In Reply

Pasquier et al.¹  bring up the topic of perioperative bleeding and its management in resource-limited settings as a global public health issue, particularly in the context of massive, and often fatal, hemorrhage in the postpartum and trauma contexts. While the topic is a very pertinent one, we did not focus on it in our study, which aimed to describe anesthetic procedures that are safe and feasible in the rather unusual clinical contexts where Médecins Sans Frontières (MSF) operates.²  Given the limitations of our database, we were unable to ascertain the cause of perioperative mortality and could not quantify the incidence of specific perioperative complications or their management, like perioperative bleeding. The extraction of such information would require a dedicated chart review of individual patient records, a topic worthy of research in the future when the resources are available.

They mention their experience with the French Military Health Service and the use of dedicated guidelines for blood transfusion in exceptional settings, such as the one their forward surgical teams apply to the combat and civilian casualties that they treat. MSF also has a comprehensive perioperative blood management policy in place, which includes a transfusion protocol for patient safety and access to adjuvant therapies such as QuikClot and tranexamic acid. Because of limited resources, the approach utilized for blood management at a particular location depends on the situational context, with most facilities not being equipped with a dedicated blood bank.

Frontline MSF facilities are usually located in “safe” zones where they operate in an expectant mode, awaiting patients to arrive at the hospital for treatment after initial stabilization in the field or other locations, usually by non-MSF personnel. They are not designated triage locations and usually do not have patients coming in with acute traumatic hemorrhage. The use of tranexamic acid is of limited value in these scenarios as patients mostly arrive outside of the safe 3-h window for administration. When acute hemorrhage in wound and trauma surgeries is encountered in these frontline facilities, clinical strategies to minimize the need for blood transfusion are utilized first. Standard resources available at frontline MSF facilities include QuikClot in the emergency department and the use of permissive hypotension, tourniquets, and autologous transfusion from appropriate hemothorax and hemoperitoneum patients (according to the International Committee of the Red Cross recommendations) in the operating room. When blood transfusion is absolutely required, whole blood is available for use at most frontline facilities as opposed to separated blood components.

In hospitals that provide obstetrical care, the capacity for blood transfusion is required as a part of our Comprehensive Emergency Obstetric and Neonatal Care policy. While not standard, MSF is sometimes able to maintain a small blood bank in these hospitals using specialized refrigerators depending on the resources and permissions at that particular location. Otherwise, a living donor blood bank is established, where people have already been preidentified and screened for emergency blood donation. As a matter of policy, all donor blood is tested at MSF facilities, even if it is coming from the local national blood transfusion centers. It is primarily the tertiary MSF facilities located in more urban and well-resourced settings that have classic blood banks and are therefore able to handle trauma resuscitation in more traditional ways with the use of separated blood components.

In summary, we agree with Pasquier et al.¹  that this is an area of global public health significance. While we are unable to answer their questions regarding causes of mortality and incidences of blood transfusions at this time, we hope to investigate these further in the future. The various practices mentioned regarding blood transfusion capabilities and practices at MSF facilities have evolved to be dependent on the context of the facility’s location and purpose. We feel that such an approach might potentially provide the initial outline for future programmatic work in this arena across the disparate healthcare settings found in low- and middle-income countries. We thank you for prompting the conversation on this very important topic.