These effects are likely caused by increases in factor VIII and von Willebrand factor (vWF). What has mystified researchers, however, is how DDAVP is successful in bleeding disorders other than hemophilia and vWD, where factor VIII and vWF are within normal limits.

Various theories exist for DDAVP’s success, including increased platelet adhesion to the vessel wall. These theories include heightened coagulability because of supranormal levels of factor VIII and by the fresh appearance of ultralarge vWF multimers in plasma.²² Regardless of the underlying mechanism, studies have shown the efficacy of DDAVP in providing hemostasis.

Treatment using DDAVP in the emergency department is best accomplished using an intravenous drip at a rate of 0.2-0.3 mcg/kg over 10 minutes; alternatively, the same dose can be diluted in 50-100 mL normal saline and infused over 15-30 minutes.^18,23 Maximum benefit will occur in approximately 30 minutes as peak levels of both factor VIII and vWF are achieved.

The use of DDAVP is contraindicated in cases of polydipsia, unstable angina, or severe congestive heart disease because of its antidiuretic effect. Adverse effects include facial flush, mild and transient headaches, small decreases in blood pressure and heart rate, hyponatremia, seizure, and thromboembolic episodes.²³

Life-Threatening Bleeding

A vascular surgeon should be emergently consulted if hemorrhage cannot be quickly controlled. An adjunctive suture may be placed if there appears to be a small laceration of the graft rather than a puncture wound. This suture is used only after other measures to control bleeding described above have also failed.²⁴

Worst-case scenario, a tourniquet or strong manual pressure can be applied proximal to the puncture site. This will invariably result in thrombosis formation within the graft or fistula, making it nonfunctional. Such extreme measures are rarely necessary, but may be life-saving in specific circumstances.

Conclusion

Vascular access complications are frequently encountered in the emergency department and often warrant an inpatient hospital stay. ESRD patients have coagulopathies that are associated with chronic renal failure or occurring because of repeated utilization of their access sites.²⁵

A more stress-provoking situation is the potential severe hemorrhage that can occur at dialysis access sites.

All bleeding does stop eventually; however, it is incumbent on the emergency physician to know how to manage such bleeding in the uremic patient using the most effective and least invasive method.

References

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