Maintaining a whole blood-centered transfusion improves survival in hemorrhagic resuscitation

J Trauma Acute Care Surg. 2024 May 1;96(5):749-756. doi: 10.1097/TA.0000000000004222. Epub 2023 Dec 21.


Background: Whole blood (WB) transfusion has been shown to improve mortality in trauma resuscitation. The optimal ratio of packed red blood cells (pRBC) to WB in emergent transfusion has not been determined. We hypothesized that a low pRBC/WB transfusion ratio is associated with improved survival in trauma patients.

Methods: We analyzed the 2021 Trauma Quality Improvement Program (TQIP) database to identify patients who underwent emergent surgery for hemorrhage control and were transfused within 4 hours of hospital arrival, excluding transfers or deaths in the emergency department. We stratified patients based on pRBC/WB ratios. The primary outcome was mortality at 24 hours. Logistic regression was performed to estimate odds of mortality among ratio groups compared with WB alone, adjusting for injury severity, time to intervention, and demographics.

Results: Our cohort included 17,562 patients; of those, 13,678 patients had only pRBC transfused and were excluded. Fresh frozen plasma/pRBC ratio was balanced in all groups. Among those who received WB (n = 3,884), there was a significant increase in 24-hour mortality with higher pRBC/WB ratios (WB alone 5.2%, 1:1 10.9%, 2:1 11.8%, 3:1 14.9%, 4:1 20.9%, 5:1 34.1%, p = 0.0001). Using empirical cutpoint estimation, we identified a 3:1 ratio or less as an optimal cutoff point. Adjusted odds ratios of 24-hour mortality for 4:1 and 5:1 groups were 2.85 (95% confidence interval [CI], 1.19-6.81) and 2.89 (95% CI, 1.29-6.49), respectively. Adjusted hazard ratios of 24-hour mortality were 2.83 (95% CI, 1.18-6.77) for 3:1 ratio, 3.67 (95% CI, 1.57-8.57) for 4:1 ratio, and 1.97 (95% CI, 0.91-4.23) for 5:1 ratio.

Conclusion: Our analysis shows that higher pRBC/WB ratios at 4 hours diminished survival benefits of WB in trauma resuscitation. Further efforts should emphasize this relationship to optimize trauma resuscitation protocols.

Level of evidence: Therapeutic/Care Management; Level III.

MeSH terms

  • Adult
  • Blood Transfusion* / methods
  • Blood Transfusion* / statistics & numerical data
  • Erythrocyte Transfusion / methods
  • Erythrocyte Transfusion / statistics & numerical data
  • Female
  • Hemorrhage / mortality
  • Hemorrhage / therapy
  • Humans
  • Injury Severity Score
  • Male
  • Middle Aged
  • Quality Improvement
  • Resuscitation* / methods
  • Retrospective Studies
  • Shock, Hemorrhagic / mortality
  • Shock, Hemorrhagic / therapy
  • Trauma Centers
  • Wounds and Injuries* / mortality
  • Wounds and Injuries* / therapy