Skip to main content

Artificial oxygen carriers: a new future?

Despite the fact that allogeneic red blood cell (RBC) transfusions can be life-saving in exsanguinating trauma patients, many adverse events impacting patient outcome have documented [1]. Therefore, artificial oxygen carriers were initially been developed as “blood substitutes” in the 1980s and 1990s. Artificial oxygen carriers can be grouped into hemoglobin-based oxygen carriers (HBOCs) and perfluorocarbon-based oxygen carriers (PFCs) [2].

The clinical use of artificial oxygen carriers has mainly been studied in trauma and major surgery [3]. HBOC studies in general did not show a benefit in the primary outcome parameter such as avoidance/reduction of RBC transfusions or 28-day mortality [3] and signs of vasoconstriction/hypertension due to nitric oxide scavenging and increased relative risk of myocardial infarction and death were shown in a meta-analysis [4]. Consequently, the Food and Drug Agency in 2008 put all HBOC trials on hold.

PFC studies in non-cardiac surgery were successful in reversing physiologic transfusion triggers and in reducing the need for allogeneic RBC transfusions [5]. In addition, there were no major safety issues. However, a PFC study in cardiac surgery was prematurely stopped due to an increased incidence of neurologic adverse events, and this program has never been re-started.

In recent years, focus on the potential clinical use of artificial oxygen carriers moved away from “blood substitutes” towards “oxygen therapeutics”. Due to the relatively short half-life of 12–24 h, this may indeed be reasonable. However, clinical studies showing clear benefits in this new area are still scarce. The area with most documented evidence are “compassionate use” programs. In such programs, patients were treated with HBOCs at a median hemoglobin concentration of 39 g/l [6]. Survival of patients with severe anemia for whom RBC transfusion was not an option was clearly and significantly higher if treated with an HBOC [7]. It is also conceivable that an HBOC may be capable of bridging a patient with severe anemia until RBC transfusions become available.

In animal models, artificial oxygen carriers have also proven to be efficacious in relieving organ ischemia such as fetal hypoxia in pre-eclampsia [8] and cerebral ischemia [9]. However, in a recent study myocardial perfusion with an oxygenated HBOC-enriched solution did not reduce the infarct volume nor was post-ischemic cardiac function improved [10]. In contrast, HBOC attenuated intense exercise-induced cardiac dysfunction [11].

Machine perfusion of liver grafts after prolonged cold ischemia with HBOC enriched perfusate appears to be efficacious in improving the condition of the liver graft prior to transplantation in multiple animal experiments [12]. And recently the first human liver transplantation after machine perfusion with HBOC was performed.Footnote 1 The use of artificial oxygen carriers in pre-transplant perfusion is also conceivable in other organs such as lung and heart. The future will tell whether HBOCs or PFCs are more efficacious.

PFCs may also be used as contrast agents [13] and, in conjunction with magnetic resonance imaging, as infection tracers [14].

Finally yet importantly, artificial oxygen carriers look like a logical adjunct to Patient Blood Management. Patient Blood Management is already highly successful: a reduction in the use of allogeneic blood product transfusion of approximately 40%, a decrease in hospital mortality (−28%), infection rate (−21%), combined myocardial infarction and stroke (−31%), length of hospital stay (−15%), and annual costs ($7–29 million) has been described in a study on 605,000 patients in Western Australia [15]. Nevertheless, having an artificial oxygen carrier to bridge the period of low hemoglobin/hematocrit or in the context of augmented hemodilution [5] might broaden the spectrum of Patient Blood Management and may make it even more successful.

Artificial oxygen carriers thus may indeed have a new future in a large variety of clinical scenarios and diagnostic/therapeutic concepts.




  1. Spahn DR, Goodnough LT. Alternatives to blood transfusion. Lancet. 2013;381(9880):1855–65.

    Article  PubMed  Google Scholar 

  2. Spahn DR, Kocian R. Artificial O2 carriers: status in 2005. Curr Pharm Des. 2005;11(31):4099–114.

    Article  CAS  PubMed  Google Scholar 

  3. Keipert PE. Hemoglobin-based oxygen carrier (HBOC) development in trauma: previous regulatory challenges, lessons learned, and a path forward. Adv Exp Med Biol. 2017;977:343–50.

    Article  PubMed  Google Scholar 

  4. Natanson C, Kern SJ, Lurie P, Banks SM, Wolfe SM. Cell-free hemoglobin-based blood substitutes and risk of myocardial infarction and death: a meta-analysis. JAMA. 2008;299(19):2304–12.

    Article  CAS  PubMed  Google Scholar 

  5. Spahn DR, Keipert PE. An overview of two human trials of perfluorocarbon emulsions in non-cardiac surgery. Shock. 2017. doi: [Epub ahead of print]

  6. Mackenzie CF, Moon-Massat PF, Shander A, Javidroozi M, Greenburg AG. When blood is not an option: factors affecting survival after the use of a hemoglobin-based oxygen carrier in 54 patients with life-threatening anemia. Anesth Analg. 2010;110(3):685–93.

    Article  CAS  PubMed  Google Scholar 

  7. Weiskopf RB, Beliaev AM, Shander A, Guinn NR, Cap AP, Ness PM, Silverman TA. Addressing the unmet need of life-threatening anemia with hemoglobin-based oxygen carriers. Transfusion. 2017;57(1):207–14.

    Article  CAS  PubMed  Google Scholar 

  8. Ohta H, Kaga M, Li H, Sakai H, Okamura K, Yaegashi N. Potential new non-invasive therapy using artificial oxygen carriers for pre-eclampsia. J Funct Biomater. 2017;8:32.

    Article  PubMed Central  Google Scholar 

  9. Kaneda S, Ishizuka T, Sekiguchi A, Morimoto K, Kasukawa H. Efficacy of liposome-encapsulated hemoglobin in a rat model of cerebral ischemia. Artif Organs. 2014;38(8):650–5.

    Article  CAS  PubMed  Google Scholar 

  10. Garcia-Ruiz JM, Galan-Arriola C, Fernandez-Jimenez R, Aguero J, Sanchez-Gonzalez J, Garcia-Alvarez A, Nuno-Ayala M, Dube GP, Zafirelis Z, Lopez-Martin GJ, et al. Bloodless reperfusion with the oxygen carrier HBOC-201 in acute myocardial infarction: a novel platform for cardioprotective probes delivery. Basic Res Cardiol. 2017;112(2):17.

    Article  PubMed  Google Scholar 

  11. Li T, Zhu D, Zhou R, Wu W, Li Q, Liu J. HBOC attenuates intense exercise-induced cardiac dysfunction. Int J Sports Med. 2012;33(5):338–45.

    Article  PubMed  Google Scholar 

  12. Fontes PA. The evolution of oxygen carrier solutions for machine perfusion. Transplantation. 2017;101(11):2657–8.

    Article  PubMed  Google Scholar 

  13. Xu X, Song R, He M, Peng C, Yu M, Hou Y, Qiu H, Zou R, Yao S. Microfluidic production of nanoscale perfluorocarbon droplets as liquid contrast agents for ultrasound imaging. Lab Chip. 2017;17(20):3504–13.

    Article  CAS  PubMed  Google Scholar 

  14. Bonner F, Merx MW, Klingel K, Begovatz P, Flogel U, Sager M, Temme S, Jacoby C, Salehi Ravesh M, Grapentin C, et al. Monocyte imaging after myocardial infarction with 19 F MRI at 3 T: a pilot study in explanted porcine hearts. Eur Heart J Cardiovasc Imaging. 2015;16(6):612–20.

    Article  CAS  PubMed  Google Scholar 

  15. Leahy MF, Hofmann A, Towler S, Trentino KM, Burrows SA, Swain SG, Hamdorf J, Gallagher T, Koay A, Geelhoed GC, et al. Improved outcomes and reduced costs associated with a health-system-wide patient blood management program: a retrospective observational study in four major adult tertiary-care hospitals. Transfusion. 2017;57:1347–58.

    Article  PubMed  Google Scholar 

Download references


Thanks for the invitation.



Author information

Authors and Affiliations



DRS wrote the editorial.

Corresponding author

Correspondence to Donat R. Spahn.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

Dr. Spahn's academic department receives grant support from the Swiss National Science Foundation, Berne, Switzerland, the Ministry of Health (Gesundheitsdirektion) of the Canton of Zurich, Switzerland for Highly Specialized Medicine, the Swiss Society of Anesthesiology and Reanimation (SGAR), Berne, Switzerland, the Swiss Foundation for Anesthesia Research, Zurich, Switzerland, CSL Behring, Berne, Switzerland, Vifor SA, Villars-sur-Glâne, Switzerland.

Dr. Spahn is the co-chair of the ABC-Trauma Faculty, managed by Physicians World Europe GmbH, Mannheim, Germany and sponsored by unrestricted educational grants from Novo Nordisk Health Care AG, Zurich, Switzerland, CSL Behring GmbH, Marburg, Germany, LFB Biomédicaments, Courtaboeuf Cedex, France and Octapharma AG, Lachen, Switzerland.

In the past 5 years, Dr. Spahn has received honoraria or travel support for consulting or lecturing from the following companies and organizations: Danube University of Krems, Austria, US Department of Defense, Washington, USA, European Society of Anesthesiology, Brussels, BE, Baxter AG, Volketswil, Switzerland, Baxter S.p.A., Roma, Italy, Bayer (Schweiz) AG, Zürich, Switzerland, Bayer Pharma AG, Berlin, Germany, B. Braun Melsungen AG, Melsungen, Germany, Boehringer Ingelheim (Schweiz) GmbH, Basel, Switzerland, Bristol-Myers-Squibb, Rueil-Malmaison Cedex, France and Baar, Switzerland, CSL Behring GmbH, Hattersheim am Main, Germany and Berne, Switzerland, Curacyte AG, Munich, Germany, Daiichi Sankyo (Schweiz) AG, Thalwil, Switzerland, Fresenius SE, Bad Homburg v.d.H., Germany, GlaxoSmithKline GmbH & Co. KG, Hamburg, Germany, Haemonetics, Braintree, MA, USA, LFB Biomédicaments, Courtaboeuf Cedex, France, Merck Sharp & Dohme AG, Luzern, Switzerland, Octapharma AG, Lachen, Switzerland, Organon AG, Pfäffikon/SZ, Switzerland, PAION Deutschland GmbH, Aachen, Germany, Pharmacosmos A/S, Holbaek, Denmark, Photonics Healthcare B.V., Utrecht, Netherlands, ratiopharm Arzneimittel Vertriebs-GmbH, Vienna, Austria, Roche Diagnostics International Ltd, Reinach, Switzerland, Roche Pharma (Schweiz) AG, Reinach, Switzerland, Sarstedt AG & Co., Sevelen, Switzerland and Nümbrecht, Germany Schering-Plough International, Inc., Kenilworth, New Jersey, USA, Tem International GmbH, Munich, Germany, Verum Diagnostica GmbH, Munich, Germany, Vifor Pharma, Munich, Germany, Vienna, Austria and Villars-sur-Glâne, Switzerland, Vifor (International) AG, St. Gallen.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Spahn, D.R. Artificial oxygen carriers: a new future?. Crit Care 22, 46 (2018).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: