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Permissive Hypotension and Desmopressin

Enhance Clot Formation
Article in The Journal of trauma January 2010
Impact Factor: 2.96 DOI: 10.1097/TA.0b013e3181c66393 Source: PubMed

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ORIGINAL ARTICLE

Permissive Hypotension and Desmopressin Enhance Clot

Formation
Joao B. Rezende-Neto, MD, PhD, Sandro B. Rizoli, MD, PhD, Marcus V. Andrade, MD, PhD,
Daniel D. Ribeiro, MD, Thiago A. Lisboa, BS, Elizabeth R. Camargos, PhD, Paula Martins, MD, PhD,
and Jose R. Cunha-Melo, MD, PhD

Background: Experimental studies of uncontrolled hemorrhage demonstrated that permissive hypotension (PH) reduces blood loss, but its effect on
clot formation remains unexplored. Desmopressin (DDAVP) enhances platelet adhesion promoting stronger clots. We hypothesized PH and DDAVP
have additive effects and reduce bleeding in uncontrolled hemorrhage.
Methods: Rabbits (n 42) randomized as follows: sham; normal blood
pressure (NBP) resuscitation; PH resuscitation 60% baseline mean arterial
pressure; NBP plus DDAVP 1 hour before (DDAVP NBP) or 15 minutes after
beginning of shock (DDAVP T1 NBP); and PH plus DDAVP 1 hour before
(DDAVP PH) or 15 minutes after beginning of shock (DDAVP T1 PH). Fluid
resuscitation started 15 minutes after aortic injury and ended at 85 minutes.
Intraabdominal blood loss was calculated, aortic clot sent for electron microscopy. Activated partial thromboplastin time, platelet count, thromboelastometry,
arterial blood gases, and complete blood count were performed at baseline and
85 minutes. Analysis of variance was used for comparison.
Results: NBP received more fluid volume and had greater intraabdominal blood
loss. DDAVP, when administered preshock, significantly reduced blood loss in NBP
and fluid requirement when given postshock. Platelets, arterial blood gas, complete
blood count, and activated partial thromboplastin time were similar at 85 minutes.
NBP delayed clot formation and worsened thrombodynamic potential on thromboelastometry, whereas PH and DDAVP improved. Electron microscopy showed
lack of fibrin on NBP clots, whereas DDAVP and PH clots displayed exuberant
fibrin/platelet aggregates. DDAVP NBP presented intermediate clots.
Conclusion: PH reduced bleeding and improved hemostasis compared with
normotensive resuscitation. DDAVP given preshock exerted similar effects
with normotensive resuscitation.
Key Words: Hemorrhage model, Resuscitation, Desmopressin (DDAVP).
(J Trauma. 2010;68: 4251)

evere hemorrhage is the second most common cause of

death in trauma patients, the most frequent cause of early
in-hospital mortality, and the leading cause of preventable

Submitted for publication December 22, 2008.

Accepted for publication August 28, 2009.
Copyright 2010 by Lippincott Williams & Wilkins
From the Universidade Federal de Minas Gerais-Belo Horizonte (J.B.R.-N.,
M.V.A., D.D.R., T.A.L., E.R.C., P.M., J.R.C.-M.), Brazil; and Sunnybrook
Tory Regional Trauma Centre (S.B.R.), University of Toronto, Toronto,
Canada.
Presented at the 22nd Annual Meeting of the Eastern Association for the Surgery
of Trauma, January 1317, 2009, Lake Buena Vista, Florida.
No financial or property interest in the subject or materials discussed in the article.
Address for reprints: Joao B. Rezende-Neto, MD, PhD, Department of
Surgery, Universidade Federal de Minas Gerais, Brazil; email: ljrezende@
yahoo.com.br.
DOI: 10.1097/TA.0b013e3181c66393

42

death.15 Management guidelines for posttraumatic hemorrhage emphasize rapid restoration of end-organ perfusion and
normotension with infusion of large volumes of crystalloids
such as lactated Ringers (LR) solution.1,6,7 This approach
however, interferes with adequate hemostasis, in which the
clots that are formed can be easily dislodged, which results in
rebleeding and unabated blood loss.1,8 14 This concept has
been investigated in several animal models demonstrating
that normotensive resuscitation leads to greater blood loss
and ultimately higher mortality when compared with hypotensive resuscitation or permissive hypotension (PH).15,16
Hypotensive resuscitation has been investigated in only a few
prospective clinical trials in trauma.9,17,18 Although the results of these trials continue to be actively debated, current
guidelines, such as the most recent edition of the Advanced
Trauma Life Support manual, have prudently started to advocate judicious fluid infusion and blood pressure increase,
particularly in penetrating torso trauma and uncontrolled
bleeding.6,7,19 No clinical studies have explored the effect of
PH on clot formation.
Another evolving concept in traumatic hemorrhage is
the use of intravenous hemostatic drugs as adjunctive therapy, such as recombinant factor VIIa, with inconsistent results.20 24 An intravenous hemostatic agent, scarcely studied
in trauma, is desmopressin (1-deamino-8-d-arginine vasopressin; DDAVP) acetate, which has been used in the management of patients with hemophilia A and von Willebrand
disease for more than 30 years.2527 DDAVP increases
plasma levels of both factor VIII (FVIII) and von Willebrand
factor and enhances platelet adhesion to injured endothelium,
supposedly resulting in the formation of a stronger clot, less
bleeding, and improved hemostasis.2527 We set forth in this
study to investigate the effect of PH on hemostasis in an
animal model of uncontrolled hemorrhagic shock that closely
simulates the human condition. In addition, we also investigated the effect of DDAVP with PH and with normotensive
resuscitation in the same setting.

MATERIALS AND METHODS

The study was approved by the Animal Research Committee and Ethics Committee of the Universidade Federal de
Minas Gerais, Belo Horizonte, Brazil, and conducted under
stringent animal ethical protocols.

The Journal of TRAUMA Injury, Infection, and Critical Care Volume 68, Number 1, January 2010

The Journal of TRAUMA Injury, Infection, and Critical Care Volume 68, Number 1, January 2010

Animals
Male New Zealand Rabbits (2,000 2,800 g) were
maintained at 25C on 12-hour light/dark cycles. The animals
were housed individually in an authorized facility at the
Faculty of Medicine, fed rabbit chow (Nutricoelho-Purina;
Cotia, Sao Paulo, Brazil), and given water ad libitum. All
animals were acclimated for 2 weeks before the experiment.

Preshock Procedures
Animals were anesthetized with 60 mg/kg of ketamine
and 8 mg/kg of xylazine (Fort Dodge Animal Health, Fort
Dodge, IA) administered intramuscularly. Additional doses
were administered intravenously as needed (15 mg/kg of
ketamine and 2 mg/kg of xylazine). Operative sites were
prepared with 10% povidone iodine solution and infiltrated
1% lidocaine (AstraZeneca, Sao Paulo, Brazil). A tracheotomy was performed, and a 3-cm segment of a 14-FR vinyl
urethral catheter was partially inserted into the trachea. The
right internal jugular vein and the right carotid artery were
cannulated with polyethylene tubing (PE10; Clay Adams,
Sparks, MD) previously filled with LR solution. A midline
laparotomy (5 cm) was performed under sterile conditions to
expose the left side of the infrarenal aorta. A 2-0 nylon
continuous full-thickness running sutures were placed
through the edges of the laparotomy for later abdominal
closure. At this time, blood samples (4 mL total) were
obtained from the carotid artery for arterial blood gas, complete blood count, platelet count, activated partial thromboplastin time (aPTT), and thromboelastometry. The later was
performed using a ROTEM Coagulation Analyzer (Pentapharm, Munich, Germany) in temperature-corrected blood
samples, activated by calcium chloride. The thromboelastometry parameters were calculated using the coagulation dynamics evaluation software (DyCoDerivAn; Avordusol, Rissov,
Denmark).

Experimental Groups

Forty-two animals (n 42) were randomly divided into

seven groups (n 6 animals per group) according to the fluid
resuscitation regimen used. Sham animals underwent preshock procedures but not hemorrhagic shock; all other
animals underwent both. Normotensive or normal blood pressure (NBP) resuscitation group received intravenous LR to

Role of Hypotension and Desmopressin in Clot

Formation

maintain mean arterial pressure (MAP) at baseline (preshock)

values. PH group received LR to maintain MAP at 60% of
baseline. Two groups (DDAVP NBP and DDAVP PH) received 0.3 g/kg (intravenous bolus) of DDAVP (Ferring
Pharmaceuticals, Limhamn, Sweden) in 0.1 mL/kg normal
saline 1 hour before shock, whereas another two groups
(DDAVP T1 NBP and DDAVP T1 PH) received DDAVP at
the beginning of fluid resuscitation and 15 minutes after the
start of shock (time point one [T1]), respectively.

Hemorrhagic Shock Procedure

All animals were placed on a heating pad to maintain
rectal temperature above 35C. The heating pad was kept off
until fluid infusion was started at T1. MAP was continuously
monitored with a Pro-Paq (Protocol Systems, Beaverton, OR)
connected to the right carotid artery. At time zero, hemorrhagic shock was induced by a single puncture injury to the
left side of the infrarenal aorta using a 16-gauge needle
(Jelco; Medex, Carlsbad, CA), 2 mm below the lower pole of
the left kidney; the injury did not go through the right side of
the artery. The abdomen was immediately closed by pulling
on the previously placed sutures. For the next 15 minutes, no
fluids were infused to simulate the time that emergency
medical service (EMS) takes to arrive at the scene. After 15
minutes (T1), 39C LR was continuously infused through the
right jugular vein through an infusion pump (Stoelting, Wood
Dale, IL). The infusion rate was set to maintain the predetermined MAP for each group to a maximum of 5 mL/min. LR
infusion continued until 85 minutes after the aortic injury or
time point two (T2; Fig. 1). Infusion rate was decreased every
time the preset MAP was reached, and the total LR volume
infused was recorded. Blood samples for laboratorial tests
were collected at baseline time zero and 85 minutes T2. The
abdomen was then opened, and the total blood loss calculated
as the difference between blood-soaked sponges minus the
weight of preweighed dry sponges. The blood clot closest to
the aortic injury was carefully removed for transmission
electron microscopy (Tecnai G2-12; FEI, Hillsboro, OR).
The clots were placed in 2.5% glutaraldehyde 0.1 mol/L
phosphate buffer solution for 12 hour at 4C, postfixed in
buffered 1% osmium tetraoxide with potassium ferricyanide,
and embedded in Epon resin (Polysicences, Warrington, PA).

Figure 1. Study design and time intervals for the uncontrolled hemorrhagic shock and resuscitation in rabbits.
2010 Lippincott Williams & Wilkins

43

The Journal of TRAUMA Injury, Infection, and Critical Care Volume 68, Number 1, January 2010

Rezende-Neto et al.

The ultrathin sections were then stained with 3% uranyl

acetate and 1% lead citrate. All reagents were purchased from
Sigma-Aldrich (St. Louis, MO). All animals were killed at
the end of the experiment by ketamine and xylazine overdose
and sectioning of the aorta.

Statistical Analysis

Data are reported as the mean SEM. One-way

analysis of variance was performed with the post hoc analysis
using Tukeys test for multiple comparisons between experimental means. To assess for interaction between variables,
the conditions PH, NBP, DDAVP, and DDAVP T1 were
modeled in a factorial analysis of variance. The unpaired
Students t test was used to analyze comparisons between two
groups. A p 0.05 was considered statistically significant.

RESULTS
Hemodynamic Response

The baseline MAP varied between 63.4 mm Hg 1.8

mm Hg and 75 mm Hg 1.4 mm Hg. Uncontrolled bleeding
from the aorta resulted in a significant decrease in MAP by 5
minutes compared with baseline values, affecting all shock
groups equivalently (Fig. 2). The MAP in the NBP groups
was successfully restored to baseline and sham animal levels
at 30 minutes after shock (50.2 mm Hg 4.3 mm Hg to 57
mm Hg 3.9 mm Hg) with LR infusion. The model also
succeeded in maintaining the MAP of the PH groups at 60%
of the baseline, thus, significantly lower than the NBP groups
throughout the whole experiment (39.0 mm Hg 1.0 mm Hg
to 43.5 mm Hg 1.0 mm Hg; Fig. 2).
Baseline rectal temperature varied from 37C 0.1C
to 37.9C 1.5C. Although the average temperature of
shocked animals was lower (35.6C 1.2C), there was no
statistical difference in temperature compared with sham
animals (37.0C 0.1C; p 0.05). Four animals died

during hemorrhage before fluid resuscitation started and were

replaced.

Intraabdominal Bleeding
Animals in the NBP group presented the largest intraabdominal blood loss (15.8 mL/kg 1.7 mL/kg; Fig. 3). The
administration of DDAVP 1 hour before hemorrhagic shock
to normotensive resuscitated animals (DDAVP NBP) resulted
in significantly smaller blood loss (8.0 mL/kg 0.3 mL/kg;
p 0.05). In contrast, when DDAVP was administered 15
minutes after the beginning of shock, no significant reduction
in blood loss was noted (Fig. 3). Animals managed with PH
had the lowest amount of intraabdominal bleeding (Fig. 3).
With that resuscitation strategy, DDAVP given 1 hour before
or 15 minutes after shock had a negligible effect in reducing
blood loss compared with the group that did not receive the
drug (PH).

Fluid Resuscitation
Animals in the NBP group required significantly more
intravenous fluid to maintain their MAP at baseline levels,
compared with all other groups (155.8 mL/kg 14.5 mL/kg;
p 0.05). Interestingly, there was a significant reduction in
the need of intravenous fluid to maintain the same endpoint
blood pressure when DDAVP was given either 1 hour
before or 15 minutes after shock (Fig. 4). As expected, PH
animals required less intravenous fluid, and DDAVP administration had a nonsignificant effect in decreasing fluid requirement (Fig. 4).

Laboratorial Test: Arterial Blood Gases,

Hemoglobin, Hematocrit, and Coagulation
Parameters
All animals had similar baseline arterial blood gas,
hematocrit, and hemoglobin, which were significantly different
by 85 minutes T2 (Table 1). Shock animals developed a com-

Figure 2. MAP of the groups during hemorrhagic shock and different resuscitation strategies, beginning of resuscitation (LR)
at 15 minutes. Data represent mean SEM (6 animals per group). *p 0.05 compared with Sham; p 0.05 compared
with Sham, NBP, DDAVP NBP, and DDAVP T1 NBP.
44

2010 Lippincott Williams & Wilkins

The Journal of TRAUMA Injury, Infection, and Critical Care Volume 68, Number 1, January 2010

Role of Hypotension and Desmopressin in Clot

Formation

Figure 3. Transmission electron microscopy of clots in relation to intraabdominal blood loss at 85 minutes after aortic injury
and uncontrolled hemorrhage in rabbits subjected to different fluid resuscitation strategies. Small arrows show aggregates of
fibrin and platelets; electron micrographs scale marker 2 m; stain 3% uranyl acetate and 1% lead citrate. Data represent
mean SEM (6 animals per group). *p 0.05 NBP compared with all other groups except DDAVP T1 NBP; p 0.05 blood
loss compared with DDAVP T1 NBP.

Figure 4. Total intravenous fluid infusion (LR) using different resuscitation strategies. Data represent mean SEM (6 animals
per group). *p 0.05 compared with all other groups; p 0.05 compared with sham and DDAVP PH.

pensatory hyperventilation, with a drop in Paco2 and partial

correction of the pH assessed at 85 minutes T2 (Table 1).
Mean hemoglobin levels dropped equivalently in shock
animals, even though bleeding and resuscitation fluid volume
were different (Table 2). Similar drop was registered for the
mean hematocrit of the shock animals, except for the
DDAVP PH group.
All animals had similar baseline values of aPTT and
platelet count (Table 2). Platelet count dropped similarly in all
shock animals compared with baseline and sham animals. There
2010 Lippincott Williams & Wilkins

were no statistical differences in aPTT regardless of the resuscitation strategy used or DDAVP administration (Table 2).

Laboratorial Test: Thromboelastometry

Baseline thromboelastometry values for clot formation
time (CFT), maximum clot firmness, maximum velocity of
clot formation (MaxV), and the thrombodynamic potential
index (TPI) were similar among all animals (Fig. 5). The CFT
increased in the NBP group after shock (p 0.05). However,
when was preceded by DDAVP given 1 hour before shock
45

The Journal of TRAUMA Injury, Infection, and Critical Care Volume 68, Number 1, January 2010

Rezende-Neto et al.

TABLE 1.

Arterial Blood Gases in the Trauma-Shock Model

Baseline
PH
Paco2 (mm Hg)
Pao2 (mm Hg)
BE (mmol/L)
T2
PH
Paco2 (mm Hg)
Pao2 (mm Hg)
BE (mmol/L)

Sham

NBP

PH

DDAVP NBP

DDAVP PH

DDAVP T1 NBP

DDAVP T1 PH

7.4 0.1
53.0 4.0
72.0 4.3
5.2 1.6

7.39 0.2
49.8 1.6
77.7 7.3
3.7 2.6

7.4 0.2
51.0 1.5
68.2 7.2
4.9 1.2

7.4 0.3
46.3 3.0
73.0 9.0
3.9 2.1

7.35 0.2
51 1.6
72.4 9.3
3.9 1.1

7.38 0.2
47.7 2.2
67.5 5.3
3.8 1.4

7.42 0.1
51.7 1.5
62.8 3.2
3.4 1.2

7.42 0.4
44.3 2.3
81.3 4.2
0.5 1.0

7.3 0.8
25.2 3.1*
160.5 25.0
9 3.5*

7.2 0.3
25.4 2.6*
171.7 14.4*
10 3.2*

7.3 0.3
26.8 2.7*
202.6 19.1*
5.7 0.5*

7.3 0.5
29.0 0.6*
162.6 24.2
6.7 1.4*

7.24 0.6
30.0 1.4*
188.3 26.7*
5.6 0.3*

7.2 0.3
26.1 2.0*
150.2 16.4
10.1 4.0*

BE, base excess.

Data reported as mean SEM.
* p 0.05 vs. Sham and baseline values.

p 0.05 vs. baseline values.

TABLE 2.

Coagulation Parameters, Hemoglobin, and Hematocrit in the Trauma-Shock Model

Baseline
aPTT
Platelets 105
Hemoglobin (g/dL)
Hematocrit (%)
T2
aPTT
Platelets 105 (mm/3)
Hemoglobin (g/dL)
Hematocrit (%)

DDAVP
NBP

DDAVP
PH

DDAVP T1
NBP

DDAVP T1
PH

1.0 0.3
3.0 0.2
12.5 0.4
36.8 0.9

0.8 0.1
4.8 0.2
11.6 0.2
35.0 0.6

1.0 0.1
3.5 0.8
12.7 0.2
38.2 0.4

0.73 0.2
4.0 0.6
12.6 0.3
36.8 0.8

0.62 0.1
3.7 0.1
12.9 0.3
38.5 0.7

0.9 0.2
2.1 0.4*
7.9 0.6*
23.3 1.8*

1.0 0.1
2.9 0.08*
7.5 0.3*
22.7 1.0*

1.7 0.7
3.0 0.1*
8.0 0.5*
26.7 0.7*

1.0 0.2
2.3 0.4*
7.3 0.4*
21.4 1.3*

0.8 0.2
2.8 0.4*
8.3 0.3*
25.1 0.8*

Sham

NBP

PH

0.95 0.1
3.8 0.6
11.8 0.7
38.5 0.8

0.90 0.1
3.6 0.4
12.0 0.5
36.1 1.3

0.90 0.1
3.6 0.5
11.8 0.1
36.7 0.8

1.2 0.3
2.3 0.3*
7.4 0.8*
22.4 2.5*

aPTT, activated partial thromboplastin time (ratio, animal value in seconds/laboratory reference control).
Data reported as mean SEM.
* p 0.05 vs. Sham and baseline values.

(DDAVP NBP), an almost fourfold reduction in time to clot

formation was noted (378.0 seconds 96 seconds vs. 101
seconds 3.5 seconds; p 0.05). A less striking decrease in
CFT was observed when DDAVP was given 15 minutes after
the beginning of shock, 175.3 seconds 57.6 seconds
(DDAVP T1 NBP). A significant reduction in the time to clot
formation was also noted when DDAVP was administered to
the PH group 1 hour before shock (DDAVP PH; Fig. 5).
No statistical difference was noted in the maximum clot
firmness between the groups (Fig. 5). Normotensive resuscitation (NBP) resulted in a significant reduction in the MaxV.
In contrast, the administration of DDAVP 1 hour before
shock increased the velocity (MaxV) by threefold (4.9 mm/
100 sec 0.5 mm/100 sec vs. 13.2 mm/100 sec 0.4
mm/100 sec; p 0.05). A smaller effect was noted when
DDAVP was given 15 minutes after shock (Fig. 5). In PH
groups the effect of DDAVP, given 1 hour before shock, led
to a significant increase in MaxV compared with baseline.
However, the effect was not significant compared with PH
alone (10.0 mm/100 sec 1.6 mm/100 sec vs. 15.5 mm/100
sec 2.0 mm/100 sec; p 0.05; Fig. 5).
46

The overall TPI was significantly lower in the NBP

group (13.1 5.1) but DDAVP, administered either before
or after shock, resulted in a more than twofold increase in TPI
(36.3 2.2 and 27 9; p 0.05), respectively (Fig. 5).
Similar results were noted when PH was performed (Fig. 5).

Transmission Electronic Microscopy

Normotensive resuscitation without DDAVP led to a
clot with almost complete absence of fibrin (Fig. 3). When
DDAVP was administered to NBP animals, apparently stronger clots containing larger amounts of fibrin and platelet
aggregates were formed. PH with DDAVP administration, 1
hour before shock, resulted in the formation of clots with
thicker and more intertwined fibrils of fibrin and abundant
aggregates of platelets, fibrin, and red blood cells (Fig. 3).

DISCUSSION
Despite being a current topic of heated debates, the
concept of resuscitating trauma patients with PH is not novel.
The deleterious effect of overzealous crystalloid loading and
raising blood pressure to normal levels before hemorrhage
2010 Lippincott Williams & Wilkins

The Journal of TRAUMA Injury, Infection, and Critical Care Volume 68, Number 1, January 2010

Role of Hypotension and Desmopressin in Clot

Formation

Figure 5. Rotational thromboelastometry results after uncontrolled hemorrhagic shock in rabbits and different resuscitation
strategies and DDAVP administration. Data represent mean SEM (6 animals per group). *p 0.05 compared with all other
groups; p 0.05 compared with baseline.

control has been known since World War I.28 PH was further
refined during World War II in soldiers with penetrating torso
injuries and, only more recently, in civilian trauma popula 2010 Lippincott Williams & Wilkins

tion.9,17,18,29 Similar to previous reports, particularly those

from experimental models of uncontrolled hemorrhagic
shock, our study demonstrates that the attempt to restore the
47

Rezende-Neto et al.

The Journal of TRAUMA Injury, Infection, and Critical Care Volume 68, Number 1, January 2010

blood pressure or MAP to normal levels with crystalloid

infusion interferes with adequate hemostasislonger time to
form a clot and reduced TPIresulting in significantly higher
blood losses than hypotensive resuscitation.15
The debate concerning PH includes the fact that some
bleeding trauma patients may be harmed by this strategy. In
patients with traumatic brain injury, hypotension has been
shown to lead to a significant worse outcome, and in these
patients, normotensive resuscitation should be aggressively
pursued.6 The original findings of this study include the
demonstration that DDAVP, given preinjury, and only in that
condition, improved the hemostatic response in uncontrolled
traumatic bleeding evidenced by a shorter time to clot formation, improved MaxV, and the overall thrombodynamic potential. Moreover, DDAVP given preinjury also resulted in a
reduction of intraabdominal blood loss in animals that underwent normotensive resuscitation, with no statistically significant
difference in animals that underwent PH resuscitation.
DDAVP is a synthetic analog of the neurohypophyseal hormone vasopressin, pharmacologically altered by
deamination of hemicysteine at position 1 and substitution
of d-arginine for l-arginine at position 8. These changes
eliminate its vasopressor activity and prolong its action by
increasing resistance to proteolytic degradation.30 The hemostatic effect of DDAVP is mainly linked to the release of von
Willebrand factor from endothelial cells, which stimulates
FVIII. The plasma concentration of both factors approximately quadruples after DDAVP infusion.2527,30,31 FVIII and
von Willebrand factor form a complex with platelets, which
enhances platelet aggregation and adhesion to the disrupted
endothelium.27,30,31 DDAVP is mainly used for bleeding
disorders related to hemophilia A, von Willebrands disease,
and uremic thrombocytopathy.26,30 The use of DDAVP to
reduce surgical blood loss has been investigated in many
randomized controlled trials, all of which failed to demonstrate any significant effect.30,31 Furthermore, a meta-analysis
of 12 randomized controlled trials in cardiac surgery reported
a higher incidence of myocardial infarction with DDAVP
(4.4% vs. 1.6% for placebo).32 These studies, however, have
been criticized for including patients with low risk of bleeding and, consequently, obscuring any potential hemostatic
effect of DDAVP.33,34 In noncardiac surgery, there is supporting evidence that DDAVP reduces surgical blood loss in a
subset of patients requiring more extensive procedures and, thus,
more likely to have major bleeding.35 No clinical study to date
has explored the use of DDAVP in traumatic hemorrhage.
Concerning experimental studies, a recent one by Ryan
et al.36 failed to demonstrate a reduction in blood loss,
improvement in prothrombin time (PT) and platelet count, as
well as von Willebrand factor activity with the use of
DDAVP in a rodent model of uncontrolled hemorrhagic
shock. This study contradicts the current one where DDAVP,
administered before shock to animals undergoing normotensive resuscitation, significantly reduced intraabdominal blood
loss. This contradiction could be attributed to several factors.
In this study, the animals were subjected to a more severe
hemorrhagic shock where the effects of DDAVP could become more apparent. Furthermore, the fact that DDAVP use
48

led to improvement in hemostasis only when given preinjury

suggests that a longer time exposed to the drug may be
necessary to significantly improve hemostasis. In addition, in
both studies, standard laboratorial coagulation tests (aPTT
and PT) were not affected by any interventions. PT and aPTT
were not designed to assess hemostatic disturbances such as
those occurring in trauma, and in certain clinical situations,
they may have a limited role. In contrast to Ryan et al.s
study, our results did not rely on these standard tests but on
the thromboelastometric assessment of hemostasis, a method
potentially superior to standard coagulation tests.36 39 Finally, differences in fluid resuscitation strategy between the
studies and animals speciesrabbits may be a better species
than rats to study clot firmness and plateletsmight account
for the different results.40
From this study, we can further speculate that the use of
DDAVP preinjury, in animals subjected to normotensive
resuscitation, may have led to the formation of more resistant
clots. Considering that DDAVP lacks a vasopressor effect,
we speculate that the need for less fluid to maintain normotension in the DDAVP NBP group could be because of the
formation of a more resistant clot that is not dislodged by the
increased intravascular hydrostatic pressure and MAP, thus,
halting bleeding and precluding rebleeding. Furthermore, all
shocked animals experienced a similar drop in platelet count,
but animals treated with DDAVP had less intraabdominal
blood loss. This finding could be explained by an enhanced
platelet function caused by DDAVP. Other evidence indicating that the use of DDAVP may result in a more resistant clot
when given preinjury to normotension resuscitated animals
was demonstrated by electron microscopy. A richer network
of thicker and more abundant fibrils of fibrin was seen in
DDAVP-treated animals, trapping platelets and red blood
cells. Some parameters of the thromboelastometric assessment of hemostasis also improved with preinjury infusion of
DDAVP. Particularly in NBP animals, DDAVP markedly
reduced the time and increased the velocity to form a clot
while increasing the overall thrombodynamic potential of
these animals. The fact that only normotensive resuscitated
animals showed improvement in hemostasis when receiving
DDAVP, albeit given preinjury, leads us to hypothesize a
potential role for DDAVP in trauma patients who cannot
undergo hypotensive resuscitation, such as those with traumatic brain injuries, but are bleeding. In this study, we also
speculate that the lesser effect of DDAVP when PH resuscitation is performed could be simply because of the already
noticeable effects that PH alone exerts in hemostasis during
hemorrhagic shock.33,34
It is difficult to design an experimental model capable
of reproducing all the mechanisms involved in hemostasis
dysfunction associated with trauma.2,15,16 The model we designed meets many of the criteria for an ideal model as
proposed recently by Parr et al.s review of experimental
models of traumatic hemorrhage. It reproduces the time
intervals between injury, EMS notification and arrival at the
scene in an urban center, and self resuscitation as demonstrated by Hirshberg et al. using computer modeling.16,41 45 It
also reproduces soft tissue trauma (laparotomy) before hem 2010 Lippincott Williams & Wilkins

The Journal of TRAUMA Injury, Infection, and Critical Care Volume 68, Number 1, January 2010

orrhagic shock, thus priming the animals cardiovascular

response and adding a clinically relevant initiator to the
coagulation process.5,16,43 Furthermore, by closing the laparotomy immediately after the aortic injury and not manipulating the blood clots, we reestablished the tamponade effect
of the abdominal wall and did not interfere with the extraluminal clot formation, thus reproducing the clinical events of
hemostasis in the experiment. Like in humans, the animals in
this study partially corrected the shock-induced metabolic
acidosis by hyperventilating, regardless of the resuscitation
strategy used. We anticipate that a more prolonged exposure
to shock would have led to exhaustion of the compensatory
mechanisms. Rewarming was started only after instituting
fluid resuscitation, which reproduced the average crystalloid
infusion by EMS during transport of 1.7 mL/kg/min or
about the maximum of 5 mL/min administered to our rabbits
that weighed 2.5 kg in average.16,44 46 Endpoint MAP for all
shock animals was reached in 15 minutes, which coincides
with the average of urban EMS scene transport time described in the literature.46 The degree of PH used, 60% of
baseline MAP, was tolerated by the animals throughout the
study period.
This study has limitations, most inherit to experimental
models. Although our small animal model simulates many of
the human conditions, it is a different species with unique
hemostatic responses that may differ from that of humans.
Certain known contributors to trauma-associated coagulopathy
were not included in this model such as severe hypothermia and
acidosis, and a more complete assessment of hemostasis was not
performed, including assessment of fibrinolysis, intravascular
coagulation, and hypercoagulabilitythe latter a possible
complication of DDAVP. Furthermore, in this study, only
when DDAVP was given preinjury was there an improvement in hemostasis. Although this finding lacks clinical
relevance, it provides an intriguing strategy capable of generating future research in traumatic hemorrhage.
In summary, our model reinforces the concept that PH
has a favorable effect on hemostasis after traumatic hemorrhage, resulting in less blood loss than normotensive resuscitation. Our study also demonstrated that DDAVP infusion
may enhance hemostasisan effect that is dependent on the
resuscitation regimen used and time of infusion and may
involve strengthening of the clot. Further investigations that
include different amounts of time on DDAVP are warranted
to test the clinical usefulness of this drug as part of the
resuscitation strategy of hemorrhaging trauma patients.
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DISCUSSION
Dr. Myung Park (Rochester, Minnesota): I would like
to thank EAST for the opportunity to discuss this well
designed study by Doctor Rezende Neto and colleagues and
I wish to thank the authors for their timely submission of the
manuscript.
The overall strategy of damage control resuscitation of
patients in hemorrhagic shock involves limiting dilutional
coagulopathy and earlier and continual replenishment of
plasma and platelets. This is in concert with accepting a lower
perfusion pressure and the administration of pharmacological
adjuncts to optimize clot formation.
The use of DDAVP is in sync with the damage control
resuscitation strategy and Dr. Rezende Neto and his group set
forth to determine if DDAVP leads to enhanced clot formation in the state of hemorrhagic shock and if that effect is
dependent on the resuscitation strategy used.
50

Utilizing an uncontrolled hemorrhagic shock model,

the authors compared hemodynamic and coagulation parameters between the sham group and the normal blood pressure
(NBP) and permissive hypotensive groups with or without
Desmopressin given prior to injury or after injury.
The authors found essentially that blood loss in animals
given DDAVP prior to hemorrhage and normotensive resuscitation was significantly lower than normotensive resuscitation alone. However, this was not reproducible when DDAVP
was given after injury. Also, the permissive hypotensive
groups had the lowest amount of blood loss and DDAVP had
a negligible effect on these groups and hence, use of DDAVP
in addition to permissive hypotension did not result in added
benefit.
Finally, utilizing the ROTEM Analyzer, the preinjury
administration of DDAVP appears to be beneficial in inducing
quicker clot formation, increasing velocity of clot formation, and
thrombodynamic potential, i.e., thrombin generation, whether
NBP or permissive hypotensive resuscitative resuscitation strategies were used. However, again, there were no significant
improvements in these clotting parameters if DDAVP was given
post-injury. Hence, DDAVP appears to have its beneficial effects if given before an expected injury, regardless of resuscitation strategy.
Based on these findings, I would like to ask the authors
to comment on the following questions. Number one, I
noticed that there were six animals per group. How did you
come up with this number per group? Was this a pilot study
to generate preliminary data to perform a larger study to show
that DDAVP may be beneficial in increasing the rate of clot
formation and maintaining clot strength?
Number two, how did you determine the permissive
hypotensive mean arterial pressure goal of 60 percent? Three,
in regards to potential increased risks of DVT and PE when
using DDAVP, did you perform necropsies on animals to
look for evidence of venothromboembolism?
Four, in the ROTEM, were there any differences in the
clotting time parameter between groups of animals with
different resuscitation strategy with or without DDAVP? I
presume the clotting time parameter is similar to the R time
that we commonly use with thromoboelastograms.
Number five, is there a plan to translate this animal
study to a clinical trial in your own trauma patients, since the
most benefit to be gained appears to be if DDAVP is given
prior to injury? Where do you see DDAVP fitting into the
resuscitation strategy of the hypotensive bleeding patients?
Based on recent work by Crescenzi et al in their
metanalysis of thirty-eight randomized, placebo-controlled
trials using DDAVP in surgical patients published earlier this
year, there is a small, 0.3 unit blood product, but statistically
significant reduction in blood transfusions. The other advantage to consider is that DDAVP, unlike Factor VIIa, is very
inexpensive. Its only $5 to $10 for the recommended 0.3
microgram per kilogram dose. It was a pleasure reviewing
this manuscript and I look forward to the authors comments.
Dr. Joao Rezende Neto (Nova Lima, Brazil): To address
your first question, we did not perform a power calculation and
the choice of using 6 animals per group was based on a pilot
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The Journal of TRAUMA Injury, Infection, and Critical Care Volume 68, Number 1, January 2010

study we performed prior to the current one with twenty animals. The second question was why we defined permissive
hypotension as a mean arterial blood pressure of 60 percent of
the baseline. We borrowed this definition from previous animal
studies such as the one by Sondeen, Stern & Kowalenko using
a swine model, and clinical studies on controlled hypotension
where the MAP was deliberately allowed to drop in elective
surgery to 50 65 mmHg.
An autopsy was performed in all animals after the
experiment. No significant findings of VTE were noticed in
the animals that received DDAVP compared with the animals
that did not receive the drug. However, VTE was not an
outcome of interest and may have been overlooked.
Concerning your fourth question, yes, clotting time
parameters were studied in all animals receiving or not
DDAVP. The R time of the animals not treated with DDAVP
was longer when we translate the Rotem clotting time
results to the TEG methodology.
Concerning the final questions, it is important to note
that DDAVP had a more striking - but not exclusive beneficial effect on hemostasis when given before the hemorrhage. Consequently the clinical relevance of the model
appears to lessen since in practice its not possible to administer any drug prior to an accident. However, when we
analyzed the data from the electron microscopy, we found
evidence that even if DDAVP is given after the hemorrhage,
it is associated to stronger clots with more fibrin and platelet

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Role of Hypotension and Desmopressin in Clot

Formation

aggregates. Furthermore, the fluid required to normalize the

blood pressure of the animals undergoing normal blood
pressure resuscitation and DDAVP (given after hemorrhage)
was lower than in animals not receiving DDAVP and normotensive resuscitation. Considering that DDAVP has no
vasomotor effect, the lesser fluid requirement could be due to
a reduction in blood loss in the animals treated with DDAVP
after the hemorrhage started.
We gave DDAVP fifteen minutes after the beginning of
the hemorrhagic shock, but we studied the animals for only
seventy minutes after that. We suspect that if we had extended the experiment further, we would have found a more
significant effect of DDAVP on hemostasis, in spite of it
being administered after the bleeding.
Finally, to answer the question if are we ready to
reproduce this study on patients now? In spite of our enthusiasm with permissive hypotension & DDAVP and DDAVP
low cost and safety profile, I think we have a long way to go
before testing it in humans who are in hemorrhagic shock.
Studies on dose response are badly needed as well as investigations on DDAVP in models mimicking blunt and traumatic brain injury. Nevertheless, we were impressed with the
results of our study where permissive hypotension and
DDAVP were associated with stronger clots being formed
and less bleeding.
I would like to thank the Eastern Association for the
Surgery of Trauma for the privilege to present our study.

51