Abstract
BackgroundFast and effective treatment of hemorrhagic shock is one of the most important preclinical trauma care tasks e.g., in combat casualties in avoiding severe end-organ damage or death. In scenarios without immediate availability of blood products, alternate regimens of fluid resuscitation represent the only possibility of maintaining sufficient circulation and regaining adequate end-organ oxygen supply. However, the fluid choice alone may affect the extent of the bleeding by interfering with coagulation pathways. This study investigates the impact of hydroxyethyl starch (HES), gelatine-polysuccinate (GP) and balanced electrolyte solution (BES) as commonly used agents for fluid resuscitation on coagulation using a porcine hemorrhagic shock model.MethodsFollowing approval by the State and Institutional Animal Care Committee, life-threatening hemorrhagic shock was induced via arterial blood withdrawal in 24 anesthetized pigs. Isovolumetric fluid resuscitation with either HES, GP or BES (n = 3 × 8) was performed to compensate for the blood loss. Over four hours, hemodynamics, laboratory parameters and rotational thromboelastometry-derived coagulation were analyzed. As secondary endpoint the porcine values were compared to human blood.ResultsAll the agents used for fluid resuscitation significantly affected coagulation. We measured a restriction of laboratory parameters, clot development and clot firmness, particularly in HES- and GP-treated animals. Hemoglobin content dropped in all groups but showed a more pronounced decline in colloid-treated pigs. This effect was not maintained over the four-hour monitoring period.ConclusionHES, GP, and BEL sufficiently stabilized the macrocirculation, but significantly affected coagulation. These effects were most pronounced after colloid and particularly HES administration. Despite suitability for rapid hemodynamic stabilization, colloids have to be chosen with caution, because their molecular properties may affect coagulation directly and as a consequence of pronounced hemodilution. Our comparison of porcine and human coagulation showed increased coagulation activity in pig blood.
Highlights
Fast and effective treatment of hemorrhagic shock is one of the most important preclinical trauma care tasks e.g., in combat casualties in avoiding severe endorgan damage or death
In the GP group, one animal died during a tachyarrhythmia episode one hour after the fluid resuscitation
All values returned to the baseline level, with the exception of heart rate in the balanced electrolyte solution (BES) group (Table 1)
Summary
Fast and effective treatment of hemorrhagic shock is one of the most important preclinical trauma care tasks e.g., in combat casualties in avoiding severe endorgan damage or death. The instability that results from massive blood loss induces an undersupply of oxygen and can cause irreversible organ failure (Nielsen et al, 2014; Dubniks, Persson & Grande, 2009) To combat this problem, different regimens and guidelines focusing on fluid resuscitation have been established (Kozek-Langenecker et al, 2013; Spahn et al, 2019). In 2018 and 2019, the EMA re-permitted administration of HES for the management of acute blood loss-induced hypovolemia while pointing out several contraindications, including sepsis, severe coagulopathy and renal impairment or replacement therapy (Spahn et al, 2019; EMA, 2018) These recommendations are undermined by lack of alternative solutions and clinical scenarios that represent a grey zone between defined indications and prohibitions. Comparisons between HES and GP have shown similar detrimental effects, but only few studies have investigated these effects during hemorrhagic shock (Witt et al, 2012; Haas et al, 2008; Mittermayr et al, 2007)
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