Page 19 - JSOM Spring 2018

Military Prehospital Use of Low Titer Group O Whole Blood

Nicholas Warner ; Jackson Zheng ; Greg Nix, MPAS, APA-C ;
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Andrew D. Fisher, MPAS, PA-C, MS-2 *; Jeffery C. Johnson, MD, FACS ;
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John E. Williams, CRNA ; D. Marc Northern, MD ; John S. Hellums, MD, MPH 8
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ABSTRACT
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The military’s use of whole-blood transfusions is not new but the list of preferred resuscitation fluids. To adhere to these
has recently received new emphasis by the Tactical Combat guidelines, the 75th Ranger Regiment (75RR), in conjunc-
Casualty Care Committee. US Army units are implementing tion with the US Army Institute of Surgical Research and the
a systematic approach to obtain and use whole blood on the Armed Services Blood Program (ASBP) developed the Ranger
battlefield. This case report reviews the care of the first patient Group O Low-Titer (ROLO) Fresh Whole Blood (FWB) Pro-
to receive low titer group O whole blood (LTOWB) transfu- gram. This program identifies all group O members of the unit
sion, using a new protocol. and then tests them to determine possible donors with anti-A
and anti-B immunoglobulin (Ig) M titer levels less than 256. 4
Keywords: blood transfusion; group O whole blood; Tactical
Combat Casualty Care Previous research and publications have demonstrated that
WB with low anti-A and anti-B IgM titers support a low to
negligible risk of a catastrophic acute hemolytic transfusion
reaction when given to individuals not of the same blood
Introduction
group. 1,2,5 Kendrick noted from the Korean War, “The practice
Group O whole blood (WB) was first described as the universal of using O blood for massive transfusions of non-O recipients
donor in 1911. There were few uses of it during World War I, did not seem harmful provided that so-called dangerous uni-
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but during World War II (WWII), the majority of transfusions versal donors were avoided. These donors, who are extremely
were of group O WB. However, one Soldier received 50mL of uncommon, have plasma that contains a high titer of anti-A
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group O WB, with IgM anti-A titer of 8000, which resulted in antibodies, which can produce an unmistakable hemolytic
a severe reaction, so the US Army moved to change its policy. transfusion reaction, with all the signs associated with major
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This policy, enacted late in WWII, determined group O low- incompatibility.” There is no accepted international standard
titer WB as titers of anti-A and anti-B of less than 250. This of “low” titer; for example, the Norwegian Naval Special Op-
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policy carried forward into the Korean War, during which erations Command uses IgM and IgG titers of 100 and 400,
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there were more than 400,000 units of LTOWB transfused. 1 respectively. Following the example of blood programs from
WWII and the Korean War, the 75RR chose to define group O
The US military has used WB in every conflict since the early low titer as IgM titers less than 256.
20th century; however, starting with Vietnam, the use of crys-
talloid solutions became synonymous with resuscitation. It has The use of group O low-titer donors eliminates steps and the
been late in the recent conflicts in Afghanistan and Iraq that possibility of incorrectly misinterpreting group-specific donors
WB has seen its resurgence. The reappearance of WB in com- in the blood transfusion process, which may cause an acute he-
bat and at the point of injury can be found in the Committee molytic transfusion reaction. In addition, the ASBP also tests
on Tactical Combat Casualty Care guidelines, where WB tops these individuals for transfusion-transmitted diseases. With
*Address correspondence to andrew.d.fisher.mil@mail.mil
1 SGT Warner is currently serving as a SOCM-qualified company medic in 2nd Battalion, 75th Ranger Regiment. He holds a bachelor's degree
in biology and is a licensed paramedic. He has served two deployments with Regiment in support of the War on Terror. Mr Zheng is currently
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a paramedic, pursuing a BSN. He was previously assigned to 2nd Battalion, 75th Ranger Regiment, where he was a Special Operations Combat
Medic. CPT Nix is a physician assistant assigned to Joint Special Operations Command. He is a graduate of the Interservice Physician Assistant
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Program and the Special Operations Combat Medic course and a former Ranger Medic assigned to 1st Battalion, 75th Ranger Regiment. MAJ
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Fisher is a second-year medical student at Texas A&M College of Medicine and a physician assistant in the Texas National Guard. He was pre-
viously the regimental physician assistant assigned to the 75th Ranger Regiment. CDR Johnson is currently assigned to Naval Medical Center
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Portsmouth as a staff cardiothoracic surgeon, serving on numerous committees, and currently serving as the department head of cardiothoracic
surgery. He is a graduate from The University of Texas Medical School at Houston and Vanderbilt University Medical Center. In 2015, he was
selected to serve with the JSOC and has deployed in support of the JSOC. LTC Wilson Jr, AN, USA, is an instructor at the Army Trauma Train-
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ing Detachment in Miami, FL. Previously, he served as chief CRNA at Brooke Army Medical Center in San Antonio, TX. Additionally, LTC
Wilson worked closely with USSOC. He is a 2008 graduate of the US Army Graduate Program in Anesthesia Nursing, which was affiliated with
University of Texas Health Services in Houston, TX. Maj Northern is a general surgeon assigned to Air Force Special Operations as a part of a
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Special Operations Surgical Team, assigned to Hurlburt Field, FL. LTC Hellums, MC, USA, is the brigade surgeon for the 101st Combat Avia-
tion Brigade in Fort Campbell, KY. Prior to this assignment, he served as the Battalion Surgeon with 5th Special Forces Group (Airborne), a staff
physician at Blanchfield Army Community Hospital, and with JSOC.
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