Invited Commentary
From Balanced Blood Products to Personalized Medicine in Acute Resuscitation of Trauma Patients
Taylor E. Wallen, John B. Holcomb
JAMA Surg Published Online: March 11, 2026
doi: 10.1001/jamasurg.2026.0195
Resuscitation of patients experiencing hemorrhagic shock has changed tremendously over the last 30 years, moving from crystalloid and red blood cells to balanced components, and now with whole blood (WB) administration gaining favor. Numerous observational studies have evaluated the efficacy and safety of WB compared to component therapy; however, these studies have largely been underpowered and provided conflicting results. Two large ongoing prospective randomized clinical trials of WB vs component therapy will definitively inform this transition (TROOP [Trauma Resuscitation With Low-Titer Group O Whole Blood or Products] and TOWAR [Type O Whole Blood and Assessment of Age During Prehospital Resuscitation Trial]).1 We would like to congratulate Ibrahim and colleagues2 on their updated systematic review and meta-analysis investigating the mortality benefit of WB over component therapy.
Ibrahim and colleagues2 analyzed 40 publications and found that WB administration reduced 24-hour mortality by 27% within civilian trauma patients, with an absolute risk reduction of 4.6%. Although a difference in mortality was identified within civilian trauma patients, a significant difference within the military setting was not appreciated.2 While the data do trend toward supporting WB administration, the authors conclude that due to significant patient heterogeneity, WB should be selectively administered based on clinical setting and patient presentation. Although the retrospective and observational data examined in this study are compelling, they have many unmeasured confounding factors that may impact the significance of the overall result. This is even more true regarding the military data examined, given that they come from the battlefield and use a walking blood bank, which differs from the cold-stored WB used within civilian settings.2 It is interesting that the pendulum swing toward WB comes from the military experience, yet the authors’ analytic technique did not show a significant difference.3,4
In our opinion, the more important question raised by this evolution of resuscitation practice is how we can tailor treatment based on the individual patient presenting to the trauma bay. We know that one size does not fit all, yet we treat all traumatically injured patients the same regardless of sex, age, mechanism of injury, or genetic profile. Current investigation into the development of a “patient-specific precision injury signature” is underway, helping to elaborate on how mechanical tissue damage, cumulative hypoperfusion, immunologic response, and demographics will guide selection of resuscitation products and surgical intervention and predict postprocedural outcomes.5 Further, there has been continued investigation into the underlying metabolic and genetic profiles of traumatically injured patients and how initial interventions should be tailored based on these findings.6,7
As we continue to discover robust, timely, and practical techniques for patient biologic profiling, coupled with appropriate research and individualized patient interventions, we believe that significant improvements in the outcome of patients with traumatic injury will occur. All other medical specialties are moving toward precision medicine—it is time we care for the traumatically injured precisely as well.
