title: 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.
abstract: 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.
  
  
  CONCLUSIONS
  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.
  
  
  METHODS
  Therapeutic study, level V.
authors.affiliation: 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.
authors.forename: Geir
authors.initials: G
authors.lastname: Strandenes
authors.forename: Ivar
authors.initials: I
authors.lastname: Austlid
authors.forename: Torunn O
authors.initials: TO
authors.lastname: Apelseth
authors.forename: Tor A
authors.initials: TA
authors.lastname: Hervig
authors.forename: Jan
authors.initials: J
authors.lastname: Sommerfelt-Pettersen
authors.forename: Maryanne C
authors.initials: MC
authors.lastname: Herzig
authors.forename: Andrew P
authors.initials: AP
authors.lastname: Cap
authors.forename: Heather F
authors.initials: HF
authors.lastname: Pidcoke
authors.forename: Einar K
authors.initials: EK
authors.lastname: Kristoffersen
mesh_terms: D001771:Blood Banks; D001777:Blood Coagulation / Q000502:physiology; D001793:Blood Preservation; D005240:Feasibility Studies; D006801:Humans; D008887:Military Medicine; D009664:Norway; D012771:Shock, Hemorrhagic / Q000628:therapy*; D013916:Thrombelastography