BICARBONATE Does BICARBONATE Correct Coagulation Function impaired by Acidosis in Swine ? The Journal of TRAUMA injury, infection and Critical Care Wenjun S. Martini, Ph D, Michael A. Dubick, PhD … … ACCEPTED FOR PUBLICATION FEB 8,2006 PRESENTOR : INT 黃曉禹

Abstract METHODS: 12 pigs by infusing 0.2 mol/L HCl to pH 7.1. LR to maintain a pH of 7.1 (A-LR, n= 6) or 0.3 mol/L bicarbonate to a pH of 7.4 (A-Bi, n= 6). 15 min after A-bi bicarbonate neutralization. Coagulation function was assessed by PT, PTT, thrombin generation,initial clot formation time (R), clotting rapidity (α), and clot strength(MA). RESULT: Reduced fibrinogen Platelet counts Thrombin generation clotting rapidity and MA Prolonged PT and PTT After pH neutralization, no reversal CONCLUSION: coagulopathy induced by acidosis can’t be reversed Objective: The effects of acidosis and bicarbonate neutralization on coagulation function were investigated in vivo.

Introduction ---why do this experiment ? Acidosis in trauma patients –High mortality Due to tissue hypoxia from massive hemorrhage and massive transfusion of stored blood.  Disruption in coagulation (PT & PTT prolonged) Study: ISS (Injury Severity Scores)=30 with 58 massively transfused patient  58% coagulopathy, if hypothermia & low SBP(<70mmHg)  98%

Acidosis in trauma patients –Cause of disruption in coagulation Hypothermia (reported)  hypothermia reversal may correct hypothermia associated coagulation defects. Thrombin – –detrimental effects of acidosis and hypothermia on thrombin generation kinetics in a swine model. –How about correct with pH neutralization??

Injury Severity Score The Injury Severity Score (ISS) is an anatomical scoring system that provides an overall score for patients with multiple injuries. Each injury is assigned an Abbreviated Injury Scale (AIS) score and is allocated to one of six body regions (Head, Face, Chest, Abdomen, Extremities (including Pelvis), External). Only the highest AIS score in each body region is used. The 3 most severely injured body regions have their score squared and added together to produce the ISS score.Abbreviated Injury Scale The ISS score takes values from 0 to 75. If an injury is assigned an AIS of 6 (unsurvivable injury), the ISS score is automatically assigned to 75. The ISS score is virtually the only anatomical scoring system in use and correlates slinearly with mortality, morbidity, hospital stay and other measures of severity. RegionInjury Description AISSquare Top Three Head & NeckCerebral Contusion39 FaceNo Injury0 ChestFlail Chest416 AbdomenMinor Contusion of Liver Complex Rupture Spleen ExtremityFractured femur3 ExternalNo Injury0 Injury Severity Score: 50

The Abbreviated Injury Scale (AIS) is an anatomical scoring system first introduced in Since this time it has been revised and updated against survival so that it now provides a reasonably accurrate was of ranking the severity of injury. The latest incarnation of the AIS score is the 1990 revision. The AIS is monitored by a scaling committee of the Association for the Advancement of Automotive Medicine. Injuries are ranked on a scale of 1 to 6, with 1 being minor, 5 severe and 6 an unsurvivable injury. This represents the 'threat to life' associated with an injury and is not meant to represent a comprehensive measure of severity. The AIS is not an injury scale, in that the difference between AIS1 and AIS2 is not the same as that between AIS4 and AIS5. There are many similarities between the AIS scale and the Organ Injury Scales of the American Association for the Surgery of Trauma. Organ Injury Scales AIS ScoreInjury 1Minor 2Moderate 3Serious 4Severe 5Critical 6Unsurvivable

Materials and Methods Protocol

Materials and Methods ~ 1 Materials –12 crossbred Yorkshire swine 33 kg +/- 1 kg≈ Overnight fast Preaneshetized with glycopyrrolate (0.1 mg/kg) and Telazol (6 mg/kg) Induced with 5% isoflurane in 100% oxygen and maintained 1%~3% isoflurane after intubation Right femoral artery and the right external jugular vein were cannulated for blood sampling and fluid infusion Arterial BT BP HR PH by XXXbrand

Materials and Methods ~ 2 Induce metabolic acidosis 0.2 mol/L HCL in LR solution 0.07 mL/KG/min for initial 60ml solution followed by increase to 0.14 mL/kg/min to reach pH 7.3, then 0.21 mL/kg/min to reach pH 7.25, then 0.28 mL/kg/min to reach pH 7.1 Divide 2 group –A-Bi infusion of sodium bicarbonate at the rate of 0.28 mL/kg/min to neutralize arterial pH to 7.4. after 15 min with stable PH

Materials and Methods ~ 3 Minimize coagulation effects from shear-induced platelet activation –25mm single use catheter made from Tygon tubing –Withdrawn from the catheter and the first 3 mL of blood withdrawn –Hct, Platelet count, blood chemistry, PT, PTT, ACT by XXXbrand

Materials and Methods ~ 4 Statistical analysis –Mixed model ANOVA with SAS statistical Approved by the Institutional Animal Care and Use Committee Guide for the Care and Use of Laboratory Animals, National Research Council, 1996

Results HR, MAP, BE, Hct … …  no significant change in acidosis induction pH, Na, K, CA++, Cl-, HCO3- Coagulation Profile –Fibrinogen, –platelet, –PT, PTT, ACT, –clotting rapidity, clot strength –thrombin generation

235±34 min15 min after stabilized

Conclusion -1 Infusion 0.2N HCL solution over nearly a 4 hr period –35% depletion in fibrinogen concentration –50% decrease in platelet count –50% inhibition in thrombin generation –Blood clotting time was prolonged and clot formation and strength were impaired

Conclusion -2 Lack of improvement while Infusion of bicarbonate neutralized pH to 7.4 –Based on previous observations: drug or resuscitation fluid may not be sufficient to restore normal coagulation function. –Specific clotting factor replacement may be necessary for the ultimate reversal of impaired coagulation associated with acidosis

Disscussion - OUTLINE Possible mechanisms of coagulopathy in acidosis –PT, PTT, Thrombin time, fibrinogen, total protein (albumin and fibrinogen) –Comparison with other studies Lactic acid vs hydrochloric acid Hemodilutional effects

Disscussion ~ possible mechanism-1 35% depletion in fibrinogen concentration –Infusion 0.2N HCL solution over nearly a 4 hr period Degradation or inhibit? –2-4% fibrinogen synthesis rate per hr (in swine)  degradation, irreversible –Without intervention, 10 hr for endogenous synthesis to replenish fibrinogen availability to normalize coagulation folowing acidosis even if there were no degradation

Total protein was only decreased about 10% - 15% during the infusion –Fibrinogen MW340,000 primarily confined in vascular pool, precursor in the coagulation process, T1/2= 3~4 day –Albumin MW 65,000 50% in vascular pool,, T1/2=16-18 days. Only 10% decrease in albumin concentration. –  different protein different vulnerable level??

35% depletion in fibrinogen concentration  significant degradation –Prospective study of 202 major torso trauma p’t Mckinley et al.. Coagulopathy remained uncorrected throughout a 24 hr ICU period –Possible need for fibrinogen supplementation

Disscussion ~ possible mechanism-2 50% decrease in platelet count –Unable to explain, further studies is needed 50% inhibition in thrombin generation –Acidosis depleted some coagulation substrates and inhibiting the thrombin generation burst –Bicarbonate prevented the return of normal thrombin generation PT, PTT prolong –Unable to define specific sites due to too many enzymes, factors and cofactors

Disscussion ~Comparison with other studies Coagulation & bicarbonate administration –Wong et al. Bicarbonate increased from 12 mEq/L blood to 37 mEq/L Thrombin time increased by 20% In acidotic patients(n=4), a 50% to 100% prolongation in PT and PTT occurred. –Our report shows that bicarbonate interferes with fibrin monomer assembly into fibrin polymer and inhibits thrombin production. –  MATCH!

Disscussion ~Lactic acid vs hydrochloric acid –Life threatening acidosis  lactate –hemolysis and high mortality

Disscussion ~Hemodilutional effects –1st portion: infusing 1.5L of 0.2N HCL in LR for 4 hrs no changes observed in fibrinogen concentration, platelet counts and coagulation function in the group –2 nd Portion A-Bi 0.9 L of bicarbonate was infusing Did not cause significant changes in plasma total protein, albumin and fibrinogen levels PT, PTT?? –Present study: At least 50% is required before a significant change in clotting parameters is observed Estimate 10% - 15% in this hemodilution effect

Thanks for your attention 黃曉禹