For purpose of consideration of the use of hyperbaric oxygen (HBO2) therapy, exceptional blood loss anaemia is by definition loss of enough red blood cell mass to compromise sufficient oxygen delivery to tissue in patients who cannot be transfused for medical or religious reasons.

Medical reasons may include the threat of blood product incompatibility or concern for transmissible disease. Religious beliefs may prohibit the receipt of transfused blood products. Red blood cells (RBCs) contain the respiratory pigment haemoglobin (Hb). Haemoglobin has the powerful ability to pick up oxygen as RBCs pass through the blood vessels of the lungs. Haemoglobin then has the equally powerful ability to off-load oxygen in the tissues of the body’s organ systems.

If plasma were the only vehicle to deliver dissolved oxygen, each 100 ml of blood flowing to an organ system would carry only 0.3 ml of gaseous oxygen. The consumption of oxygen by human tissues far exceeds this. For instance, the kidney extracts approximately 2 ml of oxygen for every 100 ml of blood which circulates through it. From the same 100 ml of blood, the brain extracts approximately 6.5 ml and the heart 10.5 ml of oxygen. In most instances, humans average 15 grams of haemoglobin per 100 cc of blood. Each gram of haemoglobin transports 1.34 ml of oxygen. This is in addition to the oxygen carried by plasma. So, 100 ml of blood, by containing 15 grams of haemoglobin, can carry approximately 20 ml of gaseous oxygen (1.34 ml X 15 g Hb = 20 ml of oxygen).

In the 1960s, the Dutch thoracic surgeon Boerema demonstrated that one could exchange transfused piglets with a simulated plasma mixture of buffered normal saline (Ringer’s Lactate solution), dextrose and dextran. In this process, blood was removed from the blood vessels and the substitute liquid (without haemoglobin) replaced. He then pressurized the piglets in a hyperbaric chamber while the animals breathed 100% oxygen. By the trick of pressurization, enough oxygen could be dissolved in the simulated plasma mixture to supply tissue oxygen requirements. This was enough to adequately sustain the animal, as evidenced by the fact that the animals survived and could be brought out of the chamber to be successfully re-exchange transfused with their previously extracted blood.

As hyperbaric oxygen (or for that matter normobaric oxygen) administered for long periods can become toxic, intermittent administration of HBO2 is essential. This point has been demonstrated clinically by the American thoracic surgeon, George Hart. In 1974, he reported a series of 26 severe blood loss patients who were treated with HBO2 as an alternative to otherwise disallowed red blood cell transfusion. The survival rate was 70%.

Alternative approaches include use of fluorocarbons or stroma-free haemoglobin. While potentially promising, these treatment solutions still pose uncertainties for their potential ability to unfavourably alter the immune system. While erythropoietin may be used to stimulate the bone marrow to produce RBCs, HBO2 therapy only complements its use in exceptional blood-loss anaemia.

References:

1. Adir Y, Bitterman N, Katz E, Melamed Y, Bitterman H. Salutary consequences of oxygen therapy on the long-term outcome of hemorrhagic shock in awake, unrestrained rats. Undersea Hyperbaric Med 1993;22(1):23-30.
2. Boerema I, Meijne NG, Brummelkamp WH, Bouma S, Mensch MH, Kamermans F, Hanf S, Van Aalderen A. Life without blood. J Cardiovasc Surg 1960;182:133-146.
3. Castro O, Nesbit AE, Lyles D. Effect of a perfluorocarbon emulsion (Fluosol-DA) on reticuloendothelial system clearance function. Am J Hematol 1984;16:15-21.
4. Advanced Trauma Life Support for Doctors, Instruction Manuel, Chapter 3, Shock, American College of Surgeons, Chicago IL, 1997, pp 97-146.
5. Hart G. HBO and exceptional blood loss anemia. In: Hyperbaric Medicine Practice, Kindwall EP, Whalen HT, eds. Best Publishing Co, Flagstaff AZ, 1999; 741-751.
6. Hart GB, Lennon PA, Strauss MB. Hyperbaric oxygen in exceptional acute blood-loss anemia. J Hyperbaric Med 1987;2:205-210.
7. Hart GB. Exceptional blood loss anemia. Treatment with hyperbaric oxygen. JAMA 1974; 228: 1028-1029.