Katz, D, et al. “The association between the introduction of quantitative assessment of postpartum blood loss and institutional changes in clinical practice: an observational study” International Journal of Obstetric Anesthesia. 2019 in press.
This retrospective study compared 3,807 patients using Triton for both cesarean and vaginal deliveries with 3,811 historical control patients at an academic center. Triton was fully incorporated into existing practices and PPH protocols and used both during delivery and postpartum. There was a lower median and wider range of blood loss with Triton (vaginal 258 mL [151–384] vs 300 mL [300–350]; cesarean 702 mL [501–857] vs 800 ml [800–900], P<0.001 for both) and hemorrhage recognition (blood loss > 1 L) increased using Triton (vaginal 2.2% vs 0.5%; cesarean 12.6% vs 6.4%, P<0.001 for both). For vaginal delivery the proportion of transfusions on the postpartum ward decreased (47% vs 71%, P=0.046) although the transfusion rate and dose did not change. This suggests that accurate recognition of blood loss led to earlier but not more transfusion. For cesarean delivery there was a significant decrease in the transfusion dose with Triton (P=0.043) and secondary uterotonic use was greater with Triton (vaginal 22% vs 17.3%, 22%, P<0.001; cesarean 7.0% vs 6.0%, P=0.177). A cost analysis demonstrated a 152% ROI for Triton.
Rubenstein, et al. "Clinical Experience with the Implementation of Accurate Measurement of Blood Loss During Cesarean Delivery: Influences on Hemorrhage Recognition and Allogeneic Transfusion" American Journal of Perinatology 2018; 35(07): 655-659
This 2781 patient study compared the outcomes of C-sections performed using traditional visual estimation versus those performed using the Triton system. Triton showed over 4x more hemorrhage recognition (>1000cc blood loss cases) yet resulted in significantly less blood use per transfusion. In addition, hospital stay was shorter for patients in whom Triton was used. The authors conclude that the use of the Triton system appeared to improve care, perhaps due to earlier recognition and treatment of postpartum hemorrhage.
Bernal N, et al. “Accurate Measurement of Intraoperative Blood Loss during Wound Excision Leads to More Appropriate Transfusion and Reduced Blood Utilization” Journal of Anesthesia & Clinical Research 2017, 8:11
This study in burn patients was focused on the potential impact of Triton on transfusion practice. The use of Triton (n=221) versus traditional visual blood loss estimation (n=178) significantly decreased the average dose of transfusion. Furthermore, transfusion decision making was more efficient as evidenced by fewer patients requiring multiple transfusion episodes and delayed postoperative transfusions.
Thurer R, et al. “Accurate Measurement of Intraoperative Blood Loss Improves Prediction of Postoperative Hemoglobin Levels” Journal of Anesthesia & Clinical Research 2017, 8:743
This analysis from the aforementioned burn study shows that postoperative day 1 hemoglobin levels are better predicted when using Triton to measure blood loss as compared to visual estimation. This potentially impacts proper transfusion decision-making surrounding surgery.
Muniz-Castro, et al. “How Does Blood Loss Relate to the Extent of Surgical Wound Excision?” Burns 2018; 44:1130-1134.
This study determined the relationship between blood loss measured by Triton and the excised area in 130 wound excision procedures. The results were compared to 105 procedures using visual estimation. The correlation between measured blood loss and the excised area was poor while visual estimates were more closely related to the extent of excision.The authors concluded that visual estimates are based on the size of excision rather than the actual amount of bleeding. The measured blood loss is not well correlated with the extent of excision and clinicians should use accurate measurement rather than visual estimates to guide care.
Doctorvaladan, S, et al. “Accuracy of Blood Loss Measurement during Cesarean Delivery” American Journal of Perinatology Reports 2017;7(2): e93-e100-
This in-vivo study of 50 C-sections compared the accuracy and precision of visual, quantitative gravimetric (weighing), and Triton to a validated assay as a reference standard. Triton showed superior accuracy and precision when analyzing total surgical blood loss in both sponges and canisters as compared to both visual estimation and the gravimetric method.
Konig G, et al; In Vitro Evaluation of a Novel System for Monitoring Surgical Hemoglobin Loss. Anesthesia & Analgesia 2014 Volume 119 Issue 3, p 595-600
This in-vitro study concludes that the Triton device is accurate when measuring blood content on surgical sponges in an OR setting. 207 sponges of different brands and with varying amounts of blood and saline were measured under 3 different ambient light conditions for a total of 621 measurements. Bland-Altman analysis revealed a bias of only 0.01g Hgb per sponge compared to the pre-measured amounts.
Konig G, et al. “In Vitro Evaluation of a Novel System for Monitoring Surgical Hemoglobin Loss” Anesthesia & Analgesia 2014;119:595–600
This in-vitro study concludes that the Triton device is accurate when measuring blood content in canisters in an OR setting. 207 sample canisters of different volumes with varying amounts of blood, saline, plasma, and blood cell hemolysis were imaged under 3 different ambient light conditions for a total of 621 measurements. Bland-Altman analysis revealed Triton having a bias of +4.7g, +3.4g, and +4.1g for dark, medium and bright lighting conditions, respectively, compared to the pre-measured canister hemoglobin mass.
Holmes A, et al. “Clinical Evaluation of a Novel System for Monitoring Surgical Hemoglobin Loss” Anesthesia & Analgesia 2014; 119(3): 588–594
This in-vivo study focused on Triton’s accuracy analyzing sponge Hgb content compared to both gravimetric analysis and a reference standard (Hgb extraction from rinsed sponges). 46 patients treated within orthopedics, general surgery, cardiac surgery and obstetrics were included. Bland-Altman analysis showed superiority of the Triton system compared to the gravimetric method, and showed clinically meaningful accuracy during surgical use.
Sharareh B, et al. “Real Time Intraoperative Monitoring of Blood Loss with a Novel Tablet Application” The Open Orthopedics Journal 2015, 9, 422-426
This is a 50-patient study focused on the feasibility and accuracy of Triton during orthopedic surgery. Real-time Triton measurements gathered throughout the course of surgery were compared to both gravimetric analysis and a photometric “gold standard” method. The results showed that Triton was significantly correlated with the photometric method and more accurate than the gravimetric method.
Konig G, et al. “Real-time Evaluation of an Image Analysis System for Monitoring Surgical Hemoglobin Loss” Journal of Clinical Monitoring and Computing 2018; 32(2):303-31
In this study, the real-time accuracy and performance of Triton was evaluated throughout the duration of 50 surgical cases. Surgeries included orthopedic, general surgery, urology, and obstetrics. Real-time use of the Triton system to measure Hb loss on sponges proved to be feasible and accurate throughout the duration of surgery.
Nowicki PD et al. “Measurement of Intraoperative Blood Loss in Pediatric Orthopaedic Patients: Evaluation of a New Method”. Journal of the American Academy of Orthopedic Surgeons Global Research & Reviews. 2018; 2:e014.
In this prospective study of 55 pediatric orthopedic procedures, the hemoglobin content in surgical sponges was estimated using Triton, visual estimation, a gravimetric method and a reference spectrophotometric assay. The Triton estimation was more strongly correlated with the reference standard (R2 = 0.88) than was the gravimetric method (R2 = 0.49) and the Triton system had a lower bias and narrower limits of agreement relative to the reference method than the gravimetric method. The authors concluded that estimated blood loss measured using the Triton system correlated better with the reference method than with the gravimetric method. The visual estimation was inaccurate.
Fedoruk K et al. “Assessing the Association Between Blood Loss and Postoperative Hemoglobin After Cesarean Delivery: A Prospective Study of 4 Blood Loss Measurement Modalities”. Anesthesia & Analgesia. 2019; 128:926-932.
This prospective study of 61 women having cesarean deliveries assessed the relationship between postpartum hemoglobin levels and blood loss measured in four ways: gravimetric, visually by a blinded obstetrician and anesthesiologist, and the Triton System. Hemoglobin was measured preoperatively and within 10 minutes after delivery. A statistically significant correlation was observed with the Triton blood loss estimation but not with the visual or quantitative estimates. Since all of the correlations were weak, the authors concluded that there may be limited clinical utility in estimating postpartum hemoglobin from blood loss values.
Rubenstein A, et al. “Accurate Assessment of Blood Loss during Cesarean Delivery Improves Estimation of Postoperative Hemoglobin” American Journal of Perinatology. 2019; 36:434–439.
This retrospective study of cesarean deliveries compared the predicted postpartum day one hemoglobin level using blood loss estimated by Triton (n=756) or visual estimation (n=2,025) with the actual measured value. The correlation was better in the Triton group (R2 = 0.519) than in the visual group (R2= 0.429) (p = 0.005). For patients in the Triton group where the estimated blood loss was >1,000 mL (n = 53), the predicted hemoglobin level was also better correlated with the actual value (R2 = 0.319) than the predictions using visual estimation (n = 32) (R2 = 0.035) (p = 0.027). The authors concluded that Triton blood loss is better at predicting postoperative day 1 hemoglobin concentration than visual estimation.