Blood Supply in the Bundeswehr:
Resilience in Operations and Defense

Diana Sauer^a, Jan Ammann^b

^a Department of Transfusion Medicine and Hemotherapy, Bundeswehr Central Hospital Koblenz

^b Department of Anesthesiology, Intensive Care, Emergency Medicine, and Pain Medicine, Bundeswehr Hospital Ulm

Summary

Blood and blood products are indispensable in clinical routine and a critical factor in military contexts involving hemorrhagic shock. Declining donor numbers, short shelf lives, particularly for platelet concentrates, and high logistical demands increase vulnerability. In Large-Scale Combat Operations, the demand for whole blood equivalents spikes, while evacuation times and supply routes may become extended.

This review outlines the planning factors, the roles of cold-stored whole blood and dried plasma in the concept of remote damage control resuscitation, and the peculiarities of blood supply within the Bundeswehr under national and alliance defense conditions. The necessity of accelerated approval for refrigerated whole blood products, the importance of civil-military cooperation, multinational interoperability, and standardized procedures for the collection and application of whole blood in the area of operation are highlighted.

Keywords: blood supply; whole blood; dried plasma; transfusion medicine; civil-military cooperation

Introduction and Background

The supply of blood and blood products is a crucial element of patient care. Blood transfusions are particularly significant for critically injured or ill patients and in the treatment of chronically ill patients. Blood and blood products, such as erythrocyte and platelet concentrates, as well as plasma and specific products derived from it, such as coagulation factor concentrates or albumin, are continuously needed.

In Germany, as in many other countries, the willingness to donate blood has decreased in recent years, especially among young donors. This leads to repeated shortages in blood donation service depots each year, during summer, cold waves, or holidays. This primarily affects very short-life products, such as platelet concentrates, which expire after five days, and universal donor blood group O erythrocyte concentrates.

In addition to chronically transfusion-dependent patients, particularly in hemato-oncology, blood products are mainly required for treating severely injured individuals. Hemorrhage is one of the main causes of death in polytrauma [4], even the most common initial cause of death in potentially survivable injuries. This is even more pronounced in military contexts due to specific peculiarities such as injury patterns, evacuation and treatment options, and tactical situations [8].

In Germany, blunt trauma, e.g., from traffic accidents or falls from heights, still predominates regarding injury patterns, while penetrating injuries combined with blast injuries dominate in military conflicts [11]. In recent years, modern weaponry and the use of combat drones have more frequently led to thermomechanical combination injuries. In any case, the aim is to achieve optimal, early hemotherapy as one of the cornerstones of so-called Damage Control Resuscitation [8]. This includes restrictive volume therapy with crystalloids, early use of hemostatic procedures, prevention of hypothermia, acidosis, and hypocalcemia, and, if necessary, permissive hypotension.

Blood Supply in Operational Scenarios

The evaluation of blood demand in operational scenarios of the last decades and the second half of the last century laid the foundation for the NATO Blood Panel’s calculations, which assume a need for eight whole blood equivalents (WBE) for about 20% of hospitalized casualties (Figure 1).

 

Fig. 1: Required whole blood equivalents for 100 wounded in action (WIA), left in the form of 160 units of whole blood, right corresponding to component therapy: 160 erythrocyte concentrates (RB), 160 plasmas, 40 platelet concentrates (PLTS), plus 40 cryoprecipitates or about 10 g fibrinogen concentrate (Source: NATO Blood Panel Planning Factors, Memorandum 2022, see also [6]) (Image rights: NATO Blood Panel)

Considering the expected daily number of casualties in a large scale combat operation (LSCO), such as a NATO Article 5 collective defense scenario, the challenge of adequately and timely providing the required numbers of WBE becomes apparent. The following overview clearly shows why supplying whole blood in the operational area offers both medical and logistical advantages:

1. Platelet concentrates (PC) supply in the Area of Operation (AOO) is very limited, at best, and relies on cold-stored platelets (CSP) or cryopreserved platelets, which are not approved in Germany. Thus, by using components, one of the essential components for adequate hemostasis is missing.
2. Due to manufacturing processes and additive solutions, even with an optimal component ratio, the transfused volume and thus the dilution of the individual components are higher (Figure 2).
3. All used components have different storage and transport temperatures and shelf lives, posing logistical challenges.

Superiority of Whole Blood in Operations

It is undisputed that whole blood in the area of operation is an essential part of patient care in hemorrhagic shock due to the advantages described above. Therefore, the approval of a Cold-Stored Whole Blood (CSWB) product in Germany should be enabled as soon as possible, at least for the specific needs of the military. A corresponding statement by the Medical Advisory Board of the Armed Forces (WMB) was adopted in 2024, following an ad hoc working group of civilian and military stakeholders, led by Prof. Dr. Holger Hackstein, responsible for transfusion medicine, that presented the evidence in this field.

Accelerated Approval of Cold-Stored Whole Blood?

The recent increase in military cooperation with civilian experts in transfusion medicine reflects a strong interest in topics such as resilience and strategies for blood supply in disaster and crisis scenarios, driven by changing geopolitical circumstances. Overall, the understanding of the specific needs of the Bundeswehr has significantly grown. Notably, the German Society for Transfusion Medicine and Immunohematology (DGTI) established a “Whole Blood” working group in its Hemotherapy section in 2025 (Chair: Prof. Dr. Birgit Gathof and Colonel Dr. Diana Sauer). At the last annual congress, the significance of a safe blood supply during both civilian and military crises was the focus of a dedicated session. Also, in 2025, following the development by the civil-military sub-working group “Whole Blood” of the Blood Working Group of the Federal Ministry of Health (Chair: Dr. Ruth Offergeld), the AK Blood’s Vote 50 on the use of whole blood in military contexts was created [1]. This vote recommends “accelerated approval” of CSWB in Germany and “the creation of an immediate interim solution for military operations... at least for the Bundeswehr by exploiting existing exemptions.” A consultation regarding the approval of a leukocyte-depleted whole blood product with the responsible federal authority has already been conducted by the Department of Transfusion Medicine and Hemotherapy of the Bundeswehr Central Hospital, Koblenz; the collection of quality and stability data for the approval procedure is planned promptly.

Challenges in the LSCO Scenario

The particular challenge of supplying blood and blood products for an LSCO scenario is multifactorial. Required are

• timely and continuous donor recruitment over time,
• sufficient production capacities, including the necessary personnel, material, and infrastructural resources, and
• logistical capacities for storage and transport domestically and into and within the AOO.

The demand for the earliest possible, and thus often already pre-hospital, supply of blood in the context of resource-limited damage control resuscitation (rDCR) is gaining importance, especially given significant delays in the rescue chain until emergency surgical care in the form of damage control surgery (DCS) is reached. Data on timelines from the Ukraine war indicate that this should be factored into LSCO scenarios.

Perfect hemotherapeutic care with whole blood is hardly possible even under optimal logistical conditions. Therefore, especially in the pre-hospital setting, dried plasma (DP) is an option for stabilization until whole blood is available and until a DCS facility is reached. A corresponding memorandum of the NATO Blood Panel from 2022 and a 2025 Food-for-Thought Paper on this subject, taken up in a commentary of the Blood Panel in The Lancet [5], support the use of DP in the far-forward area and recommend increasing the production capacities of lyophilized plasma (freeze-dried plasma, FDP) and research into alternatives, especially spray-dried plasma (spray-dried plasma, SDP).

Blood Supply as a National Task

Adequate supply of blood and blood products in possible military conflicts, as well as in civilian crises or disasters, can only be solved as a national task. This means that civil-military cooperation and the Bundeswehr’s reliance on civilian partners are indispensable. National crisis plans as well as plans for multinational cooperation, e.g., within the EU, NATO, and partner nations, are urgently needed and are continuously being developed. Whether the new EU legislation for substances of human origin (Regulation (EU) 2024/1938 on Standards of Quality and Safety for Substances of Human Origin (SoHO-Regulation)) will contribute to this remains to be seen [5]. However, in the context of the Bundeswehr’s reorientation, its own internal expertise in the central area of transfusion medicine and hemotherapy is of significant importance, including the Bundeswehr Blood Donation Service.

The Concept of Blood Supply in the Bundeswehr

Under the leadership of the Department II Principles of Defense/Operational Medicine/Preclinical of the Bundeswehr Medical Support Command and with the participation of other experts of different clinical faculties a fully revised concept paper on blood supply in the Bundeswehr (K1-9000/4011) has been developed in recent months and is expected to be signed and published in the Bundeswehr regulatory management in the near ­future. Due to the changed geopolitical situation and the associated reorientation of the Bundeswehr, a fundamental revision of the previous concept was necessary, particularly with regard to defense scenarios. The concept establishes general principles, uniform terms, and peculiarities of transfusion medical and hemotherapeutic supply of blood and blood products within the Bundeswehr. The necessary professional and legal framework is presented; the requirements for training, further education, and personnel training, as well as for infrastructural facilities, cooperating institutions, and the area of capability development, are defined. This includes the logistical peculiarities of blood supply. Here, the corresponding cold chains must be considered, as the various configured blood products have different requirements. Since this involves not only storage but also transport, it is a comprehensive task of medicine, logistics, and planning.

Collection and Application of Whole Blood in ­Operations

In addition to conventional products manufactured in blood donation facilities, whole blood collected in the AOO is used when standard products are unavailable or unavailable in time. In the Bundeswehr, this procedure of collecting and using whole blood is currently approved as “Emergency Blood Collection (EBC)” for immediate use only as a last resort, based on an exceptional permit under § 26 paragraph 3 of the Transfusion Act [3] in coordination with the Federal Ministries of Defense and Health. Collection with the intention of storage in blood depot shortage situations, so-called “Contingency Blood Collection (CBC),” is not permitted to this day. The corresponding procedural instructions were first signed in 2022 in consultation with the Federal Ministries. A necessary revision was developed last year and signed in 02/2026, so it is expected to take effect soon. Important innovations in this revision include the extended time window until transfusion:

• Six instead of previously four hours uncooled,
• up to 24 hours if storage at +2–6°C is possible.

Furthermore, the determination of the complete Rhesus formula using Grifols MultiCard is replaced by a short blood group, consisting of the ABO system and Rhesus factor D.

To safely and qualitatively conduct whole-blood collection and application in operations, curricular training for “Whole Blood Donation User” is necessary.

The collection of blood in the AOO is undoubtedly a relevant and helpful building block, but cannot replace the regular supply of conventionally manufactured blood and blood products, as the donor population is too small, and physiological, albeit minor, restrictions after donation must be considered in operational-tactical decisions. For an optimal pool of potential donors, an examination for irregular erythrocyte antibodies (antibody screening test in the context of repeated blood group determination) and an examination for blood-transmitted diseases should be conducted as recently as possible, no more than 4–6 months before deployment.

International Cooperation

Both in a NATO Article 5 collective defense case and in the context of international crisis management (ICM) ­operations, multinational cooperation is necessary. Integrating national concepts into international ones at the NATO level, for example, is essential to ensure the highest possible interoperability and supply security. Experts from more than 25 NATO nations and the PIAG (Partner Interoperability Advocacy Group) work together in the NATO Blood Panel to develop standards, such as STANAG 2939 and the associated Standard Related Document (SRD), and provide technical advice to the Committee of the Chiefs of Military Medical Services (COMEDS) and the Joint Health Group. STANAG (Standardization Agreement) is a NATO standardization document that unifies technical specifications, procedures, and equipment for the armed forces of the member states. Based on insights from the last five to ten years, STANAG 2939 has been completely revised, and the version accepted by NATO NSO is currently being reviewed by all member states. The aim of the STANAG is to reach agreement on minimum standards for blood and blood products to enable their exchange between partner nations during operations. Recommendations are also found in STANAG and SRD for blood collected in the AOO, for training on the collection and application of whole blood in the AOO, and for the benefit-risk assessment of various blood products and options.

Conclusion

The supply of blood and blood products is of utmost importance in both clinical routine and in domestic settings, and especially in military operational scenarios. Even though this supply can only succeed in civil-military cooperation and as a national approach, internal Bundes­wehr expertise in the absolutely central area of transfusion medicine is essential. This includes not only clinical expertise in hemotherapy and hemostaseology but also the Bundeswehr Blood Donation Service. Participation in national and international expert committees and the development of high-quality supply strategies are of immense importance. Examples of this include collaboration with command authorities, logistics, and all branches of the Bundeswehr, as well as participation in civilian professional societies, the Blood Working Group of the Ministry of Health, and international collaborations at NATO or EU levels.

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Manuscript Data

Citation

Sauer D, Ammann J. Blood Supply in the Bundeswehr: Resilience in Operations and Defense. WMM 2026;70(5E):2.

DOI: https://doi.org/10.48701/opus4-878

For the Authors

Colonel (MC) Dr. Diana Sauer

Department of Transfusion Medicine and Hemotherapy

Bundeswehr Central Hospital Koblenz

Rübenacher Str. 170, D-56072 Koblenz

E-Mail: dianasauer@bundeswehr.org