A paper published in Transfusion Medicine examines cold stored low-titer group O whole blood (LTOWB) being carried and used by the Israel Defense Forces Medical Corps (IDF-MC) ground ambulance teams. The authors explained that in 2022, “recognizing the benefits of early transfusion of whole blood, the IDF-MC deployed whole blood in ground ambulances for the first time in Israel.” The paper not only describes the experiences from the field, but also “present a case-series of the first patients receiving LTOWB.”
The authors noted that “the IDF-MC provides prehospital trauma care to both civilians and soldiers injured in military or civilian circumstances (i.e., road traffic collision, falls) occurring in proximity to IDF bases. The deployment of LTOWB in 2022 “to several ICU ambulances, replac[ed] the previous IDF-MC’s standard fluid of choice for trauma resuscitation — freeze-dried plasma (FDP).” All intensive care unit ambulances carried two units of LTOWB that were replaced after being used or expired. A retrospective review of the IDF Trauma Registry (IDF-TR) was conducted by the authors to “identify cases of whole blood administration by ground ICU ambulance teams, between January and December 2022 [excluding] patients administered whole blood for the indication of traumatic cardiac arrest.”
The LTOWB units were derived from “whole blood donations of male–only O Rh+ volunteer donors, with a volume of 450 ± 50 mL. All whole blood units are collected in CPDA-1, with a maximal expiration of 35-days. Each unit undergoes an automated screening procedure, and only units with a titer of Anti-A or Anti-B of <1:100 were classified as LTOWB during the study period…Currently, platelet-sparing leukocyte reduction is not utili[z]ed during unit processing as quality control tests performed during the validation of the filtration procedure revealed a significant reduction in the platelet content of the final LTOWB product. Units are supplied to the IDF ICU ambulance teams upon demand, to be used within 21 days from the time of collection. LTOWB units can be issued within three days after collection, due to preparation and transport times to the remote military units.”
The study included seven cases of LTOWB being administered by ground ambulance teams. “Of the seven patients administered LTOWB for profound shock, six were males with a median age of 28 (IQR 19.5–42) years. Five of the patients were injured in military circumstances, all from gunshot wounds, while two sustained blunt injuries in civilian road traffic collisions…LTOWB was administered after a hypotensive measurement (≤90 mmHg) in two cases. In the remaining five cases, the indication for volume resuscitation was altered mental status, in the absence of head injury or premedication with unmeasurable blood pressure. Whole blood was administered through intravenous access in 6 [of] 7 cases and was administered through a blood warmer in 5 [of] 7 cases. The median time from injury to LTOWB administration was 35 (IQR 28.5–40) minutes, and median time from injury to hospital arrival 53 (IQR 41.5–63) minutes. In only one case, a second unit of volume resuscitation (with the highest priority blood product available to the team) was indicated following reassessment and prior to hospital arrival. In this case, a unit of FDP was administered, as the team had only one unit of non-expired whole blood on hand. Additionally, 1g of IV tranexamic acid was administered in 6 [of] 7 cases. No adverse events were recorded after whole blood administration…All patients except one survived to discharge following ICU admission.”
The authors concluded, “this small case series presents the initial experience of the IDF-MC in deploying LTOWB in ground ambulances, for the first time in Israel. This series demonstrates that administration of LTOWB by paramedic-lead ICU ambulance teams is feasible, and based on current evidence, could be safe and potentially improve outcomes of patients with severe traumatic h[e]morrhage. The hospital data of patients in this case-series demonstrates that they were indeed seriously wounded, suffered from severe bleeding, and that prehospital LTOWB transfusion was indeed indicated…Future studies are required to better characteri[z]e the indications, safety, and benefits of whole blood in resuscitating severely injured trauma patients in the prehospital setting.”
Citation: Talmy, T., Malkin, M., Esterson, A. et al. “Low-titer group O whole blood in military ground ambulances: Lessons from the Israel Defense Forces initial experience.” Transfusion Medicine. 2023.