Management of anticoagulation and its reversal during paediatric cardiopulmonary bypass: a review of current UK practice

Abstract

Protocols for management of heparin and protamine administration in patients undergoing open-heart surgery have been developed from experience gained mainly in adult practice. However, it has been demonstrated that there are marked differences between paediatric and adult patients in their response to systemic anticoagulation and its reversal. The aim of this study was to obtain an overview of current practice of management of anticoagulation and its reversal from paediatric cardiac surgical units of Great Britain and Ireland. All centres performing paediatric cardiac surgery agreed to participate in the survey (n = 16). Telephone interviews were carried out with the chief or a senior perfusionist from all participating institutions, which were based on a structured questionnaire compiled specifically for the purpose. The answers were anonymized. At present, in the UK and Ireland, unfractionated heparin is the anticoagulant of choice in all units, with a slight prevalence of porcine mucosal (9/16, 56.5%) versus bovine lung preparation (7/16, 44.0%). The policy for administration of heparin to the patient is uniform, with a dose of 300 IU/kg. However, there is great variability in the amount of heparin added to the prime and to the volume infused during cardiopulmonary bypass (CPB). Monitoring of anticoagulation is achieved by activated coagulation time alone in all but one centre, with lower limits varying between 400 and 750 s. Use of aprotinin is widely accepted, but clinical indications are highly variable. No centre adopts heparin-bonded or heparin-coated circuitry for CPB. Calculation of initial and additional protamine doses followed a variety of criteria, resulting in a very wide distribution of doses. The data obtained highlighted the lack of uniformity among paediatric cardiac surgical units of Great Britain and Ireland with regard to most of the issues related to the management of anticoagulation and its reversal. The striking heterogeneity of our cross-sectional observations clearly underlines the need for prospective, multicentre studies on a national basis to relate different clinical practices to outcome measures.