Severe trauma, hemorrhoea and major operation usually need massive blood transfusion or massive transfusion (MT), including blood exchange transfusion. MT is the replacement of large amount of blood, for example transfusion that is equal to a complete blood volume replacement over 24 h (1). MT has classically been defined as the administration of >10 units of red blood cells (RBC) in a 24-h period (2).

MT occurs in 1–3% of civilian trauma admissions (3,4) and this specific subset of patients suffers a high mortality (5,6). MT occurs in 10–15% of the most severely injured patients (7,8). In most institutions, the most common reason for MT is trauma (9). MT is also frequently required as treatment for severe hemorrhage in patients with gastrointestinal (GI) bleeding (10–12) and those undergoing surgery.

Several retrospective studies have demonstrated a survival benefit for bleeding trauma patients when transfused with an early high RBC:fresh frozen plasma (FFP) 1:1 ratio, in civilian as well as military settings (13–16). To promote the clinical treatment of MT, the present study aimed to explore the effective blood component transfusion ratio through a retrospective study of MT.

During the time period examined in the present study, 2002–2011, 1,658 patients received a MT. The study comprised 902 men and 756 women, with a mean age of 52 years. The 7-day hospital mortality for patients who received a MT was 27.3%. In our study, 28,030 units of RBC were received, accounting for 2.8% of the total blood transfusion during the observation period. Moreover, patients were also administered 4.2% of FFP, 0.7% of blood platelets (PLT) and 13.1% of the entire cryoprecipitate usage in MT (Table I).

Baseline demographic data comparing survivors and non-survivors in the MT group are presented in Table II. In all diseases, patients receiving MT showed a higher survival rate compared with patients succumbing to various diseases. Additionally, a higher survival rate was detected in male compared to female patients. The ratio and amount of various blood components used in the survivors and non-survivors are shown in Table III. The median of FFP and RBC was 0.63, and 0.73 and 0.58 in the non-survivors and survivors, respectively. Similarly, the median of PLT and RBC was 0.64 in the non-survivors, and 0.57 in the survivors. To explore the correlation between the survival rate and blood component, FFP:RBC were divided into three levels: >1.2 was the high value group; 0.8–1.2 was the equal group and <0.8 was the low group (Table IV).

Timely and adequate blood transfusion to patients with blood loss is extremely significant. However, due to the coagulation disorders, hypothermia, acidosis and additional complications associated with blood transfusion, the clinical mortality rate remains high. MT in trauma patients affects a small percentage of civilian and military trauma patients, a great number of whom is expected to succumb to the disease early in their course from hemorrhage and to consume a great deal of trauma center resources (13,17–24).

In their study, Riskin et al (25) suggested that implementation of a MT protocol and fixed blood component ratio are associated with reduced mortality. Trauma is a public health problem that draws worldwide attention and ranks third, following heart and cancer disease as the leading cause of mortality. In trauma patients, traumatic blood loss accounted for 40% of deaths, followed by traumatic brain injury (26). For patients with large blood loss, MT is one of the main treatment options. However, large importation of red blood cell suspension would dilute the clotting factors, which leads to coagulation disorders and further trauma-induced aggravated acidosis and hypothermia (27). Traumatic coagulopathy markedly affects patient survival rate. The 24-h mortality rate in patients with trauma coagulopathy was demonstrated to be eight times more compared to other patients (28), while the overall mortality rate was four times more. Wafaisade et al (29) found that the survival rate improves significantly in patients with a FFP:RBC ratio of >1:1. However, Sperry et al (16) found that the infusion of FFP and RBC improved the survival rate at a ratio of 1:1.5.

The most appropriate transfusion amount of plasma, platelet and cryoprecipitation and volume of other coagulation factors and RBC remain unknown, but the ratio of RBC:FFP:PLT has recently been identified as 1:1:1. While previous studies suggest that the FFP:RBC ratio is a significant variable, its importance has yet to be fully elucidated. Additional studies used a computer model to assess the outcome of blood transfusion management, indicating that the optimal ratio of FFP:RBC and PLT:RBC are 2:3 and 8:10, respectively (30).

We recommend a fixed ratio of RBC:FFP:PLT at 1:1:1. In his study, Johansson (31) concluded that the optimal transfusion by proper monitoring improved the survival of massively bleeding patients. At present, MT delivers blood products at a certain ratio, as well as order and time intervals. Recent studies have found that early detection of coagulation, early and active intervention of blood component proportion is extremely significant in patients with severe trauma. MT of almost whole blood markedly reduces mortality (32). Therefore, fixed blood component ratios improve the use of blood components and reduce mortality.