Blood far forward program: Update on French armed forces policy

Abstract

Hemorrhage is still the leading cause of preventable deaths in the battlefield and transfusion of blood products has a pivotal role in the management of these patients.1 Of note, time to transfusion has a major impact on patient's outcome and transfusion should be performed within the first 30 min. In order to provide the most suitable standard of care to soldiers, the French Armed Forces Health Service (FAFHS) has implemented a dedicated blood field transfusion policy since several decades.2 This policy is regularly updated, based on the most recent evidences from the literature and on the availability of improved logistic equipment. Up to now, four principles rule this policy of trauma-related massive hemorrhage management: transfuse as early as possible, transfuse plasma rather than crystalloids, provide platelets during massive transfusion protocol and reach a 1:1:1 ratio between red cells concentrates, plasma and platelets units at the end of the protocol.3-6 Additionally, recent advances now allows for safe packaging and transport of several blood products: French Lyophilized Plasma (FLyP), red blood cells units (RBC), and cold-stored low-titer (<1/64) group O whole blood (LTOWB).7 In the field, this transfusion support is adapted from role 1 to role 3, with each role providing a higher level of care. Since 2009, each role 1 medical team deployed on an operational mission carries FLyP when the situation requires it. Prepared by the French Military Blood Institute (FMBI), FLyP is particularly suitable for remote and austere settings, as it can be stored at temperatures from 4 to 25°C, for 2 years (even in hot environments), then reconstituted in less than 6 min, while being compatible for all blood types.8 RBCs are available in medical treatment facilities (role 2), in rotary and fixed wings MEDEVACs, as well as on the ground in the prehospital setting for some special operations. The large use of Golden hour boxes (GHB) enables RBCs and LTOWB deployment on the field. Indeed, current GHB may contain three RBCs or two LTOWB units, under safe conditions, regardless of external temperatures, up to 48 h.7 Moreover, FAFHS prehospital medical teams deployed in the field are trained to perform warm fresh whole blood (wFWB) collection and transfusion, even in austere setting by using a whole blood transfusion kit prepared by the FMBI which enables trained team to deliver safe wFWB unit within an hour.9 This wFWB program was set up in 2005 and is based on a walking blood bank composed of pre-screened servicemen, including: past medical history and clinical conditions, ABO testing, serological and Nucleic Acid Testing testing, and hemolysin titer, in accordance with French regulations on blood donor screening. The main goal of the current FAFHS blood policy is to provide the most appropriate blood product to bleeding combat casualties as early as possible, in order to restore blood volume and hemostatic function. After applying dedicated techniques from the Sauvetage au combat (the French doctrine for Tactical Combat Casualty Care), early use of blood products in the battlefield is considered in the management of a bleeding combat casualty, when at least one of the three following points is present: systolic blood pressure ≤70 mmHg; systolic blood pressure ≤70 mmHg AND heart rate ≥110 beats per minute; limb amputation at or above the elbow, the knee. When a blood transfusion is indicated, the forward medical team is using the following preferred option. Priority 1: LTOWB prepared and delivered by the French Military Blood Institute; Priority 2: RBC and FLYP in a 1:1 ratio.*RBCs are RH1;Priority 3: RBCs or FLyP if only one is available; Priority 4: saline solution (0.9% or 7.5% NaCl) before reaching blood products availability. When a blood transfusion is indicated, but with no possibility to achieve Priority 1 or 2 within 1 h, the wFWB procedure should be started without delay. Such a procedure presents specific issues in the battlefield. Particularly, it is challenging for one single medical team to concurrently manage multiple combat casualties and whole blood collections in the field. Figure 1 summarizes the medical blood supply in FAFHS. In February 2021, LTOWB units will gradually replace RBCs units in MEDEVAC blood kits. Finally, to enhance these new insights of the FAFHS blood policy, further collaborations between civilian and military medical teams are ongoing, including a prospective randomized multicentric clinical trial which will test LTOWB to components therapy in the in-hospital management of trauma patients with massive hemorrhage.10

Topics & Concepts