PROPPR Trial Supports Use of Transfusion Protocol Initially Developed for Battlefield Trauma Patients

In a groundbreaking multisite prospective clinical trial, the damage control resuscitation (DCR) protocol for massive blood transfusion significantly improved severe trauma patient outcome from hemorrhagic shock, when compared to another commonly used protocol.

DCR, used in most hospitals today, was first developed by a multidisciplinary team of US military trauma surgeons in treating soldiers suffering massive blood loss upon injury in the Afghanistan and Iraq wars. Observational studies suggested that DCR (also called balanced transfusion) improves patient outcomes, then in 2012 researchers launched the large “Pragmatic, Randomized Optimal Platelet and Plasma Ratios” (PROPPR) clinical trial to better gauge its effects. The study involved 680 severely injured patients treated at 12 Level I trauma centers in the US and Canada.

DCR calls for administration of equal parts (1:1:1 ratio) of plasma, platelets, and red blood cells, simultaneously if possible. DCR was tested against a common similar therapy that uses a 1:1:2 ratio of plasma, platelets, and red blood cells. In a head-to-head comparison of randomly assigned patients (within 8 minutes of arriving at a hospital), significantly more patients in the DCR (1:1:1) group achieved hemostasis and fewer experienced death due to exsanguination by 24 hours. Thereafter, mortality rates in the two groups were about the same up to the trial’s 30 day endpoint. The study also addressed concerns of safety by comparing 23 complications and found no significant differences between the two protocols.

“If I needed a massive blood transfusion, I would want DCR,” said Dr. John B. Holcomb, the study’s principal investigator, director of Acute Care Surgery, University of Texas Health Medical School (Houston, TX, USA), and a retired US Army surgeon who had helped develop DCR: “Bleeding to death is the leading, potentially preventable cause of death in military and civilian trauma patients,” he said.

“This is one of the biggest blood transfusion studies ever,” said Dr. Holcomb, “The network involved hundreds of people across North America including doctors, nurses, and technicians. The hard work they put into this study was phenomenal.”

“The National Heart, Lung, and Blood Institute (NHLBI) has a strong commitment to supporting resuscitation research. We were proud to collaborate with the US Department of Defense and our Canadian colleagues in this important trial focused on long-standing clinical questions for treating severe trauma patients,” said Dr. Gail Pearson, director of Adult and Pediatric Cardiac Research, NHLBI, part of the US National Institutes of Health (NIH).

“This study represents a translation of practice from what has been learned during wartime into civilian practice after scientific evaluation. The lessons learned have definitely changed practice and saved lives. Perhaps, as has been said before, this is the only good thing to come out of war,” said Dr. David Hoyt, of the Resuscitation Outcomes Consortium and executive director of the American College of Surgeons.

"This study is an important milestone in trauma care," said Prof. Thomas M. Scalea, MD, Physician-in-Chief of the Cowley Shock Trauma Center, University of Maryland Medical Center (Baltimore, MD, USA), who was part of the committee that designed and oversaw the study. "This impressive collaboration has the potential to yield immediate benefit for trauma patients," said Prof. E. Albert Reece, MD, PhD, MBA, vice president for U. Maryland’s Medical Affairs and dean of the School of Medicine.

The PROPPR Randomized Clinical Trial study, by Holcomb JB et al., was published online February 3, 2015, in the Journal of the American Medical Association (JAMA).

Related Links:
Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR)