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Operation of Blood Bank Systems

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 bank systems in the Armed Forces during World War II and the Korean war, with special emphasis on our accomplishments, inadequacies and recommendations for improvements in the system of blood supply to our fighting forces.

In the annals of military history there is probably nothing that has made a greater impact on the curing of ills and the restoration of function resulting from war wounds than the adequate and judicious use of whole blood. It is a strange paradox that, in an era of medicine that will long be remembered as the culmination of the renaissance of this great art, approximately a half century elapsed before it became generally accepted that the mortality rates from war wounds were almost directly proportional to the availability and proper use of whole blood. Although the lessons learned in World War II were convincing evidence of this concept, it remained for the Korean war to establish this principle firmly in the minds of operating surgeons and statisticians alike. It is not surprising, then, that when the history of World War II is reviewed, the errors of omission, related to the inadequacy of the supply of whole blood, are so apparent.

With the knowledge which we possess today as to the needs for whole blood for resuscitation and major surgery, it seems incredible that we could have permitted so much delay during World War II in making whole blood available to the theaters of operation throughout the world. But in all fairness to those concerned and for the sake of the record, it should be pointed out that the supply of blood to theaters, far removed from the mainland, depends on four cardinal features: a completely closed, sterile, pyrogen-free system of collection in a container which will maintain its integrity; an efficient anticoagulant and preservative solution which will extend the longevity of red blood cells to meet the logistical demands; maintenance of constant temperature during shipment; and availability of sufficient long-range airplanes to permit a continuous and dependable supply of blood. These four requirements first became available in the summer of 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 quantities from the homeland to both the European and Pacific theaters.

A brief resumé of the struggle encountered during World War II to develop a system of blood supply in active theaters, and from the United States to units in the field will help to emphasize the difficulty of trying to 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 safely in recipients several days after collection.

The next important development was in the field of blood-collecting equipment. In the processing of liquid plasma, it became apparent that the successful manufacture of liquid plasma for transfusion was dependent upon the use of a completely closed system with sterile, pyrogen-free containers and collecting sets. This principle was carried over to the collection of blood for transfusion, and from it stemmed the development of sterile vacuum bottles and disposable collecting and administration sets. With the advent of these transfusion units in 1942, recommendations were made to make these sets available to all hospitals in combat areas, to replace the makeshift equipment such as open flasks and funnels filled with cotton gauze as filters. Despite repeated pleas by personnel in the Mediterranean theater for suitable blood transfusion equipment, the newly-developed equipment was not made available because the great need for blood in addition to plasma was not recognized by those in a position to provide it, and secondly, it was ruled that overseas surface shipping capacities for medical equipment were not adequate to allow for the use of disposable blood bottles in overseas theaters. Thus, makeshift transfusion equipment continued to be employed in the Mediterranean theater and the European theater until early 1944. As a result of persistent effort on the part of transfusion officers in Italy and England, and despite other handicaps, excellent blood bank systems were developed locally and blood was collected from troops in the communications zones and made available to hospitals in combat areas in each theater.

Anticipating the needs for larger quantities of blood for the invasion of the continent, the National Research Council in April 1944, recommended collecting blood in the United States and transporting it to England by air. This recommendation was opposed, and it was not until August 1944, after requirements for blood exceeded that afforded from England, that a plan was permitted to go forward to fly blood to England. This plan was quickly implemented, and within 2 weeks 1,000 bottles of blood a day, with a dating period of 14 days, were being shipped. This was quickly raised to 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 Italy regarding blood shipments, delivery to individual units and the proper use of blood in the treatment of casualties were of inestimable value in the Pacific. By November 1944, through the cooperation of the Army and Navy, daily blood shipments were being made to Leyte and other islands in the Pacific, and supplies from the United States continued as the major source of blood for the Pacific until the end of the Japanese war.

Although, to many of you, the history of the development of blood bank systems in World War II may seem incongruous and woefully slow, I wish to remind you that as late as 1940 and 1941 transfusions of whole blood were done with considerable trepidation because of the frequent mishaps that resulted; furthermore, there was no standardization of equipment, and even direct transfusions were still being employed because of the fear of reactions from citrate; and the transfusion of a patient rarely exceeded the injection of 500 cc. of blood. Thus, the development of blood bank systems between 1941 and 1945 for the armed services entailed not only the investigation of suitable equipment for collecting, shipping, preserving and injecting blood, but required the indoctrination of all medical officers in the proper use of blood transfusions.

What were the lessons learned about blood bank systems in World War II?

    1. To prevent contamination and permit long storage and shipment, blood must 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-Mollison solution) up to 21 days with an expected 70 percent post-transfusion survival rate of red blood cells.

    4. Low-titer, Group "O" blood was found to be relatively safe and more desirable for use in combat hospitals than group-specific blood.

    5. During hostilities, blood can be collected from troops in the communications zones, but the majority of blood utilized should be obtained from the Zone of Interior.

    6. To permit the proper collection of blood from troops in the communications zone, adequate supplies of transfusion equipment must be included in medical supplies in support of armies, corps and regimental combat teams.


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    7. In World War II the administrative control of blood bank systems developed as awkwardly as the technical procedures. In 1945, based upon a review of the blood bank system in World War II, it was recommended that in case of future conflict a transfusion branch in the Office of The Surgeon General should be established to inaugurate a whole blood procurement program. Sufficient personnel should be trained in transfusion therapy to man the various positions required.

    8. In addition to the transfusion branch in the Office of The Surgeon General, there should be a Consultant on Blood and Transfusions attached to the office of each Theater Surgeon who will be responsible for the blood supply to communications zone hospitals and combat units in that theater. There should be sufficient collecting and distributing teams to collect and deliver blood in the theater, and sufficient equipment to store and process blood received from the United States.

These were the lessons learned and the recommendations made at the end of World War II. Only 5 years elapsed before we were called upon to test out the recommendations set forth in 1945.

Blood Bank System during the Korean War

In 1949, in preparation for any future national emergency, a Blood and Blood Derivatives Committee was set up in the Medical Director's Office of the Department of Defense and plans were made to make available adequate equipment for the collection, shipment and administration of whole blood as well as plasma and albumin. This Committee was responsible for developing all policy related to the needs for blood and blood derivatives for the Armed Forces. The recommendations of this Committee were implemented by the 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, equipment for the collection and administration of blood was available in the Far East theater. A blood collection program was initiated promptly in Japan, and through the cooperation of troops, civilian nationals and foreign nationals as donors, the initial requirements for blood were met. By August 1950 increasing casualty rates indicated the need for much larger quantities of blood; therefore, a supplemental supply was requested from the United States. The request for whole blood was reviewed and acted upon by the Blood Committee of the Defense Department. As a result, an operational group, designated the Blood and Blood Derivatives Group, was established under the Directorate of the Armed Services Medical Procurement Agency. This


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group was charged with the responsibility of securing adequate supplies of blood, obtaining equipment and supplies for shipment, processing blood and filling the orders for blood as they were received from the Far East theater. The Defense Department asked the American Red Cross to collect blood for the Armed Forces and this organization worked in unison with the blood group in meeting quotas as they developed. By using existing American Red Cross centers, Defense centers operated by ARC, cooperating blood banks working with ARC, and by the development of Armed Forces centers on military bases throughout the country, sufficient blood was collected to cover our needs in Korea, as well as to supply plasma-processing plants and albumin-fractionation plants in the United States.

For shipment overseas, only low-titer group "O" blood, collected in 120 cc. of ACD solution, was used. It was collected in sterile, pyrogen-free, vacuum glass bottles, providing a completely closed system. Blood collected in centers scattered throughout the country was transported by air lift to the Armed Services blood-processing center at Travis Air Force Base. This processing laboratory was adequately staffed with trained personnel who usually screened all bottles of blood, retyped it, re-titered it, and determined the suitability of each bottle for shipment by checking for abnormalities in appearance and volume. Storage and re-icing facilities were available to maintain an adequate supply of blood to meet the daily overseas quotas. The Processing Center also coordinated the shipment of blood overseas with the cooperation of the Military Air Transport Service.

Blood shipments were consigned to the 406th Laboratory in Japan, and this organization had the responsibility of supplying the distribution centers in Korea with their daily requirements. Blood for this purpose was available both from Japan as well as the United States; approximately 75 percent of the blood came from the Zone of Interior. It is interesting to note that although the 406th Laboratory distributed blood directly to medical installations in Japan, the supply of blood to medical units in Korea was a function of various Army medical depots in Korea, which in turn delivered to Army surgical hospitals and other installations using blood. Where supply lines were long, there were intermediate storage and supply points. It should be pointed out that in this type of blood bank system it is necessary for each depot, intermediate storage and supply point to maintain a sufficient amount of blood to permit each to meet its maximum requirements at all times. It is admittedly desirable to have the pipeline filled at all times, but multiple supply and resupply points are undesirable.

During Word War II and the Korean war there appeared to be an unlimited reservoir of blood available. In the future, because of the requirement for civilian as well as military casualties, resulting from


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atomic warfare, whole blood will have to be conserved more than ever before. This can best be done by having a blood-collection and delivery system, which is a separate, complete unit, centrally coordinated and supervised and given the authority and responsibility for making blood available to using medical installations. In this manner, usage rates can be determined and stores of blood formally trapped in multiple supply points can be mobilized. During wartime it is expected that, because of the perishability of blood and unpredictable enemy action, a certain percentage of blood may become outdated. However, in planning for total war, we must revise our thinking and reduce our blood losses to the barest minimum.

Comments

With this brief historical review of the development of blood bank systems during World War II and the Korean war, it seems appropriate to recapitulate by outlining the lessons learned in Korea and the inadequacies which remain to be corrected. First I shall mention the basic principles of military blood bank systems which have been clearly established, and follow this by pointing out the inadequacies which still exist.

    1. Whole blood is an essential part of the armamentarium for treating casualties produced by war.

    2. The collection of blood in a closed, sterile, pyrogen-free container and 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-dextrose and maintaining it at a constant temperature of 4° to 6° C, it can be preserved and administered safely for 21 days.

    4. Low-titer group "O" blood is more acceptable for use in combat medical units than type-specific blood.

    5. Although blood can be preserved for 21 days, the need for transfusions can best be served with fresh blood, and every effort should be made to balance supply and demand so that the freshest blood possible can be used.

    6. Reusable blood-shipping containers have proved to be efficient and economical. Rigid, fiber board, trunklike containers with 3-inch plastic, waterproofed insulation have been most effective in maintaining a constant temperature at fairly extreme ambients.

Inadequacies which continue to plague us in military blood bank systems are divided into administrative and technical problems.

1. Administrative Problems

Organization of a Military Blood Bank System. Experience during two 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 break out. This has resulted in delays, inefficiency, greater expense and inability to capitalize on the tremendous research potentialities afforded us by the collection and clinical use in war casualties of millions of units of blood.

It is my firm conviction that the technology involved in the collection, preservation, shipment, storage, distribution and clinical use of whole blood-in other words, blood bank systems-is a professional responsibility. Whole blood is a rapidly perishable biological that should be treated like no other medical item that we have and, therefore, should not be placed in supply channels. Its potentialities for salvaging maimed bodies are such that the organization and personnel responsible for the blood bank system of our Armed Services should be of the highest order. Entirely too little emphasis has been placed on the organization of a Transfusion Service in the past, and it has been forced to fight for its existence without benefit of adequately trained personnel and without the backing and support of professional services. Primary support for the Transfusion Service in World War II and Korea has been afforded by the Supply Division, and proper credit 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 professional logistic project requiring the greatest coordination of skilled professional personnel. Cognizance should be taken of this and a continuing effort made to train personnel in the laboratory phases, clinical phases and research requirements for blood transfusions, so as to organize blood bank systems in the future staffed with well trained physicians thoroughly versed in all phases of military blood banking. It is recommended that the Blood Bank System for the Armed Forces be established along the lines indicated on the following chart.

Because of the extremely limited dating period of blood and the need for highly specialized personnel to manage whole blood in all phases of its use, it seems desirable during a national emergency to place the responsibility for the blood bank system in the hands of a professional blood group that should be a part of a professional directorate, the membership of which would represent the three Surgeons General.

The Blood Group would have the responsibility for the complete operation of the Armed Forces Blood Bank System. The main functions would be to develop standard procedures of operation, establish training facilities for transfusionists, develop and provide transfusion supplies and equipment, develop and operate military donor centers, supervise research in whole blood for transfusions, operate the blood-


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Proposed Military Blood Bank System.


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processing centers and maintain liaison and supervision over the Transfusion Service in each theater, regulating supplies as required.

A Medical Transfusion Officer in each theater will be responsible for the Transfusion Service in his area. The local collection of blood and the storage and distribution of blood directly to using medical installations in 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 France in World War II. To have blood processed and distributed as a medical supply item through medical supply channels is considered improper handling, and this 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 each storage and supply point, and is conducive to the utilization of the oldest blood routinely. The Transfusion Officer in the theater who controls the request for blood should be responsible for its direct delivery to using hospitals-this is by far the most efficient way to balance supply and demand and reduce gross waste resulting from outdating.

To provide an efficient worldwide Blood Bank System, it is essential that the Blood Group maintain close liaison with Transfusion Officers in each theater and that standard procedures be utilized.

2. Technical Problems

a. Equipment suitable for collection and shipment of blood must be immediately available at the outbreak of hostilities. It is recommended that this equipment be purchased and stored, and sufficient quantities be made available in overseas theaters.

b. It is recommended that research be continued in the fields of transfusion reactions, improvement of solutions to increase red blood cell survival and improvements in equipment with emphasis on the use of plastic bags for blood (see also 2f, below).

c. It is recommended that technical manuals be prepared covering all phases of blood bank systems, and that medical officers be educated in the proper utilization of whole blood transfusion for resuscitation.

d. It is recommended that in the event of hostilities, the Armed Forces establish and operate their own blood-collecting centers. In this way the entire Blood Bank System for the Military can be properly controlled front point of collection through delivery to medical treatment facility.

e. It is recommended tliat standard operating procedures for the collection, processing, storage, shipment, distribution and proper utilization of whole blood, and technical manuals on the use of existing blood 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 plastic bags suitable for the collection, storage and administration of blood can be fabricated and used safely. Logistically, plastic bags are desirable because a bag containing 500 cc. of blood occupies only one-half the space of a bottle similarly filled. Our present blood-shipping containers will accommodate 48 bags instead of the usual 24 bottles. It is recommended that acceptable plastic bags replace bottles for the field use of whole blood and that only plastic bags be used for overseas shipment.

Summary

A brief history of the development of blood bank systems in World War II and in the Korean War has been presented. The lessons learned in relation to supplying whole blood in support of armies in combat situations have been outlined. Recommendations, based on the lessons learned in the field of blood bank systems, have been presented with the hope that from this discussion will emerge a well organized military blood bank system which will control, in time of war, the collection, delivery, and utilization of whole blood.