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well as a better ability to shut down the thrombin generation 5. Monroe DM, Hoffman M. What does it take to make the perfect
once started. clot? Arterioscler Thromb Vasc Biol. 2006;26(1):41–48.
6. White NJ, Ward KR, Pati S, et al. Hemorrhagic blood failure: oxy-
gen debt, coagulopathy, and endothelial damage. J Trauma Acute
Final Recommendations Care Surg. 2017;82(6S Suppl 1):S41–S49.
7. Bjerkvig CK, Strandenes G, Eliassen HS, et al. “Blood failure”
It should be remembered at this stage that a transfusion proce- time to view blood as an organ: how oxygen debt contributes
dure between comrades must never delay the evacuation of the to blood failure and its implications for remote damage control
injured person to the operating theater if a rapid evacuation resuscitation. Transfusion. 2016;56(Suppl 2):S182–189.
is possible. Depending on the delay, it may also be possible 8. Shackelford SA, Del Junco DJ, Powell-Dunford N, et al. Associ-
to collect blood in the field and give it to the injured person ation of prehospital blood product transfusion during medical
during transport. Similarly, other lifesaving interventions evacuation of combat casualties in Afghanistan with acute and
30-day survival. JAMA. 2017;318(16):1581–1591.
should continue to be performed as soon as possible (stopping 9. Pusateri AE, Moore EE, Moore HB, et al. Association of prehos-
external bleeding, tranexamic acid, etc.). pital plasma transfusion with survival in trauma patients with
hemorrhagic shock when transport times are longer than 20 min-
During blood donation, a point of attention should be the fill- utes: a post hoc analysis of the PAMPer and COMBAT clinical
ing of the blood bag. The donation should be stopped when trials. JAMA Surg. 2020;155(2):e195085.
the bag is filled with 420 to 500mL of blood. If the bag is un- 10. Martinaud C, Scorer T, Lozano M, et al. International forum on
walking blood bank programmes: summary. Vox Sang. 2021;116
derfilled (<300mL, approximately 15% incidence in a large US (8):924–929.
28
series), the blood bag should not be administered. The citrate 11. Oh JY, Marques MB, Xu X et al. Damage to red blood cells during
anticoagulant concentration in the bag would then be too high whole blood storage. J Trauma Acute Care Surg. 2020;89(2):
and thus deleterious. Operators must be therefore trained to 344–350.
recognize the correct filling of the bag. A technique described 12. Shah A, Brunskill SJ, Desborough MJ, et al. Transfusion of red
by Meledeo et al. can be used on the battlefield. It consists in blood cells stored for shorter versus longer duration for all condi-
tions. Cochrane Database Syst Rev. 2018;12:CD010801.
constricting the center of the blood bag by a cord at a 6.5-inch 13. Spinella PC, Perkins JG, Grathwohl KW, et al. Warm fresh whole
circumference. This method is efficient, and reliable for con- blood is independently associated with improved survival for pa-
29
trolling the collection volume in austere environment. tients with combat-related traumatic injuries. J Trauma. 2009;66
(4 Suppl):S69–S76.
Another point of attention must be hypocalcemia. This can be 14. Crowe E, DeSantis SM, Bonnette A, et al. Whole blood transfu-
accelerated by the anticoagulants and preservative solutions sion versus component therapy in trauma resuscitation: a system-
contained in the blood-collection bags. In trauma, low calcium atic review and meta-analysis. J Am Coll Emerg Physicians Open.
2020;1(4):633–641.
levels on admission are associated with both increased mor- 15. Drew B, Montgomery HR, Butler FK. Tactical Combat Casualty
tality and increased need for transfusion. 30,31 Calcium supple- Care (TCCC) guidelines for medical personnel: 05 November
mentation is necessary as early as the prehospital phase and 2020. J Spec Oper Med. 2020;20(4):144–151.
should be protocolized in advance. The Joint Trauma System 16. Martinaud C, Travers S, Pasquier P, et al. Blood far forward pro-
recommends the administration of 1g of calcium with the first gram: update on French armed forces policy. Transfusion. 2021;
61(Suppl 1):S354–S355.
unit of blood product and to re-dose 1g of calcium after every 17. Eliassen HS, Hervig T, Backlund S, et al. Immediate effects of
4 units of blood products. 1 blood donation on physical and cognitive performance—a ran-
domized controlled double-blinded trial. J Trauma Acute Care
Surg. 2018;84(6S Suppl 1):S125–S131.
Conclusion 18. Morand C, Rolland C, Coudurier N, et al. Prévention des malaises
WB donation between comrades on the battlefield is a truly en don de sang total: étude randomisée par cluster pour évaluer
lifesaving procedure that must be implemented and taught l’éfficacité d’une hydratation par solution isotonique ou par de
l’eau avec ou sans exercices de tension musculaire: EVASION.
within units called upon to conduct military operations in Transfus Clin Biol. 2015;22(4):189.
remote settings. The risks inherent to this procedure can be 19. Fisher SA, Allen D, Dorée C, et al. Interventions to reduce vaso-
controlled by the rigor of the medical teams, their training, and vagal reactions in blood donors: a systematic review and meta-
the scrupulous oversight of previously validated procedures. analysis. Transfus Med. 2016;26(1):15–33.
20. Daurat G. Oui, il faut conserver le test d’agglutination ABO dans
Author Contributions le contrôle ultime au lit du malade [Yes, we should keep ABO ag-
YD drafted the manuscript. CD, PM, ST, and CM carefully glutination test within bedside transfusion checks]. Transfus Clin
Biol. 2008;15(5):322–326.
revised the manuscript. 21. Strandenes G, Berséus O, Cap AP, et al. Low titer group O whole
blood in emergency situations. Shock. 2014;41(Suppl 1):70–75.
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48 | JSOM Volume 22, Edition 4 / Winter 2022