the following is a detailed description of the invention including composition selection from 4 different compositions and 4 specific methods of uses in disease models of tbi + hs , stroke , scd , and tbi + hs resuscitation with conjunctive use of 100 % oxygen . methods of preparation of three ( 3 ) polynitroxylated pegylated carboxy hemoglobins and polynitroxylated carboxy potyheme : ( a ) 250 ml of pegylated bovine hemoglobin ( pegylated with 5 kda polyethylene glycol ) at 4 % ( 40 g / l ) hemoglobin protein supplied by prolong pharmaceuticals inc . n . j . was first converted to carboxy pegylated hemoglobin under 15 psi of co gas pressure in a sterile sealed glass container with mechanical stirring at 37 ° c . then 4 -( 2 - bromoacetamido )- 2 , 2 , 6 , 6 - tetramethyl - 1 - piperidinyloxyl ( bractpo ), equivalent to 16 nitroxides per hemoglobin molecule , was added and ph was adjusted to 9 . 5 . the reaction was permitted to proceed for 4 . 0 hours . at the termination of the reaction , the reaction mixture was first coarse filtered through a 0 . 4 - micron filter followed with a 0 . 22 - micron fitter . the filtrate was then washed with 15 volumes of water - for - injection and concentrated to 4 % ( 40 g / l ) hemoglobin . the concentrated bpnph was then 0 . 22 - micron filtered and filled into a series of 50 ml transfusion bags pre - gamma irradiated to ensure sterility and stored at 4 ° c . before use . positive co pressure was used during entire procedure to ensure the final product was fully in its carboxy liganded state . ( b ) human stroma free carboxy hemoglobin was pegylated by reaction with 3 molar equivalents activated peg - maleimide ( mw 20 kd , purchased from sunbio , s . korea ) according to a modified published procedure ( cabrales p ., et al ., 2004 ). 250 ml of pegylated human carboxy hemoglobin at 4 % ( 40 g / l ) was then polynitroxylated under 15 psi of co gas pressure in a sterile sealed glass container with mechanical stirring at 37 ° c . in the following manner . bractpo , equivalent to 28 nitroxides per hemoglobin , was added and the ph was adjusted to 9 . 5 . the reaction was permitted to proceed for 4 . 0 hours . at the termination of the reaction , the reaction mixture was first coarse filtered through a 0 . 4 - micron fitter followed with a 0 . 22 - micron fitter . the filtrate was then washed with 15 volumes of water - for - injection and concentrated to 4 % hemoglobin . the concentrated hpnph20 was then 0 . 22 - micron filtered and filled into a series of 50 ml transfusion bags pre - gamma irradiated to ensure sterility and stored at 4 ° c . before use . positive co pressure was used during entire procedure to ensure the final product was fully in its carboxy liganded state . ( c ) human stroma free carboxy hemoglobin was pegylated by reaction with 15 molar equivalents activated peg - maleimide ( mw 5 kd , purchased from sunbio , s . korea ) according to a modified published procedure ( cabrales p ., et al ., 2004 ). 250 ml of pegylated human carboxy hemoglobin at 4 % ( 40 g / l ) was then polynitroxylated under 15 psi of co gas pressure in a sterile sealed glass container with mechanical stirring at 37 ° c . in the following manner . bractpo , equivalent to 18 nitroxides per hemoglobin , was added and the ph was adjusted to 9 . 5 . the reaction was permitted to proceed for 4 . 0 hours . at the termination of the reaction , the reaction mixture was first coarse tittered through a 0 . 4 - micron fitter followed with a 0 . 22 - micron filter . the filtrate was then washed with 15 volumes of water - for - injection and concentrated to 4 % hemoglobin . the concentrated hpnph05 was then 0 . 22 - micron filtered and filled into a series of 50 ml transfusion bags pre - gamma irradiated to ensure sterility and stored at 4 ° c . before use . positive co pressure was used during entire procedure to ensure the final product was fully in its carboxy liganded state . ( d ) human polyheme with a hemoglobin protein concentration of 12 % ( 120 g / l ) from northfield laboratories , chicago , ill ., was first converted to carboxy polyheme and then potynitroxylated under 15 psi of co gas pressure in a sterile sealed glass container with mechanical stirring at 37 ° c . in the following manner . bractpo , equivalent to 20 nitroxides per hemoglobin , was added and the ph was adjusted to 9 . 5 . the reaction was permitted to proceed for 4 . 0 hours . at the termination of the reaction , the reaction mixture was first coarse filtered with a 0 . 4 - micron filter followed with a 0 . 22 - micron filter . the filtrate was then washed with 15 volumes of water - for - injection and concentrated to 4 % ( 40 g / l ) hemoglobin . the concentrated polynitroxylated carboxy polyheme was then 0 . 22 - micron filtered and filled into a series of 50 ml transfusion bags pre - gamma irradiated to ensure sterility and stored at 4 ° c . before use . positive co pressure was used during entire procedure to ensure the final product was fully in its carboxy liganded state . efficacy of potynitroxylation : the nitroxide to hemoglobin ratio determined by electron paramagnetic resonance spectroscopy of the potynitroxylated pegylated carboxy hemoglobins is approximately 12 for bpnph , 24 for hpnpfh20 and 14 for hpnph05 and 10 for polynitroxylated carboxy polyheme . the molecular weight analyses of the bpnph , hpnph20 and hpnph05 by fplc post potynitroxylation are shown in fig1 . these pnph preparations are essentially free of un - pegylated hemoglobin . fplc elution profile of polynitroxylated carboxy polyheme was essentially unaltered by polynitroxylation ( result not shown ). fig2 shows the difference in their ) vitro neuroprotective activities of the three ( 3 ) pnph preparations as well as bovine stroma free hemoglobin ( used as control ). all test and control preparations were at 4 % ( 40 g / l ) hemoglobin . the neuroprotective potency order is bpnph & gt ; hpnph20 & gt ; hpnph05 . it appears that the neuroprotective activities of the pnphs are not directly correlated to their nitroxide to hemoglobin ratio , i . e . hpnph20 with 24 nitroxides per hemoglobin was less effective than bpnph with 12 nitroxides per hemoglobin . bovine stroma free hemoglobin is neurotoxic while the bpnph appears to be the most neuroprotective . the remaining two pnphs also appear to be neuroprotective but are somewhat less potent ( see fig2 ). in vivo neuroprotective properties of the bovine polynitroxylated pegylated carboxy hemoglobin fig3 shows the in vivo neuroprotective activities of bpnph against a standard crystalloid ( lactated ringer ( lr ), standard for civilian resuscitation ) and a standard colloid ( hextend ( hex ), standard for military resuscitation ) in a mouse model of traumatic brain injury ( tbi ) complicated with hemorrhagic shock ( hs ) simulating the pre - hospital patient care according to a published method ( dennis a m , et al ., 2009 ). according to this model the mouse first received a tbi followed by 90 min of hs with hypotensive resuscitation and then re - infusion of shed blood 120 min post resuscitation . histology and histological staining on surviving mice performed 7 days after brain injury was used to determine neuroprotection . it is clear that bpnph provided the most neuroprotection as compared to the 2 standard pre - hospital resuscitative fluids . hemodynamic properties of the bovine polynitroxylated pegylated carboxy hemoglobin in mouse model of tbi + hs fig4 shows the hemodynamic properties of bpnph vs lactated ringers ( lr ) in a mouse model of tbi + hs . in a hypotensive resuscitation strategy for tbi + hs to control bleeding , bpnph clearly showed superiority to lr in mean arterial pressure ( map ) restoration and stability . the volume required for resuscitation ( restoration of mean arterial pressure ) with the bovine polynitroxylated pegylated carboxy hemoglobin in a mouse model of tbi + hs is only 18 % or 64 % of the volume required for resuscitation with lactated ringers ( lr ) or hextend ( hex ), respectively ( results not shown ). when expressed in volume per kilogram dose , bpnph , hex , and lr treated groups required 6 . 7 ± 1 . 8 ml / kg , 9 . 6 ± 2 . 6 ml / kg , and 36 . 3 ± 11 . 5 ml / kg , respectively . the smaller volume requirement with bpnph would make it much easier to have therapeutic quantities available in a pre - hospital setting as well as in field use for combat casualty care . however , more importantly , the smaller infusion volume would reduce edema of the brain , which is an even more important therapeutic benefit for tbi treatment in a pre - hospital setting . cerebral oxygenation with the bovine polynitroxylated pegylated carboxy hemoglobin in mouse model of tbi + hs fig5 shows the direct measurement of the brain tissue oxygenation alter tbi impact immediately below the tbi impact as measured by an implanted oxygen electrode . it is clear that bpnph maintains the cerebral oxygen levels much better than lactated ringers . this beneficial effect is most pronounced 2 hours post tbi . therefore the bpnph appears to have a long lasting effect in maintaining cerebral blood blow and tissue oxygenation . this is truly a remarkable finding which supports the histological finding of neurological - tissue protection shown in fig3 above . intra cranial pressure ( icp ) reduction by the bovine polynitroxylated pegylated carboxy hemoglobin in mouse model of tbi + hs fig6 shows that the rate and extent of icp increase is significantly reduced in bpnph treated animals as compared to that of the lactated ringers resuscitated animals . this result indicates that there is less brain swelling and edema in this tbi + hs model . this is a highly significant benefit of bpnph in pre - hospital resuscitation as this treatment adds valuable time for evacuation during the golden hour for the patient to reach the hospital in time for definitive surgical treatment to relieve icp . intra cranial pressure ( icp ) reduction with conjunctive use of 100 % oxygen and the bovine polynitroxylated pegylated carboxy hemoglobin in mouse model of tbi + hs fig6 also shows that the rate and extent of icp increase is significantly reduced in bpnph treated animals and can be further reduced with conjunctive inhalation of 100 % oxygen in the pre - hospital setting . this result is highly significant based on the increased mortality of pre - hospital use of 100 % oxygen ( jama clinical trial report 2010 ). kilgannon j h , et al ., reported in june issue of jama in 2010 that patients who have excessive oxygen levels in arterial blood ( hyperoxia ) following resuscitation from cardiac arrest have a higher rate of death in the hospital than similar patients without arterial hyperoxia . this may be a highly significant benefit of pnph when used in conjunction with 100 % oxygen in pre - hospital resuscitation . we hypothesize that there is a potential synergy of combined use of pnph with oxygen in a pre - hospital setting . pnph for infarct reduction in a rat mcao model of ischemic stroke fig7 shows infarct reduction with bpnph resuscitation in transient mcao model of ischemic stroke in rat . the neuroprotection is significant 4 - 6 hours post bpnph transfusion . based on these neuroprotective properties of bpnph , it is hypothesized that pnph may be used to treat both ischemic and hemorrhagic stroke in a pre - hospital setting . fig8 shows that one mechanism of action of bpnph in stroke infarct reduction is promotion of the blood flow in both the ischemic core and the border region . we hypothesize that bpnph may also have the potential therapeutic benefit of extending the therapeutic window of delayed tpa treatment of ischemic stroke to up to 6 hours . fig9 shows that in a transgenic scd mouse model the aortic stiffness resulting from global nitric oxide induced vascular dysfunction is reduced with bpnph treatment . in transgenic scd mice , a top loading infusion of bpnph equivalent to 1 - 2 units of packed rbcs appears to correct the nitric oxide dysfunction manifested as aortic stiffness as measured by pulse wave velocity ( pwv ). peghb and other controls had no significant effects on pwv . we hypothesize that infusion of bpnph may significantly correct the nitric oxide induced vascular dysfunction in scd patients . bpnph infusion in place of rbc transfusion may also reduce the oxidative stress from chronic hemolytic anemia . in conjunction with current use of hydroxylurea treatment bpnph transfusion may result in the reduction or even elimination of allogenic blood transfusion for scd patients . pulmonary hypertension is a highly prevalent complication of scd and is a strong risk factor for early mortality . hsu et al published their results in blood in 2007 showing that in transgenic scd mice chronic hemolytic anemia is sufficient to produce pulmonary hypertension . fig1 shows that the chronic pulmonary hypertension induced by chronic hemolysis in transgenic sickle mice is reversed by bpnph transfusion and is aggravated by control stroma free hemoglobin transfusion . this result in a model of scd is significant in that the chronic vascular dysfunction of scd may be treatable by bpnph transfusion . this therapeutic efficacy may open the possibility of demonstrating bpnph as a novel transfusion therapy in sickle cell disease . preoperative transfusions are frequently given to prevent perioperative morbidity in patients with sickle cell anemia . in 1995 , vichinsky e p et al reported that a conservative transfusion regimen was as effective as an aggressive regimen in preventing perioperative complications in patients with sickle cell anemia , and the conservative approach resulted in only half as many transfusion - associated complications . the transfusion - associated complications are often caused by oxidative stress such as over production of vascular superoxide , which can be simulated with elevated stroma free hemoglobin level in transgenic mice . fig1 shows that infusion of bpnph simulating perioperative transfusion is capable of reducing the chronically high plasma superoxide levels in transgenic sickle mice to nearly that of their heterozygous littermate controls . this is further demonstration that a therapeutic mechanism of bpnph is via reduction of superoxide , which in turn enhances plasma nitric oxide levels . we speculate that the potential to reduce perioperative complication would also be reflected by normalization of plasma nitric oxide levels as a result of bpnph transfusion . fig1 shows the restoration of plasma nitric oxide levels as a result of bpnp h transfusion as measured by downstream cgmp levels . this is further demonstration of the therapeutic mechanism of bpnph in scd . taken together , the results for this invention , shown in fig2 - 12 , clearly demonstrate that bpnph functions as a high therapeutic index , multifunctional agent that has the potential to treat specific diseases with oxidative stress such as scd , stroke , and traumatic brain injury . these are likely the therapeutic efficacies required by fda for a potential next generation hboc . what is novel in this invention is that the nphs , such as bpnph , do not require the oxygen carrier as the essential therapeutic function . to the inventors this represents a major shift in the treatment paradigm in transfusion and critical care medicine . fda / nih workshop “ hemoglobin based oxygen carriers : current status and future directions ”, bethesda , md ., wednesday , apr . 30 , 2008 natanson c ., et al ., cell - free hemoglobin - based blood substitutes and risk of myocardial infarction and death : a meta - analysis . jama 299 : 2304 - 2312 , 2008 . yu b ., et al ., endothelial dysfunction enhances vasoconstriction due to scavenging of nitric oxide by a hemoglobin - based oxygen carrier . anesthesiology march , 112 ( 3 ): 586 - 94 , 2010 . dennis a m ., et al ., hemorrhagic shock after experimental traumatic brain injury in mice : effect on neuronal death . j neurotrauma june , 26 ( 6 ) 889 - 899 , 2009 . cabrales p ., et al ., microvascular po 2 during extreme hemodilution with hemoglobin site specifically pegylated at cys - 93 ( beta ) in hamster window chamber . am j physiol heart circ physiol 287 : h1609 - h1617 , 2004 . exo j l , et al ., resuscitation of traumatic brain injury and hemorrhagic shock with polynitroxylated albumin , hextend , hypertonic saline , and lactated ringer &# 39 ; s : effects on acute hemodynamics , survival , and neuronal death in mice . j . neurotrauma 26 ( 12 ): 2403 - 8 , 2009 . kilgannon j h ., et al ., excess oxygen in blood after cardiac resuscitation may increase risk of in - hospital death . jama . 303 [ 21 ]: 2165 - 2171 , 2010 . hsu l l , et al ., hemolysis in sickle cell mice causes pulmonary hypertension due to global impairment in nitric oxide bioavailability . blood 109 ( 7 ): 308 - 3098 , 2007 . vichinsky e p ., et al ., a comparison of conservative and aggressive transfusion regimens in the perioperative management of sickle cell disease . the preoperative transfusion in sickle cell disease study group . n eng j . med . 333 ( 4 ): 206 - 13 , 1995 .