Page 74 - JSOM Spring 2025

given immediately to the casualty or re-infused into the do- References
38
nor).” However, a closer look at regulation source docu- 1. Howard JT, Kotwal RS, Stern CA, et al. Use of combat casualty
ments reveals an alternative option. care data to assess the US military trauma system during the Af-
ghanistan and Iraq conflicts, 2001–2017. JAMA Surg. 2019;154
(7):600–508. doi:10.1001/jamasurg.2019.0151
Fine print in the JTS CPG for whole blood transfusion (CPG 2. Kellerman A, Elster E, Babington C, Harris R, eds. Out of the
ID: 21) gives the caveat, “If placed into refrigerated storage Crucible: How the US Military Transformed Combat Casualty
within 8 hours of collection, the unit may be stored for 21 or Care in Iraq and Afghanistan. Borden Institute; 2017.
35 days depending on the anticoagulant used. Joint Blood Pro- 3. Remondelli MH, Remick KN, Shackelford SA, et al. Casualty
gram Office approval is required for storage of whole blood care implications of large-scale combat operations. J Trauma
units for longer than 24 hours.” Although walking blood Acute Care Surg. 2023;95(2 Suppl 1):S180–S184. doi:10.1097/
8
TA.0000000000004063
banks are typically used reactively, there may be value in us- 4. Gurney J, Pamplin J, Remondelli M, et al. The “Survival Chain”:
ing available donors to pre-emptively stockpile WB. As previ- medical support to military operations on the future battlefield.
ously mentioned, early transfusion appears to correlate with Joint Force Quarterly. 2024;112:94–99.
improved survival, so having WB immediately available would 5. Keenan S, Riesberg JC. Prolonged field care: beyond the “golden
facilitate prompt transfusion at the point of injury or in for- hour.” Wilderness Environ Med. 2017;28 (2S):S135–S139. doi:10.
1016/j.wem.2017.02.001
ward medical facilities. 30,31 A stockpiling approach would also 6. Epstein A, Lim R, Johannigman J, et al. Putting medical boots
give donors a longer recovery period ahead of a large military on the ground: lessons from the war in Ukraine and applications
operation to improve combat effectiveness. When properly for future conflict with near-peer adversaries. J Am Coll Surg.
stored at 1–6°C, WB collected in this manner should be safe 2023;237(2):364–373. doi:10.1097/XCS.0000000000000707
and effective for the shelf life associated with the given anti- 7. Voller MJ, Tobin CJM, Denoyer HM, et al. CPG 82: Prehospital
coagulant (21 d for CPD or 35 d for CPDA-1). The standard Blood Transfusion. Joint Trauma System; 2020.
requirements of using pre-screened donors and performing 8. Beckett LA, Benov MA, Borgman LM, et al. CPG 21: Whole
Blood Transfusion. Joint Trauma System; 2018.
pathogen testing, when possible, still apply. 9. Hess JR. Measures of stored red blood cell quality. Vox Sang.
2014;107(1):1–9. doi:10.1111/vox.12130
10. Association for the Advancement of Blood & Biotherapies. Stan-
Conclusion dards for Blood Banks and Transfusion Services. 33rd ed. AABB
Press; 2022.
A retrospective review of military casualty data showed that 11. U.S. Food and Drug Administration. Exceptions and alternative
transport to definitive care within the golden hour reduced procedures approved under 21 CFR 640.120(a). Updated May
39
mortality rates by 39%. Meanwhile, patients who appro- 12, 2023. Accessed November 17, 2024. https://www.fda.gov/
priately received a prehospital blood transfusion had an 83% vaccines-blood-biologics/regulation-blood-supply/exceptions-
lower mortality rate compared to those who needed blood and-alternative-procedures-approved-under-21-cfr-640120
when none was available. In an LSCO against a near-peer ad- 12. Hess JR. Scientific problems in the regulation of red blood cell
40
versary, casualty movement will be restricted, and the golden products. Transfusion. 2012;52(8):1827–1835. doi:10.1111/j.1537-
2995.2011.03511.x
hour may be impossible. For casualties who need blood, start- 13. U.S. Food and Drug Administration. 610.53 Dating periods for
ing transfusion early will be crucial; however, blood products whole blood and blood components. 21 CFR Part 610 – Gen
may need to navigate enemy-controlled airspace and endure Biol Prod Stand. Published May 4, 2016. Accessed Novem-
degraded storage conditions before reaching the patient. Un- ber 15, 2024. https://www.ecfr.gov/current/title-21/chapter-I/
der these circumstances, the only available blood may exceed subchapter-F/part-610/subpart-F/section-610.53
the recommended storage duration or temperature limits. 14. Riley BC, Stansbury LG, Roubik DJ, Hasan RA, Hess JR. Inten-
tional transfusion of expired blood products. Transfusion. 2024;
While a preemptive walking blood bank may prove useful, 64(4):733–741. doi:10.1111/trf.17754
providers should also be aware that blood storage regulations 15. Pulliam KE, Joseph B, Veile RA, et al. Expired but not yet
have a conservative safety margin, and modest deviations may dead: examining the red blood cell storage lesion in extended-
be clinically appropriate. storage whole blood. Shock. 2021;55(4):526–535. doi:10.1097/
SHK.0000000000001646
16. Meledeo MA, Peltier GC, McIntosh CS, Bynum JA, Cap AP. Opti-
Author Contributions mizing whole blood storage: hemostatic function of 35-day stored
BCR conceived the paper concept and wrote the initial draft. All product in CPD, CP2D, and CPDA-1 anticoagulants. Transfusion.
authors reviewed, edited, and approved the final manuscript. 2019;59(S2):1549–1559. doi:10.1111/trf.15164
17. Schubert P, Culibrk B, Bhakta V, et al. Minimal impact of anti-
Disclosures coagulant on in vitro whole blood quality throughout a 35-day
JRH is the inventor of the AS-7 extended red blood cell storage cold-storage regardless of leukoreduction timing. Transfusion.
2022;62(S1):S98–S104. doi:10.1111/trf.16977
solution, the APEX whole blood storage system, and a consul- 18. Picker SM, Radojska SM, Gathof BS. In vitro quality of red blood
tant to Hemerus Medical, LLC, licensee of the patents. BCR, cells (RBCs) collected by multicomponent apheresis compared to
MJL, and DJR have no financial disclosures. manually collected RBCs during 49 days of storage. Transfusion.
2007;47(4):687–696. doi:10.1111/j.1537-2995.2007.01172.x
Disclaimer 19. Cooper DJ, McQuilten ZK, Nichol A, et al. Age of red cells for
The views expressed are those of the author(s) and do not re- transfusion and outcomes in critically ill adults. N Engl J Med.
2017;377(19):1858–1867. doi:10.1056/NEJMoa1707572
flect the official policy of the Department of the Army, the 20. Heddle NM, Cook RJ, Arnold DM, et al. Effect of short-term vs.
Department of the Air Force, the Department of Defense, or long-term blood storage on mortality after transfusion. N Engl J
the U.S. Government. Although the authors are or were mil- Med. 2016;375(20):1937–1945. doi:10.1056/NEJMoa1609014
itary Servicemembers, this work was not prepared as part of 21. Lacroix J, Hébert PC, Fergusson DA, et al. Age of transfused
our official duties. blood in critically ill adults. N Engl J Med. 2015;372(15):1410–
1418. doi:10.1056/NEJMoa1500704
22. Steiner ME, Ness PM, Assmann SF, et al. Effects of red-cell stor-
Funding age duration on patients undergoing cardiac surgery. N Engl J
No funding was received for this work. Med. 2015;372(15):1419–1429. doi:10.1056/NEJMoa1414219

72 | JSOM Volume 25, Edition 1 / Spring 2025