Marilah kita membiasakan diri menjadi manusia yang jujur.

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Marilah kita membiasakan diri menjadi manusia
yang jujur.
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Laboratory Approach to Patient with Hemostasis
(Bleeding) Disorders
Dr.Nadjwa ZD, SpPK-K 16 April 2012
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Hemostasis

• Is the complex process by which the body
  spontaneously stop bleeding and maintains blood
  in the fluid state within the vascular
  compartment.
• Normal hemostasis rapid localized.

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• The major role of the hemostasis system is to
  maintain a complete balance of the bodys
  tendency toward clotting and bleeding.

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Hemostasis can be divided into 2 stages

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Primary Hemostasis (platelet plug)
Secondary Hemostasis (Hemostatic Plug)
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Highly integrated regulated
Hemostasis
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Hemostasis Disorders
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Approach to Hemostasis Disorders

• Clinical

History Taking -
Physical Examination -

• Laboratory

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Physical Examination

• Petechaie
• Ecchimosis
• Hematom
• Epistaxis
• Gingival bleeding

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Any Questions ???
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Hemostasis Test
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Hemostasis Tests

• Screening assays in hemostasis
• Patients without any signs/symptoms ?
  preoperative
• Monitoring of anticoagulant therapy
• Disseminated Intravascular Coagulation
• Thrombophilia
• Inhibitor (Lupus Anticoagulant, Anti Phospholipid
  Antibody)

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Hemostasis Screening Test

1. Tourniquet Test
2. Bleeding Time
3. Clotting Time
4. Clot Retraction
5. Platelet Count
6. PT
7. APTT
8. TT
9. Fibrinogen
10. Euglobulin Clot Lysis Test
11. D-Dimer

• Thrombelastography

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Single, comprehensive hemostasis screening test
Thrombelas- tography
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Tourniquete Test

• Capillary Resistance Test.
• Rumpel Leede Test
• Hesss Test

Principle This test measures the ability of the
capillaries to resist pressure. In healthy
individu, the capillaries in the arm will resist
a pressure of 100 mmHg. If the capillaries can
not resist, they will break or rupture, tiny spot
will then appear. These spots are hemorrhages or
petechiae.
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TOURNIQUET TEST
SYSTOLIC DIASTOLIC
100 mmHg
5 min
Leave for 5 min

• Normal lt 10 petechiae
• gt 10 petechiae ? abnormal, due to
• Increased capillary resistance
• Decreased platelet number

petechiae
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BLEEDING TIME (Dukes Method Ivys Method)

• Principle
• The skin is incised, blood flowing out is
  aspirated with a filter paper, and then the time
  until hemostasis is measured.
• Purpose
• To evaluate platelet and vascular ability in
  performing platelet plug.

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Interpretation

• Time in minutes equals number of blots divided by
  2

• When the blood spot becomes 1 mm or smaller, stop
  the stop watch.
• If the bleeding doesnt stop in 10 min.,
  discontinue testing. Indicate the result as 10
  min or longer.
• Cover the wound with a sterile gauze for a while,
  hemostasis should be confirmed, after which the
  patient may leave.
• The size of the blood spot about 1 cm in diameter
  is desirable, but becomes larger in some cases.
  However bleeding usually stops for several
  minutes regardless of the size.
• Dont wipe off the blood. Gently touch. Note so
  as not to touch the wound.

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CLOT RETRACTION

• Principle
• When whole blood is allowed to clot
  spontaneously, the initial coagulum is composed
  of all elements of the blood.
• With time the coagulum reduces in mass, and fluid
  serum is expressed from the clot, and its volume
  stated in .
• This is due to an action of platelets on the
  fibrin network.

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Clotting Time
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BEDSIDE CLOTTING TIME

• Principle
• Record the time interval from the blood contact
  with glass surface, until fibrin network is
  performed at the room temperature.
• Sample
• Capillary blood

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Clotting Time Lee White
blood 3 ml
1 cc 1 cc 1cc
37oC
N 5 11 min
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Coagulation Screening Tests Related to
the Coagulation Cascade
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Coagulometer
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Prothrombin Time (PT)

• Screening test for the extrinsic and common
  pathways of coagulation (factors II, VII, V, X).
• Limited sensitivity to fibrinogen.
• Normal range 11-13 sec

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INR (International Normalized Ratio)

• To overcome some of the difficulties with the
  variability of thromboplastin ? normalizing the
  responses of thromboplastin reagents against an
  international standard.
• INR -----------

PTpat
ISI
PTn
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ISI(International Sensitivity Index)

• Needs to be developed for each thromboplastin
  reagent and instrument combination used in
  performing PT and calculation of INR.
• Ideal reagent ? ISI lt 1.7

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Activated Partial Thromboplastin Time (aPTT)

• Screening test for the intrinsic and common
  pathways of coagulation (factors XII, XI, IX,
  VIII, X, V and II).
• Limited sensitivity to fibrinogen.
• Maybe normal in some cases of vWD
• Normal range lt 35 sec

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Thrombin Time (TT)

• Identified stage 3 defects in the coagulation
  mechanism
• Clinical significant ? Prolonged TT
• Decreased fibrinogen concentration
• Presence of dysfunctional fibrinogen
• Presence of heparin
• Presence of FDP

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• Prothrombin Time
• Principle of the test
• Time required for the formation of a fibrin clot
  when plasma is added to a thromboplastin-calcium
  mixture.
• Measure extrinsic and common pathway
  (FI,II,V,VII,X)

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Prothrombin Time

• Purpose
• Evaluation of coagulation disorders
• Evaluation of liver function
• Monitoring anticoagulan therapy
• Result ? inform in
• Second
• Percent
• INR (International Normalized Ratio)

PT prolonged if coagulation factors in extrinsic
pathway decreased lt30
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APTT

• Activated Partial Thromboplastin Time
• (APTT)
• Principle of the test
• Time required for the formation of a fibrin clot
  without additional thromboplastin.
• Measured intrinsic and common pathway

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• D-Dimer Test
• Principle
• Is the time required for the formation of a
  fibrin clot if thrombin is added.
• Affected by
• Concentration and fibrinogen reaction
• Inhibitor (also FDP and heparin).

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D-dimer
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Thromboelastography

• Screening control therapy
• Easy to perform, no reagent needed, fast
• Record clot formation and converse to graph
• TEG ruler
• Conversion table

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1. TEG NORMAL PATTERN
m. a
20 mm
r k
r reaction time (start to amplitudo 1 mm)
k coagulation time (end of r to amplitudo
20 mm) m .a maximum amplitudo (mm) m . e
maximum elasticity 100 x a m .
e ------------- 100 - a
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2. THROMBOCYTOPENIA
r normal k normal/prolonged m.a. shortened
m. a
r k
3. HYPERFIBRINOLYSIS
r normal k normal m.a. previously normal,
but suddenly become shortened
m.a
r k
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4. HEMOPHILIA
r prolonged k prolonged m.a.
normal/shortened
m. a
r k
5. HYPERCOAGULATION
r shortened k shortened m.a prolonged
m.a
r k
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TEG pattern
Normal
Hemophilia
Thrombocytopenia
Hyperfibrinolysis
Hypercoagulation

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Thank you for your attention