Does the 1:1:1 Transfusion Ratio Mortality Benefit Hold True in Ultra-massive Transfusion? A Study From the Product (Patient Related Outcomes During Ultra-massive transfusion multi-Center Trial) Consortium

Abstract

Objective

The gold standard for resuscitation in traumatic hemorrhagic shock is 1:1:1 transfusion (FFP:PLT:RBC). However, this practice guideline was established based on patients who received low-volume blood transfusions. Therefore, this study sought to investigate the relationship of transfusion ratios on mortality in trauma patients undergoing ultra-massive transfusion (UMT) (≥20 units of red blood cell product/24 hours).

Methods

A multicenter retrospective review of patients receiving UMT was conducted across 11 level I trauma centers from 2016 to 2024. Patients were analyzed based on the following categories: FFP:RBC or Platelet:RBC <1:2 (low), 1:2-1:1 (moderate), and ≥1:1 (high). The primary outcome of interest was mortality.

Results

Across the centers, 1155 patients received UMT with an overall mortality rate of 62.9%. They were predominantly males (81.6%) with a median age of 32 years (IQR 25-48). The majority (72.4%) received moderate FFP:RBC transfusion ratios and either low (44.8%) or moderate (42.6%) Platelet:RBC ratios. As Platelet:RBC ratio trended higher, the mortality rate decreased with a 24-hour mortality of 70.8% in the low group, 59.1% in the moderate, and 47.6% in the high. Transfusion ratio of Platelet:RBC was an independent risk factor for mortality, with OR 0.54 in the moderate group (P < 0.001) and OR 0.39 in the higher group (P < 0.001).

Conclusion

Our analysis utilizes one of the largest, multicenter cohorts of UMT patients and found a statistically significant decrease in mortality with more balanced Platelet:RBC transfusion ratios. These findings suggest that perhaps earlier and more aggressive transfusion of platelets may confer a survival benefit for trauma patients undergoing UMT.