Intravenous Fluids and Coagulation
Colloids and crystalloids are frequently use to restore intravascular volume. Both solutions interfere with the coagulation process in different ways. Increasing amounts of fluids result in dilutional coagulopathy. Artificial colloids exert additive effec
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Intravenous Fluids and Coagulation Herbert Schöchl, Christoph Schlimp, and Wolfgang Voelckel
9.1
Introduction
In hemorrhagic shock, intravascular hypovolemia is one of the key factors contributing to insufficient oxygen delivery and subsequent tissue hypoxemia. Thus, in order to restore tissue perfusion, restoration of intravascular volume is one of the main aims of shock therapy. Both crystalloid and colloid solutions are frequently used. Compared to colloids, higher volumes of crystalloids are required to exert an equal intravascular volume effect (Jacob et al. 2012). It is noteworthy that large quantities of crystalloids have significant side effects, such as tissue edema, diminished blood viscosity, and hemostatic alterations. Colloids provide larger increases in intravascular volume, resulting in faster hemodynamic stabilization. However, artificial colloids can also cause adverse effects such as anaphylactic reactions, impairment of renal function, and alteration of hemostasis, which is potentially associated with an increased tendency to bleed (Choi et al. 1999). Controversy regarding the optimal choice and composition of resuscitation fluids is ongoing. Randomized controlled trials (RCTs) have failed to prove that resuscitation with colloid solutions provides survival benefits compared to fluid therapy with crystalloids (Perel and Roberts 2012). The use of colloids is associated with an increased mortality compared to crystalloids in patients with severe sepsis and in trauma patients (Perner et al. 2012). This finding could be related to the negative effects of colloids on blood coagulation and platelet function
H. Schöchl (*) AUVA Trauma Center, Salzburg, Austria Ludwig Boltzmann Institute for experimental and clinical Traumatology, Viennna, Austria e-mail: [email protected] C. Schlimp Ludwig Boltzmann Institute for experimental and clinical Traumatology, Viennna, Austria W. Voelckel AUVA Trauma Center, Salzburg, Austria C.E. Marcucci, P. Schoettker (eds.), Perioperative Hemostasis, DOI 10.1007/978-3-642-55004-1_9, © Springer-Verlag Berlin Heidelberg 2015
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132 Table 9.1 Mechanisms potentially related to the effects of fluid therapy on hemostasis
H. Schöchl et al. Direct effects of hemodilution on (a) Coagulation factor activity (b) Inhibitors of the coagulation system (c) Platelet count Reduction of coagulation factors (a) Factor VIII (b) von Willebrand factor Diminished fibrin polymerization (a) Reduction in clot strength (b) Increased fibrinolysis Direct effects on platelet function (a) Coating (b) Intracellular signal transduction Changes in blood viscosity
Fig. 9.1 ROTEM® results from an in vitro model of 33 % hemodilution. Two ROTEM® tests were performed: an extrinsically activated test using tissue factor (EXTEM) and an extrinsically activated test without platelet component (FIBTEM). The most pronounced reduction in maximum clot firmness (MCF) was observed with 6 % HES 130/0.4. Dilution of whole blood with 5 % human albumin and 4 % gelatin produced similar reductions
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