- Email: [email protected]
The effects of gynaecological surgery on coagulation activation, fibrinolysis and fibrinolytic inhibitor in patients with and without ketorolac infusion
Thmmbsis
Pergamon
Research.
Volume 79, Nos. 5/6. PD. 501-514 1995 Copyright 0 1995 Elsevier Science Ltd Printed in the USA. AR rights reserved 0049-3&a/95 $9.50 + .oo
THE EFFECTS OF GYNAECOLOGICAL SURGERY ON COAGULATION ACTIVATION, FIBRINOLYSIS AND FIBRINOLYTIC INHIBITOR IN PATIENTS WITH AND WITHOUT KETOROLAC INFUSION Stephen C. L. Koh, Department of Obstetrics and University Hospital, Singapore Hospital*,
H. L. Pud, Dicky H. B. Tay**, S. S. Ratnam Gynaecology, National University of Singapore, National 0511 and Department of Anaesthesia, Singapore General Kandang Kerbau Hospital**, Singapore.
(Received 16 December 1994 by Editor J. Swedenborg;
Abstract
reviseoYaccepted 11 July 1995)
The effects of gynaecological surgery on the fibrinolytic and inhibitor mechanisms were followed up for 24h post-operatively in patients receiving a single dose of ketorolac infusion (n= 18) as compared with those not receiving ketorolac infusion (n = 11). A pre-operative state of lower mean t-PA activity and higher PAI- levels with increased platelet activation than that reported in normal subjects were observed in both groups of patients. Increased t-PA activity upon anaesthetic induction together with a decreased level at 24h post-operation was seen in both groups. However, fibrinolytic ‘shut-down’ was not evident as significant increase in D-dimer levels was observed post-operatively, suggesting an enhanced lytic state concurrent with an enhanced activation of coagulation and diminished platelet activation although B-TG remained above the normal level; plasmin from this enhanced lytic state affects platelet adhesion and cleaves platelet glycoprotein Ib thus inhibit release reaction. Ketorolac infusion elicited a significant response in PAT-1 activity within 24h post-operation and this was not seen in the nonketorolac group in spite of the rising trend by 24h post-operation which did not achieve statistical significance. There were no statistical signifcant differences in blood loss and duration of surgery between the two groups of patients. Overall, both groups of patients showed similar haemostatic changes post-operatively for 24h, a longer duration of post-operative study would have revealed any subtle changes in the molecular markers of thrombosis which was not the objective of this study.
Haemostatic and fibrinolytic changes occurring intra- and post-operatively have been evaluated previously but the results were conflicting (l-4). Fibrinolysis which keeps the vascular compartment patent is regulated by the activities of both tissue plasminogen activator (t-PA) and plasminogen activator inhibitor (PAI-1). PAI- has been suggested to play a Key words: Gynaecological surgery, ketorolac, plasminogen activators and inhibitor (PAI-1) Correspondence to: Stephen C L Koh 501
502
EFFECTS OF NSAID IN SURGERY
Vol. 79, Nos. 516
central role in the regulation of fibrinolysis after trauma (S-6). Following surgery numerous haemostatic plugs are formed through the activation of endogenous haemostatic mechanisms in preventing excessive bleeding from the surgical wound and tibrinolysis maintaining vascular patency. Decreased fibrinolytic activity after major surgery has been reported (7-8) and the impairment of the fibrinolytic system has been associated with the development of post-operative deep vein thrombosis (3, 9, 10). Increased fibrinolysis has been observed intra-operatively (3) and attributed to release of t-PA from surgically damaged tissue (ll), and upon anaesthetic induction (12). Physiological “fibrinolytic shutdown” in the first post operative days has been reported (2, 8, 13), and implicated in the pathogenesis of postoperative venous thrombosis (14) but not supported by Rowbotham et al (15) who demonstrated substantial increase in cross-linked fibrin degradation product (XL-FDP) levels which occurred virtually in all patients suggesting that fibrinolysis was not “shutdown” postoperatively. XL-FDP reflects lytic activity at the fibrin surface more accurately than measurements of PAS and PAI- 1. A hypercoagulable state was observed 24h post-operation (12) and lower levels of PA compared to pre-operative stage were also noted by others (1, 2, 12, 16). Whether defective fibrinolysis is due to a decreased PA or elevated inhibitor levels has yet to be established (10, 17). Ketorolac tromethamine (Ketorolac) is an analgesic, non-steroidal anti-inflammatory agent and a cycle-oxygenase inhibitor. It inhibits the biosynthesis of prostaglandin in various animal models (18) resulting in inhibition of platelet release reaction and aggregation (19). In the management of acute post-operative pain, studies have shown that it achieves analgesia equal to that of pethidine and morphine (20-24). Ketorolac produced significant prolonged bleeding times (25-27) and the magnitude of change was similar to that reported previously for patients given aspirin (28-29). The effects of ketorolac on haemostasis during surgery must be considered when used perioperatively. The aim of the study was to investigate the effects of gynaecological surgery on fibrinolysis, ftbrinolytic inhibitor and coagulation activation in patients receiving a single intravenous dose of ketorolac compared with control patients not receiving ketorolac for surgery and their follow-up for 24h post-operation. MATERIALS
AND METHODS
Patients. The recruitment of patients to the study was carried out at the Kandang Kerbau Hospital for Women. Approval from Hospital Ethics Committee and written informed consent from all patients were obtained. All patients belonged to either ASA Class I or II. Pre-operative evaluation consisted of a thorough medical history, pre-operative physical examination and laboratory investigations which includes a complete blood count, urea, creatinine and electrolyte levels. The following patients were excluded from the study: patients with chronic liver or renal diseases, known or suspected malignancies, haemorrhagic diathesis, thrombocytopenia. Patients on anticoagulant therapy, aspirin or other NSAID, dipyridamole and other anti-platelet drugs were also excluded.
Ml. 79, Nos. 96
EFFECTS WNSAtD
IN SURGERY
503
Thirty-three patients scheduled for gynaecology surgery were recruited and comprised of 20 patients receiving 30 mg of intravenous ketorolac pre-operatively and 13 patients who did not receive ketorolac for comparison. Four patients (two each from ketorolac and non-ketorolac group) received blood transfusion within 24h period of study were left out from the final analysis. Three patients received blood transfusion within one and four hours from the start of operative procedure and one about 24h post operation. The mean age of patients in the ketorolac group was 42 + 9.8 yrs (n= 18) and ranged between 22 and 61 yrs; in the nonketorolac group it was mean 45 f 8.8yrs (n= 11) ranging between 24 and 59 years. Infusions and anaesthesiu. In the control group, 500 ml of 5% dextrose in normal saline was administered over 30 min whilst in the ketorolac group, 30 mg of ketorolac was added to the dextrose saline infusion before general anaesthesia was induced with thiopentone. Tracheal intubation was facilitated by succinylcholine. Anaesthesia was maintained with 70% nitrous oxide in 30% oxygen and 0.5 % isoflurane, and muscle paralysis maintained by either d-tubocurare or atracurium. Blood Collection. A clean venepuncture which served as the control blood sample from the antecubital vein was performed before infusion. An 18G venous cannula inserted into the dorsum vein for infusion was kept patent by flushing with 2 ml of heparinsed saline (201U heparin) after each blood sampling. Further blood samples were obtained 5 min, 2h, 4h, and 24h after infusion. All blood samples were collected using a two-syringe technique. The initial 3 ml sample was discarded and blood collected using plastic syringes were dispensed into cold plastic tubes containing 0.21M HEPES (Sigma) in 0.129M &i-sodium citrate (Merck). Nine parts of blood were mixed with one part HEPES-citrate anticoagulant. Mixing was done by inverting the tube several times and then kept in crushed ice. Extreme care was taken to avoid ex-vivo activation of the platelets in B-Thromboglobulin (B-TG) assays, blood was collected in the Diatube-HTM tubes (Stago, France) containing sodium citrate/citric acid mixtures (0.109M) and platelet aggregation inhibitors. The blood samples were immediately centrifuged at about 2000g for 15 min in a refrigerated centrifuge, the plasma separated for t-PA activity analysis and the remainder aliquoted and stored at -70°C until assayed.
Determinution
of Plusminogen
Activators (PAS) and PA-Znhibitor
(PAZ-l)
The functional activities of t-PA, PAI- and urokinase plasminogen activator (U-PA) were determined using chromogenic substrates as described previously (30-32). The ELISA kits for the measurement of t-PA, PAI- antigens were obtained from American Diagnostics Inc., New York, USA and u-PA from Monozyme, Sweden. Assay of Ddimer,
J-thromboglobulin
(j3-TG) and Thrombin Antithrombin
(TAT)-complex.
The AsserachromR D-dimer and R-TG kits were obtained from Stago, France. The assays are based on the sandwiched method of ELISA using monoclonal antibodies. The kits for TAT-complex assay were from Behring, Marburg, FRG.
504
EFFECTS OF NSAID IN SURGERY
Vol. 79, Nos. 5/6
Statist’cal Analysis Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS). One way Analysis of Variance (ANOVA), post hoc Student-Newman-Keuls test with significance level 0.050 were used. Log-transformed values for the parameters measured were used for further analysis. Unpaired Student’s t-test was used in the analysis for blood loss and duration of surgery. A P value of co.05 was considered statistically significant.
RESULTS The clinical diagnosis, type and duration of surgery including blood loss are shown in Tables I and II. The surgeons at the onset of operation did not know which patient receive ketorolac infusion. No statistical significant differences were seen for blood loss and duration of surgery between the two groups (Table II). The patients were given between 1 litre and 2.5 litres of crystolloidal fluid peri-operatively. Our laboratory normal reference ranges (& 2SD) from a cohort of more than 40 nonpregnant subjects together with the pre- and post-operative haemostatic parameters studied in patients receiving Ketorolac and those not receiving Ketorolac (non-Ketorolac) infusions are shown in Tables III to V.
TABLE
I
The Clinical Diagnosis and Type of Gynaecological Surgery in Patients Under Study. Ketorolac Diagnosis: Uterine Fibroid Ovarian Cyst Uterine Prolapse Type of Surgeiy: Total Hysterectomy (TH) THBSO Myomectomy Ovarian Cystectomy Myomectomy & Ov. Cyst VH & PFR
Non-Ketorolac
13 4 1
11
6 4 3 4
5 4 1 1
1
THBSO = Total Hysterectomy aad Bilateral Salpingo-Oophorectomy, VH & PFR = Vaginal Hysterectomy & Pelvic Floor Repair
Vol. 79, Nos. 516
EFFECTS OF NSAID IN SURGERY
TABLE
505
II
Duration of Surgery and Blood Loss Following Surgery in Patients Under Study. Ketorolac
Non-Ketorolac
P
Duration of Surgery: Mean (SD) min Range (min)
80.6 (26.9) (30 - 120)
82.3 (23.9) (45 - 135)
NS
Blood Loss: Mean (SD) ml Range (ml)
520 (313) (200 - 1170)
447 (246) (200 - 940)
NS
NS = not significant
Plasminogen
Activators and Inhibitor
PAZ-l
Non-Ketorolac group (Table III). There were statistical significant differences in t-PA activity (PC 0.001) and U-PA antigen (P< 0.05) levels in the non-ketorolac group when analysed by ANOVA using log-transformed values. Significant increase in t-PA activity was observed following anaesthesia induction (5 min) of mean 0.68 IU/ml as compared to preoperative mean of 0.34 III/ml; and a significant decline from the former level was seen even at 24h post-operation which was significantly below the preoperative level. U-PA antigen level showed significant decline from pre-operative stage of mean 0.51 rig/ml to 0.35 and 0.38 rig/ml at 4h and 24h post-operation respectively. No statistical significant differences were seen post-operatively for t-PA antigen, u-PA activity and PAI- level when using ANOVA. Ketorolac group (Table IV). Significant differences post-operatively were observed for t-PA activity (P
D-dimer and TAT-complex
levels
Non-KetoroZac Group (Table V). Significant differences in D-Dimer (PC 0.001) and TATcomplex (PC 0.05) levels were observed post-operatively. A gradual significant increase in D-dimer levels were observed from 2h and significantly raised to mean 1499 rig/ml at 24h
506
EFFECTS OF NSAID IN SURGERY
TABLE The Effects of Surgery on Plasminogen Patients Not Receiving Ketorolac Infusion Normal Females. Normal Reference Non-Ketoroiac t-PA (acti . 3 FJ? (I”’ Normal Range
Smin
2h
4h
24 h
P
0.34 0.26-0.45
0.%%4
0.29 0.26-0.32
O.l%:32
0.19 * 0.15-0.24
5.6%t3
6.5%31
6.7!?;.31
5.3z.46
5.4308
0.35 0.27-0.45
0.31 0.25-0.37
O.&Z34
0.28 0.23-0.32
0.2%!32
0.51 0.44 4.60
0.50 0.42-0.58
0.35 * 0.29-0.43
0.38 * 0.31-0.45
<0.05
o.LE!50
c 0.001
(0.25-1.10)
t-PA (an . en) Fp (aisP ml) Normal
JII
Activators and Plasminogen Activator Inhibitor (PA&l) (n=ll) and Our Laboratory Normal Reference Ranges from
Pre
0.63
Vol. 79, Nos. 5/6
7.0
Range
ns
(d 15.0) 0.76
ns
(< 1.50) u-PA (antigen) Mean (q/ml) Cl Normal Range
1.1 (0.1-2.0)
PAI-l(activit ) Mean (AU/m s) CI Normal Range PAI-l(aatigen) gem Wml) Normal
29.9 21.0-42.5
26.0 13.7-35.9
30.0 22.2-40.4
21.6 17.7-26.3
17.2 12.5-23.7
17.9 12.7-25.2
18.3 15.7-21.3
ns
14%.0
(4.0-18.0) 9.6
Range
19.8 16.6-23.7
ns
20%3.3
10.8
(< 20.0)
TABLE The Effects of Surgery on Plasminogen Receiving Ketorolac Infusion (n=lS). Pre Ketorolac t-PA (a&iv’
)
Activators
IV
and Plasminogen smin
Activator
2h
Inhibitor
@AI-l)
in Patients
24h
4h
P
< 0.001
0.29 0.24-0.38
EK.58
0.26 0.23-0.31
0.25 0.24-0.30
0.19 * 0.15-0.23
%3.5.41
z5.6.52
z7.7.24
z-7.77
k!Jd.75
0.42 0.32-0.56
0.27 0.22-0.32
0.34 0.24-0.46
0.27 * 0.19-0.37
K.28
0.60 0.51-0.71
0.52 0.44463
0.48 0.40-0.59
0.47 0.39-0.58
0.46 0.41-0.54
ns
PAI- (a&v. ) Mean (AU/m “K Cl
19.7 17.2-22.6
15.9 13.9-18.2
28.3 * 22.6-35.4
35.1 * 31.0-39.7
%1.9
PAIMean Cl
24.3 20.3-29.1
18.4 15.3-22.1
18.9 15.3-23.3
19.1 14.l?24.5
22.2 19.0-25.9
ns
Fiii”
(IUlm
“K
t-PA (anti en) I&em (n d ml) u-PA (activit d i!i= O”’
ns
)
u-PA (antigen) gfm Wml)
(antigen) (&ml)
*post hoc Student-Newman-ICeIds CI = 95% Confidence Jnterval,
-ot
test with tmt signitlcance signilicant
level 0.05 when conpared
<0.05
to pre-operativa
paiod,
in
Vol. 79, Nos. 516
507
EFFECTS OF NSAID IN SURGERY
TARLEV The Effects of Surgery on BTG, D-diier and TAT-complex in Patients Receiving (n=lS) and Not Receiving (nn=ll) Ketorolac Infusion and Our Laboratory Normal Reference Ranges from Normal Females. Normal Reference Non-Ketorolac BTG Mean (W/ml) CI Normal Range
23.9
Pre
5min
2h
4h
24h
228 202-256
213 154-296
252 214298
172 134221
154 115-206
-co.05
277 207-371
341 265440
%89
527 * 393-707
1499 * 942-2384
< 0.001
z-7.0
7.4-21.3 12.5 *
6.1-46.0 16.7 *
9.6-36.5 18.7 *
8.6-27.8 15.5 *
co.05
233 197-276
181 151-217
206 153-279
189 157-230
142 * 121-167
co.05
P
k 40)
D-dimer Mean (&ml) Cl Normal Range
(< 400)
TAT Mean &/I) CI Normal Range
(< 7.0)
152
3.0
Ketorolac PTG Mean (IUlmi) CI D-dimer PY
bp/ml)
229 190-276
228 171303
679 * 324-1421
763 * 366-1590
874 * 465-1644
TAT Mean Cl
t&l)
ik7.2
3.8-9.1 6.28
25.8 12.6-52.9 *
12.8 -* 49.0 25.0
18.9 * 12.6-28.4
<0.001
* post-hoc Student-Newman-Kueis CI = 95 % Coniidence Interval.
test with test significance
level 0.05 when compared
to pre-operative
period,
post-operation when compared to mean 277 rig/ml pre-operatively. TAT-complex levels were significantly raised during and at 24h post-operation when compared to pre-operative levels of mean 4.09 pglml. Significant decline in B-TG levels was observed from 227.5 W/ml preoperative level to 154.1 ‘IU/ml at 24h post-operation. Ketorolac group (Table V). Significant differences in D-TG (P
DISCUSSION The present study was undertaken to observe changes in plasma levels of fibrinolysis, fibrinolytic inhibitor and markers.of coagulation and platelet activation intra-operatively for 24h post-operation comparing the influence of ketorolac and non-ketorolac infusions on the haemostatic mechanisms studied.
EFFECTS OF NSAID IN SURGERY
Vol. 79, Nos. 5/6
Ketorolac is relatively free from the problems like nausea, vomiting and respiratory depression associated with the use of opiates. Being a potent cyclooxygenase inhibitor it is known to affect platelet function and interfere with haemostasis (18, 19). Haemostatic mechanisms are activated following surgery (33, 34) resulting in the formation of numerous haemostatic plugs to achieve haemostasis (35), and the fibrinolytic system to remove the plugs for vascular patency. Per&operative changes in fibrinolysis run a biphasic course with in&a-operative phase involving tibrinolysis activation and the post-operative phase fibrinolytic “shut-down” due to decrease post-operative t-PA activity levels have been reported (2, 8, 13, 36, 37). Decreased fibrinolytic activity and impairment of the fibrinolytic system have been associated with increased risk of deep vein thrombosis (3, 9, 10). In our study the non-ketorolac and ketorolac groups displayed increased t-PA activities intraoperatively upon anaesthesia induction which was similar to other studies (12, 38). This could also be due to the surgical trauma inducing an initial phase of enhanced fibrinolysis due to the release of t-PA from the endothelium and post-operative fibrinolytic ‘shut-down’ seen on the first post-operative day (5, 6). However, both groups displayed decreased t-PA activity of mean 0.19 IU/ml at 24h post-operation compared to pre-operative levels of mean 0.34 and 0.29 IU/ml in non-ketorolac and ketorolac groups respectively. t-PA antigen levels were not significantly altered by surgery which could not be explained. This finding is in contrast to the report of Katzel et al (38) who demonstrated increased antigen and activity levels and a fall after thoracic surgery which remained above the pre-operative level. The mean pre-operative t-PA activity level in both groups was lower than in normal female subjects of mean activity 0.63 IU/ml and as reported earlier (39). In the ketorolac group u-PA showed a significant decrease in activity at 4h and 24h postoperation whilst in the non-ketorolac group a decreased trend was observed but did not achieve statistical significance. Decrease trend in u-PA antigen level was observed but it was statistically significant only in the non-ketorolac group at 4h post-operation. u-PA is involved in tissue degradation, remodelling and cell migration (40), the decrease in u-PA postoperatively could be due to their role in surgical trauma in tissue repair thus depleting their level in the systemic circulation. The pre-operative PAI- mean levels in both groups were higher than that observed in our laboratory’s normal female reference range of mean 10.8 AU/ml activity and mean 9.6 rig/ml antigen levels (39). Increased trend in PAI- activity was seen in both groups but was only statistically significant in the ketorolac group post-operatively from 2h and 24h whilst the PAI- antigen levels remained unaltered. Increased PAI- levels have been reported on Day One after surgery (42), after general anaesthesia (38), due to decrease t-PA available for inhibition (41) and has also been suggested to be an acute phase reactant protein due to increase synthesis by the liver (5, 43) and their presence in platelets could have contributed to its level in the circulation. In this study, post-operative increase in PAI- activity levels in the ketorolac group could be the result of less free circulating t-PA available for inhibition. In the nonketorolac group an increasing post-operative trend in PAI- activity was observed but it did not reach statistical significance although decreasing trend in t-PA activity levels was similar with the ketorolac group. PAI- antigen, the latent form found in platelets did not show any
Vol. 79, Nos. 5/6
EFFECTS OF NSAID IN SURGERY
509
increase post-operatively and could be due to the effect of plasmin in an environment of enhanced lytic state inhibits platelet adhesion and cleaves platelet glycoprotein Ib (44) thus inhibiting the release reaction. Enhanced thrombin formation as indicated by raised TAT-complex levels was evident perioperatively and increased degradation of fibrin indicated by raised D-dimer levels postoperatively were observed in both groups. These observations indicate an on-going thrombin formation possibly resulting from surgical trauma enhancing increased fibrinolysis process in the degradation of formed fibrin resulting in a lytic state but does not indicate fibrinolytic ‘shut-down’ post-operatively although the t-PA activity level was significantly decreased 24h post-operation, a similar finding to that reported by others (15, 33, 38). Enhanced platelet activation was observed in both groups pre-operatively, the normal level for B-TG reported by the manufacturer and in our laboratory was I 40 IU/ml. A significant decrease was observed by 24h post-operation but the level remained above normal mean level. The decrease in B-TG levels post-operatively could also be due to the effects of fibrin exposure to plasmin resulting in a marked decrease in platelet adhesion (44) and cleavage of platelet glycoprotein Ib (45) inhibiting release reaction. The post-operative fall in t-PA activity has been suggested to indicate increased t-PA adsorption on fibrin stimulating increased fibrin degradation (40) and indicating fibrinolytic ‘shut-down’ by others (2, 5, 8, 6, 13). Increased PAI- levels may protect the tissue from excessive proteolysis or an acute phase reaction (46) and have been suggested to be high risk for DVT in orthopaedic surgery (47). We were not able to demonstrate any other coagulation abnormality except for a shortened reaction time in the non-ketorolac group when Thromboelastograph was used to assess haemostasis status (unpublished). Variable bleeding times from previous studies in patients receiving ketorolac remains within the normal range of less than 10 min with some individuals showing a marked prolongation. These has been considered to be of little clinical significance (25-27, 48). The bleeding time known to be a poor indicator of platelet function cannot be used reliably to predict the risk of haemorrhage (49). Moreover, in our study no significant differences were observed in patients receiving ketorolac in blood loss or duration of surgery compared to the non-ketorolac control group. In conclusion, both study groups displayed a lower mean t-PA activity and higher PAIlevels pre-operatively concurrent with a mean increase in platelet activation as evident by raised B-TG levels.
Similar haemostatic findings were seen in both the non-ketorolac and ketorolac groups in enhanced activation of coagulation during surgery, increased fibrinolysis upon anaesthesia induction and a decreased t-PA activity level at 24h post-operation. A mean decrease in u-PA activity was seen post-operatively in the ketorolac group concurrent with a mean decrease u-PA antigen in the non-ketorolac group. PAI- activity in the ketorolac group was significantly elevated 2h post-surgery even at 24h post-operation. Although t-PA activity was significantly decreased at 24h post-operation in both groups, fibrinolysis ‘shut-down’ was not
510
EFFECTS OF NSAID IN SURGERY
Vol. 79, Nos. 5l6
evident as D-dimer levels were significantly elevated reflecting increased lytic activity at the fibrin surface, a finding more accurate than do measurements of PA and PAI-1. A decreased B-TG post-operatively indicates the inhibition of further platelet activation by plasmin. No significant differences were seen for blood loss and duration of surgery in both groups studied. The study suggests that the post-operative changes seen may be the general physiological response against surgical trauma at least in abdominal surgery (35). In addition ketorolac infusion elicits a significant response in PAI- activity within 24h post-operation. This indicates an increase in free PAI- availability for t-PA inhibition to prevent excessive proteolysis in an environment of increased lytic activity. A longer duration of post-operative study may reveal any subtle changes in molecular markers of thrombosis which was not the objective of this study.
Acknowledgements The study was supported by the National Unviversity of Singapore, Department of Obstetrics and Gynaecology Research Fund. The expert technical assistance of MS Chua SE, Mr Yuen WK and MS Ng BL is acknowledged.
REFERENCES 1.
YGGE, J. Changes in blood coagulation and fibrinolysis period. Amer J Surg 119, 225 - 232, 1970.
during the postoperative
2.
MANSFIELD, A.O. Activation of fibrinolysis associated with surgery and venous thrombosis. Br J Surg 59, 754 - 775, 1972.
3.
GORDON-SMITH, I.C., HICKMAN, J.A., QUESNE, L.P. Postoperative fibrinolytic activity and deep vein thrombosis. Br J Surg 61, 213 - 218, 1974.
4.
REM, J., FEDDERSEN, C., BRANT, M.R., KEHLET, H. Postoperative changes in coagulation and fibrinolysis independent from neurogenic stimuli and adrenal hormones. Br J Surg 1981; 68, 229 - 233, 1981.
5.
KLUFT, C., VERHEIJEN, J.H., JIE, A.F.H., RIJKEN, D.C., PRESTON, F.E., SUE-LING, H.M., MANUCCI, P.M. The postoperative fibrinolytic shutdown: a rapidly reverting acute phase pattern for the fast acting inhibitor of tissue-type plasminogen activator after trauma. Stand J Clin Lab Invest 45, 605 - 610, 1985.
6.
D’ANGELO, A., KLUFT, C., VERHEIJEN, J.H., RIJKEN, D.C., MOZZI, E., MANUCCI, P.M. Fibrinolytic shutdown after surgery: impairment of the balance between tissue-type plasminogen activator and its specific inhibitor. Eur J Clin Invest 15, 308 - 312, 1985.
Vot. 79, Nos. 5t6
EFFECTS OF NSAED IN SURGERY
511
7.
MACINTYRE, I.M.C., WEBBER, R.G., CRISPIN, J.R., JONES, D.R.B., WOOD, J.K, ALLAN, N.C., PRESCOTT, R.J., RUCKLY, C.V. Plasma fibrinolysis and postoperative deep vein thrombosis. Br J Surg 63, 694 - 697, 1976.
8.
KNIGHT, M.T.N., DAWSON, R., MELROSE D.G. Fibrinolytic response to surgery. Labile and stable patterns and their relevance to post-operative deep vein thrombosis. Lancet 1, 370 -373, 1977.
9.
MELLBRING, G., DAHLGREN, S., REIZ, S., WIMAN, B. Fibrinolytic activity in plasma and deep vein thrombosis after major abdominal surgery. Thromb Res 32, 575 - 584, 1983.
10.
SUE-LING, H.M., JOHNSTON, D., VERHEIJEN, J.H., KLUFT, C., PHILIPS, P.R., DAVIES, J.A. Indicators of depressed fibrinolytic activity in pre-operative prediction of deep vein thrombosis. Br J Surg 74, 275 - 278, 1987.
11.
STRIBBE, J., KLUFT, C., BROMMER, E.J.P., GOMEZ, M., DEJONG, D.S., NAUTA, J. Enhanced fibrinolytic activity during cardiopulmonary bypass in open heart surgery in man is caused by extrinsic (tissue type) plasminogen activator. Eur J Clin Invest 14, 375 - 382, 1984.
12.
MELISSARI, E., SCULLY, M.F., PAES, T., KAKKAR, V.V. The influence of LMW heparin on the coagulation and tibrinolytic response to surgery. Throm Res 37, 115 - 126, 1985.
13.
ARANDA, A., PARAMO, J.A., ROCHA, E. Fibrinolytic activity in plasma after gynecological and urological surgery. Haemostasis 18, 129 - 134, 1988.
14.
ERIKSSON, B.I., ERIKSSON, E., GYZANDER, E., TEGER-NILSSON, A. C., RISBERG, B. Thrombosis after hip replacement. Relationship to the fibrinolytic system. Acta Ortho Stand 60, 159 - 163, 1989.
15.
ROWBOTHAM, B-J., WHITAKER, A.N., HARRISON, J., MURTAUGH, P., REASBECK, P., BOWIE, E.J.W. Measurement of crosslinked fibrin derivatives in patients undergoing abdominal surgery: use in the diagnosis of postoperative venous thrombosis. Blood Coag and Fibrin01 3, 25 - 31, 1992.
16.
BROZOVIC, M. Physiological Bull 33, 231 - 238, 1977.
17.
KLUFT, C., VERHEIJEN, J.H., COOPER, P., CHANG, G.T.G., JIE, A.F.H., BLAMEY, S., LOWE, G.D.O., FORBES, C.D., PRESTON, F.E. Post-operative changes in the activity in blood of extrinsic (tissue type) plasminogen activator and its fast acting inhibitor. Haemostasis 14: 41 (Abstract), 1984.
18.
ROOKS, W.J., TOMOLOUIS, A.J., MALONEY, SCHULER, M.E. The analgesic and anti-inflammatory
mechanisms in coagulation and fibrinolysis.
Br Med
P.J., WALLACH, M.B., profile of (+)d-benzoyl-1,
512
EFFECTS OF NSAID IN SURGERY
2-dihydro-3H-pyrrolol[ 684 - 690, 1982.
1, llpyrrole-1-carboxylicacid
Vol. 79, Nos. 546
@ES-37619). Agents Actions 12,
19.
MONCADA, S., VANE, J.R. Arachidonic acid metabolites and the interactions between platelets and blood vesel walls. N Eng J Med 300, 1142 - 1147, 1979.
20.
YEE, J.P., KOSHIRER, J.E., ALLBON, C., BROWN, C.R. Comparison of intramuscular ketorolac tromethamine and morphine sulfate for analgesia after major surgery. Pharmacotherapy 6, 253 - 261, 1986.
21.
O’HARA, D.A., FRAGEN, R.J., KINZER, M., PEMBERTON, D. Ketorolac tromethamine as compared with morphine sulfate for treatment of post-operative pain. Clin Pharmacol Ther 41, 556 - 561, 1987.
22.
GILLES, G.W.A., KENNY, G.N.C., BULLINGHAM, R.E.S., MCARDLE, C.S. The morphine sparing effects of ketorolac tromethamine. A study of a new, parental non-steroidal anti-inflammatory agent after abdominal surgery. Anaesthesia 42,727 731, 1987.
23.
BROWN, C.R., MOODIE, J.E., EVANS, S.A., CLARKE, P.J., ROTHERHAM, B.A., BYNUM, L. Efficacy of intramuscular ketorolac and meperidine in pain following major oral surgery. Clin Pharmacol Ther 43, 161, 1988.
24.
KINSELLA, J., MOFFAT, A.C., PATRICK, J.A., PRENTICE, J. W., MCARDLE, C.S., KENNY, G.N. C. Ketorolac thrometamol for postoperative analgesias after orthopaedic surgery. Br J Anaesth 69, 19 -22, 1992.
25.
ROE, R-L., BRUNNO, J.J., ELLIS, D.J. Effects of a new nonsteroidal antiinflammatory agent on platelet function in male and female subjects. Clin Pharmacol Ther 29, 277, 1981.
26.
CONRAD, K.A., FAGAN, T.C., MACKIE, M.J., MAYSHAN, P.V. Effects of ketorolac tromethamine on haemostasis in volunteers. Clin Pharmacol Ther 43, 542 546, 1988.
27.
SPOWART, K., GREER, LA., MCLAREN, M., LLOYD, J., BULLINGHAM, R.E.S., FORBES, C.D. Haemostatic effects of ketorolac with and without concomitant heparin in normal volunteers. Thromb Haemost 1988; 60: 382 - 386.
28.
SCHWARTZ, B.S., LEIS, L.A., JOHNSON, G.J. In vivo platelet retention in human bleeding time wounds. II Effects of aspirin ingestion. .I Lab Clin Med 94, 574 - 584, 1979.
29.
AMREIN, P.C., ELLMAN, L., HARRIS, W.H. Aspirin-induced prolongation bleeding time and perioperative blood loss. JAMA 245, 1825 - 1828, 1981.
of
Vol. 79, Nos. 516
513
EFFECTS OF NSAID IN SURGERY
30.
KOH, C.L.S., YUEN, R., VIEGAS, O.A.C., CHUA, S.E.,NG, B.L., SEN, D.K., RATNAM, S.S. A plasmin generation method for the determination of tissue plasminogen activator (t-PA) activity in blood. Immunol Cell Biol 67, 197 - 203, 1989.
31.
KOH, C.L.S., YUEN, R., VIEGAS, O.A.C., CHUA, S.E., NG, B.L., SEN, D.K., RATNAM, S.S. Plasma tissue plasminogen activator inhibitor (t-PAI) activity in normal subjects. Med Sci Res 17, 135 - 136, 1989.
32.
KOH, S.C.L., YUEN, R., VIEGAS, O.A.C., RATNAM, S.S. Plasma urokinase activity and antigen levels in normalmales, females and in late pregnancy. Med Sci Res 20, 601 - 602, 1992.
33.
KAMBAYASHI, J-I., SAKON, M., YOKOTA, M., SHIBA, E-I., KAWASAKI, T., MORI, Y. Activation of coagulation and fibrinolysis during surgery, analysed by molecular markers. Thromb Res 60, 157 - 167, 1990.
34.
JOHNSON, E.J., HARIMAN, H., HAMPTON, K.K., GRANT, P.J., DAVIES, J.A., PRENTICE, C.R.M. Fibrinolysis during major abdominal surgery. Fibrinolysis 4, 147 - 151, 1990.
35.
KANG, J., KAMBAYASHI, J., SAKON, M., TSUJINAKA,. T., MORI, Postoperative changes in haemostasis analysed by the serial determination fibrinopeptides and D-dimer. Jap J Surg 19, 262 - 268, 1989.
36.
MELLBRING,G., NILSSON, T. BERGSDORF, N., WALLEN, P. Tissue plasminogen activator concentration in major abdominal surgery. Relationship to postoperative deep vein thrombosis. Thromb Res 36, 331 - 334, 1984.
37.
PARAMO, J.A., ALFARO, M.J., ROCHA, E. Postoperative changes in the plasma level of tissue type plasminogen activator and its fast acting inhibitor. Thromb Haemost 54, 713 - 716, 1985.
38.
KATZEL, R., WIEDEMANN, B., KEUPER, H., BRETHNER, L. The effect of the anaesthesia procedure on intraoperative fibrinolysis activation and postoperative fibrinolysis shut-down. Fibrinolysis 8, 309 - 316, 1994.
39.
KOH, C.L.S., YUEN, R., VIEGAS,O.A.C., CHUA,S.E.,NG, B.L.,SEN, D.K., RATNAM, S.S. Plasminogen activators t-PA, u-PA and its inhibitor (PAI) in normal males and females. Thromb Haemost 66, 581 - 585, 1991.
40.
DANO, K., ANDREASEN, P.A., GRENDAHL-HANSEN, J. Plasminogen activators, tissue degradation and cancer. Adv Ca Res 44, 139 - 266, 1985.
41.
SORENSEN, J.V. Levels of fibrinolytic activators and inhibitors severe trauma. Blood Coag Fibrin01 5, 43 - 49, 1994.
T. of
in plasma after
ERECTS
514
OF NSAD lN SURGERY
voI.?9,Nos.?5/6
42.
ESTELLES, A., GILABERT, J., ESPANA, F., VILA, J., MARTINEZ, M, HENDL, S., AZNAR, J. Alterations in fibrinolytic and protein C pathways in gynaecological surgery; low molecular weight heparin prophylaxis. Haemostasis 24, 252 - 260, 1994.
43.
LOSKUTOFF, 1991.
44.
HAMAGUCHI, M., BUNCE, L.A., SPORN, L.A., FRANCIS, C.W. Plasmic degradation of fibrin rapidly decreases platelet adhesion and spreading. Blood 84, 1143 - 1150, 1994.
45.
ADELMAN, B., MICHELSON, A.D., LOSCALZO, HANDIN, R.I. Plasmin effect on platelet glycoprotein interactions. Blood 65, 32-40, 1985.
46.
KRUITHOF, E.K.O., NICOLOSO, G., BACHMANN, F. Plasminogen activator inhibitor 1: Development of a radioimmunoassay and observations on its plasma concentration during venous occlusion and after platelet aggregation. Blood 70, 1645 1653, 1987.
47.
E. Impaired fibrinolysis and postoperative ERIKSSON, B.I., ERIKSSON, thromboembolism in orthopaedic patients. Thromb Res 62, 55 - 64, 1991.
48.
GREER, I.A. Effects of ketorolac tromethamine 10 (part 2), 71s - 76S, 1990.
49.
RODGERS, R.P.C., LEVIN, J. A critical re-appraisal of the bleeding time. Semin Thromb Haemost 16, l-20, 1990.
D.J. Regulation of PAI-
gene expression. Fibrinolysis
5, 197 - 206,
J., GREENBERG, J., Ib-von Willebrand factor
on haemostasis. Pharmacotherapy
Pergamon
Research.
Volume 79, Nos. 5/6. PD. 501-514 1995 Copyright 0 1995 Elsevier Science Ltd Printed in the USA. AR rights reserved 0049-3&a/95 $9.50 + .oo
THE EFFECTS OF GYNAECOLOGICAL SURGERY ON COAGULATION ACTIVATION, FIBRINOLYSIS AND FIBRINOLYTIC INHIBITOR IN PATIENTS WITH AND WITHOUT KETOROLAC INFUSION Stephen C. L. Koh, Department of Obstetrics and University Hospital, Singapore Hospital*,
H. L. Pud, Dicky H. B. Tay**, S. S. Ratnam Gynaecology, National University of Singapore, National 0511 and Department of Anaesthesia, Singapore General Kandang Kerbau Hospital**, Singapore.
(Received 16 December 1994 by Editor J. Swedenborg;
Abstract
reviseoYaccepted 11 July 1995)
The effects of gynaecological surgery on the fibrinolytic and inhibitor mechanisms were followed up for 24h post-operatively in patients receiving a single dose of ketorolac infusion (n= 18) as compared with those not receiving ketorolac infusion (n = 11). A pre-operative state of lower mean t-PA activity and higher PAI- levels with increased platelet activation than that reported in normal subjects were observed in both groups of patients. Increased t-PA activity upon anaesthetic induction together with a decreased level at 24h post-operation was seen in both groups. However, fibrinolytic ‘shut-down’ was not evident as significant increase in D-dimer levels was observed post-operatively, suggesting an enhanced lytic state concurrent with an enhanced activation of coagulation and diminished platelet activation although B-TG remained above the normal level; plasmin from this enhanced lytic state affects platelet adhesion and cleaves platelet glycoprotein Ib thus inhibit release reaction. Ketorolac infusion elicited a significant response in PAT-1 activity within 24h post-operation and this was not seen in the nonketorolac group in spite of the rising trend by 24h post-operation which did not achieve statistical significance. There were no statistical signifcant differences in blood loss and duration of surgery between the two groups of patients. Overall, both groups of patients showed similar haemostatic changes post-operatively for 24h, a longer duration of post-operative study would have revealed any subtle changes in the molecular markers of thrombosis which was not the objective of this study.
Haemostatic and fibrinolytic changes occurring intra- and post-operatively have been evaluated previously but the results were conflicting (l-4). Fibrinolysis which keeps the vascular compartment patent is regulated by the activities of both tissue plasminogen activator (t-PA) and plasminogen activator inhibitor (PAI-1). PAI- has been suggested to play a Key words: Gynaecological surgery, ketorolac, plasminogen activators and inhibitor (PAI-1) Correspondence to: Stephen C L Koh 501
502
EFFECTS OF NSAID IN SURGERY
Vol. 79, Nos. 516
central role in the regulation of fibrinolysis after trauma (S-6). Following surgery numerous haemostatic plugs are formed through the activation of endogenous haemostatic mechanisms in preventing excessive bleeding from the surgical wound and tibrinolysis maintaining vascular patency. Decreased fibrinolytic activity after major surgery has been reported (7-8) and the impairment of the fibrinolytic system has been associated with the development of post-operative deep vein thrombosis (3, 9, 10). Increased fibrinolysis has been observed intra-operatively (3) and attributed to release of t-PA from surgically damaged tissue (ll), and upon anaesthetic induction (12). Physiological “fibrinolytic shutdown” in the first post operative days has been reported (2, 8, 13), and implicated in the pathogenesis of postoperative venous thrombosis (14) but not supported by Rowbotham et al (15) who demonstrated substantial increase in cross-linked fibrin degradation product (XL-FDP) levels which occurred virtually in all patients suggesting that fibrinolysis was not “shutdown” postoperatively. XL-FDP reflects lytic activity at the fibrin surface more accurately than measurements of PAS and PAI- 1. A hypercoagulable state was observed 24h post-operation (12) and lower levels of PA compared to pre-operative stage were also noted by others (1, 2, 12, 16). Whether defective fibrinolysis is due to a decreased PA or elevated inhibitor levels has yet to be established (10, 17). Ketorolac tromethamine (Ketorolac) is an analgesic, non-steroidal anti-inflammatory agent and a cycle-oxygenase inhibitor. It inhibits the biosynthesis of prostaglandin in various animal models (18) resulting in inhibition of platelet release reaction and aggregation (19). In the management of acute post-operative pain, studies have shown that it achieves analgesia equal to that of pethidine and morphine (20-24). Ketorolac produced significant prolonged bleeding times (25-27) and the magnitude of change was similar to that reported previously for patients given aspirin (28-29). The effects of ketorolac on haemostasis during surgery must be considered when used perioperatively. The aim of the study was to investigate the effects of gynaecological surgery on fibrinolysis, ftbrinolytic inhibitor and coagulation activation in patients receiving a single intravenous dose of ketorolac compared with control patients not receiving ketorolac for surgery and their follow-up for 24h post-operation. MATERIALS
AND METHODS
Patients. The recruitment of patients to the study was carried out at the Kandang Kerbau Hospital for Women. Approval from Hospital Ethics Committee and written informed consent from all patients were obtained. All patients belonged to either ASA Class I or II. Pre-operative evaluation consisted of a thorough medical history, pre-operative physical examination and laboratory investigations which includes a complete blood count, urea, creatinine and electrolyte levels. The following patients were excluded from the study: patients with chronic liver or renal diseases, known or suspected malignancies, haemorrhagic diathesis, thrombocytopenia. Patients on anticoagulant therapy, aspirin or other NSAID, dipyridamole and other anti-platelet drugs were also excluded.
Ml. 79, Nos. 96
EFFECTS WNSAtD
IN SURGERY
503
Thirty-three patients scheduled for gynaecology surgery were recruited and comprised of 20 patients receiving 30 mg of intravenous ketorolac pre-operatively and 13 patients who did not receive ketorolac for comparison. Four patients (two each from ketorolac and non-ketorolac group) received blood transfusion within 24h period of study were left out from the final analysis. Three patients received blood transfusion within one and four hours from the start of operative procedure and one about 24h post operation. The mean age of patients in the ketorolac group was 42 + 9.8 yrs (n= 18) and ranged between 22 and 61 yrs; in the nonketorolac group it was mean 45 f 8.8yrs (n= 11) ranging between 24 and 59 years. Infusions and anaesthesiu. In the control group, 500 ml of 5% dextrose in normal saline was administered over 30 min whilst in the ketorolac group, 30 mg of ketorolac was added to the dextrose saline infusion before general anaesthesia was induced with thiopentone. Tracheal intubation was facilitated by succinylcholine. Anaesthesia was maintained with 70% nitrous oxide in 30% oxygen and 0.5 % isoflurane, and muscle paralysis maintained by either d-tubocurare or atracurium. Blood Collection. A clean venepuncture which served as the control blood sample from the antecubital vein was performed before infusion. An 18G venous cannula inserted into the dorsum vein for infusion was kept patent by flushing with 2 ml of heparinsed saline (201U heparin) after each blood sampling. Further blood samples were obtained 5 min, 2h, 4h, and 24h after infusion. All blood samples were collected using a two-syringe technique. The initial 3 ml sample was discarded and blood collected using plastic syringes were dispensed into cold plastic tubes containing 0.21M HEPES (Sigma) in 0.129M &i-sodium citrate (Merck). Nine parts of blood were mixed with one part HEPES-citrate anticoagulant. Mixing was done by inverting the tube several times and then kept in crushed ice. Extreme care was taken to avoid ex-vivo activation of the platelets in B-Thromboglobulin (B-TG) assays, blood was collected in the Diatube-HTM tubes (Stago, France) containing sodium citrate/citric acid mixtures (0.109M) and platelet aggregation inhibitors. The blood samples were immediately centrifuged at about 2000g for 15 min in a refrigerated centrifuge, the plasma separated for t-PA activity analysis and the remainder aliquoted and stored at -70°C until assayed.
Determinution
of Plusminogen
Activators (PAS) and PA-Znhibitor
(PAZ-l)
The functional activities of t-PA, PAI- and urokinase plasminogen activator (U-PA) were determined using chromogenic substrates as described previously (30-32). The ELISA kits for the measurement of t-PA, PAI- antigens were obtained from American Diagnostics Inc., New York, USA and u-PA from Monozyme, Sweden. Assay of Ddimer,
J-thromboglobulin
(j3-TG) and Thrombin Antithrombin
(TAT)-complex.
The AsserachromR D-dimer and R-TG kits were obtained from Stago, France. The assays are based on the sandwiched method of ELISA using monoclonal antibodies. The kits for TAT-complex assay were from Behring, Marburg, FRG.
504
EFFECTS OF NSAID IN SURGERY
Vol. 79, Nos. 5/6
Statist’cal Analysis Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS). One way Analysis of Variance (ANOVA), post hoc Student-Newman-Keuls test with significance level 0.050 were used. Log-transformed values for the parameters measured were used for further analysis. Unpaired Student’s t-test was used in the analysis for blood loss and duration of surgery. A P value of co.05 was considered statistically significant.
RESULTS The clinical diagnosis, type and duration of surgery including blood loss are shown in Tables I and II. The surgeons at the onset of operation did not know which patient receive ketorolac infusion. No statistical significant differences were seen for blood loss and duration of surgery between the two groups (Table II). The patients were given between 1 litre and 2.5 litres of crystolloidal fluid peri-operatively. Our laboratory normal reference ranges (& 2SD) from a cohort of more than 40 nonpregnant subjects together with the pre- and post-operative haemostatic parameters studied in patients receiving Ketorolac and those not receiving Ketorolac (non-Ketorolac) infusions are shown in Tables III to V.
TABLE
I
The Clinical Diagnosis and Type of Gynaecological Surgery in Patients Under Study. Ketorolac Diagnosis: Uterine Fibroid Ovarian Cyst Uterine Prolapse Type of Surgeiy: Total Hysterectomy (TH) THBSO Myomectomy Ovarian Cystectomy Myomectomy & Ov. Cyst VH & PFR
Non-Ketorolac
13 4 1
11
6 4 3 4
5 4 1 1
1
THBSO = Total Hysterectomy aad Bilateral Salpingo-Oophorectomy, VH & PFR = Vaginal Hysterectomy & Pelvic Floor Repair
Vol. 79, Nos. 516
EFFECTS OF NSAID IN SURGERY
TABLE
505
II
Duration of Surgery and Blood Loss Following Surgery in Patients Under Study. Ketorolac
Non-Ketorolac
P
Duration of Surgery: Mean (SD) min Range (min)
80.6 (26.9) (30 - 120)
82.3 (23.9) (45 - 135)
NS
Blood Loss: Mean (SD) ml Range (ml)
520 (313) (200 - 1170)
447 (246) (200 - 940)
NS
NS = not significant
Plasminogen
Activators and Inhibitor
PAZ-l
Non-Ketorolac group (Table III). There were statistical significant differences in t-PA activity (PC 0.001) and U-PA antigen (P< 0.05) levels in the non-ketorolac group when analysed by ANOVA using log-transformed values. Significant increase in t-PA activity was observed following anaesthesia induction (5 min) of mean 0.68 IU/ml as compared to preoperative mean of 0.34 III/ml; and a significant decline from the former level was seen even at 24h post-operation which was significantly below the preoperative level. U-PA antigen level showed significant decline from pre-operative stage of mean 0.51 rig/ml to 0.35 and 0.38 rig/ml at 4h and 24h post-operation respectively. No statistical significant differences were seen post-operatively for t-PA antigen, u-PA activity and PAI- level when using ANOVA. Ketorolac group (Table IV). Significant differences post-operatively were observed for t-PA activity (P
D-dimer and TAT-complex
levels
Non-KetoroZac Group (Table V). Significant differences in D-Dimer (PC 0.001) and TATcomplex (PC 0.05) levels were observed post-operatively. A gradual significant increase in D-dimer levels were observed from 2h and significantly raised to mean 1499 rig/ml at 24h
506
EFFECTS OF NSAID IN SURGERY
TABLE The Effects of Surgery on Plasminogen Patients Not Receiving Ketorolac Infusion Normal Females. Normal Reference Non-Ketoroiac t-PA (acti . 3 FJ? (I”’ Normal Range
Smin
2h
4h
24 h
P
0.34 0.26-0.45
0.%%4
0.29 0.26-0.32
O.l%:32
0.19 * 0.15-0.24
5.6%t3
6.5%31
6.7!?;.31
5.3z.46
5.4308
0.35 0.27-0.45
0.31 0.25-0.37
O.&Z34
0.28 0.23-0.32
0.2%!32
0.51 0.44 4.60
0.50 0.42-0.58
0.35 * 0.29-0.43
0.38 * 0.31-0.45
<0.05
o.LE!50
c 0.001
(0.25-1.10)
t-PA (an . en) Fp (aisP ml) Normal
JII
Activators and Plasminogen Activator Inhibitor (PA&l) (n=ll) and Our Laboratory Normal Reference Ranges from
Pre
0.63
Vol. 79, Nos. 5/6
7.0
Range
ns
(d 15.0) 0.76
ns
(< 1.50) u-PA (antigen) Mean (q/ml) Cl Normal Range
1.1 (0.1-2.0)
PAI-l(activit ) Mean (AU/m s) CI Normal Range PAI-l(aatigen) gem Wml) Normal
29.9 21.0-42.5
26.0 13.7-35.9
30.0 22.2-40.4
21.6 17.7-26.3
17.2 12.5-23.7
17.9 12.7-25.2
18.3 15.7-21.3
ns
14%.0
(4.0-18.0) 9.6
Range
19.8 16.6-23.7
ns
20%3.3
10.8
(< 20.0)
TABLE The Effects of Surgery on Plasminogen Receiving Ketorolac Infusion (n=lS). Pre Ketorolac t-PA (a&iv’
)
Activators
IV
and Plasminogen smin
Activator
2h
Inhibitor
@AI-l)
in Patients
24h
4h
P
< 0.001
0.29 0.24-0.38
EK.58
0.26 0.23-0.31
0.25 0.24-0.30
0.19 * 0.15-0.23
%3.5.41
z5.6.52
z7.7.24
z-7.77
k!Jd.75
0.42 0.32-0.56
0.27 0.22-0.32
0.34 0.24-0.46
0.27 * 0.19-0.37
K.28
0.60 0.51-0.71
0.52 0.44463
0.48 0.40-0.59
0.47 0.39-0.58
0.46 0.41-0.54
ns
PAI- (a&v. ) Mean (AU/m “K Cl
19.7 17.2-22.6
15.9 13.9-18.2
28.3 * 22.6-35.4
35.1 * 31.0-39.7
%1.9
PAIMean Cl
24.3 20.3-29.1
18.4 15.3-22.1
18.9 15.3-23.3
19.1 14.l?24.5
22.2 19.0-25.9
ns
Fiii”
(IUlm
“K
t-PA (anti en) I&em (n d ml) u-PA (activit d i!i= O”’
ns
)
u-PA (antigen) gfm Wml)
(antigen) (&ml)
*post hoc Student-Newman-ICeIds CI = 95% Confidence Jnterval,
-ot
test with tmt signitlcance signilicant
level 0.05 when conpared
<0.05
to pre-operativa
paiod,
in
Vol. 79, Nos. 516
507
EFFECTS OF NSAID IN SURGERY
TARLEV The Effects of Surgery on BTG, D-diier and TAT-complex in Patients Receiving (n=lS) and Not Receiving (nn=ll) Ketorolac Infusion and Our Laboratory Normal Reference Ranges from Normal Females. Normal Reference Non-Ketorolac BTG Mean (W/ml) CI Normal Range
23.9
Pre
5min
2h
4h
24h
228 202-256
213 154-296
252 214298
172 134221
154 115-206
-co.05
277 207-371
341 265440
%89
527 * 393-707
1499 * 942-2384
< 0.001
z-7.0
7.4-21.3 12.5 *
6.1-46.0 16.7 *
9.6-36.5 18.7 *
8.6-27.8 15.5 *
co.05
233 197-276
181 151-217
206 153-279
189 157-230
142 * 121-167
co.05
P
k 40)
D-dimer Mean (&ml) Cl Normal Range
(< 400)
TAT Mean &/I) CI Normal Range
(< 7.0)
152
3.0
Ketorolac PTG Mean (IUlmi) CI D-dimer PY
bp/ml)
229 190-276
228 171303
679 * 324-1421
763 * 366-1590
874 * 465-1644
TAT Mean Cl
t&l)
ik7.2
3.8-9.1 6.28
25.8 12.6-52.9 *
12.8 -* 49.0 25.0
18.9 * 12.6-28.4
<0.001
* post-hoc Student-Newman-Kueis CI = 95 % Coniidence Interval.
test with test significance
level 0.05 when compared
to pre-operative
period,
post-operation when compared to mean 277 rig/ml pre-operatively. TAT-complex levels were significantly raised during and at 24h post-operation when compared to pre-operative levels of mean 4.09 pglml. Significant decline in B-TG levels was observed from 227.5 W/ml preoperative level to 154.1 ‘IU/ml at 24h post-operation. Ketorolac group (Table V). Significant differences in D-TG (P
DISCUSSION The present study was undertaken to observe changes in plasma levels of fibrinolysis, fibrinolytic inhibitor and markers.of coagulation and platelet activation intra-operatively for 24h post-operation comparing the influence of ketorolac and non-ketorolac infusions on the haemostatic mechanisms studied.
EFFECTS OF NSAID IN SURGERY
Vol. 79, Nos. 5/6
Ketorolac is relatively free from the problems like nausea, vomiting and respiratory depression associated with the use of opiates. Being a potent cyclooxygenase inhibitor it is known to affect platelet function and interfere with haemostasis (18, 19). Haemostatic mechanisms are activated following surgery (33, 34) resulting in the formation of numerous haemostatic plugs to achieve haemostasis (35), and the fibrinolytic system to remove the plugs for vascular patency. Per&operative changes in fibrinolysis run a biphasic course with in&a-operative phase involving tibrinolysis activation and the post-operative phase fibrinolytic “shut-down” due to decrease post-operative t-PA activity levels have been reported (2, 8, 13, 36, 37). Decreased fibrinolytic activity and impairment of the fibrinolytic system have been associated with increased risk of deep vein thrombosis (3, 9, 10). In our study the non-ketorolac and ketorolac groups displayed increased t-PA activities intraoperatively upon anaesthesia induction which was similar to other studies (12, 38). This could also be due to the surgical trauma inducing an initial phase of enhanced fibrinolysis due to the release of t-PA from the endothelium and post-operative fibrinolytic ‘shut-down’ seen on the first post-operative day (5, 6). However, both groups displayed decreased t-PA activity of mean 0.19 IU/ml at 24h post-operation compared to pre-operative levels of mean 0.34 and 0.29 IU/ml in non-ketorolac and ketorolac groups respectively. t-PA antigen levels were not significantly altered by surgery which could not be explained. This finding is in contrast to the report of Katzel et al (38) who demonstrated increased antigen and activity levels and a fall after thoracic surgery which remained above the pre-operative level. The mean pre-operative t-PA activity level in both groups was lower than in normal female subjects of mean activity 0.63 IU/ml and as reported earlier (39). In the ketorolac group u-PA showed a significant decrease in activity at 4h and 24h postoperation whilst in the non-ketorolac group a decreased trend was observed but did not achieve statistical significance. Decrease trend in u-PA antigen level was observed but it was statistically significant only in the non-ketorolac group at 4h post-operation. u-PA is involved in tissue degradation, remodelling and cell migration (40), the decrease in u-PA postoperatively could be due to their role in surgical trauma in tissue repair thus depleting their level in the systemic circulation. The pre-operative PAI- mean levels in both groups were higher than that observed in our laboratory’s normal female reference range of mean 10.8 AU/ml activity and mean 9.6 rig/ml antigen levels (39). Increased trend in PAI- activity was seen in both groups but was only statistically significant in the ketorolac group post-operatively from 2h and 24h whilst the PAI- antigen levels remained unaltered. Increased PAI- levels have been reported on Day One after surgery (42), after general anaesthesia (38), due to decrease t-PA available for inhibition (41) and has also been suggested to be an acute phase reactant protein due to increase synthesis by the liver (5, 43) and their presence in platelets could have contributed to its level in the circulation. In this study, post-operative increase in PAI- activity levels in the ketorolac group could be the result of less free circulating t-PA available for inhibition. In the nonketorolac group an increasing post-operative trend in PAI- activity was observed but it did not reach statistical significance although decreasing trend in t-PA activity levels was similar with the ketorolac group. PAI- antigen, the latent form found in platelets did not show any
Vol. 79, Nos. 5/6
EFFECTS OF NSAID IN SURGERY
509
increase post-operatively and could be due to the effect of plasmin in an environment of enhanced lytic state inhibits platelet adhesion and cleaves platelet glycoprotein Ib (44) thus inhibiting the release reaction. Enhanced thrombin formation as indicated by raised TAT-complex levels was evident perioperatively and increased degradation of fibrin indicated by raised D-dimer levels postoperatively were observed in both groups. These observations indicate an on-going thrombin formation possibly resulting from surgical trauma enhancing increased fibrinolysis process in the degradation of formed fibrin resulting in a lytic state but does not indicate fibrinolytic ‘shut-down’ post-operatively although the t-PA activity level was significantly decreased 24h post-operation, a similar finding to that reported by others (15, 33, 38). Enhanced platelet activation was observed in both groups pre-operatively, the normal level for B-TG reported by the manufacturer and in our laboratory was I 40 IU/ml. A significant decrease was observed by 24h post-operation but the level remained above normal mean level. The decrease in B-TG levels post-operatively could also be due to the effects of fibrin exposure to plasmin resulting in a marked decrease in platelet adhesion (44) and cleavage of platelet glycoprotein Ib (45) inhibiting release reaction. The post-operative fall in t-PA activity has been suggested to indicate increased t-PA adsorption on fibrin stimulating increased fibrin degradation (40) and indicating fibrinolytic ‘shut-down’ by others (2, 5, 8, 6, 13). Increased PAI- levels may protect the tissue from excessive proteolysis or an acute phase reaction (46) and have been suggested to be high risk for DVT in orthopaedic surgery (47). We were not able to demonstrate any other coagulation abnormality except for a shortened reaction time in the non-ketorolac group when Thromboelastograph was used to assess haemostasis status (unpublished). Variable bleeding times from previous studies in patients receiving ketorolac remains within the normal range of less than 10 min with some individuals showing a marked prolongation. These has been considered to be of little clinical significance (25-27, 48). The bleeding time known to be a poor indicator of platelet function cannot be used reliably to predict the risk of haemorrhage (49). Moreover, in our study no significant differences were observed in patients receiving ketorolac in blood loss or duration of surgery compared to the non-ketorolac control group. In conclusion, both study groups displayed a lower mean t-PA activity and higher PAIlevels pre-operatively concurrent with a mean increase in platelet activation as evident by raised B-TG levels.
Similar haemostatic findings were seen in both the non-ketorolac and ketorolac groups in enhanced activation of coagulation during surgery, increased fibrinolysis upon anaesthesia induction and a decreased t-PA activity level at 24h post-operation. A mean decrease in u-PA activity was seen post-operatively in the ketorolac group concurrent with a mean decrease u-PA antigen in the non-ketorolac group. PAI- activity in the ketorolac group was significantly elevated 2h post-surgery even at 24h post-operation. Although t-PA activity was significantly decreased at 24h post-operation in both groups, fibrinolysis ‘shut-down’ was not
510
EFFECTS OF NSAID IN SURGERY
Vol. 79, Nos. 5l6
evident as D-dimer levels were significantly elevated reflecting increased lytic activity at the fibrin surface, a finding more accurate than do measurements of PA and PAI-1. A decreased B-TG post-operatively indicates the inhibition of further platelet activation by plasmin. No significant differences were seen for blood loss and duration of surgery in both groups studied. The study suggests that the post-operative changes seen may be the general physiological response against surgical trauma at least in abdominal surgery (35). In addition ketorolac infusion elicits a significant response in PAI- activity within 24h post-operation. This indicates an increase in free PAI- availability for t-PA inhibition to prevent excessive proteolysis in an environment of increased lytic activity. A longer duration of post-operative study may reveal any subtle changes in molecular markers of thrombosis which was not the objective of this study.
Acknowledgements The study was supported by the National Unviversity of Singapore, Department of Obstetrics and Gynaecology Research Fund. The expert technical assistance of MS Chua SE, Mr Yuen WK and MS Ng BL is acknowledged.
REFERENCES 1.
YGGE, J. Changes in blood coagulation and fibrinolysis period. Amer J Surg 119, 225 - 232, 1970.
during the postoperative
2.
MANSFIELD, A.O. Activation of fibrinolysis associated with surgery and venous thrombosis. Br J Surg 59, 754 - 775, 1972.
3.
GORDON-SMITH, I.C., HICKMAN, J.A., QUESNE, L.P. Postoperative fibrinolytic activity and deep vein thrombosis. Br J Surg 61, 213 - 218, 1974.
4.
REM, J., FEDDERSEN, C., BRANT, M.R., KEHLET, H. Postoperative changes in coagulation and fibrinolysis independent from neurogenic stimuli and adrenal hormones. Br J Surg 1981; 68, 229 - 233, 1981.
5.
KLUFT, C., VERHEIJEN, J.H., JIE, A.F.H., RIJKEN, D.C., PRESTON, F.E., SUE-LING, H.M., MANUCCI, P.M. The postoperative fibrinolytic shutdown: a rapidly reverting acute phase pattern for the fast acting inhibitor of tissue-type plasminogen activator after trauma. Stand J Clin Lab Invest 45, 605 - 610, 1985.
6.
D’ANGELO, A., KLUFT, C., VERHEIJEN, J.H., RIJKEN, D.C., MOZZI, E., MANUCCI, P.M. Fibrinolytic shutdown after surgery: impairment of the balance between tissue-type plasminogen activator and its specific inhibitor. Eur J Clin Invest 15, 308 - 312, 1985.
Vot. 79, Nos. 5t6
EFFECTS OF NSAED IN SURGERY
511
7.
MACINTYRE, I.M.C., WEBBER, R.G., CRISPIN, J.R., JONES, D.R.B., WOOD, J.K, ALLAN, N.C., PRESCOTT, R.J., RUCKLY, C.V. Plasma fibrinolysis and postoperative deep vein thrombosis. Br J Surg 63, 694 - 697, 1976.
8.
KNIGHT, M.T.N., DAWSON, R., MELROSE D.G. Fibrinolytic response to surgery. Labile and stable patterns and their relevance to post-operative deep vein thrombosis. Lancet 1, 370 -373, 1977.
9.
MELLBRING, G., DAHLGREN, S., REIZ, S., WIMAN, B. Fibrinolytic activity in plasma and deep vein thrombosis after major abdominal surgery. Thromb Res 32, 575 - 584, 1983.
10.
SUE-LING, H.M., JOHNSTON, D., VERHEIJEN, J.H., KLUFT, C., PHILIPS, P.R., DAVIES, J.A. Indicators of depressed fibrinolytic activity in pre-operative prediction of deep vein thrombosis. Br J Surg 74, 275 - 278, 1987.
11.
STRIBBE, J., KLUFT, C., BROMMER, E.J.P., GOMEZ, M., DEJONG, D.S., NAUTA, J. Enhanced fibrinolytic activity during cardiopulmonary bypass in open heart surgery in man is caused by extrinsic (tissue type) plasminogen activator. Eur J Clin Invest 14, 375 - 382, 1984.
12.
MELISSARI, E., SCULLY, M.F., PAES, T., KAKKAR, V.V. The influence of LMW heparin on the coagulation and tibrinolytic response to surgery. Throm Res 37, 115 - 126, 1985.
13.
ARANDA, A., PARAMO, J.A., ROCHA, E. Fibrinolytic activity in plasma after gynecological and urological surgery. Haemostasis 18, 129 - 134, 1988.
14.
ERIKSSON, B.I., ERIKSSON, E., GYZANDER, E., TEGER-NILSSON, A. C., RISBERG, B. Thrombosis after hip replacement. Relationship to the fibrinolytic system. Acta Ortho Stand 60, 159 - 163, 1989.
15.
ROWBOTHAM, B-J., WHITAKER, A.N., HARRISON, J., MURTAUGH, P., REASBECK, P., BOWIE, E.J.W. Measurement of crosslinked fibrin derivatives in patients undergoing abdominal surgery: use in the diagnosis of postoperative venous thrombosis. Blood Coag and Fibrin01 3, 25 - 31, 1992.
16.
BROZOVIC, M. Physiological Bull 33, 231 - 238, 1977.
17.
KLUFT, C., VERHEIJEN, J.H., COOPER, P., CHANG, G.T.G., JIE, A.F.H., BLAMEY, S., LOWE, G.D.O., FORBES, C.D., PRESTON, F.E. Post-operative changes in the activity in blood of extrinsic (tissue type) plasminogen activator and its fast acting inhibitor. Haemostasis 14: 41 (Abstract), 1984.
18.
ROOKS, W.J., TOMOLOUIS, A.J., MALONEY, SCHULER, M.E. The analgesic and anti-inflammatory
mechanisms in coagulation and fibrinolysis.
Br Med
P.J., WALLACH, M.B., profile of (+)d-benzoyl-1,
512
EFFECTS OF NSAID IN SURGERY
2-dihydro-3H-pyrrolol[ 684 - 690, 1982.
1, llpyrrole-1-carboxylicacid
Vol. 79, Nos. 546
@ES-37619). Agents Actions 12,
19.
MONCADA, S., VANE, J.R. Arachidonic acid metabolites and the interactions between platelets and blood vesel walls. N Eng J Med 300, 1142 - 1147, 1979.
20.
YEE, J.P., KOSHIRER, J.E., ALLBON, C., BROWN, C.R. Comparison of intramuscular ketorolac tromethamine and morphine sulfate for analgesia after major surgery. Pharmacotherapy 6, 253 - 261, 1986.
21.
O’HARA, D.A., FRAGEN, R.J., KINZER, M., PEMBERTON, D. Ketorolac tromethamine as compared with morphine sulfate for treatment of post-operative pain. Clin Pharmacol Ther 41, 556 - 561, 1987.
22.
GILLES, G.W.A., KENNY, G.N.C., BULLINGHAM, R.E.S., MCARDLE, C.S. The morphine sparing effects of ketorolac tromethamine. A study of a new, parental non-steroidal anti-inflammatory agent after abdominal surgery. Anaesthesia 42,727 731, 1987.
23.
BROWN, C.R., MOODIE, J.E., EVANS, S.A., CLARKE, P.J., ROTHERHAM, B.A., BYNUM, L. Efficacy of intramuscular ketorolac and meperidine in pain following major oral surgery. Clin Pharmacol Ther 43, 161, 1988.
24.
KINSELLA, J., MOFFAT, A.C., PATRICK, J.A., PRENTICE, J. W., MCARDLE, C.S., KENNY, G.N. C. Ketorolac thrometamol for postoperative analgesias after orthopaedic surgery. Br J Anaesth 69, 19 -22, 1992.
25.
ROE, R-L., BRUNNO, J.J., ELLIS, D.J. Effects of a new nonsteroidal antiinflammatory agent on platelet function in male and female subjects. Clin Pharmacol Ther 29, 277, 1981.
26.
CONRAD, K.A., FAGAN, T.C., MACKIE, M.J., MAYSHAN, P.V. Effects of ketorolac tromethamine on haemostasis in volunteers. Clin Pharmacol Ther 43, 542 546, 1988.
27.
SPOWART, K., GREER, LA., MCLAREN, M., LLOYD, J., BULLINGHAM, R.E.S., FORBES, C.D. Haemostatic effects of ketorolac with and without concomitant heparin in normal volunteers. Thromb Haemost 1988; 60: 382 - 386.
28.
SCHWARTZ, B.S., LEIS, L.A., JOHNSON, G.J. In vivo platelet retention in human bleeding time wounds. II Effects of aspirin ingestion. .I Lab Clin Med 94, 574 - 584, 1979.
29.
AMREIN, P.C., ELLMAN, L., HARRIS, W.H. Aspirin-induced prolongation bleeding time and perioperative blood loss. JAMA 245, 1825 - 1828, 1981.
of
Vol. 79, Nos. 516
513
EFFECTS OF NSAID IN SURGERY
30.
KOH, C.L.S., YUEN, R., VIEGAS, O.A.C., CHUA, S.E.,NG, B.L., SEN, D.K., RATNAM, S.S. A plasmin generation method for the determination of tissue plasminogen activator (t-PA) activity in blood. Immunol Cell Biol 67, 197 - 203, 1989.
31.
KOH, C.L.S., YUEN, R., VIEGAS, O.A.C., CHUA, S.E., NG, B.L., SEN, D.K., RATNAM, S.S. Plasma tissue plasminogen activator inhibitor (t-PAI) activity in normal subjects. Med Sci Res 17, 135 - 136, 1989.
32.
KOH, S.C.L., YUEN, R., VIEGAS, O.A.C., RATNAM, S.S. Plasma urokinase activity and antigen levels in normalmales, females and in late pregnancy. Med Sci Res 20, 601 - 602, 1992.
33.
KAMBAYASHI, J-I., SAKON, M., YOKOTA, M., SHIBA, E-I., KAWASAKI, T., MORI, Y. Activation of coagulation and fibrinolysis during surgery, analysed by molecular markers. Thromb Res 60, 157 - 167, 1990.
34.
JOHNSON, E.J., HARIMAN, H., HAMPTON, K.K., GRANT, P.J., DAVIES, J.A., PRENTICE, C.R.M. Fibrinolysis during major abdominal surgery. Fibrinolysis 4, 147 - 151, 1990.
35.
KANG, J., KAMBAYASHI, J., SAKON, M., TSUJINAKA,. T., MORI, Postoperative changes in haemostasis analysed by the serial determination fibrinopeptides and D-dimer. Jap J Surg 19, 262 - 268, 1989.
36.
MELLBRING,G., NILSSON, T. BERGSDORF, N., WALLEN, P. Tissue plasminogen activator concentration in major abdominal surgery. Relationship to postoperative deep vein thrombosis. Thromb Res 36, 331 - 334, 1984.
37.
PARAMO, J.A., ALFARO, M.J., ROCHA, E. Postoperative changes in the plasma level of tissue type plasminogen activator and its fast acting inhibitor. Thromb Haemost 54, 713 - 716, 1985.
38.
KATZEL, R., WIEDEMANN, B., KEUPER, H., BRETHNER, L. The effect of the anaesthesia procedure on intraoperative fibrinolysis activation and postoperative fibrinolysis shut-down. Fibrinolysis 8, 309 - 316, 1994.
39.
KOH, C.L.S., YUEN, R., VIEGAS,O.A.C., CHUA,S.E.,NG, B.L.,SEN, D.K., RATNAM, S.S. Plasminogen activators t-PA, u-PA and its inhibitor (PAI) in normal males and females. Thromb Haemost 66, 581 - 585, 1991.
40.
DANO, K., ANDREASEN, P.A., GRENDAHL-HANSEN, J. Plasminogen activators, tissue degradation and cancer. Adv Ca Res 44, 139 - 266, 1985.
41.
SORENSEN, J.V. Levels of fibrinolytic activators and inhibitors severe trauma. Blood Coag Fibrin01 5, 43 - 49, 1994.
T. of
in plasma after
ERECTS
514
OF NSAD lN SURGERY
voI.?9,Nos.?5/6
42.
ESTELLES, A., GILABERT, J., ESPANA, F., VILA, J., MARTINEZ, M, HENDL, S., AZNAR, J. Alterations in fibrinolytic and protein C pathways in gynaecological surgery; low molecular weight heparin prophylaxis. Haemostasis 24, 252 - 260, 1994.
43.
LOSKUTOFF, 1991.
44.
HAMAGUCHI, M., BUNCE, L.A., SPORN, L.A., FRANCIS, C.W. Plasmic degradation of fibrin rapidly decreases platelet adhesion and spreading. Blood 84, 1143 - 1150, 1994.
45.
ADELMAN, B., MICHELSON, A.D., LOSCALZO, HANDIN, R.I. Plasmin effect on platelet glycoprotein interactions. Blood 65, 32-40, 1985.
46.
KRUITHOF, E.K.O., NICOLOSO, G., BACHMANN, F. Plasminogen activator inhibitor 1: Development of a radioimmunoassay and observations on its plasma concentration during venous occlusion and after platelet aggregation. Blood 70, 1645 1653, 1987.
47.
E. Impaired fibrinolysis and postoperative ERIKSSON, B.I., ERIKSSON, thromboembolism in orthopaedic patients. Thromb Res 62, 55 - 64, 1991.
48.
GREER, I.A. Effects of ketorolac tromethamine 10 (part 2), 71s - 76S, 1990.
49.
RODGERS, R.P.C., LEVIN, J. A critical re-appraisal of the bleeding time. Semin Thromb Haemost 16, l-20, 1990.
D.J. Regulation of PAI-
gene expression. Fibrinolysis
5, 197 - 206,
J., GREENBERG, J., Ib-von Willebrand factor
on haemostasis. Pharmacotherapy