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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

Strandenes, Geir MD; Austlid, Ivar MD; Apelseth, Torunn O. MD, PhD; Hervig, Tor A. MD, PhD; Sommerfelt-Pettersen, Jan MD; Herzig, Maryanne C. PhD; Cap, Andrew P. MD, PhD; Pidcoke, Heather F. MD, PhD; Kristoffersen, Einar K. MD, PhD

Journal of Trauma and Acute Care Surgery: June 2015 - Volume 78 - Issue 6 - p S31–S38
doi: 10.1097/TA.0000000000000628
Original Articles

BACKGROUND Formulation of a medical preparedness plan for treating severely bleeding casualties during naval deployment is a significant challenge because of territory covered during most missions. The aim of this study was to evaluate the concept of “walking blood bank” as a supportable plan for supplying safe blood and blood products.

METHODS In 2013, the Royal Norwegian Navy conducted antipiracy operations from a frigate, beginning in the Gulf of Aden and ending in the Indian Ocean. Crews were on 24-hour emergency alert in preparation for an enemy assault on the frigate. Under an approved command protocol, a “walking blood bank,” using crew blood donations, was established for use on board and on missions conducted in rigid-hulled inflatable boats, during which freeze-dried plasma and leukoreduced, group O low anti-A/anti-B titer, cold-stored whole blood were stored in Golden Hour Boxes. Data demonstrating the ability to collect, store, and provide whole blood were collected to establish feasibility of implementing a whole blood–focused remote damage-control resuscitation program aboard a naval vessel. In addition, ROTEM data were collected to demonstrate feasibility of performing this analysis on a large naval vessel and to also measure hemostatic efficacy of cold-stored leukoreduced whole blood (CWB) stored during a period of 14 days. ROTEM data on CWB was compared with reconstituted whole blood.

RESULTS Drills simulating massive transfusion activation were conducted, in which 2 U of warm fresh whole blood with platelet sparing leukoreduction were produced in 40 minutes, followed by collection of two additional units at 15-minute increments. The ROTEM machine performed well during ship-rolling, as shown by the overlapping calculated and measured mechanical piston movements measured by the ROTEM device. Error messages were recorded in 4 (1.5%) of 267 tests. CWB yielded reproducible ROTEM results demonstrating preserved fibrinogen function and platelet function for at least 3.5 weeks and 2 weeks, respectively. The frequency of ROTEM tests were as follows: EXTEM (n = 88), INTEM (n = 85), FIBTEM (n = 82), and APTEM (n = 12). CWB results were grouped. Compared with Days 0 to 2, EXTEM maximum clot firmness was significantly reduced, beginning on Days 10 to 14; however, results through that date remained within reference ranges and were comparable with the EXTEM maximum clot firmness for the reconstituted whole blood samples containing Day 5 room temperature–stored platelets.

CONCLUSION A “walking blood bank” can provide a balanced transfusion product to support damage-control resuscitation/remote damage-control resuscitation aboard a frigate in the absence of conventional blood bank products. ROTEM analysis is feasible to monitor damage-control resuscitation and blood product quality. ROTEM analysis was possible in challenging operational conditions.

LEVEL OF EVIDENCE Therapeutic study, level V.

From the Norwegian Naval Special Operation Commando (G.S.); Department of Immunology and Transfusion Medicine (G.S., T.O.A., T.A.H., E.K.K.), and Laboratory of Clinical Biochemistry (T.O.A.), Haukeland University Hospital; and Royal Norwegian Navy (I.A.), Maritime Logistics, Bergen; and Norwegian Armed Forces Joint Medical Service (J.S.-P.), Sessvollmoen, Ullensaker, Norway; Coagulation and Blood Research Program (M.C.H., A.P.C., H.F.P.), US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, Texas.

Submitted: November 29, 2014, Revised: February 3, 2015, Accepted: February 17, 2015.

This study was presented at the 4th Annual Remote Damage Control Resuscitation Symposium of the Trauma Hemostasis and Oxygenation Research Network, June 9–11, 2014, in Bergen, Norway.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

Address for reprints: Geir Strandenes, MD, Haukeland Hospital, Department of Immunology & Transfusion Medicine, Jonas Liesvei 65, N-5021 Bergen, Norway Bergen, Norway Norway; email:

© 2015 Lippincott Williams & Wilkins, Inc.