Variability of prothrombin time and activated partial thromboplastin time in the diagnosis of increased surgical bleeding

Corresponding Author

David J. Murray MD

Professor

Department of Anesthesia, Washington University School of Medicine; and Division of Pediatric Anesthesia, 6W4, St. Louis Children's Hospital, One Children's Place, St. Louis, MO 63110. [Reprint requests]

Beverly Pennell MS,

Beverly Pennell MS

Director

Special Hematology, Department of Pathology, University of Iowa College of Medicine, Iowa City, IA.

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John D. Olson MD, PhD,

John D. Olson MD, PhD

Professor

Department of Pathology; and Director, Clinical Laboratories, University of Iowa College of Medicine, Iowa City, Iowa.

Current position: Professor, Department of Pathology, University of Texas San Antonio, San Antonio, TX.

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David J. Murray MD,

Corresponding Author

David J. Murray MD

Professor

Beverly Pennell MS,

Beverly Pennell MS

Director

Special Hematology, Department of Pathology, University of Iowa College of Medicine, Iowa City, IA.

Search for more papers by this author

John D. Olson MD, PhD,

John D. Olson MD, PhD

Professor

Department of Pathology; and Director, Clinical Laboratories, University of Iowa College of Medicine, Iowa City, Iowa.

Current position: Professor, Department of Pathology, University of Texas San Antonio, San Antonio, TX.

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First published: 19 December 2002

https://doi.org/10.1046/j.1537-2995.1999.39199116895.x

Citations: 38

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Abstract

BACKGROUND: Prothrombin time (PT) and activated partial thromboplastin time (APTT) are used to diagnose causes of increased surgical bleeding and to guide treatment of acquired coagulation factor deficiency. This study compared the sensitivity of various commercial PT and APTT tests in patients with dilutional coagulopathy.

STUDY DESIGN AND METHODS: A prospective study was used to identify patients who experienced increased surgical bleeding during elective extensive (>10 spinal segments) spinal fusion and instrumentation. In patients with clinical signs of increased bleeding, blood was obtained to compare the sensitivity of various commercial PT and APTT tests. PT, PT ratio, the International Normalized Ratio (INR), APTT, and APTT ratio were compared for their sensitivity in the diagnosis of a dilutional coagulopathy.

RESULTS: Sixteen patients experienced increased bleeding during surgery. Mean estimated blood volume lost exceeded 1 blood volume (1.14 ± 0.28). PT and APTT test results varied markedly. In the most sensitive PT and APTT tests, the results were 1.5 times the mean reference range values in all but on of the patients. The least sensitive combination of tests had results that were 1.5 times the mean reference range values in only 2 of 16 patients. Variability among tests was not reduced by the use of the PT or the APTT ratio, by the use of INR, or by incorporation of a measure of PT or APTT test sensitivity to factor-deficient serum.

CONCLUSION: In surgical patients with dilutional coagulopathy, diagnostic and treatment decisions could depend on which PT and APTT test was used to determine the etiology of increased bleeding. This study indicates that the relationship between increased bleeding and an increased PT and APTT may be more difficult to define than is suggested by current practice guidelines. Each laboratory must establish guidelines based on reagent and instrument sensitivity to coagulation factor dilution.

REFERENCES

1 Leslie SD, Toy PT. Laboratory hemostatic abnormalities in massively transfused patients given red blood cells and crystalloid. Am J Clin Pathol 1991; 96: 770–3.
10.1093/ajcp/96.6.770
CAS PubMed Web of Science® Google Scholar
2 Murray DJ, Olson J, Strauss R, Tinker JH. Coagulation changes during packed red cell replacement of major blood loss. Anesthesiology 1988; 69: 839–45.
10.1097/00000542-198812000-00007
CAS PubMed Web of Science® Google Scholar
3 Murray DJ, Pennell BJ, Weinstein SL, Olson JD. Packed red cells in acute blood loss: dilutional coagulopathy as a cause of surgical bleeding. Anesth Analg 1995; 80: 336–42.
10.1097/00000539-199502000-00022
CAS PubMed Web of Science® Google Scholar
4 Consensus conference. Fresh-frozen plasma. Indications and risks. JAMA 1985; 253: 551–3.
PubMed Google Scholar
5 Stehling L, Luban NLC, Anderson KC, et al. Guidelines for blood utilization review. Transfusion 1994; 34: 438–48.
10.1046/j.1537-2995.1994.34594249058.x
CAS PubMed Web of Science® Google Scholar
6 Practice parameter for the use of fresh-frozen plasma, cryoprecipitate, and platelets. Fresh-frozen plasma, cryopre-cipitate, and platelets administration practice guidelines development task force of the College of American Pathologists. JAMA 1994; 271: 777–81.
PubMed Google Scholar
7 Contreras M, Ala FA, Greaves M, et al. Guidelines for the use of fresh frozen plasma. British Committee for Standards in Haematology, Working Party of the Blood Transfusion Task Force. Transfus Med 1992; 2: 57–63.
10.1111/j.1365-3148.1992.tb00135.x
CAS PubMed Web of Science® Google Scholar
8 Toy PT. Effectiveness of transfusion audits and practice guidelines. Arch Pathol Lab Med 1994; 118: 435–7.
CAS PubMed Web of Science® Google Scholar
9 Solomon RR, Clifford JS, Gutman SI. The use of laboratory intervention to stem the flow of fresh-frozen plasma. Am J Clin Pathol 1988; 89: 518–21.
10.1093/ajcp/89.4.518
CAS PubMed Web of Science® Google Scholar
10 Ciavarella D, Reed RL, Counts RB, et al. Clotting factor levels and the risk of diffuse microvascular bleeding in the massively transfused patient. Br J Haematol 1987; 67: 365–8.
10.1111/j.1365-2141.1987.tb02359.x
CAS PubMed Web of Science® Google Scholar
11 Marlar RA, Bauer RT, Endres-Brooks JL, et al. Comparison of the sensitivity of commercial APTT reagents in the detection of mild coagulopathies. Am J Clin Pathol 1984; 82: 436–9.
10.1093/ajcp/82.4.436
CAS PubMed Web of Science® Google Scholar
12 Turi DC, Peerschke EI. Sensitivity of three activated partial thromboplastin time reagents to coagulation factor deficiencies. Am J Clin Pathol 1986; 85: 43–9.
10.1093/ajcp/85.1.43
CAS PubMed Web of Science® Google Scholar
13 Bussey HI, Force RW, Bianco TM, Leonard AD. Reliance on prothrombin time ratios causes significant errors in anticoagulation therapy. Arch Intern Med 1992; 152: 278–82.
10.1001/archinte.1992.00400140032009
CAS PubMed Web of Science® Google Scholar
14 Hirsh J. Substandard monitoring of warfarin in North America: Time for change (editorial). Arch Intern Med 1992; 152: 257–8.
10.1001/archinte.152.2.257
PubMed Web of Science® Google Scholar
15 Shojania AM, Tetreault J, Turnbull G. The variations between heparin sensitivity of different lots of activated partial thromboplastin time reagent produced by the same manufacturer. Am J Clin Pathol 1988; 89: 19–23.
10.1093/ajcp/89.1.19
CAS PubMed Web of Science® Google Scholar
16 Bjornsson TD, Nash PV. Variability in heparin sensitivity of APTT reagents. Am J Clin Pathol 1986; 86: 199–204.
10.1093/ajcp/86.2.199
CAS PubMed Web of Science® Google Scholar
17 Brill-Edwards P, Ginsberg JS, Johnston M, Hirsh J. Establishing a therapeutic range for heparin. Ann Intern Med 1993; 119: 104–9.
10.7326/0003-4819-119-2-199307150-00002
PubMed Web of Science® Google Scholar
18 Loeliger EA, Poller L, Samama M, et al. Questions and answers on prothrombin time standardization in oral anticoagulant control. Thromb Haemost 1985; 54: 515–7.
PubMed Web of Science® Google Scholar
19 International Committee for Standardization in Haematology, International Committee on Thrombosis and Haemostasis: ICSH/ICTH recommendations for reporting prothrombin time in oral anticoagulant control. Thromb Haemost 1985; 54: 155–6.
Google Scholar
20 Loeliger EA, van den Besselaar AM, Lewis SM. Reliability and clinical impact of the normalization of the prothrombin times in oral anticoagulant control. Thromb Haemost 1985; 53: 148–56.
CAS PubMed Web of Science® Google Scholar
21 Poller L. A simple nomogram for the derivation of international normalised ratios for the standardisation of prothrombin times. Thromb Haemost 1988; 60: 18–20.
Google Scholar
22 Bland JM, Altman DG. Comparing methods of measurement: why plotting difference against standard method is misleading. Lancet 1995; 346: 1085–7.
10.1016/S0140-6736(95)91748-9
CAS PubMed Web of Science® Google Scholar
23 Kovacs MJ, Wong A, MacKinnon K, et al. Assessment of the validity of the INR system for patients with liver impairment. Thromb Haemost 1994; 71: 727–30.
10.1055/s-0038-1642513
CAS PubMed Web of Science® Google Scholar
24 Rosen NR, Bates LH, Herod G. Transfusion therapy: improved patient care and resource utilization. Transfusion 1993; 33: 341–7.
10.1046/j.1537-2995.1993.33493242644.x
PubMed Web of Science® Google Scholar
25 Silberstein LE, Kruskall MS, Stehling LC, et al. Strategies for the review of transfusion practices. JAMA 1989; 262: 1993–7. erratum appears JAMA 1990;263:2302.
10.1001/jama.1989.03430140111034
CAS PubMed Web of Science® Google Scholar
26 Aggeler PM. Physiological basis for transfusion therapy in hemorrhagic disorders: a critical review. Transfusion 1961; 1: 71–86.
10.1111/j.1537-2995.1961.tb00017.x
PubMed Web of Science® Google Scholar
27 Miller RD, Robbins TO, Tong MJ, Barton SL. Coagulation defects associated with massive blood transfusions. Ann Surg 1971; 174: 794–801.
10.1097/00000658-197111000-00010
CAS PubMed Web of Science® Google Scholar
28 Counts RB, Haisch C, Simon TL, et al. Hemostasis in massively transfused trauma patients. Ann Surg 1979; 190: 91–9.
10.1097/00000658-197907000-00020
CAS PubMed Web of Science® Google Scholar
29 Surgenor DM, Wallace EL, Hale SG, Gilpatrick MW. Changing patterns of blood transfusions in four sets of United States hospitals, 1980 to 1985. Transfusion 1988; 28: 513–8.
10.1046/j.1537-2995.1988.28689059022.x
CAS PubMed Web of Science® Google Scholar

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Volume39, Issue1

January 1999

Pages 56-62

Variability of prothrombin time and activated partial thromboplastin time in the diagnosis of increased surgical bleeding

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Variability of prothrombin time and activated partial thromboplastin time in the diagnosis of increased surgical bleeding

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