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Point-Of-Care Testing for Anticoagulation Monitoring In
Point-of-Care Testing for Anticoagulation PATIENT SAFETY Monitoring in Neuroendovascular Procedures H.M. Hussein SUMMARY: POC testing is defined as diagnostic testing at or near the site of patient care. Rapid A.L. Georgiadis measurement of the intensity of anticoagulation and, more recently, platelet inhibition allows dose titration of adjuvant medications such a heparin and antiplatelet agents during neuroendovascular A.I. Qureshi procedures. However, knowledge among practicing physicians regarding the pathophysiologic basis of these measurements and variations in knowledge about the differences among devices is often limited. This review discusses the role of anticoagulation in endovascular procedures and the currently available POC tests for anticoagulation monitoring. ABBREVIATIONS: ACT ϭ activated clotting time; Anti-Xa ϭ quantitative chromogenic heparin assay; aPTT ϭ activated partial thromboplastin time; AT ϭ antithrombin; CI ϭ confidence interval; GP IIb/IIIa ϭ glycoprotein IIb/IIIa; Hemonox-CT ϭ Hemonox clotting time; HIT ϭ heparin-induced thrombocytopenia; HMT ϭ Heparin Management Test; IV ϭ intravenous; LMWH ϭ low-molecular- weight heparin; MI ϭ myocardial infarction; OR ϭ odds ratio; PCI ϭ percutaneous coronary intervention; POC ϭ point of care; UFH ϭ unfractionated heparin hromboembolism ensues from activation of platelets and Brief Overview of Anticoagulant Medications Tthe coagulation cascade and is a major source of compli- Anticoagulants reduce the activity of proteases in the coagula- cations during endovascular procedures. Multiple studies tion cascade. On the basis of their mechanism of action (Fig 1), have demonstrated accelerated platelet activation during cor- anticoagulants can be divided into 4 major groups: vitamin K onary and cerebral angioplasty.1,2 The coagulation cascade antagonists (warfarin), heparins (UFH and LMWH), direct (Fig 1) consists of a sequential conversion of a series of proen- thrombin inhibitors, and direct factor Xa inhibitors. -
Syllabus: Page 23
The University of Texas at El Paso College of Health Sciences Clinical Laboratory Science Program CLSC 3364 Hematology II Course Outline Spring What do you see? What is in your Head? Video or audio recordings will not be permitted. Instructor M. Lorraine Torres, Ed. D, MT (ASCP) College of Health Sciences Room 423 Phone: 747-7282 E-Mail: [email protected] Office Hours TR 3:00 – 4:00 p.m., Friday 2 – 3 p.m. or by appointment Class Schedule Monday and Wednesday 11:00 – 12:30 A.M. HSCI 135 Course Description This course is a sequel to Hematology I. It will include but is not limited to the study of the white blood cells with emphasis on white cell formation and function and the etiology and treatment of white blood cell disorders. This course will also encompass an introduction to hemostasis and laboratory determination of hemostatic disorders. Prerequisite; CLSC 3356 & CLSC 3257. Topical Outline 1. Maturation series and biology of white blood cells 2. Disorders of neutrophils 3. Reactive lymphocytes and Infectious Mononucleosis 4. Acute and chronic leukemias 5. Myelodysplastic syndromes 6. Myeloproliferative disorders 7. Multiple Myeloma and related plasma cell disorders 8. Lymphomas 9. Lipid (lysosomal) storage diseased and histiosytosis 10. Hemostatic mechanisms, platelet biology 11. Coagulation pathways 12. Quantitative and qualitative vascular and platelet disorders (congenital and acquired) 13. Disorders of plasma clotting factors 14. Interaction of the fibrinolytic, coagulation and kinin systems 15. Laboratory methods REQUIRED TEXTBOOKS: same books used for Hematology I Keohane, E.M., Smith, L.J. and Walenga, J.M. 2016. Rodak’s Hematology: Clinical Principles and applications. -
The Role of the Laboratory in Treatment with New Oral Anticoagulants
Journal of Thrombosis and Haemostasis, 11 (Suppl. 1): 122–128 DOI: 10.1111/jth.12227 INVITED REVIEW The role of the laboratory in treatment with new oral anticoagulants T. BAGLIN Department of Haematology, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK To cite this article: Baglin T. The role of the laboratory in treatment with new oral anticoagulants. J Thromb Haemost 2013; 11 (Suppl. 1): 122–8. tion of thromboembolism in patients with atrial fibrilla- Summary. Orally active small molecules that selectively tion. For some patients, these drugs offer substantial and specifically inhibit coagulation serine proteases have benefits over oral vitamin K antagonists (VKAs). For the been developed for clinical use. Dabigatran etexilate, majority of patients, these drugs are prescribed at fixed rivaroxaban and apixaban are given at fixed doses and doses without the need for monitoring or dose adjustment. do not require monitoring. In most circumstances, these There are no food interactions and very limited drug inter- drugs have predictable bioavailability, pharmacokinetic actions. The rapid onset of anticoagulation and short half- effects, and pharmacodynamic effects. However, there life make the initiation and interruption of anticoagulant will be clinical circumstances when assessment of the therapy considerably easier than with VKAs. As with all anticoagulant effect of these drugs will be required. The anticoagulants produced so far, there is a correlation effect of these drugs on laboratory tests has been deter- between intensity of anticoagulation and bleeding. Conse- mined in vitro by spiking normal samples with a known quently, the need to consider the balance of benefit and risk concentration of active compound, or ex vivo by using in each individual patient is no less important than with plasma samples from volunteers and patients. -
Approach to Coagulopathy in the Icu Dic and Thrombotic Emergencies
APPROACH TO COAGULOPATHY IN THE ICU DIC AND THROMBOTIC EMERGENCIES NEIL KUMAR, MD UNIVERSITY OF ROCHESTER MEDICAL CENTER Disclosures u I have no financial disclosures u I am NOT A HEMATOLOGIST Outline u Review of hemostasis and coagulopathy u Discuss laboratory markers for coagulopathy u Discuss an approach to a few specific coagulopathies and thrombotic emergencies Outline u Review of hemostasis and coagulopathy u Discuss laboratory markers for coagulopathy u Discuss an approach to a few specific coagulopathies and thrombotic emergencies Coagulation u Coagulation is the process in which blood clots u Fibrinolysis is the process in which clot dissolves u Hemostasis is the stopping of bleeding or hemorrhage. u Ideally, hemostasis is a balance between coagulation and fibrinolysis Coagulation (classic pathways) Michael G. Crooks Simon P. Hart Eur Respir Rev 2015;24:392-399 Coagulation (another view) Gando, S. et al. (2016) Disseminated intravascular coagulation Nat. Rev. Dis. Primers doi:10.1038/nrdp.2016.37 Coagulation (yet another view) u Inflammation and coagulation intersect with platelets in the middle u An example of this is Disseminated Intravascular Coagulation. Gando, S. et al. (2016) Disseminated intravascular coagulation Nat. Rev. Dis. Primers doi:10.1038/nrdp.2016.37 Outline u Review of hemostasis and coagulopathy u Discuss laboratory markers for coagulopathy u Discuss an approach to a few specific coagulopathies and thrombotic emergencies PT / INR u Prothrombin Time u Test of Extrinsic Pathway u Take plasma (blood without cells) and re-add calcium u Calcium was removed with citrate in tube u Add tissue factor u See how long it takes to clot and normalize PT to get INR Coagulation (classic pathways) Michael G. -
Anticoagulation of Children Undergoing Cardiopulmonary Bypass Is Overestimated by Current Monitoring Techniques
PAPER Anticoagulation of Children Undergoing Cardiopulmonary Bypass Is Overestimated by Current Monitoring Techniques John T. Owings, MD; Marc E. Pollock, MD; Robert C. Gosselin, MT; Kevin Ireland, RN, CCP; Jonathan S. Jahr, MD; Edward C. Larkin, MD Hypothesis: Children who undergo cardiopulmonary reserve, fibrinogen; the natural antithrombotic, anti- bypass (CPB) are proportionally more hemodiluted than thrombin; and heparin concentration. adults who undergo CPB. Current methods of monitor- ing high-dose heparin sulfate anticoagulation are depen- Results: Ten children and 10 adults completed the study. dent on fibrinogen level. Because of the decreased fi- Children had lower fibrinogen levels than adults through- brinogen levels in children, current methods of monitoring out CPB (P,.05). All adults had both therapeutic ACT and heparin anticoagulation overestimate their level of anti- Heparin Management Test levels measured throughout coagulation. CPB. Although children had therapeutic ACT levels, their Heparin Management Test levels were subtherapeutic while Design: Prospective controlled trial. undergoing CPB. The children had significantly higher thrombin-antithrombin complexes and prothrombin Main Outcome Measure: Production of thrombin (ad- fragment F1.2 than adults, indicating ongoing thrombin equacy of anticoagulation). production (P,.01). The increases in thrombin- antithrombin complexes and prothrombin fragment F1.2 Methods: Children and adults undergoing cardiac sur- in children were inversely proportional to their weight. gery who received CPB were anticoagulated in the stan- dard fashion as directed by activated clotting time Conclusions: Children undergoing CPB with heparin (ACT) results. Each subject had blood sampled at base- dosing adjusted to optimize the ACT manifest inad- line; heparinization; start of the CPB; CPB at 30, 60, equate anticoagulation (ongoing thrombin formation). -
P R O G R a M Guide
2015 PROGRAM GUIDE APPROVED BY CLIA, COLA, JCAHO ACCEPTED BY THE COLLEGE OF AMERICAN PATHOLOGISTS 2015 Program Guide Cover - 14831PTS.indd 3 12/18/14 2:18 PM GENERAL TABLE OF CONTENTS 2015 Schedule…......................…………………………………………………………….…………….....................................................................................3 General Instructions……………………………………………………………………………….............................................................................................4-7 Online Reporting Instructions………………………………………………………………………………...............................................................................7-8 Reporting Form Instructions......................................................................................................................................................................9 Chemistry............................................................................................................................................................................................10-20 Specialty Programs…………………………………………………………………………..…………………………………………………………..………………………………19-20 Clinical Microscopy & Urinalysis.........................................................................................................................................................20-21 Coagulation.........................................................................................................................................................................................21-24 General Hematology Instructions............................................................................................................................................................24 -
Updates on Anticoagulation and Laboratory Tools for Therapy Monitoring of Heparin, Vitamin K Antagonists and Direct Oral Anticoagulants
biomedicines Review Updates on Anticoagulation and Laboratory Tools for Therapy Monitoring of Heparin, Vitamin K Antagonists and Direct Oral Anticoagulants Osamu Kumano 1,2,* , Kohei Akatsuchi 3 and Jean Amiral 1 1 Research Department, HYPHEN BioMed, 155 Rue d’Eragny, 95000 Neuville sur Oise, France; [email protected] 2 Protein Technology, Engineering 1, Sysmex Corporation, Kobe 651-2271, Japan 3 R&D Division, Sysmex R&D Center Americas, Inc., Mundelein, IL 60060, USA; [email protected] * Correspondence: [email protected]; Tel.: +81-78-991-2203 Abstract: Anticoagulant drugs have been used to prevent and treat thrombosis. However, they are associated with risk of hemorrhage. Therefore, prior to their clinical use, it is important to assess the risk of bleeding and thrombosis. In case of older anticoagulant drugs like heparin and warfarin, dose adjustment is required owing to narrow therapeutic ranges. The established monitoring methods for heparin and warfarin are activated partial thromboplastin time (APTT)/anti-Xa assay and pro- thrombin time – international normalized ratio (PT-INR), respectively. Since 2008, new generation anticoagulant drugs, called direct oral anticoagulants (DOACs), have been widely prescribed to prevent and treat several thromboembolic diseases. Although the use of DOACs without routine monitoring and frequent dose adjustment has been shown to be safe and effective, there may be clinical circumstances in specific patients when measurement of the anticoagulant effects of DOACs Citation: Kumano, O.; Akatsuchi, K.; is required. Recently, anticoagulation therapy has received attention when treating patients with Amiral, J. Updates on Anticoagulation coronavirus disease 2019 (COVID-19). In this review, we discuss the mechanisms of anticoagulant and Laboratory Tools for Therapy drugs—heparin, warfarin, and DOACs and describe the methods used for the measurement of Monitoring of Heparin, Vitamin K their effects. -
15-7022 Quick Guide 115X200 2015.Indd
H A E M O S T A S tPA FDP I S -1 D-Dimer PAI Plasminogen Plasmin Fibrin T M Fibrinogen IIa PC IIa T A APC PS II PS AP T V C A Activated Va Xa Platelet vWF X A T XI IXa VIIIa APC PS VIII XIa IX T A Activation pathways Inhibition pathways Coagulation PAI-1 AT All rights reserved - 04/2013 Ref. 27646 VIIa AT AGO - Fibrinolysis Xa TFPI T S APC PS Xa TFPI A TF © 2009 DIAGNOSTIC 4614 Diagnostica Stago S.A.S. RCS Nanterre B305 151 409 9, rue des Frères Chausson 92600 Asnières sur Seine (France) AT THE HEART OF HAEMOSTASIS Ph.: +33 (0)1 46 88 20 20 Quick Guide Fax: +33 (0)1 47 91 08 91 [email protected] At the Heart of Haemostasis www.stago.com To Haemostasis Screening assays in Haemostasis Anticoagulant therapy monitoring (1): Vitamin K antagonists Anticoagulant therapy monitoring (2): Heparin Assays for other anticoagulant therapy (3) Disseminated Intravascular Coagulation (DIC) Thrombophilia D-Dimer assay for the exclusion of venous thromboembolism (VTE) Lupus anticoagulants / Antiphospholipid antibodies For more information, visit our website at www.stago.com Screening assays in Haemostasis 1) Questionnaire l Personal and familial history l Treatments l Diseases l Clinical symptoms 2) Physical examination 3) Pre-operative Haemostasis screening assays l Prothrombin time (PT) n Screening test for the extrinsic and common pathways of coagulation (factors II, V, VII, X). Limited sensitivity to fibrinogen. n Usual normal ranges: 12 - 13 sec (may vary between reagents, please refer to manufacturer’s insert) l Activated Partial Thromboplastin Time (aPTT) n Screening test for the intrinsic and common coagulation pathways of coagulation (factors VIII, IX, XI, XII, V and II). -
Cathlab Hemochron Activated Clotting Time
Provincial Health Services Authority Hemochron Activated Clotting Time Low Range Procedure for CathLab Identifier: CWPC ACT 0180 Version #: 2 Folder: CW POCT Type: Procedure (3yr) Subfolder: ACT Effective on: 2021-05-13 HEMOCHRON Activated Clotting Time Low Range Procedure for CathLab This procedure provides instructions on how to perform Activated Clotting Time (ACT) on the Hemochron® Signature Elite in settings of low to moderate heparin doses. The Hemochron® Signature Elite is a point-of-care coagulation testing system. When used with the Hemochron® Jr Low Range Activated Clotting Time (ACT-LR) cuvette, it provides a quantitative assay for monitoring heparin anticoagulation during various medical procedures when heparin is used. It is intended for use in monitoring low to moderate heparin doses frequently associated with procedures such as cardiac catheterization and Extracorporeal Membrane Oxygenation (ECMO). ACT values from different assays or instruments are NOT interchangeable. Do NOT switch between different types of ACT tests or methods when monitoring a patient. Use only the ACT- LR when low to moderate heparin doses are being administered. This method exhibits considerable variability and anticoagulation status should be assessed in concert with other clinical and laboratory features. Samples: Sample Collection The Hemochron® Jr ACT-LR test is performed using fresh whole blood. Collect samples as per clinical protocol. The Hemochron® Jr ACT-LR Cuvette employs a Celite activator and is intended for monitoring heparin therapy. -
Chapter 4 HEMOSTASIS and BLOOD
Chapter 4 HEMOSTASIS AND BLOOD TRANSFUSION Tony Chang, MD, Elizabeth Donegan, MD The infusion of blood and blood products from one individual to another to stop or prevent bleeding, provide adequate oxygen delivery, and to prevent death from hemorrhage saves millions of lives. Nevertheless, the practice of Transfusion Medicine remains in its infancy. In the 20th century, blood transfusion became a relatively safe and common practice, despite the relative absence of transfusion guidelines based on randomized, prospective controlled trials. Most transfusion practices are based on convention and convenience. The understanding of hemostasis, safe transfusion practices, appropriate testing of blood and blood products, as well as the consequences of transfusion continues to unfold. An understanding of these principles is very important for anesthetists who transfuse about half of the blood transfused in hospitals. Without this knowledge, transfusion practices often result in poor outcomes. This chapter will discuss the current understanding of hemostasis, laboratory tests that assist in the decision of which components or products to transfuse and when to transfuse. Current pediatric transfusion practices, and the laboratory collection, preparation, and testing of blood and blood components are included. HEMOSTASIS Hemostasis is now understood to be a complex system of checks and balances designed to prevent abnormal clotting and uncontrolled bleeding. Coagulation is a cell-based event initiated on the surface of endothelial cells, in the subendothelium, and on platelets (Figure 4-1). 87 Chapter 4: HEMOSTASIS AND BLOOD TRANSFUSION Figure 4-1: Coagulation Overview of coagulation: Coagulation is activated when endothelium is disrupted and blood contacts tissue factor (TF). TF activates factor VII in turn activators factor X, which in combination with factor V, forms the prothombinase complex. -
Collaborative Study on Monitoring Methods to Determine Direct Thrombin Inhibitors Lepirudin and Argatroban
Collaborative Study On Monitoring Methods To Determine Direct Thrombin Inhibitors Lepirudin And Argatroban On behalf of the Control of Anticoagulation Subcommittee of the Scientific and Standardization Committee of the International Society of Thrombosis and Haemostasis E. Gray 1 and J Harenberg * SUMMARY Background: Direct thrombin inhibitors are now used clinically for the prophylaxis and treatment of thrombosis and related cardiovascular diseases. Although all these inhibitors bind to thrombin, their modes of action are different. Routine anticoagulant monitoring tests such as the APTT are used to estimate the activity of these inhibitors. However, no studies have been carried out to assess the suitability of these tests. Methods: An international collaborative study was carried out utilising a panel of plasmas spiked with lepirudin and argatroban to evaluate the robustness and the sensitivity of the different monitoring methods. Results: Thirteen laboratories took part in the trial. The point-of-care TAS-analyser, using cards with high or low concentrations of ecarin reagents gave the lowest intra- and inter- laboratory variation. APTT using local or common APTT reagents also showed acceptable within and between-laboratory variations. The chromogenic anti-IIa activity and the wet ecarin clotting time gave higher inter-laboratory variations. The ELISA for lepirudin had the highest inter-laboratory variation. Conclusion: APTT and the TAS-analyser with ECT-cards gave the most reproducible results compared to other methods. Further studies will evaluate the validity for patient samples. INTRODUCTION Direct and indirect serine protease inhibitors are used clinically for inhibition of blood coagulation (1). Direct inhibitors such as hirudin and fondaparinux inhibit individual serine proteases such as thrombin and factor Xa. -
Test Abbreviations
TEST ABBREVIATIONS A1A Alpha-1 Antitrypsin CONABO Confirmatory Type A1c Hemoglobin A1c CPK Creatine Phosphokinase AB Antibody Cr Creatinine ABG Arterial Blood Gas CRCL, CrCl Creatinine Clearance ABRH ABO Group and Rh Type CRD Cord Type and DAT ABT Antibody Titer CREAT Creatinine ACA Anti-Cardiolipin Antibodies CRP C-Reactive Protein ACE Angiotensin Converting Enzyme Cu Copper ACID PHOS Acid Phosphatase D Bil Direct Bilirubin ACP Acid Phosphatase DAT Direct Antiglobulin (Coombs) Test ACT Activated Clotting Time DCAS DAT and AB Screen ACTH Adrenocorticotropic Hormone DHEA Dehydroepiandrosterone ADA Adenosine Deaminase DHEAS Dehydroepiandrosterone-Sulfate AFB Acid-Fast Bacillus DIFM Differential AFLM Amniostat Dig Digoxin AFP Alpha Fetoprotein EOS Eosinophils AG Antigen EPO Erythropoietin ALA Aminolevulinic Acid ERA Estrogen Receptor Assay Alb Albumin ESR Erythrocyte Sedimentation Rate Alk Phos Alkaline Phosphatase ETOH Ethanol ALP Alkaline Phosphatase FBS Fasting Blood Sugar (Glucose) ANA Antinuclear Antibody Fe Total Iron Anti-HBc Hepatitis B Core Antibodies FEP Free Erythrocyte Protoporphyrin Anti-HBe Hepatitis Be Virus Antibody FFN Fetal Fibronectin Anti-HBs Hepatitis B Surface Antibody Fol Folate Anti-HCV Hepatitis C Antibody FSH/LH FSH/LH Evaluation APT APT – Stool for Fetal Hemoglobin FT3 Free T3 aPTT Activated Partial Thrombin Time FT4 Free Thyroxine ASN Antibody Screen G2PP 2 Hour Postprandial Glucose ASO Antistreptolysin-O G-6-PD Glucose-6-Phosphate AT III Antithrombin-III Activity Dehydrogenase B12 Vitamin B12 Gamma GT Gamma Glutamyl