PLASMA SUBSTITUTES

Need
To restore the blood volume
temporarily while the
recipient replaced the lost
protein
Limited
supplies
of plasma

Cost of
producing
the dried
form

Risk of
transmitti
ng serum
hepatitis

Properties of ideal plasma

substitute
Same colloidal osmotic pressure as whole
blood
Viscosity similar to plasma
Molecular weight so that the molecules do not
diffuse through capillary walls
A fairly low rate of excretion or destruction by
the body
Eventual and complete elimination from the
body
Freedom from toxicity eg. No impairment of
renal function

Freedom from antigenicity, pyrogenicity and confusing

effects on important tests like blood grouping,
erythrocyte sedimentation rate etc
Isotonicity equal to plasma
High stability in liquid form at normal and sterilizable
temperatures and during transport and storage
Ease of preparation, ready availability and low cost

Various plasma substitutes

Gum saline
Polyvinylpyrolidone
Absorbable gelatin sponge
Oxidised cellulose
Calcium alginate
Dextran
Hetastarch
Gelatin

Dextran

Dextran was first

discovered byLouis
Pasteuras a microbial
product in wine
Dextran is synthesized
from sucrose by certain
lactic-acid bacteria
eg.Leuconostoc
mesenteroidesand
Streptococcus mutans

Leuconostoc
mesenteroids

Dextran-sucrase

Sucrose containing
medium

Long
unbranched
chains of glucose
units
Dextran
produced

By different
strains of
microorganism
Highly branched
polymers

Joined by (1:6)
glycosidic
linkage
Short chains of
(1:6) units
joined by (1:4)
and (1:3)
linkages
Allergic reactions

Production

Same as that of antibiotic production.

It involves:
1.
2.

Asepsis not necessary to be maintained-as synthesis of

enzyme and the action on sucrose is rapid.
No need to supply sterile air as aeration inhibits the process.
Necessary to prevent hydrolysis of sucrose to glucose and
fructose during sterilisation of culture medium.
.

Laboratory culture
Growth in seed tanks and then in fermenters

Preventive Measures: Adjustment of the media to neutral pH

before sterilization of the culture media & avoiding overheating.

When maximum conversion is done, dextran is precipitated

by addition of organic solvent

DRAWBACKS OF LARGER
MOLECULES

Natural dextran consists of chains of

200,000 glucose units and molecular
weights up to about 50 million.
Very large molecules with molecular
weights above 250,000 have serious
drawbacks
Therefore it is necessary to produce the
molecules of reduced size suitable for
medical use

They yield
viscous
solutions that
are difficult to
administer

Renal damage
and allergic
reactions

They interfere
with blood
matching and
sedimentation
tests by
causing
rouleaux
formation ie
aggregated
red cells that
resemble piles
of plates.

Produce
colloidal
osmotic
pressures that
are lower than
those of small
molecules.

Various
methods

Reduction of size

Acid
hydrolysis

Thermal
degradati
on

Ultrasonic
disintegrat
ion

Seeding
the
fermentor

Acid hydrolysis
Dextran is adjusted at pH 2 and
heated at 90C.
As hydrolysis proceeds it becomes
less viscous and the reaction is
stopped at the required viscosity.
Frequently used method.
Size range ->10,000 to 1 million

Thermal degradation

Heated under pressure at 160C in

presence of sodium sulphite to prevent
oxidative deterioration and calcium
carbonate to neutralize acidity.
The method is slower - better yield
fewer reducing groups are produced

Ultrasonic disintegration

Bombardment with ultrasonic waves

splits the molecules into fragments of
the same size
The product is clinically acceptable while
in the previous methods require
considerable fractionation.
This technique is more expensive

Seeding the fermentor

Normally, low mol. weight dextran is

included in the culture medium before
fermentation where the dextran is used
as a template by the organism to build
more glucose molecules on it.
If no dextran is added, avg.mol. weight is
much lower

Drawbacks of small
molecules

Molecular wt below 60,000

Rapidly excreted in the urine
They pass into the tissue fluids causing
an adverse osmotic pressure.

Therefore to summarize
60,000
and
lesser
Rapidly
excreted in
urine and lost
in tissue fluids

60,000 to
1,00,000
Lost into
tissue fluids

1,00,000
to
2,50,000

2,50,000
and
higher

ACCEPTABLE
RANGE

Cause allergy
and renal
damage,
interfere with
tests

Process continued
Then the neutralised
hydrolysate is
subjected to fractional
precipitation process .

The solution is finally

diluted to 5%
concentration in either
5% dextrose Injection
or NaCl Injection

Packed in sulphur
treated soda-lime
bottles

Water miscible organic

solvent eg. alcohol
and acetone is added
under controlled
conditions.

Then the selected

fraction contains small
proportions of very
large and very small
molecules, therefore
the selected fraction
is subjected to
purification process.

Closure: lacquered
rubber plugs.

Required fraction is
gradually separated
by repeated
retreatment of either
precipitate or
supernatant fluid.

Cost decides the

narrowness of the
fraction accepted.

Final step: sterilization

by autoclaving

Purification

Done to remove
Reducing sugars

By solvent
precipitation.

The main
contaminant
is fructose,
the byproduct of
fermentation

Fractionatio
n solvents

Evaporation
under
reduced
pressure

Inorganic salts

Phosphates
is the major
contaminant
cause
precipitation
during
sterilization
and storage

By
demineralisa
tion in a
mixed bed
ion
exchanger

Colour

Pyrogens

Microrganis
ms

By
adsorption
on activated
charcoal

By
adsorption
on asbestos,
or cellulose
derivatives

By filtration

Dextran preparations

American type dextran

British type dextran
Dextran 110 injection
Dextran 40 injection
Dextran 70 injection

American type
dextran

British type
dextran (dextran
150 injection)

Avg. mol.wt = 75000

Avg.mol.weight=1,50,000

Restores the colloidal osmotic

pressure quickly

Prolonged effect due to

preponderance of larger molecules
that are not lost from blood vessels.

Rapid elimination from the body.

It slows the flow of blood in the

capillaries and post-capillary veins.

Reduction in rouleaux formation.

Causes rouleaux formation,

condition called sludging .

High dosage to compensate

excretion losses

It is replaced with Dextran 110

Injection

Dextran 110 Injection, BP

It is a solution of the polymer in dextrose
Injection 5g/l, or in NaCl injection which has
been sterilised by autoclaving or filteration.
It is colourless, slightly viscous solution
which should not be used if it is cloudy or if a
deposit is present.
The distribution of molecular weight in
Dextran 110 injection is controlled by BP
tests

BP tests

Determination of intrinsic viscosity of the material

precipitated by the addition of 4 volumes of 95%
ethanol. A value within the range 0.27 to 0.32 is
required.
Determination of intrinsic viscosity of top 10 %, i.e.
the material in the first 10 percent of the total dextran
present to be precipitated when the ethanol conc. Is
progressively increased. The intrinsic viscosity for this
fraction or cut should not exceed 0.40.
A urinary excretion test in rabbit. A high excretion rate
indicates an excessive content of material of too small
a molecular size

Apart from these test BP specifies the

following tests:
i.
The permitted pH range.
ii.
Maximum permitted contents for heavy
metals, acetone, ethanol, nitrogen and
reducing sugars.
iii. Maximum sulphated ash.
iv. Tests for foreign protein and pyrogens

Storage

Dextran 110 Injection 5g/l dextrose

stored below 25C will retain its
properties for atleast 5 years.

In Sodium Chloride Injection, Dextran

110 stored at tempeartures upto 40C
will retain its properties for atleast 5 yrs.

Labeling

Additional to general requirements:

Conc. Of dextran
The name of the solvent.
The strain of Leuconostoc mesenteroides

Dextran 40 injection
Fractionation is used to produce the clinical material which has
an avg.mol. weight of 40,000
Contains polymers of low mol.wt. which lowers the plasma
viscosity and improves capillary flow
The method of preparation, the appearance of the product and
required control test are similar to those of Dextran 110.
It should be stored at temp. not exceeding 25C and temp.
fluctuations should be avoided. (5yrs)
Cell aggregation reduces and the flow improves therefore used
in thromboembolic conditions.
Used for the treatment of acute peritonitis, severe burns etc
that are accompanied by severe degree of sludging in the
blood

Dextran 70 injection

It is used as a short term plasma

expander.

Used as Infusion (Solution for infusion)

glucose intravenous infusion 5% or
sodium chloride intravenous infusion
0.9%

Contra-indications: CHF, renal failure;

bleeding disorders

Dosage

Short-term blood volume expansion, by

rapid intravenous infusion
Adult 5001000 ml initially, followed by
500 ml if necessary; total dosage should
not exceed 20 ml/kg during the initial 24
hours; if required 10 ml/kg daily may be
given for a further 2 days (treatment
should not continue for longer than 3
days);
Child total dosage should not exceed 20
ml/kg

 Hypersensitivity, fever, nasal

congestion, joint pains,
urticaria, hypotension,
transient increase in bleeding
time
monitor urine output
monitor central venous
pressure
can interfere with blood
group cross-matching and
biochemical tests

Adverse
effects
Precautio
ns

Hetastarch

Hetastarch is an artificial colloid derived from a waxy starch

composed almost entirely of amylopectin.
Hydroxyethyl ether groups are introduced into the glucose
units of the starch, and the resultant material is hydrolyzed
to yield a product with a suitable molecular weight
Hetastarch is characterized by its molar substitution and
also by its molecular weight.
The molar substitution is approximately 0.75 which means
Hetastarch has an average of approximately 75 hydroxyethyl
groups for every 100 glucose units.
The weight average molecular weight is approximately
600,000 with a range of 450,000 to 800,000 and with at least
80% of the polymers falling within the range of 20,000 to
2,500,000

6% Hetastarch in 0.9% Sodium Chloride Injection

(Hetastarch Injection) is a sterile, nonpyrogenic solution
for intravenous administration.
The composition of each 100 mL is as follows:
Hetastarch................................................................6
gSodium Chloride, USP.............................................0.9
gWater for Injection, USP..........................................qspH
adjusted with Sodium Hydroxide, NF if necessary
Concentration of Electrolytes (mEq/L): Sodium 154,
Chloride 154pH: approximately 5.5 with negligible
buffering capacity
Calculated Osmolarity: approximately 309 m0sM

Hetastarch injection is a clear, pale

yellow to amber solution.
Exposure to prolonged adverse storage
conditions may result in a change to a
turbid deep brown or the formation of a
crystalline precipitate.
Do not use the solution if these
conditions are evident.

Elimination of hetastarch

Intravenous infusion of Hetastarch

injection results in expansion of plasma
volume that decreases over the
succeeding 24 to 36 hours
Hetastarch molecules below 50,000
molecular weight are rapidly eliminated
by renal excretion.
A single dose of approximately 500 mL
of Hetastarch injection (approximately
30 g) results in elimination in the urine
of approximately 33% of the dose within

Larger molecules are slowly metabolised

by enzymes (amylase) until they are
small enough to undergo renal excretion

It has low antigenicity

Does not impair renal function
Large dose of hetastarch may reduce
hematocrit and cause hypocoagulability

Gelatin

Gelatin from bones or hides is subjected to controlled

hydrolysis to produce a material with a suitable
molecular weight
The Mol. Wt. of Gelatin Plasma Substitutes is 35000
Renal Excretion accounts for >60% and plasma half
life is 8-18 hr
Gelatin Plasma Substitutes produces potentially lifethreatening effects which includeAnaphylactic
reactionswhich are responsible for the
discontinuation of Gelatin Plasma Substitutes therapy
Limited use