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Damage-control resuscitation and emergency laparotomy: Findings from the PROPPR study

Undurraga Perl, Vicente J. MD; Leroux, Brian PhD; Cook, Mackenzie R. MD; Watson, Justin MD; Fair, Kelly MD; Martin, David T. MD; Kerby, Jeffrey D. MD, PhD; Williams, Carolyn RN; Inaba, Kenji MD; Wade, Charles E. PhD; Cotton, Bryan A. MD, MPH; Del Junco, Deborah J. PhD; Fox, Erin E. PhD; Scalea, Thomas M. MD; Tilley, Barbara C. PhD; Holcomb, John B. MD; Schreiber, Martin A. MDon behalf of the PROPPR Study Group

Journal of Trauma and Acute Care Surgery: April 2016 - Volume 80 - Issue 4 - p 568–575
doi: 10.1097/TA.0000000000000960
AAST 2015 Plenary Papers
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BACKGROUND The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial has demonstrated that damage-control resuscitation, a massive transfusion strategy targeting a balanced delivery of plasma–platelet–red blood cell in a ratio of 1:1:1, results in improved survival at 3 hours and a reduction in deaths caused by exsanguination in the first 24 hours compared with a 1:1:2 ratio. In light of these findings, we hypothesized that patients receiving 1:1:1 ratio would have improved survival after emergency laparotomy.

METHODS Severely injured patients predicted to receive a massive transfusion admitted to 12 Level I North American trauma centers were randomized to 1:1:1 versus 1:1:2 as described in the PROPPR trial. From these patients, the subset that underwent an emergency laparotomy, defined previously in the literature as laparotomy within 90 minutes of arrival, were identified. We compared rates and timing of emergency laparotomy as well as postsurgical survival at 24 hours and 30 days.

RESULTS Of the 680 enrolled patients, 613 underwent a surgical procedure, 397 underwent a laparotomy, and 346 underwent an emergency laparotomy. The percentages of patients undergoing emergency laparotomy were 51.5% (174 of 338) and 50.3% (172 of 342) for 1:1:1 and 1:1:2, respectively (p = 0.20). Median time to laparotomy was 28 minutes in both treatment groups. Among patients undergoing an emergency laparotomy, the proportions of patients surviving to 24 hours and 30 days were similar between treatment arms; 24-hour survival was 86.8% (151 of 174) for 1:1:1 and 83.1% (143 of 172) for 1:1:2 (p = 0.29), and 30-day survival was 79.3% (138 of 174) for 1:1:1 and 75.0% (129 of 172) for 1:1:2 (p = 0.30).

CONCLUSION We found no evidence that resuscitation strategy affects whether a patient requires an emergency laparotomy, time to laparotomy, or subsequent survival.

LEVEL OF EVIDENCE Therapeutic study, level IV.

From the Department of Surgery (V.J.U.P., J.W., K.F., M.R.C., M.A.S.), Oregon Health & Science University, Portland, Oregon; Department of Biostatistics (B.L.), University of Washington, Seattle, Washington; Department of Surgery (D.T.M.), University of California San Francisco-East Bay, Oakland; and Division of Trauma & Critical Care (K.I.), University of Southern California, Los Angeles, California; Division of Trauma, Burns, and Surgical Critical Care (J.D.K.), University of Alabama (C.W.), Tuscaloosa, Alabama; Center for Translational Injury Research (C.E.W., B.A.C., D.J.D.J., E.E.F., J.B.H.), Division of Acute Care Surgery, Department of Surgery, Medical School, and Division of Biostatistics (B.C.T.), School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas; Shock Trauma Center (T.M.S.), University of Maryland School of Medicine, Baltimore, Maryland.

Submitted: September 7, 2015, Revised: October 27, 2015, Accepted: November 9, 2015, Published online: January 21, 2016.

This study was presented at the 74th annual meeting of the American Association for the Surgery of Trauma, September 9–12, 2015, in Las Vegas, Nevada.

The opinions or conclusions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of any sponsor. This article has been reviewed by the PROPPR Publication Committee for scientific content and consistency of data interpretation with previous PROPPR publications.

Address for reprints: Vicente J. Undurraga Perl, MD, Department of Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239–3098; email: undurrag@ohsu.edu.

© 2016 Lippincott Williams & Wilkins, Inc.