➢ BLEEDING TIME METHODS

BLEEDING TIME & ✓ IVY’S METHOD

CLOTTING TIME
❖ TEST FOR HEMOSTASIS & COAGULATION
➢ TESTS FOR VASCULAR COMPONENT
• Capillary fragility test
• Bleeding Time (BT)
➢ TESTS FOR PLATELET COMPONENT
• Platelet count
• Platelet adhesion test
• Platelet aggregation test
• Clot retraction test
➢ TESTS FOR COAGULATION FACTORS
• Clotting Time (CT)
• Prothrombin Time (PT)
• Activated Partial Thromboplastin Time (APTT)
• Thrombin Time (TT)
• Factor XIII screening
• Specific tests- factor assays, mixing studies
➢ TESTS FOR FIBRINOLYSIS
• Whole blood clot lysis test
• Euglobulin lysis test
• FDP and D-Dime
❖ BLEEDING TIME
• First functional platelet evaluation test.
• Introduced by duke in 1900.
• Used to detect defects in primary hemostasis.
• Used as a screening test for vascular disorders as
well as platelet disorders.
- Bleeding time is defined as the time taken for a
standard skin wound to stop bleeding, upon
vessel injury, platelets adhere and form a
hemostatic platelet plug.
- Bleeding time measures the ability of the
platelets to arrest bleeding and therefore
measures platelet number and function.
➢ Bleeding Time Principle
• A standardized incision is made on the volar
surface of the forearm.
• The time when incision bleeds is recorded.
• Cessation of bleeding indicate the formation of
hemostatic plug.
• Depends on the adequate number of platelets
and on the ability of the platelets to adhere to
the sub-endothelium.
o BP CUFF
o DISPOSABLE LANCET
o STOPWATCH
o FILTER PAPER
o ALCOHOL
o COTTON
✓ IVY’S METHOD PROCEDURE
• Clean the inner aspect of the forearm.
• Place a BP cuff on the upper arm, inflate to 40
mm of mercury.
• Select an area on the volar surface which is
devoid of veins.
• Should be performed at room temperature.
• A disposable lancet with a point of about 3mm
/No. 11 bard parker surgical blade is used.
• Two skin punctures 3mm deep is made.
• Stopwatch is started as soon as the bleeding
starts in each wound.
• Using the edge of a filter paper (Whatman No:1),
blot the blood accumulated over the wound
without touching the wound.
• The time from which incision was made to the
time at which the bleeding stops to stain the
filter paper is taken.
• The average of the 2-bleeding time is taken.
• The BP cuff is removed.
• The puncture wounds are cleaned.
• Sterile bandage is applied.
• Longer bleeding time-puncture of superficial
veins.
• If bleeding continues more than 15 min-apply
pressure
• Repeat the bleeding time on another arm.
• Report-greater than 15 min.
• Reports correlated with platelet count.
• Reference range: 2-7 minutes
ADVANTAGE LIMITATION
Standardized Not very reliable test
method
More accurate The puncture wound may close
before the cessation of
bleeding
 ADVANTAGE:
• The ear lobule
✓ STANDARD TEMPLATE METHOD contains
o More standardized method. abundant
o Uses a glass or plastic template. subcutaneous
o Allows the lancet to make a cut-11 mm long and tissue and is
1mm deep. vascular.
✓ PROCEDURE • Flow of the
blood is quite
good.
• Normal
bleeding time-
3-5 minute.
DISADVANTAGE:
✓ ADVANTAGES • Difficult to get
• Test is very sensitive and reproducible. a standardized
• Detects even minor alterations in platelet function wound.
❖ DUKE’S METHOD
• Easy to perform ❖ Variables affecting
• Requires minimal equipment Bleeding time
• Patients with thrombocytopenia (<100×109
➢ Requirements: /L) will have increased BT.
• Alcohol • Aspirin, penicillin, cephalothin prolongs BT.
• Cotton • Pediatric patients and neonates -smaller
• Sterile lancet incisions are required. pressure -20 mm of Hg.
• Stopwatch • Anemia prolongs the bleeding time
• Filter paper
➢ Procedure ❖ Clotting Time
• Clean the fingertip with • The time taken for whole blood, drawn from a
alcohol sponge. vein and immediately placed in a container to
• If the patient is infant- the clot.
site is their heel of foot. • It measures all stages of intrinsic coagulation.
• Make a deep puncture with • It is not a very sensitive method.
sterile lancet. • Avoid contamination with tissue fluid.
• Start the stopwatch.
• Using filter paper blot the ❖ Clotting time methods
drop of blood coming out • Modified Lee and White Method (Venipuncture
from incision. Method)
• When bleeding ceases stop the stopwatch. • Capillary Method
• Count the number of
➢ Lee & White method
drops on the filter
REQUIREMENTS:
paper.
• Cotton wool, surgical gauze soaked in alcohol, plastic
• Multiply by 30 sec. syringe
• Report the closest • Test tube-acid washed (10ml)
minute. • Water bath -37° c
• If the cut bleeds • Stopwatch
more than 10 SAMPLE COLLECTION:
minutes, discontinue • TWO SYRINGE TECHNIQUE - avoid interference of
the test. tissue fluid.
• Draw 1 ml of blood into first syringe.
• Without disturbing the position of the needle and
syringe is attached and 5ml of blood is drawn.
➢ Procedure ❖ CAPILLARY METHOD
• Draw 3 ml of venous blood with aseptic REQUIREMENTS:
precautions. • Disposable lancet
• Label 3 test tubes as No. 1, 2, 3 and keep in a • Capillary tubing10-15 cm length and 1.5 mm
water bath at 37ºC. diameter without anticoagulant
• Deliver 1 ml of blood into each of the above 3 • Alcohol swab
test tubes and start the stopwatch. • Cotton
• After 3 min, take out tube No 1, tilt it every 30 • Stopwatch
seconds till a clot develops. • PPEs
• Note the time when the tube can be inverted
➢ Capillary Method principle
completely.
• Puncture the skin, blood is taken to a plain
• Next examine the No 2 every 30 seconds, exactly
capillary tube and stopwatch started.
the same way as tube No 1, till the clot forms
• Formation of fibrin strings is noted by breaking
and note the time.
the capillary tube at regular intervals.
• Finally, invert the third test tube as above till the
• The time taken for the first appearance of the
blood clots. Stop the watch.
fibrin string is noted.
• Record the time from the moment blood is
delivered in to the test tube to the complete ➢ PROCEDURE
clotting in the third tube. • Warm up the finger for skin puncture.
• The clotting time of the third tube is reported as • Make an incision with a sterile disposable lancet
the clotting time to depth of 3mm.
✓ NORMAL VALUES: 4-11 MINUTES • As soon as blood is visible- start the stopwatch.
• Wipe off the first drop of blood.
• Allow 2nd drop of blood to flow to capillary tube
• After 2nd break off the capillary tubing, 1-2 cm
from the end.
• When a thin string of fibrin
can be seen in between
the broken end of the
capillary tube, stop the
watch and note the time.
• Report the time
✓ NORMAL VALUES: 2-4 MINS.
ADVANTAGE:
• Can be performed when venous blood cannot be
ADVANTAGE: obtained
• standard method DISADVANTAGE:
• Test can be run with control • This method is insensitive
DISADVANTAGE: • This method is unreliable
• Not a sensitive test • Capillary blood always contaminated with tissue
• Only a rough method fluid
• There can be contamination of syringe /tubes ❖ CLINICAL SIGNIFICANCE
Sources of error • Prolonged clotting time seen in deficiency states
- Faulty technique involving, Plasma thromboplastin component,
- Inappropriate volume of blood plasma thromboplastin activator.
- Faulty venipuncture • Also prolonged in pt with bone marrow
- Air bubble entering the syringe depression and thrombocytopenia.
- Diameter of the glass tube should be uniform • Deficiency of Factor V, VII, and X, fibrinogen,
- Always use clean glass wares and plastic syringe • Liver diseases
- Vigorous agitation should be avoided.