Revised french military transfusion doctrine for large-scale combat operations: a consensus framework

Background: Large-scale combat operations (LSCO) pose unique logistical and clinical challenges to haemorrhagic casualty management. The existing French military transfusion doctrine, originally designed for low-intensity conflicts (LIC), does not meet the demands of LSCO. This work aimed to develop a revised, consensus-based transfusion doctrine integrating operational, medical, and safety requirements for LSCO environments. Methods: At the request of the Central Directorate of the Military Health Service, a Delphi-based consensus process was conducted between November 2024 and April 2025. Eight senior military physicians—anaesthesiologist-intensivists, emergency and operational clinicians, and medical biologists with over five years of specialty experience—reviewed eleven thematic domains identified for revision. Drafts, developed from doctrinal texts, operational feedback, and international literature (including systematic reviews), were iteratively refined through three Delphi cycles until full consensus (100%) was reached. This consensus reflects expert doctrinal guidance for LSCO operational preparedness under limited/heterogeneous evidence rather than proof of clinical efficacy. The resulting doctrine was compared with the previous LIC framework and international LSCO transfusion strategies. Results: The new doctrine establishes a scalable, safety-focused system integrating forward whole-blood resuscitation, enhanced logistical autonomy, and reinforced haemovigilance. Cold-stored whole blood will be prioritised as the primary resuscitation product for Roles 1 and 2, while Role 3 will employ component therapy. A new dedicated operational medical unit will oversee in-theatre collection, testing, and distribution. Forward transfusion by trained nurses using universal blood products under predefined criteria will be authorised, with strict traceability and targeted training ensuring transfusion safety in LSCO. Conclusions: This consensus defines the modern French transfusion doctrine for LSCO, combining operational flexibility with rigorous safety oversight and alignment with international standards.