Should we increase the ratio of plasma/platelets to red blood cells in massive transfusion: what is the evidence?

INTRODUCTION

Based on relatively recent clinical work, considerable enthusiasm has been generated for the increased use of plasma and platelet in the earlier resuscitation of massively transfused patients. The aim of this review was to examine the currently available evidence for the increase in plasma/platelet to red cell transfusion ratio during massive transfusion.

METHODS

In May of 2009, a systematic review of studies reporting the effects of plasma and platelet to red cell component transfusion ratio on mortality outcome was performed.

RESULTS

There were no prospective randomized controlled trials on this topic. Eleven retrospective studies were identified evaluating the effects of plasma : red cell ratio on mortality in massive transfusion after trauma. Most studies demonstrated a survival advantage of increased plasma ratio in massive transfusion. While the majority of the studies suggested the optimal plasma : red cell ratio to be 1 : 2 or higher, others demonstrated the optimal ratio to be lower. Three of these studies also demonstrated a survival advantage with increased platelet : red cell transfusion ratio.

CONCLUSION

Although there is some evidence to support the increase use of plasma and platelets in massive transfusion, the true efficacy of such practice has not yet been proven by prospective randomized controlled trials. The available retrospective studies raise many important questions that need to be addressed in future clinical trials.

Laparoscopic versus open splenectomy in the pediatric population: a contemporary single-center experience

The purpose of this study was to compare a recent contemporaneous experience between laparoscopic (LS) and open (OS) splenectomy in children. All splenectomy cases between 1994 and 1999 at our institution were reviewed. The study included open and laparoscopic cases performed according to surgeon preference. Emergency splenectomies for trauma were excluded. The patient record was reviewed for the diagnosis, indications, postoperative length of stay, operative technique, postoperative complications, blood loss/blood transfusion, total amount of parenteral narcotics, and time to resumption of oral intake. Chi-square and t tests were used to compare measured differences for statistical significance. Between May 1994 and December 1999, 52 splenectomies were performed at Vanderbilt Children's Hospital. Of these, 45 were elective operations with 29 open and 16 laparoscopic procedures. During four OS and five LS operations a concomitant cholecystectomy was performed. The median patient age was 9.2 years (range 0.5 to 17.3). There was no statistical difference between the two groups in terms of age, weight, American Society of Anesthesiologists class, or estimated blood loss. There were no immediate postoperative complications in either group. There were no conversions from LS to OS. The mean duration of surgery was 264 minutes (LS) versus 169 minutes (OS) (P < 0.05). The average time to first oral intake was shorter in patients undergoing LS (1.1 vs 1.6 days, P < 0.05) and the mean postoperative length of stay was also shorter in the LS group (1.3 vs 3.1 days, P < 0.05). The use of postoperative intravenous narcotics (in morphine-equivalent doses) was significantly less in LS patients than in OS patients (7.5 mg or 0.15 mg/kg vs 46.9 mg or 1.5 mg/kg, P < 0.001), as was the need for PCA pump analgesia (90% in the OS group vs 25% in LS group, P < 0.01). Overall the average hospital charge (anesthesia fee, narcotics charge, and hospital room charge) was $5400 (range $4240-6250) in the OS group and $4950 (range $4450-6240) in the LS group (P < 0.05). Among the nine patients undergoing splenectomy with cholecystectomy, findings between the OS and LS groups were similar except for one late complication consisting of a diaphragmatic hernia in an LS patient. Both LS and OS with or without a concomitant procedure can be accomplished safely in children. LS appears to result in longer operative times but shorter lengths of stay, earlier first oral intake, and significantly fewer requirements for intravenous narcotics; all of these contribute to a reduction in hospital charges compared with the open operation.

Decreased ADP-ribosylation of the Galpha(olf) and Galpha(s) subunits by high glucose in pancreatic B-cells

In HIT-T15 insulinoma B-cells incubated in presence of [(32)P]NAD, we identified by autoradiography and immunoblotting ADP-ribosylation (ADP-R) of the trimeric G-protein Galpha(s) and Galpha(olf) subunits (45 kDa) induced by cholera toxin in M1 (120,000g) and M2 (70,000g) subcellular fractions containing plasma membranes, insulin granules, and mitochondria. This ADP-R indicates that these two fractions contain functionally competent Galpha subunits for adenylyl cyclase activation. Prolonged exposure of HIT-T15 cells to high glucose (25 mM instead of 6 mM) specifically reduced the ADP-R in Galpha(s) and Galpha(olf) subunits in the M1 fraction only, despite the clear increase of their accumulation in this compartment. A similar alteration in the ADP-R of the M1-associated Galpha(s) and Galpha(olf) subunits was observed in pancreatic islets isolated from fasted and fed rats. These results may explain, at least in part, the undesirable effects of sustained hyperglycemia on the cAMP-dependent process of insulin secretion in diabetes.

Dynamics of pancreatic cell growth and differentiation during diabetes reversion in STZ-treated newborn rats

Cellular processes underlying ontogenesis and regression of streptozotocin (STZ)-induced diabetes in newborn rats were investigated at the most severe stage of diabetes at day 3 and after recovery of normoglycemia at day 8 by immunocytochemistry and quantitative analysis. A previously unknown endocrine cell type subpopulation (PEPS) was identified. It was characterized by granule polymorphism, coexpression of insulin and glucagon immunoreactivity, and a proliferative capacity transiently higher than in B cells. In STZ-treated rats at day 3, B cell mass decreased 14-fold, whereas PEPS cells were unaffected. The islet mass was restored to 55.7% by day 8, with a concomitant appearance of numerous small islets contiguous to small ducts. B cell mass increased by 6.9-fold compared with 1.8-fold in control rats, although proliferative capacities remained similar. Proliferation dropped considerably by day 8, preventing complete B cell mass recovery in STZ-treated rats. STZ-induced neonatal diabetes thus stimulates neogenesis of islets close to ducts and proliferation of PEPS cells. Those partially differentiated islet cells appear to be on the differentiation pathway of stem cells to fully differentiated B cells.

Processing of vasoactive intestinal peptide and transferrin in human cancerous colonic cells

Endocytosis of vasoactive intestinal peptide (VIP) and of transferrin (Tf) was comparatively studied in human cancerous colonic HT-29 cells. Cellular depletion in potassium inhibits the internalization of VIP (23%) and to a greater extent (42%) that of Tf. This indicates that clathrin-coated pits are also involved, at least in part, in VIP uptake. The distribution of 125I-Tf- or 125I-VIP-containing vesicles in sucrose gradients revealed low and high density vesicle subpopulations. The low density vesicle subpopulation represented a transient compartment from which incoming vesicles containing N-leucyl-beta naphthylamidase were recycled back to the membrane while those containing beta-hexosaminidase (HA) and ligand were mostly transferred into the high density compartment. Subsequent fusion of the latter with heavy vesicles was demonstrated by the shift of HA and ligand with vesicles that had been prelabeled with horseradish peroxidase (HRP). Simultaneous internalization of Tf-HRP and 125I-VIP showed that both the low and high density vesicle subpopulations comprised of two types of VIP-containing vesicle, as confirmed by the density shift reaction: two-thirds of VIP shifted with the Tf-HRP-containing vesicles to denser fractions and the remaining was found with unshifted vesicles. These findings indicate that the VIP-receptor complex processing in HT-29 cells follows two routes, the major route being common with Tf endocytosis.

Computer analysis of double labeling: ultrastructural distribution of vasoactive intestinal peptide and transferrin in human colon cancer cells

Transferrin (Tf) and vasoactive intestinal peptide (VIP) were labeled with horseradish peroxidase (HRP) and 125I, respectively. To determine whether two simultaneously incubated ligands are conveyed by the same population of endosomal vesicles in human colon carcinoma cells (HT-29), we used an analysis system derived from the cross-fire method for quantitation of autoradiographic data. This system permitted the collection of data and the statistical calculations required by the double labeling of the cells. HRP-labeled Tf organelles were chosen as reference structures of the endosomal apparatus and taken as the conventional source of the radiolabeling. Our data established from the co-localization hypothesis strongly suggest that after a 30-sec (T 1/2) and a 10-min (T10) internalization at 37 degrees C, VIP and Tf share in major part the same endocytic pathway and even the recycling route to the cell surface. At T10, most of the radiolabeling was located inside the tubulovesicular network, and we also detected slight radiolabeling inside the vesicles recycling Tf. The number of double-labeled endosomes involved in ligand traffic were advantageously observed with our computer-assisted analysis system.

Hamster intestinal disaccharide absorption: extracellular hydrolysis precedes transport of the monosaccharide products

Hydrolase-related transport was re-investigated in hamster small intestine by the tissue accumulation method. The Na+-dependent, phlorizin-sensitive monosaccharide transport system saturates with 30 mM-D-glucose. According to the hydrolase-related transport hypothesis, additional glucose units will be taken up if they are given in the form of a disaccharide susceptible to hydrolysis. But in experiments with [14C]sucrose we found no evidence for any such surplus glucose uptake. The uptake of 14C label from sucrose was abolished by using Tris, a strong inhibitor of sucrase, by adding competitive inhibitors of the D-glucose transport system (D-glucose, beta-methyl-D-glucopyranoside or phlorizin), and by substituting Li+ for the Na+ in the incubation medium. Glucose and fructose derived from sucrose did not enter the tissues in equimolar amounts: the glucose moiety was taken up much faster. We conclude that in hamster intestine there is no evidence for the existence of hydrolase-related transport with sucrose as the monosaccharide donor. The enzymatic hydrolysis of sucrose and the transport of its products, glucose and fructose, are two distinct events, acting sequentially.