1
|
Dorgalaleh A. Novel Insights into Heterozygous Factor XIII Deficiency. Semin Thromb Hemost 2024; 50:200-212. [PMID: 36940714 DOI: 10.1055/s-0043-1764471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
The prevalence and clinical significance of heterozygous factor XIII (FXIII) deficiency has long been debated, with controversial reports emerging since 1988. In the absence of large epidemiologic studies, but based on a few studies, a prevalence of 1 per 1,000 to 5,000 is estimated. In southeastern Iran, a hotspot area for the disorder, a study of more than 3,500 individuals found an incidence of 3.5%. Between 1988 and 2023, a total of 308 individuals were found with heterozygous FXIII deficiency, of which molecular, laboratory, and clinical presentations were available for 207 individuals. A total of 49 variants were found in the F13A gene, most of which were missense (61.2%), followed by nonsense (12.2%) and small deletions (12.2%), most occurring in the catalytic domain (52.1%) of the FXIII-A protein and most frequently in exon 4 (17%) of the F13A gene. This pattern is relatively similar to homozygous (severe) FXIII deficiency. In general, heterozygous FXIII deficiency is an asymptomatic condition without spontaneous bleeding tendency, but it can lead to hemorrhagic complications in hemostatic challenges such as trauma, surgery, childbirth, and pregnancy. Postoperative bleeding, postpartum hemorrhage, and miscarriage are the most common clinical manifestations, while impaired wound healing has been rarely reported. Although some of these clinical manifestations can also be observed in the general population, they are more common in heterozygous FXIII deficiency. While studies of heterozygous FXIII deficiency conducted over the past 35 years have shed light on some of the ambiguities of this condition, further studies on a large number of heterozygotes are needed to answer the major questions related to heterozygous FXIII deficiency.
Collapse
|
2
|
In Vivo Effects of Balanced Crystalloid or Gelatine Infusions on Functional Parameters of Coagulation and Fibrinolysis: A Prospective Randomized Crossover Study. J Pers Med 2022; 12:jpm12060909. [PMID: 35743694 PMCID: PMC9225437 DOI: 10.3390/jpm12060909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/21/2022] [Accepted: 05/28/2022] [Indexed: 02/05/2023] Open
Abstract
Prudent administration of fluids helps restore or maintain hemodynamic stability in the setting of perioperative blood loss. However, fluids may arguably exacerbate the existing coagulopathy. We sought to investigate the influence of balanced crystalloid and synthetic gelatine infusions on coagulation and fibrinolysis in healthy volunteers. This prospective randomized crossover study included 25 males aged 18–30 years. Infusions performed included 20 mL/kg of a balanced crystalloid solution (Optilyte®) or 20 mL/kg of gelatine 26.500 Da (Geloplasma®) in a random order over a period of 2 weeks. Laboratory analysis included conventional coagulation parameters and rotational thromboelastometry (ROTEM) assays. We confirmed a decrease in fibrinogen concentration and the number of platelets, and prolongation of PT after infusions. Compared to baseline values, differences in the ROTEM assays’ results after infusions signified the decrease in coagulation factors and fibrinogen concentration, causing impaired fibrin polymerization and clot structure. The ROTEM indicator of clot lysis remained unaffected. In the case of both Optilyte® and Geloplasma®, the results suggested relevant dilution. Gelatine disrupted the process of clot formation more than balanced crystalloid. Infusions of both crystalloid and saline-free colloid solutions causing up to 30% blood dilution cause significant dilution of the coagulation factors, platelets, and fibrinogen. However, balanced crystalloid infusion provides less infusion-induced coagulopathy compared to gelatine.
Collapse
|
3
|
Lewis SR, Pritchard MW, Evans DJW, Butler AR, Alderson P, Smith AF, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill people. Cochrane Database Syst Rev 2018; 8:CD000567. [PMID: 30073665 PMCID: PMC6513027 DOI: 10.1002/14651858.cd000567.pub7] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Critically ill people may lose fluid because of serious conditions, infections (e.g. sepsis), trauma, or burns, and need additional fluids urgently to prevent dehydration or kidney failure. Colloid or crystalloid solutions may be used for this purpose. Crystalloids have small molecules, are cheap, easy to use, and provide immediate fluid resuscitation, but may increase oedema. Colloids have larger molecules, cost more, and may provide swifter volume expansion in the intravascular space, but may induce allergic reactions, blood clotting disorders, and kidney failure. This is an update of a Cochrane Review last published in 2013. OBJECTIVES To assess the effect of using colloids versus crystalloids in critically ill people requiring fluid volume replacement on mortality, need for blood transfusion or renal replacement therapy (RRT), and adverse events (specifically: allergic reactions, itching, rashes). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and two other databases on 23 February 2018. We also searched clinical trials registers. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs of critically ill people who required fluid volume replacement in hospital or emergency out-of-hospital settings. Participants had trauma, burns, or medical conditions such as sepsis. We excluded neonates, elective surgery and caesarean section. We compared a colloid (suspended in any crystalloid solution) versus a crystalloid (isotonic or hypertonic). DATA COLLECTION AND ANALYSIS Independently, two review authors assessed studies for inclusion, extracted data, assessed risk of bias, and synthesised findings. We assessed the certainty of evidence with GRADE. MAIN RESULTS We included 69 studies (65 RCTs, 4 quasi-RCTs) with 30,020 participants. Twenty-eight studied starch solutions, 20 dextrans, seven gelatins, and 22 albumin or fresh frozen plasma (FFP); each type of colloid was compared to crystalloids.Participants had a range of conditions typical of critical illness. Ten studies were in out-of-hospital settings. We noted risk of selection bias in some studies, and, as most studies were not prospectively registered, risk of selective outcome reporting. Fourteen studies included participants in the crystalloid group who received or may have received colloids, which might have influenced results.We compared four types of colloid (i.e. starches; dextrans; gelatins; and albumin or FFP) versus crystalloids.Starches versus crystalloidsWe found moderate-certainty evidence that there is probably little or no difference between using starches or crystalloids in mortality at: end of follow-up (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.86 to 1.09; 11,177 participants; 24 studies); within 90 days (RR 1.01, 95% CI 0.90 to 1.14; 10,415 participants; 15 studies); or within 30 days (RR 0.99, 95% CI 0.90 to 1.09; 10,135 participants; 11 studies).We found moderate-certainty evidence that starches probably slightly increase the need for blood transfusion (RR 1.19, 95% CI 1.02 to 1.39; 1917 participants; 8 studies), and RRT (RR 1.30, 95% CI 1.14 to 1.48; 8527 participants; 9 studies). Very low-certainty evidence means we are uncertain whether either fluid affected adverse events: we found little or no difference in allergic reactions (RR 2.59, 95% CI 0.27 to 24.91; 7757 participants; 3 studies), fewer incidences of itching with crystalloids (RR 1.38, 95% CI 1.05 to 1.82; 6946 participants; 2 studies), and fewer incidences of rashes with crystalloids (RR 1.61, 95% CI 0.90 to 2.89; 7007 participants; 2 studies).Dextrans versus crystalloidsWe found moderate-certainty evidence that there is probably little or no difference between using dextrans or crystalloids in mortality at: end of follow-up (RR 0.99, 95% CI 0.88 to 1.11; 4736 participants; 19 studies); or within 90 days or 30 days (RR 0.99, 95% CI 0.87 to 1.12; 3353 participants; 10 studies). We are uncertain whether dextrans or crystalloids reduce the need for blood transfusion, as we found little or no difference in blood transfusions (RR 0.92, 95% CI 0.77 to 1.10; 1272 participants, 3 studies; very low-certainty evidence). We found little or no difference in allergic reactions (RR 6.00, 95% CI 0.25 to 144.93; 739 participants; 4 studies; very low-certainty evidence). No studies measured RRT.Gelatins versus crystalloidsWe found low-certainty evidence that there may be little or no difference between gelatins or crystalloids in mortality: at end of follow-up (RR 0.89, 95% CI 0.74 to 1.08; 1698 participants; 6 studies); within 90 days (RR 0.89, 95% CI 0.73 to 1.09; 1388 participants; 1 study); or within 30 days (RR 0.92, 95% CI 0.74 to 1.16; 1388 participants; 1 study). Evidence for blood transfusion was very low certainty (3 studies), with a low event rate or data not reported by intervention. Data for RRT were not reported separately for gelatins (1 study). We found little or no difference between groups in allergic reactions (very low-certainty evidence).Albumin or FFP versus crystalloidsWe found moderate-certainty evidence that there is probably little or no difference between using albumin or FFP or using crystalloids in mortality at: end of follow-up (RR 0.98, 95% CI 0.92 to 1.06; 13,047 participants; 20 studies); within 90 days (RR 0.98, 95% CI 0.92 to 1.04; 12,492 participants; 10 studies); or within 30 days (RR 0.99, 95% CI 0.93 to 1.06; 12,506 participants; 10 studies). We are uncertain whether either fluid type reduces need for blood transfusion (RR 1.31, 95% CI 0.95 to 1.80; 290 participants; 3 studies; very low-certainty evidence). Using albumin or FFP versus crystalloids may make little or no difference to the need for RRT (RR 1.11, 95% CI 0.96 to 1.27; 3028 participants; 2 studies; very low-certainty evidence), or in allergic reactions (RR 0.75, 95% CI 0.17 to 3.33; 2097 participants, 1 study; very low-certainty evidence). AUTHORS' CONCLUSIONS Using starches, dextrans, albumin or FFP (moderate-certainty evidence), or gelatins (low-certainty evidence), versus crystalloids probably makes little or no difference to mortality. Starches probably slightly increase the need for blood transfusion and RRT (moderate-certainty evidence), and albumin or FFP may make little or no difference to the need for renal replacement therapy (low-certainty evidence). Evidence for blood transfusions for dextrans, and albumin or FFP, is uncertain. Similarly, evidence for adverse events is uncertain. Certainty of evidence may improve with inclusion of three ongoing studies and seven studies awaiting classification, in future updates.
Collapse
Affiliation(s)
- Sharon R Lewis
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Michael W Pritchard
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - David JW Evans
- Lancaster UniversityLancaster Health HubLancasterUKLA1 4YG
| | - Andrew R Butler
- Royal Lancaster InfirmaryDepartment of AnaesthesiaLancasterUK
| | - Phil Alderson
- National Institute for Health and Care ExcellenceLevel 1A, City Tower,Piccadilly PlazaManchesterUKM1 4BD
| | - Andrew F Smith
- Royal Lancaster InfirmaryDepartment of AnaesthesiaLancasterUK
| | - Ian Roberts
- London School of Hygiene & Tropical MedicineCochrane Injuries GroupNorth CourtyardKeppel StreetLondonUKWC1E 7HT
| | | |
Collapse
|
4
|
Singh-Ranger D, Leung E, Lau-Robinson ML, Ramcharan S, Francombe J. Nontraumatic Emergency Laparotomy: Surgical Principles Similar to Trauma Need to Be Adopted? South Med J 2017; 110:688-693. [PMID: 29100217 DOI: 10.14423/smj.0000000000000721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES In 2011, the Royal College of Surgeons published Emergency Surgery: Standards for Unscheduled Care in response to variable clinical outcomes for emergency surgery. The purpose of this study was to examine whether different treatment modalities would alter survival. METHODS All patients who underwent emergency laparotomy between April 2011 and December 2012 at Warwick Hospital (Warwick, UK) were included retrospectively. Information relating to their demographics; preoperative score; primary pathology; timing of surgery; intraoperative details; and postoperative outcome, including 30-day mortality, were collated for statistical analysis. RESULTS In total, 91 patients underwent 97 operations. The median age was 64 years (range 50-90, male:female 1:2). Sixty-five percent of cases were obstruction and perforation, and 66% of all operations were performed during office hours. The unadjusted 30-day mortality was 15.4%. Compared with nonsurvivors, survivors had a significantly higher Portsmouth-Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity score (P < 0.001), prolonged duration of hypotension and use of inotropes (P = 0.013), higher volume of colloid use (P = 0.04), and lower core body temperature (P < 0.05). Grades of surgeons did not influence mortality. CONCLUSIONS The 30-day mortality rate is comparable to the national standard. Further studies are warranted to determine whether trauma management modalities may be adopted to target high-risk patients who exhibit the lethal triad of hypotension, coagulopathy, and hypothermia.
Collapse
Affiliation(s)
| | - Edmund Leung
- From the Warwick Hospital, Warwick, United Kingdom
| | | | | | | |
Collapse
|
5
|
Moeller C, Fleischmann C, Thomas-Rueddel D, Vlasakov V, Rochwerg B, Theurer P, Gattinoni L, Reinhart K, Hartog CS. How safe is gelatin? A systematic review and meta-analysis of gelatin-containing plasma expanders vs crystalloids and albumin. J Crit Care 2016; 35:75-83. [DOI: 10.1016/j.jcrc.2016.04.011] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 04/07/2016] [Accepted: 04/08/2016] [Indexed: 12/22/2022]
|
6
|
Basora M, Colomina MJ, Moral V, Asuero de Lis MS, Boix E, Jover JL, Llau JV, Rodrigo MP, Ripollés J, Calvo Vecino JM. Clinical practice guide for the choice of perioperative volume-restoring fluid in adult patients undergoing non-cardiac surgery. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:29-47. [PMID: 26343809 DOI: 10.1016/j.redar.2015.06.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 06/24/2015] [Accepted: 06/26/2015] [Indexed: 06/05/2023]
Abstract
The present Clinical practice guide responds to the clinical questions about security in the choice of fluid (crystalloid, colloid or hydroxyethyl starch 130) in patients who require volume replacement during perioperative period of non-cardiac surgeries. From the evidence summary, recommendations were made following the GRADE methodology. In this population fluid therapy based on crystalloids is suggested (weak recommendation, low quality evidence). In the events where volume replacement is not reached with crystalloids, the use of synthetic colloids (hydroxyethyl starch 130 or modified fluid gelatin) is suggested instead of 5% albumin (weak recommendation, low quality evidence). The choice and dosage of the colloid should be based in the product characteristics, patient comorbidity and anesthesiologist's experience.
Collapse
Affiliation(s)
- M Basora
- Anestesiología y Reanimación, Hospital Clínic, Barcelona, España.
| | - M J Colomina
- Anestesiología y Reanimación, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - V Moral
- Anestesiología y Reanimación, Hospital Sant Pau, Barcelona, España
| | - M S Asuero de Lis
- Anestesiología y Reanimación, Hospital Universitario Ramón y Cajal, Madrid, España
| | - E Boix
- Anestesiología y Reanimación, Hospital Universitario del Vinalopó, Elche, Alicante, España
| | - J L Jover
- Anestesiología y Reanimación, Hospital Verge dels Lliris, Alcoi, Alicante, España
| | - J V Llau
- Anestesiología y Reanimación, Hospital Clínico Universitario, Valencia, España
| | - M P Rodrigo
- Anestesiología y Reanimación, Hospital de Basurto, Bilbao, España
| | - J Ripollés
- Anestesiología y Reanimación, Hospital Universitario Infanta Leonor, Madrid, España
| | - J M Calvo Vecino
- Anestesiología y Reanimación, Hospital Universitario Infanta Leonor, Universidad Complutense, Madrid, España
| |
Collapse
|
7
|
|
8
|
Na HS, Shin HJ, Lee YJ, Kim JH, Koo KH, Do SH. The effect of tranexamic acid on blood coagulation in total hip replacement arthroplasty: rotational thromboelastographic (ROTEM®) analysis. Anaesthesia 2015; 71:67-75. [PMID: 26559015 DOI: 10.1111/anae.13270] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2015] [Indexed: 11/30/2022]
Abstract
We evaluated changes in rotational thromboelastometry (ROTEM(®) ) parameters and clinical outcomes in patients undergoing total hip replacement arthroplasty, with concomitant infusions of tranexamic acid and of 6% hydroxyethyl starch 130/0.4. Fifty-five patients were randomly assigned to either the tranexamic acid (n = 29) or the control (n = 26) group. Hydroxyethyl starch was administered in the range of 10-15 ml.kg(-1) during the operation in both groups. In the control group, the clot formation time and maximum clot firmness of APTEM showed significant differences when compared with those of EXTEM at one hour postoperatively, suggestive of fibrinolysis. In the tranexamic acid group, there was no significant difference between each postoperative EXTEM and APTEM parameter. In the tranexamic acid and control group, postoperative blood loss was 308 ml (210-420 [106-745]) and 488 ml (375-620 [170-910], p = 0.002), respectively, and total blood loss was 1168 ml (922-1470 [663-2107]) and 1563 ml (1276-1708 [887-1494], p = 0.003). Haemoglobin concentration was higher in the tranexamic acid group on the second postoperative day (10.5 (9.4-12.1 [7.9-14.0]) vs. 9.6 (8.9-10.5[7.3-16.0]) g.dl(-1) , p = 0.027). In patients undergoing total hip replacement arthroplasty, postoperative fibrinolysis aggravated by hydroxyethyl starch was attenuated by co-administration of 10 mg.kg(-1) tranexamic acid, which may have led to less postoperative blood loss.
Collapse
Affiliation(s)
- H S Na
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
| | - H J Shin
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
| | - Y J Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
| | - J H Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
| | - K H Koo
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
| | - S H Do
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
| |
Collapse
|
9
|
|
10
|
Abstract
PURPOSE OF REVIEW Severe trauma is associated with hemorrhage, coagulopathy and transfusion of blood and blood products, all associated with considerable mortality and morbidity. The aim of this review is to focus on resuscitation, transfusion strategies and the management of bleeding in trauma as well as to emphasize on why coagulation has to be monitored closely and to discuss the rationale of modern and future transfusion strategies. RECENT FINDINGS Coagulopathy and uncontrolled bleeding remain leading causes of death in trauma, lead to blood transfusions and increased mortality as it has been recently shown that blood transfusion per se results in an adverse outcome. In the last years, damage control resuscitation, a combination of permissive hypotension, hemostatic resuscitation and damage control surgery, has been introduced to treat severely traumatized patients in hemorrhagic shock. Goals of treatment in trauma patients remain avoiding metabolic acidosis, hypothermia, treating coagulopathy and stabilizing the patient as soon as possible. The place of colloids and crystalloids in trauma resuscitation as well as the role of massive transfusion protocols with a certain FFP : RBC ratio and even platelets have to be reevaluated. SUMMARY Close monitoring of bleeding and coagulation in trauma patients allows goal-directed transfusions and thereby optimizes the patient's coagulation, reduces the exposure to blood products, reduces costs and may improve clinical outcome.
Collapse
|
11
|
Fenger-Eriksen C, Christiansen K, Laurie J, Sørensen B, Rea C. Fibrinogen concentrate and cryoprecipitate but not fresh frozen plasma correct low fibrinogen concentrations following in vitro haemodilution. Thromb Res 2013; 131:e210-3. [DOI: 10.1016/j.thromres.2013.02.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 02/05/2013] [Accepted: 02/11/2013] [Indexed: 11/17/2022]
|
12
|
Abstract
BACKGROUND Colloid solutions are widely used in fluid resuscitation of critically ill patients. There are several choices of colloid, and there is ongoing debate about the relative effectiveness of colloids compared to crystalloid fluids. OBJECTIVES To assess the effects of colloids compared to crystalloids for fluid resuscitation in critically ill patients. SEARCH METHODS We searched the Cochrane Injuries Group Specialised Register (17 October 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library) (Issue 10, 2012), MEDLINE (Ovid) 1946 to October 2012, EMBASE (Ovid) 1980 to October 2012, ISI Web of Science: Science Citation Index Expanded (1970 to October 2012), ISI Web of Science: Conference Proceedings Citation Index-Science (1990 to October 2012), PubMed (October 2012), www.clinical trials.gov and www.controlled-trials.com. We also searched the bibliographies of relevant studies and review articles. SELECTION CRITERIA Randomised controlled trials (RCTs) of colloids compared to crystalloids, in patients requiring volume replacement. We excluded cross-over trials and trials involving pregnant women and neonates. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and rated quality of allocation concealment. We analysed trials with a 'double-intervention', such as those comparing colloid in hypertonic crystalloid to isotonic crystalloid, separately. We stratified the analysis according to colloid type and quality of allocation concealment. MAIN RESULTS We identified 78 eligible trials; 70 of these presented mortality data.COLLOIDS COMPARED TO CRYSTALLOIDS: Albumin or plasma protein fraction - 24 trials reported data on mortality, including a total of 9920 patients. The pooled risk ratio (RR) from these trials was 1.01 (95% confidence interval (CI) 0.93 to 1.10). When we excluded the trial with poor-quality allocation concealment, pooled RR was 1.00 (95% CI 0.92 to 1.09). Hydroxyethyl starch - 25 trials compared hydroxyethyl starch with crystalloids and included 9147 patients. The pooled RR was 1.10 (95% CI 1.02 to 1.19). Modified gelatin - 11 trials compared modified gelatin with crystalloid and included 506 patients. The pooled RR was 0.91 (95% CI 0.49 to 1.72). (When the trials by Boldt et al were removed from the three preceding analyses, the results were unchanged.) Dextran - nine trials compared dextran with a crystalloid and included 834 patients. The pooled RR was 1.24 (95% CI 0.94 to 1.65). COLLOIDS IN HYPERTONIC CRYSTALLOID COMPARED TO ISOTONIC CRYSTALLOID: Nine trials compared dextran in hypertonic crystalloid with isotonic crystalloid, including 1985 randomised participants. Pooled RR for mortality was 0.91 (95% CI 0.71 to 1.06). AUTHORS' CONCLUSIONS There is no evidence from randomised controlled trials that resuscitation with colloids reduces the risk of death, compared to resuscitation with crystalloids, in patients with trauma, burns or following surgery. Furthermore, the use of hydroxyethyl starch might increase mortality. As colloids are not associated with an improvement in survival and are considerably more expensive than crystalloids, it is hard to see how their continued use in clinical practice can be justified.
Collapse
Affiliation(s)
- Pablo Perel
- Cochrane Injuries Group, London School of Hygiene & Tropical Medicine, London, UK.
| | | | | |
Collapse
|
13
|
The effect of fibrinogen concentrate and factor XIII on thromboelastometry in 33% diluted blood with albumin, gelatine, hydroxyethyl starch or saline in vitro. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2012; 11:510-7. [PMID: 23245725 DOI: 10.2450/2012.0171-12] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 09/25/2012] [Indexed: 01/02/2023]
Abstract
BACKGROUND Fluid replacement results in dilutional coagulopathy. We investigated the potential role of fibrinogen, factor XIII and a combination of both to reverse dilutional coagulopathy, assessed by thromboelastometry (ROTEM(®)). MATERIAL AND METHODS Blood samples from healthy volunteers were analysed undiluted and after 33% dilution in vitro with albumin, gelatine, 130/0.4 hydroxyethyl starch or saline. Diluted samples were incubated with fibrinogen (3 g/70 kg bodyweight equivalent), factor XIII (10,000 IU/70 kg bodyweight equivalent), or a combination of both. Measurements were performed using an extrinsic activated assay (EXTEM(®)) and a functional fibrin polymerisation test (FIBTEM(®)). RESULTS Compared with baseline, EXTEM clotting time increased with hydroxyethyl starch, exceeding the upper limit of the reference value. Albumin prolonged clotting time within normal limits. Gelatine did not change clotting time, and saline reduced clotting time. Clot formation time increased in colloids only. Maximum clot firmness of both EXTEM and FIBTEM decreased with all fluids, but was less pronounced in saline. Incubation with fibrinogen had no effect on EXTEM maximum clot firmness but improved FIBTEM maximum clot firmness in saline (P <0.001) and albumin (P <0.05), but not gelatine and hydroxyethyl starch). Factor XIII had no effect on any EXTEM and FIBTEM maximum clot firmness results. Fibrinogen and factor XIII combined did not improve EXTEM maximum clot firmness. Fibrinogen and factor XIII did not change FIBTEM maximum clot firmness in hydroxyethyl starch but improved FIBTEM maximum clot firmness in albumin (P <0.001), gelatine (P <0.01) and saline (P <0.001). DISCUSSION ROTEM parameters in dilutional coagulopathy in vitro cannot be improved with factor XIII alone in any tested diluent. The combination of fibrinogen and factor XIII is highly effective in raising FIBTEM maximum clot firmness after dilution with albumin, gelatine and saline back to normal values, but is ineffective in 130/0.4 hydroxyethyl starch.
Collapse
|
14
|
Abstract
BACKGROUND Colloids are widely used in the replacement of fluid volume. However, doubts remain as to which colloid is best. Different colloids vary in their molecular weight and therefore in the length of time they remain in the circulatory system. Because of this, and their other characteristics, they may differ in their safety and efficacy. OBJECTIVES To compare the effects of different colloid solutions in patients thought to need volume replacement. SEARCH METHODS We searched the Cochrane Injuries Specialised Register (searched 1 December 2011), the Cochrane Central Register of Controlled Trials 2011, issue 4 (The Cochrane Library); MEDLINE (Ovid) (1948 to November Week 3 2011); EMBASE (Ovid) (1974 to 2011 Week 47); ISI Web of Science: Science Citation Index Expanded (1970 to 1 December 2011); ISI Web of Science: Conference Proceedings Citation Index-Science (1990 to 1 December 2011); CINAHL (EBSCO) (1982 to 1 December 2011); National Research Register (2007, Issue 1) and PubMed (searched 1 December 2011). Bibliographies of trials retrieved were searched, and for the initial version of the review drug companies manufacturing colloids were contacted for information (1999). SELECTION CRITERIA Randomised controlled trials comparing colloid solutions in critically ill and surgical patients thought to need volume replacement. DATA COLLECTION AND ANALYSIS Two review authors independently extracted the data and assessed the quality of the trials. The outcomes sought were death, amount of whole blood transfused, and incidence of adverse reactions. MAIN RESULTS Eighty-six trials, with a total of 5,484 participants, met the inclusion criteria. Quality of allocation concealment was judged to be adequate in 33 trials and poor or uncertain in the rest.Deaths were reported in 57 trials. For albumin or plasma protein fraction (PPF) versus hydroxyethyl starch (HES) 31 trials (n = 1719) reported mortality. The pooled relative risk (RR) was 1.06 (95% confidence interval (CI) 0.86 to 1.31). When the trials by Boldt were removed from the analysis the pooled RR was 0.90 (95% CI 0.68 to 1.20). For albumin or PPF versus gelatin, nine trials (n = 824) reported mortality. The RR was 0.89 (95% CI 0.65 to 1.21). Removing the study by Boldt from the analysis did not change the RR or CIs. For albumin or PPF versus dextran four trials (n = 360) reported mortality. The RR was 3.75 (95% CI 0.42 to 33.09). For gelatin versus HES 22 trials (n = 1612) reported mortality and the RR was 1.02 (95% CI 0.84 to 1.26). When the trials by Boldt were removed from the analysis the pooled RR was 1.03 (95% CI 0.84 to 1.27). RR was not estimable in the gelatin versus dextran and HES versus dextran groups.Forty-one trials recorded the amount of blood transfused; however, quantitative analysis was not possible due to skewness and variable reporting. Twenty-four trials recorded adverse reactions, with two studies reporting possible adverse reactions to gel and one to HES. AUTHORS' CONCLUSIONS From this review, there is no evidence that one colloid solution is more effective or safe than any other, although the CIs were wide and do not exclude clinically significant differences between colloids. Larger trials of fluid therapy are needed if clinically significant differences in mortality are to be detected or excluded.
Collapse
Affiliation(s)
- Frances Bunn
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK.
| | | |
Collapse
|
15
|
Abstract
BACKGROUND Colloid solutions are widely used in fluid resuscitation of critically ill patients. There are several choices of colloid and there is ongoing debate about the relative effectiveness of colloids compared to crystalloid fluids. OBJECTIVES To assess the effects of colloids compared to crystalloids for fluid resuscitation in critically ill patients. SEARCH METHODS We searched the Cochrane Injuries Group Specialised Register (searched 16 March 2012), Cochrane Central Register of Controlled Trials 2011, issue 3 (The Cochrane Library), MEDLINE (Ovid) 1946 to March 2012, Embase (Ovid) 1980 to March 2012, ISI Web of Science: Science Citation Index Expanded (1970 to March 2012), ISI Web of Science: Conference Proceedings Citation Index-Science (1990 to March 2012), PubMed (searched 16 March 2012), www.clinical trials.gov and www.controlled-trials.com. We also searched the bibliographies of relevant studies and review articles. SELECTION CRITERIA Randomised controlled trials (RCTs) of colloids compared to crystalloids, in patients requiring volume replacement. We excluded cross-over trials and trials in pregnant women and neonates. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and rated quality of allocation concealment. We analysed trials with a 'double-intervention', such as those comparing colloid in hypertonic crystalloid to isotonic crystalloid, separately. We stratified the analysis according to colloid type and quality of allocation concealment. MAIN RESULTS We identified 74 eligible trials; 66 of these presented mortality data.Colloids compared to crystalloids Albumin or plasma protein fraction - 24 trials reported data on mortality, including a total of 9920 patients. The pooled relative risk (RR) from these trials was 1.01 (95% confidence interval (CI) 0.93 to 1.10). When we excluded the trial with poor quality allocation concealment, pooled RR was 1.00 (95% CI 0.92 to 1.09). Hydroxyethyl starch - 21 trials compared hydroxyethyl starch with crystalloids, n = 1385 patients. The pooled RR was 1.10 (95% CI 0.91 to 1.32). Modified gelatin - 11 trials compared modified gelatin with crystalloid, n = 506 patients. The pooled RR was 0.91 (95% CI 0.49 to 1.72). (When the trials by Boldt et al were removed from the three preceding analyses, the results were unchanged.) Dextran - nine trials compared dextran with a crystalloid, n = 834 patients. The pooled RR was 1.24 (95% CI 0.94 to 1.65).Colloids in hypertonic crystalloid compared to isotonic crystalloid Nine trials compared dextran in hypertonic crystalloid with isotonic crystalloid, including 1985 randomised participants. Pooled RR was 0.91 (95% CI 0.71 to 1.06). AUTHORS' CONCLUSIONS There is no evidence from RCTs that resuscitation with colloids reduces the risk of death, compared to resuscitation with crystalloids, in patients with trauma, burns or following surgery. As colloids are not associated with an improvement in survival, and as they are more expensive than crystalloids, it is hard to see how their continued use in these patients can be justified outside the context of RCTs.
Collapse
Affiliation(s)
- Pablo Perel
- Cochrane Injuries Group, London School of Hygiene & Tropical Medicine, London, UK.
| | | |
Collapse
|
16
|
Abstract
BACKGROUND Colloids are widely used in the replacement of fluid volume. However doubts remain as to which colloid is best. Different colloids vary in their molecular weight and therefore in the length of time they remain in the circulatory system. Because of this and their other characteristics, they may differ in their safety and efficacy. OBJECTIVES To compare the effects of different colloid solutions in patients thought to need volume replacement. SEARCH METHODS We searched the Cochrane Injuries Specialised Register (searched 1 Dec 2011), Cochrane Central Register of Controlled Trials 2011, issue 4 (The Cochrane Library); MEDLINE (Ovid) (1948 to November Week 3 2011); EMBASE (Ovid) (1974 to 2011 Week 47); ISI Web of Science: Science Citation Index Expanded (1970 to 1 Dec 2011); ISI Web of Science: Conference Proceedings Citation Index-Science (1990 to 1 Dec 2011); CINAHL (EBSCO) (1982 to 1 Dec 2011); National Research Register (2007, Issue 1) and PubMed (searched 1 Dec 2011). Bibliographies of trials retrieved were searched, and for the initial version of the review drug companies manufacturing colloids were contacted for information (1999). SELECTION CRITERIA Randomised controlled trials comparing colloid solutions in critically ill and surgical patients thought to need volume replacement. DATA COLLECTION AND ANALYSIS Two authors independently extracted the data and assessed the quality of the trials. The outcomes sought were death, amount of whole blood transfused, and incidence of adverse reactions. MAIN RESULTS Ninety trials, with a total of 5678 participants, met the inclusion criteria. Quality of allocation concealment was judged to be adequate in 35 trials and poor or uncertain in the rest.Deaths were obtained in 61 trials. For albumin or PPF versus hydroxyethyl starch (HES) 32 trials (n = 1769) reported mortality. The pooled relative risk (RR) was 1.07 (95% CI 0.87 to 1.32). When the trials by Boldt were removed from the analysis the pooled RR was 0.90 (95% CI 0.68 to 1.20). For albumin or PPF versus gelatin, nine trials (n = 824) reported mortality. The RR was 0.89 (95% CI 0.65 to 1.21). Removing the study by Boldt from the analysis did not change the RR or confidence intervals. For albumin or PPF versus Dextran four trials (n = 360) reported mortality. The RR was 3.75 (95% CI 0.42 to 33.09). For gelatin versus HES 25 trials (n = 1756) reported mortality and the RR was 1.03 (95% CI 0.84 to 1.26). When the trials by Boldt were removed from the analysis the pooled RR was 1.04 (95% CI 0.85 to 1.27). RR was not estimable in the gelatin versus dextran and HES versus dextran groups.Forty five trials recorded the amount of blood transfused, however quantitative analysis was not possible due to skewness and variable reporting. Twenty-four trials recorded adverse reactions, with two studies reporting possible adverse reactions to Gel and one to HES. AUTHORS' CONCLUSIONS From this review, there is no evidence that one colloid solution is more effective or safe than any other, although the confidence intervals are wide and do not exclude clinically significant differences between colloids. Larger trials of fluid therapy are needed if clinically significant differences in mortality are to be detected or excluded.
Collapse
Affiliation(s)
- Frances Bunn
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK.
| | | |
Collapse
|
17
|
Abstract
BACKGROUND Colloids are widely used in the replacement of fluid volume. However doubts remain as to which colloid is best. Different colloids vary in their molecular weight and therefore in the length of time they remain in the circulatory system. Because of this and their other characteristics, they may differ in their safety and efficacy. OBJECTIVES To compare the effects of different colloid solutions in patients thought to need volume replacement. SEARCH STRATEGY We searched the Cochrane Injuries Group's specialised register, CENTRAL (2007, Issue 1), MEDLINE (1994 to March 2007), EMBASE (1974 to March 2007), and the National Research Register (2007, Issue 1). Bibliographies of trials retrieved were searched, and drug companies manufacturing colloids were contacted for information. The search was last updated in March 2007. SELECTION CRITERIA Randomised and quasi-randomised trials comparing colloid solutions in critically ill and surgical patients thought to need volume replacement. The outcomes measured were death, amount of whole blood transfused, and incidence of adverse reactions. DATA COLLECTION AND ANALYSIS Two authors independently extracted the data and assessed the quality of the trials. MAIN RESULTS Seventy trials, with a total of 4375 participants, met the inclusion criteria. Quality of allocation concealment was judged to be adequate in 24 trials and poor or uncertain in the rest.Deaths were obtained in 46 trials. For albumin or PPF versus hydroxyethyl starch (HES) 25 trials (n = 1234) reported mortality. The pooled relative risk (RR) was 1.14 (95% CI 0.91 to 1.43). When the trials by Boldt are removed from the analysis the pooled RR was 0.97 (95% CI 0.70 to 1.35). For albumin or PPF versus gelatin, seven trials (n = 636) reported mortality. The RR was 0.97 (95% CI 0.68 to 1.39). For albumin or PPF versus Dextran four trials (n = 360) reported mortality. The RR was 3.75 (95% CI 0.42 to 33.09). For gelatin versus HES 18 trials (n = 1337) reported mortality and RR was 1.00 (95% CI 0.80 to 1.25). RR was not estimable in the gelatin versus dextran and HES versus dextran groups.Thirty-seven trials recorded the amount of blood transfused, however quantitative analysis was not possible due to skewness and variable reporting. Nineteen trials recorded adverse reactions, but none occurred. AUTHORS' CONCLUSIONS From this review, there is no evidence that one colloid solution is more effective or safe than any other, although the confidence intervals are wide and do not exclude clinically significant differences between colloids. Larger trials of fluid therapy are needed if clinically significant differences in mortality are to be detected or excluded.
Collapse
Affiliation(s)
- Frances Bunn
- Centre for Research in Primary and Community Care, University of Hertfordshire, College Lane, Hatfield, Hertfordshire, UK, AL10 9AB
| | | | | |
Collapse
|
18
|
Abstract
BACKGROUND Colloid solutions are widely used in fluid resuscitation of critically ill patients. There are several choices of colloid and there is ongoing debate about the relative effectiveness of colloids compared to crystalloid fluids. OBJECTIVES To assess the effects of colloids compared to crystalloids for fluid resuscitation in critically ill patients. SEARCH STRATEGY We searched the Cochrane Injuries Group Specialised Register, CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE, EMBASE, ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED), ISI Web of Science: Conference Proceedings Citation Index-Science (CPCI-S), and The Controlled Trials metaRegister (www.controlled-trials.com). Reference lists of relevant studies and review articles were searched for further trials. The searches were last updated in September 2008. SELECTION CRITERIA Randomised controlled trials (RCTs) of colloids compared to crystalloids, in patients requiring volume replacement. We excluded cross-over trials and trials in pregnant women and neonates. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and rated quality of allocation concealment. We analysed trials with a 'double-intervention', such as those comparing colloid in hypertonic crystalloid to isotonic crystalloid, separately. We stratified the analysis according to colloid type and quality of allocation concealment. MAIN RESULTS We identified 65 eligible trials; 56 of these presented mortality data.Colloids compared to crystalloidsAlbumin or plasma protein fraction - 23 trials reported data on mortality, including a total of 7754 patients. The pooled relative risk (RR) from these trials was 1.01 (95% confidence interval (95% CI) 0.92 to 1.10). When we excluded the trial with poor quality allocation concealment, pooled RR was 1.00 (95% CI 0.91 to 1.09). Hydroxyethyl starch - 17 trials compared hydroxyethyl starch with crystalloids, n = 1172 patients. The pooled RR was 1.18 (95% CI 0.96 to 1.44). Modified gelatin - 11 trials compared modified gelatin with crystalloid, n = 506 patients. The pooled RR was 0.91 (95% CI 0.49 to 1.72). (When the trials by Boldt et al were removed from the three preceding analyses, the results were unchanged.) Dextran - nine trials compared dextran with a crystalloid, n = 834 patients. The pooled RR was 1.24 (95% CI 0.94 to 1.65).Colloids in hypertonic crystalloid compared to isotonic crystalloidEight trials compared dextran in hypertonic crystalloid with isotonic crystalloid, including 1283 randomised participants. Pooled RR was 0.88 (95% CI 0.74 to 1.05). AUTHORS' CONCLUSIONS There is no evidence from RCTs that resuscitation with colloids reduces the risk of death, compared to resuscitation with crystalloids, in patients with trauma, burns or following surgery. As colloids are not associated with an improvement in survival, and as they are more expensive than crystalloids, it is hard to see how their continued use in these patients can be justified outside the context of RCTs.
Collapse
Affiliation(s)
- Pablo Perel
- Cochrane Injuries Group, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK, WC1E 7HT
| | | |
Collapse
|
19
|
Surgical intensive care unit--the trauma surgery perspective. Langenbecks Arch Surg 2011; 396:429-46. [PMID: 21369845 DOI: 10.1007/s00423-011-0765-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 02/21/2011] [Indexed: 01/04/2023]
Abstract
PURPOSE This review addresses and summarizes the key issues and unique specific intensive care treatment of adult patients from the trauma surgery perspective. MATERIALS AND METHODS The cornerstones of successful surgical intensive care management are fluid resuscitation, transfusion protocol and extracorporeal organ replacement therapies. The injury-type specific complications and unique pathophysiologic regulatory mechanisms of the traumatized patients influencing the critical care treatment are discussed. CONCLUSIONS Furthermore, the fundamental knowledge of the injury severity, understanding of the trauma mechanism, surgical treatment strategies and specific techniques of surgical intensive care are pointed out as essentials for a successful intensive care therapy.
Collapse
|
20
|
Fenger-Eriksen C, Moore GW, Rangarajan S, Ingerslev J, Sørensen B. Fibrinogen estimates are influenced by methods of measurement and hemodilution with colloid plasma expanders. Transfusion 2011; 50:2571-6. [PMID: 20576008 DOI: 10.1111/j.1537-2995.2010.02752.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Measurement of plasma fibrinogen is often required in critically ill patients or massively bleeding patients being resuscitated with colloid plasma expander. This study aimed at evaluating different assays of plasma fibrinogen after in vitro dilution with commonly used plasma expanders and challenged the hypothesis that levels of fibrinogen are estimated significantly higher in plasma diluted with colloid plasma expander compared with isotonic saline. STUDY DESIGN AND METHODS Fibrinogen measurements were established in plasma samples each diluted in vitro to 30 or 50% with isotonic saline, hydroxyethyl starch (HES) 130/0.4, and human albumin. Fibrinogen levels were assessed using an antigen determination, three photo-optical Clauss methods, one mechanical Clauss method, a prothrombin-derived method, and viscoelastic measurement through thromboelastometry. RESULTS Measurement of fibrinogen levels was significantly different when performed on alternate analytical platforms. By 30 and 50% dilution with HES 130/0.4 coagulation analyzers using the photo-optical Clauss methods significantly overestimated levels of fibrinogen. Dilution with human albumin did not affect fibrinogen levels except from one analyzer by 50% dilution level. Viscoelastic measurement of fibrin polymerization was reduced at both dilution levels and appeared to reflect the impairment of fibrin polymerization induced by HES 130/0.4 and to a lesser extent human albumin. CONCLUSION This study demonstrated that different automated coagulation analyzers revealed significantly different levels of fibrinogen. The presence of colloid plasma expander gave rise to erroneous high levels of fibrinogen returned from some coagulation analyzers employing the method of Clauss.
Collapse
Affiliation(s)
- Christian Fenger-Eriksen
- Department of Anaesthesiology and the Center for Haemophilia and Thrombosis, Aarhus University Hospital, Denmark.
| | | | | | | | | |
Collapse
|
21
|
Llewellyn RL, James MFM. The effect of low molecular weight heparin (enoxaparin) on enhanced coagulation induced by crystalloid haemodilution. Anaesthesia 2010; 65:1013-6. [PMID: 20731638 DOI: 10.1111/j.1365-2044.2010.06475.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The purpose of this study was to establish whether a low molecular weight heparin (enoxaparin) attenuated or abolished the enhanced coagulation induced by crystalloid fluid therapy. Twenty young, healthy male volunteers were injected subcutaneously with either enoxaparin 40 mg or saline on two separate occasions one week apart, in a randomised, blinded study. Twelve hours later, a blood sample was taken for thrombelastography analysis and haematocrit. Saline 14 ml.kg⁻¹ was then infused over thirty minutes and thrombelastography and haematocrit measurements repeated. There was a significant post-dilutional difference in the alpha angle (p = 0.002) and k-time (p = 0.001) between the two groups. There was a trend towards reduced shortening of r-time in the enoxaparin group compared to the saline control (p = 0.18). The findings suggest that enoxaparin diminished acceleration of clot formation due to haemodilution.
Collapse
Affiliation(s)
- R L Llewellyn
- Department of Anaesthesiology, University of Cape Town Medical School, South Africa.
| | | |
Collapse
|
22
|
Innerhofer P, Kienast J. Principles of perioperative coagulopathy. Best Pract Res Clin Anaesthesiol 2010; 24:1-14. [DOI: 10.1016/j.bpa.2009.09.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
23
|
|
24
|
Fenger-Eriksen C, Tønnesen E, Ingerslev J, Sørensen B. Recombinant factor VIIa and fibrinogen display additive effect during in vitro haemodilution with crystalloids. Acta Anaesthesiol Scand 2009; 53:332-8. [PMID: 19243319 DOI: 10.1111/j.1399-6576.2008.01875.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Major blood loss requires fluid resuscitation for maintaining hemodynamic stability. Excessive volume infusions predispose to dilutional coagulopathy through loss, consumption and dilution of cells and proteins involved in haemostasis. Further treatment with fibrinogen concentrate and/or recombinant activated factor VII (rFVIIa) may be initiated, although the haemostatic effects in a situation with haemodilution are not fully detailed. The present study evaluates haemostatic effect of fibrinogen and rFVIIa and their combination in an in vitro model of haemodiluted whole blood with two commonly used crystalloids. METHODS Eight healthy, male volunteers were enrolled. Outcome variables were clot initiation, propagation and strength assessed by thrombelastographic parameters: clotting time, clot formation time, maximum velocity, time until maximum velocity, maximum clot firmness evaluated at dilution levels of 0% (control), 10%, 30% and 50% with isotonic saline and Ringer's lactate in a model of tissue factor-activated whole blood. Fibrinogen and rFVIIa were additional final reaction concentrations, reflecting commonly used clinically therapeutic dosages. RESULTS Dose-dependent coagulopathy developed following haemodilution with isotonic saline and Ringer's lactate, characterised by a prolonged clot initiation, reduced clot propagation and reduced clot strength. Fibrinogen improved clot strength and propagation phase while rFVIIa shortened clot initiation, both with a positive dose dependency. CONCLUSIONS The combination of fibrinogen and rFVIIa displays an additive effect and improves overall in vitro whole blood clot formation in a model of in vitro crystalloid-induced haemodilution.
Collapse
Affiliation(s)
- C Fenger-Eriksen
- Department of Anesthesiology, Center for Haemophilia and Thrombosis, Aarhus University Hospital, Aarhus, Denmark.
| | | | | | | |
Collapse
|
25
|
Green RS, Hall RI. Con: Starches Are Not Preferable to Albumin During Cardiac Surgery: A Contrary Opinion. J Cardiothorac Vasc Anesth 2008; 22:485-91. [DOI: 10.1053/j.jvca.2008.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2007] [Indexed: 11/11/2022]
|
26
|
Mittermayr M, Streif W, Haas T, Fries D, Velik-Salchner C, Klingler A, Innerhofer P. Effects of colloid and crystalloid solutions on endogenous activation of fibrinolysis and resistance of polymerized fibrin to recombinant tissue plasminogen activator added ex vivo. Br J Anaesth 2008; 100:307-14. [DOI: 10.1093/bja/aem363] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
27
|
Abstract
BACKGROUND Colloids are widely used in the replacement of fluid volume. However doubts remain as to which colloid is best. Different colloids vary in their molecular weight and therefore in the length of time they remain in the circulatory system. Because of this and their other characteristics, they may differ in their safety and efficacy. OBJECTIVES To compare the effects of different colloid solutions in patients thought to need volume replacement. SEARCH STRATEGY We searched the Cochrane Injuries Group specialised register, CENTRAL (2007, Issue 1), MEDLINE (1994 to March 2007), EMBASE (1974 to March 2007), and the National Research Register (2007, issue 1). Bibliographies of trials retrieved were searched, and drug companies manufacturing colloids were contacted for information. The search was last updated in March 2007. SELECTION CRITERIA Randomised and quasi-randomised trials comparing colloid solutions in critically ill and surgical patients thought to need volume replacement. The outcomes measured were death, amount of whole blood transfused, and incidence of adverse reactions. DATA COLLECTION AND ANALYSIS Two authors independently extracted the data and assessed the quality of the trials. MAIN RESULTS Seventy trials, with a total of 4375 participants, met the inclusion criteria. Quality of allocation concealment was judged to be adequate in 24 trials and poor or uncertain in the rest. Deaths were obtained in 46 trials. For albumin or PPF versus hydroxyethyl starch (HES) 25 trials (n = 1234) reported mortality. The pooled relative risk (RR) was 1.14 (95% CI 0.91 to 1.43). For albumin or PPF versus gelatin, seven trials (n = 636) reported mortality. The RR was 0.97 (95% CI 0.68 to 1.39). For albumin or PPF versus Dextran four trials (n = 360) reported mortality. The RR was 3.75 (95% CI 0.42 to 33.09). For gelatin versus HES 18 trials (n = 1337) reported mortality and RR was 1.00 (95% CI 0.80 to 1.25). RR was not estimable in the gelatin versus dextran and HES versus dextran groups.Thirty-seven trials recorded the amount of blood transfused, however quantitative analysis was not possible due to skewness and variable reporting. Nineteen trials recorded adverse reactions, but none occurred. AUTHORS' CONCLUSIONS From this review, there is no evidence that one colloid solution is more effective or safe than any other, although the confidence intervals are wide and do not exclude clinically significant differences between colloids. Larger trials of fluid therapy are needed if clinically significant differences in mortality are to be detected or excluded.
Collapse
Affiliation(s)
- F Bunn
- University of Hertfordshire, Centre for Research in Primary and Community Care (CRIPACC), College Lane, Hatfield, Hertfordshire, UK AL10 9PN.
| | | | | |
Collapse
|
28
|
Abstract
BACKGROUND Colloid solutions are widely used in fluid resuscitation of critically ill patients. There are several choices of colloid and there is ongoing debate about the relative effectiveness of colloids compared to crystalloid fluids. OBJECTIVES To assess the effects of colloids compared to crystalloids for fluid resuscitation in critically ill patients. SEARCH STRATEGY We searched the Cochrane Injuries Group's specialised register, CENTRAL, MEDLINE, EMBASE, the National Research Register, Web of Science and MetaRegister. Bibliographies of trials and review articles retrieved were searched. The searches were last updated in December 2006. SELECTION CRITERIA Randomised controlled trials (RCTs) of colloids compared to crystalloids, in patients requiring volume replacement. Cross-over trials and trials in pregnant women and neonates were excluded. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and rated quality of allocation concealment. Trials with a 'double-intervention', such as those comparing colloid in hypertonic crystalloid to isotonic crystalloid, were analysed separately. The analysis was stratified according to colloid type and quality of allocation concealment. MAIN RESULTS We identified 63 eligible trials, 55 of these presented mortality data. COLLOIDS COMPARED TO CRYSTALLOIDS: Albumin or plasma protein fraction - 23 trials reported data on mortality, including a total of 7,754 patients. The pooled relative risk (RR) from these trials was 1.01 (95% confidence interval [95% CI] 0.92 to 1.10). When the trial with poor quality allocation concealment was excluded, pooled RR was 1.00 (95% CI 0.91 to 1.09). Hydroxyethyl starch - 16 trials compared hydroxyethyl starch with crystalloids, n = 637 patients. The pooled RR was 1.05 (95% CI 0.63 to 1.75). Modified gelatin - 11 trials compared modified gelatin with crystalloid, n = 506 patients. The pooled RR was 0.91 (95% CI 0.49 to 1.72). Dextran - nine trials compared dextran with a crystalloid, n = 834 patients. The pooled RR was 1.24 (95% CI 0.94 to 1.65). COLLOIDS IN HYPERTONIC CRYSTALLOID COMPARED TO ISOTONIC CRYSTALLOID: Eight trials compared dextran in hypertonic crystalloid with isotonic crystalloid, including 1,283 randomised participants. Pooled RR was 0.88 (95% CI 0.74 to 1.05). AUTHORS' CONCLUSIONS There is no evidence from RCTs that resuscitation with colloids reduces the risk of death, compared to resuscitation with crystalloids, in patients with trauma, burns or following surgery. As colloids are not associated with an improvement in survival, and as they are more expensive than crystalloids, it is hard to see how their continued use in these patients can be justified outside the context of RCTs.
Collapse
Affiliation(s)
- P Perel
- London School of Hygiene & Tropical Medicine, Nutrition & Public Health Intervention Research Unit, Keppel Street, London, UK, WC1E 7HT.
| | | |
Collapse
|
29
|
Ruttmann TG, Montoya-Pelaez LF, James MFM. The Coagulation Changes Induced by Rapid In Vivo Crystalloid Infusion Are Attenuated When Magnesium Is Kept at the Upper Limit of Normal. Anesth Analg 2007; 104:1475-80, table of contents. [PMID: 17513645 DOI: 10.1213/01.ane.0000261256.88414.e4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Rapid crystalloid infusion enhances coagulation, regardless of electrolytes, pH or osmolality, an effect thought to be related to deep vein thrombosis and other clot formations. Altered serum magnesium may play a role in the balance of coagulation. In this in vivo study we investigated the coagulation response to rapid hemodilution when serum magnesium is maintained or partially increased. METHODS Twenty-five healthy volunteers were investigated on three occasions, randomly receiving normal saline, Balsol (magnesium 1.5 g/L), and Balsol plus additional magnesium (magnesium 3.0 g/L). Investigators were blinded to the solution's identity. Baseline blood samples were taken measuring hematocrit, serum magnesium, and thrombelastography (TEG), whereafter 14 mL/kg (20% blood volume) was infused over 30 min, followed by a second blood sample. All results were compared to their own baseline values using ANOVA with LSD post hoc significance testing. RESULTS All groups had a similar postdilutional hematocrit decrease, with significant magnesium reduction in the saline group (0.81 +/- 0.07 to 0.74 +/- 0.07 (approximately -8.6%) (P < 0.003)), no change in the Balsol group and significant increase in the Balsol + magnesium group (0.84 +/- 0.07 to 0.99 +/- 0.06 (approximately 17.9%) (P < 0.001)). Postdilutional TEG results reflected no significant change from control in the Balsol + magnesium group. Both of the other two groups had statistically significant increased clot formation (reaction time to onset of clotting and clotting time shortened; alpha-angle increased). CONCLUSIONS Rapid hemodilution-induced coagulation may be partially due to decreased magnesium, and the effect is attenuated by maintaining magnesium at the upper limit of normal. Crystalloid resuscitation fluids should possibly contain higher magnesium levels, around 3 mmol/L.
Collapse
Affiliation(s)
- Thomas G Ruttmann
- Department of Anaesthesiology, University of Cape Town Medical School, Cape Town, Republic of South Africa.
| | | | | |
Collapse
|
30
|
Holte K, Kehlet H. Fluid Therapy and Surgical Outcomes in Elective Surgery: A Need for Reassessment in Fast-Track Surgery. J Am Coll Surg 2006; 202:971-89. [PMID: 16735213 DOI: 10.1016/j.jamcollsurg.2006.01.003] [Citation(s) in RCA: 156] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2005] [Revised: 01/06/2006] [Accepted: 01/16/2006] [Indexed: 11/18/2022]
Affiliation(s)
- Kathrine Holte
- Department of Surgical Gastroenterology, Hvidovre University Hospital, Copenhagen, Denmark
| | | |
Collapse
|