PLATELET-INSPIRED NANOMEDICINE FOR THE HEMOSTATIC MANAGEMENT OF BLEEDING COMPLICATIONS IN THROMBOCYTOPENIA AND TRAUMA by DASHAWN A. HICKMAN Submitted in partial fulfillment of the requirement for the degree of Doctor of Philosophy Department of Pathology CASE WESTERN RESERVE UNIVERSITY January, 2019 CASE WESTERN RESERVE UNIVERSITY SCHOOL OF GRADUATE STUDIES We hereby approve the thesis/dissertation of DaShawn A. Hickman candidate for the degree of Doctor of Philosophy*. Committee Chair Nicholas Ziats, PhD Committee Member Anirban Sen Gupta, PhD Committee Member James Anderson, MD, PhD Committee Member Agata Exner, PhD Committee Member Howard Meyerson, MD Committee Member Clive Hamlin, PhD Date of Defense August 16, 2018 *We also certify that written approval has been obtained for any proprietary material contained therein. Dedication I would like to dedicate my dissertation to my family who have always supported me and encouraged me to be great, especially my parents and siblings; my friends for setting the bar high and keeping my spirits higher, the MSTP entering class of 201l and my labmates. i Table of Contents Dedication ................................................................................................................... i List of Tables ............................................................................................................. ix List of Figures ............................................................................................................. x Acknowledgements .................................................................................................. xvi List of Abbreviations ................................................................................................ xvii Abstract ................................................................................................................ xxvii Chapter 1 : Bleeding Complications in Thrombocytopenia and Trauma ........................ 1 1.1 Introduction ..........................................................................................................1 1.2 Trauma ..................................................................................................................2 1.3 Thrombocytopenia.................................................................................................4 1.4 Complex Mechanism of Hemostasis .......................................................................7 1.5 Management of Traumatic Bleeding ..................................................................... 10 1.6 Acknowledgments ............................................................................................... 12 1.7 References ........................................................................................................... 12 Chapter 2 : Externally Administered (Topical and Intracavitary) Biomaterials and Advanced Technologies for Management of Traumatic Bleeding .............................. 28 2.1 Introduction ........................................................................................................ 28 2.2 Tourniquets ......................................................................................................... 28 2.3 Naturally derived biomaterials for hemostatic applications ................................... 30 ii 2.3.1 Absorptive and passively interactive materials in hemostatic technologies ......................... 31 2.3.2 Bioactive materials in hemostatic technologies .................................................................... 35 2.4 Synthetically derived hemostatic materials ........................................................... 52 2.5 Compression bandage technologies ...................................................................... 57 2.6 Combination systems and advanced technologies ................................................. 61 2.7 Hemostatic materials and technologies for intracavitary applications.................... 62 2.8 Discussion ............................................................................................................ 63 2.9 Acknowledgments ............................................................................................... 66 2.10 References ........................................................................................................... 66 Chapter 3 : Intravenously Administered Biomaterials and Advanced Technologies for Management of Traumatic Non-compressible Hemorrhage .................................... 110 3.1 Introduction ...................................................................................................... 110 3.2 Naturally derived intravascular pro-coagulant materials ..................................... 111 3.3 Synthetically derived pro-coagulant systems ...................................................... 114 3.4 Materials and technologies to enhance clot strength and stability ....................... 116 3.5 Materials and technologies for vascular embolization ......................................... 122 3.6 Natural platelet-derived systems ........................................................................ 124 3.7 Synthetic biomaterials-based platelet mimics and substitutes ............................. 134 3.8 Discussion .......................................................................................................... 139 3.9 Acknowledgments ............................................................................................. 143 iii 3.10 References ......................................................................................................... 143 Chapter 4 : Designing an Ideal Platelet-inspired System for the Intravenous Management of Traumatic Bleeding....................................................................... 166 4.1 Introduction ...................................................................................................... 166 4.2 Current State of Traumatic Bleeding Management .............................................. 167 4.3 Designing an Ideal System .................................................................................. 169 4.4 Design of SynthoPlateTM Nanoparticle System .................................................... 171 4.5 SynthoPlateTM In Vitro Evaluation ....................................................................... 173 4.6 In Vivo Evaluation of SynthoPlateTM In Thrombocytopenia Model ....................... 174 4.7 Discussion .......................................................................................................... 178 4.8 Acknowledgments ............................................................................................. 180 4.9 References ......................................................................................................... 181 Chapter 5 : Intravenous administration of synthetic platelets (SynthoPlate) in a mouse liver injury model of uncontrolled hemorrhage improves hemostasis ...................... 189 5.1 Introduction ...................................................................................................... 189 5.2 Materials and Methods ...................................................................................... 190 5.2.1 Animals ................................................................................................................................ 190 5.2.2 SynthoPlate Manufacture .................................................................................................... 190 5.2.3 Liver Laceration Model of Uncontrolled Hemorrhage and SynthoPlate Evaluation ........... 191 5.2.4 In Vivo Biodistribution of SynthoPlate Particles .................................................................. 193 5.2.5 Statistics............................................................................................................................... 194 iv 5.3 Results ............................................................................................................... 194 5.3.1 SynthoPlate Transfusion as a Pretreatment Results in Decreased Blood Loss and Improved Hemodynamics During Acute, Severe Hemorrhagic Shock ............................................................... 194 5.3.2 Systemic Biodistribution SynthoPlate Particles Following Liver Laceration ........................ 196 5.3.3 SynthoPlate Particles Reduce Blood Loss and Improve Hemodynamics in Mice in Hemorrhagic Shock ............................................................................................................................ 198 5.4 Discussion .......................................................................................................... 198 5.5 Authorship......................................................................................................... 203 5.6 Acknowledgement ............................................................................................. 203 5.7 Disclosure .......................................................................................................... 203 5.8 References ......................................................................................................... 204 Chapter 6 : Intravenous synthetic platelet (SynthoPlateTM) nanoconstructs reduce bleeding and improve ‘golden hour’ survival in a porcine model of traumatic arterial hemorrhage ........................................................................................................... 207 6.1 Introduction .....................................................................................................