• Oxygenation Defined as change in arterial blood oxygenation [ Time Frame: pre infusion and post infusion (every 3 to 6 hours, for 24 hours) ]
  tested by arterial blood oxygen content difference - arterial blood gas (ABG) An ABG is a blood test that measures the acidity, or potential of hydrogen (pH), and the levels of oxygen (O2) and carbon dioxide (CO2) from an artery. The test is used to check the function of the patient's lungs and how well they are able to move oxygen and remove carbon dioxide. The aforementioned five components all have different normal values and represent different aspects of the blood gas. According to the National Institute of Health, typical normal values are: pH: 7.35-7.45 Partial pressure of oxygen (PaO2): 75 to 100 mmHg Partial pressure of carbon dioxide (PaCO2): 35-45 mmHg Bicarbonate (HCO3): 22-26 milliequivalent/Liter (mEqL) Oxygen saturation (O2 Sat): 94-100%
• Oxygenation Defined as change in venous blood oxygenation CO2 ABG vs. VBG: VBG CO2 6mm Hg higher [ Time Frame: pre infusion and post infusion (every 3 to 6 hours, for 24 h) ]
  tested by venous blood oxygen content difference - venous blood gas (VBG). An ABG is a blood test that measures the acidity, or pH, and the levels of oxygen (O2) and carbon dioxide (CO2) from an a vein. The test is used to check the function of the patient's lungs and how well they are able to move oxygen and remove carbon dioxide. pH ABG vs. VBG: VBG pH 0.03-0.05 lower HCO3 ABG vs. VBG: VBG HCO3 1.5-2.0 mEq/L lower CO2 ABG vs. VBG: VBG CO2 6mm Hg higher
• Increase in peripheral tissue oxygenation [ Time Frame: continuous monitoring from start of transfusion until next morning. Approximately 24 hours ]
  tested with near infrared spectroscopy. An Infrared spectroscopy (IR spectroscopy or vibrational spectroscopy) involves the interaction of infrared radiation with matter. It covers a range of techniques, mostly based on absorption spectroscopy. As with all spectroscopic techniques, it can be used to identify and study chemicals.

• Oxygenation Defined as change in arterial blood oxygenation [ Time Frame: pre infusion and post infusion (every 3 to 6 hours, for 24 h) ]
  tested by arterial blood oxygen content difference - arterial blood gas (ABG) An ABG is a blood test that measures the acidity, or potential of hydrogen (pH), and the levels of oxygen (O2) and carbon dioxide (CO2) from an artery. The test is used to check the function of the patient's lungs and how well they are able to move oxygen and remove carbon dioxide. The aforementioned five components all have different normal values and represent different aspects of the blood gas. According to the National Institute of Health, typical normal values are: pH: 7.35-7.45 Partial pressure of oxygen (PaO2): 75 to 100 mmHg Partial pressure of carbon dioxide (PaCO2): 35-45 mmHg Bicarbonate (HCO3): 22-26 milliequivalent/Liter (mEqL) Oxygen saturation (O2 Sat): 94-100%
• Oxygenation Defined as change in vein blood oxygenation CO2 ABG vs. VBG: VBG CO2 6mm Hg higher [ Time Frame: pre infusion and post infusion (every 3 to 6 hours, for 24 h) ]
  tested by venous blood oxygen content difference - venous blood gas (VBG). An ABG is a blood test that measures the acidity, or pH, and the levels of oxygen (O2) and carbon dioxide (CO2) from an a vein. The test is used to check the function of the patient's lungs and how well they are able to move oxygen and remove carbon dioxide. pH ABG vs. VBG: VBG pH 0.03-0.05 lower HCO3 ABG vs. VBG: VBG HCO3 1.5-2.0 mEq/L lower CO2 ABG vs. VBG: VBG CO2 6mm Hg higher
• Increase in peripheral tissue oxygenation [ Time Frame: continuous monitoring from start of transfusion until next morning. Approximately 24 h ]
  tested with near infrared spectroscopy. An Infrared spectroscopy (IR spectroscopy or vibrational spectroscopy) involves the interaction of infrared radiation with matter. It covers a range of techniques, mostly based on absorption spectroscopy. As with all spectroscopic techniques, it can be used to identify and study chemicals.

Transfusion is the most common therapeutic intervention employed to maintain and/or improve tissue and end-organ oxygen delivery. Despite the conceptual simplicity of this treatment recent studies indicate that RBC infusion often produces little clinical benefit and may actually harm the recipient by exacerbating rather than correcting anemia-induced tissue hypoxia.

The main driver/regulator of tissue oxygenation is blood flow not blood oxygen content. In turn flow into the microvasculature is controlled by small molecules called S-nitrosothiols (SNOs), the most important of which is S-nitrosylated hemoglobin (SNO-Hb).

The investigators determined that storage of human blood leads to rapid losses in SNO-Hb that are precisely paralleled by losses in the ability of stored RBCs to dilate blood vessels and thereby deliver oxygen. The investigators have now recently completed an autologous human blood transfusion that confirms the pre-clinical findings in that administration of 1 unit of packed RBCs to young healthy subjects did not improve tissue oxygenation and reduced circulating SNO-Hb levels.

This novel mechanism for the loss of physiological activity in banked blood and, more importantly, a putative intervention for its correction, raise the possibility that restoration of NO bioactivity could correct the deficit in oxygen delivery. As such, The Investigators plan to repeat our transfusion study with the addition of administering an S-nitrosylating agent during RBC infusion.

• Drug: SNO
  S-nitrosylating agent (SNO) Inhalation
• Drug: Normal Saline
  Normal Saline transfusion
• Drug: Red Blood Cell
  Blood transfusion (RBCs)

• Active Comparator: Blood transfusion with SNO agent

  Autologous blood transfusion packed red blood cells (RBCs) while inhaling S-nitrosylating agent (SNO)

  A single intra venous blood transfusion of one unit of packed Red Blood Cells (RBCs) will be given over the standard transfusion flow rate of 5 ml/min under the direction of a physician or a licensed medical professional.

  Inhalation of SNO agent, 20-40 parts per million will occur during the transfusion.

  Interventions:

  • Drug: SNO
  • Drug: Red Blood Cell
• Placebo Comparator: Normal Saline with SNO agent

  Normal Saline Transfusion while inhaling S-nitrosylating agent (SNO)

  A single intra venous infusion of one unit of normal saline, will be given over the standard transfusion flow rate of 5 ml/min under the direction of a physician or a licensed medical professional.

  Inhalation of the SNO agent at 20-40 parts per million, will occur during the transfusion.

  Interventions:

  • Drug: SNO
  • Drug: Normal Saline

• Reynolds JD, Ahearn GS, Angelo M, Zhang J, Cobb F, Stamler JS. S-nitrosohemoglobin deficiency: a mechanism for loss of physiological activity in banked blood. Proc Natl Acad Sci U S A. 2007 Oct 23;104(43):17058-62. Epub 2007 Oct 11.
• Singel DJ, Stamler JS. Chemical physiology of blood flow regulation by red blood cells: the role of nitric oxide and S-nitrosohemoglobin. Annu Rev Physiol. 2005;67:99-145. Review.
• McMahon TJ, Ahearn GS, Moya MP, Gow AJ, Huang YC, Luchsinger BP, Nudelman R, Yan Y, Krichman AD, Bashore TM, Califf RM, Singel DJ, Piantadosi CA, Tapson VF, Stamler JS. A nitric oxide processing defect of red blood cells created by hypoxia: deficiency of S-nitrosohemoglobin in pulmonary hypertension. Proc Natl Acad Sci U S A. 2005 Oct 11;102(41):14801-6. Epub 2005 Oct 3.
• Pawloski JR, Hess DT, Stamler JS. Export by red blood cells of nitric oxide bioactivity. Nature. 2001 Feb 1;409(6820):622-6.
• VALTIS DJ. Defective gas-transport function of stored red blood-cells. Lancet. 1954 Jan 16;266(6803):119-24.
• Bunn HF, May MH, Kocholaty WF, Shields CE. Hemoglobin function in stored blood. J Clin Invest. 1969 Feb;48(2):311-21.
• Sugerman HJ, Davidson DT, Vibul S, Delivoria-Papadopoulos M, Miller LD, Oski FA. The basis of defective oxygen delivery from stored blood. Surg Gynecol Obstet. 1970 Oct;131(4):733-41.
• Shah DM, Gottlieb ME, Rahm RL, Stratton HH, Barie PS, Paloski WH, Newell JC. Failure of red blood cell transfusion to increase oxygen transport or mixed venous PO2 in injured patients. J Trauma. 1982 Sep;22(9):741-6.
• Rao SV, Jollis JG, Harrington RA, Granger CB, Newby LK, Armstrong PW, Moliterno DJ, Lindblad L, Pieper K, Topol EJ, Stamler JS, Califf RM. Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes. JAMA. 2004 Oct 6;292(13):1555-62.
• Vincent JL, Baron JF, Reinhart K, Gattinoni L, Thijs L, Webb A, Meier-Hellmann A, Nollet G, Peres-Bota D; ABC (Anemia and Blood Transfusion in Critical Care) Investigators. Anemia and blood transfusion in critically ill patients. JAMA. 2002 Sep 25;288(12):1499-507.
• Malone DL, Dunne J, Tracy JK, Putnam AT, Scalea TM, Napolitano LM. Blood transfusion, independent of shock severity, is associated with worse outcome in trauma. J Trauma. 2003 May;54(5):898-905; discussion 905-7.

Eligibility Criteria

Recruiting and studying of healthy human subjects with no pre-existing pathologic conditions from the local population. As a result the inclusion criteria is deliberately broad.

Inclusion Criteria

1. Hemoglobin > 12 g/dl
2. Healthy, non-pregnant adults with no pre-existing blood disorders or disease states that impact oxygen delivery.

2a. Active blood and platelet donors will be sought as study participants since these individuals are familiar with the routines for blood withdrawal and re-infusion.

Exclusion Criteria

The exclusion criteria is derived from the American Red Cross(ARC) Standard Operating Procedure (SOP) for autologous donation AND the parameters set out in the investigational new drug application (IND).

1. Individuals who are pregnant, breastfeeding, or are unwilling to avoid pregnancy during the study.
2. Individuals with an anatomic anomaly that would increase the risks associated with placement of the vascular catheters.
3. Individuals who report chronic diseases requiring medication of the heart, lungs, kidney, liver, etc or afflicted with any acute or chronic pathology that in the opinion of the screening physician makes them unsuitable for study.
4. Individuals with a recent history of antibiotic therapy (check for underlying cause).
5. Individuals unwilling to refrain from taking any phosphodiesterase 5 (PDE-5) inhibitor for at least 24 h prior to donation and/or autologous transfusion.
6. Individuals taking a vitamin K antagonist (warfarin) or other anticoagulant (e.g. heparin, clopidogrel, enoxaparin or dalteparin).
7. Individuals taking allopurinol, beta-adrenergic blockers, tricyclic antidepressants, meperidine (or related central nervous system (CNS) agents), or nitrates.
8. Individuals on long-term antihistamine therapy 8a. The study physician will determine on a case by case basis the suitability for inclusion of individuals who control seasonal or acute allergies with occasional antihistamine use.
9. Individuals with blood pressure parameters outside the normal range of 90-180 mm Hg systolic and 50-100 mm Hg diastolic.
10. Individuals with heart rates outside the range of 50 to 100 beats per minutes or with a pathologic irregularity.

10a. Pulses lower than 50 may be acceptable if the study participant participates in endurance training. The study physician will be consulted for evaluation.

11. Individuals with an inherited or acquired blood coagulation disorder, congenital methemoglobinemia, or a familial hemoglobinopathy that impacts oxygen delivery (e.g. sickle cell).

12. Individuals with any illness that may increase the risks associated with the study.

13. Individuals who previously received blood products to treat an acute condition will be evaluated on a case by case basis.

14. Individuals who report an acute or chronic disease state that may impact oxygen delivery.

15. Individuals with evidence of diminished lung capacity.

16. Individuals who might have difficulty with the placement of a face mask (e.g. claustrophobia, uncontrolled asthma, severe allergies, sensitive skin) and/or the inhalation of a product for approximately 1-2 hr.

• Case Western Reserve University
• National Heart, Lung, and Blood Institute (NHLBI)