Sunday, September 20, 2015

Q: 58 year old male with ESRD (End Stage Renal Disease) is status post cardiac bypass (CABG) surgery. Patient continue to have generalized "oozing". All coagulation profiles and blood counts including platelet count are normal. You decided to try DDAVP to counter effect of impaired platelet function . You repeated dose twice and it helped partially. Your next step?

A) Repeat DDAVP to get full effect 
B) Transfuse FFP
C) Transfuse pRBC if hemodynamic instability
D) Try low dose Factor 7
E) Perform Hemodialysis

Answer: C

Objective of this question is to emphasis that Desmopressin (DDAVP) though counter impaired platelet function resulting from uremia and common in ESRD patients, but should not be repeated more than twice for two reasons. Firstly, tachyphylaxis quickly develops after 2 doses of DDAVP. Secondly, further DDAVP administration may cause symptomatic hyponatremia.

Choice B is wrong as all coagulation profile is normal so FFP is not required.

Choice is acceptable as a supportive treatment.

Choice D should be used with very very high caution only in life-threatening (life and death) situations as it may thrombose the bypass grafts!

Choice E has no role in immediate post-op CABG patients and actually may be harmful.

Practically, in above situation continuous close observation or prophylactic transfusion of platelet may be carried out.

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