The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology: Clinical Practice Guidelines ∗ —Anticoagulation During Cardiopulmonary Bypass

Abstract

Despite more than a half century of "safe" cardiopulmonary bypass (CPB), the evidence base surrounding the conduct of anticoagulation therapy for CPB has not been organized into a succinct guideline. For this and other reasons, there is enormous practice variability relating to the use and dosing of heparin, monitoring heparin anticoagulation, reversal of anticoagulation, and the use of alternative anticoagulants. To address this and other gaps, The Society of Thoracic Surgeons, the Society of Cardiovascular Anesthesiologists, and the American Society of Extracorporeal Technology developed an Evidence Based Workgroup. This was a group of interdisciplinary professionals gathered to summarize the evidence and create practice recommendations for various aspects of CPB. To date, anticoagulation practices in CPB have not been standardized in accordance with the evidence base. This clinical practice guideline was written with the intent to fill the evidence gap and to establish best practices in anticoagulation therapy for CPB using the available evidence. To identify relevant evidence, a systematic review was outlined and literature searches were conducted in PubMed using standardized medical subject heading (MeSH) terms from the National Library of Medicine list of search terms. Search dates were inclusive of January 2000 to December 2015. The search yielded 833 abstracts, which were reviewed by two independent reviewers. Once accepted into the full manuscript review stage, two members of the writing group evaluated each of 286 full papers for inclusion eligibility into the guideline document. Ninety-six manuscripts were included in the final review. In addition, 17 manuscripts published before 2000 were included to provide method, context, or additional supporting evidence for the recommendations as these papers were considered sentinel publications. Members of the writing group wrote and developed recommendations based on review of the articles obtained and achieved more than two thirds agreement on each recommendation. The quality of information for a given recommendation allowed assessment of the level of evidence as recommended by the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Recommendations were written in the three following areas: (1) heparin dosing and monitoring for initiation and maintenance of CPB; (2) heparin contraindications and heparin alternatives; and (3) reversal of anticoagulation during cardiac operations. It is hoped that this guideline will serve as a resource and will stimulate investigators to conduct more research and to expand on the evidence base on the topic of anticoagulation therapy for CPB.

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“…Activated clotting time is not highly specific for UFH activity, however, and may be confounded by hypothermia, haemodilution, loss of platelets and loss of coagulation factors, 136 137 Whole-blood viscoelastic coagulation test systems (thromboelastography rotational thromboelastometry) provide point-of-care analysis of clot generation and stability with short response times. In conjunction with treatment algorithms, they have been shown to be helpful in differential diagnosis and treatment of post-CPB bleeding.…”

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“…In instances where heparin is contraindicated, such as in the case of heparin-induced thrombocytopenia, intravenous direct thrombin inhibitors have been shown to be safe. 26 See Table 6 for recommended dosing and monitoring.…”

“…24 Prothrombin complex concentrates are potentially less likely than recombinant activated factor VII to cause thrombosis. 26 Argatroban is recommended in the context of significant renal dysfunction. Abbreviations: ACT, activated clotting time; aPTT, activated partial thromboplastin time; HIT, heparin-induced thrombocytopenia; IV, intravenous; UFH, unfractionated heparin.…”

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“…This is a complex process, involving primarily the Surgery, Anesthesiology, and Perfusion specialty subteams. If the initial dose of heparin does not provide sufficient anticoagulation, a series of additional measures based on best practices [12, 32] will be applied, with the ACT checked after each is tried. If none of these is successful, the surgeon may decide to switch to an “off-pump” procedure (in the case of CABG) or to abort the procedure altogether.…”

“…For the Heparinization subprocess, a recommended dose of heparin is calculated before the surgery according to the guidelines [32]. To begin this subprocess, that dose is physically administered to the patient by the anesthesiologist.…”