Low-Titer Group O Whole-Blood Resuscitation in the Prehospital Setting in Israel: Review of the First 2.5 Years’ Experience

Abstract

<b><i>Introduction:</i></b> The Israeli Defense Forces Medical Corps (IDF-MC) implemented the use of low-titer group O whole blood (LTOWB) as the first-choice resuscitation fluid in the IDF airborne Combat Search and Rescue Unit (IDF-CSAR) for aerial evacuation of both military and civilian casualties in June 2018 for injured patients with hemorrhagic shock and at least one of the following: systolic blood pressure <90 mm Hg, heart rate >130 beats/min, deterioration of consciousness without head injury or hemoglobin concentration ≤7 g/dL. <b><i>Method:</i></b> All casualties treated with LTOWB by IDF-CSAR providers from June 2018 to January 2021 were included. Demographic and prehospital treatment data were collected in order to check compliance and adherence to the IDF-MC guidelines. This is a follow-up retrospective report. <b><i>Results:</i></b> Overall, 1,608 LTOWB units were supplied to the IDF-CSAR during the study period. Of these, 33 were transfused to 27 casualties; 17 (69%) with blunt injury, 8 (29.6%) with penetrating injuries, and 1 (3.7%) with gastrointestinal bleeding without trauma. The leading cause of injury was motor vehicle accidents. A total of 23 casualties received 1 unit of LTOWB, 3 received 2 units and 1 patient received 4 units. Two casualties were children. The median heart rate was 120 beats/min, 8 (29.6%) casualties had heart rates >130 beats/min. Median systolic blood pressure was 95 mm Hg, 7 (26%) casualties had blood pressure <90 mm Hg. The median Glasgow Coma Score was 14. No adverse reactions were documented following the administration of LTOWB. 77.8% of patients received LTOWB in adherence to the guidelines. <b><i>Conclusion:</i></b> Appropriate administration of LTOWB has improved over time in IDF-CSAR. Using LTOWB is feasible and simpler than administering packed red blood cells and plasma concurrently. Further efforts are needed to introduce LTOWB in other prehospital and in-hospital scenarios, with an increase in the maximum antibody titer threshold, to meet the expected increase in demand.

Implementation of a low-titre whole blood transfusion program in a civilian helicopter emergency medical service

“…Military use of whole blood has become a key element in RDCR, due to simpler logistics, reduced time to transfusion, and improved survival in combat causalities [5,20]. Whole blood may have better global haemostasis effects, a reduced incidence of transfusion hypocalcaemia and haemodilution, and a reduction in overall blood use compared to components with higher citrate and additives contents [4,21].…”

“…An out of hospital balanced transfusion approach with components is challenging due to different storage conditions for PRBCs, plasma and platelets. Whole blood represents an alternative that is logistically superior and easier to handle in time-critical emergencies with short on-scene and flight times compared to blood components [20]. The production of a leukocyte-reduced, platelet-containing LTOWB unit in our blood bank also requires fewer logistical steps compared to a unit of PRBC concentrate.…”

Toward a more complete understanding of who will benefit from prehospital transfusion

“…There is also observational evidence that prehospital transfusion improves survival in military casualties. [4][5][6][7] In a retrospective study, Shackelford et al reported that injured soldiers who received prehospital transfusions (plasma, RBC, or both; n = 62) had significantly lower mortality than matched non-recipients (n = 324) at 24 h and 30 days. 8 This analysis found that only the transfusions that were administered within 15 min of MEDE-VAC rescue (median 36 min from injury) were associated with reduced 24-h mortality [hazard ratio, 0.17 (95% CI: 0.04-0.73; p = 0.02)]; there was an approximately 17% absolute risk reduction in 24-h mortality among the patients who received transfusions within 15 min compared with those whose transfusions were administered after that time (3.2% vs. 21.0%, respectively).…”

“…There is also observational evidence that prehospital transfusion improves survival in military casualties 4–7 . In a retrospective study, Shackelford et al reported that injured soldiers who received prehospital transfusions (plasma, RBC, or both; n = 62) had significantly lower mortality than matched non‐recipients ( n = 324) at 24 h and 30 days 8 .…”

Recent Developments in Emergency Blood Transfusion

“…As whole blood may contain red blood cells, plasma (together with preserved clotting factors), and platelets (with considerable hemostatic function after cold storage) combined in one bag, it is obvious that it might become a suitable blood product for pre-hospital blood transfusion. In this special issue of TMH, Dan Levin et al [15] and Christopher Bjerkvig et al [16] demonstrate this for Israeli military and civilian casualties as well as for Norwegian civilian patients with severe hemorrhage, respectively. However, the Nor- wegian group report on whole blood and blood component transfusion (freeze-dried plasma and red blood cell concentrates) depending on the transfusion strategy of different Norwegian helicopter emergency medical services.…”