The Journal of TRAUMA Injury, Infection, and Critical Care

Resuscitation With Normal Saline (NS) vs. Lactated Ringers (LR) Modulates Hypercoagulability and Leads to Increased Blood Loss in an Uncontrolled Hemorrhagic Shock Swine Model
Laszlo N. Kiraly, MD, Jerome A. Differding, MS, T. Miko Enomoto, MD, Rebecca S. Sawai, MD, Patrick J. Muller, MS, Brian Diggs, PhD, Brandon H. Tieu, MD, Michael S. Englehart, MD, Samantha Underwood, MS, Tracy T. Wiesberg, MD, and Martin A. Schreiber, MD
Background: Lactated ringers (LR) and normal saline (NS) are used interchangeably in many trauma centers. The purpose of this study was to compare the effects of LR and NS on coagulation in an uncontrolled hemorrhagic swine model. We hypothesized resuscitation with LR would produce hypercoagulability. Methods: There were 20 anesthetized swine (35 3 kg) that underwent central venous and arterial catheterization, celiotomy, and splenectomy. After splenectomy blinded study fluid equal to 3 mL per gram of splenic weight was administered. A grade V liver injury was made and animals bled without resuscitation for 30 minutes. Animals were resuscitated with the respective study fluid to, and maintained, at the preinjury MAP until study end. Prothrombin Time (PT), Partial Thromboplastin Time (PTT), and fibrinogen were collected at baseline (0) and study end (120). Thrombelastography was performed at 0and postinjury at 30, 60, 90, and 120. Results: There were no significant baseline group differences in R value, PT, PTT, and fibrinogen. There was no significant difference between baseline and 30 minutes R value with NS ( p 0.17). There was a significant R value reduction from baseline to 30 minutes with LR ( p 0.02). At 60 minutes, R value ( p 0.002) was shorter while alpha angle, maximum amplitude, and clotting index were higher ( p < 0.05) in the LR versus the NS group. R value, PT, and PTT were significantly decreased at study end in the LR group compared with the NS group ( p < 0.05). Overall blood loss was significantly higher in the NS versus LR group ( p 0.009). Conclusions: This data indicates that resuscitation with LR leads to greater hypercoagulability and less blood loss than resuscitation with NS in uncontrolled hemorrhagic shock. Key Words: Coagulation, Trauma, Thrombelastogram, Saline, Ringers.
J Trauma. 2006;61:57 65.

he choice of intravenous fluid for the resuscitation of hemorrhagic shock has been a source of ongoing controversy for over a century. Normal saline (NS) and lactated Ringers (LR) are treated as equivalent resuscitation fluids in many trauma systems. Numerous studies have examined differences in outcomes and parameters in patients receiving a saline solution versus a balanced salt solution. In vitro and in vivo experiments suggest that crystalloid resuscitation may lead to a hypercoagulable state.1 4 The majority of these trials have associated LR with a hypercoagulable state. A recent trial compared Hetastarch in a balanced salt solution, LR, and hetastarch in normal saline in terms of coagulation during surgery.4 The normal saline based hetastarch treated patients were hypocoagulable compared with
Submitted for publication December 20, 2005. Accepted for publication March 14, 2006. Copyright 2006 by Lippincott Williams & Wilkins, Inc. From the Oregon Health & Science University, Portland, Oregon. This work was supported in its entirety by US Army Medical Research Acquisition Activity Award# W81XWH-04-1-0104. Presented at the 19th Annual Meeting of the Eastern Association for the Surgery of Trauma, January 10 14, 2006, Orlando, Florida. Corresponding Author: Martin A. Schreiber, MD, FACS, Associate Professor of Surgery, Director of Surgical Critical Care, Trauma/Critical Care Section, Oregon Health & Science University, 3181 SW Sam Jackson Road L223A, Portland, OR 97239; email: schreibm@ohsu.edu. DOI: 10.1097/01.ta.0000220373.29743.69

baseline while the LR treated patients were hypercoagulable. The in vivo experiments have mainly focused on elective surgery patients.1,35 In vitro studies usually use blood from healthy volunteers diluted with a set amount of fluid. A study in an intact large animal trauma model has not been previously performed. Given the significant morbidity and mortality of both coagulopathic hemorrhage and thromboembolic disease in trauma patients, further investigation is warranted to assess the impact of resuscitation fluids on the coagulation system. Beyond the hypercoagulable state seen in the setting of LR resuscitation, the use of NS has been associated with a hyperchloremic acidosis that has the potential to affect coagulation. Waters et al. found that in patients undergoing abdominal aortic aneurysm repair, NS resuscitation resulted in the use of significantly more blood products.5 This suggests that NS may have a harmful effect on the coagulation system. The purpose of this study was to compare coagulation parameters after uncontrolled hemorrhage and resuscitation in an animal model and to determine the etiology of the differences seen between LR and NS. This model is intended to represent the prehospital or battlefield scenario. In this setting, surgical control has not been established and the treatment choices are limited to fluid resuscitation. We hypothesized that, in a swine grade V liver injury model, animals resuscitated with LR would become hypercoagulable compared with animals resuscitated 57

Volume 61 Number 1

The Journal of TRAUMA Injury, Infection, and Critical Care

with NS. This model offers an excellent reproduction of the massive resuscitation efforts commonly seen in the modern trauma setting. Given the complex interplay of fluid shifts, inflammatory mediators, and coagulation factors this model may offer a more realistic scenario as compared with previous in vivo and in vitro dilution studies. This rate is approximately one half the rate delivered by the Level I rapid infuser as the animals were approximately one half the weight of an average human. Resuscitation fluid was administered to achieve and maintain the baseline MAP for 90 minutes postinjury. Upon completion of the 2-hour study period, the abdomen was reopened and the secondary blood loss was determined by adding the volume of intra-abdominal blood to the weight of the intra-abdominal blood clots. After the completion of the study the animals were sacrificed by exsanguination. To ensure comparable injuries between the study groups, we removed the liver and identified the number of hepatic vessels injured. Blood specimens were collected at baseline and every 30 minutes until completion of the 2-hour study. Blood assays included lactate level, arterial blood gases, chemistry panel and hematocrit. Coagulation studies included partial thromboplastin time (PTT), prothrombin time (PT), and fibrinogen. A TEG analyzer (TEG) (Hemoscope Corporation, Niles, Ill.) was used as a test for overall coagulation. This test was performed immediately after blood was removed from the animal and kaolin activation was utilized. The TEG values were measured every 30 minutes. Thrombelastography has been documented to be a more sensitive measure of coagulation disorders as compared with standard coagulation measures.7 Previous studies have documented hypercoagulability in trauma patients using thrombelastography.8,9 Individual parameters of the thrombelastograms (Fig. 1) can detail the cause of coagulopathy. The R value or reaction time represents the time to onset of clot formation. Elongation of the R value signifies a deficiency in coagulation factors. The angle represents the rapidity of fibrin buildup and cross-linking. This value is affected by fibrinogen function and to a lesser extent, platelets. The K time is a measure of the speed to reach a certain level of clot strength. K is shortened by increased fibrinogen function and, to a lesser extent, by platelet function, and is prolonged by anticoagulants that affect both. The maximum amplitude (MA) measures the strength of the clot and is affected primarily by platelets but also by

MATERIALS AND METHODS

This was a randomized controlled trial using twenty female Yorkshire crossbred pigs. The pigs underwent a 16hour preoperative fast except for water ad libitum and were preanesthetized with an intramuscular injection of 8 mg/kg Telazol (Fort Dodge Animal Health, Fort Dodge, Ind.). They then underwent oro-tracheal intubation with a 7.0 mm or 7.5 mm endotracheal tube and were placed on mechanical ventilation. Respiratory rate was adjusted to keep pCO2 values between 40 to 50 mm Hg. Anesthesia was maintained using 2% isoflurane in 100% oxygen. An esophageal thermometer was inserted. Animal temperature was controlled utilizing external warming devices. Once the swine were anesthetized, left cervical cut downs were performed and polyethylene catheters were inserted into the common carotid artery and external jugular vein. The arterial catheter was used for continuous blood pressure monitoring and blood sampling. Mean arterial pressure (MAP) and heart rate (HR) were continuously recorded and averaged every 10 seconds using a digital data collection system with a blood pressure analyzer (DigiMed, Louisville, Ky.). The venous line was used for administration of the resuscitation fluids. The animals underwent a midline celiotomy, suprapubic Foley catheter placement, and splenectomy. Splenectomies are performed in swine hemorrhage models because of the spleens distensibility and the resultant variation in amounts of sequestered blood. The spleen was weighed and, based on randomization, either LR or NS solution was infused to replace three times the spleen weight. The abdomen was than closed with towel clamps. Following a 15-minute stabilization period, the abdomen was opened and residual peritoneal fluid was removed. Preweighed laparotomy pads were placed in both paracolic gutters and the pelvis to facilitate blood collection. A standardized grade V liver injury (injury to a central hepatic vein) was created with a specially designed clamp. The clamp was positioned in the middle of the liver, placing the right hepatic vein, the left hepatic vein, and the portal vein at risk for injury. This protocol is based upon our experience in previous studies of uncontrolled hemorrhagic shock using the grade V liver injury model.6 The time of injury was considered the start time of the two-hour study period. Following 30 minutes of uncontrolled hemorrhage, the initial blood loss, measured by wall suction and the preweighed laparotomy pads, was determined. The abdomen was then closed. We blindly randomized (using a random numbers table) the swine to receive either NS or LR resuscitation at 165 mL/min. 58

Fig. 1. Example of TEG tracing. R value or reaction time represents the time to onset of clot formation. The value represents the rapidity of fibrin buildup and cross-linking. The K time is a measure of the speed to reach a certain level of clot strength. The MA value is maximum amplitude and measures the strength of the clot.

July 2006

Resuscitation With NS vs. LR

fibrinogen. The Clotting Index (CI) is a composite score of coagulation taking into account all of the above values. This protocol was approved by the Institutional Animal Care and Use Committee at Oregon Health & Science University. This facility adheres to the National Institutes of Health guidelines for the use of laboratory animals. An independent samples t test was used to compare the means of continuous variables between the two groups. Statistical significance was defined as a p value 0.05. Values within a group were compared using a post hoc analysis of the variance (ANOVA). These values were calculated using SPSS version 13.0 software (SPSS Inc., Chicago, Ill.) and graphs were produced using Microsoft Excel 2003 (Microsoft Inc., Redmond, Wash.).

RESULTS
Ten animals were randomized to each group. One animal in the NS group died just before completion of the 2 hour study period. All other animals survived. Table 1 shows the mean initial weight, blood pressure, temperature, vessels injured, blood loss and fluid replacement compared between groups. Despite the fact that the number of vessels injured and initial blood loss were similar between groups, the NS group had greater blood loss after resuscitation and required more than twice the volume of resuscitation fluid to achieve and maintain the baseline blood pressure during the 90 minute resuscitation study period. The NS group was significantly more acidotic compared with the LR pigs after resuscitation. Figures 2 through 4 detail the trend of laboratory parameters. pH was significantly lower in the NS group 30 minutes after injury until the

Fig. 2. pH values at discrete time intervals after injury in NS and LR groups. *Indicates a significant difference (p 0.05) between groups at that time interval.

Table 1 Baseline and Postinjury Values. Comparison Between NS and LR Groups of Physiologic Parameters
Parameter Study Fluid Mean SE Statistical Significance

Survived Weight (kg) Starting Temp (C) Baseline MAP Veins injured Spleen replacement fluid (cc) EBL after injury per kg EBL after resuscitation per kg Total EBL per kg Fluids per kg

NS LR NS LR NS LR NS LR NS LR NS LR NS LR NS LR NS LR NS LR

9 10 33.6 1.0 35.6 0.9 37.3 0.6 37.9 0.2 70.4 2.7 68.6 3 1.8 0.25 1.5 0.22 627 52 612 33 23 2 19 2 12 2 51 34 3 24 2 331 38 148 20

0.343 0.165 0.356 0.66 0.382 0.811 0.102 0.014* 0.009* 0.001*

end of study. Interestingly, at this point of the study, the only difference in treatment between the two groups was the equivalent volumes of splenic replacement fluids. The bicarbonate value and base excess were significantly lower 60 minutes after injury and beyond. The LR group did show an elevation of lactate level compared with the NS group. The elevation of lactate in the LR group was not accompanied by acidosis and it probably reflects the load of Na lactate from the rapid infusion. Selected laboratory values are displayed in Table 2. The two groups had equivalent hematocrit values at the start of the study. By the end of the study, the NS group had a lower hematocrit. The partial thromboplastin time (PTT) and prothrombin time (PT) were both significantly greater in the NS group compared with the LR group. Fibrinogen was decreased in both groups compared with baseline. Figures 5 through 8 show the R value, alpha angle, MA, and CI of the two groups. All the parameters showed significant changes during the course of the study. At 60 minutes after injury and beyond, the R value and the alpha angle were significantly different in the LR group as compared with the NS group. At 30 minutes after injury and beyond the MA and CI were significantly higher in the LR group. By the end of the study all of the values in the groups were significantly different from baseline with the exception of the alpha angle in the NS group. These results indicate relative hypercoagulability in both groups but significantly more so in the LR group.

DISCUSSION
This study evaluated multiple measures of coagulation in a swine model of uncontrolled hemorrhage. There were sig59

* Signifies statistical significance with p 0.05.

Volume 61 Number 1

The Journal of TRAUMA Injury, Infection, and Critical Care

Fig. 3. HCO3 and Base Excess values at discrete time intervals after injury in NS and LR groups. *Indicates a significant difference (p 0.05) between groups at that time interval.

nificant differences between animals that received LR and NS in nearly every marker of coagulation measured. It is important to note that the saline group did not develop a significant hypocoagulable state in terms of the measured parameters. The more significant changes reflected a hypercoagulable state in the LR animals. There were multiple physiologic and chemical differences between the two groups. The NS group received a mean of 10.9 L of fluid compared with 5.2 L in the LR group. This indicates that the saline group may have had a relative coagulation disorder secondary to a dilutional coagulopathy. Theoretically, this should

have the most notable effect on the R value as it involves contact activation and fibrin formation. However, a previous in vitro study measured the coagulation effects of LR and hetastarch solutions by simple dilution. In vitro dilution of blood with LR up to 75% resulted in no significant effect on R time.10 There was a significant difference in several TEG parameters at the 30 minute interval. At this point in the study, the only difference between the two groups was the type of splenic replacement fluid. The actual volume of fluids was equivalent. This suggests that the coagulation changes are at

Fig. 4. Lactate values at discrete time intervals after injury in NS and LR groups. *Indicates a significant difference (p 0.05) between groups at that time interval.

60

July 2006

Resuscitation With NS vs. LR

model, resuscitation with NS results in a profound hyperchloremic acidosis.11 Chloride levels were not measured in this experiment. However, as described in Figure 4, lactate levels were not elevated in the NS group. The resultant acidosis likely accounts for the physiologic differences between groups. Acidosis decreases cardiac contractility, and decreases the effectiveness of circulating catecholamines. Subsequent trials in our laboratory that are not yet published have documented a profound vasodilation in NS resuscitated swine. It is likely that increased blood loss during resuscitation combined with systemic vasodilatation resulted in the high fluid requirements seen with the NS animals. Acidosis has been implicated as a contributor to ongoing bleeding in trauma patients.12 The overall mechanism has not been completely elucidated. An in vitro study documented a decrease in FVIIa and FVIIa tissue factor complex.13 Acidosis has been associated with coagulation changes in vivo as well.14 A recent in vivo model examined the independent contribution of acidosis to coagulopathy. The findings suggested that the acidosis caused a decrease in thrombin generation rates reflected as a decrease in the alpha angle of the TEG. The LR group did have a significantly higher alpha value compared with the NS group at 60 minutes. However, at this time point, the NS value was not significantly different from its baseline value. Given the large blood loss in both groups and the significantly higher volume of fluid given to the NS group, the more pronounced hypercoagulable state in the LR group may be affected by relative hemoconcentration. The difference in hematocrit between the LR and NS groups at 120 minutes was significant ( p 0.028). The difference in actual red

Table 2 Baseline and End Study Laboratories.

Comparison Between NS and LR Groups of Hematologic Laboratory Parameters Drawn at Discrete Time Points
Parameter Study Fluid Mean SE Statistical Significance

Baseline Hct HCT 120 min post injury Baseline PTT PTT 120 min post injury Baseline PT PT 120 min post injury Baseline Fibrinogen Fibrinogen 120 min post injury

NS LR NS LR NS LR NS LR NS LR NS LR NS LR NS LR

26.0 0.8 26.2 0.9 12.7 1.1 16.6 1.2 24.2 1.0 22.9 0.7 25.2 1.1 21.4 0.5 13.3 0.2 13.2 0.1 19.0 1.5 15.5 0.6 149.8 12.2 146.1 12.8 68.2 8.2 80.5 5.5

0.870 0.028*

0.314 0.004*

0.893 0.037*

0.838 0.219

Signifies statistical significance with p 0.05.

least partially explained by the chemical composition of LR versus NS. The acid base status of the groups was another area of significant difference. At 30 minutes, the mean pH of the NS group was significantly lower than the LR group. This difference progressively increased throughout the course of the study. Our laboratory has previously shown that, in this

Fig. 5. TEG R values at discrete time intervals after injury in NS and LR groups. *Indicates a significant difference (p 0.05) between groups at that time interval. #Indicates a significant difference from the baseline value (p 0.05). The shaded area indicates normal ranges.

Volume 61 Number 1

61

The Journal of TRAUMA Injury, Infection, and Critical Care

Fig. 6. TEG Alpha Angle values at discrete time intervals after injury in NS and LR groups. *Indicates a significant difference (p 0.05) between groups at that time interval. #Indicates a significant difference from the baseline value. (p 0.05) The shaded area indicates normal ranges.

blood cell concentration contributes to coagulation. Several studies have detailed red blood cell membrane effects on the coagulation cascade. Activation of factor IX by erythrocyte membranes may cause intrinsic coagulation.15 A third notable difference between the groups was the calcium level. Along with volume dilution, the nontrivial amount of calcium in LR most likely explains this difference. At study end, the LR group had a concentration of 1.34 versus 1.22 for the NS group. Calcium is an important cofactor in the coagulation cascade. Though this difference reached statistical significance, the actual clinical relevance of this decrease

is unclear. A recent study investigated coagulopathy and hypocalcemia in humans.16 Using citrated blood from healthy volunteers, various concentrations of calcium were added and TEGs were performed. Coagulopathy was only notable at concentrations less than 0.56 mmol/L. Given the small absolute difference, calcium likely does not account for the coagulation changes seen. The total measured blood loss was significantly higher in the NS group suggesting that the differences in coagulation seen were clinically relevant. There is limitation in this measurement as the total intra-abdominal fluid represents both

Fig. 7. TEG MA values at discrete time intervals after injury in NS and LR groups. *Indicates a significant difference (p 0.05) between groups at that time interval. #Indicates a significant difference from the baseline value. (p 0.05) The shaded area indicates normal ranges.

62

July 2006

Resuscitation With NS vs. LR

Fig. 8. TEG CI values at discrete time intervals after injury in NS and LR groups. *Indicates a significant difference (p 0.05) between groups at that time interval. #Indicates a significant difference from the baseline value. (p 0.05) The shaded area indicates normal ranges.

blood and ascites. The NS group presumably had more ascites secondary to higher volumes of crystalloid administered. The relative hypercoagulability seen in both animal groups is likely the result of significant tissue trauma. Following injury tissue factor is exposed, de-encrypted and released into the bloodstream. It then complexes with activated factor VII resulting in activation of factors IX and X.17 Additional mechanisms relate to an imbalance of procoagulant and anticoagulant factors. A study measuring extensive coagulation profiles in critically injured patients found a negative correlation of functional protein C with severity of injury.18 Further studies show a decrease in plasma antithrombin III in the setting of trauma.18,19 These mechanisms combined with post-traumatic inflammation lead to a hypercoagulable state that has been documented in trauma patients early after admission.8,9 We have previously shown, using TEG, that Grade V liver injury without resuscitation results in a hypercoagulable state that is not affected by resuscitation with LR.20 This suggests that the use of LR for resuscitation has minimal effects on the coagulation changes after trauma. Alternatively, NS appears to modulate the post-trauma hypercoagulability by a series of physiologic derangements including acidosis and increased volume requirements. Our study did have limitations in that the volume of fluid given was variable. However, the fluid was given with set resuscitation endpoints. In this way the physiology guided the resuscitation. This algorithm helped recreate the setting of a clinical trauma resuscitation. Therefore, the difference in volume reflects a more realistic scenario.

state seen after injury and LR resuscitation. This effect most likely relates to acidosis and may be contributed to by the increased volume of fluid given to NS animals. This study suggests that the choice of crystalloid resuscitation has significant effects on coagulation. Administration of LR during resuscitation appears to have no effect on the hypercoagulable state induced by trauma. This hypercoagulable state may reduce bleeding and be protective initially, but may lead to thromboembolic complications later in the course of trauma admission. Resuscitation with NS modulates hypercoagulability after trauma and results in increased fluid requirements. These changes are associated with increased blood loss after injury and uncontrolled hemorrhage.

REFERENCES
1. Bergmann H, Blauhut B, Brucke P, Necek S, Vinazzer H. Early influence of acute preoperative haemodilution with human albumin and ringers lactate on coagulation. Anaesthesist. 1976;25:175180. 2. Dailey SE, Dysart CB, et al. An in vitro study comparing the effects of Hextend, Hespan, normal saline, and lactated ringers solution on thrombelastography and the activated partial thromboplastin time. J Cardiothorac Vasc Anesth. 2005;19:358 336. 3. Ruttmann TG, James MF, Viljoen JF. Haemodilution induces a hypercoagulable state. Br J Anaesth. 1996;76:412 414. 4. Martin G, Bennett-Guerrero E, Wakeling H, et al. A prospective, randomized comparison of thromboelastographic coagulation profile in patients receiving lactated Ringers solution, 6% hetastarch in a balanced-saline vehicle, or 6% hetastarch in saline during major surgery. J Cardiothorac Vasc Anesth. 2002;16:441 446. 5. Waters JH, Gottlieb A, Schoenwald P, Popovich MJ, Sprung J, Nelson DR. Normal saline versus lactated Ringers solution for intraoperative fluid management in patients undergoing abdominal aortic aneurysm repair: an outcome study. Anesth Analg. 2001; 93:817 822. 6. Schreiber MA, Holcomb JB, et al. The effect of recombinant factor VIIa on noncoagulopathic pigs with grade V liver injuries. J Am Coll Surg. 2003;196:691 697.

CONCLUSION
In a swine model of uncontrolled hemorrhage, resuscitation with NS resulted in modulation of the hypercoagulable Volume 61 Number 1

63

The Journal of TRAUMA Injury, Infection, and Critical Care

7. Zuckerman L, Cohen E, Vagher JP, Woodward E, Caprini JA. Comparison of thrombelastography with common coagulation tests. Thromb Haemst. 1981;46:752756. Kaufmann CR, Dwyer KM, Crews JD, Dols SJ, Trask AL. Usefulness of thrombelastography in assessment of trauma patient coagulation. J Trauma. 1997;42:716 720. Schreiber MA, Differding J, Thorborg P, Mayberry JC, Mullins RJ. Hypercoagulability is most prevalent early after injury and in female patients. J Trauma. 2005;58:475 480. Roche AM, James MF, Grocott MP, Mythen MG. Coagulation effects of in vitro serial haemodilution with a balanced electrolyte hetastarch solution compared with a saline-based hetastarch solution and lactated Ringers solution. Anaesthesia. 2002;57:950 955. Todd SR, Malinoski D, Schreiber MA. Lactated Ringers is Superior to Normal Saline in Uncontrolled Hemorrhagic Shock. Shock. 2003; 19(suppl):169. Moore EE. Staged laparotomy for the hypothermia, acidosis, and coagulopathy syndrome. Am J Surg. 1996;172:40510. Meng ZH, Wolberg AS, Monroe DM 3rd, Hoffman M. The effect of temperature and pH on the activity of factor VIIa: implications for the efficacy of high-dose factor VIIa in hypothermic and acidotic patients. J Trauma. 2003;55:886 891. Martini WZ, Pusateri AE, Uscilowicz JM, Delgado AV, Holcomb JB. Independent contributions of hypothermia and acidosis to coagulopathy in swine. J Trauma. 2005;58:10021009. Iwata H, Kaibara M. Activation of factor IX by erythrocyte membranes causes intrinsic coagulation. Blood Coagulation and Fibrinolysis. 2002;13:489 496. James MF, Roche AM. Dose-response relationship between plasma ionized calcium concentration and thrombelastography. J Cardiothorac Vasc Anesth. 2004;18:581586. Eilertsen KE, Osterud B. Tissue factor (patho)physiology and cellular biology. Blood Coagul Fibrinolysis. 2004;15:521538. Engelman DT, Gabram SG, Allen L, Ens GE, Jacobs LM. Hypercoagulability following multiple trauma. World J Surg. 1996; 20:510. Owings JT, Bagley M, Gosselin R, Romac D, Disbrow E. Effect of critical injury on plasma antithrombin activity: low antithrombin levels are associated with thromboembolic complications. J Trauma. 1996;41:396 405. Todd SR, Malinoski D, Schreiber MA. Hextend attenuates the hypercoagulability following severe liver injury in swine. J Trauma. 2004;56:226.

8.

9.

10.

11.

12. 13.

14.

15.

16.

17. 18.

19.

20.

DISCUSSION
Dr. Stephen M. Cohn (San Antonio, Texas): In this investigation, the authors have expanded their work focusing on the effects of various resuscitation fluids upon changes in coagulation following trauma. In this experiment, pigs were resuscitated to baseline blood pressure with either lactated ringers or normal saline following 30 minutes of uncontrolled hemorrhage from a severe liver injury. The animals receiving lactated ringers developed a hypercoagulable state, noted by a reduction in PT, PTT, and TEG values. Swine infused with normal saline required much greater fluid volumes to achieve baseline vital signs and did not become hypercoagulable. I have a few questions for the authors. Why did the authors choose to resuscitate animals to baseline parameters, rather than, say, a mean pressure of 60? Resuscitation to lower target blood pressure would more closely replicate the 64

typical clinical scenario and might have impacted on outcome measures, such as the volume of fluid required, the degree of blood loss and the subsequent coagulopathy noted. What is the impact of the type of anesthesia administered on this animal hemorrhage model? Have the authors tried other methods of anesthesia with similar results? Who ran the TEG analysis? And how did hypothermia impact on the results? This is a very user-dependent test. In fact, thats, I think, one of the major reasons why we have not applied it clinically in the trauma scenario. Why did the normal saline group receive twice the volume of resuscitative fluid? Were these animals actually more severely injured or more ill at baseline? The volume of resuscitative fluid may have diluted out the effects of various coagulation factors as well as impacted on platelet aggregation. How can we be assured that the impact of fluid volume was not the primary factor causing differences in coagulation between lactated ringers and normal saline rather than the type of fluid itself? Another interesting question for the authors is what changes in coagulation would you expect to see over time in a hemorrhage model like this one? It would appear that becoming hypercoagulable after injury would lead to a survival advantage. Do you have survival data? We currently routinely use normal saline for the resuscitation of trauma patients in the setting of head injury. Do the authors think that normal saline is dangerous? Should we avoid this in clinical care? Dr. L. N. Kiraly (Portland, Oregon): In response to your first question, why we resuscitated to a MAP of 60, our previous models have resuscitated to a baseline blood pressure. We were varying one element of this model. However, the mean pressures of these animals were a MAP of 70, so we were not going to the point of extreme resuscitation. The pigs do have a variable baseline blood pressure. And we were trying to keep things consistent from that point. Next, in terms of anesthesia, we actually have developed a model, which was completed this summer, of a total IV anesthesia regimen and compared it to the isoflurane regimen. Preliminary results indicate that the isoflurane Does have a vaso dilatory response and results in a lower blood pressure. Next, who ran the TEGs? We had an overwhelming majority of the TEGs run by a skilled technician that has done hundreds of these TEGs. In terms of hypothermia, these animals were actively externally re-warmed to keep their temperature within a range of 36 to 38 degrees, so hypothermia was not an issue in these patients. The TEG machine can account for that by setting a different temperature if so desired. Next, why they required different volumes of fluid? We have done some subsequent analysis and found that the normal saline group does have a profound vasodilatory response, July 2006

Resuscitation With NS vs. LR

making it more difficult for them to be resuscitated to their baseline MAPs. In terms of the question of why is this alone responsible for the coagulation differences, as I mentioned, previous in vitro studies havent shown this from just a simple dilution of blood products with crystalloid fluid in terms of the TEG values that we found. Furthermore, another point is just with acidosis alone, a previous swine model by another group showed TEG changes similar to ours. That leads me to believe that acidosis is more responsible rather than just simple volume. The next question is, is this clinically relevant? Do we have survival data? We plan to expand our animal model to a survival model to really investigate how these animals will do in the days following a trauma like this. But the clinically relevant point to take from this study is the blood loss, which does seem to be increased in the normal saline group. Finally, in terms of head injury, based on this study, we see the normal saline animals required much more resuscitation fluid. They had increased bleeding and were more acidotic and made it difficult to maintain blood pressure. I think all these argue against using normal saline in the setting of head injuries based on this study. We have alternatives such as the judicious use of hypertonic saline or diuretics. But I have not seen evidence saying that the LR would be harmful in the setting of a head trauma. Dr. Michael F. Rotondo (Greenville, North Carolina): I have one question from the podium. Your acid base status, you sort of suggested that animals develop an acidosis, yet they were getting a lot of normal saline. Is this a hyperchloremic acidosis, or do you have any lactate levels to suggest what ideology this acidosis is? Dr. L. N. Kiraly: From this study, we didnt gather the chloride levels. We had a previous model that used normal saline and showed a similar acidosis, and it was clearly a hyperchloremic acidosis. Dr. Ken Proctor (Miami, Florida): Did you control PCO2? Dr. L. N. Kiraly: PCO2 was controlled within a range of 40 to 50, and we did that based on the ABGs we did every half hour. Dr. Ken Proctor: So why, then, as the Ph was falling in the normal saline group, didnt you hyperventilate? Dr. L. N. Kiraly: The method we used, we based our ventilatory maneuvers based on the PCO2, not the pH.

Volume 61 Number 1

65