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Blood and Blood Products
Topic Collection
April 18, 2024

Topic Collection: Blood and Blood Products

Mass casualty incidents (MCIs) rarely place significant stress on the blood supply. However, for victims of blast and penetrating trauma requiring massive transfusion, the blood components already on the shelf in hospital transfusion services save lives. When multiple victims requiring emergency transfusions present at once, multiple massive transfusions protocols may create inventory challenges for local hospitals and their blood suppliers. The blood supply may also be affected by other disasters or infectious diseases, which can potentially be transmitted by transfusion (e.g., Zika virus) or disrupt blood donations (e.g., COVID-19).

Additionally, transfusion medicine professionals provide blood components to patients experiencing hemostatic abnormalities and coagulopathy that can accompany massive transfusion. Therefore, critical transfusion needs are not limited to massive transfusion because there is likely to be a concurrent increased need for routine crossmatching to provide compatible blood products for numerous patients in a short period of time.

More than 400 units of packed red blood cells were used after the Aurora (CO) movie theatre shooting.  A similar number were used after the Pulse Nightclub shooting in Orlando, and 222 were given by a Las Vegas trauma center after the 2017 mass shooting. Hospitals should plan internally and with their external blood suppliers for these types of MCIs to ensure adequate supplies are available. Local and regional preparedness training and drills support planning and benefit patients as well as professionals providing transfusion services and emergency services.

Transfusion strategies are beyond the scope of this Topic Collection, though we include selected relevant articles. This domain is rapidly evolving, and providers should include their blood bank and blood supplier in planning to ensure their resuscitation strategies are optimized, they understand limitations, (e.g., availability of whole blood) and plan adjustments during periods of critical demand.

In the aftermath of MCIs and natural disasters, people from affected communities and across the nation often feel the urge to “do something” to help. This may cause people to rush to donate blood locally, including presenting to the hospital or other locations to donate, which can add another challenge to incident management. Realistically, hospitals must rely on their blood suppliers for blood products donated well in advance of the need to treat the patients affected by the incident. Every blood collection undergoes extensive testing to protect patient safety (requiring about 2 days or more to complete labeling and distribution) and has a limited shelf life that varies by blood component, ranging from days to weeks.

Ensuring that an adequate supply of the various blood components is available at hospitals for transfusion during a mass casualty incident presents another planning challenge. Communications through the media and community organizations can help educate community members about the importance of proactive blood donation to help ensure lifesaving blood products are immediately available to emergency patients. With a greater awareness that blood collected on community blood drives is the blood that saves lives in a crisis, the public hopefully will proactively donate rather than rush to donate after the crisis that could overwhelm blood donor centers and hospitals actively responding to emergency events. However, to the degree possible, motivated donors following a disaster should be captured and hopefully will become repeat blood donors.

This Topic Collection includes links to guidance, lessons learned (from disasters, no-notice incidents, and specific to transfusions), plans, tools, and templates, general research, and research specific to the disaster blood supply chain. Related information can be found in the following ASPR TRACIE resources (listed alphabetically): Burns; Crisis Standards of Care; Disaster Ethics; the infectious disease-specific guidance on blood issues in the VHF/Ebola and Zika Topic Collections; the Mass Gatherings/Special Events and Pre-Hospital Topic Collections; and the Select Materials on Drug Shortages and Scarce Resources web page.   

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Must Reads

Cohn, C., Delaney, M., Johnson, S. et al. (2023). AABB Technical Manual, 21st Edition. Association for the Advancement of Blood & Biotherapies.
Laboratory professionals rely on this authoritative resource for blood collection and transfusion information related to quality and regulatory issues, donor eligibility, component preparation, blood groups, antigen/antibody testing, transfusion practice, and transfusion outcomes.
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Doughty, H. and Green, L. (2022). Transfusion Support During Mass Casualty Events. British Journal of Anaesthesia. 128(2):E75-E79.
The authors discuss lessons incorporated into blood transfusion emergency preparedness and stock management, protocols, and safety during/after mass casualty incidents. They emphasize the importance of simulation exercises for transfusion and highlight future directions for the field of blood products management (e.g., identifying promising processes and products, reviewing, and incorporating lessons learned from other incidents including cyberattacks and extreme weather).
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Lozada, M.J., Cai, S., Li, M., et al. (2019). The Las Vegas Mass Shooting: An Analysis of Blood Component Administration and Blood Bank Donations. (Abstract only.) Journal of Trauma and Acute Care Surgery. 86(1):128-133.
The authors gathered data from all hospitals which received patients and blood banks which provided blood products to patients after the 2017 Las Vegas shooting. They found that 220 patients required hospital admission while 68 were admitted to critical care. Almost 500 blood components were transfused in the first 24 hours after the incident, and available blood supply met demand. Planning for future mass shooting incidents ought to include first aid training for hemorrhage control among the public, encouraging routine blood donation, while only calling for additional blood donations if local blood suppliers request them to prevent blood product wastage.
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Mulcahy, A., Kapinos, K., Briscombe, B., et al. (2016). Building a More Sustainable U.S. Blood System. RAND Corporation.
Recent medical advances have contributed to a lower demand for blood and blood products. This presents an economic and supply-related challenge (e.g., seasonal shortages). The authors share how changing payment policies, improving emergency/surge capacity, and technological advances can help ensure a safe, sustainable blood supply.
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Ramsey, G. (2020). Blood Transfusions in Mass Casualty Events: Recent Trends. Vox Sanguinis. 115(5):358-366.
The author reviewed the literature to understand the needs for blood products after mass casualty incidents. He uses tables and graphs to describe mass casualty events and blood transfusion needs from 1980-2019, highlighting similarities, differences, and trends. He also provides recommendations for the amount of red blood cells, plasma, and platelets to have on hand when planning for these events for both trauma centers and blood banks.
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Clinical Practice

Carson, J., Stanworth, S., Guyatt, G., et al. (2023). Red Blood Cell Transfusion: 2023 AABB International Guidelines. (Abstract only.) JAMA. 330(19):1892–1902.
An international panel of experts conducted a systematic review and meta-analysis of 45 randomized clinical trials for adults and seven for pediatric populations to update the red blood cell transfusion guidelines. The guidance includes four recommendations for transfusions in adult and pediatric populations.
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de Roulet, A., Kerby, J., Weinberg, J. et al. (2021). Group A Emergency-Release Plasma in Trauma Patients Requiring Massive Transfusion. The Journal of Trauma and Acute Care Surgery. 89(6):1061-1067.
The authors analyzed whether group A emergency-release plasma was noninferior to group AB emergency release plasma, finding group A an acceptable option for massive transfusion, especially when group AB is unavailable.
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Meneses, E., Boneva, D., McKenney, M., et al. (2020). Massive Transfusion Protocol in Adult Trauma Population. (Abstract only.) The American Journal of Emergency Medicine. 38(12):2661-2666.
This literature review provides information on massive transfusion protocols (MTP), which are typically used at trauma centers to quickly provide blood to bleeding patients. The authors found that protocols should use between 1:1:1 and 1:1:2 ratios of plasma, platelets, and red blood cells. MTP were effective at reducing mortality, especially when blood products were available and administered as soon as the patient arrived to the trauma bay.
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Olsen, G., Passwater, M., Huggins, M., et al. (2021). Evaluation of A Plasma for Incompatible Patients. (Abstract only.) Transfusion. 61(2):375-378.
The authors evaluate the safety of using A plasma instead of AB for bleeding patients in life-threatening emergencies. They found that among 93 patients, no ABO immune-mediated hemolysis was found. The study supports the hypothesis that A plasma can be used in B and AB patients.
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Ontario Regional Blood Coordinating Network. (2017). Blood Inventory Management Best Practices for Hospital Transfusion Services.
This document contains 10 recommendations for management of hospital blood transfusion inventory and services. The best practices include maintaining target inventory levels, ensuring oldest units are used first, establishing a “maximum surgical blood order schedule,” and avoiding having many blood units which expire on the same day. It also includes references and suggested reading.
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Pidcoke, H., Aden, J., Mora, A., et al. (2012). Ten-year Analysis of Transfusion in Operation Iraqi Freedom and Operation Enduring Freedom: Increased Plasma and Platelet Use Correlates with Improved Survival. (Abstract only.) The Journal of Trauma and Acute Care Surgery. 73(6 Suppl 5):S445-52.
The authors reviewed data in the Joint Theater Trauma Registry database to analyze blood transfusions and time, survival, and the effect of increasing transfusion ratios. They found that high transfusion ratios of fresh frozen plasma and plasma and platelet to red blood cells were correlated with higher survival but not decreased blood requirement.
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Pusateri, A., Moore, E., Moore, H., et al. (2020). Association of Prehospital Plasma Transfusion with Survival in Trauma Patients with Hemorrhagic Shock When Transport Times Are Longer Than 20 Minutes. JAMA Surgery. 155(2):e195085.
The authors randomly assigned 626 patients in hemorrhagic shock after trauma to receive either standard pre-hospital care or two units of thawed plasma. They found that during emergency medical services transport times longer than 20 minutes, plasma transfusion before arrival at the hospital significantly reduced 28-day mortality.
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Radiation Emergency Medical Management. (2023). Use of Blood Products in a Radiation Emergency. U.S. Department of Health and Human Services.
This webpage contains information on the use of blood products in a radiation emergency (e.g., in the event patients require blood product transfusion two to four weeks after high doses of whole-body radiation exposure). The site includes background information on transfusion issues and policies, post-transfusion graft-versus-host disease, platelet transfusion guidance, and pediatric red cell transfusions in radiation emergencies.
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Ramsey, G. (2017). Blood Component Transfusions in Mass Casualty Events. Vox Sanguinis. 112: 648-659.
The author describes the results of a literature review (n=24 articles) on mass casualty incident blood component usage (articles on natural disasters were excluded). He writes, “Five RBCs per admission would have sufficed for 87% of events” and notes that more current data would help establish predictive models.
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  • Bridget Kanawati Thank you, Mr. Ramsey. We have updated the resource citation.
    8/30/2018 7:52:09 PM
  • Glenn Ramsey Source display should read: Vox Sanguinis 112:648-59, 2017
    8/30/2018 4:03:49 PM
Smethurst, P., McAndrew, M., Proffitt, S., et al. (2022). Evaluating Apheresis Platelets at Reduced Dose as a Contingency Measure for Extreme Shortages. Transfusion. 62(1):173-182.
The authors discuss splitting double apheresis platelets into triples to conserve platelet inventory in extreme cases of shortages while maintaining acceptable platelet quality for transfusion. They conclude that this strategy is feasible, maintains quality, and should be considered as a contingency plan during shortages.
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* Stanworth, S., Dowling, K., Curry, N., et al. (2022). Haematological Management of Major Haemorrhage: A British Society for Haematology Guideline. British Journal of Haematology. 198(4):654-667.
The authors provide recommendations and guidance related to managing major hemorrhage which emphasizes collaboration between emergency departments, blood banks, and hospitals in general. The authors also highlight the potential role of antifibrinolytics in these cases.
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* World Health Organization. (2023). Blood Safety and Availability.
This factsheet provides a demographic overview of blood donors, summarizes how blood is screened by high-, middle-, and low-income countries (for HIV, hepatitis B and C, and syphilis), and highlights the World Health Organization’s response (Blood and Transfusion Safety programme) regarding disease transmission and shortages.
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Lessons Learned

Addams, J., Arbabi, S., Bulger., E., et al. (2022). How We Built a Hospital-Based Community Whole Blood Program. (Abstract only.) Transfusion. 62(9):1699-1705.
The authors established a whole blood program for a hospital so that whole blood was available for treatment of hemorrhagic shock or patients otherwise needing massive transfusions. Within a 1.5-year period, 2,269 units were received and 89% were transfused to trauma patients. The authors conclude that establishing a whole blood program is complex but that the time and resource investment can improve care, save nursing effort, and reduce charges to patients.
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Badami, K., Mercer, S., Chiu, M., et al. (2020). Analysis of Transfusion Therapy During the March 2019 Mass Shooting Incident in Christchurch, New Zealand. (Abstract only.) Vox Sanguinis. 115(5):424-432.
The authors analyzed how blood transfusions were conducted after the 2019 mass shooting in Christchurch, New Zealand. Of the 37 patients admitted with gunshot wounds, 65% received a transfusion. The authors noted, “On average, each gunshot wound patient was transfused 4, 3·1, 1·2 and 0·4 units of RBC, FFP, cryoprecipitate and platelets, respectively,” on the day of the incident; the percent of patients who received transfusions was higher for this incident than for other similar events. The ratios of blood components in transfusions were close to the recommended guidelines.
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Bala, M., Kaufman, T., Keidar, A., et al. (2014). Defining the Need for Blood and Blood Products Transfusion Following Suicide Bombing Attacks on a Civilian Population: A Level I Single-Centre Experience. (Abstract only.) 45(1):50-5.
This study highlights findings specific to blood and blood product transfusions following suicide bombings in Israel from 2000 to 2005. The authors share that more than one third of casualties received transfusions (mainly in the first two hours post-incident). One-tenth of casualties received a massive transfusion. Healthcare facilities can incorporate the data from this study into their mass casualty incident response plans.
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Ciaraglia, A., Brigmon, E., Braverman, M., et al. (2022). Use of Whole Blood Deployment Programs for Mass Casualty Incidents: South Texas Experience in Regional Response and Preparedness. (Abstract only.) Journal of Acute Care Surgery. 93(6):e182-e184.
The authors describe a Southwest Texas Regional Advisory Council program designed to distribute blood products after a mass casualty incident. The prehospital whole blood program was first used to distribute O-positive whole blood and packed cells to Uvalde Memorial Hospital after the mass shooting in 2022 and was used in a successful operation. Given improved mortality with whole blood administration, the development of similar programs in other states may reduce preventable deaths.
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Doughty, H. and Green, L. (2022). Transfusion Support During Mass Casualty Events. British Journal of Anaesthesia. 128(2):E75-E79.
The authors discuss lessons incorporated into blood transfusion emergency preparedness and stock management, protocols, and safety during/after mass casualty incidents. They emphasize the importance of simulation exercises for transfusion and highlight future directions for the field of blood products management (e.g., identifying promising processes and products, reviewing, and incorporating lessons learned from other incidents including cyberattacks and extreme weather).
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Gammon, R., Rosenbaum, L., Cooke, R., et al. (2021). Maintaining Adequate Donations and a Sustainable Blood Supply: Lessons Learned. Transfusion. 61(1):294-302.
The authors reviewed the literature to understand how blood centers prepare for disaster management and to create recommendations for blood centers and hospitals. They emphasize the need for blood centers to participate in planning for disasters and for hospitals to maintain a sufficient supply in case distribution is disrupted. They also highlight the benefits of the Association for the Advancement of Blood & Biotherapies’ Choosing Wisely initiative, including bolstering patient and provider education and helping hospitals overcome logistical challenges to ensuring a robust and optimally used blood supply.
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Gates, J., Arabian, S., Biddinger, P., et al. (2014). The Initial Response to the Boston Marathon Bombing: Lessons Learned to Prepare for the Next Disaster. (Abstract only.) Annals of Surgery. 260(6):960-6.
The authors provide an overview of the medical response to the Boston Marathon bombing and list the factors that contributed to positive outcomes. They note that 10% of patients required immediate transfusion of packed red blood cells in the emergency department.
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Glasgow, S., Allard, S., Doughty, H., et al. (2012). Blood and Bombs: The Demand and Use of Blood Following the London Bombings of 7 July 2005-A Retrospective Review. (Abstract only.) Transfusion Medicine. 22(4): 244-250.
The authors collected data from the United Kingdom’s National Blood Service and the hospitals involved in caring for patients after the 2005 bombings. They describe the blood components requested and used, blood stock levels at the time of the incident, and patient injury profiles. They conclude by emphasizing that incidents involving patients suffering from major hemorrhage will cause an increased demand for plasma, platelets, and cryoprecipitate.
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Glynn, S., Busch, M., Schreiber, G., et al. (2003). Effect of a National Disaster on Blood Supply and Safety: The September 11 Experience. Journal of the American Medical Association. 289(17): 2246-2253.
The authors examine data gathered four weeks before and after 9/11/2001 and compared it to the same period in 2000. They found an increase in donations and a three-fold increase in donations confirmed positive for certain viruses (e.g., HIV and hepatitis B and C) one week before September 11 (0.1%) and one week after the attacks (0.3%). This was explained by the increase in first-time and lapsed repeat donors. The authors emphasize the need for better education that could encourage repeat donations.
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Heinrich, J. (2002). Maintaining an Adequate Blood Supply Is Key to Emergency Preparedness. U.S. General Accounting Office.
This post-9/11 report discusses the adequacy of the blood supply after the incident; how blood suppliers responded to the 9/11 attacks; and how blood suppliers planned for future incidents.
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* Kenan, N. and Diabat, A. (2022). The Supply Chain of Blood Products in the Wake of the COVID-19 pandemic: Appointment Scheduling and Other Restrictions. Transportation Research Part E: Logistics and Transportation Review. 159:102576.
The authors aimed to understand how the COVID-19 pandemic affected blood banks when demand and supply were uncertain, which may inform blood bank planning for future disasters. They modeled the supply for red blood cells, plasma, and platelets and developed a heuristic to solve blood supply issues commercial software did not resolve quickly, including a sensitivity analysis.
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Lozada, M.J., Cai, S., Li, M., et al. (2019). The Las Vegas Mass Shooting: An Analysis of Blood Component Administration and Blood Bank Donations. (Abstract only.) Journal of Trauma and Acute Care Surgery. 86(1):128-133.
The authors gathered data from all hospitals which received patients and blood banks which provided blood products to patients after the 2017 Las Vegas shooting. They found that 220 patients required hospital admission while 68 were admitted to critical care. Almost 500 blood components were transfused in the first 24 hours after the incident, and available blood supply met demand. Planning for future mass shooting incidents ought to include first aid training for hemorrhage control among the public, encouraging routine blood donation, while only calling for additional blood donations if local blood suppliers request them to prevent blood product wastage.
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Martinez, T., Francois, A., Pouget, T., et al. (2020). Blood Product Needs and Transfusion Timelines for the Multisite Massive Paris 2015 Terrorist Attack: A Retrospective Analysis. The Journal of Trauma and Acute Care Surgery. 89(3):496-504.
The authors conducted a retrospective analysis to understand how blood products were administered after the 2015 Paris terrorist attacks. They found that it is more important in transfusion procedures to shorten blood product time to the bedside rather than focusing on growing the stockpile of blood products.
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Melmer. P., Carlin, M., Castater, C., et al. (2019). Mass Casualty Shootings and Emergency Preparedness: A Multidisciplinary Approach for an Unpredictable Event. Journal of Multidisciplinary Healthcare. 12: 1013-1021.
The authors review mass casualty shootings in the U.S. and abroad and emphasize the value of multi-disciplinary teams (MDT) in incident response and the delivery of life-saving care. They also highlight the importance of blood bank preparedness, incorporating lessons learned into plans, simulation exercises, and the “Stop the Bleed” campaign in MDT preparedness and response efforts.
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Phan-Tang, M., Lee, C., Fang, A., et al. (2022). Logistics of Managing a Trauma Whole Blood Inventory in a Civilian Level 1 Trauma Center. (Abstract only.) Transfusion. 62(9):1772-1778.
The authors maintained a low-titer O positive whole blood inventory so that it was available for trauma patients in a trauma center. They found that challenges to the program included inventory shortages, low utilization rates, and failure to meet clinical demand. They suggest extending shelf life, expanding the donor pool, and identifying barriers to utilization to overcome the challenges.
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Propper, B., Rasmussen, T., Davidson, S., et al. (2009). Surgical Response to Multiple Casualty Incidents Following Single Explosive Events. (Abstract only.) Annals of Surgery. 250(2): 311-315.
This study describes surge response to multiple casualty incidences following explosive events handled at a U.S. trauma hospital in Iraq. The authors noted that 48% of the mass casualty military patients needed blood, but 4 patients consumed 43% of the blood used, emphasizing the importance of related resource utilization planning.
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Qiao, J., Ray, B., Wians, F., et al. (2021). Transfusion Management of Trauma from the 2019 El Paso Mass Shooting Incident. Vox Sanguinis. 117(3):299-312.
The authors examined the response to the 2019 El Paso mass shooting, focusing on blood transfusion management in the hospital setting. Fifteen casualties were treated at University Medical Center with hemostatic agents, tranexamic acid, and blood products, while rotational thromboelastometry (ROTEM, a test for hemostasis) guided transfusion decisions in three patients. The use of ROTEM reduced the need for transfusions and improved the authors’ understanding of acute resuscitation.
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Ramsey, G. (2020). Blood Transfusions in Mass Casualty Events: Recent Trends. Vox Sanguinis. 115(5):358-366.
The author reviewed the literature to understand the needs for blood products after mass casualty incidents. He uses tables and graphs to describe mass casualty events and blood transfusion needs from 1980-2019, highlighting similarities, differences, and trends. He also provides recommendations for the amount of red blood cells, plasma, and platelets to have on hand when planning for these events for both trauma centers and blood banks.
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Shackelford, S., Del Junco, D., Powell-Dunford, N., et al. (2017). Association of Prehospital Blood Product Transfusion During Medical Evacuation of Combat Casualties in Afghanistan With Acute and 30-Day Survival. Journal of the American Medical Association. 318(16): 1581–1591.
A retrospective cohort study of U.S. military combat casualties found that prehospital transfusion was linked to improved survival at both 24 hours and 30 days.
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Stevens, W., Morse, B., Bernard, A., et al. (2017). Incompatible Type A Plasma Transfusion in Patients Requiring Massive Transfusion Protocol: Outcomes of an Eastern Association for the Surgery of Trauma Multicenter Study. (Abstract only.) The Journal of Trauma and Acute Care Surgery. 83(1):25-29.
The authors reviewed data on 1,536 patients (92% received compatible plasma transfusions and 8% received incompatible type A plasma). There were no differences in morbidity or mortality between the two groups.
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Torres Vasconcelos, F., Faddy, H., Merollini, K., et al. (2023). Impact of Natural Disasters and Pandemics on Blood Supply: A Systematic Review. Health Sciences Review. 7:100087.
The authors reviewed the literature to understand how pandemics and natural disasters affect the blood supply. They note that there was a drop in donations during the COVID-19 pandemic and increases in first time donors after earthquakes. Public campaigns, transportation for donors, home visits, minimizing blood product wastage, contingency plans, and changing donor eligibility are all important to promoting donations, reducing blood product procurement costs, and improving robustness of the blood supply.
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Plans, Tools, and Templates

Association for the Advancement of Blood & Biotherapies. (n.d.). Example Blood Component Shortage Notification and Contingency Plan for Hospital. (Accessed 4/11/2024.)
This hospital plan is offered as a template which can help hospitals to prepare for platelet, red blood cell, plasma, or other blood component shortages. It includes recommendations for assessments by transfusion physicians, notification strategies for blood bank leaders, and additional steps for long-term planning (e.g., creating a system to move blood products between facilities, improving blood bank notification to hospitals, and increasing community donations).
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Association for the Advancement of Blood & Biotherapies. (2008). Disaster Operations Handbook—Hospital Supplement. Coordinating the Nation’s Blood Supply During Disasters and Biological Events.
While it does not address internal policies, this handbook can help hospitals plan for and ensure that they have enough blood for transfusion in the event of a disaster. It includes a flow chart and a needs assessment chart that can help with calculating the total number of units needed from the task force. Access the hospital supplement here: https://aabb.org/docs/default-source/default-document-library/about/disaster-operations-handbook-hospital-supplement.pdf?sfvrsn=ba6a852c_0
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Association for the Advancement of Blood & Biotherapies. (2008). Response Plan Flow Chart.
These four steps summarize how an incident would be handled by the AABB and partners, from start (blood collector assesses medical need for blood) to finish (coordinated messaging and implementation of task force recommendations).
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Association for the Advancement of Blood & Biotherapies. (2021). Extending the Blood Supply – Tips for Hospitals.
This two-page tipsheet contains information for hospitals on strategies and policies to maintain the blood supply. It covers topics such as reviewing orders and crossmatching units to conserve the blood supply and using salvage strategies during surgery to reduce the need for donated blood. It also contains links to relevant resources for more information.
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Association for the Advancement of Blood & Biotherapies. (2024). Emerging Infectious Disease Fact Sheets.
In February 2024, AABB released an updated comprehensive library of Emerging Infectious Diseases (EID) Fact Sheets. The EID Fact Sheets describe 72 agents identified as having an actual or potential risk of transfusion-transmission. The Fact Sheets are intended to inform collection facilities and transfusion services about individual pathogens for which questions may arise and for consideration of a starting point for policy development. They contain an assessment of each disease’s clinical features, possible interventions for blood collection facilities, and the anticipated impact on blood safety. Infectious agents considered include prion diseases, viruses, bacteria, protozoa, and nematodes.
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Brigmon, E.P., Cirone, J., Harrell, K., et al. (2024). Walking Blood Bank: A Plan to Ensure Self-Sufficiency in an Era of Blood Shortage. Trauma Surgery Acute Care Open. 9(Suppl 1):e001151.
The authors describe a Southwest Texas Regional Advisory Council program to supply emergency blood products to the region whereby preselected blood donors function as a “walking blood bank,” donating blood in the event of a mass casualty incident. The blood would be rapidly and rigorously screened and tested before being used to treat patients, potentially saving lives, and bolstering local supply.
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California Blood Bank Society. (2015). Disaster Response Plan.
This plan highlights how the activities of all California Regional Blood Centers will be coordinated in the event of a local, regional, or national emergency.
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Canadian Blood Services. (2022). National Plan for the Management of Shortages of Labile Blood Components.
This plan addresses four phases of inventory availability (green, amber, red, and recovery) and describes the roles and responsibilities of key stakeholders. Appendix G, beginning on page 92 of the document provides an algorithm (triage tools) for making decisions during Red Phase Blood Shortages.
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DC Emergency Healthcare Coalition. (n.d.). Intra-hospital Blood Bank Needs Identification Tool. (Accessed 4/11/2024.)
This template was developed to improve and expedite the communication of needs from clinical departments to their intra-facility blood bank. Facilitating this interaction can expedite the transmission of projected blood product needs to regional blood banks, reducing the probability that blood products will be delayed or insufficient to meet emergency needs. While some material may be dated, hospitals may find it useful to review their massive transfusion protocols and adjust the ratios of blood products needed to have on hand.
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Doughty, H., Green, L., Callum, J., et al. (2020). Triage Tool for The Rationing of Blood for Massively Bleeding Patients During a Severe National Blood Shortage: Guidance from the National Blood Transfusion Committee. (Abstract only.) British Journal of Haematology. 191(3):340-346.
The authors discuss how a decrease in blood donation during the COVID-19 pandemic might lead to blood shortages and the need to make difficult decisions about which patients receive blood. This article provides a tool for ethically allocating blood for patients with hemorrhage during a severe shortage to save lives.
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Holcomb, J., Spinella, P., Oveland Apelseth, T., et al. (2021). Civilian Walking Blood Bank Emergency Preparedness Plan. Transfusion. 61(S1): S313-S325.
The authors provide recommendations for providing blood to bleeding patients when there are blood shortages. A multidisciplinary, international group of clinicians developed a planning document and found precedent in remote locations, battlefields, and civilian contexts. They highlight the importance of planning and discuss the possibility of transfusing emergency untested whole blood when no blood is otherwise available.
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Mclennan, J., Mackway-Jones, K., and Smith, J. (2018). Prediction of Massive Blood Transfusion in Battlefield Trauma: Development and Validation of the Military Acute Severe Haemorrhage (MASH) Score. (Abstract only.) Injury. 49(2):184-190.
This tool was developed to predict blood transfusion requirements in the military deployed hospital environment. Emergency planners may consider using it for mass casualty incidents in the civilian world.
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Minnesota Department of Health, Office of Emergency Preparedness, Minnesota Healthcare System Preparedness Program. (2021). Patient Care: Strategies for Scarce Resource Situations.
This card set can help facilitate an orderly approach to resource shortfalls (including blood products) at a healthcare facility. It is a decision support tool to be used by key personnel, along with incident management, who are familiar with ethical frameworks and processes that underlie these decisions.
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Simonetti, A. and Forshee, R. (2018). FDA Blood Supply and Demand Simulation Model Could Help Nation Prepare for Emergencies.
Authors from the U.S. Food and Drug Administration describe the recently-developed blood supply model that estimates the amount of blood available nationally during routine and emergency conditions. This model can also be customized to help planners understand various scenarios.
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* Stanworth, S., Dowling, K., Curry, N., et al. (2022). Haematological Management of Major Haemorrhage: A British Society for Haematology Guideline. British Journal of Haematology. 198(4):654-667.
The authors provide recommendations and guidance related to managing major hemorrhage which emphasizes collaboration between emergency departments, blood banks, and hospitals in general. The authors also highlight the potential role of antifibrinolytics in these cases.
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World Health Organization. (2023). Guidance on Ensuring a Sufficient Supply of Safe Blood and Blood Components During Emergencies.
This document aims to help national blood services to develop plans for disasters. It includes necessary considerations, background on why they are included, and how to prepare for blood shortages due to fewer blood donors or shortages of essential equipment.
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Yale New Haven Hospital. (n.d.). Development and Design of the Disaster Prediction Model. (Contact ASPR TRACIE for this document: askasprtracie@hhs.gov.)
This appendix describes a tool developed by Yale New Haven Hospital to predict the blood needs of a particular disaster.
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Research

Brill, J., Tang, B., Hatton, G., et al. (2022). Impact of Incorporating Whole Blood into Hemorrhagic Shock Resuscitation: Analysis of 1,377 Consecutive Trauma Patients Receiving Emergency-Release Uncrossmatched Blood Products. Journal of the American College of Surgeons. 234(4):408-418.
The authors reviewed the use of whole blood for resuscitation after trauma to understand how it affected survival. They analyzed outcomes for 1,377 patients and found that whole blood transfusion for hemorrhagic shock was associated with better survival and fewer overall blood transfusions.
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Cannon, J., Igra, N., Borge, P.D., et al. (2022). U.S. Cities Will Not Meet Blood Product Resuscitation Standards During Major Mass Casualty Incidents: Results of a THOR-AABB Working Party Prospective Analysis. (Abstract only.) Transfusion.
The authors simulated a mass casualty incident in several major U.S. cities to understand how much blood product would be used and whether the blood supply is ready for these events. They found that in the simulation, demand for blood products exceeded supply, and changes to meet demand should be considered.
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Crombie, N., Doughty, H., Bishop, J., et al. (2022). Resuscitation with Blood Products in Patients with Trauma-Related Haemorrhagic Shock Receiving Prehospital Care (Rephill): A Multicentre, Open-Label, Randomised, Controlled, Phase 3 Trial. Lancet Haematology. 9(4):e250-e261.
The authors conducted a randomized control trial to compare prehospital packed red blood cells and lyophilized plasma (PRBC-LyoPlas) to 0.9% sodium chloride to improve perfusion and reduce mortality after traumatic hemorrhage. The trial did not demonstrate that PRBC-LyoPlas was superior to sodium chloride in the prehospital setting. The authors recommend further research on transfusion protocols and careful consideration before implementing prehospital transfusion programs.
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Doughty, H. and Strandenes, G. (2019). Whole Blood in Disaster and Major Incident Planning. International Society of Blood Transfusion.
The authors discuss planning for multiple casualty incidents or emergencies requiring blood products. They cover the assumptions used for planning, demand per patient, inventory management, transfusion triage, resilience and resupply in remote communities, patient safety, and future areas of research.
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Dunbar, N. and Yazer, M. (2017). Safety of the Use of Group A Plasma in Trauma: The STAT Study. (Abstract only.) Transfusion. 57(8):1879-1884.
This study examined the use of thawed group A plasma for the initial resuscitation of trauma patients (i.e., before blood type is known). There was no difference in in-hospital mortality, early mortality, or hospital length of stay for the patients treated with group A plasma versus those treated with group B and AB.
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Edwards, T. and Hoareau, G. (2020). Fluids of the Future. Frontiers in Veterinary Science. 7:623227.
The authors discuss the contributions of military and civilian research to fluid resuscitation for hemorrhage or shock, and new scientific developments to develop improved fluid resuscitation in military, civilian, and veterinary contexts. They provide background on fluid resuscitation, discuss characteristics of “the ideal fluid,” the potential of novel crystalloids, novel blood products, and limitations of the study.
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Gammon, R., Cooke, R., Rosenbaum, L., et al. (2019). Donation vs. Supply White Paper. Association for the Advancement of Blood & Biotherapies.
This white paper contains information on the history of blood product use and distribution in the United States, managing surges in donations after mass casualty incidents, disaster management and the blood supply, and the appropriate use of O-negative red blood cells. Recommendations for addressing overuse of blood products includes not using more than necessary, not transfusing red blood cells for iron deficiency when a patient is hemodynamically stable, and not routinely using blood products to reverse the effects of blood thinners.
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Gshwender, A. and Gillard, L. (2017). Disaster Preparedness in the Blood Bank. Clinical Laboratory Science. 30(4):250-257.
The authors explore blood bank planning for various natural disasters and mass casualty incidents. They recommend running simulations of these events to better prepare blood banks and iteratively improve emergency plans. The article covers agencies which have created guidelines and standards to support disaster management, predictive modeling for disasters, and using risk assessment to develop plans.
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Hazelton, J., Ssentongo, A., Oh, J., et al. (2022). Use of Cold-Stored Whole Blood is Associated with Improved Mortality in Hemostatic Resuscitation of Major Bleeding: A Multicenter Study. Annals of Surgery. 276(4):579-588.
The authors conducted a prospective, observational study to understand how whole blood versus blood component therapy affected patient outcomes in bleeding trauma patients. They found that compared with blood component therapy, whole blood was associated with a 48% reduction in mortality for these patients.
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Holcomb, J., Tilley, B., Baraniuk, S., et al. (2015). Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients with Severe Trauma: The PROPPR Randomized Clinical Trial. (Abstract only.) Journal of the American Medical Association. 313(5): 471-482.
The authors sought to evaluate the safety and effectiveness of transfusing patients with major bleeding (as a result of severe trauma) using a different ratio of plasma, platelets, and red blood cells. No significant differences were detected in mortality at 24 hours or at 30 days. This classic article may provide guidance though there is some variance in individual health care facility protocol.
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Mould-Millman, N., Wogu, A., Fosdick, B., et al. (2024). Association of Freeze-Dried Plasma with 24-H Mortality Among Trauma Patients at Risk. Transfusion.
The study compared trauma patients that were transfused with only freeze-dried plasma, freeze-dried plasma and blood products, and blood products only to determine if there were any significant differences in 24-hour mortality. The study concluded that was no difference found in 24-hour mortality in these trauma patients. The authors concluded that this study may serve as evidence that freeze-dried plasma may play a role in hemorrhagic shock resuscitation especially in settings where there is restrictive access to traditional blood products.
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Prat, J., Meyer, A., Ingalls, N., et al. (2017). Rotational Thromboelastometry Significantly Optimizes Transfusion Practices for Damage Control Resuscitation in Combat Casualties. The Journal of Trauma and Acute Care Surgery. 83(3):373-380.
A high proportion of combat casualties with a truncal injury die of hemorrhage before reaching a surgeon. This article describes damage control resuscitation methods, which are “focused on replacing shed whole blood by empirically transfusing blood components in a 1:1:1:1 ratio of platelets : fresh frozen plasma : erythrocytes : cryoprecipitate.”
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Stinger, H., Spinella, P., Perkins, J., et al. (2008). The Ratio of Fibrinogen to Red Cells Transfused Affects Survival in Casualties Receiving Massive Transfusions at an Army Combat Support Hospital. (Abstract only.) The Journal of Trauma. 64(2 Suppl): S79-85.
The authors sought to determine whether increased ratios of fibrinogen (a soluble protein present in blood plasma) to red blood cells (RBCs) decreased mortality in combat casualties requiring massive transfusion. They found that “the transfusion of an increased fibrinogen: RBC ratio was independently associated with improved survival to hospital discharge, primarily by decreasing death from hemorrhage.”
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U.S. Department of Health and Human Services. (2020). Adequacy of the National Blood Supply.
This report to Congress describes challenges related to maintaining an adequate blood supply, how to ensure adequacy in the event of a public health emergency, the transfusion monitoring system, and other strategies and new technologies that can help promote supply safety and innovation.
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Williams, J., Gustafson, M., Bai, Y., et al. (2021). Limitations of Available Blood Products for Massive Transfusion During Mass Casualty Events at US Level 1 Trauma Centers. Shock. 56(1 Suppl):62-69.
The authors used a computerized model to understand how prepared U.S. trauma centers’ blood banks are to respond to mass casualty incidents (MCIs). They conducted 9,000 simulations for each of 16 U.S. level 1 trauma centers. They note that non-traditional blood products with longer shelf lives (e.g., freeze dried plasma, cryopreserved red blood cells, recent advances in platelet storage techniques) may improve trauma centers’ ability to meet these needs for future MCIs.
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Supply Chain Modeling

Ahmadimanesh, M., Tavakoli, A., Pooya, A., et al. (2020). Designing an Optimal Inventory Management Model for the Blood Supply Chain. Medicine. 99(29):e21208.
The authors “aim to design an optimal management model of blood transfusion” using a simulation technique and a deep neural network. They implemented the model for a blood transfusion network, which helped with predicting hospital demand, optimal reserves, hospital orders, and hospital delivery. They conclude that the model can reduce blood units used in health care facilities, increase inventory, and reduce costs.
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Association for the Advancement of Blood & Biotherapies. (2023). Blood Community Proposes New ACBTSA Recommendations to Strengthen Blood Supply.
This webpage provides an update on recommendations for the Advisory Committee on Blood and Tissue Safety and Availability (ACBTSA) from organizations in the blood community, with the goal of strengthening the blood supply. The three recommendations include establishing a baseline inventory of blood, modeling unprecedented emergency scenarios, and funding for a sustained increase in blood inventories. The webpage also provides feedback on ACBTSA’s current recommendations.
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Association for the Advancement of Blood & Biotherapies. (2024). AABB23: Supply Chain Shortages Analyzed.
This webpage provides information on counterpoints to the “lean manufacturing” principles when used for blood bank preparedness. The page includes the perspectives of three speakers who highlighted steps for a resilient blood supply, planning tools for surge in demand for blood products, and demographic trends among blood donors.
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Basavaraju, S., Free, R., Chavez Ortiz, J., et al. (2023). Impact of the COVID-19 Pandemic on Blood Donation and Transfusions in the United States in 2020. Transfusion. 63(Suppl 4): S1-S7.
The authors aimed to understand how the COVID-19 pandemic impacted blood donation and transfusions in the United States. They found that while some month-to-month variability occurred, no substantial shortage of blood was noted on an aggregate, national level.
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Doughty, H., Glasgow, S., and Kristoffersen, E. (2016). Mass Casualty Events: Blood Transfusion Emergency Preparedness Across the Continuum of Care. Transfusion. 56(Suppl 2). S208-S216.
The authors describe two models of transfusion planning for mass casualty incidents and suggest exploring the use of alternative transfusion products and other means to promote community resilience.
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Fahimnia, B., Jabbarzadehab, A., Ghavamifarb, A., and Bella, M. (2017). Supply Chain Design for Efficient and Effective Blood Supply in Disasters. Emergency Medicine Journal. 26(12):899-902.
The authors share a “stochastic bi-objective supply chain design model” that examines the cost- and time-efficient delivery of blood after disasters.
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Glasgow, S., Vasilakis, C., Perkins, Z., et al. (2016). Managing the Surge in Demand for Blood Following Mass Casualty Events: Early Automatic Restocking May Preserve Red Cell Supply. (Abstract only.) The Journal of Trauma and Acute Care Surgery. 81(1): 50-57.
In this article, the authors describe the development of a computerized simulation model of a major trauma transfusion system. After 35,000 simulations, the authors found positive results for the early-automated push approach to restocking red blood cells compared with holding excess stock permanently at trauma centers.
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* Kenan, N. and Diabat, A. (2022). The Supply Chain of Blood Products in the Wake of the COVID-19 pandemic: Appointment Scheduling and Other Restrictions. Transportation Research Part E: Logistics and Transportation Review. 159:102576.
The authors aimed to understand how the COVID-19 pandemic affected blood banks when demand and supply were uncertain, which may inform blood bank planning for future disasters. They modeled the supply for red blood cells, plasma, and platelets and developed a heuristic to solve blood supply issues commercial software did not resolve quickly, including a sensitivity analysis.
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Samani, M., Torabi, S., and Hosseini-Motlagh, S. (2018). Integrating Blood Supply Chain Planning for Disaster Relief.
The model described comprehensively in this article accounts for traditional aspects of the blood supply chain and also “provides a trade-off analysis between the cost efficiency…responsiveness …and effectiveness of the designed network.” The authors base a case study using the model on a relatively earthquake-prone city in Iran.
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Simonetti, A., Ezzeldin, H., Walderhaug, M., et al. (2018). An Inter-regional US Blood Supply Simulation Model to Evaluate Blood Availability to Support Planning for Emergency Preparedness and Medical Countermeasures. (Abstract only.) Disaster Medicine and Public Health Preparedness. 12(2): 201-210.
The authors created an inter-regional blood transfer system including multiple blood collectors and distributors and tested it on mass pandemic and mass casualty incident scenarios across U.S. regions.
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Torrado, A. and Barbosa-Póvoa, A. (2022). Towards an Optimized and Sustainable Blood Supply Chain Network under Uncertainty: A Literature Review. Cleaner Logistics and Supply Chain.
The authors reviewed the literature to understand best practices in managing the blood products supply chain. The authors characterize phases of the blood supply chain, discuss relevant models, and describe sustainability strategies which may inform future research on the blood supply.
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Agencies and Organizations

American Red Cross. Biomedical Services.
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American Red Cross. Disaster Relief.
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Association for the Advancements of Blood & Biotherapies. Disaster Response.
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Blood Centers of America. Disaster Response.
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Blood Emergency Readiness Corps.
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Southwest Texas Regional Advisory Council (STRAC). Regional Whole Blood Program.
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This ASPR TRACIE Topic Collection was comprehensively reviewed in April 2024 by the following subject matter experts (listed in alphabetical order):

Sridhar V. Basavaraju, MD, Office of Blood, Organ, and Other Tissue Safety, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, CDC; James Berger, MS (MT ASCP) SBB, Senior Advisor for Blood & Tissue Safety, Office of the Assistant Secretary for Health; Claudia S. Cohn, MD, PhD, Professor of Laboratory Medicine and Pathology, University of Minnesota and Chief Medical Officer, Association for the Advancement of Blood and Biotherapies (AABB); Heidi Doughty, MBA, DrPhilos, FRCP, FRCPath, Consultant in Transfusion Medicine, and Honorary Reader, University of Birmingham; Mark T. Friedman, DO, Associate Professor of Pathology, Director, Transfusion Services, NYU Langone Health; Betzabel Gonzalez, MS, BB(ASCP); America’s Blood Center; John Hick, MD, Hennepin Healthcare; Leah Mendelsohn Stone, JD, Vice President, Public Policy and Advocacy, Association for the Advancement of Blood and Biotherapies (AABB).

It was comprehensively reviewed in June and July 2018 by the following subject matter experts (listed in alphabetical order): Neil Blumberg, MD, Professor of Pathology and Laboratory Medicine, Director, Blood Bank/Transfusion Medicine, University of Rochester Medical Center; Willie K. Carley, Ph.D., VISN 2 Network Emergency Manager, Department of Veterans Affairs; Heidi Doughty, MB, BChir, MBA, Dr.philos, Consultant in Transfusion Medicine, NHS Blood and Transplant, UK; William P. FitzGerald, BA, Senior Advisor – Biomedical Preparedness, American Red Cross; Jed Gorlin, MD, MBA, Innovative Blood Resources; John Hick, MD, HHS ASPR and Hennepin County Medical Center; Richard Hunt, MD, HHS/ASPR. Office of Emergency Management; Louis Katz, MD, Americas Blood Centers; and Ruth Sylvester, MS, Americas Blood Centers.  

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