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© 2002 International Anesthesia Research Society
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Abstract |
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Gelatin solutions are often given in clinical practice once the maximal dose of a median-weight hydroxyethyl starch (HES) has been reached. Colloids are usually combined with lactated Ringer’s solution (RL). Whether the combined administration of colloids and/or crystalloids affects blood coagulation is not known. We diluted blood by 20%, 40%, and 60% with RL, gelatin (Gelofusin®), 6% HES 130/0.4 (Voluven®), and 6% HES 200/0.5 (Iso-Hes®), as well as with combinations of these solutions at a ratio of 1:1 (gelatin/RL, 6% HES 130/0.4:RL, 6% HES 200/0.5:RL, 6% HES 130/0.4:gelatin, 6% HES 200/0.5:gelatin). Thereafter, blood was analyzed by using modified thrombelastograph® coagulation analysis (ROTEG®) and clotting time, clot formation time, and maximal clot firmness were determined. RL had the least effect on hemostasis. Gelatin administered alone impaired the coagulation system significantly less than each median-weight HES administered alone. We conclude that gelatin combined with 6% HES 200/0.5 or 6% HES 130/0.4 decreases hemostasis <6% HES 200/0.5 or 6% HES 130/0.4 administered alone.
IMPLICATIONS: The effect of the combined administration of different colloids and/or crystalloids on coagulation is not known. We show that hemostasis is less impaired using a combination of gelatin and median-weight starches than using median-weight starches alone. Furthermore, the combination of lactated Ringer’s solution and gelatin decreases the coagulation system to the same extent as the combination of lactated Ringer’s solution and 6% hydroxyethyl starch 130/0.4.
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Introduction |
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The choice of the appropriate colloid for intravascular volume replacement is still controversial. Since the results of the Cochrane Injuries Group Albumin Reviewers were published (1), the use of albumin is controversial. Obviously, the administration of dextran solutions has also decreased markedly because of the considerable impairment on the coagulation system (2,3). The impairment of hemostasis is a major concern with the infusion of gelatin and hydroxyethyl starch (HES). Should gelatin or HES solutions be used with major blood loss? Gelatin is often administered once the maximal dose of HES has been reached (4); however, this procedure has not been supported by clinical investigations.
The administration of large amounts of colloid solutions causes a dilutional coagulopathy, regardless of the kind of colloid used. In addition, each colloid solution impairs the coagulation system in a particular way: Gelatin-based colloids reduce the weight and elasticity of the clot and disturb the reticular fibrin network, thereby altering the quality of the clot (5). Furthermore, denatured collagen (gelatin) binds fibronectin, which forms covalent cross-linkages and noncovalent associations with fibrin (6).
Several studies have documented an increased bleeding tendency induced by the administration of HES, especially high-molecular HES (7). HES solutions cause a syndrome similar to the von Willebrand type I syndrome, which is characterized by a diminished factor VIII activity, decreased von Willebrand factor plasma levels, as well as a decreased factor VIII-associated ristocetin cofactor in plasma. Apart from the quantity of the administered volume, the effect on the coagulation system depends on the concentration, molecular weight, degree of substitution as well as on the ratio (C1:C4) of substitution. HES 130/0.4 is a new median-weight HES solution, which seems to impair the coagulation system less than higher-molecular-weight HES solutions (4,8–10).
Crystalloids also affect the coagulation system. A moderate hemodilution with crystalloids probably produces a mild hypercoagulability, as shown in vitro (11) and in vivo (12,13). In daily routine, colloids are administered not as individual substances but in combination with lactated Ringer’s solution (RL) in cases of moderate blood loss.
The aim of this study was to investigate the effect of the combination of these artificial colloid solutions, as well as of their combination with RL, on the coagulation system. We hypothesized that the administration of two different colloids or of a colloid and RL, targeting the coagulation cascade at different points, would probably result in a different total impairment of the coagulation system than the administration of the individual substances alone.
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Methods |
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Citrated blood, 15 mL, was withdrawn from 10 healthy male volunteers. Blood was taken from an antecubital vein through a 1.2-gauge needle avoiding venous stasis. The subjects were between 28 and 39 yr of age (mean 32.5 yr). They showed normal renal and hepatic function in their medical history as well as in their routine laboratory values. Their baseline prothrombin time, partial thromboplastin time, antithrombin, fibrinogen, platelet count, and red blood cell count, as well as their baseline ROTEG® values were in the normal range. None of the subjects received anticoagulant or antiplatelet medication during the last 2 wk before blood withdrawal. The study was approved by the Ethics Committee of the University of Innsbruck and written informed consent was given by the volunteers.
We analyzed the test samples by using modified thrombelastograph® coagulation analysis (ROTEG®; Pentapharm Co., Munich, Germany), which is based on the thrombelastograph® system (TEG®)after Hartert (14). Technical details of the ROTEG® coagulation analyzer are described in the literature (9,15). ROTEG® shows good correlation with conventional TEG® determination1,2 and an excellent reproducibility and precision.3 The automatic pipetting system makes the ROTEG® coagulation analyzer easy to handle in daily routine. ROTEG® uses a ball-bearing system for power transduction, which makes it less susceptible to mechanical stress, movement, and vibration. Furthermore, the activation of the test samples accelerates the measurement process and seems to enhance reproducibility when compared with conventional TEG® analysis.4 The variables of ROTEG® analysis are "coagulation time" (CT) corresponding to the reaction time (r time) in a conventional TEG®, "clot formation time" (CFT) in accordance with the coagulation time (k time), and "maximum clot firmness" (MCF), which is equivalent to the maximum amplitude.
The following solutions were investigated:
- 4% gelatin, Gelofusin®, B. Braun Co., Melsungen, Germany
- 6% HES 130/0.4, Voluven®, Fresenius Co., Bad Homburg, Germany
- 6% HES 200/0.5, Iso-Hes®, Fresenius, Pharma Austria Co., Graz, Austria
- RL, Fresenius, Pharma Austria Co., Graz, Austria
In addition to the individual substances, the effect of the combined administration of these solutions at a ratio of 1:1 (gelatin/RL, 6% HES 130/0.4:RL, 6% HES 130/0.4:gelatin, 6% HES 200/0.5:RL, 6% HES 200/0.5:gelatin) was evaluated. Citrated blood was mixed with the test solutions in plastic cuvettes. In the first of the 4 ROTEG® channels, we always took a baseline measurement without dilution. In the other 3 channels, we diluted blood by 20%, 40%, and 60% using the test solutions as well as the respective combinations. The volume of the undiluted baseline measurements as well as of the diluted samples in the cuvettes was always 300 µL. The test temperature was 37°C. If this in vitrotest model is transferred to an in vivo situation, 20% dilution corresponds to an infusion of approximately 14 mL/kg, 40% to 28 mL/kg, and 60% to 42 mL/kg. Undiluted and diluted samples were recalcified with 20 µL of CaCl2 0.2 M (Start-TEG®; Nobis Co., Endingen, Germany) activated with 20 µL of thromboplastin-phospholipid (InTec®; Nobis Co.) and analyzed by using ROTEG®.
We used a repeated-measures analysis of variance as applied for the analysis of the influence of dilution on thrombelastographic variables within each group. Between-group differences were compared separately at 20%, 40%, and 60% dilution by using a general linear model. The baseline value was subtracted to increase statistical power and Tukey’s post hoc test for individual intergroup comparisons was applied. A P value < 5% was considered significant.
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Results |
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The coagulation system was significantly impaired with increasing dilution in all groups compared with baseline measurements. We observed no significant intergroup differences in CT, CFT, or MCF at 20% dilution but did so at 40% and 60% dilution. The significant intergroup differences involved CFT and MCF, whereas CT did not show any significant differences between the groups.
Figure 1A–C demonstrates CT, Figure 2A–C shows CFT, and Figure 3A–C presents MCF at 20%, 40%, and 60% dilution. Tables 1 and 2 show the differences in CFT and MCF at 40% and 60% dilution. Table 3 presents the degree of the effect on the coagulation system in a sequence. The normal range for CT is between 95 and 205 s; for CFT it is <180 s. MCF is normally between 56 and 74 mm (16). A CFT between 180 and 249 s indicates a moderate coagulation disorder, whereas a CFT between 250 and 299 s indicates a major coagulation disorder. An MCF smaller than 39 mm indicates a strongly impaired hemostasis. Less than 20 mm there is no coagulation potential.
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Referring to the manufacturers’ normal values, at 40% dilution mainly the colloids and combined colloid solutions showed hypocoagulable values, whereas at 60% dilution, all groups (including RL and the combinations with RL) were hypocoagulable.
RL
RL impaired the coagulation system to a significantly lesser degree at 40% and 60% dilution than the individually tested artificial colloid solutions and the various combinations.
Gelatin
The samples tested with gelatin alone showed a significantly stronger MCF and a significantly shorter CFT at 40% and 60% dilution than the samples diluted with 6% HES 200/0.5. Compared with 6% HES 130/0.4, the MCF of gelatin was significantly stronger only at 60% dilution, and CFT was significantly shorter at 40% and 60% dilution.
Six Percent HES 130/0.4
At 60% dilution, the new starch impaired the coagulation system significantly <6% HES 200/0.5 with regard to MCF. However, we detected a weaker MCF at 40% dilution compared with 6% HES 200/0.5; this was, however, of little statistical significance.
Six Percent HES 200/0.5
Of all tested solutions, 6% HES 200/0.5 had the most pronounced effects on the coagulation system with regard to CFT at 40% dilution and MCF at 60% dilution.
Combined Gelatin and RL
This combination did not differ significantly from the combination of 6% HES 130/0.4 and RL. At 40% dilution, 6% HES 200/0.5 with RL showed a significantly increased CFT as well as a smaller MCF when compared with the combination of gelatin and RL.
Combined 6% HES 130/0.4 and RL
We observed a significantly shorter CFT and a significantly stronger MCF at 40% dilution in this group when compared with the combination of 6% HES 200/0.5 and RL.
Combined 6% HES 200/0.5 and RL
The combination of 6% HES 200/0.5 and RL impaired the coagulation system significantly <6% HES 200/0.5 administered alone with regard to MCF at 40% and 60% dilution as well as with regard to CFT at 40% dilution.
Combined 6% HES 130/0.4 and Gelatin
HES 130/0.4 combined with gelatin showed a significantly shorter CFT at 40% dilution than 6% HES 130/0.4 administered alone. The MCF at 60% dilution was, however, significantly weaker than after the administration of gelatin alone.
Combined 6% HES 200/0.5 and Gelatin
At 60% dilution, we found a significantly stronger MCF when gelatin was combined with 6% HES 130/0.4 compared with the combination of 6% HES 200/0.5 and gelatin. Testing 6% HES 200/0.5 with gelatin versus 6% HES 200/0.5 alone, we detected a significantly stronger MCF as well as a significantly increased CFT at 40% dilution.
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Discussion |
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Hemodilution with all investigated solutions induced a hypocoagulable state as shown in the ROTEG® analysis by increased CFT and decreased MCF. We found statistically significant differences not only to baseline but also between the various types of solutions.
The Effect of Single Substances on the Coagulation System
As expected, RL showed the least degree of hemostatic impairment. Our results showed significant differences between RL and all other tested colloids and combinations at 40% and 60% dilution. In contrast to the results of other in vitrostudies testing RL or saline solutions (17–20), our results showed no significant activation of the coagulation process at moderate dilution with RL or with the combination of colloids and RL. These other studies suggested a mismatch in the thrombin/antithrombin ratio to account for this phenomenon (17–20), but the finding of an increased coagulability by hemodilution is probably an artificial in vitroeffect of native nonactivated thrombelastograph® tracings (21).
In contrast to HES solutions, gelatin has not been studied thoroughly for its effect on the coagulation system. Only a few in vitro (5,11,18) and in vivo studies (22,23) have been published. Our results, however, indicate that gelatin impairs the coagulation system significantly less than median-weight HES solutions. The findings of other in vitrostudies are in line with our results. Egli et al. (11) investigated the effect of in vitrodilution with 6% HES 200/0.5, gelatin, and albumin. All solutions compromised blood coagulation significantly compared with baseline, but the most pronounced effect was documented using 6% HES 200/0.5. Another TEG® study assessed the consequences of in vitrodilution with various gelatin, dextran, and low-, median-, and high-molecular-weight HES solutions. The tested gelatin solutions showed the least effect on the coagulation system, whereas 10% dextran-40 most impaired the coagulation process (18).
In vivo studies showed similar results. For example, in patients undergoing total hip replacement, a larger blood loss was observed in the 6% HES 200/0.5 group than in the gelatin-treated group (24). Only Haisch et al. (15) compared the effect of gelatin with the new 6% HES 130/0.4. They investigated 42 patients undergoing major abdominal surgery, who received approximately 2500 mL of 6% HES 130/0.4 or gelatin within 24 hours. They did not find any significant differences between the two intravascular volume replacement regimes with regard to the use of allogeneic blood, blood products, or the standard coagulation variables and TEG® measurements. However, the study by Haisch et al. (15) had some limitations. All patients received RL and some received fresh frozen plasma, which probably blurred potential differences.
Whether a clinically relevant difference exists between the two median-weight HES solutions, 6% HES 200/0.5 and 6% HES 130/0.4, is not clear. According to our data, 6% HES 130/0.4 impaired the coagulation system to nearly the same degree as 6% HES 200/0.5 administered alone. Our results are well in agreement with the findings of Entholzer et al. (9), who also used TEG® to investigate the effects of a 30% dilution with different HES preparations in vitro. They found only a slight and not significant difference between 6% HES 130/0.4 and 6% HES 200/0.5. Diluting blood even more to 30% and 60% in vitro, Jamnicki et al. (25) did not detect any difference in TEG® variables between 6% HES 130/0.4 and 6% HES 200/0.5.
The in vivo investigation by Langeron et al. (4) came to a different conclusion. They compared 6% HES 130/0.4 with 6% HES 200/0.5 in patients undergoing orthopedic surgery and found a smaller decrease in Factor VIII in the group treated with 6% HES 130/0.4.
Perhaps, the lower molecular weight of 130,000 Da, the substitution degree of 0.4 and the C2:C4 ratio of 9:1 are not the only factors determining the influence on hemostasis. The contrasting findings of the in vivo and in vitrostudies probably result from a shorter plasma half-life of the new starch solution, which cannot be considered in vitro.
The Effect of the Combined Solutions on the Coagulation System
The effect of RL administered in combination with synthetic colloids has not been investigated. Earlier in vitrostudies investigated only individual substances, and previous in vivo studies infused synthetic colloids in combination with RL, but did not study control groups receiving only RL. Our data show that the combinations of RL with gelatin, 6% HES 130/0.4, or 6% HES 200/0.5 impair the coagulation system to a significantly lesser degree than each colloid administered alone. The combination of RL with gelatin did not differ from the combination of RL with 6% HES 130/0.4. In clinical practice, however, colloids are usually given in combination with RL. Our data confirm this practice and show that the coagulation system is significantly less impaired when infusing colloids combined with RL rather than colloid solutions alone.
There are no clinical or in vitrodata about the effect of the combination of different colloids available, although in clinical practice, once the maximal dose of HES has been reached, gelatin is frequently administered. Our suggestion was that different colloids, targeting the coagulation system at different points, probably produce a different effect on the coagulation system than the administration of just one colloid alone. Compared with the administration of 6% HES 130/0.4 alone, the combination of 6% HES 130/0.4 and gelatin produced a relevant advantage concerning the impairment of hemostasis. Testing 6% HES 200/0.5 with gelatin versus 6% HES 200/0.5 alone, we mea-sured a statistically significant shorter CFT and stronger MCF at 40% dilution.
In view of these results, we conclude that if the maximal dose of a median-weight HES has been given, the application of gelatin does not impair the coagulation system more than the administration of a median-weight HES alone. The administration of gelatin once the maximal dose of 6% HES 200/0.5 has been given, is probably better than the administration of 6% HES 200/0.5 alone. The clinical relevance of our results has to be elucidated in further studies.
It is difficult to extrapolate from our in vitro findings and apply our results to an in vivo situation, because the endothelial effects, the pharmacokinetics, and metabolism of these synthetic colloids are not included in this model. We nevertheless chose this model because it is not practicable to dilute patients’ circulating blood volume up to 60% without using blood products or coagulation factors, which would certainly blur possible differences between the different volume replacement regimes. Furthermore, extraneous factors, such as tissue damage, endothelial injury, and stress response, can be eliminated in an in vitro model.
The main finding of the present study was that, when testing individual substances, gelatin affects the coagulation system <6% HES 130/0.4 or 6% HES 200/0.5. The effect of the combination of RL and gelatin did not differ from that of the mixture of RL and 6% HES 130/0.4. Moreover, the combined administration of gelatin and 6% HES 200/0.5 or 6% HES 130/0.4 impaired hemostasis <6% HES 200/0.5 alone, as evidenced by ROTEG® analysis.
We believe that our results justify testing the clinical hypothesis that bleeding could be reduced by the selection of gelatin solutions rather than HES solutions, when larger volume infusions of colloid are required or the maximal dose of HES has already been administered in patient-care situations.
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Acknowledgments |
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The study was supported by the Lorenz-Boehler-Foundation.
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Footnotes |
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1 Calatzis AN, Fritzsche P, Calatzis AI, et al. An analysis of the correlation of the ROTEG coagulation analyzer and the Hellige Thrombelastograph D [abstract]. Ann Hematol 1996;72(Suppl I):P87.
2 Calatzis AN, Kling M, Sternberger A, et al. Pitfalls in the application of TEG during liver transplantation and ways to escape [abstract]. Ann Hematol 1995;70(Suppl I):P83.
3 Fritzsche P, Calatzis AL, Stemberger A, et al. The ROTEG-4 coagulation analyzer: technology and precision [abstract]. Ann Hematol 1998;76(Suppl I):A88.
4 Calatzis AN, Kling M, Calatzis AL, et al. Fast and specific coagulation monitoring through modified thrombelastography [abstract]. Ann Hematol 1996;72(Suppl I):P92.
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D. Fries, P. Innerhofer, C. Reif, W. Streif, A. Klingler, W. Schobersberger, C. Velik-Salchner, and B. Friesenecker The Effect of Fibrinogen Substitution on Reversal of Dilutional Coagulopathy: An In Vitro Model Anesth. Analg., February 1, 2006; 102(2): 347 - 351. [Abstract] [Full Text] [PDF]
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D. Fries, A. Krismer, A. Klingler, W. Streif, G. Klima, V. Wenzel, T. Haas, and P. Innerhofer Effect of fibrinogen on reversal of dilutional coagulopathy: a porcine model Br. J. Anaesth., August 1, 2005; 95(2): 172 - 177. [Abstract] [Full Text] [PDF]
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V. G. Nielsen, R. T. Lyerly III, and W. Q. Gurley The Effect of Dilution on Plasma Coagulation Kinetics Determined by Thrombelastography Is Dependent on Antithrombin Activity and Mode of Activation Anesth. Analg., December 1, 2004; 99(6): 1587 - 1592. [Abstract] [Full Text] [PDF]
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M. W. Dunser, D. R. Fries, W. Schobersberger, H. Ulmer, V. Wenzel, B. Friesenecker, W. R. Hasibeder, and A. J. Mayr Does Arginine Vasopressin Influence the Coagulation System in Advanced Vasodilatory Shock with Severe Multiorgan Dysfunction Syndrome? Anesth. Analg., July 1, 2004; 99(1): 201 - 206. [Abstract] [Full Text] [PDF]
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R Stephens and M Mythen Resuscitation fluids and hyperchloraemic metabolic acidosis Trauma, April 1, 2003; 5(2): 141 - 147. [Abstract] [PDF]
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P. Innerhofer, D. Fries, A. Klingler, W. Streif, K. F. J. Ng, C. C. K. Lam, and L. C. Chan In vivo effect of haemodilution with saline on coagulation Br. J. Anaesth., December 1, 2002; 89(6): 934 - 939. [Full Text] [PDF]
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P. Innerhofer, D. Fries, J. Margreiter, A. Klingler, G. Kuhbacher, B. Wachter, E. Oswald, E. Salner, B. Frischhut, and W. Schobersberger The Effects of Perioperatively Administered Colloids and Crystalloids on Primary Platelet-Mediated Hemostasis and Clot Formation Anesth. Analg., October 1, 2002; 95(4): 858 - 865. [Abstract] [Full Text] [PDF]
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