Journal of Fluorine Chemistry 109 (2001) 5965

Review

Fluorinated blood substitutes and oxygen carriers

Kenneth C. Lowe*
School of Life & Environmental Sciences, University of Nottingham, University Park, Nottingham NG7 2RD, UK Accepted 16 January 2001

Abstract Peruorochemicals (PFCs) are highly uorinated, inert organic compounds that can dissolve large volumes of O2 and other respiratory gases. PFCs are unreactive in the body and excreted primarily as a vapour by exhalation. However, PFC liquids are immiscible with aqueous systems, including blood, but can be injected safely into the bloodstream as emulsions. Such emulsions are currently being assessed clinically as temporary, intravascular respiratory gas-carriers and tissue oxygenating uids (so-called `blood substitutes'). One such emulsion, a commercial perubron-based formulation, OxygentTM, is in advanced clinical trials as an alternative to allogeneic (donor) blood transfusion during surgery. Basic and clinical studies indicate that OxygentTM can support O2 delivery to tissues during acute blood loss with no abnormal haemodynamic changes. # 2001 Elsevier Science B.V. All rights reserved.
Keywords: Peruorochemicals; Blood substitutes; Respiratory gas carriers; Tissue oxygenation; Blood transfusion; Fluoro-surfactants; Emulsication

1. Introduction Increasing concerns about the safety of conventional blood transfusion have fuelled the search for effective alternatives, often referred to as so-called `blood substitutes'. One class of such materials are PFCs that can be administered safely into the bloodstream in an emulsied form. Such emulsions are currently in advanced clinical trials for use during surgery as temporary tissue oxygenating uids, thereby reducing patient exposure to donor blood. The focus of this paper is to review the properties of PFCs relevant to their current and predicted uses in medicine, especially as intravascular respiratory gas carriers. 2. General physico-chemical properties of PFCs PFCs are chemically inert, heat stable, uorine-substituted, linear, cyclic or polycyclic anthropogenic hydrocarbons that can dissolve large volumes of O2, CO2 and other non-polar gases. O2 solubility in PFC liquids (STP) is ca. 45 ml per 100 ml, whereas CO2 solubility can be >200 ml per 100 ml [13]. This gas solubility decreases in the order CO2 @ O2 > CO > N2 correlating with the decrease in molecular volume of the solute [13]. Linear PFCs, such as bromoperuoro-n-octane (empirical formula: C8F17Br,
* Tel.: 44-115-951-3311; fax: 44-115-951-3251. E-mail address: kenneth.lowe@nottingham.ac.uk (K.C. Lowe).

more commonly known by the generic name of perubron; Fig. 1), dissolve O2 more readily than cyclic molecules (e.g. peruorodecalin, C10F18; Fig. 1). O2 solubility in PFC liquids is ca. 2025 times greater than in water or blood plasma under identical conditions. In contrast to the chemical binding of O2 to the porphyriniron sites of the respiratory pigment, haemoglobin, O2 dissolution in PFCs occurs passively, with gas molecules occupying intermolecular spaces within the PFC liquid. Unlike the characteristic sigmoid binding curve of O2 to haemoglobin, O2 solubility in PFCs and their emulsions increases linearly with partial pressure (pO2) approximating to Henry's Law. In addition, gas solubility in PFC liquids is independent of temperature. Details of the synthesis and other physico-chemical properties of PFCs relevant to their uses in biological systems have been reviewed in detail elsewhere [110]. PFC liquids are immiscible with aqueous-based systems, including blood and other body uids, but can be injected intravascularly as emulsions. Such emulsions, typically consisting of submicron PFC droplets (ca. 0.10.2 mm diameter) dispersed in a buffered, isotonic aqueous phase, have been evaluated clinically as, for example, temporary respiratory gas-carrying uids for intravascular infusion (including their use to potentiate the tumour-killing effects of ionising radiation or chemotherapeutic drugs) and perfusates for isolated organs [114] (Table 1). When administered into the bloodstream, PFC emulsions provide their main benet by increasing the O2 solubility in the plasma phase [114], as discussed later. As indicated in Table 1, neat PFC liquids

0022-1139/01/$ see front matter # 2001 Elsevier Science B.V. All rights reserved. PII: S 0 0 2 2 - 1 1 3 9 ( 0 1 ) 0 0 3 7 4 - 8

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are currently being evaluated clinically as ultrasound contrast imaging agents [110,23,24]. PFCs have also been used in liquid or emulsied form as respiratory gas-carrying culture media supplements for both prokaryotic and eukaryotic cells, including fermenter systems (Table 1), highlighting the growing interest in the biotechnological applications of these compounds [16]. 3. First generation injectable PFC mulsions The rst injectable PFC emulsion to be produced commercially was Fluosol1 (Green Cross, Japan), which consisted of 14.0% (w/v) peruorodecalin, 6% (w/v) peruorotri-n-propylamine [(C3F7)3N] (Table 2) and the surfactants, Pluronic1 F-68 (poloxamer 188), egg yolk phospholipids (EYP) and potassium oleate. Fluosol1 received regulatory approval in the USA and Europe in 19891990 for clinical use as an O2-carrying adjunct to coronary balloon angioplasty in high-risk patients [114,25]. It was not, however, widely adopted by cardiologists, mainly because subsequent improvements in angioplasty technology made its use redundant and, therefore, manufacture of the emulsion ceased in 1994. The main limitations of Fluosol1 were:  stem emulsion unstable at room temperature;  relatively poor efficacy as an O2 carrier;  unwanted side effects, including complement activation and altered white blood cell function, attributed mainly to the synthetic Pluronic1 F-68 surfactant component [114]. Despite its shortcomings, Fluosol1 did provide a baseline for the subsequent development of improved, `second-generation' PFC emulsions for intravascular applications. Concurrent with the development of Fluosol1 was the production of other, rst-generation, PFC emulsions, including Emulsion No. II and Perftoran from China and Russia, respectively (Table 2) [113,26]. As with Fluosol1, Perftoran

Fig. 1. Chemical structures of perfluorodecalin (upper) and perflubron (lower) (from [13]).

Table 1 Some biomedical applications for PFC liquids and their emulsions Biomedical application Tissue oxygenation fluids (`blood substitutes', `oxygen therapeutics') Anti-cancer agents Perfusates for isolated organs Cell culture media supplements Liquid ventilation fluids Surgical tools in ophthalmology Diagnostic imaging agents PFC liquid (L) or emulsion (E) E E E E/L L L La Reference(s) [114] [15] [114] [16] [1720] [21,22] [23,24]

a Interest currently focused on PFCs that are gaseous at body temperature (e.g. perfluoro-propane, C3F8, and perfluoro-pentane, C5F12).

are also being assessed clinically as ventilation uids for the treatment of acute respiratory failure [1720], and as tools in ophthalmologic surgery, primarily for retinal manipulation [21,22] (Table 1). Low molecular weight (Mw) PFCs, that are gaseous at body temperature such as, for example, peruoropropane (C3F8) and peruoro-n-pentane (C5F12),

Table 2 First- and second-generation PFC emulsions for use as intravascular oxygen carriers and tissue oxygenation fluids (so-called `blood substitutes') Commercial name First-generation emulsions Emulsion No. II Fluosol Oxypherol Perftoran Second-generation emulsions Fluxonb Oncosol Oxyfluor Oxygent
a b

PFC(s) constituents Perfluorodecalin, Perfluorotripropylamine Perfluorodecalin, Perfluorotripropylamine Perfluorotributylamine Perfluorodecalin, Perfluoromethylcyclopiperidine Perfluorodecalin, Perfluorodimorpholinopropane Perfluorophenanthrene Perfluorodichlorooctane Perflubron, Perfluorodecyl bromide

Country of origin China Japan Japan Russia Europe USA USA USA

Clinical trails Yes Yes No Yes No Yes Yes Yes

Availabilitya Available Discontinued Discontinued Available Available Available Available Available

Based on current information concerning availability for non-clinical studies. Provisional commercial name.

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also consists of 14% (w/v) peruorodecalin, but contains 6.0% (w/v) peruoromethylpiperidine (C12F23N] in place of peruorotri-n-propylamine [26]. Emulsion No. II is a 20% (w/v) emulsion based on the same PFCs as Fluosol1. For both emulsions, a poloxamer-type compound is incorporated as sole or major surfactant. Following clinical evaluation in >500 patients, Perftoran was approved (in 19951996) by the Russian health regulatory authorities as a temporary intravascular O2 carrier for haemorrhagic shock patients and perfusate for isolated human organs. Emulsion No. II has been administered to over 340 patients, some of them war casualties [27], but little information is available about its current clinical status. A further commercial emulsion, Oxypherol1, containing 20% (w/v) of peruorotributylamine [(C4F9)3N] (Table 2), was also manufactured by Green Cross, but not for clinical use owing to the high Mw (671) of its core PFC giving a prolonged body retention half-time (>500 days) [13]. 4. Second-generation injectable PFC emulsions The main objectives of the research and development effort to produce superior PFC emulsions to supersede Fluosol1 and other rst-generation emulsions were to:  identify highly purified PFCs with acceptable biocompatibility and excretion properties;  improve stability characteristics and hence, shelf-life, through the use of perfluorinated stabilisers and more appropriate surfactants (e.g. EYP, fluoro-surfactants);  develop concentrated emulsions having significantly increased PFC content conferring superior O2-carrying capacity [114]. For the latter point, it was necessary to achieve a compromise between producing highly concentrated PFC emulsions with increased O2-carrying capacity, whilst avoiding formulations with viscosities that are too high for use in the blood. 4.1. Biocompatible PFCs Perubron and peruorodecalin (Fig. 1) are the two compounds most widely evaluated as the principal constituents of injectable PFC emulsions. The Mw of both compounds are within the range 460500, which is recognised as that giving acceptable tissue retention times [114]. Both of these PFCs can be manufactured to a very high degree of purity, thereby avoiding unwanted side-effects that have often been attributed to partially-uorinated contaminants when used in vivo [114]. 4.2. Production of stable emulsions As noted already, one major objective in the production of second-generation, injectable PFC emulsions was to

improve stability and, consequently, extend shelf life. Emulsions are thermodynamically unstable systems and, in PFCbased formulations, the primary mechanism by which droplets grow is through a process of molecular diffusion known as Ostwald Ripening. This occurs when PFC molecules from smaller droplets diffuse through the continuous phase to the larger droplets which progressively increase in size at the expense of the former [28,29]. However, Ostwald Ripening in emulsions of peruorodecalin can be retarded by adding a small amount of a peruorinated, high Mw, high boiling point oil (HBPO) additive, such as peruoroperhydrophenanthrene [30,31] (C16F26) (Table 2). This strategy was employed in the production of both Fluosol1, in which emulsied peruorodecalin was stabilised with peruorotri-n-propylamine, and Perftoran, where peruoromethylpiperidine was used as the HBPO [110] (Table 2). Second-generation emulsions based on perubron or peruorodecalin have similarly been stabilised against Ostwald Ripening using small quantities of an appropriate HBPO, as discussed later. 4.3. Perflubron emulsions Perubron has one of the highest respiratory gas-dissolving capacities (ca. 50 ml per 100 ml) of any of the PFCs commonly used for biomedical applications. It is also an attractive compound for clinical use because of its excellent imaging properties [23]. Perubron can be readily emulsied with EYP and is rapidly excreted from the body, primarily because of its very high lipophilicity endowed by the presence of a single bromine atom on the terminal carbon (Fig. 1). Indeed, studies in animals have shown that the body retention half-time of perubron is ca. 4 days [1 10]. Perubron is the major PFC component in a commercial O2-carrying emulsion (OxygentTM; Table 2) developed by the Alliance Pharmaceutical Corporation in San Diego. The current OxygentTM formulation (AF0144) consists of 58% (w/v) perubron and 2% (w/v) of its higher homologue, peruoro-decyl bromide (C10F21Br) (Table 2), to stabilise against Ostwald Ripening [68]. OxygentTM, which has a shelf life at 5108C of >1 year, is stabilised with EYP (3.6% w/v), that are excellent stabilisers of PFC emulsions [28,29]. However, EYP are sensitive to slow oxidative degradation but, in some PFC-based emulsions, this can be retarded by adding an antioxidant, such as a-tocopherol [32]. In this respect, a-tocopherol is added routinely (ca. 0.10.2% w/v) to some commercial phospholipid formulations (e.g. Lipoid E100, Lipoid GmbH, Germany) that have been used in other PFC emulsions, as described later. 4.4. Perfluorodecalin emulsions Peruorodecalin (Fig. 1) has also been used as the basis of second-generation injectable PFC emulsions. This is because its acceptable tissue retention time outweighs its

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relatively poor emulsifying properties [110]. Peruorodecalin dissolves ca. 40 ml per 100 ml of O2 and ca. 140 ml per 100 ml of CO2 and has a body clearance half-time of ca. 7 days [110]. A novel series of peruorodecalin-based emulsions, stabilised with up to 2.5% (w/v) of lecithin (Lipoid E100) and given the provisional commercial name of Fluxon (Table 2), have been produced recently by a European research team [33]. Some of the emulsions also contained 1.0% (w/v) of peruoro-1,3-dimorpholinopropane (C11F22N2O2) (Table 2) to suppress droplet growth by Ostwald Ripening, analogous with earlier related studies [30,31]. Peruorodimorpholinopropane has a Mw of 610, a boiling point of 1828C and can dissolve ca. 43 ml per 100 ml of O2. It has an estimated body clearance half-time of 55 days [34]. This compares favourably with corresponding values of 60 days for the peruorotripropylamine and peruoromethylpiperidine constituents of Fluosol1 and Perftoran1, respectively [110]. The novel emulsions were prepared by homogenisation and had a PFC content of 2040% (w/v). The emulsions were steam sterilisable and showed no signicant changes in droplet diameter (ca. 0.2 0.3 mm) during >300 days' storage at room temperature. The novel emulsions are currently being assessed as O2-carrying perfusates of animal organs, including the dog heart and pig liver. 4.5. Other concentrated emulsions A further, second-generation PFC emulsion is Oxyuor1, developed in the USA by Hemagen-PFC of St. Louis. Oxyuor1 consists of 76% (w/v) of a linear compound, peruoro-1,8-dichlorooctane (C8F16Cl2) (Table 2), together with safower oil as stabiliser and EYP as surfactant. The emulsion has an average droplet diameter of ca. 0.22 0.25 mm. Oxyuor1 has been evaluated as an intravascular O2 carrier in preclinical studies [35], and as a perfusate for

cardiopulmonary bypass (CPB) machines [36], but little further information on its current commercial or clinical status is available. 5. Novel fluoro-surfactants PFC emulsion stability has been markedly improved by adding specially synthesised, `uorophilic' surfactants and/ or co-surfactants [3740]. The most effective compounds are those derived from sugars, amino acids and lipids. A novel series of uoro-surfactants, derived from glycosides (monosaccharides; `S' series) or polyols (ureas or carbamates; `P' series), have recently been synthesised for PFC emulsication (Fig. 2). Such uoro-surfactants were produced via simple, but highly selective, routes using highly uorinated isocyanates with amino alcohols, polyethoxylated alcohols and partially protected sugars at anomeric carbon; yields were 8895% [41]. The resultant compounds were peruoroalkylated with hydroxylic ``head'' groups (Fig. 2). One promising uoro-surfactant to emerge from this research effort is an amphiphilic, poly(oxyethylene) monocarbamate, C 8 F 17 C 2 H 4 NHC(O)(CH 2 CH 2 O) 2 Me (designated as compound P6). Interestingly, some of these novel uoro-surfactants, particularly the polyol compounds, inhibited spontaneous platelet aggregation in human blood in vitro [42], suggesting possible applications for these compounds as anti-thrombotic agents which warrant further investigation. 6. Safety and biocompatibility The PFCs are unreactive in the body and excreted primarily as a vapour through the lungs. PFC droplets infused into the bloodstream are cleared by phagocytic cells of the

Fig. 2. Chemical structures of novel glycosidic (compounds S2 and S4) and polyol (compounds P1 and P4) fluoro-surfactants (from [40]).

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monocyte-macrophage system (MMS), mainly liver Kupffer cells and spleen macrophages. PFCs subsequently diffuse back into the blood where they are carried in plasma lipids to the lungs and exhaled [43]. Animal studies have shown that the pulmonary elimination of perubron does not affect functional residual capacity, vital capacity, lung compliance or the dynamic behaviour of the natural lung surfactant [44,45]. Injection of PFCs is often followed by temporary increases in the weights of liver and spleen coupled, in some instances, with transient alterations in cellular enzymes, especially the cytochromes P-450 complex [15]. However, the duration and magnitude of such responses are highly species-specic and dependent, in part, on dose and type of PFC injected [15]. It been claimed [11,13] that most of the side-effects attributed to secondgeneration PFC emulsions, such as delayed febrile reactions and u-like symptoms, in some patients, can be attributed to the normal activity of the phagocytic cells of the MMS scavenging PFC droplets from the blood. Further detailed discussion on the fate and effects of PFCs and other emulsion constituents in the body can be found in recent reviews [110]. 7. Oxygen transport and delivery by PFCs Oxygen dissolves in PFC droplets as they pass through the lungs. The total amount of O2 dissolved in a PFC emulsion depends on the concentration of PFC and the solubility coefcient of the compound for the gas. Alveolar O2 loading in PFCs increases linearly in proportion to the pO2 and is, therefore, enhanced if the recipient breathes supplementary O2. For example, a typical physiological pO2 gradient between the lungs and tissues during air breathing would be about 60 Torr. Under such conditions, normal blood (packed cell volume 45%, haemoglobin 15 g per 100 ml) releases ca. 5 ml O2 per 100 ml, representing an extraction rate of ca. 25%. In contrast, the corresponding value for a 60% (w/v) perubron emulsion under ambient pO2 would be ca. 2 ml O2 per 100 ml. However, if an atmosphere containing 90100% O2 were breathed, thus raising the arterial pO2 to >400 Torr, about 10 ml O2 per 100 ml would be released, thus representing an extraction rate of ca. 90% [46,47]. This example illustrates why, in clinical studies where a PFC emulsion was used to enhance tissue oxygenation, efcacy was maximised when patients breathed an O2-enriched atmosphere [1113]. Oxygen extraction from PFCs is signicantly increased by the lack of chemical xation and by the large surface area provided by the emulsion droplets which, as noted already, are ideally only ca. 23% of the diameter of the normal erythrocyte (ca. 78 mm). O2 delivery by PFC is also much simpler than the release of O2 from haemoglobin, where the gas has to cross the red cell membrane, pass through the plasma, and then diffuse through both the

membranes of the endothelial cells and those of the tissues it is supplying. Oxygen delivery by PFCs appears to be more complex than simple `bulk' transport. In this respect, it has been proposed [4649] that PFCs may enhance O2 transfer into tissues by acting as `stepping stones' between red cells and blood vessel walls. In vessels with rapid ow (e.g. arterioles), PFC emulsion droplets in the circulation are believed to ow mainly in the plasma layer that forms close to the vessel walls as a result of red cell streaming [11]. In the microcirculation, PFC droplets will occupy the plasma gaps between erythrocytes and thereby perfuse even the smallest capillaries. Some perfusion by PFCs will be expected to occur in vessels that effectively exclude red cells through local vasoconstriction or ischaemia. Thus, under such conditions, a PFC emulsion will make a signicant contribution to overall tissue O2 delivery. Patel and Mehra [50,51] studied aspects of O2 transport in mathematical models of both uniform and non-uniform blood-PFC systems focusing on O2 uptake from large (>300 mm diameter) and smaller (<300 mm) vessels into tissues. Their modelling approach was based on an earlier study which used engineering mass transfer principles to compare O2 uptake in PFC emulsions and blood [52]. Patel and Mehra [50,51] compared their theoretical ndings with experimental observations on PFC-mediated O2 supply [53,54]. At elevated O2 tensions, PFC emulsion signicantly increased O2 ux at the vessel wall, leading to enhanced tissue oxygenation. Such an increased O2 ux was greater for non-uniform dispersions, where the red blood cells were predicted to migrate towards the central, low shear regions of the vessel [50,51]. It was also noted that a near-wall excess of PFC droplets was not essential to cause this increase but, where it occurred, the overall plasma O2 concentration achieved was even greater [50,51]. Additional support for PFC-enhanced increased transfer of O2 from red cells to tissues also comes from the modelling studies described by Perevedentseva et al. [55]. Overall, such theoretical analyses assist in predicting the precise mechanisms by which PFCs improve tissue oxygenation and form a baseline for the interpretation of in vivo studies. 8. PFC emulsions as tissue oxygenation fluids and potential transfusion alternatives Faithfull et al. [56] described computer programme which predicted that the infusion of ca. 1.5 ml per 100 ml of OxygentTM to haemodiluted patients breathing supplementary O2 during surgery would temporarily maintain adequate tissue oxygenation, as measured by the mixed venous O2 tension (pvO2). Such use of OxygentTM would, therefore, delay the indication for transfusion of donor (allogeneic) blood and, thus, the patients pre-donated (autologous) blood could be kept in reserve until needed. The programme has subsequently been validated in animal studies and in

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ongoing clinical trials [1113,5760]. In this respect, Batra and co-workers [5759] subjected anaesthetised dogs to moderate haemodilution (nal haemoglobin concentration 8 g per 100 ml) using hydroxyethyl starch solution. Following haemodilution, and during concurrent 100% O2 breathing, animals were then given a single dose of 1.8 g kg1 OxygentTM (60% w/v perubron) which signicantly raised the mean pO2 in skeletal muscle, brain parietal cortex and gut serosa. Infusion of OxygentTM also increased the pvO2 by 16%, conrming this variable to be a reliable indicator of PFC-induced increased tissue pO2, in accord with predictions from the earlier computer modelling [56]. The potential oxygenation benets from a PFC-based O2 carrier (assuming stable O2 consumption), as noted by Keipert [11], were:       increased increased increased increased increased increased plasma O2 concentration; systemic O2 delivery; uptake of dissolved O2; venous drainage pO2; tissue oxygenation; mixed venous O2.

and re-infused into the patient towards the end of surgery, or in the post-operative period, as needed. Thus, the use of PFC emulsion in conjunction with ANH not only minimises the need to infuse allogeneic blood, but also allows surgery to be initiated at a lowered packed cell volume, thereby reducing red cell loss during subsequent bleeding [11]. In September 1997, Keipert et al. [64] reported that over 250 surgical patients had received OxygentTM during the Phase II clinical trials, whilst in [65], Keipert subsequently noted that by November 2000, the number had risen to >1300. Crucial Phase III studies with OxygentTM were initiated towards the end of 1998. One problem with the perioperative use of current PFCbased O2 carriers is their relatively short i.v. persistence compared to transfused red blood cells [66] This raises the question of whether perioperative ANH, coupled with autologous blood transfusion, is a desirable and cost-effective strategy for blood conservation and limiting the use of banked blood [6769]. Future research should focus on resolving this important issue. References
[1] K.C. Lowe, Vasc. Med. Rev. 5 (1994) 1532. [2] K.C. Lowe, Sci. Prog. 80 (1997) 169193. [3] K.C. Lowe, Fluorocarbon emulsions as blood substitutes, in: E. Tsuchida (Ed.), Present and Future Perspectives of Blood Substitutes, Elsevier, Lausanne, 1998, pp. 327338. [4] T.F. Zuck, J.G. Riess, Crit. Rev. Clin. Lab. Sci. 31 (1994) 295324. [5] R.K. Spence, Perfluorocarbons, in: E.C. Rossi, T.L. Simon, G.S. Moss, S.A. Gould (Eds.), Principles of Transfusion Medicine, 2nd Edition, Williams and Watkins, Baltimore, 1996, pp. 189196. [6] J.G. Riess, M.P. Krafft, Art. Cells, Blood Subs., Immob. Biotechnol. 25 (1997) 4352. [7] J.G. Riess, M.P. Krafft, Biomaterials 19 (1998) 15291539. [8] J.G. Riess, Fluorocarbon-based oxygen-delivery: basic principles and product development, in: T.M.S. Chang (Ed.), Blood Substitutes: Principles, Methods, Products and Clinical Trials, Vol. II, Karger Landes, Basel, 1998, pp. 101126. [9] T. Frietsch, C. Lenz, K.F. Waschke, Eur. J. Anaesthesiol. 15 (1998) 571584. [10] N.S. Faithfull, J.G. Weers, Vox Sang. 74 (Suppl. 2) (1998) 243248. [11] P.E. Keipert, Art. Cells, Blood Subs., Immob. Biotechnol. 23 (1995) 381394. [12] S.F. Flaim, Perflubron-based emulsion: efficacy as temporary oxygen carrier, in: R.M. Winslow, K.D. Vandegriff, M. Intaglietta (Eds.), Advances in Blood Substitutes. Industrial Opportunities and Medical user, Boston, 1997, pp. 91132. Challenges, Birkha [13] P.E. Keipert, Perfluorochemical emulsions: future alternatives to transfusion, in: T.M.S. Chang (Ed.), Blood Substitutes: Principles, Methods, Products and Clinical Trials, Vol. II, Karger Landes, Basel, 1998, pp. 127156. [14] K.C. Lowe, Blood Rev. 13 (1999) 171184. [15] B.A. Teicher, Art. Cells, Blood Subs., Immob. Biotechnol. 23 (1995) 395406. [16] K.C. Lowe, M.R. Davey, J.B. Power, Trends Biotechnol. 16 (1998) 272277. [17] R.C. Leonard, Anaesth. Intens. Care 26 (1998) 1121. [18] S.E. Day, R.G. Gedeit, Clin. Perinatol. 25 (1998) 711722. [19] M. Quintel, J. Meinhardt, K.E. Waschke, Anaesthetist 47 (1998) 479489.

OxygentTM is currently being evaluated in advanced clinical trials as a temporary tissue oxygenation uid for use in patients undergoing potentially high blood loss (typically 3 units or more) surgical procedures. Reports on Phase I safety studies using OxygentTM infused intravascularly into healthy volunteers (1.2 or 1.8 g PFC kg1 body weight) indicated that there were no marked adverse effects on blood coagulation parameters, excepting a 17% reduction in the platelet count after 3 days with the higher dose [61]. Some subjects also exhibited minor u-like symptoms, coupled with increased serum interleukin-6 concentration, at 24 h after receiving the emulsion [62]. The latter ndings were consistent with previous observations of transient alterations in immune system function following intravascular infusion of emulsied PFC [11,13]. Multiple-site Phase IIa efcacy trials with OxygentTM in surgical patients began in the USA and Europe during 1995 1996. In one preliminary study, patients were initially subjected to acute normovolaemic haemodilution (ANH) with a colloidal plasma expander to collect ca. 2 units of fresh autologous blood from each individual immediately before surgery. A single bolus dose of a 90% (w/v) perubron emulsion (0.9 g PFC kg1 body weight) was infused into 100% O2-breathing patients as an alternative to blood [60]. Infusion of the emulsion was followed by a 17% increase in mean pvO2, with no corresponding change in cardiac index or total O2 consumption. More recently, Spahn et al. [63] reported that, in an extensive study involving 147 orthopaedic patients, infusion of 1.8 g of Perubron emulsion per kilogram body weight combined with 100% O2 ventilation was more effective than autologous blood or colloid solution in reversing physiologic transfusion triggers. Such use of relatively low doses of PFC emulsion to maintain tissue oxygenation means that autologous blood can be conserved

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