The Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) Study: Comparative Effectiveness of a Time-varying Treatment with Competing Risks
By J. Holcomb, D. D. del Junco, E. Fox, C. Wade, M. Cohen, M. Schreiber, L. Alarcon, Y. Bai, K. Brasel, E. Bulger and 8 more. JAMA Surgery, 2013
1,026 citations recorded by the source corpus.
Context Hemorrhagic shock is the leading potentially preventable cause of death after injury. Transfusion of early and increased ratios of plasma and platelets to red blood cells (RBCs) has been associated with decreased mortality; however conflicting reports and the time-varying nature of transfusions and hemorrhagic death raise concern for the validity of the clinical conclusions drawn from the retrospective data. Objective To relate in-hospital mortality to: 1) early transfusion of plasma and/or platelets and 2) time-varying plasma:RBC and platelet:RBC ratios. Design Prospective cohort study documenting the timing of transfusions during active resuscitation and patient outcomes. Data were analyzed using time-dependent proportional hazards models. Setting Ten US Level 1 trauma centers. Patients Adult trauma patients surviving for 30 minutes after admission, transfused at least 1 unit RBC within 6 hours of admission (n=1245, the original study group) and at least 3 total units (of RBC, plasma or platelets) within 24 hours (n=905, the analysis group). Main outcome measure In-hospital mortality Results Plasma:RBC and platelet:RBC ratios were not constant over the first 24 hours (p<.001 for both). In a multivariable time-dependent Cox model, increased ratios of plasma:RBC (adjusted hazard ratio, HR=0.31, 95% CI=0.16–0.58) and platelets:RBC (adjusted HR=0.55, 95% CI=0.31–0.98) were independently associated with decreased 6-hour mortality, when hemorrhagic death predominated. In the first 6 hours, patients with ratios < 1:2 were 3–4 times more likely to die than patients with ratios ≥1:1. After 24 hours, plasma and platelet ratios were unassociated with mortality, when competing risks from non-hemorrhagic causes prevailed. Conclusions Higher plasma and platelet ratios early in resuscitation were associated with decreased mortality in patients transfused at least three units of blood products during the first 24 hours after admission. Among survivors at 24 hours, the subsequent risk of death by day 30 was not associated with plasma or platelet ratios.
Subfields: Biochemistry, Critical Care and Intensive Care Medicine, Emergency Medicine
View Paper: https://www.semanticscholar.org/paper/b978021283f90bb6dc7d26ef1903e81b68a5ff03
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Citations in the corpus
- The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition (2016, background): “30 However, recent large prospective cohort studies showed that a high platelet:RBC ratio was 31 associated with survival benefit as early as 6 h after admission, suggesting that survivor bias 32 is unlikely [469, 471].”
- The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition (2019, background): “However, large prospective cohort studies showed that a high platelet:RBC ratio was associated with survival benefit as early as 6 h after admission, suggesting that survivor bias is unlikely [576, 679].”