Versorgung mit Blut und Blutprodukten in militärischen Einsatzgebieten

Zusammenfassung

Das Trauma mit hämorrhagischem Schock ist eine der führenden Todesursachen in militärischen Konflikten. Die möglichst frühzeitige optimale Versorgung inklusive Transfusion von Blut(-produkten) im Rahmen der sogenannten Damage Control Resuscitation spielt hierbei eine zentrale Rolle. Eine besondere Herausforderung im militärischen Einsatz stellt in Bezug auf die Blutversorgung die Logistik hinsichtlich des Transportes wie auch vor Ort dar. Eingeschränkte Ressourcen im Hinblick auf Produkte, Material, Laborkapazität und Personal wirken sich ebenso aus. Eindeutig favorisiert für die Versorgung von akut blutenden Traumapatienten wird aus medizinischer wie auch logistischer Sicht Vollblut, hier vor allem Vollblut der Blutgruppe Null mit niedrigem Isoagglutinintiter (LTOWB). Dieses kommt bis dato in der Bundeswehr aufgrund fehlender rechtlicher Rahmenbedingungen jedoch nicht zum Einsatz.

Nationale Notfallpläne zur resilienten Versorgung in militärischen und nicht-militärischen Krisen sind unabdingbar und werden von der EU-Kommission in der 2024 verabschiedeten SoHO-Verordnung gefordert, auch um internationale Abstimmungen zur Interoperabilität zu ermöglichen.

Abstract

Traumatic Haemorrhage is one of the leading causes of death in military conflicts. Providing early optimal care (Damage Control Resuscitation) plays a central role; this includes early prehospital transfusion of blood. Regarding blood supply, challenges in military mission are logistics in transport and in theatre as well as limited resources for blood (products), materials, lab capacity and personnel.

From medical and logistical point of view, Whole Blood is clearly favored, especially Low-titer Group O Whole Blood (LTOWB). However, this is not integrated in the Blood Concept of the German Armed Forces up to now due to missing legal framework conditions.

National “Blood Planning Concepts” for resilient blood supply in military and non-military crises are absolutely essential. They are also required by the SoHO Regulation, which was adopted by the EU-Commission in 2024, to enable international coordination regarding interoperability.

Schlüsselwörter

Blutversorgung - Vollblut - Wehrmedizin - Hämorrhagischer Schock - Damage Control Resuscitation

Keywords

Blood Supply - Whole Blood - Military Medicine - Traumatic Haemorrhage - Damage Control Resuscitation

Publication History

Article published online:
11 February 2025

• Literatur

• 1 Center for Disease Control and Prevention, United States. Annual reports: Death Leading Causes for 2021. Published 8^th Apr 2024. Zugriff am: 19.08.2024 unter: https://www.cdc.gov/nchs/nvss/leading-causes-of-death.htm#publications
• 2 Sakran JV, Greer SE, Werlin E. et al. Care of the injured worldwide: trauma still the neglected disease of modern society. Scand J Trauma Resusc Emerg Med 2012; 20: 64
• 3 Gurney JM, Spinella PC. Blood transfusion management in the severely bleeding military patient. Curr Opin Anaesthesiol 2018; 31: 207-214
• 4 Weymouth W, Long B, Koyfman A. et al. Whole Blood in Trauma: A Review for Emergency Clinicians. J Emerg Med 2019; 56: 491-498
• 5 Deutsche Gesellschaft für Unfallchirurgie (DGU). Jahresbericht 2023 - TraumaRegister DGU. Zugriff am: 30.08.2024 unter: https://www.traumaregister-dgu.de/fileadmin/user_upload/TR-DGU-Jahresbericht_2023.pdf
• 6 Remondelli MH, Remick KN, Shackelford SA. et al. Casualty care implications of large-scale combat operations. J Trauma Acute Care Surg 2023; 95: 180-184
• 7 Almog O, Benov A, Beer Z. et al. Deploying whole blood to the battlefield - The Israel Defense Forces Medical Corps initial experience during the 2023 war. Transfusion 2024; 64: 14-18
• 8 European Parliament and Council. Regulation (EU) 2024/1938 of the European Parliament and of the Council of 13 June 2024 on standards of quality and safety for substances of human origin intended for human application and repealing Directives 2002/98/EC and 2004/23/EC (Text with EEA relevance). Zugriff am: 25.10.2024 unter: https://eur-lex.europa.eu/eli/reg/2024/1938/oj
• 9 Black JA, Pierce VS, Kerby JD. et al. The Evolution of Blood Transfusion in the Trauma Patient: Whole Blood Has Come Full Circle. Semin Thromb Hemost 2020; 46: 215-220
• 10 Ebert RV, Emerson CP. A clinical study of transfusion reactions: The hemolytic effect of blood-O-group and pooled plasma containing incompatible isoagglutinins. J Clin Invest 1946; 25: 627-638
• 11 Zielinski MD, Jenkins DH, Hughes JD. et al. Back to the future: the renaissance of whole-blood transfusions for massively hemorrhaging patients. Surgery 2014; 155: 883-886
• 12 Yazer MH, Cap AP, Spinella PC. Raising the standards on whole blood. J Trauma Acute Care Surg 2018; 84: S14-S17
• 13 Gallaher JR, Schreiber MA. A Review of Whole Blood: Current Trauma Reports. Current Trauma Reports 2019; 5: 210-215
• 14 Murdock AD, Berséus O, Hervig T. et al. Whole blood: the future of traumatic hemorrhagic shock resuscitation. Shock 2014; 41: 62-69
• 15 Annecke T, Tjardes T, Limper U. et al. Damage Control Resuscitation and Damage Control Surgery. Anästhesiol Intensivmed Notfallmed Schmerzther 2024; 59: 340-352
• 16 Cap AP, Pidcoke HF, Spinella P. et al. Damage Control Resuscitation. Mil Med 2018; 183: 36-43
• 17 Joint Trauma System Clinical Practice Guideline (JTS CPG): Damage Control Resuscitation (DCR) in Prolonged Field Care (PFC). Publication Date 01 Oct 2018. Zugriff am 14.08.2024 unter: https://jts.health.mil/assets/docs/cpgs/Damage_Control_Resuscitation_PFC_01_Oct_2018_ID73.pdf
• 18 Ponschab M, Schöchl H, Gabriel C. et al. Haemostatic profile of reconstituted blood in a proposed 1:1:1 ratio of packed red blood cells, platelet concentrate and four different plasma preparations. Anaesthesia 2015; 70: 528-536
• 19 Hanna K, Bible L, Chebab H. et al. Nationwide analysis of whole blood hemostatic resuscitation in civilian trauma. J Trauma Acute Care Surg 2020; 89: 329-335
• 20 Lee JS, Khan AD, Wright FL. et al. Whole Blood Versus Conventional Blood Component Massive Transfusion Protocol Therapy in Civilian Trauma Patients. Am Surg 2022; 88: 880-886
• 21 Ngatuvai M, Zagales I, Sauder M. et al. Outcomes of Transfusion With Whole Blood, Component Therapy, or Both in Adult Civilian Trauma Patients: A Systematic Review and Meta-Analysis. J Surg Res 2023; 287: 193-201
• 22 Shea SM, Staudt AM, Thomas KA. et al. The use of low-titer group O whole blood is independently associated with improved survival compared to component therapy in adults with severe traumatic hemorrhage. Transfusion 2020; 60: 2-9
• 23 Stubbs JR, Zielinski MD, Jenkins D. The state of the science of whole blood: lessons learned at Mayo Clinic. Transfusion 2016; 56: 173-181
• 24 Van der Horst RA, Rijnhout TWH, Noorman F. et al. Whole blood transfusion in the treatment of acute hemorrhage, a systematic review and meta-analysis. J Trauma Acute Care Surg 2023; 95: 256-266
• 25 Joint Trauma System Clinical Practice Guideline (JTS CPG): Prehospital Blood Transfusion. (Publication Date 30 Oct 2020). Zugriff am 14.08.2024 unter: https://jts.health.mil/assets/docs/cpgs/Prehospital_Blood_Transfusion_30_Oct_2020_ID82.pdf
• 26 Joint Trauma System Clinical Practice Guideline (JTS CPG): Whole Blood Transfusion. (Publication Date 15 May 2018). Zugriff am 14.08.2024 unter: https://jts.health.mil/assets/docs/cpgs/Whole_Blood_Transfusion_15_May_2018_ID21.pdf
• 27 Levin D, Zur M, Shinar E. et al. Low-Titer Group O Whole-Blood Resuscitation in the Prehospital Setting in Israel: Review of the First 2.5 Years' Experience. Transfus Med Hemother 2021; 48: 342-349
• 28 Strandenes G, Austlid I, Apelseth TO. et al. Coagulation function of stored whole blood is preserved for 14 days in austere conditions: A ROTEM feasibility study during a Norwegian antipiracy mission and comparison to equal ratio reconstituted blood. J Trauma Acute Care Surg 2015; 78: S31-S38
• 29 Vanderspurt CK, Spinella PC, Cap AP. et al. The use of whole blood in US military operations in Iraq, Syria, and Afghanistan since the introduction of low-titer Type O whole blood: feasibility, acceptability, challenges. Transfusion 2019; 59: 965-970
• 30 Shackelford SA, Del Junco DJ, Powell-Dunford N. et al. Association of prehospital blood product transfusion during medical evacuation of combat casualties in Afghanistan with acute and 30 day survival. JAMA 2017; 318: 1581-1591
• 31 Bundesministerium der Justiz. Gesetz zur Regelung des Transfusionswesens (Transfusionsgesetz – TFG). Zugriff am: 14.08.2024 unter: https://www.gesetze-im-internet.de/tfg/TFG.pdf
• 32 Hess JR. Resuscitation of trauma-induced coagulopathy. Hematology Am Soc Hematol Educ Program 2013; 2013: 664-667
• 33 Bundesärztekammer. Richtlinie zur Gewinnung von Blut und Blutbestandteilen und zur Anwendung von Blutprodukten (Richtlinie Hämotherapie), Gesamtnovelle 2023. Zugriff am: 14.08.2024 unter: https://www.wbbaek.de/fileadmin/user_upload/BAEK/Themen/Medizin_und_Ethik/Richtlinie-Haemotherapie-2023_neu2.pdf
• 34 Remy KE, Yazer MH, Saini A. et al. Effects of platelet-sparing leukocyte reduction and agitation methods on in vitro measures of hemostatic function in cold-stored whole blood. J Trauma Acute Care Surg 2018; 84: S104-S114
• 35 Thomas KA, Shea SM, Yazer MH. et al. Effect of leukoreduction and pathogen reduction on the hemostatic function of whole blood. Transfusion 2019; 59: 1539-1548
• 36 Yazer MH, Beckett A, Bloch EM. et al. It is time to reconsider leukoreduction of whole blood for use in patients with life-threatening hemorrhage. Transfusion 2024; 64
• 37 Kiefel C. Hrsg. Transfusionsmedizin und Immunhämatologie. 4 Aufl. Heidelberg: Springer; 2010
• 38 Meledeo MA, Peltier GC, McIntosh CS. et al. Optimizing whole blood storage: hemostatic function of 35-day stored product in CPD, CP2D, and CPDA-1 anticoagulants. Transfusion 2019; 59: 1549-1559
• 39 Torres CM, Kent A, Scantling D. et al. Association of Whole Blood With Survival Among Patients Presenting With Severe Hemorrhage in US and CanadianAdult Civilian Trauma Centers. JAMA Surg 2023; 158: 532-540
• 40 Dorken-Gallastegi A, Spinella PC, Neal M. et al. Whole Blood and Blood Component Resuscitation in Trauma: Interaction and Association with Mortality. Ann Surg 2024; 280: 1014-1020
• 41 Hazelton JP, Ssentongo AE, Oh JS. et al. Use of Cold-Stored Whole Blood is Associated With Improved Mortality in Hemostatic Resuscitation of Major Bleeding. Ann Surg 2022; 276: 579-588
• 42 Sperry JL, Cotton BA, Luther JF. et al. Whole Blood Resuscitation and Association with Survival in Injured Patients with an Elevated Probability of Mortality. J Am Coll Surg 2023; 237: 206-219
• 43 Morgan KM, Yazer MH, Triulzi DJ. et al. Safety profile of low-titer group O whole blood in pediatric patients with massive hemorrhage. Transfusion 2021; 61: 8-14
• 44 Malkin M, Nevo A, Brundage SI. et al. Effectiveness and safety of whole blood compared to balanced blood components in resuscitation of hemorrhaging trauma patients – A systematic review. Injury 2021; 52: 182-188
• 45 Clements TW, Van Gent JM, Menon N. et al. Use of Low-Titer O-Positive Whole Blood in Female Trauma Patients: A Literature Review, Qualitative Multidisciplinary Analysis of Risk/Benefit, and Guidelines for Its Use as a Universal Product in Hemorrhagic Shock. J Am Coll Surg 2024; 238: 347-357
• 46 Seheult JN, Dunbar NM, Hess JR. et al. Transfusion of blood components containing ABOincompatible plasma does not lead to higher mortality in civilian trauma patients. Transfusion 2020; 60: 2517-2528
• 47 Bailey JD, Fisher AD, Yazer MH. et al. Changes in donor antibody titer levels over time in a military group O low-titer whole blood program. Transfusion 2019; 59: 1499-1506
• 48 Malone JR. Ethical considerations in the use of RhD-positive blood products in trauma. Transfusion 2024; 64: S4-S10
• 49 Cardigan R, Latham T, Weaver A. et al. Estimating the risks of prehospital transfusion of D-positive whole blood to trauma patients who are bleeding in England. Vox Sanguinis 2022; 117: 701-707
• 50 Pusateri AE, Malloy WW, Sauer D. et al. Use of Dried Plasma in Prehospital and Austere Environments. Anesthesiology 2022; 136: 327-335
• 51 Sperry JL, Guyette FX, Brown JB. et al Prehospital plasma during air medical transport in trauma patients at risk for hemorrhagic shock. N Engl J Med 2018; 379: 315-326
• 52 Apelseth TO, Raza S, Callum J. et al. A review and analysis of outcomes in randomized clinical trials of plasma transfusion in patients with bleeding or for the prevention of bleeding: The BEST collaborative study. Transfusion 2024; 64: 1-16
• 53 Donohue JK, Sperry JL, Spinella PC. et al. Incompatible plasma transfusion is not associated with increased mortality in civilian trauma patients. Hematology 2023; 28
• 54 Food and Drug Administration. Fact Sheet for Health Care Professionals or Other Authorized Providers. Zugriff am 30.08.2024 unter: https://www.fda.gov/media/180724/download
• 55 Scorer T, Williams A, Reddoch-Cardenas K. et al. Manufacturing variables and hemostatic function of cold-stored platelets: a systematic review of the literature. Transfusion 2019; 59: 2722-2732
• 56 Nair PM, Pandya SG, Dallo SF. et al. Platelets stored at 4°C contribute to superior clot properties compared to current standard-of-care through fibrin-crosslinking. Br J Haematol 2017; 178: 119-129
• 57 Marini I, Tamamushi Y, Althaus K. Kaltlagerung von Thrombozyten: Aktuelle Herausforderungen und zukünftige Perspektiven. Hämotherapie 2019; 33: 4-11
• 58 Fisher AD, Stallings JD, Schauer SG. et al. A safety and feasibility analysis on the use of cold stored platelets in combat trauma. J Trauma Acute Care Surg 2024; 97: S91-S97
• 59 Deitenbeck R, Weinstock C. Seltene Blutgruppen - Versorgung mit frischen und/oder kryokonservierten Erythrozytenkonzentraten in Deutschland - Ein Situationsbericht. Hämotherapie 2023; 41: 13-22
• 60 Joint Trauma System Clinical Practice Guideline (JTS CPG): Frozen and Deglycerolized Red Blood Cells (Publication Date 05 Aug 2024). Zugriff am 14.08.2024 unter: https://jts.health.mil/assets/docs/cpgs/Frozen_Deglycerolized_Red-Blood_Cells_05_Aug_2024_ID26.pdf
• 61 Schiffer CA, Aisner J, Dutcher JP. Platelet cryopreservation using dimethylsulfoxide. AnnNYAcadSci 1983; 411: 161-169
• 62 Noorman F, van Dongen TT, Plat MJ. et al. Transfusion: − 80 ̊C Frozen Blood Products Are Safe and Effective in Military Casualty Care. PLoS One 2016; 11: e0168401