1. French army 2009 update of transfusion policy in military overseas operations S. Ausset 1, E. Meaudre 2, E. Kaiser 2, B. Clavier 3, P. Gerome 4, A.V. Deshayes 3, A. Sailliol 3 1 Percy military hospital. Clamart, France 2 Saint Anne military hospital. Toulon, France 3 French Army transfusion center R.Batany. Clamart, France 4 Desgenettes military hospital. Lyon, France

2. Aims To assess blood transfusion practices during military operations overseas according to European laws and missions of French Army medical service (SSA) To improve the process, under control of French medical & transfusion society

3. www.gradeworkingruop.org Grading of Recommendations Assessment, Development, and Evaluation Working Group SYSTEM FOR ASSESSMENT QUALITY OF EVIDENCE AND STRENGTH OF RECOMMENDATIONS Method

4. Results (1) 1.Haemorrhage is the leading cause of preventable death for war casualties. Level of evidence C 2.¼ of war casualties needs a blood transfusion, and 5% a massive transfusion (MT). Level of evidence B 3.Mortality varies according to transfusion requirements: 13% for overall transfused patients vs 22% for MT. Level of evidence B Borgman, MA et al. J Trauma. 2007;63:805–813. 5293 war casualties (nov 2003 - sept 2005) at Bagdad US CSH. 246 (4.6%) MT

5. Results (2) Hemorrhage 4.This increased mortality is associated with clotting abnormalities. Level of evidence B Borgman, MA et al. J Trauma. 2007;63:805–813.

6. Results (2) 5.The ratio of blood products transfused strongly impacts mortality – especially for MT. Level of evidence B Holcomb et al. Ann Surg 2008;248:447-458 466 MT Civilian Trauma Patients ➔ 12 cohort studies (4737 patients, 1206 war casualties, 3531 civilian trauma) – 11 retrospective - 1 before/after – 11 « pro » massive transfusion of clotting factors– 1 inconclusive – 9 on MT– 4 on all type transfusion

7. The sound transfusion policy Transfusion in trauma = 1 RBC1 FFP1 platelets unit++

8. Freeze-Dried Plasma (FDP) Can be stored at ambient temperature for two years Reconstituted in < 10 min Issued from lyophilisation of pooled apheresis plasma (<10 different donors), deleukocyted and secured by quarantine. Compatible with every blood types.

9. Blood bank on the field 20-40 PRBC and 10-20 plasma units according the threat level = 1 hour of transfusion therapy

10. Platelets? Weekly supply? Apheresis on the field?

11. A new job to learn! Fresh whole blood (FWB) transfusion –Indications & therapeutic use Collective indications (shortage) Individual indications: Severe trauma with coagulopathy –Indication of collection 6.This need of MT (& FWB) can be predicted early on the basis of prehospital data. Level of evidence A

12. A new job to learn! -Biologic testing (viral serology - Blood typing) -Hemovigilence 7.The viral risk associated with FWB on the field could be 0.11% forle hepatitis C and 0.07% for HTLV. Level of evidence C

13. Conclusion Paradigm for transfusion policy in trauma has changed This needs us to learn new jobs: –Blood collection –Hemovigilence… The challenge is even greater in a multinational setting

14. THANK YOU FOR YOUR ATTENTION