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 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, 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.