Tests of Hemostasis

Testsofcoagulation: Thrombintime TT ReagentsUsed Bovine/human thrombin Citratedplasma Tissuethromboplastin (TF) Ca++ Citratedplasma Phospholipid Surfaceactivator Ca++ Citratedplasma Measureseparatelyas detectorsforabove testscandetectsmall amountsoffibrin Factorsmeasured Fibrinogendeficiencyor thrombininhibition Normaltime 2025s 1112s INR=PTpatient PTnormal "therapeutic"INRforpts onoralanticoagulants= 23 Abnormalitiesindicated DIC Heparintherapy Renalandliverdz dysfibrinogenemias LiverDz Warfarintherapy DIC Hemophilia Christmasdz LiverDz Warfarintherapy DIC DIC Liverdisease hereditary hypofibrinogenemia NOTVitKdeficiency

PT

Prothrombin timePT

Deficiencyorinhibition of:VII,X,V,II,fibrinogen

aPTT

Activated partial thromboplastin timeaPTT

Deficiencyorinhibition of:XII,XI,IX,VIII,X,V,II andfibrinogen

30s

Fibrinogen concentration

Fibrinogen

normalfibrinogenconc= 200400mg/dL

Afterextendedclottingtimedo50:50test Mixnormalplasmawithpatientsplasma Ifincreasedtimenormalizesproblemwasdeficiency Ifincreasedtimeremains,problemisaninhibitorofcoagulation Whatlevelofdeficiencywillcauseabnormaltesttimesandwhatwillmakeyoubleed? <40%ofnormalclottingfactorlevelswillleadtoabnormalPTandPTT <30%ofnormallevelswithproduceexcessivebleeding Clottingsystemworksdifferently"invivo" Invivo,tissuefactorVIIaactivatesfactorIXtoXIa,andinthepresenceoffactor VIII,isabletoactivatefactorXtoXa. Inthetesttube,theintrinsicandextrinsicsystemsareindependentofone

2.

3.

NormalPTbutaPTT. DefectiveclottingfactorsmustincludefactorsXII,XI,IXorVIII FactorXIIdeficiencygreatlyprolongsaPTT,butnota/wbleeding FactorsVIIIdeficiencyhemophiliaA FactorIXdeficiencyhemophiliaB PTandaPTT Either1clottingfactordeficiencyin"commonpathway"ormultipleclotting factordeficienciesinbothpathways Inheriteddisordermostlikelythatasingleclottingfactordeficiencyisthe problem(e.g.,factorXorfactorVdeficiency) Usuallymultipleclottingfactordeficiencies CausesvitaminKdeficiency,liverdisease,orDIC.

another;i.e.,tissuefactorVIIaactivatesfactorXtoXadirectly

Coagulationtests:Bettertogether: 1. PTwithnormalaPTT DeficiencyoffactorVII. Caneitherbehereditaryoracquired,asinpatientswithearlyvitaminK deficiency FactorVIIhasaveryshorthalflifeof45hrs

DisseminatedIntravascularCoagulation(DIC)activationofthecoagulationsystem (thrombingeneration)invivowithinthevascularsystem. Factorsare"consumed"inreaction:fibrinogen,factorsVandfactorVIII Plateletsmayalsobeconsumedviathrombinmediatedplateletaggregation,or depositioninmicrocirculation Fibrindegradationproducts(Ddimer)aregeneratedbytheactionofplasminon fibrin. CanalsoprolongTTandinterferew/plateletfunction TypicalDICLabs: PT24seconds(normal1113seconds) aPTT65seconds(normal2535seconds) Thrombintime35seconds(normal2030seconds) Fibrinogenconcentration40mg/dL(normal200400mg/dL) Plateletcount50,000/cmm(normal200400,000/cmm Bleedingtime18minutes(normal<10minutes) Ddimer16g/mL(normal<0.25g/mL) TheLupusAnticoagulant=antiphospholipidantibodyinterferesw/bindingofclotting factorstophospholipidsurfaces. ScreeningteststhatdependonphospholipidareprolongedespaPTT (sometimesPT,butnotTT) Mixingstudieswillnotcorrectindicatinganinhibitor,becausethelupus anticoagulantalsoeffectsbindingofnrlclottingfactors Lupusanticoagulantsdonotcausebleeding (despiteaPTT)maybea/w thrombosis! ClottingFactorAssays MeaureclottingfactoractivityviaaPTTorPT Testsystemusessequentialknownfactordeficientplasmawhichisaddedtothe patientsplasma Thetestisthensensitiveonlytosinglefactordepletion. ScreeningTestsofHemostaticPlugFormation Plateletcountmeasuresthenumberofplatelets Ivybleedingtime/PFA100measureplateletfunction PFA100 =invitroplateletfunctiontestlargelyreplacedbleedingtimeinmany places o Citratedwholebloodisforcedacrossacollagenimpregnatedgridathigh shearinthepresenceofeitherepinephrineorADP. o Maydetectplateletfunctiondefects,butunclearifaccuratelypredicts futurebleeding Componentsofplateletfunctionmeasured: o PlateletadhesiontocollagenvonWFandglycoproteinIb(orGPI) o Releasereaction(ADP,TXA2) o Plateletaggregation(fibrinogen,GPIIb/IIIa).

ScreeningTestsofFibrinolysis=euglobulinclotlysistimemeasuresfreefibrinolytic enzymesintheplasma(TPA,plasmin) Notroutinelyorderedexceptinsituationswheresystemicfibrinolysisissuspected: e.g.,thrombolytictherapy,liverdisease,amyloidosis. NormalEGCLTis>60minutes,abnormal=<60minutes.