STS/SCA/AmSECT Clinical Practice Guidelines: Anticoagulation during Cardiopulmonary Bypass

Despite more than a half century of “safe” cardiopulmonary bypass (CPB), the evidence base surrounding the
conduct of anticoagulation 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
(STS), the Society of Cardiovascular Anesthesiologists (SCA),
and the American Society of Extracorporeal Technology
(AmSECT) developed an Evidence Based Workgroup. This was
a group of interdisciplinary professionals gathered together 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 for CPB using the available evidence. To
identify relevant evidence a systematic review was outlined and
literature searches were conducted in PubMed® using standardized 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 prior to 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 AHA/ACCF Task Force on Practice
Guidelines. Recommendations were written in the three fol-
lowing areas 1) Heparin dosing and monitoring for initiation and
maintenance of CPB, 2) Heparin contraindications and heparin
alternatives, 3) Reversal of anticoagulation during cardiac op-
erations. It is hoped that this guideline will serve as a resource
and will stimulate investigators to conduct more research and
expand upon the evidence base on the topic of anticoagulation
for CPB.