The use of red cell concentrate by the armed forces Overseas
Summary
1. This SGPL lays down the policy for the use of red cell concentrate (RCC) by the UK
Armed Forces overseas. Where there is no UK registered Biomedical Scientist (BMS)
available, the supply of RCC will be restricted to groups O Rh (D) Pos and O Rh (D) Neg.
Where BMS support is available, multiple blood groups may be supplied, but a later restriction
to group O RCC may apply on mature operations to reduce unnecessary stock holdings and
wastage. More specifically, this SGPL provides guidance on the use of group O Rh (D)
Neg RCC and replaces SGPL 11/04 which is hereby cancelled. Apart from the
exceptions identified in this SGPL, RCC and other blood components reaching the end of
their shelf life are not to be offered to local or host medical facilities.
Introduction
2. The M&GS IPT Blood Supply Team (BST), as a Blood Establishment, is authorised by
the Medicines and Healthcare Products Regulatory Agency (MHRA) to distribute RCC and
other blood components to support the UK Armed Forces overseas 1. The BST is supplied
with all of MOD’s requirements by the NHS Blood and Transplant services (NHSBT).
3. The provision of compatible RCC requires not only an adequate supply of cells to
transfuse, but also an ability to manage stocks efficiently and carry out pre-transfusion testing.
In contrast to the NHS, the principal situation requiring the use of RCC in the military is the
management of trauma. However, in an environment constrained by extended supply chains,
the lack of a rapid cross matching capability and blood components with an inherently short
shelf life, available treatment options are limited.
Aim
4. The aims of this policy letter are to define the blood types of RCC held to support the
UK Armed Forces overseas, to provide guidelines on the use of group O Rh (D) Neg RCC,
and provide direction on the disposal of unused RCC and other blood components.
Background
5. The BST can supply a mixture of ABO Rh (D) Pos and Neg RCC if required and UK
NHSBT transfusion guidelines2 specify only that red cells must be compatible with recipient
ABO and Rh (D) type; it does not specify that recipients may only receive red cells from
the same ABO Rh (D) donor type. Groups O Rh (D) Pos and O Rh (D) Neg RCC are
almost invariably compatible with patients of all ABO types.
The role of the state registered Biomedical Scientist
6. Biomedical scientists (BMS) registered by the Health Professions Council (HPC)
are qualified to perform blood grouping and compatibility testing, which allows for patients
requiring a blood transfusion to be blood grouped and donor RCC selected accordingly.
No other personnel are qualified to undertake this task.
Limitations on RCC groups supplied
7. For operations and exercises where BMS are deployed, BST may supply a mixture of
1 Authorisation is required for compliance with the Blood Safety and Quality Regulations 2005. The MOD Blood Establishment
Authorisation Number is 4537. 2 Handbook of Transfusion Medicine. Table 1: Prescribing and Use Information Common to all Blood Components (accessed 3
Dec 07). Available from: http://www.transfusionguidelines.org.uk/docs/pdfs/htm_edition-4_all-pages.pdf
2 JSP 950 Part 1 Lft 2-24-2 (v1.1 Dec 07)
group A and O RCC3
. The quantity of RCC and the groups represented will be supplied
against the PAR and operational risk assessment as supplied by PJHQ in the case of
operations, or lead Service in the case of exercises. Where the requirement for transfusion
support is low or may reduce, BST may limit supply to group O RCC only allowing for overall
stock levels to be reduced whilst maximising flexibility and minimising wastage.
8. For operations and exercises where a BMS is not deployed, supplies of RCC must be
restricted to group O Rh (D) Neg and O Rh (D) Pos. The amount issued will be dependent
on the PAR, the operational risk assessment and the medical evacuation route, but group O
Rh (D) Neg will normally constitute less than 40% of the shipment.
The use of Group O Rh (D) Negative Red Cells
9. Group O Rh (D) Neg RCC is used as the universal donor group for patients in need of
urgent blood transfusion when there is no time to test for compatibility. However, as only
8% of the population are group O Rh (D) Neg, blood of this type is a scarce and valuable
commodity and unnecessary use must be avoided. Military populations on operations are at
particular risk of being involved in such incidents.
10. Group O Rh (D) Neg RCC is to be used in the following cases where ABO compatibility
testing has not taken place:
a. Rh (D) Neg patients with anti-D4
.
b. Rh (D) Neg females of child-bearing age (<60 years).
c. Pre-menopausal adult females (<60 years old) and female children of
unknown blood group.
11. Group O Rh (D) Neg RCC may also be used in the following circumstances:
a. In an emergency situation while the patient’s blood group is being established.
Once the patient’s blood group has been established, a switch to group/type specific
RCC can be made, if available.
b. If the specific phenotype blood provided for compatibility testing is group O Rh
(D) Neg.
12. Patients known to have a clinically significant antibody5 should receive appropriately
selected and typed blood, as even group O Rh (D) Neg blood may be incompatible.
Use of Group O Rh (D) Pos blood for Group O Rh (D) Neg patients
13. To conserve stocks of group O Rh (D) Neg RCC when in extremely short supply
group O Rh (D) Pos RCC may be used for group O Rh (D) Neg males and postmenopausal
women providing that no anti-D antibody is detected on pre-transfusion testing (where pretransfusion testing is available). The sensitivity of current testing techniques is such that
the risk of a sensitised Rh (D) Neg patient having undetectable anti-D antibody is very
low. Only when totally unavoidable, in the case of life threatening haemorrhage for
instance, should group O Rh (D) Pos blood be used for group O Rh (D) Neg potentially
childbearing females. In terms of maintaining maximum flexibility of supply, the management
of stocks of RCC and blood components is the responsibility of the BMS (when available) in
theatre but will need to be undertaken in consultation with the relevant clinicians.
3 Groups AB and B will not normally be supplied as only relatively small numbers of the UK population have these blood
groups, however, if the PAR included a significant proportion of Ghurkhas or other ethnic groups with a different blood group
profile, then the composition of the groups supplied may be amended accordingly. 4 UK military personnel should have this noted on their medical warning tag. 5 Any known antibody should be stated on a NATO warning tag.
3 JSP 950 Part 1 Lft 2-24-2 (v1.1 Dec 07)
14. Follow Up. All individuals who are Rh (D) Neg and have received Rh (D) Pos RCC
are to have their serum tested for anti-D antibody and other clinically significant blood
group antibodies 3 to 6 months post transfusion. If detected, their F Med 4 Operational
Medical Record card and electronic patient records are to be annotated appropriately by their
unit medical officer who is also to initiate the staff action required to record the finding on the
patient’s NATO Medical Warning Tag so that the individual does not receive further
transfusions with incompatible blood.
Clinical responsibilities
15. Deployed clinicians who are involved in the resuscitation of casualties are to take
particular care to ensure that all field medical documentation, including the recording of blood
transfusion, is completed and secured with the casualty. This is in order to minimise the risk
of transfusion records becoming detached from the patient during evacuation, which might
subsequently result in sub-optimal follow up action being taken. The final decision on
whether to use Rh (D) incompatible blood will remain with the clinician in charge of the
individual patient.
Red cell concentrate approaching expiry time.
16. RCC and other blood components approaching time expiry may only be donated to a
local healthcare provider within existing limited arrangements in Gibraltar and Brunei
where full traceability from donor to patient can be ensured. In all other circumstances,
RCC and other blood components coming to the end of their life are not to be offered to a
third party. The perceived humanitarian benefits are considered to be outweighed by the
risk of liability arising from possible harm. Such harm could arise from Transfusion
Transmitted Infections, transfusion reactions or cold chain failures. In addition, any donation
would result in the failure of the BST to establish full traceability from donor to recipient
RCC and blood components that have time expired on operations or exercises are to be
treated as clinical waste and disposed of accordingly.