Effects of colloid and crystalloid solutions on endogenous activation of fibrinolysis and resistance of polymerized fibrin to recombinant tissue plasminogen activator added ex vivo  M Mittermayr, W Streif, T Haas, D Fries, C Velik-Salchner, A Klingler, P Innerhofer  British Journal of Anaesthesia  Volume 100, Issue 3, Pages 307-314 (March 2008) DOI: 10.1093/bja/aem363 Copyright © 2008 British Journal of Anaesthesia Terms and Conditions

Fig 1 ROTEM® variables analysed in plasma samples are ‘CT’ (s), ‘MCF’ (mm), ‘LI30’ (%), ‘LOT’ (s), and ‘LT’ (s). CT values mainly depend on the concentration of coagulation factors and the presence of inhibitors and display initial thrombin generation and the formation of the first trace amounts of fibrin. MCF reflects the polymerization of fibrinogen/fibrin, which depends on fibrinogen concentration and activity of FXIII. LI30 is defined as the percentage of clot firmness remaining after 30 min in relation to maximum measured clot firmness. LOT is defined as the time needed for clot firmness to decrease by 15% of MCF, LT as the time needed for clot firmness to decrease by 90% of MCF. British Journal of Anaesthesia 2008 100, 307-314DOI: (10.1093/bja/aem363) Copyright © 2008 British Journal of Anaesthesia Terms and Conditions

Fig 2 Left side: measurement of (a) t-PA (normal range <10 ng ml−1), (b) PAI-1 (normal range 1–25 ng ml−1), and (c) calculated PAI:t-PA ratio, at baseline before induction of anaesthesia (A), 60 min later immediately before surgical incision (B), and then every 90 min (C–D) during administration of gelatin (GEL), hydroxyethyl starch (HES), or exclusively Ringer's lactate solution (RL). Right side: differences between the groups were analysed by comparing the calculated area under the curve minus baseline from time point A to D (AUC−BLA–D). Values are expressed as medians (min, max). British Journal of Anaesthesia 2008 100, 307-314DOI: (10.1093/bja/aem363) Copyright © 2008 British Journal of Anaesthesia Terms and Conditions

Fig 3 Left side: thrombelastographic variables of tissue factor-activated (EXTEM) ROTEM® assay performed in plasma samples: (a) CT (s) and (b) MCF (mm). Plasma samples were taken at baseline (undiluted), and after 240 min (diluted) [about 40% dilution with gelatin solution (GEL), hydroxyethyl starch (HES), or Ringer's lactate solution (RL)] and exposed to 0.1 µg r-tPA (+ r-tPA) or not (No r-tPA). Right side: differences between the groups were analysed by comparing changes in CT and MCF [differences between the diluted (+r-tPA−No r-tPA) and undiluted lysis effect (+r-tPA−No r-tPA)]. Values are expressed as medians (min, max). *P<0.05 when compared with Ringer's lactate solution. British Journal of Anaesthesia 2008 100, 307-314DOI: (10.1093/bja/aem363) Copyright © 2008 British Journal of Anaesthesia Terms and Conditions

Fig 4 Left side: thrombelastographic variables of tissue factor-activated (EXTEM) ROTEM assay performed in plasma samples: (a) LI30 (%), (b) LOT (s), and (c) LT (s). Plasma samples were taken at baseline (undiluted), and after 240 min (diluted) [about 40% dilution with gelatin solution (GEL), hydroxyethyl starch (HES), or Ringer's lactate solution (RL)] and exposed to 0.1 µg r-tPA (+r-tPA) or not (No r-tPA). Right side: differences between the groups were analysed by comparing changes in LI30, LOT, and LT [differences between the diluted lysis effect (+r-tPA−No r-tPA) and the undiluted lysis effect (+r-tPA−no r-tPA)]. Values are expressed as medians (min, max). *P<0.05 when compared with Ringer's lactate solution. British Journal of Anaesthesia 2008 100, 307-314DOI: (10.1093/bja/aem363) Copyright © 2008 British Journal of Anaesthesia Terms and Conditions

Fig 5 Representative graphs of modified thrombelastography analysis (ROTEM®) performed with diluted plasma samples obtained after 240 min (time point D) from patients who were given gelatin solution (GEL), hydroxyethyl starch (HES), or solely Ringer's lactate solution (RL). Left side: diluted control sample without r-tPA (diluted No r-tPA). Right side: in vitro activation of fibrinolysis by adding recombinant tissue plasminogen activator (diluted+r-tPA). MCF decreased significantly more when patients received gelatin or HES than when they were given Ringer's lactate solution (left side). Clots disintegrate faster in the gelatin and HES group than in the Ringer's lactate solution group when exposed to tissue plasminogen activator (right side) as indicated by a decrease in LI30, LOT, and LT in the thrombelastographic analysis. British Journal of Anaesthesia 2008 100, 307-314DOI: (10.1093/bja/aem363) Copyright © 2008 British Journal of Anaesthesia Terms and Conditions