Page 91 - JSOM Winter 2019

IgG. There is no universally dedicated “safe” titer of anti-A is to optimally resuscitate casualties prior to their arrival at a
2
and anti-B antibodies, so the 1:256 dilution was implemented Role 2 and therefore improve outcome. DCR should not delay
as policy by the Ranger-O-low titer (ROLO) protocol. Use transport of casualty to definitive surgical care.
2
of LTOWB minimizes the risk of hemolytic transfusion reac-
tions, and it can be therefore considered “universal WB.” The Current Use in US SOF
ASBP only supplies LTOWB to OCONUS units for use as it
decreases the risk of severe transfusion reactions. The US To mitigate the challenges of WB delivery, US SOF have im-
1,3
Army has relied on LTOWB to treat casualties in World War plemented various measures to ensure optimal donor pool,
II, Korea, and Vietnam, and it has resurged in OEF, OIF, and awareness/education among medics and specialized equipment
Operation Inherent Resolve. 1–4 for tactical methods of blood-carry and delivery. In general,
steps taken include:
WB contains red blood cells (RBCs), plasma, and platelets.
CONUS medical centers split donor blood into these compo- 1. Prior to deployment, unit soldiers are screened for blood
nents in order to preserve storage longevity (e.g., plasma can type and titers to establish a large donor pool. Support Sol-
be frozen and stored for up to a year, but freezing platelets diers have been found to be particularly beneficial donors
would destroy them ), target therapy (some medical patients as they typically are in closer proximity to the blood sup-
1,5
may need only platelets rather than WB), and minimize trans- port detachment. 4,10
fusion reactions. While component therapy is practical for This list is kept on hand by the unit surgeon so donors
most CONUS medical center use, it creates several disadvan- may be called upon to donate at the blood support detach-
tages when relied on in an operational setting. ment when supply is running low. Additionally, in larger
units or in emergent situations, it can be used to initiate a
WBB.
Advantages
Units of SWB are then ordered and pushed to SOF out-
Clinical data from nearly 2 decades of war during OIF and stations, which are often colocated with either a Role 2 or
OEF suggest that WB is both safe and effective compared with Role 3 facility. Colocation with a Role 2 allows for utiliza-
component therapy and far superior to crystalloid and colloid tion of existing medical supply routes and product storage
resuscitation fluids. 1,6–8 WB has been shown to be as effective as in a dedicated blood refrigerator. Once SWB units are allo-
component therapy in resuscitating trauma patients and may cated for the mission, team medics retrieve the SWB units
actually improve survival. 1,6,7 CONUS medical centers resusci- from the Role 2.
tate trauma patients using component therapy in a 1:1:1 ratio 2. In units that operate in smaller teams, medics are outfitted
of RBCs, plasma, and platelets. On the battlefield, thawing with “blood kits” to carry blood on missions for point of
plasma and managing multiple infusion bags with potentially injury transfusion. Using the prolonged field care frame-
limited vascular access are impractical. WB allows prehospital work (ruck, truck, house) as a template, medics now use
medical providers to infuse a single resuscitative product that different methods to store and transport the SWB depend-
provides all of the critical components to address both oxygen ing on phase. Medic “truck” and “house” kits include
debt and coagulopathy and requires minimal preparation be- the Dometic CFX powered coolers that run on AC, DC,
™
fore the casualty reaches a surgeon. Additionally, in emergency or solar power and allow for constant temperature mon-
situations, Soldiers themselves can act as the transport vessel itoring. When on foot, medics carry tactical blood cool-
for the product via WBB. ers including the Pelican Biomedical Medic 4 or Combat
™
Medical Blood Box along with a Belmont Buddy-Lite IV
™
™
Many Operators now incorporate freeze-dried plasma (FDP) infusion warmer and IV administration kit with standard
into their trauma care algorithms, and it has become a valu- micron filter. In units with larger teams, donors are identi-
able tool for battlefield resuscitation. However, current proto- fied on missions and deliver FWB in the event of casualties. 2
cols still recommend FDP be used only if WB is not available. 2,9 3. Medics receive a WB transfusion refresher tabletop exercise
and review after-action reviews from previous rotations.
Additionally, prehospital WB delivery is a required com-
Limitations
ponent of scenario-based premission training. The expec-
Given the limited shelf-life of 21 to 35 days, WB requires a tation is that medics will administer WB on missions when
constant steady pool of donors. Additionally, identifying and tactically feasible.
tracking LTOWB donors limit the number of Soldiers eligible
to donate and may require repeated testing. Soldiers should Way Forward and Conclusion
not donate more often than every 56 days and may need to be
on limited duty in the days following a donation. Additionally, Utilization of LTOWB as a universal blood product shattered
blood titers can change over time and donors should intermit- preexisting medical practice, and much of its implementation
tently be retested for titer level, which can prove difficult when in SOF can be attributed to the ROLO program. Presently,
2
Soldiers are in austere environments (although in the absence SOF medics have the donor support, logistical framework,
of receiving blood products, most individuals trend to remain training, and equipment to deliver WB at the point of injury.
low titer). The cold-chain requirement for storage also poses However, widespread implementation has yet to occur. Adop-
challenges for SOF on long missions without access to blood tion of WB at the point of injury as a standard expectation will
refrigerators. SOF operating in less-developed theaters face require expanded distribution and standardization of “blood
additional logistical challenges. kits.” Additionally, SOF medical planners must put greater
emphasis on education and the importance of WB over crys-
It is important to note that WB will never substitute for defin- talloids or colloids—as many medics continue to carry only
itive surgical hemorrhage control. The role of WB transfusion these products out of convenience.

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