Optimizing transfusion ratios in massive transfusion protocols: An argument against the 1:1:1 dogma and approach to trauma resuscitation

Abstract

We believe that the current practice of transfusing red blood cells (RBCs), plasma, and platelets in a 1:1:1 ratio is not optimal in massive transfusion protocols (MTPs) and is based on a simple yet profound misconception regarding the preparation of component blood products. This 1:1:1 approach ignores the additional fluids added for anticoagulation and preservation of the components and assumes that there is a one-size-fits-all ratio that must be used across all types of trauma. In this article, we explain the rationale behind our conclusion with supporting figures and suggest that although the 1:1:1 ratio might be within the range of hemostasis, it falls near the lower cusp of hemostasis, making it less than ideal. The patient in mind was one in whom transfusion was expected to exceed 10 units of packed RBCs (pRBCs) in a combat environment where the situation was too hectic for additional testing. The goal was to keep the patient within a hemostatic range until the crisis phase was averted and the transition could then be made to goal-directed therapy with point-ofcare testing.