An observational study of the blood use in combat casualties of the French Armed Forces, 2013-2021.
damage control
military trauma
severe hemorrhage
transfusion
whole blood
Journal
Transfusion
ISSN: 1537-2995
Titre abrégé: Transfusion
Pays: United States
ID NLM: 0417360
Informations de publication
Date de publication:
01 2023
01 2023
Historique:
revised:
30
08
2022
received:
05
07
2022
accepted:
07
09
2022
pubmed:
27
11
2022
medline:
18
1
2023
entrez:
26
11
2022
Statut:
ppublish
Résumé
The French Armed Forces conduct asymmetric warfare in the Sahara-Sahel Strip. Casualties are treated with damage control resuscitation to the extent possible. Questions remain about the feasibility and sustainability of using blood for wider use in austere environments. We performed a retrospective analysis of all French military trauma patients transfused after injury in overseas military operations in Sahel-Saharan Strip, from the point of injury, until day 7, between January 11, 2013 to December 31, 2021. Forty-five patients were transfused. Twenty-three (51%) of them required four red blood cells units (RBC) or more in the first 24H defining a severe hemorrhage. The median blood product consumption within the first 48 h, was 8 (IQR [3; 18]) units of blood products (BP) for all study population but up to 17 units (IQR [10; 27.5]) for the trauma patients with severe hemorrhage. Transfusion started at prehospital stage for 20 patients (45%) and included several blood products: French lyophilized plasma, RBCs, and whole blood. Patients with severe hemorrhage required a median of 2 [IQR 0; 34] further units of BP from day 3 to day 7 after injury. Eight patients died in theater, 4 with severe hemorrhage and these 4 used an average of 12 products at Role 1 and 2. The transfusion needs were predominant in the first 48 h after the injury but also continued throughout the first week for the most severe trauma patients. Importantly, our study involved a low-intensity conflict, with a small number of injured combatants.
Sections du résumé
BACKGROUND
The French Armed Forces conduct asymmetric warfare in the Sahara-Sahel Strip. Casualties are treated with damage control resuscitation to the extent possible. Questions remain about the feasibility and sustainability of using blood for wider use in austere environments.
METHODS
We performed a retrospective analysis of all French military trauma patients transfused after injury in overseas military operations in Sahel-Saharan Strip, from the point of injury, until day 7, between January 11, 2013 to December 31, 2021.
RESULTS
Forty-five patients were transfused. Twenty-three (51%) of them required four red blood cells units (RBC) or more in the first 24H defining a severe hemorrhage. The median blood product consumption within the first 48 h, was 8 (IQR [3; 18]) units of blood products (BP) for all study population but up to 17 units (IQR [10; 27.5]) for the trauma patients with severe hemorrhage. Transfusion started at prehospital stage for 20 patients (45%) and included several blood products: French lyophilized plasma, RBCs, and whole blood. Patients with severe hemorrhage required a median of 2 [IQR 0; 34] further units of BP from day 3 to day 7 after injury. Eight patients died in theater, 4 with severe hemorrhage and these 4 used an average of 12 products at Role 1 and 2.
CONCLUSION
The transfusion needs were predominant in the first 48 h after the injury but also continued throughout the first week for the most severe trauma patients. Importantly, our study involved a low-intensity conflict, with a small number of injured combatants.
Types de publication
Observational Study
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
69-82Informations de copyright
© 2022 AABB.
Références
Hoencamp R, Vermetten E, Tan ECTH, Putter H, Leenen LPH, Hamming JF. Systematic review of the prevalence and characteristics of battle casualties from NATO coalition forces in Iraq and Afghanistan. Injury [Internet]. 2014;45(7):1028-34. https://doi.org/10.1016/j.injury.2014.02.012
Beekley AC, Martin MJ, Spinella PC, Telian SP, Holcomb JB. Predicting resource needs for multiple and mass casualty events in combat: lessons learned from combat support hospital experience in operation Iraqi freedom. J trauma - Inj infect. Crit Care. 2009;66(4 Suppl):S129-37.
Mazuchowski EL, Kotwal RS, Janak JC, Howard JT, Harcke HT, Montgomery HR, et al. Mortality review of US special operations command battle-injured fatalities. J Trauma Acute Care Surg. 2020;88(5):686-95.
Holcomb JB, McMullin NR, Pearse L, Caruso J, Wade CE, Oetjen-Gerdes L, et al. Causes of death in U.S. special operations forces in the global war on terrorism: 2001-2004. Ann Surg [Internet]. 2007 Jun [cited 2021 Dec 16];245(6):986 Available from: /pmc/articles/PMC1876965/.
Eastridge BJ, Mabry RL, Seguin P, Cantrell J, Tops T, Uribe P, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012;73(6 SUPPL. 5):431-7.
Holcomb JB, Jenkins D, Rhee P, Johannigman J, Mahoney P, Mehta S, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma-Inj Infect Crit Care. 2007;62(2):307-10.
Jenkins DH, Rappold JF, Badloe JF, Berséus O, Lorne Blackbourne C, Brohi KH, et al. THOR position paper on remote damage control resuscitation: definitions, current practice and knowledge gaps NIH public access. Shock. 2014;41(1):3-12.
Ditzel RM, Anderson JL, Eisenhart WJ, Rankin CJ, DeFeo DR, Oak S, et al. A review of transfusion- and trauma-induced hypocalcemia: is it time to change the lethal triad to the lethal diamond? J Trauma Acute Care Surg. 2020;88(3):434-9.
Morrison JJ, ChB M, Dubose JJ, Rasmussen TE, Midwinter MJ. ONLINE FIRST military application of Tranexamic acid in trauma emergency resuscitation (MATTERs) study. Arch Surg. 2012;147(2):113-9.
Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma-Inj Infect Crit Care. 2007;63(4):805-13.
Holcomb JB, Del Junco DJ, Fox EE, Wade CE, Cohen MJ, Schreiber MA, et al. ONLINE FIRST the prospective, observational, multicenter, major trauma transfusion (PROMMTT) study comparative effectiveness of a time-varying treatment with competing risks. JAMA Surg. 2013;148(2):127-36.
Pidcoke HF, Aden JK, Mora AG, Borgman MA, Spinella PC, Dubick MA, et al. Ten-year analysis of transfusion in operation Iraqi freedom and operation enduring freedom. J Trauma Acute Care Surg [Internet]. 2012 Dec [cited 2021 Jan 11];73(6 SUPPL. 5):S445-52. Available from: http://journals.lww.com/01586154-201212005-00012
Langan NR, Eckert M, Martin MJ. Changing patterns of in-hospital deaths following implementation of damage control resuscitation practices in US forward military treatment facilities. JAMA Surg [Internet]. 2014 Sep 1 [cited 2021 Apr 7];149(9):904-12. Available from: https://jamanetwork.com/
Howard JT, Kotwal RS, Stern CA, Janak JC, Mazuchowski EL, Butler FK, et al. Use of combat casualty care data to assess the US military trauma system during the Afghanistan and Iraq conflicts, 2001-2017. JAMA Surg [Internet]. 2019 Jul 1 [cited 2021 Nov 13];154(7):600-8. Available from: https://jamanetwork-com.ezproxy.u-paris.fr/journals/jamasurgery/fullarticle/2729451
Sperry JL, Guyette FX, Brown JB, Yazer MH, Triulzi DJ, Early-Young BJ, et al. Prehospital plasma during air medical transport in trauma patients at risk for hemorrhagic shock. N Engl J Med. 2018;379(4):315-26.
Hoffmann C, Poyat C, Alhanati L, Bouix J, Falzone E, Donat N, et al. Épidémiologie des blessés de guerre français en Afghanistan: de la blessure à la réinsertion. Urgences. 2015;(June);83:1-22.
Vitalis V, Carfantan C, Montcriol A, Peyrefitte S, Luft A, Pouget T, et al. Early transfusion on battlefield before admission to role 2: a preliminary observational study during “Barkhane” operation in Sahel. Injury. 2017 [cited 2021 Mar 10];49:903-10. https://doi.org/10.1016/j.injury.2017.11.029
Carfantan C, Goudard Y, Butin C, Duron-martinaud S, Even J, Anselme A, et al. Forward medevac during serval and Barkhane operations in Sahel: a registry study. Injury [Internet]. 2017;48(1):58-63. https://doi.org/10.1016/j.injury.2016.10.043
Kotwal RS, Scott LLF, Janak JC, Tarpey BW, Howard JT, Mazuchowski EL, et al. The effect of prehospital transport time, injury severity, and blood transfusion on survival of US military casualties in Iraq. J Trauma Acute Care Surg. 2018;85(1 S Suppl 2):S112-21.
Martinaud C, Travers S, Pasquier P, Sailliol A, Ausset S. Blood far forward program: update on French armed forces policy. Transfusion. 2021;61(S1):S354-5.
Javaudin O, Baillon A, Varin N, Martinaud C, Pouget T, Civadier C, et al. Air-drop blood supply in the French Army. J R Army Med Corps. 2018;164(4):240-4.
Shackelford SA, del Junco DJ, Powell-Dunford N, Mazuchowski EL, Howard JT, Kotwal RS, et al. Association of Prehospital Blood Product Transfusion during Medical Evacuation of combat casualties in Afghanistan with acute and 30-day survival. JAMA [Internet]. 2017;318(16):1581-91. Available from: https://jamanetwork.com/
Thierry Burkhard G. Gagner la guerre avant la guerre.
Beehner L, Collins L. Dangerous myths how the crisis in Ukraine explains future great power conflict. Modern war institute 2020. https://mwi.usma.edu/dangerous-myths-ukraine-and-future-of-great-power-competition/
Knipper P, Bégué T, Pasquesoone L, Guerre E, Khonsari R, Girard P, et al. Chirurgie plastique et conflit armé: notre expérience lors du conflit au Haut-Karabakh en 2020. Ann Chir Plast Esthétique. 2021;66(3):201-9.
Brutyan S, Babayan K, Barseghyan N, Petrosyan V, Knipper P, Bégué T, et al. Evidence for chemical burns by white phosphorus in Armenian soldiers during the 2020 Nagorno-Karabakh war. Injury. 2021;52(4):1100-1.
Khorram-Manesh A, Goniewicz K, Burkle FM, Robinson Y. Review of military casualties in modern conflicts-the Re-emergence of casualties from armored warfare. Mil Med. 2022;187(3-4):e313-21. https://doi.org/10.1093/milmed/usab108/6179198
Schauer SG, Long BJ, Rizzo JA, Walrath BD, Baker JB, Gillespie KR, et al. A conceptual framework for non-military investigators to understand the joint roles of medical care in the setting of future large scale combat operations. Prehosp Emerg Care. 2022;1-8. https://doi.org/10.1080/10903127.2021.2008070.
Atlantic N, Organization T. Allied joint Doctrine. 2019. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/841686/doctrine_nato_med_spt_ajp_4_10.pdf
Malgras B, Barbier O, Petit L, Rigal S, Pons F, Pasquier P. Surgical challenges in a new theater of modern warfare: the French role 2 in Gao. Mali Injury. 2016;47(1):99-103.
Luft A, Pasquier P, Soucanye de Landevoisin E, Morel-Stum N, Baillon A, Louis S, et al. The damage control resuscitation and surgical team: the new French paradigm for Management of Combat Casualties. Mil Med. 2022;187(3-4):e275-81.
Pasquier P, Dubost C, Boutonnet M, Chrisment A, Villevieille T, Batjom E, et al. Predeployment training for forward medicalisation in a combat zone: the specific policy of the French military health service. Injury. 2014;45(9):1307-11.
Planchon J, Vacher A, Comblet J, Rabatel E, Darses F, Mignon A, et al. Serious game training improves performance in combat life-saving interventions. Injury [Internet]. 2018;49(1):86-92. https://doi.org/10.1016/j.injury.2017.10.025
Vertu N, Travers S, Pasquier P. Predeployment training for prolonged field care in current combat zones. J Trauma Acute Care Surg. 2021;91(5):e125.
Sailliol A, Martinaud C, Cap AP, Civadier C, Clavier B, Deshayes AV, et al. The evolving role of lyophilized plasma in remote damage control resuscitation in the French armed forces health service. Transfusion. 2013;53(SUPPL. 1):65S-71S.
Ponsin P, Swiech A, Poyat C, Alves F, Jacques AE, Franchin M, et al. Strategic air medical evacuation of critically ill patients involving an intensive care physician: a retrospective analysis of 16 years of mission data. Injury [Internet]. 2021 [cited 2022 Apr 17];52:1176-82. https://doi.org/10.1016/j.injury.2020.10.010
Garrigue D, Godier A, Glacet A, Labreuche J, Kipnis E, Paris C, et al. French lyophilized plasma versus fresh frozen plasma for the initial management of trauma-induced coagulopathy: a randomized open-label trial. J Thromb Haemost. 2017;16:481-9.
Daniel Y, Sailliol A, Pouget T, Peyrefitte S, Ausset S, Martinaud C. Whole blood transfusion closest to the point-of-injury during French remote military operations. J Trauma Acute Care Surg. 2017;82(6):1138-46.
Aymard J. La transfusion sanguine pendant la Grande Guerre (1914-1918) * blood transfusion during world war I (1914-1918). 2016;353-66.
Stanworth SJ, Davenport R, Curry N, Seeney F, Eaglestone S, Edwards A, et al. Mortality from trauma haemorrhage and opportunities for improvement in transfusion practice. 2016. Available from: www.bjs.co.uk
James A, Abback PS, Pasquier P, Ausset S, Duranteau J, Hoffmann C, et al. The conundrum of the definition of haemorrhagic shock: a pragmatic exploration based on a scoping review, experts' survey and a cohort analysis. Eur J Trauma Emerg Surg. 2022. doi:10.1007/s00068-022-01998-9
Fisher AD, Carius BM, April MD, Naylor JF, Maddry JK, Schauer SG. An analysis of adherence to tactical combat casualty care guidelines for the Administration of Tranexamic Acid. J Emerg Med [Internet]. 2019;57(5):646-52. https://doi.org/10.1016/j.jemermed.2019.08.027
April MD, Fisher AD, Hill R, Rizzo JA, Mdaki K, Bynum J, et al. Adherence to a balanced approach to massive transfusion in combat casualties. Mil Med. 2021:usab313. https://doi.org/10.1093/milmed/usab313
Nguyen C, Bordes J, Cungi PJ, Esnault P, Cardinale M, Mathais Q, et al. Use of French lyophilized plasma transfusion in severe trauma patients is associated with an early plasma transfusion and early transfusion ratio improvement. J Trauma Acute Care Surg. 2018;84(5):780-5.
Boyé M, Py N, Libert N, Christment A, Pissot M, Dedome E, et al. Step by step transfusion timeline and its challenges in trauma: a retrospective study in a level one trauma center. Transfusion. 2022;62 Suppl 1:S30-42.
Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, Podbielski JM, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma the PROPPR randomized clinical trial. 2015; Available from: https://jamanetwork.com/
Cardenas JC, Zhang X, Fox EE, Cotton BA, Hess JR, Schreiber MA, et al. Platelet transfusions improve hemostasis and survival in a substudy of the prospective, randomized PROPPR trial. 2018; Available from: http://ashpublications.org/bloodadvances/article-pdf/2/14/1696/881038/advances017699.pdf
Daban JL, Kerleguer A, Clavier B, Salliol A, Ausset S. Transfusion de sang frais total en temps de guerre: Expérience du groupement médicochirurgical Warehouse durant la période 2006-2009. Ann Fr Anesth Reanim. 2012;31(11):850-6.
Brill JB, Tang B, Hatton G, Mueck KM, McCoy CC, Kao LS, et al. Impact of incorporating whole blood into hemorrhagic shock resuscitation: analysis of 1,377 consecutive trauma patients receiving emergency-release Uncrossmatched blood products. J Am Coll Surg [Internet]. 2022 Apr 1 [cited 2022 May 19];234(4):408-18. Available from: https://journals-lww-com.ezproxy.u-paris.fr/journalacs/Fulltext/2022/04000/Impact_of_Incorporating_Whole_Blood_into.2.aspx
Braverman MA, Smith A, Pokorny D, Axtman B, Shahan CP, Barry L, et al. Prehospital whole blood reduces early mortality in patients with hemorrhagic shock. Transfusion. 2021;61(S1):S15-21.
Gurney J, Staudt A, Cap A, Shackelford S, Mann-Salinas E, Le T, et al. Improved survival in critically injured combat casualties treated with fresh whole blood by forward surgical teams in Afghanistan. Transfusion. 2020;60(S3):S180-8.
Gurney JM, Staudt AM, del Junco DJ, Shackelford SA, Mann-Salinas EA, Cap AP, et al. Whole blood at the tip of the spear: a retrospective cohort analysis of warm fresh whole blood resuscitation versus component therapy in severely injured combat casualties. Surg (United States) [Internet]. 2022;171(2):518-25. https://doi.org/10.1016/j.surg.2021.05.051
Martinaud C, Fleuriot E, Pasquier P. Journal pre-proof implementation of low titer whole blood for French overseas operations: O positive or negative products in massive hemorrhage? 2020 [cited 2022 Mar 6];29:164-7. https://doi.org/10.1016/j.tracli.2022.02.005
Aloird J, Martinaud C, Pasquier P. First transfusion of cold-stored low-titer group O whole blood in the French armed forces. Transfusion. 2022;62(6):1305-09.
Jansen JO, Morrison JJ, Midwinter MJ, Doughty H. Changes in blood transfusion practices in the UK role 3 medical treatment facility in Afghanistan, 2008-2011. Transfus Med. 2014;24(3):154-61.
Hamada SR, Garrigue D, Nougue H, Meyer A, Boutonnet M, Meaudre E, et al. Impact of platelet transfusion on outcomes in trauma patients. Crit Care. 2022;26(1):49.
Kleinveld DJ, Sloos PH, Noorman F, Adrie Maas MW, Kers J, Rijnhout TW, et al. The use of cryopreserved platelets in a trauma-induced hemorrhage model. 2020.
Derkenne C, Travers S, Kedzierewicz R, Jost D, Prunet B, Martinaud C. Performances of iceless containers for lightweight transport of red cell concentrate units during military operations [internet]. Transfusion Clinique et Biologique. 2020 [cited 2022 Mar 20];27:98-102. https://doi.org/10.1016/j.tracli.2020.02.001
Vanderspurt CK, Spinella PC, Cap AP, Hill R, Matthews SA, Corley JB, 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 [Internet]. 2019 Mar 1 [cited 2022 Mar 19];59(3):965-70. https://doi.org/10.1111/trf.15086
Clarke EE, Hamm J, Fisher AD, April MD, Long BJ, Mdaki KS, et al. Trends in prehospital blood, crystalloid, and colloid administration in accordance with changes in tactical combat casualty care guidelines. 2021;(Iv):1-6.
Fisher AD, Paulson MW, McKay JT, Bynum J, Flarity KM, Howell M, et al. Blood product administration during the role 1 phase of care: the prehospital trauma registry experience. Mil Med. 2022;187(1-2):e70-5.
Pusateri AE, Moore EE, Moore HB, Le TD, Guyette FX, Chapman MP, et al. Association of Prehospital Plasma Transfusion with Survival in trauma patients with hemorrhagic shock when transport times are longer than 20 minutes a post hoc analysis of the PAMPer and COMBAT clinical trials. 2019; Available from: https://jamanetwork.com/
Fisher AD, Lavender JS, April MD, Hill R, Bynum J, Schauer SG. A descriptive analysis of supermassive transfusion recipients among US and coalition forces during combat operations in Afghanistan and Iraq. Mil Med. 2021;00:1-6.
Carfantan C. Aeromedical evacuations within the French armed forces: analysis of 2,129 patients. Mil Med [Internet]. 2019 [cited 2022 Feb 15];185:2020 Available from: https://academic.oup.com/milmed/article/185/3-4/468/5586484
Martinez T, François A, Pouget T, Carli P, Lapostolle F, Gauss T, et al. Blood product needs and transfusion timelines for the multisite massive Paris 2015 terrorist attack: a retrospective analysis. J Trauma Acute Care Surg. 2020;89(3):496-504.
April MD, Stednick PJ, Christian NB. A descriptive analysis of notional casualties sustained at the joint readiness training center: implications for health service support during large-scale combat operations. Med J (Fort Sam Houston, Tex). 2021;(PB 8-21-04/05/06);3-8.
Daniel Y, Habas S, Malan L, Escarment J, David JS, Peyrefitte S. Tactical damage control resuscitation in austere military environments. J R Army Med Corps. 2016;162(6):419-27.
Keenan S, Riesberg JC. Prolonged field care: beyond the “Golden hour”. Wilderness and Environmental Medicine; Elsevier Ltd. 2017;28:S135-9.
Travers S, Carfantan C, Luft A, Aigle L, Pasquier P, Martinaud C, et al. Five years of prolonged field care: prehospital challenges during recent French military operations. Transfusion [Internet]. 2019 Apr 13 [cited 2020 Sep 28];59(S2):1459-66. https://doi.org/10.1111/trf.15262