Abstract
Pharmacologic manipulation of hemostasis is a prerequisite for cardiac surgery with
cardiopulmonary bypass (CPB) to prevent clot formation in the extracorporeal circuit.
Children who require surgical correction of congenital heart defects are at increased
risk for prolonged and excessive bleeding after separation from CPB. Heparin remains
the anticoagulant of choice for surgery requiring CPB. Traditional regimens of empiric
heparin dosing and a fixed-dose ratio of protamine to heparin for reversal of anticoagulation
do not account for individual differences in the half-life of heparin, clearance of
heparin, and duration of CPB, particularly in children. In addition, the use of prolongation
of the activated clotting time (ACT) as a measure of adequate anticoagulation does
not account for alterations in ACT by factors unrelated to heparin activity, including
hemodilution and hypothermia, that are frequently present during CPB. This manuscript
reviews the pitfalls in the management of anticoagulation for children undergoing
surgery that requires CPB. Pertinent literature related to the use of aprotinin, a
serine protease inhibitor that has been shown to improve hemostasis during and after
CPB, is discussed. It is hoped that this article will provide a practical guideline
for the rational management of anticoagulation in children with congenital heart disease
undergoing CPB surgery.
Keywords:
Anticoagulation - heparin - protamine - cardiopulmonary bypass - age group - pediatric
