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      Anticoagulation Management and Heparin Resistance During Cardiopulmonary Bypass: A Survey of Society of Cardiovascular Anesthesiologists Members

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      Author(s): , MD, MSc * , , , MD † , , MD ‡
      Publication date (Electronic):
      Journal: Anesthesia and Analgesia
      Publisher: Lippincott Williams & Wilkins

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          Abstract

          We surveyed Society of Cardiovascular Anesthesiologists members regarding anticoagulation practices for cardiopulmonary bypass and attitudes on heparin resistance. Of 550 respondents (18.5% response rate), 74.9% (95% CI, 71.3%–78.5%) used empiric weight-based dosing of heparin, and 70.7% (95% CI, 66.9%–74.5%) targeted an activated clotting time of either 400 or 480 seconds to initiate cardiopulmonary bypass. Of note, 17.1% (95% CI, 13.9%–20.2%) of respondents reported activated clotting time targets lower than those recommended by recent 2018 Society of Thoracic Surgeons/Society of Cardiovascular Anesthesiologists/American Society of Extracorporeal Technology guidelines or failed to monitor heparin effects at all. When heparin resistance was encountered, 54.2% of respondents (95% CI, 50.0%–58.4%) administered antithrombin concentrates as a first-line therapy.

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          2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines.

          Victor A. Ferraris, Jeremiah R Brown, George Despotis … (2011)
          Practice guidelines reflect published literature. Because of the ever changing literature base, it is necessary to update and revise guideline recommendations from time to time. The Society of Thoracic Surgeons recommends review and possible update of previously published guidelines at least every three years. This summary is an update of the blood conservation guideline published in 2007. The search methods used in the current version differ compared to the previously published guideline. Literature searches were conducted using standardized MeSH terms from the National Library of Medicine PUBMED database list of search terms. The following terms comprised the standard baseline search terms for all topics and were connected with the logical 'OR' connector--Extracorporeal circulation (MeSH number E04.292), cardiovascular surgical procedures (MeSH number E04.100), and vascular diseases (MeSH number C14.907). Use of these broad search terms allowed specific topics to be added to the search with the logical 'AND' connector. In this 2011 guideline update, areas of major revision include: 1) management of dual anti-platelet therapy before operation, 2) use of drugs that augment red blood cell volume or limit blood loss, 3) use of blood derivatives including fresh frozen plasma, Factor XIII, leukoreduced red blood cells, platelet plasmapheresis, recombinant Factor VII, antithrombin III, and Factor IX concentrates, 4) changes in management of blood salvage, 5) use of minimally invasive procedures to limit perioperative bleeding and blood transfusion, 6) recommendations for blood conservation related to extracorporeal membrane oxygenation and cardiopulmonary perfusion, 7) use of topical hemostatic agents, and 8) new insights into the value of team interventions in blood management. Much has changed since the previously published 2007 STS blood management guidelines and this document contains new and revised recommendations. Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
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            Review article: heparin sensitivity and resistance: management during cardiopulmonary bypass.

            Alan Finley, Charles S. Greenberg (2013)
            Heparin resistance during cardiac surgery is defined as the inability of an adequate heparin dose to increase the activated clotting time (ACT) to the desired level. Failure to attain the target ACT raises concerns that the patient is not fully anticoagulated and initiating cardiopulmonary bypass may result in excessive activation of the hemostatic system. Although antithrombin deficiency has generally been thought to be the primary mechanism of heparin resistance, the reasons for heparin resistance are both complex and multifactorial. Furthermore, the ACT is not specific to heparin's anticoagulant effect and is affected by multiple variables that are commonly present during cardiac surgery. Due to these many variables, it remains unclear whether decreased heparin responsiveness as measured by the ACT represents inadequate anticoagulation. Nevertheless, many clinicians choose a target ACT to assess anticoagulation, and interventions aimed at achieving the target ACT are routinely performed in the setting of heparin resistance. Treatments for heparin resistance/alterations in heparin responsiveness include additional heparin or antithrombin supplementation. In this review, we discuss the variability of heparin potency, heparin responsiveness as measured by the ACT, and the current management of heparin resistance.
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              The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology: Clinical Practice Guidelines ∗ —Anticoagulation During Cardiopulmonary Bypass

              Linda Shore-Lesserson, Robert Baker, Victor A. Ferraris … (2018)
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                Author and article information

                Journal
                Journal ID (nlm-ta): Anesth Analg
                Journal ID (iso-abbrev): Anesth. Analg
                Journal ID (publisher-id): ANE
                Title: Anesthesia and Analgesia
                Publisher: Lippincott Williams & Wilkins
                ISSN (Print): 0003-2999
                ISSN (Electronic): 1526-7598
                Publication date (Print): August 2019
                Publication date (Electronic): 11 December 2018
                Volume: 129
                Issue: 2
                Pages: e41-e44
                Affiliations
                From the [* ]Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
                [† ]Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, New York
                [‡ ]Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.
                Author notes
                Address correspondence to Roman M. Sniecinski, MD, MSc, Department of Anesthesiology, Emory University Hospital, 1364 Clifton Rd, NE, Atlanta, GA 30322. Address e-mail to rsnieci@ 123456emory.edu .
                Article
                Accession ID: 00009
                DOI: 10.1213/ANE.0000000000003981
                PMC ID: 6629168
                PubMed ID: 30540616
                SO-VID: dfa4049f-1952-42e6-9286-7c8adc8a9ba6
                Copyright © Copyright © 2018 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Anesthesia Research Society.
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

                History
                Date accepted : 13 November 2018
                Categories
                Subject: Cardiovascular and Thoracic Anesthesiology
                Series title: Brief Report
                Custom metadata
                OPEN-ACCESS TRUE
                SDC T
                STATUS ONLINE-ONLY

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