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What's New in Shock.

This Military Supplement to Shock highlights the state of the science on oxygen carrier solutions that was the focus of a DoD Combat Casualty Care Research Program meeting held in February 2017. In anticipation of military preparation of its medical capabilities to meet the needs on future battlefields, projected to be more complex and quite different than the conditions experienced in the recent conflicts in Iraq and Afghanistan, the meeting reviewed the current state of hemoglobin-based oxygen carriers (HBOC) and perfluorocarbons (PFC) and lessons learned from previous clinical trials with these products. Despite the push by the military to get more blood products, including low titer type O whole blood, closer to the point-of-injury, it is recognized that logistic constraints will limit the availability of blood products on the battlefield. In addition, the military anticipates future military operations occurring in multidomain battlespaces, which presents medical challenges associated with prolonged care, that is, care beyond the current golden hour and the usual time to hold a casualty based on the injury. These scenarios present significant challenges to providing state-of-the-art medical care for resuscitation of injured servicemembers. To address this anticipated medical need, the military is again exploring the possibilities of employing solutions that carry oxygen as resuscitation alternatives when blood products or whole blood is not available or an option. Thus, this Shock Supplement presents eight papers on HBOCs, seven on PFCs, and one paper describing a possible interdisciplinary approach for designing more robust clinical trials for future evaluation of these products. Three reviews examine the basic chemistry and design of HBOCs and challenges regarding their development. An ideal HBOC would deliver oxygen to tissue efficiently, require no special storage conditions, have a long shelf life, low toxicity, and be manufactured in high yields and have a low cost. Gupta (1) provides a comprehensive analysis of the various designs of HBOC molecules that have been developed over the years and the potential advantages and limitations of each product. In addition, the choice of chemically modified cell-free hemoglobin or an encapsulated product, and the source of the hemoglobin molecule, including recombinant forms, are discussed with regard to manufacturing challenges and clinical efficacy and safety. The review by Alayash (2) also mentions the various