Category: Anticoagulant Therapy

Anti-Xa to Replace PTT

From frequent contributor, Kim Kinney: Hi George, our Indiana University Health Pathology Laboratory is thinking of making the push again to use the Anti-Xa to monitor unfractionated (UFH) heparin therapy in place of the activated partial thromboplastin time (aPTT). I would like to hear from institutions that have made the transition successfully even in light of the fact that the chromogenic anti-Xa is a more expensive test than the aPTT. That seems to be where our admin gets stuck.
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Using the PTT After Cardiac Catheterization

This question was forwarded by an American Society for Clinical Laboratory Science Consumer Web Forum volunteer: Our hospital currently uses activated clotting time (ACT) results during heart catheterizations to monitor heparin dosage. The ACT is also used as a guide for pulling the sheath. The nurse confirms that the ACT is less than a certain value before removing the sheath. Would it be possible/advisable to use the partial thromboplastin time (PTT) result instead of ACT as a guide to pulling the sheath if the patient has been transferred to a room and the ACT device is not available for testing?

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How Long to Stop Infusion

From Kim Kinney at Indiana University Health:

Hi George. We frequently get asked how long to stop an unfractionated heparin infusion before drawing for a partial thromboplastin time (PTT) from a central line or peripheral stick above the infusion site. We have always referred them to pharmacy. is there a standard practice used by nursing at other institutions that someone would share?

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Discard Tubes for Heparin?

From Dennis Ernst, Center for Phlebotomy Education, Inc: I am chairing the CLSI Document Development Committee on the venipuncture standard revision. At today’s web meeting the question came up about the necessity for discard tubes on heparinized patients. It’s been widely reported that discard tubes are not necessary, and haven’t been for some time. However, it came to our attention today that the passage in the CLSI coag standard (H21) that states discard tubes are not necessary for partial thromboplastin time assays (PTTs, APTTs) and prothrombin times (PTs), for that matter cites four studies, all of which have been conducted on patients who are not on heparin therapy. Here are the citations:

  •  Gottfried EL, Adachi MM. Prothrombin time and activated partial thromboplastin time can be performed on the first tube. Am J Clin Pathol. 1997;107:681–3.
  • Adcock DM, Kressin DC, Marlar RA.  Are discard tubes necessary in coagulation studies?  Lab Med. 1997;28:530–3.
  • Yawn B, Loge C, Dale J. Prothrombin time, one tube or two.  Am J Clin Pathol. 1996;105:794–7.
  • Bamberg R, Cottle J, Williams J. Effect of drawing a discard tube on PT and APTT results in healthy adults.  Clin Lab Sci. 2003;16:16-19.

Are you aware of any study that had attempted to establish discard tubes may not be necessary for heparinized patients as well? In your opinion, is it safe to assume it shouldn’t matter if they are heparinized or not?

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Anti-Xa versus PTT

Hi George! Our HCO is wanting to change unfractionated heparin (UFH) monitoring to the anti-Xa test from the partial thromboplastin time (PTT). The research supports decreased lenghth of stay, quicker theurapeutic range achievement and improved patient safety monitoring with anti-Xa, as many patients may appear theurapeutic with the PTT but may actually be under or over anticoagulated. Our physicians seem to know nothing about anti-Xa as well as few of our lab co-workers and do not see the need to change. What are your thoughts? Julia Witt.

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Pradaxa Monitoring Debate

A February 7, 2014 Heartwire article describes how Boehringer Ingelheim has released internal documents indicating their scientists had debated the need for laboratory monitoring of dabigatran.

Cortisone and Coumadin

From Prof. Jeanne Isabel, Northern Illihois University, a long-time friend and colleague. Hi George, a colleague who works at a cancer center has a patient on hydrocortisone (not sure how much) and her prothrombin time and international normalized ratio (PT/INR) were elevated to 54 s/4.9. she is on Coumadin and last time her INR was in the therapeutic range. She did not have symptoms to correlate with the elevated results. would the hydrocortisone cause this? Thanks.

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Discontinuing DOACs and Thrombosis

From Karen Dallas, MD, Saskatoon Health Region: I have searched the internet and cannot find a direct connection between thromboembolism prophylaxis with direct thrombin inhibitors and the induction of a prothrombotic state once discontinued. We have observed a few cases which seem to exhibit this phenomenon at my institution. Can you guide me towards any information on this occurrence?
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