Biomaterials for human space exploration: A review of their untapped potential

As biomaterial advances make headway into lightweight radiation protection, wound healing dressings, and microbe resistant surfaces, a relevance to human space exploration manifests itself. To address the needs of the human in space, a knowledge of the space environment becomes necessary. Both an understanding of the environment itself and an understanding of the physiological adaptations to that environment must inform design parameters. The space environment permits the fabrication of novel biomaterials that cannot be produced on Earth, but benefit Earth. Similarly, designing a biomaterial to address a space-based challenge may lead to novel biomaterials that will ultimately benefit Earth. This review describes several persistent challenges to human space exploration, a variety of biomaterials that might mitigate those challenges, and considers a special category of space biomaterial. STATEMENT OF SIGNIFICANCE: This work is a review of the major human and environmental challenges facing human spaceflight, and where biomaterials may mitigate some of those challenges. The work is significant because a broad range of biomaterials are applicable to the human space program, but the overlap is not widely known amongst biomaterials researchers who are unfamiliar with the challenges to human spaceflight. Additionaly, there are adaptations to microgravity that mimic the pathology of certain disease states ("terrestrial analogs") where treatments that help the overwhelmingly healthy astronauts can be applied to help those with the desease. Advances in space technology have furthered the technology in that field on Earth. By outlining ways that biomaterials can promote human space exploration, space-driven advances in biomaterials will further biomaterials technology.

Artificial Blood: A Futuristic Dimension of Modern Day Transfusion Sciences

Artificial blood is an innovative concept of transfusion medicine where specifically designed compounds perform the task of transport and delivery of oxygen in the body to replace this function of allogenic human blood transfusion. Several molecules have been developed in the past few decades to achieve this objective and continous refinements are being continuously made in the quest of the ideal blood substitute. Currently, available technology manufactures artificial blood from haemoglobin obtained from outdated human/bovine blood (Haemoglobin Based Oxygen Carriers) or utilizing Perfluorocarbons. These synthetic blood substitutes are advantageous in that they do not require compatibility testing, are free from blood borne infections, have prolonged shelf life and do not require refrigeration. Artificial blood is projected to have a significant impact on the development of medical care in the future. It can complement the current blood products for transfusion and create a stable supply of safe and effective products. It is likely to reduce the requirements of blood transfusions drastically especially in settings of trauma and surgery thereby reducing the reliance on banked donated blood.

Thermophysical Characterization of Ionic Liquids Based on the Perfluorobutanesulfonate Anion: Experimental and Soft-SAFT Modeling Results

Fluorinated ionic liquids (FILs) exhibit complex molecular behavior, where three different nanodomains (polar, hydrogenated nonpolar, and fluorinated nonpolar) have been identified by molecular simulations. Given the high number of possible anion/cation combinations, a theoretical tool able to describe the thermophysical properties of these compounds in a systematic, rapid, and accurate manner is highly desirable. We present here a combined experimental-theoretical methodology to obtain the phase, interface, and transport properties of the 1-alkyl-3-methylimidazolium perfluorobutanesulfonate ([C_n C₁ Im][C₄ F₉ SO₃ ]) family. In addition to providing new experimental data, an extended version of the Statistical Associating Fluid Theory (soft-SAFT) is used to describe the physicochemical behavior of the [C_n C₁ Im][C₄ F₉ SO₃ ] family. A mesoscopic molecular model is built based on the analysis of the chemical structures of these FILs, and supported by quantum chemical calculations to study the charge distribution of the anion, where only the basic physical features are considered. The resulting molecular parameters are related to the molecular weight, providing the basis for thermophysical predictions of similar compounds. The theory is also able to predict the minimum in the surface tension versus the length of the hydrogenated alkyl chain, experimentally found at n=8. The viscosity parameters are also in agreement with the free-volume calculations obtained from experiments.

Fluorinated methacrylamide chitosan sequesters reactive oxygen species to relieve oxidative stress while delivering oxygen

Antioxidants play an important role in regulating overabundant reactive oxygen species (ROS) in wound healing to reduce oxidative stress and inflammation. In this work, we demonstrate for the first time that functionalization of methacrylamide chitosan (MAC) with aliphatic pentadecafluoro chains, to synthesize pentadecafluoro-octanoyl methacrylamide chitosan (MACF), enhances the antioxidant capacity of the MAC base hydrogel material, while being able to deliver oxygen for future enhanced wound healing applications. As such, MACF was shown to sequester more nitric oxide (p < 0.01) and hydroxyl (p < 0.0001) radicals as compared to the negative control even when delivering additional oxygen. MACF's beneficial antioxidant capacity was further confirmed in in vitro cell culture experiments using human dermal fibroblasts stressed with 2,2'-azobis(2-methylpropionamidine) dihydrochloride (AAPH). © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 105A: 2368-2374, 2017.

Femtogram Resolution of Iron Content on a Per Cell Basis: Ex Vivo Storage of Human Red Blood Cells Leads to Loss of Hemoglobin

The magnetic characteristics of hemoglobin (Hb) changes with the binding of dioxygen (O2) to the heme prosthetic groups of the globin chains: from paramagnetic ferrous Hb to diamagnetic ferrous oxyhemoglobin (oxyHb) with reversibly bound O2, or paramagnetic ferric methemoglobin (metHb). When multiplied over the number of Hb molecules in a red blood cell (RBC), the effect is detectable through motion analysis of RBCs in a high magnetic field and gradient. This motion is referred to as magnetophoretic mobility, which can be conveniently expressed as a fraction of the cell sedimentation velocity. In this Article, using a previously developed and reported instrument, cell tracking velocimetry (CTV), we are able to detect difference in Hb concentration in two RBC populations to a resolution of 1 × 107 Hb molecules per cell (4 × 107 atoms of Fe per cell or 4-5 femtograms of Fe). Similar resolution achieved with inductively coupled plasma-mass spectrometry requires on the order of 105-106 cells and provides an average, whereas CTV provides a measurement for each cell. CTV analysis revealed that RBCs lose, on average, 17% of their Hb after 42 days of storage, the maximum FDA-approved length of time for the cold storage of RBCs in additive solution. This difference in Hb concentration was the result of routine RBC storage; clinical implications are discussed.

Improving O2 reduction at an enzymatic biocathode: mimicking the lungs

Here, we demonstrate the use of phospholipid micelles to enhance O₂ concentrations by two-fold at the surface of a bilirubin oxidase biocathode. Specifically, 1,2-diarachidoyl-sn-glycero-3-phosphocholine was used in a glucose enzymatic fuel cell to limit power losses due to O₂ transport, even in a quiescent solution.

Significantly enhanced heme retention ability of myoglobin engineered to mimic the third covalent linkage by nonaxial histidine to heme (vinyl) in synechocystis hemoglobin

Heme proteins, which reversibly bind oxygen and display a particular fold originally identified in myoglobin (Mb), characterize the "hemoglobin (Hb) superfamily." The long known and widely investigated Hb superfamily, however, has been enriched by the discovery and investigation of new classes and members. Truncated Hbs typify such novel classes and exhibit a distinct two-on-two α-helical fold. The truncated Hb from the freshwater cyanobacterium Synechocystis exhibits hexacoordinate heme chemistry and bears an unusual covalent bond between the nonaxial His(117) and a heme porphyrin 2-vinyl atom, which remains tightly associated with the globin unlike any other. It seems to be the most stable Hb known to date, and His(117) is the dominant force holding the heme. Mutations of amino acid residues in the vicinity did not influence this covalent linkage. Introduction of a nonaxial His into sperm whale Mb at the topologically equivalent position and in close proximity to vinyl group significantly increased the heme stability of this prototype globin. Reversed phase chromatography, electrospray ionization-MS, and MALDI-TOF analyses confirmed the presence of covalent linkage in Mb I107H. The Mb mutant with the engineered covalent linkage was stable to denaturants and exhibited ligand binding and auto-oxidation rates similar to the wild type protein. This indeed is a novel finding and provides a new perspective to the evolution of Hbs. The successful attempt at engineering heme stability holds promise for the production of stable Hb-based blood substitute.

Blood doping: risks to athletes' health and strategies for detection

Blood doping has been defined as the misuse of substances or certain techniques to optimize oxygen delivery to muscles with the aim to increase performance in sports activities. It includes blood transfusion, administration of erythropoiesis-stimulating agents or blood substitutes, and gene manipulations. The main reasons for the widespread use of blood doping include: its availability for athletes (erythropoiesis-stimulating agents and blood transfusions), its efficiency in improving performance, and its difficult detection. This article reviews and discusses the blood doping substances and methods used for in sports, the adverse effects related to this practice, and current strategies for its detection.

Current status of pharmacologic therapies in patient blood management

Patient blood management(1,2) incorporates patient-centered, evidence-based medical and surgical approaches to improve patient outcomes by relying on the patient's own (autologous) blood rather than allogeneic blood. Particular attention is paid to preemptive measures such as anemia management. The emphasis on the approaches being "patient-centered" is to distinguish them from previous approaches in transfusion medicine, which have been "product-centered" and focused on blood risks, costs, and inventory concerns rather than on patient outcomes. Patient blood management(3) structures its goals by avoiding blood transfusion(4) with effective use of alternatives to allogeneic blood transfusion.(5) These alternatives include autologous blood procurement, preoperative autologous blood donation, acute normovolemic hemodilution, and intra/postoperative red blood cell (RBC) salvage and reinfusion. Reviewed here are the available pharmacologic tools for anemia and blood management: erythropoiesis-stimulating agents (ESAs), iron therapy, hemostatic agents, and potentially, artificial oxygen carriers.

[The "Seville" Consensus Document on Alternatives to Allogenic Blood Transfusion. Sociedades españolas de Anestesiología (SEDAR), Medicina Intensiva (SEMICYUC), Hematología y Hemoterapia (AEHH), Transfusión sanguínea (SETS) Trombosis y Hemostasia (SETH)]

The Consensus Document on Alternatives to Allogenic Blood Transfusion (AABT) has been drawn up by a panel of experts from 5 scientific societies. The Spanish Societies of Anesthesiology (SEDAR), Critical Care Medicine and Coronary Units (SEMICYUC), Hematology and Hemotherapy (AEHH), Blood Transfusion (SETS) and Thrombosis and Hemostasis (SETH) have sponsored and participated in this Consensus Document. Alternatives to blood transfusion have been divided into pharmacological and non-pharmacological, with 4 modules and 12 topics. The main objective variable was the reduction of allogenic blood transfusions and/or the number of transfused patients. The extent to which this objective was achieved by each AABT was evaluated using the Delphi method, which classifies the grade of recommendation from A (supported by controlled studies) to E (non-controlled studies and expert opinion). The experts concluded that most of the indications for AABT were based on middle or low grades of recommendation, "C", "D", or "E", thus indicating the need for further controlled studies.

Use of hemoglobin-based oxygen-carrying solution-201 to improve resuscitation parameters and prevent secondary brain injury in a swine model of traumatic brain injury and hemorrhage: laboratory investigation

OBJECT

Traumatic brain injury (TBI) often occurs as part of a multisystem trauma that may lead to hemorrhagic shock. Effective resuscitation and restoration of oxygen delivery to the brain is important in patients with TBI because hypotension and hypoxia are associated with poor outcome in head injury. We studied the effects of hemoglobin-based oxygen-carrying (HBOC)-201 solution compared with lactated Ringer (LR) solution in a large animal model of brain injury and hemorrhage, in a blinded prospective randomized study.

METHODS

Swine underwent brain impact injury and hemorrhage to a mean arterial pressure (MAP) of 40 mm Hg. Twenty swine were randomized to undergo resuscitation with HBOC-201 (6 ml/kg) or LR solution (12 ml/kg) and were observed for an average of 6.5 +/- 0.5 hours following resuscitation. At the end of the observation period, magnetic resonance (MR) imaging was performed. Histological studies of swine brains were performed using Fluoro-Jade B, a marker of early neuronal degeneration.

RESULTS

Swine resuscitated with HBOC-201 had higher MAP, higher cerebral perfusion pressure (CPP), improved base deficit, and higher brain tissue oxygen tension (PbtO(2)) than animals resuscitated with LR solution. No significant difference in total injury volume on T2-weighted MR imaging was observed between animals resuscitated with HBOC-201 solution (1155 +/- 374 mm(3)) or LR solution (1246 +/- 279 mm(3); p = 0.55). On the side of impact injury, no significant difference in the mean number of Fluoro-Jade B-positive cells/hpf was seen between HBOC-201 solution (61.5 +/- 14.7) and LR solution (48.9 +/- 17.7; p = 0.13). Surprisingly, on the side opposite impact injury, a significant increase in Fluoro-Jade B-positive cells/hpf was seen in animals resuscitated with LR solution (42.8 +/- 28.3) compared with those resuscitated with HBOC-201 solution (5.6 +/- 8.1; p < 0.05), implying greater neuronal injury in LR-treated swine.

CONCLUSIONS

The improved MAP, CPP, and PbtO(2) observed with HBOC-201 solution in comparison with LR solution indicates that HBOC-201 solution may be a preferable agent for small-volume resuscitation in brain-injured patients with hemorrhage. The use of HBOC-201 solution appears to decrease cellular degeneration in the brain area not directly impacted by the primary injury. Hemoglobin-based oxygen-carrying-201 solution may act by improving cerebral blood flow or increasing the oxygen-carrying capacity of blood, mitigating a second insult to the injured brain.

Modified haemoglobins and perfluorocarbons

After decades of research activities and product improvements in the field of artificial oxygen carriers based on either haemoglobin modifications or perfluorocarbon emulsions, these products have reached a critical stage of their development. Varieties of haemoglobin-based oxygen carriers and perfluorocarbon emulsions are under current clinical investigation. Although the clinical availability of artificial oxygen carriers may result in profound changes of fluid resuscitation from haemorrhage, the transfusion of human blood components as an integral part of medical trauma management will not be replaced. However, a rapid and effective restoration of tissue oxygenation by the use of artificial oxygen carriers in the treatment of severe haemorrhage may bridge time delays until stored and cross-matched human packed red cells are available. Whether artificial oxygen carriers could provide additional clinical benefits by sustaining tissue oxygenation even under conditions of a disturbed macro- or microcirculation is the subject of current investigations. Therefore, the application of safe and effective artificial oxygen carriers would not only be restricted to the treatment of severe haemorrhage, but additional therapeutic indications of artificial oxygen carriers in emergency medicine, trauma anaesthesia and other medical specialities would emerge.

Conjugation of methoxypolyethylene glycol to the surface of bovine red blood cells

Methoxypolyethylene glycol (mPEG) covalently bound to the surface of human red blood cells (hRBCs) has been shown to decrease immunological recognition of hRBC surface antigens (Bradley et al., 2002). However, there is an increasing shortage of hRBC donations, thus making hRBCs scarce and expensive (Davey, 2004; Riess, 2001). The goal of this study is to similarly PEGylate the surface of bovine RBCs (bRBCs) with the aim of reducing the demand on human blood donations needed for blood transfusions. This study investigates the feasibility of modifying the surface of bRBCs with the succinimidyl ester of methoxypolyethylene glycol propionic acid (SPA-mPEG) for use as a potential blood substitute. The oxygen binding affinity of PEGylated bRBCs was moderately increased with increasing initial SPA-mPEG concentrations up to 4 mM when reacted with bRBCs at a hematocrit of 12%. Oxygen transport simulations verified that SPA-mPEG conjugated bRBCs could still transport oxygen to pancreatic islet tissues even under extreme conditions. PEGylated bRBCs reconstituted to a hematocrit of 40% exhibited viscosities on the order of approximately 3 cp, similar to hRBCs at the same hematocrit. Taken together, the results of this study demonstrate the success of PEGylating bRBCs to yield modified cells with oxygen binding, transport and flow properties similar to that of hRBCs.

Biochemistry, physiology, and complications of blood doping: facts and speculation

Competition is a natural part of human nature. Techniques and substances employed to enhance athletic performance and to achieve unfair success in sport have a long history, and there has been little knowledge or acceptance of potential harmful effects. Among doping practices, blood doping has become an integral part of endurance sport disciplines over the past decade. The definition of blood doping includes methods or substances administered for non-medical reasons to healthy athletes for improving aerobic performance. It includes all means aimed at producing an increased or more efficient mechanism of oxygen transport and delivery to peripheral tissues and muscles. The aim of this review is to discuss the biochemistry, physiology, and complications of blood doping and to provide an update on current antidoping policies.

Oxygen Therapeutics: Oxygen Delivery Without Blood

Nearly 14 million units of packed red blood cells are transfused in the United States each year. According to the U.S. Department of Health and Human Services, in 1999, 6% of hospitals reported a shortage of blood, resulting in the cancellation or postponement of surgical procedures. The many limitations and risks of transfusions of packed red blood cells in critically ill patients have facilitated interest in developing alternative agents for oxygen delivery. Over the past few decades, safe and effective substitutes have been in development. However, no currently approved agent provides both oxygen transport and volume in place of packed red blood cells. Oxygen therapeutic products have several advantages compared with packed red blood cells, including a prolonged shelf-life, lack of a cross-matching requirement, and minimal infectious risks or concerns about immunogenicity. Hemoglobin-based oxygen carriers and perfluorocarbons are being developed. Two products are undergoing clinical trials. Polyheme is undergoing a phase III study in trauma patients, and Hemopure is being evaluated in a phase II study in patients undergoing cardiopulmonary bypass surgery. A third product (Hemolink) was being evaluated in a phase III study in patients undergoing coronary artery bypass grafting surgery; however, the trial was suspended. In addition, several other hemoglobin-based oxygen carriers are in the preclinical stages. Oxygen therapeutics have several potential clinical applications in the management of perioperative blood loss, trauma, acute normovolemic hemodilution, traumatic brain injury, and blood requirements in patients who refuse or have contraindications to transfusions of red blood cells.

Perioperative blood transfusion and outcome

PURPOSE OF REVIEW

As a result of advances in pathogen testing and transfusion standards over the last decade, the risk of disease transmission through allogeneic blood transfusions has decreased markedly. The effects of allogeneic blood transfusions on the immune system, however, have received more attention, as they appear to influence outcome. The following review summarizes the effects of allogeneic blood transfusions on selected outcome parameters and the influence of white blood cell reduction on these parameters.

RECENT FINDINGS

Adverse effects of allogeneic blood transfusions on outcome variables such as postoperative infection, cancer recurrence, pulmonary function, length of stay, and mortality have been shown in multiple trials, but most were not randomized or blinded. One proposed approach to reduce unwanted side-effects is to reduce the donor's white blood cell count before transfusion. This can be done either by individual bedside filtration or by pre-storage (or post-storage) universal white blood cell reduction. Studies investigating this approach have yielded conflicting results.

SUMMARY

Although the results of a number of studies suggest a negative impact of allogeneic blood transfusions on immune function and consequently outcome parameters, this has not been proven in rigorously controlled randomized trial, or in meta-analyses. Reduction of white blood cells might be beneficial in selected patient populations, but at this time does not appear warranted in the general surgical population. As universal white blood cell reduction is a very costly process, it probably should not be implemented until such a benefit is proven.

Rationale for blood conservation

BACKGROUND

Exposure of patients to allogeneic blood transfusion can be minimized or avoided by the systematic use of multiple blood conservation techniques. Current use of these technologies is variable.

METHODS

Review of pertinent English language literature.

RESULTS

Enthusiasm for preoperative autologous blood donation (PAD) has declined considerably, perhaps due to increased cost and inconvenience to patients. Acute normovolemic hemodilution (ANH) has several practical advantages over PAD, but has not become generally accepted as a blood conservation strategy. Erythropoietin, iron, and artificial oxygen carriers are pharmacologic alternatives.

CONCLUSIONS

Pharmacologic stimulation of erythropoiesis offers substantial potential to progress toward a goal of bloodless medicine. The potential of artificial blood substitutes is still being defined.

Acute Normovolemic Hemodilution

This article examines the technique of hemodilution and the consequences, benefits, efficacy, cost effectiveness, and future of acute normovolemic hemodilution.

Purification and characterization of human hemoglobin: effect of the hemolysis conditions

Human hemoglobin was isolated and purified by anion exchange chromatography. To isolate hemoglobin, outdated red blood cells (RBC) were transformed into carbonylhemoglobin, by reaction with carbon monoxide, and submitted to washing/centrifugation procedures, to eliminate other plasma proteins. Albumin was quantified in each supernatant, by the bromcresol green method. Hemolysis was performed in three different hypotonic media (water, 0.01 M NaCl and 5 mM Tris/HCl buffer at pH 7.4), at 8 degrees C for 24 h. Sonication for 5 min was also used to lyse RBC. After isolation of hemoglobin, additional purification was carried out by anion exchange chromatography on AG MP-1, Q-SFF and both exchangers. Hemoglobin concentration of hemolysates and of purified solutions were determined by the hemiglobincyanide method. Residual phospholipids were extracted from the four different hemolysates, as well as from the purified hemoglobin solutions, and were analyzed by high performance liquid chromatography. Native and SDS-polyacrylamide gel electrophoresis experiments were performed on purified hemoglobin samples to verify the presence of proteins other than hemoglobin. According to the results, the hemolysis conditions have influence on the purification of hemoglobin.

Pharmacokinetics of PEG-hemoglobin SB1, a hemoglobin-based oxygen carrier, after its intravenous administration in beagle dogs

The purpose of the present study was to investigate the pharmacokinetics of PEG-hemoglobin SB1, a modified bovine hemoglobin with polyethylene glycol, after its single and multiple administration in beagle dogs. For this purpose, the analytical method of free hemoglobin in the plasma was developed and validated. Excellent linearity (r2=0.999) was observed in the calibration curve data, with the limit of quantification of 0.005 g/dL. The precision and the deviation of the theoretical values for accuracy were always within +/-15% in both the between- and the within-day results. The method was tested by measuring the plasma concentrations following intravenous administration to beagle dogs and was shown to be suitable for pharmacokinetic studies. In a single dose study, the plasma half-life (t1/2) increased and the total body clearance (CLt) decreased with the dose (i.e., 0.017 to 0.75 gHb/kg as PEG-hemoglobin SB1) in both sexes. The volume of distribution at steady-state (Vd(ss)) showed no difference with the dose. In contrast, the values of t1/2, CLt and the area under the plasma concentration-time curve (AUC) after the multiple dose were significantly different from those of the single dose administration. The values of t1/2 in the multiple administration were about two times higher than that of the single dose. As a result, t1/2 of hemoglobin after the administration of PEG-hemoglobin SB1 was about 15-30 h, indicating the PEG modification of the hemoglobin lead to a prolongation of plasma concentration of the protein. Therefore, these observations suggested that the PEG modification of hemoglobin is potentially applicable in the hemoglobin-based therapeutics.

Oxygen therapeutics in trauma and surgery

A number of oxygen therapeutics have completed safety trials and are now undergoing efficacy evaluation in multicenter phase III trials in North America and Europe. There are numerous potential advantages of these solutions when compared with packed red blood cells. They are readily available and have a long shelf life; do not require type and cross-matching; are virtually free of viral or bacterial contamination; have a much lower viscosity than blood; and may lack the immunosuppressive effects of blood. These products may also deliver more oxygen per unit mass than an equivalent amount of hemoglobin from red blood cells, providing the potential to sustain life in certain clinical situations. A few problems remain, including short biologic half-life, which may limit the application to times when the patient is most acutely anemic (i.e., in the intraoperative or immediate perioperative phase) or for emergent use. Nevertheless, a safe, effective alternative therapy providing oxygen delivery characteristics comparable to red blood cells may soon be available that could have significant impact on the way that we resuscitate trauma patients.

Pretreatment of serum containing hemoglobin vesicles (oxygen carriers) to prevent their interference in laboratory tests

Hemoglobin vesicles (HbV, diameter: 251 +/- 81 nm) are artificial oxygen (O2) carriers encapsulating concentrated hemoglobin (Hb) solution with phospholipid bilayer membrane, and their O2 transporting ability in vivo has been extensively studied. It is important to clarify the interference of the HbV suspension in clinical laboratory tests performed on serum and to establish a pretreatment method to avoid such an interference. The HbV suspension, acellular Hb solution ([Hb] = 10 g/dl) or saline, was mixed with a pooled human serum at various ratios up to 50 vol% ([Hb] = 5 g/dl), and the magnitude of the interference effect of HbV and Hb on 30 analytes was studied. The mixture of the HbV suspension and serum was ultracentrifuged (50,000 g, 20 min) to remove the HbV particles as precipitate, and the supernatant was analyzed and compared with the saline control group. The HbV particles were also removed by centrifugation (2,700 g, 30 min) in the presence of dextran (Mw 200 kDa). The HbV suspension showed considerable interference effects in most analytes. The majority of these effects was more serious than those of the acellular Hb solution. These findings are thought to be due to the light absorption of Hb in HbV and/or the light scattering generated in the suspension that interferes with the colorimetric and turbidimetric measurements. The components of HbV may also interfere with the chemical reactions of the studied assays. However, removal of the HbV from the supernatant diminished the interference in most of the assays: this is an advantage of HbV in comparison with acellular chemically modified Hb solutions.

Transfusion medicine: looking to the future

The evolution of transfusion medicine into a clinically oriented discipline emphasising patient care has been accompanied by challenges that need to be faced as specialists look to the future. Emerging issues that affect blood safety and blood supply, such as pathogen inactivation and more stringent donor screening questions, bring new pressures on the availability of an affordable blood supply. Imminent alternatives for management of anaemia, such as oxygen carriers, hold great promise but, if available, will require close oversight. With current estimates of HIV or hepatitis C viral (HCV) transmission approaching one in 2000000 units transfused, keeping to a minimum bacterial contamination of platelet products (one in 2000) and errors in transfusion, with its estimated one in 800000 mortality rate, assume great urgency. Finally, serious difficulties in blood safety and availability for poor, developing countries require innovative strategies and commitment of resources.

Preserved gastric tonometric variables in cardiac surgical patients administered intravenous perflubron emulsion

Low gastric intramucosal pH (pHi) and an increased gastric-arterial PCO2 difference (CO2 gap) are markers of tissue hypoperfusion. Perfluorocarbons (PFCs) have a large oxygen-carrying capacity and release oxygen when encountering low tissue oxygen tension. Nine cardiac surgical patients instrumented for gastric tonometry were enrolled as part of a multicenter, randomized, single-blinded study of a PFC emulsion (perflubron emulsion [Oxygent]). Patients were randomized to receive PFC (n = 4) or placebo (n = 5) after intraoperative autologous blood harvesting by acute normovolemic hemodilution. At baseline there were no intergroup differences in tonometric-, hemodynamic-, or oxygen delivery-derived variables, e.g., Control group (pHi, 7.37 +/- 0.06; CO2 gap, 6.4 +/- 1.3 mm Hg) versus PFC group (pHi, 7.38 +/- 0.06; CO2 gap, 6.7 +/- 1.5 mm Hg). After acute normovolemic hemodilution, pHi was significantly lower (P < 0.01) in the Control group (7.22 +/- 0.25) than in the PFC group (7.44 +/- 0.25), and CO2 gap was significantly higher (P < 0.001) in the Control group (23.4 +/- 5.1 mm Hg) than in the PFC group (1.8 +/- 0.8 mm Hg). These differences in tonometric variables persisted during surgery. The PFC group showed a significantly (P < 0.007) shorter time to first bowel movement postoperatively (2.0 +/- 0.8 vs 5.4 +/- 1.6 days). Time to consumption of solid food was also shorter in the PFC group and almost achieved statistical significance (P = 0.056).

IMPLICATIONS

This study suggests that the administration of perflubron emulsion prevents gastrointestinal tract ischemia in cardiac surgical patients and may preserve postoperative gastrointestinal tract function.

Co-oximetry interference by hemoglobin-based blood substitutes

The blood substitutes now being developed from molecularly modified hemoglobin interfere with a wide variety of clinical analyzers, but their effects on cooximeters are unknown. Therefore, we investigated the effects of five hemoglobin-based blood substitutes on the measurements of eight different oximeters and cooximeters: the AVL Omni 6, the AVOXimeters 1000 and 4000, the Ciba Corning (now Bayer) CC270 CO-Oximeter, the Instrumentation Laboratory Synthesis 35, the IL482 and IL682 CO-Oximeters, and the Radiometer OSM3 Hemoximeter. The five blood substitutes in this study were obtained from Apex Bioscience (Research Triangle Park, NC), Baxter Healthcare Corp. (Deerfield, IL), Biopure Corp. (Cambridge, MA), Hemoglobin Therapeutics, and Hemosol, Inc. (Etobicoke, Ontario, Canada). A cooximeter control was used to compare the eight different instruments' measurements on unaltered human hemoglobin. The instruments yielded measurements of total hemoglobin concentration in undiluted blood substitutes that were generally not more variable than those on the control material. By contrast, when compared with readings on controls, the test instruments yielded measurements of the fractional concentrations of oxy-, deoxy-, carboxy-, and methemoglobin that showed greater instrument-to-instrument disparities and larger standard deviations about the all-instrument means. In some cases, the interference was even more obvious: five of six cooximeters gave negative carboxyhemoglobin readings on one particular product. Our findings indicate that the instruments will give less accurate but clinically useful measurements in the presence of these hemoglobin-based blood substitutes.

IMPLICATIONS

We investigated the effects of five hemoglobin-based blood substitutes on the measurements of eight different cooximeters. Some blood substitutes caused obvious interference, such as negative carboxyhemoglobin readings; however, the findings indicate that cooximeters will generally give less accurate but clinically useful measurements in the presence of the hemoglobin-based blood substitutes that were tested.

Influence of long-term preservation with endobronchially administered perfluorodecalin on pulmonary graft function

BACKGROUND

Experimental studies demonstrated a suppression of oxygen-derived free radicals, reduced adhesion of activated neutrophils on the endothelium and an increase of de novo synthesis of surfactant during liquid ventilation with perflurocarbon. The purpose of this study was to assess the pulmonary graft function after preservation with endobronchially administered perfluorocarbon as an alternative to flush perfusion.

METHODS

Native bred pigs underwent orthotopic left lung transplantation. Donor lungs were flushed in situ with either a low-potassium dextran solution (LPD, n=6) or a perfluorochemical was administered endobronchially (PFC, n=6) and were then stored after removal for 18 hr at 4 degrees C. Pulmonary graft function was assessed after reperfusion for 5 hr by measuring pulmonary gas exchange and hemodynamics during isolated ventilation and perfusion. Tissue specimens were taken for analysis of morphology and wet/dry ratio. All values were compared to a sham-operated group (n=6).

RESULTS

Pulmonary gas exchange of the graft revealed reduced paO2 values and elevated paCO2 values in the PFC group throughout the observation period as compared with the LPD group and sham group. Endothelial alterations and fibrin exudate in the PFC group were significantly more pronounced. Lungs in the LPD group showed functional and morphological recovery close to sham group.

CONCLUSIONS

Long-term preservation with endobronchially administered perfuorocarbon is possible. Impaired pulmonary graft function and pronounced morphological alterations indicate an aggravation of the ischemic reperfusion injury after lung transplantation compared to LPD preserved lungs.

Effect of alpha-alpha diaspirin crosslinked hemoglobin (DCLHb) on the potency of sodium nitroprusside and nitroglycerine to decrease blood pressure in rats: a dose-response study

The nitrovasodilators, sodium nitroprusside and nitroglycerine, effect a dose-dependent decrease in mean arterial blood pressure (MABP) by liberating nitric oxide. Alpha-alpha diaspirin crosslinked hemoglobin (DCLHb) is known to bind nitric oxide. We studied the effect of DCLHb on the potency of sodium nitroprusside (n=36) and nitroglycerine (n=36) to decrease MABP in rats which received 1, 10, 100, 1,000, or 10,000 mg/kg of the DCLHb, or normal saline as the Control. Six doses of sodium nitroprusside or nitroglycerine were given to each rat in a systematically varied sequence. For both drugs, in rats given 1, 10, or 100 mg/kg of DCLHb there were no between groups differences in the change in MABP compared to the Control group. For rats that received 1,000 or 10,000 mg/kg of DCLHb, the potency of nitroglycerine and sodium nitroprusside to decrease MABP was less (p<0.05) than the other groups. These data support the hypothesis that small doses of DCLHb effect a minimal change in the potency of nitrovasodilators to reduce blood pressure. However, they suggest that clinically relevant doses of DCLHb attenuate the vasodilatory ability of sodium nitroprusside and nitroglycerine.

Blood conservation in patients undergoing non-cardiac surgery

Concerns about the safety, inventory, and cost of allogeneic blood have led to a renewed interest in blood conservation. Autologous blood collection techniques, including preoperative autologous donation, acute normovolemic hemodilution, and perioperative blood recovery are routinely used as alternatives to allogeneic transfusion. In the future, these techniques may be combined with pharmacological strategies, such as presurgical erythropoietin therapy or red cell substitutes, to reduce further the need for allogeneic blood.

Biochemical aspects of the reaction of hemoglobin and NO: implications for Hb-based blood substitutes

The role of Hemoglobin (Hb) on nitric oxide (NO) biology has received much attention. Until recently, the reaction between erythrocytic Hb and NO was generally considered in the context of mechanisms that safely detoxify NO. However, recent insights suggest that properties associated with the red blood cell limit NO-Hb interactions under physiological conditions, and provide some resolution to the question of how NO functions in the presence of blood. Furthermore, Hb-dependent mechanisms that preserve, not destroy NO bioactivity in vivo have also been proposed. The emerging picture suggests that the interplay between NO and erythrocytic Hb is important in regulating the functions of both these molecules in vivo. However, Hb-dependent scavenging and loss of NO function is significant when this heme protein is present outside the red blood cell. This can occur during hemolysis or administration of Hb-based blood substitutes. Scavenging of NO is a significant problem that limits the use of Hb-based blood substitutes in the clinic, and development of Hb molecules that do not efficiently react with NO remains an important area of investigation. In this article, the reactions between NO and erythrocytic Hb or cell-free Hb are described and the effects on NO and Hb function in vivo and development of blood substitutes discussed.

The reduction of the allogenic transfusion requirement in aortic surgery with a hemoglobin-based solution

OBJECTIVE

Because of allogenic red blood cell (RBC) availability and infection problems, novel alternatives, including hemoglobin-based oxygen-carrying solutions (HBOC), are being explored to minimize the perioperative requirement of RBC transfusions. This study evaluated HBOC-201, a room-temperature stable, polymerized, bovine-HBOC, as a substitute for allogenic RBC transfusion in patients undergoing elective infrarenal aortic operations.

METHODS

In a single blind, multicenter trial, 72 patients were prospectively randomized two-to-one to HBOC (n = 48) or allogenic RBC (n = 24) at the time of the first transfusion decision, either during or after elective infrarenal aortic reconstruction. Patients randomized to the HBOC group received 60 g of HBOC for the initial transfusion and had the option to receive three more doses (30 g each) within 96 hours. In this group, any further blood requirement was met with allogenic RBCs. Patients randomized to the allogenic RBC group received only standard RBC transfusions. The efficacy analysis was a means of assessing the ability of HBOC to eliminate the requirement for any allogenic RBC transfusions from the time of randomization through 28 days. Safety was evaluated by means of standard clinical trial methods.

RESULTS

The two treatment groups were comparable for all baseline characteristics. Although all patients in the allogenic RBC group required at least one allogenic RBC transfusion, 13 of 48 patients (27%; 95% CI, 15% to 42%) in the HBOC group did not require any allogenic RBC transfusions. The only significant changes documented were a 15% increase in mean arterial pressure and a three-fold peak increase in serum urea nitrogen concentration after HBOC. The complications were similar in both groups, with no allergic reactions. There were two perioperative deaths (8%) in the allogenic RBC group and three perioperative deaths (6%) in the HBOC group (P = 1.0).

CONCLUSION

HBOC significantly eliminated the need for any allogenic RBC transfusion in 27% of patients undergoing infrarenal aortic reconstruction, but did not reduce the median allogenic RBC requirement. HBOC transfusion was well tolerated and did not influence morbidity or mortality rates.

Chemical characterization of pyridoxalated hemoglobin polyoxyethylene conjugate

Pyridoxalated hemoglobin polyoxyethylene conjugate (PHP) was developed in the 1980s as an oxygen carrier and is now under development for treatment of nitric oxide-dependent, volume refractory shock. PHP is made by derivatizing human stroma-free hemoglobin with pyridoxal-5-phosphate and polyoxyethylene (POE). A unique aspect of using POE for modification is that unlike its mono-methoxy polyethylene glycol (PEG) relatives, POE is bifunctional. The result of derivatization of stroma-free hemoglobin is a complex mixture of modified hemoglobin and other red cell proteins. The molecular weight profile, based on size exclusion chromatography, is bimodal and has a number average molecular weight of approximately 105¿ omitted¿000 and a weight average molecular weight of approximately 187¿ omitted¿000. The mixture of hemoglobin molecules has on average 3.3 pyridoxal and 5.0 polyoxyethylene units per tetramer. A portion of the tetramers are linked by POE crosslinks. The hemoglobin tetramers retain their ability to dissociate into dimer pairs and only a small percentage of the dimer pairs are not modified with POE. The SDS-PAGE profile exhibits the ladder-like appearance commonly associated with polyethylene glycol-modified proteins. The isoelectric focusing profile is broad, demonstrating a pI range of 5.0-6.5. The hydrodynamic size of PHP was determined to be approximately 7.2 nm by dynamic light scattering. Soluble red blood cell proteins, such as catalase, superoxide dismutase, and carbonic anhydrase, are present in PHP and are also modified by POE.