Page 131 - JSOM Winter 2021

to an administrative or blood typing error. Type-specific response on the mission. Further, the use of Eldon cards to de-
blood has been used as a source of fresh whole blood termine blood type was found by Bienek and Perez in 2013 to
on forward surgical teams embarked on naval surface be only 80% accurate when compared to the ABO group in the
49
combatant vessels. A recent case series described the use subjects’ medical record. The subjects in this study included
of 39 units of type-specific whole blood during a mass physicians, corpsmen, and medical service corps officers.
casualty event on the USS Bataan. 37
The use of a prescreened type O low-titer donor pool also min-
imizes the risk for a reaction to high anti-A and anti-B anti-
Cold-Stored Low-Titer Group O Whole Blood body titers by eliminating those type O individuals with high
Following US military implementation of a cold-stored whole titers from the donor pool during the predeployment screening
blood program, several US civilian trauma centers and pre- process. 11
hospital providers began incorporating CS-LTOWB into their
38
respective trauma resuscitation protocols. Williams et al. re-
ported a decrease in post-emergency department blood prod- Prehospital Considerations
Several factors must be considered in developing pre hospital
uct utilization and two-fold increased likelihood of survival fluid resuscitation strategies for casualties in hemorrhagic
with CS-LTOWB when controlling for age and severity of in- shock, including the fact that medics and corpsmen will deliver
jury. In a separate prospective observational study, Duchesne the preponderance of medical care in the tactical environment.
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et al. evaluated trauma patients receiving whole blood as part CS-LTOWB is the safest option as an FDA-complaint univer-
of their initial emergency department resuscitation. They sal blood product, but it requires significant logistical support
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found that CS-LTOWB patients received significantly fewer for cold chain requirements. This requirement may make the
PRBCs and FFP during hospitalization. They also observed use of cold stored whole blood and blood components (plasma
a decreased incidence of ARDS, but contrary to Williams et and RBCs) infeasible in some tactical settings.
al, found no survival benefit in those receiving CS-LTOWB.
40
A third recently published study again found no difference in Where cold chain storage cannot be maintained, freeze dried
24-hour or 30-day mortality between groups receiving compo- plasma and fresh whole blood remain reasonable options for
41
nent therapy or CS-LTOWB. Importantly, the studies men- fluid resuscitation. While the FDA Emergency Use Authoriza-
tioned previously have thus far demonstrated no increased rate tion remains in place for the French freeze-dried plasma prod-
of complications in comparison to component therapy in the uct (FLyP), the producer has not yet increased the supply of
civilian trauma setting. Furthermore, the use of CS-LTOWB FLyP to quantities sufficient to meet US military demand. Mil-
has recently expanded to the fields of obstetrics and pediat- itary logistics systems are therefore not able to reliably supply
ric trauma. 42–44 With increased adoption in the civilian trauma this product to combat units.
setting as well as in other medical specialties, a greater base of If units decide to implement prescreened fresh LTOWB as an
knowledge and evidence regarding the use of CS-LOTWB is option, formal training and education on the safe collection
already developing.
and utilization of fresh whole blood must be implemented.
As noted previously, both safety considerations and DoD Donham et al. addressed prior concerns that fresh whole blood
policy make CS-LTOWB the option of choice when logistic training was excessively high risk for operational units, and
considerations make that a feasible choice. This option also published experiences with over 3,400 autotransfusion cases
eliminates the time delay caused by the need to draw a unit of with no anaphylactic or hemolytic reactions in the training
fresh whole blood from a member of the donor pool. Finally, environment. Similarly, the Ranger O Low Titer, Special Op-
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it avoids having to take blood from a combatant who is still on erations O Low Titer, Naval Special Warfare Special Opera-
the battlefield and could possibly be wounded during ongoing tions Tactical Medic Course and Marine Corps Valkyrie Fresh
combat action. 5 Whole Blood training programs have developed curricula with
didactic and practical exercises to successfully support this
Fresh Whole Blood emerging capability.
Experience during Operation Enduring Freedom and Opera-
tion Iraqi Freedom has demonstrated that FWB is safe and (2) Should crystalloid solutions and Hextend be
that outcomes after FWB administration are equivalent, if not removed as TCCC-recommended fluids for resuscitation
superior, to outcomes following component therapy. 30,31,45 of casualties in hemorrhagic shock?
Risks associated with the use of FWB include transfusion- Hextend and Other Hetastarches (HESs)
transmittable infections and the potential for acute hemolytic There are significant variations in the composition and prop-
reactions due to ABO mismatch. The risk, however, has thus erties of HESs. The different HES products are commonly
far been very low. Recent data encompassing approximately described by their weight-averaged molecular weight. The
10,000 FWB transfusions to US personnel during OIF/OEF physiologic effects of hetastarch solutions may vary depend-
have resulted in one hepatitis C (HCV) infection, one human ing on both the type of hetastarch molecule, the concen-
T-lymphocyte virus (HTLV) seroconversion, and one fatal case tration of the solution, the diluent fluid, and the volume of
of transfusion-associated graft-versus-host disease that was fluid infused. Hextend (6% HES in physiological solution)
potentially due to an FWB transfusion. 46–48 is a physiologically balanced, first-generation, high-molecu-
lar-weight HES preparation that was included in prior TCCC
In the prehospital setting, a structured approach such as the 51,52
Ranger Type O Low (ROLO) or Marine Corps Valkyrie pro- recommendations.
gram 11,13 minimizes the chance of an ABO mismatch by clearly The 2013 Zarachanski study found that hetastarches admin-
identifying the LTOWB donor pool before the unit leaves for istered to critically ill patients did not improve survival and
combat operations, rather than having to take the time to test resulted in an increased risk of acute kidney injury. 25,53 The
potential donors with Eldon cards in the midst of a casualty authors of the Zarychanski study recommended against the

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