Hyponatremia After Desmopressin (DDAVP) Use in Pediatric Patients With Bleeding Disorders Undergoing Surgeries

Abstract

Desmopressin (DDAVP) 1-deamino-8-D-arginine vasopressin is used in patients with bleeding disorders, including mild factor VIII deficiency, types 1 and 2 von Willebrand disease, and platelet function defects, undergoing surgeries to help control bleeding. We conducted a retrospective chart review of bleeding disorder patients undergoing inpatient surgery at Toledo Children's Hospital, OH, from 2005 to 2009. Our study population included 107 patients aged 2 to 19 years with platelet function defects and von Willebrand disease. Our study aimed to evaluate the extent of hyponatremia caused by DDAVP and to propose a safe and effective treatment regimen for these patients. The mean change in sodium level before and after DDAVP was statistically significant within each age group. Thirteen patients had second dose of DDAVP withheld, and 11 patients had postoperative sodium levels ≤ 130 mEq/L. There were 2 patients with significant complications: a 6-year-old with postoperative bleeding and a 2-year-old with post-DDAVP tonic-clonic seizures. We conclude that DDAVP causes significant hyponatremia, despite appropriate fluid restrictions. On the basis of our analysis, we recommend monitoring sodium levels before each dose of DDAVP and fluid restriction. These patients should be observed in the hospital setting after DDAVP administration for complications such as seizures and postoperative bleeding.

Side effects of desmopressin in patients with bleeding disorders

“…Other studies and case reports reporting hyponatraemia after desmopressin were performed mostly in young children or in cases where fluid intake was not controlled . The youngest patient in our study was 5 years old and all patients were carefully instructed with respect to fluid intake.…”

“…As a result, reported side effects are headache, flushing, nausea [4,5,11]. Multiple case reports have been published describing severe side effects in patients with bleeding disorders receiving desmopressin, giving the impression that desmopressin use often results in potential dangerous situations [12][13][14][15][16][17][18][19][20][21][22]. Despite the fact that this may occasionally occur, underlying factors other than desmopressin may be responsible.…”

Management of severe perioperative bleeding

“…570,572 Response rates are reduced in children less than 2 years old. 568 Tachyphylaxis 570 and hyponatraemia 573 Currently licensed plasma-derived VWF concentrates in all countries are virally inactivated formulations with varying ratios of VWF to factor VIII ranging from approximately 1 : 1 to 2.4 : 1. 575 Products with a VWF/factor VIII ratio more than 1 are preferred in the management of VWD.…”

How I treat low von Willebrand factor levels

“…36 Fluid intake should be restricted to 1 L for adults in the 24 hours post-DDAVP administration to minimize the risk of dilutional hyponatremia, the rate of which may be higher in adolescents. 11,50 Confirmation of normal serum sodium levels is essential prior to any subsequent doses of DDAVP. 11 Plasma FVIII and VWF levels should be monitored daily and maintained at .50 IU/dL for 5 to 7 days posttonsillectomy.…”