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Objective
PRINCIPLES
The PT measures the activity of the so-called extrinsic and common pathways of coagulation Therefore dependent on the functional activity of factors VII, X, V, II (Prothrombin) and fibrinogen.
REFERENCE RANGES
Each laboratory should establish its own normal range BUT in general, the prothrombin time lies between 13-15 seconds.
INTERPRETATION
The PT is usually performed as part of a series of tests which will include the APTT and sometimes the measurement of fibrinogen levels and possibly a thrombin time is based on: 1) Isolated prolonged PT
Factor VII deficiency
Vitamin K deficiency Vitamin K antagonists; Eg Warfarin,Phenindione, Rodenticides Liver disease Malabsorption (Leading to Vit.K deficiency) High concentrations of unfractionated heparin Afibrinogenaemia and dysfibrinogenaemia Dilutional coagulopathy Eg Massive blood transfusion Multiple clotting factor deficiencies; Eg FV and FVIII deficiency
3) Shortened PT
Following the use of rVIIa (NovoSeven) The PT is often shortened
COMMENTS
The prothrombin time forms the basis for the assaying Factors VII, V, X, II and I. However the PT can be relatively insensitive to minor reductions in some clotting factors. Normal PT does not exclude a significant underlying coagulopathy
Eg: The PT is normal in severe haemophilia A, B and Factor XI deficiency
What Next??
In case in which there is an isolated prolongation of the PT and the remainder of the screening tests (APTT, TT and Fibrinogen) ARE NORMAL The next most logical test is a Factor VII assay Factor VII deficiency is rare Its more common to find a prolonged PT in combination with other abnormalities of the screen; Eg Prolonged APTT In these case consult the possible differential diagnose The history including a drugs history and the examination are VITALLY important. REMEMBER Warfarin & oral Vit.K antagonists
Will significantly prolonged the PT, but may prolong the APTT by only a few seconds (except in overdose)
APTT - Introducton
The APTT in contrast to the PT measures the activity of the intrinsic and common pathways of coagulation. The division of the clotting cascade into the intrinsic, extrinsic and common pathways has little in vivo validity but remains a useful concept for interpreting the results of laboratory investigations.
REFERENCE RANGES
The clotting time for the APTT lies between 27 35 seconds. However, this varies widely between laboratories and is dependent upon a number of variables including whether
Automated or manual Type of surface activator Incubation time
COMMENTS
The APTT is frequently used to monitor patients receiving unfractionated heparin (UFH).
PRINCIPLES
The APTT forms the basis for a number of factor assays including:
Factors VIII, IX, XI and XII. Factors II, V and X
The APTT is used to screen for the presence of a number of clotting factors inhibitors including FVIII and FIX.
INTERPRETATION
1) ISOLATED PROLONGED APTT
Deficiencies of Factor XII, XI, IX, VIII, V, II and Fibrinogen. Contact factor deficiencies
Pre-kallikrein
DIC due to consumption of clotting factor. Massive blood transfusion Patient receive Thrombolytic Therapy
Due to reduction of fibrinogen
3) Short APTT
An acute phase response leading to high FVIII levels
MIXING STUDIES
Involve repeat performance of abnormal tests as a mixed plasma Normal plasma + Test plasma Many possible mix volumes Usual 1:1
EXCLUSIVE
VII XII, XI, IX and VIII
COMMON
I, II, V and X I, II, V and X
TT
EXERCISE 1
NORMAL PLASMA PT: NRR (10-18) APTT: (NRR:24-36) TT: (NRR:1218) TEST PLASMA MIX (1:1) PLASMA NR 37 Interpretation
12 30
13 38
15
14
NR
ANSWER 1
NORMAL PLASMA PT: NRR (10-18) APTT: (NRR:24-36) TT: (NRR:12-18) TEST PLASMA MIX (1:1) PLASMA NR Interpretation
12
13
30
38
37
15
14
NR
**Weak inhibitor; Eg LA, FVIII (check hx), perform additional tests if hx indicated.
EXERCISE 2
NORMAL PLASMA PT: NRR (10-18) APTT: (NRR:24-36) TT: (NRR:12-18) TEST PLASMA MIX (1:1) PLASMA NR 31 NR Interpretation
12 30 15
13 38 14
ANSWER 2
NORMAL PLASMA PT: NRR (10-18) APTT: (NRR:24-36) TT: (NRR:1218) TEST PLASMA MIX (1:1) PLASMA NR 31 NR Correction Interpretation
12 30 15
13 38 14
EXERCISE 3
NORMAL PLASMA PT: NRR (10-18) APTT: (NRR:24-36) TT: (NRR:12-18) TEST PLASMA MIX (1:1) PLASMA NR 32 NR Interpretation
12 30 15
13 58 14
ANSWER 3
NORMAL PLASMA PT: NRR (10-18) APTT: (NRR:24-36) TT: (NRR:1218) TEST PLASMA MIX (1:1) PLASMA NR 32 NR Correction Interpretation
12 30 15
13 58 14
EXERCISE 4
NORMAL PLASMA PT: NRR (10-18) APTT: (NRR:24-36) TT: (NRR:1218) TEST PLASMA MIX (1:1) PLASMA NR 42 NR Interpretation
12 30 15
13 58 14
ANSWER 4
NORMAL PLASMA PT: NRR (10-18) APTT: (NRR:24-36) TT: (NRR:1218) TEST PLASMA MIX (1:1) PLASMA NR 42 Non correction (partial) Interpretation
12 30
13 58
15
14
NR
EXERCISE 5
NORMAL PLASMA PT: NRR (10-18) APTT: (NRR:24-36) TT: (NRR:1218) TEST PLASMA MIX (1:1) PLASMA >120 >120 >120 Interpretation
12 30 15
ANSWER 5
NORMAL PLASMA PT: NRR (10-18) TEST PLASMA MIX (1:1) PLASMA >120 Interpretation
Non correction (partial)
12
>120
APTT: (NRR:24-36)
TT: (NRR:12-18)
30 15
>120 >120
>120 >120
EXERCISE 6
NORMAL PLASMA PT: NRR (10-18) APTT: (NRR:24-36) TT: (NRR:12-18) TEST PLASMA MIX (1:1) PLASMA 15 Interpretation
12
60
30 15
35 16
NR NR
ANSWER 6
NORMAL PLASMA PT: NRR (10-18) APTT: (NRR:24-36) TT: (NRR:1218) TEST PLASMA MIX (1:1) PLASMA 15 Interpretation
12
60
Correction
30 15
35 16
NR NR
Thank You