Dr. John Holcomb
Dr. John Holcomb

Working to save the lives of military personnel suffering massive blood loss in the Afghanistan and Iraq wars, United States military trauma surgeons developed a blood transfusion protocol that is employed in most military and civilian hospitals today.

Observational studies suggested that the protocol, known as damage control resuscitation, improves patient outcomes after hemorrhagic shock. In 2012, researchers launched a large prospective clinical trial to gauge its effect on patient survival.

The results are in from the study involving 680 severely injured patients at 12 trauma centers in the United States and Canada – including Memorial Hermann Texas Trauma Institute. Damage control resuscitation exceeds or matches another widely used blood transfusion protocol, report researchers from The University of Texas Health Science Center (UTHealth) and other institutions.

The findings appear in JAMA in an article titled “Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 ratio vs a 1:1:2 Ratio and Mortality in Patients With Severe Trauma: The PROPPR Randomized Clinical Trial.”

“If I needed a massive blood transfusion, I would want damage control resuscitation,” said Dr. John Holcomb, the study’s principal investigator, a retired U.S. Army surgeon and the director of the Division of Acute Care Surgery at McGovern Medical School.

“This is one of the biggest blood transfusion studies ever,” he said. “The network involved hundreds of people across North America including doctors, nurses, and technicians. The hard work they put into this study was phenomenal.”

In a head-to-head comparison, damage control resuscitation reduced the risk of death due to blood loss during the first 24 hours. Thereafter, mortality rates in the two groups were about the same up to the trial’s 30 day endpoint. Researchers also compared 23 complications and found no significant differences between the two blood transfusion protocols.

“The National Heart, Lung and Blood Institute (NHLBI) has a strong commitment to supporting resuscitation research. We were proud to collaborate with the U.S. Department of Defense and our Canadian colleagues in this important trial focused on long-standing clinical questions for treating severe trauma patients,” said Dr. Gail Pearson, director of the Adult and Pediatric Cardiac Research Program at the NHLBI. The NHLBI is part of the National Institutes of Health and supported the research.

The term “damage control resuscitation” originated in the U.S. military and refers to the guidelines for combat casualties developed by a multidisciplinary team including Holcomb, who was an Army colonel at the time.

“Bleeding to death is the leading, potentially preventable cause of death in military and civilian trauma patients,” said Holcomb, noting that it was previously estimated that as many as one in two patients requiring a massive blood transfusion die.

Damage control resuscitation is a form of therapy that calls for the administration of equal parts plasma, red blood cells and platelets – simultaneously if possible. When Holcomb started his research more than a decade ago, patients were given clear fluids and red blood cells at the onset. Only later would they receive plasma and platelets.

Also called the balanced transfusion approach, damage control resuscitation was tested against a similar therapy, which includes one half the amount of plasma and platelets and equal amounts of red blood cells.

“This study represents a translation of practice from what has been learned during wartime into civilian practice after scientific evaluation. The lessons learned have definitely changed practice and saved lives. Perhaps, as has been said before, this is the only good thing to come out of war,” said Dr. David Hoyt, of the Resuscitation Outcomes Consortium and executive director of the American College of Surgeons.

In the study to determine effectiveness and safety, patients were assigned to one of two component therapies within 8 minutes of arriving at a hospital. The trial was built on the findings from an earlier trial showing that most trauma surgeons use one of the two component ratio therapies.

Holcomb said it was important for researchers to confirm the earlier reported benefits of damage control resuscitation.

Holcomb’s UTHealth co-authors are Drs. Barbara Tilley, Sarah Baraniuk, Erin Fox, Charles Wade, Deborah del Junco, Bryan Cotton, Nena Matijevic, and Jeanette Podbielski, R.N. Tilley is the holder of the Lorne Bain Distinguished Professorship in Public Health and Medicine at UTHealth.

Holcomb is the holder of the Jack H. Mayfield, M.D. Chair in Surgery, professor and vice chair of surgery, and director of the Center for Translational Injury Research. He is the director of the Memorial Hermann Texas Trauma Institute.

Participating centers included UTHealth/Memorial Hermann Texas Trauma Institute, the University of Alabama, the University of Arizona, the University of Southern California, Los Angeles, the University of California, San Francisco, the University of Maryland School of Medicine, the University of Cincinnati, Oregon Health and Science University, the University of Tennessee Health Science Center, the University of Washington/Harborview Medical Center, Medical College of Wisconsin and Sunnybrook Health Science Center in Toronto, Canada.

PROPPR is a protocol of the Resuscitation Outcomes Consortium, which is funded by the NHLBI, the U.S. Department of Defense, the Defence Research and Development Canada, and the Canadian Institutes of Health Research-Institute of  Circulatory and Respiratory Health.

-Rob Cahill, Office of Public Affairs, Media Relations