Use of hyperbaric oxygen therapy and PEGylated carboxyhemoglobin bovine in a Jehovah's Witness with life-threatening anemia following postpartum hemorrhage

Hyperbaric Oxygen Therapy-Induced Molecular and Pathway Changes in a Rat Model of Spinal Cord Injury: A Proteomic Analysis

Hyperbaric Oxygen Therapy (HBOT) has definitive therapeutic effects on spinal cord injury (SCI), but its mechanism of action is still unclear. Here, we've conducted a systemic proteomic analysis to identify differentially expressed proteins (DEPs) between SCI rats and HBOT + SCI rats. The function clustering analysis showed that the top enriched pathways of DEPs include oxygen transport activity, oxygen binding, and regulation of T cell proliferation. The results of functional and signal pathway analyses indicated that metabolic pathways, thermogenesis, LXR/RXR activation, acute phase response signaling, and the intrinsic prothrombin pathway in the SCI + HBOT group was higher than SCI group.

Bloodless Management of the Anemic Patient in the Emergency Department

Anemia is a commonly encountered condition in emergency medicine; transfusion of packed red blood cells is commonly performed for anemic patients in the emergency department (ED), but some patients are unable to accept transfusion of blood products due to medical or religious concerns. The unique, acute, and time-sensitive nature of emergency medicine practice requires that physicians maintain an enhanced awareness of bloodless medicine treatment modalities. Identification of bloodless medicine patient preferences in the ED can help guide physicians in the recommendation of acceptable methods of treating anemia in this patient population. A focus on early hemostasis and resuscitation, instead of attempts to convince the patient to accept blood transfusion, can be lifesaving in patients with acute bleeding. Treatment strategies including the use of methods to reduce unnecessary blood loss, enhance red blood cell production, and increase the oxygen-carrying capacity of blood should also be considered early in patient presentation. Timely involvement of the Hospital Liaison Committee can help facilitate successful interpersonal communication and shared decisionmaking between emergency physicians and bloodless medicine patients. By embracing an understanding of bloodless medicine patient needs as well as available treatment strategies, ED physicians can contribute to optimal overall outcomes for anemic bloodless medicine patients.

[Treatment of extreme anemia with polymerized bovine hemoglobin : Case report and review of the literature]

This article reports the case of a 29-year-old female Jehovah's Witness with severe anemia after intrauterine fetal death in the 25th week of gestation, complicated by vaginal bleeding, acute renal failure and hemolysis. Due to her religious beliefs the patient categorically refused blood transfusions. Despite adhering to the recommendations for patient blood management, the hemoglobin (Hb) level gradually decreased to 1.9 g/dl on day 10, when she fainted and had to be sedated and invasively ventilated. Inhalative isoflurane was chosen for sedation because of its potential organ-protective effects and because it provides deep sedation with reduced oxygen requirements, while enabling rapid neurological examination during the sedation windows as well as regular and calm spontaneous breathing. Posthypoxic encephalopathy was demonstrated clinically and electroencephalographically by seizure activity during the sedation windows. Anticonvulsive treatment was started. At a hemoglobin of 1.8 g/dl, she received 2 units of polymerized bovine hemoglobin (Hemopure®, Hemoglogin Oxygen Therapeutics LLC, Souderton, PA, USA), repeated several times on subsequent days because of its short half-life. Considerable methemoglobinemia was noted. After subtracting methemoglobin, the hemoglobin rose by 0.4-0.8 g/dl after each 2 units, initially increasing the oxygen binding capacity of the blood by 33%. After a full neurological recovery and weaning from the ventilator but still on hemodialysis, the patient was transferred to another hospital after 38 days.If allogeneic blood transfusion is not an option, administration of polymerized bovine hemoglobin can temporarily increase the oxygen transport capacity as a last resort treatment. Reduction of oxygen requirements by deep inhaled sedation with isoflurane also seems beneficial and provides advantages.

Targeting the Heme Oxygenase 1/Carbon Monoxide Pathway to Resolve Lung Hyper-Inflammation and Restore a Regulated Immune Response in Cystic Fibrosis

In individuals with cystic fibrosis (CF), lung hyper-inflammation starts early in life and is perpetuated by mucus obstruction and persistent bacterial infections. The continuous tissue damage and scarring caused by non-resolving inflammation leads to bronchiectasis and, ultimately, respiratory failure. Macrophages (MΦs) are key regulators of immune response and host defense. We and others have shown that, in CF, MΦs are hyper-inflammatory and exhibit reduced bactericidal activity. Thus, MΦs contribute to the inability of CF lung tissues to control the inflammatory response or restore tissue homeostasis. The non-resolving hyper-inflammation in CF lungs is attributed to an impairment of several signaling pathways associated with resolution of the inflammatory response, including the heme oxygenase-1/carbon monoxide (HO-1/CO) pathway. HO-1 is an enzyme that degrades heme groups, leading to the production of potent antioxidant, anti-inflammatory, and bactericidal mediators, such as biliverdin, bilirubin, and CO. This pathway is fundamental to re-establishing cellular homeostasis in response to various insults, such as oxidative stress and infection. Monocytes/MΦs rely on abundant induction of the HO-1/CO pathway for a controlled immune response and for potent bactericidal activity. Here, we discuss studies showing that blunted HO-1 activation in CF-affected cells contributes to hyper-inflammation and defective host defense against bacteria. We dissect potential cellular mechanisms that may lead to decreased HO-1 induction in CF cells. We review literature suggesting that induction of HO-1 may be beneficial for the treatment of CF lung disease. Finally, we discuss recent studies highlighting how endogenous HO-1 can be induced by administration of controlled doses of CO to reduce lung hyper-inflammation, oxidative stress, bacterial infection, and dysfunctional ion transport, which are all hallmarks of CF lung disease.

Alternatives to Transfusion

OBJECTIVES

We discuss two main categories of blood substitutes: perfluorocarbons and hemoglobin-based oxygen carriers.

METHODS

We provide a review of the notable products developed in both categories and include their attributes as well as their setbacks.

RESULTS

We contribute a case report tothe growing literature of the successful use of Sanguinate.

CONCLUSIONS

We find that artificial oxygen carriers are an attractive field of research because of the practical limitations and the multitude of potential complications that surround human blood transfusions.

Early Experiences With PEGylated Carboxyhemoglobin Bovine in Anemic Jehovah’s Witnesses: A Case Series and Review of the Literature

Jehovah’s Witnesses (JW) represent a complex patient population due to their refusal to accept blood transfusions on religious grounds. Pharmacologic management of anemic JW patients is limited to stimulation of hematopoiesis by iron and erythropoietin supplementation and reduction of blood loss by prothrombin complex concentrates (PCCs). Hemoglobin-based oxygen carriers (HBOCs) represent the only pharmacologic modality for JW patients capable of acutely increasing a patient’s oxygen carrying capacity in the setting of organ failure, yet clinical safety and efficacy data are lacking in this population. We report 3 cases in which the HBOC, PEGylated carboxyhemoglobin bovine (Sanguinate®), was requested under emergent circumstances for severely anemic (hemoglobin <5 g/dL) JW patients who refused blood transfusions. Two patients received PEGylated carboxyhemoglobin infusions for severe anemia, while the third patient died prior to receiving the medication. One patient who received Sanguinate died after 5 units of medication. The other patient’s hemoglobin recovered and she was discharged in stable condition. This series demonstrates the complex nature of the critically anemic JW population and highlights the clinical considerations of using HBOCs in clinical practice and the critical need for further research before they can be broadly recommended.