A Descriptive Analysis of Supermassive Transfusion Recipients Among US and Coalition Forces During Combat Operations in Afghanistan and Iraq

A Scoping Review of Military Combat Casualty Data on Submassive, Massive, and Supermassive Transfusions

INTRODUCTION

Blood transfusions are common during combat casualty care, aiming to address the loss of blood volume that often accompanies severe battlefield injuries. This scoping review delves into the existing military combat casualty data to analyze the efficacy, challenges, and advances in the use of massive and super-massive transfusions in the management of critically injured warfighters.

MATERIALS AND METHODS

We performed a scoping review of combat-related literature published between 2006 and 2023 pertaining to massive transfusions used during combat deployments. We utilized PubMed to identify relevant studies and utilized the PRISMA-ScR Checklist to conduct the review.

RESULTS

We identified 53 studies that met the inclusion criteria with the majority being retrospective studies from registries used by the United States, British, French, and Dutch Militaries. Most of the studies focused on transfusion ratios, the movement of blood transfusions to more forward locations, implementation of massive transfusions with different fibrinogen-to-red blood cell ratios, the addition of recombinant factor VII, and the use of predictive models for transfusion. Lastly, we identified reports of improved survival for casualties with the rapid implementation of various blood products (warm fresh whole blood, cold-stored low titer group O blood, freeze-dried plasma, and component therapy) and literature relating to pediatric casualties and submassive transfusions. Notable findings include the establishment of hemodynamic and cell blood count parameters as predictors of the requirement for massive transfusions and the association of higher fibrinogen-to-red blood cell ratios with decreased mortality.

CONCLUSIONS

We identified 53 studies focused on blood transfusions from the Global War on Terrorism conflicts. The majority were related to transfusion ratios and the movement of blood transfusions to more forward locations. We highlight key lessons learned on the battlefield that have been translated into scientific developments and changes in civilian trauma methods.

The employment of resuscitative endovascular balloon occlusion of the aorta in deployed settings

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been often used in place of open aortic occlusion for management of hemorrhagic shock in trauma. There is a paucity of data evaluating REBOA usage in military settings.

STUDY DESIGN AND METHODS

We queried the Department of Defense Trauma Registry (DODTR) for all cases with at least one intervention or assessment available within the first 72 h after injury between 2007 and 2023. We used relevant procedural codes to identify the use of REBOA within the DODTR, and we used descriptive statistics to characterize its use.

RESULTS

We identified 17 cases of REBOA placed in combat settings from 2017 to 2019. The majority of these were placed in the operating room (76%) and in civilian patients (70%). A penetrating mechanism caused the injury in 94% of cases with predominantly the abdomen and extremities having serious injuries. All patients subsequently underwent an exploratory laparotomy after REBOA placement, with moderate numbers of patients having spleen, liver, and small bowel injuries. The majority (82%) of included patients survived to hospital discharge.

DISCUSSION

We describe 17 cases of REBOA within the DODTR from 2007 to 2023, adding to the limited documentation of patients undergoing REBOA in military settings. We identified patterns of injury in line with previous studies of patients undergoing REBOA in military settings. In this small sample of military casualties, we observed a high survival rate.

A survey of low titer O whole blood use within the trauma quality improvement program registry

INTRODUCTION

The use of low titer O whole blood (LTOWB) has expanded although it remains unclear how many civilian trauma centers are using LTOWB.

METHODS

We analyzed data on civilian LTOWB recipients in the American College of Surgeons Trauma Quality Improvement Program (TQIP) database 2020-2021. Unique facility keys were used to determine the number of centers that used LTOWB in that period.

RESULTS

A total of 16,603 patients received LTOWB in the TQIP database between 2020 and 2021; 6600 in 2020, and 10,003 in 2021. The total number of facilities that reported LTOWB use went from 287/779 (37%) in 2020 to 302/795 (38%) in 2021. Between 2020 and 2021, among all level 1-3 designated trauma facilities that report to TQIP LTOWB use increased at level-1 centers (118 to 129), and level-2 centers (81 to 86), but decreased in level-3 facilities (9 to 4). Among pediatric and dual pediatric-adult designated hospitals there was a decrease in the number of pediatric level-1 centers (29 to 28) capable of administering LTOWB. Among centers with either single or dual level-1 trauma center designation with adult centers, the number that administered LTOWB to injured pediatric patients also decreased from 17 to 10, respectively.

CONCLUSIONS

There was an increase in the number of facilities transfusing LTOWB between 2020 and 2021. The use of LTOWB is underutilized in children at centers that have it available. These findings inform the expansion of LTOWB use in trauma.

Defining Ultra-Massive Transfusion through a Systematic Review

Background

Despite the widespread use of ultra-massive transfusion (UMT) as an intervention for trauma patients in hemorrhagic shock, no standard definition exists. We performed a systematic review to determine a consensus definition for UMT.

Methods

A search was performed from 1979-2022. The authors screened studies defining UMT and associated outcomes as defined by our prespecified PICO questions. The PRISMA guidelines were used.

Results

1662 articles met criteria for eligibility assessment, 17 for full-text review and eight for data extraction. Only two studies demonstrated a consensus definition of UMT, which used ≥20 units of red blood cell product within 24hrs. Parameters associated with increased mortality included lower blood pressure, lower pulse and lower Glasgow Coma Score at the time of presentation and a higher injury severity score and undergoing a resuscitative thoracotomy.

Conclusions

The absence of a consensus definition for UMT raises challenges from clinical, research and ethical perspectives. Based on our findings, the authors advocate for the feasibility of standardizing the definition of UMT as ≥20 units of red blood cell product within 24hrs.

First transfusion of cold-stored low-titer group O whole blood in the French armed forces

BACKGROUND

Hemorrhage is the most frequent cause of preventable death in the combat setting. Therefore, early transfusion can improve survival of combat casualties. In the case of hemorrhagic shock, massive transfusion must be performed immediately with high transfusion ratios (i.e., approximately 1:1:1 plasma:platelet:red blood cells). The use of cold-stored low-titer group O whole blood could address this challenging transfusion strategy in combat setting.

RESULTS

We present here a clinical case illustrating this strategy of high transfusion ratios, which includes-for the first time in a modern conflict involving French Armed Forces-the use of cold-stored low-titer group O whole blood. A 29-year-old French soldier suffered multiple gunshot wounds. Because of the critical condition of the patient in hemorrhagic shock, successive medical teams initiated an early and massive transfusion, using French lyophilized plasma, red blood cells, cold-stored low-titer group O whole blood, and warm fresh whole blood.

CONCLUSION

This case report of a bleeding combat casualty, transfused with cold-stored low-titer group O whole blood for the first time in the French Armed Forces, emphasizes two important points: the importance of clinical assessment in the management of a bleeding patient with hemorrhagic shock and the feasibility of early massive transfusion using cold-stored low-titer group O whole blood.