pragmatic, randomized optimal platelet and plasma ratios

Conditions: Trauma

Summary: pragmatic, randomized, optimal platelet and plasma ratios (proppr)is a phase iii trial designed to evaluate the difference in 24-hour and 30-day mortality among subjects predicted to receive massive transfusion (\[mt\] (defined as receiving 10 units or more red blood cells (rbcs) within the first 24 hours). the goal of proppr is to improve the basis on which clinicians make decisions about transfusion protocols for massively bleeding patients. proppr is a resuscitation outcomes consortium (roc) protocol. roc is funded by the national heart, lung, and blood institute (nhlbi), the united states' department of defense (dod) and the defence research and development canada. proppr will be conducted as a phase iii trial at level i adult trauma centers in north america.

background: multiple observational studies have reported that blood product component ratios (i.e., plasma:platelets:rbcs) that approach the 1:1:1 ratio, found in fresh whole blood, are associated with significant decreases in truncal hemorrhagic death and in overall 24-hour and 30-day mortality among injured patients. the rationale for the 1:1:1 ratio is that the closer a transfusion regimen approximates whole blood, the faster hemostasis will be achieved with minimum risk of coagulopathy. the current dod guideline specifies the use of 1:1:1, and this practice is followed on almost all combat casualties. in other observational studies, leading centers have reported good outcomes across a range of different blood product ratios. for example, a 1:2 plasma:rbc ratio is used with little guidance regarding platelets. the proposed randomized trial is intended to resolve debate and uncertainty regarding optimum blood product ratios. study design: randomized, two-group, controlled phase iii trial with a vanguard stage. equal random allocation to treatment using stratified, permuted blocks with randomly chosen block sizes and stratification by site. objective: to conduct a phase iii multi-site, randomized trial in subjects predicted to have a massive transfusion, comparing the efficacy and safety of 1:1:1 transfusion ratios of plasma and platelets to red blood cells (the closest approximation to reconstituted whole blood) with the 1:1:2 ratio. the co-primary outcomes will be 24-hour and 30-day mortality. the proppr trial will be conducted with exception from informed consent (efic). additionally, laboratory data from the trial will add to the understanding of trauma induced coagulopathy (tic) and inflammation.

Eligibility criteria:
inclusion criteria: * subjects who require the highest trauma team activation at each participating center, * estimated age of 15 years or older or greater than/equal to weight of 50 kg if age unknown, * received directly from the injury scene, * initiated transfusion of at least one unit of blood component within the first hour of arrival or during prehospital transport, and * predicted to receive a mt by exceeding the threshold score of either the assessment of blood consumption (abc) score or the attending trauma physician's judgment criteria exclusion criteria: * received care (as defined as receiving a life saving intervention) from an outside hospital or healthcare facility (procedures and care given at an outside health facility cannot be documented or controlled resulting in a high variability of standards of care and clinical outcomes.) * moribund patient with devastating injuries and expected to die within one hour of emergency department (ed) admission * prisoners, defined as those who have been directly admitted from a correctional facility * patients requiring an emergency thoracotomy * children under the age of 15 years or under 50 kg body weight if age unknown * known pregnancy in the ed * greater than 20% total body surface area (tbsa) burns * suspected inhalation injury * received greater than five consecutive minutes of cardiopulmonary resuscitation (cpr with chest compressions) in the pre-arrival or ed setting * known do not resuscitate (dnr) prior to randomization * enrolled in a concurrent, ongoing interventional, randomized clinical trial * patients who have activated the "opt-out" process or patients/legally authorized representatives that refuse blood products on arrival to ed.

Keywords: massive transfusion trauma coagulopathy trauma induced coagulopathy plasma platelets red blood cells mortality wounds and injuries shock, hemorrhagic shock pathologic processes hemorrhage hemostatics coagulation transfusion-related acute lung injury (trali) inflammation