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

Abstract

IMPORTANCE 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. DESIGN, SETTING, AND PARTICIPANTS 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. INTERVENTIONS 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). MAIN OUTCOMES AND MEASURES 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 AND RELEVANCE 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. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01545232

Research in Review: Driving Critical Care Practice Change

“…However, hemostasis was higher and death due to exsanguination by 24 hours was lower in the patients in the 1:1:1 group. 47 This study supports the practice of 1:1:1 blood product ratios in the initial resuscitation of patients requiring a massive transfusion.…”

“…The PROPPR trial was the first large multisite study in which blood product ratios in massive transfusion protocols for treatment of the severely injured were examined prospectively. 47 Mortality at 24 hours or 30 days and safety issues did not differ significantly between patients receiving plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio. However, hemostasis was higher and death due to exsanguination by 24 hours was lower in the patients in the 1:1:1 group.…”

“…Thus, clinicians do not have definitive guidance on the correct ratio or safety of massive transfusions. 47 In February 2015, the results of the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) clinical trial were published. The PROPPR trial was the first large multisite study in which blood product ratios in massive transfusion protocols for treatment of the severely injured were examined prospectively.…”

Fibrinogen in traumatic haemorrhage: A narrative review

“…However, even in high ratios the delivered replacement is potentially dilute in terms of factors (39). The subsequent Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial reported no difference in survival between a 1:1:1 or 1:1:2 transfusion strategy but more patients in the 1:1:1 group achieved haemostasis and fewer died from exsanguination (48). A number of studies have reported that in patients receiving higher ratios there is an increase in the amount of plasma transfused and an increased incidence of transfusion-related adverse events without a survival benefit, however, these concerns were not confirmed in the PROPPR trial (49) (50) (51).…”

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“…[3] The volume of transfusion therapy and the ratio of transfused blood components is a subject of modern top research. [9] Aim of the research This study aims to study the rate of increase and volume of blood components delivered to medical organizations of Kazakhstan over the period of 2008-2015.…”