title: Plasma is the physiologic buffer of tissue plasminogen activator-mediated fibrinolysis: rationale for plasma-first resuscitation after life-threatening hemorrhage.
abstract: BACKGROUND
  Prehospital resuscitation with crystalloid exacerbates fibrinolysis, which is associated with high mortality. We hypothesized that plasma compared with crystalloid resuscitation prevents hyperfibrinolysis in a tissue plasminogen activator (tPA)-rich environment via preservation of proteins essential for regulation of fibrinolysis.
  
  
  METHODS
  Healthy individuals donated blood, which was assayed using a native (nonactivated) thrombelastography (TEG). Whole-blood was mixed with normal saline (NS) or platelet poor plasma (PPP) at progressive dilutions. Tissue plasminogen activator was added to promote a fibrinolytic environment. In a separate experiment, PPP was run through a 100 kDa filter and liquid remaining on top of the filter (TFP) and below the filter (BFP) was obtained. Whole blood was diluted by 50% with TFP, BFP, and NS and assayed with a tPA TEG challenge. The TFP and BFP were assayed for protein concentration and protein composition.
  
  
  RESULTS
  Normal saline and PPP dilution of whole blood without tPA did not affect clot lysis at 30 minutes (LY30) (NS Spearman's rho 0.300, p = 0.186 and PPP 0.294, p = 0.288). When tPA was added, NS dilution of whole blood increased LY30 in a percentage-dependent manner (0.844, p < 0.001), but did not significantly increase with PPP dilution (0.270, p = 0.202). The difference in LY30 from whole blood to diluted whole blood with PPP (mean change, -1.05, 95% CI, -9.42 to 7.33) was similar with TFP (1.23, 95% CI, -5.20 to 7.66, p = 0.992). However, both BFP (37.65, 95% CI 24.47 to 50.82, p = 0.001) and NS (47.36, 95% CI 34.3 to 60.45, p < 0.001) showed large increases in fibrinolysis compared with PPP.
  
  
  CONCLUSIONS
  Crystalloid and plasma dilution of whole blood does not increase fibrinolysis. However, NS dilution of whole blood increases susceptibility to tPA-mediated fibrinolysis. Plasma resuscitation, simulated by plasma dilution of whole blood, attenuates increased susceptibility to tPA-mediated fibrinolysis. The benefits of plasma resuscitation are mediated through preservation of plasma proteins.
authors.affiliation: Department of Surgery, University of Colorado, Denver, CO. Electronic address: hunter.moore@ucdenver.edu.
authors.forename: Hunter B
authors.initials: HB
authors.lastname: Moore
authors.affiliation: Department of Surgery, University of Colorado, Denver, CO; Denver Health Medical Center, Denver, CO.
authors.forename: Ernest E
authors.initials: EE
authors.lastname: Moore
authors.affiliation: Department of Surgery, University of Colorado, Denver, CO.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Gonzalez
authors.affiliation: Department of Surgery, University of Colorado, Denver, CO.
authors.forename: Gregory
authors.initials: G
authors.lastname: Wiener
authors.affiliation: Department of Surgery, University of Colorado, Denver, CO.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Chapman
authors.affiliation: Department of Surgery, University of Colorado, Denver, CO.
authors.forename: Monika
authors.initials: M
authors.lastname: Dzieciatkowska
authors.affiliation: Department of Surgery, University of Colorado, Denver, CO.
authors.forename: Angela
authors.initials: A
authors.lastname: Sauaia
authors.affiliation: Department of Surgery, University of Colorado, Denver, CO.
authors.forename: Anirban
authors.initials: A
authors.lastname: Banerjee
authors.affiliation: Department of Surgery, University of Colorado, Denver, CO.
authors.forename: Kirk C
authors.initials: KC
authors.lastname: Hansen
authors.affiliation: Department of Surgery, University of Colorado, Denver, CO; Bonfils Blood Center, Denver, CO.
authors.forename: Christopher
authors.initials: C
authors.lastname: Silliman
mesh_terms: D000328:Adult; D000368:Aged; D016913:Blood Component Transfusion; D000077324:Crystalloid Solutions; D005260:Female; D005342:Fibrinolysis / Q000187:drug effects*; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000494:pharmacology*; D006470:Hemorrhage / Q000628:therapy*; D006801:Humans; D066298:In Vitro Techniques; D007552:Isotonic Solutions / Q000008:administration & dosage / Q000494:pharmacology; D008297:Male; D008875:Middle Aged; D010949:Plasma; D012151:Resuscitation / Q000379:methods*; D012965:Sodium Chloride / Q000008:administration & dosage / Q000494:pharmacology; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000494:pharmacology*
chemical_list: D000077324:Crystalloid Solutions; D005343:Fibrinolytic Agents; D007552:Isotonic Solutions; D012965:Sodium Chloride; D010959:Tissue Plasminogen Activator
references.citation: Ann R Coll Surg Engl. 1967 Jul;41(1):51-4
references.pmid: 4951632
references.citation: N Engl J Med. 1994 Oct 27;331(17):1105-9
references.pmid: 7935634
references.citation: Surgery. 1965 Nov;58(5):851-6
references.pmid: 5845188
references.citation: Br J Anaesth. 2002 Apr;88(4):470-2
references.pmid: 12066719
references.citation: J Trauma Acute Care Surg. 2013 Dec;75(6):961-7; discussion 967
references.pmid: 24256667
references.citation: Rev Col Bras Cir. 2012 Jul-Aug;39(4):314-21
references.pmid: 22936231
references.citation: J Trauma Acute Care Surg. 2012 Aug;73(2):365-70; discussion 370
references.pmid: 22846941
references.citation: J Am Coll Surg. 2012 Oct;215(4):496-502
references.pmid: 22766227
references.citation: J Biol Chem. 1982 Mar 25;257(6):2912-9
references.pmid: 7199524
references.citation: J Trauma Acute Care Surg. 2013 May;74(5):1207-12; discussion 1212-4
references.pmid: 23609269
references.citation: J Trauma. 1992 Nov;33(5):749-53
references.pmid: 1464926
references.citation: Ann Surg. 2007 May;245(5):812-8
references.pmid: 17457176
references.citation: Thromb Res. 2014 Sep;134(3):652-8
references.pmid: 25086657
references.citation: J Thromb Haemost. 2007 Jul;5 Suppl 1:102-15
references.pmid: 17635716
references.citation: Surgery. 2014 Sep;156(3):570-7
references.pmid: 24962188
references.citation: J Thromb Haemost. 2010 Sep;8(9):2017-24
references.pmid: 20586921
references.citation: Shock. 2014 Jun;41(6):514-21
references.pmid: 24667610
references.citation: J Trauma Acute Care Surg. 2014 Dec;77(6):811-7; discussion 817
references.pmid: 25051384
references.citation: J Trauma Acute Care Surg. 2013 May;74(5):1223-9; discussion 1229-30
references.pmid: 23609271
references.citation: Blood Coagul Fibrinolysis. 2013 Jul;24(5):489-97
references.pmid: 23406662
references.citation: J Trauma. 2008 May;64(5):1211-7; discussion 1217
references.pmid: 18469643
references.citation: Ann Surg. 2010 Sep;252(3):434-42; discussion 443-4
references.pmid: 20739843
references.citation: J Thromb Haemost. 2011 Jul;9 Suppl 1:26-34
references.pmid: 21781239
references.citation: Semin Thromb Hemost. 2010 Nov;36(8):865-75
references.pmid: 21049387
references.citation: Shock. 2015 Jan;43(1):39-46
references.pmid: 25072794
references.citation: Clin Chem. 1958 Dec;4(6):452-61
references.pmid: 13608907
references.citation: Thromb Haemost. 2014 Mar 3;111(3):417-28
references.pmid: 24196490
references.citation: Cell Mol Life Sci. 2011 Mar;68(5):785-801
references.pmid: 21136135
references.citation: Biochem Biophys Res Commun. 2014 Jan 10;443(2):395-9
references.pmid: 24309108
references.citation: J Emerg Trauma Shock. 2013 Jul;6(3):171-5
references.pmid: 23960372
references.citation: J Trauma. 2009 Jul;67(1):125-31
references.pmid: 19590321