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Edwards TH, Venn EC, Le TD, Grantham LE, Hogen T, Ford R, Ewer N, Gunville R, Carroll C, Taylor A, Hoareau GL. Comparison of shelf-stable and conventional resuscitation products in a canine model of hemorrhagic shock. J Trauma Acute Care Surg 2024; 97:S105-S112. [PMID: 38706102 DOI: 10.1097/ta.0000000000004332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
BACKGROUND Treatment of severe hemorrhagic shock typically involves hemostatic resuscitation with blood products. However, logistical constraints often hamper the wide distribution of commonly used blood products like whole blood. Shelf-stable blood products and blood substitutes are poised to be able to effectively resuscitate individuals in hemorrhagic shock when more conventional blood products are not readily available. METHODS Purpose-bred adult dogs (n = 6) were anesthetized, instrumented, and subjected to hemorrhagic shock (mean arterial pressure <50 mm Hg or 40% blood volume loss). Then each dog was resuscitated with one of five resuscitation products: (1) lactated ringers solution and hetastarch (LRS/Heta), (2) canine chilled whole blood (CWB), (3) fresh frozen plasma (FFP) and packed red blood cells (pRBC), (4) canine freeze-dried plasma (FDP) and hemoglobin-based oxygen carrier (HBOC), or (5) HBOC/FDP and canine lyophilized platelets (LyoPLT). Each dog was allowed to recover after the hemorrhage resuscitation event and was then subjected to another hemorrhage event and resuscitated with a different product until each dog was resuscitated with each product. RESULTS At the time when animals were determined to be out of shock as defined by a shock index <1, mean arterial pressure (mmHg) values (mean ± standard error) were higher for FFP/pRBC (n = 5, 83.7 ± 4.5) and FDP/HBOC+LyoPLT (n = 4, 87.8 ± 2.1) as compared with WB (n = 4, 66.0 ± 13.1). A transient increase in creatinine was seen in dogs resuscitated with HBOC and FDP. Albumin and base excess increased in dogs resuscitated with HBOC and FDP products compared with LRS/heta and CWB ( p < 0.01). CONCLUSION Combinations of shelf-stable blood products compared favorably to canine CWB for resolution of shock. Further research is needed to ascertain the reliability and efficacy of these shelf-stable combinations of products in other models of hemorrhage that include a component of tissue damage as well as naturally occurring trauma.
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Affiliation(s)
- Thomas H Edwards
- From the US Army Institute of Surgical Research (T.H.E., E.C.V., T.D.L., L.E.G.II), JBSA Fort Sam Houston; Department of Veterinary Small Animal Clinical Sciences (T.H.E.), School of Veterinary Medicine, Texas A&M University, College Station; Department of Epidemiology and Biostatistics (T.D.L.), University of Texas Tyler School of Medicine, Tyler, Texas; Oak Ridge Institute for Science and Education (L.E.G.II), Oak Ridge, Tennessee; Nora Eccles-Harrison Cardiovascular Research and Training Institute (T.H., G.L.H.); Biomedical Engineering Department (G.L.H.), and Department of Emergency Medicine (R.F., N.E., R.G., C.C., A.T., G.L.H.), University of Utah Health, Salt Lake City, Utah
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Jahr JS, Kim HW, Rojhani A, Iskandar S. Small-Volume Multifunctional Emergency Resuscitation Fluid Including Colloid Plasma Expander, Artificial Oxygen Carrier, and Coagulation Factors in Traumatic Hemorrhagic Shock When Blood Is Unavailable. Am J Ther 2024; 31:e39-e42. [PMID: 38231580 DOI: 10.1097/mjt.0000000000001673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Affiliation(s)
- Jonathan S Jahr
- Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Hae Won Kim
- Department of Molecular Pharmacology, Physiology and Biotechnology, Alpert School of Medicine, Brown University, Providence, RI
| | - Allen Rojhani
- Department of Urology, St. Joseph's Medical Center, Stockton, CA; and
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Samaja M, Malavalli A, Vandegriff KD. How Nitric Oxide Hindered the Search for Hemoglobin-Based Oxygen Carriers as Human Blood Substitutes. Int J Mol Sci 2023; 24:14902. [PMID: 37834350 PMCID: PMC10573492 DOI: 10.3390/ijms241914902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/30/2023] [Accepted: 10/02/2023] [Indexed: 10/15/2023] Open
Abstract
The search for a clinically affordable substitute of human blood for transfusion is still an unmet need of modern society. More than 50 years of research on acellular hemoglobin (Hb)-based oxygen carriers (HBOC) have not yet produced a single formulation able to carry oxygen to hemorrhage-challenged tissues without compromising the body's functions. Of the several bottlenecks encountered, the high reactivity of acellular Hb with circulating nitric oxide (NO) is particularly arduous to overcome because of the NO-scavenging effect, which causes life-threatening side effects as vasoconstriction, inflammation, coagulopathies, and redox imbalance. The purpose of this manuscript is not to add a review of candidate HBOC formulations but to focus on the biochemical and physiological events that underly NO scavenging by acellular Hb. To this purpose, we examine the differential chemistry of the reaction of NO with erythrocyte and acellular Hb, the NO signaling paths in physiological and HBOC-challenged situations, and the protein engineering tools that are predicted to modulate the NO-scavenging effect. A better understanding of two mechanisms linked to the NO reactivity of acellular Hb, the nitrosylated Hb and the nitrite reductase hypotheses, may become essential to focus HBOC research toward clinical targets.
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Affiliation(s)
- Michele Samaja
- Department of Health Science, University of Milan, 20143 Milan, Italy
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Jahr JS. Blood substitutes: Basic science, translational studies and clinical trials. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 4:989829. [PMID: 36062262 PMCID: PMC9433579 DOI: 10.3389/fmedt.2022.989829] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 07/28/2022] [Indexed: 11/25/2022] Open
Affiliation(s)
- Jonathan S. Jahr
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
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Blood Component Requirements and Erythrocyte Transfusion and Mortality Related to Hemoglobin Deficit in Phase III Trial of Hemoglobin-Based Oxygen Carrier: HBOC-201. Am J Ther 2022; 29:e279-e286. [PMID: 35421008 DOI: 10.1097/mjt.0000000000001494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Hemoglobin-based oxygen carriers (HBOCs) may cause coagulopathy, changes in total hemoglobin (THb), and affect mortality. Low total hemoglobin concentrations [THb] during hemorrhage may worsen outcomes. STUDY QUESTION The database of the Hemopure HEM-0115 phase III trial was queried to determine the use of platelets, plasma, or cryoprecipitate and compare transfusion requirements and coagulation studies between patients randomized to erythrocyte transfusion or HBOC-201 infusion. Modeling of hemoglobin (Hb) changes produced by HBOC-201, erythrocyte, and blood product administration were related to [THb], coagulopathy, and mortality. DATA SOURCES Hemopure HEM-0115 phase III trial database. STUDY DESIGN Retrospective and Novel Hemoglobin Deficit Formulas Tested Against Existing Database. RESULTS The HBOC-201 database (n = 688) demonstrated less than 6% of subjects in both groups were administered non-Hb containing blood products (fresh frozen plasma, platelets, or cryoprecipitate) and low rates of coagulopathies in both erythrocyte and HBOC-201 arms. There were no differences in mortality in elective orthopedic patients administered up to 10 bags HBOC-201 (equivalent to 3 units erythrocytes). Low total [Hb] and lack of adequate oxygen carrying capacity was found to be an independent predictor of morbidity/mortality. CONCLUSIONS The elective use of HBOC-201 for orthopedics versus erythrocytes demonstrated low incidence of blood product requirements in both cohorts and no differences in mortality up to the HBOC-201 equivalent of 3 units erythrocytes. High total Hb may be important to maintain in acute hemorrhage and [Hb] deficit, whereas later in recovery might not be as crucial. Future trauma trials may benefit from the use of HBOC-201 containing 13 g/dL in prehospital management, when erythrocytes are commonly not available.
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Fattorutto M, Bouckaert Y, Brauner J, Franck S, Bouton F, Heuse D, Bouckaert C, Bruyneel A. Pragmatic study of a thromboprophylaxis algorithm in critically ill patients with SARS-COV-2 infection. J Thromb Thrombolysis 2022; 53:58-66. [PMID: 34173169 PMCID: PMC8233177 DOI: 10.1007/s11239-021-02514-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2021] [Indexed: 01/08/2023]
Abstract
The optimal thromboprophylactic strategy for patients affected by Coronavirus disease 2019 (COVID-19) has been debated among experts. This study evaluated the safety and efficacy of a thromboprophylaxis algorithm. This was a retrospective, single-center study in critically ill patients admitted to the intensive care unit (University affiliated Hospital) for acute respiratory failure due to Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV-2). From March 16 to April 9, 2020, thromboprophylaxis was adjusted according to weight (control group, n = 19) and after this date, thromboprophylaxis depended on an algorithm based on thrombotic and hemorrhagic risk factors (protocol group, n = 13). With regard to safety (number of major bleeding events and blood transfusions), the groups were not significantly different. With regard to efficacy, the number of thrombotic events decreased from 37 to 0%, p = 0.025 after implementation of the algorithm. Also, peak fibrinogen dropped from 8.6 (7.2-9.3) to 6.5 (4.6-8.4) g/L, p = 0.041 and D-dimers from 2194 (1464-3763) to 1486 (900-2582) ng/mL, p = 0.0001. In addition, length of stay declined from 19 (10-31) to 5 (3-19) days, p = 0.009. In conclusion, a tailored thromboprophylaxis algorithm (risk stratification based on clinical parameters and biological markers) reduce thrombotic phenomena in critically ill COVID-19 patients without increasing major bleeding.
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Affiliation(s)
- Maurizio Fattorutto
- Department of Anesthesiology, Centre Hospitalier Universitaire Tivoli, Avenue Max Buset 34, 7100, La Louvière, Belgium.
| | - Yves Bouckaert
- Intensive Care Unit, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | - Jonathan Brauner
- Department of Clinical Biology/Blood Bank, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | - Stéphane Franck
- Intensive Care Unit, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | - Fabrice Bouton
- Intensive Care Unit, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | - Danielle Heuse
- Intensive Care Unit, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | | | - Arnaud Bruyneel
- Intensive Care Unit, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
- School of Public Health, Université Libre Bruxelles, Brussels, Belgium
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Portörő I, Mukli P, Kocsis L, Hermán P, Caccia D, Perrella M, Mozzarelli A, Ronda L, Mathe D, Eke A. Model-based evaluation of the microhemodynamic effects of PEGylated HBOC molecules in the rat brain cortex: a laser speckle imaging study. BIOMEDICAL OPTICS EXPRESS 2020; 11:4150-4175. [PMID: 32923034 PMCID: PMC7449705 DOI: 10.1364/boe.388089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 04/24/2020] [Accepted: 05/04/2020] [Indexed: 06/11/2023]
Abstract
Hemoglobin-based oxygen carriers (HBOCs) were developed with the aim of substituting transfusions in emergency events. However, they exhibit adverse events, such as nitric oxide (NO) scavenging, vasoactivity, enhanced platelet aggregation, presently hampering their clinical application. The impact of two prototypical PEGylated HBOCs, Euro-PEG-Hb and PEG-HbO2, endowed by different oxygen affinities and hydrodynamic volumes, was assessed on the cerebrocortical parenchymal microhemodynamics, and extravasation through the blood-brain-barrier (BBB) by laser speckle contrast imaging (LSCI) method and near-infrared (NIR) imaging, respectively. By evaluating voxel-wise cerebrocortical red blood cell velocity, non-invasively for its mean kernel-wise value ( v ¯ RBC ), and model-derived kernel-wise predictions for microregional tissue hematocrit, THt, and fractional change in hematocrit-corrected vascular resistance, R', as measures of potential adverse effects (enhanced platelet aggregation and vasoactivity, respectively) we found i) no significant difference between tested HBOCs in the systemic and microregional parameters, and in the relative spatial dispersion of THt, and R' as additional measures of HBOC-related adverse effects, and ii) no extravasation through BBB by Euro-PEG-Hb. We conclude that Euro-PEG-Hb does not exhibit adverse effects in the brain microcirculation that could be directly attributed to NO scavenging.
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Affiliation(s)
- István Portörő
- Institute of Translational Medicine, Semmelweis University, Hungary
- These authors contributed equally to this work
| | - Péter Mukli
- Institute of Translational Medicine, Semmelweis University, Hungary
- Department of Physiology, Semmelweis University, Hungary
- These authors contributed equally to this work
| | - László Kocsis
- Institute of Translational Medicine, Semmelweis University, Hungary
| | - Péter Hermán
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT 06520, USA
| | - Dario Caccia
- Department of Biomedical Science and Technology, University of Milan, Italy
- Department of Food and Drug, University of Parma, Italy
| | - Michele Perrella
- Department of Biomedical Science and Technology, University of Milan, Italy
| | - Andrea Mozzarelli
- Department of Food and Drug, University of Parma, Italy
- Institute of Biophysics, National Research Council, Pisa, Italy
- Biopharmanet-TEC, University of Parma, Italy
| | - Luca Ronda
- Institute of Biophysics, National Research Council, Pisa, Italy
- Biopharmanet-TEC, University of Parma, Italy
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Domokos Mathe
- CROmed Research and Service Centers Ltd., Budapest, Hungary
| | - Andras Eke
- Institute of Translational Medicine, Semmelweis University, Hungary
- Department of Physiology, Semmelweis University, Hungary
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Efficacy of Resuscitative Transfusion With Hemoglobin Vesicles in the Treatment of Massive Hemorrhage in Rabbits With Thrombocytopenic Coagulopathy and Its Effect on Hemostasis by Platelet Transfusion. Shock 2019; 50:324-330. [PMID: 30106387 DOI: 10.1097/shk.0000000000001042] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION We have developed hemoglobin vesicles (HbVs) as a substitute for red blood cells (RBCs). We investigated the efficacy of HbV transfusion in the treatment of massive hemorrhage in rabbits in the setting of thrombocytopenic coagulopathy, focusing on the efficacy of hemostasis by subsequent platelet transfusion. METHODS Thrombocytopenic coagulopathy was induced in rabbits by repeated blood withdrawal and isovolemic retransfusion of autologous RBC (platelet counts <45,000/μL). A penetrating liver injury was then made. For 30 min, bleeding volume was measured every 10 min, after which subjects were transfused with an equivalent volume of stored RBC, HbV, or platelet poor plasma (PPP) to compensate for blood loss, simulating initial prehospital resuscitation. Thereafter, we transfused platelet rich plasma (PRP) to stop bleeding, which simulated inhospital resuscitation. RESULTS During the initial resuscitation, the HbV group was similar to the RBC group (but not the PPP group) in their hemodynamics and tissue circulation/oxygenation as assessed by plasma lactate levels. All rabbits showed similar bleeding volumes (20-30 mL) in this period. HbV-transfused rabbits sustained hemoglobin levels, but showed lower hematocrit levels compared with RBC-transfused rabbits. Subsequent PRP transfusion effectively stopped bleeding in all RBC-transfused rabbits (6/6) and most HbV-transfused rabbits (7/8) but not PPP-transfused rabbits (2/8). In addition, 83% of RBC-transfused rabbits and 75% of HbV-transfused rabbits survived for 24 h, although no PPP-transfused rabbits survived. HbV transfusion did not scavenge nitric oxide in rabbits. CONCLUSIONS HbV transfusion effectively rescued rabbits from severe hemorrhage with coagulopathy, without disturbing hemostasis after the platelet transfusion. HbV transfusion may be practical and useful in prehospital resuscitation.
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Morton AP, Moore EE, Moore HB, Gonzalez E, Chapman MP, Peltz E, Banerjee A, Silliman C. Hemoglobin-based oxygen carriers promote systemic hyperfibrinolysis that is both dependent and independent of plasmin. J Surg Res 2017; 213:166-170. [PMID: 28601310 PMCID: PMC5467451 DOI: 10.1016/j.jss.2015.04.077] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 04/14/2015] [Accepted: 04/21/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND Hyperfibrinolysis plays an integral role in the genesis of trauma-induced coagulopathy. Recent data demonstrate that red blood cell lysis promotes fibrinolysis; however, the mechanism is unclear. Hemoglobin-based oxygen carriers (HBOCs) have been developed for resuscitation and have been associated with coagulopathy. We hypothesize that replacement of whole blood (WB) using an HBOC results in a coagulopathy because of the presence of free hemoglobin. MATERIALS AND METHODS WB was sampled from healthy donors (n = 6). The clotting profile of each citrated sample was evaluated using native thromboelastography. Serial titrations were performed using both HBOC (PolyHeme) and normal saline (NS; 5%, 25%, and 50%) and evaluated both with and without a 75-ng/mL tissue plasminogen activator (tPA) challenge. Tranexamic acid (TXA) was added to inhibit plasmin-dependent fibrinolysis. Fibrinolysis was measured and recorded as lysis at 30 min (LY30), the percentage of clot LY30 after maximal clot strength. Dilution of WB with NS or HBOC was correlated using LY30 via Spearman rho coefficients. Groups were also compared using a Friedman test and post hoc analysis with a Bonferroni adjustment. RESULTS tPA-provoked fibrinolysis was enhanced by both HBOC (median LY30 at 5%, 25%, and 50% titrations: 11%, 21%, and 44%, respectively; Spearman = 0.94; P < 0.001) and NS (11%, 28%, and 58%, respectively; Spearman = 0.790; P < 0.001). However, HBOC also enhanced fibrinolysis without the addition of tPA (1%, 4%, 5%; Spearman = 0.735; P = 0.001) and NS did not (1%, 2%, 1%; r = 0.300; P = 0.186. Moreover, addition of TXA did not alter or inhibit this fibrinolysis (WB versus 50% HBOC: 1.8% versus 5.7%, P = 0.04). There was no significant difference in fibrinolysis of HBOC with or without TXA (50% HBOC versus 50% HBOC + TXA: 5.6% versus 5.7%, P = 0.92). In addition, the increased fibrinolysis seen with NS was reversed when TXA was present (WB versus 50% NS: 1.8% versus 1.7%, P = 1.0). CONCLUSIONS HBOCs enhance fibrinolysis both with and without addition of tPA; moreover, this mechanism is independent of plasmin as the phenomenon persists in the presence of TXA. Our findings indicate the hemoglobin molecule or its components stimulate fibrinolysis by both tPA-dependent and innate mechanisms.
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Affiliation(s)
- Alexander P Morton
- Department of Surgery-Trauma Research Center, University of Colorado, Denver, Colorado.
| | - Ernest E Moore
- Department of Surgery-Trauma Research Center, University of Colorado, Denver, Colorado; Department of Surgery-Denver Health Medical Center, Denver, Colorado
| | - Hunter B Moore
- Department of Surgery-Trauma Research Center, University of Colorado, Denver, Colorado
| | - Eduardo Gonzalez
- Department of Surgery-Trauma Research Center, University of Colorado, Denver, Colorado
| | - Michael P Chapman
- Department of Surgery-Trauma Research Center, University of Colorado, Denver, Colorado
| | - Erik Peltz
- Department of Surgery-Trauma Research Center, University of Colorado, Denver, Colorado
| | - Anirban Banerjee
- Department of Surgery-Trauma Research Center, University of Colorado, Denver, Colorado
| | - Christopher Silliman
- Department of Surgery-Trauma Research Center, University of Colorado, Denver, Colorado; Bonfils Blood Center, Denver, Colorado
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