Medical Science Publication No. 4, Volume 1
OPERATION OF BLOOD BANK SYSTEMS*
COLONEL DOUGLAS B.KENDRICK, MC
It is the purpose of this paper to review the development of blood banksystems in the Armed Forces during World War II and the Korean war, withspecial emphasis on our accomplishments, inadequacies and recommendationsfor improvements in the system of blood supply to our fighting forces.
In the annals of military history there is probably nothing that hasmade a greater impact on the curing of ills and the restoration of functionresulting from war wounds than the adequate and judicious use of wholeblood. It is a strange paradox that, in an era of medicine that will longbe remembered as the culmination of the renaissance of this great art,approximately a half century elapsed before it became generally acceptedthat the mortality rates from war wounds were almost directly proportionalto the availability and proper use of whole blood. Although the lessonslearned in World War II were convincing evidence of this concept, it remainedfor the Korean war to establish this principle firmly in the minds of operatingsurgeons and statisticians alike. It is not surprising, then, that whenthe history of World War II is reviewed, the errors of omission, relatedto the inadequacy of the supply of whole blood, are so apparent.
With the knowledge which we possess today as to the needs for wholeblood for resuscitation and major surgery, it seems incredible that wecould have permitted so much delay during World War II in making wholeblood available to the theaters of operation throughout the world. Butin all fairness to those concerned and for the sake of the record, it shouldbe pointed out that the supply of blood to theaters, far removed from themainland, depends on four cardinal features: a completely closed, sterile,pyrogen-free system of collection in a container which will maintain itsintegrity; an efficient anticoagulant and preservative solution which willextend the longevity of red blood cells to meet the logistical demands;maintenance of constant temperature during shipment; and availability ofsufficient long-range airplanes to permit a continuous and dependable supplyof blood. These four requirements first became available in the summerof 1944, and it was
*Presented 20 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center. Washington, D. C.
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at that time that we began to make blood available in vast quantitiesfrom the homeland to both the European and Pacific theaters.
A brief resumé of the struggle encountered during World War IIto develop a system of blood supply in active theaters, and from the UnitedStates to units in the field will help to emphasize the difficulty of tryingto introduce new methods of medical management during a worldwide conflict.As early as 1940, DeGowin and Hardin had demonstrated, by shipping in planes,blood refrigerated with wet ice in marmite cans back and forth across country,the feasibility of transporting blood long distances and using it safelyin recipients several days after collection.
The next important development was in the field of blood-collectingequipment. In the processing of liquid plasma, it became apparent thatthe successful manufacture of liquid plasma for transfusion was dependentupon the use of a completely closed system with sterile, pyrogen-free containersand collecting sets. This principle was carried over to the collectionof blood for transfusion, and from it stemmed the development of sterilevacuum bottles and disposable collecting and administration sets. Withthe advent of these transfusion units in 1942, recommendations were madeto make these sets available to all hospitals in combat areas, to replacethe makeshift equipment such as open flasks and funnels filled with cottongauze as filters. Despite repeated pleas by personnel in the Mediterraneantheater for suitable blood transfusion equipment, the newly-developed equipmentwas not made available because the great need for blood in addition toplasma was not recognized by those in a position to provide it, and secondly,it was ruled that overseas surface shipping capacities for medical equipmentwere not adequate to allow for the use of disposable blood bottles in overseastheaters. Thus, makeshift transfusion equipment continued to be employedin the Mediterranean theater and the European theater until early 1944.As a result of persistent effort on the part of transfusion officers inItaly and England, and despite other handicaps, excellent blood bank systemswere developed locally and blood was collected from troops in the communicationszones and made available to hospitals in combat areas in each theater.
Anticipating the needs for larger quantities of blood for the invasionof the continent, the National Research Council in April 1944, recommendedcollecting blood in the United States and transporting it to England byair. This recommendation was opposed, and it was not until August 1944,after requirements for blood exceeded that afforded from England, thata plan was permitted to go forward to fly blood to England. This plan wasquickly implemented, and within 2 weeks 1,000 bottles of blood a day, witha dating period of 14 days, were being shipped. This was quickly raisedto 1,500 bottles a day. Within
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a short time improved preservative solutions were developed and utilized,which made it possible to allow a 21-day dating period.
The lessons learned in the European theater of operations and Italyregarding blood shipments, delivery to individual units and the properuse of blood in the treatment of casualties were of inestimable value inthe Pacific. By November 1944, through the cooperation of the Army andNavy, daily blood shipments were being made to Leyte and other islandsin the Pacific, and supplies from the United States continued as the majorsource of blood for the Pacific until the end of the Japanese war.
Although, to many of you, the history of the development of blood banksystems in World War II may seem incongruous and woefully slow, I wishto remind you that as late as 1940 and 1941 transfusions of whole bloodwere done with considerable trepidation because of the frequent mishapsthat resulted; furthermore, there was no standardization of equipment,and even direct transfusions were still being employed because of the fearof reactions from citrate; and the transfusion of a patient rarely exceededthe injection of 500 cc. of blood. Thus, the development of blood banksystems between 1941 and 1945 for the armed services entailed not onlythe investigation of suitable equipment for collecting, shipping, preservingand injecting blood, but required the indoctrination of all medical officersin the proper use of blood transfusions.
What were the lessons learned about blood bank systems in World WarII?
1. To prevent contamination and permit long storage and shipment, bloodmust be collected under a closed system into sterile, pyrogen-free containers.
2. Storage and shipment at a constant temperature of 38° to 42°F. are essential to preserve red blood cells for the allotted 3 weeks.
3. Blood can be preserved with acid-citrate dextrose solution (Loutet-Mollisonsolution) up to 21 days with an expected 70 percent post-transfusion survivalrate of red blood cells.
4. Low-titer, Group "O" blood was found to be relatively safeand more desirable for use in combat hospitals than group-specific blood.
5. During hostilities, blood can be collected from troops in the communicationszones, but the majority of blood utilized should be obtained from the Zoneof Interior.
6. To permit the proper collection of blood from troops in the communicationszone, adequate supplies of transfusion equipment must be included in medicalsupplies in support of armies, corps and regimental combat teams.
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7. In World War II the administrative control of blood bank systemsdeveloped as awkwardly as the technical procedures. In 1945, based upona review of the blood bank system in World War II, it was recommended thatin case of future conflict a transfusion branch in the Office of The SurgeonGeneral should be established to inaugurate a whole blood procurement program.Sufficient personnel should be trained in transfusion therapy to man thevarious positions required.
8. In addition to the transfusion branch in the Office of The SurgeonGeneral, there should be a Consultant on Blood and Transfusions attachedto the office of each Theater Surgeon who will be responsible for the bloodsupply to communications zone hospitals and combat units in that theater.There should be sufficient collecting and distributing teams to collectand deliver blood in the theater, and sufficient equipment to store andprocess blood received from the United States.
These were the lessons learned and the recommendations made at the endof World War II. Only 5 years elapsed before we were called upon to testout the recommendations set forth in 1945.
Blood Bank System during the Korean War
In 1949, in preparation for any future national emergency, a Blood andBlood Derivatives Committee was set up in the Medical Director's Officeof the Department of Defense and plans were made to make available adequateequipment for the collection, shipment and administration of whole bloodas well as plasma and albumin. This Committee was responsible for developingall policy related to the needs for blood and blood derivatives for theArmed Forces. The recommendations of this Committee were implemented bythe Directorate of the Armed Services Medical Procurement Agency, and consequently,during 1949 and 1950 considerable blood transfusion equipment was procured.
Thus, at the outset of hostilities in June 1950 in Korea, equipmentfor the collection and administration of blood was available in the FarEast theater. A blood collection program was initiated promptly in Japan,and through the cooperation of troops, civilian nationals and foreign nationalsas donors, the initial requirements for blood were met. By August 1950increasing casualty rates indicated the need for much larger quantitiesof blood; therefore, a supplemental supply was requested from the UnitedStates. The request for whole blood was reviewed and acted upon by theBlood Committee of the Defense Department. As a result, an operationalgroup, designated the Blood and Blood Derivatives Group, was establishedunder the Directorate of the Armed Services Medical Procurement Agency.This
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group was charged with the responsibility of securing adequate suppliesof blood, obtaining equipment and supplies for shipment, processing bloodand filling the orders for blood as they were received from the Far Easttheater. The Defense Department asked the American Red Cross to collectblood for the Armed Forces and this organization worked in unison withthe blood group in meeting quotas as they developed. By using existingAmerican Red Cross centers, Defense centers operated by ARC, cooperatingblood banks working with ARC, and by the development of Armed Forces centerson military bases throughout the country, sufficient blood was collectedto cover our needs in Korea, as well as to supply plasma-processing plantsand albumin-fractionation plants in the United States.
For shipment overseas, only low-titer group "O" blood, collectedin 120 cc. of ACD solution, was used. It was collected in sterile, pyrogen-free,vacuum glass bottles, providing a completely closed system. Blood collectedin centers scattered throughout the country was transported by air liftto the Armed Services blood-processing center at Travis Air Force Base.This processing laboratory was adequately staffed with trained personnelwho usually screened all bottles of blood, retyped it, re-titered it, anddetermined the suitability of each bottle for shipment by checking forabnormalities in appearance and volume. Storage and re-icing facilitieswere available to maintain an adequate supply of blood to meet the dailyoverseas quotas. The Processing Center also coordinated the shipment ofblood overseas with the cooperation of the Military Air Transport Service.
Blood shipments were consigned to the 406th Laboratory in Japan, andthis organization had the responsibility of supplying the distributioncenters in Korea with their daily requirements. Blood for this purposewas available both from Japan as well as the United States; approximately75 percent of the blood came from the Zone of Interior. It is interestingto note that although the 406th Laboratory distributed blood directly tomedical installations in Japan, the supply of blood to medical units inKorea was a function of various Army medical depots in Korea, which inturn delivered to Army surgical hospitals and other installations usingblood. Where supply lines were long, there were intermediate storage andsupply points. It should be pointed out that in this type of blood banksystem it is necessary for each depot, intermediate storage and supplypoint to maintain a sufficient amount of blood to permit each to meet itsmaximum requirements at all times. It is admittedly desirable to have thepipeline filled at all times, but multiple supply and resupply points areundesirable.
During Word War II and the Korean war there appeared to be an unlimitedreservoir of blood available. In the future, because of the requirementfor civilian as well as military casualties, resulting from
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atomic warfare, whole blood will have to be conserved more than everbefore. This can best be done by having a blood-collection and deliverysystem, which is a separate, complete unit, centrally coordinated and supervisedand given the authority and responsibility for making blood available tousing medical installations. In this manner, usage rates can be determinedand stores of blood formally trapped in multiple supply points can be mobilized.During wartime it is expected that, because of the perishability of bloodand unpredictable enemy action, a certain percentage of blood may becomeoutdated. However, in planning for total war, we must revise our thinkingand reduce our blood losses to the barest minimum.
Comments
With this brief historical review of the development of blood bank systemsduring World War II and the Korean war, it seems appropriate to recapitulateby outlining the lessons learned in Korea and the inadequacies which remainto be corrected. First I shall mention the basic principles of militaryblood bank systems which have been clearly established, and follow thisby pointing out the inadequacies which still exist.
1. Whole blood is an essential part of the armamentarium for treatingcasualties produced by war.
2. The collection of blood in a closed, sterile, pyrogen-free containerand shipment of it to the far corners of the globe by air are feasible.
3. By collecting blood in an optimum solution of acid-citrate-dextroseand maintaining it at a constant temperature of 4° to 6° C, itcan be preserved and administered safely for 21 days.
4. Low-titer group "O" blood is more acceptable for use incombat medical units than type-specific blood.
5. Although blood can be preserved for 21 days, the need for transfusionscan best be served with fresh blood, and every effort should be made tobalance supply and demand so that the freshest blood possible can be used.
6. Reusable blood-shipping containers have proved to be efficient andeconomical. Rigid, fiber board, trunklike containers with 3-inch plastic,waterproofed insulation have been most effective in maintaining a constanttemperature at fairly extreme ambients.
Inadequacies which continue to plague us in military blood bank systemsare divided into administrative and technical problems.
1. Administrative Problems
Organization of a Military Blood Bank System. Experience duringtwo wars in the past 10 years has revealed the fallacy of not having
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a well organized blood bank system established when hostilities breakout. This has resulted in delays, inefficiency, greater expense and inabilityto capitalize on the tremendous research potentialities afforded us bythe collection and clinical use in war casualties of millions of unitsof blood.
It is my firm conviction that the technology involved in the collection,preservation, shipment, storage, distribution and clinical use of wholeblood-in other words, blood bank systems-is a professional responsibility.Whole blood is a rapidly perishable biological that should be treated likeno other medical item that we have and, therefore, should not be placedin supply channels. Its potentialities for salvaging maimed bodies aresuch that the organization and personnel responsible for the blood banksystem of our Armed Services should be of the highest order. Entirely toolittle emphasis has been placed on the organization of a Transfusion Servicein the past, and it has been forced to fight for its existence withoutbenefit of adequately trained personnel and without the backing and supportof professional services. Primary support for the Transfusion Service inWorld War II and Korea has been afforded by the Supply Division, and propercredit should be accorded it for its constant and loyal support. However,the provisions for whole blood and the operation of blood bank systems,including distribution, are not Supply problems, but rather a professionallogistic project requiring the greatest coordination of skilled professionalpersonnel. Cognizance should be taken of this and a continuing effort madeto train personnel in the laboratory phases, clinical phases and researchrequirements for blood transfusions, so as to organize blood bank systemsin the future staffed with well trained physicians thoroughly versed inall phases of military blood banking. It is recommended that the BloodBank System for the Armed Forces be established along the lines indicatedon the following chart.
Because of the extremely limited dating period of blood and the needfor highly specialized personnel to manage whole blood in all phases ofits use, it seems desirable during a national emergency to place the responsibilityfor the blood bank system in the hands of a professional blood group thatshould be a part of a professional directorate, the membership of whichwould represent the three Surgeons General.
The Blood Group would have the responsibility for the complete operationof the Armed Forces Blood Bank System. The main functions would be to developstandard procedures of operation, establish training facilities for transfusionists,develop and provide transfusion supplies and equipment, develop and operatemilitary donor centers, supervise research in whole blood for transfusions,operate the blood-
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Proposed MilitaryBlood Bank System.
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processing centers and maintain liaison and supervision over the TransfusionService in each theater, regulating supplies as required.
A Medical Transfusion Officer in each theater will be responsible forthe Transfusion Service in his area. The local collection of blood andthe storage and distribution of blood directly to using medical installationsin the theater should be under his supervision. This system is not novel,nor does it lack precedent, for it proved its efficiency in Italy and Francein World War II. To have blood processed and distributed as a medical supplyitem through medical supply channels is considered improper handling, andthis function should be directly under the Theater Transfusion Officer.Distributing blood through supply depots slows up its ultimate destination,increases the requirements for blood to maintain maximum credits at eachstorage and supply point, and is conducive to the utilization of the oldestblood routinely. The Transfusion Officer in the theater who controls therequest for blood should be responsible for its direct delivery to usinghospitals-this is by far the most efficient way to balance supply and demandand reduce gross waste resulting from outdating.
To provide an efficient worldwide Blood Bank System, it is essentialthat the Blood Group maintain close liaison with Transfusion Officers ineach theater and that standard procedures be utilized.
2. Technical Problems
a. Equipment suitable for collection and shipment of blood mustbe immediately available at the outbreak of hostilities. It is recommendedthat this equipment be purchased and stored, and sufficient quantitiesbe made available in overseas theaters.
b. It is recommended that research be continued in the fieldsof transfusion reactions, improvement of solutions to increase red bloodcell survival and improvements in equipment with emphasis on the use ofplastic bags for blood (see also 2f, below).
c. It is recommended that technical manuals be prepared coveringall phases of blood bank systems, and that medical officers be educatedin the proper utilization of whole blood transfusion for resuscitation.
d. It is recommended that in the event of hostilities, the ArmedForces establish and operate their own blood-collecting centers. In thisway the entire Blood Bank System for the Military can be properly controlledfront point of collection through delivery to medical treatment facility.
e. It is recommended tliat standard operating procedures forthe collection, processing, storage, shipment, distribution and properutilization of whole blood, and technical manuals on the use of existingblood transfusion equipment be prepared for instruction purposes.
f. Plastic bags for whole blood. Plastic bags have been undergoing
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tests for the past 4 years. Results of these tests indicate that plasticbags suitable for the collection, storage and administration of blood canbe fabricated and used safely. Logistically, plastic bags are desirablebecause a bag containing 500 cc. of blood occupies only one-half the spaceof a bottle similarly filled. Our present blood-shipping containers willaccommodate 48 bags instead of the usual 24 bottles. It is recommendedthat acceptable plastic bags replace bottles for the field use of wholeblood and that only plastic bags be used for overseas shipment.
Summary
A brief history of the development of blood bank systems in World WarII and in the Korean War has been presented. The lessons learned in relationto supplying whole blood in support of armies in combat situations havebeen outlined. Recommendations, based on the lessons learned in the fieldof blood bank systems, have been presented with the hope that from thisdiscussion will emerge a well organized military blood bank system whichwill control, in time of war, the collection, delivery, and utilizationof whole blood.
