Cardiology Clinical Practice Guidelines: 2018 Midyear Review

John Anello; Brian Feinberg; John Heinegg; Yonah Korngold; Richard Lindsey; Cristina Wojdylo; Olivia Wong, DO


June 28, 2018

In This Article

Cardiopulmonary Bypass and Anticoagulation

Society of Thoracic Surgeons, Society of Cardiovascular Anesthesiologists, and American Society of ExtraCorporeal Technology

A functional whole blood test of anticoagulation, in the form of a clotting time, should be measured and demonstrate adequate anticoagulation before initiation of, and at regular intervals during, cardiopulmonary bypass (CPB).

Discontinuation of protamine and implementation of resuscitative measures, including reinstitution of CPB with adequate anticoagulation, may be lifesaving for patients at high risk for anaphylactic response to protamine who have pulmonary hypertension and circulatory collapse.

Heparin dosing calculations may differ so long as the result achieves the desired target level of anticoagulation.

It's reasonable to maintain an activated clotting time (ACT) above 480 seconds during CPB. However, ACT is a "gross and imperfect" test, and the testing platform affects the target value of ACT.

Heparin reversal should be carefully calculated with low doses of protamine, so long as heparin rebound is controlled for.

Bivalirudin is a reasonable option for patients in need of urgent surgery requiring CPB with a diagnosis of heparin-induced thrombocytopenia (HIT).

In patients with significant renal dysfunction who are seropositive for HIT and require urgent CPB-assisted surgery, use of plasmapheresis, argatroban, or heparin with antiplatelet agents, such as tirofiban and ilioprost, may be considered, understanding that there are increased risks of bleeding with these interventions.

For patients given bivalirudin who have excessive bleeding after CPB, a combination of modified ultrafiltration, hemodialysis, and the administration of recombinant factor VIIa with blood product replacement may be considered to improve hemostasis.



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