Desmopressin for reducing postoperative blood loss and transfusion requirements following cardiac surgery in adults

Abstract

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, in adult patients undergoing cardiac surgery requiring extracorporeal cardiopulmonary bypass (CPB), does administration of desmopressin acetate (DDAVP) reduce postoperative blood loss and transfusion requirements? Altogether 38 papers were found using the reported search, of which 19 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Perioperative administration of DDAVP in adult patients undergoing cardiac surgery requiring CPB may result in a small but significant reduction in postoperative blood loss. However, this does not translate into a reproducible, clinically significant reduction in exposure to transfusion in unselected patients exposed to CPB. Several sub-groups of patients have been identified in whom DDAVP reduces postoperative blood loss and transfusion requirements. These sub-groups include patients who have received preoperative aspirin within 7 days of surgery, patients with CPB times in excess of 140 min and patients with demonstrable pre- or perioperative platelet dysfunction as determined by TEG analysis or platelet function assays. Platelet dysfunction at the time of surgery may be secondary to preoperative administration of antiplatelet medications, the result of pathological processes such as von Willebrands disease, uraemia or aortic stenosis with its associated sheer stress, as well as operative variables such as prolonged exposure to CPB. The evidence does not support the routine use of DDAVP in all cardiac surgery; indeed, it is clear that there is no significant reduction in postoperative blood loss or transfusion requirements with the administration of DDAVP in patients undergoing isolated coronary artery bypass grafting (CABG) in the absence of the features noted above. Given the absence of a clinically significant reduction in exposure to blood transfusion in unselected patients, we cannot recommend the routine use of DDAVP in patients exposed to CPB. However, DDAVP may reduce postoperative bleeding in patients who have received preoperative aspirin within 7 days of surgery, patients with CPB times in excess of 140 min and patients with demonstrable platelet dysfunction and should be used selectively in these subgroups.

Evaluation of postoperative clinical outcomes in Jehovah's Witness patients who receive prothrombin complex concentrate during cardiac surgery

“…DDAVP is approved for the treatment of inherited coagulation defects such as Von Willebrand's disorder and can be used off‐label for acquired hemorrhagic conditions such as bleeding in uremic patients. A recent best evidence review concluded that DDAVP may decrease bleeding in patients undergoing CPB who: (a) received aspirin within 7 days of surgery, (b) had CPB times > 140 minutes, and (c) demonstrated platelet dysfunction 21 . We found no significant differences noted between the two groups of this study with respect to DDAVP usage or dose; approximately half of the patients in each group received DDAVP.…”

“…18 Intraoperatively platelet dysfunction. 21 We found no significant differences noted between the two groups of this study with respect to DDAVP usage or dose; approximately half of the patients in each group received DDAVP. Recombinant activated factor VII has been used in the setting of acute hemorrhage as well as uncontrolled bleeding postcardiac surgery.…”

2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery

“…The effects of DDAVP on bleeding in patients having cardiac surgery are summarized in a Cochrane systematic review of 29 RCTs 256 and 2 metaanalyses. 222,257 Summing up the evidence, the prophylactic use of DDAVP did not reduce blood loss (weighted mean difference 241 ml, 95% CI -387.55 to -96.01 ml) or the risk of blood transfusions (OR 0.96, 95% CI 0.87-1.06). Recently published meta-analyses concluded that DDAVP has a small effect on the volume of blood loss and allogeneic blood product transfusions.…”

Desmopressin after cardiac surgery in bleeding patients. A multicenter randomized trial

“…Pharmacological options to control peri‐operative bleeding consist of topical agents, antifibrinolytic drugs, and drugs that improve primary and/or secondary hemostasis. Among the latter drugs, desmopressin (1‐deamino‐8‐ d ‐arginine vasopressin, DDAVP) has been extensively studied in several types of surgical intervention, but mostly in patients undergoing cardiac surgery with extracorporeal circulation . Desmopressin stimulate increases in plasma concentrations of factor VIII and von Willebrand factor and exerts other, less well‐characterized pro‐hemostatic effects …”