Low Volume Blood Product Transfusion Patterns And Ratios After Injury


      • Low Volume Blood Product Transfusion Patterns And Ratios After Injury: Highlights.
      • Platelet & plasma transfusion ratios were more balanced at low volume transfusions.
      • Transfusion ratios were increasingly unbalanced in high volume transfusions.
      • The ideal transfusion ratio in low volume trauma resuscitation is unknown.



      The benefit of a balanced resuscitation in low volume transfusions remains unclear This study is aimed at characterizing blood product ratios in this cohort.


      A retrospective analysis (2017–2019) of the ACS TQIP was performed to identify adult trauma patients who received ≥1 unit of packed red blood cells (pRBCs) 4 and 24 h after admission. Blood products received were used to calculate plasma and platelet ratios.


      Plasma and platelet ratios were closer to the target 1:1 ratio for ≤4 units pRBCs. Plasma and platelet ratios increased for those receiving ≤10 units pRBCs, demonstrating increasingly unbalanced resuscitation. Transfusion ratios were unbalanced for those receiving ≥5 units pRBC.


      Transfusion ratios were closer to the desired transfusion ratio for low volume blood product resuscitation. In those receiving ≥5 units pRBC, plasma and platelet ratios were not balanced. The optimal transfusion ratio in low volume trauma resuscitation is unknown.

      Graphical abstract


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. 10 leading causes of death by age group, United States - 2018. Centers for disease control and prevention.
        (Available at:)
        • Eastridge B.J.
        • Holcomb J.B.
        • Shackelford S.
        Outcomes of traumatic hemorrhagic shock and the epidemiology of preventable death from injury.
        Transfusion. 2019; 59: 1423-1428
        • Van P.Y.
        • Holcomb J.B.
        • Schreiber M.A.
        Novel concepts for damage control resuscitation in trauma.
        Curr Opin Crit Care. 2017; 23: 498-502
        • Holcomb J.B.
        • Jenkins D.
        • Rhee P.
        • et al.
        Damage control resuscitation: directly addressing the early coagulopathy of trauma.
        J Trauma. 2007; 62: 307-310
        • Cantle P.M.
        • Cotton B.A.
        Balanced resuscitation in trauma management.
        Surg Clin. 2017; 97: 999-1014
        • Silverboard H.
        • Aisiku I.
        • Martin G.S.
        • Adams M.
        • Rozycki G.
        • Moss M.
        The role of acute blood transfusion in the development of acute respiratory distress syndrome in patients with severe trauma.
        J Trauma. 2005; 59: 717-723
        • Holena D.N.
        • Netzer G.
        • Localio R.
        • et al.
        The association of early transfusion with acute lung injury in patients with severe injury.
        J Trauma Acute Care Surg. 2012; 73: 825-831
        • Holcomb J.B.
        • Tilley B.C.
        • Baraniuk S.
        • et al.
        Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial.
        JAMA. 2015; 313: 471-482
        • Cole E.
        • Weaver A.
        • Gall L.
        • et al.
        A decade of damage control resuscitation: new transfusion practice, new survivors, new directions.
        Ann Surg. 2021; 273: 1215-1220
        • Stein P.
        • Kaserer A.
        • Sprengel K.
        • et al.
        Change of transfusion and treatment paradigm in major trauma patients.
        Anaesthesia. 2017; 72: 1317-1326
        • Program ACoSTQI
        Level I & II TQIP: an overview.
        (Available at:)
        • Hynes A.M.
        • Geng Z.
        • Schmulevich D.
        • et al.
        Staying on target: maintaining a balanced resuscitation during damage-control resuscitation improves survival.
        J Trauma Acute Care Surg. 2021; 91: 841-848
        • ACoSCo Trauma
        ACS TQIP massive transfusion in trauma guidelines.
        (Available at:)
        • Holcomb J.B.
        • Fox E.E.
        • Wade C.E.
        • Group P.S.
        The PRospective observational multicenter major trauma transfusion (PROMMTT) study.
        J Trauma Acute Care Surg. 2013; 75: S1-S2
        • Camazine M.N.
        • Hemmila M.R.
        • Leonard J.C.
        • et al.
        Massive transfusion policies at trauma centers participating in the American College of Surgeons trauma quality improvement Program.
        J Trauma Acute Care Surg. 2015; 78: S48-S53
        • Cannon J.W.
        • Khan M.A.
        • Raja A.S.
        • et al.
        Damage control resuscitation in patients with severe traumatic hemorrhage: a practice management guideline from the Eastern Association for the Surgery of Trauma.
        J Trauma Acute Care Surg. 2017; 82: 605-617
        • Etchill E.
        • Sperry J.
        • Zuckerbraun B.
        • et al.
        The confusion continues: results from an American Association for the Surgery of Trauma survey on massive transfusion practices among United States trauma centers.
        Transfusion. 2016; 56: 2478-2486
        • Demetriades D.
        • Martin M.
        • Salim A.
        • et al.
        Relationship between American College of Surgeons trauma center designation and mortality in patients with severe trauma (injury severity score > 15).
        J Am Coll Surg. 2006; 202 (; quiz A45): 212-215
        • Hamidi M.
        • Zeeshan M.
        • Kulvatunyou N.
        • et al.
        Outcomes after massive transfusion in trauma patients: variability among trauma centers.
        J Surg Res. 2019; 234: 110-115
        • Nunn A.
        • Fischer P.
        • Sing R.
        • Templin M.
        • Avery M.
        • Christmas A.B.
        Improvement of treatment outcomes after implementation of a massive transfusion protocol: a level I trauma center experience.
        Am Surg. 2017; 83: 394-398
        • Holcomb J.B.
        Damage control resuscitation.
        J Trauma. 2007; 62: S36-S37
        • Powell E.K.
        • Hinckley W.R.
        • Gottula A.
        • Hart K.W.
        • Lindsell C.J.
        • McMullan J.T.
        Shorter times to packed red blood cell transfusion are associated with decreased risk of death in traumatically injured patients.
        J Trauma Acute Care Surg. 2016; 81: 458-462
        • Kasotakis G.
        • Starr N.
        • Nelson E.
        • et al.
        Platelet transfusion increases risk for acute respiratory distress syndrome in non-massively transfused blunt trauma patients.
        Eur J Trauma Emerg Surg. 2019; 45: 671-679
        • Inaba K.
        • Branco B.C.
        • Rhee P.
        • et al.
        Impact of plasma transfusion in trauma patients who do not require massive transfusion.
        J Am Coll Surg. 2010; 210: 957-965
        • Chang R.
        • Holcomb J.B.
        Optimal fluid therapy for traumatic hemorrhagic shock.
        Crit Care Clin. 2017; 33: 15-36
        • Brill J.B.
        • Brenner M.
        • Duchesne J.
        • et al.
        The role of TEG and ROTEM in damage control resuscitation.
        Shock. 2021; 56: 52-61
        • Stensballe J.
        • Henriksen H.H.
        • Johansson P.I.
        Early haemorrhage control and management of trauma-induced coagulopathy: the importance of goal-directed therapy.
        Curr Opin Crit Care. 2017; 23: 503-510
        • Johansson P.I.
        • Sorensen A.M.
        • Larsen C.F.
        • et al.
        Low hemorrhage-related mortality in trauma patients in a Level I trauma center employing transfusion packages and early thromboelastography-directed hemostatic resuscitation with plasma and platelets.
        Transfusion. 2013; 53: 3088-3099
        • Gonzalez E.
        • Moore E.E.
        • Moore H.B.
        • et al.
        Goal-directed hemostatic resuscitation of trauma-induced coagulopathy: a pragmatic randomized clinical trial comparing a viscoelastic assay to conventional coagulation assays.
        Ann Surg. 2016; 263: 1051-1059