Haemodilution-induced profibrinolytic state is mitigated by fresh-frozen plasma: implications for early haemostatic intervention in massive haemorrhage.
BACKGROUND
Fibrinolysis contributes to coagulopathy after major trauma and surgery. We hypothesized that progressive haemodilution is responsible, at least in part, for increased fibrinolytic tendency of blood clot.


METHODS
The study was performed in two parts. First, whole blood (WB) samples collected from six healthy, consented volunteers were diluted in vitro with either saline or fresh-frozen plasma (FFP) to 40% and 15% of baseline. We quantified factor levels related to coagulation and fibrinolysis, and measured endogenous thrombin generation in undiluted control plasma samples and in samples diluted with saline or FFP. Additionally, thromboelastometry was used to assess susceptibility to fibrinolysis after adding tissue plasminogen activator in undiluted WB samples and in samples diluted with saline before and after substitution of fibrinogen or FFP. Secondly, as a model of in vivo haemodilution, we evaluated the same parameters before and after operation in nine consented patients undergoing off-pump coronary artery bypass surgery.


RESULTS
The dilution with saline caused dose-dependent decreases in plasma levels of coagulation and antifibrinolytic factors, and in thrombin generation. In FFP-supplemented samples, factor levels and thrombin generation were maintained within normal ranges. Fibrinolytic tendency was significantly higher after haemodilution with saline independent of fibrinogen substitution compared with FFP. Similarly, increased tendency for fibrinolysis was also observed in the in vivo haemodilution.


CONCLUSIONS
We demonstrated in vitro and in vivo that progressive haemodilution decreases endogenous antifibrinolytic proteins including alpha(2)-antiplasmin and thrombin-activatable fibrinolysis inhibitor, resulting in increased fibrinolytic tendency. Therefore, early fluid replacement therapy with FFP might be advantageous after massive haemorrhage.
Department of Anesthesiology, Emory University School of Medicine, 1364 Clifton Road, NE, Atlanta, GA, USA.
D
D
Bolliger
F
F
Szlam
J H
JH
Levy
R J
RJ
Molinaro
K A
KA
Tanaka
D000328:Adult; D000368:Aged; D000933:Antifibrinolytic Agents / Q000097:blood; D025901:Carboxypeptidase B2 / Q000097:blood; D047549:Coronary Artery Bypass, Off-Pump; D005260:Female; D005342:Fibrinolysis / Q000187:drug effects / Q000502:physiology*; D006438:Hemodilution / Q000009:adverse effects*; D006488:Hemostasis, Surgical / Q000379:methods; D006801:Humans; D066298:In Vitro Techniques; D008297:Male; D008875:Middle Aged; D010949:Plasma; D012965:Sodium Chloride / Q000494:pharmacology; D013916:Thrombelastography / Q000379:methods; D013917:Thrombin / Q000096:biosynthesis; D010959:Tissue Plasminogen Activator / Q000494:pharmacology; D055815:Young Adult; D000979:alpha-2-Antiplasmin / Q000032:analysis
D000933:Antifibrinolytic Agents; D000979:alpha-2-Antiplasmin; D012965:Sodium Chloride; D025901:Carboxypeptidase B2; D013917:Thrombin; D010959:Tissue Plasminogen Activator