Because there has been a lack of standardized guidelines on the use of anticoagulants during cardiac surgery, three medical organizations have published major new clinical practice guidelines. These guidelines cover the use of heparin and other anticoagulants.
The guidelines were developed by The Society of Thoracic Surgeons (STS), the Society of Cardiovascular Anesthesiologists (SCA), and the American Society of ExtraCorporeal Technology and were published simultaneously in The Annals of Thoracic Surgery, Anesthesia & Analgesia, and the Journal of ExtraCorporeal Technology,
The new evidence-based recommendations include optimal heparin dosing for initiation and maintenance of cardiopulmonary bypass (CPB), identification of contraindications to the use of heparin, options for alternatives to heparin, and ideal methods for reversal of anticoagulation after CPB.
Heparin and protamine sulfate, which is used to reverse the effects of heparin, have been cardiac surgery staples for more than 50 years and remain the gold standard, but “they are not perfect,” says Linda Shore-Lesserson, MD, lead author and anesthesiologist at North Shore University Hospital in Manhasset, NY, says in a statement from STS.
As a result, “a call to action is now in place for investigators to conduct important prospective scientific trials and meta-analyses so that new knowledge is generated,” the professional statement says.
Practice in this area has been highly variable and without standardization regarding medication doses and the optimal degree of anticoagulation used during CPB, according to Shore-Lesserson and STS. “Until now, there has been no standardization of this important practice or the use of these anticoagulant drugs,” Shore-Lesserson says. “These recommendations will help fill the evidence gap and establish best practices in anticoagulation therapy for cardiopulmonary bypass.”
The recommendations were developed after a systematic review and extensive literature searches by a workgroup, and are based on around 100 highly cited articles. “This study examined the relevant existing literature on anticoagulation and its reversal and synthesized cogent recommendations for the clinicians,” Shore-Lesserson says.
However, even with these new guidelines, “more and better evidence” must be generated to answer many questions that clinicians still have, especially in the area of alternative drugs to heparin, the STS says. “We hope that this guideline will stimulate investigators to conduct more research and to expand on the evidence base regarding anticoagulation therapy for cardiopulmonary bypass,” Shore-Lesserson says.