Don’t Forget the Platelets

Balanced blood component administration during massive transfusion (MT) is standard of care. Most literature focuses on the impact of red blood cell (RBC):fresh frozen plasma (FFP) ratio while the value of balanced RBC:platelet (PLT) administration is less established. The aim of this study was to evaluate and quantify the independent impact of RBC:PLT on 24-hour mortality in trauma patients receiving MT.Methods: Using the 2013-18 ACS-TQIP database, adult patients who received MT (≥10 units of RBC/24-hours) and ≥ 1 unit of RBC, FFP and PLT within 4-hours of arrival were retrospectively included. To mitigate survival bias, only patients with consistent RBC:PLT and RBC:FFP ratios between 4 and 24-hours were analyzed. Balanced FFP or PLT transfusions were defined as having RBC:PLT and RBC:FFP of ≤2, respectively. Multivariable logistic regression was used to compare the independent relationship between RBC:FFP, RBC:PLT, balanced transfusion and 24- hour mortality.A total of 9,215 MT patients were included. The number of patients who received transfusion with RBC:PLT > 2 (1,942 [21.1%]) was significantly higher than those with RBC:FFP > 2 (1,160 [12.6%]) (p < 0.001). Compared to an RBC:PLT ratio of 1:1, a gradual and consistent risk increase was observed for 24-hour mortality as the RBC:PLT ratio increased (p < 0.001). Patients with both FFP and PLT balanced transfusion had the lowest adjusted risk for 24-hr mortality. Mortality increased as resuscitation became more unbalanced, with higher odds of death for unbalanced PLT (OR = 2.48 [2.18-2.83]) than unbalanced FFP (OR = 1.66 [1.37-1.98]), while patients who received both FFP and PLT unbalanced transfusion had the highest risk of 24- hour mortality (OR = 3.41 [2.74-4.24]).Trauma patients receiving MT significantly more often have unbalanced PLT rather than unbalanced FFP transfusion. The impact of unbalanced PLT transfusion on 24-hour mortality is independent and potentially more pronounced than unbalanced FFP transfusion, warranting serious system-level efforts for improvement.Level 4, Therapeutic.