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: the PROPPR randomized clinical trial
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Overview
In severely injured patients predicted to need massive transfusion, a 1:1:1 blood product ratio did not reduce 24-hour or 30-day mortality versus 1:1:2.
Clinical takeaway
PROPPR did not prove that 1:1:1 saves more lives than 1:1:2 at 24 hours or 30 days, but more patients achieved hemostasis and fewer died of exsanguination.
Key result
24-hour mortality was 12.7% with 1:1:1 vs 17.0% with 1:1:2 (difference -4.2%; not significant).
Practice impact
When massive transfusion is underway for trauma, a 1:1:1 plasma-platelet-RBC ratio is a reasonable default for uncontrolled bleeding.
Evidence
Study design
Pragmatic, phase 3, multisite, randomized clinical trial.
Enrollment
680
Follow-up
All-cause mortality at 24 hours and 30 days.
Geography
North America
Clinical question
Does a 1:1:1 plasma-platelet-RBC ratio reduce mortality compared with 1:1:2 in severe trauma with major bleeding?
Population
- Severely injured patients who arrived at a North American level I trauma center from the scene and were predicted to require massive transfusion.
Intervention
Plasma, platelets, and red blood cells in a 1:1:1 ratio during active resuscitation.
Comparator
Plasma, platelets, and red blood cells in a 1:1:2 ratio, plus local standard care in both arms.
Primary outcome
24-hour and 30-day all-cause mortality.
A 1:1:1 ratio did not significantly reduce 24-hour or 30-day mortality versus 1:1:2, though more patients achieved hemostasis and fewer died of exsanguination.
Risk difference / -4.2 / 95% CI -9.6% to 1.1% / p=0.12
Key results
- 24-hour mortality: 12.7% with 1:1:1 vs 17.0% with 1:1:2; difference -4.2% (95% CI -9.6% to 1.1%; P=0.12).
- 30-day mortality: 22.4% vs 26.1%; difference -3.7% (95% CI -10.2% to 2.7%; P=0.26).
- Death from exsanguination within 24 hours was lower with 1:1:1 (9.2% vs 14.6%; difference -5.4%; P=0.03), and more patients achieved hemostasis (86% vs 78%; P=0.006).
- The 1:1:1 group received more plasma and platelets but similar red blood cells, without differences in 23 prespecified complications.
Harms
- No differences were found for 23 prespecified complications, including ARDS, multiple organ failure, venous thromboembolism, sepsis, and transfusion-related complications.
Clinical Use
Practice impact
- When massive transfusion is underway for trauma, a 1:1:1 plasma-platelet-RBC ratio is a reasonable default for uncontrolled bleeding.
Applicability
- Most applicable to severely injured patients arriving from the scene at a level I trauma center who are predicted to need massive transfusion.
Limitations
- Both coprimary mortality endpoints were nonsignificant.
- Local standard-of-care interventions were uncontrolled.
- Enrollment was limited to patients predicted to need massive transfusion at 12 North American level I centers.
Common misinterpretations
- A nonsignificant mortality difference does not mean the ratios are interchangeable; more 1:1:1 patients achieved hemostasis.
- PROPPR compared 1:1:1 with 1:1:2, not with a low-plasma historical strategy.
Citation
Holcomb JB, Tilley BC, Baraniuk S, et al. 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. JAMA. 2015;313(5):471-482. doi:10.1001/jama.2015.12
Among patients with severe trauma and major bleeding, early administration of plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality at 24 hours or at 30 days.
- PMID
- 25647203