In Vitro impairment of whole blood coagulation and platelet function by hypertonic saline hydroxyethyl starch

Abstract

BackgroundHypertonic saline hydroxyethyl starch (HH) has been recommended for first line treatment of hemorrhagic shock. Its effects on coagulation are unclear. We studied in vitro effects of HH dilution on whole blood coagulation and platelet function. Furthermore 7.2% hypertonic saline, 6% hydroxyethylstarch (as ingredients of HH), and 0.9% saline solution (as control) were tested in comparable dilutions to estimate specific component effects of HH on coagulation.MethodsThe study was designed as experimental non-randomized comparative in vitro study. Following institutional review board approval and informed consent blood samples were taken from 10 healthy volunteers and diluted in vitro with either HH (HyperHaes®, Fresenius Kabi, Germany), hypertonic saline (HT, 7.2% NaCl), hydroxyethylstarch (HS, HAES6%, Fresenius Kabi, Germany) or NaCl 0.9% (ISO) in a proportion of 5%, 10%, 20% and 40%. Coagulation was studied in whole blood by rotation thrombelastometry (ROTEM) after thromboplastin activation without (ExTEM) and with inhibition of thrombocyte function by cytochalasin D (FibTEM), the latter was performed to determine fibrin polymerisation alone. Values are expressed as maximal clot firmness (MCF, [mm]) and clotting time (CT, [s]). Platelet aggregation was determined by impedance aggregrometry (Multiplate) after activation with thrombin receptor-activating peptide 6 (TRAP) and quantified by the area under the aggregation curve (AUC [aggregation units (AU)/min]). Scanning electron microscopy was performed to evaluate HyperHaes induced cell shape changes of thrombocytes.Statistics: 2-way ANOVA for repeated measurements, Bonferroni post hoc test, p < 0.01.ResultsDilution impaired whole blood coagulation and thrombocyte aggregation in all dilutions in a dose dependent fashion. In contrast to dilution with ISO and HS, respectively, dilution with HH as well as HT almost abolished coagulation (MCFExTEM from 57.3 ± 4.9 mm (native) to 1.7 ± 2.2 mm (HH 40% dilution; p < 0.0001) and to 6.6 ± 3.4 mm (HT 40% dilution; p < 0.0001) and thrombocyte aggregation (AUC from 1067 ± 234 AU/mm (native) to 14.5 ± 12.5 AU/mm (HH 40% dilution; p < 0.0001) and to 20.4 ± 10.4 AU/min (HT 40% dilution; p < 0.0001) without differences between HH and HT (MCF: p = 0.452; AUC: p = 0.449).ConclusionsHH impairs platelet function during in vitro dilution already at 5% dilution. Impairment of whole blood coagulation is significant after 10% dilution or more. This effect can be pinpointed to the platelet function impairing hypertonic saline component and to a lesser extend to fibrin polymerization inhibition by the colloid component or dilution effects.Accordingly, repeated administration and overdosage should be avoided.

The Complex Process of Haemostasis and Interactions due to Hyperosmotic Fluids

“…In both cases, induced disorders are mainly dependent on fibrinogen-fibrin interactions as demonstrated by ROTEM®. The results are consistent with those of previously published studies (12)(13)(14), although the new contribution is the combination of both osmotic solutions with starch currently used in current practice.…”

A Comparison of the Effects of 20% Mannitol and 3% NaCl on Coagulation Parameters In Vitro using ROTEM: A Prospective Randomized Crossover Study

“…We observed that the negative effect of 3% HS on functional fibrinogen--fibrin interaction was less than with 20% mannitol. All of the fluids that we have used in the study impair coagulation, depending on their molecular properties (especially the high osmolarity) and through haemodilution (12). These results indicated that whole-blood coagulation disorder induced by mannitol and HS is mainly dependent on the final fibrinogen--fibrin interaction, which results in a fibrin-poor clot.…”

“…In the present study, three different activators (InTEM, ExTEM and FibTEM) were used to examine the intrinsic and extrinsic coagulation pathways, platelet function and fibrinogen--fibrin interaction. Previous studies showed that HES, 20% mannitol and 3% HS caused coagulation impairment (7,11,12). When we searched the literature, we found two deficiencies:…”

Blood Loss and Massive Transfusion in Patients Undergoing Major Oncological Surgery: What Do We Know?

“…Metabolic acidemia as encountered during hemorrhagic shock and/or excessive resuscitation with saline solution may also have significant effects on the coagulation system. This phenomenon has been shown in experiments in which hydrochloric acid (HCl) added to blood obtained from patients and titrated to a pH of 7.0 caused inhibition of thrombin propagation and a decrease in the activity of the Xa/Va, which was observed as prolonged clotting times on standard coagulation tests and abnormal patterns on thromboelastography [28,29]. Finally, dilutional thrombocytopenia, especially after massive blood transfusion and excessive administration of isotonic crystalloid solutions, is a common cause of perioperative coagulopathy [30].…”