Low-Titer O Positive Whole Blood Versus Component Therapy for Emergent Transfusion in Trauma Patients
Phase: PHASE3
Conditions: Hemorrhagic Shock, Acute Blood Loss Anemia, Traumatic Brain Injury
Sponsor: Loma Linda University

 
1 
PROTOCOL OUTLINE AND GUIDELINES 
 
Investigators must submit well-organized, detailed information about the study, demonstrating 
sound research design that minimizes risks to the subject.  PI should assure that the content 
outlined below is addressed and may exercise some discretion as to how the information is 
organized.  The quality and content of the protocol should demonstrate that scientific and merit 
review of the study has occurred at the departmental level prior to submission to the IRB. 
  
 
 
1. 
PROTOCOL INFORMATION  
Title: Low-Titer Type O Positive Whole Blood Versus Component Therapy for 
Emergent Transfusion in Trauma Patients 
Funding Source: Internal 
Phase of Study: RCT (Phase IV) 
Version Date of Protocol: 3/25/2021 
 
2. 
PRINCIPAL INVESTIGATOR’S INFORMATION 
Kaushik Mukherjee 
N/A 
Acute Care 
Surgery 
4-4286 
kmukherjee@llu.edu 
Facul
ty 
 
3. 
STUDY PERSONNEL 
Anthony Michael 
Strada 
N/A 
Acute Care 
Surgery 
4-4286 
astrada@llu.edu 
Resident 
Physician 
Xian Luo-Owen 
N/A 
Acute Care 
Surgery 
4-4877 
xluoowen@llu.edu 
Faculty 
Martin Gideon 
Rosenthal 
N/A 
Acute Care 
Surgery 
4-4286 
mrosenthal@llu.edu 
Faculty 
W. Tait Stevens 
N/A 
Pathology 
4-3209 
wstevens@llu.edu 
Faculty 
 
4. 
STUDY INFORMATION 
Location(s) of Research Activity: Loma Linda University Medical Center 
Expected Start/Stop Dates of Research: 07/01/2021 to 06/30/2023 
Special Time Sensitivities:N/A 
Type of Research: Randomized controlled trial of two alternative standard-of-care 
transfusion strategies 
 
5. 
INCLUSION / EXCLUSION CRITERIA 
Criteria for inclusion of subjects: Adult male patients brought to the emergency 
department as Level A trauma activations who are receiving emergency blood 
transfusion 
Criteria for exclusion of subjects (other than those opposite the inclusion criteria): 
Female patients (specifically excluded due to risk of alloimmunization of Rh-negative 
female patients of childbearing age against Rh-positive blood), children, prisoners, 
patients classified as dead on arrival who will still be randomized but who will have 
their data excluded to eliminate the effect of survivor bias in the remaining subjects. 
 
6. 
SUBJECT RECRUITMENT & SCREENING 

 
2 
Based on the results from Cotton et al, median transfusion in the component therapy 
group was 6 PRBC in the first 24 hours and 4 PRBC equivalents in the whole blood 
group.  The standard deviation (estimated from the interquartile range) was 
approximately 4.  Thus with an expectation of alpha = 0.05 and expected power of 
90% to detect a similar 2 unit difference in transfusion volume, a sample size of 190 
should be sufficient; thus our projected sample size of 200 should be more than 
adequate.  Age range will be 18 years and older, and only males will be included in 
the study.  Our expected racial/ethnic distribution will be approximately 60% white, 
15% black, 8% Asian, and 18% other race.  No actual recruitment will be performed; 
rather all qualifying patients will be included.  Consent waiver is being requested. 
 
7. 
INFORMED CONSENT PROCESS 
Consent waiver is being requested.  
 
8. 
STUDY DESIGN 
a. 
Background or rationale for this study.   
Whole blood transfusion was used in World War I, World War II, Korea and 
Vietnam.  By the end of the Vietnam conflict, whole blood had been separated 
into components for ease of use and more focused transfusion.  As a result, 
transfusion practices did not catch up with the available units.  More recent 
investigations have revealed that patients have fewer deaths from hemorrhage 
when the ratios of FFP:RBC units and platelet:RBC units approaches 1:1. 
Furthermore, the success of “walking blood banks” with fresh whole blood 
transfusion in the 2nd Iraq war and the war in Afghanistan have prompted new 
interest in the civilian use of whole blood.  While civilian centers cannot use 
walking blood banks as we do not have  a pre-screened population from which 
to draw, low-titer type O positive whole blood (LTOWB) can be used.  One 
LTOWB unit is equivalent to one unit of PRBC and one unit of FFP.  While 
LTOWB has been studied, the inclusion criteria for past studies has been less 
inclusive than in this trial, specifically excluding patients with severe traumatic 
brain injuries even if they also had exsanguinating hemorrhage.  Furthermore, at 
Loma Linda University Medical Center we will have the opportunity to 
randomize patients to receive whole blood as their first transfusion, thus 
maximizing the potential benefits.  Finally, we have the opportunity to study the 
coagulopathy associated with these patients by using viscoelastic testing.   
b. 
Objectives 
1. Evaluate PRBC equivalents transfused in each group in the first 24 hours 
(Primary outcome) 
2. Evaluate total transfusion in each group in the first 24 hours (Secondary 
Outcome) including breakdown by FFP equivalents, platelet units, and 
cryoprecipitate 
3. Evaluate 6 hour, 24 hour, and hospital mortality (Secondary Outcome) 
4. Evaluate ICU outcomes in each group: 
1. ICU length of stay 

 
3 
2. Ventilator days 
3. SOFA score on day of ICU discharge 
4. Presence of ARDS? 
5. Presence of TRALI? 
6. Presence of DVT/PE? 
7. Necessity for Dialysis? 
8. Necessity for Tracheostomy? 
5. Evaluate viscoelastic testing parameters in both groups when sent on 
arrival in ICU 
1. Percentage of patients with EXTEM clotting time > 80 sec 
2. Percentage of patients with EXTEM amplitude at 10 min < 40mm 
and FIBTEM amplitude at 10 min ≤ 10mm 
3. Percentage of patients with EXTEM amplitude at 10 min < 40mm 
and FIBTEM amplitude at 10 min > 10mm 
4. Percentage of patients with maximum thrombolysis > 15% 
6. Interval analyses to be performed after 6 and 12 months with provision to 
continue the study out to 24 months.   
1. Stopping rule: A statistically significant difference in hospital 
mortality at 6 months or 12 months 
1. If in favor of LTOWB, consideration of trial termination 
and making LTOWB the primary standard of care for all 
trauma patients receiving emergency transfusion except for 
child-bearing age females (unless Rh immunoglobulin can 
be administered) 
2. If in favor of component therapy, consideration of trial 
termination and making component therapy the primary 
standard care for all trauma patients receiving emergency 
transfusion 
c. 
Procedures involved (Research Interventions) 
Chronological order of all research interventions, distinguishing standard of 
care vs. research intervention. 
1. Level A trauma paged out with gender of patient 
2. For female patients, care proceeds as normal 
1. Standard trauma cooler containing 4 units O- PRBC and 4 units FFP 
dispatched to trauma bay (if overall supply is short the first cooler may 
contain 2 units O- PRBC and 2 units FFP) 
2. Transfusion proceeds per trauma and ED team 
3. Patient data not included in the study 

 
4 
3. For male patients, the blood bank will randomize patients to the LTOWB group or 
the CT (component therapy) group based on a prespecified calendar-based 
randomization scheme by week: 
1. LTOWB: Cooler containing 2 or 4 units of LTOWB dispatched to trauma 
bay depending on supply 
2. CT: Standard trauma cooler containing 4 units O+ PRBC and 4 units FFP 
dispatched to trauma bay (if overall supply is short the first cooler may 
contain 2 units O+ PRBC and 2 units FFP) 
3. Transfusion proceeds per trauma and ED team 
4. Blood work (CBC, BMP, tox screen, ROTEM viscoelastic test, PT/INR, 
PTT, venous lactate) sent as per standard of care for all patients. 
5. Hemorrhage control and other diagnostic evaluations performed in all 
patients per standard of care. 
6. Patients arrive in ICU and have additional blood work (CBC, CMP, 
possibly ABG, ROTEM viscoelastic test, PT/INR, PTT, venous lactate, 
possibly fibrinogen) sent per standard of care by the ICU team. 
7. Clincial data on survival and transfusion monitored 
d. 
Alternative procedures, if any, that are not included in the study but might be 
advantageous to the subject. N/A 
e. 
If any deception is required for validity of this study, explain why this is 
necessary and how subject(s) will be debriefed. N/A 
f. 
Concise review of literature that supports the rationale, objectives, and 
methodology of the proposed study.  
Whole blood transfusion has been used in multiple military conflicts for more than one hundred 
years. (1)  As mentioned above, during the 1960’s and 1970’s advancements in blood banking 
allowed for the transfusion of isolated components, although this was done without detailed 
investigation.  The institution first of fresh whole blood, followed by cold-stored whole blood, 
was made necessary during the recent conflicts in Iraq and Afghanistan.  Cold-stored whole 
blood has since been adapted for the civilian setting, with one unit considered equivalent to 1 
unit of PRBC and 1 unit of FFP.   
Low-titer O negative whole blood has been safely administered through a trial performed at UT 
Houston, with no transfusion reactions in the whole blood group. (1)The group at Barnes-Jewish 
Hospital in St. Louis, MO, performed a prospective observational trial over an eighteen-month 
comparing outcomes before and after whole blood was introduced into their system.  In this 
study of 86 patients, there was no unadjusted difference in survival, although there was an 
improved odds of survival in the whole blood group after adjusting for maximum clot firmness 
as measured by viscoelastic testing. (2) A retrospective cohort study of 270 matched patients 
indicated no difference in clinical outcomes. (3)A large retrospective analysis of the data from 
the Trauma Quality Improvement Program indicated that 280 patients receiving whole blood had 
reduced 24-hour and hospital mortality, reduced rate of complications after adjustment for 
clinical covariates. (4)  However, none of these studies are randomized, most use O-negative 
whole blood or a mixture of O-positive and O-negative whole blood, and there is no discussion 
of alloimmunization of female recipients against the Rh positive whole blood.   
There is only one previously published randomized clinical trial of leukoreduced type specific 
whole blood for type O and type A recipients.  In this trial of 107 patients, performed at the 

 
5 
University of Texas at Houston, patients were blood typed prior to inclusion in the study.  
Furthermore, all type B and AB patients were excluded, as were patients with significant 
traumatic brain injury or if they received more than 4 units of blood prior to randomization.  
Patients were also excluded if they could not, in the judgment of the attending surgeon, wait for 
blood typing. Thus, out of 357 patients who could have met criteria for inclusion, only 107 were 
actually randomized, introducing selection bias.  In particular, the exclusion for the patients felt 
to be “too sick to wait” for blood typing may have excluded some sicker patients who would 
have benefited from whole blood.  However, this study did demonstrate a reduction in 
transfusion volumes for patients after those with brain injury were excluded. (5) 
As can be seen, the current field of literature leaves multiple unanswered questions that will be 
answered by the proposed study. 
1) Does transfusion with low-titer O-positive whole blood reduce the amount of transfusion 
within 24 hours of arrival? 
2) Does transfusion with low-titer O-positive whole blood reduce 6 hour, 24 hour, or 
hospital mortality? 
3) What is the effect of low-titer O-positive whole blood transfusion on coagulopathy after 
trauma, as demonstrated by viscoelastic testing? 
4) Is the potential benefit of transfusion with low-titer O-positive whole blood restricted 
only to patients receiving massive transfusion (6 units PRBC or more) or in all patients 
receiving emergency transfusion? 
g. 
If an Investigational New Drug (IND) is involved, provide the following 
information: (1) name of drug, (2) source of drug, (3) dosage and schedule of 
administration, (4) status with Food and Drug Administration and IND#, (5) 
review of animal studies and previous human studies, (6) reported side effects 
N/A 
h. 
For an approved drug used in an experiment, provide similar information: (1) 
name, (2) source, (3) dosage, (4) how administered, (5) side effects.  
N/A 
i. 
If an Investigational Device (ID) is involved, provide the following information: 
(1) name of device, (2) manufacturer, (3) status with Food and Drug 
Administration and ID#, (4) review of animal studies and previous human 
studies, (5) reported adverse effects.  
N/A 
 
9. 
DATA COLLECTION 
Data collection procedures: to include lab evals, tests, specimen amounts and 
schedules, clinical assessments/schedule/follow up procedures, case report forms, 
data collection forms (with description of subject codes), study instruments, rating 
scales, interview guides.   
 
RedCap Database to be created with the following data 

 
6 
 
Age (years) 
Penetrating Trauma (0=no, 1=yes) 
Penetrating Mechanism (1=stab, 2=gsw, 3=impalement, 9=other) 
Blunt Mechanism (1=MVC, 2=Fall, 3=MCC, 4=ped vs auto, 5=assault, 9=other) 
Scene transport (0=no, 1=yes) 
Injury Severity Score (1-75) 
Abbreviated Injury Score-Head (0-6) 
Predominant site of hemorrhage (1=upper extremity, 2=lower extremity, 3=axilla, 4=groin, 
5=head/neck, 6=chest, 7=abdomen, 8=pelvis, 9=other) 
Tourniquet in Place (0=no, 1=yes) 
 
Pre-LLUMC PRBC (# units) 
Pre-LLUMC FFP (# units) 
Pre-LLUMC PLT (# unitss 
Pre-LLUMC Cryo (# units) 
Pre-LLUMC Crystalloid (# liters) 
Pre-LLUMC Cardiac Arrest? (0=no, 1=yes with ROSC, 2=yes without ROSC) 
 
Arrival SBP (0 = in arrest) 
Arrival HR (0 = in arrest) 
Arrival Temperature (Celsius) 
Arrival O2 saturation (0 = in arrest) 
Arrival  GCS (3-15) 
Treatment Group (0 = Component Therapy, 1 = LTO+WB) 
 
LLUMC ED WB (# units) 
LLUMC ED PRBC (# units) 
LLUMC ED FFP (# units) 
LLUMC ED PLT (# unitss 
LLUMC ED Cryo (# units) 
LLUMC ED Crystalloid (# liters) 
LLUMC ED Cardiac Arrest? (0=no, 1=yes with ROSC, 2=yes without ROSC) 
LLUMC ED Thoracotomy (0=no, 1=yes) 
LLUMC ED Laparotomy (0=no, 1=yes) 
LLUMC ED Death? (0=no, 1=yes) 
 
LLUMC ED ABG results 
pH 
Hgb 
Lactate 
 
LLUMC ED Hgb from CBC 
LLUMC ED PLT count from CBC 
LLUMC ED INR 
LLUMC ED PTT 
LLUMC ED Fibrinogen 
 
LLUMC ED ROTEM results 
EXTEM CT  

 
7 
EXTEM A10 
If EXTEM A10 < 40mm, FIBTEM A10 
EXTEM ML 
 
Hemorrhage Control Environment (HCE) (0=none, patient died in ED, 1=none, patient direct to 
ICU, 2=OR, 3=IR, 4=OR and IR, 5=Hybrid OR) 
LLUMC HCE WB (# units) 
LLUMC HCE PRBC (# units) 
LLUMC HCE FFP (# units) 
LLUMC HCE PLT (# unitss 
LLUMC HCE Cryo (# units) 
LLUMC HCE Crystalloid (# liters) 
LLUMC HCE Cardiac Arrest? (0=no, 1=yes with ROSC, 2=yes without ROSC) 
LLUMC HCE Thoracotomy (0=no, 1=yes) 
LLUMC HCE Laparotomy (0=no, 1=yes) 
LLUMC HCE Pelvic Packing (0=no, 1=yes) 
LLUMC HCE Neck Exploration (0=no, 1=yes) 
LLUMC HCE Exploration for Axilla/Upper Extremity (0=no, 1=yes) 
LLUMC HCE Exploration for Groin/Lower Extremity (0=no, 1=yes) 
LLUMC HCE Death? (0=no, 1=yes) 
 
LLUMC HCE ABG results #1 (first in HCE) 
pH 
Hgb 
Lactate 
 
LLUMC HCE ABG results #2 (last in HCE) 
pH 
Hgb 
Lactate 
 
LLUMC HCE ROTEM results #1 (first in HCE, if sent) 
EXTEM CT  
EXTEM A10 
If EXTEM A10 < 40mm, FIBTEM A10 
EXTEM ML 
 
LLUMC HCE ROTEM results #2 (last in HCE, if sent) 
EXTEM CT  
EXTEM A10 
If EXTEM A10 < 40mm, FIBTEM A10 
EXTEM ML 
 
LLUMC ICU/Floor Transfusion within first 24 hours (not including blood given prior to 
LLUMC, in LLUMC ED, and in LLUMC HCE) 
LLUMC ICU WB (# units) 
LLUMC ICU PRBC (# units) 
LLUMC ICU FFP (# units) 
LLUMC ICU PLT (# unitss 
LLUMC ICU Cryo (# units) 

 
8 
LLUMC ICU Crystalloid (# liters) 
 
LLUMC ICU ABG results 
pH 
Hgb 
Lactate 
 
LLUMC ICU Hgb from CBC 
LLUMC ICU PLT count from CBC 
LLUMC ICU INR 
LLUMC ICU PTT 
LLUMC ICU Fibrinogen 
 
LLUMC ICU ROTEM results 
EXTEM CT  
EXTEM A10 
If EXTEM A10 < 40mm, FIBTEM A10 
EXTEM ML 
 
Clinical Endpoints 
Patient Dead on Arrival (0=no, 1=yes) 
Patient Died within 6 hours of arrival (0=no, 1=yes) 
Patient Died within 24 hours of arrival (0=no, 1=yes) 
Patient Died Prior to Discharge (0=no, 1=yes) 
Duration of Mechanical Ventilation (Days) 
Duration of ICU Stay (Days) 
Duration of Hospital Stay (Days) 
Presence of ARDS? 
Presence of TRALI? 
Presence of DVT/PE? 
SOFA Score on Day of ICU Discharge 
Need for Dialysis During Hospitalization (0=no, 1=yes) 
 
 
10. 
LABELING & STORAGE OF DATA & SPECIMENS 
No data to be stored in hard copy form.  Data will be entered into secure REDCAP 
database, with a master list correlating study ID number, MRN, and treatment arm to 
be kept on LLUMC secure server.  
 
11. 
DATA ANALYSIS 
Analysis to be performed by median/IQR with nonparametric comparison of medians 
for central tendency.  P value of 0.05 indicates statistical significance.  Patients with 
death on arrival will be excluded from data reporting as they are a different patient 
population.  Intentional sub-analysis will be performed on patients who received less 
than 6 units PRBC or equivalent in the first 4 hours or 6 units and more PRBC in the 
first 4 hours (massive transfusion).  Also, an intentional sub-analysis will be 
performed on the patients who were classified as dead on arrival.  Separate sub-
analyses will be performed on patients with Abbreviated Injury Score (Head) of 3 or 
greater indicating severe traumatic brain injury. 
 

 
9 
12. 
RISK AND INJURY 
This trial is a randomized clinical trial involving a test of two different standard-of-
care transfusion strategies.  As such, it has been verified by the director of the blood 
bank that neither of these transfusion strategies involves more than minimal risk.  
Female patients are excluded at this time to ensure that there is no possibility of 
inadvertent alloimmunization of Rh-negative childbearing women with Rh-positive 
blood products.  As both the component therapy (O+ or O-) and the O+ whole blood 
that is administered at LLUMC would be uncrossmatched, there is a risk of 
transfusion reaction but this risk is not different between groups.   
 
13. 
BENEFIT(S) 
It is possible that patients transfused with LTO+WB may experience improved 
resolution of coagulopathy.  As such it is possible that they may experience either 
reduced transfusion or even a survival benefit. Thus far, available literature has not 
demonstrated a survival benefit consistently, nor has it consistently demonstrated 
reduced need for transfusion.  As such, it is felt by the investigators that clinical 
equipoise still exists between the two randomized treatment arms. 
 
14. 
COMPENSATION 
N/A 
 
15. 
CONFIDENTIALITY 
At the time of data entry into the database, MRN and date of birth will be redacted.  A 
single master list will exist on a LLUMC secure server with the assignment list until 
the data collection is complete.  The RedCap database is endorsed by LLUMC and 
felt to be secure, and in addition will not contain PHI. 
 
16.  
LITERATURE REVIEW 
 
 
1. 
Williams J, Merutka N, Meyer D, Bai Y, Prater S, Cabrera R, et al. Safety profile and 
impact of low-titer group O whole blood for emergency use in trauma. J Trauma Acute Care 
Surg. 2020 Jan;88(1):87–93.  
2. 
Shea SM, Staudt AM, Thomas KA, Schuerer D, Mielke JE, Folkerts D, et al. The use of 
low-titer group O whole blood is independently associated with improved survival 
compared to component therapy in adults with severe traumatic hemorrhage. Transfusion. 
2020 Jun;60 Suppl 3:S2–S9.  
3. 
Seheult JN, Anto V, Alarcon LH, Sperry JL, Triulzi DJ, Yazer MH. Clinical outcomes 
among low-titer group O whole blood recipients compared to recipients of conventional 
components in civilian trauma resuscitation. Transfusion. John Wiley & Sons, Ltd; 2018 
Aug;58(8):1838–45.  
4. 
Hanna K, Bible L, Chehab M, Asmar S, Douglas M, Ditillo M, et al. Nationwide analysis of 
whole blood hemostatic resuscitation in civilian trauma. J Trauma Acute Care Surg. 2020 
Aug;89(2):329–35.  
5. 
Cotton BA, Podbielski J, Camp E, Welch T, del Junco D, Bai Y, et al. A Randomized 
Controlled Pilot Trial of Modified Whole Blood Versus Component Therapy in Severely 

 
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Injured Patients Requiring Large Volume Transfusions. Annals of Surgery. 2013 Aug;:1.