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

Protocols for management of heparin and protamine administration in patient s 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 I reland. All centres performing paediatric cardiac surgery agreed to partici pate 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 purp ose. The answers were anonymized. At present, in the UK and Ireland, unfrac tionated 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 t he amount of heparin added to the prime and to the volume infused during ca rdiopulmonary bypass (CPB). Monitoring of anticoagulation is achieved by ac tivated coagulation time alone in all but one centre, with lower limits var ying between 400 and 750 s. Use of aprotinin is widely accepted, but clinic al indications are highly variable. No centre adopts heparin-bonded or hepa rin-coated circuitry for CPB. Calculation of initial and additional protami ne doses followed a variety of criteria, resulting in a very wide distribut ion of doses. The data obtained highlighted the lack of uniformity among pa ediatric cardiac surgical units of Great Britain and Ireland with regard to most of the issues related to the management of anticoagulation and its re versal. The striking heterogeneity of our cross-sectional observations clea rly underlines the need for prospective, multicentre studies on a national basis to relate different clinical practices to outcome measures.