1
|
Quispe-Cornejo AA, Alves da Cunha AL, Njimi H, Mongkolpun W, Valle-Martins AL, Arébalo-López M, Creteur J, Vincent JL. Effects of rapid fluid infusion on hemoglobin concentration: a systematic review and meta-analysis. Crit Care 2022; 26:324. [PMID: 36274172 PMCID: PMC9588219 DOI: 10.1186/s13054-022-04191-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022] Open
Abstract
Background Rapid fluid administration may decrease hemoglobin concentration (Hb) by a diluting effect, which could limit the increase in oxygen delivery (DO2) expected with a positive response to fluid challenge in critically ill patients. Our aim was to quantify the decrease in Hb after rapid fluid administration. Methods Our protocol was registered in PROSPERO (CRD42020165146). We searched PubMed, the Cochrane Database, and Embase from inception until February 15, 2022. We selected studies that reported Hb before and after rapid fluid administration (bolus fluid given over less than 120 min) with crystalloids and/or colloids in adults. Exclusion criteria were studies that included bleeding patients, or used transfusions or extracorporeal circulation procedures. Studies were divided according to whether they involved non-acutely ill or acutely ill (surgical/trauma, sepsis, circulatory shock or severe hypovolemia, and mixed conditions) subjects. The mean Hb difference and, where reported, the DO2 difference before and after fluid administration were extracted. Meta-analyses were conducted to assess differences in Hb before and after rapid fluid administration in all subjects and across subgroups. Random-effect models, meta-regressions and subgroup analyses were performed for meta-analyses. Risk of bias was assessed using the Cochrane Risk of Bias Assessment Tool. Inconsistency among trial results was assessed using the I2 statistic. Results Sixty-five studies met our inclusion criteria (40 in non-acutely ill and 25 in acutely ill subjects), with a total of 2794 participants. Risk of bias was assessed as “low” for randomized controlled trials (RCTs) and ‘low to moderate’ for non-RCTs. Across 63 studies suitable for meta-analysis, the Hb decreased significantly by a mean of 1.33 g/dL [95% CI − 1.45 to − 1.12; p < 0.001; I2 = 96.88] after fluid administration: in non-acutely ill subjects, the mean decrease was 1.56 g/dL [95% CI − 1.69 to − 1.42; p < 0.001; I2 = 96.71] and in acutely ill patients 0.84 g/dL [95% CI − 1.03 to − 0.64; p = 0.033; I2 = 92.91]. The decrease in Hb was less marked in patients with sepsis than in other acutely ill patients. The DO2 decreased significantly in fluid non-responders with a significant decrease in Hb. Conclusions Hb decreased consistently after rapid fluid administration with moderate certainty of evidence. This effect may limit the positive effects of fluid challenges on DO2 and thus on tissue oxygenation. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04191-x.
Collapse
Affiliation(s)
- Armin A. Quispe-Cornejo
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium ,Instituto Académico Científico Quispe Cornejo, La Paz, Bolivia
| | - Ana L. Alves da Cunha
- grid.465290.cDepartment of Intensive Care, Hospital da Senhora da Oliveira, Guimarães, Portugal ,Instituto Académico Científico Quispe Cornejo, La Paz, Bolivia
| | - Hassane Njimi
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Wasineenart Mongkolpun
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Ana L. Valle-Martins
- grid.414826.d0000 0004 0496 9134Department of Intensive Care, Hospital Mater Dei, Belo Horizonte, Brazil
| | - Mónica Arébalo-López
- Department of Intensive Care, Hospital Univalle Norte, Cochabamba, Bolivia ,Instituto Académico Científico Quispe Cornejo, La Paz, Bolivia
| | - Jacques Creteur
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Jean-Louis Vincent
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| |
Collapse
|
2
|
Adamik KN, Yozova ID, Regenscheit N. Controversies in the use of hydroxyethyl starch solutions in small animal emergency and critical care. J Vet Emerg Crit Care (San Antonio) 2016; 25:20-47. [PMID: 25655725 DOI: 10.1111/vec.12283] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 08/14/2014] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To (1) review the development and medical applications of hydroxyethyl starch (HES) solutions with particular emphasis on its physiochemical properties; (2) critically appraise the available evidence in human and veterinary medicine, and (3) evaluate the potential risks and benefits associated with their use in critically ill small animals. DATA SOURCES Human and veterinary original research articles, scientific reviews, and textbook sources from 1950 to the present. HUMAN DATA SYNTHESIS HES solutions have been used extensively in people for over 30 years and ever since its introduction there has been a great deal of debate over its safety and efficacy. Recently, results of seminal trials and meta-analyses showing increased risks related to kidney dysfunction and mortality in septic and critically ill patients, have led to the restriction of HES use in these patient populations by European regulatory authorities. Although the initial ban on the use of HES in Europe has been eased, proof regarding the benefits and safety profile of HES in trauma and surgical patient populations has been requested by these same European regulatory authorities. VETERINARY DATA SYNTHESIS The veterinary literature is limited mostly to experimental studies and clinical investigations with small populations of patients with short-term end points and there is insufficient evidence to generate recommendations. CONCLUSIONS Currently, there are no consensus recommendations regarding the use of HES in veterinary medicine. Veterinarians and institutions affected by the HES restrictions have had to critically reassess the risks and benefits related to HES usage based on the available information and sometimes adapt their procedures and policies based on their reassessment. Meanwhile, large, prospective, randomized veterinary studies evaluating HES use are needed to achieve relevant levels of evidence to enable formulation of specific veterinary guidelines.
Collapse
Affiliation(s)
- Katja N Adamik
- Department of Veterinary Clinical Medicine, Division of Small Animal Emergency and Critical Care, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | | | | |
Collapse
|
3
|
Wurlod VA, Howard J, Francey T, Schweighauser A, Adamik KN. Comparison of the in vitro effects of saline, hypertonic hydroxyethyl starch, hypertonic saline, and two forms of hydroxyethyl starch on whole blood coagulation and platelet function in dogs. J Vet Emerg Crit Care (San Antonio) 2015; 25:474-87. [PMID: 26037241 DOI: 10.1111/vec.12320] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 11/22/2013] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To compare the in vitro effects of hypertonic solutions and colloids to saline on coagulation in dogs. DESIGN In vitro experimental study. SETTING Veterinary teaching hospital. ANIMALS Twenty-one adult dogs. INTERVENTIONS Blood samples were diluted with saline, 7.2% hypertonic saline solution with 6% hydroxyethylstarch with an average molecular weight of 200 kDa and a molar substitution of 0.4 (HH), 7.2% hypertonic saline (HTS), hydroxyethyl starch (HES) 130/0.4 or hydroxyethyl starch 600/0.75 at ratios of 1:22 and 1:9, and with saline and HES at a ratio of 1:3. MEASUREMENTS AND MAIN RESULTS Whole blood coagulation was analyzed using rotational thromboelastometry (extrinsic thromboelastometry-cloting time (ExTEM-CT), maximal clot firmness (MCF) and clot formation time (CFT) and fibrinogen function TEM-CT (FibTEM-CT) and MCF) and platelet function was analyzed using a platelet function analyzer (closure time, CTPFA ). All parameters measured were impaired by saline dilution. The CTPFA was prolonged by 7.2% hypertonic saline solution with 6% hydroxyethylstarch with an average molecular weight of 200 kDa and a molar substitution of 0.4 (HH) and HTS but not by HES solutions. At clinical dilutions equivalent to those generally administered for shock (saline 1:3, HES 1:9, and hypertonic solutions 1:22), CTPFA was more prolonged by HH and HTS than other solutions but more by saline than HES. No difference was found between the HES solutions or the hypertonic solutions. ExTEM-CFT and MCF were impaired by HH and HTS but only mildly by HES solutions. At clinically relevant dilutions, no difference was found in ExTEM-CFT between HTS and saline or in ExTEM-MCF between HH and saline. No consistent difference was found between the 2 HES solutions but HH impaired ExTEM-CFT and MCF more than HTS. At high dilutions, FibTEM-CT and -MCF and ExTEM-CT were impaired by HES. CONCLUSIONS Hypertonic solutions affect platelet function and whole blood coagulation to a greater extent than saline and HES. At clinically relevant dilutions, only CTPFA was markedly more affected by hypertonic solutions than by saline. At high dilutions, HES significantly affects coagulation but to no greater extent than saline at clinically relevant dilutions.
Collapse
Affiliation(s)
- Virginie A Wurlod
- Division of Small Animal Emergency and Critical Care, Department of Veterinary Clinical Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Judith Howard
- the Diagnostic Laboratory, Department of Veterinary Clinical Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Thierry Francey
- Small Animal Internal Medicine, Department of Veterinary Clinical Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Ariane Schweighauser
- Small Animal Internal Medicine, Department of Veterinary Clinical Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Katja N Adamik
- Division of Small Animal Emergency and Critical Care, Department of Veterinary Clinical Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| |
Collapse
|
4
|
Winstedt D, Hanna J, Schött U. Albumin-induced coagulopathy is less severe and more effectively reversed with fibrinogen concentrate than is synthetic colloid-induced coagulopathy. Scandinavian Journal of Clinical and Laboratory Investigation 2013; 73:161-9. [DOI: 10.3109/00365513.2012.762114] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
5
|
Fukazawa K, Pretto EA. Reversal of hypercoagulability with hydroxyethyl starch during transplantation: a case series. J Clin Anesth 2011; 23:61-5. [DOI: 10.1016/j.jclinane.2009.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2009] [Revised: 10/06/2009] [Accepted: 10/11/2009] [Indexed: 10/18/2022]
|
6
|
|
7
|
Schramko A, Suojaranta-Ylinen R, Kuitunen A, Raivio P, Kukkonen S, Niemi T. Hydroxyethylstarch and gelatin solutions impair blood coagulation after cardiac surgery: a prospective randomized trial. Br J Anaesth 2010; 104:691-7. [PMID: 20388624 DOI: 10.1093/bja/aeq084] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- A Schramko
- Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, Meilahti Hospital, Helsinki HUS, Finland.
| | | | | | | | | | | |
Collapse
|
8
|
Kozek-Langenecker SA. Influence of fluid therapy on the haemostatic system of intensive care patients. Best Pract Res Clin Anaesthesiol 2009; 23:225-36. [PMID: 19653441 DOI: 10.1016/j.bpa.2008.11.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Haemostatic alterations associated with the use of fluids are related to non-specific dilutional effects and colloid-specific effects, such as acquired von Willebrand syndrome, inhibition of platelet function and fibrin polymerization. Judging by currently available evidence, dextran, hetastarch and pentastarch have a more pronounced impact than tetrastarch, gelatin and albumin. In patients with hypocoagulability, tetrastarch appears to be a suitable volume expander due to its high safety index and volume efficacy. Gelatins have lower inhibitory effects on clot strength compared with tetrastarch, but their volume efficacy is also lower. Dextrans are potent anticoagulants with a high risk for adverse reactions. Albumin has negligible effects on haemostasis, but low volume efficacy and costs limit the use of a blood product as a routine volume replacement fluid. To avoid potential acidosis-induced changes in haemostasis, plasma-adapted carrier solutions may be used instead of saline-based solutions.
Collapse
Affiliation(s)
- Sibylle A Kozek-Langenecker
- Department of Anaesthesiology, General Intensive Care and Pain Management, Vienna Medical University, Währinger Gürtel 18-20, 1090 Vienna, Austria.
| |
Collapse
|
9
|
Schramko AA, Suojaranta-Ylinen RT, Kuitunen AH, Kukkonen SI, Niemi TT. Rapidly Degradable Hydroxyethyl Starch Solutions Impair Blood Coagulation After Cardiac Surgery: A Prospective Randomized Trial. Anesth Analg 2009; 108:30-6. [DOI: 10.1213/ane.0b013e31818c1282] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
10
|
Kozek-Langenecker SA, Jungheinrich C, Sauermann W, Van der Linden P. The Effects of Hydroxyethyl Starch 130/0.4 (6%) on Blood Loss and Use of Blood Products in Major Surgery: A Pooled Analysis of Randomized Clinical Trials. Anesth Analg 2008; 107:382-90. [DOI: 10.1213/ane.0b013e31817e6eac] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
11
|
KOZEK-LANGENECKER SIBYLLEA, SCHARBERT GISELA. Effects of hydroxyethyl starches on hemostasis. ACTA ACUST UNITED AC 2007. [DOI: 10.1111/j.1778-428x.2007.00074.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
12
|
Kuitunen AH, Suojaranta-Ylinen RT, Kukkonen SI, Niemi TT. Tranexamic acid does not correct the haemostatic impairment caused by hydroxyethyl starch (200 kDa/0.5) after cardiac surgery. Blood Coagul Fibrinolysis 2007; 17:639-45. [PMID: 17102650 DOI: 10.1097/01.mbc.0000252598.25024.68] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
We investigated the effect of intravenous tranexamic acid on hydroxyethyl starch (HES)-induced clot strength impairment after cardiac surgery. Patients were randomized to receive either 1 g tranexamic acid or the same volume of 0.9% saline after administration of 15 ml/kg of 6% HES (molecular weight, 200 kDa; degree of substitution, 0.5) in the immediate postoperative period. Modified thromboelastometry (ROTEM) using different activators [intrinsic ROTEM (InTEM), extrinsic ROTEM (ExTEM), fibrinogen ROTEM (FibTEM)] was carried out to evaluate clot formation and lysis. The clot formation time was prolonged, and the maximum clot firmness (MCF) and shear elastic modulus [G = 5000 x MCF / (100-MCF), dynes/cm(2)] decreased (all activators of ROTEM) after completion of HES (P < 0.001, two-factor analysis of variance). These abnormalities in blood coagulation persisted despite tranexamic acid. Maximal lysis (FibTEM), indicative of fibrinolytic activity, was increased after HES but no effect of tranexamic acid was observed. The cumulative chest tube drainage until the first postoperative morning was not different between the groups (1008 +/- 251 and 1081 +/- 654 ml, P = 0.698, respectively). We conclude that after cardiopulmonary bypass, HES-induced impairment in clot formation and strength, or increased fibrinolytic capacity, is not reversed by the administration of tranexamic acid.
Collapse
Affiliation(s)
- Anne H Kuitunen
- Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, Meilahti Hospital, Helsinki, Finland
| | | | | | | |
Collapse
|
13
|
Abstract
PURPOSE Colloid solutions are widely used to prevent or to correct hypovolemia in surgical patients. Although more efficacious than crystalloids, they are more expensive and can be associated with adverse effects, in particular when they interfere with the hemostatic system. METHODS This narrative review focuses on the effects of albumin and synthetic colloids on the biological markers of coagulation and their clinical consequences. RESULTS All colloidal plasma substitutes interfere with the physiological mechanisms of hemostasis either through a non-specific effect correlated to the degree of hemodilution or through specific actions of these macromolecules on platelet function, coagulation proteins, and the fibrinolytic system. Albumin has the least effect, while high molecular weight (Mw) dextrans and hydroxyethyl starches (HES) have the most significant effects. Gelatins and medium Mw HES with a low molar substitution ratio have moderate and, probably, comparable effects. The use of dextrans and high in vivo Mw HES may be associated with increased bleeding, while gelatins and low in vivo Mw HES are unlikely to have such an effect. CONCLUSIONS In most cases, the clinical consequences of the biological effects of colloids on hemostasis are limited, provided that safety considerations are observed (maximum daily dosage, duration of treatment, patient's hemostatic status, clinical conditions). The implications may be different in patients with hemostatic disorders, either inherited or related to preoperative antiplatelet or anticoagulant treatment. In these patients, crystalloids, gelatins or even albumin solutions should be preferred when hemodilution exceeds 30% of the circulating blood volume.
Collapse
Affiliation(s)
- Philippe Van der Linden
- Department of Anesthesiology, CHU Brugmann - HUDERF, 4 Place Van Gehuchten, B-1020 Brussels, Belgium.
| | | |
Collapse
|
14
|
Shander A, Moskowitz D. Hydroxyethyl Starch and Risk of Bleeding: The Missing Links. Anesth Analg 2006; 102:968; author reply 968. [PMID: 16492868 DOI: 10.1213/01.ane.0000190871.13578.57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
15
|
Sander O, Reinhart K, Meier-Hellmann A. Equivalence of hydroxyethyl starch HES 130/0. 4 and HES 200/0. 5 for perioperative volume replacement in major gynaecological surgery. Acta Anaesthesiol Scand 2003; 47:1151-8. [PMID: 12969111 DOI: 10.1034/j.1399-6576.2003.00220.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Hydroxyethyl starch solutions (HES) are increasingly used for the compensation of surgical blood loss. The objective of this clinical trial was to compare a novel 6% HES 130/0.4 solution with a favourable pharmacological profile and a standard 6% HES 200/0.5 solution for maintenance of haemodynamic stability in major gynaecological surgery. METHODS Sixty female patients aged 18-80 years undergoing major gynaecological surgery with indication for perioperative colloidal volume replacement were enrolled in this prospective, randomized double-blinded clinical study. The administration of study medication was dependent on individual requirements to maintain haemodynamic stability. The amount of study medication required from induction of anaesthesia until 6 h postoperatively served as the primary investigative parameter. RESULTS The two one-sided test procedure by Westlake demonstrated equivalence of mean infused volumes between HES 130/0.4 and HES 200/0.5 during the study period (1224 +/- 544 ml and 1389 +/- 610 ml, respectively, P < 0.05). Perioperatively, haemodynamics did not differ significantly between treatment groups. While none of the mean values of coagulation parameters shifted outside the normal range, the degree of haemodilution revealed reduced haematocrit values in HES 200/0.5 treated patients at 6 h postoperatively (P < 0.05). Moreover, prothrombin time (PT) was higher and consequently international normalized ratio (INR) was lower at the same time point for patients who received HES 130/0.4 (P < 0.05). CONCLUSION This clinical trial demonstrated therapeutic equivalence of this novel low-substituted HES 130/0.4 solution and a standard HES 200/0.5 solution for perioperative volume replacement. Moreover, both HES preparations were equally well-tolerated and safe.
Collapse
Affiliation(s)
- O Sander
- Department of Anaesthesiology and Intensive Care Medicine, Friedrich-Schiller-University Jena, Jena, Germany
| | | | | |
Collapse
|
16
|
Petroianu GA, Maleck WH, Koetter KP, Liu J, Schmitt A. Effect of in vitro hemodilution with hydroxyethyl starch and dextran on the activity of plasma clotting factors. Crit Care Med 2003; 31:250-4. [PMID: 12545024 DOI: 10.1097/00003246-200301000-00039] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE A recent thrombelastography study indicated a compromised in vitro blood coagulation after 10:10 (equal parts of blood and infusion) and 10:4 (10 parts blood to four parts infusion) hemodilution with several plasma substitutes. Oncovertin N (Oncovertin) (a 10% dextran 40 solution) had the strongest anticoagulant effect of all solutions tested, and HAES-sterile 10% (HAES) (a 10% hydroxyethyl starch 200/0.5 solution) showed the strongest effect of five different hydroxyethyl starch preparations. The aim of this study was to determine how in vitro hemodilution with HAES and Oncovertin affects the activity of coagulation factors. DESIGN HAES and Oncovertin were tested to determine the intrinsic effect of colloid molecules, as opposed to hemodilution. Normal saline (NaCl) and nonlactated Ringer solution were used as noncolloidal controls. SETTING University research institute. PATIENTS Six healthy volunteers. INTERVENTIONS Twenty milliliters of blood was obtained from each subject. MEASUREMENTS AND MAIN RESULTS Prothrombin index, activated partial prothrombin time, soluble fibrin monomers, and the activity of coagulation factors I, II, V, VII, VIII, IX, X, XI, and XII were measured with the Behring Chromotimer according to the manufacturer's instructions. Two dilution ratios of citrated blood to infusion were used: 10:10 (equal parts of blood and infusion) and 10:4 (10 parts blood to four parts infusion). Baseline was undiluted. Hemodilution with NaCl at both 10:4 and 10:10 influenced the coagulation variables measured. The activities of factors I, VII, and soluble fibrin monomers were less influenced than expected by hemodilution alone. The activities of factors II, V, IX, and XI were significantly (p <.04) lower with both 10:4 and 10:10 dilution with NaCl. In the assays for factors IX, XI, and XII, clots formed immediately after adding the appropriate reagents in the presence of Ringer solution at 10:10 hemodilution, so that the activities of those factors could not be measured. For the other factors and for 10:4 dilution, the outcome after Ringer solution was similar to that of NaCl. The activities were less influenced after 10:4 hemodilution with both HAES and Oncovertin than after dilution with NaCl and Ringer solution, with no significant differences from baseline. At 10:10 hemodilution with both HAES and Oncovertin, several factor activities were significantly (p <.04) lower than baseline. CONCLUSIONS Both NaCl and Ringer solution cause measurable effects on coagulation factors at 10:4 hemodilution that can be explained by hemodilution alone. The effects on clotting factors of 10:4 hemodilution with HAES and Oncovertin were not significant. Even at 10:10 hemodilution with HAES or Oncovertin, the reduction in factor activities, although significantly (p <.04) different from baseline, was less than what was expected by dilution alone.
Collapse
Affiliation(s)
- Georg A Petroianu
- Department of Pharmacology, United Arab Emirates University, Al Ain.
| | | | | | | | | |
Collapse
|
17
|
McCammon AT, Wright JP, Figueroa M, Nielsen VG. Hemodilution with Albumin, but Not Hextend®, Results in Hypercoagulability as Assessed by Thrombelastography® in Rabbits: Role of Heparin-Dependent Serpins and Factor VIII Complex. Anesth Analg 2002. [DOI: 10.1213/00000539-200210000-00010] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
18
|
McCammon AT, Wright JP, Figueroa M, Nielsen VG. Hemodilution with albumin, but not Hextend, results in hypercoagulability as assessed by Thrombelastography in rabbits: role of heparin-dependent serpins and factor VIII complex. Anesth Analg 2002; 95:844-50, table of contents. [PMID: 12351255 DOI: 10.1097/00000539-200210000-00010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Isovolemic hemodilution (IVHD) has been advocated as an effective method of reducing the need for transfusion but has been associated with hypercoagulability. We tested the hypothesis that IVHD enhances hemostatic function by decreasing circulating antithrombin activity in rabbits. Furthermore, it was determined whether different replacement solutions would affect hemostasis. Sedated rabbits were randomly assigned to groups that underwent IVHD (40% blood volume removed) with 5% human albumin (n = 10) or a 6% hetastarch solution (Hextend). Antithrombin and Factor VIII complex (VIII:C) activities were determined, and thrombelastography(R) was performed with or without platelet inhibition. IVHD resulted in a significant (P < 0.05) decrease in antithrombin (32%-39%) without fluid-specific differences observed. VIII:C did not change in the albumin group, whereas the hetastarch group had a significant (P < 0.05) decrease (43%) in VIII:C that was also significantly (P < 0.05) less than the albumin group. The time to clot initiation was decreased, and the rate of clot formation increased significantly via thrombelastography(R) in albumin animals. No significant change in clot kinetics was observed in hetastarch animals. In rabbits, the primary determinant of hemostasis after IVHD was the interaction of changes in antithrombin activity and VIII:C. These data serve as a rational basis to determine whether IVHD-mediated hypercoagulability encountered clinically may be attenuated or exacerbated by the choice of colloid administered. IMPLICATIONS Isovolemic hemodilution (IVHD) is associated with hypercoagulability. Rabbits hemodiluted with albumin, but not Hextend, became hypercoagulable secondary to a loss of antithrombin activity with simultaneous maintenance of Factor VIII complex activity (VIII:C). Hextend-treated animals had proportionate decreases in both antithrombin activity and VIII:C. IVHD-mediated hypercoagulability encountered clinically may be attenuated or exacerbated by the choice of colloid administered.
Collapse
Affiliation(s)
- Andrew T McCammon
- Department of Anesthesiology, The University of Alabama at Birmingham, 35249, USA
| | | | | | | |
Collapse
|