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, MD; Robert A. Baker, PhD, CCP; Victor A. Ferraris, MD, PhD; Philip E. Greilich, MD; David Fitzgerald, MPH, CCP; Philip Roman, MD, MPH; John W. Hammon, MD


Anesth Analg. 2018;126(2):413-424. 

In This Article

Search Methods

To identify relevant evidence, a systematic review was outlined and literature searches were conducted in PubMed using standardized medical subject heading (MeSH) terms from the National Library of Medicine list of search terms and were inclusive of the dates January 2000 to December 2015. The following terms comprised the standard baseline search terms for topics and were connected with the logical "OR" connector:

  • Extracorporeal circulation (MeSH number E04.292 includes extracorporeal membrane oxygenation, left heart bypass, hemofiltration, hemoperfusion, and cardiopulmonary bypass)

  • Cardiovascular surgical procedures (MeSH number E04.100 includes off-pump coronary artery bypass graft surgery, coronary artery bypass graft surgery, myocardial revascularization, all valve operations, and all other operations on the heart)

  • Pharmacologic actions of anticoagulant drugs (MeSH number D27.505 includes molecular mechanisms, physiologic effects, and therapeutic use of drugs)

  • Anticoagulation reversal (MeSH number D12.776 includes protamine sulfate and other protamines and nuclear proteins)

These broad search terms allowed specific topics to be added to the search with the logical "AND" connector and publication types and groups to be excluded (Supplemental Digital Content 1, Appendix, This search methodology provided a broad list of generated references specific for the search topic. The searches yielded 833 abstracts. Abstracts were reviewed by two independent reviewers for acceptance into the paper review stage. Abstracts with at least one acceptance were sent to full manuscript review. In all, 286 full papers were reviewed by at least two members of the writing group for inclusion eligibility in the guideline. To be included, a paper had to report data on both of the following: (1) anticoagulant used for cardiopulmonary bypass; and (2) the monitoring techniques used to measure that anticoagulation. After passing mandatory inclusion criteria, it was preferable that included papers have a prospective study design and also report on the frequency of anticoagulation monitoring, bleeding outcomes, and transfusion outcomes. Ninety-six manuscripts were included in the final review. In addition, 17 manuscripts published before 2000 that were referenced within a manuscript and considered to be sentinel papers were included to provide method, context, or additional supporting evidence for the recommendations.

Individual members of the writing group read the retrieved references for their assigned topics and formulated recommendations based on assessment of the relevant literature. Only English language articles contributed to the final recommendations. For almost all topics reviewed, only evidence relating to adult patients entered into the final recommendations, primarily because of limited availability of high-quality evidence relating to pediatric patients having cardiac procedures. Evidence tables were constructed to ensure that selected studies conformed to minimum requirements in terms of study design and reporting of outcomes. (A representative evidence table evaluating the anticoagulation studies is shown in Supplemental Digital Content 2, Table 1,; study appraisals of randomized controlled trials and meta-analyses are shown in Supplemental Digital Content 3, Table 2,; and the Newcastle-Ottawa appraisal for nonrandomized studies is depicted in Supplemental Digital Content 4, Table 3,