EBQ:PROPPR Trial

incomplete Journal Club Article

Holcomb JB, Tilley BC, Baraniuk S, et al.. "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". JAMA. 2015. 313(5):471-482.
PubMed

Clinical Question

Compare 1:1:1 vs 1:1:2 in safety and efficacy in trauma rescus

Conclusion

No significant differences in mortality at 24 hours or at 30 days between two groups
More patients in the 1:1:1 group achieved hemostasis and fewer experienced death due to exsanguination by 24 hours (86% vs 78%; p=0.006)
Exsanguination in first 24 hours decreased in the 1:1:1 group (9.2% vs 14.6%; p=0.03)
No other safety differences were identified between the two groups

Major Points

This was a negative trial - the 1:1:1 was as safe as 1:1:2
They did not meet the 10% mortality advantage which the study was powered to but found 4.2% improvement in the 1:1:1 group at 24hr and 3.7% at 30d

Study Design

Randomized clinical trial

Population

680 patients from of 12 participating level I trauma centers in North America

Patient Demographics

No differences were detected between treatment groups in baseline characteristics

Characteristics	1:1:1	1:1:2
Age	34.5 (25-51)	34 (24-50)
Male	263 (77.8%)	283 (82.7%)
Race - White	210 (62.1%)	224 (65.5%)
Race - Black	94 (27.8%)	93 (27.2%)
Race - Other	35 (10.4%)	25 (7.3%)

Inclusion Criteria

Highest trauma level activation
≥15 yo or weight ≥50 kg if age unknown
Received directly from the injury scene
Transfusion initiated with at least 1 U of blood component within the first hour of arrival
Predicted to receive a massive transfusion

Exclusion Criteria

Received a lifesaving intervention from OSH
Terminal injuries and expected to die within 1 hour of admission (eg, lethal traumatic brain injury)
Directly admitted from a correctional facility
Required a thoracotomy prior to randomization
<15 yo or <50 kg if age unknown
Pregnant
Burns >20% total BSA
Suspected inhalation injury
>5 mins of CPR
DNR
Enrolled in a concurrent, ongoing, interventional, randomized clinical trial
>3 U of pRBC given before randomization

Interventions

Two cohorts received blood product ratios of 1:1:1 (n=338) vs 1:1:2 (n=342) during active resuscitation

Outcomes

Primary Outcome

Absolute percentage group differences for 24-hour and 30-day mortality

Time Period	1:1:1 n=338	1:1:2 n=342	Difference	Adjusted RR	p value
24h mortality	43 (12.7%)	58 (17.0%)	−4.2 (−9.6-1.1)	0.75 (0.52-1.08)	0.12
30d mortality	75 (22.4%)	89 (26.1%)	−3.7 (−10.2-2.7)	0.86 (0.65-1.12)	0.26

Secondary Outcomes

Time to hemostasis
- 1:1:1 - 291 (86.1%)
- 1:1:2 - 267 (78.1%)
- p=0.006
Exsanguination within first 24h
- 1:1:1 - 9.2%
- 1:1:2 - 14.6%
- p=0.03
Exsanguination within 30d
- 1:1:1 - 10.7%
- 1:1:2 - 14.7%
- p value no reported
Number and type of blood products used from randomization until hemostasis was achieved
- 1:1:1 - 25.5 units (pRBC 9u, FFP 7u, Plt 12u)
- 1:1:2 - 19 units (pRBC 9u, FFP 5u, Plt 6u)
- p=0.001 for units of platelets
Number and type of blood products used after hemostasis was achieved up to 24 hours postadmission
- 1:1:1 group received fewer blood products during the postintervention period than the 1:1:2 group (median of 1 U vs 2 U, respectively)
Analysis of 23 complications
- Differences were not detected in any of the 23 complications at 30 days
Incidence of major surgical procedures
- 1:1:1 - 290 (85.8%)
- 1:1:2 - 284 (83.0%)
Functional status at hospital discharge or 30 days (median , whichever occurred first
- 1:1:1 - 4 (3-6)
- 1:1:2 - 4.5 (3.5-7.0)
- p=0.11
Hospital-free days, ventilator-free days, and ICU-free days

	1:1:1	1:1:2	p value
Hospital-free days	1 (0-17)	0 (0-16)	0.83
Ventilator-free days	8 (0-16)	7 (0-14)	0.14
ICU-free days	5 (0-11)	4 (0-10)	0.10

Criticisms & Further Discussion

This is best evidence to date the 1:1:1 ratio is a worthy initial target. - Ryan Radecki

External Links

Podcast 144 – The PROPPR trial with John Holcomb

Funding

Sources

Authors: