Bleeding in Cardiac Surgery: Should Massive Transfusion Be in a 1:1:1 Ratio?

  • James M. Bardes
  • Kenji InabaEmail author
Part of the Difficult Decisions in Surgery: An Evidence-Based Approach book series (DDSURGERY)


Nearly 10% of postoperative cardiothoracic surgery patients will require transfusion of at least five units of packed red blood cells. This transfusion requirement is multifactorial, however cardiothoracic patients should be considered higher risk for hemorrhage. The optimal transfusion ratio for post cardiac surgery hemorrhage is unclear. Conversely, for trauma patients, the effect of transfusion ratios on outcomes has been studied extensively. For these patients, a balanced transfusion ratio of 1:1:1 (plasma, platelets, red blood cells) results in a decrease in bleeding specific mortality.


Massive transfusion Cardiothoracic surgery Postoperative complication Postoperative hemorrhage Transfusion ratios 


  1. 1.
    Cobain TJ, Vamvakas EC, Wells A, Titlestad K. A survey of the demographics of blood use. Transfus Med. 2007;17(1):1–5.CrossRefGoogle Scholar
  2. 2.
    Delaney M, Stark PC, Suh M, Triulzi DJ, Hess JR, Steiner ME, Stowell CP, Sloan SR. Massive transfusion in cardiac surgery: the impact of blood component ratios on clinical outcomes and survival. Anesth Analg. 2017;124(6):1777–82.CrossRefGoogle Scholar
  3. 3.
    Karkouti K, Wijeysundera DN, Yau TM, Beattie WS, Abdelnaem E, McCluskey SA, Ghannam M, Yeo E, Djaiani G, Karski J. The independent association of massive blood loss with mortality in cardiac surgery. Transfusion. 2004;44(10):1453–62.CrossRefGoogle Scholar
  4. 4.
    Mazzeffi MA, Chriss E, Davis K, Zhan M, Harris A, Rock P, Gammie JS, Tanaka K. Optimal plasma transfusion in patients undergoing cardiac operations with massive transfusion. Ann Thorac Surg. 2017;104(1):153–60.CrossRefGoogle Scholar
  5. 5.
    Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, Sebesta J, Jenkins D, Wade CE, Holcomb JB. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma Acute Care Surg. 2007;63(4):805–13.CrossRefGoogle Scholar
  6. 6.
    Inaba K, Lustenberger T, Rhee P, Holcomb JB, Blackbourne LH, Shulman I, Nelson J, Talving P, Demetriades D. The impact of platelet transfusion in massively transfused trauma patients. J Am Coll Surg. 2010;211(5):573–9.CrossRefGoogle Scholar
  7. 7.
    Stinger HK, Spinella PC, Perkins JG, Grathwohl KW, Salinas J, Martini WZ, Hess JR, Dubick MA, Simon CD, Beekley AC, Wolf SE. The ratio of fibrinogen to red cells transfused affects survival in casualties receiving massive transfusions at an army combat support hospital. J Trauma Acute Care Surg. 2008;64(2):S79–85.CrossRefGoogle Scholar
  8. 8.
    Holcomb JB, Wade CE, Michalek JE, Chisholm GB, Zarzabal LA, Schreiber MA, Gonzalez EA, Pomper GJ, Perkins JG, Spinella PC, Williams KL. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg. 2008;248(3):447–58.PubMedGoogle Scholar
  9. 9.
    Snyder CW, Weinberg JA, McGwin G Jr, Melton SM, George RL, Reiff DA, Cross JM, Hubbard-Brown J, Rue LW III, Kerby JD. The relationship of blood product ratio to mortality: survival benefit or survival bias? J Trauma Acute Care Surg. 2009;66(2):358–64.CrossRefGoogle Scholar
  10. 10.
    Shaz BH, Dente CJ, Nicholas J, MacLeod JB, Young AN, Easley K, Ling Q, Harris RS, Hillyer CD. Increased number of coagulation products in relationship to red blood cell products transfused improves mortality in trauma patients. Transfusion. 2010;50(2):493–500.CrossRefGoogle Scholar
  11. 11.
    Holcomb JB, Del Junco DJ, Fox EE, Wade CE, Cohen MJ, Schreiber MA, Alarcon LH, Bai Y, Brasel KJ, Bulger EM, Cotton BA. The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study: comparative effectiveness of a time-varying treatment with competing risks. JAMA Surg. 2013;148(2):127–36.CrossRefGoogle Scholar
  12. 12.
    Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, Podbielski JM, Del Junco DJ, Brasel KJ, Bulger EM, Callcut RA, Cohen MJ. 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(5):471–82.CrossRefGoogle Scholar
  13. 13.
    Park PK, Cannon JW, Ye W, Blackbourne LH, Holcomb JB, Beninati W, Napolitano LM. Transfusion strategies and development of acute respiratory distress syndrome in combat casualty care. J Trauma Acute Care Surg. 2013;75(2):S238–46.CrossRefGoogle Scholar
  14. 14.
    Johnson JL, Moore EE, Kashuk JL, Banerjee A, Cothren CC, Biffl WL, Sauaia A. Effect of blood products transfusion on the development of postinjury multiple organ failure. Arch Surg. 2010;145(10):973–7.CrossRefGoogle Scholar
  15. 15.
    Baumann Kreuziger LM, Morton CT, Subramanian AT, Anderson CP, Dries DJ. Not only in trauma patients: hospital-wide implementation of a massive transfusion protocol. Transfus Med. 2014;24(3):162–8.CrossRefGoogle Scholar
  16. 16.
    Teixeira PG, Inaba K, Karamanos E, Rhee P, Shulman I, Skiada D, Chouliaras K, Demetriades D. The survival impact of plasma to red blood cell ratio in massively transfused non-trauma patients. Eur J Trauma Emerg Surg. 2017;43(3):393–8.CrossRefGoogle Scholar

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© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Division of Trauma and Acute Care SurgeryLos Angeles County and University of Southern California Medical CenterLos AngelesUSA

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