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Zhang J, Cao S, Kwansa H, Crafa D, Kibler KK, Koehler RC. Transfusion of hemoglobin-based oxygen carriers in the carboxy state is beneficial during transient focal cerebral ischemia. J Appl Physiol (1985) 2012; 113:1709-17. [PMID: 23042910 DOI: 10.1152/japplphysiol.01079.2012] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Exchange transfusion of large volumes of hemoglobin (Hb)-based oxygen carriers can protect the brain from middle cerebral artery occlusion (MCAO). Hb in the carboxy state (COHb) may provide protection at relatively low volumes by enhancing vasodilation. We determined whether transfusion of rats with 10 ml/kg PEGylated COHb [polyethylene glycol (PEG)-COHb] at 20 min of 2-h MCAO was more effective in reducing infarct volume compared with non-carbon monoxide (CO) PEG-Hb. After PEG-COHb transfusion, whole blood and plasma COHb was <3%, indicating rapid release of CO. PEG-COHb transfusion significantly reduced infarct volume (15 ± 5% of hemisphere; mean ± SE) compared with that in the control group (35 ± 6%), but non-CO PEG-Hb did not (24 ± 5%). Chemically dissimilar COHb polymers were also effective. Induction of MCAO initially produced 34 ± 2% dilation of pial arterioles in the border region that subsided to 10 ± 1% at 2 h. Transfusion of PEG-COHb at 20 min of MCAO maintained pial arterioles in a dilated state (40 ± 5%) at 2 h, whereas transfusion of non-CO PEG-Hb had an intermediate effect (22 ± 3%). When transfusion of PEG-COHb was delayed by 90 min, laser-Doppler flow in the border region increased from 57 ± 9 to 82 ± 13% of preischemic baseline. These data demonstrate that PEG-COHb is more effective than non-CO PEG-Hb at reducing infarct volume, sustaining cerebral vasodilation, and improving collateral perfusion in a model of transient focal cerebral ischemia when given at a relatively low dose (plasma Hb concentration < 1 g/dl). Use of acellular Hb as a CO donor that is rapidly converted to an oxygen carrier in vivo may permit potent protection at low transfusion volumes.
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Affiliation(s)
- Jian Zhang
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, Maryland 21287, USA
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Klaus JA, Kibler KK, Abuchowski A, Koehler RC. Early treatment of transient focal cerebral ischemia with bovine PEGylated carboxy hemoglobin transfusion. ACTA ACUST UNITED AC 2011; 38:223-9. [PMID: 20486873 DOI: 10.3109/10731199.2010.488635] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The effect of transfusion of PEGylated hemoglobin (PEG-Hb) was evaluated in anesthetized rats subjected to 2 hours of focal cerebral ischemia and 1 day of reperfusion. PEG-Hb was stored in the carboxy state (PEG-COHb) to reduce autooxidation and increase the shelf life. Transfusion of 10 ml/kg of PEG-COHb at 20 minutes of ischemia did not alter arterial blood pressure or increase red cell flux in the ischemic core. Plasma hemoglobin increased to only 0.6 g/dL, yet infarct volume was markedly decreased and neurological deficits were improved. We conclude that early topload transfusion of PEG-COHb protects the brain from ischemic stroke.
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Affiliation(s)
- Judith A Klaus
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University/JHMI, 600 North Wolfe Street, Baltimore, MD 21287, USA
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Creteur J, Vincent JL. Potential uses of hemoglobin-based oxygen carriers in critical care medicine. Crit Care Clin 2009; 25:311-24, Table of Contents. [PMID: 19341911 DOI: 10.1016/j.ccc.2008.12.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hemoglobin-based oxygen carriers (HBOCs) were initially developed to provide an alternative to blood transfusion. With the realization that hemoglobin solutions not only are red blood cell substitutes but also have a number of additional properties, including hemodynamic effects related to their oncotic and nitric oxide-scavenging effects, the broader concept of "hemoglobin therapeutics" was born. Promising effects on oxygen transport and the microcirculation need to be confirmed, and the results of studies with newer, second-generation HBOCs are eagerly awaited. In the meantime, possible adverse effects need to be carefully evaluated before HBOCs can be widely used in the ICU, emergency room, or prehospital setting.
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Affiliation(s)
- Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
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Mito T, Nemoto M, Kwansa H, Sampei K, Habeeb M, Murphy SJ, Bucci E, Koehler RC. Decreased damage from transient focal cerebral ischemia by transfusion of zero-link hemoglobin polymers in mouse. Stroke 2008; 40:278-84. [PMID: 18988905 DOI: 10.1161/strokeaha.108.526731] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND PURPOSE Transfusion of large polymers of hemoglobin avoids the peripheral extravasation and hypertension associated with crosslinked tetrameric hemoglobin transfusion and may be more effective in rescuing brain from focal ischemia. Effects of transfusion of high-oxygen-affinity hemoglobin polymers of different weight ranges were determined. METHODS Hypervolemic exchange transfusion was performed during 2 hours of middle cerebral artery occlusion in mice. RESULTS Compared to transfusion with a 5% albumin solution or no transfusion, infarct volume was reduced 40% by transfusion of a 6% solution containing hemoglobin polymers in the nominal range 500 to 14 000 kDa. Infarct volume was not significantly reduced by transfusion of a lower concentration of 2% to 3% of this size range of polymers, 6% hemoglobin solutions without removal of polymers <500 kDa or >14000 kDa, or crosslinked hemoglobin tetramers with normal oxygen affinity. Exchange transfusion with the 6% solution of the 500 to 14 000 kDa hemoglobin polymers did not improve the distribution of cerebral blood flow during focal ischemia and, in mice without ischemia, did not affect flow to brain or other major organs. CONCLUSIONS An intermediate size range of polymerized bovine hemoglobin possessing high oxygen affinity appears optimal for rescuing mouse brain from transient focal cerebral ischemia. A minimum concentration of a 6% solution is required, the rescue is superior to that obtained with crosslinked tetrameric hemoglobin possessing normal oxygen affinity, and tissue salvage is not associated with increased blood flow. This polymer solution avoids the adverse effects of severe renal and splanchnic vasoconstriction seen with crosslinked tetrameric hemoglobin.
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Affiliation(s)
- Toshiaki Mito
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 1404, Baltimore, MD 21287, USA
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Nemoto M, Mito T, Brinigar WS, Fronticelli C, Koehler RC. Salvage of focal cerebral ischemic damage by transfusion of high O2-affinity recombinant hemoglobin polymers in mouse. J Appl Physiol (1985) 2006; 100:1688-91. [PMID: 16424069 PMCID: PMC1764455 DOI: 10.1152/japplphysiol.01374.2005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Cell-free hemoglobin solutions with high oxygen affinity might be beneficial for selectively delivering oxygen to ischemic tissue. A recombinant hybrid hemoglobin molecule was designed using the human alpha-subunit and the bovine beta-subunit, with placement of surface cysteines to permit disulfide bond polymerization of the tetramers. The resulting protein generated from an Escherichia coli expression system had a molecular mass >1 MDa, a P50 of approximately 3 Torr, and a cooperativity of n = 1.0. Anesthetized mice were transfused during 2-h occlusion of the middle cerebral artery. Compared with transfusion with 5% albumin, cerebral infarct volume was reduced by 41% with transfusion of a 3% solution of the high oxygen-affinity hemoglobin polymer and by 50% with transfusion of a 6% solution of the polymer. Transfusion of a 6% solution of a 500-kDa polymer possessing a P50 of 17 Torr and a cooperativity of n = 2.0 resulted in a 66% reduction of infarct volume. These results indicate that cell-free Hb polymers with P50 values much lower than that of red blood cell hemoglobin are highly capable of salvaging ischemic brain. The assumption that the P50 of blood substitutes should be similar to that of blood might not be warranted when used during ischemic conditions.
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Affiliation(s)
- Masaaki Nemoto
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, Maryland; and
| | - Toshiaki Mito
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, Maryland; and
| | | | - Clara Fronticelli
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, Maryland; and
| | - Raymond C. Koehler
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, Maryland; and
- Address for reprint requests and other correspondence: R. C. Koehler, Dept. of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, 600 North Wolfe St., Blalock 1404, Baltimore, MD 21287 (e-mail: )
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Malhotra AK, Schweitzer JB, Fox JL, Fabian TC, Proctor KG. Cerebral Perfusion Pressure Elevation with Oxygen-Carrying Pressor after Traumatic Brain Injury and Hypotension in Swine. ACTA ACUST UNITED AC 2004; 56:1049-57. [PMID: 15179245 DOI: 10.1097/01.ta.0000127765.75643.66] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Previously, we had shown that elevation of cerebral perfusion pressure, using pressors, improved short-term outcomes after traumatic brain injury and hemorrhagic shock in swine. The current study evaluates outcomes after resuscitation with diaspirin cross-linked hemoglobin (DCLHb)--a hemoglobin-based oxygen carrier with pressor activity--in the same swine model of traumatic brain injury and hemorrhagic shock. METHODS Anesthetized and ventilated swine received traumatic brain injury via cortical fluid percussion (6-8 atm) followed by 45% blood volume hemorrhage. One hour later, animals were randomized to either a control group (SAL) resuscitated with normal saline equal to three times shed blood volume or to one of two experimental groups resuscitated with DCLHb. The two experimental groups consisted of a low-dose group, resuscitated with 250 mL of DCLHb (Hb1), and a high-dose group, resuscitated with 500 mL of DCLHb (Hb2). Animals were observed for 210 minutes postresuscitation. Outcomes evaluated were cerebral oxygenation by measuring partial pressure and saturation of oxygen in cerebrovenous blood; cerebral function by evaluating the preservation and magnitude of cerebrovascular carbon dioxide reactivity; and brain structural damage by semiquantitatively assessing beta amyloid precursor protein positive axons. RESULTS Postresuscitation, cerebral perfusion pressure was higher in the DCLHb groups (p < 0.05, Hb1 and Hb2 vs. SAL), and intracranial pressure was lower in the Hb2 group (p < 0.05 vs. SAL). Cerebrovenous oxygen level was similar in all groups (p > 0.05). At baseline, 5% carbon dioxide evoked a 16 +/- 1% increase in cerebrovenous oxygen saturation, indicating vasodilatation. At 210 minutes, this response was nearly absent in SAL (4 +/- 4%) (p < 0.05 vs. baseline) and Hb1 (1 +/- 5%), but was partially preserved in Hb2 (9 +/- 5%). There was no intergroup difference in beta amyloid precursor protein positive axons. Five of 20 SAL and 0 of 13 DCLHb animals developed brain death (flat electroencephalogram) (p = 0.05, SAL vs. DCLHb). Postresuscitation, DCLHb animals maintained higher mean pulmonary arterial pressure (28 +/- 1 mm Hg, SAL; 42 +/- 1 mm Hg, Hb1; 45 +/- 1 mm Hg, Hb2) (p < 0.05, Hb1 and Hb2 vs. SAL) and lower cardiac output (3.9 +/- 1.6 L/min, SAL; 2.6 +/- 0.1 L/min, Hb1; 2.7 +/- 0.1 L/min, Hb2) (p < 0.05, Hb1 and Hb2 vs. SAL). Three Hb2 animals died as a result of cardiac failure, and one SAL animal died as a result of irreversible shock. CONCLUSION In this swine model of traumatic brain injury and hemorrhagic shock, resuscitation with DCLHb maintained a higher cerebral perfusion pressure. Low-dose DCLHb (minimal increase in oxygen carriage) failed to significantly improve short-term outcome. With high-dose DCLHb (significant improvement in oxygen carriage), intracranial pressure was lower and cerebrovascular carbon dioxide reactivity was partially preserved; however, this was at the cost of poorer cardiac performance secondary to high afterload.
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Affiliation(s)
- Ajai K Malhotra
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
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Abstract
OBJECTIVE To review current knowledge about cell-free hemoglobin solutions. DATA SOURCE A computerized MEDLINE search was used to retrieve all studies concerning cell-free hemoglobin solutions from 1990 to 2003. The reference lists of all available review articles and primary studies were also reviewed to identify references not identified in the computerized search. STUDY SELECTION All clinical and experimental studies involving cell-free hemoglobin solutions were included. DATA EXTRACTION From the selected studies, information was obtained regarding the experimental model or the study population in which cell-free hemoglobin solutions were investigated, the type of cell-free hemoglobin solution used, their deleterious or beneficial effects, and their possible indications. DATA SYNTHESIS In many studies, hemoglobin solutions were considered as efficient resuscitative agents and good alternatives to red blood cell transfusion, owing to their marked vasopressor effect, coupled with their capacity to improve the microcirculation and rapidly restore metabolic parameters. The main problems identified include excessive systemic vasoconstriction and oxidative damage. Initial enthusiasm in the development of hemoglobin solutions has been tempered recently by the negative results of a U.S. multicenter trial studying the early infusion of diaspirin cross-linked hemoglobin in trauma patients. Nevertheless, the properties of diaspirin cross-linked hemoglobin (and particularly the strong vasopressor effects) cannot be attributed to all hemoglobin solutions, and results of new clinical studies are eagerly awaited to evaluate the potential benefit of such solutions in the management of trauma patients. CONCLUSIONS Today, we are aware of the effects of the first generation of blood substitutes. Further research is ongoing into newer solutions. One area of interest is the development of new molecular structures to decrease nitric oxide binding, thus minimizing any adverse events and maximizing potential benefits. Nevertheless, possible adverse effects need to be carefully evaluated before these agents can be widely administered.
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Affiliation(s)
- Jacques Creteur
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Belgium
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Contaldo C, Schramm S, Wettstein R, Sakai H, Takeoka S, Tsuchida E, Leunig M, Banic A, Erni D. Improved oxygenation in ischemic hamster flap tissue is correlated with increasing hemodilution with Hb vesicles and their O2 affinity. Am J Physiol Heart Circ Physiol 2003; 285:H1140-7. [PMID: 12738620 DOI: 10.1152/ajpheart.00285.2003] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The aim of this study was to test the influence of oxygen affinity of Hb vesicles (HbVs) and level of blood exchange on the oxygenation in collateralized, ischemic, and hypoxic hamster flap tissue during normovolemic hemodilution. Microhemodynamics were investigated with intravital microscopy. Tissue Po2 was measured with Clark-type microprobes. HbVs with a P50 of 15 mmHg (HbV15) and 30 mmHg (HbV30) were suspended in 6% Dextran 70 (Dx70). The Hb concentration of the solutions was 7.5 g/dl. A stepwise replacement of 15%, 30%, and 50% of total blood volume was performed, which resulted in a gradual decrease in total Hb concentration. In the ischemic tissue, hemodilution led to an increase in microvascular blood flow to maximally 141-166% of baseline in all groups (median; P < 0.01 vs. baseline, not significant between groups). Oxygen tension was transiently raised to 121 +/- 17% after the 30% blood exchange with Dx70 (P < 0.05), whereas it was increased after each step of hemodilution with HbV15-Dx70 and HbV30-Dx70, reaching 217 +/- 67% (P < 0.01) and 164 +/- 33% (P < 0.01 vs. baseline and other groups), respectively, after the 50% blood exchange. We conclude that despite a decrease in total Hb concentration, the oxygenation in the ischemic, hypoxic tissue could be improved with increasing blood exchange with HbV solutions. Furthermore, better oxygenation was obtained with the left-shifted HbVs.
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Affiliation(s)
- Claudio Contaldo
- Division Orthopedic, Reconstructive and Hand Surgery, Inselspital University Hospital, CH-3010 Berne, Switzerland
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9
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Erni D, Wettstein R, Schramm S, Contaldo C, Sakai H, Takeoka S, Tsuchida E, Leunig M, Banic A. Normovolemic hemodilution with Hb vesicle solution attenuates hypoxia in ischemic hamster flap tissue. Am J Physiol Heart Circ Physiol 2003; 284:H1702-9. [PMID: 12521933 DOI: 10.1152/ajpheart.00821.2002] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The aim of this study was to test whether oxygenation in acutely ischemic, collateralized tissue may be improved by normovolemic hemodilution with a solution containing liposome-encapsulated human Hb (HbV). A skin flap model in anesthetized hamsters was used, which consisted of two parts receiving either anatomic or collateral perfusion. Microhemodynamics were investigated with intravital microscopy. Partial tissue oxygen tension was measured with a Clark-type microprobe. Hemodilution was obtained by exchanging 50% of the total blood volume with HbV suspended in 8% human serum albumin (HSA8) or 6% Dextran 70 (Dx70). The size of the vesicles was 276 nm, the P(50) was 22 mmHg, and the Hb concentration of the solutions was 7.5 g/dl. Colloid osmotic pressure and viscosity were 49.9 mmHg and 8.7 cP for HbV-Dx70 and 40.0 mmHg and 2.9 cP for HbV-HSA8, respectively. Hemodilution with HbV-Dx70 led to an increase in microvascular blood flow in the ischemic microvessels to maximally 158% (median, P < 0.01), whereas blood flow remained virtually unchanged after hemodilution with HbV-HSA8. In the ischemic tissue, oxygen tension was improved from 11.9 to 17.0 mmHg (P < 0.01) after hemodilution with HbV-Dx70 but remained virtually unchanged after hemodilution with HbV-HSA8. Our study suggests that the oxygenation in acutely ischemic, collateralized tissue may be improved by normovolemic hemodilution with HbV suspended in Dx70. The effect was achieved by an increase in microcirculatory blood flow related to the rheological properties of the suspending medium.
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Affiliation(s)
- Dominique Erni
- Department of Orthopedic, Plastic, and Hand Surgery, Inselspital University Hospital, 3010 Berne, Switzerland.
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Bedell E, Prough DS. Anesthetic management of traumatic brain injury. ANESTHESIOLOGY CLINICS OF NORTH AMERICA 2002; 20:417-39. [PMID: 12166003 DOI: 10.1016/s0889-8537(01)00010-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The management of TBI remains an important and frustrating component of the practice of anesthesiology and critical care medicine. The difficulties in management of TBI as well as the poor response rates to medical therapy after TBI are not new. The following passage appeared in the introductory chapter of a text on TBI from 1897: "The manner of treatment is of importance in only a minority of cases, since many subjects of intracranial injury are fated to die whatever measures may be adopted for their relief, and a still greater number are destined to recover though left entirely to the resources of nature. It is probable that in by far the larger proportion of cases in which the issue is determined by treatment it is met in the initial stage, and by insuring restoration from primary shock" [111]. Although secondary insults from factors such as hypotension, hypoxemia, and hyperventilation increase morbidity and mortality, data are not yet available to indicate whether scrupulous prevention and prompt treatment of secondary injuries will reduce morbidity and mortality. In addition, no specific intervention to date has improved overall long-term outcome. With ongoing research, perhaps active interventions will become available. Until that time, thoughtful and careful attention to physiologic management provides the greatest opportunity for a good outcome.
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Affiliation(s)
- Eric Bedell
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd., Galveston, TX 77555-0591, USA.
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Rebel A, Ulatowski JA, Joung K, Bucci E, Traystman RJ, Koehler RC. Regional cerebral blood flow in cats with cross-linked hemoglobin transfusion during focal cerebral ischemia. Am J Physiol Heart Circ Physiol 2002; 282:H832-41. [PMID: 11834476 DOI: 10.1152/ajpheart.00880.2001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The beneficial effect of hemodilution on cerebral blood flow (CBF) during focal cerebral ischemia is mitigated by reduced arterial oxygen content (CaO2). In anesthetized cats subjected to permanent middle cerebral artery occlusion, the time course of regional CBF was evaluated after isovolemic exchange transfusion with either albumin or a tetrameric hemoglobin-based oxygen carrier. The transfusion started 30 min after arterial occlusion. We tested the hypothesis that bulk oxygen transport (CBF x CaO2) to ischemic tissue is increased by hemoglobin transfusion at a hematocrit of 18% compared with albumin-transfused cats at a hematocrit of 18% or control cats at a hematocrit of 30% and equivalent arterial pressure. In the nonischemic hemisphere, CBF increased selectively after albumin transfusion, and oxygen transport was similar among groups. In the ischemic cortex, albumin transfusion increased CBF, but oxygen transport was not increased above that of the control group. Hemoglobin transfusion increased both CBF and oxygen transport in the ischemic cortex above values in the control group, but the increase was delayed until 4 h of ischemia. Consequently, acute injury volume measured at 6 h of ischemia was not significantly attenuated. In contrast to the cortex, CBF in the ischemic caudate nucleus was not substantially increased by either albumin or hemoglobin transfusion. Therefore, in a large animal model of permanent focal ischemia in which transfusion starts 30 min after ischemia, tetrameric cross-linked hemoglobin transfusion can augment oxygen transport to the ischemic cortex, but the increase can be delayed and not necessarily provide protection. Moreover, an end-artery region such as the caudate nucleus is less likely to benefit from hemodilution.
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Affiliation(s)
- Annette Rebel
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland 21205, USA
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Liu Y, Belayev L, Zhao W, Busto R, Belayev A, Ginsberg MD. Neuroprotective effect of treatment with human albumin in permanent focal cerebral ischemia: histopathology and cortical perfusion studies. Eur J Pharmacol 2001; 428:193-201. [PMID: 11675036 DOI: 10.1016/s0014-2999(01)01255-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In recent experimental studies, we demonstrated a highly beneficial neuroprotective effect of moderate- to high-dose human albumin treatment of transient focal cerebral ischemia, but we did not define the effect of albumin therapy in permanent focal cerebral ischemia. In this study, anesthetized Sprague-Dawley rats were subjected to permanent middle cerebral artery occlusion by retrograde insertion of an intraluminal nylon suture coated with poly-L-lysine. Albumin was administered i.v. at 2 h after onset of middle cerebral artery occlusion, in doses of either 1.25 (n=8) or 2.5 g/kg (n=6). In a separate group of animals, albumin (2.5 g/kg) was given 1 h after middle cerebral artery occlusion (n=6). Vehicle-treated rats (n=6) received 0.9% saline in equivalent volumes. Neurological status was evaluated during and 24 h after middle cerebral artery occlusion. One day after middle cerebral artery occlusion, infarct volumes and brain edema were determined. In a separate group of animals, cortical perfusion was assessed by Laser-Doppler perfusion imaging. Albumin (1.25 g/kg; n=3) or vehicle (sodium chloride 0.9%; n=3) was administered at 2 h after onset of middle cerebral artery occlusion. Higher-dose albumin therapy (2.5 g/kg) significantly improved the neurological score compared to vehicle rats at 24 h, when administered at either 1 or 2 h after middle cerebral artery occlusion. Total infarct volume was reduced by albumin (2.5 g/kg given at 2 h) by 32% compared with vehicle-treated rats. Both albumin doses (1.25 and 2.5 g/kg) significantly reduced cortical and striatal infarct areas at several coronal levels when administered at 2 h after middle cerebral artery occlusion. Brain swelling was not affected by albumin treatment. Cortical perfusion declined during middle cerebral artery occlusion in both groups. Treatment with albumin led to 48% increases in cortical perfusion (P<0.002), but saline caused no change. These results support a beneficial effect of albumin therapy in permanent focal cerebral ischemia.
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Affiliation(s)
- Y Liu
- Cerebral Vascular Disease Research Center, Department of Neurology (D4-5), University of Miami School of Medicine, P.O. Box 016960, Miami, FL 33101, USA
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Riess JG. Oxygen carriers ("blood substitutes")--raison d'etre, chemistry, and some physiology. Chem Rev 2001; 101:2797-920. [PMID: 11749396 DOI: 10.1021/cr970143c] [Citation(s) in RCA: 544] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- J G Riess
- MRI Institute, University of California at San Diego, San Diego, CA 92103, USA.
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14
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Belayev L, Liu Y, Zhao W, Busto R, Ginsberg MD. Human albumin therapy of acute ischemic stroke: marked neuroprotective efficacy at moderate doses and with a broad therapeutic window. Stroke 2001; 32:553-60. [PMID: 11157196 DOI: 10.1161/01.str.32.2.553] [Citation(s) in RCA: 218] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We examined the neuroprotective efficacy of moderate-dose human albumin therapy in acute focal ischemic stroke and defined the therapeutic window after stroke onset, within which this therapy would confer neurobehavioral and histopathological neuroprotection. METHODS Sprague-Dawley rats were anesthetized with halothane/nitrous oxide and received 2-hour middle cerebral artery occlusion (MCAo) by a poly-L-lysine-coated intraluminal suture. Neurological status was evaluated during occlusion (60 minutes) and daily for 3 days after MCAo. In the dose-response study, human albumin doses of either of 0.63 or 1.25 g/kg or saline vehicle (5 mL/kg) were given intravenously immediately after suture removal. In the therapeutic window study, a human albumin dose of 1.25 g/kg was administered intravenously at 2 hours, 3 hours, 4 hours, or 5 hours after onset of MCAo. Three days after MCAo, brains were perfusion-fixed, and infarct volumes and brain swelling were determined. RESULTS Moderate-dose albumin therapy significantly improved the neurological score at 24 hours, 48 hours, and 72 hours and significantly reduced total infarct volume (by 67% and 58%, respectively, at the 1.25- and 0.63-g/kg doses). Cortical and striatal infarct volumes were also significantly reduced by both doses. Brain swelling was virtually eliminated by albumin treatment. Even when albumin therapy (1.25 g/kg) was initiated as late as 4 hours after onset of MCAo, it improved the neurological score and markedly reduced infarct volumes in cortex (by 68%), subcortical regions (by 52%), and total infarct (by 61%). CONCLUSIONS Moderate-dose albumin therapy markedly improves neurological function and reduces infarction volume and brain swelling, even when treatment is delayed up to 4 hours after onset of ischemia.
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Affiliation(s)
- L Belayev
- Cerebral Vascular Disease Research Center, Department of Neurology, University of Miami School of Medicine, Miami, FL 33101, USA
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Erhart SM, Cole DJ, Patel PM, Drummond JC, Burhop KE. 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. ARTIFICIAL CELLS, BLOOD SUBSTITUTES, AND IMMOBILIZATION BIOTECHNOLOGY 2000; 28:385-96. [PMID: 11009111 DOI: 10.3109/10731190009118583] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- S M Erhart
- Department of Anesthesiology, Loma Linda University, CA 92354, USA
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Abstract
OBJECTIVE To review current knowledge about cell-free hemoglobin solutions. DATA SOURCES All studies involving cell-free hemoglobin were retrieved from a computerized MEDLINE search from 1980 to 1998. We also reviewed the reference lists of all available review articles and primary studies to identify references not found in the computerized search. STUDY SELECTION Clinical and experimental studies in which cell-free hemoglobin solutions were studied. DATA EXTRACTION From the selected studies, information was obtained regarding the experimental model or the study population in which cell-free hemoglobin solutions were investigated, the type of cell-free hemoglobin solution, their deleterious or beneficial effects, and their possible indications. DATA SYNTHESIS In many studies, hemoglobin solutions were considered as efficient resuscitative agents and good alternatives to red blood cell transfusion, because of their marked vasopressor effect coupled with their capacity to improve the microcirculation and quickly restore metabolic parameters. Nevertheless, potential problems include an increased susceptibility to infection, immunosuppression, oxidative damage, excessive pulmonary and systemic vasoconstriction, and platelet activation. CONCLUSIONS Hemoglobin solutions are more than mere blood substitutes. Promising effects on oxygen transport and the microcirculation need to be confirmed, and the results of continuing research are eagerly awaited.
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Affiliation(s)
- J Creteur
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Belgium
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Bruder N, Gouvitsos F. [Vascular loading in the first 24 hours following severe head injuries]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2000; 19:316-25. [PMID: 10836121 DOI: 10.1016/s0750-7658(99)00151-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The main goal at the acute phase of head injury is to prevent a decrease in blood pressure, which promotes cerebral ischemia. Volume loading is therefore frequently indicated. A normal or increased plasma osmolarity should be maintained. Thus hypotonic fluids should be avoided. Hyperglycaemia is also a risk factor for brain injury and glucose use has to be restricted in the first hours after trauma. Isotonic saline 0.9% is the first solution to be infused. Lactated Ringer solutions are mildly hypotonic as approximately 114 mL of free water is contained in each litre of the solution. Isotonic colloids are indicated to replace blood losses, but have no advantage over cristalloids, concerning the development of cerebral oedema. Fluid restriction minimally affects cerebral edema. Because of the severe consequences of hypovolaemia and hypotension, fluids should not be restricted until haemodynamic stability is achieved. Hypertonic fluids rapidly restore intravascular volume and decrease intracranial pressure. Although they probably have a place in prehospital intensive therapy, the demonstration of their benefit is still lacking. Monitoring of intravascular volume is essential. Continuous arterial pressure and central venous pressure monitoring are mandatory. New monitoring techniques as the measurement of systolic pressure variations or transoesophageal Doppler echocardiography will probably find a place in the management of trauma patients in the near future.
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Affiliation(s)
- N Bruder
- Département d'anesthésie-réanimation, hôpital Timone, Marseille, France
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Mackensen GB, Nellgård B, Sarraf-Yazdi S, Dexter F, Steffen RP, Grocott HP, Warner DS. Post-ischemic RSR13 amplifies the effect of dizocilpine on outcome from transient focal cerebral ischemia in the rat. Brain Res 2000; 853:15-21. [PMID: 10627303 DOI: 10.1016/s0006-8993(99)02212-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In a recent study of focal cerebral ischemia in rats, pre-ischemic administration of the synthetic allosteric hemoglobin modifier RSR13 (2-[4-[[3,5-dimethylanilino) carbonyl] methyl] phenoxy]-2-methylproprionic acid) reduced cerebral infarct size when combined with the NMDA receptor antagonist dizocilpine (MK-801) but not when given alone. We hypothesized that post-ischemic RSR13 administration would enhance neuroprotection afforded by NMDA receptor antagonism in a rat model of transient middle cerebral artery occlusion (MCAO). Fasted normothermic Wistar rats underwent 75 min of temporary MCAO. At onset of reperfusion, rats randomly received: (1) 0.9% NaCl (vehicle) i.v. alone (n=16); (2) 0.9% NaCl+dizocilpine (0.25 mg/kg) i.v. (n=16); or (3) RSR13 (150 mg/kg)+dizocilpine (0.25 mg/kg) i.v. (n=17). Seven days later, neurologic deficit and cerebral infarct size were determined. Dizocilpine alone compared to vehicle reduced mean+/-S.D. subcortical (52+/-24 mm(3) vs. 122+/-64 mm(3), P=0.003) and cortical (35+/-35 mm(3) vs. 125+/-72 mm(3), P=0.00074) infarct volumes. When compared to dizocilpine alone, the combination of RSR13+dizocilpine further reduced subcortical (37+/-14 mm(3) vs. 52+/-24 mm(3), P=0. 034) and cortical (8+/-19 mm(3) vs. 35+/-35 mm(3), P=0.018) infarct size. RSR13+dizocilpine improved neurologic scores vs. either dizocilpine alone (P=0.0014) or vehicle (P=10(-7)). The combination of NMDA receptor antagonism and a RSR13 mediated rightward shift of the oxy-hemoglobin dissociation curve improved outcome from MCAO. Because this occurred after reperfusion, our results suggest that the post-ischemic brain continues to suffer from hypoperfusion defects, which are amenable to therapy by enhanced O(2) delivery. The results also support the concept that neuroprotective strategies, which combine drugs with different mechanisms of action, may yield cumulative benefits.
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Affiliation(s)
- G B Mackensen
- Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.
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20
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Crago MS, West SD, McKenzie JE. Effects of diaspirin crosslinked hemoglobin infusion in treadmill-exercised swine. Heart Vessels 1999; 14:1-8. [PMID: 10543308 DOI: 10.1007/bf02481737] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The hemodynamic and metabolic effects of diaspirin crosslinked hemoglobin (DCLHb) were investigated using graded treadmill exercise in swine (n = 5/group). Swine received DCLHb (10% solution, 5 ml/kg) or oncotically-matched human serum albumin (HSA, 5ml/kg). Baseline metabolic and hemodynamic data were similar. In both groups exercise increased hemodynamic parameters. Exercise increased heart rate (HR) from 139 +/- 12 to 293 +/- 28 bpm with DCLHb and from 136 +/- 13 to 314 +/- 13 bpm with HSA. Exercise increased cardiac output (CO) from 5.7 +/- 0.75 to 15.6 +/- 2.01/min in the DCLHb group and from 5.3 +/- 0.48 to 15.7 +/- 0.881/min in the HSA group. However, CO returned to baseline faster with DCLHb upon stopping exercise. The DCLHb-treated group demonstrated a significantly higher oxygen extraction during exercise (12.04 +/- 0.38 vs 9.48 +/- 0.99 ml O2/100 ml blood) and a lower oxygen delivery throughout recovery (74.6 +/- 6.6 vs 102.2 +/- 7.21 O2/min), indicating enhanced oxygen delivery during exercise in the treatment group. DCLHb infusion did not impair metabolic or hemodynamic functions. These data indicate that DCLHb may increase oxygen delivery to working tissue more efficiently than HSA during treadmill exercise in swine.
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Affiliation(s)
- M S Crago
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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21
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Zhou F, Xiang Z, Yu YS, Jun SS, Piper I, Thomson D, Miller J. Brain TXA2 and PGI2 levels related to diffuse brain injury with secondary insults. J Clin Neurosci 1999. [DOI: 10.1016/s0967-5868(99)90052-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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22
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Sarraf-Yazdi S, Sheng H, Grocott HP, Bart RD, Pearlstein RD, Steffen RP, Warner DS. Effects of RSR13, a synthetic allosteric modifier of hemoglobin, alone and in combination with dizocilpine, on outcome from transient focal cerebral ischemia in the rat. Brain Res 1999; 826:172-80. [PMID: 10224294 DOI: 10.1016/s0006-8993(99)01233-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This study examined the effect of a pharmacologically induced rightward shift in the partial pressure of oxygen at which 50% of hemoglobin is saturated (P50) on outcome from transient focal cerebral ischemia in the rat. Halothane anesthetized rats (n=20 per group) were given saline or a single 15-min infusion of 150 mg/kg RSR13 (2-[4-[[3,5-dimethylanilino) carbonyl]methyl]phenoxy]-2-methylproprionic acid) intravenously before or 30 min after onset of 75 min of middle cerebral artery filament occlusion (MCAO). Seven days later, severity of hemiparesis and cerebral infarct size were examined. RSR13 alone did not significantly improve outcome. Conscious normothermic rats (n=12 per group) were also given RSR13 (150 mg/kg) or 0.9% NaCl intravenously and subjected to 75 min of MCAO with 7 days of recovery. Again, RSR13 alone did not significantly reduce infarct size or improve neurologic score. A dose-response curve for dizocilpine (MK-801) was then constructed in conscious normothermic rats subjected to 75 min of MCAO. Dizocilpine (0.5 mg/kg i.v.) caused a 90% reduction in mean infarct size while 0.25 mg/kg reduced infarct size by 48%. Other rats were then subjected to 75 min of MCAO after being given dizocilpine (0.25 mg/kg i.v.; n=18) or RSR13 (150 mg/kg i.v. )+dizocilpine (0.25 mg/kg i.v.; n=15). RSR13+dizocilpine resulted in smaller cortical infarct volume (8+/-14 mm3 vs. 34+/-37 mm3, p<0.02) and total cerebral infarct volume (46+/-28 mm3 vs. 81+/-60 mm3, p<0. 05) compared to dizocilpine alone, respectively. We conclude that a pre-ischemic peak increase in P50 of approximately 25 mmHg alone is insufficient to reduce focal ischemic injury, but may be advantageous when used in conjunction with other neuroprotective agents.
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Affiliation(s)
- S Sarraf-Yazdi
- Duke University School of Medicine, Duke University Medical Center, Durham, NC 27710, USA
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23
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Caron A, Menu P, Faivre-Fiorina B, Labrude P, Alayash AI, Vigneron C. Cardiovascular and hemorheological effects of three modified human hemoglobin solutions in hemodiluted rabbits. J Appl Physiol (1985) 1999; 86:541-8. [PMID: 9931189 DOI: 10.1152/jappl.1999.86.2.541] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The cardiovascular effects of human albumin (Alb) and three human hemoglobin (Hb) solutions, dextran-benzene-tetracarboxylate Hb, alphaalpha-crosslinked Hb, and o-raffinose-polymerized Hb were compared in anesthetized rabbits undergoing acute isovolemic hemodilution with Hct reduction from 41.4 +/- 2.7 to 28.8 +/- 1.6%. The impact of the vasoconstricting properties of Hb was examined by measuring heart rate (HR), mean arterial pressure (MAP), abdominal aortic, and femoral arterial blood flow, vascular resistance (VR), and aortic distension during the first 3 h after hemodilution. The impact of the hemorheological parameters was assessed by measurements of hemodiluted blood viscosity. In contrast to Alb, the Hb solutions elicited an immediate increase in MAP (20-38%). The effects of Alb and Hb solutions on HR, as well as on aortic and femoral arterial blood flow, were similar. VR decreased with Alb (20-28%) and increased with all three Hb solutions (30-90%), but the MAP and VR rising trends were different with each Hb solution. Aortic distension decreased in Hb groups compared with the Alb group for the first 60 min. The viscosity of hemodiluted blood was similar for all groups at high shear rates but was dependent on the viscosity of the solutions at low shear rates. We conclude that the vasoconstriction elicited by the Hb solutions overrides the vasodilation associated with viscosity changes due to hemodilution and would be the major factor responsible to the cardiovascular changes.
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Affiliation(s)
- A Caron
- Department of Hematology and Physiology, School of Pharmacy, University Henri Poincaré- Nancy 1, 54001 Nancy cedex, France.
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24
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Cole DJ, McKay L, Jacobsen WK, Drummond JC, Patel PM. Effect of subarachnoid administration of alpha-alpha diaspirin crosslinked hemoglobin on cerebral blood flow in rats. ARTIFICIAL CELLS, BLOOD SUBSTITUTES, AND IMMOBILIZATION BIOTECHNOLOGY 1997; 25:95-104. [PMID: 9083630 DOI: 10.3109/10731199709118901] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
As extravasated red blood cells have been implicated in the pathogenesis of perfusion deficits after subarachnoid hemorrhage, alpha-alpha diaspirin crosslinked hemoglobin (DCLHb) might have a detrimental effect on cerebral perfusion after subarachnoid hemorrhage. We evaluated the effect of subarachnoid administration of DCLHb on cerebral blood flow (CBF). Rats were randomized to receive one of the following solutions into the cisterna magna: Control-0.3 ml of mock cerebrospinal fluid; Blood-0.3 ml of autologous blood; DCLHb-0.3 ml of 10% DCLHb. After 20-min, the area of cerebral hypoperfusion was determined (CBF < 40 ml.100g-1.min-1). The area of hypoperfusion (% area of a coronal brain section, mean +/- SD) was greater in the Blood group (58 +/- 16) than the DCLHb (16 +/- 7) and Control (5 +/- 5) groups (p < 0.05), and was greater in the DCLHb group than the Control group (p < 0.05). These data support a hypothesis that extravasation of blood from the intravascular to the subarachnoid space induces cerebral hypoperfusion. Moreover, the data support the hypothesis that although extravasated molecular hemoglobin decreases CBF, the adverse effect is not as severe as a similar volume of blood.
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Affiliation(s)
- D J Cole
- Department of Anesthesiology-School of Medicine, Loma Linda University, California 92354, USA
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