Thread by @DrBloodandGuts

My assessment of the 3 commercially available hemostatic powders:

@CookMedical Hemospray
@OlympusMedUS Endoclot
@MedtronicGI Nexpowder

We will review clogging, deployment ease, learning curve, visualization, safety, powder volume, environmental waste, and cost.

(1/)

Efficacy of powders relative to one another are unknown.

Hemospray obviously has the greatest evidence basis including level 1 (RCT) evidence, with non-inferiority to standard therapy.

acpjournals.org/doi/abs/10.732…

And massive post market registry spanning ~10 years.

(2/)

Hemospray clogs easiest, precludes suction, requires pre-flushing as it has no protective continuous air flow like Endoclot or Nexpowder.

Off label modifications can over come this, however.

ncbi.nlm.nih.gov/pmc/articles/P…

Also, catheter is the flimsiest, as well (esp 7Fr)

(3/)

Endoclot and Nexpowder produce a continuous flow of ROOM AIR (not CO2), and the powder is propelled by the air stream. This makes the catheters impossible to clog.

However, risk of barotrauma is greater with effectively continuous insufflation of room air.

(4/)

One must desufflate lumen constantly including during catheter passage.

After powder Hemospray deployment, desufflating tends to gunk the accessory channel, precluding another catheter passage.

This is less of an issue with Endoclot and Nexpowder (less airborne)

(5/)

Hemospray has by far the most generous amount of powder (20g) vs Nexpowder (3g) and Endoclot (3 or 5g).

Thus, there is some risk of running out of powder with latter 2. I have never run out of Hemospray. If you run out of Hemospray, it’s not going to stop with more.

(6/)

Endoclot and Nexpowder have adjustable flow rates!

Hemospray has one speed: super high. This produces a snowstorm effect (esp if auto fire) and worst visualization but can dump tons of powder on torrential bleeds.

Semi-auto fire and keeping 1-2 cm distance reduces this.

(7/)

The adjustable flow rate of Endoclot and Nexpowder preserve visualization. They allow a controlled application, ramping up easily.

Endoclot requires tilting and tapping the powder out of a bellow into air stream and is much less elegant than Nexpowder’s adjustable lever

(8/)

Powder adherence is best with Nexpowder bc it forms a sticky blue gel, not easily washed off. Endoclot forms a translucent film but washes off easily like Hemospray which forms an opaque white cake.

Visualization is a wash (pun!) between Endoclot and Nexpowder.

(9/)

The gel of Nexpowder (lasts 3d) is not FDA approved for EMR/ESD prophylaxis against rebleeding (like Purastat below) but research is warranted.

…prophylaxis against peptic ulcer rebleeding?

(10/)

The learning curve of deployment for the technician (hardest to easiest):

Endoclot > Nexpowder > Hemospray

The powder deployment of Endoclot is crude and less responsive (tapping a ketchup bottle), and thus you may shy away from it w/ inexperienced tech on call.

(11/)

Endoclot is the only system with reusable equipment: air compressor (mist being to bedside ICU bleede). It does have a battery though and is the most environmentally friendly

Nexpowder is the least so with internal batteries you trash after one use.

(12/)

Cost:

@CookMedical Hemospray
$1500-3000 (20g)

@OlympusMedUS Endoclot
$1200-1500 + 900$ air compressor (3-5g)

@MedtronicGI Nexpowder
$750 (3g)

Only competition can bring down cost and increase quality at once.

@NeenaSAbrahamMD @alan_barkun @AustinChiangMD @GI_Guy @stevenbollipo @drkeithsiau @AmCollegeGastro @KMonkemuller @GIhospitalist @Samir_Grover @BilalMohammadMD @AasmaShaukatMD @IrisWangMD @EndoscopyOthman @neilRsharmaMD @JonathanBuscag1 @DouglasAdlerMD @EndoCollabcom @MendozaLadd

Endoclot does not have FDA approval for indication of Forest 1a (arterial bleeding) ulcers.

Nexpowder does not have FDA indication for lower GI bleeding.

Hemospray has the widest FDA approval: upper and lower non-variceal bleeds (including Forest 1a ulcers).

My opinion:

I will stick with Hemospray as the rescue device for active GIB. It has the best evidence and I won’t compromise in life threatening situations.

If there’s a very deep ulcer, then the CO2 propellant of Hemospray is safest (barotrauma).

With Bone wax tipped catheters or CO2 Borrow method (combined with 3-way stopcock), Hemospray should not clog and with 1T gastroscope, should allow suctioning as well.

A few very short shots and patience are key.

videogie.org/article/S2468-…

As for tumor bleeds, which are easier to control, any of the three may work.

For Forrest 1 ulcer for which hemostasis was achieved using clips/thermal, Nexpowder for prophylaxis is a strong consideration, but needs data!

For EMR/ESD, Purastat for now. Nexpowder needs data.

If evidenced grows for Endoclot or Nexpowder with respect to the efficacy of the powder itself, then cost would make me reconsider.

It may be that I have 2 powders on the shelf in the future, like clips.

If I were only allowed one, it would still be Hemospray for now.