title: Resuscitate early with plasma and platelets or balance blood products gradually: findings from the PROMMTT study.
abstract: BACKGROUND
  The trauma transfusion literature has yet to resolve which is more important for hemorrhaging patients, transfusing plasma and platelets along with red blood cells (RBCs) early in resuscitation or gradually balancing blood product ratios. In a previous report of PROMMTT results, we found (1) plasma and platelet:RBC ratios increased gradually during the 6 hours following admission, and (2) patients achieving ratios more than 1:2 (relative to ratios <1:2) had significantly decreased 6-hour to 24-hour mortality adjusting for baseline and time-varying covariates. To differentiate the association of in-hospital mortality with early plasma or platelet transfusion from that with delayed but gradually balanced ratios, we developed a separate analytic approach.
  
  
  METHODS
  Using PROMMTT data and multilevel logistic regression to adjust for center effects, we related in-hospital mortality to the early receipt of plasma or platelets within the first three to six transfusion units (including RBCs) and 2.5 hours of admission. We adjusted for the same covariates as in our previous report: Injury Severity Score (ISS), age, time and total number of blood product transfusions upon entry to the analysis cohort, and bleeding from the head, chest, or limb.
  
  
  RESULTS
  Of 1,245 PROMMTT patients, 619 were eligible for this analysis. Early plasma was associated with decreased 24-hour and 30-day mortality (adjusted odds ratios of 0.47 [p = 0.009] and 0.44 [p = 0.002], respectively). Too few patients (24) received platelets early for meaningful assessment. In the subgroup of 222 patients receiving no early plasma but continuing transfusions beyond Hour 2.5, achieving gradually balanced plasma and platelet:RBC ratios of 1:2 or greater by Hour 4 was not associated with 30-day mortality (adjusted odds ratios of 0.9 and 1.1, respectively). There were no significant center effects.
  
  
  CONCLUSIONS
  Plasma transfusion early in resuscitation had a protective association with mortality, whereas delayed but gradually balanced transfusion ratios did not. Further research will require considerably larger numbers of patients receiving platelets early.
authors.affiliation: Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston, Houston, Texas 77030, USA. deborah.j.deljunco@uth.tmc.edu
authors.forename: Deborah J
authors.initials: DJ
authors.lastname: del Junco
authors.forename: John B
authors.initials: JB
authors.lastname: Holcomb
authors.forename: Erin E
authors.initials: EE
authors.lastname: Fox
authors.forename: Karen J
authors.initials: KJ
authors.lastname: Brasel
authors.forename: Herb A
authors.initials: HA
authors.lastname: Phelan
authors.forename: Eileen M
authors.initials: EM
authors.lastname: Bulger
authors.forename: Martin A
authors.initials: MA
authors.lastname: Schreiber
authors.forename: Peter
authors.initials: P
authors.lastname: Muskat
authors.forename: Louis H
authors.initials: LH
authors.lastname: Alarcon
authors.forename: Mitchell J
authors.initials: MJ
authors.lastname: Cohen
authors.forename: Bryan A
authors.initials: BA
authors.lastname: Cotton
authors.forename: Charles E
authors.initials: CE
authors.lastname: Wade
authors.forename: John G
authors.initials: JG
authors.lastname: Myers
authors.forename: Mohammad H
authors.initials: MH
authors.lastname: Rahbar
mesh_terms: D000328:Adult; D001803:Blood Transfusion / Q000379:methods*; D005260:Female; D006470:Hemorrhage / Q000401:mortality / Q000628:therapy*; D017052:Hospital Mortality; D006801:Humans; D015601:Injury Severity Score; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012151:Resuscitation / Q000379:methods*; D013997:Time Factors; D014193:Trauma Centers; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D014947:Wounds and Injuries / Q000401:mortality / Q000628:therapy*