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Clinical practice guidelines released for anticoagulant use in surgery
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New guideline recommendations regarding the use of anticoagulants during heart surgery have been released by The Society of Thoracic Surgeons, the Society of Cardiovascular Anesthesiologists and the American Society of ExtraCorporeal Technology.
The guidelines were published simultaneously in the Annals of Thoracic Surgery, Anesthesia & Analgesia and the Journal of ExtraCorporeal Technology,
“Despite more than a half century of ‘safe’ cardiopulmonary bypass, the evidence base surrounding the conduct of anticoagulation therapy for [cardiopulmonary bypass] has not been organized into a succinct guideline.” Linda Shore-Lesserson, MD, of North Shore University Hospital in Manhasset, New York, and colleagues wrote in the guidelines. “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.”
The members of the writing group developed the guideline recommendations based on review of literature from PubMed using standardized medical subject heading terms from the National Library of Medicine list of search terms.
Heparin dosing
The authors made several recommendations on the optimal doses of heparin for initiation and maintenance of cardiopulmonary bypass.
The one Class I recommendation in this area is that a functioning whole blood test of anticoagulation should be measured and should demonstrate sufficient anticoagulation before initiating and at regular intervals during cardiopulmonary bypass.
Heparin contraindications, alternatives
The guidelines state that clinical scoring estimates that use a 50% or greater drop in platelet count or a thrombotic event between 5 and 14 days post-heparin exposure can be used to determine whether a heparin–platelet antibody test is necessary to diagnose heparin-induced thrombocytopenia.
According to the guidelines, the ideal anticoagulation strategy for cardiac surgery with cardiopulmonary bypass in patients who cannot take heparin does not exist, but there are acceptable alternatives.
In patients who are seropositive for heparin-platelet antibodies or have a recent history of heparin-induced thrombocytopenia, the researchers suggest that it is reasonable to delay elective cardiac operations requiring cardiopulmonary bypass until a patient’s functional test or antigenic (antibody) assay are negative, with the expectation that heparin anticoagulation therapy for cardiopulmonary bypass is likely to be safe and effective.
Use of bivalirudin is reasonable in patients with heparin-induced thrombocytopenia who need an urgent operation requiring cardiopulmonary bypass, according to the authors.
Anticoagulation after cardiopulmonary bypass
According to the authors, there is no well-defined reversal agent for bivalirudin, and patients with coagulopathy and excessive bleeding require unusual interventions for hemorrhage control, but it can be beneficial to calculate the protamine reversal dose based on a titration to existing heparin in the blood, as this technique has been associated with reduced bleeding and blood transfusion.
“It is our hope that these guidelines will help clinicians practice consistent and safe anticoagulation and that there will be more standardization in practice,” Shore-Lesserson said in a press release. “Surgeons, anesthesiologists, and perfusionists will better appreciate the science behind the practices that they conduct every day.”– by Dave Quaile
Disclosure: Cardiology Today was unable to obtain relevant financial disclosures.
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