Review of Point of Care Coagulation Monitoring Devices / Blood Test 2 Flashcards Preview

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Flashcards in Review of Point of Care Coagulation Monitoring Devices / Blood Test 2 Deck (44):
1

The patient’s activated whole blood clotting time is measured at baseline (without heparin) and in the presence of 1.5 and 2.5 units/ml of heparin. The difference in these clotting times is the in-vitro response of the patient’s blood to heparin (slope).

Results from the Heparin
Dose Response test include:
- Baseline ACT
- Projected heparin concentration (based on the patient’s blood volume, the dosing protocol, and extracorporeal circuit parameters).
- Amount of heparin required to reach the target ACT and Projected Heparin Concentration.

The slope of the ACT clotting times is used to determine the patient’s response to heparin, and help identify patients who are potentially sensitive or resistant to heparin.


Heparin Dose Response (HDR)

2

The Heparin Assay by Heparin-Protamine Titration determines the quantitative amount of heparin present in a blood sample by titration with protamine. Known quantities of protamine added to each cartridge channel react with the heparin present in the patient’s blood sample. The amount of heparin present is determined based on the titration relationship between heparin and protamine. The Hepcon® HMS PLUS uses this information to indicate additional heparin required to maintain the patient at the required heparin concentration. The instrument also calculates the amount of protamine sulfate required to neutralize the heparin.

Heparin Protamine Titration (HPT):

3

Heparin Assay Test

Test with 6 different colored wells loaded with different levels of protamine. Once the sample of heparinized blood has been added, the one that clots represents the one that had the perfect ratio between heparin and protamine.

4

Why should we even bother with a Heparin Assay Test if we can clearly see that the patient remains anti-coagulated ?

Although we might not see a physical clot formation, there may still be some level of SUB CLINICAL COAGULATION. Meaning that the clotting factors have activated their way down the clotting cascade, it just never made it to a complete clot formation.

5

How can we detect sub-clinical coagulation ?

Presence of C5a or Membrane Attack Complex (MAC)

6

What are 2 ways to monitor ACT ?

- Heparin Dose Response
Curve

- Weight Based Heparin
Delivery

7

In regards to the Sonoclot signature waveform, what do the following represent ?

1.) Flat Line
2.) First hump
3.) Drop in waveform

1.) ACT
2.) Clot Rate
3.) Fibrinolysis

8

What is the purpose of the Heparinase Test ?

To know if we have any Heparin left on board.

9

What does TEG-R indicate ?
What are the normal levels ?
Lab value of > 10 min can be treated with what?

Clotting Factors
5 - 10 min
FFP

10

What dos a PROLONGED TEG-R indicate ?

Shortage of clotting factors

11

What does that Alpha Angle on the TEG represent?
What are the normal values?

Reflects the speed of Fibrin accumulation.
53 - 72 degrees

12

A TEG Alpha Angle of < 53 degrees represents what ?
How would I treat this ?

Fibrinogen Deficiency
Treat with Cryoprecipitate

13

TEG Alpha Angle is impacted by what ?

Fibrinogen

14

What does the TEG-MA represent ?
What are the normal values ?

Platelet Function
50 - 70 mm

15

What does a TEG-MA of < 50 represent ?
How would I treat this ?

Platelet deficiency
Treat with Platelets

16

What does the TEG-G represent ?

Clot Strength

17

What does the TEG-K represent ?
What are the normal values ?

Time until clot reaches a fixed strength
1 - 3 min

18

A TEG-K value > 3 min indicates what ?
How would I treat this ?

Fibrinogen Deficiency
Treat with Cryoprecipitate

19

What does the TEG-Ly30 represent ?
What are the normal values?

Percentage of Fibrinolysis at 30 minutes
0 - 8%

20

A TEG-Ly30 value > 8 represents what ?
How would you treat this ?

Excess Fibrinolysis
Treat with Antifibrinolytics (Amicar)

21

What is a Lab Test that measures Residual heparin ?
Example: During Heparin rebound

Anti-Xa

22

What is a POC Test that measures Residual heparin ?
Example: During Heparin rebound

Heparin Level Assay
or
Heparinase ACT

23

What is a Lab Test that measures Platelets?
What is the normal value ?

Platelet Count
150k - 400k

24

What are 3 POC Test that measure Platelets ?

TEG-MA
ROTOM
SONOCLOT

25

What is a Lab Test that measures Platelet Activity?

Platelet Function Analysis

26

What is a Lab Test that measures Fibrinogen ?

Fibrinogen Concentration

27

What is a POC Test that measures Fibrinogen ?

ACT
TEG-K & TEG-Alpha Angle

28

What is a Lab Test that measures Coagulation Factors ?

PT = Extrinsic Pathway
PTT = Intrinsic Pathway

29

What is a POC Test that measures Coagulation Factors ?

ACT
TEG-R

30

What are 5 reason why we might remain anticoagulated post surgery ?

1.) Heparin
2.) Hypothermia
3.) Platelet Function
4.) Coagulation Factor Deficiency
5.) Fibrinolysis

31

Why would Hypothermia cause us to remain anticoagulated post surgery?

Coagulation system does not work properly under hypothermic circumstances, warm back up to 37 degrees.

32

Why would Hemodilution cause us to remain anticoagulated post surgery?

Hemodilution > 75% of blood volume causes a disruption in clotting factors.

33

Inaccurate anticoagulation during surgery would result in what after surgery ?

Total consumption of the clotting factors during surgery, therefore the patient would remain anticoagulated.

34

Why would Fibrinolysis cause us to remain anticoagulated post surgery?

A low fibrinogen concentration and byproducts of clot formation and dissolution (Fibrin Split Products & D-dimer) would continue to cause anticoagulation.

35

What are 5 possible reasons why we would see post-op bleeding ?

1.) Residual Heparin
2.) Platelet Dysfunction
3.) Coagulopathy
4.) Fibrinolysis
5.) Surgical complications

36

What process should I use to evaluate why were still bleeding ?

1.) Rule out Residual Heparin
2.) Make sure the patient is warm
3.) Run your favorite Lab tests

37

What LAB Tests should I run if I suspect Residual Heparin ?

Anti-Xa
Heparin Level Assay
Heparinase ACT

38

What LAB Tests should I run if I suspect Platelet Dysfunction ?

Platelet Count
Platelet Function Analysis (PFA)

39

What LAB Tests should I run if I suspect Coagulopathy (Bleeding or Clotting Disorder) ?

PT
PTT
Factor Assays Extrinsic / Intrinsic
TEG-R
vWF

40

What LAB Tests should I run if I suspect Fibrinolysis ?

Fibrinogen Concentration
TEG-K
TEG-Alpha Angle

41

How would I treat Residual Heparin or Heparin Rebound in patients who are still bleeding?

Protamine

42

How would I treat ATIII deficiency with patients who are still bleeding ?

* Recombiant ATIII
* FFP

43

How would I treat Hemophelia A & B patients who are still bleeding and patients whose treatment has not responded to conventional methods?

Recombiant Factor VIIa. rFVIIa, which is activated form factor VII, bypasses factors VIII and IX and causes coagulation of blood without the need for factors VIII and IX

44

How would I treat patients who are still breeding as a result of Excess Fibrinolysis ?

Antifibrinolytics (Amicar or Tranaxemic Acid) which prevents the breakdown of clot by blocking the conversion of plasminogen to plasmin down the fibrinolytic pathway?