Cardiopulmonary bypass and the coagulation system

Cardiopulmonary bypass exerts intended and unintended effects on the enzymatic and formed elements of the coagulation and inflammatory systems. Compared with adults, children are at special risk for known, and unknown, differences in their hemostatic systems. Management of these risks will be presented from a surgical perspective, supporting those strategies with a combination of peer-reviewed data and empiric experience. Preoperatively, strategies discussed are management of preoperative anticoagulants, autologous and directed donation, erythropoietin, and special considerations in the care of pediatric Jehovah's Witnesses. Intraoperatively, strategies discussed include basic management of cardiopulmonary bypass, heparin and heparin monitoring, protamine, alternative anticoagulant strategies for heparin sensitivity, and intraoperative pharmacologic adjuncts promoting postoperative hemostasis. Postoperative strategies discussed include blood product utilization, recombinant factor VII, the use of thromboelastography to guide therapy, topical strategies, cell saver therapy, and surgical reexploration.