood should be

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