COAGULATION TESTS:

Clotting Time, Bleeding Time, Prothrombin

Time, Activated Partial Thromboplastin
Time
 PURPOSE OF COAGULATION TESTS
• Unexplained bleeding
Hemostasis is the natural process that stops blood loss when an injury occurs.
• Preoperative testing
It involves three steps:
• Liver disease
(1) vascular spasm ( vasoconstriction )
• Vitamin K deficiency

• Thrombophilia (which is excessive clotting)

• Hemophilia (which is an inability to clot normally)

(2) platelet plug formation
• An injury that causes severe blood loss

• Bruising easily
(3) coagulation
• Persistent swelling

• Unexplained pain and stiffness

• Blood clot
TYPES OF COAGULATION TESTS
1. Complete Blood Count – The results of the test can provide information about anemia or a low platelet count, which can
interfere in person’s clotting ability.

2. Factor V Assay – An abnormally low level may be indicative of liver disease, primary fibrinolysis (a breakdown of clots),
or disseminated intravascular coagulation (DIC).

3. Fibrinogen Level – This test measures how much fibrinogen is in your blood. Abnormal results may be a sign of excessive
bleeding or hemorrhage, fibrinolysis, or placental abruption (a separation of the placenta from the uterine wall). Other names
for this test include factor I and hypofibrinogenemia test.

4. Platelet Count – An abnormally low platelet count is notable on conditions including chemotherapy, medications of certain
drugs, having had a massive blood transfusion. Other causes of a low platelet count are celiac disease, vitamin K deficiency,
and leukemia. Anemia, primary thrombocythemia, or chronic myelogenous leukemia (CML) may cause an abnormally high
number of platelets.

5. Thrombin time – The test may be used to help diagnose problems such as inherited conditions that lead to low fibrinogen or
fibrinogen disorders. Liver diseases such as cirrhosis, hepatitis, and liver cancer. Cancers such as kidney cancer (renal
carcinoma) or multiple myeloma.
TYPES OF COAGULATION TESTS
6. Prothrombin time (PT or PT-INR)
7. Activated Partial Thromboplastin Time
8. Bleeding time
9. Clotting Time
PROTHROMBIN TIME
A prothrombin time (PT) test measures the amount of time it takes for the blood plasma to clot.
It measures the time (seconds) necessary to generate fibrin after activation of factor VII (after reagent
substances are added) . It is associated in the integrity of the "extrinsic" and "common" pathways
(factors VII, V, X, prothrombin, and fibrinogen).
The PT and INR are used to monitor the effectiveness of the anticoagulant
warfarin.

Warfarin is prescribed for people with a variety of conditions to “thin” their

blood and prevent inappropriate clotting. Clinicians prescribe warfarin and
monitor the activity of the doses that effectively “thins” blood using the
PT/INR. The dose may be adjusted up or down depending on the result and to
ensure the dose is sufficient in preventing clots without causing excessive
bleeding. This balance requires careful monitoring.

Warfarin may be prescribed for conditions such as:

1. Irregular heartbeat (atrial fibrillation)

2. The presence of artificial heart valves
3. Deep vein thrombosis (DVT), pulmonary embolism (PE)
4. Antiphospholipid Syndrome
5. Occasionally, in heart attackes with certain risk factors

The PT is often performed along with a partial thromboplastin time and together they assess the
amount and function of proteins called coagulation factors that are an important part of proper blood
clot formation.
PROTHROMBIN TIME
TECHNIQUE
Citrated plasma is centrifuged at 2500-3000 RPM for 15 minutes to automate its performance. The sample is activated
with calcium-thromboplastin in the presence of a thrombin-specific chromogenic peptide substrate.
Sysmex CA-600 analyzer is used that can perform testing for full patient profile, up to 60 samples/hour.

Sysmex CA-600 Series

INTERPRETATION Detection principles Clotting: scattered light detection method

13 positions (with 4 cooled and 3 dedicated

Each laboratory has its own normal value, usually between 11.5 and 13.5 seconds, INR of 0.8 to 1.1. Reagent holder
to diluents, buffers or cleaning reagents)

Reference curves 1 reference curve per parameter 1 lot per

A prolonged PT may reflect either factor deficiency or a circulating inhibitor of coagulation. parameter Maximum 14 parameters

The test is more sensitive than the aPTT for deficient levels of factors, and a relatively small drop in factor VII levels
may prolong the PT.
Analytical excellence
The imprecision of manual coagulation testing is high, with coefficient of
variation (CV) of greater than 20%; and duplicate measurement is thus
recommended. With CA-600, fully automated coagulation analyzer, the
accuracy has greatly improved, attaining a CV of less than 5%, and as low as
1% for some tests.

CLINICAL SIGNIFICANCE
Inherited deficiency of factor VII is a rare bleeding disorder characterized by a prolonged PT and a normal aPTT.
Acquired deficiencies are usually related to liver disease, warfarin therapy, or depletion secondary to consumptive
coagulopathy, severe bleeding, or massive transfusion.
Workflow Efficiency
Simultaneous analysis of up to 5 parameters and optimal throughput allow
laboratories to perform routine and specialty testing in greater efficiency.
Excellent data management
Sample barcode reader simplifies sample ID processing and enables security
and integrity of patient records.
Handheld 2D barcode reader simplifies the data entry process for ISI, control
and calibrator values, lot numbers, and expiry information.
Data up to 600 samples or 3000 tests can be stored onboard for easy retrieval
for review.
ACTIVATED PARTIAL THROMBOPLASTIN TIME

The partial thromboplastin time (PTT; also known as activated partial thromboplastin time (aPTT)) is a
screening test that helps evaluate a person’s ability to appropriately form blood clots.
This measures the time necessary to generate fibrin from initiation of the intrinsic pathway.
Activation of factor XII is accomplished with an external agent (e.g., kaolin) capable of activating factor XII
without activating factor VII. Since platelet factors are necessary for the cascade to function normally, the test
is performed in the presence of a phospholipid emulsion that takes the place of these factors. The classic
partial thromboplastin time depends on contact with a glass tube for activation. Since this is considered a
difficult variable to control, the "activated" test uses an external source of activation.
ACTIVATED PARTIAL THROMBOPLASTIN TIME

TECHNIQUE
Citrated plasma is centrifuged at 2500-3000 RPM for 15 minutes to automate its performance. The sample is activated with calcium-thromboplastin in the presence of a
thrombin-specific chromogenic peptide substrate.
Sysmex CA-600 analyzer is used that can perform testing for full patient profile, up to 60 samples/hour.

INTERPRETATION
A normal range is around 21 to 35 seconds. Test results may vary depending on equipment and methods used, thus, it is expected that standard normal results may differ
in each lab.
This test is abnormal in the presence of reduced quantities of factors XII, IX, XI, VIII, X, V, prothrombin, and fibrinogen (all integral parts of the "intrinsic" and
"common" pathway. It is usually prolonged if a patient has less than approximately 30% normal activity. It can also be abnormal in the presence of a circulating inhibitor
to any of the intrinsic pathway factors.

CLINICAL SIGNIFICANCE
The aPTT is a good screening test for inherited or acquired factor deficiencies. Inherited disorders including classic hemophilia A (factor VIII deficiency) and hemophilia
B (factor IX deficiency, or Christmas disease) are well-known diseases in which the aPTT is prolonged. Other intrinsic and common pathway factors may also be
congenitally absent. These conditions are rare but have been described for all factors. A number of kindreds with abnormalities of factor XII activation have been
described. They are usually associated with a prolonged aPTT without clinical signs of bleeding. Acquired factor deficiency is common. Vitamin K deficiency, liver
dysfunction, and iatrogenic anticoagulation with warfarin are most common. Factor depletion may also occur in the setting of disseminated intravascular coagulation
(DIC), prolonged bleeding, and massive transfusion.
 BLEEDING TIME

The time from when the incision is made until all bleeding has stopped is called the bleeding time.
The Bleeding Time (BT) was introduced as a tool for predicting the risk of bleeding in relation to
surgery.
There are three methods that are commonly used in for bleeding time:

1. Duke’s Method - According to the Duke method, the ear lobe is incised with a lancet, and the
blood is blotted every 30 seconds until the bleeding ceases. Normal Bleeding Time 2-6
Minutes.

2. Ivy’s Method –In the Ivy method, a blood pressure cuff is placed on the upper arm and inflated
to 40 mmHg. A disposable lancet is used to make two separate cuts into the forearm usually 5-
10cm apart in quick succession. Using a stopwatch, filter paper is used to draw off the blood
every 30 seconds. The time from when the incision is made until all bleeding has stopped is
called the bleeding time. Normal Bleeding Time 3-8 Minutes.

Note: The filter paper should not touch the edge of the clot as this may disturb the formation of the
platelet plug. The test is finished when bleeding has stopped completely.
 BLEEDING TIME
3. Fingertip Method

TECHNIQUE
The test is performed using a disposable template that produces a uniform incision. The incision, either
horizontal or vertical, is placed on the tip of the finger. A standard-sized incision is made around 10 mm long
and 1 mm deep. Blood may be absorbed off the skin using a blotting paper, but care must be taken to avoid
pressure. The time is measured from the moment of incision to the moment bleeding stops. The filter paper
should not touch the edge of the clot as this may disturb the formation of the platelet plug. The test is finished
when bleeding has stopped completely.

INTERPRETATION
The time may vary based on the commercial template used, the direction of the incision, and the location.
Each institution has an established upper limits of normal.
The normal bleeding time is between 1-3 (2-7) minutes. The normal clotting time in a person is between 3-
7(8-15) minutes. By understanding the time taken for blood to clot, it can be determined if the person has
haemophilia or von Willibrand's disease.
 BLEEDING TIME
3. Fingertip Method

The vascular platelet phase of hemostasis consists of a primary vasoconstriction that serves to decrease blood flow, followed by adherence of platelets to
the ruptured endothelium (adhesion) and each other (aggregation). This platelet aggregate, called the platelet plug, stops the bleeding and forms a matrix
for the clot. The bleeding time is an excellent screening test for the vascular platelet phase of hemostasis. It depends on an intact vasospastic response in a
small vessel and an adequate number of functionally active platelets.

CLINICAL SIGNIFICANCE
Patients with abnormalities of the vascular platelet phase of hemostasis present with purpura (petechiae and ecchymoses) and spontaneous bruising. They
may have mucosal bleeding and fundus hemorrhages. Commonly, the problem is either thrombocytopenia, easily evaluated by a platelet count, or abnormal
platelet function, which can be diagnosed with platelet function studies. The most common acquired platelet function abnormalities are drug induced
(aspirin and the nonsteroidal anti-inflammatory agents) and uremia. The most common hereditary abnormality is von Willebrand's disease.
 CLOTTING TIME

Clotting time measures the time required to form a clot. This test is usually taken together with
bleeding time. CT-BT is performed to check the level of bleeding and the amount of time taken by
your blood to clot in order to stop bleeding.

Variety of methods can estimate clotting time:

1. Capillary method – Prick the finger with the lancet. Hold the capillary over the blood, and the
capillary will fill automatically. After regular intervals, break the capillary. When a clot starts
forming, that is the endpoint and clotting time. Normal range is 3-8 minutes.

2. Test tube method – For the tube method, take 4 ml of blood and start the time. Note the time
when there is the first appearance of the clot formation. This test can be done in multiple tubes
to be more accurate. This test is performed at 37 ° C. Normal range is 3-6 minutes.

3. Lee and white method – Venous blood is collected in 8mm diameter glass tube, rocked in a
waterbath at 37ºC and time is noted from the time of vein puncture until the blood stops
flowing. Normal range is 6-12 minutes.
..
The average time range for blood to clot is about 10 to 13 seconds. A number higher than that
range means it takes blood longer than usual to clot. A number lower than that range means blood
clots more quickly than normal. Normal range will depend on the established standards of every
institution.
 CLOTTING TIME

4. Slide Method

TECHNIQUE
Prick the finger with the lancet and blot it in a clean slide. The surface of the glass slide
initiates the clotting process. After regular intervals, check for the appearance of sticky string
formation using the tip of the lancet. The string is indicative of clot formation. Formation of
fibrin strings that is the endpoint and clotting time This measured.

INTERPRETATION
The expected range for clotting time is 3-5 minutes.

The whole blood clotting time is a rough measure of all intrinsic clotting factors in the
absence of tissue factors.

..
CLINICAL SIGNIFICANCE
It is useful in detecting Coagulation Disorder, Epistaxis, Platelet Disorder. Its chief application
is in monitoring anticoagulant therapy.
Blood Clots: Your Body's Built-In Bandage
 #rciconnects

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