Page 76 - JSOM Spring 2023

Approach to Handling
Atypical Field Blood Transfusion Scenarios

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Richard Neading ; Tyler Scarborough ; Michael O’Connell ; John Leasiolagi ;
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Mark Little ; John Burgess ; Maxwell Hargrove, PA-C ; Amelia Goodfellow, MD ;
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Christopher J. Scheiber, MD *; Andrew Cap, MD, PhD ; Mark H. Yazer, MD 10
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ABSTRACT
Special Operations Forces (SOF) medical personnel have been In a civilian hospital, the practice is to stop the infusion at the
at the forefront of administering blood products in the austere first sign of a reaction. This practice minimizes the potential
field medicine environment. These far-forward medical pro- risk to the patient from allowing the transfusion to proceed.
viders regularly treat patients and deliver blood transfusions in This assumes another unit of blood is readily available, which
some of the world’s most extreme environments with minimal is not always true in the field environment. Furthermore, many
resources. A multitude of questions have been raised on this field transfusions are rapidly administered and so a reaction
topic based on the unique experiences of senior providers in may not be recognized until after the infusion is complete. The
this field. In this paper, we analyze the available literature and advice below is offered in the event that a transfusion is ad-
present the recommendations of several experts in transfusion ministered slowly, and the patient’s circumstance permits time
medicine for managing atypical field transfusion scenarios. to consider the differential diagnosis of their signs and symp-
toms. Most transfusion reactions are mild and will resolve on
Keywords: low titer O whole blood; field medicine; transfu- their own or with the administration of benign medications.
sion reactions; blood products Thus, in the setting of an unstable, exsanguinating patient
who is demonstrating signs or symptoms of a reaction, the
life- saving transfusion should continue unless it becomes clear
that the reaction itself is life-threatening.
Introduction
Within the past several years, the medical personnel of the Allergic reactions are quite common (1:100 transfusions) and
Special Operations Forces (SOF) have been on the forefront are typically mild, however, they can also be life threatening.
of administering blood products in the austere field medicine Additionally, the severity of the reaction can be difficult to as-
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environment. The procedures for field transfusion collection certain at its onset. Table 1 presents some of the common signs
and administration are specified in the clinical practice guide- and symptoms of an allergic reaction. Detecting a mild allergic
lines (CPGs). However, as a result of the rare and unique sit- reaction in which the patient has a rash and stable vital signs
uations experienced by senior medics several questions have (especially the blood pressure and oxygen saturation) should
been raised about circumstances that relate to transfusions not prompt the discontinuation of the transfusion. Rather, the
that extend beyond these CPGs. In this manuscript, guidance transfusion should be paused, and if feasible, antihistamines ad-
is provided for these challenging situations, based on the avail- ministered if available. Once the signs and symptoms of the re-
able evidence and expert opinion as appropriate, in order to action begin to dissipate, the transfusion may be restarted. Table
provide options for the field medic. 2 provides some guidance on how to manage these reactions.
The most important calculus when dealing with an allergic
Transfusion Reactions reaction is how urgently the patient requires the transfusion
Although relatively uncommon, adverse events caused by the versus the risk that the patient is experiencing a life-threaten-
transfused blood product themselves (transfusion reactions) ing reaction. Classically, severe allergic or anaphylactic reac-
can occur with manifestations ranging from benign rash to tions tend to occur immediately and the patient experiences
life-threatening shock. With complex, unstable patients, it is severe hypotension. Thus, if the patient manifests a rash, pru-
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not always possible to definitively ascribe the etiology of the ritis, or localized angioedema but no hypoxia or hemodynamic
patient’s change in condition to the transfused blood products, instability, it would be appropriate to administer antihistamine
but reactions should be in the differential diagnosis along with medications and continue with the transfusion. One should
the medications administered and the patient’s underlying pay closer attention to the patient’s vital signs and breathing in
condition. order to quickly intervene if the reaction progresses in severity.
*Correspondence to cscheiber1107@gmail.com
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1 SCPO Richard Neading, HM1 Michael O’Connell, CPO John Burgess, and LT Amelia Goodfellow are all affiliated with the 2d Marine Raider
Battalion, Marine Forces Special Operations Command (MARSOC), Camp Lejeune, NC. SCPO Tyler Scarborough is affiliated with the 4th Ma-
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rine Reconnaissance Battalion, San Antonio, TX. SCPO John Leasiolagi is affiliated with the Joint Special Operations Medical Training Center,
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Fort Bragg, NC. MCPO Mark Little is affiliated with the Marine Raider Regiment, Marine Forces Special Operations Command (MARSOC),
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Camp Lejeune, NC, 28542. LTJG Maxwell Hargrove is affiliated with the 1st Marine Raider Battalion, Marine Forces Special Operations Com-
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mand (MARSOC), Camp Lejeune, NC, 28542. Dr Christopher Scheiber is affiliated with the Department of Anesthesiology, University of North
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Carolina at Chapel Hill, Chapel Hill, NC. COL Andrew Cap is affiliated with the US Army Institute of Surgical Research, Fort Sam Houston,
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TX. Dr Mark H. Yazer is affiliated with the Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA.
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