Current controversies and advances in massive transfusion: Balancing evidence and practice

Massive transfusion protocols (MTPs) are essential frameworks for rapidly managing severe hemorrhage, particularly in trauma scenarios. This review addresses ongoing controversies and advancements in MTPs, including optimal blood product ratios, the role of viscoelastic hemostatic assays (VHAs), renewed interest in whole blood transfusions, and distinctions between civilian and military practices. Current evidence supports balanced transfusion strategies (approximately 1:1:1 ratios of plasma:platelets: red blood cells), significantly improving early hemorrhage control, though individual patient variability remains under investigation. Viscoelastic tests like TEG and ROTEM offer real-time clot assessment, allowing individualized treatment. However, evidence from randomized trials, such as ITACTIC, reveals mixed outcomes, limiting consensus on widespread implementation. Whole blood transfusions, previously eclipsed by component therapy, are gaining traction due to demonstrated survival benefits, logistical simplicity, and fewer transfusions needed. Military experiences significantly influence civilian practices, demonstrating survival improvements with early and aggressive blood product use. Despite general agreement on balanced transfusion as the cornerstone of massive hemorrhage management, ongoing studies emphasize refining protocols, optimizing implementation speed, and tailoring strategies to patient-specific conditions. Future directions will likely integrate precision medicine approaches and advanced diagnostics to enhance patient outcomes in massive hemorrhage scenarios.