1
|
A Safety Assessment of Diaspirin Cross-Linked Hemoglobin (DCLHb) in the Treatment of Hemorrhagic, Hypovolemic Shock. Prehosp Disaster Med 2012. [DOI: 10.1017/s1049023x00027722] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjective:To determine the safety and possible efficacy of diaspirin cross-linked hemoglobin (DCLHb) in the treatment of patients in Class II–IV hemorrhagic, hypovolemic shock.Design:Multicenter, randomized, normal saline-controlled, dose-escalation study.Setting:Eleven hospitals in the U.S. and Belgium.Subjects:One hundred and thirty-nine (139) hospitalized patients with Class II–IV hemorrhagic, hypovolemic shock within the previous 4 hours who still were requiring therapy for shock.Interventions:Beginning with the lowest dose, patients were randomized to receive 50,100, or 200 mL of either 10% DCLHb or normal saline infused intravenously over 15 minutes. Following infusion of either treatment, further fluid resuscitation could be given, as necessary, to maintain perfusion. Vital signs, laboratory assessments, blood and fluid administration, complications, and adverse events were recorded at various times from the end of infusion through 72 hours after infusion.Results:A total of 29 (13 DCLHb- and 16 saline-treated) patients died during the study period. Adverse events were experienced by 61% of patients in the DCLHb group and 53% of patients in the saline group; serious adverse events occurred in 28% of DCLHb-treated patients and 30% of saline-treated patients. The incidence of prospectively defined, clinical complications, including renal insufficiency and renal failure, was similar between the treatment groups except for the occurrence of dysrhythmias/conduction disorders, which occurred significantly more frequently in the saline-treated patients than the DCLHb-treated patients (p = 0.041). At the highest dose level (200 mL), statistically significant between-group differences were observed with greater increases in serum amylase, LDH, the isoenzymes LD1,2,4 and 5, and CK-MB in the DCLHb group compared to the control group; none were of clinical significance. The volume of blood administered did not differ between the groups. Overall 24- and 72-hour survival rates were similar between treatment groups, although the hospital discharge rate was slightly higher in the DCLHb-treated patients (80%) compared with the saline-treated patients (74%).Conclusion:Administration of 50 to 200 mL of DCLHb to patients in hemorrhagic, hypovolemic shock was not associated with evidence of end organ toxuity or significant adverse events. Further studies involving larger doses and, perhaps, earlier administration of DCLHb are warranted.
Collapse
|
2
|
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.
Collapse
Affiliation(s)
- Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | | |
Collapse
|
3
|
Hungerer S, Nolte D, Botzlar A, Messmer K. Effects of Diaspirin Crosslinked Hemoglobin (DCLHb) on microcirculation and local tissue pO2 of striated skin muscle following resuscitation from hemorrhagic shock. ACTA ACUST UNITED AC 2006; 34:455-71. [PMID: 16893810 DOI: 10.1080/10731190600769008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The hemoglobin based oxygen carrier (HBOC) Diaspirin Crosslinked Hemoglobin (DCLHb) has been developed to substitute not only the blood volume, but also to restore the oxygen-carrying properties of blood during hemorrhagic shock. However, it has been suggested that HBOCs may enhance the formation of free oxygen radicals through the release of free iron ions via the Haber-Weiss reaction. The aim of this study was to investigate the effects of DCLHb on the microcirculation, leukocyte-endothelial cell interaction and local tissue oxygenation in striated skin muscle of Syrian golden hamsters during and after resuscitation from hemorrhagic shock. In particular we focused on the local tissue oxygenation after resuscitation with DCLHb (hemoglobin content 10 g%) compared to resuscitation using autologous blood diluted to a hemoglobin content of 10 g%. Hemorrhagic shock was induced for 45 minutes by bleeding the animals at a rate of 33 ml/kg BW maintaining a mean arterial pressure of 30 +/- 5 mmHg. Animals were resuscitated either with 33 ml/kg BW 6% Dextran-60.000 or with 10 g% DCLHb. The control group received shed blood diluted with Ringers to a hemoglobin content of 10 g%. Intravital microscopy was used for investigation of the microcirculatory parameters and a multiwire platinum surface electrode for measurement of local tissue pO2 in striated skin muscle in the dorsal skinfold chamber of Syrian golden hamsters. Resuscitation from hemorrhagic shock with 10 g% AUB revealed significant increase of leukocytes rolling in postcapillary venules at 30 to 120 minutes after resuscitation compared to baseline values. DCLHb turned out to reduce the number of firmly adherent leukocytes after resuscitation compared to 10 g% AUB. Microvascular permeability as an indicator for functional endothelial integrity revealed no significant differences between the groups. DCLHb and 10 g% AUB led to a significant increase in local tissue oxygenation after resuscitation from hemorrhagic shock. However, 10 g% AUB turned out to be most effective to restore the local tissue pO2 compared to Dx-60. Our findings indicate that DCLHb restores microvascular perfusion after critical hemorrhagic shock as efficient as Dx-60 and 10 g% AUB. The absence of enhanced leukocyte-endothelium interaction after resuscitation with DCLHb implies that this HBOC does not exacerbate formation of oxygen free radicals during reperfusion. DCLHb effectively increases local tissue pO2 after resuscitation from hemorrhagic shock; however, not as effectively as 10 g% AUB.
Collapse
Affiliation(s)
- Sven Hungerer
- Department for Surgery, Trauma Clinic Murnau, Murnau, Germany.
| | | | | | | |
Collapse
|
4
|
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.
Collapse
Affiliation(s)
- Jacques Creteur
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Belgium
| | | |
Collapse
|
5
|
Schubert A, O'Hara JF, Przybelski RJ, Tetzlaff JE, Marks KE, Mascha E, Novick AC. Effect of diaspirin crosslinked hemoglobin (DCLHb HemAssist) during high blood loss surgery on selected indices of organ function. ARTIFICIAL CELLS, BLOOD SUBSTITUTES, AND IMMOBILIZATION BIOTECHNOLOGY 2002; 30:259-83. [PMID: 12227646 DOI: 10.1081/bio-120006118] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The safety of the hemoglobin based oxygen carrier diaspirin crosslinked hemoglobin (DCLHb) has been reported only in the low (50-200 mg/kg) dose range [Przybelski. R.J.; Daily, E.K.; Kisicki, J.C.; Mattia-Goldberg, C.; Bounds, M.J.; Colburn, W.A. Phase I study of the safety and pharmacologic effects of diaspirin crosslinked hemoglobin solution. Crit. Care Med. 1996, 24 (12), 1993-2000, Bloomfield, E.; Rady, M.; Popovich, M.; Esfandiari, S.; Bedocs, N. The use of diaspirin crosslinked hemoglobin (DCLHb 1996, 95, (3A), A220.]. We conducted a randomized prospective open-label trial of DCLHb and packed red blood cells (PRBCs) in high-blood loss surgical patients to show the effect of 750 ml DCLHb (approximately 1000 mg/kg) on selected indices of organ function. METHOD After institutional approval, 24 patients scheduled to undergo elective orthopedic or abdominal surgery, were randomized to receive either PRBCs or 10% DCLHb within 12 hours after the start of surgery. Patients with renal insufficiency, abnormal liver function, severe coronary artery disease (CAD) and ASA physical status > or = IV were excluded. The anesthetic technique was left to the judgment of the anesthesiologist. Autologous predonation and intraoperative blood conservation techniques were utilized as appropriate. The indications for blood transfusion were individualized on disease state, stage of surgery, and plasma Hb concentration. Laboratory studies were obtained preoperatively and up to 28 days postoperatively. Patients were observed daily for development of jaundice, hematuria, nausea, vomiting, gastrointestinal discomfort, cardiac, respiratory, and infectious complications. Organ effects were assessed with urinalysis, creatinine clearance, electrocardiogram (ECG), and a panel of blood and serum laboratory tests. RESULTS The dose of DCLHb administered ranged from 680-1500 mg/kg (mean = 999 mg/kg). Estimated blood loss was 27 +/- 13 ml/kg and 31 +/- 15 ml/kg in the control and DCLHb groups, respectively. Fewer PRBCs (1.9 +/- 1.2 vs. 3.4 +/- 2.4 units. P = 0.06) were transfused to DCLHb patients on the operative day although this difference was no longer apparent later on. In the DCLHb group, 4/12 patients avoided any allogeneic PRBC transfusion vs. none in the control group (P = 0.09). Systolic, diastolic and mean blood pressure increased moderately after DCLHb for a period of 24-30 hours. There were no occurrences of cardiac ischemia. myocardial infarction, stroke, or pulmonary edema, by clinical or laboratory parameters up to the 28th postoperative day (POD). Seven of 12 (58%) DCLHb patients had yellow skin discoloration vs. none in the PRBC group (P < 0.01). Two of four non-urologic surgery patients developed asymptomatic postoperative hemoglobinuria after DCLHb. Creatinine clearance was unchanged postoperatively. Because of hemoglobin interference, bilirubin, gamma-glutamyl transferase (GGT), and amylase could not be measured reliably on POD1; on POD2. amylase was transiently elevated to 3 times ULN along with mild elevations of bilirubin, transaminases and BUN. Mean total creatine phoshokinase (CPK) peaked at 8 times the upper limit of normal (ULN) in the DCLHb group, compared with less than twice ULN for controls. Three DCLHb patients had prolonged ileus. Two of these patients had postoperative hyperamylasemia, one of whom developed mild pancreatitis. DCLHb did not affect white blood cell count or coagulation tests. CONCLUSION Administration of approximately 1000 mg/kg DCLHb was associated with transient arterial hypertension, gastrointestinal side effects, laboratory abnormalities, yellow skin discoloration, and hemoglobinuria. These observations point to opportunities for improvement in future synthetic hemoglobin design.
Collapse
Affiliation(s)
- Armin Schubert
- Department of General Anesthesiology, The Cleveland Clinic Foundation, OH 44195, USA.
| | | | | | | | | | | | | |
Collapse
|
6
|
Sloan EP, Koenigsberg M, Brunett PH, Bynoe RP, Morris JA, Tinkoff G, Dalsey WC, Ochsner MG. Post hoc mortality analysis of the efficacy trial of diaspirin cross-linked hemoglobin in the treatment of severe traumatic hemorrhagic shock. THE JOURNAL OF TRAUMA 2002; 52:887-95. [PMID: 11988654 DOI: 10.1097/00005373-200205000-00011] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The efficacy trial of diaspirin cross-linked hemoglobin (DCLHb) in traumatic hemorrhagic shock demonstrated an unexpected mortality imbalance, prompting a three-step review to better understand the cause of this finding. METHODS Patients were enrolled in this DCLHb hemorrhagic shock study using 28-day mortality as the primary endpoint. Mortality data were primarily analyzed using the TRISS method and a nonblinded clinical review, followed by an independent Pennsylvania Trauma Outcome Study (PTOS)-derived probability of survival analyses. Finally, a trauma expert conducted a blinded clinical review of cases incorrectly predicted by these PTOS analyses. RESULTS More of the DCLHb patients predicted to survive using TRISS actually died than in the control subgroup (24% vs. 3%, p < 0.002). Nonblinded clinical review noted that 72% of the patients who died had prior traumatic arrest, a presenting Glasgow Coma Scale score of 3, or a base deficit > 15 mEq/L. DCLHb patients predicted to survive using PTOS also more often died than did control patients (30% vs. 8%, p < 0.04). Blinded clinical review determined that 94% of the deaths were clinically justified. Both the TRISS and the PTOS models gave an adjusted mortality relative risk of 2.3, similar to the unadjusted risk data. CONCLUSION Mortality analysis in this shock study involved both clinical case reviews and mortality prediction models. Despite the observation that nearly all of the deaths were clinically justified, the TRISS and PTOS models demonstrated excess unpredicted deaths in the DCLHb subgroup. A combined process, using both mortality prediction models and clinical case reviews, is useful in trauma studies that use a mortality endpoint.
Collapse
Affiliation(s)
- Edward P Sloan
- Department of Emergency Medicine, University of Illinois at Chicago, 60612, USA.
| | | | | | | | | | | | | | | |
Collapse
|
7
|
Vane LA, Funston JS, Kirschner R, Harper D, Deyo DJ, Traber DL, Traber LL, Kramer GC. Comparison of transfusion with DCLHb or pRBCs for treatment of intraoperative anemia in sheep. J Appl Physiol (1985) 2002; 92:343-53. [PMID: 11744677 DOI: 10.1152/jappl.2002.92.1.343] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Isoflurane-anesthetized sheep were transfused with packed red blood cells (pRBCs) or diaspirin cross-linked hemoglobin (DCLHb) for treatment of intraoperative hemorrhage. A rapid 15-min hemorrhage with lactated Ringer (LR) infusion maintained filling pressure at baseline and reduced blood hemoglobin (Hb) to ~5 g/dl. Sheep received 2 g/kg Hb, DCLHb (n = 6), or pRBCs (n = 7); control group received LR alone (n = 6). After 2 h, anesthesia was discontinued; sheep were monitored in the animal intensive care unit for 48 h. DCLHb expanded blood volume more, but increased total blood Hb less, than pRBCs. Lower Hb and increased methemoglobin resulted in lower arterial oxygen content compared with the pRBCs. DCLHb caused pulmonary hypertension (from 13 to 30 mmHg) and elevated filling pressure (from 6 to 15 mmHg). Cardiac outputs (CO) were similar for all groups during anesthesia; however, during recovery CO increased only in the LR and packed pRBCs groups. DCLHb may limit the reflex ability to increase CO after volume expansion. Hemodynamic effects of DCLHb may be exaggerated when infused after large-volume LR.
Collapse
Affiliation(s)
- Luiz A Vane
- Resuscitation Research Laboratories, Departments of Anesthesiology and Physiology, University of Texas Medical Branch, Galveston, Texas 77555-080, USA
| | | | | | | | | | | | | | | |
Collapse
|
8
|
Orlinsky M, Shoemaker W, Reis ED, Kerstein MD. Current controversies in shock and resuscitation. Surg Clin North Am 2001; 81:1217-62, xi-xii. [PMID: 11766174 DOI: 10.1016/s0039-6109(01)80006-2] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Many controversies and uncertainties surround resuscitation of hemorrhagic shock caused by vascular trauma. Whereas the basic pathophysiology is better understood, much remains to be learned about the many immunologic cascades that lead to problems beyond those of initial fluid resuscitation or operative hemostasis. Fluid therapy is on the verge of significant advances with substitute oxygen carriers, yet surgeons are still beset with questions of how much and what type of initial fluid to provide. Finally, the parameters chosen to guide therapy and the methods used to monitor patients present other interesting issues.
Collapse
Affiliation(s)
- M Orlinsky
- Department of Emergency Medicine, University of Southern California, Keck School of Medicine, Los Angeles County and University of Southern California Medical Center, Los Angeles 90033, USA.
| | | | | | | |
Collapse
|
9
|
Abstract
For the past 4 decades, the standard approach to the trauma victim who is hypotensive from presumed hemorrhage has been to infuse large volumes of fluids as early and as rapidly as possible. The goals of this treatment strategy are rapid restoration of intravascular volume and vital signs towards normal, and maintenance of vital organ perfusion. The most recent laboratory studies and the only clinical trial evaluating the efficacy of these guidelines however, suggest that in the setting of uncontrolled hemorrhage, today's practice of aggressive fluid resuscitation may be harmful, resulting in increased hemorrhage volume and subsequently greater mortality. This has been demonstrated in animal models representative of penetrating trauma as well as those representative of blunt trauma. The data strongly suggest that limited or hypotensive resuscitation may be preferable for the trauma victim with the potential for ongoing uncontrolled hemorrhage. Limited resuscitation provides a mechanism of avoiding the detrimental effects associated with early aggressive resuscitation, while maintaining a level of tissue perfusion that although decreased from the normal physiologic range is adequate for short periods. Large randomized clinical trials are necessary to confirm this new laboratory data. Future research should focus on developing resuscitation methods that may actually enhance tissue perfusion during limited resuscitation and therefore offset its potential detrimental effects.
Collapse
Affiliation(s)
- S A Stern
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan 48109-0303, USA.
| |
Collapse
|
10
|
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.
| |
Collapse
|
11
|
Wang P, Ba ZF, Koo DJ, Cioffi WG, Bland KI, Chaudry IH. Continuous resuscitation after hemorrhage and acute fluid replacement improves cardiovascular responses. Surgery 2001; 129:559-66. [PMID: 11331448 DOI: 10.1067/msy.2001.112596] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Although acute fluid replacement after trauma and severe hemorrhage remains the cornerstone in the management of trauma victims, it remains unknown whether continuous resuscitation after trauma-hemorrhage and acute fluid replacement produces salutary effects on cardiovascular function and reduces proinflammatory cytokine release. METHODS Adult male rats underwent laparotomy (ie, soft tissue trauma) and were bled to and maintained at a mean arterial pressure of 40 mm Hg until 40% of the shed blood volume was returned in the form of Ringer's lactate (RL). The animals were then resuscitated with 4 times the volume of shed blood with RL for 60 minutes, followed by continuous resuscitation with RL at 5 mL/h/kg for 48 hours after the acute fluid replacement. At 48 hours after hemorrhage, mean arterial pressure, cardiac output, and left ventricular contractility parameters, such as the maximal rates of ventricular pressure increase (+dP/dt(max)) and decrease (-dP/dt(max)), were determined. Microvascular blood flow in the intestine and kidney was assessed by laser Doppler flowmetry. In addition, plasma levels of TNF-alpha were assayed by enzyme-linked immunosorbent assay. RESULTS The mean arterial pressure and cardiac output were decreased by 34% and 18%, respectively, at 48 hours after hemorrhage and acute resuscitation. Continuous resuscitation, however, markedly improved these parameters. Similarly, +dP/dt(max) and -dP/dt(max) decreased significantly after hemorrhage and acute fluid replacement but was restored to sham values after continuous resuscitation. Microvascular blood flow in the gut and kidneys was decreased after hemorrhage and acute resuscitation by 34% and 35%, respectively. However, intestinal and renal perfusion was maintained at the sham levels at 48 hours after continuous resuscitation. In addition, the upregulated TNF-alpha after acute resuscitation alone was reduced after continuous resuscitation. CONCLUSIONS Continuous resuscitation after acute fluid replacement appears to be a useful approach for restoring and maintaining cardiovascular function and organ perfusion after trauma and severe hemorrhage.
Collapse
Affiliation(s)
- P Wang
- Brown University School of Medicine, and Rhode Island Hospital, USA
| | | | | | | | | | | |
Collapse
|
12
|
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.
Collapse
Affiliation(s)
- S M Erhart
- Department of Anesthesiology, Loma Linda University, CA 92354, USA
| | | | | | | | | |
Collapse
|
13
|
Abstract
Haemoglobin-based oxygen carriers are being developed for use in blood replacement therapies, either for perioperative haemodilution or for resuscitation from haemorrhagic blood loss. There is a high demand for these products because of risks associated with blood transfusions and pending worldwide blood shortages. Development of these products has required new technologies in protein engineering; since the haemoglobin is cell-free in solution, the molecule must be modified to be retained within blood circulation. Three classes of haemoglobin are under development: intramolecular cross-linked, intermolecular polymerised and surface conjugated with polyethylene glycol. Two products based on cross-linking chemistry have been discontinued because of serious adverse events and/or increased mortality rate in Phase III clinical trials. Three products based on polymerisation chemistry are in ongoing Phase III clinical trials. A new product based on surface conjugation is in preclinical evaluation. Although cross-linked and polymerised products have shown to be safe in preclinical and early Phase I/II clinical trials, they have had difficulty in proving efficacy. The primary adverse effect for the majority of cross-linked or polymerised products is a haemodynamic response, leading to increased vascular resistance to blood flow. The physiological mechanisms are still incompletely understood, so that safety and efficacy cannot be completely dissociated. New understandings on the mode of action of these products will help to define their utility and application. New products are under development, designed specifically to maximise blood flow and tissue perfusion and therefore, oxygenation.
Collapse
Affiliation(s)
- K D Vandegriff
- Sangart, Inc., 11199 Sorrento Valley Rd, Ste. L, San Diego, CA 92121, USA.
| |
Collapse
|
14
|
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.
Collapse
Affiliation(s)
- J Creteur
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Belgium
| | | | | |
Collapse
|
15
|
Friedman HI, Devenuto F, Kerwin A, Carson K, Bynoe R. Hemoglobin solutions as blood substitutes. J INVEST SURG 2000; 13:79-94. [PMID: 10801045 DOI: 10.1080/089419300272122] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- H I Friedman
- Department of Surgery, University of South Carolina, School of Medicine, Columbia 29203, USA
| | | | | | | | | |
Collapse
|
16
|
Conover CD, Linberg R, Lejeune L, Nagy M, Shum KL. PEG-Hemoglobin as a resuscitation solution in the treatment of hypovolemic shock in the anesthetized rat. Artif Organs 1999; 23:1088-98. [PMID: 10619927 DOI: 10.1111/j.1525-1594.1999.06429.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This study was designed to determine the advantages of using the hemoglobin-based oxygen carrier, polyethylene glycol conjugated bovine hemoglobin (PEG-Hb), as an additive to Ringer's lactate solution (RLS) for the treatment of acute hemorrhage in anesthetized female rats. Different compositions of PEG-Hb and RLS were administered intravenously in a paradigm that provided 30 ml/kg of resuscitation fluid following an episode of 15 min of hypotension. Hypotension was achieved by the removal of blood (1 ml/min) from the femoral vein until the mean arterial pressure was lowered to or below 50 mmHg and subsequently maintained until resuscitation. Short-term cardiovascular assessment showed that resuscitation fluids containing PEG-Hb resulted in higher mean arterial pressure, aortic blood flow, renal blood flow, and less dramatic shifts in arterial base excess and respiratory blood gases than plain RLS. The long-term survival experiment showed lower lactate dehydrogenase, alkaline phosphatase, and serum glutamic pyruvic transaminase levels in most groups resuscitated with solutions containing PEG-Hb, but no differences in survival (100%) were observed. The data suggest that the addition of PEG-Hb to RLS improves its resuscitative effects. Specifically, a solution of 50% RLS:50% PEG-Hb appeared to have the most favorable cardiovascular and metabolic effects in this anesthetized rat hypovolemic shock resuscitation model. Presumably, the improved effects seen with the addition of PEG-Hb were due to its innate plasma expansion and oxygen-delivery capabilities.
Collapse
Affiliation(s)
- C D Conover
- Research and Development, Pharmacology and Toxicology Department, Enzon, Inc., Piscataway, NJ 08854
| | | | | | | | | |
Collapse
|
17
|
Fischer SR, Burnet M, Traber DL, Prough DS, Kramer GC. Plasma volume expansion with solutions of hemoglobin, albumin, and Ringer lactate in sheep. THE AMERICAN JOURNAL OF PHYSIOLOGY 1999; 276:H2194-203. [PMID: 10362704 DOI: 10.1152/ajpheart.1999.276.6.h2194] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We have measured plasma volume expansion (Evans blue and hematocrit changes) and hemodynamic responses in conscious hemorrhaged and normovolemic splenectomized sheep after a 30-min infusion of either 20 ml/kg of diaspirin cross-linked hemoglobin (DCLHb), 20 ml/kg of human albumin (Alb), or 60 ml/kg of a solution of Ringer lactate (RL). All regimens expanded blood volume and increased blood pressure and cardiac output after hemorrhage. However, only 15 +/- 3% of the infused volume of RL was evident as intravascular expansion 10-min postinfusion, compared with 67 +/- 16% and 139 +/- 139% for Alb and DCLHb, respectively. DCLHb infusions were associated with higher blood pressures and lower cardiac outputs compared with RL and Alb infusions, but the increased oxygen content of blood with DCLHb resulted in systemic delivery of oxygen similar to that of the other infusions. These differences in hemodynamics and vascular volume continued for 6 h, and at 24 h vascular volume and all hemodynamics were similar in all three groups. The better volume expansion with DCLHb may be due to greater mobilization of endogenous interstitial protein or reduced transcapillary loss as total intravascular endogenous plasma protein increased after infusion of DCLHb, whereas there was an apparent loss of endogenous intravascular protein after infusions of Alb and RL. Vasoconstriction by DCLHb is one mechanism that could lower blood-to-tissue transport of fluid and protein. In addition to its oxygen-carrying capacity and vasoactivity, DCLHb is associated with volume expansion properties out of proportion to its colloid osmotic pressure.
Collapse
Affiliation(s)
- S R Fischer
- Department of Anesthesiology, University of Texas Medical Branch and Shriners Burns Hospital, Galveston, Texas 77555, USA
| | | | | | | | | |
Collapse
|
18
|
van Iterson M, Sinaasappel M, Burhop K, Trouwborst A, Ince C. Low-volume resuscitation with a hemoglobin-based oxygen carrier after hemorrhage improves gut microvascular oxygenation in swine. THE JOURNAL OF LABORATORY AND CLINICAL MEDICINE 1998; 132:421-31. [PMID: 9823936 DOI: 10.1016/s0022-2143(98)90113-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Using palladium-porphyrin quenching of phosphorescence, we investigated the influence of diaspirin cross-linked hemoglobin (DCLHb) on gut microvascular oxygen pressure (microPO2) in anesthetized pigs. Values of gut microPO2 were studied in correlation with regional intestinal as well as global metabolic and circulatory parameters. A controlled hemorrhagic shock (blood withdrawal of 40 mL/kg) was followed by resuscitation with either a combination of lactated Ringer's solution (75 mL/kg) and modified gelatin (15 mL/kg)(lactR/Gel) or 10% DCLHb (5 mL/kg). After resuscitation, gut microPO2 was similarly improved in the lactR/Gel group (from 25 +/- 10 mm Hg to 53 +/- 8 mm Hg) and the DCLHb group (from 23 +/- 9 mm Hg to 46 +/- 6 mm Hg), which was associated with increased gut oxygen delivery. However, the improvement after resuscitation with DCLHb was sustained for longer periods of time (75 vs 30 min). Mesenteric venous PO2 was increased after resuscitation with lactated Ringer's solution and modified gelatin but not with DCLHb, which was associated with an increased gut oxygen consumption in the latter group. We conclude that measurement of microPO2 by the palladium-porphyrin phosphorescence technique revealed DCLHb to be an effective carrier of oxygen to the microcirculation of the gut. Also, this effect can be achieved with a lower volume than is currently used in resuscitation procedures.
Collapse
Affiliation(s)
- M van Iterson
- Department of Anesthesiology, Academic Medical Centre, University of Amsterdam, The Netherlands
| | | | | | | | | |
Collapse
|
19
|
Noone RB, Mythen MG, Vaslef SN. Effect of alpha(alpha)-cross-linked hemoglobin and pyridoxalated hemoglobin polyoxyethylene conjugate solutions on gastrointestinal regional perfusion in hemorrhagic shock. THE JOURNAL OF TRAUMA 1998; 45:457-69. [PMID: 9751534 DOI: 10.1097/00005373-199809000-00006] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Hemoglobin-based blood substitutes may cause vasoconstriction, which could limit organ perfusion during trauma resuscitation. We investigated the effect of two hemoglobin solutions on regional blood flow and mucosal perfusion in the gastrointestinal tract in a hemorrhagic shock model. METHODS Twenty-four swine were bled 30% of blood volume over 1 hour. Six additional animals were anesthetized and monitored but did not undergo hemorrhage. Bled animals were resuscitated with alpha(alpha)-hemoglobin (alpha(alpha)Hb), pyridoxalated hemoglobin polyoxyethylene conjugate (PHP), shed blood, or lactated Ringer's solution. Regional blood flow was measured by radiolabeled microspheres. Gastric mucosal perfusion was estimated by measuring intramucosal pH (pHi) by tonometry. RESULTS PHP and shed blood restored small-bowel flows to sham values, whereas lactated Ringer's solution and alpha(alpha)Hb did not. Shed blood and PHP, but not alpha(alpha)Hb, restored cardiac index (CI) to baseline (p < 0.05). Mean pulmonary artery pressure was elevated over baseline with alpha(alpha)Hb and PHP and remained elevated with alpha(alpha)Hb (p < 0.05). pHi was significantly lower after resuscitation with PHP than with other fluids. CONCLUSION PHP was efficacious in restoring CI and small-bowel flow, but the pHi remained low, indicating possible continued mucosal ischemia. Alpha(alpha)Hb led to limited recovery of CI and small-bowel blood flow but restored pHi close to baseline. Shed blood was efficacious in restoration of pHi, gastrointestinal blood flows, and systemic hemodynamics.
Collapse
Affiliation(s)
- R B Noone
- Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA
| | | | | |
Collapse
|
20
|
Loeb AL, McIntosh LJ, Raj NR, Longnecker DE. Resuscitation after hemorrhage using recombinant human hemoglobin (rHb1.1) in rats: effects on nitric oxide and prostanoid systems. Crit Care Med 1998; 26:1071-80. [PMID: 9635658 DOI: 10.1097/00003246-199806000-00030] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Hemoglobin-based oxygen carriers are designed to replace blood volume and to increase oxygen delivery to tissues after blood loss. The goals of the present study were two-fold: a) to determine the systemic and regional vascular effects of resuscitation with recombinant human hemoglobin (rHb1.1) in rats during controlled hemorrhage; and b) to determine whether nitric oxide (NO) or prostaglandins were involved in the observed responses. DESIGN Paralyzed, ventilated rats were hemorrhaged (18 mL blood/kg body weight) during halothane anesthesia and allowed to stabilize for 30 mins. Systemic and regional hemodynamics and oxygen delivery were monitored at three time points, using the radioactive microsphere method. Microspheres were first infused at the end of the hemorrhage stabilization period (t=0 min). rHb1.1 (1 g/kg body weight) or rHb1.1 diluent (phosphate buffered saline, 36 mL/kg body weight) were infused over 20 mins and microspheres were administered again, 30 mins later (t=50 mins). Saline (0.5 mL), indomethacin (5 mg/kg to inhibit cyclooxygenase), or NG-monomethyl-L-arginine (L-NMMA, 100 mg/kg, to inhibit NO synthase) were then infused in rHb1.1-treated rats and microspheres injected once more (t=80 mins). SETTING Research laboratory. SUBJECTS Male Wistar rats (n=37). INTERVENTIONS Recombinant human hemoglobin (rHb1.1), rHb1.1 diluent (phosphate buffered saline) resuscitation of hemorrhaged rats. Saline, L-NMMA, or indomethacin treatment after resuscitation. MEASUREMENTS AND MAIN RESULTS Resuscitation with rHb1.1 increased mean arterial pressure (MAP), cardiac output, and systemic oxygen delivery significantly when compared with diluent. After rHb1.1 resuscitation, regional blood flows were significantly increased in skin, kidney, spleen, and heart compared with diluent resuscitation. Compared with saline treatment after rHb1.1 resuscitation, L-NMMA increased MAP and regional resistances in virtually all tissues; indomethacin did not alter MAP, but increased resistance in the brain. CONCLUSIONS These data indicate that rHb1.1 resuscitation was more effective than diluent in improving systemic and regional hemodynamics and oxygen delivery, suggesting that rHb1.1 may be of benefit in the treatment of acute blood loss. Increased resistance after L-NMMA in the presence of rHb1.1 indicated that rHb1.1 resuscitation did not eliminate NO dependent circulatory control. Increased resistance after indomethacin in brain indicated that vasodilator prostanoids were important in regulating vascular resistance in these tissues after rHb1.1 resuscitation.
Collapse
Affiliation(s)
- A L Loeb
- Department of Anesthesia, University of Pennsylvania, Philadelphia 19104-4283, USA
| | | | | | | |
Collapse
|
21
|
Abstract
Haemoglobin-based red cell substitutes have recently passed a myriad of safety studies and are now undergoing efficacy evaluation. There are numerous potential benefits with use of these solutions: they are readily available and have a long shelf-life; do not require typing and cross-matching; are free of viral or bacterial contamination; lack the immunosuppressive effects of blood; and have a much lower viscosity than blood. One-third of the 10 million units of blood transfused in the United States each year is utilized in the emergency setting. Therefore, a safe, effective substitute for blood should have significant impact upon the way we resuscitate bleeding patients. In this article, the current status of the various haemoglobin-based red cell substitutes is reviewed.
Collapse
Affiliation(s)
- S M Cohn
- Department of Surgery, University of Miami School of Medicine, FL 33101, USA.
| |
Collapse
|
22
|
de Figueiredo LF, Mathru M, Solanki D, Macdonald VW, Hess J, Kramer GC. Pulmonary hypertension and systemic vasoconstriction may offset the benefits of acellular hemoglobin blood substitutes. THE JOURNAL OF TRAUMA 1997; 42:847-54; discussion 854-6. [PMID: 9191666 DOI: 10.1097/00005373-199705000-00015] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE We tested the hypothesis that the pharmacologic properties of a small volume of alpha alpha-cross-linked hemoglobin (alpha alpha Hb) could effectively resuscitate pigs subjected to hemorrhage. METHODS Fourteen pigs hemorrhaged to a mean arterial pressure (MAP) of 40 mm Hg for 60 minutes were treated with a 4-mL/kg 2-minute infusion of 10 g/dL alpha alpha Hb or 7 g/dL human serum albumin, an oncotically matched control solution. RESULTS The removal of blood (17 +/- 1.5 mL/kg) caused the typical physiologic responses to hemorrhagic hypovolemia. Infusion of alpha alpha Hb restored mean arterial pressure and coronary perfusion pressure, but cardiac output and mixed venous O2 saturation did not improve significantly. Pulmonary arterial pressure and pulmonary vascular resistance increased markedly and were higher than baseline levels after alpha alpha Hb. Infusion of human serum albumin produced only minor hemodynamic changes. Brain blood flow did improve to baseline values after alpha alpha Hb, but was the only tissue to do so. In the human serum albumin group, superior mesenteric artery blood flow recovered to baseline values, whereas brain blood flow did not. Blood flows to other tissues were similar in both groups. CONCLUSION Small-volume infusion of alpha alpha Hb restored mean arterial pressure and brain blood flow, but pulmonary hypertension and low peripheral perfusion may offset benefits for trauma patients.
Collapse
Affiliation(s)
- L F de Figueiredo
- Department of Cardiopneumology, INCOR, FMUSP, Universidade de São Paulo, Brazil
| | | | | | | | | | | |
Collapse
|
23
|
Cohn SM, Zieg PM, Rosenfield AT, Fisher BT. Resuscitation of pulmonary contusion: effects of a red cell substitute. Crit Care Med 1997; 25:484-91. [PMID: 9118666 DOI: 10.1097/00003246-199703000-00018] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To determine the impact of a vasoactive red cell substitute, diaspirin cross-linked hemoglobin, on respiratory derangements after traumatic lung injury. DESIGN Randomized, controlled animal experiment. SETTING Large-animal laboratory. SUBJECTS Mechanically ventilated, anesthetized young Yorkshire male swine (15 to 20 kg). INTERVENTIONS Pigs (n = 6/group) received two pneumatic blasts to the right thoracic cage at baseline, were hemorrhaged 30 mL/kg from t = 0 to 20 mins, resuscitated with 0.9% saline (group 1, 90 mL/ kg) or diaspirin cross-linked hemoglobin (group 2, 15 mL/kg) from t = 20 to 40 mins, and then observed to t = 240 mins. MEASUREMENTS AND MAIN RESULTS Serial pulmonary and systemic hemodynamic measurements, total thoracic compliance assessment, spiral three-dimensional computed tomography scan, and lung weights (n = 3/group) were used to assess lesion size and lung water. Mean arterial pressure was restored in both animal groups. Mean pulmonary arterial pressure was significantly higher after resuscitation in animals receiving the red cell substitute. Oxygenation worsened mildly in both groups. Compliance diminished in both groups but was significantly worse at the end of the experiment in animals infused with diaspirin cross-linked hemoglobin. Right lung weights and right thoracic computed tomography scan volume were higher with diaspirin cross-linked hemoglobin than with saline. CONCLUSIONS After pulmonary contusion, resuscitation with diaspirin cross-linked hemoglobin led to pulmonary hypertension, greater pulmonary contusion lesion size, and stiffer lungs in this porcine model.
Collapse
Affiliation(s)
- S M Cohn
- Department of Surgery, Yale School of Medicine, New Haven, CT, 06510, USA
| | | | | | | |
Collapse
|
24
|
DeAngeles DA, Scott AM, McGrath AM, Korent VA, Rodenkirch LA, Conhaim RL, Harms BA. Resuscitation from hemorrhagic shock with diaspirin cross-linked hemoglobin, blood, or hetastarch. THE JOURNAL OF TRAUMA 1997; 42:406-12; discussion 412-4. [PMID: 9095107 DOI: 10.1097/00005373-199703000-00007] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND An oxygen-transporting hemoglobin solution should be more effective than a nonhemoglobin solution for resuscitation from hemorrhagic shock. A way to evaluate this effectiveness is to determine whether a hemoglobin solution can reverse the base deficit accumulated during hemorrhage at a faster rate than a nonhemoglobin solution. Using this criterion, we compared the resuscitative powers of autologous blood, hetastarch (Het), and diaspirin cross-linked hemoglobin (DCLHb). METHODS Fifteen sedated, spontaneously breathing sheep (37.5 +/- 10.2 kg) were bled until base deficits fell to -5 to -10 mEq/L, and plasma lactate concentrations rose to 6 to 9 mg/L. The animals were resuscitated with autologous blood (n = 5), Het (n = 5), or DCLHb (n = 5) (3.5-4.0 mL/kg every 15 minutes) until base deficits returned to prehemorrhage baseline. RESULTS Exsanguination to target base deficits required removal of an average of 41.4 +/- 5.5 mL blood/kg (estimated total blood volume, 80 mL/kg). Resuscitation required 18 +/- 3, 38 +/- 2 (different from blood), and 35 +/- 1 (different from blood) mL/kg of autologous blood, Het and DCLHb, respectively, over periods of 78 +/- 8, 163 +/- 10 (different from blood), and 129 +/- 9 minutes (different from blood and different from Het (p < or = 0.05)). Based on regression analysis, autologous blood, Het, and DCLHb corrected the base deficit at rates of, respectively, 0.074 (different from Het (p < or = 0.05)), 0.016, and 0.056 (different from Het (P < or = 0.05)) mEq/L/min. CONCLUSIONS Based on the rate of base deficit correction and the volume of solution required, autologous blood was the most effective resuscitation solution. However, DCLHb was more effective than Het. DCLHb may be an attractive alternative to blood for resuscitation from hemorrhagic shock.
Collapse
Affiliation(s)
- D A DeAngeles
- Department of Surgery, University of Wisconsin-Madison Medical School, USA
| | | | | | | | | | | | | |
Collapse
|
25
|
Figueiredo LFPD, Mathru M, Jones JR, Solanki D, Kramer GC. Inhaled nitric oxide reverses cell-free hemoglobin-induced pulmonary hypertension and decreased lung compliance. Preliminary results. Crit Care 1997; 1:111-116. [PMID: 11056704 PMCID: PMC28996 DOI: 10.1186/cc114] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/1997] [Revised: 12/10/1997] [Accepted: 12/11/1997] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND: In order to test the hypothesis that inhaled nitric oxide (NO) reverses the pulmonary hypertension induced by alphaalpha-diaspirin crosslinked hemoglobin (alphaalphaHb), were studied anesthetized pigs that were administered with a total dose of 200 mg/kg of 10% alphaalphaHb. Inhaled NO (5 ppm) was administered for 10 min, and then discontinued for 10 min. This cycle was then repeated with 10 ppm inhaled NO. RESULTS: alphaalphaHb caused pulmonary arterial pressure (PAP) to increase from 27 +/- 1.7 to 40 +/- 3.0 mmHg (P<0.05) and dynamic lung compliance to decrease from 29+/- 1.5 to 23+/- 1.6 ml/cmH2O (P < 0.05). After both doses of inhaled NO, but particularly 10 ppm, PAP was reduced (P < 0.05) and lung compliance increased (P < 0.05) from the alphaalphaHb levels. When inhaled NO was discontinued PAP again increased and lung compliance decreased to levels significantly different from baseline (P < 0.05). CONCLUSION: We conclude that cell-free hemoglobin-induced pulmonary hypertension and decreased lung compliance can be selectively counteracted by inhaled NO.
Collapse
Affiliation(s)
- Luiz F Poli de Figueiredo
- Department of Cardiopneumology, DEX-Instituto do Coração, Faculdade do Medicina, Universidade de São Paulo, SP, Brazil
| | - Mali Mathru
- Department of Anesthesiology, Univ. of Texas Medical Branch, Galveston, TX, USA
| | - Jaclyn R Jones
- Department of Pulmonary Care Services, Univ. of Texas Medical Branch, Galveston, TX, USA
| | - Daneshvari Solanki
- Department of Anesthesiology, Univ. of Texas Medical Branch, Galveston, TX, USA
| | - George C Kramer
- Department of Anesthesiology, Univ. of Texas Medical Branch, Galveston, TX, USA
| |
Collapse
|
26
|
Xu L, Sun L, Rollwagen FM, Li Y, Pacheco ND, Pikoulis E, Leppäniemi A, Soltero R, Burris D, Malcolm D, Nielsen TB. Cellular responses to surgical trauma, hemorrhage, and resuscitation with diaspirin cross-linked hemoglobin in rats. THE JOURNAL OF TRAUMA 1997; 42:32-41. [PMID: 9003255 DOI: 10.1097/00005373-199701000-00007] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Resuscitation with acellular oxygen carrier solutions offers the potential advantage of improved oxygen delivery compared with crystalloid solutions, but the detailed consequences of improved resuscitation have not been fully evaluated. This study evaluated local and systemic cellular effects of trauma, hemorrhage, and resuscitation in a model of hemorrhage and surgical trauma. METHODS Rats with a 10 cm full-thickness incisional wound and a 15 mL/kg hemorrhage were either not resuscitated or resuscitated with blood or diaspirin cross-linked hemoglobin (DCLHb). Cellular proliferative responses were evaluated at 1.5, 6, 24, and 48 hours after wounding by labeling in vivo with 5-bromo-2'-deoxyuridine. Plasma levels of interleukin-6, tumor necrosis factor-alpha, and interferon-gamma were measured by bioassay or enzyme-linked immunosorbent assay (ELISA). Bacterial translocation was measured by culturing liver homogenates. RESULTS Trauma inhibited keratinocyte and hepatocyte proliferation at 1.5 and 6 hours, and stimulated subsequent proliferation of keratinocytes and liver nonparenchymal cells. DCLHb stimulated wound keratinocyte proliferation, attenuated the inhibition of hepatocyte proliferation, eliminated bacterial translocation to the liver, protected the intestine from ischemic damage, and induced a rapid increase of interleukin-6 during the early phase of injury. CONCLUSIONS Surgical trauma alone, or in combination with hemorrhage, modulated cell proliferation both in the wound and in the remote organs of intestine and liver. DCLHb enhanced wound healing and cell proliferation as well as, or better than, freshly drawn blood, which may be beneficial for trauma care.
Collapse
Affiliation(s)
- L Xu
- Resuscitative Medicine Program, Naval Medical Research Institute, Bethesda, MD 20889-5607, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Poli de Figueiredo LF, Elgjo GI, Mathru M, Rocha e Silva M, Kramer GC. Hypertonic acetate-alpha alpha hemoglobin for small volume resuscitation of hemorrhagic shock. ARTIFICIAL CELLS, BLOOD SUBSTITUTES, AND IMMOBILIZATION BIOTECHNOLOGY 1997; 25:61-73. [PMID: 9083627 DOI: 10.3109/10731199709118898] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Hypertonic acetate solution in small volumes greatly improves cardiac output and corrects acid-base disturbances in hemorrhaged animals. We hypothesized that the combination of alpha alpha-crosslinked human hemoglobin (alpha alpha Hb), an oxygen carrier and vasoconstrictor, with hypertonic sodium acetate (HAHb), a vasodilator, may be effective for small volume resuscitation of hemorrhagic shock. Six pigs hemorrhaged to a mean arterial pressure of 40 mmHg for 60 min (bled volume: 23.6 +/- 2.5 ml.kg-1) received a single bolus of 4 ml.kg-1 of HAHb infused over two min. HAHb restored arterial pressure, increased systemic vascular resistance and caused a modest increase in cardiac output and SvO2, while pulmonary arterial pressure and vascular resistance were markedly increased. In two animals, transient severe hypotension and low cardiac output may have been due to acute pulmonary hypertension during injection. Compared to our previous study, in which animals received 4 ml-kg-1 of alpha alpha Hb alone, HAHb produced higher cardiac output and a smaller increase in systemic and pulmonary vascular resistance. However, slower, titrated infusions may be needed when hemoglobin solutions are combined with drugs or solutions that cause vasodilation in order to decrease the likelihood of acute hemodynamic instability.
Collapse
Affiliation(s)
- L F Poli de Figueiredo
- Department of Anesthesiology, University of Texas Medical Branch, Galveston 77555-0749, USA
| | | | | | | | | |
Collapse
|
28
|
Przybelski RJ, Daily EK, Kisicki JC, Mattia-Goldberg C, Bounds MJ, Colburn WA. Phase I study of the safety and pharmacologic effects of diaspirin cross-linked hemoglobin solution. Crit Care Med 1996; 24:1993-2000. [PMID: 8968267 DOI: 10.1097/00003246-199612000-00011] [Citation(s) in RCA: 105] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate the safety, pharmacokinetics, and pharmacodynamics of diaspirin cross-linked hemoglobin solution (DCLHb) in normal, healthy volunteers. DESIGN Randomized, double-blind, controlled, crossover study. SETTING Phase I research facility of a contract research organization. PATIENTS Twenty-four healthy adult volunteers. INTERVENTIONS Diaspirin cross-linked hemoglobin solution (25, 50, or 100 mg/kg) or equal volume of lactated Ringer's solution was infused on day 1; the alternate solution was infused 6 days later. Laboratory analyses, electrocardiograms, and Holter and telemetry monitoring were performed to assess organ function, pharmacokinetics, and potential toxicity. Vital signs, pulse oximetry, laser Doppler flowmetry, and toe temperature were measured to evaluate diaspirin cross-linked hemoglobin solution's pharmacodynamic effects. MEASUREMENTS AND MAIN RESULTS There were no serious adverse events associated with diaspirin cross-linked hemoglobin solution infusion. Abdominal pain occurred in three subjects after control infusion and in six subjects after diaspirin cross-linked hemoglobin solution infusion; no treatment was required. A dose-related increase in lactic dehydrogenase (LDH)-5 isoenzyme concentrations was observed in 12 subjects after diaspirin cross-linked hemoglobin solution infusion. There were no associated increases in the circulating concentrations of total LDH, aspartate aminotransferase, alanine aminotransferase, or alkaline phosphatase. Total serum creatine kinase concentrations increased significantly after infusion of 100 mg/kg of diaspirin cross-linked hemoglobin solution; the isoenzyme creatine kinase-myocardial band (CK-MB) was not increased, nor were there any abnormal electrocardiogram findings. There were no differences in laser Doppler, pulse oximetry, or toe temperature measurements during or after either infusion. The half-life of diaspirin cross-linked hemoglobin solution was 2.5 hrs for the 25- and 50-mg/kg doses and 3.3 hrs for the 100-mg/kg dose. A dose-related increase in blood pressure occurred with diaspirin cross-linked hemoglobin solution. CONCLUSIONS Diaspirin cross-linked hemoglobin solution doses of 25, 50, and 100 mg/kg are well tolerated, without evidence of organ dysfunction or toxicity. Diaspirin cross-linked hemoglobin solution's pressor effect is without evidence of decreased peripheral perfusion. Further investigations of its use in certain patient populations are warranted.
Collapse
Affiliation(s)
- R J Przybelski
- Substitutes Division, Baxter Healthcare Corporation, Round Lake IL, USA
| | | | | | | | | | | |
Collapse
|
29
|
Cohn SM, Zieg PM. Experimental pulmonary contusion: review of the literature and description of a new porcine model. THE JOURNAL OF TRAUMA 1996; 41:565-71. [PMID: 8810987 DOI: 10.1097/00005373-199609000-00036] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In the setting of pulmonary contusion, massive crystalloid resuscitation of hemorrhagic shock may promote increased lung water leading to stiffer lungs and ultimately culminating in adult respiratory distress syndrome. The emergence of fluids that enable the clinician to resuscitate the bleeding trauma victim by using minimal fluid volumes offers new avenues of investigation for resuscitation of traumatic lung injury. Unfortunately, there has been very little experimental work in the area of pulmonary contusion in the past 15 years. We describe a new porcine model for experimental traumatic lung injury that appears to replicate the clinical scenario.
Collapse
Affiliation(s)
- S M Cohn
- Section of Trauma/Surgical Critical Care, Yale University School of Medicine, New Haven, Connecticut 06520, USA
| | | |
Collapse
|