BLOOD USE IN THE ARSC ENVIRONMENT

Blood is a resource that cannot be improvised and must be communicated to operational leadership as a mission critical requirement. Logistical factors with the ARSC team has to be considered even more so than at the Role 2 or Role 3. ARSC teams do not have dedicated personnel to manage the blood supply, storage, temperature regulation, accounting and resupply. Blood supply and resupply must be considered early and often. This is often managed through medical operations channels and requires close coordination with the combatant command blood program and regional blood logistic process. Maintaining stored blood products within a narrow temperature range and subsequently warming them in a timely manner are two of the greatest challenges of austere trauma medicine.13,50 In an unstable and critically ill combat casualty, early balanced blood resuscitation (ideally whole blood) has been clearly shown to improve 72-hour mortality.4,13,76-79 ARSC teams must anticipate blood requirements, work with the theater blood program manager to meet those requirements, plan for their own walking blood bank, and prepare for contingencies.13,58

Fresh Whole Blood (FWB) use in the combat casualty setting is associated with improved survival when compared to administration of packed red blood cells (PRBCs) and fresh frozen plasma (FFP) alone.80 FWB eliminates the need for blood cooling, storage, and rewarming equipment, but carries increased risk of transmissible disease, and FWB donors may be limited in some operational environments. It is recommended, and will be doctrinal in an upcoming DoD Instruction, that anti-A and anti-B titer levels be drawn on all deploying personnel with type O blood in addition to FDA recommended infectious disease testing. This strategy provides a constant blood donor pool for contingencies. For U.S. casualties, FWB donors should be U.S. personnel, rarely from coalition, and from local nationals only in the most extreme cases. See the JTS Whole Blood Transfusion CPG, 15 May 2018 for detailed guidance.81 Point of care testing for some transmittable diseases exist (e.g., human immunodeficiency virus), but the required time for interpretation may be prohibitive in patients in severe hemorrhagic shock. Have a plan in place for patients and donors who test positive for such diseases, and recognize that there may be significant cultural implications with local nationals and partner nation forces who test positive for such diseases.

The need to remain light and mobile further increases the challenge of retaining an adequate supply of blood products for mission support.50 Portable battery-operated blood refrigerators and freezers are available (e.g. HemaCool®) but require mobility platforms to move over long distances and mechanical failures in hot and dusty environments may occur. Refrigerators and freezers require a constant and reliable power source, further increasing the team’s weight and footprint and reducing maneuverability. Mission requirements for increased mobility may limit the size and number of refrigeration equipment and thus blood availability,13 and vice versa.

RBC and frozen plasma are readily available at Role 2, Role 3 and at ARSC teams, but supply of platelet components are limited despite increasing use of cold stored platelets. Stored LTOWB and never-frozen liquid plasma are increasingly available via the ASBP theater blood distribution system. Freeze-Dried Plasma may be available for some ARSC missions supporting SOF. Options for acquiring blood outside official supply and resupply channels include walking blood bank drives (requires blood typing capability such as Eldon cards as well as citrate bags) and blood from the local “economy” such as local hospitals for use on host nation casualties should be considered when appropriate. Inform the theater JBPO if considering local host nation supply of blood products.

BLOOD WARMING

Conventional warming techniques for blood transfusion such as the Belmont® Rapid Infuser or plasma thawing devices draw significant power requirements and may be unavailable in the austere setting. Battery operated, in-line products are easily packed, however flow rates are inversely proportional to infusion temperature and may be inadequate for the trauma patient in severe hemorrhagic shock. Plasma thawing devices may be available in some equipment sets, but may not be suitable for small/highly mobile surgical teams or in the ARSC environment. There is no light, portable, approved plasma-thawing device. Portable water heaters and thermometers can be used to create a 30-37oC bath of water to thaw FFP and warm PRBCs to the appropriate temperature of 37oC; however, they are not FDA approved for this use. Approximately 10 percent of FFP bags may break during thawing and this should be factored into the supply. Pre-thawing frozen plasma saves time in the acute setting but once thawed, plasma must be used within 5 days.

WALKING BLOOD BANK

Every ARSC team member must be trained to draw and transfuse fresh whole blood, and must be able to recognize and manage transfusion reactions. Recruitment and blood typing of potential blood donors may take time, so early initiation of walking blood bank is recommended for patients with the suspected need for massive transfusion. Fresh whole blood transfusion must be type-specific, unless the donor has been pre-designated low-titer type O by laboratory testing. All low-titer type O donors must provide documentation of titer-testing prior to donation. See the JTS Whole Blood Transfusion CPG, 15 May 2018.81 Standard equipment sets should contain blood drawing kits. Ensure that Eldon cards and point-of-care infectious disease testing kits are available and team members are trained on their use. Ensure a reliable system for marking and numbering: 1) individual donors, 2) blood donor bags, and 3) Eldon cards.