Female patients receiving massive transfusion are less likely to receive whole blood despite survival benefit

BACKGROUND Female trauma patients may be less likely to receive whole blood (WB) because of clinician concern regarding RhD alloimmunization and physiologic differences despite evidence supporting the safety of WB use in this population. We hypothesized that, in female patients requiring massive transfusion (MT), high proportions of WB are associated with decreased mortality but that females are less likely to receive WB than males. METHODS Adults aged 18 to 64 years from the 2020–2023 Trauma Quality Improvement Program database who received MT (≥5 blood units within 4 hours of arrival) were retrospectively reviewed. Transfers, burns, deaths within 1 hour, and patients who received >100 U of any blood product were excluded. The proportion of MT given as WB was calculated as WB ratio (WB/total red blood cell–containing units). The median of nonzero WB ratios was used to divide patients who received WB into two cohorts, ultimately creating three groups (no WB, low WB, and high WB). Mixed-effect logistic regressions were performed to assess the effect of sex on receiving WB and the effect of WB proportions on mortality. RESULTS Of 33,811 patients (19.2% female), 29.6% received WB. After controlling for confounders, both pre- and postmenopausal females were significantly less likely to receive WB than males (premenopausal: adjusted odds ratio aOR, 0.403 0.367–0.442; postmenopausal: aOR, 0.655 0.531–0.808). On mixed-effect regression analysis, high WB ratios were associated with decreased 30-day mortality for both males (aOR, 0.808 0.725–0.901) and females (aOR, 0.776 0.617–0.976). On subanalysis, this effect persisted only for postmenopausal females (aOR, 0.589 0.384–0.903). CONCLUSION Female trauma patients are less likely than males to receive WB during MT despite a survival benefit. These results underscore the need to address sex-based differences in transfusion practices. The root of this disparity should be investigated to optimize outcomes for all patients. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.