Clinical Pathology Top Topics part 8:

Emergency/critical care testing

Coagulation testing and blood transfusion

We common use hand-held glucometers like this in

vet med

Labwork interpretation is diagnostic "detective work."

This nine-part series will increase your comfort level with evaluating lab results.

The eClinPath website is an excellent visual resource.

Coagulation testing
Primary hemostasis:
Formation of platelet plug 
Platelet count and volume (for platelet parameters see top topics Clin Path Top Topics part 2:
CBC) 
Platelet function 
Test using buccal mucosal bleeding time (BMBT)
Only perform if platelet count is normal; low platelet count prolongs BMBT
Normal BMBT is less than four mins
Proteins: e.g., Von Willebrand factor assay, integrins
Clinical presentation of platelet abnormalities: 
Mucosal bleeding: e.g., epistaxis, scleral hemorrhage, GI bleeding, gingival bleeding,
petechiation, and ecchymosis
Clinical correlates: Canine immune-mediated thrombocytopenia (common), von Willebrand
disease (most common inherited bleeding disorder in dogs, also reported in cats, cattle,
pigs, and horses)

Secondary hemostasis:
Formation of fibrin clot via coagulation factors
Extrinsic, intrinsic, and common pathways
Both extrinsic and intrinsic pathways lead to common
pathway
Extrinsic pathway:
 Unique features: Factor VII, tissue factor
Testing: Prothrombin time (PT)
Intrinsic pathway:
Unique features: Factors XI, IX, XII, VIII
Testing: Activated partial thromboplastin time (aPTT)
Common pathway:
Factors II (a.k.a. prothrombin), X, XIII, V, fibrinogen
Testing: aPTT and PT
Remember the vitamin K-dependent factors (affected by
anticoagulant rodenticides, coumarin-based anticoagulants):
Factors II, VII, IX,X
The coagulation cascade (click to
Testing:
enlarge)
Typically run PT and aPTT together for most complete
picture
Perform on citrated plasma (blue top tube in North
America)
In-hospital analyzer (most common in small animal) or
send-out test (more common in large animal)
Always assess abnormal values in light of clinical
picture
Traumatic blood draw or improper sample
handling (e.g., underfilled tube) can result in
spurious results
Activated coagulation time (ACT)
Assesses all pathways, but is less sensitive and more
subjective
No longer commonly used
Requires a specific blood tube
Can measure individual factors if suspect congenital factor
deficiency 

Clinical presentation: “Cavity bleeding” - e.g., hemoabdomen,

hemothorax
Clinical correlates: Anticoagulant rodenticide
toxicosis, congenital factor VIII deficiency (a.k.a. hemophilia
A), hepatic failure
Anticoagulant rodenticide toxicosis: PT prolonged before
aPTT because factor VII has the shortest half-life of the Anticoagulant rodenticides first
vitamin-K dependent factors, so is depleted first cause a prolonged PT due to the
Fibrinolysis short half-life of factor VII
Clot breakdown
Proteins: e.g., tissue plasminogen activator (tPA),
plasminogen
Testing: Fibrin-degradation products, D-dimers
Newer test modalities (e.g., thromboelastography) provide
global assessment of blood clotting abnormalities
Clinical correlates: Pathologic thrombosis occurs due to
loss of anticoagulant factors or an excess or procoagulant
factors
 Protein-losing nephropathy in dogs, early stages
of disseminated intravascular
coagulation, colic, laminitis in horses

Transfusion medicine
Blood typing:
Specific antigens (Ag) on red blood cell (RBC) surface determine
blood type
Ag and typing are species-specific
Incompatible blood transfusion can result in a severe, sometimes
fatal (i.e., in cats), transfusion reaction
There are two types of antibodies (Ab) to RBC Ag:
Naturally occuring: Present in blood without prior Blood transfusions may be indicated
transfusion exposure after trauma (e.g., hit by car), or a
Acquired following RBC Ag exposure: i.e., previous hemolytic crisis
transfusion of RBC or other blood product containing RBC
Ag
Some large animal vaccines also contain RBC Ag
which can cause Ab formation
Canine
Major blood groups: Dog erythrocyte antigen (DEA) 1 to 8
Blood typing assesses DEA 1.1 Ag:
DEA 1.1 positive (pos) or negative (neg)
DEA 1.1 neg are universal donors
DEA 1.1 neg suitable for DEA 1.1 neg and pos recipients 
Only give DEA 1.1 pos blood as first time transfusion
to DEA 1.1 pos recipient
Other blood groups exist, e.g., Dal, Kai  
Acute hemolytic transfusion reaction can occur in DEA 1.1 neg if
dog was sensitized by previous transfusion
Naturally-occuring Ab to RBC Ag do not exist
Cross-match not required prior to first transfusion, but must
be performed prior to all subsequent transfusions

Feline
AB system:
Most cats are blood group A
Blood group B less common, typically purebred cats - e.g.,
Devon and Cornish Rex; Exotic and British shorthairs
Blood group AB rare
Type A and B cats have naturally-occuring Ab to the other blood
group Ag (i.e., type B have anti-A antibodies)
Type AB cats do not have Ab and can receive type A or B
Some purebred cats like this Cornish
blood
rex are blood group B
Incompatible transfusion can result in fatal hemolytic
reaction
Never give type A blood to type B cat 
No universal donor
Neonatal isoerythrolysis (NI) can occur if A or AB kittens born to
B queen mated to A tom
 Always type donor and recipient
Cross-match prior to all, even first, transfusions due to other
RBC Ag (e.g. Mik) and naturally occurring Ab not detected by
blood typing

Equine
Seven recognized blood types: A, C, D, K, P, Q, U, and each type
has additional membrane proteins called factors (labeled a
through g)...leading to over 400,000 combinations of blood type!
Aa and Qa most important for NI and hemolytic transfusion
reactions
Significant breed variation
Less than 10% of horses have naturally occurring alloantibodies
so usually first transfusion w/o cross-matching is safe
 

Ruminants
Cattle: Eleven major blood groups
B group has multiple Ag making close matching of donor
and recipient difficult
Some vaccines contain RBC Ag and can cause Ab
Foals with neonatal isoerythrolysis
formation without blood transfusion
may require a blood transfusion in
NI does not occur naturally addition to supportive care
Sheep: Seven major blood groups
Goats: Five major blood groups

Cross-matching 
Perform [after typing in dogs, cats] to determine blood
transfusion compatibility
Two types of cross-match:
Major: Most important
Donor RBC + recipient serum Equine hospitals often perform
Determines if recipient has preformed Ab to donor major/minor cross matches on a
RBC Ag slide like this (see text for details)
Minor: Less important because donor serum is typically
very diluted
Donor serum + recipient RBC
Determines if donor has preformed Ab to recipient
RBC Ag
When to perform a cross-match:
Cats: Before first, and with every subsequent, transfusion
because they have naturally-occuring RBC Ab
All other species: After first, and with every subsequent,
transfusion because Ab are induced by exposure to foreign
RBC 
Cross-match procedure:
First wash RBC three times to remove substances that may
cause agglutination not associated with a recipient-donor
reaction (e.g., red-cell directed Ab in dogs with immune-
mediated hemolytic anemia (IMHA))
 Cross-matching can be difficult with autoagglutination
- i.e., in canine IMHA because Ab adhered to RBC
membrane cause spontaneous agglutination or in
horses that tend to form rouleaux
Assess for agglutination after mixing RBC with serum (see
image at right)
Microscopic (or macroscopic) agglutination and
macroscopic hemolysis, (particularly in horses)
indicate an incompatible transfusion
Mix together drops of blood and serum and
evaluate for agglutination 
See image to right for example: In this image the
left slide is compatible, while the right slide
agglutinated and is not compatible
Do not administer blood product if incompatible
Minor cross-match: 
Only perform in small patients receiving significant
plasma volume 
Donor Ab to recipient RBC are usually diluted enough
to not be of significant concern
Mare-foal, mare-stallion incompatibility test:
Cross-match to assess incompatibility to determine risk of
NI
Assesses Ab in mare serum to RBC Ag of foal or stallion

Images courtesy of: Uwe Gille (glucometer); Hardyplants (rodenticides); Joe D (coagulation cascade); RL

GNZLZ (injured dog); Korona Lacasse (Cornish rex cat); Nora Grenager (NICU foal); Alextrevelian 006 (cross-
match).