deamino-arginine-vasopressin and Transfusion-Reaction

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.

Topics: Adult; Benchmarking; Blood Transfusion; Cardiac Surgical Procedures; Cardiopulmonary Bypass; Deamino Arginine Vasopressin; Evidence-Based Medicine; Hemostatics; Humans; Patient Selection; Postoperative Hemorrhage; Risk Assessment; Risk Factors; Time Factors; Transfusion Reaction; Treatment Outcome

Evaluating the patient's individual bleeding history with a standardized questionnaire, using "point-of-care" - methods for coagulation analyses and providing autologous transfusion techniques are preconditions of a modern coagulation management. Therapy of coagulopathic patients should be based on structured hemotherapy algorithms. Surgical haemostasis and the maintenance of the basic conditions for haemostasis are elementary requirements for an effective therapy. In cases of diffuse bleeding, early antifibrinolytic therapy should be considered. Coagulation factor deficiencies should be corrected "goal-directed" using coagulation factor concentrates. Transfusion of fresh frozen plasma is only indicated in the clinical setting of massive transfusions. DDAVP and transfusion of platelet concentrates are options to optimize primary haemostasis. In cases of on-going bleeding, recombinant activated coagulation factor VII represents an option for "ultima-ratio" therapy.

Topics: Algorithms; Antifibrinolytic Agents; Blood Coagulation; Blood Coagulation Disorders; Blood Coagulation Tests; Blood Loss, Surgical; Blood Transfusion; Coagulation Protein Disorders; Deamino Arginine Vasopressin; Hemostasis; Humans; Hypotension, Controlled; Intraoperative Care; Plasma; Platelet Transfusion; Point-of-Care Systems; Transfusion Reaction

Hemorrhage in trauma is a significant challenge, accounting for 30% to 40% of all fatalities, second only to central nervous system injury as a cause of death. However, hemorrhagic death is the leading preventable cause of mortality in combat casualties and typically occurs within 6 to 24 hrs of injury. In cases of severe hemorrhage, massive transfusion may be required to replace more than the entire blood volume. Early prediction of massive transfusion requirements, using clinical and laboratory parameters, combined with aggressive management of hemorrhage by surgical and nonsurgical means, has significant potential to reduce early mortality.. Although the classification of massive transfusion varies, the most frequently used definition is ten or more units of blood in 24 hrs. Transfusion of red blood cells is intended to restore blood volume, tissue perfusion, and oxygen-carrying capacity; platelets, plasma, and cryoprecipitate are intended to facilitate hemostasis through prevention or treatment of coagulopathy. Massive transfusion is uncommon in civilian trauma, occurring in only 1% to 3% of trauma admissions. As a result of a higher proportion of penetrating injury in combat casualties, it has occurred in approximately 8% of Operation Iraqi Freedom admissions and in as many as 16% during the Vietnam conflict. Despite its potential to reduce early mortality, massive transfusion is not without risk. It requires extensive blood-banking resources and is associated with high mortality.. This review describes the clinical problems associated with massive transfusion and surveys the nonsurgical management of hemorrhage, including transfusion of blood products, use of hemostatic bandages/agents, and treatment with hemostatic medications.

Topics: Acidosis; Antifibrinolytic Agents; Bandages; Blood Coagulation Disorders; Blood Transfusion; Cause of Death; Critical Care; Deamino Arginine Vasopressin; Factor VIIa; Factor VIII; Fibrinogen; Hemorrhage; Hemostatics; Humans; Hyperkalemia; Hypocalcemia; Hypothermia; Military Medicine; Recombinant Proteins; Resuscitation; Risk Factors; Transfusion Reaction; United States; Wounds and Injuries; Zeolites

Topics: Antifibrinolytic Agents; Blood Transfusion; Deamino Arginine Vasopressin; Fibrin Tissue Adhesive; Hemorrhage; Hemostatics; Humans; Serine Proteinase Inhibitors; Transfusion Reaction; Vitamin K

Von Willebrand disease (vWD) is a frequent inherited disorder of hemostasis that affects both sexes. Two abnormalities are characteristic of the disease, which is caused by a deficiency or a defect in the multimeric glycoprotein called von Willebrand factor: low platelet adhesion to injured blood vessels and defective intrinsic coagulation owing to low plasma levels of factor VIII. There are 2 main options available for the treatment of spontaneous bleeding episodes and for bleeding prophylaxis: desmopressin and transfusional therapy with plasma products. Desmopressin is the treatment of choice for most patients with type 1 vWD, who account for approximately 70% to 80% of cases. This nontransfusional hemostatic agent raises endogenous factor VIII and von Willebrand factor 3 to 5 times and thereby corrects both the intrinsic coagulation and the primary hemostasis defects. In patients with the more severe type 3 and in most patients with type 2 disease, desmopressin is ineffective or is contraindicated and it is usually necessary to resort to plasma concentrates containing both factor VIII and von Willebrand factor. Concentrates treated with virucidal methods should be preferred to cryoprecipitate because they are equally effective and are perceived as safer. (Blood. 2001;97:1915-1919)

Topics: Blood Loss, Surgical; Combined Modality Therapy; Contraindications; Deamino Arginine Vasopressin; Endothelium, Vascular; Factor VIII; Female; Hemorrhage; Humans; Isoantibodies; Male; Myocardial Infarction; Postoperative Hemorrhage; Postpartum Hemorrhage; Pregnancy; Pregnancy Complications, Hematologic; Receptors, Vasopressin; Safety; Stroke; Thrombocytopenia; Transfusion Reaction; Virus Diseases; von Willebrand Diseases; von Willebrand Factor

Topics: Anesthesiology; Aprotinin; Blood Component Transfusion; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Body Temperature Regulation; Deamino Arginine Vasopressin; Hemodilution; Hemostatics; Humans; Hypotension, Controlled; Hypothermia, Induced; Renal Agents; Risk Factors; Transfusion Reaction

The emergence of the acquired immunodeficiency syndrome (AIDS) has fueled concerns of both physicians and their patients about safety of blood transfusions. Although AIDS has generated the most fear, the risk today is extremely remote (1/60.000 units of blood). The risk of transmitting infectious disease by homologous transfusion is decreasing, as more donor screening and testing measures are implemented. The blood supply is safer that at any time, but small transfusion risks exist. The most common problems associated with transfusions are temporary: one in 100-300 recipients will experience fever or rash. The biggest problem is a mismatch of the well-known ABO blood groups and once in every 100-400.000 transfusions the hemolytic reaction is fatal. Viral hepatitis is another serious and important risk. At present hepatitis seems to strike between 1 and 3 percent of transfusion recipients. Most, if not all, of transfusion-associated hepatitis cases are caused by hepatitis C virus. Cytomegalovirus can cause primary infection, reactivation or reinfection by transfusion. Immunosuppressed patients are more likely to develop more severe disease. Epstein-Barr virus does not seem to cause significant post-transfusion disease. Bacterial or protozoal infections are an infrequently encountered adverse effect of transfusion. However, some clinical cases document the potential hazard of blood components as a vector for bacteria or protozoa. Homologous blood transfusion down-regulates some immune functions. Host defences against malignancy and infection may in some instances be severely compromised by transfusions of homologous blood.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Acquired Immunodeficiency Syndrome; Adult; Blood Donors; Blood Transfusion, Autologous; Deamino Arginine Vasopressin; Epoprostenol; Erythropoietin; Female; Graft vs Host Disease; Hemodilution; Hepatitis, Viral, Human; Humans; Infant, Newborn; Infections; Male; Pregnancy; Prognosis; Protozoan Infections; Risk Factors; Transfusion Reaction

Topics: Anesthesia; Blood Loss, Surgical; Blood Substitutes; Blood Transfusion; Blood Transfusion, Autologous; Christianity; Deamino Arginine Vasopressin; Decision Making; Emergencies; Hematocrit; Hemodilution; Hemodynamics; Hemoglobins; Humans; Intraoperative Care; Oxygen; Surgical Procedures, Operative; Transfusion Reaction; Vasopressins

Topics: Blood Platelet Disorders; Blood Transfusion; Deamino Arginine Vasopressin; Hemorrhage; Hepatitis, Viral, Human; Humans; Infant, Newborn; Plasma Exchange; Platelet Transfusion; Purpura; Purpura, Thrombocytopenic; Purpura, Thrombotic Thrombocytopenic; Thrombocytopenia; Transfusion Reaction; von Willebrand Diseases

Cardiac surgery is one of the largest users of blood and blood products--currently estimated at 15% of U.K. blood stocks. While the blood supply could be considered to be the safest it has ever been, there are well recognised risks associated with the transfusion of red cells and blood products. It is appropriate that attempts should be made to decrease and optimise the transfusion of blood and blood products.

Topics: Algorithms; Aprotinin; Blood Loss, Surgical; Blood Substitutes; Blood Transfusion; Cardiac Surgical Procedures; Deamino Arginine Vasopressin; Factor VIIa; Hemodilution; Hemostatic Techniques; Hemostatics; Humans; Operative Blood Salvage; Perioperative Care; Positive-Pressure Respiration; Recombinant Proteins; Tranexamic Acid; Transfusion Reaction; United Kingdom

Blood components are a limited and expensive resource, and transfusions may cause serious side effects. Drug treatment is an option to reduce the need for transfusions related to surgery. Tranexamic acid reduces transfusion requirements after total hip and knee arthroplasty, and after various cardiac surgical procedures. Desmopressin does not reduce the need for transfusions after surgery in patients with normal preoperative hemostasis. Treatment with recombinant factor VIIa may be considered in patients with massive hemorrhage caused by blunt trauma, post-partum hemorrhage, cardiac surgery, and in uncontrolled bleeding in surgery in general.

Topics: Antifibrinolytic Agents; Aprotinin; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Deamino Arginine Vasopressin; Factor VIIa; Hemostatics; Humans; Recombinant Proteins; Surgical Procedures, Operative; Tranexamic Acid; Transfusion Reaction

Haemophilia is a rare and complex disorder and its successful management will depend upon the establishment of a network of 'comprehensive care' including the services of haematologists, orthopaedic surgeons, rheumatologists, dental surgeons, physiotherapists, specialised nurses and counsellors. One of the major lessons to be learned from the HIV epidemic in haemophilia is that it is critical to strive to obtain the safest and purest forms of blood products for these patients. The advent of clinically available recombinant factor VIII is expected soon; in the meantime there is a move towards treating all patients with high purity products.

Topics: Cerebral Hemorrhage; Deamino Arginine Vasopressin; Factor IX; Factor VIII; Genetic Counseling; Hemarthrosis; Hemophilia A; Hemophilia B; Humans; Male; Patient Care Team; Prevalence; Transfusion Reaction; Virus Diseases; von Willebrand Diseases

The last few paragraphs will summarize pertinent characteristics of this material in relation to other current sources of factor VIII. First, at a time when safety is the paramount concern in hemophilia therapy, plasma exchange donation offers a product with a very low intrinsic risk of blood borne infection; in many cases, this risk can be equivalent to a single unit of blood. This is much lower than previous versions of commercial factor VIII and much lower than the intrinsic risk of the starting material for current products. We believe this risk is low enough to justify its use without viral inactivation, although certain additional measures, such as the 6-month quarantine devised by Dr. Noel, could increase the margin of safety even further. Note that the principle of limitation of donor exposure is a proven one, which should be effective against any infectious agents, including those unknown to us at this time. Second, at a time when efforts to improve the safety of commercial factor VIII have led to extraordinary increases in cost, factor VIII from plasma exchange donation promises to be relatively inexpensive. Our data indicate that most blood centers could produce factor VIII in this way at 25-50% of the price of the newest commercial products. Finally, there is the matter of supply. At present, commercial factor VIII is in short supply. It may be that worldwide demand for other plasma derivatives, combined with the reduced yield of factor VIII associated with viral inactivation measures, will dictate chronic shortages for the forseeable future. In this unsettled milieu, plasma exchange donation offers a new source of factor VIII, which need not be tied to the supply of, or demand for any other plasma products. Instead, it depends on local initiatives in blood banks and hemophilia centers, and donor activity that can be tailored specifically to the needs of hemophilia patients. Thus, in spite of the impressive advances in the safety of commercial factor VIII which have recently been implemented, we believe there is a place for single donor cryoprecipitate from plasma exchange donation in the treatment of hemophilia and other bleeding disorders in the 1990's. Its use should be more widely and more extensively investigated.

Topics: Blood Donors; Deamino Arginine Vasopressin; Factor VIII; Fibrinogen; Humans; Plasma Exchange; Transfusion Reaction