Among profoundly injured trauma patients with major bleeding, both early (24 hour) and late (30 day) mortality were similar between those who received transfusions of plasma, platelets, and red blood cells in a 1:1:1 ratio and those who received them in a 1:1:2 ratio in a phase III clinical trial, which was reported online Feb. 3 in JAMA.
Transfusion protocols for such patients have been “predominantly guided by tradition rather than evidence from large, multicenter randomized trials.” Moreover, transfusion protocols have changed markedly during the past decade, with many clinicians changing over to the 1:1:1 ratio because it is more balanced and more closely replicates the ratio present in whole blood than the traditional 1:1:2 ratio, said Dr. John B. Holcomb of the Center for Translational Injury Research, University of Texas Health Science Center, Houston, and his associates in the PROPPR (Pragmatic, Randomized Optimal Platelet and Plasma Ratios) trial.
They described the study as the first multicenter randomized trial using approved blood products to compare these two transfusion ratios, using mortality as the primary end point. They enrolled 680 adults treated at 12 Level 1 trauma centers in North America for severe injury with major bleeding during a 16-month period.
Overall 24-hour mortality was not significantly different, at 12.7% in the 1:1:1 group and 17% in the 1:1:2 group, and 30-day mortality also was not significantly different (22.4% vs 26.1%). These results were confirmed in sensitivity analyses. However, exsanguination, the predominant cause of death within 24 hours, was significantly decreased in the 1:1:1 group (9.2% vs 14.6%), and significantly more patients in the 1:1:1 group achieved anatomic homeostasis (86.1% vs 78.1%). Thus, clinicians “should consider using a 1:1:1 transfusion protocol,” Dr. Holcomb and his associates said (JAMA 2015 Feb. 3 [doi:10.10001/jama.2015.12]).
There also were no significant differences between the two study groups in 23 complications, including transfusion-related complications. And,“despite significant concerns that the 1:1:1 group would experience higher rates of multiple inflammatory-mediated complications, such as acute respiratory distress syndrome, multiple organ failure, infection, venous thromboembolism, and sepsis, no differences were detected between the two treatment groups,” they noted.