Managing Traumas During the ‘Forever’ Blood Shortage

Who hasn't been there? Sunday morning, 2:30 a.m., and the first-up, last-call car wreck is wheeled into your emergency department. The automated cuff keeps cycling without reporting a number, so the blood pressure must be low. The patient is not stable for the CT scanner, and you aren't sure what's bleeding. A massive transfusion protocol is activated. That's when the blood bank tells you that platelets are critically low and there is only one pack to give you (and only if you really need it).The era of plentiful blood, if it ever existed, is well and truly gone. Blood shortages are the norm. Contemporary resuscitation practice recognizes that red cell transfusion alone is insufficient to treat severe hemorrhage. Anatomic surgical bleeding is worsened by microvascular medical bleeding caused by the consumption, dilution, or inactivation of hemostatic activators. Judicious restoration of “clot-ability” most often requires fractionated, noncellular component therapies – thawed plasma, pooled platelets, and (at some centers) cryoprecipitate products. The causes of shortages are simple: increased use of products, and insufficient donors. The Red Cross estimates that 29,000 units of red cells, 6,000 units of plasma, and 5,600 packs of platelets are transfused daily in the United States, requiring 38,000 daily donors. While 62% of the U.S. population is eligible to donate, only 3% will donate blood at least once each year. How many surgeons and anesthesiologists do you know who donate blood? Although shortages of other components may be more problematic for massive trauma transfusions, red cell shortages are most publicized. For trauma, where uncross-matched blood is used commonly, shortage of type O blood is common. In January 2026, the Red Cross declared a critical shortage of type O- blood after a 35% drop in donations over the December 2025 holidays. For trauma, platelet shortages are felt with greatest urgency. Platelets are depleted in major traumatic hemorrhage, and the implementation of “1:1:1” massive transfusion protocols triggers aggressive platelet transfusion, even in the absence of lab-supported thrombocytopenia. Platelet pools are typically prepared from five to six whole-blood donations, so the production is lower. The shorter shelf-life (just seven days) increases loss to wastage. In times of adequate supply, the Red Cross reports that 10%-15% of platelet products are wasted. To stretch limited supplies, some centers are now issuing “half-pools.” Single-donor apheresis platelets are ideal and can be collected from volunteer donors as often as weekly; however, only the most dedicated donors will commit to the two-hour donation time and discomfort from the apheresis machine. Plasma shortages are rare. Fractionated plasma products are produced 1-to-1 from whole-blood donations and can be frozen for up to two years. Plasma is also used five times less often, so shortages are usually limited to smaller facilities where plasma products are not stocked in large volumes. Cryoprecipitate, a plasma-fraction product, is used at some specialty trauma centers to replace fibrinogen. Cryoprecipitate has a higher acquisition cost and must be used within five hours after thaw. Smaller hospital blood banks may not stock it. Shelf-stable fibrinogen products, like RiaSTAP Human Fibrinogen (CSL Behring) or Intercept® Fibrinogen Complex (Cerus), are also an option, although more expensive. Rolling blood product shortages will persist for the foreseeable future. How should the trauma anesthesiologist react? One temptation might be to switch to crystalloid resuscitation, but this should be discouraged given the concern for tissue swelling, renal injury, and coagulopathy. Albumin is also a poor fluid choice due to its high sodium content and enormous price tag, especially when given in liter quantities. Neither crystalloids nor albumin will restore the hemostatic axes if they are altered. Neither fluid transports oxygen. A better approach may be to integrate blood-sparing practices into trauma care. Hemostatic drugs like tranexamic acid and desmopressin may treat some causes of microvascular bleeding. Hypocalcemia should be rigorously avoided, not just treated. Prothrombin complex concentrates are sometimes considered “super-plasma” for trauma patients, although superior hemostasis has not been shown in trauma. Some anesthetic techniques can also be considered. The tolerance of hypotension, such as maintaining a mean arterial pressure >50 or >55 for short periods, may reduce bleeding from highly perfused organs. Ventilation strategies that reduce intrathoracic pressure may also reduce stressed venous pressures in patients with venous bleeding (such as pelvic bleeding). The Trendelenburg position can mimic a leg raise to improve perfusion pressures without transfusion, if situationally appropriate. Unfortunately, there is no avoiding transfusion during hemorrhage. When fractionated products are unavailable, consider cold-stored whole blood. While literature debates the clinical outcomes for fresh-warm and cold-stored whole blood, especially relative to “1:1:1” regimes, whole blood has several logistical advantages. Most hemostatic factors survive processing and storage in proportions to avoid diluting native coagulation mediators (a problem for large-volume resuscitations with fractionated products). Whole blood is easier and cheaper to collect than platelets and has a longer shelf-life – up to 28 days. Unused whole blood can still be fractionated into other blood products, so there is less waste. Low-titer type O whole blood, or LTOWB, is not yet available to all hospitals, but for centers plagued by shortages of fractionated products, it should be considered to alleviate supply problems. Ultimately, practitioners need to adjust to the reality that the blood supply is unstable and that periodic (and unpredictable) shortages have become the status quo. Solutions include diligent blood stewardship, thoughtful transfusion practices, blood-sparing techniques, and supply-chain adaptations, which are essential to maintaining high-quality outcomes for these patients. Disclosure: Dr. Knittel received honoraria from Cerus Corporation.Kevin Blaine, MD, MPH, FASA, ASA Committee on Trauma and Emergency Preparedness, and Associate Professor, University of California, Davis, Sacramento, California.Justin Knittel, MD, Associate Professor of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri.Balbino E. Lopez, MD, Associate Clinical Professor, Department of Anesthesiology and Perioperative Care, University of California, Irvine, Orange, California.Rajen V. Nathwani, MBBS, FRCA, Associate Professor, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington.