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Walking donor transfusion in a far forward environment.

Abstract: This case report details the walking donor transfusion (WDT) option for management of exsanguinating hemorrhage performed in an austere environment. It has civilian application in situations in which local blood supply is overwhelmed by demand due to a natural or manmade (ie, terrorist) disaster. WDT is discussed in light of alternative transfusion techniques, and the history of WDT is briefly discussed. Walking donor transfusion is appropriate for use in extreme cases of patient exsanguination.

Key Words: transfusion, walking donor, military medicine, disaster planning

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Patients in the United States are envied worldwide by those who see American medical technology as miracles in action. With the onset of the Global War on Terrorism in 2001, US military medical personnel have brought such miracles to places such as Afghanistan and Iraq. Acting as ambassadors of goodwill and hope, American doctors, nurses, and medics save lives in austere conditions by using medical technology that while possibly considered crude or unrefined, nonetheless represents life itself to war weary nations. We present a case in which Americans gave everything possible, including their own blood, to save a life in Afghanistan.

Case Report

A 30-year-old male received a gunshot wound to the right midcalf while in combat in Afghanistan. One hour later, he arrived by van at an American aid station with a profusely bleeding right lower extremity. While conscious on presentation, his Glasgow Coma Score quickly degraded to 8. Medical history, surgical history, medication list, and drug allergies were unknown. No defined blood vessels at the wound site could be visualized for potential clamping or suture ligation. Pulses distal to the injury were absent. Hemorrhage was controlled with two tourniquets proximal to the wound and a pressure dressing. The patient underwent orotracheal intubation and insertion of two 18-gauge intravenous catheters. He lost his femoral pulse and blood pressure and was noted to be in pulseless electrical activity on the cardiac monitor. Treatment with two doses of intravenous epinephrine, closed-chest compressions, and fluid boluses (5 L of 0.9% saline) resulted in a return of pulse and blood pressure. Aeromedical evacuation was at least 2 hours but probably longer because of weather. Ground-evacuation time to a US military hospital was 1 to 2 days through hostile (enemy) territory. The patient was transfused with 450 mL of walking donor whole blood. His pulse strengthened and perfusion improved. Hemostasis was maintained at the wound site while an additional unit of whole blood was drawn from a different donor and administered without incident. The patient was flown to a US Army Forward Surgical Team, where additional blood products were transfused and a below knee amputation was performed for his nonviable lower extremity. The patient recovered without further incident and was seen in follow-up at the aid station 4 weeks later, neurologically intact with normal cardiopulmonary and renal function.

Discussion

The need to perform walking donor transfusion is an exceedingly rare event that has the potential to become more common. Walking donor transfusion is the emergent collection and transfusion of previously typed and screened whole blood from a healthy donor (soldier) to a patient in need of a lifesaving transfusion. Fortunately, all service members are typed and screened during initial processing to the military; this is located on their military identification tags (dog tags).

The key to successful utilization of this technique is planning. In a deployed environment, planning occurs in the pre-deployment phase by identifying O-negative and O-positive personnel. All potential donors are also screened for sexually transmitted diseases, viral illnesses, malaria exposure, and so forth. Supplies must already be in place for donor collection. Resuscitation with whole blood near the point of injury, after proper hemostasis, saves lives. The decision to pursue such high-risk transfusion is forced when the person remains unstable after crystalloid administration, evacuation time is prohibitive, and it is clear that the patient will die if not transfused immediately. There are other scenarios in which walking donor transfusions could be used, such as a mass casualty situation, where the local blood supply is exhausted or the blood holding facility itself is destroyed.

Since the discovery of major blood types by Landsteiner in 1900 and the recognition of Rh factor in 1939, millions of transfusions have been safely performed. The overwhelming majority of these transfusions are of preserved, banked blood components; thereby giving the patient only the blood product needed while maintaining the ability to provide any stocked blood component at any time. Nonetheless, banked blood (specifically packed red blood cells) is not without intrinsic challenges to the medical system. A modern blood repository is a large logistical facility with requirements for skilled staff, refrigeration, reagents, and space. Although blood cell preservatives have improved the storage capability of blood over several decades, the acid-citrate-dextrose (ACD), citrate-phosphate-dextrose (CPD), and citrate-phosphate-double-dextrose-adenine (CP2D-A) preservative systems may bind calcium or otherwise change the recipient's condition. The banked red blood cell becomes relatively deficient in 2,3 diphosphoglycerate and adenine triphosphate, which may change the red cell's ability to carry oxygen, hindering the initial purpose of the transfusion. These nonimmune system principles of blood transfusion have prompted research into noncellular oxygen-carrying liquids that may be transported and stored at ambient temperatures, cause no recipient immune response, require no recipient replenishment of 2,3 diphosphoglycerate or adenine triphosphate, and are cost-effective for widespread use. In the US military medical system, these blood substitutes must remain stable despite 60[degrees]C heat and prolonged warehouse storage, and compete for space aboard transport aircraft. Although research has been performed on nonblood oxygen-carrying fluids for such scenarios (eg, free hemoglobin bovine blood substitutes, and so forth), we believe that the US Army Medical Department physicians cannot rely on these products being delivered on time and in sufficient quantities. These blood substitutes are not without their own peculiar side effects, nor have they gained widespread approval throughout the world. Walking donor transfusions are currently a more viable option to the military provider in austere conditions with limited medical supplies and evacuation assets.

Conclusion

Blood transfusion practices in the United States are unparalleled in the rest of the world. US military physicians, while using modern transfusion practices and techniques remote from the battlefield, may be forced to use creative, nontraditional methods of transfusion to save lives in an austere environment. Further research into synthetic oxygen-carrying resuscitative fluids, prolonging the shelf life of walking donor blood and further simplifying the transfusion process, would provide additional benefits to deployed American fighting forces and emergency disaster management personnel. In the continental United States, disaster-planning scenarios should include walking blood donors, as traditional blood banking practices and facilities may be depleted or destroyed by terrorist attack.

Maj Robert Malsby III, MC, DO, US, Maj (P) James Frizzi, MD, USA, Maj Peter Ray, MD, USA, Cpt John Raff, MD, USNR

From the 528th Special Operations Support Battalion, Fort Bragg, NC.

Reprint requests to Maj Robert Malsby III, MC, US, 528th Special Operations Support Battalion, Fort Bragg, NC 28310. Email: robert.malsby@us.army.mil

Accepted October 20, 2004.

RELATED ARTICLE: Key Points

* Blood transfusions in the United States are unparalleled in the rest of the world.

* US military physicians and emergency disaster personnel may be forced to use creative, nontraditional methods of transfusion to save lives in an austere environment.

* Further research into synthetic oxygen-carrying resuscitative fluids, prolonging the shelf life of walking donor blood, and further simplifying the transfusion process would provide additional benefits to deployed American fighting forces and emergency disaster personnel.

* Disaster planning scenarios should include walking blood donors, as traditional blood banking practices and facilities may be depleted or destroyed by terrorist attack.
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Title Annotation:Case Report
Author:Raff, John
Publication:Southern Medical Journal
Date:Aug 1, 2005
Words:1265
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