To the Editor:
1-Deamino, 8-D-arginine vasopressin (DDAVP) releases factor VIII:C and von Willebrand factor (vWF) from the endothelium, improving platelet function in uremic patients . Evaluation of DDAVP has not been reported with the thromboelastograph (TEG), a viscoelastic measure of whole blood clotting .
A 42-yr-old male, after having undergone a renal transplant, presented for open renal biopsy with a blood urea nitrogen of 29 mg/dL and creatinine 2.8 mg/dL. The platelet count was 99 x 103/mm 3, the bleeding time 13.5 min, with normal prothrombin and partial thromboplastin times and normal hematocrit. DDAVP and fresh frozen plasma administration had been advised because of the uremia and laboratory abnormalities.
After induction of anesthesia with thiopental, fentanyl, rocuronium, and esmolol, ultrasound revealed a dilated ureter causing a 45-min delay for radiology consultation. Anesthesia was maintained with isoflurane (0.5%-0.7%) and N2 O/O (2). A TEG was performed before and 45 min after DDAVP administration (28 micro g intravenously) (Figure 1) during the delay. The post-DDAVP trace showed significant improvement in R time (fibrin formation), K time and alpha angle (fibrinogen-platelet interaction), and maximum amplitude (platelet function) without change in fibrinolysis. A percutaneous nephrostomy was performed without complication.
The TEG changes were compatible with the expected shortened bleeding time and increased vWF levels after DDAVP administration in uremic patients  in the absence of surgically induced increases in factor VIII:C and vWF . The TEG may be valuable in the perioperative assessment of these patients.
Evan G. Pivalizza, MBCHB, FFASA
Department of Anesthesiology
University of Texas Medical School at Houston
Houston, TX 77030
1. Stoelting RK, Dierdorf SF. Anesthesia and co-existing disease. New York: Churchill Livingston, 1993:297.
2. Mallett SV, Cox JA. Thromboelastography. Br J Anaesth 1992;69:307-13.
3. Mannucci PM, 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.
4. Kuitunen A, Hynynen M, Salmenpera M, et al. Anaesthesia affects plasma concentrations of vasopressin, von Willebrand factor and coagulation factor VIII in cardiac surgical patients. Br J Anaesth 1993;70:173-80.