title: The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study: comparative effectiveness of a time-varying treatment with competing risks.
abstract: OBJECTIVE
  To relate in-hospital mortality to early transfusion of plasma and/or platelets and to time-varying plasma:red blood cell (RBC) and platelet:RBC ratios.
  
  
  METHODS
  Prospective cohort study documenting the timing of transfusions during active resuscitation and patient outcomes. Data were analyzed using time-dependent proportional hazards models.
  
  
  METHODS
  Ten US level I trauma centers.
  
  
  METHODS
  Adult trauma patients surviving for 30 minutes after admission who received a transfusion of at least 1 unit of RBCs within 6 hours of admission (n = 1245, the original study group) and at least 3 total units (of RBCs, plasma, or platelets) within 24 hours (n = 905, the analysis group).
  
  
  METHODS
  In-hospital mortality.
  
  
  RESULTS
  Plasma:RBC and platelet:RBC ratios were not constant during the first 24 hours (P < .001 for both). In a multivariable time-dependent Cox model, increased ratios of plasma:RBCs (adjusted hazard ratio = 0.31; 95% CI, 0.16-0.58) and platelets:RBCs (adjusted hazard ratio = 0.55; 95% CI, 0.31-0.98) were independently associated with decreased 6-hour mortality, when hemorrhagic death predominated. In the first 6 hours, patients with ratios less than 1:2 were 3 to 4 times more likely to die than patients with ratios of 1:1 or higher. After 24 hours, plasma and platelet ratios were unassociated with mortality, when competing risks from nonhemorrhagic causes prevailed.
  
  
  CONCLUSIONS
  Higher plasma and platelet ratios early in resuscitation were associated with decreased mortality in patients who received transfusions of at least 3 units of blood products during the first 24 hours after admission. Among survivors at 24 hours, the subsequent risk of death by day 30 was not associated with plasma or platelet ratios.
authors.affiliation: Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center at Houston, 6410 Fannin, Ste 1100, Houston, TX 77030, USA. john.holcomb@uth.tmc.edu
authors.forename: John B
authors.initials: JB
authors.lastname: Holcomb
authors.forename: Deborah J
authors.initials: DJ
authors.lastname: del Junco
authors.forename: Erin E
authors.initials: EE
authors.lastname: Fox
authors.forename: Charles E
authors.initials: CE
authors.lastname: Wade
authors.forename: Mitchell J
authors.initials: MJ
authors.lastname: Cohen
authors.forename: Martin A
authors.initials: MA
authors.lastname: Schreiber
authors.forename: Louis H
authors.initials: LH
authors.lastname: Alarcon
authors.forename: Yu
authors.initials: Y
authors.lastname: Bai
authors.forename: Karen J
authors.initials: KJ
authors.lastname: Brasel
authors.forename: Eileen M
authors.initials: EM
authors.lastname: Bulger
authors.forename: Bryan A
authors.initials: BA
authors.lastname: Cotton
authors.forename: Nena
authors.initials: N
authors.lastname: Matijevic
authors.forename: Peter
authors.initials: P
authors.lastname: Muskat
authors.forename: John G
authors.initials: JG
authors.lastname: Myers
authors.forename: Herb A
authors.initials: HA
authors.lastname: Phelan
authors.forename: Christopher E
authors.initials: CE
authors.lastname: White
authors.forename: Jiajie
authors.initials: J
authors.lastname: Zhang
authors.forename: Mohammad H
authors.initials: MH
authors.lastname: Rahbar
mesh_terms: D000328:Adult; D001803:Blood Transfusion / Q000379:methods*; D004906:Erythrocyte Count; D005260:Female; D006470:Hemorrhage / Q000401:mortality / Q000628:therapy*; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D008297:Male; D008875:Middle Aged; D010976:Platelet Count; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012151:Resuscitation / Q000379:methods*; D014193:Trauma Centers; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D055815:Young Adult
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