Transfusion in Major Trauma: The PROPPR Trial

What should we be transfusing in major trauma?

• Should we aim towards 1:1:1 ratios or is that unnecessary? Most trauma centers have gone towards a 1:1:1 ratio or a 1:1:2 ratio with a greater percentage of RBCs transfused in the latter
• Our strategy should be to avoid coagulopathy, acidosis, and hypothermia
• This trial looks at transfusion of Plasma, Platelets, and RBCs in a 1:1:1 vs a 1:1:2 ratio
• Is it safe to give 1:1:1 ratios?

The Trial

• RCT, Non-blinded
• 12 Trauma Centers in North America
• 15 years or older; highest level trauma activation
• Predicted to receive massive transfusion
• Transfusions stopped when clinically indicated

Results

• 24 hour or 30 day mortality no significant difference
• Post-hoc analysis: death by exsanguination (9% vs 15%) in the 1^st 24hrs was significantly decreased in the 1:1:1 group
• Achieved hemostatis (86% vs 78%; p = 0.006) greater in the 1:1:1 group

Conclusions

• Was not powered to detect a difference of less than 10% in mortality
• There was less mortality from exsanguination in the 1:1:1 ratio.
• Worth noting that platelets given first in 1:1:1 group (in control group 6 U and 3 FFP given prior to platelets)
• There was some "catch up" in the 1:1:2 group (after the initial transfusions, these patients got more than expected plasma and platelets based on INR/Plt counts)
• TEG was used in the majority of the patients and TXA was used in a majority of patients (but similar in both groups)

How does this affect my practice?

A 1:1:1 transfusion practice is safe and can decrease mortality from hemorrhage in major trauma

Other points: control bleeding, permissive hypotension, avoid crystalloids, use TEG to guide therapy (TXA etc)

References

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.