A Trial of Desmopressin (1-Desamino-8-D-Arginine Vasopressin) to Reduce Blood Loss in Uncomplicated Cardiac Surgery

Abstract

Previous studies have suggested that desmopressin may reduce the bleeding diathesis that often complicates open-heart surgery. To pursue this question further, we performed a double-blind, randomized, placebo-controlled trial to determine whether the previously reported beneficial effect of desmopressin on hemostasis during complex cardiac surgery was applicable to all elective cardiac surgical procedures involving cardiopulmonary bypass. In 150 consecutive patients, most of whom underwent primary coronary-artery bypass grafting, we compared the effects of intravenous desmopressin (0.3 microgram per kilogram of body weight) with those of saline placebo on postoperative blood loss and the need to replace blood products. The median amount of blood lost within the first 24 hours after operation was similar in the desmopressin and placebo groups (865 vs. 738 ml; P = 0.26). The postoperative use of blood replacement products did not differ significantly between the groups (1025 ml [95 percent confidence interval, 300 to 4140 ml] in the desmopressin group and 860 ml [247 to 5346 ml] in the placebo group). Desmopressin is believed to exert its hemostatic effect by releasing von Willebrand factor. The level of ristocetin cofactor, a functional index of the level of von Willebrand factor, was increased approximately twofold from base line in both treatment groups 90 minutes and 24 hours after the administration of medication. Similarly, the levels of von Willebrand factor multimers increased uniformly in both groups. These findings may be consistent with a normal stress response of von Willebrand factor to major surgery and could explain our failure to detect a therapeutic effect of desmopressin. We conclude that the majority of patients who undergo elective cardiac surgery receive no hemostatic benefit from the use of desmopressin.

Pharmacological Strategies to Decrease Excessive Blood Loss in Cardiac Surgery: Meta‐analysis of Clinically Relevant Endpoints*

“…Nine studies were excluded because no clinical outcome other than blood loss was available, [7][8][9][10][11][12][13][14][15] eight studies were found not to be randomized after more thorough analysis, [16][17][18][19][20][21][22][23] five studies concerned cardiac surgery in child- ren, [24][25][26][27][28] and there was one double report. 29,36 66,75,[86][87][88][89][90][91][92][93][94][95][96][97][98][99] In addition, 12 studies compared treatment with the conventional dose of aprotinin with lower doses of aprotinin. 30,38,40,41,44,46,48,50,56,…”

Randomized study of aprotinin and DDAVP to reduce postoperative bleeding after cardiopulmonary bypass surgery.

“…26 In a randomized trial comparing DDAVP versus placebo, we could not confirm that DDAVP reduces the total blood loss and transfusion requirements, although it was observed to significantly reduce intraoperative blood loss. 16 These results were later confirmed by Hackmann et al 27 Furthermore, four additional studies did not find significant improvement in postoperative blood loss,28-31 and one report shows that the total postoperative blood loss and the red cell transfusion rates were significantly higher in the DDAVP group than in the control group, which could be related to the DDAVP-induced TPA release from endothelial cells and subsequent fibrinolysis. 32 Since, as suggested by our findings, the administration of DDAVP was effective only in reducing intraoperative bleeding, we decided to administer a second dose 6 hours after surgery to establish whether it could also improve the postoperative blood loss.…”

Blood Conservation During Pediatric Cardiac Surgery

“…100 Further studies have not supported this advantage. [101][102][103] Seear found no difference in blood loss when comparing DDAVP with placebo in children. 104 DDAVP at 0.3 µg/kg showed a maximal increase in FVIII:vWF in adults.…”