Advertisement

World Journal of Surgery

, Volume 32, Issue 1, pp 2–6 | Cite as

Fresh Whole Blood Transfusions in Coalition Military, Foreign National, and Enemy Combatant Patients during Operation Iraqi Freedom at a U.S. Combat Support Hospital

  • Philip C. SpinellaEmail author
  • Jeremy G. Perkins
  • Kurt W. Grathwohl
  • Thomas Repine
  • Alec C. Beekley
  • James Sebesta
  • Donald Jenkins
  • Kenneth Azarow
  • John B. Holcomb
  • the 31st CSH Research Working Group
Article

Abstract

Background

United States military doctrine permits the use of fresh whole blood (FWB), donated by U.S. military personnel on site, for casualties with life-threatening injuries at combat support hospitals. U.S. Military Medical Department policy dictates that all patients treated at military facilities during combat (coalition military personnel, foreign nationals, and enemy combatants) are to be treated equally. The objectives of this study were to describe admission vital signs and laboratory values and injury location for patients transfused with FWB, and to determine if FWB was employed equally among all patient personnel categories at a combat support hospital.

Methods

This retrospective cohort study evaluated admission vital signs and laboratory values, injury location, and personnel category for all patients receiving FWB at a U.S. Army combat support hospital in Baghdad, Iraq, between January and December 2004.

Results

Eighty-seven patients received 545 units of FWB. Upon admission, the average (±S.D.) heart rate was 144 bpm (±25); systolic blood pressure, 106 mmHg (±33); base deficit, 9 (±6.5); hemoglobin, 9.0 g/dl (±2.6); platelet concentration, 81.9 × 103/mm3 (±81); international normalized ratio (INR), 2.0 (±1.1); and temperature 95.7°F (±2.6). The percentages of intensive care patients who received FWB by personnel category were as follows: coalition soldiers, 51/592 (8.6%); foreign nationals, 25/347 (7.2%); and enemy combatants, 11/128 (8.5% (p = 0.38). The amount of FWB transfused by personnel category was as follows: coalition soldier, 4 units (1–35); foreign national, 4 units (1–36); and enemy combatant, 4 units (1–11) (p = 0.9).

Conclusions

Fresh whole blood was used for anemic, acidemic, hypothermic, coagulopathic patients with life-threatening traumatic injuries in hemorrhagic shock, and it was transfused in equal percentages and amounts for coalition soldiers, foreign nationals, and enemy combatants.

Keywords

Injury Severity Score Hemorrhagic Shock Abbreviate Injury Scale Foreign National Operation Iraqi Freedom 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgments

The authors thank Col. Ruth Lee, LTC Emmett Gourdine, and the 31st CSH Research Working group (Drs. Jack Chiles, Lorne Blackbourne, Dennis Nichols, Jennifer Greco, Cynthia Clagett, and Gregory Thibault), for assistance with data collection; Amy Newland and Dr. Charles E. Wade, for support, helpful discussions, and critical evaluation of the manuscript. Philip C. Spinella, MD, had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis

References

  1. 1.
    Hess JR, Thomas MJ (2003) Blood use in war and disaster: lessons from the past century. Transfusion 43(11):1622–1633PubMedCrossRefGoogle Scholar
  2. 2.
    Emergency War Surgery (2004) Third Revised Edition, United States of America: US Department of DefenseGoogle Scholar
  3. 3.
    Kauvar DS, Holcomb JB, Norris GC, et al. (2006) Fresh whole blood transfusion: a controversial military practice. J Trauma 61(1):181–184PubMedGoogle Scholar
  4. 4.
    McMullin NR, Holcomb JB, Sondeen J (2006) Hemostatic resuscitation. In Vincent J, editor, Yearbook of Intensive Care and Emergency Medicine. New York, Springer, 265–278CrossRefGoogle Scholar
  5. 5.
    Repine TB, Perkins JG, Kauvar DS, et al. (2006) The use of fresh whole blood in massive transfusion. J Trauma 60(6 Suppl):S59–69PubMedGoogle Scholar
  6. 6.
    Spinella PC, Perkins JG, Grathwohl KW et al. (2007) The risks associated with fresh whole blood and red blood cell transfusions in a combat support hospital. Crit Care Med 35:2576–2581PubMedGoogle Scholar
  7. 7.
    AAAM (1998) Abbreviated Injury Scale 1998 Edition, Chicago, Illinios, 1998Google Scholar
  8. 8.
    Facts about Blood and Blood Banking, 2006. (Accessed at http://www.aabb.org/Content/About_Blood/Facts_About_Blood_and_Blood_Banking/)
  9. 9.
    Grosso SM, Keenan JO (2000) Whole blood transfusion for exsanguinating coagulopathy in a US field surgical hospital in postwar Kosovo. J Trauma 49(1):145–148PubMedGoogle Scholar
  10. 10.
    Brohi K, Singh J, Heron M, et al. (2003) Acute traumatic coagulopathy. J Trauma 54(6):1127–1130PubMedGoogle Scholar
  11. 11.
    Cosgriff N, Moore EE, Sauaia A, et al. (1997) Predicting life-threatening coagulopathy in the massively transfused trauma patient: hypothermia and acidoses revisited. J Trauma 42(5):857–861; discussion 861–862PubMedGoogle Scholar
  12. 12.
    Eastridge BJ, Malone D, Holcomb JB (2006) Early predictors of transfusion and mortality after injury: a review of the data-based literature. J Trauma 60(6 Suppl):S20–25PubMedGoogle Scholar
  13. 13.
    Hess JR, Holcomb JB, Hoyt DB (2006) Damage control resuscitation: the need for specific blood products to treat the coagulopathy of trauma. Transfusion 46(5):685–686PubMedCrossRefGoogle Scholar
  14. 14.
    Holcomb JB, Jenkins D, Johannigman J, et al. (2007) Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma 62(2):307–310PubMedGoogle Scholar
  15. 15.
    Malone DL, Dunne J, Tracy JK, et al. (2003) Blood transfusion, independent of shock severity, is associated with worse outcome in trauma. J Trauma 54(5):898–905; discussion 907PubMedCrossRefGoogle Scholar
  16. 16.
    Carrico CJ, Holcomb JB, Chaudry IH (2002) Scientific priorities and strategic planning for resuscitation research and life saving therapy following traumatic injury: report of the PULSE Trauma Work Group. Post Resuscitative and Initial Utility of Life Saving Efforts. Shock 17(3):165–168PubMedCrossRefGoogle Scholar
  17. 17.
    Martini WZ, Pusateri AE, Uscilowicz JM, et al. (2005) Independent contributions of hypothermia and acidosis to coagulopathy in swine. J Trauma 58(5):1002–1009; discussion 1009–1010PubMedGoogle Scholar
  18. 18.
    Hess JR, Lawson JH (2006) The coagulopathy of trauma versus disseminated intravascular coagulation. J Trauma 60(6 Suppl):S12–19PubMedGoogle Scholar
  19. 19.
    Martinowitz U, Michaelson M (2005) Guidelines for the use of recombinant activated factor VII (rFVIIa) in uncontrolled bleeding: a report by the Israeli Multidisciplinary rFVIIa Task Force. J Thromb Haemost 3(4):640–648PubMedCrossRefGoogle Scholar
  20. 20.
    Schreiber MA (2005) Coagulopathy in the trauma patient. Curr Opin Crit Care 11(6):590–597PubMedCrossRefGoogle Scholar
  21. 21.
    Gonzalez EA, Moore FA, Holcomb JB, et al. (2007) Fresh frozen plasma should be given earlier to patients requiring massive transfusion. J Trauma 62(1):112–119PubMedGoogle Scholar
  22. 22.
    Ho AM, Karmakar MK, Dion PW (2005) Are we giving enough coagulation factors during major trauma resuscitation? Am J Surg 190(3):479–484PubMedCrossRefGoogle Scholar
  23. 23.
    Malone DL, Hess JR, Fingerhut A (2006) Massive transfusion practices around the globe and a suggestion for a common massive transfusion protocol. J Trauma 60(6 Suppl):S91–96PubMedCrossRefGoogle Scholar
  24. 24.
    Borgman M, Spinella PC, Perkins JG et al. (2007) The ratio of blood products transfused affects mortality in patients massive transfusions at a combat support hospital. J Trauma 63(4):805–813PubMedGoogle Scholar
  25. 25.
    Spinella PC, Perkins JG, Mc Laughlin DF et al. (2007) The effect of recombinant activated factor VII on survival in combat related casualties with severe trauma requiring massive transfusion. J Trauma In PressGoogle Scholar
  26. 26.
    Armand R, Hess JR (2003) Treating coagulopathy in trauma patients. Transfus Med Rev 17(3):223–231PubMedCrossRefGoogle Scholar
  27. 27.
    Napolitano LM, Corwin HL (2004) Efficacy of red blood cell transfusion in the critically ill. Crit Care Clin 20(2):255–268PubMedCrossRefGoogle Scholar
  28. 28.
    Tinmouth A, Fergusson D, Yee IC et al. (2006) Clinical consequences of red cell storage in the critically ill. Transfusion 46(11):2014–2027PubMedCrossRefGoogle Scholar
  29. 29.
    Bickell WH, Wall MJ Jr, Pepe PE, et al. (1994) Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 331(17):1105–1109PubMedCrossRefGoogle Scholar
  30. 30.
    Ho J, Sibbald WJ, Chin-Yee IH (2003) Effects of storage on efficacy of red cell transfusion: when is it not safe? Crit Care Med 31(12 Suppl):S687–697PubMedCrossRefGoogle Scholar
  31. 31.
    Purdy FR, Tweeddale MG, Merrick PM (1997) Association of mortality with age of blood transfused in septic ICU patients. Can J Anaesth 44(12):1256–1261PubMedGoogle Scholar
  32. 32.
    Zallen G, Offner PJ, Moore EE, et al. (1999) Age of transfused blood is an independent risk factor for postinjury multiple organ failure. Am J Surg 178(6):570–572PubMedCrossRefGoogle Scholar
  33. 33.
    Martini WZ, Dubick MA, Pusateri AE, et al. (2006) Does bicarbonate correct coagulation function impaired by acidosis in swine? J Trauma 61(1):99–106PubMedCrossRefGoogle Scholar
  34. 34.
    Carter BS (1994) Ethical concerns for physicians deployed to Operation Desert Storm. Mil Med 159(1):55–59PubMedGoogle Scholar
  35. 35.
    Tuck JJ (2005) Medical management of Iraqi enemy prisoners of war during Operation Telic. Mil Med 170(3):177–182PubMedGoogle Scholar
  36. 36.
    Annas GJ (2005) Unspeakably cruel—torture, medical ethics, and the law. N Engl J Med 352(20):2127–2132PubMedCrossRefGoogle Scholar
  37. 37.
    Bloche MG, Marks JH (2005) When doctors go to war. N Engl J Med 352(1):3–6PubMedCrossRefGoogle Scholar
  38. 38.
    Lifton RJ (2004) Doctors and torture. N Engl J Med 351(5):415–416PubMedCrossRefGoogle Scholar
  39. 39.
    Cappucci DT Jr, Flemming SL (1994) Medical observations of malingering in Iraqi enemy prisoners of war during Operation Desert Storm. Mil Med 159(6):462–464PubMedGoogle Scholar
  40. 40.
    Marcum JM, Cline DW (1993) Combat stress reactions in Iraqi enemy prisoners of war. Bull Menninger Clin 57(4):479–491PubMedGoogle Scholar
  41. 41.
    Viercinski JA (1992) Hospital pharmacy technicians function in Desert Storm enemy prisoner of war camps. Hosp Pharm 27(3):231–232, 240PubMedGoogle Scholar
  42. 42.
    Geneva Conventions: A Reference Guide. 2003. (Accessed at http://www.genevaconventions.org/)
  43. 43.
    Erber WN, Tan J, Grey D, et al. (1996) Use of unrefrigerated fresh whole blood in massive transfusion. Med J Aust 165(1):11–13PubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2007

Authors and Affiliations

  • Philip C. Spinella
    • 6
    • 7
    Email author
  • Jeremy G. Perkins
    • 2
  • Kurt W. Grathwohl
    • 1
  • Thomas Repine
    • 3
  • Alec C. Beekley
    • 4
  • James Sebesta
    • 4
  • Donald Jenkins
    • 5
  • Kenneth Azarow
    • 4
  • John B. Holcomb
    • 6
  • the 31st CSH Research Working Group
  1. 1.Brooke Army Medical CenterSan AntonioUSA
  2. 2.Walter Reed Army Medical CenterWashingtonUSA
  3. 3.William Beaumont Army Medical CenterEl PasoUSA
  4. 4.Madigan Army Medical CenterWashingtonUSA
  5. 5.Wilford Hall Air Force Medical CenterSan AntonioUSA
  6. 6.U.S. Army Institute of Surgical ResearchSan AntonioUSA
  7. 7.Connecticut Children’s Medical CenterHartfordUSA

Personalised recommendations