title: 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.
abstract: OBJECTIVE
  Severely injured patients experiencing hemorrhagic shock often require massive transfusion. Earlier transfusion with higher blood product ratios (plasma, platelets, and red blood cells), defined as damage control resuscitation, has been associated with improved outcomes; however, there have been no large multicenter clinical trials.
  
  
  OBJECTIVE
  To determine the effectiveness and safety of transfusing patients with severe trauma and major bleeding using plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio.
  
  
  METHODS
  Pragmatic, phase 3, multisite, randomized clinical trial of 680 severely injured patients who arrived at 1 of 12 level I trauma centers in North America directly from the scene and were predicted to require massive transfusion between August 2012 and December 2013.
  
  
  METHODS
  Blood product ratios of 1:1:1 (338 patients) vs 1:1:2 (342 patients) during active resuscitation in addition to all local standard-of-care interventions (uncontrolled).
  
  
  METHODS
  Primary outcomes were 24-hour and 30-day all-cause mortality. Prespecified ancillary outcomes included time to hemostasis, blood product volumes transfused, complications, incidence of surgical procedures, and functional status.
  
  
  RESULTS
  No significant differences were detected in mortality at 24 hours (12.7% in 1:1:1 group vs 17.0% in 1:1:2 group; difference, -4.2% [95% CI, -9.6% to 1.1%]; P = .12) or at 30 days (22.4% vs 26.1%, respectively; difference, -3.7% [95% CI, -10.2% to 2.7%]; P = .26). Exsanguination, which was the predominant cause of death within the first 24 hours, was significantly decreased in the 1:1:1 group (9.2% vs 14.6% in 1:1:2 group; difference, -5.4% [95% CI, -10.4% to -0.5%]; P = .03). More patients in the 1:1:1 group achieved hemostasis than in the 1:1:2 group (86% vs 78%, respectively; P = .006). Despite the 1:1:1 group receiving more plasma (median of 7 U vs 5 U, P < .001) and platelets (12 U vs 6 U, P < .001) and similar amounts of red blood cells (9 U) over the first 24 hours, no differences between the 2 groups were found for the 23 prespecified complications, including acute respiratory distress syndrome, multiple organ failure, venous thromboembolism, sepsis, and transfusion-related complications.
  
  
  CONCLUSIONS
  Among patients with severe trauma and major bleeding, early administration of plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality at 24 hours or at 30 days. However, more patients in the 1:1:1 group achieved hemostasis and fewer experienced death due to exsanguination by 24 hours. Even though there was an increased use of plasma and platelets transfused in the 1:1:1 group, no other safety differences were identified between the 2 groups.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT01545232.
authors: Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center, Houston.
authors: John B
authors: JB
authors: Holcomb
authors: Division of Biostatistics, School of Public Health, University of Texas Health Science Center, Houston.
authors: Barbara C
authors: BC
authors: Tilley
authors: Division of Biostatistics, School of Public Health, University of Texas Health Science Center, Houston.
authors: Sarah
authors: S
authors: Baraniuk
authors: Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center, Houston.
authors: Erin E
authors: EE
authors: Fox
authors: Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center, Houston.
authors: Charles E
authors: CE
authors: Wade
authors: Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center, Houston.
authors: Jeanette M
authors: JM
authors: Podbielski
authors: Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center, Houston.
authors: Deborah J
authors: DJ
authors: del Junco
authors: Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee22Dr Brasel is now with the Division of Trauma, Critical Care and Acute Care Surgery, School of Medicine, Oregon Health & Science University, Portland.
authors: Karen J
authors: KJ
authors: Brasel
authors: Division of Trauma and Critical Care, Department of Surgery, School of Medicine, University of Washington, Seattle.
authors: Eileen M
authors: EM
authors: Bulger
authors: Division of General Surgery, Department of Surgery, School of Medicine, University of California, San Francisco.
authors: Rachael A
authors: RA
authors: Callcut
authors: Division of General Surgery, Department of Surgery, School of Medicine, University of California, San Francisco.
authors: Mitchell Jay
authors: MJ
authors: Cohen
authors: Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center, Houston.
authors: Bryan A
authors: BA
authors: Cotton
authors: Division of Trauma and Surgical Critical Care, Department of Surgery, College of Medicine, University of Tennessee Health Science Center, Memphis.
authors: Timothy C
authors: TC
authors: Fabian
authors: Division of Trauma and Critical Care, University of Southern California, Los Angeles.
authors: Kenji
authors: K
authors: Inaba
authors: Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, School of Medicine, University of Alabama, Birmingham.
authors: Jeffrey D
authors: JD
authors: Kerby
authors: Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio23Dr Muskat is now with the Division of General Surgery, Department of Surgery, School of Medicine, University of California, San Franc.
authors: Peter
authors: P
authors: Muskat
authors: Division of Trauma, Critical Care and Emergency Surgery, Department of Surgery, University of Arizona, Tucson.
authors: Terence
authors: T
authors: O'Keeffe
authors: Trauma and Acute Care Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
authors: Sandro
authors: S
authors: Rizoli
authors: Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
authors: Bryce R H
authors: BR
authors: Robinson
authors: R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore.
authors: Thomas M
authors: TM
authors: Scalea
authors: Division of Trauma, Critical Care and Acute Care Surgery, School of Medicine, Oregon Health & Science University, Portland.
authors: Martin A
authors: MA
authors: Schreiber
authors: R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore.
authors: Deborah M
authors: DM
authors: Stein
authors: Division of Trauma and Surgical Critical Care, Department of Surgery, College of Medicine, University of Tennessee Health Science Center, Memphis.
authors: Jordan A
authors: JA
authors: Weinberg
authors: Sunnybrook Research Institute, Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
authors: Jeannie L
authors: JL
authors: Callum
authors: Department of Laboratory Medicine, School of Medicine, University of Washington, Seattle.
authors: John R
authors: JR
authors: Hess
authors: Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center, Houston.
authors: Nena
authors: N
authors: Matijevic
authors: Department of Emergency Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
authors: Christopher N
authors: CN
authors: Miller
authors: Division of Critical Care and Perioperative Medicine, Department of Anesthesiology, School of Medicine, University of Alabama, Birmingham.
authors: Jean-Francois
authors: JF
authors: Pittet
authors: American College of Surgeons, Chicago, Illinois.
authors: David B
authors: DB
authors: Hoyt
authors: Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.
authors: Gail D
authors: GD
authors: Pearson
authors: Department of Biostatistics, School of Public Health, University of Washington, Seattle.
authors: Brian
authors: B
authors: Leroux
authors: Department of Biostatistics, School of Public Health, University of Washington, Seattle21Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, Seattle.
authors: Gerald
authors: G
authors: van Belle
mesh_terms: D016913:Blood Component Transfusion / Q000379:methods*; D001792:Blood Platelets; D004912:Erythrocytes; D058734:Exsanguination / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D005260:Female; D006487:Hemostasis; D006801:Humans; D008297:Male; D010949:Plasma; D012771:Shock, Hemorrhagic / Q000209:etiology / Q000628:therapy*; D014947:Wounds and Injuries / Q000150:complications / Q000401:mortality / Q000628:therapy*
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