Imaging crystals, polymers, and processes in water with the atomic force microscope

The atomic force microscope (AFM) can be used to image the surface of both conductors and nonconductors even if they are covered with water or aqueous solutions. An AFM was used that combines microfabricated cantilevers with a previously described optical lever system to monitor deflection. Images of mica demonstrate that atomic resolution is possible on rigid materials, thus opening the possibility of atomic-scale corrosion experiments on nonconductors. Images of polyalanine, an amino acid polymer, show the potential of the AFM for revealing the structure of molecules important in biology and medicine. Finally, a series of ten images of the polymerization of fibrin, the basic component of blood clots, illustrate the potential of the AFM for revealing subtle details of biological processes as they occur in real time.

The scanning ion-conductance microscope

A scanning ion-conductance microscope (SICM) has been developed that can image the topography of nonconducting surfaces that are covered with electrolytes. The probe of the SICM is an electrolyte-filled micropipette. The flow of ions through the opening of the pipette is blocked at short distances between the probe and the surface, thus, limiting the ion conductance. A feedback mechanism can be used to maintain a given conductance and in turn determine the distance to the surface. The SICM can also sample and image the local ion currents above the surfaces. To illustrate its potential for imaging ion currents through channels in membranes, a topographic image of a membrane filter with 0.80-micrometer pores and an image of the ion currents flowing through such pores are presented.

Scanning probe microscopy of biological samples and other surfaces

Scanning probe microscopes derived from the scanning tunnelling microscope (STM) offer new ways to examine surfaces of biological samples and technologically important materials. The surfaces of conductive and semiconductive samples can readily be imaged with the STM. Unfortunately, most surfaces are not conductive. Three alternative approaches were used in our laboratory to image such surfaces. 1. Crystals of an amino acid were imaged with the atomic force microscope (AFM) to molecular resolution with a force of order 10(-8) N. However, it appears that for most biological systems to be imaged, the atomic force microscope should be able to operate at forces at least one and perhaps several orders of magnitude smaller. The substitution of optical detection of the cantilever bending for the measurement by electron tunnelling improved the reliability of the instrument considerably. 2. Conductive replicas of non-conductive surfaces enabled the imaging of biological surfaces with an STM with a lateral resolution comparable to that of the transmission electron microscope. Unlike the transmission electron microscope, the STM also measures the heights of the features. 3. The scanning ion conductance microscope scans a micropipette with an opening diameter of 0.04-0.1 micron at constant ionic conductance over a surface covered with a conducting solution (e.g., the surface of plant leaves in saline solution).

Recombinant human erythropoietin and autologous blood donation

Risks of transfusion are minimized with autologous blood. However, autologous donation programs require 2 to 5 weeks to yield only 2.2 units per patient. Recombinant human erythropoietin (r-HuEPO) has been shown to increase erythropoiesis. This study evaluated the effects of r-HuEPO on an aggressive autologous donation program. Twelve adult male baboons were randomized into two groups of six. All animals were studied three times per week for 5 weeks. A unit of blood was donated when on any study day the hematocrit was greater than 30%. Animals received intravenously either 750 units/kg of r-HuEPO (n = 6) or placebo (n = 6) on each study day. Iron dextran was given intravenously to replace 150% of shed iron. The r-HuEPO group had an earlier onset of reticulocytosis (2.7 vs 5.5 days, p less than 0.01) and donated 35% more blood (13.5 vs 10.0 units, p = 0.01) than the control group. No adverse reactions to r-HuEPO were observed. The data show that an aggressive autologous donation program can yield 10 units of blood over a 5-week period. Further, r-HuEPO increases that yield by an additional 35%. This aggressive autologous donation program with r-HuEPO may significantly reduce the need for homologous transfusion and its attendant risks.

Limits of cardiac compensation in anemic baboons

The risk of homologous blood may cause physicians to withhold red cell treatment after acute blood loss. We believe that in the euvolemic patient with acute anemia, the heart is the principal organ at risk. The cardiac compensation to extreme anemia is unknown and is the purpose of this report. Fourteen adult baboons were anesthetized, paralyzed, and ventilated with room air. Left atrial and coronary sinus catheters were inserted surgically. Experimental animals (n = 7) were hemodiluted at constant left atrial pressure with 5% human serum albumin. Control animals (n = 7) underwent similar volume exchanges with fresh, cross-matched, homologous red blood cells resuspended in human serum albumin, also at constant left atrial pressure. Six of seven experimental animals survived until hematocrit levels were 4%. Adequate cardiac compensation was observed until hematocrit levels were less than 10%. Increased flow, without increases in the O2 extraction ratio, was the mechanism of compensation used by the healthy heart with patent coronary vessels.

Plasma expanders. An update

This review of the literature has revealed that isotonic fluids, such as 0.9 percent sodium chloride and Ringer's lactate, are effective plasma volume expanders. Despite the continued use of a variety of colloid solutions in resuscitation, there is no good evidence to document a benefit of these solutions over the crystalloid solutions. The additional cost of colloid compared with crystalloid is another argument against colloid use. The most interesting solution currently being assessed is hypertonic saline solution. Its major benefit is that a small volume of fluid can achieve effective resuscitation. The smaller weight gain and lower incidence of peripheral edema may also prove to be significant benefits. Further evaluations are needed to verify the efficacy of this therapy. Finally, a recent National Institute of Health consensus panel identified the appropriate indications for fresh frozen plasma. They concluded that there is no indication for the use of fresh frozen plasma as a volume expander.

Characteristics of polymerized pyridoxylated hemoglobin

Polymerization of SFH-P currently provides the only approach that leads to a hemoglobin solution that approximates the O2 carrying capacity of whole blood and can be infused without altering the COP of plasma. It appears to have an adequate O2 loading and unloading characteristic and a greatly improved intravascular half-life. In addition, stable shelf-life at 4 degrees C of greater than five months, makes it a prime candidate for future pre-clinical and clinical investigations.

Oxygen extraction ratio: a valid indicator of myocardial metabolism in anemia

We have shown that primates adequately compensate for acute normovolemic anemia to hematocrits (HCT) of 10%. We have described a whole-body extraction ratio (O2 consumption/O2 delivery; ER) of 50% as a reliable physiologic indicator of transfusion need. There is concern that whole-body ER may not accurately reflect impaired myocardial metabolism. The onset of significant lactate production by the left ventricle is an indicator of anaerobic metabolism. Our purpose is to compare left ventricular lactate metabolism (arterial-coronary sinus lactate; delta [L]) to ER in acute normovolemic anemia. Fourteen adult baboons were anesthetized, paralyzed, and ventilated on room air. Left atrial, coronary sinus, aortic, and Swan-Ganz catheters were inserted. Experimental animals (N = 7) were hemodiluted, at constant left atrial pressure (LAP), with 5% human serum albumin (HSA) to a HCT below 4%. Control animals (N = 7) underwent similar volume exchanges, also at constant LAP, with homologous RBCs resuspended in HSA. Whole-body extraction ratio and left ventricular lactate production were measured at baseline and at hematocrits of 20, 10, 6, and 4% in the experimental group. Data were obtained at similar volume exchange points in the control group. Significant lactate production occurred only in the experimental animals (P less than 0.05) when extraction ratio exceeded 50%. Significant lactate production does not occur before the whole-body ER exceeds 50%. ER appears to be a valid indicator of myocardial metabolism in anemia, in this setting.

The development of polymerized pyridoxylated hemoglobin solution as a red cell substitute

Development continues for a safe and effective hemoglobin solution to be used as a temporary red cell substitute. Our own efforts have progressed from the unmodified tetramer, to the pyridoxylated tetramer, to our current product--polymerized, pyridoxylated hemoglobin (Poly SFH-P). We recently completed two studies to evaluate the efficacy of Poly SFH-P. The results document that Poly SFH-P supports life in the absence of red cells while maintaining baseline hemodynamics and O2 consumption. In addition, Poly SFH-P achieves a near-normal plasma [Hb], and has a longer intravascular persistence than any unpolymerized product. Poly SFH-P thus is an improved red cell substitute for use in the clinical setting.

Polymerized pyridoxylated hemoglobin: efficacy as an O2 carrier

We have prepared a polymerized pyridoxylated hemoglobin solution (Poly SFH-P) with a normal [Hb] of 14 gm/dl and a normal COP of 20 torr. Although this normal [Hb] is a significant improvement over prior products, the P50 of 16-20 torr raises a concern about the ability of Poly SFH-P to effectively transport O2 in the presence of red cells with their normal P50 of 26 torr. This study quantitatively assessed the contribution of Poly SFH-P to total O2 delivery and consumption in the clinically relevant range of hematocrits. The results document that Poly SFH-P supports life at zero hematocrit, and makes significant contributions to total O2 delivery and consumption in the presence of red cells. Poly SFH-P permits a higher plasma [Hb], and has a longer intravascular persistence than any unpolymerized hemoglobin solution. Poly SFH-P is thus an effective O2 carrier, and offers greater potential than prior products as a clinically useful red cell substitute.

Fluosol-DA as a red-cell substitute in acute anemia

We assessed the safety and efficacy of Fluosol-DA as a red-cell substitute in acute anemia. Twenty-three surgical patients with blood loss and religious objections to receiving blood transfusions were evaluated. Fifteen moderately anemic patients with a mean hemoglobin level (+/- SE) of 7.2 +/- 0.5 g per deciliter had no evidence of a physiologic need for increased arterial oxygen content and did not receive Fluosol-DA. Eight severely anemic patients with a mean hemoglobin level of 3.0 +/- 0.4 g per deciliter met the criteria of need and received the drug until the physiologic need disappeared or a maximal dose of 40 ml per kilogram of body weight was reached. We observed no adverse reactions to Fluosol-DA. The average peak increment in arterial oxygen content with the drug was only 0.7 +/- 0.1 ml per deciliter. There were no appreciable beneficial effects of Fluosol-DA, perhaps because of the small increase in arterial oxygen content, the brief half-life of the drug (24.3 +/- 4.3 hours), and the limited total dose. Six of the eight patients receiving Fluosol-DA died. One of the survivors received red-cell transfusions against his wishes, under a court order, after his total Fluosol-DA dose. Fourteen of the 15 moderately anemic patients survived. The data in this select group of patients refusing blood products suggest that, after blood loss, Fluosol-DA is unnecessary in moderate anemia and ineffective in severe anemia.

Methodology to assess the oxygen concentration of red cells and stroma-free hemoglobin solutions

Stroma-free hemoglobin (SFH) solution is an acellular oxygen carrier under development as a temporary red blood cell (rbc) substitute. SFH will be of value if it contributes to oxygen loading (delivery) and unloading (consumption). If there is no interaction between red cell hemoglobin and SFH, then the composite oxygen dissociation curve for whole blood (WB) can be written as: SWB = rSSFH + (1 - r) Srbc, where S is the fractional saturation, and r is the SFH/WB hemoglobin ratio. This composite whole-blood curve was compared with the calculated curve, and the root mean square difference was 0.9%. Direct and indirect methods of measuring oxygen concentration ([O2]) of whole blood or plasma were compared. The regression line was [O2]indirect = 0.995 [O2]direct + 0.07 (r = 0.995, N = 16, p less than .01). The adequacy of anaerobic separation of plasma was evaluated by measuring the changes in PO2 and PCO2. The PO2 increased by less than 2 torr and the PCO2 decreased by less than 1 torr during in vitro tests. Both the direct and indirect methodology yielded consistent [O2] values for each carrier.

Red cell substitutes: an update

The two acellular oxygen carriers currently being evaluated as red cell substitutes are hemoglobin solutions and fluorocarbon emulsions. We have shown that both products can maintain normal levels of oxygen consumption, CO2 production, and circulatory dynamics in primates in the virtual absence of the red blood cell. Although each solution thus satisfies the most important criteria for a red cell substitute, development continues with both products. The clinical trials with the fluorocarbons have been discontinued due to the lack of efficacy of Fluosol-DA--20% in the setting of acute blood loss. Our current hemoglobin preparation is a polymerized, pyridoxylated product that has a normal oxygen-carrying capacity. Clinical testing must await further evaluation of the safety and efficacy of this product. Alternative uses for both of these oxygen carriers continue to be explored, and may eventually be the area of their greatest utility in the clinical setting.

Effect of Intralipid on measurements of total hemoglobin and oxyhemoglobin in whole blood

A co-oximeter study of whole blood samples containing Intralipid concentrations of 100 to 2000 mg/dl found that the light-scattering effect was greater at lower hematocrits. The methemoglobin reading was affected the most, and led to erroneous displays of total hemoglobin and percent oxyhemoglobin. The O2-content value, however, was accurate over the entire hematocrit and Intralipid concentration range tested. We suggest that an unexplained high methemoglobin value in whole blood samples from patients receiving Intralipid may reflect a light-scattering problem in the instrument.

Polymerized pyridoxylated hemoglobin: a red cell substitute with normal oxygen capacity

Polymerization of pyridoxylated stroma free hemoglobin (poly SFH-P) yields a solution with a normal hemoglobin concentration, normal colloid osmotic pressure (COP), and a suitable P50. In the present study we compared its in vivo O2-carrying capacity and intravascular persistence with those of pyridoxylated hemoglobin (SFH-P), following a partial exchange transfusion (900 ml) in adult baboons (n = 4 in each group). Poly SFH-P in plasma had an O2-carrying capacity that was 77% greater than that achieved with SFH-P (8.0 versus 4.5 vol%). Furthermore, poly SFH-P provided 5.0 vol% at the end of 24 hours and 2.5 vol% at the end of 48 hours; in contrast SFH-P provided only 2.2 vol% at the end of 6 hours and none within 24 hours. A normal COP was maintained throughout the postexchange period with poly SFH-P despite a 68% increase in plasma protein concentration (from 7.1 to 11.9 gm/dl). The plasma P50 of poly SFH-P decreased from 16 torr immediately after exchange to 12 torr at the end of 48 hours. The in vivo rate of conversion to methemoglobin was similar with both solutions. Polymerized pyridoxylated hemoglobin is currently the only modification of hemoglobin solution that approximates the O2-carrying capacity of whole blood and can be infused without altering the plasma COP.

Hemoglobin solution--from tetramer to polymer

Efforts to produce a clinically acceptable hemoglobin solution that could function as a temporary oxygen carrier have evolved through several stages. Beginning with the simple tetramer, we have lowered the affinity state by pyridoxylation and then polymerized the modified tetramer. This new substance, polyhemoglobin, has a normal oxygen capacity and a half-life of 38 hours. Issues of nephrotoxicity and immunocompetence after infusion remain to be defined.

Assessment of a 35% fluorocarbon emulsion

We have previously reported on the efficacy of a 20% fluorocarbon emulsion (Fluosol-DA, 20%) as an acellular O2 carrier at an FIO2 = 1.0. We are concerned, however, about the potential O2 toxicity that may result from extended exposure to FIO2 = 1.0. The O2 content of the fluorocarbon phase is linearly related to both the FIO2 and the fluorocarbon concentration (Fct). It should therefore be possible to maintain the same O2 content by raising the Fct using a higher fluorocarbon concentration and lowering the FIO2. The purpose of this report is to assess the ability of a 35% fluorocarbon emulsion (Fluosol-DA, 35%) at an FIO2 = 0.6 to support hemodynamics and O2 transport. Five adult baboons were paralyzed, anesthetized, intubated, and mechanically ventilated at FIO2 = 0.6. An isovolemic total exchange transfusion (E.T.) with Fluosol-DA, 35% was performed. Measurements were made at Hct's of 20, 10, 5, and less than 2%. All animals survived the exchange. Total arterial O2 content fell from 17.4 +/- 0.7 to 3.3 +/- 0.2 vol% (p less than 0.01), and O2 delivery decreased from 21.8 +/- 2.2 to 5.1 +/- 0.7 cc/min-kg (p less than 0.01) during the exchange. There was no significant change in MAP, H.R., C.O., or VO2 during the exchange transfusion. Fluosol-DA, 35% maintains normal hemodynamics and O2 transport despite a marked fall in arterial O2 content and total O2 delivery. Fluosol-DA, 35% is thus an effective O2 carrier at the safe FIO2 of 0.6.