Objectives: To establish the first national standards and guidelines for best practice in perfusion for patients undergoing cardiothoracic surgery in Saudi Arabia. Cardiopulmonary bypass (CPB) enables complex cardiac surgeries; however, it poses risks of potential complications.

Methods: We used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to develop these guidelines and assess the certainty of evidence through a collaborative process. A panel of 16 Cardiovascular perfusion experts across Saudi Arabia formulated 22 key clinical questions relevant to local practice. PubMed, Scopus, and Embase databases were searched for each question to identify relevant systematic reviews, randomized controlled
trials (RCTs), non-randomized trials, post hoc analyses, and pooled analyses published from 2010 to 2024. The guideline panel voted for every question using the GRADEpro system, requiring a minimum consensus of 70% for approval.

Results: A total of 16 conditional recommendations and 6 good practice statements were finally approved, categorized into 5 key domains. Ofthese, 4 addressed guidelines, protocols, and general practices; 2 focused on surgical techniques; 8 covered heart-lung machine hardware; 3 centered on cardioplegia and Priming Solutions; and 5 emphasized monitoring and perioperative management. Six statements were based on expert opinion due to insufficient supporting evidence.
Using a standardized pre-bypass checklist to enhance safety and implementing perioperative glycemic management to control glucose levels and reduce complications were strongly recommended by the panel. Conditional recommendations focus on pumpselection, biocompatible oxygenators, and continuous cerebral oxygenation monitoring. Anticoagulation, myocardial protection, and transfusion management were also highlighted.

Conclusion: These Saudi guidelines provide evidence-based recommendations to enhance the care of patients undergoing cardiac surgery with CPB, offering clear guidance for clinicians to achieve optimal outcomes. Nevertheless, future locally relevant research and regular updates are essential to bridge existing evidence gaps.