Point-Of-CareCoagulationTesting:Whatisit?Whydowedoit?Wherearewegoing?,JohnA.Saavedra,InternationalSalesManagerInternationalTechnidyneCorporation(ITC)Edison,NewJersey,USA,WhatisPointofCareTesting?,AccordingtoCAP(CollegeofAmericanPathologists):testingperformedatthebedsidenotinfixeddedicatedspacePerformedbyalargenumberofdifferentnon-laboratoryhealthcarepersonnelUtilizesportabledevicesorsimplereagentkitsdifferentfromthoseusedintheprimarylaboratory.,WhyTestCoagulation?,MonitoranticoagulationtherapyHeparinandWarfarinaremonitoredBothhavehighlyvariablepatientdoseresponse.AtherapeuticdoseforpatientAThromboticdoseforpatientBHemorrhagicdoseforpatientCDeterminepatientshemostaticstatus,WhyPoint-Of-CareTesting?,PromptTurnAroundTimeImprovedClinicalOutcomeReducedLengthofStayStandardizationImproved,timelypatientcare,Benefit-ImmediateTurnAround,WhenisTurnAroundImportantOperatingRoomandCathLabICU/CCUDoseAdjustmentsEmergencyRoom,ImmediateTurnAround,Fitch,et.al,J.ClinMonit2x106KIUpumpprime;0.5x106KIU/hrinfusionHalfHammersmith1x106KIUloadingdose;1x106KIUpumpprime;0.25x106KIU/hrinfusion,ACTMonitoringwithAprotininTreatment,CeliteACTNotrecommendedStillusedwithtargettimesof750secondsKaolinACTUnaffectedbymoderatedosesofaprotininUsedwithtargettimesof480secondsACT+UnaffectedbyALLdosesofaprotininUsedwithtargettimesof400seconds,ACTMonitoringwithAprotininTreatment,Datafromclinicalevaluation,onfile,ITC,OtherPoint-Of-CareCoagulationTestingintheOperatingRoom,APTTsomepatientsmayberesistantorsensitivetoheparinTheycanrepresent20-40%ofpatientpopulation,ManagingHeparinandProtamineDosing,HeparinResistance:Repeatedexposuretoheparin(frompreviousprocedures)mayreducepatientsresponsetothedrugPatientrequiresahigherdoseofheparininordertoobtainthesameanticoagulanteffect,ManagingHeparinandProtamineDosing,HeparinSensitivity:Patientsresponsetoheparinisgreaterthantheaveragepatientofthesameheight,weightandgender.Patientrequiresalowerheparindosetoobtainthesameanticoagulanteffect.,ManagingHeparinandProtamineDosing,Benefits:IndividualizesheparindoseforsensitiveandresistantpatientsReducesuseofbloodproductsneededforpost-operativetransfusionsJOBESDR,etal.1995.INCREASEDACCURACYANDPRECISIONOFHEPARINANDPROTAMINEDOSINGREDUCESBLOODLOSSANDTRANSFUSIONREQUIREMENTSINPATIENTSUNDERGOINGPRIMARYCARDIACOPERATIONS.JTHORACCARDIOVASCSURG110:36-45,ManagingHeparinandProtamineDosing,Benefits:ReducespotentialforprotaminedosesideeffectsProtaminereducedbyaverageof30%ZUCKERML.,etal.1997.UTILITYOFINVITROHEPARINANDPROTAMINETITRATIONFORDOSINGDURINGCARDIOPULMONARYBYPASSSURGERY.JEXTRA-CORPTECH.29:176-180.CostSavingsJOBESD,etal.1996.COSTEFFECTIVEMANAGEMENTOFHEPARIN/PROTAMINEINCPBYPASS:ANALYSISBYTYPEOFSURGERY.ANESTHES85:3A,OtherPoint-Of-CareCoagulationTestingintheOperatingRoom,HeparinneutralizationverificationEnsurecompleteremovalofcirculatingheparinaPTTPDA-O-ACTbasedTT/HNTT-ThrombinTimebased,ClinicalStudies,ReducedBloodLoss/TransfusionUseofHRTandPRT(RxDxSystem)Jobes,D.et.al.,1995.J.Thorac.Cardiovasc.Surg.ReducedCostResultingfromPOCAssaysRxDxcombinedwithTT/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,ClinicalApplicationsOperatingRoomCardiacSurgeryInterventionalCardiologyandRadiologyCriticalCareSatelliteSitesDialysisECMOEmergencyRoomAnticoagulationClinic,CriticalCare,ACTDeterminewhentopullthefemoralsheathHighACTvaluesindicatethepresenceofheparin.Prematuresheathpullcanleadtobleedingcomplications.DelayedremovalcanincreasetimeinboththeCCUandhospitalTargetACTsetateachsiteVariesfrom150secto250secondMonitorheparintherapyTargettimesdeterminedbyeachfacilityTargetsusuallysetas1.5-2xbaselineACTvalues(180-240seconds).,CriticalCare,APTTLaboratoryorPointofCareHighAPTTvaluesindicatethepresenceofheparinorunderlyingcoagulopathyDeterminewhentopullthefemoralsheathTargettimesdeterminedbyeachfacility.MonitorheparintherapyTargettimesdeterminedbyeachfacilityTargetsaresetas1.5-2xbaseline50-80secondsMonitorduringheparin/coumadincross-over,HeparinversusWarfarin,WhatDotheTestResultsMean?,PTLaboratoryorPointofCareMonitorwarfarintherapyMonitorheparin/warfarincrossoverTargettimesaresetbyInternationalNormalizedRatio(INR)ISI=internationalSensitivityIndexINRtargetrangesarespecifiedbypatientpopulationsprophylactictherapyforDVT:INR=2.0-3.0artificialheartvalve:INR=3.0-4.0,WillResultsMatchtheLab?,ProbablynotbuttheyWILLcorrelate,Why?,PointofCareWholeBloodNoAddedAnticoagulantNoDilutionNoPreanalyticalDelay,StandardLaboratoryPlateletPoorPlasmaSodiumCitrateAnticoagulant1:9DilutionVariablePreanalyticalDelay,Correlationswithdifferentsystems,SignatureINRvsLab,Point-Of-CareCoagulationTesting,ClinicalApplicationsOperatingRoomCardiacSurgeryInterventionalCardiologyandRadiologyCriticalCareSatelliteSitesDialysisECMOEmergencyRoomAnticoagulationClinic,Dialysis/ECMO,ACTusedtomonitorheparinUseP214glassactivatedACTtubeorACT-LRcuvetteTargetsg