Here is a message sent on Monday, May 11, 2009 from Emily Oakley:

With minimal staffing, I am trying to cut down on the number of phone calls placed to unit staff. In your lab, do you have two PTT critical values, one for heparinized patients, and one for non-heparin patients such as pre-admits or emergency department patients? At what point do the physicians have to take responsibility for looking at the results of the tests they have ordered?

Mr. Fritsma,

Greetings! Thank you for having such a great website for hemostasis!

I am looking at autoverification of our PTs, PTTs, fibrinogens and D-dimers. I am especially interested in using a delta flag for the PTs to prevent errors. I was thinking that the INR would be the easiest to flag with delta checks. We do have many patients initiating and or being monitored for coumadin therapy.  Do you have any thoughts (or any of the website users) for some good guidelines for delta checks on PTs? Any information would be appreciated.

Sincerely,
Ann Tidwell, SH(ASCP)
VCU Health System
Richmond, VA

Susan Buchholz sent this question Wednesday, January 21:

What should you do with prolonged PTTs on patients with multiple myeloma?

A note about the bleeding time test from Col. Lucia More at Elmendorf AFB:

Hi George!  In my continuing quest to try to bring AF labs into the 21st century I'm proposing we eliminate bleeding times in AF labs and stop teaching the test in our lab tech training program.

Col More continues...

Here is an interesting message from Twyla Bader at Peace Health:

1. What is a reasonable lower limit for reporting an APTT? We have Diagnostica Stago Compacts, our normal range is 23.0 - 35.0 seconds and our reportable range currently is 4.0 - 200.0 seconds. I don't believe I have ever encountered a sample with a value less than 19.0 that wasn't a clotted sample. 
 
2. While investigating an APTT result reported the previous evening from our lab of <4.0 seconds I discoverd the specimen contained fibrin and also that the sample had been collected minutes before the patient expired. Is it possible that this plasma had been activated in vivo, therefore an accurate result?

I received this interesting question on Friday, October 3 from Priscilla Koernert:

Hi George,

I ran across your site while researching a method discrepancy regarding PTT results. We are currently using Stago Compacts obtained a result of 100.9 on a non-heparinized patient.  The physician subsequently ordered further coag testing which we send over to the local university hospital lab.  They perform their coags using the Beckman ACL TOP.  Their result differed from ours significantly, it was 26.6!  This patient was post-surgery, also had an elevated FVIII and fibrinogen.  Further studies were suspicious for lupus anticoagulant with follow-up testing recommended.  What are your thoughts on the discrepancy?  Is it a result of different methodologies?  Any insight you can provide will be much appreciated.
Thank you.

Here is some follow-up to the question posted last week by Julie Schartiger MLT (ASCP) from Holzer Medical Center, Gallipolis, OH. Julie wrote: "I was wondering if there was a list of the specific disease states and the correction factors involved.  For example, if a specimen was corrected by the addition of normal pooled plasma, but the Russell viper venom test was abnormal, what disease state would this indicate?  It would be nice to have a chart for quick reference."

It occurred to me that we need a summary of presumed acquired and congenital coagulation deficiencies related to prothrombin time (PT) and partial thromboplastin time (PTT) results in bleeding patients. Here is a table that may be useful...

On Monday, June 2, I provided two 90-minute lectures for Dr. Ingrid Oakley's graduate Nurse Anesthesia Program students at the University of Alabama at Birmingham (UAB).

The first lecture was "Hemostasis Overview and Managing the Bleeding Patient," and the second was "Thrombophilia and Managing Antithrombotic Therapy." It is tough on students to attempt to cover all of hemostasis in four hours, but fortunately, these are bright, advanced students. Working with students of this caliber is fun for me, though perhaps grueling for them.