Implementation of Low Titer Whole Blood for French overseas operations: O positive or negative products in massive hemorrhage?

Massive hemorrhage is the leading preventable cause of death during military operations. During these operations, the delay between initial treatment and arrival at a surgical facility is considerably longer than in Metropolitan settings. This increased prehospital period requires the availability of blood products during the prehospital stage and justifies the availability of Low Titer Whole Blood (LTOWB) for surgical facilities. This product is a fully authorized labile blood product processed by the French Military Blood Institute according to French regulations. Its shelf life is 21 days when stored between 2 and 6°C. It provides the three products necessary for the transfusion management of war injuries in a single product and in physiological proportions. The low anti-A and anti-B titers (<1/64) make LTOWB compatible with any recipient. However, the RhD antigen remains an issue due to its potential harm in cases of transfusion to a D-negative childbearing-age woman due to the potential risk of fetal-maternal incompatibility. This risk must be balanced with the availability of D-negative blood products. Considering the epidemiology of war injuries and LTOWB use guidelines, in addition to the current knowledge on anti-RhD fetal-maternal alloimmunization, the harm-benefit assessment favors the use of RhD-positive LTOWB during overseas operations. Follow-up of childbearing recipients and setup of countermeasures to prevent alloimmunization in those cases remain key points of transfusion safety.