LandmarkRCT

PROPPR

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 · Multicenter (12 Level I trauma centers, North America), randomized controlled trial.

Clinical question

In severe trauma requiring massive transfusion, does a 1:1:1 plasma:platelet:RBC transfusion ratio improve survival compared with a 1:1:2 ratio?

Population: 680 severely injured trauma patients predicted to require massive transfusion.
Intervention: Plasma, platelets, and RBCs in a 1:1:1 ratio.
Comparator: Plasma, platelets, and RBCs in a 1:1:2 ratio (relatively more RBCs).
Primary outcome: 24-hour and 30-day all-cause mortality.
Secondary outcomes: Exsanguination within 24 hours.
Achievement of hemostasis.
Result: No significant difference in 24-hour or 30-day mortality, but the 1:1:1 group had less early exsanguination and more often achieved hemostasis. (Exsanguination 9.2% (1:1:1) vs 14.6% (1:1:2), p=0.03; hemostasis achieved 86% vs 78%, p=0.006)

What the trial found

A 1:1:1 transfusion ratio did not significantly reduce overall mortality compared with 1:1:2, but did reduce early death from exsanguination and improved the rate of achieving hemostasis.

Current guideline position

Balanced (near 1:1:1) transfusion ratios are now standard practice in most massive transfusion protocols for trauma, based substantially on this trial's secondary findings.

Clinical interpretation

PROPPR is the primary trial basis for balanced-ratio massive transfusion protocols, even though its overall mortality result was neutral — the reduction in early exsanguination and improved hemostasis are read as clinically meaningful secondary findings, though this requires interpreting a non-primary endpoint as practice-changing, which is a real limitation of the trial's design as basis for the current standard.

Limitations

Primary mortality outcome was not statistically significant — the practice-changing conclusions rest on secondary outcomes.
Restricted to trauma patients predicted to need massive transfusion; may not generalize to non-traumatic major hemorrhage.

Moderate certainty

Clinical Context & Relevant Topics (2)

Disease Reference

Major Bleeding, Hemorrhagic Shock, & Damage Control Resuscitation

The trauma lethal diamond (hypothermia, acidosis, coagulopathy, hypocalcemia), 1:1:1 massive transfusion (PROPPR trial), early TXA (CRASH-2), and TEG/ROTEM algorithms.

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Blood Product Transfusion in Critical Care

Patient-specific RBC transfusion thresholds, current platelet/procedural thresholds, plasma/cryoprecipitate use, and the TRALI vs TACO diagnostic matrix.

View Topic Context →