Recent developments in military transfusion practice and their impact on civilian healthcare

Introduction. Massive haemorrhage is the leading cause of preventable death following trauma. The mortality rate is high unless actively managed from Point of Injury (POI). However, during the last decade advances in military medicine, including transfusion support, appear to have delivered extraordinary survival advantages. A new transfusion policy was introduced in 2007 in response to the emerging analysis of combat experience underpinned by a revised understanding of the pathophysiology of trauma. Transfusion support was redesigned as part of Damage Control Resuscitation (DCR) to mitigate Trauma Induced Coagulopathy. The Massive Transfusion Capability was an ambitious programme designed to provide transfusion support throughout the continuum of care. The success has led to transfusion support being considered in military and civilian environments where there is a risk of haemorrhage but there is minimal medical infrastructure. Developments such as: a more portable cold chain; whole blood and lyophilised products offered Remote Damage Control Resuscitation (RDCR) whilst addressing the logistic tail. The delivery of the military capability has required considerable innovation during an era in which transfusion practice became subject to an increase in legislative and regulatory measures. The overall objective of this study is to evaluate the recent developments in military transfusion practice and to assess the impact on civilian practice. Methods. The study describes the developments in military transfusion support in a linear sequence from 2006 to 2016. The adoption of military principles and practice is then explored in the context of civilian practice and national emergency transfusion preparedness for Mass Casualty Events (MCE). The source material thesis is derived from the author’s military and civilian, professional and academic practice. The thesis submission is structured around four aims; two military thematic areas which are the recent changes in UK military blood transfusion practice and the development of prehospital transfusion. These are followed by two civilian themes; the introduction of Massive Transfusion Protocols (MTPs) and transfusion planning for Mass Casualty Events (MCEs). The military data has been extracted from the UK Joint Theatre Trauma Registry complimented by quality management systems. The civilian data is derived from the relevant Trauma Registries, Patient Administration Systems and Laboratory Information Management Systems. Descriptive statistics were used to summarize the number of components by year, speciality and patient demographics. Statistical analysis was performed using a variety of software tools. Results. The paradigm of military transfusion has changed in the last decade. The developments have been credited with contributing to survival of the critically injured. Survival is the product of the entire system of care, which – in this setting of combat, incorporates the early external haemorrhage control, hybrid resuscitation; rapid and physician-led recovery from the battlefield, damage control surgery, transfusion support and expert critical care. It is thus not possible to ascertain the individual contribution of transfusion however it has been an important element. Transfusion support is increasingly being considered in at risk environments with minimal infrastructure and logistic support. The collection of Whole blood from a pre-tested Emergency Donor panel is a viable transfusion management option. Knowledge sharing from the Bergen based Blood Far Forward program has enabled the further development of UK military practice. In addition, the concept of the safe universal whole blood donor has informed the wider transfusion community leading to the acceptance of group O Low titre as a new standard. Massive Transfusion Protocols (MTP) have been successfully introduced into civilian practice for both trauma and other causes of massive haemorrhage. Massive Transfusion (MT) is a phenomenon of surgery not trauma and the organisational principles can be applied to all causes of haemorrhage. MT is resource intensive and has implications for both hospital and blood service organisation. However, the civilian studies have not demonstrated a survival advantage and the definitions of MT require standardisation to allow comparison of practice and the design of further studies. The pattern of blood use in civilian Mass Casualty Events differs from that seen in the recent military experience in Afghanistan and Iraq. Far fewer injured require blood and few require Massive Transfusion and haemostatic component support. However, military style planning has added value to the preparation for MCEs and the response to Major Incidents. Elements of military planning have included the optimisation of pre-hospital care, haemorrhage control, transfusion triage, MTPs and emergency donor management. Transfusion Emergency Preparedness should become an integrated part of healthcare emergency planning. Conclusions. Transfusion has emerged as an essential and successful element of modern combat care. The success must be placed in the context of the whole healthcare system, especially pre-hospital care. The nature of military and civilian trauma differs however, many of the recent lessons identified have been intelligently applied to civilian hospital healthcare. Military practice has also informed both pre-hospital emergency care, blood component development and transfusion planning for MCEs. In turn, combat care has benefitted from civilian transfusion governance and regulatory expertise. The continued military-civilian collaboration and innovation in transfusion practice has the potential to benefit not only the military, but also the wider healthcare community