Desmopressin nasal spray reduces blood loss and improves the quality of the surgical field during functional endoscopic sinus surgery

An Algorithm for Control of Excessive Perioperative Bleeding and Ecchymosis in Rhinoplasty Patients Based on 4 Decades of Experience

BACKGROUND

Persistent intraoperative bleeding, excessive postoperative ecchymosis, epistaxis, and blood collection in the supratip area increase the complexity of rhinoplasty, causing suboptimal outcomes. The authors present an intraoperative bleeding management algorithm, developed by the senior author (B.G.) based on 43 years of experience, and assess its efficacy in achieving hemostatic control through 103 consecutive cases.

METHODS

A retrospective chart review was conducted on 103 consecutive patients who had undergone septorhinoplasty performed by a single surgeon. The authors reviewed patient demographics; coagulopathies; medications; diet; intraoperative use of tranexamic acid (TXA), deamino-8- d -arginine vasopressin (DDAVP), and vitamin K; and postoperative complications.

RESULTS

Twenty-six patients (25.2%) did not receive intraoperative hemostatic agents. Twenty-six patients (25.2%) required TXA only, 3 patients (2.91%) were given DDAVP only, 1 patient (0.97%) received vitamin K only, and 46 patients (44.7%) required both TXA and DDAVP. One patient (0.97%) needed TXA, DDAVP, and vitamin K. Intraoperative bleeding was controlled in all patients. One patient with known factor 11 deficiency received both TXA and DDAVP intraoperatively but did not require fresh frozen plasma. Intraoperative bleeding was controlled by first administering 10 mg/kg of TXA intravenously, followed by DDAVP with a maximum dose of 0.3 µg if needed, and 10 mg of vitamin K if bleeding persisted. Patients with known type I or IIa von Willebrand disease received DDAVP preoperatively. No patient experienced postoperative epistaxis, thromboembolism, or other associated complications.

CONCLUSION

The algorithm of TXA, DDAVP, and vitamin K is effective in controlling excessive intraoperative bleeding, postoperative ecchymosis, and epistaxis.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Potential clinical applications of current and future oral forms of desmopressin (Review)

Desmopressin is a synthetic analogue of vasopressin and a selective vasopressin receptor 2 agonist. It was first synthesised in 1967 and utilised for its antidiuretic properties. It is also used in bleeding disorders to enhance clotting. Other potential uses of the drug have been reported. The present review aims to provide a broad overview of the literature on potential further uses of oral forms of desmopressin. Key therapeutic areas of interest were identified based on known physiological activities/targets of desmopressin or reports of an effect of desmopressin in the literature. The feasibility of adequate dosing with oral forms of the drug was also considered. Systematic literature searches were carried out using the silvi.ai software for the identified areas, and summaries of available papers were included in tables and discussed. The results of the searches showed that desmopressin has been investigated for its efficacy in a number of areas, including bleeding control, renal colic, the central nervous system and oncology. Evidence suggests that oral desmopressin may have the potential to be of clinical benefit for renal colic and bleeding control in particular. However, further research is needed to clarify its effect in these areas, including randomised controlled studies and studies specifically of oral formulations (and doses). Further research may also yield findings for cancer, cognition and overactive bladder.

Does Desmopressin Reduce Intraoperative Bleeding in Patients Who Undergo Nasal Surgery? A Systematic Review and Meta-Analysis

Background and Objectives

This study aimed to determine the efficacy of prophylactic desmopressin administered via the intranasal or intravenous route in reducing intraoperative bleeding during nasal surgery. We conducted a meta-analysis of the relevant literature to investigate the role of preoperative desmopressin in minimizing bleeding complications associated with nasal surgery.

Methods

We screened the relevant literature published before February 2023. Nine articles that compared the perioperative use of desmopressin (treatment) with a placebo or no treatment (control) were included. The analyzed outcomes were intraoperative bleeding during nasal surgery and postoperative morbidity.

Results

The treatment group showed significant improvements in intraoperative bleeding, the surgical field, and surgeon satisfaction compared to the control group. However, the prophylactic use of desmopressin was associated with elevated blood pressure and decreased serum sodium levels compared to the control group. Nonetheless, no significant adverse effects were reported in the included studies. Subgroup analyses comparing the route of administration (intravenous vs. intranasal) and type of surgery (rhinoplasty vs. endoscopic sinus surgery) showed that desmopressin had a beneficial effect on intraoperative bleeding and the surgical field, regardless of the route of administration or type of surgery.

Conclusion

The prophylactic use of desmopressin for nasal surgery effectively reduced intraoperative bleeding, improved the surgical field, and increased surgeon satisfaction, with no significant adverse effects. However, caution should be exercised when administering desmopressin as it may cause an elevation in postoperative blood pressure in patients with cardiopulmonary problems.

Investigation of the effects of intranasal desmopressin on the bleeding of the patients during open septorhinoplasty: A randomized double-blind clinical trial

Objectives

Rhinoplasty is one of the most common cosmetic surgeries in the world. Lack of adequate local homeostasis may lead to excessive bleeding during the operation, which increases the time of operation and recovery period, and the prevalence of complications. This study investigated the effects of nasal desmopressin on the quality of the surgical field and the volume of bleeding during rhinoplasty.

Materials and methods

This double-blind randomized clinical trial was performed on 120 patients aged 18-40 years who were candidates for rhinoplasty. Patients were randomly divided into three groups: low-dose desmopressin group and high-dose desmopressin group and placebo group. Hemodynamic changes and surgical field based on BOEZAART criteria, and the volume of bleeding were calculated.

Results

In this study 115 women (95.8%) and 5 men (4.2%) participated. The mean age of patients was (27 ± 6.8). Bleeding volume in high dose desmopressin group was (21.7 cc ± 12.3), (27.7 cc ± 12.3) in low dose group, and (38.3 cc ± 12.3) in the placebo group, The difference in blood volume among the three groups was statistically significant with p < 0.005. Clean surgical field according to BOEZAART classification was marginally significant in both desmopressin groups. The differences in blood pressure, heart rate, blood and urine sodium, and hemoglobin before and after surgery between groups there not statistically significant.

Conclusion

Based on the results of the present study topical nasal spray desmopressin can reduce surgical field bleeding during rhinoplasty. To generalize the results to other surgeries in the ENT field it is recommended to conduct studies.

Efficacy of prophylactic pre-operative desmopressin administration during functional endoscopic sinus surgery for chronic rhinosinusitis: A systematic review and meta-analysis of randomised placebo-controlled trials

OBJECTIVES

To examine the efficacy of prophylactic desmopressin versus placebo among patients undergoing functional endoscopic sinus surgery (FESS).

DESIGN

Systematic review and meta-analysis of randomised controlled trials (RCTs).

SETTING

The Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Scopus, and Web of Science databases were screened from inception until 18 March 2022.

PARTICIPANTS

Patients undergoing FESS.

MAIN OUTCOME MEASURES

Primary efficacy endpoints comprised intraoperative blood loss, visual clarity, and operation time. Secondary endpoints comprised side effects. The efficacy endpoints were summarised as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI).

RESULTS

Five RCTs comprising 380 patients (desmopressin = 191 patients and placebo = 189 patients) were included. Collectively, the included RCTs had an overall low risk of bias. The pooled results showed that the mean intraoperative blood loss (n = 5 RCTs, MD = -37.97 ml, 95% CI [-56.97, -18.96], p < .001), 5-point Boezaart scores (n = 2 RCTs, MD = -.97, 95% CI [-1.21, -.74], p < .001), and 10-point Boezaart scores (n = 2 RCTs, MD = -3.00, 95% CI [-3.61, -2.40], p < .001) were significantly reduced in favour of the desmopressin group compared with the placebo group. Operation time did not significantly differ between both groups (n = 5 RCTs, MD = -3.73 min, 95% CI [-14.65, 7.18], p = .50). No patient in both groups developed symptomatic hyponatremia (n = 3 RCTs, 194 patients) or thromboembolic events (n = 2 RCTs, 150 patients).

CONCLUSIONS

Among patients undergoing FESS, prophylactic administration of desmopressin does not correlate with significant clinical benefits. Data on safety is limited. Future research may explore the synergistic antihaemorrhagic efficacy and safety of tranexamic acid (TXA) plus desmopressin versus TXA alone among patients undergoing FESS.

Effect of desmopressin on bleeding during endoscopic sinus surgery: A randomized clinical trial

Background

This study aimed to evaluate the effect of local nasal desmopressin premedication on blood loss and the quality of surgical field in Functional Endoscopic Sinus Surgery (FESS).

Material and methods

In a randomized clinical trial, patients referred for FESS to treat their bilateral chronic rhinosinusitis were recruited. The participants were adults (≥18 years). They were randomly assigned (1:1:1) to receive low-dose (20 μg) or high-dose (40 μg) intranasal desmopressin (DDAVP) or placebo 60 min before the induction of general anesthesia. Standard FESS was performed by the same surgeon. The primary outcomes were volume of intraoperative bleeding and the quality of surgical field. Clean surgical field was defined as a score ≤2 on the Boezaart grading system.

Results

A total of 120 patients were included on an intention-to-treat basis (mean age: 41.0 years; 40 women, 80 men). There were no significant differences in primary outcomes between low-dose DDAVP and placebo. As for the volume of blood loss, however, there was a significant difference between high-dose DDAVP and placebo (mean difference: 29.6 ml; adjusted Cohen's d: -1.02; p < .001). Also, in the high-dose DDAVP, the probability of having a good surgical field over time was about two times higher than in the placebo group (RRs for first and second surgical sides: 1.89 and 2.18). The number needed to treat for the two time points was 1.6 and 1.3, respectively.

Conclusion

The present study showed that the use of desmopressin at a dose of 40 μg 1 h before surgery can reduce bleeding and improve the quality of the surgical field. Further studies are recommended to be able to generalize these findings to other ENT surgeries.

Level of evidence

1b.