Selective aortic arch perfusion with hemoglobin-based oxygen carrier-201 for resuscitation from exsanguinating cardiac arrest in swine.

OBJECTIVE: The prospects for resuscitation after blunt traumatic cardiac arrest are dismal. Selective aortic arch perfusion (SAAP) with a hemoglobin-based oxygen carrier (HBOC-201) offers a potentially effective therapy. This study evaluated the acute cardiovascular and metabolic effects of SAAP with HBOC-201 in an exsanguination model of cardiac arrest. DESIGN: Randomized, controlled, laboratory investigation. SETTING: University research laboratory. SUBJECTS: Domestic swine, 25-39 kg. INTERVENTIONS: Partial resection of four liver lobes rapidly led to profound hemorrhagic shock and subsequent cardiac arrest at 10-13 mins. At 15 mins, swine were randomized to receive either SAAP with oxygenated lactated Ringer's (LR) solution (n = 6) or SAAP with oxygenated HBOC-201 (n = 6) at a rate of 10 mL x kg(-1) x min(-1) until return of spontaneous circulation with a mean aortic pressure of 60 mm Hg (8.0 kPa) was achieved. Epinephrine (0.005 mg/kg) was given via intra-aortic route every 30 secs as needed to promote return of spontaneous circulation beginning at 18 mins after onset of liver injury (3 mins after beginning SAAP). MEASUREMENTS AND MAIN RESULTS: Mean aortic pressure, cardiac output, total blood loss, and time of arrest were similar for both groups before SAAP therapy. In the SAAP-HBOC group, return of spontaneous circulation with a sustained mean aortic pressure of 60 mm Hg (8.0 kPa) was achieved in six of six swine at 1.9 +/- 0.3 mins of SAAP, and none of these swine required epinephrine. In the SAAP-LR group, no swine (from a total of six) achieved return of spontaneous circulation before intra-aortic epinephrine administration, and only two of six swine had brief return of spontaneous circulation with an mean aortic pressure of 60 mm Hg (8.0 kPa) after intra-aortic epinephrine that was sustained for <10 mins. One-hour survival was five of six in the SAAP-HBOC group and none of six in the SAAP-LR group (p <.05, Fisher's exact test). CONCLUSION: SAAP with oxygenated HBOC-201 rapidly restored viable cardiovascular function after exsanguinating cardiac arrest in this swine model of liver injury with profound hemorrhagic shock.

Absence of immunopathology associated with repeated IV administration of bovine Hb-based oxygen carrier in dogs.

BACKGROUND: A Hb-based oxygen carrier, HBOC-301, is licensed by the FDA for use as a single-dose product to treat anemia in canines. The objective of this study was to investigate the immunopathologic consequences of multiple doses of HBOC-301. STUDY DESIGN AND METHODS: HBOC-301 was administered intravenously at 1.3 g per kg (10 mL/kg) nine times over 50 weeks to each of eight splenectomized beagles. During interim weeks, HBOC-301-specific IgG antibody was quantified in serum by immunoassay. Immunofluorescence studies were performed on thin sections of control and test dog livers and kidneys to detect any IgG, IgM, IgA, or C3 deposition. Physiology (p50) studies evaluated the capacity of circulating HBOC-301-specific IgG antibody to competitively block the binding of oxygen to HBOC-301. RESULTS: HBOC-301-specific IgG antibody was detected in seven of eight HBOC-301-treated dogs by Week 6. Peak antibody levels occurred by Week 10 (after the third dose). Immunofluorescence studies detected comparable IgG, IgA, IgM, or C3 deposition patterns in the kidneys and livers of both control and test dogs, which indicated no selective antibody-mediated deposition from multiple HBOC-301 administrations. Moreover, HBOC-301-specific IgG antibody in serum was unable to inhibit oxygen binding to the HBOC-301 in vitro, which indicated that circulating antibody did not diminish the oxygen-binding capacity of HBOC-301. CONCLUSION: The immunologic, histologic, and physiologic data support the safety of multidose administration of HBOC-301 in canines.

Bovine hemoglobin-based oxygen carrier (HBOC-201) for resuscitation of uncontrolled, exsanguinating liver injury in swine. Carolina Resuscitation Research Group.

In the setting of rapidly exsanguinating hemorrhage, resuscitation with intravenous (i.v.) crystalloid solution may not sustain survival before availability of allogenic blood transfusion and surgery. This study tested the hypothesis that bovine hemoglobin-based oxygen carrier, HBOC-201, would improve resuscitation and extend early survival from exsanguinating hemorrhage. This study simulated the prehospital scenario of rapidly exsanguinating hemorrhage with prolonged prehospital time and lack of blood availability. Severe hemorrhagic shock was induced in swine by using multiple liver lacerations. At 9 min after the onset of bleeding, swine were randomized to receive approximately 10 mL/kg/min of i.v. lactated Ringer's solution (n = 10) or HBOC-201 (n = 7) to achieve a mean aortic pressure (MAP) of 60 mmHg. Thereafter, infusion rate was adjusted to maintain MAP at 60 mmHg for up to 2 h. All animals were initially successfully resuscitated. The results showed 2-h survival was 1 of 10 with lactated Ringer's and 7 of 7 with HBOC-201 (P = 0.0004). Nine lactated Ringer's swine had cardiovascular collapse at 36 +/- 10 min. Lactate at 30 min was 18 +/- 3 mmol/L with lactated Ringer's and 12 +/- 2 mmol/L with HBOC-201 (P < 0.05). Hematocrit was <1% in 9 of 10 lactated Ringer's and 6 of 7 HBOC-201 animals. These data indicate that HBOC-201 improved early survival and stabilized hemodynamic and metabolic parameters vs. lactated Ringer's in this swine model of liver injury with uncontrolled, lethal hemorrhage that simulates the prehospital care environment where allogenic blood is unavailable.

In vitro effects of a novel hemoglobin-based oxygen carrier on routine chemistry, therapeutic drug, coagulation, hematology, and blood bank assays.

Red blood cell (RBC) replacement solutions are being developed as alternatives to allogeneic RBC use in blood transfusions in the treatment of massive trauma, to achieve hemodynamic stability during elective surgery, and to increase oxygen-carrying capacity in anemia. Hemoglobin-based oxygen carrier (HBOC)-201 (Biopure Corp.) is a purified, sterile, isosmotic glutaraldehyde-polymerized bovine hemoglobin. Because this product is acellular, blood components containing this substance appear hemolyzed. This study reports on the interferences produced by the presence of HBOC-201 in a variety of clinical assays. This product was added in vitro at concentrations up to 60 g/L (6.0 g/dL) to normal human serum, plasma, or whole blood before testing for serum chemistries, coagulation profiles, and hematology and blood bank assays. In addition, a set of normal human sera containing HBOC-201 was supplemented with various therapeutic drugs and assayed for these agents. The results of these studies demonstrate that the presence of HBOC-201 in blood components does not result in significant analytical interference that would be of concern with many clinical assays at HBOC-201 concentrations encountered during routine clinical use of this RBC replacement solution in patients.

The effects of a blood-salvaging device on blood containing a hemoglobin-based oxygen carrier, HBOC-201.

OBJECTIVES: Hemoglobin-based oxygen carriers will be used concurrently with intraoperative blood salvage. The effects of salvage and processing on blood containing one such solution (HBOC-201; Biopure Corp, Boston, MA) were studied. DESIGN: Prospective, randomized. SETTING: Laboratory. INTERVENTIONS: Sixteen blood units from healthy volunteers had either HBOC (1,500 mg/dL; n = 10) or normal saline (equivalent volume; n = 6) added. All units were salvaged and processed using a blood salvage device. Samples were analyzed for the concentration and molecular weight distribution of plasma hemoglobin and red cell morphology presalvage (pre) and following processing and washing (post 1). Five of the HBOC units underwent a second 1,000 mL wash (post 2). MEASUREMENTS AND MAIN RESULTS: Processing and washing decreased the concentration of plasma hemoglobin (mg/dL) in HBOC units (1311 +/- 265 pre to 27.8 +/- 19.6 post 1 to 6.5 +/- 2.19 post 2), but did not change the plasma hemoglobin concentration in saline units (2.05 +/- 1.27 pre v 3.18 +/- 0.79 post 1). Total plasma hemoglobin in HBOC units (6.56 +/- 2.19) was significantly greater than in saline units (3.18 +/- 0.79), even after the second wash (post 2). The concentration of unstable hemoglobin in the plasma phase was not different between groups. Red cell morphology was altered by the salvage process but was not different between groups. CONCLUSIONS: Salvage and processing of blood containing HBOC yield concentrated red cells that are indistinguishable from those obtained from blood without HBOC. Residual HBOC remains but is unchanged from the HBOC initially administered.

Selective aortic perfusion and oxygenation: an effective adjunct to external chest compression-based cardiopulmonary resuscitation.

OBJECTIVES: The purpose of this study was to compare the perfusion pressure and rate of return of spontaneous circulation produced by standard advanced cardiac life support with that resulting from advanced cardiac life support with simultaneous aortic occlusion and proximal infusion with oxygenated fluid. BACKGROUND: Cardiopulmonary resuscitation based solely on external chest compression is unable to achieve return of spontaneous circulation in most patients with cardiac arrest. Adjunctive therapies that enhance myocardial oxygen supply may improve outcomes. METHODS: We conducted a prospective, randomized study in mongrel dogs using a fibrillatory model of cardiac arrest with a 20-min arrest time. Dogs were randomized to two groups. Aortic arch and right atrial micromanometers were placed to measure intravascular pressure. Manual external chest compression was used and standardized to an esophageal pulse pressure of 50 mm Hg. Two minutes after initiation of advanced cardiac life support, selective aortic perfusion and oxygenation were initiated in dogs assigned to one group by inflation of an occluding balloon in the descending aorta and infusion of 450 ml of ultrapurified polymerized bovine hemoglobin through a large bore central infusion port. RESULTS: Maximal aortic pressure during standard advanced cardiac life support was 42 +/- 23 (mean +/- SD) versus 69 +/- 28 mm Hg during advanced cardiac life support with selective aortic perfusion and oxygenation. Maximal coronary perfusion pressure during standard therapy was 33 +/- 21 versus 62 +/- 26 mm Hg during combined therapy. Only 2 of 10 dogs receiving standard therapy had return of spontaneous circulation versus 6 of 7 dogs receiving combined therapy. Balloon occlusion alone did not increase perfusion pressure significantly. CONCLUSIONS: The use of selective aortic perfusion and oxygenation increases aortic and coronary perfusion pressures during cardiopulmonary resuscitation, resulting in a large increase in the rate of return of spontaneous circulation. This technique may be an effective adjunct to advanced cardiac life support based on any method of external chest compression and may improve the poor prognosis of patients with cardiac arrest.

Effect of hemoglobin solution on the response of intracranial and subcutaneous 9L tumors to antitumor alkylating agents.

The 9L gliosarcoma growing subcutaneously in the hind leg of the Fisher 344 rat contains major areas of severe (< 5 mmHg) hypoxia, making up about 49% of the tumor. Intravenous administration of an ultrapurified polymerized bovine hemoglobin solution (8 ml/kg) along with normal air breathing reduces the percentage of severe hypoxia to about 24% and increases oxygenation throughout the tumor. Coadministration of the hemoglobin solution increased the tumor growth delay of subcutaneously implanted 9L tumors treated with carmustine (BCNU), cyclophosphamide, or ifosfamide but did not significantly change the tumor growth delay produced by cisplatin (CDDP). Coadministration of the hemoglobin solution with each of the four antitumor alkylating agents resulted in a near doubling of the percentage of increase in life span in animals bearing intracranial tumors treated with the combination as compared with animals treated with the drugs alone. Increases in serum blood urea nitrogen (BUN) and creatinine levels in treated animals returned to normal by 11 days posttreatment. Major changes in liver enzymes occurred with the combination of cyclophosphamide and the hemoglobin solution at 4 days posttreatment; however, these values returned to the levels in the untreated control animals within 1 week thereafter. These results indicate that further exploration of the use of hemoglobin solutions in cancer therapy is warranted.

Plasma concentrations of complement-activation complexes correlate with disease activity in patients diagnosed with isolated central nervous system vasculitis.

Isolated central nervous system (CNS) vasculitis is rare medium- sized vessel disease limited to intracerebral vessels. The two most common symptoms of this inflammatory disorder observed at entry to a hospital are headaches and mild memory deficits. Further progression of this disease may result in focal neurologic alterations and seizures. Currently, the most common laboratory abnormality noted is an elevated erythrocyte sedimentation rate. The complement (C) system is known to play a role in many inflammatory processes; it may also be involved in CNS vasculitis. In this longitudinal study of patients with CNS vasculitis, we detected C activation by highly sensitive and specific assays that are capable of identifying breakdown products formed after C activation: C3a des arg, C4a des arg, C5a des arg, C1rC1s-C1-inhibitor complex, and terminal C complex (C5b-9). We present two cases of documented CNS vasculitis in which serial measurements of these C-activation products correlate with disease activity. Our results indicate that a temporal association exists between C activation and the clinical presentation of CNS vasculitis. We conclude that physicians should monitor C-activation by-products in plasma when they attempt to follow the clinical course of CNS vasculitis.

Accentuated complement activation in patient plasma during the adult respiratory distress syndrome: a potential mechanism for pulmonary inflammation.

The adult respiratory distress syndrome (ARDS) represents an acute inflammatory lung disorder, characterized by both refractory hypoxemia and a mortality rate approaching 95%. Researchers have proposed that activation of the complement (C) system may play a role in the development of the pulmonary inflammation associated with ARDS. The purpose of this investigation was to determine whether complement activation occurs to a greater extent in patients with ARDS than in patients without ARDS, thereby providing a potential mechanism for the acute inflammation seen in ARDS. In this study, we assessed plasma complement activation by measuring complement activation by-products: C1rC1s-C1 inhibitor complex and C3b-P complex, generated subsequent to activation of the classical and alternative pathways, respectively, and also the terminal complement complex, formed after activation of either the classical or alternative complement pathway. Multivariate discriminant analysis revealed that these three complement activation complexes could distinguish patients with ARDS from those without ARDS (p less than 0.04). Furthermore, these three complexes provided a more sensitive discriminator of ARDS than did plasma levels of C3a desarginine (p greater than 0.30), C5a desarginine (p greater than 0.41) and total hemolytic complement activity (CH50) (p greater than 0.72). We conclude that a temporal association exists between the complement activation and the development of ARDS. Therefore, we suggest that complement activation by-products be included in the armamentarium for ARDS.

Analysis of human C8 with monoclonal antibodies. Characterization of a monoclonal antibody that recognizes free C8 alpha-gamma subunit.

The eighth component of human C is essential for the formation of the membranolytic C attack complex. C8 has a unique structure in that two covalently linked chains, C8 alpha and C8 gamma, are associated non-covalently with the third chain, C8 beta. In order to study the structure and assembly of the C8 molecule, a panel of mAb has been produced against the C component C8. Eight of these mAb had reactivity to the C8 alpha-gamma subunit, whereas four reacted with C8 beta. One of the C8 alpha-gamma mAb, C8A2, had specificity for an epitope on the C8 alpha-chain and exhibited no cross-reactivity to any of the other terminal C components, including C8 beta. C8A2 inhibited the hemolytic activity of the C8 alpha-gamma subunit but had no effect on the activity of fluid phase whole C8 or C8 within membrane-bound C5b-8. Functional experiments suggest that C8A2 inhibits C8 alpha-gamma activity by interfering with its interaction with the C8 beta-chain. In an enzyme immunoassay using the C8A2 mAb, free C8 alpha-gamma subunit could be detected in both homozygous and heterozygous C8 beta-deficient serum. However, only low level binding was observed when homozygous C5- and C7-deficient sera were tested. Thus the mAb, C8A2, recognizes an epitope expressed on the C8 alpha-gamma subunit but not on intact C8 and can detect free C8 alpha-gamma in the presence of native C8.

Accentuated formation of the terminal C5b-9 complement complex in patient plasma precedes development of the adult respiratory distress syndrome.

Extensive studies have been conducted to determine the pathogenesis of the adult respiratory distress syndrome (ARDS) by investigating the role of complement, a mediator of inflammation. Complement activation products have been detected in blood samples from patients during ARDS. However, the individual complement components that have been assessed only indicated generalized inflammation, and none could unequivocally discriminate the onset of this acute inflammatory lung injury. In this two-year prospective study of 87 septic patients, 22 of whom developed ARDS (25%), we determined complement activation by quantifying the terminal complement complex (TCC), C5b-9. The TCC is a stable complement by-product formed following activation of either the classical or alternative pathways. Our results show that plasma TCC concentrations increased an average of 110% (p = 0.002) two days prior to the onset of ARDS and also transiently increased an average of 45% (p = 0.01) immediately preceding its resolution. Furthermore, plasma TCC concentrations were a more sensitive measure of this acute inflammatory lung injury than levels of C3a desarginine, C4a desarginine, C5a desarginine, and total hemolytic complement activity. We conclude that a temporal association exists between accentuated formation of plasma TCC and the development and also resolution of septic ARDS. Therefore, we suggest that researchers include plasma TCC concentrations in clinical studies when they could use a potential early indicator for ARDS.

Complement activation occurs through both classical and alternative pathways prior to onset and resolution of adult respiratory distress syndrome.

We have previously reported that plasma concentrations of the terminal complement (C) complex (TCC), C5b-9, increased significantly 2 days prior to onset of adult respiratory distress syndrome (ARDS) and also 1 day preceding its resolution. To determine the pathway of complement activation that preceded development and resolution of this acute inflammatory lung injury in septic patients, we quantified the C1rC1s-C1 inhibitor complex and the C3bP complex, which are generated following activation of classical and alternative complement pathways, respectively. Two days prior to diagnosis of ARDS, the plasma C1rC1s-C1 inhibitor complex and C3bP complex levels increased 22 and 14%, respectively. Furthermore, significant correlations were identified between concentrations of the TCC and C1rC1s-C1 inhibitor complex (r = 0.73, P = 0.003) and also with the levels of the TCC and C3bP complex (r = 0.81, P = 0.002) before onset of ARDS. Equally of interest, the C1rC1s-C1 inhibitor complex and C3bP complex concentrations increased 68 and 35%, respectively, 1 day before resolution of ARDS. Similarly, significant elevations of TCC concentrations preceding resolution of ARDS correlated with C1rC1s-C1 inhibitor complex (r = 0.66, P = 0.02) and also with C3bP complex (r = 0.72, P = 0.002) levels. Our results indicate that both the classical and alternative complement pathways are activated prior to onset of ARDS and also before its resolution in septic patients.

Detection of the terminal complement complex in patient plasma following acute myocardial infarction.

The mechanisms of inflammation responsible for the myocardial tissue damage seen after an acute myocardial infarction (AMI) have not been clearly identified. Recent lines of evidence, demonstrating depressed sera levels of individual complement components in patients after myocardial infarction, have suggested involvement of the complement (C) system in micro- and macrovascular injury subsequent to AMI. The present study assessed the role of complement as a mediator of myocardial inflammation by quantifying products of complement activation including, the terminal complement complex (TCC) the cytolytic component of the complement system, C1rC1s-C1 inhibitor complex and C3bBbP complex, formed following activation of the classical and alternative pathway, respectively, and anaphylatoxins C3a and C5a in 41 patients following AMI. Plasma TCC and C1rC1s-C1 inhibitor complex concentrations increased up to 32-fold (P less than 0.001) and 8-fold (P less than 0.001), respectively, while the C3bBbP complex, C3a des-Arg and C5a des-Arg each increased over 2-fold (P less than 0.001) 16 h after AMI, and were only minimally detectable during non-inflammatory myocardial conditions. Furthermore, TCC concentrations increased over 150% (P less than 0.001) one day after patients reinfarcted, subsequent to hospitalization for a primary AMI. These results demonstrate activation of complement after AMI and suggest that inflammatory mediators of the complement system may contribute to myocardial tissue damage during the infarction process.

The terminal complement complex, C5b-9, a marker of disease activity in patients with systemic lupus erythematosus.

Concentrations of the terminal complement complex (TCC), C5b-9, were examined in 120 serum samples from 28 patients with systemic lupus erythematosus. Eleven patients with various manifestations of the disease were followed longitudinally for a 2-year period during active and inactive phases of the disease. In 9 of the 11 patients, elevations in TCC concentrations correlated with disease exacerbations. In many of these patients, C3 and C4 levels remained normal during the study and were less sensitive indicators of disease activity than were TCC concentrations. We believe that measurements of TCC are useful in monitoring patients with rheumatic diseases in which complement activation is a component.

Identical complement concentrations in blood obtained from central venous catheters, arterial lines, and antecubital phlebotomy.

In vitro complement activation has been detected during passage of blood through tubing used in hemodialysis and cardiopulmonary bypass surgery, in addition to tubing being investigated for vascular grafts. Because tubing from arterial lines and central venous catheters are composed of similar materials and are used when blood is withdrawn from patients for complement assays, a study was undertaken to assess the degree of complement activation in blood obtained from these sites. Complement activation was determined by a terminal complement complex enzyme-linked immunosorbent assay (ELISA), C1rC1s-C1 inhibitor complex ELISA, and 50% complement hemolytic activity (CH50) assay. Blood simultaneously obtained from the arterial lines and central venous catheters had identical terminal complement complex, C1rC1s-C1 inhibitor complex, and CH50 levels when compared with blood withdrawn by antecubital phlebotomy. Because blood may be obtained from the arterial lines and central venous catheters for complement assays, the pain and possible bruising from antecubital phlebotomy could be eliminated. Furthermore, blood may now be withdrawn from indwelling catheters without fear of in vitro complement activation causing a misinterpretation of results.