High fresh frozen plasma to packed red blood cell ratios are associated with lower rates of acute kidney injury and acute respiratory distress syndrome in Trauma Quality Improvement Program: A propensity score-matched analysis.

BACKGROUND

Balanced transfusion with (1:1:1) ratios of fresh frozen plasma (FFP), packed red blood cells (PRBCs), and platelets is a core tenet of management in traumatic hemorrhagic shock. However, preclinical data suggest that PRBCs transfusion may contribute to endothelial dysfunction, a complication that may be mitigated by FFP. We examined the impact of high FFP:PRBC ratios on mortality and major complications using the American College of Surgeons Trauma Quality Improvement Program database.

METHODS

Trauma patients (18 years or older) in Trauma Quality Improvement Program (2017-2022) who received ≥1 U FFP and 1 U PRBC within 4 hours were included. Those transfused with whole blood or FFP:PRBC <0.9 were excluded. Patients were classified as balanced (FFP:PRBC 0.9-1.1) or excess FFP (FFP:PRBC >1.1), propensity matched based on odds of mortality, and compared by multivariate regression.

RESULTS

Of 50,594 patients analyzed (75% male; median age, 38 years; Injury Severity Score, 25), 31,960 (63%) were classified as balanced, and 18,634 (37%) as excess FFP. Propensity matching generated 16,939 pairs (mean standard difference, <0.1). After multivariable adjustment, excess FFP was associated with 40% decreased odds of acute respiratory distress syndrome ( p  < 0.001) and 32% decreased odds of acute kidney injury ( p  = 0.027) compared with balanced transfusion, with no difference in hospital mortality (odds ratio, 1.01; 95% confidence interval, 0.92-1.11; p  = 0.87).

CONCLUSION

We found that early excess FFP (FFP:PRBC ratio >1.1) was associated with a significantly decreased odds of key complications compared with a strictly defined balanced transfusion (FFP:PRBC ratio 0.9-1.1), supporting further investigation of the potential benefits of plasma. ( J Trauma Acute Care Surg. 2026;100: 760-767. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved).

LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.