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.
Explore This IssueACEP News: Vol 29 – No 10 – October 2010
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
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.
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.
- Pérez-Oliva JF, Parodis Y, Benítez O, et al. Use of recombinant streptokinase for hemodialysis catheter recovery. MEDICC Review 2005;8(5):1.
- Bittl JA. Catheter interventions for hemodialsysi fistulas and grafts. JACC Cardiovasc. Interv. 2010;3(1):1-11.
- Schild AF. Maintaining vascular access: The management of hemodialysis arteriovenous grafts. J. Vasc. Access 2010;11:92-9.
- Loran MJ, McErlean M, Eisele G, et al. The emergency department care of hemodialysis patients. Clin. Nephrol. 2002;57:439-43.
- Marx JA, ed. Rosen’s Emergency Medicine: Concepts and Clinical Practice, vol. 2. 2006. Philadelphia: Mosby Elsevier.
- Haage P, Vorwerk D, Wildberger JE, et al. Percutaneous treatment of thrombosed primary arteriovenous hemodialysis access fistulae. Kidney Int. 2000;57:1169-75.
- National Kidney Foundation Kidney Disease Outcomes Quality Initiative. Guidelines for vascular access: Treatment of stenosis without thrombosis in dialysis AV grafts and primary AV fistulae. 2000. Available at www.kidney.org. Accessed April 12, 2010.
- Tintinalli J, ed. “Emergencies in renal failure and dialysis patients.” In: Emergency Medicine: A Comprehensive Study Guide, vol. 6. 2004. New York: McGraw-Hill.
- Bernal NP, Grammer ME, Mark JR, et al. Surgical thrombectomy remains a standard of care for treatment of thrombosed arteriovenous grafts. J. Surg. Res. 2008;144:362-3.
- Maha Y, McDonald M, Walker R. The management and outcome of occluded hemodialysis access. NZMJ 2002;115:1-5.
- NFK-K/DOQI clinical practice guidelines and clinical practice recommendations: 2006 updates. Am. J. Kid. Dis. 2006;48:S1-322.
- Daeihagh P, Jordan J, Chen J, et al. Efficacy of tissue plasminogen activator administration on patency of hemodialysis access catheters. Am. J. Kidney Dis. 2000;36:75-9.
- Beathard G. Catheter thrombosis. Seminars in Dialysis. 2001;14:441-5.
- Clase CM, Crowther MA, Ingram AJ, et al. Thrombolysis for restoration of patency to hemodialysis central venous catheters. J. Thromb. Thrombolysis 2001;11:127-36.
- Vogel P, Bansal V, Marshall MW. Thrombosed hemodialysis grafts: Lyse and wait with tissue plasminogen activator or urokinase compared to mechanical thrombolysis with the Arrow-Trerotola Percutaneous Thrombolytic Device. J. Vasc. Interv. Radiol. 2001;12:1157-65.
- Hodde LA, Sandroni S. Emergency department evaluation and management of dialysis patient complications. J. Emerg. Med. 1992;10:317-34.
- Cloonan CC, Gatrell CB, Cushner HM. Emergencies in continuous dialysis patients. Am. J. Emerg. Med. 1990;8:134-48.
- Gelfoam. Available at www.pfizer.com. Accessed April 20, 2010.
- Lew WK, Weaver FA. Clinical use of topical thrombin as a surgical hemostat. Biologics 2008;2:593-9.
- Topical Thrombin: Drug Information. April 29, 2010.
- Mannucci P, Remuzzi G, Pusineri F, et al. Deamino-8-d-arginine vasopressin shortens the bleeding time in uremia. N. Engl. J. Med. 1983;308:8-12.
- Mannucci PM. Desmopressin (DDAVP) in the treatment of bleeding disorders: The first 20 years. Blood 1997;90:2515-21.
- Lethagen S. Desmopressin (DDAVP) and hemostasis. Ann. Hematol. 1994;69:173-80.
- Padberg FT Jr., Calligaro KD, Sidawy AN. Complications of arteriovenous hemodialysis access: Recognition and management. J. Vasc. Surg. 2008;48(suppl 5):55S-80S.
- Bachtell N, Goodell T, Grunkemeier G, et al. Treatment of dialysis access puncture wound bleeding with chitosan dressings. Dialysis Transplant. 2006:35:1-6.