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1、Point-Of-CareCoagulationTesting:Whatisit?Whydowedoit?Wherearewegoing?,JohnA.Saavedra,InternationalSalesManagerInternationalTechnidyneCorporation(ITC)Edison,NewJersey,USA,WhatisPointofCareTesting?,AccordingtoCAP(CollegeofAmericanPathologists):testingperformedatthebedsidenotinfixeddedicatedspacePerfor
2、medbyalargenumberofdifferentnon-laboratoryhealthcarepersonnelUtilizesportabledevicesorsimplereagentkitsdifferentfromthoseusedintheprimarylaboratory.,WhyTestCoagulation?,MonitoranticoagulationtherapyHeparinandWarfarinaremonitoredBothhavehighlyvariablepatientdoseresponse.AtherapeuticdoseforpatientAThr
3、omboticdoseforpatientBHemorrhagicdoseforpatientCDeterminepatientshemostaticstatus,WhyPoint-Of-CareTesting?,PromptTurnAroundTimeImprovedClinicalOutcomeReducedLengthofStayStandardizationImproved,timelypatientcare,Benefit-ImmediateTurnAround,WhenisTurnAroundImportantOperatingRoomandCathLabICU/CCUDoseAd
4、justmentsEmergencyRoom,ImmediateTurnAround,Fitch,et.al,J.ClinMonit2x106KIUpumpprime;0.5x106KIU/hrinfusionHalfHammersmith1x106KIUloadingdose;1x106KIUpumpprime;0.25x106KIU/hrinfusion,ACTMonitoringwithAprotininTreatment,CeliteACTNotrecommendedStillusedwithtargettimesof750secondsKaolinACTUnaffectedbymod
5、eratedosesofaprotininUsedwithtargettimesof480secondsACT+UnaffectedbyALLdosesofaprotininUsedwithtargettimesof400seconds,ACTMonitoringwithAprotininTreatment,Datafromclinicalevaluation,onfile,ITC,OtherPoint-Of-CareCoagulationTestingintheOperatingRoom,APTTsomepatientsmayberesistantorsensitivetoheparinTh
6、eycanrepresent20-40%ofpatientpopulation,ManagingHeparinandProtamineDosing,HeparinResistance:Repeatedexposuretoheparin(frompreviousprocedures)mayreducepatientsresponsetothedrugPatientrequiresahigherdoseofheparininordertoobtainthesameanticoagulanteffect,ManagingHeparinandProtamineDosing,HeparinSensiti
7、vity:Patientsresponsetoheparinisgreaterthantheaveragepatientofthesameheight,weightandgender.Patientrequiresalowerheparindosetoobtainthesameanticoagulanteffect.,ManagingHeparinandProtamineDosing,Benefits:IndividualizesheparindoseforsensitiveandresistantpatientsReducesuseofbloodproductsneededforpost-o
8、perativetransfusionsJOBESDR,etal.1995.INCREASEDACCURACYANDPRECISIONOFHEPARINANDPROTAMINEDOSINGREDUCESBLOODLOSSANDTRANSFUSIONREQUIREMENTSINPATIENTSUNDERGOINGPRIMARYCARDIACOPERATIONS.JTHORACCARDIOVASCSURG110:36-45,ManagingHeparinandProtamineDosing,Benefits:ReducespotentialforprotaminedosesideeffectsPr
9、otaminereducedbyaverageof30%ZUCKERML.,etal.1997.UTILITYOFINVITROHEPARINANDPROTAMINETITRATIONFORDOSINGDURINGCARDIOPULMONARYBYPASSSURGERY.JEXTRA-CORPTECH.29:176-180.CostSavingsJOBESD,etal.1996.COSTEFFECTIVEMANAGEMENTOFHEPARIN/PROTAMINEINCPBYPASS:ANALYSISBYTYPEOFSURGERY.ANESTHES85:3A,OtherPoint-Of-Care
10、CoagulationTestingintheOperatingRoom,HeparinneutralizationverificationEnsurecompleteremovalofcirculatingheparinaPTTPDA-O-ACTbasedTT/HNTT-ThrombinTimebased,ClinicalStudies,ReducedBloodLoss/TransfusionUseofHRTandPRT(RxDxSystem)Jobes,D.et.al.,1995.J.Thorac.Cardiovasc.Surg.ReducedCostResultingfromPOCAss
11、aysRxDxcombinedwithTT/HNTTJobes,D.et.al.,1996.AmSocAnesthMtg.,ClinicalStudies,ReducedComplicationRatesTT/HNTTRe-ExplorationforBleedingReducedfrom2.5%to1.1%Re-ExplorationforCoagulopathyReducedfrom1.0%to0.0%Jobes,et.al.1997,NACBPresentation,Phila,PA.,Point-Of-CareCoagulationTesting,ClinicalApplication
12、sOperatingRoomCardiacSurgeryInterventionalCardiologyandRadiologyCriticalCareSatelliteSitesDialysisECMOEmergencyRoomAnticoagulationClinic,CriticalCare,ACTDeterminewhentopullthefemoralsheathHighACTvaluesindicatethepresenceofheparin.Prematuresheathpullcanleadtobleedingcomplications.Delayedremovalcaninc
13、reasetimeinboththeCCUandhospitalTargetACTsetateachsiteVariesfrom150secto250secondMonitorheparintherapyTargettimesdeterminedbyeachfacilityTargetsusuallysetas1.5-2xbaselineACTvalues(180-240seconds).,CriticalCare,APTTLaboratoryorPointofCareHighAPTTvaluesindicatethepresenceofheparinorunderlyingcoagulopa
14、thyDeterminewhentopullthefemoralsheathTargettimesdeterminedbyeachfacility.MonitorheparintherapyTargettimesdeterminedbyeachfacilityTargetsaresetas1.5-2xbaseline50-80secondsMonitorduringheparin/coumadincross-over,HeparinversusWarfarin,WhatDotheTestResultsMean?,PTLaboratoryorPointofCareMonitorwarfarint
15、herapyMonitorheparin/warfarincrossoverTargettimesaresetbyInternationalNormalizedRatio(INR)ISI=internationalSensitivityIndexINRtargetrangesarespecifiedbypatientpopulationsprophylactictherapyforDVT:INR=2.0-3.0artificialheartvalve:INR=3.0-4.0,WillResultsMatchtheLab?,ProbablynotbuttheyWILLcorrelate,Why?
16、,PointofCareWholeBloodNoAddedAnticoagulantNoDilutionNoPreanalyticalDelay,StandardLaboratoryPlateletPoorPlasmaSodiumCitrateAnticoagulant1:9DilutionVariablePreanalyticalDelay,Correlationswithdifferentsystems,SignatureINRvsLab,Point-Of-CareCoagulationTesting,ClinicalApplicationsOperatingRoomCardiacSurgeryInterventionalCardiologyandRadiologyCriticalCareSatelliteSitesDialysisECMOEmergencyRoomAnticoagulationClinic,Dialysis/ECMO,ACTusedtomonitorheparinUseP214glassactivatedACTtubeorACT-LRcuvetteTargetsg
