Randomized blinded study comparing a bipolar sealer and standard electrocautery in reducing transfusion requirements in anterior supine intermuscular total hip arthroplasty

Clinical Outcomes and Experience of a Multiyear Consecutive Case Series of Total Knee Arthroplasty Procedures Conducted with a Bipolar Sealer System for Hemostasis

Maximizing hemostasis during total knee replacement procedures remains a key challenge in current practice. Bipolar sealer technology achieves intraoperative hemostasis through tissue sealing and coagulation with adjustable radio frequency energy and a saline-irrigated tip. Optimal surgical site hemostasis is important to avoid potential complications such as hemarthrosis, wound drainage, increased pain, delayed discharge, and readmissions. The aim of this study is to evaluate the safety and effectiveness of the bipolar sealer device in primary knee replacement in the largest consecutive series to date. A consecutive, treatment-control series of subjects who underwent a primary total knee arthroplasty (TKA) utilizing a bipolar sealer for hemostasis, one subgroup with concomitant tranexamic acid (TXA) administration (n = 1599) and one subgroup without TXA administration (n = 3582), compared with a control group of primary TKA under tourniquet only (n = 667). Statistical analyses were performed through two-tailed unpaired t-tests. There was less total postoperative drain output and a lower overall transfusion rate in the bipolar sealer group (807ml ± 428) (2.5%) than the tourniquet only group (1290 ± 658, p = 0.001) (8.4%, p = 0.0001), respectively. Drainage output in bipolar sealer + TXA (450 ± 297 ml) was lower than the other two groups (bipolar sealer 807 ± 428 mL, p = 0.0001; tourniquet only 1290 ± 658 ml, p = 0.0001). The bipolar sealer group had a higher hematocrit at postoperative day 1 (POD1) (bipolar sealer: 33.1 ± 4.3 cc, tourniquet only: 32.5 ± 4.3 cc, p = 0.001) and at discharge (POD2, bipolar sealer: 31.5 ± 3.7 cc, tourniquet only: 30.2 ± 3.9 cc, p = 0.0001). There were zero reported serious adverse events related to hemostasis management in any group. The bipolar sealer system is a safe and effective instrument to achieve intraoperative hemostasis during primary TKA. The bipolar sealer group required significantly fewer postoperative blood product transfusions and maintained a higher hematocrit concentration at the time of discharge compared with subjects treated solely with tourniquet mediated hemostasis. Addition of TXA to local hemostasis methods may further reduce blood loss and transfusion requirements. LEVEL OF EVIDENCE:  This is a Level III study.

Epsilon Aminocaproic Acid to Reduce Blood Loss and Transfusion After Total Hip and Total Knee Arthroplasty

BACKGROUND

Total hip and knee arthroplasty (THA and TKA) are associated with significant blood loss and some patients require postoperative blood transfusion. While tranexamic acid has been studied extensively among this population, we tested the hypothesis that epsilon aminocaproic acid (EACA) can reduce blood loss and transfusion after joint arthroplasty.

METHODS

In April 2014, our Veterans Affairs Medical Center introduced a protocol to administer EACA during THA and TKA. No antifibrinolytics were used previously. We retrospectively compared blood loss and incidence of transfusion among patients who underwent primary arthroplasty in the year before standardized administration of EACA with patients having the same procedures the following year. Blood loss was measured as delta hemoglobin (preoperative hemoglobin - hemoglobin on postoperative day 1). All patients undergoing primary THA or TKA were included. Patients having revision surgery were excluded.

RESULTS

We identified 185 primary arthroplasty patients from the year before and 184 from the year after introducing the EACA protocol. There were no changes in surgical technique or attending surgeons during this period. Delta hemoglobin was significantly lower in the EACA group (2.7 ± 0.8 mg/dL) compared to the control group (3.4 ± 1.1 mg/dL) (P < .0001). The incidence of blood transfusion was also significantly lower in the EACA group (2.7%) compared to the control group (25.4%) (P < .0001). There was no difference in venous thromboembolic complications between groups.

CONCLUSION

We demonstrated reductions in hemoglobin loss and transfusion following introduction of the EACA protocol in patients undergoing primary arthroplasty. EACA offers a lower cost alternative to TXA for reducing blood loss and transfusion in this population.

Efficacy of Hybrid Plasma Scalpel in Reducing Blood Loss and Transfusions in Direct Anterior Total Hip Arthroplasty

BACKGROUND

Allogeneic blood transfusions have inherent risk and direct cost in total hip arthroplasty. Anterior total hip arthroplasty has grown in popularity with increased utilization. This approach may offer an enhanced recovery but has been associated with increased blood loss. Several technologies have been developed including the Canady Hybrid Plasma Scalpel (CHPS) and Aquamantys Bipolar Sealer (BS) to decrease blood loss.

METHODS

Two hundred forty-four consecutive patients undergoing anterior supine intermuscular total hip arthroplasty were separated by intraoperative cautery device (CHPS vs BS). Exclusion criteria included blood dyscrasias and contraindication to tranexamic acid. Demographic data, blood loss, transfusion requirements, and Harris Hip Scores were obtained. Differences between groups were evaluated using the Student t-test or Wilcoxon rank-sum test for continuous variables and chi-square test for categorical variables.

RESULTS

There were no differences in demographic data between the groups. Patients in the CHPS group had a significantly smaller decrease in postoperative hemoglobin (-2.3 mg/dL vs -2.7 mg/dL, P < .05), estimated blood loss (240.3 mL vs 384.4 mL, P < .001), and calculated actual blood loss (1.11 L vs 2.47 L, P < .001). There were 12 transfusions in the BS group and none in CHPS group (P < .001).

CONCLUSION

The use of the hybrid plasma scalpel resulted in significantly less blood loss and transfusions than the BS. Additionally, patients treated with the hybrid plasma scalpel had significantly shorter operative times and reduced hospital length of stay. The hybrid scalpel shows promise in reducing blood loss in anterior total hip arthroplasty and is a valuable tool in the multimodal approach to avoiding transfusions.

The less invasive anterior approach for total hip arthroplasty: a comparison to other approaches and an evaluation of the learning curve - a systematic review

There is still discussion about possible advantages and disadvantages of the less invasive anterior approach for total hip arthroplasty (THA). The purpose of our systematic review was to evaluate literature regarding the anterior approach in comparison to other approaches. Furthermore, we investigated if there is a description of a learning curve for the anterior approach.Data were obtained from EMBASE, Cochrane, PsycINFO, CINAHL, Web-of-Science, Scopus, Google scholar, and PubMed since their inception up to June 2015. 2 reviewers independently selected the studies and independently conducted the quality assessment. Because studies were considered heterogeneous regarding outcome measures, determinants studied, and methodological quality, we decided to perform a "best evidence synthesis". A total of 64 studies met the inclusion criteria.Strong evidence for no difference in component placement between the anterior approach and other approaches was found. Also, strong evidence for faster postoperative recovery and less need for assistive devices after the anterior approach were found. All other studied parameters only demonstrated conflicting evidence. Although the learning curve for the anterior approach is not yet clear, this learning curve should not to be neglected.In conclusion, the less invasive anterior approach provides benefits in the early postoperative period only, when compared to other approaches.

No Effect of a Bipolar Sealer on Total Blood Loss or Blood Transfusion in Nonseptic Revision Knee Arthroplasty-A Prospective Study With Matched Retrospective Controls

BACKGROUND

Postoperative anemia is frequent after revision of total knee arthroplasty (TKA) with reported transfusion rates up to 83%. Despite increased efforts of reducing blood loss and enhancing fast recovery within the fast-track setup, a considerable transfusion rate is still evident. The aim of this study was therefore to evaluate the effect of a bipolar sealer on blood loss and transfusion in revision TKA.

METHODS

In this single-center prospective cohort study with retrospective controls, 51 patients were enrolled in a fast-track setup for revision TKA without the use of a tourniquet. Twenty-five prospectively enrolled patients received treatment with both a bipolar sealer and electrocautery, whereas 26 patients had received treatment with a conventional electrocautery only in the retrospective group.

RESULTS

No significant differences were found neither for calculated blood loss, with 1397 (standard deviation, ± 452) mL in the bipolar sealer group vs 1452 (SD, ± 530) mL in the control group (P = .66), nor for blood transfusion rates of 53% and 46% (P = .89), respectively. Four controls were readmitted within 90 days follow-up.

CONCLUSION

The use of a bipolar sealer in a TKA revision setting without the use of a tourniquet did not reduce blood loss or blood transfusion rates.

The efficacy of a novel saline/bipolar radiofrequency energy instrument for arresting ongoing solid and non-solid organ hemorrhage in a swine model

INTRODUCTION

Ongoing hemorrhage is often life threatening and can be challenging to stop in critically injured patients. Traditional techniques for addressing this issue include high voltage cautery (Bovie), topical hemostatic application, and the delivery of ignited argon gas. The goal of this study was to evaluate the efficacy of a novel energy device for arresting ongoing bleeding from both solid and non-solid organs within a swine model.

METHODS

A novel instrument utilizing bipolar radiofrequency (RF) energy which acts to ignite/boil dripping saline from a small hand piece was employed to arrest ongoing hemorrhage from an escalating series of injuries in large male swine. Liver, spleen, kidney, lung, heart, inferior vena cava and abdominal wall targets were evaluated and digitally recorded. Methodology was descriptive.

RESULTS

Four large male swine received escalating injuries to their liver, spleen, kidney, lung, heart, inferior vena cava and abdominal wall. Injury patterns included a variety of surface decapsulation, superficial lacerations, deep lacerations, "through and through" missiles and complete transections. Application of the bipolar/RF instrument to sites of ongoing hemorrhage was successful in 97% of all scenarios. Depth of tissue penetration via microscopic evaluation ranged from 1.1mm to 3.0mm depending on the target organ composition. No air leaks were observed following application to the bleeding lung. Surgeon reported 'ease of use' score was high (4.8/5).

CONCLUSION

This energy technology is successful in arresting ongoing hemorrhage from varying intensities of traumatic injuries to the liver, spleen, kidney, abdominal wall, lung and heart in the swine model. Additional testing is required before advocating its use on any thoracic organs.

Use of a novel saline/bipolar radiofrequency energy instrument as an adjunct for arresting ongoing solid organ surface and laceration bleeding in critically injured patients

INTRODUCTION

Solid organ (liver, spleen and kidney) haemorrhage is often life threatening and can be difficult to stop in critically ill patients. Traditional techniques for arresting this ongoing bleeding include coagulation by high voltage cautery (Bovie), topical haemostatic application, and the delivery of ignited argon gas. The goal of this study was to evaluate the efficacy of a new energy device for arresting persistent solid organ haemorrhage.

PATIENTS AND METHODS

A novel instrument utilizing bipolar radiofrequency (RF) energy which acts to ignite/boil dripping saline from a simple hand piece was employed to arrest ongoing bleeding from solid organ injuries at 2 high volume, level 1 trauma centres. This instrument is extrapolated from experience within elective hepatic resections. Standard statistics were employed (p<0.05=significant).

RESULTS

From January 2013 to January 2015, 36 severely injured patients (mean injury severity score=31; blunt mechanisms=32/36 (89%)) underwent use of this new saline/RF energy instrument to arrest ongoing haemorrhage from the liver (29), spleen (5) and kidney (2). Of these patients, 25 received instrument use during an initial laparotomy, while 11 patients underwent use following removal of sponges during a return laparotomy after an initial damage control procedure. Success in arresting ongoing haemorrhage was 97% (35/36) in these highly selected cases. The surgeons reported an 'ease of use' score of 4.9 out of 5. No postoperative complications (including delayed haemorrhage) were noted as a direct result of the energy instrument.

CONCLUSIONS

This simple saline/RF energy instrument has the potential to arrest ongoing solid organ surface/capsular bleeding, as well as moderate haemorrhage associated with deep lacerations.

The Efficacy of Bipolar Sealer on Blood Loss in Primary Total Hip Arthroplasty: A Meta-Analysis

The blood loss during total hip arthroplasty is difficult to manage and there is no consensus about the effect of bipolar sealer used during operation. Thus, a systematic review of randomized controlled trials (RCTs) was performed to evaluate the efficacy and safety of blood loss using bipolar sealer after total hip arthroplasty (THA).Relevant literature of comparisons of bipolar sealer after THA for blood loss were searched for in Embase, PubMed, Web of Science, the Cochrane Central Register of Controlled Trials, and Google scholar from their inception to October, 2015. High-quality RCTs were selected to evaluate the need for transfusion, blood loss, and other complications. The software RevMan 5.30 was used for the meta-analysis.Six studies reporting on 6 RCTs comprising 751 patients were included. Compared with standard electrocautery, bipolar sealer was associated with lower rates of need for transfusion (relative risk [RR] = 0.60; 95% confidence interval [CI] 0.39-0.94), estimated blood loss (mean differences [MD] = -127.39; 95% CI -233.32 to -21.46; P = 0.02), and lower total blood loss (MD = -226.57; 95% CI -350.80-102.34; P = 0.0004). There is no significant difference between the hemoglobin drop, blood loss in drainage, intraoperative blood loss, Harris score, and rates of infection.The present meta-analysis indicated that bipolar sealer can decrease the need for transfusion and total blood loss; however, there is no benefit of bipolar sealer from the recovery. It is still need for samples to determine the balance between the economic cost and transfusion.

Effects of tranexamic acid and bipolar sealer alone or in combination in primary total knee arthroplasty: a prospective, randomized, controlled trial

Background

The purpose of this study was to compare 2 blood management interventions, tranexamic acid (TXA) and bipolar sealer system (BSS) used independently or in combination with a control group during primary total knee arthroplasty (TKA).

Methods

A total of 127 TKA patients were enrolled and randomized into 4 groups: Intravenous TXA plus the BSS (N = 29, group 1); TXA only (N = 29, group 2); BSS only (N = 31, group 3); and intravenous normal saline as a control group (N = 32, group 4).

Results

Changes in hemoglobin from baseline to postoperative follow-up were significantly lower among patients who received TXA plus BSS and those receiving TXA only when compared with the control. BSS only did not differ significantly when compared to the control group. In addition, TXA plus BSS was as efficacious as TXA only in preserving postoperative hemoglobin.

Conclusions

In other terms, using bipolar sealer did not add to the effect of TXA in reducing the postoperative hemoglobin drop in primary TKA.

Use of a Bipolar Blood-Sealing System During Total Joint Arthroplasty

The goal of the clinical use of a bipolar blood-sealing system is to reduce perioperative blood loss in total joint arthroplasty (TJA). This study was performed to determine whether a bipolar sealer is safe and effective in TJA and whether there are any advantages over monopolar sealers. The authors searched electronic databases and reference lists of relevant articles; retrieved all published randomized, controlled trials concerning the subject; and then performed a meta-analysis. Nine clinical trials involving 871 patients were included. The results of the meta-analysis indicate that using a bipolar sealer in TJA could reduce total measured blood loss, intraoperative blood loss, and operative time, which was especially observed in revision TJA for infection and primary total knee arthroplasty without tourniquet use. However, there was no significant difference between the 2 groups in terms of calculated blood loss, hemoglobin decrease, transfusion requirements, length of stay, and complications. The results of the comparison between bipolar and monopolar sealers used in TJA indicate that the routine use of a bipolar sealer for TJA may be of limited benefit except in revision TJA and primary total knee arthroplasty without tourniquet use. In the future, more high-quality randomized, controlled trials are needed to provide robust evidence and confirm the best option.

Prospective, Randomized Trial to Evaluate Efficacy of a Bipolar Sealer in Direct Anterior Approach Total Hip Arthroplasty

Total hip arthroplasty can be associated with substantial blood loss requiring allogenic transfusions. Intraoperative blood loss patterns in DAA differ from other approaches. This study evaluated the hemostatic efficacy of a bipolar sealer in DAA THA on surgical blood loss and transfusion requirements. 118 patients were enrolled in this prospective, randomized, double-blinded trial. Primary outcome measure was transfusion rate, while secondary measures included calculated blood loss. A lower transfusion rate was found in the treatment group (3.5 % vs 16.4%, P=.03). There were differences in Hemoglobin-drop (P=.04), calculated blood loss (P=.02), and hidden blood loss (P=.02), favoring the treatment group. The use of a bipolar sealer decreased intraoperative blood loss and transfusion requirements in the study population.

Bipolar sealer not superior to standard electrocautery in primary total hip arthroplasty: a meta-analysis

Introduction

To assess whether bipolar sealer has advantages over standard electrocautery in primary total hip arthroplasty (THA).

Methods

All studies published through November 2013 were systematically searched in PubMed, Embase, ScienceDirect, The Cochrane Library, and other databases. Relevant journals or conference proceedings were searched manually. Only randomized controlled trials were included. Two independent reviewers identified and assessed the literature. Mean difference in blood loss and risk ratios of transfusion rates and of complication rates in the bipolar sealer group versus the standard electrocautery group were calculated. The meta-analysis was conducted using RevMan 5.1 software.

Results

Five studies were included, with a total sample size of 559 patients. The use of bipolar sealer did not significantly reduce intraoperative blood loss, hemoglobin drop, hospital stay, and operative time. There were no significant differences in need for transfusion and the incidence of infection between the study groups.

Conclusion

The available evidence suggests that the use of bipolar sealer was not superior to standard electrocautery in patients undergoing primary THA. The use of bipolar sealer is not recommended in primary THA.

Radiofrequency bipolar hemostatic sealer reduces blood loss, transfusion requirements, and cost for patients undergoing multilevel spinal fusion surgery: a case control study

Background

A relatively new method of electrocautery, the radiofrequency bipolar hemostatic sealer (RBHS), uses saline-cooled delivery of energy, which seals blood vessels rather than burning them. We assessed the benefits of RBHS as a blood conservation strategy in adult patients undergoing multilevel spinal fusion surgery.

Methods

In a retrospective cohort study, we compared blood utilization in 36 patients undergoing multilevel spinal fusion surgery with RBHS (Aquamantys®, Medtronic, Minneapolis, MN, USA) to that of a historical control group (n = 38) matched for variables related to blood loss. Transfusion-related costs were calculated by two methods.

Results

Patient characteristics in the two groups were similar. Intraoperatively, blood loss was 55% less in the RBHS group than in the control group (810 ± 530 vs. 1,800 ± 1,600 mL; p = 0.002), and over the entire hospital stay, red cell utilization was 51% less (2.4 ± 3.4 vs. 4.9 ± 4.5 units/patient; p = 0.01) and plasma use was 56% less (1.1 ± 2.4 vs. 2.5 ± 3.4 units/patient; p = 0.03) in the RBHS group. Platelet use was 0.1 ± 0.5 and 0.3 ± 0.6 units/patient in the RBHS and control groups, respectively (p = 0.07). The perioperative decrease in hemoglobin was less in the RBHS group than in the control group (−2.0 ± 2.2 vs. –3.2 ± 2.1 g/dL; p = 0.04), and hemoglobin at discharge was higher in the RBHS group (10.5 ± 1.4 vs. 9.7 ± 0.9 g/dL; p = 0.01). The estimated transfusion-related cost savings were $745/case by acquisition cost and approximately 3- to 5-fold this amount by activity-based cost.

Conclusions

The use of RBHS in patients undergoing multilevel spine fusion surgery can conserve blood, promote higher hemoglobin levels, and reduce transfusion-related costs.

Use of a bipolar sealer in total hip arthroplasty: medical resource use and costs using a hospital administrative database

Perioperative blood loss during total hip arthroplasty (THA) increases patient morbidity, length of stay (LOS), medical resource use (MRU), and costs. Minimizing blood loss may reduce postoperative anemia, the need for blood transfusions, and the increased risk of infections and longer hospital stays associated with blood transfusions. Pharmacologic agents and bipolar sealer devices can minimize perioperative bleeding. A retrospective, comparative cohort study in the US hospital setting was conducted to assess MRU and associated costs and the incidence of transfusion and complications among patients undergoing THA with or without the use of a bipolar sealer. Using a nationwide all-payer hospital administrative database, THA procedures from January 1, 2008, to March 31, 2011, were identified using International Classification of Diseases, Ninth Revision, Clinical Modification procedure code 81.51. The bipolar sealer cohort (n=2683) and matched control cohort (n=2683) had a mean age of 65 years from 38 hospitals. The 2 groups had similar incidences of pre-operative anemia and medical comorbidities. Patients in the bipolar sealer group required significantly fewer blood transfusions (21.3% vs 23.8%; P=.0286) and had significantly lower incidence of hematomas (0.2% vs 0.9%; P=.0015) and significantly shorter LOS (2.90 vs 3.31 days; P<.0001) overall. The bipolar sealer group had higher supply costs, which were offset by reduced hospital inpatient room and board and operating room costs; there was no significant difference in total hospital costs between the 2 groups ($18,937 vs $18,734; P=.56). A bipolar sealer decreases postoperative blood transfusions and LOS during primary THA without increasing total hospital costs.

Hemostasis in brain tumor surgery using the Aquamantys system

Background

Adequate hemostasis in cranial and spinal tumor surgery is of paramount importance in neurosurgical practice. Generalized ooze bleeding from the surgical walls cavity, coming from neoplastic vessels or nervous tissue, may be problematic. Recent technical advances have dramatically reduced intraoperative complications related to blood loss. Several techniques are usually employed to control hemostasis in tumor surgery, including preoperative embolization, intraoperative hypotension, electrical coagulation, and local application of fibrin sealants or hemostatic matrix, which influence coagulation.

Material/Methods

Our aim in this study was to evaluate the efficacy and the safety of the Aquamantys^® system (Medtronic Advanced Energy, Portsmouth, NH, USA), a novel bipolar coagulation device that incorporates a new bipolar coagulation technique. This device has been used in 10 consecutive patients affected by cerebral tumor along with the standard microsurgical technique and well-known intraoperative tools. The technique is associated with simultaneous delivery of bipolar radio frequency energy and conductive fluid through its electrode tip. The volume of saline passing by the electrode tip prevents charring and maintains a clean tip. This cools the tissue as it raises the temperature sufficiently to shrink the collagen of veins and arteries.

Results

Effective hemostasis was achieved in all the cases. No complications or unwanted reactions associated with the device have been observed.

Conclusions

Our findings suggest that the Aquamantys^® system may be a highly effective adjuvant tool in minimizing blood loss in a patient with brain tumor, as well as reducing time of surgery.