War doctors should consider controlling blood loss with surgery and limiting blood transfusion

Trauma surgeons should consider surgically-controlling severe blood loss and limiting the amount of blood transfusion, according to a Lancet research letter by our Co-Founder David Nott and others. These findings are the results of preliminary research carried out by David in Syria in 2013, under austere conditions with limited blood stocks.

In 2013, the Syrian regime targeted hospitals and healthcare workers in Aleppo. David recorded the clinical outcomes of 57 war-injured patients undergoing surgery. Of 55 severely injured civilians, median age was 25 years and 17 (31%) were children.

Triage identified the people most in need of surgery, and immediate surgical control of the bleeding followed. All patients received whole blood after bleeding was surgically controlled. Every patient selected for surgery survived.

Although an extensive study in regulated hospital conditions is needed to validate the findings, this analysis suggests children and young adults with blast and penetrating war wounds, who are rushed to hospital and receive rapid surgical control of bleeding, are more likely to survive. For these patients, minimising all infusions, including blood, appeared to be safe, preserved scarce blood stocks and could even be considered clinically beneficial.

The most startling finding was that patients could survive major trauma with haemoglobin concentrations down to 4.8g/dL, with the majority between 5 and 7 g/dL.

Humanitarian war surgery is often characterised by poor conditions, resources and isolation. Transfusion supplies (and clinicians available to administrate blood) can be severely limited. Nott’s approach in Syria was borne from necessity, yet all patients selected for surgery lived.

Russia’s invasion of Ukraine is forcing hospitals underground and resources will soon become scarce. This observation of quick judgement, early surgical intervention, minimal whole blood transfusion and better-than-expected outcomes in Aleppo, should be considered by healthcare workers treating patients in Ukraine.

David Nott, our Co-Founder, said:

“Some of the conditions within which I’ve worked have been incomprehensible. But we trauma surgeons must do all we can to save lives, no matter the resources available.

In ideal circumstances blood stocks would be bountiful, but conflict strips hospitals of that luxury. This research suggests rapid surgical intervention to control blood loss, with limited blood transfusion, can lead to good outcomes. Although more research is needed, this insight could help surgeons in Ukraine save more lives.”

Read the Lancet letter