Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial.

Holcomb JB, Tilley BC, Baraniuk S, et al.
JAMA 2015;313:471-482.
NATA Rating :
Review by : J. Stensballe
NATA Review

Holcomb and colleagues lead the way in high-quality trauma resuscitation research, setting the standard for future haemostatic resuscitation. It does make a difference!

In this multicentre randomised controlled trial, 680 severely injured patients needing massive transfusion with plasma, platelets and red blood cells were transfused using a 1:1:1 or a 1:1:2 ratio. A beautiful design and set-up in 12 Level 1 trauma centres enabling research in a very difficult population, and also making blood products available early already at mean time 8 minutes.

Mortality at 24 hours was 12.7% in the 1:1:1 group compared with 17.0% in the 1:1:2 group, and mortality at 30 days was 22.4% versus 26.1%; unfortunately, the differences did not reach statistical significance. Exsanguination was significantly decreased by 37% (9.2% in the 1:1:1 group versus 14.6% in 1:1:2 group) and, also very exciting, death due to traumatic brain injury was reduced (8.1% versus 10.3%). The most impressive evidence in the report is the figure showing the Kaplan-Meier Failure Curves for Mortality.

PROPPR study Kaplan-Meier Failure Curves for Mortality

This is formally a negative trial, with mortality (at 24 hours and 30 days) as the primary endpoint. However, when you dive in you’ll be positively surprised. Statistical underpower is a limitation, and a late catch up of haemostatic blood products, using more plasma and platelets later in the 1:1:2 ratio group, possibly stirs up the signal of effect. More research on these important results will undoubtedly come soon. Hopefully, the group can shed more light on the importance of timing, fluids, haemostatic monitoring and coagulopathy during haemostatic resuscitation.

Holcomb and colleagues set the standard of aiming for 1:1:1 blood product ratios and early availability of plasma, platelets and red blood cells as the primary resuscitative fluids for trauma haemorrhage. This will secure the best outcome for our patients.

– Jakob Stensballe

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