Whole Blood Transfusion – The Current State of Developments

Markus Raida^a, Jan Ammann^a, Diana Sauer^b

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

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

Summary

Whole-blood transfusion is becoming increasingly important in modern trauma and emergency medicine. While whole blood was largely replaced by component therapy for many decades, new insights into hemorrhagic shock’s pathophysiology and extensive military experience have sparked renewed interest in this approach.

Whole blood combines red blood cells, plasma, clotting factors, and platelets into one product, addressing key needs for volume replacement and hemostatic therapy in severe hemorrhage. Compared to component therapy, the lower amount of additive solutions may reduce the dilution of circulating blood, potentially improving coagulation, maintaining electrolyte balance, and lowering the risk of transfusion-related circulatory overload.

These advantages are particularly significant in military settings, where logistical challenges often restrict access to conventional blood components. Whole blood requires simpler storage and transportation conditions and enables earlier transfusions in resource-limited environments. Concepts like low-titer group O whole blood (LTOWB) further support its use as a readily available universal blood product during emergencies. Additionally, studies demonstrate that cold-stored whole blood retains adequate functional properties for clinically relevant durations. Overall, current evidence suggests that whole blood can be an effective and practical addition to traditional component therapy for managing massive hemorrhage, though further research is needed to establish standardized protocols and evaluate long-term safety and efficacy.

Keywords: whole blood; hemorrhagic shock; trauma care; military medicine; low-titer-O-whole-blood (LTOWB); walking blood bank; component therapy

Introduction

The use of whole blood (WB) experienced a resurgence in the early 2000s when certain military units operating in extended deployment areas recognized the need to produce their own blood products [49–51]. The logistical challenge of supplying such units with blood products primarily arose during special forces operations. Small teams with a high risk of injury had to ensure the survival of the wounded for several hours until reaching a medical treatment facility. It was unrealistic to apply blood components with their specific storage requirements in these types of missions. Generating fresh whole blood from suitable donors within their own ranks thus appeared a rational option (“walking blood bank”) [46].

In the surgical care of war injuries, whole blood had already been successfully used decades earlier, beginning in World War II, enabling the survival of many young soldiers [34]. Until the late 1960s, whole blood was the only transfusion option [18]. In the conflicts in Iraq and Afghanistan, numerous whole-blood transfusions were performed until 2010 [51]. These proved not only safe in later years but also seemingly advantageous compared with treatment using blood components. Whole blood is now also used in civilian trauma centers across various countries for the treatment of hemorrhagic shock, including in the USA, Israel, and several Scandinavian nations [47].

At the University of Pittsburgh Medical Center, WB has been successfully used for several years in all patients over 50 years old with hypotension following severe bleeding. The safety and rationale of this use have been demonstrated in this context [18][37][59]. Several civilian trauma centers and prehospital emergency services are now following this example [44]. There is also strong interest in Europe for whole blood as the primary volume replacement agent for hemorrhagic shock [1].

This review aims to provide an update on the use of whole blood in both clinical and military settings.

Comparison of Whole Blood Therapy with Component Therapy

The advantages of using WB instead of individual blood components are especially clear in certain situations, such as when a reliable supply chain cannot be guaranteed or when blood products are not initially available. Treating patients in hemorrhagic shock after trauma often requires transfusing large amounts of blood. A deeper understanding of the pathologies of severe injuries has resulted in a shift in trauma care [6][10][18]. The term Damage Control Resuscitation (DCR) has emerged (see also the article on DCR in this issue). Multiple studies have demonstrated that early transfusion of plasma and platelets enhances hemostasis and improves survival in trauma patients [19]. Consequently, recommendations for volume replacement in trauma patients have shifted in recent decades toward a whole-blood-like 1:1:1 ratio of erythrocyte concentrates (EK), plasma, and platelet concentrates (TK) [29].

Whole Blood, an Ideal Blood Product?

An ideal blood product intended for use in severe, life-threatening bleeding must meet several criteria (according to [18]):

1. It should increase the circulating blood volume to ensure adequate perfusion pressure.
2. It should be able to transport oxygen.
3. It should stabilize blood coagulation.
4. It should be simple to handle.

Whole blood fulfills these criteria almost completely. Additionally, it is efficient in application, as it achieves a high therapeutic effect with the same amount [18]. Therefore, it is especially important to compare the established strategy of component administration with the direct administration of whole blood based on evidence.

Whole Blood versus Component Therapy

Cruciani et al. examined data from seven studies involving a total of 3642 patients in 2020, comparing trauma therapy with WB versus blood components. Of these patients, 675 received WB. Four of these studies were conducted in civilian trauma centers. In these studies, therapy with WB was associated with a significantly ­lower 30-day mortality compared to component therapy; however, 24-hour survival was similar in both groups [9]. Smith et al. also investigated the use of WB versus blood components in 942 trauma patients in the prehospital setting of civilian air rescue services and found no difference in 24-hour survival [44].

Brill et al. analyzed 1,377 trauma patients who were in hemorrhagic shock both prehospital and in the shock room due to severe trauma. Of these, 840 patients received WB, while 537 received only component therapy. The study found a 60% higher 30-day survival rate in the whole blood group compared to the component group, with a simultaneous reduction in overall transfusion requirements. Exclusively low-titer O whole blood (LTOWB) was used.

Reduced Dilution Effect Compared to Component Therapy

A major advantage of whole blood therapy is the lower proportion of additive solution compared to 1:1:1 component therapy. The more pre-packaged blood products are transfused, the more the circulating blood volume is diluted by the additives they contain. In component transfusion, about a quarter of the administered volume consists of these so-called additive solutions. Part of the anticoagulant and additive solutions consists of citrate, which must be metabolized in the liver. Traumatic liver failure or hypothermia impairs citrate breakdown, leading to decreased calcium and magnesium levels in the blood. This can cause further coagulopathies and cardiac arrhythmias. Another potential complication during transfusions in severe blood loss is transfusion-associated circulatory overload (TACO), which can result in volume overload [29].

Another benefit is the presence of platelets in freshly obtained WB, although reduced, whereas platelet concentrates (TK) must be stored under constant, gentle agitation and are often underused in mass transfusion settings.

Military Application of Whole Blood

More than 10,000 WB transfusions in the conflicts in Iraq and Afghanistan alone have established its use in tactical medicine [17]. The guidelines from the Committee on TCCC (Tactical Combat Casualty Care) have recommended administering various whole blood products for treating hemorrhagic shock for several years before transfusing blood components [8]. These guidelines are crucial for the procedures used to treat the wounded in some countries. The training of German medics, as well as police and fire brigades and other personnel deployed in hazardous situations, is largely focused on these principles. Numerous case reports describe not only the use of previously obtained cold-stored whole blood but also the transfusion of freshly obtained whole blood in the field (English: Fresh Whole Blood = FWB). In current military conflicts, like the war in Ukraine, the transfusion of locally obtained whole blood allows the wounded to reach treatment facilities often far away alive in the first place. Further care by medical professionals would not be possible in many cases without prehospital hemotherapy.

Logistical Simplification Leads to Better Therapy

Whole blood contains oxygen carriers, plasma volume, coagulation factors, and a reduced number of functional platelets in a single bag. It requires significantly less storage space and has lower storage needs than traditional blood products. These benefits are especially important for military use because they enable transfusions even outside large treatment facilities, such as in Role 1 and Role 2 settings. Shackelford et al. demonstrated that this simpler logistics approach results in earlier transfusions and provides a crucial survival advantage in military operations [27][38]. Unlike studies at civilian trauma centers, the logistical benefits of WB help reduce 24-hour mortality in this context.

The military application of pharmaceuticals is often limited by deviations from recommended storage conditions. Climatic factors and failures of temperature-stabilizing systems could make entire stockpiles unusable. However, short-term deviations in storage temperature of about +10°C do not harm the shelf life of whole blood units. Sivertsen et al. tested cooled whole blood units exposed to a 28°C environment for four hours weekly and found no differences after 35 days compared to continuously cooled units. This had no adverse effect on their hemostatic function or oxygen transport capacity [42].

Similarly, exposure to 32°C for two hours did not significantly affect the quality of whole blood [41]. Of course, the risk of bacterial growth and contamination increases as the unit’s temperature approaches 37°C.

“Universal Blood” – Low-Titer O Whole Blood (LTOWB)

Research has been conducted for several years on universal blood to simplify logistical processes, increase transfusion safety during mass casualty incidents, and improve the availability of WB. The armed forces of various countries, including the USA, Norway, Canada, the UK, France, and the Netherlands, have already established standardized procedures for supplying their soldiers with whole blood. The use of low-titer whole blood of blood group O (Low-Titer O Whole Blood, LTOWB) is recommended as a universally applicable WB even when the recipient’s blood group is unknown (see [8]).

When transfusing WB, two potential mechanisms of incompatibility must be considered: the transfusion of incompatible donor erythrocytes, against which the recipient has antibodies, causes pronounced hemolysis. This major reaction is life-threatening and must be avoided under all circumstances. However, if antibodies against surface antigens of the recipient’s own erythrocytes are transfused via whole blood or plasma, the effect is considerably less pronounced due to dilution in the circulating recipient blood volume and is therefore called a minor reaction. If the transfused blood product contains very high antibody concentrations, this reaction can also be life-threatening.

Regarding natural antibodies against ABO traits, known as isoagglutinins Anti-A and Anti-B, these should be as low as possible in LTOWB. Some publications recommend a titer of less than or equal to 1:100 for IgM antibodies and less than or equal to 1:400 for IgG antibodies in donors [11][13][59]. However, current practices, evaluations, and further research now accept a titer of 1:256 for both antibody classes as safe [18]. Studies show that 70–80% of blood group O donors have low Anti-A and Anti-B titers when using this threshold [3][14][15]. Titers are not fixed and tend to decrease with age, but they generally remain stable within small fluctuations over longer periods, up to a year [3]. The UK civilian air rescue program recently used LTOWB, and its risks and benefits compared to component therapy were reviewed in nearly 1,000 patients by Smith et al. (2026). No significant disadvantages of the logistically simpler LTOWB were found [44]. Therefore, using whole blood from blood group O with low antibody titer (LTOWB) as universal donor blood is feasible, safe, and life-saving, especially in military settings [3][5][29][39][48][59].

Fig. 1: Continuously cooled WB versus cyclically warmed WB from [42]

Storage of Whole Blood

Especially for civilian use, cold-stored whole blood is significantly more attractive than FWB, which can be used uncooled for up to 72 hours under certain circumstances [18]. Obtained whole blood can be stored at a constant cooling temperature of 2–6°C in various solutions (English: cold-stored whole blood, CSWB). Agitation does not seem to be advantageous, and CSWB can be stored at rest [33][59]. FWB is usually specified to not exceed 24 hours at room temperature (22°C) [52]; some studies have reported longer shelf lives [55].

Limited Significance of Different Additives

The specific additive solution used is of minor significance. No notable difference was observed among common solutions like CPD, CP2D, and CPDA-1 [21]. Several studies indicate that storage for at least 21 days seems safe, with the blood components maintaining high activity levels [21][25][28]. CPD, which is the most frequently used, has a stated shelf life of 21 days. CPDA-1 contains additional adenine and 25% more dextrose compared to CPD. In the US Armed Services Blood Program, whole blood is stored at 1–6°C in CPD or CP2D for 21 days and in CPDA-1 for 35 days [2].

Platelet Preservation

Particular attention is paid to the function of the included platelets. It has been observed that their number decreases by about 1-2% of the initial value each day due to agglutination. Up to 15 days of cooled storage has minimal effect on clot formation [20][58]. The function of cooled platelets in vivo after transfusion is only short-lived [22], but their function is significantly better in vitro than platelets stored under agitation and at 22–24°C [16][18][24][30]. The brief duration of cooled platelets’ function after transfusion may be of little significance for hemorrhagic shock therapy, as they are immediately consumed in coagulation [18][36]. Plasma and erythrocytes appear to enhance platelet metabolism when used together. Red blood cells supply oxygen and decrease nitric oxide levels. Overall, these processes appear to utilize platelets [7][35], thereby generally improving recovery and survival after WB transfusion compared to apheresis TK [43][53]. For practical military use, this fact becomes secondary, as the logistical challenges of storing and transporting platelet concentrates limit their use to medical treatment facilities above Role 3.

Research is currently being conducted on various additives to preserve platelet function and count over longer periods [35]. The addition of apoptotic and necrotic inhibitors improves the preservation of platelet count but does not enhance their function [31].

Donor Selection

Intense combat combined with extensive frontline sections can lead to a surge in casualties that surpasses the planned capacity for blood products. Likewise, smaller units operating relatively autonomously may find themselves dependent on blood supplies. In both cases, it is essential to obtain blood locally. Ideally, personnel chosen for such donations should come from support forces or other non-combatant units. Transfusion safety is greatly improved if these potential donors have already been screened before deployment for their blood group, bloodborne diseases, and, in case of LTOWB use, their Anti-A and Anti-B titers (known as a prescreened donor pool). It is the responsibility of the tactical commander of these units to decide whether they can spare soldiers for donation and who can be assigned to it. It is also important to consider how this donation affects their ability to perform their military duties afterward.

Several studies have examined the performance reductions of donors after donating approximately 500 ml of whole blood. In the context of military activities like shooting or other concentration tasks, no significant differ­ences were observed before or after blood donation. Aerobic performance capacity decreases by about 10% in a physically fit group, while anaerobic capacity remains unchanged [12][23][54].

To prevent antibody-mediated transfusion reactions such as transfusion-associated acute lung injury (TRALI), male donors or women who have never been pregnant should be preferred [18].

Measures to Increase Transfusion Safety

It is crucial to emphasize that the safety of every whole-blood transfusion relies on various factors. Each user must ensure that blood products meet the specified standards before administration. This greatly reduces the risk of severe complications.

These standards are [29]:

• avoiding transmissible infectious diseases,
• proper donor selection,
• ensuring the blood product’s shelf life and compatibility,
• clear recipient identification,
• adherence to hygienic standards during collection and transfusion,
• preparation for potential complications, rapid diagnosis, and symptomatic treatment,
• evidence-based regulations for storage, transport, and expiration of blood products,
• clear protocols for determining transfusion needs,
• use of qualified transfusion sets, and
• consideration of donors’ possible performance limitations after donation during future procedures.

Occurrence of Transfusion Reactions

Whole blood contains all the necessary natural components. To lower the risk of immune-mediated, hemolytic transfusion reactions, whole blood is often transfused only after leukocyte depletion using a filter, including in many places within the German legal system. After weighing the benefits against potential reactions and the delay caused by filtration, some countries have intentionally chosen not to use filter systems. This decision favors the quicker availability and transfusibility of FWB in a remote-damage-control-resuscitation (rDCR) scenario [29][46][49].

Leukocyte Depletion

Whole blood initially contains leukocytes; in conventional blood product use, these are removed during processing using appropriate filters. Leukocyte depletion filters greatly reduce the number of transferred leukocytes (<1*10⁶/unit) [29].

This process significantly lowers the risk of febrile non-hemolytic transfusion reactions (FNHTR); however, such reactions are usually mild, self-limiting, and therefore of secondary importance during urgent, life-saving transfusions. Other immune reactions, such as transfusion-associated graft-versus-host disease (TA-GvHD) or the transfer of leukocyte-bound viruses like HTLV, are rare and mainly occur in immunocompromised individuals.

The negative effects of leukocytes in whole blood transfusions for hemorrhagic shock are inconclusive due to the complex clinical situation. While severe leukocyte-mediated transfusion reactions are extremely rare in this context, they cannot be entirely ruled out but are generally considered as acceptable in critical emergencies.

The impact of leukocytes in stored whole blood units remains under debate. A negative effect on the function of other blood components has not been definitively proven [40]. However, leukocyte depletion does improve the shelf life of erythrocytes and platelets within units [4][26][32][41][56][60].

Most available filters also remove platelets alongside leukocytes. Options for platelet-sparing filters are very limited, and even then, a reduction of 10–20% of platelets is observed [45][57]. During immediate whole blood collection for urgent transfusion – often a life-saving measure – this filtration process can cause a significant delay. Omitting it can reduce the time from venipuncture to product readiness by approximately 50% [29].

Infection Transmission through Whole Blood

Regarding the transmission of infectious diseases, whole-blood transfusion is generally safe [5]. Statistically, the risk is even lower because only one donor is required to produce whole blood, while three donors are needed for a 1:1:1 transfusion.

Pathogen Inactivation

Pathogen inactivation aims to lower the risk of transfusion-transmitted infections. Most methods used also affect the proteins and other cellular components of the targeted whole blood fractions. Concerning plasma, a reduction in coagulation factor activity of up to 44% is observed when applying riboflavin and UV light [35]. The activity of red blood cells appears unaffected and does not differ from irradiated erythrocyte concentrates [60]; this technique has CE certification and is particularly useful in regions where access to blood components and their production is limited, especially where there are many donors infected with HIV or malaria, for example [18].

Conclusion

• Compared to component therapy, whole blood offers logistical advantages, reduced dilution effects, and more efficient use.
• Studies suggest that whole-blood transfusions in trauma patients have at least comparable, possibly better survival rates than traditional component therapy.
• Especially in military settings, whole blood allows for early transfusion under limited logistical conditions and can thus increase the chances of survival for the wounded.
• The concept of Low-Titer-Group-O-Whole-Blood (LTOWB) aims to enable the near-universal use of whole blood in many emergency situations.
• Cold-stored whole blood remains functionally stable for several weeks under appropriate storage conditions, making it a practical option for preclinical and military care.
• Careful donor selection and adherence to transfusion medicine standards are essential for safe application.
• Concepts like the Walking Blood Bank are designed to ensure blood availability in extreme situations.
• Despite promising preclinical results, further research is needed, and there is a lack of standardization, especially regarding storage, platelet function, and optimal deployment strategies.

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Manuscript Data

Citation

Raida M, Ammann J, Sauer D. Whole blood transfusion – the current state of developments. WMM 2026;70(5E):5.

DOI: https://doi.org/10.48701/opus4-876

For the Authors

Major (MC)Dr. Markus Raida

Department of Anesthesiology, Intensive Care, Emergency Care, Pain Treatment

Bundeswehr Hospital Ulm

Oberer Eselsberg 40, D-89081 Ulm

E-Mail: markusraida@bundeswehr.org

Whole Blood Training Program in the Bundeswehr Medical Service – Concept, Implementation, and Qualification Profile

Martin Teufel^a, Diana Sauer^b, Christoph Jänig^c, Jens Prein^d, Tobias Markmeyer^d, Jan Ammann^e

^a Training and Simulation Center, Medical Regiment 3 Dornstadt

^b Department of Transfusion Medicine, Bundeswehr Central Hospital Koblenz

^c Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine, and Pain Therapy, Bundeswehr Central Hospital Koblenz

^d Rapid Deployment Medical Command Leer

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

Summary

Trauma-related hemorrhage remains one of the leading preventable causes of death in both military and civilian settings. Logistical constraints, longer evacuation times, and limited infrastructure can significantly restrict the availability of component-based blood products, especially in deployed military environments. In this context, structured whole blood transfusion strategies are becoming increasingly important. The Bundeswehr Medical Service has developed a standardized, team-based training program for whole blood donation and transfusion. The program trains physicians and selected non-physician medical personnel to collect, process, and administer whole blood in operational conditions, in accordance with transfusion law. The curriculum is simulation-based, competency-oriented, and fully integrated within the regulatory framework. This article describes the legal background, training structure, exam procedures, and qualification requirements, and places the concept within the broader scope of military medicine.

Keywords: whole blood; emergency transfusion; military medicine; hemotherapy; training; transfusion law; simulation-based training

Introduction

Uncontrolled bleeding remains one of the most common preventable causes of death in both military and civilian settings [5][10]. Early hemotherapy is a key part of damage-control resuscitation (DCR) and greatly affects morbidity and mortality [9]. Whole blood includes erythrocytes, plasma, and, depending on the manufacturing process, platelets in a physiological ratio, and it is considered a first-line treatment in tactical medicine according to current guidelines [12]. The organized use of whole blood is therefore becoming increasingly important in both military and civilian environments [3][11], including in Germany [7][8].

Internationally, the adoption of whole blood programs in civilian emergency medicine is being actively encouraged. Notable examples are the Norwegian Blood Preparedness Project [1] and the whole blood program of Royal Caribbean Cruise Lines [6].

Blood donations and transfusions in Germany are governed by the binding requirements of the Transfusion Act and the Hemotherapy Guidelines of the German Medical Association; this is also fully applicable in the military sector.

In response, the Bundeswehr Medical Service has created a standardized, multidisciplinary training program for whole blood donation and transfusion to enable personnel with diverse qualifications to collect, process, indicate, and administer whole blood in compliance with regulations. This article outlines the structure, content, and qualification framework of this training and situates it within the context of military medical and transfusion law.

Legal Framework and Conditions

The conduct of blood donations, transfusions, and the use of blood products are thoroughly regulated by law in Germany. Even in the military context, the collection, production, and use of blood products must comply with civil legal standards. The purpose of these legal norms, guidelines, and regulations is to ensure the highest level of safety for both donors and recipients of blood products.

For the Bundeswehr Medical Service, it means the obligation to follow the core principles of quality, safety, and traceability even during operations. Training for whole blood donation and transfusion is therefore consistently aligned with recognized standards of transfusion medicine and the relevant official requirements.

Training

Overview

The goal of the training is to provide participants with the necessary theoretical knowledge and practical skills to safely perform an emergency transfusion or blood donation, including the production of a transfusion-ready whole blood unit. Participants also gain insights into organizational and structural quality assurance processes and are trained on safety issues related to whole blood products, including relevant infectious factors. A key aspect of the training is its interprofessional approach. The certification for collecting and using whole blood is not limited to medical personnel; it has been extended to qualified non-medical staff under specific legal and professional conditions. This ensures the availability of whole blood even during extreme operational circumstances.

The following groups are generally eligible for the “Whole Blood Donation Practitioner” training.

• Medical personnel,
• specially qualified nurses for anesthesia and intensive care,
• specially qualified emergency medical technicians, and
• specially qualified deployment paramedics (especially Combat First Responder C or similar qualifications).

With the revision of the procedural instruction for collecting and using whole blood in Bundeswehr military operations in 2026, emergency nursing staff will also be included.

The qualification’s validity is limited to 36 months for medical personnel and 24 months for all other participants.

In 2022, initial pilot trainings for practitioner development took place, initially for special and specialized forces of the Bundeswehr. Building on these experiences, the Expert Working Group on Whole Blood at the Training and Simulation Center of Medical Regiment 3 developed the curriculum “Whole Blood Donation Practitioner” in 2023, which was then tested in a pilot phase. Since 2024, the training has been part of the official Bundeswehr training catalog.

In 2025, a compressed two-day training variant for anesthesiology specialists with continuing education as transfusion officers was established. The performance evaluations are identical in content and form to those of the regular practitioner training. Additionally, a curriculum-embedded e-learning format is used.

So far, approximately 260 individuals have completed the regular practitioner training, from sergeant to senior medical officer. Of these, 27% were medical personnel and 73% were non-medical personnel. The average pass rate was nearly 87% (n=226). Twelve specialists completed the shorter training version with a 100% pass rate.

Practitioner Training

The training is based on the theory of experiential learning according to Kolb [2] and is consistently simulation-based. The goal is to develop operational security under realistic conditions. Additionally, an e-learning module built on Moodle was implemented via the Bundeswehr “link&learn” platform. Providing teaching materials, supplementary literature, and instructional videos significantly enhanced the theoretical foundational understanding of non-medical participants. The preparatory learning phase ends with a mandatory online pre-test. Although the result is not a formal requirement for participation, it enables differentiated learning-group analysis and targeted adjustments to classroom instruction.

The week-long classroom phase includes 16 theoretical units and 15 practical training units in small groups. The training ends with an individual exam before a panel, comprising written, practical, and oral components. The total time commitment is approximately 2 to 2.5 hours per participant.

Theoretical Training Content

Theoretical instruction covers, among other aspects:

• Physiology of hemorrhage and shock, including basics of hemostasis and coagulation diagnostics.
• Blood products and coagulation-modulating drugs, as well as concepts of massive transfusion.
• Immunohematology, including blood group characteristics (ABO, Rhesus, Kell), blood typing, and clinical-chemical diagnostic procedures, including sample shipping and transport.
• Transfusion-relevant infectious diseases, including diagnostic procedures, risk assessment, transfusion reactions, and management of adverse events.
• Algorithm-based indications for (massive) transfusions.
• Donor selection and guideline-compliant blood donation, including performance capacity post-donation.
• Documentation on both donor and recipient sides.
• Legal foundations, including relevant guidelines, recommendations, and documentation requirements.
• Logistics and proper handling of blood products (component-based products and whole blood).

The theoretical training starts with the e-learning phase, then moves to classroom instruction in a closed seminar room. The practical training is closely connected to the theoretical modules and gradually increases throughout the course. Starting on the third day, the focus shifts to scenario-based execution of the entire process – from indication to transfusion. Practical training takes place in small groups of three to four soldiers, each with an instructor. The instructor ratio is one medical and one non-medical instructor for every six participants (Figure 1).

Fig. 1: German soldier performing a whole blood donation during training, shown at the start of leukocyte depletion after blood collection (Source: Bundeswehr Media Database)

Practical Training Content

Practical training includes the following steps:

• indication based on the existing algorithm,
• determination of ABO, Rhesus, and Kell blood groups on the recipient’s side, including the use of commercially available bedside tests,
• subsequent donor selection, donor history, counseling, and assessment or determination of suitability for blood donation, including prioritization of donors in mass casualty incidents,
• performing whole blood donation, including collection of reserve samples,
• diagnostics for HIV, hepatitis B and C, and syphilis, including rapid test-based infection serology as point-of-care diagnostics,
• determination of ABO, Rhesus, and Kell blood groups on the donor’s side, including the use of commercially available bedside tests, and
• leukocyte depletion and the production/labeling of the final transfusion product, including documentation on both donor and recipient sides, as well as
• transfusion of the finished whole blood product after blood group confirmation.

Participation in puncture is voluntary only. The maximum donation limit is 150 ml per person. Autologous retransfusion is not performed. The training uses the current blood donation systems (Figure 2).

Fig. 2: Material overview of whole blood donation showing the donor, recipient, test components, and the prepared system, including a puncture simulator and artificial skin (Source: Bundeswehr, A. Schmidt)

Simulation and Scenario Training

The training is conducted using prepared blood donation systems. The fill weight is continuously monitored with a spring scale (target value: 475 g ± 10%) to ensure realistic product quality.

In simulation-based training and assessments, it is important not only to provide a realistic puncture experience but also to realistically vary or control both the blood flow rate and the duration of filtration (leukocyte depletion). Accurately representing the puncture site on living humans is important but challenging. The use of large-bore donation needles significantly limits the usability of IV skill trainers, as they cannot be sealed after puncture and can only be used once. To address this, a cost-effective, safe puncture simulator was developed using standard cross-sectional items and leftover materials, combined with homemade artificial skin, offering an inexpensive and realistic simulation option. By utilizing polyethylenglycol (PEG) bags as artificial blood supplies, any donation volume and duration can be realistically simulated using commercially available products. Developing artificial blood recipes based on commercially available components allows for the realistic mimicking of blood behavior during leukocyte depletion, including temperature- or environment-dependent changes, enabling filtration intervals of 12 to 25 minutes to be reliably simulated.

Therefore, on the third day of training, participants focus almost entirely on practically implementing the entire process, from indication to donor selection and examination, counseling, whole blood donation, and the initiation of transfusion. After practicing individual steps or working in a controlled classroom environment during the previous two days, the third training day takes place under realistic conditions. The training is conducted in full combat gear, typically outdoors. The goal is to prepare participants to be ready for transfusion within 45 minutes of initial contact with the donor. During this session, 12 participants are trained and evaluated by 4 instructors.

Examination Procedures

The assessment of the training is conducted similarly to the practical exam, using a standardized test form that covers all individual activities of the entire process in 30 steps. Errors are categorized into three groups:

• red: immediately life-threatening (e.g., major incompatible transfusion),
• yellow: indirectly threatening but not immediately life-threatening,
• green: minor errors.

Four errors within one category equate to one error in the next higher category.

On the following training day, participants undergo individual assessments. This exam is a vital part of the training to ensure and showcase the high quality of future practitioners’ skills. Examinations are performed in written, oral, and practical formats before an examination board composed of two equal examiners, one medical and one non-medical instructor. If the examiners cannot agree on the evaluation, the practical exam must be repeated before three examiners. This situation has not yet happened.

The written exam lasts 60 minutes and includes 40 multiple-choice questions, with a passing threshold of 75%. The practical exam follows, with the same time limit of 45 minutes, from donor contact to transfusion readiness. The exam is considered failed if there is one red error. The oral exam takes place shortly after the practical exam. Participants answer 25 questions covering various course topics, and the exam lasts approximately 30 minutes. The same evaluation standards apply as in the written exam. Grading is on a scale of 1 to 6, with a minimum average grade of 4.49 needed to pass. The written and oral grades can compensate for each other. The practical exam is a barrier subject, meaning a result of at least 4 is required to pass. With excellent scores, an Instructor Potential (IP) is awarded, qualifying participants for further instructor training or required for it. To earn the IP, none of the three partial grades can be worse than 2, and the overall score must be 90% or higher. The IP must be confirmed by both examiners and emphasizes solid answers or a deep understanding of the topics (Figure 3).

Fig. 3: New algorithm for whole blood donation presented as a pocket card (Source: Bundeswehr, procedural instruction whole blood)

Participants’ learning progress can be objectively measured based on the results of the pre-test and final exam (n = 266). The performance development aligns with the subjective satisfaction of the participants. Since 2025, a shortened training format with a total duration of two days has been offered for specialists in anesthesiology with completed further training as transfusion officers (specialist knowledge in transfusion medicine). This allows key personnel with high routine and expertise to be less burdened by absences. Participants have access to the same self-paced e-learning; along with the high level of training, the theoretical training is reduced to the necessary minimum of two teaching units in favor of practical training. To maximize practical training time, the exam is conducted by three examination boards with six participants each. This arrangement, along with the parallelization of the written and practical-oral components in two exam groups, limits the total exam time to three hours. The modalities of the final exam are identical to those used in regular practitioner training.

Instructor Training

Despite the challenges brought by the SARS-CoV-2 pandemic, a one-week instructor training by the Expert Working Group on Whole Blood at the Bundeswehr Central Hospital in Berlin started after a pilot phase in 2021. During practitioner training and the new training priorities, the previous instructor training was assigned to the Training and Simulation Center of Medical Regiment 3 in 2023, where it was adapted both structurally and content-wise, and continued.

The instructor training follows, similar to internationally validated training formats, two modules: Module 1 “Preparation Course” and Module 2 “Mentoring.”

Module 1, the “Preparation Course,” involves a training week covering the planning, organization, and execution of practitioner training, as well as training content, teaching methods, and guidelines for consistent, standardized training. It requires teaching samples and intensive practical training focusing on teaching, assessment, didactic skills, team leadership, and evaluation and improvement. The module ends with a comprehensive assessment; a formal exam is not included.

Module 2, “Mentoring,” takes place within six months of Module 1 at the latest and lasts one week. Under the supervision of experienced instructors at the Training and Simulation Center of Medical Regiment 3, candidates independently conduct at least one “Whole Blood Donation Practitioner” course. Similar to Module 1, there is no final exam, but a comprehensive evaluation.

To qualify as an instructor for whole blood donation, one must complete both modules. This qualification is valid for 24 months and is available to both medical and non-medical personnel. The teaching qualification is maintained through active instructor involvement; within 24 months, at least two regular practitioner courses must be conducted. The qualification is renewed by extending the practitioner certification.

Conclusion

The implementation of a structured whole blood program addresses the urgent treatment of life-threatening bleeding in logistically constrained situations. The interprofessional approach greatly expands operational capabilities without compromising regulatory safety standards. The presented concept combines operational flexibility with transfusion law compliance and offers a structured, quality-assured model for military deployment. The Bundeswehr Medical Service is the only national institution [4] that provides and promotes this capability. This opens opportunities for further international and civil-military cooperation in military and disaster medicine.

Key Statements

• Traumatic hemorrhage is one of the leading preventable causes of death in military operations.
• Whole blood allows for logistically practical emergency transfusions, even in resource-­limited settings.
• The training is interprofessional, simulation-­based, and consistently aligned with transfusion law requirements.
• Medical and non-medical personnel are trained and qualified for application.
• The concept combines regulatory safety with operational effectiveness.

References

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Conflict of Interest Statement:

The authors declare no conflict of interest in accordance with the guidelines of the International Committee of Medical Journal Editors.

Manuscript Data

Citation

Teufel M, Sauer D, Jänig C, Prein C, Markmeyer T, Ammann J. Whole Blood Training Program in the Bundeswehr Medical Service – Concept, Implementation, and Qualification Profile. WMM 2026;70(5E):6.

DOI: https://doi.org/10.48701/opus4-882

For the Authors

Lieutenant Colonel (MC) Martin TEUFEL

Training and Simulation Center Sanitätsregiment 3

Auf dem Lerchenfeld 1, D-89160 Dornstadt

E-Mail: martinteufel@bundeswehr.org