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Original Investigation
March 8, 2017

Association Between Ratio of Fresh Frozen Plasma to Red Blood Cells During Massive Transfusion and Survival Among Patients Without Traumatic Injury

Author Affiliations
  • 1Division of Trauma, Department of Surgery, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston
  • 2Department of Pathology and Transfusion Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
  • 3Department of Medicine, Massachusetts General Hospital, Boston
JAMA Surg. Published online March 8, 2017. doi:10.1001/jamasurg.2017.0098
Key Points

Question  Is hemostatic resuscitation being practiced for rapidly bleeding patients without trauma?

Findings  In this retrospective study of 865 massive transfusion events in an urban academic hospital, nearly 90% of all massive transfusions were received by patients without trauma, but there was no evidence that a ratio-based transfusion strategy of high fresh frozen plasma to red blood cells ratio improved survival.

Meaning  The practice of hemostatic resuscitation has spread to other patient populations without supporting evidence of benefit.


Importance  Hemostatic resuscitation has been shown to be beneficial for patients with trauma, but there is little evidence that it is equally beneficial for bleeding patients without trauma. The practice of a high transfusion ratio of fresh frozen plasma (FFP) to red blood cells (RBCs) has spread to other surgical and medical fields.

Objective  To identify whether ratio-based resuscitation in patients without trauma is associated with improved survival.

Design, Setting, and Participants  This study is a retrospective review of all massive transfusions provided in an urban academic hospital from January 1, 2009, through December 31, 2012. Massive transfusion was defined as the transfusion of at least 10 U of RBCs in the first 24 hours after a patient’s admission to the operating room, emergency department, or intensive care unit. All patients who received massive transfusions within the study period and survived more than 30 minutes after hospital arrival were counted (n=865). Patients were grouped into those with trauma and those without trauma. Sources of data included the Research Patient Data Registry, patients’ medical records, and blood bank records. All data collection occurred between April 26, 2013, and April 26, 2015. Data analysis took place from April 27, 2015, and June 22, 2016.

Main Outcomes and Measures  Examination of FFP:RBC transfusion ratios for patients without trauma.

Results  There were 865 massive transfusion events that occurred within 4 years, transfusing 16 569 U of RBCs, 13 933 U of FFP, 5228 U of cryoprecipitate, and 22 635 U of platelets. Most of these transfusions were received by patients without trauma (767 [88.7%]), by men (582 [67.3%]), and for intraoperative bleeding (544 [62.9%]). The FFP:RBC ratios of survivors and nonsurvivors were nearly identical: the ratio for survivors was 1:1.5 (interquartile range [IQR], 1:1.1-1:2.2) and for nonsurvivors was 1:1.4 (IQR, 1:1.1-1:1.9; P = .43). Among the 767 patients without trauma, there was no difference in the adjusted odds ratio (aOR) for 30-day mortality when comparing the high FFP:RBC ratio vs the low FFP:RBC ratio subgroups (aOR, 1.10; 95% CI, 0.72-1.70; P = .65). In vascular surgery, the aOR for death favored the high FFP:RBC ratio subgroup (aOR, 0.16; 95% CI, 0.03-0.79; P = .02). However, in general surgery and medicine, the aOR for death favored the low FFP:RBC ratio subgroup; general surgery: aOR, 4.27 (95% CI, 1.28-14.22; P = .02); medicine: aOR, 8.48 (95% CI, 1.50-47.75; P = .02).

Conclusions and Relevance  High FFP:RBC transfusion ratios are applied mostly to patients without trauma, who account for nearly 90% of all massive transfusion events. Thirty-day survival was not significantly different in patients who received a high FFP:RBC ratio compared with those who received a low ratio.