Clinical Studies of A Perfluorochemical Whole BloodSubstitute (Fluosol-DA)

Summary of 186 Cases

TAKAO MITSUNO, M.D., HARUMASA OHYANAGI, M.D., PH.D., RYOICHI NAITO M.D., PH.D.

After the experimental and phase one studies of our so-called"artificial blood," Fluosol-DA (20%), an emulsified mixture ofperfluorodecalin and perfluorotripropylamine, were successfullycompleted, phase two and three clinical studies were carriedout on 186 patients in Japan. The initial dose was 20 ml/Kgbody weight (BW), and additional 10 ml/Kg BW doses were

From the Kobe National Hospital, Kobe, Japan, FirstDepartment of Surgery, Kobe University School of

Medicine, Kobe, Japan, and The Green CrossCorporation, Osaka, Japan

Coworkers were: T. Oyama and A. Matsuki (Department of Anes-thesiology, Hirosaki University School of Medicine, Hirosaki); S.Tsuchida, T. Harada, and Y. Watabe (Department of Urology andDepartment of Anesthesiology, Akita University School of Medicine,Akita); T. Saito (Department of Pediatrics, Tohoku University Schoolof Medicine, Sendai); K. Honda, S. Hoshino, and A. Usuba (I. De-partment of Surgery, Fukushima Medical College, Fukushima); T.Fujita (Department of Anesthesiology, Gumma University School ofMedicine, Maebashi); H. Nakamura and K. Fukushima (Departmentof Urology and Department of Anesthesiology, National DefenseMedical College, Tokorozawa); N. Nishimura and T. Sugi (Depart-ment of Critical Care Medicine, Nihon Medical College, Tokyo); H.Akiyama and T. Kawamura (Department of Gastroenterological Sur-gery, Toranomon Hospital, Tokyo); K. Okada and I. Kosugi (De-partment of Anesthesiology, Teikyo University School of Medicine,Tokyo), A. Torii and Y. Egusa (Department of Surgery, NationalMedical Center, Tokyo); A. Amemiya (Department of Gynecologyand Obstetrics, St. Marianna University School of Medicine, Ka-wasaki); S. Yamamoto (Department of Surgery, Saiseikai KanagawaPref. Hospital, Yokohama); S. Eguchi (II. Department of Surgery,Niigata University School of Medicine, Niigata); S. Murakami (De-partment of Anesthesiology, Kanazawa University School of Medi-cine, Kanazawa); S. Baba (II. Department of Surgery, HamamatsuMedical College, Hamamatsu); T. Yamada (Department of Medicine,Yasu Hospital, Yasu); H. Handa and Y. Oda (Department of Neu-rosurgery, Kyoto University School of Medicine, Kyoto); M. Ohta(Senri Emergency Critical Care Center, Osaka); M. Fujimori (De-partment of Anesthesiology, Osaka City University Medical School,Osaka); M. Watanabe (Department of Surgery, Kawanishi City Hos-pital, Kawanishi); Y. Saitoh (Department of Surgery, Kobe UniversitySchool of Medicine, Kobe); Y. Kawa (Department of Surgery, KobeNational Hospital, Kobe); M. Takaori (Department of Anesthesiol-ogy, Kawasaki Medical College, Kurashiki); and N. Yoshimura(Department of Anesthesiology, Kagoshima University School ofMedicine, Kagoshima).

Reprint requests: Dr. Takao Mitsuno, Kobe National Hospital, 3-1 Nishiochiai, Suma-ku, Kobe, 654 Japan.Submitted for publication: April 22, 1981.

applied as needed. Oxygen-supplying and plasma-extendingeffects were established. No untoward reaction was observedin any of the 186 cases except in a case that involved long-termrepeated administration. Initial studies on Fluosol-DA suggestreasonable safety; however, additional clinical trials appearwarranted.

R ESEARCH OVER TEN YEARS has led to the devel-opment of an emulsion of perfluorochemicals

(PFCs) as an oxygen-carrying artificial blood substi-tute. A fine particulate, stable emulsion, in which par-ticles average 0.1 , (maximum 0.6 g) in diameter, isnecessary for low toxicity and good retention in cir-culation. Fluosol-DA, an emulsion mixture of perfluo-rodecalin and perfluorotripropylamine, was finally cho-sen as the candidate for an artificial substitute forerythrocytes.No untoward side effects were found in the functions

of heart, liver, kidney, etc., in either the short-term orthe long-term, following administration. The lifesavingeffect of Fluosol-DA in acute hemorrhagic shock andin acute carbon monoxide poisoning was confirmed.Monkeys that underwent nearly total exchange trans-fusion survived well for over a year, without any un-toward reaction.The safety and efficacy of Fluosol-DA were indicated

not only in comprehensive animal studies,5 but also in"decerebrate human subjects,3 in normal human volun-teers,6 and, recently, in clinical practice."2'4'7'8 Based onthese findings, extended clinical studies seemed war-ranted.The results of the 186 cases of therapeutic application

of this oxygen-transporting blood substitute, Fluosol-

0003-4932/82/0100/0060$01.00 © J. B. Lippincott Company

60

WHOLE BLOOD SUBSTITUTE 61

DA (20%), are summarized by members of a clinicalstudy group consisting of 26 hospitals in Japan. Fluosol-DA is a biologically inert emulsion with plasma-ex-panding properties as well as a high oxygen-carryingcapacity (7.2 vol% at 37 C, compared to 17 to 20 vol%for erythrocytes).

Materials and Methods

Perfluorochemical Emulsion

Fluosol-DA,* a fine particulate, stable emulsion ofPFCs with no untoward reactions, was used throughoutthe course. Fluosol-DA is an emulsified mixture of sevenparts perfluorodecalin and three parts perfluorotripro-pylamine (Table 1) with physiochemical properties ap-

propriate for clinical use.

Subjects

The 186 patients ranged in age from seven to 84years, and approximately two-thirds were between theages of 31 and 60. They were treated by members ofthe clinical study group, which consisted of 26 hospitaldepartments in Japan.t Patients were treated withFluosol-DA instead of blood transfusions for the fol-lowing reasons:

1. Blood transfusion refused by the patient or familyfor religious reasons (22);

2. Blood transfusion refused by the patient for otherreasons (7);

3. Nonavailability of compatible blood (9);4. Delayed delivery of compatible blood due to trans-

portation or other factors (18);

* Made and supplied by The Green Cross Corporation, 15-1, Im-abashi -chome, Higashi-ku, Osaka, Japan. Their records confirmthese cases.

t Emergency critical care unit-2; anesthesiology-9; surgery-9;neurosurgery- 1; urology-2; gynecology and obstetrics- 1; internalmedicine- 1; pediatrics- 1.

TABLE 1. Composition of Fluosol-DA (20%)

Perfluorodecalin 14.0 w/v%Perfluorotripropylamine 6.0 w/v%Pluronic F-68 2.7 w/v%Yolk phospholipids 0.4 w/v%Glycerol 0.8 w/v%NaCl 0.600 w/v%KCI 0.034 w/v%MgCl2 0.020 w/v%CaCl2 0.028 w/v%NaHCO3 0.210 w/v%Glucose 0.180 w/v%Hydroxyethyl starch 3.0 w/v%

5. "Bloodless surgery" chosen by the surgeons forprotection from risk of hepatitis infection (78);

6. For CO-intoxication (2);7. For improvement of cerebral hypoxia (28);8. For improvement of coronary circulation (3);9. For severe autoimmune hemolytic anemia (2); and

10. As plasma expander with oxygen transport for var-

ious kinds of impaired blood flow (17).

Common protocol for clinical study previously indi-cated a standard initial infusion dose of 20 ml/Kg bodyweight (BW) followed by additional doses of 10 ml/KgBW, if necessary, not administered earlier than 12hours after the first infusion. The standard rate of in-fusion was not faster than 10 ml/min. In accordancewith the conditions of patients, however, Fluosol-DAwas administered at volumes and rates described inTable 2 and Table 3. Seventy-eight of 186 cases re-

ceived the emulsion at rates in excess of 0.2 ml/KgBW/min.Of the 134 patients with hemorrhages, 88 lost more

than 1500 ml of blood, of whom 79 received only Fluo-sol-DA. Of the 186 patients who received Fluosol-DA,only nine received repeated infusions, as follows: seven

cases of cerebral anoxia-two to three infusions; one

case of malignant tumor surgery-two infusions; andone case of severe hemolytic anemia-two infusions.

TABLE 2. Total Dose of Fluosol-DA (20%)

ml/kg BW (iv)

Indication 1 - 5 6 - 10 11 - 15 16 - 20 21 - 25 26 - 30 .31

With hemorrhage: (n = 134)Blood loss replacement (112) 1 44 24 23 17 2 1Prevention of hemorrhagic

shock (22) 6 9 2 4 1

Without hemorrhage: (n = 52)Cerebral circulationimprovement (28) 2 22 4

CO intoxication (2) 1 1Miscellaneous (22) 2 1 5 10 4

Total (n = 186) 5 73 42 36 26 3 1

Vol. 195 * No. I

Ann. Surg. * January 1982

TABLE 3. Rate of Administration

(ml/min)

Indication I 5 6 - 10 11 - 15 16 - 20 .21

With hemorrhage: (n = 134)Blood loss replacement (112) 22 53 17 19 1Hemorrhagic shock (22) 3 11 5 3

Without hemorrhage: (n = 52)Cerebral circulationimprovement (28) 4 13 10 1

CO intoxication (2) 2Miscellaneous (22) 5 2 14 1

Total (n = 186) 34 79 29 39 5

Effect of Fluosol-DA (20%) on HemodynamicsHemodynamics were examined in conventional pa-

rameters, i.e. blood pressure, pulse rate, central venouspressure, ECG, etc. Blood gases were analyzed with theAstrup Micromethod, Lex 02 cont., and gas chroma-tography. The PFC content was measured by gas chro-matography. The oxygen content of PFC dispersed inthe blood (V) was calculated by the following formula,because partial pressure of oxygen in the PFC particlesis equilibrated with PaO2 or PvO2:

V WX-X P02p 760

where,

a: oxygen solubility of PFC (ml/ml) at given P02(e.g., a = 0.45 when P02 = 760 mmHg);

(mmHg)

200-

180-

160

140

120

100

Tbefore during

W: content of PFC in g/ml blood, determined by4gas chromatography;

p: density of PFC, = 1.8.

Influence of Fluosol-DA on Hematology and SerumChemistry

Hematological effects were examined in hemoglobin,hematocrit, erythrocytes, reticulocytes, leucocytes, andthrombocytes. Blood coagulation variables, includingbleeding time (Duke's method), whole blood coagula-tion time (Lee-White method), and prothrombin timewere examined. Serum chemistry was tested for totalprotein, SGOT, SGPT, alkaline phosphatase, BUN,and electrolytes.

Results

Clinical indications for the use of Fluosol-DA in the186 cases are broken down as follows: With hemor-rhage-replacement for lost blood and treatment (pre-vention) of hemorrhagic shock, including 51 cases withmalignant tumors, 134; without hemorrhage-improve-ment of cerebral hypoxia 28, CO intoxication 2, andmiscellaneous 22, a total of 52.

' Us4-2 Effect of Fluosol-DA (20%) on Hemodynamics

Blood pressure (systolic). As shown in Figure 1, aoup moderate rise in systolic blood pressure was observed

J2*, . during and after infusion especially in the patients withhemorrhage. The blood pressure rise was more re-markable in patients displaying lower blood pressures(<100 mmHg), but less so in those with normal bloodpressure (121-140 mmHg), as shown in Figure 2. In

*P<0 05 the nonhemorrhagic patients, a blood pressure rise wasobserved in those patients who received larger doses.None of the patients manifested hypotension during orafter infusion.

Pulse rate. In both groups, those with and withouthemorrhage, no significant change in pulse rate was

infusion of Fluosol-DA (20%)FIG. 1. Changes in blood pressure, systolic.

62 MITSUNO, OHYANAGI, AND NAITO

WHOLE BLOOD SUBSTITUTE

Pre-infusion level:-100mmHg (n=32)

before during afterinfusion of Fluosol-DA (20%)

mmHg Pre-infusion level:101 - 120mmHg (n=32)

150140

130120110100

90

80

70

601 n

150140

130120

110

100

90

80

70

601 r_

" before during afterinfusion of Fluosol-DA (20%)

63mmHg Pre-infusion level:

| 121 -140mmHg (n=31)

- before duringinfusion of Fluosol-DA

after(20%)

FIG. 2. Changes in blood pressure (hemorrhage group).

seen before, during, or after the infusion of Fluosol-DA,except for 12 hemorrhage cases with low blood pres-

sures (<100 mm Hg) and high pulse rates (<100) ini-tially, who showed normalization of pulse rates afterinfusion.

Central venous pressure (CVP). CVP was monitoredin patients before, during, and after infusion (Table 4).The group with CVPs lower than 5 cm H20 beforeinfusion of Fluosol-DA, recovered to normal CVPs afterinfusion. In the group with normal or high CVPs beforeinfusion (.6), high CVPs were observed after infusionin the nonhemorrhagic subgroup, suggesting "over-

load", while no change in CVP was seen in the hem-orrhagic subgroup.ECG, respiration, and body temperature. Fluosol-

DA did not have any demonstrable effect on any ofthese parameters.

Circulating blood volume. In eight patients who re-

ceived 500 ml of Fluosol-DA during surgical proce-

dures, circulating blood and plasma volumes were mon-

itored before and after infusion of Fluosol-DA(Table 5).

Blood Gas Analysis

Blood gases were determined before and after infu-sion of Fluosol-DA.

PaO2. The data indicates that the PaO2 was elevatedafter the infusion of Fluosol-DA, and, moreover, it iscorrelated with the fractional concentration of oxygen

in inspired gas (FiO2), as shown in Figure 3. When thepatients were classified into two groups, one inspiredwith gas lower than FiO2 = 0.4 and the other higherthan 0.5, the elevation of the PaO2 was remarkably

TABLE 4. Changes of CVP

Infusion of Fluosol-DA (20%) (c)(C X 100

Group n Before During After (a)

CVP (<5)hemorrhage 14 3.21 ± 1.77 6.08 ± 3.74* 8.22 ± 4.38* 256.1nonhemorrhage 17 2.86 ± 1.73 5.58 ± 2.65 9.14 ± 6.31* 319.6

CVP (.6)hemorrhage 23 9.24 ± 2.86 10.07 ± 3.45 10.05 ± 5.05 108.8nonhemorrhage 8 9.50 ± 1.58 15.63 ± 5.19* 17.00 ± 4.69* 178.9

* p < 0.05.

mmHg

150

.140130120110

10090'070

VOl. 195 - NO. I

MITSUNO, OHYANAGI, AND NAITO

TABLE 5. Circulating Blood Volume

ImmediatelyBefore AfterInfusion Infusion(ml/kg (ml/kgBW) BW)

Blood volume, average 64.4 ± 3.0 74.6 ± 2.2Plasma volume, average 41.8 ± 1.8 49.8 ± 1.2

higher in the latter, as shown in Figure 4. These findingsindicate that a FiO2 higher than 0.5 is necessary toachieve a PaO2 higher than 200 mmHg with the aidof Fluosol-DA (20%).

PvO2, PaCO2, PvCO2, pH, and base excess showedno significant changes after infusion of Fluosol-DA.

Fluorocrit and oxygen supplied by Fluosol-DA(20%). Fluorocrit (a measurement of the volume percent of the white bottom layer of PFC centrifuged fromblood, analogous to hematocrit) was performed before,immediately after, and at 1, 2, 3, 4, 6, 12, 24 hours, 2,and 3 days respectively after infusion of Fluosol-DA.The fluorocrit has shown to correlate well with gas chro-matographic determinations of PFC in blood, 1 vol%

equalling 13 mg of PFC. The data from patients whoreceived 500 ml and 1,000 ml of Fluosol-DA are shownin Figures 5 and 6, respectively. The fluorocrit was de-tectable, usually .1%, up to 24 hours after infusion.

The role ofPFC in supplying oxygen in circulatingblood. Table 6 shows a blood gas analysis, including 02content in PFC contained in blood, before, immediatelyafter, and 1.5-2 hours after infusion of 1,000 ml ofFluosol-DA (20%). Here, the oxygen supplied by PFC,contained in circulating blood was 12-13% of the totaloxygen-supply, even though the PFC content in bloodwas only 45 mg/ml blood.

Hematological Findings

Hemoglobin (g/dl), hematocrit, and erythrocytecount. These parameters showed about a 10% reductionimmediately after infusion of Fluosol-DA in 93 patientsin the hemorrhagic group (Fig. 7). No change was seenin 35 patients in the nonhemorrhagic group. It is likely

PaO2mmHg

87 cases of hemorrhage group 400

300

200

100

rI~~~~~~~~~~

1' : -I~~~~~~~

I.

FIG.~~ ~ ~3.Pa2atrifso o loo-A(0)

I 0

I

0.30 0.33 0.40 0.50 0.60 0.80 1.0 Fi02FIG. 3. PaO2 after infusion of Fluosol-DA (20%).

u beforeFIG. 4. PaO2 and FiO2-

64

POO2mmHg

500

400-

300k

200 -

1010

afterIL

Ann. Surg. * January 1982

-

-

-

-

WHOLE BLOOD SUBSTITUTE

(%)4

3

FIG. 5. Fluorocrit after in- 2fusion of 500 ml of Fluosol-DA (20%).

1

Dose: 500mQ of Fluosol-DA (20%)(n=23)

1 3

65

time after Fluosol-DA infusion

that infusion of Fluosol-DA has no direct influence onerythrocyte count or hemoglobin content, but that thisphenomenon is a result of dilution.

Reticulocytes. No change was seen after infusion ofFluosol-DA.

Leucocytes. In 93 patients in the hemorrhagic group,an increase of approximately 10% in leucocytes wasseen immediately after infusion. These values returnedto within normal limits three days after infusion. Nochange was observed in the nonhemorrhagic patients.As for the leucocytes, a slight increase of neutrophilsand a slight decrease of lymphocytes was seen imme-diately after infusion of Fluosol-DA. These returned tonormal within a week after infusion.

Thrombocytes. In the hemorrhagic group, a slightdecrease of thrombocytes was observed both immedi-ately and three days after infusion, but these changeswere within normal ranges. No change was seen in the'nonhemorrhagic group (Fig. 8).

Influence on Blood Coagulation Factors

Bleeding time (Duke's method). As shown in Figure9, some prolongation of bleeding time, within the nor-mal range, was found in the hemorrhagic group, butno prolongation was observed in the nonhemorrhagic

group. The bleeding time was found to have returnedto normal 12-24 hours after infusion in all cases.

Whole blood coagulation time (Lee-White method)and prothrombin time. In both the hemorrhagic (n

atter time after FluosolDA infusion

FIG. 6. Fluorocrit after infusion of 1,000 ml of Fluosol-DA (20%).

Vol. 195 * No. I

MITSUNO, OHYANAGI, AND NAITO Ann. Surg. - January 1982

TABLE 6. Percent 02 Supplied by PFC Following Administration of 1,000 ml of Fluosol-DA (20%) (n = 6)

Before Immediately 1.5 - 2 HoursInfusion After Infusion After Infusion

(1) Hb content (g/dl) 11.2 ± 2.8 10.8 ± 1.4 10.4 ± 2.0(2) PaO2 (torr) 200.5 ± 39.3 246.8 ± 46.7 198.3 ± 74.0(3) PvO2 (torr) 59.4 ± 7.6 62.1 ± 10.1 62.7 ± 7.7(4) CaO2 (v/v%) 15.03 ± 4.49 16.07 ± 3.12 15.65 ± 3.79(5) CvO2 (v/v%) 11.90 ± 3.99 13.30 ± 3.78 12.85 ± 4.37(6) Ca-vO2 (v/v%) 3.13 ± 0.63 2.77 ± 0.82 2.80 ± 1.20(7) PFC concn. (mg/ml) - 45.9 ± 8.2 43.2 ± 11.6(8) Va (v/v%) - 0.442 ± 0.076 0.399 ± 0.079(9) Vv (v/v%) - 0.081 ± 0.019 0.077 ± 0.020

(10) Va-v (v/v%) - 0.361 ± 0.063 0.322 ± 0.066(11) Percent 02 supplied

by PFC* (%) - 13.05 ± 2.99 11.70 ± 2.76

* The ratio (16) in %. CaO2 and CvO2 indicate oxygen content of(6)

= 43) and nonhemorrhagic groups (n = 24), no signif-icant change was observed after the infusions. Despitethe prolongation of bleeding time as mentioned above,none of the surgeons who participated in this study ob-served oozing or other hemorrhagic complications dur-ing or after surgery.

Influence on Serum ChemistryTotal protein. In the hemorrhagic group (Fig. 10),

total protein levels in blood decreased three days afterinfusion, but returned to normal a week after infusion.SGOT, SGPT, and alkaline phosphatase. Among the

186 cases, 122 were thoroughly monitored for SGOT-and SGPT. Of these, eight showed elevated SGOT (40units or elevation rated higher than 110% of preinfusionlevel), a week after infusion. Seven of them still showed

(Xl04/mm3)500 F

3 days 7 days

infusion of Fluosol-DAFIG. 7. Erythrocyte count.

arterial and venous blood. Va and Vv indicate oxygen content in PFCin arterial and venous blood.

I

somewhat elevated SGOT a month after infusion. Ofthese, only four showed significant elevation, nonegreater than 183. These four patients also showed el-evated SGOT prior to infusion (Table 7). No changeswere observed in SGPT and alkaline phosphatase.BUN and creatinine levels in plasma. No significant

influence was found.Serum electrolytes. No significant changes in Na+,

K+, and Cl- were found during or after infusion ofFluosol-DA.

Influence on Kidney Function

Urinary output. No significant change in urinary out-put was observed in either the hemorrhagic (n = 70)or the nonhemorrhagic group (n = 25) after infusionof Fluosol-DA. None of the patients manifested anuriaor oliguria during or after infusion.

Glucosuria and proteinuria. Of 106 patients exam-ined, glucosuria or proteinuria was observed in two.However, these findings were considered unrelated tothe administration of Fluosol-DA.

Untoward Reactions and Retention ofPFC in Liver and.Spleen

In 184 of the 186 patients analyzed, no untowardreactions were observed or reported during or after in-fusion of Fluosol-DA. Neither acute hypotension noracute anaphylactoid reactions were observed.One case of laparotomy for cancer of the papilla of

Vater manifested a slight, diffuse petechia on the mes-enterium during surgery, immediately following a 500-ml infusion of Fluosol-DA. Its nature was not known.(None of the other patients who underwent abdominalsurgery following Fluosol-DA therapy manifested mes-enteric petechia.) The patient died of liver metastasis'and carcinomatous peritonitis seven months after the

66

450 I

400 I

350 1

300 F

before imm. afterT

WHOLE BLOOD SUBSTITUTE

(X104/mm3)40 -

FIG. 8. Thrombocytes.

-before imm. after 3 days

infusion of Fluosol-DA (20%)

(sec)300 F

2501

200 F

FIG. 9. Bleeding time. 150

100F

0L

non-hemorrhage.group (n=22)

_ _ _ _ w

before imm. afterinfusion of Fluosol-DA

NormalValue

after 1 2-24hr(20%)

301-

ml

20F

101T-

NormalValue

L

7 days

VOl. 195 . NO. I 67

MITSUNO, OHYANAGI, AND NAITO Ann. Surg. * January 1982

T

3 days

FIG. 10. Plasma total pro-tein.

*P<0.05

71da7 days 30 days

infusion of Fluosol-DA (20%)

operation. At autopsy, no retention of PFC was foundin either the liver or the spleen.One particular case illustrates that repeated admin-

istration of Fluosol-DA may not be appropriate in caseswhere only heroic measures may be left to the treatingphysician. A 64-year-old male, who underwent emer-gency surgery for a dissecting aortic aneurism, wastransfused with 3,200 ml of blood that resulted in apositive Coomb's, anti-E, anti-PI, anti-JKb, severe he-molytic anemia with hemoglobinuria, and anuria, whichled to dialysis. Due to the severe anemia (Hb: 6.0 g/dl), the susceptibility to shock, and the unavailabilityof compatible blood, an infusion of Fluosol-DA (20%)was started on the 17th day after surgery and was re-peated six times in order to increase the PaO2, whichhad been consistently lower than 73 mmHg, [total 4,000ml (80 ml/kg BW)]. The patient died due to renalinsufficiency on the 28th day after the operation, oneday after the last infusion of 500 ml of Fluosol-DA.Autopsy revealed significant retention of PFC in theRES in both liver and spleen. The dose of Fluosol-DAgiven this patient was much greater than that agreedupon in the protocol, but was administered based onthe deteriorating condition of the patient and the in-compatibility of available blood and the lack of otheralternatives.

Discussion

Fluosol-DA (20%), a perfluorochemical oxygentransport medium and plasma expander ("whole bloodsubstitute") consisting of perfluorodecalin and perfluo-rotripropylamine, was administered to 186 patients forreplacement of blood lost during surgery or for im-provement of cerebral circulation in phase 2 and 3 clin-ical trials at 26 hospital departments in Japan. Dosesgiven ranged from 6-25 ml/kg body weight, except forone extreme case of 80 ml/kg. With regard to arterialblood oxygen tension, arterial blood oxygen content,blood oxygen transport, oxygen consumption, and acid-base balance, beneficial effects were generally observedafter infusion of the emulsion following blood loss, es-pecially when the fractional concentration of oxygen ininspired gas (FiO2) was kept higher than 0.5. Theemulsion also manifested beneficial plasma expandereffects on hemodynamics (blood pressure, pulse rate,and central venous pressure).No anaphylactoid or other untoward reaction was

observed or reported during or after infusion of theemulsion. Bleeding time (Duke) was in the normalrange, and the surgeons never observed any hemor-rhagic tendencies during or after the operations. Slightand transient elevations of SGOT were found in a small

68(g/dQ)8F

71p

6p

51

41

before

Vol. 195 No. I WHOLE BLOOD SUBSTITUTE 69

TABLE 7. Abnormal Changes ofSGOT After Infusion of Fluosol-DA

Infusion of Fluosol-DA

Case One Week One Month Infused BloodGroup No. Before After After Diagnosis Surgery Fluosol-DA Transfusion Remarks

Hemorrhagegroup

1 19 171 50 Gastric cancer Yes 1000 ml - 3 M, afterinfusionSGOT:34

2 45 118 90 Aneurysm of mid. Yes 500 ml 400 mlcerebr. art.

3 123 336 76 Cholelithiasis Yes 1000 ml 2 M, afterinfusionSGOT:30

4 103 118 183 Stress ulcer Yes 1000 ml 1300 ml 3 M, afterinfusionSGOT:48

5 75 52 103 Meningioma Yes 500 ml -

Non-hemorrhagegroup

1 85 167 164 Aneurysm of ant. No 500 mlcomm. art.

2 59 110 127 Occlusion of 1. mid. No 500 mlcerebr. art.

3 128 189 112 Aneurysm of ant. No 500 ml X 3comm. art.

number of patients. Only four of 122 patients main-tained elevated SGOT a month after infusion of Fluo-sol-DA, but these patients had manifested elevation ofSGOT before the infusion, and one of them had receiveda blood transfusion. SGPT and alkaline phosphataselevels remained normal in all cases. It is assumed, there-fore, that infusion of Fluosol-DA does not affect liverfunction. All other hematological and biochemical pa-rameters measured in blood, serum, and urine remainedwithin normal ranges.

Concerning the untoward reaction in the patient withautoimmune hemolytic anemia, in which significant re-tention of PFC in the RES appeared in autopsy, ourexperimental studies have clarified that PFC particleswere retained in the RES as foreign bodies, but thatthey were eliminated with time. Although the main PFCingredients of Fluosol-DA demonstrate minimal organretention and the maximum speed of elimination amongthe various PFC emulsions, it is to be expected thathyperfunctioning RES will phagocytize a significantamount of PFC particles. Therefore, it should bestrongly suggested that patients with immunologicalhyperactivity, such as those who are Coomb's positive,be contraindicated for the administration of Fluo-sol-DA.

However, it is important to keep in mind that themajority of the cases presented here, patients who wereanemic, who refused blood or blood products for reli-gious reasons, or for whom no compatible blood wasavailable, responded favorably to the pre- and post-op-erative administration of Fluosol-DA (20%). Further

studies are encouraged to examine its usefulness as ablood substitute.

AcknowledgmentThe authors are indebted to all co-workers who participated in the

clinical study.

References1. Honda K, Hoshino S, Shoji M, et al. Clinical use of blood sub-

stitute. N Engl J Med 1980; 303:391-392.2. Lapin R, Friedman AE, Levine EM, et al. The preoperative use

of Fluosol-DA 20% in major abdominal surgery. Journal ofAbdominal Surgery 1980; 22:15-16.

3. Makowski H, Tentschev P, Frey R, et al. Tolerance of an oxygen-carrying colloidal plasma substitute in human being. Proceed-ings IVth International Symposium on PerfluorochemicalBlood Substitutes. Kyoto, October 1978 (publ. Excerpta Med-ica).

4. Mitsuno T, Kawa Y, Matsunaga Y, et al. A successful case oftotal resection of intrathoracic esophageal cancer followed byone stage esophagogastrostomy with infusion of artificial bloodbut without blood transfusion. Shujutsu (Operation) 1980;34:963-970 (in Japanese).

5. Naito R, Yokoyama K. Perfluorochemical Blood SubstitutesFluosol-43, Fluosol-DA 20% and 35%. Technical InformationSeries No. 5. The Green Cross Corporation, June 30, 1978.

6. Ohyanagi H, Toshima K, Mitsuno T, et al. Clinical studies ofperfluorochemical whole blood substitutes: safety of Fluosol-DA in normal human volunteers. Clinical Therapeutics 1979;2: 306-312.

7. Ohyanagi H, Toshima K, Okumura, S, et al. Clinical applicationof Fluosol-DA to Jehovah's Witness patient during operationfor choledocholithiasis and duodenal diverticle. Igaku-no-Ayumi(Progress in Medicine) 1980; 115:943-949 (in Japanese).

8. Tremper KK, Lapin R, Levine E, et al. Hemodynamic and oxygentransport effects of a perfluorochemical blood substitute, Fluo-sol-DA (20%). Crit Care Med 1980; 8:738-741.